1
Q
% of those with emphysema that have a1-ATD
A
1-2 %
2
Q
First layer of EUS
A
hyperechocic - epithelium and lamia propria
3
Q
Types of emphysema
A
- proximal acinar
- pan- acinar
- distal acinar
- Irregular
4
Q
Distal acinar emphysema
A
Fibrosis Sub-pleural, associated with Ptx
5
Q
interstitial lung disease associated with the development of spontaneous pneumothorax
A
mnemonic : IES TLC
- Idiopathic pulmonary fibrosis
- Eosinophilic granuloma
- Sarcoidosis
- Tuberous sclerosis
- Lymphangioleiomyomatosis
- Collagen vascular disease
6
Q
Lung abscess etiology
A
- Aspiration
- Post pneumonic
- Opportunistic
- Bronchial obstruction
7
Q
alpha1-anti-trypsin enzyme
A
synthesized in the liver inhibits PMN leucocyte esterase –> protects elastic fibers from hydrolysis
8
Q
alpha 1 - antitrypsin disease
A
40K patients in the US 1-2% of patients with emphysema Heterozygous - normal phenotype Homo - 10% of normal enzyme levels
9
Q
Type A esophageal atresia
A
Esophageal atresia without TEF 8% of cases
10
Q
Anatomic subtypes of emphysema
A
4 variants:
- proximal acinar
- panacinar
- distal fibrosis
- Irregular
11
Q
Bacteriology of Bronchiectasis
A
- H. flu
- E. coli
- klebsiella
12
Q
stages of empyema as corelates to optimal intervention
A
Exudative (Acute) - tube thoracostomy Fibropurulent (transitional) VATS or open thoracotomy Organizing (chronic : 4-6 weeks): open thoracotomy, decortication
13
Q
Surgical management of isolated esophageal atresia
A
- Surgery
- prompt esophagostomy with the upper esophageal puch brought out the Left neck - to control saliva
- Gastrostomy is performed for feeding until esophageal replacement can be done at age 1
- Alternatively, daily bougiage for primairy anastomosis by age 3 mo
- natural growth and primairy repair at six months
14
Q
Occupational / social issues prompting surgery for ptx
A
Pilot Scuba diver Lives in isolated area
15
Q
First phase of the esophogram
A
First phase: mucosal exam with double contrast:
- barium
- CO2 tablets
16
Q
Esophagoscopy - four points of narrowing
A
- 15cm: upper esophageal sphicncer
- 23 cm: Aortic constriction
- indention on the left anterior lateral wall
- 23: Left atrium - wave like pulsation of the distal esophagus
- 40cm: LES
17
Q
% of patients with emphysema who have clinical significant disease
A
10%
18
Q
What is the point at which the esophagus become intrabdominal?
A
The insertion of the phrenoesophageal membrane (a continuation of the diaphragm endoabdominal fascia) is the point where the esophagus becomes intrabodiminal.
19
Q
Second phase of the esophogram
A
Function evaluation with single swallow low density barium at 30 second interval
20
Q
CXR of type A emphysema
A
oVer inflation, flat diaphragm, no fibrosis, decreased pulmonary vasculatory
21
Q
Post pneumonectomy empyema
Treatment options and success rate
A
- Drainage with a balanced chest tube until mediastinum is fixed and stable
- Open drainage with an Eloesser flap using the anterior end of the previous thoracotomy incision
- When the cavity is clean and the cultures are negative the cavity is filled with antibiotic slution and then closed tightly
- Success rate 25-75%
22
Q
Surface anatomy - extent of the diaphragm
A
Expiration - on the right - the nipple (T4), the left - one rib space below Inspiration - right to the 11th rib , left to the 12th
23
Q
For what is throacoplasty used ?
A
- Afte 2-4 failed attempts of sterilizing the chest cavity for empyema –>
- obliterate the space with muscle flaps
24
Q
Second layer of EUS
A
hypoechoic - muscularis propria
25
Risk of pulmonary disease with a1-ATD
20-30x the general population
26
irregular acinar emphysema
Effect in an irregular way - associated with scaring and fibrosis seen in all lungs to some degree
27
EUS- number of layers?
