Multi-drug-resistant tuberculosis surgery: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Multi-drug-resistant tuberculosis}} | {{Multi-drug-resistant tuberculosis}} | ||
{{CMG}} | {{CMG}} ; {{AE}} {{Ammu}} | ||
==Overview== | ==Overview== | ||
[[Surgery]] may be necessary, especially to drain [[abscess]]es , [[empyema]], venticular shunt in tubercular meningitis, surgical resection of tissues affected in abdominal tuberculosis, stabilize the spine in case of [[Pott's disease]] , [[lobectomy]], [[pneumonectomy]], [[pericardiocentesis]] or surgical repair of [[pericardium]]. | |||
==Surgery== | |||
In extremely resistant disease, surgery is sometimes the last port of call. The centre with the largest experience in this is the [[National Jewish Medical and Research Center]] in Denver, Colorado. In 17 years of experience, they have performed 180 operations; of these, 98 were lobectomies, 82 were pneumonectomies. There is a 3.3% operative mortality, with an additional 6.8% dying following the operation; 12% experienced significant morbidity (particularly extreme breathlessness). Of 91 patients who were culture positive before surgery, only 4 were culture positive after surgery. | |||
===Indications for surgery=== | |||
{|style="border: 0px; font-size: 90%; margin: 3px; width: 500px;" align=center | |||
! style="width: 500px;background: #4479BA"|{{fontcolor|#FFF| '''''Indications for surgery'''''}} | |||
|- | |||
| style="padding: 0 5px; width: 120px; background: #F5F5F5"| Localised leision | |||
|- | |||
| style="padding: 0 5px; width: 120px;background: #DCDCDC"| Sufficient treatment is available to reduce the bacterial burden and allow healing of stump | |||
|- | |||
| style="padding: 0 5px; width: 120px;background: #F5F5F5"|Complications of tuberculosis including [[hemoptysis]], [[empyema]] and [[bronchiectasis]] | |||
|- | |||
| style="padding: 0 5px; width: 120px;background: #DCDCDC"|Increased relapse risk | |||
|- | |||
| style="padding: 0 5px; width: 120px;background: #F5F5F5"|Persistent acid fast bacilli in the sputum amidst of aggressive chemotherapy.<ref name="pmid22281142">{{cite journal| author=Kempker RR, Vashakidze S, Solomonia N, Dzidzikashvili N, Blumberg HM| title=Surgical treatment of drug-resistant tuberculosis. | journal=Lancet Infect Dis | year= 2012 | volume= 12 | issue= 2 | pages= 157-66 | pmid=22281142 | doi=10.1016/S1473-3099(11)70244-4 | pmc=PMC3741680 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22281142 }} </ref> | |||
|} | |||
===Pulmonary tuberculosis=== | |||
*[[Pneumonectomy]] or removal of one entire lung is reserved as a treatment option for serious conditions of tuberculosis which are drug resistant. <ref name=Tuberculosis>{{cite web | title = Surgery tuberculosis| url = http://thorax.bmj.com/content/62/5/416.full.pdf }}</ref> | |||
*[[Lobectomy]] or removal of lobes of lung are used to treat drug resistant tuberculosis if it has affected only a part of lung. | |||
*Surgery can also be an option for removal of cold abscess and tuberculous empyema. | |||
*[[Segmentectomy]] or wedge resection is used in some conditions for treating tuberculosis resistant to anti tubercular drugs. | |||
{|style="border: 0px; font-size: 90%; margin: 3px; width: 500px;" align=center | |||
! style="width: 500px;background: #4479BA"|{{fontcolor|#FFF| '''''Pre operative investigations'''''}} | |||
|- | |||
| style="padding: 0 5px; width: 120px; background: #F5F5F5"| Bronchoscpoy to rule out malignancy , contra lateral leison and endobronchial [[tuberculosis]] | |||
|- | |||
| style="padding: 0 5px; width: 120px;background: #DCDCDC"| Pulmonary function test and ventilation perfusion scan to asses the pumonary function reserve | |||
|- | |||
| style="padding: 0 5px; width: 120px;background: #F5F5F5"|[[CT]] Chest to asses the extet to the lesion and to rue out malignancy | |||
|- | |||
| style="padding: 0 5px; width: 120px;background: #DCDCDC"|[[ECHO]] to asses the cardiac function | |||
|- | |||
| style="padding: 0 5px; width: 120px;background: #F5F5F5"|Nutritional assessment | |||
|} | |||
===Renal tuberculosis=== | |||
Surgery is necessary to remove the [[urinary obstruction]] in genito urinary tuberculosis. 3 most common sites which can cause urinary obstruction is as follows. <ref name="pmid14066180">{{cite journal| author=HANLEY HG| title=TREATMENT OF RENAL TUBERCULOSIS. | journal=Br Med J | year= 1963 | volume= 2 | issue= 5373 | pages= 1611-2 | pmid=14066180 | doi= | pmc=PMC1873944 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14066180 }} </ref> | |||
*Pelvi- ureteral junction | |||
*Calyx | |||
*Lower end of ureter | |||
{| style="border: 0px; font-size: 90%; margin: 3px; width: 500px;" align=center | |||
|valign=top| | |||
|+ | |||
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Types of surgery}} | |||
