Download - Surgery of Pulmonary Infections
![Page 1: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/1.jpg)
Surgery for Pulmonary Infections
Prof. Ahmed DeebisHead of Cardiothoracic
Surgery Department - Zagazig University
![Page 2: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/2.jpg)
Surgery of Pulmonary Infections
ObjectivesI. Lung AbscessII. BronchiectasisIII. Surgery for Pulmonary Tuberculosis
![Page 3: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/3.jpg)
Lung abscess
![Page 4: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/4.jpg)
Lung abscess
Definition: Necrosis of the pulmonary tissue caused by microbial infection and the formation of cavities containing necrotic debris or fluid.
• There may be continuity with the airway, with partial drainage air fluid level on chest X-ray.
• If complicated with erosion into the pleural space, empyema with bronchopleural fistula.
![Page 5: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/5.jpg)
Etiology of lung abscessA. Primary abscess :
Infectious in origin, caused by:i. aspiration
impaired consciousness (e.g. anesthesia, alcoholism, head trauma),
poor oral hygiene, dental infection.],
ii. pneumonia in the healthy host.B. Secondary abscess:
caused by: a preexisting condition (eg, obstruction with tumor, foreign body), spread from an extrapulmonary site (e.g. subphrenic abscess), bronchiectasis, and/or an immunocompromised state.
![Page 6: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/6.jpg)
Pathology
• Acute lung abscess: Duration of symptoms prior to presentation for medical care < one month.
• Chronic lung abscess: Duration of symptoms prior to presentation for medical care > one month.
![Page 7: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/7.jpg)
Pathology• Parenchymal involvement occurs in segmental distribution.• What are the commonly affected segments?
Posterior segment of upper lobe and superior segment of lower lobe, The right side more affected than left side.why? As these segments are dependent when the patient is in recumbent position so aspiration more to these segments. The right side more affected as right bronchus more in line with trachea so aspiration more to the right.
![Page 8: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/8.jpg)
Clinical Picture
History:• Intermittent fever, cough, malaise, weight
loss, night sweats, and may be hemoptysis
• When cavitations occurs, putrid expectoration and is usually pronounced in patient with anaerobe infection.
![Page 9: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/9.jpg)
Clinical Picture, Cont.
• Physical examination: a small area of dullnesssuppressed breath sound (rather than bronchial). Fine or medium moist crackles may be present. If the cavity is large, there may be tympany or amphoric breath.
![Page 10: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/10.jpg)
Diagnosis
1. History, and physical examination. 2. Sputum should be examined by smear and
culture should be obtained. 3. Bronchoscopy. 4. Chest x ray show cavitary space within the
lung with an air fluid level .5. CT scan: for better anatomic interpretation.
![Page 11: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/11.jpg)
![Page 12: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/12.jpg)
![Page 13: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/13.jpg)
Diagnosis, cont.
Differential Diagnosis: a)Hydropneumothorax, b)Cavitary neoplasm, c) Loculated empyema with airway fistulation,d)Interlobar fluid collection.
![Page 14: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/14.jpg)
Treatment
Medical therapy : Successful in 85 – 90 % 0f cases.
• 1- Antibiotic: Initial therapy should be intravenous unless the patient is minimally symptomatic, for 6 -8 weeks.
• 2- Pulmonary clearance techniques : Humidification,Expectorant, Chest physiotherapy.
![Page 15: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/15.jpg)
Surgical therapy
The availability of effective antibiotic therapy for primary lung abscess has diminished the role of surgery.
• External drainage: i) Percutaneously under CT, or ultrasound guidance, ii) Edoscopic drainage, or iii) Video-assisted thoracoscopic (VATS) drainage.
• Surgical resection: Required in less than 10% of cases.
![Page 16: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/16.jpg)
Surgical therapy, cont.
Indications of surgical resection: Failure of medical therapy for 8 weeks. Bronchopheural frstula of empyema, Massive or significant hemoptysis. Persistence of cavity larger that 6cm after medical therapy. Necrotizing infection associated with multiple abscesses. Strong suspicion of carcinoma.
Lobectomy is usually required, as segmentectomy may be inadequate and pneumonectomy is rarely necessary.
