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Every phthisiatrician with a sufficient number of patients with artificial pneumothorax knows that the success of treatment with this method often depends on the condition of the pleura. Where pleural adhesions prevent collapse of the affected part of the lung, the artificial pneumothorax (i.p.) mostly does not reach its goal. More often such adhesions are found in the upper pulmonary field.

Of all the currently used types of surgical intervention in the treatment of pulmonary tbc, as you know, the most common and justified are actually 3 operations: a) virtually bloodless intervention - artificial pneumothorax (pneum.), B) almost bloodless and technically easy operation - frenico -exeresis and, finally, c) bloody, serious and technically difficult operation - extensive thoraco-plasty. Despite the significant difference in the technique of these operations, they are all based on one general idea collapse therapy, that is, the desire to obtain a therapeutic effect by more or less significant compression and immobilization of the affected lung. I will not touch upon the technique and clinic of these operations here, but I will dwell briefly on the fundamental side of this method of treatment, on the essence of the action of collapse therapy (col. Ter.).

Tuberculosis (TB) is an important clinical and public health issue worldwide. Despite improved treatment success rates following the introduction of antibiotics in daily clinical practice, the expected decline in incidence has been hampered by HIV epidemics and multi- and extensively drug-resistant TB. During the pre-antibiotic era, TB therapies were mainly based on improving hygiene conditions, strengthening the immune system, and targeting the rest of the affected lungs with invasive techniques. Detailed knowledge of old non-pharmacological therapies might support physicians and researchers in the identification of new solutions for difficult-to-treat patients. We performed a narrative literature review on the main old therapeutic options prescribed for patients with TB. The main recommendations and contraindications of sanatorium therapies (i.e., bed rest, fresh air, sunlight) and pulmonary collapse techniques are reviewed, evaluating their physiological basis and their impact on patient outcomes. We report studies describing new interventional pulmonary and surgical techniques and assess new perspectives based on old medical and surgical treatments, whose potential implementation could help complicated patients. Keywords: Tuberculosis, Collapse therapy, Hemoptysis, Sanatorium, Sunlight, Vitamin D, Surgery

Multidrug-resistant tuberculosis (TB), extensively drug-resistant TB, and TB-human immunodeficiency virus (HIV) coinfection require a special approach in anti-TB treatment. Most patients cannot be successfully cured by conventional chemotherapy alone. They need a modern approach using minimally invasive therapeutic and surgical techniques. The novel approaches of collapse therapy techniques and minimally invasive osteoplastic thoracoplasty increase the effectiveness of complex anti-TB therapy. Achieving the required selective collapse of lung tissue in destructive pulmonary TB, especially in cases of drug resistance and/or HIV coinfection, leads to bacteriologic conversion, cavity closure, and successful cure.

La colapsoterapia es una técnica usada para obliterar lesiones cavernomatosas por destrucción pulmonar como secuelas de infecciones por tuberculosis. Fue descrita inicialmente en 1882 y se utilizaron diversos materiales como tejido adiposo y óseo, mezcla de varias parafinas y esferas de polimetilmetacrilato (esferas de Lucite), que causaron complicaciones importantes. Con el advenimiento de la terapia antibiótica disminuyó su uso dada la excelente respuesta al tratamiento. En la actualidad y en especial por la aparición de cepas multidrogorresistentes, se están presentado casos nuevos de pacientes con cavernas extensas cuya única opción terapéutica es la intervención quirúrgica para obliterar la caverna. En este contexto, desempeña, un papel importante las prótesis mamarias expandibles ya que disminuyen las complicaciones generadas por las técnicas empleadas en el pasado. Se expone el caso de un paciente de 49 años con tuberculosis de difícil manejo asociada a gran caverna pulmonar tratada con colapsoterapia con prótesis mamaria expandible con respuesta excelente a corto plazo.

To improve the treatment of destructive tuberculosis of a single lung by using of collapse surgery.The authors analyzed an experience of collapse surgery for destructive tuberculosis of a single lung.Collapse surgery was effective in 77.5% of patients.Endoscopic surgical collapse improves the outcomes in patients with destructive tuberculosis of a single lung and expands the possibilities for surgery in these patients when resection is not applicable.Повышение эффективности лечения пациентов с деструктивным туберкулезом единственного легкого путем совершенствования коллапсохирургических операций.Проанализирован опыт применения коллапсохирургических операций по поводу деструктивного туберкулеза единственного легкого.У 77,5% пациентов операции коллапса были эффективны.Коллапсохирургические вмешательства при использовании рекомендуемых ВАТС-методик улучшают результаты лечения деструктивного туберкулеза единственного легкого и расширяют операбельность больных этой тяжелейшей категории в тех случаях, когда резекционная хирургия неприменима.

Objective. Improve the effectiveness of surgical treatment in patients with bilateral destructive pulmonary tuberculosis by mini-invasive resection and collapse therapy. Materials and Methods: Retrospective analysis of 222 patients ’ cards with bilateral destructive pulmonary tuberculosis who were treated in the period from 1995 to 2014 in the thoracic department of Dnepropetrovsk regional clinical therapeutic and prophylactic association "Phthisiology". Patients were divided into 2 groups: basic (111 patients who underwent mini-invasive surgery) and control (111 patients, who underwent standard surgical approach). The distribution of patients in investigated groups was representative by the majority of parameters. Results and discussion. The average duration of simultaneous bilateral VATS lung resections was 1,90 ± 0,12 hour, standard thoracotomies - 2,13 ± 0,19 per hour, estimated blood loss was 234±5,20ml and 433±3,70ml respectively. The average postoperative time in-patient was 52,40±2,63 days in basic and 80,10±3,58 days in the control group. Number of p ostoperative complications after lung resection with VATS was significantly lower (1.6 times), as compared with standard surgical approach. Volume of blood loss less than 400 ml was 93,40±3,20% in basic and 72,60±4,80% in the control group, the amount of intraoperative complications reduced by 2.2 times. Complete clinical response (decontamination and closing of cavities) have been achieved in patients of the basic group by 1.6 times more often. Conclusions: For patients with bilateral pulmonary tuberculosis to perform mini-invasive surgical approach is the best option. Mini-invasive interventions with VATS due to its good abilities to visualize tissue s and anatomical structures may significantly decrease the amount of intraoperative blood and plasma loss in the first postoperative day. It leads to the stabilization of tuberculosis process in the contralateral lung, responsible for overall positive clinical effect in patients with advanced pulmonary tuberculosis. For patients with bilateral destructive pulmonary tuberculosis, who can’t undergo resection, performing a mini-invasive therapeutic thoracoplasty is the optimal approach.

