Different of pleural diseases and their surgical treatment

1. Surgery of Pleural Diseases
Staff Members of Cardio-
thoracic Surgery Departments
Egypt

2. Definition
• The pleura is a thin serous membrane lined by
mesothelial cells that surrounds the lungs
(Visceral pleura) and lines the inside of the chest
wall, diaphragm and mediastinum (Parietal
pleura) .
• The pleural space is the potential space between
visceral and parietal pleurae. It is normally at
subatmospheric pressure, which keeps the lungs
inflated.
• The pleural fluid: Only a few (10-20) milliliters of
liquid, which helps lubricate the normal "to and
fro" motion of the lungs during breathing.

3. Objectives
• Pleural Effusion
• Empyema
• Haemothorax (Chapter of trauma)
• Pneumothorax (Chapter of trauma)
• Chylothorax
• Mesothelioma
• Procedures

4. I) PLEURAL EFFUSION

5. PLEURAL EFFUSION
Definition:
It is an abnormal collection of fluid in
the pleural space resulting from
excess fluid production or decreased
absorption.

6. Types:
• Hydrothorax: accumulation of serous fluid in
pleura
• Haemothorax: accumulation of blood in pleura
• Pyothorax (Empyema thoracis): accumulation of
pus in pleura
• Chylothorax: accumulation of chyle in pleura

7. Etiology of hydrothorax:
The normal pleural space contains fluid,
representing the balance between (1)
hydrostatic and oncotic forces - plasma
proteins - in the visceral and parietal pleural
vessels and (2) extensive lymphatic drainage.
Pleural effusions result from disruption of this
balance. (3) Inflammatory process of the
capillary wall results in increased exudation.

8. Types of Hydrothorax:
Pleural effusions are generally classified as
transudates or exudates, based on the
mechanism of fluid formation and pleural fluid
chemistry.
1. Transudates (an imbalance in oncotic and
hydrostatic pressures, low in proteins, usually
systemic)
• Congestive heart failure.
• Hepatic failure.
• Renal failure.
• Hypoalbuminemia.

9. 2. Exudates (the result of inflammation of the pleura or
decreased lymphatic drainage. High in proteins, usually
local causes)
• Infections (bacterial, tuberculous, fungal, parasitic, viral).
• Malignancy (1ary tumour as mesothelioma, 2aries from
lung cancer, metastases, lymphoma…).
• Collagen disease (rheumatoid Lupus,..) .
• Pulmonary embolus.
• Pseudochylothorax (chronic condition with elevated
cholesterol in pleural fluid)
• Abdominal disease (pancreatitis, subphrenic abscess,…) .
• Drug induced.
• Miscellaneous (esophageal perforation, postoperative,
radiation therapy, sarcoidosis, iatrogenic, Meig’s
syndrome…).
• Idiopathic.

10. Clinical Picture:
• Small effusion may be asymptomatic.
• Large effusion may be associated with
dyspnea, dry cough, chest pain (more with
exudative effusion, pleuritic chest pain
indicates inflammation of the parietal pleura)
and low cardiac output syndrome if under
tension.

11. • Signs of the cause
• Local:
o Inspection: Limited chest movement + chest
bulge
o Palpation: mediastinal shift
o Percussion: Stony dullness
o Auscultation: Decreased air entry

12. Investigations:
1. Laboratory:
CBC, ESR,…
2. CXR :
1. Blunting of the costophrenic angle is an early
radiologic sign. It already indicates
accumulation of more than 400 ml of fluid.
2. A lateral decubitus film confirms the
presence of free-flowing (vs. loculated)
pleural fluid.

13. CXR left pleural effusion

14. Hydropneumothorax

15. 4. Diagnostic Thoracentesis:
Aspiration of pleural fluid to establish the diagnosis.
The aspirate is subjected to:
• Physical examination: colour, odour, specific gravity.
Gross appearance:
Bloody effusions occur with malignancy, post traumatic, after
traumatic tap, with pulmonary embolus or tuberculosis.
Milky fluid suggests chylothorax.
Pus is diagnostic of empyema. a. Physical examination:
Clear yellowish fluid in hydrothorax
• Microbiology: Culture and sensitivity & acid fast bacilli. : in
suspected pyothorax
• Cytology: RBC, WBC. Malignant Cells: positive in up to 80%
in 3 successive samples to detect malignant cells and its
type.

16. 5. Pleural biopsy:
• Abrams needle pleural biopsy (blind
technique).
• Ultrasonic guided.
• CT guided.
• Thoracoscopic (VATS).
• Open (mini-thoracotomy).

