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SURGICAL MANAGEMENT OF TUBERCULOSIS

SURGICAL MANAGEMENT OF TUBERCULOSIS. Paul Bolanowski, MD Associate Professor of Surgery Division of Cardiothoracic Surgery UMDNJ-NJ Medical School. HISTORY OF TUBERCULOSIS. Scourge Of Early Humanity Hippocrates – Phthisis Disease characterized by progressive weight loss and wasting

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SURGICAL MANAGEMENT OF TUBERCULOSIS

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  1. SURGICALMANAGEMENTOF TUBERCULOSIS Paul Bolanowski, MD Associate Professor of Surgery Division of Cardiothoracic Surgery UMDNJ-NJ Medical School

  2. HISTORY OF TUBERCULOSIS • Scourge Of Early Humanity • Hippocrates – Phthisis • Disease characterized by progressive weight loss and wasting • Romans – Consumption • Consumed its victims • Schonlein - Tuberculosis • First to use term based on autopsy findings

  3. SURGICAL HISTORY • 1821 - Carson - collapse therapy • 1925 - Alexander • 1869 - Simon - thoracoplasty • 1920 - Sauerbruch & Alexander • 1882 - Block - first resection • 1891 - Tuffier – first partial resection • 1934 - Freelander – first lobectomy

  4. COLLAPSE THERAPY • Pneumothorax • Phrenic nerve crush • Pneumoperitoneum • Extrapleural pneumolysis • Plombage thoracoplasty • Extraperiosteal • Thoracoplasty

  5. EFFICACY OF COLLAPSE THERAPY • 1880 - 300 deaths/100,000 • 1935 - 69 deaths /100,000 • Plombage thoracoplasty • Sputum negative - 30-60% • Thoracoplasty • Closure of cavity in 80% • Mortality 10%

  6. SURGICAL INDICATIONS - 1 • Failure of medical treatment • Cavity with persistently positive sputum • Resistant strains • MDR-TB • XDR-TB • Atypical organisms • M. kansasii - surgery infrequent • M. avium - localized – lobectomy • Solitary nodule • Lung carcinoma vs. tuberculoma

  7. SURGICAL INDICATIONS - 2 • Massive or recurrent hemoptysis • Etiology • Bronchial collateral circulation • Rasmussin aneurysm • Aspergilloma • Bronchiectasis • Treatment • Embolization • Surgery

  8. MASSIVE HEMOPTYSIS - 1 • Definition • Based on amount and duration • MASSIVE 600 ml WITHIN 16 hrs • 200ml, >300ml, >500ml, >600ml / 24-48hrs • Based on threat to life • Acute airway obstruction • Shock • Persistent hemoptysis despite good medical management

  9. MASSIVE HEMOPTYSIS - 2 • Position patient • Chest x-ray • Bronchoscopy • Localize site • Intubation • Bronchial arteriography • Surgery • Resection • Videoendoscopic thoracoscopy

  10. VATS CAVERNOSTOMY

  11. BRONCHIAL ARTERIOGRAPHY • Advantages • Localize site • Control bleeding by embolization • Prevent contamination of normal lung • Buy time to improve pulmonary function • Less blood loss during surgery • Disadvantages • Spinal cord paralysis • Temporary • Acute control - 75% effective • Rebleed rate - 43%

  12. EMBOLIZATION - 1

  13. EMBOLIZATION - 2

  14. EMBOLIZATION - 3

  15. MASSIVE HEMOPTYSIS • Surgical results • Massive • 600ml in < 16hrs 18% MORTALITY • Conservative management • Massive • 600ml or more in 16hrs – 75% MORTALITY • 600ml or more in 48hrs – 54% MORTALITY • Embolization + surgery • Acute control in 75% • Mortality 7-9%

  16. SURGICAL INDICATIONS - 1 • Bronchopleural fistula • Complication of disease • Treatment • Lobectomy or pneumonectomy • Complication of surgery • Treatment • Immediate chest tube • Pneumonectomy • Thoracotomy with closure using intercostal muscle flap

  17. SURGICAL INDICATIONS - 2 • Empyema • Acute • No chest tube unless respiration compromised • Chronic • Decortication • Trapped lung • Muscle transposition

  18. AVAILABLE TISSUE

  19. SURGICAL INDICATIONS - 3 • Destroyed lung or lobe • Surgical resection • Pott’s abscess • Drainage • Spine reconstruction • Mycetoma (aspirgeloma) • Recurrent hemoptysis • Resection

  20. SURGICAL INDICATIONS - 4 • Pericarditis • Acute • With or without tamponade • Pericardial window • Chronic • Constrictive pericarditis • Total pericardioectomy • Cardiopulmonary bypass • Lymphadenitis • Cervical (scrofula) • Mediastinal • Drainage

  21. SURGICAL INDICATIONS - 5 • Destroyed lung or lobe • Surgical resection • Pott’s abscess • Drainage • Spine reconstruction • Mycetoma (aspirgeloma) • Recurrent hemoptysis • Resection

  22. SURGICAL INDICATIONS - 6 • Pericarditis • Acute • With or without tamponade • Pericardial window • Chronic • Constrictive pericarditis • Total pericardioectomy • Cardiopulmonary bypass • Lymphadenitis • Cervical (scrofula) • Mediastinal • Drainage

  23. PRE-OP MANAGEMENT - 1 • Medical management • Nutrition • Atypical mycobacterium • M. avium • Perioperatively – ethambutol, rifabutin, biaxan, and amikacin • Operate when sputum converts to negative • M. abscessus • Pre-op – imipenem & amakacin for 2 months • Post-op – same drugs for 4 months • M. kansasii – surgery infrequent

  24. PRE-OP MANAGEMENT - 2 • Multi-drug resistant tuberculosis • Pre-op • 2-3 months of 3 or 4 drugs they have never received • Post-op • 18 to 24 months of therapy • These patients must be followed diligently post-op for recurrence

  25. PRE-OP MANAGEMENT - 3 • PET-CT scan • Determine extent of disease • Bronchoscopy • Determine if line of transection is disease free • Arteriography • To control bleeding pre-operatively • To decrease blood loss at time of surgery

  26. POST-OP MANAGEMENT • Immediate • Intensive care unit • Isolation • Room with air exchange • Ventilator • Collaborative medical management • Anti-tuberculous drugs • Length of stay • Long term

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