Thoracic Surgery

Question 1

What is GERD?

Answer 1

GE reflux that results in symptoms or tissue changes due to loss of normal reflux barrier. 2 episodes/wk + extra-luminal symptoms.
Inappropriate transient relaxations of LES/low basal LES tone. Contributing factors include delayed esophageal clearance, delayed gastric emptying, obesity, pregnancy, acid hypersecretion.

Question 2

What makes up the normal reflux barrier?

Answer 2

LES, stomach reservoir, esophageal motility, antacid effect of saliva.

Question 3

Symptoms of GERD

Answer 3

Typical: heartburn, water brash (sour taste in mouth).
Atypical: chest pain, regurg, wheeze, cough, hoarseness, recurrent PNA, belching.
Alarm signs: wt loss, dysphagia, hematemesis/melena/anemia.
Triggers: lying down, EtOH, spicy/fatty food, chocolate, mint, caffeine.

Question 4

Mgmt of GERD

Answer 4

Lifestyle modification: wt loss, decreased intake aggravating foods, avoid eating before bed, elevate head of bed.
Meds: trial PPI.

Question 5

Investigations to look for secondary causes of GERD:

Answer 5

1) barium esophagram (anatomical cause)
2) 24 hr pH monitoring (gold standard)– pt records symptoms while probe is in. Calculate DeMeester score to look for correlation between symptoms and reflux. A higher score = more responsive to tx.

3) UGI endoscopy: look at anatomy, for hiatus hernia, esophagitis, Barrett’s.
4) UGI contrast study: anatomy, hernia, can see swallowing/reflux.
5) esophageal manometry: rule out motility disorders, LES competence.

Question 6

Describe hiatus hernia.

Answer 6

Stomach above the diaphragm, can worsen symptoms of GERD.
Sliding HH: GE junction moves up through hiatus.
Paraesophageal HH: stomach moves up through esophegeal hiatus with undisplaced GE junction.

Question 7

Role of Surgery for GERD

Answer 7

Use if there is persistent or progressive disease despite medical mgmt.
Fundoplication: wrap fundus of stomach around the distal portion of the esophagus to create a sphincter.
Fix hiatal hernia.

Question 8

Define Barrett’s esophagus, risk factors and mgmt options.

Answer 8

Intestinal metaplasia of esophagus (squamous –> columnar cells in esophagus).
Consider when alarm symptoms are present with GERD (do esophagogastroscopy with biopsy).

RF: chronic/severe reflux, hiatus hernia, motility disorders, obesity.

Mgmt: surveillance endoscopy. If Barrett’s present, endoscopy every 3-5 yrs, low grade dysplasia q6-12 months, high grade dysplasia q3 months.

Question 9

Risk of malignant transformation with Barrett’s

Answer 9

Overall, slow progression. Has <2% lifetime risk of transformation.
Low grade dysplasia: 4% risk over 5 yrs.
High grade dysplasia: 50% risk over 5 yrs.
Carcinoma

Question 10

Adeno vs squamous cell carcinoma of esophagus

Answer 10

Adenocarcinoma: associated with GERD, affects distal esophagus.
SCC: associated with achalasia, Plummer-Vinson syndrome. Affects mid-esophagus.

Question 11

Differentiate dysphagia, oropharyngeal dysphagia and esophageal dysphagia.

Answer 11

Dysphagia = difficulty swallowing/globus sensation.
First characterize: solid vs liquids, progressive, associated odynophagia, wt loss.

Oropharyngeal dysphagia: difficulty initiating swallowing. Symptoms: choking, coughing, nasal regurg. Causes = neurological, muscular, structural.

Esophageal dysphagia: inability to move food down esophagus. Causes = mechanical obstruction (solids only) or neuromuscular (solids and liquids), progressive solid esophageal dysphagia suggestive of carcinoma or peptic stricture.

Question 12

Approach to esophageal carcinoma

Answer 12

1) Assess resectability and stage: PET, CT, endoscopic US (allows visualization of local disease and regional node involvement).
2) Assess operability: PFT, cardiac fxn tests.
3) Staging: T2 has invaded muscuarlis.

Mgmt:
1) Surgery: esophagectomy. Multiple types (Ivor Lewis, Transhiatal, throacoabdominal, etc).

