McNeil's - surgery Flashcards
All of the following increase the incidence of hernia/wound dehiscence EXCEPT
a. wound infection
b. steroids
c. pulmonary complications
d. previous surgery
e. NIDDM
D?
[Incisional hernias] occur as a result of excessive tension and inadequate healing of a previous incision, which is often associated with surgical site infections. These hernias enlarge over time, leading to pain, bowel obstruction, incarceration, and strangulation. Obesity, advanced age, malnutrition, ascites, pregnancy, and conditions that increase intra-abdominal pressure are predisposed factors to the development of an incisional hernia.
- Sabiston
Poor surgical technique is the worst, wound infection second worst, then age, then comorbidities, then obesity … See Way p793
The incidence of wound disruption ranges from 0.5 to 3.0% and averages about 2% in abdominal operations. The incidence rises to 5% in elderly patients, which suggests that coexisting diseases or the integrity of the fascial tissue itself is also an important factor. Other predisposing factors include malnutrition, obesity, acquired or pharmacologic immune deficiency, diabetes, renal insufficiency, and advanced malignancy. Local wound events, such as infection, hematoma, and ischemia, are also causative factors. Improper or inadequate surgical technique is assumed to be the cause in most cases of dehiscence, because the use of properly placed retention sutures greatly reduces the incidence of dehiscence. In adults, improper closure of fascia around an ostomy or the inclusion of a stoma within an incision also predisposes to dehiscence.
Wound dehiscence is also associated with vitamin deficiency, drug treatment, and other therapy. Vitamin C deficiency is associated with wound disruption, particularly in elderly patients. Zinc, which is an important cofactor for epithelial and fibroblast growth and function, may be deficient due to malnutrition, chronic diarrhea, or hepatic disease. Chronic steroid use, chemotherapy, and radiation therapy also impair the inflammatory response of healing and are associated with greater rates of dehiscence.
- Sabiston
Complications of cough include wound dehiscence.
- Cough: A Worldwide Problem. Otolaryngologic Clinics of North America - Volume 43, Issue 1 (February 2010)
Which of the following is the most ideal place to bring out an end colostomy from a sigmoid colon resection:
a) left upper quadrant lateral to the rectus sheath
b) Right lower quadrant above the inguinal ligament
c) Left lower quadrant through the rectus sheath
d) Left lower quadrant lateral to the rectus sheath
c) Left lower quadrant through the rectus sheath
- left b/c sigmoid colon
- through the rectus sheath to help it stay together
A patient develops acute pancreatitis post ERCP. The best way to feed this patient is:
a) Enteral
b) parenteral
c) enteral via gastric tube
d) clear fluids per os
a) Enteral
Three randomized control trials have demonstrated that enteral feeding is not only safe and feasible but also associated with fewer infectious complications and lower cost than parenteral nutrition is.
- Goldman: Cecil Medicine, 23rd ed.
Several investigative groups have recently demonstrated that most patients with pancreatitis, including those with severe pancreatitis, can actually tolerate small amounts of enterally administered nutrients. They have shown that those nutrients can be tolerated if given either into the stomach (through a nasogastric tube) or into the small intestine (through a nasojejunal tube).
- Townsend: Sabiston Textbook of Surgery, 18th ed.
What is the most common abnormality associated with a Meckel’s diverticulum? A. Patent urachus B. Enteroumbilical fistula C. Ectopic gastric mucosa D. Intestinal volvulus
C. Ectopic gastric mucosa
most common complication = gi bleeding
The Meckel diverticulum occurs as a result of failed involution of the vitelline duct, which connects the lumen of the developing gut to the yolk sac. This solitary diverticulum is a small pouch extending from the antimesenteric side of the bowel ( Fig. 17-2 ). It is a true diverticulum with a wall that includes mucosa, submucosa, and muscularis propria. Meckel diverticulae occur in approximately 2% of the population, are generally present within 2 feet (85 cm) of the ileocecal valve, are approximately 2 inches (5 cm) long, are twice as common in males as in females, and are most often symptomatic by age 2 (although only ∼4% of Meckel diverticulae are symptomatic). These facts comprise the “rule of 2s” that is often used to help remember characteristics of Meckel diverticulae. The mucosal lining of Meckel diverticulae may resemble that of normal small intestine, but ectopic pancreatic or gastric tissue may also be present.
- Kumar: Robbins and Cotran Pathologic Basis of Disease, Professional Edition , 8th ed.
Intestinal obstruction caused by intussusception, volvulus, herniation, or entrapment of a loop of bowel through a defect in the diverticular mesentery (6%)
The majority of complicated cases of Meckel diverticulum contain ectopic mucosa (75% gastric, 15% pancreatic).
- Ferri: Ferri’s Clinical Advisor 2010, 1st ed.
Cancer of the head of the pancreas obstructing the bile duct will cause all of the following except:
a) Increased serum bilirubin
b) Increased urine bilirubin
c) Increased urine urobilirubin
d) Decreased stool pigmentation
Urine urobilinogen is decreased or absent when normal amounts of bilirubin are not excreted into the intestinal tract. This usually indicates partial or complete obstruction of the bile ducts.
What is the most common cause of appendicitis?
a) Fecalith
b) Immunologic tissue hyperplasia
c) Infection
d) Crohn’s
DEPENDS ON THE AGE??
a) Fecalith
Answer = fecalith vs immunolgoic tissue hyperplasia
obstruction related to lymphoid hyperplasia (>60%)
- ? source
In the young, lymphoid follicular hyperplasia due to infection is thought to be the main cause. In older patients, luminal obstruction is more likely to be caused by fibrosis, fecaliths, or neoplasia (carcinoid, adenocarcinoma, or mucocele)
-uptodate
Acute appendicitis is thought to be initiated by progressive increases in intraluminal pressure that compromise venous outflow. In 50% to 80% of cases, acute appendicitis is associated with overt luminal obstruction, usually caused by a small stone-like mass of stool, or fecalith, or, less commonly, a gallstone, tumor, or mass of worms (oxyuriasis vermicularis).
