Thoracic Surgery

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jknell
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Thoracic Surgery
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2014-01-19 21:22:54
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Thoracic Surgery
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  1. ANATOMY
      -Mediastinum
      -Lungs
      -Vasculature
      -Lymphatics
    • MEDIASTINUM:
    • -Anterior: thymus, LNs, aorta, great veins
    • -Visceral: pericardium, heart, trachea, hilar structures, esophagus, phrenic nerves, LNs

    • LUNGS:
    • -Right: oblique and horizontal fissures
    • -Left: single oblique fissure, lingula
    • -Bronchopulmonary Segments: separate blood supply, allowing resection. R: 10, L: 8

    • VASCULATURE:
    • -Pulmonary artery (unoxygenated)
    • -Bronchial artery (oxygenated)

    • LYMPHATICS:
    • -flow from parietal to visceral pleura
    • -drainage is cephalad
    • -contralateral flow from LLL
  2. Rigid Bronchoscopy
    • -trachea and main bronchi
    • -good for biopsies and clearing secretions and blood
    • -requires skill
  3. Flexible Fiberoptic Bronchoscopy
    • -visualize lobar bronchi and small bronchopulmonary segments
    • -not as effective at clearing secretions
    • -especially useful in intubated patients
  4. Mediastinoscopy
    • -instrument inserted behind sternum at tracheal notch
    • -direct biopsy of LNs, sarcoidosis, lymphoma, fungal infections
  5. Thoracic Incisions
    Median Sternotomy: anterior mediastinum exposure

    • Posterolateral Thoracotomy: lung, esophagus, posterior mediastinum

    • Axillary Thoracotomy: upper lobe bx, sympathectomy

    Anterolateral Thoracotomy: rapid exposure (trauma), unstable CV status, good control of airway during incision

    Anterior Parasternal Mediastinotomy (Chamberlain procedure): direct visualization of mediastinal LNs, insert scope
  6. Immediate Life-Threatening Thoracic Injuries
    • -Airway obstruction
    • -Tension pneumothorax
    • -Open pneumothorax
    • -Massive hemothorax
    • -Cardiac Tamponade
    • -Flail Chest
  7. Tension Pneumothorax
    • CAUSES:
    • -trauma
    • -CPR
    • -mechanical ventilation

    • CLINICAL PRESENTATION:
    • -hypoTN
    • -distended neck veins
    • -tracheal deviation
    • -decreased breath sounds

    • TREATMENT:
    • -immediate needle thoracotomy
    • -replace later with chest tube
  8. Open Pneumothorax
    Open wound in the chest wall that has exposed pleural space to the atmosphere

    • CLINICAL PRESENTATION:
    • -air moves through defect → ineffective alveolar ventilation

    • TREATMENT:
    • -cover wound
    • -chest tube
  9. Massive Hemothorax
    *surgical indications
    • TREATMENT:
    • -chest tube
    • -volume resuscitation

    • COMPLICATIONS:
    • -empyema
    • -fibrothorax

    • INDICATIONS FOR SURGERY:
    • -initial drainage of at least 1000 mL
    • -hemorrhage of 200 ml/hr for 4 hrs
  10. Cardiac tamponade
    • CLINICAL PRESENTATION:
    • -narrowed pulse pressure
    • -pulsus paradoxus (>10 mmHg pressure drop during inspiration)
    • -electrical alternans on EKG (not diagnostic)

    • BECK'S TRIAD:
    •    1. Hypotension
    •    2. Muffled heart sounds
    •    3. JVD

    • TREATMENT:
    • -pericardiocentesis (unstable)
    • -median sternotomy/L anterior thoracotomy (stable)
  11. Flail Chest
    • CAUSES:
    • -anterior and posterior rib fractures
    • -sternocostal disconnection

    • CLINICAL PRESENTATION:
    • -paradoxical chest movement

    • TREATMENT:
    • -pain control (intercostal blocks, epidural narcotics)
    • -aggressive pulmonary toilet
  12. Potentially Life-Threatening Injuries
    • -Tracheobronchial Disruption
    • -Aortic Disruption
    • -Diaphragmantic Disruption
    • -Esophageal Disruption
    • -Cardiac Contusion
    • -Pulmonary Contusion
  13. Tracheobronchial Disruption
       -clinical presentation
       -diagnosis
       -treatment
    -usually occurs within 2cm of the carina

