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Contents Preface: Surgery for Thoracic InfectionsçThe Mother of All Surgeries xiii Gaetano Rocco The History of Surgery for Pulmonary Tuberculosis 257 John A. Odell Thoracic surgical procedures evolved from surgical management of tuberculosis; lung resections, muscle flaps, and thoracoscopy all began with efforts to control the disease. The discovery of antituberculosis drugs in 1944 to 1946 made sanato- rium therapy and collapse therapy in all its forms obsolete and changed thoracic surgery dramatically. Currently, management of tuberculosis is primarily medical, and surgery has a minimal role. Today surgery is usually only performed in patients with tuberculosis when the diagnosis is necessary, who have complications or sequelae of the disease, or who have active disease resistant to therapy. Multidrug-Resistant Pulmonary Tuberculosis: Surgical Challenges 271 Michael J.Weyant and John D. Mitchell Multidrug-resistant tuberculosis (MDR-TB) continues to be a significant public health problem worldwide. The treatment of MDR-TB consists mainly of chemotherapy. However, surgery has been reported to be an effective adjunctive therapy in selected cases. This article discusses the scope of the problem of MDR-TB and the most accepted modern standard therapy. The indications for surgical interven- tion as well as an analysis of the results of this therapy are also discussed. Surgical Treatment of Atypical Mycobacterial Infections 277 Jessica A.Yu, Michael J.Weyant, and John D. Mitchell Surgical evaluation in nontuberculous mycobacterial (NTM) infections plays an essential role as part of multidisciplinary management of this complex pulmonary process. Resection of damaged lung parenchyma combined with appropriate anti- microbial therapy may interrupt a cycle of disease progression and relapse in select patients. Relevant technical considerations for managing both minimally invasive and open anatomic resection in this unique population are discussed. Results of anatomic resection of NTM damaged lung in the modern era are also summarized. Surgery for the Sequelae of Postprimary Tuberculosis 287 Gilbert Massard, Anne Olland, Nicola Santelmo, and Pierre-Emmanuel Falcoz This review describes diagnosis and management of sequelae of post-primary tuberculosis. It addresses elementary lesions such as bronciectasis, fibrostenosis, cavitation and broncholithiasis, the more complex situation of destroyed lung, and complications such as aspergilloma, hemoptysis and broncho-esophageal fistula. Diagnosis and Management of Lung Infections 301 Dawn E. Jaroszewski, Brandon J. Webb, and Kevin O. Leslie This article describes contemporary methods of diagnosis and current treatment regimens for most pulmonary infections. Modern techniques used to improve Surgical Management of Infectious Pleuropulmonary Diseases

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Surgical Management of Infectious Pleuropulmonary Diseases

Contents

Preface: Surgery for Thoracic InfectionsçThe Mother of All Surgeries xiii

Gaetano Rocco

The History of Surgery for Pulmonary Tuberculosis 257

John A. Odell

Thoracic surgical procedures evolved from surgical management of tuberculosis;lung resections, muscle flaps, and thoracoscopy all began with efforts to controlthe disease. The discovery of antituberculosis drugs in 1944 to 1946 made sanato-rium therapy and collapse therapy in all its forms obsolete and changed thoracicsurgery dramatically. Currently, management of tuberculosis is primarily medical,and surgery has a minimal role. Today surgery is usually only performed in patientswith tuberculosis when the diagnosis is necessary, who have complications orsequelae of the disease, or who have active disease resistant to therapy.

Multidrug-Resistant Pulmonary Tuberculosis: Surgical Challenges 271

MichaelJ.Weyant andJohn D.Mitchell

Multidrug-resistant tuberculosis (MDR-TB) continues to be a significant public healthproblem worldwide. The treatment of MDR-TB consists mainly of chemotherapy.However, surgery has been reported to be an effective adjunctive therapy inselected cases. This article discusses the scope of the problem of MDR-TB andthe most accepted modern standard therapy. The indications for surgical interven-tion as well as an analysis of the results of this therapy are also discussed.

