Thoracic Surgery Flashcards
1
Q
What is VATS?
A
Video-Assisted Thoracic Surgery
2
Q
What is thoracic outlet syndrome?
A
Compression of the subclavian artery, subclavian vein, or brachial plexus at the superior outlet of the thorax
3
Q
What are the causes of thoracic outlet syndrome?
A
- Various congenital anomalies, including cervical rib or abnormal fascial bands to the first rib, or abnormal scalene muscle.
- Trauma: clavicular fracture or first rib fracture, dislocation of humeral head, crush injuries.
- Repetitive motor injuries.
4
Q
What are the symptoms of thoracic outlet syndrome?
A
- Paresthesias (neck, shoulder, arm, hand) with 90% in ulnar distribution
- Weakness (neural or arterial)
- Coolness of involved extremity (arterial)
- Edema, venous distention, discoloration (venous)
5
Q
What is the most common type of symptoms in thoracic outlet syndrome?
A
Neurologic
6
Q
Which nerve is most often involved in thoracic outlet syndrome?
A
Ulnar nerve
7
Q
What are the signs of thoracic outlet syndrome?
A
- Paget-von Schroetter syndrome (venous thrombosis leading to edema, arm discoloration, and distention of the superficial veins)
- Weak brachial and radial pulses in the involved arm
- Hypesthesia or anesthesia
- Occasionally, atrophy in the distribution of the ulnar nerve
- Positive Adson maneuver or Tinel’s sign
- Edema
8
Q
What is the Adson maneuver?
A
Evaluates for arterial compromise:
The patient (1) Extends neck, (2) Takes deep breath and holds, and (3) Turns head toward examined side.
The physician monitors radial pulse on examined side.
The test finding is positive if the radial pulse decreases or disappears during the maneuver.
9
Q
What is Tinel’s test?
A
Tapping of the supraclavicular fossa producing paresthesias
10
Q
What is the treatment for thoracic outlet syndrome?
A
PT; decompression of the thoracic outlet by resecting the first rib and cervical rib (if present) if PT fails and as a last resort.
11
Q
What are the most common benign chest wall tumors?
A
- Fibrous rib dysplasia (posterolateral rib)
- Chondroma (at costochondrial junction)
- Osteochondroma (any portion of rib)
12
Q
What is the treatment for benign chest wall tumors?
A
Wide excision and reconstruction with autologous or prosthetic grafts
13
Q
What are the most common malignant chest wall tumors?
A
Fibrosarcoma, chondrosarcoma, osteogenic sarcoma, rhabdomyosarcoma, myeloma, Ewing’s sarcoma
14
Q
What is the treatment for malignant chest wall tumors?
A
Excision +/- XRT
15
Q
What is Tietze’s syndrome?
A
Non-infectious costochondral cartilage inflammation
16
Q
What is a pleural effusion?
A
Fluid in the pleural space
17
Q
What are the causes of pleural effusion?
A
Pulmonary infections; CHF; SLE; RA; pancreatitis; trauma; PE; renal disease; cirrhosis; malignancy (mesothelioma, lymphoma, metastasis); post-pericardiotomy syndrome
18
Q
What are the symptoms of pleural effusion?
A
Dyspnea, pleuritic chest pain
19
Q
What are the signs of pleural effusion?
A
Decreased breath sounds, dullness to percussion, ego phony at the upper limit
20
Q
What are the properties of a transudate?
A
Specific gravity: < 1.016
Protein: < 3 g/dL
Few cells
21
Q
What are the properties of an exudate?
A
Specific gravity: > 1.016
Protein: > 3 g/dL
Many cells
22
Q
What is the key diagnostic test for pleural effusion?
A
Thoracentesis with studies including cytology
23
Q
What is the treatment for pleural effusion?
A
- Pigtail catheter or thoracostomy
- Treat underlying condition
- Consider sclerosis
24
Q
What is an empyema?
A
Infected pleural effusion.
