Post-operative Chest Changes After Lung Resection and Thoracotomy
•Download as PPTX, PDF•
1 like•133 views
Post operative chest
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Post-operative Chest Changes After Lung Resection and Thoracotomy
Similar to Post-operative Chest Changes After Lung Resection and Thoracotomy (20)
More from Milan Silwal
More from Milan Silwal (20)
Recently uploaded
Recently uploaded (20)
Post-operative Chest Changes After Lung Resection and Thoracotomy
- 1. THE POST-OPERATIVE CHEST SUNDAR SUWAL
- 2. OVERVIEW THORACOTOMY PNEUMONECTOMY LOBECTOMY SEGMENTECTOMY COMPLICATIONS OF THORACOTOMY EARLY LATE CARDIAC SURGERY THORACIC COMPLICATIONS OF GENERAL SURGERY
- 3. INTRODUCTION Most frequently for resection of all or part of a lung, or for cardiac disease Apparent radiographic changes, acute or long term Complications
- 4. THORACOTOMY With increasing use of thoracoscopic and minimally invasive surgery for lung resection, thoracotomy is typically reserved for procedures that require a larger surgical field, such as lobectomy and pneumonectomy. Lung resection usually through posterolateral 4th or 5th intercostal space Part of rib resected or Periosteum stripped or Ribs simply spread apart An understanding of the expected post-thoracotomy appearance of the chest is essential, as postoperative complications can make imaging findings additionally complex. Accurate identification and timely diagnosis of complications is crucial in minimizing increased morbidity and mortality. Surgical route often not obvious on the CXR, or Marked by some narrowing of the intercostal space Soft tissue swelling Subcutaneous emphysema
- 6. PNEUMONECTOMY It is important for the remaining lung to be fully expanded, and For the mediastinum to remain close to the midline. Excessive mediastinal shift may compromise respiration and venous return to the heart Initial post-operative film Trachea close to the midline Remaining lung normal or slightly plethoric Small amount of fluid in pneumonectomy space Drainage tube ± Next several days Gradual mediastinal shift ipsilaterally with gradual obliteration of pneumonectomy space Accumulation of fluid
- 7. Pneumonectomy space usually half filled within about a week, and completely opacifies over the next 2-3 months. Fluid accumulates in the postoperative space at a variable rate. the surgical space may fill faster following extrapleural pneumonectomy, as quickly as 1 week, likely because of the absence of fluid resorption following excision of the pleura. Contralateral mediastinal shift: too rapid accumulation of fluid; or atelectasis in the remaining lung Sudden shift: may indicate a bronchopleural fistula.
- 9. Post pneumonectomy changes Initial post op period Trachea midline, air in the space and small amount of the fluid and chest tube in situ. Remaining lung plethoric Several days later Fluid increases and ipsilateral mediastinal shift 2-3 months: Fluid fills up the hemithorax and contralateral shift Months later Fluid resolves and compensatory hypertrophy of remaining lung and ipsilateral mediastinal shift and elevated hemidiaphragm; minimal fluid remains.
- 11. Changes in patient position and inspiration may produce corresponding changes in air-fluid level in the pneumonectomy space. However, in an upright patient the air-fluid level should not drop more than 1.5 cm. Similarly, air should not reappear in the pneumonectomy space when none was visible previously.
- 12. Central- communication with lobar bronchus or trachea peripheral- communication with distal airways Imaging: CXR Sinography or brnochography CT B-P fistula:
- 13. LOBECTOMY The remaining lung should expand to fill the space of the resected lobes Immediately Pleural drains to prevent accumulating pleural fluid Mediastinum may be shifted to ipsilateral side Hyperinflation of the remaining lung – mediastinum returns to its normal position Drains removed – small pleural effusion commonly occurs; usually resolves within a few days leaving residual pleural thickening
- 15. SEGMENTAL OR SUBSEGMENTAL LUNG RESECTION Cut surface of the lung is oversewn, and air leaks are fairly common – may cause persistent pneumothorax Wire sutures or staples at site of bronchial stump or lesser lung resection On computed tomography (CT), the presence of surgical material and changes in central lung anatomy are key to determining the type and location of limited lung resection. A peripheral suture line with intact segmental bronchi and vessels should suggest wedge resection, whereas central surgical clips and ligated bronchi and vessels indicate segmentectomy or lobectomy.
