Chest wall tuberculosis: precision surgery with indigo carmine in limited cases for safe and intuitive lesion excision

Abstract

In addition to treatment with antituberculosis drugs, complete surgical excision is important for the cure of chest wall tuberculosis. However, surgery is often challenging to perform due to different factors such as the strong adhesion of tuberculous lesions to the surrounding normal tissue, growth of neovascularization and presence of fragile necrotic tissues. Firm adhesions, bleeding and fragile tissue make it difficult to determine the boundary with normal tissue and completely excide the lesion. Moreover, ingenuity is required. Herein, we report the identification of the boundary between the lesion and normal tissue by injecting indigo carmine into the abscess to completely excide the lesion, which is considered an intuitive and safe method.

Chest wall tuberculosis is a relatively rare type of extrapulmonary tuberculosis.

INTRODUCTION

Chest wall tuberculosis is a relatively rare type of extrapulmonary tuberculosis. It is an important differential disease of chest wall masses [1], and it requires radical treatment. Medical therapy alone is not often successful for managing this condition, and combined treatment with surgery and antituberculosis drugs is consequently required to prevent recurrence [2, 3]. In addition, complete excision of the abscess, including a portion of the involved chest wall, is mandatory to prevent recurrence [4, 5]. However, surgery is often challenging to perform due to different factors such as the strong adhesion of tuberculous lesions to the surrounding normal tissue, growth of neovascularization and presence of fragile necrotic tissues. Firm adhesions, bleeding and fragile tissue make it difficult to determine the boundary with normal tissue and completely excide the lesion. Further, ingenuity is required. Hence, complete excision with indigo carmine injection into the abscess is performed to prevent residual lesions.

DESCRIPTION

Surgical technique

Indigo carmine has great applicability in diagnostic procedures and surgical evaluations using its intense colour to assess the analysed structure. It is a relatively safe drug due to its predominantly renal excretion [6, 7]. The injection of indigo carmine into the abscess is used in the radical excision of chest wall tuberculosis. Thus, the boundary between the lesion and normal tissue can be identified, and lesions can be excided without any remnants. Based on the preoperative computed tomography findings, the decision was made to administer an indigo carmine injection. These findings were used to identify if the abscesses were in contact with adjacent organs such as the lungs or great vessels. Furthermore, the computed tomography scan helped determined if the abscess had caused any damage to the ribs, sternum or peripheral soft tissue, which may have obscured the borders of the abscess.

Figure 1 shows a 72-year-old female who developed chest wall tuberculosis 4 years after treatment for tuberculous pleuritis. A pleural effusion sample was collected to diagnose tuberculous pleuritis, and chest wall tuberculosis could have formed in the drainage route punctured from the skin into the thoracic cavity. A small incision was made just above the subcutaneous nodule (on the surface of the abscess capsule), and the pus inside was aspirated to the greatest extent. Then, a sufficient volume of indigo carmine was injected into the abscess, and the incision on the surface of the capsule was sutured. Using the indigo carmine-stained abscess capsule as a marker, the abscess was dissected from the surrounding tissue without leaving any residual lesions.

Figure 1:

(A–C) The arrows indicate the lesions. A computed tomography scan showed a low-attenuate density extending from the chest wall to the thoracic cavity, indicating the possibility of chest wall tuberculosis forming in the drainage route punctured from the skin into the thoracic cavity. (D and E) A small incision was made just above the subcutaneous nodule (on the surface of the abscess capsule), and the pus inside was aspirated to the greatest extent. Then, a sufficient volume of indigo carmine was injected into the abscess, and the incision on the capsule surface was closed. Using the indigo carmine-stained abscess capsule as a marker, the abscess was dissected from the surrounding tissue without leaving any residual lesions. (F) The excised abscess was filled with indigo carmine.

Patients

Six patients with chest wall tuberculosis who received treatment with indigo carmine staining at the National Hospital Organization Fukuokahigashi Medical Centre between January 2011 and May 2019 were evaluated by reviewing their medical records. The abscess was completely excised in all patients. Complete excision with rib resection was required in 3 patients, with soft tissue reconstruction using the pedicled rectus abdominis to fill the extensive defect in one of them. All patients underwent pre- and postoperative antituberculosis drugs, with a minimum of 6 months of postoperative treatment. Thereafter, they were returned to primary care unless medical issues were detected. Long-term data on recurrence were obtained via a telephone interview in December 2022. The clinical data of all patients are listed in Table 1. The mean age of the patients was 66.2 years (55–72 years). The mean follow-up period after surgery was 106 months (36–136 months). No adverse events were observed in any of the patients. Additionally, there were no cases of tuberculosis recurrence in those who underwent surgical resection with indigo carmine staining.

Table 1:

Patients’ clinical data of chest wall tuberculosis with indigo carmine injection

No	Age	Sex	Comorbidity	History of tuberculosisa	Location	Operation
1	70	Male	Hypertension Diabetes mellitus	Past	Right anterior chest wall	Abscess resection with the 5th to 7th ribs The defect filled with the pedicled rectus abdominis
2	65	Female	Hypertension	Past	Right lateral chest wall	Abscess resection
3	70	Male	Post oesophageal cancer	None	Left anterior chest wall	Abscess resection with the 5th rib
4	65	Female	Hypertension	Past	Left anterior chest wall	Abscess resection
5	55	Female	none	None	Right anterior chest wall	Abscess resection with the 6th rib
6	72	Female	Hypertension Bronchial asthma	Past	From right lateral chest wall into thoracic cavity	Abscess resection

^aIn all patients, concomitant pulmonary tuberculosis was not observed.

COMMENT

According to previous reports, the combination of appropriate excision of infected lesions and antituberculosis drugs is crucial for reducing the recurrence rate in the treatment of chest wall tuberculosis [3, 8]. Furthermore, Kim et al. [4] demonstrated that patients who only underwent abscess debridement and drainage had a higher recurrence rate compared to those who underwent complete excision in receiving postoperative antituberculosis drugs (40.0% vs 9.2%), this suggests the beneficial role of complete excision in preventing recurrence. Although limited by a small number of cases at our hospital, 6 patients who underwent precise complete excision with indigo carmine injection have not experienced recurrence. Staining with indigo carmine is considered intuitive, safe and easy, aiding in identifying the boundaries between lesions and normal tissue.

FUNDING

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Conflict of interest: none declared.

DATA AVAILABILITY

The data underlying this article will be shared on reasonable request to the corresponding author.

Reviewer information

Interdisciplinary CardioVascular and Thoracic Surgery thanks Mohamed Salama, Petre Vlah-Horea Botianu and the other anonymous reviewers for their contribution to the peer review process of this article.

ETHICAL STATEMENT

This study was approved by the Institutional Review Board for Clinical Research of National Hospital Organization Fukuokahigashi Medical Centre on 17 January 2023 (approval No. 2022-87). Informed consent was obtained from each patient for the use of clinical data.