Must be drained, usually with chest tube; decortication may be necessary if the empyema is solid.
25
What is a decortication?
Thoracotomy and removal of an infected fibrous rind from around the lung
26
What are the signs and symptoms of a lung abscess?
Fever, sputum, sepsis, fatigue
27
What are the associated diagnostic studies for lung abscess?
CXR (air-fluid level); CT (define position and differentiate from empyema); bronchoscopy (cancer/culture)
28
What is the treatment for lung abscess?
Antibiotics and bronchoscopy for culture and toilet, +/- surgery
29
What are the indications for surgery for lung abscess?
Underlying cancer/tumor or refractory to antibiotics
30
What are the surgical options for lung abscess?
Lobectomy of lobe with abscess, tube drainage
31
What is middle lobe syndrome?
Recurrent right middle lobe pneumonia caused most commonly by intermittent extrinsic bronchial obstruction
32
What is hemoptysis?
Bleeding into the bronchial tree
33
What are the causes of hemoptysis?
1. Bronchitis
2. Tumor mass
3. TB
Also, bronchiectasis, pulmonary catheters, trauma.
34
What is massive hemoptysis?
> 600 cc/day
35
What comprises the workup of hemoptysis?
CXR; bronchoscopy; bronchial A-gram
36
What is the treatment for massive hemoptysis?
Bronchoscopy, intubation of unaffected side; Fogarty catheter occlusion of bleeding bronchus; bronchial A-gram +/- embolization; surgical resection of involved lung
37
What is the treatment of moderate to mild hemoptysis?
Laser coagulation +/- epinephrine
38
What is a spontaneous PTX?
Atraumatic spontaneous development of a PTX
39
What are the causes of spontaneous PTX?
Idiopathic, bleb disease, emphysema
40
What body habits is associated with spontaneous PTX?
Thin and tall
41
How is the diagnosis of spontaneous PTX made?
CXR
42
What is the treatment for spontaneous PTX?
Chest tube
43
What are the options if spontaneous PTX is refractory, recurrent, or bilateral?
Pleurodesis:
Scar the lung to the parietal pleura with a sclerosant (talc) via chest tube/thoracoscopy or thoracotomy and mechanical dilation.
44
What is a catamenial PTX?
PTX due to intrathoracic endometriosis
45
What is malignant mesothelioma?
Primary pleural neoplasm
46
What are the 2 types of malignant mesothelioma?
1. Localized
| 2. Diffuse
47
What are the risk factors for malignant mesothelioma?
Exposure to asbestos; smoking
48
What are the symptoms of malignant mesothelioma?
Dyspnea and pain.
Localized: pleuritic pain, joint pain and swelling.
Diffuse: chest pain, malaise, weight loss, cough.
49
What are the signs of malignant mesothelioma?
Pleural effusion:
Localized: 10-15%
Diffuse: >75%
50
What are the associated radiographic tests for malignant mesothelioma?
CXR (peripheral mass, often forming obtuse angle with chest wall); CT
51
How is the diagnosis of malignant mesothelioma made?
Pleural biopsy, pleural fluid cytology
52
What is the treatment for localized malignant mesothelioma?
Surgical excision
53
What is the treatment for diffuse malignant mesothelioma?
Early: Resection, then XRT.
Advanced: XRT, chemotherapy
54
What is the prognosis for malignant mesothelioma?
Localized: poor
Diffuse: dismal
55
What is benign mesothelioma?
Benign pleural mesothelioma
56
What pleura is usually involved in benign mesothelioma?
Visceral pleura
57
What is the gross appearance of benign mesothelioma?
Pedunculated "broccoli or cauliflower" tumor on a stalk coming off of the lung
58
What is the treatment for benign mesothelioma?
Surgical resection with at least 1 cm clear margin
59
What is the prognosis for benign mesothelioma?
Excellent: cure in vast majority of cases
60
What is the annual incidence of lung cancer in the US?
170,000 new cases
61
What is the number of annual deaths from lung cancer?
