Lung abscess surgery: Difference between revisions
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==Overview== | ==Overview== | ||
Surgery is considered as the last resort of therapy when both medical and chest drain failed to resolve symptoms | Surgery is considered as the last resort of therapy when both medical and chest drain failed to resolve symptoms and is considered when [[Abscess]] > 6 cm in diameter and in conditions where symptoms last for more than 12 weeks with appropriate therapy. | ||
==Surgical Options== | |||
*Options for surgery includes: [[Chest tube|Chest tube drainage]] and [[surgical resection]] of the lung abscess with the surrounding lung tissue | |||
=== | ===Chest tube drainage=== | ||
* | *[[Thoracentesis|Percutaneous and endoscopic]] drainage techniques are considered as a first-line management, especially for patients who are not candidates for surgery <ref name="KelogrigorisTsagouli2011">{{cite journal|last1=Kelogrigoris|first1=M|last2=Tsagouli|first2=P|last3=Stathopoulos|first3=K|last4=Tsagaridou|first4=I|last5=Thanos|first5=L|title=Ct-guided percutaneous drainage of lung abscesses: review of 40 cases|journal=Journal of the Belgian Society of Radiology|volume=94|issue=4|year=2011|pages=191|issn=1780-2393|doi=10.5334/jbr-btr.583}}</ref> | ||
* | *ACR-SIR-SPR practice guideline for specifications and performance of image-guided percutaneous drainage/aspiration of abscesses and fluid collections (PDAFC) had submiited guidelines on image-guided percutaneous drainage/aspiration of abscesses and fluid collections. | ||
====Advantages==== | |||
=== | *These techniques demonstrated benefits even in patients without contraindications to surgery. More specifically, cases of primary lung abscess that were treated by Yellin A et al during a 5-year period (1978-1982) underwent successful percutaneous drainage, without any complications or relapse after 2-5 years of monitoring.<ref name="pmid39774692">{{cite journal |vauthors=Yellin A, Yellin EO, Lieberman Y |title=Percutaneous tube drainage: the treatment of choice for refractory lung abscess |journal=Ann. Thorac. Surg. |volume=39 |issue=3 |pages=266–70 |year=1985 |pmid=3977469 |doi= |url=}}</ref> | ||
* | *Percutaneous drainage of lung abscesses is characterized by high therapeutic effectiveness and preservation of functional lung tissue, it is a minimally invasive method with fewer complications and lower mortality rates (approximately 4%) in comparison to surgical management.<ref name="pmid123743592">{{cite journal |vauthors=Wali SO, Shugaeri A, Samman YS, Abdelaziz M |title=Percutaneous drainage of pyogenic lung abscess |journal=Scand. J. Infect. Dis. |volume=34 |issue=9 |pages=673–9 |year=2002 |pmid=12374359 |doi= |url=}}</ref> | ||
*In case of pleural space obliteration, with peripheral localization of lung abscess, it is possible to perform pneumostomy or cavernostomy-open drainage of abscess(Monaldi procedure) but it is limited due to its invasiveness. | |||
{| class="wikitable" | {| class="wikitable" | ||
!Type of chest drain | !Type of chest drain | ||
| Line 22: | Line 21: | ||
!Procedure | !Procedure | ||
!Complications | !Complications | ||
|- | |- | ||
|Percutaneous thoracocentesis | |Percutaneous thoracocentesis | ||
| | | | ||
* | *Patients who failed to respond to antibiotic therapy .<ref name="pmid1987590">{{cite journal |vauthors=vanSonnenberg E, D'Agostino HB, Casola G, Wittich GR, Varney RR, Harker C |title=Lung abscess: CT-guided drainage |journal=Radiology |volume=178 |issue=2 |pages=347–51 |year=1991 |pmid=1987590 |doi=10.1148/radiology.178.2.1987590 |url=}}</ref> | ||
*Patients | *Patients with severe immunodeficiency or on mechanical ventilation | ||
* | *Large lung abscesses(>6cms) | ||
| | | | ||
*Performed under fluoroscopic, ultrasound or computed tomography guidance. | *Performed under fluoroscopic, ultrasound or computed tomography guidance. | ||
*Two techniques of insertion of chest tube employed: Seldinger, and Trochar | *Two techniques of insertion of chest tube employed: Seldinger, and Trochar | ||
*Seldinger technique of insertion the tube is considered as it is safer | *Seldinger technique of insertion the tube is considered as it is safer and is accompanied by fewer complications<ref name="pmid10765396">{{cite journal |vauthors=Erasmus JJ, McAdams HP, Rossi S, Kelley MJ |title=Percutaneous management of intrapulmonary air and fluid collections |journal=Radiol. Clin. North Am. |volume=38 |issue=2 |pages=385–93 |year=2000 |pmid=10765396 |doi= |url=}}</ref> | ||
