7.2 Justification and evidence

The recommendation in this section addresses one PICO question:

PICO question (DR-TB, 2016): Among patients on MDR-TB treatment, are the following two interventions (delay in start of treatment and elective surgery) likely to lead to cure and other outcomes?49

SSurgery has been employed in treating TB patients since before the advent of chemotherapy. In many countries, it remains one of the treatment options for TB. With the challenging prospect in many settings of inadequate regimens to treat DR-TB, and the risk of serious sequelae, the role of pulmonary surgery is being re-evaluated as a way to reduce the amount of lung tissue with intractable pathology and reduce bacterial load, and thus improve prognosis. The review for this question was based on both an IPD meta-analysis to evaluate the effectiveness of different forms of elective surgery as an adjunct to combination medical therapy for MDR-TB (124), and a systematic review and study-level meta-analysis (125). Demographic, clinical, bacteriological, surgical and outcome data of MDR-TB patients on treatment were obtained from the authors of 26 cohort studies that supplied data for the adult IPD (aIPD) (55). The analyses summarized in the GRADE tables consist of three strata comparing treatment success (e.g. cure and completion) with different combinations of treatment failure, relapse, death and loss to follow-up. Two sets of such tables were prepared, one for partial pulmonary resection and one for pneumonectomy. Based on an assessment of the certainty of the evidence, carried out using predefined criteria and documented in GRADEpro, the certainty of the evidence was rated as very low to low, depending on the outcome being assessed and type of study.

In the study-level meta-analysis that examined all forms of surgery together, there was a statistically significant improvement in cure and successful treatment outcomes among patients who received surgery. However, when the aIPD meta-analysis examined patients who underwent partial lung resection and those who had a more radical pneumonectomy compared with patients who did not undergo surgery, those who underwent partial lung resection had statistically significantly higher rates of treatment success. Patients who underwent pneumonectomy did not have better outcomes than those who did not undergo surgery. Prognosis appeared to be better when partial lung resection was performed after culture conversion. This effect was not observed in patients who underwent pneumonectomy. There are several important caveats to these data. Substantial bias is likely to be present, because only patients judged to be fit for surgery would have been operated on. No patient with HIV coinfection in the aIPD underwent lung resection surgery. Therefore, the effects of surgery among People with HIV with MDR-TB could not be evaluated. Rates of death did not differ significantly between those who underwent surgery and those who received medical treatment only. However, the outcomes could be biased because the risk of death could have been much higher among patients in whom surgery was prescribed had they not been operated on.

49 The outcomes comprise 1. Cured/completed by end of treatment, 2. Culture conversion by 6 months, 3. Failure, 4. Relapse, 5. Survival (or death), 6. Adverse reactions (severity, type, organ class), and 7. Adherence to treatment (or treatment interruption due to non-adherence).

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