European Journal of Cardiovascular Medicine

Surgery was the only way to treat tuberculosis (TB) before the availability of anti-tuberculosis drugs.  However, with the introduction of anti-tuberculosis drugs, medical treatment became the first line therapy for TB. Yet with the emergence of drug-resistant TB (DR-TB), the prevalence of sequelae of TB has risen significantly and hence, the lung resection surgeries are increasingly being required as surgical treatment for various TB sequelae[1]. During the healing of active TB variety of sequelaecan occur like lung cavitation with aspergilloma formation within the cavities, fibrosis affecting lung tissue causing traction over bronchi leading to bronchiectasis,lung fibrosis and scarring leading to significant lung tissue destruction and pus formation causingchronic empyema leading to adjacent lung lobe collapse and eventually destruction.These lesions, either isolated or combined in different amounts, can cause the destruction of a lobe or even the entire lung[1,2]. The typical symptoms include; chronic cough, recurrent hemoptysis, recurrent chest infections, purulent sputum and dyspnea.Sequelaeof tuberculosis may also lead to catastrophic emergencies such as massive hemoptysis [1,2]. Complications of TB amenable to surgical resection of the lung include recurrent hemoptysis at times massive due to cavitatory lesions with aspergillomas, bronchiectasis,and destroyed lung[1,2,10]. As recommended by WHO, surgical treatment for the TB sequela requires multi-disciplinary approach where the decision is expected to be made together by physicians, surgeons, an anesthesiologist, physiotherapists, and other specialists.This approach helps to limit complications and ensure an acceptable outcome following surgery [10]. Preoperative work-up usually includes chest X-ray, HRCT (CT Thorax) and Pulmonary Function Tests (PFTs) to predict postoperative respiratory function [8]. The surgical intervention started with collapse therapy like wax or Lucite ball plombage, induced pneumothorax, thoracoplasty and phrenic nerve interruption. But recently lung resection surgeries like segmentectomy, lobectomy and pneumonectomy are commonly required to prevent fatal complications of pulmonary TB and improve the patient’s quality of life[10].This study aims to study the surgical management required in terms of lung resection surgeries for Pulmonary TB sequelae and its outcome

Study Design and Patient Characteristics:

A study was conducted at our institute between 2017 and 2020 on 27 patients who underwent various lung resection surgeries for pulmonary TB sequelae such as, cavitary lesions with aspergillomas, bronchiectasis, destroyed lung and chronic empyema. Data were collected based on age, gender, symptoms, diagnosis, radiographic findings, preoperative lung function based on Pulmonary Function tests (PFTs),type of the lung resection surgery performed, postoperative complications and outcome. Patients’ cohort comprised of 15 male and 12 female patients ranged from 17 to 67 years, with an average age of 35.5 years. The most affected age group was 30–40 years, often presenting cavitary lesions with aspergillomas as a post-TB sequela. Active TB (sputum positive patients) were excluded from this study.

Surgical Indications and Preoperative Preparation:

Patients were categorized based on pulmonary TB sequelae they had in the form of cavitary lesions with aspergillomas, bronchiectasis, destroyed lung and chronic empyema.Patients were assessed clinically and investigated with routine blood investigations and radiological studies like chest X-ray and CT thorax (HRCT). Preoperative lung function assessment was done based on Pulmonary Function Tests (PFTs). The surgical indications included symptomatic aspergillomas with cavitatory lesions, bronchiectasis, lung destruction mostly due to lung fibrosis and scaring and chronic empyema. Preoperative preparation included lifestyle changes, improvement in the nutritional status, anti-tuberculosis and antibiotic therapy [2,9,10].

Surgical Procedures and Postoperative Management:

A total of 27 definitive surgical procedures were performed, with two reoperations one for air leak closure and one for postoperative bleeding. All surgeries were performed under general anesthesia with the placement of a double-lumen endobronchial tube. A posterolateral thoracotomy was employed, with pleural space entry through the fifth intercostal space. Significant adhesions were a frequently encountered intraoperative problem, requiring rib resection in some cases. The most frequent type of lung resection surgeries performed were lobectomy and pneumonectomy. Pulmonary vessels were ligated and transfixed, while the bronchial stump was closed using staplers, with additional sutures if needed. Two chest tubes were inserted, and aggressive postoperative analgesia along with chest physiotherapy was administered. Excessive bleeding was defined as drainage exceeding 1 liter within the first 24 hours, while a prolonged air leak was classified as a leak lasting more than 7 days. Patients were instructed to attend follow-up appointments at the outpatient department for ongoing assessment.

All 27 patients in our study underwent surgical resection due to long-term pulmonary complications following tuberculosis. The most frequently encountered post-TB issue was the presence of cavitary lung lesions colonized by aspergillomas, which affected 13 patients (48.1%) followed by bronchiectasis in 7 patients (25.9%) and destroyed lung seen in, (18.5%) patients. Only 2 patients (7.4%) had chronic empyema associated with lung tissue destruction. The leading clinical symptoms reported by these individuals included a persistent cough, repeated episodes of hemoptysis, frequent chest infections and dyspnea in some patients. Few patients also suffered massive hemoptysis.

