title: Emergent pneumonectomy for lung gangrene: does the outcome warrant the procedure?
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, Klinikum Nuremberg, Nuremberg, Germany; Department of Surgery, Klinikum Neumarkt, Neumarkt i.d. Oberpfalz, Germany. Electronic address: michael.schweigert@klinikum.neumarkt.de.
authors.forename: Michael
authors.initials: M
authors.lastname: Schweigert
authors.affiliation: Department of Thoracic Surgery, Hospital Universitario Virgen de las Nieves, Granada, Spain.
authors.forename: Carlos F
authors.initials: CF
authors.lastname: Giraldo Ospina
authors.affiliation: Szent István University, Budapest, Hungary.
authors.forename: Norbert
authors.initials: N
authors.lastname: Solymosi
authors.affiliation: Thoracic and Vascular Surgery, PeaceHealth Southwest Medical Center, Vancouver, Washington.
authors.forename: Riyad
authors.initials: R
authors.lastname: Karmy-Jones
authors.affiliation: Department of Surgery, Klinikum Nuremberg, Nuremberg, Germany.
authors.forename: Attila
authors.initials: A
authors.lastname: Dubecz
authors.affiliation: Department of Thoracic Surgery, Hospital Universitario de la Princesa, Madrid, Spain.
authors.forename: Marta Jiménez
authors.initials: MJ
authors.lastname: Fernández
authors.affiliation: Department of Thoracic Surgery, Hospital Universitario Virgen de las Nieves, Granada, Spain.
authors.forename: Florencio
authors.initials: F
authors.lastname: Quero Valenzuela
authors.affiliation: Department of Surgery, Paracelsus Medical University, Salzburg, Austria.
authors.forename: Dietmar
authors.initials: D
authors.lastname: Ofner
authors.affiliation: Department of Surgery, Klinikum Nuremberg, Nuremberg, Germany.
authors.forename: Hubert J
authors.initials: HJ
authors.lastname: Stein
mesh_terms: D001999:Bronchoscopy; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D005734:Gangrene; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D008171:Lung Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods*; D011013:Pneumonectomy / Q000379:methods*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome