European Journal of Cardiovascular Medicine

Tuberculosis is considered a major cause of ill health and one among the leading causes of death worldwide. Incidence of Pulmonary Tuberculosis is currently increasing; particularly, there is a marked rise in the number of multi-drug resistant cases. It has been aptly defined as “the Phoenix of the Thoracic surgery”. According to the Global Tuberculosis Report 2021, the estimated incidence of cases was 188 per 100,000 population. Before the advent of  Anti Tuberculosis drugs, surgery was the only mode of treatment for Tuberculosis. The surgical intervention started with collapse therapy like wax or Lucite ball plombage, induced pneumothorax, pneumoperitoneum, thoracoplasty and phrenic nerve interruption.[1,2]     

Current recommendations by WHO suggest that surgical resection needs a multidisciplinary approach which includes physicians, surgeons, anesthesiologists and physiotherapists. This will help in limiting the complications and ensures better outcomes following surgery. This study aims to estimate the incidence, indications, practice, outcomes and complications of surgical intervention in Tuberculosis in the current era.

The study was a prospective and retrospective study initiated after obtaining approval from the Institutional Ethics Committee. Data was collected, and patients were assessed based on age, gender, mode of presentation, duration of symptoms, duration of ATT, procedure performed, postoperative complications and management. The data of patients who underwent surgery for Pulmonary Tuberculosis from January 2017 to December 2022 was collected. 50 Patients who were identified to have had surgery for Pulmonary Tuberculosis in their medical records were included in the study.

 Inclusion Criteria: All the patients who underwent surgery for either diagnosis or treatment of Tuberculosis, or in whom it was diagnosed incidentally.

 Exclusion Criteria: All those patients who did not have Thoracic Tuberculosis, Immunocompromised patients, Redo-surgery of the thorax.

Consent was taken for the patients who were studied prospectively.

All the data from the case records, presenting complaints, diagnosis, surgery performed, OT notes and follow up records were collected and analysed in Excel spreadsheet. Bar charts and pie charts were made for pictorial data representation wherever suitable.

History of surgical treatment in Tuberculosis has progressed from isolation, fresh air sanatoria era to various collapse therapies and now surgical resection. Surgical therapy in pulmonary Tuberculosis is a multi-disciplinary approach. A limited number of observational studies and reviews are available on the role of surgery in Tuberculosis; the majority suggest that adjuvant surgery in the selected patients improves the outcome. Identifying the need for surgery at the optimal point of time strongly impacts the outcome. [3,4]

Drug resistance is becoming an significant problem worldwide. In addition, the retreatment cases have higher drug resistance than those with the new onset of TB. Current indications for surgical therapy are multidrug resistance with poor response to medical therapy, complications of Tuberculosis (Aspergilloma, bronchiectasis, haemoptysis, destroyed lung) and Tuberculosis of the pleura. Few meta-analyses are available on the topic. In Marrone’s meta-analysis, 24 studies identified a significant association between surgery and successful treatment compared to non-surgical intervention.[5,6]

In the present study, out of the 50 patients, there were 27 males and 23 females. Male: female ratio was 1.17:1. In Epke et al.[6] study male: female ratio is 1.3:1.⁹⁶ Many other studies have also shown male preponderance, and it was attributed to smoking alcohol and more social mixing in males compared to females.

The range of age among the patients was from 14-70 years. The maximum number of patients who underwent surgery were in the age group 31-40 years, accounting to 26% (n= 13). In a study by R K Dewan et al.[7] the most common age group undergoing surgery was 21-30 years. In the study by Epke et al[6]., the range of age was 2-68 years, and most patients were in the age group 41-50 years, 30.3%.⁹⁶ In a study by Somocurio et al., the range of age was 16-66 years with male to female ratio of 2:1.[8]

Involvement of the right lung was more common than the left lung (50% vs 40%). Although not all previous studies have included laterality in analysis, the right lung is usually infected by mycobacterium tuberculosis more than the left, and hence, the complications arising from Tuberculosis is also more common on the right.

