584 J THE INDIAN MEDICAL GAZETTE [Oct., 1941

/ ? THORACOSCOPY AND PNEUMOLYSIS IN

TUBERCULOSIS

y R. VISWANATHAN, b.a., mj>, M.E.C.P. (Lond.), T.D.D.

Lecturer in Tuberculosis and Infectious Diseases, Andhra Medical College, Vizagapatam

Artificial pneumothorax is, perhaps, the easiest and the most efficient method of collapse therapy in pulmonary tuberculosis. The efficacy of pneumothorax is in direct proportion to the degree to which the diseased portions of the lung can be collapsed. Adhesive pleurisy, depend- ing on its extent, might either completely prevent induction of pneumothorax, or allow

only a partial collapse of the lung. According to Alexander (1937), in about 20 per cent of all cases in which it was undertaken, induction of pneumothorax failed, while in 42 per cent the presence of adhesions produced only partial pneumothorax. Any supportive surgical pro- cedure which can transform a partial pneumo- thorax into a complete one with minimum risk and complications and maximum efficiency must therefore take the .highest place of importance in the surgical collapse-therapy programme. Intrapleural pneumolysis under thoracoscopic control is the method of choice.

Jacobaeus of Stockholm in 1913 originated the method of cauterizing adhesions in the

pleural cavity through the help of a thoraco-

scope. By him, and by many others after him, has intrapleural pneumolysis been brought to a high level of effectiveness. The several reports published so far in medical literature testify to its importance and efficacy. Moore in 1934 reviewed the literature and summarized the

published reports of 2,043 cases of intrapleural pneumolysis. Matson (1934) reports that

among his 249 patients the operation was tech- nically and clinically successful in 152 (61 per cent) patients and that all of these have nega- tive sputum and 83 per cent are working. In 19 patients the operation was technically unsuccessful but clinically successful, all have

negative sputum and 68 per cent are working. In 76 patients the operation was both clinically and technically unsuccessful. Jacobaeus (1915) had technical success in 80 per cent of 150

patients and clinical success in 60 per cent. Gravesen (1930) reports that technical success was obtained in 60 of 85 patients (clinically)' 25 of the 60 patients were much improved, 29 were merely improved, two became worse ana four died. Newton (1940) claims 87 per cent clinical success in 146 patients on whom

pneumolysis was performed. In Benjamin'8 (1939) report on 186 patients, 121 cases are

reviewed in detail. Only in 38 could all the adhesions be cauterized. Amongst them lie

obtained 76.2 per cent positive results. In the 83 patients in whom not all the adhesions were cauterized he reports 73.4 per cent positive results. In my series of 56 cases all adhesions were severed in 34 cases. Technical and clinic*1' successes were obtained in 24 cases givin? thereby 70 per cent positive results. Among5*1 16 cases in whom not all adhesions were Cl1

62.4 per cent positive results were obtained- Six cases proved unsuitable for pneumolyslS after thoracoscopic examination.

Indications for thoracoscopy.?Artifici^ pneumothorax is a necessary preliminary thoracoscopy. Apart from its usefulness 111

cauterizing adhesions in the interpleural space? examination by thoracoscope will enable diagnosis of other diseases and tumours affecting the pleura and the mediastinum.

Indications for pneumolysis.?Closed intra'

pleural pneumolysis is the operative procedme for making an incomplete pneumothorax com-

plete by the severance of adhesions. yie presence of adhesions is not always an indication for cutting them, for bands of adhesions ma}

exist without preventing the necessary relaxa*-, tion of the lung. Moreover, many adhesions g?' either naturally' severed or get sufficients stretched as to be innocuous in course of time-

Hence ordinarily pneumolysis should not o

attempted before three months, after inductio of pneumothorax. Even such an experience^ thoracic surgeon as Alexander considers pnellc molysis a difficult, and potentially danger011", operation. It should not therefore be empl?ye unless there is definite indication.

