Surgical management of MDR and XDR TB

Surgical management of MDR and XDR TB

Surgical management of MDR and XDR TB

Lehlohonolo Dongo

Hannes Meyer Cardiothoracic Surgery Research an Trainining Symposium

Stellenbosch

22-24 March 2012

Lehlohonolo Dongo

Hannes Meyer Cardiothoracic Surgery Research an Trainining Symposium

Stellenbosch

22-24 March 2012

IntroductionIntroduction• Sanatoria 100 yrs. Ago

• Carlo Forlanini 1888, Italy

• In past the past 2 decades- “re-emergence of sanatoria”

• Rekindled interest in surgery

• Surgery is a useful adjunct (Van Leuven et al, 1997)

• Sanatoria 100 yrs. Ago

• Carlo Forlanini 1888, Italy

• In past the past 2 decades- “re-emergence of sanatoria”

• Rekindled interest in surgery

• Surgery is a useful adjunct (Van Leuven et al, 1997)

Milestones in the evolution of surgery for TB

Milestones in the evolution of surgery for TB

Event Date comment

Carson 1819 Therapeutic artificial pneumothorax

Carlo Forlanini 1882 First artificial pneumothorax

Simon 1869 Thoracoplasty to control empyema thoracis

Estlander 1879 description of thoracoplasty

Bernard de Cerenville

1885 First thoracoplasty for TB

E. Delorme 1894 Pulmonary decortication

H. Lilienthal 1933 PneumonectomyS. freedlander 1935 Lobectomy

Monaldi 1938 Carvena drainage

Cont’dCont’d• ↑incidence worldwide- 10% all new TB case, 40% of

recurrent cases

• Recently XDR

• MDR- resistance to INH and RIF

• XDR- resistance to INH, RIF and FQN and at least 1 of the 3 2nd line drugs

• Clinical diagnosis– +ve smear– No improvement– No ∆ / worsening CXR– Resistance to 1st line drugs

• ↑incidence worldwide- 10% all new TB case, 40% of recurrent cases

• Recently XDR

• MDR- resistance to INH and RIF

• XDR- resistance to INH, RIF and FQN and at least 1 of the 3 2nd line drugs

• Clinical diagnosis– +ve smear– No improvement– No ∆ / worsening CXR– Resistance to 1st line drugs

Cont’dCont’d

• 48%-80% treatment success on 2nd line drugs

• Primary indication for resectional surgery in the US

• Pomerantz et al,– 180 resections: early mortality=3%, late mortality of 7%,

morbidity 12 %– Mostly localised disease (often cavitory), destroyed lung, BPF– 50% pts +ve sputum pre-op– 98% -ve sputum at mean length 7 yrs post-op– More aggressive resectional surgery & FQN– Indications for surgery– Management guidelines

• 48%-80% treatment success on 2nd line drugs

• Primary indication for resectional surgery in the US

• Pomerantz et al,– 180 resections: early mortality=3%, late mortality of 7%,

morbidity 12 %– Mostly localised disease (often cavitory), destroyed lung, BPF– 50% pts +ve sputum pre-op– 98% -ve sputum at mean length 7 yrs post-op– More aggressive resectional surgery & FQN– Indications for surgery– Management guidelines

Is there evidence for surgical resection in MDR-TB?

Is there evidence for surgical resection in MDR-TB?

Author Year Number Operations

Mortality Morbidity Cure rate (-ve sputum

Van Leuven 1997 62 1.6% 23% 80%

Sung 1999 27 0% 25.9% 96.3%

Pomerantz 2001 180 3.3% 12% 98%

Shiraishi 2004 95 0% 11.5% 93%

Naidoo 2005 23 0% 17.4% 95.6%

Dewan 2006 74 4.1% 32% 89.8%

Mohsen 2007 23 4.3% 34.7% 96.0%

Evolving surgical indications for thoracic TBEvolving surgical indications for thoracic TB1957 1974 1989 1995 2005 2007

