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SAM Sx > Thoracic Surgery 2 > Flashcards

Thoracic Surgery 2 Flashcards

1
Q

Term referred to loss of continuity of diaphragm resulting in movement of abdominal organs into thoracic cavity

A

Diaphragmatic hernia

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2
Q

Is congenital or traumatic diaphragmatic hernias more common?

A

TRAUMATIC – most common diaphragmatic hernia

– blunt trauma to thorax and/or abdomen

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3
Q

Diaphragmatic hernia occur due to rapid deflation of lungs with ___ ____ that produces large pleuroperitoneal pressure gradient

A

Open glottis

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4
Q

T/F: Muscular portions are most susceptible to tears with diaphragmatic hernias.

A

TRUE

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5
Q

T/F: 15-25% of diaphragmatic hernias are diagnosed weeks after injury

A

TRUE

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6
Q

Respiratory and GI SIGNS are most common in which diaphragmatic hernia: (acute or chronic)

A

Chronic diaphragmatic hernias are associated with GI SIGNS + resp distress.

Signs include:

    • dyspnea, exercise intolerance, lethargy
    • V+, Regurg, inappetance
    • pleural / peritoneal effusion
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7
Q

Most common organ to displace with diaphragmatic hernia.

A

LIVER

– when displaced it most likely will start to have some venous outflow obstruction further resulting in pleural effusions.

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8
Q

Name some common clinical signs found on PE with diaphragmatic hernia.

A

Clinical signs for diaphragmatic hernia depend on organs that are displaced:

    • muffled lung sounds
    • borborgmi ausculated on thoracic auscultation
    • tachycardia
    • tachypnea
    • empty abdomen on palpation ***
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9
Q

Diagnostic of choice for diaphragmatic hernia:

A

UTRASOUND

    • US ( 93% accurate)
    • Rads (66% accurate)
    • Positive contrast celiography: (poor) –
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10
Q

First line of treatment for a diaphragmatic hernia:

A

STABALIZE THE PATIENT FIRST!

    • look for other life threatening conditions in acute cases.
    • consider possibility of pleural effusion in chronic cases (US guided thoracocentesis if indicated.
    • provide oxygen therapy
    • Prop patient on a slant to promote movement of abdominal organs caudally.
    • proceed to surgery when patient is stable.
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11
Q

When is surgery considered emergent in diaphragmatic hernias

A

If stomach has herniated.

— if the stomach moves up into the chest & they get gastric dilatation or volvulus then it is a surgical emergency. (cause them to decompensate rapidly).

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12
Q

What surgical approach is used for a diaphragmatic herniorrhaphy:

A

Ventral midline abdominal approach

– be prepared to perform median sternotomy if required

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13
Q

T/F: Liver is the most common herniated organ

A

TRUEEE

– Pope said it twice : KNOW

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14
Q

What type of suture pattern & suture is used in a diaphragmatic herniorrhaphy:

A

Simple continuous PDS or prolene

– Diaphragmatic herniorrhaphy = simple continuous PDS or prolene

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15
Q

T/F: there is no treatment for re-expansion pulmonary edema

A

TRUE

– fatal

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16
Q

Is re-expansion pulmonary edema associated with chronic or acute hernias

A

Chronic hernias are most common in re-expansion pulmonary edema.

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17
Q

What occurs when re-inflating any atelectic lung?

A

Re-expansion pulmonary edema – Associated with rapid expansion of previously ateletic lung

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18
Q

It is important in a Diaphragmatic Herniorrhaphy to keep close control of PPV during surgery. What pressure does the PPV need to be maintained at:

A

Keep pressure <15 cm H2O

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19
Q

Common complications of a diaphragmatic hernia are:

A
    • Re-expansion pulmonary edema
    • Persistent pneumothorax
    • Hemorrhage
    • Failure of repair and re-herniation
    • Loss of domain
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20
Q

Persistent pneumothorax is a complication with diaphragmatic herniorrhaphy. It is secondary to lung parenchymal tears during sx. How is this tx:

A

Typically resolve with continued suction via thoracostomy tube

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21
Q

Is the prognosis good or bad for diaphragmatic herniorrhaphy:

A

Excellent if patient survives 24 hrs following sx.

