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GS8General and Thoracic Surgery Toronto Notes 2023

Drains

. NG tube

• indications: gastric decompression, analysis of gastric contents, irrigation /dilution of gastric

contents, feeding, and/or administration of medications, if necessary

2 types: NG tube (for drainage or feeding) and Dobhoff (for feeding only)

insertion should be done in stages with x-ray protocol to avoid injury

• contraindications:suspected basalskull fracture, obstruction of nasal passages,esophageal

stricture, esophageal varices

• Foley catheter with urometer

indications: to accurately monitor urine output, decompression of bladder, relieve obstruction,

rapidly expanding suprapubic mass

contraindications:suspected urethral injury and difficult insertion of catheter

Drain Sire

Measured by the unit French:

French ~ diameter (mm) x 3

Surgical Complications

• general principles in preventing complications during the postoperative p

• frequent examination of the patient (daily or more) and their wound

• removal of surgical tubes assoon as possible (e.g. Foley catheters and surgical drains)

early mobilization

monitor fluid balance and electrolytes

• analgesia - enough to adequately address pain (minimize opioids through routine use of antiinflammatories and acetaminophen)

eriod Include:

Postoperative Fever

• postoperative fever is considered a temperature higher than 38C on two consecutive postoperative

days or higher than 39C on any postoperative day

• fever does not necessarily imply infection, particularly in the first 24-48 h postoperative!)'

• fever may not be present or may be blunted if patient is receiving chemotherapy, glucocorticoids, or

other immunosuppressive agents

• timing of fever may help identify cause

• hours aftersurgery - POD #1

inflammatory reaction in response to physiological stressfrom surgery; most common cause

of fever on POD #1-3and unlikely to be infectious(unless necrotizing fasciitis or another

severe infection)

reaction to blood products received during surgery

malignant hyperthermia

• POD #1-2 (acute)

atelectasis

early necrotizing fasciitis wound infection (especiallyClostridium perfringens, (5-hemolytic

Group A Streptococcus)

-,feel for crepitus and look for “dishwater"

drainage

• aspiration pneumonitis

• other: acute adrenal insufficiency, thyroid storm, and transfusion reaction

POD #3-7: likely infectious

UT1,surgicalsite infection, IV site/line infection (commonly with Staphylococcus),septic

thrombophlebitis, and leakage at bowel anastomosis (tachycardia, hypotension,oliguria, and

abdominal pain)

POD #8+

intra-abdominal abscess, DVT/PE (can be anytime postoperative, most commonly POD #8-

10, may occur earlier but recognition is often delayed), and drug fever

other: URT’

I, infected scroma/hiloma/hcmatoma,C difficile colitis, and endocarditis

Treatment

• resuscitation then treat primary cause

Wound/Incisional Complications

WOUND CARE (see Plastic Surgery, PL8)

• can shower POD #2-3 after epithelialization of wound (or earlier depending on dressing)

• most dressings can be removed POD #2 and left uncovered if dry

• Steristrips or dermabond glue should be left on for up to 2 wk

• examine wound for wet dressing,signs of infection (fever, tachycardia, and pain)

• skin sutures and staples can be removed POD # 7-10

exceptions:incision crosses crease (groin), closed under tension, in extremities (hand) or patient

factors(elderly, corticosteroid use, or immunosuppressed) removed POD #14 or earlier if there are

signs of infection

• negative pressure dressings consist of foam and suction, promote granulation

ideal for large (grafted sites) or non-healing wounds (irradiated skin or ulcer)

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GS9 General and Thoracic Surgery Toronto Notes 2023

DRAINS

• drains may be placed selectively at the time ofsurgery to prevent fluid accumulation (blood, pus,

serum, bile,and urine)

can be used to assess quantity of third space fluid accumulation postoperativelv

• potential route of infection; to decrease risk of wound infection bring out through separate incision

(vs. operative wound) and remove as soon as possible

• types of drains

• open (e.g. Penrose), higher risk of infection

closed: 1) gravity drainage (e.g. Foley catheter); 2) underwater-seal drainage system (e.g. chest

tube);3) suction drainage (e.g.lackson-Pratt)

sump (e.g. NG tube)

• monitor drain outputs daily

• drainsshould be removed once drainage is minimal (usually <30-50 cc/24 h)

• drains do not guarantee that the patient will not form a collection of fluid

• ridged drains can erode through internal structures, and excessive suction can cause necrosis

• evidence does notsupport routine postoperative drainage of abdominal cavity

Complication laboratory/lmaging Tests

Wound Wound cultutc. CBC. Cl scan

Complication

Fever CSC. eteebotytes. glucose,

creatinine. BUN.U/A.CXR,

urine/blood sputum and

wound cultureif applicable

EKG,echo,CXR,ABG,CTangiography of the chest

AKI/Oliguria Electrolytes,glucose.

creatinine. 8UH. U ’A

with microscopy,urine

electrolytes. EKG. renal U/S

Hypotension CSC. electrolytes,glucose,

creatinine. 8UH. lactate.

ABG.ACTHstimutation

testing,cortisol level,and

coagulation studies

Electrolytes,glucose,

creatinine,8UH. AXR

Stress Ulcer CBC. upper endoscopy

Respiratory

Distress

SURGICAL SITE INFECTION

Etiology

• most surgical wounds are contaminated by bacteria often consisting of normal endogenous flora from

skin, respiratory, GU, or GI tracts(depending on surgery)

• e.g. skin flora (Gram positive cocci: S. aureus. Streptococcus spp.) and GI flora (Gram positive

microbes: Enterococcus spp., Clostridium spp.; Gram negative rods: E. coli; anaerobic species)

Risk Factors

Ileus

PreoperativeSkin Antisepticsfor Preventing

Surgical Wound Infections after CleanSurgery

Cochrane DB Syst Rev 2015;4:CD003949

Purpose:lo determine whether preoperalive skin

antisepsis prior to dean surgery prerentssurgicalsite infection (SSI) and to compare the effectiveness

of other antiseptics.

Methods:Systematic renew of RCIs part ol the

Cothiane Wounds Group Specialised Register and

the Cochrane Central Register of Coufroled Trials

(CENTRAL). Main outcome wasSSI.Secondary

outcomes included quality of bfe.mortaldy. and

resource use.

Resnlts:13RCTs ( n-2S23 patients)were included

that made11 total comparisons between skin

antiseptics.A single stu dy foun d that0.5%

chtorhendine solution in methylated spirits was

significantly superior m preventing SSIs after dean

surgery compared toalcobol-trased povidone lor) ne

solution. No ocher statistically vgiificant differences

weielound.

Conclusions:Further research is warranted to

determine tlreellectireness o< one antiseptic over the

others at preventing SSI post dean surgery.

