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Surgical Treatment of Pulmonary Disease Due to Mycobacterium kansasii
Surgical Treatment of Pulmonary Disease Due to Mycobacterium kansasii James R. Zvetina, M.D., William E. Neville, M.D., Hayward C. Maben, M.D., Hiram T. Langston, M.D., and Noble 0. Correll, Jr., M.D. ABSTRACT Over a period of thirteen years, 35 patients at the Veterans Administration Hospital, Hines, Ill., have undergone thirty-eight surgical procedures, including thirty-four pulmonary resections and four collapse procedures, for pulmonary disease due to Mycobacterium hnsasii. Major complications following operation occurred in 2 patients; 1 died from staphylococcal empyema. All patients with positive sputum cultures achieved prompt bacteriological conversion following operation. Long-term follow-up ranging from one to more than eleven years following operation was available in 31 of the 35 patients. All patients achieved a quiescent or inactive status. There were 2 late deaths due to unrelated causes.
I
n our experience, treatment of pulmonary disease caused by Mycobacterium kansasii with standard antituberculosis drugs alone has been inadequate in most patients. This would appear to be due to the primary drug resistance of many patients to one or more of the antimicrobial agents used. T h e result is that the therapeutic response is unpredictable as determined by bacteriological conversion and the effect on the cavitary component. Furthermore, even patients with M. kansasii infection who have shown apparently satisfactory results from chemotherapy experience relapses more frequently than do patients with pulmonary disease caused by M. tuberculosis. This report evaluates the experience with surgical treatment of pulmonary disease caused by M. kansasii observed at the Veterans Administration Hospital, Hines, Ill. CLINICAL MATERIAL
During the past thirteen years, 176 patients were admitted to the Pulmonary Disease Service with chronic pulmonary disease in which M . kansasii (Ru'hyon's Group I) was the only organism isolated. Of these 176 patients, 35 underwent operation. All patients were men, and they ranged in age from 26 to 65 years. The mean age was 41 years (Table 1). There were 25 whites From the Surgical and GM&S Research Services, Veterans Administration Hospital, Hines, Ill. Presented at the Seventh Annual Meeting of T h e Society of Thoracic Surgeons, Dallas, Tex., Jan. 18-20, 1971. Address reprint requests to Dr. Zvetina, Veterans Administration Hospital, Bldg. 200, Room 1552, Hines, Ill. 60141.
ZVETINA E T AL. TABLE 1. AGE DISTRIBUTION IN 35 PATIENTS UNDERGOING OPERATIVE TREATMENT FOR PULMONARY DISEASE DUE T O M. KANSASII
Ages 20-29 30-39 40-49 50-59 60-69 Total
No. of Patients 2 1f i
12 3 2 35
and 10 blacks. O n admission, the extent of the disease was classified as moderately advanced in 18 patients and far-advanced in 17. Lung involvement was bilateral in 13. Unilateral cavitary disease was present in 31 and bilateral disease in 4. T h e principal indication for surgical treatment was the persistence of cavitation. Twenty-three of the 35 patients continued to excrete M. kansasii in their sputum prior to operation. Chemotherapy prior to operation consisted of isoniazid, usually in combination with streptomycin or para-aminosalicylic acid or both. T h e duration of the preoperative chemotherapy in 33 of the 35 patients ranged from 3 to 26 months, with an average of 10.5 months. Of the 2 remaining patients, 1 was suspected of having a pulmonary neoplasm in addition to M. kansasii infection, and an operation was performed after 1% months of chemotherapy. I n the other patient the preoperative diagnosis was a pulmonary cyst, and resection was carried out without chemotherapy. Eighteen patients received secondary drugs for extra protection at the time of the operation. These included one or two of the following: ethionamide, viomycin, pyrazinamide, cycloserine, and streptomycin.
