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SURGICAL RESECTION IN PULMONARY TUBERCULOSIS DUE TO ATYPICAL MYCOBACTERIUM TUBERCULOSIS
SURGICAL RESECTION I N P U L M O N A R Y TUBERCULOSIS
DUE
TO ATYPICAL MYCOBACTERIUM TUBERCULOSIS Raymond F. Corpe, M.D.*
E
and Joseph Liang, M.D.,** Rome, Ga.
with over 180 cases of atypical pxilmonary tuberculosis, treated with conventional antituberculosis drug therapy at Battey State Hospital, has shown the conversion rate to be about 22 per cent. In typical tuberculosis, the conversion rate is about 90 per cent after 6 months of drug therapy. In atypical tuberculosis, the great shortcomings of this medical approach have led us to continue excisional surgery in selected cases. Our experience would indi cate that resection can be done with a low morbidity and a reasonably low mor tality with resultant high sputum conversion in well-chosen cases and affords reasonably good results in the long-term tenure. XPERIENCE
MATERIALS AND METHODS
From Jan. 1, 1950, to the end of April, 1959, 25 patients with atypical tuberculosis were subjected to pulmonary resection. Of the 23 white patients, 18 were male and 5 were female. The 2 Negro patients were male. Twelve pa tients subjected to resection were in their forties; 6 were in their thirties; 5 were in their fifties; and the youngest patient was 28 and the oldest 67 years of age. According to the classification of the National Tuberculosis Association, the disease was minimal in 1 case, moderately advanced in 13, and far advanced in the remaining 10 cases. On admission bactériologie studies, 16 of the patients were positive by both direct smear and culture and 9 were negative on direct smear but positive on culture. Using Runyon's classification,1 22 of the positive cultures were nonphotochromogenics (Group III-Battey type). In 2 patients, there were photochromogenic strains (Group I ) , and in 1 there was a scotochromogenic strain (Group I I ) . As soon as a working diagnosis of pulmonary tuberculosis was established, 24 of the 25 patients were placed on antituberculous drug therapy. Twelve of these patients received isonicotinic acid hydrazide (INH) and pava-aminosalicylie acid (PAS), 9 received INH, streptomycin, and PAS, 3 received strepto mycin and PAS, and 1 patient received INH, streptomycin, PAS, and Dalicin From the Battey State Hospital, Rome, Ga. Received for publication Oct. 19, 1959. •Superintendent. »•Chief of Surgery. 93
CORPE AND LIANG
94
J. Thoracic and Cardiovas. Surg.
in the preoperative period. Additional chemotherapy was used in the post operative period. Ten of the 12 patients having had INH and PAS received streptomycin in the postoperative period. Another patient who received INH and PAS had pyrazinamide (PZA) added in the postsurgical period. There was 1 patient who received no drug therapy before or after surgery. Two patients had no sensitivity studies done prior to surgery. Of the 23 patients who did have, 23 were completely resistant to isoniazid, and 13 of these 23 were totally resistant to streptomycin-5 were partially sensitive, and 5 were completely sensitive to streptomycin on the last studies done prior to surgery. Four of the 25 patients had negative sputum studies at the time of surgery; 1 patient had been negative for 3 months, 2 for 5 months, and 1 for 10 months. Of the remaining 21 patients, 2 were intermittently positive and 19 had never had negative cultures. Twenty-three of these patients had preoperative bronchoscopies. One had a partial stenosis of the right upper lobe bronchus. One patient had severe endobronchitis which required postponement of surgery for 2 months until the inflammatory process had subsided under treatment. Resection was then suc cessfully performed. Five of these patients had bronchograms. One revealed extensive bronohiectasis of the left lung and this patient eventually had a left pneumonectomv. Twenty οΓ the 25 patients were operated upon for open cavities plus posi tive sputum. One patient had an open cavity and a negative sputum, 1 pa tient had residual fibrocaseous disease and a positive sputum, 3 patients had residual fibrocaseous disease with a negative sputum. There were 26 resections performed on these 25 patients (Table I ) . One patient had a right upper lobectomy first followed 20 days later by a segmentectomy by the removal of the upper division of the left upper lobe. TABLE I.