Objectives Surgical interventional has been key in the treatment of tuberculosis (TB) for a long time. Its importance diminished after the emergence of chemotherapy. However, the spread of rapid multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB has led us to return to surgery to treat TB. Today, every second patient in Russia with destructive TB has either MDR or XDR TB, which is the reason for the low efficacy of conservative treatment. In 2015, treatment with drugs resulted in clinical recovery in only 29.8% of new cases of destructive TB acid-fast bacilli (AFB)+. Methods The author's data from 1999 to 2016 have been analysed. The author performed 5599 surgeries on patients with pulmonary TB aged from 1 to 87 years (mean age 34.6 years). The most common reasons for surgical treatment were fibrotic cavitary and cavitary pulmonary TB, tuberculoma with destruction, tuberculous pleural empyema, caseous pneumonia and intrathoracic lymph nodes. The strategy of early collapse therapy and the use of surgery to treat TB was proposed in the Penza region of Russia; the results were analysed to estimate the long-term outcomes of treatment. Results In 5599 surgeries, the full clinical effect was achieved in 93% of operated patients with MDR TB, in 92.1% of those with XDR TB and in 98% of patients without MDR or XDR resistance. According to the data from the Penza region, 3 years after surgery, 93.9% (149 of 159 cases) of the operated patients exhibited clinical recovery. Conclusions Taking into account the data from the World Health Organization on the insufficient level of therapeutic success in the treatment of MDR and XDR pulmonary TB, surgical treatment is necessary in regions with a high frequency of drug-resistant cases.

In the early twentieth century, treatment of pulmonary tuberculosis (PTB) consisted not only of bed rest, proper nutrition, and exposure to sunlight, but also of medical procedures such as surgery or artificial pneumothorax or pneumoperitoneum, because there were no antibacterial drugs. With the availability of anti-tuberculosis (TB) drugs (isoniazid, rifampin, etc.), the majority of TB can be cured by clinical treatment with proper drug regimens. Surgical procedures are used only when necessary. In recent years, the emergence of drug-resistant TB, especially MDR-TB and XDR-TB, expanded the surgical indications, which include tuberculous cavity, large tuberculoma, tuberculous empyema, and recurrent hemoptysis. The medical team must consider the indications and contraindications for surgery and strictly follow preoperative and postoperative anti-TB chemical treatment. Performing 3–6 months of anti-PTB treatment is the most important measure to take before PTB surgery. The two main methods of PTB surgery are collapse therapy (mostly abandoned in the present day) and removal of primary lesions. The primary techniques associated with lesion removal are wedge resection, lung segment resection, lobectomy, and pneumonectomy. The most common complications associated with PTB surgery are bleeding, bronchopleural fistula (BPF), and empyema. PTB surgery plays an important role in diminishing and eliminating sources of PTB infection.

OBJECTIVE: To evaluate lung fissures completeness, post-treatment radiological response and quantitative CT analysis (QCTA) in a population of severe emphysematous patients submitted to endobronchial valves (EBV) implantation. MATERIALS AND METHODS: Multi-detectors CT exams of 29 patients were studied, using thin-section low dose protocol without contrast. Two radiologists retrospectively reviewed all images in consensus; fissures completeness was estimated in 5% increments and post-EBV radiological response (target lobe atelectasis/volume loss) was evaluated. QCTA was performed in pre and post-treatment scans using a fully automated software. RESULTS: CT response was present in 16/29 patients. In the negative CT response group, all 13 patients presented incomplete fissures, and mean oblique fissures completeness was 72.8%, against 88.3% in the other group. QCTA most significant results showed a reduced post-treatment total lung volume (LV) (mean 542 ml), reduced EBV-submitted LV (700 ml) and reduced emphysema volume (331.4 ml) in the positive response group, which also showed improved functional tests. CONCLUSION: EBV benefit is most likely in patients who have complete interlobar fissures and develop lobar atelectasis. In patients with no radiological response we observed a higher prevalence of incomplete fissures and a greater degree of incompleteness. The fully automated QCTA detected the post-treatment alterations, especially in the treated lung analysis. OBJETIVO: Avaliar a completude das fissuras, resposta radiológica ao tratamento e análise quantitativa por TC (AQTC) em população de pacientes com enfisema grave submetidos ao implante de valvas endobrônquicas (VEB). MATERIAIS E MÉTODOS: Foram estudados exames de TC multidetectores de 29 pacientes, realizados com protocolo de baixo dose, cortes finos, sem contraste. Dois radiologistas revisaram, retrospectivamente, os exames em consenso. A completude das fissuras foi estimada em escala de 5% e a resposta radiológica (atelectasia/perda volumétrica do lobo alvo) foi avaliada. AQTC foi realizada nos exames pré e pós-tratamento utilizando programa completamente automático. RESULTADOS: Resposta radiológica positiva foi vista em 16/29 pacientes. Os 13 pacientes sem resposta à TC apresentavam fissuras incompletas e completude média das fissuras obliquas de 72,8%, contra 88,3% no outro grupo. Os resultados mais significativos da AQTC mostraram redução do volume pulmonar (VP) total (média de 542 ml), VP tratado (700 ml) e volume de enfisema (331,4 ml) no grupo com resposta positiva, que também apresentou melhora nos testes funcionais. CONCLUSÃO: O benefício das VEB é maior em pacientes com fissuras completas e que desenvolvem atelectasia lobar. Nos pacientes sem resposta radiológica encontramos maior prevalência de fissuras incompletas e grau de incompletude das fissuras. Nossa AQTC automática detectou as alterações pós-tratamento, principalmente considerado a análise do pulmão tratado.