A cavity that has not been closed by. '

partial pneumothorax of sufficient duratio constitutes the chief indication for the operatio^ of pneumolysis. Peripheral cavities that ha^? as it were by adhesions should be freed ^

cauterization. The operation is indicated a!-

in those non-cavernous lesions which are keP

under tension by adhesion particularly 1

exudative types. Excessive coughing, pain and haemoptys1^

when^ provoked by pneumothorax refills ar

occasional indications for pneumolysis. Acute exudative serous pleurisy and empyej^

are contra-indications for pneumolysis in \1 acute stages. But in the later stages of effusi?

pneumolysis can be attempted after respiratm' It should also not be performed in the preseni of progressive obliterative pleuritis. No attemP

?ct., 1941] THORACOSCOPY & PNEUMOLYSIS : VISWANATHAN 585

Ut; *

f

|.i lnternal pneumolysis should be made when

are Parietal and the visceral layers of the pleura for ln.timately adherent and without band

. lna^lon or when a cone-shaped projection of incA ^ssue is found extending to the periphery

*de the band of adhesion.

st XcePt under exceptionally favourable circum-

0 nces cauterization should not be attempted an adhesion which is less than two centi-

mes in length.

Kr ̂ r^}vi^nary study of adhesions.?Radio-

tin fluoroscopic and tomographic examina- ?f the adhesions ought to be done in order

dir ll?^ers^and their location, size, number,

si ectl?n and extent. Very often many adlie-

raH-S are missed in radiographs as they are not a(jl l0~0Paque. The thickness and extent of the

lesi?ns and the presence of lung tissue in them

Results of intra-pleural pneumolysis

adhesions cut

Martially cut Ptleumo] ysis not attempted

Number of

patients

34

16

6

Total . J 56

Per centage

60.7

28.0

11.3

Clinical success

Num- Per- ber Rentage

24

10

34

70.0

62.4

60.7

SHOWING SITUATION OF ADHESIONS

I number of adhesions seen .. .. 243

I Pper Posterior .. .. .. 142

I al .. .. .. 41

I ypper middle .! .. .. ..41 i ^o\ver 41

COMPLICATIONS

umber 0f patients .. .. 56

^?morrhage .. .. .. ..2

l"xt?US e^us'on ? * ' * ? ? ? ? ?

ensjyg subcutaneous emphysema .. .. 6

Sp0'terat'Ve pleur'tis ?? ?" " 1

?ntaneous pneumothorax .. .. .. nil

_pye^a .. .. .. nil

grapj ?^en be accurately judged by radio-

studi "Ti" ^nc'er these circumstances they can be

c?sCOpy onbr by direct visualization by thora-

sior[a^re ?/ adhesions.?More than one adhe- the ]are a^ways found. In my experience 54 is

aVlan^rSest number found in a single patient,

^nds ac^lesions are in the form of string-like ' ?ornetimes they are like flat tapes.

fan>SLare very thick and fleshy. Occasionally Case TaPe<^ adhesions are met with. In one

frojjj .,^ad to cut such an adhesion extending the r-u anterior axillary line to the angle of

adhes behind. The vast majority of the

Pherai]?ns are found over the upper lobe. Peri- [y they are attached mostly to the cupola

of the pleura or in the posterior axillary line or near the angle of the rib. Out of the total number of 243 adhesions seen in all the 56 cases, 142 were in the upper posterior, 41 apical, 41 upper middle and 19 in the lower part of

the pleural cavity. Pre-operative preparation.?A refill is to be

given the day previous to the operation and the patient is radiographed to localize the adhesion. The chest is prepared as if it is for major sur- gical procedure to ensure complete asepsis. A

quarter grain of morphia and one hundredth

grain of atropine is given an hour before the operation. As local anaesthesia is usually chosen, there is no need to starve the patient.

