Asian Cardiovasc Thorac Ann 2001;9:339-341
© 2001 Asia Publishing EXchange Pte Ltd
Pulmonary Parenchymal Abscess: VATS Approach to Diagnosis and Treatment
Francis J Podbielski, MD,
Heron E Rodriguez, MD,
Irvin M Wiesman, MD,
Andrew M Brown, MD,
Emily D Quiros, MD,
Mohammed F Ziauddin, MD
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Department of Surgery Catholic Health Partners Chicago, Illinois, USA
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For reprint information contact: Francis J Podbielski, MD Tel: 1 508 334 8996 Fax: 1 508 334 6296 email: PodbielF{at}ummhc.org Division of Thoracic Surgery, UMass Memorial Medical Center, 67 Belmont Street, Worcester, MA 01605-2657, USA.
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ABSTRACT
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Lung abscesses are usually treated with antibiotic regimens and postural drainage. Treatment failure necessitates transbronchial drainage with radiographically guided or open procedures. A patient with a lung abscess remained febrile despite a 2-week course of antibiotics and 3 unsuccessful percutaneous drainage attempts. Video-assisted thoracoscopic exploration localized the abscess and facilitated endoscopic unroofing and debridement of the cavity. Thoracoscopic drainage techniques offer a reliable and expedient option for refractory lung abscesses when compared to standard therapy alone.
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INTRODUCTION
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The therapeutic approach to lung abscesses has evolved continuously throughout the last century. Cure rates as low as 30% and significant mortality were reported with external drainage and resection, but the advent of antibiotics and flexible bronchoscopy heralded a new era in the management.l,2 Proper antimicrobial treatment, early bronchoscopy, and postural drainage proved effective in the vast majority of cases. Failure of this regimen necessitated an abscess cavity drainage procedure. Pneumonostomy or cavernostomy with direct tube drainage (the Monaldi procedure) commonly achieved this goal. Lung resection was undertaken as the definitive procedure only after complete resolution of the infection. These modalities achieved cure rates of 90%, but with concomitant mortality rates of 11% to 28%.3–5 In the last 2 decades, percutaneous drainage has proven effective in appropriately selected adult and pediatric patients.6,7
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CASE REPORT
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A previously healthy 41-year-old man presented with fever and cough of 10 days duration. He was a nonsmoker with no history of recurrent pneumonia. He was started on a 7-day course of oral antibiotics, but he returned after 6 days with chills, fever (39.5°C), and a productive cough. A chest radiograph revealed a left lower lobe infiltrate, and a tuberculin skin test was nonreactive. His oral antibiotic regimen was changed and he was discharged. After completing a second 7-day course of therapy with no improvement, he was admitted for broad-spectrum intravenous antibiotics. Thoracic computed tomography (CT) showed a 10-cm inflammatory mass with an enhancing ring, containing an air pocket, at the periphery of the left lower lobe. Flexible bronchoscopy demonstrated no obstructing lesions, and bronchoalveolar lavage specimens were negative for malignancy and organisms. The patient underwent percutaneous CT-guided abscess aspiration (Figure 1
). Cytology after 3 days of intravenous antibiotics was again negative for malignancy and no organisms were cultured; chemical analysis of the thoracentesis specimen was consistent with an exudate. CT-guided aspiration was repeated 2 days later and a 12-gauge pigtail catheter was left in place. No clinical or radiographic response was observed, and the drainage catheter was repositioned 4 days after its initial insertion. The patient remained febrile with a leukocyte count of 18.5 x 106/L (normal range, 4.5–11.0 x 106/L).
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Figure 1. Attempted percutaneous drainage of left lower lobe lung abscess under computed tomographic guidance. Abscess cavity measured approximately 10 x 7 cm.
