Thoracic surgery

• Bronchiectasis

  Chronic irreversible dilatation of medium size bronchi
• Etiology of bronchiectasis

  • Congenital (cystic fibrosis)
  • Acquired (TB, pneumonia, inhaled FB, bronchial tumor)
• Clinical pectur Bronchiectasis

  • Hemoptysis
  • Recurrent chest infection
  • Productive cough with copious sputum
• Treatment of bronchiectasis

  Generalized - treated conservatively

  Localized - pulmonary resection
• Lung abscess

  Cavitary lesion with air-fluid level on CXR

  
• Etiology of lung abscess

  • Pneumonia
  • Bronchial obstruction
  • Chronic chest infection
  • Septicemia
  • Penetrating lung injury

  
• Treatment of lung abscess

  Acute abscess - appropriate antibiotic & postural drainage

  Sometimes - radiographic guided tube drain in ICU
• Surgery in pulmonary TB

  Associated with anti-TB treatment
• Indications for surgery in pulmonary TB

  • Malignant lesion on CXR cannot be excluded
  • Chronic TB abscess not responding to anti-TB
  • Aspergilloma within TB cavity
  • Life threatening hemoptysis
• Example of surgery in pulmonary TB

  Lobectomy for aspergilloma in chronic cavity causing life threatening hemoptysis
• Chest trauma

  • Signs may be easily missed

  Responsible for 70% of death following RTA

  Blunt trauma fatal in 10% of cases, increases to 30% if other injuries present

  Mortality rate 3% for simple stabbing, 15% for gunshot wound
• Causes of early death in chest trauma

  • Hypoxemia
  • Hypovolemia
  • Tamponade
• Management of chest trauma

  Diagnosis and treatment of life threatening conditions as soon as possible

  Highly suspicious approach to anticipate and treat life threatening conditions
• Diaphragmatic hernia

  Can be congenital or acquired
• Types of congenital diaphragmatic hernia

  • Morgagni hernia (defect in anterior part, transverse colon most common)
  • Bochdalec hernia (defect in dome, posteriorly)

  
• Acquired diaphragmatic hernia

  Traumatic hernia from blunt or penetrating trauma

  Urgent operation indicated for bleeding or strangulation
• Cervical rib


  Fibrous band originating from C7 and inserting onto 1st rib
• Symptoms of cervical rib

  • Neurological: compression on lower trunk of brachial plexus, wasting of interossi, altered sensation in T1 distribution

  Vascular: pressure on subclavian artery, post-stenotic dilatation with thrombus and embolus formation
• Diagnosis of cervical rib

  Cervical X-ray

  Nerve conductive study

  Duplex study
• The aetiology of post-stenotic aortic dilatation remains controversial. It may be due to haemodynamic factors caused by a stenotic valve, involving high velocity and turbulent flow downstream of the stenosis, or due to intrinsic pathology of the aortic wall. This may involve an abnormality in the process of extracellular matrix remodelling in the aortic wall including inadequate synthesis, degradation and transport of extracellular matrix proteins.

  
• Pectus excavatum


  The sternum is depressed with dish-shaped anterior portion of the ribs, never a cause of respiratory problem
• Pectus carinatum (Pigeon chest)

  The sternum is elevated above the level of ribs, treated for cosmetic reasons

  Most patients are asymptomatic

  
• Surgical treatment of chest wall deformities

  Involves mobilizing the sternum with the costal cartilages and holding the central part anteriorly with steel bar

  Surgery is best left until the late teens, when further growth of the chest wall is unlikely