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Surgery Review RD > 4: Thoracic and cardiothoracic disorders > Flashcards

4: Thoracic and cardiothoracic disorders Flashcards

1
Q

What laboratory workup should be performed for a solitary pulmonary nodule?

A

Fungal serum titers, and sputum acid-fast bacilli stain.

Also skin tests: histoplasmosis and PPD

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2
Q

What is the major complication of needle biopsy of a lung nodule/mass?

A

Pneumothorax

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3
Q

What radiographic features of a coin lesion of the lung favor malignancy in terms of:

  1. Size?
  2. Evolution?
  3. Calcifications?
  4. CT density?
A

Size: >3 cm
Evolution: increased in size, with doubling time from 35-280 days
Calcifications: usually noncalcified (occassionally eccentrically calcified)
Density: Low CT density (<110 HU) (Benign likely more dense, >164 HU)

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4
Q

Other than malignancy, what can present as a lung nodule/mass on CXR?

A

Infectious granuloma (actinomycosis, histoplasmosis, coccidiomyocosis, blastomycosis, cryptococcis, aspergilloma)

Hamartoma

Round atelectasis

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5
Q

What do you think of with a lung nodule associated with a dental abscess or sinus involving the chest wall?

A

Actinomycosis (actually a bacteria despite the name, treat with penicillin)

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6
Q

What do you think of for a lung nodule with concentric or homogenous calcification?

A

Histoplasmosis

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7
Q

What do you think of for a lung nodule with a thin-walled cavity and air-fluid level?

A

Coccidiomycosis

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8
Q

What do you think of for a lung nodule associated with chronic skin ulcers?

A

Blastomycosis

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9
Q

What do you think of a lung nodule resulting from superinfection in an immunocompromised patient?

A

Cryptococcosis

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10
Q

What do you think of a lung nodule with an “air-crescent” sign?

A

Aspergillosis (fungus ball surrounded by air)

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11
Q

What do you think of a lung nodule with a well-defined border with slight lobulations?

A

Hamartoma

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12
Q

What do you think of a lung nodule with a comet-tail vessel pattern adjacent to thickened pleura?

A

Round atelectasis

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13
Q

What are endemic areas for blastomycosis, coccidiomycosis, and histoplasmosis?

A

Histoplasmosis and blastomycosis: Midwest US

Coccidiomycosis: Western US

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14
Q

What invasive tests can be used to assess pulmonary nodules/masses?

A

Needle biopsy, bronchoscopy, mediastinoscopy

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15
Q

How do small cell and non-small cell lung cancers differ in their pattern of spread? Treatment?

A

Small cell: systemic disease, early metastasis, usually chemotherapy (unless caught very early)

Non-small cell: local spread through nodes before mets, usually primarily surgery if caught early (stage I or II), chemo and radiation as adjunct

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16
Q

What are the types of non-small cell lung cancer?

A

Adenocardinoma

Epidermoid (squamous cell) carcinoma

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17
Q

What is the therapy for a stage I non-small cell lung cancer not involving major bronchi?

A

Lobectomy

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18
Q

What is the therapy for a stage I non-small cell lung cancer involving the origin of a lobar bronchus?

A

Pneumonectomy of sleeve lobectomy (remove part of main bronchus with lobectomy and re-anastomose remaining lobe(s) to more proximal bronchus)

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19
Q

What defines stage I lung cancer? Stage II? III? IV?

A

Stage I: Local only, no lymph node involvement
Stage II: Involvement of intrapulmonary and/or ipsilateral hilar nodes only
Stage III: Involvement of nodes beyond ipsilateral hilar nodes (mediastinal, supraclavicular, contralateral), or lymph nodes + chest wall involvement
Stage IV: Distant mets

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20
Q

How does therapy for non-small cell lung cancer vary by stage?

A

Stage I and II: Primarily surgery

Stage III and IV: Chemo and radiation

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21
Q

What are the differences in technical difficulty and perioperative mortality between pneumonectomy and sleeve lobectomy?

