For developmental defects, see pediatric surgery.

Pneumothorax

There is air entering pleural space in pneumothorax (PNO). It leads to pressure equalization between pleural cavity and external environment and to lung collapse. Etiology may be either traumatic or spontaneous or iatrogenic. The trauma can be penetrating (stab wound, gunshot wound) or blunt (rib fractures, parenchymal tear). In spontaneous PNO, air enters pleural space from a ruptured bulla or emphysema. Primary spontaneous PNO arises from healthy parenchyma, typically in young, tall men. Secondary spontaneous PNO occurs in already diseased lung (COPD, sarcoidosis, pneumonia). Iatrogenic PNO is produced during central venous canulation or pleural fluid puncture.

Pathophysiological division of PNO is as follows: In closed PNO, there is no air communication between pleural and external spaces, the air entering either from the lung or from a penetrating wound, which seals well. In open PNO, there is air flow through the injury and subsequent mediastinal flailing and corrupted ventilation mechanics occurs, if the square area of the communication is large enough. Tension or valve PNO is produced by on-way air entry into the pleural space. Progressive rise of intrapleural pressure occurs. Ipsilateral lung collapse is followed by contralateral mediastinal shift, superior and inferior vena cava compression, decreased venous return and acute circulatory failure. Morphological description includes complete PNO (complete lung collapse) and partial PNO (with part of the lung fixed with adhesions to the chest wall).

PNO clinically presents as dyspnea, hypoxia, chest pain, diminished or absent breathing sounds, hyperresonant percussion. In tension PNO, hemodynamic compromise with hypotension, tachycardia, paleness and loss of consciousness may be present. Plain chest x-ray is performed. If unclear, CT scan provides detailed information. PNO is managed with chest tube insertion. Very small pneumothorax (less than 3cm) may be observed only with serial imaging.

Hemothorax

It is characterized by the presence of blood in the pleural cavity. Etiology is traumatic (rib fractures, injuries to the lung parenchyma, heart, large vessels, chest wall vessels) or iatrogenic (postoperative bleeding, after CSF puncture, chest drainage or lung biopsy). Depending on the volume, it can be small (<500 ml), medium sized (500-1500 ml) or large (>1500 ml). Standard history is taken. On clinical exam, dyspnea, signs of hemorrhagic shock, hypotension, tachyarrhythmias, pallor and even impaired consciousness are present. On the chest, there are auscultatory findings of diminished breathing, percussion dullness, decreased to absent phremitus pectoralis. Two projection chest x-ray and ultrasound are used as first line imaging methods to determine the amount of pleural fluid. Contrast enhanced CT scan is more accurate in determining the quantity and distribution of blood and possibly showing the etiology. Pleural punction can further verify hemothorax, if unclear on imaging studies. For small hemothorax, observation alone is warranted. For larger hemothorax, relieving pleural punction or large bore chest tube insertion with suction is used. Blood products are administered according to laboratory values and transfusion principles. Surgical treatment is indicated according to the patient's condition and the chest tube output (watch out for clot blockage!!!). Several rules can be followed: 1. One-time discharge of 1000-1500ml of blood and hemodynamical compromise present; 2. Output greater than 300 ml/h in the following 3 hours; 3. Output greater than 200 ml/h in the following 5 hours. Stable patients may benefit from initial miniinvasive approach (VATS), but thoracotomy in the unstable is urgently performed. During the operation, the source of the bleeding is found and adequately treated, all blood and blood clots are cleared to prevent adhesions formation and empyema.

Chest empyema

It is characterized by the presence of pus or infected effusion in the pleural cavity. It most often arises in pneumonias, as parapneumonic empyema. It may also arise in lung abscess, bronchial obstruction (e.g. bronchogenic carcinoma), after TB, in pneumothorax with persistent bronchopleural fistula, after penetrating trauma to the chest, as secondarily infected hemothorax, after esophageal perforation, in the presence of subphrenic abscess, osteomyelitis, pleuritis, cholecystitis, after thoracic surgery, or hematogenously. The bacteria involved are usually Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella pneumoniae, Haemophilus influensae, Bacteroides, Peptostreptococcus.