SURGICAL PROCEDURES
PROCEDURES
NO.
WITHOUT COMPLICATION
WITH COMPLICATION
DEATH
Subsegmentectoiny Segmentectoniy Lobectomy, alone Lobectomy, plus Pneumonectomy Total
4 7 10 3 2 26
3 6 9 1 2 21
1 1 1* 2* 0 5
0 0 1 2 0 3
• I n these cases, the complications were followed by death. MORBIDITY AND MORTALITY
The patient who had bilateral resections had an uncomplicated course fol lowing each resection. Five patients (20 per cent) had postoperative complica tions (Table I I ) . One of the 4 subsegmental resections was followed by a bronchopleural fistula which required post-resection thoracoplasty. One of the 7 segmental resections was also complicated by a bronchopleural fistula and residual space problem that required a post-resection thoracoplasty. There were no deaths in the 11 patients who had small resections.
Vol. 40, No. 1 July, 1960
TABLE I I .
ATYPICAL MYCOBACTERIUM TUBERCULOSIS
95
MORBIDITY AND MORTALITY D U E TO SURGICAL COMPLICATION
PROCEDURES
COMPLICATION
MORTALITY
POSTOP. S P U T U M STATUS
1. Subsegmenteetomy, apical posterior seg ment, LUL, with postresection thoracoplasty
Bronchopleural fis tula and residual space
Sputum converted 28 months after surgery
2. Segmentectomy, apical posterior segment, RUL, with post-resec tion thoracoplasty
Bronchopleural fis tula and residual space
Sputum converted following surgery
3 RUL lobectomy plus segmentectomy, su perior segment, R L L
Pneumonia
Died of pneumonia on seventh postop. day
4 KUL and RML lobeeBronchopleural fis tomies plus wedge of tula and residual superior segment, RLL, space with post-resection thoracoplasty
Died of pulmonary insufficiency on fourth postop. day
S RUL lobectomy
Died of hypoxia, 48 hours 5 Cases
Total
Pulmonary insuf ficiency
Of the 10 patients who had lobectomy only, 9 had no complications. One patient died of pulmonary insufficiency 48 hours after a right upper lobectomy. There were 3 patients who had lobectomies plus removal of other lung tissue, and 2 of these procedures were accompanied by complications which led to death. One was a 67-year-old white woman who had a right upper and a right middle lobectomy plus removal of a wedge from the lower lobe. There was not enough tissue to adequately fill the pleural space and a post-resection thoraco plasty was performed 3 weeks after the resection. Following this, the patient died of pulmonary insufficiency on the fifth postoperative day. Another pa tient, having had a right upper lobectomy plus a superior segmental resection of the superior division of the right lower lobe, died on the seventh postopera tive day of pneumonia and atelectasis on the operative side, which was revealed at autopsy. There were 2 patients who had pneumonectomies and both had uncomplicated courses postoperatively. The surgical mortality rate, therefore, was 12 per cent. Pathologic and bactériologie studies of the surgical specimens revealed 2 surgical specimens negative on direct smear and culture. Twenty-four of the 26 surgical specimens had positive direct smears and, of these, 18 wore positive on culture. According to C. Edwin Smith, Battey Laboratory Director, these cultures were the same in each case as had been isolated preoperatively from each individual. Dr. I. Stergus, Pathologist at Battey State Hospital, says that "Pathologically, these lesions are indistinguishable from those of typical tuber culosis, grossly and microscopically." RESULTS
Four of the 25 patients had negative sputum at the time of surgery which remained consistently negative following surgery. Of these 4 patients who had