Rule out cancer

✓ ✓ ✓ ✓ ✓ ✓Failure of chemotherapy

✓ ✓ ✓ - ✓ -

Sequelae/destroyed lung

✓ ✓ ✓ ✓ ✓ ✓Failed operation/complication

✓ ✓ - - - -

Hemoptysis - ✓ ✓ ✓ ✓ ✓MDR-TB - - ✓ ✓ ✓ ✓Pleural disease/BPF

- ✓ - ✓ ✓ ✓Aspergilloma

- - ✓ - - -

What are the indications for surgery in MDR and XDR-TB?

What are the indications for surgery in MDR and XDR-TB?

PRIMARY• Resistant TB to at least 2 drugs,

including isoniazid and rifampin with localized resectable disease

• Persistent cavitary disease• Persistent positive sputum—

with/without cavity• MDR/XDR-TB with destroyed

lung (atelectasis/collapse/bronchiectasis)

• Massive hemoptysis• Bronchopleural fistula• Bronchostenosis with distal disease• Lung mass—unknown etiology,

rule out carcinoma

PRIMARY• Resistant TB to at least 2 drugs,

including isoniazid and rifampin with localized resectable disease

• Persistent cavitary disease• Persistent positive sputum—

with/without cavity• MDR/XDR-TB with destroyed

lung (atelectasis/collapse/bronchiectasis)

• Massive hemoptysis• Bronchopleural fistula• Bronchostenosis with distal disease• Lung mass—unknown etiology,

rule out carcinoma

SECONDARY1. -ve sputum but symptoms result of

permanently altered anatomy • infection, • destroyed lobe• Bronchiectasis• bronchial stenosis• cavity)

2. -ve sputum with localized disease in whom reactivation is likely

3. Decortication of trapped lung

SECONDARY1. -ve sputum but symptoms result of

permanently altered anatomy • infection, • destroyed lobe• Bronchiectasis• bronchial stenosis• cavity)

2. -ve sputum with localized disease in whom reactivation is likely

3. Decortication of trapped lung

Surgical optionsSurgical options

Diagnostic proceduresDiagnostic procedures• Thoracentesis

• Transthoracic needle aspirate

• Closed/open pleural biopsy

• Bronchoscopy (flexible/rigid) (transbronchial needle aspiration)

• Medistinoscopy/anterior mediasternotomy (Chamberlain procedure)

• Thoracoscopy (video-assisted thoracic surgery)

• Exploratory/diagnostic thoracotomy—wedge biopsy

• Thoracentesis

• Transthoracic needle aspirate

• Closed/open pleural biopsy

• Bronchoscopy (flexible/rigid) (transbronchial needle aspiration)

• Medistinoscopy/anterior mediasternotomy (Chamberlain procedure)

• Thoracoscopy (video-assisted thoracic surgery)

• Exploratory/diagnostic thoracotomy—wedge biopsy

Therapeutic proceduresTherapeutic procedures• Decortication—with/without lung

resection

• Drainage (closed/open) (temporary/permanent); Eloesser procedure

• Thoracotomy with resection

– Segment/wedge

– Lobectomy

– Pneumonectomy (transpleural; extrapleural; completion)

• Chest wall/vertebral body-disc resection/stabilization

• Muscle flaps (myoplasty)

• Thoracoplasty (modified/tailored)

• Omental transfer

• Decortication—with/without lung resection

• Drainage (closed/open) (temporary/permanent); Eloesser procedure

• Thoracotomy with resection

– Segment/wedge

– Lobectomy

– Pneumonectomy (transpleural; extrapleural; completion)

• Chest wall/vertebral body-disc resection/stabilization

• Muscle flaps (myoplasty)

• Thoracoplasty (modified/tailored)

• Omental transfer

Treatment of tuberculosis: indications for surgery

Treatment of tuberculosis: indications for surgery

• Complications resulting from previous surgery

• Delayed complications of plombage

• Complications of insufficient surgery (early/late)

