thoracic surgery ppt #5
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Lung Volume Reduction Surgery
• Emphysematous lung compresses normal lung and depresses diaphragm.
• Paradoxically can improve FEV1 and exercise function by resecting focally emphysematous lung.
• Still investigational.
Remove from nonfunctional lung
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Lung Transplantation• Last resort for lung
disease otherwise untreatable with death immanent.
• Selection– disease, age, co-morbidity
• Surgical techniques– lobe, one or both lungs
• Immunosuppression• BOOP
Next in line:
Not for CA
Better prognosis, better candidate
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Carcinoid Tumor
• Approx 1-3% % of malignant tumors of lung.
• Central- smooth cherry red tumor.
• Peripheral nodule• Airway obstruction and
atelectasis• Typical vs. atypical
Submucosal tumor; different from GI carcinoids (causes carcinoid syndrome)
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Olser-Weber-RenduHemorrhagic Telangiectasia
Syndrome• Familial• Nosebleeds• Lip and tongue
telangiectasia on exam• Cyanosis • Cerebral abscess• Peripheral pulmonary
nodules• Rx occlude feeding vessels
by angio or surgery• Rare type of A-V malformation
arising from a central PA
In lung, skin, brain
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Invasive Aspergillosis• Immunosuppressed pt. With
prolonged neutropenia
• Fever
• Chest pain
• Hemoptysis
• Pathognomonic radiographic features
• Amphotericin +/- pulmonary resection may be curative
Big cavity in lungs; was thought to be TB
Necrosis of lung
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Esophageal Perforation:• Cervical or thoracic• Spontaneous-
Boorhave syndrome• Iatrogenic- esophageal
dilatation, intubation• Chest pain, fever• L>R pleural effusion
with low pH• Dx by esophagram
• Survival will depend upon surgical repair or drainage within 6-24 hours.
• Very limited role for non-surgical management.
Know this for test
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Clubbing and Osteoarthropathy• Clubbing may occur
with chronic cyanosis , inflammatory disease or tumor.
• Hypertrophic pulmonary osteoarthropathy (HPO) occurs only with tumor.
• Lung CA, fibrous tumor of pleural
Pulmonary clubbing; also seen in cyanotic heart Dz
Clubbing with arthralgias
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Clubbing and HPO
• Pain in knees ankles and tibia > wrists and elbows.
• Pain disappears almost immediately following resection of tumor.
• Clubbing resolves more slowly
• Recurrence of either clubbing or HPO means that there is recurrence of tumor.
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Pneumothorax:• Very common.• Spontaneous- young tall
people.• Apical blebs• Chest tube drainage.• Bleb resection and
pleurodesis if recurrent.• Secondary- older patients
with COPD• Much higher M+M• Tension- lethal
Increased percussion note
May cause recurrence
More difficult w/ underlying lung Dz.
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Pneumothorax:
• Rarely pneumothorax is caused by necrotic or cystic tumors, typically sarcomas.
• In this case the pneumothorax was caused by lung metastasis from an angiosarcoma of the scalp.
Lung mets that is cystic
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Tracheal Neoplasms
• Mucoepidermoid tumor
• Adenocystic carcinoma
• Squamous carcinoma
In anterior wall of trachea
Types that block the airway; in bronchi, add carcinoid
May present with wheezing; DDX for asthma
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Laser Ablation:
• YAG laser ablation of endobronchial tumor offers effective palliation in Lung CA patients with dyspnea.
• Mean 3 mo.• EndobrachyRT
increases palliation to mean 6 mo.
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Cardiac Herniation• If a defect is left in the
pericardium more than approximately 3-4 cm in diameter, herniation of the heart may occur.
• Larger defects should be repaired with 2mm PFTE
• Sudden profound shock following right pneumonectomy
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Continuing Medical Education:
• The questions that will be asked on your exam will be the same questions that will be asked twenty years from now.
• BUT• The answers will
change.
• The bad news is that you will have to form a life-long practice of continuous self-education.
• The good news is that you will still be learning new and exciting information twenty years from now.
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Thoracic Surgery: An evolving practice
• Technological change occurs with blinding rapidity.
• The information and technical skills that allow one to successfully practice medicine WILL change.
• Success in practice will depend upon careful evaluation of new technology with retraining as indicated.