Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment

Factors affecting survival after anatomical lung resection in pulmonary aspergilloma: Our 10-year single institution experience

Background

The aim of this study was to investigate the long-term outcomes of patients who underwent anatomic lung resection for pulmonary aspergilloma and to evaluate the prognostic factors affecting early postoperative morbidity.

Methods

Between January 2007 and January 2017, we retrospectively evaluated a total of 55 patients (40 males, 15 females; mean age: 44.6 years; range, 18 to 75 years) who underwent lobectomy and pneumonectomy for pulmonary aspergilloma. All patients were evaluated for simple or complex aspergilloma based on imaging and thoracotomy findings.

Results

Thirty-two (58.2%) patients presented with hemoptysis. Seven (12.7%) patients underwent emergency surgery due to massive hemoptysis. Postoperative morbidity was observed in 15 (27.3%) patients. Prognostic factors that had an effect on morbidity were resection type, Charlson Comorbidity Index >3, and massive hemoptysis (p<0.05). There was no intra- or postoperative mortality. The five-year survival rate was 89.4%. None of the factors evaluated in the study were associated with survival.

Conclusion

The main finding of this study is the absence of mortality after surgical treatment for pulmonary aspergilloma. The success of surgical treatment depends on the management of postoperative complications.

Monaldi cavernostomy for lung aspergillosis: A case report

Pulmonary aspergillosis in patients with respiratory failure can severely affect the pulmonary functional status and may aggravate it through pulmonary suppuration, by recruitment of new parenchyma and hemoptysis, which can sometimes be massive, with lethal risk by flooding the bronchus. The treatment consists of a combination of medical therapy, surgery and interventional radiology. In small lesions, less than 2-3 cm, medical therapy methods may be sufficient; however, in invasive forms (larger than 3 cm) surgical resection is necessary. Surgical resection is the ideal treatment; nevertheless, when lung function does not allow it, action must be taken to eliminate the favorable conditions of the infection. In such cases, whenever the lung cavity is peripheral, a cavernostomy may be performed. Four cases of lung cavernous lesions colonized with aspergillus, in which the need for a therapeutic gesture was imposed by repeated small to medium hemoptysis and by the progression of respiratory failure, were evaluated, one of which is presented in the current study. Cavernostomy closure can be realized either surgically with muscle flap or spontaneously by scarring, after closure of the bronchial fistulas by epithelization and granulation. There were no recurrences of hemoptysis or suppurative phenomena. There was one death, a patient with severe respiratory failure caused by superinfection with nonspecific germs. However, in the case presented in this study, the patient recovered following cavernostomy, which seems to be an effective and safe method for cases in which lung resection is not feasible.

Surgical management of pulmonary aspergilloma-12 years' experience from a tertiary care centre in India

Introduction and purpose

Pulmonary aspergilloma is the formation of saprophytic colonies of fungus in pre-existing pulmonary cavities. They may cause life-threatening haemoptysis. As medical treatment often fails, surgery is the mainstay of treatment in symptomatic patients. Earlier studies had reported high levels of mortality and morbidity with surgery while more recent studies have shown better results. Hence, being in a large tertiary care centre in India, we decided to analyse the details of our own experience in the surgical management of pulmonary aspergilloma.

Methods

Details of all adult patients treated surgically for pulmonary aspergilloma, between the years 2009 and 2020, maintained in a live database in our institute, were retrieved and analysed.

Results

There were 102 patients in the study. The average age was 40 years. There was a male (M: F, 3:1) and right side preponderance. Pulmonary tuberculosis (TB) was the commonest cause for cavities in which aspergilloma developed as identified in 84 (82%) patients and diabetes mellitus, the commonest comorbidity present in 28 (27.5%) patients. Parenchyma-preserving lung resections (PPLRs) were feasible in 8 (44%) of the non-tubercular patients, but only in 14 (17%) of the TB patients. Post-operative complications (11.7%) were higher among the patients with TB. There were 2 (1.9%) post-operative mortalities.

Conclusion

Though surgery is technically complex in the presence of pulmonary aspergilloma, it is yielding better results with improvements in treatment strategies. Surgery for aspergilloma in patients with prior or current pulmonary TB has more morbidity and mortality when compared to the non-TB patients.

Uniportal VATS Lobectomy and Decortication: Not an Everyday Occurrence

Management of trapped lung with an underlying lung lesion and hydropneumothorax remains controversial. Furthermore, Aspergillus empyema and aspergilloma are rare pathologies for which uniportal video-assisted thoracoscopic (VATS) surgical management remains controversial. We present a young patient referred to our service after recent hospitalization for pneumonia. The patient was found to have a chronic effusion with a right lower lobe cystic parenchymal lesion and was taken to the operating room. The patient underwent right uniportal VATS surgery with evacuation of empyema, total pulmonary decortication, and right lower lobectomy. His postoperative course was unremarkable, and he was discharged home. Postoperative workup demonstrated lymphocyte variant hypereosinophilia. He continues to follow with thoracic surgery at the time of this report and remains asymptomatic. We conclude that uniportal VATS is a most minimally invasive, safe, and efficient approach for management of complex intrathoracic pathology including total pulmonary decortication and lobectomy.