RESULTS Thirty-two resectional procedures were performed in 31 patients. Collapse procedures were carried out in 4 patients, 2 of whom had undergone resection for disease involving the opposite lung. T h e type and extent of the procedures are shown in Table 2. One patient who underwent a successful surgical collapse procedure subsequently had a pulmonary resection, following which he developed a staphylococcal empyema. H e died on the forty-first postoperative day. T h e other major complication occurred in a diabetic who experienced postoperative bleeding following a lobectomy. This required reoperation for control of bleeding TABLE 2. OPERATIVE PROCEDURES I N 35 PATIENTS WITH PULMONARY DISEASE DUE T O M. KANSASII
Type Collapse Segmentectomy Lobectomy Lobectomy plus Pneumonectomy Total
552
THE ANNALS OF THORACIC SURGERY
No. of Procedures 4 r,
22
4 2 38
Surge1.y of Pulmonary Disease Due to M . hnnsasii TABLE 3. POSTOPERATIVE COMPLICATIONS I N 35 PATIENTS W I T H PULMONARY DISEASE DUE T O M. KANSAS11
No. of Patien tu 1
TvDe Empyema Delayed expansion of residual space Traumatic pneumothorax Atelectasis Postoperative bleeding
7 1
3 1 13
Total
from the anterior pulmonary ligament and chest wall. Following this, his course was complicated by hypoglycemia and uncontrollable diabetes. Eleven patients had minor complications, as shown in Table 3. Of the 34 patients who survived, the 13 who had had negative secretions prior to operation achieved an inactive status. T h e 21 patients with preoperative positive sputum cultures converted promptly after operation. T h u s in the entire group of 35 patients treated surgically, immediate satisfactory results were achieved in 34. T h e average period of chemotherapy subsequent t o operation was 37.4 months, with a range of 3.5 to 118 months. With the exception of 1 patient who was lost to observation 6.5 months following his operation, the remaining 34 patients had a follow-up ranging from 8 months to more than eleven years, with an average of 65.3 months (Table 4). There was reactivation of disease in 6 patients who had achieved an inactive status following operation. T w o had relapse according to both bacteriological and roentgenographic studies at 12 and 15 months postoperatively. Bacteriological relapse alone occurred in 2 patients at 31 and 44 months following their operation, and the remaining 2 patients showed roentgenographic changes at 15 months and eight years following their operations. Reactivation of disease was seen on roentgenograms in 4 patients, and in 3 of these it was on the side of the original operation. I n 5 patients the disease was controlled by chemotherapy alone, and in 1 by chemotherapy and an additional resection. One patient died 8.5 months following resection from causes unrelated to his atypical mycobacterial disease. One late death occurred from coronary occlusion in a patient whose disease was considered inactive. T h e status of clinical activity at the time of the last observation according to National Tuberculosis Association standards is shown in Table 5. T'ABLE 4. DURATION OF FOLLOW-UP I N 35 PATIENTS UNDERGOING SURGICAL TREATMENT FOR PIJLMONARY DISEASE DUE T O M. KANSAS11
No. of Patients 4 5
Years Less than 1 1 to 3 3 to 5 5 to 8 8 to 10 10 or more Total
6 11 6
3 35 VOL.
11, NO.
6,
JUNE,
1971
553
ZVETINA E T AL. TABLE 5 . STATUS OF CLINICAL ACTIVITY" A T LAST OBSERVATION I N 35 PATIENTS TREATED OPERATIVELY FOR PULMONARY DISEASE DUE T O M. KANSAS11
Clinical Activity Inactive Noncavi tary Cavi tary Quiescent Noncavitary Cavitary Total
No. of Patients
28
2
2 3 35
'Based on Diagnostic Standards ant1 Classification of Tuberculosis, National Tuberculosis Association, 1969. Quiescent status: at least 3 months of sputum negativity. Inactive status: at least 6 months of sputum negativity if the disease is noncavitary, 18 months if it is cavitary.