Table 5. Classification of Surgical Wound Contamination

Classification Clean Clean-Contaminated Contaminated Dirty/Infected

Definition Established infection present

before wound is made in skin;

contamination of wound during traumalic wound with delayed

procedure (i.e.gross spillage Ireatment

of stool, inlection in biliary, Traumatic wound with delayed

respiratory,oi GU systems) treatment

Incision under

sterile conditions;

nontraumatic;no

entrance of hollow

organ

Incision under sterile

conditions;ENTRANCE of hollow conditions:MAJOR

viseus with no spillage: no

evidence of active infection:

minimal conlamrnalion with

no spillage

Incision under sterile

Roulme cholecystectomy; colon Bowel obstruction with

resection

Appendiceal abscess: traumatic

wound with contaminated

devitalized tissue;perforated

viscus

Example Hernia repair

enterotomy and spillage ol

contents;necrotic bowel

resection:fresh traumatic

wounds

Infection Rate "

2%

Wound Closure Primary closure

3-4%

Primary closure

7-10%

Often secondary closure

30- 40%

Secondary closure

•patient characteristics

• age, DM,steroids, immunosuppression,smoking, obesity, burn, malnutrition, patient with other

infections, traumatic wound, radiation, and chemotherapy

•other factors

» prolonged preoperative hospitalization,skin preparation, multiple antibiotics, reduced blood

flow, break in sterile technique,foreign bodies (drains,sutures, grafts), excessive tension,

hematoma,serorna, hypoxemia, and hypothermia

Prophylaxis

•preoperative antibiotics for most surgeries (ccfazolin ± metronidazole or if p-lactam allergy,

clindamycin ± gentamicin or vancomycin)

• within 1 h pre-incision; can re-dose at 1-2 half-lives (~q4-8 h ) in the OR

• not required for low-risk or clean surgery, e.g. elective thyroidectomy, cholecystectomy,

hemorrhoidectomy, fistulotomy, and sphincterotomy for fissure

• important to review patient factors and clinical context; immunosuppression (transplant,

Cushing’s, malignancy, etc.) would likely warrant preoperative antibiotics

some evidence suggests role in breast surgery

• important that redosing antibiotics is performed if surgery is longer than the half-life of

antibiotics

•reserve postoperative antibiotics for treatment of suspected or documented intra-abdominal infection

• normothermia (maintain patient temperature 36-38*C in the OR)

•hyperoxygenation (consider EiO:of 80% in OR)

•chlorhexidine-alcohol wash ofsurgical site

•hair removal should not be performed unless necessary;if so, clipping superior to shaving done at the

time of surgery

•consider delayed primary closure of incision for contaminated wounds

•use sterile closing tray for laparotomy

Primary vs. Delayed Primary Incision Closure

in Contaminated Abdominal Surgery:AMeta - Anilysis

JSurg Res 2019:239:22 30

Purpose: lo determine il delayed pnnaiy inns or

closure (DPC) haslower rates of surgicalsite

rrrfections(SSI|and length of stay (LOS) compared

tp primary incision closure (PC) in contaminated

abdominalsurgery.

Methods:Systematic renew and meta-analysis of

RCIs in Medline. Embase, and Cochrane data base

between 1980-2017.

Results: 12 RCIs were included andanalyzed.Using

a tried effect model. OPC showed Significantly

reduced SSI with nsk ratio of 0.64 (9S\Cl 0.51-0.79;

P> 0.0001) and reduced 10S with amean difference

oi lessthan one day compared with PC.However,

usng a random-effect model, there was no significant

rtfference in SSI or LOS.

Conclusions: DPC may be the preferential option

in contaminated abdominal incisions, however

higher quality research is required to proride a more

comprehensive evidence base.

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GS10 General and Thoracic Surgery Toronto Notes 2023

Clinical Features

• typically fever POD #5-8 (

.Streptococcus and Clostridium can present in 24 h)

• localized pain, blanchablc erythema, induration, purulent discharge, and warmth

• complications:fistula,sinus tracts,sepsis, abscess,suppressed wound healing,superinfection,

spreading infection to myonecrosis or fascial necrosis (necrotizing fasciitis), wound dehiscence,

evisceration, and hernia

Treatment

• examination of the wound:inspect, compress adjacent areas,swab drainage for C&S and Gram stain

• reopen affected part of incision, drain, pack, heal by secondary intention in most cases

• for deeper or necrotizing infections, debride necrotic and non-viable tissue

• antibiotics and demarcation of erythema only if cellulitis or immunodeficiency

WOUND HEMORRHAGE/HEMATOMA

Risk Factors

• anticoagulant therapy, coagulopathies, thrombocytopenia, DIC,severe liver disease,

myeloproliferative disorders,severe arterial HT'

N, and severe cough

• more common with transverse incisions through muscle due to vascularity of muscle

• more clinically relevant in small working spacessuch as breast or thyroid surgery (airway edema/

compression)

Clinical Features

• pain,swelling, discolouration of wound edges, and leakage

• rapidly expanding neck hematoma can compromise airway and is a surgical emergency: consider

having a suture kit at bedside in all neck surgery in the event of having to open the wound emergently

(most important treatment in this case isto protect the airway with intubation)

Treatment

• pressure dressing

• open drainage ± wound packing (large hematoma only)

• ifsignificant bleeding, may need to re-operate to find source (often do not find a discrete source)

SEROMA

• fluid collection related to serous lymph drainage

• secondary to transection of lymph vessels

• increased infection risk if drained

Treatment

• observation

• consider pressure dressing ± needle drainage (this may increase infection risk)

WOUND DEHISCENCE

• disruption of a wound that was primarily closed, causing loss of barrier of skin or fascia

Risk Factors

• local: technical failure of closure, excessive tension on the wound, increased intra-abdominal pressure

(c.g.CQPD, ileus, bowel obstruction), hematoma, infection, poor blood supply,radiation, and

transverse incision

• systemic:male,smoking, malnutrition (hypoalbuminemia, vitamin C deficiency), connective tissue

diseases, immunosuppression, pulmonary disease, ascites, poor nutrition,steroids, chemotherapy,

obesity, and other (e.g. age,sepsis, and uremia)

• DM alone is not a risk factor

Clinical Features

• typically POD #1-3 or «7-10; most common presentation sign is serosanguinous(salmon-coloured)

drainage from wound;erythema or leakage of enteric material

• + evisceration

• palpation of wound edge:should normally feel a “healing ridge” from abdominal wall closure (raised

area of tissue under incision)

Treatment

• place moist dressing over wound with binder around abdomen and transfer to OK

• may consider conservative management with debridement of fascial and/orskin margins

• evisceration (i.e.‘burst abdomen’) is a surgical emergency:take patient for operative re-closure

INCISIONAL HERNIA

• a late complication of fascial dehiscence and failure of fascial closure;G1 contents are still contained

within sack of peritoneum

• hernia can develop 6-8 wk postoperatively due to poor wound healing and/or increased stress on

abdominal wall

• symptoms aggravated by coughing orstraining

• smaller fascial defectssuch aslaparoscopic port sites have a higher risk of incarceration

• definitive treatment:surgical repair

large hernias that pose little risk of incarceration do not need to be repaired as minimal chance of

bowel obstruction

Small lilts«s.Large B itesIor Closure of

Abdominal Midlint Incisions (Stitch):A Double

Blind.Multkentre.Randomistd Controlltd Trial

Lancet 2015:336:1254-1260

Purpose:To compare the large bitessuture technique

with the small b.testechnique for lascial closure of

midline laparobonrp iochrons.