- 17. Post-thoracotomy complications following lung resection Early postoperative complications •Pulmonary edema •Acute lung injury/acute respiratory distress syndrome •Pneumonia •Hemorrhage/hemothorax •Chylothorax •Dehiscence of bronchial stump, formation of bronchopleural fistula •Esophagopleural fistula •Empyema •Lobar torsion •Cardiac herniation •Gossypiboma Late postoperative complications •Pneumonia •Disease recurrence (tumor, infection) •Dehiscence of bronchial stump, formation of bronchopleural fistula •Esophagopleural fistula •Empyema •Stricture of bronchial anastomosis •Pulmonary artery stump thrombosis •Postpneumonectomy syndrome •Herniation of lung or chest wall soft tissues via thoracotomy defect •Gossypiboma
- 18. COMPLICATIONS OF THORACOTOMY Post-operative spaces Air spaces that correspond to the excised lung Fluid may collect in them, but usually resolve after a few wks or months If persist and are associated with constitutional symptoms, increasing fluid and pleural thickening – empyema or bronchopleural fistula suspected Pulmonary edema Rapidly occurring, life-threatening complication. Its prevalence is reportedly 2.5% to 5% with a mortality rate historically greater than 80%. increased hydrostatic pressure applied to the remaining lung, more common following right pneumonectomy; because of its smaller size, the left lung normally receives 45% of total pulmonary blood flow and contains 45% of the total lymphatic capacity when compared with the right Noncardiogenic, related to increased permeability of the capillary endothelial cell–alveolar wall barrier from vasoactive inflammatory mediators, a notion supported by histologic findings resembling ARDS.
- 21. Bronchopleural fistula Commonest cause – lung surgery May be due to – rupture of lung abscess, erosion by a lung cancer, or penetrating trauma Early – due to faulty closure of the bronchus Less common Late – due to infection or recurrent tumor of the bronchial stump Radiography = sudden appearance of, or increase in the amount of air in the pleural space, with a corresponding decrease in the amount of the fluid in the space A fluid level is always present On an upright radiograph, the air-fluid level in the postpneumonectomy space should not drop by more than 1.5 cm; if so, BPF should be suspected. Concurrent shift of the mediastinum away from the surgical space should also suggest airway dehiscence and fistula formation. Similarly, if the postoperative hemithorax has become completely opacified with fluid, a new air-fluid level should raise suspicion of BPF. Fluid may enter airways and is aspirated into remaining lung – consolidation Abnormal air may also be identified in the mediastinum or tracking into the subcutaneous tissues via the surgical incision site or a chest tube tract. Sinography or bronchograpy may demonstrate the fistula
- 22. MDCT imaging can serve as a valuable tool in cases of suspected BPF. In many cases, thin section images on the order of 1 to 2 mm can demonstrate direct evidence of fistulization, with a clear tract connecting the bronchial lumen to the surgical space. Indirect signs such as small bubbles of air around the bronchial stump should also suggest BPF.
- 23. Empyema associated with dehiscence of the bronchial stump in up to 75% to 80% of cases. conditions that place patients at higher risk of BPF also convey higher risk of empyema: completion pneumonectomy after previous lobectomy, right pneumonectomy, preoperative radiation, and postoperative mechanical ventilation when the bronchial stump is intact, empyema is typically due to hematogenous spread of infection. Usually occurs few wks post surgery; may be months or yrs later Mediastinal shift towards contralateral side Increasing gas in the pneumonectomy space may be due to infection by a gas forming organism. (bronchopleural fistula also a cause) CT typically demonstrates expansion of the postpneumonectomy space with fluid, which is often complex with intermediate density, frequently producing mass effect on the adjacent heart and mediastinal structures. also frequently demonstrates irregular thickening of the parietal pleura with enhancement following administration of intravenous contrast.
- 26. Lobar torsion rare and serious complication of lobectomy in the early postoperative setting, with an incidence of 0.09% to 0.2%. Mostly involves the right middle lobe as it moves cranially following removal of the right upper lobe or, less commonly, the left upper lobe as it moves caudally after removal of the left lower lobe. Findings of lobar torsion on chest radiographs are suggestive but not specific, mimicking atelectatic lung or pleural hematoma. the affected lobe shifts into the vacant postsurgical space and demonstrates increasing opacification, often within hours. The torsed lobe typically increases in size as venous outflow obstruction occurs, and bulging of the fissure may be seen, producing perihilar convexity. MDCT provides better characterization of distorted postoperative anatomy, which is optimized with administration of intravenous contrast. the corresponding pulmonary artery is tapered and obliterated much like the lobar bronchus, and the two have an abnormal orientation. Poor pulmonary arterial enhancement of the affected lobe also helps make
- 30. Postpneumonectomy syndrome Uncommon complication that occurs in the late postoperative period, in which exaggerated anatomic changes produce respiratory symptoms. typically seen in children, young adults, and women, who presumably have greater tissue compliance than older patients and men. much more commonly seen after right pneumonectomy, because of the relatively large right hemithorax. Radiographs Pronounced displacement of the trachea, mediastinum, and heart into the pneumonectomy space, with the cardiac apex pointing toward the posterior lateral hemithorax. Air may be seen on either side of the mediastinum as the remaining lung hyperexpands and crosses the midline into the pneumonectomy space. CT will clearly illustrate narrowing and compression of the distal trachea and mainstem bronchus by adjacent vascular structures.
