THORACIC Flashcards by Conrad Hamilton

major points of VATS

Camera port
Fifth intercostal space mid axillary line

Working ports
Fourth or seven intercostal space

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Solitary pulmonary nodule if it is cancer what is the most common type expected

75% are NSCLC.

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Solitary pulmonary nodule what is most common benign diagnosis

80% are infectious granulomas.

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Solitary pulmonary nodule

Six important factors that significantly increase the likelihood of an SPN being cancer

(1) age > 60 years,
(2) tobacco history > 20 pack-years,
(3) prior history of cancer,
(4) size > 2 cm on chest x-ray or CT,
(5) the presence of spiculations on chest x-ray or CT,
(6) doubling size

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Solitary pulmonary nodule > 1 cm who have an intermediate probability are managed hwo

FDG-PET scan

to assess the need for surgical excision

versus

surveillance with serial CT scans.

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Solitary pulmonary nodule high clinical and/ or radiographic probability of cancer

undergo surgical excision

even without tissue (like whipple)

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For patients with stage 1a what is recommended treatement

This is ONLY I AAAA (all the other stage I get chemo)

lobectomy alone is recommended.

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For patients with stage 1 what is recommended treatement

stage 1 SCLC, lobectomy followed by platinum-based adjuvant chemotherapy is recommended.

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IIIb disease tx

no surgery

cisplantinum
and
xrt

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who gets preop chemo

IIIA

pancost tumor and ipsilateral node

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mass and ipsilateral node

mediastinoscopy
shows positive

this is stage IIIa - needs neoadjuvant

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mass and contralateral node

mediastinoscopy
shows positive

this is stage IIIb

no surgery

cisplantinum
and
xrt

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pulmonary function

FEV1

1.6 need for lobectomy

each lobe is about 20%

Can do functional reserve with V/Q.

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FEV1 needed for pneumontectomy

Greater than 2 L

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FEV1 needed for lobectomy

Greater than one 1.6 L

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FEV1 needed for wedge resection

Greater than 0.6 0.8

Pre-op testing for considered long resection

PFTs
VQ scan predicted postop FEV1
ABG
CT pet - include liver and adrenals

If any nodes light-up:
medianstinoscopy

Contraindications for surgery on lung cancer

T4
N3 - contralateral positive node

Post our predicted FEV1 less than 0.8

Malignant affusion

Extra thoracic metastasis (CAREFUL - may still go for care if isolated brain met!)

STC syndrome

Recurrent laryngeal your nerve involvement

Phrenic nerve paralysis

Great vessel involvement

Small cell lung cancer (these get chemoradiation)

Horner syndrome

Positive cervical lymph node

Tracheoesophageal fistula

When is the pneumonectomy resection required

hilar lesion

Crosses the fishers and involves all lobes

When should you do a Chamberlain procedure

Right-sided nodes

Left para tracheal nodes

Hormones that long cancer Cancer secrete

squamous

PTH like hormones squamous

both squamous and calcium can affect the skin.

small cell

(SIADH) in small cell

“systemic therapy so systemic diuresis”

Still go for cure in non-small cell lung cancer

IIIa
up to T3 (pericardium, chest wall, bronchus) N1 (ipsilateral)

T2 N2 (ipsilateral mediastiunm)

Differential diagnosis of mediastinal tumor

Anterior:
Thymoma, teratoma, terrible lymphoma

Medial
Pericardial
Bronchogenic
Sarcoid

Posterior
Mesothelioma
Neurogenic
(the Esophageal duplication)
Germ cell tumor
Substernal thyroid
Sarcoidosis
Neurogenic humor

What physical examinations do a mediastinal mask patient need

Testicles exam!

Heading and neck exam

What laboratory studies does a mediastinal mass patient meet

Baby hCG AFP LDH Metanephrines TSH

Treatment of mediastinal non-seminoma

Chemotherapy alone

Treatment of mediastinal seminoma

Chemotherapy and XRT Very do you sensitive

Treatment of male genitalia

Wide local excision XRT Chemotherapy

Treatment of thymoma

Preoperative plasmapheresis to remove anti-cholenergic receptor antibody Steroids Excision via MEDIAN sternotomy

Thoracic duct course

Enters the chest via the aortic hiatus travels on the right side until T4/T5 Gaines into the common loans of the internal jugular and subclavian vein cisterna chyli is at L2 The cisterna chyli (or cysterna chyli, and etymologically more correct, receptaculum chyli) is a dilated sac at the lower end of the thoracic duct into which lymph from the intestinal trunk and two lumbar lymphatic trunks flow.

What is the advantage of using thin barium besides for subtle leak

If concerned of aspiration (example: tracheoesophageal fistula) not harmful for aspiration

Treatment for chylothorax / fistula

You can try medium chain triglycerides TPN If fail: VATS ligation in the chest

What strap muscle should be used to buttress your internal jugular repair or ligation

Cricothyroid muscle

what are the strap muscles that are retracted during thyroidectomy

sternohyoid and sternothyroid These may also be divided

what side nodes does mediastinoscopy biopsy

Right "Regular procedure equals right"

Website node does Chamberlin procedure biopsy

Left "left = sinister = Walt Chamberlain the left hand basketball player"

Patient after retropharyngeal abscess drainage continues to have high fever in the ICU postop day five. They are sick and cannot get off the ventilator what is the next step

CT scan for food collection Paratracheal Right chest drainage This is mediastinitis

Patient after mandibular fracture in the chest tube output characters changed it is layering out in the container now

Thoracic duct injury ``` Send triglycerides Cholesterol Chylomicron LDH Lymphocytes ``` Nonfat diet versus Medium medium chain triglycerides NPO three weeks Monitor chest tube output

What test do you need after you've done a cardiac repair for penetrating heart injury

Echocardiogram Make sure valve was not injured et cetera.