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Utah / kirklin > Thoracic 1.0 > Flashcards

Thoracic 1.0 Flashcards

1
Q

% of those with emphysema that have a1-ATD

A

1-2 %

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2
Q

First layer of EUS

A

hyperechocic - epithelium and lamia propria

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3
Q

Types of emphysema

A
  1. proximal acinar
  2. pan- acinar
  3. distal acinar
  4. Irregular
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4
Q

Distal acinar emphysema

A

Fibrosis Sub-pleural, associated with Ptx

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5
Q

interstitial lung disease associated with the development of spontaneous pneumothorax

A

mnemonic : IES TLC

  1. Idiopathic pulmonary fibrosis
  2. Eosinophilic granuloma
  3. Sarcoidosis
  4. Tuberous sclerosis
  5. Lymphangioleiomyomatosis
  6. Collagen vascular disease
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6
Q

Lung abscess etiology

A
  1. Aspiration
  2. Post pneumonic
  3. Opportunistic
  4. Bronchial obstruction
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7
Q

alpha1-anti-trypsin enzyme

A

synthesized in the liver inhibits PMN leucocyte esterase –> protects elastic fibers from hydrolysis

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8
Q

alpha 1 - antitrypsin disease

A

40K patients in the US 1-2% of patients with emphysema Heterozygous - normal phenotype Homo - 10% of normal enzyme levels

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9
Q

Type A esophageal atresia

A

Esophageal atresia without TEF 8% of cases

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10
Q

Anatomic subtypes of emphysema

A

4 variants:

  1. proximal acinar
  2. panacinar
  3. distal fibrosis
  4. Irregular
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11
Q

Bacteriology of Bronchiectasis

A
  • H. flu
  • E. coli
  • klebsiella
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12
Q

stages of empyema as corelates to optimal intervention

A

Exudative (Acute) - tube thoracostomy Fibropurulent (transitional) VATS or open thoracotomy Organizing (chronic : 4-6 weeks): open thoracotomy, decortication

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13
Q

Surgical management of isolated esophageal atresia

A
  • Surgery
    1. prompt esophagostomy with the upper esophageal puch brought out the Left neck - to control saliva
    2. Gastrostomy is performed for feeding until esophageal replacement can be done at age 1
  • Alternatively, daily bougiage for primairy anastomosis by age 3 mo
  • natural growth and primairy repair at six months
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14
Q

Occupational / social issues prompting surgery for ptx

A

Pilot Scuba diver Lives in isolated area

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15
Q

First phase of the esophogram

A

First phase: mucosal exam with double contrast:

  1. barium
  2. CO2 tablets
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16
Q

Esophagoscopy - four points of narrowing

A
  • 15cm: upper esophageal sphicncer
  • 23 cm: Aortic constriction
    • indention on the left anterior lateral wall
  • 23: Left atrium - wave like pulsation of the distal esophagus
  • 40cm: LES
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17
Q

% of patients with emphysema who have clinical significant disease

A

10%

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18
Q

What is the point at which the esophagus become intrabdominal?

A

The insertion of the phrenoesophageal membrane (a continuation of the diaphragm endoabdominal fascia) is the point where the esophagus becomes intrabodiminal.

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19
Q

Second phase of the esophogram

A

Function evaluation with single swallow low density barium at 30 second interval

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20
Q

CXR of type A emphysema

A

oVer inflation, flat diaphragm, no fibrosis, decreased pulmonary vasculatory

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21
Q

Post pneumonectomy empyema

Treatment options and success rate

A
  1. Drainage with a balanced chest tube until mediastinum is fixed and stable
  2. Open drainage with an Eloesser flap using the anterior end of the previous thoracotomy incision
  3. When the cavity is clean and the cultures are negative the cavity is filled with antibiotic slution and then closed tightly
  • Success rate 25-75%
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22
Q

Surface anatomy - extent of the diaphragm

A

Expiration - on the right - the nipple (T4), the left - one rib space below Inspiration - right to the 11th rib , left to the 12th

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23
Q

For what is throacoplasty used ?

