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Ann Thorac Surg 1995;59:1405-1407
© 1995 The Society of Thoracic Surgeons

Current Role of Surgery in Mycobacterium Tuberculosis

Texas Center for Infectious Disease, San Antonio State Chest Hospital, San Antonio, Texas

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
From January 1986 through December 1993, we operated on 59 patients with documented Mycobacterium tuberculosis infection. Indications for operation were as follows: multidrug-resistant tuberculosis (MDRTB) in 19 patients; bronchopleural fistula secondary to Mycobacterium tuberculosis infection in 12; massive hemoptysis in 5; destroyed lung in 7; solitary nodule in 7; trapped lung in 3; complicated cavity in 4; and empyema in 2. Sixty-five operative procedures were performed: pneumonectomy with latissimus muscle flap in 15 patients; pneumonectomy in 3; lobectomy in 16; segmental or wedge resection in 11; decortication in 5; window thoracostomy in 3; thoracoplasty with myoplasty in 4; tube thoracostomy in 4; return to operating room for bleeding in 2; Clagett procedure in 1; and drainage of a cold abscess in 1. There were no operative deaths. Major postoperative complications occurred in 5 patients. The two late deaths were in patients with MDRTB: 1 with progressive disease and massive hemoptysis and the other with a relapse of MDRTB. Of the patients operated on as part of their therapeutic regimen for MDRTB, 17 (89%) of 19 have remained culture negative. We conclude that (1) surgery still plays an important role in the management of patients with Mycobacterium tuberculosis infection; (2) surgical intervention can be performed with acceptable mortality and morbidity; (3) a variety of procedures are needed to effect cure; and (4) encouraging results in patients with MDRTB support surgical therapy in this difficult group of patients.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 1408.

The current role of surgery in the therapy for Mycobacterium tuberculosis (MTB) is not defined. Medical therapy alone is successful in most patients. Although the introduction of rifampin and short-course chemotherapy has theoretically allowed nearly 100% cure of sensitive disease, tuberculosis has reemerged as an important public health problem [1, 2]. Complacency on the part of health care workers, closing of sanitoriums, the rising incidence of homelessness, intravenous drug abuse, lack of access to health care, immigration, and the human immunodeficiency virus epidemic have led to a dramatic upsurge in the incidence of MTB since 1985 [3]. Many patients fail to complete therapy, thus allowing drug resistance and progressive disease to occur. Pulmonary complications of MTB develop including empyema, bronchopleural fistula, large persistent cavities that may be associated with hemoptysis or secondary infection, bronchiectasis, and pulmonary destruction. Surgical intervention, long neglected, is once again needed to address these problems [4].

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
From January 1986 through December 1993, we performed 65 operations on 59 patients with documented MTB. One patient with Mycobacterium bovis infection whose clinical picture, progress, and drug resistance were the same as in patients with MTB was included. We excluded all other patients with nontuberculous mycobacterial infections from this series, as the clinical course and response to treatment differ from those of patients with MTB.

There were 44 men and 15 women. The mean age was 39 years with a range of 16 to 72 years. There were 38 Hispanics, 10 whites, 8 blacks, and 3 Asians. The indications for operation were as follows: multidrug resistant tuberculosis (MDRTB), 19 patients; bronchopleural fistula, 12; destroyed lung, 7; solitary nodule, 7; hemoptysis, 5; cavity, 4; trapped lung, 3; and empyema, 2.

The most common indication was organisms resistant to multiple drugs. Seventeen of these 19 patients had true multidrug-resistant disease, defined as having organisms resistant to at least isoniazid and rifampin. Two patients had organisms sensitive to isoniazid but resistant to rifampin and other drugs. All 19 patients were operated on as part of their therapeutic regimen. Intensive medical therapy was used in an attempt to convert the results of sputum culture to negative before operation. This effort was successful in 17 patients. Medical regimens were tailored to the individual patient and contained an injectable agent and an average of three oral drugs. In this group of 19 patients, we performed 8 pneumonectomies with latissimus dorsi reinforcement of the bronchial stump, 9 lobectomies, and 2 segmental resections. All surviving patients were followed up postoperatively for at least 12 months. One patient was followed clinically for 12 months and remained well. The others had additional studies comprising chest roentgenography, sputum cul ture, or both. The mean follow-up was 26 months with a range of 12 to 60 months.

The second most common indication was bronchopleural fistula. All 12 patients had a persistent air leak for more than 1 month and were smear and culture positive for MTB sensitive to all drugs on initial examination. Eleven of the 12 patients were initially treated with tube thoracostomy. Thoracostomy tube drainage was continued for 1 month to 4 months and was successful in closing the fistula in 4 patients. The remaining patients required a variety of procedures to effect closure. Definitive surgical therapy was delayed until sputum and pleural fluid cultures were negative. We performed 3 pneumonectomies, 1 window thoracostomy, 2 tailoring thoracoplasties with myoplasty, and 2 decortications.

Destroyed lung tissue and associated symptoms were present in 7 patients. Pneumonectomy was performed on 5 patients who had associated problems including bronchostenosis, recurrent hemoptysis, and persistent drug-sensitive tuberculosis. We performed a segmental resection on 1 patient and a lobectomy with superior segmentectomy on 1.

