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Lu M, Fitzgerald D, Karpelowsky J, Selvadurai H, Pandit C, Robinson P, Marais BJ. Surgery in nontuberculous mycobacteria pulmonary disease. Breathe (Sheff) 2018; 14:288-301. [PMID: 30519295 PMCID: PMC6269180 DOI: 10.1183/20734735.027218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Medical treatment of pulmonary nontuberculous mycobacteria (NTM) disease has highly variable outcomes. Despite the use of multiple antibiotics, sputum clearance is often difficult to achieve, especially in cases with macrolide resistant NTM infection. Immunocompromised patients and those with structural lung disease are at increased risk, although occurrence in immunocompetent patients without structural lung disease is well recognised. Most pulmonary NTM disease involves Mycobacterium avium complex (MAC), but with enhanced identification multiple species have now been recognised as opportunistic pathogens. The observed increase in NTM disease, especially infection with multidrug-resistant Mycobacterium abscessus complex, is probably multifactorial. Surgery has been used as adjuvant treatment in patients with 1) focal disease that can be removed or 2) bothersome symptoms despite medical treatment that can be ameliorated. Early post-surgical mortality is low, but long-term morbidity and mortality are highly dependent on the degree of lung involvement and the residual lung function, the potency of medical treatment and the type of surgical intervention. In conjunction with antibiotic therapy, reported post-surgical sputum clearance was excellent, although publication bias should be considered. Bronchopleural fistulae were problematic, especially in pneumonectomy cases. Study results support the use of minimal resection surgery, in a carefully selected subgroup of patients with focal disease or persistent symptoms. Educational aims To critically review the literature describing the use of surgery in the treatment of pulmonary disease caused by nontuberculous mycobacteria (NTM).To assess the outcomes and complications observed with different surgical approaches used in the treatment of pulmonary NTM disease.
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Affiliation(s)
- Mimi Lu
- Dept of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
| | - Dominic Fitzgerald
- Dept of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia.,Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Jonathan Karpelowsky
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia.,Dept of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, Australia
| | - Hiran Selvadurai
- Dept of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia.,Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Chetan Pandit
- Dept of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia.,Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Paul Robinson
- Dept of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia.,Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Ben J Marais
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia.,Dept of Infectious Diseases, The Children's Hospital at Westmead, Sydney, Australia
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Aznar ML, Zubrinic M, Siemienowicz M, Hashimoto K, Brode SK, Mehrabi M, Patsios D, Keshavjee S, Marras TK. Adjuvant lung resection in the management of nontuberculous mycobacterial lung infection: A retrospective matched cohort study. Respir Med 2018; 142:1-6. [PMID: 30170795 DOI: 10.1016/j.rmed.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/18/2018] [Accepted: 07/07/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Lung resection in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) is considered when medical therapy alone fails to provide long term control. Data regarding comparative and long-term outcomes are limited. We aimed to review indications and outcomes of adjuvant lung resection for NTM-PD compared with controls. METHODS We retrospectively studied 27 surgically treated patients, matched 1:1 for age, sex, NTM species, and radiologic pattern of disease, with control patients treated exclusively with antibiotics. RESULTS In the surgical group, the median (IQR) age was 55 (49-61) years and 74.1% were female. Eighteen patients had Mycobacterium avium complex, and 9 had M. xenopi. Operations included 8 pneumonectomies, 20 lobectomies, one segmentectomy and one lobectomy plus segmentectomy. Post-surgical complications occurred in 6 patients (20%), including 2 acute respiratory distress syndrome, 1 bronchopleural fistula, 1 pericardial tamponade, and 2 empyema. Complications were more common among patients operated upon for progressive disease despite medical therapy (OR 10, p = 0.025). Of 24 matched pairs followed for ≥1 year, sustained culture conversion was observed in 21 (87.5%) patients in the surgical group and in 11 (45.8%) patients in the non-surgical group (RR 2.36, 95%CI 1.37-4.03, p = 0.002). Median (IQR) percentage of follow-up time on antibiotics was 14% (0-100%) in the surgical group and 83% (10.8%-100%) in the non-surgical group (p = 0.195) during a median (IQR) follow-up of 16 (2-36) months. CONCLUSIONS NTM-PD patients who underwent adjuvant lung resection experienced significant morbidity and more frequently achieved sputum culture conversion. Long term antibiotic requirements may have been reduced.
