CURRENT REVIEW

Current Aspects of Surgery for

Pulmonary Tuberculosis
Joseph S. McLaughlin, M.D., a n d John R. Hankins, M.D.

ABSTRACT An entire generation of thoracic surgeons received much of their

training and were well-versed in the operative treatment of pulmonary tubercu-
losis. Chemotherapy has revolutionized this aspect of thoracic surgery, and
operations for tuberculosis have markedly decreased. But pulmonary tubercu-
losis, though reduced in incidence, is still a widespread scourge, and it is vital
for the thoracic surgeon to understand the role of operative treatment. This re-
view brings up to date the role of the surgeon in the treatment of pulmonary
tuberculosis.

F ive years ago the late Dr. John Steele [29],then editor of T h e Annals
of Thoracic Surgery, reviewed the history of the operative treatment
of pulmonary tuberculosis, outlining the radical changes which had
occurred in the preceding two decades because of the introduction of effec-
tive antimicrobial agents. T h e article remains timely. It places in historical
and scientific perspective the present-day operative treatment of what con-
tinues to be the greatest infectious disease killer of our times. A considerable
volume of literature has since accumulated concerning the relative merits of
resection and other forms of therapy, the indications for and results of opera-
tion, and proper handling of the complications which occur. T h e purpose
of this review is to present the current surgical therapy for pulmonary tu-
berculosis in light of this increased experience.

From the Division of Thoracic and Cardiovascular Surgcry, Univcrsity of Maryland School
of Medicine, Baltimore, Md.
T h e authors gratefully acknowledge the training and guidance of Drs. John E. Miller,
Eugene Linberg, Elmer R. Sailer, and William Newcomer of the Mount Wilson State Hospital,
Baltimore, and thank Dr. David G . Simpson, Professor of Medicine and Chief of the Division
of Pulmonary Disease, University of Maryland Hospital, for his review of the manuscript.
Address reprint rcqucsts to Dr. McI,aiighlin. Division of Thoracic and Cardiovascular
Surgery, University of Maryland School of Medicine, Baltimore, Md. 21201.
MC LAUGHLIN AND HANKINS

Present Indications for Operative Treatment

With the advent of adequate chemotherapeutic agents, the indications
for surgical treatment of pulmonary tuberculosis were widely extended.
Previously, operative treatment had been indicated only for those patients
in whom collapse of a portion of the lung would be potentially beneficial
or in whom some complication made operative intervention mandatory.
Chemotherapy would stop the progression of the disease, heal tuberculous
bronchitis, and bring about resolution of pneumonia while necrotic areas in
the lung underwent fibrosis. Resection of residual foci of necrosis and fibro-
sis could then be performed safely. T h e literature of the 1950s and 1960s is
replete with series of superb operative results” [l, 17, 19, 251.
However, it became apparent that many patients who had undergone
resection would have been cured whether or not resection had been carried
out. For example, patients treated with chemotherapy and thoracoplasty,
either conventional or of the modified plombage type, had a high cure rate:
and, most importantly, patients whose sputums became bacteriologically
negative and who for some reason or other were not operated upon despite
residual cavitary disease often were cured” [8, 251. Considerable controversy
existed over whether or not the patient with an “open negative” cavity
should be operated upon, and it was not until studies based upon controlled
series were completed that the proper course of action was placed on a
scientific basis [8].
Recently the trend has been to operate on those patients in whom
chemotherapy does not bring about a rapid halt in the progression of the
disease or in whom social, economic, or other factors-including the presence
of atypical mycobacterial disease-militate against the success of chemo-
therapy alone. Thus, patients with pulmonary tuberculosis who are operated
on at the present time are a considerably different group of patients than
those operated upon previously. Their disease may be active, other com-
plicating factors often are present, and the incidence of complications has
increased. Further, operation for tuberculosis and treatment of the com-
plications of tuberculosis per se once again have become important aspects
of the thoracic surgeon’s involvement in this disorder.
T h e following are indications for surgical treatment of tuberculosis:
1. Active localized disease not responding to chemotherapy, including
infection with atypical bacteria
2. Residual foci of disease in patients in whom social or medical indi-
cations of potential reactivation exist or foci which interfere with
proper pulmonary function or toilet
3. T h e possibility of coexisting carcinoma
4. Various complications of pulmonary and pleural tuberculosis, in-
*Corpe, R. F., and Liang, J. Current concepts of indications of excisional therapy for
pulmonary tuberculosis. Unpublished data, 1973.

