Surgical Therapy for Necrotizing Pneumonia and

Lung Gangrene
Michael Schweigert
1
Attila Dubecz
1
Martin Beron
1
Dietmar Ofner
2
Hubert J. Stein
1
1
Department of General and Thoracic Surgery, Klinikum Nuernberg
Nord, Nuernberg, Germany
2
Department of Surgery, Paracelsus Medical University, Salzburg,
Austria
Thorac Cardiovasc Surg
Address for correspondence and reprint requests Michael Schweigert,
M.D., Klinik fuer Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum
Nuernberg Nord, Prof-Ernst-Nathan-Str. 1, 90419 Nuernberg, Germany
(e-mail: michael.schweigert@klinikum-nuernberg.de).
Keywords
necrotizing
pneumonia
lung gangrene
lung abscess
Abstract Objective Necrotizing pneumonia, pulmonary abscess, and lung gangrene are rare
complications of severe pulmonary infection with devitalization and sloughing of lung
tissue. Pulmonary necrosis is often associated with alcoholism and other chronic
disorders with known immunodeciency. Mortality is signicant and both treatment
strategies as well as the role of surgery are controversially debated.
Methods In a retrospective review at a German tertiary referral hospital, 20 patients
with pulmonary resection for necrotizing lung disorders were identied since 2008. At
hospital admission, all patients suffered from pulmonary sepsis and despite adequate
medical treatment progressing parenchymal destruction and devitalization took place.
The majority of the patients sustained pleural empyema (13/20) and ve patients a
persisting air leak. On account of failing medical therapy, eight patients (40%)
developed severe sepsis with septic shock and four patients (20%) were already
preoperatively ventilated. Chronic alcoholism was present in 10 patients (50%).
Results Gangrene of a complete lung was seen in four cases. Lobar gangrene or
necrotizing pneumonia complicated by fulminate abscess was seen in the right lower
lobe (8/20), middle lobe (4/20), right upper lobe (2/20), and left lower lobe (2/20).
Procedures included pneumectomy (4/20), lobectomy (13/20), and limited resection
(3/20). The bronchial stump was reinforced with a pedicle muscle ap in seven cases.
There were three postoperative deaths due to septic shock with multiorgan failure. The
remaining 17 patients (85%) recovered well and were transferred to rehabilitation clinics
specialized on pulmonary disorders.
Conclusion Necrotizing pulmonary infections are infrequent but are life-threatening
disease entities. Patients often present with severe comorbidity and chronic disorders
causing immunodeciency. If initial medical therapy fails surgery offers a reasonable
therapeutic approach. Aim of surgical therapy is resection of all gangrenous lung
parenchyma and effective drainage of pleural empyema. Then recovery is feasible in up
to 80%.
received
December 22, 2011
accepted after revision
February 27, 2012
Copyright 2012 by Thieme Medical
Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA.
Tel: +1(212) 584-4662.
DOI http://dx.doi.org/
10.1055/s-0032-1311551.
ISSN 0171-6425.
Special Report
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Introduction
Necrotizing pneumonia, lung abscess, and pulmonary gan-
grene have become rare disorders in modern times. They are
part of a spectrum of disease that is dened by the degree of
inammation as well as by the degree of parenchymal
destruction, progressing necrosis, and ongoing sloughing of
lung tissue.
1,2
In the preantibiotic era, lung abscess was
mainly caused by accidental aspiration of oral contents as
well as by aspiration of blood and pus following tonsillectomy
or tooth extraction.
3,4
Lung gangrene was a consequence of
multiple abscesses resulting insuppurative devitalization and
sloughing of pulmonary parenchyma. Following the advent of
antibiotics necrotizing, pulmonary infections became rare
illnesses that were henceforth only infrequently encountered
in medical or surgical departments.
Nowadays necrotizing pneumonia, lung abscess, or pul-
monary gangrene is often associated with risk factors result-
ing in immunodeciency.
1,5
Chronic alcoholism, chronic
respiratory disease, diabetes mellitus, malnutrition, and con-
ditions associated with an elevated risk of aspiration like
seizure disorders or proximal foregut carcinomas are most
common.
