Pulmonary tuberculosis and the surgeon.

Cavitary TB carries a poor prognosis. There is a higher risk of treatment failure and relapse if cavities are radiographically present during the first two months of therapy.[ 46 ] Then, if cavities persist after 6 months of treatment, the risk of relapse doubles compared to those whose cavities close by treatment completion.[ 47 ] studies suggest that pulmonary resection combined with anti-TB chemotherapy for MDR-TB can achieve high success rates.[ 48 49 50 ] Guidelines also suggest that surgery for drug-resistant TB be done early in the course of the disease when the patient’s risk of additional morbidity and mortality is low.[ 51 ] Unfortunately, the lack of robust trials evaluating the true role of surgery are lacking thus making definitive opinions difficult if not impossible.[ 52 ] Between 20 and 50% of cavitary TB patients have persistent cavities after completion of anti-TB treatment.[ 53 ] Their management evokes strong diverse opinions. The prevalent opinion is that surgery for residual cavitary lesions after successful medical treatment in a sputum-negative patient without symptoms is not warranted or justified but certain caveats exist. It is known that the healing response may be incomplete and may result in fibrotic scarring which can lead to open (cavity airspace remains) or closed healing (cavity resolved to scar tissue or calcified foci).[ 54 55 ] Whether the belief that cavities which have become smaller or fibrosed do not need surgery is true or not is uncertain because occasional case reports provide contrary evidence.[ 56 ] Certainly, greater acceptance for surgery exists for cavitary lung lesions with negative sputum/culture and where the lesion is larger than 8-10 cm because these lesions have been shown to be prone to reactivation and relapse.[ 57 58 ] The transformation of the cold cavity to a hot one happens in 20-30% according to Russian experience,[ 35 ] justifying an active surgical attitude even in culture-negative cases though controversy exists, especially in countries with low incidence but a 10% relapse rate in medically treated patients is cannot be easily dismissed.[ 41 59 ] Therapy-resistant caseous pneumonia, infiltrative pulmonary tuberculosis with positive sputum after 6–8 month of treatment have also been seen as indications for resection though again, there is no consensus.[ 60 61 ] Tuberculomas come to surgery (VATS resection) because of the difficulty of differentiating them from a lung cancer. If the diagnosis is made by non-invasive means then a tuberculoma larger than 2 cm in a sputum/culture negative patient, is usually treated with extended anti-tuberculous medication. Others argue that the inflammatory barrier is the hindrance of the sufficient drug concentration and advise resection.[ 6 10 12 35 ] The possibility of a malignancy should not be forgotten in a patient whose tuberculoma is refractory to treatment.[ 62 ]

Reliable radiographic criteria to distinguish between malignant and TB lesions do not exist. Surgical exploration with histological examination may be required. This specially applies to Tuberculomas or unresolving or progressing consolidations or suspected scar carcinomas. A VATS approach is preferable. If non-invasive modalities of diagnosis fail, video-assisted thoracoscopy (for node or parenchymal disease) or mediastinoscopy (for Level 2, 3, 4 and 7 mediastinal nodes) are valid alternatives with accuracy reaching 100%. Diagnostic thoracotomy may occasionally be required in situations of resource crunch. When contemplating surgery, a multidisciplinary approach to risk and benefit assessment is important. In MDR-TB patients, where chemotherapy alone has been unsuccessful, surgical resection of pulmonary bacillary lesions may be useful to improve treatment outcome. It is important to resort to the surgical option before significant destruction of lung parenchyma has taken place. Parenchyma preservation should be an important priority. Surgical treatment can be performed in patients with bilateral disease if the contralateral disease is stable. Bronchoscopic biopsy of the bronchial mucosa should be done before surgery to exclude active endobronchial disease. Tuberculomas, especially which are stable or progressive despite appropriate anti-microbial therapy should be surgically treated to reduce infectiousness. Diagnosis can be confusing and appropriate imaging techniques should be used to differentiate between lung cancer and tuberculoma. A surgical diagnostic approach may be needed when pleural effusion occurs without an etiologic clue. Surgery is justified for patients with major residual pleural thickenings or fibrothorax. Mediastinal node tuberculosis may need VATS surgery for diagnosis or drainage of mediastinal abscesses. Post-operative chemotherapy is mandatory; after the