World Tuberculosis Day 2018: Can surgery help to treat multi drug-resistant TB?

Probably surgery will be the only hope if medications fail to treat MDR/XDR TB.

By: Debjani Arora | | Published: March 23, 2018 7:14 pm

While the government is ambitious about eradicating TB by the year 2025 the ground reality is that the number of people suffering from primary multidrug-resistant TB (MDR TB) is on the rise. Initially, people would get a TB infection which would need an antibiotic treatment to be cured. The standard treatment for TB has always been to put patients on the first line of drugs or antibiotics to fight the bacterial invasion. The most common antibiotics prescribed are Isoniazid (INH), Rifampin (RIF), Ethambutol, Pyrazinamide and the treatment can span anywhere from six months to a year. Read to know why India is under the threat of MDR-TB.

Tuberculosis (TB) is a potentially serious contagious disease caused by a group of bacteria called Mycobacterium tuberculosis complex. However, if the TB bacteria continue to proliferate in the body and develop resistance to the prescribed drugs it turns to become drug-resistant TB. It evolves when one is infected with a TB strain that is resistant to one or more of the standard antibiotics. Patients who develop resistance to isoniazid (INH) and rifampin (RIF) are said to harbour MDR-TB. MDR-TB cases worldwide have extensive drug-resistant TB (XDR-TB) where the infection becomes resistant to at least four anti-TB drugs. Such patients in addition to being resistant to INH and RIF, are resistant to fluoroquinolones (such as levofloxacin or moxifloxacin) and to at least one second-line drug (amikacin, capreomycin or kanamycin). This makes it challenging for doctors to treat multi-drug or extensive drug-resistant TB. Read to know how is tuberculosis diagnosed.

So we spoke to Dr Amol Bhanushali, Consultant Thoracic Surgeon at Center for Lung Surgery, Dr Bhanushali Hospital, Thane to know if surgery can help to treat MDR-TB or XDR-TB.

Can surgical interventions help to treat MDR-TB, TDR-TB and XDR-TB?

In India we come across Drug-Resistant TB (DR-TB), Multidrug-resistant TB (MDR-TB) and Totally drug-resistant (TDR TB) / extremely drug-resistant TB (XXDR TB) which is extremely difficult, although not always impossible to treat. But one should definitely take a surgical opinion if there is no improvement even after six months of Drug-sensitive Anti Tubercular Treatment (ATT) or medications.

Even the World Health Organisation (WHO) has clearly stated that surgery for tuberculosis is indicative when the patient does not respond to ATT i.e. the sputum is still positive for TB bacteria after six months of ATT if there is a progressive worsening of the disease even when on ATT or if there is a relapse.

Even with early diagnosis, timely treatment and adherence to medications why do the drugs fail at times?

Anti-TB drugs do not penetrate parts of the lung which are destructed by TB. Surgery is performed to remove part or whole of the destructed lung thus eliminating a majority of the bacterial load and preventing the infection from spreading to the healthy part of the lungs. Further course of drugs kills the remnant bacteria thus rendering the patient disease-free after surgery. These days, a combined medical and surgical approach is increasingly being used to treat patients with M/XDR-TB.

Complications of TB such as blood in a cough, persistent Tuberculous cavity, fungal infection (aspergilloma) in the cavity, the formation of a bronchopleural fistula and collapse or destruction of the lung preventing its expansion and proper functioning, need to be addressed surgically. Another common condition wherein pus accumulates between lung and ribs (empyema) needs timely surgical treatment. Read to know how delaying proper treatment for TB can be detrimental to health.

How is the surgery done?

For many decades, lung surgery is being done via an 8-10-inch-long incision over the chest. This technique is called open thoracic surgery, which though effective causes a lot of post-operative discomforts, pain, prolonged hospital stays and a very big scar. With advances in technology and expertise, now-a-days, we perform most of the lung surgeries through the video-assisted thoracoscopic surgery (VATS) approach. This is a minimally invasive technique in which the entire surgery is done using a small camera attached to a scope, along with specially designed instruments and endo-staplers which are inserted through 3 to 4 tiny (1 cm) incisions in the chest wall.

What are the after-effects of the surgery?

Since VATS is done via small incisions, the patient is extremely comfortable with minimum post-operative pain. He can go home in 3-4 days, can regain full level of function and go back to his routine within 2-3 weeks as against 2-3 months if done via the Open approach. The patient has negligible scars as compared to the long scar of Open Surgery. Also, in VATS there is no cutting of muscles and no injury to the ribs, thus making the overall experience of surgery a lot more comfortable. Almost all surgeries in the chest, which were traditionally done by open surgery, can now be done by VATS.

Image source: Shutterstock

Published: March 23, 2018 7:14 pm

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