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 CURRENT REVIEW: Surgeiy for Pulmonary Tuberculosis

cluding empyema, bronchopleural fistula, and massive hemorrhage

from a cavitary lesion
5. Management of complications following resection for tuberculosis

ACTIVE LOCALIZED DISEASE NOT RESPONDING

TO CHEMOTHERAPY
T h e only absolute indication for operative excision in pulmonary tu-
berculosis is positive sputum after adequate antimicrobial therapy. Chemo-
therapy is effective in controlling pulmonary tuberculous infection and ren-
dering the sputum negative to culture within 90 days in more than 95y0 of
the patients" [9, 14,22, 231. However, some patients, for a variety of reasons,
do not respond adequately; the sputum remains positive and resolution of
the infectious process is indolent. If the residual process is relatively local-
ized, resection of the infected tissue is an effective means of dealing with this
situation.
Certain problems are inherent in the operative management of the
patient with positive sputum. T h e studies of Corpe and Liang are per-
tinent in this regard. From 1945 to 1964, these authors carried out resections
in 645 patients with positive sputum. Forty percent of this group had had
interrupted treatment; the others were on original continuous drug therapy
at the time of resection. Pneumonectomy was carried out in 159 patients
(240/,); 301 (47y0) had lobectomy alone or, in some cases, lobectomy plus
resection of additional lung tissue; 141 (22y0) underwent segmental resec-
tion; and 44 patients (7y0) had less than one segment removed. Of the 645
patients, 478 (74y0) had uneventful postoperative courses. T h e remaining
167 patients (26y0) had various postoperative complications, and 35 patients
died, an overall operative mortality of 5.4y0. T h e greatest number of deaths
occurred in the pneumonectomy group (loyo), but 5% of the patients who
had lobectomy also died. At the time of discharge, 532 patients (82%) had
achieved negative sputum status. Seventy patients (1 lye) still had positive
sputum and are considered therapeutic failures. Including the 35 operative
deaths, 43 patients died, a total mortality of 7y0.
T h e studies of Teixeira [31] in Rio de Janeiro complement the above
results. I n a group of 428 patients with positive sputum who were operated
upon without additional drug coverage, 35 (8.2y0)died at operation and 42
(9.8%) died late. Three hundred twenty-one patients (75y0) were discharged
with good results. This contrasts sharply with a second group of 103 patients
with positive sputum prior to operation who were given secondary drugs
for 4 to 8 weeks prior to and after the operative period. Less than 2y0of this
group (2 patients) died from operation, and 99 patients (96yo)were dis-
charged from the hospital with good results. None of these patients developed
bronchopleural fistula or empyema or had a relapse.
These studies indicate the importance of chemotherapy. T h e sputum
of many patients presumably had become negative, or at least there had
MC LAUGHLIN AND HANKlNS

been a decrease in the numbers of bacteria in the sputum, at the time of

operation. One may argue that with the number of effective drugs now avail-
able, prolonged infectiousness can be treated by other combinations of
drugs, thus precluding the necessity for operative intervention. However,
there is still a group of patients, admittedly small, who do not respond. It is
vital that operation be considered before all combinations of effective drugs
are utilized.
Disease caused by atypical mycobacteria frequently constitutes an indi-
cation for operative treatment since these bacteria are usually resistant to
most forms of chemotherapy. In early studies, Corpe [7] noted that the prob-
ability of achieving an inactive, negative disease status was two to three times
greater with operative and drug treatment than with drug treatment alone.
With the introduction of ethambutol and, more recently, rifampin, the
Runyon group I infections, which include those due to Mycobacterium
Itansusii, have proved less resistant to drug therapy, and improved initial
results have been obtained. Despite this, however, resistance still occurs,
treatment is long and often complicated by the necessity for multiple com-
binations and schedules of drugs, and relapse is frequent. Isolated or lo-
calized infections are rapidly and effectively treated by surgical resection.
Unfortunately, such infections often occur in older persons in whom the
disease is diffuse, frequently precluding effective surgical care.
Zvetina and his associates [34] reported the results of operative treat-
ment in 35 patients with M . lzansasii infections at the Hines, Illinois, Vet-
erans Administration Hospital. Twenty-three of the 35 patients had positive
sputum at the time of operation, and there had been a 60y0drug failure rate
as opposed to present-day failure rates of 25y0 or less with this specific or-
ganism. Postoperatively all patients promptly achieved negative sputum
status and had long-term control of their infection. There were two major
operative complications, one related to the only death-a rate comparable
with that of surgical treatment of typical strains of tuberculosis.
Type I11 infections, which include itfycobacterium intracellulare
(Battey), present a much more difficult treatment problem. Fewer than 40y0
respond to a drug therapy regimen that includes ethambutol and rifampin
[Ill. This difference in response to chemotherapy is related in part to the
fact that M. kansasii is a single serotype, whereas M . intracellulare organisms
constitute a heterogeneous population comprising many serological types
and hence varying degrees of sensitivity and resistance to the available drugs.
Operative treatment has achieved impressive results in patients with
type I11 infections. From 1957 through 1967 a total of 159 patients with
atypical tuberculosis, representing 301, of the patients with mycobacterial
disease, were seen at the Duke Hospital and the North Carolina Sanitorium
[I 13. T h e indications for operation in this group were broadened to include
localized residual disease-even that without cavitation or positive sputum-
so that 37 of 95 patients with Battey bacilli infections were operated on. T h e

