Surgery and pleuro-pulmonary tuberculosis: a scientific literature review

Abstract

Tuberculosis (TB) is still a major public health concern, mostly affecting resource-constrained settings and marginalized populations. The fight against the disease is hindered by the growing emergence of drug-resistant forms whose management can be rather challenging. Surgery may play an important role to support diagnosis and treatment of the most complex cases and improve their therapeutic outcome. We conducted a non-systematic review of the literature based on relevant keywords through PubMed database. Papers in English and Russian were included. The search was focused on five main areas of intervention as follows: (I) diagnosis of complicated cases; (II) elimination of contagious persisting cavities, despite appropriate chemotherapy; (III) treatment of destroyed lung; (V) resection of tuberculomas; (VI) treatment of tuberculous pleural empyema. Although specific practical guidelines concerning surgical indications and approaches are currently unavailable, a summary of the evidence emerged from the scientific literature was elaborated to help the clinician in the management of severely compromised TB patients. The decision to proceed to surgery is usually individualized and a careful assessment of the patient's risk profile is always recommended before performing any procedure in addition to appropriate chemotherapy.

Keywords: Tuberculosis (TB); lobectomy; pneumonectomy; review; surgical treatment; tuberculoma.

Figure 1

Modification of extra-pleural pneumolysis with plombage. Methyl methacrylate spheres are collected within a polypropylene mesh, which is placed in the newly created extra-pleural space. As a detail, at the bottom, the postoperative chest radiography.

Figure 2

Ovoid, tumour-like lesion of unknown origin, subsequently confirmed as tuberculosis. In the picture a detail of the resected specimen is shown: a tuberculous lesion with a fibrocaseous component, well localized within a lung parenchyma. At the bottom: preoperative chest radiography.

Figure 3

Central lung cancer lesion associated with bilateral bullous emphysema and bilateral TB sequelae—1: lung cancer lesion; 2,3: specific TB sequelae. At the bottom—computerized tomography: right lower lobe cancer lesion.

Figure 4

Disease relapse after surgery for multidrug-resistant tuberculosis (MDR-TB). (A) Combined destructive, fibrocaseous and fibrotic left lung lesions in a 54 years old male; (B) 5 years after the left upper lobectomy for MDR TB; (C) radiographic aspect after 24 months of chemotherapy.

Figure 5

Pleuropneumonectomy for tuberculosis destroyed lung. Upper row: postero-anterior radiography and computerized tomography (CT) of a 53-year-old male with destructive extensively drug-resistant tuberculosis of the left lung; radiographic aspect after 12 months of chemotherapy. Lower row: female, 37 years old, thoracic CT aspect after 30 months of chemotherapy with details on operative specimen.