肺摘除例の遠隔成績からみた手術適応の再検討

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From Jan. 1951 to Dec. 1970 eighty-three patients with pulmonary tuberculosis underwent pneumonectomy at the Seirei Hospital. By analysing bacteriologic and histopathologic findings of the resected specimen and post-operative course, operative indication of these cases was retrospecti-vely examined. In 1963 the author proposed a criterion of surgical curability. Scores were given on unfavourable factors for the success of surgery according to its grade: namely, 5 points for %VC less than 30 (I''), 4 points for %VC 30 to 40 (I'), 3 points for %VC 40 to 50 (I), 2 points for sputum positive with or without drug resistance (b), one point for bi-lateral operation (II) combined with "b" plus extensive lesions with solitary cavity larger than 5 cm in diameter or multiple cavities (c), or low pulmonary function plus "b" or "I bc", one point for "c" combined with I II or II b, and one point for re-operation (a) combined with "b" or "bc". According to the total sum of given scores, the author classified the surgical curability as follows: Grade-0 (0 point), Grade-1 (1 or 2 points), Grade-2 (3 or 4 points), Grade-3 (5 to 7 points) and Grade-4 (8 or 9 points). Death during hospitalization was observed in 7 patients. The causes of immediate death in one case of Grade-1 was bleeding and one another case of Grade-3 was anaesthetic accident. Early death in 2 cases of Grade-3 and one case of Grade-4, and late death in 2 cases of Grade-3 were all due to cor pulmonale. These 5 cases were judged as contraindication for pneumonectomy. The remaining 76 cases converted to negative and were discharged from the hospital, and only one case of Grade-3 died from haemoptoe 3 years later due to progression of the disease. During several years after discharge, non-tuberculous death occured in 12 cases, 9 cases died from cardiopulmonary insufficiency and 3 from pneumonia within 2.5 to 21 (average 8.6) years after the operation. Two died from suicide, one each from cancer, aortic aneurysm and traffic accident, and 2 from unknown cause. Questionnaires of 8 patients were not yet obtained. Forty-eight cases were ascertained to be alive and healthy. Dividing by the grade, 10 out of 17 in Grade-0, 7 out of 11 in Grade-1, 17 out of 23 in Grade-2, 13 out of 28 in Grade-3 and one out of 4 in Grade-4. Average %VC of these cases at the time of discharge was 56. 05±13. 13 in Grade-0, 41.42±11.41in Grade-1, 47.30±4. 05 in Grade-2, and 39. 50±3.86 in Grade-3 and 4. Analysing restrospectively, 13 cases were judged as no need of operation, 7 as curable by lo-bectomy and 5 as contra-indication for pneumonectomy. From the present day view of surgical indication in the Rifampicin-era, almost all cases except 3 cases of destroyed lung with haemoptoe and 10 cases of empyema with or without bronchial fistulae, may be considered to be controlled successfully by chemotherapy alone and, therefore, no need of any surgical procedure. Although empyema with positive sputum and pleural fluid, associated with destroyed lung and bronchial fistulae, may be justified as the absolute indication for pneumonectomy, however, the operation should not be done for those with pulmonary hypo-function, unless uni-lateral pulmonary artery occulusion test is successful. Nevertheless, primary pneumonectomy in those cases is often so dangerous that it is recommended initially to evacuate pleural contents by means of open drainage for the purpose of preventing aspiration to the opposite lung, and to pack gauze permeating the suspension of Rifampicin and Etambutol, each 300mg in 100ml of 15% alcohol, in the pleural space. Such preliminary treatment is very useful in controlling the disease process.
一般社団法人日本結核病学会の論文

著者

関口一雄
聖隷三方原病院

肺摘除例の遠隔成績からみた手術適応の再検討

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