Background. MDR/XDR has become a vast problem in pulmonary tuberculosis. Drug resistance and persisting lung cavity are often combined what complicates treatment and prevents from disease healing. Collapse therapy (CT) promotes healing in the lung cavities and improved prognosis. Aims. The aim of the study was to assess the role of valvular bronchial blocking (VBB) in the treatment of CPTB. Materials and methods. VBB was applied in 145 patients with CPTB with fibrotic caverns and lower lobe lesions inaccessible for artificial pneumothorax (AP). MDR was in 114 cases, XDR in 31 ones. Blocking was performed by fiberbronchoscope under local anesthesia. When atelectasis was not formed, repeated bronchoscopy to control and reinstalling the valve was performed in 3-4 weeks. Duration of VBB was 6 – 18 months. Individualized therapy regimens based on drug susceptibility test were applied in all cases. Results. No complication followed VBB procedures. Complete atelectasis was formed in 87 (60%) of patients, incomplete atelectais – in 43(30%) ones. Closing the cavity and sputum culture conversion was achieved in 84 and 24 cases respectively. No atelectasis was formed in 15 (10,0%) of patients. The patients where VBB was ineffective were subjected to surgery. The results of treatment in patients with CPTB treated without CT were significantly lower: 59 of 136 ones (43,4%) (p Conclusion. VBB as a method of CT is of value in the treatment of CPTB including MDR/XDR where AP is impossible or contraindicated. VBB allows to treat the cavity successfully and reduces the need for surgery. Proper endobronchial placement of the valve and atelectasis formation depends on anatomic peculiarity of the bronchi.

Background: The poor treatment outcomes of multidrug-resistant tuberculosis (TB) and the emergence of extensively drug-resistant TB and extremely and totally drug-resistant TB highlight the urgent need for new antituberculous drugs and other adjuvant treatment approaches. Objectives: We have treated cavitary tuberculosis by the application of endobronchial one-way valves (Zephyr®; Pulmonx Inc., Redwood City, Calif., USA) to induce lobar volume reduction as an adjunct to drug treatment. This report describes the feasibility, effectiveness and safety of the procedure. Methods: Patients with severe lung destruction, one or more cavities or those who were ineligible for surgical resection and showed an unsatisfactory response to standard drug treatments were enrolled. During bronchoscopy, endobronchial valves were implanted in the lobar or segmental bronchi in order to induce atelectasis and reduce the cavity size. Results: Four TB patients and 1 patient with atypical mycobacteriosis were treated. The mean patient age was 52.6 years. Complete cavity collapses were observed on CT scans in 4 of the 5 cases. All patients showed improvements in their clinical status, and sputum smears became negative within 3-5 months. There were no severe short- or long-term complications. The valves were removed in 3 of the 5 patients after 8 months on average; there was no relapse after 15 months of follow-up. Conclusion: These data suggest that endobronchial valves are likely to be useful adjuncts to the treatment of therapeutically difficult patients. More data are required to confirm our findings.

Thoracic surgical procedures evolved from surgical management of tuberculosis; lung resections, muscle flaps, and thoracoscopy all began with efforts to control the disease. The discovery of antituberculosis drugs in 1944 to 1946 made sanatorium therapy and collapse therapy in all its forms obsolete and changed thoracic surgery dramatically. Currently, management of tuberculosis is primarily medical, and surgery has a minimal role. Today surgery is usually only performed in patients with tuberculosis when the diagnosis is necessary, who have complications or sequelae of the disease, or who have active disease resistant to therapy.

This paper explores the complex reflexive relationships among technologies associated with tuberculosis care and treatment: the fresh air cure, surgical collapse therapy, architecture, and chemotherapy. We review the architectural histories of the Royal Edward Laurentian Hospital (now the Montreal Chest Institute) to track important transformations of treatment environments. We recount how the rest-cure prevalent at the beginning of the twentieth century started a tradition, lasting until the age of antibiotics, in which architectural settings were deployed as physical agents of treatment. A technology in this sense, then, is a set of resource-using practices marshaled to eradicate the disease. We argue that the endurance of specialized tuberculosis architecture, with its porches, balconies, and sunning galleries, provided crucial material and spatial continuity for therapy, even after chemotherapy’s successes augured the end of dedicated tuberculosis hospitals and sanatoria.

The surgical management of pulmonary tuberculosis has evolved since collapse therapy was the mainstay of treatment. Despite this, resection for active tuberculosis is viewed with circumspection. Details of 106 patients with pathologically proven active pulmonary tuberculosis, who were operated on from January 1997 to January 2005, were reviewed retrospectively. Demographic data, radiographic profiles, indications for surgery, sputum status, and preoperative drug therapy were analyzed in relation to outcomes. The indications for surgery included multidrug-resistant tuberculosis in 27 patients, hemoptysis in 44, bronchiectasis in 27, and diagnostic dilemmas where a tumor could not be excluded in 8. All patients were operated on while receiving antituberculous therapy, and 17 were sputum positive at the time of surgery. Two (1.9%) patients died postoperatively. Morbidity was 16.9%, including 6 cases of postpneumonectomy empyema and one of bronchopleural fistula. Surgery for active tuberculosis may be undertaken with acceptable morbidity and mortality.

