Surgical aspects of thoracic tuberculosis: a contemporary review--part 1

Long-Term Outcome of Chest Wall and Diaphragm Repair with Biological Materials

INTRODUCTION

 Chest wall and/or diaphragm reconstruction aims to preserve, restore, or improve respiratory function; conserve anatomical cavities; and upkeep postural and upper extremity support. This can be achieved by utilizing a wide range of different grafts made of synthetic, biological, autologous, or bioartificial materials. We aim to review our experience with decellularized bovine pericardium as graft in the past decade.

PATIENTS AND METHODS

 We conducted a retrospective analysis of patients who underwent surgical chest wall and/or diaphragm repair with decellularized bovine pericardium between January 1, 2012 and January 13, 2022 at our institution. All records were screened for patient characteristics, intra-/postoperative complications, chest tube and analgesic therapy duration, length of hospital stay, presence or absence of redo procedures, as well as morbidity and 30-day mortality. We then looked for correlations between implanted graft size and postoperative complications and gathered further follow-up information at least 2 months after surgery.

RESULTS

 A total of 71 patients either underwent isolated chest wall (n = 51), diaphragm (n = 12), or pericardial (n = 4) resection and reconstruction or a combination thereof. No mortality was recorded within the first 30 days. Major morbidity occurred in 12 patients, comprising secondary respiratory failure requiring bronchoscopy and invasive ventilation in 8 patients and secondary infections and delayed wound healing requiring patch removal in 4 patients. There was no correlation between the extensiveness of the procedure and extubation timing (chi-squared test, p = 0.44) or onset of respiratory failure (p = 0.27).

CONCLUSION

 A previously demonstrated general viability of biological materials for various reconstructive procedures appears to be supported by our long-term results.

Pure uniportal video-assisted thoracic surgery for treating thoracic tuberculous spondylitis: an initial case series of seven patients

BACKGROUND

The development of thoracic surgical techniques has provided a new avenue for treating thoracic tuberculosis. Moreover, microscopic treatment of spinal tuberculosis has attracted increasing attention, as it affords good visual access and reduces trauma. Traditional thoracoscopic treatment of spinal tuberculosis usually requires 2-3 passages, accompanied by a corresponding number of incisions. With a large number of conventional thoracoscopic surgeries performed, improved resolution of the microscopic field of view, effective hemostasis of the peripheral vessels using the ultrasonic knife, and many reports in the literature, thoracic tuberculosis can now be treated microscopically by creating a single channel. The aim of this study was to explore the feasibility and surgical technique for thoracic tuberculous spondylitis treatment via debridement and bone graft fusion surgery employing pure uniportal video-assisted thoracic surgery (VATS), combined with posterior internal fixation.

METHODS

Seven patients with relatively complete documentation were included in this study. All patients underwent lesion removal and bone graft reconstruction via uniportal VATS with posterior internal fixation. The mean patient age was 39.6 years. Surgical duration, blood loss volume, postoperative recovery time, and thoracic kyphosis angle were recorded.

RESULTS

The surgeries were successful with no severe postoperative complications. All patients were followed-up, and no recurrence of tuberculosis was observed. Imaging data, including computed tomography scans, confirmed the complete removal of the lesions. Additionally, bone fusion at the graft site was successful, no loss of the thoracic kyphosis angle was noted postoperatively, and the thoracic kyphosis angle improved.

CONCLUSIONS

Pure uniportal VATS yields satisfactory results and inflicts less trauma than previous surgical techniques. This technique also offers a reference value for treating thoracic tuberculous spondylitis.