17. ABRAMS PLEURAL BIOPSY NEEDLE

18. Treatment:
• Transudates and some exudates: treatment of
underlying cause.
• Medical treatment:
Symptomatic treatment: anti-tussives, analgesics
Diuretics and protein supplementation
• Drainage with thoracocentesis or intercostal tube
(Malignant pleural effusion:
1. pleurodesis,
2. surgery,
3. home management with indwelling pleural
catheter.

19. 1. Pleurodesis:
Definition: Fusion between visceral and parietal pleura.
Types:
• Mechanical: intraoperative or thoracoscopic
• Chemical: by injecting sclerosing agent into chest tube as:
Talc powder, Tetracycline, Blood, Betadine, cytostatic
agents as Bleomycin, Viscum, cisplatinum or 5-fluorouracil .
Technique:
• Chest tube inserted.
• Once all fluid is drained, a “sclerosing” agent is placed into
the chest cavity. The sclerosing agents cause an
inflammatory reaction that obliterates the potential space
in the chest cavity (pleural symphysis).
• When the drainage decreases, the chest tube can be
removed.
• is indicated in recurrent symptomatic malignant effusions.

20. 2. Surgery:
Thoracoscopic surgery (VATS): For diagnosis and
management @ drainage of collections of fluid
and adding a sclerosing agent @ removing the
lining of the chest cavity (pleurectomy) for
pleurodesis.
Thoracotomy: for complicated pleural effusions.
Pleurectomy and decortication.
3. Home management of an indwelling pleural
catheter: The PLEURX® catheter is used; it is a
soft, 16F elastic catheter with a one-way valve for
safety and polyester cuff for long term
placement. When the drainage ceases, the
catheter can be removed.

21. Pleurx catheter after placement

22. II) EMPYEMA THORACIS

23. Empyema Thoracis
Definitions:
Thoracic empyema is accumulation of infected
fluid or pus in the pleural cavity.
It may be localized or involve the entire
pleural space.

24. Etiology:
• Contamination from contiguous sources:
– Lung: Pneumonia (the most common cause) & Lung
abscess,
– Mediastinitis & Mediastinal abscess (esophageal
perforation).
• Direct inoculation: (Post traumatic):
– Penetrating chest injuries.
– Iatrogenic as complication of thoracocentesis &
postoperative as post resection bronchopleural fistula.
• Transdiaphragmatic spread from subphrenic
abscess.
• Hematogenous spread from distant sites.

25. Pathogenesis
The commonest isolated organisms are:
• Aerobic:
– Gram-positive: Streptococcus, staphylococcus.
– Gram-negative: Coliforms, proteus, H.influenzae.
• Anerobic: Bacteroids.

26. Complications of untreated empyema:
• Pulmonary: fibrosis and chest wall deformities.
• Spontaneous drainage of pus through chest wall
(empyema necessitatis) or through bronchial
tree (bronchopleural fistula).
• Local spread of infection to pericardium or
mediastinum and rare to subdiaphragmatic area.
• General complications of chronic sepsis:
clubbing of the fingers and pulmonary
osteoarthropathy, general toxemia and cachexia,
amyloidosis, septicemia and septic embolization.
Distant infection (osteomyelitis). Septic shock and
Multi-organ failure.

27. Investigations:
1. Laboratory:
Leucocytosis, high sedimentation rate.
2. Imaging:
• CXR: Posteroanterior and lateral. 175- 500 ml needed
to blunt costophrenic angle.
• CT: Differentiating empyema, lung abscess, or
subphrenic abscess. Assess loculations,
thickness of pleural peel, coexisting thoracic
disease.
• Ultrasound: Define pleural collections and
loculations, prior to percutaneous drainage.

28. Investigations: Cont.
3. Thoracocentesis :
Pus is examined for:
• Physical
• Biochemistry:
• Microbiology:
• Cytology: pus cells.

29. The following criteria are accepted for
the diagnosis of thoracic empyema:
1- Frank pus at tapping or organisms
demonstrated on Gram stain (direct) or
culture (indirect)
2- All of the tests positive for:
• pH ˂ 7.2
• Glucose level of fluid ˂ 40 mg%
• LDH ˃1000 IU/ml
• Protein level ˃ 3 g/dl
• WBC ˃ 15 000 cells/mm3.

30. A- CXR left empyema free in pleural space (blunt costophrenic
angle and the upper limit rises towards the axilla);
B- Right loculated empyema.

