Invasive aspergillosis and surgery. Literature review

Purpose. The aim of this literature review is to determine the role of surg ery in the treatment of invasive aspergillosis, to estimate the postoperati ve mortality and to assess long-term benefit of this strategy. Patients. Methods. For invasive pulmonary aspergillosis (IPA), 141 patients were treated by surgery and antifungal agent. In elective surgery 114 pati ents were operated for residual aspergillosis lesion despite antifungal the rapy. The time between the diagnosis of IPA and the operation was 16 days t o 42 days. The CT scan showed peripheral aspergillosis lesions in all patie nts and a pulmonary cavitation in 54 % of patients. In the following weeks, a new hematologic therapy (chemotherapy, bone marrow transplantation) was indicated. In emergency, the operation was performed for massive hemoptysis in 5 patients after marrow recovery. Results. Ten patients were operated in emergency for prevention of massive hemoptysis. At the time of surgery, 9 patients had less than 1000 absolute neutrophils cells/mu L. The criteria for operation were repeated CT scans s howing an aspergillosis lesion near a pulmonary artery and disappearance of the fatty border between the vessel wall and the aspergillosis lesion. Mor tality was 7 % for elective surgery and 7 % for emergency. Mortality for al l patients operated TPA was 7 %. At long-term no hemoptysis was reported. A mong 111 patients followed, 12 patients (11 %) presented a new aspergillosi s infection. At long-term 48 patients (43 %) died, the causes of death were relapse of hematologic disease in 37 patients, relapse of aspergillosis in fection in 9 patients, cytomegalovirus infection in one patient and bacteri al sepsis in one patient. For Aspergillus rhinosinusitis, 76 cases were treated by surgery and antifu ngal agent. Three patients (4 %) died postoperatively due to intracerebral hemorrhage. For cerebral aspergillosis, 15 patients were treated by surgery and antifun gal agent. Among three deaths (20 %), two patients died post-operative from intracerebral hemorrhage by destruction of vessel wall, the resection had been incomplete. For aspergillosus endocarditis, 12 patients were operated and the mortality was 50 % (6/12). For Aspergillus osteomyelitis one case of a vertebral localization was succ essfully treated by laminectomy and antifungal agent after follow-up period of 14 months. Conclusion. Despite insufficient scientific evidence, we can recommend: if a aspergillosis lesion localized in lung or sinuses or brain persists despi te antifungal agent, surgery is indicated especially when a new immunosuppr essive therapy is indicated in the next weeks. When a aspergillosis lesion is located near a pulmonary artery, we recommend emergency operation before marrow recovery for the prevention of massive hemoptysis. For other sites, scientific evidence is too scant to recommend a strategy.