Ann Thorac Surg 2004;78:1846-1848
© 2004 The Society of Thoracic Surgeons
Case report
Cavernoscopic Removal of a Fungus Ball for Pulmonary Complex Aspergilloma
Motoyasu Sagawa, MD*,a,
Tsutomu Sakuma, MDa,
Tsugimasa Isobe, MDb,
Makoto Sugita, MDa,
Yuko Waseda, MDc,
Hideo Morinaga, MDb,
Keiji Iuchi, MDd
a Department of Thoracic Surgery, Kanazawa Medical University, Uchinada, Ishikawa, Japan
b Department of Surgery, Tatsunokuchi Houju Memorial General Hospital, Japan
c Department of Internal Medicine, Tatsunokuchi Houju Memorial General Hospital, Tatsunokuchi, Ishikawa, Japan
d Department of Surgery, National Kinki Chuo Hospital, Sakai, Osaka, Japan
Accepted for publication July 17, 2003.
* Address reprint requests to Dr Sagawa, Thoracic Surgery, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Ishikawa 920-0293, Japan
sagawam{at}kanazawa-med.ac.jp
 |
Abstract
|
|---|
Lobectomy of the lung for aspergilloma is not always appropriate in elderly patients because of the high surgical risk. A 78-year-old male diagnosed with complex aspergilloma was referred to our hospital for recurrent hemoptysis. Because he refused lobectomy, we conducted a cavernoscopic removal of the fungus ball. The site of the skin incision was carefully designed preoperatively. After achieving access, the fungus ball was removed piece by piece under endoscopic view. Intraoperative blood loss equaled 30 mL. At 5 months postoperative follow-up, the patient had no evidence of recurrence. This procedure may be useful in some patients with complex aspergilloma.
|
Introduction
|
|---|
Although lobectomy of the lung is the preferred therapy for localized pulmonary aspergilloma, this procedure is sometimes inappropriate in elderly patients because of the high risk of intraoperative and postoperative complications, particularly massive hemorrhage [1–3]. We report the case of a pulmonary aspergilloma treated successfully by cavernoscopic removal of the fungus ball with minimum blood loss.
A 73-year-old male visited a regional hospital for hemoptysis and was diagnosed with pulmonary aspergilloma measuring 4 cm in diameter. Although oral itraconazole was administrated continuously for 5 years, hemoptysis recurred intermittently, and the aspergilloma was seen to gradually enlarge. The patient was referred to our hospital in May 2002 at the age of 78. On admission, the aspergilloma was 7 cm in diameter and was located in the right upper lung field (Fig 1A). The wall of the cavity was thick and there were underlying parenchymal and pleural sequelae (Fig 1B) indicating a complex aspergilloma [1]. Strong adhesion between the right upper lobe and the chest wall was expected. An echocardiogram suggested that the patient had aortic valve insufficiency. Because of his age and cardiac disease, the patient refused right upper lobectomy. Therefore, we decided to conduct a cavernoscopic removal of the fungus ball, a procedure originally reported by Iuchi and colleagues [4].
View larger version (161K):
[in this window]
[in a new window]
|
Fig 1. (Top) Chest roentgenograms and (bottom) chest computed tomographic scans of the patient (A and B) on admission and (C and D) at 5 months after surgery. Fungus ball is completely removed and there is no evidence of recurrence.
