J Thorac Cardiovasc Surg 2005;130:1732
© 2005 The American Association for Thoracic Surgery
Video-assisted thoracoscopic surgery for pulmonary tuberculosis
C.S. Pramesh, MS, FRCS,
Rajesh C. Mistry, MS,
Sandeep P. Tandon, MD
Division of Thoracic Surgery and General Medicine, Tata Memorial Hospital, Mumbai, India
To the Editor:
We read with interest Olgac and colleagues' remarkable experience
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with the surgical management of pulmonary tuberculosis and empyemas. The role of surgical intervention in tuberculosis has decreased dramatically with the advent of powerful antituberculous drugs. Our experience with the disease has been similar to that of the authors.Very few of the chronically collapsed lungs expand, even after drainage of the empyema and even decortication. Complication rates after resectional surgery are forbidding, with high rates of parenchymal air leaks and bronchopleural fistula. We agree with the authors that decortication is preferable to attempting resectional surgery, but we believe that this can be achieved more satisfactorily by means of video-assisted thoracoscopic surgery (VATS) rather than open thoracotomy. Patients with tuberculous empyema are frequently cachectic and emaciated, and a less invasive surgical procedure would be preferable to an open thoracotomy, with its attendant morbidity. In most cases the empyema cavity is well formed, and thoracoscopy is usually quite easy. Visualization of the empyema cavity, drainage, adhesiolysis, and decortication can be performed adequately and safely with thoracoscopy by using multiple ports.
It has been established in a meta-analysis
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that VATS is superior to chest tube drainage with streptokinase with regard to duration of chest tubes and hospital stay in the management of pleural empyemas. VATS has the potential to be both diagnostic and therapeutic and has been established to be safe and effective.
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VATS has the potential to achieve full lung expansion in patients with trapped lung or tuberculous empyema with minimal morbidity. It is similar to open thoracotomy in that therapeutic lung resection in patients with tuberculosis is both technically demanding and potentially hazardous.
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We conclude by agreeing with the authors that simple drainage and decortication would be preferable to resectional surgery in pulmonary tuberculous empyemas but affirm that this would be better achieved with VATS.
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References
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- Olgac G, Yilmaz MA, Ortakoylu MG, Kutlu CA. Decision-making for lung resection in patients with empyema and collapsed lung due to tuberculosis. J Thorac Cardiovasc Surg. 2005;130:131-135.[Abstract/Free Full Text]
- Coote N. Surgical versus non-surgical management of pleural empyema. Cochrane Database Syst Rev. 2002;CD001956..
- Yim AP, Izzat MB, Lee TW. Thoracoscopic surgery for pulmonary tuberculosis. World J Surg. 1999;23:1114-1117.[Medline]
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