In Silico and In Vitro Assessment of Antimicrobial and Antibiofilm Activity of Some 1,3-Oxazole-Based Compounds and Their Isosteric Analogues

In this paper, we report on the antimicrobial activity assessment of 49 compounds previously synthesized as derivatives of alanine or phenylalanine that incorporate a 4-(4-X-phenylsulfonyl)phenyl fragment (X = H, Cl, or Br), namely 21 acyclic compounds (6 × N-acyl-α-amino acids, 1 × N-acyl-α-amino acid ester, and 14 × N-acyl-α-amino ketones) and 28 pentatomic heterocycles from the oxazole-based compound class (6 × 4H-1,3-oxazol-5-ones, 16 × 5-aryl-1,3-oxazoles, and 6 × ethyl 1,3-oxazol-5-yl carbonates). Both in silico and in vitro qualitative and quantitative assays were used to investigate the antimicrobial potential of these derivatives against planktonic and biofilm-embedded microbial strains. Some of the tested compounds showed promising antimicrobial and antibiofilm activity depending on their chemical scaffold and lipophilic character.

Synthesis and Biological Evaluation of New N-Acyl-α-amino Ketones and 1,3-Oxazoles Derivatives

In order to develop novel bioactive substances with potent activities, some new valine-derived compounds incorporating a 4-(phenylsulfonyl)phenyl fragment, namely, acyclic precursors from N-acyl-α-amino acids and N-acyl-α-amino ketones classes, and heterocycles from the large family of 1,3-oxazole-based compounds, were synthesized. The structures of the new compounds were established using elemental analysis and spectral (UV-Vis, FT-IR, MS, NMR) data, and their purity was checked by reversed-phase HPLC. The newly synthesized compounds were evaluated for their antimicrobial and antibiofilm activities, for toxicity on D. magna, and by in silico studies regarding their potential mechanism of action and toxicity. The 2-aza-3-isopropyl-1-[4-(phenylsulfonyl)phenyl]-1,4-butanedione 4b bearing a p-tolyl group in 4-position exhibited the best antibacterial activity against the planktonic growth of both Gram-positive and Gram-negative strains, while the N-acyl-α-amino acid 2 and 1,3-oxazol-5(4H)-one 3 inhibited the Enterococcus faecium biofilms. Despite not all newly synthesized compounds showing significant biological activity, the general scaffold allows several future optimizations for obtaining better novel antimicrobial agents by the introduction of various substituents on the phenyl moiety at position 5 of the 1,3-oxazole nucleus.

The emerging role of gasotransmitters in the pathogenesis of tuberculosis

Mycobacterium tuberculosis (Mtb) is a facultative intracellular pathogen and the second largest contributor to global mortality caused by an infectious agent after HIV. In infected host cells, Mtb is faced with a harsh intracellular environment including hypoxia and the release of nitric oxide (NO) and carbon monoxide (CO) by immune cells. Hypoxia, NO and CO induce a state of in vitro dormancy where Mtb senses these gases via the DosS and DosT heme sensor kinase proteins, which in turn induce a set of ∼47 genes, known as the Mtb Dos dormancy regulon. On the contrary, both iNOS and HO-1, which produce NO and CO, respectively, have been shown to be important against mycobacterial disease progression. In this review, we discuss the impact of O2, NO and CO on Mtb physiology and in host responses to Mtb infection as well as the potential role of another major endogenous gas, hydrogen sulfide (H2S), in Mtb pathogenesis.

The Role of Video-Assisted Thoracoscopic Therapeutic Resection for Medically Failed Pulmonary Tuberculosis