A

Pneumonectomy: Technically easier, but actually higher perioperative mortality
Sleeve lobectomy: Technically more difficult, but lower perioperative mortality. (Also better preserves pulmonary function)

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22
Q

What is a Pancoast tumor?

A

Tumor involving the superior sulcus of the lung (also known as superior sulcus tumor), the extreme apex of the lung near the sublavian artery?

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23
Q

What structures can a Pancoast tumor invade?

A

Chest wall, brachial plexus, sublavian artery, sympathetic ganglia

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24
Q

What do you think of a patient with haziness at the lung apex on CXR and ipsilateral Horner syndrome?

A

Pancoast tumor involving sympathetic chain

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25
What is treatment for a Pancoast tumor without metastasis?
Two phases: Radiation/chemo, then surgery
26
What is the most likely cause of hemoptysis + atelectasis in an otherwise healthy young person?
Bronchial adenoma leading to an obstructed bronchus
27
What are the two main types of bronchial adenoma?
Carcinoid tumor and adenocystic carcinomas
28
What are potential sequelae of bronchial adenomas?
Either type can lead to bronchial obstruction and atelectasis Carcinoid tumors: carcinoid syndrome, occasionally widespread metastasis Adenocystic carcinomas: local invasion
29
How is definitive diagnosis of a bronchial adenoma performed?
Bronchoscopy and biopsy
30
What is a risk of bronchoscopic biopsy of a bronchial adenoma?
Significant bleeding
31
What is treatment for a carcinoid tumor of the lung?
Complete tumor resection with mediastinal lymph node sampling or dissection
32
What is the workup for pleural effusion in an older person that is not related to CHF?
Thoracocentesis and pleural biopsy, with culture and examination for malignant cells in the pleural fluid
33
Pleural effusion in an older patient is what until proven otherwise?
Cancer (although most commonly related to CHF)
34
What can cause a pleural effusion in an older patient?
CHF, lung cancer, mesothelioma, infection
35
What is the treatment for early stage mesothelioma?
Extrapleural pneumonectomy (resect entire lung and both pleura) + Radiation + Chemo (But mesothelioma usually discovered late, non-surgical, very poor prognosis)
36
What is the origin of spontaneous pneumothorax?
Breakdown of septae at the lung apex, allowing for formation of apical blebs that rupture and allow air into the pleural space
37
What is the initial treatment for spontaneous pneumothorax?
Chest tube attached to a water-seal-type drainage
38
What are causes of failure of spontaneous pneumothorax to resolve with a chest tube?
Technical error (improper placement, etc) Large leak from lung parenchyma from large blebs Leaks from larger bronchi
39
When is treatment beyond a chest tube required for spontaneous pneumothorax? What is that treatment?
Persistent (despite proper chest tube), recurrent or bilateral spontaneous pneumothorax requires thorascopic bleb excision + pleurodesis (adhesion of pleural layers to obliterate pleural space)
40
What do you think of a patient recovering from appropriately-treated pneumonia with increased chest pain, increased cough, and recurrent fever?
Empyema (collection of pus in pleural space)
41
What are the most common causative organisms for empyema?
Community-acquired: Pneumococcus Hospital-acquired: Staph aureus, coag-neg Staph, and gram-negatives (e.g. Pseudomonas, Klebsiella) Aspiration risk history: oral anaerobes (e.g. Fusobacterium, Prevotella, Peptostreptococcus, Bacteroides)
42
What is the treatment for empyema?
* Evacuate pus * Reexpand lung: Chest tube drainage, and if that fails decortication (remove fibrous tissue trapping lung) * Antibiotics
43
What is the immediate management of a patient coming in with unstable angina showing ischemic changes on EKG?
Bed rest, sedation, and oxygen to reduce cardiac demand. Beta blockers, aspirin, heparin, and IV nitroglycerin. Cardiac enzymes to rule out MI.
44
What is a normal ejection fraction?
55-75% In older adults, more like 50-60%. Below 40-50% is abnormal in all age groups.
45
What is the treatment for high-grade left main coronary artery disease?
