High Yield Mycobacterium: TB & Non-TB

Question 1

Treatment of drug-sensitive tuberculosis is largely.

Answer 1

Treatment of drug-sensitive tuberculosis is largely medical, with high cure rates, if adequate therapy is delivered.

Question 2

Antibiotic regimen for drug-sensitive tuberculosis

Answer 2

The initial prescribed treatment for active tuberculosis is a 6- to 9-month regimen consisting of four drugs: isoniazid, rifampin, pyrazinamide, and ethambutol.

With this regimen, almost 90% of patients have bacteriologically negative sputum at the end of the 6-month period.

Question 3

Antibiotic regimen for drug resistent TB:

Answer 3

• The treatment of drug-resistant tuberculosis is complex, and is frequently changing, but typically consists of 4-5 drugs from different classes of medications.
• Newer drugs such as bedaquiline (a diarylquinolone antibiotic) and pretomanid/delamanid (a mycobacterial cell wall synthesis inhibitor) have also begun to be incorporated into MDR-TB regimens, particularly in combination (linezolid/bedaquiline/pretomanid).

Question 4

Patients with latent tuberculosis who are at high risk for progression to tuberculosis disease, such as patients with HIV infection and those who are at increased risk for recent infection (e.g., contacts of patients with tuberculosis), are treated with:

Answer 4

Patients with latent tuberculosis who are at high risk for progression to tuberculosis disease, such as patients with HIV infection and those who are at increased risk for recent infection (e.g., contacts of patients with tuberculosis), are treated with 9 months of isoniazid.

Question 5

Treatment of NTM Cervical Lymphadenitis

Answer 5

NTM cervical lymphadenitis is due to MAC in the majority of cases and treated primarily by surgical excision, with a greater than 90% cure rate. A macrolide-based regimen should be considered for patients with extensive MAC

Question 6

Indications for surgery:

Answer 6

1. Massive Hemoptysis
2. Bronchopleural fistula
3. Bronchial stenosis
4. Trapped Lung
5. Cavitary lesions/areas of destroyed lung failed medical therapy
6. Extensive drug resistance
7. Superimposed Fungal infection
8. r/o cancer

Question 7

Most common indication for surgery

For non-tuberculous mycobacterium (NTM)

Answer 7

For non-tuberculous mycobacterium (NTM), failure of medical treatment and symptom relief are the most common indications for surgery

Question 8

TB and non-tuberculous mycobacterium (NTM)

Goal of surgery:

Answer 8

In most cases of NTM or TB, the goal of surgery is:

To remove focal, persistent lung damage (bronchiectasis, cavitation, consolidation or destroyed lung) amenable to anatomic resection

Question 9

Anatomic resection poses increased technical complexity as compared to surgery for cancer, due to:

Answer 9

Anatomic resection poses increased technical complexity as compared to surgery for cancer, due to

1. pleural symphysis
2. adhesions
3. bronchial circulation hypertrophy
4. chronic hilar fibrosis associated with lymphadenopathy

Question 10

ATS/IDS Guidelines for NTM Treatment.

Nodular/bronchiectatic disease

Answer 10

Nodular/bronchiectatic disease:
a three-times-weekly regimen of :

1. clarithromycin (1,000 mg) or azithromycin (500 mg),
2. rifampin (600 mg), and
3. ethambutol (25 mg/kg) is recommended.

Question 11

ATS/IDS Guidelines for NTM Treatment.

Fibrocavitary MAC or severe nodular/bronchiectatic disease:

Answer 11

Fibrocavitary MAC or severe nodular/bronchiectatic disease: a daily regimen of

1. clarithromycin (500–1,000 mg) or azithromycin (250 mg),
2. rifampin (600 mg) or rifabutin (150–300 mg), and
3. ethambutol (15 mg/kg)
4. with consideration of three times- weekly amikacin or streptomycin early in therapy is recommended.

Patients should be treated until culture negative on therapy for 1 year.

Question 12

The minimum evaluation of a patient suspected of NTM should include the following

Answer 12

1. chest radiograph or, in the absence of cavitation, chest CT scan
2. three or more sputum specimens for acid-fast bacilli (AFB) analysis
3. exclusion of other disorders, such as tuberculosis (TB).

