Lung Surgery

Question 1

Diagnostic methods in lung disease

Answer 1

CT
PET
Lung function test
Bronchoscopy
Pleural aspiration
Percutaneous biopsy
Mediastinoscopy
Thoracoscopy
Anterior mediastinotomy
Thoracotomy

Question 2

CT

Answer 2

Invaluable for staging of bronchogenic carcinoma

Question 3

PET

Answer 3

Evaluated for diagnostic accuracy for malignancy

Question 4

Lung function test

Answer 4

Detailed portrait of the physiological effects of the particular chest disease, and be used to monitor disease or treatment

Question 5

Bronchoscopy

Answer 5

Direct visualization & Biopsy (bronchial lesions or lung parenchyma (transbronchial biopsy))

Question 6

Pleural aspiration

Answer 6

Pleural effusion aspiration and cytology

Question 7

Percutaneous biopsy

Answer 7

X-ray or CT guidance

Question 8

Mediastinoscopy

Answer 8

Biopsy paratracheal and sometimes subcarinal lymph nodes. Access to entire middle and posterior mediastinum except sub-aortic fossa. NB close to SVC, Innominate artery, aorta, recurrent laryngeal nerve

Question 9

Thoracoscopy

Answer 9

Technique of choice for most pleural surgery (biopsy, pleurectomy, sampling of bull and evacuation of early empyema.; also for sampling of mediastinal lymph nodes and cervical sympathectomy.

Question 10

Anterior mediastinotomy

Answer 10

Obtain tissue from lesions in anterior mediastinum (e.g., thyme tumors). Enter on left or right side of sternum

Question 11

Thoracotomy

Answer 11

Full access for biopsy of paratracheal, subcarinal and hilar LN, the great vessels, esophagus, lung and pericardium

Question 12

Pneumothorax - Classification

Answer 12

Closed pneumothorax: Pleural defect closes spontaneously –> fixed amount of air in pleural space
Open pneumothorax: Free passage of air via an open defect in the visceral pleura
Tension pneumothorax: pleural defect acts as a flap valve; allowing progressive entry of air.

Question 13

Etiology of pneumothorax

Answer 13

Spontaneous - rupture of bull (young, lean, tall men)

Traumatic

Question 14

Evaluation of Pneumothorax

Answer 14

Hx and PE - deviated trachea, dilated neck veins, dyspnea, absent breath sounds, or no signs. Pleuritic chest pain, trauma, hypoxia and hyper-resonance to percussion.
Tension pneumothorax –> Immediate TX!
CXR in other cases (expiratory film) (2 PROJECTIONS!!!)
Also CT?!

Question 15

Treatment of Pneumothorax

Answer 15

• Semi sitting position
• Oxygen
• Aspiration of air (20 ml syringe)
• Chest tube if recurrence
• In tension pneumothorax: Large needle into the pleural space (2nd intercostal space midclavicular line). An apical chest drain position soon thereafter.
• Stapling of bullae
• Pleurectomy

Question 16

Etiology of Excess pleural fluid

Answer 16

Transudate (35 g/L of protein) (due to leakage of capillaries)

• Infections
• Inflammation
• Primary lung cancers
• Metastatic cancer of breast
• Mesothelioma

Question 17

Excess pleural fluid - Evaluation:

Answer 17

• Hx and PE: usually asymp or dyspnea, pleuritic chest pain, dull percussion, diminished breath sounds. Large effusions –> tracheal deviation
• X-ray: blunt costophrenic angles; larger= concave upper borders; Complete horizontal upper border = also air
• US: Identify presence of fluid and guiding of Dx or Tx aspiration

Question 18

Excess pleural fluid - Management:

Answer 18

• Tx underlying cause
• Semi sitting position
• Oxygen
• Drainage if symptomatic. Best removed slowly (

Question 19

Empyema - definition

Answer 19

Pleural fluid becomes infected, and pus accumulate in the pleural cavity. In early stages can be drained by intercostal tube w/ irrigation. In chronic cases a thick fibrous wall or cortex forms.

Question 20

Empyema - Dx:

Answer 20

Diagnostic aspiration

Question 21

Empyema - Tx:

Answer 21

Draining

Surgical removal

Question 22

Hemothorax - etiology:

Answer 22

Following chest trauma

Following open chest surgery

Question 23

Hemothorax - Evaluation

Answer 23

X-ray (2 projections!!!!)
US
Diagnostic aspiration/drainage

Question 24

Hemothorax - management:

Answer 24

• Drain via 2 large drains, one apically and one basally.
• Clotted blood may need evacuation w/ a thoracoscope or thoracotomy
• Persistent or increasing drainage of blood indicated continuing intrathoracic bleeding which often need surgical correction.

Question 25

Lung cancer - Etiology

Answer 25

Smoking
Passive smoking
Exposure to environmental factors
- Asbestos
- Arsenic
- Chromium
- Iron oxide
- Petroleum products
- Coal tar
- Products of coal combustion
- Radiation

Question 26

RED FLAGS of lung cancer

Answer 26

Cough
Recurrent pneumonia or unresponsive to AB
Nontypical asthma
Hemoptysis

Question 27

Symptoms of lung cancer

Answer 27

Cough
Chest pain
Coughing blood (hemoptysis - must do bronchoscopy and chest CT)
Chest infections
Malaise
Weight loss (>5% of body weight)
Shortness of breath
Hoarseness - pancoast tumor
Distant spread
Can give paraneoplastic syndrome

Question 28

Typical location of lung cancer:
1 - SCC
2- Adenocarcinoma

Answer 28

1 - centrally

2 - peripherally

Question 29

Treatment of lung cancer:

Answer 29

• TNM staging - fundamental for planning = CT
• Surgery: vary according to tumor type, and responsiveness of the tumor to other therapies. Also the general state of the pt. As a general principle, surgery is reserved for patients who are potentially curable. Surgery involves lobectomy or pneumonectomy sometimes with resection of involved chest wall and loco-regional LN sampling. If N0/N1 and M0 = 50% 5 yr survival rate.
• Radiotherapy = palliative)
  Used for disses to advanced for surgery
  Can increase life-expectancy, and provide effective palliation for troublesome complications, such as lobar collapse, hemoptysis, SVC obstruction or symptomatic metastases in brain or bone.
• Chemotherapy: (neoadjuvant, adjuvant, palliative)
  Non-small cell are usually resistant to chemo.
  No proven benefit of this therapy in patients with surgically resectable and potentially curable disease