This document summarizes surgical treatments for several pleural diseases: 1) Pneumothorax is treated with observation for small cases or tube thoracostomy for large/symptomatic cases. Surgery like VATS is used for recurrent cases. 2) Empyema is diagnosed by pleural fluid analysis and treated initially with tube thoracostomy and fibrinolytics. Thoracoscopy or decortication surgery is used for later stages with loculations. 3) Mesothelioma is associated with asbestos exposure and difficult to diagnose, often requiring biopsy. Treatment options provide limited success.

1. Surgical treatment
of pleural diseases
Prof. Ahmed Deebis
Head of Cardiothoracic Surgery
Department – Zagazig University

2. Objectives
• Pneumothorax
• Empyema
• Mesothelioma
• Surgical procedures

3. Pneumothorax

4. Physiology

5. Physiology
• Normally, the intrapleural pressure is negative
and this keeps the two pleurae together .
• During expiration, intrapleural pressure is
approximately -4cmH20 (-3 mmHg) (below
atmosphere)
• During inspiration, the intrapleural pressure is
approximately -8cmH20 (-6 mmHg) (below
atmosphere)
• Intrapleural pressure also fluctuates with
breathing ~ 4 cmH2O less than the
intrapulmonary pressure

6. I) Pneumothorax
Definition:
• Pneumothorax is the collection of air in the
pleural space.
Classification of Pneumothorax
• 1)Spontaneous
• 2)Acquired

7. Pneumothorax
1)Spontaneous
• i) Primary:
• no apparent lung disease
• Believed to be due to
subpleural bleb rupture.
• ii) Secondary:
• Due to underlying pulmonary
disease
• COPD / Asthma / Cystic
Fibrosis
• Immunocompromised
Infections
2)Acquired
• i) Traumatic:
• Penetrating chest trauma
• blunt chest trauma
• ii) Iatrogenic:
• Transthoracic or
transbronchial lung biopsy,
• Pleural biopsy
• Placement of central venous
catheter,
• Thoracentesis
• iii) Barotraumas

8. Spontaneous Pneumothorax
1-Primary Spontaneous Pneumothorax (PSP)
• A disease of younger individuals (15 - 30 yrs of
age)
• Patients tend to be tall and thin
• Males > females 6:1
• Cigarette smoking implicated
• Believed to arise from sub pleural blebs mostly
in the apex of upper lobes and superior segment
of lower lobes
• Usually occurs when the patient is at rest or
during normal activities

9. Primary Spontaneous Pneumothorax
Clinical Diagnosis:
• Sudden onset of pleuritic chest pain and
dyspnea at rest or during normal activities
• Decreased movement of the chest wall,
hyperresonance to percussion, diminished
fremitus, and decreased or absent breath
sounds on the affected side.
Radiological diagnosis:
P-A chest X-ray obtained with the patient in
an upright position

12. 2-Secondary Spontaneous
Pneumothorax (SSP)
• In contrast to PSP, secondary spontaneous
pneumothorax (SSP) is a potentially life-
threatening event, because patients have
associated lung disease and limited
cardiopulmonary reserve.
• In patients with SSP, dyspnea may be severe
and out of proportion to the size of the
pneumothorax,
• Hypoxemia, hypercarbia, and hypotension
may be the dominant findings.

13. Complications of Spontaneous
Pneumothorax
• i) Persistent air leak from chest tube
• ii) Pneumomediastinum,
• iii) Hemopneumothorax,
• vi) Tension pneumothorax, and
• v) Recurrence

14. Treatment of Spontaneous
Pneumothorax
• 1) Observation:
for asymptomatic patient with pneumothorax less
than 20 %, with careful instruction for follow up
within 12 – 48 hours.
• 2) Tube Thoracostomy
a) Tube thoracostomy is recommended for :
i) Patients with large or symptomatic PSP.
ii) For most patients with SSP.
iii) Patients presenting with tension pneumothorax.
b) Tube placement is through the fifth intercostal space in
the midaxillary line

16. Treatment of Spontaneous
Pneumothorax, Cont.
• 3) Pleurodesis
After tube thoracostomy, chemical
pleurodesis may help prevent SP recurrence.
Sclerosing agents are instilled to create pleural
symphysis.
The most commonly used agents are sterile
talc slurry and doxycycline solution.

