Role of Surgery in Pulmonary and Pleural Tuberculosis

Introduction

I. GENERAL PRINCIPLES OF SURGERY IN TB

• Surgery is never a primary treatment — it is always preceded and followed by antituberculous chemotherapy (ATT)
• Pre-operative ATT should be given for at least 3 months to reduce bacillary load and improve surgical outcome
• Post-operative ATT is mandatory and continued for 12–24 months
• Over 90% of patients deemed good surgical candidates are cured when appropriate combined medical and surgical therapy is used
• Surgical complications are doubled if sputum remains AFB-positive at the time of surgery
• Complications are reduced if the remaining lung tissue is fully expanded within the chest post-operatively

II. INDICATIONS FOR SURGERY IN PULMONARY TB

A. Drug-Resistant TB (MDR-TB / XDR-TB)

1. Persistently positive sputum cultures beyond 4–6 months of optimized antituberculous therapy
2. Extensive drug resistance unlikely to be cured with ATT alone
3. Lung destruction with persistent thick-walled cavitation
4. Failure of optimized medical therapy — progressive disease, lung gangrene, or intracavitary aspergillosis superinfection (aspergilloma complicating a TB cavity)

B. Life-Threatening Complications

1. Massive hemoptysis — the most urgent indication
   • Defined as ≥600 mL blood in 24 hours (or amount sufficient to threaten airway)
   • Mechanisms: erosion into bronchial arteries at cavitation margins, Rasmussen aneurysm (pseudoaneurysm of pulmonary artery branch), bronchiectasis
   • Management: stabilize → bronchial artery embolization (BAE) as bridge → surgical resection
   • Emergency lobectomy/pneumonectomy when BAE fails or is not feasible; operative mortality may exceed 20% in emergencies
2. Persistent bronchopleural fistula (BPF) — immediately life-threatening; requires surgical closure

C. Complications of Pulmonary Scarring

1. Cavitating disease — large, thick-walled cavities that harbor persistently positive cultures
2. Bronchiectasis — localised, post-TB bronchiectasis causing recurrent infections or hemoptysis
3. Bronchostenosis — fibrous stricture of a bronchus causing lobar or segmental collapse; may need resection or bronchoplasty
4. Destroyed lung — entire lung replaced by fibrosis, bronchiectasis, and cavities → pneumonectomy

D. Diagnostic Indications

1. Need for tissue diagnosis — where sputum/BAL are non-diagnostic; suspected concurrent malignancy (cancer diagnosis should be considered for any newly identified mass, even with positive tuberculin test and AFB-positive sputum)
2. Tuberculoma — a discrete pulmonary mass that cannot be reliably distinguished from carcinoma; resected for diagnosis

E. Complications of Previous Surgery

1. Post-thoracoplasty complications (historically: space problems, BPF, empyema)
2. Stump problems after previous resection

III. TYPES OF SURGICAL PROCEDURES FOR PULMONARY TB

1. Resectional Surgery

2. Cavernostomy / Cavernoplasty

• Open drainage of a large, thick-walled cavity (Monaldi procedure — historically)
• Rarely used today; reserved for high-risk patients unfit for resection
• The cavity is drained, marsupialized, and packed; promotes healing

3. Thoracoplasty (Collapse Therapy)

• Historical procedure — largely abandoned after effective ATT became available
• Involved surgical removal of several ribs to collapse the underlying lung, obliterating cavities
• Still occasionally used as a space-sterilization procedure after pneumonectomy to prevent empyema in contaminated space
• Thoracomyoplasty: modification using muscle flaps to fill the pleural space

4. Bronchial Artery Embolization (BAE)

• Endovascular (not open surgical) procedure
• First-line intervention for massive hemoptysis; temporary measure before definitive surgery
• Embolizes hypertrophied bronchial arteries feeding the bleeding site

IV. SURGERY IN PLEURAL TUBERCULOSIS

• Tuberculous pleural effusion (primary pleuritis)
• Tuberculous empyema thoracis
• Fibrothorax / Trapped lung

A. Tuberculous Pleural Effusion

• Primary treatment is ATT — most effusions resolve completely with chemotherapy alone
• Therapeutic thoracentesis for large symptomatic effusions
• Surgery is NOT routinely indicated for uncomplicated TB pleural effusion
• Intercostal tube drainage may be needed if effusion is loculated or does not resolve
• Pleural biopsy (closed Abrams needle or VATS) is indicated when:
  • Cytology/biochemistry is non-diagnostic
  • Tissue is required for culture and sensitivity (especially MDR-TB)