Background: MDR/XDR has become a crucial trouble in pulmonary tuberculosis. Persisting lung cavity prevents disease healing and promotes growth of drug resistance. Objectives: Collapse therapy (CT) improved prognosis in drug resistant CPTB when therapy alone fails. The aim of the study was to find out if combined application of artificial pneumothorax (AP), valve bronchial blockade (VBB) and pneumopertitoneum (PP) expanded the possibilities of CT. Materials and methods: CT was applied in 364 patients with CPTB. MDR was in 288 cases, XDR in 76 ones. AP was applied in 297 patients with CPTB located in upper and middle lobes. We used VBB in 67 patients with fibrotic caverns and lower lobe lesions inaccessible for AP. PP was added in 67 patients with AP or VBB where foci in lower lobes took place. Duration of AP was 3 - 6 months, VBB - 6 – 18 months. Individualized therapy regimens based on drug susceptibility test were applied in all cases. Results: No complication followed CT procedures. AP/PP resulted in sputum culture conversion in 254 patients (85,5%). Complete atelectasis of diseased segment after VBB was achieved in 38 patients with sputum culture conversion in 36 (94,7%). Incomplete atelectasis resulted in conversion in 17 of 29 patients (58,6%). Total effectiveness of VBB was thus 79,1%. Total effectiveness of CT was 84,3% (307 conversions of 364 cases). The results of treatment in patients with CPTB treated without CP were significantly lower: 45 of 109 ones (41,3%)(p Conclusion: VBB complements the capabilities of CT. Combined CT is promising in cases with multiple lung cavities included bilateral ones. Proper endobronchial placement of the valve remains a problem to be solved.

Introduction: In selected cases, the management of cavities in tubercolosis consists in the combination of anti-TB chemotherapy and adjuvant lung resection. Method: We hypothesized that lung collapse therapy using one-way endobronchial valves may be effective in the treatment of TB with cavities. We report our early experience with 3 MDR-TB, 1 patient with Atypical Mycobacteriosis, and 1 TB patient with DRESS (Drug Rush Eosinophilia and Systemic Symptoms) Syndrome in whom TB cavity collapse was attempted using Zephyr valves (Pulmonx Inc., Redwood City, CA, USA). All except the one with DRESS syndrome, were treated with optimal anti-TB chemotherapy. Outcome: The insertion of Zephyr valves was achieved by standard bronchoscopy without complications. Two to three valves were inserted to isolate a cavity, and in most cases to exclude the whole lobe. 4 out of 5 patients were sputum + at the time of the procedure. A cavity collapse was observed in 4 out of 5 cases. All of the patients improved in clinical status and sputum smear was negative at last FU. There were no short and long-term complications related to this treatment. View this table: TABLE 1 - Conclusion: Our early experience shows that creating a hypoventilation and hypo-oxygenation zone by closing the TB cavities using Zephyr endobronchial valves is feasible and appears to provide long term clinical benefits.

Tuberculosis was once believed to be a hereditary disease and the cause of death in 25% of the population in Europe in the 17th century. The American physician and poet Oliver Wendell Holmes called it the white plague and the English writer Charles Dickens described it as a disease which medicine never cured. When the German scientist Robert Koch discovered Mycobacterium tuberculosis in 1882 it evoked great hopes for a specific anti-tuberculous drug. His discovery is celebrated annually by the World TB Day. Not until 1944 was Streptomycin proven effective as a single drug and soon after also PAS (paraaminosalicylic acid). Tuberculosis was conquered and the former sanatorium treatment based on fresh air, rest, and good nutrition became obsolete. Collapse therapy also belonged to the sanatorium era. It consisted of different interventional procedures in order to deflate the diseased part of the lung and thereby introduce a less favorable environment for bacterial growth. The introduction of radiology had great impact on diagnosis and follow-up of therapy and was later followed by screening of the general population. Initially successful screening was later abandoned because of low efficiency. There are still patients alive with radiologic signs or even late complications from collapse therapy which must be recognized by the radiologist such as artificial pneumothorax, thoracoplasty, plombage, and phrenic nerve crush with pneumoperitoneum. Furthermore, tuberculosis is almost an iconic disease as described in art, literature, and music (1–6). Thoracoplasty has been dramatically illustrated by Alice Neel in her painting T.B. Harlem from 1940. The author George Orwell experienced both collapse therapy and serious side-effects from Streptomycin therapy. Why is tuberculosis still important? This disease is still a global problem in poor countries but also in the US and Western world because of migration from highburden countries bringing active cases or persons with a risk of reactivation of latent tuberculosis. Drug resistance is now a greater obstacle with multipledrug, extensively, extremely, and even totally drug resistant bacterial strains respectively. In 1993 WHO declared tuberculosis a global emergency and later The Global Plan to Stop TB 2006–2015 was initiated. New diagnostic tests, vaccine, drugs, and socioeconomic improvements are still needed to more effectively fight tuberculosis worldwide (7–11). What is the role of radiology? Like every clinician radiologists must also be aware of tuberculosis as a possible differential diagnosis in order to avoid unnecessary diagnostic delay. Patients may initially be treated as having community-acquired pneumonia (8). Furthermore, it may be possible to radiologically detect active disease (3,7). The radiologist must also have ‘‘peripheral vision’’ and knowledge about extrapulmonary manifestations like tubercular lymph glands, disease in bone, brain, pleura or pericardium, and abdomen (7). The frequency of extrapulmonary tuberculosis was 22% in 2011 within the European Union (12). Furthermore, radiology can be important in diagnosing certain forms of pulmonary atypical or nontuberculous mycobacterial infections which in turn are recognized in increasing frequency (13). From a radiological point view it is worth mentioning reports on skeletal abnormalities such as pectus excavatum and scoliosis that are linked to lung disease with atypical tuberculous mycobacteria (14). Tuberculosis is also described as a mimic of other diseases (7,15). Over the years there have been several excellent reviews and series regarding tuberculosis both from radiological and general medical points of view, including the most recent articles in Acta Radiologica (16–18).

