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Thoracic Surgery, C71 P621-648 Flashcards

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1
Q

What does VATS stand for?

P621

A

Video-Assisted Thoracic Surgery

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2
Q

THORACIC OUTLET SYNDROME (TOS)
What is it?
P621

A 
Compression of the:
Subclavian artery
Subclavian vein or
Brachial plexus at the superior outlet
    of the thorax
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3
Q

THORACIC OUTLET SYNDROME (TOS)
What are the causes (3)?
P621

A 
1. Various congenital anomalies,
    including cervical rib or abnormal
    fascial bands to the first rib, or
    abnormal anterior scalene muscle
2. Trauma:
       Fracture of clavicle or first rib
       Dislocation of humeral head
       Crush injuries
3. Repetitive motor injuries (baseball
    pitchers)
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4
Q

THORACIC OUTLET SYNDROME (TOS)
What are the symptoms?
P621

A

Paresthesias (neck, shoulder, arm, hand);
90% in ulnar nerve distribution
Weakness (neural/arterial)
Coolness of involved extremity (arterial)
Edema, venous distension, discoloration
(venous)

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5
Q

THORACIC OUTLET SYNDROME (TOS)
What are the most common
symptoms with TOS?
P621

A

Neurologic

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6
Q

THORACIC OUTLET SYNDROME (TOS)
Which nerve is most often
involved?
P621

A

Ulnar nerve

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7
Q

THORACIC OUTLET SYNDROME (TOS)
What are the signs?
P622

A 
Paget-von Schroetter syndrome—venous
    thrombosis leading to edema, arm
    discoloration, and distension of the
    superficial veins
Weak brachial and radial pulses in the
    involved arm
Hypesthesia/anesthesia
Occasionally, atrophy in the distribution
    of the ulnar nerve
Positive Adson maneuver/Tinel’s sign
Edema
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8
Q

THORACIC OUTLET SYNDROME (TOS)
What is the Adson
maneuver?
P622

A 
Evaluates for arterial compromise
Patient:
    1. Extends neck (lifts head)
    2. Takes a deep breath and holds
    3. Turns head toward examined side
Physician:
    Monitors radial pulse on examined side
    Test finding is positive if the radial
       pulse decreases or disappears
       during maneuver
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9
Q

THORACIC OUTLET SYNDROME (TOS)
What is Tinel’s test?
P622

A

Tapping of the supraclavicular fossa

producing paresthesias

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10
Q

THORACIC OUTLET SYNDROME (TOS)
What is the treatment?
P622

A

Physical therapy (vast majority of cases)
Decompression of the thoracic outlet by
resecting the first rib and cervical rib
(if present) if physical therapy fails
and as a last resort

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11
Q 
CHESTWALL TUMORS
BENIGN TUMORS
What are the most common
types?
P622
A
  1. Fibrous rib dysplasia (posterolateral rib)
  2. Chondroma (at costochondral
    junction)
  3. Osteochondroma (any portion of rib)
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12
Q

CHESTWALL TUMORS
BENIGN TUMORS
What is the treatment?
P622

A

Wide excision and reconstruction with

autologous or prosthetic grafts

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13
Q 
CHESTWALL TUMORS
MALIGNANT TUMORS
What are the most common
types?
P623
A
  1. Fibrosarcoma
  2. Chondrosarcoma
  3. Osteogenic sarcoma
  4. Rhabdomyosarcoma
  5. Myeloma
  6. Ewing’s sarcoma
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14
Q

CHESTWALL TUMORS
MALIGNANT TUMORS
What is the treatment?
P623

A

Excision with or without radiation

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15
Q

CHESTWALL TUMORS
MALIGNANT TUMORS
What is Tietze’s syndrome?
P623

A

Noninfectious costochondral cartilage

inflammation

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16
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is it?
P623

A

Fluid in the pleural space

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17
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the causes?
P623

A
  1. Pulmonary infections (pneumonia)
  2. Congestive heart failure (CHF)
  3. SLE or rheumatoid arthritis
  4. Pancreatitis (sympathetic effusion)
  5. Trauma
  6. Pulmonary embolism
  7. Renal disease
  8. Cirrhosis
  9. Malignancy (mesothelioma,
    lymphoma, metastasis)
  10. Postpericardiotomy syndrome
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18
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the symptoms?
P623

A

Dyspnea, pleuritic chest pain

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19
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the signs?
P623

A

Decreased breath sounds, dullness to

percussion, egophony at the upper limit

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20
Q 
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the properties of a
transudate?
P623
A

Specific gravity <3 g/dL

Few cells

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21
Q 
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the properties of
an exudate?
P623
A

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

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22
Q 
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is the key diagnostic
test?
P624
A

Thoracentesis (needle drainage) with

studies including cytology

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23
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is the treatment?
P624

A
  1. Pigtail catheter or thoracostomy (chest
    tube)
  2. Treat underlying condition
  3. Consider sclerosis
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24
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is an empyema?
P624

A

Infected pleural effusion; must be
drained, usually with chest tube(s)
Decortication may be necessary if the
empyema is solid

