Tuberculous Stenosis Research Articles

S2195 A Masquerade Ball at the Descending Colon

Introduction: Abdominal tuberculosis (TB) accounts for up to 5% of TB cases worldwide and the proximal colon is the most affected site. It can involve any part of the GI tract, however, TB in the descending colon is rarely reported. Most cases present with non-specific symptoms and without concomitant pulmonary TB making the diagnosis challenging and delayed. Case Description/Methods: An 80-year-old man was found with new-onset microcytic anemia on routine labs. His PCP ordered a FIT test which came back positive. He reported being asymptomatic and denied GI bleeding. Diagnostic colonoscopy was performed which revealed a tumorous lesion in the descending colon occupying over 50% of the lumen. Preliminary endoscopic impression was concerning for malignancy and multiple biopsies were obtained. Pathology report revealed an acute focal colitis with an aphthous ulcer and few non-necrotizing granulomas. Given incongruity in pathology findings, a sigmoidoscopy was performed, and biopsy findings again revealed granulomatous inflammation as well as 2 small acid-fast positive structures. The patient underwent QuantiFERON testing which was positive. He reported a childhood exposure to mycobacterium tuberculosis but did not recall receiving treatment. Chest CT scan did not reveal any significant pulmonary findings and Abdominal CT scan did not show additional organ involvement. A definite diagnosis of M. tuberculosis could not be ascertained as biopsied samples were not cultured. Thus, another colonoscopy was performed with emphasis on tuberculosis microscopy and culture. Empiric treatment with RIPE and Azithromycin was started to cover tuberculosis and non-tuberculosis mycobacterium. M. tuberculosis was diagnosed by DNA probe and azithromycin was discontinued. Discussion: Abdominal TB possesses a diagnostic challenge due to its non-specific clinical presentation. When intestinal involvement is present, abdominal pain, weight loss, and changes in bowel habits are the most common manifestations. Endoscopically, it can mimic Crohn’s Disease given its ulcerative nature as well as malignancy due to a hyperplastic reaction occasioning an inflammatory mass in the lumen. In the intestines it frequently leads to stricture formation resulting in bowel obstruction. Abdominal TB is generally responsive to standard anti-tuberculous drugs and has shown significant resolution of symptoms in cases of tuberculous strictures. High clinical suspicion is necessary to ensure early diagnosis and treatment leading to favorable outcomes.

Endotracheal Tuberculous Stenosis: Ventilation Rescue and Bronchography Guided Stenting

We present the case of a 16-year-old female patient who presented with dyspnoea, cough and noisy breathing that progressed further in hospital with the development of stridor and severe respiratory compromise requiring mechanical ventilatory support. Investigations were consistent with a diagnosis of endotracheal tuberculosis with tracheal and bronchial stenosis. Despite adequate anti-tuberculous therapy and ventilation the patient had high airway pressures, low tidal volumes and hypercapnia, which prevented weaning from mechanical ventilation. Balloon dilatation and stenting of the 4.5cm long, 2.3mm diameter stenotic tracheal segment was performed under radiological guidance. The patient was weaned successfully from the ventilator post-procedure. This report illustrates the successful management of an uncommon presentation of a common disease with modern endoscopic therapy.

Safety and efficacy of non-fluoroscopic endoscopic dilatation of gastrointestinal tuberculosis related strictures

IntroductionStricturing gastrointestinal tuberculosis (GITB) may result in persistent symptoms even after antitubercular therapy (ATT) and may require surgical intervention. Data on efficacy and safety of endoscopic dilatation for management GITB related strictures is scarce.MethodsA retrospective analysis of database of patients who underwent endoscopic balloon dilatation for suspected or proven gastrointestinal tuberculosis was performed. The analysis included the site of involvement, technical success, clinical success (response), relapse and requirement of surgery in these patients.ResultsOut of 34 patients (47.1% males, mean age 31.9 ± 12.9 years), eventually four patients were diagnosed to have Crohn’s disease while the rest had GITB. Initial technical success was achieved in 30 (88.2%) patients. Initial clinical success was achieved in 28 (82.3%) patients. Median number of dilatation sessions required to obtain symptomatic relief were 2.5 (1–5) per patient. Two patients with initial clinical success had recurrence of symptoms over follow up of 1 year, out of which one patient was managed with repeat endoscopic balloon dilatation successfully. Of 30 patients with technical success, 16 (53.4%) were on ATT when they underwent dilatation while two were in intestinal obstruction. Eventually 7 patients required surgical intervention for various reasons.ConclusionNon-fluoroscopic endoscopic balloon dilatation is an acceptable and fairly safe modality for symptomatic tuberculous strictures of gastrointestinal tract.

