Surgical Intervention for Tb

8/12/2019 Surgical Intervention for Tb

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Surgery for Tuberculosis

World TB Day Conference

Salt Lake City

3/22/2013

Barbara C. Cahill, M.D.


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What is the Prognosis of Untreated TB?

PLoS ONE 6 (4);e17601 doi:10:137/journal.pone.0017601


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What is the Prognosis of Untreated TB?

Current models of untreated TB

3 years until self cure or death

TB Case fatality rates

70% for smear positive TB

20% for smear negative, culture positive TB

PLoS ONE 6 (4);e17601 doi:10:137/journal.pone.0017601


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Historical Therapies for Tuberculosis

The sanatorium - diet, rest, sunshine, immobilization

Exercise

The touch of the king (1200s 1700s)

Phlebotomy

Emetics, cyanide, creosote, arsenic, lard

Vapors

Laudanum

Vaccination

Surgery


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Extrapulmonary Tuberculosis

2011 Centers for Disease Control Data regarding 2188 reported

extrapulmonary TB cases (~20% all reported TB cases)

Extrapulmonary TB site Percent

Lymphatic (scrofula) 37.2Pleural 16.9

Bone +/- joint 11.1

Meningeal 5.7

Peritoneal 5.4

Genitourinary 5.0Other 18.6

http://www.cdc.gov/tb/statistics/reports/2011/pdf/report2011.pdf


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Tuberculous Bone/Joint Disease

Bony disease

isolated bony disease without spread to a joint fails to attract attention

Arthritis

nonspecific, often indolent clinical presentation

usually monoarticular, diagnosis often delayed

average duration of symptoms before diagnosis ~2 years

four drug therapy, joint irrigation, drainage and open synovectomy


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TB arthritis of intervertebral joints

aka Potts Disease


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Historical Surgical Procedures for Pulmonary TB

Anecdotal observationTB pts with spontaneous pneumothorax improved

Collapse therapy

Why does collapse therapy work?

Placing the diseased organ quiescent state

Resting, relaxing, immobilizing, compressing lung

favorably affects disease course


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Pneumothorax, Pneumoperitoneum

James Carson (8140) Carlo Forlanini (1882)

.the lung shrivels.the lung no longer breathes.the lung that cannotbreathe anymore, cannot anymore cough or expectorate.

Introduction of nitrogen gas into the pleural space

increases intrapleural pressure

Extrinsic pressure on lung + Intrinsic lung elasticity = collapse

Cavity walls approximate, close

Bronchi empty their secretions

Lymphatic flow decreases

Blood flow?

Thorax.1983;38:326-332.


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Collapse Therapies

Pneumothorax, pneumoperitoneum

Phrenicotomy (phrenic nerve crush)

Scalenectomyremoval of accessory muscles of respiration

Plombageextraperiosteal or extrapleural pneumonolysis

Thoracoplastyremoval of ribs


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Pneumothorax


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Collapse Therapies cont

Pneumothorax Instilled gas is absorbed, repeat procedures requiredPneumoperitoneum

More permanent collapse therapies

Phrenicotomy (phrenic nerve crush)

Plombage

Thoracoplasty


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Phrenicotomy (Phrenic Nerve Crush)


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Pleural Space

http://medicalclipart.tripod.com/respirbw/PLEURA.gif

d


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Barbecued Ribs

Removing the membrane = removing the parietal pleura

You are sort of a thoracic surgeon!

http://bbq.about.com/od/rib1/ss/aa011009a_2.htm


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Collapse Therapy - Plombage

The use of an inert material to fill an abnormal body cavity

Oleothorax

Lucite balls

Muscle, Fat, Bone

Rubber gloves

Rubber sheeting

Sponges


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Collapse Therapy - Oleothorax

Intrapleural or extrapleural insertion of oil in to the thoracic cavity to collapse lung

Oils used

Mineral oil

Olive oil

Cotton seed oilCod liver oil

Nut oils

Paraffin

Antiseptics addedGomenol (myrtle plant extract)

Bismuth

Iodinated compounds


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Oleothorax

Dissection of parietal pleura away from ribs, collapse of lung

Instillation of paraffin to fill the space between lung and ribs

The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937.


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Oleothorax


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Lucite Ball Plombage


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Oleothorax, Lucite Ball Plombage Outcomes

Reported outcomes

disappearance of tubercle bacilli from sputum

cured

cavities closed

greatly improved, improved, died

working and negative for tubercle bacilli

mortality rates ~10-30%



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Plombage Complications

Short and long term complicationsInfection

Sinking

Extrusion through chest incision, rib destruction

Erosion in to airway, mediastinum, great vessels

Extrinsic compression of airway, great vessels

Horners syndrome

The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937.Thorax.1985;40:328-340.


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Infected extraperiosteal plombage space in a

56-year-old man who presented with fever and

chest pain.

