Endoscopic drainage of an infected giant bulla
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《血管的通路杂志》
Department of Surgery, Teikyo School of Medicine, 2-11 Kaga 2-Chome, Itabashi-Ku, Tokyo 173, Japan
Abstract
A 42-year-old man was hospitalized because of an infectious giant bulla. The infected giant bulla did not improve by the administration of antibiotics. Some infectious bullae were considered to be difficult to allow for simple cutaneous drainage, so endoscopic drainage was performed to remove the infection. Our experience with endoscopic abscess drainage is excellent in patients in whom conventional therapy fails. We consider the endoscopic drainage an alternative to percutaneous drainage in patients who have an infectious bulla.
Key Words: Infectious giant bulla; Endoscopic drainage; Video-assisted thoracoscope
1. Introduction
The most common therapeutic approach to infectious bullae of the lung is the administration of systemic antibiotics [1]. Surgical resection was reported to be a contraindication in fluid-filled bullae because of persistent postoperative air leakage due to lung injury [1]. If the conservative treatment with antibiotics fails, drainage is usually considered [2]. No report has been published on the endoscopic drainage of an infected bulla. We describe endoscopic drainage of an infected giant bulla and suggest this may present a viable treatment option for cases in which the infection does not resolve with conservative therapy.
2. Case report
A 42-year-old man was admitted to our hospital with complaints of fever. Bullae of the right lung had been found 5 years earlier during a periodic healthy examination. On admission, an examination revealed a male patient in moderate distress with a temperature of 38.5 °C. A chest roentgenogram and CT scans of the chest showed some bullous lesions with niveau-like shadow in the right upper lobe of the lung (Figs. 1 and 2). Sputum and blood cultures were obtained, and therapy was begun with the plan to manage his disease conservatively. An analysis of sputum disclosed no significant findings, and blood culture showed no growth. Laboratory examination revealed that his white blood count was 11700/mm3, and C-reactive protein was 14.5 mg/dl. The patient continued to have a daily temperature of 39 °C, and white blood count and C-reactive protein were high despite a number of changes in antibiotic therapy. The infected giant bulla did not improve by the administration of antibiotics, and it was concluded that the contents of the bulla needed to be drained. Although thoracostomy tube-drainage for fluid-filled bullae has been described [2], some infectious bullae were considered to be difficult to allow for simple cutaneous drainage. So endoscopic drainage was performed to remove the infection. The patient underwent general anesthesia, and endoscopic surgery in the cavity was performed with the patient in a supine position. A skin incision of approximately 3 cm in size was made and thoracostomy was made to introduce a wound edge protector (Lap-Protector FF0707; Hakko; Tokyo, Japan) through the 2nd intercostal space about 5 cm lateral to the parasternal line, and a video-assisted thoracoscope (EL2-TF410 type 31; Fujinon; Tokyo, Japan) was directly introduced from the wound edge protector into the lumen of the bulla. A yellow-turbid fluid was suctioned and caseous necrosis was resected from the bulla wall with the use of thoracic surgery. There were three abscessed bullae, and the interbullous walls were thin. The interbullous walls were easily opened, and the internal trabeculae were excised by using endoscopic scissors to help drainage more efficiently. An air leakage test showed no air leakage from the inside wall of the bulla. A tube was inserted percutaneously for drainage. Suction at 10 cm water pressure was applied to the tube. Culture of the fluid for routine bacteria, fungal, and tuberculous organisms showed no growth. The infection subsided on the next day, and laboratory examination revealed that white blood count and C-reactive protein soon became within normal range. A subsequent radiograph and CT scan of the chest demonstrated a near-complete resolution of the bullae. The patient was discharged following two weeks of drainage without complications, and he has remained asymptomatic for 6 months.
3. Discussion
We report this case because there have been no previous reports in the literature on the endoscopic drainage of an infected giant bulla. Intracavity suction and drainage was a safe and effective treatment of emphysematous bulla in patients considered to be at poor risk for formal thoracotomy [2]. The percutaneous insertion of a catheter to drain an infectious bulla would be favorable. But if the patient had some infectious bullae, the infection following a catheter insertion may be persistent because a catheter could not always lead to resolution of all fluid-filled bullae. Thus, the percutaneous drainage may be problematic if anatomic sutures do not allow for access to some of the infectious cavities. Nomori et al. [3] reported that opening of a bulla with the use of video-assisted thoracoscopic surgery (VATS) from the thoracic cavity was effective for infectious bulla. The VATS from the thoracic cavity would be difficult if the lungs firmly adhered to the thoracic wall. Also the risk of empyema following the opening of an infectious bulla may be present. Endoscopic drainage does not carry the risk of soiling the pleural space. Our experience with endoscopic abscess drainage is excellent in patients in whom conventional therapy fails. A subsequent CT scan of the chest demonstrated a near-complete resolution of the bulla. When an infected bulla does not improve by the administration of antibiotics, we think the endoscopic drainage is indicated. We consider the endoscopic drainage an alternative to percutaneous drainage in patients who have infectious bulla.
References
Mahler DA, D'Esopo ND. Periemphysematous lung infection. Clin Chest Med 1981; 2:51–57.
Kirschner LS, Stuffer W, Krenzel C, Duane PG. Management of a giant fluid-filled bulla by closed-chest thoracostomy tube drainage. Chest 1997; 111:1772–1774.
