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Pediatric surgery > Pediatric thoracic surgery > Flashcards

Pediatric thoracic surgery Flashcards

1
Q

Formation of trachea

A

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

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2
Q

Broncho-pulmonary malformations (BPM)

PRENATAL DIAGNOSIS

A

• 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

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3
Q

BPM POSTNATAL DIAGNOSIS

A

• 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

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4
Q

BPM MANAGEMENT

• PRENATAL

A 
• 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)
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5
Q

BPM MANAGEMENT

• POSTNATAL

A

• classical / minimally-invasive approach
• elective indication – if there are no
complications
• emergency in case of ARDS
• atypical, segmentary orlobar resections
• pleural drainage

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6
Q

Congenital adenomatoid cystic malformations of the

lung

A

• 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)

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7
Q

Congenital adenomatoid cystic malformations of the
lung
CLINICAL FEATURES:

A
  • 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
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8
Q

Congenital adenomatoid cystic malformations of the
lung
DIFFERENTIAL DIAGNOSIS

A
  • Other BPMs (bronchogenic cysts, congenital lobar emphysema, pulmonary sequestration)
  • Congenital diaphragmatic hernia
  • Pneumatocele
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9
Q

Congenital adenomatoid cystic malformations of the
lung
COMPLICATIONS

A
  • prenatal - like in all BPMs
  • postnatal – specific to all BPMs, but more likely – infection, pneumothorax
  • specific – malignant potential – rabdomyosarcoma, pulmonary blastoma, bronho-alveolary carcinoma
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10
Q

Congenital adenomatoid cystic malformations of the
lung
TREATMENT

A
  • Elective – considering the possible complications (malignant potential!)
  • Segmentectomy
  • Lobectomy
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11
Q

Broncho-pulmonary sequestration (BPS)

A

• 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

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12
Q

BPS CLINICAL FEATURES

A

• feeding problems, breathing
difficulties, cardiac failure signs – VASCULAR STEAL
• infection – despite no communication with the respiratory tree

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13
Q

BPS
IMAGISTIC EVALUATION – highly
suggestive

A

• Homogeneity,
good delineation,
triangular aspect (lateral base),
identification of an aberrant feeding vessel (75% - an aortic branch)

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14
Q

Congenital lobar emphysema

A

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

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15
Q

Congenital lobar emphysema

IMAGISTIC EVALUATION

A
  • High lung translucency and vascular markings paucity

* Mediastinum shift / heart shift / diaphragmatic flattening

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16
Q

Congenital lobar emphysema

TREATMENT

A
  • Conservatory
  • Lobectomy
  • Segmentectomy
  • Specific – may constitute an emergency
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17
Q

Bronchogenic cyst

A

• 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

18
Q

Bronchogenic cyst

IMAGISTIC EVALUATION

A
  • 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)
19
Q

Bronchogenic cyst

MANAGEMENT

A

Excision,
enucleation,
segmentectomy,
lobectomy

20
Q

Pneumothorax (PTX)

A

Air accumulation into the pleural space

between the visceral and parietal pleural layers

21
Q

SPONTANEOUS PNEUMOTHORAX

A

• 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

22
Q

WORK-UP IN PTX

A

IMAGISTICS
• Pulmonary X-ray
• Thoracic CT/MRI
• Etiological diagnosis

BLOOD WORK-UP
• Etiological diagnosis depending on the clinical
background

23
Q

PTX TREATMENT

A
  • Pleural drainage – chest tube
  • Segmentectomy
  • Exploratory thoracotomy / VATS in recurrent or persistent PTXs. (bronchic fistula?)
24
Q

PARTICULAR TYPES OF PTX

A
  1. OPEN PTX
  2. TEMSION PTX
  3. BILATERAL PTX
  4. HEMOPTX
25
Q

OPEN PTX

A
  • Usually – post-traumatic
  • Bidirectional air flow – Pressureintrapleural=Patm
  • Heimlich valve / “3 point” dressing
26
Q

TENSION PTX

A
  • Unidirectional air flow
  • Absolute emergency – without any radiologic evaluation
  • Cardiovascular collapse risk
  • Sudden cyanosis
27
Q

HEMOPTX

A

traumatic, neoplasia etc.

28
Q

DDx PTX

A

Cardiac tamponade – importantce of precordial percussion (!) and tracheal deviation

29
Q

SURGICAL TREATMENT IN PTX

A

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

30
Q

Hemothorax (HTX.)

A

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)

31
Q

HTX PLEURAL DRAINAGE

A

• 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

32
Q

WHEN IS SURGICAL EXPLORATION NEEDED IN HTX.?

A
  • 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
33
Q

Pleural empyema

A

Empyema = pleureal effusion, accumulation of pus in the pleural space
++ Streptococcus Pneumoniae, + Staphylococcus aureus, +Haemophillus influenzae, tip B

34
Q

Pleural empyema

stages

A

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

35
Q

Pleural emphyema

IMAGISTICS

A

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

36
Q

Pleural emphyema

A

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

37
Q

Pulmonary abscess

A

• 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

38
Q

Pulmonary abscess

CLINICAL BACKGROUND

A
  • 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
39
Q

Pulmonary abscess

CLINICAL FEATURES

A
  • Fever
  • Thoracic pain
  • Malaise
  • Productive cough, hemoptysis
  • Stationary / descending weight curve
  • Percussion dullness, low lung sounds, bronchi/alveoli pathologic sounds
40
Q

Pulmonary abscess

DIAGNOSIS

A
  • 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
41
Q

Pulmonary abscess

TREATMENT

A
  • 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

Pediatric surgery (11 decks)

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