    • 90% survival rate
    • perioperative mortality increase for: chronic hernias, older feline patients, and patients with concurrent injuries.
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22
Q

Term referred to as congenital communication between pericardium & peritoneal cavity (chest no technically involved)

A

Peritoneaopericardial diaphragmatic Hernia (PPDH)

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23
Q

PPDH is unknown cause of defect in ______

A

Embryogenesis

    • PPDH: commonly associated with other congenital defects.
    • PPDH may be a incidental finding
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24
Q

Around what age group does PPDH commonly occur:

A

Middle aged

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25
Q

Common clinical signs of PPDH:

A
    • Respiratory ***
    • GI ***
    • Cardiac or Neurogenic systems
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26
Q

Breeds with increased risk for PPDH:

A
    • Weimaraners
  • – Cocker spaniels
    • DLH
    • Himalayans
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27
Q

Type of PPDH that has a pent logy of defects

A

Congenital Cranial Abdominal wall & diaphragmatic defects — DOGS

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28
Q

List the Pentalogy of defects in congenital cranial abdominal wall & diaphragmatic defects:

A

Pentalogy of defects:

  1. Cranial abdominal wall defect
  2. Caudal sternal fusion defect
  3. Pericardial defect
  4. Diaphragmatic defect
  5. Intracardiac defect (VSD most common)
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29
Q

Breeds predisposed for congenital cranial abdominal wall and diaphragmatic defects:

A
    • Weimaraners
    • Cocker spaniels
    • Dachshunds
    • Collies
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30
Q

Common PE findings for PPDH:

A

– Muffled heart sounds
–Ascites
–Murmur
+/- Concurrent ventral abdominal wall defect

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31
Q

Diagnostic of choice for PPDH

A

Radiographs or US

  • -Enlarged cardiac silhouette
    • dorsal elevation of tracheal
    • overlap of heart & diaphragmatic borders
  • -discontinuity of diaphragm
    • gas filled structures in pericardial sac
    • Sternal defects
  • -Dorsal peritoneopericardial mesothelial remnant
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32
Q

T/F: It is suggested to wait a couple of weeks before treating a PPDH surgically

A

FALSE – treat ASAP

– At 6-8 weeks of age ideally so adhesions are less likely & thoracic wall is more pliable.

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33
Q

Traumatic diaphragmatic hernia and PPDH have the same surgical approach. Which is:

A

Ventral Midline abdominal approach

– BOTH traumatic diaphragmatic hernia & PPDH use the ventral midline abdominal approach

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34
Q

What suture pattern is used to surgically correct a PPDH:

**

A

Simple continuous pattern — Do NOT need to close pericardial sac separately

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35
Q

What is the outcome for a PPDH that has been surgically corrected

A

Excellent if animal survives 24 hr post op

– post op mortality rate of 14%

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36
Q

T/F: In the fetus, the ductus arteriosus shunts blood from main pulmonary artery to aorta.

A

True – direct venous blood away from fetal lungs

37
Q

Patent ductus arteriosus present when ductus remains patent ___ days after parturition

38
Q

Most common congenital cardiac defect in dogs:

A

PDA (patent ductus arteriosus)

39
Q

Signalment for PDA

A

Pure-bred, small breed dogs most effected

    • F > M
    • Heritable basis identified in poodles & Welsh corgis
40
Q

PDA shunts blood from ___ to ____side of the heart

Reverse PDA (Eisenmenger’s Syndome) will shunt blood from ____ to ___ side of the heart

A 
PDA=        L ==> R
Reverse=  R ==> L
41
Q

Does PDA result in right or left sided heart failure:

A

Left sided heart failure

    • severe volume overload of L heart that progresses to left sided failure
    • Mitral regurg contributes to the overload
42
Q

T/F: a reverse PDA can be treated with a coil embolization or amplatzer ductal occlude
*****

A

FALSE

This is the treatment for a PDA. Treatment for reverse PDA is contraindicated.
NO TREATMENT FOR REVERSE PDA

43
Q

Cause for a reverse PDA:

A
  • Severe pulmonary hypertension

Right to left shunting of blood that occurs in the face of severe pulmonary hypertension. The shunting is a defense mechanism for the hypertension. Do not tx.

