10.7 Surgery as an adjunctive treatment measure

Surgery can be considered only in optimal surgical facilities with trained thoracic surgeons.
Specialized surgical facilities should include stringent infection control measures since infectious substances and aerosols are generated in large quantities during surgery, during mechanical ventilation and post-operative pulmonary hygiene manoeuvres.

General indications for surgery for programmes with limited access to surgery include patients with resistance to a large number of drugs and localized pulmonary disease. Computerized tomography, pulmonary function testing, and quantitative lung perfusion/ventilation are recommended as part of the preoperative work-up.

The most common operative procedure in patients with MDR-TB is resection of part or all of a lung. Large case series analysis suggest surgical resection can be effective and safe under appropriate surgical conditions26,27. It is considered an adjunct to chemotherapy and appears to be beneficial for patients when skilled thoracic surgeons and excellent postoperative care are available28. It is not indicated in patients with extensive bilateral disease.

Resection surgery should be timed so as to offer the patient the best possible chances of cure with the least morbidity. Thus, the timing of surgery may be earlier in the course of the disease when the patient’s risk of morbidity and mortality are lower, for example, when the disease is still localized to one lung or one lobe. Furthermore, bacilli excretion during treatment has a “window” when the bacilli load decreases under pressure of anti-TB drugs and it can be registered by decreasing or even disappearing of mycobacteria in smear and/or culture. This “window” is the best time for surgery. It is critical to operate before the mycobacterial count begins to rise. The best time for surgery is usually considered to be between two and six months after initiation of treatment28,29,30. Surgery should not be considered a last resort.

Even with successful resection, an additional 12 to 24 months of chemotherapy should be given.