Esophagus
During an Ivor Lewis esophagectomy, while in the abdomen, you notice that there is no pulse in the right gastroepiploic artery. What is the best course of action?
A. Close the patient, and discuss other conduit options such as left colon interposition or jejunal free graft.
B. Resect the esophagus, and use the unprepared left colon as a conduit.
C. Continue the operation, basing the stomach on the left gastric artery.
D. Continue the operation, basing the stomach on the right gastric artery.
A. Close the patient, and discuss other conduit options such as left colon interposition or jejunal free graft.
A 24-year-old male is brought to the trauma bay after a motor vehicle accident. After a thorough primary and secondary survey, imaging reveals multiple right-sided rib fractures and associated hemothorax. A chest tube is placed with drainage of 350 mL sanguineous fluid. Three days later, the patient develops worsening fever, cough, dyspnea, and malaise. CT chest reveals a loculated right pleural effusion. Which of the following is the most appropriate management?
A. Administration of fibrinolytics (tPA, DNase) via chest tube
B. Thoracoscopic decortication
C. Initiation of IV antibiotics and serial imaging
D. Removal of the chest tube as it is a nidus for infection
B. Thoracoscopic decortication
This patient has a retained hemothorax with signs of secondary infection, given the fever and malaise. When discovered, retained hemothorax should be drained because of the risk for subsequent fibrosis and the development of a "trapped" lung or fibrothorax. This can lead to chronic dyspnea and chest pain. Administration of fibrinolytics for a hemothorax is not indicated and could exacerbate bleeding. Antibiotics will not evacuate the retained fluid.
A 40-year-old patient on chronic anticoagulation for his ventricular assist device that was placed 2 years ago for end-stage heart failure now presents to the ED reporting shortness of breath following a ground-level fall. He is hemodynamically stable with a hematocrit of 38% and an INR of 4.5. CT demonstrates a large left pleural effusion (HU of 50) and a grade III splenic injury with active extravasation. His coagulopathy is corrected, and he is taken to interventional radiology (IR) for splenic embolization. What other intervention is warranted at this time?
A. Transesophageal echocardiography
B. Thoracentesis
C. Tube thoracostomy
D. Video-assisted thoracoscopic washout
E. Splenectomy
C. Tube thoracostomy
Notwithstanding the unique circumstances surrounding this patient’s ventricular assist device, the standard Advanced Trauma Life Support (ATLS) approach still applies in this trauma case. Following the primary and secondary surveys, he is stable enough to undergo CT, where 2 key findings are described: (1) a grade III splenic injury with active extravasation and (2) a large hemothorax. To address the splenic injury, IR embolization is the appropriate choice. If IR embolization fails, splenectomy would be the next step.
To address a hemothorax, tube thoracostomy is the preferred option over thoracentesis. Chest tube placement offers superior evacuation of the chest and a means of measuring ongoing output. Recall that blood has a higher attenuation (typically HU > 35) than simple pleural fluid. Also, if tube thoracostomy fails to fully evacuate the hemothorax, video-assisted thoracoscopic washout may be necessary to prevent progression to lung entrapment and fibrothorax.
Note that transesophageal echocardiography is not necessary at this point in management, but it would be prudent to have this patient’s ventricular assist device interrogated.
The inventor of thoracoscopy ?
In 1910, Professor Hans Christian Jacobaeus used a modified cystoscope to perform thoracic pneumolysis in Stockholm. Although Jacobaeus has been called the “father of thoracoscopy,”
Staging of tuberculous pleurisy, malignant pleural effusion, rheumatoid and parapneumonic effusion, empyema, and pneumothorax was published in 1925
Which popular condiment was once sold as a medicinal cure for diarrhea?
Ketchup
A 20-year-old woman, a college student, presents to the emergency department after an apparent suicide attempt. She drank approximately 500 mL of an unknown liquid from a chemistry laboratory. She is speaking in complete sentences without respiratory distress and has mild epigastric discomfort. After establishment of airway patency and hemodynamic stability, as well as placement of intravenous access, which of the following is the next best management step?
