Surgery_Schwartz

Surgery_Schwartz. fistula is very small (<4 mm), bronchoscopic fibrin glue application has been used successfully to seal the hole in some patients. Patients often have concomitant empy-ema, and open drainage may be necessary.Spontaneous PneumothoraxSpontaneous pneumothorax is secondary to intrinsic abnormali-ties of the lung and can be classified as primary and secondary. Primary spontaneous pneumothorax is defined as a spontaneous pneumothorax without underlying lung disease. The most com-mon cause is rupture of an apical subpleural bleb. The cause of these blebs is unknown, but they occur more frequently in smokers and males, and they tend to predominate in young postadolescent males with a tall thin body habitus. Treatment is generally chest tube insertion with water seal. If a leak is present and persists for greater than 3 days, thoracoscopic man-agement (i.e., bleb resection with pleurodesis by talc or pleural abrasion) is performed. Recurrences or complete lung collapse with the first episode


Surgery_Schwartz

Surgery_Schwartz. for greater than 3 days, thoracoscopic man-agement (i.e., bleb resection with pleurodesis by talc or pleural abrasion) is performed. Recurrences or complete lung collapse with the first episode are generally indications for thoracoscopic Brunicardi_Ch19_p0661-p0750.indd 70501/03/19 7:01 PM 706SPECIFIC CONSIDERATIONSPART IIintervention.86 Additional indications for intervention on the first episode include occupational hazards such as air travel, deep-sea diving, or travel to remote locations. CT findings of multiple small bullae or a large bleb are associated with an increased risk of recurrent pneumothorax.87 Many surgeons are now using screening CT scan to recommend VATS bleb resection with pleurodesis for first-episode spontaneous pneumothorax.Secondary spontaneous pneumothorax occurs in the set-ting of underlying lung disease, such as emphysema (rupture of a bleb or bulla), cystic fibrosis, acquired immunodeficiency syndrome (AIDS), metastatic cancer (especially sarcoma),


Surgery_Schwartz

Surgery_Schwartz. occurs in the set-ting of underlying lung disease, such as emphysema (rupture of a bleb or bulla), cystic fibrosis, acquired immunodeficiency syndrome (AIDS), metastatic cancer (especially sarcoma), asthma, lung abscess, and occasionally lung cancer. Catame-nial pneumothorax, a rare but interesting cause of spontaneous pneumothorax in women in their second and third decades, occurs within 72 hours of the onset of menses and is possibil-ity related to endometriosis. Management of pneumothorax in these circumstances is similar to that of primary spontane-ous pneumothorax in that drainage and lung reexpansion are required. Additional therapy, however, is often tied to therapy of the specific disease process and may involve lung resection, thoracoscopic pleurectomy, or talc pleurodesis.Pulmonary InfectionsLung Abscess. A lung abscess is a localized area of pulmonary parenchymal necrosis caused by an infectious organism; tissue destruction results in a solitary or dominant cavity measuring


Surgery_Schwartz

Surgery_Schwartz. InfectionsLung Abscess. A lung abscess is a localized area of pulmonary parenchymal necrosis caused by an infectious organism; tissue destruction results in a solitary or dominant cavity measuring at least 2 cm in diameter. Less often, there may be multiple, smaller cavities (<2 cm). In that case, the infection is typically referred to as a necrotizing pneumonia. An abscess that is pres-ent for more than 6 weeks is considered chronic.Based on the etiology (Table 19-17), lung abscesses are further classified as primary or secondary. A primary lung abscess occurs, for example, in immunocompromised patients, as a result of highly virulent organisms inciting a necrotizing pulmonary infection, or in patients who have a predisposition to aspirate oropharyngeal or gastrointestinal secretions. A second-ary lung abscess occurs in patients with an underlying condition such as a partial bronchial obstruction, a lung infarct, or adjacent suppurative infections (subphrenic or hepatic


Surgery_Schwartz

Surgery_Schwartz. A second-ary lung abscess occurs in patients with an underlying condition such as a partial bronchial obstruction, a lung infarct, or adjacent suppurative infections (subphrenic or hepatic abscesses).88Pathogenesis Lung abscesses result when necrotizing micro-organisms infect the lower respiratory tract via inhalation of aerosolized particles, aspiration of oropharyngeal secretions, or hematogenous spread from distant sites. Direct extension from a contiguous site is less frequent. Most primary lung abscesses are suppurative bacterial infections secondary to aspiration. Risk factors for pulmonary aspiration include advanced age, conditions of impaired consciousness, suppressed cough reflex, dysfunctional esophageal motility, laryngopharygeal reflux disease, and centrally acting neurologic diseases (e.g., stroke). At the time of aspiration, the composition of the oropharyn-geal flora determines the etiologic organisms. With increasing use of proton pump inhibitors to suppress acid


Surgery_Schwartz

Surgery_Schwartz. diseases (e.g., stroke). At the time of aspiration, the composition of the oropharyn-geal flora determines the etiologic organisms. With increasing use of proton pump inhibitors to suppress acid secretion in the stomach, the oropharyngeal flora has shifted, and the risk of developing bacterial lung infections after an aspiration event has increased.89 Secondary lung abscesses occur most often distal to an obstructing bronchial carcinoma. Infected cysts or bullae are not considered true abscesses.Microbiology Normal oropharyngeal secretions contain many more Streptococcus species and more anaerobes (approxi-mately 1 × 108 organisms/mL) than aerobes (approximately 1 × 107 organisms/mL). Pneumonia that follows from Table 19-17Causes of lung abscess I. Primary A. Necrotizing pneumonia 1. Staphylococcus aureus, Klebsiella, Pseudomonas, Mycobacterium 2. Bacteroides, Fusobacterium, Actinomyces 3. Entamoeba, Echinococcus B. Aspiration pneumonia 1. Anesthesia 2. Stroke 3. Drugs or


Surgery_Schwartz

Surgery_Schwartz. aureus, Klebsiella, Pseudomonas, Mycobacterium 2. Bacteroides, Fusobacterium, Actinomyces 3. Entamoeba, Echinococcus B. Aspiration pneumonia 1. Anesthesia 2. Stroke 3. Drugs or alcohol C. Esophageal disease 1. Achalasia, Zenker’s diverticulum, gastroesophageal reflux D. Immunodeficiency 1. Cancer (and chemotherapy) 2. Diabetes 3. Organ transplantation 4. Steroid therapy 5. Malnutrition II. Secondary A. Bronchial obstruction 1. Neoplasm 2. Foreign body B. Systemic sepsis 1. Septic pulmonary emboli 2. Seeding of pulmonary infarct C. Complication of pulmonary trauma 1. Infection of hematoma or contusion 2. Contaminated foreign body or penetrating injury D. Direct extension from extraparenchymal infection 1. Pleural empyema 2. Mediastinal, hepatic, subphrenic abscessAdapted with permission from Schwartz SI, Fischer JE, Daly JM, et al: Principles of Surgery, 7th ed. New York, NY: McGraw-Hill Education; 1999.aspiration, with or without abscess development, is typically polymicrobial. An


Surgery_Schwartz

Surgery_Schwartz. from Schwartz SI, Fischer JE, Daly JM, et al: Principles of Surgery, 7th ed. New York, NY: McGraw-Hill Education; 1999.aspiration, with or without abscess development, is typically polymicrobial. An average of two to four isolates present in large numbers have been cultured from lung abscesses sam-pled percutaneously. Overall, at least 50% of these infections are caused by purely anaerobic bacteria, 25% are caused by mixed aerobes and anaerobes, and 25% or fewer are caused by aerobes only. In nosocomial pneumonia, 60% to 70% of the organisms are gram-negative bacteria. Immunosuppressed patients may develop abscesses because of the usual pathogens as well as less virulent and opportunistic organisms such as Salmonella species, Legionella species, Pneumocystis carinii, atypical mycobacteria, and fungi.Clinical Features and Diagnosis The typical presentation may include productive cough, fever (>38.9°C), chills, leuko-cytosis (>15,000 cells/mm3), weight loss, fatigue, malaise, pleu-ritic


Surgery_Schwartz

Surgery_Schwartz. and fungi.Clinical Features and Diagnosis The typical presentation may include productive cough, fever (>38.9°C), chills, leuko-cytosis (>15,000 cells/mm3), weight loss, fatigue, malaise, pleu-ritic chest pain, and dyspnea. Lung abscesses may also present in a more indolent fashion, with weeks to months of cough, mal-aise, weight loss, low-grade fever, night sweats, leukocytosis, and anemia. After aspiration pneumonia, 1 to 2 weeks typically elapse before cavitation occurs; 40% to 75% of such patients produce putrid, foul-smelling sputum. Severe complications Brunicardi_Ch19_p0661-p0750.indd 70601/03/19 7:01 PM


Surgery_Schwartz

Surgery_Schwartz. CHAPTER 19707CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAABCFigure 19-30. Lung abscess resulting from emesis and aspi-ration after an alcoholic binge. A. Chest X-ray showing an abscess cavity in the left upper lobe. B. A coronal tomogram highlights the thin wall of the abscess. C. Healing of the abscess cavity after 4 weeks of antibiotic therapy and pos-tural drainage.such as massive hemoptysis, endobronchial spread to other portions of the lungs, rupture into the pleural space and devel-opment of pyopneumothorax, or septic shock and respiratory failure are rare in the modern antibiotic era. The mortality rate is about 5% to 10%, except in the presence of immunosuppres-sion, where rates range from 9% to 28%.The CXR is the primary tool for diagnosing a lung abscess (Fig. 19-30). Its distinguishing characteristic is a density or mass with a relatively thin-walled cavity. An air-fluid level observed within the abscess indicates communication with the tracheobronchial tree. CT scan of the


Surgery_Schwartz

Surgery_Schwartz. characteristic is a density or mass with a relatively thin-walled cavity. An air-fluid level observed within the abscess indicates communication with the tracheobronchial tree. CT scan of the chest clarifies the diag-nosis when CXR is equivocal and identifies endobronchial obstruction and/or an associated mass and other pathologic anomalies. A cavitating lung carcinoma is frequently mistaken for a lung abscess. Differential diagnosis also includes loculated or interlobar empyema, infected lung cysts or bullae, tuberculo-sis, bronchiectasis, fungal infections, and noninfectious inflam-matory conditions (e.g., Wegener’s granulomatosis).Ideally, the specific etiologic organism is identified before antibiotic administration. Bronchoscopy, which is essential to Brunicardi_Ch19_p0661-p0750.indd 70701/03/19 7:01 PM 708SPECIFIC CONSIDERATIONSPART IIrule out endobronchial obstruction due to tumor or foreign body, is ideal for obtaining uncontaminated cultures using bronchoal-veolar lavage.


