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Surgery > Thoracics > Flashcards

Thoracics Flashcards

1
Q

what is GERD

A

when significant symptoms or tissue changes occur with heartburn, with 2 or more episodes per week and extraluminal symptoms like dysphagia

normally there is the LES and 2 cm of intraabdominal esophagus beneath the diaphgram at the angle of His –> there is esophageal motility and the antacid effect of saliva

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2
Q

typical symptoms of GERD

A

heart burn

water brash (sour taste)

triggers (lying down, alcohol, spicy/fatty food, chocolate, caffeine etc)

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3
Q

atypical symptoms of GERD

A

chest pain

regurg

respiratory sx

belching

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4
Q

alarm symptoms of GERD

A

weight loss

dysphagia

hematemesis/melena/anemia

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5
Q

tests used in evaluating GERD

A

barium esophagram

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6
Q

where do you find a hiatal hernia

A

at junction between esophagus and stomach

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7
Q

what 4 tests should you consider before doing anti-reflux surgery for GERD

A
  1. gold standard to confirm GERD is 24 hour pH monitoring–> pH probe inserted to GE junction, left in for 24 hours as patient goes home with diary of symptoms–> gives a DeMeester score
  2. Upper GI endoscopy –> identify anatomy, hiatus hernia, esophagitis, Barrett’s
  3. UGI contrast study–> confirm anatomy, hiatus hernia, visualize swallowing/reflux
  4. esophageal manometry–> measures pressures in the esophagus, rules out motility disorders
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8
Q

define barrett’s esophagus

A

intestinal metaplasia of the esophagus–> squamous to intestinal columnar

*associated with risk of malignancy

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9
Q

risk factors for barretts esophagus

A

chronic reflux

hiatus hernia

motility disorders

obesity

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10
Q

how do you characterize dysphagia?

A
  1. solids? liquids?
  2. progressive?
  3. painful?
  4. weight loss?
  5. cervico-thoracic versus oropharygneal
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11
Q

what is cervico-thoracic dysphagia

A

related to food getting stuck in the thoracic esophagus

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12
Q

what is orophayngeal dysphagia

A

initiation of swallowing, choking or coughing, associated with neuromuscular diseases, strokes

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13
Q

what do you order to evaluate dysphagia?

A

esophagastroscopy

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14
Q

what type of esophageal cancer is associated with chronic GERD

A

adenocarcinoma

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15
Q

what type of esophageal cancer is associated with achalasia

A

SCC

typically mid-esophageal in location

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16
Q

what is achalasia

A

failure of LES opening when you eat, causing back up of food in esophagus

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17
Q

how do you stage esophageal cancer

A

TNM

T–tumour size and location into wall

N–nodal involvement and number of nodes involved

M–distant mets

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18
Q

how do you treat esophageal cancer

A

surgery, chemo, radiation

surgery–> usually entails esophagectomy–> often multiple approaches and different cavities

may have pre or postop chemo with or without radiation

investigate with CT/PET, endoscopic U/S, biopsy

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19
Q

what is the overall survival rate of lung cancer

A

less than 10%

lung ca is often asymptomatic early, and patients usually present with metastatic disease (usually what brings up symptoms)

beware of new resp symptoms in smokers, this may represent lung ca

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20
Q

most common symptoms of lung ca? next most common?

A

cough–75%

dyspnea–50%

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21
Q

symptoms of lung ca

A 
cough
dyspnea
wheeze
hemoptysis
pneumonia
extrapulmonary--> invasion of nearby structures--> chest pain, dysphagia etc...
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22
Q

list 4 examples of conditions associated with paraneoplastic syndromes

A
  1. increased cortisol secretion from small cell lung cancer (ACTH secretion)
  2. hyponatremia–> SIADH
  3. hypercalcemia–> PTH related peptide secretion
  4. bone manifestations
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23
Q

what is the best investigation for lung ca

A

CXR

there are some worrisome imaging characteristics (also on CT)

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24
Q

what signs do you look for on CXR that suggest lung cancer

A
  1. spiculation –> looks like a star
  2. thick walled cavitation
  3. lack of calcification (though eccentric asymmetric calcification is also worrying
  4. growth over time
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25
Q

what tests should you order to image lung cancer

A

CXR
CT chest
(PET)

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26
Q

what info does CT chest give you RE: lung ca

A

anatomic info

info about lymph node involvement or mets

may give histologic info too

any patient with suspected lung ca should have one to determine if they are a surgical candidate along with PET scan

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27
Q

when do you do chemo and radiation instead of surgery for lung ca

A

if N2 nodes are positive

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28
Q

define a solitary lung nodule

A

(solid on CT)

less than 3 cm is nodule

more than 3cm is mass

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29
Q

what are the most common cancers to metastasize to the lung

A

breast
colon
sarcoma

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30
Q

list the types of lung cancer

A

non small cell lung cancer–> adenocarcinoma, SCC, large cell carcinoma

small cell lung cancer

carcinoid

sarcoma

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31
Q

how do you stage lung cancer

A

TNM staging

T1–> less than 3cm, peripheral

T2–> 2-7 cm, invades the main airway, extends into periphery/visceral pleura

T3–> larger than 7 cm, invades chest wall or main bronchus or phrenic nerve or pericardium or there are two modules in the same lobe that are both cancerous (regardless of size)