P12‐22: Three‐dimensional printing of reconstructed airway model for complex post tuberculous tracheobronchial stenosis

P12‐22: Three‐dimensional printing of reconstructed airway model for complex post tuberculous tracheobronchial stenosis

Nonsurgical management of gastroduodenal tuberculosis: Nine-year experience from a tertiary referral center.

Background and study aims Gastroduodenal tuberculosis (GDTB) is an uncommon disease. Surgery has been standard of care both for diagnosis and management of GDTB. The aim of this study was to evaluate the efficacy of non-surgical management of GDTB using a combination of anti-tuberculous therapy (ATT) along with endoscopic dilatation of the tuberculous stricture. Patients and methods Patients suspected to have gastroduodenal TB were evaluated: clinical, endoscopic, radiological, and histopathological data were recorded. Patients in whom a definite diagnosis of tuberculosis could not be confirmed on mucosal biopsies underwent endoscopic mucosal resection (EMR). Patients were treated with ATT and endoscopic dilatation was done if indicated. Patients were followed up to evaluate clinical, radiological and endoscopic response. Results Over a 9-year period from 2009 to 2017, 52 patients (mean age 28.5yrs) were diagnosed with GDTB. The most common presenting symptoms were vomiting (n = 51, 98 %) and weight loss (n = 52,100 %). The most common anatomical site of involvement was D1–D2 junction (n = 22, 42 %). Histopathological diagnosis could be made in 43 patients (82.6 %); 36 (69 %) on mucosal biopsies and in 7 of 10 patients (70 %) who underwent snare biopsy/EMR. Endoscopic dilatation was done in 37 patients (71 %) and median dilatation sessions were two. Failure of endotherapy occurred in four patients (7.6 %). All responders had complete amelioration of symptoms after 4 to 6 weeks of combination therapy. Median period of follow-up was 23.5 months and none of the patients reported any recurrence of symptoms. Conclusion ATT and endoscopic dilatation combined has a high success rate in management of GDTB and should be considered the standard of care.

Primary Tuberculous Stricture of Splenic Flexure of Colon

Abdominal tuberculosis is an increasingly common disease that poses diagnostic challenge as the nonspecific features of the disease may lead to diagnostic delays and the development of complications. Tuberculosis of gastrointestinal tract commonly affects distal ileum and ileocaecal junction. Segmental colonic tuberculosis is uncommon and constitute 9.2 % of all abdominal tuberculosis. We are presenting a case of primary tuberculous stricture of splenic flexure which posed a diagnostic dilemma.

Efficacy of Surgical Airway Plasty for Benign Airway Stenosis.

Long-term patency is required during treatment for benign airway stenosis. This study investigated the effectiveness of surgical airway plasty for benign airway stenosis. Clinical courses of 20 patients, who were treated with surgical plasty for their benign airway stenosis, were retrospectively investigated. Causes of stenosis were tracheobronchial tuberculosis in 12 patients, post-intubation stenosis in five patients, malacia in two patients, and others in one patient. 28 interventional pulmonology procedures and 20 surgical plasty were performed. Five patients with post-intubation stenosis and four patients with tuberculous stenosis were treated with tracheoplasty. Eight patients with tuberculous stenosis were treated with bronchoplasty, and two patients with malacia were treated with stabilization of the membranous portion. Anastomotic stenosis was observed in four patients, and one to four additional treatments were required. Performance status, Hugh-Jones classification, and ventilatory functions were improved after surgical plasty. Outcomes were fair in patients with tuberculous stenosis and malacia. However, efficacy of surgical plasty for post-intubation stenosis was not observed. Surgical airway plasty may be an acceptable treatment for tuberculous stenosis. Patients with malacia recover well after surgical plasty. There may be untreated patients with malacia who have the potential to benefit from surgical plasty.

