Asian Cardiovasc Thorac Ann 2004;12:246-249
© 2004 Asia Publishing EXchange Ltd
Surgical Management of Pulmonary Cavity Associated with Fungus Ball
Chareonkiat Rergkliang, MD,
Apirak Chetpaophan, MD,
Vorawit Chittithavorn, MD,
Prasert Vasinanukorn, MD
Division of Cardiovascular and Thoracic surgery, Prince of Songkla University, Songkhla, Thailand
For reprint information contact: Chareonkiat Rergkliang, MD Tel: 66 74 451 401 Fax: 66 74 429 384 Email: Chareonkiat{at}yahoo.com Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Prince of Songkla University, Had Yai, Songkhla 90110, Thailand.
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ABSTRACT
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Surgery for pulmonary cavity associated with fungus ball is challenged by chronic lung disease. The purpose of this report was to review patient data, operative procedures and results of surgery. This was a retrospective study. Twenty patients were operated on between January 1997 and December 2002. Fourteen (70%) patients were male and the mean age was 46.30 ± 13.10 years (range, 24 to 76 years). The most common underlying pulmonary disorder was tuberculosis (70%). Ninety five percent of the patients had a history of hemoptysis, and 35% presented with massive hemoptysis. Lobectomy was performed in 11 (55%) patients and 6 (30%) patients were operated on by cavernostomy with transposition of muscle flap technique. There was no operative mortality and 8 complications (3 prolonged airleaks, 2 wound infections, 1 postoperative bleeding, 1 seroma and 1 empyema). It was also found that emergency surgery and cavernostomy with transposition of muscle flap compromised the postoperative course. Surgery is very effective in controlling and preventing hemoptysis in patients who have pulmonary cavity associated with fungus ball. Elective surgery and formal pulmonary resection may be the proper option for low risk patients. Cavernostomy with transposition of muscle flap may be suitable for patients who have poor pulmonary reserve.
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INTRODUCTION
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The formation of a fungus ball in a pulmonary cavity is a rare but potentially life-threatening complication for a patient who is already challenged by chronic lung disease. The most common preceding pulmonary lesion is an open healed tuberculous cavity and the most common organism found in the cavity is Aspergillus.1–3 The clinical spectrum of this pathology ranges from an incidental radiologic finding to life-threatening hemoptysis. Medical treatment has little role in the management and surgery offers significant benefits for the patient.4 However, high mortality and morbidity rates of the operation have been reported in literature.5–7 The purpose of this study was to evaluate patient data, operative techniques and results in the surgical management of pulmonary cavity associated with fungus ball.
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PATIENTS AND METHODS
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Twenty patients of pulmonary cavity associated with fungus ball were diagnosed and operated on at Songkhlanagarind Hospital between January 1997 and December 2002. The medical records of these patients were reviewed for demographic data, presenting symptoms, underlying pulmonary lesions, preoperative investigations, surgical procedures, postoperative courses and midterm results. The data were collected and descriptively analyzed.
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RESULTS
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There were 20 patients diagnosed with pulmonary cavity associated with fungus ball and treated in our surgical unit. Fourteen (70%) patients were male and mean age at operation was 46.30 ± 13.10 years (range, 24 to 76 years). The underlying pulmonary disorder was tuberculosis in 14 (70%) cases, bronchiectasis in 1 (5%) case, lung abscess in 1 (5%) case and in 4 (20%) patients there was no preceding pulmonary lesion. The average latent period from active tuberculosis to the occurrence of fungus ball and symptoms was 8.2 years (range, 2 to 20 years).
Nineteen (95%) patients presented with hemoptysis and only one patient presented with chronic cough. Seven (35%) patients suffered from massive hemoptysis. The diagnosis was made by chest radiography in 4 (20%) patients. The other 16 (80%) patients were diagnosed by computerized tomography (CT). In 9 (45%) patients bronchoscopy was performed to identify the bleeding site. Selective bronchial artery embolization was attempted to control hemoptysis in 3 (15%) patients but it was unsuccessful. The pulmonary function test was performed in 13 (65%) elective patients. The average forced expiratory volume in 1 Second (FEV1) was 1.1 liter (range, 0.8 to 2.1 liter).