• Failure of medical therapy (active disease) (positive sputum/culture)

• Progressive disease, lung destruction, and left bronchus syndrome (sequelae)

• Drug resistance (MDR-TB; XDR-TB)

• Complications resulting from previous surgery

• Delayed complications of plombage

• Complications of insufficient surgery (early/late)

• Failure of medical therapy (active disease) (positive sputum/culture)

• Progressive disease, lung destruction, and left bronchus syndrome (sequelae)

• Drug resistance (MDR-TB; XDR-TB)

• Aspergillosis complicating treatment

• Surgery for diagnosis

• Pulmonary lesions of unknown cause (rule out malignancy)

• Mediastinal adenopathy of unknown cause

• Complications of scarring (sequelae)

• Severe hemoptysis (200 mL/24 hours; massive: 600 mL/24 hours)

• Aspergillosis complicating treatment

• Surgery for diagnosis

• Pulmonary lesions of unknown cause (rule out malignancy)

• Mediastinal adenopathy of unknown cause

• Complications of scarring (sequelae)

• Severe hemoptysis (200 mL/24 hours; massive: 600 mL/24 hours)

Indications.....cont’dIndications.....cont’d

• Cavernoma: positive sputum with cavitation 5 to 6 months post chemotherapy; negative

• sputum with cavitation (size/thickness of cavity)

• Tracheo- or bronchoesophageal fistula

• Bronchiectasis

• Extrinsic airway obstruction by tuberculous lymph nodes

• Endobronchial tuberculosis and bronchostenosis

• Right middle lobe syndrome (bronchial compression/obstruction)

• Cavernoma: positive sputum with cavitation 5 to 6 months post chemotherapy; negative

• sputum with cavitation (size/thickness of cavity)

• Tracheo- or bronchoesophageal fistula

• Bronchiectasis

• Extrinsic airway obstruction by tuberculous lymph nodes

• Endobronchial tuberculosis and bronchostenosis

• Right middle lobe syndrome (bronchial compression/obstruction)

• Pleural tuberculosis

• Pleural effusion

• Empyema (TB/mixed pyogenic); with/without lung parenchyma involvement; trapped lung

• Bronchopleural fistula

• Intrathoracic disease

• Tuberculosis of the heart and great vessels

• Vascular malformations

• Constrictive pericarditis

• Cold abscesses and osteomyelitis of the chest wall

• Pott’s disease (thoracic spine/disc)

• Pleural tuberculosis

• Pleural effusion

• Empyema (TB/mixed pyogenic); with/without lung parenchyma involvement; trapped lung

• Bronchopleural fistula

• Intrathoracic disease

• Tuberculosis of the heart and great vessels

• Vascular malformations

• Constrictive pericarditis

• Cold abscesses and osteomyelitis of the chest wall

• Pott’s disease (thoracic spine/disc)

PrecautionsPrecautions

• Peri-operative

– Patient

• Early diagnosis

• Isolation

• Masks

• Prompt treatment

– Health workers

– Environment (ward, theater, ICU)

• Natural ventilation

• Negative pressure-window fans,exhaust ventilation fans

• Air filtration

• UV germicidal irradiation

• Peri-operative

– Patient

• Early diagnosis

• Isolation

• Masks

• Prompt treatment

– Health workers

– Environment (ward, theater, ICU)

• Natural ventilation

• Negative pressure-window fans,exhaust ventilation fans

• Air filtration

• UV germicidal irradiation

Surgical considerationsSurgical considerations

1. Pre-operative evaluation/assessment

2. Operative/anesthesia considerations

3. Surgical/Technical

4. Postoperative considerations

1. Pre-operative evaluation/assessment

2. Operative/anesthesia considerations

3. Surgical/Technical

4. Postoperative considerations

1. Pre-operative evaluation/assessment1. Pre-operative evaluation/assessment

• History and physical examination

• Nutrition—weight loss/debilitation/albumin 3.0 g/dL/Vit C

• HIV/AIDS

• Severity

• Comorbidity

• Associated diseases +/-Sputum

• Polymicrobial infection

• Chemotherapy—minimum of 3 months when feasible

• Pulmonary/infectious disease consultation

• Diagnostic studies—CXR/CT scan

• Cardiopulmonary evaluation—ECG, PFT, V/Q scan

• Confirmed diagnosis (smear or culture)