* Drainage duration varies but a minimum of 4-5 weeks are required and is done according to radiographic findings. | |||
* Chest tubes should not be flushed in order to avoid bronchogenic spread of the pus.<ref name="KelogrigorisTsagouli2011">{{cite journal|last1=Kelogrigoris|first1=M|last2=Tsagouli|first2=P|last3=Stathopoulos|first3=K|last4=Tsagaridou|first4=I|last5=Thanos|first5=L|title=Ct-guided percutaneous drainage of lung abscesses: review of 40 cases|journal=Journal of the Belgian Society of Radiology|volume=94|issue=4|year=2011|pages=191|issn=1780-2393|doi=10.5334/jbr-btr.583}}</ref> | |||
* Drainage duration varies but a minimum of 4-5 weeks are required and is done according to radiographic findings.Chest tubes should | * The usage of intra-cavitary fibrinolytic agents (streptokinase, urokinaze) is not recommended, due to possibility of bronchopulmonary or bronchopleural fistula can occur.<ref name="pmid18513667">{{cite journal |vauthors=Hogan MJ, Coley BD |title=Interventional radiology treatment of empyema and lung abscesses |journal=Paediatr Respir Rev |volume=9 |issue=2 |pages=77–84; quiz 84 |year=2008 |pmid=18513667 |doi=10.1016/j.prrv.2007.12.001 |url=}}</ref> | ||
* The usage of intra-cavitary fibrinolytic agents (streptokinase, urokinaze) is not recommended, due to possibility of | |||
| | | | ||
* | *Bending or leaking of the drainage catheter.<ref name="pmid3047789">{{cite journal |vauthors=Silverman SG, Mueller PR, Saini S, Hahn PF, Simeone JF, Forman BH, Steiner E, Ferrucci JT |title=Thoracic empyema: management with image-guided catheter drainage |journal=Radiology |volume=169 |issue=1 |pages=5–9 |year=1988 |pmid=3047789 |doi=10.1148/radiology.169.1.3047789 |url=}}</ref> | ||
*Hemothorax, | *Hemothorax, | ||
*Hemoptysis, | |||
*Pyopneumothorax | |||
*Fistula | |||
*Empyema. | |||
|- | |- | ||
|Endoscopic thoracic drainage | |Endoscopic thoracic drainage | ||
| Line 57: | Line 53: | ||
*For the abscesses with central locations in lungs. | *For the abscesses with central locations in lungs. | ||
| | | | ||
*A guidewire is inserted into the cavity through the working channel of a flexible bronchoscope.Once guidewire location has been ascertained by fluoroscopy, a 7 French pigtail catheter is advanced. | *A guidewire is inserted into the cavity through the working channel of a flexible bronchoscope. | ||
*If infusion of contrast medium via the catheter confirms its proper positioning, the guidewire and bronchoscope are withdrawn and the catheter tip is stabilized at the | *Once guidewire location has been ascertained by fluoroscopy, a 7 French pigtail catheter is advanced. | ||
*If the infusion of contrast medium via the catheter confirms its proper positioning, the guidewire and bronchoscope are withdrawn and the catheter tip is stabilized at the . | |||
*Subsequently, the cavity is flushed daily with normal saline solution through the catheter, along with antibiotic infusions (e.g. gentamicin or amphotericin in confirmed fungal infections).<ref name="pmid15821219">{{cite journal |vauthors=Herth F, Ernst A, Becker HD |title=Endoscopic drainage of lung abscesses: technique and outcome |journal=Chest |volume=127 |issue=4 |pages=1378–81 |year=2005 |pmid=15821219 |doi=10.1378/chest.127.4.1378 |url=}}</ref> | *Subsequently, the cavity is flushed daily with normal saline solution through the catheter, along with antibiotic infusions (e.g. gentamicin or amphotericin in confirmed fungal infections).<ref name="pmid15821219">{{cite journal |vauthors=Herth F, Ernst A, Becker HD |title=Endoscopic drainage of lung abscesses: technique and outcome |journal=Chest |volume=127 |issue=4 |pages=1378–81 |year=2005 |pmid=15821219 |doi=10.1378/chest.127.4.1378 |url=}}</ref> | ||
| Line 65: | Line 62: | ||
*The catheter is inserted through a bronchoscope and laser is used in order to perforate the wall of the abscess through the airway and to lead the catheter inside the cavity. The catheter is removed after 4-6 days with immediate improvement of clinical status and radiological imaging within the first 24 hours | *The catheter is inserted through a bronchoscope and laser is used in order to perforate the wall of the abscess through the airway and to lead the catheter inside the cavity. The catheter is removed after 4-6 days with immediate improvement of clinical status and radiological imaging within the first 24 hours | ||
| | | | ||
*Spillage of necrotic detritus | *Spillage of necrotic detritus . | ||
|} | |} | ||
===Surgical Intervention === | ===Bronchoscopy=== | ||