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25
DISEASES OF THE PLEURA PLEURAL EFFUSION What is a decortication? P624
Thoracotomy and removal of an infected fibrous rind from around the lung (think of it as taking off a fibrous “cortex” from the lung)
26
``` DISEASES OF THE PLEURA LUNG ABSCESS What are the signs/ symptoms? P624 ```
Fever, sputum, sepsis, fatigue
27
``` DISEASES OF THE PLEURA LUNG ABSCESS What are the associated diagnostic studies? P624 ```
``` CXR: air-fluid level CT scan to define position and to differentiate from an empyema Bronchoscopy (looking for cancer/culture) ```
28
DISEASES OF THE PLEURA LUNG ABSCESS What is the treatment? P624
Antibiotics and bronchoscopy for culture | and toilet, with or without surgery
29
``` DISEASES OF THE PLEURA LUNG ABSCESS What are the indications for surgery? P624 ```
Underlying cancer/tumor | Refractory to antibiotics
30
``` DISEASES OF THE PLEURA LUNG ABSCESS What are the surgical options? P624 ```
Lobectomy of lobe with abscess | Tube drainage
31
``` DISEASES OF THE PLEURA LUNG ABSCESS What is middle lobe syndrome? P624 ```
Recurrent right middle lobe pneumonia caused most commonly by intermittent extrinsic bronchial obstruction
32
DISEASES OF THE PLEURA HEMOPTYSIS What is it? P624
Bleeding into the bronchial tree
33
DISEASES OF THE PLEURA HEMOPTYSIS What are the causes? P625
1. Bronchitis (50%) 2. Tumor mass (20%) 3. TB (8%) Other causes: bronchiectasis, pulmonary catheters, trauma
34
DISEASES OF THE PLEURA HEMOPTYSIS Define MASSIVE hemoptysis P625
>600 cc/24 hours
35
DISEASES OF THE PLEURA HEMOPTYSIS What comprises the workup? P625
CXR Bronchoscopy Bronchial A-gram
36
``` DISEASES OF THE PLEURA HEMOPTYSIS What is the treatment if massive? P625 ```
``` Bronchoscopy, intubation of unaffected side, Fogarty catheter occlusion of bleeding bronchus, bronchial A-gram with or without embolization, surgical resection of involved lung ```
37
``` DISEASES OF THE PLEURA HEMOPTYSIS What is the treatment of moderate to mild bleeding? P625 ```
Laser coagulation, +/-- epinephrine | injection
38
DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX What is it? P625
Atraumatic spontaneous development of | a pneumothorax
39
DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX What are the causes? P625
Idiopathic (primary), bleb disease, | emphysema, etc. (secondary)
40
``` DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX What body habitus is associated with spontaneous pneumothorax? P625 ```
Thin and tall
41
DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX How is the diagnosis made? P625
CXR
42
DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX What is the treatment? P625
Chest tube
43
``` DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX What are the options if refractory, recurrent, or bilateral? P625 ```
Pleurodesis: scar the lung to the parietal pleura with a sclerosant (talc) via chest tube/thoracoscopy, or by thoracotomy and mechanical abrasion
44
``` DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX Who might also need a pleurodesis after the first episode? P625 ```
Those whose lifestyles place them at increased risk for pneumothorax (e.g., pilots, scuba divers)
45
``` DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX What is a catamenial pneumothorax? P626 ```
Pneumothorax due to intrathoracic | endometriosis
46
``` DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What is it? P626 ```
Primary pleural neoplasm
47
``` DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What are the two types? P626 ```
1. Localized | 2. Diffuse (highly malignant)
48
``` DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What are the risk factors? P626 ```
Exposure to asbestos | Smoking
49
``` DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What are the symptoms? P626 ```
Dyspnea and pain = 90% Localized: pleuritic pain, joint pain and swelling, dyspnea Diffuse: chest pain, malaise, weight loss, cough
50
``` DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What are the signs? P626 ```
Pleural effusion: Localized (10%–15%) Diffuse ( >75%)
51
``` DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What are the associated radiographic tests? P626 ```
X-ray may reveal a peripheral mass, often forming an obtuse angle with the chest wall; CT scan is also performed
52
``` DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma How is the diagnosis made? P626 ```
Pleural biopsy, pleural fluid cytology
53
``` DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What is the treatment if localized? P626 ```
Surgical excision
54
``` DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What is the treatment if diffuse? P626 ```
Early stages may be resected, followed by radiation; for more advanced stages, radiation, chemotherapy, or both are done
55
``` DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What is the prognosis? P626 ```
Localized: poor Diffuse: dismal (average life span after diagnosis is about 1 year)
56
``` DISEASES OF THE PLEURA MESOTHELIOMA Benign Mesothelioma What is it? P626 ```
Benign pleural mesothelioma
57
``` DISEASES OF THE PLEURA MESOTHELIOMA Benign Mesothelioma What pleura is usually involved? P626 ```
Visceral pleura
58
``` DISEASES OF THE PLEURA MESOTHELIOMA Benign Mesothelioma What is the gross appearance? P627 ```
Pedunculated “broccoli or cauliflower” | tumor on a stalk coming off of the lung
59
``` DISEASES OF THE PLEURA MESOTHELIOMA Benign Mesothelioma What is the treatment? P627 ```
Surgical resection with at least 1 cm clear | margin
60
``` DISEASES OF THE PLEURA MESOTHELIOMA Benign Mesothelioma What is the prognosis? P627 ```
In contrast to malignant mesothelioma, the benign mesothelioma has an excellent prognosis with cure in the vast majority of cases
61
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the annual incidence of lung cancer in the United States? P627 ```
170,000 new cases/year
62
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the number of annual deaths from lung cancer? P627 ```
150,000; most common cancer death in | the United States in men and women
63
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the #1 risk factor? P627
Smoking (85%!)
64
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA Does asbestos exposure increase the risk in patients who smoke? P627 ```