96
COEPE AND LIANG
J. Thoracic and Cardiovas. Surg.
negative sputum, 1 had an open cavity and the other 3 had residual fibrocaseous disease. Whether or not the sputum of these 4 patients would have remained negative without surgery cannot be stated, but we count these 4 patients as combined medical-surgical treatment successes. The sputum was positive in 21 patients at the time of surgery. In 14 cases, it converted immediately following surgery and has remained negative. We consider these 14 successes primarily attributable to surgery. There were 3 more patients who had cavitary disease with positive sputum at the time of surgery which did not convert immediately following surgery. The sputum of 1 patient converted within 3 months with new chemotherapy and in the other 2 converted after longer periods of chemotherapy. These successes are also attributed to combined surgical-medical therapy. Our failures are limited to 3 patients who died as a result of their surgery. We believe that 22 of the 25 patients, or 88 per cent, who are now alive and with negative sputum, are treatment successes with the main credit being given to the addition of surgical therapy (Table I I I ) . TABLE Ι Π .
SPUTUM
STATUS FOLLOWING
Negative before and after surgery Positive prior to surgery and negative thereafter Positive prior to surgery and after surgery but still converted subsequently Positive prior to surgery and died as a result of surgery Total
!
SURGERY NO.
|
PER CENT
4 14
16 66
4
16
3 25
12 100
DISCUSSION
In judging surgical therapy, one has to weigh the risk of surgery against the risk the patient must take without this treatment. In the group of patients at Battey State Hospital with atypical tuberculosis, only 20 per cent have been treated successfully by chemotherapy alone. In this small group of 25 patients treated by surgery and chemotherapy, 88 per cent have been treated success fully. I t is our belief that patients who are surgical candidates should be sub jected to resection as soon as possible. We have not attempted to reach a target point of negativity in this group. The surgical mortality rate was 12 per cent. Up to the present time, there have been 31 deaths in the 155 patients treated medically, for a mortality rate of 20 per cent. In this medically treated group, 8 patients have died of atypical pulmonary tuberculosis, 7 have died of cardiac disease, and 13 have died of pulmonary tuberculosis and cardiac failure. In a previous publication, 2 we suggested that resections of less than a lobe were unsatisfactory. With a somewhat larger experience, we found a complica tion rate of 20 per cent in resections of less than a lobe, and there were no deaths in this group. Although bronchopleural fistulas are serious complica tions, they are amenable to post-resection thoraeoplasties. We believe that smaller resections may be used wherever indicated.
Vol. 40. No. l July, I960
ATYPICAL MYCOBACTERIUM TUBERCULOSIS
Q7 Ul
The deaths in our group of patients followed lobectomy plus segmental resection and/or wedge resections. Two of these three deaths might have been averted. The patient who had had a right upper and right middle lobectomy plus a wedge resection of the superior segment of the right lower lobe could have been treated better by a pre-resection thoracoplasty and then completion of the thoracoplasty and tailoring of her chest to fit the remaining lung tissue at the time of the resection. The patient who died from pulmonary insufficiency following a right upper lobectomy might not have been subjected to surgery if a more detailed preoperative pulmonary function evaluation had been made. SUMMARY
1. Twenty-two of 25 cases of atypical tuberculosis are alive and well fol lowing combined surgical-medical therapy. 2. The morbidity rate was 20 per cent. Three patients had bronchopleural fistulas, 2 of whom were successfully treated by post-resection thoracoplasty. 3. There were 3 postoperative deaths. 4. Early resection is advocated in suitable candidates. 5. Resections of less than a lobe are also advocated when indicated. REFERENCES
1. Runyon, E . H. : Anonymous Myeobacteria in Pulmonary Disease, M. Clin. North America 43: 273-290, 1959. 2. Crow, H. E King, C. T., Smith, C. E., Corpe, R. F., and Stergus, I . : A Limited Clinical, Pathologic, and Epidemiologie Study of Patients With Pulmonary Lesions Asso ciated With Atypical Acid-Fast Bacilli in the Sputum, Am. Rev. Tuberc. 7 5 : 199222, 1957.