*It is reserved for patients who have an unchanged or increasing air-fluid level, patients who remain septic after 3 to 4 days of antimicrobial therapy, or where an endobronchial tumor is suspected.<ref name="pmid15821219">{{cite journal |vauthors=Herth F, Ernst A, Becker HD |title=Endoscopic drainage of lung abscesses: technique and outcome |journal=Chest |volume=127 |issue=4 |pages=1378–81 |year=2005 |pmid=15821219 |doi=10.1378/chest.127.4.1378 |url=}}</ref> | |||
*[[Bronchoscopy|Rigid bronchoscopy]] provides a greater capacity for suctioning but, it is not advisable to drain large (>6- to 8-cm diameter) abscesses, as sudden unloading of pus causes asphyxiation or acute respiratory distress syndrome.<ref name="pmid682290">{{cite journal |vauthors=Reeder GS, Gracey DR |title=Aspiration of intrathoracic abscess. Resultant acute ventilatory failure |journal=JAMA |volume=240 |issue=11 |pages=1156–9 |year=1978 |pmid=682290 |doi= |url=}}</ref> | |||
*Endobronchial catheters with the use of laser have been successfully employed for the drainage of refractory lung abscesses in selected patients. | |||
===Surgical Intervention=== | |||
Surgical resection is considered in about 10% of the patients when the chest drain has failed to improve symptoms and patients presenting with one of the following conditions. | Surgical resection is considered in about 10% of the patients when the chest drain has failed to improve symptoms and patients presenting with one of the following conditions. | ||
* Hemoptysis, | * [[Hemoptysis]], | ||
*Prolonged sepsis and febricity,<ref name="pmid22115254">{{cite journal |vauthors=Schweigert M, Dubecz A, Stadlhuber RJ, Stein HJ |title=Modern history of surgical management of lung abscess: from Harold Neuhof to current concepts |journal=Ann. Thorac. Surg. |volume=92 |issue=6 |pages=2293–7 |year=2011 |pmid=22115254 |doi=10.1016/j.athoracsur.2011.09.035 |url=}}</ref> | *[[Sepsis|Prolonged sepsis]] and [[Fever|febricity]],<ref name="pmid22115254">{{cite journal |vauthors=Schweigert M, Dubecz A, Stadlhuber RJ, Stein HJ |title=Modern history of surgical management of lung abscess: from Harold Neuhof to current concepts |journal=Ann. Thorac. Surg. |volume=92 |issue=6 |pages=2293–7 |year=2011 |pmid=22115254 |doi=10.1016/j.athoracsur.2011.09.035 |url=}}</ref> | ||
*Bronchopleural fistula, | *[[Bronchopleural fistula]], | ||
*Rupture of abscess in the pleural cavity with pyopneumothorax/empyema. | *Rupture of abscess in the pleural cavity with [[Pneumothorax|pyopneumothorax]]/[[empyema]]. | ||
*Unsuccessfully treated lung abscess more than 6 weeks, | *Unsuccessfully treated lung abscess more than 6 weeks, | ||
*Suspicion of cancer, | *[[Lung cancer|Suspicion of cancer]], | ||
*Cavitary lesion larger than 6 cm, | *Cavitary lesion larger than 6 cm, | ||
*Leukocytosis despite the use of antibiotics. | *[[Leukocytosis]] despite the use of antibiotics. | ||
===Surgical resection=== | ====Surgical resection==== | ||
*The surgical approach is thoracotomy and the extent of surgical resection depends on the size of the underlying lesion. <ref name="pmid22115254">{{cite journal |vauthors=Schweigert M, Dubecz A, Stadlhuber RJ, Stein HJ |title=Modern history of surgical management of lung abscess: from Harold Neuhof to current concepts |journal=Ann. Thorac. Surg. |volume=92 |issue=6 |pages=2293–7 |year=2011 |pmid=22115254 |doi=10.1016/j.athoracsur.2011.09.035 |url=}}</ref> | *The surgical approach is [[thoracotomy]] and the extent of surgical resection depends on the size of the underlying lesion. <ref name="pmid22115254">{{cite journal |vauthors=Schweigert M, Dubecz A, Stadlhuber RJ, Stein HJ |title=Modern history of surgical management of lung abscess: from Harold Neuhof to current concepts |journal=Ann. Thorac. Surg. |volume=92 |issue=6 |pages=2293–7 |year=2011 |pmid=22115254 |doi=10.1016/j.athoracsur.2011.09.035 |url=}}</ref> | ||
