Barbara C. Cahill, M.D. What is the Prognosis of Untreated TB? PLoS ONE 6 (4);e17601 doi:10:137/journal.pone.0017601 What is the Prognosis of Untreated TB? Current models of untreated TB
3 years until self cure or death
TB Case fatality rates
70% for smear positive TB
20% for smear negative, culture positive TB PLoS ONE 6 (4);e17601 doi:10:137/journal.pone.0017601 Historical Therapies for Tuberculosis
The sanatorium - diet, rest, sunshine, immobilization
Exercise
The touch of the king (1200s 1700s)
Phlebotomy
Emetics, cyanide, creosote, arsenic, lard
Vapors
Laudanum
Vaccination
Surgery Extrapulmonary Tuberculosis 2011 Centers for Disease Control Data regarding 2188 reported extrapulmonary TB cases (~20% all reported TB cases)
Extrapulmonary TB site Percent Lymphatic (scrofula) 37.2 Pleural 16.9 Bone +/- joint 11.1 Meningeal 5.7 Peritoneal 5.4 Genitourinary 5.0 Other 18.6 http://www.cdc.gov/tb/statistics/reports/2011/pdf/report2011.pdf Tuberculous Bone/Joint Disease Bony disease isolated bony disease without spread to a joint fails to attract attention
Arthritis nonspecific, often indolent clinical presentation
usually monoarticular, diagnosis often delayed
average duration of symptoms before diagnosis ~2 years
four drug therapy, joint irrigation, drainage and open synovectomy
TB arthritis of intervertebral joints aka Potts Disease Historical Surgical Procedures for Pulmonary TB Anecdotal observation TB pts with spontaneous pneumothorax improved
Collapse therapy
Why does collapse therapy work?
Placing the diseased organ quiescent state
Resting, relaxing, immobilizing, compressing lung
favorably affects disease course Pneumothorax, Pneumoperitoneum James Carson (8140) Carlo Forlanini (1882)
.the lung shrivels.the lung no longer breathes.the lung that cannot breathe anymore, cannot anymore cough or expectorate.
Introduction of nitrogen gas into the pleural space
increases intrapleural pressure
Extrinsic pressure on lung + Intrinsic lung elasticity = collapse
Scalenectomy removal of accessory muscles of respiration
Plombage extraperiosteal or extrapleural pneumonolysis
Thoracoplasty removal of ribs
Pneumothorax Pneumoperitoneum Collapse Therapies cont Pneumothorax Instilled gas is absorbed, repeat procedures required Pneumoperitoneum
More permanent collapse therapies
Phrenicotomy (phrenic nerve crush)
Plombage
Thoracoplasty
Phrenicotomy (Phrenic Nerve Crush) Pleural Space http://medicalclipart.tripod.com/respirbw/PLEURA.gif d Barbecued Ribs Removing the membrane = removing the parietal pleura
You are sort of a thoracic surgeon! http://bbq.about.com/od/rib1/ss/aa011009a_2.htm Collapse Therapy - Plombage The use of an inert material to fill an abnormal body cavity
Oleothorax Lucite balls Muscle, Fat, Bone Rubber gloves Rubber sheeting Sponges Collapse Therapy - Oleothorax Intrapleural or extrapleural insertion of oil in to the thoracic cavity to collapse lung
Oils used Mineral oil Olive oil Cotton seed oil Cod liver oil Nut oils Paraffin
Antiseptics added Gomenol (myrtle plant extract) Bismuth Iodinated compounds Oleothorax Dissection of parietal pleura away from ribs, collapse of lung
Instillation of paraffin to fill the space between lung and ribs
The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937. Oleothorax Lucite Ball Plombage Oleothorax, Lucite Ball Plombage Outcomes Reported outcomes disappearance of tubercle bacilli from sputum cured cavities closed greatly improved, improved, died working and negative for tubercle bacilli mortality rates ~10-30% The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937. Plombage Complications Short and long term complications Infection
Sinking
Extrusion through chest incision, rib destruction
Erosion in to airway, mediastinum, great vessels
Extrinsic compression of airway, great vessels