- 32. Gossypiboma technically refers to a cotton matrix, the term is generally used for retained surgical material not limited to surgical sponges. aseptic foreign-body reaction with fibroblast proliferation and encapsulation; can also serve as a nidus for infection Radiographs: unusual opacity or mass that changes little over time.High density can sometimes be confused with surgical sutures, epicardial pacing wires, or pleural plaques. CT shows a thin-walled or thick-walled mass, often with a hyperdense enhancing rim and a high attenuation central nidus. Can demonstrate concentric layers of differing densities, including calcification. may invaginate or become enveloped by the surrounding lung parenchyma, mimicking an intrapulmonary lesion such as abscess or intracavitary fungus ball. A spongiform pattern of gas bubbles is characteristic; although this air has been thought to represent trapped gas among fibers, many believe that over time there is also communication with the bronchial tree.
- 34. Diaphragmatic elevation May indicate phrenic nerve damage Best assessed by flouroscopy or USG
- 35. CARDIAC SURGERY Sternotomy incision – wire sternal sutures Some widening of cardiovascular silhouette usual – represents bleeding and oedema Marked widening – significant hemorrhage Some air commonly remains in the pericardium – pneumopericardium Pulmonary opacities very common Left basal shadowing invariable – usually resolves over a week or two Small pleural effusions also common Pneumoperitoneum sometimes seen, no pathological significance Pneumothorax – due to violation of left or right pleural space Chylothorax or chyloma Phrenic nerve damage
- 36. Sternal dehiscence – linear lucency appearing in the sternum and alterations in position of the sternal sutures on consecutive films May be associated with osteomyelitis 1st or 2nd ribs may be fractured when sternum is spread apart – may explain post-operative chest pain Acute mediastinitis – mediastinal widening or pneumomediastinum Chronic mediastinal infection – may be difficult to differentiate from post-surgical granulation tissue and hematoma Mediastinal gas may persist for some wks or months after surgery – only increasing amounts of gas on subsequent examination is a reliable indication of the presence of a gas forming organism Post-cardiotomy syndrome – autoimmune phenomenon, months after surgery Fever, pleurisy, pericarditis
- 40. THORACIC COMPLICATIONS OF GENERAL SURGERY ATELECTASIS Commonest pulmonary complication of thoracic or abdominal surgery Predisposing factors: long anaesthetic, obesity, chronic lung disease and smoking Result of retained secretions and poor ventilation Painful to breathe deeply or cough post-operatively Elevation of diaphragm, due to poor inspiration Linear, sometimes curved, opacities in the lower zones – usually appear about 24 hrs post-operatively and resolve within 2 or 3 days PLEURAL EFFUSIONS Common immediately following abdomen surgery, usually resolves within 2 wks Associated with pulmonary infarcts
- 41. PNEUMOTHORAX Usually complication of positive pressure ventilation or CVP insertion ASPIRATION PNEUMONIA Patchy consolidation within a few hours, usually basal or around the hila Clearing occurs within a few days, unless there is super- infection PULMONARY EDEMA Cardiogenic or non-cardiogenic PNEUMONIA SUBPHRENIC ABSCESS PULMONARY EMBOLISM
- 42. CONCLUSION Thoracic surgery can produce challenging imaging appearances. Surgical complications can present in the early or late postoperative period, with morbidity and mortality ranging from benign to catastrophic. In many instances, postoperative complications require urgent intervention. Understanding the imaging appearances of both anticipated postsurgical changes and unexpected complications will improve the timeliness and accuracy of diagnosis. Thoracic complications are also very common following general surgery, causing significant morbidity.
- 43. THANK YOU
- 44. QUESTIONS Post-pneumonectomy imaging findings in chest Early complications of thoracotomy Late complications of thoracotomy Bronchopleural fistula Imaging findings in chest after cardiac surgery Common thoracic complications of general surgery
Editor's Notes
- A: typical sharply truncated rib defect following right thoracotomy (right upper lobectomy for carcinoma) B: Late postsurgical changes following periosteal stripping at time of left 5th interspace thoracotomy for mitral valvotomy. There is a wavy line of calcification below the affected rib.