*Lobectomy is the most common type of surgical resection. Segmentectomies are performed in smaller abscesses (<2 cm), whereas a pneumonectomy should be performed in the presence of multiple abscesses or gangrene. <ref name="pmid9354511">{{cite journal |vauthors=Refaely Y, Weissberg D |title=Gangrene of the lung: treatment in two stages |journal=Ann. Thorac. Surg. |volume=64 |issue=4 |pages=970–3; discussion 973–4 |year=1997 |pmid=9354511 |doi= |url=}}</ref>,<ref name="pmid19101324">{{cite journal |vauthors=Chen CH, Huang WC, Chen TY, Hung TT, Liu HC, Chen CH |title=Massive necrotizing pneumonia with pulmonary gangrene |journal=Ann. Thorac. Surg. |volume=87 |issue=1 |pages=310–1 |year=2009 |pmid=19101324 |doi=10.1016/j.athoracsur.2008.05.077 |url=}}</ref> | *[[Lobectomy]] is the most common type of surgical resection. Segmentectomies are performed in smaller abscesses (<2 cm), whereas a [[pneumonectomy]] should be performed in the presence of multiple abscesses or [[gangrene]]. <ref name="pmid9354511">{{cite journal |vauthors=Refaely Y, Weissberg D |title=Gangrene of the lung: treatment in two stages |journal=Ann. Thorac. Surg. |volume=64 |issue=4 |pages=970–3; discussion 973–4 |year=1997 |pmid=9354511 |doi= |url=}}</ref>,<ref name="pmid19101324">{{cite journal |vauthors=Chen CH, Huang WC, Chen TY, Hung TT, Liu HC, Chen CH |title=Massive necrotizing pneumonia with pulmonary gangrene |journal=Ann. Thorac. Surg. |volume=87 |issue=1 |pages=310–1 |year=2009 |pmid=19101324 |doi=10.1016/j.athoracsur.2008.05.077 |url=}}</ref> | ||
*Open surgical drainage is employed either by creating a pouch-like cavity communicating with the thoracic wall through limited rib resection in case of thoracotomy contraindication. | *Open surgical drainage is employed either by creating a pouch-like cavity communicating with the thoracic wall through limited rib resection in case of [[Thoracotomy|thoracotomy contraindication.]] | ||
*When sepsis cannot be controlled with conservative measures and in conditions that prohibit resection, debridement of the dead tissue is followed by immediate filling of the cavity with highly vascular tissue, or debridement and cavity fistulization into the pleural space followed by drainage by means of a chest tube is proposed. | *When [[sepsis]] cannot be controlled with conservative measures and in conditions that prohibit resection, [[Debridement|debridement of the dead tissue]] is followed by immediate filling of the cavity with highly vascular tissue, or debridement and cavity [[Fistula|fistulization]] into the pleural space followed by drainage by means of a chest tube is proposed. | ||
*When the chronic inflammatory process of pulmonary infection causes incomplete re-expansion of the remaining lobes, it is quite possible that a portion of the pleural space will remain empty. Some thoracic surgeons recommend filling that space with a large pedicled ipsilateral latissimus dorsi muscle flap or omentum. | *When the chronic inflammatory process of [[Pneumonia|pulmonary infection]] causes incomplete re-expansion of the remaining lobes, it is quite possible that a portion of the [[pleural space]] will remain empty. Some thoracic surgeons recommend filling that space with a large pedicled ipsilateral [[Latissimus dorsi muscle|latissimus dorsi]] muscle flap or [[omentum]]. | ||
*In addition, bronchial stump reinforcement with a pedicled intercostal muscle flap or other highly vascular tissue may prevent the formation of a bronchopleural fistula. | *In addition, bronchial stump reinforcement with a [[Intercostal muscle|pedicled intercostal muscle flap]] or other highly vascular tissue may prevent the formation of a bronchopleural fistula. | ||
*Cross-contamination of contralateral lung is the main complication to be feared of during surgery. Placement of a double-lumen endotracheal tube, prone positioning of the patient and artificial obstruction of the main bronchus before removing the abscess are the usual measures for preventing cross-contamination. | *[[Contamination|Cross-contamination]] of contralateral lung is the main complication to be feared of during surgery. Placement of a double-lumen [[endotracheal tube]], [[Prone position|prone positioning]] of the patient and artificial obstruction of the [[main bronchus]] before removing the abscess are the usual measures for preventing cross-contamination. | ||
*Recently, a thoracoscopic technique (Video-assisted thoracoscopic surgery: VATS) for abscess debridement and drainage has been effectively implemented in a small number of patients | *Recently, a thoracoscopic technique (Video-assisted thoracoscopic surgery: VATS) for abscess debridement and drainage has been effectively implemented in a small number of patients | ||
== Reference == | == Reference == | ||
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American Roentgen Ray Society Images of Lung abscess surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Surgery is considered as the last resort of therapy when both medical and chest drain failed to resolve symptoms and is considered when Abscess > 6 cm in diameter and in conditions where symptoms last for more than 12 weeks with appropriate therapy.