Methods: PCI conducledat 10 hospitalsln the

Netherlands.Patients undergoing elective abdominal

surgery randomiied (1:1|to small or large bite

technique.Primary outcomewas incisional hernia

occurrence.

Results:At one year follow-up, the large bites

group had a greater incidence olincisional hernia

occurrence than the small bitesgroup (21% us.13V

respectively).Rates ol adveise events did not differ

between the groups.

Conclusion:Small bitessuture technique a

superior to the large bitestechnique for preveotioo

of incisional hernia io m id line incisionsand is not

associated with a higher rate of adverse events.

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GS11 General and Thoracic Surgery Toronto Notes 2023

Urinary and Renal Complications

URINARY RETENTION

• may occur after any operation with general anesthesia or more commonly with spinal anesthesia

• more likely in older males with history of benign prostatic hyperplasia and patients on

anticholinergics but can also happen in young, healthy patients

Clinical Features

• abdominal discomfort, palpable bladder,overflow incontinence, post-void residual urine volume >100 mL

Treatment

• Foley catheter to rest bladder, then trial of voiding

• often accompanied by an a-blocker such as tamsulosin (does notstart working for 48 h)

• if postoperative retention:patients may need to be sent home with foley catheter to follow-up within

the week for trial

-of-void

OLIGURIA/ANURIA

Etiology

• prerenal (e.g. hypovolemia due to transient renal hypoperfusion) vs.renal (e.g.ATN, acute interstitial

nephritis (AIN), acute glomerulonephritis) vs. postrenal (e.g. urinary tract obstruction)

• most common postoperative cause is prerenal ± ischemic ATN

external fluid loss: hemorrhage, dehydration, and diarrhea

internal fluid loss: third-spacing due to bowel obstruction and pancreatitis

Clinical Features

• urine output <0.5 cc/kg/h (e.g. <450 cc in 75 kg patient in 12 h),increasing Cr and BUN

Treatment

• according to underlying cause; fluid deficit is treated with crystalloid ( NS or RL)

Postoperative Dyspnea

•see Respiratory Complications and CardiacComplications, GSI 2

Etiology

• respiratory: atelectasis, pneumonia/pneumonitis, pulmonary embolism ( PE), ARDS, asthma, and

pleural effusion

•cardiac: Ml, arrhythmia, and CHF

•inadequate pain control

Respiratory Complications

ATELECTASIS

• comprises 90% of postoperative pulmonary complications

Risk Factors

• COPD,smoking, obesity,and elderly persons

• upper abdominal/thoracic surgery, oversedation,significant postoperative pain, and poor inspiratory

effort

Clinical Features

• postoperative atelectasis may be asymptomatic or present as low-grade fever on POD #1, tachycardia,

crackles, decreased breath sounds, bronchial breathing, and tachypnea

Treatment

• preoperative prophylaxis

smoking cessation (best if >8 wk preoperative)

• postoperative prophylaxis

incentive spirometry,deep breathing exercise,chest physiotherapy, and intermittent positivepressure breathing

• short-acting neuromuscular blocking agents

minimize use of respiratory depressive drugs, and ensure adequate pain control, and early

ambulation r n

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PNEUMONIA/PNEUMONITIS

• may be secondary to aspiration of gastric contents during anesthetic induction or extubation causing

a chemical pneumonitis

Risk Factors

• aspiration:general anesthetic, decreased LOG,GERD, full stomach, bowel/gastric outlet obstruction +

non-functioning NG tube, pregnancy, and seizure disorder

• non-aspiration: atelectasis, immobility, and pre-existing respiratory disease

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GS12 General and Thoracic Surgery Toronto Notes 2023

Clinical Features

• productive cough and fever

• tachycardia, cyanosis, respiratory failure, and decreased LOG

• CXR: pulmonary infiltrate

Treatment

• prophylaxis:see atelectasis prophylaxis, preoperative NPO/NG tube, and rapid sequence anesthetic

induction

• immediate removal of debris and fiuid from airway

• consider endotracheal intubation and flexible bronchoscopic aspiration

• empiric IV antibiotics to cover oral nosocomial aerobes and anaerobes (e.g. piperacillin- tazobactam,

cefepime + metronidazole)

PULMONARY EMBOLUS

Clinical Features

• unilateral leg swelling and pain (DVT as a sourceof PH),sudden onset dyspnea, pleuritic chest pain,

tachycardia, and fever

• most commonly POD #8-10, but can occur anytime postoperatively, even after discharge

• diagnosis made by chest CT scan usually

Treatment

• initial treatment: IV heparin or subcutaneous LMWH, bridging to therapeutic anticoagulation

is required for a minimum of 3 mo (usually 6 mo);for patients with cancer, or other risk factors

for hypercoagulability, the duration of anticoagulation may be longer;severe cases may require

endovascular thrombectomy and thrombolysis

• Greenfield (1VC) filter if contraindications to anticoagulation helps prevent worsening of PH

• prophylaxis:subcutaneous heparin (5000 units BID) or LMWH, compression stockings (TEDTTM

Hose), and sequential compression devices

PULMONARY EDEMA

Etiology

• cardiogenic vs. noncardiogenic

• circulatory overload: excess fluid overload, left ventricular (LV ) failure, shift of fluid from peripheral to

pulmonary vascular bed, negative airway pressure, and alveolar injury due to toxins (e.g. ARDS)

• more common with pre-existing cardiac disease

• negative pressure pulmonary edema due to inspiratory efforts against a closed glottis upon awakening

from general anesthesia

Clinical Features

• shortness of breath, crackles at lung bases, and CXR abnormal

Treatment (LMNOP)

• Lasix* (furosemide)

• Morphine (decreases symptoms of dyspnea, venodilator, and afterload reduction)

• Nitrates (venodilator)

• Oxygen + non-invasive ventilation

• Position (sit patient up)

