Surgical Treatment of Pulmonary Diseases
Sina Ercan MD Professor of Thoracic Surgery Contents Thoracentesis Intercostal chest tube drainage Pleurodesis
Rigid Bronchoscopy Mediastinoscopy Video Assisted Thoracoscopic Surgery (VATS) Thoracotomy Preparation for all the procedures
Accurate detailed history should be obtained (concomitant diseases, potential risk factors, coagulopathies, drug use etc.) Physical Examination Chest radiogram, PFT Informed consent Experienced staff Technical support Convenient positioning of the patient and the doctor THORACENTESIS Therapeutic thoracentesis is performed for the drainage of excess fluid accumulated in the pleural cavity Indications: Contraindications
Used in exudative pleural effusion, empyema or chylothorax To relieve dyspnea To relieve chest pain To decrease the mediastinal shift Contraindications Transudative effusions that can be resolved by medication Coagulopaties Thrombocytopenia Trapped lung Complications Local pain Syncope
Hemorrage Pneumothorax Hemothorax Infection Hemodynamic changes Pulmonary edema Spleen or liver laceration Chest x ray should be taken after the procedure No aspiration > cc at a time to avoid complications If the patient starts coughing or feels dyspnea stop the procedure After thoracentesis, total lung capacity (TLC) increases by approximately one-third the volume of fluid removed, and the forced vital capacity (FVC) increase by one-half the increase in TLC. The improvement in FVC and TLC after thoracentesis is variable and is greatest in patients with high lung compliance. Intercostal Chest Tube Drainage
Intercostal drain is inserted to remove intrapleural air and/or fluid Frequently required on an emergency basis and may be life saving One way valve mechanism is achieved by a water seal or a flutter valve Technique Comfortably position the patient
Lying semisupine position is recommended Chest wall sterilization and local anesthetic application F rubber or silastic catheter is inserted Contraindications Inadequate operator experience Fused pleura Coagulopathy Indications Tension Px Large Px Traumatic HemoTx Large effusion Empyema Complications Subcutaneus emphysema Abdominal entry
Subcutaneous placement Lung penetration Major bleeding Continuous air leak Suction can be applied to drain to remove air and fluid faster
Drain removed when air leakage or fluid loss ceases and chest X-ray shows expansion Pleurodesis Aim is to achieve fusion between visceral and parietal pleural layers Chemical pleurodesis used for palliation in recurrent, symptomatic malignant effusions No survival advantage but better quality of life Besides malignant effusions, also used in benign recurrent effusions that are resistant to medical therapy Recurrent pneumothorax Various chemicals used; Bleomycin, tetra and doxycycline, betadine, autologus blood, talc Sclerosant causes inflammation which ends up with fibrosis
Lung should reexpand completely Applied via a chest tube or during VATS Chest tube positioned Radiographic confirmation of complete reexpansion Intrapleural analgesia Application of sclerosant, and clamp tube 1-4 h. Rotate patient q15 min Chest tube then reconnected to 20 cm H2O suction for 48 h Initial failure due to Suboptimal technique Inappropriate patient selection (e.g. a patient with a trapped lung or mainstem bronchial occlusion) Recurrence after pleurodesis is unusual with talc but does occur occasionally Complications Re-expansion pulmonary edema Usually unilateral sometimes on the controlateral lung ARDS and acute pneumonitis Empyema Systemic side effects:
Talc particles have been detected in distant organs after talc pleurodesis Coagulopathies Fever (in hours) Rigid Bronchoscopy Rigid bronchoscope is a metal open tube inserted under general anesthesia It is used for Laser application Dilatation of tracheobronchial stenosis Airway stent placement Extraction of foreign bodies Management of massive hemoptysis Cleaning of retarded mucous plugs Cryotherapy Electrocoterization Tumoral resection Airway Stenting Stent uygulamas Contraindications Unstable cardiovascular status Severe hypoxia
Unstable neck Severe cervical ankylosis Severely restricted motion of temporomandibular joints Bleeding diathesis Complications Hypoxemia Bleeding Pneumothorax Bronchial perforation
Bronchial obstruction Infection Cardiac complications Complications due to general anesthesia Mediastinoscopy The mediastinoscope is introduced into the pretracheal plane from a 3 cm suprasternal skin incision The procedure requires a considerable level of surgical skill Mediastinoscopy allows the surgeon to reach the
Paratracheal Pretracheal Anterior carinal Subcarinal areas Used to diagnose mediastinal lymphadenopathy of any cause
Biopsy the mass lesions of the mediastinum Surgical staging of bronchogenic carcinoma Anterior mediastinotomy (Chamberlain procedure)
Allows the surgeon to sample anterior mediastinal masses Subaortic, preaortic lymph nodes A 5 cm long incision is made from the left second intercostal, parasternal region Relative contraindications:
VCS Syndrome Bleeding disorders and anticoagulation Severe kyphosis Cervical spine instability Complications Hemorhage due to injury of major vessels Air embolism
Tracheal or esophageal perforation Pneumothorax Mediastinal infection VATS (Video Assisted Thoracoscopic Surgery)
Endoscopic examination of the pleural cavity Visceral and parietal pleura Pericardium Lungs Mediastinum Hilum Diaphragm can be visually evaluated This technique is used for diagnosis and treatment
Biopsy and pleurodesis Decortication Wedge resections Formal anatomic resections It is relativelly safe and usefull technique 95-98% leads to diagnosis Thoracoscopy VATS Endoscopy room Surgery room LA / sedation GA No intubation Intubation 1-2 entries to thorax Multipl entries Minimal invasive Invasive Low cost Costly Tools of thoracoscopy Indications Pleural biopsy Pleurodesis Mediastinal biopsy
Indeterminate pulmonary nodule Interstitial lung disease Assesment of operability in bronchogenic carcinoma patients Early empyema Contraindications Absolute: Absence of pleural cavity
Inability to tolerate one-lung ventilation Relative contraindications; Poor general condition Cardiovascular instability Hypoxemia caused other than pleural effusion Fever Intractable cough Uncontrolled bleeding diathesis Complications Perforation of the lung parenchyma Hypotension
Tachycardia, arrhythmia Empyema Pneumomediastinum Fever after the procedure (12-24 hr) (talc) Local infection Major bleeding Air embolism Re-expansion pulmonary edema Tumoral implantation Mortality