Clinical And Research Questions

Question 1

Characterize aortic valve Vmax of 4.9.

Answer 1

Severe high gradient AS.
Generally identified by an aortic jet velocity over ≥4.0 m/s or mean transvalvular pressure gradient ≥40 mmHg.

Question 2

Characterize an AVA of 0.9 cm2.

Answer 2

aortic valve area (AVA) ≤1.0 cm2 is typically seen but is not required to identify high gradient severe AS (high gradient severe AS, stage D1).

Question 3

What is an approach to identifying AS patients for valve replacement?

Answer 3

Know: symptoms, hemodynamic severity, LVEF, other indications for heart surgery, procedural risk.
Sx: symptomatic severe AS is a key indication for AVR.
Severity: echo - Vmax ≥4, ΔP ≥40.
LVEF <50.
Concomitant heart surgery: mod AS could get AVR.

Question 4

In a comorbid patient with severe symptomatic AS, who would be treated with palliative or medical management?

Answer 4

Life expectancy <1 yr or quality of life unlikely to improve.

Question 5

Pt has STS-PROM >8 with severe AS. What valve intervention would be preferred?

Answer 5

TAVI transfemoral.

Question 6

For patients with sx severe AS (Vmax ≥4, ΔP ≥40), with intermediate surgical risk (STS-PROM 4-8) in whom transfemoral TAVI is feasible…
AND WITHOUT high risk anatomic features (adverse aortic root, low coronary ostia height, heavily calcified bicuspid AV, and severe LVOT calcification)…
What is recommended?

Answer 6

TAVI transfemoral

Question 7

Symptomatic severe AS with intermediate surgical risk (ie, STS-PROM 4 to 8), but unable to get transfemoral TAVI. What is recommendation?

Answer 7

SAVR

Question 8

Sx severe AS w/ low surgical risk (STS-PROM <4)…
AND
1) ≥65 years
2) transfemoral TAVI approach feasible
3) AV is trileaflet
4) no other high risk TAVI anatomy (adverse aortic root, low coronary height, severe LVOT calcification)…
What is recommended?

Answer 8

TAVI transfemoral

Question 9

What’s the evidence on concurrent MVr and CABG in patients with ischemic/secondary/functional MR?

Answer 9

A randomized trial, as well as some observational studies, found no improvement in symptoms or risk of mortality from the addition of mitral valve surgery to CABG compared with CABG alone. However, Duke Activity Status Index (DASI) was significantly better in the combined procedure group at two years.

Randomized Ischemic Mitral Evaluation (RIME) multicenter randomized trial of 73 patients with MODERATE ischemic MR found that the addition of mitral ANNULOPLASTY to CABG did not affect mortality rates but improved FUNCTIONAL capacity (peak oxygen consumption) and LV reverse remodeling.

The available evidence suggests that for patients with SEVERE ischemic MR, SURVIVAL IS SIMILAR following mitral valve replacement with CHORDAL SPARING TECHNIQUE compared to surgical mitral valve repair. However, recurrent MR is much more frequent following surgical mitral valve repair.

For patients with SEVERE ischemic MR who are undergoing mitral valve surgery, we suggest concurrent BIOPROSTHETIC mitral valve replacement with CHORDAL SPARING technique rather than surgical mitral valve repair. Recurrent MR is much more common after mitral valve repair than after mitral valve replacement.

For patients with nonischemic MR who are undergoing mitral valve surgery, we suggest mitral valve replacement with chordal sparing unless valve anatomy is favorable for surgical mitral valve repair and intraoperative transesophageal echocardiography demonstrates minimal residual MR after repair.

Question 10

What is the NEJM study showing TAVR vs medical therapy outcomes from 2010?
What did they do? What did it show?

Answer 10

PARTNER trial.
RCT: Severe AS pts unfit for surgery to TAVR vs best medical therapy (including balloon valvuloplasty).
Improved mortality and readmission in TAVR.

Question 11

What was the PARTNER 2 trial, and what did it show?

Answer 11

2016. Randomized intermediate risk pts (STS PROM 3-8%) to SAVR vs TAVR.
      Rates of death and disabling stroke were similar.

Question 12

What is the PARTNER 3 trial, and what did it show?

Answer 12

2019. Observed improved rtes of the composite outcome of death, stroke, or rehospitalization in low risk (STS PROM <3%) patients treated with TAVR.