31. • Small amount:
obliteration of
costophrenic angle
and rising towards
the axilla.
• Moderate below
the hilum.
• Massive exceeding
the hilum.

32. • Air fluid level: in case of pyopneumothorax

33. CT Scan: Right and left empyemas.
CT scanning is superior to plain chest radiography in
Identify adhesions and loculations
may detect endobronchial obstruction
may detect lung abscess

34. Ultrasonography

35. Basic rules for treatment
1. Medical Management: Control of
causative organisms, Aggressive
physiotherapy, nutritional support in
every phase of treatment
2. Drainage: of the content of infected
space.
3. Elimination of the cavity and complete
lung expansion

36. Treatment:
I- Medical management:
• General: Treat underlying cause, associated
medical conditions (diabetes mellitus),
respiratory physiotherapy, antipyretic analgesics,
fluids and nutrition.
• Antibiotics: Systemic antibiotics directed by
thoracocentesis culture and sensitivity. Generally
successful for stage I NOT stage II or III. Local
irrigation with antibiotics is not recommended.
• Metronidazole is added for anaerobic infection.
(Foul-smelling fluid indicates anaerobic infection).

37. Treatment Cont.
II- Drainage:
Thoracentesis without pleural drain placement is not
recommended.
Image-guided small bore pleural drain placement can
only be considered in patients that are not surgical
candidates. Insertion of pigtail catheter (8 fr to 14 fr)
with administration of fibrinolytics such as
streptokinase or urokinase until the pleural space is
cleared.
Closed intercostal tube drainage: Is the preferred
first line for early stage acute empyema. The tube is
connected to closed underwater seal drainage. It is
removed when the lung re-expands.

38. Treatment Cont.
Chest tubes
• Early insertion before the formation
of loculated pleural effusion
• Position the chest tube in a
dependent part of the pleural
effusion
• Large-bore (32-36F) tubes are
recommended

39. Treatment Cont.
Causes of failure of
empyema drainage:
a-Non-dependent
drainage,
b- tube inserted too far,
c- tube too small,
d-peel too thick due to
late drainage,
e-bronchopleural fistula
and
f-presence of foreign
body.

40. Treatment Cont.
III- Options to manage patients with
empyema who have incomplete lung
expansion:
1- Open intercostal tube drainage: the
tube is connected to a drainage bag
(not under water seal) till lung inflation.
This can be done in chronic empyema,
after more than 3 weeks of closed
drainage if only a small pleural pocket
remains.

41. Treatment Cont.
2- Rib resection: This can be done for chronic cases if the
patient’s general condition cannot withstand
decortication. A segment (4-6 cm)of 1-3 ribs is resected
subperiosteally in a dependent position. A chest tube is
placed into the pleural pocket for irrigation and open
drainage. The intercostal vessels running along the
lower border of that rib is ligated and cut away.
Ligation of the intercostal vessels will prevent their
erosion by the tube if it is left for a long time.
3- Eloesser flap: It is a type of rib resection where the
skin is sutured to the pleura to prevent premature
closure and allow prolonged drainage of empyema
cavity. The procedure will need prolonged wound care
and dressing changes.

42. Eloesser flap

43. Treatment Cont.
4- Decortication: To remove all purulent fluid,
fibrinous debris, thickened parietal pleura &
Resection of visceral pleural peel to re-
expand the lung; through:
A- VATS decortication:
In early cases (stage II) if the patient can tolerate single
lung ventilation.
B- Surgical decortication:
Posterolateral thoracotomy in chronic cases with thick
peel and loculations (stage III empyema), and if the
patient cannot tolerate single lung ventilation.

44. Treatment Cont.
5- Tissue flaps: consisting of pedicled
muscle flaps or omentum to fill
empyema cavities where there is
space created by incomplete lung
expansion after decortication or to
close a bronchopleural fistula.

45. Treatment Cont.
6- Thoracoplasty (Deroofing or Multiple rib resections): used to
obliterate persistent pleural spaces after decortication and for
bronchopleural fistulas when the patient will not tolerate surgical
closure of the fistula. The principle behind thoracoplasty is that by
removing the skeletal support, the overlying chest wall will collapse
to the visceral pleura obliterating the residual infected cavity. By
obliterating the infected cavity the complications of chronic sepsis
mentioned above are avoided.
Original Thoracoplasty (Schede): involves removal of the ribs as well
as the intercostal muscles and the thickened parietal pleura over
the entire cavity. The cavity is left open and packed with gauze. It is
of historical interest only, as the modern thoracoplasty has largely
replaced it.
Modern Thoracoplasty (Alexander): Tailored subperiosteal resection
of several ribs overlying the residual space is performed. The
intercostal muscles and parietal pleura are not removed. This allows
collapse of the intercostal and chest wall muscles to obliterate this
space and close the bronchopleural fistula.

