Lung abscesses, necrotizing pneumonia, and lung gangrene, all belong to necrotizing pulmonary infection span with different severity of parenchymal destruction, degree of inflammation, necrosis, and radiographic patterns, although all three can coexist (1). Lung abscess, as an infectious pulmonary disease condition, first described by Hippocrates (2), was characterized by the presence of a cavity filled with pus or necrotic debris within the parenchyma (3,4). The characteristic radiographic finding of necrotizing pneumonia was consolidation of pulmonary parenchyma with peripheral necrosis and multiple small cavities and which could be rapidly progressed. Central vascular or bronchial obstruction with larger abscess collections was the most typical radiographic finding of lung gangrene (5).
Early symptoms and signs of lung abscess could not be clearly distinguished from other pulmonary infection (e.g., pneumonia, necrotizing pneumonia, and lung gangrene) and include cough, dyspnea, fever with chills, chest pain, night sweats, weight loss and fatigue (3). Initially, non-productive was mentioned, but when communication with bronchus appeared, the typical sign was the productive cough (6,7). Sometimes productive cough with hemoptysis was also complained. Clubbing fingers could be found in some patients with chronic lung abscess (3).
Differential diagnosis of cavitary lesion includes excavating tuberculosis and mycosis but seldom can been seen radiological sign of air-fluid level. Localized pleural empyema or pulmonary cystic lesions, such as intrapulmonary sequestration, located bronchial cysts, and emphysematous bullae with secondary infection, would be difficult to be differentiated from lung abscess; however, the localization of lesion, clinical signs and image study (e.g., roentgenogram, computed tomography (CT) scan, ultrasound) could help to make the appropriate diagnosis (3,8).
Lung abscess was caused by polymicrobial flora in most cases (9). The etiologic pathogen found in lung abscesses predominant isolated being anaerobic and gram-negative organism. The most commonly isolated organisms are anaerobic bacteria (Prevotella, Bacteroides, Fusobacterium, and Peptostreptococcus) or streptococci; on alcoholics with poor oral hygiene, the spectrum of pathogens includes Staphylococcus aureus, Streptococcus pyogenes, and Actinomyces (10,11). During the last decade, Klebsiella pneumoniae has been the most isolated bacteria in lung abscess, especially in Taiwan (3,10).
Divisions of lung abscess
According to the duration, lung abscess could be divided into chronic (more than 6 weeks) and acute (less than 6 weeks) (3,12). Depending on whether the underlying lung disease existed, lung abscess could be classified as primary or secondary. Primary lung abscess, occurred without other underlying pulmonary disease and which were a direct result of aspiration or pneumonia (13). Secondary lung abscess was associated with coexisting lung diseases [bronchiectasis, bullous emphysema, cystic fibrosis, infected pulmonary infarcts, lung contusion or with bronchial obstructions (by foreign body, tumor, or enlarged lymph nodes)] (3). In addition to the direct spreading of broncho-esophageal fistula, subphrenic abscess or pneumonia, the source of pathogenic organism, causing lung abscess, could be from extrapulmonary sites-hematogenous origin due to severe sepsis of liver abscess, septic thromboembolisms or infective endocarditis, etc. (3,14).
Localization of the abscess (affected lung)
The superior segments of the lower lobes or the posterior segments of the upper lobes were predominantly affected area in aspiration pneumonia related lung abscess. The right side was more often affected than the left one. The right lower lobe was the single most frequent location of abscess formation (15). Bilateral or multiple segments involved abscesses were rarely caused by aspiration, and pathogenic organism originated from an extrapulmonary focus by hematogenous spreading due to severe sepsis of intra-abdominal infection, septic thromboembolisms or infective endocarditis should be suspected (16).
Surgical therapy before antibiotic introduction
In the pre-antibiotic era, acute lung abscess was nearly always fatal; 169 of 227 patients admitted into Massachusetts General Hospital for acute lung abscess died in spite of conservative treatment efforts (2). Putrid lung abscess was a life-threatening condition until Doctor Neuhof proposed a novel concept of one-stage open drainage operation for lung abscess in the early decades of the 20th century, which effectively decreased the mortality rate of lung abscess from 75% to 2.5% (12).
Surgical therapy combined with antibiotic treatment
Initial therapy of lung abscess mainly involves proper systemic antibiotics, physiotherapy, and, where indicated, percutaneous tube thoracostomy drainage (17,18). In about 84% of patients received percutaneous tube thoracostomy drainage, as a definitive therapy for lung abscess, had procedure related complication rate about 16% (19). The major complications of tube thoracostomy are spreading of necrotic debris, which would cause subsequent formation of pleural empyema, bronchopleural fistula or procedure related bleeding (20).
