## 3 Surgery and TB
### Evaluating the Role of Surgery Through IPD
In a regional WHO European guidance the indications and contra-indications for surgery were clearly defined [19; 37]. Surgical interventions may have emergency (life threatening conditions), urgent (irreversible TB and haemoptysis), and elective natures. Elective surgery indications include localised unilateral forms of bacteriologically-confirmed cavitary disease, MDR-/XDR-TB failing medical treatment, and complications/sequelae (spontaneous pneumothorax /pyopneumothorax; pleural empyema with or without bronchopleural fistula; aspergillus; nodular-bronchial fistula; broncholith; and pachypleuritis/pericarditis with respiratory and blood circulation insufficiency; trachea/large bronchi stenosis; and post-TB bronchiectasis). The following contra-indications have been identified [19; 37]:  
* Bilateral, extensive cavities;
* Impaired pulmonary function (forced expiratory volume in one second FEV1 (forced expiratory volume in 1 s) <1.5 L for lobectomy and < 2.0 L for pneumonectomy);
* Pulmonary-heart failure III-IV (New York Hart Association functional classification);
* Body mass index (BMI) up to 40%-50% of normality;
* Severe co-morbid conditions (uncontrolled diabetes, ulcer exacerbation, and liver/renal insufficiency);
* Active bronchial TB. The UNION guidelines (which are not designed with the GRADE approach) suggest that'surgery should be considered for treating drug-resistant (DR)-TB only in patients meeting the three following conditions: 1) a fairly localised lesion, 2) an adequate respiratory reserve, and 3) a lack of sufficient available drugs to design a regimen potent enough to ensure a cure. Ideally, surgery needs to be performed at the moment chemotherapy has achieved the lowest possible bacillary load (sputum smear and culture converted to negative) within a complete cycle of chemotherapy [38]. In the recently published ATS/CDC/ERS/IDSA guidelines [39] the PICO (population, intervention, comparator, outcomes) question 19 was on 'Surgery for MDR-TB' as follows: 'Should elective lung resection surgery (i.e., a lobectomy or pneumonectomy) be used as an adjunctive therapeutic option in combination with antimicrobial therapy, versus medical therapy alone for adults with MDR-TB?' The following recommendations were issued:  
'Recommendation 19A: We suggest elective partial lung resection (e.g., a lobectomy or wedge resection), rather than medical therapy alone, for adults with MDR-TB receiving antimicrobial-based therapy (conditional recommendation, very low certainty in the evidence). The writing committee believes this option would be beneficial for patients for whom clinical judgement, supported by bacteriological and radiographic data, suggest a strong risk of treatment failure or relapse with medical therapy alone. Recommendation 19B: We suggest medical therapy alone, rather than including elective total lung resection (pneumonectomy), for adults with MDR-TB receiving antimicrobial therapy (conditional recommendation, very low certainty of evidence)' [39]. In summary, all major guidelines are consistent in recommending surgery in selected cases, following chemotherapy and favouring elective partial lung resection when possible, based on specific indications: failure of drug therapy, relapse, localized (e.g., cavity) or extensive pulmonary TB, clinical complications (e.g., haemoptysis or empyema) [39]. However, recent evidence suggests that bilateral surgery can also be safe and effective [40]. The patients undergoing surgery are candidates for pulmonary rehabilitation [20; 39].