Thoracic Flashcards
transpulmonary pressure calculation?
Alveolar pressure - pleural pressure.
pleural: -5 at sea level closed chest.
alv: 0.
What is catamenial pneumothorax?
Thoracic ectopic endometrial tissue implants (most common extrapelvic location of endo).
Indication for ED thoracotomy?
BTK: 1. penetrating thoracic trauma pulseless with <15 mins of CPR
2. penetrating extrathoracic and exsanguinating with < 5 min of CPR
3. blunt who lose pulse en route to ED with <10 min CPR or tamponade with no other injuries
4. HD instability despite fluid resuscitation due to tamponade, hemorrhage, or air embolism.
Fiser:
1. penetrating thoracic 15 min
2. penetrating extrathoracic 5 min
3. penetrating signs of life on the way
4. blunt 5 min anywhere
ED access for penetrating chest trauma?
STERNOTOMY: heart and great vessels.
ANTEROLATERAL: resuscitative thoracotomy
POSTEROLATERAL: lungs, pulm vasculature, RIGHT (trachea, mainstem, bronchi, prox/mid esophagus), LEFT (left ventricle, descending aorta, distal esophagus)
Chest tube location?
4th or 5th IC space of mid/ant axillary. Nipple line vs inframammary fold.
btk says 5th
Small bore catheter?
2nd IC mid clavic.
Indications for pleurodesis?
Air leak for 4+ days, lung not yet expanded with chest tube, prevention of recurrent PTX (after 1st spont PTX, esp with high risk job, or limited access)
VATS blebectomy procedure?
Lateral decubitus (or supine if bilateral), single lung ventilation, 7th IC space midaxillary (for thoracoscope), 1-2 working ports in 4th or 5th IC space between mid and anterior axillary lines. Ring forcep the apex to look for blebs, staple with EndoGIA blue or green (45-60mm), 3.4/4.8m staple).
VATS pleurodesis or pleurectomy procedure?
Lateral decut (or supine if b/l), single lung ventilation, 7th IC space midaxillary for scope, working ports should be inferior to working area; PLEURECTOMY (incise pleura transversely with cautery at 4th or 5th IC space and peanut dissector to rip off the pleura). PLEURODESIS (Bovie cautery and abrasion with scratch pad in ring clamp from 4th or 5th IC space apically).
Chest tubes after pleurectomy, pleurodesis, or blebectomy?
1-2 chest tubes under direct vision via working ports pointed apically and place to suction for reexpansion
Chemical pleurodesis?
Instillation of talc slurry or doxycycline or TPA via pleural tube or catheter.
TPA-Dornase is best outcome
3 days of instillation
Management of small PTX? <3 cm on CXR and without underlying disease (“primary spontaneous PTX”).
3-6 hours obs with repeat CXR. If stable, f/u 12-48 hours after with repeat CXR. If worsening, admit for obs with chest catheter.
Management of small PTX. < 3 cm on CXR but with underlying pulmonary disease (“secondary spontaneous PTX”).
Place a chest tube/pigtail.
Management of large spontaneous PTX. 3+ cm on CXR. Hemodynamically stable.
Place pigtail <14Fr or chest tube 16-22 Fr. Repeat CXR. Connect to Heimlich or water seal if expansion adequate. Admit.
Management of large spontaneous PTX. 3+ cm on CXR. Hemodynamically unstable.
Place pigtail <14Fr or chest tube 16-22 Fr. Place 24-28 Fr if BPF suspected or PPV anticipated. CXR. W/S or suction. Admit.
Needle thoracostomy?
Could be an ABSITE question, but in practice, just chest tube. 14 or 16G at 5th IC in midaxillary. Follow with chest tube.
Or 2nd IC space (find at angle of louis)
Only modifiable risk factor to reduce recurrence rate after primary spontaneous PTX?
Smoking cessation.
Risk of recurrence of primary spontaneous pneumothorax after operative treatment?
1% pleurectomy
2-5% VATS bleb resection and pleurodesis
Risk of recurrence of primary spontaneous pneumothorax without operative treatment?
1st: 20%, 2nd 60%, 3rd 80%.
Most common site of esophageal perforation overall?
Cricopharyngeus muscle.
narrowest part of esophagus
cricopharyngeus 14 mm
aortic arch and L main bronchus 15-17 mm
diaphragm 19mm
normal is 2.5 cm
Most common site of esophageal injury during endoscopy?
Stricture at original disease.
Diagnostic study of choice for suspected esophageal perforation?
Esophagram with watersoluble contrast (GG or omnipaque). If positive, OR. If negative/unclear, Ba swallow.
When do you get a CT scan for esophageal perforation?
Quicker than esophagram; bolus with PO contrast. Oreder for preop planning (chest exploration).