removal of the main lung lesion as small areas of active disease may persist and can result in relapses. Definite treatment recommendations have been established. Evidence-based guidelines are needed to define patient categories that are likely to benefit from surgical intervention and to define the exact role of surgery in these patients and its anticipated benefit. Reliable radiographic criteria to distinguish between malignant and TB lesions do not exist. Surgical exploration with histological examination may be required. This specially applies to Tuberculomas or unresolving or progressing consolidations or suspected scar carcinomas. A VATS approach is preferable. If non-invasive modalities of diagnosis fail, video-assisted thoracoscopy (for node or parenchymal disease) or mediastinoscopy (for Level 2, 3, 4 and 7 mediastinal nodes) are valid alternatives with accuracy reaching 100%. Diagnostic thoracotomy may occasionally be required in situations of resource crunch. When contemplating surgery, a multidisciplinary approach to risk and benefit assessment is important. In MDR-TB patients, where chemotherapy alone has been unsuccessful, surgical resection of pulmonary bacillary lesions may be useful to improve treatment outcome. It is important to resort to the surgical option before significant destruction of lung parenchyma has taken place. Parenchyma preservation should be an important priority. Surgical treatment can be performed in patients with bilateral disease if the contralateral disease is stable. Bronchoscopic biopsy of the bronchial mucosa should be done before surgery to exclude active endobronchial disease. Tuberculomas, especially which are stable or progressive despite appropriate anti-microbial therapy should be surgically treated to reduce infectiousness. Diagnosis can be confusing and appropriate imaging techniques should be used to differentiate between lung cancer and tuberculoma. A surgical diagnostic approach may be needed when pleural effusion occurs without an etiologic clue. Surgery is justified for patients with major residual pleural thickenings or fibrothorax. Mediastinal node tuberculosis may need VATS surgery for diagnosis or drainage of mediastinal abscesses. Post-operative chemotherapy is mandatory; after the removal of the main lung lesion as small areas of active disease may persist and can result in relapses. Definite treatment recommendations have been established. Evidence-based guidelines are needed to define patient categories that are likely to benefit from surgical intervention and to define the exact role of surgery in these patients and its anticipated benefit. There are no conflicts of interest.

Even after successful medical treatment, the tuberculosis afflicted lung may become totally non-functional. The term “destroyed lung” has been used in these cases and has the potential for repeated secondary infections, hemoptysis and causing infection in the contralateral lung. Patients with this medical condition may have a history of exposure to multiple TB therapies, with delayed recovery and/or drug resistance.[ 63 64 ] The surgical rationale is to interrupt further M. tuberculosis transmission and to prevent life-threatening complications. In most cases, a pneumonectomy will be necessary. Secondary (tuberculous) pneumothorax may occur and its management is often made difficult because of the inability of the remaining lung to expand.[ 65 ] Thoracic empyema with or without bronchopleural fistula is treated with established methods. In case of a bronchopleural fistula the tube thoracostomy is usually the initial treatment option. Open thoracostomy is usually recommended for severely ill patients with a high operative risk. Two-stage management with open thoracostomy and subsequent muscle plombage of the cleaned residual space is also suggested as a reasonable alternative in patients with poor general conditions and extensive calcifications precluding decortications,[ 41 66 67 ] regardless of the causative organism. Haemoptysis in most cases, can be stabilised by a combination of conservative measures supplanted with bronchial artery embolisation. Thus, emergency surgery with its higher morbidity and mortality can be avoided. Persistent or recurrent hemoptysis, however, will need surgery.[ 41 ] The risk factors associated with recurrence after successful embolisation for life-threatening haemoptysis are a lack of complete cessation of haemoptysis within seven days after the procedure, the need for blood transfusion, the presence of aspergillomas and the absence of TB.[ 68 ] Fibrothorax might benefit from decortication, stripping the encapsulating cortex and freeing the trapped lung. Re-expansion oedema, cytokine storm of a suddenly expanding lung, needs a close cooperation between surgeon and anesthetist.[ 12 21 ] Many of these decortications can now be done by minimally invasive techniques.[ 21 69 ] Tuberculous involvement of the bronchi can occur and may result in stenosis of the major airway with distal lung collapse. These need surgery but only when the active disease process has been controlled. No surgery is advised in the central airways during an active process. It is also important to ensure viability of the distal parenchyma. Pre-operative angiography and even positron emission tomography–computed tomography (PET-CT) might help in this decision. Permanent chest wall sinuses (with or without rib osteomyelitis) need active intervention following proven local sterilisation.[ 35 ]

