Post operative chest

POST OPERATIVE CHEST
23-12-2015
Dr.Y. Madhu Madhava Reddy

Introduction
 Intrathoracic surgery is performed most
frequently for resection of all or part of lung,
or for cardiac disease.
 So it is must for a radiologist to have the
knowledge of acute and chronic radiological
appearances of such surgical conditions and
their complications.

Thoracotomy
 Lung resections are usually performed
posterolaterally through the 4th or 5th intercostal
space.
 Part of rib may be resected, the periosteum may
be stripped or ribs may simply be spread apart
following a muscle incision.
 Surgical route is not obviously identified on
Chest X ray, or is marked only by some
narrowing of Intercostal space / overlying soft
tissue swelling and Sub cuteneous emphysema.

Pneumonectomy
 It is important for remaining lung to be fully
expanded following pneumonectomy, and for
mediastinum to remain close to the midline.
 Excessive mediastinal shift may compromise
respiration and venous return to the heart.
 Initial post op CXR, the trachea should be
close to midline, the remaining lung should
appear normal or slightly Plethoric.

 Pneumonectomy space also usually contain
small amount of fluid initially, and this space
begins to obliterate by gradual shift of
mediastinum to that side and accumulation of
fluid.
 If the mediastinum moves towards the opposite
side, this may indicate rapid accumulation of
fluid in pneumonectomy space or atelectasis in
remaining lung.
 A sudden shift may indicate Bronchopleural
fistula.

Following Lobectomy
 Remaining lung should expand to fill space of
resected lobe.
 Immediately Post operatively, pleural drains
are present, preventing accumulation of
pleural fluid, and mediastinum may be
shifted to the side of operation.
 With hyperinflation of the remaining lung the
mediastinum returns to its normal position.

Following Segemental /
Subsegmental resection
 A cut surface of lung is oversewn, and air
leaks are common, sometimes causing
persistent pneumothorax which may require
prolonged drainage.
 Wire sutures or staples may be visible at the
site of bronchial stump or lesser lung
resections.

Complications of Thoracotomy
 Postoperative spaces
 Empeyma
 Bronchopleural fistula
 Pleural fluid
 Diaphragmatic elevation

Postoperative spaces
 These may persist following lobectomy and
segmental or subsegmental resections.
 There are the air spaces that correspond to
the excised lung.
 Fluid may collect in them, they usually
resolve after few weeks or months.
 If they persist, they may cause an empyema
or bronchopleural fistula.

Empyema
 It usually occurs a few weeks after surgery, it
may occur few months or years later.
 Rapid accumulation of fluid may cause
mediastinal shift to normal side.
 If a fistula develops between the
pneumonectomy space and a bronchus or
skin, the air fluid level in the space will
suddenly drop.

Bronchopleural Fistula
 This is communication between bronchial tree or
lung tissue and pleural space.
 The commonest cause of this is a lung surgery.
 It can be resulted from rupture of a lung abscess,
erosion by a lung cancer or penetrating trauma.
 BPF complicating complete or partial lung
resection may occur early, when it is due to
faulty closure of bronchus. But it commonly
occurs late due to infection or tumour of the
bronchial stump.

 Radiographic appearance is sudden
appearance of, or increase in the amount of
air in the pleural space, with a corresponding
decrease in the amount of fluid in the space.
 If fluid enters airways and is aspirated into the
remaining lung, widespread consolidation is
seen.
 Sinography of pleural space or
bronchography may demonstrate the fistula.

Esophagopleural fistula
2 yrs post-op

Esophago-nod-bronchial Fistula

Pleural fluid
 Usually seen on CXR following thoracic
surgery.
 If the amount is excessive it may be due to
bleeding or chylothorax.

Diaphragmatic elevation
 Elevation may indicate phrenic nerve damage
and is best assessed by fluoroscopy or
ultrasound.

Cardiac surgery
 Most of them are performed through a
sternotomy incision and wire sternal sutures
are often seen on postoperative films.
 Following cardiac surgery, some widening of
the cadiovascular silhouette is usual, and
represents bleeding and oedema.
 Marked mediastinal widening suggests
significant haemorrhage.

 Some air remains in pericardium following
cardiac surgery.
 Pulmonary opacities are very common
following open heart surgery, and left basal
shadowing is almost invariable, indicating
atelectasis.
 Small pleural effusions are also common in
immediate post op period.

Haemorrhage following
cardiac transplantation
4hrs postop After chest tube insertion

 Pneumoperitoneum is sometimes seen due
to involvement of peritoneum by sternotomy
incision.
 Violation of left or right pleural space may
lead to chylothorax or more localised
collection, a chylonur.
 Phrenic nerve damage cause paresis or
paralysis of hemidiaphragm.

 Prosthetic heart valves are usually visible of
CXR.
 Surgical clips or other metallic markers have
sometimes been used to mark ends of
coronary artery bypass grafts.