EGD for diagnosis of esophageal perforation?
Not the best; can miss subtle tears.
How does soilage post esophageal perforation guide management?
Drain all effusions.
Complex effusions may need VATS or open washout.
Decort the lung.
Drain mediastinum through either chest via posterior mediastinal pleura.
How does nutrition guide esophageal perforation management?
If esophagectomy risk is LOW, can do PEG (because conduit needs to be OK via no injury to gastroepiploic aa). Consider a J tube.
How does traumatic mechanism change diagnostic modality for suspected esophageal perforation?
EGD is primarily used as esophagram is not readily available.
Rate of esophageal perforation in EGD and rigid endoscopy?
0.03% for flexible.
0.11% for rigid.
Annual incidence of battery ingestion?
6-15 cases / 1 million.
Presentation of pharyngeal perforation?
Respiratory distress, chest pain, neck pain, dysphagia, salivation, neck emphysema, inability to pass OG/NGT, fever, tachycardia
Chest access for specific location of esophageal injury?
Left upper, right mid, left lower.
airway: RIGHT for upper/med, LEFT for lower
For AIRWAY/CARINA/BRONCHUS: RIGHT.
Mackler’s triad? For esophageal perforation.
<50% of cases.
1. Subcutaneous emphysema
2. Chest pain
3. Vomiting
When to suspect intra-abdominal esophageal perforation?
Posterior perforation - pain radiates to the back, communicating with the lesser sac.
Anterior perforation - pain is peritonitis.
Timing of XR findings in esophageal perforation?
Mediastinal emphysema within 1 hour, pleural effusions/mediastinal widening 2+ hours.
Indication for NOM in esophageal perforation?
NOM = NPO, abx, nutritional support.
Well contained leak OR minimal mediastinal contamination, clinically stable.
Preoperative preparation for esophageal perforation?
Airway, aggressive fluids, 2 large bore, correct acidosis/lytes, abx, antifungals, T&C.
Repeat esophagram after esophageal perforation repair?
7-10 days postop.
Follow up outpatient after esophageal perforation repair?
6-12 mos to r/o stricture formation or TEF formation.
boerhaave site
left lateral distal esopahgeus (3-5 cm above GEJ)
hartmanns sign in esophageal perforation
mediastinal crunching on auscultation
Integrated relaxation pressure? IRP
Measure of GEJ pressure during a swallow (normally LES to allow bolus to pass).
Distal contractile integral? DCI
Summation of the contractile force of the distal esophagus during a swallow.
Diagnosis of achalasia?
IRP > 15 mm Hg and absent/impaired peristalsis.
w/ barium swallow
Diagnosis of distal esophageal spasm?
Normal IRP, early contractions in distal esophagus, uncoordinated peristalsis is >20% swallows.
Diagnosis of nutcracker esophagus?
2+ swallows with DCI > 8000 mm Hg.
Esophageal dysmotility disorders? 3.
Achalasia, DES, nutcracker esophagus.
Achalasia incidence?
25-60 YO, 1.6 per 100,000.
pathophys achalasia
autoimmune destruction neuronal ganglion cells in muscle wall “NITRIC-OXIDE-PRODUCING inhibitory neurons in the LES”
DES incidence?
4% of manometries for dysphagia.
Nutcracker incidence?
12% manometries for dysphagia.
two types of achalasia
Type I: lack of peristalsis and partial or absent relaxation of the lower esophageal sphincter in response to swallowing; normal pressures
Type II achalasia: panesophageal contraction of the esophagus with partial or absent lower esophageal sphincter relaxation.; higher pressures
Type III: no peristalsis, SPASTIC distal contractions
Treatment of achalasia?
Heller myotomy (6 on eso, 2cm on stomach) and fundoplication vs POEM.
nonop: pneumatic dilation > botox > CCBs and nitrates
if perforated, repair the perf + contralateral myotomy
Heller myotomy steps
- divide gastrohepatic ligament
- identify R crus and posterior vagus nerve
- divide phrenoesophageal membrane and identify anterior vagus and L crus
- divide the short gastrics
- exposed GEJ (phrenoesophageal fat pad resection)
- perform myotomy (5-6 cm on esophagus, 2-2.5cm on stomach)
- complete partial fundo Dor or toupet
treatment of scleroderma - causing esophagitis (atony causing severe reflux)
high dose PPI
DES on CT esophagram
corkscrew
Treatment DES and nutcracker esophagus?
CCB > Botox or nitric oxide (isosorbide or sildenafil)
then, LONG SEGMENT myotomy (2x ES for nutcracker)
Trachealization or feline esophagus?
Finding on EGD “concentric mucosal rings” typically seen in eosinophilic esophagitis.
Eosinophilic esophagitis histology dx?
15+ EOS/HPF.
