Pulmonary abscess

By Atiq ur Rahman
Roll no 21
Dpt B 12
Reference book :bailys love short surgery pg 937
 Pulmonary absces

 Lung abscess is a type of liquefactive necrosis of the lung

tissue and formation of cavities (more than 2 cm)containing
necrotic debris or fluid caused by microbial infection.
Pulmonary Abscess on Ct- Scan
Chest x-ray
 the key radiological difference lies in the appearance and characteristics: a fungal ball tends to be a
solid, rounded mass within a cavity, while a cavity with fluid (like a lung abscess) shows a space
containing both fluid and air, often with a visible fluid level. This distinction can help radiologists
and clinicians in diagnosing and differentiating between these conditions based on imaging
findings.
 Management

 Most acute abscesses resolve with appropriate

 antibiotic therapy and postural drainage. Surgery is avoided.
 Small radiologically sited drains are used sometimes in the ICU
CT-guided transthoracic needle aspirate
 Antibiotic therapy is given on the basis of aspirate examination
 Anti bacterial, antifungal etc
 The treatment is divided according to the type of abscess, acute or chronic. For acute cases
the treatment is
 antibiotics:
 if anaerobic: metronidazole or clindamycin
 if aerobic: beta-lactams, cephalosporins
 if MRSA or Staphylococcus infection: vancomycin or linezolid
Postural drainage
Bronchoscopy
In case of extreme hemoptysis
 Pulmonary Cysts

 A pulmonary cyst is a round air space defined pathologically by an epithelial or

fibrous outer wall.

 Instead of fluid, they usually contain gas. They can affect breathing. They often
develop as a person ages but may also indicate an underlying medical
condition.
 Bullae: Large air spaces in the lungs exceeding 1 cm in diameter, often resulting from lung tissue destruction,
commonly associated with conditions like emphysema.
 Conservative Management: Small, asymptomatic bullae might not require active intervention. Monitoring and
managing underlying conditions, such as treating chronic obstructive pulmonary disease (COPD) or emphysema,
can help prevent bullae progression.
 Surgical Intervention: Large or symptomatic bullae that cause breathing difficulties might necessitate surgical
treatment, such as bullectomy (surgical removal of bullae) or lung volume reduction surgery to improve lung
function and alleviate symptom
 Management of Cysts

 Observation: Small, asymptomatic pulmonary cysts might not require immediate treatment.
Regular monitoring through imaging studies is often recommended to assess any changes in size or
symptoms.
 Treatment for Symptomatic or Complicated Cysts: Symptomatic cysts or those causing
complications might require intervention. Treatments could involve surgical removal, drainage
(percutaneous aspiration), or other minimally invasive procedures to alleviate symptoms or reduce
the risk of complications.
 Pulmonary Hydatid Cysts: Parasitic Lung Infections

 Pulmonary hydatid cysts, caused by Echinococcus granulosus, form fluid-filled

structures in the lungs.
 Symptoms vary but often include coughing, chest pain, and difficulty breathing.
 Diagnosis involves imaging and serological tests.
 Surgical removal is the primary treatment, but complications like cyst rupture can occur.
 Prevention focuses on avoiding contact with infected animals and promoting hygiene.
Pulmonary hydated Cyst
No Questions

