10.10 Surgery

Surgery is an adjunct to the pharmacological treatment of MDR/RR-TB patients.

It can be performed only by trained thoracic surgeons, in specialized surgical units with excellent postoperative care. These units must implement strict infection prevention and control measures because thoracic surgery, mechanical ventilation and post-operative physiotherapy generate large quantities of aerosols.

When access to surgery is limited, it should be considered in priority for patients with resistance to a large number of drugs and localized lung damage.

Surgery can be performed early, when the disease is still localized (e.g. to a lobe). Partial lung resection (lobectomy or wedge resection) can be effective and safe if performed under appropriate conditions [1] Citation 1. Fox GJ, Mitnick CD, Benedetti A, Chan ED, Becerra M, Chiang C-Y, et al. Surgery as an adjunctive treatment for multidrug-resistant tuberculosis: An individual patient data meta-analysis. Clin Infect Dis. 2016; 62(7):887–95.
https://doi.org/10.1093/cid/ciw002 [2] Citation 2. Harris RC, Khan MS, Martin LJ, Allen V, Moore DAJ, Fielding K, et al. The effect of surgery on the outcome of treatment for multidrug-resistant tuberculosis: a systematic review and meta-analysis. BMC Infect Dis. 2016; 16(1).
https://doi.org/10.1186/s12879-016-1585-0 [3] Citation 3. World Health Organization. WHO treatment guidelines for drug-resistant tuberculosis, 2016 update. October 2016 revision. Geneva. 2016.
https://apps.who.int/iris/bitstream/handle/10665/250125/9789241549639-eng.pdf .

At the beginning of treatment, there is a window of opportunity during which the bacillary load decreases transiently under the pressure of TB drugs (decrease in mycobacteria in smears and/or culture). This window is the optimal time for surgery. The prognosis is better when resection is performed after culture conversion [1] Citation 1. Fox GJ, Mitnick CD, Benedetti A, Chan ED, Becerra M, Chiang C-Y, et al. Surgery as an adjunctive treatment for multidrug-resistant tuberculosis: An individual patient data meta-analysis. Clin Infect Dis. 2016; 62(7):887–95.
https://doi.org/10.1093/cid/ciw002 [2] Citation 2. Harris RC, Khan MS, Martin LJ, Allen V, Moore DAJ, Fielding K, et al. The effect of surgery on the outcome of treatment for multidrug-resistant tuberculosis: a systematic review and meta-analysis. BMC Infect Dis. 2016; 16(1).
https://doi.org/10.1186/s12879-016-1585-0 .

It is recommended to perform culture and DST of the resection material. Depending on the results, modification of treatment may be required.