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Interact CardioVasc Thorac Surg 2009;8:334-337. doi:10.1510/icvts.2008.191619
© 2009 European Association of Cardio-Thoracic Surgery
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Institutional report - Thoracic non-oncologic

The role of surgery in the management of pleuropulmonary tuberculosis – seven years' experience at a single institution{star}

Csaba-Antal Kerti*, Iris Miron, Gabriel V. Cozma, Ovidiu N. Burlacu, Calin P. Tunea, Voicu T. Voiculescu, Eustatiu F. Memu and Alexandru C. Nicodin

Municipal Clinical Emergency Hospital Timisoara, Romania

Received 28 August 2008; received in revised form 26 November 2008; accepted 1 December 2008

{star} Presented at the 22nd Annual Meeting of the European Association for Cardio-thoracic Surgery, Lisbon, Portugal, September 14–17, 2008.

*Corresponding author. Victor Babes Clinical Hospital of Infectious Diseases and Pneumology, Str. Gheorghe Adam nr. 13, 300310 Timisoara, Timis, Romania. Tel.: +40740153811; fax: +40256431437.

E-mail address: csaba.kerti{at}gmail.com (C.-A. Kerti).


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Conference discussion
 References
 
Pleuropulmonary tuberculosis (TB) is a relatively frequent condition (the incidence of (TB) was 176/100,000 in our county in 2004) and some of these patients with TB are undergoing surgical interventions. The authors share their experience in surgical treatment of pleuropulmonary tuberculosis, based on minimal invasive techniques such as VATS and filling the residual cavities with muscle or skin-muscle grafts. The authors are retrospectively revising 144 patients between 1 January 2001 and 31 December 2007 who underwent surgical treatment for tuberculosis in this period. Two hundred and thirteen surgical procedures were performed for pleuropulmonary tuberculosis, representing 4% of all the procedures done in the department. For most of the patients the etiological diagnosis was not established until the operations, all the patients were sputum-negative. The diagnoses at the admittance were: pulmonary nodules or tumors (42 patients), pleural collections (46), pleural thickening and post-tuberculosis syndromes (46), fibrocavitary tuberculosis (6), and tuberculous pericarditis (4). Of all the procedures applied, 14 were pulmonary resections, 50 atypical (wedge) resections, 70 video-assisted thoracic surgery (VATS) procedures, and nine patients needed muscle or skin-musle flap for residual pleural cavities. Eleven patients (7.6%) had to undergo secondary surgery due to complications. No in-hospital mortality was registered. The mean hospitalisation period was 10.1±4.2 (S.D.) days.

Key Words: Pleural/pulmonary tuberculosis; Tuberculosis surgery


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 Conference discussion
 References
 
Until recently tuberculosis (TB) was often considered of historical significance. However, there are serious reasons for concerns regarding TB recrudescence – the ongoing HIV epidemic, the emergence of multi-drug-resistant (MDR) and extensively drug-resistant (XDR) Mycobacterium Tuberculosis strains, the growing indigent population in some areas, and last, but not least, workforce and population migration.

The 27 countries of the EU, and Andorra, Iceland, Israel, Norway and Switzerland (West, no data from Monaco and San Marino), reported 89,032 TB cases in 2006. TB notification rates (17/100,000 overall) were highest in Romania (128/100,000) among the European countries in 2006. In our county (Timis County), TB notification rates are even higher than the Romanian average, as shown in Table 1.


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  		Table 1 TB incidence (cases/100,000 population) in Romania and Timis County 2004–2007

 
The role of surgery in the management of pleural/pulmonary TB would be: (1) in establishing the correct diagnosis after failed attempts with other approaches; (2) in treating MDR TB and medical failure cases; (3) in treating TB or previous surgery complications [1].

