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The Value of Pre-operative Assessment and Preparation in Chronic

Tuberculous Pyothorax Surgery

Article · January 2021

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 Case Report
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The Medical Observer 2021, Vol I; N°1: in Press

The Value of Pre-operative Assessment and Preparation in Chronic

Tuberculous Pyothorax Surgery: About Two Case Reports
Marouane Lakranbi1, 2*, Laila Belliraj1, Sani Rabiou3, Hicham Harmouchi1, Fatima Zahra Ammor1,
Maroua Raouti1, Fatima Zahra Lamouime1, Yassine Ouadnouni1,2, Mohamed Smahi1,2
1
Thoracic Surgery Unit, Hassan II University Hospital, Fez, Morocco.
2
Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Fez, Morocco.
3
Thoracic surgery department, HGR, Niamey, Niger.
ABSTRACT
Corresponding Author:

Lakranbi marouane, MD.

Affiliation : Service de chirurgie thoracique, route
Sidi Hrazem, CHU Hassan II , Fes, Maroc.
Tel: 00(212) 663660432
E-mail: marouane.lak@gmail.com
Copyright © 2021 Dr. M. Lakranbi et al. This is an
open access article published under Creative
Commons Attribution -Non Commercial- No
Derives 4.0 International Public License (CC BY-
NC-ND). This license allows others to download the
articles and share them with others as long as they credit
you, but they can’t change them in any way or use them
commercially.
The management of chronic tuberculous pyothorax is mainly surgical yet
conditioned by a sound assessment and pre-operative medical preparation as
sole safeguards for good surgical results. Through two clinical cases, we report
on our experience in the pre-operative evaluation and preparation for chronic
tuberculous pyothorax surgery. Pulmonary decortication is technique of choice
in the surgical management of tuberculous pyothorax. It is, however, a
technique which remains weighty due to the blood loss and significant air leaks
it generates whence the value of an assessment and a medical preparation
adapted to the tuberculous pyothorax.
Keywords: Pyothorax; Tuberculosis; Pulmonary decortication; Thoracotomy

Article in Press. INTRODUCTION

The management of chronic Tuberculous pyothorax is chiefly surgical, mainly

doi: 10.46327/msrjg.1.0---
url: https://doi.org/10.46327/msrjg.1---
based on the pleuro pulmonary decortication technique but which is not risk
free given the significant blood loss and extended air leaks it generates. [1, 2, 3,
4]. Through two clinical cases, we report on our experience in the evaluation
and pre-operative preparation of chronic tuberculous pyothorax surgery
CASE REPORTS:

CASE REPORT #1:

A 46-year-old diabetic, chronic smoker male patient, admitted in another hospital structure for microscopy
positive pulmonary tuberculosis complicated by a left pyopneumothorax previously drained in the same structure.
Upon admission to our unit clinical examination identified a thin (45 kg) altered patient, in a depressed
psychological condition and in diabetic imbalance. Thoracic CT had come out in favour of an fluid air pleural
collection with ipsi and contra lateral lesions of pulmonary tuberculosis and the patient was therefore rejected for
surgery (Figures 1/A, B). The patient benefited from a pleural re-drainage placing the drain in the para-vertebral
groove, facing towards the pulmonary top, with the addition of extra holes in the thoracic drain. Anti- tuberculosis
treatment was initiated and at the same time a home ambulatory medical preparation was set up based on a
correction of hydroeletrolytic disorders and anemia, diabetic rebalancing, hypercaloric and hyperproteidic oral re-
nutrition, intensive respiratory physiotherapy by incentive spirometer. Within a 3 months preparation period, the
evolution was marked by a clinical improvement with 19 kg weight gain and a marked improvement in the general
and psychological condition. Sputum examination turned out negative. Radiological evolution was marked by a
regression of pulmonary tuberculous lesions and a relative re-expansion of the pulmonary parenchyma but with
the persistence of a pleural collection (Figure 1 C)
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Figure 1: A/ Chest CT scan showing a fluid air pleural pocket with a thoracic drain barely in touch with the pocket. B/ Chest
CT showing contra lateral lung tuberculosis lesions. C/ Chest CT scan showing regression of pulmonary tuberculous lesions
and a relative re-expansion of the pulmonary parenchyma but with persistence of a pleural pocket .

The patient had undergone a pleuro pulmonary decortication accessed through a conservative postero lateral
thoracotomy with costal resection that enabled the resection of an important one centimetre thick parietal and
visceral pacchypleuritis and a satisfactory lung re-expansion by the end of the procedure with minimal intra-
operative bleeding. Post-operative follow-ups were simple with minimal air leakage that dried up by Day (D) +3.
Radiographic check-up was satisfactory on D + 1. The patient was declared discharged on D+4.