A
  1. Afte 2-4 failed attempts of sterilizing the chest cavity for empyema –>
  2. obliterate the space with muscle flaps
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24
Q

Second layer of EUS

A

hypoechoic - muscularis propria

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25
Q

Risk of pulmonary disease with a1-ATD

A

20-30x the general population

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26
Q

irregular acinar emphysema

A

Effect in an irregular way - associated with scaring and fibrosis seen in all lungs to some degree

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27
Q

EUS- number of layers?

A

5

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28
Q

Chemical characteristics of exudate (empyema)

A
  1. Pleural protein / serum protein > 0.5
  2. Pleural fluid LDH / serum LDH > 0.6
  3. Pleural fluid LDH > ULN of serum LDH
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29
Q

4th layer of EUS

A

Muscularis propria - hypoechoic

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30
Q

Third layer of EUS

A

hyperechoic submucosa

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31
Q

Distal acinar (praseptal)

A

Distal acinus, ducts, alveolar ducts Fibrosis Subpleural location, PTx, bollus disease

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32
Q

Type A emphysema: path

A

panacinar type of destruction

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33
Q

TEF __% have some imperforate anus

A

TEF - 10% have an imperforate anus

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34
Q

Waterson Class C

A

weight < 2000gm and otherwise well or severe other cardiac anomaly

Survival: 65%

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35
Q

5th layer of EUZS

A

hyper echoic paraesophageal tissue

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36
Q

Number of phases to the Esophogram

A

Esophogram has Three phases:

  1. Mucosal
  2. Functional
  3. Contour
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37
Q

time course for “late” BP fistula

A

after two weeks

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38
Q

TEF __% have some variant of CHD

A

TEF - 20% have some variant of congenital heart disease

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39
Q

Emphysema associated with smoking

A

Proximal acing emphysema (centrilobar) usually upper airways in an uneven distribution

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40
Q

Indications for surgery for lung abscess

A
  1. Infection specific:
    1. Unsuccessful medical Rx after 5 weeks of treatment
    2. residual cavity, larger than 2 cm, after Rx with persistent symptoms
  2. Reasons we always operate
    1. suspicion of carcinoma
    2. Significant hemotypsis
    3. Empyema
    4. BP fistula
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41
Q

Fraction of population with emphysema at autopsy % with clincial diseae

A

2/3 - fraction with emphysema 10% have clinical disease

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42
Q

Most important “layer” with respect to GERD

A

Phrenoesophageal membrane, which anchors the esophagus with the esophageal hiatus.

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43
Q

From where do leiomyomas originate ?

A

esophogeal leiomyomas 97% from the inner circular layer

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44
Q

bolus emphysema has what type of Acinar involvement?

A

Distal Acinar

45
Q

Phenotype of Type A Emphysema

A

Pink puffer with barrel chest, dry cough and non productive

46
Q

Complications of ptx that are indications for surgery

A
  1. Hemothorax, 2. Empyema 3. Chronic
47
Q

TEF - __ have some variation of the VATER syndrome

A

17.5% of TEF have some variant of the VATER syndrome

48
Q

GERD in Scleroderma

A

Epidemiology:

  • seen in 90% of patients with scleroderma

Pathology:

  • atrophy of the smooth muscle components
  • LES: Fiberous infiltration with loss of emptying mechanisms
49
Q

Type B or wet emphysema

A

The Bloater

a) Phenotype:

i) A productive cough and sputum production
ii) “Blue Bloater”
b) CXR:
i) moderate hyperinflation, ii) fibrosis – in the lower lobes, increased central vascularity, with tapering

c) Pathology:

i) Centrilobular type of changes

d) Prognosis

i) Poor prognosis
ii) The major complication is retention of secretions and respiratory failure.

