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Flashcards in Thoracic Surgery Deck (235):
1

What is VATS?

Video-Assisted Thoracic Surgery

2

What is thoracic outlet syndrome?

Compression of the subclavian artery, subclavian vein, or brachial plexus at the superior outlet of the thorax

3

What are the causes of thoracic outlet syndrome?

1. Various congenital anomalies, including cervical rib or abnormal fascial bands to the first rib, or abnormal scalene muscle.
2. Trauma: clavicular fracture or first rib fracture, dislocation of humeral head, crush injuries.
3. Repetitive motor injuries.

4

What are the symptoms of thoracic outlet syndrome?

1. Paresthesias (neck, shoulder, arm, hand) with 90% in ulnar distribution
2. Weakness (neural or arterial)
3. Coolness of involved extremity (arterial)
4. Edema, venous distention, discoloration (venous)

5

What is the most common type of symptoms in thoracic outlet syndrome?

Neurologic

6

Which nerve is most often involved in thoracic outlet syndrome?

Ulnar nerve

7

What are the signs of thoracic outlet syndrome?

1. Paget-von Schroetter syndrome (venous thrombosis leading to edema, arm discoloration, and distention of the superficial veins)
2. Weak brachial and radial pulses in the involved arm
3. Hypesthesia or anesthesia
4. Occasionally, atrophy in the distribution of the ulnar nerve
5. Positive Adson maneuver or Tinel's sign
6. Edema

8

What is the Adson maneuver?

Evaluates for arterial compromise:
The patient (1) Extends neck, (2) Takes deep breath and holds, and (3) Turns head toward examined side.
The physician monitors radial pulse on examined side.
The test finding is positive if the radial pulse decreases or disappears during the maneuver.

9

What is Tinel's test?

Tapping of the supraclavicular fossa producing paresthesias

10

What is the treatment for thoracic outlet syndrome?

PT; decompression of the thoracic outlet by resecting the first rib and cervical rib (if present) if PT fails and as a last resort.

11

What are the most common benign chest wall tumors?

1. Fibrous rib dysplasia (posterolateral rib)
2. Chondroma (at costochondrial junction)
3. Osteochondroma (any portion of rib)

12

What is the treatment for benign chest wall tumors?

Wide excision and reconstruction with autologous or prosthetic grafts

13

What are the most common malignant chest wall tumors?

Fibrosarcoma, chondrosarcoma, osteogenic sarcoma, rhabdomyosarcoma, myeloma, Ewing's sarcoma

14

What is the treatment for malignant chest wall tumors?

Excision +/- XRT

15

What is Tietze's syndrome?

Non-infectious costochondral cartilage inflammation

16

What is a pleural effusion?

Fluid in the pleural space

17

What are the causes of pleural effusion?

Pulmonary infections; CHF; SLE; RA; pancreatitis; trauma; PE; renal disease; cirrhosis; malignancy (mesothelioma, lymphoma, metastasis); post-pericardiotomy syndrome

18

What are the symptoms of pleural effusion?

Dyspnea, pleuritic chest pain

19

What are the signs of pleural effusion?

Decreased breath sounds, dullness to percussion, ego phony at the upper limit

20

What are the properties of a transudate?

Specific gravity:

21

What are the properties of an exudate?

Specific gravity: > 1.016
Protein: > 3 g/dL
Many cells

22

What is the key diagnostic test for pleural effusion?

Thoracentesis with studies including cytology

23

What is the treatment for pleural effusion?

1. Pigtail catheter or thoracostomy
2. Treat underlying condition
3. Consider sclerosis

24

What is an empyema?

Infected pleural effusion.
Must be drained, usually with chest tube; decortication may be necessary if the empyema is solid.

25

What is a decortication?

Thoracotomy and removal of an infected fibrous rind from around the lung

26

What are the signs and symptoms of a lung abscess?

Fever, sputum, sepsis, fatigue

27

What are the associated diagnostic studies for lung abscess?

CXR (air-fluid level); CT (define position and differentiate from empyema); bronchoscopy (cancer/culture)

28

What is the treatment for lung abscess?

Antibiotics and bronchoscopy for culture and toilet, +/- surgery

29

What are the indications for surgery for lung abscess?

Underlying cancer/tumor or refractory to antibiotics

30

What are the surgical options for lung abscess?

Lobectomy of lobe with abscess, tube drainage

31

What is middle lobe syndrome?

