TB Intensive Tyler, Texas December 5-8, 2006

Transcription

1 TB Intensive Tyler, Texas December 5-8, 2006 Surgical Management of Tuberculosis James A. Caccitolo, MD December 7, 2006 Surgical Management of Tuberculosis James A. Caccitolo, M.D. Clinical Assistant Professo sor Cardiothoracic Surg rgery University of Texas Health Center, Tyler 1

2 Tuberculosis Phthisis Greek = decaying Scrofula swollen neck glands Consumption 1546 Hieronymus Fracastorius Theory of contagion 1679 Francisucus Delaboe Sylvius Opera Medica Tubercula = small knots 1821 Rene Laennec Totalitarium theory 1839 Johann Schonlein Tuberculosis 1868 Jean-Antoine Villemin confirmed infectious transmission Tuberculosis Robert Koch 1882 Berlin Physiologic Society Koch bacillus Demonstrated the bacillus responsible for the disease Established microbiologic principles Developed the first vaccine Alexander J. The collapse therapy of pulmonary tuberculos is, Springfield, Charles C. Thomas

3 Tuberculosis Early treatments Sanatoriums Rest Nutrition Mortality rates Advanced disease 69% Moderately advanced 23% Minimal disease 13% Surgical Management of Tuberculosis 18 th Century observation: Patients with spontaneous pneumothoraces had favorable evolution of the lesions Collapse - decreases ventilation inhibiting Mycobacterial metabolism Served as basis for development of first surgical interventions for treatment of tuberculosis 3

4 Surgical Management of Tuberculosis Carlo Forlanini The Collapse Therapy of Pulmonary Tuberculosis Collapse produces: fibrosis containment of disease prevention of spread to other areas Medical therapy could be supplemented with creation and maintenance of pneumothorax Alexander J. The collapse therapy of pulmonary tuberculos is, Springfield, Charles C. Thomas 1937 Surgical Management of Tuberculosis Pneumothorax Devices Air Sterile needle Water manometer Pressure and volume measurement Procedure repeated Every days x 3 years Adhesions limited collapse 4

5 Surgical Management of Tuberculosis Hans Christian Jacobeus The practical importance of thoracoscopy in surgery of the chest Surg Gynecol Obstet 1922; 34: 289 Advanced collapse therapy with surgical thoracoscopy Division of pleural adhesions Two incisions: scope, cautery Long procedure Usually required multiple sittings Alexander J. The collapse therapy of pulmonary tuberculos is, Springfield, Charles C. Thomas 1937 Surgical Management of Tuberculosis Eloesser and Brown 1925 Open division of adhesions Extraplerual approach Avoids tearing the lung Empyema, Fistulas Fey B et al: Traite de technique chirurg icale. Paris, L i brairies de L Academle de Medec ine

6 Surgical Management of Tuberculosis Stuertz 1912 Phrenicectomy Reduced respiratory movements small operation- popular Greatest effect on lower lobes Scalenectomy added to immobilize upper lobe Tearing of the nerve advocated to ensure destruction of collaterals Alcohol ablation Surgical Management of Tuberculosis Intercostal neurotomy open division alcohol ablation Vajda 1933 pneumoperitoneum 6

7 Surgical Management of Tuberculosis Thoracoplasty 1879 Estlander first to use the term thoracoplasty removal of the ribs to bring chest wall down to a lung which would not expand after drainage of an empyema 1885 de Cerenville resection of 2 or more ribs to collapse the chest over areas of apical tuberculosis Surgical Management of Tuberculosis Thoracoplasty 1890 Schede localized empyema resection of ribs, patietal pleura, periosteum, intercostal muscles, intercostal neurovascular bundles mutilating, unprotected heart, paresthesias, large wound 1907 Brauer and Freidrich single stage full length resection of ribs 2-9 including periosteum and intercostal muscles (40% mortality) 7

8 Surgical Management of Tuberculosis Thoracoplasty Alexander three stage thoracoplasty extrapleural eventually included first through tenth ribs done in stages to limit flail chest resection of posterior ribs and transverse process leave periosteum and neurovascular bundles Surgical Management of Tuberculosis 1934 Semb Extrafascial Apicolysis extrapleural division of adhesions between the pleural dome at the apex and the soft tissues around the base of the neck 8

