Late Complications of Collapse Therapy for Pulmonary Tuberculosis

doi:10.1378/chest.120.3.847

Chest

Volume 120, Issue 3, September 2001, Pages 847-851

https://doi.org/10.1378/chest.120.3.847 Get rights and content

Abstract

Study objectives

Collapse therapy for pulmonary tuberculosis involved placement of various materials to occupy space and keep the lung collapsed. Complications are encountered decades later.

Patients and methods

Between 1980 and 1997, we treated 31 patients with a history of pulmonary tuberculosis in whom collapse therapy had been used and who later developed complications related to their treatment. Pyogenic empyema was present in 24 patients, pleural calcifications with bronchopleural fistula was present in 3 patients, pleural calcification with nonresolvable pneumothorax was present in 1 patient, and migration of a foreign body with formation of subcutaneous mass occurred in 3 patients. All patients with empyema were treated with antibiotics and tube drainage of pus. In addition, Lucite balls were extracted in 4 patients, lung decortication was performed in 6 patients, thoracoplasty was performed in 2 patients, and fenestration was performed in 16 patients. Bronchopleural fistulas were closed with sutures and reinforced with intercostal muscle flap in three patients; in one patient with pleural calcification and nonresolvable pneumothorax, tube drainage was attempted. In three patients with subcutaneous mass due to paraffin migration, paraffin was extracted.

Results

Pulmonary decortication (six patients) and thoracoplasty (two patients) resulted in elimination of empyema. Extraction of Lucite balls resulted in lung expansion and elimination of empyema in three of four patients; draining sinus remains in one patient. Fenestration resulted in elimination of empyema in 12 of 16 patients, with 3 patients with residual draining sinuses and 1 patient with remaining empyema. All bronchopleural fistulas closed with intercostal muscle flap remained closed. Following extraction of paraffin blocks, infection developed in one patient. During the follow-up period, three patients died, all of unrelated causes.

Conclusions

Delayed complications of collapse therapy for tuberculosis should be treated without delay. Pressure on adjacent structures or their erosion presents danger and mandates immediate extraction; however, there is no need for routine removal of every residual plombe. Further increase in the number of multiple-drug resistant strains may force the return of collapse therapy.

Section snippets

Materials and Methods

Between 1980 and 1997, we admitted 31 patients with a history of pulmonary tuberculosis. These patients had been treated in the 1930s through 1950s with a range of invasive methods, such as artificial pneumothorax and various forms of plombage. Although no effective chemotherapy was available at that time, the disease was arrested in all patients. However, the invasive therapeutic procedures and the materials used for plombage resulted in a variety of complications. There were 21 men and 10

Results

Pulmonary decortication resulted in complete expansion of the lung and return to normal activity in all six patients. In both patients treated with thoracoplasty, the empyema was eliminated, and they did well. Extraction of Lucite balls resulted in complete lung expansion and elimination of empyema in three of four patients; draining sinus remains in one patient who also underwent fenestration. Fenestration resulted in obliteration of the pleural cavity by granulation tissue and elimination of

Discussion

Before the discovery of antimicrobial drugs and development of techniques of pulmonary resection, collapse therapy was the mainstream of treatment for pulmonary tuberculosis. It evolved from the idea that collapse of the lung would put the lung at rest and thus promote the healing process.² Also, it would limit the spread of tuberculous infection by collapsing the diseased portion of the lung and so prevent spread of tuberculous material to other, uninvolved parts of both lungs. A successful

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Extensively drug-resistant (XDR) tuberculosis is rare in France. Treatment of XDR tuberculosis is difficult and therapeutic failures are frequent. Surgery is considered as one of the therapeutic options, but is of little use regarding its high morbi-mortality. We report successful treatment of a XDR tuberculosis case with a 21-month antibiotic regimen followed by a surgical collapse therapy because of persistence of a large cavity. No relapse was observed after five years. Surgery in the XDR tuberculosis treatment is discussed.
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As the method gained in popularity, many means to create and maintain the collapse were applied: artificial pneumothorax with air refills, phrenic nerve crush, thoracoplasty, and extrapleural plombage. In the latter case, many available materials were used: fat, paraffin wax, bone, gauze sponge, silk, gelatin, rubber balloons, oil and, as in our case, Lucite balls.2 The occurrence of long-term complication of these treatments is debated.2-4
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Two patients required femoral/femoral bypass to repair aortic erosion. Weissberg and Weissberg3 reported 31 patients with complications following collapse therapy. Pyogenic empyema occurred in 24 patients.
Foreign Bodies in Pleura and Chest Wall
2008, Annals of Thoracic Surgery
Citation Excerpt :
However, leaving the FB in the chest (either in the pleural cavity or extrapleurally) predisposed the patient to a potential infection at some future time. Indeed, a certain proportion of the FBs became infected, resulting in some of the patients in a full-blown empyema; in others, in smaller collections of pus or in draining sinuses [7, 8]. In other patients, migration of paraffin blocks or Lucite balls into the mediastinum, muscles of the chest wall, or the subcutaneous tissue has been observed.
In contrast to other locations, foreign bodies in pleura and chest wall have been rarely reported and there is no consensus with regard to treatment.
Between 1971 and 2001, 22 patients with foreign bodies in pleura or chest wall were admitted to our department. Their charts were reviewed for preoperative diagnosis, history, kind and location of the foreign bodies, length of retention, management of patients, and complications.
Three etiologic groups were identified: iatrogenic (11 patients), traumatic-intentional (10), and accidental (1). Foreign bodies were extracted in 21 patients: at thoracotomy in 6, direct pleuroscopy in 6, video-thoracoscopy in 4, and simple incision in 5. One foreign body was left behind because of objection of parents. There were no complications and no deaths. Follow-up lasted from one year to 7 years in 15 patients (68.2%). Seven patients did not show for follow-up.
Foreign bodies should be removed from pleura and chest wall, when possible. Small, blunt, peripherally located foreign bodies may be left behind if difficulties at extraction are anticipated. Thoracotomy may be needed for treatment of associated injuries, and for removal of materials used in plombage, because of adhesions. In others the use of videothoracoscopy is preferable. Physicians performing diagnostic and therapeutic procedures in anatomic proximity of pleura should exert utmost care to avoid iatrogenic introduction of a foreign body.

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Clinical InvestigationsSurgeryLate Complications of Collapse Therapy for Pulmonary Tuberculosis

Abstract

Study objectives

Patients and methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Chest

Chest

Chest

Surg Clin North Am

Chest

Chest

Plombage in the 1980s

Thorax

Late complication of plombage thoracoplasty

Thorax

Clinical Investigations
Surgery
Late Complications of Collapse Therapy for Pulmonary Tuberculosis