150,000
62
What is the #1 risk factor for lung cancer?
Smoking
63
Does asbestos exposure increase the risk of lung cancer run patients who smoke?
Yes
64
What type of lung cancer arises in non-smoking patients?
Adenocarcinoma
65
In which lung does cancer arise more often?
Right > left and Upper > lower
66
What are the signs and symptoms of lung cancer?
Change in a chronic cough; hemoptysis, chest pain, dyspnea; pleural effusion; hoarseness; SVC syndrome; diaphragmatic paralysis; paraneoplastic syndrome; finger clubbing
67
What is Pancoast's tumor?
Tumor at the apex of the lung or superior sulcus that may involve the brachial plexus, sympathetic ganglia, and vertebral bodies, leading to pain, upper extremity weakness, Horner's syndrome
68
What is Horner's syndrome?
Injury to the cervical sympathetic chain:
1. Miosis
2. Anhydrosis
3. Ptosis
69
What are the 4 most common sites of extrathoracic metastases from lung cancer?
1. Bone
2. Liver
3. Adrenals
4. Kidney
70
What are paraneoplastic syndromes?
Syndromes that are associated with tumors but may affect distant parts of the body.
They may be caused by hormones released from endocrinologically active tumors or may be of uncertain etiology.
71
What are 5 general types of paraneoplastic syndrome?
1. Metabolic (Cushing's, SIADH, hypercalcemia)
2. Neuromuscular (Eaton-Lambert, cerebellar ataxia)
3. Skeletal (hypertrophic osteoarthropathy)
4. Dermatologic (acanthosis nigricans)
5. Vascular (thrombophlebitis)
72
What are the associated radiographic tests for lung cancer?
CXR, CT, PET scan
73
How is lung cancer diagnosed?
1. Sputum cytology
2. Needle biopsy (CT or fluoro guidance)
3. Bronchoscopy with brushings, biopsies, or both
4. Mediastinoscopy, mediastinotomy, scalene node biopsy, or open lung biopsy for definitive diagnosis
74
What is the usual site of squamous cell lung cancer and what is its natural course?
66% occur centrally in lung hilus, may also be Pancoast's tumor.
Slow growth, late metastasis, associated with smoking.
75
What is the usual site of lung adenocarcinoma and what is its natural course?
Peripheral.
| Rapid growth with hematogenous/nodal metastsasis, associated with lung scarring.
76
What is the usual site of small (oat) cell lung cancer and what is its natural course?
Central.
| Highly malignant, usually not operable.
77
What is the usual site of large cell lung cancer and what is its natural course?
Peripheral.
| Very malignant.
78
What is stage Ia lung cancer?
Tumor < 3 cm, no nodes, no metastases
79
What is stage Ib lung cancer?
Tumor 3-5 cm, no nodes, no metastases
80
What is stage IIa lung cancer?
1. Tumor < 5 cm and positive nodes to lung or ipsilateral hilum, no metastases, or
2. Tumor 5-7 cm, no nodes, no metastases
81
What is stage IIb lung cancer?
1. Tumor 5-7 cm and positive nodes in lung or ipsilateral hilum, no metastases, or
2. Tumor that invades chest wall, diaphragm, mediastinal pleura, phrenic nerve, pericardial sac, or bronchus (not carina) and no nodes, no metastases
82
What is stage IIIa lung cancer?
1. Tumor < 7 cm and positive nodes in ipsilateral mediastinum or subcarina, no metastases, or
2. Tumor > 7 cm or extends into chest wall, parietal pleura, diaphragm, phrenic nerve, or pericardium, positive node in ipsilateral, mediastinal, or subcarinal nodes, or
3. Any size tumor that invades heart, great vessels, trachea, esophagus, carina, or ipsilateral lobe, or positive nodes in peribronchial or ipsilateral hilum or intrapulmonary nodes
83
What is stage IIIb lung cancer?