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Proceedure}} | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Cavernotomy]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" | It involves removal of avascular caeseous material which helps in preventing complications like abscess rupture. It has got excellent prognosis | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Partial [[nephrectomy]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" | This was an old technique to remove the affected tissue. Recently the drug regimen helps to heal the calyx and hence partial [[nephrectomy]] is not widely practised now. | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Nephrectomy]] | |||
| style="padding: 5px 5px; background: #F5F5F5;" |Chief indication of [[nephrectomy]] is obstruction of pelvi-ureteric junction. Plastic surgery of pelvi uretric junction is also an option for it. Drianage improves the treatment | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Excision of stricture and re implantation of ureter into the bladder. | |||
| style="padding: 5px 5px; background: #F5F5F5;" |This is another conservative surgical management which has shown promising results. | |||
|} | |||
===Spinal tuberculosis=== | |||
*Biopsy is used to make a diagnosis. | |||
* Gross instability and neurological complications are treated by decompression and fusion of the anterior segments. | |||
* Joint damage may be repaired by late surgery and arthrodosis. | |||
The main stay of treatment for skeletal tuberculosis is antibiotics and surgery. Surgical management of tuberculosis of spine of various stages are given below. <ref name=Tuberculosis>{{cite web | title = tech ortho TB| url = http://www.global-help.org/publications/articles/techortho_tuberculosismusculoskeletal.pdf }}</ref> | |||
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center | |||
|valign=top| | |||
|+ | |||
! style="background: #4479BA; width: 250px;" | {{fontcolor|#FFF|Stage}} | |||
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Treatment}} | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |Stage 1 (synovitis) | |||
| style="padding: 5px 5px; background: #F5F5F5;" |<br> Chemotherapy<br> Rest<br> Restriction of movements<br> Splinting | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 2 (Early arthritis) | |||
| style="padding: 5px 5px; background: #F5F5F5;" |<br> Chemotherapy<br> Rest<br> Restriction of movements<br> Splinting<br> Synovectomy | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 3 (Advanced arthritis) | |||
| style="padding: 5px 5px; background: #F5F5F5;|<br> Chemotherapy<br> [[Osteotomy]]<br> Arthrodesis<br> Arthroplasty | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 4 (Advanced arthritis) | |||
| style="padding: 5px 5px; background: #F5F5F5;"|<br> Chemotherapy<br> [[Osteotomy]]<br> Arthrodesis<br> Arthroplasty | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" |Stage 5 | |||
| style="padding: 5px 5px; background: #F5F5F5;"|<br> Chemotherapy<br> [[Osteotomy]]br> Arthrodesis<br> Arthroplasty | |||
|} | |||
===Tuberculosis pericarditis=== | |||
Surgical removal or repair of infected sac of [[pericardium]] is often the treatment of choice if it is not responding to antibiotics. There are two different types of surgical proceedure. Open surgical removal and pericardiocentesis. Pericardiectomy is reserved for patients who deteriorates even after 4-8 weeks of anti tuberculous therapy. <ref name="pmid12959199">{{cite journal| author=Bozbuga N, Erentug V, Eren E, Erdogan HB, Kirali K, Antal A et al.| title=Pericardiectomy for chronic constrictive tuberculous pericarditis: risks and predictors of survival. | journal=Tex Heart Inst J | year= 2003 | volume= 30 | issue= 3 | pages= 180-5 | pmid=12959199 | doi= | pmc=PMC197314 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12959199 }} </ref> | |||
===Tuberculosis meningitis=== | |||
Surgical placement of shunt is used to drain the fluid and prevent the damage to brain caused by build up of fluid. | |||
===Abdominal tuberculosis=== | |||
Surgical resection of intestine affected by tuberculosis which is not responding to multi drug regimen helps in preventing complications of abdominal tuberculosis | |||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Bacterial diseases]] | [[Category:Bacterial diseases]] | ||
[[Category:Pulmonology]] | [[Category:Pulmonology]] | ||
[[Category:Tuberculosis]] | [[Category:Tuberculosis]] | ||
Latest revision as of 18:07, 18 September 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Ammu Susheela, M.D. [2]
Overview
Surgery may be necessary, especially to drain abscesses , empyema, venticular shunt in tubercular meningitis, surgical resection of tissues affected in abdominal tuberculosis, stabilize the spine in case of Pott's disease , lobectomy, pneumonectomy, pericardiocentesis or surgical repair of pericardium.
