Early Pulmonary Resection for Mycobacterium Avium Complex Lung Disease Treated With Macrolides and Quinolones

doi:10.1016/j.athoracsur.2006.01.031

The Annals of Thoracic Surgery

Volume 81, Issue 6, June 2006, Pages 2026-2030

https://doi.org/10.1016/j.athoracsur.2006.01.031 Get rights and content

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.

Section snippets

Patients and Methods

This study was carried out in accordance with the guidelines set by the Japanese Ministry of Health, Labor, and Welfare. The Institutional Review Board approved this study, and informed consent was waived. Surgical and medical records of all patients who underwent pulmonary resection for MAC pulmonary disease between January 1, 1990, and July 31, 2005, at Keio University Hospital were reviewed. Smears, cultures, and polymerase chain reaction examinations of sputum or bronchial washings were

Patient Population

Between January 1, 1990, and July 31, 2005, pulmonary resections for MAC were performed in 15 women and 7 men ranging in age between 30 and 77 years (mean, 54). The main characteristics of the patient population are shown in Table 1. No patients suffered from immunodeficient disorders, such as human immunodeficiency virus. One patient, however, had primary lung cancer combined with MAC pulmonary disease. All patients underwent lung resection to treat MAC disease and not for diagnostic purposes.

Preoperative Condition and Chemotherapy

Comment

The management of MAC pulmonary infection has made progress since the introduction of oral macrolides, and quinolones antibiotics. However, recent reports indicate that the medical treatment of MAC remains challenging. The conversion rates of sputum cultures from positive to negative with clarithromycin-containing regimens has been reported to be between 54% and 87% [4, 5, 6, 7, 8]. Moreover, reported recurrence rates after conversion range between 20% and 44% [4, 5, 7, 8]. Therefore we

