major points of VATS
Camera port
Fifth intercostal space mid axillary line
Working ports
Fourth or seven intercostal space
Solitary pulmonary nodule if it is cancer what is the most common type expected
75% are NSCLC.
Solitary pulmonary nodule what is most common benign diagnosis
80% are infectious granulomas.
Solitary pulmonary nodule
Six important factors that significantly increase the likelihood of an SPN being cancer
(1) age > 60 years,
(2) tobacco history > 20 pack-years,
(3) prior history of cancer,
(4) size > 2 cm on chest x-ray or CT,
(5) the presence of spiculations on chest x-ray or CT,
(6) doubling size
Solitary pulmonary nodule > 1 cm who have an intermediate probability are managed hwo
FDG-PET scan
to assess the need for surgical excision
versus
surveillance with serial CT scans.
Solitary pulmonary nodule high clinical and/ or radiographic probability of cancer
undergo surgical excision
even without tissue (like whipple)
For patients with stage 1a what is recommended treatement
This is ONLY I AAAA (all the other stage I get chemo)
lobectomy alone is recommended.
For patients with stage 1 what is recommended treatement
stage 1 SCLC, lobectomy followed by platinum-based adjuvant chemotherapy is recommended.
IIIb disease tx
no surgery
cisplantinum
and
xrt
who gets preop chemo
IIIA
pancost tumor and ipsilateral node
mass and ipsilateral node
mediastinoscopy
shows positive
this is stage IIIa - needs neoadjuvant
mass and contralateral node
mediastinoscopy
shows positive
this is stage IIIb
no surgery
cisplantinum
and
xrt
pulmonary function
FEV1
1.6 need for lobectomy
each lobe is about 20%
Can do functional reserve with V/Q.
FEV1 needed for pneumontectomy
Greater than 2 L
FEV1 needed for lobectomy
Greater than one 1.6 L
FEV1 needed for wedge resection
Greater than 0.6 0.8
Pre-op testing for considered long resection
PFTs
VQ scan predicted postop FEV1
ABG
CT pet - include liver and adrenals
If any nodes light-up:
medianstinoscopy
Contraindications for surgery on lung cancer
T4
N3 - contralateral positive node
Post our predicted FEV1 less than 0.8
Malignant affusion
Extra thoracic metastasis (CAREFUL - may still go for care if isolated brain met!)
STC syndrome
Recurrent laryngeal your nerve involvement
Phrenic nerve paralysis
Great vessel involvement
Small cell lung cancer (these get chemoradiation)
Horner syndrome
Positive cervical lymph node
Tracheoesophageal fistula
When is the pneumonectomy resection required
hilar lesion
Crosses the fishers and involves all lobes
When should you do a Chamberlain procedure
Right-sided nodes
Left para tracheal nodes
Hormones that long cancer Cancer secrete
squamous
PTH like hormones squamous
both squamous and calcium can affect the skin.
small cell
(SIADH) in small cell
“systemic therapy so systemic diuresis”
Still go for cure in non-small cell lung cancer
IIIa
up to T3 (pericardium, chest wall, bronchus) N1 (ipsilateral)
T2 N2 (ipsilateral mediastiunm)
Differential diagnosis of mediastinal tumor
Anterior:
Thymoma, teratoma, terrible lymphoma
Medial
Pericardial
Bronchogenic
Sarcoid
Posterior Mesothelioma Neurogenic (the Esophageal duplication) Germ cell tumor Substernal thyroid Sarcoidosis Neurogenic humor
What physical examinations do a mediastinal mask patient need
Testicles exam!
Heading and neck exam
What laboratory studies does a mediastinal mass patient meet
Baby hCG
AFP
LDH
Metanephrines
TSH
Treatment of mediastinal non-seminoma
Chemotherapy alone
Treatment of mediastinal seminoma
Chemotherapy and XRT
Very do you sensitive
Treatment of male genitalia
Wide local excision
XRT
Chemotherapy
Treatment of thymoma
Preoperative plasmapheresis to remove anti-cholenergic receptor antibody
Steroids
Excision via MEDIAN sternotomy
Thoracic duct course
Enters the chest via the aortic hiatus travels on the right side until T4/T5
Gaines into the common loans of the internal jugular and subclavian vein
cisterna chyli is at
L2
The cisterna chyli (or cysterna chyli, and etymologically more correct, receptaculum chyli) is a dilated sac at the lower end of the thoracic duct into which lymph from the intestinal trunk and two lumbar lymphatic trunks flow.
What is the advantage of using thin barium besides for subtle leak
If concerned of aspiration (example: tracheoesophageal fistula) not harmful for aspiration
Treatment for chylothorax / fistula
You can try medium chain triglycerides
TPN
If fail:
VATS ligation in the chest
What strap muscle should be used to buttress your internal jugular repair or ligation
Cricothyroid muscle
what are the strap muscles that are retracted during thyroidectomy
sternohyoid and sternothyroid
These may also be divided
what side nodes does mediastinoscopy biopsy
Right
“Regular procedure equals right”
Website node does Chamberlin procedure biopsy
Left
“left = sinister = Walt Chamberlain the left hand basketball player”
Patient after retropharyngeal abscess drainage continues to have high fever in the ICU postop day five. They are sick and cannot get off the ventilator what is the next step
CT scan for food collection
Paratracheal
Right chest drainage
This is mediastinitis
Patient after mandibular fracture in the chest tube output characters changed it is layering out in the container now
Thoracic duct injury
Send triglycerides Cholesterol Chylomicron LDH Lymphocytes
Nonfat diet versus
Medium medium chain triglycerides
NPO three weeks
Monitor chest tube output
What test do you need after you’ve done a cardiac repair for penetrating heart injury
Echocardiogram
Make sure valve was not injured et cetera.