1. Surgical Treatment of Pulmonary Diseases
Sina Ercan MD
Professor of Thoracic Surgery

2. Contents Thoracentesis Intercostal chest tube drainage Pleurodesis
Rigid Bronchoscopy
Mediastinoscopy
Video Assisted Thoracoscopic Surgery (VATS)
Thoracotomy

3. 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

4. THORACENTESIS
Therapeutic thoracentesis is performed for the drainage of excess fluid accumulated in the pleural cavity

6. 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

7. 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

8. 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.

9. 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

10. Technique Comfortably position the patient
Lying semisupine position is recommended
Chest wall sterilization and local anesthetic application
F rubber or silastic catheter is inserted

12. Contraindications
Inadequate operator experience
Fused pleura
Coagulopathy
Indications
Tension Px
Large Px
Traumatic HemoTx
Large effusion
Empyema

13. Complications Subcutaneus emphysema Abdominal entry
Subcutaneous placement
Lung penetration
Major bleeding
Continuous air leak

14. 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

15. 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

16. 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

17. Sclerosant causes inflammation which ends up with fibrosis
Lung should reexpand completely
Applied via a chest tube or during VATS

18. 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

20. 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

21. Complications
Re-expansion pulmonary edema
Usually unilateral sometimes on the controlateral lung
ARDS and acute pneumonitis
Empyema

22. Systemic side effects:
Talc particles have been detected in distant organs after talc pleurodesis
Coagulopathies
Fever (in hours)

23. 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

26. Cryotherapy
Electrocoterization
Tumoral resection

27. Airway Stenting
Stent uygulaması

28. Contraindications Unstable cardiovascular status Severe hypoxia
Unstable neck
Severe cervical ankylosis
Severely restricted motion of temporomandibular joints
Bleeding diathesis

29. Complications Hypoxemia Bleeding Pneumothorax Bronchial perforation
Bronchial obstruction
Infection
Cardiac complications
Complications due to general anesthesia

30. 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

32. Mediastinoscopy allows the surgeon to reach the
Paratracheal
Pretracheal
Anterior carinal
Subcarinal areas

35. Used to diagnose mediastinal lymphadenopathy of any cause
Biopsy the mass lesions of the mediastinum
Surgical staging of bronchogenic carcinoma

36. 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

38. Relative contraindications:
VCS Syndrome
Bleeding disorders and anticoagulation
Severe kyphosis
Cervical spine instability

39. Complications Hemorhage due to injury of major vessels Air embolism
Tracheal or esophageal perforation
Pneumothorax
Mediastinal infection

40. VATS (Video Assisted Thoracoscopic Surgery)
Endoscopic examination of the pleural cavity
Visceral and parietal pleura
Pericardium
Lungs
Mediastinum
Hilum
Diaphragm can be visually evaluated

41. 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

42. 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

44. Tools of thoracoscopy

46. Indications Pleural biopsy Pleurodesis Mediastinal biopsy
Indeterminate pulmonary nodule
Interstitial lung disease
Assesment of operability in bronchogenic carcinoma patients
Early empyema

47. 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

48. Complications Perforation of the lung parenchyma Hypotension
Tachycardia, arrhythmia
Empyema
Pneumomediastinum
Fever after the procedure (12-24 hr) (talc)
Local infection

49. Major bleeding
Air embolism
Re-expansion pulmonary edema
Tumoral implantation
Mortality <0.1%

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

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