Indications for surgery comprise: complications resulting from previous surgery, failure of medical therapy (progressive disease, lung destruction, and left bronchus syndrome, lung gangrene, drug resistance, aspergillosis), surgery for diagnosis (pulmonary lesions or mediastinal adenopathy of unknown cause), complications of scarring (massive hemoptysis, cavernoma, lung cancer, tracheoesophageal or bronchoesophageal fistula, bronchiectasis, extrinsic airway obstruction by tuberculous lymph nodes, endobronchial tuberculosis and bronchostenosis, middle lobe syndrome), extrapulmonary thoracic disease (tuberculosis of the heart and great vessels, vascular malformations, pericarditis, cold abscesses and osteomyelitis of the chest wall, Pott's disease), pleural tuberculosis (pleural effusions including pleural thickening, bronchopleural fistula), and infections with Mycobacteria other than Tubercle Bacilli [2].


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 Conference discussion
 References
 
Between January 2001 and December 2007, 144 patients underwent surgical procedures for pulmonary and/or pleural tuberculosis. All the patients were sputum smear-negative for acid-fast bacilli (sputum smear-positive patients are treated in other, specialized departments). Four patients with pleuropericarditis and ten patients with mediastinal adenopathy of unknown etiology were also included in this study. Patients with lung cancer and known history of TB were not included in this study.

Ninety-seven men and 47 women entered the study (M:F=2.1:1). The mean age was 44±14.7 (S.D.) years, range 16–79 years.

Most of the patients (107 patients or 74%) had no etiological diagnosis at their admittance; they were referred to us mostly with the diagnoses of pulmonary nodules or tumors or pleural collections of unknown etiology. The remaining 37 patients (26%) with known history of TB have received complete anti-TB chemotherapy cure(s) according to the Romanian National Program of Tuberculosis Control by the time of their admission to our clinic.

The diagnoses at the admittance for which surgery was indicated are shown in Table 2.


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  		Table 2 Diagnoses at the admittance

 
According to a standard protocol, previous to the operation, all the patients had routine laboratory analyses; smears for acid-fast bacilli, pulmonary function tests, cardiology and anesthesiology evaluation, and all the patients were informed about the ensuing operation and risks and signed an informed consent form for surgery. Most of the patients (131 patients or 91%) had preoperative CT-scan, and the majority of patients (93 or 65%) had bronchoscopy before the surgery.

Intraopertive samples were taken and sent for histopathological examinations (native or frozen sections), however, these samples did not change the fact that the majority of the patients had not had a confirmed diagnosis until the operation.

After having been discharged, all the patients were referred to a pulmonologist for anti-TB chemotherapy.

We retrospectively reviewed these smear-negative surgical TB cases in the terms of primary surgical procedures, postoperative morbidity and mortality, management of the complications, re-operations, and length of stay. No long-term follow-up was possible. Clinical data are reported as mean±standard deviation (S.D.) with the indication of range. The protocol of the current study was approved by the Ethical Committee of Municipal Clinical Emergency Hospital Timisoara.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 Conference discussion
 References
 
One hundred and eighty-one surgical procedures were primarily performed on 144 patients. Thirty patients underwent two distinct surgical procedures in the same operation (for example decortication and lobectomy). Seven patients had an initial tube pleurostomy and afterwards underwent a VATS procedure for pneumothorax – these VATS procedures were not considered re-interventions. The initial surgical procedures are detailed in Table 3.


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  		Table 3 Primary surgical procedures

 
Seventy-four patients underwent thoracotomy procedures. There were 6 pneumonectomies for destroyed lung (5 left and 1 right-sided), 8 lobectomies (5 upper right and 3 upper left lobectomies for fibrocavitary TB – 4 cases – and for aspergilloma – 4 cases). Parenchyma-sparing atypical (wedge) resections were favored for pulmonary nodules, in all cases intraoperative sampling of the lesion was done that showed the non-cancerous nature of the nodule. Wedge resections were also done for previously non-imaged pulmonary lesions additionally to the main procedure. Decortications were performed for pachypleuritis and trapped lung, chronic empyemas and multiloculated pleural collections, and additionally to other procedures, when decortication of the thick pleura represented the first step to reach the pulmonary lesion. Six myoplasties using latissimus dorsi muscle and four thoracoplasties were done as primary space-filling methods.

