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
2
Q
Is congenital or traumatic diaphragmatic hernias more common?
A
TRAUMATIC – most common diaphragmatic hernia
– blunt trauma to thorax and/or abdomen
3
Q
Diaphragmatic hernia occur due to rapid deflation of lungs with ___ ____ that produces large pleuroperitoneal pressure gradient
A
Open glottis
4
Q
T/F: Muscular portions are most susceptible to tears with diaphragmatic hernias.
A
TRUE
5
Q
T/F: 15-25% of diaphragmatic hernias are diagnosed weeks after injury
A
TRUE
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
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.
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 ***
9
Q
Diagnostic of choice for diaphragmatic hernia:
A
UTRASOUND
- US ( 93% accurate)
- Rads (66% accurate)
- Positive contrast celiography: (poor) –
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.
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).
12
Q
What surgical approach is used for a diaphragmatic herniorrhaphy:
A
Ventral midline abdominal approach
– be prepared to perform median sternotomy if required
13
Q
T/F: Liver is the most common herniated organ
A
TRUEEE
– Pope said it twice : KNOW
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
15
Q
T/F: there is no treatment for re-expansion pulmonary edema
A
TRUE
– fatal
16
Q
Is re-expansion pulmonary edema associated with chronic or acute hernias
A
Chronic hernias are most common in re-expansion pulmonary edema.
17
Q
What occurs when re-inflating any atelectic lung?
A
Re-expansion pulmonary edema – Associated with rapid expansion of previously ateletic lung
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
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
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
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.
22
Q
Term referred to as congenital communication between pericardium & peritoneal cavity (chest no technically involved)
A
Peritoneaopericardial diaphragmatic Hernia (PPDH)
23
Q
PPDH is unknown cause of defect in ______
A
Embryogenesis
- PPDH: commonly associated with other congenital defects.
- PPDH may be a incidental finding
24
Q
Around what age group does PPDH commonly occur:
A
Middle aged
25
Common clinical signs of PPDH:
- - Respiratory ***
- - GI ***
- - Cardiac or Neurogenic systems
26
Breeds with increased risk for PPDH:
- - Weimaraners
- -- Cocker spaniels
- - DLH
- - Himalayans
27
Type of PPDH that has a pent logy of defects
Congenital Cranial Abdominal wall & diaphragmatic defects --- DOGS
28
List the Pentalogy of defects in congenital cranial abdominal wall & diaphragmatic defects:
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)
29
Breeds predisposed for congenital cranial abdominal wall and diaphragmatic defects:
- - Weimaraners
- - Cocker spaniels
- - Dachshunds
- - Collies
30
Common PE findings for PPDH:
-- Muffled heart sounds
--Ascites
--Murmur
+/- Concurrent ventral abdominal wall defect
31
Diagnostic of choice for PPDH
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
32
T/F: It is suggested to wait a couple of weeks before treating a PPDH surgically
FALSE -- treat ASAP
-- At 6-8 weeks of age ideally so adhesions are less likely & thoracic wall is more pliable.
33
Traumatic diaphragmatic hernia and PPDH have the same surgical approach. Which is:
Ventral Midline abdominal approach
-- BOTH traumatic diaphragmatic hernia & PPDH use the ventral midline abdominal approach
34
What suture pattern is used to surgically correct a PPDH:
| **********
Simple continuous pattern --- Do NOT need to close pericardial sac separately
35
What is the outcome for a PPDH that has been surgically corrected
Excellent if animal survives 24 hr post op
-- post op mortality rate of 14%
36
T/F: In the fetus, the ductus arteriosus shunts blood from main pulmonary artery to aorta.
True -- direct venous blood away from fetal lungs
37
Patent ductus arteriosus present when ductus remains patent ___ days after parturition
> 3 days
38
Most common congenital cardiac defect in dogs:
PDA (patent ductus arteriosus)
39
Signalment for PDA
Pure-bred, small breed dogs most effected
- - F > M
- - Heritable basis identified in poodles & Welsh corgis
40
PDA shunts blood from ___ to ____side of the heart
Reverse PDA (Eisenmenger's Syndome) will shunt blood from ____ to ___ side of the heart
```
PDA= L ==> R
Reverse= R ==> L
```
41
Does PDA result in right or left sided heart failure:
Left sided heart failure
- - severe volume overload of L heart that progresses to left sided failure
- - Mitral regurg contributes to the overload
42
T/F: a reverse PDA can be treated with a coil embolization or amplatzer ductal occlude
*****
FALSE
This is the treatment for a PDA. Treatment for reverse PDA is contraindicated.
NO TREATMENT FOR REVERSE PDA
43
Cause for a reverse PDA:
- 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
Asymptomatic to fulminant left heart failure is the main clinical sign associated with:
PDA (patent ductus arteriosus)
45
What is the following clinical signs associated with:
- - differential cyanosis
- - exercise intolerance
- - PL collapse
- - polycythemia
Reverse PDA
46
What 2 findings are present on PE with a patient with PDA:
```
Continuous murmur
Hyperkinetic pulses (BB shot, waterhammer) -- +/- stunted growth
```
47
Animals with PDA have a good prognosis without treatment.
