[05.48] Approach to Surgical Diagnostics in Cardiorespiratory Diseases V2.2.pdf

Obtain tissue for histopathologic examination

What is one of the main objectives of invasive diagnostic procedures in thoracic surgery?

Cervical lymph node biopsy

What is the simplest procedure listed in the order from least to most invasive?

Open lung or video assisted biopsy

What is the most invasive and complicated procedure in the order listed?

Change the management/outcome

What factor must be assessed when deciding on a diagnostic intervention?

Benefits, risks, and cost

What three factors must be considered regarding a diagnostic procedure?

55 y/o male, smoker

What was the profile of the patient in Case #1 for Cervical Lymph Node Biopsy?

Cervical lymph node biopsy

What was the ideal procedure for a patient presenting with a palpable cervical lymph node above the right clavicle?

Open procedure

What type of procedure is Cervical Lymph Node Biopsy (CLNB) for sampling enlarged nodes?

Scalene triangle

What location is a possible site for CLNB?

Low anterior cervical region superficial to the anterior scalene muscle

What cervical region is a possible biopsy site for CLNB?

Palpable lymph node

What can guide the surgeon in finding the lymph node during CLNB?

Diagnosis of thoracic diseases that spread to the neck nodes

What is a primary indication for CLNB?

Lung cancer

What thoracic disease is commonly diagnosed via CLNB due to its spread to neck nodes?

Tuberculosis, Lymphoma, GI malignancy

What three differential diagnoses make CLNB an important procedure?

Virchow’s nodes

What is the enlargement of the left supraclavicular lymph node called?

Metastatic abdominal malignancy

What condition is strongly indicated by Virchow's nodes?

No absolute contraindications

What is the status regarding absolute contraindications for CLNB?

Poor wound healing (especially in patients with irradiated necks)

What condition should be avoided when performing CLNB?

Coagulopathy

What blood disorder should be avoided when performing CLNB?

Bulky adenopathy and extranodal tumor infiltration

What mass characteristic should be avoided when performing CLNB?

Negligible

What is the mortality rate associated with CLNB?

Internal carotid artery

What major vascular structure is at risk of injury during CLNB?

Phrenic nerve injury

What nerve injury is a risk, especially during scalene node biopsy?

Chylous fistula

What complication can develop, especially if CLNB is done on the left side?

Pneumothorax

What pulmonary complication can occur in CLNB if the parietal pleura is violated?

Cupola of the lungs

What anatomical structure is paper-thin at the base of the neck, violation of which can cause pneumothorax during CLNB?

Level 1

What is the difficulty level assigned to CLNB?

Level 1

What is the risk level assigned to CLNB?

Level 1

What is the cost level assigned to CLNB?

Pleural effusion (Left)

What was the chest X-ray finding for the patient in Case #2 for Thoracentesis?

Aspiration of the thoracic cavity using a needle

What is the definition of thoracentesis?

Diagnostic and therapeutic

What are the two purposes of thoracentesis?

Draining the fluid will allow re-expansion of the lungs

What is the therapeutic indication for thoracentesis?

Severe coagulopathy

What is the absolute contraindication for thoracentesis?

Above the rib

Where must the needle always be inserted in thoracentesis to avoid neurovascular structures?

Ultrasound guidance

What technique is nowadays preferred to guide the site of puncture in thoracentesis?

Sitting

What is the preferred position for the thoracentesis procedure?

Lateral decubitus or Upright position of the bed

What are the two alternative positions if the patient is bedridden for thoracentesis?

Local anesthesia

What type of anesthesia is usually done for thoracentesis?

Vein, Artery, Nerve

What does VAN refer to in the context of avoiding structures beneath the rib?

More than 1000 mL

What volume of fluid requires caution during aspiration in thoracentesis?

Re-expansion pulmonary edema (RPE)

What complication is a risk if massive effusion is rapidly evacuated?

Pneumothorax

What is the most common complication of thoracentesis (11% incidence)?

2%

What percentage of pneumothorax patients after thoracentesis will require Chest Tube Thoracostomy (CTT)?

Intercostal vessels

What vascular structure may bleed if the needle is carelessly inserted below the rib in thoracentesis?

Lungs

What organ is the most common site of bleeding in thoracentesis, causing hemo- and pneumothorax?

Rapid evacuation of massive effusion present for several days to weeks

What is the cause of RPE?

Slow evacuation of fluid

What method is used to prevent RPE?