Surgery
In extremely resistant disease, surgery is sometimes the last port of call. The centre with the largest experience in this is the National Jewish Medical and Research Center in Denver, Colorado. In 17 years of experience, they have performed 180 operations; of these, 98 were lobectomies, 82 were pneumonectomies. There is a 3.3% operative mortality, with an additional 6.8% dying following the operation; 12% experienced significant morbidity (particularly extreme breathlessness). Of 91 patients who were culture positive before surgery, only 4 were culture positive after surgery.
Indications for surgery
| Indications for surgery |
|---|
| Localised leision |
| Sufficient treatment is available to reduce the bacterial burden and allow healing of stump |
| Complications of tuberculosis including hemoptysis, empyema and bronchiectasis |
| Increased relapse risk |
| Persistent acid fast bacilli in the sputum amidst of aggressive chemotherapy.[1] |
Pulmonary tuberculosis
- Pneumonectomy or removal of one entire lung is reserved as a treatment option for serious conditions of tuberculosis which are drug resistant. [2]
- Lobectomy or removal of lobes of lung are used to treat drug resistant tuberculosis if it has affected only a part of lung.
- Surgery can also be an option for removal of cold abscess and tuberculous empyema.
- Segmentectomy or wedge resection is used in some conditions for treating tuberculosis resistant to anti tubercular drugs.
| Pre operative investigations |
|---|
| Bronchoscpoy to rule out malignancy , contra lateral leison and endobronchial tuberculosis |
| Pulmonary function test and ventilation perfusion scan to asses the pumonary function reserve |
| CT Chest to asses the extet to the lesion and to rue out malignancy |
| ECHO to asses the cardiac function |
| Nutritional assessment |
Renal tuberculosis
Surgery is necessary to remove the urinary obstruction in genito urinary tuberculosis. 3 most common sites which can cause urinary obstruction is as follows. [3]
- Pelvi- ureteral junction
- Calyx
- Lower end of ureter
| Types of surgery | Proceedure |
|---|---|
| Cavernotomy | It involves removal of avascular caeseous material which helps in preventing complications like abscess rupture. It has got excellent prognosis |
| Partial nephrectomy | This was an old technique to remove the affected tissue. Recently the drug regimen helps to heal the calyx and hence partial nephrectomy is not widely practised now. |
| Nephrectomy | Chief indication of nephrectomy is obstruction of pelvi-ureteric junction. Plastic surgery of pelvi uretric junction is also an option for it. Drianage improves the treatment |
| Excision of stricture and re implantation of ureter into the bladder. | This is another conservative surgical management which has shown promising results. |
Spinal tuberculosis
- Biopsy is used to make a diagnosis.
- Gross instability and neurological complications are treated by decompression and fusion of the anterior segments.
- Joint damage may be repaired by late surgery and arthrodosis.
The main stay of treatment for skeletal tuberculosis is antibiotics and surgery. Surgical management of tuberculosis of spine of various stages are given below. [2]
| Stage | Treatment |
|---|---|
| Stage 1 (synovitis) | Chemotherapy Rest Restriction of movements Splinting |
| Stage 2 (Early arthritis) | Chemotherapy Rest Restriction of movements Splinting Synovectomy |
| Stage 3 (Advanced arthritis) | Chemotherapy Osteotomy Arthrodesis Arthroplasty |
| Stage 4 (Advanced arthritis) | Chemotherapy Osteotomy Arthrodesis Arthroplasty |
| Stage 5 | Chemotherapy Osteotomybr> Arthrodesis Arthroplasty |
Tuberculosis pericarditis
Surgical removal or repair of infected sac of pericardium is often the treatment of choice if it is not responding to antibiotics. There are two different types of surgical proceedure. Open surgical removal and pericardiocentesis. Pericardiectomy is reserved for patients who deteriorates even after 4-8 weeks of anti tuberculous therapy. [4]
Tuberculosis meningitis
Surgical placement of shunt is used to drain the fluid and prevent the damage to brain caused by build up of fluid.
Abdominal tuberculosis
Surgical resection of intestine affected by tuberculosis which is not responding to multi drug regimen helps in preventing complications of abdominal tuberculosis
References
- ↑ Kempker RR, Vashakidze S, Solomonia N, Dzidzikashvili N, Blumberg HM (2012). "Surgical treatment of drug-resistant tuberculosis". Lancet Infect Dis. 12 (2): 157–66. doi:10.1016/S1473-3099(11)70244-4. PMC 3741680. PMID 22281142.
- ↑ 2.0 2.1 "Surgery tuberculosis" (PDF).
- ↑ HANLEY HG (1963). "TREATMENT OF RENAL TUBERCULOSIS". Br Med J. 2 (5373): 1611–2. PMC 1873944. PMID 14066180.
- ↑ Bozbuga N, Erentug V, Eren E, Erdogan HB, Kirali K, Antal A; et al. (2003). "Pericardiectomy for chronic constrictive tuberculous pericarditis: risks and predictors of survival". Tex Heart Inst J. 30 (3): 180–5. PMC 197314. PMID 12959199.