B. J. Bickford, F. Edwards, J. R. Esplen
Dec 1, 1952
Eighteen months ago we published an account of lung resection for pulmonary tuberculosis (Thorax, 1951, 6, 25). l he following communication is a reassertion of the general principles of this form of treatment, a record of our further experiences in 729 cases, and a follow-up of all our cases of pulmonary tuberculosis that have had a resection two years or more previously. Some confusion still exists not only concerning the type of tuberculous disease that should be resected but of the time when the resection operation should be done, and we would make it clear that certain guiding principles govern our selection of cases for this type of operation. Resection of lung tissue affected by tuberculosis is carried out for two reasons: (1) To remove an area of disease which remains persistently active despite bed rest, chemotherapy, and simple relaxation therapy (2) to remove an area of disease which has reached a stage of apparent " quiescence," but is nevertheless of a type that experience shows to be in not inconsiderable danger of reactivation under conditions of stress and intercurrent infection. Resection is an insurance for the future. Resection is only carried out when the body defences against the disease have been mobilized as fully as possible. The maximum localization of the disease is obtained by simple means before resection is undertaken. Most cases of pulmonary tuberculosis after treatment as above have one or more areas of confluent disease together with scattered small foci. The confluent areas are assessed as to the likelihood of final healing. If this is doubtful they are considered for resection. The small scattered foci are unlikely to reactivate. provided that hyperexpansion of the remaining lung tissue is not permitted. It is recognized that at the stage of onset tuberculosis may be a generalized disease, and that resection of any primary pulmonary infection is not indicated unless, after a long period of time. activity of the lesion persists despite all other forms of treatment. The continued activity of a caseous pneumonia following ruLpture of an intrabronchial gland ma\ require removal of the affected area of the lung. The chances of children controlling their disease by simple methods is very high, and resection of lung tissue under the age of 16 is only carried out where the disease has remained active over a long period. Between the ages of 16 and 20 there is considerable instability of the disease, and resection is only carried out between these ages after careful assessment. After resection the remaining lung tissue on either side of the chest must not be permitted to expand beyond its normal size. This entails reducing the volume of the hemithorax by elevation of the diaphragm and/or resection of ribs. Tuberculous endobronchitis at the proposed line of section of the bronchus must be cleared as much as possible by chemotherapy before resection. Resection is contraindicated while tuberculous ulceration, granuLlation tissue, or oedema persists at the line of section, but simple redness of the mucosa does not obviate operation. The use of chemotherapy to control the acLIte phase or an exacerbation of the disease takes precedence over its use as a cover for operation, although it is routinely used during the operation.