Failure of adequate medical therapy beyond 4-6 months of sputum-positive multidrug-MDR and XDR tuberculosis patients who have anatomically limited lesion (s) (usually a cavity) is a generally accepted indication for resection.[ 33 ] Sputum/smear negative, but culture positive, patients with similar focal lesions are also candidates for surgery.[ 34 35 36 37 38 39 40 41 ] In patients with bilateral lung involvement (40-90% of the total cases), dominant lesions are usually unilateral; consequently, small contralateral nodules or cavities should be initially managed only with post-operative medical therapy. However, if sputum conversion does not occur after surgery for dominant lesions, small contralateral cavitary lesions may need to be removed as well[ 37 38 39 40 41 ] Patients who relapse, especially those with a recurrent limited lesion during or after treatment, are also amenable to surgery. These may also include patients who are sensitive to standard regimens.[ 37 38 39 40 41 ] Patients with high risk of relapse based on drug resistance profile (e.g. XDR-TB cases). The onset of quinolone resistance is a strong pro-surgery argument, as a signal of the impeding MDR to XDR transition, and such patients may be candidates for surgery, provided appropriate target lesions exist.[ 39 ] Severe life-threatening hemoptysis non-responsive to conservative treatment or bronchial artery embolisation and persisting bronchopleural fistula of M/XDR patients with focal disease is also an indication for surgery.[ 41 ] Rare indications include drug intolerance, allergy, liver/kidney diseases contraindicating standard anti-tuberculous medication, and special social indications like addictions and problems with patient compliance.[ 39 ] Tension pneumothorax, secondarily infected thoracic empyema leading to sepsis, are absolute indications for surgical intervention, regardless of drug sensitivity.[ 39 41 ] Loculated effusions presenting during or after completion of medical treatment cause lung collapse and entrapment, restriction and loss of lung volume and changes in chest contour as above. As discussed above, patients with loculated effusions are more likely to have residual pleural thickening with significant reductions in forced vital capacity.[ 28 29 30 ] Early VATS or open decortication seems to be beneficial and safe with low recurrence rates.[ 42 ] and significant improvements in lung function occur with early intervention.[ 43 ] A large number of complications needing surgery have followed tubercular involvement of mediastinal nodes. Though uncommon, most need surgery. It has been suggested, that serious complications usually following necrosis of mediastinal nodes, the so-called mediastinal lymph node tuberculous abscesses (MLNTA). MLNTA can be of two types: a) local abscesses secondary to mediastinal tuberculous lymphadenitis; in this group, presentation can be with persistent or recurrence of fever, cough or pressure symptoms. The second group presents with supraclavicular, suprasternal or/and parasternal abscesses or fistulisation into neighbouring organ secondary to MLNTA.[ 44 ] VATS or open drainage is required and is usually successful.[ 44 ] A further issue is the persistence of lymph nodes despite completion of treatment. This occurs in 17-20% of patients.[ 18 ] and if a question of incomplete treatment or drug resistance may arise and necessitate a surgical excision. If surgery is indicated, a maximally parenchymal-sparing approach is always recommended whenever possible since disease relapse may occur despite adequate surgical intervention and appropriate chemotherapy. The amount of lung resected should be the minimal necessary to achieve the objective. Lung resection possibilities may range from wedge resection to segmental resection,[ 45 ] lobectomy and even lobectomy. In most cases, it is strongly recommended that resectional surgery be carried out after anti-tuberculous medication for some time. Normally, a period of 3-4 (and up to 6-8) months has been recommended but this is empirical. VATS is preferable to open surgery but availability of surgical expertise and specialised equipment availability are important considerations. Failure of adequate medical therapy beyond 4-6 months of sputum-positive multidrug-MDR and XDR tuberculosis patients who have anatomically limited lesion (s) (usually a cavity) is a generally accepted indication for resection.