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Panelists of Role of Surgery in Management of Tuberculosis and GHDonline staff

Role of Surgery in Management of Tuberculosis

Posted: 05 Jan, 2015   Recommendations: 14   Replies: 84

In an era of increasing rates of drug resistant tuberculosis and lack of fully effective medicines, the role of surgery in management of tuberculosis is being revisited. In 2012-2013, WHO Regional Office for Europe hosted an international Task Force who developed an expert opinion paper based on the available evidence. In order to discuss further and exchange opinion, GHDonline is pleased to welcome a panel composed of the following experts (in alphabetic order):

• Paul Bolinowski, Thoracic surgeon, New Jersey, USA
• Dmitriy Giller, Thoracic surgeon, Moscow, Russian Federation
• Igor Kalabukha, Thoracic surgeon, Kiev, Ukraine
• Ravindra Kdewan, Thoracic surgeon, New Delhi, India
• Denis Krasnov, Thoracic surgeon, Novosibirsk, Russian Federation
• Alfred Lardizabal MD, New Jersey, USA
• Giovanni Sotgiu MD and Public Health expert, Sassari, Italy
• Jean-Pierre Zellweger MD, Bern, Switzerland

Moderated by: Masoud Dara MD, Brussels, Belgium

During our week-long discussion from 12 to 16 January 2015, the panelists will address the following questions:

1. Which patients and at which stage of their disease would benefit most from surgical interventions?
2. What are the risk/benefits of surgical interventions and how to mitigate them?
3. How to combine medical and surgical treatment?
4. Which types of surgical interventions are recommended?
5. What are the requirements for a successful outcome of a surgical operation?
6. How to build further the evidence for rational use of surgery?

We’re looking forward to a rich discussion the week of 12 January 2015 week – please join the conversation and share your questions and/or comments with the panelists!

Replies

 

Sudip Bhandari Replied at 1:48 PM, 5 Jan 2015

In preparation for next week's discussion, I want to share a resource that might be of interest.

The attached document is developed by WHO Regional Office for Europe in 2014, and presents an Expert Opinion on the role of surgery in the treatment of pulmonary TB and M/XDR-TB.

Attached resource:

Sandeep Saluja Replied at 4:34 PM, 5 Jan 2015

Interesting and very pertinent!

However,our discussion could soon be outdated once more new drugs come in!

Masoud Dara, MD Replied at 4:44 PM, 5 Jan 2015

Dear Sudeep,

That would be a dream come true. Let's wait and discuss it with all the members and the panel next week as I am sure there will be also other opinions.

Juan Jose Guadamuz Vado Replied at 5:22 PM, 5 Jan 2015

In Nicaragua no have operatios for tuberculosis. I hope goods ideas after the panel
thanks for yourm invitation

Murali Ramachandran Replied at 11:57 PM, 5 Jan 2015

Dear all,

Thanks for the invitation.

Considering the current status of drug resistant tuberculosis worldwide the
above discussion on Surgical interventions in pulmonary tuberculosis is
important in a public health aspect . Attached herewith are my remarks on
the said topic in response to the questions for further discussion in the
panel.

Murali Ramachandran Replied at 1:39 AM, 6 Jan 2015

Dear all,
Thanks for the invitation.
Considering the current status of drug resistant tuberculosis worldwide the above discussion on Surgical interventions in pulmonary tuberculosis is important in a public health aspect . Attached herewith are my remarks on the said topic in response to the questions for further discussion in the panel.
Prof.Dr. R. Murali
Public Health Expert
Chettinad Hospital and Research Institute
Kelambakkam,Tamilnadu,India

1 . Patients who benefit most from surgical intervention :
• a high probability of failure of medical therapy in MDR-TB patients (due to persistent
cavitary disease and lung or lobar destruction) and massive haemoptysis or tension
pneumothorax
• persistent positivity of sputum-smear or sputum-culture despite adequate chemotherapy
• Recurrent or recalcitrant localized disease
• Destroyed lung with recurrent infection (with adequate pulmonary reserve)
• Bronchopleural fistula
progression of TB despite adequate chemotherapy
• Repeated haemoptysis or secondary infection
• Localized disease amenable to resection
• polyresistant and MDR-TB;
• absence of any radiological and/or bacteriological improvements during the initial three to four months of chemotherapy;
• allergic, toxic and mixed side-effects of drugs;chronic diseases of the gastrointestinal organs hindering effective chemotherapy
Stage of disease for surgical intervention :
- Surgery should be seriously considered when:
• the disease is sufficiently localized to allow surgery;
• the remaining lung tissue around the resection margins is estimated to be free of TB;
• the patient’s surgical risk level is acceptable, with sufficient pulmonary reserve to tolerate
the resection.
2. Risk of surgical interventions :
Early complications :
Respiratory failure
• BP fistula
• Wound infection
• Post op hemorrhage
• Recurrent laryngeal nerve injury
• Intrathoracic bowel herniation
Late complications :
• Late respiratory failure
• Recurrent MDR-TB
• Drug overdose
• Myocardial infarction
• Renal failure
Surgical complication rate may range from 1- 16%
3.Combining medical and surgical intervention :
• culture-positive patients at the time of surgery:
• with susceptible TB, four to six months after culture conversion
– with MDR-TB, at least 18 months after culture conversion
– with XDR-TB, at least 24 months after culture conversion;
• culture-negative patients at the time of surgery:
– with susceptible TB, at least four months after surgery
– with M/XDR-TB, six to eight months after surgery (depending on postoperative
recovery).
4. Types of surgical intervention:
– wedge resection
– segmentectomy
– lobectomy and bilobectomy
– combined resection (lobectomy plus minor resection)
– pneumonectomy or pleuropneumonectomy
– lung resections with different correction methods of the haemithorax’s volume;
- extrapleural thoracoplasty;
- extrapleural pneumolysis;
- thoracomyoplasty;
- pleurectomy and decortications of the lung;
- operations on the bronchi:
– occlusion
– resection
– bronchoplasty
– re-amputation of the stump;
-thoracocentesis and thoracostomy (drainage of the pleural space);
- artificial pneumothorax and pneumoperitoneum;
- operations on both lungs.
5.
• indications for surgical treatment
• conditions for and timing of surgery
• types of operation to treat TB
• contraindications for elective surgical treatment
• preoperative management
• patient-centered approach
• postoperative management.
6.
• assessment of the surgical interventions for treatment of tuberculosis with emphasis on risk vs benefit
• a common data base to report all surgical interventions for analysis and decision making and further planning
The decision depends on prioritizing and weighing the option available depending medical and other conditions like age/stage of the disease etc.

Prof.Dr.Matiur Rahman Replied at 2:49 AM, 6 Jan 2015

Excellent topic for panel discussion.I will love to participate.
Regards
Mati

Prof.Dr.Matiur Rahman Replied at 2:51 AM, 6 Jan 2015

Excellent input Dr.Murali Ramchandran

AMINA HAMZA Replied at 4:15 AM, 6 Jan 2015

Thank you, am looking forward to it.

Mansour Ramadhan Replied at 10:14 AM, 6 Jan 2015

Its a good topic for discussion

Matchecane Cossa Replied at 10:58 AM, 6 Jan 2015

Hello everyone!

I am very excited with the topic to be discussed.

Here in Mozambique 80% of my surgical work is related to complications of tuberculosis and HIV/AIDS.

I hope its going to be a nice discussion

Matchecane cossa
Thoracic surgeon
Maputo, Mozambique

Herbert Kadama Replied at 11:10 AM, 6 Jan 2015

Looking forward to the discussion.

Elie AHORUGEREYE Replied at 12:04 PM, 6 Jan 2015

Very interesting discussion!

Rajbir Singh Replied at 1:16 PM, 6 Jan 2015

yes I confirm my participation.

Emmanuel Edward Replied at 1:41 PM, 6 Jan 2015

It's really important,this discuss,because of the frequently encountered complications of PTB in many patients. My problem, as as it concerns this intervention is the challenge of funding,as TB is frequently seen in people of low socioeconomic status,and I'm hoping this respected panel will say a word or two about that.

Salem Barghout Replied at 1:58 PM, 6 Jan 2015

Thanks Masood for your invitation and look forward to participating in the
discussion.

Umashankar Kumpatla Replied at 4:37 AM, 7 Jan 2015

Dear Team,


The following is the input that can be provided for 3 questions out of 6:


1] Which patients and at which stage of their disease would benefit most
from surgical interventions?

Ans: Patients who have localized disease affecting only a part of lung
tissue will benefit most from surgical intervention in conjunction with
chemotherapy. Surgery can also be considered in cases where there is
extensive parenchymal involvement .


Question that can be raised from my side:


There is a need to develop definite criteria for selecting a TB patients
with MDR/XDR TB for surgical intervention. Till date there is no defined
specific criteria hence question to be raised is *What will be the definite
criteria’s for considering surgery in MDR/XDR patients on chemotherapy?*



2] Which types of surgical interventions are recommended?

Ans: Surgical resection of solitary cavitary lesion, pneumonectomy,
lobectomy and segmentectomy are the type of surgeries that are recommended
in Tuberculosis patients.



3] What are the requirements for a successful outcome of a surgical
operation?

Ans: Pre-requisite for a successful outcome of a surgical operation include
patients who are:

· On chemotherapy for 6 to 9 months and is culture negative

· MDR/XDR patient who is HIV negative

· MDR/XDR patient who is not on immunosuppressant’s or
anti-diabetics

· MDR/XDR patients who do not have bilateral extensive disease

· Localized lesion/cavity where is infection is placed in the lung

Post surgery the outcome can succeed if the patients is continued
on anti-TB treatment as per WHO guidelines or on individualized regimen
based on their drug susceptibility profile.

