Asian Cardiovasc Thorac Ann 2008;16:112-114
© 2008 Asia Publishing EXchange Ltd
Abscess of Residual Lobe After Pulmonary Resection for Lung Cancer
Tommaso Ligabue, MD,
Luca Voltolini, MD,
Claudia Ghiribelli, MD,
Luca Luzzi, MD,
Cristian Rapicetta, MD,
Giuseppe Gotti, MD
Thoracic Surgery Unit, University Hospital of Siena, Siena, Italy
For reprint information contact: Tommaso Ligabue, MD, Tel: 39 57 758 6140, Fax: 39 57 758 6140, Email: tligabue{at}hotmail.com, Thoracic Surgery Unit, University Hospital of Siena, Viale Bracci 14, 53100 Siena, Italy.
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ABSTRACT
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Abscess of the residual lobe after lobectomy is a rare but potentially lethal complication. Between January 1975 and December 2006, 1,460 patients underwent elective pulmonary lobectomy for non-small-cell lung cancer at our institution. Abscess of the residual lung parenchyma occurred in 5 (0.3%) cases (4 bilobectomies and 1 lobectomy). Postoperative chest radiography showed incomplete expansion and consolidation of residual lung parenchyma. Flexible bronchoscopy revealed persistent bronchial occlusion from purulent secretions and/or bronchial collapse. Computed tomography in 3 patients demonstrated lung abscess foci. Surgical treatment included completion right pneumonectomy in 3 patients and a middle lobectomy in one. Complications after repeat thoracotomy comprised contralateral pneumonia and sepsis in 1 patient. Residual lobar abscess after lobectomy should be suspected in patients presenting with fever, leukocytosis, bronchial obstruction and lung consolidation despite antibiotic therapy, physiotherapy and bronchoscopy. Computed tomography is mandatory for early diagnosis. Surgical resection of the affected lobe is recommended.
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INTRODUCTION
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Abscess of the residual lobe after lobectomy or bilobectomy represents a rare but potentially lethal complication. This condition must be differentiated from hemorrhagic infarction, usually due to lobar torsion with venous occlusion.1 Previous studies have concentrated on risk factors and treatment of postoperative pulmonary complications, but little information exists on this particular condition. Therefore, we reviewed our experience.
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PATIENTS AND METHODS
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From January 1975 to December 2006, 1,460 patients underwent elective pulmonary lobectomy or bilobectomy for non-small-cell lung cancer at our unit. Abscess of the residual lung parenchyma occurred in 5 (0.3%) patients. In the same period, only 1 case of lobar torsion was noted. Demographic data are listed in Table 1
. In 4 patients, the clinical presentation of lung cancer was postobstructive pneumonia; 1 received specific antibiotic therapy for Pseudomonas aeruginosa, and 3 were treated with prolonged wide-spectrum antibiotic therapy. None had preoperative chemotherapy or radiotherapy. Surgical resections comprised upper bilobectomy in 2, lower right lobectomy in 1 and lower bilobectomy in 2. Left or right-sided double-lumen endotracheal tubes were used during all surgical procedures, and the patients were extubated at the end of the operation. They were given antibiotic prophylaxis with cefamandole 1 g intravenously 1 hour before anesthetic induction, and every 6 hours after surgery. None received regional analgesia. All patients required at least 1 blood transfusion within the 1st 24 hours postoperatively.
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RESULTS
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During the first 72 hours postoperatively, all patients developed white blood cell counts > 11 x 109/L, and 4 experienced pyrexia > 38.5°C. None presented with pleural empyema. Chest radiography immediately after the operation revealed incomplete expansion of the residual lung parenchyma in all patients. Subsequent chest radiography showed lung consolidation in 4 patients, and infective infiltrates with sub-atelectasis in one. All patients had an active postoperative program of physiotherapy, including deep breathing and incentive spirometry. Despite physiotherapy, all patients presented sputum retention and required bronchoscopic toilet on the 1st postoperative day. Flexible bronchoscopy showed persistent bronchial occlusion from purulent secretions in 2 patients, and bronchial collapse in 3. Pathogens recovered from fiberoptic bronchoscopy samples were Pseudomonas aeruginosa in 2 patients, Staphylococcus aureus in 2, and Staphylococcus aureus and Haemophilus influenzae in 1. Despite specific antibiotic therapy, standard respiratory physiotherapy and repeated bronchial toilet by flexible bronchoscopy, purulent phlogosis with sepsis of the residual lobe became evident in all cases. In the last 3 patients, computed tomography (CT) demonstrated foci of lung abscesses in the residual lobe. Diagnosis of residual lobar abscess was made at a mean of 8 days after surgery (range, 6–10 days). Four patients underwent a repeat thoracotomy on postoperative days 8–12 (mean, 10 days after the first pulmonary resection). Surgical treatment included completion right pneumonectomy in 3 patients and middle lobectomy in one. Pathological confirmation of lung abscess was obtained in all cases. One patient could not tolerate repeat thoracotomy because of poor cardiorespiratory function (% predicted preoperative forced expiratory volume in 1 sec < 0.6, and previous myocardial infarction); he required mechanical ventilation and died of sepsis on the 11th postoperative day. Complications after repeat thoracotomy occurred in one patient who developed contralateral pneumonia and died of respiratory insufficiency on the 17th postoperative day.
