Risk factor analysis of postoperative complications after adjunctive pulmonary resection in patients with multidrug-resistant tuberculosis: A multi-institutional study

BACKGROUND AND OBJECTIVE

Multidrug-resistant tuberculosis (MDR-TB) requires extended treatment with regimens with multiple side effects, resulting in high treatment failure rates. Adjunctive lung resection combined with anti-tubercular agents improves outcomes. However, few studies have evaluated the potential harm from surgery and determined the optimal conditions for surgery. We aimed to analyze perioperative conditions to assess risk factors for postoperative complications in a multi-institutional setting.

METHODS

This retrospective study included 44 patients with MDR-TB who underwent adjunctive lung resection at three management groups of the Taiwan MDR-TB consortium between January 2007 and December 2020. Demographic data, clinical characteristics, radiological findings, sputum culture status before surgery, primary or acquired drug resistance, surgical procedure, complications, and treatment outcomes were collected and analyzed. Multivariate logistic regression was used to identify risk factors for postoperative complications.

RESULTS

Twenty-seven patients (61.4%) underwent lung resection using video-assisted thoracic surgery (VATS). The overall surgical complication rate was 20.5%, and the surgical mortality rate was 9.1%. Postsurgical hemothorax was the most common complication (11.4%). According to the univariate analysis, hilum involvement in images, positive preoperative sputum culture, and thoracotomy approach were unfavorable factors. VATS approach [adjusted OR, 0.088 (95% CI, 0.008-0.999)] was the only favorable factor identified by multivariate analysis.

CONCLUSION

The minimally invasive approach is a growing trend, and lobectomies and sublobar resections were the main procedures for MDR-TB. The VATS approach significantly reduced the surgical complication rate. Postsurgical hemothorax was noteworthy, and meticulous hemostasis of the chest wall and residual lung surface is critical for successful resections.

Genomic analyses of Mycobacterium tuberculosis from human lung resections reveal a high frequency of polyclonal infections

Polyclonal infections occur when at least two unrelated strains of the same pathogen are detected in an individual. This has been linked to worse clinical outcomes in tuberculosis, as undetected strains with different antibiotic resistance profiles can lead to treatment failure. Here, we examine the amount of polyclonal infections in sputum and surgical resections from patients with tuberculosis in the country of Georgia. For this purpose, we sequence and analyse the genomes of Mycobacterium tuberculosis isolated from the samples, acquired through an observational clinical study (NCT02715271). Access to the lung enhanced the detection of multiple strains (40% of surgery cases) as opposed to just using a sputum sample (0-5% in the general population). We show that polyclonal infections often involve genetically distant strains and can be associated with reversion of the patient's drug susceptibility profile over time. In addition, we find different patterns of genetic diversity within lesions and across patients, including mutational signatures known to be associated with oxidative damage; this suggests that reactive oxygen species may be acting as a selective pressure in the granuloma environment. Our results support the idea that the magnitude of polyclonal infections in high-burden tuberculosis settings is underestimated when only testing sputum samples.

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.

Endobronchial valve treatment of destructive multidrug-resistant tuberculosis

BACKGROUND

In accordance with the existing hypothesis, the application of an endobronchial valve (EbV) leads to selective curative atelectasis of the affected part of the lung, contributing to early closure of cavities.

OBJECTIVE

To assess the effect of EbV treatment on the course of tuberculosis (TB).

METHODS

We compared the efficacy of EbV treatment and complex second-line treatment in treating patients with destructive pulmonary multidrug-resistant TB (MDR-TB). Bacteriological conversion and closure of cavities were selected as criteria to assess the effectiveness of EbV application. A total of 102 patients with destructive MDR-TB were enrolled into the study and randomly divided into two groups: 49 patients had an EbV installed (intervention group) and 53 patients received complex second-line treatment (control group). Complex chemotherapy was administered to both groups throughout the study period.

RESULTS

The cure rate in the short- and long-term follow-up periods in the intervention group was shown to be much higher, 95.9% by bacteriological conversion and 67.3% by cavity closure. On comparison with the control group, this was respectively 37.7% and 20.7% (P < 0.0001).

CONCLUSIONS

The application of EbV treatment can significantly improve the effectiveness of second-line chemotherapy regimens in MDR-TB patients.

Lung Resection for Multidrug-Resistant Tuberculosis

The emergence of multidrug-resistant tuberculosis poses a serious challenge to traditional drug therapy. In view of the relapse rate of up to 50% following medical management, there has been renewed interest in the role of surgery for this problem. We report our experience with lung resection for this condition. Over a 5-year period, resection was performed in 23 patients who were diagnosed with multidrug resistance after completing a course of standard chemotherapy and at least 3 months of second-line therapy. Pneumonectomy was performed in 17 patients and lobectomy in 6. There was no operative or postoperative mortality. Major complications developed in 4 patients (17.4%): 2 had post-pneumonectomy empyema and 2 underwent rethoracotomy for bleeding. Ten patients were sputum positive preoperatively, and only 1 remained positive after surgery. The patients were put on appropriate chemotherapy and followed up for 18 months. The cure rate was 95.6%. Pulmonary resection can be considered as an important adjunct to medical therapy in carefully selected patients: those who have localized disease with adequate pulmonary reserve, or who have multiple previous relapses, or whose sputum remains positive after 4 to 6 months of appropriate medical treatment. Surgery offers high cure rates with acceptable morbidity and mortality.