Surgical reconstruction for tuberculous airway stenosis: management for patients with concomitant tracheal malacia.

Surgical reconstruction is commonly recommended for the treatment of tuberculous airway stenosis. The clinical conditions underlying tuberculous airway stenosis often involve both cicatricial stenosis and malacia. Surgical reconstruction alone may not improve the respiratory symptoms of patients with both types of airway stenosis. This study retrospectively reviewed patients who underwent surgical reconstruction for tuberculous airway stenosis to investigate the most appropriate treatment for this complicated condition. Twelve patients with tuberculous airway stenosis underwent surgical reconstruction at our institute from January 2003 to December 2013. The clinical courses of these patients were retrospectively reviewed. The 12 patients were 2 men and 10 women with a mean age of 36years (range 17-61years). The site of stenosis was the left main bronchus in six patients, trachea in four patients, and right main bronchus in two patients. The procedure performed was sleeve lobectomy in five patients, bronchial resection in four patients, and tracheal resection in three patients. Additional airway stenting was performed in two patients with concomitant malacia of the lower trachea. The performance status and Hugh-Jones classification improved postoperatively in all patients. The forced expiratory volume in 1s as a percent of forced vital capacity and percent of forced expiratory volume in 1s improved significantly. Surgical reconstruction is an acceptable treatment for tuberculous airway stenosis. Additional airway stenting may be needed in patients with symptomatic malacia.

Tuberculous pyloric stenosis; successful medical therapy may obviate surgery

Gastroduodenal involvement occurs in only 0.3 to 2.3% of patients with tuberculosis (TB). Clinically, it may resemble peptic ulcer disease or malignancy. We present a 36 year old man with gastric outlet obstruction proven to be pyloric stricture due to primary pyloric tuberculosis. Diagnosis was established endoscopically and patient was successfully managed by standard anti-tuberculous therapy. Although rare, tuberculous involvement of the stomach should be considered in the differential diagnosis of gastric outlet obstruction especially in regions where tuberculosis is endemic. This case also emphasizes that medical management with anti-TB medications can be tried solely as the first line therapy for strictured pyloric stenosis. However, surgical intervention is required more often than none in cases where gastrointestinal obstruction is the main clinical problem.

Successful repair of tubercular tracheal stenosis: a rare case report

We report a rare case of successful surgical management of tubercular tracheal stenosis. There was no history of tracheostomy except for trauma management. A 24-year-old man presented with breathing difficulty. He had previously sustained blunt chest injury, a fractured mandible and minor head injury in a traffic accident. Despite successful mandibular fracture fixation, he subsequently developed progressive breathing difficulty with stridor. The patient was treated successfully with surgical resection and bronchoplastic reconstruction. Post-operatively, endotracheal tuberculosis was diagnosed. Endotracheal tuberculosis is rare despite the high incidence of pulmonary tuberculosis in India. Early diagnosis and prompt treatment are necessary to prevent tuberculous tracheobronchial stenosis, an extremely rare but serious clinical problem which can cause obstructive pneumonia and exertional dyspnoea. Surgical resection and bronchoplastic reconstruction is the established treatment for such stenosis. Patients with active tuberculosis usually respond to conventional antitubercular treatment.

A Case of Obstructive Jaundice Caused by Paradoxical Reaction during Antituberculous Chemotherapy for Abdominal Tuberculosis

Abdominal tuberculosis is not a rare disease, but obstructive jaundice caused by tuberculosis (tuberculous lymphadenitis, tuberculous enlargement of the head of pancreas, and/or tuberculous stricture of the biliary tree) is rare. We recently experienced a case of obstructive jaundice as a result of paradoxical reaction of periportal tuberculous lymphadenopathy that was treated successfully with corticosteroid and biliary drainage. No similar cases have been reported previously.

