Thoracic Surgery
Lec: 6
Hydatid Disease of the Lung:-
by Dog Tape Worm known as
Is commonly caused
which lives in the dog intestine
Ecchinococcus granulosus
( Primary host ) and it shed eggs which may contaminate
grass and Vegetables these may be ingested by sheep or
) and when the ova reach small
human ( Secondary host
the intestine wall
penetrate
hatch and
Embryo
intestine the
and lodge in the liver or lung and develop into Primary
Hydatid Cyst .
Pathology :- The cyst wall is about 3 mm thickness and
consist of two layers , the external called the Ectocyst which
is white laminated semi permeable layer and the internal
germinative layer The Endocyst whose cells produce
scolices ,clear hydatid fluid and the external layer.
The cyst grow much faster in the lung than in the other
organ even to large size with minimal reversible
compression of lung parenchyma, after removal of the cyst
loss of lung volume may be insignificant, in 70% of cases
lung cyst is solitary. A pericyst or capsule forms around the
cyst and consist of host fibrous tissue and compressed lung
parenchyma it sticks to the cyst without adhesion so the
surgeon can separate them easily.
Clinical featuers :- Patient infected with P.H.C. usually
remain asymptomatic ( when the cyst is intact ) and the cyst
continue to grow and they are discovered incidentally when
a CXR done as a screening or for non resolving chest
infection. Rupture of the cyst which represent the Main
Danger to the patient's life, mostly The H.C. ruptures into
the bronchus and may lead to suffocation, haemoptysis,
pneumonitis, abscess, bronchiatasis the patient present with
productive cough with salty taste sputum and cough up a
Grape –Like whitish membrane, these are the daughter cysts
, anaphylaxis may occur from Hydatid fluid, in 10% of cases
rupture occur to pleural cavity leading to Pneumothorax,
Empyma and Pleural secondary H.C.
Dx:- CXR show different pictures according to the stage
of H.C :-
Intact H.C:-Rounded homogenous opacity with thick
boarders
Intact H.C in communication with bronchus: - air will just
compress the cyst known as Signet Ring Appearance .
Ruptured H.C :- when the Endocyst ruptures and air enters
inside it giving The Water Lilly Appearance .
Expectorated H.C :- when the whole content of cyst was
coughed out an empty cavity will appear on CXR
Infected H.C :- seen as a heterogenous opacity from
infected endocyst and pus inside the cavity.
CT scan will help to delinate the size and site of lesion and
the presence of bronchial communication .
Classification :- The Informal Working Group on
Echinococcosis ( WHO-IWGE) proposed a standerized
classification based on the state of the activity of cyst
G 1 active group :- cyst > 2 cm and often fertile
G 2 Transition group :- cyst start to degenerate because of
host resistance or Rx but may contain viable protoscolices
G 3 Inactive group :- degenerated , calcified ,unlikely
contain viable protoscolieses.
Surgical Rx :- Since the Medical Rx of no proven value
surgery is mostly required, surgery become urgent when
cyst ruptures to bronchial tree, when haemothorax or
haemoptysis develop, when a hepatic cyst penetrates
through diaphragm. Methods of surgical Rx are :-
1.-Enucleation method in which the visceral pleura and lung
parenchyma incised till pericyst is reached which also
incised widely trying to remove the endocyst intact
2- Aspiration –Evacuation method in which the cyst is
punctuered by blood giving set to evacuate it s fluid by
gravity then the endocyst removed then the remained cavity
sterilized by 10% Iodene.
3- Ruptuered H.C with damdged lung tissue may require
resection of part of lung e.g Wedge Resection
,Segmentectomy, Lobectomy, in all methods any site of air
leak must be sutuered…
Indication of surgery in Mx of Pulmonary T.B :-
1. Complication from previous thoracic surgery to Rx T.B.
2. Failure of medical Rx leading to progress of disease, intra
cavitary aspergellosis.
3. Complicated T.B with Massive haemoptysis,
bronchiactasis .
4. Extra Pulmonary thoracic involvement.
5. T.B Fibrous Empyma.
6. Need for histopathologic examination for definitive Dx.
Massive Haemoptysis: - Is defined as expectoration of >
600 ml of blood with in 24 hour, the rate of bleeding
necessary to produce respiratory compromise is highly
dependant on the individual's prior Respiratory status.
The Lung has 2 sources of blood supply:-
1. Low pressure pulmonary A. system 2. High pressure
bronchial A. system which arise from Thoracic Aorta.
Massive Haemoptysis is mostly Due to bleeding from
bronchial A. Or from pulmonary A. exposed pathologically
to high Pressure of bronchial A.
Etiology: - Is usually Secondary to inflammatory process
which cause destruction and erosion of vascular structure
leading to bleeding, these factors are classified to:-
1. Pulmonary causes :- Like pulmonary parenchymal
diseases e.g bronchitis ,bronchiactasis , T.B , Lung Abscess ,
pneumonia , Cavitary fungal infection , Pulmonary
Embolism and Infarct , Trauma , Neoplasm , A-V
malformation.
2. Extra pulmonary causes: - Drugs, Mitral Stenosis,
congestive heart failure , coagulopathy.
3.Iatrogenic e.g intrapulmonary catheterization.
Rx
Priorities in Mx of Massive H.
1. Achieve respiratory control and prevent asphyxia
2.Localize and control sites of bleeding.
3. Determine the cause and percent of recurrence.
Scenario 1 :- Significant , persistent, but not massive
bleeding :- in such case the Pt. is able to clear secretion or
blood with own respiratory reflex .
Mx :- 1. ICU admission, bed rest, sedation, pt. must sleep
with the affected side down when it is known.
2.Large I.V Line + humidified O2 +aerosolized adrenaline
3. monitor arterial blood gases .
4.I.V Antibiotics, correct abnormal blood coaguloathy.
5.I.V Vasopressin 20u/15 min followed by 0.2u/ min
infusion.
CT chest help to localize lesion.
Bronchoscopy help to Dx air way abnormality, localize site
of bleeding
Bronchial A. angiography and Embolization settle Dx and
provide Temporary acute control of bleeding, sometimes
P.A angio may be necessary.
Scenario 2 :-Persistant Massive Bleeding :-
1.Immediate ETT to control ventilation and suction.
2.Rigid bronchoscopy to Dx bleeding sites and then to
advance the bronchoscope to non bleeding side to ventilate
Pt. + ice N/S Lavage of bleeding side
3.Blocking of Main stem Bronchus of bleeding side by
Double Lumen ETT or by intubation of the non affected
bronchus with Single Lumen ETT , the best way is by use
of Bronchial Blocker which is inflated and left in place for
24 hours and then the area re-examined by re-bronchoscopy
and then to do Bronchial A Embolization.
Surgical intervention :- most cases of bleeding can stop by
above mentioned measures
Sec 1:- requires further evaluation by CT Scan , PFTs
Sce 2 :- requires surgical intervention in same admission and
it is individualized acc. To 1.Source of bleeding , 2. Pt.
medical condition ,3.Pulmonary Reserve , in 10% of cases
the operation must be done Emergently.
Indication for Surgery
1.Presence of Fungal ball
2.= = Lung Abcess
3.= = Significant cavitary Lesion
4.Failuer to control bleeding