The Role of Video-Assisted Thoracoscopic Therapeutic Resection for Medically Failed Pulmonary Tuberculosis

There are few reports regarding video-assisted thoracoscopic therapeutic resection for medically failed pulmonary tuberculosis (TB). We reviewed our surgical results of video-assisted thoracoscopic surgery (VATS) therapeutic resection for pulmonary TB with medical failure, and its correlation with image characteristics on chest computed tomography (CT) scan.Between January 2007 and December 2012, among the 203 patients who had surgery for TB, the medical records of 89 patients undergoing therapeutic resection for medically failed pulmonary TB were reviewed. Clinical information and the image characteristics of CT scan were investigated and analyzed.Forty-six of the 89 patients undergoing successful VATS therapeutic resection had significantly lower grading in pleural thickening (P < 0.001), peribronchial lymph node calcification (P < 0.001), tuberculoma (P = 0.015), cavity (P = 0.006), and aspergilloma (P = 0.038); they had less operative blood loss (171.0 ± 218.7 vs 542.8 ± 622.8 mL; P < 0.001) and shorter hospital stay (5.2 ± 2.2 vs 15.6 ± 15.6 days; P < 0.001). They also had a lower percentage of anatomic resection (73.9% vs 93.0%; P = 0.016), a higher percentage of sublobar resection (56.5% vs 32.6%; P = 0.023), and a lower disease relapse rate (4.3% vs 23.3%; P = 0.009). Eighteen of the 38 patients with multi-drug resistant pulmonary tuberculosis (MDRTB) who successfully underwent VATS had significantly lower grading in pleural thickening (P = 0.001), peribronchial lymph node calcification (P = 0.019), and cavity (P = 0.017). They were preoperatively medicated for a shorter period of time (221.6 ± 90.8 vs 596.1 ± 432.5 days; P = 0.001), and had more sublobar resection (44.4% vs 10%), less blood loss (165.3 ± 148.3 vs 468.0 ± 439.9 mL; P = 0.009), and shorter hospital stay (5.4 ± 2.6 vs 11.8 ± 6.9 days; P = 0.001).Without multiple cavities, peribronchial lymph node calcification, and extensive pleural thickening, VATS therapeutic resection could be safely performed in selected patients with medically failed pulmonary TB as an effective adjunct with satisfactory results.

[EFFICACY OF ALGORITHM OF SURGICAL HELP PROVISION FOR PATIENTS, SUFFERING MULTIRESISTENT PULMONARY TUBERCULOSIS]

The impact of preoperative patients state in multiresistent pulmonary tuberculosis on results of their surgical treatment was investigated. The actions sequence with determination of optimal kind and volume of surgical intervention, depending on clinico-anatomical peculiarities of pathological process, was regulated. Algorithm of surgical treatment organization in patients, suffering multiresistent pulmonary tuberculosis, was elaborated and introduced, concerning the term and volume of preoperative examination and preparation determination, sequence of actions for determination of kind and technique of the operative intervention performance, as well as postoperative treatment issues. Application of the algorithm elaborated have guaranteed a reconvalescence of 97.6% patients with absent lethality.

[APPLICATION OF LINEAR WELDING SUTURE WHILE PERFORMANCE OF A VIDEO-ASSISTED SEGMENTECTOMY FOR MULTIRESISTANT PULMONARY TUBERCULOSIS]

The results of treatment of 40 patients, suffering multiresistant pulmonary tuberculosis (MRPT), were analyzed. There was proved the efficacy of the tissues biological welding while performing video-assisted segmentectomy. The duration of postoperative treatment for the patients have reduced down to (15.7 ± 3.8) days. Clinical aprobation was conducted, concerning application of a welding complex EK300 M1 in automatic regimen while pulmonary surgery performance. Application of the algorithm elaborated, concerning providing of surgical aid for patients, suffering MRPT, guarantees a curative outcome in 97.6% of them.

A retrospective review comparing treatment outcomes of adjuvant lung resection for drug-resistant tuberculosis in patients with and without human immunodeficiency virus co-infection

OBJECTIVES

This review was undertaken to compare treatment outcomes in human immunodeficiency virus (HIV) negative versus HIV-positive patients following adjuvant lung resection for drug-resistant tuberculosis (DR-TB) in patients deemed feasible for surgery. Despite appropriate medical therapy, mortality remains extremely high and cure rates poor in patients with DR-TB and HIV co-infection. Therefore, adjuvant lung resection may warrant a more prominent role in the treatment of these patients.

METHODS

A retrospective review of all case records from 1 January 2012 to 31 March 2013 of all patients admitted to the Department of Cardiothoracic Surgery King Dinuzulu Hospital with DR-TB and treated with adjuvant lung resection was undertaken. Prior to surgery, all patients were treated for at least 3 months with appropriate drug therapy for DR-TB. This was continued for the recommended period following lung resection.

RESULTS

Fourteen patients with extensively drug-resistant tuberculosis (XDR-TB) were deemed suitable for lung resection. Of these patients, 10 patients were HIV-positive and 4 were HIV-negative. In the XDR-TB/HIV-positive group, 7 patients were cured, 2 converted and 2 patients developed a post-pneumonectomy broncho-pleural fistula. One patient was lost to follow-up. In the XDR-TB/HIV-negative group, 1 patient was cured, 3 converted and 1 patient developed a post-thoracotomy superficial wound infection. There was no in-hospital mortality in both groups. Thirty-six patients with multi-drug-resistant tuberculosis (MDR-TB) were deemed suitable for lung resection. Of these patients, 19 were HIV-positive and 17 HIV-negative. In the MDR-TB/HIV-positive group, 12 patients were cured and 6 converted. One patient developed a post-thoracotomy superficial wound infection and another patient who developed a post-pneumonectomy empyema thoracis was also regarded as a treatment failure. In the MDR-TB/HIV-negative group, 15 patients were cured, 2 converted and 1 patient developed a post-pneumonectomy lower respiratory tract infection which necessitated a short period of mechanical ventilation. There was no in-hospital mortality in both groups.

CONCLUSIONS

Lung resection for DR-TB may be safely undertaken in selected patients who are HIV-positive with cure rates equivalent to that of HIV-negative patients. More importantly, these patients also have significantly higher cure rates than those patients treated with medical therapy alone.

[Surgery for thoracic tuberculosis]

Tuberculosis is mainly a medical disease. Surgery has been the unique therapeutic tool for a long time before the advent of specific antituberculous drugs, and the role of surgery was then confined to the treatment of the sequelae of tuberculosis and their complications. The resurgence of tuberculosis and the emergence of multidrug-resistant TB combined to immunosuppressed patients represent a new challenge for tuberculosis surgery. Surgery may be indicated for a diagnostic purpose in patients with pulmonary, pleural, mediastinal or thoracic wall involvement, or with a therapeutic purpose (drainage, resection, residual cavity obliteration). Modern imaging techniques and the advent of video-assisted thoracic surgery allowed a new approach of this pathology; the majority of diagnostic interventions and selected cases requiring lung resection can be performed through a mini-invasive approach. Patients proposed for aggressive surgery may be treated with the best results thanks to a good evaluation of the thoracic lesions, of the patients' nutritional, infectious and general status combined with a good coordination between the specialized medical team for an optimal preparation to surgery.

