Thoracic Surgery Flashcards
Boundaries of cervicoaxillary canal
First rib inferiorly
Clavicle superiorly
Costoclavicular ligament medially
Layers seen on esophageal EUS
1st (hyperechoic) - epithelium/lamina propria
2nd (hypoechoic) - muscularis mucosa
3rd (hyperechoic) - submucosa
4th (hypoechoic) - muscularis propria
5th (hyperechoic) - paraesophageal tissue/adventitia
Muscle = dark (hypoechoic)
Normal Demeester Score
Less than 14.72
Preoperative PFT assessment for lung resection
Goals:
FVC > 50% predicted
FEV1 > 50% predicted
DLCO > 60% predicted (best predictor of mortality)
If FEV1 and DLCO >60% predicted, can resect up to pneumonectomy
If less than 60% predicted, calculate predicted postop FEV1 and DLCO
- Take the number of remaining segments divided by 18 and multiply by the preop FEV1 and DLCO
If PPO FEV1 and DLCO >40%, resection should be tolerated
Incision for innominate artery injury
Sternotomy
Incision for proximal right common carotid artery injury
Sternotomy
Incision for proximal right subclavian artery injury
Sternotomy
Incision for distal carotid artery injury
Supraclavicular or anterior SCM
Incision for distal subclavian/axillary artery injury
Infraclavicular
Incision for proximal leftsubclavian artery injury
Left posterolateral thoracotomy or trapdoor
Management of traumatic coronary artery injury
If cardiac dysfunction, initiate CPB and repair/bypass the artery
Indications for VATS in thoracic trauma
- Ongoing hemorrhage
- Retained hemothorax
- Persistent pneumothorax
- Diagnosis and treatment of diaphragmatic injury
- Pericardial window for relief of cardiac tamponade
- Management of thoracic duct injuries
- Treatment of post-trauma empyema
- Removal of foreign bodies
NETT trial for LVRS
Survival benefit in surgical arm for patients with heterogenous disease (upper-lobe predominant)
Patients whose emphysema was predominantly in the upper lobes and whose exercise capacity was low after pulmonary rehabilitation were more likely to function better two years after the surgery then those who received only medical therapy. These patients also appear to have a survival advantage with LVRS.
Indications for surgery for lung abscess
- Unsuccessful medical treatment after 5 weeks (residual cavity, thick-walled, and larger than 2cm)
- Suspicion of carcinoma
- Significant hemoptysis
- Empyema
- Bronchopleural fistula
Operation of choice is lobectomy
Most common organism in postpneumonectomy empyema
Staph aureus
If polymicrobial, this suggests enteropleural fistula
Management of early post-op BP fistula (
Return to OR, resuture bronchus, cover with muscle flap
Indications for surgery in Aspergillosis
Only operate if there are symptoms (don’t want to operate if you don’t have to)
- Resect once hemoptysis develops
- No role for prophylactic resection (mortality 5% for simple aspergilloma, 33% for complex aspergilloma)
Indications for surgery in TB
- Persistently positive sputum cultures with cavitation after 5-6 months of continuous optimal medical therapy with 2 or more drugs
- Localized pulmonary disease caused by MAI, TB, or other atypical mycobacterium which is drug-resistant
- Mass lesion of the lung in area of TB involvement
- Life-threatening or recurrent severe hemoptysis
- BP fistula in association with mycobacterial infection that doesn’t respond to chest tube
Treatment of seminomatous germ cell mediastinal tumors
Radiation +/- cisplatin-based chemotherapy
Treatment of non-seminomatous germ cell mediastinal tumors
Cisplatin-based chemotherapy
Surgery if markers normalize after 4 cycles of chemotherapy but with residual mediastinal mass
Treatment of cystic adenomatoid malformation
Lobectomy (segmentectomy –> prolonged air leak and other complications)
Management of bronchogenic cysts
Indications for treatment:
