[continued from previous message]

Given the suboptimal outcomes of medical therapy for NTM lung disease (15,70). Surgical resection is considered in selected individuals. However, the role of surgery is not definitively established. The severity and geographical distribution of the
disease, responsiveness to antimicrobial therapy, and pulmonary reserve all influence the decision to pursue surgical management. Ideally, positive sputum needs to be converted and remain negative for at least three months if the infecting organism is
susceptible to medical therapy. Optimization of bronchial hygiene with chest physical therapy or mechanical devices is recommended pre-operatively and post-operatively. Some authors recommend resected specimens be “double cultured’ with samples sent
to two different microbiology laboratories to minimize sampling error (71). Pre-operative or intraoperative bronchoscopy is performed to exclude endobronchial pathology when suspected. Surgical resection is typically indicated in the setting of focal
persistent disease amenable to complete anatomical resection. In more diffuse disease, surgery may be indicated to reduce disease burden and systemic symptoms of chronic infection in selected patients. There are not clearly established criteria upon
which to recommend surgery in these cases.

Go to:
Surgical technique
The largest experience with resection for atypical mycobacteria is reported from Denver, USA. These authors have reported both open thoracotomy and video-assisted thoracoscopic surgery (VATS) approaches to pulmonary resection with good results (71).
However, in many instances the disease incites an inflammatory response, which obliterates the pleura, making a VATS approach difficult.

Mitchell and colleagues from Denver appear to have a low tolerance for use of muscle flaps (Latissimus dorsi) or omentum to fill large spaces or buttress the bronchial stump. One of the present author’s (JAO) approaches is to perform a muscle-sparing
thoracotomy for any disease process where the risk of bronchopleural fistula and/or empyema is increased. In many instances, a muscle flap is not needed and is preserved and available for use, but only if necessary. The author’s experience advocates
that dissection should proceed in the intrapleural plane rather than the sometimes easier extrapleural plane, because of excessive bleeding from myriads of small vessels. Lymph node and other tissue surrounding the bronchus should be retained and
utilized to cover the bronchial stump. There exists a belief that resection for TB is associated with a high incidence of bronchopleural fistula, but in truth, this complication is infrequent (72).

If a pneumonectomy is performed, drainage is avoided if possible, recognizing that the risk of empyema increases with the duration of the presence of a chest tube. In those with persistent oozing or bleeding, a chest tube is necessary, but should be
removed as soon as drainage becomes serous.

In patients with TB, the ipsilateral lung remaining after resection may be abnormal and fibrotic and may not completely fill the thoracic cavity. Options in these circumstances are to do nothing, with the anticipation and hope that in the post-operative
period the space will become obliterated. Pleural tents are often not possible if there have been extensive adhesions that have been freed. In these instances where pleural space problems are anticipated, a multihole catheter alongside the phrenic nerve,
with local anesthetic infused so that the hemidiaphragm is temporarily paralyzed is indicated.

Go to:
Results of surgery
In the Denver experience, the overall operative mortality was low at 2.6%. Eleven patients developed a bronchopleural fistula (4.2%), of whom 10 had positive sputums at the time of surgery (71). In contradistinction to the experience with TB, where left
pneumonectomy is undertaken twice as commonly as right pneumonectomy, right pneumonectomy is more commonly performed for atypical mycobacteria (71). Bronchopleural fistulae occurred after right pneumonectomy (71). A similarly high incidence of
bronchopleural fistula after right pneumonectomy was also reported by Shiraishi and coworkers (73). These reports suggest that prophylactic muscle flaps are likely necessary in this patient sub group.

In a recent series of 110 patients who underwent surgical resection for right middle lobe or lingual bronchiectasis from NTM, 84% had negative post-operative cultures and smears (74). Eight of the negative patients subsequently became positive again,
representing either relapse or reinfection. Sixteen percent did not convert, suggesting failure of surgical therapy. Therefore, 22% in total (24/110) remained positive (74). Although some may suggest these data argue unfavorably against surgical
resection, it must be highlighted that symptoms of chronic cough and a feeling of being unwell were relieved in most. The impact of removal of the bulk of disease in those with persistent or subsequent positive sputum cultures on future health is not
established, although, excision of a large focus of infection may facilitate medical management of remaining sites of disease (75).

Go to:
The role of surgery in control of complications of NTM infections
In addition to surgery for control of the disease, surgery may be necessary to deal with complications of disease such as hemoptysis, cavitation with or without fungal ball formation, and empyema. These situations often require urgent treatment
precluding the luxury of pre-operative testing, antibacterial therapy, and optimization of the patient’s cardiopulmonary and nutritional status.

Go to:
NTM skin and soft tissue infection
NTM may infect surgical wounds post-operatively. The etiology of these infections is unknown, but it is most likely due to direct implantation or contamination of surgical instruments. Both host and organism characteristics are contributory, as these
infections occur more commonly in those who are immunosuppressed, and the causative organisms are usually rapidly growing NTM.

The author (JAO) has noticed some characteristics of these wounds. They tend to appear very clean with minimal slough, and pus does not exude. If there is a liquid component to the wound, it is of low volume, clear, and watery. Granulation tissue is not
abundant. The patient may have pain out of proportion to the extent of the wound and, in these patients, magnetic resonance imaging (MRI) or CT scans may identify deep tissue involvement. Curiously, some patients have minimal pain. Under normal
circumstances, healing would be expected, as these wounds appear quite clean, but this does not readily occur despite adjunctive therapies such as the use of a wound vac or other similar device. Once the diagnosis is established with appropriate
culturing, healing occurs with the institution of appropriate antimicrobial therapy.

Go to:
Summary
The incidence of NTM infections surpasses that of TB infections in developed countries. Although infection may occur in virtually any organ, pulmonary infections are most common. M. avium, M. kansasii, and M. abscessus are the most frequently identified
organisms causing lung disease. The isolation of an NTM organism does not necessarily equate with active infection; clinical, radiologic, and microbiologic parameters are all needed to establish the diagnosis of infection. Eradication of disease with
drug therapy requires prolonged combination therapy. Surgical resection is often indicated in localized disease, in the presence of drug resistant organisms, or in some cases, of failure of medical therapy.

There remain significant gaps in our knowledge of the acquisition and management of NTM pulmonary infections. Susceptibility to disease is incompletely understood and, thus, it is unclear what preventative measures may be effective. Additionally, given
the difficulty of eradicating NTM and its substantial re-occurrence, identifying appropriate candidates for treatment and the timing of initiation of therapy are clinically difficult decisions. A better understanding of the natural history of untreated
MAC infection in association with nodular bronchiectasis, the identification of markers for disease progression, and improved understanding of the risk factors for re-infection would be of substantial help to clinicians and patients. Additionally, there
exists a substantial need for improved pharmacotherapy for M. abscessus.

Go to:
Acknowledgements
Disclosure: The authors declare no conflict of interest.

Go to:
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Nontuberculous mycobacterial disease prevalence and risk factors: a changing epidemiology.
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The epidemiology of nontuberculous mycobacterial diseases in the United States. Results from a national survey.
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Isolation of non-tuberculous mycobacteria from pastoral ecosystems of Uganda: public health significance.
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Investigation of opportunistic pathogens in municipal drinking water under different supply and treatment regimes.
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Review An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases.
[Am J Respir Crit Care Med. 2007]
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