New onset 'asthma" and wheezing in

the elderly Is cardiogenic until proven

otherwise

RESPIRATORY FAILURE

Clinical Features

• dyspnea, cyanosis,and evidence of obstructive lung disease

• earliest manifestations- tachypnea and hypoxemia (RR >25, PO’ <60)

• pulmonary edema and unexplained decrease in SaO’

Treatment

• ABCs, O2, ± positive pressure ventilation, and intubation

• bronchodilators and diuretics to treat CHI'

• adequate blood pressure to maintain pulmonary perfusion

• if these measures fail to keep Pa02 >60, consider ARDS (see Respirology. R26)

Cardiac Complications

•abnormal HCGs common in postoperative period (compare to preoperative HCG)

•common arrhythmias: supraventricular tachycardia, atrial fibrillation (secondary to fluid overload,

PH, and Ml)

MYOCARDIAL INFARCTION

•see Cardiology and Cardiac Surgery, C9

•surgery increases risk of Ml

•incidence

0.5% in previously asymptomatic men ages >50

40-fold increase in men ages >50 with previous Ml

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GS13 General andUtoracic Surgery Toronto Notes 2023

Risk Factors

• preoperative H IN,CHI

• previous Ml (highest risk <6 mo, but risk never returns to baseline)

• increased age

• intraoperative hypotension

• operations >3 h

• angina

Clinical Features

• majority of cases on day of operation or POD*3-4 (shifting of third space fluid back into intravascular

compartment)

• often silent without chest pain, may only present with new-onset CHF (dyspnea), arrhythmias, and

hypotension

Intra-Abdominal Abscess

Definition

• collection of pus walled-off from rest of peritoneal cavity by inflammatory adhesions and viscera

Etiology

• usually polymicrobial:Gram-negative bacteria, and anaerobes

• consider Gram-positivesif coexisting cellulitis

Risk Factors

• emergency surgery and contaminated OR

• GI surgery with anastomotic leak

• poor healing risk factors (DM, poor nutrition, etc.)

• may occur POD «3 after laparotomy when third space fluid redistribution occurs

Clinical Features

• manifests at least 5-7 d aftersurgery. Cannot manifest earlier as it takes time to form collection

• persistentspiking fever, dull pain, and weight loss

• peritoneal signs if abscess perforation and secondary peritonitis

• leukocytosis or leukopenia (immunocompromised and elderly)

• coexisting effusion (pleural effusion with subphrenic abscess)

• mass is often difficult to palpate

• common sites:pelvis, Morrisons pouch (space between kidney and liver),subphrenic, paracolic

gutters,lesser sac, peri-appendiceal,post-surgical anastomosis,diverticular, and psoas

Investigations

• CBC, blood cultures x2

• CT ± IV and water-soluble contrast

• DUE (pelvic abscess)

Treatment

• drain placement by interventional radiology (preferred), laparoscopy, and open drainage

• subsequent antibiotic coverage; ceftriaxone metronidazole or piperacillin-tazobactani (Pip-Tazo)

Differential Diagnosis of Upper 61

Symptoms

GI Causes Non Cl Causes

Cholelithiasis

Diverticulitis

Peptic ulcer

Achalasia

Pancreatitis

Ml

Angina Paralytic Pericarditis Ileus

• see Paralytic Ileus,GS3I

GERD

Gastritis Delirium Hiatus hernia

• see Psychiatry, PS23 and Neurology, N21

Horner has a MAPof the Coast

A Pancoast tumour compresses the

cervical sympathetic plexus causing

Horner's syndrome:

Miosis

Anhydrosis

Ptosis

Thoracic and Foregut Surgery

Approach to the Solitary Pulmonary Nodule

•see Medical Imaging. MIS

Definition

•lesion up to 3cm, which may or may not be calcified and is surrounded by normal lung

•can be benign or malignant

r -i

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Differential of an Anterior

Compartment Mass

4 Ts

Thymoma +

Thyroid enlargement (goitre)

Teratoma

Tumours (lymphoma,parathyroid,

esophageal, angiomatous)

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GSM General and Thoracic Surgery Toronto Notes 2023

Table 6. Differential Diagnosis for Benign vs. Malignant Solitary Nodule

Benign (70%) Malignant (30%)

Bronchogenic carcinoma

Adenocarcinoma

Infectious granuloma (histoplasmosis, coccidiomycosis,16.

atypical mycobacteria) •most common

Other infections (bacterial abscess. POP. aspergilloma)

Benign neoplasms( hamartoma, lipoma, fibroma)

Vascular (AVmalformation, pulmonary varix)

Developmental (bronchogeniccyst)

Inflammatory (granulomatosis with polyangiitis, rheumatoid

nodule,sarcoidosis, amyloidosis)

Other (infarct, pseudotumour, rounded atelectasis, lymph nodes,

amyloidoma)

Metastatic lesions

Breast

Head and neck

Melanoma

Colon

Kidney

Sarcoma

Gerin cell tumours

SCC

Large cell carcinoma

Small cell carcinoma

Small cell lung cancer

Investigations

• CXR:always compare with previous CXR

• CT and contrast-enhanced CT of thorax

• biopsy (bronchoscopic or percutaneous) or excision (thoracoscopy):if clinical and radiographic

features do not help distinguish between benign or malignant lesion

if at risk forlung cancer,biopsy may be performed regardless of radiographic features

if a biopsy is non-diagnostic, whether to observe, re-biopsy, or resect will depend on the level of

suspicion

• watchful waiting: repeat CT scan at 3,6, 12 mo depending on nodule characteristics and patient risk

• PET scan can narrow the differential diagnosis

Table 7. CT Characteristics of Benign vs. Malignant Solitary Nodule

Parameters Benign Malignant

Sire Module ("3 cm)

Smooth or lobulaled

Calcified pattern:diffuse, central,laminated,

'‘popcorn"

pattern if hamartoma, usually no cavitation:if cavitating.

wall issmooth and thin, no other lung pathology

Doubles in <20 or >400 d

Mass (»3cm)

Irregular or spiculated

Usually not calcified:if calcified, pattern is eccentric,

stippled,no satellite lesions, cavitation with thick wall,may

have pleuralelfusions. lymphadcnopalhy

Doubles between 20 and 400 d

Borders

Features

Doubling Time

Table 8. Evaluation of a Solitary Pulmonary Nodule

SOLID NODULES

Size <6 mm («100 mm'

) Size 6-8 mm (100-250 mm1

) Size >8 mm (>250 mm1 Nodule Type )

