1. Asian Cardiovascular and Thoracic Annals
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Role and Outcome of Surgery for Pulmonary Tuberculosis
Aysun Olcmen, Mehmet Z Gunluoglu, Adalet Demir, Hasan Akin, Hasan V Kara and Seyyit I Dincer
Asian Cardiovascular and Thoracic Annals 2006 14: 363
DOI: 10.1177/021849230601400503
The online version of this article can be found at:
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2. ORIGINAL CONTRIBUTION
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
ABSTRACT
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 fi stula 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 fi stula 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.
INTRODUCTION
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.
PATIENTS AND METHODS
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,
(Asian Cardiovasc Thorac Ann 2006;14:363–6)
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 confi rmed by either
For reprint information contact:
Adalet Demir, MD Tel: 90 212 664 1700 Fax: 90 212 547 2233 Email: dradalet@hotmail.com
Yuzyil mah. Kisla Cad. Yesil zengibar sitesi, A-3 Blok, D-9 Bagcilar, Istanbul, Turkey.
ASIAN CARDIOVASCULAR & THORACIC ANNALS 363 2006, VOL. 14, NO. 5
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3. Surgery for Pulmonary Tuberculosis Olcmen
Table 3. Complications in 57 Patients
No. of
Complication Patients %
Prolonged air leak 12 21.1
Pleural space problem 7 12.3
Empyema 5 8.8
Hematoma 2 3.5
Bronchopleural fi stula 1 1.8
Chylothorax 1 1.8
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 fi stula 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.
RESULTS
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 fi stula. 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.
Table 1. Surgical Indications in 57 Patients
No. of
Indication Patients %
Trapped lung 18 31.6
Multidrug-resistant tuberculosis 10 17.5
Aspergilloma 10 17.5
Destroyed lung lobe 5 8.8
Massive hemoptysis 4 7.0
Bronchopleural fi stula 3 5.3
Persistent cavity 2 3.5
Undiagnosed 5 8.8
Table 2. The 72 Surgical Procedures in 57 Patients
No. of
Procedure Procedures %
Lobectomy 23 31.9
Decortication 18 25.0
Wedge resection 12 16.7
Pneumonectomy 10 13.9
Segmentectomy 2 2.8
Myoplasty 2 2.8
Others 5 6.9
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 fi rst 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 confi rmed
either by direct examination or by culture.
Multidrug-resistant pulmonary tuberculosis was defi ned
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 suffi cient 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 defi ned as
ASIAN CARDIOVASCULAR & THORACIC ANNALS 364 2006, VOL. 14, NO. 5
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4. Olcmen Surgery for Pulmonary Tuberculosis
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 fi stula 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 fi stula were performed. However, the fi stula
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%.
DISCUSSION
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 fi stula and/or empyema, pleural drainage
is suffi cient 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 fi stula, 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 fi ll 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 fi stula which has been found in 3% to 7%
of patients.6,1 The mortality rate of bronchopleural fi stula
after cancer surgery is 9.2%, whereas it is 25%–28% after
surgery due to infl ammatory diseases.9 The mortality rate
of surgery for pulmonary tuberculosis has been reported
as 0–3.3%.1,3,4 These fi gures 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
fi stula 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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