EXTRAPERIOSTEAL PLOMBAGE WITH POLYSTAN SPONGE .COLLAPSE THERAPY IN SEVERE PULMONARY TUBERCULOSIS.

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP83-00423R000500010001-4
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 27
• Document Creation Date: November 9, 2016
• Document Release Date: November 16, 1998
• Sequence Number: 1
• Publication Date: May 31, 1952
• Content Type: REPORT

Vh((CifS')
25X1A2g ,
Ferrosan Export Corp. a/s
72, Blegdamsvej
Copenhagen, Denmark
Extraperiosteal Plombage with Pol;ystan Sponge.
Collapse Therapy in Severe Prlmonar;y Tuberculosis.
by
Harald Engberg and Jens L. Hansen
From the Oresund Hospital, Copenhagen
Department of Thoracic Surgery (Chief: Tage KJar, M.D.).
Read before the 16th Scandinavian Tuberculosis Congress.
Oslo, May 31, 1952.
Authors' address.:: $resundshospitalet,
Copenhagen, 0.
(LT URA it t A
L18I ARC
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Extraperiosteal pneumonolysis with the Polystan sponge was used by us for
the first time on November 18, 1950. During the subsequent year, we per-
formed this operation with the same technique 90 times on 80 patients, es-
tablishing 87 plombe spaces. In this paper we shall present the results of
the first 52 consecutive cases operated upon at the Chest Hospital of Copen-
hagen and followed up for a minimum of one year.
PRINCIPLES OF THE METHOD
1. Preservation of Ribs.
For a long time, efforts have been made to obtain permanent collapse of
parts of the lungs affected with severe tuberculous lesions without sac-
rificing the bony thorax. Even the most selective form of thoracoplasty
(of any extent) will entail permanent sequelae, viz. major or minor de-
formity, not infrequently persistent pain, and limited mobility of the
shoulder and arm - despite adequate physical therapy instituted immedi-
ately after the operation. In the presence of emphysema or heart disease,
major thoracoplasty entails persistent dyspnoea. During the post-opera-
tive period, thoracoplasty involves a risk of paradoxical respiration,
i
atelectasis, and spread of the tuberculosis. This risk may be consider-
ably reduced by carrying out the operation in sufficiently small - and
consequently sufficiently many - stages. This, however, increases the
psychic trauma.
Extrapleural pneumonolysis permits collapse of the lung while the bony
thorax is left intact. It is not, however, applicable in severe tuber-
culous lesions requiring a permanent collapse? The procedures of fat
implantation (Tuffier), paraffin plombage (Baer (a) ), etc. have been
practically abandoned. Combined collapse operations, i.e. limited thor-
acoplasty with apicolysis and extrapleural pneumonolysis (Graf, cock,
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et al., Gravesen, Rischel) have not gained much ground. Sufficient exper-
ience has not yet accumulated, although some late results have been report-
ed by Buhl. The latest modification of the Hoist operation is also of com-
bined thoracoplasty and extrapleurai pneumonolysis, but with covering of
the lung against the pneumonolysis space, as a continuous and adherent
fibro-musculo-osseous layer is sutured over the apex and to the inside of
the chest wail as well as to the mediastinal pleura. Semb's modified meth-
od (b) differs from his original procedure (a), as small pieces of bone
are placed on the periosteum over the covered apex. This makes for a more
rapid regeneration of the ribs. G. Maurer's combined collapse operation -
using the scapula as an intrathoracic "plombe" - spares the bony thorax to
a certain extent. Pending further experience, however, we cannot assess
the value of these methods.
The bony thorax is better preserved by the Paneth and Bailey methods which
do not involve removal of any ribs. Especially with the last-mentioned
method, the entire collapsed apex is covered with intercostal muscles and
periosteum in a continuous layer, just as in ordinary thoracoplasty. The
ribs are preserved (but denuded of periosteum). They receive their nutri-
tion from the bone marrow (and from the wound, effusion ?). The thoracic
stability is practically speaking equally well preserved by the Overholt
costoversion thoracoplasty.
Preservation of the ribs reduces the operative risk; paradoxical respira-
tion, atelectasis, and tuberculous spread are less apt to occur. Deformity
of the chest and reduced mobility of the arm are avoided. Even total pneu-
monolysis may as a rule be accomplished in one stage, when the ribs are
preserved.
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2. Prevention of Local Complications.
The solid covering of the apex.in ordinary thoracoplasty and in pneumonolysis
of the Bailey and Overholt types almost entirely obviates the risk of local
complications. We call these types of pneumonolysis extraperiosteal*), be-
cause the periosteum (and, in continuation, the intercostal muscles with the
intercostal vessels) is preserved as a solid covering layer over the tubercu-
lous part of the lung. The superficial part of cavities, particularly large
ones adherent to the chest wall, is not infrequently supplied by the inter-
costal arteries and is drained in part through intercostal veins and lympha-
tics. These important patho-physiological factors are respected in extraper.,
iosteal, not in extrapleural pneumonolysis. Therefore, thoracoplasty is very
seldom followed by cavity necrosis which is a common complication following
ntrapleural and extrapleural pneumonolysis in the presence of superficial
cavities.
tJhen a correctly performed extraperiosteal pneirn onolysis is followed by space:
infection, the source is probably in most cases lymphatics and lymph nodes
which are inevitably damaged in freeing the lung over the cupula and in the
costovertebral gutter. Like other workers, we have in several instances been
able to demonstrate tubercle bacilli and pyogenous cocci. in the lymph nodes
posteriorly in the upper intercostal spaces. Another, evidently more un-
common cause of tuberculous space infection (and of bronchial fistula) may
be cavity wall necrosis due to ligation of the upper intercostal vessels in
apicolysis which compromises the blood supply to the superficial cavity wall.
