Pleuropneumonectomy in Tuberculosis

In 38 pneumonectomies performed at the Chicago State Tuberculosis Sanitarium during the past three years, the extrapleural plane of dissection was utilized over whatever areas of lung were firmly fixed to chest wall. Of these 38 patients, eight were done by the total extrapleural method. Four of these eight had preoperative bronchopleural fistulae with mixed empyemata. Antituberculosis drugs have made more patients amenable to surgery and have stimulated interest in this technique.

Empyema following pneumonectomy is a cause of greater morbidity than that following lobectomy, where lung tissue remains to eventually fill the pleural space. Among patients requiring pneumonectomy for tuberculosis, who have also had tuberculous pleuritis and especially empyema, it is of the greatest importance to remove all the pleural peel. This is infected tissue, in which the tubercle bacillus is firmly established. If left behind, it represents a continuous source of contamination for the dead space within the hemithorax. The removal of this peel is most easily accomplished by developing the extrapleural plane as completely as possible early in the procedure and if feasible, removing the empyema completely without entering its cavity. Preserving the integrity of the empyema, however, is not as important as removing the entire empyema wall, since the surface of relatively normal tissue remaining after extrapleural dissection can withstand a single contamination by empyema fluid, whereas it may not withstand the continuous contamination by remaining infected tissue.

From the technical standpoint, the extrapleural plane, if properly developed, is safe, and in patients with marked pleural disease, often the easier plane of dissection. In addition, one is less apt to break into thin-walled apical cavities with the added thickness of the pleura between the lung and dissecting finger. With this technic, bleeding may actually be less than in procedures where cut surface of peel is left in situ, for vessels in normal tissue retract more certainly than those developed as a result of inflammation.