Pulmonary aspergilloma: from classification to management

Pulmonary aspergilloma is a form of aspergillosis characterized by the colonization of a preexisting pulmonary cavity, most often of tuberculosis origin. Clinical symptoms are predominately hemoptysis that can be life-threatening, and thoracic computed tomography can distinguish simple from complex pulmonary aspergilloma. The best therapeutic option remains surgery which allows surgical resection of the mycetoma and the underlying cavity. Nonsurgical treatment is performed in inoperable patients because of severe respiratory failure or a poor general condition.

New advances in the management of pulmonary sarcoidosis

Sarcoidosis is a highly variable granulomatous multisystem syndrome. It affects individuals in the prime years of life; both the frequency and severity of sarcoidosis are greater in economically disadvantaged populations. The diagnosis, assessment, and management of pulmonary sarcoidosis have evolved as new technologies and therapies have been adopted. Transbronchial needle aspiration guided by endobronchial ultrasound has replaced mediastinoscopy in many centers. Advanced imaging modalities, such as fluorodeoxyglucose positron emission tomography scanning, and the widespread availability of magnetic resonance imaging have led to more sensitive assessment of organ involvement and disease activity. Although several new insights about the pathogenesis of sarcoidosis exist, no new therapies have been specifically developed for use in the disease. The current or proposed use of immunosuppressive medications for sarcoidosis has been extrapolated from other disease states; various novel pathways are currently under investigation as therapeutic targets. Coupled with the growing recognition of corticosteroid toxicities for managing sarcoidosis, the use of corticosteroid sparing anti-sarcoidosis medications is likely to increase. Besides treatment of granulomatous inflammation, recognition and management of the non-granulomatous complications of pulmonary sarcoidosis are needed for optimal outcomes in patients with advanced disease.

Is adjuvant antifungal therapy after video-assisted thoracic surgery for pulmonary aspergilloma necessary?

Background

The aim of this current retrospective study was to assess the necessity of postoperative antifungal therapy for pulmonary aspergilloma (PA) patients who underwent video-assisted thoracic surgery (VATS) lung resection.

Methods

We enrolled 22 PA patients who underwent VATS lung resection between 2014 and 2018. Of these, 12 patients were prescribed antifungal agents during the perioperative period (group A), and the other 10 were treated with surgery alone without any antifungal therapy postoperatively (group B). All patients were immunocompetent.

Results

Seven patients (58.3%) developed postoperative complications in group A, including 2 cases of empyema (16.7%), 1 case of bronchopleural fistula (8.3%), 1 case of pneumonia (8.3%), 1 case of wound infection (8.3%), 1 case of bleeding (8.3%) and 1 case of atelectasis (8.3%). In group B, 3 patients (30%) developed postoperative complications, including 2 cases of pneumonia (20%) and 1 case of empyema (10%). There was no significant difference between the groups with respect to postoperative complications rates (P=0.23). The follow-up period ranged from 1 to 38 months (a median of 19 months), during which no hospital deaths, recurrence of disease or lesion relapses were noted in either group.

Conclusions

Our results suggested that postoperative adjuvant antifungal therapy has limited advantages for the surgical treatment of PA in immunocompetent patients.

Surgical management of non-mycobacterial fungal infections

Fungal infections of the lung are common in endemic areas and in immunocompromised patients. Antifungal therapy is the cornerstone of medical therapy for most pulmonary fungi but surgery is an important adjunct in cases of complicated disease or resistant organisms. A multidisciplinary approach including pulmonary medicine, infectious disease, interventional radiology, and thoracic surgery is favored. This article reviews the surgical management of common fungal pulmonary infections and their sequelae.

Complications of surgery for infectious lung cavities

Background Infectious lung cavities are a common entity for the respiratory physician. Sometimes these lesions require surgical treatment, but surgery is challenging, and complications are common. Methods Patients with infectious lung cavities amenable to surgical treatment were included in a case-control study. The control group included patients with no complications. The cases group comprised patients with any of the following complications up to 90 days after surgery: death, persistence of hemoptysis, empyema, operative blood loss > 500 mL, vascular lesion requiring repair, massive transfusion (>5 units of packed red blood cells per 48 h) or reoperation for bleeding, postoperative mechanical ventilation, intensive care unit stay > 48 h, prolonged air leak, and persistent atelectasis. The potential risk factors for complications analyzed were demographic data, exposure to contaminants, comorbidities, preoperative embolization, surgical indication, spirometry results, and sputum test positive for Mycobacterium tuberculosis. Results Forty-five patients were included in the study and divided into 24 cases and 21 controls. We found a significant difference in the time to removal of chest tubes in favor of the noncomplicated cases (6.45 vs. 4.05 days, p = 0.030), and persistent active infection at the time of surgery tended to be a risk factor for complications (odds ratio = 6.6, 95% confidence interval: 0.7-60, p = 0.061). Conclusion The presence of persistent active infection at the time of surgery could be a risk factor for complications in resection surgery for infectious lung cavities.