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Surgical evaluation by video-assisted thoracoscopy was carried out on the 8th hospital day. Exploration of the left chest was performed using selective lung ventilation. While no pleural effusion was encountered, a segment of the left lower lobe was loosely adherent to the parietal pleura. Electrocautery and sharp-scissor dissection revealed a discrete area of inflamed lung parenchyma with a firm consistency on digital palpation. Tissue thinning and a grayish-green discoloration were noted in the area of the lung cavity visualized by CT. A 16-gauge needle inserted into the abscess verified the presence of purulent material. After placement of an endoscopic dissector into the cavity to delineate its dimensions, electrocautery and suction were used to unroof and debride the abscess space, the contents of which were under pressure, and approximately 15 cc was drained upon entry. What remained was a cavity lined by a thickened friable inflammatory peel. In contrast to atelectasis with consolidation, nothing resembling lung tissue was noted in the cavity; this area of parenchyma had been completely liquefied and encased by an inflammatory peel. The abscess cavity and the entire thorax were irrigated thoroughly, and two 32F thoracic drains were placed in the pleural space adjacent to, but not in, the unroofed cavity. The patient's fever abated on the 2nd postoperative day and his leukocyte count normalized. On the 4th postoperative day, with no air leak noted, both drains were removed and he was discharged. Serial chest radiographs showed complete resolution of the infiltrate after 6 months, with minimal scarring (Figure 2).
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Figure 2. Chest radiograph 6 months after surgical intervention. Note that there is minimal scarring in the left lower lobe where the abscess was located.
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DISCUSSION
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Pneumonotomy or thoracotomy with resection, although effective treatment modalities for lung abscesses, are associated with empyema and bronchopleural fistula in 10% to 20% of cases, and have significant mortality (11%) due largely to the patient's debilitated physical status.4,5 Safe and effective pneumonotomy depends on accurate topical localization of the abscess and a high degree of certainty that the underlying lung is firmly adherent to the overlying parietal pleura. After entry into the abscess with cautery, suction and gentle mechanical debridement are performed. A 36F to 40F mushroom catheter is inserted and sewn to the skin for long-term drainage.
The standard treatment for pulmonary abscess consists of directed antibiotic therapy with early bronchoscopy and postural drainage. While this regimen is effective, almost 15% of patients remain symptomatic and eventually require some type of drainage procedure. Percutaneous radiographic-guided drainage is less invasive but effective in only a selected subgroup of patients. Reported catheter drainage times average 9.8 to 20.1 days, with a range of 4 to 59 days.6,8 Perhaps most importantly, further intervention is required in one-third of cases initially treated by this approach.8 The clinical course of lung abscess patients underscores the importance of prompt effective treatment as those who fail to respond to initial antibiotic therapy usually have protracted hospital stays with extended courses of intravenous antibiotics and repeated radiographic drainage procedures.
Thoracoscopy was undertaken in this case because of the failure of antibiotic therapy as well as 3 percutaneous catheter drainage procedures. Tuberculosis with super-infection as the abscess etiology had been excluded, and the peripheral location of the lesion precluded transbronchial drainage. Although abscess drainage into the pleural space carries the risk of empyema, it was felt that the antibiotic pretreatment and negative fluid cultures, coupled with thorough irrigation and complete thoracic drainage with large bore chest tubes, would prevent this complication. Thoracoscopic visualization of the left hemithorax showed filamentous adhesions between the visceral and parietal pleura of the lower lobe, beneath which there was a 5-cm translucent area with adjacent normal-appearing lung parenchyma. The relative lack of bleeding during the procedure and the absence of a postoperative bronchopleural fistula was attributed to the overlying fibrous rind. Given the character of the abscess and the lack of exposed major bronchi (as visualized through the thoracoscope), it was felt that a thoracostomy tube would provide adequate drainage. Exposure of segmental bronchi would have necessitated thoracoscopic or open direct suture repair preferably with a pedicled muscle flap buttress, or a segmental lung resection. Because of the risk of hemorrhage from parenchymal debridement, we were prepared for an open thoracotomy and lung resection if necessary.
This case illustrates the usefulness of thoracoscopy in the treatment of selected lung abscesses refractory to conventional antibiotic or catheter-drainage regimens. After failure of conservative measures, we believe that prompt intervention with a minimally invasive approach can be successful and result in a shorter treatment course with preservation of viable lung parenchyma.
Presented at the Society of Laparoendoscopic Surgeons, Endo Expo 1998 Meeting, Coronado, California, USA, December 10, 1998.
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ABSTRACT
INTRODUCTION