[ 33 ] Sputum/smear negative, but culture positive, patients with similar focal lesions are also candidates for surgery.[ 34 35 36 37 38 39 40 41 ] In patients with bilateral lung involvement (40-90% of the total cases), dominant lesions are usually unilateral; consequently, small contralateral nodules or cavities should be initially managed only with post-operative medical therapy. However, if sputum conversion does not occur after surgery for dominant lesions, small contralateral cavitary lesions may need to be removed as well[ 37 38 39 40 41 ] Patients who relapse, especially those with a recurrent limited lesion during or after treatment, are also amenable to surgery. These may also include patients who are sensitive to standard regimens.[ 37 38 39 40 41 ] Patients with high risk of relapse based on drug resistance profile (e.g. XDR-TB cases). The onset of quinolone resistance is a strong pro-surgery argument, as a signal of the impeding MDR to XDR transition, and such patients may be candidates for surgery, provided appropriate target lesions exist.[ 39 ] Severe life-threatening hemoptysis non-responsive to conservative treatment or bronchial artery embolisation and persisting bronchopleural fistula of M/XDR patients with focal disease is also an indication for surgery.[ 41 ] Rare indications include drug intolerance, allergy, liver/kidney diseases contraindicating standard anti-tuberculous medication, and special social indications like addictions and problems with patient compliance.[ 39 ] Tension pneumothorax, secondarily infected thoracic empyema leading to sepsis, are absolute indications for surgical intervention, regardless of drug sensitivity.[ 39 41 ] Loculated effusions presenting during or after completion of medical treatment cause lung collapse and entrapment, restriction and loss of lung volume and changes in chest contour as above. As discussed above, patients with loculated effusions are more likely to have residual pleural thickening with significant reductions in forced vital capacity.[ 28 29 30 ] Early VATS or open decortication seems to be beneficial and safe with low recurrence rates.[ 42 ] and significant improvements in lung function occur with early intervention.[ 43 ] A large number of complications needing surgery have followed tubercular involvement of mediastinal nodes. Though uncommon, most need surgery. It has been suggested, that serious complications usually following necrosis of mediastinal nodes, the so-called mediastinal lymph node tuberculous abscesses (MLNTA). MLNTA can be of two types: a) local abscesses secondary to mediastinal tuberculous lymphadenitis; in this group, presentation can be with persistent or recurrence of fever, cough or pressure symptoms. The second group presents with supraclavicular, suprasternal or/and parasternal abscesses or fistulisation into neighbouring organ secondary to MLNTA.[ 44 ] VATS or open drainage is required and is usually successful.[ 44 ] A further issue is the persistence of lymph nodes despite completion of treatment. This occurs in 17-20% of patients.[ 18 ] and if a question of incomplete treatment or drug resistance may arise and necessitate a surgical excision. If surgery is indicated, a maximally parenchymal-sparing approach is always recommended whenever possible since disease relapse may occur despite adequate surgical intervention and appropriate chemotherapy. The amount of lung resected should be the minimal necessary to achieve the objective. Lung resection possibilities may range from wedge resection to segmental resection,[ 45 ] lobectomy and even lobectomy. In most cases, it is strongly recommended that resectional surgery be carried out after anti-tuberculous medication for some time. Normally, a period of 3-4 (and up to 6-8) months has been recommended but this is empirical. VATS is preferable to open surgery but availability of surgical expertise and specialised equipment availability are important considerations.

It is important to remember the risks posed by surgical procedures on TB patients to healthcare personnel involved in the care of such patients. TB is an airborne infection and can spread through the air even during a surgical procedure. OR personnel have been reported to develop infection after surgery.[ 70 ] This can be prevented by mandatory adoption of strict precautions against airborne infections during medical procedures on a patient with confirmed or suspected active TB. This also applies to staff in endoscopy units and pathology departments during handling of respiratory tract specimens. Excellent protocols exist and can be adopted by individual units.[ 21 ]