How do acids cause injury?
(toilet bowl cleaner, metal cleaner, paint thinner, batteries) pH < 1.5; cause coagulation necrosis, eschar.
How do bases cause injury?
(lye, caustic soda, dishwater detergent, degreaser, drain cleaner) pH > 12; liquefactive necrosis and full thickness damage.
Staging of esophageal injury?
FIRST DEGREE: mucosal hyperemia/edema
SECOND DEGREE: partial thickness with patchy ulceration with vesicles, grayish exudate, pseudomembrane.
THIRD DEGREE: full thickness, deep ulceration with eschar, mucosal sloughing, submucosal vessel thrombosis; very likely to progress to stricture formation.
When to use steroid in esophageal injuries to minimize stricture formation?
Partial thickness injuries, but must weight risks with delayed wound healing.
Treatment of eosinophilic esophagitis?
Eliminate allergen, MDI steroids > systemic steroids, PPI, endoscopic dilation if needed.
Treatment of congenital esophageal stenosis?
If short abrupt, high risk perforation with dilation. Segmental resection vs esophagomyotomy.
If fibromuscular dysplasia (short tapered), can dilate.
Rigid vs flexible endoscope?
Rigid has larger operating channel and can evaluate proximal cervical esophagus better. Flexible can see the distal esophagus and stomach much better, less trauma. Better for high BMI and short necks.
Options for dilation of esophageal stricture?
Balloon (radial, better) vs bougienage (tangential, not recommended).
No more than 2 mm each session
Local treatment for recurrent stricture at the time of dilation?
Intralesional steroids or topical mitomycin C.
Thoracic duct anatomic course?
Cisterna chyli to right of aorta (at level of celiac plexus L1-L2), travels through aortic hiatus at T12, travels posterior to esophagus at T7, crosses midline at T5. Dumps into L subclavian/IJ junction “left venous angle”.
Phrenic vs Vagus nerve in relation to hilum?
Phrenic runs anterior to hilum; Vagus posterior to hilum.
Accessory muscles for respiration?
SCM, levators, serratus posterior, scalenes
Pores of Kahn?
Direct gas exchange between alveoli.
Pneumocytes?
Type I - gas exchange.
Type II - surfactant (mainly phosphatidylcholine)
Predicted postop FEV1 necessary? FEV1 is the BEST PREDICTOR of postop pulmonary complications and getting off the vent.
FEV1 > 0.8 or >40% of predicted postop value.
What if FEV1 is borderline?
Get VQ scan to see contribution of lung portion to overall FEV1, if low - resect.
Predicted postop DLCO necessary?
DLCO measures CO diffusion, representing oxygen exchange capacity (reflects pulmonary capillary surface surface area, Hgb content, alveolar architecture)
DLCO > 10 mL/min/mm Hg CO (or >40% of predicted postop value)
Contraindications (pCO2, pO2, VO2 max) to resection? VO2 max is maximum oxygen consumption… measured with max HR at maximal exercise.
pCO2 > 50, pO2 < 60, VO2 max < 10-12 ml/min/kg
MC complication after
- wedge?
- lobe?
- pneumonectomy?
wedge: air leak
lobe: atelectasis
pneumonectomy: Afib
Strongest predictor of survival in lung ca?
Nodal involvement.
MC met to the LUNG
COLORECTAL
MC met from LUNG?
Brain.
When to scan the brain?
Stage I or II with neurologic complaint.
All stage III and IV.
All small cell and Pancoast.
How to screen if hx of smoking?
Low dose CT scan 55-80 YO with 20+ pk year smoking hx and quit within past 15 years.
Overall survival rate of lung ca?
10% at 5 years; 30% with curative resection.
Pancoast syndrome?
shoulder/arm pain, ulnar nerve paresthesia, Horner syndrome (miosis, ptosis, anhidrosis).
pancoast dx
CT with IV contrast first
then, Bx however (I.e. transthoracic perc core needle bx)
then, PETCT for staging
pancoast tx
- chemoradiation (radiation only if palliative) x
- resection
Five year survival of lung cancer based on stage?
I: 50%
II: 30%
III: 5-15%
IV: <5%.
Resectable lung ca?
Stage I and II (Stage IIIa T3, N1, M0 possibly)… consider restagng after neoadjuvant chemo for IIIb
Unresectable Pancoast tumor?
relative:
N1 or N3 nodal dz
invasion of SCA
<50% vertebral body
intraforaminal extension
invasion of CCA or vert aa
absolute:
distant mets
N2 or N3 dz
>50% vert body
brachial plexus above T1 involved
invasion esophagus/trachea
Mediastinal lymphadenectomy stations?
RIGHT: 2R, 4R, 7, 8, 9.
LEFT: 4L, 5, 6, 7, 8, 9.