- Increasing cyst size
- Air/fluid level
- Symptoms
- Subcarinal cyst (cause obstruction)
Surgery = cyst excision (spare pulmonary tissue)
Extralobar vs. Intralobar sequestration
- Presentation
- Arterial supply
- Venous drainage
- Bronchial communication
- Treatment
Extralobar presents in neonates with respiratory distress. intralobar presents in adolescence or young adulthood with cough, fever, sputum production
Both have systemic arterial supply from aorta
Extralobar venous drainage = systemic (azygous vein)
Intralobar venous drainage = pulmonary vein
Intralobar communicates with bronchial tree, extralobar does not
Extralobar treated with simple excision and ligation of anomalous artery if lesion is compressing lung tissue and causing symptoms
Intralobar treated with lobectomy during quiescent phase of illness (watch out for anomalous artery in inferior pulmonary ligament)
Bronchoalveolar carcinoma
Now called adenocarcinoma in situ in WHO classification
May present as pneumonia-like infiltrate (or ground-glass) instead of a mass
EBUS accessible nodal stations
2, 3, 4, 7, 10, 11, 12
Chamberlain procedure-accessible nodal stations
5, 6
Lung cancer T1
- Less than or equal to 3cm
- Surrounded by lung or visceral pleura
- No invasion proximal to lobar bronchus
T1a = less than or equal to 2cm T1b = between 2 and 3cm
Lung cancer T2
- Larger than 3cm but less than or equal to 7cm
- Invades visceral pleura
- Lobar atelectasis or obstructive pneumonitis
- Involves main bronchus but not within 2cm of carina
T2a = 3cm-5cm T2b = 5cm-7cm
Lung cancer T3
- > 7cm
- Any size that invades chest wall (including superior sulcus/Pancoast), diaphragm, parietal or mediastinal pleura, pericardium, phrenic nerve
- Atelectasis or obstructive pneumonia of entire lung
- Within 2cm of carina but not involving carina
- Separate tumor nodule(s) in same lobe
Lung cancer T4
- Any size that invades mediastinum, heart, great vessels, esophagus, trachea, carina, vertebral body, recurrent laryngeal nerve
- Satellite tumor nodules in a different ipsilateral lobe
Lung cancer N0
No nodal metastasis
Lung cancer N1
- Peribronchial or ipsilateral hilar nodes (double digit stations, 10-14)
- Includes involvement by direct extension into node
Lung cancer N2
Ipsilateral mediastinal or subcarinal nodes (single digit stations, 1-9)
N2 disease = Stage IIIA, except for T4N2M0, which is IIIB
Lung cancer N3
- Contralateral mediastinal or hilar nodes
- Scalene or supraclavicular nodes (ipsilateral or contralateral)
Lung cancer M0
No distant metastasis
Lung cancer M1 (M1a and M1b)
Distant metastasis
M1a = Separate tumor nodules in contralateral lung, pleural nodules, or malignant pleural or pericardial effusion
M1b = Distant metastasis (most common = brain, bone, adrenals, liver)
Lung cancer inoperability based on TNM Staging
- Supraclavicular or contralateral mediastinal nodes (N3)
- Invasion of spine, esophagus, trachea, carina, aorta, or heart (T4)
- Separate tumor nodules in different ipsilateral lobe (T4)
- Separate tumor nodules in contralateral lung (M1a)
- Malignant pleural/pericardial effusion (M1a)
- Distant extrathoracic mets (M1b)
Management of N2 disease
Single station or multistation, non-bulky disease should get surgery after neoadjuvant therapy
If N2 disease found at time of VATS resection, can abort for neoadjuvant therapy
If N2 disease found at time of thoracotomy, continue surgical resection
Treatment of small cell lung cancer
- Not treated surgically
- Limited disease treated with chemoradiation
- Extensive disease treated with chemotherapy
Predictors of metastasis vs. primary lung cancer in patients with lung nodule and other cancer
Almost always metastatic - melanoma, sarcoma, highly anaplastic carcinoma
More likely lung primary if other primary is squamous cell