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The burden of nontuberculous mycobacterial pulmonary disease (NTM-PD) is increasing worldwide. Amidst the poor treatment success of antibiotic therapy, adjunctive surgery is gaining attention; however, discrepancies in reported outcomes exist.
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The MEDLINE, Embase, and Cochrane databases were searched for eligible studies before January 2022. Studies reporting the outcomes of adjunctive surgery in adult patients who satisfied the diagnostic criteria for NTM-PD were included. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Data were extracted by two independent observers. Estimates of proportion were pooled using a random-effects model. Sputum mycobacterial culture negative conversion, recurrence, complications, and in-hospital mortality after surgery were primary outcomes that had been set before data collection began. Heterogeneity was evaluated by using the I² statistic, and publication bias was assessed by using funnel plots and the Egger test.
Fifteen of the 2,739 screened studies, with 1,071 patients, were assessed. The weighted proportion of postoperative sputum culture negative conversion was 93% (95% CI, 87%-97%), and recurrence was 9% (95% CI, 6%-14%) for a median follow-up of 34 months. The proportion of patients who experienced postoperative complications was 17% (95% CI, 13%-23%), and in-hospital mortality was 0% (95% CI, 0%-2%). Studies that performed multilobar lung resection in > 30% of the study population showed comparable rates of complications with studies that did not.
Adjunctive surgery is an effective therapeutic option with acceptable rates of complications for selected patients with NTM-PD.
PROSPERO; No.: CRD42022310663; URL: https://www.crd.york.ac.uk/prospero/
Surgical Treatment of Nontuberculous Mycobacterial Pulmonary Disease and a Combination of Nontuberculous Mycobacterium Pulmonary Disease and Pulmonary Tuberculosis
2022, International Journal of Infectious Diseases
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Such proficient treatment results were possibly achieved because of the use of delayed VATS TP 3 weeks after pneumonectomies and for some lung resections (Tables 2 and 4, Figure 5). We investigated which operations were presented in the literature (Asakura et al., 2017; Corpe, 1981; Fukushima et al., 2020b; Guntupova et al., 2016; Jarand et al., 2011; Kang et al., 2015; Koh et al., 2008; Lang-Lazdunski et al., 2001; Mitchell et al., 2008; Moran et al., 1983; Nelson et al., 1998; Pomerantz et al., 1991; Sherwood et al., 2005; Shiraishi et al., 2013, 2004, 2002; Watanabe et al., 2006; Yamada et al., 2019; Yu et al., 2011). From a total of 1,087 operations, we observe that the most common were lobectomies - 614 (56.49%), segmentectomies and subsegmentectomies -138 (12.70%), combined resections - 99 (9.11%), bilobectomies - 47 (4.32%), and wedge resections - 42 (3.86%).
Nontuberculous mycobacterial pulmonary disease (NTMPD) is an important health system problem worldwide. Surgical treatment experience is limited, and the safety of such operations is still unclarified. Therefore, improving our knowledge of NTMPD is important.
In this retrospective observational study, we analyzed the medical records of 2,432 patients operated on from January 2011 through December 2017 in our hospital. There were 20 patients with NTMPD in group 1 and 23 patients with combined NTMPD and pulmonary tuberculosis in group 2. Patients received antibiotic treatment before and after surgery as per Russian Federal clinical guidelines and individual drug susceptibility.
Postoperative complications occurred in 2 (10%) cases in group 1 and 4 (17.4%) in group 2, and intraoperative complications occurred in 2 (8.7%) cases in group 2. There was no 30-day mortality in both groups. After 1 year, all 40 traced patients had neither bacterial excretion nor cavities in the lungs. After 3 years and 5 years, the efficacy among 32 and 13 traced patients was 100%, respectively.
Modern surgery for small NTMPD forms is safe - helping improve outcomes for ineffective antibiotic treatment. Combined surgery and antibiotic treatment are acceptable in both the short and long term.
Extensive Lung Resection for Nontuberculous Mycobacterial Lung Disease With Multilobar Lesions
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Nontuberculous mycobacterial lung disease often spreads to multiple lobes, and extensive lung resection (ELR) is sometimes required to control the disease. The safety and feasibility of ELR for nontuberculous mycobacterial lung disease remain unclear, however.
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ELR for nontuberculous mycobacterial lung disease has some drawbacks compared with SALR but seems as safe and feasible as SALR. ELR may provide improved disease control in some cases of nontuberculous mycobacterial lung disease with multilobar lesions.
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Successful surgical treatment of patients with Mycobacterium avium complex pulmonary disease is thought to require complete removal of parenchymal destructive lesions. This study aimed to evaluate the short-term and long-term outcomes and the predictors of microbiological recurrence after surgery for M avium complex pulmonary disease.
We conducted a retrospective review of 184 patients undergoing unilateral lung resection for M avium complex pulmonary disease at a single center in Japan between January 2008 and December 2017.
Median age of the 184 patients was 55.5 years; 133 were female (72.3%). All but 2 patients had anatomical lung resection. A total of 116 patients had limited disease and underwent complete resection (63.0%); the remaining 68 patients had extensive disease and underwent debulking surgery (37.0%). No operative mortalities occurred. In 18 of 184 patients, 21 morbidities occurred (9.8%), including 3 bronchopleural fistulas (1.6%). Postoperative sputum-negative status was achieved in 183 patients (99.5%). Microbiological recurrences occurred in 15 patients (8.2%). By multivariate analysis, extensive disease was an independent risk factor for recurrence (hazard ratio, 5.432; 95% confidence interval, 1.372-21.50; P = .016). Recurrence-free rates were significantly higher in patients with limited disease compared with those with extensive disease (99.0%, 97.4%, and 95.0% versus 93.0%, 89.2%, and 75.1% at 1, 3, and 5 years, respectively; P < .001).
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Post tuberculosis treatment infectious complications
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However, tolerability and availability can be an issue with inhaled antibiotics. Occasionally surgical resection of the involved segment or lobe may be indicated when there is failure of medical management of localized disease (Watanabe et al., 2006). Evidence suggests that the global burden of NTM infection is increasing (Brode et al., 2014).
Following greater attention and follow-up of patients with treated pulmonary tuberculosis (TB), it has emerged that infections are more likely to occur in this cohort of patients. This comes as no surprise, as pulmonary TB is a destructive process that leads to cicatrization, alteration of parenchyma, bronchiectasis, and scarring of the lung, with reduction of lung volumes and an impact on pulmonary function. In addition to relapse and re-infection with TB, other pathogens are increasingly recognized in post-TB patients. This paper serves as a summary and guide on how to approach the post-TB patient with new signs and symptoms of pulmonary infection in order to ensure optimal management and rehabilitation.
Adjuvant lung resection in the management of nontuberculous mycobacterial lung infection: A retrospective matched cohort study
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Similarly, we observed that all patients with an infection by M. xenopi who underwent lung resection achieved culture conversion and did not need a subsequent course of antibiotics after the peri-operative course, while only half of the patients from the control group infected by M. xenopi achieved culture conversion with medical therapy alone. In most of the published series a high proportion of patients achieved culture conversion after surgery [11,12,16,18,19], however, comparison with patients treated exclusively with antibiotics has been absent. We observed that a higher proportion of patients receiving lung resection achieved culture conversion compared with those treated exclusively with antibiotics.
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.
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.
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.
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Original articleGeneral thoracicEarly Pulmonary Resection for Mycobacterium Avium Complex Lung Disease Treated With Macrolides and Quinolones

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Patient Population

Preoperative Condition and Chemotherapy

Comment

Respir Med

Chest

Nontuberculous mycobacteria. An underappreciated cause of geriatric lung disease

Am J Respir Crit Care Med

Diagnosis and treatment of disease caused by nontuberculous mycobacteria

Am J Respir Crit Care Med

Clarithromycin regimens for pulmonary Mycobacterium avium complex. The first 50 patients

Am J Respir Crit Care Med

Effect of clarithromycin regimen for Mycobacterium avium complex pulmonary disease

Am J Respir Crit Care Med

The effect of combined therapy according to the guidelines for the treatment of Mycobacterium avium complex pulmonary disease

Intern Med

Original article
General thoracic
Early Pulmonary Resection for Mycobacterium Avium Complex Lung Disease Treated With Macrolides and Quinolones