Surgery for Lung Infection
When medical therapy has been optimised and an operation is the next step

• Surgery is the last step. The decision to operate is multidisciplinary, made with respiratory medicine and microbiology/infectious diseases after medical therapy has been optimised. Referrals come from those teams.
• Localised bronchiectasis is operated on for symptom control. Disease confined to one lobe on CT, with recurrent exacerbations despite airway clearance and antibiotics for acute episodes, on a respiratory-medicine referral. Resection is usually a lobectomy.
• Aspergilloma is operated on for symptoms or growth. A fungal ball in a cavity with an air-crescent sign on CT. Haemoptysis can be life-threatening and is controlled first by bronchial artery embolisation. Antifungal therapy continues around the operation.
• Abscess and tuberculosis surgery follow failed medical treatment or a destroyed lung. A prolonged antibiotic course for abscess; weeks of anti-tuberculous therapy under TB or infectious-diseases direction for tuberculosis. Both are usually open operations.
• The main technical risk is spillage. In aspergilloma, abscess and hydatid disease the operative priorities are to avoid spilling infected contents into the pleural space and to mobilise the lung so that no fixed residual cavity remains.

Most lung infection is treated without surgery. Antibiotics, antifungals, anti-tuberculous therapy, physiotherapy and interventional radiology resolve the great majority of cases. The small number that come to surgery share one feature: localised disease that has not resolved despite optimised medical treatment. It remains symptomatic, is enlarging, has destroyed a segment of lung, or is bleeding despite every non-surgical measure.

Surgery is the last step of a pathway that begins with the physician. The surgeon’s judgement lies as much in deciding when not to operate, and in confirming that medical treatment has been adequate, as in the operation itself. Whether antimicrobial therapy has been adequate, and whether the disease has failed it, is decided by the physicians managing the infection: respiratory medicine, microbiology and infectious diseases, and tuberculosis services. Mr Okiror therefore takes these referrals from physician colleagues and works alongside the referring team. He does not take over the patient’s medical care.

Each condition has its own medical preparation and its own threshold for surgery, set out below. Where a disease has a national service, the National Aspergillosis Centre for complex fungal disease and the UCLH Echinococcosis multidisciplinary team for hydatid, that service is part of the decision.

Most bronchiectasis is diffuse and is managed medically for life; surgery has no part in it. The exception is the patient whose disease is confined to a single lobe on CT and who remains symptomatic with recurrent chest infections, sometimes with haemoptysis, despite good medical care. The British Thoracic Society’s 2019 bronchiectasis guideline reserves surgical resection for this group: localised disease, in a symptomatic patient, where medical management has not controlled the burden of infection.

Unlike the abscess and tuberculosis pathways below, these patients are not usually on a continuous or prolonged antibiotic course before surgery. Bronchiectasis is managed with airway clearance and physiotherapy, with antibiotics given for acute exacerbations. Antibiotics around the operation are perioperative cover only. The case for surgery rests on the pattern of recurrent localised infection and its effect on the patient, assessed on a respiratory-medicine referral.

The operation is usually a lobectomy, and it is often begun robotically. Bronchiectatic lungs can be densely adherent after years of inflammation, and the operation is converted to open surgery where adhesions make a keyhole approach unsafe. The aim is complete removal of the diseased lobe with the lung fully mobilised so that the remaining lung expands to fill the space. The mechanics of lobectomy and the robotic approach are described on the robotic lobectomy and segmentectomy pages; where haemoptysis is a feature, bronchial artery embolisation is the first measure, as set out in central airway interventions.

An aspergilloma is a fungal ball within a lung cavity: a mass of fungal hyphae, mucus and cellular debris, most often colonising a pre-existing cavity such as an old tuberculous space. On CT it characteristically shows an air-crescent sign, a rim of air separating the fungal ball from the cavity wall. Referrals come from respiratory medicine or from microbiology and infectious diseases. Surgery is indicated for symptomatic disease, and the dominant symptom is haemoptysis, which in this condition can be life-threatening, or, in an asymptomatic patient, for a lesion that is enlarging on serial imaging.

Two things are in place before and around any operation. First, haemoptysis is controlled: significant bleeding is treated initially by interventional radiology with bronchial artery embolisation, which stabilises the patient and allows the operation to be planned. Second, the patient is established on antifungal therapy, usually a triazole such as voriconazole or itraconazole, which continues around the operation and for a period afterwards. Dosing and duration are decided by the microbiology/infectious-diseases team. Surgery is added to antifungal treatment; it does not replace it.

These are difficult operations, almost always performed open through a thoracotomy, because the cavity and surrounding lung are bound down by dense adhesions and the pleural space is often obliterated. The technical priorities are to remove the lesion, usually by lobectomy, without spilling fungal contents into the pleural space, and to mobilise the lung fully so that no fixed residual cavity is left, since a persistent space can become infected again. A surgical review in the Journal of Thoracic Disease reports recurrence after resection of around 7%, and complex aspergillomas, those with an obliterated pleural space and a fixed hilum, are more difficult than simple ones. Complex and chronic pulmonary aspergillosis cases are discussed with the National Aspergillosis Centre at Wythenshawe Hospital in Manchester, the NHS England-commissioned national service, which holds a weekly remote multidisciplinary meeting for difficult cases. The patient-facing page on coughing up blood (haemoptysis) covers the symptom in lay terms, and an aspergilloma is one of the causes of a shadow on a lung scan that is not cancer.