As a rule, however, the supply of arterial blood through anterior and inferior
anastomoses proves sufficient.
The "extraperiosteal" thoracoplasty and apicolysie procedures previously
used by A. Maurer and W. Kremer (a) are entirely different methods, worked
out on principles and points of view differing widely from ours.
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With extensive apicolysis in the presence of large cavities, however, the
pathophysiological condition following extraperiosteal pneumonolysis may
partly resemble that which is risked in extrap].eural pneumonolysis: A-too
limited blood supply and a consequent risk of cavity necrosis.
In this way, there will be a competition between the advantages of extensive
apicolysis and the risk of cavity necrosis resulting in tuberculous space irk-
faction and bronchial fistula.
It is generally recognized that extraperiosteal, pneumonolysis is less apt to
be followed by local complications than the extrapleural method. Extrapleu-
ral pneumothorax resulted in tuberculous empyema in 16% of J.H.E. Roberts'
patients. Bronchia fistulae occurred in 10% of the Rohrbaoh series (Heidel-
bach). Extrapleural paraffin plombes have been almost entirely abandoned.
Plombage with polymethyl metacrylate (lucite balls) was followed by extra-
pleural tuberculous empyemas in 21.5% (Trent et al.). Following extrapleur-
al plombage with Polystan sponge and Spongostan (gel foam) Linden & v." Rosen
have reported bronchial fistula with tuberculous infection in 10%.
These complications are far less common following extraperiosteal pneumono-
lysis, i.e. ordinary thoracoplasty (with sub periosteal rib resections) or
the Bailey and Overholt types. Kremer (b) is now reported to employ extra-
periosteal paraffin plombage. Lucas & Cleland use lucite balls or solid
polyethylene ("Polythene") spheres, Morriston Davies et al. extraperiosteal
~olythene packs. In these English series, bronchial fistulae and tuberculous
infection occurred in only about 1%. v. Rosen has also adopted extraperio-
steal plombage.
Ensuring Permanent Colla.se. - r es of Plombes.
Insufflation of air, filling with oil, paraffin plombes, or tissue transplan-
tation have proved unsatisfactory means of preserving a permanent collapse.
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The Overholt costoversion thoracoplasty is the first transplantation method
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which appears to ensure collapse, but no late results have yet been published.
The advent of plastics afforded plombage material which is chemically indiffer-
ent and which may be made in practically any desirable physical property. Al-
though Kleinschmidt, as early as 1941, had introduced plastics in surgery, major
experiments with these substances in collapse therapy of pulmonary tuberculosis
were not instituted until after the war. Wilson introduced lucite balls in 1946,
Morriston Davies polythene packs in 1948, and Bing the Polystan sponge in 1950.
Today there is hardly any doubt that the spongy plombe has marked advantages
above other types with a smooth, continuous surface. We have abandoned the ori-
ginal plombe, which is too soft.,. and. now use a somewhat harder Polystan sponge
the shape of which fits a normal apicolysis space. Fixation in the tissues,
through ingrowth of connective tissue in the meshes of the Polystan sponge, is
a sine qua non, if a large foreign body is to be tolerated, particularly by an
organism with chronic inflammation in the vicinity?
Plombes with a smooth surface have frequently given rise to effusion, infection,
and other complications. Lucas & Cleland reported effusion in 18 out of 125
cases and rupture of the wound in five following extraperiosteal plombage with
lucite balls and polythene spheres. In 17 out of :L02 cases, Morriston Davies
et al. had to remove the extraperiosteal polythene pack because of effusion or
infection. In our opinion, the explanation is that smooth plombes rub against
the walls of the pneumonolysis cavity in each respiration, i.e. more than 20,000
times in the 24 hours. According to biological experience, such constant trau-
mati~zation of the tissue given rise to effusion. (This takes place irrespective
of the chemically indifferent character of the plombe. It is a reaction to a
purely physical trauma). The presence of effusion increases the risk of infec-
tion. The movements of the plombe in relation to the tissues will be the more
marked, the bigger the plombe. The smaller, multiple plombes in Lucas & Cleland's
series gradually become fixed to a certain extent. Unlike Morriston Davies'
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larger solitary pack, they have more rarely given rise to infection, and their
removal has been required only in exceptional cases.
The considerable incidence of complications which followed upon Linden and V.
Rosen's application of the Polystan sponge was due to the extrapleural insertion
of the plombe. In addition, the combination with Spongostan in their series gave
rise to marked effusion during the first post-operative weeks.
According to what has been stated above, we feel that when plombage is indicated,
extraperiosteal plombage with a chemically indifferent substance which may be
fixed by the tissues is the most attractive method, in theory as well as in prac-
tice, Of the plastic plombes made to date, the Polystan sponge appears to be
most suitable in the permanent collppse therapy of pulmonary tuberculosis.