1. Any size tumor, positive nodes in contralateral hilum or mediastinum, or
2. Positive supraclavicular or scalene nodes, no distant metastases
84
What is stage IV lung cancer?
Distant metastases
85
What are the surgical contraindications for non-small cell lung cancer?
Stage IIIb-IV, poor lung function (FEV1 < 0.8 L)
86
What is the treatment for stage I non-small cell lung cancer?
Surgical resection
87
What is the treatment for stage II non-small cell lung cancer?
Surgical resection
88
What is the treatment for stage IIIa non-small cell lung cancer?
Chemotherapy and XRT +/- surgical resection
89
What is the treatment for stage IIIb non-small cell lung cancer?
Chemotherapy and XRT
90
What is the treatment for stage IV non-small cell lung cancer?
Chemotherapy +/- XRT
91
What is the treatment for isolated brain metastasis from lung cancer?
Surgical resection
92
What is the prognosis (5-year survival after treatment of non-small cell lung cancer?
Stage I: 50%
Stage II: 30%
Stage III: < 10%
Stage IV: 1%
93
How is small cell lung cancer treated?
Chemotherapy +/- XRT
94
What are the contraindications to surgery for lung cancer?
```
STOP IT:
SVC syndrome, Supraclavicular or Scalene node metastasis
Tracheal carina involvement
Oat cell cancer
Pulmonary function tests poor
Infarction (myocardial)
Tumor elsewhere
```
95
What postoperative FEV1 must you have after treatment for lung cancer?
FEV1 > 800 cc, thus a preoperative FEV1 > 2 L is usually need for a pneumonectomy.
If FEV1 < 2 L, a VQ scan should be performed.
96
What is hypertrophic pulmonary osteoartropathy?
Periosteal proliferation and new bone formation at the end of long bones and in the bones of the hand
97
What are solitary pulmonary nodules (coin lesions)?
Peripheral circumscribed pulmonary lesions
98
What is the differential diagnosis for solitary pulmonary nodules
Granulomatous disease, benign neoplasms, malignancy
99
What percentage of solitary pulmonary nodules are malignant?
5-10%
100
What are the symptoms of solitary pulmonary nodules?
Usually asymptomatic.
| May include coughing, weight loss, chest pain, hemoptysis.
101
What are the signs of solitary pulmonary nodules?
Physical findings uncommon.
| Rarely, clubbing.
102
How is the diagnosis of solitary pulmonary nodules made?
CXR, chest CT
103
What is the significance of popcorn calcification on CXR?
Most likely benign hamartoma
104
What are the risk factors for malignancy with solitary pulmonary nodules?
1. Size: lesions > 1 cm have a significant chance of malignancy
2. Indistinct margins (corona radiata)
3. Documented growth on followup CXR
4. Increasing age
105
What are the associated lab test for solitary pulmonary nodules?
1. TB skin tests
2. Sputum cultures
3. Sputum cytology is diagnostic in 5-20% of cases
106
Which method of tissue diagnosis is used for solitary pulmonary nodules?
Chest CT with needle biopsy; bronchoscopy (+/- tracheal biopsy); excisional biopsy (open or thoracoscopic)
107
What is the treatment for solitary pulmonary nodules?
1. Surgical excision is the mainstay.
2. Excisional biopsy is therapeutic for benign lesions, solitary metastasis, and for primary cancer in patients who are poor risks for more extensive surgery.
3. Lobectomy for centrally placed lesions.
4. Lobectomy with node dissection for primary cancer (if resectable by preoperative evaluation).
108
Which solitary pulmonary nodules can be followed without a tissue diagnosis?
Popcorn calcifications and masses unchanged for 2 years on previous CXR
109
What are the signs of hypertrophic osteoarthropathy?
Clubbing of fingers, diagnosed by XR of long bones
110
What is a carcinoid tumor of the lung?
APUD cell tumor of the bronchus
111
What is APUD?
Amine-Precursor Uptake and Decarboxylation
112
What is the natural course of carcinoid tumors of the lung?