The presenting symptoms in the study included cough (62%), shortness of breath (50%), fever (30%), haemoptysis (24%) and chest pain (16%). In R K Dewan et al.[7] study, the most common indication of surgery was massive recurrent hemoptysis. In the study by Epke et al.[6] most common presenting symptom was shortness of breath (97%) and fever (97%). In the study by Ernile[9], cough occurred in 70.5%, fever in 29.6%, haemoptysis in 11.1% and shortness of breath only in  5.2%. Karkhanis VS et al[10] noted that shortness of breath was an important symptom which determined the need for surgical intervention in 72.3% of patients with the pleural collection.

Most patients presented with a duration of symptoms less than 3 months (62%). The longest duration of symptoms was noted in a 29-year old female patient with bronchiectasis who presented with cough with sputum for 9 years. The shortest duration of symptoms were noted in a 32 year old female patient who presented shortness of breath and haemoptysis for 10 days.

Of the 50 patients, 22 had associated comorbidities; most common being diabetes mellitus in 9 (18%) patients. Patients with diabetes had delayed wound healing. Some of them developed serous discharge, which was controlled with regular dressing. In patients with uncontrolled diabetes, there was wound infection, and they needed prolonged antibiotics and more extended hospital stay. None of them developed wound dehiscence. One patient with chronic pancreatitis developed acute pancreatitis following surgery. 7 (14%)  patients were smokers, and 9 (18%) patients consumed alcohol. No significant difference was noted between smokers and non-smokers postoperatively. In the study by Somocurcio et al.[8], 5% of patients had diabetes mellitus, 9.1% of patients had alcoholism, and 6.7% of patients were tobacco users.

All 50 patients underwent pulmonary function tests and bronchoscopy preoperatively. In 4 (8%) patients pulmonary function test was normal, and in 17 (34%) patients bronchoscopy was normal. The most common finding on pulmonary function test was mild obstruction in 26% (n= 13) patients and mild restriction in 24% (n= 12). A severe restrictive pattern was seen in 22% of patients. Most common bronchoscopy finding was mucoid secretions inside the bronchus suggestive of infective aetiology. The study by Somocurcio et al[8]. Suggested an incidence of respiratory insufficiency postoperatively in patients with severe restriction preoperatively.

13 patients were on ATT at the time of surgery, and 37 patients have already taken ATT. Sputum for acid-fast bacilli was negative in 98% of patients and was positive in one patient taking ATT since 4 months. He was diagnosed with loculated empyema with lung collapse. Due to the worsening of symptoms, decortication was done. A case series by Chen et al.[11] suggests that the timing of surgery should be at least 6 months of standard therapy in order to have better outcomes.

In our study, no patient had drug-resistant Tuberculosis. In R K Dewan et al[7] study, among 2878 patients, 98 patients were sputum positive; among them 15 patients had drug-resistant Tuberculosis, which accounts for 0.005%. Drug-resistant Tuberculosis recorded in Indian studies is low compared to western studies. MDR and XDR TB is comparatively less common in the Indian population.

The most common radiological feature in the study was hydropneumothorax in 44% of patients, followed by fibrocavitary disease in 24% and bronchiectasis in 20% of patients. Hydropneumothorax alone was seen in 30% of patients, the remaining had associated lung collapse, bulla, bronchiectasis and destroyed lung. In Somocurcio et al[8] study, fibrocavitary disease was seen in 91.7%, and bronchiectasis was seen in 22.9%. Likewise, in the study by Takeda et al. cavity on X-ray was seen in 85.7% of patients.

As per the study, the common indications for surgery were loculated empyema in 42% (n=21), bronchiectasis in 22% (n=11), followed by Aspergilloma in 16% (n=8). The primary indications for surgical intervention in the previous studies included haemoptysis, drug resistance, possible neoplasm and bronchiectasis.¹⁰³ In a study by Dewan et al.[7] 70.3% of patients were diagnosed with empyema of 2878. It was observed to be a frequent complication of Tuberculosis. In most Indian studies, loculated empyema remains the most common indication of surgery.  Although chemotherapy should be instituted for tuberculous empyema, it is unlikely to clear the pleural space infection in the chronic stage, most probably because the penetration of the anti-tuberculosis agents is limited. For this reason, surgical intervention is often necessary. This can be accomplished by thoracostomy tube or thoracotomy and decortication. In the study by Epke et al.[6] significant and symptomatic pleural effusion was found to be the most common indication for surgery in 39.4% of patients. In the index study, pleural effusion with empyema thoracis constituted 51.5% of the surgical indications of PTB. In this study, Bronchopleural fistula and spontaneous pneumothorax secondary to Tuberculosis was seen in 10% of patients. In other studies, this also formed 11.9% and 5.3%  of the indications for surgical intervention in pulmonary Tuberculosis.[12] Two of the patients with spontaneous pneumothorax had massive and prolonged air leak causing lung collapse.