B. Tuberculous Empyema Thoracis

• Exudative → Fibrinopurulent → Organising/Chronic

Early/Acute Empyema:

• Intercostal tube (ICT) drainage — adequate drainage of pus
• Intrapleural fibrinolytics (streptokinase, urokinase) to break down loculations and facilitate drainage — reserved for multiloculated empyema not draining adequately

Chronic Empyema (Organising Stage):

1. Decortication — the definitive surgical procedure
   • Removal of the thick fibrous peel/cortex overlying the visceral pleura
   • Allows the trapped, compressed lung to re-expand and fill the pleural space
   • Eliminates the empyema cavity
   • Requires the underlying lung to be functional (not destroyed)
   • Best results when performed before extensive fibrosis
   • Open decortication via thoracotomy; VATS decortication in early/selected cases
2. Open Window Thoracostomy (Eloesser flap)
   • For patients unfit for major surgery or those with BPF
   • Rib resection + skin flap to create permanent open drainage
   • Allows long-term packing and granulation
3. Thoracomyoplasty / Plombage
   • Space obliteration using muscle flaps (latissimus dorsi, serratus anterior) or omentoplasty
   • Used when re-expansion of the lung is not possible

C. Fibrothorax / Calcified Pleural Peel (Trapped Lung)

• Sequela of chronic TB pleuritis with dense fibrous encasement of lung
• Causes restrictive ventilatory impairment
• Decortication restores lung expansion and improves respiratory function
• Timing is important: ideally 3–6 months after acute episode once ATT is established, before calcification becomes dense

V. BRONCHOPLEURAL FISTULA (BPF) IN TB

• Communication between the bronchial tree and pleural space
• Causes: post-resection leak, cavitary rupture, erosion by caseating lymph nodes
• Presents with sudden increase in air leak, surgical emphysema, persistent pneumothorax, or expectoration of pleural contents
• Management:
  • ICT drainage of associated empyema
  • Conservative: small fistulas may heal with prolonged drainage
  • Bronchoscopic instillation of sealants (fibrin glue, etc.)
  • Surgical: direct stump repair + muscle flap reinforcement (intercostal, latissimus dorsi); stump revision + thoracoplasty/myoplasty to obliterate the space

VI. SPECIAL SITUATIONS

Aspergilloma Complicating TB Cavities

• Fungal colonization of residual post-TB cavities is common
• Indication for surgery: massive/recurrent hemoptysis, increasing size, immunosuppression
• Procedure of choice: lobectomy (technically demanding due to dense adhesions)
• Simple drainage/cavernostomy + antifungal instillation in high-risk patients

Pericardial TB (Constrictive Pericarditis)

• Pericardiectomy (pericardial stripping) for chronic constrictive pericarditis
• Must be covered with ATT

Lymph Node TB causing Bronchial Obstruction

• Mediastinal or hilar nodes eroding into bronchi (broncholithiasis, extrinsic compression)
• Bronchoscopic management (dilation, laser) or surgical resection of obstructed segment

VII. PRE-OPERATIVE AND POST-OPERATIVE CARE

• Minimum 3 months ATT before elective surgery
• Nutritional optimization (TB is a catabolic disease)
• Pulmonary function testing; predicted post-op FEV₁ > 40%
• Sputum negativity preferred (complications doubled with positive sputum)
• Informed consent regarding risks: BPF, empyema, endobronchial spread, respiratory failure

• Full course of ATT for 12–24 months post-operatively
• All patients must complete ATT regardless of sputum culture status
• Physiotherapy and breathing exercises
• Monitor for surgical complications: empyema, BPF, respiratory insufficiency

VIII. COMPLICATIONS OF SURGERY IN TB

IX. OUTCOMES

• When appropriate patient selection + pre-operative ATT + surgery + post-operative ATT are combined: >90% cure rate for patients deemed good surgical candidates
• MDR-TB surgical outcomes: studies show sputum conversion rates of 60–90% after resection in selected MDR/XDR-TB cases
• BPF post-surgery: significantly worsens prognosis; avoided by sputum negativity before resection

Summary Table: Surgery in TB — Quick Revision