MC lung ca?
NSC (adenocarcinoma peripheral > squamous central)
Lung nodule workup >6mm
Spiral CT, bronch, sputum analysis, head scan –> FDG-PET.
POSITIVE PET –> TBNA vs EUS FNA Bx –> stage –> IIIA/B+ definitive chemoRT.
If IIIA, superior sulcus T3No/N1, selected IIIB, then induction chemoRT.
NEGATIVE PET –> resect.
SPN = coin lesion risk of ca based on age and size
<50 YO 5% risk
>50 YO: 50% risk
<5mm 1%
5-10mm 10%
11-20mm 50%
21-30 70%
31+mm is a straight up mass
TNM staging lung ca.
T1: < 3cm
T2: >3cm but >2cm from carina
T3: invasion of chest wall, pericardium, diaphragm/phrenic, or < 2 cm from carina
T4: mediastinum, esophagus, trach, vert, heart, vessels, different lobe, *effusion
N1 (PET): ipsilateral hilum nodes
N2: ipsilateral mediastinal, subcarinal, or aortopulmonary window
N3: contralateral mediastinal or supraclavicular
M1: distant mets.
Stage based off TNM lung
I: T1-2N0
IIa: T1N1
IIb: T2N1 or T3N0
IIIa: T1-3N2 or T3N1
IIIb: T4 or N3
IV: M1
Lymph node stations?
- high mediastinal
2*. upper paratracheal (EBUS vs mediastinoscopy) - retrotracheal
4*. lower paratracheal (inc azygos)
(EBUS vs mediastinoscopy) - subaortic (AP)* L MLND
- paraaortic (ascending or phrenic)* L MLND
7. subcarinal (EBUS vs mediastinoscopy)
8. paraesophageal (below carina)
9*. pulmonary ligament - hilar
- interlobar
- lobar
- segmental
- subsegmental
Napsin A and thyroid transcription factor 1 in determining primary lung ca?
If positive, likely a primary lung carcinoma.
Staging with malignant effusion confirmed?
M1a.
Small cell lung ca?
20% of all, NET origin, <5% surgical candidates, <5% 5 yr survival
Treatment for NET-SCLC?
ChemoXRT. Because usually presents late.
Paraneoplastic syndromes?
Squamous cell ca: PTHrP
Small cell ca: ACTH**MC, ADH
Most malignant lung tumor?
MESOTHELIOMA. Aggressive invasion, nodal/mets at Dx. Hx asbestos.
asbestos inc risk of lung ca by how much
90X
Chemotherapy regimen. FOR LUNG CANCERS
NSC: carboplatin, taxol
SC: cisplatin, etoposide
+/- EGFR (erlotinib)
+/- VEGF (bevacizumab)
+/- ALK anaplastic lymphoma kinase (crizotinib, alectinib)
Postop surveillance lung ca resection?
Stage I & II: postop CT q6mos x 2-3 yrs then yearly.
Stage III & IV: CT q3-6 mo x 3 years then 6 mos then yearly.
Mediastinoscopy role in lung ca? And limitation for nodal eval.
For central tumors > 0.8cm or subcarinal > 1cm on chest CT>
Does not assess AP window nodes (left lung drainage) - Chamberlain procedure can(parasternal mediastinoscopy/anterior thoracotomy)
Assess ipsilateral N2 and contralateral N3 mediastinal nodes = unresectable
SVC syndrome (swelling head, neck, extremity, breathing issues) tx? +/- Horners too!
Emergent radiation of 2/2 malignancy. typically 2/2 SMALL CELL LUNG > LYMPHOMA (NOT ADENO!!!! OR NONSMALL CELL!!!!)
Lung mets that are resectable?
From colon, RCC, sarcoma, melanoma, ovarian, endometrial.
Carcinoid tumor in lung?
Resect, has OK prognosis 60-90%, usually central.
Bronchial adenomas?
MC is carcinoid 90%»_space;» mucoepidermoid, mucous gland adenoma, adenoid cystic adenoma…
mucoepidermoid and mucous gland are slow growing, resect with 1 cm margin
adenoid cystic adenoma: from submucosal glands, PERINEURAL LYMPHATICS very XRT sensitive, slow growing, resect if poss vs XRT.
what lung tumor looks like PNA symptom wise?
bronchoalveolar tumor
and can be multifocal
Hamartoma.
MC benign adult lung tumor. Fat/cartilage/connective tissue. CALCIFIED POPCORN ON CHEST CT. Leave alone. Confirm with 6 mo CT stable.
Mediastinal tumor in adults?
Anterior (5T’s: thymoma»_space;> thyroid, T cell lymphoma, teratoma/GCT, paraThyroid adenoma)
Middle: bronchiogenic cyst, pericardial cyst, enteric cyst, lymphoma
Posterior: enteric cyst, neurogenic tumor, lymphoma
MC cause of mediastinal lymphadenopathy?