COMMENT
Adverse effects of operation in the treatment of pulmonary disease due to M . kansasii were reported by Lester and associates [lo] in 1958 and by Harrison and his colleagues [6] in 1959. Because of the high rate of major complications, these authors emphasized the importance of achieving negative bacteriological status prior to resection and strongly recommended lobectomy as the minimum extent of resection to be used. Goldman [5] in 1968 performed 6 resections, 3 thoracoplasties, and 1 plombage in 10 patients with M . kansasii disease, and 8 had negative sputum cultures postoperatively. Pulmonary bleeding and bronchopleural fistula caused the death of 1 patient following segmental resection. Hattler and associates [7] in 1970 reported that 2 of 3 patients with M . kansasii disease who underwent segmental resection developed a bronchopleural fistula. On the other hand, Law and his co-workers [8, 91 in 1961 and 1963 indicated that the results expected today from the treatment of pulmonary disease due to M . kansasii compare favorably with the results of treatment for M . tuberculosis [l, 31. They demonstrated that positive sputum cultures and drug-resistant organisms have not influenced the morbidity or ultimate control of the disease and therefore concluded that the attainment of negative bacteriological status before operation is not a prerequisite for successful surgical treatment. Fox and associates [4] in 1970 reported 163 operations in patients with atypical mycobacterial pulmonary disease with no postoperative deaths and a 7.1% rate of major complications. Their final, long-range success rate was 92%. Chapman [2] recommends operation in patients with M . kansasii infection whenever the pulmonary lesion is localized and the patient has good pulmonary function and generally good health. He indicated 554
T H E ANNALS OF THORACIC SURGERY
Surgery of Pulmonary Disease Due to M . kansasii
that results reported for combined chemotherapeutic and surgical treatment have been fairly good. He also reported that sputum conversion has been achieved in about 75% of patients with drugs alone, while cavity closure without operation has been done in about 25%. Patient observation in our series has demonstrated that for pulmonary disease associated with M . kansasii, surgical treatment employing principally pulmonary resection is effective and reasonably safe despite positive bacteriological status at the time of operation. REFERENCES 1. Brouhard, J. W., Langston, W. T., and Milloy, F. J. Surgery in the treatment of pulmonary tuberculosis. Arch. Surg. (Chicago) 81:269, 1960. 2. Chapman, V. J. The atypical mycobacteria. Hosp. Pract. 5:69, 1970. 3. Foster, J. H., Killen, D. A., Diveley, W. L., McCracken, R. L., and Hubbard, W. W. Pulmonary resection in the treatment of tuberculosis. Dis. Chest 40: 5, 1961. 4. Fox, R. T., Veerraju, K., Lees, W. M., and Shields, T. W. Surgical considerations in “atypical” mycobacterial pulmonary disease. ]. Thorac. Cardiovasc. Surg. 59:1, 1970. 5. Goldman, K. P. Treatment of unclassified mycobacterial infection of the lungs. Thorax 23:94, 1968. 6. Harrison, R. W., Reimann, A. F., Long, E. T., Lester, W., Jr., and Adams, W. E. Adverse surgical experience in the treatment of pulmonary disease caused by atypical acid-fast bacilli. ,J. Thorac. Cardiovasc. Surg. 38:481, 1959. 7. Hattler, B. G., Young, W. G., Sealy, W. E., Gentry, W. H., and Cox, C. B. Surgical management of pulmonary tuberculosis due to atypical mycobacteria. J. Thorac. Cardiovasc. Surg. 59: 366, 1970. 8. Law, S. W. Surgical treatment of atypical mycobacterial disease: A survey of experience in Veterans Administration hospitals. Dis. Chest 40:5, 1961. 9. Law, S. W., Jenkins, D. D., Chofnas, L., Bahar, D., Whitcomb, F., Barkley, H. T., and De Bakey, M. E. Surgical experience in the management of atypical mycobacterial infections. J. Thorac. Cardiovasc. Surg. 46:689, 1963. 10. Lester, W., Jr., Botkin, J., and Colton, R. An Analysis of Forty-nine Cases of Pulmonary Disease Caused by Photochromogenic Mycobacteria. In Transactions of the Seventeenth Conference on Tubercu’osis, Memphis, Feb. 3-6, 1958. Washington, D.C.: Government Printing Office, 1958. P. 289. DISCUSSION DR. SAMUEL W. LAW (Houston, Tex.): I would like to congratulate Dr. Neville and his coauthors on the fine results they have reported and to thank them for bringing this perhaps mundane but very important problem back to our attention. Their results again reaffirm the positive contribution that resection surgery can offer in the control of pulmonary disease caused by atypical mycobacteria. I n 1963 I reported a series of 68 surgical procedures done in 64 patients with atypical disease, most of whom had Group I infections. Fifty-four of these patients showed evidence of infection at the time of operation, either in the form of continued positive sputums or in resected lung tissue. There were no operative deaths, and so-called major complications occurred in only 7 patients. Of the 64 patients, there were only 2 in whom the combined medical and surgical program failed to achieve control of their disease. VOL.