- Normal pneumonectomy appearances: A – 1 day, B – 6 days, C – 5 wks, D – 8 wks. The pneumonectomy space is gradually obliterated by rising fluid level and mediastinal shift.
- Frontal radiographs illustrate gradual opacification of the postpneumonectomy space in a patient following left pneumonectomy. (A) Immediately after surgery, air fills the postpneumonectomy space. The trachea is in the midline, and there is slight vascular congestion in the remaining lung. Subcutaneous air is noted. (B) Radiograph on postoperative day 1 demonstrates fluid occupying one-third of the left hemithorax. The left hemidiaphragm is elevated. (C) By postoperative day 4, roughly two-thirds of the pneumonectomy space is fluid filled. (D) Three weeks after surgery, a small volume of air remains at the left apex. (E) Months later, the hemithorax is completely opacified; the heart has shifted into the left chest, and the right lung has hyperinflated (arrowheads). (F) Corresponding axial CT images in soft-tissue window confirms expected postoperative changes. Only a small volume of fluid remains in the postsurgical space. The esophagus (asterisk) is located adjacent to the left bronchial stump.
- Bronchopleural fistula. 13 days after right pneumonectomy the space is filling with fluid and the mediastinum is deviated to the right. B. 2 days later, after the pt coughed up a large amount of fluid, the fluid level has dropped and the mediastinum has returned to the midline.
- Posteroanterior chest radiograph demonstrating right upper lobectomy. There is right-sided volume loss, and surgical clips are seen at the right hilum (arrow). The hyperinflated right middle and lower lobes have shifted to occupy the vacant surgical space.
- Axial-oblique computed tomography (CT) image in lung window demonstrates right middle lobectomy. The lobar bronchus (arrowhead) is truncated and surrounded by high-density surgical material. A nearby suture line corresponds to the distorted right major fissure (arrow).
- Pulmonary edema in a 50-year-old man after right pneumonectomy for lung cancer. (A) Chest radiograph on postoperative day 5 demonstrates left perihilar airspace opacity with indistinct pulmonary vessels and air bronchograms. (B) The accompanying CT image shows predominantly perihilar ground-glass opacity.
- A 59-year-old man with a complicated postoperative course following right extrapleural pneumonectomy for mesothelioma. (A) Radiograph 3 days after surgery demonstrates heterogeneous airspace opacity at the left lung base, consistent with pneumonia. (B) Two days later, there is heterogeneous opacification of the entire lung, compatible with acute respiratory distress syndrome. Increased air in the right postpneumonectomy space is also noted. (C) Corresponding CT image illustrates ground-glass opacity and mild septal thickening in the nondependent left lung; there is increasingly dense opacification of the atelectatic dependent lung. Small left effusion is also noted. (D) Repeat radiograph on postoperative day 6 shows further expansion of the pneumonectomy space with air, indicating airway dehiscence. There is flattening of the right hemidiaphragm and leftward shift of the mediastinum, indicating tension pneumothorax. Increased subcutaneous air is also noted (arrow). (E) Thinsection 1-mm axial CT image at the level of the carina shows a small volume of air tracking from the bronchial stump to the postpneumonectomy space (arrow).
- Hollaus and colleagues found that a bronchial stump diameter of greater than 25 mm was associated with a greater incidence of BPF formation. Patients undergoing right pneumonectomy have a greater likelihood of bronchial stump dehiscence and fistula formation, related to a greater diameter of the right bronchial stump in comparison with the left. Others suggest greater likelihood after right pneumonectomy because of shorter stump length and greater vulnerability of the stump to ischemia, owing to a single bronchial artery supply.
- Repeat radiograph on postoperative day 6 shows further expansion of the pneumonectomy space with air, indicating airway dehiscence. There is flattening of the right hemidiaphragm and left ward shift of the mediastinum, indicating tension pneumothorax. Increased subcutaneous air is also noted (arrow). (E) Thinsection 1-mm axial CT image at the level of the carina shows a small volume of air tracking from the bronchial stump to the postpneumonectomy space (arrow).
- Empyema in a 79-year-old man after right upper lobectomy. (A) Axial CT image shows an air-fluid level in the superior right hemithorax with associated pleural thickening. There is high-density surgical material at the hilum, and the bronchus intermedius is filled with debris. (B) Reformatted coronal CT image illustrates empyema compressing the atelectatic right lung (R). A small amount of pleural fluid (white asterisks) is seen at both lung bases, and there is ascites (black asterisks) in the upper abdomen.