Question 13

What is the expected 10-year freedom from structural valve degeneration of bioprosthetic SAVR?

Answer 13

85-99% depending on the valve, patient factors, and definitions of degeneration

Question 14

What does the ACC/AHA guidelines say about the age for bio vs mech AVR?

Answer 14

<50 mech is preferred.
>65 bio is preferred.

Question 15

A patient is expected to have a <12 mo life expectancy after TAVR placement. What should be done?

Answer 15

Best medical management.

Question 16

What are standard hemodynamic targets post heart surgery for CI and MAP?

Answer 16

CI of 2.2
MAP of 65

Question 17

63F w/ hx of GERD and EGD showing 7cm hiatal hernia, esophagitis, and gastropathy. Demeester on Bravo is 50.8. No alarm symptoms or dysphagia.
What are the next steps?

Answer 17

You could do CT scan and manometry to eval anatomy and swallowing, but a VEG would also allow you to do the same if there aren’t major risk factors for things like scleroderma or extrinsic compression (she has no dysphagia)

Question 18

Risk factors for APF/PAL?

Answer 18

COPD, female, low FEV1/DLCO, smoking, DM, chronic steroid use, marked pleural adhesions, upper lobe emphysema or diffuse emphysema, increased age, large bullae

Question 19

When should APF be suspected?

Usually not fatal, so why are they problematic?

Answer 19

PAL on chest tube drainage system >5 days.

Prolonged hospital stay, higher rates of ICU admission, higher morbidity (PNA, empyema, VTE)

Question 20

What is drainage-dependent air leak?

Why is it significant?

What about drainage-INdependent?

Answer 20

Occurs when there is nonexpandable lung (eg after lung resection) and stops when drainage is discontinued (clamp trial does not worsen ptx). Usually 2/2 mismatch b/w remaning lung parenchyma and thoracic cavity.

Drainage-independent is 2/2 direct visceral pleural injury.

Question 21

First line management for PAL/APF.

Answer 21

Continued chest tube thoracostomy w/ low or no wall suction. Especially w/ non-expandable lung. It is viable to have a period of high suction if fistula is large (eg secondary spontaneous in COPD from ruptured bullae) in order to facilitate apposition of the visceral and parietal pleura.

DC ETT to reduce positive pressure trans-parenchymal gradient.

Optimize nutrition and perfusion.

Monitor for improvement with time.

If no improvement in 4-5 days, consider VATS.

Question 22

How do you manage PAL/APF if first line/conservative management fails?

How do you decide vs bronchoscopic valves vs VATS blebectomy and mech/chem pleurodesis vs ambulatory drainage devices?

Answer 22

If possible, eval the size, location, and integrity of the INTERLOBAR FISSURE.

Leaks associated with minimal collateral ventilation between the target lobe and adjacent lobes are better suited to bronchoscopic therapy.
Large leaks associated with significant collateral ventilation might be suited for surgical repair or pleural procedures, depending on clinical status of the patient.

Question 23

How can you localize air leak in PAL/APF?

How can you eval for fissure completeness?

Answer 23

Sequential balloon occlusion; this can also help eval for fissure completeness - a reduction of airflow >50% indicates a likely response to bronchoscopic mgmt.

High-res CT showing fissure integrity >90% (ie complete fissure) suggests minimal collateral ventilation and suggests bronchoscopic valve management may be beneficial.

In the largest trial of 75 patients with APF and PAL who underwent valve implantation, air leak resolution occurred in 70 percent of patients with a median time to resolution of 16 days. Additional subsequent procedures were needed in 20 percent of patients (eg, Heimlich valve, chemical pleurodesis).

Question 24

What is needed for chemical pleurodesis to work well in APF/PAL?

Answer 24

direct apposition of the visceral and parietal pleura and thus should only be done if there is a small or no residual pneumothorax when the chest tube is on water seal; autologous blood patch can also directly seal the air leak as well as induce pleural inflammation and pleurodesis

Question 25

When should ambulatory drainage devices be used?

What are some requirements for discharging a PAL/APF patient home with an ambulatory drainage device?

