Introduction to

CTS ,CHEST
WALL and
PLEURA
Ashenafi Berhanu
MD, General surgeon , CTVS
UOG
INTRODUCTION TO CARDIOTHORACIC
SURGERY

• Few milestones
• Preioperative management of thoracic patient
• Anatomy of the chest wall , pleura and lungs
Few mile stones in CTS

A, Rene Laennec introduced the

stethoscope in 1818 when he rolled a
sheet of papers to listen to heart and
lung sounds. Painting by Robert A.
Thom (1915-1979), circa 1960.
Permission granted by the University
of Michigan.
B, Parts of his stethoscope are shown,
along with the detachable chest and
ear piece. Photo courtesy of the US
National Library of Medicine.
A, Wilhelm Conrad von
Röntgen discovered x-ray in
1895,
(B) with his wife's hand and
ring as the first human x-ray.
Dr Franz John A. Torek performed the first transthoracic
esophagectomy for squamous cell cancer in 1913 (A)
on a 67-year-old woman who had progressive dysphagia
and weight loss (B) (reprinted with permission from
Elsevier). Thirty-three years later, Dr Ivor Lewis
performed the first 2-stage esophagectomy via an
abdominal approach and right thoracotomy in 1946 (C)
(reprinted with permission from Karger).
Killian  tracheoscopy
Hans Christian Jacobaeus,
the inventor of laparoscopy
and thoracoscopy,
performing a thoracoscopy to
address pulmonary
adhesiolysis.
Preoperative assessment of patients for CTS
Key points of evaluation
• History and physical examination
• SPo2 ,ABG
• Pulmonary function
• Cardiac assessment
• Nutritional assessment
• Functional capacity
• Cardiopulmonary reserve
• Comorbid conditions
Pulmonary function assessment
• Both preoperative and predicted post operative values
• Regional pulmonary function assessment
• Cardiorespiratory interaction
Tools
Spirometry
DLCO
VO2max ,exercise tolerance
Ventilation /Perfusion scans
Spirometry
• Measures respiratory mechanics and volumes
• FEV1,Fvc, mechanical voluntary ventilation MVV , RV/TLC
• Most single valid test for respiratory complications is ppoFEV1%
ppoFEV1% = PreopFEV1 x (1-%of lung tissue removed )/100
30% high risk
30% -40% moderate risk
>40% low risk
DLCO
• Predicted values
• 40% is cut off value
• below 20% contraindicated
VO2max and exercise tolerance
• Asses cardiopulmonary interaction and reserve
• The oxygen consumption per minute
• <10 ,10 - 15 , >15ml /kg/min
• Exe. Tests
Stair climbing
SWT
6MWT
Regional pulmonary function
• Radionuclide Ventilation perfusion scanning
• Pulmonary quantitative scanning
• MRI
Anatomy of the chest wall pleura and lungs

Chest wall
• Contains bones ,cartilages ,ligaments ,nerves, muscles, soft tissue
• Bones : sternum, vertebra ,ribs ,scapulae , clavicle
Broncho pleuropulmonary anatomy
PLEURA
• It is a serous membrane arranged as a closed invaginated sac that covers the lung and
lines the chest wall
• Each pleura has two parts:
1. Parietal layer (outer layer), which lines the thoracic wall,
2. Visceral layer (inner layer), which completely covers the outer surfaces of the lungs
• The two layers become continuous with one another by means of a cuff of pleura at the
hilum of each lung. the pleural cuff hangs down as a loose fold called the pulmonary
ligament
• The parietal and visceral layers of pleura are separated from one another by the pleural
cavity (pleural space) that contains a small amount of the pleural fluid
Division of the parietal pleura
parietal pleura divided according to the region in
which it lies or the surface that it covers.
The cervical pleura extends up into the neck,1 to 1.5 in. (2.5 to 4 cm
The costal pleura
The diaphragmatic pleura
The mediastinal pleura constitute the lung root and continuous with the visceral pleura.
Pleural recesses
The costodiaphragmatic recesses
The costomediastinal recesses.
Dome of the
pleura

