In their investigation of 19 patients, 15 had a total endoscopic approach, three had thoracotomy, and one had a video-assisted BVD-523 in vitro approach, which demonstrates that in some cases because of intraoperative complications thoracotomy might be necessary; however, most patients can profit from the smaller extent of the thoracoscopy. The benefit of lung resection for patients with pulmonary aspergillosis and underlying haematological malignancy was investigated by Matt et al.  in 41
cases. They found that a perioperative mortality of 10% which might seem promising. Authors concluded that surgery might be an option; however, the most important factor in long-term survival remains the management of the underlying haematologic disease. In 43 paediatric patients with IPA, Gow et al.  found that surgical resection of the involved lung parenchyma was significantly prognostic for survival (P < 0.001). As surgery is not a relevant option in those patients with underlying haematological malignancies under the highest risk for developing fatal IPA (while undergoing allogeneic haematopoietic stem cell transplantations or induction therapies for acute
leukaemia) selection bias in those studies might be an issue. Resection of a singular pulmonary lesion in case of planned high-dose chemotherapy or transplantation may be an option to prevent reactivation after high-dose chemotherapy or stem cell/solid Exoribonuclease organ transplantation as reactivation selleck may occur in up to 30% in absence of surgery.[83-85] Studies evaluating this issue, however, are mostly 10 or more years old. Surgery also is a key factor in the management of Aspergillus pleural empyema. Pleural empyema mostly develops continuously from IPA by direct expansion or from a broncho-pleural fistula. Bonatti et al.  reported of four patients with pleural empyema after lung resection for various reasons. All four patients received surgical treatment, which consisted of partial pneumectomy, implantation of thoracostoma, secondary closure of the leaking
bronchial stump and subsequent closure of the thoracic gap, with pectoral or omental flaps in addition to systemic antifungal therapy. In this report, Aspergillus infection had to be cleared in the pleural cavity in order to be able to perform successful closure of the thoracic gap. In case of bronchopleural-cutaneous fistula, successful treatment of pleural empyema with antifungal treatment administered through a tube that is placed through the fistula, has been reported without further surgical intervention. A large study, including 67 cases of fungal pleural empyema by Ko et al. , reported that all patients receiving surgery or pleural irrigation with antifungal agents survived. Surgery included also pleural decortication, which was performed in six patients (9%).