9 Surgical Management of Tuberculosis Thoracoplasty Intrapleural Schede - resection of ribs, pleura, muscles and neruovascular bundles Heller, Kergin - preservation of intercostal muscles Horrigan and Snow - limited rib resection Extrapleural Alexander ribs only Semb extrafascial apicolysis Björk osteoplastic thoracoplasty Plombage Tuffier extrapleural plombage Sawamura extrafascial pneumoysis and plombage Andrews thoracomyoplasty Limited limited resection of ribs Surgical Management of Tuberculosis Plombage Tuffier popular in the 1950 s alternative to thoracoplasty Extrapelural dissection Collapse affected area Held by plomb Lucite balls 9

10 Surgical Management of Tuberculosis Plombage collapse obtained with one operation no physical deformity applicable to poor risk patients preserved lung function it was applicable to bilateral disease hospital stay was short reduced postoperative complications cured up to three-fourths of the patients Surgical Management of Tuberculosis Plombage Materials omentum fresh lipoma paraffin wax bone gauze sponge silk gelatin rubber balloons methyl-methacrylate Lucite balls oil Oleothorax 10

11 Surgical Management of Tuberculosis Plombage only cured 75% of patients infection mediastinal compression migration erosion malignancy Limited application today silastic tissue expanders Weissberg D. Weissberg D. Late complications of collapse therapy for pulmonary tuberculosis Chest. 120(3):847-51, 2001 Sep. Surgical Management of Tuberculosis Thoracoplasty Modern Indications: infected spaces after pulmonary resection apical spaces after lobectomy empyema after penumonectomy chronic empyema unrelated to resection apical empyemas (tuberculosis or pneumonia) infected space after pneumothorax aspergillosis tailored thoracoplasty with lung resection Not indicated in basilar spaces 11

12 Surgical Management of Tuberculosis Thoracoplasty Techniques Limited Subperiosteal rib resections preservation of first rib to maintain skeletal stability stripping of undersurface to allow apical collapse Muscle flap transposition Closure of bronchopleural fistulas Surgical Management of Tuberculosis Thoracoplasty Complications Disfiguring Paraesthesia Frozen shoulder Scoliosis 12

13 Surgical Management of Tuberculosis Primary treatment of tuberculosis Collapse Therapy Pneumothorax Thoracoscopy Phrenic nerve destruction Plombage Thoracoplasty Treatment of complications Pleural Space empyemas Flap drainage Thoracoplasty Surgical Management of Tuberculosis Samuel Robinson (1915) The treatment of chronic non-tuberculosis empyema Proc. Mayo Clinic (1915) adequate drainage obliteration of space U shaped incision 13

14 Surgical Management of Tuberculosis Leo Eloesser (1935) An operation for tuberculosis empyema Surg Gynecol Obstet 1935 U shaped incision - one way valve Resection of rib Sutured flaps to pleura and skin together Negative pressure maintained Lung expands to fill the space Surviving aspect of procedure is open drainage Surgical Management of Tuberculosis Eloesser flap 14

15 Surgical Management of Tuberculosis Open Thoracic Window Cllagett OT, Geraci JE J Thorac Cardiavasc Surg 1936; 45:141-5 Surgical Management of Tuberculosis Introduction of antibiotic therapy Primary treatment Medical - antibiotics Surgery adjunct for management of complications and antibiotic failures Development of endotracheal ventilation Lung resection techniques improved 15

16 Surgical Management of Tuberculosis Anatomical Lung Resection Lobectomy Pneumonectomy Segmentectomy Excellent way to eradicate disease Creates pleural space problems Surgical Management of Tuberculosis Tissue flap transposition Latissimus dorsi Serratus anterior Pectoralis major Rectus abdominus Omentum Latissimus dorsi m. 16

17 Surgical Management of Tuberculosis Tissue Flaps Used as pedicle grafts moved into the thorax window created limited rib resection fills space vascularized tissue coverage Surgical Management of Tuberculosis Previous Thoracotomy limits use of latissimus Muscle sparing incisions 17

18 Surgical Management of Tuberculosis Current Indications for Operation Multidrug resistant TB Infections other than M. tuberculosis Failed medical therapy Resection for diagnosis - cancer Destroyed lung, bronchiectasis Airway obstruction, endobronchial, compression Fistula broncopleural, tracheo-esophageal Massive hemoptysis (>600 cc/24hours) Trapped lung Complicated Cavity (bleeding, infection) Empyema Other thoracic involvement: heart, great vessels, pericardium Surgical Management of Tuberculosis Current Surgical Options Lung parenchyma Segmentectomy Lobectomy Penumonectomy Pleural space Tube thoracostomy Decortication Open drainage Thoracoplasty Pneumoperitoneum Tissue transposition 18