Thank you
MEDIASTINUM
MAHNOOR HAFEEZ
ROLL NO 34
Reference book: bailey s short surgery practice book pg 935
INTRODUCTION
 Central area in the chest between the thoracic inlet and the diaphragm, between the right and
left pleural surfaces, and which extends from the inner aspect of the sternum to the vertebral
column.
 It contains the heart, great vessels, trachea and oesophagus.
 Subdivided into compartments (superior, inferior, anterior, middle and posterior).
 Many of the regional lymph node chains draining the chest and its organs are also found in
the mediastinum.
SURGICAL PROCEDURES
 The surgical approach when mediastinal tumors require resection depends on the anatomical
location of the tumor.
 It includes ;
 Median sternotomy for anterior mediastinal pathology
 VATS for posterior mediastinal pathology
 Transcervical (neck incisions) for superior mediastinal pathology
MEDIASTINAL MASSES
PRIMARY TUMORS OF MEDIASTINUM
1. THYMOMA
 Most common mediastinal tumor , accounting for 25% of total.
 Derived from the thymus gland.
 Thymomas vary in behaviour from benign to aggressively invasive.
 They are often related to mysthemia gravis (MG), a neuromuscular condition which can
have a high associated incidence of thymomas.
 The only reliable indicator of malignancy is capsular invasion.
 Diagnosis and treatment are best achieved by complete thymectomy, which is usually
performed as a median sternotomy.
 However, if the thymoma is small or when the patient has MG and the thymus is being
excised as a treatment, a transcervical approach with or without an additional VATS
procedure can be performed.
2. GIANT CELL TUMOR
 The anterior mediastinum is the most common site of extragonadal germ cell tumors.
 They account for 13% of all mediastinal masses and cysts and contain elements from all
three cell types (mesoderm, endoderm and ectoderm).
 They tend to present in young adults and 75% are benign and cystic.
 They may cause compression of neighbouring structures.
 Malignancy is suspected if elevated levels of serum alpha-fetoprotein, human chorionic
gonadotrophin and carcinoembryonic antigen are detected.
 After initial treatment with chemotherapy a persistent mass on CT may be considered for
surgical resection.
 If tumor markers fail to normalize, further chemotherapy is usually offered.
3. LYMPHOMA
 Lymphoma is a common in the anterior mediastinum.
 Can lead to superior vena cava obstruction or other symptoms of local compression.
 The main treatment is chemotherapy.
 Surgery is rarely required.
4. MESENCHYMAL TUMORS
 Lipomas are common in the anterior mediastinum.
 Other mesenchymal tumors are very rare.
5. THYROID
 Ectopic thyroid (and parathyroid) tissue may be found in the anterior mediastinum but
usually the mass is an extension of a thyroid lesion (retrosternal goiter).
 Excision of retrosternal thyroids may be required if there is local airway compression and
stridor.
 Can be performed via a transcervical incision, but occasionally median sternotomy may be
required.
6. NEUROGENIC TUMORS
 These may derive from the sympathetic nervous system or the peripheral nerves and are
more prevalent in the posterior mediastinum.
 They may be painful but are more often discovered accidentally on routine chest radiography
and can be quite large.
 It includes ; Neuroblastoma in childhood
 Schwannomas and neurofibromas in adults, which are usually benign.
 Phaeochromocytoma arises from the sympathetic chain and produces the characteristic
endocrine syndrome.
 Excision is generally recommended, particularly if the patient is developing symptoms.
 This can be performed through a thoracotomy, though for smaller tumors a VATS approach
can be used.
7. ENLARGED MEDIASTINAL LYMPH NODES
 Commonly involved by metastatic tumor, mimicking a primary mediastinal lesion.
 Symptoms are generally secondary to compression.
 Surgery such as mediastinoscopy is reserved for diagnosis only.
PROBLEMS RELATED
TO DIAPHRAGM
Aisha bibi
Roll no 02
 DISORDERS OF THE DIAPHRAGM
• Diaphragm is the Fibromuscular structure Separating the thorax from the abdomen.
• Disorders of the diaphragm can be broadly classified as disorders of innervation i.e Tumor
that compresses the phrenic nerve,Surgical trauma, Spinal cord injury to the phrenic nerve,
Neuromuscular disorders
• All the above conditions lead to the paralysis of diaphragm with elevation and reduction of
thoracic volume which further leads to the breathlessness.
• Disorders of the diaphragm further catagorised into congenital diaphragmatic hernias or
acquired hernias secondary to trauma.
• Two well recognised Congenital sites Where abdomianl viscera can herniate into the chest.
 MORGAGNI’S HERNIA:

