Review Asian Cardiovascular & Thoracic Annals 0(0) 1–12 ß The Author(s) 2016 Surgical aspects of pulmonary Reprints and permissions: sagepub.co.uk/journalsPermissions.nav tuberculosis: an update DOI: 10.1177/0218492316661958 aan.sagepub.com Ravindra Kumar Dewan1 and A Thomas Pezzella2 Abstract Tuberculosis remains a major global medical challenge and concern. In the world’s population of over 7.4 billion people, 8.6 million are estimated to be infected with Mycobacterium tuberculosis; another 2.2 billion have latent tuberculosis. There is an annual incidence of 16,000 new cases in the USA and 7–8 million new cases worldwide, of which 440,000 are multidrug-resistant or extensively multidrug-resistant, mainly in developing countries or emerging economies. According to the World Health Organization, the incidence of tuberculosis is 133 cases per 100,000 of the population; 3.3% new cases are drug resistant and 20% are already treated cases. Of the drug-resistant cases, 9.7% are extensively drug- resistant. The annual global mortality attributable to tuberculosis is over 1.3 million people. The association with HIV/ AIDS in 430,000 people has compounded the global concern and challenge. This review presents the historical indica- tions for surgical treatment of tuberculosis, reviews the current literature and clinical experience, and collates this into increased awareness and contemporary understanding of the indications and need for surgery in primary active tuber- culosis, adjuvant surgical therapy for multidrug-resistant tuberculosis, and the complications of chronic tuberculosis sequelae or previous tuberculosis surgery. Keywords Antitubercular agents, Extensively drug-resistant tuberculosis, Latent tuberculosis, Pneumonectomy, Tuberculosis, multidrug-resistant, Tuberculosis, pulmonary Introduction disposables. At present, there is no global database of TB surgical availability, operative cases, or surgical Tuberculosis (TB), be it latent or active disease, remains results. It is perceived that less than 5% of TB patients a major global communicable disease. Despite continu- undergo surgery. It is also perceived that more than 5% ing advances in medical treatment, challenges remain in of TB patients require surgery primarily or as an 3 areas: the emergence of increasing primary and sec- adjunct to medical therapy. In the majority of cases, ondary multidrug-resistant (MDR) TB, extensively active TB affects the thoracic cavity, mainly the pul- multidrug-resistant (XDR) TB, and the prevalence of monary structures. This review gives a contemporary residual or persistent sequelae not amenable to medical overview of the surgical approaches and advances in management alone.1 Only a 50% success rate has been the care of the pulmonary TB population. It is import- reported for medical management of MDR-TB cases, ant that surgeons involved in the care of TB patients according to the 2015 World Health Organization know the indications and contraindications for surgery, report.2 This last challenge would benefit from surgical the timing of surgery, and the new as well as the older treatment. Unfortunately, surgery is either unavailable or underutilized globally. Ironically, current TB surgi- 1National Institute of Tuberculosis & Respiratory Diseases, New Delhi, cal expertise is not readily available in developed coun- India tries with low volumes of cases, despite the availability 2International Children’s Heart Fund, Worcester, MA, USA of current clinical and technical advances, whereas sur- Corresponding author: gical experience is available in developing countries and Ravindra Kumar Dewan, National Institute of Tuberculosis & Respiratory emerging economies with large caseloads but a paucity Diseases, New Delhi 110030, India. of state-of-the-art technology, equipment, and Email: [email protected] Downloaded from aan.sagepub.com by guest on July 31, 2016 2 Asian Cardiovascular & Thoracic Annals 0(0) operative techniques available. Subsequent postopera- ability to withstand decolorization with staining, being tive management that includes complications, follow- intracellular parasites, obligate aerobes, and the ability up, and surveillance is crucial to successful early and to cause a granulomatous response in normal host long-term results. Unfortunately, there is a dearth of tissue.5,7,8 Mycobacterium tuberculosis is a hardy organ- evidence-based literature to guide the surgical pathway. ism that can lead to recurrence as well as persisting in The disability-adjusted life year is a measure of overall the atmosphere. Mycobacterium tuberculosis is an obli- disease burden, expressed as the number of years lost gate aerobic rod-shaped bacillus that is spread primar- due to ill-health, disability, or early death. It was devel- ily through