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Pleuro-Pulmonary Tuberculosis - Surgical Principles


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Presented at 2nd Annual Conference of College of Gynaecology and Obstetrics of Rwanda, Kigali, Rwanda, Africa, on 5th – 6th May 1999. Pictured in Hotel Mille Collins, rendered famous in the movie "Hotel Rwanda", which depicted the genocide in Rwanda in 1994. "Hotel Rwanda" is Hotel Mille Collins ('Thousand Hills).

Published in: Health & Medicine

Pleuro-Pulmonary Tuberculosis - Surgical Principles

  1. 1. 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
  2. 2. Bird’s-eye view <ul><li>TB, specifically PT , needs no introduction </li></ul><ul><li>ATT - drastic reduction in indications for surgical treatment </li></ul><ul><li>MDRT strains - 33-70% of all cases, depending on region </li></ul><ul><li>5-10% PT require surgical treatment </li></ul><ul><li>Post-WW II era-maximum strides in intra-thoracic surgery </li></ul>
  3. 3. The therapeutic spectrum <ul><li>Pulmonary tuberculosis </li></ul><ul><ul><li>90-95%-----ATT (prolonged, regular) </li></ul></ul><ul><ul><li>5-10%-------Require surgery </li></ul></ul><ul><li>Procedures of choice </li></ul><ul><ul><li>Pulmonary resection-------------90% </li></ul></ul><ul><ul><li>Thoracoplasty--------------------10% </li></ul></ul>TB : Tuberculosis; PT : Pulmonary Tuberculosis, ATT : Anti-Tuberculosis Treatment; MDRT : Multi-Drug Resistant Tuberculosis
  4. 4. Classification of Rx – Pulmonary <ul><li>Resection ---------Segmental resection </li></ul><ul><li>---------Lobectomy </li></ul><ul><li>---------Pneumonectomy </li></ul><ul><li>Relaxation (collapse) therapy </li></ul><ul><li>Major--------------Thoracoplasty </li></ul><ul><li>-------------- Plombage </li></ul><ul><li>--------------Pneumonolysis (extrapleural) </li></ul>
  5. 5. Classification – Cont’d <ul><li>Relaxation (collapse) therapy </li></ul><ul><li>Minor-----------Phrenic paralysis </li></ul><ul><li>----------- Pneumothorax </li></ul><ul><li>-----------Pneumoperitoneum </li></ul><ul><li>Drainage therapy </li></ul><ul><li>-----------Cavernostomy </li></ul><ul><li>-----------Monaldi catheter drainage </li></ul>
  6. 6. Thoracoplasty (Relax Rx) principle <ul><li>TB heals by fibrosis, contraction, collapse, obliteration of diseased area / cavity. </li></ul><ul><li>Bony chest wall mechanically hinders this. </li></ul><ul><li>Removal of sufficient portion of wall obliterates pleural space </li></ul><ul><li>Allows lung to contract / retract concentrically towards hilum, and thus ‘relax’ . </li></ul>
  7. 7. Thoracoplasty – Indications <ul><li>TB too widespread for safe removal </li></ul><ul><li>Resection unduly risky </li></ul><ul><li>‘ Open-positive’ with MDRT strains </li></ul><ul><li>Elderly patients-as ‘compromise’ procedure </li></ul><ul><li>Broncho-pleural fistula) following pul. resection-as ‘secondary’ procedure </li></ul><ul><li>Failed decortication of TB empyema </li></ul>
  8. 8. Thoracoplasty – Types <ul><li>Standard (extrapleural, paravertebral) thora-coplasty = selective (upper lobe); Alexander </li></ul><ul><li>Lateral thoracoplasty; Sauerbruch </li></ul><ul><li>Semb’s apicolytic modification </li></ul><ul><li>Apical thoracoplasty (adjunctive procedure) </li></ul><ul><li>Modified (‘tailoring’) thoracoplasty </li></ul><ul><li>Radical thoracoplasty; Friedrich </li></ul>
  9. 9. Pulmonary resection <ul><li>Aims: Remove / assist in healing / control of destructive residuals; prevent reactivation </li></ul><ul><li>Advantages: Greater diseased part removed; no external deformity; little respiratory disturbance </li></ul><ul><li>Disadv: Unsafe in extensive disease; inadvisable in MDRT strains . </li></ul><ul><li>(These are indications for thoracoplasty) </li></ul>