- Kumar: Robbins and Cotran Pathologic Basis of Disease, Professional Edition , 8th ed.
Review of pathologic series shows that luminal obstruction is found in the minority of cases. Fecaliths are present in only 8% to 44% of cases of acute appendicitis, with most series at the lower end of the range, [14] [15] [17] and lymphoid hyperplasia is more common in noninflamed appendices than in acute appendicitis.
- Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8th ed.
What is the difference between an omphalocele and gastrocshisis?
Omphalocele has the sac and gastrocshisis has no sac at all
Omphalocele- the intestines or other body organs extend outside the infant’s abdominal cavity through an opening in the area of the umbilical cord. The protruding intestines or organs are covered with a thin-like membrane.
Gastroschisis- there is also an opening in the abdominal wall through which internal organs spill out of the abdominal cavity. The opening develops in the same manner as with an omphalocele, and the opening can also be small or large. However, in newborns with gastroschisis, the aperture is usually located on the right side of the umbilical cord and the organs are not covered with a membrane. Since the organs are uncovered in the amniotic fluid, there is a greater chance of infection or damage to them.
9 month pregnant lady with RUQ pain. What is the most likely diagnosis:
a. Acute cholecystitis
b. Gastric ulcer
c. GERD
d. Acute Appendicitis
e. PDU
Acute appendicitis is the most common nonobstetric surgical emergency during pregnancy, with an incidence of about 1 per 1,000 pregnancies. Displacement of the appendix by the gravid uterus during late pregnancy may cause the point of maximal abdominal pain and tenderness to migrate superiorly and laterally from McBurney’s point.
- Gabbe: Obstetrics: Normal and Problem Pregnancies, 5th ed.
Duodenal Atresia is most often associated with:
a. Down’s syndrome
b. Cardiac anomalies
c. Trisomy
d. Radiation exposure
e. Marfan syndrome
a. Down’s syndrome
Trisomy 21 is strongly associated with duodenal atresia / stenosis / web in that anywhere from 25% to more than 50% of cases occur in infants and children with this chromosomal anomaly.
- Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8th ed.
Duodenal atresia is complete obliteration of the duedenal lumen. Etiology is unknown… but thought to be due to failure to recanalize 2nd part of duodenum. 1 in 6000 births. 50% of infants with duodenal atresia are born prematurely. Most commonly associated with trisomy 21. About 22-30% of patients with duodenal obstruction have trisomy 21.
In a complete SBO:
a. The small bowel remains sterile
b. Fecal organism predominate
c. Gram positive organisms predominate
d. Mixed organism predominate
e. Fungi predominate
b. Fecal organism predominate?
In the absence of intestinal obstruction, the jejunum and proximal ileum of the human are virtually sterile. With obstruction, however, the flora of the small intestine changes dramatically, in both the type of organism (most commonly Escherichia coli, Streptococcus faecalis, and Klebsiella species) and the quantity, with organisms reaching concentrations of 10^9 to 10^10/mL.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
What vitamin deficiency will short bowel syndrome have?
Vitamin B12 if less than 100 cm of ileum b/c bile salts still absorbed
Resection of over 100 cm of ileum leads to a reduction in the bile salt pool that results in steatorrhea and malabsorption of fat-soluble vitamins (ADEK).
(see detailed notes)
Vitamin K is absorbed predominantly in the ileum and requires the presence of bile salts. Clinically significant vitamin K deficiency occurs with malabsorption of fat-soluble vitamins secondary to obstructive jaundice or with malabsorption caused by intrinsic small bowel diseases, including celiac sprue, short-bowel syndrome, and inflammatory bowel disease.
- Goldman: Cecil Medicine, 23rd ed.
The most common cause of colovesicular fistula is:
a. Crohn’s disease
b. Diverticulitis
c. Radiation
d. Bladder cancer
e. Colon Cancer
b. Diverticulitis
Diverticulitis accounts for approximately 50%-70% of vesicoenteric fistulae, almost all of which are colovesical.
- http://emedicine.medscape.com/article/442000-overview
30 year old male patient presents to the clinic with bright red blood per rectum. the next step in management is:
a. Full colonoscopy and barium enema
b. Colonoscopy and banding haemorrhoids
c. Sigmoidscopy and banding of haemorrhoids
d. Sigmoidoscopy only
e. Banding of haemorrhoids only
Answer: Sigmoidscopy and banding of haemorrhoids
Anoscopy is the definitive examination, but a flexible proctosigmoidoscopy should always be added to exclude proximal inflammation or neoplasia. Colonoscopy or barium enema should be added if the hemorrhoidal disease is unimpressive, the history is somewhat uncharacteristic, or the patient is older than 40 years or has risk factors for colon cancer, such as a family history.
- Townsend: Sabiston Textbook of Surgery, 18th ed
1) All are manifestation of abdominal compartment syndrome except:
a. UOP 10cc/hr
b. Increase airway pressure
c. Hypoxia
d. Elevated CVP
2) Patient suddenly becomes hypotensive while intubated and ventilated. Which of the following is a sign of abdominal compartment syndrome
a – increased peak inspiratory pressure
b – deceased cardiac output
c – lymphocytosis
c?
b- reduced cardiac output
I’m not sure
Clinical manifestations:
Cardiovascular: cephalad movement of diaphragm. Can cause direct cardiac compression, reducing both ventricular compliance and contractility. Functionally obstruct IVC and femoral viens and subsequently reduce venous return to the heart. Invasively measured intravascular pressures, including PCWP and CVP are elevated with increased IAP despite reduced venous return and CO. But… not reflective of true intravascular volume.
Pulmonary: intraabdominal pressure is transmitted through the thorax through the elevated diaphragm, resulting in extrinsic compression of pulm parenchyma. This results in atelectasis, edema, decrease o2 transport, increased intrapulm shunt fraction and increased alveolar dead space. In mechanically ventillated patient peak inspiratory and mean airway pressures are increased.