1,5
Massive life-threatening pulmonary infection in those
patients at risk occasionally results in necrotizing pneumonia
with irreversible devitalization of lung parenchyma. Despite
adequate medical treatment, parenchymal necrosis may ad-
vance to lung abscess or actually pulmonary gangrene with
sloughing of one lobe or even an entire lung. Such necrotizing
pulmonary infections are associated with substantial mor-
bidity and mortality.
5
However, treatment of this crushing disease entity is still
controversially discussed. While initial medical treatment is
generally accepted, there are no clearly established indica-
tions for surgery.
2
Furthermore surgical interventions are
considerably complicated by the extent of lung necrosis,
pleural empyema, pre-existent respiratory failure, the re-
quired range of pulmonary resection, and the often already
preoperatively reduced performance status.
2
The existence of
severe pulmonary sepsis eventually resulting in multiorgan
failure adds further difculty. It is not yet established that the
results of surgery warrant the risk. Moreover there is neither
agreement about the appropriate point of time for surgery
nor about the adequate operative strategy. Surgical drainage
procedures
3,6
and pulmonary resection
7,8
are both advocated
as well as one stage
9,10
and staged operations.
11
Aimof this retrospective study was therefore to investigate
the feasibility and results of surgical intervention for necro-
tizing pulmonary infections refractory to initial medical and
supportive management and to clarify indications for opera-
tive therapy.
Material and Methods
In a retrospective review at a German tertiary referral hospi-
tal, 20 patients with pulmonary resection for necrotizing lung
disorders have been identied since January 2008 (Table 1).
All procedures were performed by the same thoracic surgeon
(MS) at the Klinikum Nuernberg Nord, which serves a popu-
lation of approximately half a million people and is the main
provider of emergency surgery for an even larger urban and
rural population. The study was approved by an institutional
ethics committee and the need for individual consent was
waived because of the study's retrospective design.
At hospital admission all patients suffered from pulmo-
nary sepsis and despite adequate medical treatment pro-
gressing parenchymal destruction and devitalization took
place (Fig. 1). Median age of the sufferers was 60.25 years
and there were 16 men and 4 women (Table 1). Computed
tomography of the chest with intravenous contrast was
obtained in all cases as well as exible bronchoscopy for
exclusion of airway stenosis or central tumoral lesions.
Microbiological testing was done on blood culture, sputum
smear, and bronchoalveolar lavage uid. In case of pleural
effusion ultrasound-guided needle aspiration biopsy was
Table 1 Characteristics of the Patients
Number of patients 20
Median age (years) 60.25
Male 16 (80%)
Female 4 (20%)
Chronic alcoholism 10 (50%)
Figure 1 Necrotizing pneumonia resulting in right upper lobe gan-
grene. (A) Bronchoscopic image: Bronchoscopy shows necrosis of the
upper lobe bronchus. (B) Computed tomography of the chest: Gan-
grene of the entire upper lobe with formation of a huge slough lled
abscess cavity is visible.
Thoracic and Cardiovascular Surgeon
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performed. Ziehl-Neelsen staining for acid-fast bacteria was
routinely obtained from all samples.
The majority of the patients sustained pleural empyema
(13/20) and ve sustained a persisting air leak (Table 2). On
account of failing medical therapy eight sufferers (40%)
developed severe sepsis with septic shock and four patients
(20%) were already preoperatively ventilated. Chronic alco-
holism was present in 10 cases (50%) (Table 2).
Decision for surgical intervention was based on the pres-
ence of ongoing pulmonary sepsis despite sufcient medical
treatment. Furthermore, septic shock related to advancing
necrosis and sloughing of pulmonary tissue as well as radio-
graphic evidence of complete gangrene of one lobe (Fig. 1)
or even an entire lung were indications for operative man-
agement. Spontaneous abscess perforation into the pleural
cavity with subsequent empyema and persisting air leak also
gave reason to perform surgery.