Yes
65
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What type of lung cancer arises in nonsmoking?Adenocarcinoma P627 ```
Adenocarcinoma
66
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA Cancer arises more often in which lung? P627 ```
Right > left; upper lobes > lower lobes
67
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the signs/ symptoms? P627 ```
``` Change in a chronic cough Hemoptysis, chest pain, dyspnea Pleural effusion (suggests chest wall involvement) Hoarseness (recurrent laryngeal nerve involvement) Superior vena cava syndrome Diaphragmatic paralysis (phrenic nerve involvement) Symptoms of metastasis/paraneoplastic syndrome Finger clubbing ```
68
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is Pancoast’s tumor? P628
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, and Horner’s syndrome
69
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is Horner’s syndrome? P628
``` Injury to the cervical sympathetic chain; Think: “MAP” 1. Miosis (small pupil) 2. Anhydrosis of ipsilateral face 3. Ptosis ```
70
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the four most common sites of extrathoracic metastases? P628 ```
1. Bone 2. Liver 3. Adrenals 4. Kidney
71
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are paraneoplastic syndromes? P628 ```
``` 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 ```
72
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA Name five general types of paraneoplastic syndromes. P628 ```
``` 1. Metabolic: Cushing’s, SIADH, hypercalcemia 2. Neuromuscular: Eaton-Lambert, cerebellar ataxia 3. Skeletal: hypertrophic osteoarthropathy 4. Dermatologic: acanthosis nigricans 5. Vascular: thrombophlebitis ```
73
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the associated radiographic tests? P628 ```
CXR, CT scan, PET scan
74
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA How is the tumor diagnosed? P628 ```
1. Sputum cytology 2. Needle biopsy (CT or fluoro guidance) 3. Bronchoscopy with brushings, biopsies, or both 4. With or without mediastinoscopy, mediastinotomy, scalene node biopsy, or open lung biopsy for definitive diagnosis
75
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA For each tumor listed, recall its usual site in the lung and its natural course: Squamous cell? P629 ```
66% occur centrally in lung hilus; may also be a Pancoast’s tumor; slow growth, late metastasis; associated with smoking (Think: Squamous = Sentral)
76
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA For each tumor listed, recall its usual site in the lung and its natural course: Adenocarcinoma? P629 ```
Peripheral, rapid growth with hematogenous/nodal metastasis, associated with lung scarring
77
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA For each tumor listed, recall its usual site in the lung and its natural course: Small (oat) cell? P629 ```
Central, highly malignant, usually not | operable
78
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA For each tumor listed, recall its usual site in the lung and its natural course: Large cell? P629 ```
Usually peripheral, very malignant
79
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage Ia? P629 ```
Tumor <3 cm, no nodes, no metastases
80
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage Ib? P629 ```
Tumor 3–5 cm, no nodes, no | metastases
81
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage IIa? P629 ```
``` 1. Tumor <5 cm and positive nodes to lung or ipsilateral hilum; no metastases, or 2. Tumor 5–7 cm, no nodes, no metastases ```
82
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage IIb? P629 ```
``` 1. Tumor 5–7 cm and positive nodes in lung or ipsilateral hilum, or 2. Tumor that invades chest wall, diaphragm, mediastinal pleura, phrenic nerve, pericardial sac, or bronchus (not carina) and no nodes, no metastases ```
83
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage IIIa? P630 ```
1. Tumor 7 cm or extends into chest wall, parietal pleura, diaphragm, phrenic nerve, or pericardium and + lymph node metastases to ipsilateral, mediastinal, or subcarinal nodes 3. Any size tumor that invades heart, great vessels, trachea, esophagus, carina, or ipsalateral lobe, or + nodes peribronchial and/or ipsilateral hilum, or intrapulmonary nodes
84
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage IIIb? P630 ```
Any tumor, + lymph node metastases to contralateral hilum or mediastinum Supraclavicular/scalene nodes, NO distant metastases
85
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage IV? P630 ```
Distant metastases
86
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the surgical contraindications for NON-small cell carcinoma? P630 ```
Stage IV, Stage IIIb, poor lung function | FEV1 <0.8L
87
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment by stage for NON-small cell lung carcinoma: Stage I? P630 ```
Surgical resection
88
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment by stage for NON-small cell lung carcinoma: Stage II? P630 ```
Surgical resection
89
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment by stage for NON-small cell lung carcinoma: Stage IIIa? P630 ```
Chemotherapy and XRT +/- surgical | resection
90
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment by stage for NON-small cell lung carcinoma: Stage IIIb? P630 ```
Chemotherapy and XRT
91
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment by stage for NON-small cell lung carcinoma: Stage IV? P630 ```
Chemotherapy +/- XRT
92
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment for isolated brain metastasis? P630 ```
Surgical resection
93
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma by stage: Stage I? P631 ```
50%
94
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma by stage: Stage II? P631 ```
30%
95
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma by stage: Stage III? P631 ```
10%
96
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma by stage: Stage IV? P631 ```
1%
97
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA How is small cell carcinoma treated? P631 ```
Chemotherapy +/- XRT (very small | isolated lesions can be surgically resected)
98
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the contraindications to surgery for lung cancer? P631 ```