2nd costal
cartilage

4th costal
cartilage

1 th
6 costal
t
h 2 rib
cartilage

1 th rib in
midaxillary
0
line

8th rib in
midclavicular
line
Nerve Supply of the Pleura
• The parietal pleura is sensitive to pain, temperature, touch, and
pressure and is supplied as follows:
• The costal pleura is segmentally supplied by the intercostal nerves.
• The mediastinal pleura is supplied by the phrenic nerve.
• The diaphragmatic pleura is supplied over the domes by the phrenic
nerve and around the periphery by the lower six intercostal nerves.
• The visceral pleura covering the lungs is sensitive to stretch but is
insensitive to common sensations such as pain and touch. It receives
an autonomic nerve supply from the pulmonary plexus
Anatomy of Lungs
• The lungs are the essential organs of respiration.
• They are situated on either side of the heart and other mediastinal contents
• the lungs are soft, spongy and very elastic.
• Each lung is conical in shape, covered with visceral pleura, being attached
to the mediastinum only by its root
• In the child, they are pink, but with age, they become dark and mottled
Each lung has an apex, base, three borders and two surfaces

• Apex each lung has a blunt apex, which projects upward into the neck for about 1 in. (2.5 cm) above the
clavicle;
• Base is concave, and rests upon the upper surface of the diaphragm ;
• The costal surface is smooth and convex which corresponds to the concave chest wall;
• The medial surface has a posterior vertebral part and anterior mediastinal part.
• The vertebral part lies in contact with the sides of the thoracic vertebrae and intervertebral discs
• The mediastinal part is deeply concave, and related to the mediastinal content which causes impressions
on this surface. The hilum, where various structures enter or leave the lung lies on this surface
• The anterior border is thin and overlaps the heart; it is here on the left lung that the cardiac notch is found.
• The posterior border is thick and lies beside the vertebral column.
• Inferior border
Hilum of the lung

• The hilum is the part of the lung on its medial surface which gives passage to
the structures enters or leaves the lung (root of the lung)
• The pulmonary root is formed by a group of structures that enter or leave the
hilum.
• These structures are:
• the principal bronchus, pulmonary artery, two pulmonary veins,
bronchial vessels, a pulmonary autonomic plexus, lymph vessels,
bronchopulmonary lymph nodes and loose connective tissue.
Lobes and fissure

• 3 lobes on the
right and 2 on
the left
• 2 fissures on
the right and 1
in the left
Bronchopulmonary Segments

• The bronchopulmonary segments are the anatomic, functional,

and surgical units of the lungs.
• Each lobar (secondary) bronchus, which passes to a lobe of the
lung, gives off branches called segmental (tertiary) bronchi.
• Each segmental bronchus passes to a structurally and functionally
independent unit of a lung lobe called a bronchopulmonary
segment, which is surrounded by connective tissue.
Blood Supply of the Lungs
lymphatic Drainage of the Lungs
Chest wall tumors

• These are constellation of neoplastic changes involving or

originating from the chest wall structures
Classification
• PRIMARY
• SECONDARY
• METASTATIC
Epidemiology
• Majority metastatic or locally advanced
• Primary account 5% of all thoracic tumors and 1% of all primary
tumors
• 40 -60% of all primary tumors are malignant
• Rib cage is the commonest site of origin
Primary chest wall tumors
Benign soft tissue origin :
• Lipoma
• Fibroma
• Lymphangioma Hemangioma
• Rhabdomyoma
• Neurofibroma Cutaneous nevi
Benign bonny origin :
Fibrous dysplasia
• Chondroma
• Osteochondroma
• Osteoblastoma
• Giant cell tumor
• Aneurysmal bone cyst
Malignant soft tissue origin :
• Soft tissue sarcoma
• Desmoid
• Melanoma
• Squamous cell carcinoma
• Basal cell carcinoma
• Primitive neuroectodermal tumor (PNET)
Malignant bony/ cartilage origin
• Chondrosarcoma
• Osteosarcoma
• Solitary plasmacytoma
• Ewing's sarcoma
C/F

• Slowly growing mass

• Painful
• Fever, leukocytosis ,eosinophilia
Diagnosis
• CXR
• CT-scan
• MRI
• Biopsy
Treatment
Factors :
• Feasibility and completeness of resection
• Feasibility of reconstruction
• Histologic type
• Tumor stage (size)
• Surgical resection and reconstruction  main stay of treatment
• Radiotherapy  neoadjuvant or adjuvant
• Chemotherapy  neoadjuvant or adjuvant
•Empyema thoracis
Out line
• Definition
• Historical background
• Etiology
• Bacteriology
• Classification
• Pathophysiology
• Clinical presentation
• Work up
• Treatment
• Complications
Definition

