INDICATIONS FOR LOBECTOMY AND PNEUMONECTOMY IN PULMONARY TUBERCULOSIS* PAUL C. SAMSON, M.D. OAKLAND, CALIF. PULMONARY RESECTION as a treatment for tul)erculosis may be classified in two separate periods: In I88i, Block1 performed unsuccessfully what prob- ably was the first planned pulmonary resection for tuberculosis. From I88i to 1895, cases were reportedlby Ruggi,- Tuffier,3 and others. Tuffier believed that pulmonary resection shotuld be employed wlhein the tuberculosis was local- ized. He felt that by removal of the primary focus, a spread of the disease might be prevented. No cases were reported from 1895 to 1934. Probably the poor results previously obtained discouraged surgeons. In addition, the acceptance of collapse therapy was becominig more widespread and the efficiency of thoraco- plasty was increasing. The second period began in 1934. In that year Freedllander4 performed a successful right upper lobe lobectomy for a tuberculous cavity that could not be closed by plneuimotlhorax. In 1938, Jones and Dolley) reported their series of two lobectomies and three pneumonectomies performed in tuber- culous patienits. They were the first to suggest some of the criteria for planned pulmonary resection in tuberculosis. Scattered cases presented by Beye," Eloesser,7 O'Brien,8 Brunn,9 Rienhoff,10 Lindskog," Crafoord,'2 andI others have brought the total numnber n1ow reported5' in the literature to 22. In several of these, tuberculosis was an uinexpectecI miiicroscopic diagnosis following the removal of a lobe or a lunig for suppurationi. Many thoracic surgeons now feel that lobectomly and pneumiionectomy prob- ably have a definite place in the surgery of pulmonary tuberculosis. As is usually the case with procedures not in geIleral uise, no attempt can be made to list clear-cut indications. Our reasons for recommending lobectomy and pneumonectomy at the present time undoubtedly will be modified by further experience. In the present report, six cases of planned pulmonary resection in tuberculosis are summarized (three lobectonmies and three pneumonec- tomies). From this experience and that of others, particularly of Jones and Dolley, some attempt will be made further to crystallize our present attitude about the indications and contraindications for lobectomy and pneumonectomy in patients with phthisis. Operation upon two of the six cases was performed by Dr. John Alexander, and their iinclusion in this series is with his permission. Detailed reports of these two cases will be published subsequently by him. * Read before the Section on Thoracic Surgery, Third Congress of the Pan-Pacific Surgical Association, at Honolulu, T. H., September 15-22, 1939. Submitted for publi- cation March 2, I940. 201 PAUL C. SAMSON AnnalsofSurgery August. 1940 Case i.-L. C., white, female, age 32. On August 3, 1936, a total left pneumonec- tomy was performed at the University of Michigan Hospital by Dr. John Alexander, assisted by the author. This patient had an atelectasis of the left lung and an advanced fibrostenosis of the left stem bronchus. She was seriously ill because of obstruction of secretions. Thoracoplasty seemed inadvisable because of the marked bronchial obstruc- tion. Dilatation of the stricture was impossible. After a prolonged convalescence she eventually became well and to-day is leading practically a normal life. It is interesting that this is one of the first planned pneumonectomies in tuberculosis of which we have record. Case 2.-A. O.'s., white, female, single, age 33, was referred by Dr. Robert Peers, of Colfax, Calif. A total right pneumonectomy was performed by Dr. Emile Holman and the writer at the Stanford Hospital, San Francisco, June 5, 1937. Symptoms of right-sided pulmonary tuberculosis developed in October, I932. Bed rest alone, later supplemented FIG. I.-Case 2: Postero-anterior roentgeno- FIG. 2.-Case 2: Roentgenogram with Pottei- gram prior to thoracoplasty. The basse is atelectatic. Bucky technic following ten-rib thoracoplasty. The Q2uestionable areas of cavitation at the level of right lung is completely collapsed. Patient symp) the fifth and sixth ribs posteriorly. tomatically unimproved. by induced pneumothorax for one anld one-half years, resulted in slow improvemenlt During this time she suffered from "asthmatic attacks'" The sputum became negative for tubercle bacilli although she still coughed and raised purulent sputum. Her "attacks" were characterized by cessation of sp)utum for two or three days, fever, and an irritative nonproductive cough. On about the third day, sputum would be produced in large quain- tities and the temperature would fall. These attacks often occurred at the time of men1- struation. A phrenicectomy effected little change in her condition. Roentgenogramus showed some suggestion of cavitation in the upper lobe (Fig. I). Late in 1936, a two- stage, ten-rib thoracoplasty was performed by Doctor Holman. There were no visible uncollapsed cavities following thoracoplasty (Fig. 2). The sputum was decreased in amount but the patient still expectorated from 25 to 50 cc. The harassing cough re- mained unchanged. Between the stages of her thoracoplasty, stenosis of the right stem bronchus was demonstrated bronchoscopically. Following the second stage, bronchoscopy againl was performed on two occasions (P. C. S.)