The effect of surgery on the outcome of treatment for multidrug-resistant tuberculosis: a systematic review and meta-analysis.
In 2014 only 50 % of multidrug-resistant tuberculosis (MDR-TB) patients achieved a successful treatment outcome. With limited options for medical treatment, surgery has re-emerged as an adjuvant therapeutic strategy. We conducted a systematic review and meta-analysis to assess the evidence for the effect of surgery as an adjunct to chemotherapy on outcomes of adults treated for MDR-TB.



Databases and grey literature sources were searched using terms incorporating surgery and MDR-TB. No language or publication type limits were applied. Articles published pre-1990, without a comparator group, or reporting <10 surgical participants were excluded. Two-stage sifting in duplicate was employed. Data on WHO-defined treatment outcomes were abstracted into a standardised database. Study-level risk of bias was evaluated using standardised tools. Outcome-level evidence quality was assessed using GRADE. Forest plots were generated, random effects meta-analysis conducted, and heterogeneity assessed using the I(2) statistic.



Of 1024 unique citations identified, 62 were selected for full-text review and 15 retained for inclusion. A further four articles were included after bibliography/citation searching, and one additional unpublished manuscript was identified, giving 20 articles for final inclusion. Six were meta-analyses/systematic reviews and 14 were primary research articles (observational studies). From the 14 primary research articles, a successful outcome (cured/treatment completed) was reported for 81.9 % (371/453) and 59.7 % (1197/2006) in the surgical and non-surgical group respectively, giving a summary odds ratio of 2.62 (95 % confidence interval 1.94-3.54). Loss to follow-up and treatment failure were lower in the surgery group (both p = 0.01). Overall GRADE quality of evidence for all outcomes considered was "very low".



This meta-analysis suggests that surgery as an adjunct to chemotherapy is associated with improved treatment outcomes in MDR-TB patients. However, inherent limitations in observational study design, insufficient reporting, and lack of adjustment for confounders, led to grading of the evidence as very low quality. Data on rationale for surgical referral, subsequent outcomes and resource-limited settings are scarce, precluding evidence-based recommendations on the suitability of surgery by patient characteristics or setting. It is hoped that highlighted methodological and reporting gaps will encourage improved design and reporting of future surgical studies for MDR-TB.
TB Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. rebecca.harris@lshtm.ac.uk.
Rebecca C
RC
Harris
TB Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.|Saw Swee Hock School of Public Health, National University of Singapore, Singapore, 119077, Singapore.
Mishal S
MS
Khan
Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK.
Laura J
LJ
Martin
Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK.
Victoria
V
Allen
TB Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
David A J
DA
Moore
TB Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.|The School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
Katherine
K
Fielding
Department of Infection, Immunology and Rheumatology, Institute of Child Health, University College London, Guilford Street, London, WC1E 6BT, UK.
Louis
L
Grandjean
D000995:Antitubercular Agents / Q000627:therapeutic use*; D006801:Humans; D016017:Odds Ratio; D011013:Pneumonectomy; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000628:therapy*; D014397:Tuberculosis, Pulmonary / Q000628:therapy*
D000995:Antitubercular Agents
Extensively drug resistant; Meta-analysis; Multi-drug resistant; Pneumonectomy; Surgery; Systematic review; Tuberculosis