• Presence of pus in the pleural cavity

• It is not a primary disease
• It is secondary to other underlying diseases
• It is a complication of other diseases
HISTORICAL BACKGROUND

• For centuries, ET has been recognized as a serious problem

• Around 500 BC, Hippocrates recommended treating ET with open
drainage
• In 1876,Hewitt described a method of UWSD
• In early 20th century surgical therapies for ET i.e. thoracoplasty
and decortication were introduced
Begins with introduction of bacteria in the
pleural space
Etiology (Introduction of infection )
EMPYEMA
NON TRAUMATIC TRAUMATIC

THORACIC EXTRATHORACIC
SEPSIS IATROGENIC NON-
SEPSIS IATROGENIC

SUBPHRENIC LUNG
PULMONARY OSTEOMYELI RESECTION,
DISEASE MEDIASTINITIS TIS ABSCESS, OESOPHAGEAL STABBINGS,G
HEPATIC TEARS, UNSHOT
ABSCESS PARACETESIS WOUNDS,ETC
THORACIS,
PNEUMONIA, TB, LIVER BIOPSY
BRONCHIECTASIS STERNUM,
,LUNG ABCESS VERTEBRAE,
RIBS
Bacteriological data

• Streptococcus pneumoniae: 15-20%

–Increased resistance
• Staphylococcus:15-30%
• Streptococcus spp
• Gram Negative: 20-50%
–Klebsiella, Enterobacter, Pseudomonas, Hemophilus, E.Coli
• Anaerobes: –Fusobacterium, Bacteroides fragilis
Influence of predisposing factors

• In adults – empyema arises as a complication of CAP,often

pneumococcal.
• Frank aspiration – anaerobes.
• Aerobic gram negative bacilli infection likely to affect pleura – from
below diaphragm or as a result of oesophageal instrumentation.
• Mycobacteria and fungi more common in immunocompromised.
Uncommon microbial causes

• Tuberculous ??????
• Fungal – Aspergillous,Cryptococcus,Blastomyces, Histoplasmosis.
• Actinomyces – aerobic gram negative filamentous bacteria.
• Clostridia – anaerobic organism.
• Hydatid disease – Echinococcus.
• Lung fluke – Paragonimus westermani.
• Protozoa – Trichomonas,Entamoeba histolytica.
CLASSIFICATIONS

• Anatomical classification
• Clinical classification
• Pathological classification
Anatomical classification
Total thoracic empyema – The whole pleural cavity is involved
Localized or encysted thoracic empyema – Only part of the thoracic cavity is
involved
Clinical classification
Acute thoracic empyema – In which there is profound toxemia and shock –
Patient presents with high grade fever, cough with pleuritic chest pain and
shallow breathing
Sub-acute thoracic empyema – This is less severe form of presentation in
patients who was on antibiotics for pneumonia
Chronic thoracic empyema – This usually results from mismanagement of the
acute form
Pathological classification
• Exudative (early) empyema
• Fibrino-purulent (established) empyema
• Organizing empyema
Acute (exudative) stage: Approximately in 7 days.
• Infected by pathogenic organism, pleural membranes becomes
edematous and produce exudation of proteinaceous fluid that starts
to fill the pleural cavity.
• Pleura fills with thin serous fluid that shows relatively low white
cell count.
• Visceral pleura and underlying lung remains mobile.
Transitional (Fibrinopurulent) stage: From day 7 to 21 day.
• If infection proceeds unchecked by antimicrobials.
• Thick, Opaque fluid with positive culture (pus) and Deposition of
thin fibrin layer over the pleura.(mainly parietal pleura).
• Empyema fluid now becomes more thicker and turbid.
• Higher white cell count.
• Lung movements in this later stages become increasingly
restricted.
• Progressive loculation and formation of pouches in the pleura.
Stage of vascularization:
• Fibrinous layers starts to organize as collagen.
• Becomes vascularized by ingrowth of capillaries.
Organizing (chronic) Stage: after 21 days.
• Usually 4-6 weeks.
• Empyema cavity becomes surrounded by a cortex.
• Contains frank pus.
• Inner layers shows inflammatory cells.
• Outer layers gets fibrous – exerts restrictive effect.
• Compressing the underlying lung (trapped lung effect).
• Draws the ribs together producing chest deformity.
• Later on gets calcified – fibrothorax.
Symptoms & signs
• Depends on nature of infecting organism and competence of patients immune system.
• Ranges from complete absence of symptoms to a severe illness with all usual manifestations
of systemic toxicity.
• Fever
• Cough & Expectoration.
• Pleuretic chest pain.
• Dyspnoea
• Easy fatiguability.
• Loss of weight.
• Night sweating.
• Finger clubbing.
• Signs of pleural effusion.
• Empyema necessitants
Diagnosis and work up

