Pneumonectomy, or surgical removal of one entire lung (versus removal of smaller segments of the lung) is a major surgery which is not performed without serious consideration to alternative treatments. Pneumonectomy is indicated as the treatment of choice for otherwise unresectable cancers, as well as serious lung infections such as tuberculosis.
In fact, surgery for tuberculosis (including pneumonectomy) was one of the first set of procedures that helped establish thoracic surgery as a specialty. In the era preceeding the development of antibiotics, there was no effective treatment for tuberculosis – which carried a high mortality rate. Surgical resection of the affected lung was the treatment of choice.
Once antibiotics were established as an effective treatment for this disease, surgery faded into the background – and was primarily reserved for cases complicated by hemoptysis or empyema.
However, in recent years, due to the rise of multi-drug resistance tuberculosis (MDR-TB), surgical resection for the treatment of Tuberculosis has been making a comeback. According to World Health Organization statistics; there were more than 8.8 million cases of TB in 2010. While the death rate has fallen significantly (40%) since 1990 – over 1.4 million people died of TB during that same year. In addition to multi-drug resistant Tuberculosis, there is another subtype called extensively drug resistant tubeculosis (XDR-TB) which is resistant to several drug regimens. (Most cases of non-XDR forms of TB are currently treated with a four drug regimen for several months.)
The emergence of these antibiotic resistant strains have brought us full circle in the surgical management of the disease. Failure of medical therapies leads to a mortality of fifty percent (Kir, et. al (1997). The re-emergence of surgery for tuberculosis is two-fold; surgery is used for both the treatment of active disease and the management of complications from tuberculosis (i.e. removal of dead or damaged lung tissue from previous TB infection.)
A review of the literature surrounding the surgical treatment of tuberculosis explores the modern surgical indications; potential complications and post-operative outcomes. Shiraishi et al. (2008) detail their experiences with surgical resection of several cases of XDR-TB at a Tokyo facility. As explained by Shiraishi, larger operations such as pneumonectomy are preferred over smaller resection procedures because the success of the operation hinges on the ability to remove all of the gross lesions (cavities) or destroyed tissue.
In this article (1997) from Saudi Arabia, Ashour discusses his experiences (from 1985 to 1995) using pneumonectomy to treat post-TB lung destruction.
By reviewing several historical sources, we can review the changing perspectives regarding the treatment of tuberculosis and the indications for surgical resection. While it may be surprising to many readers, the current indicators for surgical resection and pneumonectomy for tuberculosis encourage earlier surgical intervention. In comparison to the late 20th century, where surgery was reserved for cases of extensive lung destruction with gross hemoptysis after years of unsuccessful medical treatment, the development of MDR- TB and XDR-TB provides for ample incentive for surgeons to intervene earlier in the disease process.
Additional References:
Imaging References: Post-pneumonectomy
This article by Padovani et al. (2009) demonstrates examples of normal chest radiographs following pneumonectomy. (article is in French). Post-pneumonectomy films are shown sequentially, from immediately post-operatively, through recovery as the pneumonectomy space fills in. (fig. 1 – 4a.) Figures 4b – 11 show different views of CT scans after pneumonectomy, including views showing partial pleurectomies with mesh placement.
Chandrashekhara SH, Bhalla AS, Sharma R, Gupta AK, Kumar A, Arora R. Imaging in postpneumonectomy complications: A pictorial review. J Can Res Ther 2011;7:3-10 More radiographs following pneumonectomy – depicting potential complications. This is an excellent article reviewing potential early, late and chronic problems after pneumonectomy.
Tuberculosis:
Scannel, J. G. Tuberculosis as a surgical disease.
Naef, A. P. (1993). The 1900 tuberculosis epidemic: starting point of thoracic surgery.
Sakula, A. (1983). Carlos Forlanini, inventor of artificial pneumothorax for treatment of pulmonary tuberculosis. Thorax 1983; 38: 326 – 332.
Shampo, M. A., & Rosenow III, E. C. (2009). A history of tuberculosis on stamps. Chest; 2009; 136; 578 – 582.