  10. 10. Pulmonary resection – Indications <ul><li>‘ Open-positive’ beyond 3-6 months of Rx </li></ul><ul><li>‘ Closed-positive’ with pathologic residuals </li></ul><ul><li>‘ Open-negative’ with thick-walled cavity </li></ul><ul><li>Negative sputum with blocked cavities / > 2 cm nodules / tuberculoma / fibrocaseous </li></ul><ul><li>TB bronchiectasis middle / lower lobe </li></ul>
  11. 11. Indications – Cont’d <ul><li>Atypical mycobacterial infection </li></ul><ul><li>Neoplasm -can’t differentiate / concomitant / cancer at site of TB scar </li></ul><ul><li>Haemoptysis -recurrent / persistent / massive </li></ul><ul><li>Encapsulated, un-expandable lobe / lung with empyema </li></ul>
  12. 12. Resection – Extent <ul><li>Wedge resection: Tuberculoma, coin lesion; for frozen section biopsy confirmation </li></ul><ul><li>Segmental resection: Localised residual cavities, fibrocaseous, especially bilateral </li></ul>
  13. 13. Resection – Extent <ul><li>Lobectomy: Active disease with +ve sputum and drug-resistant bacilli </li></ul><ul><li>Pneumonectomy: Gross destruction one lung, persistent +ve sputum, recurrent haemoptysis </li></ul>
  14. 14. Resection – Complications <ul><li>Empyema, with or without }When +ve spu- </li></ul><ul><li>Broncho-pleural fistula }tum, drug-resi- </li></ul><ul><li>Bronchogenic spread of TB }stant, or exten- </li></ul><ul><li>}sive resection Adjunctive procedures </li></ul><ul><li>Temporary phrenic nerve paralysis </li></ul><ul><li>Small apical thoracoplasty </li></ul>
  15. 15. Childhood resection <ul><li>Vast majority respond to long-term ATT </li></ul><ul><li>Only 5% require resection for: </li></ul><ul><ul><li>Progressive primary TB </li></ul></ul><ul><ul><li>Reinfection TB </li></ul></ul><ul><ul><li>Destructive residuals </li></ul></ul><ul><li>Lobar atelectasis or emphysema due to hilar nodes don’t need operation. </li></ul><ul><li>With ATT nodes regress and lobes become normal </li></ul>
  16. 16. TB empyema – Aims of Rx <ul><li>Control of infection by : </li></ul><ul><ul><li>Regular needle aspiration (thoracentesis) </li></ul></ul><ul><ul><li>Intrapleural and systemic ATT </li></ul></ul><ul><li>Open drainage should be avoided </li></ul><ul><ul><li>(2° infection of pleural space inevitable) </li></ul></ul>
  17. 17. Aims of Rx – Cont’d <ul><li>Obliteration of empyema cavity </li></ul><ul><li>a) Active lung infection : </li></ul><ul><ul><li>ATT for 3-6 months </li></ul></ul><ul><ul><li>Followed by thoracoplasty or pleuro-pneumonectomy </li></ul></ul><ul><li>b) Inactive lung infection : </li></ul><ul><ul><li>Repeated thoracentesis (prolonged) </li></ul></ul><ul><ul><li>Decortication (procedure of choice) </li></ul></ul>
  18. 18. Decortication – Principle <ul><li>Much better alternative to drainage </li></ul><ul><li>Aim: Early expansion of lung </li></ul><ul><li>Principles of technique: </li></ul><ul><li>Incising empyema sac, evacuating purulent contents, excising ‘peel’; OR </li></ul><ul><li>Excising entire empyema sac in toto from ‘outside - inwards’. </li></ul>
  19. 19. Decortication – Illustration
  20. 20. Combined procedures <ul><li>Pleuro-lobectomy or pleuro-pneumonectomy </li></ul><ul><ul><li>If TB empyema associated with active pulmonary disease (cavitation, positive sputum or both) </li></ul></ul><ul><li>Pleuro-pneumonectomy and eventual thoracoplasty </li></ul><ul><ul><li>If TB empyema with broncho-pleural fistula and secondary pathogenic infection </li></ul></ul>
  21. 21. Conclusion Decortication and pleuro- pneumonectomy have dramatically altered outlook in most cases and have rendered all other procedures obsolete.
  22. 22. THAN-Q