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Oral Board Review: Thoracic Surgery Mock Orals (Podcast)
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Oral Board Review: Thoracic Surgery Mock Orals (Podcast)
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Behind the Knife. The surgery podcast. Where we take a behind-the-scenes intimate look at surgery from leaders in the field. [ Music ] >> Welcome back to Behind the Knife and this week we are going to have another mock oral scenario today. And one of the feedback we got from listeners is in some of the mock oral scenarios, they've been having some thoracic cases and depending on the program we ask, there's more or less thoracic exposure.
And so, today we have Dr. Berfield, chief of thoracic surgery at the Seattle VA. And Woo Do actually worked with her while he was on his thoracic rotation out there and asked her and she was generous enough to spend part of her Sunday afternoon with us. So, thank you Kathleen Berfield for joining us on Behind the Knife. >> Of course, happy to. >> So, before we begin, actually there's a slight piece of lore that we wanted to confirm with you, Dr. Berfield. We heard that when you were a thoracic surgery fellow at the University of Washington, you once completed a bilateral lung transplant with a co-fellow in three hours, is that correct?
>> Oh, that is true. Were you talking to Dustin Walters? >> We were [laughter]. >> That is definitely a highlight of our residency. >> And just for our listeners our there, you are actually the first graduate of the cardiothoracic residency at University of the Washington, is that correct? >> I am. So, I'm the first in the integrated thoracic program at the UW, yeah. >> And how long is that at UW?
>> It is a six-year residency. >> A six-year residency, and then they took you on as staff afterwards? >> Correct, yes. I was fortunate enough to get to stay. >> That's awesome, So, Dr. Berfield, let's tie it right in. I'll be the first sacrificial lamb here. >> All right, Woo. Okay. So, our first scenario is a 42-year-old woman who had a head trauma in a motor vehicle collision about a month ago.
Ultimately ended up vent-dependent. And is now three weeks status post tracheostomy by the trauma service. And you are the resident on-call and you were called because of brisk bleeding coming out of her tracheostomy appliance. >> So, I would definitely have a high alarm for concern here. The leading item on my differential is a bleeding from a tracheoinnominate fistula. So, massive hemoptysis.
While I'm on the phone with the nurse that has called me, I would ask her if she can over-inflate the cuff and I would quickly make my way down to the patient and assess the vital signs as well his ABCs. >> All right. Excellent. So, upon arrival at the bedside, you find that the hyperinflation of the cuff did work a little bit. So, she's not totally exsanguinating. The patient, however, is tachycardic, currently normotensive.
There's about 700 cc of blood in the suction canister. Her oxygen saturation is 96% on 50% SiO2. And what do you want to do now? >> Okay, boy so the patient does sound somewhat stabilized, but I'm also very concerned that this needs to go into the operating room. I would alert all of the means I have to get anesthesia, and all the help that I can get.
I would alert my attending. My next move would actually be to place my finger through the stoma and direct it kind of downwards toward the xyphoid process and lift up anteriorly with my finger to try to compress what I presume is the location of this tracheoinnominate fistula. When I do that maneuver do, I get any more control of the bleeding? >> Yes, you do. >> Okay, so with my finger in that position, I would certainly be asking for help to make sure this patient is adequately lined up, that she has two large port peripheral IVs at least.
I would have massive transfusion protocol initiated. And I would try to get our team mobilized down to the OR as soon as possible. >> All right. So, you make it down to the OR. >> Okay. At this point. With anesthesia, and all the help around me, I would want to try to get a more definitive airway access across this. Am I able to orotracheally intubate across the stoma?
>> Yeah, how would you do that? I would have anesthesia from above try to do it orotracheally. >> Okay. So, they're able to get the endotracheal tube into the trachea, but your finger and the tracheostomy appliance are still in there. So, I assume you're going to take it out? >> So, I'm going to start by taking out the tracheostomy, but leaving my finger in there.
>> So, bleeding is better controlled. And where are you going to place the tip of your endotracheal tube? Or ask anesthesia to put the tip of their endotracheal tube? >> I think I would try to go just about 2 centimeter proximal to the [inaudible]. >> All right sounds good. All right. So, with the endotracheal tube in place and your finger in there, so far, bleeding seems controlled. They have all the access they want.
The nurses have astutely prepped and draped the patient. And what is your plan in terms of proceeding with repair, or evaluation of what you think is a Tracheoinnominate fistula? >> So, at this point, with my finger prepped in, what I want my team to help me do is make an incision directly overlying my finger and just carefully go down until we encounter the fistula and just try to ligate that fistula.
>> Okay, want incision are? So, are you just making a skin incision? Or are you? What kind of incision are you making? Like what is your plan in order to be able to get access to that innominate artery? >> Got you. I have a high suspicion that this is not going to be controlled with just s kin incision and that it's actually going to need to go down through a medium sternotomy. >> All right.