Surgery_Schwartz

Surgery_Schwartz. 70701/03/19 7:01 PM 708SPECIFIC CONSIDERATIONSPART IIrule out endobronchial obstruction due to tumor or foreign body, is ideal for obtaining uncontaminated cultures using bronchoal-veolar lavage. Culture samples can also be obtained by percu-taneous, transthoracic FNA under ultrasound or CT guidance. Routine sputum cultures are often of limited usefulness because of contamination with upper respiratory tract flora.Actinomycosis and nocardiosis, although rare, are particu-larly virulent infections associated with lung abscess. Diagnosis can be difficult.90 Both frequently masquerade as other clinical syndromes; thus, it is important for the surgeon to keep these bacteria in mind when considering the differential diagnosis for cavitary lung lesions. Actinomyces, a normal oropharyngeal bacterium, causes extensive pulmonary damage. Actinomyco-sis lung infection typically begins as acute pneumonitis after pulmonary aspiration. The symptoms mimic pulmonary tuber-culosis, including


Surgery_Schwartz

Surgery_Schwartz. bacterium, causes extensive pulmonary damage. Actinomyco-sis lung infection typically begins as acute pneumonitis after pulmonary aspiration. The symptoms mimic pulmonary tuber-culosis, including chronic cough, night sweats, weight loss, and hemoptysis.Ongoing infection leads to chronic inflammation and fibrosis; cavitation occurs due to destruction of the pulmonary tissues. Without treatment, the infection continues to destroy surrounding structures, resulting in fistula formation to adja-cent structures, including the adjacent lung, interlobar fissures, pleural space, chest wall, and mediastinum. Actinomyces israelii is the most common of the species to cause disease. Nocardi-osis is also a rare opportunistic infection that usually occurs in an immunocompromised host (HIV or cancer patients) and causes both local and systemic suppurative infections. The most common site is pulmonary, caused by Nocardia asteroides in 90% of cases. Infection is slowly progressive, with weight loss,


Surgery_Schwartz

Surgery_Schwartz. and causes both local and systemic suppurative infections. The most common site is pulmonary, caused by Nocardia asteroides in 90% of cases. Infection is slowly progressive, with weight loss, fatigue, cough, and hemoptysis. An acute pulmonary infec-tion is common, with necrotizing pneumonia and cavitation or slowly enlarging pulmonary nodule. In some cases, empyema also develops.Management of Lung Abscess Systemic antibiotics directed against the causative organism represent the mainstay of therapy. The duration of antimicrobial therapy varies from 3 to 12 weeks for necrotizing pneumonia and lung abscess. It is likely best to treat until the cavity is resolved or until serial radiographs show significant improvement. Parenteral therapy is generally used until the patient is afebrile and able to demonstrate consistent enteral intake. Oral therapy can then be used to complete the course of therapy. For community-acquired infections second-ary to aspiration, likely pathogens are


Surgery_Schwartz

Surgery_Schwartz. and able to demonstrate consistent enteral intake. Oral therapy can then be used to complete the course of therapy. For community-acquired infections second-ary to aspiration, likely pathogens are oropharyngeal streptococci and anaerobes. Penicillin G, ampicillin, and amoxicillin are the main therapeutic agents, but a β-lactamase inhibitor or metro-nidazole should be added to cover the increasing prevalence of gram-negative anaerobes that produce β-lactamase. Clindamycin is also a primary therapeutic agent. For hospital-acquired infec-tions, Staphylococcus aureus and aerobic gram-negative bacilli are common organisms of the oropharyngeal flora. Piperacillin with a β-lactamase inhibitor (or equivalent alternatives) provide better coverage of likely pathogens.Surgical drainage of lung abscesses is uncommon since drainage usually occurs spontaneously via the tracheobron-chial tree. Indications for intervention are listed in Table 19-18. Drainage and resection may be required for


Surgery_Schwartz

Surgery_Schwartz. abscesses is uncommon since drainage usually occurs spontaneously via the tracheobron-chial tree. Indications for intervention are listed in Table 19-18. Drainage and resection may be required for actinomycosis and nocardiosis; diagnosis is often delayed because the bacteria are difficult to culture; invasion of the infection into surrounding structures is, therefore, common. Once identified, long-term antibiotics (months to years) are typically required along with drainage, debridement, and resection as needed. While penicil-lin derivatives are effective against most Actinomyces species, the infections are typically polymicrobial, and broad-spectrum parenteral antibiotics may be required. Nocardia species, in contrast, are highly variable; specific identification of the infect-ing species with antibiotic sensitivities is needed to direct appro-priate therapy. Evaluation for malignant spread, particularly to the brain, is also required in the management of nocardiosis, as systemic


Surgery_Schwartz

Surgery_Schwartz. with antibiotic sensitivities is needed to direct appro-priate therapy. Evaluation for malignant spread, particularly to the brain, is also required in the management of nocardiosis, as systemic dissemination occurs early and frequently.External drainage may be accomplished with tube tho-racostomy, percutaneous drainage, or surgical cavernostomy. The choice between tube thoracostomy versus radiographically guided catheter placement depends on the treating physician’s preference and institutional technical expertise in placing image-guided thoracostomy tubes. Surgical resection is required in fewer than 10% of lung abscess patients. Lobectomy is the preferred intervention for bleeding from a lung abscess or pyo-pneumothorax. An important intraoperative consideration is to protect the contralateral lung with a double-lumen tube, bron-chial blocker, or contralateral main stem intubation. Surgical treatment has a 90% success rate, with associated mortality of 1% to


Surgery_Schwartz

Surgery_Schwartz. is to protect the contralateral lung with a double-lumen tube, bron-chial blocker, or contralateral main stem intubation. Surgical treatment has a 90% success rate, with associated mortality of 1% to 13%.Bronchiectasis. Bronchiectasis is defined as a pathologic and permanent dilation of bronchi with bronchial wall thickening. This condition may be localized to certain bronchial segments, or it may be diffuse throughout the bronchial tree, typically affecting the medium-sized airways. Overall, this is a rare clini-cal entity in the United States with a prevalence of less than 1 in 10,000, although the incidence has increased in recent years and noncystic fibrosis–related bronchiectasis is now thought to affect 27.5 out of every 10,000 persons over age 75.Pathogenesis Development of bronchiectasis can be attributed to either congenital or acquired causes. The principal congeni-tal diseases that lead to bronchiectasis include cystic fibrosis, primary ciliary dyskinesia, and


Surgery_Schwartz

Surgery_Schwartz. of bronchiectasis can be attributed to either congenital or acquired causes. The principal congeni-tal diseases that lead to bronchiectasis include cystic fibrosis, primary ciliary dyskinesia, and immunoglobulin deficiencies (e.g., selective IgA deficiency). Congenital causes commonly produce a diffuse pattern of bronchial involvement. Acquired causes are categorized broadly as infectious and inflammatory. Bronchial obstruction from cancer, inhaled objects, extrinsic airway compression, or inspissated sputum promotes localized infection and subsequent medium airway destruction. Diffuse pneumonic processes from pathogens including necrotizing bacterial pneumonia, pertussis and measles pneumonia, severe influenza, or varicella pneumonia can lead to widespread bron-chiectasis. Chronic granulomatous disease, immunodeficiency disorders, and hypersensitivity disorders can also lead to diffuse bronchiectasis.Noninfectious causes of bronchiectasis include inhala-tion of toxic gases such as


Surgery_Schwartz

Surgery_Schwartz. disease, immunodeficiency disorders, and hypersensitivity disorders can also lead to diffuse bronchiectasis.Noninfectious causes of bronchiectasis include inhala-tion of toxic gases such as ammonia, which results in severe Table 19-18Indications for surgical drainage procedures for lung abscesses 1. Failure of medical therapy 2. Abscess under tension 3. Abscess increasing in size during appropriate treatment 4. Contralateral lung contamination 5. Abscess >4–6 cm in diameter 6. Necrotizing infection with multiple abscesses, hemoptysis, abscess rupture, or pyopneumothorax 7. Inability to exclude a cavitating carcinomaBrunicardi_Ch19_p0661-p0750.indd 70801/03/19 7:01 PM


Surgery_Schwartz

Surgery_Schwartz. CHAPTER 19709CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAFigure 19-31. Multiple cystic-type bronchiectatic cavities can be seen on a cut section of right lower lobe lung.and destructive airway inflammatory responses. Allergic bronchopulmonary aspergillosis, Sjögren’s syndrome, and α1-antitrypsin deficiency are some additional examples of presumed immunologic disorders that may be accompanied by bronchiectasis.In addition, recent studies have suggested an association between chronic gastroesophageal reflux disease, acid sup-pression, and nontuberculous mycobacterial infection with bronchiectasis.91,92 This interaction is thought to be related to chronic aspiration of colonized gastric secretions in the setting of acid suppression; while not proven to be causative, these findings suggest a role for gastroesophageal reflux dis-ease in the pathogenesis of bronchiectasis. The process shared by all causes of bronchiectasis is impairment of airway defenses or deficits in immunologic mechanisms,


Surgery_Schwartz

Surgery_Schwartz. for gastroesophageal reflux dis-ease in the pathogenesis of bronchiectasis. The process shared by all causes of bronchiectasis is impairment of airway defenses or deficits in immunologic mechanisms, which permit bacterial colonization and chronic infection. Common organisms include Haemophilus species (55%), Pseudomonas species (26%), and Streptococcus pneu-moniae (12%).93 Both the bacterial organisms and the inflamma-tory cells recruited to thwart the bacteria elaborate proteolytic and oxidative molecules, which progressively destroy the mus-cular and elastic components of the airway walls; those compo-nents are then replaced by fibrous tissue. Thus, chronic airway inflammation is the essential pathologic feature of bronchiec-tasis. The dilated airways are usually filled with thick purulent material; more distal airways are often occluded by secretions or obliterated by fibrous tissue. Bronchial wall vascularity increases, bronchial arteries become hypertrophied, and abnor-mal


Surgery_Schwartz

Surgery_Schwartz. purulent material; more distal airways are often occluded by secretions or obliterated by fibrous tissue. Bronchial wall vascularity increases, bronchial arteries become hypertrophied, and abnor-mal anastomoses form between the bronchial and pulmonary arterial circulation.There are three principal types of bronchiectasis, based on pathologic morphology: cylindrical—uniformly dilated bronchi; varicose—an irregular or beaded pattern of dilated bronchi; and saccular (cystic)—peripheral balloon-type bronchial dilation. The saccular type is the most common after bronchial obstruc-tion or infection (Fig. 19-31).Clinical Manifestations and Diagnosis Typical symptoms are a daily persistent cough and purulent sputum production; the quantity of daily sputum production (10 mL to >150 mL) corre-lates with disease extent and severity. Other patients may appear asymptomatic or have a dry nonproductive cough (“dry bronchi-ectasis”). These patients are prone to have involvement of the upper lobes.


