SURGICALMANAGEMENT

OF TUBERCULOSIS

SURGICALMANAGEMENT

OF TUBERCULOSIS

Paul Bolanowski, MDAssociate Professor of Surgery

Division of Cardiothoracic SurgeryUMDNJ-NJ Medical School

HISTORY OF TUBERCULOSISHISTORY OF TUBERCULOSIS

• Scourge Of Early Humanity– Hippocrates – Phthisis

• Disease characterized by progressive weight loss and wasting

– Romans – Consumption

• Consumed its victims– Schonlein - Tuberculosis

• First to use term based on autopsy findings

SURGICAL HISTORYSURGICAL HISTORY

• 1821 - Carson - collapse therapy– 1925 - Alexander

• 1869 - Simon - thoracoplasty– 1920 - Sauerbruch & Alexander

• 1882 - Block - first resection

• 1891 - Tuffier – first partial resection

• 1934 - Freelander – first lobectomy

COLLAPSE THERAPYCOLLAPSE THERAPY

• Pneumothorax

• Phrenic nerve crush

• Pneumoperitoneum

• Extrapleural pneumolysis– Plombage thoracoplasty– Extraperiosteal

• Thoracoplasty

EFFICACY OF COLLAPSE THERAPYEFFICACY OF COLLAPSE THERAPY

• 1880 - 300 deaths/100,000

• 1935 - 69 deaths /100,000

• Plombage thoracoplasty– Sputum negative - 30-60%

• Thoracoplasty– Closure of cavity in 80%– Mortality 10%

SURGICAL INDICATIONS - 1SURGICAL INDICATIONS - 1

• Failure of medical treatment– Cavity with persistently positive sputum

• Resistant strains

– MDR-TB

– XDR-TB

• Atypical organisms– M. kansasii - surgery infrequent

– M. avium - localized – lobectomy

• Solitary nodule– Lung carcinoma vs. tuberculoma

SURGICAL INDICATIONS - 2SURGICAL INDICATIONS - 2

• Massive or recurrent hemoptysis– Etiology

• Bronchial collateral circulation

– Rasmussin aneurysm

– Aspergilloma

– Bronchiectasis

– Treatment

• Embolization

• Surgery

MASSIVE HEMOPTYSIS - 1MASSIVE HEMOPTYSIS - 1

• Definition– Based on amount and duration

• MASSIVE 600 ml WITHIN 16 hrs

• 200ml, >300ml, >500ml, >600ml / 24-48hrs– Based on threat to life

• Acute airway obstruction

• Shock

• Persistent hemoptysis despite good medical management

MASSIVE HEMOPTYSIS - 2MASSIVE HEMOPTYSIS - 2

• Position patient

• Chest x-ray

• Bronchoscopy– Localize site– Intubation

• Bronchial arteriography

• Surgery– Resection– Videoendoscopic thoracoscopy

VATS CAVERNOSTOMYVATS CAVERNOSTOMY

BRONCHIAL ARTERIOGRAPHYBRONCHIAL ARTERIOGRAPHY

• Advantages– Localize site– Control bleeding by embolization– Prevent contamination of normal lung– Buy time to improve pulmonary function– Less blood loss during surgery

• Disadvantages– Spinal cord paralysis– Temporary

• Acute control - 75% effective

• Rebleed rate - 43%

EMBOLIZATION - 1EMBOLIZATION - 1

EMBOLIZATION - 2EMBOLIZATION - 2

EMBOLIZATION - 3EMBOLIZATION - 3

MASSIVE HEMOPTYSISMASSIVE HEMOPTYSIS

• Surgical results• Massive

• 600ml in < 16hrs 18% MORTALITY

• Conservative management• Massive

• 600ml or more in 16hrs – 75% MORTALITY• 600ml or more in 48hrs – 54% MORTALITY

• Embolization + surgery• Acute control in 75%• Mortality 7-9%

SURGICAL INDICATIONS - 1SURGICAL INDICATIONS - 1

• Bronchopleural fistula– Complication of disease

• Treatment

– Lobectomy or pneumonectomy

– Complication of surgery

• Treatment

– Immediate chest tube

» Pneumonectomy

– Thoracotomy with closure using intercostal muscle flap

SURGICAL INDICATIONS - 2SURGICAL INDICATIONS - 2

• Empyema– Acute

• No chest tube unless respiration compromised– Chronic

• Decortication

– Trapped lung

– Muscle transposition

AVAILABLE TISSUEAVAILABLE TISSUE

SURGICAL INDICATIONS - 3SURGICAL INDICATIONS - 3

• Destroyed lung or lobe– Surgical resection

• Pott’s abscess– Drainage– Spine reconstruction

• Mycetoma (aspirgeloma)– Recurrent hemoptysis

• Resection

SURGICAL INDICATIONS - 4SURGICAL INDICATIONS - 4

• Pericarditis– Acute

• With or without tamponade

– Pericardial window

– Chronic

• Constrictive pericarditis

– Total pericardioectomy

» Cardiopulmonary bypass

– Lymphadenitis

• Cervical (scrofula)

• Mediastinal

– Drainage

SURGICAL INDICATIONS - 5SURGICAL INDICATIONS - 5

• Destroyed lung or lobe– Surgical resection

• Pott’s abscess– Drainage– Spine reconstruction

• Mycetoma (aspirgeloma)– Recurrent hemoptysis

• Resection

SURGICAL INDICATIONS - 6SURGICAL INDICATIONS - 6

• Pericarditis– Acute

• With or without tamponade

– Pericardial window

– Chronic

• Constrictive pericarditis

– Total pericardioectomy

» Cardiopulmonary bypass

– Lymphadenitis

• Cervical (scrofula)

• Mediastinal

– Drainage

PRE-OP MANAGEMENT - 1PRE-OP MANAGEMENT - 1

• Medical management– Nutrition– Atypical mycobacterium

• M. avium

– Perioperatively – ethambutol, rifabutin, biaxan, and amikacin

– Operate when sputum converts to negative

• M. abscessus

– Pre-op – imipenem & amakacin for 2 months

– Post-op – same drugs for 4 months

• M. kansasii – surgery infrequent

PRE-OP MANAGEMENT - 2PRE-OP MANAGEMENT - 2

• Multi-drug resistant tuberculosis– Pre-op

• 2-3 months of 3 or 4 drugs they have never received

– Post-op

• 18 to 24 months of therapy– These patients must be followed diligently post-op

for recurrence

PRE-OP MANAGEMENT - 3PRE-OP MANAGEMENT - 3

• PET-CT scan– Determine extent of disease

• Bronchoscopy– Determine if line of transection is disease free

• Arteriography– To control bleeding pre-operatively– To decrease blood loss at time of surgery

POST-OP MANAGEMENTPOST-OP MANAGEMENT

• Immediate– Intensive care unit

• Isolation

• Room with air exchange

• Ventilator

• Collaborative medical management

– Anti-tuberculous drugs

• Length of stay

• Long term