Thoraxheelkunde P. De Leyn
5 hoorcolleges (5x2u)
1 multidisciplinaire les longcarcinoom
4 grote klinieken (1u)
Thoraxwand
Longtransplantatie
Pleurale pathologie
Bronchuscarcinoom
Ex: casussen (MC)
Inhoudsopgave
Aandoeningen pleura, thoraxwand en diafragma .................................................................................... 3
1. Pneumothorax (PT) .................................................................................................................................. 3
PT types ................................................................................................................................................... 4
Spontane secundaire PT – catameniale PT (EX!!) ............................................................................. 8
Casus PT 1 ............................................................................................................................................... 9
Casus PT 2 ............................................................................................................................................. 10
2. Empyeem à ETTER ............................................................................................................................... 11
Casus ..................................................................................................................................................... 14
3. Pleurale tumoren ................................................................................................................................... 15
Goedaardig: Pleurale plaques ............................................................................................................... 15
Goedaardig: Fibreuze pleuratumor (pleuraal fibroom) ........................................................................ 16
Kwaadaardig: Mesothelioom ................................................................................................................ 16
Pleurale metastasen.............................................................................................................................. 18
Casus ..................................................................................................................................................... 18
4. Aangeboren afwijkingen thoraxwand ................................................................................................... 20
Pectus excavatum (trechterborst) ........................................................................................................ 20
Casus ..................................................................................................................................................... 21
Pectus Carinatum (kippeborst) ............................................................................................................. 22
5. Aandoeningen diafragma ...................................................................................................................... 22
Unilaterale diafragmaparalyse .............................................................................................................. 22
Bilaterale diafragmaparalyse ................................................................................................................ 23
Hernia diafragmatica ............................................................................................................................. 23
Neoplasiën van long en mediastinum .................................................................................................... 24
Perifere longtumor – casus ........................................................................................................................ 24
Longtumor met metastase – casus............................................................................................................ 24
Centrale tumor – casus .............................................................................................................................. 24
Klinische presentatie: 2 vormen................................................................................................................. 25
Symptomen op moment diagnose longkanker .......................................................................................... 26
Epidemiologie, symptomen, pathologie & diagnose ................................................................................. 26
Speciale tumor: carcinoïd tumor long........................................................................................................ 26
1
, Carcinoïd tumor – casus ........................................................................................................................ 27
Nieuwe diagnose van longkanker.............................................................................................................. 27
Medische evaluatie .................................................................................................................................... 27
Oncologische evaluatie .............................................................................................................................. 28
Stadiëring longtumor................................................................................................................................. 28
PET-CT – vb............................................................................................................................................ 29
Bot meta op PET – vb. ........................................................................................................................... 29
T(tumor) EX!! ........................................................................................................................................ 29
N (nodes): locoregionale klieren ................................................................................................................ 30
Stadiering mediastinale klieren ............................................................................................................. 30
M (metastasen) ......................................................................................................................................... 31
Behandeling niet-kleincellig longcarcinoom .............................................................................................. 31
Behandeling kleincellig loncarcinoom ....................................................................................................... 34
Heelkundige behandeling .......................................................................................................................... 34
Dubbellumen intubatie ......................................................................................................................... 34
Peridurale catheter ............................................................................................................................... 34
Toegangswegen voor longresectie........................................................................................................ 34
Wigexcisie ............................................................................................................................................. 35
Pneumonectomie .................................................................................................................................. 35
Lobectomie ........................................................................................................................................... 36
Sublobaire resectie: definitie ................................................................................................................ 36
Sleeve lobectomie ................................................................................................................................. 36
Welke resectie voor primaire longtumor? ............................................................................................ 37
Thoraxwand resectie ............................................................................................................................. 37
Postoperatief verloop na longresectie ....................................................................................................... 38
Postoperatieve complicaties ...................................................................................................................... 38
1. Atelectase, mucusimpactie en pneumonie ....................................................................................... 38
2. Ritmestoornissen (VKF) ..................................................................................................................... 39
3. Bronchopleurale fistel (na pneumonectomie) .................................................................................. 39
4. Empyeem (post-pneumonectomie) .................................................................................................. 39
5. Verlengd luchtlek .............................................................................................................................. 40
Resultaten.................................................................................................................................................. 40
Long kanker screening met CT .............................................................................................................. 41
Coin lesion ................................................................................................................................................. 41