5
28
Chemical characteristics of **exudate** (empyema)
1. Pleural protein / serum protein \> 0.5
2. Pleural fluid LDH / serum LDH \> 0.6
3. Pleural fluid LDH \> ULN of serum LDH
29
4th layer of EUS
Muscularis propria - hypoechoic
30
Third layer of EUS
hyperechoic submucosa
31
Distal acinar (praseptal)
Distal acinus, ducts, alveolar ducts Fibrosis Subpleural location, PTx, bollus disease
32
Type A emphysema: path
panacinar type of destruction
33
TEF \_\_% have some imperforate anus
TEF - 10% have an imperforate anus
34
Waterson Class C
**weight \< 2000gm and otherwise well** *or* **severe other cardiac anomaly**
Survival: 65%
35
5th layer of EUZS
hyper echoic paraesophageal tissue
36
Number of phases to the **Esophogram**
*Esophogram has Three phases:*
1. Mucosal
2. Functional
3. Contour
37
time course for "late" BP fistula
after two weeks
38
TEF \_\_% have some variant of CHD
TEF - 20% have some variant of congenital heart disease
39
Emphysema associated with smoking
Proximal acing emphysema (centrilobar) usually upper airways in an uneven distribution
40
Indications for *surgery* for _lung abscess_
1. _Infection specific:_
1. Unsuccessful medical Rx after 5 weeks of treatment
2. residual cavity, larger than 2 cm, after Rx with persistent symptoms
2. _Reasons we always operate_
1. suspicion of carcinoma
2. Significant hemotypsis
3. Empyema
4. BP fistula
41
Fraction of population with emphysema at autopsy % with clincial diseae
2/3 - fraction with emphysema 10% have clinical disease
42
Most important "layer" with respect to GERD
**_Phrenoesophageal membrane_**, which anchors the esophagus with the esophageal hiatus.
43
From where do leiomyomas originate ?
esophogeal leiomyomas 97% from the inner circular layer
44
bolus emphysema has what type of Acinar involvement?
Distal Acinar
45
Phenotype of Type A Emphysema
Pink puffer with barrel chest, dry cough and non productive
46
Complications of ptx that are indications for surgery
1. Hemothorax, 2. Empyema 3. Chronic
47
TEF - __ have some variation of the VATER syndrome
17.5% of TEF have some variant of the VATER syndrome
48
GERD in Scleroderma
_Epidemiology_:
* seen in 90% of patients with scleroderma
_Pathology_:
* atrophy of the smooth muscle components
* LES: Fiberous infiltration with loss of emptying mechanisms
49
Type B or wet emphysema
The Bloater
_a) Phenotype:_
i) A productive cough and sputum production
ii) “Blue Bloater”
b) CXR:
i) moderate hyperinflation, ii) fibrosis – in the lower lobes, increased central vascularity, with tapering
_c) Pathology:_
i) Centrilobular type of changes
_d) Prognosis_
i) Poor prognosis
ii) The major complication is retention of secretions and respiratory failure.
50
prevelance of emphysema at autopsy
2/3 of adults
51
Most common causes of empyema
1. Pneumonia
2. Surgical
52
Bugs most common with bronchiectasis
1. H. Flu
2. E Coli
3. Klebsiella
53
Seminoma
Treatment
Radiation
with Cis- based chemotherapy for metastatic disease
surgical ressection with any residual disease
54
Hyper vs hypoechoic layers of EUS
hyper - white hypo- black (muscle)
55
Frequency of hemotypsis in patients with bronchectasis
50% of adults, but rare in children - 10% of those with hemotypsis - severe.
56
Waterson class A
**Weight \> 2500g** and **otherwise healthy**
_Survival_: 100%
Repair should be immediate
57
Grades of Myasthenia Gravis
I. Focal disease - ocular muscle weakness
II. Generalized mild to moderate disease
III. Severe generalized weaknes
IV Life threatening weakness
58
Pan-acinar bolus emphysema
Associated with alpha1-AT disease- or other protease inhibitor deficiency Uniform (carried within the blood) lower lung zones (carried in blood -- liquid goes down)
59
WHO & ATS definition of emphysema
increase beyond the normal size of an airspace - distal to the terminal non-respiratory bronchiole - caused by the destruction of their wall
60
**Grade** of _Myasthenia Gravis_, *Severe generalized weaknes* ?
_Grade III_
## Footnote
I. Focal disease - ocular muscle weakness
II. Generalized mild to moderate disease
**_III. Severe generalized weaknes_**
IV Life threatening weakness
61
Type B emphysema
B- Blue Bloater associated with Brohchitis severe cough and sputum production Centrilobular change Poor px major complication is retention of secretion and respiratory failure
62
**Gastroesophageal junction**
1. functionally, what is it?
2. Histologicaly ?
3. relationship with the PE membrane?
**Gastroesophageal junction**
1. **_functionally:_** *where esophageal peristalsis stops*.