Recurrent right middle lobe pneumonia caused most commonly by intermittent extrinsic bronchial obstruction

32

What is hemoptysis?

Bleeding into the bronchial tree

33

What are the causes of hemoptysis?

1. Bronchitis
2. Tumor mass
3. TB
Also, bronchiectasis, pulmonary catheters, trauma.

34

What is massive hemoptysis?

> 600 cc/day

35

What comprises the workup of hemoptysis?

CXR; bronchoscopy; bronchial A-gram

36

What is the treatment for massive hemoptysis?

Bronchoscopy, intubation of unaffected side; Fogarty catheter occlusion of bleeding bronchus; bronchial A-gram +/- embolization; surgical resection of involved lung

37

What is the treatment of moderate to mild hemoptysis?

Laser coagulation +/- epinephrine

38

What is a spontaneous PTX?

Atraumatic spontaneous development of a PTX

39

What are the causes of spontaneous PTX?

Idiopathic, bleb disease, emphysema

40

What body habits is associated with spontaneous PTX?

Thin and tall

41

How is the diagnosis of spontaneous PTX made?

CXR

42

What is the treatment for spontaneous PTX?

Chest tube

43

What are the options if spontaneous PTX is refractory, recurrent, or bilateral?

Pleurodesis:
Scar the lung to the parietal pleura with a sclerosant (talc) via chest tube/thoracoscopy or thoracotomy and mechanical dilation.

44

What is a catamenial PTX?

PTX due to intrathoracic endometriosis

45

What is malignant mesothelioma?

Primary pleural neoplasm

46

What are the 2 types of malignant mesothelioma?

1. Localized
2. Diffuse

47

What are the risk factors for malignant mesothelioma?

Exposure to asbestos; smoking

48

What are the symptoms of malignant mesothelioma?

Dyspnea and pain.
Localized: pleuritic pain, joint pain and swelling.
Diffuse: chest pain, malaise, weight loss, cough.

49

What are the signs of malignant mesothelioma?

Pleural effusion:
Localized: 10-15%
Diffuse: >75%

50

What are the associated radiographic tests for malignant mesothelioma?

CXR (peripheral mass, often forming obtuse angle with chest wall); CT

51

How is the diagnosis of malignant mesothelioma made?

Pleural biopsy, pleural fluid cytology

52

What is the treatment for localized malignant mesothelioma?

Surgical excision

53

What is the treatment for diffuse malignant mesothelioma?

Early: Resection, then XRT.
Advanced: XRT, chemotherapy

54

What is the prognosis for malignant mesothelioma?

Localized: poor
Diffuse: dismal

55

What is benign mesothelioma?

Benign pleural mesothelioma

56

What pleura is usually involved in benign mesothelioma?

Visceral pleura

57

What is the gross appearance of benign mesothelioma?

Pedunculated "broccoli or cauliflower" tumor on a stalk coming off of the lung

58

What is the treatment for benign mesothelioma?

Surgical resection with at least 1 cm clear margin

59

What is the prognosis for benign mesothelioma?

Excellent: cure in vast majority of cases

60

What is the annual incidence of lung cancer in the US?

170,000 new cases

61

What is the number of annual deaths from lung cancer?

150,000

62

What is the #1 risk factor for lung cancer?

Smoking

63

Does asbestos exposure increase the risk of lung cancer run patients who smoke?

Yes

64

What type of lung cancer arises in non-smoking patients?

Adenocarcinoma

65

In which lung does cancer arise more often?

Right > left and Upper > lower

66

What are the signs and symptoms of lung cancer?

Change in a chronic cough; hemoptysis, chest pain, dyspnea; pleural effusion; hoarseness; SVC syndrome; diaphragmatic paralysis; paraneoplastic syndrome; finger clubbing

67

What is Pancoast's tumor?

Tumor at the apex of the lung or superior sulcus that may involve the brachial plexus, sympathetic ganglia, and vertebral bodies, leading to pain, upper extremity weakness, Horner's syndrome

68

What is Horner's syndrome?

Injury to the cervical sympathetic chain:
1. Miosis
2. Anhydrosis
3. Ptosis

69

What are the 4 most common sites of extrathoracic metastases from lung cancer?

1. Bone
2. Liver
3. Adrenals
4. Kidney

70

What are paraneoplastic syndromes?

