Surgical treatment of pulmonary tuberculosis began in the late 19th century, and the emergence of effective anti-tuberculosis drugs in the 1940s played a decisive role in the selection of surgical indications and surgical methods. The primary condition for surgical treatment is that the lesion has stabilized through medical treatment and is no longer in the active progressive dissemination phase, but some lesions are irreversible and require surgical treatment to remove the lesion or to promote healing by atrophy therapy. In summary, the two main types of surgical treatment are excisional therapy and atrophic therapy. The objectives of surgery are: to relieve the symptoms of tuberculosis intoxication; to improve the effect of drug therapy; to slow down or stop the occurrence of dysfunction; to shorten the course of treatment; to completely remove the tuberculosis lesions; and to create conditions for second-stage functional reconstruction. The surgical methods for tuberculosis are as follows.
I. Pneumonectomy
What conditions require pneumonectomy?
1.Tuberculous cavity
2.Tuberculosis spheres
3.Destruction of the lung Destruction of the lung lobe or one lobe with extensive lesions, cavities, fibrosis and bronchial stenosis or dilatation
4.Tuberculous bronchial stenosis or bronchial dilatation
5.Recurrent or persistent hemoptysis
6, other indications such as chronic fibrous caseous pulmonary tuberculosis that has not resolved over time, recurrent episodes, lesions that are more concentrated in a lobe or still draining after thoracoplasty, and suspicious mass shadows in the lungs with uncertain diagnosis or unexplained pulmonary dysplasia.
What conditions are not suitable for pneumonectomy?
1.Pulmonary tuberculosis is spreading or in active stage, with heavy systemic symptoms, abnormal blood sedimentation and other basic indicators, or infiltrative lesions in other parts of the lung.
2.Poor general condition and cardiopulmonary compensatory capacity.
3, Clinical examination and pulmonary function measurement suggest that the lung resection will seriously affect the patient’s respiratory function.
4, Combined with other tuberculosis of other organs outside the lung, and the disease is still progressing or deteriorating after systematic anti-tuberculosis treatment.
Possible complications after pneumonectomy.
1.Bronchopleural fistula
2.Persistent air-containing residual cavity
3.Septic chest
4.Disseminated tuberculosis.
Second, thoracoplasty
It is a subperiosteal resection of different number of rib fragments, so that part of the chest wall is sunken near the mediastinum and the lung underneath is atrophied, thus it is a kind of atrophy therapy.
What cases require thoracoplasty?
1.Upper lobe hollow, patient with poor general condition cannot tolerate pneumonectomy.
2.Upper lobe cavity, but the middle and lower lobes also have tuberculosis lesions.
3.Widespread tuberculosis foci on one side, sputum positive, drug treatment is ineffective, poor general condition can not tolerate total pneumonectomy, but the bronchial changes are not serious.
4.Pulmonary tuberculosis combined with abscess thorax or bronchopleural fistula, which cannot tolerate pneumonectomy.
What conditions are not suitable for thoracoplasty?
1, Tension cavity, thick-walled cavity and cavity located in the middle and lower lobes or near the mediastinum.
2.Tuberculous spherical lesions or tuberculous bronchiectasis.
3.Adolescent patients should avoid it because it can cause obvious deformation of the thorax or spine after surgery.
Pleuropneumonectomy
Because this procedure can maintain the integrity of the thorax, it has gradually replaced thoracoplasty in recent years, but it is difficult, risky, bleeding intraoperatively, and has high technical requirements. A suitable incision should be selected to take care of the pleural apex and diaphragm surface as much as possible, and one to two ribs at the incision should be removed and extra pleural dissection should be performed. The mediastinal surface can be separated first (adhesions at the pericardium are easier to separate), and the anatomical level can be found and then separated to the pulmonary hilum layer by layer, with the principle of easy first and then difficult carefully.
IV. Latest clinical developments in pulmonary tuberculosis
The incidence of multidrug-resistant tuberculosis is gradually increasing due to the irregular implementation of treatment regimens and the irrational application of drug therapy in recent years.
The surgical treatment of multidrug-resistant tuberculosis is receiving more and more attention. Internal treatment is likely to produce resistance to more drugs, and the effect of internal chemotherapy is poor. Surgical procedures are gaining attention as an important therapeutic measure. During the treatment of pulmonary tuberculosis, surgical treatment should be promptly considered once sputum conversion is not achieved by medical therapy and the lesion is limited or the patient cannot tolerate chemotherapy.
Indications for surgery for multidrug-resistant tuberculosis are.
(1) Persistent or recurrent sputum positivity with limited lesions during regular treatment;
(2) Patients with rigid sputum that can cause recurrent TB lesions such as TB cavities and destroyed lungs;
(3) Pulmonary tuberculosis causing complications such as bronchopleural fistula, abscess chest, hemoptysis or combined malignant tumor. The key point of surgery is that active TB lesions should be removed as much as possible so as to achieve relative radical treatment. Postoperatively, the duration of chemotherapy should be determined according to the drug-resistant type of tuberculosis and postoperative residual lung status, and four or more sensitive anti-tuberculosis drugs should be given for 18 months.