So decision for operative management was always based
on clinical deterioration despite adequate medical and sup-
portive treatment including bronchoscopical or radiological
interventions. An open thoracotomy was the approach of
choice in all patients. If radiographic imaging indicated an
extended procedure in a septic patient at high risk for
postoperative bronchopleural stula, a pedicle muscle ap
was obtained either from the M. latissimus dorsi or the M.
serratus anterius upon thoracotomy for later reinforcement of
the bronchial stump. The extent of pulmonary resection was
dened by the range of gangrene and sloughing. If feasible
limited resections were preferred. However, all lung tissue of
dubious viability was removed along with the obviously
gangrenous parenchyma to avoid persisting septic disease.
Chest tubes were routinely inserted and in case of empyema
the pleural cavity was irrigated with Ringers solution via the
drainages tubes twice daily.
Results
We encountered gangrene of a whole lung in four cases
(Table 3). One 60-year-old alcohol addicted man had been
found unconscious on the oor of his apartment after con-
suming an unknown amount of alcohol. He had remained on
the oor for some time and had probably aspirated. He was
rst admitted to a local hospital and upon pulmonary sepsis
with respiratory failure he was transferred to our hospital.
Computed tomography revealed inammatory lesions in
both lungs with rather small abscesses in the right lung
and multiple abscess cavities and pleural empyema on the
left side. His condition deteriorated fast and thus left emer-
gency thoracotomy was ultimately performed. Preliminarilya
M. latissimus dorsi ap was prepared. Upon thoracotomy the
left lung was complete gangrenous and sloughed due to
multiple abscesses with liquefaction of the parenchyma.
Furthermore advanced pleural empyema caused suppuration
and brinous mass throughout the left pleural cavity. Pneu-
mectomy was unavoidable due to gangrene of the entire lung.
The bronchial stump was reinforced with the previously
obtained muscle ap. Because of severe diffuse bleeding
tamponade of the chest with towels was performed. Hence-
forth the patient's condition got stabilized and the tampo-
nade was removed after 48 hours. He recuperated further and
was nally transferred to a rehabilitation facility specialized
on pulmonary disorders.
Complete gangrene of an entire lung occurred in three
further cases. In this study, the men were between 60 and
76 years old and at least two of them had a history of heavy
alcohol abuse. One of them had previously undergone resec-
tion of oral cancer and another en-bloc-esophagectomy for
esophageal squamous cell carcinoma. Both experienced dif-
culty in swallowing resulting in substantial dysphagia with
recurrent aspiration of food and other oral contents into the
lungs. Moreover all three suffered from chronic obstructive
lung disease caused by longstanding tobacco abuse. Right
pneumectomy was ineluctable due to gangrene of the whole
lung including the airways. In each case, the bronchial stump
was reinforced with a pedicle muscle ap obtained from the
M. serratus anterius. One patient recovered while the remain-
ing two died from persisting sepsis with septic shock.
Lobar gangrene or necrotizing pneumonia complicated by
fulminate abscess which resulted in sloughing of a full lobe
came about in 16 cases (Table 3) (Fig. 1). The right lower
lobe was most frequentlyaffected (8/20) (Fig. 2) followed by
the middle lobe (4/20). The right upper (Fig. 1) and left
lower lobe was each impaired in two cases. Lobectomy was
mandatory in 13 subjects whereas in three cases limited
resection and debridement were feasible (Table 4). Limited
resection and unroong of the abscess cavity were only
practicable when the central parts of the affected lobe were
unimpaired. While 15 patients nally recuperated, one 77-
year-old man died from ongoing pleural empyema with
sepsis. He sustained necrotizing pneumonia leading to gan-
grene of the entire right lower lobe and received therefore
lower lobectomy. Despite daily irrigation via the inserted
Table 3 Localization of Gangrenous Lesions
Affected lobe or lung Number Percentage
Complete right lung 3 15%
Complete left lung 1 5%
Right upper lobe 2 10%
Middle lobe 4 20%
Right lower lobe 8 40%
Left lower lobe 2 10%
Table 2 Clinical Presentation
Number of patients 20
Pleural empyema 13 (65%)
Preoperative persisting air leak 5 (25%)
Respiratory failure with preop-
erative need of ventilation
4 (20%)
Severe sepsis with septic shock 8 (40%)
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chest tubes and specic antibiotic therapy his condition
deteriorated. Chest radiographs showed an enclosed space
within the right lower pleural cavity accordant with a persist-
ing empyema sack. Therefore open thoracostomy with estab-
lishment of a pleural window was performed.
