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History of Emphysema Surgery

1997; Elsevier BV; Volume: 64; Issue: 5 Linguagem: Inglês

10.1016/s0003-4975(97)00864-3

1552-6259

Andreas Naef,

Pleural and Pulmonary Diseases

Ever since the advent of modern chest surgery, surgical pioneers have attempted operations to alleviate, if not cure, patients with emphysema. From the physiologic standpoint illogical procedures such as costochondrectomy, phrenisectomy, or thoracoplasty lead to disastrous results, whereas the effect of operations on the autonomous nervous system was unpredictable. The only worthwhile procedure was bullectomy for localized bullous emphysema. The concept of volume reduction developed by Brantigan in the 1950s and rediscovered by Cooper is the only successful surgical approach to an essentially incurable pulmonary disease. Ever since the advent of modern chest surgery, surgical pioneers have attempted operations to alleviate, if not cure, patients with emphysema. From the physiologic standpoint illogical procedures such as costochondrectomy, phrenisectomy, or thoracoplasty lead to disastrous results, whereas the effect of operations on the autonomous nervous system was unpredictable. The only worthwhile procedure was bullectomy for localized bullous emphysema. The concept of volume reduction developed by Brantigan in the 1950s and rediscovered by Cooper is the only successful surgical approach to an essentially incurable pulmonary disease. Diffuse pulmonary emphysema has always been considered to be a “medical” disease. The term “vanishing lung” describes the extreme stage of progressive destruction of pulmonary parenchyma, for which surgery has nothing to offer. With the rise of modern thoracic surgery in the field of tuberculosis, bronchiectasis, and carcinoma during the mid-20th century, some surgeons started to attempt all sorts of more or less palliative procedures in apparently hopeless situations. In the case of emphysema surgery, the small series reported with little long-term follow-up did not allow objective appraisal of the results until the development of pulmonary function studies [1.Lambert A.V.S. Berry F.B. Cournand A. Richards Jr., D.W. Pulmonary and circulatory function before and after thoracoplasty.J Thorac Cardiovasc Surg. 1938; 7: 302-325Google Scholar], first by André Cournand and Eleanor Baldwin, and more recently by Gaensler and others. The most important surgical approaches were directed at the chest wall, the pleura, major airways, the autonomous nervous system, or the lung itself. Operations on the chest wall or diaphragm to compress distended lung—thoracoplasty or phrenycectomy—or, in contrast, to give the distended lung more room to breathe—costochondrectomy—were doomed to failure by interfering with respiratory function, and in fact worsening dyspnea. Parietal pleurectomy with talcum poudrage, suggested by Crenshaw and Rowles [2.Crenshaw G.L. Rowles D.F. Surgical management of pulmonary emphysema.J Thorac Cardiovasc Surg. 1952; 24: 398-410Google Scholar] in 1952 to compensate for avascular degeneration of emphysematous parenchyma by collateral circulation, was another not very successful approach. Trachoplasty for major airways obstruction at the tra-cheobronchial bifurcation due to dynamic expiratory collapse of an atrophic, flaccid membranous portion was suggested by Nissen [3.Nissen R. Tracheoplastik zur Beseitigung der Erschlaffung des membranösen Teils der intrathoracalen Luftröhre.Schweiz Med Wochenschr. 1954; 84: 219Google Scholar] in 1954. In a few cases of severe emphysema due to this mechanism, he performed a “tracheoplasty” by splinting the membranous portion with bone grafts, and later with polytetrafluoroethylene (Gore-Tex; W.L. Gore & Assoc, Flagstaff, AZ) and other materials. The operation never became really popular because of technical difficulties, foreign body reaction, and unpredictable results. Surgery of the autonomous nervous system was very much en vogue before and right after World War II. Under the influence of leading surgeons, Leriche and Fontaine [4.Leriche R. Fontaine R. Position actuelle de la question du traitement chirurgical de l’asthme bronchique.Arch MédChir App Respir. 