 Sternal dehiscence appears radiographically
as a linear lucency appearing in sternum and
alteration in position of the sternal sutures.
 It may be associated with osteomyelitis.
 Fractures of 1st or 2nd rib occur when the
sternum is spread apart, and they explain the
chest pain in postoperative period.

 Acute mediastinitis can occur as complication
or surgery. It is more commonly associated
with esophageal perforation or surgery.
 Radiographically there will be mediastinal
widening or pneumomediastinum.

 Chronic mediastinal infection – includes
sternal osteomyelitis may occur after median
sternotomy.
 Increasing amounts of gas in mediastinum on
subsequent examination is indicative of the
presence of a gas forming organism.

Infected Mediastinal Collection

 The postpericardotomy syndrome is an
autoimmune phenomenon, usually occuring
in the month after surgery.
 It presents with fever, pleurisy, and
pericarditis.
 Pleural effusions and cardiomegaly may be
present on CXR.
 Ultrasound demonstrate pericardial fluid.
 Patchy consolidation may occur in lung
bases.

Late appearances after chest
surgery
 Resected ribs, healed rib fractures are
frequently seen, there may be irregular
regeneration of rib related to disturbed
periosteum.
 Rearrangement of remaining lung occurs
after lobectomy, causing alteration in
anatomy of fissures.

 Following esophageal surgery, stomach or
loops of bowel may produce unusual soft
tissue opacities or fluid levels if they have
been brought up into chest.

Misc.
 Surgery for Pulmonary tuberculosis is now
rarely performed.
 The objective of surgery was to reduce
aeration to infected lung, usually upper lobe.
 Thoracoplasty is combined with
pneumonectomy for treatment of Chronic
tuberculous empyema.

 Alternative method was, Plombage, which
was the extrapleural insertion of some inert
material to collapse the underlying lung.
 Solid or hollow Incite balls were commonly
used. Other substances incluse crumpled
cellophane packs and paraffin.

Thoracic complications of
General surgery
 Atelectasis
 Pleural effusions
 Pneumothorax
 Aspiration pneumonitis
 Pulmonary edema
 Pneumonia
 Subphrenic abscess
 Pulmonary embolism

Atelectasis
 Commonest after thoracic or abdominal surgery.
 Predisposing factors: long anaesthetic, obesity,
chr. Lung disease and smoking.
 It results form retained secretions and poor
ventilation. Postoperatively it is painful to
breathe deeply or cough.
 CXR findings: elevation of diaphragm due to
poor inspiration. Lower zone opacities
representing subsegmental volume loss and
consolidation (appear at 24hrs- resolve by 2-
3days).

Pleural effusions
 Occur immediately following abdominal
surgery and resolve in 2 weeks.
 May be associated with pulmonary infarction.
 Effusions due to sub phrenic infection usually
occur later.

Pneumothorax
 When it complicates extrathoracic surgery, it
is a complication of positive pressure
ventilation or central venous line insertion.
 It may complicate nephrectomy.

Aspiration pneumonitis
 It is common during anaesthesia but
insignificant.
 When significant, patchy consolidation
appears within a few hours, usually basally or
around the hila.
 Clearing occurs within few days, unless there
is super added infection.

Pulmonary edema
 It be may due to cardiogenic or non-
cardiogenic.
 Non-cardiogenic includes fluid overload and
the adult respiratory distress syndrome.

Pneumonia
 Post op atelectasis and aspiration
pneumonitis may be complicated by
pneumonia.
 They tend to be associated with bilateral
basal shadowing.

Subphrenic abscess
 It produces elevation of hemidiaphragm,
pleural effusion and basal atelectasis.
 Loculated gas may be seen below diaphragm
and fluoroscopy may show splinting of
diaphragm.
 It can be demonstrated by ct or ultrasound.

Pulmonary embolism
 It produces pulmonary shadowing, pleural
effusion or elevation of diaphragm.
 Normal chest radiograph does not exclude
pulmonary embolism.
 So initial investigation is perfusion lung scan.

Patient in ICU
 Patients are shifted to an intensive care unit
post operatively, following major trauma or
circulatory or respiratory failure.
 A number of monitoring and life support
devices are used.
 Radiology plays an important role in
management of these devices.

CVP catheters
 Used to monitor RA pressure.
 One end of CVP line needs to be
intrathoracic, ideally in SVC.
 Subclavian approach for their insertion
carries a risk of pneumothorax and
mediastinal hematoma.
 Catheters have potential risk of coiling,
knotting or fracture leading to embolism.

Swan-Ganz catheters
 Used to measure pulmonary artery and
pulmonary wedge pressures(indicator of LA
pressure).
 Introduced via antecubital vein / jugular vein.
 Inflatable balloon at the tip guides it through
the right heart.
 End of catheter should be maintained 5-8cms
beyond bifurcation of Main pul. artery in
either LA or RA.

 When wedge pressure is measured, balloon is
inflated and flow of blood carries the catheter
tip peripherally, to a wedge position.
 After measurement, balloon is deflated and
catheter returns to a central position,
otherwise there is a risk of pulmonary
infarction.

