HomeSurgical resection of lungs affected with active TB disease predates the antibiotic era. With the advent of effective antibiotic therapy, use of surgery declined and was reserved only for emergencies, such as hemoptysis. However, there has been renewed interest in surgical resection as an adjunct to medical therapy in patients with MDR-TB, given the limitations of medical therapy in these patients. Many case series have reported good success rates and some reported better outcomes in surgically treated patients than patients treated with medical therapy alone.
An IPD meta-analysis, published in 2016116 reported on the results of 478 patients who underwent surgical resection out of a total of 6,431 patients from 26 studies. Partial lung resection (lobectomy, segmentectomy or wedge resection) was associated with an improved odds of treatment success (aOR: 3.0; [95% CI: 1.5 to 5.9]). Total lung resection, or pneumonectomy, was not associated with improved success (aOR: 1.1; [0.6 to 2.3]). Mortality during medical therapy following surgery occurred in 13% of those undergoing pneumonectomy, compared to 3% of those who underwent partial lung resection and 13% of those receiving medical therapy alone. Treatment success was greater if surgery was performed after sputum culture conversion (aOR: 2.6; 0.9 to 7.1). There were a number of limitations of this analysis, in particular that no patients with HIV, nor children who underwent resection surgery, were included in the analysis. The most important limitation is the confounding of surgical resection with better clinical and functional status, which was partially controlled through sophisticated matching analyses, but some residual confounding likely remained. In addition, this analysis was based on studies published up to 2008, so there was limited use of linezolid or bedaquiline; even later generation fluoroquinolones were given only to a minority of patients. With the introduction of these more effective drugs into routine MDR-TB treatment, the benefits of surgery may be less. Analysis of a more recent IPD, which included patients who had received these newer drugs, revealed that the benefits of partial lung resection was still seen, but the effect was more modest, while total lung resection (pneumonectomy) was of no benefit, as in the earlier analysis.117
Recommendations
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We conditionally recommend, in carefully selected patients with MDR-TB, partial lung resection (lobectomy, segmentectomy or wedge resection) as an adjunct to optimized medical therapy. The optimal timing of surgical resection appears to be after culture conversion is achieved (poor evidence).
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We conditionally recommend, in patients with MDR-TB who have more extensive disease that could only be addressed by pneumonectomy, against resection surgery, as such patients do not appear to benefit from it. Surgery in these patients should be reserved for treatment of major complications, such as massive hemoptysis (poor evidence).
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