Syndromes that are associated with tumors but may affect distant parts of the body.
They may be caused by hormones released from endocrinologically active tumors or may be of uncertain etiology.

71

What are 5 general types of paraneoplastic syndrome?

1. Metabolic (Cushing's, SIADH, hypercalcemia)
2. Neuromuscular (Eaton-Lambert, cerebellar ataxia)
3. Skeletal (hypertrophic osteoarthropathy)
4. Dermatologic (acanthosis nigricans)
5. Vascular (thrombophlebitis)

72

What are the associated radiographic tests for lung cancer?

CXR, CT, PET scan

73

How is lung cancer diagnosed?

1. Sputum cytology
2. Needle biopsy (CT or fluoro guidance)
3. Bronchoscopy with brushings, biopsies, or both
4. Mediastinoscopy, mediastinotomy, scalene node biopsy, or open lung biopsy for definitive diagnosis

74

What is the usual site of squamous cell lung cancer and what is its natural course?

66% occur centrally in lung hilus, may also be Pancoast's tumor.
Slow growth, late metastasis, associated with smoking.

75

What is the usual site of lung adenocarcinoma and what is its natural course?

Peripheral.
Rapid growth with hematogenous/nodal metastsasis, associated with lung scarring.

76

What is the usual site of small (oat) cell lung cancer and what is its natural course?

Central.
Highly malignant, usually not operable.

77

What is the usual site of large cell lung cancer and what is its natural course?

Peripheral.
Very malignant.

78

What is stage Ia lung cancer?

Tumor

79

What is stage Ib lung cancer?

Tumor 3-5 cm, no nodes, no metastases

80

What is stage IIa lung cancer?

1. Tumor

81

What is stage IIb lung cancer?

1. Tumor 5-7 cm and positive nodes in lung or ipsilateral hilum, no metastases, or
2. Tumor that invades chest wall, diaphragm, mediastinal pleura, phrenic nerve, pericardial sac, or bronchus (not carina) and no nodes, no metastases

82

What is stage IIIa lung cancer?

1. Tumor 7 cm or extends into chest wall, parietal pleura, diaphragm, phrenic nerve, or pericardium, positive node in ipsilateral, mediastinal, or subcarinal nodes, or
3. Any size tumor that invades heart, great vessels, trachea, esophagus, carina, or ipsilateral lobe, or positive nodes in peribronchial or ipsilateral hilum or intrapulmonary nodes

83

What is stage IIIb lung cancer?

1. Any size tumor, positive nodes in contralateral hilum or mediastinum, or
2. Positive supraclavicular or scalene nodes, no distant metastases

84

What is stage IV lung cancer?

Distant metastases

85

What are the surgical contraindications for non-small cell lung cancer?

Stage IIIb-IV, poor lung function (FEV1

86

What is the treatment for stage I non-small cell lung cancer?

Surgical resection

87

What is the treatment for stage II non-small cell lung cancer?

Surgical resection

88

What is the treatment for stage IIIa non-small cell lung cancer?

Chemotherapy and XRT +/- surgical resection

89

What is the treatment for stage IIIb non-small cell lung cancer?

Chemotherapy and XRT

90

What is the treatment for stage IV non-small cell lung cancer?

Chemotherapy +/- XRT

91

What is the treatment for isolated brain metastasis from lung cancer?

Surgical resection

92

What is the prognosis (5-year survival after treatment of non-small cell lung cancer?

Stage I: 50%
Stage II: 30%
Stage III:

93

How is small cell lung cancer treated?

Chemotherapy +/- XRT

94

What are the contraindications to surgery for lung cancer?

STOP IT:
SVC syndrome, Supraclavicular or Scalene node metastasis
Tracheal carina involvement
Oat cell cancer
Pulmonary function tests poor
Infarction (myocardial)
Tumor elsewhere

95

What postoperative FEV1 must you have after treatment for lung cancer?

FEV1 > 800 cc, thus a preoperative FEV1 > 2 L is usually need for a pneumonectomy.
If FEV1

96

What is hypertrophic pulmonary osteoartropathy?

Periosteal proliferation and new bone formation at the end of long bones and in the bones of the hand

97

What are solitary pulmonary nodules (coin lesions)?

Peripheral circumscribed pulmonary lesions

98

What is the differential diagnosis for solitary pulmonary nodules

Granulomatous disease, benign neoplasms, malignancy

99

What percentage of solitary pulmonary nodules are malignant?

