- Email: [email protected]
The inseparability of endoscopy and thoracic surgery
April, 1934]
SURGERY
OF
This was quite wrong, plombage causing a local collapse only, a n d therefore the typical cases for this operation are those with local affections at the apex, of a fibre-cavernous type, where the general health is still good, but where a severe interference such as thoracoplasty is not wanted. The cavities suitable for extrapleural plombage should not be larger than a small apple. The re. minder is given that t h e object of the operation is not to collapse the cavity mechanically by actual compression, but rather to cause its collapse by encouraging its own natural tendency to retract ; and therefore that the extrapleural space obtained by the operation should not be filled quite full of paraffin--not fuller than is absolutely necessary to separate the lung from the ribs. Moreover, the packing should be done very loosely, the space being loosely filled with small " sausages " of the wax, packed against the ribs and not against the lung. With the technique described, no trouble was experienced in any of the 50 cases of which the writers have had personal experience: no suppuration, perforation of the lung or elimination of the plug, and very seldom any reaction, such as a rise of temperature, after the operation. An important point in the technique is that the apex must b e completely freed, " s o that the lung with the cavity falls do~wn, making a itoor for the plug." The operation is best performed by a posterior incision, although where the cavity is a large One it may be necessary to begin the operation anteriorly, and at a latter date to complete it posteriorly. Two illustrative cases are recorded, with radiograms of one of these.
THE
LUNG
317
the static and dynamic changes in the thorax led the author to form the same conclusions as those .of Omodci Zorini as to the value of the operation of apicolysis. HUDSON, "W. A. The I n s e p a r a b i l i t y of Endoscopy and Thoracic Surgery. Joztrn. of Thoracic Surgery, 1933, 2, 292. Endoscopy has proved of great value both in diagnosis and in tile treatment of various pulmonary conditions. As the writer's experience has increased, he has found that fewer cases are requiring open drainage or other radical forms of surgery, probably for three reasons: (1) Endoscopic drainage is being instituted at the earliest possible moment, once a suppurative lesion or its precursor is discovered; (2) endoscopic drainages are performed more frequently and extended over a longer period of time, so that not o n l y is a drainage canal provided, but also the canal is left open u n t i l the last vestige of inflammation has disappeared; and (3) many cases of a character that used not to be considered suitable for endoscopic treatments and were therefore hurried through some form of open surgical drainage, are now being submitted to endoscopic treatment with sHceess.
in the case of post-operative massive atelectasis, endoscopy is an invaluable adjunct to deep breathing, postural change and administration of carbon dioxide and oxygen mixtures, as a means of relieving respiration distress. In many such patients the endoscopic removal of a fibrinous plug or an accumulation of secretion gives almost immediate relief, hfany cases of Iobular 5IONALDI, V. Sull' apicolisisempliee atelectasis following influenza or whoopnel trattamento della tubercolosi pol- ing cougb infections failed to clear up monare. Risultaticlinicie meceanismo until endoscopy was resorted to. I n d'azione. Lotta colttro la T~lbcrcolosi, such cases an inflammatory obstruction 1933, ,t, 253. was found in a secondary bronchus, its The writer records 15 cases of pul- involvement being apparent from the monary tube~:zulosis in patients aged facts of its red orifice and its pouched from 20 to 52 in whom simple apicolysis mucosa. Diagnosis of malignancy of the w a s performed with the following re- bronchial tree is greatly facilitated by the sults. In four there was no marked free use of X-ray studies, but in most change, in another four there was some cases in which the diagnosis is based improvement, and in seven a clinical re- upon roentgenological findings the lesion covery was obtained. Examination of is too far advanced for the thoracic surthe respiratory function and especially of geon to be able to do much. The only way
318
TUBERCLE
for a positive and very early diagnosis to be made is by resorting to endoscopy at the appearance of the earlies~ symptoms, and even an apparently negative X-ray study should not~ interfere with the carrying out of an endoscopic examination in a patient whose symptoms suggest some pulmonary lesion. EIZAGUIRRE, E. E1 plombaje en la tuberculosis pulmonar. 27ev. de H i t . y de T~lberculosis, 1933, 26, 1, 29. The writer, who records 14 cases in patients aged from 21 to 51, comes to the following conclusions : (1) Plombage is a method of collapsotherapy which is indicated in fibre:ulcerative processes of the apex of the lung which are inactive, and are not likely to extend beyond the lower part of the first rib. (2) It is el undoubted value as a complement to insufficient thoracoplasty. (3) On some occasions it may be employed in bilateral cases after artificial pneumothorax or thoracoplasty on the opposite side and in exceptional cases bilateral plombage may be carried out. (4) The m o s t suitable material for plombage at the present time is the paraffin preparation proposed by Baer and modified by Winternitz. (5) The amount should not exceed 400 c.c. and if possible should not be more than 200 to 300 e.c. (6) The most practical route is the paravertebral in which 2 to 3 cm. of the third or fourth rib are resected. (7) The proportion of excellent results which may be regarded as a clinical cure, amounted to 42 per cent. in the writer's cases. (8) Only o n e death resulted from the operation. XALABARDER, C. La gravedad operatoria de la toracoplastia, l~ev. de Hit. y de Tuberculosis, 1933, 26, 53. The writer has collected from literature 3,758 cases of thoracoplasty in which the operative mortality was 13 per cent. Although it is extremely difficult to compare the various statistics, owing, to the difference in the cases and the technique employed, he thinks that the factors affecting the mortality of the operation m a y be classified under the headings of (a) the patient, (b) the technique and (c) the environment. (a)
