Thoracic Flashcards
Spontaneous PTX. when do you do surgery?
First time: pigtail and heimlich valve. Dc home. Pull it out in 2 weeks. Done
Second time: surgery
What is the indication to place a chest tube for TB effusion?
Never ever place a chest tube for TB. You will cause a horrible bronchopleural fistula that will never ever heal. Maybe only for empyema
Lung abscess with air fluid level. Treatment?
Just abx. This is an “open” abscess. It will clear with pulmonary toilet and abx.
Pt referred to you for aspergillosis and aspergilloma. Rx?
Medical first to clear the aspergillosis. Then surgery for the aspergilloma. Oma won’t clear with medical rx only but you need to rx the diffuse aspergillosis first otherwise they are too immunocompromised for the surgery
Voriconazole
What’s the difference in blood supply for intrapulmonary vs extrapulmonary sequestrations?
Intrapulmonary: drains with the rest of the lobe
Solitary pulmonary nodule sizes and follow-up guidelines
<4 mm: no f/u needed
4-6 mm: f/u at 1 yr
6-8 mm: f/u at 6 mo
>8 mm: needs CT, biopsy
Who needs mediastinoscopy?
Anyone with a PET (+) mediastinum
What differentiates a stage 2 from a stage 3A lung CA?
Mediastinal lymph node involvement
When can you skip mediastinoscopy?
If PET (-) and the primary tumor is <2cm
For pneumonectomy, what’s the minimum FEV1/FVC % do you need? Below what % will ppl definitely not tolerate pneumonectomy?
How many cc of lung volume does the pt need after pneumonectomy?
60%. <40% definitely not. In-between you can do a VQ scan
800cc
What size lung cancer is T1a?
< 1cm
T1b < 2cm
Lung cancer up to what size can be T2?
Up to 7cm
What T stage is a 1cm tumor with pneumonitis
T2 bc of the pneumonitis
What T stage is a 1cm lung cancer 1cm from the carina?
T3. Even though 1cm tumor is T1 by size, being <2 cm from the carina makes it T3
2cm tumor and another 1cm in the same lobe. What T stage?
What if the 1cm lesion was in another lobe on the same side?
T3
Ipsilateral different lobe: T4
Lung cancer extends into the pericardium. What T stage?
T3. When it extends into things you can take out it’s T3. Chest wall, pericardium, mediastinal pleura, diaphragm
Chest node levels. Double digit nodes vs single digit nodes. Which one has a higher N stage if (+)?
Double digits: N1
Single digits: N2
Other than distant mets, what makes a lung cancer stage 4?
Tumor in the contralateral lung
Malignant effusion
Pleural nodules
Which lung cancer can cause SIADH?
Small cell
Which lung cancer type can cause hypercalcemia?
Squamous cell. (PTH related protein)
This is the only thing squamous cell CA causes. Everything else is small cell
Which lung cancer type can cause cushing’s?
Small cell
Whats one lung cancer stage that gets neoadjuvant therapy?
Stage 3a
Any N2 disease or T3N1
Can you operate on T3 lung cancer? How about T4?
Yes T3, no T4 (maybe only if >7cm size is the only thing that’s making it T4)
remember T3: 5-7cm, attaches to things you can cut out. neoadj.
T4: >7cm, attaches to things you can’t cut out
What’s one scenario where you can offer surgery for small cell lung cancer?
T1a lesion. Peripheral, <2cm
How many compartments does the mediastinum have and which compartment has the most number of tumors associated with it?
Anterior
Middle
Posterior
Anterior has the most number of tumors associated. 4T’s
Teratomas
Thyroid
Thymus
Terrible lymphomas
Young man comes to your office with a suspected mediastinal teratoma.
- which compartment?
- what is your next step? Do you need to biopsy?
- what is the treatment?
- anterior compartment. Thymus, thyroid, teratoma, terrible lymphomas
- tumor markers. AFP, b-hcg. If they’re high, no need for biopsy
- 4 cycles of chemo then re-marker and rescan
When do you have to operate for mediastinal teratoma?
What is the operation?
If there’s any signs of residual disease after 4 cycles of chemo. If it’s completely gone after chemo, you’re done.
Median sternotomy and explore the entire mediastinum
Young man referred to you for possible mediastinal teratoma. Why is testicular exam important?
If (+) testicular exam then rx is chemo. Oncology
What is the most common mediastinal tumor found in adults?
Thymomas
What tumors are common in middle mediastinal compartment?