Perfect. So, describe your sternotomy to me and then, kind of what you're thinking on looking for. >> So, okay, as I go down through the skin and soft tissue, I try to create enough of a space above the level of the superior most portion of the sternum so that I can get a saw and take the saw from cephalad to caudad.
And once I go through and put in the retractors, I should be able to be looking directly upon the innominate. And I hope that once I'm there, the anatomy, once I clear the anatomy around will be a little bit more clear to me where the fistula is. >> Okay. So, you've done your sternotomy then, you've divided sinus and prepericardial tissue back.
Your innominate vein has been retracted superiorly so that you can see your innominate artery and then what are you going to do? >> Then, just general principles. I want to try to get maybe like a Potts tie around proximally and distally so that once I let go of where my finger is, that if I pull up I can kind of occlude that bleeding. Get proximal and distal control and then just identify the fistula and ligate that fistula.
>> Okay. So the underside of the artery is pretty adherent and kind of stuck to trachea. >> At that point, I would certainly hope that there was some additional help to help me figure out what to do next. >> Okay. So, additional helps arrived and helps you dissect the artery free from the trachea. And then how are you going to ligate your artery?
What are you going to do? >> So, I would take a silk suture, or another permanent suture and pass it through the center and then kind of wrap it around in one direction, and then in a counter direction as well in order to get a good ligation around 360 degrees. >> Okay, and then what are you going to do with the trachea? >> So, at that point, the stoma is still there.
I think that it would be nice to get some sort of healthy tissue. I'm trying think what I could use, some tissue around there to buttress or to even just interpose so that the likelihood of another fistula developing is decreased. But I'm struggling to come up with that right now. >> Okay, how would you close your trachea? Like how would you close your defect?
>> So, I would try to close the defect in an interrupted fashion and then try to flex the site repair. >> Great. So, you're going to us 3-0 Vicryl sutures to prepare your tracheal defect. And then, since this patient fortunately has some nice sinus tissue there, you're going to use that sinus you're going to buttress your repair then. All right and then, how are you going to manage this patient post-operative?
>> So, post-operatively, I'm going to continue airway management with the ET tube that was placed intraoperatively. I'm going to; ideally there would be I think a drain that was left operating room that would kind of serve as an early detection system. And I think I would wait at least 7 to 10 days before I do any sort of manipulation.
But at some point, I'm going to want to do a bronchoscopy to evaluate the integrity of the repair. >> Okay. So, now what happens, alternative scenario. So, what happens if you get in there and you see that she has a bovine arch? >> Yeah, I have to admit that I'm not sure. >> Okay, essentially you could do the same thing. You get distal and proximal control of the carotid as well.
Okay. Next scenario. So, this is a 54-year-old woman who has rheumatoid arthritis and she is on Remicade. And she presents to the emergency room with two weeks of cough, progressive shortness of breath, and pleuritic chest pain. The ER doc got a chest x-ray and she has a moderate effusion. And some consolidation in her right lower lobe. And they called you to help manage this patient.
>> It sounds like an immunocompromised patient with risk factors for infection, has a right lower lobe consolidation and an associated effusion. Okay. So, I would go down to the ER, and as I'm going into the patient's room, I'd want to quickly ascertain how sick this patient appears. I'd look at vital, assess her ABCs, ensure she has adequate IV access. And has resuscitation ongoing. >> Okay. She's on a liter of oxygen, vital signs are stable.
And she's afebrile, white count is 18. >> Okay. So, at this point I'd do a focused history. And apart from what you had mentioned about her being on Remicade, and having rheumatoid arthritis, does she have any other past medical history that's pertinent, or can she tell me anything more about associated symptoms, or anything other than the duration of this being two weeks?
>> Yeah, so she doesn't have any other significant medical history. She's not any intrathoracic surgeries or otherwise. And really, she says she started feeling poorly a couple weeks ago. Got a cold from her granddaughter and has been coughing since. And finally got to the point where she was having some shortness of breath and pain, and she felt like she should go into the ER. >> Okay. So, at this point I would move to a focused physical exam, specifically looking for a cardiopulmonary exam.
And then you know checking for any sort of epigastric tenderness that she might have that's misconstrued as thoracic chest pain. >> Okay. So, left lung sounds fine. Heart sounds fine. She's got some decreased breath sounds on the right. And no, she's maybe a little focally tender if you palpate her right side, but no epigastric pain. >> Okay. So, at this point I understand she's already had some imaging and some labs.
You mentioned the white count and the chest x-ray. I'd want to next do a non-contrast CT of the chest. >> Okay. So, the CT chest shows that she's got an intraparenchymal infiltrate in the right lower lobe. Her lung isn't completely expanded because she has a moderate size effusion. >> Okay. So, at this point, my leading differential is a parapneumonic effusion probably an empyema.
With what I know about the time course of these effusions, she's about two weeks out and so would be probably beyond the initial exudative phase going on into maybe the organizing phase, or just before then. So, given that, I think that maybe a chest tube could potentially work, and it would give us a trial I think before we commit someone who is immunocompromised onto surgery.