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DISCUSSION
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Residual lobar abscess after elective pulmonary resection for non-small-cell lung cancer is a rare but life-threatening complication. Little information exists on this postoperative event. Klippe and colleagues2 reported suppurative infection of the remaining lung in 1.5% of cases, with abscess formation in 0.25%. However, the true incidence of this complication is difficult to determine. Most reports refer to postoperative pulmonary complications and postoperative pneumonia, without identifying any subgroup at risk of suppurative necrosis.3,4 This condition can occur as result of 2 postoperative events: bronchial obstruction with atelectasis refractory to physiotherapy and bronchoscopy; and bacterial infection with suppurative necrosis despite antibiotic prophylaxis.
Bonde and colleagues5 identified current smoking, the presence of cardiorespiratory comorbidity and absence of regional analgesia as risk factors that might lead to sputum retention and postoperative atelectasis. Both chronic obstructive pulmonary disease and smoking are known to produce excessive pulmonary secretions and to paralyze the cilia. In these cases, the pain of the thoracotomy wound suppresses coughing and further impairs clearance of secretions. In our series, every patient presented with all of these risk factors. Moreover, bronchoscopy performed on the 1st postoperative day showed bronchial collapse with obstruction in 3 patients after lower bilobectomy and lower right lobectomy. This condition can be determined by marked mobility of the residual lobe with bronchial kinking.
Sok and colleagues6 observed that several factors may complicate atelectasis, with development of pneumonia: post-surgical depressed immune response, lung damage and impaired postoperative ventilation. They commented that the pathogens responsible for pleuropulmonary infective complications are probably acquired postoperatively.6 In our experience, a previous lung infection treated with prolonged wide-spectrum antibiotic therapy could be a risk factor for postoperative pneumonia with suppurative necrosis caused by multidrug-resistant pathogens. The clinical and radiological presentations of residual lobar abscess are not specific and include pyrexia, leukocytosis and early opacification with progressive consolidation of the affected lobe. The findings at flexible bronchoscopy are more specific and include bronchial occlusion from purulent secretions and/or bronchial collapse. For patients who present with these clinical, radiological and bronchoscopic findings, CT evaluation must be performed. Chest CT revealed foci of lung abscesses in the last 3 patients. This facilitated prompt diagnosis and allowed the differentiation of this condition from lobar torsion, in which case, venous occlusion is evident (Figure 1 and 2).
We consider surgical resection of the affected lobe essential to avoid complications such as bronchopleural fistula, empyema and sepsis. Once the diagnosis is made, surgical treatment should be carried out after 48 hours of ineffective medical treatment. The finding at repeat thoracotomy was complete hepatization of the residual lobe in all cases. In our patients, neither bronchopleural fistula nor empyema occurred, and only one died of contralateral pneumonia. It was concluded that residual lobar abscess after lobectomy for non-small-cell lung cancer is a rare complication that should be suspected in patients presenting with fever, leukocytosis, bronchial obstruction and lung consolidation despite antibiotic therapy, physiotherapy, and bronchoscopy. Computed tomography is mandatory to achieve an early diagnosis. Surgical resection of the affected lobe is the preferred treatment.
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REFERENCES
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- Cable DG, Deschamps C, Allen MS, Miller DL, Nichols FC, Trastek VF, et al. Lobar torsion after pulmonary resection: presentation and outcome. J Thorac Cardiovasc Surg 2001;122:1091–3.[Abstract/Free Full Text]
- Klippe HJ, Lohr J, von Windheim K. Infections after pleuropulmonary surgery. Thorac Cardiovasc Surgeon 1983;31:67–70.[Medline]
- Stephan F, Boucheseiche S, Hollande J, Flahault A, Cheffi A, Bazelly B, et al. Pulmonary complications following lung resection: a comprehensive analysis of incidence and possible risk factors. Chest 2000;118:1263–70.[Medline]
- Schussler O, Alifano M, Dermine H, Strano S, Casetta A, Sepulveda S, et al. Postoperative pneumonia after major lung resection. Am J Respir Crit Care Med 2006;173:1161–9.[Abstract/Free Full Text]
- Bonde P, McManus K, McAnespie M, McGuigan J. Lung surgery: identifying the subgroup at risk for sputum retention. Eur J Cardiothorac Surg 2002;22:18–22.[Abstract/Free Full Text]
- Sok M, Dragas AZ, Erzen J, Jerman J. Sources of pathogens causing pleuropulmonary infections after lung cancer resection. Eur J Cardiothorac Surg 2002;22:23–9.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
