Asian Cardiovasc Thorac Ann 2006;14:363-366
© 2006 Asia Publishing EXchange Ltd
Role and Outcome of Surgery for Pulmonary Tuberculosis
Aysun Olcmen, MD,
Mehmet Z Gunluoglu, MD,
Adalet Demir, MD,
Hasan Akin, MD,
Hasan V Kara, MD,
Seyyit I Dincer, MD
2nd Thoracic Surgery Clinic, Department of Thoracic Surgery, Yedikule Teaching Hospital for Chest Diseases and Thoracic Surgery, Istanbul, Turkey
For reprint information contact: Adalet Demir, MD Tel: 90 212 664 1700 Fax: 90 212 547 2233 Email: dradalet{at}hotmail.com, Yuzyil mah. Kisla Cad. Yesil zengibar sitesi, A-3 Blok, D-9 Bagcilar, Istanbul, Turkey.
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ABSTRACT
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The need and outcome of surgical intervention in patients with pulmonary tuberculosis were assessed retrospectively. Between 1993 and 2003, 72 major surgical procedures were performed in 57 patients with pulmonary tuberculosis. There were 44 males and 13 females with a mean age of 34 years. Indications for surgery were: trapped lung in 18 (31.6%), multidrug-resistant tuberculosis in 10 (17.5%), aspergilloma in 10 (17.5%), destroyed lung in 5 (8.8%), massive hemoptysis in 4 (7%), bronchopleural fistula in 3 (5.3%), persistent cavity in 2 (3.5%), and undiagnosed nodule in 5 (8.8%) patients. The most common procedure was lobectomy (31.9%). Other procedures included decortication, wedge resection, pneumonectomy, segmentectomy, and myoplasty. There were 28 complications in 18 patients, including prolonged air leak in 12 (21.1%), residual space in 7 (12.3%), empyema in 5 (8.8%), hematoma in 2 (3.5%), chylothorax and bronchopleural fistula in 1 (1.8%) each. There was no operative death, but one patient died from sepsis late in the follow-up period (mortality, 1.8%). As morbidity and mortality rates are acceptable, surgical intervention can be considered safe and effective in patients with pulmonary tuberculosis.
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INTRODUCTION
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The incidence of both tuberculosis and multidrug resistance continues to increase. Despite the success of medical therapy alone, resistance to drugs and complications of the disease still present a challenge.1–4 Thus, surgical intervention is once again needed. We reviewed our recent 10-year experience to assess the role and outcomes of major thoracic operations performed for pulmonary tuberculosis.
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PATIENTS AND METHODS
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The data of all patients with pulmonary tuberculosis who underwent major surgical procedures between 1993 and 2003 were retrospectively evaluated; 72 major operations were performed on 57 patients. Of these, 44 were male, 13 were female, and their mean age was 34 years (range, 16–66 years). Preoperative work-up included a routine chest radiograph, chest computed tomography, respiratory function tests, and arterial blood gas analysis. Quantitative perfusion scintigraphy was performed in patients with limited respiratory function to predict postoperative respiratory function. Fiberoptic and/or rigid bronchoscopy were carried out in 38.5% of patients to rule out any other disease or to evaluate complications such as hemoptysis or atelectasis. All patients except those operated on for diagnostic purposes, for an emergency, or who had multidrug-resistant (MDR) tuberculosis were put on standard 4-drug antituberculous therapy (isoniazid, rifampicin, ethambutol, and morphazinamide) for at least 3 months preoperatively. They completed a 7-month course of therapy after the operation. For MDR tuberculosis, medical regimens were tailored to the individual patient and contained an injectable agent and an average of 3 oral drugs. Thirty-three patients who had active pulmonary tuberculosis were operated on electively. Before the operation, the absence of acid-fast bacilli in sputum was confirmed by either direct examination or culture. The other 24 patients who underwent surgery for complications of tuberculosis or diagnostic purposes were not evaluated for acid-fast bacilli in sputum. Preoperative care included improvement of the nutritional status and provision of physiotherapy to clear out bronchial secretions and enhance respiratory performance. Indications for surgery are presented in Table 1
. Patients with empyema were first treated with tube thoracostomy. After at least 4 weeks of drainage, surgery was undertaken because of continuing empyema and progression of trapped lung. Before the operation, the absence of acid-fast bacilli in sputum was confirmed either by direct examination or by culture.