Answer 25

patients who fail or are not candidates for bronchoscopic or surgical approaches, ambulatory drainage devices and nonsurgical pleural procedures are options

can be discharged home with these devices as long as they are asymptomatic without subcutaneous emphysema or enlarging pneumothorax size

Question 26

A 50M who works as a driver has a stroke. DVT is confirmed, and TEE shows ASD (ostium secundum 2.3 cm). Manage.
What are your cutoffs for surgery?
Who would not benefit?

Answer 26

General: watch for AF, PH, endocarditis.

Determine if HD significant L-to-R shunt - one causing RA or RV enlargement w/ Qp/Qs ≥1.5:1.

Without significant PH:
*With functional impairment – AND w/ hemodynamically significant net L-R shunt -> ASD closure.
*Without symptoms – AND net L-R shunt, RA or RV enlargement w/ Qp/Qs ≥1.5:1, PASP <50 percent of systemic SBP, PVR < 1/3 of SVVR and no cyanosis at rest or during exercise -> ASD closure.

PVR >5 Wood units - Rx for PAH w/ re-eval of hemodynamics at f/u should be considered.

Net R-L shunt and irreversible PASP > 2/3 systemic, or irreversible PVR > 2/3 of SVR - recommend AGAINST ASD closure.

Question 27

Early surgical valve replacement versus conservative management for asymptomatic severe aortic stenosis (February 2023)?

Answer 27

In a meta-analysis that included two randomized controlled trials and 10 observational studies (over 4000 patients) comparing early SAVR with conservative management, early SAVR was associated with lower all-cause mortality, cardiovascular mortality, and heart failure hospitalization. The risks of stroke and myocardial infarction were similar with early SAVR and conservative management.

These findings support a role for early SAVR in selected patients with asymptomatic severe aortic stenosis.

Question 28

What are some causes of subvalvar aortic stenosis?

Answer 28

Usually a membrane that is either attached to the ventricular septum or encircles the LVOT (pictured).

Diffuse “tunnel-like” narrowing of the LVOT is rare and characterized by myocardial hypertrophy and can be associated with aortic annular hypoplasia.

Question 29

For symptomatic patients with chronic severe primary MR and LVEF ≤30 percent, with high likelihood of successful mitral repair, what should you do?

Answer 29

mitral repair

Question 30

For symptomatic patients with chronic severe primary MR and LVEF ≤30 percent, with mitral valve not amenable to repair, what should you do?

Answer 30

NO mitral surgery

Question 31

For symptomatic patients with chronic severe primary MR (stage D) with LVEF >30 percent, what should be done?

Answer 31

Mitral valve surgery.
Surgery should be performed as soon as symptoms develop.

Question 32

For asymptomatic patients with chronic severe primary MR and an LVEF of 30 to 60 percent and/or an LVESD ≥40 mm (stage C2), what would you recommend?

Answer 32

mitral valve surgery

Question 33

For asymptomatic patients with chronic severe primary MR undergoing cardiac surgery for other indications, what should be done?

Answer 33

recommend concomitant mitral valve repair

Question 34

For patients with chronic moderate primary MR undergoing cardiac surgery for other indications, what should be done?

Answer 34

concomitant mitral valve repair

Question 35

For asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and normal LV function (LVEF >60 percent and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair and who have new onset of atrial fibrillation, what would you recommend?

Answer 35

mitral valve repair

Question 36

For asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and normal LV function (LVEF >60 percent and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair and who have resting pulmonary hypertension (pulmonary artery systolic arterial pressure >50 mmHg), what would you recommend?

Answer 36

surgical mitral valve repair

Question 37

For asymptomatic patients with severe primary MR (stage C1) and normal LV function (LVEF >60 percent and LVESD <40 mm) who are deemed excellent candidates, what would you recommend?

Answer 37

screen for likelihood of repair without residual MR >95 percent and expected mortality rate of <1 percent by the surgical team at a heart valve center of excellence; if criteria met, do mitral repair

Question 38

Chronic SECONDARY mitral regurgitation has worse outcomes postop, so indications for surgery are more conservative. What are the indications?

Answer 38

Severe MR undergoing other cardiac surgery (IIa).
Should get chordal sparing MVR (as opposed to MVr) (IIa).
Severe MR w/ NYHA class 3-4 (IIb).
Moderate IMR at time of CABG (IIb).

Question 39

Molecular characteristics of solitary fibrous tumor (SFT)

Answer 39

Fibroblastic soft tissue neoplasm.
Recurrent inversion of long arm of chromosome 12 (12q13), resulting in the fusion of 2 genes - NAB2, and STAT6.

