Surgical treatment to increase the success rate of multidrug-resistant tuberculosis.

OBJECTIVE: Mycobacterium tuberculosis infects more than one-third of the world's population and causes an estimated 2-3 million deaths annually. The medical treatment of multidrug-resistant tuberculosis (MDR-TB) can cure 50-75% of cases. The median prevalence of new MDR-TB cases is 1.1%, while that of previously treated cases is 7%.
METHODS: We carried out a retrospective study on 45 patients with MDR-TB who underwent surgical resection at the Leon Daniello Hospital (Regional Surgery Department) between January 1995 and December 2005. The number of MDR-TB cases has continued to increase despite the implementation of MDR-TB treatment strategies. Drug susceptibility tests showed that all our patients were resistant to at least isoniazid (hydrazide) and rifampicin. Therefore, individual drug regimens including at least five antibiotics were prescribed. Surgery under general anaesthesia (double-lumen endotracheal intubation) was performed by a team of thoracic surgeons. The patients had received anti-tuberculosis (TB) treatment for at least 1 month preoperatively as well as postoperatively.
RESULTS: We collected and analysed patients' demographic data, clinical characteristics, place of origin, radiological findings, smear and culture status before surgery, TB localization, primary or secondary drug resistance, surgical procedures, complications, bacteriological smear and culture status after surgical treatment. The indications for surgery include medical treatment failure in 39 patients, persistent cavitary lesions with possible relapses in 3 patients and massive haemoptysis in 3 patients. Lobectomy was carried out in 30 cases, segmentectomy in four cases and cavernoplasty (speleoplasty) in 11 cases. Four weeks postoperatively, there were 83% smear-negative and 17% smear-positive patients. Only minor complications were registered: three patients had wound infections, two had minor haemorrhages and one presented a minor pneumothorax. Operative mortality was zero.
CONCLUSIONS: The absolute indications for the surgical treatment of MDR-TB include failure of medical therapy (due to persistent cavitary disease and lung or lobar destruction) and massive haemoptysis. Proper patient selection and the timing of operations are crucial to avoid relapses and to provide a definitive cure. Good cooperation between chest physicians and thoracic surgeons as well as patients' adherence to pre- and post-chemotherapy can increase the success rate of MDR-TB treatment.