[Prophylaxis of thrombohemorrhagic complications in surgical treatment of chemoresistant pulmonary tuberculosis]

Analysis of thrombohemorrhagic complications was conducted in 98 patients, operated on for various forms of chemoresistant pulmonary tuberculosis. To prevent such complications it is necessary to prescribe heparin in minimal doses or fraxiparine preoperatively and intraoperatively. It permits to lower the prethrombotic background significantly, to prevent thrombohemorrhagic complications, and in their incidence--to eliminate thrombotic and hemorrhagic clinical features with minimal losses.

[Possibilities of surgical treatment for advanced multiresistant pulmonary tuberculosis]

The results of surgical treatment of 37 patients, suffering relatively advanced pulmonary tuberculosis (PT), were analyzed. Chemoresistant PT was revealed in 35 (94.6%) observed patients, and multiresistant one--in 30 (81.1%). Preoperative preparation during 2-3 mo was conducted in two main directions: administration of a line II antibacterial preparations and a pneumoperitoneum (PP) establishment. A main operative procedure was resection. Intrapleural thoracoplasty in our own modification have constituted a seconf direction of treatment, it consisted obligatory of the 5 ribs resection. Initially a rib V was partially resected 8-10 cm in length, and a rib I was excised completely. Complications were absent. The patients were discharged from the hospital in 2-3 mo postoperatively. PP in 34 (91.9%) patients was completed in a same terms. In a remote postoperative period (1-4 yrs) a tuberculosis reactivation was absent. All operated patients were bacilli free.

[Conclusive pleuropulmonectomy in patients with pulmonary tuberculosis]

The results of performance of conclusive pleuropulmonectomy (CPPE) in 2004-2012 yrs in 16 patients, suffering multiresistant pulmonary tuberculosis are presented. In 75% patients during the first operation the atypical (using apparatuses) pulmonary resection was performed. CPPE was done for fibrous-cavernous tuberculosis in 11 (68.8%) patients, for cirrhotic tuberculosis - in 4 (25.0%), caseous pneumonia - in 1 (6.3%). Intraoperative complications rate was 12.5%. Early postoperative complications have had occurred in 5 (31.3%) patients, and the late - in 3 (18.8%). Total efficacy of CPPE have had constituted 81.3%.

[Role of pulmonary resections in management of multidrug-resistant tuberculosis. A monocentric series of 29 patients]

INTRODUCTION

Multidrug-resistant tuberculosis (MDR-TB) is a worldwide health problem. Surgery is often used as an adjuvent therapy with anti-tuberculosis agents. The aim of this study is to present our results of pulmonary resections in the treatment of MDR-TB.

MATERIAL AND METHODS

[corrected] This is a retrospective monocentric study of 29 patients operated on between 1995 and 2010 for MDR-TB.

RESULTS

Tuberculosis was evolving from 9 to 108 months with a median of 34.77±19.88 months. The average number of tuberculosis relapses was 2.73 per patient. All patients had a destroyed and/or cavitary parenchyma and 17 had bacilli in sputum at the time of surgery. Lobectomy (51.17%) and pneumonectomy (41.37%) were the main interventions carried out. The operative mortality was 3.44%. Complications such prolonged air leaking and empyema had occurred in 9 patients. The rate of postoperative microbiological conversion was 88.23%. One patient had a relapse 5 months after surgery.

CONCLUSION

Surgery associated with medical treatment provides a high cure rate to the detriment of an acceptable morbidity and mortality.

[Experience of application of pulmonectomy and pleuropulmonectomy for multiresistant destructive pulmonary tuberculosis]

The results of performance of pulmonectomy and pleuropulmonectomy in 89 patients, suffering multiresistant destructive pulmonary tuberculosis, were analyzed. Intraoperational methods of the bronchial stump buttressing using polymeric material and pericardial fat tissue on vascular pedicle, the methods of postoperative complications prophylaxis, the postoperative course peculiarities were elaborated and studied. General efficacy of operation while application of the methods proposed have had constituted 86.5% in the terms of observation up to 6 yrs.

[Reoperation for multidrug-resistant pulmonary tuberculosis]

We have performed pulmonary resection combined with chemotherapy for multidrug-resistant tuberculosis (MDR-TB). Postoperative complications of pulmonary resection for MDR-TB include space problem, prolonged air leak, bronchopleural fistula with or without empyema, chylothorax, and relapse. Indication, surgical technique, postoperative management, and follow-up of reoperation (thoracoplasty and muscle plombage, clousure of bronchopleural fistula, resuture of bronchial stump, open window thoracostomy, and 2nd pulmonary resection) for these complications are described.

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 multidrug-resistant tuberculosis: the Israeli experience (1998-2011)

BACKGROUND

Multidrug-resistant tuberculosis (MDR-1B) presents a difficult therapeutic problem due to the failure of medical treatment. Pulmonary resection is an important adjunctive therapy for selected patients with MDR-TB.

OBJECTIVES

To assess the efficacy of pulmonary resection in the management of MDR-TB patients.

METHODS

We retrospectively reviewed the charts of MDR-TB patients referred for major pulmonary resections as part of a treatment strategy. The operations were performed in the departments of thoracic surgery at Assaf Harofeh and Wolfson Medical Centers. For the period under study, 13 years (1998-2011), we analyzed patients' medical history, bacteriological, medical and surgical data, morbidity, mortality, and short-term and long-term outcome.

RESULTS

We identified 19 pulmonary resections (8 pneumonectomies, 4 lobectomies, 1 segmentectomy, 6 wedge resections) from among 17 patients, mostly men, with a mean age of 32.9 years (range 18-61 years). Postoperative complications developed in six patients (35.3%) (broncho-pleural fistula in one, empyema in two, prolonged air leakin two, and acute renal failure in one). Only one patient (5.84%) died during the early postoperative period, three (17.6%) inthe late postoperative period, and one within 2 years after the resection. Of 12 survivors, 9 were cured, 2 are still under medical treatment, and 1 is lost from follow-up because of poor compliance.