44
Q

Asymptomatic to fulminant left heart failure is the main clinical sign associated with:

A

PDA (patent ductus arteriosus)

45
Q

What is the following clinical signs associated with:

    • differential cyanosis
    • exercise intolerance
    • PL collapse
    • polycythemia
A

Reverse PDA

46
Q

What 2 findings are present on PE with a patient with PDA:

A 
Continuous murmur 
Hyperkinetic pulses (BB shot, waterhammer) -- +/- stunted growth
47
Q

Animals with PDA have a good prognosis without treatment.

A

FALSE – Sx is indicated in all dogs with L< R shunting.

    • Most animals will die within 1 yr if no tx provided.
    • occlusion of R > L shunting is contraindicated.
48
Q

What are 2 minimally invasive procedures for treating PDA:

A
    • Coil Embolization

- - Amplatzer ductal occlude

49
Q

What are the 3 surgical procedures in the treatment of PDA:

A
  1. Coil embolization
  2. Amplatzer ductal occlude
  3. Surgical ligation
50
Q

What is a long term complication associated with surgical ligation in a patient with PDA

A

Recanalization

Other complications of surgical ligation

    • severe hemorrhage secondary to PDA rupture
  • – bradycardia (branham reflex)
    • residual ductal flow
51
Q

T/F: In PDA patients, mitral regurgitation and myocardial insufficiency are likely to resolve following surgery

52
Q

Prognosis for a patient with PDA

A

Excellent for animals <6 months of age at time of surgery.

Older animals may do well if no previous episodes of heart failure although surgery can be more difficult

53
Q

Prognosis for a patient with a reverse PDA

A

Poor to grave for reverse PDA

54
Q

Most common cardiac neoplasia in dogs

A

Hemangiosarcoma of right auricle

55
Q

T/F: Hemangiosarcoma of the right auricle is usually a secondary occurrence:

A

FALSE

– hemangiosarcoma is usually a primary occurrence = Micrometastases typically present at time of diagnosis

56
Q

What is the emergency tx for hemangiosarcoma of the right auricle:

A

Pericardiocentesis

– emergency tx for hemangiosarcoma of right auricle because patient presents with acute cardiac tamponade (hemorrhage into pericardium)

57
Q

Best way to diagnose hemangiosarcoma of the right auricle

A

Echocardiography

58
Q

Best prognosis for a hemangiosarcoma is achieved by:

A

Excision of right auricle mass, pericardiectomy followed by chemotherapy

  • MST for surgery without chemo = 4 months
59
Q

Pericardium surrounds heart and restrains cardiac filling. Name other functions of the pericardium:

A

Pericardium functions:

  1. prevents over-distension
  2. provides gliding surface for heart (1-15 ml pericardial fluid)
  3. protects heart from spread of infection from thoracic cavity
60
Q

Thickening of pericardium or rapid raise in pericardial pressure results in:

A

Cardiac tamponade:

    • increase intra-cardiac diastolic pressure
  • -decreased SV
    • decreased CO
    • Increase in systemic pericardial contraction & scarring
61
Q

One important cause of pericardial effusion is

A

Congestive RIGHT heart failure

others causes of pericardial effusion:

    • idiopathic
  • -pericardioperitoneal diaphragmatic hernia
    • infectious & non-infectious pericarditis
  • -hemorrhage (right auricular mass vs. anticoagulant intoxication)
    • neoplastic effusion (mesopthelioma, heart base tumors)
62
Q

Pericardial disease is common in younger or older large breed dogs?

A

Large breed dogs

pericardial dz is more common in large breed dogs.
CS– weakness, lethargy, collapse, exercise intolerance

63
Q

What heart sounds will be heard when auscultating a patient with pericardial effusion

A

Muffled heart sounds with weak femoral pulses +/- pulsus paridoxicus

–weak femoral pulses +/- pulses paridoxicus: decrease in left end systolic pressure on inspiration results in decrease in arterial pressure. Pulses will feel weaker on inspiration. +/- cardogenic shock

64
Q

With pericardial disease, the patient will have weak pulses. Will the pulses feel weaker on expiration or inspiration?

A

Weak on INSPIRATION

65
Q

Diagnostics for Pericardial disease:

  5. +/-
A

Diagnostics for Pericardial Disease:

  1. Thoracic imaging - US: gives instantaneous answer AND 3 rad views
  2. Complete database - CBC, chemistry, UA, +/- coag profile
  3. Electrocardiogram – electrical alternans
  4. PERICARDIOCENTESIS
  5. +/- abdominal imaging
66
Q

T/F: Pericardiectomy can be either curative or palliative depending on underlying disease process.

