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Ann Thorac Surg 1995;59:1408-1409
© 1995 The Society of Thoracic Surgeons
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Introduction |
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 Top Introduction |
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DR ANDREAS P. NAEF (Pully-Lausanne, Switzerland): I was very much interested in this presentation by Dr Treasure, and I thought that a few comments addressing the similarities and differences between the tuberculosis surgery of today and ours of almost 50 years ago may be of interest.
Today these cases represent a very small, almost anecdotal, part of your overall activity. On the other hand, in the late 1940s and early 1950s, when our role models Overholt in Boston, Max Chamberlain in New York, John Jones in Los Angeles, and a few others practically invented thoracic surgery, they reported thousands of resections for tuberculosis. This was actually ``the'' operation that sparked the explosive development of modern thoracic surgery.
When I returned from my year of training in the United States, I did my first resection for tuberculosis in 1948 in a desperate case of a bacteriologically uncontrolled destroyed lung. With that success and others, I soon acquired the enthusiastic confidence of many tuberculosis specialists, and by 1950, I was driving all over Switzerland doing my ``saddleback'' surgery in sanatoriums and small hospitals where the contagious tuberculosis patients lived in isolation. In 1965, I reported a 15-year experience with 1,000 personal cases, 61% of my thoracic work, and in the most recent series of 215 operations between 1963 and 1965, the mortality rate and the fistula rate were both less than 1%, two cases each.
Without such enormous experience, the management of thoracic patients everywhere in the world would never have developed so rapidly, allowing us in 1951 to initiate closed cardiac surgery in Switzerland. So much for the differences between today and 50 years ago.
As for similarities, we were confronted as you are today with often desperate situations, resulting sometimes in surprising victories as well as expected defeats. The patient's immunocompetence, intact or failing, was then as important as it is today, although we knew much less about it. At small surgical meetings, we had endless discussions about surgical techniques, the prevention of bronchial fistulas, the importance of treatment-resistant bacilli, and the advisability of limited segmental versus more extensive resection.
As you can see, we faced very similar problems as you do today. All in all, however, it was a more important and probably more satisfying part of our work, far more rewarding also than surgery for lung cancer, which replaced tuberculosis surgery from 1960 on.
DR HARVEY I. PASS (Bethesda, MD): In the patients who had bronchopleural fistula, there is a preponderance of pneumonectomies. First, could you comment on when you decide to do a pneumonectomy in the patient who has treatment for bronchopleural fistula that is possibly resolved with chest tube drainage and antibiotics and why lesser procedures could not be done to encompass the fistula? Second could you comment on your use of flaps to cover the bronchus? This is a major portion of your discussion in the abstract, and I would like to know whether you use flaps routinely or only in pneumonectomies.
DR TREASURE: I will answer the last question first. I use muscle flaps only in pneumonectomies. The use of a muscle flap is not necessary in lobectomies because the risk of bronchopleural fistula is low. I prefer the latissimus dorsi muscle because it is big, has a good blood supply, and is easy to get into the chest.
In patients with bronchopleural fistula, the selection of operation is a challenge. The status of the underlying lung is the critical factor. Patients whose lungs are completely destroyed as suggested by radiographs, computed tomographic scans, or ventilation/perfusion scans and confirmed at operation are candidates for pneumonectomy. Patients with a smaller fistula and less underlying disease are the ones who respond to tube thoracostomy.
It is very important to wait until you have control of the tuberculosis medically as evidenced by conversion to negative of sputum and pleural fluid cultures before deciding on the proper procedure.
DR KENWYN G. NELSON (Tyler, TX): I have one comment and one question. Dr Treasure has beautifully reemphasized the importance of the negativity of the smear and the culture prior to operation. It is particularly important to have a quality laboratory that can do the drug sensitivities for second- and third-line drugs.
My question concerns staging for thoracoplasty in the lobectomy patients. There are difficult space problems. Dr Treasure, do you stage at the time or do you wait to see what residual space there is?
