THE ROLE OF SURGERY IN PULMONARY TUBERCULOSIS

dr. Wuryantoro, SpB, SpBT!

INTRO"UCTION
Tuberculosis has been a fatal infectious disease of humans for centuries, though
potentially treatable in recent decades.
1
It is the leading cause of death from infectious
disease world-wide, has infected an estimated one-third of the worlds population.
2
The
prevalence of TB in Indonesia in 2! is estimated 2"" per 1, population
#
.
$ppro%imately 2 million people die each year from TB. &inety five per cent of the cases and
ninety eight per cent of TB deaths ta'e place in the developing countries and 2() of the
latter are avoidable ones.
2, "

*ost clinical cases of TB occur due to reactivation of latent disease in a setting of
impaired immunity such as +I,, aging, alcoholism or a ma-or stressor such as truma or
ma-or surgery.
2
The problem of TB is further complicated by and upsurge of cases with
multidrug-resistant .*/0-1 and e%tensively drug-resistant .2/0-1 bacili in recent years.
1

*ost cases in human beings is caused by *ycobacterium tuberculosis, with a few
cases being caused by *ycobacterium bovis. 3ulmonary infection is the usual initial clinical
manifestation with lymphatic of haematogenous spread of infection occuring subse4uently.
$fter inhalation, the pathogenesis of TB develops predictably. $lveolar bacteria grow freely
or after phagocytosis by macrophages .usualy subpleural or mid lung1. 5ympho-
haematogenous spread of infected macrophages to mediastinal lympn node and
e%trapulmonary sites occurs subse4uently. Tuberculosis can affect almost any tissue or
organ system, has e%trapulmonary manifestation in between one-fift and one-4uarter of
cases.
2

6urgeon may be as'ed to intervene to diagnose TB .e.g. tissue biopsy1, treat it in
con-unction with antimicrobial chemotherapy .e.g. resection of primary pulmonary */0-TB1
or to treat its complications. The history of surgical treatment has progressed from the
isolation, fresh-air sanatoria era to various collapse techni4ues era, and now the surgical
resection era
(
. It is estimated that appro%imately 2) of TB cases and about 1() of positive
sputum TB need surgery
7
.
HISTORY OF SURGERY FOR PULMONARY TB
The surgical treatment of pulmonary TB provided the basis for the development of the
field of thoracic surgery. 3rior to the development of anti TB drugs, pulmonary TB was
treated surgically by opening the tuberculous cavity .8cavern1 to air by a procedure called a
#a$%rno&to'y. 6urgical attempts at reducing the volume of the affected lung or 8#o((ap&%
t)%rapy .thoracoplasty1 were employed ne%t.
2
$ 0oman physician, 9orgio, in 17:7,
reported that a TB patient had improved dramatically after he suffered a sword wound in his
chest, which produced a pneumothora%. This started the concept of collapse therapy.
;arson, in 1!22, suggested that something must be done in order to force artificially, by
e%ternal means, the diseased lung to rest. <orlanini, an Italian physician, observed in 1!:
that lung collapse tended to have a favorable impact on the outcome of the disease. This
ended the depressing era of helplessness in the face of advanced TB and active therapy
1
had begun. 5ater many other surgical procedures, e.g. decortication, plombage and
resection followed.
"
By the 1:7s, chemotherapy has become so effective that resectional surgery for TB
also seemed destined for the history boo's. +orsfall in 1:=( stated that surgery is
nevertheless of value in only a small number of patients. +e also mention in his article the
indications for operation in pulmonary tuberculosis at that period of time was>
=
1. 3atient with cavitated disease with drug resitance
2. ;oin lesions where diagnosis is in doubt and differentiation between tuberculoma
and carcinoma is impossible
#. 0ecurrent hemoptysis due to residual bronchiectasis
". ;hronic tuberculous empyema
(. 0ecurrent pneumonitis associated with bronchostenosis
7. ;avity with mycetoma with hemoptysis
=. 6ocial reason eg. ?ncooperative patients, alcoholics, seamen
!. Infection with $typical mycobacteria-organism which are generally drug resistant
+owever, it has recently been shown that incidenced of TB is again increasing with a
mar'ed rise in the number of */0-TB cases. Incompleteness of initial anti TB treatment,
infection with human immunodeficiency virus and intravenous drug abuse were speculated
to enhance to */0-T. 6ince */0-Tb is difficult to control by medical therapy alone, surgery
has emerged as a therapeutic option.
2, !

