Pulmonary aspergilloma--indications for surgical intervention. An analysis of 22 cases

Surgical resection of aspergillomas has generally been associated with excess mortality and morbidity; 22 patients who had a resection of complicated mycetomas were studied retrospectively. Indications for surgery were serious haemoptysis (14), massive haemoptysis (6), and recurrent infection (2). Extrapleural pneumonectomy was required in 9 patients and extrapleural lobectomy in 12; thoracoplasty alone was done in 1 patient. There was 1 hospital death (4.5%); 4 patients developed postoperative empyemas (18%), 2 with associated bronchopleural fistulas. Two further patients (9%) had stable postresectional spaces. Surgery for complicated aspergilloma was associated with significant postoperative morbidity.     

Surgical management of invasive pulmonary aspergillosis in immunocompromised patients.

The treatment of haematological malignancies with intensive chemotherapy and bone marrow transplantation results in prolonged periods of immunosuppression. This is associated with an increased incidence of invasive pulmonary aspergillosis (IPA) with reported mortalities of 67-83%. The mainstay of treatment is medical therapy, surgery being reserved for patients with haemoptysis. Resection of focal sites of infection has not been routinely considered in view of the high morbidity and mortality reported from the surgery of aspergillomas in past series. After the death of two neutropenic patients from massive haemoptysis following IPA in 1986, we have resected localised pulmonary aspergillus lesions in 16 patients following IPA. Five patients had haemoptysis. The most common procedure performed was a lobectomy. All patients were granulocytopenic and excessive post-operative bleeding occurred in three patients, one of whom required a re-thoracotomy as a result. There was one post-operative death due to cytomegalovirus pneumonia. Surgery was otherwise uneventful. There were no recurrent pulmonary aspergillus infections on follow-up and three patients proceeded to bone marrow transplantation. The success of surgical resection encourages an aggressive policy in the management of IPA to prevent life-threatening haemoptysis and to allow patients to proceed with further chemotherapy and bone marrow transplantation.     

Topical treatment of life threatening haemoptysis from aspergillomas.

BACKGROUND: The efficacy of topical treatment of 12 episodes of severe life threatening haemoptysis from a pulmonary aspergilloma in 11 patients is reviewed. METHODS: A retrospective review was performed on five white and six African-American patients of mean age 49 years. The underlying diseases were bronchiectasis, sarcoidosis, tuberculosis, or histoplasmosis. The patients were prospectively considered poor surgical risks because they had a forced expiratory volume in one second (FEV1) of < 50% predicted and an arterial oxygen tension (PaO2) of < 7.95 kPa breathing room air. As surgical intervention was not possible, local intracavitary instillation of sodium or potassium iodide was performed. Two patients were previously treated with amphotericin B. In one patient sodium iodide alone was used and in the remaining eight potassium iodide alone was instilled. The transcricothyroid approach was used in six patients and the percutaneous approach in five. RESULTS: Haemoptysis ceased within 72 hours in all patients after the instillation of sodium or potassium iodide. There was no morbidity or mortality, and side effects included slight irritation on instillation of the iodide solution and occasional cough which was easily controlled. All patients were alive at least one year later. CONCLUSION: Intracavitary treatment is a viable option in the poor risk patient with life threatening haemoptysis from an aspergilloma.     

Pulmonary aspergilloma: analysis of prognosis in relation to haemoptysis and survey of treatment.

From 1956 to 1980 85 patients were admitted to the Brompton Hospital, London, with pulmonary aspergilloma. The mean follow-up period was 8.7 years and 85% of patients were followed for five years or until death if this was earlier. There were 41 deaths, 27 from respiratory causes: 11 from pneumonia, six from chronic respiratory failure, seven after surgery for aspergilloma, and three from haemoptysis. Medical treatment alone was given to 36 patients, of whom three died of haemoptysis. Systemic antifungal treatment was given to 18 patients without benefit. Intracavitary antifungals were helpful in three out of 10 patients. Surgical resection was performed in 41 patients, of whom three (7%) died after operation and a further six (15%) developed major complications. Cavernostomy was performed in nine patients considered unfit for resection; four died after operation. Haemoptysis was absent or minor in 40 patients, of whom 19 were treated medically and 18 by resection, with similar five-year survival rates of 65% and 75%. Frank or major haemoptysis occurred in 45 patients, of whom 17 were treated medically and 23 by resection, with five-year survivals of 41% and 84% (p less than 0.02). The better survival of the surgical group in this retrospective survey may have been due to the selection of patients with better lung function and more localised pulmonary disease. Our observations suggest that surgical resection for aspergilloma should be restricted to patients with severe haemoptysis and adequate pulmonary function. In patients unfit for resection cavernostomy is hazardous.     