5-10%

100

What are the symptoms of solitary pulmonary nodules?

Usually asymptomatic.
May include coughing, weight loss, chest pain, hemoptysis.

101

What are the signs of solitary pulmonary nodules?

Physical findings uncommon.
Rarely, clubbing.

102

How is the diagnosis of solitary pulmonary nodules made?

CXR, chest CT

103

What is the significance of popcorn calcification on CXR?

Most likely benign hamartoma

104

What are the risk factors for malignancy with solitary pulmonary nodules?

1. Size: lesions > 1 cm have a significant chance of malignancy
2. Indistinct margins (corona radiata)
3. Documented growth on followup CXR
4. Increasing age

105

What are the associated lab test for solitary pulmonary nodules?

1. TB skin tests
2. Sputum cultures
3. Sputum cytology is diagnostic in 5-20% of cases

106

Which method of tissue diagnosis is used for solitary pulmonary nodules?

Chest CT with needle biopsy; bronchoscopy (+/- tracheal biopsy); excisional biopsy (open or thoracoscopic)

107

What is the treatment for solitary pulmonary nodules?

1. Surgical excision is the mainstay.
2. Excisional biopsy is therapeutic for benign lesions, solitary metastasis, and for primary cancer in patients who are poor risks for more extensive surgery.
3. Lobectomy for centrally placed lesions.
4. Lobectomy with node dissection for primary cancer (if resectable by preoperative evaluation).

108

Which solitary pulmonary nodules can be followed without a tissue diagnosis?

Popcorn calcifications and masses unchanged for 2 years on previous CXR

109

What are the signs of hypertrophic osteoarthropathy?

Clubbing of fingers, diagnosed by XR of long bones

110

What is a carcinoid tumor of the lung?

APUD cell tumor of the bronchus

111

What is APUD?

Amine-Precursor Uptake and Decarboxylation

112

What is the natural course of carcinoid tumors of the lung?

Slow-growing (but may be malignant)

113

What are the primary local findings in carcinoid tumors of the lung

Wheezing and atelectasis caused by bronchial obstruction or stenosis

114

What condition can carcinoid tumors of the lung be confused with?

Asthma

115

How is the diagnosis of carcinoid tumor of the lung made?

Bronchoscopy reveals round red-yellow-purple mass covered by epithelium that protrudes into bronchial lumen

116

What is the treatment for carcinoid tumors of the lung?

Surgical resection (lobectomy with lymph node dissection).
Sleeve resection is also an option for proximal bronchial lesions.

117

What is a sleeve resection?

Resection of a ring segment of bronchus (with tumor inside) and then end-to-end anastomosis of the remaining ends, allowing salvage of lower lobe

118

What is the 5-year survival from carcinoid tumors of the lung after complete surgical resection?

Negative nodes: > 90%
Positive nodes: 66%

119

What is the most common benign lung tumor?

Hamartoma

120

What is pulmonary sequestration?

Abnormal benign lung tissue with separate blood supply that does not communicate with the normal tracheobronchial airway

121

What is interlobar pulmonary sequestration?

Sequestration in normal lung tissue covered by normal visceral pleura

122

What is extralobar pulmonary sequestration?

Sequestration not in normal lung covered by its own pleura

123

What are the signs and symptoms of pulmonary sequestration?

Asymptomatic or recurrent pneumonia

124

How is the diagnosis of pulmonary sequestration made?

CXR, chest CT, A-gram, U/S with Doppler flow

125

What is the treatment for extralobar pulmonary sequestration?

Surgical resection

126

What is the treatment for intralobar pulmonary sequestration?

Lobectomy

127

What is the major danger during surgery for pulmonary sequestration?

Anomalous blood supply from below the diaphragm (these can be cut and retract into the abdomen resulting in exsanguination)

128

What structures lie in the superior mediastinum?

Aortic arch, great vessels, upper trachea, esophagus

129

What structures lie in the anterior mediastinum?

Thymus, ascending aorta, lymph nodes

130

What structures lie in the middle mediastinum?

Heart, lower trachea and bifurcation, lung hila, phrenic nerves, lymph nodes

131

What structures lie in the posterior mediastinum?

Esophagus, descending aorta, thoracic duct, vagus and intercostal nerves, sympathetic trunks, azygous and hemiazygous veins, lymph nodes

132

What is the major differential diagnosis for tumors in the anterior mediastinum?