It must be pointed out that the plombe is only expected to ensure collapse until
ribs. have regenerated at the end of three months. :From that time on, the regen-
erated ribs provide permanent collapse and immobilization.
INDICATIONS
Unlike most previous authors on the use of plastics in the surgical collapse
therapy of pulmonary tuberculosis, we have used this method only in striotly
selected cases - i.e. those which are inoperable or poor surgical rksks accord-
ing to ordinary criteria. These indications correspond approximately to Baer's
(b) "relative indications" for paraffin plombage 30 years ago. Only 18% of 263
patients in 1951 had extraperiosteal Polystan plombage, while 52% had other our-
gical collapse procedures, and 30% were treated by pulmonary resection.
Extraperiosteal plombage was used primarily in cases believed to be unsuitable
for any other operation. (1) Pronounced pulmonary emphysema, bronchitis, bronchial
asthma, severe corpulmonale, pronounced obesity, advanced age, etc., are indica-
tions-for the procedure. (2) Another group of indications includes severe con-
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tralateral lesions or contralateral pneumothorax, previous or planned con-
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tralateral operation. Often these indications are combined. (3) In the
presence of superficial, rather large sub-apical or lower cavities, which
so.far have been deemed suitable for extrapleura]. pneumonolysi.s because a
thoracoplasty would have to be too extensive, we used extraperiosteal plom-
bage in an endeavour to reduce the incidence of cavity rupture and empyema.
It is not our intention to let extraperiosteal plombage replace any of the
old-established surgical procedures in cases where the latter may be safely
used. Plombage was preferably used as a supplement to those operations which
have been available so far in the treatment of pulmonary tuberculosis. For
the time being, plombage is, in our opinion, primarily a procedure to be
used when traditional methods are considered too risky.
OPERATIVE TECHNIQUE.
The extent of the operation is determined as in thoracoplasty. It is carried
out like thoracoplasty, stripping the periosteum from the ribs. The only dif-
ference is the preservation of the ribs. As a rule apicolysis (by the Semb
method (a) ) is performed. In a cautious and gentle operation, a continuous,
well vascularized layer of intercostal muscles and periosteum is preserved
over the collapsed part of the lung. On top of this, the Polystan sponge is
placed. It is fixed by the denuded ribs. The plombe is separated from the
critical area of the collapsed upper lobe by osteogenic tissue. The details
of the technique have been described elsewhere (Hansen & Engberg). More de-
'
tailed descriptions of the operative procedures have been published by
Maraschhio (in whose series, however, the Polystan sponge was supplemented
with Spongostan) and by Morriston Davies et al. whose procedure is in all
essentials like ours, only performed with another type of plombe.
AF'iER-TREATMENT.
Following extraperiosteal prombage, antibiotics are administered for five or
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six days as a prophylaxis against pyogenic infection. Antibiotic therapy
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directed against the tuberculosis, if indicated., is administered before the
operation and continued on the usual lines. On the second post-operative
day, effusion and blood are aspirated from the space. The paracentesis is
repeated once or twice during the first ten post-operative days, if indicated
by the X-ray appearances and pressure symptoms, if any. Air may be itjected
into the plombe from the 10th to the 14th day, if a particularly intensive
collapse is desired, viz. in medial or very large cavities. The plombe cap-
sule can resist pressures of 120 to 140 cm of water at the end of a few weeks.
The insufflations are continued, if required, during the two or three months
following the plombage - at increasing intervals. Further refills are un-
necessary and ineffective, as ribs have regenerated over the sollapsed area.
Should a residual cavity persist at the end of three months, its size and
character must decide further treatment. Small remnants of a cavity often
have a tendency to close by shrinkage owing to the, immobilization under the
regenerated ribs, as is seen.following thoracoplasty. Larger residual cavi-
ties which fail to exhibit a tendency to shrink on conservative therapy,
should be treated by pulmonary resection below the, plombe capsule through a
stadard thoracotomy below the area of the capsule. In cases of collapse
failure following subtotal or total extraperiosteal plombage, the lung re-
section (pneumonectomy) is performed through an anterior vertical thoracotomy.
Pulmonary resection below a plombage is carried out in exactly the same manner
as following thoracoplasty, but it involves an extra risk owing to the poesi-
bil4ty of a plombe space infection, if rupture of an adherent cavity should
occur during the intervention. In our experience, secondary resection of the
lung (as well as cavity drainage) should not be done until three or four
months, preferably not until six months after the plombage. At that time,
the oedema has been replaced by fibrosis,. and the plombe capsule as well as
the regenerated ribs form a solid barrier between the operative field and the
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POSTOPERATIVE COMPLICATIONS.
The 90 extraperiosteal piombage operations with Polystan sponge on 80 patients
were not followed by serious complications, deaths, or spread of the tuberculous
infection, As a matter of routine, serosanguinolent effusion was aspirated
once or twice, but this cannot be counted as a complication. The effusion is
due to hemorrhage, as the hemoglobin content in the aspirated fluid is usually
about 50 - 60%. Infection was not demonstrated in any case despite routine
cultures (anaerobic and aerobic) from all the fluids for tubercle bacilli and
pyogenic bacteria.