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 CURRENT REVIEW: Surgery for Pulmonary Tuberculosis

sputum was positive in 26 of the patients; it converted to negative after the

initial operation in all but 4 patients. Lobectomy was the most common
operative procedure performed. It should be noted here that the results ob-
tained with lobectomy were superior to those with segmental resection, the
latter being associated with a high incidence of bronchopleural fistula and
reactivation. Comparisons with the drug-only treatment group are not en-
tirely valid since these patients usually had more widespread disease,
but 41 of 45 patients (91%) of the surgical group had negative sputum
following operation as opposed to a 277' conversion rate in patients on solely
medical therapy.
RESIDUAL FOCI OF DISEASE
With the many effective combinations of antimicrobial agents presently
available there is little, if any, strictly medical indication for removing,
as a prophylactic measure, lung tissue previously affected by tuberculosis
[ 1, 8, 161. However, sociological and psychological factors play an important
role in the treatment of tuberculosis, and at times such factors may indicate
the advisability of removing areas of potential reactivation, including re-
gions of persistent cavitation and foci of caseation or tuberculoma. There is
evidence to indicate not only that this type of involvement may constitute
a continuing threat to the patient but that resection of the affected tissue
eliminates this threat, reduces hospitalization and length of chemotherapy,
and is associated with excellent long-term control of disease [l].
T h e studies of Corpe and Blalock [8] at the Battey State Hospital are
recommended to the reader. In a discussion of the patient with an open
negative cavity, they point out the differences in results, depending on the
length and type of antituberculosis chemotherapy, which occur in the medi-
cally treated group. T h e findings of the Tuberculosis Chemotherapy Trials
Committee of the British Medical Research Council confirm these differ-
ences [16]. In one treatment group, in which an isoniazid and PAS regimen
was utilized daily, an unfavorable response was found in 167' of the pa-
tients. In patients treated with isoniazid and PAS supplemented by strepto-
mycin given daily for the first 6 weeks, an unfavorable response was found in
3%. Further, 19% of the patients, who for some reason or another had
stopped chemotherapy after 1 year, had a relapse in the second or third year,
whereas only 4%) of the patients who continued chemotherapy for a second
or third year suffered a relapse. It seems evident that if a patient is to be
treated by chemotherapy alone, then the management of such chemotherapy
must be strict and the administration of drugs must continue for at least 2
years and in many instances for considerably longer.
For various reasons, both individual and societal, certain patients are
unable to effectively and diligently maintain the drug treatment regimen.
T h e association of antituberculosis drug treatment failure and alcoholism
is widely recognized. It is estimated that as many as 40 to GOYo of the pop-
MC LAUGHLIN AND HANKINS

