Lung Cyst

A lung cyst is an air-filled, thin-walled cavity located within the lung tissue and is usually detected incidentally. It may be congenital or acquired later. The clinical picture is generally silent; however, large cysts may affect respiratory functions.

The question of what causes a lung cyst is important in understanding the etiology of the cyst. Congenital anomalies, infections, trauma, or some genetic diseases (e.g. LAM, BHD syndrome) may cause these formations. The number and location of the cysts affect the diagnostic process.

The question of how a lung cyst is diagnosed is answered with the correct imaging techniques. A chest X-ray may provide the first finding, but computed tomography (CT) is preferred for definitive diagnosis. The distinction between a cyst and a bulla, cavity, and other lesions must be made carefully.

The question of how lung cyst treatment is performed is shaped according to the patient’s symptoms and the size of the cyst. In asymptomatic cases, follow-up may be sufficient, while surgical intervention may be required in infected or ruptured cysts. Follow-up and treatment require a multidisciplinary approach.

What Is a Lung Cyst?

A Lung Cyst is a thin-walled, usually benign cavity filled with air or fluid within the lung tissue. It may be congenital, or it may develop as a result of infections, trauma, or parasitic diseases. While most do not cause symptoms, in some cases they may lead to cough, chest pain, or shortness of breath. Diagnosis is usually made by radiological imaging. Treatment is planned according to the cause of the cyst, its size, and the clinical condition of the patient.

What Are the Symptoms of a Lung Cyst?

Lung cysts may remain silent for a long time, especially when they are small or located in remote corners of the lung. Some of our patients learn about this condition incidentally on lung imaging taken during a pre-employment examination or for another reason. However, as the cyst grows or begins to cause a problem where it is located, the body gives some signals.

These symptoms are generally as follows:

• Shortness of breath
• Chest pain
• Chronic cough
• Bloody sputum
• High fever
• Fatigue
• Wheezing
• Frequent recurrent lung infections

These complaints arise from the cyst putting pressure on the airways within the lung or from the cyst becoming inflamed within itself. Especially in children, rapid growth of the cyst may block the airways and create a much more urgent and dramatic picture.

How Are the Causes of Cyst Formation and Etiological Classification Determined?

We examine lung cysts under two main headings according to where they originate. This distinction is of vital importance for us because the surgical technique for a congenital cyst and a cyst formed later due to a parasite is completely different.

Our first group is congenital cysts, that is, cysts present from birth. They occur as a result of some coding errors during the development of the lungs while the baby is in the womb. Problems experienced during the development of the bronchial tree or the lung buds lead to cysts that are present from birth. The best known of these are bronchogenic cysts. These usually do not resolve with medication because there is a structural disorder.

Our second group is acquired cysts. Here, we need to open a very special and important heading for the geography of our country: Hydatid Cyst. This condition, popularly known as a “dog cyst,” is actually a disease caused by a parasite called Echinococcus granulosus. This parasite is transmitted to humans generally through the consumption of water contaminated with dog feces or poorly washed vegetables. The parasite that enters the body reaches the lung through the bloodstream and settles there, building a wall around itself. This cyst, which contains a clear fluid and reproducing parasites, is actually a living organism. Apart from this, previous severe pneumonias or traumas may also cause cyst formation later.

Why Does a Hydatid Cyst Carry a Special Surgical Risk?

A hydatid cyst has a very different risk profile from other cysts. You can think of it as a delicate balloon filled with pressurized water. The fluid inside this cyst contains foreign proteins for the body, and if this fluid leaks out of the cyst, it may cause a very severe, life-threatening allergic reaction that we call “anaphylaxis” in the patient.

In addition, our greatest fear during surgery is the rupture of this cyst. If the cyst ruptures during surgery or spontaneously, thousands of microscopic parasites inside it spread into the chest cavity. This causes the disease to recur years later in the same place or in different places. Therefore, in hydatid cyst surgeries, the surgeon’s priority is not only to remove the cyst but also to prevent the cyst contents from touching the patient’s tissues. This is a condition that directly affects the surgical technique and the instruments to be used.

How Are the Indications for Surgical Treatment and Patient Selection Determined?

When we detect a cyst in a patient, we do not immediately say “let’s operate.” When making the decision, we set up a balance scale; on one side is the risk of the surgery, on the other side is the harm that the cyst is causing or may cause to the patient.

The situations that make surgical intervention mandatory are as follows:

• Significant shortness of breath
• Recurrent infection attacks
• Detection of growth in the cyst
• Risk of rupture of the cyst
• Suspicion of cancer
• Presence of bleeding
• Compression of the heart

Especially if a diagnosis of Hydatid Cyst has been made, we do not really have the luxury of waiting. Because these cysts may grow over time and open into the bronchi or rupture into the pleural cavity. This is the condition we call “rupture,” and it is an emergency picture. Surgery for a ruptured cyst is much more difficult than for an unruptured one, and the risk of complications is high. Therefore, in patients diagnosed with hydatid cyst, planning the surgery under “elective” conditions while the cyst still preserves its integrity is the safest way.