DUE
TO ATYPICAL MYCOBACTERIUM TUBERCULOSIS Raymond F. Corpe, M.D.*
E
and Joseph Liang, M.D.,** Rome, Ga.
with over 180 cases of atypical pxilmonary tuberculosis, treated with conventional antituberculosis drug therapy at Battey State Hospital, has shown the conversion rate to be about 22 per cent. In typical tuberculosis, the conversion rate is about 90 per cent after 6 months of drug therapy. In atypical tuberculosis, the great shortcomings of this medical approach have led us to continue excisional surgery in selected cases. Our experience would indi cate that resection can be done with a low morbidity and a reasonably low mor tality with resultant high sputum conversion in well-chosen cases and affords reasonably good results in the long-term tenure. XPERIENCE
MATERIALS AND METHODS
From Jan. 1, 1950, to the end of April, 1959, 25 patients with atypical tuberculosis were subjected to pulmonary resection. Of the 23 white patients, 18 were male and 5 were female. The 2 Negro patients were male. Twelve pa tients subjected to resection were in their forties; 6 were in their thirties; 5 were in their fifties; and the youngest patient was 28 and the oldest 67 years of age. According to the classification of the National Tuberculosis Association, the disease was minimal in 1 case, moderately advanced in 13, and far advanced in the remaining 10 cases. On admission bactériologie studies, 16 of the patients were positive by both direct smear and culture and 9 were negative on direct smear but positive on culture. Using Runyon's classification,1 22 of the positive cultures were nonphotochromogenics (Group III-Battey type). In 2 patients, there were photochromogenic strains (Group I ) , and in 1 there was a scotochromogenic strain (Group I I ) . As soon as a working diagnosis of pulmonary tuberculosis was established, 24 of the 25 patients were placed on antituberculous drug therapy. Twelve of these patients received isonicotinic acid hydrazide (INH) and pava-aminosalicylie acid (PAS), 9 received INH, streptomycin, and PAS, 3 received strepto mycin and PAS, and 1 patient received INH, streptomycin, PAS, and Dalicin From the Battey State Hospital, Rome, Ga. Received for publication Oct. 19, 1959. •Superintendent. »•Chief of Surgery. 93
CORPE AND LIANG
94
J. Thoracic and Cardiovas. Surg.
in the preoperative period. Additional chemotherapy was used in the post operative period. Ten of the 12 patients having had INH and PAS received streptomycin in the postoperative period. Another patient who received INH and PAS had pyrazinamide (PZA) added in the postsurgical period. There was 1 patient who received no drug therapy before or after surgery. Two patients had no sensitivity studies done prior to surgery. Of the 23 patients who did have, 23 were completely resistant to isoniazid, and 13 of these 23 were totally resistant to streptomycin-5 were partially sensitive, and 5 were completely sensitive to streptomycin on the last studies done prior to surgery. Four of the 25 patients had negative sputum studies at the time of surgery; 1 patient had been negative for 3 months, 2 for 5 months, and 1 for 10 months. Of the remaining 21 patients, 2 were intermittently positive and 19 had never had negative cultures. Twenty-three of these patients had preoperative bronchoscopies. One had a partial stenosis of the right upper lobe bronchus. One patient had severe endobronchitis which required postponement of surgery for 2 months until the inflammatory process had subsided under treatment. Resection was then suc cessfully performed. Five of these patients had bronchograms. One revealed extensive bronohiectasis of the left lung and this patient eventually had a left pneumonectomv. Twenty οΓ the 25 patients were operated upon for open cavities plus posi tive sputum. One patient had an open cavity and a negative sputum, 1 pa tient had residual fibrocaseous disease and a positive sputum, 3 patients had residual fibrocaseous disease with a negative sputum. There were 26 resections performed on these 25 patients (Table I ) . One patient had a right upper lobectomy first followed 20 days later by a segmentectomy by the removal of the upper division of the left upper lobe. TABLE I.