• A hernia in the anterior part of the diaphragm with a

defect between the sternal and coastal attachments.
• A hernia in this area Occurs when there is a defect
In the diaphragm i.e foramen of morgagni, allowing
abdominal organs to protrude into the thoracic cavity.
• The transverse colon is often the organ most commonly
Involved in such hernias through the foramen of morgagni.
BOCHDALEk’s HERNIAS:
• Bochdalek’s hernia is a developmental defect
In the posteriolateral diaphragm allowing herniation of
Abdominal contents into the thorax causing mechanical
Compression of developing lung paranchyma.
• Also known as pleuroperitoneal hernias.
• It is the most common type of congenital diaghramatic
Hernias.
MANAGEMENT
• Surgical repair for both types is the only curative option.
• Repairs can be done either laparoscopically or open, depending on both hernia and patient
factors
• Intra-operatively, once the hernia is reduced and any hernia sac resected, the defect can be
closed either through primary closure or with a mesh (depending on the defect location and
size) via a thoracotomy.
Reference:
https://emedicodiary.com/book/view/242/bailey-and-love-s-short-practice-of-surgery
Page 938
Pulmonary embolism
By Ayesha bibi Roll no 9
Page # 525
Clinical surgery book
Venous thromboembolism
• Venous thromboembolism is a term used to describe both deep venous thrombosis (DVT)
and pulmonary embolism (PE) caused by thrombus Formation.
Introduction
• A pulmonary embolism is a sudden blockage in your
pulmonary arteries, the blood vessels that send blood to
your lungs. It usually happens when a blood clot in the deep
veins in your leg breaks off and travels to your lungs.
• A blood clot that travels to another part of your body is
called an embolus.When a pulmonary embolus blocks blood
flow to your lungs, it's called a pulmonary embolism.
• . Pulmonary embolism is the most serious complication of venous
Thrombosis.Approximately 1in 5 patients of DVT will develop
pulmonary embolism
Pathophysiology
The lower limb is the source of embolus in 85% of patients; in 10% the embolus arises in the
right atrium, while in the remaining 5% it arises in the pelvic veins andvena cava.
Thrombi that become detached from their site
of origin migrate through the great veins, through the chambers of the right heart and lodge in
the pulmonary arteries.
• Thus a large embolus which blocks the major pulmonary arteries interrupts the circulation
and causes death.
• Smaller emboli interrupt the circulation to isolated areas of lung tissue and produce infarction
of those areas.
Symptoms

Coughing produce a cough that produce a blood

mucus
 Dizziness
 Leg pain Or swelling
 Sharp and sudden chest pain
 Shortness of breath that Worsen with exertion
 Heart palpitations
• Investigations
• The EGG and chest X-ray may provide useful
pointers to
• the diagnosis of pulmonary embolism.
Ventilation perfusion (V/Q)lung scan
• Ventilation-perfusion scanning is an isotope study
designed to identify ventilation-perfusion mismatch in
lung tissue.
In the normal lung the perfusion pattern should match the ventilation pattern
exactly.
• Two isotopes are used.
• Technetium-labelled microspheres or macroaggregates are injected
intravenously into the patient and its distribution throughout the lung detected
by a gamma-camera.
• As there is no circulation through the area of lung tissue blocked by a
pulmonary embolus, no radioactivity will be emitted from that area and it will
appear as a filling defect on the perfusion scan
• The patient then inhales a radioactive gas (krypton, Xenon) or aerosol and
• its distributionthroughout the airways is again detected by a gammacamera.
Pulmonary angiography

• Pulmonary angiography provides the most effective

means of diagnosing pulmonary embolism.
I
• Pulmonary arteriography is achieved by inserting a catheter
through the right heart into the pulmonary artery and injecting
contrast directly into the pulmonary circulation ( Pressure
measurements in the pulmonary circulation can
be obtained simultaneously and haemodynamic monitoring
established.
Management

Anticoagulation

• The majority of patients with pulmonary

embolism are treated with anticoagulation
therapy alone.

• Uncomplicated Pulmonary emboli may be

safely treated with Subcutaneous low
molecular weight haparin administered Once or
twice daily.
• Warfarin therapy is continued for 6 months but
in patients who have idiopathic pulmonary
embolism or those who suffer recurrent
pulmonary embolism lifelong anticoagulation is
indicated.
Thrombolytic therapy

• Thrombolytic therapy results in greater

improvement and normalization of the
haemodynamic responses to pulmonary emboli
than heparin alone.
• Streptokinase, urokinase and t-PA are the three
agents used for thrombolysis. Allergic reactions
may occur with Streptokinase .
• Contraindications
• Active internal bleeding ,,Peptic ulcers ,recent child
birth, pregnancy,Malignant hypertension and Recent
brain eye or spinal cord injury .
Pulmonary embolictomy

• Attempts to remove pulmonary emboli by thoracotomy

and direct operation on the pulmonary arteries with or
without bypass, are associated with a high mortality
from uncontrollable pulmonary parenchymal
haemorrhage.
• More recently, pulmonary emboli have been aspirated
from the pulmonary arteries using a special steerable
cup catheter introduced via the femoral vein and
steered through the right heart into the pulmonary
artery.
• The embolus is suctioned into the cup and the whole
apparatus is withdrawn through the femoral venotomy.