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V O L . ioo , No . 3

59 3

LUC ITE EXTRAPER IO STEAL PLOM BAGE*

ROENTGENOLOGIC REV iEW O F LA TE COM PL iCAT ION S

By CHAR LES E . SE IBERT , M .D ., an d JOSEPH TABRISKY, M.D.

D EN VE R , C OL OR AD O

S INCE 1946 ,58 ho llow lu cite b a lls have

b een u tilized in ex trap e rio s tea l p lom -

bage fo r co llapse the rapy o f pu lm onary

tu be rcu lo sis . A t the p resen t tim e , the in -

d ica tion s fo r p lom bage are ra the r s tring en t

becau se o f ad vances in chem o the rap y . A t

the N a tion al Jew ish H osp ita l, D enve r,

C olorado , patien ts are con sid ered for

p lom bag e o n ly w h en they sa tis fy all o f th e

fo llow in g condition s: (i) The d isea se ha s

been re sis tan t to a ll d rug s and the pa tien t

h as p ersis ten tly po sitive spu tum ; (2) upp e r

lo be cav ita tio n is p resen t and s tra teg ica lly

situ ated to a llow ob stru c tio n of the b ron-

ch ia l com m un ica tion by p lom bag e; and

(3) pu lm on ary re se rv e is so sign ifican tly

im pa ired tha t resec tion al the rapy w ou ld re -

su lt in a “p u lm ona ry c rip p le .” P lom bage

w ou ld pre se rve the m ax im a l am oun t o f

pu lm on ary func tion com pa tib le w ith co n-

tro l o f the d is ea se .

D esp ite the reduc tion in the num ber o f

lu cite p lom bag e ope ratio ns pe rfo rm ed ,

the re rem ain s a la rge pa tien t g roup w ho

have u nd erg on e th is typ e o f co llapse the r-

ap y an d o ccasion ally the rad io log is t w ill

be co nfron ted w ith the p ro b lem of d iag -

no sing com p lic at ion s o f the p ro cedu re .

SURG ICAL PROCEDURE

In ex traper ios tea l luc ite p lom bag e as

desc rib ed by W ilson et a l.,8 th e n um ber and

len g th o f rib s strip ped o f the ir pe rio steum

is fash ion ed to co llapse a cav ita ry le sio n ,

but to leav e the surround ing m ore norm al

lu ng func tion a l. T h e p eriosteum is str ipped

from the und ersurfa ces o f th e se lec ted

r ib s . Th e luc ite sph ere s a re then p laced

sep ara tely o r w ith in a po lye thy lene sh ee t

in th e space fash ion ed (F ig . i). Extens ive

ap ico lysis is no t don e since th is w ou ld

p red isp ose to m igra tio n and eros io n of the

Fic . i. D iagram matic illu stra tio n o f ex trape rio s tea l

luc ite sphe re im plan ta tion .

lu c ite ba lls m ed ia lly , w h ich cou ld im p air

venous r etu rn by pres su re o n the m ed iastin al

ve ins .

PATHOLOG IC RE ACT IO N TO

LUCIT E IM PL ANTAT IO N

N orm ally , th e luc ite sph eres b ecom e

r ig id ly fix ed by a process o f hya lin iza tion

and fib rosis .6 ’7 In th e im m ed iate po s top er-

ativ e p eriod , the re is a cop io us exud ate

an d a ir-flu id leve ls are dem onstra ted

w ith in the p lom bage (F ig . 2) . This exud a tereso lve s w ith in sev e ra l w eeks as hy alin iz a -

tio n occur s (F ig . 3) . Fa ilu re o f a ir-flu id

levels to regre ss in the early p ha se in d ic a tes

tu bercu lous or nontub ercu lous in fec tion

o f the su rg ica l sp ace . R are ly , in the first

* From th e Departm ent of R ad io logy , Natio nal Jew ish H osp ita l, D enver , C olorado .

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1”

.y-i

Fic . Sam e case as in F ig ure 4 , on e year la te r. T h e

patien t now has p osit ive sp u tum for tu bercu losis.

Low er b order o f p lom bage is seen bu lg in g dow n-

w a rd .

59 4 Charles E . S eib e rt and Joseph Tabrisk y J U L Y , 1967

11G . 2 . Early po sto perativ e roen tg eno gram revea lin g

the expected exuda te and air-flu id level .

few m onth s fo llow ing tile p rocedure , a

fo re ig n b od reac tion w ill d isso lve t i l e ou te r

f ib ro tic capsu le a rou nd the p lom bage .

