Pulmonale Tuberkulose – ist die Chirurgie noch notwendig?

Zusammenfassung

Hintergrund: Tuberkulose zählt weltweit neben HIV und Malaria immer noch zu den häufigsten Infektionserkrankungen und stellt eine ernste Problematik im Gesundheitsbereich dar. Durch Einwanderer und Flüchtlinge ist die Erkrankung auch in Europa weiterhin präsent. Die globale Zunahme einer multiresistenten Tuberkulose führt somit zu einer hoch bedeutsamen und aktuellen Wichtigkeit suffizienter Therapiemaßnahmen. Dies hat in den letzten Jahren zu einer erneuten Evaluation der chirurgischen Therapie im Rahmen der interdisziplinären und multimodalen Therapie der multiresistenten Tuberkulose geführt. Zudem bestehen trotz effektiver medikamentöser Therapie der antibiotikaempfindlichen Tuberkulose weiterhin Indikationen zur chirurgischen Therapie. Neben der massiven Hämoptoe als notfallmäßige Operationsindikation stehen hier vor allem tuberkulöse Sekundärkomplikationen wie Aspergillome, chronische Hämoptysen, Pneumothorax, bronchopleurale Fisteln und zerstörte Areale des Lungenparenchyms („destroyed lung“) im Vordergrund. Schlussfolgerung: Die interdisziplinäre OP-Indikation sollte stets in einem multimodalen Therapiekonzept unter Berücksichtigung von Patientenalter und Funktionsanalysen gestellt werden. Eine antituberkulostatische Therapie sollte vor und nach einer Operation suffizient durchgeführt werden, um einen nachhaltigen Therapieerfolg verzeichnen zu können.

Abstract

Background: Tuberculosis is still one of the most common infectious diseases along with HIV and malaria and therefore represents a serious problem in the health sector. Due to immigrants and refugees, the disease is also present in Europe. The global increase of multidrug resistant tuberculosis leads to a highly significant and current importance of sufficient therapeutic measures. In recent years, this fact has led to a reevaluation of surgical therapy in the context of an interdisciplinary and multimodal treatment of multidrug resistant tuberculosis. In addition, despite an effective treatment of drug sensitive tuberculosis with antibiotics, there are still indications for surgery in the treatment of tuberculosis. Beside massive hemoptysis as an emergency indication for surgical intervention, secondary complications of tuberculosis such as aspergilloma, chronic hemoptysis, pneumothorax, bronchopleural fistula and destroyed lung remain indications for surgery. Conclusion: The indication for surgery should always be made in a multimodal therapeutic approach by an interdisciplinary team, taking patient age and functional analysis into account. Effective antibiotic therapy should be performed before and after surgery in order to achieve a sustained treatment success.

Schlüsselwörter

Thoraxchirurgie - Lungentuberkulose - Aspergillom - Behandlung - Tuberkulose

Key words

thoracic surgery - pulmonary tuberculosis - aspergilloma - treatment - tuberculosis

