Department of Surgery, Klinikum Nuremberg, Nuremberg, Germany; Department of Surgery, Klinikum Neumarkt, Neumarkt i.d. Oberpfalz, Germany.
Department of Thoracic Surgery, Hospital Universitario Virgen de las Nieves, Granada, Spain.
Ann Thorac Surg. 2014 Jul;98(1):265-70. doi: 10.1016/j.athoracsur.2014.03.007. Epub 2014 May 1.
Sloughing and gangrene of a complete lung are only very infrequently encountered complications of necrotizing pneumonia and fulminant pulmonary abscess formation. Thus far the role of emergent pneumonectomy is not established.
The outcome of patients who underwent anatomic lung resection for lung gangrene at 3 centers for thoracic surgery during the last 13 years was retrospectively analyzed. Only cases of necrotizing pneumonia were included whereas malignant lesions were excluded.
Overall 44 patients were indentified (average age 56.3 years). Pulmonary sepsis (27 of 44), pleural empyema (29 of 44), persistent air leakage (14 of 44), and respiratory failure with mechanical ventilation (14 of 44) were present preoperatively. The mean Charlson comorbidity index was 2.77. Procedures were segmentectomy (7), lobectomy (26), and pneumonectomy (11). In-hospital mortality was 7 of 44; 2 following pneumonectomy and 5 after lobectomy. In comparing the pneumonectomy group with the lobectomy group we found no significant differences in age (p=0.59), Charlson comorbidity index (p=0.18), and postoperative mortality (p=1). Charlson comorbidity index 3 or greater (odds ratio [OR], 8.41; 95% confidence interval [CI], 0.88 to 421.71; p=0.04), preoperative pleural empyema (OR, 3.56; 95% CI, 0.37 to 179.62; p=0.39) and preoperative persistent air leak (OR, 7.34; 95% CI, 1.00 to 89.98; p=0.02) were associated with higher risk for fatal outcome. Furthermore, patients with sepsis (p=0.03) and patients sustaining acute renal failure (p=0.04) had significantly higher mortality.
Pulmonary sepsis and its complications as well as preexisting comorbidity are the major reasons for fatal outcome, whereas the extent of surgical resection shows no significant influence. Emergent pneumonectomy as ultimate ratio is not only justified but also life saving. Further improvement seems achievable by earlier surgical intervention before the onset of pulmonary sepsis.
肺坏死和坏疽是坏死性肺炎和暴发性肺脓肿形成的罕见并发症。目前，紧急肺切除术的作用尚未确定。
回顾性分析了过去 13 年间 3 家胸外科中心因肺坏疽行解剖性肺切除术的患者的结局。仅纳入坏死性肺炎病例，排除恶性病变。
共确定了 44 例患者（平均年龄 56.3 岁）。术前存在肺部脓毒症（44 例中的 27 例）、脓胸（44 例中的 29 例）、持续漏气（44 例中的 14 例）和机械通气呼吸衰竭（44 例中的 14 例）。Charlson 合并症指数的平均值为 2.77。手术方式为节段切除术（7 例）、肺叶切除术（26 例）和肺切除术（11 例）。院内死亡率为 44 例中的 7 例；2 例为肺切除术，5 例为肺叶切除术。比较肺切除术组与肺叶切除术组，我们发现年龄（p=0.59）、Charlson 合并症指数（p=0.18）和术后死亡率（p=1）无显著差异。Charlson 合并症指数 3 或更高（比值比[OR]，8.41；95%置信区间[CI]，0.88 至 421.71；p=0.04）、术前脓胸（OR，3.56；95%CI，0.37 至 179.62；p=0.39）和术前持续漏气（OR，7.34；95%CI，1.00 至 89.98；p=0.02）与致命结局的风险增加相关。此外，败血症患者（p=0.03）和发生急性肾衰竭的患者（p=0.04）的死亡率显著更高。
肺部败血症及其并发症以及既往合并症是致命结局的主要原因，而手术切除范围无显著影响。紧急肺切除术作为最终手段不仅合理，而且可以救命。通过在肺部败血症发作前尽早进行手术干预，可能进一步提高手术效果。
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