The specialty of thoracic surgery was born in the convergence of two worldwide plagues. These were tuberculosis, as old as humankind, and avian influenza, which struck a war-wearied world in the winter of 1917 and killed more people than the bubonic plagues of the Middle Ages. Today, with tuberculosis becoming resistant to antituberculous drugs, avian flu beginning to appear around the world, and the world weakened again by war and the new pestilence of AIDS, it seems entirely possible that thoracoplasty may become the once and future operation.
First coming to prominence in Europe in the late nineteenth century for the treatment of chronic infections in the chest with complicating space problems and bronchopleural fistulas, thoracoplasty began to receive greater attention in the United States at the time of the 1917 to 1918 influenza epidemic. The most lethal complication was empyema thoracis. The mortality in some of the 29 army camps surveyed was as high as 70%.1 A pneumonia commission and subsequently an empyema commission were appointed to study the problem in the clinic and the laboratory. In the amazing period of 1 year, through the efforts of these two commissions, mortality was reduced to an average of 4.3%.2 As reported by Graham in his insightful book, Empyema Thoracis, two early examples of productive research delineated the adverse effects of open pneumothorax on ventilation and the differing pathology between complicating infection with Streptococcus hemolyticus or Pneumococcus,3 the former being much more common. Associated with this pleural disease were a large number of patients with complicating space problems and bronchopleural fistula.
At about the same time, the other impetus for thoracoplasty was developing in the treatment of tuberculous residua when it was recognized that healing could be accelerated by collapse of residual cavities. Many techniques were employed for this, including pneumothorax, pneumoperitoneum, and even the very first videothoracoscopy, which was used to release apical adhesions.4 Not infrequently, these patients developed infected spaces requiring thoracoplastic procedures, and it was a short step from thoracoplasty for complicating spaces to thoracoplasty as the primary procedure. Enthusiasm for this procedure as an alternative to prolonged, sometimes lifelong commitment to a sanitorium can be imagined from a story told to me by a Greek colleague whose mother had an eleventh rib thoracoplasty performed in three stages by Professor Sauerbruck before World War II using local anesthesia!
The most enthusiastic American proponent of thoracoplasty was John Alexander5 of the University of Michigan, who applied and evaluated the procedure in a large group of patients. A contemporary tale from this period was shared with me by one of his residents, who, along with this fellow trainee, noted that, paradoxically, the application of thoracoplasty to nontuberculous pulmonary cavities was associated with an increased mortality, a concept he only reluctantly accepted.
Thoracoplasty can be considered in four broad categories:
Thoracoplasty with a closed pleural space.
Thoracoplasty with open pleural drainage.
Thoracoplasty with transposition of a muscle flap into the space either to fill the space or to close a bronchopleural fistula or both.
Thoracoplasty done as a preliminary to avoid postresectional space problems.
Contemplation of thoracoplasty in the modern age implies a failure of medical therapy. An open negative cavity or resistant organism with unilateral or bilateral cavitary disease, bilateral disease so extensive that resection is not feasible, and tailoring thoracoplasty to avoid space problems after resection are the probable indications. In these patients, all the precautions observed in the great age of thoracoplasty still apply. First, timing and judgment are more important than the surgery, and thorough understanding of the natural history and pathophysiology of tuberculosis is required for this judgment.6 This begins with the therapeutic value of rest, fresh air, a high-calorie diet, and patience. Time is on the side of the physician. Between 6 and 12 weeks of preoperative antituberculous medical therapy is favored.
As with any thoracic procedures, the patient should be evaluated for cardiac and pulmonary functions and, if marginal, further assessed with differential V./Q. studies or a V.o2,max study to see if the intended procedure can be tolerated. Many of these patients will have had bilateral pulmonary disease and, in some cases, prior surgery. An important part of the preoperative care is the bacteriologic analysis and treatment. Many patients are now manifesting resistance to multiple antituberculous drugs, and close collaboration with infectious disease colleagues is mandatory. Another problem here is infection with atypical tuberculosis, especially in patients with HIV infection or otherwise compromised immunity. The presence of cavitary disease in the lung, even if acid-fast bacilli-negative, leads to frequent invasion of the cavity by fungal organisms, the most frequent being Aspergillus fumigatus. These organisms or tuberculosis itself can lead to development of mycotic aneurysms in the cavity wall. The rupture of such aneurysms can create one of the true catastrophes in thoracic surgery with massive pulmonary hemorrhage. This possibility alone is reason for an aggressive approach to pulmonary cavitary disease. Finally, in this spectrum are bacterial mixed infections that may have led to bronchopleural fistula or empyema as the presenting problem. Again, the emergence of drug resistance is an ongoing problem. All these areas of consideration are made infinitely more difficult in the presence of infection and HIV infection.
Tuberculosis is best considered as a systemic disease, but when it presents in the lung, it begins as an exudative pneumonia favoring upper and posterior portions. It either goes on to resolution or to destruction of lung tissue with formation of scar or loss of vascular supply with resulting caseating necrosis. It is these foci that persist or excavate and may require surgical attention. Since the inception of antibiotic therapy, there has been a greater tendency to reepithelialization of the bronchocavitary junction with less air trapping. The cavity wall, surrounding parenchymal reaction, and pleural reaction are all less. This pleural reaction is very important because it is usually very vascular, and the adhesions formed are part of the body’s attempt to prevent bronchopleural fistula.7 For this reason, mobilization should be done in the extraperiosteal plane unless resection is contemplated both to avoid bronchopleural fistula and because the systemic vessels are difficult to control and can cause massive operative blood loss. Another suggestion that pertains to adhesions is that although during the period of pneumothorax therapy it was always felt necessary to release apical adhesions when thoracoplasty was anticipated, it is best to preserve them. Dividing them lets the lung fall lower in the chest, thereby requiring resection of more ribs to obtain complete collapse.5 Before surgery, it is best to decide how many ribs will need resection and what the often compromised patient can tolerate. It may be necessary to stage the resections to reduce morbidity.