Surgical treatment for pulmonary aspergilloma - early and long-term results

Introduction

Pulmonary aspergilloma is a difficult therapeutic problem due to the low effectiveness of conservative treatment and high surgical morbidity.

Aim

To analyze the early and late results of surgical treatment for pulmonary aspergilloma.

Material and methods

From 2005 to 2015, 49 patients were treated surgically for pulmonary aspergilloma. Symptoms occurred in 85.7% of cases, including recurrent hemoptysis in 53%. A history of immunosuppressive therapy or chemotherapy was noted in 24.5% of patients. Complex aspergilloma was diagnosed in 79.6% of cases. Immunological test results were positive in 10.2%, and bronchoalveolar lavage samples were positive for Aspergillus species in 18.5% of cases. In 59.2% of patients, the surgical risk was assessed as ASA 3. Thirty seven patients underwent lobectomy, 3 – pneumonectomy, 7 – wedge resection, 1 – decortication, and 1 – cavernostomy.

Results

In-hospital mortality was 4.1%. Postoperative complications occurred in 63.3% of patients. The most common complications were: prolonged air leak (26.3%), arrhythmias (20.4%), residual pneumothorax (16.3%), respiratory failure (14.3%), atelectasis (12.3%), and bleeding (12.3%). Of the three patients that underwent pneumonectomy, one died, two required repeat thoracotomy because of bleeding, and all three required prolonged mechanical ventilation. Two patients died during the follow-up period. Aspergilloma did not recur in any of the patients who underwent pulmonary resection.

Conclusions

Due to the high risk of complications, surgical treatment of pulmonary aspergilloma should be restricted to symptomatic patients in whom lobectomy can be performed. The long-term results of surgical treatment are good, preoperative symptoms abate in most patients, and the rate of aspergillosis recurrence is very low.

Complex pulmonary aspergilloma treated by cavernostomy

OBJECTIVE

To evaluate the effectiveness of cavernostomy in patients with complex fungal balls.

METHODS

We analyzed the medical records of patients undergoing cavernostomy between January 2005 and May 2013, evaluating: age, gender, preoperative signs and symptoms, predisposing disease, preoperative tests, location of the aspergilloma, etiologic agent, cavernostomy indication, postoperative outcome.

RESULTS

Ten patients were male. The mean age was 42.9 years (34-56). The most frequent symptom was repeated pulmonary bleeding. Cavernostomy was proposed for patients at high risk for lung resection. It was performed in 17 patients and all of them had pulmonary tuberculosis sequelae, with cavitations. The indication in all cases was hemoptysis and elimination of phlegm. The cavernostomies were performed in a single surgical procedure. In all 17 patients the cavity was left open after the withdrawal of the mycetoma. In all patients hemoptysis ceased immediately. Operative mortality was 9.5% (1).

CONCLUSION

cavernostomy is an effective treatment alternative in patients at high risk. It may be useful in some patients with complex aspergilloma, irrespective of lung function or bilateral disease. It is technically easy, has low-risk, saves parenchyma, and may be performed in a single operative time.

A Series of Transbronchial Removal of Intracavitary Pulmonary Aspergilloma

BACKGROUND

Intracavitary pulmonary aspergilloma is a chronic, debilitating fungal infection. Without definitive therapy, death can occur from massive hemoptysis, cachexia, or secondary infection. Although surgical resection is the standard therapy, it is not possible for many patients owing to poor pulmonary function or medical comorbidities. Aspergilloma removal through bronchoscopy is an important alternative therapy that may be available in select cases.

METHODS

We retrospectively reviewed all cases referred to the University of Calgary Interventional Pulmonary Service for transbronchial removal of intracavitary aspergilloma from January 1, 2009, to January 1, 2014.

RESULTS

Ten patients with intracavitary pulmonary aspergilloma were identified. In 3 patients, the aspergilloma cavity was not accessible by bronchoscopy. Successful removal of the aspergilloma with symptom improvement or resolution was achieved in 6 of 7 cases. One of the patients was lost to follow-up. Minor hypoxia lasting 12 to 72 hours was observed in 5 cases. Severe sepsis requiring an extended critical care unit stay occurred in 1 case. Follow-up ranged from 9 months to 5 years.

CONCLUSIONS

Although not without risk of minor hypoxia and possible sepsis, for carefully selected patients, bronchoscopic removal of symptomatic intracavitary pulmonary aspergilloma may be an alternative therapy to surgical resection for this life-threatening disease.