Slow-growing (but may be malignant)
113
What are the primary local findings in carcinoid tumors of the lung
Wheezing and atelectasis caused by bronchial obstruction or stenosis
114
What condition can carcinoid tumors of the lung be confused with?
Asthma
115
How is the diagnosis of carcinoid tumor of the lung made?
Bronchoscopy reveals round red-yellow-purple mass covered by epithelium that protrudes into bronchial lumen
116
What is the treatment for carcinoid tumors of the lung?
```
Surgical resection (lobectomy with lymph node dissection).
Sleeve resection is also an option for proximal bronchial lesions.
```
117
What is a sleeve resection?
Resection of a ring segment of bronchus (with tumor inside) and then end-to-end anastomosis of the remaining ends, allowing salvage of lower lobe
118
What is the 5-year survival from carcinoid tumors of the lung after complete surgical resection?
Negative nodes: > 90%
| Positive nodes: 66%
119
What is the most common benign lung tumor?
Hamartoma
120
What is pulmonary sequestration?
Abnormal benign lung tissue with separate blood supply that does not communicate with the normal tracheobronchial airway
121
What is interlobar pulmonary sequestration?
Sequestration in normal lung tissue covered by normal visceral pleura
122
What is extralobar pulmonary sequestration?
Sequestration not in normal lung covered by its own pleura
123
What are the signs and symptoms of pulmonary sequestration?
Asymptomatic or recurrent pneumonia
124
How is the diagnosis of pulmonary sequestration made?
CXR, chest CT, A-gram, U/S with Doppler flow
125
What is the treatment for extralobar pulmonary sequestration?
Surgical resection
126
What is the treatment for intralobar pulmonary sequestration?
Lobectomy
127
What is the major danger during surgery for pulmonary sequestration?
Anomalous blood supply from below the diaphragm (these can be cut and retract into the abdomen resulting in exsanguination)
128
What structures lie in the superior mediastinum?
Aortic arch, great vessels, upper trachea, esophagus
129
What structures lie in the anterior mediastinum?
Thymus, ascending aorta, lymph nodes
130
What structures lie in the middle mediastinum?
Heart, lower trachea and bifurcation, lung hila, phrenic nerves, lymph nodes
131
What structures lie in the posterior mediastinum?
Esophagus, descending aorta, thoracic duct, vagus and intercostal nerves, sympathetic trunks, azygous and hemiazygous veins, lymph nodes
132
What is the major differential diagnosis for tumors in the anterior mediastinum?
4 T's:
Thyroid tumor, Thymoma, Terrible lymphoma, Teratoma.
Also, parathyroid tumor, lipoma, vascular aneurysms.
133
What is the major differential diagnosis for tumors in the middle mediastinum?
LAD (lymphoma, sarcoidosis), teratoma, fat pad, cysts, hernias, extension of esophageal mass, bronchogenic cancer
134
What is the major differential diagnosis for tumors in the posterior mediastinum?
Neurogenic tumors, lymphoma, aortic aneurysm, vertebral lesions, hernias
135
What is the most common type of tumor arising in the mediastinum?
Neurogenic (most commonly in posterior mediastinum)
136
What is the differential diagnosis for a neurogenic tumor?
Schwannoma (neurolemmoma), neurofibroma, neuroblastoma, ganglioneuroma, ganglioneuroblastoma, pheochromocytoma
137
Where are thymomas found in the mediastinum?
Anterior
138
How is the diagnosis of thymoma made?
CT
139
What is the treatment for thymoma?
Surgical resection via midline sternotomy
140
What are the indications for post-op XRT for thymoma?
Invasive malignant tumor
141
What are the indications for pre-op chemotherapy for thymoma?
Tumor > 6 cm and CT with invasion
142
What percentage of thymomas are malignant?
25%
143
How is a malignant thymoma diagnosed?
At surgery with invasion into surrounding structures (not by histology)
144
What is myasthenia gravis?