Single

Low-Risk No routine follow-up Cl at 6-12 mo.then consider CT at

18-24 mo

Cl at 6-12 mo. then at 18 24 mo

Consider CT a 3mo.PET/CT or tissue

sampling

Consider CT a 3 mo. PET/CT or tissue

sampling

High-Risk Optional CT at 12 mo

Multiple

Low-Risk CT at 3- 6 mo. then consider CT at

18- 24 mo

CT at 3-6 mo.then at 18-24 mo

CT at 3-6 mo.then consider CT at

18-24 mo

CT at 3-6 mo then at18-24 mo

No routine follow-up

High-Risk Optional CT at12 mo

SUBSOLID NODULES

Size < 6 mm («100 mm1

) Size >6 mm (>100 mm1 Nodule Type )

Single

Ground Glass

Part Solid

CT at 6-12 mo to confirm persistence then CT every 2 yr until 5 yr

Cl at 3-6 mo to confirm persistence

If unchanged and solid component remains <6 mm.annual CT should be

performed for 5yr

CT at 3-6 mo

Subsequent managementbased on the most suspicious nodule(s)

No routine follow- up

No routine follow- up

Multiple CT at 3- 6 mo. II stable consider CT at

2 and 4 yr

Adapted from:MacMahon H.NaidichDP.Goo JM.et al.Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images. The

Fleischner Society 2017.Radiology Journal. doi:10.1148/radiol.2017161659.Feb 23 2017.

Lung Cancer

Classification

• lung tumours can be classified as:

primary or secondary

• benign or malignant

endobronchial or parenchymal

• bronchogenic carcinoma (epithelial lung tumours) are the most common type of primary lung tumour

(other types make up less than 1%)

small cell lung cancer (SCLC): 10-15%

L J

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GS15 General and Thoracic Surgery Toronto Notes 2023

• non-small

-cell lung cancer (NSCLC):85-90%

SCC:arise from the proximal respiratory epithelium

adenocarcinoma: incidence is increasing; most common subtype in nonsmokers

- mucinous adenocarcinoma: grows along the alveolar wall in the periphery; may

arise at sites of previous lung scarring

large cell carcinoma

• benign epithelial lung tumours can be classified as papillomas or adenomas

Table 9. Characteristics of Lung Cancer

Cell Type Percentage of Correlation Location Histology

Lung Cancer with Smoking

Metastasis 5 Yr Survival Rates Canadian Task Force on Preventive

Health (2016)

Screening with low-dose CT

recommended for high-risk patients

10-15% Strong Central Oat cell,

neuroendocrine

Disseminated at

entation

10-13% limitedstage.

1-2% eUensive stage

SCLC

presi

Origin in

endobronchial cells

3nl'

,:

- 55-74 yr

• >30 pack-yr smoking Hx

• Current smoker or quit within last Adenocarcinoma M:35%

F:40%

70% limitedstage.7%

extensive stage

Moderate Peripheral Papillary,lepidic. Early,distant

acinar,mucinous,

solid

Central Keratin,

intercellular

bridges

Peripheral Anaplastic,

undifferentiated

15 yr

- Annual screening low-dose CT up to

3yr ONLY in centres with expertise

in diagnosis and treatment of lung

cancer

SCC 30% Strong Local invasion and 47%limited stage.6%

distant spread,may extensive stage

cavitate

Early,distant 53%limitedstage.5%

extensive stage

Large Cell

Carcinoma

10-15% Strong

US Mortality Files. National Center tor Health Statistics.CDC

Risk Factors

• cigarette smoking: the relative risk of developing lung cancer is 10-30 times higher for smokers than

for nonsmokers

• risk of lung cancer increases with number of cigarettessmoked per day (linear) and duration of

smoking (exponential)

• other risk factors: cigarsmoking, pipe smoking,second-hand smoke, asbestos withoutsmoking

(relative risk is 5), asbestos with smoking (relative risk is 92), metals (e.g.chromium, arsenic, nickel),

radon gas, ionizing radiation, and genetics

Clinical Features

• may be due to primary lesion, metastasis, or paraneoplastic syndrome

• primary lesion

cough (75%); beware of chronic cough that changes in character

dyspnea (60%)

chest pain (45%)

hemoptysis(35%)

other pain (25%)

clubbing (21%)

constitutional symptoms: anorexia, weight loss,fever, and fatigue

• metastasis

• lung, hilum, mediastinum, pleura:pleural effusion, atelectasis, wheezing, post-obstructive

pneumonia

pericardium: pericardial effusion, pericardial tamponade

esophageal compression: dysphagia

• phrenic nerve: paralyzed diaphragm, dyspnea

• recurrent laryngeal nerve: hoarseness

superior vena cava syndrome

obstruction of SVC causing neck and facialswelling

other symptoms:dyspnea, cough, hoarseness, tongue swelling, epistaxis, and hemoptysis

physical findings:dilated neck veins, increased number of collateral veins covering the

anterior chest wall, cyanosis, edema of the face, arms,and chest, Pemberton'

ssign (facial

flushing, cyanosis, and distension of neck veins upon raising both arms above head)

milder symptoms if obstruction is above the azygos vein

• lung apex ( Pancoast tumour):Horner’ssyndrome, brachial plexus palsy (most commonly C8and

T1 nerve roots)

• rib and vertebrae: erosion, pain

• distant metastasis to brain, bone,liver, and adrenals

• paraneoplastic syndromes

• most often associated with SCLC

Malignant

©

lung tumours are the most

common cause of cancer mortality in

both men and women worldwide

Endobronchial Ultrasound (EBUS)

• Allows visualization of peri-bronchial

structures and lung lesions

• Allowsfor guided biopsies of lymph

nodes and tumours

• Used for diagnosis and staging

“»

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GSI6 General and Thoracic Surgery Toronio Notes 2023

Table 10. Paraneoplastic Syndromes

System Clinical Features Associated Malignancy

2/3 of primary lung cancer is foundin

the upper lung:2/3 of metastases occur

in the lower lung (hematogenous spread

secondary to increased blood flow to the

base of the lung)

Skeletal Clubbing, hypertrophic pulmonary osteoarthropathy (HPOA)

Acanthosis nigricans

Oermatomyosltis

Hypercalcemia (osteolysis or PIHrP)

Hypophosphatemia

Hypoglycemia

Cushing'

ssyndrome (ACIH)

Carcinoid syndrome

SIADH

lambert-Eatonsyndrome

Polymyositis

Subacute cerebellar degeneration

Spinocerebellar degeneration

Peripheral neuropathy

Nonbacterial endocarditis

trousseau'

ssyndrome (migratory thrombophlebitis)

Non -small cell lung cancer (NSCLC)

Dermatologic Lung cancer

Endocrine SCC

SCC

Saicoma

Small cell lung cancer (SCLC)

Bronchial carcinoid

SCLC

Heuromyopathic SCLC

Vascular/Hematologic Lung cancer

NSCLC

QIC

Renal Nephrotic syndiome Lung carcinoma

Investigations

• initial diagnosis

imaging: CXR, CT chest + abdomen, PET scan

biopsy: bronchoscopy, EBUS,CT-guided percutaneous needle biopsy

• staging workup

TNM staging system:T- primary tumour (size); N -regional lymph nodes;M - distant

metastasis

blood work: electrolytes, Ll'