LYMPHOMA
MC mediastinal tumor?
Neurogenic tumor (posterior).
Thymoma 50s.
50% malignant, 50% symptomatic, 50% have myasthenia gravis (10% of MG have thymoma)
thymoma tx
if early (no metastatic/nodal disease and negative markers), VATS total thymectomy
SCORE = OPEN sternotomy to prevent drop mets
+ adjuvant radiation if incompletey resected or stage II-IV
Myasthenia gravis.
anti-ACH-R.
Tx: AChase inhibitors = inc ACh = neostigmine, pyridostigmine; steroids, plasmapheresis. thymectomy even if without thymoma.
tx of post thymectomy myasthenic crisis
urgent plasmapheresis or IVIG
MC malignant GCT of mediastinum?
Seminoma (just B-hcg positive). radiate radiate radiate > chemo > resect residual. MC MALIGNANT GCT in mediastinum*
Teratoma is MC but can be benign - resect vs chemo MC GCT OVERALL IN MEDIASTINUM
Non-seminoma is rare. 90% have bHCG AND AFP. chemo chemo chemo (cisplatin, bleomycin, etoposide) and resect residual
Bronchiogenic vs pericardial cyst
of middle mediastinum.
bronchiogenic = posterior to carina. resect.
pericardial: at right costophrenic angle. leave alone. they’re benign
Neurogenic tumors.
MC MEDIASTINAL TUMOR.
10% intraspinal involvement.
MC: neurolemmoma = schwannoma
paraganglioma: catecholamine release; ass’d NF1 = extraadrenal pheo
neuroblastoma rare
neurofibroma rare
MC TRACHEAL BENIGN tumor?
Adult: papilloma
Children: hemangioma
MC TRACHEAL MALIGNANT tumor?
Adult: SQUAMOUS cell
Children: carcinoid
MC postop complicaton after tracheal resection
granulation tissue formation
Tracheostomy landmark?
2nd and 3rd tracheal ring.
Treatment for tracheoesophageal fistula?
Tracheal resection, reanastomosis, esophageal repair with sternohyoid flap between esophagus and trachea.
Lung abscess MC location?
Superior segment RLL.
Lung abscess MC bug?
S. aureus.
Indication for surgical removal of lung abscess?
Fiser: If failure of Abx 6 wks, CT guided fails, ca not ruled out >6 cm, very thick walled, >4 cm?? (BTK)
Phases of empyema course?
Exudative WEEK 1: chest tube, Abx
FIbroproliferative WEEK 2: chest tube, Abx, VATS deloculation if not reexpanded
Organized WEEK 3-4: decortication for the lung trapping (tPA); may need Eloesser.
Chylothorax fluid analysis?
Lymphocytes, Tg > 110 mL/microL; SUDAN RED STAINS FAT
Injury to lymphatic duct above and below T5-T6 results in what sided chylothorax?
LEFT above, RIGHT below.
Treatment of chylothorax?
First 2-3 weeks: conservative (chest tube, octreotide, low fat diet; medium chain fatty acid vs TPN after 7-10 days)
After/failure and traumatic >2L/dayf: Ligate thoracic duct on RIGHT SIDE (low in mediastinum) or embolize
After/failure and malignant: talc pleurodesis and chemo/XRT.
“Massive” hemoptysis quantity?
> 600 cc/24 hr.
Surgical indication in spontaneous primary pneumothorax?
Recurrence, >7 day air leak, nonexpansion despite 2 tubes, high risk profession (pilot, diver, mountain climber), remote location, tension PTX, hemothorax, b/l PTX, previous pneumonectomy, large bleb known.
Needs VATS > pleurodesis (talc, tetracycline or laser, cellulose mesh/fibrin glue, pleural abrasion with dry cauze
How much volume to make effusion visible on CXR?
200-300cc.
Treatment of clotted hemothorax?
If > 25% lung volume, suspected infected hematoma.
Do this in first week to avoid peel and risk of empyema.
Pleural fluid analysis. WBC, pH, protein (pleural:serum), LDH (pleural:serum).
<1000 WBC transudate. >50000 empyema.
7.45-7.55 transudate. <7.45 exudated, < 7.3 empyema
AVM in lungs?
Between pulmonary arteries and veins usually in LOWER lobes. Associated with Osler-Weber-Rendu. Embolize tx.
Chest wall tumors?
MC Benign: OSTEOCHONDROMA
MC Malignant: CHONDROSARCOMA (anterior at costochondral junction)
Malignant typically larger (7 cm vs 3 cm)
Translocation of Ewing sarcoma?
t(11;22)
Rhabdomyosarcoma different histology?
