Surgery 5th year, 2nd lecture (Dr. Ahmed Al-Azzawi)

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The lecture has been given on Oct. 7th, 2010 by Dr. Ahmed Al-Azzawi.

The lecture has been given on Oct. 7th, 2010 by Dr. Ahmed Al-Azzawi.

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  • 1. Dr.Ahmed Al-Azzawi M.B.Ch.B,F.I.C.M.S Cardiothoracic&Vascular Surgeon University of Sulaimani College of Medicine Thoracic Surgery
  • 2. DISEASES OF THE PLEURA AND PLEURAL SPACE Dr . Ahmed Alazzawi College of Medicine 5th year students Lectures 2010-2011
  • 3.
    • Pleural cavity
    • The pleura is a serous membrane which folds back onto itself to form a two-layered, membrane structureThe two surfaces are normaly in apposition,lubricated by a thin layer of serous fluid secreted by the mesothelium so that the steady motion of normal respiration is accomplished without friction.
    • The pleural space the thin space between the two pleural layers is known as the pleural cavity; it normally contains a small amount of pleural fluid.
    • The outer pleura ( parietal pleura ) is attached to the chest wall . The inner pleura ( visceral pleura ) covers the lungs and adjoining structures blood vessels , bronchi and nerves .
    • The parietal pleura is highly sensitive to pain while the visceral pleura is not, due to its lack of sensory innervation.
  • 4. Pleural effusion
    • A pleural effusion is an accumilation of fluid in the pleural space .Normally ,the balance of hydrostatic and colloid osmotic forces favores the movement of fluid from systemic capillaries in the parietal pleura to pulmonary capillaries.It is estimated that between 5 and 10 L of protien- free fluid traverses the pleural space in 24 hr.
    • Alterations in systemic hydrostatic or colloid osmotic pressure that disturb the balance of forces across normal pleural surfaces produce an effusion consisting of aprotein poor ultrafiltrate of plasma classified as atransudate .Changes in capillary permeability caused by inflammation or infiltration of the pleura produce a protein rich effusion classified as an exudate
  • 5. Symptoms
    • Chest pain , usually a sharp pain that is worse with cough or deep breaths
    • Cough
    • Fever
    • Hiccups
    • Rapid breathing
    • Shortness of breath
  • 6. Diagnosis:
    • Chest x-ray:oblitration of costophrenic angle suggests the presence of at least 250 mL of pleural fluid
  • 7. Types of fluids
    • Four types of fluids can accumulate in the pleural space:
    • Serous fluid ( hydrothorax )
    • Blood ( haemothorax )
    • Chyle ( chylothorax )
    • Pus ( pyothorax or empyema
  • 8. What Is a Malignant Pleural Effusion?
    • A pleural effusion is defined as an abnormal amount of fluid in the space between the layers of tissue (the pleura ) that line the lungs. If cancer cells are present in this fluid, it is called a malignant (cancerous) pleural effusion.
  • 9. Malignant pleural effusions
    • Malignant pleural effusions are caused most commonly by carcinomas of the breast, lung, gastrointestinal tract or ovary and by lymphomas. In male patients about half of malignant effusions are caused by lung cancer, 20% by lymphomas or leukemia, 7% from gastrointestinal primaries, 6% from genitourinary primaries, and 11% from tumors of unknown primary site. In female patients, about 40% of malignant effusions are caused by breast cancer, 20% from tumors arising in the female genital tract, 15% from lung primaries, 8% from lymphomas or leukemia, 4% from gastrointestinal tract primaries, 3% from melanoma, and 9% from tumors of unknown primary site. Effusions may be secondary to impaired pleural lymphatic drainage from mediastinal tumor (especially in lymphomas) and not due to direct pleural invasion.
    • A malignant pleural effusion is a complication that occurs in 30% of lung cancers
  • 10. Instruments for needle biopsy of the pleura
  • 11. Treatment The free end of the Chest Drainage Device is usually attached to an underwater seal , below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest
  • 12. Pleural empyema
    • Pleural empyema (also known as a pyothorax or purulent pleuritis ) is an accumulation of pus in the pleural cavity . Most pleural empyemas arise from an infection within the lung ( pneumonia ), often associated with parapneumonic effusions . There are three stages: exudative , fibrinopurulent and organizing. In the exudative stage, the pus accumulates. This is followed by the fibrinopurulent stage in which there is loculation of the pleural fluid (the creation of pus pockets). In the final organizing stage, scarring of the pleural space may lead to lung entrapment.
  • 13. CT chest showing large right sided hydro-pneumothorax from pleural empyema . Arrows A: air, B: fluid Encasement of the left lung by thick purulent exudate which is characteristic of pleural empyema
  • 14. Treatment
    • Definitive treatment for pleural empyema entails drainage of the infected pleural fluid. A chest tube may be inserted, often using ultrasound guidance.
    • Intravenous antibiotics are given.
    • If this is insufficient, surgical debridement of the pleural space may be required. This is frequently done using thoracoscopic techniques but if the disease is chronic, a limited thoracotomy may be necessary to fully drain the pus and remove the filbrinopurulent excudate from the lung and from the chest wall.
