The current role of thoracic surgery in tuberculosis management

Exploring Surgical Management Strategies for Endobronchial Tumors

Endobronchial tumors, though relatively uncommon, present a diverse array of pathological conditions, including both benign and malignant neoplasms. This retrospective study focuses on the surgical management of seven such cases affecting the main or lobar bronchi. The study involves a diverse patient population, ranging in age from 18 to 65 years, with a median age of 26 years. The cases include both male and female individuals, indicating the presence of these tumors across various demographics. We carried out surgical interventions to remove the tumor while preserving the lung parenchyma. Surgical techniques included video-assisted thoracic surgery (VATS), lobectomy, and/or a combination of these methods. The choice of approach was guided by the tumor's location and nature. VATS, although widely performed, can sometimes pose challenges, leading to conversions to open thoracotomy in specific cases. All seven cases resulted in uneventful postoperative periods and excellent long-term outcomes, affirming the efficacy of the surgical procedures. Notably, despite variations in age and gender, the treatment approaches consistently yielded favorable long-term results. This study demonstrates the importance of personalized surgical strategies for endobronchial tumors while considering the nature and location of the tumor. VATS stands as a viable option, particularly in benign cases, provided careful case selection and the availability of skilled surgeons. These findings contribute to the growing body of evidence supporting the benefits of VATS in the management of endobronchial tumors.

The safety and efficacy of decortication for stage III drug-resistant tuberculous empyema

OBJECTIVES

The goal of this study was to evaluate the safety and efficacy of decortication for stage III drug-resistant tuberculous empyema (TE).

METHODS

We analysed all patients with stage III TE who underwent decortication between March 2015 and October 2019 at Wuhan Pulmonary Hospital. The patients were divided into 2 groups according to drug-susceptibility testing of bronchoscopy lavage fluid, pleural effusion and tissue specimens, including a drug-resistant group and a drug-sensitive group. We collected and compared the preoperative, perioperative and postoperative data from the 2 groups to evaluate the safety and efficacy of decortication for stage III drug-resistant TE.

RESULTS

In total, 135 cases met the inclusion criteria and were enrolled, including 30 cases in the drug-resistant group and 105 cases in the drug-sensitive group. No deaths were recorded for the entire study population. Compared to the drug-sensitive group, the drug-resistant group had longer operation times (259.8 ± 78.4 min vs 187.2 ± 56.0 min, P = 0.00), a larger volume of intraoperative blood loss [300 (200,400) ml vs 200 (130, 300) ml, P = 0.00] and a higher intraoperative transfusion rate (5/30, 16.7% vs 4/105, 3.8%, P = 0.04). The rate of complications was significantly higher in the drug-resistant group (23; 76.7%) than in the drug-sensitive group (53; 50.5%) (P = 0.01). Recurrence was not reported in any of the patients. Twenty-three (76.7%) patients in the drug-resistant group and 90 (85.7%) patients in the drug-sensitive group recovered to an "excellent" level, and 3 cases in each group recovered to a "poor" level; there was no significant difference between the 2 groups in surgical effects (P = 0.21).

CONCLUSIONS

Decortication is a safe, effective and feasible option for patients with stage III drug-resistant TE, although the operation is difficult and risky.

Surgical intervention is safe, feasible, and effective in tubercular tracheobronchial stenosis

Objectives:

Posttubercular tracheobronchial stenosis is a troublesome sequela of tracheobronchial tuberculosis. Surgical resection is the treatment of choice when repeated bronchoscopic dilatations fail. Herein, we aim to present our surgical experience in the management of this problem and also to evaluate factors affecting the surgical outcomes.

Materials and Methods:

This is a retrospective analysis of a prospectively maintained database at a dedicated thoracic surgical unit in New Delhi, India, over 8 years. An analysis of demographic characteristics, perioperative variables including complications were carried out. The occurrence of postoperative complications, and/or hospital stay of >7 days was considered as “poor” surgical outcomes. Various parameters were analyzed to assess the factors predicting surgical outcomes.

