Pleuro-Pulmonary Tuberculosis - Surgical Principles

SURGICAL ASPECTS OF PLEUROPULMONARY TUBERCULOSIS Dr. SANJOY SANYAL MBBS, MS (Surgery) Department of Surgery – Central Hospital Kigali. Rwanda, Africa 1999 Presented at 2 nd Annual Conference of College of Gynaecology and Obstetrics of Rwanda, Kigali, Rwanda, Africa, on 5th – 6th May 1999

Bird’s-eye view
TB, specifically PT , needs no introduction
ATT - drastic reduction in indications for surgical treatment
MDRT strains - 33-70% of all cases, depending on region
5-10% PT require surgical treatment
Post-WW II era-maximum strides in intra-thoracic surgery

The therapeutic spectrum
Pulmonary tuberculosis
90-95%-----ATT (prolonged, regular)
5-10%-------Require surgery
Procedures of choice
Pulmonary resection-------------90%
Thoracoplasty--------------------10%
TB : Tuberculosis; PT : Pulmonary Tuberculosis, ATT : Anti-Tuberculosis Treatment; MDRT : Multi-Drug Resistant Tuberculosis

Classification of Rx – Pulmonary
Resection ---------Segmental resection
---------Lobectomy
---------Pneumonectomy
Relaxation (collapse) therapy
Major--------------Thoracoplasty
-------------- Plombage
--------------Pneumonolysis (extrapleural)

Classification – Cont’d
Relaxation (collapse) therapy
Minor-----------Phrenic paralysis
----------- Pneumothorax
-----------Pneumoperitoneum
Drainage therapy
-----------Cavernostomy
-----------Monaldi catheter drainage

Thoracoplasty (Relax Rx) principle
TB heals by fibrosis, contraction, collapse, obliteration of diseased area / cavity.
Bony chest wall mechanically hinders this.
Removal of sufficient portion of wall obliterates pleural space
Allows lung to contract / retract concentrically towards hilum, and thus ‘relax’ .

Thoracoplasty – Indications
TB too widespread for safe removal
Resection unduly risky
‘ Open-positive’ with MDRT strains
Elderly patients-as ‘compromise’ procedure
Broncho-pleural fistula) following pul. resection-as ‘secondary’ procedure
Failed decortication of TB empyema

Thoracoplasty – Types
Standard (extrapleural, paravertebral) thora-coplasty = selective (upper lobe); Alexander
Lateral thoracoplasty; Sauerbruch
Semb’s apicolytic modification
Apical thoracoplasty (adjunctive procedure)
Modified (‘tailoring’) thoracoplasty
Radical thoracoplasty; Friedrich

Pulmonary resection
Aims: Remove / assist in healing / control of destructive residuals; prevent reactivation
Advantages: Greater diseased part removed; no external deformity; little respiratory disturbance
Disadv: Unsafe in extensive disease; inadvisable in MDRT strains .
(These are indications for thoracoplasty)

Pulmonary resection – Indications
‘ Open-positive’ beyond 3-6 months of Rx
‘ Closed-positive’ with pathologic residuals
‘ Open-negative’ with thick-walled cavity
Negative sputum with blocked cavities / > 2 cm nodules / tuberculoma / fibrocaseous
TB bronchiectasis middle / lower lobe

Indications – Cont’d
Atypical mycobacterial infection
Neoplasm -can’t differentiate / concomitant / cancer at site of TB scar
Haemoptysis -recurrent / persistent / massive
Encapsulated, un-expandable lobe / lung with empyema

Resection – Extent
Wedge resection: Tuberculoma, coin lesion; for frozen section biopsy confirmation
Segmental resection: Localised residual cavities, fibrocaseous, especially bilateral

Resection – Extent
Lobectomy: Active disease with +ve sputum and drug-resistant bacilli
Pneumonectomy: Gross destruction one lung, persistent +ve sputum, recurrent haemoptysis

Resection – Complications
Empyema, with or without }When +ve spu-
Broncho-pleural fistula }tum, drug-resi-
Bronchogenic spread of TB }stant, or exten-
}sive resection Adjunctive procedures
Temporary phrenic nerve paralysis
Small apical thoracoplasty

Childhood resection
Vast majority respond to long-term ATT
Only 5% require resection for:
Progressive primary TB
Reinfection TB
Destructive residuals
Lobar atelectasis or emphysema due to hilar nodes don’t need operation.
With ATT nodes regress and lobes become normal

TB empyema – Aims of Rx
Control of infection by :
Regular needle aspiration (thoracentesis)
Intrapleural and systemic ATT
Open drainage should be avoided
(2° infection of pleural space inevitable)

Aims of Rx – Cont’d
Obliteration of empyema cavity
a) Active lung infection :
ATT for 3-6 months
Followed by thoracoplasty or pleuro-pneumonectomy
b) Inactive lung infection :
Repeated thoracentesis (prolonged)
Decortication (procedure of choice)

Decortication – Principle
Much better alternative to drainage
Aim: Early expansion of lung
Principles of technique:
Incising empyema sac, evacuating purulent contents, excising ‘peel’; OR
Excising entire empyema sac in toto from ‘outside - inwards’.

Decortication – Illustration

Combined procedures
Pleuro-lobectomy or pleuro-pneumonectomy
If TB empyema associated with active pulmonary disease (cavitation, positive sputum or both)
Pleuro-pneumonectomy and eventual thoracoplasty
If TB empyema with broncho-pleural fistula and secondary pathogenic infection

Conclusion Decortication and pleuro- pneumonectomy have dramatically altered outlook in most cases and have rendered all other procedures obsolete.

THAN-Q

Pleuro-Pulmonary Tuberculosis - Surgical Principles

by Sanjoy Sanyal on Mar 04, 2009

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