Question 13

Name the prior procedure:

Answer 13

Plombage with Lucite balls

Question 14

Complications of Prior Surgery for TB

Plombage

Answer 14

1. Erosion into surrounding structures
2. Migration
3. Infection of the foreign material
4. Tension pleural effusion
5. Malignancy

Question 15

Complications of Prior Surgery for TB

Treatment of an infected plombage space or of migration of plombage material consists of:

Answer 15

Treatment of an infected plombage space or of migration of plombage material consists of:

1. removal of the foreign bodies
2. empyemectomy
3. thoracoplasty with or without the use of muscle transposition to fill the residual space

Question 16

Define:

1. Multidrug-resistant tuberculosis (MDR-TB)
2. Extensively drug-resistant TB (XDR-TB),

Answer 16

1. Multidrug-resistant tuberculosis (MDR-TB), defined as TB resistant to at least isoniazid (INH) and rifampin (RIF),
2. extensively drug-resistant TB (XDR-TB), defined as resistance to INH and RIF plus at least one fluoroquinolone and one second-line injectable drug

Question 17

Principles of surgical resection (2)

Answer 17

1. The most important surgical principle of pulmonary resection for tuberculosis is to remove all gross disease while leaving enough tissue for adequate pulmonary function.
2. Another important principle is to undertake lung resection** only in patients who have converted their sputum. ** (Sputum negative)

Question 18

In general, three criteria can be used to evaluate for the use of surgery in Multidrug-resistant tuberculosis (MDR-TB):

Answer 18

1. Drug resistance and high probability of failure,
2. Localized disease amenable to resection
3. Enough drug reactivity to allow healing infected bronchial stumps.
   * The optimal duration of preoperative and postoperative chemotherapy is still debated, but the presence of negative cultures at the time of surgery clearly decreases operative morbidity and mortality.
   * For this reason, prior medical treatment of at least* 3 to 6 months is recommended.

Question 19

Duration of medical therapy after surgery - Culture negative

1. Susceptible TB
2. MDR TB
3. XDR TB

Answer 19

If the patient is culture-negative at the time of surgery for

1. susceptible TB, at least four months of postoperative treatment is recommended
2. TB is MDR or XDR, then six to eight months of treatment is recommended postoperatively.

Question 20

Duration of medical therapy after surgery - C ulture positive

1. Susceptible TB
2. MDR TB
3. XDR TB

Answer 20

For culture-positive patients at the time of surgery,

1. with susceptible TB, four to six months of treatment after culture conversion;
2. with MDR-TB, at least 18 months after culture conversion;
3. and with XDR-TB, at least 24 months after culture conversion.

Question 21

Superimposed Fungal Infection

Fungal disease in the setting of destroyed lung secondary to TB is most commonly cause by?

Answer 21

Fungal disease in the setting of destroyed lung secondary to TB is most commonly cause by Aspergillus

• Of patients with with destroyed lung due to pulmonary TB, about 15% are thought to develop mycetoma.

Question 22

Rasmussen’s aneurysms

Answer 22

In addition, the incorporation of pulmonary artery branches into the wall of tuberculous cavities causes small dilations of these vessels, which are referred to as Rasmussen’s aneurysms

Question 23

Most patients with hemoptysis and active tuberculosis bleed because of the development of:

Answer 23

Most patients with hemoptysis and active tuberculosis bleed because of the development of systemic bronchial circulation around the infected sites.

In addition, the incorporation of pulmonary artery branches into the wall of tuberculous cavities causes small dilations of these vessels, which are referred to as Rasmussen’s aneurysm

Question 24

Bleeding from tuberculous lesions is usually the result of:

Answer 24

Bleeding from tuberculous lesions is usually the result of bronchial ulcerations into bronchial arteries or into Rasmussen’s aneurysms.

Occasionally, bleeding is secondary to necrosis of small branches of pulmonary veins; erosion of old, calcified nodes through a bronchus (broncholith); or acute tuberculous ulcerations of the bronchial mucosa.

Question 25

Surgical Options for Cavernoma when resection is not an option.

Answer 25

1. Thoracoplasty combined with muscle plombage may be useful to collapse the cavern.
2. Another option is cavernostomy or a Monaldi procedure.

Question 26

Tracheoesophageal or Bronchoesophageal Fistula

Pathphysiology of fistula formation

Answer 26

In these cases, the fistulas are produced by the continuous pressure on and scarring of infected mediastinal nodes located between the trachea and the esophagus.

The anatomic locations of fistulas are variable; they have been reported at the levels of the trachea, right main stem bronchus, left main stem bronchus, and right lower lobe bronchus.

