Surgical Management of Pulmonary Aspergillosis

The primary objective of surgery for pulmonary aspergillosis is source control of infection, typically in patients with persistent symptoms, such as hemoptysis, or patients for whom medical therapy has failed to eradicate the disease. Good outcomes rely on appropriate patient selection, with assessment of cardiopulmonary function, nutritional status, and multidisciplinary infectious disease and pulmonology consultation being essential. Preoperative preparation should include plans for bronchial stump coverage and management of residual pleural space, as patients are at increased risk for complications such as empyema and bronchopleural fistula. For a more limited extent of disease, such as single aspergilloma, therapies such as wedge resection or lobectomy may be effective. For advanced disease in patients with refractory symptoms, or those who are not candidates for parenchymal resection, alternative interventions that focus on the management of space, rather than resection, may be considered; examples include thoracostomy, thoracoplasty, and/or muscle flap transposition. Outcomes are dependent on patient functional status, immunocompetency, and preoperative disease severity. Present-day perioperative mortality is rare, with patients with single aspergilloma treated with parenchymal resection least likely to experience complications and most likely to be cured. Close postoperative follow-up is essential to optimize the duration of antifungal therapy and monitor for signs of recurrence.