A. Nasogastric tube insertion
B. Induction of emesis
C. Oral dilution with water
D. Glucocorticoid administration
E. Urgent endoscopy
E. Urgent endoscopyEndoscopy should be performed as soon as possible after caustic ingestions, ideally within 24 hours, to assess the magnitude and extent of injury.
Blind nasogastric tube insertion is contraindicated. Forced emesis is contraindicated. Therapeutic administration of diluents is not recommended after caustic ingestions. The role of glucocorticoids in preventing future esophageal strictures is controversial and typically reserved for high-grade injury, if used at all.
A 75-year-old male presents with a recurrent right sided pleural effusion. He has undergone repeated thoracenteses, and cytology has been positive for malignant cells. He is currently undergoing palliative chemotherapy for metastatic lung cancer and on home oxygen. He is now requiring thoracentesis every 3-4 days for symptom management. What is the best option for managing a malignant pleural effusion in this patient?
A. Repeated thoracentesis
B. Tube thoracostomy
C. Thoracoscopic talc pleurodesis
D. Tunneled pleural catheter
D. Tunneled pleural catheter
Tunneled pleural catheter placement is a well-established practice for malignant pleural effusions, particularly in patients such as this one with a limited life-expectancy. A phase 3 study showed that indwelling pleural catheters are as effective as doxycycline pleurodesis in management of malignant pleural effusion. Repeated thoracentesis is not practical given the rapid recurrence of the effusion. Tube thoracostomy will treat the effusion but is difficult to care for on an outpatient basis and is painful. Thoracoscopic pleurodesis is certainly reasonable in a patient that has failed other options and has a longer life expectancy. It also requires an inpatient hospital stay.
A 72-year-old man with a history of diabetes is discharged from the hospital on postoperative day 5 after a three-vessel coronary artery bypass graft. Three days later, he presents to the emergency department with fever, tenderness and erythema around the surgical incision, and sternal instability. A complete blood count shows a leukocytosis of 17,000/µL. Posteroanterior and lateral chest x-rays show air-fluid levels in the subcutaneous tissue and mediastinum. A computed tomography scan reveals loculated pockets of mediastinal fluid. What perioperative precautions are important to decreasing the risk of this postoperative complication?
A. Use of hyperglycemia protocols to maintain early postoperative blood glucose levels to less than 180 mg/dL
B. Fast-track postoperative extubation protocols
C. Reduced duration of indwelling Foley catheters
D. Application of antibiotic paste to the sternal edges before sternal closure
A. Use of hyperglycemia protocols to maintain early postoperative blood glucose levels to less than 180 mg/dL
Aggressive blood glucose management in both the intraoperative and immediate postoperative period has serious impacts on rates of deep sternal wound infections and, subsequently, the development of mediastinitis. This has been shown to be true both in people with diabetes as well as in those without diabetes.
Increased duration of indwelling Foley catheters have been shown to increase risk of urinary tract infections, not sternal site infections. Recent studies of efficacy of vancomycin paste are lacking in evidence that they prevent sternal wound infections.
The first surgeon to performed open-heart surgery on a human?
Dr. Daniel Hale Williams in 1893 - stab wound to internal mammary and pericardium. James Cornish
(Heart surgery is generally regarded as having begun on September 10, 1896 when Ludwig Rehn in Germany sutured a myocardial laceration successfully.)
What is the national animal of Scotland?
Unicorn
A 55-year-old man has a history of gastroesophageal reflux, heavy smoking, and alcohol use. He presents with progressive dysphagia and unintentional weight loss. Investigation reveals adenocarcinoma of the distal esophagus that extends into the esophageal adventitia with one regional lymph node positive for adenocarcinoma. The man is otherwise healthy and wishes curative treatment. What is the best treatment plan?