Renal: decreased renal function caused directly by increased venous resistence (and therefore impaired venous drainage) and indirectly by arterial vasoconstriction mediated by stim. of sympathetic nervous and renin-angiotensin systems by the fall in cardiac output. ** renal dysfunction thought to be more from increased renal venous pressure rather then direct compression on parenchyma
G.I.: changes in mesenteric blood flow as low as 10mmHG. Decreased intestinal mucosal blood flow at 20 mmHg and at 40 mmHg celiac artery blood flow and SMA are decreased by 43 and 69 %
Hepatic: decreased ability of liver to clear lactic acid (only at 10mmHg)
CNS: elevated CVP can induce increases in ICP. This in combo with hypotension and decrease CO can lead to cerebral hypoperfusion.
The findings of a tensely distended abdomen, progressive oliguria despite adequate CO, or hypoxia with increasing airway pressure are sufficient to justify abdominal decompression.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
70 year old patient with history of A.fib and arthritis. Developed sudden severe abdominal pain. Had one BM today and vomited twice. Abdominal exam revealed generalized tenderness but not peritonitis. She had tubal ligation in the past. What is the most probable diagnosis:
a. Acute mesenteric embolic ischemia
b. Perforated PUD
c. Intestinal obstruction
d. Rupture AAA
Answer: Acute mesenteric embolic ischemia
keyword: afib, general tenderness but not peritonitis
If on coumadin and aspirin could have bleeding PUD.
Afib if non anticoagulated could cause emboli.
a 56 year old female develops abdominal pain and sepsis with an anion gap metabolic acidosis 4 days after undergoing a triple vessel coronary artery bypass graft. She is diagnosed with a small bowel infarction. The most likely cause is
a. ileus
b. superior mesenteric vein thrombosis
c. arterial thrombosis secondary to low flow
d. arterial thrombosis secondary to emboli
e. none of the above
Answer: arterial thrombosis secondary to emboli
???
Embolization to the intestine via the SMA (SMA embolus) accounts for 5% of peripheral emboli and nearly 50% of cases of primary noncolonic mesenteric ischemia. Emboli most commonly originate from the heart, with an aortic origin being less common ( Table 146-2 ), and tend to obstruct beyond the origin of the SMA.
- Goldman: Cecil Medicine, 23rd ed.
Acute Mesenteric Ischemia: Metabolic acidosis is a late finding.
- Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 8th ed.
All of the following are relative contraindications to laparoscopy except
a. abdominal wall infection
b. coagulopathy
c. congestive heart failure
d. umbilical hernia
e. right heart failure (cor pulmonale)
d. umbilical hernia
[P]atients who are not candidates for a general anesthetic, such as those with severe cardiopulmonary disease, should not undergo laparoscopy. Physicians must be cognizant of conditions that may alter a patient’s physiology, such as the pneumoperitoneum, which may further compromise ventilation, and compression of the vena cava, which may limit venous return (Arthure, 1970; Hodgson et al, 1970; Nunn, 1987; Lew et al, 1992). Patients with mild to moderate chronic obstructive pulmonary disease may have difficulty compensating for the hypercarbia, and the pneumoperitoneum may need to be kept at lower pressures than usual (Monk and Weldon, 1992; Adams et al, 1995a). Laparoscopy should also be avoided in patients with severely dilated bowels from either functional or obstructive ileus. In these cases, the dilated intestines take up working space and may be injured during access and dissection (Borten, 1986). Other absolute contraindications include uncorrected coagulopathy, untreated infection, and hypovolemic shock (Capelouto and Kavoussi, 1993).
Several conditions require caution when considering a laparoscopic approach. Prior intra-abdominal or retroperitoneal surgery is not a contraindication to laparoscopy; however, each case must be carefully assessed. Prior transperitoneal surgery can cause bowel adhesions to the abdominal wall or scar tissue formation about the operative site, increasing the possibility of injury during insertion of the Veress needle, trocar placement, or dissection (Borten, 1986). In approaching these patients, the Veress needle should be placed away from any scars and any prior surgical fields. Alternatively, open trocar placement can be undertaken to minimize access injuries (Hassan, 1971).
Obese patients should also be approached with discretion because abdominal wall fat may make trocar placement difficult and mask anatomic landmarks (Mendoza et al, 1996). Moreover, the weight of the pannus may raise the intra-abdominal pressure and limit the working space.
- Sabiston
all can cause post OP complication with known liver disease except :
- increase bilurubin
- increase PT
- AST, ALT
- Ascitis
- decrease albumin
Answer: ?ALT/AST
Child-Pugh Classification
Albumin, Bilirubin, PTT/INR, ascites, encephalopathy
The Model for End-Stage Liver Disease (MELD) score has replaced the Child-Pugh classification as the predominant prognostic model in end-stage liver disease. [21] [34] The MELD score, initially validated in patients undergoing elective transjugular intrahepatic portosystemic shunting, uses serum creatinine, bilirubin, and international normalized ratio. It is an independent predictor of mortality in patients with cirrhosis or those who are awaiting liver transplantation.
MODIFIED CHILD-PUGH CLASSIFICATION AND THE MELD SURVIVAL MODEL Numerical Score Parameter 1 2 3 Ascites None Slight Moderate or severe Encephalopathy None Gr 1-2 Gr 3-4 Bilirubin (mg/dl) 3 Albumin (mg/L) > 3.5 2.8-3.5 6 - Piccini & Nilsson: The Osler Medical Handbook, 2nd ed.
