Hidefumi Kita

Aggressive surgical treatment of multidrug-resistant tuberculosis

OBJECTIVE Because extensively drug-resistant tuberculosis has emerged, adequate control of drug-resistant tuberculosis has become increasingly important. We report on our experience using liberal adjuvant resectional surgery as part of aggressive treatment for multidrug-resistant tuberculosis. METHODS We retrospectively reviewed the records of 56 consecutive patients who underwent pulmonary resections for multidrug-resistant tuberculosis between January 2000 and June 2007. There were 42 males and 14 females (mean age, 46 years; range, 22-64 years). Isolates were resistant to a mean of 5.6 drugs (range, 2-10 drugs). Multi-drug regimens employing 3 to 7 drugs (mean, 4.6 drugs) were initiated in all patients. Indications for surgery were a high risk of relapse for 37 patients, persistent positive sputum for 18, and 1 with associated empyema. RESULTS The 56 patients underwent 61 pulmonary resections (3 completion pneumonectomies, 19 pneumonectomies, 33 lobectomies, and 6 segmentectomies). Bronchial stumps were reinforced with muscle flaps in 54 resections. Operative mortality and morbidity rates were 0% and 16%, respectively. All patients attained postoperative sputum-negative status. Relapse occurred in 5 patients; 3 were converted by a second resection, and 1 responded to augmentation of chemotherapy. Late death occurred for 2 patients without evidence of relapse. Among 54 survivors, 53 (98%) were considered cured. CONCLUSION Surgical treatment that complements medical treatment has proved safe and efficacious for patients with multidrug-resistant tuberculosis. In an era with extensively drug-resistant tuberculosis, an aggressive treatment approach to multidrug-resistant tuberculosis continues to be justified until a panacea for this refractory disease is available.

Adjuvant Surgical Treatment of Nontuberculous Mycobacterial Lung Disease

BACKGROUND According to the 2007 American Thoracic Society/Infectious Diseases Society of America statement on nontuberculous mycobacterial diseases, more evidence for the benefits of adjuvant nontuberculous mycobacterial lung disease surgical intervention is needed before its wide application can be recommended. METHODS A retrospective review was conducted of 60 consecutive patients who met American Thoracic Society/Infectious Diseases Society of America diagnostic criteria and underwent pulmonary resection for localized nontuberculous mycobacterial lung disease between January 2007 and December 2011. All patients were receiving chemotherapy before resection. RESULTS Included were 41 women (68%) and 19 men (32%), with a median age of 50 years (range, 20 to 72 years). Of these, 55 patients (92%) had Mycobacterium avium complex disease. Bronchiectatic disease was noted in 29 patients, cavitary disease in 25, both in 4, and nodular disease in 2. The indications for resection were a poor response to drug therapy in 52 patients, hemoptysis in 6, and a secondary infection in 2. Sixty-five pulmonary resections were performed: 1 pneumonectomy, 3 bilobectomies, 39 lobectomies, 17 segmentectomies, 3 lobectomies plus segmentectomies, and 2 wedge resections. There were no operative deaths, and all patients attained sputum-negative status postoperatively. Eleven postoperative complications occurred in 8 patients (12%); relapse was observed in only 2 (3%). CONCLUSIONS Pulmonary resection combined with chemotherapy is safe, with favorable treatment outcomes, for patients with localized nontuberculous mycobacterial lung disease. Our results support the liberal use of operations for nontuberculous mycobacterial lung disease whenever indicated.

Risk Factors That Affect the Surgical Outcome in the Management of Focal Bronchiectasis in a Developed Country