Question 27

Tracheoesophageal or Bronchoesophageal Fistula

Treatment

Answer 27

• Unless surgery is urgently required, a trial of medical therapy seems to be a reasonable first-line approach because some of these fistulas heal with medical therapy alone.
• Patients with significant associated esophageal or bronchial stenosis and patients in whom the diagnosis of malignancy cannot be excluded might require surgery.
• Correction requires closure of the esophageal defect, segmental resection of the trachea, and tissue interposition.

Question 28

Bronchiectasis

Clinical presentation and management

Answer 28

• the clinical presentation is most commonly in the form of hemoptysis.
• Unless the hemoptysis is massive, patients need to be considered for surgery only after a long trial of medical therapy.
• If the hemoptysis is recurring despite adequate medical management, surgical resection is considered,** particularly if the bronchiectasis is localized and if resection is likely to result in complete removal of the disease **

Question 29

Extrinsic Obstruction by Tuberculous Lymph Nodes

Management

Answer 29

Extrinsic airway obstruction is usually responsive to medical therapy, primarily to corticosteroids.

In the rare cases in which the obstruction becomes clinically significant, surgical decompression may be necessary.

Question 30

Endobronchial Tuberculosis and Bronchostenosis

1. Location
2. Treatment

Answer 30

1. The lower and middle lobes are more commonly affected than the upper lobes.
2. Surgical treatment needs to be based on the general status of the patient and the location of the stenosis. Balloon dilation, metallic stenting, laser vaporization, and bronchoplastic resection have been accomplished with good results. To prevent relapses or restenosis, continuous antituberculous chemotherapy is given for 9 - 12 months postoperatively.

Question 31

Middle Lobe Syndrome: TB

Define

Answer 31

• The syndrome is caused by extrinsic nodal compression of the bronchus of lingula or middle lobe, which results in post-obstructive atelectasis and chronic pneumonitis.
• the middle lobe and lingula are particularly susceptible because of the long and narrow bronchus and the absence of collateral ventilation in patients with complete fissures, combined with the collar of lymphatic tissues at the neck of the bronchus in these locations.

Question 32

Middle Lobe Syndrome: TB

Management

Answer 32

• In patients with middle lobe syndrome, it is important to rule out endobronchial obstruction by a malignant neoplasm, which could produce the same radiologic appearance.
• Once the diagnosis of benign disease has been established, patients are screened for tuberculosis, and symptomatic patients who are fit for surgery undergo pulmonary resection.

Question 33

TB: Bronchopleural Fistula

Initial Management

Answer 33

• The initial management of tuberculous bronchopleural fistula consists of tube drainage and antibiotic therapy. Although tube thoracostomy has been used on a permanent basis, it is usually a temporary measure that allows rapid resolution of sepsis and optimal preparation of patients for more definitive therapy.
• In elderly patients with chronic sepsis and in patients with HIV/AIDS, open drainage by way of a thoracic window is an alternative.

Question 34

TB: Bronchopleural Fistula - Surgical therapy

1. Timing/preperation
2. Objectives of surgery

Answer 34

• Once drainage of the pleural cavity has been established, sepsis is under control, and tuberculosis is adequately treated medically, low-risk patients can be offered permanent repair of the fistula.
• Preparation for this can take 3 - 6 months because patients with ongoing active tuberculosis at the time of surgery have higher risks for surgical complications in the form of pleural empyema and dehiscence of the repair. Nutrition and antituberculous therapy must be aggressively optimized.
  * The objectives of surgery are threefold: 1) to close the fistula, 2) to re-expand the lung via decortication if needed, and 3) to fill the space either by re-expanded lung or by vascularized muscle or omental flaps.
  * the bronchial stump is always reinforced with viable vascularized autografts

Question 35

Pleural Tuberculosis with Effusion

Pleural fluid analysis

Answer 35

• Pleural fluid protein and lactate dehydrogenase are elevated
• the pH is less than 7.4
• the glucose concentration is approximately 60 mg/dL.
• The total cell count is usually fewer than 6000/μL, the cell population being predominantly T lymphocytes, with an absence of mesothelial cells.
• Pleural adenosine deaminase levels, usually in the range of >50, can be used as a diagnostic aid as well

Question 36

Pleural Tuberculosis with Effusion

Management

Answer 36

• Surgical drainage of the pleural space is performed only in patients who have large effusions.
  * Failure of pulmonary expansion after adequate medical therapy can occur in a significant proportion of patients. In young, fit patients with significant restriction, decortication may be indicated.
• The management of pleural tuberculosis is otherwise mainly medical. Treatment with two drugs for a period of 9 months is recommended.