19 Surgical Management of Tuberculosis Preoperative evaluation Appropriate medical therapy Pulmonary function testing Positive metabolic balance Chest X-Ray High Resolution CT scanning Quantitative ventilation/ perfusion scan Cardiac evaluation *Culture negative if possible *Control of sepsis Surgical Management of Tuberculosis Candidacy Able to tolerate the operation Post-op Predicted FEV1 >0.8 liters Otherwise medically stable Appropriate timing depends on indication 19

20 Surgical Management of Tuberculosis Goals of resection total gross removal of all disease while maintaining adequate pulmonary function Surgical Management of Tuberculosis Example cases: Drug intolerance Pulmonary nodule Complicated cavity Drug resistance Bronchopleural fistula 20

21 Tuberculosis Surgical Cases Case: Drug Intolerance 80 year old male (R.T.) diagnosed with MAC one year prior attempted antibiotic therapy inconsistent due to side effects nausea, dizziness overall healthy, stable coronary disease 30 lb wt loss, stabilized off medications FEV (71% predicted) Tuberculosis Surgical Cases 21

22 Tuberculosis Surgical Cases Case: Drug Intolerance Operation Muscle sparing thoracotomy Right upper lobectomy Latissimus dorsi muscle transposition Tuberculosis Surgical Cases Case: Drug Intolerance Postop small air leak post op a-fib discharged POD #9 22

23 Tuberculosis Surgical Cases Case: Drug Intolerance At follow-up Seroma at muscle harvest site Repeated drainage Sputum smear and culture negative Tuberculosis Surgical Cases Case: Pulmonary Nodule 70 year old male (F.K.) mild fatigue urged by his wife to have a physical long history of smoking otherwise healthy Chest X-ray as part of initial evaluation right upper lobe mass 23

24 Tuberculosis Surgical Cases Case: Pulmonary Nodule Tuberculosis Surgical Cases 24

25 Tuberculosis Surgical Cases Case: Pulmonary Nodule Operation Posterior-lateral thoracotomy Right upper lobectomy Pathology Necrotizing granuloma with AFB positive organisms Tuberculosis Surgical Cases Case: Pulmonary Nodule Postop Sputum negative Air leak Pleurodesis Discharge POD #15 25

26 Tuberculosis Surgical Cases Case: Complicated Cavity 51 year old female (L.M.) Diagnosed with MAC 1983 pre-employment physical Treated for 3 years - INH, Rifampin, Streptomycin, Ethambutol Sputum negative Residual cavity in right lower lobe Stable on routine follow-up New frequent and productive cough Hemoptysis Cavity fluid filled on x-ray Tuberculosis Surgical Cases 26

27 Tuberculosis Surgical Cases Case: Complicated Cavity Operation Muscle sparing thoracotomy Right lower lobectomy Complete filling of right hemithorax by upper and middle lobes, no tissue transposition used Tuberculosis Surgical Cases Case: Complicated Cavity Postop a-fib discharged POD #9 27

28 Tuberculosis Surgical Cases Case: Macrolide Resistant MAC 55 Year old male (I.T.) Spontaneous right PTX chest tube Pleural abrasion Spontaneous Left PTX chest tube Pleural abrasion Staph empyema Bronchopleural fistula Decortication, open drainage - anterior Irrigation, eventual closure Tuberculosis Surgical Cases Case: Macrolide Resistant MAC Diagnosis of MAC 1992 Treated for almost 12 years Continued weight loss, positive sputum Mild hearing deficit FEV 1 60% of predicted 28

29 Tuberculosis Surgical Cases Case: Macrolide Resistant MAC Antibiotics Streptomycin Rifabutin Ethambutol Tuberculosis Surgical Cases 29

30 Tuberculosis Surgical Cases Case: Macrolide Resistant MAC Operation Muscle sparing thoracotomy Left upper lobectomy Transposition of latissimus dorsi and serratus anterior Well tolerated Minimal air leak Discharged POD #7 Tuberculosis Surgical Cases Case: Macrolide Resistant MAC Preoperative Postoperative 30