4 T's:
Thyroid tumor, Thymoma, Terrible lymphoma, Teratoma.
Also, parathyroid tumor, lipoma, vascular aneurysms.

133

What is the major differential diagnosis for tumors in the middle mediastinum?

LAD (lymphoma, sarcoidosis), teratoma, fat pad, cysts, hernias, extension of esophageal mass, bronchogenic cancer

134

What is the major differential diagnosis for tumors in the posterior mediastinum?

Neurogenic tumors, lymphoma, aortic aneurysm, vertebral lesions, hernias

135

What is the most common type of tumor arising in the mediastinum?

Neurogenic (most commonly in posterior mediastinum)

136

What is the differential diagnosis for a neurogenic tumor?

Schwannoma (neurolemmoma), neurofibroma, neuroblastoma, ganglioneuroma, ganglioneuroblastoma, pheochromocytoma

137

Where are thymomas found in the mediastinum?

Anterior

138

How is the diagnosis of thymoma made?

CT

139

What is the treatment for thymoma?

Surgical resection via midline sternotomy

140

What are the indications for post-op XRT for thymoma?

Invasive malignant tumor

141

What are the indications for pre-op chemotherapy for thymoma?

Tumor > 6 cm and CT with invasion

142

What percentage of thymomas are malignant?

25%

143

How is a malignant thymoma diagnosed?

At surgery with invasion into surrounding structures (not by histology)

144

What is myasthenia gravis?

Autoimmune disease with antibodies against the muscle acetylcholine receptors

145

What percentage of patients with myasthenia gravis have a thymoma?

15%

146

What percentage of patients with thymoma have or will have myasthenia gravis?

75%

147

What are mediastinal teratomas?

Tumors of branchial cleft cells.
The tumors contain ectoderm, endoderm, and mesoderm.

148

What is a dermoid cyst?

Teratoma made up of ectodermal derivatives

149

Which age group is affected by teratomas?

Usually adolescents, but can occur at any age

150

Where in the mediastinum do teratomas occur?

Anterior

151

What are the characteristic CXR findings with teratomas?

Calcifications or teeth.
Tumors may be cystic.

152

What percentage of teratomas are malignant?

15%

153

What is the treatment for benign dermoid cysts?

Surgical excision

154

What is the treatment for malignant teratoma?

Preoperative chemotherapy until tumor markers are normal, then surgical excision

155

Which tumor markers are associated with malignant teratomas?

AFP, CEA

156

What is the incidence of mediastinal neurogenic tumors?

Most common mediastinal tumors in all age groups

157

Where in the mediastinum do neurogenic tumors occur?

Posterior, in the paravertebral gutters

158

What percentage of mediastinal neurogenic tumors are malignant?

50% in children
10% in adults

159

What are the 5 histologic types of mediastinal neurogenic tumors?

1. Neurolemmoma or schwannoma (benign): arise from Schwann cell sheaths of intercostal nerves.
2. Neurofibroma (benign): arise from intercostal nerves, may degenerate into:
3. Neurosarcoma (malignant)
4. Ganglioneuroma (benign): from sympathetic chain.
5. Neuroblastoma (malignant): from sympathetic chain.

160

Where in the mediastinum do lymphomas occur?

Anywhere, but most often in the anterosuperior mediastinum or hilum in the middle mediastinum

161

What percentage of lymphomas involve mediastinal nodes?

50%

162

What are the symptoms of mediastinal lymphoma?

Cough, fever, chest pain, weight loss, SVC syndrome, chylothorax

163

How is the diagnosis of mediastinal lymphoma made?

CXR, CT, mediastinoscopy or mediastinotomy with node biopsy

164

What is the treatment for mediastinal lymphoma?

Chemotherapy, XRT, or both

165

What is acute mediastinitis?

Acute suppurative mediastinal infection

166

What are the 6 causes of acute mediastinitis?

1. Esophageal perforation (Boerhaave's)
2. Postoperative wound infection
3. Head and neck infections
4. Lung or pleural infections
5. Rib or vertebral osteomyelitis
6. Distant infections

167

What are the clinical features of acute mediastinitis?

Fever, chest pain, dysphagia, respiratory distress, leukocytosis

168

What is the treatment for acute mediastinitis?

Wide drainage, treatment of primary cause, antibiotics

169

What is chronic mediastinitis?

Mediastinal fibrosis secondary to chronic granulomatous infection

170

What is the most common etiology of chronic mediastinitis?

