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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
Q

What is treatment for a Pancoast tumor without metastasis?

A

Two phases: Radiation/chemo, then surgery

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26
Q

What is the most likely cause of hemoptysis + atelectasis in an otherwise healthy young person?

A

Bronchial adenoma leading to an obstructed bronchus

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27
Q

What are the two main types of bronchial adenoma?

A

Carcinoid tumor and adenocystic carcinomas

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28
Q

What are potential sequelae of bronchial adenomas?

A

Either type can lead to bronchial obstruction and atelectasis
Carcinoid tumors: carcinoid syndrome, occasionally widespread metastasis
Adenocystic carcinomas: local invasion

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29
Q

How is definitive diagnosis of a bronchial adenoma performed?

A

Bronchoscopy and biopsy

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30
Q

What is a risk of bronchoscopic biopsy of a bronchial adenoma?

A

Significant bleeding

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31
Q

What is treatment for a carcinoid tumor of the lung?

A

Complete tumor resection with mediastinal lymph node sampling or dissection

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32
Q

What is the workup for pleural effusion in an older person that is not related to CHF?

A

Thoracocentesis and pleural biopsy, with culture and examination for malignant cells in the pleural fluid

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33
Q

Pleural effusion in an older patient is what until proven otherwise?

A

Cancer (although most commonly related to CHF)

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34
Q

What can cause a pleural effusion in an older patient?

A

CHF, lung cancer, mesothelioma, infection

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35
Q

What is the treatment for early stage mesothelioma?

A

Extrapleural pneumonectomy (resect entire lung and both pleura)

+ Radiation + Chemo

(But mesothelioma usually discovered late, non-surgical, very poor prognosis)

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36
Q

What is the origin of spontaneous pneumothorax?

A

Breakdown of septae at the lung apex, allowing for formation of apical blebs that rupture and allow air into the pleural space

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37
Q

What is the initial treatment for spontaneous pneumothorax?

A

Chest tube attached to a water-seal-type drainage

38
Q

What are causes of failure of spontaneous pneumothorax to resolve with a chest tube?

A

Technical error (improper placement, etc)
Large leak from lung parenchyma from large blebs
Leaks from larger bronchi

39
Q

When is treatment beyond a chest tube required for spontaneous pneumothorax?
What is that treatment?

A

Persistent (despite proper chest tube), recurrent or bilateral spontaneous pneumothorax requires thorascopic bleb excision + pleurodesis (adhesion of pleural layers to obliterate pleural space)

40
Q

What do you think of a patient recovering from appropriately-treated pneumonia with increased chest pain, increased cough, and recurrent fever?

A

Empyema (collection of pus in pleural space)

41
Q

What are the most common causative organisms for empyema?

A

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
Q

What is the treatment for empyema?

A
  • Evacuate pus
  • Reexpand lung: Chest tube drainage, and if that fails decortication (remove fibrous tissue trapping lung)
  • Antibiotics
43
Q

What is the immediate management of a patient coming in with unstable angina showing ischemic changes on EKG?

A

Bed rest, sedation, and oxygen to reduce cardiac demand.

Beta blockers, aspirin, heparin, and IV nitroglycerin.

Cardiac enzymes to rule out MI.

44
Q

What is a normal ejection fraction?

A

55-75%
In older adults, more like 50-60%.
Below 40-50% is abnormal in all age groups.

45
Q

What is the treatment for high-grade left main coronary artery disease?

A

Coronary artery bypass is the gold standard.

Percutaneous angioplasty +/- stenting is another option.

46
Q

What group benefits the most from coronary artery bypass surgery?

A

Patients with three-vessel disease and reduced ejection fraction.

47
Q

What is the blood supply to the AV node?

A

AV node artery, off RCA

48
Q

What is the blood supply to the SA node?

A

SA nodal artery, off RCA 60% of time, circumflex 40%

49
Q

What is the blood supply to the left ventricle?

A

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
Q

What is the blood supply to the right ventricle?

A

RCA

51
Q

What is the blood supply of the left atrium?

A

Circumflex artery

52
Q

What is the blood supply of the right atrium?

A

RCA

53
Q

What does the RCA supply?

A

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
Q

What does the LAD supply?

A

45-55% of the LV

55
Q

What does the circumflex artery supply?

A

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
Q

What are two options for sources for coronary artery bypass?

A

Internal mammary artery a.k.a. internal thoracic artery

Great saphenous vein (put in reverse due to valves)

57
Q

What has the best long-term patency for coronary artery bypass?

A

Internal mammary: 90% or better at 10 years

58
Q

What are the risks of coronarypulmonary bypass?

A

Generalized inflammation leading to respiratory, hemorrhagic, and myocardial complications

59
Q

What is the implication for off-pump vs. on-pump (i.e. cardiopulmonary bypass) during coronary artery bypass?