Multidrug-resistant pulmonary tuberculosis was defined as tuberculosis resistant to at least two fundamental drugs, isoniazid and rifampicin. It accounted for 17.5% of the indications for surgery in this series. Before the operation, respiratory function was judged to be sufficient and the disease was limited to only one lobe or a single lung. Sixty percent of patients with aspergilloma were operated on for their symptoms, and 40% were operated on for life-threatening massive hemoptysis although they had no symptoms. Five patients who had destroyed lung were operated on for frequent episodes of infection and hemoptysis. Massive hemoptysis was defined as expectoration of more than 500 mL of blood over 24 hr, or any volume of blood that threatened the patient’s life. These patients required emergency bronchoscopy and thoracotomy. Three patients with unsuccessful closure of a bronchopleural fistula using tube thoracostomy underwent thoracotomy. All patients were approached through a posterolateral thoracotomy incision under general anesthesia with unilateral lung ventilation. Follow-up was obtained through review of clinic consultations and written correspondence. Long-term follow-up of at least 12 months was achieved in all patients.
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RESULTS
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Details of the procedures performed are presented in Table 2. Of the 72 procedures, 47 were resections. Concomitant myoplasty was performed in only one patient. There were 10 pneumonectomies: for MDR tuberculosis in 5 patients, for destroyed lung in 4, and the other patient underwent pneumonectomy for aspergilloma with a giant cavity. Pneumonectomy was performed extrapleurally in 5 patients. There were 14 conservative resections: 12 wedge resections and 2 segmentectomies. The histopathologic diagnosis was established in all cases. Full expansion of the lung was achieved in all who had trapped lung. All patients operated on for aspergilloma or destroyed lung with symptoms had excellent outcomes. Control of bleeding was accomplished in all who underwent surgery for massive hemoptysis. Successful closure was performed in those with bronchopleural fistula. The remaining patients were successfully treated by the appropriate procedures. Patients with MDR tuberculosis remained sputum culture negative and had no symptoms of active tuberculosis after surgery.
The mean follow-up time was 36.6 months. In this period, we did not encounter any relapse of the disease. There were 28 complications in 18 patients. The morbidity rate was calculated as 24.5%. Complications encountered are presented in Table 3. The most common complications were prolonged air leak and residual pleural space. In most patients, the residual spaces obliterated spontaneously. Prolonged pleural drainage was successful and there was no contamination of these spaces. There were extensive adhesions and tedious dissection was required in nearly all patients. Hemorrhage occurred postoperatively in two patients who were re-explored; hematomas were evacuated and bleeding from the thoracic wall was controlled. Empyema developed in 5 patients who had been operated on for trapped lung. These patients had empyema preoperatively. Prolonged pleural drainage was effective in these cases. Bronchopleural fistula and chylothorax was encountered in one patient who had been operated on for aspergilloma, and a right pneumonectomy was undertaken because of a giant cavity invading 2 lobes of the lung. After intensive medical therapy, thoracomyoplasty and closure of the fistula were performed. However, the fistula recurred and the patient died from sepsis 3 months after the operation. There was no other mortality, and the mortality rate was calculated as 1.7%.
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DISCUSSION
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Less than 5% of patients with tuberculosis require surgery.5,6 In agreement with our experience, the main indications for surgery are reported to be complications of the disease and a pulmonary nodule without a diagnosis. Recently, MDR tuberculosis has become a major indication for surgery.1–4 Excellent outcomes have been achieved by adding surgery to medical therapy in this group who have a high relapse risk, despite long and intensive medical therapy.7 The outcome in patients with MDR tuberculosis who were treated with medical therapy plus surgery were also superior. Surgery is effective and sometimes indispensable for the treatment of complications of pulmonary tuberculosis with serious and even life-threatening consequences. For patients with bronchopleural fistula and/or empyema, pleural drainage is sufficient in most cases. When conservative methods fail, major surgical procedures must be considered. Surgery is offered to manage the symptoms in patients with a destroyed lung, but we suggest surgery even for asymptomatic patients with aspergilloma, to avoid the potential risk of massive hemoptysis that threatens life.