Seventy patients underwent VATS procedures. VATS procedures were used in all the cases where the main objective was to establish a correct diagnosis (biopsies of the pleural, pulmonary mediastinal or pericardial lesions), but also with therapeutic goals: wedge resections, decortications, pleuro-pericardial windows.

Pathology examination of the specimens yielded evidence of TB lesions or TB sequelae in all the cases.

Eleven patients had to undergo secondary surgery due to postoperative complications (7.6% of all the patients). Ten of these patients had undergone open thoracotomy procedures (13.5% of the thoracotomy group). One patient had postoperative complications in the VATS group (1.4%). Very high morbidity was met in the pneumonectomy patients. Three patients (50%) out of six presented complications (1 postoperative hemorrhage with residual clot, 2 empyemas with bronchial stump insufficiency and 1 empyema without fistula).

The above-mentioned postoperative complications are detailed in Table 4.


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  		Table 4 Postoperative complications for which secondary surgery was done

 
The management of the postoperative complications required 32 surgical procedures, as shown in Table 5.


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  		Table 5 Surgical procedures used in the management of postoperative complications

 
The length of in-hospital stay was 10.1±4.2 days (range 4–28 days) for the whole lot; 6.5±1.9 days (range 4–15 days) for the VATS group; and 13.5±2.8 days (range 8–28 days) for the thoracotomy group.

No in-hospital mortality was registered.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
Conference discussion
 References
 
Tuberculosis is still a prevalent disease in many areas of the world; unfortunately Romania is one of the countries with very high incidence of the disease. The worldwide growing numbers of MDR TB cases and the emerging cases of XDR TB have redefined the role of surgery in tuberculosis. Besides the drug-resistant cases however, a significant number of patients with undiagnosed or diagnosed TB need surgical care [1–5].

Among the 104 open thoracotomy procedures, we prefer to do sublobar resections when cancer is excluded by preoperative or intraoperative histopathological examination in order to save as much parenchyma as possible. Therefore, atypical (wedge) resections were the most numerous in these cases with a fairly low complication rate of 8%. However, for extensive lesions that interested the whole lobe with nearly no functional parenchyma remaining we performed lobectomies; as well as for destroyed lungs pneumonectomies.

Pneumonectomies were done through classic posterolateral thoracotomies. Bronchial closure was done with a stapling device, and the bronchial stump was routinely enforced with mediastinal fat pad and by adjacent tissues in all the cases. A very high rate of postoperative major complications occurred – 3 patients out of 6 presented unfavorable course immediately after pneumonectomy: clotted hemothorax, 2 empyemas with fistula and 1 empyema without fistula.

Most authors relate acceptable mortality rates in pneumonectomies: 2.5% for Pomerantz and associates [4] and Conlan and colleagues [8] to 7.6% for Reed [9]. However, the reported morbidity rates are high varying between 25 and 38% [7–10], the two major complications being postpneumonectomy empyema and brochopleural fistula.

The management of postpneumonectomy complications is still debated, featuring a wide range of procedures in order to close the bronchial stump, to sterilize the residual cavity and to obliterate it [6–10]. The management in our cases was: one case with clotted hemothorax underwent VATS revision; however, he afterwards developed empyema without bronchopleural fistula that was resolved by re-drainage and irrigation with antiseptic solutions. The two other cases that developed empyemas with bronchial stump dehiscence were subject to re-operations, one case was resolved by revision of the bronchial stump and thoracoplasty, and in one case first an open window thoracostomy was performed and afterwards a contralaterally harvested pedicled latissimus dorsi and serratus anterior muscle-skin graft was transferred to affected side (i.e. left) for filling out the residual postpneumonectomy cavity.

Lobectomies presented a complication rate of 12.5% in our series, in a case of upper right lobectomy for aspergilloma.