CONCLUSIONS

Pulmonary resection for MDR-TB patients is an effective adjunctive treatment with acceptable morbidity and mortality.

Management of drug-resistant spinal tuberculosis with a combination of surgery and individualised chemotherapy: a retrospective analysis of thirty-five patients

PURPOSE

Drug-resistant tuberculosis is a major public-health concern globally and can be difficult to manage clinically. Spinal tuberculosis is the most common manifestation of extrapulmonary tuberculosis. However, there have been few reports on the topic of drug-resistant spinal tuberculosis. The aim of this study was to investigate the clinical characteristics and drug susceptibility patterns and the outcomes of management with a combination of surgery and individualised chemotherapy, for drug-resistant spinal tuberculosis.

METHODS

We retrospectively analysed 35 patients with drug-resistant tuberculous spondylitis. After surgery, individualised chemotherapy was tailored for each patient according to the drug-resistance profile and previous history of chemotherapy. The patients were followed up clinically and radiologically for an average period of 35.8 months.

RESULTS

Among 35 drug-resistant spinal tuberculosis cases, 13 were retreatment cases. Twelve were multi-drug resistant tuberculosis (MDR-TB), and 23 were non-MDR-TB. The patients with MDR-TB and non-MDR-TB had undergone previous chemotherapy for an average of 14.50 ± 2.00 (0-60) months and 4.56 ± 1.54 (0-74) months, respectively. A total of 32 cases underwent open operations, and the other three had percutaneous drainage and local chemotherapy. Patients received individualised chemotherapy for an average of 23.6 months postoperatively. Local recurrence was observed in six patients. Thirty-three patients had been cured at the final follow-up, and the other two were still receiving chemotherapy.

CONCLUSIONS

Drug-resistant tuberculous spondylitis is mainly acquired through previous irregular chemotherapy and the spreading of drug-resistant strains. Management with a combination of surgery and individualised chemotherapy is feasible in the treatment of severe complications and the prevention of acquired drug resistance.

[The role and landscape of surgical treatment for mycobacteriosis]

[Surgery for pulmonary multi-drug resistant (MDR) tuberculosis] For pulmonary MDR tuberculosis the author (me) had been operating many cases in Fukujuji Hospital JATA in fifteen years. For treatment, the points of operations are as follows: 1) Surgery is one of many treatable events, 2) The strategy is that cavitary foci as major sites of tuberculous expectoration have to be removed and other small foci are treated by not strong chemotherapies, 3) Final goal of surgical treatments is set up preoperatively, and its procedures are stepped up gradually. [Surgery for pulmonary non-tuberculous mycobacteriosis (NTM)] Major sites of pulmonary NTM expectorations are cavitary foci and bronchiectases. Main strategy of surgery for pulmonary NTM is the same as MDR tuberculosis, but multi-resections of cavitary and ectatic foci are more than MDR tuberculosis. Control rate of X-ray images is 80%, negative conversion rate is 88.9% in cases with more than one year postoperatively. But new or residual foci will be gradually growing up for several years postoperatively, so many discussions of surgical strategy for NTM are necessary now. [Surgery for pulmonary aspergillosis] Surgical treatments of pulmonary aspergillosis are difficult. Operations for them are mainly two procedures, resection of foci or no resection. The former is more radical than the later, but mortality rate is higher than usual pulmonary resection. However I think chest surgeons have to challenge to remove aspergillous foci, not aspergilloma but chronic necrotizing pulmonary aspergillosis.

[Contribution of the surgical treatment of drug-resistant tuberculosis during medical follow-up (experience of the pneumology department of the CHU of Cocody, in connection with five observations)]

Multidrug resistance is defined as a resistance to two major antituberculosis drugs, which are isoniazid and rifampicin. The aim of the study was to specify the place of the thoracic surgery during the medical follow-up of the TB-MDR. Five files were kept over six years during this retrospective study. On the clinical and radiological level, localised lesions and a negative HIV serology were noted in the five patients. The completion date of the surgery varied between the third month and the 22nd after the beginning of the medical treatment. This delay in carrying out the surgery was encouraged by the social conditions of the patients. Three series of expectoration culture post-surgery were all negative. After surgery, the medical treatment was drawn out over six and 12 months depending on the clinical condition of the patient. No recurrence was observed. Only one patient died one year after the surgery from hemoptysis in relation to pulmonary sequelae.

[Bacteriological tests of the operative material in patients with lung tuberculosis]

64 patients with lung tuberculosis were operated on after chemotherapy course using regimens I and III. 69 patients were operated on after the treatment by DOTS/PLUS protocol. The obtained operative material was bacteriologically tested. Bacterial growth in samples of patients treated with DOTS/PLUS protocol caused by multydrug resistance of mycobacteria. The noncoinsidence of the drug resistance spectrum in sputum and resected samples was registered in 33% of patients treated by DOTS/ PLUS protocol and 25% of patients, treated by using regimens I and III.

Decrease in CD4+CD25+FoxP3+ Treg cells after pulmonary resection in the treatment of cavity multidrug-resistant tuberculosis

OBJECTIVES

Immune regulatory mechanisms may limit the immunopathologic condition of infection with Mycobacterium tuberculosis and suppress cellular immune responses in the host. We investigated the CD4(+)CD25(+)FoxP3(+) circulating regulatory T cells (T(reg)) in patients with cavity multidrug-resistant tuberculosis (MDR-TB) before and after surgery.

METHODS

We compared the proportion of T(reg) cells in 13 patients with cavity MDR-TB pre- and postoperatively and in 10 healthy control subjects by flow cytometry using three specific markers in peripheral blood lymphocytes: cell-surface CD4 and CD25 expression and intracellular FoxP3 expression.

RESULTS

The proportion of CD4(+)CD25(high) and CD4(+)CD25(+)FoxP3(+) T(reg) was significantly higher in patients with cavity MDR-TB and at 1-month postoperatively than in healthy controls (p<0.001). The proportion of CD4(+) and CD4(+)CD25(-) cells was significantly lower in patients with cavity MDR-TB than in controls (p<0.001). Pre- and postoperative proportions of CD4(+)CD25(high) and CD4(+)CD25(+)FoxP3(+) T(reg) cells showed a positive correlation (r=0.878, p<0.001).