Embryonal vs alveolar (mostly t(2;13), causing fusion genes PAX7-FKHR, PAX3-FKHR= poor prognosis).
Diagnostic imaging of choice for chest wall masses?
CXR then MRI.
Determining surgical resectability of chest wall tumors?
of ribs involved, presence of spinal cord invasion (post), and mediastinal vascular structures (anteriorly).
Radiation indication in chest wall tumors?
If spinal cord is involved, if pleural mets persist after chemotherapy, if Ewing sarcoma has pleural involvement.
How many ribs to resect in chest wall tumors?
5+ ribs = impaired function
If Ewing/osteo: 1 rib above, 1 rib below (1cm margin)
If rhabdomyosarc: R1 = R0 because radiation postop.
Most serious complication after chest wall reconstruction?
Chest wall instability and paradoxical respiration. (prevent with stainless steel wire support, remove grafts)
How to monitor for scoliosis after chest wall reconstruction?
Twice yearly CXR if prepuberty.
Yearly if postpubertal x 5 years.
Posterolateral thoracotomy entry.
5th IC space.
Scalene insertion.
Anterior and middle insert onto FIRST rib.
Posterior insert onto SECOND rib.
“Muscle sparing thoracotomy” preserves which muscle?
Lat.
VATS positioning?
Low anterior camera port, low posterior working, 5 cm upper anterior utility incision at apex.
tPTX vs tamponade sx?
tension: hypotension, JVD, decreased breath sounds ipsi, tracheal deviation contralateral.
tamponade: hypotension, JVD, muffled heart, midline trachea.
BECKS “hypotn, JVD, absent heart”
blunt aortic injury imaging findings?
CXR widened mediastinum >6cm on upright PA; >8cm or >25% of transthoracic diameter at aortic arch level on supine AP.
Mediastinal hematoma findings on CXR?
Left apical cap, right tracheal shift, right enteric tube shift, inferior displacement of L maintem, blunting of aortic knob.
Frequency of traumatic aortic injury when first rib fracture found?
15-30%.
Repair of acute traumatic diaphragmatic injury?
Through the belly.
Debride, evert borders to approximate with nonabsorbable sutures and interrupted or running repair.
Avoid injury to phrenic.
If cannot primarily repair, incise peripheral attachemnts and close defect 2-3 IC spaces higher. Use mesh if needed.
Indications for rib fixation?
severely displaced undergoing thoracotomies, progressive deterioration of pulmonary function, inability to wean from ventilator after contusions healed, significant chest wall deformity and nonunion.
Indications for mech vent after rib fracture?
5+ rib fractures.
3+ rib with severe displacement = bicortical displacement.
3+ rib causing 50% decreased in expected FVC%
30%+ volume loss of hemithorax on CT chest.
how often to surveill Barrett’s?
q6-12 mo EGD with 4 quadrant bx every 1-2 cm of disease
if nondysplastic <3 cm, q3-5 years otherwise 2-3 years
if LGD, q 6 mos
if HGD, q3 mos
TNM staging esophageal cancer
Tis: high grade dysplasia… progression from Barret’s (endoscopic tx)
T1a: tumor invades lamina propria (endoscopic therapy)
T1b: tumor invades submucosa
T2: tumor invades muscularis propria
Tx for T1b/T2: low risk = esophagectomy vs. high risk (3+ cm, lymphovascular invasion, poorly diff) preop chemotx and esophagectomy
T3: tumor invades adventitia
T4a: tumor invades nearby resectable structures
Tx for T3/T4a: pre op chemotherapy and esophagectomy
T4b: tumor invades nearby unresectable structures
Tx: chemotherapy (5-FU and taxanes) + radiation
N1: 1-2
N2: 3-6
N3 7+
esophagectomy margin 6-8cm
( so much be at least 5 cm away from cricopharyngeus… defintiive chemorad)
postop chemoxrt for node +
siewert 2 margin: 4 cm gastric, 5 cm esophageal
15 nodes
esophageal adeno chemo
cisplatin + 5-FU
or
carboplatin + taxanes
chemo in esophageal ca
improves survival overall !
esophageal ca resectability determined by?c
CT chest & Abdomen
EUS > PET for nodes
why is 1b considered so important in esophageal ca
because lots of lymphatics in SUBMUCOSA (1b)… so can rly spread a lot in 1b.
how to assess for locoregional staging, esophageal ca?
EUS > CT PET chest with FDG (bc primary tumor can be super close to nodes)
CROSS trial for esophageal surgery
Dutch chemotherapy and radiation in esophageal surgery study (CROSS) trial
5-year survival advantage in the neoadjuvant group (47% vs 34%). Most patients in this trial had adenocarcinoma (75%), and resection was appropriate in all patients.