2) Radiation: indicated for locally advanced disease (N1, T3), positive margins, nonoperable, tx of mets.
3) Chemo: indicated for resectable tumors that extend outside hte esophagus (T4 N1), metastatic or non-operable disease.

Decision via staging:
T1-2, N0: cancer localized to esophagus, do esophagectomy. if T1 and small, do endoscopic mucosal resection.
N1+: chemo/radiation/surgery. If good operative candidate, esophagectomy + neoadj chemo or postop chemorad. If bad operative candidate, chemoradiation.

Question 13

Approach to airway obstruction

Answer 13

Consider etiology: edema, damage, spasm, foreign body.
Jaw thrust/chin lift to initially open –> clear mouth of foreign bodies.
Insert oral/nasal airway.
If GCS <8, intubate.
Surgical airway if instrumentation is unsuccessful (cricothyroidotomy)

Question 14

Tension pneumo: what, SS, approach

Answer 14

Air entering pleural space that is unable to escape, resulting in total ipsilateral lung collapse and mediastinal shift with impaired venous return and decreased cardiac output –> shock.

SS: CP, dyspnea, tracheal deviation. Hyperresonance, decreased breath sounds on affected side.

Tx: immediate 2nd ICS needle decompression. Follow up with chest tube.

Question 15

Open pneuothorax: what, SS, tx

Answer 15

Usually asymptomatic, may have CP, dyspnea.
Hyperresonance with decreased breath sounds.
Tx: tube thoracostomy confirmed with CXR.

Question 16

Massive hemothorax: what, SS, tx

Answer 16

Presence of blood in chest, >200 cc before blunting of angles on CXR.

Approach:
Chest tube placement and drainage.
Control bleeding: should usually stop spontaneously if low-velocity gunshot wound or stab wound.

Non-op mgmt: close observation with medical mgmt.
Control HTN pharmacologically.
Surgical: control bleeding, reconstruct with graft if needed. Can do endovascular stenting.

Question 17

Cardiac tamponade: Beck’s triad + tx

Answer 17

Triad: hypotension, jugular venous distension, muffled heart sounds.
Tx: needle pericardiocentesis, pericardial window, thoracotomy with manual decompression.

Question 18

Epidemiology and prevention of bronchogenic carcinoma

Answer 18

Worldwide #1 cause of cancer deaths. 80% die within 2 yrs of Dx. No effective tx for most pts.
Lung and bronchial cancers make up 14% of new cancer cases.

RF: tobacco smoking

Question 19

Presentation of lung cancer

Answer 19

80% are asymptomatic in early stages so often present with metastatic disease.

Pulm SS: cough, dyspnea, wheeze, hemoptysis, PNA.

Extrapulm SS: Chest wall pain, if mediastinal involvement, dysphagia, hoarseness.

Paraneoplastic SS: ACTH secretion–> cushingoid features, SIADH -> hypoNa, PTH-related peptide ->
hyperCa++, bone manifestations.

Met SS: brain, bone, liver.

If new resp symptoms in smokers, need to r/o lung Ca.

Question 20

Best initial test for lung ca

Answer 20

CXR: also to r/o concomitant cardiac, pulm disease.

Question 21

What is a coin lesion?

Answer 21

round or oval, well-circumscribed solitary pulmonary lesion on imaging.

Question 22

What is a solitary pulmonary nodule?

Answer 22

Opacity that is <3cm, completely within hte lung and surrounded by normal parenchyma. Not associated with atelectasis or effusion.
70% are benign, 80% of these are infectious granulomas.

Question 23

What is a solitary pulmonary mass?

Answer 23

opacity >3 cm.

Question 24

DDx of solitary lung lesion

Answer 24

Malignant: primary malignancy (NSCLC, SCLC, carcinoid, sarcoma). Secondary malignancy (breast, colon, sarcoma, etc).

Benign: granuloma, hamartoma, bronchial adenoma, chondroma.

Question 25

Characteristics on imaging worrisome for lung ca when looking at pulm lesion

Answer 25

Spiculated, thick-walled cavitation, lack of calcification (concentric benign, eccentric more worrisome if present), growth over time.

