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Ann Thorac Surg 2002;73:240-244
© 2002 The Society of Thoracic Surgeons
a Thoracic Department, Institut Mutualiste Montsouris, Paris, France
b Pathology Department, Institut Mutualiste Montsouris, Paris, France
c Hematology Department, Bone Marrow Transplant Unit, Hôpital Saint-Louis, Paris, France
Accepted for publication August 24, 2001.
* Address reprint requests to Dr Gossot, Thoracic Department, Institut Mutualiste Montsouris, 42 Bd Jourdan, F-75014 Paris, France
e-mail: dominique.gossot{at}imm.fr
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Methods. Nineteen patients (mean age 27 years) with diagnosed or probable IPA were operated on. Seventeen had an hematologic malignancy and 2 had a refractory aplastic anemia. Nine patients had undergone an allogenic SCT that was complicated by a graft-versus-host disease in 5 patients. In 3 patients, SCT was pending. All patients had preoperative systemic antifungal therapy for at least 2 weeks. Fifteen patients had only one lesion, whereas 4 had two lesions. Eight patients had an absolute neutrophil count less than 3,000 and 2 less than 1,000, and 9 were thrombopenic (platelet count <60,000) at the day of surgery. Wedge resections were performed in 7 patients and lobectomies were performed for the other 12. For the latter, an open approach via posterolateral thoracotomy was decided upon in only 1 patient. For the other 11 lobectomies, a mini-thoracotomy was needed in 3 cases for intraoperative difficulties. Conversion to conventional thoracotomy was necessary for 2 of these patients. In total, out of the 19 patients, 15 had a total endoscopic approach, 3 had a thoracotomy, and 1 had a video-assisted approach.
Results. There was no intraoperative mortality. In the group of wedge resections, no intraoperative or postoperative complication occurred. In the lobectomy group, three hemorrhages occurred during dissection of the pulmonary artery in the fissure, leading to conversion to a mini-thoracotomy in 2 patients and to a classic postero-lateral thoracotomy in 1 patient. There were two minor complications: one pneumothorax and one mild pleural effusion.
Conclusions. In these debilitated and immunocompromised patients, a full thoracoscopic resection of fungal infection is feasible, even for lobectomies. It allows a simpler postoperative course and minimizes sequelae.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Although several authors have reported video-assisted wedge resections for IPA, thoracoscopic major pulmonary resections have not been described in this situation. However, in these young patients with otherwise healthy lungs, thoracoscopy might be a valuable approach if large vessels are not involved by the fungal infection. We report our experience with a preferential thoracoscopic approach for these patients.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Bronchoalveolar lavage performed immediately before surgery was negative in 2 patients out of the 7 done. Aspergillus antigenemia was positive in 7 patients, negative in 10, and not assessed in 2. Fifteen patients had only one lesion, whereas 4 had two lesions in the same lung. Eight patients had an absolute neutrophil count less than 3,000 and 2 less than 1,000, and 9 were thrombopenic (platelet count < 60,000) at the day of surgery.
Finally, surgery was indicated as part of antifungal therapy in 12 patients, because of hemorrhagic hazard in 3 and for diagnostic confirmation before SCT in 4.
Surgery
Only one open posterolateral thoracotomy was decided upon preoperatively because of evident invasion of the pulmonary artery on computed tomography. For all other patients, a thoracoscopic approach was chosen. It was performed under split ventilation in all except 1 patient, a 15-year-old female patient in whom a double-lumen tube insertion was not possible; a lobectomy was performed on an inflated lung without major concern.
Wedge resections were performed in 7 patients. In 1 of them, a pleural resection was done to allow for an en bloc resection of both the pulmonary lesion and pleura (Fig 1). None of these seven wedge resections needed an open conversion.
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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In the lobectomy group, three hemorrhages occurred during dissection of the pulmonary artery within the fissure, leading to conversion to a mini-thoracotomy in two cases and to a classic posterolateral thoracotomy in one case. Dense adhesions and inflammation near hilar structures were a major hindrance in five cases. They were responsible for the three hemorrhages and five open conversions. However, in 5 patients, they did not prevent a full endoscopic lobectomy. None of the intraoperative hemorrhages required transfusion.
There were two minor complications in the lobectomy group: one pneumothorax that did not need to be drained and one mild pleural effusion, also not drained. The postoperative stay in surgery ranged from 4 to 7 days (average 5.4 days). The short stay in surgery is partly explained by the fact that most patients were referred to their original hematologic department after surgery. No parietal or intrapleural infection was detected. All patients received postsurgery antifungal drugs.
Follow-up
As of December 1, 2000, the median follow-up was 13 months (1 to 32 months). No patient died in the first 30 postoperative days. Four patients succumbed between the second and third months: 2 died from cerebral aspergillus infection despite the fact that the preoperative brain computed tomography was normal; 2 other patients died from unrelated causes: hepatic failure (1) and leukemic brain localization (1).
The 3 patients who were waiting for SCT were transplanted within 1 month after surgery.