A lung abscess is a localised collection of pus within the lung. The great majority resolve with antibiotics alone, over a prolonged course of several weeks. Surgery is considered only for the minority who fail adequate medical management: the patient who remains unwell, with continuing fever and raised or rising inflammatory markers despite a proper antibiotic course. Published reviews place the surgical group in this small refractory minority. The indication is failure of medical treatment; an abscess that is responding to antibiotics is not operated on.

Where a patient is failing medical therapy, the next step is considered carefully. Image-guided drainage by interventional radiology can be appropriate, but it carries a risk of spilling pus into the pleural space and converting a contained problem into an empyema, the pleural-space infection covered on the empyema and pleural infection page. When surgery is required it is almost always a lobectomy and almost always open, through a thoracotomy, because the inflamed tissue planes are densely adherent and the priority is controlled removal of the abscess-bearing lobe without contaminating the chest. As with the other infective resections, the lung is mobilised so that the remaining lung fills the space and no residual cavity is left.

Tuberculosis is a medical disease, and surgery has a narrow, defined supporting role. Any operation is undertaken only after the patient has been on anti-tuberculous medication for at least several weeks, under the direction of microbiology/infectious diseases or the respiratory TB specialists. The surgical literature is consistent that surgery is selective and adjunctive to drug therapy, and that timing and drug cover are set by the TB physicians.

Within that frame, surgery addresses three situations. The commonest is pleural: a tuberculous pleural collection that needs VATS debridement, or an organised tuberculous empyema requiring decortication, the operation to remove the fibrous rind from the lung so that it can re-expand. The decortication operation, its staging and its evidence base are described on the empyema and pleural infection page. The second is lung resection for a localised destroyed lung: a segment or lobe that has stopped functioning and remains a source of infection despite adequate treatment. The third is haemoptysis that persists despite embolisation, where resection of the bleeding focus becomes necessary after interventional radiology has been exhausted. These operations are usually performed open, and the surgeon works to the TB team’s treatment plan. Tuberculosis is also one of the diagnoses considered on the symptom page for night sweats and unexplained weight loss.

Hydatid (echinococcal) disease of the lung is very rare in UK practice and is usually seen in patients with relevant geographic exposure. It presents as a cyst within the lung. Where that cyst needs removing, surgery is undertaken once the patient is established on adequate antiparasitic treatment. Because almost no general thoracic service sees this infection regularly, it is managed in liaison with microbiology and with the Echinococcosis multidisciplinary team at the Hospital for Tropical Diseases, UCLH, the national hub-and-spoke service for the condition, which has established links to cardiothoracic surgery for thoracic cases.

Lung hydatid is managed differently from liver and spleen disease. The peri-operative antiparasitic strategy is designed to minimise the risk of cyst rupture while maintaining antimicrobial cover through the operative and post-operative period, and it is planned case by case with the UCLH team, which decides the drugs, doses and durations.

The operation is almost always open. The main technical concern is to avoid spilling the cyst contents, the scolices, into the pleural space, because spillage can seed secondary disease and provoke an acute allergic reaction. The field is isolated, a scolicidal agent such as hypertonic saline may be instilled into the lesion before it is removed, and the lung is mobilised so that no fixed residual space remains. As with every condition on this page, the surgery sits inside a medical pathway directed jointly with the infection specialists.

Mr Okiror’s wider thoracic practice is predominantly robotic and keyhole, and where the tissue allows, most often in localised bronchiectasis, an infective resection is begun that way. Infection surgery is often not minimally invasive. Previous inflammation obliterates the natural planes between the lung, the chest wall and the mediastinum and binds them with dense adhesions. In that setting a keyhole approach can be neither safe nor complete.

For that reason aspergilloma, lung abscess, a tuberculous destroyed lung and hydatid disease are usually open operations. The approach is chosen for safety and completeness. In infected tissue the priorities are the same across conditions: controlled dissection, avoiding spillage of infected material into the pleural space, and full mobilisation of the lung so that no fixed residual cavity is left to harbour further infection.

Disclosures

This page is referrer and clinician information, not medical advice for any individual case. Mr Lawrence Okiror is a Consultant Thoracic and Robotic Surgeon at Guy’s and St Thomas’ NHS Foundation Trust, with private practising privileges at London Bridge Hospital and The Lister Hospital Chelsea. Surgery for lung infection is undertaken in partnership with respiratory medicine and microbiology/infectious diseases, and, for the conditions noted, with the National Aspergillosis Centre (Manchester University NHS Foundation Trust) and the Echinococcosis multidisciplinary team at the Hospital for Tropical Diseases, UCLH. He has no commercial relationships relevant to this content. Antimicrobial, antifungal and antiparasitic prescribing decisions are made by the responsible specialist teams. Decisions about referral, surgery and treatment should be made on a case-by-case basis after appropriate clinical evaluation.