31 Tuberculosis Surgical Cases Case: Macrolide Resistant MAC 4 Months postop sputum remained positive weight stable repeat PFT s FEV L (50% predicted) repeat imaging Tuberculosis Surgical Cases 31

32 Tuberculosis Surgical Cases Case: Macrolide Resistant MAC Operation Right muscle sparing thoracotomy Right upper lobectomy Latissimus dorsi muscle transposition Bullectomy right lower lobe Tuberculosis Surgical Cases Case: Macrolide Resistant MAC Post operative CXR Residual apical space Air leak Consideration for thoracoplasty Air leak resolved Seroma drained Discharged POD #19 32

33 Tuberculosis Surgical Cases Case: Macrolide Resistant MAC Initial post op sputum negative smear and culture at 6 weeks Postop FEV cc 30% predicted Slow weight gain Improving dyspena No significant sputum production Tuberculosis Surgical Cases Case: Bronchopleural Fistula 60 year old man (R.S.) presented to local ER with dyspnea spontaneous pneumothorax CT placed Diagnosed with M. Tuberculosis Continued air leak 2 additional tubes placed uncontrolled air leak and pus draining, + for AFB 33

34 Tuberculosis Surgical Cases Case: Bronchopleural Fistula Seen by local surgeon Underwent open flap drainage Transfer to UTHCT on arrival cavity mostly clean small BPF initiated dressing changes continued antibiotic therapy extraction for dental infections exercise program Tuberculosis Surgical Cases 34

35 Tuberculosis Surgical Cases Case: Bronchopleural Fistula Three months of treatment sputum and cavity negative VQ scan negative for BPF Repeat imaging Tuberculosis Surgical Cases 35

36 Tuberculosis Surgical Cases Case: Bronchopleural Fistula Operation Left thoracotomy resection of 7 th rib decortication primary closure Tuberculosis Surgical Cases Case: Bronchopleural Fistula Small effusion Healed well Discharged home 36

37 Tuberculosis Surgical Cases Surgical Data Mostly retrospective case reviews Surgical Management of Tuberculosis DATA Thoracic Surgery 2 nd Edition F. G. Pearson 37

38 Surgical Management of Tuberculosis Summary surgery is usually supplemental treatment at least 3 months of treatment negative sputum complete antibiotics post op limit contamination of pleural space reinforce bronchial closures Surgical Management of Tuberculosis Freixinet JG, et.al. Role of surgery in pulmonary tuberculosis Med Sci Monit Dec;8(12):CR patients (56 cases multidrug resistance) None required operation 1 case of atypical tuberculosis 38

39 Surgical Management of Tuberculosis Group 1 Pleural cavity and thoracic wall pleural drainage, thoracostomy, drainage of abscesses, myoplasty Group 2 Pulmonary resections segmentectomy, lobectomy, pneumonectomy Group 3 Diagnostic procedures mediastinoscopy, thoracoscopy Surgical Management of Tuberculosis 39

40 Surgical Management of Tuberculosis Complications 36 patients (27.3%) 15 had 2 or more complications Surgical Management of Tuberculosis At 2 years 110 patients (90.1%) no signs of disease 30 day Mortality 7 (5.3%) group 2 Duration of followup mortality 4 Massive hemoptysis 2 Pneumonia 6 unrelated casues 40

41 Surgical Management of Tuberculosis Freixinet JG, et.al. Summary Optimal timing when sputum negative Limited surgical role for multi-drug resistance Bronchiaectasis Destroyed lung Scar carcinoma Asymptomatic cavities Operation in MAC Disease Review of surgical result over 8.5 years UT Tyler Microbiologic relapse two or more positive cultures with one or more being AFB smear positive, three or more positive cultures, which are all AFB smear negative after being culture negative a minimum of 4 months. 41

42 Operation in MAC Disease Over 300 patients with MAC 28 surgical patients (age 29-75) 21/28 white males most smokers all had cavitary disease on chest x -ray all symptomatic fever,weight loss, malaise, fatigue, cough with sputum, hemoptysis 22 patients 20% or more below ADA standards for height and weight 2 patients required preoperative gastrostomy for severe malnutrition Operation in MAC Disease Drug therapy 3 or more drugs drugs used dependent on treatment time isoniazid, rifampin, ethambutol, streptomycin After 1991 clarithromycin, rifabutin, and ethambutol Duration of treatment 1-2 years up to 6 years 42