46. CXR showing right sided thoracoplasty

47. III- CHYLOTHORAX

48. CHYLOTHORAX
Definition:
• Abnormal accumulation of chyle in the pleural
space due to either disruption or obstruction of
thoracic duct.
• High content of triglycerides, and chylomicrons.
• Right > left (since most of the duct is within the
right hemithorax).
• Pseudochylothorax (cholesterol pleurisy) occurs
with long-standing fluid in fibrotic pleura. The
fluid has a high content of cholesterol but no
triglycerides or chylomicrons.

49. Anatomy of the thoracic duct
• From cisterna chyli >>> Passes through the
aortic hiatus of diaphragm >>> Continues in a
rightward position between the aorta and
azygos vein >>> At level of fifth thoracic
vertebra, it crosses over the vertebral column
behind the esophagus >>> To left posterior
mediastinum >>> Arches over the subclavian
artery in the superior mediastinum >>> Empty
near junction of left internal jugular and
subclavian veins.

50. Anatomy of the thoracic duct Cont.
Thoracic duct crosses the mediastinum at fifth
thoracic vertebra.
 Lymphatic injury or obstruction below this
level results in a right–sided pleural effusion.
Disease above this level usually leads to a left–
sided effusion.

51. Anatomy of the thoracic duct

52. Etiology
• Congenital: birth trauma or thoracic duct abnormalities.
• Traumatic:
a. Blunt trauma: Spinal hyperextension results in direct rupture of the
duct above the diaphragm.
b. Penetrating injury:
• Iatrogenic: During surgery of the aortic arch, PDA, subclavian artery,
and esophagus as transhiatal esophagectomy.
• Neoplastic:
1. Extrinsic compression >>>Thoracic duct obstruction (lymphoma).
2. Direct invasion of the duct with lung or esophageal cancer.
3. Intrinsic benign tumors (lymphangioma, mediastinal hygroma).
• Infections: Tuberculous lymphadenitis, filariasis, or ascending
lymphangitis.
• Spontaneous: Violent coughing or vomiting may result in shearing at
the right diaphragmatic crus.
• Venous thrombosis: SVC, left subclavian or jugular veins.
• Idiopathic.

53. Clinical Picture:
• Postoperative: Milky chest tube drainage,
usually on resumption of oral intake (24-72
hours).
• Nonoperative: Dyspnea, physical and
radiological evidence of pleural effusion.

54. Investigations:
• Thoracocentesis:
a. Gram stain: Lymphocytosis, no bacteria.
b. Sudan III stain: Fat globules.
c. Fat content > plasma.
d. Lipid analysis: Cholesterol/triglyceride ratio<1.
e. Lipoprotein electrophoresis: Chylomicrons.
• Radionucleide scanning: 99Tc antimony sulfide colloid
demonstrates the level of thoracic duct obstruction
and site of leakage.
• Lymphangiography: Demonstrates the site of
obstruction and leakage.
• CT scanning: Define associated thoracic pathology
(mediastinal tumors).

55. Treatment:
• Conservative: Within 2 weeks, 50% would close spontaneously.
a. Intercostal tube drainage.
b. NPO.
c. TPN.
• Operative: Daily drainage of 1000 ml (adults) or 100 ml/year of
age (children) over 7 days is an indication of surgical
intervention.
a. Right thoracotomy (or thoracoscopy) and mass ligation of the
thoracic duct above the right hemidiaphragm in the azygo-
esophageal recess.
b. Direct ligation at the site of leak (open or thoracoscopic ) is
less effective .
c. Other procedures include: Anastomosis of the thoracic duct
to the azygous vein, fibrin glue, radiotherapy,
d. Pleurodesis with talc.

56. IV) Pleural Mesothelioma

57. III) Pleural Mesothelioma
• Mesothelioms is a rare cancer that develops
in the mesothelium.
• Pleural mesothelioma is the most common
type of mesothelioma.
• Associated with asbestos exposure with a
latent period of at least 20 years and up to 40
years.
• Difficult diagnosis by cytology, Therefore,
usually a biopsy is recommended.

