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Pediatric thoracic surgery Flashcards

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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

Study These Flashcards
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

Study These Flashcards
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

Study These Flashcards
A

Excision,
enucleation,
segmentectomy,
lobectomy

20
Q

Pneumothorax (PTX)

Study These Flashcards
A

Air accumulation into the pleural space

between the visceral and parietal pleural layers

21
Q

SPONTANEOUS PNEUMOTHORAX

Study These Flashcards
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

Study These Flashcards
A

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

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

23
Q

PTX TREATMENT

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

PARTICULAR TYPES OF PTX

Study These Flashcards
A
  1. OPEN PTX
  2. TEMSION PTX
  3. BILATERAL PTX
  4. HEMOPTX
25
OPEN PTX
* Usually – post-traumatic * Bidirectional air flow – Pressureintrapleural=Patm * Heimlich valve / “3 point” dressing
26
TENSION PTX
* Unidirectional air flow * Absolute emergency – without any radiologic evaluation * Cardiovascular collapse risk * Sudden cyanosis
27
HEMOPTX
traumatic, neoplasia etc.
28
DDx PTX
Cardiac tamponade – importantce of precordial percussion (!) and tracheal deviation
29
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
30
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)
31
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
32
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
33
Pleural empyema
Empyema = pleureal effusion, accumulation of pus in the pleural space ++ Streptococcus Pneumoniae, + Staphylococcus aureus, +Haemophillus influenzae, tip B
34
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
35
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
36
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
37
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
38
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
39
Pulmonary abscess | CLINICAL FEATURES
* Fever * Thoracic pain * Malaise * Productive cough, hemoptysis * Stationary / descending weight curve * Percussion dullness, low lung sounds, bronchi/alveoli pathologic sounds
40
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
41
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

Pediatric surgery (11 decks)

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