Surgical Treatment of Pleural Diseases

Surgical treatment of pleural diseases

Prof. Ahmed DeebisHead of Cardiothoracic Surgery

Department – Zagazig University

Objectives

• Pneumothorax• Empyema•Mesothelioma• Surgical procedures

Pneumothorax

Physiology

Physiology• Normally, the intrapleural pressure is negative

and this keeps the two pleurae together .• During expiration, intrapleural pressure is

approximately -4cmH20 (-3 mmHg) (below atmosphere)

• During inspiration, the intrapleural pressure is approximately -8cmH20 (-6 mmHg) (below atmosphere)

• Intrapleural pressure also fluctuates with breathing ~ 4 cmH2O less than the intrapulmonary pressure

I) Pneumothorax

Definition:• Pneumothorax is the collection of air in the

pleural space.Classification of Pneumothorax

• 1)Spontaneous• 2)Acquired

Pneumothorax1)Spontaneous

• i) Primary: • no apparent lung disease • Believed to be due to

subpleural bleb rupture.

• ii) Secondary:• Due to underlying pulmonary

disease • COPD / Asthma / Cystic

Fibrosis• Immunocompromised

Infections

2)Acquired

• i) Traumatic: • Penetrating chest trauma• blunt chest trauma

• ii) Iatrogenic: • Transthoracic or

transbronchial lung biopsy,• Pleural biopsy• Placement of central venous

catheter, • Thoracentesis

• iii) Barotraumas

Spontaneous Pneumothorax 1-Primary Spontaneous Pneumothorax (PSP)

• A disease of younger individuals (15 - 30 yrs of age)

• Patients tend to be tall and thin• Males > females 6:1• Cigarette smoking implicated • Believed to arise from sub pleural blebs mostly

in the apex of upper lobes and superior segment of lower lobes

• Usually occurs when the patient is at rest or during normal activities

Primary Spontaneous PneumothoraxClinical Diagnosis:

• Sudden onset of pleuritic chest pain and dyspnea at rest or during normal activities

• Decreased movement of the chest wall, hyperresonance to percussion, diminished fremitus, and decreased or absent breath sounds on the affected side.Radiological diagnosis: P-A chest X-ray obtained with the patient in an upright position

2-Secondary Spontaneous Pneumothorax (SSP)

• In contrast to PSP, secondary spontaneous pneumothorax (SSP) is a potentially life-threatening event, because patients have associated lung disease and limited cardiopulmonary reserve.

• In patients with SSP, dyspnea may be severe and out of proportion to the size of the pneumothorax,

• Hypoxemia, hypercarbia, and hypotension may be the dominant findings.

Complications of Spontaneous Pneumothorax

• i) Persistent air leak from chest tube• ii) Pneumomediastinum, • iii) Hemopneumothorax, • vi) Tension pneumothorax, and • v) Recurrence

Treatment of Spontaneous Pneumothorax

• 1) Observation: for asymptomatic patient with pneumothorax less than 20 %, with careful instruction for follow up within 12 – 48 hours.

• 2) Tube Thoracostomya) Tube thoracostomy is recommended for :i) Patients with large or symptomatic PSP. ii) For most patients with SSP. iii) Patients presenting with tension pneumothorax.b) Tube placement is through the fifth intercostal space in the midaxillary line

Treatment of Spontaneous Pneumothorax, Cont.

• 3) PleurodesisAfter tube thoracostomy, chemical pleurodesis may help prevent SP recurrence. Sclerosing agents are instilled to create pleural symphysis. The most commonly used agents are sterile talc slurry and doxycycline solution.

Treatment of Spontaneous Pneumothorax, Cont.

• 4) SurgerySurgical indications for PSP are:

• i) Recurrent pneumothorax • ii) Massive or persistent air leaks• iii) Incomplete lung expansion after tube thoracostomy.• Vi) Other surgical indications include patients with a

history of bilateral PSP and those in occupations that would place them at high risk if a pnemothorax recurred, such as pilots and divers.

Surgery of Spontaneous Pneumothorax, cont.

• Goals of surgery: Resection of the offending bulla, Complete lung expansion, and Surgical pleurodesis , done by

parietal pleural resection or abrasion to prevent recurrence.