In the last and most productive years of his life, George Orwell struggled with pulmonary tuberculosis, dying at the dawn of the era of chemotherapy. His case history illustrates clinical aspects of tuberculosis with contemporary relevance: the role of poverty in its spread, the limited efficacy of monotherapy, the potential toxicity of treatment, and the prominence of cachexia as a terminal symptom. Orwell's ordeals with collapse therapy may have influenced the portrayal of the tortures of Winston Smith in the novel 1984. I discuss unifying diagnoses for Orwell's respiratory problems and apparent infertility, including tuberculous epididymitis, Young syndrome, immotile cilia syndrome, and cystic fibrosis.

The idea that sick lungs would benefit from a period of enforced rest is very old and sounds compelling, even though during the 100 or so years that physicians did their best to impose it, there was a total lack of clinical and physiologic evidence to support the practice. The belief that broken and sore lungs required rest was one of the first things the writer Betty MacDonald (1), newly ill with tuberculosis, discovered when she was sequestered in a sanatorium called The Pines: “If you had a broken leg you wouldn’t dance on it nor walk on it but would have a plaster cast or splints on it so that you couldn’t use it even if you were foolish enough to try. If you had a sore on a joint or a knuckle, you would know that constant bending would break the sore open and prevent its healing quickly. When you have tuberculosis you have broken lungs with sores on them and the less you use them the quicker they will heal. How can you rest your lungs? By breathing less often and less deeply. A person resting quietly in bed, breathes two times less each minute than a person sitting up and of course much less than a person walking. . . . Rest is the answer. Rest, rest and more rest.” Lying in bed, as Betty MacDonald and hundreds of thousands of other tuberculars did for months on end, is an easy way of resting the lungs, but slowing breathing a couple of breaths each minute is not nearly as efficient as putting lungs completely to sleep. That goal was aggressively sought after by phthisiologists and surgeons who came up with pneumothorax, pneumoperitonium, and thoracoplasty, which were mainstays of the treatment of tuberculosis for over half a century. The rationale for immobilization was advanced by Carlo Forlanini (2) in 1882, the same year that Robert Koch announced his discovery of Mycobacterium tuberculosis; Forlanini wrote that the cure of pulmonary tuberculosis was impossible because the lungs were “in an unceasing motion of expansion and reduction. When this peculiarity is removed, the [static] lung becomes similar to other viscera and from that moment [healing begins].” This sounds good, but in spite of pronouncements of this sort, perhaps even because of them, the purported clinical benefits of bed rest and collapse therapy were never properly evaluated. The purpose of this review is to re-examine the physiologic evidence pertaining to these treatments and to emphasize why we should have listened to one man, William (Bill) Dock, who told us all long ago how bed rest should be performed and why certain types of collapse might be helpful.

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.

Plombage, a variant of collapse therapy for patients with pulmonary tuberculosis that uses a variety of foreign materials, was undertaken until the 1950s before the invention of effective antimicrobial therapy. Complications related to previous plombage procedures are not uncommon. Management of these complications can be challenging. We report a patient presenting with extrusion of plombage 59 years later and managed successfully with removal of the plomb and pectoral muscle flap transposition.

An 80 year-old Mexican-American woman presented to the geriatric medicine clinic to establish care and for evaluation of a rapidly enlarging right breast mass. The mass was first noticed in 2003, and at that time a breast biopsy was not performed. The lesion remained relatively constant in size until December 2007. During the subsequent 3 months, the mass grew to involve most of the right breast. Her past medical history was remarkable for pulmonary Mycobacterium tuberculosis treated by right upper lobe collapse and wax plombage in Mexico in the 1950s. Other details from the operation were unavailable. Her other medical problems included hypertension, early Dementia Alzheimer’s Type, and depression. At presentation the patient was afebrile, her blood pressure was 125/70 mm Hg with heart rate of 106 beats per minute. On physical exam, she was thin and pale but in no apparent distress. Lung sounds were absent in the superior right hemithorax with dullness to percussion in that area. Breast exam revealed a painless, diffusely engorged right breast 4 times larger than the left. Superficially, there were dilated subcutaneous veins and nipple inversion. Also present were two 1 1-cm ulcerated skin erosions on the inferior-medial quadrant of the breast. The lesions were covered by a layer of necrotic, white fibrous tissue and were draining frank puslike material. Palpation of the breast expressed a white causeous substance. The breast was diffusely edematous with an approximately 8 3-cm indurated area on the medial aspect. No nipple discharge could be elicited. On palpation of the axilla, a 1 2-cm firm, fixed mass was identified. The patient denied any recent fever, chills, cough, or shortness of breath or weight loss. The patient was admitted to the hospital for evaluation of the mass. Routine laboratory work was significant for a hemoglobin and hematocrit of 9.0 g/dL and 27.5% respectively. Also of note were a decreased mean corpuscular volume of 77.5 FL, elevated ferritin of 313 ng/mL, decreased serum iron of 32 g/dL, transferritin saturation of 23%, and a reticulocyte count of 1.0%. These data suggest that the anemia was due to chronic inflammation. Exudate from one of the lesions was sent for Gram and acid-fast bacilli stain and culture. The culture was positive for coagulase-negative staphylococci, likely representing normal skin flora. These tests were negative for tuberculosis species. Computed tomography (CT) scan of the chest with and without contrast was performed. This test demonstrated a 6.5 3.5-cm soft tissue mass with areas of calcification extending into the right axilla from the pleura with several enlarged axillary, mediastinal and hilar lymph nodes (see Figure 1). There was destruction of the first through third ribs on the right side. Examination of a biopsy of the breast mass tissue showed fat necrosis without evidence of malignant cells. It was determined that this mass represented extrusion of the wax plombage from her operation over 50 years previously. Erosion of the plombage material through the chest wall caused the formation of a cutaneous fistula. The enlarged lymph nodes likely represented reactive changes as a result of a localized inflammatory reaction to the plombage material. DISCUSSION

