Video-assisted thoracoscopic sublobar versus lobar resection for chronic pulmonary aspergillosis: a 15-year single-center cohort study.

BACKGROUND

Chronic pulmonary aspergillosis (CPA) is a progressive fungal lung disease that often requires surgical intervention. Video-assisted thoracoscopic surgery (VATS) has emerged as a minimally invasive approach, and sublobar resection may offer potential benefits in selected patients by preserving lung parenchyma. This study aimed to describe the perioperative and long-term outcomes of VATS for CPA, with exploratory comparisons between sublobar and lobar resections.

METHODS

We retrospectively reviewed 151 patients with CPA who underwent VATS lung resection, categorized into simple aspergilloma (SA), chronic cavitary pulmonary aspergillosis (CCPA), and chronic necrotizing pulmonary aspergillosis (CNPA). Perioperative and long-term outcomes were analyzed across CPA subtypes and resection extents, and compared with a propensity score-matched lung cancer cohort. To account for treatment-selection imbalance in the sublobar-versus-lobectomy comparison, propensity score analyses were additionally performed within the CPA cohort.

RESULTS

Of 151 patients, 90 had SA, 57 had CCPA, and 4 had CNPA. VATS was completed without conversion to open thoracotomy in all cases. Compared with the matched lung cancer cohort, CPA surgeries had longer operative times, more severe pleural adhesions, and higher postoperative complication rates. Among CPA patients, sublobar resection (n = 49) was associated with lower chest drainage volumes compared with lobectomy (n = 102), with similar overall complication rates (10.2% vs. 11.7%). Among patients with available paired spirometry, pulmonary function decline was smaller after sublobar resection, and this difference persisted in exploratory propensity-adjusted analyses. Long-term follow-up was available for 136 of 151 (90.1%) patients at a median of 27 months; recurrence was documented in 15 (11.0%) patients, with numerically similar rates between resection groups. Lesion diameter > 3 cm and severe pleural adhesions were independent risk factors for postoperative complications; SA subtype was independently protective.

CONCLUSIONS

In selected patients with CPA, VATS appears feasible and safe. Sublobar resection could be a plausible lung-sparing strategy for patients with localized disease; however, comparisons with lobectomy remain exploratory because of the retrospective design, potential selection bias and limited recurrence events. Prospective multicenter studies with standardized selection criteria and longer follow-up are needed to define the role of limited resection in CPA management.