Hamartoma (scherp begrensd) ............................................................................................................. 42
Casus 1....................................................................................................................................................... 42
Casus 2....................................................................................................................................................... 44
Casus 3....................................................................................................................................................... 44
Longmetastase .......................................................................................................................................... 45
Longmetastasectomie ............................................................................................................................... 46
Mediastinale tumoren ............................................................................................................................... 46
Thymoma (voorste mediastinum) ......................................................................................................... 48
Lymphoma (voorste en middenste mediastinum) ................................................................................ 48
Kiemceltumoren (voorste mediastinum) .............................................................................................. 49
Cyste...................................................................................................................................................... 49
Casus 1....................................................................................................................................................... 50
2
, Casus 2....................................................................................................................................................... 51
Functieverbeterende longchirurgie ........................................................................................................ 51
Bulla ........................................................................................................................................................... 51
Bullectomie ................................................................................................................................................ 52
Longvolumereductie (LVRS) ....................................................................................................................... 52
Longtransplantatie (LTx)............................................................................................................................ 54
Longtransplantatie types ...................................................................................................................... 54
Longtransplantatie indicaties ................................................................................................................ 54
Longtransplantatie donoren ................................................................................................................. 55
Longpreservatie .................................................................................................................................... 55
Longtransplantatie verwikkelingen ....................................................................................................... 56
Problemen ............................................................................................................................................. 56
Casus ......................................................................................................................................................... 57
Aandoeningen pleura, thoraxwand en diafragma
1. Pneumothorax (klaplong)
2. Empyeem
3. Pleurale tumoren
4. Aangeboren afwijkingen thoraxwand (pectus carinatum/excavatum)
5. Aandoeningen diafragma
1. Pneumothorax (PT)
Lucht tussen longbladen (viscerale en pariëtale pleura)
Symptomen:
- Kortademig
- Pijn bij ademen thv borstkas en tss schouders tgv luchtopstapeling
Tgv
- Traumatische breuk (messteek)
- Niet visibele trauma (auto-ongeval)
Subtotaal of partieel (vb enkel apicaal)
3
, Totale of complete pneumothorax: overal lucht rond long
Figure 1 extreme totale, rechts gecollabeerd longweefsel, rest is lucht
Opgeblazen long à vult de hele thorax
Indien long platgedrukt à zo groot als een vuist
Bep moment overdruk à spanningspneumothorax: druk op hart en contralaterale long =
levensbedreigend
Figure 2 beste opname RX thorax is bij expiratie; bij inspiratie komt de long omhoog (minder goed visibele RX)
PT types
Spontane pneumothorax
Primair 5/100 000 5 m./1 vr. – jong – mager
geen evidentie onderliggende longpathologie
typisch mannen groot gestalte
Secundair
4
5 hoorcolleges (5x2u)
1 multidisciplinaire les longcarcinoom
4 grote klinieken (1u)
Thoraxwand
Longtransplantatie
Pleurale pathologie
Bronchuscarcinoom
Ex: casussen (MC)
Inhoudsopgave
Aandoeningen pleura, thoraxwand en diafragma .................................................................................... 3
1. Pneumothorax (PT) .................................................................................................................................. 3
PT types ................................................................................................................................................... 4
Spontane secundaire PT – catameniale PT (EX!!) ............................................................................. 8
Casus PT 1 ............................................................................................................................................... 9
Casus PT 2 ............................................................................................................................................. 10
2. Empyeem à ETTER ............................................................................................................................... 11
Casus ..................................................................................................................................................... 14
3. Pleurale tumoren ................................................................................................................................... 15
Goedaardig: Pleurale plaques ............................................................................................................... 15
Goedaardig: Fibreuze pleuratumor (pleuraal fibroom) ........................................................................ 16
Kwaadaardig: Mesothelioom ................................................................................................................ 16
Pleurale metastasen.............................................................................................................................. 18
Casus ..................................................................................................................................................... 18
4. Aangeboren afwijkingen thoraxwand ................................................................................................... 20
Pectus excavatum (trechterborst) ........................................................................................................ 20
Casus ..................................................................................................................................................... 21
Pectus Carinatum (kippeborst) ............................................................................................................. 22
5. Aandoeningen diafragma ...................................................................................................................... 22
Unilaterale diafragmaparalyse .............................................................................................................. 22
Bilaterale diafragmaparalyse ................................................................................................................ 23
Hernia diafragmatica ............................................................................................................................. 23
Neoplasiën van long en mediastinum .................................................................................................... 24
Perifere longtumor – casus ........................................................................................................................ 24
Longtumor met metastase – casus............................................................................................................ 24
Centrale tumor – casus .............................................................................................................................. 24
Klinische presentatie: 2 vormen................................................................................................................. 25
Symptomen op moment diagnose longkanker .......................................................................................... 26
Epidemiologie, symptomen, pathologie & diagnose ................................................................................. 26
Speciale tumor: carcinoïd tumor long........................................................................................................ 26
1
, Carcinoïd tumor – casus ........................................................................................................................ 27
Nieuwe diagnose van longkanker.............................................................................................................. 27