• LRTI – possibility of complicating empyema.

• History and physical findings may be suggestive.
• CXR,USG,CT.
• Thoracentesis- PH < 7.4
Glucose <40 mg/dl
LDH> 1000 iu/dl
Protein > 2.5 gm/dl
Sp.gravity >1.018
• Other findings (non specific):neutrophil leucocytosis and hypoalbuminaemia.
Chest x ray
• In early stages same as uncomplicated pleural effusion.
• As time passes, fibrosis develops around empyema cavity.
• Fluid contained in one location.
• Homogenous shadow extending upwards
Other findings on cxr
• Air fluid level – pneumothorax,BPF,Iatrogenic, gas forming organisms such
as clostridia.
• Underlying pulmonary shadowing -: delayed resolution of pneumonia,lung
abcess,tumours of lung,mediastinum,pleura.
• Hydatid cyst,partial lung collapse.
• USG – pockets of fluid.
• CT thorax – similarly helpful,inflamatory lymphadenopathy
Management

Goals of the treatment

• Treat the infection.
• Drain the purulent effusion adequately and completely.
• Re-expand the lung to fill the pleural space.
• Eliminate complications and avoid chronicity.
Anti microbial therapy
• Dependent on identification of causative organism (C/S)
• Appropriate therapy requires isolation of organism from blood, pleural
fluid or sputum Empiric therapy should be based on local epidemiology
and should cover S. pneumonia, S. pyogenes and S. aureus
• Treatment with medication involves intravenously administering a two-
week course of antibiotics.
• It is important to give antibiotics as soon as possible to prevent first-stage
empyema from processing to its later stage.
• The antibiotics most commonly used are penicillin and vancomycin
Drainage options
• Thoracintesis
• Chest tube insertion with or with out fibrinolysis therapy
• Open drainage procedures ( eloissors flap )
• VATS
• Thoracotomy with decortication , resection , thoracoplasty
Thoracocenthesis
• Big caliber needle.
• Repeated aspiration is carried out.
• Use of Abrams punch biopsy needle is useful initially. Wide caliber allow easy
aspiration and also permits pleural biopsy.
• Mostly diagnosis technique
• Therapeutically used if the liquid remains fluid
• Helps in pleural lavage also.
Chest Tube
• Closed tube thoracostomy.
• As soon as the fluid is thick.
• Localization
if loculated: Chest imaging using ultrasonography and/or computed
tomography
• Size: 20 - 28 F
• Passed under USG guidance,helps in breaking fibrinous septa and pus
rapidly gets removed
• Bedside
Fibrinolytics
• Intrapleural Streptokinase;
Indications
• Acute or fibrino purulent stage
• Presence of loculations.
• Incomplete drainage after tube insertion
Contraindications:
• Chronic stage
• Post-operative empyema
• Empyema with BPF.
Decortication
• Elective surgical procedure.
• Unsuitable for patients who are ill and toxic.
• Fibrous wall of the empyema cavity, reffered to as cortex is exposed at thoracotomy is stripped
off and adjacent visceral and parietal pleura may be left intact.
• Indications
Closed drainage/thoracoscopic methods have been unsuccessful.
Patients who has entered a chronic phase in which underlying lung does not expand because of
failure of cortex to become reabsorbed.

• There is no optimal time for decortication.

• Some surgeons arguing for early intervention and others opting for a conservative approach.
Other causes of empyema
• Tuberculous empyema
• Aspergillus empyema