Notwithstanding all treatment efforts including supportive
therapies with improvement of nutritional status and intense
physiotherapy the patient died ultimately from proceeding
septic disease.
Limited resections included one extendedwedge resection
from the left lower lobe and two times unroong and
debridement of an abscess cavity situated in the right lower
lobe. All three patients suffered already preoperatively from
advanced pleural empyema and one even sustained previous
to surgery a persisting air leak. One 33-year-old man was
currently imprisoned as drug peddler and was himself heroin
addicted. Furthermore, he suffered from chronic hepatitis C
and alcoholism. Intravenous drug use had caused pneumonia
with subsequent pulmonary sepsis, abscess of the right lower
lobe, and pleural empyema. Limited thoracotomy with un-
roong of the abscess cavity, debridement, intense pleural
lavage, and placement of chest tubes and an irrigation system
was performed. He convalesced and was at last transferred to
the inrmary of the jail responsible for him.
Altogether 17 patients recovered well and were either
discharged home or straight transferred to rehabilitation
clinics specialized on pulmonary disorders (Table 4).
None of those was readmitted to our thoracic surgical service.
A total of 15 patients returned nally to their normal activi-
ties, whereas one was admitted to a nursing home and one
was still imprisoned because of illegal drug dealing.
Discussion
Lung abscess as disease entity is known since the days of
Hippocrates. However, successful therapy had yet to be
invented. So in the rst decades of the 20th century acute
putrid lung abscess was still a crushing condition and out-
come mostly fatal. Mortality extended to 75% in a series from
the Massachusetts General Hospital covering the years 1909
to 1923.
4
A total of 169 out of 227 patients admitted to this
hospital because of acute lung abscess died in spite of all
conservative treatment efforts.
4
Nonoperative management
of those times mainly consisted of unspecic drug therapy,
recommendation of fresh air and rest as well as postural
drainage.
3
However, those strategies often failed to provide
cure and so lung abscess remained an unsolved medical
problem with considerable morbidity and mortality.
With the dawn of thoracic surgery at the begininning of
the last century rst surgical approaches to lung abscess and
necrotizing lung disorders were invented. Initially staged
procedures with delayed drainage of the abscess cavity
were preferred. However, mortality remained signicant
and this was mainly attributed to postponement of sufcient
abscess drainage. Robert Shaw reported a mortality of 35.7%
in a series of 227 patients who received either medical or
delayed two-stage surgical treatment of lung abscess at the
University Hospital at Ann Arbor, Michigan, between the
years 1926 and 1937.
10
Mortality even amounted to 40.6%
in the surgical managed cases.
10
Harold Neuhof from the Mount Sinai Hospital in New York
proposed an entirely newone-stage open drainage operation
for acute lung abscess in the 1930s. The procedure consisted
of a limited thoracotomy in local anesthesia with unroong of
the abscess cavity. The wound remained unclosed so that
sufcient drainage was warranted. Neuhof himself reported a
mortality of only 2.4% in a series of 162 patients managed by
his concept at the Mount Sinai Hospital until 1943.
3
With the advent of antibiotics and notably penicillin
during the late 1940s therapy of lung abscess and necrotizing
Figure 2 Necrotizing pneumonia of the right lower lobe. (A) CT scan
shows gangrenous infection of the right lower lobe with abscess cavity.
(B) On the specimen the slough lled cavity is as clearly visible (arrow)
and perforation of the abscess into the pleural space seems to be
imminent.
Table 4 Surgical Procedures and Outcome
Pneumectomy 4 20%
Lobectomy 13 65%
Limited resection 3 15%
Recovery 17 85%
General mortality 3 15%
Mortality following pneumectomy 2 50%
Mortality following lobectomy 1 7,7%
Mortality following limited procedures 0 0%
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pulmonary disorders underwent another radical change.
While sulphonamides had shown disappointing results, pen-
icillin revolutionized the management of lung abscess.
4,12,13
Henceforth sufferers received rather medical therapy than
surgical procedures. Mortality of lung abscess declined at the
Massachusetts General Hospital from 75% (1909 to 1923) to
33.9% (19331937) and nally to 6.9% in the period between
1947 and 1956, when antibiotics were already ubiquitously
available.
