Pulmonary resection in the treatment of multidrug-resistant tuberculosis: A case series

Multidrug-resistant (MDR) and extensive drug-resistant (XDR) tuberculosis (TB) are significant health problems throughout the world. Although the main treatment is medical, adjunctive surgical resection may increase the chance of cure in selected patients with MDR-TB or XDR-TB. This study aimed to present a case series of patients who underwent surgical resection for MDR-TB.Between March 2008 and November 2011, surgical resection was performed on 54 patients including 34 with MDR-TB and 20 with XDR-TB at the Departments of Surgery of Shanghai Public Health Clinical Center (Shanghai), Henan Chest Hospital (Henan), and Anhui Chest Hospital (Henan). Preoperative sputum smear samples were positive for 28 patients and sputum quantitative polymerase chain reaction was positive for 32. Patients were treated according to a standard therapy protocol for a mean of 4.2 months before the operation. The variables that affected treatment outcomes were identified through multivariate regression analysis.Fifty-four patients were operated for MDR-TB with localized disease usually complicated by cavity formation or destroyed lung. Thirty-seven were males and 17 were females. Median age was 37.8 (range, 20-75) years. Lobectomy was performed in 46 patients and pneumonectomy in 8. Muscle flaps were used in 36 of the patients with lobectomy and 8 with pneumonectomy. Various complications occurred in 6 (11.1%) patients, including bronchopleural fistula in 1 patient, bleeding in 2 patients, and prolonged air leak in 2 patients. A favorable outcome was achieved in 47 patients (87%) who underwent surgical resection. Higher body mass index (BMI) was associated with better outcome (odds ratio = 0.537, 95% confidence interval: 0.310-0.928, P = .026).Patients with MDR-TB had good treatment outcomes after adjunctive pulmonary resection, and with few complications. Higher BMI was related to a favorable outcome.

[Interest of collapse therapy in pulmonary extensively drug-resistant tuberculosis]

Extensively drug-resistant (XDR) tuberculosis is rare in France. Treatment of XDR tuberculosis is difficult and therapeutic failures are frequent. Surgery is considered as one of the therapeutic options, but is of little use regarding its high morbi-mortality. We report successful treatment of a XDR tuberculosis case with a 21-month antibiotic regimen followed by a surgical collapse therapy because of persistence of a large cavity. No relapse was observed after five years. Surgery in the XDR tuberculosis treatment is discussed.

Favorable outcomes for multidrug and extensively drug resistant tuberculosis patients undergoing surgery

BACKGROUND

New approaches are needed in the treatment of multidrug-resistant and extensively drug-resistant pulmonary tuberculosis (M/XDR-PTB). We evaluated the role of adjunctive surgical therapy in the treatment of M/XDR-PTB in the setting of directly observed treatment strategy (DOTS)-Plus implementation.

METHODS

We conducted an observational cohort study consisting of M/XDR-PTB patients who underwent thoracic surgery at the National Tuberculosis Center in Tbilisi, Georgia between October 2008 and February 2011. Indications for surgery included presence of M/XDR-PTB, localized pulmonary disease, fit to undergo surgery, and either medical treatment failure or such extensive drug resistance that failure was likely. Second-line anti-tuberculosis medical therapy was administered per World Health Organization (WHO) recommendations.

RESULTS

Seventy-five patients (51 MDR, 24 XDR) with PTB underwent adjunctive thoracic surgery. Median age was 30 years and average duration of preoperative M/XDR-PTB medical therapy was 342 days. The following surgical procedures were performed: pneumonectomy (11%), lobectomy (54%), and segmentectomy (35%). Mean postoperative follow-up time was 372 days. Of 72 patients with evaluable outcomes, 59 (82%) had favorable outcomes including 90% of MDR and 67% of XDR-TB patients. There was no postoperative mortality; postoperative complications occurred in 7 patients (9%). Risk factors for poor treatment outcomes in univariate analysis included bilateral disease, XDR, increasing effective drugs received, positive preoperative sputum culture, and major postoperative surgical complication.

CONCLUSIONS

Patients with M/XDR-PTB undergoing adjunctive thoracic surgery had high rates of favorable outcomes, no surgical-related mortality, and low rates of complications. Adjunctive surgery appears to play an important role in the treatment of select patients with M/XDR-PTB.

