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Thoracic Surgery: Answers
209
Birim O, Kappetein AP, Stijnen T, Bogers AJ. Meta-analysis of positron emission
tomographic and computed tomographic imaging in detecting mediastinal lymph node
metastases in nonsmall cell lung cancer. Ann Thorac Surg. 2005;79:375–382.
Fischer BM, Mortensen J, Højgaard L. Positron emission tomography in the diagnosis and
staging of lung cancer: a systematic, quantitative review. Lancet Oncol. 2001;2:659–666.
Gould MK, Maclean CC, Kuschner WG, Rydzak CE, Owens DK. Accuracy of positron
emission tomography for diagnosis of pulmonary nodules and mass lesions: a meta-
analysis. JAMA. 2001;285:914–924.
van Tinteren H, et al. Effectiveness of positron emission tomography in the preoperative
assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre
randomised trial. Lancet. 2002;359:1388–1393.
Viney RC, Boyer MJ, King MT, et al. Randomized controlled trial of the role of positron
emission tomography in the management of stage I and II non-small-cell lung cancer. J
Clin Oncol. 2004;22:2357–2362.
Herder GJ, Kramer H, Hoekstra OS, et al. Traditional versus up-front [
18
F]
fluorodeoxyglucose-positron emission tomography staging of non-small-cell lung cancer:
a Dutch cooperative randomized study. J Clin Oncol. 2006;24:1800–1806.
3.5 Answer: E
Evaluation of the specific morphologic features of solitary pulmonary nodules (SPNs)
can
help differentiate benign from malignant nodules. Small, smooth
nodules with well-
defined margins are suggestive of, but not
diagnostic for, benignity; and a lobulated contour
or an irregular
or spiculated margin with distortion of adjacent vessels is
typically associated
with malignancy. Diffuse, laminated, central
nodular, and popcornlike calcifications within
nodules suggest benignity.
On the other hand, eccentric or stippled calcifications have
been
described in malignant nodules. Fat or calcification may
be observed in up to 50% of
pulmonary hamartoma. In a study
by Jeong et al., multivariate analysis was used to identify
criteria independently associated with a diagnosis of a malignant
nodule that had a higher
odds ratio for malignancy than other
radiologic finding criteria; the criteria were a lobulated
margin, a
spiculated margin, and the absence of a satellite nodule. Considerable overlap
exists
between the internal characteristics (air bronchogram, cavitation,
wall thickness, attenuation,
and so forth) of benign and malignant nodules.
References
Jeong YJ, Yi CA, Lee KS. Solitary pulmonary nodules: detection, characterization, and
guidance for further diagnostic workup and treatment. AJR Am J Roentgenol.
2007;188:57-68.
Erasmus JJ, Connolly JE, McAdams HP, Roggli VL. Solitary pulmonary nodules. Part I.
Morphologic evaluation for differentiation of benign and malignant lesions. Radio
Graphics. 2000; 20:43 -58.
Jeong YJ, Lee KS, Jeong SY, et al. Solitary pulmonary nodule: characterization with
combined washin and washout features at dynamic multi-detector row CT. Radiology.
2005; 237:675 -683.
Shahzad G. Raja
210
3.6 Answer: D
Surgical resection remains the treatment of choice for anatomically resectable non-small
cell lung cancer despite advances in radiation therapy and chemotherapy. However, the
frequent presence of coexisting chronic obstructive pulmonary disease and ischemic heart
disease increases the morbidity and mortality of surgical resection.
Spirometry with lung volumes, arterial blood gases, diffusion capacity (DLCO), and
maximum voluntary ventilation (MVV) are tests of static lung function
that have been
evaluated as outcome predictors for pneumonectomy.
The most commonly used index to
determine operability is FEV
1
,
or more accurately, predicted postoperative FEV
1
(FEV
1
ppo).
A patient is considered able to
tolerate lung resection as long as the FEV
1
ppo is greater than
800 mL. This 800mL level was established in a 1975 landmark
study by Olsen and associates,
who reported on 56 patients
deemed to be at high risk for lung resection. They chose this
level
on the basis of their observation that patients with an
FEV
1
lower than 800 mL tended to have
carbon dioxide retention
and a reduced level of day-to-day function. In general, patients who
are considered acceptable for lobectomy have an FEV
1
> 1 L, and MVV > 40% of predicted.
On the other hand, if DLCO is < 40% of predicted, pO
2
< 60 mmHg or pCO
2
>45 mmHg
there is a very high rate of pulmonary morbidity and a markedly elevated postoperative
mortality.