Treatment of pulmonary aspergilloma with itraconazole.

In a 12 month open study of itraconazole in pulmonary aspergilloma nine patients received oral itraconazole 200 mg daily for six months followed by further itraconazole or observation for a further six months. There was no change in the serum IgG specific for Aspergillus fumigatus (mean (SE) change -4% (10%)) or symptoms of chronic cough and haemoptysis. In two of the three patients who continued treatment beyond six months symptoms and radiographic appearances improved and a temporary reduction in A fumigatus specific IgG occurred in one patient. Further experience of the effects of longer treatment are needed before oral itraconazole can be recommended for aspergilloma.     

Major haemoptysis in children with cystic fibrosis: a 20-year retrospective study.

BACKGROUND: Major haemoptysis occurs in approximately 1% of children with cystic fibrosis (CF). This report describes management and follow-up of these children at a tertiary centre in Australia. METHODS: Retrospective review of medical records from 1980-1999. RESULTS: Fifty-one children (45% female) had major haemoptysis (102 episodes). Mean age at first episode was 15 years (range 7-19) and mean FEV(1) was 56% predicted (range 14-98). Massive life-threatening haemoptysis was not confined to those with severe lung disease (FEV1 < 50% predicted). Bronchial artery embolisation (BAE) was more likely to be the initial treatment for those with massive haemoptysis and chronic recurrent bleeding tended to be treated conservatively (P = 0.01). Overall, 52 BAE were performed in 28 children with an immediate success rate of 98%; 13 children (46%) had repeated BAE. Four patients died as a direct result of severe haemoptysis. Mean follow-up was 54 months (range 0.5-183). Median survival time (Kaplan-Meier estimate) after first haemoptysis was 70 months, with a significantly longer survival for male patients independent of age (RR 3.8; 95% CI 1.7-8.8; P = 0.001). Median survival time following initial treatment with BAE was longer (103 months) compared to conservative treatment (52 months, P = 0.09). CONCLUSIONS: Massive haemoptysis was unrelated to the severity of lung disease and was more likely to be treated with embolisation. BAE was highly effective, however, 46% of the children required re-embolisation at some time, which is similar to the recurrence risk for major hemoptysis treated conservatively on longer term follow-up.     

Surgery for pulmonary aspergilloma in post-tuberculous vs. immuno-compromised patients.

OBJECTIVE: To compare the outcome of surgical resection for aspergilloma between patients with post-tuberculous complex and neutropenia. METHODS: We retrospectively reviewed our surgical experience with pulmonary resection for aspergilloma in 30 patients. Of the 20 patients with complex aspergilloma complicating healed tuberculosis (group 1), 14 were male and six were female with an average age of 54 years (SD 7). The indication for surgery was recurrent haemoptysis in all and there were 17 lobectomies, two pneumonectomies and one bilateral lobectomy. There were ten patients with acute myeloid or lymphoid leukemia (group 2), six male and four female with an average age of 26 years (SD 4). Twelve lesions required lobectomy in eight and wedge excision in four. RESULTS: In group 1 there was one post-operative death (5%), in a patient with massive haemoptysis and completely destroyed lungs with bilateral upper lobe aspergilloma secondary to pneumonia. Morbidity accounted for 25% (five patients), two required re-exploration for bleeding, two had prolonged air leak more than 7 days and one developed empyema. The later was treated with drainage and rib resection. One patient had recurrence of haemoptysis during the follow up period (mean 42 months). In group 2 there was no mortality or morbidity and six patients proceeded to bone marrow transplantation with no complication or recurrence. CONCLUSIONS: Surgical resection for pulmonary aspergilloma in selected patients provides the best chance of cure. Pulmonary resection for post-tuberculous complex aspergilloma is associated with higher morbidity than resection for immuno-compromised patients.     

Efficacy and cost-effectiveness of bronchial arterial embolisation in the treatment of major haemoptysis.

