title: Surgery as an Adjunctive Treatment for Multidrug-Resistant Tuberculosis: An Individual Patient Data Metaanalysis.
abstract: BACKGROUND
  Medical treatment for multidrug-resistant (MDR)-tuberculosis is complex, toxic, and associated with poor outcomes. Surgical lung resection may be used as an adjunct to medical therapy, with the intent of reducing bacterial burden and improving cure rates. We conducted an individual patient data metaanalysis to evaluate the effectiveness of surgery as adjunctive therapy for MDR-tuberculosis.
  
  
  METHODS
  Individual patient data, was obtained from the authors of 26 cohort studies, identified from 3 systematic reviews of MDR-tuberculosis treatment. Data included the clinical characteristics and medical and surgical therapy of each patient. Primary analyses compared treatment success (cure and completion) to a combined outcome of failure, relapse, or death. The effects of all forms of resection surgery, pneumonectomy, and partial lung resection were evaluated.
  
  
  RESULTS
  A total of 4238 patients from 18 surgical studies and 2193 patients from 8 nonsurgical studies were included. Pulmonary resection surgery was performed on 478 patients. Partial lung resection surgery was associated with improved treatment success (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.5-5.9; I(2)R, 11.8%), but pneumonectomy was not (aOR, 1.1; 95% CI, .6-2.3; I(2)R, 13.2%). Treatment success was more likely when surgery was performed after culture conversion than before conversion (aOR, 2.6; 95% CI, 0.9-7.1; I(2)R, 0.2%).
  
  
  CONCLUSIONS
  Partial lung resection, but not pneumonectomy, was associated with improved treatment success among patients with MDR-tuberculosis. Although improved outcomes may reflect patient selection, partial lung resection surgery after culture conversion may improve treatment outcomes in patients who receive optimal medical therapy.
authors.affiliation: Montreal Chest Institute, McGill University, Canada.
authors.forename: Gregory J
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authors.lastname: Fox
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.
authors.forename: Carole D
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authors.lastname: Mitnick
authors.affiliation: Montreal Chest Institute, McGill University, Canada.
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authors.affiliation: Departments of Medicine and Academic Affairs, Denver Veterans Affairs Medical Center, Colorado.
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authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.
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authors.affiliation: Wan Fang Hospital, Taipei Medical University, Taiwan.
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authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.
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authors.affiliation: Section of Chest Surgery, Fukujuji Hospital, Tokyo, Japan.
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authors.affiliation: Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
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mesh_terms: D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011013:Pneumonectomy / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy / Q000453:epidemiology / Q000601:surgery*; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy / Q000453:epidemiology / Q000601:surgery*
chemical_list: D000995:Antitubercular Agents
keywords: individual patient data; metaanalysis; multidrug resistant tuberculosis; pneumonectomy; thoracic surgery