11, NO.
6, JUNE,1971
555
ZVETINA E T AL.
I stated at the time that I was unable to relate sputum positivity or in vitro drug resistance to the complications that were encountered or the results obtained, and I did not believe that there were any grounds for comparing the atypical mycobacteria with the drug-resistant Mycobacterium tuberculosis and certainly no reason to try to relate this disease to the status of surgery in the preantibiotic era. I n our hands segmentectomy, when it can be performed through a clean intersegmental plane, has given results that are equal to if not better than the results of lobectomy. Our principal difficulties have arisen following lobectomy or pneumonectomy, an indication of the far-advanced stage of disease in these patients. Since that time a number of other reports, many by members of this organization, have again reaffirmed the excellent results that can be obtained with resectional surgery. T h e principal point of difference among these reports seems to be the place and safety of the segmental resection. While I recognize the difficulties that have occurred, I continue to use segmentectomy whenever I think I can perform it through a clean plane and thus preserve functioning lung tissue. I would like to ask Dr. Nevi1:e if he has any figures on the patients in his series who were not operated upon concerning the conversion times that were required before their sputum became negative. DR. ROBERTT. Fox (Evanston, Ill.): I have reviewed our patients infected with atypical bacilli. We have performed 202 major surgical procedures in 182 patients with no deaths, fortunately. T h e point I want to emphasize-and I certainly couldn’t agree more with those Dr. Neville and Dr. Law brought out-is that the trouble we have is not with the patient o r the operation; it is with the internist who is managing the patient. Many of these physicians rely solely on chemotherapy. T h e patient’s sputum may or may not turn negative. If it does, the physician is lulled into a sense of security and his patients are told that they are noninfectious; therefore they think that they are not dangerous. Actually, they are as dangerous as can be to themselves, if not to anybody else. We have seen a few of them go on to progression of their disease and death. This is a very indolent disease, very poorly controlled with available chemotherapy. Certainly one cannot beat the excellent surgical statistics that have been reported. I want to emphasize again that a fairly high percentage of these patients shou!d be considered for resection.
DR. NEVILLE:I am unable to answer appropriately Dr. Law’s question concerning the figures on conversion time because I do not have the statistics immediately available. I am certain my medical colleague Dr. James Zvetina would be able to give him the data. As far as Dr. Fox is concerned, I cannot see why he has to be concerned about his internists. H e has performed almost 200 resections on 220 patients and we have done only 35 in 176. Obviously, his medical confreres are more surgically oriented than ours.
556
THE ANNALS O F THORACIC SURGERY
I
n our experience, treatment of pulmonary disease caused by Mycobacterium kansasii with standard antituberculosis drugs alone has been inadequate in most patients. This would appear to be due to the primary drug resistance of many patients to one or more of the antimicrobial agents used. T h e result is that the therapeutic response is unpredictable as determined by bacteriological conversion and the effect on the cavitary component. Furthermore, even patients with M. kansasii infection who have shown apparently satisfactory results from chemotherapy experience relapses more frequently than do patients with pulmonary disease caused by M. tuberculosis. This report evaluates the experience with surgical treatment of pulmonary disease caused by M. kansasii observed at the Veterans Administration Hospital, Hines, Ill. CLINICAL MATERIAL
During the past thirteen years, 176 patients were admitted to the Pulmonary Disease Service with chronic pulmonary disease in which M . kansasii (Ru'hyon's Group I) was the only organism isolated. Of these 176 patients, 35 underwent operation. All patients were men, and they ranged in age from 26 to 65 years. The mean age was 41 years (Table 1). There were 25 whites From the Surgical and GM&S Research Services, Veterans Administration Hospital, Hines, Ill. Presented at the Seventh Annual Meeting of T h e Society of Thoracic Surgeons, Dallas, Tex., Jan. 18-20, 1971. Address reprint requests to Dr. Zvetina, Veterans Administration Hospital, Bldg. 200, Room 1552, Hines, Ill. 60141.