But that said, I would consider VATS early. So, I would discuss those options with her, but I think I would recommend starting with the chest tube. >> Okay, what kind of chest tube are you going to place? >> I would place a chest tube that was large enough to drain out what I suspect is pus and that would facilitate me putting intrapleural tPA and dornase at some point. So, I think I'd do at least a 28-French, probably about a 28-French.
>> Okay. So, you put a 28-French chest tube in her right side and end up getting fluid that's kink of purulent appearing. What do you want to do then? >> So, first having gotten that fluid out, I want to send the pleural fluid for studies. Specifically, I'd want to test for gram-stain culture that's aerobic, anaerobic, as well as fungal and acid fast to check for TB.
And then, after I send those studies, I'd start her on antibiotics. And then I would admit her and just kind of observe how she, over the course of the next couple hours or so how she responds to this. And then, I'm thinking the next morning, I would repeat a chest x-ray to see, or at least a couple hours later I would repeat a chest x-ray to see if there's any degree of improvement in the lung expansion.
>> Okay. So, gram-stain is 4 plus GPC's. Fungal culture isn't back yet, acid fast isn't back yet. You started her on some Cephtriaxone. Her chest tube drained about 100 cc of fluid and her follow-up chest x-ray is largely unchanged. >> Okay. So, given that the findings are unchanged, I think I would try a short-course of intrapleural tPA and dornase.
I suspect there are loculations that are preventing the lung from completely re-expanding. And so, I would try about 12 hours apart, a couple iterations of tPA and dornase intrapleural. >> Okay. So, when you put the tPA and dornase in, she has significant pain with the instillation and you only get about 100 cc out of kind of bloody serosanguinous purulent looking fluid.
>> Okay. So, at this point, I think the pain that I've seen associated with this can be quite dramatic. And so, I would not necessarily be too alarmed with that, but I would want to help control her pain. I would do, I think I would continue with it for about another 24 hours and then repeat a CT non-con to see if there's any degree of improvement before committing her to a next step.
>> Okay, so you continued, and you got 50 cc out, which is about the volume of the tPA and dornase that you put in and her CT scan shows that her lung is still trapped, and she still has a loculated effusion. >> Okay. So, at this point, I'd approach the patient and discuss with her that my leading suspicion is that the lung continues to be entrapped due to loculations and organizations that is not being broken up adequately.
That this was a good trial at a non-operative approach, but I do think that she's going to benefit from an operative attempt to fully re-expand your lung. So, I would consent her for a I believe this is right side, so a right-sided VATS. Maybe possible decortication and possible pleurodesis.
>> Okay. So, you get her to the OR, what are you going to do? >> So, I would have anesthesia attempt to place a double lumen endotracheal tube. If she's able to tolerate, I would attempt single-lung ventilation. I would place her left lateral decubitus, the right side up. I would start with a VATS approach, place the trocar for the camera in about the fifth intercostal space, about anterior, between the anterior and midaxillary line.
And I would try to enter, once we have the lung down on that side. That may not be an issue, because the lung's already kind of entrapped, but still I would make good effort at that. Then, under direct visualization, I would place them, to additional ports, most likely ranging between the fourth and seventh intercostal space, but kind of triangulating up towards the apex. And I would take a good look and see which areas look organized, where the loculations are.
I would attempt to fully drain everything and then break apart these major loculations. >> Okay, so you stick your camera in, and you see that there's a lot of fibrinous material all over the lung. She still has a pretty decent size retained effusion. Then even after placing your second and third port, you're unable to really effectively get this rind peel off.
>> And she's tolerating the operation okay thus far? >> Yeah. She's fine. >> Okay. So, if that's the case, I think that there actually is probably going to be no benefit to this approach as it is right now. So, what I would do is I would convert to a thoracotomy. I would try to pull off as much of the rind as I can.
And then, apply some sealant and do some pleurodesis to see if I could get the lung to stick up. >> Okay. All right. Now, where are you going to put your chest tube? So, you were able to get her decorted, you placed your sealant, although where are you placing your sealant? >> I would kind of see where, because invariably, I think as I take down and do the decortication, there are going to be areas that bubble up with air leaks.
And I think I would target those with the sealant. >> Okay. And then, where are you going to put your chest tubes? >> I would place one posteriorly and directed apically. And then, I'd place like a flexible Blake tube directed posteriorly, and into the [inaudible]. >> All right. And then what? >> And then, we take her back to the ICU. Or, before I leave, I'd want to do intercostal injection on the local intercostal to do a nerve block.
Then, I'd take her out to the ICU for her recovery. And then I'd kind of watch and see how she does in terms of her pulmonary status. >> Okay, did you extubate her? Or, did you leave her intubated? >> I would attempt a trial of extubating. >> Okay. All right. So, she was successfully extubated in the OR. Went up to ICU, did fine.
And discharged from the hospital happily and thank you for saving her life. All right. So, review, yeah? >> Yes, thank you. That was challenging. >> You did well. I'm glad that you got to spend some time with us on this video, since I know you got to see some decorts up there. >> We did.