T4–> invasion of essentially unresectable organs (trachea, great vessels, heart, esophagus)–> 2 nodules in different lobes that are both cancerous is automatically T4

location is more important than number

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32
Q

where does lung cancer met to

A

contralateral lung

brain

bone

etc

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33
Q

who is a good candidate for surgery for lung ca

A

must be possible to resect with acceptable morbidity and have limited enough disease that surgery will provide improved outcomes, alone or with chemo/radiation

patient must be able to undergo the operation with an acceptable risk of complications

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34
Q

what are the principles of surgery for lung ca

A
  1. gross resection of all tumour
  2. free resection of margins
  3. systemic assessment of metastatic deposits
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35
Q

what is the surgical treatment for lung ca

A

LOBECTOMY is standard of care for stage 1 and 2

but some patients may not be able to have a lobectomy because of limited lung function–> can do removal of tumour with negative margin (wide resection) instead but this tends to have lower survival and greater return of disease

segmentectomy has better outcomes oncologically with more preservation of lung function

pneumonectomy with removal of entire lung if it is not isolated to single lobe

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36
Q

how do you assess a patient for lung ca operability

A

pulm function–

  • PFTs with FEV1 etc
  • exercise testing (i.e 6 minute walk test)

cardiac function–

  • baseline ECG
  • stress testing
  • echo
  • coronary angiography
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37
Q

when do you use chemo and radiation to treat lung ca

A

used if surgery is contraindicated or advanced

radiation is about equivalent to wedge therapy

38
Q

what is the most common outpatient GI complaint

A

GERD

39
Q

what is the normal esophageal reflux barrier

A

LES–> diaphragm, intraabdominal esophagus, angle of His

stomach reservoir

esophageal motility

antacid effect of saliva

40
Q

how would you manage GERD initially

A

lifestyle mods (elevate head of bed, avoid eating late at night) and trial daily PPI

41
Q

what syndrome is associated with esophageal SCC

A

plummer-vinson syndrome

achalasia

42
Q

where is esophageal adenocarcinoma usually found in the esophagus

A

distal

43
Q

where is esophageal SCC usually found in the esophagus

A

mid esophagus

44
Q

how do you assess esophageal cancer resectability

A

PET
CT
endoscopic U/S

45
Q

what are the stages of esophageal cancer

A

T1–invades mucosa

T2–invades muscularis

T3–invades adventitia

T4–invades adjacent structures

46
Q

define Ivor lewis esophagectomy

A

laparotomy plus right thoracotomy

47
Q

define transhiatal esophagectomy

A

laparotomy plus cervical incision

48
Q

define left thoracoabdominal esophagectomy

A

single incision through left chest and abdomen

49
Q

define McKeown esophagectomy

A

right thoracotomy and left cervical incision laparotomy

50
Q

what is the most common chemo regime for esophageal cancer

A

cisplatin or carboplatin

paclitaxel

5-fluoruracil

51
Q

what is the most common chemo regime for esophageal cancer

A

cisplatin or carboplatin

paclitaxel

5-fluoruracil

52
Q

symptoms of myasthesia gravis

A

progressive muscle weakness that gets worse throughout the day

associated with diplopia, blurred vision, occasional dyspnea and dysphonia

53
Q

what is myasthenia gravis

A

autoimmune disorder with antibodies targeting neuromuscular junction and resulting in neuromuscular weakness

54
Q

what blood test is used to evaluation myasthenia gravis

A

anti-AChR (acetylcholine receptor) antibody test

55
Q

how do you work someone up for myasthenia gravis

A

anti-AChR antibody test

edrophonium testing (Ach mimetic that can improve symptoms temporarily

electromyography

CT for eval for associated conditions like thymic malignancy

56
Q

what cancer is associated with myasthenia gravis

A

thymus

57
Q

ddx of anterior mediastinal mass

A

thymic tumor/thymoma
teratoma/germ cell tumours
thyroid goiter
terrible lymphoma

58
Q

workup for mediastinal mass

A

workup:
look at anti-AChR antibody, CBC, tumour markers

AFP and beta HCG–> elevations are diagnostic of non-seminomatous germ cell tumour

LDH–>for lymphoma

biopsy indicated if advanced tumour stage or large bulky disease likely needing adjuvant chemo, LAD, suspicion for seminomatous germ cell tumour

59
Q

medical management of myasthenia gravis

A
  1. cholinesterase inhibitor (pyridostigmine)
  2. corticosteroids (anti-inflammatories)
  3. maybe IVIG
  4. surgery?
60
Q

when to do surgery in the case of myasthenia gravis/thymoma

A

for severe symptoms that may or may not be refrectory to medical management

removal of thymic gland if indicated

61
Q

is surgery indicated for non-seminomatous germ cell tumours

A

sometimes, though are sensitive to chemo

biopsy no required

62
Q

how do you treat a thymoma

A

stage I-IIb–> thymectomy

stage III completely resected–> thymectomy with or without chemo

stage III incompletely resected–> thymectomy plus chemo plus radiation

stage IV–> chemo plus or minus radiation

63
Q

why do patients with myasthenia gravis have associations with thymomas

A

thymus gland has role in immune system and in MG it stays large and abnormal into adulthood via lymphoid hyperplasia