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Affiliation(s)
- María Luisa Aznar
- Division of Respirology, Department of Medicine, University Health Network, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Marijana Zubrinic
- Division of Thoracic Surgery, University Health Network, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G2C4, Canada
| | - Miranda Siemienowicz
- Joint Department of Medical Imaging, University Health Network, Women's College Hospital and Mount Sinai Hospital, Toronto, ON, Canada
| | - Kohei Hashimoto
- Division of Thoracic Surgery, University Health Network, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G2C4, Canada
| | - Sarah Kathleen Brode
- Division of Respirology, Department of Medicine, University Health Network, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada; West Park Healthcare Centre, 82 Buttonwood Ave., Toronto, ON, M6M 2J5, Canada; Department of Medicine, University of Toronto, 27 King's College Circle, Toronto, ON, M5S 1A1, Canada
| | - Mahtab Mehrabi
- Division of Respirology, Department of Medicine, University Health Network, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Demetris Patsios
- Joint Department of Medical Imaging, University Health Network, Women's College Hospital and Mount Sinai Hospital, Toronto, ON, Canada
| | - Shafique Keshavjee
- Division of Thoracic Surgery, University Health Network, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G2C4, Canada
| | - Theodore Konstantine Marras
- Division of Respirology, Department of Medicine, University Health Network, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada; Department of Medicine, University of Toronto, 27 King's College Circle, Toronto, ON, M5S 1A1, Canada.
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Haworth CS, Banks J, Capstick T, Fisher AJ, Gorsuch T, Laurenson IF, Leitch A, Loebinger MR, Milburn HJ, Nightingale M, Ormerod P, Shingadia D, Smith D, Whitehead N, Wilson R, Floto RA. British Thoracic Society guidelines for the management of non-tuberculous mycobacterial pulmonary disease (NTM-PD). Thorax 2017; 72:ii1-ii64. [DOI: 10.1136/thoraxjnl-2017-210927] [Citation(s) in RCA: 351] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 01/18/2023]
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Kang HK, Park HY, Kim D, Jeong BH, Jeon K, Cho JH, Kim HK, Choi YS, Kim J, Koh WJ. Treatment outcomes of adjuvant resectional surgery for nontuberculous mycobacterial lung disease. BMC Infect Dis 2015; 15:76. [PMID: 25887191 PMCID: PMC4342798 DOI: 10.1186/s12879-015-0823-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 02/10/2015] [Indexed: 01/15/2023] Open
Abstract
Background Outcomes of antibiotic treatment for lung disease caused by nontuberculous mycobacteria (NTM) are unsatisfactory. The role of adjunctive surgery in the treatment of NTM lung disease is still unclear. Methods We conducted a retrospective review of 70 patients who underwent pulmonary resection for NTM lung disease from March 2007 to February 2013. All patients received recommended antibiotic treatment before and after the surgery. Results A total of 70 patients underwent 74 operations. The median age of the patients was 50 years. Of the 70 patients, 45 (64%) had Mycobacterium avium complex infection (24 M. intracellulare and 21 M. avium) and 23 (33%) had M. abscessus complex infection (15 M. abscessus and 8 M. massiliense). Thirty-eight (54%) patients had the nodular bronchiectatic form and 28 (40%) had the fibrocavitary form of NTM lung disease. The indications for surgery were a poor response to drug therapy (n=52), remnant cavitary lesions and severe bronchiectasis (n=14), and hemoptysis (n=4). Preoperative sputum acid-fast bacilli staining results were positive in 44 (63%) patients, and sputum culture was positive in 54 (76%). The surgery included lobectomy or lobectomy plus segmentectomy (n=50, 68%), segmentectomy (n=11, 15%), pneumonectomy or completion pneumonectomy (n=8, 11%), bilobectomy or bilobectomy plus segmentectomy (n=4, 5%), and wedge resection (n=1, 1%). Postoperative complications occurred in 15 (21%) patients, including one postoperative death and bronchopleural fistula in 5 patients with the fibrocavitary form of the disease. A negative sputum culture was achieved and maintained in 57 (81%) patients. Conclusions Although adjuvant pulmonary resection is associated with a relatively high complication rate, this procedure may provide a high level of treatment success for selected patients with NTM lung disease, such as those with a poor response to antibiotic treatment alone.
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Affiliation(s)
- Hyung Koo Kang
- Departments of Medicine, Division of Pulmonary and Critical Care Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Hye Yun Park
- Departments of Medicine, Division of Pulmonary and Critical Care Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Dohun Kim
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. .,Department of Thoracic Surgery, Chungbuk National University Hospital, Cheongju, Chungbuk, South Korea.
| | - Byeong-Ho Jeong
- Departments of Medicine, Division of Pulmonary and Critical Care Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Kyeongman Jeon
- Departments of Medicine, Division of Pulmonary and Critical Care Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Jong Ho Cho
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Hong Kwan Kim
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Yong Soo Choi
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Jhingook Kim
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Won-Jung Koh
- Departments of Medicine, Division of Pulmonary and Critical Care Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Ullery B, Pieracci FM, Hydo LJ, Eachempati SR, Barie PS. Treatment of severe sepsis secondary to mycobacterium avium-intracellulare with recombinant human activated protein C. Surg Infect (Larchmt) 2008; 9:389-94. [PMID: 18570580 DOI: 10.1089/sur.2007.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mycobacterium avium-intracellulare (MAI) is a well-described pathogen in patients with acquired immune deficiency syndrome (AIDS). However, peritonitis and severe sepsis as a complication of disseminated MAI is rare. We report a case that represents the first successful use of recombinant human activated protein C (rhAPC) in the treatment of severe sepsis secondary to mycobacterial infection and only the second reported case of MAI peritonitis with no known predisposing factor other than AIDS. METHODS Case report and review of the pertinent literature. RESULTS A 36-year-old man with AIDS presented to the emergency department with acute-onset right-sided abdominal pain, fever, and chills. Abdominal computed tomography revealed multiple rim-enhancing fluid collections. Despite immediate surgical drainage and debridement and appropriate antimicrobial therapy targeting the non-tuberculous acid-fast bacilli found in intraperitoneal fluid, the patient developed severe sepsis and septic shock. Clinical improvement occurred after infusion of recombinant human activated protein C (rhAPC) and specific antimicrobial chemotherapy directed against MAI. CONCLUSIONS Treatment with rhAPC decreases the mortality rate of bacterial sepsis of abdominal origin and may confer a similar benefit in the treatment of abdominal mycobacterial sepsis.