We did. >> All right. So, how do you think it went, in looking at going over your first scenario? Anything you think that you would have mentioned in retrospect earlier? Or, done different? >> I think the first scenario, especially raised my sphincter tone a little bit. It's definitely a frightening scenario, that I kind of luckily haven't had to deal with yet. I think the challenging thing for me is visualizing what I do in the operating room.
Particularly because this isn't something that I've ever seen done before. So, I definitely appreciate your feedback on what your approach might be to actually try to ligate this fistula, or if even the approach that I took was the appropriate approach. >> Okay. So, I think that you did the right thing in terms of initially, when you go the call of having kind of first stab at just over-inflating the cuff to see if that would clamp on the bleeding.
And it kind of worked. And then, you're able to get control over the bleeding a little better by inserting your finger into the stoma, which is the next step and then applying some kind of anterior pressure against the sternum which is correct. Luckily in this scenario, it bought you some time to get down to the OR. And then, really, the key right is trying to establish her airway. Because you know you're going to have to take her tracheostomy appliance out in order to kind of re-evaluate and see what's actually going on.
So, intubating from above is great. And having your anesthesia team kind of help you with that. Alternatively, if they're unsuccessful or if there's too much blood, then trying to do a rigid bronchoscopy and using that to maintain your airway initially is always something that's available to you as well. And then, when it comes down to doing your sternotomy, really if your finger's; so, sometimes when you get your oral endotracheal tube in, simply blowing up that cuff in the right place can give you some control, and you can always see if then you can potentially take your finger out.
Because the idea of having to do a sternotomy with a saw with your finger right there is a little dicey. But it happens. So, you try to you know stick a ray tech or a lap in the stoma essentially to see if that will kind of buy you a little bit of time while you get your saw at least in place. I think otherwise, you know bringing the retractor in. So, the first thing you do see right is all that thymus and pericardial fat and your innominate vein. And at this point you may or may not have your finger in the wound again in order to hold pressure on your innominate.
But you have the right idea about you know finding and locating your innominate vein. That generally if you retracted toward the head in order to give you some good visualization. Because innominate artery and the arch are just going to sit right under there. And so, just working to clear off those tissues. And you did the right idea about getting proximal and distal control. Getting that looped out so that you can at least identify where your hole is.
And then, the key is you know respecting that little area of where your fistula is off of your innominate artery. And then over sewing the ends of your stump. I think usually like. >> Yeah, I think that part had trouble visualizing how that would take place. >> Yeah, and you know depending on how friable the tissue is, you can get a right angle, or you know you can get a right angle around it at the very tip and then you know like a stick tie and like a good two-layer closure just to over sew the ends.
And then, I think the hard part was, you know what to do with this big tracheal defect for you. And so, closing your trachea. And we usually will use double sutures for closing the tracheal defect. And then, it is hard to find a good muscle flap. Sometimes you know, if you have really prominent mesial fat and sinus will work. It's harder to find a big flap like strap muscles, because they don't really reach down there.
So, generally trying to use the thymus there is useful. So, not resecting all that. And then, the, you know the key is like keeping that endotracheal tube in. Sometimes at the end you'll have to bronch just to clean out airways. And so, keep that in mind as well. Since they've been bleeding into their airway the whole time. Otherwise, I think you handled that scenario nicely. >> Just to be clear, do you completely ligate the innominate artery? >> Correct.
>> In this scenario. Yeah. >> Correct. Yeah, I mean essentially, right it's similar to if you're doing a T bar and you're covering your subclavian, usually you don't get CO or have ischemia in your arm. And presuming this person is otherwise young and should have a good Circle of Willis and should be able to be fine with the you know flow from her left carotid, assuming that she doesn't have a bovine arch, so. >> And with the bovine arch, do you need to divide the carotid and re-implant it or anything?
>> No, so it kind of depends on where it is. Usually the origin of your carotid is the closer to the arch and so quite frankly you're going to be able to get around the kind of ongoing innominate to your common carotid without having to sacrifice your carotid artery. >> Okay. >> I can show you a picture later. >> Great. Great.
>> All right and so for your second scenario, the empyema. I think that you, in terms of these went well, you know, it's kind of obvious if we're talking about a consolidation on the right side, and she has an effusion and she has a white count, we're probably going down the role of your parapneumonic effusion, or an empyema. So, you have your differential there which was great. I think that starting out in getting a CT chest.
So, depending on creatine plus minus on using contrast as well. It will give you more rim enhancement. And kind of give you a break up to the rind if you're able to get contrast. It's obviously not absolutely necessary. But it sometimes give you a little bit more information about the rind and the septations of loculations and things. You placed a chest tube, which his fine. I think that you'll never faulted for putting in a larger bore chest tube.