Surgery of Spontaneous Pneumothorax, cont.

• Video-assisted thoracoscopic surgery (VATS) is the surgical procedure of choice for PSP, replacing the previous procedure, axillary thoracotomy.

II) EMPYEMA THORACIS

II) Empyema Thoracis Definition: Accumulation of pus in the pleural cavity.Incidence: 5-10 % of hospitalized patient with parapneumonic effusion.

Etiology: -• Lung diseases: Pneumonia (the most common cause), Lung

abscess.• Post traumatic.• Iatrogenic e.g., complications of thoracocentesis (aspiration

of pleural effusion).• Postoperative : Postresection bronchopleural fistula . • Mediastinitis with pleural extension• Extension of subphrenic abscess.• Blood spread

Pathology Empyema ThoracisParapneumonic effusion progress through 3 stages to an empyema.

• First or exudative stage: has relatively low LDH, normal glucose and normal PH.

• Second or fibropurulent stage: If 1st stage not well treated with invasion of pleural fluid by bacteria increased fibrin deposition, cellular debris and blood cells formation of fibrinous membranes producing loculations.

• Third or organization stages: occurs as fibroblasts grow into fibrin sheet coating the visceral and parital pleura "pleural peel" causing entrapment of the lung.

Clinical Stages of Empyema Thoracis

• Acute stage: Within the first 2 weeks of the onset.

• Chronic Stage: After 2 weeks or with the formation of the thick peel and loculations.

Diagnosis of Empyema Thoracis

• 1- Pus obtained on thoracocentesis. Glucose concentration < 40 mg/dl, LDH > 3 times the upper limit of normal, and PH < 7.2.

• 2- Chest x ray: Posteroanterior and lateral. 175- 500 ml needed to blunt costophrenic angle.

Diagnosis of Empyema Thoracis , Cont

• 3- Ultrasonography: Localize small amount of fluid and loculation and identify pleural peel.

Diagnosis of Empyema Thoracis , Cont

• 4- CT Scan: Differentiating empyema, lung abscess, subdiaphragmatic fluid

Management of Empyema Thoracis

• Medical management: Non interventional therapy often contraindicated, Thoracocentesis and culture sensitivity based antibiotic therapy generally successful for stage I NOT stage II or III.

Surgical management of Empyema Thoracis

1) Tube thoracostomy using large bore chest tube (30-32 fr.), the tube withdrawn slowly several weeks until removed. 2) Recently: Insertion of pigtail catheter (8 fr to 14 fr) with administration of fibrinolytics such as streptokinase or urokinase until the pleural space is cleared.

Surgical management of Empyema Thoracis , cont.

3) Thoracoscopy (VATS):The next therapeutic option after fibrnolysis, Advantage of VATS Visualize the infected pleural space Determine if complete drainage of all empyema Disruption of all adhesions and loculations.

Surgical management of Empyema Thoracis , cont.

• 4) Decortication: Via thoracotomy should be performed when third stage is suggested by CT Scan. i) Remove all purulent fluid, fibrinous debris, thickened parietal pleura from the pleural space. ii) Resection of visceral pleural peel.

III) Pleural Mesothelioma

III) Pleural Mesothelioma

• Mesothelioms is a rare cancer that develops in the mesothelium.

• Pleural mesothelioma is the most common type of mesothelioma.

• Associated with asbestos exposure with a latent period of at least 20 years and up to 40 years.

• Difficult diagnosis by cytology, Therefore, usually a biopsy is recommended.

Pleural Mesothelioma, cont.

• Three histological subtypes: i) Epithelial, ii) Sarcomatous, and iii) Mixed.

• Median survival from time of diagnosis is 12-18 months.

Pleural Mesothelioma, cont.

Pleural mesothelioma, cont.

Treatment:• Chemotherapy, surgery, irradiation,

immunotherapy have all been used with limited success.

• Pleurodesis gives symptomatic relief of pleural effusion.

SURGICAL PROCEDURES

Thoracocentesis

Chest tube insertion- Insertion Site

• mid or anterior axillary line behind pectoralis major• above 5th rib since on expiration diaphragm rises • count down from sternomanubrial joint (2nd rib)

Chest tube insertion, Cont.

Thoracoscopy

Thoracotomy

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