Strongest contraindication to PEG tube
a. history of colon resection
b. previous lap chole
c. inability to transilluminate abdominal wall
d. previous appendectomy
e. reflux esophagitis
Answer: inability to transilluminate abdominal wall No longer a contra-indication****
Absolute contraindications
Inability to perform an esophagogastroduodenoscopy
Uncorrected coagulopathy
Peritonitis
Untreatable (loculated) massive ascites
Bowel obstruction (unless the PEG is sited to provide drainage)
Relative contraindications
Massive ascites
Gastric mucosal abnormalities: large gastric varices, portal hypertensive gastropathy
Previous abdominal surgery, including previous partial gastrectomy: increased risk of organs interposed between gastric wall and abdominal wall
Morbid obesity: difficulties in locating stomach position by digital indentation of stomach and transillumination
Gastric wall neoplasm
Abdominal wall infection: increased risk of infection of PEG site
- Gastroenterological endoscopy. Meinhard Classen, G. N. J. Tytgat, Charles J. Lightdale. 2002
A number of contraindications to PEG tube placement exist:
- No endoscopic access
- Severe coagulopathy
- Gastric outlet obstruction
- Anticipated survival of less than 4 weeks
- Inability to approximate the gastric wall to the abdominal wall
- Townsend: Sabiston Textbook of Surgery, 18th ed.
A 30 year old male has a palpable node along the right inguinal ligament. What WOULD NOT be a possible source?
a) cellulitis of the right thigh
b) a scrotal incision
c) a lesion of the glans of the penis
d) a testicular tumour
e) a mass on the lower right abdominal wall
Answer: a testicular tumour – drains to para-aortic nodes
Testicular cancer [has] a very predictable and systematic pattern of metastatic spread from the primary site to the retroperitoneal lymph nodes and, subsequently, to the lung and posterior mediastinum
- Wein: Campbell-Walsh Urology, 9th ed.
The following statements regarding the spleen are true EXCEPT:
a. Lack of Howell-Jolly bodies after splenectomy suggests an accessory spleen or splenosis.
b. Levels of properdin and tuftsin fall after splenectomy.
c. Accessory spleens are found in 15-30% of people.
d. The spleen can only remove cells coated with immunoglobulin A (IgA).
e. All of the above statements are true.
Answer: The spleen can only remove cells coated with immunoglobulin A (IgA).
It has also been found that immunoglobulin (Ig) G-sensitized red cells are rapidly removed from the circulation by the spleen and that unusually rapid clearance persists well into the convalescent phase.
- Hoffman: Hematology: Basic Principles and Practice, 5th ed.
Which of the following is MOST effective in preventing LATE complications of splenectomy?
A. Adminstration of pneumococcal and H. flu vaccines
B. Perform only laparoscopic splenectomy
C. Perform sub-total splenectomy
D. Give patients antibiotic prophylaxis post-operatively
Answer: Adminstration of pneumococcal and H. flu vaccines
The current recommendations for patients who are undergoing elective splenectomy include vaccination of persons susceptible to Pneumococcus strains.
For patients who are at particularly high risk because of immunosuppression, polyvalent vaccines are also available against Neisseria meningitidis and Haemophilus influenzae type B
The pneumococcus is singularly the most important organism in PSS, involved in 50% to 90% of cases.[26,27] In a review of 349 PSS cases, Streptococcus pneumoniae was causative in 66% of episodes in which a bacterium could be identified.
Type b H. influenzae (Hib) is the second most common organism in PSS.[26,27] Most Hib-associated PSS cases have occurred in children younger than 15 years, 86% in one review,[27] with a frequency about 10 times lower than that of the pneumococcus. Neither nontypable nor non-b capsular strains (a, c-f) are significant PSS pathogens. Use of the conjugated Hib vaccine has dramatically decreased the incidence of invasive Hib disease.
- Mandell: Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 7th ed.
Pneumococcal infections account for 50-90% of cases reported in the literature and may be associated with a mortality rate of up to 60%. H influenza type B, meningococci, and group A streptococci account for an additional 25% of infections
Which of the following is indicative of a blood test post splenectomy? A. Thrombocytosis B. Neutropenia C. Spherocytosis D. Anemia
A. Thrombocytosis
Can also have leukocytosis
“Leukocytosis and increased platelet counts commonly occur following splenectomy as well. “
Postsplenectomy thrombocytosis may be associated with both hemorrhagic and thromboembolic phenomena.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
Granulocytosis immediately, then Thrombocytosis, RBC’s have inclusion bodies ie Howell-Jolly bodies and friends…
Splenectomy results in characteristic changes to blood composition, including the appearance of Howell-Jolly bodies and siderocytes. Leukocytosis and increased platelet counts commonly occur following splenectomy as well.
In addition, thrombocytosis and leukocytosis are observed because the spleen functions as a reservoir for these blood cells.
- http://emedicine.medscape.com/article/885226-diagnosis
All of the following have an enlarged spleen except:
a) ITP
b) Liver cirrhosis
ITP.
Splenomegaly excludes the diagnosis of ITP!
With regards to intra-aortic balloon pumps, which of the following is TRUE?
A. It consistently decreases inotropic dosages required
B. It deflates during early systole
C. It maintains a high diastolic pressure
D. It increases cardiac preload
C. It maintains a high diastolic pressure
Intraaortic balloon pump (IABP) counterpulsation is a very effective means of increasing diastolic coronary blood flow and reducing left ventricular afterload, which act in concert to reduce ischemia.
- Libby: Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.
As it is inflated with an internal pressure of helium that is greater than intraaortic pressure, it will displace 40ml of blood from the aorta. This added volume causes an increase in aortic pressure and diastolic blood flow (diastolic augmentation). The rapid deflation of the balloon leaves a 40ml void, which effectively decreases aortic pressure and thus left ventricular afterload, during early systole. These beneficial hemodynamic changes – diastolic augmentation and systolic afterload reduction – can greatly increase coronary blood flow and decrease myocardial oxygen consumption.
- Critical care handbook of Mass General pg 219
Intra-aortic balloon pumping improves mean blood pressures and coronary artery perfusion and decreases cardiac work and oxygen demand.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
Insertion of an intra-aortic balloon pump (IABP) for counterpulsation increases diastolic coronary artery perfusion pressure, decreases LV afterload, improves cardiac output, and decreases myocardial oxygen demand.