CONCLUSION

Circulating T(reg) cells are increased in proportion in patients with cavity MDR-TB and decreased after surgery. Infection with M. tuberculosis may induce T(reg) cell-surface molecular changes with increased numbers of cells.

[Surgical treatment of drug-resistant spinal tuberculosis]

OBJECTIVE

To study the curative effect of surgical treatment of drug-resistant spinal tuberculosis.

METHODS

From March 2005 and April 2009, the clinical data of 60 patients with drug-resistant spinal tuberculosis were retrospectively analyzed. Including 36 males and 24 females; aged from 5 to 79 years with an average of 47.3 years. Thirty-four patients had neurological deficits, among them, 2 cases were grade A, 5 cases were grade B, 13 cases were grade C, 14 cases were grade D according to ASIA standard. According to the severity and location of the infection, the patients underwent anterior, posterolateral costotransversectomy or posterior debridement and bone grafting and internal fixation. The antituberculous chemotherapy for a total of 12 to 18 months was guided by conventional and genotypic drug susceptibility testing. Tubercular relapse, neurological function, spinal fusion were observed by ASIA grade, X-ray and CT scan.

RESULTS

All cases were followed up from 1 to 5 years with an average of 3.1 years. Recurrence was found in 2 cases who were cured after second operation. 34 cases with neurological deficits recovered totally or partially. X-ray or CT films showed spinal fusion in 57 patients.

CONCLUSION

The therapeutic effect of individuall operative options is good in treating drug-resistant spinal tuberculosis after antituberculous chemotherapy based on conventional and genotypic drug susceptibility testing.

[Prognostic value of morphological signs of the activity of tuberculous inflammation in patients with circumscribed drug-resistant pulmonary tuberculosis]

The paper provides the morphological characteristics of a specific process in patients with drug-resistant pulmonary tuberculosis. Morphological study of intraoperative samples has shown a predominance of common active inflammatory changes in most cases. There is evidence for an association of the morphological activity of a tuberculous process with the clinical types and duration of the disease and their spectrum of drug resistance. The high morphological activity of specific inflammation (IV-V) substantially increases the risk of specific postoperative complications and relapses in the late follow-up periods.

[Surgical treatment of multidrug-resistant tuberculosis]

Although the results of medical treatment for multidrug-resistant tuberculosis (MDR-TB) has improved, adjuvant surgical treatment remains achieving better outcomes for MDR-TB patients. We have performed pulmonary resection for MDR-TB patients aggressively. Indications for surgery include (1) persistent positive sputum despite state-of-the-art chemotherapy and (2) a high risk of relapse. For 56 patients undergoing 61 pulmonary resections for MDR-TB between January 2000 and June 2007 at our institution, the overall cure rate was 98%. An aggressive treatment approach to MDR-TB continues to be justified until a panacea for this refractory disease is available.

[Surgical treatment of 133 cases of multi-drug-resistant pulmonary tuberculosis]

OBJECTIVE

To evaluate the clinical significance of pulmonary resection for multi-drug-resistant pulmonary tuberculosis.

METHODS

The clinical data were retrospectively reviewed for patients with multi-drug-resistant pulmonary tuberculosis for which surgical resection of the lung was undertaken.

RESULTS

From January 1980 to December 2007, 1188 patients with pulmonary tuberculosis, including 133 multi-drug resistant cases, underwent pulmonary resection in Beijing Chest Hospital. Surgical procedures included pneumonectomy in 45, pulmonary lobectomy in 73 (including sleeve resection of the bronchus in 5), pleuropneumonectomy in 13, segment resection in 1, and wedge resection in 1 cases. Preoperative and postoperative antituberculosis chemotherapy was given for no less than 6 months and 6 to 18 months, respectively. Two cases died of perioperative respiratory failure, and 1 died of internal bleeding, the mortality rate being 2.3% (3/133). The incidence of postoperative complications was 17.3% (23/133), including 9 cases with stump fistula of bronchus. Follow-up lasted for 6 months to 15 years (average 52 months), and medical treatment lasted for 6 - 18 months. After follow-up, the sputum negative conversion rate was 90.2% (101/112).

CONCLUSIONS

Pulmonary resection is an effective approach to multi-drug resistant pulmonary tuberculosis with long-term sputum positivity of limited local lesions, or negative sputum of local lesions but failure to antituberculosis chemotherapy for at least 3 months.

Pulmonary resection in the treatment of multidrug-resistant tuberculosis: a retrospective study of 56 cases

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) has become a challenge to TB control, and surgical resection is regaining its status as an integral component of multimodal treatment. We evaluated the efficacy and risks of pulmonary resection in the treatment of MDR-TB.

METHODS

A retrospective review was performed of 56 patients who had undergone pulmonary resection for MDR-TB from January 1995 to July 2006. Preoperative diagnoses included cavitation in 25 patients, lung destruction in 17, endobronchial TBs in 10, and tuberculoma in 4.

RESULTS

Mycobacterium tuberculosis resistant to both isoniazid and rifampin was isolated from the sputum of all patients preoperatively but in only 5 patients postoperatively. Pneumonectomy was performed on 25 patients and lobectomy on 31. No patients died perioperatively, but major complications occurred in 14 patients, with a morbidity of 25%. Complications included reoperation due to uncontrollable postoperative bleeding in 1 patient, chylothorax in 1, wound infection in 1, bronchopleural fistula in 9, and chronic tuberculous empyema in 2. Analysis of variance showed that lung function was significantly correlated with the type of preoperative diagnosis. Univariate and multivariate logistic regression analyses revealed that endobronchial TB significantly contributed to the development of bronchopleural fistula, and bronchial stump reinforcement could prevent its occurrence.

CONCLUSIONS

Pulmonary resection plays an important role in the treatment of MDR-TB. Endobronchial TB is a significant risk factor for developing bronchopleural fistula, but bronchial stump reinforcement can effectively prevent its occurrence.

[Surgery for pulmonary tuberculosis. Review of 33 operated patients]

BACKGROUND

Surgical treatment for pulmonary tuberculosis is mainly limited to the management of sequelae such as bronchiectasis, hemoptysis and brochopleural fistulae.