CASE REPORT # 2

A 45-year-old male patient, taken into care in another hospital facility for right pyopneumothorax with microscopy
positive pulmonary tuberculosis , and who had benefited in that same facility from a pleural drainage without
improvement . When he was admitted in our unit, the clinical examination finds an altered, thin patient (weighing
55kg), in a depressive psychological condition. The patient had undergone a radiological assessment (chest CT)
and objectified a right posterior pleural collection with ipsi and contra lateral lesions of pulmonary tuberculosis
(Fig. 2/A; B). The patient benefited from an elective pleural re-drainage of the pleural collection with the addition
of extra holes on the chest drain and the initiation of an anti-bacillary treatment associated with intensive medical
preparation, in a manner similar to patient #1. After a 3 months preparation, the evolution was marked by a
clinical improvement with a 5 kg weight gain and a clear improvement in the general and psychological condition.
The sputum examination turned out negative. Radiological progress was marked by a regression of pulmonary
tuberculous lesions and a relative re-expansion of the pulmonary parenchyma but with the persistence of a
sheathing pacchypleuritis (Fig. 2/C).

Figure 2: A/ Chest CT Scan objectifying a posterior pleural pocket (note the position of the pleural drain barely in contact
with the pleural pocket). B/ Chest CT Scan showing ipsi and contra lateral pulmonary tuberculosis lesions. C/ Post chest
drainage control chest X-ray showing a re-ventilation of the pulmonary prenchyma with persistent pacchypleuritis (note the
position of the pleural drain oriented towards the pleural pocket)
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The patient had undergone a pleuro-pulmonary decortication accessed through a conservative posterolateral
thoracotomy with a costal resection which enabled the resection of a more than 1 cm thick significant parietal and
visceral pacchypleuritis and a satisfactory pulmonary re-expansion by the end of the operation with minimal
intraoperative bleeding. Post-operative follow-ups were simple with minimal air leakage that dried up by Day 3+.
Radiographic check-up was satisfactory on D 1+. The patient was declared discharged by D 4+.

DISCUSSION

Both our clinical cases illustrate the problematic of the tuberculous pyothorax due to its rapid evolution towards
chronicity and important impact on the respiratory function and general condition [5, 6]. In fact, the tuberculous
pyothorax is accompanied by the formation of a large parietal and visceral pacchypleuritis sheathing the lung and
imprisoning it against the mediastinum thereby concurrently hindering the respiratory function. Chronic
pyothorax results in an important basic hypercatabolism process that causes an alteration of the general condition
and hydro-electrolyte disorders [7, 8]. Furthermore, this type of patients has often a depressive psychological
profile with a tendency towards self-isolation on account of the foul breath that accompanies purulent sputum and
because of the purulent secretions that flow through the chest tube.
Pulmonary decortication is, nonetheless, a technique of choice in the surgical management of tuberculous
pyothorax. It is, however, a technique that remains weighty due to the blood loss and important air leakage it
generates and hence its ordering for an altered patient may be dramatic [2, 8,9 ,10]. This is why in our current
practice, we consider pyothorax to be a medical and surgical emergency and we advocate good pre-operative
medical preparation based on a correcting of the disorders linked to the weakened condition by:
 Functional respiratory rehabilitation by incentive spirometer and intensive respiratory physiotherapy.
 Sepsis control by:
 Pleural drainage directed towards the pulmonary apex in the free pleural effusions or elective in the
pleural collection guided by CT scan data or rarely after ultrasound detection. Generally, we use CH
20 or 24 drains with extra orifices added to the chest tube and this until the drying up of the pleural
effusion associated with the initiation of an antituberculous treatment up to Koch’s bacillus
negativation.
 Biological disorders correction (hydroeletrolytic disorder correction, anemia correction, search for
renal amyloidosis by carrying out a 24-hour proteinuria assay) [11];
 Hyper caloric oral re-nutrition by recommending to the patient genuine hyper protidic force-feeding
with at least 6 to 8 diversified meals a day containing meat, eggs, milk, etc. [7].
 Fighting off the depressive condition by carrying out as an outpatient this preoperative preparation so that
he can benefit from his family’s psychological support.

CONCLUSION

These two clinical cases are the example of a thoracic surgeon’s daily experience in developing countries. They
also bear witness to the fact that one should not surgery be rejected for any chronic pyothorax in an altered patient
upon the first consultation but instead carry out a rigorous medical preparation alongside regular reassessment of
the condition, and in this surgical indication case, throughout the preoperative preparation process. It has even
been found in some occurrences that this medical preparation is sufficient enough to secure healing and thus spare
surgery.

ACKNOWLEDGMENTS

To Miss Wiam Ghayour for her assistance throughout all aspects of our study and for her help in writing the
manuscript.

CONFLICT OF INTEREST

Authors declare no conflict of interest

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