Telzak et. al (1995) explored the phenomenon of multidrug resistant TB in New York City from it’s emergence in the late 1980’s, early 1990’s in this paper, “Multidrug-resistant tuberculosis in patients without HIV infection.” published in the New England Journal of Medicine (1995; 333: 907- 911.) In comparison to other studies, Telzak reported successful outcomes with medical management (at that point in time.)
CDC information on XDR-TB in the United States (1993 – 2006).
Surgical Management:
Adebonojo, S. A., Adebo, O. A., Osinowo, O., & Grillo, I. A. (1981). Management of tuberculosis destroyed lung in Nigeria. Journal of the National Medical Association 1981; 73 (1): 39-42. Report of the results of 20 pneumonectomies performed (1969 – 1979) in cases of moderate to massive hemoptysis. All of these patients were notably sicker than their western counterparts with active symptomology such as night sweats, weight loss, malnutrition, chest pain and varying degrees of hemoptysis. 75% had displayed symptoms for more than five years in spite of receiving several years of antibiotic therapies. Despite this, surgical mortality was low, with acceptable surgical outcomes – giving an interesting historical perspective on this treatment.
Ashour, M. (1997). Pneumonectomy for tuberculosis. Eur J Cardiothorac Surg 1997; 12: 209-213. [full pdf cited in text above.] This study is interesting since the average patient is several years younger than patients in the other studies presented here – demonstrating some of the geographic variability in disease patterns, which is discussed by the author of this article.
Harrison, E. (1967). Present views on the application of surgery in the treatment of pulmonary tuberculosis. Dis Chest 1967; 52: 305 – 309. A beautiful article reviewing the historical applications as well as current (1960’s) indications for surgical treatment of tuberculosis.
Kir, A., Tahaoglu, K., Okur, E., & Hatipoglu, T. (1997). Role of surgery in multi-drug-resistant tuberculosis: Results of 27 cases. Eur J. Cardiothorac Surg 1997; 12: 531 – 534. Turkish study.
Nuboer, J. F. (1956). Lung resection in the treatment of pulmonary tuberculosis. Journal of National Medical Association 1956; 48 (6): 407 – 414. Dutch paper on the use of surgical resection for the treatment of tuberculosis.
Pecora, D. (1965). Pneumonectomy for pulmonary tuberculosis. Dis Chest 1965; 48: 153 – 159. Historical review of pneumonectomy for tuberculosis.
Quinlan, J. J., Schaffner, V. D., Kloss, G. A., & Hiltz, J. E. (1962). Pulmonary resection for tuberculosis: a review of 1257 operations. Journal of the Canadian Medical Association, 1962; 86 (17).
Shiraishi, Y., Katsuragi, N., Kita, H., Toishi, M., & Onda, T. (2008). Experience with pulmonary resection for extensively drug resistance tuberculosis. Interact CardioVasc Thorac Surg 2008; 7:1075-1078. [full text pdf link in text].
Shiraishi, Y., Katsuragi, N., Kita, H., Tominaga, Y., & Hiramalsu, M. (2010). Different morbidity after pneumonectomy: multidrug-resistant tuberculosis versus nontuberculosis mycobacterial infection. Interact CardioVasc Thorac Surg 2010; 11:429-432.
Smith, R. A. (1982). The development of lung surgery in the United Kingdom. Thorax 1982; 37: 161 -168. [full text cited above.].
Takahashi, N., Ohsawa, H., Mawatari, T., Watanabe, A. & Abe, T. Case Report: multidisciplinary treatment by pneumonectomy, PMX and CHDF in a case of pulmonary supparation complicated with septic shock. Ann Thorac Cardiovasc Surg 2003; 9: 319-322.
Trapp, W. G., & Allan, M. L. (1963). Changing indications for resection of pulmonary tuberculosis. Dis Chest 1963; 43: 486 – 493.
UCLA case studies in surgical management of TB and complications.
Yaldiz, S., Gursoy, S., Ucvet, A., & Kaya, S. (2011). Surgery offers high cure rate for drug resistant tuberculosis. Ann Thorac Cardiovasc Surg 2011; 17:143-147. A Turkish study looking at pulmonary resection and chemotherapy for drug resistant TB in 13 patients (from Jan 2003 to Dec 2006). High operative mortality (7.6%) in this study reflects small study size (1 patient). No patients relapsed after surgery.
Thoracic Surgery 