Advances in surgical treatment of tuberculous pustulosis or encapsulated tuberculous pleurisy
Tuberculous abscess chest or encapsulated tuberculous pleurisy with poor medical outcome, significant thickening of the fibrous plate, significant residual pus cavity or the presence of bronchopleural fistula requires surgical treatment. Song Yanzheng [19] et al. suggested that a targeted removal of the lesion could be used for limited pus thorax; Marks [20] and Jin Minghua [21] suggested that video-assisted thoracoscopic surgery (VATS) pus thorax contouring was suitable for the treatment of tuberculous pus thorax in the fibrinous stage and the early stage of mechanization, especially for tuberculous pus thorax in the fibrinous stage. Marks [2] noted that VATS has the significant advantage of reducing the length of hospital stay without reducing the incidence of mortality and complications. In developed countries, VATS application is currently approaching and maintaining around 50%. yang [22] compared the pleural thickness after pleurodesis between OPEN and VATS groups using 3D 3D imaging, which was 15.3 mm and 11.1 mm, respectively, p = 0.042, which was statistically significant. Jin Feng, Department of Thoracic Surgery, Shandong Provincial Chest Hospital
Postoperative pus thorax with bronchopleural fistula after total pneumonectomy is the most serious complication. Although some progress has been made in the perioperative management of pneumonectomy in the past decades, it is difficult to identify effective methods that are less invasive and suitable for all patients.Bobocea [23] reported a case of a 40-year-old female patient who underwent left total pneumonectomy for tuberculosis-damaged lung combined with Treponema pallidum infection at an outside hospital and developed a postoperative pustulothorax with BPF.Bronchoscopy revealed a bronchial stump approximately 15 mm long. The patient had no mediastinal lesions and no anatomical abnormalities. A TV-assisted mediastinoscopic procedure was performed under general anesthesia to close the bronchial stump at the root of the left main bronchus. This approach is the least invasive compared to transthoracic and transthoracic split pericardial approaches. Of course, patients must be carefully selected for this procedure, and the bronchial stump must not be smaller than 10 mm, and even surgeons with extensive experience with mediastinoscopy must be prepared for immediate conversion to open surgery.
In the last 10 years, Watanabe Spigot Embolisation (EWS) has shown some efficacy in embolizing the bronchus to treat bronchopleural fistula (BPF).Dalar [24] reported a case of a 39-year-old male admitted to the ICU with respiratory failure, CT showed a large right upper cavity and a middle lobe BPF, and mycobacterium tuberculosis was found in the pleural fluid. The respiratory failure was caused by tuberculous septic chest with BPF. On day 7, the upper chest drainage tube was removed and the abscess chest was pre-drained with pezzer drainage. On day 50, septic chest drainage was discontinued and the fiberoptic bronchoscope was retrieved again rigid bronchoscopy removed both EWSs. No complications occurred.Dalar [24] concluded that the use of EWS is a reversible means and safe and effective in patients with tuberculous septic chest combined with BPF.
In severe tuberculous septic chest, closed chest drainage or pleurodesis alone is not effective. Ahn [25] reported 18 cases with preoperative diagnosis of tuberculous septic chest in 8 cases and postoperative confirmation in another 10 cases. Four cases underwent open window thoracostomy (OWT) alone, 7 cases underwent direct intrathoracic muscular transposition (IMT), and 7 cases underwent OWT after 4 years. Among the 14 cases of IMT, 10 cases were single flap, 2 cases of pectoralis major, 4 cases of anterior serratus, 3 cases of latissimus dorsi and 1 case of rectus abdominis; 4 cases required double flap, 1 case of latissimus major and latissimus dorsi and 3 cases of latissimus dorsi and anterior serratus respectively. 11 cases of TB septic chest combined with BPF were found among the 14 cases of IMT, and 1 case of postoperative infection was found. Ahn[25] concluded that IMT is an effective treatment option for chronic tuberculous septic chest with combined BPF.