    • CLINICAL PRESENTATION:
    • -collapsed lung fails to expand after CT placement
    • -massive air leak persists
    • -progressive subcutaneous emphysema

    • DIAGNOSIS:
    • -broncoscopy

    • TREATMENT:
    • -primary repair
  14. Aortic Disruption
       -cause
       -clinical presentation
       -diagnosis
       -treatment
    • CAUSE:
    • -deceleration injury (ascending aorta and arch mobile, descending aorta is fixed)
    • -fracture of intima and media (adventitia intact)

    • CLINICAL PRESENTATION:
    • -widened mediastinum
    • -apical cap
    • -left pleural effusion
    • -indistinct aortic knob

    • DIAGNOSIS:
    • -aortogram

    • TREATMENT:
    • -interposition graft
  15. Diaphragmatic Disruption
       -cause
       -clinical presentation
       -diagnosis
       -treatment
    • CAUSE:
    • -blunt trauma, beginning at esophageal hiatus
    • CLINICAL PRESENTATION:
    • -severe respiratory distress

    • DIAGNOSIS:
    • -CXR: evidence of stomach or intestines in chest

    • TREATMENT:
    • -immediately place NG tube (prevents acute gastric dilation
    • -transabdominal repair
    • *transthoracic repair if not diagnosed for 7-10 days (adhesions to lung)
  16. Esophageal Disruption
       -cause
       -clinical presentation
       -treatment
    • CAUSE:
    • -penetrating trauma

    • CLINICAL PRESENTATION:
    • -rapidly progressive mediastinitis

    • TREATMENT:
    • -wide mediastinital drainage
    • -primary closure (tissue reinforcement with pleura, intercostal muscle, stomach)
  17. Cardiac Contusion
       -cause
       -diagnosis
       -treatment
       -complications
    • CAUSE:
    • -direct sternal impact

    • DIAGNOSIS:
    • -EKG
    • -cardiac enzymes
    • -echo

    • TREATMENT:
    • -monitoring (cardiac, hemodynamic)
    • -control arrhythmias
    • -ionotropic support if cardiogenic shock develops

    • COMPLICATIONS:
    • -arrhythmias (PVCs, SVT, Afib)
    • -myocardial rupture
    • -ventricular septal rupture
    • -LV failure
  18. Pulmonary Contusion
       -epidemiology
       -causes
       -diagnosis
       -treatment
    • EPIDEMIOLOGY:
    • -most common injury in thoracic trauma
    • -30-75%

    • CAUSES:
    • -blunt trauma (intra-alveolar hemorrhage and edema → small airway obstruction)

    • DIAGNOSIS:
    • -CXR
    • -ABG

    • TREATMENT:
    • -fluid restriction
    • -supplemental O2
    • -chest physiotherapy
    • -analgesia
    • -prompt chest tube drainage if necessary
  19. Pectus Excavatum
    • -most common chest wall deformity
    • -usually asymptomatic

    • SURGICAL INDICATIONS:
    • -moderate to severe deformities
    • -at 4-5 years old
  20. Pectus Carinatum
    • -overly prominent sternum
    • -less likely to cause functional impairment than pectus excavatum
  21. Poland's Syndrome
    -unilateral absence of costal cartilage, pec muscle and breast

    • TREATMENT:
    • -surgery
  22. Thoracic Outlet Syndrome
       -3 clinical presentations
       -diagnosis
       -treatment
    • CLINICAL PRESENTATIONS:
    • 1. Compression of neurovascular bundle:
    • -pain and paresthesia in neck, shoulder, arm, hand
    • 2. Compression of brachial plexus
    • -most common
    • -pain in neck, shoulder, arm, anterior chest wall
    • -paresthesia of hand (ulnar nerve)
    • 3. Vascular Compression
    • -less common

    • DIAGNOSIS:
    • -clinical
    • -rule out cervical disc disease with MRI

    • TREATMENT:
    • 1. Conservative: physical therapy
    • 2. Surgical (refractory sxs)
    •    -supraclavicular scalenectomy
    •    -brachial plexus neurolysis
    •    -first rib resection
  23. Benign Chest Wall Tumors
    • FIBROUS DYSPLASIA OF RIB:
    • -posterior or lateral rib
    • -slow growing, not painful
    • -may be part of Albright's syndrome

