Pediatric thoracic surgery Flashcards
Formation of trachea
Week 4 – laryngo-tracheal bud, rising from the anterior
foregut (primitive esohagus)
= future trachea – separating from the proenteron by tracheo-esophageal septum
– and bifurcation into -> primitive bronchi
End of process – more than (10)7 airways
Broncho-pulmonary malformations (BPM)
PRENATAL DIAGNOSIS
• ULTRASOUND (W18-W24)
• Differential diagnosiS for other BPM (+/- fetal MRI)
• Differential diagnosis with other congenital anomalies
(dyaphragmatic hernias, cardiac malformations etc.)
• Perinatal management planning
• Associated anomalies diagnosis
!!• Fetal distress
• Fetal hydrops
• Fetal death in utero
BPM POSTNATAL DIAGNOSIS
• 25% symptomatic at birth/neonatal period
• ACUTRE RESPIRATORY DISTRESS SYNDROME
(ARDS) of the newborn
• Cough, tachypnea, cyanosis, respiratory effort
(thoraco-abdominal balancement – paradoxal
breathing, intercostal retractions etc.)
• 75% - incidental finding or following a complication
• Pulmonary infection
• Pneumothorax
• Chronic cough, shortness of breath – dyspnea,
cyanosis
• No lung sounds, thoracic asymmetry, percussion
changes (hyperresonance or dullness), respiratory
failure signs
BPM MANAGEMENT
• PRENATAL
• ultrasound follow-up (+/- MRI), if there are no fetal distress / hydrops signs • thoraco-aminiotic shunt • thoracocentesis (if possible – macrocysts) • premature birth indication • steroids therapy • fetal surgery (laser ablation) • EXIT (ex-utero intrapartum therapy)
BPM MANAGEMENT
• POSTNATAL
• classical / minimally-invasive approach
• elective indication – if there are no
complications
• emergency in case of ARDS
• atypical, segmentary orlobar resections
• pleural drainage
Congenital adenomatoid cystic malformations of the
lung
• heterogenous group of cystic/non-cystic lung malformation – excessive proliferation of the immature terminal bronchioles in a pulmonary segment
(pseudoglandulary stage ☝)
• 0,66-1,5 : 10000 births – the most frequent BPM (50-70% of all BPMs)
• Vascular intake from the pulmonary system
• Communication with the bronchi tree
• Hybrid lesions are well known(systemic vascular intake – most frequently, aorta)
Congenital adenomatoid cystic malformations of the
lung
CLINICAL FEATURES:
- uniqe, unilateral, unilobar mass
- more frequently on the right, and upper lobes
- asymptomatic in most of the cases
- identified following a pulmonary infection or pneumothorax
- most of the cases- no associated congenital malformations
Congenital adenomatoid cystic malformations of the
lung
DIFFERENTIAL DIAGNOSIS
- Other BPMs (bronchogenic cysts, congenital lobar emphysema, pulmonary sequestration)
- Congenital diaphragmatic hernia
- Pneumatocele
Congenital adenomatoid cystic malformations of the
lung
COMPLICATIONS
- prenatal - like in all BPMs
- postnatal – specific to all BPMs, but more likely – infection, pneumothorax
- specific – malignant potential – rabdomyosarcoma, pulmonary blastoma, bronho-alveolary carcinoma
Congenital adenomatoid cystic malformations of the
lung
TREATMENT
- Elective – considering the possible complications (malignant potential!)