Medische evaluatie .................................................................................................................................... 27
Oncologische evaluatie .............................................................................................................................. 28
Stadiëring longtumor................................................................................................................................. 28
PET-CT – vb............................................................................................................................................ 29
Bot meta op PET – vb. ........................................................................................................................... 29
T(tumor) EX!! ........................................................................................................................................ 29
N (nodes): locoregionale klieren ................................................................................................................ 30
Stadiering mediastinale klieren ............................................................................................................. 30
M (metastasen) ......................................................................................................................................... 31
Behandeling niet-kleincellig longcarcinoom .............................................................................................. 31
Behandeling kleincellig loncarcinoom ....................................................................................................... 34
Heelkundige behandeling .......................................................................................................................... 34
Dubbellumen intubatie ......................................................................................................................... 34
Peridurale catheter ............................................................................................................................... 34
Toegangswegen voor longresectie........................................................................................................ 34
Wigexcisie ............................................................................................................................................. 35
Pneumonectomie .................................................................................................................................. 35
Lobectomie ........................................................................................................................................... 36
Sublobaire resectie: definitie ................................................................................................................ 36
Sleeve lobectomie ................................................................................................................................. 36
Welke resectie voor primaire longtumor? ............................................................................................ 37
Thoraxwand resectie ............................................................................................................................. 37
Postoperatief verloop na longresectie ....................................................................................................... 38
Postoperatieve complicaties ...................................................................................................................... 38
1. Atelectase, mucusimpactie en pneumonie ....................................................................................... 38
2. Ritmestoornissen (VKF) ..................................................................................................................... 39
3. Bronchopleurale fistel (na pneumonectomie) .................................................................................. 39
4. Empyeem (post-pneumonectomie) .................................................................................................. 39
5. Verlengd luchtlek .............................................................................................................................. 40
Resultaten.................................................................................................................................................. 40
Long kanker screening met CT .............................................................................................................. 41
Coin lesion ................................................................................................................................................. 41
Hamartoma (scherp begrensd) ............................................................................................................. 42
Casus 1....................................................................................................................................................... 42
Casus 2....................................................................................................................................................... 44
Casus 3....................................................................................................................................................... 44
Longmetastase .......................................................................................................................................... 45
Longmetastasectomie ............................................................................................................................... 46
Mediastinale tumoren ............................................................................................................................... 46
Thymoma (voorste mediastinum) ......................................................................................................... 48
Lymphoma (voorste en middenste mediastinum) ................................................................................ 48
Kiemceltumoren (voorste mediastinum) .............................................................................................. 49
Cyste...................................................................................................................................................... 49
Casus 1....................................................................................................................................................... 50
2
, Casus 2....................................................................................................................................................... 51
Functieverbeterende longchirurgie ........................................................................................................ 51
Bulla ........................................................................................................................................................... 51
Bullectomie ................................................................................................................................................ 52
Longvolumereductie (LVRS) ....................................................................................................................... 52
Longtransplantatie (LTx)............................................................................................................................ 54
Longtransplantatie types ...................................................................................................................... 54
Longtransplantatie indicaties ................................................................................................................ 54
Longtransplantatie donoren ................................................................................................................. 55
Longpreservatie .................................................................................................................................... 55
Longtransplantatie verwikkelingen ....................................................................................................... 56
Problemen ............................................................................................................................................. 56
Casus ......................................................................................................................................................... 57
Aandoeningen pleura, thoraxwand en diafragma
1. Pneumothorax (klaplong)
2. Empyeem
3. Pleurale tumoren
4. Aangeboren afwijkingen thoraxwand (pectus carinatum/excavatum)
5. Aandoeningen diafragma
1. Pneumothorax (PT)
Lucht tussen longbladen (viscerale en pariëtale pleura)
Symptomen:
- Kortademig
- Pijn bij ademen thv borstkas en tss schouders tgv luchtopstapeling
Tgv
- Traumatische breuk (messteek)
- Niet visibele trauma (auto-ongeval)
Subtotaal of partieel (vb enkel apicaal)
3
, Totale of complete pneumothorax: overal lucht rond long
Figure 1 extreme totale, rechts gecollabeerd longweefsel, rest is lucht
Opgeblazen long à vult de hele thorax
Indien long platgedrukt à zo groot als een vuist
Bep moment overdruk à spanningspneumothorax: druk op hart en contralaterale long =
levensbedreigend
Figure 2 beste opname RX thorax is bij expiratie; bij inspiratie komt de long omhoog (minder goed visibele RX)
PT types
Spontane pneumothorax
Primair 5/100 000 5 m./1 vr. – jong – mager
geen evidentie onderliggende longpathologie
typisch mannen groot gestalte
Secundair
4