Autoimmune disease with antibodies against the muscle acetylcholine receptors
145
What percentage of patients with myasthenia gravis have a thymoma?
15%
146
What percentage of patients with thymoma have or will have myasthenia gravis?
75%
147
What are mediastinal teratomas?
Tumors of branchial cleft cells.
| The tumors contain ectoderm, endoderm, and mesoderm.
148
What is a dermoid cyst?
Teratoma made up of ectodermal derivatives
149
Which age group is affected by teratomas?
Usually adolescents, but can occur at any age
150
Where in the mediastinum do teratomas occur?
Anterior
151
What are the characteristic CXR findings with teratomas?
Calcifications or teeth.
| Tumors may be cystic.
152
What percentage of teratomas are malignant?
15%
153
What is the treatment for benign dermoid cysts?
Surgical excision
154
What is the treatment for malignant teratoma?
Preoperative chemotherapy until tumor markers are normal, then surgical excision
155
Which tumor markers are associated with malignant teratomas?
AFP, CEA
156
What is the incidence of mediastinal neurogenic tumors?
Most common mediastinal tumors in all age groups
157
Where in the mediastinum do neurogenic tumors occur?
Posterior, in the paravertebral gutters
158
What percentage of mediastinal neurogenic tumors are malignant?
50% in children
| 10% in adults
159
What are the 5 histologic types of mediastinal neurogenic tumors?
1. Neurolemmoma or schwannoma (benign): arise from Schwann cell sheaths of intercostal nerves.
2. Neurofibroma (benign): arise from intercostal nerves, may degenerate into:
3. Neurosarcoma (malignant)
4. Ganglioneuroma (benign): from sympathetic chain.
5. Neuroblastoma (malignant): from sympathetic chain.
160
Where in the mediastinum do lymphomas occur?
Anywhere, but most often in the anterosuperior mediastinum or hilum in the middle mediastinum
161
What percentage of lymphomas involve mediastinal nodes?
50%
162
What are the symptoms of mediastinal lymphoma?
Cough, fever, chest pain, weight loss, SVC syndrome, chylothorax
163
How is the diagnosis of mediastinal lymphoma made?
CXR, CT, mediastinoscopy or mediastinotomy with node biopsy
164
What is the treatment for mediastinal lymphoma?
Chemotherapy, XRT, or both
165
What is acute mediastinitis?
Acute suppurative mediastinal infection
166
What are the 6 causes of acute mediastinitis?
1. Esophageal perforation (Boerhaave's)
2. Postoperative wound infection
3. Head and neck infections
4. Lung or pleural infections
5. Rib or vertebral osteomyelitis
6. Distant infections
167
What are the clinical features of acute mediastinitis?
Fever, chest pain, dysphagia, respiratory distress, leukocytosis
168
What is the treatment for acute mediastinitis?
Wide drainage, treatment of primary cause, antibiotics
169
What is chronic mediastinitis?
Mediastinal fibrosis secondary to chronic granulomatous infection
170
What is the most common etiology of chronic mediastinitis?
Histoplasma capsulatum
171
What are the clinical features of chronic mediastinitis?
50% are asymptomatic.
| SVC syndrome, bronchial and esophageal strictures, constrictive pericarditis.
172
How is the diagnosis of chronic mediastinitis made?
Surgical biopsy, CXR, CT
173
What is the treatment for chronic mediastinitis?
Antibiotics (surgical resection of granulomas rarely helpful)
174
What is SVC syndrome?
Obstruction of the SVC, usually by extrinsic compression
175
What is the primary cause of SVC syndrome?
Malignant tumors cause 90% of cases.
| Lung cancer is by far the most common (though also, thymoma, lymphoma, Hodgkin's disease).
176
What are the clinical manifestations of SVC syndrome?
1. Blue discoloration and puffiness of the face, arms, and shoulders.
2. CNS manifestations may include headache, N/V, visual distortion, stupor, convulsions.
3. Cough, hoarseness, dyspnea.
177
What is the treatment for SVC syndrome?
