Complex pulmonary aspergilloma treated with single stage cavernostomy and myoplasty

Abstract

Objective: Complex pulmonary aspergilloma (CPA) following pulmonary tuberculosis may lead to massive and fatal hemoptysis. Pulmonary resection, as initial therapy, carries high morbidity and mortality. Resection is contraindicated in patients with compromised lung function (FEV1<40%) and in those with bilateral disease. We reviewed the results of patients undergoing single stage cavernostomy and myoplasty as an alternative therapy in patients with normal and compromised lung function.

Methods: Patients suffering from recurrent massive hemoptysis (600ml/24h or >150ml/h) due to CPA were selected for single stage cavernostomy and myoplasty. We performed rib resection, cavernostomy, closure of the bronchial openings and total/partial obliteration of the cavity with a muscle flap as a single stage technique in patients with CPA regardless of pulmonary function or bilateral disease. Patients began oral Itracanozole two weeks prior to surgery and continued for 3 months post-operatively.

Results: Three women and four men (median age 38 years; range 24-59 years) with CPA were evaluated. Four patients had either bilateral disease or compromised lung function. Pectoralis major muscle was used for the myoplasty in five and trapezius or latissimus dorsi in the other two patients. The median number of bronchial fistulae closed during the surgery was six (range 2-12). Blood loss was minimal (median 227ml). Two patients underwent successful re-exploration for significant air leak. The median hospital stay was 9 days (6-27days). Six patients are alive and hemoptysis free (median follow-up 57.2 months).

Conclusions: Cavernostomy and myoplasty as a single stage technique is safe and reliable in the management of patients with complex pulmonary aspergilloma. Morbidity is low even in patients with compromised lung function or bilateral disease.