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Ann Thorac Surg 1998;66:183-186
© 1998 The Society of Thoracic Surgeons

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Original articles: general thoracic

Early pulmonary resection for localized mycobacterium avium complex disease

^a Department of Thoracic Surgery, National Tokyo Hospital, Kiyose, Tokyo, Japan
^b Department of Pulmonary Medicine, National Tokyo Hospital, Kiyose, Tokyo, Japan

Address reprint requests to Dr Shiraishi, Department of Thoracic Surgery, Fukujuji Hospital, 3-1-24 Matsuyama, Kiyose, Tokyo, 204-0022, Japan

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Results of antituberculous chemotherapy for Mycobacterium avium complex disease remain disappointing. Pulmonary resection during an early stage of the disease, therefore, may be beneficial to patients whose disease is localized and who can tolerate a resectional operation.

Methods. Thirty-three patients with localized M avium complex disease underwent 33 pulmonary resections between 1979 and 1996. There were 17 males and 16 females, with a mean age of 50 years (range, 30 to 69 years). Lobectomy was performed in 26 patients, pleuropneumonectomy in 1, segmentectomy in 5, and wedge resection in 1.

Results. There was no operative mortality. After pulmonary resection, 31 (94%) patients attained sputum-negative status. Bronchopleural fistula occurred in one patient who underwent a right upper lobectomy. There were two late deaths. A patient with bronchopleural fistula died of respiratory failure two years postoperatively. Another patient died of an unknown cause 12 years postoperatively. Of the 31 patients with negative sputum status postoperatively, only 2 patients (6%) had relapse at 1 and 9 years after operation.

Conclusions. We recommend that patients with this disease be considered for pulmonary resection as early as possible.

	Introduction

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Mycobacterium avium complex disease has recently become an increasingly significant problem in both immunocompromized [1] and nonimmunocompromized [2, 3] patients. Mycobacterium avium complex is, however, frequently difficult to treat because of its drug resistance. Medical treatment is often effective at first, but relapse is common once treatment is stopped. In addition, pulmonary disease caused by this pathogen can be lethal [2]. Therefore, patients with this disease have long been considered candidates for surgical treatment when the disease is localized [4–6]. This strategy remained unchanged [7, 8] even after significant progress in the therapy of mycobacterial infections had been made.

Recent clinical trials have demonstrated that clarithromycin produces significant beneficial effects in patients with pulmonary disease caused by this stubborn pathogen [9]. However, it remains to be investigated whether M avium complex disease can be treated with the clarithromycin-containing regimens alone. Therefore, surgical treatment still plays an important role in the treatment of this disease. The rate of relapse after surgical treatment has been reported to be satisfactorily low [4–8]. Should postoperative morbidity and mortality be acceptably low, early pulmonary resection may be beneficial to patients whose disease is still localized and who can tolerate resectional operation. This study was undertaken to investigate the outcome of pulmonary resection for patients with localized M avium complex disease.

	Material and methods

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Between 1979 and 1996, 33 patients with M avium complex disease underwent 33 pulmonary resections at the National Tokyo Hospital, a former sanatorium located in Tokyo. There were 17 men and 16 women, with a mean age of 50 years (range, 30 to 69 years). Twenty-eight of the 33 patients had a variety of symptoms. Productive cough, nonproductive cough, and hemoptysis were the most common. Other symptoms included chest pain, fever, shortness of breath, and weakness. The remaining 5 patients were asymptomatic but had abnormalities on routine chest roentgenograms. All but 1 male patient were active smokers. Three patients had been treated previously for Mycobacterium tuberculosis infection.

Upon admission, smear and culture of sputum or a bronchial washing was examined. When a positive culture was obtained, susceptibility testing was performed against the conventional antituberculosis drugs. The diagnosis of M avium complex disease was made by using the recommended diagnostic criteria established by the American Thoracic Society [10]. Preoperative work-up included chest roentgenogram, computed tomographic scan, pulmonary function tests, arterial blood gas analysis, and quantitative perfusion scan. Bronchoscopy was used in most cases to rule out contralateral disease and coexisting malignancies.

Thirty-two patients had unilateral disease that was localized; one lobe to one side of the lung was affected. The remaining patient had bilateral disease in both upper lobes, in which right-sided involvement predominated. The radiographic manifestations included cavity (64%), bronchiectasis (21%), pneumonia (9%), nodule (3%), and destroyed lung (3%). Preoperative work-up showed that most patients had nearly normal pulmonary functions before operation (Table 1).

View larger version (8K): [in this window] [in a new window]   Fig 1. Interval between diagnosis and operation in 33 patients undergoing pulmonary resection.

	Results

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Despite preoperative drug therapy, only 10 of the 28 patients who had positive results of sputum test upon admission had had their sputum converted before the operation. Therefore, 18 patients (55%) had positive sputum status and the remaining 15 patients (45%) had negative sputum status at the time of operation. In 4 of the patients with negative sputum status, cultures from their resected specimens were positive for M avium complex. Thirty-one of 33 patients (94%) attained negative sputum status after pulmonary resection. One patient who underwent a right lower lobectomy did not initially have his sputum converted. After a completion pneumonectomy at his primary hospital 3 months later, however, this patient was converted to sputum-negative status. The remaining 1 patient never had his sputum converted postoperatively.