![Page 17: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/17.jpg)
II) Bronchiectasis
![Page 18: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/18.jpg)
II) Bronchiectasis Definition: Abnormal, irreversible dilatation of part of
the bronchial tree.Etiology
Acquired• Adults • Due to an infections insult,• Impairment of drainage,• Airway obstruction
and /or • Defect in host defense
Congenital• Infants and children• Due to development arrest
of bronchial tree• Include, cystic fibrosis,
Kartagner's syndrome, congenital deficiency of bronchial cartilage, IgA and IgG deficiency and 1 antitrypsin deficiency
![Page 19: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/19.jpg)
Pathology
• Regardless of the etiology, there is :abnormal bronchial dilatation & bronchial wall destruction & transmural inflammation, vicious circle of bronchial damage and bronchial dilatation with impaired clearance of secretions and recurrent infection more bronchial damage.
• Site: Typically involve basal segments of lower lobes and it is bilateral in 30 – 50 % of patients.
![Page 20: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/20.jpg)
Pathology
• Regardless of the etiology, there is :Abnormal bronchial dilatation & bronchial wall destruction & inflammation, vicious circle of bronchial damage and bronchial dilatation with impaired clearance of secretions and recurrent infection more bronchial damage.
![Page 21: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/21.jpg)
Pathology, cont.
Site: Typically involve basal segments of lower lobes and it is bilateral in 30 – 50 % of patients.
Types: Three types:
1.Cylindrical (fusiform) 2.Varicose (traction) 3.Cystic (saccular)
![Page 22: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/22.jpg)
Clinical Picture
Bronchiectasis can present in two forms: a. Local form, involve a lobe or segment of a lungb. diffuse form, involving much of both lungs. • History of cough, daily mucopurulent, tenacious
sputum production lasting months to years. • Dyspnea, pleuritic chest pain, fever, wheezing. • Hemoptysis occur in about 50% of adult but it is
not usually sever
![Page 23: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/23.jpg)
Clinical Picture, cont.
Physical examination• Non specific and may include, crackles,
rhonchi, wheezing.• Manifestations of chronic illness:
Digital clubbing, cyanosis, plethora, wasting and weight loss indicate the chronic nature of disease.
![Page 24: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/24.jpg)
Diagnosis• History and physical exam. • Chest x Ray, suggestive not diagnostic
volume loss with crowding of pulmonary vasculature areas of atelectasis and persistent infiltrate.
• High resolution CT:The diagnostic tool of choice and replace bronchography Shows bronchial dilatation and parenchymal disease,
"signet ring" sign (the abnormal dilated bronchi appears much larger than adjacent pulmonary artery branch).
• Bronchoscopy: Helpful for both diagnostic and therapeutic purposes
![Page 25: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/25.jpg)
Plain Chest x Ray P-A View suggesting Bronchiectasis
![Page 26: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/26.jpg)
CT Scan
![Page 27: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/27.jpg)
Therapy• Medical therapy:
the 1ry approach, and is focused on airway secretion and control of recurrent infection and include appropriate antibiotic, postural drainage, humidifiers and bronchodilators as indicated.
• Surgical therapy: Resection of the diseased lobe or segment.The role of surgery has evolved from early curative to more palliative.
![Page 28: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/28.jpg)
Therapy, cont.
Indications of pulmonary resection for bronchiectasis : Persistent, recurrent infection following
discontinuation of medication.Massive hemoptysis. Where removal of a foreign body or tumor is
indicated.• Ideal candidates:
Unilateral, segmental or labor distribution disease or bilateral localized bronchiectasis.
![Page 29: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/29.jpg)
Surgery for Pulmonary Tuberculosis
![Page 30: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/30.jpg)
Surgery for Pulmonary Tuberculosis
• Medical therapy is the standard management for pulmonary tuberculosis.
• Also, Surgery plays a role in the treatment of patients with TB
![Page 31: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/31.jpg)
Indications of Surgery for pulmonary tuberculosis
Multidrug-resistant tuberculosis.Emergencies, almost exclusively for haemoptysis.Those in whom there is a need to rule out cancer.Surgery for complicatIon :• Bronchiectasis• destroyed lung• cavitary disease, with or without positive sputum
smears; • bronchopleural fistulas
![Page 32: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/32.jpg)
Surgical therapy
• Resectional surgery in form of:Segmentectomy, lobectomy or pneumonectomy
represents the majority of operations, Operations on the pleura (as decortication).Rarely, thoracoplasty may be done.
![Page 33: Surgery of Pulmonary Infections](https://reader033.vdocuments.site/reader033/viewer/2022042517/587347471a28abf21b8b84a9/html5/thumbnails/33.jpg)
THANK YOU