Coronary artery bypass is the gold standard. | Percutaneous angioplasty +/- stenting is another option.
46
What group benefits the most from coronary artery bypass surgery?
Patients with three-vessel disease and reduced ejection fraction.
47
What is the blood supply to the AV node?
AV node artery, off RCA
48
What is the blood supply to the SA node?
SA nodal artery, off RCA 60% of time, circumflex 40%
49
What is the blood supply to the left ventricle?
LAD: 45-55% In right dominant hearts (70%): RCA: 25-35% (via posterior descending artery, PDA) Circumflex: 15-25% In left dominant hearts (10%): RCA: 0% Circumflex: 40-50% (directly and via PDA) (In co-dominant hearts, PDA gets branches from both circumflex and RCA)
50
What is the blood supply to the right ventricle?
RCA
51
What is the blood supply of the left atrium?
Circumflex artery
52
What is the blood supply of the right atrium?
RCA
53
What does the RCA supply?
RA, RV, AV node. SA node in 60% (other is circumflex) 25-35% of LV in right-dominant hearts (70%), none in left-dominant hearts
54
What does the LAD supply?
45-55% of the LV
55
What does the circumflex artery supply?
LA 15-25% of LV in right-dominant hearts (70%), 40-50% of LV in left-dominant hearts (10%) SA node in 40% of patients
56
What are two options for sources for coronary artery bypass?
Internal mammary artery a.k.a. internal thoracic artery | Great saphenous vein (put in reverse due to valves)
57
What has the best long-term patency for coronary artery bypass?
Internal mammary: 90% or better at 10 years
58
What are the risks of coronarypulmonary bypass?
Generalized inflammation leading to respiratory, hemorrhagic, and myocardial complications
59
What is the implication for off-pump vs. on-pump (i.e. cardiopulmonary bypass) during coronary artery bypass?
Off-pump has theoretically less inflammation and therefore postulated to have fewer complications, but there are not good data to support this?
60
What are alternatives to sternotomy for coronary artery bypass?
Minimally invasive direct coronary artery bypass grafting (MIDCAB), robot-assisted bypass.
61
What is the most common cause of mitral regurgitation? | What are other causes?
Myxomatous degeneration following mitral valve prolapse Other causes: ischemic heart disease (papillary muscle dysfunction, LV dilation), rheumatic fever, Marfan's, Ehlers Danlos
62
What can cause sudden onset mitral valve insufficiency?
Acute bacterial endocarditis (usually Staph aureus) | Papillary muscle rupture/dysfunction (usually ischemic)
63
What is the most common cause of mitral stenosis?
Rheumatic fever (so it is now rare)
64
What are treatments for mitral valve stenosis?
Percutaneous ballon valvotomy, open mitral commissurotomy (rarely performed, requires cardiopulmonary bypass), valve replacement
65
What are contraindications to percutaneous balloon mitral valvotamy for mitral stenosis? (4)
LA thrombus (risk of dislodging part) Moderate to severe mitral regurgitation (worsened by balloon) Valve calcification (treatment failure) Severe subvalvular distortion (treatment failure)
66
What is treatment for mitral regurgitation?
Repair: Excise insufficient/redundant portions, narrow and reinforce mitral annulus with annuloplasty. Valve replacement
67
What are the main causes of aortic valve stenosis? (2)
Calcific ("senile", involves endothelial damage, inflammation, and associated with hyperlipidemia) Congenital bicuspid valve Rheumatic fever now a rare cause (more commonly involves MV, but can involve AV)
68
What are the symptoms that angina can present with?
Dyspnea, angina, and syncope
69
What tests are indicated in a patient with dyspnea, chest pain, and syncope?
Echocardiogram, cardiac catheterization, Carotid duplex US
70
What is the natural history of aortic stenosis?
Long latent period, then rapid deterioration when symptoms present (angina, syncope, CHF). May present with sudden death.
71
What are the benefits of different types of replacement valves?
Mechanical: long-lasting, but require lifelong anticoagulation Tissue: nonthrombogenic, but last only about 7 years
72
What types of drugs are used to treat dilated cardiomyopathy?