Seven (35%) patients had emergency surgery due to massive hemoptysis and 13 patients had elective surgery. The operation was performed via posterolateral thoracotomy approach. The operative procedure was decided according to patient’s physical performance status, data from pulmonary function test, findings from CT and operative findings. A formal pulmonary resection was attempted in a patient who had a good physical performance status and an acceptable pulmonary function test. If the patient’s fitness was limited and CT showed severe adhesion between lung and chest wall, cavernostomy with transposition of muscle flap was chosen. The variation in operative procedures is shown in Table 1
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The most common operative procedure was lobectomy (55%). Pneumonectomy was performed in 2 (10%) patients, the first one due to severe adhesion at major fissure, when the lobes could not be technically separated, and the second one had 2 cavities in both left upper lobe and lower lobe. Cavernostomy with transposition of muscle flap was performed in 6 (30%) patients. The latissimus dorsi (3 patients) or serratus anterior muscle (3 patients) was dissected and cut at distal attachment before the pleural cavity was approached. After the pleural cavity was opened, adhesiolysis over the culprit lobe and chest wall was done as much as possible to cut the collateral artery to the cavity. Bleeding from the chest wall was checked and stopped and the fungus ball was removed. The end-on vessels and airways were carefully identified and secured with 4/0 polypropylene sutures. The lung was fully inflated to check for any residual airleaks inside the cavity. The segment of the third and fourth ribs were resected, the muscle flap transposed into the cavity and secured in place with multiple absorbable sutures.
There were no operative deaths. Eight complications were found in the 20 (40%) patients. The most common complication was prolonged airleak (3 patients) which was successfully managed by prolonged chest tube drainage. The other complications were: 2 wound infections; 1 seroma; 1 empyema; and 1 major bleeding which required reoperation. Seven complications were found in patients who were operated on by cavernostomy with transposition of muscle flap technique.
There were 8 (40%) patients who required ventilator support postoperatively but only three needed the support for more than 24 hours. The mean postoperative hospital stay was 15.8 ± 10.54 days (range, 4 to 46 days).
The mean follow up period was 19.0 ± 13.1 months (range, 4 to 48 months) for all of patients. Four complications occurred during follow-up: 2 recurrent mild hemoptysis; 1 pneumonia; and 1 empyema. The two recurrent hemoptysis occurred in patients who underwent cavernostomy with transposition of muscle flap and both of them were successfully treated by selective bronchial artery embolization.
Comparing emergency surgery and elective surgery, we found that the emergency surgical group required more ventilator support, had slightly higher complications and longer postoperative hospital stay (Table 2). The patients who underwent cavernostomy with transposition of muscle flap had a greater ventilator requirement, higher complication rates and longer postoperative hospital stay when compared with the patients who had formal pulmonary resection (Table 3). The organism in the cavity was Aspergillus in 17 (85%) cases and Actinomycosis in 3 (15%) cases. The pathologic report of pulmonary resection (14 cases) was bronchiectasis in 13 cases and the other was a lung cyst.
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DISCUSSION
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Pulmonary cavity associated with fungus ball usually follows chronic lung disease. Tuberculosis is the most common underlying disease which ranges from 50% to 90% of the patients.1–3,8,13 In our series, we found that open healed tuberculous cavity contributed 70% of the patients. The airborne method of spread and chronic underlying pathology led to fungus ball developing in individual patients.4 The British Thoracic and Tuberculosis Association reported 6% of patients with open healed tuberculous cavity developing an aspergilloma within three years.9 Our patients had a history of tuberculosis ranging from 2 to 20 years (average 8.2 years) before surgery, similar to the findings reported by Tseng and colleagues.11 This may be explained by the long latent period before the occurrence of symptoms as all of our patients were symptomatic.14
Hemoptysis is the most common presenting symptom, occurring in 48% to 100% of patients.1–3,8,10 Ninetyfive percent of our patients presented with hemoptysis. Seven (35%) of these patients had massive hemoptysis that required emergency surgery. Several mechanisms for hemoptysis have been proposed including erosion of vascular cyst wall, elaboration of endotoxin by the fungus and the patient’s underlying disease.1,12,14
Bronchial artery embolization rarely results in control of hemoptysis because of the massive collateral blood vessels.2,8,14 This modality was attempted in 15% of the patients in this study, but it failed to control the hemoptysis permanently. However, it should be considered as a temporary treatment in patients with life-threatening hemoptysis.14 Bronchial artery embolization may play an important role in controlling minor hemoptysis after cavernostomy (2 patients in our series) because the majority of collateral blood vessels have been surgically controlled already. We emphasize the need to dissect the culprit lobe from the chest wall as much as possible when performing the cavernostomy as this maneuver may prevent recurrent hemoptysis.
Surgery offers three potential benefits: control of symptoms; prevention of hemoptysis; and prolongation of life.3,4 The ideal operative procedure should be a formal pulmonary resection. However, the technique involved ranks among the most complex in thoracic surgery due to severe intrapleural adhesion and many patients already have a poor pulmonary reserve that is a contraindication of pulmonary resection. Recent reports show mortality rates of 1% to 9.5%.1,2,8,13 There were no operative deaths in our series, despite 35% of our patients being operated on under an emergency basis. This may be due to the improvement of perioperative care and proper selection of the operative procedure for an individual patient.