Histoplasma capsulatum

171

What are the clinical features of chronic mediastinitis?

50% are asymptomatic.
SVC syndrome, bronchial and esophageal strictures, constrictive pericarditis.

172

How is the diagnosis of chronic mediastinitis made?

Surgical biopsy, CXR, CT

173

What is the treatment for chronic mediastinitis?

Antibiotics (surgical resection of granulomas rarely helpful)

174

What is SVC syndrome?

Obstruction of the SVC, usually by extrinsic compression

175

What is the primary cause of SVC syndrome?

Malignant tumors cause 90% of cases.
Lung cancer is by far the most common (though also, thymoma, lymphoma, Hodgkin's disease).

176

What are the clinical manifestations of SVC syndrome?

1. Blue discoloration and puffiness of the face, arms, and shoulders.
2. CNS manifestations may include headache, N/V, visual distortion, stupor, convulsions.
3. Cough, hoarseness, dyspnea.

177

What is the treatment for SVC syndrome?

Diuretics and fluid restriction; prompt XRT +/- chemotherapy for any causative cancer

178

What is the prognosis for SVC syndrome?

SVC obstruction is fatal in

179

What are the primary functions of the upper and lower esophageal sphincters?

UES: swallowing
LES: prevention of reflux

180

Why is it important that the esophageal venous plexus drains inferiorly into the gastric veins?

Gastric veins are part of the portal venous system.
Portal hypertension can thus be referred to the esophageal veins, leading to varices.

181

What is the blood supply to the proximal esophagus?

Inferior thyroid and anterior intercostal arteries

182

What is the blood supply to the middle esophagus?

Esophageal and bronchial arteries

183

What is the blood supply to the distal esophagus?

Left gastric and left inferior phrenic arteries

184

What is the length of the esophagus?

25 cm in the adult

185

Why is the esophagus notorious for anastomotic leaks?

Esophagus has no serosa

186

What nerve runs with the esophagus?

Vagus nerve

187

What is Zenker's diverticulum?

Pharyngoesophageal diverticulum.
A false diverticulum containing mucosa and submucosa at the UES at the pharyngoesophageal junction through Killian's triangle.

188

What is the most common esophageal diverticulum?

Zenker's diverticulum

189

What are the signs and symptoms of Zenker's diverticulum?

Dysphagia, neck mass, halitosis, food regurgitation, heartburn

190

How is the diagnosis of Zenker's diverticulum made?

Barium swallow

191

What is the treatment for Zenker's diverticulum?

1. Diverticulectomy
2. Cricopharyngeus myotomy (if > 2 cm)

192

What is achalasia?

1. Failure of the LES to relax during swallowing
2. Loss of esophageal peristalsis

193

What are the proposed etiologies of achalasia?

1. Neurologic (ganglionic degeneration of Auerbach's plexus, vagus nerve, or both). Possibly infectious in nature.
2. Chagas' disease in South America.

194

What are the long-term conditions associated with achalasia?

Esophageal carcinoma secondary to Barrett's esophagus from food stasis

195

What are the symptoms of achalasia?

Dysphagia for both solids and liquids, followed by regurgitation.
Dysphagia for liquids is worse.

196

What are the diagnostic findings with achalasia?

Barium swallow (dilated esophageal body with narrowing inferiorly); manometry (increased pressure in LES and failure of LES to relax during swallowing)

197

What are the treatment options for achalasia?

1. Balloon dilation of the LES.
2. Medical treatment of reflux vx. Belsey Mark IV 270 fundoplication.
3. Myotomy of the lower esophagus and LES.

198

What is diffuse esophageal spasm?

Strong, non-peristaltic contractions of the esophageal body.
Sphincter function is usually normal.

199

What is the condition associated with diffuse esophageal spasm?

GERD

200

What are the symptoms of diffuse esophageal spasm?

Spontaneous chest pain that radiates to the back, ears, neck, jaw or arms

201

What is the differential diagnosis of diffuse esophageal spasm?

Angina pectoris; psychoneurosis; nutcracker esophagus

202

What are the associated diagnostic tests for diffuse esophageal spasm?

Manometry (repetitive, high-amplitude contractions with normal sphincter response); upper GI (normal or segmented spasms, corkscrew esophagus); endoscopy

203

What is the classic finding on upper GI with diffuse esophageal spasm?

