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Surgıcal Management Of Tuberculosıs-Related Hemoptysıs
MAKALE #323 © Yazan Doç.Dr.Abdullah ERDOĞAN | Yayın Ekim 2007 | 4,260 Okuyucu
SURGICAL MANAGEMENT OF TUBERCULOSIS-RELATED HEMOPTYSIS



Running Head:


Surgery of TB related hemoptysis



Authors:


Abdullah Erdogan1, MD, Arif Yegin2, MD, Gülsüm Gürses1, MD, Abid Demircan1, MD,


Institution and affiliations: Akdeniz University Faculty of Medicine Departments of Cardiothoracic Surgery1, and Anesthesiology2, Antalya, Turkey


Keywords: Hemorrhage, tuberculosis, surgery

Word count: 2454



Correspondence Address:


Dr. Abdullah Erdogan


Akdeniz Universitesi Hastanesi


GKDC Anabilim Dali, 07058 Antalya, Turkey


Telephone number: + 90 242 2274343


Fax number: +90 242 2274490




Abstract

Background: Tuberculosis is a disease, which is often treated with chemotherapy. However, medical treatment usually fails in the management of tuberculosis-related hemoptysis. In this paper, we review our experience in the surgical treatment of tuberculosis-related hemoptysis.

Methods: Fifty-nine patients with tuberculosis-related hemoptysis (46 men, 13 women) who underwent surgical treatment were enrolled in this study. A thoracotomy was performed urgently in 21 patients with massive (>600 mL/day) hemoptysis, and within the first 2 days in 24 with major (200-600 mL/day) hemoptysis, and within the first 4 days in 14 with persistent minor (<200 mL/day) hemoptysis.

Results: A chest x-ray showed cavitary lesion in all of the patients with massive hemoptysis (21 patients), in 22 of 24 patients with major hemoptysis, and in 3 of 14 patients with persistent minor hemoptysis. Pneumonectomy was performed in 4 patients, and lobectomy in 39 patients, and segmentectomy or wedge resection in 16 patients. The average hospitalization period was 13 days. The mortality rate was 6.8% peroperatively. Of the patients deceased, 3 were intubated with a single lumen endotracheal tube and one with a double lumen endotracheal tube. During the postoperative period, empyema and bronchopleural fistula developed in 3 patients, and no other severe complications occurred. The average postoperative follow-up period was 3 years. The number of thoracotomies performed in the years from 1995 to 2003 was significantly decreased, compared to the years between 1985-1994 (p=0.042).

Conclusion: In tuberculosis related hemoptysis, thoracotomy with double lumen endotracheal intubation and resection of the cavity may be curative and life saving.

Abstract word count: 253

Introduction

Although the definition of massive and major hemoptysis varies in the literature, expectoration of blood of 200-600 mL/day is commonly defined as major hemoptysis and expectoration of blood of more than 600 mL/day as massive hemoptysis [1,2].

The etiology for massive hemoptysis, in various parts of the world, reflects the socioeconomic development of the geographic location [3,4]. In developed western societies the incidence of tuberculosis is considerably low and tuberculosis-related hemoptysis is rather low, whereas in underdeveloped or poor societies, the incidence of tuberculosis is quite high and some patients with tuberculosis related massive hemoptysis can still be lost [5].

Massive hemoptysis is an alarming and life-threatening symptom that warrants closer surveillance. It is impossible to predict when hemoptysis evolves into a massive hemoptysis. In such cases, urgent surgery will be life saving [6]. In this study, we evaluated the long-term results of the patients who had urgently been operated due to hemoptysis related tuberculosis.

Patients and Methods

Fifty-nine patients with tuberculosis-related hemoptysis were investigated retrospectively. All the patients were previously diagnosed as having pulmonary tuberculosis in various health institutions and admitted with hemoptysis to the thoracic surgery department of Akdeniz University Hospital between January 1985 and December 2003. Of these patients, 46 were males and 13 females, ranging from 16 to 71 years (mean: 36.6±13.7).