You've done all of the right studies. I would refer folks to the AATS consensus guidelines. Because they have a nice set of guidelines on the management of pyemia and usually it starts with an ultrasound guided thoracentesis. Check your fluids plus minus chest tube placement initially. Like we talked about, at some point, you did the right thing in terms of repeating your x-rays and make sure that you had either resolution of you effusion and re-expansion of your lung, kind of seeing what things look like.
Right now, you know the use of tPN and dornase or fibrinolytics is controversial. But generally, not a first line thing that you do unless there are extenuating circumstances and the patient is unstable, or not a candidate to go to the operating room for whatever reason. So, I'd say for board purposes, you're a surgeon, and surgeons operate, and so. >> Okay, so early VATS preferred? >> Yeah. Sometimes, and I don't know that you necessarily need to mentioned it, that you know a lot of times the anesthesiologist, as long as there's no fever are okay putting epidurals in for pain control.
But otherwise, you know you have the right idea in terms of planning for a VATS. I think you got just a little turned around because you said VATS possible decortication. We know we're going to do a decrot. So, you know, you're right that's possible thoracotomy for decortication. And so making sure that she has a thoracotomy on there. I will usually also include a bronchoscopy on my consents, because quite frequently at the end, either before or after, in order to make sure that you can get really good line re-expansion, you might feel obligated to go in and clean out the airways on that right lower lobe, just to see.
She hasn't had a bronch before and just to make sure that there isn't anything in there that you can clean out to help her get re-expansion. Otherwise, I think starting VATS is fine. You know depending on the CT scan and whether you put your, if you have a chest tube in, frequently you can place your, go through the same hole. Or, you could make a separate incision and have some of that based on your CT scan. Some people would prefer to go kind of where you went, which is in the fifth intercostal space and anterior axillary line in order to stick a camera in.
I'd look around first, because a lot of times once you look in, you stick your grasper in and start trying to peel things off, you can get a better sense of whether or not you're going to be successful staying VATS, or if you're going to need to convert before you put a bunch of other ports in. Just style points. And then, so as long as everyone's clear, you know, it's like stating your goals at some point. You know, the goals, the decortication is to remove all of the infectious tissue, and then to also to affect lung re-expansion.
And so, you know making sure that you clear off the lower lobe along the diaphragm posterior anteriorly and make sure that your fissures are nice and clear. And then wide drainage. Usually you don't need to put sealants in. So, sometimes you will, like you mentioned, make little rents in the parenchyma. But usually there's so much blood in there anyway, and they're easy inflammation.
So you generally don't need to actually put sealants in. Unless it's you know, unless it's a really large gash. So, I don't think you need to mention that. But otherwise, the other key is you know, it's trying to get them extubated as soon as possible. Because that positive pressure staying intubated will certainly prevent their lung from being fully expanded and it will continue to allow those small air leaks that make it harder to ventilate and things. So, trying to get them extubated as soon as possible is important.
>> Great. That's fantastic feedback, ma'am. Thank you so much. >> Of course. Kevin, you now? >> Yep. Here I am. So, now this will be a good comparison to see, you know the residents that got the UW rotation verse the one that did not rotate on thoracic. And here we go. >> [Laugther].
All right. I'm sure it will be just fine. Okay so you are a 50-year-old. Or, sorry, you are fine. You're not 50. You have a 50-year-old man who has intractable nausea and vomiting. He's an alcoholic. He has excruciating chest pain and came into the ER and you are the person on-call in the ER and have been called to see him.
>> Okay. So, intractable chest paid after vomiting makes me concerned for the worst case scenario, which would be in esophageal perf. So, I'm going to go see the patient, assess his ABCs. But it sounds like he's stable at this point in time? >> Yeah, he's tachycardic, heart rate is 110, but his blood pressure is fine. >> Okay, so I'd get bilateral, you know large bore IV's send labs off on him.
And then I'd perform a focuses physical exam looking for crepitus and listening for lung sounds. I'd do an abdominal exam. >> Okay, so on physical exam, he's tachycardic, a little diaphoretic, but otherwise has decreased breath sounds on the left side, and his abdomen is a little tender. >> Okay. I would perform a chest x-ray while I'm in the ER as I'm calling radiology to get set up for my esophagram.
>> Okay, so he has a small left-sided effusion. >> Okay. So, I'd called radiology and tell them I want to start with put a Gastrografin, upper GI to evaluate for a possible esophageal leak. But I'd like to get some more history on this patient too. Does he have any other pertinent medical history, or medications that he's on? >> He's a smoker. He's not on any medications. Doesn't really see doctors. And hasn't had any surgery.
>> And I'm sorry did you say he is an alcoholic? I can't remember. >> He is. >> He is an alcoholic, okay. So, yeah, I'd go perform the Gastrografin and swallow. And if it's unrevealing I would proceed with a thin barium swallow. >> Okay, so the swallow shows that he has an extrav of contrast in his left chest. But, some of the contrast goes distally into the stomach. >> Okay. So, I would start him on broad spectrum antibiotics, and fluid resuscitate him.