BACKGROUND The purpose of this study was to demonstrate our surgical experience for focal bronchiectasis in the setting of modern diagnostic modalities and state-of-the-art medical treatment in a developed country. METHODS Thirty-one patients undergoing 33 lung resections for the treatment of focal bronchiectasis from 1991 to 2009 were reviewed. The mean age was 54 years. Twenty-nine patients (94%) were female; 21 patients (68%) had nontuberculous mycobacterial infection; and 22 patients (71%) received preoperative multiple-drug regimens containing clarithromycin. Five patients (16%) were in an immunocompromised status. All were diagnosed by chest computed tomography scan, and either the right middle lobe or left lingula were involved in 29 (94%). The curve for relapse-free interval was estimated by Kaplan-Meier methods. The factors that affected this curve were examined using Coxs regression analysis. RESULTS Operative morbidity and mortality were 18% and 0%, respectively. All patients became asymptomatic postoperatively. During the median follow-up of 48 months (11 to 216), 8 patients (26%) experienced recurrence, and the mean relapse-free interval was 34 months (3 to 216). By univariate analysis, an immunocompromised status (p=0.017), Pseudomonas aeruginosa infection (p=0.040), the preoperative extent of bronchiectatic lesion (p=0.013), and the extent of residual bronchiectasis after surgery (p=0.003) were significantly associated with the shorter relapse-free interval. By multivariate analysis, an immunocompromised status (p=0.039), Pseudomonas aeruginosa infection (p=0.033), and the extent of residual bronchiectasis (p=0.009) were independent and significant factors. CONCLUSIONS Complete resection of bronchiectasis while the disease is localized and is free from Pseudomonas aeruginosa infection is the key for a success. Also, immunocompromised status was suggested to be a risk factor.

A case of dermatofibrosarcoma protuberans in the skin over the breast of a young woman

A 19-year-old woman with dermatofibrosarcoma protuberans (DFSP) of the breast is described. She presented with a tumor of the left breast with redness and swelling. She had noticed a small tumor five years previously, but it had begun to grow rapidly three months previously. Mammography, ultrasonography and aspiration biopsy cytology demonstrated an apparently benign tumor of the breast preoperatively. Wide excision was performed to confirm the diagnosis. Histologically, the tumor was composed of a uniform population of fibroblasts in a distinct storiform pattern. DFSP was diagnosed in the skin over the breast. This lesion ordinarily originates from the dermis in the trunk and proximal extremities. It is important to diagnose a soft tissue lesion accurately when it occurs in the breast.

Experience with pulmonary resection for extensively drug-resistant tuberculosis☆

Extensively drug-resistant tuberculosis is becoming a global threat. It is a relatively new phenomenon, and its optimal management remains undetermined. We report our experience in using pulmonary resection for treating patients with this disease. Records were reviewed of 54 consecutive patients undergoing a pulmonary resection for multidrug-resistant tuberculosis at Fukujuji Hospital between 2000 and 2006. These patients were identified using the definition approved by the World Health Organization Global Task Force on extensively drug-resistant tuberculosis in October 2006. Five (9%) patients (3 men and 2 women) aged 31-60 years met the definition. None of the patients was HIV-positive. Although the best available multidrug regimens were initiated, no patient could achieve sputum conversion. Adjuvant resectional surgery was considered because the patients had localized disease. Procedures performed included pneumonectomy (2) and upper lobectomy (3). There was no operative mortality or morbidity. All patients attained sputum-negative status after the operation, and they were maintained on multidrug regimens for 12-25 months postoperatively. All patients remained free from disease at the time of follow-up. Pulmonary resection under cover of state-of-the-art chemotherapy is safe and effective for patients with localized extensively drug-resistant tuberculosis.

Different morbidity after pneumonectomy: multidrug-resistant tuberculosis versus non-tuberculous mycobacterial infection

To assess whether there is any difference in postoperative morbidity and mortality after pneumonectomy between patients with multidrug-resistant tuberculosis (MDR-TB) and patients with non-tuberculous mycobacterial (NTM) infections. Between January 2000 and December 2007, 61 patients with MDR-TB and 60 patients with NTM infections underwent 66 and 64 pulmonary resections, respectively. Of these, 33 patients were analyzed who underwent a pneumonectomy, including 22 patients with MDR-TB (seven right, 15 left) and 11 patients with NTM infections (seven right, four left). All bronchial stumps were covered with the latissimus dorsi. Patients with NTM infections were predominantly more female, older, thinner, and presented with a higher frequency of culture-positive sputum at operation than patients with MDR-TB. Operative mortality was zero. Morbidities were bronchial stump dehiscence (n=1) and mycobacterial empyema (n=1) for patients with MDR-TB, and acute respiratory failure (n=1), bronchial stump dehiscence (n=5) and mycobacterial empyema (n=2) for patients with NTM infections. Prevalence of bronchial stump dehiscence was significantly higher in patients with NTM infections (P=0.010). Five of six dehiscences occurred after right pneumonectomy. The optimal management of the bronchial stump in the setting of pneumonectomy for NTM infections needs further investigation.