Surgical Treatment of Atypical Mycobacterial Infections 277

Jessica A.Yu,MichaelJ.Weyant, andJohn D.Mitchell

Surgical evaluation in nontuberculous mycobacterial (NTM) infections plays anessential role as part of multidisciplinary management of this complex pulmonaryprocess. Resection of damaged lung parenchyma combined with appropriate anti-microbial therapy may interrupt a cycle of disease progression and relapse in selectpatients. Relevant technical considerations for managing both minimally invasiveand open anatomic resection in this unique population are discussed. Results ofanatomic resection of NTM damaged lung in the modern era are also summarized.

Surgery for the Sequelae of Postprimary Tuberculosis 287

GilbertMassard, AnneOlland, Nicola Santelmo, and Pierre-Emmanuel Falcoz

This review describes diagnosis and management of sequelae of post-primarytuberculosis. It addresses elementary lesions such as bronciectasis, fibrostenosis,cavitation and broncholithiasis, the more complex situation of destroyed lung, andcomplications such as aspergilloma, hemoptysis and broncho-esophageal fistula.

Diagnosis and Management of Lung Infections 301

Dawn E. Jaroszewski, BrandonJ. Webb, andKevin O. Leslie

This article describes contemporary methods of diagnosis and current treatmentregimens for most pulmonary infections. Modern techniques used to improve

Contentsviii

diagnostic yield in pulmonary infection include bronchoscopy, ultrasound- and elec-tromagnetic-guided endoscopy, transthoracic needle biopsy, and samples obtainedwith thoracoscopy. The spectrum of bacterial, mycobacterial, fungal, and viral path-ogens implicated in pulmonary disease is discussed. Treatment strategies andguideline recommendations for antimicrobial selection are described for commu-nity-acquired, health care–associated, hospital-acquired, and ventilator-associatedpneumonia, and for the most common fungal, mycobacterial, and viral infections.The state-of-the art in topical and aerosolized anti-infective therapy and an algorithmfor managing hemoptysis are also presented.

Indications for Surgery in Patients with Localized Pulmonary Infection 325

Robert E. Merritt andJoseph B. Shrager

Nowadays, antibiotic and antifungal therapy is effective in treating some of the infec-tions that can involve the lung parenchyma in a localized manner, such as bacterialabscess and infection with nonresistant tuberculosis strains. However, other local-ized pulmonary infections, for example aspergilloma and mucormycosis, are highlyresistant to nonsurgical therapy, and in these diseases there are no generallysuccessful options that do not include surgical resection. This article reviews theindications for surgical intervention in the treatment of common infections involvingthe lung, and also focuses on the general approaches to their management.

Results of Surgery for Bronchiectasis and PulmonaryAbscesses 333

ThirugnanamAgasthian

Bronchiectasis and lung abscess are generally treated medically, reserving surgeryfor when medical treatment has failed. Current goals of surgical therapy for bronchi-ectasis are to offer possible cure and better quality of life after medical treatment hasfailed and to resolve and prevent complications, such as empyema, severe hemop-tysis, and lung abscess. Whenever possible, complete resections of localizeddisease should be done, reserving palliative resections to selected diffuse bronchi-ectasis with localized severe disease. Most lung abscesses can be successfullytreated medically provided early diagnosis and prompt treatment are instituted.

PulmonaryAspergilloma: Clinical Aspects and Surgical Treatment Outcome 345

Eliseo Passera, Adriano Rizzi, Mario Robustellini, Gerolamo Rossi, Claudio Della Pona,FabioMassera, and Gaetano Rocco

Aspergillomas are fungal balls within lung cavities. The natural history is variable.Hemoptysis is a dangerous sequela. Medical therapy is ineffective because of thelack of a lesion blood supply. Randomized trials are lacking. Surgery should bethe treatment of choice in cases of hemoptysis, and even in asymptomatic patients,if lung function is not severely compromised. Cavernostomy and cavernoplasty maybe options for high-risk patients. Percutaneous therapy should be reserved forpatients who are not fit for surgery. Bronchial artery embolization is appropriatefor symptomatic patients not suitable for surgery. Embolization could be considereda preoperative and temporary strategy.