And cross and type him for two units. I would call the operating room and get him set up for a left thoracotomy in order to repair his esophageal; his ruptured esophagus. >> Okay. So, what would you consent him for? >> I would consent him for a left thoracotomy with esophageal repair, possible esophagectomy.
And I would also consent him for an EGD. >> All right. All right. So you perform your EGD and see that he has a perforation in his distal esophagus, just above the GEJ. >> Okay, just above the GEJ. I would also have on that consent a feeding tube. But, he's asleep now I will call his wife. >> Okay.
>> So, I'm sorry you said I did the EGD and there's a perf just at the lower part of the esophagus is that? >> Yeah, so distal esophagus. It doesn't involve the GEJ. There's no evidence of malignancy or stricture. >> Okay, so it sounds like he has kind of the classic boar hogs. So, I'd place the patient in the right lateral decubitus and perform a single lung ventilation.
It's not necessary, but if anesthesia is able to provide it and he tolerates it well, it could help exposure. And I would, as I'm making my thoracotomy in the seventh intercostal space, I would plant for an intercostal flap as I'm making my incision. And then, I would evacuate out the purulence out of his chest and irrigate copiously at the beginning of the case. And then, attempt to identify my anatomy.
Generally, I would open up the, a lot of times the muscle defect is a lot smaller than what's in the mucosa. So, I would make a myotomy longitudinally in order to identify my mucosa defect. Once I identified my mucosal defect, I would close it with like a 3-0 Vicryl running stitch and then do interrupted silks for my second layer of muscle.
And then, place an intercostal muscle flap to buttress this repair. I would place two chest tubes in the chest to help adequately drain the mediastinum. One apically, and one along the diaphragm. And at the conclusion of my case, I would likely place a jejunostomy tube.
And I'm sorry, when I perform that repair, I would perform it over a 48-French Bougie in order to help hopefully prevent a stricture. And then, I would laparoscopically place a jejunostomy tube at the conclusion of the case for feeding access as he's going to be NPO for a long period of time. >> Okay. So, we'll go back for a second.
So, you actually arrive in the OR, and he's unstable. Blood pressure is in the toilet. Anesthesia is starting pressors. And when you start looking at the esophagus, the tissue is just falling apart and there's no healthy tissue. What would you do then? >> Okay. At this point, I would widely drain his chest. I would irrigate. And you know if he's tanking that badly and I can't, if I don't have time to do like a spit fistula, I think irrigation and widely draining, and making him NPO with IV antibiotics will hopefully get him to a point where we could take him back to the OR and perform an esophageal diversion.
If at that time, I'm able to perform an esophageal diversion, I would with a kind of cervical esophago-fistula, would be my plan. Those would be my two options. So, right now, if he's that unstable, I would just irrigate out, widely drain, and get him on broad spectrum antibiotics. >> Okay. Are there any other options?
>> I mean I think I could have divided the, dividilized esophagus and performed like a gastrostomy and a cervical fistula. >> Okay. All right. So, you mobilize the esophagus. And how are you going to form you esophagostomy?
>> I would make a left neck incision, carefully mobilize the esophagus and proximally and distally in order to give me some length. I would divide the esophagus and then generally what I've seen is just under, or just near the clavicle you bring out the distal aspect of the cervical esophagus for drainage.
>> Okay. And would you plan on reconstructing him later at all? >> Yes. If that were the case. You know, I could potentially use his stomach is still okay, then I could potentially perform a gastric conduit reconstruction. >> Okay. Great. Next scenario. You have a 63-year-old woman who is a former 30 pack year smoker.
No other medical history. And she was found to have a 10-millimter, peripheral, right upper lobe nodule seen on chest x-ray, which was part of a preoperative work up for a knee replacement. How would you proceed with management of this patient? >> Okay. So, you told me already that she has a pack year history. Does she have any previous history of lung cancer, or any other cancers? >> She does not.
>> Any other significant comorbidities? >> No. She has a little bit of hypertension, is on lisinopril, but otherwise no other medications and no prior surgeries. >> Okay, it's a pretty small nodule, but given her smoking history I'm concerned. So, I would go ahead and get a CT scan of the chest in combination with a PET scan in order to help further define this lesion.
>> Okay, so the CT scan shows that you have a 10-millimeter peripheral nodule on the right upper lobe. Smooth borders, close to the pleura. Not calcified. She doesn't have any significant mediastinal adenopathy. She has mild emphysema, upper lobe predominant. And her PET CT scan shows that she has an SUV of 3.5 in the nodule, but no other SUV uptake.
>> Okay. Given her smoking history and given the concerning findings, I would you know give her two options of you know watching and closely; waiting and closely watching versus a wedge resection of this region. Given her smoking history, and SUV uptake by the PET scan, I would counsel her that I recommend a wedge resection of this after she had a completion, pulmonary function test and cardiac evaluation to make sure she qualifies for surgery.