2. **_Histologicaly_**: *distal to the gastric mucosal junction (turns to gastric mucosae higher)*
3. **_relationship with the PE membrane_**: *3-4 cm distal to the insertion of the PE membrane.*
63
Indications for Surgery For GERD
1. Symptomatic after 3 months of medical therapy
a. persistent esophagistis
b. stricture
c. aspiration
d. bleeding
2. positive 24hr pH study
3. Manometry suggestive of LES dysfunction with adequate motility (peak \>30mmHg)
a. would think of 360 degree wrap
4. Barrets mucosae with benign bx
64
_Third phase_ of the **esophogram**
**_Contour_**:
multiple, quick swallows of barrium that fills the esophagus optimizing the *contour*
65
Emphysema associated with A-ATD
Panacinar emphysema (pan lobar) seen with A1ATD and other PI disease lower lung zones
66
Irregular emphysema
Affects acinus in an irregular manner Always associated with scaring and fibrosis Occurs to some degree in all lungs
67
Waterson class B
**Weight: 1800-2500g** *or* **moderate anomaly** (PDA, VSD, ASD)
Survival: 85%
_no delayed primairy repair_:
* prox decompression
* G-tube
* antibotic
68
anatomical derivation of the phrenoesophagel membrane
the **_phrenoesopageal membrane_**: extenetion ofthe _endoabdominal fascial_ off the underside ofthe _diaphragmatic muscle_
69
Type II Hiatal hernia
Type II (paraesophageal hiatal hernia) 1) Less common 2) Defect in the phrenoesophegeal membrane - usually on the left ventral aspect of the hiatus. 3) Natural history is progressive enlargement of the true hernia sac 4) May get: gastric volvulus, tortion, obstruction, strangulation, and gastric dilation. - Requires surgery.
70
Treatment of caustic burns to the esophagus
1. Appropriate dilution
2. no emesis (this will cause products to pass 2x)
3. Fluids
4. Abx
5. Fiberoptic
71
**Grade** of _Myasthenia Gravis_, *Respiratory failure*?
_Grade IV: Respiratory Failure_
## Footnote
I. Focal disease - ocular muscle weakness
II. Generalized mild to moderate disease
III. Severe generalized weaknes
**IV Life threatening weakness**
72
Type I Hiatal hernia
Type I Esophageal hernia (COMMON) 1) Axial sliding hiatial hernia 2) Phrenoesophageal ligament is stretched 3) G-E jxn can migrate to an intrathoracic position 4) G-E jxn remains cephalad to stomach 5) Reducible, unless esophagus is foreshortened from stricture 6) NOT significant unless there is signficant Reflux (which usually coresponds to al larger hernia )
73
Conditions that predispose to bronchiectasis (4)
1. selective IgA deficiency
2. primairy hypogammaglobulinemia
3. a1 AT D
4. Kartageners Syndrome
74
Waterson classification
chances of mortality with repair of TEF - risk stratifies strategy of repair
75
Complications of repair of TEF - 5 big ones
1. Anastomoic leak - 15-20%
2. Post operative stricture - 5-50%
3. Tracheomalacia - 10-15%
4. GERD in up to 50%
5. TEF recurrence 10%
76
Esophageal atresia - mortality mainly due to
accompanying congenital heart disease
77
**_Cervicoaxillary canal_** - boundries
_Cervicoaxillary canal:_
1. _Inferior_: first rib
2. _Superior_: clavicle
3. _Medial_: costoclavicular ligaent
78
How do the oblique fissures corelate with surface anatomy ?
