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1、外科手术与耐多药治疗结果江振源 肺健康部主任 国际防痨与肺部疾病联合会2009/11/27 济南Treatment of Tuberculosis in Pre- Chemotherapy Era : 1882-1944 Rest: by putting the organism to as little physical exertion as possible, we conserve the greatest amount of vital energy and nutrition with which to resist the progress of the disease. Cli
2、mate: dry equable climate, moderate altitude Cold fresh air Proper dietHermann BrehmerIn 1894 this German Doctor In 1894 this German Doctor built the First tuberculosis built the First tuberculosis Sanatorium in GorbersdorfSanatorium in Gorbersdorf (Silesia) in the German Alps(Silesia) in the German
3、 Alps (650 m).(650 m).Slide courtesy: Caminero JAAssy Plateau Sanatorium Slide courtesy: Caminero JASanatoriumsSanatoriums were built with large were built with large patios where TB patios where TB patients patients could rest.could rest.Slide courtesy: Caminero JASUN Therapy to Treat Spinal TBSlid
4、e courtesy: Caminero JAMagic Mountain- Thomas Mann the dangers of such a milieu for young people, the narrowness of this charmed circle of isolation and invalidism. It is a sort of substitute existence, and it can, in a relative short time, wholly wean a young person from actual and active life. He
5、will become completely incapable of life in the flatland. . .Carlo Forlanini (1874-1918) ), ,First Doctor to apply artificial First Doctor to apply artificial Pneumothorax for the treatment Pneumothorax for the treatment of tuberculosis.of tuberculosis.Slide courtesy: Caminero JAFirst apparatus used
6、 toFirst apparatus used to produce a Therapeutic produce a Therapeutic Pneumothorax.Pneumothorax.Used for the first time by Used for the first time by Carlo Forlanini (1874-1918).Carlo Forlanini (1874-1918).Slide courtesy: Caminero JAPerform an artificial Pneumothorax (1928)Slide courtesy: Caminero
7、JA Collapse Therapy Artificial pneumothorax Pneumoperitoneum and phrenic nerve paralysis Thoracoplasty Extrapleural pneumothorax or plombageSurgical Intervention in theTreatment of Pulmonary TuberculosisN Engl J Med 2009;360:23 Resectional TherapyLandmark in the treatment of TuberculosisStreptomycin
8、(SM) Introduction of streptomycin(SM) in 1944 : Albert Schatz and Dr. Waksman First control clinical trial : 1947 SM 2g per day 4 injection q6h for 4 months plus bed rest Bed restTreatment of Pulmonary TB with Streptomycin (SM) and Para-aminosalicylic acid (PAS) PAS+SM (3 months)SM (3 months)Culture
9、 negativity CXR improvementat 3 monthsat 6 months SM resistance by 3 months33% of4675% of 53 87% of 536% of 3319% of 4870% of 54 74% of 5457% of 47Medical Research Council. Br Med J 1950:2:1073-85Singapore, Controlled clinical trial of Short- Course Chemotherapy in the treatment of pulmonary tubercu
10、losis(1973)RegimenPatients N=Sputum Culture negative at 2 Months (%)Relapse rate in 2yr follow-up (%)2SHRZ/2HRZ 2SHRZ/4HRZ 2SHRZ/2HR 2SHRZ/4HR1651659811 0 8 2Fox W, et al. Int J Tuberc Lung Dis 1999;3:S231-79Fate of tuberculosis patients By quality of their carePer cent of casesGrzybowski S, Enarson
11、 DA Bull Int Union Tuberc Lung Dis 1978;53(2):70-5.Fate of tuberculosis patients By quality of their carePer cent of casesPer cent of casesCourtesy Professor Enarson DASurgery for Muitidrug-Resistant TB, Criteria for Selection Patients with medical treatment failure, or whose drug resistance so exte
12、nsive that there was a high probability of failure or relapse. Disease predominantly localized. Sufficient drug activity to diminish the mycobacterial burdenIseman MD, et al. Am Rev Respir Dis 1990;141:623-5Surgical Procedures Performed, n=27Explanation of abbreviations: RUL = right upper lobe; LUL
13、= left upper lobe; RLL = right lower lobe;LLL = left lower lobe; RUL plus = RUL lobectomy plus segmentectomy and/or wedge resectionIseman MD, et al. Am Rev Respir Dis 1990;141:623-5Surgical Outcomes, n=27* Excludes 1 peri-operative death.Pulmonary resection in the treatment pulmonary MDR -TB Indicat
14、ion of surgery Group A: Medical treatment failure Persistent sputum culture-positive for M. tuberculosis despite treatment with adequate second-line anti-TB drugs for at least 12 months. Group B: Prevention of treatment failure Surgery in the early stages of treatment for patients whose resistance p
15、attern and extent of lung destruction, based on our previous experience, predicted a high probability of treatment failure Group C: Prevention of relapse Surgery in the late stages of treatment for patients with sputum conversion, yet still demonstrating a possibility of relapse that was of concern
16、to usChiang C-Y, et al Int J Tuberc Lung Dis 2001;5:272-7.Pulmonary resection in the treatment of pulmonary MDR-TB patients, TaiwanPre-operative treatment Mean and range (months)Bacteriological Response n (%)Medical treatment failure, n=620.6 (1333)5 (83.3)Prevention of treatment failure, n=154.5 (27)13 (92.8)Prevention of relapse, n=514.2 (1019)5 (100)Chiang C-Y, et al Int J Tuberc Lung Dis 2001
