UpToDate Surgery Research Flashcards
Most common congenital chest wall deformities
Pectus excavatum
In general, what is the cause of pectus deformities
abnormal costal cartilage growth
Pectus excavatum usually spares which two ribs
First and second
During pectus surgery, what is meant to be left intact/preserved when resecting the abnormal cartilage?
perichondrial sheath
What is the definitive/preventative management for pneumothorax?
pleurodesis
A patient presents with a pneumothorax caused by an underlying disorder that was non-traumatic. What is the classification, and what are the treatment options? What is risk of recurrence?
Secondary spontaneous pneumothorax - risk of recurrence 30-50% in the first year.
Is the patient a surgical candidate (medically)?
- no -> chemical pleurodesis w/ talc or tetracycline
- yes -> VATS w/ mechanical abrasion +/- chemical insufflation/pleurectomy/blebectomy
For a patient with a primary spontaneous pneumothorax, what are some indications for definitive procedures?
Recurrence
Size or severity enough to warrant tube/catheter thoracostomy
High risk profession or hobby (diver, pilot; pressure changes)
High cyst burden
PAL (>4 days)
Other reason for VATS (biopsy)
Patient preference
What is the most likely location of blebs in the lung?
Does this affect operative decision making in definitive management of spontaneous pneumothorax?
Apex.
Some surgeons will always do apical blebectomy/bullectomy along with pleurodesis (mechanical +/- chemical) based on retrospective data showing recurrence <5% with the combined approach.
How do thymomas and thymic carcinomas present? (3 general presentations)
Incidental on imaging in asx pt.
Local thoracic symptoms (CP, SoB, cough, phrenic nerve palsy).
Paraneoplastic syndromes (MG, pure red cell aplasia, immunodeficiency, multiorgan autoimmunity).
Describe myasthenia gravis.
Pathophys? Presentation?
Autoimmune disorder - auto-antibodies with AChR of voluntary muscle at NM junction.
Causes diplopia, ptosis, dysphagia, weakness, fatigue.
1/2 of patients w/ thymoma have MG.
MG is rare in thymic carcinoma.
Sx pts tend to cause earlier detection of thymoma.
Surgery usually cures sx, but not always.
What percentage of thymoma patients get pure red cell aplasia?
5-15%. More common in older adult females.
Red cell aplasia will not likely improve after thymectomy for thymoma, but it is still pursued.
Can thymectomy improve immunoglobulin levels in patients with hypogammaglobulinemia immunodeficiency associated with thymoma?
How common is this paraneoplastic syndrome?
What population does it usually affect?
Not reliably.
Hypogammaglobulinemia and pure white blood cell aplasia are present in fewer than 5% of patients with thymoma.
Most common in older adult females?
Several case reports have described a syndrome of thymoma-associated multiorgan autoimmunity (TAMA). How does this present?
Similar to graft-versus-host disease. Morbilliform skin eruption, chronic diarrhea, and liver enzyme abnormalities.
Histopathology of the skin or bowel mucosa is similar to that seen with graft-versus-host disease.
What is the imaging workup for an anterior mediastinal mass suspicious of thymoma?
What are you trying to determine?
CT or MRI.
Need to determine whether the thymoma is well circumscribed or if it infiltrates other structures. Need to determine resectability.
*Pic of thymic mass not well circumscribed.
What imaging findings are more concerning for thymic carcinoma as opposed to thymoma?
Necrotic, cystic, or calcified areas.
T staging for thymic tumors.
AJCC UICC 8th edition
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Tumor encapsulated or extending into the mediastinal fat; may involve the mediastinal pleura
T1a Tumor with no mediastinal pleura involvement
T1b Tumor with direct invasion of mediastinal pleura
T2 Tumor with direct invasion of the pericardium (either partial or full thickness)
T3 Tumor with direct invasion into any of the following: Lung, brachiocephalic vein, superior vena cava, phrenic nerve, chest wall, or extrapericardial pulmonary artery or veins
T4 Tumor with invasion into any of the following: Aorta (ascending, arch, or descending), arch vessels, intrapericardial pulmonary artery, myocardium, trachea, esophagus
N staging for thymic tumors.
AJCC UICC 8th edition
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in anterior (perithymic) lymph nodes
N2 Metastasis in deep intrathoracic or cervical lymph nodes
M staging for thymic tumors.
AJCC UICC 8th edition
M0 No pleural, pericardial, or distant metastasis
M1 Pleural, pericardial, or distant metastasis
M1a Separate pleural or pericardial nodule(s)
M1b Pulmonary intraparenchymal nodule or distant organ metastasis
Other than thymoma and thymic carcinoma, what else is on the differential for anterior mediastinal mass?
What other preop tests should be done in light of this?
Retrosternal thyroid, lymphoma, and mediastinal germ cell tumor.
Preoperative evaluation may include germ cell tumor markers (beta-human chorionic gonadotropin [hCG] and alpha fetoprotein), LDH, as well as pulmonary function tests.
How do you obtain definitive diagnosis of a thymoma or thymic carcinoma?
Tissue:
For patients thought to have a thymoma that will be amenable to complete resection, the initial step in management is surgical resection, which can definitively establish the diagnosis.
For patients with a tumor that is not considered amenable to complete resection or in whom surgery is contraindicated because of age or comorbidity, a tissue diagnosis with a core needle biopsy or an open biopsy is required prior to therapy.
Can preop imaging predict stage in thymomas and thymic carcinomas?
In approximately two-thirds of thymomas and thymic carcinomas, preoperative chest CT can accurately predict the pathologic TNM stage.
What pathological consideration must be taken when a thymoma or thymic carcinoma is adherent to a nearby structure?
surgeon should designate the site of adhesion on the specimen so that the pathologist can take sections from that area; specimen should be oriented by the surgeon to identify the exact margins of resection, which should then be inked
What are the recommendations for TAVI postop anticoag vs antiplatelet specifics?
If no indications for DAPT or anticoagulation, then SAPT is used. Otherwise follow concomitant indications for other medications.
What factors generally favor SAVR over TAVR?
- Presence of another indication for cardiac surgery (root enlargement)
- Lack of femoral access
- Younger age (<65, longer life expectancy, particularly if patient is a candidate for surgical mechanical valve replacement)
- Anatomic feature that would make TAVI high risk: adverse aortic root, low coronary ostia height, heavily calcified bicuspid aortic valve, and severe left ventricular outflow tract calcification.
Preprocedural TAVI/TAVR needs:
Abx ppx?
Monitoring/lines?
Pacing?
Anticoag - ACT, when?
- ancef
- at least 1 large bore; art line; warming
- temporary pacing
- wt adjusted, ACT 250-300 before placement of large sheath
If severe/sx AS pt is not SAVR candidate, but cannot get transfemoral access, what are other options for TAVR?
subclavian/axillary approach, two transthoracic approaches (transaortic and transapical), the transcaval approach, and the transcarotid approach
General steps of TAVI/TAVR?
obtaining vascular access, establishing a clear coplanar view of the aortic annulus, balloon aortic valvuloplasty (in selected cases), delivery of the transcatheter heart valve (THV), repositioning (if indicated and feasible), and post-deployment valvuloplasty (if indicated to improve frame expansion)