50
Q

prevelance of emphysema at autopsy

A

2/3 of adults

51
Q

Most common causes of empyema

A
  1. Pneumonia
  2. Surgical
52
Q

Bugs most common with bronchiectasis

A
  1. H. Flu
  2. E Coli
  3. Klebsiella
53
Q

Seminoma

Treatment

A

Radiation

with Cis- based chemotherapy for metastatic disease

surgical ressection with any residual disease

54
Q

Hyper vs hypoechoic layers of EUS

A

hyper - white hypo- black (muscle)

55
Q

Frequency of hemotypsis in patients with bronchectasis

A

50% of adults, but rare in children - 10% of those with hemotypsis - severe.

56
Q

Waterson class A

A

Weight > 2500g and otherwise healthy

Survival: 100%

Repair should be immediate

57
Q

Grades of Myasthenia Gravis

A

I. Focal disease - ocular muscle weakness

II. Generalized mild to moderate disease

III. Severe generalized weaknes

IV Life threatening weakness

58
Q

Pan-acinar bolus emphysema

A

Associated with alpha1-AT disease- or other protease inhibitor deficiency Uniform (carried within the blood) lower lung zones (carried in blood – liquid goes down)

59
Q

WHO & ATS definition of emphysema

A

increase beyond the normal size of an airspace - distal to the terminal non-respiratory bronchiole - caused by the destruction of their wall

60
Q

Grade of Myasthenia Gravis, Severe generalized weaknes ?

A

Grade III

I. Focal disease - ocular muscle weakness

II. Generalized mild to moderate disease

III. Severe generalized weaknes

IV Life threatening weakness

61
Q

Type B emphysema

A

B- Blue Bloater associated with Brohchitis severe cough and sputum production Centrilobular change Poor px major complication is retention of secretion and respiratory failure

62
Q

Gastroesophageal junction

  1. functionally, what is it?
  2. Histologicaly ?
  3. relationship with the PE membrane?
A

Gastroesophageal junction

  1. functionally: where esophageal peristalsis stops.
  2. Histologicaly: distal to the gastric mucosal junction (turns to gastric mucosae higher)
  3. relationship with the PE membrane: 3-4 cm distal to the insertion of the PE membrane.
63
Q

Indications for Surgery For GERD

A
  1. Symptomatic after 3 months of medical therapy
    a. persistent esophagistis
    b. stricture
    c. aspiration
    d. bleeding
  2. positive 24hr pH study
  3. Manometry suggestive of LES dysfunction with adequate motility (peak >30mmHg)
    a. would think of 360 degree wrap
  4. Barrets mucosae with benign bx
64
Q

Third phase of the esophogram

A

Contour:

multiple, quick swallows of barrium that fills the esophagus optimizing the contour

65
Q

Emphysema associated with A-ATD

A

Panacinar emphysema (pan lobar) seen with A1ATD and other PI disease lower lung zones

66
Q

Irregular emphysema

A

Affects acinus in an irregular manner Always associated with scaring and fibrosis Occurs to some degree in all lungs

67
Q

Waterson class B

A

Weight: 1800-2500g or moderate anomaly (PDA, VSD, ASD)

Survival: 85%

no delayed primairy repair:

  • prox decompression
  • G-tube
  • antibotic
68
Q

anatomical derivation of the phrenoesophagel membrane

A

the phrenoesopageal membrane: extenetion ofthe endoabdominal fascial off the underside ofthe diaphragmatic muscle

69
Q

Type II Hiatal hernia

A

Type II (paraesophageal hiatal hernia) 1) Less common 2) Defect in the phrenoesophegeal membrane - usually on the left ventral aspect of the hiatus. 3) Natural history is progressive enlargement of the true hernia sac 4) May get: gastric volvulus, tortion, obstruction, strangulation, and gastric dilation. - Requires surgery.

