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Chapter 10 : Role of Surgery in the Diagnosis and Management of Tuberculosis

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Abstract:

The history of thoracic surgery as a specialty is inseparable from that of the development of tuberculosis (TB) management. Many surgeons would suggest that the very first surgical procedure in the chest was probably performed in the time of the Ancient Greeks. Hippocrates himself described a technique of open pleural drainage for empyema thoracis resulting from TB ( ). Modern thoracic surgery as clinicians would recognize it today was born soon after the identification of by Koch in the 1880s. When it was realized that the microbe responsible for “consumption” was an obligate aerobe, a variety of collapse therapies were developed in the late 19th and early 20th centuries to kill the organism through oxygen deprivation. These included thoracoplasty, induced pneumothorax, ball plombage, pneumoperitoneum, and phrenic nerve crushing ( ). Crucially, most of the basic skills and approaches still used in modern thoracic surgery today were also honed at this time, including the ubiquitous thoracotomy incision. Even minimally invasive thoracic surgery traces its roots to this period, when Jacobeus introduced the technique of thoracoscopy for pleural biopsy and adhesiolysis in TB patients ( ).

Citation: Sihoe A. 2017. Role of Surgery in the Diagnosis and Management of Tuberculosis, p 159-186. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0043-2017
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Figures

Image of Figure 1
Figure 1

A traditional posterolateral thoracotomy is traumatic but gives good access for complex thoracic operations such as thoracoplasty . The thoracotomy wound is long , and the surgical trauma is known to cause morbidity postoperatively in many patients. The cosmetic result can be compared to figures showing VATS procedures in this review.

Citation: Sihoe A. 2017. Role of Surgery in the Diagnosis and Management of Tuberculosis, p 159-186. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0043-2017
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Image of Figure 2
Figure 2

A conventional 3-port VATS procedure. The standard 3-port strategy is used with the ports arranged in a baseball diamond pattern (dotted line).

Citation: Sihoe A. 2017. Role of Surgery in the Diagnosis and Management of Tuberculosis, p 159-186. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0043-2017
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Image of Figure 3
Figure 3

Needlescopic VATS is performed using 3-mm instruments that are little wider than a cocktail stick . Here, a lung wedge excision biopsy is performed using two 3-mm ports and one 10-mm port required for delivery of the resected specimen. The 3-mm ports will be barely visible after healing, and the 10-mm port is only as wide as a standard chest tube .

Citation: Sihoe A. 2017. Role of Surgery in the Diagnosis and Management of Tuberculosis, p 159-186. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0043-2017
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Image of Figure 4
Figure 4

Uniportal VATS is performed with the video-thoracoscope and instruments all applied via a single 3-cm incision, thereby minimizing the surgical access “footprint” . Major thoracic procedures, including anatomic major lung resections, can be performed via an incision barely longer than a standard chest drain incision wound .

Citation: Sihoe A. 2017. Role of Surgery in the Diagnosis and Management of Tuberculosis, p 159-186. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0043-2017
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Image of Figure 5
Figure 5

Systematic lymph node dissection at all intrathoracic stations is performed effectively using VATS (in these photos, using a uniportal approach). These photos show examples of good access to the right paratracheal , right subcarinal , left aorto-pulmonary window , and left inferior pulmonary ligament lymph node stations.

Citation: Sihoe A. 2017. Role of Surgery in the Diagnosis and Management of Tuberculosis, p 159-186. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0043-2017
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Image of Figure 6
Figure 6

Decortication for pleural empyema can be performed in most patients using VATS—in this case, with a conventional 3-port approach . The cosmetic result is satisfactory given that the surgery itself is often technically difficult or tedious . During the operation, all pus is drained and the exudative pleural peel is stripped meticulously from the chest wall and especially from the lung surface, allowing the lung to fully reexpand . In a stage II/III empyema, the exudative pleural peel can be considerably thick, almost like an orange peel . Other than surgery, there is no effective means of removing such a thick peel that restricts the lung.

Citation: Sihoe A. 2017. Role of Surgery in the Diagnosis and Management of Tuberculosis, p 159-186. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0043-2017
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Image of Figure 7
Figure 7

VATS decortication is performed for a TB empyema necessitans using a 3-port “inside-out” approach. The 3 ports are sited well away from the chest wall/subcutaneous collection pointed out by the white arrow . The chest wall collection is reached from inside the pleural space, via the opening in the intercostal space. Here, a catheter is seen being inserted via that intercostal opening outwards into the chest wall collection to flush and drain it .

Citation: Sihoe A. 2017. Role of Surgery in the Diagnosis and Management of Tuberculosis, p 159-186. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0043-2017
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Image of Figure 8
Figure 8

Modern CT scanning with 3D reconstruction images gives highly detailed images that are invaluable for planning surgical interventions. In a patient with a stenotic left main bronchus following endobronchial TB, the site, diameter, and length of the stenotic segment are clearly visualized in preparation for a dilatation and stenting procedure . In a patient with NTM infection complicating a right lower lobe intralobar pulmonary sequestration, the 3D reconstruction clearly delineates the course of the abnormally feeding arteries from the abdominal aorta, allowing them to be safely identified during subsequent VATS resection ( and ).

Citation: Sihoe A. 2017. Role of Surgery in the Diagnosis and Management of Tuberculosis, p 159-186. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0043-2017
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Tables

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Table 1

Summary of selected case series reporting lung resection surgery for MDR-TB (2006 to 2016)

Citation: Sihoe A. 2017. Role of Surgery in the Diagnosis and Management of Tuberculosis, p 159-186. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0043-2017

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