title: Results of surgery for chronic pulmonary Aspergillosis, optimal antifungal therapy and proposed high risk factors for recurrence--a National Centre's experience.
abstract: 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.
authors.forename: Shakil
authors.initials: S
authors.lastname: Farid
authors.forename: Shaza
authors.initials: S
authors.lastname: Mohamed
authors.forename: Mohan
authors.initials: M
authors.lastname: Devbhandari
authors.forename: Matthew
authors.initials: M
authors.lastname: Kneale
authors.forename: Malcolm
authors.initials: M
authors.lastname: Richardson
authors.forename: Sing Y
authors.initials: SY
authors.lastname: Soon
authors.forename: Mark T
authors.initials: MT
authors.lastname: Jones
authors.forename: Piotr
authors.initials: P
authors.lastname: Krysiak
authors.forename: Rajesh
authors.initials: R
authors.lastname: Shah
authors.forename: David W
authors.initials: DW
authors.lastname: Denning
authors.forename: Kandadai
authors.initials: K
authors.lastname: Rammohan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000627:therapeutic use*; D002908:Chronic Disease; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011013:Pneumonectomy / Q000379:methods*; D011183:Postoperative Complications; D055732:Pulmonary Aspergillosis / Q000175:diagnosis / Q000188:drug therapy / Q000601:surgery*; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents
references.citation: Ann Thorac Surg. 1989 Dec;48(6):779-82
references.pmid: 2688579
references.citation: N Engl J Med. 2002 Aug 8;347(6):408-15
references.pmid: 12167683
references.citation: Interact Cardiovasc Thorac Surg. 2011 Oct;13(4):392-5
references.pmid: 21729950
references.citation: J Thorac Cardiovasc Surg. 1971 Sep;62(3):411-22
references.pmid: 5126682
references.citation: Clin Infect Dis. 1998 Apr;26(4):781-803; quiz 804-5
references.pmid: 9564455
references.citation: Ann Thorac Surg. 1992 Dec;54(6):1159-64
references.pmid: 1449303
references.citation: Ann Thorac Surg. 2002 Jan;73(1):240-4
references.pmid: 11834016
references.citation: Eur Respir J. 2011 Apr;37(4):865-72
references.pmid: 20595150
references.citation: Ann Thorac Surg. 2010 May;89(5):1603-10
references.pmid: 20417786
references.citation: Thorax. 2011 Jul;66(7):638-40
references.pmid: 21460371
references.citation: Mycoses. 2013 Sep;56(5):559-70
references.pmid: 23496375
references.citation: Ann Thorac Surg. 1985 Jun;39(6):512-6
references.pmid: 3890782
references.citation: Eur J Cardiothorac Surg. 1997 Dec;12(6):876-9
references.pmid: 9489873
references.citation: Emerg Infect Dis. 2009 Jul;15(7):1068-76
references.pmid: 19624922
references.citation: Clin Infect Dis. 2013 Sep;57(6):828-35
references.pmid: 23788240
references.citation: Int Angiol. 2008 Aug;27(4):319-28
references.pmid: 18677295
references.citation: Ann Thorac Surg. 2005 Sep;80(3):1067-72
references.pmid: 16122488
references.citation: Bull World Health Organ. 2011 Dec 1;89(12):864-72
references.pmid: 22271943
references.citation: J Thorac Cardiovasc Surg. 1986 Dec;92(6):981-8
references.pmid: 3097424
references.citation: Sci Transl Med. 2012 Dec 19;4(165):165rv13
references.pmid: 23253612
references.citation: Interact Cardiovasc Thorac Surg. 2012 Jul;15(1):77-80
references.pmid: 22499801
references.citation: Thorac Surg Clin. 2012 Aug;22(3):345-61
references.pmid: 22789598
references.citation: J Cardiothorac Surg. 2011 Oct 05;6:129
references.pmid: 21974978
references.citation: J Thorac Cardiovasc Surg. 1995 Oct;110(4 Pt 1):1125-9
references.pmid: 7475141
references.citation: Ann N Y Acad Sci. 2012 Dec;1272:58-67
references.pmid: 23231715
references.citation: Med Mycol. 2013 May;51(4):361-70
references.pmid: 23210682
references.citation: Ann Thorac Surg. 2000 Mar;69(3):898-903
references.pmid: 10750780