Lung abscess surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Surgery is considered as the last resort of therapy when both medical and chest drain failed to resolve symptoms

Indications

• Abscess > 6 cm in diameter
• If symptoms last more than 12 weeks with appropriate therapy

Surgical Options

• Options for surgery includes: Chest tube drainage and surgical resection of the lung abscess with the surrounding lung tissue

Chest tube drainage

• Percutaneous and endoscopic drainage techniques are considered as a first-line management, especially for patients who are not candidates for surgery
• ACR-SIR-SPR practice guideline for specifications and performance of image-guided percutaneous drainage/aspiration of abscesses and fluid collections (PDAFC) had submiited guidelines on image-guided percutaneous drainage/aspiration of abscesses and fluid collections.

Percutaneous drainage

Type of chest drain	Indications	Procedure	Complications	Advantages
Percutaneous thoracocentesis	It is the treatment of choice for patients who have failed to respond to antibiotic therapy . Patients who are unsuitable for surgical intervention (e.g. due to severe immunodeficiency or mechanical ventilation). Lung abscesses with diameters greater than 4-8 cm	Performed under fluoroscopic, ultrasound or computed tomography guidance.(CT is generally preferred due to additional information provided about location, content and wall-thickness of the abscess.) Two techniques of insertion of chest tube employed: Seldinger, and Trochar Seldinger technique of insertion the tube is considered as it is safer and it permits greater control in the positioning of the drainage tube and is accompanied by fewer complications Chest tube drainage with trocar is highly effective surgical procedure and is recommended for thoracic surgeries Drainage duration varies but a minimum of 4-5 weeks are required and is done according to radiographic findings.Chest tubes should not be flushed in order to avoid bronchogenic spread of the pus. The usage of intra-cavitary fibrinolytic agents (streptokinase, urokinaze) is not recommended, due to possibility of bronchopulmonary or bronchopleural fistula can occur.	Technique related includes :advancing of the guidewire through the thicked-wall abscess may cause bending or rupture of the guidewire or the catheter. Hemothorax, hemoptysis, pyopneumothorax and fistula formation between the pleural cavity and the abscess resulting in empyema. Less significant complications are those related to bending or leaking of the drainage catheter.	These techniques demonstrated benefits even in patients without contraindications to surgery. More specifically, cases of primary lung abscess that were treated by Yellin A et al during a 5-year period (1978-1982) underwent successful percutaneous drainage, without any complications or relapse after 2-5 years of monitoring. Percutaneous drainage of lung abscesses is characterized by high therapeutic effectiveness and preservation of functional lung tissue, it is a minimally invasive method with fewer complications and lower mortality rates (approximately 4%) in comparison to surgical management. In case of pleural space obliteration, with peripheral localization of lung abscess, it is possible to perform pneumostomy or cavernostomy-open drainage of abscess(Monaldi procedure) but it is limited due to its invasiveness.
Endoscopic thoracic drainage	Patients with poor general condition, Coagulopathies For the abscesses with central locations in lungs.	A guidewire is inserted into the cavity through the working channel of a flexible bronchoscope.Once guidewire location has been ascertained by fluoroscopy, a 7 French pigtail catheter is advanced. If infusion of contrast medium via the catheter confirms its proper positioning, the guidewire and bronchoscope are withdrawn and the catheter tip is stabilized at the nasal wall. Subsequently, the cavity is flushed daily with normal saline solution through the catheter, along with antibiotic infusions (e.g. gentamicin or amphotericin in confirmed fungal infections). The catheter remains open for the rest of the day, thus ensuring the drainage of the abscess. In a small number of patients with recurrent lung abscesses, endoscopic drainage was performed with the help of laser. The catheter is inserted through a bronchoscope and laser is used in order to perforate the wall of the abscess through the airway and to lead the catheter inside the cavity. The catheter is removed after 4-6 days with immediate improvement of clinical status and radiological imaging within the first 24 hours	Spillage of necrotic detritus in other parts of the lungs

Surgical Intervention

• Surgical resection is considered in about 10% of the patients when the chest drain has failed to improve symptoms and patients presenting with one of the following conditions.
• Hemoptysis,
• Prolonged sepsis and febricity,
• Bronchopleural fistula,
• Rupture of abscess in the pleural cavity with pyopneumothorax/empyema.
• Unsuccessfully treated lung abscess more than 6 weeks,
• Suspicion of cancer,
• Cavitary lesion larger than 6 cm,
• Leukocytosis despite the use of antibiotics.

Surgical resection

• The surgical approach is thoracotomy and the extent of surgical resection depends on the size of the underlying lesion.
• Lobectomy is the most common type of surgical resection. Segmentectomies are performed in smaller abscesses (<2 cm), whereas a pneumonectomy should be performed in the presence of multiple abscesses or gangrene. ,
• Open surgical drainage is employed either by creating a pouch-like cavity communicating with the thoracic wall through limited rib resection in case of thoracotomy contraindication.
• When sepsis cannot be controlled with conservative measures and in conditions that prohibit resection, debridement of the dead tissue is followed by immediate filling of the cavity with highly vascular tissue, or debridement and cavity fistulization into the pleural space followed by drainage by means of a chest tube is proposed.
• When the chronic inflammatory process of pulmonary infection causes incomplete re-expansion of the remaining lobes, it is quite possible that a portion of the pleural space will remain empty. Some thoracic surgeons recommend filling that space with a large pedicled ipsilateral latissimus dorsi muscle flap or omentum.
• In addition, bronchial stump reinforcement with a pedicled intercostal muscle flap or other highly vascular tissue may prevent the formation of a bronchopleural fistula.
• Cross-contamination of contralateral lung is the main complication to be feared of during surgery. Placement of a double-lumen endotracheal tube, prone positioning of the patient and artificial obstruction of the main bronchus before removing the abscess are the usual measures for preventing cross-contamination.
• Recently, a thoracoscopic technique (Video-assisted thoracoscopic surgery: VATS) for abscess debridement and drainage has been effectively implemented in a small number of patients

Reference

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