``` Think: “STOP IT” Superior vena cava syndrome, Supraclavicular node metastasis, Scalene node metastasis Tracheal carina involvement Oat cell carcinoma (treat with chemotherapy +/- radiation) Pulmonary function tests show FEV1 <0.8L Infarction (myocardial); a.k.a. cardiac cripple Tumor elsewhere (metastatic disease) ```
99
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What postoperative FEV1 must you have? P631 ```
``` FEV1 >800 cc; thus, a preoperative FEV1 >2L is usually needed for a pneumonectomy If FEV1 is <2L, a ventilation perfusion scan should be performed ```
100
``` DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is hypertrophic pulmonary osteoarthropathy? P631 ```
Periosteal proliferation and new bone formation at the end of long bones and in the bones of the hand (seen in 10% of patients with lung cancer)
101
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What are they? P631
Peripheral circumscribed pulmonary | lesions
102
``` DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What is the differential diagnosis? P632 ```
Granulomatous disease, benign | neoplasms, malignancy
103
``` DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What percentage are malignant? P632 ```
Overall, 5% to 10% (but >50% are | malignant in smokers >50 years)
104
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) Is there a gender risk? P632
Yes; the incidence of coin lesions is 3 to 9x higher and malignancy is nearly twice as common in men as in women
105
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What are the symptoms? P632
Usually asymptomatic with solitary nodules, but may include coughing, weight loss, chest pain, and hemoptysis
106
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What are the signs? P632
Physical findings are uncommon; clubbing is rare; hypertrophic osteoarthropathy implies 80% chance of malignancy
107
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) How is the diagnosis made? P632
CXR, chest CT
108
``` DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What is the significance of “popcorn” calcification? P632 ```
Most likely benign (i.e., hamartoma)
109
``` DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What are the risk factors for malignancy? P632 ```
``` 1. Size: lesions >1 cm have a significant chance of malignancy, and those >4 cm are very likely to be malignant 2. Indistinct margins (corona radiata) 3. Documented growth on follow-up x-ray (if no change in 2 years, most likely benign) 4. Increasing age ```
110
``` DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What are the associated lab tests? P632 ```
1. TB skin tests, etc. 2. Sputum cultures 3. Sputum cytology is diagnostic in 5% to 20% of cases
111
``` DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) Which method of tissue diagnosis is used? P632 ```
Chest CT scan with needle biopsy, bronchoscopy ( +/- transtracheal biopsy), excisional biopsy (open or thoracoscopic)
112
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What is the treatment? P633
Surgical excision is the mainstay of treatment Excisional biopsy is therapeutic for benign lesions, solitary metastasis, and for primary cancer in patients who are poor risks for more extensive surgery Lobectomy for centrally placed lesions Lobectomy with node dissection for primary cancer (if resectable by preop evaluations)
113
``` DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) Which solitary nodule can be followed without a tissue diagnosis? P633 ```
Popcorn calcifications Mass unchanged for 2 years on previous CXR
114
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What is the prognosis? P633
For malignant coin lesions 2 cm, 5-year | survival is ≈70%
115
``` DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What if the patient has an SPN and pulmonary hypertrophic osteoarthropathy? P633 ```
>75% chance of carcinoma
116
``` DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What is hypertrophic pulmonary osteoarthropathy? P633 ```
Periosteal proliferation and new bone formation at the end of long bones and in bones of the hand
117
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What is its incidence? P633
≈7% of patients with lung cancer | 2%–12%
118
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What are the signs? P633
Associated with clubbing of the fingers; diagnosed by x-ray of long bones, revealing periosteal bone hypertrophy
119
DISEASES OF THE LUNGS CARCINOID TUMOR What is it? P633
APUD (Amine-Precursor Uptake and | Decarboxylation) cell tumor of the bronchus
120
``` DISEASES OF THE LUNGS CARCINOID TUMOR What is its natural course in the lung? P633 ```
Slow growing (but may be malignant)
121
``` DISEASES OF THE LUNGS CARCINOID TUMOR What are the primary local findings? P633 ```
Wheezing and atelectasis caused by | bronchial obstruction/stenosis
122
``` DISEASES OF THE LUNGS CARCINOID TUMOR What condition can it be confused with? P634 ```
Asthma
123
DISEASES OF THE LUNGS CARCINOID TUMOR How is the diagnosis made? P634
Bronchoscopy reveals round red-yellowpurple mass covered by epithelium that protrudes into bronchial lumen
124
DISEASES OF THE LUNGS CARCINOID TUMOR What is the treatment? P634
Surgical resection (lobectomy with lymph node dissection) Sleeve resection is also an option for proximal bronchial lesions
125
DISEASES OF THE LUNGS CARCINOID TUMOR What is a sleeve resection? P634
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
126
``` DISEASES OF THE LUNGS CARCINOID TUMOR What is the prognosis (5-year survival) after complete surgical resection of carcinoid: Negative nodes? P634 ```
>90% alive at 5 years
127
``` DISEASES OF THE LUNGS CARCINOID TUMOR What is the prognosis (5-year survival) after complete surgical resection of carcinoid: Positive nodes? P634 ```
66% alive at 5 years
128
``` DISEASES OF THE LUNGS CARCINOID TUMOR What is the most common benign lung tumor? P634 ```
Hamartoma (normal cells in a weird | configuration)
129
DISEASES OF THE LUNGS PULMONARY SEQUESTRATION What is it? P634
Abnormal benign lung tissue with separate blood supply that DOES NOT communicate with the normal tracheobronchial airway
130
``` DISEASES OF THE LUNGS PULMONARY SEQUESTRATION Define the following terms: Interlobar P634 ```
Sequestration in normal lung tissue | covered by normal visceral pleura
131