Felix Rosario Teimoso Replied at 3:36 AM, 10 Jan 2015

Hi everyone!
The topic to be discussed is very interesting. I will be very happy to follow it!
Regards

Felix
Mozambique

Sofia Alexandru Replied at 1:22 PM, 10 Jan 2015

Thanks Masoud,
It is really the important topic and is necessary to be discussed
As you know, in Moldova, surgery is used in management of tuberculosis cases..

Abdul ghafoor Replied at 11:12 PM, 10 Jan 2015

Looking forward for an exciting and informative discussion on a very important and relevant topic.
Dr. Ghafoor

Kenneth Adagba Replied at 1:27 PM, 11 Jan 2015

Looking forward to an exciting and educative discussion......Experienced shared would go a long way in enhancing efficient service delivery....

Abraham Lebenthal Replied at 1:49 PM, 11 Jan 2015

Hi
very important topic
would be happy to be part of taskforce.
Avi Lebenthal

egh Eduardo Gotuzzo Replied at 9:45 PM, 11 Jan 2015

as everybody know in peru we have important problem with TBCMDR and one
specifc indication is patient with clinical cure but sputum positive after
6 months with cavity or focal lesion .other indication is slow cure or
progression of tbc even with good and proven senstive drugs in 2nd line
because was organized to have fixed critera and only one specific group of
thorac surgery the mortality wae 4% and the improve was important with more
the 75%of reduction even with bilateral surgery
We feel this option is clear and we need to promote in specfic cases with
poor evolution or positve sputum after several months with clinical
improvement
warm regards
e. gotuzzo

Ravindra Dewan Replied at 11:06 PM, 11 Jan 2015

I am Ravindra Kumar Dewan, Head, Department of Thoracic Surgery at the National Institute of TB and Respiratory Diseases, New Delhi, India. National (erstwhile LRS) Institute of TB & Respiratory Diseases, New Delhi, is a 500-bedded tertiary referral center for all types of chest diseases & functions as an autonomous Institute under Government of India. My unit consists of one more Thoracic Surgeon Dr. Rajat Saxena, two senior residents and two junior residents. We get referrals from almost the whole of North India and adjoining countries like Nepal and Bangladesh. The referrals usually include cases of complications and sequel of pulmonary tuberculosis like drug failure, hemoptysis, Empyema or destroyed lungs or Bronchiectasis, carcinoma lung, interstitial lung disease, mediastinal or chest wall tumors, constrictive pericarditis or referrals for bronchoscopy, foreign body removal from airway, mediastinoscopy or Video-assisted Thoracic Surgery. The experience and expertise is somewhat unique as there is an extreme shortage of practitioners engaged in general thoracic surgery. Three working days of the week are OT days and two or three thoracotomies are done on these days. On other days, endoscopic procedures are done at a frequency of about 5-6 per day. About 20 referrals are assessed in the outpatient clinic twice a week, which is held in the afternoon.

Ravindra Dewan Replied at 11:13 PM, 11 Jan 2015

In the context of DR-Tuberculosis, in my opinion, the following are the best indications:
Broad Indications for Surgery
-Suitable for selected cases
-Localized Disease
-Adequate Trial of ATT
-Localized cavities/nodules Drug Failures
-Chronic secretors
Specific Situations Suitable for Surgery:
Cultures persistently positive beyond 4-6 months of appropriate treatment 
Culture re-version to positive during treatment
 MDR TB with additional resistance to 2nd line drugs
Extensive TB (more than one lobe/bilateral)
Cavities ( diameter or > 10cm )or extensive fibrosis of the lungs ( more than one lobe/bilateral)
Previous non-adherence to treatment (interruption or missing doses is >20%)
High bacillary load before starting the treatment
Some co-morbidities (diabetes, COPD, HIV), low BMI, alcoholism
In addition to DR- Tuberculosis, massive recurrent hemoptysis, repeated chest infections because of persisting bronchiectatic lung segments/destroyed lungs and Empyema are other situations where surgical intervention is required in the life journey of a TB patient. Of course, there are many diagnostic situations, where surgery is required for getting appropriate biopsy or culture specimens.

Haluk Çalışır Replied at 12:05 AM, 12 Jan 2015

Thanks for invitation,
Our experience in Turkey, surgery may be part of the management of drug resistance cases. Quinolone resistance is an important factor for the nomination of surgery. Surgical treatment of MDRTB was used more late 90'ties and early 2000. I think, Quinolone resistance and XDRTB are major indications of surgical intervention of drug resistance management in our country.
It must be a team work among, medical, surgical and anesthesia clinics for success.
Best regards,
Haluk C Çalışır M.D.
Assoc. Prof. Pulmonary Disease
Atakent Acibadem University Hospital
Istanbul/ Turkey

Masoud Dara, MD Replied at 1:48 AM, 12 Jan 2015

Thank you very much Dr Çalışır for this useful feedback. In addition to quinolone resistance and XDR-TB, what are the other indications for surgical interventions in your setting? Age, unilateral lesion, extent of the lesion, other associated conditions? Today we try to focus on the election criteria and our panelists will also share their experiences, so your inputs and those of the GHD online DR-TB community are highly welcome.

CLEMENT ADESIGBIN Replied at 3:09 AM, 12 Jan 2015

In addition to Dr Dewan long list of indications, we have seen in Nigeria, although not often, cases of non mycobacteria tuberculosis(NTMs) particularly MAC which could re occur in a patient and surgery may be the last hope.
One that is very fresh in my memory, was in a lady of about 50 years old who had about 4 episodes of this disease. She improved and get cured following each episode. She was not having any immunosuppressive condition. However, she's had MTB before the 4 episodes mentioned above with complication(fibrotic distortion of respiratory anatomy allowing for the present condition)

In such patients, surgery could play a significant role.

Ravindra Dewan Replied at 3:38 AM, 12 Jan 2015

Dear Dr. Clement, any patient having two relapses or a single relapse while ON therapy should be actively considered for surgery.

CLEMENT ADESIGBIN Replied at 4:10 AM, 12 Jan 2015

Agreed Dr Dewan. I want to believe in the course of this discussion we would have sessions on the challenges we face in the field especially in developing nations.

Jean-Pierre Zellweger Replied at 5:07 AM, 12 Jan 2015

I am a retired pulmonary physician, former chief of the TB department at the University hospital in Lausanne, with some experience of the management of TB in different settings (Europe, Africa and Eastern Europe). During my working time (25 years), we used surgery in my hospital only in two cases of MDR-TB, one who came in with a bronchopulmonary fistula after surgery performed in a foreign country and another because of acute hemoptysis. All other cases of MDR-TB and no single case of drug-sensitive TB had to be submitted to surgery and could be managed by a conservative drug treatment. Among the last 51 cases of MDR-TB observed in Switzerland and recently summarized by the Federal Office of Public Health, only 2 had to be treated surgically, and our cure rate is 76%.

My position is:
1. Surgery is useful
a) in life-threatening situations (in drug-sensitive and MDR-TB) and
b) in M/XDR-TB with unilateral involvement but persistant smear or culture positivity in spite of optimized drug treatment.
2. In my opinion, there is NO indication for surgery in drug-sensitive TB apart from life-threatening situations (massive hemoptysis). Surgery for residual lesions at the end of treatment is a NONSENSE (but I have seen it performed in the ancient times, before 1980)
2. The progressive availability of new drug treatments (linezolid, delamanid, bedaquilin, etc) will probably reduce the number of desperate situations where surgery is the only hope
3. Persistance of smear positivity in correctly treated drug-sensitive patients may be due to malabsorption of drugs and is better corrected by an increase in drug dose or a change in treatment (measurement of serum level of rifampicin may be a very useful addition to our diagnostic tools) than by resecting a part of the lung.
4. The experience in surgery of TB is scarce in many high-income / low-incidence countries. On the contrary, availability of lung surgery may be totally absent in many low-income / high-incidence countries. Therefore, the discussion and the choice of treatment are partially linked with the local resources.

Haluk Çalışır Replied at 5:25 AM, 12 Jan 2015

Dear Dr. Dara,

We have treat MDRTB cases since early nighties in Turkey. There were
several cases who used quinolons and some other minor antitb drugs before
diagnosed MDRTB in those days. There were less drugs available during those
days in the country. We used surgical treatment for the management of MDRTB
cases. Our main criterias for adjuvant surgical approach were;
1. Local, cavitary lesions,
2. Available medical treatment regimen, at least 4 drugs
3. General conditions suitability such as any other thoracic operations,
including pulmonary function test and postoperative predictive pulmonary
function tests,
4. Preferred surgical operation time was generally 3.rd month of the
medical treatment, unless emergency situation.
5. Extended resections rather than limited.
6. Social and physiological support for patient and his/her family.

Practically, MDRTB treatment have been done only for centers since the
nighties in the country. Fortunately, quinolones and enjectables were used
under some control and MDRTB rate stayed stable or declined during time.
There were 262 MDRTB cases, 116 of them new cases in 2011 according to The
MoH data. There is some increase for MDRTB rate among previously treated
cases. ( The rate was 17,7% in 2005 and 24,3% in 2011)

There is also some increase for foreign origin cases. There were 63 (all)
cases in 2005 and 202 foreign born cases in 2011. Most of the foreign
origin cases also have previous treatment history and usually they have
already used quinolons and enjectables. ( Probably XDRTB) Surgical
treatment is now an option in such cases with optimal medical treatment. I
think surgical management of MDRTB cases will be done more frequently than
past. 6 criteria which we used can be consider for patient selection.

