Articulo anexado Alejandro Arvizo

CHEMICAL TREATMENT OF THE PERIOSTEUM IN THORACOPLASTY
TO INHIBIT RIB REGENERATION
BY C. M. VAN ALLEN, M.D.
OF PEIPING, CHINA
FROM THE DEPARTMENT OF SURGERY, PEIPING UNION MEDICAL COLLEGE
FIVE years ago, Jerome Head' described experiments in which he tested
the effectiveness of various chemical agents for preventing osteogenesis after
subperiosteal costectomy. He removed pieces of several ribs from each of
a number of dogs and then painted the rib-free periosteum with the chemicals
before closing the wound. After a lapse of time amply sufficient for bone to
regenerate, the animals were sacrificed and the rib beds were examined by
X-rays and dissection. Zenker's solution seemed the most suitable of the
agents employed, since it prevented osteogenesis completely without producing
appreciable necrosis. Meiss2 reported a similar investigation in I930.
Although he found Zenker's solution quite effective in preventing the formation
of new bone, he noted perforation into the pleural cavity in one instance
and symptoms (undescribed) of systemic poisoning. He preferred IO per
cent. solution of formalin-an agent not tested by Head-for it had all the
advantages of Zenker's solution and none of the disadvantages.
Both authors suggested clinical uses for their methods in certain types of
thoracoplasty. Thus, it was recalled that where ribs have to be resected in
stages for producing collapse of the chest-wall, "the true collapse occurs only
with the removal of the last ribs. Until then the part of the wall of the chest
which is already mobilized hangs from the ribs like the curtain of a tent, and,
if the bones reform in this position, the final collapse is compromised."'
Furthermore, the lapse of three weeks between the first and last stages of
operation may be sufficient to bring about this undesired result, and yet
that or even a much greater interval between the stages is often advantageous
or imperative, in order to replenish the patient's strength and morale, to
prevent advancement of associated diseases, to permit infected wounds to
heal, to test the effectiveness of preceding stages, etc. It seemed to Meiss that
the method would be useful in paravertebral extrapleural thoracoplasty for
pulmonary tuberculosis because it would allow wider intervals between the
stages of operation and would permit the chest-wall to continue collapsing
slightly for several months after operation, in response to the gradual
fibrosis and shrinkage of the lung that occurs with the healing of the disease.
He believed that the prevention of rib regeneration would not leave
the thoracic wall sufficiently unstable to jeopardize the healing of the pulmonary
lesion, for he knew of a patient who had received paravertebral
thoracoplasty by supraperiosteal costectomy and had obtained full benefit
to the tuberculous lesion of the lung. Head advised against this application
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TREATMIENT OF PERIOSTEUM IN THORACOPLASTY
of the method, on the theoretical grounds of mural instability. Other uses
suggested by these authors were as follows: Employment in the graded
Estlander operation for chronic empyaema or bronchiectasis, to permit wider
spacing of the stages and more prolonged collapse; use in the Brauer cardiolysis,
to ensure permanent pliability of the precordium; use in the rib
resection for drainage of empyema or lung abscess, to prevent new bone
from forming in, and encroaching upon, the sinus; and use in the rib resection
for cautery pneumectomy, to obviate the difficulty which may arise
from regeneration of bone in the field of cauterization.
Neither one of the authors has reported clinical experience with his
method, and the only reference of the kind that I can find is the bare statement
of Trout3 that he had used the method of Head with satisfaction in
thoracoplasty for pulmonary tuberculosis. I began to use Zenker's solution
in plastic operations for chronic empyema soon after the appearance of
Head's publication, but changed later to formalin. Twelve cases of that
type have been treated with one or the other chemical, and, besides, twentythree
cases with drainage of empyaema, three with drainage of lung abscess,
and two with cautery pneumectomy. While this experience is quite insufficient
for final evaluation of the methods, the results have been satisfactory
and consistent enough to warrant preliminary report.