One patient had a giant bulla arising from the left upper lobe, and two patients had destroyed lung. 39-year old post tuberculosis patient had a left upper lobe mass with collapse with enlarged lymph nodes in the left hilar region. Despite of advances in the chemotherapy and management of Tuberculosis, the traditional indications remain the primary indications for surgery.

All the patients in this study have undergone open procedures. We did not prefer VATS in these cases because of the extensive disease and adhesions and to avoid exposing the patient to more morbidity.

In this study, the most common procedure performed was decortication in 50% of the patients, followed by lobectomy in

38%, pneumonectomy in 10%, and bullectomy in 2%. In Takeda et al.[13] study most common procedure performed was lobectomy in 77% of patients. The patient with left upper lobe mass needed hilar dissection. A lobectomy or pneumonectomy for TB is considered a high-risk procedure and technically hazardous because of adhesions, scarring and areas of chronic sepsis. Even for experienced surgeons, hilar dissection may pose significant problems. The violation of the disease cavity in the lung parenchyma during surgery, cavity eroding into pleura, excessive bleeding and other problems, including poor nutrition, may affect the outcome of surgery. Contrary to lung cancer, resection in Tuberculosis is more riskier.

Overall early complication rate was 48%, with one patient of right upper lobectomy with wedge resection of the apical segment of the lower lobe. Patient developed significant bleeding and needed re-exploration and the bleeding vessel was identified and ligated. No further bleed was noted. The remaining 46% of patients developed air leak postoperatively. Most of the patients had air leak for less than two days. One patient who underwent decortication with the closure of the bronchopleural fistula closure with latissimus dorsi flap was on ventilator support for a day. Because of significant air leak, pleurodesis was done. Postoperative bronchoscopy was done, which suggested persistent bronchopleural fistula. The patient was taken for pneumonectomy due to persistent air leak with lung collapse.

The overall late complication rate was 30%, and 26% of the patients had wound infection. Wound infection was commonly associated with patients with diabetes mellitus. No patient had wound dehiscence. All those patients were managed by antibiotics and regular dressings. 4% of patients needed redo- thoracotomy and pneumonectomy due to persistent lung collapse. Meticulous intervention is needed to obliterate the pleural space to avoid lung collapse. Morbidity reported in most other recent series ranges from 3% to 53.7%. In Somocurcio et al[8]. study, overall morbidity was 22.6% (n=27), of which major complications were seen in 19 patients.

The mortality rate in our study was 2% which is almost comparable with many other studies. One patient with right-loculated empyema with sputum positive for AFB, a known case of chronic pancreatitis, underwent decortication. The patient developed acute on chronic pancreatitis postoperatively. The patient was in sepsis, and on POD 3 patient was intubated because of respiratory distress. The patient suffered cardiac arrest and expired. In the study by Dewan et al.[8], overall mortality was 4.2%, of which early mortality was 1.37%, and late mortality was 2.83%. Recent published series have demonstrated mortality ranging from 0% to 3.1%. There were no intraoperative deaths. The outcomes are better in the study as most of the patients received adequate chemotherapy prior to surgery, and there was no drug resistance.

The mean duration of hospital stay was 5.54 days, and range was 3 days to 24 days. Based on our experience, an early decision regarding surgical intervention and salvage of the lung parenchyma helps improve outcomes. Furthermore, proper patient selection and timing of operation are crucial in avoiding relapse and impact the surgical results. In case of bilateral disease, special attention should be paid to pulmonary functional reserve. Significant incidence of superimposed Aspergilloma and lung destruction after surgery are still serious problems in the treatment of Tuberculosis. Massard and colleagues[14] advocated resection of asymptomatic mycetoma to prevent long-standing cavitation and to avoid catastrophic complications.