There was no operative mortality. Chest tubes were removed between the 2nd and the 11th postoperative day. In 3 patients (9%), chest tubes were kept in place beyond 7 days because of excessive drainage. A residual pleural space occurred in 5 patients (15%) who underwent an upper lobectomy. In these patients thoracoplasty was performed 17 to 38 days postoperatively to obliterate the space. No positive cultures were obtained from the space at the time of thoracoplasty. However, 1 of these patients, who underwent a right upper lobectomy, eventually developed a bronchopleural fistula. This patient never had his sputum converted postoperatively. There were two late deaths (6%). The patient with bronchopleural fistula died of respiratory failure 2 years after operation. Another patient died of an unknown cause 12 years postoperatively.

Of the 31 patients with negative sputum status after pulmonary resection, 2 patients (6%) who underwent a right middle lobectomy relapsed 1 and 9 years after operation. The first patient who relapsed at 1 year was converted by instituting drug therapy and has been doing well. The second patient responded to resumption of drug therapy at first but still has positive sputum status and remains on drug therapy. Another 3 patients had occasional cultures containing small numbers of M avium complex at 6, 7, and 8 years postoperatively. Nevertheless, these positive cultures converted to negative status spontaneously and were not interpreted as indicative of a reactivation. Therefore, the 5-year and 10-year relapse-free rates were 97% and 88%, respectively (Fig 2).

View larger version (7K): [in this window] [in a new window]   Fig 2. Kaplan-Meier curve of freedom from relapse in 31 patients with negative sputum status postoperatively.

	Comment

Top Abstract Introduction Material and methods Results Comment References

As in other studies [7, 8], our series mainly consisted of middle-aged patients. Although male [7] or female [8] patients predominated in previous reports, there was an equal distribution of men and women in this study. Most of our patients had sufficient pulmonary functions for pulmonary resection. Therefore, in terms of pulmonary function, our series is composed of carefully selected patients. Pulmonary resections were more frequently performed in the right lung, similar to other reports [7, 8]. All but one middle lobectomy and all lingulectomies were performed in female patients. Pomerantz and coworkers [12] recently reported a specific female phenotype in middle lobe syndrome. Our female patients were also slender but had no associated skeletal abnormalities.

Since we surgically treated localized disease at its earlier stage, about two thirds of our patients underwent pulmonary resection within 1 year after the diagnosis was made. Unfortunately, certain delays in diagnosis are inevitable. The slow progression of radiographic abnormalities and unobtrusive presenting features of this disease were thought to contribute to those delays [2]. We encourage our medical colleagues to refer the patients in whom this disease is suspected to us at an earlier stage [12]. In addition, not until a culture is obtained can M avium complex be identified. We have recently applied the AMPLICOR Mycobacterium tuberculosis/avium/intracellulare test (Roche Diagnostic Systems, Inc, Branchburg, NJ) [13] for rapid diagnosis of this organism.

Postoperative complications are not uncommon after pulmonary resection for inflammatory diseases. Pomerantz and associates [8] reported a high incidence of morbidity. In their study, bronchopleural fistulas occurred in 8 of 38 patients with mycobacterial infections other than tuberculosis, and all occurred after pneumonectomy. Conversely, only 1 bronchopleural fistula occurred in our study, and none in the study by Moran and associates [7]. Pomerantz’s group performed a larger number of pneumonectomies than did we and the other group [7]. Therefore, the low frequency of pneumonectomy might have resulted in only 1 bronchopleural fistula in our study.

The high rate of conversion to sputum-negative status preoperatively is crucial to the low rate of postoperative complications [7]. However, this is believed not to be possible for all patients. In our series, only about half the patients had negative sputum status at the time of operation. Nevertheless, major postoperative complications were not frequent. Elkadi and associates [5] pointed out that postponing the operation for too long a period of time in a patient with active disease and resistant organisms might increase the complication rate. One of our patients had been kept on antituberculosis drugs for 5 years despite persistently positive sputum. When this patient was finally referred to us, we had to perform a right upper lobectomy as a rescue therapy. However, he did not attain sputum conversion and had a complicated postoperative course. We, therefore, emphasize that surgical treatment should be performed before the pulmonary disease becomes too extensive to resect.

It could be argued whether a residual space without bronchopleural fistula should be obliterated. On the basis of our long experience in treating mycobacterial infections, we hypothesize that the innocuous residual space after pulmonary resection for these infections might cause morbidity. In our study, postoperative empyema and consequent bronchopleural fistula occurred in a patient in whom the space persisted even after thoracoplasty. We preferred thoracoplasty to transposition of extrathoracic skeletal muscles [14] to treat a residual space problem. We and others [15] thought that thoracoplasty was more effective than muscle transposition to obliterate the space. In our technique of thoracoplasty, the first rib is always left intact to minimize the deformity in the chest wall. Instead, apicolysis is performed to achieve obliteration of the apical space. However, we now plan to use the muscle flap when a persistent pleural space is anticipated.

We achieved an equivalently satisfactory outcome after pulmonary resection as did others [6–8]. In our study, the sputum conversion rate after operation was 94%. In a patient who required a completion pneumonectomy later, lower lobectomy might not have been a sufficient procedure. Of the 31 patients with negative sputum status postoperatively, only 2 patients relapsed. The lack of postoperative drug therapy might have contributed to an early relapse in a patient who relapsed at 1 year. In our current protocol, patients are kept on drugs for at least 6 months after operation. With regard to the occasional positive cultures, we did not interpret these positive cultures as indicative of a definite relapse, in conformity with the statement of the American Thoracic Society [10].

In summary, pulmonary resection for localized M avium complex disease provides a satisfactory outcome, with low morbidity and mortality. We recommend that patients with this disease be considered for pulmonary resection as early as possible.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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