Management of RV infarction consists of early maintenance of RV preload with intravenous fluids, reduction of RV afterload (i.e., afterload-only reducing drugs as for LV dysfunction; consider intra-aortic balloon pump).
- Goldman: Cecil Medicine, 23rd ed.
balloon deflated prior to and during early left ventricular ejection thus reducing aortic pressure and thus afterload.
- http://www.aic.cuhk.edu.hk/web8/IABP.htm
Which of the following is a contraindication for Intra-Aortic Balloon Pump?
a) severe AS
b) severe AR
c) CHF
d) Recent MI
e) ventricular aneurysm
The use of IABP is absolutely contraindicated in the setting of aortic insufficiency and aortic dissection. Relative contraindications for use via a femoral arterial approach relate to the vascular consequences of cannulation—significant aortoiliac or iliofemoral disease, and abdominal or descending thoracic aortic aneurysms.
- Libby: Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.
Anterior mediastinal mass, is likely
a-Lymphoma
b-Lung Cancer
c-Thymoma was not one of the options
a-Lymphoma
Most common anterior mediastinal mass is:
a) Lymphoma
b) Teratoma
c) Bronchogenic cyst
d) Pericardial cyst
1) Lymphoma
All mediastinal masses:
Thymoma (20%) > Lymphoma > Teratoma or Thyroid goiter
Anterior mediastinum Four Ts Thymoma (45%) “Terrible” lymphoma (20%) Teratoma (15%) Thyroid (or parathyroid) (15%) Also neurogenic or mesenchymal tumors (5%)
4 T’s” (Thymoma, Terrible lymphoma, Teratoma, and Thyroid)
Middle Mediastinum:
- Lymphoma
- bronchogenic lung CA
Posterior Mediastinum neurogenic tumors (schwannoma, neurofibroma,)
A patient presents with fatigue, muscle weakness and tires with chewing. A CXR reveals a 7cm mass in the anterior mediastinum. Which of the following tests would CONFIRM the diagnosis? A. CT with contrast B. Tensilon test C. Deltoid muscle biopsy D. Bronchoscopy
B. Tensilon test
About 50% of patients with an underlying thymic tumour are asymptomatic, and diagnosis is often incidental. However, the most important factor to elicit is a history of myasthenia gravis or muscle weakness consistent with myasthenia gravis (about 30% of patients with a thymoma have associated myasthenia gravis). Patients with myasthenia gravis may have ocular symptoms only (double vision, drooping eyelids) or generalised muscle weakness, especially facial and oropharyngeal weakness (suggested by difficulty in chewing and swallowing) and/or proximal limb weakness (suggested by difficulty with getting out of chairs or climbing stairs).
The diagnosis of MG is based on clinical disease history and typical clinical findings. MG can be confirmed pharmacologically by edrophonium (Tensilon) test which is positive in 90% of MG patients, giving an immediate but transitory improvement of MG signs.
A battery of tests can be used in the assessment of the patient with suspected myasthenia gravis, but only a few are available to the emergency clinician. ACh receptor antibody assay is positive in more than 80% of patients with myasthenia but has a turnaround time of several days. Repetitive nerve stimulation and single-fiber electromyography tests are available in the electrophysiology laboratory. Several pharmacologic tests have been used to aid in the diagnosis of suspected myasthenia gravis including parenteral administration of edrophonium chloride (Tensilon), neostigmine, or curare. Edrophonium chloride administration for diagnosis of myasthenia gravis (Tensilon test) is described in detail because of the drug’s rapid onset, short duration of action, and widespread acceptance for this diagnostic challenge.
- Roberts: Clinical Procedures in Emergency Medicine, 5th ed.
All the following are absolute indications for thoracotomy tube except:
a) open pneumothorax
b) spontaneous pneumothorax
c) empyema
d) chyleme
b) spontaneous pneumothorax
Clinically stable patients with small pneumothoraces (PTXs) should be observed in the emergency department (ED) for 3–6 hr and discharged home if a repeat chest radiograph excludes progression of the PTX (good consensus).
- Roberts: Clinical Procedures in Emergency Medicine, 5th ed.
A man is injured waterskiing, resulting in a massive laceration across his chest. He presents to the ER with a stable BP of 100/60, HR of 100, and a chest tube is inserted draining 1200 ml immediately. He is stabilized at the community hospital and when he arrives at the trauma center he continues to drain 600 ml over the hour. What is the next step?
a) CT chest
b) Insert another chest tube
c) Irrigate, debride and repair the chest wound and clamp off the chest tube
d) Emergent thoracotomy
d) Emergent thoracotomy
Indications for emergency thoracotomy are initial chest tube output of 1500 mL of blood or persistent drainage of 200 to 300 mL/hr.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
A chest xray shows a right tension pneumothorax and a left diaphragmatic hernia. What is the MOST appropriate immediate action? A. Insert chest tube on the right B. Insert chest tube on the left C. Perform an emergent thoracotomy D. Insert NG tube
A. Insert chest tube on the right
The commonest cause of empyema is:
a. Malignancy
b. Bacterial pneumonia
c. Asthma
d. Viral pneumonia
e. Trauma
b. Bacterial pneumonia
Infections of the pleural space most commonly follow pneumonia, accounting for 40% to 60% of all empyemas. Thoracotomy is the next most common precursor of empyema, accounting for 20%, and trauma accounts for 4% to 10%. Less commonly, empyema can develop as a result of esophageal rupture and subdiaphragmatic spread. Other uncommon causes include hematogenous seeding of an existing pleural effusion and direct extension from head and neck infections.
- Mandell: Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 7th ed.