ulation of tuberculosis sanitoriums are alcoholics [5]. One has only to work in
a sanitorium for a short time to become aware of the contraband activity
in alcohol and the tragic consequence of this disorder on the maintenance of
an adequate treatment regimen. The problem of alcoholism and its conse-
quences is magnified in the nonhospital environment. Similarly, patients
with psychological disorders ranging from psychosis to simple denial of a
physical disease state to mental incompetence may be unable to maintain
an adequate drug regimen. Resection of tuberculous foci with the potential
to recur if the long-term requirements of drug therapy are not met is the
logical course if such treatment alleviates or reduces the need for prolonged
therapy.
Tuberculosis is a necrotizing infection, and certain patients, although
cured of the infectious process, carry in their lungs the residuum of this
destruction. Patients with a destroyed lobe or lung, bronchial stenosis with
distal recurrent secondary infection and atelectasis, bronchiectasis with
chronic infection and its consequences, and other similar residua may be
candidates for operative intervention. These abnormalities are at best
doubtful indications, however, unless associated with significant symptoms
that cannot be controlled by current medical modalities.
THE POSSIBILITY OF COEXISTING CARCINOMA
At times the differential diagnosis between bronchogenic carcinoma
and pulmonary tuberculosis is impossible without operative intervention.
Given these circumstances, operation is mandatory.
There is increasing evidence that the association of these two diseases
is more frequent than would be expected by random chance. Steinitz [30]
reported from Israel in 1965 a five-fold risk of cancer in male patients with
tuberculosis and a ten-fold risk in female patients. Campbell and Hughes [6]
noted that bronchogenic carcinoma occurred twenty times more frequently
in patients with pulmonary tuberculosis than in patients from the general
population. Our experience has been similar.*
Of 7,986 patients admitted to Mount Wilson State Hospital for Pul-
monary Diseases between 1960 and 1970, coexisting pulmonary tuberculosis
and bronchogenic carcinoma were proved in 72.* These patients usually
were in the older age group and usually smoked. There was a high predilec-
tion for the tumor to occur in the upper lobes. Active tuberculosis was
present in 36 of the 72 patients, and tumor and tuberculosis were present in
the same area SOYo of the time. Cell diagnosis was possible in 43 patients
(60y0) without utilizing thoracotomy. Diagnosis usually was made late in the
course of the disease, and therapeutic results were poor. Only 13 patients
had disease that was operable, and only 4 are presently alive. Earlier recog-

*Gopalakrishnan, P., Mi,ller, J. E., and McLaughlin, J. S. Pulmonary tuberculosis and co-
existing carcinoma. Unpublished data. 1974.

518 THE ANNALS OF THORACIC SURGERY

 CURRENT Surgery for Pulmonury Tuberculosis
REVIEW:

nition, based on a high degree of suspicion, is vital to adequate treatment.

Although it is clear that the two diseases frequently may exist concomitantly,
no specific cause-and-effect relationship has been identified.
COMPLICATIONS OF PULMONARY
AND PLEURAL TUBERCULOSIS
Tuberculous Empyema. T h e term tuberculous empyema is an all-
inclusive one, ranging in meaning from asymptomatic pleural effusion to
massive, frankly purulent involvement of the pleura with bronchopleural
fistula and trapping of the lung. Langston, Barker, and Graham [IS] have
suggested the term pleural tuberculosis to describe this spectrum and have
presented a treatment protocol based upon their experience at the Univer-
sity of Illinois and the Chicago State Tuberculosis Sanitorium.
Simple pleural effusion with or without associated parenchymal disease
responds rapidly to antituberculosis chemotherapy [13, 271. Thoracocentesis
was used to confirm the diagnosis and to relieve symptoms of dyspnea due to
pulmonary compression. Chest tube drainage was not used because of the
fear of mixed infection, possibly a residual of the thinking of the era prior
to effective broad-spectrum antibiotics, but primarily because of the excel-
lent response to chemotherapy alone. Needle biopsy of the pleura has proved
a useful diagnostic tool in such effusions.
Unfortunately, some patients develop a restricting pleural peel and re-
quire a more aggressive approach. Langston and associates [13] suggest that
these patients be treated by appropriate antimicrobial therapy until such time
as maximum resolution of parenchymal disease and associated sepsis is
achieved. At that point an evaluation of the anatomical residua of the
pleural and parenchymal disease is carried out by appropriate roentgeno-
graphic studies, including anteroposterior and lateral laminagrams and
bronchograms. T h e operative procedure is planned on the basis of these
findings. Decortication with or without pulmonary resection is the primary
mode of surgical therapy. If the decortication alone is adequate, the results
are excellent.
In the 35 patients requiring only decortication in Langston’s series,
there were no operative deaths and few serious complications. If pulmonary
resection is required in addition to decortication, there is a progressive in-
crease in morbidity and mortality, depending upon the extent of lung re-
moved and the association of bronchopleural fistula. Decortication with
resection carried a 7.7y0mortality rate and pleuropneumonectomy a 21.9%
mortality. It should be pointed out that in those instances in which pleuro-
pneumonectomy was required, there was always an associated bronchopleural
fistula.
Bronchopleural Fistula. In a sense, every patient with active pulmo-
nary tuberculosis who develops pneumothorax has a bronchopleuraI fistula.
Auerbach and Lipstein [2] described the pathogenesis of these pneumo-