Surgery_Schwartz

Surgery_Schwartz. with disease extent and severity. Other patients may appear asymptomatic or have a dry nonproductive cough (“dry bronchi-ectasis”). These patients are prone to have involvement of the upper lobes. The clinical course is characterized by progressive 9symptoms and respiratory impairment. Increasing resting and exertional dyspnea are the result of progressive airway obstruc-tion. Acute exacerbations may be triggered by viral or bacterial pathogens. Bleeding attributable to chronically inflamed, friable airway mucosa causes increasingly more frequent hemoptysis with disease progression. Massive bleeding may result from ero-sion of the hypertrophied bronchial arteries.Both mild and severe forms of bronchiectasis are read-ily demonstrated with chest CT scanning because it provides a highly detailed, cross-sectional view of bronchial architecture. CXRs, although less sensitive, may reveal characteristic signs of bronchiectasis such as lung hyperinflation, bronchiectatic cysts, and dilated,


Surgery_Schwartz

Surgery_Schwartz. cross-sectional view of bronchial architecture. CXRs, although less sensitive, may reveal characteristic signs of bronchiectasis such as lung hyperinflation, bronchiectatic cysts, and dilated, thick-walled bronchi forming train track–like pat-terns radiating from the lung hila. Sputum culture may identify characteristic pathogens.Sputum acid-fast bacillus smears/cultures should be performed to evaluate for nontuberculous mycobacteria, which is common in this setting. Spirometry provides assessment of the severity of airway obstruction and can be followed to track the course of disease. Management of Bronchiectasis Standard therapy includes optimizing airway clearance, use of bronchodilators to reverse any airflow limitation, and correction of reversible underly-ing causes whenever possible.94 Chest physiotherapy based on vibration, percussion, and postural drainage is widely accepted, although randomized trials demonstrating efficacy are lacking. Acute exacerbations should be treated


Surgery_Schwartz

Surgery_Schwartz. Chest physiotherapy based on vibration, percussion, and postural drainage is widely accepted, although randomized trials demonstrating efficacy are lacking. Acute exacerbations should be treated with a 2to 3-week course of broad-spectrum intravenous antibiotics tailored to culture and sensitivity profiles, followed by an oral regimen; this will result in a longer-lasting remission.Macrolide antibiotics have been shown to decrease sputum production, inhibit cytokine release, and inhibit neutrophil adhe-sion and formation of reactive oxygen species. They also inhibit migration of Pseudomonas, disrupt biofilm, and prevent release of virulence factors.95 While macrolide therapy does appear to be efficacious, it is important to remember that macrolides have sig-nificant activity against nontuberculous mycobacteria, and wide-spread prophylactic use for patients with bronchiectasis may lead to multidrug-resistant nontuberculous mycobacterial species. It has also been suggested that inhaled


Surgery_Schwartz

Surgery_Schwartz. mycobacteria, and wide-spread prophylactic use for patients with bronchiectasis may lead to multidrug-resistant nontuberculous mycobacterial species. It has also been suggested that inhaled antibiotics, such as tobramy-cin and colistin, improve rates of bacterial clearance and slow the decline in pulmonary function associated with bronchiectasis. Meta-analysis of 12 randomized trials involving 1154 patients showed efficacy of inhaled antibiotics compared to controls, but did not reduce risk of acute exacerbation. Quality of life, like-wise, was not improved and antibiotic-resistant Pseudomonas rates were similar. Importantly, inhaled antibiotics were associ-ated with a statistically significant reduction in forced expiratory volume in 1 second measures over time.96,97In addition to antibiotics, daily nebulized hypertonic saline appears to be effective. A recent randomized crossover study comparing lung function and quality of life has shown that 7% normal saline, compared to isotonic


Surgery_Schwartz

Surgery_Schwartz. daily nebulized hypertonic saline appears to be effective. A recent randomized crossover study comparing lung function and quality of life has shown that 7% normal saline, compared to isotonic saline, results in a statisti-cally significant 15% increase in FEV1 and an 11% increase in forced vital capacity (compared to 1.8% and 0.7%, respec-tively, with isotonic saline). Antibiotic use and emergency room utilization were significantly decreased; from this, hypertonic saline appears to be a reasonable adjunct to maintaining quality of life and decreasing exacerbations by reducing sputum vol-ume, improving mucociliary clearance, and slowing the decline in lung function.98 Studies supporting mucolytics such as DNase and Mucomyst for non–cystic fibrosis bronchiectasis have Brunicardi_Ch19_p0661-p0750.indd 70901/03/19 7:01 PM 710SPECIFIC CONSIDERATIONSPART IIshown either no change or a worsening of pulmonary status and require further study in the non–cystic fibrosis population.Surgical


Surgery_Schwartz

Surgery_Schwartz. 70901/03/19 7:01 PM 710SPECIFIC CONSIDERATIONSPART IIshown either no change or a worsening of pulmonary status and require further study in the non–cystic fibrosis population.Surgical resection of a localized bronchiectatic segment or lobe, preserving as much functional lung as possible, may bene-fit patients with refractory symptoms while on maximal medical therapy. Multifocal disease must be excluded before any attempt at surgery; any uncorrectable predisposing factor (e.g., ciliary dyskinesia) must also be excluded. Patients with end-stage lung disease from bronchiectasis may be potential candidates for a bilateral lung transplant. Surgical resection is also indicated in patients with significant hemoptysis, although bronchial artery embolization is the preferred first option. Antireflux surgery may also prove beneficial in patients with chronic aspiration, but further studies are required. It is particularly important to recognize that antireflux surgery in patients with


Surgery_Schwartz

Surgery_Schwartz. Antireflux surgery may also prove beneficial in patients with chronic aspiration, but further studies are required. It is particularly important to recognize that antireflux surgery in patients with severe under-lying pulmonary dysfunction has higher risk for perioperative adverse outcomes than in the general population. It should be undertaken only by very experienced surgeons with direct involvement of the pulmonary medicine physicians to minimize postoperative pulmonary compromise.Mycobacterial Infections Epidemiology Tuberculosis is a widespread problem that affects nearly one-third of the world’s population. It is the ninth lead-ing cause of death worldwide and the leading infectious cause of death. The rate of death from tuberculosis has declined, from 1.7 million in 2000 to 1.3 million among HIV-negative people in 2016. There were 6.3 million new cases of tubercu-losis worldwide in 2016 according to the World Health Orga-nization (WHO); 56% are in the countries of India,


Surgery_Schwartz

Surgery_Schwartz. million among HIV-negative people in 2016. There were 6.3 million new cases of tubercu-losis worldwide in 2016 according to the World Health Orga-nization (WHO); 56% are in the countries of India, Indonesia, China, the Philippines, and Pakistan. Treatment success rate was 83%. Only 9257 new cases were reported to the WHO in the United States in 2016. HIV infection is the strongest risk fac-tor for developing active tuberculosis. The elderly, minorities, and recent immigrants are the most common populations to have clinical manifestations of infection, yet no age group, sex, or race is exempt from infection. In most large urban centers, reported cases of tuberculosis are more numerous among the homeless, prisoners, and drug-addicted populations. Immunocompromised patients additionally contribute to an increased incidence of tuber-culosis infection, often developing unusual systemic as well as pulmonary manifestations.99 As compared with past decades, presently surgical intervention is


Surgery_Schwartz

Surgery_Schwartz. to an increased incidence of tuber-culosis infection, often developing unusual systemic as well as pulmonary manifestations.99 As compared with past decades, presently surgical intervention is required more frequently in patients with multidrug-resistant or rifampicin-resistant (but isoniazid-susceptible) tuberculosis organisms (MDR/RR-TB) who do not respond to medical treatment and in selected patients with nontuberculous mycobacterial infections (NTM).Microbiology Mycobacterial species are obligate aerobes. They are primarily intracellular parasites with slow rates of growth. Their defining characteristic is the property of acid-fastness, which is the ability to withstand decolorization by an acidalcohol mixture after being stained. Mycobacterium tuberculosis is the highly virulent bacillus of this species that produces invasive infection among humans, principally pulmonary tuberculosis.100 Infections with M tuberculosis are primary when they are the first infection in a previously


Surgery_Schwartz

Surgery_Schwartz. of this species that produces invasive infection among humans, principally pulmonary tuberculosis.100 Infections with M tuberculosis are primary when they are the first infection in a previously unsensitized host and secondary or postprimary when reactivation of a previous infection occurs.Because of improper application of antimycobacterial drugs and multifactorial interactions, MDR-TB organisms, defined by their resistance to at least two of the first-line anti-mycobacterial drugs (isoniazid and rifampin), and rifampicin-resistant (but isoniazid-susceptible) (RR-TB), have emerged. According to the WHO Global Tuberculosis Report 2017, in 2014, there were 108 reported cases of TB from MDR/RR-TB organisms, with 78% of cases successfully treated. In addition, there is another rare variant termed extensively drug-resistant tuberculosis (XDR-TB). These organisms are resistant to iso-niazid and rifampin and have also developed resistance to either fluoroquinolones and injectable


Surgery_Schwartz

Surgery_Schwartz. variant termed extensively drug-resistant tuberculosis (XDR-TB). These organisms are resistant to iso-niazid and rifampin and have also developed resistance to either fluoroquinolones and injectable second-line drugs (e.g., capreomycin, amikacin, kanamycin), the two other classes of medications in the MDR-TB treatment regimen. In 2014, there were 109,680 MDRTB cases globally, with 6777 (6.2%) extensively drug resistant. Successful treatment was achieved in 54% of MDRTB and only 30% of XDR-TB. In 2016, it was estimated that MDR/RR was the responsible organism for more than 4% of new cases and nearly 20% of previously treated cases.The more important NTM organisms include Mycobacte-rium kansasii, M avium and M intracellulare complex (MAC), and M fortuitum. The highest incidence of M kansasii infection is in Midwestern U.S. cities among middle-aged men from good socioeconomic surroundings. MAC organisms are important infections in elderly and immunocompromised patient groups. M fortuitum


Surgery_Schwartz

Surgery_Schwartz. infection is in Midwestern U.S. cities among middle-aged men from good socioeconomic surroundings. MAC organisms are important infections in elderly and immunocompromised patient groups. M fortuitum infections are common complications of underly-ing severe debilitating disease. None of these organisms are as contagious as M tuberculosis.Pathogenesis and Pathology The main route of transmission is via airborne inhalation of viable mycobacteria. Three stages of primary infection have been described. In the first stage, alveolar macrophages become infected through ingesting the bacilli. In the second stage, from days 7 to 21, the patient typi-cally remains asymptomatic while the bacteria multiply within the infected macrophages. The third stage is characterized by the onset of cell-mediated immunity (CD4+ helper T cells) and delayed-type hypersensitivity. Activated macrophages acquire an increased capacity for bacterial killing. Macrophage death increases, resulting in the formation of a


Surgery_Schwartz

Surgery_Schwartz. (CD4+ helper T cells) and delayed-type hypersensitivity. Activated macrophages acquire an increased capacity for bacterial killing. Macrophage death increases, resulting in the formation of a granuloma, the charac-teristic lesion found on pathologic examination.Tuberculous granulomas are composed of blood-derived macrophages, degenerating macrophages or epithelioid cells, and multinucleated giant cells (fused macrophages with nuclei around the periphery; also known as Langerhans cells). The low oxygen content of this environment inhibits macrophage func-tion and bacillary growth, with subsequent central caseation as macrophage death occurs. A Ghon complex is a single, small lung lesion that is often the only remaining trace of a primary infection. The primary infection is usually located in the periph-eral portion of the middle zone of the lungs.Reactivation tuberculosis may occur after hydrolytic enzymes liquefy the caseum. Typically, the apical and posterior segments of the upper


