In Brief

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Tuberculosis (TB) is an infectious or communicable disease that has plagued humans since Neolithic times. Before 1500 b.c., Myocobacterium bovis was predominant. Thereafter, M. tuberculosis evolved. In India, circa 400 b.c., TB was noted in the Athara Vega: “The physician who values his future should not undertake to take care of a patient who has three great symptoms—fever, cough, and bloody sputum. If, however, the patient has a good appetite and digests well the food, and the disease is in its infancy, a cure may be possible” (Udwadia FE. Man and Medicine—A History. New Delhi, India: Oxford University Press; 2003:404-407). Aristotle (384-322 b.c.), when queried about the contagiousness of TB, remarked “…why, when one comes near consumptives,…one contracts the disease” (Udwadia FE. Man and Medicine—A History. New Delhi, India: Oxford University Press; 2003:404-407). Tuberculosis remains a major global medical challenge and concern. Of the world population of more than 6.5 billion, approximately one third, or more than 2.2 billion, is infected with M. tuberculosis. There is an annual incidence of more than 20,000 new cases in the United States, and 8 to 9 million new cases worldwide, with more than 80% in high burden countries. It is estimated that more than 100 million people have died from tuberculosis over the past 100 years, despite chemotherapy being available for the past 60 years. More than 10% of all infected individuals will ultimately develop active disease in their lifetime. With human immunodeficiency virus (HIV) coinfection, the incidence increases to 10% per year. The annual global mortality attributable to TB is now more than 1.7 million people (195,000 with coinfection of HIV/acquired immunodeficiency syndrome [AIDS]). The association with HIV/AIDS has added to the global concern and challenge. The incidence and prevalence of multiple drug-resistant TB (MDR-TB) continues to rise, with more than 500,000 new cases reported in 2005. The recent discovery and quarantine of a patient in the United States has increased the awareness and emotional response in the American public.

There has been an increased global concern and effort to control TB. The United Nation's World Health Organization (http://www.who.int/gtb) and the Millennium Development Goals have given TB high priority. Other multipartnership groups, including the TB Alliance–Global Alliance for Drug Development (http://www.tballiance.org/home/home.php), the Stop TB Partnership (http://www.stoptb.org), the Global Fund to Fight AIDS, Tuberculosis and Malaria (http://www.theglobalfund.org/en/), and the International Union against Tuberculosis and Lung Disease (http://www.iuatld.org/index_en.phtml), composed of governments, nongovernment organizations (NGOs), private, and corporate entities, have formed. Their ultimate goal is to control and ultimately eradicate TB (defined as 1 new case per 1 million people).

TB is caused by Mycobacterium tuberculosis. It was isolated and identified by Robert Koch in 1882. Tuberculosis complex includes M. tuberculosis, M. africanus, M. bovis, M. microti, and M. canetti. Infection is defined as a positive tuberculin skin test (TST) with reactivation, active, or tuberculous disease being the postprimary tuberculosis condition that constitutes the major clinical problem. Humans are the primary host for M. tuberculosis with no intermediate host, and transmission is by aerosol inhalation of airborne droplet nuclei. The usual parasitic transmission via “food, fingers, flies, feces, fomites” is rarely seen with TB. At the alveolar level, an immediate then cell-mediated and delayed type IV hypersensitivity immunological process occurs. During the early or primary stage, an acute symptomatic disease state can occur. In children, a severe primary miliary pattern may be seen. The usual quiescent period can proceed to postprimary TB reactivation. Lifetime, this is the overall pattern in 5% to 10% of infected TB patients. More than 80% of clinical cases are pulmonary, the remaining extrapulmonary. In children and HIV/AIDS patients the incidence of extrapulmonary infection is higher.

The clinical presentation varies from asymptomatic to symptomatic stages characterized by the protean manifestations of fever, night sweats, weight loss (consumption), malaise, and either chronic productive or nonproductive, or recent cough of 2 to 3 weeks duration, along with varying degrees of recurrent hemoptysis in approximately 25% of cases. The diagnosis is suspected from the clinical features, recent contact with an active case, and suspicion in high risk individuals, especially HIV/AID or immunosuppressed patients. Sputum smear and culture, chest radiograph (CXR), and computerized tomography (CT) are the basic diagnostic tests. Emerging sophisticated laboratory testing, including nucleic acid amplification techniques and immunologic biological technology methods, offer promise in accelerating and increasing diagnostic confirmation as well as determining specific drug susceptibility.

The major goals of contemporary therapy include prevention, patient education, screening, and direct observation treatment strategies (DOTS). The World Health Organization has set target detection of at least 70% of all new smear-positive cases occurring each year, and cure of at least 85% of these cases. This was planned for 2005, and in a number of countries (eg, India) has been achieved.

Despite the advances and success of medical therapy, treatment failures occur, along with asymptomatic and symptomatic sequelae in sputum-negative patients. The role of surgery has increased in recent years, especially among treatment failures and in the MDR-TB group.

The history of surgical treatment has progressed from the isolation, fresh-air sanitaria era to the various surgical collapse techniques era, and now the surgical resection era. Surgical therapy peaked in the mid-1950s, but subsequently decreased with the emergence of effective drug chemotherapy. At present, a whole generation of thoracic surgeons has had limited or no experience with TB surgery. This is especially true in the United States.

Familiarization with some of the older techniques and concepts, including thoracoplasty, the local effects of inflammatory disease, combined with newer operations, including muscle flaps and greater omentum transfer, have advanced the strategies for surgical treatment of patients with tuberculosis, especially in complex cases.

Given the increase of failed medical management, MDR-TB, and both symptomatic and worrisome asymptomatic sequelae patients, there is emerging a group of patients who will require and can benefit from surgery. Understanding the complexity of TB surgery, and experience with current indications for surgery are all necessary in both developing and developed countries. The difficulties and complications of incomplete resection, extent of resection, infected pleura/pleural space, air leaks, residual space problems, bleeding, bronchopleural fistula (BPF), empyema, and surgical treatment failure remain a challenge for the thoracic surgeon.

For those thoracic surgeons experienced or interested in TB surgery, the starting point is an awareness of the growing incidence of TB, and familiarization with the spectrum of radiographic features, since this is the usual first encounter with potential surgical candidates. Background knowledge of surgical techniques, coupled with the nuances of surgery for inflammatory diseases, including tuberculosis, as well as fungus disease, are prerequisites for a better understanding and appreciation for both the disease processes and operative challenges. In developed countries there are fewer individuals or centers with surgical capability and TB experience. In developing countries and emerging economies there are larger caseloads, as well as many surgeons with a large clinical experience, but insufficient clinical and logistical support. Combining the advanced techniques, devices, and technology with practical methods and experience will certainly advance the surgical armamentarium of the individual surgeon and program.

The goal of this review is to present the historical indications for the surgical treatment of tuberculosis, review the current literature and clinical experience, and collate this material into a contemporary elucidation and understanding of the indications for surgery, as well as improved utilization of both old and new surgical concepts and techniques.