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Ann Thorac Surg 1997;64:973-974
© 1997 The Society of Thoracic Surgeons
Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Jacksonville, 4500 San Pablo Rd, Jacksonville, FL 32224.
Livid, bloody, foul-smelling or billious sputum supervening in cases of continued fever is of bad significance. However if such expectoration removes the diseased tissues all may be well Hippocrates [1]
The association of lung abscess with a poor prognosis has been known since the age of Hippocrates. A lung abscess usually follows aspiration or a pneumonia occurring in a compromised patient. Sequelae depend on the volume and composition of the inoculum and the resistance of the host, which may be modified by malnutrition, anemia, the presence of underlying disease or damaged lung, and the adequacy of antibiotic therapy. Microabscesses or larger abscesses, single, multiple, or multiloculated may then develop depending on the extent of necrotizing gangrenous infection. The visceral pleura and a thin layer of subjacent lung usually survive owing to independent blood supply from the subpleural vascular plexus. A pleuritis usually results in the visceral pleura adhering to the parietal pleura, but occasionally progression is so rapid that an associated empyema develops as in the patients described by Refaely and Weissberg. Death of tissue or gangrene occurs to a variable extent in every lung abscess; when it is confined to a whole lobe or lung the term "pulmonary gangrene" may be applied. Use of this term does not imply that treatment is different, only that it is more extensive. When large areas of pulmonary gangrene are present, antibiotic therapy is ineffective because of poor diffusion of the drug into an avascular region; thus alternative therapy is necessary.
In the early decades of this century when thoracic surgery was finding its feet, Neuhoff and Tourhoff [2] as well as Shaw [3] advocated drainage rather than resection of lung abscess with excellent results. With the advent of antibiotics, immunization, and chest physical therapy, lung abscess today is an infrequent problem in the First World. Open drainage as a form of management has been largely forgotten but periodically surfaces in the literature as advocated by Refaely and Weissberg. One of the largest series on lung abscess and drainage was published in the South African Journal of Surgery [4] by Postma and Le Roux of Durban, South Africa, from an institution where I trained. Two periods were compared: a series where resection was emphasized (268 patients) and a later period (417 patients) where drainage followed by later resection in selected patients was the usual first form of management. Roughly the same percentages (27.5% and 29%) had an operation. The mortality in the first series (resection) was 15.4% and the rate of complications was 34.6%; in the second series (drainage) the corresponding results were 0.9% and 15.7%, strongly suggesting that drainage should be the first procedure in a toxically ill patient and that pulmonary resection should only be undertaken in the quiescent phase of the disease. The excellent results of Refaely and Weissberg confirm this and emphasize the importance of drainage in a sick septic patient before any major thoracic procedure.
Although excellent results have been achieved in this small series of 3 patients, one must be careful not to extrapolate all of their conclusions into general practice. The statement that resection of all gangrenous tissue is mandatory and is life-saving implies that the second stage after drainage is necessary in all patients with this condition. This is not so: in some of our patients, especially those with Klebsiella pneumonia, drainage of the gangrenous lobe resulted in a large cavity with bronchi appearing like a stunted tree. Occasionally very rapid improvement in symptoms with a chest radiograph demonstrating either an empty space and in others the destroyed lobe obliterated by expansion of the remaining lobes allowed discharge. We used to call this autoamputation of the lobe. We did not proceed with pulmonary resection, indicating that effective drainage can sometimes result in cure. Obviously, if the whole lung is involved this is unlikely to occur. What is life-saving is the initial drainage procedure. Effective drainage of the empyema in the series of Refaely and Weissberg resulted in rapid improvement of their patients, but the source of infection—gangrenous lung—was left unmanaged in a desperately ill patient, begging the question, which can only be unanswered, whether the gangrenous lung should have been additionally surgically managed. Fenestration, or the creation of a large defect by multiple rib resection and folding skin inward, is usually reserved for patients with a chronic empyema, those unfit for any major procedure, or patients with a postpneumonectomy empyema, yet in Refaely and Weissberg's patients pulmonary resection and closure of the defect occurred within 8 days. Although Refaely and Weissberg had no indication of response to drainage and the timing of the second procedure it does appear an excessive procedure and that similar drainage, with the same objective of complete evacuation of pus and fibrinous debris, may have been achieved with simple rib resection. It is stated that dissection of hilar structures in the presence of severe infection can lead to mediastinitis and should be avoided. There is no evidence to support such a statement. Although most patients with pulmonary gangrene have, because of the rapidity of the disease process, a free pleural space, occasionally the pleura is adherent; in these situations drainage of the abscess followed by later resection depending on response and symptoms is recommended.
References
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