ZVETINA E T AL. TABLE 1. AGE DISTRIBUTION IN 35 PATIENTS UNDERGOING OPERATIVE TREATMENT FOR PULMONARY DISEASE DUE T O M. KANSASII
Ages 20-29 30-39 40-49 50-59 60-69 Total
No. of Patients 2 1f i
12 3 2 35
and 10 blacks. O n admission, the extent of the disease was classified as moderately advanced in 18 patients and far-advanced in 17. Lung involvement was bilateral in 13. Unilateral cavitary disease was present in 31 and bilateral disease in 4. T h e principal indication for surgical treatment was the persistence of cavitation. Twenty-three of the 35 patients continued to excrete M. kansasii in their sputum prior to operation. Chemotherapy prior to operation consisted of isoniazid, usually in combination with streptomycin or para-aminosalicylic acid or both. T h e duration of the preoperative chemotherapy in 33 of the 35 patients ranged from 3 to 26 months, with an average of 10.5 months. Of the 2 remaining patients, 1 was suspected of having a pulmonary neoplasm in addition to M. kansasii infection, and an operation was performed after 1% months of chemotherapy. I n the other patient the preoperative diagnosis was a pulmonary cyst, and resection was carried out without chemotherapy. Eighteen patients received secondary drugs for extra protection at the time of the operation. These included one or two of the following: ethionamide, viomycin, pyrazinamide, cycloserine, and streptomycin.
RESULTS Thirty-two resectional procedures were performed in 31 patients. Collapse procedures were carried out in 4 patients, 2 of whom had undergone resection for disease involving the opposite lung. T h e type and extent of the procedures are shown in Table 2. One patient who underwent a successful surgical collapse procedure subsequently had a pulmonary resection, following which he developed a staphylococcal empyema. H e died on the forty-first postoperative day. T h e other major complication occurred in a diabetic who experienced postoperative bleeding following a lobectomy. This required reoperation for control of bleeding TABLE 2. OPERATIVE PROCEDURES I N 35 PATIENTS WITH PULMONARY DISEASE DUE T O M. KANSASII
Type Collapse Segmentectomy Lobectomy Lobectomy plus Pneumonectomy Total
552
THE ANNALS OF THORACIC SURGERY
No. of Procedures 4 r,
22
4 2 38
Surge1.y of Pulmonary Disease Due to M . hnnsasii TABLE 3. POSTOPERATIVE COMPLICATIONS I N 35 PATIENTS W I T H PULMONARY DISEASE DUE T O M. KANSAS11
No. of Patien tu 1
TvDe Empyema Delayed expansion of residual space Traumatic pneumothorax Atelectasis Postoperative bleeding
7 1
3 1 13
Total
from the anterior pulmonary ligament and chest wall. Following this, his course was complicated by hypoglycemia and uncontrollable diabetes. Eleven patients had minor complications, as shown in Table 3. Of the 34 patients who survived, the 13 who had had negative secretions prior to operation achieved an inactive status. T h e 21 patients with preoperative positive sputum cultures converted promptly after operation. T h u s in the entire group of 35 patients treated surgically, immediate satisfactory results were achieved in 34. T h e average period of chemotherapy subsequent t o operation was 37.4 months, with a range of 3.5 to 118 months. With the exception of 1 patient who was lost to observation 6.5 months following his operation, the remaining 34 patients had a follow-up ranging from 8 months to more than eleven years, with an average of 65.3 months (Table 4). There was reactivation of disease in 6 patients who had achieved an inactive status following operation. T w o had relapse according to both bacteriological and roentgenographic studies at 12 and 15 months postoperatively. Bacteriological relapse alone occurred in 2 patients at 31 and 44 months following their operation, and the remaining 2 patients showed roentgenographic changes at 15 months and eight years following their operations. Reactivation of disease was seen on roentgenograms in 4 patients, and in 3 of these it was on the side of the original operation. I n 5 patients the disease was controlled by chemotherapy alone, and in 1 by chemotherapy and an additional resection. One patient died 8.5 months following resection from causes unrelated to his atypical mycobacterial disease. One late death occurred from coronary occlusion in a patient whose disease was considered inactive. T h e status of clinical activity at the time of the last observation according to National Tuberculosis Association standards is shown in Table 5. T'ABLE 4. DURATION OF FOLLOW-UP I N 35 PATIENTS UNDERGOING SURGICAL TREATMENT FOR PIJLMONARY DISEASE DUE T O M. KANSAS11
No. of Patients 4 5
Years Less than 1 1 to 3 3 to 5 5 to 8 8 to 10 10 or more Total
6 11 6
3 35 VOL.