Question 37

Pleural Tuberculosis with Empyema

Management

Answer 37

In this condition, tube thoracostomy with negative suction is used first, but if lung expansion cannot be obtained, open decortication may become necessary.

Question 38

Preperation (Abx) for surgery in non-tuberculous mycobacterial (NTM) infection

Answer 38

• Targeted antimycobacterial therapy, often including intravenous or inhaled aminoglycosides, should be administered for at least 2 to 3 months before surgical intervention.
• This duration aims to reach a nadir in organism counts before surgery and in many cases dictates the timing of surgery.

Question 39

Indications for surgery in non-tuberculous mycobacterial (NTM) infection

Answer 39

Three main indications exist –
1) failure of medical therapy,
2) for relief of intractable symptoms (cough/recurrent hemoptysis)
3) in select cases, to limit progression.
* An example of this would be a patient with a destroyed lung on one side, and limited parenchymal disease in the contralateral lung. Resection of all areas of lung disease might be impossible, but the patient would clearly benefit from removal of the destroyed, nonfunctional lung to limit “spillage” into the better lung from infected cavities.

Question 40

Most common indication for surgery in non-tuberculous mycobacterial (NTM) infection

Answer 40

• Most commonly surgery is performed to clear focal, residual disease after medical therapy.
• Persistent lung damage (bronchiectasis, cavitation, consolidation and destroyed lung) amenable to compete anatomic resection after initiation of appropriate antimicrobial therapy represents the most common indication for surgery in NTM.

Question 41

Technical Challenges and Considerations During Anatomic Resection

Concern for contamination of the contralateral lung. Mgmt of the bronchus.

Answer 41

On top of this, the surgeon must be wary of contamination of the contralateral lung. To this end, It may be beneficial to attempt to approach the bronchus and control it first, which is a change from a standard VATS approach for cancer for example where the bronchus would be controlled last.

Question 42

Managing the Pneumonectomy Space and BPF

Indications for flap coverage?

Answer 42

. Indications for flap coverage include poorly controlled infection, drug resistant organisms, and pneumonectomy especially those done on the right side.

Question 43

Managing the Pneumonectomy Space and BPF

Pleural space mgmt

Answer 43

Managing the pneumonectomy space is controversial, however, in the face of gross contamination it may be necessary to take preventive measures against post-pneumonectomy empyema.

Many methods have been employed, which range from continuous irrigation of antibiotic and antituberculous chemotherapy to simple tube drainage.

Question 44

Managing the Pneumonectomy Space and BPF

Bronchopleural fistula Mgmt

Answer 44

• The mainstays of treatment are tube drainage, antibiotics and antituberculous therapy, protection of the contralateral lung and stabilization of the patient.
• This is followed by operative drainage of the chest with either the accelerated treatment (the Weder procedure), or creation of an Eloesser flap, depending on the timing of occurrence, stability of the mediastinum, patient condition and surgeon preference and comfort with the techniques.

Question 45

Name the procedure

Patient is placed in anterolateral decubitus position. The previous thoracotomy (generally an anterolateral incision) was reopened, and a radical debridement of the
pleural cavity by partial pleurectomy and curettage of all necrotic and fibrous infected tissue was performed and followed with irrigation.

The presence of minor BSI wasconfirmed by flooding the chest cavity with saline and
observing escaping air bubbles from the mediastinum. If present, the BSI was closed through various techniques and secured by omentopexy.

Answer 45

Weder procedure

Question 46

Managing the Pneumonectomy Space and BPF

Uncontrolled sepsis with positive sputum cultures. Surgical consideration.

Answer 46

Flap coverage should be considered in these cases with either intercostal muscle, posterior pleura, muscle from the back (latissimus or serratus), or even omental coverage

Question 47

TB in Children

Question 48

TB in Children

Question 49

Indications for Surgery: TB

Answer 49

Question 50

Indications for Surgery: NTM

Answer 50

Question 51

Indications for Surgery: MDR-TB

Answer 51

Question 52

Name the procedure

Answer 52

Eloesser Flap Thoracostomy Window

Question 53

Name the procedure

Answer 53

Claggett Window

Question 54

Name the procedure