Results:

A total of 20 patients were surgically managed in the study period. Two patients had tracheal stenosis. The left main bronchus was involved in 16 patients. In these 16 cases, 12 cases underwent lung preserving surgery (bronchial sleeve resection and sleeve lobectomy) and rest of 4 cases required pneumonectomy. All postoperative complications occurred in 5 (25%) patients. Prolonged air leak was the most common postoperative complication. On univariate analysis, surgical outcomes were poor in patients who had longer duration of symptoms (P = 0.03) and with >2 episodes of preoperative balloon dilatations (<0.001). On multivariate analysis, “total number of dilatations <4 times,” emerged as a significant predictive factor for lung preservation surgery.

Conclusions:

Surgical intervention is safe, feasible, and effective in tubercular tracheobronchial stenoses which fail to respond to bronchoscopic interventions. Early referral for surgery favors lung preservation.

Global surgery and the sustainable development goals

Background

The field of global surgery has gained significant recent momentum, catalysed by the 2015 publication of the Lancet Commission on Global Surgery, Disease Control Priorities 3 and World Health Assembly resolution 68.15. These reports characterized the global burden of disease amenable to surgical care, called for global investment in surgical systems, and recognized surgery and anaesthesia as essential components of universal health coverage.

Methods

A strategy proposed to strengthen surgical care is the development of national surgical, obstetric and anaesthesia plans (NSOAPs). This review examined how NSOAPs could contribute to the achievement of sustainable development goals (SDGs) 1, 3, 5, 8, 9, 10, 16 and 17 by 2030, focusing on their potential impact on the healthcare systems in Ethiopia, Tanzania and Zambia.

Results

Due to the cross-cutting nature of surgery, obstetrics and anaesthesia, investing in these services will escalate progress to achieve gender equality, economic growth and infrastructure development. Universal health coverage will not be achieved without addressing the financial ramifications to the poor of seeking and receiving surgical care. NSOAPs provide a strategic framework and a data collection platform for evidence-based policy-making, accountability and implementation guidance.

Conclusion

The development and implementation of data-driven NSOAPs should be recognized as a powerful road map to accelerate achievement of the SDGs by 2030.

Salmonella houtenae-induced Empyema Complicated with Chronic Tuberculous Empyema

Salmonella spp. are food-borne pathogens that usually cause gastroenteritis, although bacteremia and subsequent focal metastatic infection can also occasionally occur. Of the known Salmonella spp., Salmonella houtenae is a rare subspecies, comprising less than 1% of all Salmonella strains. We herein report the first case of S. houtenae-induced empyema complicated with chronic tuberculous empyema, which was successfully treated by antibacterial agents alone. We wish to highlight the importance of being aware that Salmonella spp. can cause empyema in cases suffering from chronic tuberculous empyema; moreover, despite the successful completion of treatment with antibacterial agents, periodical follow-up is mandatory in such cases.

Surgery and pleuro-pulmonary tuberculosis: a scientific literature review

Tuberculosis (TB) is still a major public health concern, mostly affecting resource-constrained settings and marginalized populations. The fight against the disease is hindered by the growing emergence of drug-resistant forms whose management can be rather challenging. Surgery may play an important role to support diagnosis and treatment of the most complex cases and improve their therapeutic outcome. We conducted a non-systematic review of the literature based on relevant keywords through PubMed database. Papers in English and Russian were included. The search was focused on five main areas of intervention as follows: (I) diagnosis of complicated cases; (II) elimination of contagious persisting cavities, despite appropriate chemotherapy; (III) treatment of destroyed lung; (V) resection of tuberculomas; (VI) treatment of tuberculous pleural empyema. Although specific practical guidelines concerning surgical indications and approaches are currently unavailable, a summary of the evidence emerged from the scientific literature was elaborated to help the clinician in the management of severely compromised TB patients. The decision to proceed to surgery is usually individualized and a careful assessment of the patient's risk profile is always recommended before performing any procedure in addition to appropriate chemotherapy.