Denis Krasnov Replied at 5:49 AM, 12 Jan 2015

Since TB and especially DR-TB are widespread in Russia, we try to use
surgical methods in a complex treatment as often as possible. In
Novosibirsk Tuberculosis Research Institute 350-400 surgical operations
every year are performed, including lung resections of different size,
pneumonectomy or pleuropneumonectomy, extrapleural thoracoplasty,
osteoplastic thoracoplasty, pleurectomy and decortications of the lung,
operations on the bronchi, thoracocentesis and thoracostomy (drainage of
the pleural space), artificial pneumothorax and pneumoperitoneum.
In each case we make an individual decision regarding the surgery, but in
general we follow to well known indicators:
the disease should be sufficiently localized to allow surgery, the
remaining lung tissue around the resection margins is estimated to be free
of TB;
the patient’s surgical risk level is acceptable, with sufficient pulmonary
reserve to tolerate the resection. Additionally we try to provide surgery
for all patients with TB/HIV, in complicated cases.

Igor Kalabukha Replied at 10:11 AM, 12 Jan 2015

Dear Colleagues,
I am a chief of the surgical department of the National Institute of Tuberculosis and Pulmonology, National Academy of Medical Sciences of Ukraine. Kiev Ukraine.
First of all, I would like to thank prof. Murali Ramachandran for his excellent report. I agree with all the provisions which are presented in this report. We use the same indications for surgery and the same types of operations. We think that indications for the use of surgery are morphologically irreversible lung damages as a result of TB. I present used in our clinic table with types of tuberculous lesions, indications, and the types of surgery in attached file.
I want to note that I do not quite agree with Dr. Jean-Pierre Zellweger in several positions. I think that drug-sensitive TB is also subject to surgery, if it led to the morphologically irreversible consequences: the destruction of the lung, large or multiple cavities, extensive cirrhosis with bronchiectasis and multiple foci. Also I consider it necessary regarded differentially large residual changes tuberculosis. According to my observations, most of relapse occurs against a background of large residual changes. Correct application of surgical treatment of large residual changes reduces the number of relapses.

Attached resource:

Jean-Pierre Zellweger Replied at 4:25 PM, 12 Jan 2015

I thank Dr Kalabukha for his commments and agree with him that he touched one of the key issues: is there an indication for surgery in drug-sensitive cases? Of course, a patient with a destroyed lung, bronchectasies, aspergillosis or a threatening condition should be treated surgically in order to avoid a serious risk of massive hemoptysis. The point is if this is a frequent situation (in drug-sensitive patients) or a very seldom event. Furthermore, another point is to know if this situation is a risk of respiratory failure for the patient apart from the risk of recurrent TB. I am always struck by the fact that the reported rate of relapse is very different between countries and programmes, from 0.4% in Australia (Dobler CC et al, Recurrence of tuberculosis in a low-incidence setting, Eur Respir J 2009;33:160-7) to 10 to 15% in other countries. In my experience (mostly with immigrants, socially disadvantaged, or maginalized patients, many of them with extensive disease), the rate of relapse was less than 1%, but we used DOT and social support routinely. And the only patients I have seen with a destroyed lung or respiratory failure were patients treated before the advent of modern chemotherapy (in the 70es) and treated with pneumothorax, mutilating surgery or insufficient chemotherapy. Therefore, the point is not to know how to treat relapses with a destoyed lung but how to avoid that the patient progress to this serious situation. Another point is the definition of relapse (bacteriologically documented or clinically suspected) , and the distinction from re-infection, but this is beyond the scope of this forum. I maintain that a patient with bacteriologicaly documented cure and a normal lung function (whatever the radiological appearance) is not a candidate for surgery.

Francesco Aloi Replied at 5:35 PM, 12 Jan 2015

thanks for the invitation and looking fw



*Dr. Francesco Aloi *
*AISPO Country Representative | Project Manager*
C/o St. Francis Hospital Nsambya | P. O. Box 7146, Kampala
*Tel/Fax:* *+256 414 269 100*, *Cell 1**:* *+256 772 826 952*, *Cell 2**:* *+39
339 3245072*
*e-mails:* , ,

Alfred Lardizabal Replied at 8:58 PM, 12 Jan 2015

Dear colleagues,
Thank you for the invitation to be part of this panel discussion on the on the role of surgery in the management of TB. My name is Alfred Lardizabal a pulmonologist and Executive director of the Global Tuberculosis Institute at Rutgers University in New Jersey. The institute provides medical consultation, clinical care, education and training in tuberculosis for the state as well as the northeast region of the United States.

With regards to surgery and TB, I would say that the most frequent role would be as a tool for diagnosis by obtaining biopsies using video assisted thoracoscopy, mediastinoscopy, and occasionally open lung biopsies. The next most frequent role for surgery would be to manage complications of TB such as hemoptysis, vascular aneurysms requiring grafts, pericarditis/peicardial effusions, bronchopleural fistulas and TB empyemas, chylothoraces, and resection of severely damaged lung parenchyma infected by non-TB mycobacteria such as M. abscesses.

A majority of patients with pulmonary TB, including extensively drug resistant cases, can be successfully managed medically as long as drug supply and adherence to treatment is assured by comprehensive case management. However, there are instances when surgery needs to be consider as an adjunct to medical management, particularly when medical options are extremely limited due to resistance, drug allergies/intolerance/adverse effects. In these situations, consideration for surgery should be done earlier (within the first 4-6 months) rather than later. It would be ideal if the lesion is localized but that is not always the case. At the very least, some clinical response to medical treatment should be documented. Better if they convert their culture to negative. Segmentectomies or lobectomies and done frequently, nut there are situations wherein a pneumonectomy may need to be performed. This possibility should be prepared for and assessed prior to pursuing surgery. I would be remiss if I do not mention the importance of optimizing nutrition in preparation for surgery.

Ravindra Dewan Replied at 11:42 PM, 12 Jan 2015

Some interesting points have been raised here. I have already delineated the main situations in DR-TB where surgery is warranted. However, even in drug sensitive TB, if the patient continues to be sputum positive beyond six months( and this situation is not uncommon, at least in India), surgery definitely improves the overall chances of sputum conversion and more significantly for persistence of the negative state, provided the disease is limited to maximum of one lung and the patient is fit to tolerate surgery. I may mention that I have operated upon 107 patients of DR-TB and 38 patients for persistent sputum positive status in the last 19 years. In addition, we did 6 such cases in Armenia
However, much greater number of patients require surgery for complications and sequel. We never operate upon post TB sequel until and unless they are causing symptoms and problems for the patient. These situations are recurring chest symptoms requiring frequent medical attention, massive recurrent hemoptysis, aspergilloma in residual cavities causing continuing hemoptysis for a long time and empyema with or without BPF.
These situations are quite frequent in India. For instance, in the year 2014, we carried out a total of 786 procedures in out OT and roughly 70% of these procedures are done for TB and TB complications. There were 39 pneumonectomies, 48 lobectomies, 49 decortications, 27 thoracoplasties, 178 open window thoracostomies and 25 rib resections. I have yet to compile data of these procedures according to indications but majority are definitely for TB.
However, it has to be realized that TB surgery is a high risk enterprise and has to be undertaken only when there is a clear indication and medical management is unlikely to be sufficient. The following new technologies have added to the safety of this surgery and have helped us minimize morbidity:
Double lumen endotracheal tube
Pediatric fibrebronchoscope to position the DLT
Surgical staplers
Tissue patch
Fibrin glue and other hemostatic agents
Argon beam coagulation
Digital portable chest drainage systems having adjustable suction

Ravindra Dewan Replied at 11:58 PM, 12 Jan 2015

I agree with Dr. Alfred Lardizabal that the most frequent role would be as a tool for diagnosis by obtaining biopsies using video assisted thoracoscopy, mediastinoscopy, and occasionally open lung biopsies and the next most frequent role for surgery would be to manage complications of TB such as hemoptysis, vascular aneurysms requiring grafts, pericarditis/peicardial effusions, bronchopleural fistulas and TB empyemas, chylothoraces, and resection of severely damaged lung parenchyma infected by non-TB mycobacteria such as M. abscesses.

Giovanni Sotgiu Replied at 3:25 AM, 13 Jan 2015

Goodmorning! My name is Giovanni Sotgiu. I'm professor of Medical Statistics and Clinical Epidemiology in the University of Sassari, with a specific ID background. I work in the University of Sassari, Italy, and I contributed to the WHO Euro document on TB surgery.
I agree with the previous interventions of Dr JP Zellweger on the issue of surgery and drug-susceptible TB. The current pharmacological background can support the management of the most difficult-to-treat cases.
The early diagnosis and the rapid administration of the anti-TB drugs should avoid the clinical evolution. The surgery can raise several issues, particularly in settings (for instance in high-income countries) where the surgical experience with TB patients is not relevant.
One of the most important risks is represented by the infection control.
Before going to surgery, the clinical and public health evaluation should be careful.
BW
Giovanni

Ravindra Dewan Replied at 5:10 AM, 13 Jan 2015

I wish that the entire world was as orderly and well managed as Sassari. TB and its complications continue to bother public health authorities in most of South Asia, Sub-Saharan Africa, former Soviet Republics, Peru and pockets in inner cities of the West. Though we should hope at almost 90% cure rate with good medical management, this is not always the case and in some parts the remaining 10% also become huge in absolute numbers. Hence, the contrast in the experience.