For complex pulmonary aspergillomas (5) we performed four lobectomies. In one case with poor general status and severe pulmonary dysfunction we chose the one-stage cavernostomy and myoplasty procedure, similarly to the procedures reported by Gebitekin et al. [11]. The outcomes were favorable, with only one patient presenting a residual infected pleural space after right upper lobectomy, that was resolved by an initial re-drainage and afterwards by a partial upper thoracoplasty.

Thoracoplasties were performed in our institution at the beginning of the studied period; recently plombage procedures with muscle flaps are favored for filling out dead thoracic spaces and reinforcing bronhial stumps. These procedures are considered less mutilating and offer a superior esthetical outcome. Latissimus dorsi and serratus anterior muscles were used similarly to other authors' experience [12] either as primary procedures or for managing postoperative complications.

VATS approach for surgical TB is increasingly used either for its diagnostic or therapeutic role [1, 13–15]. Seventy patients in our study underwent VATS procedures. Pleural biopsy was the most frequent procedure, followed by mediastinal biopsies, wedge resections, decortications and pleuro-pericardial window. While the first enumerated procedures had a primary diagnostic purpose, the latter ones had mainly therapeutic aim although no patient from the VATS group had etiological diagnosis before the operation.

Pleural effusions remain undiagnosed in up to 25% of the cases after the usual investigations (biochemistry, cytology, bacteriology, needle biopsy of the pleura). This percentage of pleurisies of unknown etiology can be reduced to 4% by thoracoscopic biopsies. In a study [13] that compared various diagnostic modalities for TB pleural effusions, thoracoscopy was the most accurate tool for establishing the diagnosis with a diagnostic accuracy of 100% on histology and 76% positivity on culture.

In our series 36 pleural biopsies, 10 mediastinal biopsies and 4 pericardic biopsies yielded evidence of the tuberculous etiology of the underlying disease. Ten atypical (wedge) resections were performed for visible pulmonary lesions which were relatively small (nodules under 3 cm) and marginally situated. VATS decortication for multiloculated pleural effusions was done in ten cases. The pathological examination showed tuberculous lesions in the resected specimens. No conversion to classic open thoracotomy was needed in the studied lot. No in-hospital mortality was registered and only one patient out of 70 presented postoperative complications.

We had confirmation of TB in 21% of the pleural effusions of unknown etiology we had operated on; 61% turned out to be of malignant and 18% of inflammatory origin. In indeterminate empyema and pachypleuritis cases the percentage of TB etiology was 54%, 46% having been caused by non-specific infections. Of all the cases of pneumothoraces operated, 10% were secondary pneumothoraces due to TB infection and 90% were spontaneous. Mediastinal adenopathies were found of neoplastic origin in 72%, of inflammatory origin in 17%, and of tuberculous origin in 11% of the cases. For pulmonary nodules the figures were: 27% tuberculous, 69% malignant, and 4% benign lesions. These data are summarized in Table 6.


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  		Table 6 Percentage of TB results for indeterminate conditions

 
In spite of the recent achievements in thoracic surgery, dealing with tuberculosis remains a serious challenge for thoracic surgeons. TB surgery, although technically difficult, can be done with acceptable mortality rates but with high mortality figures. The management of the complications is often an arduous task.


   Conference discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Conference discussion
References
 
Dr. R. Santosham (Chennai, India): One of the common indications for surgery in our setup is recurrent massive hemoptysis, which we didn't see in your group. The second point is that we do have to operate on patients with aspergilloma, and even if you resect, the incidence of bronchopleural fistula is high. When we leave a cavity of aspergilloma and try to fill it up and try to suture it with intercostal muscle or pedicle, I personally feel in the long number of cases that the incidence of bronchopleural fistula will be certainly higher.

Dr. Kerti: Yes, the operative complication is pretty high. And, as I said, this is a study about sputum-negative cases because this is an emergency hospital and we are not allowed to manage TB-sputum-positive cases. And I know that the rate of complications, including bronchopleural fistula, in TB-positive cases and MDR cases is even higher.