1928; 3: 500-534Google Scholar] in France and Smithwick and others in the United States, sympathectomy became the treatment of choice for hypertension, Raynaud's or Sudeck's disease, and other conditions. Prominent thoracic surgeons, among others Rienhoff, Brian Blades, and Osler Abbot, tried to treat asthma-related emphysema by sympathectomy, vagotomy, stellate gangliectomy, or plexectomy [5.Rienhoff W.M. Gay L.N. Treatment of intractable bronchial asthma by bilateral resection of posterior pulmonary plexus.Arch Surg. 1938; 37: 456-469Crossref Google Scholar, 6.Blades B. Beattie Jr., E.J. Elias W.S. The surgical treatment of intractable asthma.J Thorac Cardiovasc Surg. 1950; 20: 584-597Google Scholar, 7.Abbott O.A. Hopkins W.A. Guilfoil P.H. Therapeutic status of pulmonary autonomic nerve surgery.J Thorac Cardiovasc Surg. 1950; 20: 571-583Google Scholar]. This approach, practically abandoned today, was so much en vogue that, at the 1950 Denver meeting of The American Association for Thoracic Surgery three papers and about 10 discussion remarks on this subject occupied half a morning of the most important thoracic meeting of the year! One last highly criticized operation to cure asthma was the controversial glomectomy introduced and promoted by Nakayama in Japan, and by Overholt and others in the United States. Lung volume reduction is a relatively modern term. Operations on the lung to obtain redevelopment and better ventilation of compressed segments have been, for many years, the most logical and at least temporarily successful approaches. The eradication of giant bullae by resection or drainage to redevelop crowded, nonfunctioning segments of the lung was an early attempted solution. For the functionally desperate cases, intracavitary suction, as proposed by Monaldi in 1933 for tuberculous cavities, was a logical palliative option. At the 1952 meeting of The American Association for Thoracic Surgery, this approach was proposed and discussed by Head and Avery [8.Head J.R. Avery E. Intracavitary suction (Monaldi) in the treatment of emphysematous bullae and blebs.J Thorac Cardiovasc Surg. 1949; 18: 761-776Google Scholar]. They had treated a series of cases at the Hines Veterans and North Western University Hospitals since the early 1940s, and recommended intracavitary suction in most cases as less dangerous than bullectomy by thoracotomy. Jerome Head (1893–1974) was the leading chest surgeon in Chicago in the 1930s. During his training at the Peter Bent Brigham Hospital he was summarily dismissed by his chief, the great Harvey Cushing, who strongly disapproved of marriage during internship—an anecdote typical of the training environment for young surgeons at the time. Thus Jerome Head left for an equally remarkable training at the Mayo Clinic before coming to Chicago. In spite of the Monaldi approach advocated by Head and Avery, most surgeons preferred open bullectomy, except for inoperable cases. There is, of course, a floating transition from resection of giant bullae to the so-called lung volume reduction for diffuse nonbullous emphysema. As a surgeon-historian familiar with those early years from personal experience, I am able to put recent developments in their historical context. It is customary to attribute early lung reduction surgery to Otto Charles Brantigan (1904–1981), who was an active general and thoracic surgeon, professor of anatomy at the University of Maryland and chief of surgery at the Baltimore City Hospital. He was a typical self-made man who started out in the steel mills of Gary, Indiana, before coming to North Western University in Chicago as a medical student. I first heard about Brantigan from my good friend Thomas J. E. O’Neill of the Bailey group, who helped me with my first commissurotomies in 1951. O’Neill, who had trained with Brantigan as an intern, remembered him with great admiration as an exceptional general surgeon whose interests and competence ranged from prostatectomy to hip fractures, tuberculosis surgery, tracheal resection, and mitral commissurotomy. Unfortunately, in Baltimore he lived under the shadow of the great Blalock and his revolutionary blue baby operation at Hopkins, next door. Brantigan's first publications in local journals (Virginia Medical Journal and Maryland Medical Journal [9.Brantigan O.C. Surgical treatment of pulmonary emphysema.W Virginia Med J. 1954; 50: 283-285PubMed Google Scholar,10.Brantigan O.C. Surgical treatment of pulmonary emphysema.Maryland Med J. 1957; 6: 409Google Scholar) on what was to be called lung volume reduction go back to 1954 and 1957, before he presented his well-illustrated concept on June 19,1958, at a symposium on emphysema sponsored by the National Tuberculosis Association and the American Trudeau Society in Aspen, Colorado [11.Brantigan O.C. Mueller E. Kress M.B. A surgical approach to pulmonary emphysema.Ann Rev Respir Dis. 1959; 80: 194-206PubMed Google Scholar]. His presentation was followed by a lively, mostly critical discussion from surgeons and pulmonologists. From a historical point of view Brantigan's final concept certainly