Surgery for Tuberculosis

World TB Day Conference

Salt Lake City
3/22/2013

Barbara C. Cahill, M.D.
What is the Prognosis of Untreated TB?
PLoS ONE 6 (4);e17601 doi:10:137/journal.pone.0017601
What is the Prognosis of Untreated TB?
Current models of untreated TB

3 years until self cure or death


TB Case fatality rates

70% for smear positive TB

20% for smear negative, culture positive TB
PLoS ONE 6 (4);e17601 doi:10:137/journal.pone.0017601
Historical Therapies for Tuberculosis


The sanatorium - diet, rest, sunshine, immobilization

Exercise

The touch of the king (1200s 1700s)

Phlebotomy

Emetics, cyanide, creosote, arsenic, lard

Vapors

Laudanum

Vaccination

Surgery
Extrapulmonary Tuberculosis
2011 Centers for Disease Control Data regarding 2188 reported
extrapulmonary TB cases (~20% all reported TB cases)

Extrapulmonary TB site Percent
Lymphatic (scrofula) 37.2
Pleural 16.9
Bone +/- joint 11.1
Meningeal 5.7
Peritoneal 5.4
Genitourinary 5.0
Other 18.6
http://www.cdc.gov/tb/statistics/reports/2011/pdf/report2011.pdf
Tuberculous Bone/Joint Disease
Bony disease
isolated bony disease without spread to a joint fails to attract attention

Arthritis
nonspecific, often indolent clinical presentation

usually monoarticular, diagnosis often delayed

average duration of symptoms before diagnosis ~2 years

four drug therapy, joint irrigation, drainage and open synovectomy


TB arthritis of intervertebral joints
aka Potts Disease
Historical Surgical Procedures for Pulmonary TB
Anecdotal observation
TB pts with spontaneous pneumothorax improved

Collapse therapy

Why does collapse therapy work?

Placing the diseased organ quiescent state

Resting, relaxing, immobilizing, compressing lung

favorably affects disease course
Pneumothorax, Pneumoperitoneum
James Carson (8140) Carlo Forlanini (1882)

.the lung shrivels.the lung no longer breathes.the lung that cannot
breathe anymore, cannot anymore cough or expectorate.



Introduction of nitrogen gas into the pleural space

increases intrapleural pressure

Extrinsic pressure on lung + Intrinsic lung elasticity = collapse

Cavity walls approximate, close

Bronchi empty their secretions

Lymphatic flow decreases

Blood flow?
Thorax.1983;38:326-332.
Collapse Therapies
Pneumothorax, pneumoperitoneum

Phrenicotomy (phrenic nerve crush)

Scalenectomy removal of accessory muscles of respiration

Plombage extraperiosteal or extrapleural pneumonolysis

Thoracoplasty removal of ribs


Pneumothorax
Pneumoperitoneum
Collapse Therapies cont
Pneumothorax
Instilled gas is absorbed, repeat procedures required
Pneumoperitoneum



More permanent collapse therapies

Phrenicotomy (phrenic nerve crush)

Plombage

Thoracoplasty



Phrenicotomy (Phrenic Nerve Crush)
Pleural Space
http://medicalclipart.tripod.com/respirbw/PLEURA.gif
d
Barbecued Ribs
Removing the membrane = removing the parietal pleura

You are sort of a thoracic surgeon!
http://bbq.about.com/od/rib1/ss/aa011009a_2.htm
Collapse Therapy - Plombage
The use of an inert material to fill an abnormal body cavity

Oleothorax
Lucite balls
Muscle, Fat, Bone
Rubber gloves
Rubber sheeting
Sponges
Collapse Therapy - Oleothorax
Intrapleural or extrapleural insertion of oil in to the thoracic cavity to collapse lung

Oils used
Mineral oil
Olive oil
Cotton seed oil
Cod liver oil
Nut oils
Paraffin

Antiseptics added
Gomenol (myrtle plant extract)
Bismuth
Iodinated compounds
Oleothorax
Dissection of parietal pleura away from ribs, collapse of lung

Instillation of paraffin to fill the space between lung and ribs

The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937.
Oleothorax
Lucite Ball Plombage
Oleothorax, Lucite Ball Plombage Outcomes
Reported outcomes
disappearance of tubercle bacilli from sputum
cured
cavities closed
greatly improved, improved, died
working and negative for tubercle bacilli
mortality rates ~10-30%
The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937.
Plombage Complications
Short and long term complications
Infection

Sinking

Extrusion through chest incision, rib destruction

Erosion in to airway, mediastinum, great vessels

Extrinsic compression of airway, great vessels

Horners syndrome
The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937.
Thorax.1985;40:328-340.
Infected extraperiosteal plombage space in a
56-year-old man who presented with fever and
chest pain.
Jeung M et al. Radiographics 1999;19:617-637.
1999 by Radiological Society of North America
Thoracoplasty
The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937.
Thoracoplasty
Before rib resection After rib resection
Thoracoplasty Operative Mortality
The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937.
(657 Surgeries)
25/39 (64%)
post op deaths
occurred in first
30 days
Tuberculosis Therapeutic Options
The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937.
Oleothorax and Thoracoplasty
Surgery for TB Current Paradigm