Surgical Options
- Options for surgery includes: Chest tube drainage and surgical resection of the lung abscess with the surrounding lung tissue
Chest tube drainage
- Percutaneous and endoscopic drainage techniques are considered as a first-line management, especially for patients who are not candidates for surgery [1]
- ACR-SIR-SPR practice guideline for specifications and performance of image-guided percutaneous drainage/aspiration of abscesses and fluid collections (PDAFC) had submiited guidelines on image-guided percutaneous drainage/aspiration of abscesses and fluid collections.
Advantages
- These techniques demonstrated benefits even in patients without contraindications to surgery. More specifically, cases of primary lung abscess that were treated by Yellin A et al during a 5-year period (1978-1982) underwent successful percutaneous drainage, without any complications or relapse after 2-5 years of monitoring.[2]
- Percutaneous drainage of lung abscesses is characterized by high therapeutic effectiveness and preservation of functional lung tissue, it is a minimally invasive method with fewer complications and lower mortality rates (approximately 4%) in comparison to surgical management.[3]
- In case of pleural space obliteration, with peripheral localization of lung abscess, it is possible to perform pneumostomy or cavernostomy-open drainage of abscess(Monaldi procedure) but it is limited due to its invasiveness.
| Type of chest drain | Indications | Procedure | Complications |
|---|---|---|---|
| Percutaneous thoracocentesis |
|
|
|
| Endoscopic thoracic drainage |
|
|
|
Bronchoscopy
- It is reserved for patients who have an unchanged or increasing air-fluid level, patients who remain septic after 3 to 4 days of antimicrobial therapy, or where an endobronchial tumor is suspected.[8]
- Rigid bronchoscopy provides a greater capacity for suctioning but, it is not advisable to drain large (>6- to 8-cm diameter) abscesses, as sudden unloading of pus causes asphyxiation or acute respiratory distress syndrome.[10]
- Endobronchial catheters with the use of laser have been successfully employed for the drainage of refractory lung abscesses in selected patients.
Surgical Intervention
Surgical resection is considered in about 10% of the patients when the chest drain has failed to improve symptoms and patients presenting with one of the following conditions.
- Hemoptysis,
- Prolonged sepsis and febricity,[11]
- Bronchopleural fistula,
- Rupture of abscess in the pleural cavity with pyopneumothorax/empyema.
- Unsuccessfully treated lung abscess more than 6 weeks,
- Suspicion of cancer,
- Cavitary lesion larger than 6 cm,
- Leukocytosis despite the use of antibiotics.
Surgical resection
- The surgical approach is thoracotomy and the extent of surgical resection depends on the size of the underlying lesion. [11]
- Lobectomy is the most common type of surgical resection. Segmentectomies are performed in smaller abscesses (<2 cm), whereas a pneumonectomy should be performed in the presence of multiple abscesses or gangrene. [12],[13]
- Open surgical drainage is employed either by creating a pouch-like cavity communicating with the thoracic wall through limited rib resection in case of thoracotomy contraindication.
- When sepsis cannot be controlled with conservative measures and in conditions that prohibit resection, debridement of the dead tissue is followed by immediate filling of the cavity with highly vascular tissue, or debridement and cavity fistulization into the pleural space followed by drainage by means of a chest tube is proposed.