Fuad Mirzayev Replied at 5:26 AM, 13 Jan 2015

interesting discussion and thanks to both organizers and panelists.
I have a question to the panel, part of the answer has already been discussed but it might be good to make a summary. What are, in your view, 3 (or 4) main reasons why surgery is, apparently, being used much more frequently in some countries and is much less frequent in others?

Igor Kalabukha Replied at 6:39 AM, 13 Jan 2015

Regarding what was said above.
I absolutely agree with colleagues who recommend the use of surgery for the diagnosis of tuberculosis. In our clinic are performed annually about 150 diagnostic videothoracoscopy. Most often, they are produced in patients with pleural effusion syndrome. Also, according to indications, performed a biopsy of mediastinal lymph nodes and lung biopsy (resection margins). We are sure that videothoracoscopy should be performed in all cases of pleural effusion syndrome, if the diagnosis has not been established as a result of pleural puncture.
Thank Dr. JP Zellweger for his extended comments. Probably significant differences in treatment outcomes in different countries are determined significant differences in the indications for surgery. Unfortunately, we often see the outcomes of drug therapy, which can`t be considered satisfactory even if mycobacteria in sputum no longer be detected. So, I can`t agree that the radiological picture is not important.

Denis Krasnov Replied at 7:24 AM, 13 Jan 2015

Dear Colleagues,

thank you very much to all of you for your comments. Indicates which we
use in Russia for surgery in TB patients are very close to indicates
provided by Dr Kalabukha. I also agree with his point of view regarding
surgery for patients with drug sensitive TB, we consider surgery as a part
of complex treatment in both categories of patients with sensitive and
resistant TB.

According to a wide spread of M/XDR-TB in Siberia and Far East Federal
Districts, we consider it is important to apply operations leading to
collapse of lung tissue, such as extrapleural thoracoplasty. We have
developed a version of extrapleural thoracoplasty with mini invasive
access, in this case the cosmetic defect is completely absent. We use this
type of operation for patients with complicated cavitary forms of TB for
whom lung resection is contraindicated for any reason.
Since 2011 225 patients were operated by this method in our institute and
we have quite good and optimistic results. We will be glad share both
theoretical knowledge about the effectiveness of this method of surgical
treatment, as well as practical skills. We will be happy if this technique
will be useful for patients not only in Russia but also in other
countries.

Jean-Pierre Zellweger Replied at 8:06 AM, 13 Jan 2015

I fully agree with Igor Kalabukha that the difference in outcome and the difference in rate of relapses between countries is one of the reasons for the differing indications for surgery. The strange point is that there are such differences, given the fact that the mycobacteria are the same everywhere and the treatment schedules should be the same in all countries.
What I do not understand is why in some countries the rate of relapse from healed lesions is so high whereas in other regions it is quite seldom. I suspect that there is something with the definition of cure, but I do not see why a patient with three negative cultures and no symptoms should be submitted to surgery after the drug treatmebnt, whatever the size of the fibrotic lesions on the chest X-ray.

Najib Safieddine Replied at 9:57 AM, 13 Jan 2015

Thanks you for the discussion.very interesting esp for those of us who practice in nonendemic areas but who are seeing more of this disease.

Sergo Vashakidze Replied at 12:36 PM, 13 Jan 2015

I am Sergo Vashakidze, Coordinator of Surgical Work at the National Center for Tuberculosis and Lung Diseases of Georgia.
Despite the fact that DOTS+ program functions in Georgia since 2008, the problem of MDR / XDR TB remains a very important to our country.In 2013, we published an article on the surgical treatment of 80 patients with MDR / XDR TB : Ann Thorac Surg. Jun 2013; 95 (6): 1892-1898."Favorable Outcomes for Multi- and Extensively Drug Resistant Tuberculosis Patients Undergoing Surgery."Today the number of patients with MDR/XDR TB operated by us has reached 176. Our experience (as well as the experiences of many of our colleagues) shows, that such patients can and should be operated with relatively few complications and mortality rate.Currently we conducting a comparative study of long-term results (2 years or more after removal from TB register) of medical and surgical treatment of patients with MDR/XDR TB.
I want to support a colleague Dr. Igor Kalabukha in his discussion with Dr.Jean-Pierre Zellweger about the advisability of surgical treatment of patients with so-called large residual changes of tuberculosis, as well as patients with sensitive TB. There are many cases (at least in Georgia) which support the need of surgery in such cases, similar to examples given in the attachment below.
I think we need to clarify the concept-residual changes of tuberculosis and seriously think about the definition - cure from tuberculosis.

Attached resource:

Masoud Dara, MD Replied at 1:55 PM, 13 Jan 2015

Thank you very much Sergo for your input and sharing your publication. In some settings like Georgia with very high resistance to second line drugs, the role of surgery is even more important. I am also aware that you assess every case on an individual basis for rational use of surgery.

Masoud Dara, MD Replied at 2:20 PM, 13 Jan 2015

Dear Fuad,

Thank you for your question. I start and other colleagues may wish to add:

I believe the following factors play a role in why in some countries, more proportion of TB patients are operated than in other countries:

- Treatment failure rate / linked to prevalence of resistance to anti-TB medicines

- School of medicine of the country and interaction of surgeons and clinicians within the health system including the referral and follow-up mechanisms.

- Availability and affordability of operating theatres and experienced surgeons

There are limited international publications particularly in Russian speaking countries on the use of surgery. One also needs to analyse whether in some settings, invasive approaches have been used rationally, in other words how many patients could have been successfully cured without surgical intervention.

I have also noticed in some settings, some surgeons are reluctant to operate on HIV positive individuals, despite the fact that special protective measures can be made available.

Igor Kalabukha Replied at 3:50 PM, 13 Jan 2015

About p. 2: What are the risk/benefits of surgical interventions and how to mitigate them?

I believe that the benefits of surgery are: the ability to healing of patients who can`t be cured without surgery; the prevention of complications and recurrences of TB.
We have analyzed the unsatisfactory results of TB surgery and developed a conditions of performing lung resection with minimal risk.
By the time of the operation, we strive to achieve:
• termination or reduction of bacterial excretion;
• readjustment of the bronchi and cavities;
• healing of concomitant nonspecific inflammation;
• compensation of respiratory and cardiovascular disorders;
• correction of dis-coagulation disorders;
• remission comorbidities.
If necessary, we perform preoperative preparation to solve the above problems.
Sublobe/lobe resection or pneumonectomy may be done subject to the following conditions:
• no destruction in the contralateral lung (by CT-scan);
• absence of endobronchitis in the contralateral lung and not less than 1 cm distal from the zone bronchus suture on the side of the resection;
• not removed part of lung adequately fills the hemithorax
• resection is performed in accordance with anatomical regions of the lungs;
• separate processing of elements of root of the lung or lobe.
Using these principles, we have operated and have been observed in a period from 1 to 3 years 147 patients with MDR TB (8 - pleuropneumonectomy, 21 - pneumonectomy, 46 - lobectomy, 14 - combined resection, 58 - segment/polisegmentektomy). Postoperatively, patients were continued anti-TB therapy in accordance with the profile of drug sensitivity during 12 months . Unsatisfactory immediate results and mortality was not observed, there were 2 TB recurrences (1.3%).
Based on the foregoing, high safety can be achieved in well-equipped hospitals in the presence of an experienced multidisciplinary team of specialists.
I also want to emphasize that our recommendations are basic. Features of surgery may be more extensive, but it increases the risk, that may be the prerogative of only experienced surgeons with a high level of skill.

Jean-Pierre Zellweger Replied at 5:12 PM, 13 Jan 2015

I would like to answer to Dr D. Giller (not available on the Internet forum), who states that
"4. It is advisable to made lung resection when coming formation of large single and multiple tuberculoma (encapsulated foci of caseous necrosis larger than 2cm.) especially in the presence decay in to this tuberculoma. Often these changes in the lung occur without clinical manifestations and the presence of MB in the sputum. In these cases, their removal is the prevention of the formation of these cavities. The risk of transformation tuberculoms in the cavity according to Russian scientists is 20-30%.
5. Аvailability destructive tuberculous lesions lobe or lung with active progression and the expressed intoxication on the background of conservative treatment (caseous pneumonia), regardless of drug resistance is an absolute indication for immediate surgery."

I just wonder how the russian scientist come to such a conclusion that the risk of transformation of tuberculomas into cavities is 20-30% and would be happy to read a good publication on this topic (please indicate a good reference). The point is that I can find no publication in a non-russian Journal and no data from my former department which supports this claim. What is so special about TB in Russia which makes it different from the rest of the world? Or is this (again) a matter of definition of cure and are some patients simply not cured at the end of the treatment because of incomplete adherence or inadequate treatment schedule? Then the problem is not if surgery is indicated or not or if the surgeons are capable of chopping off the lungs but how to increase the cure rate of the patients.



Dmitriy Giller

Alfred Lardizabal Replied at 9:59 PM, 13 Jan 2015

Risk vs benefits of surgery (when used as adjunct to medical management of pulmonary TB):
Blood loss anemia, development of bronchi-pleural fistulas, infections, and in patients with borderline pulmonary reserve, possible chronic respiratory failure should a pneumonectomy be required (when a planned lobectomy is not possible).

Mitigating complications:
Pre-op, we do a bronchoscopy and do several endobronchial biopsies along the line of possible resection to rule out disease activity. We have also found that pre-op embolization has minimized intra-op bleeding and blood loss. On occasion, we have utilized PET scanning to locate areas of diseased lung with inflammatory activity and targeted those sites for resection. Finally, I need to emphasize that the most important factor to mitigate complications is to have the patient on the most potent drug regimen available before and after surgery.

Ravindra Dewan Replied at 2:11 AM, 14 Jan 2015

Dear colleagues, A number of interesting points have been raised in the discussion above. I would like to share my thoughts about them.
Regarding differing indications and outcomes in different settings, I have got the following comments to offer:
1. Rational indications should generally be uniform but as the issue has not been discussed and addressed sufficiently and hence the variation. Some centers do resort to surgery without a justifiable indication. I don't think that residual lesions in a sputum negative patient without much symptoms have got a justified indication for surgical intervention.
2. Availability of trained and skilled thoracic surgeons is vastly variable in most parts of the globe. In India, almost all of cardiothoracic surgeons are engaged in cardiac surgery alone and not doing much thoracic surgery. Hence, available expertise is limited.
3. There are places where there are extremely limited number of patients who require surgery for TB. Hence, surgeons working in these areas have got almost negligible caseloads to be able to develop skills in this challenging area of surgery.
4. TB surgery is a high cost intervention and requires good infrastructural support. As I have mentioned above that newer technologies (Double lumen endotracheal tube, Pediatric fibrebronchoscope to position the DLT, Surgical staplers, Tissue patch, Fibrin glue and other hemostatic agents and Argon beam coagulation) are very useful in decreasing morbidity. The focus of TB control public health authorities is in early diagnosis, drug supply and epidemiological issues and thoracic surgery does not get sufficient financial support, which is essential for risk free surgery and acceptable outcomes. This leads on to decreasing referrals for surgery even if there is an indication.

Now, I would like to list the measures necessary to improve outcomes and prevent morbidity and mortality:
1. Good case selection and carefully evaluating cardio-respiratory reserve and nutritional status of the patient before surgery.
2. Pre-operative and post operative physiotherapy and making the patient as dry as possible before surgery
3. Fully equipped operation theaters
4. Efforts to achieve sputum negative status before surgery, if possible
5. Bronchoscopy- preoperative as well as postoperative
6. Skilled anesthesia support, especially relating to correct placement of double lumen tube, central venous lines and epidural catheter

I agree with Dr. Denis Krasnov that extra-pleural thoracoplasty is an excellent procedure in some patients of bilateral disease and complex cavities. Many surgeons are not familiar with this procedure, which gives highly satisfactory results in carefully selected patients. We do it on a number of occasions in our Institute.

Ravindra Dewan Replied at 2:26 AM, 15 Jan 2015

Dear Colleagues, There have been no further comments on this topic for quite some time. I urge that please come forward to carry this discussion forwards. We have yet to discuss views of various professionals about morbidity, mortality and management of complications, methodologies to improve results, role of minimal access surgery and the studies required to clarify issues in this field of medicine.

Denis Krasnov Replied at 2:40 AM, 15 Jan 2015

Dear Colleagues, a lot of words have been dedicated to surgery in
sputum negative patients. Of course, surgical interventions in those
cases have definite diagnostic value, but I consider it necessary to
note, that the main task of surgery in the treatment of TB patients is
bacteriological conversion. Therefore, in countries with a low TB
burden there is no practice of surgical care for TB patients or the
number of operations is minimal. In countries with a high TB
prevalence surgical activity should be increased especially for sputum
positive M/XDR TB patients who have cavities in the lungs after 6
months of adequate anti-TB therapy. In the treatment of these patients
the entire arsenal of thoracic surgery should be used. The main
methods are various sizes lung resections and pneumonectomy, if these
types of operations cannot be performed such as operations like
extrapleural thoracoplasty should be used.
Extrapleural thoracoplasty indicated for patients with complicated
advanced destructive pulmonary TB, when lung resection or
pneumonectomy contraindicated or associated with a high risk of
severe pleuro-pulmonary complications. Extrapleural thoracoplasty is
the most effective if cavities located in the upper lobe and /or 6
segment of the lung.
In order to improve the efficiency of extrapleural thoracoplasty we
widely use endobronchial valves. Methodology of this procedure
(endobronchial valve installation) is available on www.medlung.ru
website. According to our data the combination of extrapleural
thoracoplasty and endobronchial valve allows achieve cavity closing
and bacteriological conversion in 86% of cases.

daniel chemane Replied at 4:12 AM, 15 Jan 2015

Thats ano intresting discussion, and I will follow it... Furthermore I can't give an string opinion cause I'm not familiarised with theis manegment

Dmitry B. Giller Replied at 4:54 AM, 15 Jan 2015

DB Giller -Director University Clinic of Thoracic Surgery and Tuberculosis I.M. Sechenov First Moscow State Medical University.

My experience of Thoracic Surgery and treatment of tuberculosismore than 32 years. Personally, for tuberculosis performed more than 4000 operations.
Modern surgical treatment efficiency XDR- TB and DR-TB according to my information is presented in the theses sent to Congress ESTS, which will be held in Lisbon in 2015. I present to this information for you now….

Can we count on the success of surgery in the treatment destructive pulmonary tuberculosis with extremely drug-resistant?
Giller DB, Enilenis II, Vishnevskaya GA
Department of Thoracic Surgery and Phthisiopulmonology named Perelman.
I.M. Sechenov First Moscow State Medical University.

Objectives: Prove the possibility of achieving high efficiency of treatment of patients with XDR-TB using surgery.

Material and methods: Studied the immediate and long-term results of treatment of 267 patients with XDR-TB, operated for the past 10 years by a single surgeon.

In 238 patients (89.0%) in the lungs were determined radiologically fibrotic cavity with a lifetime of 1 to 15 years. Before surgery, all patients received long-term medication without effect. Bilateral lung damage had 73.0% of the operated. In 267 patients underwent 523 operations, including bilateral and multi-stage intervention. Most lung resections and pneumonectomy followed by delayed VATS thoracoplasty, developed by us.

Was performed 132 pneumonectomy, 85 lob- bilobektomy, 68 polisementarnyh resections, 25 transsternal occlusion of the main bronchus and 215 torako- and torakomioplastik operations.

In 224 (84.0%) of the patients was made two or more operations, including 58 - at the two sides, 18 - single lung resection, and 60 operations directed at correcting the volume hemithorax for treating cavities in a single lung.

Results: Intraoperative complications occurred in 7 (2.6%) patients, postoperative in 38 (14.2%). 30 - day mortality after 523 operations was 1.1% Clinical effect in the form of sputum negativation and the absence cavities at the time of hospital discharge was achieved in 246 (92.1%) cases. Two years later, after leaving the full clinical effect was maintained in 90% of patients tracked.

Conclusions. Given the fact that in Russia in 2013, the effectiveness of the treatment first diagnosed TB MDR - MBT resistance was only 23.6%, we have received the effectiveness of surgical treatment can be considered high.

In addition, I report on the treatment of MDR-TB:
Over the same period, 637 patients were operated on with MDR-TB. In 474 patients with a lifetime of cavities in the lungs more than 1 year (74.4%). In most patients, operation was performed on two sidesorconducted a stage treatment. Altogether 637 patients underwent 1034 operation, including 214 pneumonectomy, 224 lobectomy or bilobektomii, lobectomy with segmental resection, 215 segmental resections, 40 transsternal occlusion of the main bronchus, and 329 thoracoplasty and torakomioplastik.
In 57 patients (8.9%) resection operation performed with 2 sides, including 16 patients with single lung resection.

The effectiveness of treatment at discharge from the department was 97.8%.
30-day mortality rate - 0.09% (1 patient) after 1034 operations
After 2 years or more after the treatment effect was maintained in 91% of patients tracked.

Dmitry B. Giller Replied at 4:57 AM, 15 Jan 2015

Answer the questions: Which patients and at which stage of their disease would benefit most from surgical interventions?
1. Patients with lesions of the pleura - pleuritisand empyema should be operated at a very early stage of the disease. In this situation we use VATS.
2. Patients with persistent bacterial excretion and destruction of lung tissue with no tendency to a decrease in cavity after 4 months of treatment, regardless of the presence of DR.
3. Patients with the presence of chronic fibrotic cavities (there are more than a year), in most cases have in sputum the МВ with MDR or XDR and they are epidemiologically dangerous. Surgical treatment, of these patients, have absolute indications, but are already late, because the level of complications, mortality and recurrence of tuberculosis have repeatedly increases compared with surgical treatment in the first year of the disease.
4. It is advisable to made lung resection when coming formation of large single and multiple tuberculoma (encapsulated foci of caseous necrosis larger than 2cm.) especially in the presence decay in to this tuberculoma. Often these changes in the lung occur without clinical manifestations and the presence of MB in the sputum. In these cases, their removal is the prevention of the formation of these cavities. The risk of transformation tuberculoms in the cavity according to Russian scientists is 20-30%.
5. Availability destructive tuberculous lesions lobe or lung with active progression and the expressed intoxication on the background of conservative treatment (caseous pneumonia), regardless of drug resistance is an absolute indication for immediate surgery.

Piotr Yablonskii Replied at 2:34 PM, 15 Jan 2015

Dear colleagues, I am professor, President of Russian Association of Thoracic Surgeons, Director of Saint-Petersburg Research Institute Phthysiopulmonology, Peter Yablonskii. I was a member of Task Force group on the Role of Surgery in cases of tuberculosis. Our institute have more than 80 years’ experience of multimodal treatment (surgical and medical) of pulmonary tuberculosis. In our clinic more than 400 thoracic procedures in patients with pulmonary tuberculosis performs per year. The topic of this discussion is very interesting and I am happy to join.
First off all, I want to thank doctors Masoud Dara for the chance to continue the discussion in a format of the online panel. I also want to thank the doctors Murali Ramachandran, Umashankar Kumpatla, Ravindra Dewan and my colleagues of Task Force group (Doctors Denis Krasnov and Igor Kalabukha) for their posts. I think that surgeons should more aggressive to offer surgery for patients. The reason for this point of view is in the lack of effectiveness of medical treatment (76%, according to Jean-Pierre Zellweger).
I will answer on questions on the top of discussion to show the position of our Clinic:
1. Which patients and at which stage of their disease would benefit most from surgical interventions?
Answer:
-sputum positive patients with localized forms of cavitary DR-TB after adequate course of chemotherapy based on DST of MTB.
- sputum negative TB-patients with persistent cavities in lungs, including drug sensitive TB.
2. What are the risk/benefits of surgical interventions and how to mitigate them?
Answer: There are two types of surgical risk in TB-cases:
1) specific risk factor associated with MTB. This is MDR/XDR-TB patients with persistent MTB positive sputum after (at list) 6-months chemotherapy based on DST. Therefore it is important to continue chemotherapy based on DST of MTB after surgery.
2) non-specific risk factors, which include: age of the patient, underweight, comorbidities (diabetes, peptic ulcer, cardio-vascular insufficiency, renal failure, liver failure (viral hepatitis, toxic hepatitis), immunodeficiency (HIV / AIDS)).
To reduce the risk factors require careful preparation of patients before surgery with an interdisciplinary approach in some cases.
3. How to combine medical and surgical treatment?

Answer: Pulmonary tuberculosis is a therapeutic disease that must be cured with medication. Surgery is only step of treatment, more exactly – this is a method for best outcomes of treatment. Chemotherapy based on DST before and after operation is key point of successful outcomes of surgery (indication for surgery presented in materials of Task Force group on the Role of Surgery in cases of tuberculosis).
4. Which types of surgical interventions are recommended?
Answer: There are two types of surgery for DR-TB: radical operations (when removed pathological focus in lung: anatomical resection and pneumonectomy) and palliative surgery, when it is impossible to perform resection or pneumonectomy (bilateral subtotal lung damage, functional contraindications resection). It is possible to combine both types of surgery in patients with bilateral tuberculosis.
Palliative surgery is operations leading to collapse of lung tissue (mostly - extrapleural thoracoplasty combined with bronchial valve, pneumoperitoneum, pneumothorax).
The effectiveness of radical and palliative surgery for treatment of DR-TB is 90-100% and 50-60% respectively in our experience.
5. What are the requirements for a successful outcome of a surgical operation?
Answer: For a successful outcome, you must have a multidisciplinary team of TB specialist, therapeutist, radiologist, bronchologist, anesthesiologist and thoracic surgeon. I especially want to note the importance of the work culture for TB specialist and laboratory staff. Also, the clinic should have an appropriate level of equipment for the diagnostics and surgical treatment of this patient group. It is necessary to note the presence of adherence to treatment and patient's motivation for the successful outcome of the surgery.
6. How to build further the evidence for rational use of surgery?
Answer: Currently, there are controversial issues on this topic: surgical treatment for tuberculomas and persistent cavitary lesions with negative sputum on MTB. It is very important: the long-term follow up these patients and randomized multicenter trials.
In general our position for surgical treatment of patients with DR-TB, were presented in the ERM, 2013

Attached resource:
  • ERM (external URL)

    Link leads to: http://www.ers-education.org/publications/ers-monograph/archive/complex-pleuropulmonary-infections.aspx)

Piotr Yablonskii Replied at 2:38 PM, 15 Jan 2015

Correction - see adequate link

Attached resource:
  • ERM (external URL)

    Link leads to: http://www.ers-education.org/publications/ers-monograph/archive/complex-pleuropulmonary-infections.aspx

Sofia Alexandru Replied at 5:48 PM, 15 Jan 2015

Dear colleagues,
Multidrug resistant tuberculosis, remains a major public health problem for
Moldova.
Institute of Phthisiopneumology, has a department of diagnosis and surgical
treatment of tuberculosis, with a capacity of 45 beds.
The choice of timing for surgery of patients with MDR TB, is an important
factor determining the successful outcome
At patients with infiltrative pulmonary tuberculosis,wich following an
appropriate treatment regimen according to the spectrum of resistance and
not get sputum negativity for 6-8 months, is indicated of surgery
For patients with fibro-cavitary pulmonary tuberculosis, when the lung
lezions is stabilization and health conditions are improvement in
according of clinical factors, bacteriological, radiological and
functional, this time is the best for surgery treatment
Progressive pulmonary tuberculosis complicated with exudative pleurisy,
encysted pleurisy, pneumothorax spontaneous and rigid, pleural empyema with
or without fistula, pulmonary hemorrhage are indications for surgical
treatment as a stage further of medicamentos treatment: mostly indications
are urgently.
Bronchopulmonary suppurations, bronchiectasis posttuberculosis, localized
and intracavitary aspergillosis are absolute indications for surgical
treatment.
Patients with major pulmonary MDR TB sequelae, which can lead to
reactivation of tuberculosis, will be re-evaluated for the possibility of
surgical treatment.
Of course, patients with bilateral processes are not subject to surgery.
Also is a thorough examination before surgery, to minimize the risk of
complications and consolidate treatment success.
About duration of treatment after surgery:
To patients with positive smears or culture at the time of surgery,
treatment is continued for at least 18 months to culture negativity
documented, and include a long period of injectable drugs (Amicacin or
Capriomicin).
To patients who are negative smears and culture at the time of surgery,
treatment should be continued for at least 18 months after culture
conversion and no more than six months after surgery.
If the culture is positive, it may be reasonable to continue treatment for
18 months after surgery, rather than the 18 months preceding the conversion
of sputum.
Type of surgery commonly performed are segmentectomies, lobectomies,
thoracentesis with drainage of empyema etc. . diagnostic thoracotomy with
biopsy of lung or pleural tissue; thoracotomy with biopsy of
mediastinal/traheobrohials lymph node;
thoracoscopy video asistata for biopsy purposes of differential diagnosis
Very important!!! To continuing a Chemotherapy based on DST before and
after operation is key point of successful outcomes of surgery!!!

2015-01-15 21:58 GMT+02:00 Piotr Yablonskii via GHDonline <
>:

daniel chemane Replied at 11:51 PM, 15 Jan 2015

Thank you for that clear explanation

Ravindra Dewan Replied at 12:11 AM, 16 Jan 2015

Dr. Piotr Yablonskii has very clearly and succinctly summarized answers to all the questions raised in the discussion and I agree with him on almost all counts. I would further like to add that modern tools like Double lumen endotracheal tube, Pediatric fibrebronchoscope to position the DLT, Surgical staplers, Tissue patch, Fibrin glue and other hemostatic agents, Argon beam coagulation and digital postoperative suction devices should be made available to all the thoracic surgeons as they make substantial difference to the results. Thoracic surgery for TB should be aggressively pursued, developed and supported as the cost benefit analysis of this intervention is HUGE in terms of alleviation of human suffering.
The idea that Dr. Denis Krasnov has put forward regarding adding endobronchial valves to extra-pleural thoracoplasty is very interesting and worth working upon.
I also wish to say that aggressive introduction of modalities like VATS (Video-assisted Thoracic Surgery) and robotics is more industry driven for commercial purposes and had very limited role in surgery for pulmonary tuberculosis and may lead on to frittering away of precious resources. These advances have a definite role but limited in TB Surgery.

Ravindra Dewan Replied at 12:17 AM, 16 Jan 2015

Regarding all the surgical intervention, a nice summary is already published by us in the guidelines that we developed in Armenia for TB Surgery under with support from the MSF:
for diagnosis and management of TB. They can be classified as under:
A. Procedures of historical interest
i. Sandbag/diseased side down;
ii. Pneumothorax, artificial;
iii. Intra-pleural pneumonolysis; apicolysis (injection of air, or paraffin-oleo thorax), utilizing open or Thoracoscopic approach of Jacobaeus;
iv. Pneumo-peritoneum;
v. Multiple intercostal neurectomies to decrease costal excursions;
vi. Scalenectomy to decrease upper costal excursions and to depress the lung apex;
vii. Phrenic nerve crush or paralysis;
viii. Transection of accessory muscles of respiration (scalenotomy);
ix. Extra pleural plombage of pneumothorax (space between parietal pleura and endo-thoracic fascia); (injection of air, nitrogen, paraffin wax);
x. Sub costal and extra periosteal plombage (“bird cage”) (periosteal stripped from upper five ribs) Lucite balls used most commonly;
xi. Cavernostomy (monaldi procedure);
xii. Thoracoplasty (staged).
Although many of these procedures are for historical significance in the western world, some of these procedures are still being used, at least in developing countries. These procedures are tailored to address the clinical condition and scenario and form a very important part of the surgeon’s armamentarium.
B. Diagnostic procedures
i. Thoracocentesis;
ii. Trans thoracic needle aspiration;
iii. Closed/open pleural biopsy;
iv. Bronchoscopy (flexible/rigid), trans-bronchial needle aspiration;
v. Mediastinoscopy/anterior mediastinoscopy (Chamberlain procedure);
vi. Thoracoscopy (video-assisted thoracic surgery);
vii. Exploratory/diagnostic thoracostomy-wedge biopsy.
C. Therapeutic procedures
i. Decortication—with or without lung resection;
ii. Drainage (closed/open) (temporary/permanent); pleuro-cutaneous window;
iii. Thoracotomy with resection;
 Segment/wedge
 Lobectomy
 Pneumonectomy (trans-pleural; extra pleural; completion)
iv. Chest wall/vertebral body-disc resection/stabilization;
v. Muscle flaps (myoplasty);
vi. Thoracoplasty (modified/tailored);
vii. Omental transfer.