Surgery_Schwartz

Surgery_Schwartz. in the periph-eral portion of the middle zone of the lungs.Reactivation tuberculosis may occur after hydrolytic enzymes liquefy the caseum. Typically, the apical and posterior segments of the upper lobes and the superior segments of the lower lobes are involved. Edema, hemorrhage, and mononuclear cell infiltration are also present. The tuberculous cavity may become secondarily infected with other bacteria, fungi, or yeasts, all of which may con-tribute to enhanced tissue destruction.The pathologic changes caused by NTM organisms are similar to those produced by M tuberculosis. M intracellulare complex infections commonly occur, not only in immunocom-promised patients but also in patients with previously damaged lungs. Caseous necrosis is uncommon and is characterized by clusters of tissue macrophages filled with mycobacteria. It has a poor granulomatous response and confinement of immune cell infiltration to the interstitium and alveolar walls. Cavitary dis-ease is infrequent,


Surgery_Schwartz

Surgery_Schwartz. tissue macrophages filled with mycobacteria. It has a poor granulomatous response and confinement of immune cell infiltration to the interstitium and alveolar walls. Cavitary dis-ease is infrequent, although nodules may be noted.Brunicardi_Ch19_p0661-p0750.indd 71001/03/19 7:01 PM


Surgery_Schwartz

Surgery_Schwartz. CHAPTER 19711CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAClinical Presentation and Diagnosis The clinical course of infection and the presentation of symptoms are influenced by many factors, including the site of primary infection, the stage of disease, and the degree of cell-mediated immunity. About 80% to 90% of tuberculosis patients present with clinical dis-ease in the lungs. In 85% to 90% of these patients, involution and healing occur, leading to a dormant phase that may last a lifetime. The only evidence of tuberculosis infection may be a positive skin reaction to tuberculin challenge or a Ghon com-plex observed on CXR. Within the first 2 years of primary infec-tion, reactivation may occur in up to 10% to 15% of infected patients. In 80%, reactivation occurs in the lungs; other reacti-vation sites include the lymph nodes, pleura, and the musculo-skeletal system.After primary infection, pulmonary tuberculosis is fre-quently asymptomatic. Systemic symptoms of low-grade fever,


Surgery_Schwartz

Surgery_Schwartz. reacti-vation sites include the lymph nodes, pleura, and the musculo-skeletal system.After primary infection, pulmonary tuberculosis is fre-quently asymptomatic. Systemic symptoms of low-grade fever, malaise, and weight loss are subtle and may go unnoticed. A productive cough may develop, usually after tubercle cavita-tion. Many radiographic patterns can be identified at this stage, including local exudative lesions, local fibrotic lesions, cavita-tion, bronchial wall involvement, acute tuberculous pneumonia, bronchiectasis, bronchostenosis, and tuberculous granulomas. Hemoptysis often develops from complications of disease such as bronchiectasis or erosion into vascular malformations associ-ated with cavitation.Extrapulmonary involvement is due to hematogenous or lymphatic spread from pulmonary lesions. Virtually any organ can become infected, giving rise to the protean manifestations of tuberculosis. The pleura, chest wall, and mediastinal organs may all be involved. More than


Surgery_Schwartz

Surgery_Schwartz. pulmonary lesions. Virtually any organ can become infected, giving rise to the protean manifestations of tuberculosis. The pleura, chest wall, and mediastinal organs may all be involved. More than one-third of immunocompro-mised patients have disseminated disease, with hepatomegaly, diarrhea, splenomegaly, and abdominal pain.The definitive diagnosis of tuberculosis requires identi-fication of the mycobacterium in a patient’s bodily fluids or involved tissues. Skin testing using purified protein deriva-tive is important for epidemiologic purposes and can help exclude infection in uncomplicated cases. For pulmonary tuberculosis, sputum examination is inexpensive and has a high diagnostic yield.Bronchoscopy with alveolar lavage may also be a useful diagnostic adjunct and has high diagnostic accuracy. Chest CT scan can delineate the extent of parenchymal disease.Management Medical therapy is the primary treatment of pul-monary tuberculosis and is often initiated before a mycobacte-rial


Surgery_Schwartz

Surgery_Schwartz. accuracy. Chest CT scan can delineate the extent of parenchymal disease.Management Medical therapy is the primary treatment of pul-monary tuberculosis and is often initiated before a mycobacte-rial pathogen is definitively identified. Combinations of two or more drugs are routinely used in order to minimize resistance, which inevitably develops with only single-agent therapy. A current treatment algorithm is outlined in Fig. 19-32. Gener-ally, therapy lasts about 26 weeks (2 months intensive therapy followed by 4 months continuation therapy). A 7-month con-tinuation phase should be considered for patients with cavitary pulmonary TB who remain positive on sputum culture after the 2-month intensive therapy, those patients who did not receive pyrazinamide during the intensive phase, HIV-positive patients who did not receive concomitant antiretroviral therapy, and patients treated with INH and rifapentine once weekly (not rec-ommended) who have persistent positive sputum after 2 months of


Surgery_Schwartz

Surgery_Schwartz. patients who did not receive concomitant antiretroviral therapy, and patients treated with INH and rifapentine once weekly (not rec-ommended) who have persistent positive sputum after 2 months of intensive therapy.In the United States, surgical intervention is most often required in order to treat patients with MDR/RR-TB organ-isms whose lungs have been destroyed and who have persis-tent thick-walled cavitation.101 The indications for surgery related to mycobacterial pulmonary infections are presented in Table 19-19. The governing principle of mycobacterial surgery is to remove all gross disease while preserving any uninvolved lung tissue. Scattered nodular disease may be left intact, given its low mycobacterial burden. Antimycobacterial medications should be given preoperatively (for about 3 months) and con-tinued postoperatively for 12 to 24 months. Overall, more than 90% of patients who were deemed good surgical candidates are cured when appropriate medical and surgical therapy is


Surgery_Schwartz

Surgery_Schwartz. 3 months) and con-tinued postoperatively for 12 to 24 months. Overall, more than 90% of patients who were deemed good surgical candidates are cured when appropriate medical and surgical therapy is used.Pulmonary Fungal Infections. The incidence of fungal infections has increased significantly, with many new opportu-nistic fungi emerging. This increase is attributed to the growing population of immunocompromised patients (e.g., organ trans-plant recipients, cancer patients undergoing chemotherapy, HIV patients, and young and elderly patients) who are more likely to become infected with fungi.102 Clinically significant examples include species of Aspergillus, Cryptococcus, Candida, and Mucor. Other at-risk patient populations include those who are malnourished, severely debilitated, or diabetic or who have hematologic disorders.Patients receiving high-dose, intensive antibiotic therapies are also susceptible. There are, however, some fungi that are primary or true pathogens, able to


Surgery_Schwartz

Surgery_Schwartz. or who have hematologic disorders.Patients receiving high-dose, intensive antibiotic therapies are also susceptible. There are, however, some fungi that are primary or true pathogens, able to cause infections in other-wise healthy patients. Some endemic examples in the United States include species of Histoplasma, Coccidioides, and Blastomyces.103Direct identification of the organism in body exudates or tissues, preferably as growth in culture, provides definitive diag-nosis. Serologic testing to identify mycotic-specific antibodies may also be useful. Several new classes of antifungal agents have proven effective against many life-threatening fungi and are less toxic than older agents. In addition, thoracic surgery may be a useful therapeutic adjunct for patients with pulmonary mycoses.Aspergillosis The genus Aspergillus comprises over 150 spe-cies and is the most common cause of mortality due to inva-sive mycoses in the United States. It is typically acute in onset and


Surgery_Schwartz

Surgery_Schwartz. mycoses.Aspergillosis The genus Aspergillus comprises over 150 spe-cies and is the most common cause of mortality due to inva-sive mycoses in the United States. It is typically acute in onset and life-threatening and occurs in the setting of neutropenia, chronic steroid therapy, or cytotoxic chemotherapy. It can also occur in the general intensive care unit population of critically ill patients, including patients with underlying chronic obstruc-tive pulmonary disease (COPD), postoperative patients, patients with cirrhosis or alcoholism, and postinfluenza patients, with-out any of these factors present. The species most commonly responsible for clinical disease include A fumigatus, A flavus, A niger, and A terreus. Aspergillus is a saprophytic, filamentous fungus with septate hyphae. Spores (2.5 to 3 µm in diameter) are released and easily inhaled by susceptible patients; because the spores are microns in size, they are able to reach the distal bronchi and alveoli.Diagnosis of


Surgery_Schwartz

Surgery_Schwartz. Spores (2.5 to 3 µm in diameter) are released and easily inhaled by susceptible patients; because the spores are microns in size, they are able to reach the distal bronchi and alveoli.Diagnosis of aspergillosis requires one or more cavities on lung imaging, with or without fungal ball or nodules, micros-copy or culture positive for Aspergillus, or antibodies (precipi-tins) to Aspergillus on serum testing. The characteristics must have been present for 3 months. Aspergillus can manifest as one of three clinical syndromes: Aspergillus hypersensitivity lung disease, aspergilloma, or invasive pulmonary aspergil-losis. Overlap occurs between these syndromes, depending on the patient’s immune status.104 Aspergillus hypersensitiv-ity manifests as a productive cough, fever, wheezing, pulmo-nary infiltrates, eosinophilia, and elevation of IgE antibodies Brunicardi_Ch19_p0661-p0750.indd 71101/03/19 7:01 PM 712SPECIFIC


Surgery_Schwartz

Surgery_Schwartz. manifests as a productive cough, fever, wheezing, pulmo-nary infiltrates, eosinophilia, and elevation of IgE antibodies Brunicardi_Ch19_p0661-p0750.indd 71101/03/19 7:01 PM 712SPECIFIC CONSIDERATIONSPART IIINH/RIFINH/RIFINH/RIFINH/RIFINH/RIF/EMB*/PZA†0123469Time (months)INH/RPT‡§INH/RIF2-monthculture negativeHigh clinicalsuspicionfor activetuberculosis2-monthculture positiveCavitation on CXRorpositive AFB smearat 2 monthsNo cavitation on CXRandnegative AFB smearat 2 monthsNo cavitationCavitationFigure 19-32. Treatment algorithm for tuberculosis. Patients in whom tuberculosis is proven or strongly suspected should have treatment initiated with isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB) for the initial 2 months. A repeat smear and cul-ture should be performed when 2 months of treatment has been completed. If cavities were seen on the initial chest radiograph (CXR) or the acid-fast bacillus (AFB) smear results are positive at completion of 2 months of


Surgery_Schwartz

Surgery_Schwartz. when 2 months of treatment has been completed. If cavities were seen on the initial chest radiograph (CXR) or the acid-fast bacillus (AFB) smear results are positive at completion of 2 months of treatment, the continuation phase of treatment should consist of INH and RIF daily or twice daily for 4 months to complete a total of 6 months of treatment. If cavitation was present on the initial CXR and the culture results at the time of completion of 2 months of therapy are positive, the continuation phase should be lengthened to 7 months (total of 9 months of treatment). If the patient has HIV infection and the CD4+ cell count is <100/µL, the continuation phase should consist of daily or three times weekly INH and RIF. In HIV-uninfected patients with no cavitation on CXR and negative results on AFB smears at completion of 2 months of treatment, the continuation phase may consist of either once weekly INH and rifapentine (RPT) or daily or twice weekly INH and RIF to complete a total of 6


Surgery_Schwartz

Surgery_Schwartz. on AFB smears at completion of 2 months of treatment, the continuation phase may consist of either once weekly INH and rifapentine (RPT) or daily or twice weekly INH and RIF to complete a total of 6 months of treatment (bottom). For patients receiving INH and RPT whose 2-month culture results are positive, treatment should be extended by an additional 3 months (total of 9 months). *EMB may be discontinued when results of drug susceptibility testing indicate no drug resistance. †PZA may be discontinued after it has been taken for 2 months (56 doses). ‡RPT should not be used in HIV-infected patients with tuberculosis or in patients with extrapulmonary tuberculosis. §Therapy should be extended to 9 months if results of 2-month culture are positive. (Reproduced with permission from Blumberg HM, Burman WJ, Chaisson RE, et al. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis, Am J Respir Crit Care Med.