Analysis of Surgical Treatment for Pulmonary Aspergilloma

Surgery for pulmonary aspergilloma is reputed to be risky. The results of surgical treatment of pulmonary aspergilloma in 41 patients between 1988 and 2003 were evaluated retrospectively. Hemoptysis occurred in 31 patients (75.6%) and it was massive (> 300 mL in 24 hr) in 3. The underlying lung disease was tuberculosis in 35, bullous lung disease in 2, hydatid cyst in 2, and lung carcinoma in 2 patients. Lobectomy, bilobectomy, wedge resection, and pneumonectomy were performed in 27, 4, 6, and 4 patients respectively. The postoperative complication rate was 24.4%. One patient, who had a right pneumonectomy, died due to respiratory failure; the mortality rate was 2.4%. Recurrent hemoptysis was observed in only one patient. Early surgical treatment of patients with pulmonary aspergilloma resulted in a satisfactory outcome with acceptable morbidity, low mortality, and effective prevention of recurrent hemoptysis. Pneumonectomy has a high morbidity, thus it should be avoided if possible.

Surgical Management of Pulmonary Aspergilloma

Records of 59 patients (41 males and 18 females) who underwent 70 operations for pulmonary aspergilloma in a 23-year period were examined retrospectively. Sixty-three operations were for primary treatment of pulmonary aspergilloma, and 7 were for complications of surgery. Twenty-six postoperative complications occurred in 19 patients. Three lobectomies that resulted in bronchopleural fistula were managed by intercostal muscle-flap closure and partial thoracomyoplasty. Two patients died within the first week of surgery. Surgery is the treatment of choice for most patients with pulmonary aspergilloma. Selective bronchial artery embolization is helpful only in combating hemoptysis, and this has been considered a temporary measure in most reports. Thus, open thoracotomy and anatomical resection are recommended as early as possible after the diagnosis is established.

Surgical treatment of pulmonary aspergillosis: A single center experience

BACKGROUND

Aspergillus fumigatus is a saprophytic fungus which colonizes in the cavitary lesions in the lungs. In our part of the world, where tuberculosis is endemic, the healed tubercular cavities form a good nidus for this fungus. The fungus forms a fungal ball or aspergilloma within the cavity, which erodes the walls of the cavity and causes hemoptysis by erosion of the bronchial vessels. Hemoptysis is the main symptom. Antifungal agents are not useful against the fungal ball. Surgery in the form of lobectomy is the primary treatment. Surgery for aspergilloma is known to be risky because of intra-pleural adhesions, obliteration of the interlobar fissures, massive hemorrhage during dissection and poor pulmonary reserve of the patient due to the underlying disease.

MATERIALS AND METHODS

Clinical presentation, radiological investigations, operative techniques, postoperative outcome, and follow-up of 24 cases of pulmonary aspergilloma treated surgically were studied prospectively between August 2010 and July 2013 at IPGMER and SSKM Hospital, Kolkata.

RESULTS

There were 15 male (62.5%) and 9 female (37.5%) patients. Mean age of the study population was 34.54 years. All the patients had complex aspergilloma. Tuberculosis was the underlying disease in 22 patients (91%). Hemoptysis was the main symptom in 79.16% cases. Chest X-ray was the first investigation, which gave a clue to the diagnosis. Computed tomography scan was diagnostic in all cases. Lobectomy was done in 16 patients (66.67%). There was one mortality and the overall complication was 33.33%. The average follow-up period was 21.65 months, during which there was no mortality and no recurrence of hemoptysis in these patients.

CONCLUSIONS

Though surgery for aspergilloma is considered to be risky, excision of the cavity along with the involved lobe can be done with acceptable morbidity and mortality to provide the patient complete cure and symptom-free survival.

Successful Treatment of Aspergillus Empyema Using Open Window Thoracostomy Salvage Treatment and the Local Administration of an Antifungal Agent

A 76-year-old woman received long-term immunosuppressive treatment for collagen vascular disease-associated interstitial pneumonia. The patient developed a cavitary mass lesion in the right lower lung field, and both nontuberculous mycobacteria and Aspergillus spp. were isolated after bronchial washing. The patient underwent a right lower lobectomy but developed Aspergillus empyema. Empyema due to Aspergillus spp. is a rare and life-threatening condition; however, the standard therapeutic strategies for treating Aspergillus empyema are not clear. We herein report a case of Aspergillus empyema that was successfully treated with a combination therapy which included open-window thoracostomy and the administration of antifungal agents (systemic micafungin and local amphotericin-B).

Surgical treatment of chronic pulmonary aspergillosis using preventive latissimus dorsi muscle flaps

Background

Surgery for chronic pulmonary aspergillosis is often technically risky. The choice of immediate thoracoplasty or muscle flap plombage to prevent postoperative space problems remains controversial. This study focused on the use of muscle flaps to prevent postoperative complications.