AIM

To review the data of patients who underwent surgical treatment for pulmonary tuberculosis.

MATERIAL AND METHODS

Retrospective review of 33 patients aged 18 to 73 years (24 males) who underwent lung resection surgery for the management of pulmonary tuberculosis. Follow-up data were obtained from outpatient visit records and registries of the national tuberculosis program.

RESULTS

The reasons to perform surgery were the following: fifteen for hemoptysis, nine for lung destruction and nine for an active and multiresistant disease. No patient died in the postoperative period. The morbidity observed included empyema (n =5), pneumothorax (n =2), bronchopleural fistula (n =2) and hemothorax (n =2). At six months of follow up, six of the nine patients with active tuberculosis had negative acid-fast bacilli on sputum smear. Two of these patients died, one due to respiratory failure and another by an unrelated cause. Both dead patients had negative acid-fast bacilli on sputum smear.

CONCLUSIONS

Surgery in pulmonary tuberculosis has a high rate of complications but may be useful in selected patients.

Perioperative care of the patient with tuberculosis

Approximately 1.7 billion people are thought to be infected with Mycobacterium tuberculosis. The estimated mortality rate is 3 million people per year. Multidrug resistant-tuberculosis (MDR-TB) and extensively drug-resistant TB (XDR-TB) are serious problems that threaten global TB control. Patients who are inadequately treated remain chronic carriers and can spread the disease to family members and their communities. Treatment recommendations for TB include directly observed treatment and monitoring the patient's response to medications. Perioperative nurses must protect the patient and other health care workers when a patient with TB undergoes a surgical procedure.

[Efficiency of surgical treatment in patients with drug-resistant pulmonary tuberculosis in relation to the course of a disease]

The immediate results of surgical treatment were analyzed in 225 patients with polyresistant and multidrug-resistant pulmonary tuberculosis; the process was first detected in 95 patients of them; 34 patients had recurrent tuberculosis; chronic tuberculosis was found in 93 patients. The highest clinical efficiency of surgical treatment and the least frequency of postoperative complications were determined in new cases of tuberculosis (94.9 and 20.8%, respectively). In recurrent tuberculosis, clinical efficiency was achieved in 94.1% with the frequency of complications being 29.4% and when tuberculosis was chronic, it was 93.6% with the frequency of complications being 32.2%. The optimum time of surgical interventions was defined in patients with various courses of the disease.

[Surgical treatment for pulmonary tuberculosis with Mycobacterium resistance to drugs]

The results of surgical treatment were analyzed in 481 patients who had been preoperatively found to have drug resistance. Patients with fibrocavernous, cirrhotic tuberculosis, chronic pleural empyema, and cavernous pneumonia constituted the vast majority (83.2%). Chemotherapy was performed by individual schemes, by taking into account MBT susceptibility. Glutoxim and pentaglobin were used as pathogenetic therapy for immunity correction. Resection-type operations [n = 368 (68.9%)], thorocoplastic interventions [n = 78 (14.6%)], thoracostomy or cavernostomy [n = 35 (6.5%)], pleurectomy [n = 26 (4.9%)], operation on the stump of the main bronchus [n = 15 (2.8%)], and mediastinal lymphadenectomy [n = 12 (2.2%)] were predominant. Postoperative complications occurred in 15.5% of cases; mortality was 1.7%. The mycobacterium resistance to drugs verified by laboratory studies exerted no evident impact on the number and pattern of postoperative complications. The results of treatment depended on the extent and presence of complications of a tuberculous process, comorbidity, suppressed immunity, and the scope of a surgical intervention.

[The experience of applying of exogenous monoxide of nitrogen and argon plasma coagulation by cavernotomy in patients with fibro-cavernous pulmonary tuberculosis with the presence of multiple drug resistance]

The presented paper discusses the experience with exogenous nitric oxide (NO) and argon plasma coagulation (APC) used at cavernotomy in 31 patients with multidrug-resistant fibrocavernous pulmonary tuberculosis. Supplementary treatments depending in infectious risk factors were comprehensively evaluated. The application of APC and NO significantly improved the results of open cavern sanitation, as evidenced by the bacterial excretion index, and doubled the immediate efficiency of surgical treatment.

[Efficiency of partial pneumonectomies in patients with multidrug-resistant tuberculosis]

The immediate results of partial resections were analyzed in 120 patients with drug-resistant pulmonary tuberculosis, among whom 70 patients had multidrug resistance. A complete clinical effect (abacillation and no decay cavities) was achieved in 117 (97.5%) patients, including in 67 (95.7%) patients with multidrug resistance who showed improvement in 3 (2.5%) cases, fatal outcomes being absent.

[Systemic transplantation of autologous mesenchymal stem cells of the bone marrow in the treatment of patients with multidrug-resistant pulmonary tuberculosis]

The study undertaken 3 years ago examined the effect of systemic transplantation of autologous mesenchymal stem cells (MSC) in the complex therapy of 27 patients with pulmonary tuberculosis, including 15 patients with multidrug-resistant pulmonary tuberculosis and 12 with extensive drug resistance of Mycobacterium tuberculosis. All the patients were bacteria-discharging persons with disseminated destructive processes in lung tissue, most (n=17) of them had chronic fibrocavernous tuberculosis. In all the patients, previous long specific antituberculous treatment was ineffective or inadequately effective. After systemic MSC transplantation, 16 patients were followed up for 1.5-2 years or more and the remaining 11 patients for at least 6 months. After MSC administration, a positive clinical effect was observed in all 27 cases; bacterial discharge stopped in 20 patients after 3-4 months; resolution of sustained lung tissue cavities further occurred in 11 patients. At present, a persistent remission of a tuberculous process may be stated in 9 of the 16 patients in whom MSCs were transplanted 1.5-2 years, significant positive bacteriological and morphological changes are observed in 6 patients. Thus, inclusion of transplantation of the autologous MSCs propagated in the culture into a course of antituberculous therapy may be a promising procedure for enhancing the efficiency of therapy in patients with resistant forms of pulmonary tuberculosis.

The role of surgery and fluoroquinolones in the treatment of multidrug-resistant tuberculosis

SETTING

Although modern tuberculosis treatment relies on chemotherapy, surgery is accepted as adjuvant treatment for multidrug-resistant tuberculosis (MDR-TB).

