Cardiothoracic surgery - non-malignant situations

Question 1

What is an abscess?

Answer 1

A collection of pus in the lungs surrounded by granulation tissue

Question 2

What is most likely to cause an abscess? What pneumonia is most likely to forma an abcess?

Answer 2

Aspiration of a foreign object, mostly peanuts in children… Usually caused by the lung segment/lobe being blocked off by a blocked bronchus, then infection causes necrosis of tissues which then develops into an abscess.

Staphycoccus Aureus, but many pneumonias can develop into lung abcesses.

Question 3

What happens to the abscess?

Answer 3

Most abcesses want to find their way out, so will make way to surface of body or organ and then discharge the pus. - in the lung, this can lead to empyema.

Question 4

What is the safest way of dealing with an abcess?

Answer 4

Chest drain

Question 5

What is a empyema? when can it occur?

Answer 5

When most of the pleural cavity is filled with pus. Can occur after an abcess.

Question 6

What is Boerhaave’s syndrome and how is this related to empyema? How to distinguish mi

Answer 6

Boerhaave’s syndrome is when someone is drunk, and vomits but the sphincters aren’t coordinated and so the oesophagus ruptures and the sick goes internally - usually within pleural cavity. Can cause empyema. If not diagnosed correctly within first 24h or so can lead to death. Can sometimes be confused with myocardial infarctions as same symptoms - severe chest pain and vomiting BUT

In Myocardial infarctions they get chest pain first
In Boerhaave’s syndrome they get the vomiting first.

Question 7

WHat is a pleurectomy?

Answer 7

Removal of paarietal pleura off the chest wall. Usually peels off quite easily.

Question 8

What is decortication?

Answer 8

Taking the cortex of fibrous tissue off the surface of the lungs that can build up with empyema.

Question 9

What disease are myasthemia gravis (facial muscle weakness) liked with?

Answer 9

Thymoma (rare tumors that form in cells on the thymus)

Question 10

A- C which worse/better of thymomas? What is the worst one?

Answer 10

A is best, increasingly worse to C and the worst is Thymic carcinoma

Question 11

What are thymic tumours?

Answer 11

rare tumors that form in cells on the thymus. Usually stay within the thymus and so can be surgically resected easily but tend to invade local structures which can make them i npoperable eg aortic arch/superior vena cava. Thymic Carcinomas spread a lot faster than Thymomas.

Question 12

WHat are the benign lung tumours?

Answer 12

Harmatomas
Fibroma
Lipoma
Neural tumours
Papillomas
Chondroma

Question 13

What is the difference Hamartoma or teratoma

Answer 13

Harmatomas contain proliferating cells from within the area it is found, teratomas have tissue that is not usually found in its location, can be benign or malignant.

Question 14

Why migt fibroma kill you?

Answer 14

Big fibroma, compresses heart and other lung.

Question 15

What is von Recklinghausen’s disease (Neurofibromatosis)?

Answer 15

Benign neurofibromas forming all over the body, autosomal dominant condition, but if they are found the neurofibromas should be removed as they can become malignant.

Question 16

What is the difference recurrent vs persistant pneumothorax?

Answer 16

Recurrent means happens 2 or more times, persistant means the same pneumothorax doesn’t quite heal correctly - still bubbling through chest drain 7 days after put in.

Question 17

What is an open pneumothorax? How big to die?

Answer 17

Hole in the chest wall, causes very ineffective ventilation and go into respiratory failure v fast. Hole only has to be half diameter of trachea to kill you. Best thing to do is wet towel over area.

Question 18

What do you notice in a tension pneumothorax? What is it associated with?

Answer 18

Mediasteinal shift. Associated with air travel and diving.

Question 19

What do you do in the case of a tension pneumothorax? If it leads to a bilateral pneumothorax, how long for survival?

Answer 19

Drain out the air!! Survival 10-15 minutes with bilateral pneumothoraxes.

Question 20

pneumothorax with fluid level, could be what?

Answer 20

Haemopneumothorax = pneumothorax (especially in recurrant pneumothoraxes) when the lung shrinks it can also take adhesions between lung and chest wall, causing bleeding.

Question 21

What is a bullus lung disease?

Answer 21

Unusual air space in lung 2cm in diameter or bigger.

Question 22

Whta s the difference between a bullus and a bleb?

Answer 22

Bullus over 2cm diameter air space, bleb is smaller.

Question 23

WHat is Boyles law?

Answer 23

P1V1 = P2V2

Question 24

How can a Bulla cause a stroke?

Answer 24

Eg if go flying, bulla can increase in size due to decrease in pressure, can cause tear of pulmonary veins around the wall of bulla, Air can transmit from bulla to left atrium then ventrical, get lodged in brain - stroke.

Question 25

How do you deal with giant bulla?

Answer 25

Drain it (let the air escape)

Question 26

Indications of surgery in pneumothorax

Answer 26

Recurrence or persistance

Question 27

What is a talc pleurodesis?

Answer 27

The best treatment for pneumothoraxes, basically talc (irritant) is sprayed within pleural space, irritates the lining and then causes the layers to stick togther (and so helping to hold the lung to the chest wall).

Question 28

Why would we undertake surgery after first episode?

Answer 28

If the patient was a diver, did a lot of long haul/international flying/worked in the army/was going to be in remote areas for extended periods of time.

Question 29

What are Bronchogenic Cysts? Where are they usually located?

Answer 29

Congenital cysts usually found trachea or carina of trachea. Belong to “foregut duplication cysts”

Question 30

Conditions for Lung transplants

Answer 30

Cystic Fibrosis (double lung transplant)
Fibrosis of the lung (usually Ideopathic cause)
Emphysema when the cause is Alpha-1-Antitrypdin deficiency - causing premature emphysema throughout the lung (not just in upper lobes)

Question 31

Physical state for lung transplantation

Answer 31

Age < 65 years
Not overweight (as given prednisolone postoperatively - causes weight gain)
Not diabetic (same reason as above, prednisolone kicks diabetic control out the window)
No renal failure (immunosuppressive drugs can cause renal failure)
No mental illness
Good social support (eg to help driving to appointments and follow ups etc)

Question 32

Operative mortalities single and double lung transplantations.

Answer 32

Single = 10%
Double = 20%