Ts, calcium, ALP

• imaging: CXR, CT thorax and abdomen, PET'

scan, bone scan (

-in confirmed stage I cancer),

neuroimaging (MRI Brain)

• invasive: bronchoscopy (EBUS), mediastinoscopy, VATS

Prevention

• Smoking cessation

• Avoidance of exposures

• Early detection

Terminology

• "Nodule" <3 cm

• "Mass" >3 cm

Table 11. SCLC vs. NSCLC

Stage Definition Treatment Median Survival Mutations in endothelial growth factor

receptor are more common in nonsmoking patients with adenocarcinoma Limited stage Confined lo single radiation port (one Radiation t chemotherapy

hemithorax and regional lymph nodes) i prophylactic to brain

Extensive stage Extension beyond a single radiation port Chemotherapy

SCLC 1-2 yr (12 vvk without

treatment)

6 mo (5 wk without

treatment)

Stage TNM Treatment 5 Yr Survival (%)•

Corona Radiata Sign on Chest CT

• Fine striations that extend linearly

from a nodule in a spicutated fashion

• Highly associated with malignancy

HSCLC 0 TisNOMO

TtaNOMO

TlbNOMO

TkNOMO

T2aN0M 0

T2bH0M0

1st line iscomplete surgical resection

(VAIS or open thoracotomy) with possible 90-92

83-85

77-80

68-73

60-65

IA1

IA2 postoperative adjuvant chemotherapy

with stage IB and stage It:radiotherapy

for non-surgical candidates

IA3

IB

IIA

IIB T3N0M 0 or T1H1M 0 or T 2N1M 0 53 56

Carcinoids

• Early onset (40-60 yr)

• Most are central and can produce

symptoms and signs of bronchial

obstruction

• Hemoptysis is present in-50% of

cases

• Assuming adequate pulmonary

function,surgicalresection (i.e.

segmentedomy. wedge resections,

and lobectomy) is the preferred

treatment approach

T 4N0M0 or T 4H1M0 or I3M1N 0 or T1N 2M0 Combined modality appioach (chemo 36- 41

or T 2N 2M0

IMA

t radiation, and sometimessurgical

resection)

IIIB T3N 2 M0 or I4M2 N0 or T1N3M 0 or I 2 N 3M0 24 26

IIC f 3N 3M0 or I4N 3M0

T1-4N 0-3M1a-1b

1213

IVA Systemic therapy or molecularly targeted 10

therapy orsymptom-based palliative

management (radiation):isolated

metastasis may be resected

IVB T1-4H 0 -3M1C 0

'Depends on clinical vs. pathologic stage Reler to AJCC Cancel Staging Manual.8th ed. 2017 lor complete TNM classification

Treatment

• options include surgery, radiotherapy, ablation, chemotherapy, and palliative care lor end-stage

disease

• surgery not usually performed for SCLC since it is generally non-curable

• contraindications for surgery

spread to contralateral mediastinal lymph nodes or distant sites

patients with potentially resectable disease must undergo mediastinal node sampling since

CT thorax is not accurate in 20-40% of cases

poor pulmonary status (e.g. unable to tolerate resection of lung)

postoperative estimated l-

'HVi and DLCO must be at least 40% of predicted to tolerate surgery

• chemotherapy (used in combination with other treatments)

• common agents: cisplatin-vinorelbine (standard of care), etoposide, ifosfamide, vincristine,

anthracyclines, paclitaxel. irinotecan, gefitinib (an endothelial growth factor receptor inhibitor)

• pembrolizumab, a HD-1 monoclonal antibody is used in those with tumour PD-l.l levels >50%;

for those with PD-L1 levels <50%, combination of doublet chemotherapy and pembrolizumab is

initiated

r -l

L J

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GS17 General and Thoracic Surgery Toronto Notes 2023

targeted therapiessuch as EGFR tyrosine kinase inhibitors and ALK tyrosine kinase inhibitors

are used if tumourtests positive for these mutations

complications

acute:tumourlysissyndrome,infection,bleeding,myelosuppression, hemorrhagic cystitis

(qxlophosphamide),cardiotoxicitv (doxorubicin),renal toxicity (dsplatin), peripheral

neuropathy (vincristine)

chronic:neurologicdamage,leukemia,additional primary neoplasms

Pleura, Lung, and Mediastinum

• see Respirologv.R23

Hamartomas

• 10% of benign lung lesions

. Composed of tissues normally

present in lung (fat epithelium,

fibrous tissue, and cartilage), but

they exhibit disorganized growth

• Peak incidence is age 60. more

common in men

• Usually peripheral and clinically silent

• CXR shows clustered "popcorn"

pattern of calcification

(pathognomonic for hamartoma)

• Peripheral small hamartomas

can generally be observed with

occasional follow-up to monitor

growth:symptomatic endobronchial

hamartomas are removed via rigid

transbronchial resection

Complicated Parapneumonic Effusion

Definition

• persistent bacteria in the pleural space but fluid is non-purulent

• neutrophils, pleural fluid acidosis ( pH<7.20),low glucose (<40mg/dL)

• often no bacteria grown since rapidly cleared from pleural space

Clinical Features

• fever, pleuritic chest pain,dyspnea, and sputum production

Treatment

• antibiotics depending on Gram stain and culture

• chest tube drainage

Empyema

Definition

• bacteria in pleural space or an effusion with organismsseen on a Gram stain or culture (e.g. pleural

fluid is grossly purulent in advanced stage empyema)

• positive culture is not required for diagnosis

Etiology

• contiguousspread from lung infection (most commonly anaerobes) or infection through chest wall

(e.g.trauma,surgery)

Clinical Features

• fever, pleuritic chest pain,dyspnea,and sputum production

Investigations

• CT chest

• thoracentesis

PMNs (lymphocytesin TB) ± visible organisms on Gram stain

Treatment

• antibiotic therapy for at least -1-6 wk (rarely effective alone)

• complete pleural drainage with chest tube

• if loculated, more difficult to drain - may require surgical drainage with VATS, or fibrinolysis

(surgical or tPA/DNAse) to allow lung re-expansion (decortication)

Pneumothorax

Definition

• presence of air in the pleural space

• can be classified as:

primary orsecondary

open or closed

simple or tension or occult (only visible on CTscan)

Pathophysiology

• entry of air into pleuralspace raisesintrapleural pressure causing partial or complete lung deflation

Etiology

• traumatic:penetrating or non-penetrating chest injuries

• iatrogenic:central venous catheter,thoracentesis,mechanical ventilation with barotrauma,surgery +