Stair climbing and cardiopulmonary stress testing are two of the most commonly used
exercise tests. Stair climbing has been used for years by thoracic surgeons to discriminate
between patients who would and patients who would not tolerate resection regardless of static
pulmonary function. This has been validated as a useful predictor in several studies. The
maximum oxygen consumption (VO2max) as measured by the cardiopulmonary stress test
has also been proposed as a better predictor of patient outcome.
Patients with borderline pulmonary function can
undergo resection safely if they have an
FEV
1
equal to or greater
than 1.0 L or 40% of its predicted value, a maximum oxygen
consumption of 10 mL/
kg/min or greater, or stair climbing of three
flights or more.
Cardiopulmonary stress testing and stair climbing
add valuable clinical information for
patients with an FEV
1
of less than 1.6 L.
References
Olsen GN, Block AJ, Swenson EW, et al. Pulmonary function evaluation of the lung
resection candidate: a prospective study. Am Rev Respir Dis. 1975;111: 379-87.
Pate P, Tenholder MF, Griffin JP, et al. Preoperative assessment of the high-risk patient for
lung resection. Ann Thorac Surg. 1996;61:1494-1500.
Burke JR, Duarte IG, Thourani VH, Miller JI Jr. Preoperative risk assessment for marginal
patients requiring pulmonary resection. Ann Thorac Surg. 2003;76:1767-73.
Colice GL, Shafazand S, Griffin JP, et al. Physiologic evaluation of the patient with lung
cancer being considered for resectional surgery: ACCP evidenced-based clinical practice
guidelines (2nd edition). Chest. 2007;132(3 Suppl):161S-77S.
Bernstein WK, Deshpande S. Preoperative evaluation for thoracic surgery. Semin
Cardiothorac Vasc Anesth. 2008;12:109-21.
3.7 Answer: C
Acute lung injury and its more severe manifestation, acute respiratory distress syndrome
(ARDS), continue to represent substantial clinical challenges with alarming mortality rates of
Thoracic Surgery: Answers
211
up to 60%. Treatment in this patient population remains predominantlly supportive, with
mechanical ventilation until the acute insult resolves. Although necessary, positive pressure
mechanical ventilation has been implicated as a cause of secondary lung injury, acting to
aggravate and perpetuate the primary lung injury. This ventilator-induced lung injury (VILI)
contributes to the high mortality rates associated with ARDS. Three main mechanisms of
VILI have been proposed: volutrauma, or alveolar overdistension; atelectrauma, or repetitive
shear stresses of the alveolar epithelium caused by unstable alveoli recruiting and
derecruiting; and biotrauma, or inflammation secondary to the mechanical injury induced by
volutrauma and atelectrama. Intraparenchymal pneumatoceles commonly develop in non-
dependent lung following mechanical ventilator support for severe respiratory failure.
Protective mechanical ventilation strategies utilizing low tidal volumes (Vts) have
become the standard of care in ARDS patients. While a recent prospective randomized study
with low Vt ventilation found a significant reduction in mortality, use of elevated levels of
positive end-expiratory pressure (PEEP) has shown promise both in the laboratory and in a
prospective randomized clinical study conducted by Amato and associates. Institution of
pressure control ventilation delivers maximal tidal volume and minute ventilation while
limiting the peak airway pressure and usually leads to a reduction in mean intrathoracic
pressure. This in turn may lead to decreased minute ventilation and retention of carbon
dioxide. Hypercapnea, which in this circumstance usually develops gradually, is well-
tolerated provided the pH does not fall below 7.20.
References
Amato MB, Barbas CS, Medeiros DM, et al. Beneficial effects of the "open lung approach"
with low distending pressures in acute respiratory distress syndrome. A prospective
randomized study on mechanical ventilation. Am J Respir Crit Care Med. 1995;152(6 Pt
1):1835-46.
Mead MO, Cook DJ, Guyatt GH, et al. Ventilation strategy using low tidal volumes,
recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury
and acute respiratory distress syndrome: a randomized controlled trial. JAMA.
2008;299:637-45.
Verbugge SJ, Lachmann B, Kesecioglu J. Lung protective ventilatory strategies in acute lung
injury and acute respiratory distress syndrome: from experimental findings to clinical
application. Clin Physiol Funct Imaging. 2007;27:67-90.
3.8 Answer: C
Since its
introduction by Carlens in 1959, mediastinoscopy has become
the standard to
which all other methods of assessing the mediastinum
are compared. The efficacy of
mediastinoscopy, with
a procedural sensitivity of greater than 90% and specificity
of 100%, in
the preoperative
staging of bronchogenic carcinoma is well established. Similarly,
mediastinoscopy, with an ability to establish a diagnosis
in greater than 90% of cases, has
been shown to be
efficacious in the diagnosis of mediastinal disease other than
bronchogenic
carcinoma. However, mediastinoscopy
continues to be a subject of debate among thoracic
surgeons.