The first case to be treated was that of a white male, aged thirty-two years. At
the time of admission to the hospital, he had been ill for eleven months with productive
cough, fever, dyspncea, and weakness. Five months before the symptoms had become
so exaggerated that the patient had to stop work. His physician at the time made the
diagnosis of empyema of the left pleural cavity and established drainage by intercostal
catheter. Considerable improvement followed, but soon the cough and fever returned.
On admission the patient was found to be emaciated, weak, and toxic. The left half
of the chest was markedly retracted and fixed, and it exhibited a narrow sinus at the
seventh intercostal space in the posterior axillary line. Tubercle bacilli were abundant
in the sputum and in the pus from the sinus. X-ray examination showed an empyaema
cavity on the left side with very thick walls, extending from the third rib to the diaphragm
and from the anterior axillary line to the vertebral column. An operation
was done immediately to widen the sinus. A specimen of the pleura which was obtained
at the time revealed the presence of tuberculous infection. The drainage thus established
and the supportive treatment that followed produced great improvement of the constitutional
condition within two months; but the cavity was unchanged in size, so the
decision was made to obliterate it with the graded thoracoplasty of Schede. At the
first stage, the lower one-third of the roof of the cavity was removed; but the shock
was very severe. So, two months later, when the patient's strength was sufficiently
restored, the milder operation of Estlander was resorted to, with the addition that
the rib-free portions of periosteum were painted with Zenker's solution. The parts
of the ribs lying over the cavity, together with a part of one rib (second) above, were
removed in two sittings, with an interval of six weeks between to allow for delayed
wound healing. The immediate effect of this was only partial obliteration of the
empyaema cavity; but the collapse proved to be progressive and fourteen months after
the last operation the cavity was closed, the sinus was healed, and the patient felt well.
In the three other cases of tuberculous empyama treated since then, the
entire lengths of the ribs overlying the cavities were removed subperiosteally
24 369
C. M. VAN ALLEN
in small and widely spaced steps, with application of one or the other chemical
to the periosteum. The cavities collapsed satisfactorily, and only one
(see the case report below), which was operated upon very recently, has
not yet healed. Graded subperiosteal resection of only the posterior segments
of ribs was employed for the patients with extenisive non-tuberctnlous
empyaema. This included the ribs over the cavity-and onie above if
the cavity was subtotal. The result was that the anterolateral segments of
ribs, the thickened parietal pleura, and the superficial tissues, which remailled
over the cavity, fell progressively during and after the operations until obliteration
was complete. One of these cases required further work, to uniroof a
small residual cavity. Thus, in both types of empyema, the Estlander operation
almost entirely replaced the Schede procedure, which hitherto had been
indispensable. Since the parietal pleura and intercostal structures were not
removed, as in the Schede thoracoplasty, the operations were accompanied by
relatively little blood loss and shock and by no paralysis of the abdominal
wall. A comparatively small but noteworthy advantage of the chemical treatment
was that, after resection of the posterior segments of ribs, the posterior
ends of the anterolateral segments developed no spurs.* No appreciable (lisadvantage
was experienced from paradoxical respiratory movements of the
clhest-wall. Scoliosis developed, but it was no greater-indeed, uisually mucl
less-than that after Schede resections for equally extenisive cavities. Chemical
poisoning was watched for but was not detected. Chronic empy.sema cavities,
-which were so small as to extend under no more than three ribs, were
still treated by the Schede thoracoplasty.
The expected benefits were derived, also, in connection with rib resection
in the other types of cases. Although the benefits were comparatively
sliglht, they were worth while.
One case was outstandinig, because it made possible a direct comparison
between Zenker's ancd forniialin solution-s as to their effectiveness in prevenltinlg
osteogeniesis.