Esophageal duplication cyst
Bronchial cyst
What types of tumors are common in posterior mediastinal compartment?
Lymphomas in kids
Neuroendocrine tumors
What C level innervates the diaphragm?
How many hiatuses does the diaphragm have?
C3-5
- IVC, aorta, esophagus
For paraesophageal hernias, the preferred approach is through the abdomen most of the time. When do you do a thoracic approach?
When the LES is >7cm from the hiatus (likely >50% of the stomach is in the chest)
Paraesophageal hernia repair when do you use a mesh?
Synthetic or biologic mesh? Does it make a difference?
If they’re >50yo and/or the defect is huge. Small defect in <50: no mesh
Biologic is preferred to prevent mesh erosion
Do a nissen
Morgagni vs bochdalek
- Left vs right? Anterior vs posterior?
- presents in kids vs adults?
- Bochdalek is left. Morgagni is right. Bochdalek: back. Morgagni: anterior
- kids: Bochdalek, adults: morgagni
SVC syndrome in ED. Satting 100%. what’s the first thing you do? IV steroids? Emergent external beam radiation?
1) Elevate the head of bed -> improves venous drainage
2) supplemental O2 if sob or desat
Radiation is not emergent
Most common presentation of a mediastinal tumor in adults?
Asymptomatic
Most common presenting symptom of lung cancer?
Persistent cough
What is the most common cause of acute mediastinitis?
Direct contamination by esophageal perforation
What % of pts with thymoma will have myasthenia gravis?
What % of pts with myasthenia will have a thymoma?
What % of myasthenia pts will improve after thymectomy?
50% of those with thymoma will have myasthenia
10% of pts with myasthenia will have a thymoma?
80% of pts will show improvement
After you repair the tracheoinnominate fistula, what do you need to do?
How do you close the initial tracheal stoma?
What if the field is contaminated?
You have to relocate the tracheostomy more proximally
Closure of the initial tracheal stoma is by local strap muscle flaps. Primary closure is NOT acceptable
Contaminated field -> omental flap
What are the three stages of empyema
If you let the empyema go untreated, what is the most serious complication?
Exudative < 7 days
Fibrinopurulent b/w 7-21 days
Organizing > 21 days
Bronchopleural fistula
Lung cancer. What makes it stage III without nodal involvement/mets?
T4 lesions are stage III
- > 7 cm
- Extending into things you can’t cut out such as invasion of mediastinum, heart, great vessels, trachea, esophagus, carina
- Tumor in a different lobe on same side
Positive ipsilateral mediastinal lymph node makes cancer automatically what stage?
Stage III
Indication to do a collis gastroplasty?
If unable to get 2-3 cm of intra-abdominal esophagus
71M got EGD. Fungating mass. Presents after 2 hrs. CXR shows pneumomediastinun. Stable.
- What do you do?
- presents after 24hr. Fever, hypotensive. What do you do?
- UGI first. If no leak: npo, ivf, ngt. If (+) leak: operate, emergency ivor lewis
- 24hr later unstable: esophagectomy. Left+right chest tubes, ng tube down to the proximal staple line. Needs a quick 1hr operation to save a life
Iatrogenic esophageal perforations are now managed more nonoperatively. What are the 3 criteria that need to be met to go non-op?
Most common complication of non-op mngmt?
1) mild symptoms
2) perforation contained within mediastinum
3) minimal sepsis
Stent migration
20’s M, Spontaneous pneumomediastinun. Treatment/next step?
From alveolar rupture with tracking along the brknchovascular bundle to the mediastinum
Observation, pain Ctrl. Usually resolved in 1-3 days
If there is a history of emesis, fever or pleural effusion then esophagram
Can you do pleurodesis in pt who has malignant effusion?
Yes you can. You can’t do it if the lung is trapped however.
When do lung cancers get neoadjuvant chemo/rad?
Starting stage IIIa
Any N2 disease: ipsilateral mediastinal or subcarinal disease
T3 (5-7cm) N1
Any T4 (>7cm)
Achalasia is a risk factor for what kind of cancer?
Esophageal squamous cell carcinoma
Treatment for diffuse esophageal spasm when CCB is not one of the answer choices?
Nitrates
What is the treatment for nutcracker esophagus?
Extended myotomy after balloon dilation
It’s a hypertensive peristaltic disease. Really high amplitudes
Most common location for spontaneous esophageal perforation?