64
Q

why do patients with myasthenia gravis have associations with thymomas

A

thymus gland has role in immune system and in MG it stays large and abnormal into adulthood via lymphoid hyperplasia

65
Q

what might you see on CXR in a pleural effusion

A

blurred costophrenic angle

66
Q

what might you see on CXR in a pleural effusion

A

blurred costophrenic angle

67
Q

what is the worldwide numer 1 cause of cancer deaths

A

lung ca

68
Q

what is the number 1 risk factor for lung ca

A

smoking

69
Q

what % die from lung ca within 2 years of dx

A

80%

70
Q

what % of solitary pulmonary nodules on CXR are malignant

A

70%

71
Q

ddx of benign pulmonary nodules

A

granuloma
hamartoma
bronchial adenoma
chondroma

72
Q

ddx of benign pulmonary nodules

A

granuloma
hamartoma
bronchial adenoma
chondroma

73
Q

AFP tumor marker for?

A

non seminomatous germ cell tumour

74
Q

what is the most common cause of pleural effusion

A

increased capillary intravascular pressure (from increased intravascular volume or obstruction)

  • -venous obstruction
  • -cardiac failure
  • -hypervolemia

second most common–> increased intrapleural oncotic pressure

  • -malignancy
  • -inflammatory or infectious cause

can also be due to–>

  • -decreased capillary oncotic pressure
  • -decreased intrapleural hydrostatic pressure
75
Q

what is the most common cause of pleural effusion

A

increased capillary intravascular pressure (from increased intravascular volume or obstruction)

  • -venous obstruction
  • -cardiac failure
  • -hypervolemia

second most common–> increased intrapleural oncotic pressure

  • -malignancy
  • -inflammatory or infectious cause

can also be due to–>

  • -decreased capillary oncotic pressure
  • -decreased intrapleural hydrostatic pressure
76
Q

define transudate

A

imbalance in the pleural forces (hydrostatic and oncotic pressures) allows watery fluid to leak into the pleural space

from decreased intrapleural hydrostatic pressure, intravascular oncotic pressure or increase in intravascular hydrostatic pressure

77
Q

define exudate

A

a disease process causes protein, pus or other oncotic material to enter the pleural space which draws out fluid from the capillary bed

78
Q

what determines transudative or exudative

A

lights criteria

79
Q

what tests should you perform on pleural fluid

A
  1. glucose and pH–> both low in infection
  2. cell count
  3. cytology (positive indicates malignancy)
  4. gram stain
  5. amylase (high in esophageal perforation)
  6. triglycerides/chylomicrons (high in chylothorax)
80
Q

what should you order in all patients with a pleural effusion

A

thoracocentesis

81
Q

what are indications for drainage of a parapneumonic effusion

A
  1. symptomatic–> uncontrolled sepsis, dyspnea etc
  2. asymptomatic –> large pleural effusion (more than 50% of hemithorax), positive gram stain of bacterial culture on pleural fluid analysis, frank pus
  3. relative indications–> thickened pleura, loculated pleural effusion
82
Q

define simple parapneumonic effusion

A

free flowing serious fluid with negative culture

only need drainage if symptomatic

83
Q

define complicated pleural effusion

A

loculated

empyema

drainage sometimes indicated

84
Q

what condition is often associated with bloody pleural effusion

A

malignancy

can also be caused by trauma/iatrogenic, TB, sometimes PE

85
Q

what is the mechanism of bloody pleural effusion in malignancy

A

increased interstitial oncotic pressure due to malignant cells

most common cause for malignant pleural effusion in males is lung cancer–> in females it is breast, uterine and ovarian cancer

86
Q

what is malignant mesothelioma

A

primary cancer of the pleura

main risk factor is asbestos exposure but smoking multiplies this risk

uniformly poor outcomes

treatment includes removal of the pleura with or without some lung removal–> radiotherapy commonly performed

87
Q

how do you manage malignant pleural effusion

A

repeated drainage

pleurodesis–> intentional scarification of the pleural surfaces (chemical or mechanical)

tunneled indwelling pleural catheter

88
Q

with what conditions do we associated transudative pleural effusion

A

beign disease

usually associated with chornic end organ disease like CKD, cirrhosis

treatment is treatment of underlying organ dysfunction

89
Q

why do we care about parapneumonic effusions

A

high risk for progressing to empyema–> draining should be performed when indicated

90
Q

what are the three phases of empyema and their treatment

A
  1. phase I–> exudative with minimal pleural reaction–> drain
  2. phase II–> fibrinopurulent with heavy fibrin deposits on the pleural surfaces–> drain or surgery
  3. phase III–> organizing with thick peel on the pleural surfaces–> surgery almost always indicated

Surgery (20 decks)

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