70
Q

Treatment of caustic burns to the esophagus

A
  1. Appropriate dilution
  2. no emesis (this will cause products to pass 2x)
  3. Fluids
  4. Abx
  5. Fiberoptic
71
Q

Grade of Myasthenia Gravis, Respiratory failure?

A

Grade IV: Respiratory Failure

I. Focal disease - ocular muscle weakness

II. Generalized mild to moderate disease

III. Severe generalized weaknes

IV Life threatening weakness

72
Q

Type I Hiatal hernia

A

Type I Esophageal hernia (COMMON) 1) Axial sliding hiatial hernia 2) Phrenoesophageal ligament is stretched 3) G-E jxn can migrate to an intrathoracic position 4) G-E jxn remains cephalad to stomach 5) Reducible, unless esophagus is foreshortened from stricture 6) NOT significant unless there is signficant Reflux (which usually coresponds to al larger hernia )

73
Q

Conditions that predispose to bronchiectasis (4)

A
  1. selective IgA deficiency
  2. primairy hypogammaglobulinemia
  3. a1 AT D
  4. Kartageners Syndrome
74
Q

Waterson classification

A

chances of mortality with repair of TEF - risk stratifies strategy of repair

75
Q

Complications of repair of TEF - 5 big ones

A
  1. Anastomoic leak - 15-20%
  2. Post operative stricture - 5-50%
  3. Tracheomalacia - 10-15%
  4. GERD in up to 50%
  5. TEF recurrence 10%
76
Q

Esophageal atresia - mortality mainly due to

A

accompanying congenital heart disease

77
Q

Cervicoaxillary canal - boundries

A

Cervicoaxillary canal:

  1. Inferior: first rib
  2. Superior: clavicle
  3. Medial: costoclavicular ligaent
78
Q

How do the oblique fissures corelate with surface anatomy ?

A

Anterior at the level of the 6th rib

79
Q

Indications for anti-refux surgery in the pedicatric population

A
  1. Life threatening apenic spells
  2. Displacement of a major portion of the stomach into chest
  3. Significant esophagitis
  4. Esophageal stricture
  5. Pulmonary changes
  6. Failure to thrive (50) of all indications
80
Q

Bronchiectasis: Clinical presentation?

A
  1. Recurrent pneumonia
  2. Persistent Cough
  3. Copious Foul smelling sputum
  4. Hemotypsis
81
Q

Lung abscess 2/2 Aspiration - location - bacteria type

A

Location: posterior segment RUL superior segment RLL, LLL Bacteriology: Anerobic and aerobic

82
Q

Mediastinal mass with slightly elevated ß-HCG

A

Seminoma

The most common GCT in the mediastinum

Almost exclusively in males, 30-40 years old

CT Scan - large homogenious mass with smooth boardsrs

Grow slowly and are sensitive to RT

83
Q

Cervicoaxillary canal - contents

A
  1. Sublcavian vein
  2. Subclavian artery
  3. Brachial plexis
84
Q

Fluid characteristics of Exutade

A
  1. Pleural : Serum Potein>0.5
  2. Pleural: Serum LDH> 0.6
  3. Plural LDH > 2/3 ULN for serum LDH
85
Q

Type E esophageal atresia

A

“H type” TEF without atreasia 4% of cases

86
Q

Structures below the Angle of Louis (right , middle, left)

A
  • Right - azygous joins the SVC
  • Mid - carina, thoracic duct croses
  • Left - AP window
87
Q

Surgical approach for repair of TEF

A
  1. Side determined by the size of the aortic arch – Left for Right vv 2. 70% of H-type fistula, occur above the 2nd vertebrae, which can be approched through a neck incision
88
Q

Grade of Myasthenia gravis : Focal disease - ocular muscle weakness

A

Grade I

I. Focal disease - ocular muscle weakness

II. Generalized mild to moderate disease

III. Severe generalized weaknes

IV Life threatening weakness

89
Q

T2 Esophageal tumor on EUS

A

Mnemonic T2 goes through the Second muscle layer

90
Q

CT scan with bronchiectasis:

A

Lack of bronchial tapering, Bronchial dilatation wall thicekening

91
Q

Most frequent esophageal atresia

A

Type C - Esophageal atresia with distal tef

92
Q

EUS - accuracy of staging regional lymph nodes

A

70-80%

93
Q

How do the horizontal fissures corelate with surface anatomy ?

