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Pneumonectomy: for Tuberculosis
Pneumonectomy, or surgical removal of one entire lung (versus removal of smaller segments of the lung) is a major surgery which is not performed without serious consideration to alternative treatments. Pneumonectomy is indicated as the treatment of choice for otherwise unresectable cancers, as well as serious lung infections such as tuberculosis.In fact, surgery for tuberculosis (including pneumonectomy) was one of the first set of procedures that helped establish thoracic surgery as a specialty. In the era preceeding the development of antibiotics, there was no effective treatment for tuberculosis – which carried a high mortality rate. Surgical resection of the affected lung was the treatment of choice.
Once antibiotics were established as an effective treatment for this disease, surgery faded into the background – and was primarily reserved for cases complicated by hemoptysis or empyema.
However, in recent years, due to the rise of multi-drug resistance tuberculosis (MDR-TB), surgical resection for the treatment of Tuberculosis has been making a comeback. According to World Health Organization statistics; there were more than 8.8 million cases of TB in 2010. While the death rate has fallen significantly (40%) since 1990 – over 1.4 million people died of TB during that same year. In addition to multi-drug resistant Tuberculosis, there is another subtype called extensively drug resistant tubeculosis (XDR-TB) which is resistant to several drug regimens. (Most cases of non-XDR forms of TB are currently treated with a four drug regimen for several months.)
The emergence of these antibiotic resistant strains have brought us full circle in the surgical management of the disease. Failure of medical therapies leads to a mortality of fifty percent (Kir, et. al (1997). The re-emergence of surgery for tuberculosis is two-fold; surgery is used for both the treatment of active disease and the management of complications from tuberculosis (i.e. removal of dead or damaged lung tissue from previous TB infection.)
A review of the literature surrounding the surgical treatment of tuberculosis explores the modern surgical indications; potential complications and post-operative outcomes. Shiraishi et al. (2008) detail their experiences with surgical resection of several cases of XDR-TB at a Tokyo facility. As explained by Shiraishi, larger operations such as pneumonectomy are preferred over smaller resection procedures because the success of the operation hinges on the ability to remove all of the gross lesions (cavities) or destroyed tissue.
In this article (1997) from Saudi Arabia, Ashour discusses his experiences (from 1985 to 1995) using pneumonectomy to treat post-TB lung destruction.
By reviewing several historical sources, we can review the changing perspectives regarding the treatment of tuberculosis and the indications for surgical resection. While it may be surprising to many readers, the current indicators for surgical resection and pneumonectomy for tuberculosis encourage earlier surgical intervention. In comparison to the late 20th century, where surgery was reserved for cases of extensive lung destruction with gross hemoptysis after years of unsuccessful medical treatment, the development of MDR- TB and XDR-TB provides for ample incentive for surgeons to intervene earlier in the disease process.