[April, 1934
The gravity of the operation varies according to the patient's age, sex, side affected, general condition and the anatomical form of the disease. (b) The technical skill of the operator acquired by the p r a c t i c e of general surgery is of great importance. While the mortality in Bull's cases was 8"4 per cent. in 16S cases, and Tandberg's 6'7 per cent. in 101 cases, the mortality el 129 cases operated on by 11 Scandinavian surgeons was 13 per cent. (c) I f the operation is carried out by a surgeon who is also a phthisiologist, the operative mortality should not be higher than t h a t of any other major operation. hlILOCH, F. L'apieolyse avec plombage paraffin6 dans le t r a i t e m e n t do la tuberculose du sommet. Th2se deParis, 1933, No. 353. The author, who records 19 illustrative cases, states that the indication for paraffin plombage are restricted to the following conditions: (1) Bilateral foci in which the operation enables the maximum amount of health respiratory parenchyma to be preserved. (2) Ex. tensive unilateral foci when the patient is not in a fit state to support the shock of thoraeoplasty. (3) Limited apical foci with smallcavities. The complications of apieolysis such as sepsis, hmmorrhage and sero-hmmorrhagic effusion, pleuro.pulmonary laceration and extra-pulmonary suppuration can be avoided by a careful and gentle technique. TORELLI, G. Lo stomaco dopo la frenieocxeresi. Lotta conlro la Tuber. colosi, 1933, 4,473. The writer records 14 cases of patients, aged from 15 to 40 years, of cascade stomach following pbrenicectomy on the left side. In none of these cases were any gastric symptoms present. He also describes seven cases of gastric disturbance following phrenicectomy, which were the only examples of the kind among over 400 patients who had undergone this operation. I n most of these cases he considers that t h e s e disturbances were a mere coincidence, and that the occurrence is no coutraindication to t h e operation.
SURGERY
OF
This was quite wrong, plombage causing a local collapse only, a n d therefore the typical cases for this operation are those with local affections at the apex, of a fibre-cavernous type, where the general health is still good, but where a severe interference such as thoracoplasty is not wanted. The cavities suitable for extrapleural plombage should not be larger than a small apple. The re. minder is given that t h e object of the operation is not to collapse the cavity mechanically by actual compression, but rather to cause its collapse by encouraging its own natural tendency to retract ; and therefore that the extrapleural space obtained by the operation should not be filled quite full of paraffin--not fuller than is absolutely necessary to separate the lung from the ribs. Moreover, the packing should be done very loosely, the space being loosely filled with small " sausages " of the wax, packed against the ribs and not against the lung. With the technique described, no trouble was experienced in any of the 50 cases of which the writers have had personal experience: no suppuration, perforation of the lung or elimination of the plug, and very seldom any reaction, such as a rise of temperature, after the operation. An important point in the technique is that the apex must b e completely freed, " s o that the lung with the cavity falls do~wn, making a itoor for the plug." The operation is best performed by a posterior incision, although where the cavity is a large One it may be necessary to begin the operation anteriorly, and at a latter date to complete it posteriorly. Two illustrative cases are recorded, with radiograms of one of these.
THE
LUNG
317
the static and dynamic changes in the thorax led the author to form the same conclusions as those .of Omodci Zorini as to the value of the operation of apicolysis. HUDSON, "W. A. The I n s e p a r a b i l i t y of Endoscopy and Thoracic Surgery. Joztrn. of Thoracic Surgery, 1933, 2, 292. Endoscopy has proved of great value both in diagnosis and in tile treatment of various pulmonary conditions. As the writer's experience has increased, he has found that fewer cases are requiring open drainage or other radical forms of surgery, probably for three reasons: (1) Endoscopic drainage is being instituted at the earliest possible moment, once a suppurative lesion or its precursor is discovered; (2) endoscopic drainages are performed more frequently and extended over a longer period of time, so that not o n l y is a drainage canal provided, but also the canal is left open u n t i l the last vestige of inflammation has disappeared; and (3) many cases of a character that used not to be considered suitable for endoscopic treatments and were therefore hurried through some form of open surgical drainage, are now being submitted to endoscopic treatment with sHceess.