A

level of the 4th rib and joints the oblique fissure at the level of the 5th rib laterally

94
Q

% of BPF that heal follwoing surgery for repair of it

i.e. taken back post operatively

A

20% heal

provided the margins are free of:

  1. infection,
  2. Nerotic tissue, or
  3. Tumor
95
Q

Opportunistic lung abscess

A

Multiple location:

in hospital patien Bacteriology:

  1. staph
  2. pseuromonas
  3. proteus
  4. E.Coli,
  5. Klebsiella
96
Q

GERD:

  1. most common etiology (name)
  2. Physiology
A

GERD:

  1. most common etiology: Idiopathic - responsible for 60-70% of all GERD
  2. Physiology : LES is weak (< 6mmHg)
    • further acid exposure weakens the LES and causes mucosal damage
    • Aspiration from reflux presents as nocturnal cough with reguritation in the mouth
    • Morning horseness
97
Q

Indication for surgery for spontaneous ptx

A
  1. Massive air leak (i.e. no re-expansion)
  2. Persistent air leak (4-7 days)
  3. 2nd episode
  4. Complication of ptx (Hemo, Empyema, chronic)
  5. Occupational / social issues
  6. Previous contralateral
  7. Bilatteral
  8. Lung cyst obvious on imaging
98
Q

WHO / ATS definition of emphysema

A

Emphysema: Increase beyond normal in size of airspace distal to the terminal non respiratory bronchiole that arises from the destruction of their walls

99
Q

Type A emphysema

A

Dry emphysema - “pink puffer” - with barrel chest 1. dry cough with dyspnea 2. CXR - overinflation with flat diaphragm and decreased pulmonary vasculature 3. Path - pan acing type of destruction 4. good prognosis, major complication is a PTx

100
Q

Type A emphysema

A

Dry emphysema - Pink Puffer Barrel chest cxr shows over inflation, flat diaphragm no fibrosis, and cecreased pulm vasculature PAN ACINAR distribution Be wary of Ptx

101
Q

Mechanism that cig smoke causes emphysema

A
  1. oxidative stress that inactivates a1-at 2. ROS release
102
Q

alpha-1 protease inhibitor

  • where is it synthesized?
  • where does it effect?
  • and how does it work?
A
  • alpha 1 protease inhibitor is Synthesized in the liver
  • It is the major protease inhibitor of the lower respirtory tract
  • It I_nhibitis PMN leukesterase_ (protecting the lung elastic fibers from hydrolysis)
103
Q

what type of hiatial hernia does not have a peritoneal sac

A

Type 1

104
Q

Lung abscess 2/2 post pneumonic - location - bacteriology

A
  • May occur in any segment - typically staph and strep
105
Q

Proximal acinar bolus emphysema

A

(centrilobular) Associated with cigarette smoking Associated with inflamm in distal airways Effects the upper lung zones (where smoke goes) with uneven distribution

106
Q

Leo Elosesser

A

Stanford Surgeon TB, treatment of empyema Friend of Frieda Kahlo

107
Q

Grade of Myasthenia Gravis: Generalized mild to moderate disease ?

A

Grade II Disease

I. Focal disease - ocular muscle weakness

II. Generalized mild to moderate disease

III. Severe generalized weaknes

IV Life threatening weakness

108
Q

Patients susceptible to bronchiectasis

A
  • selective IgA deficiency - primairy hypogammaglobulinemia - alpha - 1- at defficiency Less common - CF, congenital deficiency bronchial cartilage, Kargageners;s

Utah / kirklin (12 decks)

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