- When the chronic inflammatory process of pulmonary infection causes incomplete re-expansion of the remaining lobes, it is quite possible that a portion of the pleural space will remain empty. Some thoracic surgeons recommend filling that space with a large pedicled ipsilateral latissimus dorsi muscle flap or omentum.
- In addition, bronchial stump reinforcement with a pedicled intercostal muscle flap or other highly vascular tissue may prevent the formation of a bronchopleural fistula.
- Cross-contamination of contralateral lung is the main complication to be feared of during surgery. Placement of a double-lumen endotracheal tube, prone positioning of the patient and artificial obstruction of the main bronchus before removing the abscess are the usual measures for preventing cross-contamination.
- Recently, a thoracoscopic technique (Video-assisted thoracoscopic surgery: VATS) for abscess debridement and drainage has been effectively implemented in a small number of patients
Reference
- ↑ 1.0 1.1 Kelogrigoris, M; Tsagouli, P; Stathopoulos, K; Tsagaridou, I; Thanos, L (2011). "Ct-guided percutaneous drainage of lung abscesses: review of 40 cases". Journal of the Belgian Society of Radiology. 94 (4): 191. doi:10.5334/jbr-btr.583. ISSN 1780-2393.
- ↑ Yellin A, Yellin EO, Lieberman Y (1985). "Percutaneous tube drainage: the treatment of choice for refractory lung abscess". Ann. Thorac. Surg. 39 (3): 266–70. PMID 3977469.
- ↑ Wali SO, Shugaeri A, Samman YS, Abdelaziz M (2002). "Percutaneous drainage of pyogenic lung abscess". Scand. J. Infect. Dis. 34 (9): 673–9. PMID 12374359.
- ↑ vanSonnenberg E, D'Agostino HB, Casola G, Wittich GR, Varney RR, Harker C (1991). "Lung abscess: CT-guided drainage". Radiology. 178 (2): 347–51. doi:10.1148/radiology.178.2.1987590. PMID 1987590.
- ↑ Erasmus JJ, McAdams HP, Rossi S, Kelley MJ (2000). "Percutaneous management of intrapulmonary air and fluid collections". Radiol. Clin. North Am. 38 (2): 385–93. PMID 10765396.
- ↑ Hogan MJ, Coley BD (2008). "Interventional radiology treatment of empyema and lung abscesses". Paediatr Respir Rev. 9 (2): 77–84, quiz 84. doi:10.1016/j.prrv.2007.12.001. PMID 18513667.
- ↑ Silverman SG, Mueller PR, Saini S, Hahn PF, Simeone JF, Forman BH, Steiner E, Ferrucci JT (1988). "Thoracic empyema: management with image-guided catheter drainage". Radiology. 169 (1): 5–9. doi:10.1148/radiology.169.1.3047789. PMID 3047789.
- ↑ 8.0 8.1 Herth F, Ernst A, Becker HD (2005). "Endoscopic drainage of lung abscesses: technique and outcome". Chest. 127 (4): 1378–81. doi:10.1378/chest.127.4.1378. PMID 15821219.
- ↑ Shlomi D, Kramer MR, Fuks L, Peled N, Shitrit D (2010). "Endobronchial drainage of lung abscess: the use of laser". Scand. J. Infect. Dis. 42 (1): 65–8. doi:10.3109/00365540903292690. PMID 19883156.
- ↑ Reeder GS, Gracey DR (1978). "Aspiration of intrathoracic abscess. Resultant acute ventilatory failure". JAMA. 240 (11): 1156–9. PMID 682290.
- ↑ 11.0 11.1 Schweigert M, Dubecz A, Stadlhuber RJ, Stein HJ (2011). "Modern history of surgical management of lung abscess: from Harold Neuhof to current concepts". Ann. Thorac. Surg. 92 (6): 2293–7. doi:10.1016/j.athoracsur.2011.09.035. PMID 22115254.
- ↑ Refaely Y, Weissberg D (1997). "Gangrene of the lung: treatment in two stages". Ann. Thorac. Surg. 64 (4): 970–3, discussion 973–4. PMID 9354511.
- ↑ Chen CH, Huang WC, Chen TY, Hung TT, Liu HC, Chen CH (2009). "Massive necrotizing pneumonia with pulmonary gangrene". Ann. Thorac. Surg. 87 (1): 310–1. doi:10.1016/j.athoracsur.2008.05.077. PMID 19101324.