Surgical management of MDR and XDR TB

1. Surgical management of MDR and XDR TB Lehlohonolo Dongo Hannes Meyer Cardiothoracic Surgery Research an Trainining Symposium Stellenbosch 22-24 March 2012

2. Introduction • Sanatoria 100 yrs. Ago • Carlo Forlanini 1888, Italy • In past the past 2 decades- “re-emergence of sanatoria” • Rekindled interest in surgery • Surgery is a useful adjunct (Van Leuven et al, 1997)

3. Milestones in the evolution of surgery for TB

4. Cont’d • ↑incidence worldwide- 10% all new TB case, 40% of recurrent cases • Recently XDR • MDR- resistance to INH and RIF • XDR- resistance to INH, RIF and FQN and at least 1 of the 3 2nd line drugs • Clinical diagnosis • +ve smear • No improvement • No ∆ / worsening CXR • Resistance to 1st line drugs

5. Cont’d • 48%-80% treatment success on 2nd line drugs • Primary indication for resectional surgery in the US • Pomerantz et al, • 180 resections: early mortality=3%, late mortality of 7%, morbidity 12 % • Mostly localised disease (often cavitory), destroyed lung, BPF • 50% pts +ve sputum pre-op • 98% -ve sputum at mean length 7 yrs post-op • More aggressive resectional surgery & FQN • Indications for surgery • Management guidelines

6. Is there evidence for surgical resection in MDR-TB?

7. Evolving surgical indications for thoracic TB

8. PRIMARY Resistant TB to at least 2 drugs, including isoniazid and rifampin with localized resectable disease Persistent cavitary disease Persistent positive sputum—with/without cavity MDR/XDR-TB with destroyed lung (atelectasis/collapse/bronchiectasis) Massive hemoptysis Bronchopleural fistula Bronchostenosis with distal disease Lung mass—unknown etiology, rule out carcinoma SECONDARY -ve sputum but symptoms result of permanently altered anatomy infection, destroyed lobe Bronchiectasis bronchial stenosis cavity) -ve sputum with localized disease in whom reactivation is likely Decortication of trapped lung What are the indications for surgery in MDR and XDR-TB?

9. Surgical options Diagnostic procedures Therapeutic procedures Decortication—with/without lung resection Drainage (closed/open) (temporary/permanent); Eloesser procedure Thoracotomy with resection Segment/wedge Lobectomy Pneumonectomy (transpleural; extrapleural; completion) Chest wall/vertebral body-disc resection/stabilization Muscle flaps (myoplasty) Thoracoplasty (modified/tailored) Omental transfer • Thoracentesis • Transthoracic needle aspirate • Closed/open pleural biopsy • Bronchoscopy (flexible/rigid) (transbronchial needle aspiration) • Medistinoscopy/anterior mediasternotomy (Chamberlain procedure) • Thoracoscopy (video-assisted thoracic surgery) • Exploratory/diagnostic thoracotomy—wedge biopsy

10. Treatment of tuberculosis: indications for surgery • Complications resulting from previous surgery • Delayed complications of plombage • Complications of insufficient surgery (early/late) • Failure of medical therapy (active disease) (positive sputum/culture) • Progressive disease, lung destruction, and left bronchus syndrome (sequelae) • Drug resistance (MDR-TB; XDR-TB) • Aspergillosis complicating treatment • Surgery for diagnosis • Pulmonary lesions of unknown cause (rule out malignancy) • Mediastinal adenopathy of unknown cause • Complications of scarring (sequelae) • Severe hemoptysis (200 mL/24 hours; massive: 600 mL/24 hours)

11. Indications.....cont’d • Cavernoma: positive sputum with cavitation 5 to 6 months post chemotherapy; negative • sputum with cavitation (size/thickness of cavity) • Tracheo- or bronchoesophageal fistula • Bronchiectasis • Extrinsic airway obstruction by tuberculous lymph nodes • Endobronchial tuberculosis and bronchostenosis • Right middle lobe syndrome (bronchial compression/obstruction) • Pleural tuberculosis • Pleural effusion • Empyema (TB/mixed pyogenic); with/without lung parenchyma involvement; trapped lung • Bronchopleural fistula • Intrathoracic disease • Tuberculosis of the heart and great vessels • Vascular malformations • Constrictive pericarditis • Cold abscesses and osteomyelitis of the chest wall • Pott’s disease (thoracic spine/disc)