11, NO.
6,
JUNE,
1971
553
ZVETINA E T AL. TABLE 5 . STATUS OF CLINICAL ACTIVITY" A T LAST OBSERVATION I N 35 PATIENTS TREATED OPERATIVELY FOR PULMONARY DISEASE DUE T O M. KANSAS11
Clinical Activity Inactive Noncavi tary Cavi tary Quiescent Noncavitary Cavitary Total
No. of Patients
28
2
2 3 35
'Based on Diagnostic Standards ant1 Classification of Tuberculosis, National Tuberculosis Association, 1969. Quiescent status: at least 3 months of sputum negativity. Inactive status: at least 6 months of sputum negativity if the disease is noncavitary, 18 months if it is cavitary.
COMMENT
Adverse effects of operation in the treatment of pulmonary disease due to M . kansasii were reported by Lester and associates [lo] in 1958 and by Harrison and his colleagues [6] in 1959. Because of the high rate of major complications, these authors emphasized the importance of achieving negative bacteriological status prior to resection and strongly recommended lobectomy as the minimum extent of resection to be used. Goldman [5] in 1968 performed 6 resections, 3 thoracoplasties, and 1 plombage in 10 patients with M . kansasii disease, and 8 had negative sputum cultures postoperatively. Pulmonary bleeding and bronchopleural fistula caused the death of 1 patient following segmental resection. Hattler and associates [7] in 1970 reported that 2 of 3 patients with M . kansasii disease who underwent segmental resection developed a bronchopleural fistula. On the other hand, Law and his co-workers [8, 91 in 1961 and 1963 indicated that the results expected today from the treatment of pulmonary disease due to M . kansasii compare favorably with the results of treatment for M . tuberculosis [l, 31. They demonstrated that positive sputum cultures and drug-resistant organisms have not influenced the morbidity or ultimate control of the disease and therefore concluded that the attainment of negative bacteriological status before operation is not a prerequisite for successful surgical treatment. Fox and associates [4] in 1970 reported 163 operations in patients with atypical mycobacterial pulmonary disease with no postoperative deaths and a 7.1% rate of major complications. Their final, long-range success rate was 92%. Chapman [2] recommends operation in patients with M . kansasii infection whenever the pulmonary lesion is localized and the patient has good pulmonary function and generally good health. He indicated 554
T H E ANNALS OF THORACIC SURGERY
Surgery of Pulmonary Disease Due to M . kansasii
that results reported for combined chemotherapeutic and surgical treatment have been fairly good. He also reported that sputum conversion has been achieved in about 75% of patients with drugs alone, while cavity closure without operation has been done in about 25%. Patient observation in our series has demonstrated that for pulmonary disease associated with M . kansasii, surgical treatment employing principally pulmonary resection is effective and reasonably safe despite positive bacteriological status at the time of operation. REFERENCES 1. Brouhard, J. W., Langston, W. T., and Milloy, F. J. Surgery in the treatment of pulmonary tuberculosis. Arch. Surg. (Chicago) 81:269, 1960. 2. Chapman, V. J. The atypical mycobacteria. Hosp. Pract. 5:69, 1970. 3. Foster, J. H., Killen, D. A., Diveley, W. L., McCracken, R. L., and Hubbard, W. W. Pulmonary resection in the treatment of tuberculosis. Dis. Chest 40: 5, 1961. 4. Fox, R. T., Veerraju, K., Lees, W. M., and Shields, T. W. Surgical considerations in “atypical” mycobacterial pulmonary disease. ]. Thorac. Cardiovasc. Surg. 59:1, 1970. 5. Goldman, K. P. Treatment of unclassified mycobacterial infection of the lungs. Thorax 23:94, 1968. 6. Harrison, R. W., Reimann, A. F., Long, E. T., Lester, W., Jr., and Adams, W. E. Adverse surgical experience in the treatment of pulmonary disease caused by atypical acid-fast bacilli. ,J. Thorac. Cardiovasc. Surg. 38:481, 1959. 7. Hattler, B. G., Young, W. G., Sealy, W. E., Gentry, W. H., and Cox, C. B. Surgical management of pulmonary tuberculosis due to atypical mycobacteria. J. Thorac. Cardiovasc. Surg. 59: 366, 1970. 8. Law, S. W. Surgical treatment of atypical mycobacterial disease: A survey of experience in Veterans Administration hospitals. Dis. Chest 40:5, 1961. 9. Law, S. W., Jenkins, D. D., Chofnas, L., Bahar, D., Whitcomb, F., Barkley, H. T., and De Bakey, M. E. Surgical experience in the management of atypical mycobacterial infections. J. Thorac. Cardiovasc. Surg. 46:689, 1963. 