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SURGICAL MANAGEMENT OF TUBERCULOSIS

Dive into the history of tuberculosis, evaluate the efficacy of surgical interventions, and explore indications for surgical treatment. Understand the significance of collapse therapy, cavernostomy, embolization, and more in managing this infectious disease.

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SURGICAL MANAGEMENT OF TUBERCULOSIS

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  1. SURGICALMANAGEMENTOF TUBERCULOSIS Paul Bolanowski, MD Associate Professor of Surgery Division of Cardiothoracic Surgery UMDNJ-NJ Medical School

  2. HISTORY 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

  3. SURGICAL 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

  4. COLLAPSE THERAPY • Pneumothorax • Phrenic nerve crush • Pneumoperitoneum • Extrapleural pneumolysis • Plombage thoracoplasty • Extraperiosteal • Thoracoplasty

  5. EFFICACY 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%

  6. SURGICAL 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

  7. SURGICAL INDICATIONS - 2 • Massive or recurrent hemoptysis • Etiology • Bronchial collateral circulation • Rasmussin aneurysm • Aspergilloma • Bronchiectasis • Treatment • Embolization • Surgery

  8. MASSIVE 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

  9. MASSIVE HEMOPTYSIS - 2 • Position patient • Chest x-ray • Bronchoscopy • Localize site • Intubation • Bronchial arteriography • Surgery • Resection • Videoendoscopic thoracoscopy

  10. VATS CAVERNOSTOMY

  11. BRONCHIAL 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%

  12. EMBOLIZATION - 1

  13. EMBOLIZATION - 2

  14. EMBOLIZATION - 3

  15. MASSIVE 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%

  16. SURGICAL 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

  17. SURGICAL INDICATIONS - 2 • Empyema • Acute • No chest tube unless respiration compromised • Chronic • Decortication • Trapped lung • Muscle transposition

  18. AVAILABLE TISSUE

  19. SURGICAL INDICATIONS - 3 • Destroyed lung or lobe • Surgical resection • Pott’s abscess • Drainage • Spine reconstruction • Mycetoma (aspirgeloma) • Recurrent hemoptysis • Resection

  20. SURGICAL INDICATIONS - 4 • Pericarditis • Acute • With or without tamponade • Pericardial window • Chronic • Constrictive pericarditis • Total pericardioectomy • Cardiopulmonary bypass • Lymphadenitis • Cervical (scrofula) • Mediastinal • Drainage

  21. SURGICAL INDICATIONS - 5 • Destroyed lung or lobe • Surgical resection • Pott’s abscess • Drainage • Spine reconstruction • Mycetoma (aspirgeloma) • Recurrent hemoptysis • Resection

  22. SURGICAL INDICATIONS - 6 • Pericarditis • Acute • With or without tamponade • Pericardial window • Chronic • Constrictive pericarditis • Total pericardioectomy • Cardiopulmonary bypass • Lymphadenitis • Cervical (scrofula) • Mediastinal • Drainage

  23. PRE-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

  24. PRE-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

  25. PRE-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

  26. POST-OP MANAGEMENT • Immediate • Intensive care unit • Isolation • Room with air exchange • Ventilator • Collaborative medical management • Anti-tuberculous drugs • Length of stay • Long term

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