title: Surgical interventions for drug-resistant tuberculosis: a systematic review and meta-analysis.
abstract: BACKGROUND
  With the emergence of multidrug-resistant (MDR-) and extensively drug-resistant tuberculosis (XDR-TB), surgery, which had been replaced by short-course chemotherapy, is again being considered a viable treatment option.
  
  
  OBJECTIVE
  To assess the literature on the effectiveness  of surgical interventions in the treatment of drug-resistant TB.
  
  
  METHODS
  Medline, EMBASE, and PubMed were searched from 1975 to April 2012 in addition to hand searching reference lists, and the International Journal of Tuberculosis and Lung Disease. Potentially relevant studies  were assessed according to pre-defined eligibility criteria: MDR- and XDR-TB patients undergoing surgical and non-surgical treatment. Treatment outcomes were extracted according to internationally accepted definitions and included in meta-analyses using random effects models.
  
  
  RESULTS
  Summary  meta-analysis of 24 comparison studies revealed a significant association between surgery and successful treatment compared to non-surgical interventions (OR 2.24, 95%CI 1.68-2.97). A meta-analysis from 23 single-arm studies demonstrated that respectively 92% (95%CI 88.1-95) and  87% (95%CI 83-91) of surgical patients achieved successful short- and long-term outcomes. Subgroup analyses showed that favorable surgical outcomes were associated with increased drug resistance in studies reporting surgical and non-surgical treatment outcomes.
  
  
  CONCLUSIONS
  While  the results suggest that surgical intervention is associated with successful treatment outcomes in patients with drug-resistant TB, there is insufficient evidence to recommend surgery plus chemotherapy over chemotherapy alone, to evaluate the potential harm from surgery and to determine the  optimal conditions for surgery. Controlled studies are needed to better assess the effectiveness of surgery and to investigate other contextual issues.
authors.affiliation: Centers for Disease Control and Prevention, Division of Tuberculosis Elimination, Atlanta, GA 30333, USA.
authors.forename: M T
authors.initials: MT
authors.lastname: Marrone
authors.forename: V
authors.initials: V
authors.lastname: Venkataramanan
authors.forename: M
authors.initials: M
authors.lastname: Goodman
authors.forename: A C
authors.initials: AC
authors.lastname: Hill
authors.forename: J A
authors.initials: JA
authors.lastname: Jereb
authors.forename: S R
authors.initials: SR
authors.lastname: Mase
mesh_terms: D006801:Humans; D018088:Tuberculosis, Multidrug-Resistant / Q000601:surgery*; D014397:Tuberculosis, Pulmonary / Q000601:surgery*