Aninals o/ the Royal College of Surgeons of England (i979) vol 6i ASPECTS OF TREATMENT*

Surgical

treatment

D K Chattopadhyay

MS

of bronchiectasis

FRCS

Royal Infirmary, Sheffield

Introduction In recent years several reports have suggested that pulmonary resection is the treatment of choice in selected cases of primary bronchiectasis. In this study the clinical features and results of surgical treatment in 53 cases of primary bronchiectasis are described.

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Patients and methods The records of all patients undergoing surgery for primary bronchiectasis in the Cardiothoracic Unit of Nitratan Suricar Medical College, Calcutta, during the period I966-68 were reviewed. The 53 patients included in the study comprised 44 males and 9 females with an age range of 6-57 (average 24) years (Fig. i). Cases in which bronchiectasis occurred as a secondary complication of underlying disease such as bronchial neoplasm, tuberculosis, or asthma were not included in the study. The study included an analysis of the symptomatology of the illness, the findings on invesIB-

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tigation, the methods of surgical treatment, and the results of surgery. The routine preoperative assessment of the patients included posteroanterior and lateral radiographs of the chest, bronchography, bronchoscopy, and sputum culture.

Clinical features Eighteen patients gave a history of a severe antecedent illness which may have resulted in bronchiectasis (Fig. 2), a history of pneumonia being elicited in 9 of these cases. In the majority, however, no significant aetiological factor could be elicited in the history.

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Most patients complained of multiple symptoms, but the most common complaint was a productive cough (Fig. 3). General failure of health with complaints of malaise or weakness occurred in less than 5 % of cases and dyspnoea was an infrequent symptom.

*Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor.

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Bronchography In 33 patients the disease was confined to the left lung and in 20 to the right lung, while in i patient both lungs were affected. Of the 21 patients with disease of the right lung, in 6 it affected the whole lung, in 5 it was confined to the middle and lower lobes, and in i o only one lobe was affected (lower in 6 and upper in 4). Of the 33 patients with disease of the left lung, the whole lung was affected in i 6, the lower lobe and lingula in 4, and a single lobe in I 3 (I2 lower and i upper). Bronchography showed a cystic type of bronchial dilatation in 34 cases, cylindrical dilatation in 12, saccular dilatation in 6, and a composite appearance in i case.

Surgical treatment The surgical treatment consisted of pneumonectomy in 22 cases, lobectomy in 22, bilobectomy in 5, and lobectomy combined with segmental lobar resection in 4. There were 4 postoperative deaths, a mortality of 7.5%: I patient had a cardiac arrest, i developed acute pulmonary oedema, i died in irreversible shock, and i died of respiratory insufficiency. Twelve patients had non-fatal complications in the immediate postoperative period: 2 had prolonged pyrexia, 4 developed wound infection, 4 developed atelectasis of the remaining lung, i had persistent air leakage possibly resulting from a bronchopleural fistula, and i developed an empyema and bronchopleural fistula.

Follow-up The patients were followed up for periods ranging from 2 to 54 months. Forty-two patients had no symptoms. Ten patients had persistent symptoms; in 5 cases the symptoms were attributable to recurrent disease (9.43% of the total) and i patient had symptoms due to residual disease. In addition, the patient who developed a bronchopleural fistula and empyema had a prolonged illness which finally resolved with conservative treatment.

Discussion The majority of the patients in the present study presented for surgical treatment during the second and third decades of life. Similar findings were reported by Sachdeva et al.' and Bhatt et al.2, but an earlier age incidence was observed by Perry and King3. The preponderance of male patients seen in this series has been observed previously in studies of bronchiectasis4. Many workers, particularly Roles and Todd5 and Perry and King3, have shown that the prognosis of bronchiectasis without surgery is poor. Excision of permanently damaged segments of lung is the only method of obtaining a complete cure, but the excision must be complete and must not interfere with respiratory function. The use of pulmonary resection in this series was based on an analysis of the clinical features and of the extent of the disease on bronchography and an assessment of the operative risk and the status of the unaffected lung

Surgical treatment of bronchiectasis tissue. When bronchiectasis is bilateral, bilateral surgery in stages may be indicated, beginning with the worst affected side. The patient with bilateral disease in the present study was managed in this fashion. Formerly a higher mortality accompanied pulmonary resection for bronchiectasis. Recent reports have indicated a greater degree of safety in such surgery. Simpson' reported i8I cases with 6 deaths and in the series of Lindskog and Liebow7, which included bilateral cases and complicated cases in all age groups, the hospital mortality was 3%. In this series 4 patients (7.5%) died after operation. The morbidity after pulmonary resection is still fairly high, but the incidence of bronchopleural fistula and septic complications has been greatly reduced in recent years by improved operative technique and the use of modern antibiotics. Bronchopleural fistula and empyema occurred in only i patient (I.89%) in the present study. Postoperative atelectasis is a frequent complication, occurring in 4 patients (7.5%) in the present study; Simpson' reported the results of resection in I8I cases, in 29 of which atelectasis occurred. However, despite the relatively high morbidity associated with pulmonary resection in the present study, 23 patients were discharged from hospital within 2 weeks of surgery. Evaluation of the results of surgery for bronchiectasis depends to a large extent on the patient's own symptomatic assessment after the operation. In this series 42 patients

I97

(79.25%) were asymptomatic and io were improved by operation but had residual or recurrent symptoms, which in 5 cases were attributable to recurrence of the disease. Chesterman8 found recurrence of disease in IO out of I05 cases. It should be noted, however, that many patients were followed up for a relatively short period and the true incidence of recurrent disease may be determined only after a longer period of assessment. I am thankful to Professor B P Chatterjee for guiding this work. I am also grateful to Mr T T Irvin for his helpful suggestions in writing this article.

References Sachdeva, Y Y, and Manchauda, R L (I956) Indian Journal of Surgery, I8, 349. 2 Bhatt, P A, Khan, M S, Thomas, T, Gopinath, N, and Betts, R H (I960) Indian Journal of Surgery, I

22, 517-

3 Perry, M A K, and King, S D (I940) American Review of Tuberculosis, 4I, 53I. 4 Lindskog, G E, and Hubell, D S (I955) Surgery, Gynecology and Obstetrics, ioo, 643. 5 Roles, F C, and Todd, G S (I933) British Medical Journal, 2, 639. 6 Simpson, J A (I954) Medical Journal of Australia, 2, 252.

7 Lindskog, G E, and Liebow, A A (I953) Thoracic Surgery and Related Pathology, pp I6I-I90. New York, Appleton Century Crofts. 8 Chesterman, J T (I95i) British Medical Journal,

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Surgical treatment of bronchiectasis.

Aninals o/ the Royal College of Surgeons of England (i979) vol 6i ASPECTS OF TREATMENT* Surgical treatment D K Chattopadhyay MS of bronchiectasis...
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