Video-assisted thoracoscopic surgery for pulmonary aspergilloma

Chronic Pulmonary Aspergillosis: Clinical Presentation and Management

Chronic pulmonary aspergillosis (CPA) refers to a number of clinical syndromes resulting from the presence and local proliferation of Aspergillus organisms in the lungs of patients with chronic lung disease. CPA is more common than was realized two decades ago. Recognition remains poor, despite recent studies from many countries highlighting the high prevalence in at-risk populations. In low- and middle-income countries, CPA may be misdiagnosed and treated as tuberculosis (TB). In addition, CPA may develop following successful TB treatment. The coronavirus disease pandemic has resulted in significant disruption to provision of TB care, likely leading to more extensive lung damage, which could increase the risk for CPA.Although CPA refers to various syndromes, the classic presentation is that of chronic cavitary pulmonary aspergillosis, which manifests as one or more progressive cavities with or without a fungal ball, accompanied by systemic and respiratory symptoms for at least 3 months. Diagnosis relies on Aspergillus immunoglobulin G in serum, as sputum culture lacks sensitivity. Differential diagnosis includes mycobacterial infection, bacterial lung abscess or necrotizing pneumonia, lung cancer, and endemic fungi.The aim of antifungal treatment in CPA is to improve symptoms and quality of life, and to halt progression, and possibly reverse radiological changes. Current recommendations suggest treatment for 6 months, although in practice many patients remain on long-term treatment. Improvement may manifest as weight gain and improvement of symptoms such as productive cough, hemoptysis, and fatigue. Surgical management should be considered in cases of diagnostic uncertainty, in significant hemoptysis, and when there is concern for lack of response to therapy. Itraconazole and voriconazole are the first-line azoles, with more experience now accumulating with posaconazole and isavuconazole. Side effects are frequent and careful monitoring including therapeutic drug monitoring is essential. Intravenous antifungals such as echinocandins and amphotericin B are used in cases of azole intolerance or resistance, which often develop on treatment. Relapse is seen after completion of antifungal therapy in around 20% of cases, mostly in bilateral, high-burden disease.Several research priorities have been identified, including characterization of immune defects and genetic variants linked to CPA, pathogenetic mechanisms of Aspergillus adaptation in the lung environment, the contribution of non-fumigatus Aspergillus species, and the role of new antifungal agents, immunotherapy, and combination therapy.

Single- versus multi-port video-assisted thoracic surgery for pulmonary aspergilloma: a propensity-matched study

OBJECTIVES

The utilization of single-port video-assisted thoracic surgery for pulmonary aspergilloma (PA) has not been well studied. The study was performed to evaluate the safety and feasibility of it for PA compared with multi-port video thoracic-assisted surgery.

METHODS

From August 2007 to December 2019, consecutive PA patients receiving surgeries at Shanghai Pulmonary Hospital were enrolled retrospectively. Propensity score matching based on preoperative clinical variables was utilized to compare perioperative and long-term outcomes.

RESULTS

In all 358 patients, a total of 63 patients underwent single-port video-assisted thoracic surgery, and 63 out of 145 patients for multi-port surgeries were paired with the single-port video-assisted thoracic surgery recipients. The median follow-up period was 40 months (range, 2-140 months). Patients receiving single-port video-assisted thoracic surgery showed a similar operation time, intraoperative blood loss, drainage duration and drainage volume to those of multi-port video-assisted thoracic surgery recipients (P > 0.05). Patients undergoing lobectomy by single-port approach experienced a shorter postoperative hospital stay {4.9 [standard deviation (SD): 2.0] vs 5.9 (SD: 2.3), P = 0.014}. The average postoperative pain scores [day 0: 2.6 (SD: 0.7) vs 3.1 (SD: 0.8), day 3: 4.0 (SD: 0.9) vs 4.8 (SD: 3.9), day 7: 2.2 (SD: 0.5) vs 3.1 (SD: 0.8), P < 0.001] and the number of days that patients required analgesic agents [3.0 (SD: 2.2) vs 4.8 (SD: 2.1), P < 0.001] were also decreased in the single-port video-assisted thoracic surgery group.

CONCLUSIONS

Single-port video-assisted thoracic surgery is a safe and feasible alternative to multi-port video-assisted thoracic surgery for simple PA and selected complex ones, with a potential advantage of reduced postoperative pain.

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.

