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GS16 General Surgery and Thoracic Surgery Thoracic Surgery Toronto Notes 2019
Tube thoracostomy can be completed under U/S guidance by an interventional radiologist or surgeon
• ifearlystage(non-transmuralandwithoutevidenceofnodaldisease)
■ endoscopic mucosal resection can be considered for early mucosal cancer or high grade dysplasia ■ esophagectomy (transthoracic or trans-hiatal approach) and lymphadenectomy
◆ anastomosis in chest or neck
◆ stomach most often used for reconstruction; may also use colon
■ neoadjuvant chemotherapy and radiation are controversial
■ adjuvant chemotherapy ± radiation usually recommended for post-operative node-positive disease
Prognosis
• TNMstatus-usuallypoorbecausepresentationisusuallyatadvancedstage
OTHER DISORDERS
• esophagealmotordisorders(seeGastroenterology,G8) • esophagealvarices(seeGastroenterology,G26)
• Mallory-Weisstear(seeGastroenterology,G26)
Thymoma
Epidemiology
• rareneoplasmsinthymusincludingboththymomaandthymiccarcinoma • patientsbetween40and60yr
• M=F
Risk Factors
• noknownriskfactors,strongassociationwithmyastheniagravisandotherparaneoplasticsyndromes
Clinical Presentation
• frequentlyasymptomatic:incidentalfindingonimaging
• symptomsrelatedtotumoursizeandlocationormyastheniagravis:chestpain,SOB,cough,and
phrenic nerve palsy
• ddxincludesintrathoracicgoiter,lymphoma,andotheranteriormediastinaltumours(seeRespirology,
R21)
Investigations
• CTchest(and/orMRI)
• Germcelltumourmarkers(β-hCG,alphafetoprotein),thyroidfunction,andPFTs
Treatment
• forpatientswithresectabledisease
■ surgical resection of thymus via median sternotomy or VATS depending on the size ■ ± post-operative radiation based on Masaoka staging
• fornon-surgicalpatients
■ multimodal therapy including neoadjuvant or palliative chemotherapy and post-operative
chemoradiotherapy if de-bulking procedure feasible
Prognosis
• dependsuponstageofdiseaseandresectability
• generallyslowgrowingtumoursandhavegoodprognosis,howeverthymiccarcinomasmoreaggressive
and have poorer prognosis
Pleura, Lung, and Mediastinum
• seeRespirology,R21
Tube Thoracostomy
Indications
• todrainabnormallarge-volumeairorfluidcollectionsinthepleuralspace ■ hemothorax, pleural effusion, chylothorax, and empyema
■ pneumothorax, if:
◆ large or progressive
◆ patient is on mechanical ventilation ◆ bronchopleural fistula
◆ tension pneumothorax
• totreatsymptomaticand/orrecurrentpleuraleffusion
■ see Respirology, R22
■ for long-term drainage of malignant effusions use: 1. Tunneled pleural catheter; 2. Pleural drainage and chemical pleurodesis
■ via facilitation of pleurodesis (obliteration of the pleural space by instilling talc or doxycycline to cause fibrosis and adherence of parietal and visceral pleura)
Orientation
Left lung
Landmark for incision
Dissection from inferior rib to superior rib
Intercostal vessels and nerves
Kelly clamp insertion
Tip of tube at superior pole of lung
Figure 8. Tube thoracostomy
© Marina Chang 2012