``` DISEASES OF THE LUNGS PULMONARY SEQUESTRATION Define the following terms: Extralobar P634 ```
Sequestration not in normal lung covered | by its own pleura
132
DISEASES OF THE LUNGS PULMONARY SEQUESTRATION What are the signs/symptoms? P634
Asymptomatic, recurrent pneumonia
133
DISEASES OF THE LUNGS PULMONARY SEQUESTRATION How is the diagnosis made? P634
CXR, chest CT, A-gram, U/S with | Doppler flow to ascertain blood supply
134
``` DISEASES OF THE LUNGS PULMONARY SEQUESTRATION What is the treatment in the following cases: Extralobar? P635 ```
Surgical resection
135
``` DISEASES OF THE LUNGS PULMONARY SEQUESTRATION What is the treatment in the following cases: Intralobar? P635 ```
Lobectomy
136
``` DISEASES OF THE LUNGS PULMONARY SEQUESTRATION What is the major danger during surgery for sequestration? P635 ```
``` Anomalous blood supply from below the diaphragm (these can be cut and retract into the abdomen resulting in exsanguination!) Always document blood supply by A-gram or U/S with Doppler flow ```
137
``` DISEASES OF THE MEDIASTINUM MEDIASTINAL ANATOMY What structures lie in the following locations: Superior mediastinum? P635 ```
Aortic arch, great vessels, upper trachea, | esophagus
138
``` DISEASES OF THE MEDIASTINUM MEDIASTINAL ANATOMY What structures lie in the following locations: Anterior mediastinum? P635 ```
Thymus, ascending aorta, lymph nodes
139
``` DISEASES OF THE MEDIASTINUM MEDIASTINAL ANATOMY What structures lie in the following locations: Middle mediastinum? P635 ```
Heart, lower trachea and bifurcation, | lung hila, phrenic nerves, lymph nodes
140
``` DISEASES OF THE MEDIASTINUM MEDIASTINAL ANATOMY What structures lie in the following locations: Posterior mediastinum? P635 ```
Esophagus, descending aorta, thoracic duct, vagus and intercostal nerves, sympathetic trunks, azygous and hemizygous veins, lymph nodes
141
``` DISEASES OF THE MEDIASTINUM MEDIASTINAL ANATOMY What is the major differential diagnosis for tumors of the mediastinum: Anterior mediastinum? P635 ```
Classic “four Ts”: Thyroid tumor, Thymoma, Terrible lymphoma, Teratoma; also parathyroid tumor, lipoma, vascular aneurysms
142
``` DISEASES OF THE MEDIASTINUM MEDIASTINAL ANATOMY What is the major differential diagnosis for tumors of the mediastinum: Middle mediastinum? P635 ```
Lymphadenopathy (e.g., lymphoma, sarcoid), teratoma, fat pad, cysts, hernias, extension of esophageal mass, bronchogenic cancer
143
``` DISEASES OF THE MEDIASTINUM MEDIASTINAL ANATOMY What is the major differential diagnosis for tumors of the mediastinum: Posterior mediastinum? P636 ```
Neurogenic tumors, lymphoma, aortic | aneurysm, vertebral lesions, hernias
144
``` DISEASES OF THE MEDIASTINUM MEDIASTINAL ANATOMY What is the most common type of tumor arising in the mediastinum? P636 ```
Neurogenic (most commonly in posterior | mediastinum)
145
``` DISEASES OF THE MEDIASTINUM MEDIASTINAL ANATOMY What is the differential diagnosis for a neurogenic tumor? P636 ```
Schwannoma (a.k.a. neurolemmoma), neurofibroma, neuroblastoma, ganglioneuroma, ganglioneuroblastoma, pheochromocytoma
146
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Thymoma Where are they found in the mediastinum? P636 ```
Anterior
147
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Thymoma How is the diagnosis made? P636 ```
CT scan
148
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Thymoma What is the treatment? P636 ```
All thymomas should be surgically resected | via midline sternotomy
149
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Thymoma What are the indications for postop radiation therapy? P636 ```
Invasive malignant tumor
150
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Thymoma What are the indications for preop chemotherapy? P636 ```
Tumor >6 cm and CT scan with invasion
151
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Thymoma What percentage of thymomas are malignant? P636 ```
≈25%
152
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Thymoma How is a malignant thymoma diagnosed? P636 ```
At surgery with invasion into surrounding | structures (not by histology!)
153
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Thymoma What is myasthenia gravis? P636 ```
Autoimmune disease with antibodies | against the muscle acetylcholine receptors
154
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Thymoma What percentage of patients with myasthenia gravis have a thymoma? P636 ```
≈15%
155
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Thymoma What percentage of patients with thymoma have or will have myasthenia gravis? P636 ```
≈75%!
156
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Teratomas What are they? P537 ```
Tumors of branchial cleft cells; the tumors contain ectoderm, endoderm, and mesoderm
157
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Teratomas What is a dermoid cyst? P637 ```
Teratoma made up of ectodermal | derivatives (e.g., teeth, skin, hair)
158
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Teratomas Which age group is affected? P637 ```
Usually adolescents, but can occur at | any age
159
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Teratomas Where in the mediastinum do they occur? P637 ```
Anterior
160
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Teratomas What are the characteristic x-ray findings? P637 ```
Calcifications or teeth; tumors may be | cystic
161
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Teratomas What percentage are malignant? P637 ```
≈15%
162
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Teratomas What is the treatment of benign dermoid cysts? P637 ```
Surgical excision
163
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Teratomas What is the treatment of malignant teratoma? P637 ```
Preoperative chemotherapy until tumor markers are normal, then surgical resection
164
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Teratomas Which tumor markers are associated with malignant teratomas? P637 ```
AFP, CEA
165
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Neurogenic Tumors What is the incidence? P637 ```
Most common mediastinal tumors in all | age groups
166
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Neurogenic Tumors Where in the mediastinum do they occur? P637 ```
Posterior, in the paravertebral gutters
167