A. Operative resection of the esophagus and regional lymph node dissection followed by adjuvant chemoradiation
B. Neoadjuvant chemoradiotherapy followed by regional lymph node dissection
C. Neoadjuvant chemoradiotherapy followed by operative resection of the esophagus and regional lymph node dissection
D. Operative resection of the esophagus and regional lymph node dissection followed by neoadjuvant chemoradiotherapy
C. Neoadjuvant chemoradiotherapy followed by operative resection of the esophagus and regional lymph node dissection
This man has stage 3a (T3 N1) disease. The best treatment plan is neoadjuvant chemoradiotherapy followed by operative resection of the esophagus and regional lymph node dissection. The Dutch chemotherapy and radiation in esophageal surgery study (CROSS) trial, which compared neoadjuvant treatment and surgery to surgery alone, found a 5-year survival advantage in the neoadjuvant group (47% vs 34%). Most patients in this trial had adenocarcinoma (75%), and resection was appropriate in all patients.
A 50-year-old woman who has never smoked is found to have an 8-mm ground-glass nodule (GGN) in the right upper lobe on a CT scan. What is the next step in management?
A. CT-guided biopsy
B. Video-assisted thoracoscopic surgery, wedge resection
C. Positron emission tomography (PET) scan
D. Repeat CT scan in 6 monthsE. Video-assisted thoracoscopic surgery, right upper lobectomy
D. Repeat CT scan in 6 months
Subcentimeter GGNs can represent benign or premalignant disease. Surgical resection is not indicated, and surveillance imaging would be appropriate. Percutaneous biopsy results can be indeterminate. PET imaging is not usually helpful because GGNs that are smaller than 1 cm are not typically PET avid.
A 28-year-old woman sustains a precordial stab wound. On presentation to the ED, she is hypotensive and tachycardic but is able to maintain these vital signs with fluid resuscitation. She is taken urgently to the operating room for exploration. Which is the best initial incision for exposure in this woman?
A. Median sternotomy
B. Left anterolateral thoracotomy
C. Left posterolateral thoracotomy
D. Right posterolateral thoracotomy
E. Book thoracotomy
A. Median sternotomy
Median sternotomy is correct because in this woman with a precordial stab wound and possible cardiac injury, it allows for wide access to the anterior mediastinum, heart, and great vessels. Although left anterolateral thoracotomy would allow for access to the heart, it is reserved for resuscitative thoracotomy in a traumatic arrest. This woman is stable enough to make it to the operating room, and therefore median sternotomy is preferred. Posterolateral incisions allow more access to posterior structures within the chest. Finally, the use of book thoracotomy for access to the proximal left subclavian artery is controversial.
When and What was the first thoracic surgery?
1499: Rolandus, a surgeon from Parma, resected a piece of lung that was infected with worms between two ribs.
Originally, Amazon only sold what kind of product?
Books
You are seeing a patient who had a transhiatal esophagectomy for cT3N1M0 esophageal cancer and who received preoperative chemotherapy and radiation therapy. The surgical pathology report states that there were no lymph nodes removed from the subcarinal region; however, there were five lymph nodes removed from the inferior pulmonary ligament area, three removed from the celiac axis station, and four removed from the pericardial region. All of the lymph nodes were negative for cancer. What is the next step in this patient's management?
A. Recommend follow-up with CT in 6 months and then yearly.
B. Perform an endoscopic bronchoscopy with ultrasound-guided biopsy of the station 7 lymph nodes.
C. Perform a mediastinoscopy to sample station 7 lymph nodes.
D. Perform a right VATS exploration of the subcarinal lymph nodes.
A. Recommend follow-up with CT in 6 months and then yearly.
The subcarinal area in station 7 is very difficult to access via the transhiatal approach. The lymph nodes in station 9 are near the lower esophagus and should routinely be removed during an esophagectomy. Station 20 contains the celiac axis lymph nodes, and these should also be removed during an esophagectomy. Station 16 contains lymph nodes near the diaphragmatic crux; these too should be removed during an esophagectomy. Although there are no station #7 lymph nodes harvested, this does not mean they need a reexcision or had a poor operation. None of the other treatment options listed are necessary.