MIS Ivor Lewis esophagectomy.
For distal esophageal cancers, short Barretts, HG dysplasia.
Abdominal: Mobilize crus, LN dissection from L gastric to splenic hilum, divide skeletonized L gastric aa/v, vagi will be resected, dissect stomach 3-4 cm away from GE vessels, divide shorts, R GE is supply to anastomosis, 4-5 cm wide conduit, no drainage procedure, J tube palcement, mediastinal dissection up to inferior pulmonary veins, reposition LLD, level 9 pulm ligament out, dissect along pericardium, open pleura, divide azygos, mobilize goose just above azygos, divide esophagus with EndOGIA at azygos level, bring stomach up, divide stomach, send. EEA staple, trim off excess and gastrotomy, wrap with omentum.
indication for Ivor lewis
= laparotomy, R thoracotomy with upper thoracic EG anastomosis
distal tumor, if good R gastric and R GE***** artery… can use colon interposition if no good gastric conduit
indication for mckeown esophagectomy
with left incision…. for cervical anastomosis … good for proximal lesions
indication for mark iv transhiatal esophagectomy
= laparotomy and L cervical incision with cervical anastomosis
NO THORACOTOMY…. leak with cervical anastomosis is better tolerated because chest stays virgin….
but it has smaller LN harvest and large mid thoracic tumors may be hard to mobilize
equal longt erm survival compared to transthoracic approach
best test to evaluate detail of hiatal hernia
Upper GI series
esophageal ca px indicated by?
nodal disease
indication for collis gastroplasty?
in PEH repair.
need 2 to 3 cm of intra-abdominal esophagus
Zenker mgmt
observe if not sx; need OR if aspiration PNA (commonly)
Fiser says to JUST LEAVE THE SAC?!?! just do myotomy!!
TL:
- open (Via L neck incision) myotomy of the proximal and distal thyropharyngeus and cricopharyngeus muscles is performed… endoscopic if > 3 cm
- resect large sac > 5 cm
- diverticulectomy >2 cm
- diverticulopexy < 2 cm
Dohlman technique (endoscopy) diverticulectomy + myotomy (create 1 common lumen) via RIGID endoscopy > FLEXIBLE endoscopy
what LN to take in esophagectomy
level 9 - pulm ligament
level 20 - celiac axis lymph nodes
level 16 - diaphragmatic crux
MC benign tumor of the esophagus?
leiomyoma - distal2/3 of esophagus in MUSC PROPRIA
dx: esophagram, EUS - but DON’T BIOPSY***
endoscopic removal if <5cm
VATS if >5cm
do you biopsy a suspected esophageal leiomyoma?
no, scars planes for resection
mesh in hiatal hernia repari
Mesh reinforced hiatoplasty appears better in the SHORT term with a decreased incidence of recurrence.
NOT for longterm outcomes.
Always be placed as an onlay, with underlying hiatal closure. An absorbable mesh should be used, given the risk of esophageal erosion from permanent mesh.
PERMANENT bridging only; not temporary.
children with caustic ingestion?
just observe if absolutely symptomatic or only vomit/drool
adult with caustic ingestion?
needs EGD within 24 hours
caustic injury dx
primary burn: hyperemia (conservatiev; NPO 3-4 days, abx)
secondary: ulcerations/exudates (TPN vs esophagectomy)
tertiary: deep ulcer, char, narrowing (esophagectomy)
5 yr survival metastatic esophageal?
0%
where does esophageal SCC vs adeno met
SCC: lungs
adeno: liver
Borchardt triad
(severe epigastric pain, inability to vomit, and inability to pass a nasogastric tube)
= acute gastric volvulus
SVC syndrome 2/2 line; mgmt?
line removed whenever possible. The stenosis should be treated by percutaneous transluminal dilation or stent placement. If this fails, surgical thrombectomy is considered.
SVC syndrome 2/2 mass?
radiate first. high dose before resection
ground glass opacity <1 cm workup
just observe in chest
ventilator sudden increased peak pressure with normal plateau pressure
large mucus plug (compliance is normal, increased resistance to flow)
trach requirements on vent
60% and PEEP 12
traction diverticulum
TRUE. usually LATERAL MID ESOPHAGUS
etiolgy: inflamm/tumor/granulomatous disease
mgmt: like Zenker’s dysphagia.
mgmt: excision and primary closure if sx vs radiation (if cancer)
epiphrenic diverticulum found with what other issue
motility issue (like achalasia)
where is epiphrenic diverticulum
distal 10 cm of esophagus
dx with esophagram/manometry
mgmt of epiphrenic diverticulum
diverticulectomy and myotomy on OPPOSITE side of diveritculectomy
esophageal ca mgmt
<5cm to the cricopharyngeus needs def chemoXRT
then, T1b+ with high risk need neoadjuvant
everyone gets adjuvant chemo-XRT
chemotx = cisplatin/5-FU or carboplatin/taxol
swallowing center location
MEDULLA.