Horners syndrome The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937. Thorax.1985;40:328-340. Infected extraperiosteal plombage space in a 56-year-old man who presented with fever and chest pain. Jeung M et al. Radiographics 1999;19:617-637. 1999 by Radiological Society of North America Thoracoplasty The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937. Thoracoplasty Before rib resection After rib resection Thoracoplasty Operative Mortality The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937. (657 Surgeries) 25/39 (64%) post op deaths occurred in first 30 days Tuberculosis Therapeutic Options The Collapse Therapy of Pulmonary Tuberculosis. Alexander JS. 1937. Oleothorax and Thoracoplasty Surgery for TB Current Paradigm
Surgical interventions supplanted by effective medical therapy
Resurgence of surgical therapy with the emergence of MDR-TB
Indications for surgery in MDR-TB Localized disease Persistent cavitary disease Persistent sputum positivity MDR-TB with destroyed lobe of lung Massive hemoptysis Bronchopleural fistula Bronchial stenosis Surgery for Pulmonary MDR-TB U of Colorado experience 1983-2000
172 patients , 180 pulmonary resections
Most pts resistant to 6+ antibiotics
Timing of surgery MDR-TB resistant to almost all drugs Individualized Rx for 1-2 months
MDR-TB sensitive to some combination of drugs Individualized Rx for at least 3 months Follow sputum - low burden of organisms or smear negative
Post op antibiotics for two years after sputum smear and culture negative J Thorac Cardiovasc Surg 2001;1:448-453. Pre-operative Assessment for MDR-TB Surgery Chest CT scan
Bronchoscopy
Pulmonary function tests
Ventilation-perfusion scan
Right heart catheterization
Nutritional assessment and intervention J Thorac Cardiovasc Surg 2001;1:448-453. MDR-TB Thoracic Surgeries Performed Surgical Procedure (n= 180) Pneumonectomy 19 + muscle flap 46 + muscle and Eloesser flaps 1
But what was the overall MDR-TB recurrence rate in this study? J Thorac Cardiovasc Surg 2001;1:448-453. Surgery for Pulmonary MDR-TB Japanese experience 2000-2007
56 patients , 61 pulmonary resections
Pts resistant to an average of 5.6 antibiotics (range 2-10 antibiotics)
Timing of surgery Individualized antibacterial Rx for 3 months
If persistently smear positive surgical excision of cavity
If smear negative surgical resection if relapse risk high (highly drug resistant bug, large cavity, diabetes)
Post op antibiotics for two years after surgery or sputum conversion J Thorac Cardiovasc Surg 2009;138:1180-1184. MDR-TB Thoracic Surgeries Performed Surgical Procedure n= 61 ( %) Pneumonectomy 19 (30)
Post-op mean follow up 3.25 years (8 months 8.75 years)
No operative deaths!
Post op Complications (n)
BP fistula w or w/o empyema 3
Pleural space problem 5
Prolonged air leak 2
Chylothorax 1
Surgical complication rate = 16%
MDR-TB recurred after surgery in 5/56 (9%) pts Further interventions 3 surgery, 1 med Rx, 1 remained positive J Thorac Cardiovasc Surg 2009;138:1180-1184. Is Medical Therapy + Surgery better than Medical Therapy in MDR-TB? Int J Tuberc Lung Dis 2013;17(1);6-15. Is Medical Therapy + Surgery better than Medical Therapy in XDR-TB? Int J Tuberc Lung Dis 2013;17(1);6-15. Not so fast.. No assessment of the potential harm of surgery
No assessment of optimal timing or conditions for surgery
No assessment of outcomes based on level of drug resistance
No long term follow up of patients
Analysis subject to publication bias (negative studies dont get published)
None of the studies were randomized controlled trials
was there selection bias?
was the sputum data reliable?
*Insufficient evidence to recommend Med +Surg Rx over Med Rx alone Int J Tuberc Lung Dis 2013;17(1);6-15. What Role does Surgery Play in the Treatment of Tuberculosis? Massive hemoptysis
Recurrent or recalcitrant localized disease
Destroyed lung with recurrent infection (with adequate pulmonary reserve)
Bronchopleural fistula
For MDR-TB 1. Individualized antibacterial therapy 2. Nutritional resuscitation 3. Surgical resection of active disease and control of pleural space 4. Individualized antibacterial therapy 5. Collapse therapies Japan and Russia J Thorac Cardiovasc Surg 2009;138:1180-1184. Int J Tuberc Lung Dis 2013;17(1);6-15.