A Chinese male, aged twenty-three years, was admitted to the hospital with a
history of productive cough for two and one-half years. Slight weakness was the only
accompanying symptom, until one day three months before when, during unusually
strenuous coughing, sudden pain occurred in the right side of the chest and marked
dyspncea developed. He took to bed at once and soon had a chill and started to run
a high fever. On admission the man was extremely emaciated and feeble, orthopneeic,
cyanotic, and disturbed by a frequent productive cough. The sputum was fetid and
containied myriads of tubercle bacilli. Physical and r6ntgenographical examination of
the chest revealed complete collapse of the right lung, fluid and air in the right pleural
cavity, extenisive displacement of the mediastinum to the left, depression of the right
hemidiaphragm, and a light infiltration of the left upper lobe which was suspected to
he tuberculous. The chest was tapped. The fluid proved to be thick pus, containing
tubercle bacilli, streptococci, staphylococci, and other organisms, and the air was found
to be under pressure of plus 3 to 8 centimetres H20. The initial treatment consisted
* Hedblom4 has emphasized the danger of laceration of the pleura and lung that
exists during anterolateral costectomy for pulmonary tuberculosis, in removing ribs
that carry these sharp, upward curved projections.
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TREATMIENT OF PERIOSTEUM IN THORACOPLASTY
in bi-daily aspiration of large quantities of pus anid air and in general supportive measures.
Within four weeks the dyspncea was greatly relieved and the mediastinum was
returned to the mid-position (Fig. i) ; but the secondary infection and fever persisted,
so that open drainage was done. At the same operation, ten centimetres of each of
ribs II, IO and 9 were resected paravertebrally alnd the rib-free periosteum was painted
with Zenker's solution, which constituted the first stage of an Estlander operation to
de-rib the entire right half of the chest. The paravertebral wound became infected
slightly from its close proximity to the drainiage wound. The operation was well
borne, nevertheless, so it was decided not to wait for complete healing of the paravertebral
incision but to abandon the usual orderly progression of resection and operate
the second time at a considerable distance. Consequenitly, the second stage was performed
twenty-six days after the first and consisted in the resection of four to ten
centitmletres of the posterior extremities of ribs 4 to I, inclusive, with application of
Zenker's solutioni. The wounid healed well. But shortly after this, the temperature
becamie somewlhat elevated, the cough inicreased, and a rontgenogram (Fig. 2) showed
FIG. .. Fio. 2.
FIG. I.Thoracic rontgenogram of a case with secondarily infected, tuberculous empyaema and
comiplete collapse of one lung, taken just before the beginning of a graded subperiosteal costectomy
wherein Zenker's and formalin solutions were compared for effectiveness in preventing rib regeneirationi
FIG. 2.-Same case, thirty-six days after the establishment of open drainage and the resection
of the posterior segments of ribs IIto 9, and ten days after the resectioni of the posterior segments
of ribS 4 to I. The rib-free periosteum was painted with Zenker's solution. Arrows ind:cate the foci of
new bone from the first operation.
a slight increase in the lesion of the left lung. The same r6ntgenogram was initerestinig
from the fact that it gave an exceptionally distinct view of the beds of some of the
resected ribs-due to the persistence of a bridge of ribs (8 to 5) across the middle of
the hemithorax which held the beds widely out-and that it showed definlite traces of
new bone in the field of the first operation performed thirty-six days previously. The
infection in the left lung quieted sufficiently to permit the third stage to be performed
fifty-one days after the second, with removal of the anter-olateral segm'ents of the
upper four ribs; but this time i0 per cent. solution of formalin was used in place of
Zenker's solution, according to Meiss' suggestion. The wound healed per Prima,.
And once more the condition of the left lung demanded a long wait. A rdntgen-film
(Fig. 3), taken fifty days after the third stage, showed that the formalin-treated peniosteum
was free from appreciable amounts of new bonle, while the Zenker's treated
periosteum of the first operation((127 days before) had developed inicomplete but welldefined
ribs. The field of the second operation lay too close to the spine to permit clear
371
C. M. VAN ALLEN
discernment of the degree of rib regeneration. The fourth operation came the day after
this examination and the fifth came twenty-seven days later, whereby the remaining
ribs and portions of ribs were taken out and the periosteum was painted with formalin.