What Are the Lung Cyst Conditions That Require Emergency Surgery?

Most of the time, we perform surgeries in a planned manner by preparing the patient. However, there are some situations in which we need to enter the operating room urgently to save the patient’s life.

The situations requiring emergency intervention are as follows:

• Massive hemoptysis
• Tension pneumothorax
• Acute respiratory failure
• Cyst rupture and anaphylaxis
• Opening into the pleural cavity

For example, if a large cyst suddenly ruptures and causes the lung to collapse (pneumothorax), the patient becomes unable to breathe. Or if the cyst erodes a large vessel and causes serious bleeding (hemoptysis), intervention is required within minutes. In such cases, surgical planning is done very quickly, and the primary aim is first to stabilize the patient’s vital functions.

How Is the Closed Surgery (VATS) Method Performed?

Today, technology has advanced greatly in thoracic surgery. “Video-Assisted Thoracoscopic Surgery,” or VATS for short, has now become our standard approach. In this method, popularly known as “closed surgery,” instead of cutting the chest from end to end, we make small holes of approximately 1-2 centimeters between the ribs.

Through one of these holes, we send a high-resolution camera inside. This camera magnifies and illuminates the image inside and reflects it onto the screens in front of us. Through the other holes, we insert our surgical instruments and perform the procedure.

The advantages of the VATS method for patients are as follows:

• Less pain
• Small surgical scars
• Fast discharge
• Early return to work
• Less bleeding
• Low risk of infection
• Less muscle damage

For us surgeons, VATS is also a great advantage, especially in terms of providing a field of view. Thanks to the camera, we can see deep corners that are difficult to see with the naked eye very clearly and perform delicate maneuvers. Therefore, in every patient who is technically suitable, our first choice is the closed method.

In Which Situations Is Open Surgery (Thoracotomy) Preferred?

Although the closed method is the gold standard, in some situations classic open surgery, that is, “Thoracotomy,” may be mandatory and the safest option. Thoracotomy is the procedure of opening the space between the ribs through a larger incision made under the shoulder blade.

The situations in which open surgery is preferred or conversion from closed to open is made are as follows:

• Dense adhesions
• The cyst being excessively large
• Uncontrolled bleeding
• Hydatid cyst dissemination
• Anatomical difficulties
• Heart failure
• Insufficiency of technical equipment

For example, if the patient has previously had tuberculosis or severe pneumonia, the pleura may be stuck to the chest wall like glue (adhesion). Separating these adhesions with the closed method may sometimes be very risky and may injure the lung. In this case, the surgeon switches to the open method in order to work by touching and seeing with their hands.

How Is the Decision Made to Convert from Closed to Open Surgery (Conversion) During the Operation?

Our patients sometimes ask, “Doctor, you started closed but when I woke up it had become open surgery, did the operation fail?” This is definitely not a failure. On the contrary, it is a safety measure.

Surgery is a dynamic process. When we start the surgery, we base our plan on the closed method. However, the picture we encounter inside may sometimes be different from what was planned. For example, we may see that a large vessel is adherent to the cyst, or in hydatid cyst surgery we may not find enough space to safely evacuate the contents of the cyst.

In such situations, the surgeon must make a decision within seconds. If continuing closed will put the patient at risk, it is immediately converted to the open method. We call this “conversion.” The basic principle here is “first, do no harm.” The patient’s safety is far more important than cosmetic concerns or technical insistence. Therefore, conversion to open surgery shows the surgeon’s experience and success in risk management.

What Are the Techniques Used in Lung Cyst Surgery (Lobectomy, Cystectomy)?

The surgical techniques we apply vary according to the type, location, and size of the cyst. Our goal is always to completely remove the diseased tissue, but while doing this, to preserve the healthy lung tissue at the maximum level as well.

The main techniques applied are as follows:

• Cystectomy
• Wedge resection
• Segmentectomy
• Lobectomy
• Pneumonectomy
• Cystotomy
• Capitonnage

If there is a benign and well-defined cyst such as a bronchogenic cyst, we only remove the cyst; this is called “Cystectomy.” If the cyst is at the tip of the lung, we remove it in a wedge shape together with a small piece of lung, and this is called “Wedge Resection.”

However, in conditions such as “Congenital Lobar Emphysema,” the problem is not just a cyst but a lobe (section) of the lung being completely abnormal. This abnormal lobe swells and compresses the healthy lobes. In this case, it is necessary to remove that lobe completely, which we call “Lobectomy.” The human lung consists of three lobes on the right and two on the left, and the removal of one lobe does not prevent the patient from continuing life normally.

