Surgical treatment of
tuberculosis (TB)
Department of Thoracic Surgery,
General and Oncological Surgery
EPIDEMIOLOGY
Tuberculosis (TB) is an infectious disease caused by
acid-fast strains of mycobacteria, (Mycobacterium
tuberculosis), which was discovered by Robert Koch
in 1882.
 It is estimated that one third of world population is
suffering from TB and nearly half of new TB patients
come from south Asia.
 TB incidence is reported for 8-9 million new patients
a year.

EPIDEMIOLOGY
TB mortality is estimated for 3 million a year.
 Despite the presence of highly efficient
antitubercular drugs TB incidence rate is on
increase since the beginning of 1985.

EPIDEMIOLOGY
The main reasons for that are as follows:
1.
2.
3.
4.
deteriorating social conditions
intravenous drug injections
limited access to public health service
secondary resistance to treatment of
mycobacteria
5. immunosuppression in the course of
diseases such as AIDS
6. systemic chemiotherapy
EPIDEMIOLOGY
In Poland the incidence rate is on the
decrease. In the 50s of the previous
century TB was diagnosed in 20% of
the population.
 At present, each year TB afflicts nearly
100.000 people in Poland
 The most endangered are elderly
people (65 years old and more)

EPIDEMIOLOGY
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The most common site of TB infection are lungs.
In case of normally functioning immune response
TB infection is asymptomatic
Only 10% of TB infections result with
development of the disease
Approximately 5% of people develop primary TB,
directly after the infection.
Others are likely to develop TB many years after
infection due to TB reactivation
(post-primary TB).
SYMPTOMATOLOGY

The most common TB symptom is
prolonged cough (lasting over 3 weeks)first dry (non-productive),
then moist (productive) cough with
mucopurulent sputum
SYMPTOMATOLOGY
Moreover some nonspecific symptoms can be
observed such as:
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fatigue,
weakness,
weight loss,
night sweats,
low-grade fever
dyspnoea (is usually present in advanced stages
of TB infection).
SYMPTOMATOLOGY
Physical examination reveals no specific
signs.
 Chest percussion may detect a dullness
over the affected area
 Auscultation usually detects silenced
vesicular respiration as a result of
atelectasis or pulmonary infiltration.

SYMPTOMATOLOGY

In primary TB chest X-ray may reveal
condensations located in the middle or upper
lung fields.

Typical X-ray signs of TB include:
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patchy infiltrates,
cavity formation,
scar tissue,
calcium deposits, however, it may not be able
to distinguish active from inactive TB.
SYMPTOMATOLOGY
In 30% of TB cases nodular enlargement
in the hili and near trachea (mainly rightsided) is observed.
 Significant nodular enlargement may
result in atelectasis, oesophageal
compression or superior caval vein
syndrome.
 In 15% of TB cases regular chest X-ray
reveals no abnormalities!

SYMPTOMATOLOGY
Post-primary TB is characterized
by condensations located in apical
lobes and upper posterior lobes.
TB infiltrates may be absorbed or
heal by fibrosis.
DIAGNOSTICS
To confirm TB suspicion, smears and
cultures must be collected (sputum,
CSF, urine, drainage from abscess or
pleural fluid).
 In some patients microscopic
examination (Ziehl-Neelsen’s staining or
fluorescent staining methods) shows
the presence of tubercle bacilli (“open”
active TB).

DIAGNOSTICS
 Conventional methods of TB diagnostics may take
up to 4 months:
repeated bacteriological cultures- if positive
confirm TB diagnosis,
negative- have no exclusive power).
 The most recent methods include:
 BACTEC (marked fatty acids detection) -results
after 1-2 weeks
 Mycobacterium DNA detection (PCR method) -1
week.
TREATMENT
Tuberculosis
Pharmacological treatment
Surgical treatment
PHARMACOLOGICAL TREATMENT

Pharmacological treatment of TB is divided
into two phases:
-introductory (usually 2 months multi-drug
therapy: INH+RMP+PZA+EMB)
-maintaining phase (4 months: INH+RMP).
PHARMACOLOGICAL TREATMENT

The treatment usually takes 6 months
(9 months in AIDS patients).