Surgery_Schwartz

Surgery_Schwartz. HM, Burman WJ, Chaisson RE, et al. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis, Am J Respir Crit Care Med. 2003 Feb 15;167(4):603-662.)Table 19-19Indications for surgery to treat mycobacterial pulmonary infections 1. Complications resulting from previous thoracic surgery to treat tuberculosis 2. Failure of optimized medical therapy (e.g., progressive disease, lung gangrene, or intracavitary aspergillosis superinfection) 3. Need for tissue acquisition for definitive diagnosis 4. Complications of pulmonary scarring (e.g., massive hemoptysis, cavernomas, bronchiectasis, or bronchostenosis) 5. Extrapulmonary thoracic involvement 6. Pleural tuberculosis 7. Nontuberculous mycobacterial infectionto Aspergillus, whereas aspergilloma (fungal ball) is a matted sphere of hyphae, fibrin, and inflammatory cells that tends to colonize preexisting intrapulmonary cavities. Grossly, aspergil-loma appears as a


Surgery_Schwartz

Surgery_Schwartz. whereas aspergilloma (fungal ball) is a matted sphere of hyphae, fibrin, and inflammatory cells that tends to colonize preexisting intrapulmonary cavities. Grossly, aspergil-loma appears as a round or oval, friable, gray (or red, brown, or even yellow), necrotic-looking mass (Fig. 19-33). This form is the most common presentation of noninvasive pulmonary asper-gillosis. The most common symptoms are hemoptysis, chronic and productive cough, clubbing, malaise, or weight loss. CXR can suggest the diagnosis by the finding of a crescentic radiolu-cency above a rounded radiopaque lesion (Monad sign).The natural history varies greatly between patients and, therefore, treatment is individualized. Factors associated with poor prognosis include severe underlying pulmonary disease, growth in the number or size of the aspergilloma(s) during observation, immunosuppression or HIV infection, history of lung transplantation, chronic pulmonary sarcoidosis, and increasing Aspergillus-specific IgG


Surgery_Schwartz

Surgery_Schwartz. number or size of the aspergilloma(s) during observation, immunosuppression or HIV infection, history of lung transplantation, chronic pulmonary sarcoidosis, and increasing Aspergillus-specific IgG titers. 10Brunicardi_Ch19_p0661-p0750.indd 71201/03/19 7:01 PM


Surgery_Schwartz

Surgery_Schwartz. CHAPTER 19713CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAACBFigure 19-33. Pulmonary aspergilloma. A. The chest X-ray shows a solid mass within a cavity surrounded by a rim of air between the mass and cavity wall (Monad sign, arrows). B. A cut section shows the “fungus ball” occupying an old, fibrotic cavity. C. Histologic stain reveals characteristic Aspergillus hyphae invading the wall of the cavity.Asymptomatic patients can be observed without any additional therapy. Antifungals have limited utility due to the poor blood supply to the aspergilloma. Oral triazole therapy is now consid-ered the standard of care for chronic, cavitary pulmonary asper-gillosis. Hemoptysis is a harbinger of erosion of the disease into adjacent bronchial arteries and typically requires intervention. In the setting of very mild hemoptysis (e.g., blood-streaked spu-tum), cough suppression is warranted while further therapeutic evaluation is performed.Bronchial artery embolization is the first-line therapy for


Surgery_Schwartz

Surgery_Schwartz. of very mild hemoptysis (e.g., blood-streaked spu-tum), cough suppression is warranted while further therapeutic evaluation is performed.Bronchial artery embolization is the first-line therapy for massive hemoptysis and may be definitive therapy.105 This is particularly important to consider for patients with severely impaired pulmonary function who may not have sufficient reserve to tolerate even a very small pulmonary resection. Operative intervention may be required for recur-rent hemoptysis, particularly after bronchial artery emboli-zation, chronic cough with systemic symptoms, progressive infiltrate around the mycetoma, and a pulmonary mass of unknown cause.106When operative intervention is indicated, the surgeon must remain cognizant of the goals of the procedure. In the setting of simple aspergilloma, VATs wedge resection is pre-ferred. As this disease typically occurs in patients with signifi-cantly impaired pulmonary function, attempts should be made to excise all diseased


Surgery_Schwartz

Surgery_Schwartz. simple aspergilloma, VATs wedge resection is pre-ferred. As this disease typically occurs in patients with signifi-cantly impaired pulmonary function, attempts should be made to excise all diseased tissue with as limited a resection as pos-sible. Once resection is completed, the postresection space in the hemithorax should be obliterated with a pleural tent, pneu-moperitoneum, decortication of the remaining lung, intratho-racic rotation of a muscle or omental flap, or thoracoplasty. If completely resected for single aspergilloma, antifungal therapy is not needed. If multiple nodules are present or the disease is incompletely resected, however, antifungal therapy should be considered. Long-term follow-up is necessary, given that the recurrence rate after surgery is about 7%.Brunicardi_Ch19_p0661-p0750.indd 71301/03/19 7:01 PM 714SPECIFIC CONSIDERATIONSPART IIInvasive pulmonary aspergillosis typically affects immu-nocompromised patients who have dysfunctional cellular immu-nity,


Surgery_Schwartz

Surgery_Schwartz. 71301/03/19 7:01 PM 714SPECIFIC CONSIDERATIONSPART IIInvasive pulmonary aspergillosis typically affects immu-nocompromised patients who have dysfunctional cellular immu-nity, namely defective polymorphonuclear leukocytes. Invasion of pulmonary parenchyma and blood vessels by a necrotizing bronchopneumonia may be complicated by thrombosis, hemor-rhage, and then dissemination. Patients present with fever that is nonresponsive to antibiotic therapy in the setting of neutro-penia. They may also have pleuritic chest pain, cough, dys-pnea, or hemoptysis. Characteristic signs on CT scan include the halo sign and cavitary lesions. Treatment with voriconazole must be prompt and aggressive, including reversal of neutrope-nia, if there is to be any chance for recovery. Mortality ranges from 93% to 100% in bone marrow transplant recipients, to approximately 38% in kidney transplant recipients, although this improves to approximately 60% at 12 weeks with antifun-gal therapy. Several other


Surgery_Schwartz

Surgery_Schwartz. 93% to 100% in bone marrow transplant recipients, to approximately 38% in kidney transplant recipients, although this improves to approximately 60% at 12 weeks with antifun-gal therapy. Several other advances in diagnosis and treatment, including CT scans in high-risk populations and development of additional triazoles and echinocandins, have improved the early identification and response to therapy in this patient population. Additional treatment considerations include the use of hema-topoietic growth factors to minimize the neutropenic period, which contributes to uncontrolled disease. Surgical removal of the infectious nidus is advocated by some groups because medical treatment has such poor outcomes. Treatment continues until microbiologic clearance is achieved and clinical signs and radiographic imaging indicate resolution of disease. In addition, the patient should no longer be immunosuppressed. If continu-ation of immunosuppressive medications is required, antifungal therapy


Surgery_Schwartz

Surgery_Schwartz. radiographic imaging indicate resolution of disease. In addition, the patient should no longer be immunosuppressed. If continu-ation of immunosuppressive medications is required, antifungal therapy should also continue to prevent recurrence of invasive disease.Cryptococcosis Cryptococcosis is a subacute or chronic infec-tion caused by Cryptococcus neoformans, a round, budding yeast (5 to 20 µm in diameter) that is sometimes surrounded by a characteristic wide gelatinous capsule. Cryptococci are typically present in soil and dust contaminated by pigeon drop-pings. When inhaled, such droppings can cause a nonfatal dis-ease primarily affecting the pulmonary and central nervous systems. At present, cryptococcosis is one of the most common opportunistic infection in patients with HIV infection, affecting ∼3% of that population. Four basic pathologic patterns are seen in the lungs of infected patients: granulomas; granulomatous pneumonia; diffuse alveolar or interstitial involvement; and


Surgery_Schwartz

Surgery_Schwartz. affecting ∼3% of that population. Four basic pathologic patterns are seen in the lungs of infected patients: granulomas; granulomatous pneumonia; diffuse alveolar or interstitial involvement; and pro-liferation of fungi in alveoli and lung vasculature. Symptoms are nonspecific, as are the radiographic findings. Cryptococcus neoformans may be isolated from sputum, bronchial washings, percutaneous needle aspiration of the lung, or cerebrospinal fluid. If disease is suspected, serum cryptococcal antigen titers should be obtained; if positive or if the patient has persistent fever, evidence of progression, physiologic compromise, or dissemination, treatment should be promptly initiated. Accord-ing to the CDC, multiple antifungal agents are effective against C neoformans; asymptomatic infections, such as those identified through targeted screening, should be treated with fluconazole while severe lung infections require amphotericin B combined with flucytosine followed by fluconazole for


Surgery_Schwartz

Surgery_Schwartz. such as those identified through targeted screening, should be treated with fluconazole while severe lung infections require amphotericin B combined with flucytosine followed by fluconazole for an extended length of time. Duration of therapy is longer in patients who are immunocompromised.Candidiasis Candida organisms are oval, budding cells (with or without mycelial elements) that colonize the oropharynx of many healthy individuals. The fungi of this genus are com-mon hospital and laboratory contaminants. Usually, Candida albicans causes disease in the oral or bronchial mucosa, among other anatomic sites. Approximately 95% of all invasive Candida infections are caused by five species: C albicans, C tropicalis, C parapsilosis, C glabrata, and C krusei. The specific pathogen varies between patient populations and geo-graphic regions. Non–C albicans infections now constitute nearly 70% of all cases in the United States, with C glabrata leading the list. Resistance to fluconazole is


Surgery_Schwartz

Surgery_Schwartz. patient populations and geo-graphic regions. Non–C albicans infections now constitute nearly 70% of all cases in the United States, with C glabrata leading the list. Resistance to fluconazole is common in the non–C albicans species, either natural or developed in response to antifungal therapy, and the shift is likely related to the wide-spread use of this antifungal agent.107The incidence of Candida infections has increased and is no longer confined to immunocompromised patients. Increasing incidence of infection has been identified in patients with any of the following risk factors: critical illness of long duration; use of long-term antibiotics, particularly multiple; indwelling urinary or vascular catheter; gastrointestinal perforation; or burn wounds.108 With respect to the thorax, such patients commonly have candidal pneumonia, pulmonary abscess, esophagitis, and mediastinitis. Pulmonary candidal infections typically result in an acute or chronic granulomatous reaction. Because


