MANAGEMENT OF PULMONARY

TUBERCULOSIS:

IS THERE PLACE FOR SURGERY?

Piotr Yablonskii

MANAGEMENT OF

PULMONARY TUBERCULOSIS:

IS THERE PLACE FOR

SURGERY?

Piotr Yablonskii

Tuberculosis -

is an infectious

disease, but

– its threat

remains high

- there are no

absolutely

effective drugs http://www.who.int/tb/publications

«We should be able to cure

almost all our TB patients

without surgery»

Sir John Crofton

The worldwide problem!!!

The number of new cases

of tuberculosis from 2012

to 2015 increased from

8.7 to 10.4 million;

1.8 million people died

from TB

The worldwide problem of MDR-TB !!!

Globally in 2015, there were an estimated 480

000 new cases of multidrug-resistant TB (MDR-

TB).

Globally, data show an average cure rate of only

52% for treated MDR-TB patients.

In 2015, an estimated 9.5% of people with MDR-

TB had extensively drug resistant TB (XDR-TB).

XDR-TB patients had a treatment success rate of

28% in 2013

HIGH BURDEN COUNTRY LISTS FOR TB

Total New TB Cases

in the HBCs = 7,383,000

http://www.kff.org/

http://www.who.int/en/

Percentage of successful treatment of multidrug-

resistant pulmonary tuberculosis in European

countries in 2012

European Centre for

Disease Prevention

and Control/WHO. Regio

nal Office for Europe.

Surgery for pulmonary TB is modern option

for treatment MDR/XDR pulmonary TB

Subotic, D., Yablonskiy, P., Sulis, G., Cordos, I., Petrov, D., Centis, R., ... & Migliori, G. B. (2016).

Surgery and pleuro-pulmonary tuberculosis: a scientific literature review. Journal of Thoracic

Disease, 8(7), E474.

Current publications on TB surgery

http://www.euro.who.int/ http://erspublications.com/content/complex-pleuropulmonary-infections

Surgical goals

Elimination of MTB excretion

Closure of persistent cavities

Elimination of complications (airway bleeding,

spontaneous pneumothorax, empyema etc.)

Features of pulmonary tuberculosis surgery

Cavity in lungs

Dense pleural adhesions

Calcified lymph nodes in the hilum

Yen Y. T. et al. The role of video-assisted thoracoscopic surgery in therapeutic lung resection for

pulmonary tuberculosis //The Annals of thoracic surgery. – 2013. – Т. 95. – №. 1. – С. 257-263.

Features of surgery for tuberculosis

(adhesions)

Minimally invasive pulmonary resections –

are the current trend in TB-surgery

https://www.ncbi.nlm.nih.gov/pubmed

April 2017

Number of VATS procedures for pulmonary

tuberculosis increased

34,8 40,7 42,1

58,8 63,6

65,2 59,3 57,9

41,2 36,4

0

20

40

60

80

100

120

2007 2008 2009 2010 2011

Thoracotomy

VATS

Features of surgery for tuberculosis

(adhesions)

Uniportal pneumolisis Robotic pneumolisis

Features of surgery for tuberculosis (hilum)

Dynamics of Minimally Invasive Surgery

Rate of VATS operations for pulmonary TB:

Segmentectomy Lobectomy

0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

2013 2014 2015 2016 2017

thoracotomy VATS RATS

0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

2013 2014 2015 2016 2017

thoracotomy VATS RATS

Uniportal

VATS left apical tri-segmentectomy

Robot-assisted thoracoscopic left upper

lobectomy for MDR pulmonary TB

Single center experience in robotic surgery

for pulmonary tuberculosis

Yablonskii, P., Kudriashov, G., Vasilev, I., Avetisyan, A., & Sokolova, O. (2017). Robot-assisted surgery in complex treatment

of the pulmonary tuberculosis. The Journal of Visualized Surgery, 3(2).

http://jovs.amegroups.com/article/view/13597/13891

What is the best surgical tactic?

Different approach for:

-Single-sided TB

-Bilateral TB

Unpublished

series

Chance of clinical cure in patients with pulmonary

tuberculosis: focus on surgical methods

Mortality and clinical cure in patients with pulmonary

tuberculosis: focus on surgical methods

Can we help this patient?

Step 1 Step 2

Group 1 Local bilateral lung

affection prevailed

Anatomic lung resections

(LR)

Anatomic lung resections (LR)

Group 2 Total unilateral lung

destruction

Ipsi-lateral pneumonectomy

Selective thoracoplasty (STP)

and/or valve bronchial

blocade (VBB)

Group 3 Advanced sub-total

cavitary TB

No utility for lung resections. Bilateral VBB and/or STP

Surgical treatment step by step

Bilateral TB surgery: results

0

10

20

30

40

50

60

70

80

90

100

MDR XDR

100

0

66,7

42,1

57,1 53,8

Smear conversion

Group I Group II Group III

0

10

20

30

40

50

60

70

80

90

100

MDR XDR

100

100

100,0

70,0

85,7

64,3

Culture conversion

Group I Group II Group IIIUnpublished

series

“Adjunctive thoracic surgery

may improve treatment

outcome for bilateral cavitary

multidrug-resistant and

extensively drug-resistant

tuberculosis”

Conclusion

The surgical option should be implemented in a

routine algorithm for treating a patient with

pulmonary tuberculosis

Minimally invasive surgery is the preferred approach

for most procedures

Future trials should be conducted to elaborate

indications for surgical treatment

ONE WAY

ANOTHER WAY

Thank you

for your attention!