outcome of group A and B in our study include:
1. The number of bronchopleural ®stulae in the ®brocaver-
nous lesions: The edges of these ®stulae were often
fragile, necrotic, and bled easily with a tendency to reoc-
cur during the early postoperative period. In our series,
three patients hand reoccurrence of air leakage from
chest tube on the 7th, 10th, and 12th postoperative day.
If the number of ®stulae was one or two, the IMFT
2. The size of the cavern: IMFT appeared more likely to fail
if the cavitary lesions were larger than 210 cm
less of which muscle ¯ap was used. All types of muscle
¯ap including Pectoralis major, Serratus anterior, Latis-
simus dorsi and Omentum, initially appeared to appro-
priately ®ll the cavity. However, disuse atrophy of the
muscle occurred following transposition. This, combined
with the failure of the remaining lung to expand from
severe destruction, ®brosis, and adhesion was probably
responsible for the late failure. In our series, two patients
developed B±P±C ®stula on 40th and 44th postoperative
day, in which chest tubes were removed successfully
without sign of air leakage initially on 10th and 14th
3. Patients with MDRTB were probably not suitable for this
procedure, (Group B only- three of ®ve patients). Multi-
ple secondary procedures improve the outcome only in
one of these patients. Since removal of heavy bacterial
burden is essential in the treatment of MDRTB , intra-
operative cavitary instillation of anti-tuberculous drugs
followed by postoperative continuous instillation via
chest tube might help in decreasing the bacterial load
within the cavity. These drugs could also induce in¯am-
matory reaction between muscle ¯ap and cavity wall and
hasten the adhesion which might improve the result of
IMFT. The risk of drug irritation or bacterial spread to
another portion of the lung is probably nil since the
bronchopleural ®stula is closed during operation.
However, lobectomy or pneumonectomy, if possible,
continues to be the treatment of choice for patients
with MDRTB [10,11].
4. Aspergilloma within ®brocavernous tuberculosis often
causes severe hemoptysis and needs to be resected [12±
14]. In high risk patients, some authors use palliative
procedures to evacuate it . In our study, the presence
of aspergilloma in the cavity didn't appear to in¯uence
the outcome of IMFT. Grossly, all fungal material could
be readily evacuated intra-operatively without major
blood loss or technical dif®culty. In cases of tuberculous
cavity with aspergilloma treated by resection, it is safe
not to administer anti-fungal regimen during the pre- and
post- operative period and should be used only in case
with invasive aspergillosis to minimize postoperative
complication. One patient in this study had invasive
aspergillosis involving both lungs and the empty old
tuberculous cavity on left upper lobe. He was operated
on after toxic sign and fungal in®ltration on CXR
subsided. Despite the reformation of cavity, there was
no recurrence of fungal ball within the cavity for more
than 3 years of a follow-up period.
5. In our patients, cavernostomy with IMFT appeared to be
a less invasive procedure. The length of endotracheal
intubation with ventilatory support was 0:9 ^ 0:2 days
with an average stay in ICU of 1:9 ^ 0:3 days.
Based on the result of this study, cavernostomy with
IMFT should be carried out on carefully selected ®broca-
vernous tuberculosis patients based on the following consid-
erations. Firstly surgical intervention of patients with
MDRTB probably should be deferred until the disease is
medically controlled . Secondly all bronchopleural
®stulas should be carefully identi®ed and closed intra-
operatively with enforcement using muscle ¯ap transposi-
tion and thirdly, the size of the cavity should be estimated
preoperatively by computed tomography with cavities
larger than 210 cm
probably needing alternative operative
procedure. Chronicity of the cavity, poor pulmonary func-
tion tests, and recurrent hemoptysis are probably not contra-
indication for IMFT.
Based on this study, cavernostomy combined with
intrathoracic muscle ¯ap transposition, a less invasive
procedure, can be used to treat well-selected ®brocavernous
pulmonary tuberculosis patients, except in patients with
large size cavity, multiple bronchopleural ®stulae or multi-
ple drug resistant tuberculosis.
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