Jeung M et al. Radiographics 1999;19:617-637.1999 by Radiological Society of North America


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Thoracoplasty



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Thoracoplasty

Before rib resection After rib resection


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Thoracoplasty Operative Mortality


(657 Surgeries)

25/39 (64%)

post op deaths

occurred in first

30 days


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TuberculosisTherapeutic Options



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Oleothorax and Thoracoplasty


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Surgery for TBCurrent Paradigm

Surgical interventions supplanted by effective medical therapy

Resurgence of surgical therapy with the emergence of MDR-TB

Indications for surgery in MDR-TB

Localized disease

Persistent cavitary disease

Persistent sputum positivity

MDR-TB with destroyed lobe of lung

Massive hemoptysis

Bronchopleural fistula

Bronchial stenosis


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Surgery for Pulmonary MDR-TB

U of Colorado experience 1983-2000

172 patients , 180 pulmonary resections

Most pts resistant to 6+ antibiotics

Timing of surgery

MDR-TB resistant to almost all drugsIndividualized Rx for 1-2 months

MDR-TB sensitive to some combination of drugs

Individualized Rx for at least 3 months

Follow sputum - low burden of organisms or smear negative

Post opantibiotics for two years after sputum smear and culture negative

J Thorac Cardiovasc Surg 2001;1:448-453.


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Pre-operative Assessment for MDR-TB Surgery

Chest CT scan

Bronchoscopy

Pulmonary function tests

Ventilation-perfusion scan

Right heart catheterization

Nutritional assessment and intervention



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MDR-TB Thoracic Surgeries Performed

Surgical Procedure (n= 180)Pneumonectomy 19

+ muscle flap 46

+ muscle and Eloesser flaps 1

Completion pneumonectomy 3+ muscle flap 12

+ omentum 1

Lobectomy 93

Segmental resection 5



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MDR-TB Operative Mortality

Post-op follow up complete in all patients

mean follow up 7.7 years (4 months17 years)

6 patient deaths within 30-days / 180 surgeries

Cause of early post op death (n)

Respiratory failure 3

CVA 2

Myocardial infarction 1

Operative mortality rate = 3.3%



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MDR-TB Late Surgical Mortality

11/166 patients with late deaths (more than 30 days post op)

Cause of Death (n)

Late respiratory failure 4

Recurrent MDR-TB 3 (2%)

Drug overdose 1

Myocardial infarction 1

Renal failure 1

Unknown 1

Late mortality rate = 6.8%



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MDR-TB Operative Morbidity

20/166 patients experienced post-operative complications

Complication (n)

Respiratory failure 6

BP fistula 5

Wound infection 3

Post op hemorrhage 3

Recurrent laryngeal nerve injury 2

Intrathoracic bowel herniation 1

Surgical complication rate = 12%

But what was the overall MDR-TB recurrence rate in this study?



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Surgery for Pulmonary MDR-TB

Japanese experience 2000-2007

56 patients , 61 pulmonary resections

Pts resistant to an average of 5.6 antibiotics (range 2-10 antibiotics)

Timing of surgeryIndividualized antibacterial Rx for 3 months

If persistently smear positivesurgical excision of cavity

If smear negativesurgical resection if relapse risk high(highly drug resistant bug, large cavity, diabetes)

Post opantibiotics for two years after surgery or sputum conversion



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MDR-TB Thoracic Surgeries Performed

Surgical Procedure n= 61 ( %)

Pneumonectomy 19 (30)

Completion pneumonectomy 3 (5)

Lobectomy 33 (55)

Segmental resection 6 (10)



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MDR-TB Operative Outcomes

Post-op mean follow up 3.25 years (8 months8.75 years)

No operative deaths!

Post op Complications (n)

BP fistula w or w/o empyema 3

Pleural space problem 5Prolonged air leak 2

Chylothorax 1

Surgical complication rate = 16%

MDR-TB recurred after surgery in 5/56 (9%) ptsFurther interventions

3 surgery, 1 med Rx, 1 remained positive



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Is Medical Therapy + Surgery better than

Medical Therapy in MDR-TB?

Int J Tuberc Lung Dis 2013;17(1);6-15.


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Is Medical Therapy + Surgery better than

Medical Therapy inXDR-TB?



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Not so fast..

No assessment of the potential harm of surgery

No assessment of optimal timing or conditions for surgery

No assessment of outcomes based on level of drug resistance

No long term follow up of patients

Analysis subject to publication bias (negative studies dont get published)

None of the studies were randomized controlled trials

was there selection bias?

was the sputum data reliable?

*Insu ff ic ient evidence to recommend Med + Surg Rx over Med Rx alone



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What Role does Surgery Play in the

Treatment of Tuberculosis?

Massive hemoptysis

Recurrent or recalcitrant localized disease

Destroyed lung with recurrent infection (with adequate pulmonary reserve)

Bronchopleural fistula

For MDR-TB

1. Individualized antibacterial therapy2. Nutritional resuscitation

3. Surgical resection of active disease and control of pleural space

4. Individualized antibacterial therapy

5. Collapse therapiesJapan and Russia

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Surgical Intervention for Tb