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Presented at 2nd Annual Conference of College of Gynaecology and Obstetrics of Rwanda, Kigali, Rwanda, Africa, on 5th – 6th May 1999. Pictured in Hotel Mille Collins, rendered famous in the movie "Hotel Rwanda", which depicted the genocide in Rwanda in 1994. "Hotel Rwanda" is Hotel Mille Collins ('Thousand Hills).
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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.