OBJECTIVE: To determine the efficacy and cost-effectiveness of bronchial artery embolisation (BAE) in the treatment of major and massive haemoptysis in HIV-positive and negative patients with pulmonary inflammatory disease. METHODS: A retrospective review of patients admitted over a period of 24 months to Wentworth Hospital with major haemoptysis treated using BAE. RESULTS: Eighty-seven patients were treated (77 males, 10 females). Bilateral disease was present in 50 patients (57%). Thirty-two patients were HIV-positive (37%). Embolisation was successfully performed in 77 patients (88.5%), and failed for technical reasons in 10 patients (11.5%). There was only one procedural complication. Fifty-seven patients had a successful outcome, with cessation of haemoptysis within 24 hours (66.5%). Haemoptysis continued in 30 patients (34%) (20 patients embolised and the 10 patients who had failed procedures). Fourteen of these patients (16%) required lobectomy or pneumonectomy as an emergency procedure. Five patients (5.7%) died from respiratory failure or pulmonary haemorrhage. Twenty-four HIV-positive patients were successfully embolised. Costing of BAE, including a 2-day ICU and 3-day ward stay, was R6,720; together with surgical resection the cost was R14,170. CONCLUSIONS: BAE is an effective treatment for major and/or massive haemoptysis in patients with pulmonary inflammatory disease who are not surgical candidates. Patients who are HIV-positive are able to tolerate the procedure well.     

Continuing role of thoracoplasty for pulmonary tuberculosis: Review of 155 cases

Standard thoracoplasty or thoracoplasty with intercostal myoplasty was performed in 155 cases of pulmonary tuberculosis or tubercular empyema. Resectional surgery was not possible in these cases due to bilateral extensive disease and poor cardiorespiratory reserve. Sixty patients had fibrocavitary lesions, 30 were persistently sputum positive and 36 suffered recurrent haemoptysis. Following surgery, obliteration of cavity, sputum conversion and control of haemoptysis could be achieved in 58, 27 and 36 cases respectively. There was no mortality. Twenty six patients with chronic empyema were cured. Two patients out of 3 with post pneumonectomy empyema were cured.     

Transbronchial lung biopsy: A review of 85 cases.

Transbronchial lung biopsy using the fibreoptic bronchoscope was carried out in 85 patients. There were no serious complications; two patients had a 10% pneumothorax and 17 had slight haemoptysis lasting less than 24 hours. The problems of interpreting small biopsy specimens are considered. Satisfactory specimens were obtained without fluoroscopic guidance, particularly in diffuse and lobar lesions. A histological diagnosis was made in 62% of diffuse lesions and compatible histology was found in a further 22%. In a further case Pneumocytis carinii infection was diagnosed. Blind biopsy of discrete periheral lesions was less successful with only one positive diagnosis in 12 patients.     

Pulmonary sequestration with haemoptysis and an unsuspected carcinoid tumour

We report the case of a fit and healthy 41-year-old man, who presented with significant haemoptysis without a history of recurrent infections. His computed tomography scan showed a dense lesion in the left lower lobe with a feeding vessel arising from the abdominal aorta, characteristic for an intra-pulmonary sequestration. To prevent possible further haemoptysis or infections, a left lower lobectomy was performed. The histological examination showed the typical features of a sequestration. However, within the sequestration, a carcinoid tumour without atypical features was found. There was no lymph node involvement. Sequestrations are congenital lesions without communication with the bronchial tree and with a systemic blood supply. They commonly cause recurrent infection. Fatal haemoptysis has also been described, but is rare. There are very few reports of neoplastic lesions in sequestrations. This case illustrates two unusual aspects of sequestrations. Surgery offers definitive treatment for both pathologies, as opposed to embolisation.     

Laparoscopic radical prostatectomy: early safety and efficacy

BACKGROUND: To evaluate the initial results of laparoscopic radical prostatectomy at this institution. METHODS: Between January 2000 and September 2003, 30 patients underwent laparoscopic radical prostatectomy. Peri- and postoperative data were accumulated prospectively and maintained in a database. All patients have a minimum of 6 month follow up. RESULTS: There were no conversions to open surgery, and there were no re-operations. Mean operating time was 328 (195-490) min. There was one intraoperative rectal injury which was repaired laparoscopically. Three patients (10%) required blood transfusion. Postoperatively, there were two cases of respiratory depression, one case of haemoptysis and one upper gastrointestinal bleed. Two anastomotic leaks were successfully treated conservatively, one of which was the only readmission to hospital. There was one case of clot retention requiring manual irrigation of the bladder. Mean hospital stay was 2.75 (1-10) days, with six of the last 10 patients being discharged on the first postoperative day. Continence rates at 6 months are 83%. Positive surgical margins occurred in seven patients (23%). At 12 months of follow up, one patient (4.5%) has had biochemical recurrence. CONCLUSIONS: Our initial results are comparable to, or better than, the initial series in high volume centres. The procedure is feasible in appropriately selected cases in the Australasian environment.     