Since Jacobaeus performed the first thoracoscopy to explore pleural space and mechanically broke pleural adhesions to facilitate the collapse therapy for pulmonary tuberculosis in 1910, numerous thoracic surgeons have been attempting this technique as a means of accomplishing many intrathoracic procedures previously done through open thoracotomy. As the refinement of video technology has advanced, thoracoscopic surgery has played a very important role in thoracic surgery especially since the early 1990s. Because the advantages of video-assisted thoracoscopic surgery for patients include low post-thoracotomy-related morbidity, cosmetic considerations, low pain, earlier post-operative mobilization, and a shorter operation time in some indications, surgeons have been demonstrating its increasing utility in the diagnosis and treatment of the pleura, lung, mediastinum, great vessels, pericardium, and oesophagus. The most common application of the thoracoscopic approach still remains in the management of pleuropulmonary disease. The indications for the thoracoscopic technique are very broad, but its role in the management of primary lung and oesophageal cancer has yet to be confirmed. Thus, the surgeon who uses the technique in these cancerous diseases should be prudent. In conclusion, these thoracoscopic procedures will play more important roles in the practice of thoracic surgery in the future.

Seven patients underwent collapse therapy with polystyrene sphere plombage for pulmonary disease caused by multidrug-resistant mycobacteria. Four patients were infected with multidrug-resistant strains of Mycobacterium tuberculosis, two with Mycobacterium xenopi, one with Mycobacterium avium. All patients were heavily pretreated before surgery, had extensive, bilateral cavitary disease and were considered unsuitable for resection because of extensive disease or functional respiratory impairment. Six patients had active disease at time of surgery. Collapse therapy with insertion of six to 18 spheres resulted in long-standing bacteriological conversion in six patients. Collapse therapy was unilateral in six and bilateral in one. No immediate postoperative complication or death was observed. Hospital stay was short (mean 12 d). Collapse therapy is a conservative alternative therapy in patients with pulmonary disease caused by multidrug-resistant mycobacteria at high risk of treatment failure considered unsuitable for pulmonary resection.

The injection of oil into the pleural cavity was a widely used treatment of pulmonary tuberculosis until the advent of effective anti-tuberculous therapy. Long-term complications of oleothorax can occur when the oil is not removed. The authors present an unusual complication of oleothorax, reactivation of tuberculosis, 54 years after oil instillation.

An 80-year-old patient presented with a chronic right sided chest wall sinus discharging pus. The patient had undergone an ipsilateral thoracoplasty and Lucite ball plombage for the treatment of tuberculosis in 1955, and the sinus was known to communicate with a plombage cavity. Until this presentation the sinus was uncomplicated, occasionally discharging clear fluid and a conservative approach to management was adopted. At this presentation, however, the discharge was culture positive for Staphylococcus aureus . Removal of the Lucite balls …

This review describes diagnosis and management of sequelae of post-primary tuberculosis. It addresses elementary lesions such as bronciectasis, fibrostenosis, cavitation and broncholithiasis, the more complex situation of destroyed lung, and complications such as aspergilloma, hemoptysis and broncho-esophageal fistula.

Answer: Oleothorax with expansion. This 90-year-old man presented for an incidental finding on a chest radiograph of an opacification of the entire left hemithorax. He denied chest pain, haemoptysis, cough, fever, weight loss, night sweats or dyspnoea. Review of the patient's history revealed that 60 years ago he was treated in a sanatorium in Russia, and recollects that his ‘lung …

The decision to employ collapse therapy in any of its forms is a grave one, and it must only be made after repeated radiological examination and as the result of careful consultation between physician and surgeon. The importance of general sanatorium measures, diet, and more especially, prolonged bed rest, cannot be over-emphasized but there are many cases in which the anatomical and pathological features of the lesion are such that natural healing cannot occur even if general measures succeed in improving the general resistance of the patient. It is in these cases that collapse therapy is urgently indicated.

Artificial pneumoperitoneum is a form of collapse therapy that was used in the treatment of cavitary pulmonary tuberculosis before the availability of antimycobacterial chemotherapy. We report a series of cases of far-advanced pulmonary disease due to multiple-drug-resistant Mycobacterium tuberculosis, wherein artificial pneumoperitoneum with or without subsequent surgical extirpation was used as an adjunct to chemotherapy. Overall, among these desperate cases, therapeutic pneumoperitoneum provided no clear benefit.

An 82-year-old woman had a recent routine chest radiograph when she presented with a tachycardia. This demonstrated the result of a surgical procedure performed for pulmonary tuberculosis in 1947. Examination revealed a large, left sided, vertical dorsal thoracotomy scar. In the late 1940s, single agent chemotherapy with streptomycin could not guarantee a cure …

The endemic spread of tuberculosis after World War II and the deficiency of appropriate antituberculous drugs had led to a renaissance of the surgical tuberculosis therapy until the early 1950s. Late complications of plombage performed decades before are rare and are mainly related to infection and/or migration of the inserted foreign material and are scarcely recognized today. We report on a 73-year-old male patient, who was admitted to the emergency room of our hospital with acute massive haemoptysis for four days. On physical examination the patient presented with decreased breath sounds over the left lung and an old left-sided thoracotomy scar. Radiological findings and bronchoscopy revealed an empyema and a fistula as late complications 53 years after collapse therapy with insertion of a plombage for the treatment of pulmonary tuberculosis. The endobronchial nylon threads in the left bronchial tree and the fistula ending in the left lower bronchus confirmed our diagnosis. The patient was successfully treated by resection of the affected lower lobe. The present casuistic demonstrates a rare cause of spontaneous haemoptysis: late complications after extrapleural pneumolysis and plombage for cavitary tuberculosis over 50 years after the initial operation.