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GS18 General and Thoracic Surgery Toronto Notes 2023

•spontaneous: no history of trauma or other underlying cause

• primary (no underlying lung disease)

spontaneous rupture of apical subplcural bleb (pockets of air) of lung into pleural space

smoker, male, family history, Marfan'

ssyndrome

secondary (underlying lung disease)

rupture of subpleural bleb in the pleural space which can migrate along bronchioalveolar

bronchoalveolarsheath to the mediastinum then to the intrapleuralspace

necrosis of lung tissue adjacent to pleuralsurface

pneumonia, abscess, PCP,lung cancer,COPD,CP,TB,lymphangioleiomyomatosis(LAM),

pulmonary Langerhans cell histiocytosis (PLCH),lung metastasis (e.g.sarcoma)

Clinical Features

•can be asymptomatic

•acute-onset pleuritic chest pain, dyspnea

•tachypnea, tachycardia

•tracheal deviation (contralateral deviation in tension pneumothorax)

•shock (in tension pneumothorax)

•ipsilateral diminished chest expansion

•decreased tactile/vocal fremitus

•hyperresonance

•ipsilateral diminished breath sounds

Investigations

•CXR

small:separation of visceral and parietal pleura seen as fine crescentic line parallel to chest wall

at apex

large:decreased density and decreased volume oflung on side of pneumothorax

see Medical Imaging. M14 and M19

Treatment

•primary spontaneous pneumothorax

• stable,small (<3 cm), minimal symptoms:observation + ().

’

• symptomatic or large (>3 cm): aspiration or chest tube

• unstable/tension pneumothorax: needle decompression then chest tube, VATS bullectomy, and

pleurodesis if unsuccessful (25-50%)

•secondary spontaneous pneumothorax

• stable,small (<3 cm),minimal symptoms:observation + 02

symptomatic,large, or unstable: chest tube and VATS pleurodesis with or without bullectomy if

unsuccessful

Tube thoracostomy can be completed

under U/S guidance

Orientation

.fit UIM

Tube Thoracostomy

Indications

• to drain abnormal air or fluid collections in the pleural space

hemothorax, pleural effusion, chylothorax, and empyema

pneumothorax, if:

large or progressive

patient is on mechanical ventilation

bronchopleural fistula

« tension pneumothorax

• to treat symptomatic and/or recurrent pleural effusion

• see Respirology. R23

for long-term drainage of malignant effusions use: 1.Tunneled pleural catheter; 2. Pleural

drainage and Talc pleurodesis

via facilitation of pleurodesis- obliteration of the pleural space by instilling talc or betadine (less

common) to cause fusion of parietal and visceral pleura

Dissection from

inferior ribto

superior rib

Intercostal vessels

and nerves - -

Kelly clamp

riser: or

Complications

• overall complications are rare (1-3%)

• malposition (most common complication), especially by inexperienced operators

tubes may dissect along the external chest wall, or may be placed below the diaphragm

• bleeding (anticoagulation is a relative contraindication)

• local infection, empyema

• perforation of lung parenchyma or vasculature

• risk of re-expansion pulmonary edema when large volumes of air or fluid are drawn off quickly ( >I.O1.5 L)

at superior

pole ol lung

1J

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Figure 6.Tube thoracostomy

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GS19 General and Thoracic Surgery Toronto Notes 2023

Lung Transplantation

Conditions Leading to Transplantation

• obstructive: chronic acquired lung disease (e.g.COPD),CF,and emphysema due to a-l antitrypsin

deficiency

• restrictive interstitial lung disease: IPF, hypersensitivity pneumonitis

• vascular:idiopathic pulmonary arterial HT'

N (IPAH),secondary pulmonary HTN, and Eisenmenger’

s

syndrome

• other:sarcoidosis, lymphangioleiomyomatosis, and pulmonary Langerhans cell histiocytosis

Clinical Indications

• transplantation should be considered for patients with advanced lung disease refractory to maximal

medical orsurgical therapy

• patients who are symptomatic during activities of daily living and have risk of death >50% over the

next 2 yr

Criteria for Transplantation

• lung allocation score based on:1) post-transplantsurvival measure, and 2) waiting list urgency

measure

• transplant benefit = post-transplant survival (days) - waitlist survival (days)

Absolute Contraindications

• uncontrolled or untreatable pulmonary or extrapulmonary infection

• active TBinfection

• malignancy in the last 2 yr

• dysfunction of vital organs including glomerular filtration rate of <40 mL/min/1.73 m 3,stroke

within 30 d, acute liver failure or cirrhosis, acute coronary syndrome within 30 d or heart disease not

amenable to revascularization, and untreatable hematologic disorders

• active cigarette smoking

• BM1 S35 kg/m 3

• unresolved psychosocial problems or non-adherence to medical therapy

• smoking

• absence ofsocial support system

Relative Contraindications

• ages >70 years and low physiologic reserve

• BM1 30-34.9 kg/m 1

• limited functionalstatusincluding severe malnutrition or osteoporosis

• HIV infection, HBV infection

• alcohol (required to stay within healthy drinking guidelines)

Postoperative Complications

• primary graft dysfunction

• airway anastomotic complications (bronchial necrosis and dehiscence, tracheobronchomalacia,

stenosis)

• chronic lung allograft dysfunction (bronchiolitis obliteranssyndrome and restrictive allograft

syndrome)

• infectious complications (bacterial, fungal,CMV, community-acquired respiratory viruses, and

mycobacteria)

• malignancy (non-melanoma skin cancer, post-transplant lymphoproliferative disorders, colon, breast,

Kaposi’

ssarcoma, and bladder)

Prognosis

• median survival for all adult recipients: 6.5 yr;bilateral transplant survival higher than single (7.6 vs.

4.7 yr, respectively)

. 1 yr survival:COPD > IFF > IPAH

• 10 yr survival:CE, a-l antitrypsin deficiency > IPAH > COPD,IPF

Chronic Obstructive Pulmonary Disease

• see Kespirologv. R9

r t

Treatment

• indicationsforsurgical management

dyspnea despite maximal medical therapy and pulmonary rehabilitation

GT showing hyperinflation and heterogeneously distributed emphysema predominant in the

upper lung zone

may be used as a bridging procedure to lung transplantation

LJ

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GS20 General and Thoracic Surgery Toronto Notes 2023

•contraindications

ages >75, cigarette smoking within the prior 6 mo, higher risk ofsurgical mortality (e.g.severe

CAD or HE)

• homogeneously distributed emphysematous changes without areas of preserved lung tissue

severe cachexia or obesity, chest wall deformity, or pulmonary HTN (PA systolic pressure >45

mmHg)

diffusing capacity of lung for carbon monoxide <20% of predicted, PaCOt >60 mmHg, Pa02 <45

mmHg

•surgical procedures

• lung volume reduction surgery: wedge excision of emphysematous tissue

» bilateral or unilateral, thoracotomy or VAT'

