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Surgery of Pulmonary Infections

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Property of Prof Dr. Ahmed Deebis, Head of Cardiothoracic Surgery Department, Faculty of Medicine. University of Zagazig

Published in: Health & Medicine
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Surgery of Pulmonary Infections

  1. 1. Surgery for Pulmonary Infections Prof. Ahmed Deebis Head of Cardiothoracic Surgery Department - Zagazig University
  2. 2. Surgery of Pulmonary Infections Objectives I. Lung Abscess II. Bronchiectasis III. Surgery for Pulmonary Tuberculosis
  3. 3. Lung abscess
  4. 4. 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.
  5. 5. Etiology of lung abscess A. 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.
  6. 6. 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.
  7. 7. 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.
  8. 8. 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.
  9. 9. Clinical Picture, Cont. • Physical examination: a small area of dullness suppressed 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.
  10. 10. 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.
  11. 11. Diagnosis, cont. Differential Diagnosis: a)Hydropneumothorax, b)Cavitary neoplasm, c)Loculated empyema with airway fistulation, d)Interlobar fluid collection.
  12. 12. 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.
  13. 13. 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.
  14. 14. 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.
  15. 15. II) Bronchiectasis
  16. 16. 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 α1 antitrypsin deficiency
  17. 17. 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.
  18. 18. 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.
  19. 19. 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)
  20. 20. Clinical Picture Bronchiectasis can present in two forms: a.Local form, involve a lobe or segment of a lung b. 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
  21. 21. 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.
  22. 22. 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
  23. 23. Plain Chest x Ray P-A View suggesting Bronchiectasis
  24. 24. CT Scan
  25. 25. 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.
  26. 26. 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.
  27. 27. Surgery for Pulmonary Tuberculosis
  28. 28. 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
  29. 29. 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
  30. 30. 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.
  31. 31. THANK YOU

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