Similar drugs used to treat CHF (ACEIs/ARBs, beta blockers, aldosterone receptor blockers (spironolactone), diuretics, vasocilators, antiarrhythmics, inotropes). Pacemakers may also be used. Corticosteroids used to be used routinely, but major study showed no benefit.
73
What are the main causes of death from a heart transplant (after the immediate perioperative period)?
Infection (immunosuppression), accelerated coronary artery atherosclerosis (perhaps a form of chronic rejection)
74
What is the mainstay of treatment for esophageal cancer?
Chemo/radiation followed by surgery (Very early stage (T1aN0M0) may be endoscopic excision alone, stage IV focuses on palliation) (Commonly presents at late stage where palliation is primary treatment)
75
What is suggested by dysphagia and regurgitation of chewed but not digested food?
Zenker diverticulum (pharyngeal diverticulum)
76
What is the treatment options for Zenker diverticulum?
Open cricopharyngeal myotomy with divercitulum excision (may be myotomy only for small deverticulum, but risk of persistent symptoms) Endoscopic diverticulotomy (close with laser or staples)
77
What is a proposed mechanism for Zenker diverticulum?
Abnormal cricopharyngeal muscle constriction leading to high pressures above it, where the outpouching occurs. (This is why cricopharyngeal myotomy is often part of treatment)
78
What is a potential complication of an epiphrenic diverticulum?
Aspiration (due to retained food in the lower esophagus). Requires excision for this reason.
79
What is associated with a dilated esophagus and "bird's beak" in the lower esophagus on barium swallow?
Achalasia
80
What is the pathophysiology of achalasia?
Loss of inhibitory ganglion cells leads to failure of LES to relax and altered peristalsis
81
What are the treatment options for achalasia?
Calcium channel blockers and nitrates to relax. Heller myotomy: >90% effective, but invasive (often laparoscopic), risk of reflux Balloon dilation: 60% effective, noninvasive Botox injections in nonsurgical candidates.
82
What are the most common esophageal cancers by anatomic location?
Upper 2/3: Squamous cell carcinoma | Lower 1/3: Adenocarcinoma > squamous cell carcinoma
83
How are low-grade and high-grade dysplasia in Barrett's esophagus managed?
Low-grade: follow with endoscopy (2 x 6 months apart, then annually) High-grade has options: Intense surveillance (every 3 months with biopsy), endoscopic ablation, surgical resection.
84
In addition to biopsy what is used to assess extent of esophageal cancer?
Endoscopic ultrasound and chest/upper abdomen CT (abdomen needed because may spread to celiac nodes). Surgical staging (laparotomy or laparoscopy) may also be used.
85
What are two methods of surgery for esophageal cancer? What is a key difference between them in terms of possible complications?
Transthoracic esophagectomy: incisions in abdomen and thorax, escision, anastomosis with stomach in chest Transhiatal esophagectomy: incisions in abdomen and neck, anastomosis with stomach in neck Key difference: if there is leak at the anastomosis, easier to manage and less risk of sepsis if it is in the neck (THE)
86
What could be a cause of severe dysphagia and chronic cough?
Esophageal cancer leading to a tracheoesophageal fistula and chronic aspiration.
87
What do you think of a anterior mediastinal mass associated with progressive weakness in all extremities and double vision? What is the treatment?
Myasthenia gravis due to thymoma. Treat with surgical excision
88
What do you think of an anterior mediastinal mass with calcium deposits on imaging?
Teratoma (teeth)
89
What are the most common causes of anterior mediastinal mass?
``` The 4 T's: Thymoma Teratoma (and other germ cell tumors) Thyroid (ectopic) Terrible lymphoma (lame) ```
90
What are the most common causes of middle mediastinum mass?
Cysts (bronchogenic and pericardial cysts, may be excised to prevent infection and fistulas) Lymphomas
91
What are the most common causes of posterior mediastinum mass?
Neurogenic tumors (most commonly neurilemmoma nerve sheath tumors)
92
What is the treatment for neurogenic tumors of the posterior mediastinum?
These are generally benign, but may require excision depending on location. If CT shows they involve the spinal canal, they must be removed.

Surgery Review RD (4 decks)

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