VOL. ioo, No.

LUCITE EXTRAPERIOSTEAL PLOMBAGE*

ROENTGENOLOGIC REViEW OF LATE COMPLiCATIONS

By CHARLES E. SEIBERT, M.D., and JOSEPH TABRISKY, M.D.

DENVER, COLORADO

S INCE 1946,58 hollow lucite balls have

been utilized in extraperiosteal plom-
bage for collapse therapy of pulmonary
tuberculosis. At the present time, the in-
dications for plombage are rather stringent
because of advances in chemotherapy. At
the National Jewish Hospital, Denver,
Colorado, patients are considered for
plombage only when they satisfy all of the
following conditions: (i) The disease has
been resistant to all drugs and the patient
has persistently positive sputum; (2) upper
lobe cavitation is present and strategically
situated to allow obstruction of the bron-
chial communication by plombage; and
(3) pulmonary reserve is so significantly
impaired that resectional therapy would re-
sult in a “pulmonary cripple.” Plombage
would preserve the maximal amount of
pulmonary function compatible with con-
trol of the disease.
Despite the reduction in the number of
lucite plombage operations performed, Fic. i. Diagrammatic illustration of extraperiosteal
lucite sphere implantation.
there remains a large patient group who
have undergone this type of collapse ther-
apy and occasionally the radiologist will lucite balls medially, which could impair
be confronted with the problem of diag- venous return by pressure on the mediastinal
nosing complications of the procedure. veins.

SURGICAL PROCEDURE PATHOLOGIC REACTION TO

LUCITE IMPLANTATION
In extraperiosteal lucite plombage as
described by Wilson et al.,8 the number and Normally, the lucite spheres become
length of ribs stripped of their periosteum rigidly fixed by a process of hyalinization
is fashioned to collapse a cavitary lesion, and fibrosis.6’7 In the immediate postoper-
but to leave the surrounding more normal ative period, there is a copious exudate
lung functional. The periosteum is stripped and air-fluid levels are
demonstrated
from the undersurfaces of the selected within the plombage (Fig. 2). This exudate
ribs. The lucite spheres are then placed resolves within several weeks as hyaliniza-
separately or within a polyethylene sheet tion occurs (Fig. 3). Failure of air-fluid
in the space fashioned (Fig. i). Extensive levels to regress in the early phase indicates
apicolysis is not done since this would tu berculous or nontuberculous infection
predispose to migration and erosion of the of the surgical space. Rarely, in the first

* From the Department of Radiology, National Jewish Hospital, Denver, Colorado.

593
594 Charles E. Seibert and Joseph Tabrisky JULY, 1967

11G. 2. Early postoperative roentgenogram revealing

the expected exudate and air-fluid level.

Fic. . Inferior border of plombage marked on the

roentgenograms to demonstrate the progressive
few months following tile procedure, a
sag. Therapeutic pneumoperitoneum is present.
foreign bod reaction will dissolve tile outer
fibrotic capsule around the plombage.
plombage is a manifestation of recurrent

LATE COMPLICATIONS
fluid formation. The illustrations show an
increasing dependent sag of the plombage
I. REDEVELOPMENT OF FLUID WITHIN THE
PLOMBAGE SPACE
space over several years (Figs. 4 and 5). It
is obvious tilat the surrounding tissue has
Sagging of the inferior aspect of the

,1”

.y-i

Fic. . Same case as in Figure 4, one year later. The

patient now has positive sputum for tuberculosis.
Fic. 3. Normal fibrosis and hyalinization occurring in Lower border of plombage is seen bulging down-
plombage space i month after surgery. ward.
\OL. ioo, No. 3 Lucite Extraperiosteal Plom bage 595

been enzynlaticallv destroyed by bacteria.

llle spheres are 110 longer trapped in tile
fibrotic matrix.
lile lucite balls become quite fllObile ill

tile plombage.3’9 In tile erect and decubitus

roentgenogram (Fig. 6), the change in
position in relation to each other. Because
of
to
their
water,
lesser
tile
specific
lucite spheres
gravity,
tend
compared
to float.
r
As the fluid increases, tile spheres become
more widely separated.

II. MIGRATION AND EROSION 01’ SOFT TISSUES liv tic. 7. Arrow points to air in soft tissue with nearby
THE SIHERES lucite ball partially protruding into anterior inter-
costal space. ihis represents extrapleu rd bronchial
Migration and erosion of tile tiloracic
communication and peripheral migration of lucite
structures by lucite balls1’ occur if they
sphere.
erode into tile soft tissue adjacent to tile
plombage, either centrally toward tile lung be recognized roen tgellograplli cal lv. Ill e
parenchma or peripherally toward the rims of tile lucite balls are outlined by air,
chest wall. With peripheral erosion, the thus confirming tile presence of bronchial
spheres erode between the rib interspaces communication to tile space containing the
and reside in the soft tissue of the chest wall splleres (Fig. 8).
or migrate into the flank or neck (Fig. 7). The presence of fluid, mobility, broil-
If central erosion occurs, a communication chial communication, and migration of
to the pleural space or lung parencilvma is splleres invariably indIcates progressive in-
establislled. Bronchopleu ral or extrapleu ral fectious disease with extension into tile
fistulous air tracts ma be present and can pleural and extrapleural space. Extra-

11G. 6. Same case and same approximate time as in

Figure . I)ecubitus roentgenogram demonstrates 11G. 8. Air surrounding lucite balls indicative of
that lucite spheres are mobile and will float in the bronchial communication with plombage. Extra-
liquid medium. pleural fistula indicated by arrow.
596 Charles E. Seibert and Joseph Tabrisky JULY, 1967

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