Inhalation of TGF-β1 antibody: A new method to inhibit the airway stenosis induced by the endobronchial tuberculosis

Tuberculous tracheobronchial stenosis is a serious clinical problem because it can cause obstructive pneumonia, dyspnea on exertion even pulmonary atelectasis of the whole lung. More than 90% of the patients with EBTB have some degree of bronchial stenosis. The interventional therapy through bronchoscopy has been used as standard treatment to deal with the scar stenosis of EBTB routinely, which have showed significant effects to keep airway open. However the scar rapid growing and restenosis can often be seen in many patients. TGF-beta1 has been demonstrated to play a very important role in scar formation. Some agents against TGF-beta1 have been proved to inhibit the scar growing effectively. The level of TGF-beta elevated in the BALF of EBTB patients suggests TGF-beta be related to the pathogenesis of stenosis induced by EBTB. We hypothesize that inhalation of TGF-beta1 antibody can neutralize the local TGF-beta and reduce the level of this kind of cytokine so as to prevent the scar formation partially, and find a new pathway to deal with this tough clinical problem.

Laparoscopic Assisted Ileal Ureter: Technique, Outcomes and Comparison to the Open Procedure

Ureteral replacement with interposition of a bowel segment has traditionally required a large incision with substantial associated morbidity and prolonged time to convalescence. During the last 7 years a technique for laparoscopic assisted ileal interposition has evolved that mimics our open approach. We present a comparative analysis of functional and perioperative outcomes between patients undergoing laparoscopic or open ileal ureter replacement at our institution. A search of all procedures from 1980 to the present revealed 7 patients undergoing laparoscopic and 7 undergoing open ileal interposition. Functional and perioperative data from these patients are compared, and a detailed description of technique for the laparoscopic procedure is presented. Narcotic analgesic use in morphine equivalents (median 38.9 vs 322.2 mg, p = 0.035) and time to convalescence (median 4 vs 5.5 weeks, p = 0.03) were significantly less in the laparoscopic group. A trend toward shorter hospital stay (median 5 vs 8 days, p = 0.101) was also noted in patients in the laparoscopic group. There was no evidence of anastomotic stricture for patients in either group at last followup. Despite the small number of subjects involved a significant advantage was noted for postoperative recovery after laparoscopic compared to open ileal interposition. A detailed understanding of this complicated procedure can help prevent inherent pitfalls.

Tuberculous tracheobronchial stricture causing post-pneumonectomy-like syndrome corrected by insertion of a bespoke Dumon stent

Post-pneumonectomy syndrome is a well-recognised but uncommon late complication of pneumonectomy. Usually occurring after right-sided surgery, the mediastinal contents are rotated and displaced into the right hemithorax, producing airways or oesophageal compression. We report a case in which the radiological features and symptoms of post-pneumonectomy syndrome appeared to be precipitated by the development of a complex tuberculous tracheobronchial stenosis that resolved after the insertion of a bespoke Dumon stent.

UP-01.02: Management of tuberculous strictures of ureter by endourology

To assess the initial outcome on 33 patients with tuberculous ureteric strictures treated by endourology from January 1998 to January 2005.

ENDOSCOPIC MANAGEMENT OF PANCREATICO‐BILIARY STRICTURES: A MALAYSIAN EXPERIENCE

Three thousand one hundred and thirty‐seven endoscopic retrograde cholangiopancreatography procedures were carried out over a 10‐year period from 1993 to 2003. Two thousand three hundred and seventeen (73.9%) procedures were first attempt procedures, and 516 (22.2%) cases were performed for malignant biliary strictures. The majority of tumors were distally located (43.4%) followed by hilar or subhilar strictures (34.5%). Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 35 patients with non‐malignant biliary strictures: 12 were due to chronic pancreatitis and 13 due to postoperative damage one, tuberculous stricture four were benign strictures with no obvious cause, four cases of primary sclerosing cholangitis, and one case of Caroli's disease. Of 936 patients with biliary stone disease, 63 (6.7%) patients had strictures of varying degree and extent. ERCP was performed in only 12 cases of benign pancreatic strictures. Biliary stricture due to tuberculosis was distinctly uncommon and only one case was reported. Pre‐cutting with needle‐knife was used successfully in 27.0% of first attempts at common bile duct (CBD) cannulation. Overall, the use of needle knife precutting facilitated cannulation of the CBD in 159/435 (36.6%) (first and second attempts combined). The overwhelming majority of stents placed were polyethylene stents. Metallic self‐expandable stents were used only in a limited number of patients. Cytology brushings of biliary strictures were infrequently carried out. Multiple polyethylene stents were placed across benign strictures as a dilatation device for up to 12 months. Our experience with long‐term follow‐up (mean 7.7 years) of nine patients following for postoperative benign strictures has demonstrated excellent results with this management approach.