• Literatur

• 1 Perelman MI, Strelzov VP. Surgery for pulmonary tuberculosis. World J Surg 1997; 21: 457-467
• 2 Sauerbruch F. [The nature and history of the treatment of tuberculosis]. Zentralbl Chir 1951; 76: 421-430
• 3 Lucas BG, Cleland WP. Thoracoplasty with plombage; a review of the early results in 125 cases. Thorax 1950; 5: 248-256
• 4 Chambers JS. Surgical treatment of pulmonary tuberculosis; a decade of change. Calif Med 1956; 84: 388-393
• 5 Geldmacher H, Kroeger C, Branscheid D et al. [Role of surgical procedures in the diagnosis and therapy of tuberculosis]. Pneumologie 2000; 54: 318-323
• 6 Branscheid D, Albrecht CM, Diemel KD. [Surgical therapy of pulmonary tuberculosis]. Internist (Berl) 2003; 44: 1406-1412
• 7 Zumla A, George A, Sharma V et al. The WHO 2014 global tuberculosis report–further to go. Lancet Glob Health 2015; 3: e10-e12
• 8 Vashakidze S, Gogishvili S, Nikolaishvili K et al. Favorable outcomes for multidrug and extensively drug resistant tuberculosis patients undergoing surgery. Ann Thorac Surg 2013; 95: 1892-1898
• 9 Sulis G, Roggi A, Matteelli A et al. Tuberculosis: epidemiology and control. Mediterr J Hematol Infect Dis 2014; 6: e2014070
• 10 Dara M, Sotgiu G, Zaleskis R et al. Untreatable tuberculosis: is surgery the answer?. Eur Respir J 2015; 45: 577-582
• 11 Dheda K, Gumbo T, Gandhi NR et al. Global control of tuberculosis: from extensively drug-resistant to untreatable tuberculosis. Lancet Respir Med 2014; 2: 321-338
• 12 Calligaro GL, Moodley L, Symons G et al. The medical and surgical treatment of drug-resistant tuberculosis. J Thorac Dis 2014; 6: 186-195
• 13 Kempker RR, Vashakidze S, Solomonia N et al. Surgical treatment of drug-resistant tuberculosis. Lancet Infect Dis 2012; 12: 157-166
• 14 Marrone MT, Venkataramanan V, Goodman M et al. Surgical interventions for drug-resistant tuberculosis: a systematic review and meta-analysis. Int J Tuberc Lung Dis 2013; 17: 6-16
• 15 Man MA, Nicolau D. Surgical treatment to increase the success rate of multidrug-resistant tuberculosis. Eur J Cardiothorac Surg 2012; 42: e9-e12
• 16 Falzon D, Jaramillo E, Schunemann HJ et al. WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update. Eur Respir J 2011; 38: 516-528
• 17 Kang MW, Kim HK, Choi YS et al. Surgical treatment for multidrug-resistant and extensive drug-resistant tuberculosis. Ann Thorac Surg 2010; 89: 1597-1602
• 18 Freixinet J. Surgical indications for treatment of pulmonary tuberculosis. World J Surg 1997; 21: 475-479
• 19 Bobba RK, Holly JS, Loy T et al. Scar carcinoma of the lung: a historical perspective. Clin Lung Cancer 2011; 12: 148-154
• 20 Chen JC, Chang YL, Luh SP et al. Surgical treatment for pulmonary aspergilloma: a 28 year experience. Thorax 1997; 52: 810-813
• 21 Pennington JE. Aspergillus lung disease. Med Clin North Am 1980; 64: 475-490
• 22 Chun JY, Belli AM. Immediate and long-term outcomes of bronchial and non-bronchial systemic artery embolisation for the management of haemoptysis. Eur Radiol 2010; 20: 558-565
• 23 Kiral H, Evman S, Tezel C et al. Pulmonary resection in the treatment of life-threatening hemoptysis. Ann Thorac Cardiovasc Surg 2015; 21: 125-131
• 24 Wex P, Utta E, Drozdz W. Surgical treatment of pulmonary and pleuro-pulmonary Aspergillus disease. Thorac Cardiovasc Surg 1993; 41: 64-70
• 25 Halezeroglu S, Okur E. Thoracic surgery for haemoptysis in the context of tuberculosis: what is the best management approach?. J Thorac Dis 2014; 6: 182-185
• 26 Dhaliwal RS, Saxena P, Puri D et al. Role of physiological lung exclusion in difficult lung resections for massive hemoptysis and other problems. Eur J Cardiothorac Surg 2001; 20: 25-29
• 27 Farid S, Mohamed S, Devbhandari M et al. Results of surgery for chronic pulmonary Aspergillosis, optimal antifungal therapy and proposed high risk factors for recurrence–a National Centreʼs experience. J Cardiothorac Surg 2013; 8: 180
• 28 Sagan D, Gozdziuk K. Surgery for pulmonary aspergilloma in immunocompetent patients: no benefit from adjuvant antifungal pharmacotherapy. Ann Thorac Surg 2010; 89: 1603-1610
• 29 Rizzi A, Rocco G, Robustellini M et al. Results of surgical management of tuberculosis: experience in 206 patients undergoing operation. Ann Thorac Surg 1995; 59: 896-900
• 30 Aronchick JM, Miller jr. WT. Bronchiectasis. J Thorac Imaging 1995; 10: 255-267
• 31 Pei R, Zhou Y, Wang G et al. Outcomes of bronchial artery embolization for life-threatening hemoptysis secondary to tuberculosis. PLoS One 2014; 9: e115956
• 32 Erdogan A, Yegin A, Gurses G et al. Surgical management of tuberculosis-related hemoptysis. Ann Thorac Surg 2005; 79: 299-302
• 33 Ramakantan R, Bandekar VG, Gandhi MS et al. Massive hemoptysis due to pulmonary tuberculosis: control with bronchial artery embolization. Radiology 1996; 200: 691-694
• 34 Lee JH, Kwon SY, Yoon HI et al. Haemoptysis due to chronic tuberculosis vs. bronchiectasis: comparison of long-term outcome of arterial embolisation. Int J Tuberc Lung Dis 2007; 11: 781-787
• 35 Takeda S, Maeda H, Hayakawa M et al. Current surgical intervention for pulmonary tuberculosis. Ann Thorac Surg 2005; 79: 959-963
• 36 Reed CE. Pneumonectomy for chronic infection: fraught with danger?. Ann Thorac Surg 1995; 59: 408-411
• 37 Bai L, Hong Z, Gong C et al. Surgical treatment efficacy in 172 cases of tuberculosis-destroyed lungs. Eur J Cardiothorac Surg 2012; 41: 335-340
• 38 Treasure RL, Seaworth BJ. Current role of surgery in Mycobacterium tuberculosis. Ann Thorac Surg 1995; 59: 1405-1407
• 39 Brown J, Pomerantz M. Extrapleural pneumonectomy for tuberculosis. Chest Surg Clin N Am 1995; 5: 289-296
• 40 Freixinet J, Varela A, Lopez Rivero L et al. Surgical treatment of childhood mediastinal tuberculous lymphadenitis. Ann Thorac Surg 1995; 59: 644-646
• 41 Hewitson JP, Von Oppell UO. Role of thoracic surgery for childhood tuberculosis. World J Surg 1997; 21: 468-474
• 42 Worthington MG, Brink JG, Odell JA et al. Surgical relief of acute airway obstruction due to primary tuberculosis. Ann Thorac Surg 1993; 56: 1054-1062
• 43 Iseman MD. Treatment of multidrug-resistant tuberculosis. N Engl J Med 1993; 329: 784-791
• 44 Pomerantz M, Madsen L, Goble M et al. Surgical management of resistant mycobacterial tuberculosis and other mycobacterial pulmonary infections. Ann Thorac Surg 1991; 52: 1108-1111