VOL. 17, NO. 5, MAY, 1974 519

MC LAUGHLIN AND HANKINS

thoraxes as follows: Subpleural caseous infiltrates liquefy and result in

pleural necrosis and rupture. An inflammatory response develops at the site
of rupture which, if the fistula is small and chemotherapy adequate, may be
successful in sealing the leak and allow gradual reexpansion of the lung as
the pleural air is absorbed. Such is usually not the case, however.
It is generally agreed that pneumothorax associated with active pul-
monary tuberculosis should be treated with intercostal catheter drainage
rather than waiting for spontaneous reexpansion to occur. Unfortunately,
in a significant percentage of patients with tuberculosis, reexpansion cannot
be achieved even with early institution of intercostal catheter drainage.
Ihm and co-workers [12] analyzed 52 patients who developed pneumo-
thorax as a complication of active pulmonary tuberculosis. These patients
had positive sputum smears with or without positive cultures of gastric
washings or sputum within 1 year of the onset of the pneumothorax. Cavi-
tary disease was demonstrated in 42 patients, and infiltrates were bilateral
in 37. Thirty-eight patients were treated with catheter drainage plus chemo-
therapy, and expansion of the lungs occurred in 28. T h e authors analyzed
the factors affecting the success or failure of intercostal catheter drainage.
T h e initial degree of collapse of the lung had no bearing on the outcome.
A short time interval between onset of the pneumothorax and chest tube
insertion was a favorable factor, but not dramatically so, and a long interval
did not preclude success.
T h e authors concluded that the most significant factor affecting the
result of intercostal catheter drainage in treating tuberculous pneumothorax
was the size of the bronchopleural fistula that gave rise to the pneumo-
thorax. This in turn was influenced by the extent of tuberculous disease in
the lung. Patients in whom parenchymal disease was extensive and poorly
controlled by drugs had large fistulas and early development of a restricting
pleural peel-factors which militate against the success of chest tube drain-
age. Additionally, the bronchopleural fistula frequently had led to a mixed
empyema by the time of admission to the hospital. In 4 of the 10 instances of
chest tube failure the patients died, 2 of sepsis before they could be brought
into sufficiently good general condition to permit definitive operation, 1
of congestive failure 2 days following rib resection, and 1 of cor pul-
monale several months following the last of multiple operative procedures.
Five of the 6 patients who were treated by definitive operative procedures,
which included one lobectomy/thoracoplasty and two pleural pneumonec-
tomies, survived.
In summary, intercostal catheter drainage and appropriate antitubercu-
losis chemotherapy should be the initial treatment for tuberculous broncho-
pleural fistula. If a culture of the pleural fluid reveals a mixed empyema,
which almost invariably is the case with large fistulas, broad-spectrum anti-
biotics should be administered as indicated. Even with large fistulas, the
empyema space in many patients will be reduced sufficiently so that after