Dmitry B. Giller Replied at 9:24 AM, 16 Jan 2015

Dear Colleagues,
I absolutely agree with Jean-Pierre Zellweger, that questions the indications for surgery may depend on local conditions. They are given the remarkable results of conservative treatment of 51 patients with MDR tuberculosis in Switzerland, with an efficiency of 76%. Of which were operated on only 2 patients. To quote few numbers from the book of prof. CF Shilova, the main specialist in Russia on the epidemiology of tuberculosis: In 2013 in Russia clinical cure of newly diagnosed patients with MDR-TB has been achieved only in 23.6% of cases. In Russia, a separate statistics for fibro-cavernous tuberculosis. This patients have fibrotic cavity more than 1 year, and most of them have MDR, XDR tuberculosis. In 2003, we have 35,600 patients with fibrotic cavity, for the one year 25,800 people died (75%). In 2013, from of 25,100 died 7500 patients (30%). Surgical treatment of these patients in the Russian often the only chance of cure. An additional effect in the form of very large financial savings and reduce the epidemiological risk is impossible not to understand. I think, that today most of the world cannot spent on treatment of MDR and XDR tuberculosis finance, those was spent on each patient in Switzerland.
Thus, the question of surgery should be considered, and as a matter of accelerating the treatment, rehabilitation and improvement of the quality of life of patients.

By the way what happened to the 24% of uncured patients in Switzerland. Maybe some of them could help Surgery?

Piotr Yablonskii Replied at 9:46 AM, 16 Jan 2015

I want to thank Doctor Ravindra Dewan for comments. I agree with “B” and “C” groups of surgical procedures (http://www.ghdonline.org/surgery-in-tb-management/discussion/role-of-surgery-...). But I want to caution surgeons (regardless of their country of residence) from the use of all surgical procedures in “A” group, such as procedures with unproven efficiency (pleural plombage) or obviously harmful (scalenotomy, cavernostomy, multiple intercostal neurectomies).
The purpose of our discussion is to develop a standard approach to the surgical treatment of TB regardless of country of residence, health care system (government or private), level of development of country, and the views of the national leaders of Thoracic Surgery). Only this approach can ensure safety of surgical procedures for patients, and increase the confidence of TB-physicians and pulmonologists to surgery as method for treatment of limited group of TB-patients and to surgeons who perform these procedures. On the other side we have possibility first in modern history to speak the same language to each other (thoracic surgeons) and with other colleagues (TB-physicians and pulmonologists). Moreover, only this approach would be consistent to basic principles of medical ethics and evidence-based medicine.
Next I want answer to reply of Doctor Ravindra Dewan about minimally invasive techniques for treatment of pulmonary tuberculosis. Efficacy and safety of video-assisted thoracoscopic (VATS) and robot-assisted thoracoscopic (RATS) pulmonary resection proved for lung cancer. In our experience, RATS pulmonary resection for localized forms of cavitary DR-TB accompanied with good effectiveness, acceptable morbidity and absence of mortality. See our paper on this term (Yablonskii P. et al. Robot – assisted lobectomy for destructive pulmonary tuberculosis: initial experience //The International Journal of Tuberculosis and Lung Disease. – 2014. – vol.18. – №. 11. – P. 490) (http://barcelona.worldlunghealth.org/programme/abstracts).

Ravindra Dewan Replied at 11:11 AM, 16 Jan 2015

I agree with Dr. Piotr Yablonskii that most of historical procedures are not relevant, but thoracoplasty, artificial pneumothorax and pneumoperitoneum are still useful sometimes. About VATS and RATS, it is agreed that someimes, these procedures can be done in in some cases of peripheral, small and early lesions of TB or aspergilloma. We have also done a few such cases.

Giovanni Sotgiu Replied at 11:32 AM, 16 Jan 2015

I'd like to thanks Prof Yablonskii for his input. It is important to outline the role of the EBM. This field needs multi-centre studies enrolling relevant samples to assess several questions, including those related to the most appropriate procedures and the treatment outcomes. It would be crucial to conduct studies which can include numerous variables. Stratification according to confounding variables is key to avoid significant biases.

Igor Kalabukha Replied at 3:55 PM, 16 Jan 2015

Dear Colleagues!
Colleagues Murali Ramachandran, Umashankar Kumpatla, Ravindra Kdewan, Peter Jablonski presented almost complete system of necessary measures for the surgical treatment of tuberculosis, with which I fully agree. I support Dr. Denis Krasnov, Dr. Dmitri Giller, Dr. Sergo Vashakidze about the need for surgery and in some patients with drug-susceptible TB.
I know the expanded volumes of surgery in clinic by Dr Dmitry Giller that expand our understanding of the extreme possibilities of surgery tuberculosis.
I support all my colleagues who believe an obligatory condition for surgery of tuberculosis the presence of well equipped clinic, a multidisciplinary team of specialists and surgical schools which should be to preserve and multiply the accumulated experience for maintain the high level of qualification of surgeons.
I agree with everyone who considers optimal timing of surgery applications within 4-8 months from the start of chemotherapy.
I agree with the need for an international multicenter study of the effectiveness of TB surgery and would like to take part in it. In my opinion, this study should be made up of several stages. Each stage should be devoted to a particular form of tuberculosis. For example: MDR TB which was confirmed drug sensitivity test, with destruction within the same lobe of the lung, the standard chemotherapy: one group of patients who underwent surgery (standard lobectomy in 6 months from the start of chemotherapy), another group - the same patients without surgery; period of observation - 3 years from the start of chemotherapy. Another step - destruction within one lung, standard pneumonectomy, comparison principles and observation - the same. Just another step - tuberculoma with destruction, sub-lobar resection by specified beforehand rules, etc. Steps may be performed in parallel. In this case, for 5-6 years, we can accumulate a sufficient evidentiary basis.
As a result, we can create medical, juridical and economic rationale for surgery tuberculosis. This is very important, particularly for my country, because now surgery tuberculosis is funded by a residual principle, and this financing is absolutely not enough.
I am very pleased to participate in this very interesting and very representative discussion and consider the possibility of participating in as a high honor for me. Thanks to all the organizers, especially, Dr. Masoud Dara, Dr. Sudip Bhandari and all participants.

Jean-Pierre Zellweger Replied at 4:51 PM, 16 Jan 2015

I thank D. Giller for his comments. I agree that the managenent of M/XDR-TB is very expensive and that in some countries the available finances do not allow for an optimal drug treatment and that this may be an argument in favour of surgery (it may not be the case in Western Europe, where hospitalization is very expensive and one day in a specialized hospital may cost as much as the entire drug treatment!). I have to mention that one of the most efficient treatment schedule for M/XDR-TB (the so-called Bangladesh regimen) is cheap and cures more than 80% of patients (see the paper by Aung 2014). In Switzerland, in our limited series, the 24% of patients with an unfavourable outcome were mainly defaulters or immigrants who left the country before the completion of treatment. We had 2 death/51 patients (4%) but no failure or development or chronicity, so that I doubt that surgery would have added anything to the current results (see Helbling 2014)

Attached resources:

Emmanuel Edward Replied at 7:36 PM, 16 Jan 2015

I must appreciate the various contributors to this timely discuss. Working actively to take out the scourge that is TB in all its forms,especially if one has to do so in resource limited settings plagued by frequent industrial actions and a looming health crisis,is to say the least amazing. I have had to make several referrals for surgical interventions in cases of cured TB who had their quality of life reduced by the often debilitating complications of TB,and often times the story is that patients cannot afford the cost of these surgeries! It is not rocket science why this is so; most cases of TB and by extension MDR TB occur in persons of low socioeconomic standing!
If the cost utilities of our patients will improve with surgical intervention, as has been stated repeatedly, it is ideal that the international committee commits financially to this alternatives and help strengthen social insurance in developing countries to allow for better coverage.

Ravindra Dewan Replied at 11:50 PM, 16 Jan 2015

Very Interesting Discussion, which has addressed the issues quite well. Most of recommendations in favor of TB surgery are based upon case reports, individual experience, retrospective analysis and expert opinion and well designed scientific trials to address the issue are lacking and difficult to design as well. However, advocacy for this important intervention to mitigate human suffering is also important. I wish to list some of the important references regarding this issue:
1.Dewan R, Pasechnikov A. Tuberculosis (TB) surgery guideline. Paris; Médecins Sans Frontières: 2013.
2. Dewan RK. Surgery for pulmonary tuberculosis - a 15-year experience. Eur J Cardiothorac Surg 2010;37:473-7
3.Shiraishi Y, Nakajima Y, Katsuragi N, et al. Resectional surgery combined with chemotherapy remains the treatment of choice for multidrug-resistant tuberculosis. J Thorac Cardiovasc Surg 2004;128:523-8
4.. Pezzella AT, Fang W. Surgical aspects of thoracic tuberculosis: a contemporary review--part 1. Curr Probl Surg 2008;45:675-758
5. . Pezzella AT, Fang W. Surgical aspects of thoracic tuberculosis: a contemporary review--part 2. Curr Probl Surg 2008;45:771-829

Ravindra Dewan Replied at 11:52 PM, 16 Jan 2015

These are, of course, in addition to the excellent review done by Dr. Masoud Dara and others given in the beginning of this discussuion:
The role of surgery in the treatment of pulmonary TB and multidrug- and extensively drug-resistant TB (external URL) WHO Expert Opinion Document for Europe

Igor Kalabukha Replied at 4:04 AM, 17 Jan 2015

I want to pay a particular attention to the message by Dr. Emmanuel Edward. There is a need to create a document by a reputable international organization (such as WHO), based on which doctors could appeal to the national governments about need for targeted financing of Surgery TB.
Thank you Dr. Ravindra Dewan for valuable links.