Methods

During an 8-year period (2004 to 2012), all patients surgically treated for chronic pulmonary aspergillosis were enrolled in this retrospective study. Concomitant intrathoracic transposition of the latissimus dorsi muscle flap has been performed since 2011. The clinical records of these patients were reviewed retrospectively.

Results

From 2004 to 2012, 16 patients were treated for chronic pulmonary aspergillosis. Fifteen patients received lobectomies and one had a partial resection. A preventive latissimus dorsi muscle flap was used in 6 patients (37 %). No postoperative deaths occurred. Prolonged air leaks appeared in 2 patients without muscle flaps, resulting in empyema in both. None of the patients with preventive muscle flaps suffered prolonged air leaks and subsequent empyema. In the outpatient clinic, late onset air leaks developed in 2 patients, one of whom had a lobectomy with muscle flap while the other had a lobectomy without muscle flap. Residual pleural space persisted in these two patients and Aspergillus infection later recurred.

Conclusions

Concomitant latissimus dorsi muscle flaps may be effective for the prevention of prolonged air leaks and subsequent empyema. Late onset air leaks are problematic.

Cavernostomy for Pulmonary Aspergillosis Associated with Destroyed Lung after Surgery for Lung Cancer: Report of 3 Cases

Slow, progressive, and destructive changes in the residual lung after surgery for lung cancer, known as “destroyed lung,” are delayed nonrecurrent complications. Destroyed lung can be a difficult condition to treat due to repeated infections and is therefore a complication that should not be ignored. We had three cases of intractable pulmonary aspergillosis difficult to treat associated with destroyed lung, after lung cancer surgery. Two of these patients followed a characteristic clinical course, which started with a cystic change just below the pleura and subsequently led to respiratory failure and death due to repeated infections. The third patient followed a similar clinical course and is currently under regular follow-up. Our cases suggest that concomitant occurrence of severe complications following surgery for lung cancer, such as destroyed lung and pulmonary aspergillosis, should be monitored because these complications can lead to respiratory failure and fatal clinical course. Radical surgery is not possible, especially when medical treatment is ineffective in controlling repeated infections and the patient's general condition is worsened due to prolonged chronic inflammation. Therefore, aggressive surgical intervention should be considered before patients worsen.

Evaluation of the Double Agar Gel Immunodiffusion Test and of the Enzyme-Linked Immunosorbent Assay in the Diagnosis and Follow-Up of Patients with Chronic Pulmonary Aspergillosis

The diagnosis of chronic pulmonary aspergillosis (CPA) depends on the radiologic image and the identification of specific antibodies. The present study aimed to evaluate accuracy parameters of enzyme-linked immunosorbent assay (ELISA) and of the determination of serum galactomannan level in the diagnosis of patients with CPA, comparing these results with the double agar gel immunodiffusion (DID) test. In addition, the prevalence of cross-reactivity and the serological progression after treatment were evaluated by comparing DID and ELISA. Six study groups were formed: G1: 22 patients with CPA, 17 of whom had Aspergillus fungus ball, one chronic cavitary pulmonary aspergillosis (CCPA) and four chronic fibrosing pulmonary aspergillosis (CFPA); G2: 28 patients with pulmonary tuberculosis (TB); G3: 23 patients with histoplasmosis (HST); G4: 50 patients with paracoccidioidomycosis (PCM); G5: 20 patients with cryptococcosis (CRC); and G6: 200 healthy controls. Serum antibodies were measured by DID and ELISA, with two antigen preparations—Aspergillus fumigatus (DID₁, ELISA₁) and a pool of A. fumigatus, A. flavus and A. niger antigens (DID₂, ELISA₂). The Platélia Aspergillus Enzyme Immunoassay (EIA) kit was used to measure galactomannan. The cut-off points of ELISA were determined for each antigen preparation and for the 95% and 99% confidence intervals. Despite the low sensitivity, DID was the technique of choice due to its specificity, positive and negative predictive values and positive likelihood ratio–especially with the antigen pool and due to the low frequency of cross-reactivity. ELISA₁ and a 0.090 cut-off showed high sensitivity, specificity and negative predictive value, but a high frequency of cross-reactivity with CRC. The best degree of agreement was observed between ELISA₁ and ELISA₂. The detection of serum galactomannan showed high sensitivity, comparable to ELISA₂. The immunodiffusion test showed an excellent relationship with the progression after treatment, which made it the reaction of choice for patient follow-up.