    • CHONDROMA:
    • -costochondral junction

    OSTEOCHONDROMA
  24. Malignant Chest Wall Tumors
       -types
       -treatment
    • TYPES:
    • -fibrosarcoma
    • -chondrosarcoma
    • -osteogenic sarcoma
    • -myeloma
    • -Ewing's sarcoma

    • TREATMENT:
    • -wide excision and reconstruction
  25. Spontaneous Pneumothorax
       -epidemiology
       -cause
       -clinical presentation
       -treatment
       -indications for surgery
       -surgery
    • EPIDEMIOLOGY:
    • -young adults, more likely men
    • -older pts with COPD

    • CAUSE:
    • -subpleural bleb rupture

    • CLINICAL PRESENTATION:
    • -chest pain, cough, dyspnea

    • TREATMENT:
    • -Chest tube drainage
    • -surgery

    • INDICATIONS FOR SURGERY:
    • -recurrent PTX (ipsilateral or contralateral)
    • -presistent air leak (3-5 days)
    • -persistent PTX
    • -hemopneumothorax (may cause empyema/fibrosis)

    • SURGERY:
    • -VATS
    • -stapling of apical blebs
    • -pleurodesis
  26. Pleural Effusion
       -transudative effusion
       -exudative effusion
    • TRANSUDATIVE EFFUSION:
    • -systemic disorders
    • -protein-poor plasma filtrate
    • *avoid chest tube placement

    • EXUDATIVE EFFUSION:
    • -local pleural pathology
    • -protein-rich plasma filtrate
    • *chest tube, VATS, thoracotomy
  27. Pleural Empyema
       -pathophysiology
       -stages
       -diagnosis
       -treatment
    • PATHOPHYSIOLOGY:
    • -usually secondary to pulmonary infection

    • STAGES:
    • 1. Acute/Serous: 1-7 days
    • 2. Transitional/Fibrinopurulent: 7-21, septation and loculation
    • 3. Chronic/Organized: >21d, abscess formation

    • DIAGNOSIS:
    • -thoracentesis
    • -positive gram stain, pH < 7.4

    • TREATMENT:
    • -early pneumococcal: repeat aspiration and abx
    • -established: continuous closed drainage, thoracotomy/debridement
    • -TPA with CT guidance
  28. Lung Abscess
       -etiology
       -treatment
       -indications for surgery
    • ETIOLOGY:
    • -aspiration (posterior segment of upper lobe, superior segment of lower lobe)
    • -mixed infection, anaerobes

    • TREATMENT:
    • -IV abx (90%)
    • -transbrochial drainage (broncoscopy)
    • -CT-directed drainage
    • -surgery

    • INDICATIONS FOR SURGERY
    • -failure to resolve with abx
    • -hemorrhage
    • -inability to r/o carcinoma
    • ->6cm
    • -rupture with empyema
  29. Bronchiectasis
       -pathophysiology
       -diagnosis
       -treatment
    • PATHOPHYSIOLOGY:
    • -due to repeated pulmonary infections or obstruction
    • -usually affects lower lobes

    • DIAGNOSIS:
    • -CT scan
    • -broncoscopy to identify causes

    • TREATMENT:
    • -Medical: abx, pulmonary toilet
    • -Surgical: segmental resection
  30. Tuberculosis
       -indications for surgery
    • -bronchopulmonary fistula with empyema
    • -persistent open cavities with positive sputum
    • -post-tubercular bronchial stenosis
    • -pulmonary hemorrhage
    • -suspected carcinoma
    • -aspergilloma
  31. Solitary Pulmonary Nodules
       -epidemiology
       -benign lesions
       -diagnosis
    • EPIDEMIOLOGY:
    • -more often in men
    • -often asymptomatic
    • -2/3 are benign in pts <40 years old

    • BENIGN LESIONS:
    • -popcorn-like calcifications
    • -no growth over 2 years
    • -<1 cm diameter
    • -well-circumscribed

    • DIAGNOSIS:
    • -no benefit of MRI over CT
    • -dense calcification = benign
    • -otherwise need biopsy
  32. LUNG ADENOCARCINOMA
       -epidemiology
       -characteristics
    • EPIDEMIOLOGY:
    • -most common lung carcinoma (30-45%)
    • -less strongly associated with smoking
    • -more common in women

    • CHARACTERISTICS:
    • -peripheral
    • -vascular metastasis early
  33. Squamous Cell Carcinoma
       -epidemiology
       -characteristics
    • EPIDEMIOLOGY:
    • -second most common (25-40%)
    • -associated with smoking

