Pleuro-Pulmonary Tuberculosis - Surgical Principles
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Transcript of Pleuro-Pulmonary Tuberculosis - Surgical Principles
SURGICAL ASPECTS OF PLEUROPULMONARY
TUBERCULOSISDr. SANJOY SANYALMBBS, MS (Surgery)
Department of Surgery – Central Hospital Kigali.Rwanda, Africa 1999
Presented at 2nd 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.