Cardiothoracic Flashcards
Best patency rate for CABG
Internal thoracic(mammary) arteries
How to dx Barrett’s
4 quadrant biopsies every 2cm within Barrett segment showing columnar epithelium lining at least 1cm of the distal esophagus
Ongoing surveillance for Barrett’s
Endoscopy 3-5yrs
Recurrent GERD >2months s/p fundoplication
Slipped, migrated or disrupted fundoplication
Short v long segment Barrett’s
Short <3cm, long at least 3cm
Nondysplastic long segment BE; tx
Surveillance 2-5yrs
Staging workup up suspected esophageal Ca
Upper endoscopy with bx, CT CAP, PET and EUS
Esophageal cancer indicating upfront esophagectomy
T1b (submucosa) and low risk cT2 (muscular propria)
Esophageal Ca invades lamina propria; Stage and tx
T1a, Endoscopic therapy
Benign esophageal lesion approaches
Midesophagus - right thorax
Distal esophagus - left thorax/abdomen
Leiomyoma of the esophagus; tx
Enucleation and subsequent myotomy closure (<8cm and not annular)
Intermittent dysphagia, circular membrane distal esophagus; dx and tx
Schatzki’s ring, PPI and dilation or 4 quadrant biopsies
Risk of Barrett’s with Schatzki’s ring
Decreased
Blood supply esophagus
Cervical - inferior thyroid
Thoracic - aortic branches and bronchial
Abdominal - Left gastric
Sensory nerve supply to the upper epiglottis
Glossopharyngeal nerve (gag reflex)
Sensory nerve supply laryngeal mucosa above vocal cords
Internal branch of the superior laryngeal nerve (cough reflex)
Sensory nerve supply larynx below the vocal cords
Recurrent laryngeal nerve
Motor innervation to the intrinsic muscles of the larynx, except cricothyroid muscles
Recurrent laryngeal
Motor innervation to the cricothyroid
External branch of the superior laryngeal nerve
Contained, stable esophageal perforation; tx
Observation, abxs
First line for esophageal motility disorders
CCBs and nitrates
Heller myotomy; steps
5cm inner and outer myotomy above GE junction and 3cm below, expose mucosa, Dor fundoplication
Shown to increase healing in the primary repair of thoracic esophageal perforations
Pedicled intercostal muscle flap
Gold standard test dx esophageal perforation
Gastrografin swallow study
Most common cause of post-nissen dysphagia >4wks; dx test
Recurrent hiatal hernia or herniated wrap; barium swallow
Gold standard test for pathologic acid reflux
pH monitoring
DeMeester score indicating pathological reflux
> 14.72
Reflux surgery, unable to bring GE junction 3cm below diaphragm; next step
Collis gastroplasty and Toupet fundoplication
Iron deficiency anemia, esophageal webs, dysphagia; dx
Plummer-Vinson syndrome
Caustic ingestion, stable, diagnostic test
CT chest/abd with IV and oral Gastrografin
Traction or epiphrenic diverticulum; workup(why)
Endoscopy to rule out malignancy
Manometry to rule out dysmotility
Traction or epiphrenic diverticulum; tx
Myomtomy v. Diverticulectomy +/- HH repair or fundoplication
Hiatal hernia types
Type 1 sliding
Type 2 para-esophageal
Type 3 mixed
Type 4 other organs
Belsey Mark IV fundoplication
Transthoracic anterior 270-degree plication of the fundus buttressed by the diaphragmatic crura
Zenker diverticula > 2cm; tx
Stapling or diverticulectomy
Zenker diverticula <2cm; tx
Myotomy or myotomy and pexy
SCC of proximal esophagus; tx
Chemorads
Aperistalsis and failure of LES relaxation; dx and pathology
Achalasia, injury/inflammation ganglion cells
Siewert classification GE junction tumors
Type I - 5cm to 1cm above Z-line
Type II - 1cm above to 2cm below
Type III - 2cm to 5cm below
Mallory-Weiss tear s/p failed endoscopy; next step
Repeat endoscopy then angiography
Most common long-term complication related to repaired esophageal atresia
Dysphagia
Spirometric changes with right upper lobe cancer
Decreased FRC
Light’s criteria for exudative effusions
Pleural:serum protein >0.5
Pleural:serum LDH >0.6
Pleural LDH >2/3 upper limit of normal
Effusion volume detectable on upright CXR
300mL
Most common anterior and middle mediastinal tumor in children
Lymphoma
Most common posterior mediastinal tumor in children
Neurogenic
Ohio hiker with calcified RUL lesion; dx and tx
Histoplasmosis, no tx, Ampho B
Standard treatment bronchial carcinoid
Surgical resection with mediastinal node sampling
Most common anterior mediastinal tumor in adults
Thymoma
Trapped lung as a result of empyema; tx
VATS decortication and pleurodesis
Diagnostic imaging for SVC syndrome
CT with IV contrast
SOB, facial plethora/cyanosis, RUE edema and mediastinal tumor; dx
SVC syndrome,
Mortality benefit in ARDs
TV 6ml/kg and proning
Persistent air leak and pneumomediastinum s/p lung txp; dx test
Bronchoscopy to eval for bronchial dehiscence
S/p pneumonectomy with dyspnea, stridor, and recurrent pneumonia. Bronchoscopy reveals a dynamic obstruction of the left bronchus. Dx and tx
Post-pneumonectomy syndrome, tissue expander in pneumonectomy site
Swelling arm and face, lymphadenopathy, bulky mediastinal granuloma on bx; dx
Chronic fibrosing mediastinitis causing SVC syndrome
Common sites of metastasis for pheo and mutation
Bone, lung, liver, kidneys, lymph nodes; SDHB gene
Apical lung tumor causing shoulder pain, ptosis, miosis, anhidrosis, facial/UE edema; dx and tx
Pancoast tumor, chemorads followed by resection
SCC of lung associated paraneoplastic
Overproduction of PTH leading to hypercalcemia
Small cell lung cancer associated with what paraneoplastic syndrome
Overproduction of ADH or ACTH
Subxiphoid pericardial window approach
Vertical incision over xiphoid, removed, finger dissection separating diaphragm form pericardium, grasp with Allis and sharply incise, aspirate and drain through separate incisions, close in two layers
Tx of complicated parapneumonic effusions
Thoracentesis, thoracotomy or surgical drainage