Sergo Vashakidze Replied at 5:05 PM, 18 Jan 2015

Dear colleagues, I think we have got a very interesting disсussion. All of us, thoracic surgeons, involved in the surgery of pulmonary tuberculosis around the world, have long been in need of such an exchange of views. My thanks go to D-r Masoud Dara for giving us the opportunity to do so.

About main questions of our discussion:

1. Of course, patients with MDR/XDR-TB who continue to generate bacterioexcretion as well as patients with the presence of lung cavity without positive X-ray dynamics after 4-6 months of treatment DOTS (+) are the main contingent for surgery. Another group of indications for surgery are such complications of tuberculosis, as pulmonary hemorrhage, spontaneous pneumothorax, empyema, aspergiloma . Patients with sensitive TB, which after 6 months of drug treatment by DOTS program still have cavity remained in the lung, must also be operated. The problem is that for countries like Georgia and other former Soviet Union countries (with a high burden of TB and prevalence of resistance to anti-TB medicines ) are characterized by late referral of TB patients for medical care and often, even newly diagnosed patients are the patients with advanced, launched, more extensive forms of tuberculosis. This applies both to patients with MDR/XDR TB and with sensitive tuberculosis. Even when in such countries DOTS and DOTS (+) programs (as is the case in Georgia) are functioning drug treatment does not always lead to patients recovery.
Regarding the definition of cure: What I meant is, how correct is it to consider a patient with tuberculosis cavity who was being treated by DOTS and (or) DOTS (+) program and who for a certain period of time was not detected to have Mycobacterium tuberculosis in he’s sputum to be considered recovered? But if the cavity (morphological substrate of TB) remains in the lung, there is always a potential danger, likelihood that it retains Mycobacterium tuberculosis (which may be dorminant forms of Myc.tuberculosis, publications such as this are there in the literature) and under the influence of various unfavorable factors there is always the danger of reactivation of tuberculosis process. Moreover, there are evidences that cavitary lesions are a risk factor for amplification of drug resistance among patients with MDR-TB. We operated patients after 2-5-7 years after completion of treatment DOTS and DOTS (+) in connection with the development of pulmonary hemorrhage and received the growth of Mycobacterium tuberculosis from
surgical specimens.

2. Besides those already mentioned, risks of surgical interventions may be exacerbations of the tuberculous process in the case of non-radical surgery or bilateral lesions. This occurs when the patient , for whatever reason ,does not accept anti-tuberculosis drugs immediately after surgery( we have had such cases). Therefore, it is important immediately after surgery to ensure optimal mode of anti-TB therapy with mandatory inclusion of injectable drugs and a long-time anti-TB therapy after surgery. The duration of postoperative anti-tuberculosis drugs treatment - 6 months at sensitive tuberculosis and 12-18 months at MDR/XDR TB depending on availability of bacterioexcretion at the time of surgery . Although, the works devoted to proving that these terms are optimal, I have not found in literature and I would be very grateful if colleagues will help me to find such studies. Although, perhaps, in a qualitatively new conditions that are created after the operation, when the main reservoir of TB infection-cavity from the lung has already been removed, it makes no sense to treat still patients for 18-24 months?

3. I believe that it is important to study Mycobacterium tuberculosis in the operating material. Frequently, in patients with persistent negative sputum, Mycobacterium tuberculosis is detected in оperating specimens; furthermore, in such cases, the resistance may be more severe (for more antitubercular drugs than in sputum), and this should be taken into account during postoperative treatment of patients. In Georgia microbiological examination of surgical specimens were recorded in the standards of National anti-TB program.

4. Кesection surgery,of course, is the main method of surgical treatment of pulmonary tuberculosis, but if necessary thoracoplasty must be used, which necessarily must be in the arsenal of the surgeon, engaged with surgery tuberculosis.
Videothoracoscopy is the method of choice in the differential diagnosis of diseases of the lungs and pleura, when there is a suspicion of tuberculosis.

5. Careful selection of patients is required with strict observance of the indications for surgery and given the state of the cardiorespiratory system.
We need to actively introduce modern methods of surgical and resuscitative-anesthetic management -videothoracoscopy, argon laser and ultrasound, robot when it is possible, double lumen endotracheal tube for separate bronchus intubation, bronchoblockers (they are very effective!), physiotherapy before and after surgery, it is important to conduct an optimal anti-TB therapy after surgery, based on microbiological examination of оperating specimens .

6. Although high efficiency of TB surgery has long been clear, further studies are needed to substantiate its usefulness. We should go through the multicenter, randomized, (it will be difficult to make!), well designed studies by comparing long-term outcomes (including quality of life) in operated and non operated patients.

What Dr. Sandeep Saluja says about the new drugs has been said before many times. When streptomycin appeared, many TB doctors said- great, we will no longer need surgery to treat tuberculosis. The same was said after rifampicin appreared on the shelves. Unfortunately, there is no guarantee that resistance to the new drugs will not be developed; morever, their full implementation in clinical practice will take a long of time ... Surgery of tuberculosis will still be important for the years to come and we should be prepared to meet the challenges we will face.

Jean-Pierre Zellweger Replied at 5:40 AM, 19 Jan 2015

Dear colleagues,

I thank Sergo Vashakidze for the comprehensive summary of the main aspects of the discussion during the last week.

I would like to come back on one point which seems important in the global management of patients with TB, which is the assessment of the risk of recurrence after treatment, which may explain why surgery is much more used in some regions of the world than in others. For our colleagues from Russia, the presence of a residual cavity at the end of TB treatment is a threat to relapse and an indication for surgery. For others, mainly in Western Europe, it does not seem to be so. There are some publications on the relation between the presence of a residual cavity and relapse (for instance C. D. Hamilton et al, The value of end-of-treatment chest radiograph in predicting pulmonary tuberculosis relapse, INT J TUBERC LUNG DIS 2008 ;12(9):1059–1064), but other studies insist on the fact that other factors, like incomplete adherence, alcoholism, insufficient dose of TB drugs (low level of rifampicine !) also play a role.

My proposal to WHO : I strongly suggest to start a working group to analyse in detail the risk factors for relapse/recurrence of TB after treatment and define a) the optimal assessment of the patient at the end of treatment and b) the management of patients with risk factors. I wouéld be highly interested in taking part in such a working group.

Thank to WHO for organizing the highly stimulating session !

With my best regards

Jean-Pierre Zellweger, MD
TB Competence Center
Swiss Lung Association
Chutzenstrasse 10
3007 Berne / Switzerland

Believe Dhliwayo Replied at 5:49 AM, 19 Jan 2015

Thanks will do

Masoud Dara, MD Replied at 6:48 AM, 19 Jan 2015

Dear colleagues,

Many, many thanks to our exceptional panelists, and all of our community members who participated in this incredibly rich discussion. We greatly appreciate the insights everyone has shared, and look forward to continuing to discuss these important topics in the following months.

We are also preparing a proposal for a symposium on the same topic at the next World Lung Health Conference happening December this year, and to this end, we will get back to you in the coming months.

Nicaise NSABIMANA Replied at 8:08 AM, 19 Jan 2015

Sorry i delayed to respond to thyis email but i was not aware it was
a good and important discussion hope next occasion you will let us know as
early as possible

Philippe Creach Replied at 8:35 AM, 19 Jan 2015

Bonjour Jean-Pierre,
Overall, programs worldwide treating DR-TB cases are obtaining outcomes far below the Bangladesh regimen that also highlights the role of Cfz. In the pulmonology clinic in Lyon-France, the MDR-TB outcomes are similar to those of the Bangladesh regimen and only defaulters have poor outcomes. But, what is your assessment of the role of linezolid - that was not used in Bangladesh I believe (due to price consideration ?) ?
Tout de bon,
Philippe.

Sudip Bhandari Replied at 5:51 PM, 1 Jun 2015

Thank you to all the panelists and members who participated in this Expert Panel in January. We're excited to share with you the Discussion Brief that summarizes the key points and resources shared in the panel. Please see the attached link.

Attached resource:
  • Discussion Brief (external URL)

    Link leads to: http://www.ghdonline.org/surgery-in-tb-management/discussion/role-of-surgery-in-management-of-tuberculosis/brief/

Omotayo Salau Replied at 2:18 AM, 2 Jun 2015

Great!
Many thanks to the anchor group of this honourable panelists and member for sharing the discussion brief, this will go a long way to assist in internalizing the wealth of knowledge that were dispatched in bit and pieces.
However, am still having some challenges in perusing the link (discussion brief)

Thank you.

Sudip Bhandari Replied at 10:00 AM, 2 Jun 2015

If you are experiencing difficulty accessing the Discussion Brief, please try this link: http://www.ghdonline.org/surgery-in-tb-management/discussion/role-of-surgery-...
You will need to log into your GHDonline account to access the document. Also, if you are trying to reach the link through your email, then the system takes you to the GHDonline website first. From there, you can click on the link I shared.

Igor Kalabukha Replied at 10:21 AM, 2 Jun 2015

Dear Sudip! Thank you for creating a short and capacious outcome of our discussion. I hope that this document will be an important argument for the development of a national strategy for the treatment of tuberculosis in our country.

This Expert Panel is Archived.

While this Expert Panel is no longer active, we invite you to review and recommend past replies and resources. Membership for this Expert Panel is closed, but we hope you'll review the Discussion Brief or join us in one of the many communities on GHDonline.

Panelists of Role of Surgery in Management of Tuberculosis and GHDonline staff