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Affiliation(s)
- Brant Ullery
- Department of Surgery, Weill Medical College of Cornell University, New York, New York, USA
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Watanabe M, Hasegawa N, Ishizaka A, Asakura K, Izumi Y, Eguchi K, Kawamura M, Horinouchi H, Kobayashi K. Early Pulmonary Resection for Mycobacterium Avium Complex Lung Disease Treated With Macrolides and Quinolones. Ann Thorac Surg 2006; 81:2026-30. [PMID: 16731124 DOI: 10.1016/j.athoracsur.2006.01.031] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2005] [Revised: 01/04/2006] [Accepted: 01/05/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND The purpose of this study was to examine the postoperative outcomes of patients with Mycobacterium avium complex (MAC) lung lesions persisting despite treatment with multiple antibiotics. METHODS Patients with localized pulmonary lesions persisting despite extensive state-of-the art antimicrobial chemotherapy became candidates for surgical resection. Twenty-two patients who were expected to retain sufficient postoperative pulmonary function were included in this study. These patients received chemotherapy for 2 to 37 months (mean, 17). Surgical procedures were lobectomy (n = 15), segmentectomy (n = 4), and partial lung resection (n = 6). Three patients underwent bilateral resections. RESULTS Mycobacterium avium complex causing bronchiectasis or cavitary lesions was detected preoperatively in all 22 patients. There was no major operative morbidity or mortality. Postoperative chemotherapy was continued for 6 to 35 months. All patients were alive and well at follow-ups ranging from 6 to 164 months (median, 46). Both vital capacity and forced expiratory volume in 1 second after surgery were maintained at 89% and 84% of the preoperative values, respectively. Mycobacterium avium complex disappeared from sputum after surgery in all patients. In 1 patient, 4 months after resection of a cavitary lesion, MAC-positive sputum presumed to be from the contralateral lung lesion became negative during continuation of chemotherapy. CONCLUSIONS The long-term outcomes of patients operated on for MAC resistant to antimicrobial chemotherapy were excellent. For such patients, we recommend surgery before the disease becomes exceedingly advanced and nonresectable. Additionally, in extensive disease, the excision of large cavitary bacterial foci may assist the medical management of contralateral lesions.
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Affiliation(s)
- Masazumi Watanabe
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan.
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Aksamit TR. Mycobacterium avium complex pulmonary disease in patients with pre-existing lung disease. Clin Chest Med 2002; 23:643-53. [PMID: 12371000 DOI: 10.1016/s0272-5231(02)00022-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Patients with MAC-PD and pre-existing lung disease are a distinct group from the more common and recently recognized group of predominantly middle- to older-aged women without pre-existing lung disease. Those with pre-existing disease are expected to have more sputum positivity and slower conversion of sputum with treatment, and they may require combined medical treatment with surgical resection for optimal results. Attention to bronchial hygiene, avoidance of unnecessary use of macrolides, and treatment of underlying esophageal and lung disease can result in marked symptomatic improvement in many cases. Appropriate consideration must be given to mycobacterial antibiotic treatment, and awareness must be maintained for other processes such as bronchogenic cancer in select groups of high-risk patients.
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MESH Headings
- Antibiotics, Antitubercular/therapeutic use
- Chronic Disease
- Humans
- Lung Diseases, Interstitial/complications
- Lung Diseases, Interstitial/diagnostic imaging
- Lung Diseases, Interstitial/therapy
- Lung Diseases, Obstructive/complications
- Lung Diseases, Obstructive/diagnostic imaging
- Lung Diseases, Obstructive/therapy
- Mycobacterium avium Complex/isolation & purification
- Mycobacterium avium-intracellulare Infection/complications
- Mycobacterium avium-intracellulare Infection/diagnostic imaging
- Mycobacterium avium-intracellulare Infection/therapy
- Sputum/microbiology
- Tomography, X-Ray Computed
- Tuberculosis, Pulmonary/complications
- Tuberculosis, Pulmonary/diagnostic imaging
- Tuberculosis, Pulmonary/therapy
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Affiliation(s)
- Timothy R Aksamit
- Division of Pulmonary and Critical Care Medicine and Internal Medicine, Mayo Clinic, Mayo Medical School, 200 First Street, SW, Rochester, MN 55905, USA.
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