58. Pleural Mesothelioma, cont.
• Three histological subtypes:
i) Epithelial,
ii) Sarcomatous, and
iii) Mixed.
• Median survival from time of diagnosis is 12-
18 months.

59. Pleural Mesothelioma, cont.

60. Pleural mesothelioma, cont.
Treatment:
• Chemotherapy, surgery, irradiation,
immunotherapy have all been used with
limited success.
• Pleurodesis gives symptomatic relief of pleural
effusion.

61. MESOTHELIOMA
Definition
Tumor arising from mesothelial surfaces (pleura,
peritoneum or pericardium).
Types of Pleural Mesothelioma
1. Localized
• Arises from mesothelial lining of the lung.
• Well-defined encapsulated tumor, not associated with
asbestos exposure, may be benign or malignant.
• May be asymptomatic discovered incidentally on CXR, or
symptomatic presenting with cough, chest pain and
dyspnea.
• Treatment is complete surgical resection.
2. Diffuse
• Always malignant, associated with asbestos exposure.

62. Pathologic types
• Epithelial, sarcomatoid, mixed.
• Differentiated from metastatic adenocarcinoma
with electron microscopy and
immunohistochemistry.

63. Clinical Picture
Dyspnea, chest-wall pain, weight loss, weakness,
anorexia, fever.
Investigations
• Radiography (CXR, CT, MRI and PETscan): Pleural
effusions, pleural thickening, mediastinal lymph
nodes and distant metastases in advanced
tumors.
• Thoracocentesis.
• Pleural needle biopsy.
• Thoracoscopy and pleural biopsy.
• Open pleural biopsy.

64. CXR left mesothelioma

65. CT of left mesothelioma

66. Treatment
• Radiation: Palliate chest-wall or mediastinal
involvement.
• Chemotherapy: Response is disappointing.
• Immunotherapy: Promising with interferon.
• Surgery :
– Thoracoscopy and talc pleurodesis for effusion.
– Pleurectomy and decortication is difficult and palliative.
– Extrapleural pneumonectomy: En bloc resection of
pleura, lung, ipsilateral hemidiaphragm and pericardium.
Mortality is high.
– Combined modality therapy: Surgery combined with
radiotherapy and / or chemotherapy.

67. Surgical procedures

68. Thoracentesis. The patient sits upright and leans on a table.
After local anesthesia, the needle is introduced above the upper
border of the lower rib (Avoid the neurovascular bundle). Excess
fluid from the pleural space is drained into a bag.

69. Intercostal chest tube
Indications:
• To drain abnormal contents of the pleural space
as in cases of hemothorax, pneumothorax,
hemopneumothorax, empyema, chylothorax,
and some cases of effusion.
• At the end of any thoracotomy.
• With other modalities as pleurodesis in
spontaneous pneumothorax and malignant
effusions, and fibrinolytic therapy in loculated
empyema.

70. Compliations:
• Pain, wrong insertion, empyema, prolonged
air leak, and pneumothorax.

71. Chest tube insertion
Insertion Site
In the fifth intercostal space
between the anterior and
mid-axillary lines, behind
pectoralis major.
This region is termed the
“safety triangle”.
• The safety triangle is outlined
by the anterior border of the
latissimus dorsi muscle, the
lateral border of the
pectoralis major muscle, and
a horizontal line at the level
of the nipple.
• At 5th space since on
expiration diaphragm rises
• Count down from
manubriosternal junction
(2nd rib)

72. Important Landmarks

73. How to
insert an
intercostal
tube?

74. Underwater Seal
• It is an effective one way
valve allowing air and fluid
to go out of the pleural
cavity.
• All attachments should be
secure and leak free.
• The intercostal tube should
be clamped if the bottle
needs to be disconnected.
• The bottle must be kept
below the level of the
thorax.

75. Under water seal:
@Below the level of the
chest.
@The tubes should be
clamped before
disconnection.

76. Mobilization

77. When to remove the tube?
• Clinically: Equal air entery on both sides.
• Minimal oscillations in the tube (no air leak,
pleural drainage < 150cc/day).
• Radiologically lung expanded.

78. Thoracoscopy

79. Thoracoscopy
Video Assisted
Thoracoscopic
Surgery (VATS)

80. Thoracotomy
RIB SPREADER

81. RIB
APPROXIMATOR
or CONTRACTOR
Used to approximate
the ribs at the end of
thoracotomy
operations.

82. LUNG
RETRACTOR
Used to
retract the
lungs during
thoracotomy .