- Large hemothorax shortly after right pneumonectomy. (A) Frontal chest radiograph immediately after surgery demonstrates a mostly air-filled postpneumonectomy space. There is elevation of the right hemidiaphragm, and there is small subcutaneous emphysema. (B) One day later, repeat portable chest radiograph shows complete opacification of the right hemithorax with shift of the heart away from the right pneumonectomy space. (C) Corresponding coronal noncontrast CT image in soft-tissue window demonstrates a large heterogeneous area of hemorrhage (H) in the superior thorax. Small postsurgical air and simple-appearing fluid is seen inferiorly.
- Following surgery, air and fluid in the pleural space provide little resistance to movement of the remaining lung. As lobes shift to fill the newly vacant space, partial or complete rotation of the affected lobe occurs around its bronchovascular pedicle at the hilum. Occlusion of airways and pulmonary arteries produces hypoxia and ischemia; hemorrhagic infarction may occur as a result of obstructed venous outflow.
- Right middle lobe torsion in a 62-year-old man following right upper lobectomy for bronchogenic carcinoma. (A) Frontal chest radiograph shortly after surgery demonstrates right-sided volume loss with elevation of the right hemidiaphragm. (B) On postoperative day 2, there is increasing opacification of the medial right upper lung. Corresponding coronal CT image (C) demonstrates mottled ground-glass opacification (long arrow) of the torsed right middle lobe. There is denser opacification (short arrow) at the hilum, where the lobe has rotated on its bronchovascular pedicle. No patent bronchus is seen. (D) Although pulmonary vessels are opacified with intravenous contrast, none are seen perfusing the ischemic right middle lobe.
- The posterior margin of the right upper lobe herniates through a wide-necked thoracotomy defect (arrows) following partial excision of the right seventh rib for right lower lobectomy.
- (A) Frontal chest radiograph demonstrates a smoothly marginated opacity at the lateral margin of the left mid lung (arrow), initially worrisome for a pleural mass such as metastasis. (B) Corresponding coronal CT image illustrates herniation of fat and soft tissue through the chest wall into the extrapleural space at a level corresponding to prior surgery.
- Following right pneumonectomy, the heart and mediastinum shift into the surgical space and move posteriorly while the overinflated left lung shifts medially and anteriorly. The cardiac apex is rotated in a counterclockwise fashion around the craniocaudal axis toward the right lateral chest. Like the remaining lung, the trachea and left mainstem bronchus are rotated to the right; they are stretched and compressed by both the aortic arch and left pulmonary artery superiorly and anteriorly, and by the descending aorta and vertebral column posteriorly. Resultant airway narrowing produces stridor and promotes recurrent infection from impaired clearance. Over time, affected airways can develop tracheomalacia or bronchomalacia, and the resultant collapse of the air column during exhalation leads to exaggerated symptoms.
- Postpneumonectomy syndrome in a 43-year-old woman with stridor and remote history of right pneumonectomy. (A) Axial CT image in lung window reveals displacement of the heart into the posterior right hemithorax. Compensatory hyperinflation of the left lung has occurred. The left lower lobe bronchus is severely compressed by the left pulmonary artery anteriorly (white arrowhead) and descending aorta posteriorly (black arrowhead). (B) Portable chest radiograph following surgical correction of postpneumonectomy syndrome. Round silicone implants now occupy much of the right hemithorax, and the cardiac silhouette overlies the midline.
- Gossypiboma in a 59-year-old man who underwent cardiothoracic surgery 1 year earlier. A round peripheral mass containing serpiginous high density was identified on the preceding chest radiograph. Noncontrast axial CT image in mediastinal window demonstrates the soft-tissue mass, which is slightly heterogeneous and surrounded by left lower lobe parenchyma. Metallic density is embedded within the mass. Surgical gauze was retrieved following reoperation.
- Others: Atelectasis Aspiration pneumonia Pulmonary embolism Pulmonary edema (cardiogenic/ non-cardiogenic)
- Hemorrhage following cardiac transplantation. A) four hours following return from surgery, the chest radiograph reveals opacification of the right upper zone. USG confirmed a large fluid collection. B) after insertion of chest drain, there has been partial resolution of the appearances.
- Mediastinal hematoma. CECT demonstrates a soft tissue density non-enhancing mass in the anterior mediastinum 3 days following cardiac surgery Hemopneumopericardium in a woman 2 days after closure of ASD. The pericardium is outlined by air, which does not extend as high as the aortic arch. A fluid level in present in the pericardium. There are bilateral pleural effusions.
- Postsurgical mediastinitis. A) CT 3 wks following aortic valve replacement in a patient with signs of infection. There is a small retrosternal air and fluid collection, subsequently drained. B) Infected mediastinal collection in a different patient several weeks following ASD closure.