|
|
We conducted the procedure with the patient in the supine position under general anesthesia with a double lumen endobronchial tube. The site of the skin incision was carefully designed preoperatively by computed tomographic scan, 1.5 cm below the right clavicle and 4 cm long. The major pectoral muscle was split; then the first intercostal muscle, thickened pleura, and adhered lung tissue were cut with an electrical scalpel to make an access hole (1.5 cm in diameter). After the access hole was extended into the cavitary lesion, the fungus ball was removed piece by piece under endoscopic view using a spoon and forceps (Fig 2A, B). The instruments and the thoracoscope were inserted simultaneously into the cavity through the access hole without thoracoports. Complete removal of the fungus ball lasted only 2 hours. The wall of the cavity was found to be smooth and white, not reddish or granulomatous (Fig 2C). A thoracic tube (11 mm in diameter) and a long gauze strip were placed in the cavity before closure of the skin incision. The quantity of intraoperative bleeding was 30 mL. The patient's postoperative course was uneventful. On postoperative day 1, the long gauze strip was removed, and the patient began ambulating and was able to feed himself. Antibiotics were administered for 1 week postoperatively. The thoracic tube was gradually exchanged for a thinner one, which was subsequently completely removed. Acting under the assumption that not all of the Aspergillus had been removed, we decided to administer long-term oral antifungal agents. At 5 months postoperative follow-up, the patient had no symptoms, no laboratory data to indicate inflammation, and no findings of recurrent aspergilloma (Fig 1C) (at 1 day).
View larger version (84K):
[in this window]
[in a new window]
|
Fig 2. Endoscopic view shows removal of fungus ball (A) with a spoon (arrows) and (B) with forceps (arrows). After the removal, (C) the wall of the cavity is smooth and white.
|
|
|
Comment
|
|---|
Lobectomy of the lung has been regarded as an appropriate therapy for localized simple pulmonary aspergilloma [1–3], which is characterized by a thin wall and a lack of underlying parenchymal or pleural sequelae [1]. However, incidence of perioperative mortality and morbidity, including massive intraoperative hemorrhage, is still high in patients with complex aspergilloma [2], which characteristically has a thick wall or underlying parenchymal and pleural sequelae, or a combination thereof [1]. In addition, because some patients with aspergilloma are elderly, immunocompromised, or have impaired lung function, less invasive procedures have been introduced for those patients, such as cavernostomy [1–3]. Nevertheless, these procedures are not fully satisfactory because they require additional surgery or prolonged daily gauze exchange. Cavernostomy with thoracoplasty or muscle prombage does not have these requirements, but this procedure is more invasive than cavernostomy alone and carries a risk of recurrence of the cavity.
Iuchi and colleagues [4] originally reported the cavernoscopic removal of the fungus ball as a treatment of pulmonary aspergilloma. This procedure is simple and safe, and it is not time-consuming. The concept of this procedure is similar to intracavitary instillation of antifungal agents, whereby the fungus ball sometimes disappears and the patient's symptoms are relieved [5]. In our patient, hemoptysis ceased after surgery, probably due to removal of the fungus ball. The only disadvantage of this procedure is the high recurrence rate of the aspergilloma [4]. However, this is offset by the fact that in case of recurrence, other surgical procedures can easily be performed, including a repeat cavernoscopic removal.
Although long-term oral administration of the antifungal agents and careful follow-up should be required, hemoptysis ceased after surgery in the present case, suggesting a decrease in the risk of massive hemorrhage. This case indicates that the cavernoscopic removal of a fungus ball may be useful in some patients with complex aspergilloma, especially those for whom lobectomy is not appropriate because of the patient's condition.
|
References
|
|---|
- Belcher JR, Plummer NS. Surgery in bronchopulmonary aspergillosis. Brit J Dis Chest. 1960;54:335–341
- Regnard JF, Icard P, Nicolosi M, et al. Aspergilloma: a series of 89 surgical cases. Ann Thorac Surg. 2000;69:898–903[Abstract/Free Full Text]
- Babatasi G, Massetti M, Chapelier A, et al. Surgical treatment of pulmonary aspergilloma: current outcome. J Thorac Cardiovasc Surg. 2000;119:906–912[Abstract/Free Full Text]
- Iuchi K, Tanaka H, Shirahashi K, et al. Cavernostomy and simultaneous removal of fungus ball of pulmonary aspergilloma. J Jap Respir Soc. 2001;39:903–909 (abstract in English)
- Yamada H, Kohno S, Koga H, et al. Topical treatment of pulmonary aspergilloma by antifunguls. Chest. 1993;103:1421–1425[Abstract/Free Full Text]
Top
Abstract
Introduction
