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 >1000-1500 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 24 - 32F 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 24 - 48 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 uygulaması

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 <0.1%

Thoracotomy Last resort as a diagnostic procedure Usefull for definite resections (Therapeutic) In general access is gained through the 4th-5th intercostal space using 10-20 cm incision Classic Muscle sparing

Complications Respiratory infection Pulmonary embolism MI Bronchopleural fistula Empyema Pain Mortality 1-8%