Question 40

SFTs infrequently have been associated with paraneoplastic syndromes, most commonly?

Answer 40

non-islet cell tumor hypoglycemia (Doege-Potter syndrome) or hypertrophic pulmonary osteoarthropathy (Pierre-Marie-Bamberger syndrome)

Question 41

Strong nuclear expression of STAT6 is a highly sensitive and specific immunohistochemical marker for what intrathoracic tumor?

Answer 41

SFT

Question 42

mainstay of therapy for all localized SFTs, even for tumors classified as high risk (low metastatic potential)

Answer 42

multidisciplinary tumor board with sarcoma specialists who have experience with the disease; complete en bloc surgical resection with negative margins (an R0 resection)

Question 43

Indications for radiation therapy in SFT?

Answer 43

Neoadjuvant RT may be offered to patients with tumors in anatomic regions that may be difficult to initially resect (eg, pelvis and retroperitoneum) and where adjuvant RT would be challenging to deliver due to the presence of bowel or other radiosensitive structures in the RT field.

For patients with intermediate- to high-risk resected SFT and positive surgical margins who are ineligible for further resection, we suggest adjuvant RT rather than observation or chemotherapy. However, prospective data are limited for this approach and some experts may reasonably omit adjuvant RT for these patients. Management of such patients is best determined in a multidisciplinary setting. Risk stratification models may be helpful with the decision of when to offer adjuvant RT.

Question 44

For patients with resected intermediate- to high-risk SFT and positive margins, what is the preferred therapy?

Answer 44

if eligible for resection with minimal morbidity, we offer re-resection

Question 45

For SFT patients with complete resection and no high-risk histologic features, what do you do?

Answer 45

observation rather than adjuvant RT or chemotherapy

Question 46

For patients with metastatic and locally advanced unresectable tumors, what is your approach?

Answer 46

For patients with treatment-naïve disease, we suggest initial therapy with dacarbazine and doxorubicin.

For patients with progressive disease on chemotherapy, we suggest antiangiogenic therapy rather than further lines of chemotherapy

RT can provide local tumor control in some patients with unresected SFTs and palliation in the setting of metastatic disease.

Question 47

A retrospective review of 178 consecutive patients undergoing 256 surgical resections for pulmonary metastasis identified a complete resection in 248 cases. The five-year survival based upon primary disease site and complete resection was the highest for which cancers (4)?

Answer 47

renal cell carcinomas (51.4 percent), followed by colon or rectal cancer carcinoma (50.3 percent), sarcoma (21.7 percent), and melanoma (25 percent)

Question 48

Criteria for selection for pulmonary metastasis resection from another site?

Answer 48

The pulmonary metastases appear to be completely resectable based upon preoperative imaging.
The patient has adequate cardiopulmonary reserve to tolerate resection.
Metastasectomy is technically feasible.
The primary tumor is controlled or controllable.
Extrapulmonary metastatic disease is absent, or if present, the disease must be controllable with surgery or another treatment modality.

Resection of one or more lung lesions may be indicated in those who do not meet the above criteria. As examples:
A new primary lung cancer cannot be excluded.
Symptomatic metastases (eg, bronchial obstruction with distal suppuration) that cannot be managed in any other way.
Tissue needs to be obtained for a novel therapeutic strategy (eg, an autologous vaccine, molecular testing), preferably within the confines of a clinical trial.

Question 49

Contraindications to pulmonary metastasectomy (from another primary site)?
Other unfavorable prognostic factors?

Answer 49

The presence of brain metastases is a contraindication to pulmonary resection.

N2 nodal involvement is generally a contraindication for pulmonary metastasectomy for tumors other than renal cell cancer.

Inability to completely resect all areas of pulmonary involvement is widely considered to represent a contraindication to pulmonary metastasectomy. Nearly all reports indicate that complete resection of metastatic disease is associated with more favorable outcomes. In the International Registry series, for example, the median survival with complete versus incomplete resection was 35 versus 15 months, and the five-year survival rate was 36 versus 13 percent.

A prior pneumonectomy is a relative contraindication to contralateral resection of pulmonary metastases.

Unfavorable prognostic factors include an inability to completely resect all metastatic disease, a short disease-free interval following treatment of the primary tumor, a large number of pulmonary metastases (the STS consensus group considers pulmonary metastasectomy to be best suited to patients harboring three or fewer metastases) and involved lymph nodes. Tumor histology also influences outcomes.