The overall complication rate was 40% which is comparable to recent reports.1–3,8 The most common complications included prolonged airleak, wound infection, bleeding and empyema. Most of these complications could be managed conservatively with favorable outcomes. From our series, 2 factors compromised the postoperative course - namely emergency surgery and cavernostomy with transposition of muscle flap technique which was different from the other reports in that complications mostly occurred in pulmonary resected patients.1,8,13
We recommend early surgery in good surgical candidates, aiming at formal pulmonary resection to reduce morbidity. Although cavernostomy with transposition of muscle flap carries a high complication rate, most of the complications can be managed conservatively with favorable results.8,11,13 The long term survival rate of patients who underwent cavernostomy was comparable with that of patients who had formal pulmonary resection.8 We advocate the feasibility of cavernostomy with transposition of muscle flap in patients who have poor pulmonary reserve, complicated intrapleural adhesion and in emergency surgery when a patient’s condition does not permit a pulmonary function test.
Surgery is a very effective treatment modality for patients who have pulmonary cavity associated with fungus ball, in controlling and preventing hemoptysis. Because of the low operative mortality, we recommend early surgery in low surgical-risk patients and a formal pulmonary resection should be done. The cavernostomy with transposition of muscle flap technique should be performed in selected patients.
This paper was presented at the 16th Biennial Congress of Association of Thoracic and Cardiovascular Surgeons of Asia (ATCSA). November 16th to 19th, 2003, Bangkok, Thailand.
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REFERENCES
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- Babatasi G, Massetti M, Chapelier A, Fadel E, Macchiarini P, Khayat A, et al. Surgical treatment of pulmonary aspergilloma: current outcome. J Thorac Cardiovasc Surg
2000;119:906–12.[Abstract/Free Full Text]
- Chen JC, Chang YL, Luh SP, Lee JM, Lee YC. Surgical treatment for pulmonary aspergilloma: a 28 year experience. Thorax
1997;52:810–3.[Abstract]
- Park CK, Jheon S. Results of surgical treatment for pulmonary aspergilloma. Eur J Cardiothorac Surg
2002;21:918–23.[Abstract/Free Full Text]
- Kay PH. Surgical management of pulmonary aspergilloma. Thorax
1997;52:753–4.[Medline]
- Mouroux J, Maalouf J, Padovani B, Rotomondo C, Richelme H. Surgical management of pleuropulmonary tuberculosis. J Thorac Cardiovasc Surg
1996;111:662–70.[Abstract/Free Full Text]
- Souilamas R, Riquet M, Barthes FP, Chehab A, Capuani A, Faure E. Surgical treatment of active and sequelar forms of pulmonary tuberculosis. Ann Thorac Surg
2001;71:443–7.[Abstract/Free Full Text]
- Massard G, Roeslin N, Wihlm JM, Dumont P, Witz JP, Morand G. Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment. Ann Thorac Surg
1992;54:1159–64.[Abstract]
- Regnard JF, Icard P, Nicolosi M, Spagiarri L, Magdeleinat P, Jauffret B, et al. Aspergilloma: a series of 89 surgical cases. Ann Thorac Surg
2000;69:898–903.[Abstract/Free Full Text]
- British Thoracic and Tuberculosis Association. Aspergilloma and residual tuberculous cavities - the results of a resurvey. Tubercle
1970;51:227–45.[Medline]
- Jewkes J, Kay PH, Paneth M, Citron KM. Pulmonary aspergilloma: analysis of prognosis in relation to hemoptysis and survey of treatment. Thorax
1983;38:572–8.[Abstract/Free Full Text]
- Tseng YL, Wu MH, Lin MY, Lai WW. Intrathoracic muscle flap transposition in the treatment of fibrocavernous tuberculosis. Eur J Cardiothorac Surg
2000;18:666–70.[Abstract/Free Full Text]
- Solit RW, McKeown JJ Jr, Smullens S, Fraimow W. The surgical implications of intracavitary mycetomas (fungus balls). J Thorac Cardiovasc Surg
1971;62:41–22.
- Csekeo A, Agocs L, Egervary M, Heiler Z. Surgery for pulmonary aspergillosis. Eur J Cardiothorac Surg
1997;12:876–9.[Abstract]
- Soubani AO, Chandrasekar PH. The clinical spectrum of pulmonary aspergillosis. Chest
2000;121:1988–99.
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ABSTRACT
INTRODUCTION