4
So lung abscess had become a domain of medical
therapy.
Medical management not only represented the treatment
of choice but also induced a substantial decline in the inci-
dence of putrid lung abscess.
4
Pulmonary abscess and gan-
grenous lung disorders became rare diseases. Fromthe 1950s
on mainly patients suffering from chronic lung abscess or
multiple abscesses resulting in pulmonary gangrene were
occasionally encountered in surgical services. However,
drainage procedure proved to be insufcient in those cases
and thus pulmonary resection either as lobectomy or even as
pneumectomy became established. This trend was conrmed
in several series of the late 1940s and 1950s.
7,8,14
Despite the remarkable success of medical treatment
lung abscess and necrotizing pneumonia remained life-
threatening conditions associated with substantial morbidity
and mortality.
5,6
A large North American series covering the
years between 1960 and 1982 reported constant mortality of
25%.
5
The study also conrmed that lung abscess and
pulmonary gangrene were uncommon illnesses. Mainly pa-
tients showing predisposing factors were affected by necro-
tizing pneumonia, lung abscess, and pulmonary gangrene.
Immunosuppressive therapy, diabetes mellitus, chronic
alcoholism, chronic pulmonary disease and conditions gen-
erally resulting in reduced immunocompetence are now the
main risk factors for developing lung abscess. Furthermore
seizure disorders, proximal foregut carcinomas, and other
disease entities with elevated risk for aspiration of oral or
gastric contents are related to an increased risk to sustain
lung abscess and necrotizing pneumonia.
1,5
The emergence of
AIDS in the late 1980s brought about even more patients at
elevated risk for necrotizing lung disorders.
While in the early decades of the 20th century mainly
otherwise healthy individuals suffering from acute putrid
lung abscess had undergone surgery, now patients with
already poor functional status, severe comorbidity and pul-
monary sepsis refractory to medical therapy were referred to
the thoracic surgeon. Due to disappointing results of primary
resection staged procedure were advocated once again.
6,11
Our series conrms that mainly patients with already
seriously deteriorated condition and advanced septic disease
are referred for surgical intervention. In all of our patients
initial medical therapy had failed and therefore 65% suffered
from pleural empyema, 25% had sustained a persisting air
leakage, and 20% were already preoperatively ventilated
because of respiratory failure due to pulmonary sepsis
(Table 2). Severe sepsis with septic shock was present in
40%. Furthermore, our collective showed the typical predis-
posing factors. Proximal foregut carcinoma had previously
been treated in two cases, 50% of the sufferers were alcohol
addicted, most of them were or had been smokers with
consecutive chronic lung disease, and one was heroin ad-
dicted with hepatitis C.
There is a surprising paucityof current literature regarding
surgery for pulmonary gangrene and putrid lung abscess.
Nevertheless, the few available series support our observa-
tions on the characteristics of patients referred for operative
treatment. In the year 2000, a series from the University of
Washington included ve patients who received surgical
management of lung gangrene.
15
Three patients had a
long-standing history of intravenous drug and alcohol abuse
whereas one was HIV positive and another one suffered from
hepatitis B resulting in liver cirrhosis. Pleural empyema was
present in three cases and all suffered from persisting pul-
monary sepsis. These ndings are also afrmed by recent
series from Taiwan comprising 26 patients with necrotizing
pneumonia.
16
Chronic alcoholism was present in nearly one-
third of the sufferers and upon referral for surgical therapy
50% had already sustained pleural empyema whereas respi-
ratory failure, persisting air leakage, and septic shock were
each encountered in 20%.
We adopted a one-stage approach with resection of all
gangrenous lung tissue, debridement and lavage of the
affected pleural cavity and insertion of chest drainages with
postoperative irrigation via the tubes as treatment of choice.
In case of gangrene of an entire lung pneumectomy was
performed. In several cases and always following pneumec-
tomy, the bronchial stump was reinforced with a pedicle
muscle ap.
