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Department of Surgery, University of Arizona, 1501 N Campbell Ave, Rm #4402, Tucson, AZ 85724
(Email: smeyerson{at}surgery.arizona.edu).
Fungal infections of the lungs have traditionally represented a very small component of the practice of most thoracic surgeons. Hammoud and colleagues [1] present a realistic look at the spectrum of clinical disease seen by the practicing surgeon in a region with endemic histoplasmosis. The identification of only 49 patients during a 17-year period in an endemic area highlights the rarity with which the sequelae of histoplasmosis require surgical intervention.
The authors divide their patients into three subgroups of disease, each of which requires different strategies for management. Broncholithiasis is the most straightforward surgically. The goal is to relieve obstruction, and this most commonly requires a lobectomy. This is technically challenging due to inflammation and adhesions but can generally be accomplished with low morbidity and mortality.
Fibrosing mediastinitis is a much more difficult problem, and as the authors point out, the most important decision is often the decision not to operate. The fibrosis is slowly progressive over a long period of time, allowing for the development of an extensive network of collateral vessels. Patients with superior vena cava obstruction or isolated pulmonary artery occlusion are often minimally symptomatic and do not require intervention. Airway involvement is the most common indication for surgical intervention due to recurrent pneumonias. If mediastinal structures are involved bilaterally, the disease is almost uniformly fatal. If involvement is unilateral, pneumonectomy can be considered. Although pneumonectomy can be lifesaving, it has a higher than normal operative risk in this setting due to dense adhesions and collateral blood supply.
The final subgroup, granulomatous disease, often leads to esophageal pathology of the diverticulum or to bronchoesophageal fistula. These repairs can be complex, and the key as for any fistula is to débride all nonviable tissue, precisely close both sides of the fistula, and place viable tissue between the two structures. As the authors mention, a pericardial fat pad is an option; however, it is often valuable to mobilize an intercostal muscle flap, which has a more stable blood supply. The bulk of the muscle may help with healing and provides more distance between the two structures as well.
The key message of this article is the need to be prepared for multiple obstacles in these procedures. The dense fibrosis and inflammation make these operations technically very challenging. It is important to think about obtaining proximal vascular control of the main pulmonary artery early in the operation, before an injury occurs. Similarly, as the authors mention, the availability of cardiopulmonary bypass when dealing with central airway involvement can be very helpful. Preparing a muscle flap at the time of the initial thoracotomy to repair a fistula leads to a better quality flap rather than trying to find enough viable pericardial fat pad or using an intercostal muscle that was compressed by a retractor for the past several hours while dissection was performed. Attention to the multiple possible challenges in these operations will help the procedure go more smoothly, especially for surgeons who see these patients less often.
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