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Three Part Question

In [patients with pulmonary aspergilloma] is [VATS] when compared with [thoracotomy] justified in terms of [outcome]?

Clinical Scenario

A 40-year old female known pulmonary aspergilloma in the left upper lobe is scheduled for surgical resection.The patient questions which is better,VATS or Thoracotomy?

Search Strategy

Medline 1946 to October 5 2017 using OVID interface.（exp Aspergillosis, Allergic Bronchopulmonary/ OR exp Aspergillosis/ OR exp Pulmonary Aspergillosis/ OR exp Invasive Pulmonary Aspergillosis/ OR exp Lung Diseases, Fungal/ OR pulmonary aspergilloma.mp）AND(thoracotomy.mp. OR exp Thoracotomy/ OR thoracotomies.mp OR thoracic surgery.mp. OR exp Thoracic Surgery/ OR thoracic surgical procedures.mp. OR exp Thoracic Surgical Procedures/ OR )AND(VATS.mp. OR exp Thoracic Surgery, Video-Assisted/ OR endoscopy.mp. OR exp Endoscopy/ OR video recording.mp. OR exp Video Recording/ OR thoracoscopy.mp. OR exp Thoracoscopy/ OR VATSs.mp OR video-assisted thoracic surgery.mp OR video assisted thoracic surgery.mp OR
video assisted thoracoscopic surgery.mp OR video-assisted thoracoscopic surgery.mp)

Search Outcome

Seven hundred and forty-seven papers were found using the reported search strategy.From these,four articles were identified that provided the best evidence to answer the question.These are presented in Table 1.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Junji Ichinose, Tadasu Kohno,Sakashi Fujimori 2010 Japan	This was a retrospective study looking at a 23 consecutive patients who were surgically treatef.20 patients underwent VATS(SA in six patients-G1,CA in fourteen patients-G2),3 patients underwent a thoracotomy.SA-simple aspergilloma,CA-complex aspergilloma.	Retrospective review (level IV)	Outcomes	G1 G2 pValue
			Operation time （min）	143±69 1216±85 0.08
			Blood loss (ml)	10±17 307±346 ＜0.01
			Chest drain (days，median)	1.5 2.0 0.91
			Hospital stay(days,median)	5.5 8.0 0.51
Ping Yuan,Zhitian Wang,Feichao Bao,Yunhai Yang,Jian Hu 2014 China	This retrospective study analysed the outcome of 16 patients who were treated by VATS,among them,9 patients were SA(G1),7 patients were CA(G2)	Retrospective review (level IV)	Outcomes	G1 G2 pValue
			Duration of operation（min）	101.3 187.9 0.016
			Blood loss (ml)	55.6 150 0.003
			Chest drainage (ml)	523.3 1020.7 0.005
			Duration of chest drainage (days)	3.9 9.9 0.007
			Complications	5/4 3/4 0.500
			perioperative deaths	0% 0%
			total postoperative complications	8/16 50%
			Postoperative hospital stay(days)	5 11 0.004
			The mean follow-up period (21.6 months)	Further complications,recurrence,PA related death were not found.
Arvind Kumar,Belal Bin Asaf,Harsh Vardhan Puri,Vijay C Lingaraju,Shireen Siddiqui 2017 India	This retrospecyive analysis was performed on 41 patients with pulmonary asergilloma beween 2012 to 2015,23 patients were treated by VATS (G1) and 18 by thoracotomy (G2).	Retrospective review (level IV)	Outcomes	G1 G2
			Mean operation time （min）	162.13±14.17 239.44±12.089
			Intraoperative blood loss (ml)	213.913±106.033 461.111±166.765
			Duration of chest tube drainage	5.43±4.53 8.94±5.04
			Length of hospital stay	3.78±1.92 6.55±3.50
			total postoperative complications	5 11
			follow-up period (6 months)	There was no mortality or recurrence in this study.
Qian-Kun Chen,Chang Chen,Xiao-Feng Chen,Ge-Ning Jiang 2014 China	Between January 2005 and December 2012, 152 patients with PA underwent suigical intervention.Among them,76 were treated by VATS(G1) and 76 by Thoracotomy (G2).	Retrospective review (level IV)	Outcomes	G1 G2 pValue
			Median operation time （min）	138±76 152±85 0.063
			Blood loss (ml)	118±80 128±73 0.06
			Length of hospital stay (days)	10±6.5 14±12.5 0.035
			Perioperative death	0 0
			Total pospetive complications	8 16 0.032
			Cost(10^5 RMB)	4.9±1.5 4.3±0.6 0..016

Comment(s)

1.Ichinose et al.This study focused purely on patients with PA who underwent VATS and found that VATS may be associated with low mortality and morbidity.VATS for SA,in particular,might be superior to thoracotomy in terms of disease free survival. 2.Yuan et al.This study also showed that VATS for PA seems to be a safe and effective procedure,especially in patients with SA. 3.Kumar et al.VATS is alternative to thoracotomy in the management of pulmonary aspergilloma in terms of preventing ecurrence and postoperative complications. 4.Chen et al.VATS for pulmonary aspergilloma，if applicable,might be an effective and safe method of surgery for selected patients when compared with open surgery.

Clinical Bottom Line

Pulmonary aspergilloma (PA) is the most prevalent form of infection caused by Aspergillus in patients with or without underlying disease. In most, the primary dual aims of therapy are reduction of symptoms and prevention of progression.Medical management of pulmonary aspergilloma has been the cornerstone of treatment. If surgery is the chosen therapeutic path, VATS is a safe alternative to thoracotomy in the manafement of PAs and confer peroperative advantages with low total postoperative complications and recurrence rate.Our results may help clinicians in making treatment recommendations and in the design of future clinical trials.

References

1. Junji Ichinose, Tadasu Kohno,Sakashi Fujimori Video-assisted thoracic surgery for pulmonary aspergilloma Interactive CardioVasucar and Thoracic Surgery 10 (2010) 927-930
2. Ping Yuan,Zhitian Wang,Feichao Bao,Yunhai Yang,Jian Hu Is video-assisted thoracic surgery a versatile treatment for both simple and complex pulmonary aspergilloma? J Thorac Dis 2014;6(2);86-90
3. Arvind Kumar,Belal Bin Asaf,Harsh Vardhan Puri,Vijay C Lingaraju,Shireen Siddiqui Video-assisted thoracoscopic suegery for pulmonary aspergillma Lung India 2017 Jul-Aug;34(4):318-323
4. Qian-Kun Chen,Chang Chen,Xiao-Feng Chen,Ge-Ning Jiang Video-Assisted Thoracic Surgery for Pulmonary Aspergilloma: A Safe and Effective Procedure Ann Thorac Surg 2014;97:218-23