Nomori H, Horio H, Fuyuno G, Kobayashi R, Morinaga S, Suematsu K. Opening of infectious giant bulla with use of video-assisted thoracoscopic surgery. Chest 1997; 112:1670–1673.(Iwao Takanami)
Abstract
A 42-year-old man was hospitalized because of an infectious giant bulla. The infected giant bulla did not improve by the administration of antibiotics. Some infectious bullae were considered to be difficult to allow for simple cutaneous drainage, so endoscopic drainage was performed to remove the infection. Our experience with endoscopic abscess drainage is excellent in patients in whom conventional therapy fails. We consider the endoscopic drainage an alternative to percutaneous drainage in patients who have an infectious bulla.
Key Words: Infectious giant bulla; Endoscopic drainage; Video-assisted thoracoscope
1. Introduction
The most common therapeutic approach to infectious bullae of the lung is the administration of systemic antibiotics [1]. Surgical resection was reported to be a contraindication in fluid-filled bullae because of persistent postoperative air leakage due to lung injury [1]. If the conservative treatment with antibiotics fails, drainage is usually considered [2]. No report has been published on the endoscopic drainage of an infected bulla. We describe endoscopic drainage of an infected giant bulla and suggest this may present a viable treatment option for cases in which the infection does not resolve with conservative therapy.
2. Case report
A 42-year-old man was admitted to our hospital with complaints of fever. Bullae of the right lung had been found 5 years earlier during a periodic healthy examination. On admission, an examination revealed a male patient in moderate distress with a temperature of 38.5 °C. A chest roentgenogram and CT scans of the chest showed some bullous lesions with niveau-like shadow in the right upper lobe of the lung (Figs. 1 and 2). Sputum and blood cultures were obtained, and therapy was begun with the plan to manage his disease conservatively. An analysis of sputum disclosed no significant findings, and blood culture showed no growth. Laboratory examination revealed that his white blood count was 11700/mm3, and C-reactive protein was 14.5 mg/dl. The patient continued to have a daily temperature of 39 °C, and white blood count and C-reactive protein were high despite a number of changes in antibiotic therapy. The infected giant bulla did not improve by the administration of antibiotics, and it was concluded that the contents of the bulla needed to be drained. Although thoracostomy tube-drainage for fluid-filled bullae has been described [2], some infectious bullae were considered to be difficult to allow for simple cutaneous drainage. So endoscopic drainage was performed to remove the infection. The patient underwent general anesthesia, and endoscopic surgery in the cavity was performed with the patient in a supine position. A skin incision of approximately 3 cm in size was made and thoracostomy was made to introduce a wound edge protector (Lap-Protector FF0707; Hakko; Tokyo, Japan) through the 2nd intercostal space about 5 cm lateral to the parasternal line, and a video-assisted thoracoscope (EL2-TF410 type 31; Fujinon; Tokyo, Japan) was directly introduced from the wound edge protector into the lumen of the bulla. A yellow-turbid fluid was suctioned and caseous necrosis was resected from the bulla wall with the use of thoracic surgery. There were three abscessed bullae, and the interbullous walls were thin. The interbullous walls were easily opened, and the internal trabeculae were excised by using endoscopic scissors to help drainage more efficiently. An air leakage test showed no air leakage from the inside wall of the bulla. A tube was inserted percutaneously for drainage. Suction at 10 cm water pressure was applied to the tube. Culture of the fluid for routine bacteria, fungal, and tuberculous organisms showed no growth. The infection subsided on the next day, and laboratory examination revealed that white blood count and C-reactive protein soon became within normal range. A subsequent radiograph and CT scan of the chest demonstrated a near-complete resolution of the bullae. The patient was discharged following two weeks of drainage without complications, and he has remained asymptomatic for 6 months.
3. Discussion
We report this case because there have been no previous reports in the literature on the endoscopic drainage of an infected giant bulla. Intracavity suction and drainage was a safe and effective treatment of emphysematous bulla in patients considered to be at poor risk for formal thoracotomy [2]. The percutaneous insertion of a catheter to drain an infectious bulla would be favorable. But if the patient had some infectious bullae, the infection following a catheter insertion may be persistent because a catheter could not always lead to resolution of all fluid-filled bullae. Thus, the percutaneous drainage may be problematic if anatomic sutures do not allow for access to some of the infectious cavities. Nomori et al. [3] reported that opening of a bulla with the use of video-assisted thoracoscopic surgery (VATS) from the thoracic cavity was effective for infectious bulla. The VATS from the thoracic cavity would be difficult if the lungs firmly adhered to the thoracic wall. Also the risk of empyema following the opening of an infectious bulla may be present. Endoscopic drainage does not carry the risk of soiling the pleural space. Our experience with endoscopic abscess drainage is excellent in patients in whom conventional therapy fails. A subsequent CT scan of the chest demonstrated a near-complete resolution of the bulla. When an infected bulla does not improve by the administration of antibiotics, we think the endoscopic drainage is indicated. We consider the endoscopic drainage an alternative to percutaneous drainage in patients who have infectious bulla.
References
Mahler DA, D'Esopo ND. Periemphysematous lung infection. Clin Chest Med 1981; 2:51–57.
Kirschner LS, Stuffer W, Krenzel C, Duane PG. Management of a giant fluid-filled bulla by closed-chest thoracostomy tube drainage. Chest 1997; 111:1772–1774.
Nomori H, Horio H, Fuyuno G, Kobayashi R, Morinaga S, Suematsu K. Opening of infectious giant bulla with use of video-assisted thoracoscopic surgery. Chest 1997; 112:1670–1673.(Iwao Takanami)