MANAGEMENT OF PULMONARY TUBERCULOSIS: IS THERE PLACE FOR SURGERY? Piotr Yablonskii

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1 MANAGEMENT OF PULMONARY TUBERCULOSIS: IS THERE PLACE FOR SURGERY? Piotr Yablonskii

2 MANAGEMENT OF PULMONARY TUBERCULOSIS: IS THERE PLACE FOR SURGERY? Piotr Yablonskii

3 Tuberculosis - is an infectious disease, but its threat remains high - there are no absolutely effective drugs

4 «We should be able to cure almost all our TB patients without surgery» Sir John Crofton

5 The worldwide problem!!! The number of new cases of tuberculosis from 2012 to 2015 increased from 8.7 to 10.4 million; 1.8 million people died from TB

6 The worldwide problem of MDR-TB!!! Globally in 2015, there were an estimated new cases of multidrug-resistant TB (MDR- TB). Globally, data show an average cure rate of only 52% for treated MDR-TB patients. In 2015, an estimated 9.5% of people with MDR- TB had extensively drug resistant TB (XDR-TB). XDR-TB patients had a treatment success rate of 28% in 2013

7 HIGH BURDEN COUNTRY LISTS FOR TB Total New TB Cases in the HBCs = 7,383,

8 Percentage of successful treatment of multidrugresistant pulmonary tuberculosis in European countries in 2012 European Centre for Disease Prevention and Control/WHO. Regio nal Office for Europe.

9 Surgery for pulmonary TB is modern option for treatment MDR/XDR pulmonary TB Subotic, D., Yablonskiy, P., Sulis, G., Cordos, I., Petrov, D., Centis, R.,... & Migliori, G. B. (2016). Surgery and pleuro-pulmonary tuberculosis: a scientific literature review. Journal of Thoracic Disease, 8(7), E474.

10 Current publications on TB surgery ontent/complexpleuropulmonary-infections

11 Surgical goals Elimination of MTB excretion Closure of persistent cavities Elimination of complications (airway bleeding, spontaneous pneumothorax, empyema etc.)

12 Features of pulmonary tuberculosis surgery Cavity in lungs Dense pleural adhesions Calcified lymph nodes in the hilum Yen Y. T. et al. The role of video-assisted thoracoscopic surgery in therapeutic lung resection for pulmonary tuberculosis //The Annals of thoracic surgery Т С

13 Features of surgery for tuberculosis (adhesions)

14 Minimally invasive pulmonary resections are the current trend in TB-surgery April 2017

15 Number of VATS procedures for pulmonary tuberculosis increased ,2 36,4 Thoracotomy 60 65,2 59,3 57, ,8 63,6 34,8 40,7 42, VATS

16 Features of surgery for tuberculosis (adhesions) Uniportal pneumolisis Robotic pneumolisis

17 Features of surgery for tuberculosis (hilum)

18 Dynamics of Minimally Invasive Surgery Rate of VATS operations for pulmonary TB: Segmentectomy Lobectomy 100 % 100 % 90 % 90 % 80 % 80 % 70 % 70 % 60 % 60 % 50 % 50 % 40 % 40 % 30 % 30 % 20 % 20 % 10 % 10 % 0 % % thoracotomy VATS RATS thoracotomy VATS RATS

19 Uniportal VATS left apical tri-segmentectomy

20 Robot-assisted thoracoscopic left upper lobectomy for MDR pulmonary TB

21 Single center experience in robotic surgery for pulmonary tuberculosis Yablonskii, P., Kudriashov, G., Vasilev, I., Avetisyan, A., & Sokolova, O. (2017). Robot-assisted surgery in complex treatment of the pulmonary tuberculosis. The Journal of Visualized Surgery, 3(2).

22 What is the best surgical tactic? Different approach for: -Single-sided TB -Bilateral TB

23 Chance of clinical cure in patients with pulmonary tuberculosis: focus on surgical methods Unpublished series

24 Mortality and clinical cure in patients with pulmonary tuberculosis: focus on surgical methods

25 Can we help this patient?

26 Surgical treatment step by step Step 1 Step 2 Group 1 Local bilateral lung affection prevailed Anatomic lung resections (LR) Anatomic lung resections (LR) Group 2 Total unilateral lung destruction Ipsi-lateral pneumonectomy Selective thoracoplasty (STP) and/or valve bronchial blocade (VBB) Group 3 Advanced sub-total cavitary TB No utility for lung resections. Bilateral VBB and/or STP

27 Bilateral TB surgery: results Smear conversion Culture conversion 100,0 85, MDR 57,1 66,7 42,1 0 XDR 53, MDR 100 XDR 70,0 64,3 Unpublished series Group I Group II Group III Group I Group II Group III

28 Adjunctive thoracic surgery may improve treatment outcome for bilateral cavitary multidrug-resistant and extensively drug-resistant tuberculosis

29 Conclusion The surgical option should be implemented in a routine algorithm for treating a patient with pulmonary tuberculosis Minimally invasive surgery is the preferred approach for most procedures Future trials should be conducted to elaborate indications for surgical treatment

30 ONE WAY ANOTHER WAY

31 Thank you for your attention!