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Before the development of antituberculosis drugs in the mid-1940s, pulmonary resection and thoracoplasty stood as the primary therapies for the treatment of pulmonary tuberculosis. In the nineteenth century, Parker and Thompson described the use of pneumothorax to partially collapse an empyema cavity. This method, along with unilateral phrenic nerve division, plombage, and pneumonolysis, emerged as therapies for potential obliteration of tuberculous cavities during this period, but complications were common, and these operations were soon outdated.
treated a patient with tuberculous empyema by intercostal incision, rib resection, and pleural debridement with subsequent resolution of the cavity. In the last decade of the nineteenth century, several surgeons, including Estlander,
His cavity closure rate in 93% of survivors was coupled with a mortality rate of only 10%. This procedure had a significant effect on our ability to treat tuberculosis. The incidence of mortality from tuberculosis in the United States fell from 300 per 100, 000 in 1880 to only 69 per 100, 000 in 1937.
Today, thoracoplasty is rarely, if ever used to treat primary pulmonary tuberculosis. However, it remains a treatment option for tuberculosis and pneumonectomy complicated by bronchopleural fistula or empyema. Surgeons in developing countries continue to use thoracoplasty as a primary treatment of pulmonary tuberculosis complicated by empyema, bronchopleural fistula, and drug-resistant mycobacterial strains.
Thoracoplasty is better tolerated in patients in poor medical condition who may not tolerate pulmonary resection. Unfortunately, the increased incidence of AIDS over the past decade has led to the resurgence of tuberculosis and atypical mycobacterial infections in immunocompromised, debilitated patients. These patients often respond poorly to the usual drug regimen and will not tolerate pulmonary resection. Therefore, thoracoplasty once again may play a role in the treatment of this select group of patients.
Before performing thoracoplasty, the surgeon must carefully plan a detailed preoperative strategy. A traditional thoracoplasty removed up to 7 ribs. A modified or limited thoracoplasty removes only 4 or 5 ribs and may be indicated to close a small infected apical space after lung resection. The size of the cavity is the determining factor in planning the extent of resection.
The planned resection must be of adequate size to completely close the affected pleural space. A quality posteroanterior chest radiograph will allow the surgeon to determine the inferior extent of the cavity. The deforming nature of this operation creates a significant and permanent loss of unilateral ventilatory capacity. Thus, pulmonary consultation and formal pulmonary function tests are vital in assessing the patient's ability to tolerate such a resection. Today, surgeons combine limited thoracoplasty with new plastic techniques to limit the extent of rib resection and chest wall deformity.
Surgical treatment of pulmonary tuberculosis.
in: Sabiston Jr, DC Spencer FC ed 6. Surgery of the Chest. Vol 1. Saunders,
Philadelphia, PA1995: 752-772