Adjunctive surgery is effective and has acceptable rates of complications for selected patients with nontuberculous mycobacterial pulmonary disease (NTM-PD), according to meta-analysis findings published in CHEST.
Due to the poor treatment success of antibiotic therapy for NTM-PD, there is increased interest in adjunctive surgery; however, previous research has shown varying surgical outcomes. Researchers therefore conducted a systematic review and meta-analysis to verify treatment outcomes and complications of adjunctive surgery in patients with NTM-PD. Researchers conducted a literature search of the MEDLINE, Embase, and Cochrane databases for studies published in peer-reviewed journals in English before January 31, 2022.
Eligible studies reported the results of patients who met the criteria for NTM-PD according to criteria from the American Thoracic Society/Infectious Diseases Society of America, as well as details of the surgical procedures, treatment outcomes (including sputum culture conversion and recurrence), surgery-related morbidities, mortality, and follow-up duration.
The meta-analysis included 15 studies that detailed treatment outcomes and postoperative complications of adjunctive surgery in NTM-PD. Among the 1071 included patients, 975 (91.0%) received antibiotic therapy for NTM-PD before surgical resection for a median range of 2 to 24.5 months. The patients had a mean or median age of 45 to 65 years, and 25.0% to 95.5% were female.
Treatment outcomes in 15 studies with 942 patients were assessed. The weighted proportion of postoperative sputum culture negative conversion was 93% (95% CI, 87%-97%), and heterogeneity of the effect estimate (I2) was 86.0%. The pooled estimate of the recurrence rate in a median follow-up of 34 months (interquartile range, 26-46) was 9% (95% CI, 6%-14%), with substantial heterogeneity (I2 = 71.2%), based on 841 patients from 15 studies.
Subgroup analyses showed a postoperative sputum culture negative conversion of 94% in studies where extensive lung resection was performed in at least 30% of participants and 92% in those in which extensive resection was performed in less than 30% of the sample. The recurrence rate was 10% in studies of extensive resection conducted in at least 30% of patients and 9% in studies of extensive resection performed in less than 30% of the population.
Regarding the overall postoperative complication rate, the pooled estimate was 17% (95% CI, 13%-23%), with substantial heterogeneity (I2 = 75.2%). Of 182 cases with postoperative complications, 21 patients (8.2%) had a bronchopleural fistula. The postoperative in-hospital mortality rate was 0% (95% CI, 0%-2%), and little heterogeneity was observed across the studies (I2 = 27.5%).
In subgroup analysis, the rate of complications and in-hospital mortality in studies in which extensive lung resection was conducted in at least 30% of the population was 16% and 1%, respectively. In studies in which extensive lung resection was performed in less than 30% of participants, those rates were 19% and 0%, respectively.
Among several limitations, a majority of the included studies were from East Asia and studies not published in English were excluded. Also, substantial heterogeneity existed in the studies, and all were single-arm, nonrandomized, observational cohort studies without a comparator, except for 1 matched study.
“Surgical resection to achieve maximal reduction of mycobacterial burden should be actively pursued in the indicated patients as an adjunctive therapy to antibiotics,” the study authors concluded.
Kim J-Y, Lee HW, Yim J-J, Kwak N. Outcomes of adjunctive surgery in patients with nontuberculous mycobacterial pulmonary disease: a systematic review and meta-analysis. Chest. Published online October 5, 2022. doi: 10.1016/j.chest.2022.09.037