F. Ronald Edwards

A Critical Review of the Results of Lung Resection for Pulmonary Tuberculosis

Between 1947 and April, 1956, 1,575 patients have had pulmonary resection performed in the treatment of tuberculosis at Aintree and Broadgreen Hospitals, Liverpool. During this period, although a certain number of cases of active bilateral disease have been treated by thoracoplasty, resection of the affected area has been the method of choice for the surgical treatment of all types of the disease. In two previous communications (Bickford, Edwards, Esplen, Gifford, Mair, and Thomas, 1951; Bickford, Edwards, Esplen, Gifford, and Thomas, 1952) we laid down our principles for undertaking resection, and these have remained basically unchanged to date, except that our views in relation to compensatory space reduction of the thoracic cavity have crystallized in favour of corrective thoracoplasty. It is probable that during the years our indications for resection have widened somewhat, as it became clear that with sufficient chemotherapeutic control, areas of lung could be removed, leaving active disease behind which might be expected to heal without severe lung damage. The changing face of tuberculosis has resulted in a considerable number of very chronic carriers being submitted to surgery, and many of these cases fall into the above group. The surgery of the caseous nodule has changed in later years with the development of long-term therapy, and a more conservative approach to these is now being taken. We still believe that a caseous nodule of over 2.5 cm. in diameter should be excised, however much chemotherapy has been given or is proposed in the future. The use of chemotherapy has so altered the scheme of treatment that surgery must be con-

Cavo-pulmonary Anastomosis

A direct anastomosis between the superior vena cava and the right pulmonary artery will allow some 40% of the total venous return to pass directly through the lungs without any ventricular action, and for the purpose of providing palliative treatment for the above conditions might offer some advantages over the systemic-pulmonary shunts. The operation can be performed with relative ease in small children, on whom an arterial anastomosis may be difficult and may rapidly become inefficient due to the increased oxygen demands occurring with growth.

Pneumonoplasty; periosteo-plastic pneumonolysis.

For many years thoracoplasty with extrafascial apicolysis has been the major surgical procedure of choice in applying collapse therapy to the treatment of pulmonary tuberculosis. The results of this operation have been considered to be satisfactory, producing sputum-conversion figures of 70-80% in various hands. The recent advances in chemotherapy and surgical technique have enabled excision therapy to take a gradually increasing place in the surgical treatment, as it must inevitably do, for it is basically a sounder surgical principle. Nevertheless, collapse therapy is likely to remain for a long time one of the main forms of treatment of the disease. Having undertaken various forms of thoracoplasty on some 500 patients during the last 13 years, consideration and reflection upon the operation and the types of disease on which it has been performed leads me to the opinion that it should be possible to produce a similar permanent collapse of the lung in cases of apical disease without the destructive changes to the thoracic cage that are the features of this operation. These destructive changes tend not only to a deformity of one side of the chest which is aesthetically undesirable, but to difficulties of coughing and raising secretion in the post-operative stages which may lead to an extension of the disease to the lower lobe. Extrapleural pneumothorax is a kinder operation to the patient, but it is not a permanent form of collapse therapy, and the frequency of complications, among which the most serious are haemorrhage into the space, late tuberculous space infection, and gradual re-expansion of the lung, has led to its falling into disfavour, at least in most centres in Great Britain. Maintenance of lung collapse by the introduction of various solid or fluid media within the thoracic cage has been tried: fat, muscle, paraffin wax, oil, and more recently lucite balls and polythene, but the fat absorbs, the muscle atrophies, and the history of the use of the foreign bodies has been a sad one, although the newer plastic materials appear to be better tolerated by the tissues. The following features are considered to be advisable in a collapse operation.