Diuretics and fluid restriction; prompt XRT +/- chemotherapy for any causative cancer
178
What is the prognosis for SVC syndrome?
SVC obstruction is fatal in < 5% of cases.
| Mean survival time in patients with malignant obstruction is 7 months.
179
What are the primary functions of the upper and lower esophageal sphincters?
UES: swallowing
LES: prevention of reflux
180
Why is it important that the esophageal venous plexus drains inferiorly into the gastric veins?
Gastric veins are part of the portal venous system.
| Portal hypertension can thus be referred to the esophageal veins, leading to varices.
181
What is the blood supply to the proximal esophagus?
Inferior thyroid and anterior intercostal arteries
182
What is the blood supply to the middle esophagus?
Esophageal and bronchial arteries
183
What is the blood supply to the distal esophagus?
Left gastric and left inferior phrenic arteries
184
What is the length of the esophagus?
25 cm in the adult
185
Why is the esophagus notorious for anastomotic leaks?
Esophagus has no serosa
186
What nerve runs with the esophagus?
Vagus nerve
187
What is Zenker's diverticulum?
Pharyngoesophageal diverticulum.
A false diverticulum containing mucosa and submucosa at the UES at the pharyngoesophageal junction through Killian's triangle.
188
What is the most common esophageal diverticulum?
Zenker's diverticulum
189
What are the signs and symptoms of Zenker's diverticulum?
Dysphagia, neck mass, halitosis, food regurgitation, heartburn
190
How is the diagnosis of Zenker's diverticulum made?
Barium swallow
191
What is the treatment for Zenker's diverticulum?
1. Diverticulectomy
| 2. Cricopharyngeus myotomy (if > 2 cm)
192
What is achalasia?
1. Failure of the LES to relax during swallowing
| 2. Loss of esophageal peristalsis
193
What are the proposed etiologies of achalasia?
1. Neurologic (ganglionic degeneration of Auerbach's plexus, vagus nerve, or both). Possibly infectious in nature.
2. Chagas' disease in South America.
194
What are the long-term conditions associated with achalasia?
Esophageal carcinoma secondary to Barrett's esophagus from food stasis
195
What are the symptoms of achalasia?
Dysphagia for both solids and liquids, followed by regurgitation.
Dysphagia for liquids is worse.
196
What are the diagnostic findings with achalasia?
Barium swallow (dilated esophageal body with narrowing inferiorly); manometry (increased pressure in LES and failure of LES to relax during swallowing)
197
What are the treatment options for achalasia?
1. Balloon dilation of the LES.
2. Medical treatment of reflux vx. Belsey Mark IV 270 fundoplication.
3. Myotomy of the lower esophagus and LES.
198
What is diffuse esophageal spasm?
Strong, non-peristaltic contractions of the esophageal body.
| Sphincter function is usually normal.
199
What is the condition associated with diffuse esophageal spasm?
GERD
200
What are the symptoms of diffuse esophageal spasm?
Spontaneous chest pain that radiates to the back, ears, neck, jaw or arms
201
What is the differential diagnosis of diffuse esophageal spasm?
Angina pectoris; psychoneurosis; nutcracker esophagus
202
What are the associated diagnostic tests for diffuse esophageal spasm?
Manometry (repetitive, high-amplitude contractions with normal sphincter response); upper GI (normal or segmented spasms, corkscrew esophagus); endoscopy
203
What is the classic finding on upper GI with diffuse esophageal spasm?
Corkscrew esophagus
204
What is the treatment for diffuse esophageal spasm?
Medical (antireflux, CCBs, nitrates); long esophagomyotomy in refractory cases
205
What is another name for nutcracker esophagus?
Hypertensive peristalsis
206
What is nutcracker esophagus?
Very strong peristaltic waves
207
What are the symptoms of nutcracker esophagus?
Spontaneous chest pain that radiates to the back, ears, neck, jaw, or arms
208
What is the differential diagnosis for nutcracker esophagus?