Antitubercular therapy involves:
-INH (isoniazid),
-RMP (rifampicin),
-EMB (etambulol),
-SM (streptomycin),
-PZA (pyrazinamide).
HISTORY OF SURGICAL
TREATMENT OF TB
In 1882 Forlanini and in 1889
Murphy performed intrapleural
pneumothorax in TB treatment as
the immobilized part of the lung
with TB was expected to heal
faster.
HISTORY OF SURGICAL
TREATMENT OF TB
 Other
methods of surgical treatment of
TB involved:
-pneumoperitoneum (aeroperitoneum),
-phrenoplegia (phrenic nerve paralysis),
-extrapleural pneumothorax (surgical
emphysema).
HISTORY OF SURGICAL
TREATMENT OF TB

Despite many therapeutic advantages of
aforesaid surgical methods in TB
treatment, they were endangered with
many possible complications such as:
•
•
•
•
Thoracic emphyema (pyothorax)
Bronchopleural fistula
Haemorrhage
Translocation of materials used in
artificial pneumothorax creation to
other body’s cavities
HISTORY OF SURGICAL
TREATMENT OF TB
 Another
method that led to
pulmonary collapse in TB treatment
was resection of ribs (so called
thoracoplasty).
 It was first performed by Eduard de
Carneville in 1885.
HISTORY OF SURGICAL
TREATMENT OF TB
 First
pulmonectomy was conducted
by Block in 1882, but turned out
unsuccessful.
 Finally, successful pulmonary
resection took place in 1891 (Tuffier).
HISTORY OF SURGICAL
TREATMENT OF TB
Full-scale pulmonary resections were
conducted in the 30s of the 20th
century.
 The problematic issue was, however,
the Turniekitov method of surgical
supply of pulmonary hilus „en block”
without preparation of particular
anatomic elements!
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HISTORY OF SURGICAL
TREATMENT OF TB

This resulted in high
postoperative
complications rate,
that reached 20%
after lobectomy
and 40% after
pulmonectomy.
40
35
30
25
20
15
10
5
0
Lobectomy
Pulmonect
omy
HISTORY OF SURGICAL
TREATMENT OF TB
 In
the 40s and 50s more
tuberculostatic drugs were introduced
into clinical practice and surgical
techniques got improved- both
resulted in better outcomes of
surgical treatment of TB.
HISTORY OF PHARMACOLOGICAL
TREATMENT OF TB

The first effective antitubercular drug
was streptomycin, which was
discovered by Waksman and introduced
to clinical practice in 1945.