NG tube
 These may not reach stomach or may coil in
esophagus or occasionally are inserted into
trachea and into right bronchus.

Endotracheal tubes
 Used to access airways for ventilation and
management of secretions, and also protect
airway.
 CXR is essential in assessig position of tip of
ET tube relative to carina.
 Neck extension and flexion make tip of ET
tube move by 5cms.
 With neck in neutral position the tip of ET
tube should ideally be about 5-6cms above
carina.

 Tube that is inserted too far usually passess
into the right bronchus with risk of collapse of
left lung.
 If inflated cuff dilate trachea, there is risk of
ischaemic damage to tracheal mucosa.
 Late complication of over inflatted cuff is
tracheostenosis.

Tracheostomy tubes
 Used for long term ventillatory support.
 Tube tip should be situated centrally in airway
at the level ofT3.
 Acute complications of tracheostomy include
pneumothorax, pneumomediastinum and
sub cuteneous emphysema.
 Long term complications include tracheal
ulceration, stenosis and perforation.

Positive pressure
ventilation
 Complications may include:
 Interstitial emphysema
 Pneumomediastinum
 Pneumothorax
 Sub cuteneous emphysema

Pleural tubes
 Used to treat pleural effusion and
pneumothoraces.
 If patient is being nursed supine, tip of tube
should be placed anteriorly and superiorly for
a pneumothorax and posteriorly and
inferiorly for an effusion.
 A radio opaque line runs along the tubes and
interrupted where there are side holes. It is
important to check all side holes are in
thorax.

Mediastinal drains
 Apart from their position they looks like
pleural tubes.
 These are usually present following
sternotomy.

Intra-aortic balloon pump
 IABP is a long balloon temporary circulatory
device that works on the principle of cardiac
counter pulsation.
 IABP is used to support circulation.
 The balloon, approximately 25cms long, is
mounted on a catheter.
 The catheter tip is visible as a 3x4mm
rectangular metallic density, rest of catheter
is radiolucent.

 Catheter is inserted through femoral artery.
The balloon is inflated with gas during
diastole and deflates during systole, resulting
in increase in coronary blood flow and
reduction in left ventricular afterload( and
hence, reduction in myocardial oxygen
consumption).
 Indications: MI with cardiogenic shock, post
coronary by pass graft, acute mitral
insufficiency and cardiac transplantation.

Pace makers
 Used in cases of severe sinus node
dysfunction, complete heart block and
various arrythmias.
 2 main elements: pulse generator and lead
wire with electrodes.
 Single lead pacemaker is most basic type and
is positioned with its tip in the right
ventricular apex.

 An atrioventricular two lead sequential
pacemaker has one electrode in the right
atrium and other at the right ventricular apex.

 The potential complications are malposition,
intracardiac knotting , fracture, perforation

Transplantations
 Cardio pulmonary transplantations are
uncommon procedures, with only a few
thousand cases undertaken worldwide each
year.
 Heart transplant remains most frequent
procedure.

Heart transplantation
 Basal atelectasis especially in left lower lobe.
 Small effusions
 Haematoma within pleura or mediastinum.
 Chest drains are places during surgery,
pneumothorax and pneumomediastinum are
frequent.
 Pneumoperitoneum is seen in immediate
postop period.

 Pulmonary edema is seen if cardiac function
depresses in post op period.
 Complications related to rejection are usually
manifest by cardiac failure. Rejection may be
acute , within 3 months, or chronic in
subsequent months or years.
 Specific complication of heart transplantation
is accelerated coronary artery disease.
 Long term immune suppression to prevent
rejection- increased risk of lymphoma.

Lung transplant
 Low success rate.
 Single lung transplantation is preferred over
double lung transplantation.
 Radiology plays role in multidisciplinary
approach of donor selection, particularly in
excluding occult contraindications like lung
tumours / infections in opposite lung and
assessment of degree and extent of pleural
abnormality.

Complications
 Acute phase: reperfusion edema due to
prolonged ischemia resulting in increased
capillary permiability.
 Duration and severity of reimplantation
response is reduced by minimising ischaemic
time and careful restriction of postop fluid
replacement.

 Acute rejection: occur after 5th post op day.
 CXR may be normal or may demonstrate
diffuse interstitial edema with pleural
effusion.
 Infections complicate postoperative period.
 Colonisation of upper airway by virulent
hospital flora, impaired clearance of
nasopharyngeal secretions, immune
suppression theraphy, impairment of
mucociliary escalator are factors of infection.

 Anastomotic failures, occasionally vascular
but more frequently bronchial, may result in
dehiscence or stenosis.
 Bronchial dehiscence may cause mediastinal
emphysema, confirmed by CT, by identifying
bronchial wall defect.
 Late rejections commonly manifest as
bronchiolitis obliterans, confirmed by HRCT,
demonstrates variation in attenuation of
parenchyma(air trapping).

Post operative chest

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