- Segmentectomy
- Lobectomy
Broncho-pulmonary sequestration (BPS)
• rare congenital malformation, unfunctional lung tissue (not air-filled, without any
communication to the normal tracheo-bronchial tree) whose blood intake comes from
aberrant vessels originating from the system circulation
• 0,15-6,4% of all BPMs
• Systemic vascular intake
BPS CLINICAL FEATURES
• feeding problems, breathing
difficulties, cardiac failure signs – VASCULAR STEAL
• infection – despite no communication with the respiratory tree
BPS
IMAGISTIC EVALUATION – highly
suggestive
• Homogeneity,
good delineation,
triangular aspect (lateral base),
identification of an aberrant feeding vessel (75% - an aortic branch)
Congenital lobar emphysema
lower airways malformation – hyperinflation of one or more pulmonary lobes determining variable grades of secondary compression over the the adjacent pulmonary parenchima or mediastinum
• 1:20000-30000 births
• M:F 3:1
Congenital lobar emphysema
IMAGISTIC EVALUATION
- High lung translucency and vascular markings paucity
* Mediastinum shift / heart shift / diaphragmatic flattening
Congenital lobar emphysema
TREATMENT
- Conservatory
- Lobectomy
- Segmentectomy
- Specific – may constitute an emergency
Bronchogenic cyst
• Cystic malformation of the lung: unilocular, non-communicating, thick-walls, composed by smooth muscle, cartilage, mucous glands, ciliated columnar epithelium, adjacent to trachea or bronchi
• 1:68000 births, predilection for males
• 65-86% into the mediastinum, but it may be found everywhere adjacent to the respiratory tree
(pulmonary, para-tracheal, para-esophageal, para-vertebral
• Exceptional cases – retroperitoneal
Bronchogenic cyst
IMAGISTIC EVALUATION
- prenatal (positive diagnosis in >50% cases)
- postnatal – plain pulmonary X-ray, CT/MRI (mediastinum cystic image – posterior or middle mediastinum, para-tracheal mass or adjacent to the hilum; calcifications)
Bronchogenic cyst
MANAGEMENT
Excision,
enucleation,
segmentectomy,
lobectomy
Pneumothorax (PTX)
Air accumulation into the pleural space
between the visceral and parietal pleural layers
SPONTANEOUS PNEUMOTHORAX
• Incidence - 1,1-4:100000 (F-M)
• adolescents, asthenic constitutional type, ectomorph
(longilin) body type
• Uncertain etiology – rupture of developed bullae or blebs (usually in the apex)
• Acute dyspnea, coughing, thoracic sharp pain
• Hyperresonance of the thorax, no lung sounds or lung vibrations
• Tension pneumothorax – SURGICAL EMERGENCY – positive pressure accumulation in the pleural space, mediastinum shift, cardio-pulmonary collapse
WORK-UP IN PTX
IMAGISTICS
• Pulmonary X-ray
• Thoracic CT/MRI
• Etiological diagnosis
BLOOD WORK-UP
• Etiological diagnosis depending on the clinical
background
PTX TREATMENT
- Pleural drainage – chest tube
- Segmentectomy
- Exploratory thoracotomy / VATS in recurrent or persistent PTXs. (bronchic fistula?)
PARTICULAR TYPES OF PTX
- OPEN PTX
- TEMSION PTX
- BILATERAL PTX
- HEMOPTX
OPEN PTX
- Usually – post-traumatic
- Bidirectional air flow – Pressureintrapleural=Patm
- Heimlich valve / “3 point” dressing
TENSION PTX
- Unidirectional air flow
- Absolute emergency – without any radiologic evaluation
- Cardiovascular collapse risk
- Sudden cyanosis
HEMOPTX
traumatic, neoplasia etc.
DDx PTX
Cardiac tamponade – importantce of precordial percussion (!) and tracheal deviation
SURGICAL TREATMENT IN PTX
Conservative
• <15-20% pulmonary radiological surface
• Stable patient, good respiratory function, no symptoms
• Mandatory – clinical follow up, SaO2 monitoring and by multiple X-ray
Pleural drainage
• Emergency / urgency indication
• Percutaneous aspiration / pleural drainage
• IV-V intercostal space / mid-axillary line
• II-III intercostal space / mid-clavicle line
• Aspirational / non-aspirational drainage
• Complications: mediastinal organs injury, intercostal vessel injury, gastric perforation, hepatic injury
• Bronchic fistula closure
• Segmentectomy
Hemothorax (HTX.)
Blood accumulation in the pleural space
• trauma (pulmonary blunt injury, rib fractures)
• secondary to some pre-existent condition (ex: neoplasm)
• iatrogenous (internal mammary artery, intercostal artery, mediastinal vessel, lung)
HTX PLEURAL DRAINAGE
• RELATIVE INDICATION – Hemodynamic stable? Respiratory stable? Is there any
coexistent PTX?
