Full text loading...
Chapter 9 : Role of Surgery in the Diagnosis and Management of Tuberculosis
Category: Clinical Microbiology; Bacterial Pathogenesis
Ebook: Choose a downloadable PDF or ePub file. Chapter is a downloadable PDF file. File must be downloaded within 48 hours of purchase
This chapter provides an overview of the role that modern thoracic surgery can play in diagnosing and managing patients with TB and its sequelae. When operating on patients with tuberculosis (TB), the same fundamental principles and considerations of any thoracic surgical operation still apply. It is worth considering some of the common concepts before proceeding with the detailed discussion of surgery for specific aspects of TB management. The first consideration when called upon to diagnose TB through surgery is to identify a potential target site for biopsy. Secondary considerations include the patient’s suitability for surgery. For patients for whom surgery is potentially hazardous, alternative investigation modalities or even empirical anti-TB treatment may need to be considered. The primary management of TB today is undoubtedly medical, and anti-TB drugs are highly effective in the vast majority of cases. The aim of surgical treatment is to remove the predominant pulmonary lesion(s), thereby circumventing difficulty in drug penetration and reducing the mycobacterial burden. Whenever surgery is considered for a patient with bronchiectasis, it is crucial to fully counsel him or her on the implications of surgery. In patients without the need for urgent resections or who may not tolerate resections, autopneumonectomy or lobectomy may be allowed to occur. The advantage of minimally invasive thoracic surgery is not only its capacity to reduce morbidity for individual patients but also its potential to allow a wider range of TB patients to be considered for effective surgical management.
A typical VATS procedure. The standard three-port strategy is used with the ports arranged in a baseball diamond pattern: camera port at the home plate (HP), target lesion at second base (2B), and right and left instrument ports at first (1B) and third (3B) bases, respectively.
Needlescopic VATS is performed using 3-mm instruments that are little wider than a cocktail stick (A). Here, a lung wedge excision biopsy is performed using two 3-mm ports (white arrows) and one 10-mm port required for delivery of the resected specimen (black arrow). The cosmetic result is satisfactory; the 3-mm ports will be barely visible after healing (B). The excised wedge from this patient is sizeable despite the small wounds, and on cutting open the tissue the discrete target nodular lesion (arrow) is seen resected (C).
A single-shared-port approach can be used for pleural biopsy with VATS. A biopsy forceps is inserted coaxially with the video thoracoscope, minimizing the number of wounds required.
The surgical technique used for thoracic lymph node biopsy depends on the positions of the nodes. Mediastinal nodes corresponding to stations 2, 4, and 7 on the AJCC-UICC map ( ) can be biopsied using TBNA, EBUS-guided fine-needle aspiration mediastinoscopy, VATS, or thoracotomy. Aortic nodes of stations 5 and 6 ( ) are most commonly accessed by left VATS, mediastinotomy, or thoracotomy. Inferior mediastinal nodes of stations 8 and 9 ( ) and hilar nodes of stations 10 and 11 ( ) are most commonly accessed by VATS or thoracotomy.
Major lung resections are nowadays commonly performed using a VATS approach (left). The contrast with the traditional posterolateral thoracotomy approach (right) in terms of wound trauma is obvious. Both photos were taken on the first postoperative day.
If an empyema thoracis is not promptly drained, it may progress to become a fibrothorax in which a very thick postinflammatory peel (left) can encase the lung. Decortication is required to allow lung reexpansion. Nowadays, complete decortication for even advanced empyema and fibrothorax can be achieved by VATS, which gives excellent intrathoracic visualization (center) and minimal surgical wound trauma (right).
Modern CT scanning—with spectacular three-dimensional reconstruction images of the airways—gives highly detailed images that are invaluable for planning airway interventions. In this image, the site, diameter, and length of a stenotic segment in the left main bronchus can be clearly seen.
Summary of selected recent case series reporting lung resection surgery for MDR-TB