CPA caused many lesions of the lung and has been very associated with the life-threatening condition when its complication occur, such as hemoptysis [18, 19]. Immediately treatment for these cases was critical, and surgery was priority treatment of choice if the pulmonary function was not severely insufficiency [20]. Many studies had been carried out to confirm that surgical treatment (almost surgical resection) of pulmonary aspergilloma brought out many advantages such as preventing recurrent hemoptysis, and excellent long-term results [2, 3, 8, 21]. Although modern technology such as Robotic resection of lung used to get further advantages [22] but less invasive surgery such as sub-lobar resection and video-assisted thoracoscopic surgery (VATS) was more preferred with good results just in patients, who had simple pulmonary aspergilloma [23-26].
Anti-fungal medication (voriconazole, itraconazole) also was a safe and effective modality and should be considered if surgery contraindicated [27-29]. In the case of both medical and surgical treatment were ineffective or contraindicated in massive hemoptysis due to aspergilloma, intervention treatment was an alternative therapy with the success rate was 40.0% [30]. Bronchial artery embolism could be considered when systemic embolism was ineffective or to reduce perioperative bleeding [20, 31, 32]. Another therapy such as bronchoscopic procedure and radiotherapy also was a potential option for selected cases [33, 34]. The remarkable result in our study was that the hemoptysis symptoms plunged statistically significant with no cases in the TE group and 2 cases in TTB group. The recurrence rate in 24 months was low, with just only one cases in the TE group had hemoptysis, but its severity was lesser than before the operation.
In low-resource countries, surgery for CPA was very challenging, but it would be the best treatment modality for symptomatic diseases in such conditions [35]. However, in high-risk patients with CPA, alternative therapies should be advised because lung resection was considered too invasive. When resection was not feasible, patients may underwent palliative procedures such as cavernostomy [13, 32], intracavitary Amphotericin-B [36] or bronchial artery occlusion [30]. Cavernostomy was a useful option for high-risk patients [20, 37]. In our study, although four patients died, there was no death related to surgery. The reasons for all deaths were a complication of co-morbidity diseases. That results confirmed the efficacy of cavernostomy and thoracoplasty surgery for CPA with hemoptysis. Another study showed that the mortality rate was variants from one in 17 patients to 4 in nine patients. The reasons behind this may be that the number of patients was small, and the experience of the surgeon may be a lack in this type of surgery [12, 38].
Karnofsky score (Karnofsky performance status, Karnofsky Performance Scale) in this study showed statistically significant changes from time point to time point.It also has been used as an index to to monitor using in peri-operative and post-operative of lung transplantation.[39][40] In our study, the almost pulmonary function of patients was diminished. After surgery, there was no change in pulmonary function, but the Karnofsky score had significant changes that showed overall efficacy of surgery in patients with CPA. The reason behind this may be that hemoptysis was serious sequela in CPA patients that plunged remarkably [20, 41].
One of the surgical disadvantages was that the cavity after carvernostomy occurred. The collapse had to be maintained by filler, and in our study, we used the table tennis ball and tissue expander to fill the space. Over the years many tissues and materials were tried as a filler, cavernostomy had been performed and showed useful such as single-stage cavernostomy and a muscle transposition flap [15, 42], cavernostomy with limited thoracoplasty [15] and simplified cavernostomy with Alexis Wound Protector [43]. The remained space may leaded to recurrence. In our study, we performed single-stage cavernostomy, and thoracoplasty with no recurrence patient was recorded. This result was in line with Chen et al. [9]. According to our viewpoints, the critical elements of this technique to ensure the recurrence rate was low depended on the bronchial fistula and the cavity condition. The bronchial fistula must be closed that was checked by anesthesia through to expand the lung and no gas leakage if it closed. The cavity was filled with the material used (both table tennis ball and tissue expander).
The table tennis ball was the material that emerged as low-cost, easy to find anywhere, but because of the fixed size, it was difficult to manipulate when filled the space. Its complications included shortness of breath, bronchopleural fistula extrusion, superior vena cava obstruction, haemorrhage, pain [16]. There was a report showed that it still working after 46 years with uncomplicated outcome [44]. Tissue expander used in this surgery as the material used was applicable methods. It has been recognized as a standard procedure in the United States for breast reconstruction [45]. Although it has a higher risk of reconstructive failure and surgical-site infection, this was the right choice for high-risk patients or unavailable for autologous reconstruction.[46, 47] This was the reason why we choosed tissue expander because of its benefits. We can modified volume to keep fit with CPA which has been removed. Several complications of tissue expander in breast reconstruction such as infection, hematoma/seroma, and explantation were reported [48], and there were differences among stages with stage I rather than the later stage.[49] In this study, complications were low. Only one stage was performed, and no patient had the next stage.