IN"ICATION
The worldwide growing numbers of */0-TB cases and the emerging cases of 2/0-
TB have redefined the role of surgery in tuberculosis.
:
Besides the drugs-resistant cases
however, a significant number of patients with undiagnosed TB need surgical care.
:

The role of surgery in the management of pulmonary TB would be
2, ", (, :
>
.11 in establishing the correct diagnosis after failed attempts with other approaches@
.21 in treating */0-TB and medical failure cases@
.#1 in treating TB or previus surgery complications, such as broncho-pleural fistula
.B3<1, haemoptysis, or empyema.
6urgical interventions, in carefully selected cases, along with 2nd line $nti
Tuberculosis Therapy .$TT1 appears as the most favorable option since even the best
available medical therapy alone is only provides bacteriological cure in the order of ""-==)
vis a vis more than :) succes rate with ad-uvant surgery.
1

Diagnostic
2
5ung histology obtained by transbronchial lung biopsy may identify TB in up to (!)
of smear negative cases. 3ercutaneous biopsy of parenchymal lesions may yield the
diagnosis in up to :) of cases, particularly if the target is a tuberculoma. If distinction from
malignant disease is needed, video-assisted thoracoscopis surgery .,$T61 may accomplish
the tas' with reduced chest tube drainage, shorter hospital stay and less postoperative
pain.
"

MDR-TB
*/0-TB is a comple% medical problem
"
. It defined as TB caused by organisms that
are resistant to isoniaAid and rifampicin, two first-line anti-TB drugs, continues to threaten the
progress made in controlling the disease
11-1"
. The emergence of e%tensively drug-resistant
TB .2/0-TB1, defined as */0-TB that is resistant as well to any one of the
fluoro4uinolones and to at least one of three in-ectable second-line drugs .ami'acin,
capreomycin or 'anamycin1, has heightened this threat
1, 1"
. 2/0-TB has been identified in all
regions of the world since 27. Treatment outcomes are significantly worse in 2/0-TB
patients than in */0-TB patients
1"
.
*any factors contribute to the continuous prevalence of */0-TB, including
1
>
1. $symptomatic latent TB infection
2. Immune-compromised
#. The long duration of treatment
". Insufficient TB control programmes
(. 9lobaliAation and *igrations
Borldwide, the prevalence of primary and ac4uired */0-TB among all cases of TB is
=.7) and 1=.1), respectively. The tretment for */0-TB is a prolonged and e%pensive
course of medications, with a low cure rate and high rate of relapse, to%icity, morbidity and
mortality. ;hemotherapy combined with surgery is an effective way of controlling */0-TB.
12
6urgical resection plays an important ad-unctive role in the multimodal treatment approach to
multidrug-resistant tuberculosis .*/0-TB1 and non-tuberculous mycobacterial .&T*1
infection
1(
. ?sing a combination of pulmonary resection and appropriate medical treatment,
;hiang et al have achieve a :2) response rate among patients with chronic */0-TB.
11
Bhile /ravniece et al reported "=) cure with ad-unctive surgical treatment in 2/0-TB
patient.
17
6urgery is offered to patients with limited disease for the removal of the heavy
bacterial burdens in the gross lesions which hamper the efficacy of medical treatment.
1(

<or selected patients who have predominantly localised disease, pulmonary resection
could improve the outcome in the treatment of pulmonary */0-TB. +owever, treating such
patient remain a great challenge because such patient might have already had e%tensive
lung destruction and poor lung function as a result of years of treatment.
11

Indication of surgery in */0 TB remain a contentious issue, however broad
consensus is apparent in this conte%t at least in lateraliAed disease and generally accepted
indications include
1
>
#
.11 high ris' of treatment failureCrelapse, including history of 2 or more relapses
while on therapy, and persistently positive sputum despite " to 7 months of
treatment
.21 localiAed lesion
.#1 intolerence medication
."1 bilateral disease with cavitatory lesions on one side and infiltrative lesions on the
other
Dven though lung resection is the preferred operation, it may not be feasible or
appropriate in some cases having bilateral lesions. The old operation of thoracoplasty with
apicolysis is still useful.
"

Hemoptysis
6urgery is not immediately re4uired in cases of hemoptysis caused by pulmonary
tuberculosis
"
. *assive recurrent hemoptysis is the only -ustified indication in this setting
2, "
.
;onservative measures li'e positioning the good lung up after localiAing the site, antibiotics,
rest and sedation are almost always successful in control lung bleeding and surgery can be
planned. There are other interventional measures, which have their selected role in
appropriate situations
"
>
- Dndotracheal intubation to secure airway, suctioning and bronchoscopy
- Dndobronchial tamponade with <ogarty catheter
- 5aser photocoagulation .&d-yag or argon1
- Dndobronchial haemostatic agents
- 6elective bronchial artery emboliAation
+owever, surgery is the most definitive and curative modality for treating massive
and recurrent hemoptysis
"
.
Empyema
9ood drainage at correct place and ade4uate duration is the 'ey to success. If tube
drainage after #-" wee's failed, then surgical intervention migh be necessary.
"