Although some surgeons consider the procedure essential in the
assessment of the
mediastinum for lung cancer, as well as for
other conditions, others view the procedure as
excessively invasive,
with a comparatively high rate of morbidity and occasional mortality.
Shahzad G. Raja
212
Cervical mediastinoscopy has been shown to be a safe and effective
diagnostic procedure.
The overall mortality rate varies
from 0% to 0.2% with several authors reporting no
mortalities
after mediastinoscopy. At the same time there are a number of known
complications of mediastinoscopy that include haemorrhage, pneumothorax,
nerve injury
(recurrent or phrenic), oesophageal or tracheal
injury, wound infection, and other sequelae of
general anaesthesia
(cardiac ischaemia, arrhythmia, or respiratory insufficiency). A review of
the largest single-institution and collected series
published in the last 35 years shows that the
reported
morbidity rates directly attributed to mediastinoscopy range
from 0.6% to 3.7%.
However, because injury to major
vascular structures may prove fatal, haemorrhage remains
the
most feared complication.
References
Lemaire A, Nikolic I, Petersen T, et al. Nine-year single center experience with cervical
mediastinoscopy: complications and false negative rate. Ann Thorac Surg. 2006;82:1185-
9
Park BJ, Flores R, Downey RJ, et al. Management of major hemorrhage during
mediastinoscopy. J Thorac Cardiovasc Surg. 2003;126:726-731.
Jepsen O. Mediastinoscopy. Copenhagen: Munksgaaard; 1966.
Ashbaugh DG. Mediastinoscopy. Arch Surg. 1970;100:568-573.
Foster ED, Munro DD, Dobell AR. Mediastinoscopy. Ann Thorac Surg. 1972;13:273-286.
Kliems G, Savic B. Complications of mediastinoscopy. Endoscopy. 1979;1:9-12.
Luke WP, Pearson FG, Todd TR, et al. Prospective evaluation of mediastinoscopy for
assessment of carcinoma of the lung. J Thorac Cardiovasc Surg. 1986;91:53-6.
Puhakka HJ. Complications of mediastinoscopy. J Laryngol Otol. 1989;103:312-15.
Cybulshky IJ, Bennett WF. Mediastinoscopy as a routine outpatient procedure. Ann Thorac
Surg. 1994;58:176-78.
Hammoud ZT, Anderson RC, Meyers BF, et al. The current role of mediastinoscopy in the
evaluation of thoracic disease. J Thorac Cardiovasc Surg. 1999;118:894-99
Urschel JD. Conservative management (packing) of hemorrhage complicating
mediastinoscopy. Ann Thorac Cardiovasc Surg. 2000;6:9-12.
3.9 Answer: B
Diaphragmatic injury after blunt trauma is reported to occur in up to 8% of patients and is
most often the result of vehicular accidents. The majority of diaphragmatic injuries are left
sided and may be due to the protection that the liver affords the right side. The diaphragm is
rarely the only organ injured after blunt trauma and its presence is thought to be a marker for
other possibly more severe injuries. Frequently associated injuries include splenic laceration,
rib fractures, pulmonary contusion, closed head injury, and major vascular injury. Overall, the
associated injury rate has been reported to be 80% to 100%. This point is made clear as the
average mortality after the acute diagnosis of diaphragmatic rupture is made is 17% and is
most often due to pulmonary complications.
The diagnosis of diaphragmatic injury in the acute setting can be elusive. Routine chest
radiographs obtained during initial trauma evaluation are inaccurate unless obvious signs such
as gross herniation of abdominal viscera or a nasogastric tube visualized above the diaphragm
is present. The sensitivity of chest X-rays in diagnosing the presence of diaphragmatic injury
is reported to be as low as 17% for right sided lesions. The addition of computed tomography
Thoracic Surgery: Answers
213
has increased the accuracy of preoperative diagnosis. The CT characteristics that are noted to
produce the highest sensitivity include diaphragmatic discontinuity, diaphragm thickening,
and segmental nonrecognition of the diaphragm. Despite these advances, the diagnosis of
diaphragmatic rupture is reported to be made preoperatively in only 31% to 43.5% of cases.
Injuries to the diaphragm tend to be evenly distributed to each side in penetrating trauma.
Acute repair is generally undertaken through the abdomen if there are no signs of ongoing
bleeding within the chest. Abdominal injuries usually need to be treated first, and this allows
repair of the diaphragm transabdominally. Thoracic surgery may be performed
simultaneously, or immediately after abdominal surgery if bleeding is noticed. If a
diaphragmatic defect due to either blunt or penetrating trauma is discovered during a
thoracotomy, it should be repaired because of the propensity for visceral herniation and
strangulation with time. The recent approach to observe penetrating wounds nonoperatively
may result in a series of delayed diaphragm injuries becoming obvious several years later.
