Interventions for Tuberculosis Control and Elimination 2002

ment of pulmonary tuberculosis. 679,970,971 Efficacious chemotherapy has
removed the need for surgical intervention in the routine treatment of
patients.
The usual indications for surgery in the treatment of tuberculosis are
for the treatment of complications. This is true for pyopneumothorax, respiratory
distress due to massive pleural effusion, extensive restrictive pleural
thickening, restrictive pericarditis, obstructive hydrocephalus, long-tract neurological
signs in tuberculous spondylitis, and ureteral obstruction. There
are, with the exception of extensive drug resistance, virtually no indications
for surgery for primary treatment of tuberculosis. The guidelines for such
surgery follow those for any other cause of such complications.
In industrialized countries, surgery has also been used with some success
as an adjunct in patients with strains resistant to all or virtually all
medications. 972-976 Such services are not usually available in national tuberculosis
control programs of low-income countries, and are fortunately still
rarely needed in most countries.
What will be summarized here are indications that are frequent and
do not require sophisticated surgical procedures.
Surgical treatment in respiratory tract tuberculosis
Tuberculous pyopneumothorax
The development of an empyema or, more precisely, a tuberculous pyopneumothorax
is a well-recognized complication in patients with cavitary
tuberculosis whose cavities are located near the pleura. 977,978 In such
patients, penetration of anti-tuberculosis medications into the pleural space
and the empyema might be sub-optimal and may even lead to acquisition
of drug resistance. 979 Furthermore, in contrast to pleural effusions, resorption
of an empyema is less likely to occur, thus draining of the pus is usually
indicated.
In the field, the most simple and effective approach is insertion of a
drain, laid in such a way that it leads over two or three ribs before penetrating
into the pleural space. The drain should be sutured to the skin.
The patient is offered a bed that is about one meter above the floor, and
the drainage is led into a bottle filled with water serving as a water lock.
In patients whose entire lung is collapsed, full expansion of the lung can
be expected, often leaving pleural thickening, however. As decortication
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