tuberculosis – Thoracic Surgery

There’s a new video over at VUmedi by Turkish thoracic surgeon, Dr. Cagatay Tezel. In this video, as well as a related article over at CTSnet, Dr. Tezel talks about modern day surgical treatment for tuberculosis related complications. Tuberculosis, unlike measles, polio or other diseases associated with the 19th (and earlier centuries) has not faded into the past, despite the availability of a (partially effective) tuberculosis vaccine. Tuberculosis continues to carry a heavy morbidity and mortality burden globally. In fact, for all of the news media surrounding Ebola, HIV, SARS and Bird/ swine and various flu, Tuberculosis is the real killer; and is responsible for 1.8 million deaths a year*.

Complicated multi-drug regimens and poor patient adherence have resulted in the development of new strains of resistant TB. Decreased immune resistance in specific populations such as diabetics, or patients with HIV infection has resulted in a greater number of people with active disease. This means, that thoracic surgery remains a critical component in the treatment of this deadly disease.

Surgical treatment of Tuberculosis and TB related complications

As long time readers know, Thoracics.org has been following the rise of multi-drug resistant (MDR-TB) and extreme/ extensive drug resistant (XDR-TB) versions of the age-old scourge of the ‘white plague‘ as well as the evolution of the surgical treatment of this disease, from the early era of thoracoplasty, as well as more modern treatment of TB related empyemas such as VATS.

In fact, the surgical treatment of tuberculosis is the foundation on which the thoracic surgery specialty emerged, out the operating theaters of TB sanitariums around the world. However, as the development and successful use of antibiotics spread from the late 40’s thru the 50’s and 60’s – surgery took a backseat to drug therapy. The development of these drug resistant strains means that it is imperative that the thoracic surgery community continue to research, innovate and operate on patients with tuberculosis.

We welcome articles and video submissions on this topic from our colleagues around the world.

*Several statistics give the annual death toll at 2 to 3 million.We have cited the most recent WHO figures above.

Additional articles/ posts/ references

Mystery Diagnosis: Pleural Plaques

The Tuberculosis Vaccine: information about the vaccine, and who should get it (according to current CDC recommendations).

Freixinet JG¹, Rivas JJ, Rodríguez De Castro F, Caminero JA, Rodriguez P, Serra M, de la Torre M, Santana N, Canalis E. (2002). Role of surgery in pulmonary tuberculosis. Med Sci Monit. 2002 Dec;8(12):CR782-6.

Somocurcio JG¹, Sotomayor A, Shin S, Portilla S, Valcarcel M, Guerra D, Furin J. (2007). Surgery for patients with drug-resistant tuberculosis: report of 121 cases receiving community-based treatment in Lima, Peru. Thorax 2007 May;62(5):416-21. Epub 2006 Aug 23. A particularly interesting article, with an in-depth look at the surgical treatment outcomes in patients with MDR TB. Mortality was 5.0 % in this study.

Man MA¹, Nicolau D. (2012). Surgical treatment to increase the success rate of multidrug-resistant tuberculosis. Eur J Cardiothorac Surg. 2012 Jul;42(1):e9-12. doi: 10.1093/ejcts/ezs215. Epub 2012 Apr 24.

Park SK, Kim JH, Kang H, Cho JS, Smego RA Jr. (2009). Pulmonary resection combined with isoniazid- and rifampin-based drug therapy for patients with multidrug-resistant and extensively drug-resistant tuberculosis. Int J Infect Dis. 2009 Mar;13(2):170-5. doi: 10.1016/j.ijid.2008.06.001. Epub 2008 Sep 2.

LXXI Congreso Nacional de Neumologia y Cirugia de Torax

Cancun, Mexico

Yesterday was such a flurry of activity – I didn’t get a chance to post Wednesday’s Conference highlights until now.

After sitting thru some lackluster presentations for most of Tuesday, today was definitely the best day of the conference so far; as the topics become more and more thoracic surgery related (versus Asthma, and other strictly pulmonary medicine topics). There were so many enjoyable and informative lectures today that is was hard to choose, even after deciding to pick more than one – I feel like apologizing to all the other great speakers – but I’ve narrowed it down to a trifecta of great speakers, with Dr. Raimundo Santolaya, Dr. Rafael Andrade, and Dr. Enrique Guzman de Alba.

Dr. Ramundi Santolaya, MD a Chilean thoracic surgeon gave a thoroughly enjoyable overview of the diagnosis and management of pneumothoraces. Whether it was due to innate charisma, a lively discussion and multi-media presentation on one of my favorite topics, or due to that fact that with his clear, unaccented Spanish – I didn’t miss a word – he was a standout star of the day – so much so that I chased him down later for a full interview.

Dr. Raimundo Santoloya — Dr. Raimundo Santolaya, of Santiago, Chile discusses 'Actualidades en el manejo del neumotorax'

Dr. Rafael Andrade, from the University of Minnesota was also very informative, yet entertaining during his talk on the use of ultrasound for mediastinal evaluation (cancer staging). He explained that while mediastinoscopy remains the gold standard for staging lung cancer, that the new(er) ultrasound techniques including endobronchial (EBUS) and endoesophageal (EUS) ultrasound allow for tissue sampling (and biopsy) of lymph nodes that are normally inaccessible during mediastinoscopy including many of the more distal stations. These techniques do not replace mediastinoscopy, or mediastinotomy (Chamberlain) but offer complimentary information to assist in the staging of cancers to help determine the extent of disease when PET results may be inconclusive, or appear to show more extensive disease.

I had just finished reading some of his recent papers for another article I was working on, so it was both a surprise and a pleasure to see him and speak with him, in person. He sure didn’t seem to mind my questions (despite my chronically impaired Spanish.)

Of course, his English is impeccable but when in Rome, etc. so I did my best. Luckily for me, and all the readers here at Cirugia de Torax – my understanding of ‘surgical Spanish’ tends to be spot – on, particularly when there are overhead slides to assist with translation.

Dr. Rafael Andrade, University of Minnesota presents, 'Valor del ultrasonido toracico en las enfermedades pleurales

Dr. Enrique Guzman de Alba, a cardiothoracic surgeon gave two lectures, more of a part I and a part II on the current literature regarding the surgical treatment of lung cancers by staging as well as a review of the literature surrounding clinical outcomes comparing lobectomy versus segmentectomy (aka wedge resections.) As he explained, lobectomy remains the gold standard for any patient who is able to tolerate surgery, (including patients that are believed to be marginal candidates and would otherwise be relegated to wedge resection.) He reports that despite common beliefs regarding segmentectomies as ‘lung -sparing’ for patients with marginal baseline respiratory (or other functional) status – there has been no data to demonstrate that these patients perform better/ or better tolerate a wedge resection versus the more complete lobectomy. Therefore, given the increased incidence of cancer reoccurrence with segmentectomies – he advocates for the larger, but more effective lobectomy.

There was also some interesting discussion on managing malignant pleural effusions and limitations of PleurX catheter use in Mexico due to prohibitive costs for many patients.

Tag: tuberculosis

VATS decortication for Tuberculosis

Congreso Nacional: Wednesday Highlights