Surgical Management of Acute Necrotizing Lung Infections

Abstract

BACKGROUND: Surgical resection for acute necrotizing lung infections is not widely accepted due to unclear indications and high risk.OBJECTIVE: To review results of resection in the setting of acute necrotizing lung infections.METHODS: A retrospective review of patients who underwent parenchymal resection between January 1, 2000, and January 1, 2006, for management of necrotizing pneumonia or lung gangrene.RESULTS: Thirty-five patients underwent resection for lung necrosis. At the time of consultation, all patients presented with pulmonary sepsis, and also had the following: empyema (n=17), hemoptysis (n=5), air leak (n=7), septic shock requiring pressors (n=8) and inability to oxygenate adequately (n=7). Twenty-four patients were ventilated pre-operatively. Eleven patients had frank lobar gangrene, and the other patients had combinations of necrotizing pneumonia and abscesses. In 10 patients, preresection procedures were performed, including percutaneous drainage of an abscess (n=4), thoracoscopic decortication (n=4) and open decortication (n=2). Procedures included pneumonectomy (n=4), lobectomy (n=18), segmentectomy (n=2), wedge resection (n=4) and debridement (n=7). There were three (8.5%) postoperative deaths – two due to multiple organ failure and one due to anoxic brain injury. All patients not ventilated preoperatively were weaned from ventilatory support within three days. Of those ventilated preoperatively, three died, while four remained chronically ventilator dependent.CONCLUSIONS: Surgical resection for necrotizing lung infections is a reasonable option in patients with persistent sepsis who are failing medical therapy. Ventilated patients have a worse prognosis but can still be candidates for resection. Patients who are hemodynamically unstable appear to have better outcomes if they can be stabilized before resection.

Surgical Treatment of 26 Patients with Necrotizing Pneumonia

“…The 15.4% rate of mortality in our study was comparable to the rates of 8–20% reported previously, and the overall outcome mainly depends on the extent of the underlying risk factors [7,10]. In this study, the 3 patients who died postoperatively and the 3 patients who developed postoperative empyema and ventilator dependency had underlying risk factors, such as corticosteroid therapy, liver cirrhosis, renal failure and COPD.…”

“…When necrotizing pneumonia is extensive or complicated, and medical management is insufficient, surgical treatment has been shown to be the most successful approach [8]. Among the indications for surgery that have been proposed are bronchopleural fistula, empyema, hemoptysis, lung abscess and lung gangrene [3,9,10]. One previous report has reported on the outcome of surgical treatment in a large study group comprising 35 patients with necrotizing pneumonia; 3 of the 35 patients succumbed (8.5%) [10].…”

“…Among the indications for surgery that have been proposed are bronchopleural fistula, empyema, hemoptysis, lung abscess and lung gangrene [3,9,10]. One previous report has reported on the outcome of surgical treatment in a large study group comprising 35 patients with necrotizing pneumonia; 3 of the 35 patients succumbed (8.5%) [10]. The results of our study group of 26 patients with various complications and underlying risk factors treated with lung resection for necrotizing pneumonia extend the number of patients treated surgically for this condition reported in the literature.…”

Tratamento cirúrgico de crianças com pneumonia necrosante

“…(3,7) Chest pain, signs of respiratory distress, persistent fever, a worsening of the clinical status, and new complications secondary to pneumonia despite the use of optimal antibiotic therapy are all suggestive of pulmonary necrosis. (6,8,9) In patients meeting any of those criteria, axial chest CT is indicated, even if chest X-rays reveal no abnormalities, since chest X-rays have low sensitivity and early findings characteristic of necrotic complications are rare.…”

Masif Hemoptizi Etyolojisinde Nekrotizan Pnömoni: Olgu sunumu

“…Surgical intervention may be considered as an alternative treatment when the disease deteriorates or complications occur in spite of optimal medical treatment. The choice of initial antibiotics should be directed at broad coverage with commonly implicated pathogens (S. aureus, streptococci, K. pneumoniae, etc) [8]. Additional empirical anaerobic antibiotic should be considered in patients with lung abscesses.…”