Seven patients had an undiagnosed lung mass consistent with carcinoma. There were six wedge or segmental resections and one lobectomy performed in this group. We did three lobectomies and two pneumonectomies for recurrent or massive hemoptysis in 5 patients. Three patients with trapped lung underwent decortication. Two patients required drainage of an empyema. One was drained by window thoracostomy and subsequently sterilized with a Clagett procedure. The other patient had drainage of a cold abscess. Four patients had cavities that were large or complicated by superinfection. Two required lobectomy, and 2 underwent wedge resection. Two patients were returned to the operating room for bleeding. Table 1 summarizes the operative procedures performed.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

Successful closure was effected in all patients who had bronchopleural fistula. Control of the bleeding was achieved in all 5 patients who underwent operation for massive or recurrent severe hemoptysis. The 7 patients operated on for destroyed lung with symptoms all had successful outcomes. The remaining groups with solitary nodule, cavity, trapped lung, or empyema were successfully treated by a variety of procedures.

Major postoperative complications occurred in 5 patients and included hypoxic encephalopathy in 1, bronchopleural fistula in 2, and return to the operating room for bleeding in 2. Minor complications developed in 7 patients. Four of the major complications were in patients operated on for MDRTB. Postoperative bronchopleural fistula developed in 2 patients. In 1 patient with MDRTB, it responded to tube drainage alone. In the other patient, who underwent emergent pneumonectomy for massive hemoptysis, window thoracostomy and tailoring thoracoplasty were necessary to effect closure. Massive hemoptysis developed in this patient 2 years later and required thoracoplasty and myoplasty for control. The patient is currently well 2 years after the last operation.

Long-term follow-up of our patients who underwent surgical therapy for MTB ranged from 25% to 100%. Long-term follow-up was defined as at least 12 months or to death. This period was chosen because most cases of relapse occur within the first 3 months and in nearly all cases, within the first 6 months [5]. We thought that 12 months would allow us more than adequate time to evaluate the presence of relapse. Follow-up was best in those patients with MDRTB and those with empyema. Most of our patients were judged to be improved at the time of the last follow-up. Details on each group of patients and duration of follow-up are outlined in Table 2.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

Bronchopleural fistula is a devastating complication of tuberculosis. The development of this complication demands prompt drainage. Further treatment depends on the response to drainage, the fistula size, the amount of disease in the lung, the sensitivity of the organisms to first-line drugs, the body's response to the fistula, and other poorly understood factors. A variety of procedures may be necessary to effect closure. Multiple operations are frequently necessary. The institution of definitive surgical therapy should be delayed until control of the tuberculosis infection has been accomplished as evidenced by sputum and pleural fluid conversion to negative on culture. A combination of these approaches was successful in all 12 of our patients.

The natural history of patients with destroyed lungs secondary to tuberculosis has not been defined. We operated on 7 patients with a variety of associated problems including main stem bronchostenosis, repeated bacterial lower respiratory tract infections, fungal balls, and recurrent hemoptysis. All patients in this group had a favorable outcome with amelioration of the problem or symptoms.

On the basis of our experience, we draw several conclusions. (1) Surgery currently plays an important role in the management of MTB. (2) Surgical intervention can be performed with acceptable morbidity and mortality. (3) A variety of procedures are needed to effect cure. (4) Encouraging results in our patients with MDRTB support the use of surgical therapy in this difficult group of patients.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We acknowledge the assistance of Araceli Santellanes and Jeffrey W. Smedley, MPH, in the preparation of the manuscript.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10–12, 1994.

Address reprint requests to Dr Treasure, 2303 SE Military Dr, San Antonio, TX 78223.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

1. Hong Kong Chest Service/British Research Council. Controlled trial of 2, 4 and 6 months of pyrazinamide in 6-month, three times-weekly regimens for smear-positive pulmonary tuberculosis, including an assessment of a combined preparation isoniazid, rifampin and pyrazinamide: results at 30 months. Am Rev Respir Dis 1991;143:700–6.[Medline]
2. Combs DL, O'Brien RJ, Geiter LJ. USPHS tuberculosis short-course chemotherapy trial 21: effectiveness, toxicity, and acceptability: the report of final results. Ann Intern Med 1990;112:397–406.
3. CDC. Tuberculosis morbidity-United States, 1992. MMWR 1993;42(36):696–704.[Medline]
4. Reed CE, Parker EF, Crawford FA Jr. Surgical resection for complications of pulmonary tuberculosis. Ann Thorac Surg 1989;48:165–7.[Abstract]
5. Fox W, Mitchison DA. Short-course chemotherapy for pulmonary tuberculosis. Am Rev Respir Dis 1975;111:325–53.[Medline]
6. Goble M, Iseman MD, Madsen LA, Waite D, Ackerson L, Horsburgh CR Jr. Treatment of 171 patients with pulmonary tuberculosis resistant to isoniazid and rifampin. N Engl J Med 1993;328:527–32.[Abstract/Free Full Text]
7. Pomerantz M, Madsen L, Goble M, Iseman M. Surgical management of resistant mycobacterial tuberculosis and other mycobacterial pulmonary infections. Ann Thorac Surg 1991;52:1108–12.[Abstract]

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