Resectional Thoracic Surgery for Pulmonary Nontuberculous Mycobacterial Disease

Resectional thoracic surgery has been offered as a possible treatment for pulmonary nontuberculous mycobacterial (NTM) disease in some US centers. Results of a retrospective study of patients who underwent cardiothoracic surgery and had received a cross-diagnosis of NTM at 2 centers were recently published in CHEST.

The study evaluated electronic medical records of 105 patients at Oregon Health & Science University in Portland and University of Texas Health Science Center at Tyler for the period of May 2010 to September 2019. Patients studied were 90% White and 75% female, with a mean age of 65 years (±11 years; range, 36 to 84 years).

On surgical culture, Mycobacterium avium complex (MAC) was the most common species identified. Before undergoing surgery, 98% of the patients received a multidrug antibiotic regimen for NTM disease, which most often involved a macrolide (73%), ethambutol (68%), and a rifamycin (62%), for a mean of 25 months (±18 months; range, 1 to 84 months). Additionally, 55% of the patients received intravenous (IV) amikacin presurgically for a mean of 95 (±22) weeks. No intraoperative deaths were reported.

Within 90 days of hospital discharge, complications were reported in 26% (27 of 105) of the patients. Variables associated with a decreased likelihood of experiencing an adverse event within 90 days of discharge included: the use of perioperative IV amikacin (odds ratio [OR], 0.27; 95% CI, 0.11 to 0.67); female sex (OR, 0.96; 95% CI, 0.93 to 1.00); and video-assisted thoracoscopic surgery (reference: open surgery; OR, 0.15; 95% CI, 0.06 to 0.39).

Variables associated with an increased likelihood of an adverse outcome included: bacterial coinfection (OR, 5.33; 95% CI, 1.97 to 14.40); cavitary disease (reference: nodular disease; OR, 10.62; 95% CI, 2,34 to 48.15); and lobectomy/segmentectomy (reference: wedge resection). The likelihood of an adverse event was higher with the presence of Mycobacterium abscessus than with MAC (OR, 2.11; 95% CI, 0.57-7.84), though not significant

Following surgery, 53% (56 of 105) of patients used IV amikacin for a mean of 6 weeks. Among the 63% (66 of 105) of individuals with postsurgical mycobacterial cultures, 26% remained persistently negative prior to undergoing surgery, whereas 18% remained persistently positive. The majority (73%) of patients remained culture-negative or converted to negative following surgery. A total of 31 patients converted their mycobacterial cultures from persistent presurgical positive to negative within

12 months following surgery; among these converting patients, 94% had cavitary disease, whereas among nonconverters 56% had cavitary disease (P =.001).

As treatment paradigms for pulmonary NTM disease become better established, the use of video-assisted thoracoscopic surgery for resectional thoracic surgery may offer an effective treatment option for certain patients, particularly when accompanied by the use of perioperative IV aminoglycoside therapy, researchers concluded. They added that prospective, multicenter cohort studies are needed to establish the optimal timing, perioperative antimicrobial treatment, and selection criteria for surgery.

Disclosure: The study authors have declared no affiliations with biotech, pharmaceutical, and/or device companies.

Reference

Ku JH, Siegel SA, Philley J, et al. Outcomes of resectional thoracic surgery for the treatment of pulmonary nontuberculous mycobacterial disease in 105 patients in the United States. CHEST. Published online August 11, 2021. doi:10.1016/j.chest.2021.08.004