>> Okay. And so, she says okay, I'll have a wedge resection. So, what are you going to consent her for and what's your procedure going to look like? >> So, I'm going to consent her for a wedge resection of this region, possible right upper lobectomy if we're unable to identify it. And possible thoracotomy.
>> Okay. What would you do? With you do anything with her stage her mediastinum at all? >> You know, I think this is controversial, but given that there is a small lesion and that there was no adenopathy seen on PET CT. I think it's reasonable to not do any further preoperative staging. >> Okay. So, you take her to the operating room, and you do your wedge resection and she's extubated postoperatively on day one.
I'm sorry in the operating room. And then, on day one, she becomes increasingly hypoxic, what do you do? >> Okay. She's hypoxic, so is her chest tube? I would get a chest x-ray and are chest tubes de-suction? Or what is the status of her chest tube at this point? >> So, her chest tubes were left to suction, yeah. >> Left to suction.
And what does my chest x-ray show? >> So, your chest x-ray looks like she has increasing bilateral fluffy infiltrates. >> Okay. So, I would send off labs and I would send off a cardiac panel, specifically troponin. I would get a stat echo on the patient. I'm concerned that she is going into heart failure and I would kind of put her on you know high flow oxygen in the mean time and be suspicious that she may need to be intubated if she doesn't improve quickly here.
>> Okay, so she's on 100% high flow. Saturations are in the 80s. She's really working to breathe. >> Yeah, at this point, I would ask anesthesia to intubate her to protect her airway and to improve her because she's in respiratory failure at this point. >> Okay. And how would you manage her vent settings? >> Is she in heart failure?
Did her troponin come back? >> Troponins are not elevated. No EKG changes. >> No EKG changes. Yeah, that's okay. So, she's having bilateral pulmonary edema. I would probably put her on a little increased PEEP to help expand her lungs. But otherwise conventional with just slight elevation of the PEEP.
And consider diuresis to help improve this pulmonary edema. >> Okay. Alternatively, so she's extubated in the OR and then, you notice though that she has a fairly significant air leak in her chest, from her chest tube. >> Okay. So, I would. And this is like day one, like post op day one that I see the significant chest, the air leak?
>> Yep. >> Okay. I would give it 48 hours and if there's no improvement, I would attempt a blood patch. >> Okay. She still have an air leak. >> Still has an air leak? Okay, after that I would attempt a, through the chest tube, I would attempt; I would first of all one thing I would be doing is decreasing my suction in order on the chest tube.
So, hopefully not keeping this kind of an air leak open with the suction. And then, I would attempt a tall, kind of pleurodesis through the chest tube to see if I could get it to seal up. >> So, decreasing suction didn't work. She developed a pneumothorax and increased shortness of breath, and a little bit of chest pain.
And [inaudible] through the chest tube that goes in, and yet there's no real changes on her chest x-ray. She still has a pneumothorax. And she still has an air leak. >> Okay, at this point essentially, I would like a bronchopleural fistula and if she doesn't tolerate coming off of suction at all, so I think I would take her back to the operating room in order to attempt to operatively fix this air leak.
>> Okay, so what are you going to do? >> I would go back in the same VATS. I would in my same ports that I used for the wedge, I would put her lung under water and have them infiltrate and try to identify the air leak. Am I able to identify it? >> Yeah, so you have substantial air leak from your staple line. >> From my stable line. Okay. From here, I would probably make a kind of a mini thoracotomy in an area where I could bring the lung parenchyma out.
I would over sew this area with an absorbable suture and would place a sealant over top of it. And then, I would complete the surgery and put her to kind of [inaudible] overnight and see how she does. >> Okay. So, after you suture the staple line and put the sealant on, her air leak improves and next day her air leak is, she has a small air leak with Valsalva, but otherwise all that's resolved.
>> Okay, I would take her off of suction at this point in time and then see how she's, and closely monitor. >> Great. So, you take her off suction, she does fine, you're able to get the chest tube out and she should be able to go home. Her pathology shows that she has and 1 centimeter adenocarcinoma in her wedge resection with margins that are widely negative.
What sort of follow up does she need? If any? >> She close follow up with a repeat chest CT within 6 months. I would have her, I don't think there's any role for [inaudible] therapy, but I would have her evaluated by oncology just to have the discussion. And you know for the first year I would do a Ct scan at 6 months, and then at one year.
And I'd see her in my clinic both times for that. >> Okay. Great. All right. So, how do you think you did? >> I'm sweating a little bit. They were tough. But, they're very fair scenarios. So, thank you. >> Of course, you guys both did fine.
You did well. I think it's very brave for you to do this and then podcast it to everybody. I don't know that I've just felt that confident if I were in your position in residency, so. >> It's funny we have a really hard time finding volunteers to help. >> I'm not surprised. I'm not surprised you can't find people to be on the receiving side of these questions. >> Everyone seems to be on-call Sunday afternoons, so. >> Yeah, I'm sure. All those emergency surgeries happening in the hospital.
