FIBROTHORAX AND DECORTICATION OF THE LUNG GENERAL THORACIC SURGERY CHAPTER 61
Dec 22, 2015
FIBROTHORAX AND DECORTICATION OF THE LUNG
GENERAL THORACIC SURGERY
CHAPTER 61
Decortication
• Pelling or stripping a constricting menbrane from the pleural surface.
• Include– 1). Intercostals incision, wide exploration of pleural cavity. 2). Full mobilization of lung. 3). Remove fibrous peel, not the visceral pleura, 4). Suction and drainage. • VATS.
Pathophysiology of fibrothorax
• cause of fibrothorax table 61-1. • pleural fluid undrained, deposits fibrin on visceral and
parietal pleura. • Thin layer of immatured blood vessel and loose collagen
forms. • Organization produce dense avascular collagen matrix
wall of the insulting fluid. • Pulmonary compression, atelectasis. Entrapment of lung, • encasement of thoracic cage produces a restrictive
ventilatory defect.
Diagnosis and evaluation
• Symptom /Sign— Chest tightness, frank pain, dry nonproductive cough, fatigue, malaise.
• PE— Unilateral fixation of chest wall, reduce excursion of isilateral hemidiaphragm, dull to percussion, impaired transmission of breath sound.
Diagnosis and evaluation
• Chest x ray— Obliterate the costophrenic angle, narrow intercostals space, diminished the hemithorax, retraction the mediastinum to the fibrothorax, pleural calcification.
• CT— Assess the underlying pulmonary parenchyma for tuberculosis, bronchiectasis, mass lesion.
Treatment
• Preoperative evaluation—pulmonary function test, ABG.
• Indication and contraindication.• Indication— 1). Symptomatic extraparenchymal restrictive disease. 2). Tube thoracostomy, thoracentesis, thoracoscopy are fail to drain and expand of lung.
Treatment
• Timing— 1). Hemothorax over 6 weeks.
2). More than 50% compression.
3). Apex collapse.
4). In tuberculosis after chronic
antituberculosis therapy.
5). No changes on chest x-ray.
Treatment
• Contraindication—
• Major bronchial obstruction.
• Pulmonary destruction.
• Uncontrol sepsis.
• Chronic debilitation.
• Concomitant organ dysfuction.
Differential diagnosis
• Mesothelioma.
• Malignancy.
• Metastatic pleural disease.
Technique
• Bronchoscope exclude endobronchial lesion. • Posterior lateral thoracotomy. • Resection ribs.• Blunt dissection the parietal peel, plane
between the endothoracic fascia and parietal pleura.
Technique
• Prevent injury of diaphragm and phrenic nerve.• Thicked parietal peel in incised. • Empyectomy with preservation the integrity of
cavity for tuberculosis.• Perioperative antibiotics, material is cultured. • Pulmonary decortication with incision fibrous peel
overlying the visceral pleura. • Chest tube drainage.
Mortality and morbidity
• Mortality and morbidity—0-8%. • Morbidity— Sepsis, wound infection,
empyema, hemorrhage, prolong air-leak, bronchopleural fistula.
• Result— Absence of underlying parenchymal disease is best improve. Phrenic nerve injury, tuberculosis are less improve.