However, not all patients respond to non-operative management (21). If antibiotics fail to achieve the therapeutic concentration in the infected tissue, parenchymal destruction may worsen, and infection may progress, possibly resulting in life-threatening hemoptysis, bronchopleural fistula, and profound shock. If liquified necrosis of infected parenchyma broke through visceral pleura, subsequent formation of pleural empyema may occur (22).
Nowadays, surgical management for lung abscess became a more difficult challenge, since currently neither timing nor indication of related surgical procedure is well established (15). Surgical managements and outcomes are complicated by numerous factors, including underlying comorbidity, severity of lung injury, procedure of intervention required, and whether a residual space is present or anticipated (15).
Undoubtedly, aggressive resection of the necrotic pulmonary parenchyma or decortication of pleura has been considered lifesaving in cases of refractory to intensive medical management, but complicated by life-threatening hemoptysis, pyopneumothorax, or pleural empyema (23-25).
Surgical resection of lung abscess is the therapy of choice for about 10% of patients (3). Resuscitating and stabilizing patients suffered from acute lung abscess with empyema by thoracic decortication before lung resection were advised (26). Dissection of the hilar structure in the presence of pleural empyema can lead to mediastinitis or bronchopleural fistula and should be avoided (27). Indications and associated complications of surgical management for lung abscess were summarized in Table 1. Indications of surgical management are as following: refractory to intensive medical therapy, cavitary lesion >6 cm in diameter, life-threatening hemoptysis, bronchopleural fistula, and rupture of abscess in the pleural cavity with pleural empyema (15).
To our best knowledge, the definition of massive hemoptysis was varied from 200 to 1,000 mL/day (28). As an alternative, hemoptysis should be classified due to its severity and life-threatening circumstance instead of its quantity (28). Hemoptysis could be bleeding from pulmonary or bronchial artery system. Bleedings of bronchial artery system usually occur as a consequence of neovascularization and accompany inflammatory pulmonary diseases. Massive and typically fatal hemorrhage of pulmonary artery may be the result of mechanical damage formed by lung cancer, aspergilloma, or necrotizing pneumonia (29,30). Lung abscess with life-threatening hemoptysis was rare but was an emergent condition for pulmonary resection. Eradicating the affected lesions and achieving hemostasis simultaneously by pulmonary resection was the treatment of choice of life-threatening hemoptysis (28).
The goal of surgical management of localized infectious disease is to eradicate necrotic debris of lung abscess which could be a reservoir or nidus for recurrent infection (31). Lobectomy was proposed for central localized or large cavity of lung abscess (27). Atypical pulmonary resection or segmentectomy were enough, if it is possible to eradicated the affected lesions of abscess completely and, if necessary, the surrounding lung tissue with adequate resection margin (32).
Although Schweigert et al. suggest that no significant association between the extent of the surgical resection (segmentectomy, lobectomy, pneumonectomy) and the outcome (15). Complications of limited resection for localized pulmonary necrosis had been mentioned by several studies. The most common complications for patients who underwent wedge resections were recurrent pulmonary infection due to insufficient resection range, and residual infectious tissue may contribute to pulmonary complications, regardless of open thoracotomy or video-assisted thoracic surgery (VATS) approach (33). For patients receiving pulmonary resection, elderly patients were not associated with higher mortality rate (15,34,35). Significant prognostic factors for fatal outcome are pulmonary sepsis, septic complications (air leak, pleural empyema), septic organ failure (respiratory, acute renal failure), and preexisting comorbidity (Charlson index of comorbidity ≥3) (15).
Lung abscess remains a life-threatening condition with substantial morbidity and mortality. Lung abscess had become a domain of medical treatment with appropriate systemic antibiotics, physiotherapy, and, if where indicated, percutaneous tube thoracostomy drainage. Surgical interventions, including open drainage, decortication, or pulmonary resection, still play an important role for complicated lung abscess (e.g., refractory to broad spectrum antibiotic treatment, prolonged antibiotic treatment course, life-threatening hemoptysis, and ruptured abscess with empyema). Early detection of medical therapy failure and adequate control of the septic focus by pulmonary resection of all necrotic tissue are the primary goals of surgical therapy.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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Cite this article as: Zhang JH, Yang SM, How CH, Ciou YF. Surgical management of lung abscess: from open drainage to pulmonary resection. J Vis Surg 2018;4:224.