TB spike puts focus back on lung surgery

Mumbai: When extra-extremely drug-resistant (XXDR) tuberculosis made its presence felt in Mumbai last week, bureaucrats and public health experts jotted down an ingredient that was dangerously low in availability: surgeons. The BMC is planning to get surgeons to restart the surgery programme at its TB specialty hospital in Sewri, said BMC additional municipal commissioner Manisha Mhaiskar. But given the city's history, this may not be the easiest of tasks. 

    The words of the former head of surgery at the same hospital decades ago show why it's difficult to get surgeons into the TB fold. "Why should doctors who have trained in cardiothoracic surgery look at the lungs when operating on the heart is certainly more glamorous,'' asks Dr Harikant Bhanushali, 76, who still operates on TB patients using a minimal access technique at Kaushalya Hospital in Thane. 
    At Sewri's TB Hospital, he operated on over 7,600 patients from 1966 to 1991. "But it's a difficult and time-consuming surgery. May be that is the reason many don't opt for it,'' he says. India to ban 'inaccurate' and costly blood tests I ndia will soon ban blood tests to detect tuberculosis. These tests are widelyavailable across the country. Following a WHO proposal, an expert group set up by the Drug Controller General of India found that blood tests are mostly inaccurate for TB detection. Experts said they are also expensive compared to the standard culture test provided free by the government. P 11 Resistance to drugs could push surgery 
Mumbai: Dr Harikant Bhanushali, a veteran surgeon, says TB surgery is both difficult and time-consuming. It takes 45 minutes to access the lungs and another 45 minutes to close them. A cardiothoracic surgeon can complete a bypass heart surgery in the same time. 
    Doctors trained in cardiothoracic surgery can operate on both vital organs — heart and lungs. "But you get Rs 30,000 for a lung surgery while you can get 10 times that amount for a bypass surgery. The choice is clear,'' says a doctor attached to a state government hospital. 
    It is not as if surgery is not done at all. Dr Yatin Dholakia of the State Anti-TB Association says that surgery is regularly offered for cases of extra-pulmonary TB or TB in any organs other than the lungs. But extrapulmonary TB forms only about 10-15% of all TB cases. In the last few decades as medicines acted well on the bulk of TB patients, surgery took the backseat. "But with drug resistance emerging now, surgery will certainly be more often. Small lesions in the lungs that don't react well to medication need surgical treatment,'' says Dr Dholakia. But he is clear that surgery is only a way to get medicines to start acting on a patient with drug-resistance TB. In medical terms, surgery is just an adjuvant or additional therapy. 
    Considering that Mumbai adds between 3,000 and 4,000 multi-drug resistant patients to its TB pool every year, the percentage—however small—of patients needing the adjuvant 
surgical therapy could be significant. Not surprisingly then, some private hospitals also offer TB surgery. Hinduja Hospital in Mahim that first reported the 12 "totally drug resistant TB'' cases is one of the major such hospitals. Fortis Hiranandani Hospital in Vashi is another. Dr Nitish Jhawar, who is a minimal access surgeon at the Vashi Hospital, gives the example of Sia Shetty (name changed). "She was diagnosed with multidrug resistant TB and was in our ICU for a month. Her family had almost given up. That is when we surgeons were called to use the video-assisted thoracoscopic surgery to remove the diseases tissue or lesions form her lungs,'' says Dr Jhawar. 
    A video camera was fitted to one of three scopes that were introduced into the lungs through small holes."In less than two hours, we had removed the lesions and the patient started responding better to medicines thereafter,'' he added. 
    A doctor in the Sewri Hospital says the decision has to be taken judiciously. "One cannot operate on a patient who may just worsen due to complexity of surgery.'' However, Bhanushali feels many doctors delay surgery for too long. "A decision on surgery can be taken once the doctor notices that despite three months of medication, the patient is not responding well. Earlier such lesions or pus cells are removed, the better the TB medication can act,'' says Bhanushali, who was among the first to use video-assisted thoracoscopic surgery in this part of the country. "Patients can walk away from the hospital in three days of surgery.''