43 Operation in MAC Disease Indications Varied over the time course of the study Pre-macrolide initial therapy Macrolide era treatment failure, marcolide resistance, complications (hemoptysis, bronchiectasis) Operation in MAC Disease 43

44 Operation in MAC Disease Surgical Procedures Operation in MAC Disease Complications 9/28 patients Persistent air leak (6) thoracoplasty (5) closure and muscle flap (1) Atelectasis (1) bronchoscopy Bronchopleural fistula (1) omentopexy Deaths (2) MI Malnutrition, resp failure 44

45 Operation in MAC Disease Techniques Intrapleural dissection when possible Begin in least involved area Bronchial stump flap reinforcement pleura, pericardial fat pad, muscle flap serratus, latissimus Opening cavity at apex Limited stapling prevents expansion Operation in MAC Disease Evaluation post resection expansion of remaining lung alveolar leaks residual space muscle transposition pneumoperitoneum Air leaks 50% resolve in 7 days 25% resolve by 14 days 25% require re-operation Space with air leak requires re-operation Space with no air leak may be acceptable 45

46 Operation in MAC Disease Thoracoplasty resection of ribs and transverse processes 2-4 Clearing of the undersurface of 1 st rib Blood loss significant > 1,000 cc in 7 patients Operation in MAC Disease Eradication of disease 13/ 27 culture negative at operation 22/24 patients alive with follow-up culture negative at 3 months 2/24 were culture positive >4months Of 26 patients 20 completed therapy 3 were still on therapy 2 failed 1 lost to follow-up 1 Relapse 46

47 Operation in MAC Disease Overall 90% of surgical patients achieved permanent control High morbidity, but can be managed 2 year mortality rate 7% Surgical Management of Tuberculosis Extrathoracic Disease Lymphadenitis Renal Peritoneal disease Bone/ Joint 47

48 Mycobacterial Cervical Lymphadenitis Most common in children Excisional surgery without chemotherapy Recommended treatment for children with NTM cervical lymphadenitis Including M. avium complex and M. scrofulaceum Success rate 95% Incisional biopsy, incision and drainage Antibiotics alone should be avoided Antibiotics my be adjunct if Facial N. at risk Mycobacterial Cervical Lymphadenitis Adults nodal, skin, soft tissue, joints, occasionally bone Combination treatment surgical resection debridement three drug regiment 48

49 Renal Tuberculosis Hydronephrosis and non-functional kidney Replacement of parenchyma with granuloma Nephrectomy recommended following at least 1 month of treatment May be approached laprascopically Flechner SM, Gow JG. Role of nephrectomy in the treatment of non-functioning or very poorly functioning unilateral tuberculous kidney. J Urol 1980;123: Peritoneal and Intestinal Tuberculosis Uncommon lymphatic, genitourinary, osteoarticular, miliary, meningeal Non-specific inflammatory bowel disease malignacy other infections Surgical Indications: Intestinal occlusion (15-60%) Perforation (1-15%) Abscesses and fistulas (2-30%) Hemorrhage (2%) Strictures 49

50 Peritoneal and Intestinal Tuberculosis Commonly found at time of exploration 25-75% require surgery Preservation of bowel, limit resection Bowel obstruction responsive to medication Ostemyelitis and Arthritis Gardam M Mycobacterial Osteomyelitis and Arthritis Infect Dis Clin North Am Dec; 19(4); Mycobacterium Tuberculosis most common agent Atypical mycobacterium direct inoculation (trauma, surgery) Spine(40%), Hip, Knee Synovial fluid culture for diagnosis 50

51 Ostemyelitis and Arthritis Surgery Bone and Joint adjunctive to medical therapy drainage, fusion of joints Spinal Potts Disease aggressive stabilization to prevent kyphosis and neurologic compromise Summary Indications Primary treatment Cavitary disease with positive sputum after 3 to 6 months of chemotherapy Localized infection with atypical mycobacteria, multidrug resistant Complications Destroyed lung Atelectasis Bronchiectasis Bronchostenosis Unreliable patient Intolerant to medication Exclude underlying malignancy Hemoptysis Bronchopleural fistula Pleural disease 51

52 Summary Procedures Lung resection Pleural space thoracostomy decortication flap drainage tissue transfer thoracoplasty Summary Clear understanding of the problem Appropriate preop therapy Complete discussion regarding risks Tailor approach to individual patient 52