Surgery for bronchiectasis.

OBJECTIVE: The incidence of bronchiectasis has declined markedly in developed countries. However, a reasonable number of patients still need surgery, despite aggressive physiotherapy and antibiotic therapy. We have reviewed our patients to clarify the benefits from surgery and to analyse the complications. MATERIAL AND METHODS: Between 1988 and 1999, we have operated on 119 patients with bronchiectasis, 71 female and 48 male, with a mean age of 42.2 years (range 11--77 years). Surgery was indicated because of unsuccessful medical therapy in 66 patients (55%), 31 (26%) had haemoptysis, 11 (9.2%) had lung abscess, 10 (8.4%) had lung masses, and three (2.5%) had pneumothorax. The most common manifestations were cough with sputum in 90 patients (76%), haemoptysis in 45 (38%) and recurrent infections in 57 (48%). The mean duration of the symptoms was 4 years (range 1--40 years). The lower lobes were diseased in 61 patients and bilateral disease was found in ten. The mean number of involved pulmonary segments was five (range 1-15). A lobectomy was performed in 75 patients (62%), a segmentectomy in 12 (10%), a pneumonectomy in nine (7.4%) and a bilobectomy in four (3.3%). Complete resection of the disease was achieved in 108 cases (91%). RESULTS: There was no operative mortality and perioperative morbidity occurred in 15 patients (15%), including temporary broncho-pleural fistulae in 7 (5.8%), and post-operative haemorrhage and atrial arrhythmias in four (3.3%) each. After a mean follow-up was 4.5 years, 73 patients (68%) of this group were asymptomatic, and 31 (29%) had meaningful clinical improvement, while only four (3.7%) maintained or worsened prior symptoms. The best clinical improvement occurred in patients with complete resection of the disease (P=0.008). There were no differences in the respiratory function, comparing pre- and post-operative data, with a 2-year of minimum interval. The VC was 91 and 89% and the FEV1 was 83% and 81% of expected, respectively before and after surgery, (P=NS). CONCLUSION: Surgery of pulmonary bronchiectasis has few complications and markedly improves symptoms in the great majority of patients, especially when complete resection of the disease is achieved. Pulmonary resection of bronchiectasis does not alter respiratory function.     

Does bronchography have a role in the assessment of patients with haemoptysis?

The results of bronchography in 96 consecutive patients investigated for haemoptysis at Papworth Hospital from 1975 to 1983 were reviewed. None of the patients included in this study gave a history suggestive of bronchiectasis and neither chest radiography nor fibreoptic bronchoscopy had shown a cause for the bleeding. Bronchography was performed through the fibreoptic bronchoscope and all included in the study showed both lungs adequately. The chest radiographic appearances were compared with the bronchographic findings. Seven of 12 patients with appearances suggesting old fibrosis showed bronchiectasis, as did eight of 10 with radiographic appearances suggestive of bronchiectasis. Eleven out of 74 patients with normal chest radiographs, however, also showed bronchiectasis. This group of 11 was compared with the other 63 but no clinical feature was found to be significantly associated with the presence of bronchiectasis. Although bronchography is now rarely used in the investigation of haemoptysis, this high yield (15%) of bronchiectasis indicates that its use should be reappraised. Follow up of the patients indicated that bronchography was not reliable at diagnosing peripheral bronchial carcinomas, which became evident later in two cases, and that asthma was present in 15 (24%) of the 63 patients with both normal chest radiographs and normal bronchograms.     

Six years'' experience with perthoracic core needle biopsy in pulmonary lesions.

Six years' experience of percutaneous core needle biopsy using the Hausser needle in 502 patients, aged 20-89 years, is reported. A biopsy was carried out when sputum and bronchoscopic methods had failed to establish a definitive histological diagnosis. Over 60% of the lesions were peripheral and about 40% were 2-4 cm in diameter. A correct diagnosis was made by this means in 312 of the 339 patients shown eventually to have a malignant lesion (92%) and in 130 of 146 patients with a benign lesion (89%). A definitive diagnosis was never established in 17 patients. Complications arose in 15% of cases. Pneumothorax occurred in 43 patients (7%), of whom 12 required a chest drain. Further complications included a small haemoptysis (less than 30 ml) in 27 patients (5%), haemothorax necessitating a chest drain in three patients, and an intrapulmonary haematoma in five patients. There were no fatal or permanent complications. Percutaneous core needle biopsy is a valuable procedure with a high diagnostic accuracy in these patients and a low rate of complications.     