Based on the quantity of blood expectorated per day, hemoptysis was classified in 3 groups: persistent minor (<200 mL/day, lasting at least 4 days), major (200-600 mL/day), and massive (>600 mL/day). Of the patients, 21 presented with massive hemoptysis, 24 with major hemoptysis, and 14 with persistent minor hemoptysis (Table 1). A chest x-ray was performed in all patients. Patients who did not have an identifiable cavitary lesion in the x-ray underwent a thorax computed tomography (CT) scan. To localize the bleeding area, all patients underwent a fiberoptic or rigid bronchoscopy prior to surgery. For intubation, we used a double lumen endotracheal tube in 50 patients, however as it was not available in routine usage before 1987, in 9 patients, we used a single lumen endotracheal tube instead. Thoracotomy was made on an urgent basis in the patients with massive hemoptysis, within 2 days in the patients with major hemoptysis, and within 4 days in the patients with persistent minor hemoptysis. Pneumonectomy was made in the case of a destroyed lung, lobectomy or bilobectomy in the case of a cavitary lesion occupying one or two lobes, and segmentectomy or wedge resection in the case of a cavitary lesion occupying one or more segments.

Twenty of the patients had already been taking antituberculous therapy due to active tuberculosis while the remaining 39 were asymptomatic and currently receiving no medication; these patients had prematurely stopped treatment due to absence of symptoms, and had a past history of irregular drug intake.

Of 59 patients, 51 had acid-fast bacilli recovered from their cavitary lesion or sputum cultures. Triple antituberculous chemotherapy with isoniazid (5 mg/kg/day), rifampin (10 mg/kg/day) and ethambutol (25 mg/kg/day) was maintained in 20 patients currently taking medication, and newly implemented in the remaining 39 patients.

Statistical analysis

Continuous variables such as age were expressed as the mean ± standard deviation. Categorical variables were expressed by number (n) and frequencies (%). Chi-square test was used to compare the proportions. A p value of less than 0.05 was considered statistically significant.

Results

Cavitary lesions detected by chest x-ray (Figure 1) or CT (Figure 2) are shown in Table 1.
Patients were hospitalized for an average period of 13 days (range: 7-30 days) and were followed up between 6 months and 7 years (average 3 years) postoperatively. Recurrent hemoptysis was observed in none of the patients in the follow-up period.

Of all patients, 4 had a pneumonectomy, 35 had a lobectomy, 4 had a bilobectomy, 6 had a segmentectomy and 10 had wedge resection in thoracotomy. Peroperatively, 4 patients died (mortality: 6.8%). Of these 4 patients, 3 had single lumen, and one had double lumen endotracheal intubation.

Complications, mostly mild or moderate, were encountered in a total of 21 patients (Table 2). However, in 3 patients, in whom a single lumen endotracheal tube was used, intensive aspiration into the opposite lung was observed in the peroperative period, which led to asphyxia and eventually to death. In the last patient, aged 71, a double lumen endotracheal tube was used and comorbidities such as amyloidosis, chronic renal failure and destroyed lung were present. In this patient, a right pneumonectomy was performed, but the patient died of acute myocardial infarction and hemodynamic failure within the early postoperative period.

Postoperatively, empyema and bronchopleural fistula developed in 3 patients. Two of these underwent a right pneumonectomy with the diagnosis of tuberculous bronchiectasis and destroyed lung, while the other patient had a right upper lobectomy because of tuberculous bronchiectasis. In all these patients, empyema and bronchopleural fistula developed in the first month postoperatively. The two who had had pneumonectomy underwent tailoring thorachoplasty and transported intercostal muscle flap over the bronchial stump in the postoperative 6 months. The patient who had had an upper lobectomy underwent partial thoracoplasty and also transported intercostal muscle flap over the bronchial stump in the same period. In the follow-up period, all these 3 patients recovered from the brochopleural fistulas. It was noteworthy that all these 3 patients with severe complications were on antituberculous therapy at presentation.

Following induction of remission, antituberculous drug therapy was discontinued postoperatively after 3 months in 8 patients, after 6 months in 38, after 9 months in 9 and after one year in 4 patients.

During our study period, 4 patients died between 1985-1994 (Table 3). No other mortality was observed after 1995. Likewise, the number of thoracotomies performed in the years from 1995 to 2003 was significantly decreased, compared to the years between 1985-1994 (p=0.042) (Table 3).