CAUSES OF EMPYEMA Cause Frequency (%) Pyogenic pneumonia 50 Postsurgical 25 Subphrenic abscess extension 10 Posttraumatic 3–5 Lung abscess rupture 1–3 Generalized sepsis 1–3 Pulmonary tuberculosis 1 Pulmonary mycotic infection 1 Spontaneous pneumothorax
The best management of chronic empyema:
a. Decortication
b. Pneumonectomy
c. IV antibiotics
d. Lobectomy
e. Chest tube insertion
Answer: Decortication
Phases: Proliferative, Exudative, Fibrino-purulent, Fibrosis
Which of the following is the MOST common cause of a spontaneous pneumothorax? A. Cystic Fibrosis B. Pulmonary Abscess C. Apical Bleb D. Emphysema
C. Apical Bleb
vs. emphysema
The question is awkward because it doesn’t consider primary vs secondary. But … it may be easier to answer based on the scenario (young skinny tall guy vs. old smoker)
The incidence of secondary spontaneous pneumothorax is similar to that of primary spontaneous pneumothorax.
- Mason: Murray & Nadel’s Textbook of Respiratory Medicine, 4th ed.
Blebs can be found in more than 75% of patients undergoing thoracoscopy for treatment of primary spontaneous pneumothorax.
- Mason: Murray & Nadel’s Textbook of Respiratory Medicine, 4th ed.
The most common condition associated with secondary spontaneous pneumothorax is chronic obstructive pulmonary disease (COPD), which accounts for nearly 70% of cases.
- Marx: Rosen’s Emergency Medicine, 7th ed.
So maybe bleb is the right answer? The answer key says emphysema.
Spontaneous pneumothorax is a collection of air or gas in the chest that causes the lung to collapse in the absence of a traumatic injury to the chest or lung. A primary spontaneous pneumothorax usually occurs at rest.
Spontaneous pneumothorax is seven times more likely to occur in males than females. Male smokers have 22 times the likelihood of spontaneous pneumothorax compared to non-smoking males. Female smokers have a nine times increase in the likelihood of a spontaneous pneumothorax compared to nonsmoking females. A spontaneous pneumothorax is most likely to occur during the fall or winter months. There are between 800 and 900 cases a year in Canada.
Usually, the rupture of a small bleb or bullae (an air- or fluid-filled sac in the lung) causes primary spontaneous pneumothorax. Secondary spontaneous pneumothorax occurs in the setting of known lung disease, most often chronic obstructive pulmonary disease (COPD). Other lung diseases commonly associated with spontaneous pneumothorax include: tuberculosis, pneumonia, asthma, cystic fibrosis, lung cancer and certain forms of interstitial lung disease.
If left untreated, recurrence rates of a spontaneous pneumothorax are high. Without treatment same side recurrence rates are as high as 30% at six months and up to 50% at two years.
Treatment of spontaneous pneumothorax
The objective of treatment is to remove the air from the pleural space, allowing the lung to re-expand. Small pneumothoraces may resolve on their own.
Aspiration of air, through a catheter to a vacuum bottle, may re-expand the lung.
The placement of a chest tube between the ribs into the pleural space allows the evacuation of air from the pleural space when simple aspiration is not successful or when the pneumothorax is large. Re-expansion of the lung may take several days with the chest tube left in place. Hospitalization is required for chest tube management.
Surgery may be recommended for recurrent episodes.
A 23 year old male presents with a second episode of a spontaneous pneumothorax. He is otherwise healthy. His management includes chest tube drainage ad which ONE of the following?
a) Apical bullectomy (via thoracoscopy)
b) CT chest
c) Chest tube drainage only
d) pleuradhesis
a) Apical bullectomy (via thoracoscopy)
We suggest that patients who are clinically stable with a recurrent PSP undergo chest tube insertion followed by VATS Video-assisted thoracoscopic surgery
Following a primary spontaneous pneumothorax, a patient is at risk of recurrence particularly in the months immediately after the first episode. Sadikot and associates[13] followed up 153 patients with primary spontaneous pneumothorax for a mean of 54 months and reported that 39% had a recurrent ipsilateral pneumothorax, most within the first year. Once a patient has a primary spontaneous pneumothorax there is also an increased risk of having a pneumothorax on the contralateral side. In the report of Sadikot and coworkers,[13] 15% of their 153 patients developed a pneumothorax on the contralateral side as well.
There have been several attempts to predict who will develop recurrent pneumothorax. Patients who are tall and those who continue to smoke are more likely to have a recurrence.[13] Yet, there is no relationship between the number of blebs or the size of the blebs on computed tomography (CT)[14] or the appearance of the lung at thoracotomy[15] and the risk of recurrence. Once a patient has had one recurrence, the risk of another recurrence increases to more than 50%.[16]
Most patients with their first primary spontaneous pneumothorax should be managed initially with simple aspiration of the pleural air with a plastic catheter. If this is ineffective, thoracoscopy should be performed promptly, with endo-stapling of blebs and pleural abrasion to create a pleurodesis. Patients with recurrent primary spontaneous pneumothorax should undergo thoracoscopy. When thoracoscopy is unavailable, patients who fail aspiration should be managed with tube thoracostomy with an attempt at pleurodesis with either doxycycline or talc. If, after 3 days of thoracostomy drainage, there is a persistent air leak or the lungs have not re-expanded, thoracotomy should be considered.
- Murray & Nadel: Textbook of Respiratory Medicine, 3rd ed.