SUMMARY Surgical collapse of the diseased lung is an important adjunct to rest and supportive therapy in the treatment of tuberculosis. The excellent results obtained in many cases by means of surgical collapse have, however, led many persons to prescribe its use too freely, or, having successfully collapsed a lung, to fail to continue a regimen of rest and supportive therapy. The success of some methods of collapse (f.i. artificial pneumothorax, thoracoplasty) has perhaps led to excessive use of less desirable methods such as extrapleural pneumothorax. Whenever surgery is considered in a case of tuberculosis, the following questions must be answered. First, in what way will the patient be benefited by this operation? Second, do the hazards and complications, both immediate and remote, of the operation present a lesser danger than a decision to defer or abandon the operation? It is readily apparent that no blanket answers to these questions are possible. Each case must be decided on its individual merits. In tuberculosis as in other diseases the potential dangers of any operation must be weighed against the expected benefits. Above all, operations should never be done simply because they are possible, or in an effort to "do something". A haphazard approach will subject the patient to consequences which he can survive only with the greatest good luck.

SUMMARY Complete eradication of tuberculosis as a major cause of illness and death in the United States within the next generation or two is an attainable possibility by application of methods already known. If streptomycin or a similar drug proves efficacious this time would be considerably shortened. In the over-all fight against the disease the physician whose practice deals with children can contribute much in this final drive. Diagnostic tuberculin is one of the most specific of all the specific tests available for the detection of disease. The physician should use it routinely in his child patients at two to three year intervals. False negative tests occur only rarely. A positive test means only that a primary tuberculous infection has occurred at some previous time. However, the finding of a positive reaction in a child, especially a young child in the first years of life, may be the means of uncovering an hitherto unsuspected source of contagion. Furthermore, a positive test in a child identifies the individual who must be kept under observation for the possible development of chronic pulmonary tuberculosis at some future date. Mass x-raying the chests of children fails to make this distinction. Knowledge of the pathogenetic development of the various forms of tuberculosis aids the physician in recognizing the stage in the evolutionary course of the disease at which his patient may have arrived. There are fundamental differences between primary tuberculosis and reinfection tuberculosis. The development of tuberculoallergy several weeks after the initial infection is responsible for these differences. In the majority of children primary tuberculosis is limited to the pneumonic lesion and to the lymph node lesion. In a few, extension may occur by contiguity about the pulmonary focus, or by hematogenous or bronchogenic spread from the lymphnode focus. Thus accounted for are the acute reinfection forms of tuberculosis such as tuberculous broncho-pneumonia, miliary tuberculosis, and tuberculous meningitis. The latter, however, is not the direct result of hematogenous seeding, but rather, results from rupture of an older focus into the sub-arachnoid space. Chronic pulmonary tuberculosis is rarely encountered before puberty. No certain explanation exists for the remarkable freedom children between the ages of five and puberty enjoy from tuberculous morbidity and mortality. Possible factors having a bearing upon the high infection rate of chronic reinfection tuberculosis, especially in girls, during the teen age are the increased need for minerals and protein and other metabolic changes which occur in adolescence in association with the establishment of menses. The reaction of every child to tuberculin should be known at or before the onset of puberty. Positive reactors should have, at least annual x-ray films of the lungs made in order to recognize at the earliest possible time, the characteristic soft mottled apical shadows of the early infilliate. Diagnostic tuberculin and the x-ray constitute the bulwarks upon which chief dependence is placed for the diagnosis of the various forms of tuberculous disease occuring in childhood. History of exposure, symptoms of illness and physical findings are relatively poor guide posts. Demonstration of tubercle bacilli by gastric lavage is frequently helpful in clinching a previously suspected diagnosis. Studies of the blood, including the hemogram, sedimentation rate and Schilling differential count are of less value in diagnosis than in estimating prognosis and the favorable or unfavorable course of the disease. The immediate prognosis of all primary tuberculous infections is good, with the exception of the comparatively few children in the first five years of life whose primary complexes extend to the development of such acute reinfection forms as meningitis, miliary disease and tuberculous pneumonia. The remote prognosis however, is more uncertain, both from the point of view of the number who will ultimately develop chronic pulmonary tuberculosis and the number who will die from this form of the disease. An environment safe from the risks of tuberculosis infection should be provided every child. In this preventive phase the pediatrician and the physician can accomplish much. Experiments now being carried on with streptomycin may provide a specific form of therapy, but until its efficacy has been proven, rest, diet, healthful living conditions and time are the general measures to be relied upon for bringing about healing in most of the tuberculous lesions of children. Collapse therapy may occasionally be indicated.

Objective To compare a new bronchial blocker, the Cohen blocker, with the Arndt blocker and a left double-lumen tube (DLT). Design A prospective, randomized, controlled trial. Setting University hospital. Participants Forty-eight patients undergoing lung surgery. Intervention Intubation with 1 of the 3 devices. Comparisons among groups included (1) time for initial positioning, (2) degree of lung collapse at pleura opening, and (3) number of intraoperative fiberoptic examinations. Measurements and Main Results Positioning of the Cohen blocker (256 [166-341] seconds; median [interquartile range]) took no longer compared with the Arndt blocker (253 [184-305] seconds), and there was a trend toward difference between the 2 blockers and the DLT (137 [102-199] seconds) (p = 0.07). The time to place the Cohen blocker was longer in cases of left bronchus occlusion compared with a right one (340 [300-450] v 170 [124-259] seconds, p = 0.02); they were similar in the Arndt group. The degree of lung collapse was different among groups (p = 0.05), but the difference between any pair did not reach statistical significance. The number of patients who required at least 1 additional FOB examination was not statistically different (50% of patients in each blocker group v 19% in the DLT group). Conclusions There was a trend toward a difference between times to place a bronchial blocker and the DLT. The Cohen blocker is more difficult to position in the left main bronchus than in the right one.