MC cause of dysphagia after wrap?
postop edema
perfusion to esophagus
cervical: inferior thyroid artery
thoracic: bronchial and aortic branches
abdominal: LEFT gastric artery
zargar classification of esophageal injuries
0: normal
1: superficial edema/erythema: NPO/obs
2A: focal ucleration/erosion, exudate: NPO/obs
2B: deep or circumferetial ulceration: NPO obs and 3 days steroid to dec stricture risk
3A: focal NECROSIS: NPO, Abx, obs
3B: extensive necrosis: surgical intervention/Abx
4: perforation: surgery/Abx
schatzki ring dx
EGD see narrowing ~12.5 cm
distal esophagus usually
schatzki ring mgmt
- biopsy
- after path is NOT EOSINOPHILIC, can dilate 18-22 or 50Fr bougie
what is ligated in a transhiatal esophagectomy 3 field = Mckeown
middle thyroid vein
inferior thyroid artery
to expose the CERVICAL ESOPHAGUS
what two muscles does the internal thoracic = internal mammary artery run through
internal oblique and transverse mm
sengstaken blakemore tube or minnesota tube
balloon tamponade of variceal bleeding
1. throw it down
2. confrim tip in stomach
3. inflate gastric 300 cc pulled back to GEJ
4. esophageal balloon to 30cc. Hg
ppx abx before EGD
ANC <500
advanced hematologic malignancies
cirrhosis with GIB
vascular grafts < 6 mo placement
PEG
active GIB
ERCP cholangitis
panc cyst
look at ampulla of vater; clockwise identification
ampulla 1 o clock biliary duct 11 o clock.
alkali vs acid ingestion
alkali: liquefactive necrosis thru mucosa – can cause cancer
acid: coagulative necrosis thrombus of mucosal vessels and ESCHAR
NGT and EGD in acid/alkali injury?
NEITHER.
urgent vs emergent EGD
emergent; complete obstruction, BUTTON battery, sharp esophageal things
urgent < 24 hr: nonsharp esophageal FBO, nonobstructing food, MAGNET, sharp in stomach/duo, >5cm thing in staomch/duo
nonurgent: asx coin in esophagus, stomach BATTERIES > 1 day
what size may fail advancing through pylorus
2+ cm
impedance testing
electrical current in esophagus; adjunct to detect nonacid reflux\
MOS SENSITIVE INDICATOR FOR ACID DISEASE (>4.5% time with pH < 4)
bravo location
5 cm above LES
demeester score
time below pH 4 with changes in position, duration of time, and number of episodes
abnormal demeester:
14.72 (= 95th percentile acidic)
abnormal does not r/o nonacid reflux (get impedance)
belsey mark IV efundoplication
through chest
Indication: shortnened esophagus, obese, coexisting disease
frees esoph to level of the aortic arch
tension free of terminal esophagus to abdomen
RNY measurements
about 50cm from LoT, staple
bring up Y
connect BP limp 130 cm distal to alimentary limb origin
how to repair mid thoracic esophageal perforation
- RIGHT thoracotomy
- debride and perform myotomy to see full mucosal defect
- repair in 2 layers; inner absorbable mucosa, outer musc MUSC PROPRIA) permanent
- flap with intercostal, omental, or lat flap
- leak test
- place NGT distally, drain, close; consider distal feeding access
risk of esophageal ca with barrett’s?
30-60x lifetime risk
tx of esophageal scc
R0 no adjuvant even if N1+
tylosis
AD 17q25 RHBDF2 suppressor gene
palmoplantar keratoma + esophageal SCC risk
how to start screening for esophageal SCC in tylosis?
get upper GI endoscopies at age 20+
fanconi anemia ppl are at risk for what (4)
HNSCC + esophageal SCC + pancytopenia + leukemias
fanconi mutation
DNA repair genes
tracheoinnominate fistula
ligate innominate artery
close hold in tracheostomy
and strap mm between
ghon complex
hilar LAD + parenchymal lesion in TB
how much intraabdominal esophagus in nissen fundo
2 cm of eso in abdomen
phrenoesophageal membrane is what
extension of transversalis fascia
nissen soft diet
for 4-6 wks… 6 small meals/day
avoid bread, raw fruit/veg, meats, carb beverages, spicy food
puree & soup is good
1 wk of clears til edema resolves
how soon can u dilate if worried about narrowed nissen repair?
1wk earliest
when to get leak study after esophagectomy
POD 7
Fiser re: aspiration risk in suspected esophageal perf? What to use for contrast?
Fiser says DILUTED BARIUM, not gastrografin….