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Neurogenic Tumors What percentage are malignant? P637 ```
50% in children | 10% in adults
168
``` DISEASES OF THE MEDIASTINUM PRIMARY MEDIASTINAL TUMORS Neurogenic Tumors What are the histologic types (5)? (Note cells of origin and whether benign or malignant.) P638 ```
1. Neurilemmoma 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)—also from sympathetic chain
169
``` DISEASES OF THE MEDIASTINUM LYMPHOMA Where in the mediastinum does it occur? P638 ```
Anywhere, but most often in the anterosuperior mediastinum or hilum in the middle mediastinum
170
``` DISEASES OF THE MEDIASTINUM LYMPHOMA What percentage of lymphomas involve mediastinal nodes? P638 ```
≈50%
171
DISEASES OF THE MEDIASTINUM LYMPHOMA What are the symptoms? P638
Cough, fever, chest pain, weight loss, | SVC syndrome, chylothorax
172
DISEASES OF THE MEDIASTINUM LYMPHOMA How is the diagnosis made? P638
1. CXR, CT scan 2. Mediastinoscopy or mediastinotomy with node biopsy
173
DISEASES OF THE MEDIASTINUM LYMPHOMA What is the treatment? P638
Nonsurgical (chemotherapy, radiation, | or both)
174
``` DISEASES OF THE MEDIASTINUM MEDIASTINITIS Acute Mediastinitis What is it? P638 ```
Acute suppurative mediastinal infection
175
``` DISEASES OF THE MEDIASTINUM MEDIASTINITIS Acute Mediastinitis Name the six etiologies. P638 ```
``` 1. Esophageal perforation (Boerhaave’s syndrome) 2. Postoperative wound infection 3. Head and neck infections 4. Lung or pleural infections 5. Rib or vertebral osteomyelitis 6. Distant infections ```
176
``` DISEASES OF THE MEDIASTINUM MEDIASTINITIS Acute Mediastinitis What are the clinical features? P639 ```
Fever, chest pain, dysphagia (especially with esophageal perforation), respiratory distress, leukocytosis
177
``` DISEASES OF THE MEDIASTINUM MEDIASTINITIS Acute Mediastinitis What is the treatment? P639 ```
1. Wide drainage 2. Treatment of primary cause 3. Antibiotics
178
``` DISEASES OF THE MEDIASTINUM MEDIASTINITIS Chronic Mediastinitis What is it? P639 ```
Mediastinal fibrosis secondary to chronic | granulomatous infection
179
``` DISEASES OF THE MEDIASTINUM MEDIASTINITIS Chronic Mediastinitis What is the most common etiology? P639 ```
Histoplasma capsulatum
180
``` DISEASES OF THE MEDIASTINUM MEDIASTINITIS Chronic Mediastinitis What are the clinical features? P639 ```
``` 50% are asymptomatic; symptoms are related to compression of adjacent structures: SVC syndrome, bronchial and esophageal strictures, constrictive pericarditis ```
181
``` DISEASES OF THE MEDIASTINUM MEDIASTINITIS Chronic Mediastinitis How is the diagnosis made? P639 ```
CXR or CT may be helpful, but surgery/ | biopsy often makes the diagnosis
182
``` DISEASES OF THE MEDIASTINUM MEDIASTINITIS Chronic Mediastinitis What is the treatment? P639 ```
Antibiotics; surgical removal of the | granulomas is rarely helpful
183
DISEASES OF THE MEDIASTINUM SUPERIOR VENA CAVA SYNDROME What is it? P639
Obstruction of the superior vena cava, | usually by extrinsic compression
184
DISEASES OF THE MEDIASTINUM SUPERIOR VENA CAVA SYNDROME What is the #1 cause? P639
Malignant tumors cause 90% of cases; lung cancer is by far the most common; other tumors include thymoma, lymphoma, and Hodgkin’s disease
185
``` DISEASES OF THE MEDIASTINUM SUPERIOR VENA CAVA SYNDROME What are the clinical manifestations? P639 ```
``` 1. Blue discoloration and puffiness of the face, arms, and shoulders 2. CNS manifestations may include headache, nausea, vomiting, visual distortion, stupor, and convulsions. 3. Cough, hoarseness, and dyspnea ```
186
DISEASES OF THE MEDIASTINUM SUPERIOR VENA CAVA SYNDROME What is the treatment? P640
1. Diuretics and fluid restriction 2. Prompt radiation therapy +/- chemotherapy for any causative cancer
187
DISEASES OF THE MEDIASTINUM SUPERIOR VENA CAVA SYNDROME What is the prognosis? P640
SVC obstruction itself is fatal in 5% of cases; mean survival time in patients with malignant obstruction is ≈7 months
188
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS What are the primary functions of the Upper and Lower Esophageal Sphincters? P640 ```
UES: swallowing LES: prevention of reflux
189
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS The esophageal venous plexus drains inferiorly into the gastric veins. Why is this important? P640 ```
Gastric veins are part of the portal venous system; portal hypertension can thus be referred to the esophageal veins, leading to varices
190
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS Identify the esophageal muscle type: Proximal 1/3 P640 ```
Skeletal muscle
191
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS Identify the esophageal muscle type: Middle 1/3 P640 ```
Smooth muscle > skeletal muscle
192
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS Identify the esophageal muscle type: Distal 1/3 P640 ```
Smooth muscle
193
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS Identify the blood supply to the esophagus: Proximal 1/3 P640 ```
Inferior thyroid, anterior intercostals
194
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS Identify the blood supply to the esophagus: Middle 1/3 P640 ```
Esophageal arteries, bronchial arteries
195
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS Identify the blood supply to the esophagus: Distal 1/3 P640 ```
Left gastric artery, left inferior phrenic artery
196
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS What is the length of the esophagus? P640 ```
≈25 cm in the adult (40 cm from teeth to | LES)
197
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS Why is the esophagus notorious for anastomotic leaks? P640 ```
Esophagus has no serosa (same as the distal | rectum)
198
``` DISEASES OF THE ESOPHAGUS ANATOMIC CONSIDERATIONS What nerve runs with the esophagus? P641 ```
Vagus nerve
199
DISEASES OF THE ESOPHAGUS ZENKER’S DIVERTICULUM What is it? P641 (picture)
``` Pharyngoesophageal diverticulum; a false diverticulum containing mucosa and submucosa at the UES at the pharyngoesophageal junction through Killian’s triangle ```
200
``` DISEASES OF THE ESOPHAGUS ZENKER’S DIVERTICULUM What is the disease’s “claim to fame”? P641 ```
Most common esophageal diverticulum
201
``` DISEASES OF THE ESOPHAGUS ZENKER’S DIVERTICULUM What are the signs/ symptoms? P641 ```
Dysphagia, neck mass, halitosis, food | regurgitation, heartburn
202