Surgery for Other Pulmonary Fungal Infections, Actinomyces, and Nocardia 363

Joseph LoCicero III, Jason P. Shaw, and Richard S. Lazzaro

Surgical participation in the management of fungal infections has changed since theadvent of effective antimicrobials. Even so, a surgeon may be called on for a variety

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of reasons, depending on the specific fungal infection and the evolution of thoracicdisease. Specific fungal infections are enumerated. Each organism, its clinicalpicture, and method of diagnosis are briefly described and the medical and surgicalmanagement of thoracic disease are discussed.

Surgical Management for Hydatid Disease 375

Semih Halezeroglu, Erdal Okur, andM. OzanTanyu

Hydatid disease is caused by the parasite Echinococcus granulosus. The liver andthe lungs are common sites. When a cystic lesion is seen on CT scan, diagnosisis made based on the patient having lived in an endemic area. Serologic tests areused for differential diagnosis. Medical treatment is centered on albendazole.Surgery is recommended either by open or endoscopic technique depending onthe characteristics of the cysts and the patient. Complications of surgery are rareexcept for prolonged air leaks. Mortality occurs when the cyst is located in thecentral nervous system or occludes major vessels.

Pulmonary Infections of Surgical Interest in Childhood 387

Michele Loizzi, Angela De Palma,Vincenzo Pagliarulo, Domenico Loizzi, and Francesco Sollitto

Thoracic surgeons often treat children with infections: pneumonia with abscess and/or empyema, multiresistant or complicated tuberculosis, or parasitic and fungalinfections. The pediatric patient with serious infection presents anatomic and meta-bolic-functional frailty. Anesthesiologists and surgeons must consider this aspect toreduce surgical impairment and improve outcome. This article reviews the causes,pathophysiology, clinical aspects, diagnosis, and management of pleuropulmonaryinfections of surgical interest in childhood.

Pulmonary Infections Following Lung Transplantation 403

ChadA.Witt, Bryan F.Meyers, and Ramsey R. Hachem

Infectious complications are a major cause of morbidity and mortality in solid organtransplant recipients. Infections with viruses, bacteria, and fungi have all been asso-ciated with the development of bronchiolitis obliterans syndrome (chronic allograftrejection) in lung transplant recipients. Lung transplant recipients have a higherrisk of infectious complications than recipients of other solid organs because ofthe intensity of immunosuppression, blunted coughmechanism, and constant expo-sure to the environment. This review provides a broad overview of the infectiouscomplications encountered in caring for patients who have undergone lungtransplantation.

Alternatives to Resectional Surgery for Infectious Disease of the Lung: FromEmbolization toThoracoplasty 413

MarcoAlifano, Sonia Gaucher, Antoine Rabbat, Jury Brandolini, Claude Guinet,DianeDamotte, andJean-Francois Regnard

Surgical treatment of lung diseases is based on removal of the affected lung tissue,achieved by atypical or anatomic lung resection. Infectious lung diseases are gener-ally treated by medical therapy, including medications, chest physiotherapy, bron-choscopic toilet, and respiratory rehabilitation. Surgical management of infectiousdisease of the lung is integrated in the multispecialty care. This article focuses exclu-sively on nonresectional surgery and other alternatives to lung resection and ad-dresses bacterial infection and fungal disease of the lung.

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Surgical Spectrum in the Management of Empyemas 431

MatthewD.Taylor and Benjamin D. Kozower

Empyema remains a major source of morbidity and health care expenditure in thethoracic surgery community. Early intervention in pleural space infections is key toprevention of chronic empyemas and the need for surgical intervention. The adventof video-assisted thoracoscopic surgery has made it possible to treat stage I andstage II empyemas with significantly less morbidity. Although management ofchronic empyema remains a significant challenge, surgical intervention is usuallysuccessful in cleaning up the pleural space.

Index 441