It develops in three stages: I. acute, exudative stage, days 2-5, sometimes only 48 hours, the effusion is clear or slightly turbid, the lung is free, capable to re-expand, culture tends to be negative. Biochemically, leukocyte level in the exudate is low, LDH, pH and glucose are normal. Transitional II. fibropurulent stage, day 5-10, effusion thickens, fibrin is deposited on the pleura, forming a membrane that encapsulates the effusion and thus fixes the lung and prevents re-expansion. Effusion polymorphonuclear count increases, pH <7.2, glucose <60 mg/dl, LDH increases, culture may be positive or negative. III. chronic, organized stage, forms after 2-4 weeks, empyema sac forms rigid membrane, thick purulent effusion, trapped lung, unable to re-expand.

Diagnostic process starts with taking a history. On clinical examination, fever, tachypnea, tachycardia, weakened phremitus pectoralis and weakened breathing sounds are found. The signs of sepsis may be present. Laboratory markers of inflammation are increased, and X-ray, ultrasound and CT with contrast are performed. Thoracocentesis with collection of effusion for culture and biochemistry may follow. Treatment consists of remediation of the infection with antibiotics and drainage. Conventional chest drainage is indicated as the first step. If the empyema is at an early stage, it can be cured. With a longer-standing empyema, septa are already forming and fibrothorax is present. Therefore, drainage becomes difficult and complete evacuation is impossible and subsequent re-expansion of the lung does not occur. Large bore chest tubes are used (26-32 Ch). CT guided drainage of the collection can be performed using a pig-tail drain (8-14 Ch). Fibrinolytics (streptokinase, urokinase, rTPA) are sometimes used. Surgical therapy consists of VATS salvage, or thoracotomy with eventual decortication of the lung at the second time. If the entire empyema sac can be removed, the procedure is referred to as empyemectomy. In some cases, thoracoplasty is performed or pleurostoma is established (see figures in the presentation).

Chest drainage

The aim of thoracic drain (also chest tube, intercostal drain, thoracostomy tube, etc.) is to 1) evacuate pathological contents of pleural cavity and 2) restore normal pressure conditions and 3) achieve re-expansion of the lung.

Chest drainage may be active or passive. Water seal system like Bülau drainage is an example of passive drainage. Intrapleural pressure rises during expiration and air or fluid is expelled to the drainage system (e.g. one bottle) through water (water level 2 cm). During inspiration, negative pressure sucks water several centimeters up the tube, but air is prevented from entering. Caution! The drainage system must be placed below the level of the patient. Otherwise, fluid could be sucked into the pleural cavity. However, as the level of fluid collected in the bottle increases, resistance raises and drainage may become ineffective. Therefore, chest drainage must be managed by qualified personnel.

Heimlich valve is another passive drainage device. It acts as a one-way valve. It allows air and fluid to escape from the pleural cavity, but on inspiration the valve collapses and does not allow air nor fluid to re-enter. The valve is connected to the drain on one side and to the collecting bag on the other side.

Active drainage is used whenever passive drainage system does not achieve lung re-expansion. The system contains 2 or 3 bottles. The first bottle is the collecting bottle, the second bottle is a 2 cm water lock, and the third bottle regulates the maximum negative pressure by the water column (usually 15 cm). The suction force is determined by the difference between the two water levels. From the third bottle, one tube exits to the atmosphere, another is connected to the vacuum source (central suction, suction pump). The vacuum is set between 10 and 20 cmH2O (most often 12 or 15). With a three-bottle system, there is a greater risk of air entering the pleural cavity if the system is disconnected before the second bottle. In a two-bottle system, the first collection bottle is missing and the secretion from the second bottle must be drained regularly.