Anterior at the level of the 6th rib
79
Indications for **anti-refux surgery** in the *pedicatric population*
1. Life threatening **apenic** spells
2. Displacement of a major portion of the **stomach into chest**
3. Significant **esophagitis**
4. Esophageal **stricture**
5. **Pulmonary** changes
6. F**ailure to thrive** (50) of all indications
80
**Bronchiectasis**: Clinical *presentation*?
1. Recurrent pneumonia
2. Persistent Cough
3. Copious Foul smelling sputum
4. Hemotypsis
81
Lung abscess 2/2 Aspiration - location - bacteria type
Location: posterior segment RUL superior segment RLL, LLL Bacteriology: Anerobic and aerobic
82
Mediastinal mass with slightly elevated ß-HCG
Seminoma
The most common GCT in the mediastinum
Almost exclusively in males, 30-40 years old
CT Scan - large homogenious mass with smooth boardsrs
Grow slowly and are sensitive to RT
83
Cervicoaxillary canal - contents
1. Sublcavian vein
2. Subclavian artery
3. Brachial plexis
84
Fluid characteristics of Exutade
1. Pleural : Serum Potein\>0.5
2. Pleural: Serum LDH\> 0.6
3. Plural LDH \> 2/3 ULN for serum LDH
85
Type E esophageal atresia
"H type" TEF without atreasia 4% of cases
86
Structures below the **_Angle of Louis_** (right , middle, left)
* **_Right_** - *azygous* joins the SVC
* **_Mid_** - *carina*, *thoracic duct croses*
* **_Left_** - *AP window*
87
Surgical approach for repair of TEF
1. Side determined by the size of the aortic arch -- Left for Right vv 2. 70% of H-type fistula, occur above the 2nd vertebrae, which can be approched through a neck incision
88
Grade of Myasthenia gravis : Focal disease - ocular muscle weakness
**_Grade I_**
**_I. Focal disease - ocular muscle weakness_**
II. Generalized mild to moderate disease
III. Severe generalized weaknes
IV Life threatening weakness
89
T2 Esophageal tumor on EUS
Mnemonic T2 goes through the Second muscle layer
90
CT scan with bronchiectasis:
Lack of bronchial tapering, Bronchial dilatation wall thicekening
91
Most frequent esophageal atresia
Type C - Esophageal atresia with distal tef
92
EUS - accuracy of staging regional lymph nodes
70-80%
93
How do the horizontal fissures corelate with surface anatomy ?
level of the 4th rib and joints the oblique fissure at the level of the 5th rib laterally
94
% of BPF that heal follwoing surgery for repair of it
i.e. taken back post operatively
20% heal
provided the margins are free of:
1. infection,
2. Nerotic tissue, or
3. Tumor
95
Opportunistic lung abscess
Multiple location:
in hospital patien Bacteriology:
1. *staph*
2. *pseuromonas*
3. *proteus*
4. *E.Coli,*
5. *Klebsiella*
96
GERD:
1. most common etiology (name)
2. Physiology
GERD:
1. **_most common etiology_**: Idiopathic - responsible for 60-70% of all GERD
2. **_Physiology_** : LES is weak (\< 6mmHg)
* further acid exposure weakens the LES and causes mucosal damage
* Aspiration from reflux presents as nocturnal cough with reguritation in the mouth
* Morning horseness
97
Indication for surgery for spontaneous ptx
1. Massive air leak (i.e. no re-expansion)
2. Persistent air leak (4-7 days)
3. 2nd episode
4. Complication of ptx (Hemo, Empyema, chronic)
5. Occupational / social issues
6. Previous contralateral
7. Bilatteral
8. Lung cyst obvious on imaging
98
WHO / ATS definition of _emphysema_
_Emphysema:_ Increase beyond normal in size of *airspace* *distal* to the terminal non respiratory bronchiole that arises from the _destruction of their walls_
99
Type A emphysema
Dry emphysema - "pink puffer" - with barrel chest 1. dry cough with dyspnea 2. CXR - overinflation with flat diaphragm and decreased pulmonary vasculature 3. Path - pan acing type of destruction 4. good prognosis, major complication is a PTx
100
Type A emphysema
Dry emphysema - Pink Puffer Barrel chest cxr shows over inflation, flat diaphragm no fibrosis, and cecreased pulm vasculature PAN ACINAR distribution Be wary of Ptx
101
Mechanism that cig smoke causes emphysema
1. oxidative stress that inactivates a1-at 2. ROS release
102
**alpha-1 protease inhibitor**
* where is it synthesized?
* where does it effect?
* and how does it work?
* **alpha 1 protease inhibitor** is Synthesized in the _liver_
* It is the _major protease_ inhibitor of the l*ower respirtory tract*
* It I_nhibitis PMN leukesterase_ (p*rotecting the lung elastic fibers from hydrolysis)*
103
what type of hiatial hernia does not have a peritoneal sac
Type 1
104
Lung abscess 2/2 post pneumonic - location - bacteriology
- May occur in any segment - typically staph and strep
105
Proximal acinar bolus emphysema
(centrilobular) Associated with cigarette smoking Associated with inflamm in distal airways Effects the upper lung zones (where smoke goes) with uneven distribution
106
Leo Elosesser
Stanford Surgeon TB, treatment of empyema Friend of Frieda Kahlo
107
**Grade** of _Myasthenia Gravis:_ *Generalized mild to moderate disease* ?
_Grade II Disease_
## Footnote
I. Focal disease - ocular muscle weakness
**_II. Generalized mild to moderate disease_**
III. Severe generalized weaknes
IV Life threatening weakness
108
Patients susceptible to bronchiectasis
- selective IgA deficiency - primairy hypogammaglobulinemia - alpha - 1- at defficiency Less common - CF, congenital deficiency bronchial cartilage, Kargageners;s
