Section I. Overview
History of surgical treatment of lung diseases : Starting in the 1930s
Surgical approaches to pulmonary surgery: lung repair, lung biopsy, various types of pneumonectomy, lung transplantation, and various minimally invasive pulmonary procedures with the assistance of thoracoscopy.
Pneumonectomy is the most basic procedure.
Common lung diseases that are suitable for surgical treatment: congenital lung diseases
Infectious lung diseases: lung abscess, bronchiectasis, etc.
Lung tumors: lung cancer, lung sarcoma, etc.
Pulmonary vascular disease: chronic pulmonary embolism, pulmonary arteriovenous fistula
Section 2: Pulmonary alveoli
(a) Concept: Unexplained rupture of alveolar walls fusing with each other, a kind of limited emphysema.
(ii) Etiology.
Inflammatory lesions secondary to small bronchioles
Three pathological types.
Type I: narrow-necked pulmonary blister
Type II: broad-based superficial pulmonary blister
Type III: deep pulmonary herpes with a wide base
(iii) Clinical manifestations and diagnosis
There are no characteristic symptoms, and the diagnosis mainly relies on X-ray film, huge pulmonary herpes should be distinguished from pneumothorax, CT helps to distinguish, large pulmonary herpes can occur spontaneous pneumothorax or hemopneumothorax.
(D) Treatment
1, asymptomatic people can not be operated
2.Large pulmonary blisters need to be removed surgically
3.Patients who have had spontaneous pneumothorax should generally be operated
4.Recurrent pneumothorax and emphysema are feasible for pulmonary decompensation
Section III: Bronchiectasis
I. Etiology
(A) Congenital
1.Large structural defects
2.Ultra-microstructural defects
3.Metabolic defects (a1 antitrypsin deficiency)
(II) Acquired
1.Primary infection
2.Secondary infections of bronchial blockage
(iii) Concomitant disorders of immune disease (autoimmunity, allergy)
(iv) Progression of bronchial expansion itself, recurrent or persistent infections
II. Pathology.
Columnar: cystic, mixed type
Dry branched amplification: wet branched amplification
III. Clinical manifestations, diagnosis.
Recurrent cough, sputum, coughing up blood or hemoptysis, respiratory and pulmonary infections
Bronchography can confirm the diagnosis, and generally requires surgery before imaging
IV. Surgical treatment of bronchiectasis
The following factors need to be considered.
1, the presence or absence of symptoms, the severity of symptoms, the history of recurrent lung infections
2.History of hemoptysis
3.The extent of the lesion
4.Age
5.Comorbidities
6.Systemic condition
7.Living, working and medical conditions
8.Patient’s own and family’s opinion
Treatment includes: 1, antibiotics 2, treatment of comorbidities 3, symptomatic treatment (sputum volume 50 ml) 4, surgical resection or lung transplantation 5, respiratory training, physiotherapy
Indications for surgery.
(1) limited lesion with obvious symptoms
(2) Bilateral lesions: 1 heavy and 1 light for the heavy side
(3) Bilateral limited heavy lesions – staged surgery
(4) Emergency resection of large hemoptysis
(5) Bilateral extensive lesions – lung transplantation
(5) Prognosis: mixed opinions
Section IV. Surgical treatment of pulmonary tuberculosis
(I) Cavitary tuberculosis
1, Anti-tuberculosis primary and re-treatment rules for 18 months, no significant change or increase in cavity.
2, there are obvious clinical symptoms (repeated hemoptysis, infection) drug treatment is ineffective
3.Not excluding cancerous cavity
4.Atypical mycobacterium, highly drug-resistant
(B) Tuberculoma
1, 18 months of regular anti-tuberculosis, sputum positive, hemoptysis
2.Not excluding lung cancer
3, diameter greater than 3cm
(C) Destruction of the lung
(C) destruction of lung after regular anti-tuberculosis treatment, but still have bacillary excretion, hemoptysis, secondary infection
(D) Pulmonary hilar lymphatic tuberculosis
1, regular anti-tuberculosis, lesion enlargement.