TABLE I
The complications are presented in Table 1. Tear of the pleura occurred in
four instances without essentially influencing the respiration or the general
condition. Following treatment (needle aspiration in three cases, under-water
drainage for two days in one) total re-expansion of the lung below the area of
the plombe was obtained. Atelectasis, due to intrabronchial stagnation of se-
cretion in two instances and to the pressure of the effusion in a third case,
immediately yielded to treatment (aspiration of the effusion and bronchoscopy).
Two patients developed effusion, necessitating four aspirations in the course
of the first two post-operative weeks, yielding a total of 1700 and 800 ml res-
pectively. Then, the effusion ceased, and no infection occurred. Each time,
the aspirated fluid showed a hemoglobin content of 60 - 65%, so that in these
oases also the effusion appears to have been due to hemorrhage. Total rupture
of the wound occurred on the tenth post-operative day in one of our earliest
cases (a 61-year old man with severe chronic bilateral lesions, case record
451). Contrary to our custom, aspiration had not been performed, and the rup-
ture was presumably due to the effusion. Following re-suture, the course was
uneventful. Although the plombe space had been open to non-sterile surround-
ipr~ed~5~~8/diJr i~i~p-1;tI~P~~OntH1i80?38~101ti1 the patient
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suddenly died in his home from hemoptysie (from a contralateral, non-operated
cavity).
These 90 operations were, thus, followed by complications - exclusively mild
ones - in a total of eight cases (9%) during the first few post-operative weeks.
None of these complications differed from those seen following thoracoplasty
in ordinary series. Their incidence would doubtless have been perceptibly'
higher following thoracoplasty in a material of such poor risks as the present
one:. The preservation of the denuded ribs did not give rise to complications.
GENTLENESS OF THE OPERATION
Extraperiosteal pneumonolysis with Polystan sponge plombage has completely ful-
filled the expectations that it is a very gentle collapse operation. The com-
plications have not influenced the patients' health, The fact that no deaths
have attended 90 operations on 80 patients, most of whom were in poor general
condition, demonstrates the slight influence of the intervention on the cardiac
and pulmonary function. The absence of post-operative spread and re-activation
of. existent foci in this series, which consisted chiefly of severe cases, illus-
trates the gentleness to the diseased lungs. The earliest puncture at which
spread occurred was three months after the plombage in a streptomycin-resistant
patient who succumbed at the end of 10 months (90/51). Another fact which ill-
ustrates the slight influence of this intervention on the respiratory function
is.that in three instances bilateral plombage could be carried out in one stage.
Ona of these patients was a 51-year old male (959/51) with mild heart disease
(bundle branch block). On both sides the plombes reached the 7th rib (Fig. 3).
The patient developed a tear in the left pleura with resulting pneumothorax
and a small intrapleural effusion. Another male patient, 33 years of age,
(377/51), had bilateral plombage in one stage to the sixth and fifth ribs re-
ge%1 %8 CI 3/-p & 1i0( ponolysis in one
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stage, to the sixth rib on both sides. None of them exhibited post-operative
dyspnoea worth mentioning. One was able to sit up in bed two hours after the
operation during a demonstration for surgeons who were visiting the hospital.
In:one case (female, aged 26, 696/51) bilateral plombage was carried out in
two stages with an interval of only 19 days without untoward effects. In the
case of a 32-yeard old male (641/51) preoperative bronchospirometry had shown
that the left lung contributed only 10% of the total pulmonary function, ven-
tilation, diffusion, and. reserve, as it had previously been affected with
severe lesions. And yet, he exhibited only moderate dyspnoea following right-
sided extraperiosteal Polystan sponge plombage. This patient could not toler-
ate streptomycin or PAS and did not receive either. He developed a staphyloco-
coic space infection, requiring, two months later, a re-operation with removal
of the plombe and a seven-rib thoracoplasty. This intervention also was not
followed by respiratory disturbances. A 24-years old male (358/51) had a his-
tory of right-sided tuberculous empyema. Decortication of the pleura, which
was 2 - 3 cm thick, injured a small, hitherto unrecognized cavity, and the
operation only made the pulmonary function poorer, as a new empyema developed.
In the course of extraperlosteal plombage to the 6th rib on the left, three
months after the right-sided decortication, the pleura was torn. This did not,
however, lead to major dyspnoea. One year after surgery, all these six patients
are without clinical signs of disease and without demonstrable cavities. The
last-mentioned patient is sputum positive (but only one colony on culture),
whereas the others are sputum negative.
FOLLOW-UP SERIES
The first 52 consecutive patients who had extraperioateal Polystan sponge plom-
bage at the %Oresund Hospital have been followed up for one year. Seven have
had bilateral plombage (three'in one and four in two stages). In one case, an
exAe t+; ' ilePPT-*MP'1 @TaICIAOR.' 0U3ttQfl p01H} other words,
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these 52 patients had a total of 60 operations, and 59 plombe spaces were es-
tablished, If thoracoplasty had been performed to obtain a similar extent of
collapse as that planned in the extraperiosteal plombage in this series, we
have calculated (on the basis of our ordinary clinical and radiological cri-
teria) that 152 operations would have been required. These 52 patients have,
therefore, been saved 92 operations - and a high operative risk.