TYPES OF SURGERY
There are two types of surgery in pulmonary tuberculosis, resection surgery and non
resection surgery.
7
The choice is individualiAed for each patient, based on their clinical
condition. +owever in the techni4ue, some points need to be emphasiAed. 3ulmonary TB
surgery is a challenging procedure involving careful dissection because of dense and
unpredictable adhesions. 3atient is positioned for a formal fifth interspace posterolateral
thoracotomy, with careful attention to padding and avoiding pressure points during what is
often a prolonged operation. 0ib resection may be necessary for ade4uate e%posure. *uscle
sparring thoracotomy with preservation of muscle for flaps is ideal for thoracotomy in TB
cases.
2

Bronchoscopy is re4uired in pre-operative evaluation prior to all TB surgery
2, "
.
6ometimes, it is even needed in post-operative period to remove thic' secretios or blood
clots from the tracheo-bronchial tree
"
.
"
$ properly placed double endotracheal tube, by which the anesthesiologist can
collapse or inflate the lung depending upon the needs of the surgeon is crucial. The
dissection of vascular structure at hilum or in the fissure re4uires precise combination of
sharp and blunt dissection. ;losure of the bronchus with stapler is beneficial, in terms of less
time consuming and post-operative result
2
.
Figure 1. Postero-lateral thoracotomy with preparation for muscle flap (ar*% P, Ea#)%'pat* S.
Sur+%ry *n t)% 'ana+%'%nt o, tu-%r#u(o&*&. In. S#)aa, H, /u'(a A, %d*tor&. Tu-%r#u(o&*&. A
#o'pr%)%n&*$% #(*n*#a( r%,%r%n#%. Saund%r& E(&%$*%r0 1223. p. 454657.8
Resection Surgery
The therapeutic surgical goal in pulmonary tuberculosis is to e%sice all gross disease,
wheter by wedge or segmental resection .in some case1, lobectomy or pneumonectomy.
5esion amenable to wedge resection must be less than # cm in ma%imum diameter, and
either be located in the peripheral one-third of lung parenchyma or be close to a ma-or
fissure. <or refractory */0-TB that is localiAed, a timely pulmonary resection maybe the
only way to prevent further pulmonary deterioration and preserve lung function.
3neumonectomy should be performed only if the entire lung is involved or if the remaining
lung will be too small in volume to e%pand to fill the hemithora%.
2
It is wise to consider a
patient for pneumonectomy even if a lobectomy only is contemplated becauase the latter
may be found to be technically not feasible at operation.
=

Non Resection Surgery
&on resection surgery is mainly indicated in TB patient presents with empyema,
either as a complication of the disease nor from previous surgery.
2, "-7
*any surgical
techni4ues have been employed in the treatment of empyema including debridement via
,$T6, decortication, thoracoplasty and open window thoracostomy.
/ebridement via ,$T6 has gained popularity from the mid 1::s, and its success
rate ranges from 7!) to :#).
1=
It is the procedure of choice at present, regardless the
aetiology of empyema if it is diagnosed early.
2
The success rate of ,$T6 debridement very
much depends on the stage of empyema and the more patients in the organiAing phase the
higher the failure rate.
1=
Dstablished fibrosis will re4uired a thoracotomy.
2

(
/ecortication is the method of choice when the underlying lung is unable to e%pand
due to the thic' inflammatory coat and the patient is fit for ma-or surgery. /ecortication has
been shown to substantially improve both vital capacity and forced e%piratory volume in the
first second.
7, 1=
$ 3lombage is sometimes neccesarry to fill the cavity created after
decortication. $ir plombage, muscle plombage as well as omental plombage are the
options.
7

Thoracoplasty entails remodeling of the osteomuscular wall of the thoracic cage in
order to control the underlying inflammatory process. In thoracoplasty, partial decostaliAation
of the thoracic cage is underta'en to obliterate persistent pleural space. Bhenever lung is
unli'ely to e%pand because of e%tensive disease or multiple broncho-pleural fistula,
thoracoplasty is an appropriate intervention.
"
Thoracoplasty with apicolysis for treatment
failure cases when they were not suitable for lung resection, with occasional success in
achieving the sputum-negative state.
(
Epen window thoracostomy, well 'nown as Dloesser-type techni4ue
7
, is performed in
debilitated patients when thoracoplasty is not an alternative and when ,$T6 has failed to
control the disease.
1=
It can be done as a definite procedure with intent to cure, as a last
resort procedure when other treatment has failed to achieve a relatively stable state or as a
preliminary procedure prior to definite treatment.
7, 1=
Bith this techni4ue, mechanical toilet is
fasilitated. $lthough this approach is successful in controling infection and the underlying
bronchopleural fistula, a decrement of lung function is the price paid.
2