10. Lester, W., Jr., Botkin, J., and Colton, R. An Analysis of Forty-nine Cases of Pulmonary Disease Caused by Photochromogenic Mycobacteria. In Transactions of the Seventeenth Conference on Tubercu’osis, Memphis, Feb. 3-6, 1958. Washington, D.C.: Government Printing Office, 1958. P. 289. DISCUSSION DR. SAMUEL W. LAW (Houston, Tex.): I would like to congratulate Dr. Neville and his coauthors on the fine results they have reported and to thank them for bringing this perhaps mundane but very important problem back to our attention. Their results again reaffirm the positive contribution that resection surgery can offer in the control of pulmonary disease caused by atypical mycobacteria. I n 1963 I reported a series of 68 surgical procedures done in 64 patients with atypical disease, most of whom had Group I infections. Fifty-four of these patients showed evidence of infection at the time of operation, either in the form of continued positive sputums or in resected lung tissue. There were no operative deaths, and so-called major complications occurred in only 7 patients. Of the 64 patients, there were only 2 in whom the combined medical and surgical program failed to achieve control of their disease. VOL.
11, NO.
6, JUNE,1971
555
ZVETINA E T AL.
I stated at the time that I was unable to relate sputum positivity or in vitro drug resistance to the complications that were encountered or the results obtained, and I did not believe that there were any grounds for comparing the atypical mycobacteria with the drug-resistant Mycobacterium tuberculosis and certainly no reason to try to relate this disease to the status of surgery in the preantibiotic era. I n our hands segmentectomy, when it can be performed through a clean intersegmental plane, has given results that are equal to if not better than the results of lobectomy. Our principal difficulties have arisen following lobectomy or pneumonectomy, an indication of the far-advanced stage of disease in these patients. Since that time a number of other reports, many by members of this organization, have again reaffirmed the excellent results that can be obtained with resectional surgery. T h e principal point of difference among these reports seems to be the place and safety of the segmental resection. While I recognize the difficulties that have occurred, I continue to use segmentectomy whenever I think I can perform it through a clean plane and thus preserve functioning lung tissue. I would like to ask Dr. Nevi1:e if he has any figures on the patients in his series who were not operated upon concerning the conversion times that were required before their sputum became negative. DR. ROBERTT. Fox (Evanston, Ill.): I have reviewed our patients infected with atypical bacilli. We have performed 202 major surgical procedures in 182 patients with no deaths, fortunately. T h e point I want to emphasize-and I certainly couldn’t agree more with those Dr. Neville and Dr. Law brought out-is that the trouble we have is not with the patient o r the operation; it is with the internist who is managing the patient. Many of these physicians rely solely on chemotherapy. T h e patient’s sputum may or may not turn negative. If it does, the physician is lulled into a sense of security and his patients are told that they are noninfectious; therefore they think that they are not dangerous. Actually, they are as dangerous as can be to themselves, if not to anybody else. We have seen a few of them go on to progression of their disease and death. This is a very indolent disease, very poorly controlled with available chemotherapy. Certainly one cannot beat the excellent surgical statistics that have been reported. I want to emphasize again that a fairly high percentage of these patients shou!d be considered for resection.
DR. NEVILLE:I am unable to answer appropriately Dr. Law’s question concerning the figures on conversion time because I do not have the statistics immediately available. I am certain my medical colleague Dr. James Zvetina would be able to give him the data. As far as Dr. Fox is concerned, I cannot see why he has to be concerned about his internists. H e has performed almost 200 resections on 220 patients and we have done only 35 in 176. Obviously, his medical confreres are more surgically oriented than ours.
556
THE ANNALS O F THORACIC SURGERY