THE SEX RATIO AND AGE DISTRIBUTION WILL BE SEEN FROM TABLE 2
TABLE 2
There~-~s a relatively large proportion of elderly patients, as 38% were over
40 years of age. In two previous series of thoracoplasty from this hospital
only 11% and 20% respectively were over 40 (Hagn-Meincke; Kjaer & Hansen).
The severity of the tuberculous lesions was evaluated on the basis of Cold's
classification. In this series, only 20% could be assigned to Group I (ex-
clusively unilateral or mild bilateral lesions without contralateral activity),
while 42% belong to Groups III and IV (severe bilateral lesions or bilateral
cavities). In Hagn-Meincke's series 53% belonged to Group I and only 8% to
Groups III and IV. In K,1aer & Hansen's series the corresponding values were
54% and 9%. These two series include all thoracoplasties (664 cases) performed
in the hospital from 1935 to 1945 inclusive.
Table 3 gives the causes why extraperiosteal plombage was preferred to other
procedures.
TABS
OPERATIVE CRITERIA.
The 10 patients deemed too poor risks for any other operations were as follows:
Two with severe dyspnoea, two with a history of contralateral pleurisy as well
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as'bronchial asthma and emphysema, two with extensive contralateral extrapleu-
ral pneumothorax, two considerably obese subjects about 60 years of age, one
patient with a history of contralateral empyema and with severe dyspnoea. In
the last-mentioned case pulmonary resection was planned, but the patient took
ill when the anaethesia was started and therefore had plombage instead.
The 31 patients with contralateral lesions: Sixteen with Qontzalateral cavities
(five of them had bilateral plombage), eight had contralateral artificial pneu-
mothorax, two had contralateral extrapleural pneuraothorax, one had had contra-
lateral thoracoplasty and exhibited less marked, presumably inactive changes on
the contralateral side. Three patients with slight apical lesions had plombage,
because they asked for the smallest possible intervention and were reluctant to
undergo thoracoplasty. In six cases of superficial cavities, plombage was pre-
ferred, in three partly because of age (over 45) and in the other three partly
because of extremely superficial cavities making (xctrapleural pneumothorax too
risky, and partly because it was believed that thoracoplasty would have become
too extensive. In two instances it was considered inadvisable to choose a pro-
cedure which pre-supposed after-treatment with pneumothorax - as one lived far
from any phthisiologist and the other one was asocial. In the latter case, a
thoracoplasty in several stages was also out of the question.
In five cases, bacillary resistance to streptomycin and PAS had been ascertain-
ed prior to the operation. In another two cases antibiotic therapy had been
discontinued after a short time because of intolerance, before the operation
was decided. Isonicotinic acid hydrazide was not available at the time when
this series was treated.
Out of the 52 patients, 11 remained for after-treatment in the hospital, while
41 received their after-treatment in eleven different sanatoria in Denmark.
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LATE' COMPLICATIONS
Table 4 presents the late complications in the follow-up series.
TABLE 4
Staphylococcic space infection occurred in three cases (case records 641/51,
208/51, 612/51) two, eight, and fourteen months respectively after the pl,om-
bage. The symptoms were slight oppression and moderately or higher elevated
temperature and erythrocyte sedimentation rate. The general health remained
relatively unaffected. Following preliminary antibiotic therapy, according
to sensitivity tests of the bacteria from the aspirated fluid, re-operations
were performed with removal of the plombe and the over-lying ribs, and, if re-
quired, also the lower part of the scapula. The re-operations did not affect
the pulmonary function, as the firm plombe capsule and the regenerated ribs
rendered the intervention physiologically a purely extrathoracic one. The
wounds healed normally with drainage. All three patients were cured of their
tuberculosis after the plombage, and their sputa have remained negative through-
out the follow-up period. No tubercle bacilli were found in the space, and
there were no bronchial fistulae. In these instances, there has probably been
a question of lymphogenous or haematogenous infection.
One patient (840/51), while in a sanatorium, received repeated oil injections
into the plombe to prevent its shrinkage. Two months after the operation, he
developed a staphylococcic space infection. Since in this case the infection
developed after an injection of oil (the fourth injection) it was probably due
to bacteria introduced with the injection. (We have seen two other cases devel-
oping infections after oil injections into the space, but these cases had the
primary operations in a sanatorium, and are, therefore, not included in the pres-
ent series from the hospital.)
In two instances, pulmonary resection because of residual cavity (90/51, 536/51)
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was followed by tuberculous space infection with bronchial fistulae.
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In one of these oases, the pulmonary resection was performed two months after
the plombage, and this has no doubt been too early,. In the other case, the
interval was four months. In both these instances, the cavity was firmly ad-
herent to the under surface of the plombe capsule, so that rupture of the
cavity and injury of the plombe capsule occurred in the course of resection.
Both had thoracoplasty and removal of the plombe. One of these patients
(90/51) died six months later from slowly progressing bilateral lesions, where-
as the other one (536/51) is sputum negative and has only a small fistula. How-
ever., resection of the clavicle was needed to close the space.
In one case (4/51) the plombe and the overlying ribs were removed seven months
after the operation because of constant complaints of pain. It is doubtful,
however, whether real pain was present. Another patient has also complained
of pain, but has not received any special treatment. The presence of late pain
in two out of 52 cases (4J) following extraperiosteal Polystan sponge plombage
does:not distinguish this operation from ordinary thoracoplasty. In a material
treated by the latter procedure and studied particularly with a view to late
intercostal neuralgia, chronic pain was noted in 3 out of 50 cases (6%) Hensen.