Fungus ball removal with video-cavernoscopy for complex aspergilloma

OBJECTIVE

Complete resection with a clear margin is the only curative treatment for pulmonary aspergilloma. This requires a high-level technique, especially for complex aspergilloma (CA), because of patient conditions and wide dense adhesions. Fungus ball removal is used palliatively to control hemoptysis, rather than as a radical procedure, and may be performed using video-cavernoscopy as a simple and repeatable method. In this study, we examined this approach as an alternative treatment for CA.

METHODS

Eight cases of fungus ball removal with video-cavernoscopy (video-cavernoscopic removal) treated at our center were retrospectively reviewed. The patient characteristics and surgical outcomes were compared with those of patients treated with one-stage radical surgery.

RESULTS

There were 8 subjects (7 males, 1 female; median age 65 years) in the video-cavernoscopic removal group and 25 subjects (19 males, 6 females; median age 56 years) in the one-stage radical surgery group. The video-cavernoscopic removal group had a higher rate of emphysematous lung (p = 0.001), a lower body mass index (p = 0.039), and a lower percent vital capacity (p = 0.027). All cases in this group had preoperative hemoptysis that ceased after the procedure. Video-cavernoscopic removal was less invasive based on a shorter operative time (p = 0.000), less blood loss (p = 0.002), and a lower Common Terminology Criteria for Adverse Events grade (p = 0.023). However, four cases in this group (50%) relapsed with a median disease-free survival period of 471.5 days.

CONCLUSIONS

Fungus ball removal with video-cavernoscopy is a simple technique for the prevention and control of massive hemoptysis that may be an alternative treatment for CA.

Upper Airway Nerve Block for Rigid Bronchoscopy in the Patients with Tracheal Stenosis: A Case Serie

Background

Rigid bronchoscopy is often used to diagnose and treat the location of resection of the tracheal stenosis. It is a selective procedure for the dilatation of tracheal stenosis, especially when accompanied by respiratory distress.

Objectives

We introduced patients who were diagnosed with tracheal stenosis and candidate for rigid bronchoscopy dilatation by the upper airway nerve blocks.

Methods

This prospective observational study was conducted on 17 patients who underwent dilatation with rigid bronchoscopy in tracheal stenosis at Hospitals affiliated with Babol University of Medical Sciences from 2002 to 2017. The patients were given three nerve blocks, 6 bilateral superior laryngeal nerve block, bilateral glossopharyngeal nerve block, and recurrent laryngeal nerve block (transtracheal) before awake rigid bronchoscopy using 2% lidocaine. We evaluated the demographic data, the cause of tracheal stenosis, the quality of the airway nerve block (Intubation score), patients’ satisfaction from bronchoscopy and thoracic surgeons’ satisfaction. Complications of nerve blocks were recorded.

Results

From 2002 to 2017, 17 patients (14 were male and 3 were) female with tracheal stenosis who were candidates for dilatation with bronchoscopy and accepted the upper nerve block were included. The quality of the block was acceptable in 16 (94%) patients. 15 patients received fentanyl, and only two patients did not need to intravenous sedation. The mean age of patients was 29.59 ± 11.59. The average satisfaction of the surgeon was 8.82 ± 1.13 and the satisfaction of patients with anesthesia was 8.89 ± 1.16. There was one serious complication (laryngospasm) in one patient.

Conclusions

The upper airway nerve block method is a suitable anesthesia technique for patients with tracheal stenosis who are candidates for the tracheal dilatation with rigid bronoscopy, especially when the patient has respiratory distress and has not been evaluated before surgery.

Surgical Outcome of Chronic Pulmonary Aspergilloma: An Experience from Two Tertiary Referral Hospitals in Addis Ababa, Ethiopia

BACKGROUND

Surgical management of pulmonary aspergillosis is challenging and controversial. This study is designed to assess the clinical profile, indications and surgical outcome of Pulmonary aspergilloma.

METHODS

A retrospective cross-sectional analysis of 72 patients who underwent pulmonary resection for pulmonary aspergilloma over the period from November, 2014, to November, 2019 was done. Data on demographic, clinical and surgical out come were retrieved. Analysis was done using SPSS version 23. Chi-square test was used to assess for significance of the association between variables and surgical outcome.

