5 курс / Пульмонология и фтизиатрия / Clinical_Tuberculosis_Friedman_Lloyd_N_,_Dedicoat

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Introduction

Diagnosis

Management

References

INTRODUCTION

Pulmonary tuberculosis led to the birth of thoracic surgery. The techniques of pulmonary resection in use today were developed to deal with the persisting problem of tuberculosis (TB) in the 1930s, 1940s, and 1950s. In addition, collapse therapy led to the development of thoracoplasty, still of value in rare circumstances today,1 now refined by the development of video-assisted technology. Plombage has evolved into techniques of space reduction, such as myoplasty and omentoplasty. As the incidence of TB declined in developed countries, these techniques were left as a valuable legacy and were available to deal with the next epidemic—lung cancer and the chronic infective complications that resulted from this surgery.

Today, however, the management of TB and its sequelae is benefiting from the subsequent development of techniques such as mediastinoscopy, video-assisted thoracic surgery (VATS) and myoplasty. This cross-pollination has provided the modern thoracic surgeon with a broad range of procedures to deal with the continued threat of TB in Western countries, the rising incidence of multidrug-resistant organisms and the continued epidemic of TB in underdeveloped countries. The thoracic surgeon still has an important role, supporting the respiratory physician, in the diagnosis and management of difficult cases.

DIAGNOSIS

The sputum-negative patient may present with mediastinal lymphadenopathy, a pleural effusion or a pulmonary nodule, requiring biopsy to exclude other conditions, especially sarcoidosis, carcinoma and lymphoma, and to obtain tissue for culture and sensitivity. Although the chest radiograph may clearly demonstrate lymphadenopathy, a computed tomographic (CT) scan

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will often be requested to confirm that lymph nodes within reach of biopsy techniques are enlarged, to help in the choice of the appropriate technique (Figure 17.1), to identify any pulmonary focus and to clarify the relationship of vital structures that present a hazard at surgery. The surgeon has several biopsy techniques from which to choose the one that will most reliably establish the diagnosis, and if more than one is possible will choose on the basis of familiarity, the equipment available and cosmetic considerations (Figure 17.2).

Cervical mediastinoscopy

Cervical mediastinoscopy is undertaken under general anesthesia using a 2–3 cm incision midway between the suprasternal notch and the thyroid cartilage. Although a safe and relatively minor procedure, considerable experience is needed to avoid damage to the recurrent laryngeal nerves and major blood vessels in this crowded anatomical region.2 The development of video-assisted mediastinoscopy has been of considerable benefit in training surgeons to navigate safely through this region.3 The view of the surgeon is enhanced, the assistant can take part in the procedure and each case is a teaching experience (Figure 17.3).

Mediastinoscopy allows access to, and biopsy from, the nodes in the superior mediastinum that lie on either side of the trachea, in the pretracheal position and at the main carina (Figure 17.4). Nodes in the upper pole of the right hilum may be reached, but caution is necessary to avoid damage to the azygos vein and the branch of the pulmonary artery to the upper lobe.

Biopsy material, as in all these techniques, will be sent for culture in addition to histological examination, and because sarcoidosis is an ever-present possibility, biopsies should be taken from several nodal stations to avoid the pitfall of detecting only the granulomatous response in a lymph node adjacent to malignancy. Increasingly mediastinoscopy is undertaken as a day case.4

Figure 17.2  The incisions used to explore the mediastinum surgically. The patient’s chin is to the left, the clavicles are visible, as is the right nipple. The upper incision at the root of the neck provides access for cervical mediastinoscopy, the longer incision on the left chest wall is for anterior mediastinotomy. The cosmetic result of the former is very satisfactory as the scar is in the skin crease. The latter results in a visible scar that is less satisfactory.

Anterior mediastinotomy

Anterior mediastinotomy is undertaken under general anesthesia utilizing a 3–5 cm incision through the intercostal interspace over the area to be biopsied,2 most commonly the second intercostal space on the left or right (Figure 17.2). Resection of the costal cartilage is unnecessary and results in an ugly sulcus beneath the scar

Figure 17.3  A patient undergoing cervical video mediastinoscopy. The instrument is inserted beneath the pretracheal fascia, and dissection proceeds to the main carina. The surgeon and assistant view the field on the monitor allowing both to participate in the operation. The view is magnified and structures are more clearly seen than with conventional mediastinoscopy.

Figure 17.4  A nodal chart used to describe node positions. Those nodes in stations 1–4 in the paratracheal areas, stations 1 and 3 in the pretracheal area and station 7 at the main carina are accessible to cervical mediastinoscopy. Stations 5 and 6 lying beneath the aortic arch and over the ascending aorta are only accessible by anterior mediastinotomy.

that is prone to hematoma and infection. In any event, the scar is cosmetically less acceptable, particularly for younger women and those who are heavy breasted. This approach provides safe access to nodes in the anterior mediastinum and those outside the aortic arch (Figure 17.4).

Digital examination through the interspace will identify a safe target that can be incised to provide a large biopsy. The procedure can be enhanced by using the video mediastinoscope (as used for cervical mediastinoscopy). The use of the diathermy should be reserved for hemostasis after a representative biopsy has been secured; one should avoid the temptation to biopsy vascular nodes using the diathermy ventilation, and this is mandatory if more complex procedures are contemplated involving several access

(a)

ports. Although VATS can be used to access mediastinal lymph nodes that lie in a suitable location, these are usually accessible with greater ease and less equipment using one of the previous techniques. VATS is of value when biopsy of the pleura (Figure 17.5) or lung is needed.

Thoracotomy and pulmonary resection

Thoracotomy and pulmonary resection will on occasions prove the only technique that will allow a firm diagnosis and exclude covert malignancy.6 VATS surgery is becoming the preferred approach for excision of lung lesions less that 3 cm in size (although increasingly some units are utilizing a VATS approach for even larger lesions). Where the lung abnormalities are larger or confluent or dense adhesions are present, thoracotomy may be necessary to fully explore the chest (Figure 17.6). The surgeon will wish to avoid taking biopsies from the periphery of such consolidated areas because this may miss an underlying neoplasm, and the procedure must ensure for the patient a full and reliable assessment.

Progressive dissection, with frequent frozen-section biopsies, is necessary to encircle the abnormality. Often during such a dissection, the true pathology becomes apparent because this will result in material of little value to the histopathologist. The pleura is often entered when undertaking biopsy through the right side, but this is of little consequence if the breach is recognized and air evacuated before closing the wound using a temporary drain through the incision. A post-operative chest radiograph is mandatory. Most patients will wish to stay overnight before discharge.

Endobronchial ultrasound and biopsy

Endobronchial ultrasound (EBUS)-guided fine-needle aspiration biopsy of mediastinal nodes offers a less invasive alternative for sampling of the mediastinal nodes (http://guidance. nice.org. uk/IPG254). The procedure is being widely adopted by respiratory physicians and is reducing the practice of mediastinoscopy.5 This procedure is very similar to flexible bronchoscopy and can be undertaken with conscious sedation or under general anesthesia.

(b)