Surgery_Schwartz

Surgery_Schwartz. patients commonly have candidal pneumonia, pulmonary abscess, esophagitis, and mediastinitis. Pulmonary candidal infections typically result in an acute or chronic granulomatous reaction. Because Candida can invade blood vessel walls and a variety of tissues, systemic or disseminated infections can occur, but are less common.Treatment for candidal infection includes both fungicidal and fungistatic agents. The fungicidal medications include poly-enes (amphotericin B deoxycholate [AmB-D] and various lipid-associated amphotericin B preparations) and the echinocandins (caspofungin, micafungin, and anidulafungin). Fungistatic drugs include the triazoles (fluconazole, itraconazole, voricon-azole, and posaconazole). The availability of multiple effective therapies allows for specific tailoring of treatment, including combination regimens, based on the patient’s ability to toler-ate associated toxicities, the microbiologic information for the specific candidal species, and the route of


Surgery_Schwartz

Surgery_Schwartz. of treatment, including combination regimens, based on the patient’s ability to toler-ate associated toxicities, the microbiologic information for the specific candidal species, and the route of administration. While demonstrated efficacy is similar, the triazoles and echinocan-dins appear to have fewer side effects and are better tolerated than the other classes of antifungal drugs. The current initial recommended regimen for adults with invasive candidiasis is an echinocandin.107In addition to prompt institution of antifungal therapy, it is advisable to remove all central venous catheters as soon as can be safely achieved. For fungemia, an eye examination should be performed. Treatment should continue for at least 2 weeks after the last positive blood culture. For patients with Candida medi-astinitis (which has a mortality rate of >50%), surgical inter-vention to debride all infected tissues is required, in addition to prolonged administration of antifungal drugs.Mucormycosis The


Surgery_Schwartz

Surgery_Schwartz. medi-astinitis (which has a mortality rate of >50%), surgical inter-vention to debride all infected tissues is required, in addition to prolonged administration of antifungal drugs.Mucormycosis The Mucor species, rare members of the class Zygomycetes, are responsible for rapidly fatal disease in immunocompromised patients. Other disease-causing spe-cies of the class Zygomycetes include Absidia, Rhizopus, and Mortierella.109 Characteristic of these fungi are nonsep-tate, branching hyphae that are difficult to culture. Infec-tion occurs via inhalation of spores. Immunocompromised patients, including patients with neutropenia, acidosis, dia-betes, and hematologic malignancy all predispose to clinical susceptibility. In the lungs, disease consists of blood vessel invasion, thrombosis, and infarction of infected organs.Tissue destruction is significant, along with cavitation and abscess formation. Initial treatment is to correct underly-ing risk factors and administer antifungal therapies,


Surgery_Schwartz

Surgery_Schwartz. of infected organs.Tissue destruction is significant, along with cavitation and abscess formation. Initial treatment is to correct underly-ing risk factors and administer antifungal therapies, although Brunicardi_Ch19_p0661-p0750.indd 71401/03/19 7:01 PM


Surgery_Schwartz

Surgery_Schwartz. CHAPTER 19715CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAthe optimal duration and optimal total dose are unknown. Lipid formulations of amphotericin B are recommended at this time. Surgical resection of any localized disease should be performed after initial medical treatment attempts fail.Primary Fungal Pathogens Histoplasma capsulatum Histoplasma capsulatum is a dimor-phic fungus existing in mycelial form in soil contaminated by fowl or bat excreta and in yeast form in human hosts. The most common of all fungal pulmonary infections, histoplasmosis, primarily affects the respiratory system after spores are inhaled. It is endemic in the Midwest and Mississippi River Valley of the United States, where about 500,000 new cases arise each year. In immunocompromised patients, the infection becomes systemic and more virulent; because cell-mediated immunity is impaired, uninhibited fungal proliferation occurs within pulmo-nary macrophages and then spreads. Acute forms of the disease present as


Surgery_Schwartz

Surgery_Schwartz. systemic and more virulent; because cell-mediated immunity is impaired, uninhibited fungal proliferation occurs within pulmo-nary macrophages and then spreads. Acute forms of the disease present as primary or disseminated pulmonary histoplasmosis; chronic forms present as pulmonary granulomas (histoplasmo-mas), chronic cavitary histoplasmosis, mediastinal granulomas, fibrosing mediastinitis, or bronchiolithiasis. Histoplasmosis is definitively diagnosed by fungal smear, culture, direct biopsy of infected tissues, or serologic testing.The clinical presentation depends on the inoculum size and on host factors.Symptoms of acute pulmonary histoplasmosis are fever, chills, headache, chest pain, musculoskeletal pain, and nonpro-ductive cough. CXRs may be normal or may show mediastinal lymphadenopathy and patchy parenchymal infiltrates. Most patients improve in a few weeks; mild to moderate disease can be treated with itraconazole. Amphotericin B is the treatment of choice if moderate


Surgery_Schwartz

Surgery_Schwartz. and patchy parenchymal infiltrates. Most patients improve in a few weeks; mild to moderate disease can be treated with itraconazole. Amphotericin B is the treatment of choice if moderate symptoms persist for 2 to 4 weeks or if the illness is extensive, including dyspnea and hypoxia, and if patients are immunosuppressed.110As the pulmonary infiltrates from acute histoplasmosis heal, consolidation into an asymptomatic solitary nodule or histoplasmoma may occur and is usually seen incidentally on radiographs as a coin-shaped lesion. Central and concentric calcification may occur; if so, no further treatment is required. Noncalcification of the lesion requires further diagnostic workup including chest CT scan, needle biopsy, or surgical excision to rule out a malignancy. Figure 19-34 demonstrates the differ-ences in pathologic findings between infections in normal and immunocompromised hosts.111When lymph nodes and pulmonary granulomas calcify over time, pressure atrophy on the bronchial


Surgery_Schwartz

Surgery_Schwartz. the differ-ences in pathologic findings between infections in normal and immunocompromised hosts.111When lymph nodes and pulmonary granulomas calcify over time, pressure atrophy on the bronchial wall may result in erosion and migration of the granulomatous mass into the bronchus, causing bronchiolithiasis. Typical symptoms include cough, hemoptysis, and dyspnea. Life-threatening complica-tions include massive hemoptysis or bronchoesophageal fistula. In addition to radiography, bronchoscopy should be performed to aid in diagnosis. Definitive treatment requires surgical exci-sion of the bronchial mass and repair of the airway and contigu-ous structures. Endobronchial debridement is not advised as this can result in massive, fatal bleeding.Fibrosing mediastinitis is an uncommon manifestation of histoplasmosis but can be fatal due to progressive distortion and compression of the major vessels and central airways.Diagnosis can be difficult, and symptoms may be present for extended periods,


Surgery_Schwartz

Surgery_Schwartz. of histoplasmosis but can be fatal due to progressive distortion and compression of the major vessels and central airways.Diagnosis can be difficult, and symptoms may be present for extended periods, even years, before the diagnosis is made. The differential diagnosis for the disease process includes granu-lomatous mediastinitis related to recent infection, malignancy, and chronic pulmonary thromboembolism. A trial of itracon-azole is worthwhile, although it is not proven to be effective. In cases where radiographic or physiologic improvement is achieved after a trial of 12 week of therapy, continuation of therapy is con-sidered for a full 12 months. In the majority of patients, how-ever, antifungal therapy has not been proven. There is no role for corticosteroids at this time or for antifibrotics. Occasionally, intravascular stents have been helpful for severe vascular compro-mise. Balloon dilatation and endobronchial silicone stents may be needed for airway compromise, although this


Surgery_Schwartz

Surgery_Schwartz. Occasionally, intravascular stents have been helpful for severe vascular compro-mise. Balloon dilatation and endobronchial silicone stents may be needed for airway compromise, although this should be directed by a surgeon with expertise in mediastinal and airway disease management.Chronic pulmonary histoplasmosis occurs in about 10% of patients who become symptomatic after infection. Most such patients have preexisting lung pathology, particularly emphy-sema, which becomes colonized, and subsequent pneumonitis and necrosis, cavity enlargement, new cavity formation, and pulmonary dissemination occur. Nonspecific symptoms, such as cough, sputum production, fever, weight loss, weakness, and hemoptysis are common. Chest radiography may reveal intrapulmonary cavitation and scarring. Occasionally, par-tial resolution of the inflammatory changes may be observed. Itraconazole provides effective therapy, but must be given for 12 to 24 months. It is superior to ketoconazole and fluconazole;


Surgery_Schwartz

Surgery_Schwartz. par-tial resolution of the inflammatory changes may be observed. Itraconazole provides effective therapy, but must be given for 12 to 24 months. It is superior to ketoconazole and fluconazole; these should only be used if itraconazole is not tolerated. Vori-conazole and posaconazole have been found to be useful for salvage therapy. Serum itraconazole levels should be monitored to ensure that the drug is being absorbed. Occasionally, lipid-associated amphotericin B is necessary for more severe infec-tions. Surgical excision should be considered in patients with adequate pulmonary reserve and localized, thick-walled cavities that have been unresponsive to antifungal therapy.Disseminated histoplasmosis occurs most frequently in patients who are severely immunocompromised, such as post-transplantation patients, patients with HIV, and patients using immunosuppressive medications. Presentation ranges from non-specific signs of fever, weight loss, and malaise, to shock, respi-ratory


Surgery_Schwartz

Surgery_Schwartz. patients, patients with HIV, and patients using immunosuppressive medications. Presentation ranges from non-specific signs of fever, weight loss, and malaise, to shock, respi-ratory distress, and multiorgan failure. Diagnosis can be made with a combination of Histoplasma urine antigen, serologic assay, and fungal culture and should be suspected in patients with the above symptoms in any endemic area, particularly if the patient is immunosuppressed.112 Any of the antifungal thera-pies can be used in treatment of disseminated histoplasmosis. Use of amphotericin B has decreased the mortality rate to less than 25% in this type of serious infection.Coccidioides immitis Coccidioides immitis is an endemic fun-gus found in soil and dust of the southwestern United States. Agricultural workers, military personnel, and other occupa-tions with extensive exposure to soil, especially in areas of endemic growth, are at highest risk, as are immunocompro-mised individuals.113 Spores (arthroconidia)


Surgery_Schwartz

Surgery_Schwartz. personnel, and other occupa-tions with extensive exposure to soil, especially in areas of endemic growth, are at highest risk, as are immunocompro-mised individuals.113 Spores (arthroconidia) are inhaled, swell into spherules, and subdivide into endospores, and subsequent infection develops. Diagnosis can be achieved through serum analysis for anticoccidioidal antibody, spherule identification in tissue, or by isolating the fungus in cultures from sputum, other body fluid, or tissue.Inhalation of the fungus causes pulmonary involvement in 95% of patients with symptomatic disease. Three main cat-egories of pulmonary involvement, based on the associated signs and symptoms, are possible: primary, complicated, and residual pulmonary coccidioidomycosis. Primary pulmonary Brunicardi_Ch19_p0661-p0750.indd 71501/03/19 7:01 PM 716SPECIFIC CONSIDERATIONSPART IIABCDEFFigure 19-34. Pathologic findings of infection in normal and immunocompromised hosts. Histopathologic preparations are shown