Primary adenocarcinoma - could be either met or primary lung
Lymphangioleiomyomatosis
- Of mesodermal origin
- Present with spontaneous pneumothorax, chylothorax, hemoptysis, edema
- Mild disease = cxr appears normal
- Advanced disease = cxr shows honeycombing at bases, CT shows larger cystic changes
- Treated with conservative resection when symptomatic
Lung neuroendocrine tumors
Progression of malignant potential:
Typical carcinoid –> Atypical carcinoid –> Small cell undifferentiated carcinoma –> Large cell undifferentiated carcinoma –> Non-small cell carcinoma with neuroendocrine features
Division level for palmar-only hyperhidrosis
Top of 3rd or 4th rib (per STS consensus statement)
-Top of 4th rib –> moister hands, but lower incidence of compensatory hyperhidrosis
Surgical margin for chest wall tumors
Full-thickness excision with one rib margin
Chest wall mets and benign tumors - 2cm
Osteogenic sarcoma and malignant fibrous histiocytoma - 4cm
Diaphragmatic openings
IVC = T8 Esophagus = T10 Aorta = T12
Diagnosis of mesothelioma
CXR - pleural effusion, pleural thickening, calcifications
CT needed to define anatomy and extent of disease
Need tissue biopsy to confirm diagnosis (not just fluid analysis)
- Open or VATS surgical biopsy
Surgical treatment of chylothorax
Duct ligation in right hemithorax (mass ligation of tissue between azygous vein and aorta just above the diaphragm)
Management of congenital tracheal stenosis
- Dilation will just cause split in trachea and form granulation tissue –> further narrowing
- Resection –> tension, further stenosis
- Perform tracheostomy at site of stenosis, with goal of palliation while the child grows and can later undergo a resection and anastomosis
Most common tracheal neoplasms
1 = squamous cell carcinoma
Location of blood supply to trachea
Lateral
Surgical approach for upper 1/2 tracheal lesions
Collar incision +/- sternal split
- Cervical flexion is the most effective maneuver to allow for tracheal resection with primary repair (can stitch the chin to the chest)
- Suprahyoid laryngeal release useful to gain additional 1.5cm of length
- Intrapericardial release of the pulmonary vessels (more effective on right side because left mainstem bronchus tethered by aortic arch)
Surgical approach for lower 1/2 tracheal lesions
Posterolateral thoracotomy in 4th interspace
- Can perform cervical flexion to get more length
Most common T-E Fistula
Esophageal atresia with distal T-E fistula
Surgical management of TE fistula
Incision dictated by aortic arch - left thoracotomy for right-sided arch, and vice versa
-Divide fistula, repair both sides, leave tissue in place to buttress repair
Treatment of caustic esophageal ingestion
- Dilution. No emesis
- Fluids, antibiotics.
- Intubation for airway protection
- EGD. Stop when burn reached
- Sepsis/full-thickness necrosis: cervical esophagostomy, gastrostomy, esophageal isolation (resection controversial)
Manometric findings in achalasia
- Normal pharyngoesophageal junction activity
- Absent peristalsis
- Contractions weak and mirror-like at all levels
- Weaker contractions with progressive dilatation
- Normal or elevated LES pressure
- Incomplete or absent LES relaxation
Manometric findings in diffuse esophageal spasm
- Normal activity in pharyngoesophageal junction and proximal 1/3 of esophagus
- Peristalsis >10% but
Treatment of esophageal diverticulum
Diverticulectomy and myotomy
Treatment of esophageal leiomyoma
Surgical enucleation if symptomatic
Esophageal cancer Tis
High-grade dysplasia
Esophageal cancer T1
Invades lamina propria, muscularis mucosa, or submucosa
T1a = Invades lamina propria or muscularis mucosa T1b = Invades submucosa
Esophageal cancer T2
Invades muscularis propria
Esophageal cancer T3
Invades adventitia