• Conservative treatment – BETTER in selected cases
• careful, close follow-up – multiple clinical and radiological examinations
WHEN IS SURGICAL EXPLORATION NEEDED IN HTX.?
- Hemodynamically unstable patient
- Initial blood loss greater than 20-25% patient’s blood volume
- Dynamic increase of lost blood volume
- Persistent blood loss of 2-4 mL/Kg/hour
- Pleural space cannot be drained because of clots
Pleural empyema
Empyema = pleureal effusion, accumulation of pus in the pleural space
++ Streptococcus Pneumoniae, + Staphylococcus aureus, +Haemophillus influenzae, tip B
Pleural empyema
stages
Stage I
Exudativ / initial
• Clear, clean pleural fluid, low viscosity
• No adhesions between the parietal and visceral pleura
Stage II
Fibrinopurulent / transitional
• Fibrin membranes on the pleural surfaces
• Pulmonary movements limitations begins
Stage III
Organizing phase / chronic after 4-6 W
• Fibroblasts and capillary vessels in into the fibrin membranes – pleural adhesions
Pleural emphyema
IMAGISTICS
Thorax CT
Evaluation of the size, detailed anatomic picture, precise loculation identification, secondary / underlying causes, localization of the infection site
(pleural / pulmonary)
Thoracic US – available all around, fast DEPENDS ON THE OPERATOR Size evaluation Echogenicity corelates with pH Relative identification of loculations Pleurostomy live guidance
Pulmonary X-ray
Positive diagnosis
Follow-up purpose
Requires clinical and biological correlation
Pleural emphyema
Diagnosis by needle aspiration: at +10 mm
TREATMENT
• Chest tube – 5-6 intercostal space mid-axillary line (simple/aspirational) +/- enzymatic fibrinolysis (stage 2-3)
• Mediastinum shift, ARDS
• Persistent fever
• Dynamic collection growth – despite antibiotherapy
• EXPLORATORY THORACTOMY / VATS
Pulmonary abscess
• Complication of a primary or secondary lung infection (ex: bacterial pneumonia) – evolution to necrosis and cavitation
• more frequently in imunosupressed patients or in neglected cases of pneumonia (ineffective antibiotherapy, late use of antibiotics)
CLINICAL BACKGROUND
• Consecutive to pneumonia, parasitic diseases (ex: hydatid cyst)
• Primary – without any underlying cause
• Secondary – aspiration (neurologically impaired, gastroesophageal reflux disease,
eso-tracheal fistula, foreign bodies, blood aspiration after ENT/dentist surgery, after
tracheal intubation etc.)
• Infection of preexistent congenital malformations – CCAMs, bronchogenic cysts
Pulmonary abscess
CLINICAL BACKGROUND
- Consecutive to pneumonia, parasitic diseases (ex: hydatid cyst)
- Primary – without any underlying cause
- Secondary – aspiration (neurologically impaired, gastroesophageal reflux disease, eso-tracheal fistula, foreign bodies, blood aspiration after ENT/dentist surgery, after tracheal intubation etc.)
- Infection of preexistent congenital malformations – CCAMs, bronchogenic cysts
Pulmonary abscess
CLINICAL FEATURES
- Fever
- Thoracic pain
- Malaise
- Productive cough, hemoptysis
- Stationary / descending weight curve
- Percussion dullness, low lung sounds, bronchi/alveoli pathologic sounds
Pulmonary abscess
DIAGNOSIS
- Positive
- Pulmonary X-ray
- Hydro-aeric well-delimited collection (pneumotocele, ddx!)
- Thoracic CT indication
- Etiology – broncho-alveolary lavage, CT thoracic, pleural aspirate analysis, surgical exploration
Pulmonary abscess
TREATMENT
- Broad spectrum antibiotic – followed by targeted therapy, depending on the antibiogram
- Drainage
- Segmentectomy, lobectomy
- Classical or thoracoscopic approach
- Evolution - Chronic abscess, bronchic strictures, bronchiectasias, pulmonary necrosis