Results of Temporary Placement of Covered Retrievable Expandable Nitinol Stents for Tuberculous Bronchial Strictures

Covered retrievable expandable nitinol stents were successfully placed in nine patients with tuberculous bronchial strictures refractory to balloon dilation. Complications included stent migration (n = 1) and tissue hyperplasia at the proximal portion of the stent (n = 2). During the follow-up period (5-52 months), stricture recurred in three of five patients (60%) after temporary stent placement for 2 months, whereas stricture did not recur in the other four patients after temporary stent placement for 6 months. Temporary placement of covered retrievable stents appears to be an effective method for the treatment of patients with tuberculous bronchial strictures refractory to balloon dilation.

Successful treatment of long-segmental tuberculous tracheal stenosis with combined Mongomery T-stent and Hood stent

We used combined Mongomery T-stent and Hood stent in a long segment (11 cm), benign tracheal stenosis after treatment with a standard Mongomery T-stent failed. Respiratory and phonation function was restored immediately after the procedure. The patient became pregnant 2 months later. Her baby was born at full-term with a smooth vaginal delivery. She was in good health 18 months after the operation.

INFUNDIBULAR STENOSIS AFTER PERCUTANEOUS NEPHROLITHOTOMY

Acquired infundibular stenosis can develop after percutaneous nephrolithotomy. We review our experience with infundibular stenosis after this procedure. We evaluated the records of patients diagnosed with infundibular stenosis after percutaneous nephrolithotomy was performed at our institution between 1995 and 2000. Analysis included medical history, urinary stone type, stone removal procedure technique, length and number, postoperative course, stenosis time to development location, severity and treatment, and treatment outcome. Infundibular stenosis developed in 5 of 223 percutaneous nephrolithotomy cases (2%) performed during this period. Medical history in affected patients included previous ipsilateral open pyelolithotomy, diabetes and morbid obesity in 2 each. Percutaneous nephrolithotomy were done through a standard 30Fr nephrostomy tract and all cases were terminated before complete stone removal. Mean operative time was 258 minutes, which was significantly greater than the mean operative time of 207 minutes in all cases of unilateral percutaneous nephrolithotomy (p = 0.03). Postoperatively nephrostomy tube drainage was done for a mean of 33 days (range 16 to 51). All patients underwent at least 1 additional percutaneous stone removal procedure after primary percutaneous nephrolithotomy and before stenosis was detected. The mean time to stenosis detection was 9 months (range 2 to 24). Stenosis generally developed in areas corresponding to previous sites of percutaneous access and the degree of narrowing ranged from mild to severe. Mild and moderate stenosis was managed by observation and endoscopic dilation in 2 each. Severe stenosis in 1 patient was associated with significantly impaired ipsilateral renal function. Infundibular stenosis is a rare complication of percutaneous nephrolithotomy. In this series it was associated with prolonged operative time, a large stone burden requiring multiple removal procedures and extended postoperative nephrostomy tube drainage. In most cases stenosis developed at previous access sites within 1 year of initial percutaneous nephrolithotomy. Mild and moderate cases may be treated with observation and endoscopic dilation, respectively, while severe cases may result in renal impairment.

Granulation Stenosis Caused by a Dumon Stent Placed for Endobronchial Tuberculous Stenosis

Two patients with cicatric tracheobronchial stenosis caused by tuberculosis who suffered granulation stenosis after placement of a Dumon stent are reported. Dumon stents, which were long enough to cover the stenotic sites, were placed in the trachea and left main bronchus of each patient. Granulation tissue grew at both edges of the stent 3 or 4 months after stent placement, which caused restenosis and necessitated removal of the stents. The authors conclude that a Dumon stent for treatment of tracheobronchial stenosis caused by tuberculosis can cause granulation stenosis at the edges of the stent.