520 THE ANNALS OF THORACIC SURGERY

 CURRENT REVIEW: Surgery for Pulmonary Tuberculosis

6 to 8 weeks a definitive surgical procedure, i.e., decortication with or with-

out resection, will be curative. An occasional patient will be encountered
who has a fistula so large and a lung so diseased and so restricted by thick-
ened pleura that even strong suction applied to one or more large, well-
placed intercostal catheters will not effect any appreciable expansion. In
such patients only decortication plus lobectomy or pleuropneumonectomy
will be curative. The timing of this procedure is important. It is vital to
recognize the point at which no further headway is being made in the pa-
tient’s general condition and to proceed with operation at this point, even
though there may not have been time for optimal chemotherapeutic control
of the infection in the other lung tissue.
Massive Hemoptysis. There is no general agreement among authors
as to the meaning of massive hemoptysis. Crocco and associates [lo] define
massive hemoptysis as hemorrhage of greater than 600 ml. in 48 hours; they
consider it particularly massive if there is a loss of 600 ml. in 16 hours. Yeoh
and colleagues [33] use a volume of 200 ml. in any 24-hour period as the
lower-limit criterion. Linberg [ 151 points out that patients dying of pul-
monary hemorrhage do not as a rule exsanguinate but rather suffocate.
He defines hemoptysis as massive if it is sufficient in quantity to obstruct
the airway and cause death by suffocation. Thoms and co-workers [32], when
speaking of hemoptysis in lung abscess, have used the term life-threatening
hemoptysis, which seems preferable nomenclature. The authors define this
as either a bleeding episode that causes acute airway obstruction or a per-
sistent bleeding that causes anemia or hypotension severe enough to require
blood transfusion.
There is little place for medical or expectant treatment in the patient
with life-threatening hemoptysis. After 5 patients in Linberg’s series died
from suffocation while being treated expectantly, the next 2 patients were
subjected to immediate lobectomy and both survived [15].
Yeoh and colleagues [33] reported on 56 patients treated on the chest
service at Bellevue Hospital in New York who had hemoptysis in excess of
200 ml. in any 1 day in association with tuberculosis. Forty-three were man-
aged conservatively, and 10 died; the terminal event was usually asphyxia-
tion. Thirteen were operated upon, and only 2 died.
Crocco and associates 1101 reviewed the courses of 67 patients in Kings
County Hospital Center in Brooklyn who had pulmonary hemorrhage of
more than 600 ml. within 48 hours. Cavitary tuberculosis was the predomi-
nant disease in this series, being present in 49 patients. Thirty-three of the 49
had cultures positive for tuberculosis at the time of hemorrhage, while the re-
maining 16 had inactive disease. Thirty of the 49 were considered to have o p
erable conditions. Sixteen of the 33 patients with active disease (i.e., positive
culture) were operated upon, and 4 died. Eleven of the 16 with inactive dis-
ease were operated upon, and 4 died. Two patients with active disease that
was considered operable were treated by nonoperative means, and neither

VOL. 17, NO. 5 , MAY, 1974 521

MC LAUGHLIN AND HANKINS

died; 1 with inactive disease was treated without operation and died. Among
the 19 patients whose disease was considered inoperable, 7 of the 15 who had
active tuberculosis died, while 1 of the 4 whose disease was inactive died.
The majority of patients with life-threatening hemoptysis due to tu-
berculosis have bilateral disease. Localization of the side and preferably the
lobe from which the bleeding originates is vital. This can be achieved in the
vast majority of cases by bronchoscopy performed during active bleeding.
The importance of doing the bronchoscopy while the patient is bleeding
cannot be emphasized too strongly. Purse1 and Lindskog [21] considered
hemoptysis of both tuberculous and nontuberculous origin and found that
bronchoscopy performed during active bleeding was diagnostic in 18 of 21
patients.
Linberg [15] developed the following criteria for early operation in
patients with life-threatening hemoptysis: (1) the patient has demonstrated
the ability to bleed massively from the tracheobronchial tree, (2) the site
of bleeding has been located, (3) the lesion is sufficiently localized to be
resectable, and (4) the patient’s general condition does not contraindicate
pulmonary resection. Patients who satisfy these criteria should be operated
upon without delay.
Before double-lumen endotracheal tubes became available, putting the
patient in the prone position had definite advantages in that spillage into
the opposite lung was prevented. The use of the Carlens or Bryce-Smith
tube makes resection with the patient in the lateral position possible. How-
ever, these tubes are not completely spillage-proof, and maintenance of
bronchial toilet may be more difficult because of their smaller lumens. For
that reason it is advisable to occlude the bronchus of the affected lobe as
early as possible during the course of resection.
MANAGEMENT OF COMPLICATIONS FOLLOWING
RESECTION FOR TUBERCULOSIS
Pleural Air Spaces. A common complication following pulmonary re-
section is a persistent air space in the pleural cavity. Shields and co-workers
[26] in 1959 analyzed persistent air spaces that occurred in 128 of 584 pa-
tients undergoing resection for tuberculosis, an incidence of 21.9%. In-
cluded in the series were patients with air spaces that persisted for 2 weeks
or longer postoperatively or that required additional active therapy other
than routine postsurgical chest drainage. The incidence of air spaces in-
creased with the magnitude of lung tissue resected as follows: wedge resec-
tion, 9.5%; lobectomy, 21.5%; resection of a lobe plus additional lung
tissue, 24.4%.
Pleural air spaces were classified as to whether or not they produced
symptoms including cough, fever, sepsis, and positive sputum. In Shields’
series the spaces in 86 patients (67.lyO) produced no symptoms, and all
disappeared from 1 to 9 months postoperatively. Most required no treat-
ment, although needle aspiration or tube thoracostomy was performed in