RESULTS

There were 46(63.9%) males and 26(36.1%) female patients with a mean age of 35.2+/-11.6 years (Range 16- 65 years). All patients were previously treated for tuberculosis. Cough, hemoptysis, and shortness of breath were the main symptoms identified. A ball of fungus together with the surrounding lung was removed. Accordingly, 32(44,4%) lobectomies, 12(16.7%) pneumonectomy, 7(9.7%) Bi-lobectomy, and 21(29.2%) cavernostomy were done. Intraoperative and Postoperative complications were seen in 8(11.1%) and 21(29.1%) patients respectively. Major morbidity encounters included massive intraoperative blood loss, prolonged air leak, empyema, air space, bronchopleural fistula, and wound infection. The hospital mortality was 3(4.2%) and the average hospital stay was 14.8days. Postoperative complications were evaluated for the difference in socio-demographic characteristics and other variables and a statistically significant difference was detected only for the location of aspergilloma, site of the lung involved and type of surgery done. (P-value =0.05.).

CONCLUSION

Pulmonary resection done for pulmonary aspergilloma showed favorable outcomes when done with good patient selection, meticulous surgical techniques, and good postoperative management. However, its long term outcome and role of antifungal treatment as adjunctive therapy for surgical resection need further investigation.

Hemoptysis from complex pulmonary aspergilloma treated by cavernostomy and thoracoplasty

BACKGROUND

In high-risk patients with complex pulmonary aspergilloma but unable for lung resection, cavernostomy and thoracoplasty could be performed. This study aimed to evaluate this surgery compared two compressing materials.

METHODS

A total of 63 in high-risk patients who suffered from hemoptysis due to complex pulmonary aspergilloma and underwent cavernostomy and thoracoplasty surgery from November 2011 to September 2018 at Pham Ngoc Thach hospital were evaluated prospectively studied. Patients were allocated to two groups: the table tennis ball group and tissue expander group. We evaluated at the time of before operation, 6 months and 24 months after operation.

RESULTS

Tuberculosis was the most common comorbidity diseases in both groups. Upper lobe occupied almost in location. Hemoptysis symptoms plunged from time to time. Statistically significant Karnofsky score was observed in both groups. Postoperative pulmonary functions (FVC and FEV1) have remained in both groups at all time points. The remarkable results were no deaths related to surgery and low complications both short and long-term. There was no statistical significance between two groups in operative time, blood loss during operation, ICU length-stay time. Four patients died because of co-morbidity in 24 months follow-up.

CONCLUSION

Cavernostomy and thoracoplasty was safe and effective surgery for the treatment of complex pulmonary aspergilloma with hemoptysis in high-risk patients. No mortality related to surgery and low complications were recorded. The was no inferiority when compared two compressing materials .

Effect of resected length in reconstructive surgery for tracheobronchial injury

Background

Mechanical injury to the trachea and bronchi may cause mild to severe stenosis requiring surgical intervention for reconstructing the damaged trachea. The location, length, and cause of injury are important factors affecting the surgical outcome.

Method

We conducted a retrospective study to evaluate the results of reconstructive surgery on noncancerous tracheobronchial lesions in 75 patients aged 5–55 years who had undergone reconstructive tracheobronchial surgery in our hospital from 2009 to 2018.

Results

The causes of tracheobronchial injury included blunt trauma in 38 patients, sharp penetrating trauma in 24, a postintubation lesion in 6, a post-tracheotomy lesion in 3, tuberculosis in 3, and an adult congenital lesion in one. In 59 cases of a lesion in the trachea, the length of missing segment before reconnection was 1–2 cm in 6 cases, 3 cm in 22, 4 cm in 18, 5 cm in 13, and >5.5 cm in 1 case. The length of the resected segment was <5.5 cm in all survivors, whereas one death occurred when the resected length was approximately 6 cm.

Conclusions

The length of the resected segment and precision of the surgery are crucial for determining the outcome of surgery.

Uniportal Video-assisted Thoracoscopic Surgery for Pulmonary Aspergilloma: A Report of 5 Cases

Pulmonary aspergilloma is an uncommon pulmonary disease that complicated with many other respiratory disorders. Despite advances in medication, surgical treatment continues to form the basis of aspergilloma treatment. However, the use of uniportal video-assisted thoracoscopic surgery is extremely limited in pulmonary aspergilloma. In this report, 5 patients who underwent anatomic pulmonary resection safely with uniportal video-assisted thoracoscopic surgery technique without requiring a traditional thoracotomy were presented.

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.