evolved gradually by trial and error, typical for thoracic surgery in those days. He said that he advocated surgical volume reduction after an 8-year experience because when a volume of 6,000 to 7,000 mL of emphysematous lung is stuffed or crowded into a thoracic cage of only 5,000 mL the lung loses its circumferential elastic pull, which maintains collapsed peripheral bronchioles open on expiration. Lung volume reduction by resecting the most distended, functionless areas of parenchyma—adjusting the proper relation between chest cavity and lung volume—not only allows reexpansion of compressed, potentially functioning lung, but also restores the physiologic principle of circumferential elastic pull on the formerly collapsed bronchiolar walls. Although he recommended bilateral sequential operations, more than half of his patients had only one side operated on. Now, to analyze the historical development of the “Brantigan concept,” one has to realize that in his 1958 presentation Brantigan admitted that although he had “started this approach eight years earlier, he understood the mechanism of improvement only 18 to 24 months ago” [10.Brantigan O.C. Surgical treatment of pulmonary emphysema.Maryland Med J. 1957; 6: 409Google Scholar]. Furthermore he stated, somewhat naively, that having done these operations since 1950 “on a purely experimental basis,” he was “pleasantly surprised [!] by the positive results” [10.Brantigan O.C. Surgical treatment of pulmonary emphysema.Maryland Med J. 1957; 6: 409Google Scholar]. In the context of those early years of thoracic surgery, proceeding through trial and error in many fields—tuberculosis, bronchiectasis, cancer—I can personally very well visualize Brantigan's experimental progression. Like everybody else he started by resecting space-occupying giant bullae and probably, on occasion, multiple smaller blebs in diffusely hyperinflated zones. In his publications he speaks several times about the “surgical approach of emphysema with and without bullae or blebs” (emphasis added). He gradually understood or hypothetized that “bullectomy” improves function, not only by allowing “crowded” adjacent lung tissue to reexpand, but also by restoring the proper proportion between lung volume and chest cavity, and thus the “circumferential elastic pull.” Following this hypothetical reasoning in his bullectomy cases, he went one step further to resect “redundant” obviously non-functioning grossly emphysematous lung tissue usually located at the periphery of the (upper) lobes, being “pleasantly surprised by the good results,” in other words, from giant bullectomy to resection of multiple smaller blebs and “redundant” diffusely emphysematous lung tissue. In view of today's discussion concerning operative indication, it is interesting to note that Brantigan actually never refers to volume reduction in cases of homogenous emphysema of the entire lung, but speaks only of bullae, blebs, and redundant, most distended areas at the periphery of the lobes; in other words, of the logical approach in cases of a more or less heterogenous distribution. Technically he performed multiple peripheral wedge resections combined with plications, but warned against anatomic lobectomy or segmentectomy to spare functioning parenchyma, to improve postoperative reexpansion, and diminish the risk of excessive air-leaks. Air leaks, a problem until today, can also be reduced by the “pleural tent,” an artifice we used liberally in conjunction with such extensive resections as, for instance, bilobectomy for tuberculosis. To my knowledge, the New York surgeon Laurence Miscall [12.Miscall L. Discussion of: Dugan D.J. Samson P.C. The surgical treatment of giant emphysematous blebs and pulmonary tension cysts.J Thorac Cardiovasc Surg. 1950; 20: 747Google Scholar] was the first to suggest this technique, discussing a paper on tuberculosis resection at the 1950 meeting of the American Association for Thoracic Surgery in Denver. Today this technique, in conjunction with volume reduction, is recommended by Joel Cooper. As reported in his 1959 article, Brantigan combined pulmonary resection with an extensive “lung denervation,” and the resection of the bronchial arteries. Again he admits that the “physiology or function of the nerves is not clearly understood” but states that the most noticeable result is “drying of the bronchial gland secretions,” and that denervation “relieves bronchial spasm and the distressing morning cough.” The discussion of Brantigan's 1958 presentation was very critical, especially the devastating comment by Gaensler, the respected authority on pulmonary physiology at the time. From