In the present cases, mortality and morbidity were acceptable, and the role of surgery was justified in terms of outcome in spite of complications and technical difficulties. The role of surgical intervention in pulmonary Tuberculosis is unquestionable, and acts as a valuable addendum to chemotherapy. Surgical intervention is an effective alternative if the patient is not responding to ATT.  Proper indication, correct timing of referral and proper patient selection are crucial in determining the outcome of surgery. Despite advances in treating Tuberculosis, conventional indications like empyema thoracis, destroyed lung remain the major indications of surgery for Tuberculosis. Sequelae of Tuberculosis are the next common indications for surgery. Incidence of synchronous malignancy though unseen, is not rare. Surgery for drug-resistant Tuberculosis is still not common. Adequate nutrition and adequate treatment of the patient prior to surgery

improve the outcome. Persistent disease with failure to expand the lung may result in redo-surgery

Figure-1:Intraoperative Pictures.

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In the present study, out of 50 patients, there were 27 males and 23 females. This constitutes 54% and 46%, respectively

In the present study, a maximum number of patients who underwent surgery were in the age group of 31- 40 years, accounting for 26%. Most common symptom observed was cough which was seen in 31 (62%) patients. most of the patients presented to the hospital with symptom duration less than 3 months, which accounts for 62%. The longest duration of symptoms was 9 years in a 29- year old female patient with bronchiectasis, and the shortest duration of symptoms was 10 days. 22 (44%) cases had associated comorbidities. The most common is diabetes mellitus in 6 (12%) cases.

In the present study, out of 50 patients, 11 patients had addictions. The most common test report noted in the study population was mild obstruction. Only 4 (8%) patients had normal test results. Mild obstructive pattern was seen in 13 (26%) of patients; moderate obstruction was seen in 3 (6%) of patients, moderate obstruction with small airway disease was seen in 7 (14%) of patients, mild restriction was seen in 12 (24%) of patients, and severe restriction was seen in 11 (22%) of patients.

The most common finding in the study population was mucoid secretions inside the bronchus. 17 (34%) patients, bronchoscopy was normal; in 19 (38%) of patients, mucoid secretions were noted inside the bronchus; in 6 patients there was narrowing of the bronchus and in 5 patients, there was collapse of the bronchus. 13 patients were on ATT at the time of surgery. Of these 13 patients, 2 (4%) patients were on ATT since 2 months

In the present study, out of 50 patients, 49 (98%) patients were negative for acid-fast bacilli, and only 1 (2%) patient was positive. There were no cases of drug resistance in this study. Most common radiological feature was hydro-pneumothorax which was seen in 22 (44%) patients, followed by fibrocavitary lesion in 12 (24%) patients and bronchiectasis in 9 (18%) patients.

In the present study, among the 50 patients, the most common side of the chest affected was right in 25 (50%) patients. In 20 (40%) patients left side was affected, and in the remaining 5 (10%) patients, both sides were affected, with one side affected greater than the other, and that side of the chest was operated on. Most common indication for surgery was loculated empyema in 21 (42%) patients, and the next common indication was fibrosis with bronchiectasis in 9 (18%) patients.

In the present study, the most common surgical procedure performed was decortication in 19 (38%) patients, followed by upper lobectomy in 12 (24%) patients. Lower lobectomy was performed in 5 (10%) patients, and pneumonectomy was done in 5 (10%) patients.

In the present study, out of 50 patients, 21 (42%) patients were in hospital for less than 5 days, 27 (54%) patient’s duration of stay was between 5 to 10 days and 2 (4%) patients were hospitalised for more than 10 days. The longest hospital stay was for 24 days in a case of loculated empyema with bronchopleural fistula. This patient has persistent lung collapse, and hence, a completion pneumonectomy was done. The shortest duration of stay was for 3 days

Out of the 50 patients, one (2%) patient with right loculated empyema with lung collapse and acute on chronic pancreatitis who underwent decortication expired on POD 3.