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.