Pleuro-Pulmonary Tuberculosis - Surgical Principles

SURGICAL ASPECTS OF PLEUROPULMONARY

TUBERCULOSISDr. SANJOY SANYALMBBS, MS (Surgery)

Department of Surgery – Central Hospital Kigali.Rwanda, Africa 1999

Presented at 2nd Annual Conference of College of Gynaecology and Obstetrics of Rwanda,

Kigali, Rwanda, Africa, on 5th – 6th May 1999

Bird’s-eye view

• TB, specifically PT, needs no introduction

• ATT - drastic reduction in indications for surgical treatment

• MDRT strains - 33-70% of all cases, depending on region

• 5-10% PT require surgical treatment

• Post-WW II era-maximum strides in intra-thoracic surgery

The therapeutic spectrum• Pulmonary tuberculosis

– 90-95%-----ATT (prolonged, regular)– 5-10%-------Require surgery

• Procedures of choice– Pulmonary resection-------------90%– Thoracoplasty--------------------10%

TB: Tuberculosis; PT: Pulmonary Tuberculosis,

ATT: Anti-Tuberculosis Treatment; MDRT: Multi-Drug Resistant Tuberculosis

Classification of Rx – Pulmonary

• Resection---------Segmental resection

• ---------Lobectomy

• ---------Pneumonectomy

• Relaxation (collapse) therapy

• Major--------------Thoracoplasty

• --------------Plombage

• --------------Pneumonolysis (extrapleural)

Classification – Cont’d

• Relaxation (collapse) therapy

• Minor-----------Phrenic paralysis

• -----------Pneumothorax

• -----------Pneumoperitoneum

• Drainage therapy

• -----------Cavernostomy

• -----------Monaldi catheter drainage

Thoracoplasty (Relax Rx) principle

• TB heals by fibrosis, contraction, collapse, obliteration of diseased area / cavity.

• Bony chest wall mechanically hinders this.

• Removal of sufficient portion of wall obliterates pleural space

• Allows lung to contract / retract concentrically towards hilum, and thus ‘relax’.

Thoracoplasty – Indications• TB too widespread for safe removal

• Resection unduly risky

• ‘Open-positive’ with MDRT strains

• Elderly patients-as ‘compromise’ procedure

• Broncho-pleural fistula) following pul. resection-as ‘secondary’ procedure

• Failed decortication of TB empyema

Thoracoplasty – Types

• Standard (extrapleural, paravertebral) thora-coplasty = selective (upper lobe); Alexander

• Lateral thoracoplasty; Sauerbruch

• Semb’s apicolytic modification

• Apical thoracoplasty (adjunctive procedure)

• Modified (‘tailoring’) thoracoplasty

• Radical thoracoplasty; Friedrich

Pulmonary resection• Aims: Remove / assist in healing / control of

destructive residuals; prevent reactivation

• Advantages: Greater diseased part removed; no external deformity; little respiratory disturbance

• Disadv: Unsafe in extensive disease; inadvisable in MDRT strains.

• (These are indications for thoracoplasty)

Pulmonary resection – Indications

• ‘Open-positive’ beyond 3-6 months of Rx

• ‘Closed-positive’ with pathologic residuals

• ‘Open-negative’ with thick-walled cavity

• Negative sputum with blocked cavities / > 2 cm nodules / tuberculoma / fibrocaseous

• TB bronchiectasis middle / lower lobe

Indications – Cont’d

• Atypical mycobacterial infection

• Neoplasm-can’t differentiate / concomitant / cancer at site of TB scar

• Haemoptysis-recurrent / persistent / massive

• Encapsulated, un-expandable lobe / lung with empyema

Resection – Extent

• Wedge resection: Tuberculoma, coin lesion; for frozen section biopsy confirmation

• Segmental resection: Localised residual cavities, fibrocaseous, especially bilateral

Resection – Extent

• Lobectomy: Active disease with +ve sputum and drug-resistant bacilli

• Pneumonectomy: Gross destruction one lung, persistent +ve sputum, recurrent haemoptysis

Resection – Complications

• Empyema, with or without }When +ve spu-

• Broncho-pleural fistula }tum, drug-resi-

• Bronchogenic spread of TB }stant, or exten-

• }sive resection

Adjunctive procedures• Temporary phrenic nerve paralysis

• Small apical thoracoplasty

Childhood resection• Vast majority respond to long-term ATT

• Only 5% require resection for:– Progressive primary TB– Reinfection TB – Destructive residuals

• Lobar atelectasis or emphysema due to hilar nodes don’t need operation.

• With ATT nodes regress and lobes become normal

TB empyema – Aims of Rx

• Control of infection by:

– Regular needle aspiration (thoracentesis)

– Intrapleural and systemic ATT

• Open drainage should be avoided

– (2° infection of pleural space inevitable)

Aims of Rx – Cont’d

• Obliteration of empyema cavity

• a) Active lung infection:

– ATT for 3-6 months

– Followed by thoracoplasty or pleuro-pneumonectomy

• b) Inactive lung infection:

– Repeated thoracentesis (prolonged)

– Decortication (procedure of choice)

Decortication – Principle

• Much better alternative to drainage

• Aim: Early expansion of lung

• Principles of technique:

• Incising empyema sac, evacuating purulent contents, excising ‘peel’; OR

• Excising entire empyema sac in toto from ‘outside - inwards’.

Decortication – Illustration

Combined procedures

• Pleuro-lobectomy or pleuro-pneumonectomy

– If TB empyema associated with active pulmonary disease (cavitation, positive sputum or both)

• Pleuro-pneumonectomy and eventual thoracoplasty

– If TB empyema with broncho-pleural fistula and secondary pathogenic infection

Conclusion

Decortication and pleuro- pneumonectomy

have dramatically altered outlook in most cases and have rendered all other procedures obsolete.