Surgical aspects of pulmonary tuberculosis: an update

Tuberculosis remains a major global medical challenge and concern. In the world's population of over 7.4 billion people, 8.6 million are estimated to be infected with Mycobacterium tuberculosis; another 2.2 billion have latent tuberculosis. There is an annual incidence of 16,000 new cases in the USA and 7-8 million new cases worldwide, of which 440,000 are multidrug-resistant or extensively multidrug-resistant, mainly in developing countries or emerging economies. According to the World Health Organization, the incidence of tuberculosis is 133 cases per 100,000 of the population; 3.3% new cases are drug resistant and 20% are already treated cases. Of the drug-resistant cases, 9.7% are extensively drug-resistant. The annual global mortality attributable to tuberculosis is over 1.3 million people. The association with HIV/AIDS in 430,000 people has compounded the global concern and challenge. This review presents the historical indications for surgical treatment of tuberculosis, reviews the current literature and clinical experience, and collates this into increased awareness and contemporary understanding of the indications and need for surgery in primary active tuberculosis, adjuvant surgical therapy for multidrug-resistant tuberculosis, and the complications of chronic tuberculosis sequelae or previous tuberculosis surgery.

Video-assisted thoracoscopic surgery is a safe option for benign lung diseases requiring lobectomy

BACKGROUND

Lobectomy for benign lung disease is renowned to be technically complex and to be subjected to an increased complication rate. The objective of this study was to evaluate whether the results obtained with video-assisted surgery (VATS) in benign disease are comparable to those obtained in oncologic surgery, where VATS has been validated.

METHODS

We have reviewed the files of 246 consecutive patients who underwent VATS lobectomy from January 2012 to August 2015. The cohort was divided into two groups according to pathology (benign or malignant). Outcome parameters on scrutiny were demographics, pathology, duration of air leak, drainage and hospital stay, conversion, and perioperative complication rate. Comparisons were made with the χ ² test and Student's t test; any p value ≤0.05 was considered as significant.

RESULTS

Group 1 (36 patients) included patients who underwent lobectomy for benign disease and group 2 (210 patients) patients affected by lung cancer or pulmonary metastases. The two groups differed with reference to age (p < 0.001), history of cancer (p < 0.001), history of stroke (p = 0.05), and the presence of pleural adhesions (p = 0.03). There was no difference for duration of air leaks, chest tube drainage and hospital stay, conversion rate, and perioperative complication rate.

CONCLUSIONS

We conclude that pathology did not impact on outcomes after VATS lobectomy. This study suggests that VATS is as a safe option in selected patients with benign disease requiring lobectomy, despite a more complex technical context.

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.

[Surgery for thoracic tuberculosis]

Tuberculosis is mainly a medical disease. Surgery has been the unique therapeutic tool for a long time before the advent of specific antituberculous drugs, and the role of surgery was then confined to the treatment of the sequelae of tuberculosis and their complications. The resurgence of tuberculosis and the emergence of multidrug-resistant TB combined to immunosuppressed patients represent a new challenge for tuberculosis surgery. Surgery may be indicated for a diagnostic purpose in patients with pulmonary, pleural, mediastinal or thoracic wall involvement, or with a therapeutic purpose (drainage, resection, residual cavity obliteration). Modern imaging techniques and the advent of video-assisted thoracic surgery allowed a new approach of this pathology; the majority of diagnostic interventions and selected cases requiring lung resection can be performed through a mini-invasive approach. Patients proposed for aggressive surgery may be treated with the best results thanks to a good evaluation of the thoracic lesions, of the patients' nutritional, infectious and general status combined with a good coordination between the specialized medical team for an optimal preparation to surgery.

Is video-assisted thoracic surgery lobectomy in benign disease practical and effective?

BACKGROUND

The aim of this study was to analyze the surgical outcomes of video-assisted thoracic surgery (VATS) lobectomy for benign pulmonary disease and to propose surgical guidelines based on the retrospective cohort study.

METHODS

From January 2004 to December 2009, all lobectomies performed in a university-based tertiary care hospital were analyzed. The inclusion criteria were as follows: (I) VATS lobectomy for benign disease; (II) thoracotomy conversion cases initially approached by VATS lobectomy. All malignant cases were excluded. Electronic medical records were retrospectively analyzed and patients were divided into two groups: with infection and without infection. The primary outcomes were the thoracotomy conversion rate, length of hospital stay, period of thoracic drainage and complications.