Pulmonary resection for extensively drug resistant tuberculosis in Kwazulu-Natal, South Africa

BACKGROUND

Extensively drug resistant tuberculosis (XDR-TB) has been reported in 58 countries around the world and has emerged as a major public health challenge. Our objective was to determine the impact of pulmonary resection on XDR-TB treatment outcomes in a resource-constrained setting.

METHODS

We conducted a retrospective case review of 11 patients with XDR-TB who were referred for pulmonary resection between January 2007 and June 2010 at a tertiary care referral hospital in South Africa. Two pneumonectomies and three upper lobectomies were performed. Occurrence of surgical complications and TB treatment outcome were assessed.

RESULTS

No perioperative mortality or major morbidity was noted. All patients achieved sputum conversion, with 4 regarded as "cured." One patient defaulted on treatment, but subsequently returned and is regarded as a probable cure.

CONCLUSIONS

We describe pulmonary resection for XDR-TB management in Africa. Although the initial cohort of XDR-TB patients from Tugela Ferry demonstrated nearly complete mortality, our results demonstrate the potential of adjuvant surgical methods in XDR-TB treatment. With appropriate chemotherapy and timely adjuvant surgery, patients with XDR-TB localized to lobe or lung may achieve a "cure" with low morbidity and mortality. Consequently, this approach may be the most cost effective treatment for patients suitable for lung resection.

[IMMEDIATE RESULTS OF SURGICAL TREATMENT IN DESTRUCTIVE PULMONARY TUBERCULOSIS PATIENTS EXCRETING EXTREME DRUG-RESISTANT MBT]

The authors analyzed the immediate results of surgical treatment in 110 patients with destructive pulmonary tuberculosis with extreme drug resistance in Mycobacterium tuberculosis. Out of the 110 patients, 118 were discharged from hospital and 2 continued treatment at the study. A complete clinical effect (abacillation and no decay cavities) was achieved in 96 (88.9%) patients; improvement (abacillation with the decay cavity being preserved in the contralateral lung) was seen in 5 (4.6%) patients. In the discharged patients, decay cavities and bacterial excretion were preserved in 7 (6.5%) cases after palliative unilateral surgery for bilateral destructive pulmonaty tuberculosis. However, they showed a certain resolution as bleeding arrest or reduced intoxication. All postoperative complications developing in 18 (16.4%) patients were eliminated. There were no fatal outcomes. The paper discusses surgical techniques used in drug-resistant tuberculosis. Key words: surgical treatment, destructive pulmonary tuberculosis.

Comprehensive treatment of extensively drug-resistant tuberculosis

BACKGROUND

Extensively drug-resistant tuberculosis has been reported in 45 countries, including countries with limited resources and a high burden of tuberculosis. We describe the management of extensively drug-resistant tuberculosis and treatment outcomes among patients who were referred for individualized outpatient therapy in Peru.

METHODS

A total of 810 patients were referred for free individualized therapy, including drug treatment, resective surgery, adverse-event management, and nutritional and psychosocial support. We tested isolates from 651 patients for extensively drug-resistant tuberculosis and developed regimens that included five or more drugs to which the infecting isolate was not resistant.

RESULTS

Of the 651 patients tested, 48 (7.4%) had extensively drug-resistant tuberculosis; the remaining 603 patients had multidrug-resistant tuberculosis. The patients with extensively drug-resistant tuberculosis had undergone more treatment than the other patients (mean [+/-SD] number of regimens, 4.2+/-1.9 vs. 3.2+/-1.6; P<0.001) and had isolates that were resistant to more drugs (number of drugs, 8.4+/-1.1 vs. 5.3+/-1.5; P<0.001). None of the patients with extensively drug-resistant tuberculosis were coinfected with the human immunodeficiency virus (HIV). Patients with extensively drug-resistant tuberculosis received daily, supervised therapy with an average of 5.3+/-1.3 drugs, including cycloserine, an injectable drug, and a fluoroquinolone. Twenty-nine of these patients (60.4%) completed treatment or were cured, as compared with 400 patients (66.3%) with multidrug-resistant tuberculosis (P=0.36).

CONCLUSIONS

Extensively drug-resistant tuberculosis can be cured in HIV-negative patients through outpatient treatment, even in those who have received multiple prior courses of therapy for tuberculosis.