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10 patients. T h e course of the spaces giving rise to symptoms was consid-

erably different. Bronchopleural fistula with empyema occurred in 15 pa-
tients, and various less serious but significant complications developed in
25 others.
As regards treatment, the authors recommend a course of watchful
waiting if symptoms are absent. When symptoms are present, closed tube
thoracostomy with continuous suction should be the initial treatment. If the
air leak continues and the lung fails to expand, a thoracoplasty should be
carried out to collapse the space. For those spaces producing symptoms and
complicated by established bronchopleural fistulas, the use of a muscle flap
may be required in addition to the thoracoplasty [3].
Prevention is preferable to cure in this situation. Careful suturing of
the bronchial stump and covering of the stump with a flap of pleura or other
adjacent tissue cannot be overemphasized. Caution in dissecting the inter-
lobar or intersegmental plane, with suture of significant air leaks, is im-
portant. In segmental resections, care should be taken to preserve the inter-
segmental veins. Failure to do so may lead to pulmonary infarction, with a
resultant symptomatic air space [24].
Milloy, Kahdem, and Langston [18] recommend the use of a three-rib
tailoring thoracoplasty 3 or more weeks preoperatively in all patients in
whom it is anticipated that more than one lobe but less than the whole lung
will be removed. These authors found a markedly reduced incidence of air
space problems after they adopted this policy. At Mount Wilson State Hos-
pital the policy of performing preresectional thoracoplasty when more than
a lobe but less than a total lung will have to be removed has been in effect
for more than 10 years, but with the modification that four rather than three
ribs are removed. I n female patients the first rib may be stripped of its
periosteum and allowed to remain in place. T h e reduction in incidence of
postresection air spaces afforded by this policy has been impressive [17].
Other procedures-such as the construction of a “pleural tent” or a
modification of it termed air plombage-utilized during resectional pro-
cedures to prevent the formation of a space have not achieved popularity
[ Z O ] . In most instances insufficient pleura remains intact at the apex of the
chest for such procedures to be feasible.
Postpneumonectomy Embyema. Postpneumonectomy empyema pre-
viously was treated by obliterating the chronically infected space by exten-
sive thoracoplasty. Stafford and Clagett [28] recently reported their 12-year
experience with definitive closure of the space following neomycin instilla-
tion. This technique requires primarily open drainage of the empyema
cavity, usually by resection of a segment of the sixth rib near the anterior
end of the thoracotomy incision. A window is created b y suturing the sub-
cutaneous tissue to the pleura. T h e empyema cavity is irrigated daily for
4 to 8 weeks with half-strength Dakin’s solution, often on an outpatient
basis, at which time the pleural space decreases in size and becomes lined
MC LAUGHLIN AND HANKINS

with clean granulation tissue. T h e patient is readmitted at this point, and

under light general anesthesia the sinus tract is excised: the cavity is irri-
gated with saline to remove all debris and is filled with 0.25% neomycin in
saline solution. T h e chest wall window is closed in layers.
Twelve of the 18 patients so treated had undergone pneumonectomy
for primary pulmonary malignancy. Of the remaining 6, 1 had a benign
adenoma and 5 had chronic pulmonary infection: it is not stated whether
any of these 5 had tuberculosis. T h e cavity remained closed after the first
procedure in 11 of the 18 patients. T w o of the 7 in whom the empyema re-
curred refused further operative treatment. Of the remaining 5 patients,
closure was successful on a second attempt in 3 and on a third attempt in 2.
Thus, ultimate success was achieved in 16 of the 18 patients.
Barker and Langston [4] recently reported their experience with the
Clagett technique in the treatment of empyema following pneumonectomy
for tuberculosis. Success was achieved in 9 of 11 patients; it should be noted,
however, that positive cultures for tuberculosis were obtained in the 2 fail-
ures. T h u s one may speculate that this technique is of value only in those
patients in whom pyogenic, as opposed to tuberculous, empyema exists.

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