Angina pectoris, psychoneurosis, diffuse esophageal spasm
209
What are the associated diagnostic tests with nutcracker esophagus?
Manometry (repetitive, high-amplitude contractions with normal sphincter response); UGI (normal, rule out mass); endoscopy
210
What is the treatment for nutcracker esophagus?
Medical (antireflux, CCBs, nitrates); long esophagomyotomy in refractor cases
211
Which caustic agents may cause esophageal strictures if ingested?
Lye, oven cleaners, drain cleaners, batteries, sodium hydroxide tablets
212
How is the diagnosis of caustic ingestion?
History; EGD (to level of severe injury only, assess extent of damage); water soluble contrast study (rule out perforation)
213
What is the initial treatment for ingestion of a caustic substance?
1. NPO/IVF/H2 blockers
2. Do not induce emesis
3. Corticosteroids (controversial), antibiotics (penicillin, gentamicin) for moderate ulcers
4. Antibiotic for deep ulcers
5. UGI at 10-14 days
214
What is the treatment if an esophageal stricture develops after ingestion of a caustic substance?
Dilation with Maloney dilator or balloon catheter.
| In severe refractory cases, esophagectomy with colon interposition or gastric pull-up.
215
What is the long-term followup for caustic ingestion?
Endoscopies every other year (increased risk of esophageal squamous cancer)
216
What is a Maloney dilator?
Mercury-filled rubber dilator
217
What are the 2 types of esophageal cancer?
1. Adenocarcinoma at the GEJ
| 2. Squamous cell carcinoma
218
What is the most common type of esophageal cancer?
World: squamous cell carcinoma
US: adenocarcinoma
219
What is the age and gender distribution for esophageal cancer?
Most common in the 6th decade; M > F
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What are the 5 etiologic factors in esophageal cancer?
1. Tobacco
2. Alcohol
3. GERD
4. Barrett's esophagus
5. Radiation
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What are the symptoms of esophageal cancer?
Dysphagia, weight loss, chest pain, back pain, hoarseness
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What comprises the workup for esophageal cancer?
UGI; EGD; transesophageal U/S; chest and abdomen CT
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What is the differential diagnosis of esophageal cancer?
Leiomyoma, metastatic tumor, lymphoma, benign stricture, achalasia, diffuse esophageal spasm, GERD
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How is the diagnosis of esophageal cancer made?
UGI (localize tumor); EGD (obtain biopsy and assess resectability); full metastatic workup (CXR, bone scan, CT, LFTs)
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What is stage I esophageal cancer?
Tumor invades lamina propria, muscularis mucosae, or submucosa; negative nodes
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What is stage IIa esophageal cancer?
Tumor invades muscularis propria; negative nodes
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What is stage IIb esophageal cancer?
1. Tumor invades up to muscular is propria, positive regional nodes, or
2. Tumor invades adventitia, negative nodes.
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What is stage III esophageal cancer?
1. Tumor invades adventitia, positive regional nodes, or
| 2. Tumor invades adjacent structure.
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What is stage IV esophageal cancer?
Distant metastasis
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What is the treatment for esophageal cancer?
Esophagectomy with gastric pull-up or colon interposition
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What is an Ivor-Lewis procedure?
Laparotomy and right thoracotomy with gastroesophageal anastomosis in the chest after esophagectomy
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What are the treatment options for metastatic esophageal cancer?
Chemotherapy and XRT +/- dilation, stent, laser, electrocoagulation, brachytherapy, photodynamic laser therapy
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What is a blunt esophagectomy?
Esophagectomy with blunt transmittal dissection of esophagus from abdomen and gastroesophageal anastomosis in the neck
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Has XRT and/or chemotherapy been shown to decrease mortality from esophageal cancer?
No
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What is the prognosis (5-year) for esophageal cancer?
Stage I: 66%
Stage II: 25%
Stage III: 10%
Stage IV: 0%
