Background: Lung resection in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) has been reported to be associated with favorable outcomes. However, little is known regarding the risk and prognostic factors for refractory and recurrent cases. We aimed to evaluate the overall impact and benefit of adjuvant lung surgery by comparing NTM-PD patients who underwent adjuvant lung resection with those treated exclusively with antibiotics. We also investigated the efficacy of serum IgA antibody against glycopeptidolipid (GPL) core antigen (GPL core antibody) to monitor disease activity and predict the recurrence of disease after adjuvant lung resection.Methods: We retrospectively evaluated the clinical characteristics and surgical outcomes of 35 patients surgically treated for NTM-PD. Furthermore, we compared surgically treated patients and control patients treated exclusively with antibiotics who were matched statistically 1:1 using a propensity score calculated from age, sex, body mass index, and radiologic features of disease. Results: In the surgically treated patients, the median age was 58 (interquartile range, 47-65) years and 65.7% were female. Twenty-eight patients had Mycobacterium avium complex. Operations comprised four pneumonectomies, two bilobectomies, one bilobectomy plus segmentectomy, 17 lobectomies, two segmentectomies, and nine lobectomies plus segmentectomies. Postoperative complications occurred in seven patients (20%), there were no operative deaths, and 33 (94.3%) patients achieved negative sputum culture conversion. Refractory and recurrent cases were associated with remnant bronchiectasis, contralateral shadows, and positive acid-fast bacilli staining or culture. Of 28 statistically matched pairs, long-term sustained negative culture conversion was observed in 23 (82.2%) surgical group patients and in 14 (50.0%) non-surgical group patients (0.0438). The mortality rate was lower in the surgical group, but did not reach statistical significance (one in the surgical group and four in the non-surgical group, p = 0.3516). GPL core antibody was correlated with disease activity and recurrence.

Background: Among empyema cases, those with a fistula are considered to be intractable and often associated with a respiratory infectious disease caused by a variety of factors. In the present study, we examined the usefulness of a treatment strategy that combined endoscopic fistula closure with negative pressure wound therapy and present therapeutic outcomes of cases of empyema with fistula experienced since 2003. Methods: We retrospectively investigated 49 cases of empyema with fistula surgically treated for the causative disease during the period from January 2003 to December 2018 by examining medical records. Results: The causative diseases were acid-fast bacterium-related diseases such as tuberculosis, late effects of tuberculosis, or non-tuberculosis mycobacterium infection in 19, aspergillus infection in 8, post-pneumonectomy bronchial stump fistula in 8, post-pneumonectomy esophageal fistula in 2, and common bacterial respiratory infection in 12 cases. The numbers of surgical procedures performed were 55 debridement or decortication, 37 open-window thoracotomy (OWT), 28 muscle flap transposition, 16 thoracoplasty, 7 omentopexy, and 3 extra-pleural pneumonectomy. The outcome was cure and discharge in 37 (65.3%), discharge with OWT or a chest tube in 7 (14.3%), and death in the hospital in 10 (20.4%) cases.Eight of 15 patients whose open-window cavity could not be closed following an OWT procedure died in the hospital. After 2013, in addition to the above-mentioned procedures, endoscopic fistula closure was performed in 2, negative pressure wound therapy (NPWT) in 2, and concomitant use of both procedures in 3 cases. One case of endoscopic closure avoided OWT because of bronchial occlusion. Among 6 patients who underwent OWT, 5 treated with negative pressure wound therapy were cured and discharged from the hospital.Conclusions: A variety of surgery procedures were performed during the study period for treating empyema with fistula. However, a cure could not be achieved in a significant number of those patients. We consider that multimodal approaches including endoscopic fistula closure and NPWT should be considered for use as new treatment strategies in such cases.

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