Technique Choice of instruments.?There are two types

of thoracoscopes: one giving direct vision and the other right-angle vision. Whereas the field of vision is limited with the first, practically the whole pleural cavity can be surveyed by the use of the latter by merely rotating the instrument. There are also the single-puncture as well as the double-puncture thoracoscope sets. In the former the thoracoscope and the cautery are introduced by the same cannula, while in the latter they are introduced through separate cannulae. Some prefer galvano-cautery, while others favour electro-coagulation and cutting by diathermy electrodes. Jacobaeus and Alexander prefer galvano-cautery while Matson and Newton extol the advantages of electro-surgery. I have had experience only of galvano-cautery. I consider that galvano- cautery at dull-red heat will produce sufficient

coagulation of the adhesion before cutting through it, so much so that there is very little risk of haemorrhage, as suggested by the

exponents of electro-surgery. The thoracoscope is introduced through the

selected intercostal space, preferably in the anterior axillary line. After a good survey of the pleural cavity and localization of the adhe- sions the cautery is introduced through the most convenient spot on the chest depending on the situation and direction of the adhesions. Long thin bands can easily be cut a little away from

their attachment to the chest wall. The short

thick ones have actually to be released from

the chest wall by careful enucleation. This

procedure will obviate possible injury to lung tissue which might have been pulled into the

adhesion. Sometimes it may not be possible to cut through a broad thick adhesion which

might contain lung tissue inside. In such a

case a superficial cut may be made all round

the adhesion and the remaining uncut portion may be allowed to stretch. It can be tackled

at a future date.

Post-operative care.?Strict bed rest is

ordered and the pulse and respiration noted

every hour. Pain and cough ought to be con- trolled by aspirin and codeine. I usually give

586 TftE INDIAN MEDICAX GAZETTE [Oct., 1941

2 c.cm. haemoplastin as a routine before and after operation. Sulphonamide pills, two t.d.s., also form part of the routine post-operative management. A refill is done the day after the operation.

Complications

Haemorrhage is perhaps the most dangerous but fortunately is rendered rare by efficient

operative technique. I had two cases which

developed haemorrhage, both to an alarming degree. In severe cases, thoracoscopy should be attempted again and the bleeding point cauterized. Open operation is rarely necessary. Subcutaneous emphysema is a very common

complication. In most cases it does no harm

except some crackling discomfort to the patient. In three cases I found emphysema extending to the face, neck, chest, upper limb and abdomen. In one case owing to delay in refill the lung almost completely expanded and as the patient developed obliterative pleuritis pneumothorax had to be abandoned. In another case, the

patient coughed out all the air from the pleural cavity into the cellular tissue causing extensive subcutaneous emphysema; and the result was

that an x-ray after a subsequent refill showed more adhesions than he ever had before.

Spontaneous pneumothorax as a result of

inadvertent cutting of lung tissue may occur as a complication.

Tuberculous empyema might develop in some cases after pneumolysis. Sepsis and consequent non-specific empyema are avoidable through correct aseptic precautions. Some of the cases develop serous effusion

soon after pneumolysis.

REFERENCES

Alexander, J. (1937) .. Collapse Therapy of Pulmon- ary Tuberculosis. Charles C. Thomas Springfield, Illinois.

Benjamin, P. V. (1939). Proc. Tuberc. Workers Con-

ference. Gravesen, J. (1930) .. J. State Med., 38, 333.

Jacobaeus, H. C. (1915). Klin. Tuberk., 35, 1.

Mvtson, R. C. (1934) .. Surg. Gyn. and Obstet., 58, 619.

Moore, J. A. (1934) .. J. Thorac. Surg., 3, 276.

Newton, H. F. (1940). Amer. Rev. Tuberc., 41, 22.

Plate XXXIV

Fig. la.

Fig. 2a.

Fig. lb.

Fig. 2b.

Photographs through the thoracoscope.

Fig. 3. Fig. 4.

Photographs through the thoracoscope.

Fig. la. Fig. 16.

Fig. 2a. Fig. 2b.

Fig. 3. Fig. 4.