OBJECTIVE

To evaluate the effect of resectional surgery and fluoroquinolones on long-term treatment success and survival in a large group of MDR-TB cases.

DESIGN

A total of 252 patients with MDR-TB were included in this retrospective cohort study. Multiple logistic regression was used to determine independent predictive factors for long-term treatment success, and survival analyses were done based on different treatment approaches with or without surgery.

RESULTS

The mean age of the study cohort was 37.9 +/- 12.5 years; 204 (80%) were males. Long-term treatment success was associated with resistance to fewer drugs, female sex, younger age and limited disease. Sixty-six patients (26.2%) had undergone resectional surgery after 2-16 months of treatment. The highest long-term treatment success and survival rates were achieved in patients who both received fluoroquinolones and underwent surgery (P = 0.001 vs. other groups).

CONCLUSION

Although the treatment success rate was higher in patients treated with surgery and fluoroquinolones compared to other groups, an additional significant benefit from surgery could not be demonstrated. Larger scale studies are needed to clarify this issue.

Lobectomy or pneumonectomy for multidrug-resistant pulmonary tuberculosis can be performed with acceptable morbidity and mortality: A seven-year review of a single institution’s experience

OBJECTIVE

Combination chemotherapy is considered the first-line treatment for pulmonary tuberculosis. Despite related morbidity, the need for surgical resections coincides with the emergence of multidrug-resistant tuberculosis. This study presents a single-institution retrospective audit of the surgical management of 23 patients with multidrug-resistant tuberculosis.

METHODS

We analyzed 23 consecutive patients undergoing anatomic pulmonary resections for human immunodeficiency virus-negative multidrug-resistant tuberculosis. Twenty were male (87%) and 3 were female (13%); their mean age was 24.4 years. We defined resistance in this cohort as failure to respond to combination chemotherapy, including isoniazid and rifampicin, with a mean duration of administration being 90 days. Fifteen of 23 (65.3%) patients, although sputum negative, were considered at risk for relapse owing to extensive parenchymal disease. Eight (34.7%) of 23 patients were sputum positive at the time of operation. We performed pneumonectomy on 11 (47.8%) and lobectomy on 12 (52%) patients. All had adjuvant chemotherapy for 18 to 24 months, with follow-ups ranging from 14 to 27 months.

RESULTS

Stay in the intensive treatment unit was 2.9 days (range 1-17 days) and hospital stay, 8.6 days (range 5-45 days). Four (17%) patients had prolonged air leak, 3 (13%) required further treatment for empyema, with re-exploration for bleeding in 1 (4%). Hospital mortality was 4.3%. All patients attained sputum-negative status postoperatively (range 1-5 months). One (4%) patient had a relapse after 12 months.

CONCLUSION

Surgery should be considered as an adjunct to medical therapy when eradicating multidrug-resistant tuberculosis in affected patients. Anatomic lung resections can be performed with acceptable morbidity and mortality. Early referral of such patients for surgical consideration is warranted.

[A case of multidrug-resistant pulmonary tuberculosis cured by the regimen including thiacetazone]

A 30 years-old-male was referred to our hospital for surgical treatment of multidrug-resistant tuberculosis in April 1998, three years after diagnosis of tuberculosis. All first-line anti-tuberculosis drugs and second-line anti-tuberculosis drugs were resistant on drug susceptibility tests by Ogawa medium. The right upper lobectomy was done because of massive hemoptysis and enlargement of cavitary lesion in June 1998, but this surgical operation was complicated with, bronchial fistula and chronic empyema. Open drainage surgical treatment for chronic empyema was done one month after lobectomy. Sputum culture for M. tuberculosis converted 4 months after the lobectomy, but bacteriological relapse occurred 17 months after initial operation. The new cavitary lesion on middle left lung field developed and sputum smear and culture were continuously positive. Immunotherapy with interferon-gamma via aerosol didn't show any clinical effect. Thiacetazone, sparfloxcin, pyrazinamide, cycloserine was prescribed after 21 months of the initial operation. Four months after changing the regimen sputum smear and culture converted to negative. Chemotherapy was terminated in June 2003, two years after negative conversion. Three years after the termination of treatment no relapse occurred. We considered thiacetazone was effective in this case, because all of the drugs was companied with thiacetazone were resistant by the drug susceptibility tests and were previously used.

Surgery for patients with drug-resistant tuberculosis: report of 121 cases receiving community-based treatment in Lima, Peru

BACKGROUND

While most patients with tuberculosis (TB) can be successfully treated using short-course medical chemotherapy, thoracic surgery is an important adjunctive strategy for many patients with drug-resistant disease. The need for physical, technical and financial resources presents a potential challenge to implementing surgery as a component of treatment for multidrug-resistant TB (MDR-TB) in resource-poor settings. However, a cohort of patients with severe MDR-TB in Lima, Peru underwent surgery as part of their treatment.

METHODS

121 patients underwent pulmonary surgery for drug-resistant tuberculosis between May 1999 and January 2004. Surgery was performed by a team of thoracic surgeons under the Ministry of Health. Patient demographic data, clinical characteristics, surgical procedures and surgical outcomes were studied.

RESULTS

Most of the patients had failed multiple TB regimens and were resistant to a median of seven drugs. The median time of follow-up after surgery was 33 months. 79.3% of patients were culture-positive before surgery, and sustained culture-negative status among survivors was achieved in 74.8% of patients. 63% of those followed up for at least 6 months after surgery were either cured or probably cured. Postoperative complications, observed in 22.6% of patients, were associated with preoperative haemoptysis, vital capacity <50% and low forced expiratory volume in 1 s.

CONCLUSIONS

This is one of the largest cohorts with MDR-TB to be treated with surgery, and the first from a resource-poor country. Although surgery is not often considered an option for patients in resource-poor settings, the findings of this study support the argument that adjunctive surgery should be considered an integral component of MDR-TB treatment programmes, even in poor countries such as Peru.