Lobectomy is the preferred type of resection for pulmonary tuberculosis.2,5 The rate of pneumonectomy increases as MDR tuberculosis increases.1,2 Segmentectomy is not recommended due to the high risk of bronchopleural fistula, however, in certain reports that included patients operated on for undiagnosed nodules, the rate of segmentectomy or wedge resection is high.8,9 In this series, lobectomy was preferred for parenchymal resection. Concomitant myoplasty was performed in only one patient who underwent lobectomy because the remaining lung could not fill the thorax. In the group with pleural complications, we avoided parenchymal resection and preferred wedge resection to remove the localized infected areas. Although we tried to avoid pneumonectomy because of its well-known complication rates, we had to perform pneumonectomy in 10 patients because of extensive disease affecting the entire lung.
The complication rate of surgery for pulmonary tuberculosis has been reported as up to 30%.1–4 Minor complications such as atelectasis, pleural space problems, and wound infection are more frequent in this group of patients. Pneumonia and atelectasis were frequently encountered due to underlying infection. Moreover, wound infection was often seen because these patients were generally in a catabolic state. We were generally able to manage these complications by conservative methods. It has also been reported that bleeding requiring re-operation is frequent.4 The most important reported complication is bronchopleural fistula which has been found in 3% to 7% of patients.6,1 The mortality rate of bronchopleural fistula after cancer surgery is 9.2%, whereas it is 25%–28% after surgery due to inflammatory diseases.9 The mortality rate of surgery for pulmonary tuberculosis has been reported as 0–3.3%.1,3,4 These figures are no higher than the rates in resections due to other causes.
In this series, the most common complication was prolonged air leak. Although the morbidity rate was 24.5% in our study, most complications were minor, such as prolonged air leak or space problems. These complications were treated conservatively and no additional procedure was necessary. Bronchopleural fistula was observed in only one patient. We did not have any major complications in patients with MDR tuberculosis or in those who underwent wedge resection. It was concluded that surgery plays an important role in the management of complications of pulmonary tuberculosis, and recently in MDR tuberculosis. Surgery is effective and can be performed with acceptable morbidity and mortality rates.
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REFERENCES
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- Pomerantz M. Surgery for the management of Mycobacterium tuberculosis and non-tuberculous Mycobacterial infections of the lung. In Shields TW, editor. General thoracic Surgery. 5th edition. Lippincott Williams & Wilkins, 2002:1066–77.
- Souilamas R, Riquet M, Barthes FP, Chehab A, Capuani A, Faure E. Surgical treatment of active and sequelar forms of pulmonary tuberculosis. Ann Thorac Surg 2001;71:443–7.[Abstract/Free Full Text]
- Sung SW, Kang CH, Kim YT, Han SK, Shim YS, Kim JH. Surgery increased the chance of cure in multi-drug resistant pulmonary tuberculosis. Eur J Cardiothorac Surg 1999;16:187–93.[Abstract/Free Full Text]
- Treasure RL, Seaworth BJ. Current role of surgery in Mycobacterium tuberculosis. Ann Thorac Surg 1995;59:1405–9.[Abstract/Free Full Text]
- Reed CE, Parker EF, Crawford FA Jr. Surgical resection for complications of pulmonary tuberculosis. Ann Thorac Surg 1989;48:165–7.[Abstract]
- Moran JF. Surgical treatment of pulmonary tuberculosis. In Sabiston DC, Spencer FC, editors. Surgery of the Chest. 6th edition, Philadelphia:Saunders, 1995, pp 752–772.
- Pomerantz M, Madsen L, Goble M, Iseman M. Surgical management of resistant mycobacterial tuberculosis and other mycobacterial pulmonary infections. Ann Thorac Surg 1991;52:1108–12.[Abstract]
- Harrison LH Jr. Current aspects of the surgical management of tuberculosis. Surg Clin North Am 1980;60:883–95.[Medline]
- Neptune WB, Kim S, Bookwalter J. Current surgical management of pulmonary tuberculosis. J Thorac Cardiovasc Surg 1970;60:384–91.[Medline]
- Hankins JR, Miller JE, McLaughlin JS. The use of chest wall muscle flaps to close bronchopleural fistulas: experience with 21 patients. Ann Thorac Surg 1978;25:491–9.[Abstract]
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ABSTRACT
INTRODUCTION