2, lesion compression of trachea and bronchus
3.The lesion penetrates the trachea and bronchus
4.No exclusion of mediastinal tumor
(E) Emergency surgery for massive hemoptysis
1.24h>600ml
2.The bleeding site is clear
3.Cardiopulmonary function and general permission
4.Recurrent hemoptysis
(F) Spontaneous pneumothorax surgery
1.Multiple episodes of pneumothorax (more than 2-3 times)
2, closed chest drainage for more than 2 weeks still leaking
3.Liquid pneumothorax with signs of infection
4.Lungs not reopened after hemopneumothorax
5.Pneumothorax side and obvious pulmonary alveoli
6, one side and the opposite side of the pneumothorax should be operated early
Surgical methods.
A pneumonectomy
Indications: Tuberculosis cavity, tuberculosis ball, destroyed lung, tuberculous bronchial stenosis or dilatation, recurrent or persistent hemoptysis
II Thoracoplasty.
Subperiosteal resection of different number of rib segments, so that the part of the chest wall is sunken close to the mediastinum and the lung beneath it is atrophied.
Indications.
Upper lobe cavity with poor general condition of the patient who cannot tolerate pneumonectomy
upper lobe cavity with tuberculosis foci in the middle and lower lobes
Extensive tuberculosis foci on one side, positive sputum, ineffective drug therapy, poor general condition, unable to tolerate total pneumonectomy
Pulmonary tuberculosis combined with abscess chest or bronchopleural fistula, unable to tolerate pneumonectomy
Section V. Lung tumors
Lung cancer
Originates from the bronchial mucosa epithelium. Distribution is more in the right than in the left lung, and more in the upper than in the lower lobe.
Central type of lung cancer, originating from the main bronchus and lobar bronchus, located close to the hilum.
Peripheral lung cancer, lung cancer originating from below the bronchus of the lung segment, located in the peripheral part.
Classification: Squamous cell carcinoma: accounts for 50% of lung cancer, mostly central type. It is more prevalent in elderly men, with varying degrees of differentiation, slow growth rate, and sensitivity to radiation and chemotherapy. It usually metastasizes first via lymphatic metastasis and late hematogenous metastasis.
Adenocarcinoma: Mostly peripheral type. More frequent in women. Slower growth, early hematogenous metastasis and late lymphatic metastasis.
Small cell carcinoma: The least differentiated and most malignant. It is mostly central type lung cancer. It occurs mostly in 35-60 years old, more in men than women. Also known as oat cell carcinoma.
Large cell carcinoma: rare, poor prognosis.
Clinical manifestations
Early stage is often asymptomatic, mostly found during X-ray examination.
Irritating cough: mostly dry cough with no or little sputum. When secondary lung infection occurs, there may be pus sputum
Bloody sputum: mostly blood in sputum or intermittent small amount of hemoptysis, hemoptysis is rare
Different degrees of bronchial obstruction cause chest tightness, croup, shortness of breath, fever and chest pain, etc.
Metastatic symptoms in patients with advanced lung cancer such as severe chest pain, hoarseness, superior vena cava compression syndrome, cervical sympathetic nerve syndrome, diaphragm paralysis, dysphagia, pleural effusion, severe bone pain, headache, pain in liver area, etc.
Non-metastatic systemic symptoms such as osteoarthrosis syndrome, Cushing’s syndrome, myasthenia gravis, etc. due to the production of endocrine substances by the cancer.
Metastasis mode: direct spread, lymphatic metastasis, hematogenous metastasis
Diagnosis
X-ray diagnosis is an important tool for diagnosis. There are various methods including fluoroscopy, plain film, body layer film, CT, bronchography and so on.
In addition to the clearer observation of the shape, density and location of the mass, enlargement of lymph nodes in the hilum and mediastinum, general body layer film can also understand the blockage, stenosis, compression and intra-tubular mass of the larger bronchus (above the lung segment).