Comment

Hemoptysis may be a life-threatening condition with an inclination to recur if definitive treatment is not instituted. Treatment approaches depend on several factors such as comorbidities, etiological factors related to hemoptysis, or the clinical experience and practice of the physician. Among various treatment options used for hemoptysis apart from surgical therapy are; cold saline solution lavage via bronchoscopy [7], endobronchial balloon tamponade with or without endobronchial instillation of epinephrine [8], instillation of thrombin or fibrinogen-thrombin infusion endobronchially via fiberoptic bronchoscopy [9], laser photocoagulation [10], radiotherapy [11] and bronchial artery embolization [12].

In a study by Knott-Craig and colleagues, 36.4% of patients admitted with massive hemoptysis who underwent medical therapy had a recurrent episode of hemoptysis within 6 months of hospital discharge. Almost one half of these recurrent episodes (45%) proved fatal [13]. When compared with the other therapy modalities, surgical resection is really a curative solution to eradicate primary hemoptysis and its recurrences [14]. Similarly, none of our patients had recurrent hemoptysis in the follow-up period.

In etiology for hemoptysis, geographic location and socioeconomic level have great importance [15]. Pulmonary tuberculosis, with its chronic sequelae, is the most frequent cause of hemoptysis in the Third World [15]. Likewise, in Turkey, the prevalence of tuberculosis is high, and tuberculosis or its sequela are among the leading causes of hemoptysis [16]. Our series indicate that a relatively younger population with tuberculosis may still face a fatal outcome due to massive hemoptysis. On the other hand, our series also shows that there is a decreasing trend for the occurrence of tuberculosis-related hemoptysis requiring surgery, as shown by the significantly decreased number of thoracotomies in the last decade. This change in figures may be related to the socio-economic development of the country, yet we do not know the outcome in the social classes without the opportunity of access to the healthcare system. Although we did not investigate the causes of non-compliance to antituberculous drugs in nearly two thirds of our patients, it could be likely that low socio-economic status of those patients led them to stop or take the drugs irregularly.

Surgical approach is curative in the treatment of hemoptysis and prevents probable recurrences [17]. On the other hand, bronchial artery embolization (embolotherapy) may be an efficacious alternative method [18]. However, it has some important complications such as spinal cord syndromes, mediastinal hematoma after subintimal aortic dissection, bronchial stenosis, bronchoesophageal fistula, infarction of the bronchus, and transient cortical blindness [19]. Besides, embolotherapy may not be successful in 10-25 % of patients [15,20]. Because of the possible failure of embolotherapy, we gave priority to the surgical approach. On the other hand, surgical approach in massive hemoptysis, is an asphyxia-increasing factor during the intubation period, which may result in a fatal outcome. To avoid this problem, prior to surgery, the bleeding location must be identified via fiberoptic or rigid bronchoscopy, and possible aspiration from the bleeding location to the opposite lung must be prevented by using a double lumen endotracheal tube during intubation. The prone positioning of the patient as well as bronchus first technique might also prevent intraoperative aspiration.

While non-surgical approaches and/or medications should be considered as first-line treatment to manage minor hemoptysis not lasting more than 4 days, massive, major, and persistent minor hemoptysis should be treated surgically to prevent possible further recurrences.

Acknowledgments: We thank Erdal Gilgil and Carl Patrick Parry for their valuable help in revision and English-language editing of the manuscript.


