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SURGICAL MANAGEMENT OF TUBERCULOSIS. Paul Bolanowski, MD Associate Professor of Surgery Division of Cardiothoracic Surgery UMDNJ-NJ Medical School. HISTORY OF TUBERCULOSIS. Scourge Of Early Humanity Hippocrates – Phthisis Disease characterized by progressive weight loss and wasting

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surgical management of tuberculosis

SURGICALMANAGEMENTOF TUBERCULOSIS

Paul Bolanowski, MD

Associate Professor of Surgery

Division of Cardiothoracic Surgery

UMDNJ-NJ Medical School

history of tuberculosis
HISTORY OF TUBERCULOSIS
  • Scourge Of Early Humanity
    • Hippocrates – Phthisis
      • Disease characterized by progressive weight loss and wasting
    • Romans – Consumption
      • Consumed its victims
    • Schonlein - Tuberculosis
      • First to use term based on autopsy findings
surgical history
SURGICAL HISTORY
  • 1821 - Carson - collapse therapy
    • 1925 - Alexander
  • 1869 - Simon - thoracoplasty
    • 1920 - Sauerbruch & Alexander
  • 1882 - Block - first resection
  • 1891 - Tuffier – first partial resection
  • 1934 - Freelander – first lobectomy
collapse therapy
COLLAPSE THERAPY
  • Pneumothorax
  • Phrenic nerve crush
  • Pneumoperitoneum
  • Extrapleural pneumolysis
    • Plombage thoracoplasty
    • Extraperiosteal
  • Thoracoplasty
efficacy of collapse therapy
EFFICACY OF COLLAPSE THERAPY
  • 1880 - 300 deaths/100,000
  • 1935 - 69 deaths /100,000
  • Plombage thoracoplasty
    • Sputum negative - 30-60%
  • Thoracoplasty
    • Closure of cavity in 80%
    • Mortality 10%
surgical indications 1
SURGICAL INDICATIONS - 1
  • Failure of medical treatment
    • Cavity with persistently positive sputum
      • Resistant strains
        • MDR-TB
        • XDR-TB
      • Atypical organisms
        • M. kansasii - surgery infrequent
        • M. avium - localized – lobectomy
  • Solitary nodule
    • Lung carcinoma vs. tuberculoma
surgical indications 2
SURGICAL INDICATIONS - 2
  • Massive or recurrent hemoptysis
    • Etiology
      • Bronchial collateral circulation
        • Rasmussin aneurysm
        • Aspergilloma
        • Bronchiectasis
    • Treatment
      • Embolization
      • Surgery
massive hemoptysis 1
MASSIVE HEMOPTYSIS - 1
  • Definition
    • Based on amount and duration
      • MASSIVE 600 ml WITHIN 16 hrs
      • 200ml, >300ml, >500ml, >600ml / 24-48hrs
    • Based on threat to life
      • Acute airway obstruction
      • Shock
      • Persistent hemoptysis despite good medical management
massive hemoptysis 2
MASSIVE HEMOPTYSIS - 2
  • Position patient
  • Chest x-ray
  • Bronchoscopy
    • Localize site
    • Intubation
  • Bronchial arteriography
  • Surgery
    • Resection
    • Videoendoscopic thoracoscopy
bronchial arteriography
BRONCHIAL ARTERIOGRAPHY
  • Advantages
    • Localize site
    • Control bleeding by embolization
    • Prevent contamination of normal lung
    • Buy time to improve pulmonary function
    • Less blood loss during surgery
  • Disadvantages
    • Spinal cord paralysis
    • Temporary
      • Acute control - 75% effective
      • Rebleed rate - 43%
slide15

MASSIVE HEMOPTYSIS

  • Surgical results
    • Massive
      • 600ml in < 16hrs 18% MORTALITY
  • Conservative management
    • Massive
      • 600ml or more in 16hrs – 75% MORTALITY
      • 600ml or more in 48hrs – 54% MORTALITY
  • Embolization + surgery
    • Acute control in 75%
    • Mortality 7-9%
surgical indications 116
SURGICAL INDICATIONS - 1
  • Bronchopleural fistula
    • Complication of disease
      • Treatment
        • Lobectomy or pneumonectomy
    • Complication of surgery
      • Treatment
        • Immediate chest tube
          • Pneumonectomy
        • Thoracotomy with closure using intercostal muscle flap
surgical indications 217
SURGICAL INDICATIONS - 2
  • Empyema
    • Acute
      • No chest tube unless respiration compromised
    • Chronic
      • Decortication
        • Trapped lung
        • Muscle transposition
surgical indications 3
SURGICAL INDICATIONS - 3
  • Destroyed lung or lobe
    • Surgical resection
  • Pott’s abscess
    • Drainage
    • Spine reconstruction
  • Mycetoma (aspirgeloma)
    • Recurrent hemoptysis
      • Resection
surgical indications 4
SURGICAL INDICATIONS - 4
  • Pericarditis
    • Acute
      • With or without tamponade
        • Pericardial window
    • Chronic
      • Constrictive pericarditis
        • Total pericardioectomy
          • Cardiopulmonary bypass
    • Lymphadenitis
      • Cervical (scrofula)
      • Mediastinal
        • Drainage
surgical indications 5
SURGICAL INDICATIONS - 5
  • Destroyed lung or lobe
    • Surgical resection
  • Pott’s abscess
    • Drainage
    • Spine reconstruction
  • Mycetoma (aspirgeloma)
    • Recurrent hemoptysis
      • Resection
surgical indications 6
SURGICAL INDICATIONS - 6
  • Pericarditis
    • Acute
      • With or without tamponade
        • Pericardial window
    • Chronic
      • Constrictive pericarditis
        • Total pericardioectomy
          • Cardiopulmonary bypass
    • Lymphadenitis
      • Cervical (scrofula)
      • Mediastinal
        • Drainage
pre op management 1
PRE-OP MANAGEMENT - 1
  • Medical management
    • Nutrition
    • Atypical mycobacterium
      • M. avium
        • Perioperatively – ethambutol, rifabutin, biaxan, and amikacin
        • Operate when sputum converts to negative
      • M. abscessus
        • Pre-op – imipenem & amakacin for 2 months
        • Post-op – same drugs for 4 months
      • M. kansasii – surgery infrequent
pre op management 2
PRE-OP MANAGEMENT - 2
  • Multi-drug resistant tuberculosis
    • Pre-op
      • 2-3 months of 3 or 4 drugs they have never received
    • Post-op
      • 18 to 24 months of therapy
    • These patients must be followed diligently post-op for recurrence
pre op management 3
PRE-OP MANAGEMENT - 3
  • PET-CT scan
    • Determine extent of disease
  • Bronchoscopy
    • Determine if line of transection is disease free
  • Arteriography
    • To control bleeding pre-operatively
    • To decrease blood loss at time of surgery
post op management
POST-OP MANAGEMENT
  • Immediate
    • Intensive care unit
      • Isolation
      • Room with air exchange
      • Ventilator
      • Collaborative medical management
        • Anti-tuberculous drugs
      • Length of stay
  • Long term