!. The right stem bronchus was so narrowed that only a dimple remained. Successful dilatation was not possible. Inzdicationls for PncumSo)necto1n1y.-The patient had a persisting chronic infectionl and 202 Volume 112 Numiber 2 SURGERY OF PULMONARY TUBERCULOSIS a highly obstructed stem bronchus. Presumably the tuberculosis was arrested since tubercle bacilli were not found in the sputum. The patient's cough was worse following thoracoplasty. It was obvious that the lung was totally atelectatic and that the patient's illness continued because of the lack of drainage of infectious secretions. Pneumonectomy, therefore, was recommended. Operative Proceduire antd Subsequtent Course.-The right lung was exposed through a posterior incision after regenerated ribs had been removed. The visceral and parietal pleurae were densely adherent. Eventually the hilum was mobilized and a Carr automatic hilar ligature applied. The lung was amputated and the wound closed in layers. Closed intercostal drainage was established. The immediate postoperative convalescence was stormy and bronchopneumonia developed at the left base. Later the wound was opened and packed. Eventually it closed completely by granulation. Clinically, bronchial fistula was never a problem. She has led an essentially normal existence although there has been moderate dyspnea, probably as a result of a slight narrowing of the lower trachea. Recently a few tubercle bacilli were found in her sputum. Bronchoscopic examination revealed a collection of thick pus in the shallow stump of the right stem bronchus. It is possible that a tortuous bronchial tract may persist, leading to a focus in the collapsed interpleural space. The left lung remains clear. Pathologic Examination.-Dr. James B. McNaught, Stanford Department of Path- ology: The lung was shrunken, firm, and entirely atelectatic. Scattered bronchiectases were present. Microscopically, fibrous tissue replaced the alveolar structure. The bronchiectasis was nontuberculous. Most of the tuberculosis appeared quiescent. It was characterized by caseous necrosis with beginning calcification. Only occasional giant cells were seen. Of importance was the fact that the most highly cellular tubercles were located predominantly in the submucosa of the medium and larger bronchi. Case 3.-A. H., white, female, age 27. Referred by Dr. Elliott T. Smart of Bret Harte Sanatorium. A total left pneumonectomy was performed, October 4, I938, by the author. Roentgenographically, the original tuberculosis consisted of a minimal lesion in the left lower lobe (Fig. 3). Cough and sputum were out of proportion to the amount of tuberculosis. The sputum was positive for acid-fast bacilli and the patient had a constant wheeze. Accordingly, she was bronchoscoped shortly after admission. Severe tuberculous ulceration and stenosis of the left lower lobe bronchus was found. This was treated with high frequency cauterization five times at monthly intervals. Ulceration almost entirely healed and fibrous stenosis increased. Wheezing disappeared. Following an upper respiratory infection three months later, wheezing again became prominent and bronchoscopy showed extension of the ulcerative lesion to the carina. Following cauteri- zation, partial atelectasis of the left lung developed. There was subsequent clearing, followed by the development of complete atelectasis (Fig. 4). Anterior and posterior mediastinal herniation of the right lung developed. Following further cauterization, the bronchial lesion became a pure fibrous stenosis. Pneumothorax had been attempted without success. There was no change following temporary paralysis of the left phrenic nerve. Indications for Pneumonectomy.-This patient was observed for six months following the development of total atelectasis. During this time she was always moderately toxic and her sputum persistently contained tubercle bacilli. She had occasional febrile epi- sodes. Bronchial dilatation was attempted, but the patient's symptoms did not abate. Thoracoplasty appeared futile since the lung was already collapsed. The continued toxicity from obstruction of secretions due to the advanced bronchial stenosis made total removal of the lung seem the only surgical procedure offering