the surgeon's point of view the operation was a high-risk procedure in often desperate cases, with a high mortality (15% to 20%), even in the hands of an excellent surgeon like Brantigan. I think that the reason why thoracic surgeons never became interested in Brantigan's approach was not so much its high operative mortality, at the time easily tolerated for other desperate indications such as bilateral tuberculosis or bronchiectasis, but rather the all too uncertain risk/benefit relation compared with the definitely spectacular results in other fields such as tuberculosis resection. Furthermore, in those days, the selection of favorable cases was difficult, and objective functional evaluation was extremely primitive compared with today's sophisticated methods developed in conjunction with lung transplantation. Consequently, results in a small heterogeneous group of indications were highly unpredictable and far from convincing. As Gaensler ironically remarked, “it was difficult to believe that a disease characterized by diffuse loss of lung parenchyma could be effectively treated by resection of functioning lung.” Thus the operation was in fact never accepted and buried until its rediscovery by Joel Cooper. It was a streak of genius that Cooper, who had made his mark as a pioneer in lung transplantation for terminal respiratory insufficiency, understood the value of the Brantigan approach and reported the results of 20 operations at the 1994 meeting of the AATS [13.Cooper J.D. Trulock E.P. Triantafillou A.N. et al.Bilateral pneumectomy (volume reduction) for chronic obstructive lung disease.J Thorac Cardiovasc Surg. 1995; 109: 106-119Abstract Full Text Full Text PDF PubMed Scopus (894) Google Scholar]. The initial title of Cooper's presentation was “Bilateral Pneumectomy for ….”, and he explained the somewhat bizarre term of pneumectomy, recalling the amusing historical discussion on etymology of medical terms at the 1933 meeting of The American Association for Thoracic Surgery between the Greek-American surgeon Pol Coryllos and the two pioneers Howard Lilienthal and Everts Graham. When Lilienthal called his total lung resection “pneumonectomy”—as we all do today— Graham, based on the Oxford dictionary, insisted on calling the operation “pneumectomy.” Coryllos settled the dispute in favor of “pneumonectomy” because, according to him, “pneumectomy,” derived from the Greek “pneuma,” would mean the resection of breath or air, a term Cooper, 60 years later, considered to aptly describe the principle of surgical lung volume reduction. Etymology apparently was Coryllos’ hobby. During an earlier discussion on extrapleural pneumothorax, Coryllos already insisted that the operation should be called “pneu-monolysis” and not “pneumolysis” because it was the lung and not the breath (pneuma) that was detached, and that finally it should be called “pleurolysis,” as it was the pleura and not the lung that was freed from the chest wall [14.Naef A.P. The story of thoracic surgery. Hogrefe & Huber, Toronto1990Google Scholar]. Cooper said that he had been made aware of Brantigan's publication by Jean Deslauriers of Quebec, and that certain observations made in his transplantation patients suggested that Brantigan's approach might be valuable as an alternative or “bridge” to lung transplantation. From a historical point of view, I think that Cooper took up an essentially experimental hypothesis, promoted half a century before, and developed it into a modern, team-dependent, systematic approach based on sophisticated patient selection, preoperative preparation, optimal surgical technique, and systematic follow-up. Unlike the critical reception and eventual oblivion of Brantigan's idea in the 1950 environment, the enthusiastic acceptance of Cooper's methodical approach today is well-known. Lung volume reduction undoubtedly is a useful addition to our therapeutic armamentarium. It has evolved from the occasional palliation by resection of space occupying giant bullae by general thoracic surgeons. In its more sophisticated form of today, this type of surgery depends on the experience and competence of modern transplantation teams. We should listen to the lessons of history and remember the identical passage of “closed” heart surgery by individual thoracic surgeons to “open” heart surgery under extracorporeal circulation by multi-disciplinary teams. Lung volume reduction in its modern form is a risky palliative procedure. Attempted away from a transplantation environment it can only lead to disappointing results and occasional catastrophe. We only have to remember the 15% to 20% mortality of Otto Charles Brantigan.