Late complications, accordingly, occurred in a total of eight of the 52 cases
with 60 plombage operations followed up for a minimum of one year (15% of the
patients, 13% of the plombes). Three instances of space infection (5% of the
59 plombe spaces) are typical plombage complications which must be attributed
to the method per se. The remaining three cases of space infection are arti-
ficial and should be avoidable in future series of plombage. It is doubtful
whether the plombage as such is to be blamed for the late pain in two cases, as
the incidence of this symptom is the same following thoracoplasty.
EFFECT OF THE PLOMBAGE ON THE TUBMCULOSIS
Table 5 gives the results of extraperioeteal Polystan sponge plombage at least
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one Year after the operation.
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TABLE.
A total of 34 patients are sputum negative (65%), while 14 are still sputum
positive (27%) and 4 have died during the follow-up period.
This result cannot, however, be attributed solely to the plombage operation,
but also to secondary surgery. Pulmonary resection. below the plombe area was
done in five cases (4/51, 90/51, 798/51., 922/51, 536/51) because of persistent
cavities. Lobectomy was carried out in three cases, pneumonectomy in one, and
segmental resection in one, In three cases large residual cavities were pres-
ent.. Resection specimens revealed them in two cases to be extremely thick-
walled and unsuitable for collapse therapy. In two cases of lung resection,
the remnants of cavities were so small that it is doubtful whether resection
was justified, as they would probably in time have closed spontaneously due to
the immobilization. The reason why pulmonary resection was carried out because
of persistent positive findings in the sputum in these two cases (two and four
months after the plombage) was lacking experience of the efficacy of the method.
Four of the patients who had secondary pulmonary resection were rendered well
and sputum negative, while a streptomycin-resistant patient (90/i5i:) died from
slow bilateral progression six months after the lobectomy. Secondary cavity
drainage was carried out in two cases. One of the patients (591/51) who had
had bilateral plombage in two stages, exhibited a residual cavity which closed
after the drainage. She is now sputum negative. In the other case (297/51)
the clavity was probably not a residual one, but a new cavity of a lower situa-
tion which persists despite the drainage.
In three of the 34+ cases which have been cured to date, sputum conversion was
not obtained until more than one year after surgery. Such late sputum conversion
is not infrequent following ordinary thoracoplasty. Since only a small propor-
tion of the series has been followed up for more than one year, sputum conver-
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Sion may still occur in some of the positive cases.
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Of the 14 patients with positive sputa three exhibit only one or at most a few
colonies on cultures from repeated gastric washings.
The four deaths during the follow-up period (2/51, 4/51, 90/51, 574/51)
occurred 14, 10, 10 and 6 months respectively after the x traperiosteal plomb-
age', The causes of death were as follows: (1) Corr pulmonale and emphysema as
well as a persisting contralateral tuberculous empyema which closed only in
part following thoracoplasty; (2) haemoptysis from a contralateral, non-opera-
ted:cavity (autopsy not performed); (3) slow bilateral progression in a strep-
tomycin-resistant patient who, a couple of months after secondary lobectomy,
developed a psychosis and refused to take food; (4) a similar progression and
corpulmonale in a patient who had had bilateral p:Lombage in two stages 6 and
8 months respectively before death. At the time of the operation, this patient
had an apical tuberculous empyema with a bronchial fistula, but no plombe space
infection occurred.
The persistent findings of bacilli in the sputum following plombage:may, in at
least ten cases, be attributed to contralateral unoperated lesions existent
before the operation.
In series of ordinary thoracoplasty, Hagn-Meinoke and Refsvm have reported 18%
and 11% deaths respectively at the end of one year, To this may be added the
post-operative deaths: 9% and 7% respectively, or a total of 27% and 18% res-
pectively. These values are far in excess of our 8%. In the two thoracoplasty
series, 50% and 37% respectively were sputum positive one year after thoracop-
lasty, as against 32% in the present series.
Table 6 sets out the good and the poor results (sputum conversion or not) in
the two thoracoplasty series (in per cent of the original number of patients)
at the end of one year's follow-up compared with the one-year results in the
pr Approve Fo a ease 'I J9/O o r R 2 O6 l 1l @bT sion after the
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one-year limit are grouped with the poor results in this table).
TABLE 6
The table shows 60% good results one year after the plombage of preponderantly
severe oases as against 29% and 48% respectively following thoracoplasty in
mixed series with a preponderance of mild cases. Accordingly, the results of
plombage to date easily stand comparison with the outcome of thoracoplasty in
previous series, despite the marked difference in severity. Of course, anti-
biotic therapy has afforded a great help in the cases treated by plombage;
antibiotic agents were not available when the patients with thoracoplasty were
treated. It is unlikely, however, that antibiotic therapy can have exerted
essential influence on the sputum findings one year after surgery, if it has
not entailed cavity closure.
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Shy
The authors stress that preservation of the ribs in the surgical collapse
therapy of pulmonary tuberculosis contributes essentially to preventing
post-operative and late complications and that pneumonolysis according to
the thoracoplasty principle is the safest procedure to obtain permanent
collapse. Both principles are observed in extraperiosteal penumonolysis.
