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

Abstract

BackgroundSurgery 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.MethodsRetrospective study of patients who underwent surgery for pulmonary aspergillosis between September 1996 and September 2011.Results30 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.ConclusionsSurgery in patients with chronic pulmonary aspergillosis offered good outcomes with an acceptable morbidity in a difficult clinical situation; recurrence is problematic.

Chronic pulmonary aspergillosis: rationale and clinical guidelines for diagnosis and management

“…The type of disease also affects the long-term outcome. In simple aspergilloma 10-year survival rates range between 69 and 90% while morbidity and mortality is higher in CCPA, where the 10-year survival rate is ∼63-80% [125,127,129,138].…”

“…Success of the procedure depends on the ability to fully resect the aspergilloma without spillage of fungal elements into the pleural space. As such, recurrence of disease and haemoptysis are rare in simple aspergilloma while CCPA carries a lower success rate [124][125][126].…”

“…Some patients with extensive disease may require thoracoplasty with simultaneous cavernostomy and muscle transposition flap (SoR C and QoE III) [133,134]. Antifungal therapy can be administered to prevent Aspergillus empyema or to avoid recurrence of disease when complete resection is not possible [125], but there is no evidence to support this role of adjuvant triazole antifungal therapy following definitive surgical removal of a single aspergilloma [139,140], although a more nuanced approach is warranted in our view [125]. Simple aspergilloma that can be resected without spillage of fungal material probably does not require adjuvant antifungal therapy (SoR D and QoE II) [139,140].…”

“…Yet, as this approach is rarely completely effective for very severe haemorrhage, it is rather a bridge towards definite elective surgery. Prior to possible elective surgery, careful patient selection [125] is warranted as many patients are physically debilitated contributing to a higher risk of death and peri-and post-operative complications. In this regard special emphasis should be given to cardiopulmonary function.…”

“…Indications for surgery in CPA Surgical resection of aspergilloma is a definitive treatment option for patients with adequate pulmonary function (SoR A and QoE II) (table 11) [124,125]. Success of the procedure depends on the ability to fully resect the aspergilloma without spillage of fungal elements into the pleural space.…”