There are commercially manufactured sets where the three-bottle system is built into a plastic box. Electronic drainage system is the most modern alternative. It consists of a collection vessel, a manometer and a suction source. The display shows the vacuum value (-8 cmH2O represents “passive” water seal), air leak in ml/min, the amount of secretion evacuated and graphical trends over selected periods of time. Another advantage is the small size which does not hinder patients from verticalization and early rehabilitation. An alarm is also included to alert of any errors.

Absolute indications for thoracic drainage include tension pneumothorax, bilateral pneumothorax, pneumothorax in ventilated patient (the patient must be disconnected from the ventilator during drain insertion), recurrent and persistent pneumothorax, empyema, hemothorax, traumatic and postoperative chylothorax, and symptomatic effusions.

Relative indications for thoracic drainage may include non-traumatic and idiopathic chylothorax, recurrent malignant effusion, and bulky effusion of cardiac etiology if pleurodesis is planned.

There are only relative contraindications depending on the drainage indication, most commonly coagulopathy, chest wall inflammation.

Chest tube insertion

We recommend the blunt dissection technique, which is safer than the trocar technique. The site for drain insertion is chosen either in the second intercostal space in the medioclavicular line (Monaldi) or better in the fifth intercostal space in a safe triangle at the level of the mammilla behind the pectoralis muscle (Bülau). Targeted drain insertion in other locations is possible under CT or ultrasound guidance.

The procedure for drain insertion is as follows. The patient is informed and consent is signed. Prepare the equipment and position the patient. Aseptic technique is applied, disinfect and debride the surgical field, apply local anesthesia. Skin incision of about 2 cm (for the finger) is made, blunt dissection proceeds through thoracic wall at the upper edge of the rib. Parietal pleura is also penetrated bluntly with a finger and the nearby pleural cavity is palpated to exclude adhesions. Drain is introduced through the dissected channel and directed to the apex for PNO or to the costo-phrenic angle for effusion. Bent or straight tube of 24-32Ch thickness is used. CAVE! Never insert the tube against resistance, there is a risk of injury to intrathoracic structures! Fluid comes out of the pleural cavity or mist can be seen in the tube, if placed intrapleurally. Finally, the drain needs to be secured with sutures and connected to the drainage system. Chest x-ray is performed 2 hours after the procedure, or even sooner, depending on the patient's condition. We check the tube position and intrathoracic organs. Give analgesics a monitor the patient (oxygen saturation, BP, PR). Drain output of fluid and air is also monitored. Air draining out of the chest is referred to as air-leak. It comes from lung parenchymal tear, broncho-pleural fistula or from improper seal of soft tissue and skin around the tube. Effusions of various nature, blood or lymph may be drained. The fluid is sent for microbiological culture, biochemical examination (to distinguish between exudate and transudate), cytological examination. Depending on differential diagnosis, Mycobacteria may need to be proved (culture, PCR), cytological). We perform a check-up chest x-ray every time the drain is manipulated (e.g. change of suction pressure, tube removal…). Depending on the amount, nature and duration of secretion/air leak, the drain is removed or surgical revision is indicated. In recurrent non-infectious effusions (most often malignant) and with complete lung re-expansion after evacuation, pleurodesis (e.g. talc) can be performed.

Chest wall tumors

They are divided into primary, secondary and direct tumor invasion from the surrounding tissues and organs. There are benign tumors: lipoma, fibroma, chondroma, osteochondroma, neurilemoma. Semimalignant: desmoid. Malignant: malignant mesothelioma of the pleura, osteosarcoma, rhabdomyosarcoma, chondrosarcoma, leiomyosarcoma, liposarcoma, Ewing's sarcoma, neurofibrosarcoma, hemangiosarcoma, lymphoma, plasmocytic myeloma, malignant histiocytoma. Solitary fibrous tumor of the pleura is mostly benign but with malignant potential. Diagnostic methods include clinical examination, CT, MRI, PET/CT. Treatment of these cases is multidisciplinary and should be performed in specialized centers. Therapy is mainly surgical, as these tumors are very often chemo-radio resistant.