RESULTS

VATS was performed in 163 (42%) of 385 patients who underwent lobectomy for benign disease. There were 68 in the infection group and 95 in the group without infection. VATS lobectomy was successful in 157 (96%) patients while 6 were converted into thoracotomy. The mean operation time and blood loss were 160 minutes and 326 mL. Comparing two groups, operation time and blood loss were not statistically different (P value =0.92, 0.63). Moreover conversion rate, length of hospital stay, period of thoracic drainage and complications (P value =0.67, 0.18, 0.25, and 0.50) were not different.

CONCLUSIONS

VATS lobectomy for benign disease is practical and effective in selected cases regardless of the presence of infection. However, because various technical obstacles may be encountered during the procedure, therefore, careful patient selection is needed.

Use of lung-preserving surgery in left inflammatory bronchial occlusion and distal atelectasis: preliminary results

OBJECTIVES

Lung-preserving surgery was proved to be effective and safe to treat patients with benign bronchial strictures. However, this surgical treatment has been rarely reported in patients with complete occlusion in the left main bronchus. The aim of this study was to assess the value of this procedure and report our experience in the treatment of these patients with left atelectasis caused by inflammatory bronchial occlusion.

METHODS

We reviewed and analysed the medical records of 8 patients who had undergone left main bronchus sleeve resection for symptomatic left atelectasis caused by inflammatory bronchial occlusion from May 2007 to April 2011.

RESULTS

Eight patients (3 men and 5 women) with a medical history of active pulmonary tuberculosis were involved in this study. The median age was 23 years. Parenchyma-sparing left main bronchus resection was performed in 4 patients, 1 of whom received partial wedge resection in the lingual lobe. Left main bronchus sleeve resection plus superior lobectomy was performed in 2 patients and left main bronchus sleeve resection plus left inferior lobectomy in 2 patients, 1 of whom received additional partial wedge resection of the lingual lobe. The procedure was completed successfully in all 8 patients without postoperative deaths. The mean follow-up time was 49.3 months, ranging from 23 to 69 months. No major complications, including stenosis and atelectasis, were observed during the follow-up period. The symptoms of pulmonary atelectasis disappeared and pulmonary ventilation function improved significantly.

CONCLUSIONS

In symptomatic patients with left atelectasis caused by inflammatory bronchial occlusion, lung-preserving surgery is an effective and safe surgical treatment.

Surgical treatment of drug-resistant tuberculosis

The global emergence and spread of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis has led to the re-examination of surgery as a possible adjunctive treatment. We present the case of a 26-year-old HIV-seronegative patient with XDR pulmonary tuberculosis refractory to medical therapy. Surgical resection of the patient's solitary cavitary lesion was done as adjunctive treatment, and a successful outcome with a combination of surgery and drug therapy was achieved. We review the history of surgical therapy for tuberculosis and reports of its role in treatment of MDR and XDR tuberculosis. 26 case series and cohort studies were included, and together showed that surgical resection is beneficial in the treatment of drug-resistant tuberculosis. However, the results might not be applicable in all settings because investigations were observational and typically included patients with less severe disease, and all surgeries were done at specialised thoracic-surgery centres. Well designed studies are needed to establish the efficacy of surgery in treatment of drug-resistant tuberculosis.

Resection of bronchial stricture and destroyed lung after pulmonary tuberculosis

We present a 53-year old man with destroyed lung syndrome (right upper and middle lobes and S6 of lower lobe with bronchial stricture between the right main and intermediate bronchus) due to tuberculosis 25 years earlier. Aspergillus infection in the destroyed lung was suspected on the basis of antigen positivity. The patient underwent right upper and middle lobectomy, S6 segmentectomy and bronchial resection from the distal end of the right main bronchus to the proximal end of the right basal bronchus. The membranous part of the right main bronchus was cerclaged in order to circularize the flattened bronchus and to match its diameter with that of the basal bronchus. End-to-end anastomosis was then carried out. The postoperative course was uneventful. Pathological examination revealed Aspergillus infection in the cavity of the destroyed lung. Bronchoscopic findings 6 weeks after surgery revealed good healing of the anastomosed portion without stenosis.

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.