Excessive cough, Chest pain

What two symptoms are a low threshold to terminate the thoracentesis procedure?

20 ml/kg of the patient’s body weight

What is the maximum amount of fluid that should be aspirated in a short period of time to prevent RPE?

Level 1

What is the difficulty level for thoracentesis?

Level 2

What is the risk level for thoracentesis?

Level 1

What is the cost level for thoracentesis?

Blind pleural biopsy using a special needle

What is Closed Pleural Biopsy (CPB)?

Negative or inconclusive fluid tests

What is an indication for CPB when dealing with pleural effusion?

Thoracoscopy is not available or feasible

What condition makes CPB a necessary alternative diagnostic method?

Impaired coagulation

What is the contraindication for CPB?

Pneumothorax and bleeding

What two risks are augmented in CPB compared to thoracentesis?

Larger needle

Why is the risk of pneumothorax and bleeding augmented in CPB?

Parietal pleura

What structure is engaged by the notch of the biopsy needle in CPB?

Cutting cannula

What part of the CPB equipment obtains the specimen?

Level 2

What is the difficulty level for CPB?

Level 3

What is the risk level for CPB?

Level 1

What is the cost level for CPB?

50 y/o male, smoker

What was the profile of the patient in Case #3 for Thoracic or Lung Needle Biopsy?

2 cm x 1.8 cm mass with spiculations

What CT finding for Case #3 increases the risk of malignancy?

Transthoracically or Endoscopically using a bronchoscope

What are the two ways lung tissue biopsy can be done using a needle?

CT scan

What guidance method is ideal for more peripheral lesions in lung needle biopsy?

65%

What is the diagnostic sensitivity of CT scan guided lung needle biopsy?

Endobronchial ultrasound guided sheath biopsy (EBUS)

What guidance method is ideal for masses in the middle third of the lung near a large airway?

74%

What is the diagnostic sensitivity of EBUS guided sheath biopsy for lesions not touching the pleura?

Outer third of the lung

If the lesion is located here, CT scan guided biopsy is the most ideal mode?

Pulmonary mass

What is a primary indication for Thoracic or Lung Needle Biopsy (TNB)?

Mediastinal mass, Pleural-based mass or thickening

What two other masses/lesions are indications for TNB?

Pneumothorax (19%)

What is the most common complication of TNB?

2.4%

What percentage of TNB patients develop large pneumothorax requiring chest drainage?

Hemorrhage

What TNB complication involves bleeding into the thoracic cavity?

Hemoptysis

What complication is defined as coughing out of blood in TNB?

Contralateral pneumonectomy

What specific surgical history is a contraindication for TNB?

Severe emphysema

What condition predisposes to high risk of developing tension pneumothorax during TNB?

Cardiac or vascular structure in the pathway of the needle

What anatomical contraindication can lead to catastrophic hemorrhage if punctured during TNB?

Level 2

What is the difficulty level for TNB?

Level 2

What is the risk level for TNB?

Level 3

What is the cost level for TNB?

60 y/o female with recurrent hemoptysis for 3 months

What was the patient profile in Case #4 for Bronchoscopy?

Mass over the right upper lobe obstructing the right upper lobe bronchus

What CT finding in Case #4 made Bronchoscopy the ideal procedure?

Visualizing the inside of the airways for diagnostic and therapeutic purposes

What is the general technique of Bronchoscopy?

Rigid and Flexible

What are the two types of bronchoscopy?

Straight metal tube around 1 cm in diameter

What is the equipment used in Rigid Bronchoscopy (RB)?

Mouth

Where is the RB scope inserted?

Supine position with neck hyperextended

What is the patient position for RB?

General anesthesia

What type of anesthesia is required for RB?

Ventilating port

What structure in the RB delivers anesthesia?

Evaluation and biopsy of tracheal and proximal primary bronchial lesions

What is the main diagnostic indication for RB?

Deployment of stents

What therapeutic procedure for obstructing airway lesions can be done via RB?

Suctioning of inspissated secretions and massive hemoptysis

What therapeutic application of RB relates to secretions and blood?

More generous tissues obtained

What advantage does RB have due to its larger port size?

Foreign body removal

What is a key therapeutic advantage of RB?

Cannot visualize or biopsy segmental bronchi

What is a major diagnostic limitation of RB?

General anesthesia

What disadvantage of RB makes the procedure uncomfortable/painful?