A 44-year-old woman with a prior right thigh sarcoma resected 1 year ago undergoes a surveillance computed tomography scan that demonstrates three pulmonary lesions in the right upper lobe of the lung and one lesion in the left lower lobe of the lung. A positron emission tomography scan reveals no other foci of metastatic disease. What is the appropriate management?
A. Chemotherapy
B. Radiotherapy
C. Chemotherapy and radiotherapy
D. Left lower lobectomy
E. Staged bilateral wedge resections
E. Staged bilateral wedge resections
This woman has recurrence of her sarcoma with isolated bilateral pulmonary metastases. Given that she has no other foci of metastatic disease, has had complete definitive therapy for her primary tumor (1 year ago), and otherwise is in condition to undergo pulmonary resection, she should undergo metastasectomy with bilateral wedge resections of all suspicious lesions. The surgeon should spare as much lung parenchyma as possible by performing sequential wedge resections instead of a lobectomy if this can be done. Bilateral disease is often managed with staged wedge resections because concurrent bilateral thoracic incisions can be painful and difficult to recover from.
Chemotherapy, radiotherapy, or chemoradiotherapy may not sufficiently treat the disease, especially when it is amenable to metastasectomy. An isolated left lower lobectomy would not adequately treat the right-sided lesions.
A 56-year-old man with chronic obstructive pulmonary disease, gastroesophageal reflux disease, and obesity hypoventilation syndrome was brought to the emergency department 10 minutes after sustaining a gunshot wound to the chest at left parasternal border. His Glasgow Coma Scale score was 5, and vital signs were deteriorating rapidly. Emergent resuscitative thoracotomy (RT) was performed by the trauma resident. The pericardial sac was incised sharply and opened transversely, evacuating a large hemopericardium; this relieved the cardiac tamponade. The patient's vital signs improved, and he was transferred to the operating room for exploration and repair of a small right ventricular laceration. However, the patient has had a prolonged hospital course and cannot be weaned from mechanical ventilation. What finding on chest computed tomography may have resulted from the emergent RT leading to prolonged ventilator dependence?
A. Right tracheal deviation
B. Left pulmonary contusion
C. Elevation of the left hemidiaphragm
D. Left rib fractures
E. Severe gastric distention
C. Elevation of the left hemidiaphragm
The left phrenic and vagal nerves pass anterior to the aortic arch. The left phrenic nerve is susceptible to injury during resuscitative thoracotomy (RT) as it courses anterior to the left lung hilum along the lateral surface of the pericardium. The left vagus nerve descends in the posterior mediastinum; thus, it is less vulnerable to injury compared with the phrenic nerve during RT. The left vagus nerve gives rise to the left recurrent laryngeal nerve, which ascends under the aortic arch just medial to the origin of the left subclavian artery. It is important that the pericardial incision is made longitudinally and anterior to the left phrenic nerve. Transection of this nerve leads to paralysis of the left diaphragm.
The trachea is not exposed during an RT. Although the lung can be injured during RT and patients may sustain a rib fracture at the site of RT, these are unlikely to result in prolonged ventilator dependence. The left recurrent laryngeal nerve is superior to the appropriate level of RT and is less likely to be injured during a proper RT.
Father of Open Heart Surgery?
"C. Walton Lillehei"
Lillehei participated in the world's first successful open-heart operation, performed at the University of Minnesota on September 2, 1952. That historic operation, using hypothermia, was led by his longtime friend and colleague, Dr. F. John Lewis.
What does Yahoo stand for?
Yet Another Hierarchically Officious Oracle
An 82-year-old woman with a history of cervical stenosis presents to your office to discuss options for surgical management of her Zenker diverticulum. She has had multiple episodes of pneumonia over the past year. On physical examination, she is unable to fully extend her neck due to her prior history of cervical stenosis. What is the best approach for treatment?