DR TREASURE: Dr Nelson's question concerning the timing of thoracoplasty after lobectomy is a good one. I do not perform a concomitant tailoring thoracoplasty after lobectomy. I believe it is preferable to wait to see what happens in the postoperative period. Some postoperative spaces, even in cases of tuberculosis, are benign and require no therapy. Others require a tailoring thoracoplasty or combination thoracoplasty and myoplasty.
DR CAROLYN E. REED (Charleston, SC): I congratulate you on a series that has remarkably low morbidity and mortality for such difficult procedures in difficult patients. Your major indication was drug resistance, which I think had something to do with the large Hispanic population in the study. Our indication still remains preponderantly hemoptysis, and in that group, my colleagues and I find a lot of patients superinfected with Aspergillus. How many of your patients were infected with Aspergillus?
As for your pneumonectomy population, about 30% of your group, which is really quite high, I have a few comments. I think it is remarkable that you were able to do that many pneumonectomies without major complications. This is a very difficult group. I would appreciate your commenting on such things as operative time and blood loss in that group. We recently looked at the subject of pneumonectomy in our institution and found that the number of such operations is quite elevated compared with lobectomies for complex infections, including tuberculosis. We have now reverted to doing a pneumonectomy for tuberculosis or complex infections through a median sternotomy approach because of some of the difficulties encountered during ordinary resection.
DR TREASURE: Patients with Aspergillus superinfection were common in our group of patients with destroyed lung as well as those with complicated cavities.
Pneumonectomy in tuberculosis is a difficult procedure. It requires a long operating time, meticulous dissection, and avoidance of intraoperative injury to the pulmonary vessels. Blood loss can be a problem but can be minimized by the use of electrocautery and careful identification of tissue planes.
I believe it would be very difficult to perform a pneumonectomy in a patient with tuberculosis using a median sternotomy incision. The posterolateral thoracotomy gives the best exposure, allows for establishing the correct operative planes, and gives the best access to the dense adhesions as well as the pulmonary vessels.
DR FREDERICK L. GROVER (Denver, CO): I compliment Dr Treasure on superb results in a very difficult group of patients. In my career in San Antonio and in Denver, I have been very fortunate in being surrounded by expert tuberculosis surgeons and teachers. Dr Treasure is one of these people, as are his predecessor at the State Hospital, Dr Don Campbell, and Drs Marv Pomerantz, Al Hopeman, and more recently, Jamie Brown in Denver.
I reemphasize a conclusion that you reached, that is, surgery does have an important role in this disease in that it can be done by experienced surgeons with a very acceptable mortality and morbidity. Under the direction of Dr Marv Pomerantz, our group in Denver, largely through the National Jewish Hospital referral base, has experience with 111 patients with Mycobacterium tuberculosis infection. Of those, 107 underwent resection for multidrug-resistant tuberculosis: 62 had pneumonectomy or completion pneumonectomy, and the remainder had lobectomy or lobectomy plus additional resection. One half of the patients undergoing pneumonectomy had preoperative bronchopleural fistulas, and almost all of them and some of the others had resections using muscle flap interpositions, as you described.
We have had one 30-day and one 6-week hospital mortality in that group and 15 major complications, one of which was a bronchopleural fistula. More importantly, with intensive preoperative medical treatment for 3 months and 18 to 24 months of postoperative treatment combined with the resections, more than 90% of these patients have become sputum negative, a remarkable result in this difficult group of patients.
I would like to know what percentage of your patients having resection convert to sputum negativity and what your preoperative and postoperative medical regimens are.
DR TREASURE: I thank Dr Grover for his generous remarks. Dr Pomerantz and his associates in Denver provided the stimulus for us to begin operating on multidrug-resistant tuberculosis.
I believe that the medical management of multidrug-resistant tuberculosis is the most important factor in successful surgical intervention. Dr Seaworth, the coauthor of this paper, is our phthisiologist and is responsible for the medical management of our patients. She was able to convert the sputum to negative preoperatively in 17 of the 19 patients with multidrug-resistant disease. Of the 19 patients who underwent operation, 2 have had a relapse.
In closing, I enjoyed Dr Naef's presentation concerning some of the history of the surgery for pulmonary tuberculosis.
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