As for the first question, we did not have massive hemoptysis cases in the studied period that required surgical management.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Conference discussion
 References
 

  1. Yim APC. The role of video-assisted thoracoscopic surgery in the management of pulmonary tuberculosis. Chest 1996;110:829–832.[CrossRef][Medline]
  2. Mehran RJ, Deslauriers J. Tuberculosis and atypical mycobacterial diseases. In: Patterson GA, Cooper JD, Deslauriers J, Lerut AEMR, Luketich JD, Rice TW, Pearson FG, honorary editor, Pearson's thoracic and esophageal surgery. Philadelphia: Churchill Livingstone; 2008:507–527.
  3. Treasure RL, Seaworth BJ. Current role of surgery in mycobacterium tuberculosis. Ann Thorac Surg 1995;59:1405–1409.[Abstract/Free Full Text]
  4. Pomerantz M, Brown JM. Surgery in the treatment of multidrug-resistant tuberculosis. Clin Chest Med 1997;18:123–130.[CrossRef][Medline]
  5. Furak J, Trojan I, Szoke T, Tiszlavicz L, Morvay Z, Csada E, Balogh A. Surgical intervention for pulmonary tuberculosis: analysis of indications and perioperative data relating to diagnostic and therapeutic resections. Eur J Cardiothorac Surg 2001;20:722–727.[Abstract/Free Full Text]
  6. Kir A, Tahaoglu K, Okur E, Hatipoglu T. Role of surgery in multi-drug-resistant tuberculosis: results of 27 cases. Eur J Cardiothorac Surg 1997;12:531–534.[Abstract]
  7. Massard G, Dabbagh A, Wihlm J-M, Kessler R, Barsotti P, Roeslin N, Morand G. Pneumonectomy for chronic infection is a high-risk procedure. Ann Thorac Surg 1996;62:1033–1038.[Abstract/Free Full Text]
  8. Conlan AA, Lukanich JM, Shutz J, Hurwitz SS. Elective pneumonectomy for benign lung disease: modern-day mortality and morbidity. J Thorac Cardiovasc Surg 1995;110:1118–1124.[Abstract/Free Full Text]
  9. Reed CE. Pneumonectomy for chronic infection: fraught with danger? Ann Thorac Surg 1995;59:408–411.[Abstract/Free Full Text]
  10. Schneiter D, Kestenholz P, Dutly A, Korom S, Giger U, Lardinois D, Weder W. Prevention of recurrent empyema after pneumonectomy for chronic infection. Eur J Cardiothorac Surg 2002;21:644–648.[Abstract/Free Full Text]
  11. Gebitekin C, Bayram AS, Akin S. Complex pulmonary aspergilloma treated with single stage cavernostomy and myoplasty. Eur J Cardiothorac Surg 2005;27:737–740.[Abstract/Free Full Text]
  12. Meyer AJ, Krueger T, Lepori D, Dusmet M, Aubert JD, Pasche P, Ris HB. Closure of large intrathoracic airway defects using extrathoracic muscle flaps. Ann Thorac Surg 2004;77:397–404.[Abstract/Free Full Text]
  13. Diacon AH, Van de Wal BW, Wyser C, Smedema JP, Bezuidenhout J, Bolliger CT, Walzl G. Diagnostic tools in tuberculous pleurisy: a direct comparative study. Eur Respir J 2003;22:589–591.[Abstract/Free Full Text]
  14. Rodriguez-Panadero F, Janssen JP, Astoul P. Thoracoscopy: general overview and place in the diagnosis and management of pleural effusion. Eur Respir J 2006;28:409–421.[Free Full Text]
  15. Gopi A, Sethu M, Madhavan SM, Sharma SK, Sahn SA. Diagnosis and treatment of tuberculous pleural effusion in 2006. Chest 2007;131:880–889.[CrossRef][Medline]

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