.أ
م
.
د
.
احمد
عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
1
HEMOTHORAX
Objective :
To show the definition, causes and management of h
h
he
e
em
m
mo
o
ot
t
th
h
ho
o
or
r
ra
a
ax
x
x
&
&
&
c
c
ch
h
hy
y
yl
l
lo
o
ot
t
th
h
ho
o
or
r
ra
a
ax
x
x
Definition
Hemothorax is an accumulation of blood in the pleural cavities.
Causes
I.
Traumatic: to the chest wall, the lung, the mediastinal structures, or the
diaphragm (blunt or penetrating).
II.
Iatrogenic (following thoracic surgery due to slipped ligature or inadvertent
attempted central venous cannulation).
III.
Spontaneous: It is due to:
1. Pulmonary:
1) Pneumothorax with torn adhesions.
2) Pulmonary embolism with infarction
3) Arterio-venous malformation
2. Pleura:
1) Torn pleural adhesions
2) Endometriosis
3. Neoplasm:
1) Primary neoplasms in the lung or pleura.
2) Metastatic
4. Blood dyscrasia:
5. Abdominal pathology:
1) Hemoperitoneum.
6. Thoracic pathology → ruptured thoracic aortic aneurysm
Treatment of hemothorax
If the hemothorax is small (that produces just obliteration of the costophrenic angle
on the chest x-ray and bleeding has ceased, only observation is required.
For moderate amounts of estimated blood accumulation (500 ml. or more), a closed
thoracostomy with intercostal tube drainage for complete evacuation of blood
allows observation of its reaccumulation plus re-expansion of the lung .
If there is associated pneumothorax then tube thoracostomy is indicated.
.أ
م
.
د
.
احمد
عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
2
Initial blood collection of 1500ml or more or a rate of bleeding of(100-200)ml/hour
for(2-4)hours due to penetrating or blunt trauma of the chest mandates
thoracotomy to control the source of bleeding .
CHYLOTHORAX
It's the presence of chyle in the pleural cavity.
Etiology
Congenital
- Atresia of thoracic duct
- Thoracic duct-pleural space fistula
Traumatic
- Blunt
- Penetrating
Iatrogenic
- Surgery
Cervical
Excision of lymph nodes
Radical neck dissection
Thoracic
Patent ductus arterioses
Coarctation of the aorta
Esophagectomy
Sympathectomy
Resection of thoracic aneurysm
Resection of mediastinal tumors
Left Pneumonectomy or lobectomy
- Diagnostic procedures
Subclavian vein catheterization
Neoplasms
- Lymphoma
-
Metastatic carcinomas
Infections
- Tuberculous lymphadenitis
- Filariasis
Miscellaneous
- Venous thrombosis
Subclavian - jugular vein
Superior vena cava
.أ
م
.
د
.
احمد
عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
3
Diagnosis
- Pleural fluid analysis
If lymphocyte count and triglyceride level is greater than 110mg/100ml with absent
cholesterol crystals, a chylothorax is almost certainly present.
- Lymphangiography
Treatment
Conservative treatment
- Decrease chyle production, is achieved by eliminating oral intake, while the patient is
supported by total parenteral nutrition. Drainage of the pleural cavity by intercostal
tube drainage must be adequate to allow complete lung expansion.
- Somatostatin may be used with variable results.
Surgical treatment
Indication
1. If conservative treatment fails after 2 weeks .
2. Significant chyle drainage (more than 1500 ml per day or more than 100ml/kg/day) .
3. Trapped lung syndrome
4. Suspicion of malignancy
5. Multiple loculated fluid collections.
The surgical options (Thoracotomy or VATS) :-
- Ligation of the thoracic duct or mass ligation of tissues at the diaphragmatic
hiatus
If the patient has right or bilateral chylothorax, the right side is approached. If there is
left chylothorax, then left thoracotomy is done . The operation may be accompanied by
mechanical pleurodesis and/or decortication of entrapped lung .
-
Direct repair of the duct injury
The operation may also be accompanied by mechanical pleurodesis and/or decortication
of entrapped lung .
Other options are :-
Pleuroperitoneal shunt
Radiation and/or chemotherapy
Percutaneous transabdominal duct catheterization and embolization