ig. 1. Computed tomography axial image showing left upper lobe telectasis and multiple circular lesions (‘ping-pong’ balls) in an 85-yearld male. Tuberculosis (TB) is an infection by the bacterium Mycobacterium tuberculosis. Infection can be seen in all persons although with increased incidence in persons who are immune suppressed and particularly in those with HIV. Infection is typically acquired after exposure to actively infected persons or through reinfection in those carrying latent TB. Infection can be diffuse but is most often seen in the lungs. Symptoms of TB may include fever, night sweats, weight loss, fatigue, decrease in appetite, cough with or without hemoptysis, and dyspnea. Diagnosis is usually attained after a positive tuberculin skin test but ultimately requires positive sputum culture. Chest X-ray and CT may be helpful in identifying infectious processes. Multidrug regiments are required to eradicate the disease. While tuberculosis is declining in the US, the CDC still reported 13,779 cases in 2006 at a rate of 4.6/100,000. These numbers remain higher in foreign-born persons in the US and are calculated to be 21.9/100,000 when compared with only 2.3/100,000 in US-born persons [1]. Furthermore, tuberculosis rates remain higher in other regions of the world. The image above shows an old form of treatment for tuberculosis in a patient born in 1920. ‘Ping-pong’ balls inserted into the chest cavity caused atelectasis of the infected lung segment and hopefully necrosis of the tissue and confinement of disease (Fig. 1). While this treatment is no longer used in the US, it may be seen in older patients and in those emigrating or visiting the US.

We describe the case of a 79-year-old man who presented with an enlarging mass on his chest wall. He had a history of thoracoplasty performed 55 years ago for treatment of pulmonary tuberculosis. The mass was subsequently proven to be the result of empyema neccesitans caused by reactivation tuberculosis. Empyema neccesitans is a well described entity in which an empyema spontaneously decompresses by dissecting into the chest wall and extrathoracic soft tissues. This can occur following necrotizing pneumonia, including pyogenic or tuberculus, or pulmonary abscess. Complications from collapse therapy for tuberculosis can be encountered decades following the surgery, however, empyema necessitans due to reactivation tuberculosis is rare. This case affords the opportunity to review the goals, techniques, and radiologic appearance of thoracoplasty.

1 Endobronchial valve (EBV) placement has emerged as an alternative approach for treating patients with severe emphysema. The improvements in lung function after EBV placement, which allows video-assisted thoracic surgery (VATS) lung resection in a previously nonsurgical candidate, have not been reported. We present a case of VATS lung resection after EBV placement in a patient with severe emphysema to illustrate clinical and surgical aspects in this new category of patients.

Thoracic surgery began when the specialty was “chest” surgery for treating tuberculosis. Our hospital was established as a Sanatorium owned by the Japan Anti-Tuberculosis Association. The Section of Chest Surgery began to operate on patients with pulmonary tuberculosis in 1948. At first, most patients underwent thoracoplasty. However, pulmonary resection, such as lobectomy, pneumonectomy or segmentectomy, soon became the predominant operation. The number of pulmonary resections performed annually reached around 240 in 1954. On the other hand, the number of cases treated with collapse therapy decreased (Fig. 25.1).

Imaging taken early last Autumn in the hospital I worked in revealed startling images. Multiple round ring shadows, overlapping against each other, were clearly visible in the apices of both lung fields in the chest radiograph of a patient who had just been newly admitted. The junior doctors involved in the immediate care of the patient requested an urgent report on the X-ray, which confirmed that the patient had been the recipient of ‘plombage’, a form of surgical therapy used for the treatment of tuberculosis (TB) before the 1950s and prior to the use of antituberculosis drugs; the opacities in this case being ping pong balls. Plombage was …

Tuberculosis historically was a major impetus for the development of thoracic surgery, and it remains a serious health problem of global proportion. Thoracoscopy was first introduced at the turn of this century for closed chest adhesiolysis as an adjunct to collapse therapy for treatment of tuberculosis. This indication became obsolete with the discovery of streptomycin during the 1940s; and for a long time since then thoracoscopy was used only sporadically for the diagnosis of pleural disease. However, over the last few years, modern video-assisted thoracoscopic surgery (VATS) has provided a new approach to the management of pulmonary tuberculosis. Over the last 5 years we have used VATS for diagnosis or treatment (or both) of 62 patients with pulmonary tuberculosis, including 20 pleural biopsies, 8 decortications, 17 wedge lung resections, 8 drainages of empyema, and 9 lobectomies. There was no surgical mortality, and complications were few. We conclude that VATS provides a safe, effective diagnostic modality (pleural biopsy, wedge resections) and therapeutic modality (decortications, drainage of empyema) for selected patients with pulmonary tuberculosis.

A 65-year-old male, who underwent extraperiosteal plombage for pulmonary tuberculosis 46 years ago, was referred to our hospital due to relapsing hemosputa and pneumonia. A chest computed tomography scan revealed a bronchial fistula and a fluid collection in one Lucite ball. On May 20, 1996, a right-anterior thoracotomy was performed in a supine position. Five Lucite balls were removed, and the empyema space was tightly filled with an omental pedicle flap. Although the bronchial fistulas were not sutured directly, the air leakage from the drainage tube ceased 12 days later. Two years postoperatively the patient has remained well. Our simple approach of combining an anterior thoracotomy and replacement of an empyema space with an omental pedicle flap in the same posture, without closing bronchial fistulas, would be an easy procedure, and therefore exploitable in patients who have a similar problem.