• Other diagnostic studies (PCR, inflammtory markers, histology)

• History and physical examination

• Nutrition—weight loss/debilitation/albumin 3.0 g/dL/Vit C

• HIV/AIDS

• Severity

• Comorbidity

• Associated diseases +/-Sputum

• Polymicrobial infection

• Chemotherapy—minimum of 3 months when feasible

• Pulmonary/infectious disease consultation

• Diagnostic studies—CXR/CT scan

• Cardiopulmonary evaluation—ECG, PFT, V/Q scan

• Confirmed diagnosis (smear or culture)

• Other diagnostic studies (PCR, inflammtory markers, histology)

Complex AspergillomaComplex Aspergilloma

CXRCXR

Cavitory disease

CT scanCT scan

Cavitory disease

2. Operative/anesthesia considerations2. Operative/anesthesia considerations• Precautions

• Access

• Anesthesia/epidural

• Bronchoscopy (rule out copious secretions/stenosis/endobronchial disease)

• Airway—double lumen endobracheal tube or bronchial blocker/ Positioning—lateral decubitis/prone (Overholt table)

• Bronchoscopy (positioning of endotracheal tube)

• Precautions

• Access

• Anesthesia/epidural

• Bronchoscopy (rule out copious secretions/stenosis/endobronchial disease)

• Airway—double lumen endobracheal tube or bronchial blocker/ Positioning—lateral decubitis/prone (Overholt table)

• Bronchoscopy (positioning of endotracheal tube)

Curr Probl Surg, October 2008

Diagnostic proceduresDiagnostic procedures

• Diagnostic thoracentesis, closed pleural biopsy, TTNA or biopsy, and TBNA or biopsy, usually performed under fluoroscopy

• Khan et al– 22 pts CT TTNA for suspected mediastinal

lymph nodes

• True +ve rate 66% cf 20% for fiberoptic bronchoscopy, 75% for cervical mediastinoscopy and 100% for thoracotomy

• Diagnostic thoracentesis, closed pleural biopsy, TTNA or biopsy, and TBNA or biopsy, usually performed under fluoroscopy

• Khan et al– 22 pts CT TTNA for suspected mediastinal

lymph nodes

• True +ve rate 66% cf 20% for fiberoptic bronchoscopy, 75% for cervical mediastinoscopy and 100% for thoracotomy

BronchoscopyBronchoscopy

• +ve diagnosis in 30-50% cases

• >80% with BAL

• exclude endobronchial disease

• Active endobronchial disease = reconsider extent of resection

• Therapeutic bronchoscopy

• +ve diagnosis in 30-50% cases

• >80% with BAL

• exclude endobronchial disease

• Active endobronchial disease = reconsider extent of resection

• Therapeutic bronchoscopy

MediastinoscopyMediastinoscopy

• Pts with mediastinal adenopathy

• Absent radiographic features and negative bronchoscopy

• sampling of 3 or more nodal stations recommended.

• Pts with mediastinal adenopathy

• Absent radiographic features and negative bronchoscopy

• sampling of 3 or more nodal stations recommended.

3. Surgical resection3. Surgical resection

• Serratus sparing posterolateral thoracotomy

• Dissection—extrapleural; avoiding esophagus, azygous vein, subclavian vessels, internal mammary artery, recurrent laryngeal nerve.

• Preserve lung/remove destroyed lung

• Spillage (contamination of pleural space)

• Air leaks—avoid, treat

• Bleeding—cautery

• Serratus sparing posterolateral thoracotomy

• Dissection—extrapleural; avoiding esophagus, azygous vein, subclavian vessels, internal mammary artery, recurrent laryngeal nerve.