So, how do you think the esophageal perforation went? Anything that you would add in there sooner, or later, or change around? >> Yeah, I think the kind of standard esophageal perf that I read about went okay, but I don't think I was prepared enough for the scenario where you know I can't repair it in the traditional fashion. And you know, I don't really know what the exact right steps were in that aspect of it.
>> Okay, I think that you did everything in order like you should have. So, you did appropriate steps made. You knew to get the esophogram, knew about Gastrografin versus thin barium, so even if it's negative by Gastrografin, you still do the thin barium. I think that you caught yourself, I think in terms of adding on the EGD, potentially putting the PEG, like a feeding tube in or a PEG tube in or something at the time of surgery.
You otherwise were able to explain the procedure in terms of position, you know single lung ventilation if the patient tolerated it but knowing that it wasn't absolutely necessary. Site of your incision, the seventh intercostal space, taking a muscle flap, I think it important in the beginning, which some people miss, and I think that's very useful so that you have something to buttress your repair with, and then making sure that you identify the mucosal defect fully.
I think that you know, closing your; everybody closes and repairs differently. And so, knowing that you're going to use an absorbable suture, then silk closure of the esophageal muscle is perfect. And then, let's see. I think that if when you got to the point where the patient was unstable, I think that you did a good job of kind of recognizing that it wasn't a position where you were going to be able to repair successfully, just because the patient wasn't tolerating it.
Kind of focusing on just mobilization of the esophagus so that you can set yourself up for a diverting esophagostomy. And then, making sure that you had some means of drainage in the stomach. So, like a PEG tube, or a G-tube, open tube either way in the stomach and a feeding tube option so that you could set yourself up for success in the future. But otherwise, I don't think that there will be; I wouldn't expect you to be able to fully explain the intricacies of forming your diverting esophagostomy.
Aside from the fact that you would, you know try to get as much length on your esophagus as possible, and then when you pull it out into your neck, you know transecting esophagus above your perforation. And making sure that you've got good drainage of your stomach and the conduit below. And then making sure you've got good drainage, which I think you did. In terms of the solitary pulmonary nodule. You were able to recognize that the patient had a you know was high risk based on smoking history as well as age.
I think that depending on where it could have gone, I think getting your CT scan is probably the first thing. So, CT scan followed by PET CT scan is totally appropriate. You can go into kind of varying amounts of discussion about Fleischner guidelines regarding you know size of nodules, which actually are changing, change this year essentially in terms of now focusing more on you know whether or not the nodules are you know greater than less than 8 millimeters.
But essentially, you know you had the correct follow-up for the nodules and the counseling about you know watching, waiting versus resection. I think that consenting her for the wedge and a possible lobectomy is appropriate. So, generally when you're in the OR you'll send frozen in order to get your diagnosis. And then, that's kind of the conversation of you know do you do the completion lobectomy if you're in there and you know that it's cancer, versus counseling the patient about you know, I think gold standard previously for patients who could otherwise tolerate it with lobectomy for all lung cancers.
And now there's been a move, which I don't know that is particularly pertinent for the general surgery boards. But a move toward sub-lobe resection being acceptable for patients who otherwise their preference, or they're high risk. And making sure you got your PFT but making sure you have your PFTs beforehand is appropriate. The air leak managements. I think that in terms of vent management for the ARDS, it's mostly just recognizing that this patient has had some event for whatever reason, and she's going into ARDS and so Lasix and PEEP, basically just like ARDS net sort of information and managements.
And then, for the air leak, I think, you know waiting. Everyone will wait a different amount of time, it depends on how brisk the leak is and what happens as you decrease suction. So, decreasing suction was great. I would not have done a talc pleurodesis or put talc in the chest tube before re-exploring the patient, because of the ramifications of talc in your chest space, in your pleural space. Just creating a large inflammatory action and just making, if you needed to go back. And in this case, it was a pretty simple fix, it was your staple line and so you could either re-resect it or you could try to buttress it with either sutures or you could have just done potentially another wedge resection to clean up your staple line if needed.
And that would be made a little bit more difficult with talc in there already. So, probably wouldn't have talc before just re-exploring the patient. And then, follow-up for lung cancer, guidelines are a CT scan every six months for the first two years and then annually thereafter to make sure that there's no evidence of either recurrence, or new lung cancer development.
>> Would you sent them to see an oncologist ever in a small negative case like? >> Well, so we don't know that she's node negative, right? We didn't check. Normally for the patients that have the likelihood that a patient with T1A, so a small like a very early stage lung cancer having positive nodes is low. But, I generally would not, if I know that it's a T1A. I generally will follow them myself.
>> Okay. Great. >> They're not offer evaluation with oncology though. >> Well, I learned a ton and we really thank you for taking your time out to help educate us in thoracic surgery. >> Yeah, Dr. Berfield, that was fantastic, thank you so much. >> Yeah, you're welcome. Thanks for thinking of me, Woo. You guys did great. >> Have a great one.
>> Thank you. >> You too. >> Bye-bye. >> All right, bye. >> Until next time, dominate the day. [ Music ]