67
Q

What procedure for pericardial disease will:

    • decrease surface area for fluid production
    • increases surface area for fluid absorption (pleural cavity)
A

Pericardiectomy

68
Q

What is the shape of the heart in pericardial disease:

A

Globoid shape heart

– in pericardial disease

69
Q

On a electrocardiogram of a patient with pericardial disease, you see electrical alternans, what is causing this?

A

– swinging of heart in the pericardial sac (changes the amplitude of QRS complexes)

70
Q

T/F: ultrasound will give a instantaneous answer if you have fluid in pericardial disease

A

TRUEEE

– US gives INSTANT answer for pericardial dz.

71
Q

Diagnostics of choice for pericardial dz:

A

US- gives instant answer for effusion

PERICARDIOCENTESIS– diagnostic & therapeutic (culture fluid)

72
Q

What surgical approach is used for a total pericardiectomy

A

Median Sternotomy

– Phrenic nerve dissected from pericardium.

73
Q

What is different with a total pericardiectomy & Subtotal pericardiectomy

A

Total Pericardiectomy – Phrenic nerves dissected from the pericardium

Subtotal Pericardiectomy – all pericardium ventral to the phrenic nerve is removed.

74
Q

Is a total or subtotal pericardiectomy OR total pericardiectomy preferred with pericardial dz

AND why?

A

Subtotal pericardiectomy –preferred method due to limited tissue dissection.

– open vs. thoracoscopy approach

75
Q

T/F: Electrocautery best achieves hemostasis in a pericardiectomy.

76
Q

A subtotal pericardiectomy is the preferred method in treatment of pericardial dz. What are some other treatments?

A
  1. Total pericardiectomy
  2. Thoracoscopic pericardial window
  3. Percutaneous balloon pericardiectomy
77
Q

What is most important when doing a thoracoscopic pericardial window in treating pericardial disease

A

SIZE – cardiac herniation

78
Q

Procedure that acts as palliative treatment for cardiac tamponade by creating a large pericardial tear

A

Percutaneous balloon pericardiectomy

79
Q

Prognosis of pericardial disease is dependent on the disease process. What is the prognosis for the disease process below:

    • HAS: ___
    • Idiopathic pericarditis:_______
    • Heart based tumors _____
A

Prognosis of pericardial disease is dependent on the disease process. What is the prognosis for the disease process below:

    • HAS: __grave__
    • Idiopathic pericarditis: __excellent___
    • Heart based tumors __Good to fair___

Residual pleural effusion can occur

80
Q

Term that refers to abnormal vessel encircling the esophagus & trachea

A

Vascular ring anomaly [PRAA]

– results in esophageal stricture /occlusion

81
Q

There are 7 types of vascular ring anomaly (PRAA). Name the most common:

A

PRAA with ligamentum arteriosus is the most common

82
Q

What breed is predisposed to PRAA:

A

GSD – most common breed for PRAA

83
Q

When is PRAA typically diagnosed:

A

Between 2-6 months of age

    • signs occur most commonly at time of weaning
    • Regurg
    • unthrifty
    • respiration signs secondary to aspiration pneumonia
84
Q

How do you diagnose a PRAA:

A

Imaging is how PRAA is diagnosed either

    • plain & contrast rads
    • CT: provides views of all structures to help with surgical planning
85
Q

T/F: In patients with PRAA, surgery is not required to relieve the obstruction. It will heal over time.

A

FALSE

– Surgery is required to relieve obstruction

86
Q

What surgical approach is used to relieve obstruction of a PRAA:

A

Left intercostal thoracotomy (5-7 ICS)

87
Q

What is isolated in a PRAA surgery:

A

Isolate ligamentum arteriosus – take caution to avoid penetration to the esophagus

  • – double ligate and TRANSECT
    • Pass Foley catheter and ensure inflated balloon can pass through site of obstruciton
88
Q

T/F: Usually PRAA have a poor prognosis

A

FALSE: good to excellent prognosis

    • PRAA have good to excellent prognosis in 76%-92% of cases.
    • Persistent regurg in some patients = require upright feedings
    • Aspiration pneumonia may be a long term complication
89
Q

What can be a long term complication of a patient with a correct PRAA:

A

Aspiration pneumonia may be a long term complication

SAM Sx (6 decks)

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