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
What are 2 minimally invasive procedures for treating PDA:
- - Coil Embolization
| - - Amplatzer ductal occlude
49
What are the 3 surgical procedures in the treatment of PDA:
1. Coil embolization
2. Amplatzer ductal occlude
3. Surgical ligation
50
What is a long term complication associated with surgical ligation in a patient with PDA
Recanalization
Other complications of surgical ligation
- - severe hemorrhage secondary to PDA rupture
- -- bradycardia (branham reflex)
- - residual ductal flow
51
T/F: In PDA patients, mitral regurgitation and myocardial insufficiency are likely to resolve following surgery
True
52
Prognosis for a patient with PDA
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
Prognosis for a patient with a reverse PDA
Poor to grave for reverse PDA
54
Most common cardiac neoplasia in dogs
Hemangiosarcoma of right auricle
55
T/F: Hemangiosarcoma of the right auricle is usually a secondary occurrence:
FALSE
-- hemangiosarcoma is usually a primary occurrence = Micrometastases typically present at time of diagnosis
56
What is the emergency tx for hemangiosarcoma of the right auricle:
Pericardiocentesis
-- emergency tx for hemangiosarcoma of right auricle because patient presents with acute cardiac tamponade (hemorrhage into pericardium)
57
Best way to diagnose hemangiosarcoma of the right auricle
Echocardiography
58
Best prognosis for a hemangiosarcoma is achieved by:
Excision of right auricle mass, pericardiectomy followed by chemotherapy
- MST for surgery without chemo = 4 months
59
Pericardium surrounds heart and restrains cardiac filling. Name other functions of the pericardium:
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
Thickening of pericardium or rapid raise in pericardial pressure results in:
Cardiac tamponade:
- - increase intra-cardiac diastolic pressure
- -decreased SV
- - decreased CO
- - Increase in systemic pericardial contraction & scarring
61
One important cause of pericardial effusion is
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
Pericardial disease is common in younger or older large breed dogs?
Large breed dogs
pericardial dz is more common in large breed dogs.
CS-- weakness, lethargy, collapse, exercise intolerance
63
What heart sounds will be heard when auscultating a patient with pericardial effusion
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
With pericardial disease, the patient will have weak pulses. Will the pulses feel weaker on expiration or inspiration?
Weak on INSPIRATION
65
Diagnostics for Pericardial disease:
1.
2.
3.
4.
5. +/-
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
T/F: Pericardiectomy can be either curative or palliative depending on underlying disease process.
True
67
What procedure for pericardial disease will:
- - decrease surface area for fluid production
- - increases surface area for fluid absorption (pleural cavity)
Pericardiectomy
68
What is the shape of the heart in pericardial disease:
Globoid shape heart
-- in pericardial disease
69
On a electrocardiogram of a patient with pericardial disease, you see electrical alternans, what is causing this?
-- swinging of heart in the pericardial sac (changes the amplitude of QRS complexes)
70
T/F: ultrasound will give a instantaneous answer if you have fluid in pericardial disease
TRUEEE
-- US gives INSTANT answer for pericardial dz.
71
Diagnostics of choice for pericardial dz:
US- gives instant answer for effusion
| PERICARDIOCENTESIS-- diagnostic & therapeutic (culture fluid)
72
What surgical approach is used for a total pericardiectomy
Median Sternotomy
-- Phrenic nerve dissected from pericardium.
73
What is different with a total pericardiectomy & Subtotal pericardiectomy
Total Pericardiectomy -- Phrenic nerves dissected from the pericardium
Subtotal Pericardiectomy -- all pericardium ventral to the phrenic nerve is removed.
74
Is a total or subtotal pericardiectomy OR total pericardiectomy preferred with pericardial dz
AND why?
Subtotal pericardiectomy --preferred method due to limited tissue dissection.
-- open vs. thoracoscopy approach
75
T/F: Electrocautery best achieves hemostasis in a pericardiectomy.
TRUE.
76
A subtotal pericardiectomy is the preferred method in treatment of pericardial dz. What are some other treatments?
1. Total pericardiectomy
2. Thoracoscopic pericardial window
3. Percutaneous balloon pericardiectomy
77
What is most important when doing a thoracoscopic pericardial window in treating pericardial disease
SIZE -- cardiac herniation
78
Procedure that acts as palliative treatment for cardiac tamponade by creating a large pericardial tear
Percutaneous balloon pericardiectomy
79
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 _____
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
Term that refers to abnormal vessel encircling the esophagus & trachea
Vascular ring anomaly [PRAA]
| -- results in esophageal stricture /occlusion
81
There are 7 types of vascular ring anomaly (PRAA). Name the most common:
PRAA with ligamentum arteriosus is the most common
82
What breed is predisposed to PRAA:
GSD -- most common breed for PRAA
83
When is PRAA typically diagnosed:
Between 2-6 months of age
- - signs occur most commonly at time of weaning
- - Regurg
- - unthrifty
- - respiration signs secondary to aspiration pneumonia
84
How do you diagnose a PRAA:
Imaging is how PRAA is diagnosed either
- - plain & contrast rads
- - CT: provides views of all structures to help with surgical planning
85
T/F: In patients with PRAA, surgery is not required to relieve the obstruction. It will heal over time.
FALSE
-- Surgery is required to relieve obstruction
86
What surgical approach is used to relieve obstruction of a PRAA:
Left intercostal thoracotomy (5-7 ICS)
87
What is isolated in a PRAA surgery:
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
T/F: Usually PRAA have a poor prognosis
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
What can be a long term complication of a patient with a correct PRAA:
Aspiration pneumonia may be a long term complication