• Preserve lung/remove destroyed lung

• Spillage (contamination of pleural space)

• Air leaks—avoid, treat

• Bleeding—cautery

• Eliminate dead space– Collapse– Muscle

• Bronchus—avoid avascularization/coverage/protection

– Intercostal muscle flap, pericardial flap, diaphragmatic pedicle flap

• Pleural contamination

• Muscle flaps (initial use) (usually latissimus dorsi muscle)

– Positive sputum– BPF– Mixed infection pleural space– Anticipated space problem

• Omentum (previous thoracotomy); based on right gastroepiploic artery

• Eliminate dead space– Collapse– Muscle

• Bronchus—avoid avascularization/coverage/protection

– Intercostal muscle flap, pericardial flap, diaphragmatic pedicle flap

• Pleural contamination

• Muscle flaps (initial use) (usually latissimus dorsi muscle)

– Positive sputum– BPF– Mixed infection pleural space– Anticipated space problem

• Omentum (previous thoracotomy); based on right gastroepiploic artery

Options for muscle transpositionOptions for muscle transposition

Curr Probl Surg, October 2008

Rib resection insertion sitesRib resection insertion sites

Curr Probl Surg, October 2008

Latissimus dorsi transposition and insertion

Latissimus dorsi transposition and insertion

Curr Probl Surg, October 2008

Omentum transpositionOmentum transposition

Curr Probl Surg, October 2008

Types of thoracoplastyTypes of thoracoplastyEstlander 1879 Decostalization of chest wall

Schede 1890 Resection of ribs, intercostal muscles, and pleuralpeel

Alexander 1928 Staged (usually 3) resection

Grow 1946 Excision of parietal peel

Kergin 1953 Excision of thick parietal peel

Bjork 1954 Osteoplastic thoracoplasty in 1 stage maintainschest wall stability

Tailoring (modified) 1959 Tailoring the thoracoplasty (number of ribs) to sizeof postresectional spine; performed 3-4 weeksprior to lung resection

Andrews 1961 Thoracomediastinal plication

Pre and post operative modified thoracoplasty

Pre and post operative modified thoracoplasty

Thoracoplasty techniqueThoracoplasty technique

Curr Probl Surg, October 2008

Schede and traditional Alexander style thoracoplasty

Schede and traditional Alexander style thoracoplasty

Curr Probl Surg, October 2008

Kergin-Grow thoracoplastyKergin-Grow thoracoplasty

Curr Probl Surg, October 2008

Andrews procedureAndrews procedure

Approaches for the persisting space problem

Approaches for the persisting space problem

Classic Alexander 3-stage 7-rib thoracoplasty

Classic Alexander 3-stage 7-rib thoracoplasty

Post operative thoracoplasty patientPost operative thoracoplasty patient

4. Postoperative considerations4. Postoperative considerations

EARLY

• Early extubation

• Adequate analgesia

• BPF/Bleeding/Air leaks

• Atelectasis

• Ambulation

• Chest physio

• Nutrition

EARLY

• Early extubation

• Adequate analgesia

• BPF/Bleeding/Air leaks

• Atelectasis

• Ambulation

• Chest physio

• Nutrition

LATE

• Cultures/sensitivities/resistance

• Anti-TB treatment

• BPF/space problems with/out empyema

LATE

• Cultures/sensitivities/resistance

• Anti-TB treatment

• BPF/space problems with/out empyema

In conclusion:In conclusion:

Surgery is a useful adjunct with good outcomes in appropriately selected

MDR/XDR patients with acceptable morbidity and mortality.

Surgery is a useful adjunct with good outcomes in appropriately selected

MDR/XDR patients with acceptable morbidity and mortality.

There is a place for Surgery in Medicine...after all

There is a place for Surgery in Medicine...after all

World TB day!World TB day!