Question 50

Is there an absolute number of pulmonary metastases from another site that would be a contraindication to resection?

STS consensus group opinion?

Answer 50

Outcomes are better with fewer metastases. However, for patients with multiple metastases, there is no consensus among thoracic surgeons as to what disease burden represents an insurmountable obstacle.

The important issue is the feasibility of resecting all sites of disease, not the absolute number of metastases per se.

However, the STS consensus group considers pulmonary metastasectomy to be best suited to patients harboring three or fewer metastases.

Question 51

Is disease-free interval important for pulmonary metastasectomy from another primary site? Is there an absolute contraindication for a short period? Any interval studies recommended?

Answer 51

Outcomes are more favorable when there has been a longer disease-free interval between primary tumor treatment and presentation of metastatic disease; however, there is no absolute time frame (including synchronous presentation of metastatic disease) that is short enough that metastasectomy would not be considered.

However, particularly for a presentation of synchronous metastases, we recommend repeat chest computed tomography (CT) six to eight weeks after recognition of pulmonary metastases to assure that additional target lesions (or too many target lesions) have not appeared.

Question 52

Is lymph node status important for pulmonary metastasis resection (other primary site)?

Prognosis info?

Answer 52

Sarcomas and most cancers that spread to the lungs do so through the vascular system, and the metastases appear limited to the parenchyma. However, other malignancies, notably renal cell carcinoma, colon cancer, breast cancer, and melanoma, have demonstrated the ability to metastasize to the lung, and then to metastasize to the ipsilateral intrapulmonary or hilar (N1) nodes. This is believed (although not proven) to represent spread through the lymphatic system, in a manner similar to primary lung cancer, and with the capability to spread further to the ipsilateral mediastinal (N2) and contralateral mediastinal (N3) nodes.

Lymph node involvement is an important negative prognostic factor for pulmonary metastasectomy, regardless of histology. Surgical or endoscopic staging of the mediastinal and hilar lymph nodes prior to pulmonary metastasectomy provides both diagnostic and prognostic information. We agree with guidelines from the STS that recommend regional nodal sampling for evaluation of nodal metastases prior to attempted pulmonary metastasectomy in the presence of suspicious N1 or N2 nodes on preoperative staging imaging and for clinically node-negative tumors associated with nodal disease spread (ie, renal cell, breast, colorectal carcinoma, and melanoma)

Question 53

A patient is being worked up for pulmonary resection of colon cancer. He is a candidate in every way. Workup detects suspicious N2 disease. What do you do?

Answer 53

We agree with guidelines from the STS that recommend regional nodal sampling for evaluation of nodal metastases prior to attempted pulmonary metastasectomy in the presence of suspicious N1 or N2 nodes on preoperative staging imaging and for clinically node-negative tumors associated with nodal disease spread (ie, renal cell, breast, colorectal carcinoma, and melanoma).

Question 54

Is there an N stage for pulmonary metastases from other primary site that would be contraindication to curative resection?

Answer 54

In general, N3 nodal involvement represents a contraindication to potentially curative metastasectomy for any histology. Outcomes are generally poorer for those with N2 rather than just intrapulmonary or hilar nodal involvement, and we consider N2 involvement to represent a contraindication to pulmonary metastasectomy for tumors other than renal cell cancer.

Question 55

For both epithelial cancers and sarcomas, the most frequent site of relapse following pulmonary resection is?

Answer 55

The lung

Question 56

Is there a role for repeat pulmonary metastasis resection (other primary site)?

Answer 56

The largest series, the International Registry of Lung Metastases, found that 53 percent of the 5206 patients undergoing resection of pulmonary metastases relapsed in the lung. Among the 1042 patients who underwent repeat metastasectomy, the 5- and 10-year survival rates were 44 and 29 percent, respectively. In contrast, the median survival among patients who were not resected following relapse in one series was eight months.

Question 57

Discuss the outcomes of multiple sequential pulmonary metastasis resections from another primary site?

Answer 57

The likelihood of permanent disease control decreases with multiple sequential resections. In a series of 54 patients from one institution who underwent multiple resections for pulmonary metastases, the percentage of patients achieving durable local control of disease after the second, third, fourth, and fifth procedures was 27, 19, 8, and 0 percent, respectively. When local control in the chest is lost, survival becomes dismal, with an average life expectancy of a few months.