A. Endoscopic repair of the Zenker diverticulum
B. Diverticulectomy without myotomy
C. Observation
D. Diverticulectomy with myotomy
D. Diverticulectomy with myotomy
This patient is 82 years old and has a history of cervical stenosis making it difficult for her to fully extend her neck. Given this history, an open repair would be performed over endoscopic repair of the Zenker diverticulum. In all cases of an open repair, a myotomy of the proximal and distal thyropharyngeus and cricopharyngeus muscles is performed. In cases of a small diverticulum (< 2 cm), a myotomy alone is often sufficient, but a large sac (> 5 cm) requires excision of the sac. Observation is not adequate in this patient because she has had multiple episodes of aspiration pneumonia over the past year. Endoscopic repair requires maximal extension of the neck and can be difficult to perform in older patients with cervical stenosis.
A 48-year-old woman presents with vague chest pain with an intermittent cough. She undergoes cross-sectional imaging during her workup and is found to have an anterior mediastinal mass. Assuming that she is found to have the most common primary anterior mediastinal mass in adults, what might be other presenting symptoms if she were to have the most frequently associated paraneoplastic syndrome?
A. Recurrent sinus, ear, and upper airway infections
B. Lethargy, pallor, and tachycardia in the setting of profound anemia
C. Shortness of breath, facial swelling, and upper limb edema
D. Generalized weakness, dysphagia, ptosis, and diplopia
E. Unilateral ptosis, miosis, and anhidrosis
D. Generalized weakness, dysphagia, ptosis, and diplopia
Myasthenia gravis is the most commonly associated paraneoplastic syndrome encountered in patients with thymomas. It is characterized by generalized weakness of various muscle groups and usually presents with weakness of the ocular muscles. Hence, common presenting symptoms include ptosis (due to weakness of the levator palpebrae superioris) or diplopia (due to extraocular muscle weakness).
Recurrent infections are suspicious for hypogammaglobulinemia, which is a less common paraneoplastic syndrome associated with thymomas. Lethargy, pallor, and tachycardia are suspicious for pure red cell aplasia, another less common paraneoplastic syndrome seen with thymomas. Shortness of breath, facial swelling, and upper limb edema are presenting symptoms of superior vena cava syndrome. Finally, unilateral ptosis, miosis, and anhidrosis are symptoms of Horner syndrome. These last two conditions may be seen as a result of mass effect in cases of larger thymomas.
A 71-year-old woman with chronic kidney disease, idiopathic pulmonary artery hypertension, and chronic atrial fibrillation on apixaban is transferred overnight from a local hospital for management of severe COVID-19 pneumonia, respiratory failure, and acute respiratory distress syndrome. During admission and initial examination, she develops poor oxygenation saturation. An x-ray shows appropriate positioning of the endotracheal tube and new, bilateral pleural effusions. The woman is afebrile, with a heart rate of 129 beats/min and a blood pressure of 110/95 mm Hg. She was previously transitioned to therapeutic anticoagulation with heparin. On examination, the woman is mechanically ventilated with symmetric chest rise and adequate sedation. The extremities are grossly edematous. The surgical team is consulted for thoracentesis. Which of the following is the next best step?
A. Bilateral chest tube placement
B. Aggressive diuresis
C. Thoracentesis
D. Computed tomography angiogram of the chest
E. Bronchoscopy
B. Aggressive diuresis
Pleural effusion is common in the intensive care setting because of nonphysiologic use of mechanical ventilation and large intravascular and extravascular volume shifts. The woman, who was recently transferred and has an unclear prior hospital course, has multiple indicators of volume overload (such as peripheral edema) that should be addressed before more invasive intervention. She may ultimately need chest tube placement if there is a concern for bacterial infection or if oxygenation does not improve with other measures; however, diuresis is more appropriate first. Similarly, bronchoscopy may be useful in the setting of mucus plugging or to assess other concurrent pathology but is not indicated at this time. Furthermore, both of these interventions are riskier in a patient on therapeutic anticoagulation. A computed tomography angiogram can help diagnose pulmonary embolism but would not immediately change management in a patient on therapeutic anticoagulation. An unlisted alternative is an echocardiogram, which can show evidence of right heart strain and help assess cardiac function and overall volume status.
First human lung transplant?
James Hardy, June 11, 1963
What is a single strand of spaghetti called?
Spaghetto