In our opinion, staged procedures, which had again been
proposed in the 1980s
6
and 1990s,
11
have the severe disad-
vantage of leaving the destroyed and gangrenous lung as
source of septic disease within the patient. Therefore, we
avoided them and opted for single-stage operations that
simultaneously provide removal of the septic focus and
adequate drainage of the infected pleural space.
Resection of pulmonary tissue was always kept as limited
as feasible. Anatomical resections were mostly necessary and
only in one case extended atypical wedge resection was
practicable. Unroong of the abscess with debridement was
feasible in two cases of localized abscess and still vital central
parts of the affected lobe and lung. However, from this
restricted experience we conclude that more limited resec-
tion could be successfully performed if patients with probably
failing medical therapy would earlier been referred to spe-
cialized surgical services. There may be a certain risk of
occurrence of air leakage following unroong and debride-
ment of pulmonary abscess. Nevertheless we know from our
expertise in dealing with severe pleural empyema that this
peripheral air leaks mainly close spontaneously.
17
In case of
persisting peripheral air leaks, we have achieved good results
by endoscopically inserting endobronchial one-way valves in
the affected segmental bronchus.
17
Closure of a circum-
scribed air leak, which can be expected in a peripheral limited
abscess, is feasible by this bronchoscopic measure and so
further pulmonary resection is avoided.
Lobectomy either for fulminate abscess or lobar gangrene
showed excellent results in our series. Despite considerable
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delay of surgical intervention due to prolonged failed medical
therapy, severe comorbidity and already advanced septic
disease 12 out of 13 patients nally recovered well. This is
in accordance with previously reported results.
2
Therefore,
we conclude that lobectomy should routinely be considered
in case of necrotizing pulmonary disorders refractory to
medical approaches. Limited resections as well as resection
of a single-pulmonary lobe are well tolerated by the sufferers
and provide simultaneously removal of the septic focus and
sufcient drainage of pleural empyema. Thus, we recognize
here a well-dened role of surgery for the treatment of
necrotizing pneumonia and lung abscess.
The current literature gives no evidence that emergency
pneumectomy on patients suffering from pulmonary gan-
grene is justied by the results. In our series, we encountered
four patients with sloughing and necrosis of an entire lung. All
showed signs of severe sepsis and septic shock. In two cases,
even gangrene of the airways was seen due to necrotizing
infection. Here, further medical therapy including interven-
tional endoscopic or radiological means is unlikely to provide
cure and the outcome will be inevitable fatal. Hence, we
consider emergency pneumectomy in those cases of ad-
vanced necrotizing pulmonary infection as ultimate treat-
ment option. Two of our four cases recovered following
emergency pneumectomy. Therefore, we conclude that pneu-
mectomy in this particular situation is not only justied but
can also be seen as reasonable approach which provides at
least prospect of cure.
In our series general mortality was 15% (3/20). This is in
accordance with thus far reported numbers. The above-cited
Taiwanese study showed fatal outcome in 4 out of 26 cases
which resulted in a similar mortality of 15%.
16
Two of our
three postoperative deaths occurred following emergency
pneumectomy whereas 12 out of 13 patients with lobectomy
recovered. Hence, it seems reasonable that further improve-
ment of results is achievable by timely surgical intervention
when pneumectomy is still avoidable and limited procedures
or lobectomy can safely be performed.
In conclusion, necrotizing pulmonary infections are still
associated with substantial mortality. Mainly people suffer-
ing from predisposing factors are affected and therefore
patients often have severe comorbidity and already reduced
performance status. Initial treatment consists of medical and
supportive therapy including modern interventional options.
However, in case of failing conservative therapy surgical
management should be considered as early as reasonable
to avoid extended resections. Limited resections are feasible
in circumscribed disease refractory to medical means. Staged
procedures with delayed resection of gangrenous lung leave
the source of sepsis within the sufferer and should thus not be
applied. Emergency pneumectomy as ultimate therapy in
otherwise refractory necrotizing pneumonia offers a reason-
able approach to achieve.
Note
Presented at the Annual Meeting of the Society for Cardio-
thoracic Surgery in Great Britain & Ireland (ACTA/SCTS
annual meeting & cardiothoracic forumManchester18th
to 20th April, 2012).
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Thoracic and Cardiovascular Surgeon
Surgical Therapy Schweigert et al.
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