Aspergilloma and the surgeon

Aspergillus fungus is a ubiquitous saprophyte that is the causative organism for the development of an aspergilloma. The most common species causing an aspergilloma is the Apergillus fumigatus. An aspergilloma is a conglomeration of mucus, inflammatory cells and altered blood elements. Aspergillomas typically form in pre-existing lung pathology, most notably and commonly in old healed tuberculosis cavities. They are classified into simple and complex types that have clinical relevance. Symptoms are very variable and it is not uncommon to incidentally find a lung aspergilloma. In most case series, the most common presenting symptom is haemoptysis which varies from mild to catastrophic bleeds. Given the limited information about the natural history of the disease, there is unfortunately no recognised factor or variable which can predict how an aspergilloma will manifest itself, hence the manner of treatment is a still a topic of debate among treating physicians. The mainstay of treatment is surgical intervention and medical options although disappointing at the current stage, require further investigation in light of the newer available anti-fungal agents. The need for surgical intervention is however not as clear-cut as one would like, since many patients have multiple co-morbidities and other diffuse or focal lung pathology, making the decision process indeterminate in certain instances. In this review, we focus on the different surgical options available for the management of aspergilloma across variable clinical settings, and we propose an approach to its management.

Results of surgery for chronic pulmonary Aspergillosis, optimal antifungal therapy and proposed high risk factors for recurrence--a National Centre's experience

Background

Surgery for pulmonary aspergillosis is infrequent and often challenging. Risk assessment is imprecise and new antifungals may ameliorate some surgical risks. We evaluated the medical and surgical management of these patients, including perioperative and postoperative antifungal therapy.

Methods

Retrospective study of patients who underwent surgery for pulmonary aspergillosis between September 1996 and September 2011.

Results

30 patients underwent surgery with 23 having a preoperative tissue diagnosis while 7 were confirmed post-resection. The median age was 57 years (17–78). The commonest presenting symptoms were cough (40%, n = 12) and haemoptysis (43%, n = 13). Twelve (40%) patients had simple aspergilloma (including 2 with Aspergillus nodules) while the remaining 18 (60%) had chronic cavitary pulmonary aspergillosis (CCPA) (complex aspergilloma). Most of the patients had underlying lung disease: tuberculosis (20%, n = 6), asthma (26%, n = 8) and COPD (20%, n = 6). The procedures included lobectomy 50% (n = 15), pneumonectomy 10% (n = 3), sublobar resection 27% (n = 8), decortication 7% (n = 2), segmentectomy 3% (n = 1), thoracoplasty 3% (n = 1), bullectomy and pleurectomy 3% (n = 1), 6% (n = 2) lung transplantation for associated disease. Median hospital stay was 9.5 days (3–37). There was no operative and 30 day mortality. Main complications were prolonged air leak (n = 7, 23%), empyema (n = 6, 20%), respiratory failure requiring tracheostomy /reintubation (n = 4, 13%). Recurrence of CCPA was noted in 8 patients (26%), most having prior CCPA (75%). Taurolidine 2% was active against all 9 A. fumigatus isolates and used for pleural decontamination during surgery.

Conclusions

Surgery in patients with chronic pulmonary aspergillosis offered good outcomes with an acceptable morbidity in a difficult clinical situation; recurrence is problematic.

Pulmonary aspergilloma: clinical aspects and surgical treatment outcome

Aspergillomas are fungal balls within lung cavities. The natural history is variable. Hemoptysis is a dangerous sequela. Medical therapy is ineffective because of the lack of a lesion blood supply. Randomized trials are lacking. Surgery should be the treatment of choice in cases of hemoptysis, and even in asymptomatic patients, if lung function is not severely compromised. Cavernostomy and cavernoplasty may be options for high-risk patients. Percutaneous therapy should be reserved for patients who are not fit for surgery. Bronchial artery embolization is appropriate for symptomatic patients not suitable for surgery. Embolization could be considered a preoperative and temporary strategy.

Indications for surgery in patients with localized pulmonary infection

Nowadays, antibiotic and antifungal therapy is effective in treating some of the infections that can involve the lung parenchyma in a localized manner, such as bacterial abscess and infection with nonresistant tuberculosis strains. However, other localized pulmonary infections, for example aspergilloma and mucormycosis, are highly resistant to nonsurgical therapy, and in these diseases there are no generally successful options that do not include surgical resection. This article reviews the indications for surgical intervention in the treatment of common infections involving the lung, and also focuses on the general approaches to their management.

Aspergillus fumigatus fungus ball in the pleural cavity

OBJECTIVE

To report the cases of 6 patients with fungus ball caused by Aspergillus fumigatus (aspergilloma) in the pleural cavity.

METHODS

Between 1980 and 2009, 391 patients were diagnosed with aspergilloma at the Santa Casa Hospital Complex in Porto Alegre, Brazil. The diagnosis of aspergilloma in the pleural cavity was made through imaging tests revealing effusion and pleural thickening with air-fluid level; direct mycological examination revealing septate hyphae, consistent with Aspergillus sp.; and positive culture for A. fumigatus in the surgical specimen from the pleural cavity.

RESULTS

Of the 391 patients studied, 6 (2%) met the established diagnostic criteria. The mean age of those 6 patients was 48 years (range, 29-66 years), and 5 (83%) were male. The most common complaints were cough, expectoration, and hemoptysis. Four patients (67%) had a history of tuberculosis that had been clinically cured. All of the patients were submitted to surgical removal of the aspergilloma, followed by intrapleural instillation of amphotericin B, in 4; and 2 received systemic antifungal treatment p.o. There was clinical improvement in 5 patients, and 1 died after the surgery.