&on resection surgery is also done in patient who is unfit for resection surgery. In this
cases, cavernostomy according to *onaldi or Teramatsu is performed.
7
In this procedure,
the caverne is opened and locally debrided. The connection between bronchus and caverne
is then sutured. In *onaldi cavernostomy uses no muscle plug, whereas Teramatsu uses
intercostal or other surrounding muscle as plug to cover the e%isting hole.
7

PERIOPERATI!E ASSESSMENT
There are some well-established pre-re4uisites before a patient is ta'en up for
surgery. $ detailed discussion is held with the patient and his relatives. This should include a
fran' tal' about the natural course of the disease in the absence of any surgical intervention
and the e%act aim and ob-ective of the proposed surgery in a given case. 0is's of surgery
and anesthesia are carefully e%plained and also the short term and long term results, if
surgery is successful.
"

It is of vital importance that a patient of pulmonary TB has ta'en an ade4uate course
of $nti Tuberculosis Treatment .$TT1 before the surgical decision is ta'en. Dven an episode
of massive hemoptysis as a presenting feature of pulmonary TB in a non-treated case is
rarely an indication of surgical intervention
"
. 3ulmonary resection can be successful for
patients with */0-TB who have few or incomplete sensitive drugs, however, vigorous
individualiAed perioperative chemotherapy should be done. Therefore, postoperative
individualiAed chemotherapy is mandatory for */0-TB patients even after removal of the
most grossly involved lesions, to ensure long-terms cure.
!

9eneraly accepted timing of sugery is after # months of carefully prescribed 2nd line
$TT, achieving optimal bacterial supression at the time of surgery yet avoding delaying
surgery to a point where the bacillary load is at a perilious high
1
. Ideally, patient will be
7
rendered sputum culture-negative prior to surgery. If positive sputum cultures persist, the
patient probably has */0-TB. $ more urgent operation may be re4uired for massive
haemoptysis or broncho-pleural fistula.
2

3atients are urged to stop smo'ing at least three wee's before surgery in order to
ensure better post-operative results. 3ost-operative physiotherapy e%ercises li'e deep
breathing, coughing and shoulder e%ercises are taught to the patient in the pre-operative
period while forewarning him or her about a certain amount of e%pected post-operative pain.
The patient should be as 8dry as possible before surgery, meaning thereby that sputum or
pus production .in cases of empyema1 should be minimiAed by appropriate measures li'e
antibiotics, postural drainage, respiratory e%ercises, steam inhalation and nebuliAers etc.
6ome of these patients are 4uite wea' and depleted nutritionally. Their nutritional status is
built up before surgery by rest and ade4uate diet ensured by hospitaliAation.
"