What Is the Cystotomy and Capitonnage Procedure Applied in Hydatid Cyst Surgery?

Hydatid cyst surgery requires special precautions, as we mentioned above. Here, we apply an organ-preserving method that we call “Cystotomy and Capitonnage.”

The steps of the procedure are generally as follows:

• Ensuring isolation
• Evacuation of the cyst fluid
• Removal of the germinative membrane
• Cleaning of the cavity
• Closing of the bronchial openings
• Suturing of the cavity

First, we surround the cyst with cloths soaked in parasite-killing solutions. This prevents the spread of the parasite in case of a possible leak. Then we aspirate the fluid inside the cyst in a controlled manner with a needle. When the cyst is emptied, we remove the parasite layer inside it, which we call the “daughter membrane.”

An empty space (cavity) remains inside the lung. If this cavity is left as it is, it may fill with air or fluid and become infected. In addition, there may be small airways opening into this cavity. Therefore, we close this cavity with opposing internal sutures. This procedure is called “Capitonnage.” Thus, the lung tissue preserves its integrity and continues its function.

Are There Non-Surgical Methods and a Percutaneous Treatment (PAIR) Option?

In some selected hydatid cyst patients, if the patient is not in a condition to tolerate surgery or absolutely refuses surgery, a non-surgical method called “PAIR” may be tried. In this procedure, under ultrasound guidance, the cyst is entered through the skin with a needle, the fluid is evacuated, medication is given inside, and it is aspirated again.

However, the chance of success of this method is lower compared to surgery, and it cannot be applied to every cyst. Shrinkage of less than 10% of the cyst is considered failure. In addition, there is a risk of leakage of the cyst contents and allergic shock during the procedure. In congenital structural cysts, draining with a needle has no therapeutic role, because the problem is in the tissue itself, and even if the fluid is evacuated, the fluid will refill as long as the cyst wall remains there. Therefore, surgery is still the most reliable and definitive treatment method.

What Are the Additional Procedures Performed Simultaneously During Surgery?

Sometimes during surgery, we may encounter problems other than the cyst, which is our main target, or we may need to solve secondary problems caused by the cyst. In order not to operate on the patient repeatedly, we handle these in the same session.

These additional procedures are as follows:

• Bullectomy
• Decortication
• Nodule excision
• Pleurectomy
• Lymph node sampling

For example, if there are small air bubbles called “bullae” around the cyst, we remove them as well (Bullectomy). If the cyst has been there for a long time and has caused infection, the pleura may have thickened. This thick membrane prevents the lung from expanding comfortably. We call the process of peeling off this membrane and freeing the lung “Decortication.” In this way, the patient breathes much more comfortably after surgery.

What Awaits the Patient in the Postoperative Period and Recovery Process?

When the surgery is finished, we take our patient to the recovery room. A tube that we call a “drain” will have been placed to remove the air and leakage fluid accumulated in the chest cavity. This tube is the most important monitoring tool of the healing process.

The hospital stay is usually 3-4 days in closed surgeries and somewhat longer in open surgeries. During this process, our greatest expectation from the patient is to perform “respiratory physiotherapy.” Using the three-ball breathing exercise device called Triflow, coughing frequently to produce sputum, and getting out of bed and walking in the early period are the keys to recovery. These activities allow the collapsed parts of the lung to reopen and reduce the risk of pneumonia.

Today, we have very effective methods for pain management. We try to keep the patient’s comfort at the highest level with epidural catheters or intravenously controlled painkillers. After the drain is removed, the patient is usually discharged.

Is There a Risk of Complications After Lung Cyst Surgery?

As with every surgical procedure, lung cyst surgeries also carry some risks. These risks vary according to the patient’s age, general health condition, and the complexity of the cyst.

Possible complications are as follows:

• Air leak
• Infection
• Bleeding
• Atelectasis
• Pleural effusion
• Pain
• Wound site problems

The most common situation we encounter is “prolonged air leak.” If air continues to leak from the lung tissue, removal of the drain may be delayed. However, this condition generally improves with patience and additional treatments.

How Is Treatment Success Evaluated and Do Cysts Recur?

The success of the surgery is measured by the resolution of the patient’s complaints and the radiological disappearance of the cyst. Congenital cysts (bronchogenic cyst, etc.) generally do not form again when they are completely removed surgically. In other words, the treatment is definitive and permanent.

In hydatid cyst cases, however, the situation requires a more closely monitored process. If the surgery is successful and the cyst is removed without rupture, the possibility of recurrence is below 5%. However, because it is a parasitic disease, the patient’s immune system and environmental factors are also important. For this reason, we also prescribe antiparasitic medication for a certain period after surgery for our patients who have undergone hydatid cyst surgery.

Frequently Asked Questions