SURGERY FOR PULMONARY TUBERCULOSIS

PROFESSOR

ABDULSALAM Y TAHA

https://sulaimaniu.academia.edu/AbdulsalamTaha

School of Medicine/ University of Sulaimani/ Iraq

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Discovery of Mycobacteriumtuberculosis A Tribute to Robert Koch

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Tuberculosis - Captain of Death

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Historical Background

Neolithic Time– 2400 BC - Egyptian

mummies spinal columns 460 BC

– Hippocrates, Greece First clinical description:

Phthisis / Consumption (I am wasting away)

500-1500 AD– Roman occupation of

Europe it spread to Britain 1650-1900 AD

– White plague of Europe, causing one in five deaths

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Diagnostic discoveries

24th March 1882 (Robert Koch) TB Day

– Discovery of staining technique that identified Tuberculosis bacillus

– Definite diagnosis made possible and thus treatment could begin

1890 (Robert Koch)– Tuberculin discovered– Diagnostic use when injected

into skin 1895 (Roentgen)

– Discovery of X-rays– Early diagnosis of pulmonary

disease

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Selman Abraham Waksman Awarded Nobel Prize for his discovery of Streptomycin in 1952.   

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Transmission

Incubation period 4-12 weeks

Latent infection may remain dormant for years

Transmitted through droplet spread – Undiagnosed / confirmed

infected persons – Breathing, coughing,

sneezing, talking, or singing

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Pulmonary Tuberculosis a Major Public health concern

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Smear positive are highly infectious

– Pulmonary cavitary cases are usually smear positive

– Immediate isolation is necessary until proven conversion

– HIV positive are more often smear negative pulmonary or extra pulmonary cases – should they be isolated

– Culturing is needed in smear negative cases.

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Diagnosis by X-ray

Chest x-rays: Multi nodular infiltrate above or behind the clavicle with or without pleural effusion unilaterally or bilaterally.

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Types of drug resistance

Drug resistance in TB may be broadly classified as primary or acquired. When drug resistance is demonstrated in a patient who has never received anti-TB treatment previously, it is termed primary resitance

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Surgery for PTB

Despite modern anti-tuberculous chemotherapy, approximately 2% of all cases of pulmonary mycobacterial infection require surgical treatment.

Therefore, surgical treatment of pulmonary mycobacterial disease is rarely necessary.

Prof Y D Al-Naman: 65% of patients can be cured medically. 25% need surgical treatment. 10% fail to respond to therapy.

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TYPES OF SURGICAL TREATMENT

Collapse therapy. Pulmonary resection. Lung decortication. Drainage procedures: Closed tube thoracostomy. Rib resection. Open window thoracotomy.•Pulmonary resection+ collapse therapy

(thoracoplasty).

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COLLAPSE THERAPY

It is based on the concept that collapsing the affected portion of the lung allows the diseased area to rest and recover.

The efficacy of collapse therapy probably is derived from the lowering of O2 tensions in the collapsed portion of the lung thereby inhibiting growth of M tuberculosis, a strict aerobe.

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COLLAPSE THERAPY

Artificial pneumothorax.Unilateral phrenic nerve division.Extraperiosteal thoracoplasty

with plombage.Standard paravertebral

thoracoplasty.

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THORACOPLASTY

It is the decostalization of chest wall.Tailoring thoracoplasty is done in

stages: First stage: removing ribs 1, 2 and 3. Second stage: after two weeks;

removing rib 4 and 5. Third stage: removing rib 6 and 7 in a

tailoring fashion, leaving more rib anteriorly each time after the third.

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THORACOPLASTY DIAGRAM

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THORACOPLASTY DIAGRAM

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TECHNIQUE OF RIB RESECTION DRAINAGE OF EMPYAEMA

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REASONS FOR FAILURE OF EMPYAEMA DRAINAGE

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THORACOPLASTY

Extrapleural paravertebral thoracoplasty was the most frequently employed surgical procedure for the treatment of pulmonary tuberculosis before the discovery of effective chemotherapy for tuberculosis.

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THORACOPLASTY

Closure of cavities was achieved in more than 80% of patients without chemotherapy by using thoracoplasty.

Today, it is rarely indicated as primary treatment for pulmonary tuberculosis.

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POSTURE AFTER THORACOPLASTY

The posture following two-stage, seven-rib left thoracoplasty.

The grossly diminished left shoulder movement and marked scoliosis are shown.

The deformity is irreversible; prevention is essential.

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ELOESSER FLAP

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PLOMBAGE THORACOPLASTY

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THORACOPLASTY

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PARAFFIN THORACOPLASTY( PARAFFINOMA)

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LUNG DECORTICATION

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PULMONARY RESECTION

Resection of the diseased portion of the lung. Types: Wedge resection, Segmentectomy. Lobectomy, Bilobectomy, Pneumonectomy. Pleuropneumonectomy.• The extent of resection depends on the

extent of the mycobacterial disease. All gross evidence of disease should be resected.

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ACCEPTED INDICATIONS FOR PULMONARY RESECTION

Persistent positive sputum cultures with cavitation.

Localized pulmonary disease due to atypical mycobacterium ( M avium intracellulare) or drug resistent M tuberculosis.

A mass lesion of the lung in an area of tuberculous involvement.

Massive life-threatening haemoptysis or recurrent severe haemoptysis.

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INDICATIONS FOR RESECTION..

In stabilized patients with a localized site of bleeding, lobectomy is the most definitive form of therapy for massive or recurrent haemoptysis.

A bronchopleural fistula secondary to mycobacterial infection that does not respond to tube thoracostomy.

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OTHER INDICATIONS

Patients severely symptomatic from a destroyed lobe or bronchiectatic area of the lung may benefit from resection.

Patients with thick-walled cavities who have reactivated mycobacterial disease or who can not comply with prolonged chemotherapy may benefit from resection of the diseased area.

A patient with trapped lung: decortication. Secondary fungal infection of tuberculous

cavity ( Aspergillosis).

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DESTROYED LEFT LUNG

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LEFT LOWER LOBE BRONCHIECT-ASIS

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ADVANTAGES OF LUNG RESECTION

Prompt conversion into sputum- negative status in a single session.

No chest wall deformity is produced.

No limitation of ventilatory capacity.

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CONTRAINDICATIONS

Widespread pulmonary or endobronchial disease.

Children with mycobacterial disease rarely require lung resection.

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PREOPERATIVE MEASURES

Adequate cardiopulmonary reserve.Conversion of the patient into

sputum-negative status.Adequate physical and pulmonary

toilet.Adequate nutritional support.Preoperative bronchoscopy.

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INTRAOPERATIVE MEASURES

The use of a double-lumen endotracheal tube can make operation for PTB technically easier and safer.

Bronchoscopy may be required at the conclusion of the operation to clear infected secretions or blood from the airway.

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COMPLICATIONS OF RESECTION

Empyaema with or without BPF.

Bronchogenic spread of mycobacterial disease.

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COMPLICATIONS

Both complications are more frequent when the patient is sputum positive at the time of operation.

Judicious use of thoracoplasty or liberal use of muscle flaps in such patients at the time of operation can minimize the incidence of BPF and apical space problems.

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RESULTS OF RESECTION

The decreasing morbidity and mortality of pulmonary resection for PTB is due to:

1. Careful patient selection ( failure of chemotherapy, massive haemoptysis, BPF).

2. Improved anaesthetic techniques.3. Stapling devices.4. Better chemotherapy.•The prognosis after successful resection is

excellent ( 90% survive and remain disease free).

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World Tuberculosis Day (March 24)

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