Ether important aspects of TB surgery are assessment of operative ris' and
pulmonary functional reserve.
!
3atient considered for surgery must have relatively localised
disease and ade4uate lung functions, which migh be inter-related. 3atient with advanced
disease rarely have satisfactory lung function.
=
5ung resection leads to a decrease in the
pulmonary vascular bed and an increase in the possibility of acute right heart failure. In
addition, inflammation in the thora% and lungs after surgery induces acute respiratory
distress syndrome .$0/61. *oreover, 5obectomy and pneumonectomy for TB is considered
to be a high-ris' procedure and technically haAardous because the thora% is filled with
adhesions, scarring, and an area of chronic sepsis. +illar dissection may pose a significant
problems. The violation of diseased parenchymal cavity during surgery, cavity lesion eroding
to the pleura, escessive bleeding and other medical problems including poor nutrition may
afect the ris' of surgery. Blood loss for TB surgery was estimated # times larger thant that
during lung cancer surgery.
!
To prevent acute post-operative complications, namely, $0/6,
right heart failure or hypo%ia, several proposals of preoperative assessments for lung
resection were intended.
3rior to surgery an estimate of respiratory function in all # areas> mechanics,
parenchymal function and cardio-pulmonary interaction should be made for each patient.
These data can then be used to plan intra- and post-operative management and also to alter
these plans when intraoperative surgical factors necessitate that a resection becomes more
e%tensive than foreseen.
1!
The forced e%piratory volume in one second .<D,1.1 and the
vital capacity .,;1 and lung volumes were measured using spirometry. 6plit-function studies
to estimate the predicted postoperative .ppo1 and the predicted contralateral .pcl1 values of
various parameters were performed. <D,1.-ppo F preoperative <D,1. G .1 H functional
contribution of the parenchyma to be resected1, while <D,1.-pcl F preoperative <D,1. G
fraction of pulmonary blood flow of the contralateral side.
1:
If a patient has a ppo<D,1 I ")
it should be possible for that patient to be e%tubated in the operating room at the conclusion
of surgery assuming the patient is alert, warm and comfortable .J$Ba;K1. If the ppo<D,1 is
2-#) and e%ercise tolerance and lung parenchymal function e%ceed the increased ris'
thresholds then e%tubation in the operating room should be possible depending on the status
of associated diseases. Those patients in this subgroup who do not meet the minimal criteria
for cardio-pulmonary and parenchymal function should be considered for staged weaning
from mechanical ventilation post-operatively so that the effect of the increased o%ygen
=
consumption of spontaneous ventilation can be assessed. 3atients with a ppo<D,1 2-#)
and favorable predicted cardio-respiratory and parenchymal function can be considered for
early e%tubation if thoracic epidural analgesia if used. Etherwise, these patients should have
a post-operative staged weaning from mechanical ventilation.
1!
0esults in surgery for TB improve if attention to detail is given in post-operative period.
Initial management is ideally done in an Intensive ;are ?nit .I;?1. $ntibiotics and pain'illers
are routinely given. Blood is transfused as per re4uirements. 0espiratory e%ercises should
be encouraged and all measures to relieve pain should be ta'en. Incentive spirometry is a
useful tool to achieve these aims. ;are of the chest tubes is an essential ingredient of this
care and they should be removed only when their output has completely stopped.
"
;ontinuation of drugs for 1!-2" months postoperatively seems reasonable.
1

COMPLICATIONS
$s a result of careful patient selection, and improvement in thoracic anesthesia and
anti-TB agents, postoperative morbidity and mortality have dropped dramatically after lung
resection for */0-TB. $t the present time, postoperative mortality after lung resection for
*/0-TB varies from ) to #.#) and the incidence of complication from 12) to #), mainly
B3<, empyema, postoperative bleeding, respiratory failure and infections. The Laplan-*eir
survival analyses from Bang et al .<ig 21 revealed that endobronchial TB and
pneumonectomy both reduced disease free survival.
12
F*+ 1. ap(an6M%*r %&t*'at%& o, d*&%a&% ,r%% &ur$*$a( -%t9%%n :(%,t8 pat*%nt 9*t) t)% ,our
d*,,%r%nt typ%& o, d*&%a&% :p ; 2.2578 and :r*+)t8 pat*%nt 9*t) pn%u'on%#to'y and (o-%#to'y
:p;2.2158 :Wan+ H, L*n H, <*an+ G. Pu('onary r%&%#t*on *n t)% tr%at'%nt o, 'u(t*dru+6
r%&*&tant tu-%r#u(o&*&.
Ann T)ora# Sur+ 122=0=>.5>?2648
B3< is perhaps the most morbid complication associated with the treatment of */0-
TB, with the incidens ranges from ) to 17.=).
12
6hiraishi et al encountered a higher
incidence of bronchial stumps complications in patient with &T* infections than in patients
with */0-TB. $s &T* disease progresses, it spreads from the main cavity or bronchiectatic
lesions transbronchially along the draining bronchus. 6ince the right main bronchus is
shorter that the left main bronchus, the pro%imal main bronchus is more prone to be affected
on the right side. ;onse4uently, surgeons are more li'ely to be compelled to divide the main
bronchus at its deseased site when doing a right pneumonectomy.
1(

!
To prevent B3<, a vasculariAed pedicle muscle, pleura or pericardial flap is most
fre4uently used for bronchial stump reinforcement. 3reservation of blood supply to the
bronchus was crucial to the healing of the bronchial stump, and as such warned against
disecction to the point of devasculariAation of the bronchus and specifically against using
electric coagulation around the bronchus. $ multivariate analysis conduct by Bang et al
found that wrapping bronchial stump with pedicled pleura or pericardium could significantly
reduce the incidence of postoperative B3<.
12

CONCLUSION
6urgery, with good selection of patient and ade4uate perioperative management,
might serve as one of the armamentarium in the management of patient with pulmonary
tuberculosis, especially the one with */0-TB and complications of the disease.
BIBLIOGRAPHY

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