SURGERY IN PULMONARY TUBERCULOSIS
Alex Magufwa, student of 5th course
Supervisor - Dr. Madyar Vladmir Vasilovich
Sumy State University, department of general surgery
The role of surgery in the treatment of pulmonary tuberculosis has always been the subject of controversy. Surgery has played an important part in the management of tuberculosis since the 1940s. The first successful treatments for tuberculosis were all surgical. They were based on the observation that healed tuberculous cavities were all closed.
At no stage has there ever been absolute agreement on the indications for surgery and the practice of individual physicians and surgeons has always varied to some degree.
Sauerbrach and Elving introduced thoracoplasty for the treatment of cavitated tuberculosis in 1913. In modified form thoracoplasty or some other collapse procedure remained the standard surgical measure until after the introduction of chemotherapy. With the development of effective anti-tuberculous drugs in the early 1950’s resection became possible without producing an acute excerbation of disease or broncho-pleural fistula.
Indications for surgery. The British Medical Journal in 1967 gave the following indications for operation in pulmonary tuberculosis and is useful as a basis for discussion:
1. Patients with cavitated disease with drug resistance. In our practice we would consider for surgery patients with relatively localized disease with resistant organisms who had failed routine second-line drugs or whose sputum was converting with difficulty or who were having difficulty in tolerating drugs particularly in the presence of a destroyed lobe or lung, a thick-walled cavity or a cavity in the spical segment of the lower lobe. 2. Coin lesions where diagnosis is in doubt and differentiation between tuberculoma and carcinoma is impossible. 3. Recurrent haemoptysis due to residual bronchiectasis. 4. Chronic tuberculous empyema. 5. Recurrent pneumonitis associated with bronchostenosis. 6. Cavity with mycetoma with haemoptyses. 7. Infection with Atypical mycobacteria-organisms which are generally drug resistant.
Modern surgical management. In modern times, the surgical treatment of tuberculosis is confined to the management of multi-drug resistant TB. A patient with MDR-TB(multiple drug resistance tuberculosis) who remains culture positive after many months of treatment may be referred for lobectomy or pneumonectomy with the aim of cutting out the infected tissue. The optimal timing for surgery has not been defined, and surgery still confers significant morbidity.The centre with the largest experience in the US is the National Jewish Medical and Research Center in Denver, Colorado. From 1983 to 2000, they performed 180 operations in 172 patients; of these, 98 were lobectomies, and 82 were pneumonectomies. They report a 3.3% operative mortality, with an additional 6.8% dying following the operation; 12% experienced significant morbidity (particularly extreme breathlessness). Of 91 patients who were culture positive before surgery, only 4 were culture positive after surgery.
In extrapulmonary TB, surgery is often needed to make a diagnosis (rather than to effect a cure): surgical excision of lymph nodes, drainage of abscesses, tissue biopsy, etc. are all examples of this. Samples taken for TB culture should be sent to the laboratory in a sterile pot with no additive (not even water or saline) and must arrive in the laboratory as soon as possible. In spinal TB, surgery is indicated for spinal instability (when there is extensive bony destriction) or when the spinal cord is threatened. Therapeutic drainage of tuberculous abscesses or collections is not routinely indicated and will resolve with adequate treatment. In TB meningitis, hydrocephalus is a potential complication and may necessitate the insertion of a ventricular shunt or drain.