Surgery for Pulmonary NTM Disease r e t n n e o s i t e c - PowerPoint PPT Presentation

Surgery for Pulmonary NTM Disease r e t n n e o s i t e c r u P d o f o r p y e t r R e Gwen Huitt, MD p r o o Professor of Medicine f r P t o Division of Mycobacterial and Respiratory N Infections National Jewish Health Slides Courtesy of John D. Mitchell, M.D.

r e t n n e o s i t e c r Disclosures: u P d o f o r Nothing to disclose. p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

Surgery for Pulmonary NTM Disease Case Presentation • 65 year old female r e t n n • Chronic productive cough, recurrent infection e o s i t e c • Documented MAC infection by ATS criteria r u P d o f o • Repeated treatment failures, now macrolide resistant r p y e t r R e • Referral and evaluation at NJH p r o o f r • Imaging suggests areas of focal bronchiectasis P t o N involving right lung

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

Surgery for Pulmonary NTM Disease Pre-Surgery Treatment • Initiate multidrug regimen, including IV Amikacin r e t n n e o s i t e • Planned VATS RML, RUL anterior segment c r u P d resection in 8 weeks after initiation of therapy o f o r p y e t r R e p • 2 – 4 day hospital stay with surgical procedure r o o f r P t o N • 7 - 10 day stay in Colorado at time of surgery

Surgery for Pulmonary NTM Disease “VATS” Approach • Thoracoscopic Lobectomy r e t n – Two 1 cm incisions n e o s i – One 3 cm “utility” incision t e c r u P – No rib spreading d o f o r • Operation otherwise identical p y e t r R e to open approach p r o o • Double lumen tube f r P t o N • No epidural catheter • Prior surgery not absolute contraindication

Surgery for Pulmonary NTM Disease Double Lumen Endotracheal Tube r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

Surgery for Pulmonary NTM Disease Anesthesia / Analgesia • Double Lumen Tube r e t n n e o s i t e • Typically, no epidural c r u P d o f o r p y e • Intercostal blocks t r R e p r administered at surgery o o f r P t – 0.25% marcaine with epi o N • Postoperative PCA  oral NSAID ± narcotic

Surgery for Pulmonary NTM Disease Case Presentation r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

Thoracoscopic Lobectomy/Segmentectomy Instruments • 0 - 120 degree scope r e t n • Soft tissue retractor n e o s i t e • Thoracoscopic-specific: c r u P d – Clamps o f o r p y – Right angle e t r R e – Forceps p r o o f r • Small (pediatric) sucker P t o N • Kidney pedicle clamp • Staplers • Thoracoscopic clip appliers • Harmonic scalpel

Thoracoscopic Lobectomy/Segmentectomy Instruments r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

Thoracoscopic Lobectomy/Segmentectomy Wound Protection r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

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r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

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r e t n n e o s i t e c r u P d o f o r p y e t r R e p r o o f r P t o N

Surgery for Pulmonary NTM Disease Indications for Surgery r e t n n Persistent, focal (cavitary or bronchiectatic) lung e o s i t e c disease after antimicrobial treatment, usually in r u P d o f the setting of recurrent symptoms, documented o r p y e t treatment failure, or antimicrobial resistance. r R e p r o o f r P t o N Surgical resection should be seen as an adjunct to antimicrobial therapy, which remains the mainstay of treatment.

Surgery for Pulmonary NTM Disease Basics of Surgical Therapy r e t n n e o s i t e c r u P d What is the Goal? o f o r p y e t r R e p r o o f r P t o N

Surgery for Pulmonary NTM Disease Basics of Surgical Therapy - Goals • Eradicate infection r e t n n – Culture negative e o s i t e c – Off antibiotics r u P d o f – Symptom free o r p y e t r R e p r o o • Symptom control f r P t o N – Intractable cough – Hemoptysis • Limit damage to uninvolved lung

Surgery for Pulmonary NTM Disease Presentation • Middle-aged females, thin, r e t n Caucasian, nonsmokers, right n e o s i middle lobe / lingular disease t e c r u P d o f o r • Isolated large, thick-walled p y e t r R cavitary disease. e p r o o f r P t o • Elderly men, smokers, ETOH N abuse, underlying COPD. Resembles TB, may progress to complete lung destruction.

Surgery for Pulmonary NTM Disease Presentation • Middle-aged females, thin, r e t n Caucasian, nonsmokers, right n e o s i middle lobe / lingular disease t e c r u P d o f o r • Isolated large, thick-walled p y e t r R cavitary disease. e p r o o f r P t o • Elderly men, smokers, ETOH N abuse, underlying COPD. Resembles TB, may progress to complete lung destruction.

Surgery for Pulmonary NTM Disease Presentation • Middle-aged females, thin, r e t n Caucasian, nonsmokers, right n e o s i middle lobe / lingular disease t e c r u P d o f o r • Isolated large, thick-walled p y e t r R cavitary disease. e p r o o f r P t o • Elderly men, smokers, ETOH N abuse, underlying COPD. Resembles TB, may progress to complete lung destruction.

Surgery for Pulmonary NTM Disease Results of Surgical Therapy • Corpe, 1981: 131 cases, mortality 6.9%, BPF 5.3%, r e t n 93% sputum conversion rate n e o s i t e c r u P d • Nelson, 1998: 28 cases, mortality 7.1%, BPF 3.6%, o f o r p y complication rate 32%, 88% sputum conversion rate e t r R e p r o o f r • Shiraishi, 2002: 21 cases, mortality 0%, complication P t o N rate 29%, sputum conversion 100% → 90% at 2 years • Mitchell, 2008: 265 cases, mortality 2.6%, complication rate 18%, BPF 4.2%, 87% sputum conversion rate

150 r e t n n 10 e o s i t e % Mortality Rate c 100 r u Procedures P d 8 o f o r p y e t r R 6 e p r o o f r 50 P t o 4 N 2 0 1983-1990 1991-2000 2001- Mitchell JD et al Ann Thor Surg 2008;85(6):1887

Surgery for Pulmonary NTM Disease Minimally Invasive (VATS) Approach • Study period: July, 2004 to June, 2010 r e t n n e o s i t e c • 171 patients  212 cases r u P d o f o – 41 patients had bilateral resections r p y e t r R e p r o o • Mean age: 59 years (26 – 82 years) f r P t o N • Predominately Caucasian (93%) and Female (93%) Mitchell JD et al Ann Thor Surg 2012 Apr;93(4):1033-40

Surgery for Pulmonary NTM Disease Minimally Invasive (VATS) Approach • Prior thoracic surgery in 10% r e t n n e o s i t e c • Mean duration of medical therapy prior to referral for r u P d o f o surgery: 61 months (4-354 months) r p y e t r R e p r o o • Indications for surgery: Focal parenchymal disease f r P t o N with recurrent hemoptysis or pulmonary infections, or failure or intolerance of medical therapy Mitchell JD et al Ann Thor Surg 2012 Apr;93(4):1033-40