Surgical treatment (usually thoracotomy with abrasion of pleural surfaces) is advocated at the time of the first or second recurrence. [33] [34] Patients who have had one pneumothorax have a 30 to 50% chance of ipsilateral recurrence within 1 to 2 years. [33] After a second spontaneous pneumothorax, the probability of a third rises to 50 to 80%. [33] [35] Surgery may be recommended on the occasion of a patient's first pneumothorax in a number of situations: life-threatening tension pneumothorax, massive air leaks with incomplete reexpansion, an air leak persisting 4 to 5 days after a second intercostal tube has been placed, associated hemothorax with complications, cases of identifiable bullous disease, and failure of easy reexpansion in patients with cystic fibrosis. - Roberts: Clinical Procedures in Emergency Medicine, 3rd ed., Copyright © 1998
A 70 year old ♂ with a history of COPD presents acutely SOB after a vomiting episode. He is diagnosed with a right pneumothorax on presentation. He was appropriately treated with right-sided chest tube and underwater closed suction. 48 hours later, he becomes febrile, with chills, elevated WBCs, and brown purulent, foul-smelling drainage from chest tube. The MOST likely cause is:
A. Empyema secondary to insertion of chest tube
B. Esophageal perforation
C. Necrotizing pneumonia
D. Infected Hematoma
The diagnosis of esophageal rupture should always be considered in the differential diagnosis of exudative pleural effusions because, if this condition is not rapidly treated, the mortality increases, with current estimates ranging between 30% and 60%.[294] Approximately 60% of patients with esophageal perforation have a pleural effusion, whereas about 25% have a pneumothorax.[295] The pleural effusion is usually left sided ( Fig. 68.9 ), but it may be right sided or bilateral.
- Mason: Murray & Nadel’s Textbook of Respiratory Medicine, 4th ed
Older female with episode of vomiting resulting in severe retrosternal chest pain, SQ emphysema and a tender neck. CXR done, what is the next step:
a) CT chest
b) Contrast esophagogram
c) Esophagoscopy – CI
d) Bronchoscopy
b) Contrast esophagogram
2016: uptodate says Dx with contrast esophagogram or CT
When the diagnosis is considered, a water-soluble contrast agent should be administered. If this study is negative, dilute barium should be administered. Barium is relatively inert, and the fear of barium extravasating into the mediastinum through the site of injury and producing a severe reactive mediastinitis is unfounded. The risk of barium leaking into the mediastinum is far less than that of failing to recognize the perforation in a timely fashion. Also, because barium provides far better mucosal detail than water-soluble agents, only if barium has been used for the esophagogram should this study in search of a perforation be termed negative.
- Greenfield
Esophagogram is a contrast radio-graph of the esophagus. Gastrografin Contrast Esophagogram is often used to confirm the diagnosis and to locate the position of esophagial perforation.
Following gastroscopy with esophageal dilatation, a patient develops retrosternal chest pain. EKG shows tachycardia with no other abnormality. A cxr shows air within the mediastinum. A gastrograffin swallow shows extravasation of contrast. The next treatment is:
a. observation
b. antibiotics and ng tube placement fluoroscopically
c. antibiotics and repeat gastroscopy with NG tube placement
d. urgent thoracotomy and primary esophageal repair
e. none of the above
e? do a esophagogram or CT
Nonoperative management should be reserved for clinically stable patients with no evidence of systemic inflammation, expediently diagnosed perforations, and no drainage of any collection into the pleura or peritoneum.
A major leakage, or one that occurred through a tumor or an ulcer, requires urgent operation. Limited or absent extravasation on radiographic study allows treatment by intravenous antibiotics and close observation.
The esophagus or stomach is perforated during diagnostic upper endoscopy in 0.03% to 0.1% of procedures. [6] [22] [65] Perforation occurs most commonly when the endoscope is passed blindly–namely, in the pharynx or upper esophagus–and the esophagus is perforated more commonly than the stomach. [37] Osteoarthritic spurs on the cervical spine, Zenker’s diverticulum, anastomoses, strictures, and weakening of the wall of the esophagus or stomach from inflammation, neoplasm, or ingestion of caustic substances are predisposing factors. Perforation of the midesophagus usually results from biopsy of a carcinoma
Endoscopic perforation of the esophagus or stomach may be obvious immediately or within a few hours. Cervical pain, subcutaneous emphysema, fever, tachycardia, and characteristic radiographic appearances make the diagnosis easy, but some distal esophageal injuries are more subtle. [37] An esophagogram should be obtained immediately if perforation is suspected. After ensuring that the patient does not aspirate on swallowing, a water-soluble contrast material should be used for the esophagogram. If the perforation site cannot be identified by this method, a small amount of barium can be used. A major leakage, or one that occurred through a tumor or an ulcer, requires urgent operation. Limited or absent extravasation on radiographic study allows treatment by intravenous antibiotics and close observation.
- Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 6th ed., Copyright © 1998
The following is due to an abnormality in the cricopharyngeous muscle:
a. Zenkers diverticula
b. Schatzki ‘ s ring
c. Esophageal web
a. Zenkers diverticula
Not a true diverticulum (unlike meckle’s)
True diverticulum of the esophagus at the level of mediastium (due to maliganacy)
SCC of esophageal cancer is not associated with:
a. Barrett’s
b. Achalasia
c. Upper esophageal web
d. Smoking
a. Barrett’s (adenocarcinoma)
Squamous cell carcinomas arise from the squamous mucosa that is native to the esophagus and is found in the upper and middle third of the esophagus 70% of the time. This type of cancer is due to exposure to environmental factors. Smoking and alcohol both increase the risk for foregut cancers by 5-fold. Combined, the risk increases from 25- to 100-fold. Food additives, including nitrosamines found in pickled and smoked foods, long-term ingestion of hot liquids, and vitamin (vitamin A) and mineral deficiencies (zinc and molybdenum) have been implicated. Other disorders that expose the esophagus to mucosal trauma including caustic ingestion, achalasia, bulimia, tylosis (an inherited autosomal dominant trait), Plummer-Vinson syndrome, external-beam radiation, and esophageal diverticula all have known associations with squamous cell cancer.
Progressive changes from metaplastic (Barrett’s esophagus) to dysplastic cells may lead to the development of esophageal adenocarcinoma.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
Risk of transforming Barrett’s esophagus to Adeno ca is :
a. 1% / year
b. 5% /year
c. 10% /year
d. 15% /year
Prospectively following 100 patients with Barrett’s esophagus for 1 year will result in 1 patient developing adenocarcinoma, a rate of 1% per year.[13] This is a similar risk to that of patients with a 20-pack-year smoking history developing lung cancer
- Townsend: Sabiston Textbook of Surgery, 18th ed.
