1. SURGICAL MANAGEMENT OF TUBERCULOSIS Paul Bolanowski, MD Associate Professor of Surgery Division of Cardiothoracic Surgery UMDNJ-NJ Medical School

2. HISTORY OF TUBERCULOSIS Scourge Of Early Humanity –Hippocrates – Phthisis Disease characterized by progressive weight loss and wasting –Romans – Consumption Consumed its victims –Schonlein - Tuberculosis First to use term based on autopsy findings

3. SURGICAL HISTORY 1821 - Carson - collapse therapy –1925 - Alexander 1869 - Simon - thoracoplasty –1920 - Sauerbruch & Alexander 1882 - Block - first resection 1891 - Tuffier – first partial resection 1934 - Freelander – first lobectomy

4. COLLAPSE THERAPY Pneumothorax Phrenic nerve crush Pneumoperitoneum Extrapleural pneumolysis –Plombage thoracoplasty –Extraperiosteal Thoracoplasty

5. EFFICACY OF COLLAPSE THERAPY 1880 - 300 deaths/100,000 1935 - 69 deaths /100,000 Plombage thoracoplasty –Sputum negative - 30-60% Thoracoplasty –Closure of cavity in 80% –Mortality 10%

6. SURGICAL INDICATIONS - 1 Failure of medical treatment –Cavity with persistently positive sputum Resistant strains –MDR-TB –XDR-TB Atypical organisms –M. kansasii - surgery infrequent –M. avium - localized – lobectomy Solitary nodule –Lung carcinoma vs. tuberculoma

7. SURGICAL INDICATIONS - 2 Massive or recurrent hemoptysis –Etiology Bronchial collateral circulation –Rasmussin aneurysm –Aspergilloma –Bronchiectasis –Treatment Embolization Surgery

8. MASSIVE HEMOPTYSIS - 1 Definition –Based on amount and duration MASSIVE 600 ml WITHIN 16 hrs 200ml, >300ml, >500ml, >600ml / 24-48hrs –Based on threat to life Acute airway obstruction Shock Persistent hemoptysis despite good medical management

9. MASSIVE HEMOPTYSIS - 2 Position patient Chest x-ray Bronchoscopy –Localize site –Intubation Bronchial arteriography Surgery –Resection –Videoendoscopic thoracoscopy

10. VATS CAVERNOSTOMY

11. BRONCHIAL ARTERIOGRAPHY Advantages –Localize site –Control bleeding by embolization –Prevent contamination of normal lung –Buy time to improve pulmonary function –Less blood loss during surgery Disadvantages –Spinal cord paralysis –Temporary Acute control - 75% effective Rebleed rate - 43%

12. EMBOLIZATION - 1

13. EMBOLIZATION - 2

14. EMBOLIZATION - 3

15. MASSIVE HEMOPTYSIS Surgical results Massive 600ml in < 16hrs 18% MORTALITY Conservative management Massive 600ml or more in 16hrs – 75% MORTALITY 600ml or more in 48hrs – 54% MORTALITY Embolization + surgery Acute control in 75% Mortality 7-9%

16. SURGICAL INDICATIONS - 1 Bronchopleural fistula –Complication of disease Treatment –Lobectomy or pneumonectomy –Complication of surgery Treatment –Immediate chest tube »Pneumonectomy –Thoracotomy with closure using intercostal muscle flap

17. SURGICAL INDICATIONS - 2 Empyema –Acute No chest tube unless respiration compromised –Chronic Decortication –Trapped lung –Muscle transposition

18. AVAILABLE TISSUE

19. SURGICAL INDICATIONS - 3 Destroyed lung or lobe –Surgical resection Pott’s abscess –Drainage –Spine reconstruction Mycetoma (aspirgeloma) –Recurrent hemoptysis Resection

20. SURGICAL INDICATIONS - 4 Pericarditis –Acute With or without tamponade –Pericardial window –Chronic Constrictive pericarditis –Total pericardioectomy »Cardiopulmonary bypass –Lymphadenitis Cervical (scrofula) Mediastinal –Drainage

21. SURGICAL INDICATIONS - 5 Destroyed lung or lobe –Surgical resection Pott’s abscess –Drainage –Spine reconstruction Mycetoma (aspirgeloma) –Recurrent hemoptysis Resection

22. SURGICAL INDICATIONS - 6 Pericarditis –Acute With or without tamponade –Pericardial window –Chronic Constrictive pericarditis –Total pericardioectomy »Cardiopulmonary bypass –Lymphadenitis Cervical (scrofula) Mediastinal –Drainage

23. PRE-OP MANAGEMENT - 1 Medical management –Nutrition –Atypical mycobacterium M. avium –Perioperatively – ethambutol, rifabutin, biaxan, and amikacin –Operate when sputum converts to negative M. abscessus –Pre-op – imipenem & amakacin for 2 months –Post-op – same drugs for 4 months M. kansasii – surgery infrequent

24. PRE-OP MANAGEMENT - 2 Multi-drug resistant tuberculosis –Pre-op 2-3 months of 3 or 4 drugs they have never received –Post-op 18 to 24 months of therapy –These patients must be followed diligently post-op for recurrence

25. PRE-OP MANAGEMENT - 3 PET-CT scan –Determine extent of disease Bronchoscopy –Determine if line of transection is disease free Arteriography –To control bleeding pre-operatively –To decrease blood loss at time of surgery

26. POST-OP MANAGEMENT Immediate –Intensive care unit Isolation Room with air exchange Ventilator Collaborative medical management –Anti-tuberculous drugs Length of stay Long term