Question 26

TNM system for lung cancer

Answer 26

T: extension into mediastinum.
T1-2: nodules localized to lobe/lung (T1 resectable by lobectomy, 2 by pneumonectomy).
T3: Invades chest wall, main bronchus, phrenic nerve, pericardium.
T4: adjacent organ involvement.

N:
N1: ipsilateral hilar LN
N2: ipsilateral mediastinal/subcarinal LN, exntesion outside of lung but within chest.
N3: supraclavicular, contrlateral hilar/mediastinal-gross mediastinal involvement.

M: distant mets.

Question 27

Clinical stage for lung Ca: how

Answer 27

CT guided Bx/bronchoscopy/EBUS for tissue diagnosis of cancer.
CT chest.
PET scan for nodes/distant mets.
To determine N2/3status, use EBUS to sample LN. If negative, do surgery, if positive, chemorad.

Question 28

Prognosis as per staging of lung ca

Answer 28

Stage 1: curable.

Stage 4: incurable, 5 yr prognosis 2% (60% of lung cancers present at stage 4)

Question 29

Surgical options for lung Ca

Answer 29

If T3 or N2, it is NOT resectable.
Wedge resection: removal of tumor with negative margin. Use when trying to preserve as much other lung function as possible.
Segmentectomy: resection of the entire tumor and that segment. Not as good lobectomy, better than wedge.
Lobectomy: resection of entire tumor and lobe.
Pneumonectomy: removal of entire lung.

Question 30

When to use radiotherapy for lung ca.

Answer 30

Locally advanced disease (N2) unresectable.
Positive margins.
Treatment of mets.
Stereotactic radiosx: reserved for pts who are not surgical candidates. Equivalent tumor control as wedge resection.

Question 31

When chemo is indicated for lung ca

Answer 31

Tumor that extends outside of lung (N1+) or metastatic disease.

Question 32

DDx for mediastinal mass

Answer 32

4T’s: Thymoma (thymic tumor), teratoma (germ cell tumor), thyroid goitre, terrible lymphoma.

Question 33

Outline types of germ cell tumors.

Answer 33

Seminomatous germ cell tumors: tumor markers will be normal, biopsy required. Are sensitive to chemo and RT so surgery not required.

Non-seminomatous: broken down into multiple histologic subtypes including choriocarcinoma, embryonal carinoma, teratocarcinoma. Biopsy not required (many subtypes will produce tumor markers- bHCG, AFP). Are sensitive to chemo but surgery is sometimes indicated.

Question 34

Investigations for pt with mediastinal mass.

Answer 34

Hx + PEx.
Anti-AChR antibody: myasthenia gravis is associated with thymomas.
CBC: r/o lymphoma.
Tumor markers: AFP and bHCG (look for non-seminomatous germ cell tumors), LDH for lymphoma.
Edrophonium testing and EMG: if MG not ruled out.

Question 35

Indications for biopsy of a mediastinal mass

Answer 35

Advanced tumor stage or bulky disease: need for adjuvant therapy.
Lymphadenopathy or B symptoms: suspicion of lymphoma.
Suspicion for seminomatous germ cell tumor.
Not needed if high clinical indication of thymoma.

Question 36

Discuss myasthenia gravis in relation to mediastinal pathology

Answer 36

MG is associated with thymoma. 
MG is an autoimmune disorder with Ab targeting the NMJ resulting in neuromuscular weakness. 
Mgmt: 
1) Cholinesterase inhibitors: pyrostigmine. 
2) Corticosteroids.
3) Immunosuppressants. 
4) IVIG. 
5) Plasmapheresis.

Question 37

Compare exam findings between consolidation, pleural effusion, PTX, atelectasis, asthma, emphysema.

Answer 37

Consolidation: increased fremitus, dull percussion, bronchial breath sounds, crackles.

Pleural effusion: may get tracheal shift, dull percussion, decreased breath sounds, absent fremitus. No adventitious sounds.

PTX: may have tracheal shift, hyperresonance, absent breath sounds, absent fremitus.

Atelectasis: trachea to same side, dull percussion, decreased breath sounds, crackles.

Asthma: wheezes.

Emphysema: hyperresonance, decreased breath sounds, decreased fremitus.

Question 38

Describe normal fluid balance in the lung.

Answer 38

Visceral and parietal pleura produce several liters of pleural fluid per day however balance of forces causes continual reabsorption such that only 15-20 mL are present at a time.

