ROLE OF SURGERY IN MANAGING TB
Analysis by Dr SK Kapoor based on talk by Dr Pallavi Purwar and available information
The epidemiological basis of the increased need are :
a) the overall increase in global incidence of TB
b) the emergence of: i) MDR-TB ii) XDR TB
c) increasing incidence of TB in the western world due to people migration from developing countries.
Thoracic surgery offers highly effective treatment of TB and its sequel with less trauma and morbidity than ever before. Minimally Invasive Thoracic Surgery allows a wider range of TB patients to be considered for effective surgical management
The reasons for this could be:
a. DRUG RESISTANCE (detailed above) to ATT, i.e. in which clinical and radiological pictures remain unchanged or worsen (e.g., fresh cavity formation or lesion extension)
b. A TRAPPED ACTIVE LESION : which presents with AFB sputum positivity after 3-month of intensive phase treatment (i.e. with four drugs), usually evidenced by a circumscribed radiological lesion or a destroyed lung
c. RELAPSE(S), RECURRENCE OR REINFECTION in patients where treatment with proper drug regimen is adequately completed or declared ‘cured’ of TB.
d. NON ADHERENCE TO THERAPY i.e. lack of patient compliance
e. INTOLERANCE TO ANTI TB DRUGS due to concurrent liver, renal or other diseases
f. HIGH BACILLARY LOAD due to extensive disease (but confined to a particular anatomical area of ONE lung only) i.e. not miliary TB
g. ASSOCIATED DISEASE like HIV, uncontrolled T2DM
SURGICAL INDICATIONS are:
1) RESECTION IN DRUG SENSITIVE PULMONARY TB
Thin walled cavity
Persistant Sm +
Recurrent haemoptysis
High risk of relapse
Drug intolerance
Rapid progression of disease
2) RESECTION IN MDR / XDR (ISEMAN CRITERIA)
Extensive resistance –high probability of failure / relapse
Localised disease – to enable clear resection of diseased tissue and leave enough lung tissue to retain cardiopulmonary activity
Sufficient drug activity so that M.tb germs don’t hamper the healing of the residual bronchial stump
3) BRONCIECTASIS
• Commonest post TB sequlea (up to 60%)
• Apical and posterior segments of upper lobe commonly involved
4) DESTROYED LUNG
• Unilateral destruction of lung due to TB
• Cicatrization atelectasis after post primary TB (40%)
• CXR shows reduced lung volume, cavities bronchiectasis and fibrosis
• Complications are haemoptysis (repeated, sometimes life threatening), repeated and frequent secondary infections
5) empyema
6) cavity formation with or without aspergilloma
7) adenopathy with fistula
8) pleural adhesions
9) scar carcinoma
10) Rassmusen Aneurysm
11) Tracheo bronchial stenosis
12) broncholith
THORACOPLASTY
Aimed at eliminating or reducing the new space created by the resected tissue.
Surgeries designed to reduce the volume of a hemithorax
The bony parts of the chest wall are resected
Collapse therapy of chest wall
PLEURAL TB CASES NEEDING SURGERY are (those already on intercostal drainage)
• Purulent output
• Air leak suggesting BP fistula
• Unsuccessful drainage
• Excessive pain
• persistence > 2 weeks
• decortication :assess at 6 months of treatment
CONTRAINDICATIONS
i. Bilateral extensive disease
ii. Miliary TB
iii. Disseminated TB
iv. Active Bronchial TB
v. Poor PFT, V/Q so as to make it a high risk surgery
vi. Lack of GA clearance
POST-RESECTION COMPLICATIONS
Procedures are in place if need arises in order to reinforce the bronchial stump, to sterilize the residual cavity and to obliterate it.