Spontaneous: lower/thoracic esophagus
Which of the following is a risk factor for Barrett’s?
- NSAID use
- H. Pyloric
- male gender
Male > female
2:1
Esophageal cancer. What layer is involved with:
T1
T2
T3
What’s the difference between stage IIA vs IIB?
T1: mucosa, submucosa (muscularis mucosa)
T2: muscularis PROPRIA
T3: adventitia
T4a: invades resectable adj structures (pleura, pericardium, diaphragm)
T4b: invades unresectable adj structures (aorta, vertebral body, trachea)
IIA: T2
IIB: T3
Pt with new GERD. placed on PPI. only partially responds. Next step?
Only partially responds to above therapy/intervention. Next step?
Double PPI dose.
If double PPI dose doesn’t do it, then do a 24hr pH test then EGD
What is an advantage of using right colon as opposed to left colon in esophageal reconstruction?
Which colon has the advantage of having more length
Bauhin valve. Aka ileocecal valve. Prevents reflux
Left colon has the length advantage.
What tumors are common between the pericardium and the thoracic spine?
This is middle mediastinum.
Cysts (pericardial, bronchogenic, enteric cysts)
Lymphoma
What tumors are common between the tracheal bifurcation and pulmonary vessels anteriorly and anterior surfaces of the last 8 thoracic vertebrae?
This is posterior mediastinum.
NEUROGENIC TUMORS
Esophageal cysts, lymphoma
Iatrogenic perf after a scope for achalasia. Where is the most likely site of perforation?
What incision to repair?
Most common site of iatrogenic perforation in a healthy esophagus?
Distal esophagus
Left posterolateral thoracotomy
Healthy esophagus -> Killian triangle. Cricopharyngeus
Which stage of lung cancer is stage III without any node involvement?
T4 lesions
- > 7 cm
- Extending into things you can’t cut out such as invasion of mediastinum, heart, great vessels, trachea, esophagus, carina
- Tumor in a different lobe on same side
What’s the margin needed for esophageal cancer?
10-12cm proximal
At least 5cm distal
What are the borders of the Killian triangle?
Base is the cricopharyngeus muscle
On top triangularly are two inferior constrictor muscles also known as thyropharyngeus
So the space is inferior to the inferior constrictors
Superior to the cricopharyngeus
Achalasia pt perfs from vomiting. Extrav of contrast into left chest along the distal esophagus. Treatment?
Esophagectomy.
In pts with a perforation proximal to untreated achalasia, undilatable stricture, cancer, esophagectomy at the time of perforation should be performed if they’re stable
Most useful diagnostic modality to detect atrial myxoma?
Is it cardiac MRI?
Echo. Not Cardiac MRI. This is not as specific as the echo
Off pump CABG vs on pump CABG
- 30d mortality?
- 1yr mortality?
- graft patency
- length of stay
- risk of stroke
- same 30d mortality
- 1yr mortality higher for off pump CABG
- lower patency rate for off pump
- shorter length of stay for off pump CABG
- same risk of stroke
What’s the ideal timing of VATS for empyema?
Should be performed with 7 days and within 48 hrs of initial chest tube
most common primary malignant soft tissue tumor of the chest wall?
chondrosarcoma
When is esophagectomy an acceptable operation for a perforated appendix?
Undilatable stricture, malignancy, achalasia causing sigmoid esophagus or nutritional deficiency
What aortic valve area denotes significant aortic stenosis and an indication for valve replacement?
< 1cm²
Give a brief buzzword description of belsey mark IV fundoplication.
When do you do it
Thoracic approach. Anterior 240 degree fundoplication
For intrathoracic stomach, short esophagus, or any other reason to be in the chest
What is the treatment for a friable pink/purple Endobronchial mass found on bronchoscopy?
What if there’s mediastinal node involvement?
This is carcinoid
Regardless of the mediastinal nodes you have to resect and do mediastinal node sampling/dissection
what are the 4 categories for parapneumonic effusion?
glucose of the pleural fluid have anything to do with anything?
I & II: minimal to moderate. FREE FLOWING effusion. pH > 7.2
III & IV: pH > 7.2. purulence is IV. more than half of a hemithorax. thickened parietal pleura
glucose of the fluid doesn’t have anything to do with anything
85yo, trapped lung and malignant effusion. treatment?
can you pleurodese?
what if the pt was 55?
VATS and pleural catheter. decort is too aggressie for 85.
pleurodesis is contraindicated with trapped lung
if younger, may try decort