Corkscrew esophagus

204

What is the treatment for diffuse esophageal spasm?

Medical (antireflux, CCBs, nitrates); long esophagomyotomy in refractory cases

205

What is another name for nutcracker esophagus?

Hypertensive peristalsis

206

What is nutcracker esophagus?

Very strong peristaltic waves

207

What are the symptoms of nutcracker esophagus?

Spontaneous chest pain that radiates to the back, ears, neck, jaw, or arms

208

What is the differential diagnosis for nutcracker esophagus?

Angina pectoris, psychoneurosis, diffuse esophageal spasm

209

What are the associated diagnostic tests with nutcracker esophagus?

Manometry (repetitive, high-amplitude contractions with normal sphincter response); UGI (normal, rule out mass); endoscopy

210

What is the treatment for nutcracker esophagus?

Medical (antireflux, CCBs, nitrates); long esophagomyotomy in refractor cases

211

Which caustic agents may cause esophageal strictures if ingested?

Lye, oven cleaners, drain cleaners, batteries, sodium hydroxide tablets

212

How is the diagnosis of caustic ingestion?

History; EGD (to level of severe injury only, assess extent of damage); water soluble contrast study (rule out perforation)

213

What is the initial treatment for ingestion of a caustic substance?

1. NPO/IVF/H2 blockers
2. Do not induce emesis
3. Corticosteroids (controversial), antibiotics (penicillin, gentamicin) for moderate ulcers
4. Antibiotic for deep ulcers
5. UGI at 10-14 days

214

What is the treatment if an esophageal stricture develops after ingestion of a caustic substance?

Dilation with Maloney dilator or balloon catheter.
In severe refractory cases, esophagectomy with colon interposition or gastric pull-up.

215

What is the long-term followup for caustic ingestion?

Endoscopies every other year (increased risk of esophageal squamous cancer)

216

What is a Maloney dilator?

Mercury-filled rubber dilator

217

What are the 2 types of esophageal cancer?

1. Adenocarcinoma at the GEJ
2. Squamous cell carcinoma

218

What is the most common type of esophageal cancer?

World: squamous cell carcinoma
US: adenocarcinoma

219

What is the age and gender distribution for esophageal cancer?

Most common in the 6th decade; M > F

220

What are the 5 etiologic factors in esophageal cancer?

1. Tobacco
2. Alcohol
3. GERD
4. Barrett's esophagus
5. Radiation

221

What are the symptoms of esophageal cancer?

Dysphagia, weight loss, chest pain, back pain, hoarseness

222

What comprises the workup for esophageal cancer?

UGI; EGD; transesophageal U/S; chest and abdomen CT

223

What is the differential diagnosis of esophageal cancer?

Leiomyoma, metastatic tumor, lymphoma, benign stricture, achalasia, diffuse esophageal spasm, GERD

224

How is the diagnosis of esophageal cancer made?

UGI (localize tumor); EGD (obtain biopsy and assess resectability); full metastatic workup (CXR, bone scan, CT, LFTs)

225

What is stage I esophageal cancer?

Tumor invades lamina propria, muscularis mucosae, or submucosa; negative nodes

226

What is stage IIa esophageal cancer?

Tumor invades muscularis propria; negative nodes

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What is stage IIb esophageal cancer?

1. Tumor invades up to muscular is propria, positive regional nodes, or
2. Tumor invades adventitia, negative nodes.

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What is stage III esophageal cancer?

1. Tumor invades adventitia, positive regional nodes, or
2. Tumor invades adjacent structure.

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What is stage IV esophageal cancer?

Distant metastasis

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What is the treatment for esophageal cancer?

Esophagectomy with gastric pull-up or colon interposition

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What is an Ivor-Lewis procedure?

Laparotomy and right thoracotomy with gastroesophageal anastomosis in the chest after esophagectomy

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What are the treatment options for metastatic esophageal cancer?

Chemotherapy and XRT +/- dilation, stent, laser, electrocoagulation, brachytherapy, photodynamic laser therapy

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What is a blunt esophagectomy?

Esophagectomy with blunt transmittal dissection of esophagus from abdomen and gastroesophageal anastomosis in the neck

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Has XRT and/or chemotherapy been shown to decrease mortality from esophageal cancer?

No

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What is the prognosis (5-year) for esophageal cancer?

Stage I: 66%
Stage II: 25%
Stage III: 10%
Stage IV: 0%