S (preferred)

Complications of Treatment

•arrhythmias, pneumonia (may require reintubation and mechanical ventilation), prolonged air leak

from chest tube

Prognosis

•worse early mortality but belter exercise capacity and quality of life with LVRS

Mediastinal Masses

Definition

• mediastinum: bound by the thoracic inlet, diaphragm,sternum, vertebral bodies, and the pleura

• can be broken down into 3compartments: anterior, middle, and posterior

Etiology and Pathophysiology

• diagnosis is aided by location and patient'

s age

• anterior compartment: more likely to be malignant

• “Pour Ts” (see sidebar),lymphadenopathy, lipoma, pericardial cyst, goitre, and ascending aortic

aneurysm thymic tumours/cysts

• middle compartment

pericardial cyst, bronchogenic cyst/tumour,lymphadenopathy, aortic aneurysm

• posterior compartment

neurogenic tumours, meningocele, enteric cysts, lymphadenopathy, diaphragmatic hernias,

esophageal tumours, aortic aneurysm

Differential of an Anterior

Compartment Mass

4Ts

Thymoma

Thyroid enlargement (goitre)

Teratoma

Tumours(lymphoma, parathyroid,

esophageal, angiomatous)

Mediastinal Components

Anterior sternum to pericardium and

great vessels.Includes:thymus, extrapericardial aorta and branches,great

veins,lymphatic tissues

Middle: pericardium (anteriorly),

posterior pericardial reflection,

diaphragm,thoracic inlet Includes:

heart irrtrapericardial great vessels,

trachea

Posterior:posterior pericardial

reflection,posterior border of vertebral

bodies,first rib to the diaphragm.

Includes:esophagus,vagus nerve,

thoracic duct sympathetic chain,

azygous venoussystem

Clinical Features

• 50% asymptomatic (mainly benign); when symptomatic,50% are malignant

• chest pain, cough, dyspnea, recurrent respiratory infections

• hoarseness, dysphagia,Horner’ssyndrome (see sidebar),facial/upper extremity edema (SVC

compression)

• paraneoplastic syndromes (e.g.myasthenia gravis(thymomas))

Investigations

• CXR (compare to previous)

• CT with contrast (anatomic location,density, relation to mediastinal vascularstructures)

• MRI:specifically indicated in the evaluation of neurogenic tumours

• Echo: best for assessment ofstructuresin close proximity to the heart and pericardium

• radionuclide scanning: 1311 (for thyroid), gallium (for lymphoma), PET/CT

• biochemicalstudies: thyroid function,serum calcium, phosphate, PTH, APP, p-hCG, LDH

• biopsy (mediastinoscopy, bronchoscopy, and EBUS, percutaneous needle aspiration)

Management

• excision -symptomatic benign mass that is enlarging or a mass with concerns for malignancy

• resect bronchogenic cysts and localized neurogenic tumours via VAT'

S or open surgery

• diagnostic biopsy rather than major operation if mass is likely to be a lymphoma, germ cell tumour, or

unresectable invasive malignancy

• no biopsy if AEP, p-hCG, LDH elevated - pathognomonic for germ cell tumour

Masaoka Staging System

Stage I:completely encapsulated

Stage II: invasion beyond capsule

Stage III:into another organ

Stage IVa:pleural/pericardial mets

Stage IVb: hematogenous/lymphatic

IMtl

Thymoma

Definition

• rare neoplasms in thymus, located in anterior mediastinum

Epidemiology

• patients between 40 and 60 yr

. M*F

• no known risk factors,strong association with myasthenia gravis and other paraneoplastic syndromes +

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GS21 General and Thoracic Surgery Toronto Notes 2023

Clinical Features

• frequently asymptomatic: incidental finding on imaging

• symptoms related to tumour size and location (chest pain, SOB, cough, and phrenic nerve palsy)

• DDx includes intrathoracic goitre, lymphoma, and other anterior mediastinal tumours(see

Mediastinal Masses,GS20)

Investigations

• CT chest (and/or MR!): assess resectability

• germ cell tumour markers (

P-hCG,a fetoprotein),thyroid function, acetylcholinesterase antibodies

(to rule out myasthenia gravis), and PR'

s

• Masaoka staging system widely used

Treatment

• for patients with resectable disease

surgical resection of the thymoma and the thymus via median sternotomy or VATS depending on

the size

± postoperative radiation based on Masaoka staging

radiation considered forstage 11/111 disease

• for potentially unresectable disease (i.e.invasion into heart and great vessels) or non-surgical patients

definitive or palliative chemo and radiation therapy

• re-evaluation if debulking procedure feasible in situations where preoperative chemo- and radiation

therapy is offered

• common chemotherapy regimens include: I ) cyclophosphamide, doxorubicin, and dsplatin, or 2)

cisplatin and etoposide

Prognosis

• depends upon stage of disease and resectability

• generally slow-growing tumours and have good prognosis

Esophageal Carcinoma

Epidemiology

• M:E=3:1

• onset 50-60 yr

. upper (20-33%), middle (33%), and lower (33-50%)

• main types

• most common worldwide:SCC in upper 2/3of esophagus

most common in Western countries:adenocarcinoma in lower 1/3of esophagus

Risk Factors

. SCC

underlying esophageal disease such asstrictures,diverticula, and achalasia

smoking, alcohol, and hot liquids

more common in Black and Asian populations

• adenocarcinoma

» Barrett’s esophagus (most important),smoking,obesity (increased reilux), and GERL)

• more common in White populations

Clinical Features

• progressive dysphagia (mechanical):first solids then liquids, then saliva

• odynophagia then constant pain

• constitutional symptoms

• regurgitation and aspiration (aspiration pneumonia)

• hematemesis and anemia

• direct, hematogenous, or lymphatic spread

• trachea (coughing), recurrent laryngeal nerves (hoarseness, vocal paralysis), aortic,liver, lung,

bone, celiac, and mediastinal nodes

Investigations and Staging

• barium swallow:shows narrowing -suggestive but not diagnostic

• endoscopic biopsy to assess location, resectability, and confirm diagnosis

• both SCC and adenocarcinoma use TNM staging system but have separate stage groupings according

to histology'

. endoscopic U/S (EUS)

visualize local disease

regional nodal involvement (number of nodes may be more important than location)

• bronchoscopy and laryngoscopy

• rule out airway invasion in tumours of the upper and middle esophagus

• full metastatic workup (CXR, bone scan,CT head,CT chest/abdomen /pelvlx, and Ll’Ts, etc.)

• PET scan more sensitive than CT in detecting metastatic disease

r T

LJ

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