A

Off-pump has theoretically less inflammation and therefore postulated to have fewer complications, but there are not good data to support this?

60
Q

What are alternatives to sternotomy for coronary artery bypass?

A

Minimally invasive direct coronary artery bypass grafting (MIDCAB), robot-assisted bypass.

61
Q

What is the most common cause of mitral regurgitation?

What are other causes?

A

Myxomatous degeneration following mitral valve prolapse
Other causes: ischemic heart disease (papillary muscle dysfunction, LV dilation), rheumatic fever, Marfan’s, Ehlers Danlos

62
Q

What can cause sudden onset mitral valve insufficiency?

A

Acute bacterial endocarditis (usually Staph aureus)

Papillary muscle rupture/dysfunction (usually ischemic)

63
Q

What is the most common cause of mitral stenosis?

A

Rheumatic fever (so it is now rare)

64
Q

What are treatments for mitral valve stenosis?

A

Percutaneous ballon valvotomy, open mitral commissurotomy (rarely performed, requires cardiopulmonary bypass), valve replacement

65
Q

What are contraindications to percutaneous balloon mitral valvotamy for mitral stenosis? (4)

A

LA thrombus (risk of dislodging part)
Moderate to severe mitral regurgitation (worsened by balloon)
Valve calcification (treatment failure)
Severe subvalvular distortion (treatment failure)

66
Q

What is treatment for mitral regurgitation?

A

Repair: Excise insufficient/redundant portions, narrow and reinforce mitral annulus with annuloplasty.
Valve replacement

67
Q

What are the main causes of aortic valve stenosis? (2)

A

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
Q

What are the symptoms that angina can present with?

A

Dyspnea, angina, and syncope

69
Q

What tests are indicated in a patient with dyspnea, chest pain, and syncope?

A

Echocardiogram, cardiac catheterization, Carotid duplex US

70
Q

What is the natural history of aortic stenosis?

A

Long latent period, then rapid deterioration when symptoms present (angina, syncope, CHF).

May present with sudden death.

71
Q

What are the benefits of different types of replacement valves?

A

Mechanical: long-lasting, but require lifelong anticoagulation

Tissue: nonthrombogenic, but last only about 7 years

72
Q

What types of drugs are used to treat dilated cardiomyopathy?

A

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
Q

What are the main causes of death from a heart transplant (after the immediate perioperative period)?

A

Infection (immunosuppression), accelerated coronary artery atherosclerosis (perhaps a form of chronic rejection)

74
Q

What is the mainstay of treatment for esophageal cancer?

A

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
Q

What is suggested by dysphagia and regurgitation of chewed but not digested food?

A

Zenker diverticulum (pharyngeal diverticulum)

76
Q

What is the treatment options for Zenker diverticulum?

A

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
Q

What is a proposed mechanism for Zenker diverticulum?

A

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
Q

What is a potential complication of an epiphrenic diverticulum?

A

Aspiration (due to retained food in the lower esophagus).

Requires excision for this reason.

79
Q

What is associated with a dilated esophagus and “bird’s beak” in the lower esophagus on barium swallow?

A

Achalasia

80
Q

What is the pathophysiology of achalasia?

A

Loss of inhibitory ganglion cells leads to failure of LES to relax and altered peristalsis

81
Q

What are the treatment options for achalasia?

A

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
Q

What are the most common esophageal cancers by anatomic location?

A

Upper 2/3: Squamous cell carcinoma

Lower 1/3: Adenocarcinoma > squamous cell carcinoma

83
Q

How are low-grade and high-grade dysplasia in Barrett’s esophagus managed?

A

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
Q

In addition to biopsy what is used to assess extent of esophageal cancer?

A

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
Q

What are two methods of surgery for esophageal cancer?

What is a key difference between them in terms of possible complications?

A

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
Q

What could be a cause of severe dysphagia and chronic cough?

A

Esophageal cancer leading to a tracheoesophageal fistula and chronic aspiration.

87
Q

What do you think of a anterior mediastinal mass associated with progressive weakness in all extremities and double vision?

What is the treatment?

A

Myasthenia gravis due to thymoma.

Treat with surgical excision

88
Q

What do you think of an anterior mediastinal mass with calcium deposits on imaging?

A

Teratoma (teeth)

89
Q

What are the most common causes of anterior mediastinal mass?

A 
The 4 T's:
Thymoma
Teratoma (and other germ cell tumors)
Thyroid (ectopic)
Terrible lymphoma (lame)
90
Q

What are the most common causes of middle mediastinum mass?

A

Cysts (bronchogenic and pericardial cysts, may be excised to prevent infection and fistulas)
Lymphomas

91
Q

What are the most common causes of posterior mediastinum mass?

A

Neurogenic tumors (most commonly neurilemmoma nerve sheath tumors)

92
Q

What is the treatment for neurogenic tumors of the posterior mediastinum?

A

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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