CT is superior to plain chest X-ray in understanding the location of lesions, relationship with surrounding organs, small pleural implantation or small amount of effusion, segmental pulmonary atelectasis, mediastinal lymph node enlargement, and small intra-pulmonary metastases, but it also has its limitations.
Other examination methods: sputum cytology
Bronchoscopy
Radionuclide lung scan
Chest dissection
Treatment
Surgical treatment: the treatment of choice for non-small cell carcinoma.
Indications: Stage I and II non-small cell lung cancer diagnosed by various tests
Partial stage III non-small cell lung cancer that can be radically resected if the lesion is confined to one side of the chest cavity
Those who have high clinical suspicion or cannot exclude lung cancer, whose diagnosis cannot be confirmed by various examination methods and whose lesions are estimated to be resectable
Those who have no original indication for surgery and whose lesions have been significantly reduced and whose systemic symptoms have improved after comprehensive treatment should strive for surgical treatment
Contraindications: absolute contraindications: extensive metastasis, severe cardiopulmonary dysfunction, severe hepatic and renal insufficiency
Relative contraindications: widening and fixation of the ramus Recurrent laryngeal nerve or brittle nerve palsy. Pleural effusion, mild or moderate impairment of pulmonary function.
Radiation therapy
Chemotherapy
Traditional Chinese medicine treatment
Immunotherapy
Bronchial adenoma
Adenoma of bronchus mainly originates from bronchial or tracheal mucosa glands. The ratio of females to males is about 2 to 1. Adenomas grow slowly but can infiltrate and expand into adjacent tissues and may have lymph node metastasis or even hematogenous metastasis. Therefore, it should be considered as a low-grade malignant tumor.
Classification Bronchial adenoma can be divided into three types.
1.Bronchial carcinoid tumor 2.Bronchial cystic adenoid carcinoma 3.Mucinous epidermoid carcinoma
Clinical manifestations: Common symptoms are cough, hemoptysis or croup caused by bronchial obstruction, dyspnea, recurrent respiratory infections or pulmonary atelectasis. In cases of bronchial carcinoid tumor, sometimes there are paroxysmal facial flushing, edema, increased bowel movement, diarrhea, palpitation, itchy skin and other carcinoid syndromes.
Diagnosis chest X-ray and chest CT can show the shadow of tumor mass or the sign of bronchial obstruction caused by tumor. However, for smaller tumors confined in the bronchial wall, X-ray may not show the lesion, and CT or MRI examination can help to diagnose. Adenomas grow slowly, and in some cases the diagnosis is not clear until years after the symptoms appear.
Bronchoscopy is an important diagnostic method.
Treatment of bronchial adenoma, if distant metastasis has not yet occurred, should be performed after a clear diagnosis and complete removal of the tumor.
Patients with adenomas whose systemic conditions contraindicate surgery or who have metastases can be treated with radiation therapy or medication.
Benign tumor of lung or bronchus
Benign tumors of the lung or bronchus are relatively rare. The more common ones are malformation tumor, chondrosarcoma, fibroma, smooth muscle tumor, hemangioma and lipoma.
Pulmonary malformation tumor is a benign tumor formed by the disorganized combination of various normal tissues in the bronchial wall, usually mainly cartilage.
The treatment method is wedge resection of the lung. If the location is in the superficial part of the lung and the tumor is small, the tumor can also be removed.
Metastatic tumor of lung
It is quite common for malignant tumors originating from other parts of the body to metastasize to the lung. According to statistics, among the cases of death from malignant tumor, about 20%-30% have lung metastasis. Common primary malignant tumors include gastrointestinal tract, genitourinary system, liver, thyroid, breast, bone, soft tissue, skin carcinoma and sarcoma.
The surgical approach should be based on the choice of pulmonary wedge resection, segmental lung resection, lobectomy or atypical limited pneumonectomy