Surgery was a key part of treatment in all cases with lobectomy being the most commonly performed operation done in 19 patients (70.3%). It was mainly chosen for those with disease limited to one area, like a single lobe or two lobes affected by cavities containing aspergillomas, often leading to bleeding, repeated chest infections and persistent cough caused by bronchiectasis. Pneumonectomy was necessary in 5 patients (18.5%), typically where the disease had spread widely and the lung tissue was completely destroyed. These cases often involved severe scaring and tight adhesions. In 3 patients (11.1%), segmentectomy was done, particularly when it was important to preserve as much lung function as possible like in small, localized cavitary lesions.

Few patients experienced post-surgical complications like prolonged air leak in 1 patient (3.7%), bleeding in 1 patient (3.7%) and wound infection in 1 patient (3.7%). There was no mortality after surgeryand most patients reported noticeable relief in symptoms and improved lung function during follow-ups. These positive outcomes were likely due to good patient selection, proper preparation before surgery, and precise surgical techniques.

Table 1: Patient Demographics and Clinical Profile

Table 2: Distribution of Patients According to Pulmonary Sequelae

Table 3: Types of Lung Resection Surgeries Performed

Table 4: Postoperative Complications

Table 5: Distribution of Procedures Based on Type of Pulmonary Sequelae

Tuberculosis (TB) remains a major contributor to long-term lung issues, often leaving patients with lasting complications even after completing treatment. In our study, the most common post-TB sequelae that required surgical intervention were cavitatory lesions containing aspergillomas followed by bronchiectasis, destroyed lung and chronic empyema. Our findings are consistent with earlier reports from TB-endemic regions, which have highlighted that persistent lung cavities with bleeding and bronchiectasis due to traction over bronchi secondary to lung tissue fibrosis and scarring continue to be key reasons for surgery in people recovering from TB [1,2,3,5].

XRAY AND CT IMAGES OF ASPERGILLOMA

Radiology of a simple aspergilloma. (A) PA chest x-ray; (B) CT picture of the same aspergillomatransverse section (C) CT picture of the same aspergilloma coronal section

XRAY AND CT IMAGES OF POST TB CYSTIC BRONCHIECTASIS

Radiology of post TB cystic bronchiectasis (A) PA chest x-ray; (B) CT picture of the same post TB cystic bronchiectasis Transverse section (C,D) CT picture of the samepost TB cystic bronchiectasis coronal sections

XRAY AND CT IMAGES OF POST TB LUNG DESTRUCTION

Radiology of post TB Right Lung Destruction (A) PA chest x-ray; (B) CT picture of the same post TB Right Lung Destruction transverse section (C) CT picture of the samepost TB Right Lung Destruction coronal sections

Lobectomy emerged as the most frequently performed surgical procedure, echoing trends seen in other centers, where disease localized to a single lung lobe often allows for a more straightforward surgical approach [9,10]. In more severe cases with widespread lung damage, pneumonectomy was required. However, this procedure remains complex due to the presence of fibrotic tissue and dense adhesions. When lung preservation was a priority, we performed segmental resections, especially in patients with adequate pulmonary reserve [1,4,6].

Postoperative outcomes in our series were generally positive, with no perioperative deaths and only manageable complications. Few issues encountered after surgery were prolonged air leak, bleeding and wound infection, complications that have also been noted in similar studies [5,9]. These good outcomes can be largely attributed to meticulous preoperative preparation, including proper nutrition, respiratory therapy, and stringent infection control, all of which have been emphasized in previous literature [3,7,8].

Additionally, evidence suggests that patients benefit more from surgery when they are referred early before extensive scarring or respiratory decline sets in [10]. In our cohort, the majority of patients presented with disease that was still relatively localized and had not significantly impaired lung function, allowing for lung-sparing surgical options.

Our experience reinforces the growing body of research showing that surgery at right time, when paired with appropriate medical therapy and rehabilitation, can significantly enhance long-term quality of life and functional outcomes for individuals dealing with post-TB complications [6,7]. Achieving the best results requires a multidisciplinary approach, with close collaboration between pulmonologistsand thoracic surgeons to determine the right timing and candidacy for surgical treatment.

Surgery continues to play a critical role in treating complications arising from pulmonary tuberculosis, particularly in patients who develop cavitary lesions with aspergillomas, bronchiectasis or severely destroyed lung tissue. Among the available procedures, lobectomy stands out as the most frequently used and effective surgical choice. In contrast, pneumonectomy is typically reserved for situations where the disease is so extensive that preserving functional lung tissue is no longer an option. For patients with disease confined to a specific area, segmentectomies are preferred to preserve as much healthy lung as possible.

In our study, surgical outcomes were encouraging with low complication rates and no reported deaths highlighting the importance of selecting appropriate candidates, conducting detailed preoperative assessments, and performing surgery with a high degree of precision and care.

These observations are in line with findings from other research, which consistently supports the inclusion of surgical management as part of a broader, multidisciplinary strategy for patients with TB who continue to show symptoms or structural lung abnormalities after medical treatment. Surgery should be considered earlier in the course of the disease, especially when medical therapy alone does not resolve the condition, or when complications like significant hemoptysis emerge.

When supported by careful planning, skilled surgical teams, and comprehensive post-surgical care, thoracic surgery remains both a safe and potentially curative option for managing complex lung conditions linked to tuberculosis.

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