Surgical interventions supplanted by effective medical therapy

Resurgence of surgical therapy with the emergence of MDR-TB

Indications for surgery in MDR-TB
Localized disease
Persistent cavitary disease
Persistent sputum positivity
MDR-TB with destroyed lobe of lung
Massive hemoptysis
Bronchopleural fistula
Bronchial stenosis
Surgery for Pulmonary MDR-TB
U of Colorado experience 1983-2000

172 patients , 180 pulmonary resections

Most pts resistant to 6+ antibiotics

Timing of surgery
MDR-TB resistant to almost all drugs
Individualized Rx for 1-2 months

MDR-TB sensitive to some combination of drugs
Individualized Rx for at least 3 months
Follow sputum - low burden of organisms or smear negative

Post op antibiotics for two years after sputum smear and culture negative
J Thorac Cardiovasc Surg 2001;1:448-453.
Pre-operative Assessment for MDR-TB Surgery
Chest CT scan

Bronchoscopy

Pulmonary function tests

Ventilation-perfusion scan

Right heart catheterization

Nutritional assessment and intervention
J Thorac Cardiovasc Surg 2001;1:448-453.
MDR-TB Thoracic Surgeries Performed
Surgical Procedure (n= 180)
Pneumonectomy 19
+ muscle flap 46
+ muscle and Eloesser flaps 1

Completion pneumonectomy 3
+ muscle flap 12
+ omentum 1

Lobectomy 93

Segmental resection 5
J Thorac Cardiovasc Surg 2001;1:448-453.
MDR-TB Operative Mortality

Post-op follow up complete in all patients

mean follow up 7.7 years (4 months 17 years)


6 patient deaths within 30-days / 180 surgeries

Cause of early post op death (n)

Respiratory failure 3

CVA 2

Myocardial infarction 1


Operative mortality rate = 3.3%



J Thorac Cardiovasc Surg 2001;1:448-453.
MDR-TB Late Surgical Mortality
11/166 patients with late deaths (more than 30 days post op)

Cause of Death (n)

Late respiratory failure 4

Recurrent MDR-TB 3 (2%)

Drug overdose 1

Myocardial infarction 1

Renal failure 1

Unknown 1

Late mortality rate = 6.8%




J Thorac Cardiovasc Surg 2001;1:448-453.
MDR-TB Operative Morbidity
20/166 patients experienced post-operative complications

Complication (n)

Respiratory failure 6

BP fistula 5

Wound infection 3

Post op hemorrhage 3

Recurrent laryngeal nerve injury 2

Intrathoracic bowel herniation 1

Surgical complication rate = 12%


But what was the overall MDR-TB recurrence rate in this study?
J Thorac Cardiovasc Surg 2001;1:448-453.
Surgery for Pulmonary MDR-TB
Japanese experience 2000-2007

56 patients , 61 pulmonary resections

Pts resistant to an average of 5.6 antibiotics (range 2-10 antibiotics)

Timing of surgery
Individualized antibacterial Rx for 3 months

If persistently smear positive surgical excision of cavity

If smear negative surgical resection if relapse risk high
(highly drug resistant bug, large cavity, diabetes)


Post op antibiotics for two years after surgery or sputum conversion
J Thorac Cardiovasc Surg 2009;138:1180-1184.
MDR-TB Thoracic Surgeries Performed
Surgical Procedure n= 61 ( %)
Pneumonectomy 19 (30)

Completion pneumonectomy 3 (5)

Lobectomy 33 (55)

Segmental resection 6 (10)
J Thorac Cardiovasc Surg 2009;138:1180-1184.
MDR-TB Operative Outcomes

Post-op mean follow up 3.25 years (8 months 8.75 years)

No operative deaths!

Post op Complications (n)

BP fistula w or w/o empyema 3

Pleural space problem 5

Prolonged air leak 2

Chylothorax 1


Surgical complication rate = 16%


MDR-TB recurred after surgery in 5/56 (9%) pts
Further interventions
3 surgery, 1 med Rx, 1 remained positive
J Thorac Cardiovasc Surg 2009;138:1180-1184.
Is Medical Therapy + Surgery better than
Medical Therapy in MDR-TB?
Int J Tuberc Lung Dis 2013;17(1);6-15.
Is Medical Therapy + Surgery better than
Medical Therapy in XDR-TB?
Int J Tuberc Lung Dis 2013;17(1);6-15.
Not so fast..
No assessment of the potential harm of surgery

No assessment of optimal timing or conditions for surgery

No assessment of outcomes based on level of drug resistance

No long term follow up of patients

Analysis subject to publication bias (negative studies dont get published)

None of the studies were randomized controlled trials

was there selection bias?

was the sputum data reliable?

*Insufficient evidence to recommend Med +Surg Rx over Med Rx alone
Int J Tuberc Lung Dis 2013;17(1);6-15.
What Role does Surgery Play in the
Treatment of Tuberculosis?
Massive hemoptysis

Recurrent or recalcitrant localized disease

Destroyed lung with recurrent infection (with adequate pulmonary reserve)

Bronchopleural fistula


For MDR-TB
1. Individualized antibacterial therapy
2. Nutritional resuscitation
3. Surgical resection of active disease and control of pleural space
4. Individualized antibacterial therapy
5. Collapse therapies Japan and Russia
J Thorac Cardiovasc Surg 2009;138:1180-1184.
Int J Tuberc Lung Dis 2013;17(1);6-15.