Treatment of multidrug-resistant tuberculosis: evidence and controversies

In the last decade, multidrug-resistant tuberculosis (MDR-TB, defined as resistance to at least isoniazid and rifampicin) has become an epidemiological issue of first priority at the global level. Case management needs to be simplified and standardised, as in many countries MDR-TB cases cannot receive individualised attention from specialist physicians. However, before any decision can be made on standardisation, a careful analysis must first be made of the evidence and controversies behind the various published recommendations. Unfortunately, the controversies outweigh the evidence. The difficulties lie not only in the absence of controlled trials to validate specific recommendations, but also in the very different and even contradictory results found in the literature. It is therefore essential to analyse these discrepancies before developing rational, uniform recommendations. The analysis should encompass the most essential and controversial issues regarding the management of MDR-TB patients: 1) confirmation of diagnosis in a suspected MDR-TB patient, and determination of the value of drug susceptibility testing; 2) the number of anti-tuberculosis drugs required to treat MDR-TB; 3) the most rational use of effective drugs against tuberculosis; 4) the advisable length of parenteral drug administration or of the initial phase of treatment; 5) the contribution of surgery to the management of MDR-TB patients; and 6) the optimal regimen for treating MDR-TB: standardised vs. individualised regimens. The evidence and controversies regarding each of the above questions are analysed with the aim of facilitating decision making in the treatment of these complex patients.

[Surgical treatment of multi-drug resistant pulmonary tuberculosis in 188 cases]

OBJECTIVE

Multi-drug resistant pulmonary tuberculosis (MDR-PTB) is a major cause of morbidity and mortality throughout the world currently. Optimal therapy for patients infected with MDR-PTB often requires surgical intervention to eradicate the infection.

METHODS

During a 15-year period from 1990 to 2005, of the 906 cases receiving surgical treatment for pulmonary tuberculosis in Shanghai Pulmonary Disease Hospital, 188 patients with MDR-PTB underwent 200 surgical procedures. All the patients of MDR-PTB had received individualized multiple-drug chemotherapy at least 2 - 3 months before surgery, as determined by drug susceptibility studies. Of the surgical procedures, 85 lobectomies, 48 pneumonectomies and other complicated surgical techniques were performed respectively. Twelve patients underwent repeated operation. Muscle flaps and omentum in some cases were used to avoid residual space and bronchial stump problems.

RESULTS

Operative mortality was 0.5% (1/200). Postoperative mortality was 3.2% (6/187). Significant morbidity was 13.9% (26/187). All of the patients had positive sputum at the time of surgery. After the operation, the sputum remained positive in only 2 patients. Mean length of follow-up was 6.7 years (range 3 - 180 months). All of the patients after surgery continued their individualized multiple-drug chemotherapy for 3 - 18 months.

CONCLUSION

Surgery remains an important adjunct to medical therapy for the treatment of MDR-PTB. Surgical treatment should be considered for localized diseases, persistent sputum positivity, or intolerance of medical therapy.

Prognostic factors for surgical resection in patients with multidrug-resistant tuberculosis

Although surgical lung resection could improve prognosis in some patients with multidrug-resistant tuberculosis (MDR-TB), there are no reports on the optimal candidates for this surgery. The aim of the present study was to elucidate the prognostic factors for surgery in patients with MDR-TB. Patients who underwent lung resection for the treatment of MDR-TB between March 1993 and December 2004 were included in the present study. Treatment failure was defined as greater than or equal to two of the five cultures recorded in the final 12 months of treatment being positive, any one of the final three cultures being positive, or the patient having died during treatment. The variables that affected treatment outcomes were identified through univariate and multivariate logistic regression analysis. In total, 79 patients with MDR-TB were included in the present study. The treatment outcomes of 22 (27.8%) patients were classified as failure. A body mass index <18.5 kg x m(-2), primary resistance, resistance to ofloxacin and the presence of a cavitary lesion beyond the range of the surgical resection were associated with treatment failure. Low body mass index, primary resistance, resistance to ofloxacin and cavitary lesions beyond the range of resection are possible poor prognostic factors for surgical lung resection in multidrug-resistant tuberculosis patients.

Adjuvant resectional surgery improves cure rates in multidrug-resistant tuberculosis

OBJECTIVE

Multidrug-resistant tuberculosis still continues to be a major health problem. Adjuvant surgical resection combined with antituberculous drug management is the most favorable treatment modality for patients with multidrug-resistant tuberculosis. In this article we report the results of surgical resections we performed during the years 1993 through 2005.

METHODS

We performed 81 lung resections in 79 patients with multidrug-resistant tuberculosis. All these patients had at least 2 months of medical therapy before resection. Bronchial reinforcement was performed in 4 of the 81 operations. We present here the surgical results of the 81 procedures. Because 5 of 79 patients were lost to follow-up, we provide the medical treatment results on 74 of the patients.

RESULTS

During this period, we performed 4 completion pneumonectomies, 39 pneumonectomies, 7 lobectomies with segmentectomy, 30 lobectomies, and 1 segmentectomy. Operative mortality was 2.5% (2/81). Bronchopleural fistula developed in 4 (4.9%) cases. Our overall cure rate was 94.5% (70/74). Relapse and treatment failure were 1.3% (1/74) and 1.3% (1/74), respectively. All but 5 patients are still under our follow-up.

CONCLUSIONS

Surgical resection of patients with multidrug-resistant tuberculosis combined with chemotherapy provides a favorable outcome. Our results will need to be validated more strongly by using randomized clinical trials that compare surgical resection plus chemotherapy with chemotherapy alone.

Unique transcriptome signature of Mycobacterium tuberculosis in pulmonary tuberculosis

Although tuberculosis remains a substantial global threat, the mechanisms that enable mycobacterial persistence and replication within the human host are ill defined. This study represents the first genome-wide expression analysis of Mycobacterium tuberculosis from clinical lung samples, which has enabled the identification of M. tuberculosis genes actively expressed during pulmonary tuberculosis. To obtain optimal information from our DNA array analyses, we analyzed the differentially expressed genes within the context of computationally inferred protein networks. Protein networks were constructed using functional linkages established by the Rosetta stone, phylogenetic profile, conserved gene neighbor, and operon computational methods. This combined approach revealed that during pulmonary tuberculosis, M. tuberculosis actively transcribes a number of genes involved in active fortification and evasion from host defense systems. These genes may provide targets for novel intervention strategies.