The collapse is maintained by plombage of the space between the lung and
the ribs. The most suitable plombage material is the Polystan sponge, as
ingrowth of connective tissue into the plombe ensures its fixation and thus
counteracts complications.
This operation has been carried out in 80 cases of severe pulmonary tuber-
culosis (90 stages). It was reserved mainly for the poorest risks, unsuit-
able for the traditional colipase operations. The procedure was employed
in only 18% of the cases operated on in 1951. Only 20% of the patients be-
longed to the mild Group I, 42% to the severe Groups III and IV, No post-
operative deaths or serious complications occurred (Table 1.) Follow-up
of 52 patients from 12 to 18 months after the operation revealed three spon-
taneous pyogenic space infections and three artificial space infections
(Table 4.) Four patients had died during the follow-up period, 34 patients
(65%) were cured at the time of the follow-up with sputum conversion and
cavity closure, while 14 were still sputum positive (Table 5.) In at least
10 of the latter cases, the persistent sputum findings are explicable by
contralateral, non-operated lesions.
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References
Aycock, T., 0. Brantigan & H. Welch: J. Thoracic Surg. 9:391, 1940.
Baer, G. (a): Munchen. med. Wchnschr. 60: 1587, 1911,
Baer, G. (b): Munchen, med. Wchnschr. 68: 1582, 1921.
Bailey, C. P.: J. Thoracic Surg. 11: 326, 1942.
Bing, J.: Acta chir. Scandinav. 100: 293, 1951.
Bing, J.: E. Hart Hansen, K. Linden & E. von Rosen: Acta tuberc. Scandinav,
Suppi. 25, 1951.
Buhl, K.: Extrapleural Pneumonolysis. Danish. English Summary, Copenhagen,
1948.
Cold, S.: Studies on the Prognosis of Pulmonary Tuberculosis with Cavitation
Treated Conservatively. Danish. English Summary, Copenhagen, 1939.
Graf, W.: Zentralbl. f. Chir. 66: loon, 1939.
Gravesen, J.: Ugesk. f. Iaeger 104: 1321, 1942.
Grindley, J. H. & 0. T. Clagett: Prc8. Staff Meet. Mayo Clin. 24: 538, 1949.
Hagn-Meincke, F.: Thoracoplasty in Pulmonary Tuberculosis. Danish. English
Summary, Copenhagen, 1949.
Hansen, J. L.: Nordisk Medicin 46: 1710, 1951,
Hansen, J. L. & H. Engberg: Acta chir. Scandinav. In press.
Heidelbach, J. F.: Ztschr. f. Tuberk. 83: 185, 1939.
Hoist, J.: Nordisk Medicin 48: 1290, 1952.
Kjaer, T. & J. L. Hansen: First Scandinav, Congress for Thoracic Surg.,
Stockholm, 1950.
Kletlaschmidt, 0.: Chirurg 13: 714, 1941.
Kremer, W. (a): Beitr. z. Klin. d. Tuberk. 93: 537', 1939.
Kremer, W. (b): cited after Morriston Davies et al., 1951.
Linden, K. & E. von Rosen (a): Acta tuberc. Scandinav. Suppl. 25: 35, 1951.
Linden, K. & E. von Rosen (b): Personal communication, 1951.
Lucas, B.G.B. & W. P. Cleland: Thorax. 5: 248, 1950.
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Maraschio, P.: Acta tubero. Scandinav. In Press.
Maurer, A. & P. Dreyfus le Foyer: Proc. verb. Congr. franc. chir. 45: 890,
1936.
Maurer, G.: Eine kombinierte Lungenkollapemethode zur Kavernenbehandlung.
Basel, 1942.
Morr.iston Davies, H., L. J. Temple & C. Stathatos: Thorax. 6: 209, 1951
Overholt, R. H.: Personal communication, 1950.
Paneth, 0.: (cit.) Ztschr. f. Tuberk. 86: 243, 1941.
Refsum, E.: Thoracoplasty in the Treatment of Cavernous Tuberculosis of the
Lung, Oslo 1951.
R ischel, A.: Nordisk Medicin 31: 1525, 1946.
Roberts, J.H.E,: Brit. J. Tuberc. 32: 68, 1938.
Ronzoni, G.L. & G. Sampaolo: Journ, internat, de cshir. du thorax. 2: 263, 1950.
von Rosen, E.: Discussion to Engberg & Hansen, XVI Scandinav. Tuberc. Congress,
Oslo, May 31, 1952.
Semb, C. (a): Thoracoplasty with Extrafascial Apicolysis, Oslo, 1935.
Semb C. (b): Personal communication, 1950,
Simmonds, T.A.H., R. Laird & N. MacDonald: Lancet II: 347, 1952.
Trent, J.C., J.D, Moody, N.C. Durham, J.S. Hyatt & N. C. McCain: J. Thoracic
Burg. 18: 173, 1949.
Tuff.er, T.:. Sem. med. 11: 202, 1891.
Wilson, D. A.: Surg. Clin. North America 26: 1060, 1946.
Wits 5n, D. A.: J. Thoracic Surg. 17: 111, 1948.
Wilson, D. A. & H. Baker: Surg. Gynec. & Obet. 82: 735, 1946.