In 1946 para-aminosalicylic acid and
in 1951 isoniazid (INH) were
introduced to antitubercular therapy.
HISTORY OF PHARMACOLOGICAL
TREATMENT OF TB
 Since
then the number of
medicaments in TB treatment have
grown rapidly, which resulted in
diminishing of indications for surgical
treatment of TB.
SURGICAL TREATMENT OF TB
The role of surgical treatment in TB
is inversely proportional to
conservative therapy!!!
SURGICAL TREATMENT OF TB
The surgical techniques in TB treatment
comprise:
• Pulmonary segment resection
(segmentectomy) with/without thoracoplasty
• Pulmonary lobe resection (lobectomy)
with/without thoracoplasty
• Pulmonectomy with thoracoplasty
SURGICAL TREATMENT OF TB
Nowadays in clinical practice there are 2
indications for surgical treatment in TB:
1. Ineffective antitubercular therapy and
sputum-positivity that remains 12 months
after pharmacological treatment
2. Tuberculous complications, that can be
treated only with surgical methods
SURGICAL TREATMENT OF TB
Absolute indications
The most common reasons for ineffectiveness of
antitubercular therapy and sputum-positivity after 12
months of pharmacotherapy are:
• Atypical mycobacteria
• Mycobacterial resistance to antitubercular drugs
• Contraindications to conventional antitubercular
treatment
• Non-compliance of TB patient
• Other, less known reasons
SURGICAL TREATMENT OF TB
Absolute indications
TB complications, that can be treated only with
surgical methods:
• Pulmonary bleeding or haemorrhage
• Pyothorax with or without bronchopleural fistula
(that could not be treated conservatively)
• Tubercular cavity’s superinfection (aspergillosis)
• Bronchostenosis in patients who underwent
nodulo-bronchial TB
SURGICAL TREATMENT OF TB
Relative indications
Persistent tuberculous cavity- arguments in
favour of surgical treatment:
• High risk of TB recurrence
• High risk of superinfection (aspergillosis)
• The risk of bleedings
• The risk of bronchopleural fistula
formation
• The risk of pyothorax formation
SURGICAL TREATMENT OF TB
Relative indications
• Round shadows in the lungs (tuberculoma,
caseous TB)
In such cases surgical treatment is recommended
due to:
-diagnostic problems in defining the ethiology of
round shadows in the lungs (surgery is
considered better solution in comparison to
neoplastic process omission)
-poor penetration of antitubercular drugs to TB
cavities (poor blood supply of the capsule)
SURGICAL TREATMENT OF TB
Relative indications
When the lung is destroyed by tuberculous
process, surgery is recommended in case of:
• High risk of TB recurrence
• High risk of aspergillosis, pyothorax and
bleedings
• The shunt of unoxigenated blood from
destroyed lung to the healthy one
SURGICAL TREATMENT OF TB
Relative indications
The opponents of surgical treatment
consider surgery as necessity only in
case of TB recurrence or TB
complications.
SURGICAL TREATMENT OF TB
Contraindications to surgical treatment
• Respiratory system insufficiency
- VC< 1,1 or < 50% of reference value
- FEV1< 0,9 or < 50% of
- PaO2 < 55mmHg and PaCO2 > 45mmHg
• Cardiovascular insufficiency or/and renal
failure (hypouresis, increase of serum
creatinine, urea and kalium levels)
SURGICAL TREATMENT OF TB
Contraindications to surgical treatment
1. Extent of TB infiltrates in lungs
-bilateral and affecting two lobes each side.
Exceptions are:
micromacular and fibrous TB infiltrates without
features of decay unilaterally and in case of
tuberculous infiltrates affecting one lobe each
side when spirometric values are satisfactory
(one-stage or two-stage surgery can be
performed in such cases)
SURGICAL TREATMENT OF TB
Contraindications to surgical treatment
2. Patient’s age – there are no absolute criteria.
The most important is evaluation of general
condition and evident advantages of surgical
treatment in particular patient
SURGICAL TREATMENT OF TB
During the surgery, prevention of
pleural cavity infection is crucial.
 The incision should be performed within
healthy tissues, as the surgery aims at
removing the infiltrated lung’s part
„en bloc”.
 After the excision it is necessary to
apply pleural drainage.

SURGICAL TREATMENT OF TB
Postoperative management involves:
prevention of atelectasis
 fluid balance control
 if necessary
-administration of blood,
-packed RBCs,
-fresh-frozen plasma to support hemostasis.

SURGICAL TREATMENT OF TB
Postoperative complications comprise:
-bleedings
-atelectasis
-lung fibrosis
-pyothorax
-pulmonary embolism
-bronchopleural fistula
SURGICAL TREATMENT OF TB
In the recent years, videothoracoscopy
technique has developed.
It enables to perform a vast number of
diagnostic and therapeutic procedures such
as:
-pleural biopsy,
-pulmonary decortication,
-pulmonary fragment resection,
-abscess drainage,
-lobar resection.
Pharmacological treatment
must be applied as soon as
possible after surgery!