    • Occasionally, a full thoracotomy, formal decortication and pleurectomy are required. Rarely, portions of the lung have to be resected. Chest tubes in the setting of pleural empyema have a tendency to become clogged. To combat this problem, surgeons will often place large bore chest tubes, or more than one chest tube. Chest tube clogging in the setting of a pleural empyema can lead to re accumulation of pus and infected material, a worsening clinical picture, organ failure and even death. Thus managing chest tube clogging is particularly important after the treatment of a pleural empyema
  • 15. Chylothorax
    • A chylothorax (or chyle leak ) is a type of pleural effusion . It results from lymphatic fluid (chyle) accumulating in the pleural cavity
  • 16. Causes
    • Its cause is usually leakage from the thoracic duct or one of the main lymphatic vessels that drain to it. The most common causes are lymphoma and trauma caused by thoracic surgery. If the patient is on a normal diet, the effusion can be identified by its white and milky appearance as it contains high levels of triglycerides.
    • The condition is rare but serious and appears in all mammals. In animals, chylothorax usually results from diseases that cause obstruction to the thoracic duct preventing lymph from draining normally into the venous system. Examples include tumors, heartworm disease, right sided cardiac failure, or idiopathic lymphangiectasia
  • 17. Treatment
    • Since the mechanism behind chylothorax is not well understood, treatment options are limited. Drainage of the fluid out of the pleural space is essential to obviate damage to organs, esp. the inhibition of lung function by the counter pressure of the chyle. Another treatment option is pneumoperitoneal shunting (creating a communication channel between pleural space and peritoneal cavity). By this surgical technique loss of essential triglycerides that escape the thoracic duct can be prevented. Omitting fat (in particular FFA) from the diet is essential. Either surgical or chemical pleurodesis are options: the leaking of lymphatic fluids is stopped by irritating the lungs and chest wall, resulting in swelling and closure of the pleural space. The medication octreotide has been shown to be beneficial and in some cases will stop the chylothorax after a few weeks.
  • 18. Pleural Mesothelioma
    • Pleural mesothelioma is the most common type of mesothelioma , a rare cancer that develops in the mesothelium (a membrane that lines many of the body’s organs and cavities). In the case of pleural mesothelioma, the cancer develops in the lining of the lungs, called the pleura or pleural membrane. Although a mesothelioma prognosis is typically poor for the majority of patients, some who are diagnosed early may qualify for a combination of aggressive therapies to improve life expectancy.
    • In an effort to help patients understand pleural mesothelioma, Asbestos.com offers a complimentary packet that contains treatment information tailored to your specific diagnosis. The packet also covers the nation's top mesothelioma doctors and cancer centers, as well as financial assistance options to help cover medical costs. To receive your packet in the mail, please enter your information below
  • 19. Pleural Mesothelioma Symptoms
    • Once trapped in the body, asbestos fibers cause cancerous cells to divide abnormally, resulting in the thickening of the pleural membrane. This has the potential to encourage build-up of fluid (called pleural effusion). The fluid begins to place pressure on the lungs and the respiratory system in general, preventing normal breathing. Symptoms of pleural mesothelioma are largely caused by these developments and may include the following:
    • Persistent dry or raspy cough
    • Coughing up blood (hemoptysis)
    • Difficulty in swallowing (dysphagia)
    • Shortness of breath that occurs even when at rest (dyspnea)
    • Persistent pain in the chest or rib area, or painful breathing
    • Development of lumps under the skin on the chest
    • Night sweats or fever
    • Unexplained weight loss
    • Fatigue
  • 20. Pleural Mesothelioma Treatments
    • The on-going development of new drugs and detection techniques is improving the outlook for patients with pleural mesothelioma. Since pleural mesothelioma is the most common form of the cancer, more research and knowledge about this type of mesothelioma is available to utilize when discussing a treatment plan.
    • In general, pleural mesothelioma patients have three options: surgery , chemotherapy and radiation therapy. Typically, patients will receive a combination of two or more of these types of treatment
  • 21. Spontaneous pneumothorax
    • Definition
    • Spontaneous pneumothorax is a collection of air or gas in the space between the lungs and the chest that "collapses" the lung and prevents it from inflating completely
  • 22. Causes
    • There are two types of spontaneous pneumothorax:
    • Primary spontaneous pneumothorax
    • Secondary spontaneous pneumothorax
    • Spontaneous means there is no traumatic injury to the chest or lung. Primary spontaneous pneumothorax occurs in people without lung disease. It occurs most often in tall, thin, young people.
  • 23. Symptoms
    • Symptoms often begin suddenly, and may occur during rest or sleep. They can include:
    • Abnormal breathing movement
      • Restricting chest wall motion when breathing to protect against pain
      • Splinting -- bending over or holding the chest to protect against pain
    • Cough
    • Rapid respiratory rate
    • Shortness of breath
    • Sudden chest pain or chest tightness
      • Breathing or coughing makes pain worse
    • Chest pain may be dull, sharp, or stabbing
  • 24.
    • THANK YOU