Esophageal cancer T4
Invades adjacent structure
T4a = invades pleura, pericardium, or diaphragm (resectable) T4b = invades other organs (aorta, spine, trachea); unresectable
Esophageal cancer N0
No nodal mets
Esophageal cancer N1
Mets in 1-2 regional lymph nodes
Esophageal cancer N2
Mets in 3-6 regional lymph nodes
Esophageal cancer N3
Mets in 7 or more regional lymph nodes
Blood supply to anterolateral papillary muscle
LAD and circumflex artery
- Dual blood supply makes it much less susceptible to ischemic injury
Blood supply to posteromedial papillary muscle
Usually only supplied by PDA
- Makes it more susceptible to ischemic injury and rupture
How to calculate ejection fraction
Stroke volume / end-diastolic volume
What mediates calcium entry into/exit from myocyte
Cyclic AMP
Mechanism of systolic heart failure
Reduced cardiac contractility
Mechanism of diastolic heart failure
Abnormal relaxation, increased chamber stiffness, chamber dilation
Mechanism of milrinone
Inhibits phosphodiesterase, which increases cyclic AMP
Mechanism of beta agonists
Activate G protein, which increases cyclic AMP
Most common cause of ATIII deficiency, and treatment
MCC = prior heparin exposure Treatment = FFP, ATIII concentrate
Mechanism of bivalirudin
- Reversal
- Clearance
Direct thrombin inhibitor - binds to the catalytic site and anion-binding exosite of circulating and clot-bound thrombin
- No reversal agent, have to wait
- Prolongs ACT, minimal effect on platelets
- Renal excretion
Normal SVR
700-1500 dyn/cm^5
Normal A-a gradient
10-15 on room air
Effects of IABP inflating too early
- Can cause premature closing of aortic valve
- Can increase LVEDV, LVEDP, and PCWP
- Can increase LV wall stress leading to increased afterload and myocardial oxygen demand
Effects of IABP inflating too late
Inadequate coronary artery perfusion
Effects of IABP deflating too early
- Inadequate coronary artery perfusion
- Potential for retrograde coronary and carotid blood flow
- Increased myocardial oxygen demand
Effects of IABP deflating too late
- Increased myocardial oxygen consumption (due to LV ejecting against greater resistance)
- Increased afterload, LV outflow obstruction
Contraindications for IABP placement
- Aortic insufficiency
- Severe PVOD
Largest foreign surface contact area in the CPB circuit
The oxygenator
Goals for CPB flow
- 2.2 L/m/m^2 for adults
- 2.5 L/m/m^2 for infants/children
- 1.8 - 2.0 L/m/m^2 for adults with BSA greater than 2 to avoid excessive flow through oxygenator
- 1.7 L/m/m^2 is safe with moderate hypothermia
- 1.0 L/m/m^2 is adequate for deep hypothermia
Alpha stat
Method for managing CPB/Deep hypothermic circ arrest
- Don’t temperature correct the pH and pCO2. Set the standard at 37C and don’t correct as the patient gets cold.
- So as they are cooled, the pH will go up and the actual pCO2 and pO2 will go down
- Proponents argue that its better for maintenance of enzymatic function during hypothermia
pH stat
Method for managing CPB/Deep hypothermic circ arrest
- Maintain the pH at 7.40 and the pCO2 at actual temperature.
- Need to add CO2 to the inspired gas
- So the “real” values will be a lower pH and a higher CO2 than the measured values
- Increases cerebral blood flow (can cause cerebral hypertension and microembolisation)
7 variables more predictive of operative mortality after CABG
- Older age
- Female gender
- Previous CABG
- Urgency of operation
- Depressed LV function
- Left main disease
- Increasing extent of coronary disease
1/5/10 year patency of IMA graft
95%/94%/85%
1/5/10 year patency of radial artery graft
90%/85-90%/unknown
1/5/10 year patency of saphenous vein graft
85-90%/75 %/50%
Indications for surgery with post-infarct LV aneurysm
- Large aneurysm and angina
- CHF
- Recurrent V-Tach
- Risk of late rupture (?)