There are few reports regarding video-assisted thoracoscopic therapeutic resection for medically failed pulmonary tuberculosis (TB). We reviewed our surgical results of video-assisted thoracoscopic surgery (VATS) therapeutic resection for pulmonary TB with medical failure, and its correlation with image characteristics on chest computed tomography (CT) scan.Between January 2007 and December 2012, among the 203 patients who had surgery for TB, the medical records of 89 patients undergoing therapeutic resection for medically failed pulmonary TB were reviewed. Clinical information and the image characteristics of CT scan were investigated and analyzed.Forty-six of the 89 patients undergoing successful VATS therapeutic resection had significantly lower grading in pleural thickening (P < 0.001), peribronchial lymph node calcification (P < 0.001), tuberculoma (P = 0.015), cavity (P = 0.006), and aspergilloma (P = 0.038); they had less operative blood loss (171.0 ± 218.7 vs 542.8 ± 622.8 mL; P < 0.001) and shorter hospital stay (5.2 ± 2.2 vs 15.6 ± 15.6 days; P < 0.001). They also had a lower percentage of anatomic resection (73.9% vs 93.0%; P = 0.016), a higher percentage of sublobar resection (56.5% vs 32.6%; P = 0.023), and a lower disease relapse rate (4.3% vs 23.3%; P = 0.009). Eighteen of the 38 patients with multi-drug resistant pulmonary tuberculosis (MDRTB) who successfully underwent VATS had significantly lower grading in pleural thickening (P = 0.001), peribronchial lymph node calcification (P = 0.019), and cavity (P = 0.017). They were preoperatively medicated for a shorter period of time (221.6 ± 90.8 vs 596.1 ± 432.5 days; P = 0.001), and had more sublobar resection (44.4% vs 10%), less blood loss (165.3 ± 148.3 vs 468.0 ± 439.9 mL; P = 0.009), and shorter hospital stay (5.4 ± 2.6 vs 11.8 ± 6.9 days; P = 0.001).Without multiple cavities, peribronchial lymph node calcification, and extensive pleural thickening, VATS therapeutic resection could be safely performed in selected patients with medically failed pulmonary TB as an effective adjunct with satisfactory results.

Surgical intervention for thoracic infections

Multidisciplinary management of thoracic infection, including experts in thoracic surgery, pulmonology, infectious disease, and radiology, is ideal for optimal outcomes. Initial assessment of parapneumonic effusion and empyema requires computed tomographic evaluation and consideration for fluid sampling or drainage. Goals for the treatment of parapneumonic effusion and empyema include drainage of the pleural space and complete lung reexpansion. Pulmonary abscess is often successfully treated with antibiotics and observation. Surgical intervention for the treatment of fungal or tuberculous lung disease should be undertaken by experienced surgeons following multidisciplinary assessment. Sternoclavicular joint infection often requires joint resection.

Resurgence of therapeutically destitute tuberculosis: amalgamation of old and newer techniques

Most of thoracic surgery developed as a result of efforts to treat tuberculosis (TB). The role of surgical therapy has declined but the role of surgery in TB still remains in situations like diagnostic difficulties, persistent sputum positive state despite therapy and complications and sequel like haemoptysis, destroyed or bronchiectatic lungs or empyema with or without broncho-pleural fistula (BPF). Various procedures have a role according to the indication. Some of the procedures have become obsolete but lobectomy, pneumonectomy, thoracoplasty, decortication and open window thoracostomy continue to be relevant. Recent published series have demonstrated mortality ranging from 0% to 3.1%. Surgery for complications and sequel of pulmonary TB still remain an important intervention for alleviation of human misery.

A clinical study of internal fixation, debridement and interbody thoracic fusion to treat thoracic tuberculosis via posterior approach only

PURPOSE

We evaluated the clinical efficacy and feasibility of one-stage posterior internal fixation, debridement and interbody thoracic fusion in the treatment of thoracic tuberculosis.

METHODS

Sixty adult patients with monosegmental thoracic tuberculosis were studied retrospectively: 34 men and 26 women with an average age of 37.5 years. Operating time, blood loss, time in bed, complications, neurological function, rate of deformity correction and rate of interbody fusion were investigated.

RESULTS

All cases were followed up for 27.5 months on average. Average mean operating time was 251 min, evaluated blood loss during operation 780 ml, rate of kyphosis correction 79%, corrected kyphosis angle 25° and loss of corrected angle 1.2°. Patients whose neurological function improved accounted for 90.1%. Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) decreased to normal levels three months after operation. The rate of bone fusion was 100%, with a 100% cure rate. No severe complications or spinal cord injury occurred.

CONCLUSIONS

This approach can successfully remove the focus of tuberculosis with complete interbody thoracic fusion after operation, which restores spinal stability.