Surgical Treatment in Patients With NTM-PD Associated With Positive Outcomes

In patients with NTM-PD, surgical resection to reduce mycobacterial burden is a viable and effective adjunctive therapy to antibiotics.

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.

Surgical resection to achieve maximal reduction of mycobacterial burden should be actively pursued in the indicated patients as an adjunctive therapy to antibiotics.

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.

References:

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