Surgery for MDR/XDR Tuberculosis

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1 Surgery for MDR/XDR Tuberculosis John D. Mitchell, M.D. Davis Endowed Chair in Thoracic Surgery Professor and Chief, General Thoracic Surgery Department of Surgery University of Colorado School of Medicine Property of Presenter TB Course, National Jewish Health April 7, 2018

2 No relevant financial relationships to disclose. Property of Presenter

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4 University of Colorado Property of Presenter National Jewish Health

5 Case Presentation: XDR+ Tuberculosis History 38 yo male Armenian immigrant Lived in Russia ; last visit 4 years prior No known history in Russian Prison System Prior GSW to abdomen, Ankylosing Spondylitis Alcoholic, smoker 1.5 packs/day History of recurrent pneumonias, AFB (-) July 2013: Started on Remicade for AS, INH for LTBI Dec 2013: Fevers, productive cough; AFB (+) Diagnosed with drug resistant TB Property of Presenter

6 Case Presentation: XDR+ Tuberculosis Initial Drug Regimen PZA 1500 mg po qday Moxifloxacin 600 mg po qday PAS 4 gm po bid Linezolid 600 mg po qday Ethionamide 250 mg qam, 500 mg qpm Cycloserine 250 mg po bid Capreomycin 750 mg (12 mg/kg) IV qmon-fri Meropenem 2 gm IV q8h Augmentin 500 mg po bid Property of Presenter

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16 Case Presentation: XDR+ Tuberculosis Drug Sensitivity Testing (CDC) Property of Presenter

17 Case Presentation: XDR+ Tuberculosis Revised Drug Regimen Linezolid 600 mg IV q24h Cycloserine 250 mg po bid Imipenem 1 gm IV q12h Moxifloxacin 800 mg IV q24h PAS 6 gm po bid Bedaquiline 400 mg po qday Property of Presenter Clofazimine 100 mg po qday

18 Case Presentation: XDR+ Tuberculosis Treatment Course Eventually rendered sputum culture (-) Significant medication toxicities Debilitated, malnourished What is the role of surgery in this patient? Property of Presenter

19 Mycobacterium Tuberculosis General Principles Up to one-third of world s population infected with mycobacterium tuberculosis Typical treatment regimens for drug-sensitive TB last 6 to 9 months Chemotherapy usually curative; use of surgery rare Property of Presenter Emergence of drug-resistant TB: Development of new therapies Re-evaluation of surgical treatment

20 Dara M, Eur Respir J 2015; 45: 577

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22 Surgery for Drug-Resistant Tuberculosis Indications for Operation Eradicate TB Infection: Localized disease amenable to resection Persistent cavitary disease Persistent positive sputum with/without cavity Destroyed lung Complications of TB Infection: Massive hemoptysis Bronchopleural fistula Bronchial stenosis Trapped lung Property of Presenter

23 Drug Resistant Tuberculosis Predictors of Success and Failure Success Use of pyrazinamide and/or ethambutol, if susceptible Use of a fluoroquinolone Use of > 5 drugs Sputum conversion by 2 mos Surgical resection Previous therapy Number of drugs resistant Resistance to FQN Resistance to capreomycin Presence of cavitation Low BMI Property of Presenter HIV infection Poor adherence Positive cultures at 2-3 mos XDR-TB Failure

24 Surgery for Drug-Resistant Tuberculosis Factors favoring Surgery A pattern of drug-resistance so extensive that it compromises the likelihood of medical cure Localized lung damage (cavitation, destroyed lung) that might be a focus of persistent disease and/or further acquired resistance Allergies or intolerance to essential medications that might afford cure Property of Presenter Lack of access to curative chemotherapy

25 Surgery for Drug-Resistant Tuberculosis Risks/Benefits Benefits Rapid bacteriologic conversion Removal of bronchiectatic/fibrotic lung Increased chance of cure in some patients Risks Morbidity and mortality related to surgery Property of Presenter Potential long-term functional deficits Transmission in the health facility

26 Surgery for Drug-Resistant Tuberculosis Timing of Surgery Early Reduced Risk of Progression Reduced Risk Drug Resistance Property of Presenter Late Longer Treatment with Drugs Better Nutrition Control Comorbidities

27 Surgery for MDR-TB Current Results Property of Presenter

28 Surgery for MDR-TB Current Results Property of Presenter Xu HB, et al. J Antimicrob Chemother 2011; 66:

29 Thoracoscopic (VATS) Lung Resection What is a Thoracoscopic (VATS) Lobectomy? Two 5-10mm ports and a 4cm utility incision No rib spreading used Individual ligation of vessels and bronchus Muscle transposition possible Easy conversion to open Same operation as if open! Property of Presenter

30 OR Setup Property of Presenter

31 Thoracoscopic (VATS) Lung Resection Anesthesia / Analgesia Double Lumen Tube Typically, no epidural Intercostal blocks administered at surgery 0.25% marcaine with epi Postoperative PCA oral NSAID ± narcotic Property of Presenter

32 Thoracoscopic (VATS) Lung Resection Positioning Lateral decubitus, slightly rotated to better expose anterior axillary line Maximize intercostal spaces Maximum break on table Airplane for upper arm Property of Presenter

33 Thoracoscopic (VATS) Lung Resection Instruments Property of Presenter

34 Thoracoscopic (VATS) Lung Resection Incisions Property of Presenter

35 Thoracoscopic (VATS) Lung Resection Incisions Property of Presenter

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39 VATS Resection for MDR-TB Case study 29 yo man, from India 45 lb weight loss, productive cough, hemoptysis MDR-TB Property of Presenter Treated with 5 drug regimen for 9 months Sputum, culture negative for 5 months

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47 Surgery for Drug-Resistant Tuberculosis Novosibirsk TB Research Institute (NTRI) Property of Presenter

48 Levin Int J Tuberc Lung Dis 2016;20:1539

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52 Krasnov Thor Surg Clin 2017;27(2):99

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54 Surgery for MDR-TB Osteoplastic Thoracoplasty Property of Presenter DV Krasnov, personal communication

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