1. 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

2. Introduction 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)

3. Milestones in the evolution of surgery for TB EventDatecomment Carson1819Therapeutic artificial pneumothorax Carlo Forlanini1882First artificial pneumothorax Simon1869Thoracoplasty to control empyema thoracis Estlander1879description of thoracoplasty Bernard de Cerenville 1885First thoracoplasty for TB E. Delorme1894Pulmonary decortication H. Lilienthal1933Pneumonectomy S. freedlander1935Lobectomy Monaldi1938Carvena drainage

4. Cont’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 2 nd line drugs Clinical diagnosis –+ve smear –No improvement –No ∆ / worsening CXR –Resistance to 1 st 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 2 nd line drugs Clinical diagnosis –+ve smear –No improvement –No ∆ / worsening CXR –Resistance to 1 st line drugs

5. Cont’d 48%-80% treatment success on 2 nd 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 2 nd 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

6. Is there evidence for surgical resection in MDR-TB? AuthorYearNumber Operations MortalityMorbidityCure rate (-ve sputum Van Leuven1997621.6%23%80% Sung1999270%25.9%96.3% Pomerantz20011803.3%12%98% Shiraishi2004950%11.5%93% Naidoo2005230%17.4%95.6% Dewan2006744.1%32%89.8% Mohsen2007234.3%34.7%96.0%

7. Evolving surgical indications for thoracic TB 195719741989199520052007 Rule out cancer ✓✓✓✓✓✓ Failure of chemothera py ✓✓✓ - ✓ - Sequelae/de stroyed lung ✓✓✓✓✓✓ Failed operation/c omplication ✓✓ ---- Hemoptysis- ✓✓✓✓✓ MDR-TB-- ✓✓✓✓ Pleural disease/BP F - ✓ - ✓✓✓ Aspergillo ma -- ✓ ---

8. 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 SECONDARY 1. -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

9. Surgical options Diagnostic 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 Therapeutic 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

10. 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)

11. Indications.....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)

12. Precautions 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

13. Surgical 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

14. 1. 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)

17. Complex Aspergilloma

18. CXR Cavitory disease

19. CT scan Cavitory disease

20. 2. Operative/anesthesia considerations Precautions Access Anesthesia/epidural Bronchoscopy (rule out copious secretions/stenosis/endobronc hial 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/endobronc hial 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

21. Diagnostic 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

22. Bronchoscopy +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

23. Mediastinoscopy 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.

24. 3. 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

25. Options for muscle transposition Curr Probl Surg, October 2008

26. Rib resection insertion sites Curr Probl Surg, October 2008

27. Latissimus dorsi transposition and insertion Curr Probl Surg, October 2008

28. Omentum transposition Curr Probl Surg, October 2008

29. Types of thoracoplasty Estlander1879Decostalization of chest wall Schede1890Resection of ribs, intercostal muscles, and pleural peel Alexander1928Staged (usually 3) resection Grow1946Excision of parietal peel Kergin1953Excision of thick parietal peel Bjork1954Osteoplastic thoracoplasty in 1 stage maintains chest wall stability Tailoring (modified)1959Tailoring the thoracoplasty (number of ribs) to size of postresectional spine; performed 3-4 weeks prior to lung resection Andrews1961Thoracomediastinal plication

30. Pre and post operative modified thoracoplasty

31. Thoracoplasty technique Curr Probl Surg, October 2008

32. Schede and traditional Alexander style thoracoplasty Curr Probl Surg, October 2008

33. Kergin-Grow thoracoplasty Curr Probl Surg, October 2008

34. Andrews procedure

35. Approaches for the persisting space problem

36. Classic Alexander 3-stage 7-rib thoracoplasty

37. Post operative thoracoplasty patient

38. 4. 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/resi stance Anti-TB treatment BPF/space problems with/out empyema

39. In conclusion: Surgery is a useful adjunct with good outcomes in appropriately selected MDR/XDR patients with acceptable morbidity and mortality.

40. There is a place for Surgery in Medicine...after all World TB day!