Surgery_Schwartz

Surgery_Schwartz. 71501/03/19 7:01 PM 716SPECIFIC CONSIDERATIONSPART IIABCDEFFigure 19-34. Pathologic findings of infection in normal and immunocompromised hosts. Histopathologic preparations are shown contrast-ing acute diffuse pulmonary involvement in a lung segment of a normal host with a probable primary infection (A through D) with pulmonary granulomas from an immunocompromised patient who had an opportunistic reinfection with Histoplasma capsulatum (E, F). A. Diffuse interstitial pneumonitis in an adult (normal host) with recent heavy environmental exposure and subsequent development of progressive pulmonary disease. There is an inflammatory cell infiltrate primarily involving the interalveolar interstitial spaces but present within many alveolar spaces as well. The exudate consists mostly of mononuclear phagocytes, lymphocytes, and occasional plasma cells. Many of the alveolar walls are markedly thickened (hematoxylin and eosin stain [H&E], ×50). B. Another area from the same lung as in A


Surgery_Schwartz

Surgery_Schwartz. phagocytes, lymphocytes, and occasional plasma cells. Many of the alveolar walls are markedly thickened (hematoxylin and eosin stain [H&E], ×50). B. Another area from the same lung as in A showing focal vasculitis with an infiltrate of lymphocytes and macrophages (H&E, ×25). C. Relatively large alveolar macrophages packed with single and budding yeasts 2 to 4 µm in diameter (same lung as in A and B). The basophilic cytoplasm of these yeasts is retracted from their thin outer cell walls, leaving halo-like clear areas that can be confused with capsules (H&E, ×500). D. Intracellular and extracellular yeasts, 2 to 4 µm in diameter, some of which are single, budding, or in short chains (Gomori methenamine silver stain, ×500). E. Nonnecrotizing (sometimes called epithelioid cell or noncaseating) granuloma from a patient who had recently received chemotherapy for a germ cell tumor (different patient than in A through D). This lesion consists of a focal collection of macrophages (sometimes


Surgery_Schwartz

Surgery_Schwartz. granuloma from a patient who had recently received chemotherapy for a germ cell tumor (different patient than in A through D). This lesion consists of a focal collection of macrophages (sometimes referred to as histiocytes or epithelioid cells) plus lymphocytes and occasional plasma cells. A few multinucleated macrophages are present. A thin layer of fibroblasts circumscribes the lesion. Yeasts of H capsulatum, probably present within macrophages of this lesion at an earlier stage, were not identified in this granuloma or in any of several other nonnecrotizing granulomas within the specimen. Lesions of this type often undergo necrosis to become necrotiz-ing granulomas (H&E, ×50). F. Necrotizing (sometimes referred to as caseating) granuloma from the same lung as in E. This lesion has a necrotic center surrounded by macrophages, encapsulating fibroblasts, fibrous connective tissue in the periphery, and scattered lymphocytes. A prominent giant cell is present in the lower left of the


Surgery_Schwartz

Surgery_Schwartz. necrotic center surrounded by macrophages, encapsulating fibroblasts, fibrous connective tissue in the periphery, and scattered lymphocytes. A prominent giant cell is present in the lower left of the granuloma (at approximately 8 o’clock). Microorganisms are usually present only in relatively small numbers in these types of lesions. They are most frequently detected within the most central necrotic material in these granulomas (H&E, ×25). (Reproduced with permission from Hage CA, Wheat LJ, Loyd J, et al: Pulmonary histoplasmosis, Semin Respir Crit Care Med. 2008 Apr;29(2):151-165.)Brunicardi_Ch19_p0661-p0750.indd 71601/03/19 7:01 PM


Surgery_Schwartz

Surgery_Schwartz. CHAPTER 19717CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAcoccidioidomycosis occurs in about 40% of people who inhale spores. The other 60% will remain asymptomatic and develop life-long immunity. The constellation of symptoms of “valley fever,” including fever, chills, headache, erythema multiforme, erythema nodosum, polyarthralgias, nonproductive cough, and chest pain, and a CXR showing hilar and paratracheal adenopa-thy are highly suggestive of pulmonary coccidioidomycosis. In many patients, initial diagnosis is community-acquired pneumo-nia, and it is only when the patient fails to respond to appropriate antibiotic therapy that pulmonary coccidioidomycosis is consid-ered. The disease is self-limited in the majority of patients, and treatment is not required in these cases.Therapy should be considered for (a) patients with impaired cellular immunity; (b) comorbid illnesses that are adversely impacted by the infection, including chronic pulmo-nary dysfunction, renal failure, and


Surgery_Schwartz

Surgery_Schwartz. be considered for (a) patients with impaired cellular immunity; (b) comorbid illnesses that are adversely impacted by the infection, including chronic pulmo-nary dysfunction, renal failure, and congestive heart failure; and (c) when symptoms and radiographic findings persist for more than 6 to 8 weeks, at which time the disease is considered to be persistent coccidioidal pneumonia and occurs in approximately 1% of patients. Progression to caseous nodules, cavities, and calcified, fibrotic, or ossified lesions indicates complicated or residual stages of coccidioidomycosis.There are several relative indications for surgery in pulmo-nary coccidioidomycosis. A rapidly expanding (>4 cm) cavity that is close to the visceral pleura is a high risk for rupture into the pleural space and subsequent empyema. Other indications for operative intervention include life-threatening hemoptysis; hemoptysis that is persistent despite medical therapy; symptom-atic fungus ball; bronchopleural fistula;


Surgery_Schwartz

Surgery_Schwartz. empyema. Other indications for operative intervention include life-threatening hemoptysis; hemoptysis that is persistent despite medical therapy; symptom-atic fungus ball; bronchopleural fistula; cavitary lesions with persistent positive sputum; and pulmonary nodules that degen-erate over time. Finally, any nodule with signs that are concern-ing for malignancy should undergo further evaluation, including biopsy or resection, to determine the underlying etiology.Diagnosis of coccidioidomycosis is confirmed by histo-pathologic, mycologic, and serologic evaluation. Extrapulmo-nary disease may develop in approximately 0.5% of infected patients, with involvement of meninges, bones, joints, skin, or soft tissues. Immunocompromised patients are especially sus-ceptible to disseminated coccidioidomycosis, which carries a mortality rate over 40%. Treatment options for this disease vary depending on the severity of the disease as well as the stage. Amphotericin B deoxycholate or the triazoles


Surgery_Schwartz

Surgery_Schwartz. which carries a mortality rate over 40%. Treatment options for this disease vary depending on the severity of the disease as well as the stage. Amphotericin B deoxycholate or the triazoles continue to be the primary antifungal medications. If meningeal involvement is identified, fluconazole or itraconazole therapy is required for the remainder of the patient’s life. Intrathecal amphotericin B can also be administered in some cases.Blastomyces dermatitidis Blastomyces dermatitidis is a round, single-budding yeast with a characteristic thick, refrac-tile cell wall. It resides in the soil as a nonmotile spore called conidia. Exposure occurs when contaminated soil is disturbed and the conidia are aerosolized. The spore is inhaled and trans-forms into a yeast phase at body temperature.114 Infection is typically self-limited. A small minority of patients will develop chronic pulmonary infection or disseminated disease, includ-ing cutaneous, osteoarticular, and genitourinary involvement. B


Surgery_Schwartz

Surgery_Schwartz. is typically self-limited. A small minority of patients will develop chronic pulmonary infection or disseminated disease, includ-ing cutaneous, osteoarticular, and genitourinary involvement. B dermatitidis has a worldwide distribution; in the United States, it is endemic in the central states.115 With chronic infec-tion, the organism induces a granulomatous and pyogenic reac-tion with microabscesses and giant cells; caseation, cavitation, and fibrosis may also occur. Symptoms are nonspecific and con-sistent with chronic pneumonia in 60% to 90% of patients. They include cough, mucoid sputum production, chest pain, fever, malaise, weight loss, and, uncommonly, hemoptysis. In acute disease, radiographs are either completely negative or have nonspecific findings; in chronic disease, fibronodular lesions (with or without cavitation) similar to tuberculosis are noted. Pulmonary parenchymal abnormalities in the upper lobe(s) may be noted. Mass lesions similar to carcinoma are frequent, and


Surgery_Schwartz

Surgery_Schwartz. lesions (with or without cavitation) similar to tuberculosis are noted. Pulmonary parenchymal abnormalities in the upper lobe(s) may be noted. Mass lesions similar to carcinoma are frequent, and lung biopsy is frequently used. Over 50% of patients with chronic blastomycosis also have extrapulmonary manifesta-tions, but less than 10% of patients present with severe clinical manifestation.114Once a patient manifests symptoms of chronic blastomy-cosis, antifungal treatment is required to achieve resolution. Mortality approaches 60% if untreated.114 While controversial, a short course of triazole therapy (oral itraconazole 200 mg daily) for 6 months is the treatment of choice for most patients with mild to moderate forms of the disease. Because itraconazole has poor CNS penetration, the most common site of recurrence after apparently successful therapy is in the CNS. In the absence of therapy, close follow-up is warranted for evidence of progres-sion to chronic or extrapulmonary disease.


Surgery_Schwartz

Surgery_Schwartz. common site of recurrence after apparently successful therapy is in the CNS. In the absence of therapy, close follow-up is warranted for evidence of progres-sion to chronic or extrapulmonary disease. Amphotericin B is warranted for patients with severe or life-threatening disease, CNS involvement, disseminated disease, or extensive lung involvement and in immunocompromised patients. After ade-quate drug therapy, surgical resection of known cavitary lesions should be considered because viable organisms are known to persist in such lesions.Massive HemoptysisMassive hemoptysis is generally defined as expectoration of over 600 mL of blood within a 24-hour period. It is a medi-cal emergency associated with a mortality rate of 30% to 50%. Most clinicians would agree that losing over a liter of blood via the airway within 1 day is significant, yet use of an abso-lute volume criterion presents difficulties. First, it is difficult for the patient or caregivers to quantify the volume of blood


Surgery_Schwartz

Surgery_Schwartz. blood via the airway within 1 day is significant, yet use of an abso-lute volume criterion presents difficulties. First, it is difficult for the patient or caregivers to quantify the volume of blood being lost. Second, and most relevant, the rate of bleeding nec-essary to incite respiratory compromise is highly dependent on the individual’s prior respiratory status. For example, the loss of 100 mL of blood over 24 hours in a 40-year-old male with normal pulmonary function would be of little immediate con-sequence, because his normal cough would ensure his ability to clear the blood and secretions. In contrast, the same amount of bleeding in a 69-year-old male with severe COPD, chronic bronchitis, and an FEV1 of 1.1 L may be life-threatening.Anatomy. The lungs have two sources of blood supply: the pulmonary and bronchial arterial systems. The pulmonary sys-tem is a high-compliance, low-pressure system, and the walls of the pulmonary arteries are very thin and delicate. The bronchial


Surgery_Schwartz

Surgery_Schwartz. the pulmonary and bronchial arterial systems. The pulmonary sys-tem is a high-compliance, low-pressure system, and the walls of the pulmonary arteries are very thin and delicate. The bronchial arteries, part of the systemic circulation, have systemic pres-sures and thick walls; most branches originate from the proxi-mal thoracic aorta. Most cases of massive hemoptysis involve bleeding from the bronchial artery circulation or from the pul-monary circulation pathologically exposed to the high pres-sures of the bronchial circulation. In many cases of hemoptysis, particularly those due to inflammatory disorders, the bronchial arterial tree becomes hyperplastic and tortuous. The systemic pressures within these arteries, combined with a disease process within the airway and erosion, lead to bleeding.Causes. Significant hemoptysis has many causes, most com-monly including pulmonary, extrapulmonary, and iatrogenic. Table 19-20 summarizes the most common causes of hemopty-sis. Most are


