FIBROTHORAX AND DECORTICATION OF THE LUNG

GENERAL THORACIC SURGERY

CHAPTER 61

Decortication

• Pelling or stripping a constricting menbrane from the pleural surface.

• Include– 1). Intercostals incision, wide exploration of pleural cavity. 2). Full mobilization of lung. 3). Remove fibrous peel, not the visceral pleura, 4). Suction and drainage. • VATS.

Pathophysiology of fibrothorax

• cause of fibrothorax table 61-1. • pleural fluid undrained, deposits fibrin on visceral and

parietal pleura. • Thin layer of immatured blood vessel and loose collagen

forms. • Organization produce dense avascular collagen matrix

wall of the insulting fluid. • Pulmonary compression, atelectasis. Entrapment of lung, • encasement of thoracic cage produces a restrictive

ventilatory defect.

Diagnosis and evaluation

• Symptom /Sign— Chest tightness, frank pain, dry nonproductive cough, fatigue, malaise.

• PE— Unilateral fixation of chest wall, reduce excursion of isilateral hemidiaphragm, dull to percussion, impaired transmission of breath sound.

Diagnosis and evaluation

• Chest x ray— Obliterate the costophrenic angle, narrow intercostals space, diminished the hemithorax, retraction the mediastinum to the fibrothorax, pleural calcification.

• CT— Assess the underlying pulmonary parenchyma for tuberculosis, bronchiectasis, mass lesion.

Treatment

• Preoperative evaluation—pulmonary function test, ABG.

• Indication and contraindication.• Indication— 1). Symptomatic extraparenchymal restrictive disease. 2). Tube thoracostomy, thoracentesis, thoracoscopy are fail to drain and expand of lung.

Treatment

• Timing— 1). Hemothorax over 6 weeks.

2). More than 50% compression.

3). Apex collapse.

4). In tuberculosis after chronic

antituberculosis therapy.

5). No changes on chest x-ray.

Treatment

• Contraindication—

• Major bronchial obstruction.

• Pulmonary destruction.

• Uncontrol sepsis.

• Chronic debilitation.

• Concomitant organ dysfuction.

Differential diagnosis

• Mesothelioma.

• Malignancy.

• Metastatic pleural disease.

Technique

• Bronchoscope exclude endobronchial lesion. • Posterior lateral thoracotomy. • Resection ribs.• Blunt dissection the parietal peel, plane

between the endothoracic fascia and parietal pleura.

Technique

• Prevent injury of diaphragm and phrenic nerve.• Thicked parietal peel in incised. • Empyectomy with preservation the integrity of

cavity for tuberculosis.• Perioperative antibiotics, material is cultured. • Pulmonary decortication with incision fibrous peel

overlying the visceral pleura. • Chest tube drainage.

Mortality and morbidity

• Mortality and morbidity—0-8%. • Morbidity— Sepsis, wound infection,

empyema, hemorrhage, prolong air-leak, bronchopleural fistula.

• Result— Absence of underlying parenchymal disease is best improve. Phrenic nerve injury, tuberculosis are less improve.