Pathology
The diagnosis of invasive aspergillosis was confirmed in all but 3 patients. In 2 patients, only areas of necrotic infarction were found and were assumed to correspond to so-called mycotic lung sequestrum. In 1 patient, a bacterial pneumopathy with negative culture and without any sign of Aspergillus infection was found. In the other 16 patients, the diagnosis of IPA was confirmed with typical fungal elements.
In all lobectomy specimens, margins of resection were clear of Aspergillus. Of the seven wedge resections, one presented some degree of inflammation and macrophagic infiltration at the resection margin, and two were showing some septate hyphae in the margin, suggesting an incomplete resection. One of these patients died at day 50 from brain localization of Aspergillosis. The second patient is disease free after a 15-month follow-up period.
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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However, despite the fact that the intra- and perioperative morbidity of surgical resections is low in most series, one must realize that surgery usually occurs during a long and exhausting treatment. Therefore, reducing the invasiveness of surgery seems beneficial for these immunocompromised patients. Although video-assisted wedge resections of IPA lesions have recently been reported [4, 5], we have found no cases of video-assisted or endoscopic lobectomies for IPA in the literature. At first sight, an endoscopic approach for a pathology that has the reputation of being associated with major inflammation as well as lymph node enlargement seems questionable. However, there are some arguments in favor of endoscopic procedure. (1) Most patients are young (mean age of 27 years in this series) and have healthy lungs beside infected areas. Therefore, despite some degree of inflammation, the anatomy remains clear and fissures are complete in most cases. (2) Most patients are neutropenic and thrombopenic. Avoiding a thoracotomy with its inherent muscular incisions is beneficial. (3) Eventually, in these young patients who have already suffered or will suffer from several invasive treatments, avoiding the consequences of a thoracotomy must be considered.
When the lesion is small sized and subpleural, a wedge resection is the treatment of choice [2]. There were no complications in our series and the postoperative stay has always been less than 3 days. However, despite advantages, some shortcomings must be noted. (1) The limited opening of the endoscopic staplers, although improved in the new generation of staplers, does not always allow an easy resection. (2) A tight invasion of the pleura may be impossible to manage thoracoscopically, because most endoscopic instruments are not stiff enough for this use. (3) A security margin must be respected in order to avoid leaving infected tissues on the margins (Fig 3) [2, 7]. In the case of a deeply located lesion, a segmentectomy might be a better alternative than a wedge resection. But, when operating thoracoscopically, the surgeon may tend to do a lobectomy rather than a segmentectomy, a more difficult procedure when done endoscopically.
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For nonmalignant pathologies like IPA, where a complete lymphadenectomy is not needed, this approach is particularly appropriate. Inflammation of the parenchyma in the fissure and lymph node enlargement may be concerns. They were noticed in 11% of patients by Habitcht and associates [5]. But the use of ultrasonic dissection [19] as well as a thorough dissection help overcome these problems. Tight inflammatory adhesions to the vessels have been a real problem in only 5 patients and have led to open conversion. The difficulty related to inflammation is often outweighed by the facility of operating on a healthy and young lung. We have easily achieved a middle lobectomy without split ventilation, which would be almost impossible to do thoracoscopically in an older and smoker patient.
Some publications about video-assisted lobectomies have shown little benefit with respect to operative time, blood loss, and postoperative stay [11, 12]. However, these studies have compared a thoracotomy with a so-called "access incision." The latter is at least 6 to 10 cm long and the use of a rib spreader is frequent. Because we have not conducted a comparative study between full endoscopic lobectomy and video-assisted lobectomy, we cannot assert that there is a proven benefit to this technique, but the postoperative course has always been remarkably uneventful, both from the clinical and the radiographic aspect. Recently, some studies have demonstrated than the thoracoscopic approach is associated with less inflammatory response [20, 21]. Yim and associates have shown that the release of proinflammatory and inflammatory cytokines was less after video assisted thoracic surgery lobectomy than after conventional lobectomy, indicating a reduced postoperative inflammatory reaction [21]. So far, the clinical benefit of such a response is not documented. However, according to Yamada and associates, high serum levels of interleukin-6 and interleukin-8 after thoracic surgery are associated with an increased incidence of postoperative infection [22].
In severely immunocompromised and often thrombopenic patients with IPA, a full endoscopic approach limits the consequences of pulmonary resections. Another argument supporting a limited resection via thoracoscopy is that in some instances, the aim of surgery is also diagnostic, because serology and bronchial lavage is often negative [5].
There are, however, three limitations to an endoscopic approach. (1) Tight pleural invasion may be impossible to manage thoracosopically, because most endoscopic instruments are not stiff enough for this use. (2) Dense inflammation and hazardous vascular dissection may require assistance of a mini-thoracotomy, or even conversion to a standard thoracotomy. (3) Some deeply located lesions are better managed by a segmentectomy [2, 4, 5] than by a wedge resection. In these cases, a thoracotomy may be more appropriate.
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Acknowledgments |
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References |
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