SURGICAL PROCEDURES
PROCEDURES
NO.
WITHOUT COMPLICATION
WITH COMPLICATION
DEATH
Subsegmentectoiny Segmentectoniy Lobectomy, alone Lobectomy, plus Pneumonectomy Total
4 7 10 3 2 26
3 6 9 1 2 21
1 1 1* 2* 0 5
0 0 1 2 0 3
• I n these cases, the complications were followed by death. MORBIDITY AND MORTALITY
The patient who had bilateral resections had an uncomplicated course fol lowing each resection. Five patients (20 per cent) had postoperative complica tions (Table I I ) . One of the 4 subsegmental resections was followed by a bronchopleural fistula which required post-resection thoracoplasty. One of the 7 segmental resections was also complicated by a bronchopleural fistula and residual space problem that required a post-resection thoracoplasty. There were no deaths in the 11 patients who had small resections.
Vol. 40, No. 1 July, 1960
TABLE I I .
ATYPICAL MYCOBACTERIUM TUBERCULOSIS
95
MORBIDITY AND MORTALITY D U E TO SURGICAL COMPLICATION
PROCEDURES
COMPLICATION
MORTALITY
POSTOP. S P U T U M STATUS
1. Subsegmenteetomy, apical posterior seg ment, LUL, with postresection thoracoplasty
Bronchopleural fis tula and residual space
Sputum converted 28 months after surgery
2. Segmentectomy, apical posterior segment, RUL, with post-resec tion thoracoplasty
Bronchopleural fis tula and residual space
Sputum converted following surgery
3 RUL lobectomy plus segmentectomy, su perior segment, R L L
Pneumonia
Died of pneumonia on seventh postop. day
4 KUL and RML lobeeBronchopleural fis tomies plus wedge of tula and residual superior segment, RLL, space with post-resection thoracoplasty
Died of pulmonary insufficiency on fourth postop. day
S RUL lobectomy
Died of hypoxia, 48 hours 5 Cases
Total
Pulmonary insuf ficiency
Of the 10 patients who had lobectomy only, 9 had no complications. One patient died of pulmonary insufficiency 48 hours after a right upper lobectomy. There were 3 patients who had lobectomies plus removal of other lung tissue, and 2 of these procedures were accompanied by complications which led to death. One was a 67-year-old white woman who had a right upper and a right middle lobectomy plus removal of a wedge from the lower lobe. There was not enough tissue to adequately fill the pleural space and a post-resection thoraco plasty was performed 3 weeks after the resection. Following this, the patient died of pulmonary insufficiency on the fifth postoperative day. Another pa tient, having had a right upper lobectomy plus a superior segmental resection of the superior division of the right lower lobe, died on the seventh postopera tive day of pneumonia and atelectasis on the operative side, which was revealed at autopsy. There were 2 patients who had pneumonectomies and both had uncomplicated courses postoperatively. The surgical mortality rate, therefore, was 12 per cent. Pathologic and bactériologie studies of the surgical specimens revealed 2 surgical specimens negative on direct smear and culture. Twenty-four of the 26 surgical specimens had positive direct smears and, of these, 18 wore positive on culture. According to C. Edwin Smith, Battey Laboratory Director, these cultures were the same in each case as had been isolated preoperatively from each individual. Dr. I. Stergus, Pathologist at Battey State Hospital, says that "Pathologically, these lesions are indistinguishable from those of typical tuber culosis, grossly and microscopically." RESULTS
Four of the 25 patients had negative sputum at the time of surgery which remained consistently negative following surgery. Of these 4 patients who had
