Ann Thorac Surg 2005;79:299-302
© 2005 The Society of Thoracic Surgeons
Original article: General thoracic
Surgical Management of Tuberculosis-Related Hemoptysis
Abdullah Erdogan, MDa,*,
Arif Yegin, MDb,
Gülsüm Gürses, MDa,
Abid Demircan, MDa
a Department of Cardiothoracic Surgery, Akdeniz University Faculty of Medicine, Antalya, Turkey
b Department of Anesthesiology, Akdeniz University Faculty of Medicine, Antalya, Turkey
Accepted for publication May 3, 2004.
* Address reprint requests to Dr Erdogan, Akdeniz Universitesi Hastanesi, GKDC Anabilim Dali, 07058 Antalya, Turkey
aerdogan66{at}hotmail.com
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Abstract
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BACKGROUND: Tuberculosis is a disease that 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 daily) hemoptysis, and within the first 2 days in 24 with major (200 to 600 mL daily) hemoptysis, and within the first 4 days in 14 with persistent minor (<200 mL daily) hemoptysis.
RESULTS: A chest roentgenogram 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, 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% perioperatively. Of the patients deceased, 3 were intubated with a single-lumen endotracheal tube and 1 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 for tuberculosis performed in the years from 1995 to 2003 was significantly decreased, compared with the years between 1985 to 1994 (p = 0.042).
CONCLUSIONS: In tuberculosis-related hemoptysis, thoracotomy with double-lumen endotracheal intubation and resection of the cavity may be curative and lifesaving.
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Introduction
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Although the definition of massive and major hemoptysis varies in the literature, expectoration of blood of 200 to 600 mL per day is commonly defined as major hemoptysis and expectoration of blood of more than 600 mL per 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 lower 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 will evolve into massive hemoptysis. In such cases, urgent surgery will be lifesaving [6]. In this study, we evaluated the long-term results of the patients who had urgently been operated on owing to hemoptysis-related tuberculosis.
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Patients and Methods
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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 male and 13 were female, ranging in age from 16 to 71 years (mean, 36.6 ± 13.7).
Based on the quantity of blood expectorated per day, hemoptysis was classified in three groups: persistent minor (less 200 mL daily, lasting at least 4 days), major (200 to 600 mL daily), and massive (more than 600 mL daily). Of the patients, 21 presented with massive hemoptysis, 24 with major hemoptysis, and 14 with persistent minor hemoptysis (Table 1). A chest roentgenogram was performed in all patients. Patients who did not have an identifiable cavitary lesion in the roentgenogram underwent a thorax computed tomography (CT) scan. To localize the bleeding area, all patients underwent a fiberoptic or rigid bronchoscopy before 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 receiving antituberculous therapy because of active tuberculosis whereas the remaining 39 were asymptomatic and currently receiving no medication; these patients had prematurely stopped treatment owing to absence of symptoms and had a 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 daily), rifampin (10 mg/kg daily), and ethambutol (25 mg/kg daily) 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 ± SD. Categorical variables were expressed by number (n) and frequencies (%). The 
2 test was used to compare the proportions. A p value of less than 0.05 was considered statistically significant.
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Results
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Cavitary lesions detected by chest roentgenogram (Fig 1) or CT (Fig 2) are shown in Table 1.
Patients were hospitalized for an average period of 13 days (range, 7 to 30) and were followed up between 6 months and 7 years (average, 3) 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. Perioperatively, 4 patients died (mortality rate, 6.8%). Of these 4 patients, 3 had single-lumen and 1 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, whereas 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 2 patients 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 these 3 patients with severe complications were on antituberculous therapy at presentation.
After induction of remission, antituberculosis drug therapy was discontinued postoperatively after 3 months in 8 patients, after 6 months in 38, after 9 months in 9, and after 1 year in 4 patients.
During our study period, 4 patients died between 1985 and 1994 (Table 3). No other deaths were observed after 1995. Likewise, the number of thoracotomies performed in the years from 1995 to 2003 was significantly decreased, compared with the years between 1985 to 1994 (p = 0.042; Table 3).
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Comment
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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, etiologic 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 by bronchoscopy [7], endobronchial balloon tamponade with or without endobronchial instillation of epinephrine [8], instillation of thrombin or fibrinogen-thrombin infusion endobronchially through fiberoptic bronchoscopy [9], laser photocoagulation [10], radiotherapy [11], and bronchial artery embolization [12].
In a study by Knott-Craig and colleagues [13], 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 indicates 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 socioeconomic 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 noncompliance to antituberculous drugs in nearly two thirds of our patients, it could be likely that low socioeconomic status of those patients led them to stop or take the drugs irregularly.
The 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% to 25% of patients [15, 20]. Because of the possible failure of embolotherapy, we gave priority to the surgical approach. On the other hand, the surgical approach for massive hemoptysis is an asphyxia-increasing factor during the intubation period that may result in a fatal outcome. To avoid this problem, before surgery, the bleeding location must be identified through 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 the bronchus-first technique might also prevent intraoperative aspiration.
While nonsurgical approaches and medications should be considered as first-line treatment to manage minor hemoptysis not lasting longer than 4 days, massive, major, and persistent minor hemoptysis should be treated surgically to prevent possible further recurrences.
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Acknowledgments
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We thank Erdal Gilgil and Carl Patrick Parry for their valuable help in the revision and language editing of the manuscript. This study was supported by Akdeniz University Research Fund.
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References
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Abstract
Introduction