Question 58

What is the preop eval for a patient being worked up for pulmonary metastasectomy (other primary)?
What is the initial study?
Is FDG-PET always indicated?
What do you do with positive findings OUTSIDE of the chest?
Which patients should get invasive mediastinal imaging?
Which cancers should get brain imaging?

Answer 58

Prior to planned resection, contrast-enhanced, high-resolution CT of the chest should be performed.

For patients without evidence of extrapulmonary disease on chest CT, an 18-F fluorodeoxyglucose-positron emission tomography (FDG-PET) scan is indicated.

Positive extrathoracic or mediastinal uptake on a PET scan is not sufficient evidence to exclude a patient from surgery for lung metastases. Suspicious areas should be vigorously investigated (usually with a diagnostic biopsy) prior to metastasectomy.

For patients with suspicion for hilar or mediastinal (N2) adenopathy on chest CT, we suggest confirming this by endobronchial ultrasound biopsy/mediastinoscopy prior to attempted resection and not proceeding with resection if N2 disease is confirmed for histologies other than renal cell cancer. For patients with renal cell cancer and involved N2 lymph nodes, the decision to pursue complete metastasectomy must be individualized.

Contralateral mediastinal nodal involvement represents a contraindication to potentially curative metastasectomy for any histology. We also consider ipsilateral mediastinal involvement to represent a contraindication to pulmonary metastasectomy for tumors other than renal cell cancer since outcomes are generally poorer compared with involvement of just the intrapulmonary or hilar nodes.

Prior to attempted resection of apparently isolated pulmonary metastases, brain imaging should be performed for patients who have tumors that frequently metastasize to the brain (eg, breast cancer, melanoma).

Question 59

Prior to planned pulmonary met resection (from other site), who should get invasive mediastinal sampling?

Is there a situation where regional node sampling prior to surgery is appropriate even for negative clinical workup?

Answer 59

Prior to planned resection, we suggest evaluation of the mediastinal lymph nodes identified on chest CT that are >1 cm or PET-positive nodes of any size as would be done for a patient with a primary lung cancer (grade 2c). This can be accomplished either with endobronchial ultrasound-guided biopsy or mediastinoscopy prior to surgery.

We also agree with guidelines from the STS that recommend regional nodal sampling for evaluation of nodal metastases prior to attempted pulmonary metastasectomy for clinically node-negative carcinomas associated with a higher frequency of nodal disease spread (ie, renal cell, breast, colorectal carcinoma, and melanoma).

Question 60

What is the predominant cell type of superior sulcus tumors?

Answer 60

non-small cell histology (90-95%)

Question 61

For a superior sulcus tumor, what modality is preferred to ascertain neuroforaminal, dural sac, or spinal cord extension?

Answer 61

MRI

Question 62

Should all superior sulcus tumors get CT/PET?

Answer 62

Yes. This is routine baseline imaging. Focus on nodal and extrathoracic sites of FDG uptake.

Question 63

What is the best way to confirm or exclude N2 mediastinal disease for superior sulcus tumors?

Answer 63

EBUS or mediastinoscopy - mandatory for staging.

Question 64

What does N2 disease for superior sulcus tumors mean for prognosis or future treatment?

Answer 64

N2 is a strong predictor of future systemic failure.

N2 disease would be considered an absolute contraindication to resection.

Question 65

An ipsilateral supraclavicular met (technically N3 or IIIB disease by the staging system) is found for a superior sulcus tumor.

Is there a surgical option?

Answer 65

With the high apical chest location of the superior sulcus tumors, this node location biologically behaves like a locoregional N1 node and as such would be considered potentially resectable for cure at the time of the pulmonary resection

Question 66

A patient with GERD is referred for surgery eval. EGD shows esophagitis. Ok to proceed with surgery?

Answer 66

No. Repeat EGD, as esophagitis can mask Barrett, and you shouldn’t operate on active esophagitis.

Question 67

How can you tell which rib you’re palpating in a thoracotomy?

Answer 67

Go high and posterior under the scapula.
1st rib you can barely palpate. Top of box.
2nd rib is like a blade, has muscle attachments anterior, and has a larger intercostal space.
5th rib is right under tip of scapula.