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Fig. 1. Extraperiosteal plombage in case of traditional thoracoolasty.
Fig. 1. A. Female, aged 11.2, case rec. No. 11/1951. Tomogram of cavity on a
level with the 2nd - 5th ribs on the right.
Fig.l. B. Same case as Fig. 1A. One year following extraperiosteal pneumo-
nolysie with apicolysis and Polystan sponge plombage. Sputum nega-
tive. Cavity closed. Note the regenerated ribs between the apex
and the plombe..
Fig. 2. Extraperiosteal plombage for giant cavity.
Fig.: 2 A.
Female, aged 55, case rec. No. 712/1951. Cavity of a diameter of
8 cm in the left upper lobe. Infiltration in upper and lower parts
of the right lung. Severe dyspnoea.
Fig. 2 B. Same case as Fig. 2A. Following extraperiosteal pneumonolysis with-
out apicolysis, plus Polystan sponge plombage. Ineufflatione of air
into the pi:ombe space. The infiltrations in the right lung have
diminished. One year later no demonstrable cavity. Two colonies
of tubercle bacilli in the gastric washing.
Fig. 3. Bilateral plombage in one stage.
Fisk. 3,A_. Male, aged 511., case rec. No. 959/1951. Multiple cavities in the
upper lobes of both lungs.
Fi B. Same case as Fig. 3A. following bilateral. extraperiosteal pneumono-
lysie with apicolysis and Polystan sponge plombage in one stage.
One year later no demonstrable cavities. Sputum negative.
ii
Fig. ?+. Shrinkage of the plombe space due to a too soft plombe.
Fig. 4 A. Male, aged 28, case rec. No. 819/1951. One week after extraperiosteal
pneumonolysis with apicolysis and plombage with the original Polystan
sponge (S plombe). Good collapse.
Fig. 1 B. Same case as Fig. 11A. Four months after the operation, plombe space
c
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Fig. 5. Persistent cavity despite good collapse.
Fig 5A. Male, aged 25, case rec. No. 5361951. Giant cavity (diameter 6 cm)
in the left apex.
Fig. 5 B. Same case as Fig. 5A. Two months after extraperiosteal pneumonolysis
plus apicolysis with Ploystan sponge plombage. Cavity persists de-
spite good collapse of the upper half of the lung.
Fig. 6. Subtotal extraperiosteal plombage.
Male, ages 22, case rec. No. 84+4/1952. One year after extraperios-
teal Polystan sponge plombage down to the 10th rib for a destroyed
left lung. (Infiltrations were also present on the right). Good
collapse. Cavity closure. Sputum conversion. Note bolid regener-
ation of ribs over the coilpased lung and partial absorption of the
ribs superficial to the plombe.
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Table 1
Analysis of operative and postoperative complications of
90 extraperiosteal Polystan plombage operations.
(80 patients, 87 plombe spaces).
Tear in pleura .... . . . . . .
. .
4
Atelectasis . . . . . . . . .
. .
3
Rupture of wound . . . . . . .
?
1
Complications, total . . . . .
..
8
( 9%)
No complications . . . . . . .
..
82
(91%)
Table 2
Follow-up series: Sex ratio and age distribution.
Age Males
Females
Both sexes
20 - 29
11
6
17 (33%)
30 - 39
7
8
15 (29%)
4o-49
7
5
12 (23%)
50 - 59
5
1
6)
)(15%)
60 - 69
2
2)
Total
32
52
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Table 3
Follow-up series:
Criteria of extraperiosteal plombage.
Too ill for other procedures . . . . . . . . ? , , . . . . . 10
Contralateral lesions
31
Plombage preferred to extrapleural pneumothorax
because of superficial cavity (thoracoplasty would
have been too extensive to be tolerated). . . . . . . . . . . 6
Small apical cavity . . . . . . . . . . . . . . . . ? . ? . 3
.Easier after-treatment . . . . . . . . . . 2
52
Table 4
'Follow-up series:
Analysis of late complications in 52 cases
(60 operations, 59 plombe spaces).
Staphylococcic space infections
(haematogenous, lymphogenous) ? . . . . . . ? . ? ? ? . ? 3
wtaphylococcic space infections
(due to injection of oil) . 1
Tuberculous space infection (due to operative
rupture of cavity and-plombe capsule) . . . . . . . . . 2
Persistent pain (? ) . . . . . . . . . . . . . . . . . . . . 2
Late complications, total 8 (1)
No complications 44 (85%)
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Table 5
Sputum findings 12 - 18 months following extraperiosteal
Polystan sponge plombage.
Sputum
negative
Sputum
positive
Dead
Total
(Mild cases of bilateral
3
0
0
3
Bilateral
plombage.
(cavities operated in one
(stage.
Severe cases - operated
in two stages.
1
2
1
4
Unilateral
(Moderate contralateral
(lesions.
20
5
0
25
plombage.
(Severe contralateral
(lesions.
10
7
3
20
34
14
4
52
Table 6
Results of one year's follow-up:
Thoracoplasty series and plombage series.
Author Number of Severe cases Mild cases
. cases Groups III-IV Group I
Hagn-Meincke 420
Ref sum
391
Plombage 52
53
Good results: Poor results:
sputum con- Dead or sputum
version positive.
cavity closure.
29 71
48 52
60 40
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