aerosol inhalation. Unlike some other oped in the 1990s as a way of comparing the overall infectious diseases, TB does not have an intermediate health and life-expectancy in different countries. The host and is not transmitted by other means (food, flies, Global Burden of Disease Study reported that TB feces, fingers, fomites).7,8 The risk factors for TB trans- accounted for 3,669,700 disability-adjusted life years mission in endemic regions include poverty, poor edu- in 2013, and 49,396,000 years in 2010.3 The only vac- cation, nonawareness, poor nutrition, closed spaces, cine available to prevent this disease is the BCG vaccine and poor compliance with medical management. TB introduced in early 20th century, which can only pre- is acquired by inhalation of airborne droplet nuclei vent some severe forms of childhood TB and is largely (1–10 mm in diameter containing 1–3 viable mycobac- useless in prevention of the disease in its usual mani- teria) that are expelled into the air from infected festation. In view of the urgency of the situation and humans via coughing, sneezing, talking, spitting, or efforts dedicated in this direction, several new vaccines singing.8 These droplet nuclei bypass the nasal hairs are being tried; at present, 7 vaccines are in the and mucociliary apparatus of the bronchial tree and pipeline.4 lodge in the peripheral alveoli. Once within the alveo- lus, a nonspecific inflammatory reaction occurs.8 Background Phagocytosis ensues, but intracellular multiplication of the TB bacillus continues, with spread to regional Currently, nearly 1/3 of the world’s population (over lymph nodes and hematogenous spread to all parts of 2.2 billion people) are infected, and 9 million new TB the body. Ultimately, over a period of several weeks, cases occur annually.2 Although the worldwide preva- the acquired T-cell lymphocytic-mediated immune lence of TB has shown a 42% decline between 1990 and response limits further multiplication and spread of 2015, the incidence actually increased in 2015, mainly TB bacilli. Healing occurs with fibrosis and calcifica- due to better monitoring and reporting, especially in tion. Reactivation of the initial remote infection can India and Indonesia.2 The annual global mortality occur later, whereas reinfection is less common because from TB of over 1 million represents 2.7% of all the original insult renders the patient immune to further deaths, and is the 8th leading cause of overall global inhaled tubercle bacilli. Although TB can affect any- mortality. The coincident spread of HIV with TB infec- body, social factors that include poverty, undernutri- tion has enhanced the resultant impairment of induced tion, overcrowding, and lower educational or cell-mediated immunity, and has greatly complicated socioeconomic status are known to increase the inci- efforts to control this combined disorder. The increase dence in affected populations. Migrant populations, in global MDR-TB and XDR-TB has become a major prisoners, or regions affected by political special cause for concern. The causes of this increase include: groups need focus to identify TB-afflicted individuals. incomplete or insufficient initial or length of treatment HIV/AIDS patients with low CD cell counts (<500), of the primary disease, incorrect drug selection, and those with diabetes mellitus or on immunosuppressant infection via MDR or XDR patients.5,6 Intensive therapy, or patients who have undergone gastrectomy efforts to contain the scourge of TB started worldwide are additional vulnerable groups. In 5% of infected in 1995 by adopting the directly observed treatment and individuals, progressive primary disease occurs within short-term chemotherapy therapy (DOTS) strategy. As the first 1–2 years of infection, while in another 5%, the a result of this program, the world witnessed a 42% disease will develop at some point, usually as a recur- decline in the prevalence of TB. Buoyed by the success rence of the original infection following a latent period of this program, the world has dared to give a call for of waning immunity.8 uniting to end TB.2 However, there is no room for Clinically active TB can be classified anatomically complacency because the disease prevalence and inci- into intrathoracic and extrathoracic disease. dence remain quite high in India and other endemic Intrathoracic TB includes the tracheobronchial tree, countries. lung parenchyma, pleura, lymph nodes, chest wall, TB is a communicable disease caused by thoracic vertebra and discs, or direct extension into Mycobacterium tuberculosis.5 The major characteristic adjacent structures (esophagus, pericardium, or great of the genus Mycobacterium include acid-fastness or the vessels). Extrathoracic disease includes all other Downloaded from aan.sagepub.com