References

1. Pomerantz M. Surgery for the management of mycobacterium tuberculosis and nontuberculous mycobacterial infections of the lung. In: Shields TW, LoCicero III.J, Ponn RB, eds. General Thoracic Surgery. Philadelphia: Lippincott Williams and Wilkins, 2000:1066-74.
2. Winter SM, Ingbar DH. Massive hemoptysis: Pathogenesis and management. J Intensive Care Med 1988;3:171.
3. Corder R. Hemoptysis. Emerg Med Clin North Am 2003;21:421-35.
4. Mal H, Thabut G, Plantier L. Hemoptysis. Rev Prat 2003;53:975-9.
5. Kart L, Akduman D, Altin R, Tor M, Unalacak M, Bagendik F, Erdem F, Alparslan U. Fourteen-year trend of tuberculosis dynamics in the northwest of Turkey. Respiration 2003;70:468-74.
6. Metin M, Turna A, Sayar A, Gurses A. Prompt surgery for massive hemoptysis: more acceptable than it was reported. Eur J Cardiothorac Surg 2003;23:647-68.
7. Conlan AA, Hurwitz SS, Krige L, Nicolaou N, Pool R. Massive hemoptysis. Review of 123 cases. Thorac Cardiovasc Surg 1983;85:120-4.
8. Gottlieb LS, Hillberg R. Endobronchial tamponade therapy for intractable hemoptysis. Chest 1975;67:482-3.
9. Gracia J, Rosa D, Catalan E, Alverez A, Bravo C, Morell F. Use of endoscopic fibrinogen-thrombin in treatment of severe hemoptysis. Respir Med 2003; 97:790-5.
10. Edmondstone WM, Nanson EM, Woodcock AA, Millard FJ, Hetzel MR. Life threatening haemoptysis controlled by laser photocoagulation. Thorax 1983;38:788-9.
11. Shneerson JM, Emerson PA, Phillips RH. Radiotherapy for massive haemoptysis from an aspergilloma. Thorax 1980;35:953-4.
12. Endo S, Otani S, Saito N, Hasegawa T, Kanai Y, Sato Y, Sohara Y. Management of massive hemoptysis in a thoracic surgical unit. Eur J Cardiothorac Surg 2003;23:467-72.
13. Knott-Craig CJ, Oostuizen JG, Rossouw G, Joubert JR, Barnard PM. Management and prognosis of massive hemoptysis: recent experience with 120 patients. Thorac Cardiovasc Surg 1993;105:394-7.
14. Treasure RL, Seaworth BJ. Current role of surgery in Mycobacterium tuberculosis. Ann Thorac Surg 1995;59:1405-7.
15. Syabbalo N. Hemoptysis: the Third-World perspective. Chest 1991;99:1316-7.
16. Cuhadaroglu C, Erelel M, Tabak L, Kilicaslan Z. Increased risk of tuberculosis in health care workers: a retrospective survey at a teaching hospital in Istanbul, Turkey. BMJ Infect Dis 2002;262:1-4.
17. Dhaliwal RS, Saxena P, Puri D, Sidhu KS. Role of physiological lung exclusion in difficult lung resections for massive hemoptysis and other problems. Eur J Cardiothorac Surg 2001;20:25-9.
18. Ramakantan R, Bandekar VG, Gandhi MS, Aulakh BG, Deshmukh HL. Massive hemoptysis due to pulmonary tuberculosis: control with bronchial artery embolization. Radiology 1996;200:691-4.
19. Mal H, Rullon I, Mellot F, Brugiere O, Sleiman C, Menu Y, Fournier M. Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest 1999;115:996-1001.
20. Katoh O, Kishikawa T, Yamada H, Matsumoto S, Kudo S. Recurrent bleeding after arterial embolization in patients with hemoptysis. Chest 1990;97:541-6.


Table 1. Relationship of cavitary lesions with quantities of hemoptysis
Quantity of hemoptysis
(mL/day)

Cavitary lesions shown by x-ray


n (%)


Cavitary lesions shown by CTa


n (%)


Pneumonia appearance in x-ray or CTa


n (%)

<200 (n=14)

3 (5.1)


9 (15.3)


2 (3.4)

200-600 (n=24)

22 (37.3)


2 (3.4)


-

>600 (n=21)

21 (35.6)


-


-

a CT scan was performed in the patients who were not shown to have a cavitary lesion by chest x-ray. CT=Computed thorax tomography




Table 2. Complications (n=21)
Complication
n (%)
Air leak (>7 days)
7 (11.9)
Atelectasis
6 (10.2)
Pneumonia
4 (6.8)
Wound infection
4 (6.8)
Empyema
3 (5.1)
Bronchopleural fistula
3 (5.1)
Bleeding
2 (3.4)
Psychiatric complications
2 (3.4)
Arrhythmia
1 (1.7)









Table 3. Number of thoracotomies and mortalities according to the years
Years
1985-1994
1995-2003
Pa
Thoracotomies (total)
1403
1336

Thoracotomies related to tuberculosis
38
21
0.042
Mortalities related to tuberculosis
4
0
0.286
aStatistical analysis performed by c2 test.



Figure 1. Chest x-ray of a patient showing a cavitary lesion in the right upper zone


Figure 2. Computed thorax tomography showing a small cavitary lesion in the
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