in the case of post-operative massive atelectasis, endoscopy is an invaluable adjunct to deep breathing, postural change and administration of carbon dioxide and oxygen mixtures, as a means of relieving respiration distress. In many such patients the endoscopic removal of a fibrinous plug or an accumulation of secretion gives almost immediate relief, hfany cases of Iobular 5IONALDI, V. Sull' apicolisisempliee atelectasis following influenza or whoopnel trattamento della tubercolosi pol- ing cougb infections failed to clear up monare. Risultaticlinicie meceanismo until endoscopy was resorted to. I n d'azione. Lotta colttro la T~lbcrcolosi, such cases an inflammatory obstruction 1933, ,t, 253. was found in a secondary bronchus, its The writer records 15 cases of pul- involvement being apparent from the monary tube~:zulosis in patients aged facts of its red orifice and its pouched from 20 to 52 in whom simple apicolysis mucosa. Diagnosis of malignancy of the w a s performed with the following re- bronchial tree is greatly facilitated by the sults. In four there was no marked free use of X-ray studies, but in most change, in another four there was some cases in which the diagnosis is based improvement, and in seven a clinical re- upon roentgenological findings the lesion covery was obtained. Examination of is too far advanced for the thoracic surthe respiratory function and especially of geon to be able to do much. The only way
318
TUBERCLE
for a positive and very early diagnosis to be made is by resorting to endoscopy at the appearance of the earlies~ symptoms, and even an apparently negative X-ray study should not~ interfere with the carrying out of an endoscopic examination in a patient whose symptoms suggest some pulmonary lesion. EIZAGUIRRE, E. E1 plombaje en la tuberculosis pulmonar. 27ev. de H i t . y de T~lberculosis, 1933, 26, 1, 29. The writer, who records 14 cases in patients aged from 21 to 51, comes to the following conclusions : (1) Plombage is a method of collapsotherapy which is indicated in fibre:ulcerative processes of the apex of the lung which are inactive, and are not likely to extend beyond the lower part of the first rib. (2) It is el undoubted value as a complement to insufficient thoracoplasty. (3) On some occasions it may be employed in bilateral cases after artificial pneumothorax or thoracoplasty on the opposite side and in exceptional cases bilateral plombage may be carried out. (4) The m o s t suitable material for plombage at the present time is the paraffin preparation proposed by Baer and modified by Winternitz. (5) The amount should not exceed 400 c.c. and if possible should not be more than 200 to 300 e.c. (6) The most practical route is the paravertebral in which 2 to 3 cm. of the third or fourth rib are resected. (7) The proportion of excellent results which may be regarded as a clinical cure, amounted to 42 per cent. in the writer's cases. (8) Only o n e death resulted from the operation. XALABARDER, C. La gravedad operatoria de la toracoplastia, l~ev. de Hit. y de Tuberculosis, 1933, 26, 53. The writer has collected from literature 3,758 cases of thoracoplasty in which the operative mortality was 13 per cent. Although it is extremely difficult to compare the various statistics, owing, to the difference in the cases and the technique employed, he thinks that the factors affecting the mortality of the operation m a y be classified under the headings of (a) the patient, (b) the technique and (c) the environment. (a)
[April, 1934
The gravity of the operation varies according to the patient's age, sex, side affected, general condition and the anatomical form of the disease. (b) The technical skill of the operator acquired by the p r a c t i c e of general surgery is of great importance. While the mortality in Bull's cases was 8"4 per cent. in 16S cases, and Tandberg's 6'7 per cent. in 101 cases, the mortality el 129 cases operated on by 11 Scandinavian surgeons was 13 per cent. (c) I f the operation is carried out by a surgeon who is also a phthisiologist, the operative mortality should not be higher than t h a t of any other major operation. hlILOCH, F. L'apieolyse avec plombage paraffin6 dans le t r a i t e m e n t do la tuberculose du sommet. Th2se deParis, 1933, No. 353. The author, who records 19 illustrative cases, states that the indication for paraffin plombage are restricted to the following conditions: (1) Bilateral foci in which the operation enables the maximum amount of health respiratory parenchyma to be preserved. (2) Ex. tensive unilateral foci when the patient is not in a fit state to support the shock of thoraeoplasty. (3) Limited apical foci with smallcavities. The complications of apieolysis such as sepsis, hmmorrhage and sero-hmmorrhagic effusion, pleuro.pulmonary laceration and extra-pulmonary suppuration can be avoided by a careful and gentle technique. TORELLI, G. Lo stomaco dopo la frenieocxeresi. Lotta conlro la Tuber. colosi, 1933, 4,473. The writer records 14 cases of patients, aged from 15 to 40 years, of cascade stomach following pbrenicectomy on the left side. In none of these cases were any gastric symptoms present. He also describes seven cases of gastric disturbance following phrenicectomy, which were the only examples of the kind among over 400 patients who had undergone this operation. I n most of these cases he considers that t h e s e disturbances were a mere coincidence, and that the occurrence is no coutraindication to t h e operation.