12. Precautions • Peri-operative • Patient • Early diagnosis • Isolation • Masks • Prompt treatment • Health workers • Environment (ward, theater, ICU) • Natural ventilation • Negative pressure-window fans,exhaust ventilation fans • Air filtration • UV germicidal irradiation

13. Surgical considerations • Pre-operative evaluation/assessment • Operative/anesthesia considerations • Surgical/Technical • Postoperative considerations

14. 1. Pre-operative evaluation/assessment • History and physical examination • Nutrition—weight loss/debilitation/albumin 3.0 g/dL/Vit C • HIV/AIDS • Severity • Comorbidity • Associated diseases +/-Sputum • Polymicrobial infection • Chemotherapy—minimum of 3 months when feasible • Pulmonary/infectious disease consultation • Diagnostic studies—CXR/CT scan • Cardiopulmonary evaluation—ECG, PFT, V/Q scan • Confirmed diagnosis (smear or culture) • Other diagnostic studies (PCR, inflammtory markers, histology)

17. Complex Aspergilloma

18. CXR Cavitory disease

19. CT scan Cavitory disease

20. 2. Operative/anesthesia considerations • Precautions • Access • Anesthesia/epidural • Bronchoscopy (rule out copious secretions/stenosis/endobronchial disease) • Airway—double lumen endobracheal tube or bronchial blocker/ Positioning—lateral decubitis/prone (Overholt table) • Bronchoscopy (positioning of endotracheal tube) Curr Probl Surg, October 2008

21. Diagnostic procedures • Diagnostic thoracentesis, closed pleural biopsy, TTNA or biopsy, and TBNA or biopsy, usually performed under fluoroscopy • Khan et al • 22 pts CT TTNA for suspected mediastinal lymph nodes • True +ve rate 66% cf 20% for fiberoptic bronchoscopy, 75% for cervical mediastinoscopy and 100% for thoracotomy

22. Bronchoscopy • +ve diagnosis in 30-50% cases • >80% with BAL • exclude endobronchial disease • Active endobronchial disease = reconsider extent of resection • Therapeutic bronchoscopy

23. Mediastinoscopy • Pts with mediastinal adenopathy • Absent radiographic features and negative bronchoscopy • sampling of 3 or more nodal stations recommended.

24. 3. Surgical resection • Serratus sparing posterolateralthoracotomy • Dissection—extrapleural; avoiding esophagus, azygous vein, subclavian vessels, internal mammary artery, recurrent laryngeal nerve. • Preserve lung/remove destroyed lung • Spillage (contamination of pleural space) • Air leaks—avoid, treat • Bleeding—cautery • Eliminate dead space • Collapse • Muscle • Bronchus—avoid avascularization/coverage/protection • Intercostal muscle flap, pericardial flap, diaphragmatic pedicle flap • Pleural contamination • Muscle flaps (initial use) (usually latissimusdorsi muscle) • Positive sputum • BPF • Mixed infection pleural space • Anticipated space problem • Omentum (previous thoracotomy); based on right gastroepiploic artery

25. Options for muscle transposition Curr Probl Surg, October 2008

26. Rib resection insertion sites Curr Probl Surg, October 2008

27. Latissimus dorsi transposition and insertion Curr Probl Surg, October 2008

28. Omentum transposition Curr Probl Surg, October 2008

29. Types of thoracoplasty

30. Pre and post operative modified thoracoplasty

31. Thoracoplasty technique Curr Probl Surg, October 2008

32. Schede and traditional Alexander style thoracoplasty Curr Probl Surg, October 2008

33. Kergin-Grow thoracoplasty Curr Probl Surg, October 2008

34. Andrews procedure

35. Approaches for the persisting space problem

36. Classic Alexander 3-stage 7-rib thoracoplasty

37. Post operative thoracoplasty patient

38. EARLY Early extubation Adequate analgesia BPF/Bleeding/Air leaks Atelectasis Ambulation Chest physio Nutrition LATE Cultures/sensitivities/resistance Anti-TB treatment BPF/space problems with/out empyema 4. Postoperative considerations

39. In conclusion: Surgery is a useful adjunct with good outcomes in appropriately selected MDR/XDR patients with acceptable morbidity and mortality.

40. There is a place for Surgery in Medicine...after all World TB day!