All of the following are complications of chylothorax except :
a. B cell leucopenia
b. Dehydration
c. Electrolytes abnormalities
d. Hypoproteniemia
e. Low glyecero
a. B cell leucopenia
i don’t know what a glyecero is
The primary cellular component of chyle is the T lymphocyte. Prolonged loss of chyle results in severe nutritional depletion, water and electrolyte loss, hypolipemia, and lymphopenia of T cells with resulting immunosuppression.
- Murray & Nadel: Textbook of Respiratory Medicine, 3rd ed
Normal chyle flow ranges between 1.5 and 2.5 L/day but can vary much more widely depending on diet and on the fat content of the diet. During starvation or intravenous feeding, flow falls to about 250 mL/day of clear fluid. Chylothorax is frequently massive (Fig. 16-31) and symptomatic, and significant volume losses can occur through thoracentesis or chest tube drainage. Dehydration, nutritional losses, and a steady decline in circulating lymphocytes can produce significant disability and an increased susceptibility to infection
- Schwartz Chap 16
During neck surgery thoracic duct was injured and the injury was discovered during the surgery the treatment of choice is:
a. Ligate the duct
b. Insert a drain
c. Do nothing
d. Post op antibiotics
e. All of the above
a. Ligate the duct
Ligation is 1st option, if you can’t then apply a Drain and start on Medium Chain Fatty Acid Diet to decrease Lymph production, this will slow the output down and may close spontaneously. If not then go back and operate to find and ligate it.
For patients with thoracic duct injury and an effusion that persists after 1 week of drainage, video-assisted thoracoscopy or thoracotomy is employed to identify and ligate the thoracic duct above and below the leak.
- Townsend: Sabiston Textbook of Surgery, 18th ed.
During dissection in the region of the lower jugular vein, the thoracic or lymphatic duct should be carefully ligated if identified.
- Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.
In a recent review of 823 neck dissections performed by the surgeons at Memorial Hospital in New York City that included the removal of the lymph nodes in level IV, Spiro, Spiro, and Strong[68] found that 14 patients (1.9%) developed a chyle fistula. In this and other studies,[17] a chylous leakage was identified and apparently controlled intraoperatively in the majority of patients who developed the complication. These observations remind the surgeon to not only avoid injury to the thoracic duct proper but also to ligate or clip any visualized or potential lymphatic tributaries in the area of the thoracic duct.
- Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.
A chyle leak found POD 3 from a woman with neck dissection. How to best manage?
a) Leave in closed suction drain and start TPN
b) Take out drain and start TPN
c) Explore and repair duct
d) Administer enteral feeds with medium branched chain fatty acids
e) Leave in drain and make patient NPO
Answer:
- Leave in closed suction drain and start TPN
- Thoracostomy tube and TPN nutrition
Basically if you’re right there staring at the duct that is leaking, ligate it. If it’s not intra-op, TPN and drain
Total parenteral nutrition allows for control of the fluid and protein loss while avoiding flow of chyle, and in most cases it results in resolution.
Management of chyle fistulization in association with neck dissection.
- Gregor RT - Otolaryngol Head Neck Surg - 01-Mar-2000; 122(3): 434-9
Always consider conservative management because the thoracic duct leak closes spontaneously in nearly 50% of patients. Few or no symptoms and minimal chyle loss characterize these cases.
• Decompress the pleural space with tube thoracostomy or repeated thoracentesis to keep the lung expanded against the chest wall and mediastinum.
• Reduce chyle production by instituting total parenteral nutrition or a fat-restricted oral diet supplemented with medium-chain triglycerides.
Patient is post-op right thoracotomy and is draining milky fluid via incision. What is the best initial treatment?
- exploration and ligation of thoracic duct
- chest tube and TPN
- NPO
Answer: chest tube and TPN
**depends on how much per day. If 500ml/day, for 1st week, then surgical intervention is indicated*****
If significant chyle drainage (>500 mL/d in an adult, >100 mL/d in an infant) continues despite TPN and good lung expansion, early surgical ligation of the duct is recommended.
Treatment of postoperative chylothorax
Postoperative chylothorax represents a grave complication with a mortality rate that may approach 50 percent. Management includes chest tube drainage and parenteral nutrition with the patient fasting or orally supplemented with MCT (enter portal vein system directly. Somatostatin and octreotide have been reported to decrease chyle production in postoperative chylothorax and in dog models with surgical transection of the thoracic duct. Duration of conservative therapy:
1) early repair if young and low risk
2) if drain >1L/day, repair day 5-7
3) if malignancy, repair earlier as malvourishment and immunocomprimise
4) post pneumonectomy may not need chest tube
Following diagnosis, management of a chylothorax consists initially of tube thoracostomy drainage (chest tube insertion) with complete lung re-expansion and supportive measures, such as a low-fat or fat-free diet supplemented by medium-chain triglycerides and aggressive fluid, electrolyte, and nutritional replacement or correction. Often, these measures are enough to promote closure of the thoracic duct pleural fistula. If the chylothorax is caused by malignancy, primary treatment of the neoplasm may be necessary. Radiation therapy to the mediastinum has been useful in managing chylothorax secondary to lymphoma.
Conservative measures for the treatment of chylothorax generally are maintained for 1 to 2 weeks. If the chylous effusion has not responded to this management, surgical intervention is indicated. The most common procedures are ligation of the thoracic duct or mass ligation of tissue at the diaphragmatic hiatus (generally through a right thoracotomy) or direct closure of the duct injury.
- Sabiston
The best location for a closed thoracostomy is:
a) 2nd intercostals space (ICS), mid-clavicular line
b) 2-3rd ICS, medial to scapula
c) 5th ICS, posterior midaxillary line
d) 3-4th anterior midaxillary line
none of those
5th ICS, anterior to mid-axillary line
- ATLS Guidelines
The preferred approach is through the fourth, fifth, or sixth intercostal space in the mid to anterior axillary line.
- Townsend: Sabiston Textbook of Surgery, 16th ed.,