    • CHARACTERISTICS:
    • -intracellular bridge formation/cell keratinization
    • -2/3 central
    • -bulky: bronchial obstruction
    • -slow growth, late metastasis
    • -central necrosis/cavitation
  34. Small Cell Lung Cancer
       -epidemiology
       -characterstics
       -treatment
    • EPIDEMIOLOGY:
    • -15-25% of lung cancer
    • -associated with smoking

    • CHARACTERISTICS:
    • -small round cells with dark nuclei
    • -neurosecretory cytoplasmic granules
    • -central
    • -early mets (lymphatic and vascular)

    • TREATMENT:
    • -chemo radiation
    • -surgery rare (early lesions)
  35. Large Cell Lung Carcinoma
       -epidemiology
       -characteristics
    • EPIDEMIOLOGY:
    • -rarest form of lung carcinoma

    • CHARACTERISTICS:
    • -anaplastic large cells with abundant cytoplasm
    • -either central or peripheral
    • -highly malignant with early mets
  36. Pancoast Tumor
    -involves superior sulcus

    • CLINICAL PRESENTATION:
    • -brachial plexus involvement
    • -sympathetic ganglia involvement
    • -vertebral collapse (local invasion)
    • -arm pain/weakness
    • -edema
    • -Horner's syndrome
  37. Lung Cancer Staging: T
    • TX: malignant cells in secretions but no primary
    • T0: no primary tumor
    • TIS: in situ
    • T1: <3cm, surrounded by pleura or lung
    • T2: >3cm OR invades pleura OR associated atelectasis/pneumonitis
    • T3: direct extension into chest wall, diaphragm or pericardium or w/in 2 cm of carina
    • T4: involving heart, great vessels, trachea, esophagus or malignant pleural effusion
  38. Lung Cancer Staging: N
    • N0: no nodes
    • N1: peribronchial or ipsilateral hilar nodes
    • N2: ipsilateral mediastinal or subcarinal nodes
    • N3: contralateral nodes or ipsilateral scalene/supraclavicular
  39. Lung Cancer Staging: M
    • M0: none
    • M1: distant mets or separate mets
  40. Lung Cancer Treatment: Surgical
    • 1. Lobectomy (disease in one lobe)
    • 2. Pneumonectomy (involves fissure/hilum)
    • 3. Wedge resection/bronchial segmentectomy (localized disease in high risk patients)

    • Contraindications:
    • -1/2 are not candidates at the time of diagnosis
    • -N2 disease
    • -N3 disease
    • -mets
    • -pleural effusion
  41. Lung Cancer Treatment: Adjuvant therapy
    • Postoperative Adjuvant Chemo:
    • -all resected nonsmall cell lung cancers Stage Ib or higher

    • Preoperative Chemo (Neoadjuvant):
    • -stage IIIa (N2) disease
    • -may convert to resectable lesion
  42. Carcinoid Tumor
       -epidemiology
       -pathophys
       -treatment
       -prognosis
    • Epidemiology:
    • -80-90% of bronchial adenomas
    • -proximal bronchi
    • -fifth decade of life

    • Pathophys:
    • -basal bronchial stem cells (neuroendocrine differentiation)
    • -protrude --> tend to cause obstruction
    • -rarely metastasize

    • Treatment:
    • -surgical excision
    • -usually lobectomy

    • Prognosis:
    • - 5ys >90%
  43. Adenoid Cystic Carcinoma
       -pathophys
       -treatment
       -prognosis
    • Pathophys:
    • -central, lower trachea
    • -more aggressive than carcinoid
    • -1/3 present with mets (local, liver, bone, kidney)

    • Treatment:
    • -en bloc excision
    • -lobectomy
    • -radiation therapy in inoperable patients

    • Prognosis:
    • -5ys 50%
  44. Metastatic Lung Tumors
       -types
       -treatment
    • Types:
    • -breast
    • -colorectal
    • -melanoma
    • -renal

    • Treatment:
    • -surgical removal if <3-5 nodules
  45. Tracheal Anatomy
    -18-22 cartilaginous rings, incomplete with membranous portion posteriorly

    -cricoid cartilage is the only complete ring

    -shares blood supply with esophagus
  46. Congenital Tracheomalacia
    -compression of trachea by vascular rings (anomalies of aortic arch)

