Surgery for pulmonary tuberculosis

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.Types of surgical procedures for PTB include: Collapse therapy, pulmonary resection, lung decortication, drainage procedures such as closed tube thoracostomy, rib resection and open window thoracotomy beside pulmonary resection+ collapse therapy (thoracoplasty). The decreasing morbidity and mortality of pulmonary resection for PTB is due to careful patient selection ( failure of chemotherapy, massive haemoptysis, BPF), improved anaesthetic techniques, stapling devices and better chemotherapy.The prognosis after successful resection is excellent ( 90% survive and remain disease free).

1. SURGERY FOR PULMONARY
TUBERCULOSIS
PROFESSOR
ABDULSALAM Y TAHA
https://sulaimaniu.academia.edu/AbdulsalamTaha
School of Medicine/ University of Sulaimani/ Iraq
1

2. Discovery of Mycobacterium
tuberculosis
A Tribute to Robert Koch
2

3. Tuberculosis - Captain of Death
3

4. 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
4

5. Diagnostic discoveries
24
th
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
5

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

6

7. 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
singing7

8. Pulmonary Tuberculosis a
Major Public health concern
8

9. 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.
9

10. Diagnosis by X-ray
Chest x-rays: Multi
nodular infiltrate
above or behind the
clavicle with or
without pleural
effusion unilaterally
or bilaterally.
10

11. 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
11

12. 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.12

13. 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).
13

14. 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.14

15. COLLAPSE THERAPY
Artificial pneumothorax.
Unilateral phrenic nerve division.
Extraperiosteal thoracoplasty with
plombage.
Standard paravertebral
thoracoplasty.
15

16. 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.16

17. THORACOPLASTY DIAGRAM
17

18. THORACOPLASTY DIAGRAM
18

19. TECHNIQUE OF RIB RESECTION
DRAINAGE OF EMPYAEMA
19

20. 20

21. 21

22. REASONS FOR FAILURE OF
EMPYAEMA DRAINAGE
22

23. 23

24. 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.
24

25. 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.
25

26. 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.
26

27. ELOESSER FLAP
27

28. PLOMBAGE THORACOPLASTY
28

29. THORACOPLASTY
29

30. PARAFFIN THORACOPLASTY
( PARAFFINOMA)
30

31. LUNG DECORTICATION
31

32. 32

33. 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. 33

34. 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.
34

35. 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.
35

36. 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).36

37. DESTROYED LEFT
LUNG
37

38. LEFT LOWER
LOBE
BRONCHIECT-
ASIS
38

39. 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.
39

40. CONTRAINDICATIONS
Widespread pulmonary or
endobronchial disease.
Children with mycobacterial
disease rarely require lung
resection.
40

41. PREOPERATIVE MEASURES
Adequate cardiopulmonary reserve.
Conversion of the patient into sputum-
negative status.
Adequate physical and pulmonary
toilet.
Adequate nutritional support.
Preoperative bronchoscopy.
41

42. 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.42

43. COMPLICATIONS OF RESECTION
Empyaema with or without
BPF.
Bronchogenic spread of
mycobacterial disease.
43

44. 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.
44

45. 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).45

46. World Tuberculosis Day
(March 24)
46

47. 47