Schweigert Michael, Dubecz Attila, Beron Martin, Ofner Dietmar, Stein Hubert J
Department of General and Thoracic Surgery, Klinikum Nuernberg Nord, Nuernberg, Germany.
Thorac Cardiovasc Surg. 2013 Oct;61(7):636-41. doi: 10.1055/s-0032-1311551. Epub 2012 Oct 3.
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 immunodeficiency. Mortality is significant and both treatment strategies as well as the role of surgery are controversially debated.
In a retrospective review at a German tertiary referral hospital, 20 patients with pulmonary resection for necrotizing lung disorders were identified 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 five 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%).
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 flap 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.
Necrotizing pulmonary infections are infrequent but are life-threatening disease entities. Patients often present with severe comorbidity and chronic disorders causing immunodeficiency. 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%.
坏死性肺炎、肺脓肿和肺坏疽是严重肺部感染导致肺组织坏死和脱落的罕见并发症。肺坏死常与酗酒及其他已知免疫缺陷的慢性疾病相关。死亡率很高，治疗策略以及手术的作用都存在争议。
在一家德国三级转诊医院进行的回顾性研究中，自2008年起确定了20例因坏死性肺部疾病接受肺切除术的患者。入院时，所有患者均患有肺脓毒症，尽管进行了充分的药物治疗，但实质破坏和坏死仍在进展。大多数患者并发胸膜脓胸（13/20），5例患者持续漏气。由于药物治疗无效，8例患者（40%）发展为严重脓毒症并伴有感染性休克，4例患者（20%）术前已接受通气治疗。10例患者（50%）存在慢性酗酒。
4例出现全肺坏疽。右肺下叶（8/20）、中叶（4/20）、右上叶（2/20）和左肺下叶（2/20）出现肺叶坏疽或坏死性肺炎合并暴发性脓肿。手术方式包括全肺切除术（4/20）、肺叶切除术（13/20）和局限性切除术（3/20）。7例患者的支气管残端用带蒂肌瓣加固。3例患者术后因感染性休克合并多器官功能衰竭死亡。其余17例患者（85%）恢复良好，并被转至专门治疗肺部疾病的康复诊所。
坏死性肺部感染虽不常见，但却是危及生命的疾病。患者常伴有严重合并症和导致免疫缺陷的慢性疾病。如果初始药物治疗失败，手术是一种合理的治疗方法。手术治疗的目的是切除所有坏疽的肺实质并有效引流胸膜脓胸。如此，高达80%的患者有望康复。