Surgery_Schwartz

Surgery_Schwartz. to bleeding.Causes. Significant hemoptysis has many causes, most com-monly including pulmonary, extrapulmonary, and iatrogenic. Table 19-20 summarizes the most common causes of hemopty-sis. Most are secondary to inflammatory processes. Aneurysms Brunicardi_Ch19_p0661-p0750.indd 71701/03/19 7:01 PM 718SPECIFIC CONSIDERATIONSPART IITable 19-20Pulmonary and extrapulmonary causes of massive hemoptysisPULMONARYEXTRAPULMONARYIATROGENICPulmonary parenchymal diseaseBronchitisBronchiectasisTuberculosisLung abscessPneumoniaCavitary fungal infection (e.g., aspergilloma)Lung parasitic infection (ascariasis, schistosomiasis, paragonimiasis)Pulmonary neoplasmPulmonary infarction or embolismTraumaArteriovenous malformationPulmonary vasculitisPulmonary endometriosisWegener’s granulomatosisCystic fibrosisPulmonary hemosiderosisCongestive heart failureCoagulopathyMitral stenosisMedicationsIntrapulmonary catheterTable 19-21Treatment priorities in the management of massive hemoptysis 1. Achieve


Surgery_Schwartz

Surgery_Schwartz. fibrosisPulmonary hemosiderosisCongestive heart failureCoagulopathyMitral stenosisMedicationsIntrapulmonary catheterTable 19-21Treatment priorities in the management of massive hemoptysis 1. Achieve respiratory stabilization and prevent asphyxiation. 2. Localize the bleeding site. 3. Control the hemorrhage. 4. Determine the cause. 5. Definitively prevent recurrence.of the pulmonary artery (referred to as Rasmussen’s aneurysm) can develop within pulmonary cavities and can result in massive bleeding. Hemoptysis due to lung cancer is usually mild, result-ing in blood-streaked sputum. Massive hemoptysis in patients with lung cancer is typically caused by malignant invasion of pulmonary artery vessels by large central tumors. Although rare, it is often a terminal event.Management. Life-threatening hemoptysis is best managed by a multidisciplinary team of intensive care physicians, interven-tional radiologists, and thoracic surgeons. Treatment priorities begin with respiratory


Surgery_Schwartz

Surgery_Schwartz. hemoptysis is best managed by a multidisciplinary team of intensive care physicians, interven-tional radiologists, and thoracic surgeons. Treatment priorities begin with respiratory stabilization; intubation with isolation of the bleeding lung may be required to prevent asphyxiation. This can be done with main-stem intubation into the nonbleeding lung, endobronchial blockers into the bleeding lung, or double-lumen endotracheal intubation, depending on the urgency of the situation and the expertise of the providers. Once adequate ven-tilation has been achieved, the bleeding site should be localized; bronchoscopy can often provide direct visualization of blood coming from a specific area of the tracheobronchial anatomy. Control of the hemorrhage is then achieved endobronchially with laser or bronchial occlusion, endovascularly with bronchial and/or pulmonary artery embolization, or surgically with resec-tion of the involved area.116 The order of priorities in manage-ment is detailed in


Surgery_Schwartz

Surgery_Schwartz. bronchial occlusion, endovascularly with bronchial and/or pulmonary artery embolization, or surgically with resec-tion of the involved area.116 The order of priorities in manage-ment is detailed in Table 19-21.The clinically pragmatic definition of massive hemoptysis is a degree of bleeding that threatens respiratory stability. There-fore, clinical judgment of respiratory compromise is the first step in evaluating a patient.117,118 Two scenarios are possible: (a) bleeding is significant and persistent, but its rate allows a rapid but sequential diagnostic and therapeutic approach, and (b) bleeding is so rapid that emergency airway control and ther-apy are necessary.Scenario 1: Significant, Persistent, but Nonmassive Bleeding Although bleeding is brisk in scenario 1, the patient may be able to maintain clearance of the blood and secretions with his or her own respiratory reflexes. Immediate measures are admission to an intensive care unit; strict bed rest; Trendelenburg position-ing


Surgery_Schwartz

Surgery_Schwartz. to maintain clearance of the blood and secretions with his or her own respiratory reflexes. Immediate measures are admission to an intensive care unit; strict bed rest; Trendelenburg position-ing with the affected side down (if known); administration of humidified oxygen; cough suppression; monitoring of oxygen saturation and arterial blood gases; and insertion of large-bore intravenous catheters. Strict bed rest with sedation may lead to slowing or cessation of bleeding, and the judicious use of intravenous narcotics or other relaxants to mildly sedate the patient and diminish some of the reflexive airway activity is often necessary. Also recommended are administration of aero-solized adrenaline, intravenous antibiotic therapy if needed, and correction of abnormal blood coagulation study results. Finally, unless contraindicated, intravenous vasopressin (20 U over 15 minutes, followed by an infusion of 0.2 U/min) can be given.A CXR is the first test and often proves to be the most


Surgery_Schwartz

Surgery_Schwartz. results. Finally, unless contraindicated, intravenous vasopressin (20 U over 15 minutes, followed by an infusion of 0.2 U/min) can be given.A CXR is the first test and often proves to be the most revealing. Localized lesions may be seen, but the effects of blood soiling of other areas of the lungs may predominate, obscuring the area of pathology. Chest CT scan provides more detail and is nearly always performed if the patient is stable. Pathologic areas may be obscured by blood soiling.Flexible bronchoscopy is the next step in evaluating the patient’s condition. Some clinicians argue that rigid bronchos-copy should always be performed. However, if the patient is clinically stable and the ongoing bleeding is not imminently threatening, flexible bronchoscopy is appropriate. It allows diagnosis of airway abnormalities and will usually permit Brunicardi_Ch19_p0661-p0750.indd 71801/03/19 7:01 PM


Surgery_Schwartz

Surgery_Schwartz. CHAPTER 19719CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAlocalization of the bleeding site to either a lobe or even a seg-ment. The person performing the bronchoscopy must be pre-pared with excellent suction and must be able to perform saline lavage with a dilute solution of epinephrine.Most cases of massive hemoptysis arise from the bron-chial arterial tree; therefore, the next therapeutic option fre-quently is selective bronchial arteriography and embolization. Prearteriogram bronchoscopy is extremely useful to direct the angiographer. However, if bronchoscopy fails to localize the bleeding site, then bilateral bronchial arterio-grams can be performed. More recently, use of multidetec-tor CT angiography in patients with hemoptysis that is not immediately life-threatening has been shown to facilitate endovascular intervention; reformatting of the images in mul-tiple projections allows clear delineation of the pulmonary vascular anatomy.105 With this approach, abnormal bronchial and


Surgery_Schwartz

Surgery_Schwartz. to facilitate endovascular intervention; reformatting of the images in mul-tiple projections allows clear delineation of the pulmonary vascular anatomy.105 With this approach, abnormal bronchial and nonbronchial arteries can be visualized and subsequently targeted for therapeutic arterial embolization.119 Once the tar-geted arterial system has been embolized, immediate control and cessation of the hemoptysis is achieved in more than 80% of patients. If bleeding persists after bronchial artery emboli-zation, a pulmonary artery source should be suspected and a pulmonary angiogram performed at the same setting.Recurrence is seen in 30% to 60% of cases and is very common in the setting of invasive fungal infections such as aspergilloma. Recurrence after bronchial artery embolization is less common in the setting of malignancy and active tuberculo-sis but does occur and can ultimately result in patient death.120 Repeat embolization can be effective and is warranted for ini-tial management


Surgery_Schwartz

Surgery_Schwartz. in the setting of malignancy and active tuberculo-sis but does occur and can ultimately result in patient death.120 Repeat embolization can be effective and is warranted for ini-tial management of recurrent hemoptysis, but early surgical intervention should be considered, particularly in the setting of aspergilloma or other cavitary lesions.105If respiratory compromise is impending, orotracheal intu-bation should be performed. After intubation, flexible bronchos-copy should be performed to clear blood and secretions and to attempt localization of the bleeding site. Depending on the pos-sible causes of the bleeding, bronchial artery embolization or (if appropriate) surgery can be considered.Scenario 2: Significant, Persistent, and Massive Bleeding Life-threatening bleeding requires emergency airway control and preparation for potential surgery. Such patients are best cared for in an operating room equipped with rigid bronchos-copy. Immediate orotracheal intubation may be necessary to


Surgery_Schwartz

Surgery_Schwartz. airway control and preparation for potential surgery. Such patients are best cared for in an operating room equipped with rigid bronchos-copy. Immediate orotracheal intubation may be necessary to gain control of ventilation and suctioning. However, rapid trans-port to the operating room with rigid bronchoscopy should be facilitated. Rigid bronchoscopy allows adequate suctioning of bleeding with visualization of the bleeding site; the nonbleed-ing side can be cannulated with the rigid scope and the patient ventilated. After stabilization, ice-saline lavage of the bleeding site can then be performed (up to 1 L in 50-mL aliquots); bleed-ing stops in up to 90% of patients.121Alternatively, blockade of the main stem bronchus of the affected side can be accomplished with a double-lumen endo-tracheal tube, with a bronchial blocker, or by intubation of the nonaffected side by an uncut standard endotracheal tube. Place-ment of a double-lumen endotracheal tube is challenging in these


Surgery_Schwartz

Surgery_Schwartz. endo-tracheal tube, with a bronchial blocker, or by intubation of the nonaffected side by an uncut standard endotracheal tube. Place-ment of a double-lumen endotracheal tube is challenging in these circumstances, given the bleeding and secretions. Proper placement and suctioning may be difficult, and attempts could compromise the patient’s ventilation. The best option is to place a bronchial blocker in the affected bronchus with inflation. Endovascular embolization can be performed to stop the bleeding after control has been achieved with the bronchial blocker. The blocker is left in place for 24 hours; after 24 hours, the area is reexamined bronchoscopically.Surgical Intervention. In most patients, bleeding can be stopped, recovery can occur, and plans to definitively treat the underlying cause can be made. In scenario 1 (significant, persis-tent, but nonmassive bleeding), the patient may undergo further evaluation as an inpatient or outpatient. A chest CT scan and pulmonary function


Surgery_Schwartz

Surgery_Schwartz. cause can be made. In scenario 1 (significant, persis-tent, but nonmassive bleeding), the patient may undergo further evaluation as an inpatient or outpatient. A chest CT scan and pulmonary function studies should be obtained preoperatively. In scenario 2 (patients with significant, persistent, and massive bleeding), surgery, if appropriate, will usually be performed during the same hospitalization as the rigid bronchoscopy or main stem bronchus blockade. In a small number of patients (<10%), immediate surgery will be necessary due to the extent of bleeding. The bleeding site in these patients is localized using rigid bronchoscopy with immediate thoracotomy or sternotomy to follow.Surgical treatment is individualized according to the source of bleeding and the patient’s medical condition, prog-nosis, and pulmonary reserve. General indications for urgent surgery are presented in Table 19-22. In patients with significant cavitary disease or with fungus balls, the walls of the cavities