CONCLUSIONS

In adult patients with a history of cavitary lung disease or pleural fistula, a careful investigation should be carried out and fungal infection, especially aspergilloma, should be taken into consideration. In such cases, laboratory testing represents the most efficient use of the resources available to elucidate the diagnosis.

Surgical treatment for pulmonary aspergilloma: a 35-year experience in the Chinese population

The surgical treatment of pulmonary aspergilloma is challenging and controversial. This study was designed to evaluate the clinical profile, indications and surgical outcomes of pulmonary aspergilloma operated on in our institute. A total of 256 patients with pulmonary aspergilloma underwent surgical treatment from 1975 to 2010. The patients were divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160). The principal underlying lung disease was tuberculosis (71.1%). The surgical procedures consisted of 212 lobectomies in both groups; eight cavernoplasties, 10 bilobectomies, 16 pneumonectomies and six thoracoplasties in Group B; four segmentectomies and six wedge resections in Group A. Postoperative complications occurred in 40 patients (15.6%). The major complications were residual pleural space (3.9%), prolonged air leak (3.1%), bronchopleural fistula (1.6%), excessive bleeding (1.6%), respiratory insufficiency (1.9%) and empyema (1.2%). No intraoperative deaths occurred. The overall mortality within 30 days post-operation was 1.2%, occurring only in Group B. There was no statistically significant difference in the postoperative morbidity between Groups A and B (P = 0.27). With the good selection of patients, meticulous surgical techniques and good postoperative management, aggressive surgical treatment with anti-fungal therapy for pulmonary aspergilloma is safe and effective, and can achieve favourable outcomes.

Early and Long-term Outcomes of Pneumonectomy for Treating Sequelae of Pulmonary Tuberculosis

Background

Pneumonectomy remains the ultimate curative treatment modality for destroyed lung caused by tuberculosis despite multiple risks involved in the procedure. We retrospectively evaluated patients who underwent pneumonectomy for treatment of sequelae of pulmonary tuberculosis to determine the risk factors of early and long-term outcomes.

Materials and Methods

Between January 1980 and December 2008, pneumonectomy or pleuropneumonectomy was performed in 73 consecutive patients with destroyed lung caused by tuberculosis. There were 48 patients with empyema (12 with bronchopleural fistula [BPF]), 11 with aspergilloma and 7 with multidrug resistant tuberculosis.

Results

There were 5 operative mortalities (6.8%). One patient had intraoperative uncontrolled arrhythmia, one had a postoperative cardiac arrest, and three had postoperative respiratory failure. A total of 29 patients (39.7%) suffered from postoperative complications. Twelve patients (16.7%) were found to have postpneumonectomy empyema (PPE), 4 patients had wound infections (5.6%), and 7 patients required re-exploration due to postoperative bleeding (9.7%). The prevalence of PPE increased in patients with preoperative empyema (p=0.019). There were five patients with postoperative BPF, four of which occurred in right-side operation. The only risk factor for BPF was the right-side operation (p=0.023). The 5- and 10-year survival rates were 88.9% and 76.2%, respectively. The risk factors for late deaths were old age (≥50 years, p=0.02) and low predicted postoperative forced expiratory volume in one second (FEV1) (<1.2 L, p=0.02).

Conclusion

Although PPE increases in patients with preoperative empyema and postoperative BPF increases in right-side operation, the mortality rates and long-term survival rates were found to be satisfactory. However, the follow-up care for patients with low predicted postoperative FEV1 should continue for prevention and early detection of pulmonary complication related to impaired pulmonary function.

[Place of surgery in pulmonary aspergillosis and other pulmonary mycotic infections]

Surgery is part of the therapeutic strategy of aspergillosis and mucormycosis. The aspergilloma is defined as a rounded mass, developing in a cavity by the proliferation of spores of Aspergillus. The most common complication was haemoptysis reported in 50-95% of cases. The pleuropulmonary lesions predisposing are: tuberculosis, residual pleural space, emphysema and lung destroyed by fibrosis or radiotherapy or bronchiectasis. The indications for surgery depend on symptoms, respiratory function, the parenchyma and the type of aspergilloma (simple or complex). In a patient with an intrapulmonary aspergilloma, lung resection preceded by embolization is recommended based on respiratory function. For intrapleural aspergilloma, thoracoplasty is recommended according to the patient's general condition. The invasive pulmonary aspergillosis (IPA) is characterized by an invasion of lung tissue and blood vessels by hyphae in immunocompromised patients. The death rate of patients who have an API after treatment for leukemia or lymphoma was 30 to 40%, after bone marrow transplantation 60%, after solid organ transplantation from 50 to 60% and after any other cause of immunocompromising from 70 to 85%. The main cause of these deaths is massive hemoptysis. Surgery (lobectomy) is indicated for the prevention of hemoptysis when the mass is in contact with the pulmonary artery or one of its branches, and if it increases in size with the disappearance of border security between the mass and the vessel wall. The patient will be operated in an emergency before the white blood cells do not exceed the threshold of 1000 cells/μl. A persistent residual mass after antifungal treatment may justify a lung resection (lobectomy or wedge) before a new aggressive therapy. Mucormycosis affects patients following immunocompromising states--haematologic malignancy, diabetes mellitus, transplantation, burns and malnutrition. The treatment of pulmonary mucormycosis combines surgical and medical approach.