Forces: at the arterial end of the capillary, hydrostatic forces in the capillary are greater than in the lung and force fluid out. At venous end of capillary, oncotic pressure in capilary is greater than interstitium and fluid enters the vessels.

Question 39

Etiology of pleural effusion, categorized by pressure changes (e.g. oncotic/hydrostatic)

Answer 39

Increased capillary intravascular P: venous obstruction, cardiac failure, hypervolemia.

Decrease in cap oncotic P: hypoproteinemia/liver failure.

Increase in intrapleural oncotic P: infection, malignancy, inflammation.

Obstructed lymphatic flow: cancer, lymphatic disorders.

Question 40

What is empyema and what are the stages of empyema?

Answer 40

Empyema: purulent pleural effusion or positive bacterial analysis.
Phase 1: exudative with minimal pleural reaction.
Phase 2: fibrinopurulent with heavy fibrin deposits on the pleural surfaces.
Phase 3: organizing with thick peel on the pleural surface.

Question 41

Transudate vs exudative pleural effusions

Answer 41

Transudate: imbalance of hydrostatic or oncotic forces allowing watery fluid to leak into the pleural space. DDx includes benign disease processes including chronic end stage organ disease (CKD, CHF, cirrhosis). Tx underlying organ dysfunction and drain for symptomatic relief.

Exudate: Disease process causes material to enter pleural space and draws fluid in. Increase in intrapleural oncotic P (e.g. proteins, pus). Fluid is more concentrated.
DDx exudate:
Paraneumonic effusion– simple (free-flowing, serous fluid with negative culture), complicated (loculated effusion), empyema (phase 1/2/3).
Bloody effusion, malignancy, traumatic/iatrogenic, TB, PE.

Question 42

What are Light’s criteria?

Answer 42

Used to differentiate transudative vs exudative effusion.
Likely an exudative effusion if:
Pleural protein : serum protein >0.5 .
Pleural LDH : serum LDH > 0.6.
Pleural LDH > 2/3 upper limit of normal for serum.

Question 43

Diagnostic investigations to run on pleural effusion fluid

Answer 43

Glucose: low in infection, TB, cancer.
pH: low in infection.
Cell count.
Cytology: cancer.
Gram stain + culture.
Amylase: high in esophageal perforation and pancreatic effusion.
TG and chylomicrons: high in chylothorax.

Question 44

How and when to insert a chest tube.

Answer 44

Insert to drain: air, blood, bile, pus, etc.
Give local anesthetic.
Skin incision at 5th ICS, midaxillary line. Cut above the 6th rib.
Insert tube, secure and connect to suction.
Get CXR.

Question 45

Malignant pleural effusion: what, etiology, tx vs palliation

Answer 45

Malignancy –> increased intrapleural oncotic pressure +/- lymphatic flow obstruction.

Etiology:
Men -> more likely to be lung Ca. Women -> more likely to be breast, uterine, ovarian Ca.
10% have unknown primary.
Malignant mesothelioma.

Tx:
Surgery: pleurectomy vs extrapleural pneumonectomy.
Chemo/biologics.
RT.

Palliation: repeated drainage of pleural effusions. Alt can do pleurodesis (intentional scarrification of pleural surfaces to eliminate pleural space, can be done chemically or mechanically). Or, tunneled indwelling pleural catheter.

Question 46

Describe malignant mesotheliomas

Answer 46

1* cancer of pleura.
Main RF = asbestos exposure. Synergistic effect if smoking history.
8% 5 yr survival rate.

Question 47

Mgmt of parapneumonic effusion

Answer 47

Parapneumonic effusion = effusion that arises secondary to PNA, lung abscess, bronchiectasis.

Indications for drainage:
Symptomatic with uncontrolled sepsis or dyspnea.
Asymptomatic: large >50% pleural space, positive gram stain or culture, frank pus.

Relative indications for drainage: thickened pleura on chest imaging, loculated pleural effusion.

The type of parapneumonic pleural effusion will dictate the tx:
Simple- drainage rarely indicated.
Loculated- drainage sometimes indicated.
Eympyema: phase 1 always drain, 2 drain or Sx, 3 Sx always, 4 surgery/decortication.