Pulmonary Abscess, Bronchiectasis, and Pulmonary Neoplasms: Surgical Aspects

Abstract

The chief indication for surgical intervention in the treatment of pulmonary abscess is the failure of conservative measures to bring about a cure within a reasonable period of time. Perhaps only when the abscess is close to the chest wall, with pleural involvement, or when it is very large and the patient extremely ill, are we justified in resorting to operation without first trying other methods of treatment. Experience has shown that a large percentage of patients suffering from abscess of the lung are cured by postural drainage, bronchoscopy, and general supportive measures. The determination of the proper time for operation is important, as external drainage during the acute phase of the disease may be followed by a wide extension of the pneumonic process (1). Abscesses with markedly fibrosed walls almost certainly will require operation, but nothing is lost and often a great deal gained by bronchoscopic drainage and other remedial measures until the maximum benefit of such treatment has been obtained. The selection of the case and the determination of the proper time for operation is largely a matter of judgment and cannot be governed by hard and fast rules. Exact localization is of the utmost importance to the surgeon in planning the exposure of the abscess, and this is best accomplished by a joint consideration of the case with the internist, roentgenologist, and bronchoscopist. Whether an abscess is in the upper part of a lower lobe or in the lower part of an upper lobe or in the middle lobe cannot always be determined by physical signs and roentgenograms. The bronchoscopist, who is able to observe from which bronchial division pus comes, can usually settle the point in question. An antero-lateral exposure is the best for most upper lobe abscesses. In abscesses of the lower lobe, the approach should be posterior or postero-lateral, and in abscesses of the middle lobe, antero-lateral. Local anesthesia, alone or in combination with nitrous oxide analgesia, is preferable to general anesthesia for obvious reasons. Occasionally we have used avertin, supplemented by nitrous oxide or local anesthesia, but avertin is objectionable because it diminishes the cough reflex for too long a time. Morphine given by hypodermic injection half an hour before operation is useful in quieting the patient. An ample exposure of the involved area of lung is necessary to the successful handling of this condition. This is accomplished by the subperiosteal resection of three or four inches (7 or 10 cm.) of two or more ribs, depending upon the size and location of the abscess, followed by removal of the intervening intercostal structures and the periosteum of at least one rib. The abscess is widely opened and the cavity dealt with under direct vision. In most instances the operation is done in two stages, but in cases in which obliteration of the pleural space already exists the abscess may be opened at once.