L ATE COM PL ICAT ION S

I . R ED EV ELOPMENT OF FLU ID W ITH IN TH E

PLOMBAGE SPACE

Sagg in g of th e in fe rio r aspect o f th e

F ic. 3. N orm al f ib rosis an d hyalin iz atio n o ccu rring in

p lom bage sp ace i m onth afte r su rgery .

Fic. In fe rio r bo rde r of p lom bag e m arked on the

ro en tg en ogram s to dem ons tra te the pro gress ive

sag . T herapeu tic pn eum operitoneum is p resen t.

p lombag e i s a m an i fe st at io n of recurren t

flu id fo rm a tio n . Th e illu s tra tions show an

inc reasin g depend en t s ag o f the p lom bag e

sp ace over seve ra l yea rs (F igs. 4 an d 5). It

is ob v iou s t i la t the su rrou nd in g tissu e h as

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59 6 C harles E . S eibe rt and Josep h T ab risky J U L Y , 1967

p leu ral em pyem a or in fec tio n o f the

p lom bage reg io n d ev elo ps w ith e ith er tu -

bercu lous or n on tub ercu lou s b acteria .’ If

th e rad io log is t can p o in t ou t th e p resence

o f em py em a from th e s ig ns d esc ribed , then

ser iou s sequ ela e m ay be avo ided by su r-

g ical m e thod s.

S UMMARY

The rad io log is t s till see s a num ber o f

luc ite p lom bage case s and can ro en tgen -

ograph ica lly d iagnose the late complica-

tio ns. L a te com p lica tion s are u sua lly re -

la ted to the d ev e lopm en t o f tub e rcu lou s

o r n on tub ercu lo us in fec tio n w ith in th e

p lom bage sp ace .

2. The in fec tion of the p lom bage reg ion

is cha rac te rized b y : (a ) deve lopm en t o f

fluid w ith in th e p lom bag e d em on stra ted

by e ithe r ch an ge in po sition o f the luc ite

balls or sagg in g of th e in fer ior asp ect o f th e

su rg ical space ; (b ) the e rosio n an d m igra -

tio n o f th e b alls from th e p lom bag e reg ion ;

and (c) fo rm ation o f b ron chop leu ra l or ex -

t rap leu ral fis tu lae .

Jo seph T abrisky , M .D .

1 8 4 5 High Street

D en ve r, C ol or ad o 80218

R E FE RE NCE S

I. D E5F OR GES , G ., GIBBoNs , G ., and STRIEDER , J.

w . T ubercu lous in fec tions com p lica t in g sub-

costa l p lom bage w ith luc ite spheres fo r co llapse

th e rapy of pu lm onary tubercu los is . 7.Thorac ic

Surg ., ‘954 , 28 , 63 6 -637 .

2 . D RES SLER , S . H ., BRONF IN , G. J., an d GROW , J.

B . Pu lm ona ry fu nc tion stud ies be fo re and afte r

ex trap leu ra l pneum onolys is w ith p lom bage . 7.

Thorac ic Surg ., 1 9 5 0 , 19 , 938-943 .

3. INADA , K., S A T O , A. , KIsHIM0T # {244 } , S ., a nd T A N A B E ,

G . Eva lu atio n of ex trap leu ral p neum ono ly sis

w ith filling w ith p las tic ba lls . 7. Thorac ic Surg .,

1 9 5 4 , 27 , 503- 513 .

4. JOLY , H., T ULOU , P., T IRET , J., an d VILLEMIN , J.

Plom bage in su rg ica l trea tm en t o f pu lm onary

tubercu los is . 7. Tho rac ic Su rg ., 1957 ,34 , 36-48.

L U C A S , B . G . B ., and C L E L A N D , W. P . T ho ra co -

p la sty w ith p lom bag e: rev iew of early re su lts in

125 cases . Thorax, 1 9 5 0 , 5, 248-256.

6. WIL sON , D . A ., an d BAKER , H . Exper imen ta l

su rg ical pu lm onary co llapse . S urg ., G yn ec . &

Obs t . , 1946, 82 , 735-742 .

7. W I L S o N , D . A . E x trap leu ra l pn eum onolys is w ith

luc ite p lom bage . 7 . Thora cic S urg ., I948, 17 ,

111-122.

8. WIL SoN , N. J. , ARMADA , 0., VINDZBERG, W. V.,

and O’Brien, W. B. Extraperiosteal plombage

tho racop la sty : ope rativ e techn iq ue and re su lts

w ith i6 i ca se s w ith un ila te ra l su rg ica l p rob lem s.

7. Thorac ic Su rg ., 1956 ,32 , 797-8 19 .

9. YOUNG , F . H . E xtraper iostea l p lom bage in treat-

m en t o f p u lm onary tub ercu losis . Thorax , 1958 ,

13 , 13 0-135 .