    -treatment: aortopexy
  47. Tracheal Neoplasms
       -types
       -diagnosis
       -treatment
    • Types:
    • 1. Primary: rare, usually squamous cell
    • 2. Secondary: lung, esophagus, thyroid origin

    • Diagnosis:
    • -CXR
    • -defer bronchoscopy until final operation (bx can be hazardous due to bleeding and obstruction)

    • Treatment:
    • -tracheal resection (may remove up  to 1/2)
    • -end to end anastamosis
  48. Teratomas of Mediastinum
       -epidemiology
       -pathophys
       -diagnosis
       -treatment
    • Epidemiology:
    • -adolescents
    • -80% benign

    • Pathophys:
    • -originate from branchial cleft pouch (associaited with thymus)

    • Diagnosis:
    • -CXR

    • Treatment:
    • -surgical excision
  49. Lymphomas of Mediastinum
       -epidemiology
       -diagnosis
       -treatment
    • Epidemiology:
    • -50% of patients with lymphoma
    • -only 5% have mediastinal disease only

    • Diagnosis:
    • -CXR, LN bx

    • Treatment:
    • -nonsurgical
  50. Germ Cell Tumors of the Mediastinum
       -characteristics
       -diagnosis
       -treatment
    • Characteristics:
    • -rare
    • -types: seminoma, embryonal cell carcinoma, teratoma, choriocarcinoma, endodermal sinus

    • Diagnosis:
    • -CXR
    • -AFP, b-hCG

    • Treatment:
    • -seminomas: surgical resection + XRT
    • -nonseminomas: combo chemotherapy
  51. Extracorporeal Circulation
       -pros
       -technique
       -effects
    • Pros:
    • -motionless heart, bloodless field

    • Technique:
    • -drain blood from RA and pumped back to aorta
    • -through oxygenator and heat exchanger
    • -protect myocardium with hypothermia and cardioplegia

    • Effects:
    • -widespread inflammatory response
    • -release of vasoactive substances
    • -diffuse edema (retention of na)
    • -hemolysis (traumatic)
  52. Aortic Stenosis:
       -etiology
       -pathology
       -presentation
       -diagnosis
       -treatment
    • Etiology:
    • -bicuspid aortic valves (earlier presentation)
    • -acquired: calcified, rheumatic fever

    • Pathology:
    • -symptoms when valve area < 1cm
    • -causes pressure load on LV


    • Presentation:
    • -Syncope, Angina, Dyspnea
    • -SEM, radiation to carotid arteries
    • -narrow pulse pressure
    • -pulses parvus et tardus

    • Diagnosis:
    • -Echo
    • -Cath (do not cross aortic valve, may cause stroke)

    • Treatment:
    • -valve replacement
    • -indications = symptoms
    • -
  53. Aortic Insufficiency
       -etiology
       -pathology
       -presentation
       -diagnosis
       -treatment
    • Etiology:
    • -myxomatous degeneration, aortic dissection, bacteria endocarditis

    • Pathology:
    • -fibrosis and shortening of leaflets
    • -dilation of aortic annulus
    • -causes volume load on LV

    • Presentation:
    • -palpitations
    • -DOE
    • -CHF (late)
    • -diastolic murmur (duration correlates with severity)
    • -radiates to L axilla
    • -widened pulse pressure
    • -"water hammer pulses"

    • Diagnosis:
    • -echo
    • -cath

    • Treatment: Surgical indications
    • -symptoms
    • -LVEF <50%
    • -severe LV dilation
  54. Mitral Stenosis
       -etiology
       -pathology
       -presentation
       -diagnosis
       -treatment
    • Etiology:
    • -h/o rheumatic fever

    • Pathology:
    • -10-25y after RF
    • -fusion of commissures, reduce CSA to 2-2.5cm2

    • Presentation:
    • -dyspnea
    • -afib
    • -pulmonary edema
    • -chronic cough, hemoptysis
    • -thin and cachectic
    • -Triad: diastolic rumble, opening snap, loud S1
    • -cephalization on CXR

    • Diagnosis:
    • -echo
    • -cath

    • Treatment:
    • -surgery indicated if patient is symptomatic
    • -Commissurotomy: open or percutaneously (balloon valvuloplasty)
    • -Valve replacement: repair > replacement for mitral, severe chordae/papillary m disease

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