Surgery for Pulmonary Infections

Prof. Ahmed DeebisHead of Cardiothoracic

Surgery Department - Zagazig University

Surgery of Pulmonary Infections

ObjectivesI. Lung AbscessII. BronchiectasisIII. Surgery for Pulmonary Tuberculosis

Lung abscess

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.

Etiology of lung abscessA. 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.

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.

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.

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.

Clinical Picture, Cont.

• Physical examination: a small area of dullnesssuppressed 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.

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.

Diagnosis, cont.

Differential Diagnosis: a)Hydropneumothorax, b)Cavitary neoplasm, c) Loculated empyema with airway fistulation,d)Interlobar fluid collection.

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.

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.

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.

II) Bronchiectasis

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 1 antitrypsin deficiency

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.

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.

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)

Clinical Picture

Bronchiectasis can present in two forms: a. Local form, involve a lobe or segment of a lungb. 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

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.

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

Plain Chest x Ray P-A View suggesting Bronchiectasis

CT Scan

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.

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.

Surgery for Pulmonary Tuberculosis

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

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

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.

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