Laser therapy in 100 tracheobronchial tumours.

One hundred patients with tracheobronchial tumours were treated with the neodymium YAG (yttrium-aluminium-garnet) or argon laser for symptoms of airways obstruction caused by tumour (59 cases), complete collapse of a lung (17 cases), or recurrent haemoptysis (24 cases). Seventy four of them had relapsed or failed to respond to radiotherapy or chemotherapy and all were inoperable. Objective improvement in results of lung function tests or haemoptysis diary charts was seen in 37 patients with airways obstruction (63%), five (29%) with collapsed lung, and 14 (58%) with haemoptysis. Overall, 68 patients had symptomatic benefit and there was objective improvement in 56. Two deaths occurred in 288 treatment sessions both occurring as a result of asphyxia from minor haemorrhage in patients with advanced cylindromas and critical narrowing of the trachea or single remaining bronchus. In suitable patients with intraluminal tumour laser phototherapy is a valuable addition to conventional treatment.     

Poor awareness of symptoms of oesophageal cancer

Oesophageal cancer presents as advanced disease; in the majority of patients the symptoms are present for many months prior to diagnosis. Dysphagia has been described as the key to an early diagnosis of oesophageal cancer. This study aims to assess the public perception of the importance of this symptom. Ninety-six patients completed a questionnaire. This evaluated patient understanding of symptoms of dysphagia compared to the finding of a breast lump, haemoptysis, chest pain and loss of weight concerning urgency, probable cause of symptoms and treatment required. Sixty-five patients (71%) would visit their GP within 24 h of finding a breast lump or suffering from haemoptysis (82%) or having chest pain (82%). Forty-seven patients (51%) who experienced dysphagia would seek medical advice after one week and further 18 (19%) after one month (P<0.0001). Only eight patients (10%) associated dysphagia with cancer compared to 53 patients (57%) with the finding of a breast lump (P<0.031). This study concludes that there is poor understanding of the main symptoms of oesophageal cancer. New health campaigns are needed if the cancer is to be detected at an earlier and potentially curable stage.     

Abnormalities of the lungs and thoracic cage in the Ehlers-Danlos syndrome.

Twenty patients with the Ehlers-Danlos syndrome, (10 type I, six type II, and four type IV) were studied to assess the frequency of respiratory abnormalities in this condition. Five patients (25%) had had at least one episode of haemoptysis, but none had any defect of coagulation. There was a high frequency of recurrent sinusitis, notably in those with the type I syndrome. Two patients had bullous lung disease, one of whom (type IV) had had three pneumothoraces and subsequent pleurodesis; he also had tracheomegaly (the Mounier-Kuhn abnormality). Minor skeletal abnormalities such as pectus excavatum were common, particularly in patients with type IV disease. Three patients had the straight back syndrome. There were no consistent spirometric or lung volume abnormalities, but eight patients (40%) had a raised gas transfer coefficient (Kco), possibly due to an increased intrapulmonary vascular volume. Two other patients had very low values of Kco that were unexplained.     

Management of massive haemoptysis with the rigid bronchoscope and cold saline lavage.

Twelve successive patients with massive haemoptysis were treated by emergency rigid bronchoscopy and lavage of the bleeding lung with cold saline. All patients stopped bleeding during the procedure and all blood and clot was evacuated from the accessible airways. The bleeding source was localised to a lobe in seven cases, and lateralised in the remaining five patients. Five patients had a second haemorrhage during that hospital stay and cold saline lavage again terminated it. Further therapy, either surgical or medical was based on information obtained during the respite from haemorrhage achieved with this technique. There was no hospital mortality in the series.     

Risk of depression in patients with chronic obstructive pulmonary disease and its determinants

BACKGROUND: Although it has been repeatedly suggested that chronic obstructive pulmonary disease (COPD) is associated with depression, no conclusion has so far been reached. A study was undertaken to investigate whether depression occurs more often in patients with COPD than in controls. The demographic and clinical variables associated with depression were also determined. METHODS: Patients with a registered diagnosis of obstructive airway disease in general practice, aged > or=40 years, forced expiratory volume in 1 second (FEV(1)) <80% predicted, FEV(1) reversibility 相似文献