Pulmonary aspergilloma in patient with anorexia nervosa: case report

A 31-year old female with anorexia nervosa was referred to the Department of General Surgical Science at Gunma University for a surgical resection of a pulmonary aspergilloma. The patient had received treatment for anorexia nervosa at the Department of Psychiatry of the Hospital of Gunma University Graduate School of Medicine. A chest radiograph showed an infiltrative shadow with apical pleural thickening in the left upper lung field. A contrast enhanced computed tomography showed an irregular mass shadow with cavity formation that involved spherical clusters in the left upper lobe. The patient was diagnosed with pulmonary aspergilloma by serological studies and radiological features. A pulmonary segmentectomy of the left apical segment (S1 + 2) through a lateral thoracotomy was successfully performed. She had an uneventful postoperative recovery, and the final histopathological examination confirmed the diagnosis of pulmonary aspergilloma. This is a rare case study of a young female patient with anorexia nervosa who developed pulmonary aspergilloma.

Surgery offers high cure rates in multidrug-resistant tuberculosis

PURPOSE

Drug resistance has become a major problem in the treatment of tuberculosis, and pulmonary resection in combination with chemotherapy appears to be an effective measure for the treatment. The purpose of this study was to investigate the results of resection for multidrug-resistant pulmonary tuberculosis (MDR-TB).

PATIENTS AND METHODS

We retrospectively reviewed case files from January 2003 to December 2006 of 13 patients with MDR-TB underwent pulmonary resection.

RESULTS

Of 13 patients, 7 (53.9%) were sputum positive for mycobacterium tuberculosis preoperatively, though after surgery, they were sputum negative. Lobectomy was performed in 8 (61.5%) and pneumonectomy, in 5 (38.5%). In the lobectomy group, 2 patients had an additional superior segmentectomy and 1 had a middle lobectomy for other segmental or lobar lesions. Operative mortality was 7.6% (1/13). There were no late surgical deaths. In the early postoperative period, 3 patients had serious complications (postoperative bleeding, prolonged air leak, expansion deficit, bronchopleural fistula and empyema) that were resolved with surgery (morbidity 23.0%). The 12 patients who survived the operation received appropriate chemotherapy and were followed up for 24-37 months. None of the patients relapsed, and the overall cure rate was 92.3% (12/13).

CONCLUSION

Even with high morbidity in the early post-operative period, surgery, in addition to medical therapy, offers higher cure rates than only medical therapy; however, meticulous preoperative evaluation of patients is needed.

Clinical profile and surgical outcome for pulmonary aspergilloma: nine year retrospective observational study in a tertiary care hospital

BACKGROUND

The indications and the outcome of surgery for pulmonary aspergilloma remain highly controversial. This retrospective observational study was conducted to study the clinical profile, indications, post-operative complications and long term outcome of patients having pulmonary aspergilloma.

METHODS

From January 2000 to October 2008, 52 patients underwent surgery for pulmonary aspergilloma at our tertiary care institute.

RESULTS

The group consisted of 32 males and 20 females with a mean age of 39.3 ± 11.2 years. The most common indication for surgery was hemoptysis (96.15%). The underlying lung diseases were tuberculosis (75%), bronchiectasis (5.76%), and lung abscess (5.76%). In one patient (2%), concomitant ruptured lung hydatid cyst and an aspergilloma was present. The procedures performed were lobectomy (n = 43), bilobectomy (n = 3). pneumonectomy (n = 3), segmental resection (n = 3). The post-operative mortality was 1.92% (one patient). Overall complications occurred in 12 (23.07%) patients. The complications included prolonged air leak (n = 6), bleeding (n = 3), empyema (n = 1), repeated pneumothorax (n = 1), and wound dehiscence (n = 1). The mean follow-up period was 38 ± 18.6 months. There was no recurrence of disease or hemoptysis.

CONCLUSION

Pulmonary aspergilloma is common in developing countries like India in which there is high prevalence of pulmonary tuberculosis. Surgical resection of pulmonary aspergilloma is effective in preventing recurrence of symptoms including hemoptysis. We recommend early surgical resection of symptomatic aspergilloma with reasonable complications. Pre-operative preparation of the patients, meticulous surgical technique and post-operative chest physiotherapy reduces the rate of complications. Complications may still occur and are largely related to the underlying lung pathology; however, the long term outcome is good.