DISEASES OF THE ESOPHAGUS ZENKER’S DIVERTICULUM How is the diagnosis made? P641
Barium swallow
203
DISEASES OF THE ESOPHAGUS ZENKER’S DIVERTICULUM What is the treatment? P641
1. Diverticulectomy | 2. Cricopharyngeus myotomy, if >2 cm
204
DISEASES OF THE ESOPHAGUS ACHALASIA What is it? P641
1. Failure of the LES to relax during swallowing 2. Loss of esophageal peristalsis
205
DISEASES OF THE ESOPHAGUS ACHALASIA What are the proposed P641
1. Neurologic (ganglionic degeneration of Auerbach’s plexus, vagus nerve, or both); possibly infectious in nature 2. Chagas’ disease in South America
206
``` DISEASES OF THE ESOPHAGUS ACHALASIA What are the associated long-term conditions? P642 ```
Esophageal carcinoma secondary to | Barrett’s esophagus from food stasis
207
DISEASES OF THE ESOPHAGUS ACHALASIA What are the symptoms? P642 (picture)
Dysphagia for both solids and liquids, followed by regurgitation; dysphagia for liquids is worse
208
``` DISEASES OF THE ESOPHAGUS ACHALASIA What are the diagnostic findings? P642 ```
``` v\Radiographic contrast studies reveal dilated esophageal body with narrowing inferiorly Manometry: motility studies reveal increased pressure in the LES and failure of the LES to relax during swallowing ```
209
``` DISEASES OF THE ESOPHAGUS ACHALASIA What are the treatment options? P642 ```
1. Balloon dilation of the LES 2. Medical treatment of reflux versus Belsey Mark IV 270 fundoplication (do not perform 360 Nissen) 3. Myotomy of the lower esophagus and LES
210
DISEASES OF THE ESOPHAGUS DIFFUSE ESOPHAGEAL SPASM What is it? P642
Strong, nonperistaltic contractions of the esophageal body; sphincter function is usually normal
211
``` DISEASES OF THE ESOPHAGUS DIFFUSE ESOPHAGEAL SPASM What is the associated condition? P642 ```
Gastroesophageal reflux
212
DISEASES OF THE ESOPHAGUS DIFFUSE ESOPHAGEAL SPASM What are the symptoms? P642
Spontaneous chest pain that radiates to | the back, ears, neck, jaw, or arms
213
``` DISEASES OF THE ESOPHAGUS DIFFUSE ESOPHAGEAL SPASM What is the differential diagnosis? P643 ```
Angina pectoris Psychoneurosis Nutcracker esophagus
214
``` DISEASES OF THE ESOPHAGUS DIFFUSE ESOPHAGEAL SPASM What are the associated diagnostic tests? P643 ```
``` Esophageal manometry: Motility studies reveal repetitive, highamplitude contractions with normal sphincter response Upper GI may be normal, but 50% show segmented spasms or corkscrew esophagus Endoscopy ```
215
``` DISEASES OF THE ESOPHAGUS DIFFUSE ESOPHAGEAL SPASM What is the classic finding on esophageal contrast study (UGI)? P643 ```
“Corkscrew esophagus”
216
DISEASES OF THE ESOPHAGUS DIFFUSE ESOPHAGEAL SPASM What is the treatment? P643
Medical (antireflux measures, calcium channel blockers, nitrates) Long esophagomyotomy in refractory cases
217
DISEASES OF THE ESOPHAGUS NUTCRACKER ESOPHAGUS What is it also known as? P643
Hypertensive peristalsis
218
DISEASES OF THE ESOPHAGUS NUTCRACKER ESOPHAGUS What is it? P643
Very strong peristaltic waves
219
DISEASES OF THE ESOPHAGUS NUTCRACKER ESOPHAGUS What are the symptoms? P643
Spontaneous chest pain that radiates to | the back, ears, neck, jaw, or arms
220
``` DISEASES OF THE ESOPHAGUS NUTCRACKER ESOPHAGUS What is the differential diagnosis? P643 ```
Angina pectoris Psychoneurosis Diffuse esophageal spasm
221
``` DISEASES OF THE ESOPHAGUS NUTCRACKER ESOPHAGUS What are the associated diagnostic tests? P643 ```
``` 1. Esophageal manometry: motility studies reveal repetitive, high-amplitude contractions with normal sphincter response 2. Results of UGI may be normal (rule out mass) 3. Endoscopy ```
222
DISEASES OF THE ESOPHAGUS NUTCRACKER ESOPHAGUS What is the treatment? P643
Medical (antireflux measures, calcium channel blockers, nitrates) Long esophagomyotomy in refractory cases
223
DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX What is it? P644
``` Reflux of gastric contents into the lower esophagus resulting from the decreased function of the LES ```
224
DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX What are the causes? P644
.1. Decreased LES tone 2. Decreased esophageal motility 3. Hiatal hernia 4. Gastric outlet obstruction 5. NGT
225
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX Name four associated conditions/factors P644 ```
1. Sliding hiatal hernia 2. Tobacco and alcohol 3. Scleroderma 4. Decreased endogenous gastrin production
226
DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX What are the symptoms? P644
Substernal pain, heartburn, regurgitation; symptoms are worse when patient is supine and after meals
227
DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX How is the diagnosis made? P644
``` 1. pH probe in the lower esophagus reveals acid reflux 2. EGD shows esophagitis 3. Manometry reveals decreased LES pressure 4. Barium swallow ```
228
DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX What is the initial treatment? P644
Medical: H(2)-blockers, antacids, metoclopramide, omeprazole Elevation of the head of the bed; small, multiple meals
229
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX Which four complications require surgery? P644 ```
1. Failure of medical therapy 2. Esophageal strictures 3. Progressive pulmonary insufficiency secondary to documented nocturnal aspiration 4. Barrett’s esophagus
230
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX Describe each of the following types of surgery: Nissen P644 ```
360 fundoplication: wrap fundus of | stomach all the way around the esophagus
231
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX Describe each of the following types of surgery: Belsey Mark IV P645 ```
270 fundoplication: wrap fundus of | stomach, but not all the way around
232
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX Describe each of the following types of surgery: Hill P645 ```
Tighten arcuate ligament around | esophagus and tack stomach to diaphragm
233
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX Describe each of the following types of surgery: Lap Nissen P645 ```
Nissen via laparoscope
234
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX Describe each of the following types of surgery: Lap Toupet P645 ```
Lap fundoplication posteriorly with less than 220 to 250 wrap used with decreased esophageal motility; disadvantage is more postoperative reflux
235
DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX What is Barrett’s esophagus? P645
Replacement of the lower esophageal squamous epithelium with columnar epithelium secondary to reflux
236
DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX Why is it significant? P645
This lesion is premalignant
237
DISEASES OF THE ESOPHAGUS ESOPHAGEAL REFLUX What is the treatment? P645
``` People with significant reflux should be followed with regular EGDs with biopsies, H(2)-blockers, and antireflux precautions; many experts believe that patients with severe dysplasia should undergo esophagectomy ```
238
``` DISEASES OF THE ESOPHAGUS CAUSTIC ESOPHAGEAL STRICTURES Which agents may cause strictures if ingested? P645 ```
Lye, oven cleaners, drain cleaners, batteries, | sodium hydroxide tablets (Clinitest)
239
DISEASES OF THE ESOPHAGUS CAUSTIC ESOPHAGEAL STRICTURES How is the diagnosis made? P645
History; EGD is clearly indicated early on to assess the extent of damage ( <24 hrs); scope to level of severe injury (deep ulcer) only, water soluble contrast study for deep ulcers to rule out perforation
240
``` DISEASES OF THE ESOPHAGUS CAUSTIC ESOPHAGEAL STRICTURES What is the initial treatment? P645 ```
1. NPO/IVF/H2-blocker 2. Do not induce emesis 3. Corticosteroids (controversial— probably best for shallow/moderate ulcers), antibiotics (penicillin/ gentamicin) for moderate ulcers 4. Antibiotic for deep ulcers 5. Upper GI at 10 to 14 days
241
``` DISEASES OF THE ESOPHAGUS CAUSTIC ESOPHAGEAL STRICTURES What is the treatment if a stricture develops? P646 ```
``` Dilation with Maloney dilator/balloon catheter In severe refractory cases, esophagectomy with colon interposition or gastric pull-up ```
242
``` DISEASES OF THE ESOPHAGUS CAUSTIC ESOPHAGEAL STRICTURES What is the long-term follow-up? P646 ```
Because of increased risk of esophageal squamous cancer (especially with ulceration), patients endoscopies every other year
243
DISEASES OF THE ESOPHAGUS CAUSTIC ESOPHAGEAL STRICTURES What is a Maloney dilator? P646
Mercury-filled rubber dilator
244
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What are the two main types? P646 ```
1. Adenocarcinoma at the GE junction 2. Squamous cell carcinoma in most of the esophagus
245
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is the most common histology? P646 ```
Worldwide: squamous cell carcinoma (95%!) USA: adenocarcinoma
246
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is the age and gender distribution? P646 ```
Most common in the sixth decade of life; | men predominate, especially black men
247
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What are the etiologic factors (5)? P646 ```
1. Tobacco 2. Alcohol 3. GE reflux 4. Barrett’s esophagus 5. Radiation
248
DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What are the symptoms? P646
Dysphagia, weight loss Other symptoms include chest pain, back pain, hoarseness, symptoms of metastasis
249
``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What comprises the workup? P646 ```
1. UGI 2. EGD 3. Transesophageal ultrasound (TEU) 4. CT scan of chest/abdomen
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is the differential diagnosis? P646 ```
Leiomyoma, metastatic tumor, lymphomas, benign stricture, achalasia, diffuse esophageal spasm, GERD
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DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA How is the diagnosis made? P647
1. Upper GI localizes tumor 2. EGD obtains biopsy and assesses resectability 3. Full metastatic workup (CXR, bone scan, CT scan, LFTs)
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA Describe the stages of adenocarcinoma esophageal cancer: Stage I P647 ```
Tumor: invades lamina propria, muscularis mucosae, or submucosa Nodes: negative
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA Describe the stages of adenocarcinoma esophageal cancer: Stage IIa P647 ```
Tumor: invades muscularis propria (grade 3) Nodes: negative
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA Describe the stages of adenocarcinoma esophageal cancer: Stage IIb P647 ```
1. Tumor: invades up to muscularis propria Nodes: positive regional nodes 2. Invades adventitia with negative nodes
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA Describe the stages of adenocarcinoma esophageal cancer: Stage III P647 ```
1. Tumor: invades adventitia Nodes: positive regional nodes 2. Tumor: invades adjacent structures
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA Describe the stages of adenocarcinoma esophageal cancer: Stage IV P647 ```
Distant metastasis
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DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is the treatment? P647
Esophagectomy with gastric pull-up or | colon interposition
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is an Ivor-Lewis procedure? P647 ```
Laparotomy and right thoracotomy with gastroesophageal anastomosis in the chest after esophagectomy
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA Treatment options with metastatic disease (unresectable)? P647 ```
Chemotherapy and XRT +/- dilation, stent, laser, electrocoagulation, brachytherapy, photodynamic laser therapy
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is a “blunt esophagectomy”? P647 ```
Esophagectomy with “blunt” transhiatal dissection of esophagus from abdomen and gastroesophageal anastomosis in the neck
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is the operative mortality rate? P648 ```
≈5%
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA Has radiation therapy and/or chemotherapy been shown to decrease mortality? P648 ```
No
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is the postop complication rate? P648 ```
≈33%!
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is the prognosis (5-year survival) by stage: I? P648 ```
66%
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is the prognosis (5-year survival) by stage: II? P648 ```
25%
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is the prognosis (5-year survival) by stage: III? P648 ```
10%
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``` DISEASES OF THE ESOPHAGUS ESOPHAGEAL CARCINOMA What is the prognosis (5-year survival) by stage: IV? P648 ```
Basically 0%

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