96
COEPE AND LIANG
J. Thoracic and Cardiovas. Surg.
negative sputum, 1 had an open cavity and the other 3 had residual fibrocaseous disease. Whether or not the sputum of these 4 patients would have remained negative without surgery cannot be stated, but we count these 4 patients as combined medical-surgical treatment successes. The sputum was positive in 21 patients at the time of surgery. In 14 cases, it converted immediately following surgery and has remained negative. We consider these 14 successes primarily attributable to surgery. There were 3 more patients who had cavitary disease with positive sputum at the time of surgery which did not convert immediately following surgery. The sputum of 1 patient converted within 3 months with new chemotherapy and in the other 2 converted after longer periods of chemotherapy. These successes are also attributed to combined surgical-medical therapy. Our failures are limited to 3 patients who died as a result of their surgery. We believe that 22 of the 25 patients, or 88 per cent, who are now alive and with negative sputum, are treatment successes with the main credit being given to the addition of surgical therapy (Table I I I ) . TABLE Ι Π .
SPUTUM
STATUS FOLLOWING
Negative before and after surgery Positive prior to surgery and negative thereafter Positive prior to surgery and after surgery but still converted subsequently Positive prior to surgery and died as a result of surgery Total
!
SURGERY NO.
|
PER CENT
4 14
16 66
4
16
3 25
12 100
DISCUSSION
In judging surgical therapy, one has to weigh the risk of surgery against the risk the patient must take without this treatment. In the group of patients at Battey State Hospital with atypical tuberculosis, only 20 per cent have been treated successfully by chemotherapy alone. In this small group of 25 patients treated by surgery and chemotherapy, 88 per cent have been treated success fully. I t is our belief that patients who are surgical candidates should be sub jected to resection as soon as possible. We have not attempted to reach a target point of negativity in this group. The surgical mortality rate was 12 per cent. Up to the present time, there have been 31 deaths in the 155 patients treated medically, for a mortality rate of 20 per cent. In this medically treated group, 8 patients have died of atypical pulmonary tuberculosis, 7 have died of cardiac disease, and 13 have died of pulmonary tuberculosis and cardiac failure. In a previous publication, 2 we suggested that resections of less than a lobe were unsatisfactory. With a somewhat larger experience, we found a complica tion rate of 20 per cent in resections of less than a lobe, and there were no deaths in this group. Although bronchopleural fistulas are serious complica tions, they are amenable to post-resection thoraeoplasties. We believe that smaller resections may be used wherever indicated.
Vol. 40. No. l July, I960
ATYPICAL MYCOBACTERIUM TUBERCULOSIS
Q7 Ul
The deaths in our group of patients followed lobectomy plus segmental resection and/or wedge resections. Two of these three deaths might have been averted. The patient who had had a right upper and right middle lobectomy plus a wedge resection of the superior segment of the right lower lobe could have been treated better by a pre-resection thoracoplasty and then completion of the thoracoplasty and tailoring of her chest to fit the remaining lung tissue at the time of the resection. The patient who died from pulmonary insufficiency following a right upper lobectomy might not have been subjected to surgery if a more detailed preoperative pulmonary function evaluation had been made. SUMMARY
1. Twenty-two of 25 cases of atypical tuberculosis are alive and well fol lowing combined surgical-medical therapy. 2. The morbidity rate was 20 per cent. Three patients had bronchopleural fistulas, 2 of whom were successfully treated by post-resection thoracoplasty. 3. There were 3 postoperative deaths. 4. Early resection is advocated in suitable candidates. 5. Resections of less than a lobe are also advocated when indicated. REFERENCES
1. Runyon, E . H. : Anonymous Myeobacteria in Pulmonary Disease, M. Clin. North America 43: 273-290, 1959. 2. Crow, H. E King, C. T., Smith, C. E., Corpe, R. F., and Stergus, I . : A Limited Clinical, Pathologic, and Epidemiologie Study of Patients With Pulmonary Lesions Asso ciated With Atypical Acid-Fast Bacilli in the Sputum, Am. Rev. Tuberc. 7 5 : 199222, 1957.