Figure 4 gives the appearance ten days after the last operation when the chest-wall
was completely collapsed and the merest slit remained of the empyama cavity. The
patient's condition was satisfactory in other respects, also. The cough was absent, the
temperature normal, the pulse rate only slightly elevated, and the body weight increased
by four kilograms. The lesion of the left lung seemed about the same as at admission.
A prolonged period of rest was then indicated, to permit that infection and the one in
the collapsed empyama cavity to heal, but the prognosis was fair.
The results in this case suggest that formalin is much more effective than
Zenker's solution. In view of the fact that the collapse of the chest was complete,
both in this and in the other cases treated with Zenker's solution, it is
very likely that the ribs which regenerated after the use of that agent were
FIG. 3. FiG. 4-.
FIG. 3.-Same case, fifty days after the resection of the anterolateral segments of ribs 4 toI with
application of formalin solution (third costectomy). No new hone is visible. Arrows indicate the
enlarged, fragmenta'ry deposits of bone 1 27 days after the first operation.
FIG. 4 -Same case, five months and five days after the fir$t and ten days after the last (fifth)
costectomy. Ribs i i to iare absent and the empyaema cavity is totally collapsed.
fragmentary rather than solid. Although formalin seemed to prevent osteogenesis
entirely in the instance cited above, proof has since appeared that
it permits a slight amount of bone to form. In a case being treated at present
by cautery pneumectomy, the slough of the thoracic wall from the first burning
contained tiny spicules of bone along the lines of the periosteal beds which
had been stripped of ribs and painted with formalin thirty-six days before
the burning. The partial regeneration that occurs after both agents
probably accounts for the satisfactory degree of stability of the chest-wall
that resulted in all of the cases of chronic empyaema. Furthermore, it suggests
that the method of periosteal treatment can be applied to paravertebral
thoracoplasty for pulmoniary tuberculosis without danger of instability of
the thorax. This will soon be tested, first with Zenker's solution.
The solutions were applied as follows. After each rib was removed, its
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TREATMENT OF PERIOSTEUM IN THORACOPLASTY
periosteum was sponged free from blood and then wiped throughout with a
small gauze swab, which had been dipped in the solution and shaken out.
The periosteum was again sponged dry and painted with a fresh swab; and
the process was repeated five or six times. This insured that the rib bed
received thorough contact with the agent, without much contamination of the
surrounding tissues.
SUMMARY.-The discoveries of Head and Meiss are recounted, that bone
regeneration after subperiosteal costectomy in dogs can be prevented completely
by application to the periosteum of Zenker's or formalin solution,
as well as the suggestions of these authors as to possible clinical applications.
Personal experience with both agents for this purpose is briefly reported,
which concerned forty-three clinical cases, including twelve with chronic
empyaema. It is concluded that, in man, both solutions inhibit the reformation
of bone markedly but do not prevent it entirely, that formalin is much
the more effective, and that the use of one or the other of these chemicals
is advantageous in certain operations of rib resection. The chief advantages
occur in the treatment of large chronic empyaema cavities, because the
Estlander thoracoplasty can be used in place of the more destructive and
shock-producing procedure of Schede, the stages of resection can be placed
as far apart as desired, spurs do not form on the ribs, the chest-wall continues
to collapse long after the last operation.
BIBLIOGRAPHY
'Head, J.: Prevention of Regeneration of the Ribs. A Problem in Thoracic Surgery.
Arch. Surg., vol. xiv, p. I209, I927.
2 Meiss, W.: Experimenteller Beitrag zur Vereinfachung der Thoracoplastik in mehreren
Tempi. Zentralbl. f. Chir., vol. lvii, p. 349, 1930.
3 Trout, H.: The Release of Pericardial Adhesions. Arch. Surg., vol. xxiii, p. 966, I93I.
'Hedblom, C.: Anterolateral Costectomy for Inadequate Collapse Following Posterior
Extrapleural Thoracoplasty. Arch. Surg., vol. xxi, p. III4, I930.
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