17. Treatment of Spontaneous
Pneumothorax, Cont.
• 4) Surgery
Surgical indications for PSP are:
• i) Recurrent pneumothorax
• ii) Massive or persistent air leaks
• iii) Incomplete lung expansion after tube
thoracostomy.
• Vi) Other surgical indications include patients with a
history of bilateral PSP and those in occupations that
would place them at high risk if a pnemothorax
recurred, such as pilots and divers.

18. Surgery of Spontaneous
Pneumothorax, cont.
• Goals of surgery:
 Resection of the offending bulla,
 Complete lung expansion, and
 Surgical pleurodesis , done by
parietal pleural resection or
abrasion to prevent recurrence.

19. Surgery of Spontaneous
Pneumothorax, cont.
• Video-assisted thoracoscopic surgery (VATS) is
the surgical procedure of choice for PSP,
replacing the previous procedure, axillary
thoracotomy.

20. II) EMPYEMA THORACIS

21. II) Empyema Thoracis
Definition: Accumulation of pus in the pleural cavity.
Incidence: 5-10 % of hospitalized patient with parapneumonic
effusion.
Etiology: -
• Lung diseases: Pneumonia (the most common cause), Lung
abscess.
• Post traumatic.
• Iatrogenic e.g., complications of thoracocentesis (aspiration
of pleural effusion).
• Postoperative : Postresection bronchopleural fistula .
• Mediastinitis with pleural extension
• Extension of subphrenic abscess.
• Blood spread

22. Pathology Empyema Thoracis
Parapneumonic effusion progress through 3 stages
to an empyema.
• First or exudative stage:
has relatively low LDH, normal glucose and normal PH.
• Second or fibropurulent stage:
If 1st stage not well treated with invasion of pleural fluid by
bacteria increased fibrin deposition, cellular debris
and blood cells formation of fibrinous membranes
producing loculations.
• Third or organization stages:
occurs as fibroblasts grow into fibrin sheet coating the
visceral and parital pleura "pleural peel" causing entrapment
of the lung.

23. Clinical Stages of Empyema
Thoracis
• Acute stage:
Within the first 2 weeks of the onset.
• Chronic Stage:
After 2 weeks or with the formation of the
thick peel and loculations.

24. Diagnosis of Empyema Thoracis
• 1- Pus obtained on thoracocentesis.
Glucose concentration < 40 mg/dl,
LDH > 3 times the upper limit of normal, and
PH < 7.2.
• 2- Chest x ray:
Posteroanterior and lateral.
175- 500 ml needed to blunt costophrenic angle.

26. Diagnosis of Empyema Thoracis ,
Cont
• 3- Ultrasonography:
Localize small amount of fluid and loculation
and identify pleural peel.

27. Diagnosis of Empyema Thoracis , Cont
• 4- CT Scan:
Differentiating empyema, lung abscess,
subdiaphragmatic fluid

28. Management of Empyema Thoracis
• Medical management:
Non interventional therapy often
contraindicated,
Thoracocentesis and culture sensitivity based
antibiotic therapy generally successful for
stage I NOT stage II or III.

29. Surgical management of
Empyema Thoracis
1) Tube thoracostomy using large bore chest
tube (30-32 fr.), the tube withdrawn slowly
several weeks until removed.
2) Recently: Insertion of pigtail catheter (8 fr
to 14 fr) with administration of fibrinolytics
such as streptokinase or urokinase until the
pleural space is cleared.

30. Surgical management of
Empyema Thoracis , cont.
3) Thoracoscopy (VATS):
The next therapeutic option after fibrnolysis,
Advantage of VATS
Visualize the infected pleural space
Determine if complete drainage of all
empyema
Disruption of all adhesions and loculations.

31. Surgical management of
Empyema Thoracis , cont.
• 4) Decortication:
Via thoracotomy should be performed when
third stage is suggested by CT Scan.
i) Remove all purulent fluid, fibrinous debris,
thickened parietal pleura from the pleural
space.
ii) Resection of visceral pleural peel.

32. III) Pleural Mesothelioma

33. 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.

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

35. Pleural Mesothelioma, cont.

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

37. SURGICAL PROCEDURES

38. Thoracocentesis

39. Chest tube insertion
- Insertion Site
• mid or anterior axillary line behind pectoralis major
• above 5th rib since on expiration diaphragm rises
• count down from sternomanubrial joint (2nd rib)

40. Chest tube insertion, Cont.

41. Thoracoscopy

42. Thoracotomy

43. Thank you