Post surgical

Question 1

Pneumonectomy

Answer 1

Types:

• Extrapleural Pneumonectomy: En block resection of lung, visceral/parietal pleura, hemidiaphgram, pericardium
• Intrapericardial pneumonectomy: pneumonectomy + intrapericardial resection
• Sleeve pneumonectomy: central tumor resection, contralateral main bronchus anastamosed to trachea

Imaging:

• Early: Air in pneumonectomy space, midline mediastinum, gradual filling of space with fluid (air fluid level on erect films). Gradual ipsilateral tracheal and mediastinal shift.
• Late: opaque hemithorax with complete obliteration of air. Mediastinal shift TOWARDS pneumonectomy space. Heart rotates towards posterior aspect of pneumonectomy space. Contralateral lung hyperinflates.

Post Surgical Complications:

• Pulmonary oedema/pneumonia/ARDS
• Hemothorax/chylothorax/empyema: rapid fluid filling of pneumonectomy space
• Bronchopleural/esophagopleural fistula: failure of opacificaiton of pneumonectomy space or drop in fluid level, contralateral mediastinal shift
• Cardiac herniation: bulge f widening of cardiac contour
• Post pneumonectomy syndrome: severe mediastinal shift and counterclockwise rotation of heart/vessels –> compresses bronchus (usually left bronchus post right sided resection)
• Radiation pneumonitis
• Organising pneumonitis
• Tumor recurrence

Question 2

Sternotomy

Answer 2

Median sternotomy: vertical incision (access to mediastinum and limited lung access)

Clam shell sternotomy: transverse incision (access to both lungs and mediastinum)

Question 3

Heart Transplantation

Answer 3

Indication: end stage heart failure/cardiomyopathy

Types:

• Orthotopic: recipients heart removed through MS, Donar heart joined to atria/aorta/PA
• Heterotopic: rarely performed. Used when donar heart is too small/PAH.

Complications:

• Infection
• Acute allograft rejection (MRI)
• Cardiac allograft vasculopathy
• Post transplantation lymphoproliferative disease

Question 4

Lung transplant

Answer 4

Complications:

• Immediate (<1month):
  
  • Pneumothorax
  • Effusion
  • Rejection: hyperacute vs acute
  • Bronchial dehiscence
  • Vascular anastamotic complications: stenosis
  • Infection
• Late (>1 month)
  
  • Infection
  • Bronchial stenosis/bronchomalacia
  • Chronic rejection
  • Post transplant lymphoproliferative disorder: low grade to lymphoma.
  • Malignancy