Chronic diaphragmatic injuries generally are best handled by a transthoracic approach as
these are associated with significant adhesions between herniated viscera and lung.
References
Weyant MJ, Fullerton DA. Blunt thoracic trauma. Semin Thorac Cardiovasc Surg.
2008;20:26-30.
Nchimi A, Szapiro D, Ghaye B, et al. Helical CT of blunt diaphragmatic rupture. AJR Am J
Roentgenol. 2005;184:24-30.
Haciibrahimoglu G, Solak O, Olcmen A, et al. Management of traumatic diaphragmatic
rupture. Surg Today. 2004;34:111-4.
Esme H. Blunt and penetrating traumatic ruptures of the diaphragm. Thorac Cardiovasc Surg.
2006;54:324-7.
Guth AA. Pitfalls in the diagnosis of blunt diaphragmatic injury. Am J Surg. 1995;170:5-9.
3.10 Answer: E
The bronchial arteries
have variable anatomy in terms of origin, branching pattern,
and
course. The bronchial arteries arise directly from
the descending thoracic aorta, most
commonly between the levels
of the T5 and T6 vertebrae. Four classic bronchial artery
branching patterns have been reported. These include two on the
left and one on the right that
presents as an intercostobronchial
trunk (ICBT) (40% of cases); one on the left and one ICBT
on
the right (21%); two on the left and two on the right (one ICBT
and one bronchial artery)
(20%); and one on the left and two
on the right (one ICBT and one bronchial artery) (9.7%).
The right ICBT is the most frequently seen vessel at angiography
(80% of individuals). The
normal right and left bronchial arteries originate from the anterolateral
aspect of the aorta
while the right ICBT usually arises
from the right posterolateral aspect of the thoracic aorta.
Right and left bronchial arteries that
originate from the aorta as a common trunk are not
uncommon at angiography. The true prevalence of a common bronchial artery trunk
is
obscure.
The structures supplied by the bronchial arteries include the trachea, extra- and
intrapulmonary
airways, bronchovascular bundles, nerves, supporting structures,
regional
lymph nodes, visceral pleura, and esophagus as well
as the vasa vasorum of the aorta,
pulmonary artery, and pulmonary
vein.
Shahzad G. Raja
214
Bronchial arteries that arise beyond the area between the
T5 and T6 vertebrae at the level
of the major bronchi are considered
to be anomalous. The reported prevalence of bronchial
arteries with an anomalous origin ranges from 8.3% to 35%.
These aberrant bronchial arteries
may arise from the aortic
arch, internal mammary artery, thyrocervical trunk,
subclavian
artery, costocervical trunk, brachiocephalic
artery, pericardiacophrenic artery, inferior phrenic
artery,
or abdominal aorta. Aberrant bronchial arteries extend along the course of the
major
bronchi and therefore can be distinguished
anatomically and angiographically from
nonbronchial systemic
collateral vessels. On the contrary, nonbronchial systemic collateral
vessels enter the pulmonary parenchyma through the adherent pleura
or via the pulmonary
ligament, and their course is not parallel
to that of the bronchi. The majority of aberrant
bronchial
arteries arise from the aortic arch. The prevalence
of bronchial arteries with origins
outside the aorta is unknown.
References
Deffenbach ME, Charan NB, Lakshminarayan S, Butler J. The bronchial circulation: small,
but a vital attribute to the lung. Am Rev Respir Dis. 1987;135:463-481.
Yoon W, Kim JK, Kim YH, et al. Bronchial and nonbronchial systemic artery embolization
for life-threatening hemoptysis: a comprehensive review. Radiographics. 2002;22:1395-
409.
Sancho C, Escalante E, Domínguez J, et al. Embolization of bronchial arteries of anomalous
origin. Cardiovasc Intervent Radiol. 1998; 21:300-304.
3.11 Answer: D
Massive haemoptysis is a life-threatening complication of many
pulmonary disorders. It
occurs most commonly in association
with longstanding inactive tuberculosis, bronchiectasis,
lung
abscess, bronchogenic car cinoma, and fungal disease. In aetiology for haemoptysis,
geographic location and socioeconomic level have significant importance. Pulmonary
tuberculosis, with its chronic sequelae, is the most common cause of haemoptysis in the Third
World. It is
generally a neovascular change or local erosive effect of chronic
pulmonary
disease and may arise from either bronchial or
pulmonary circulation. Recurrent bleeding is
unpredictable;
therefore, diagnostic and therapeutic intervention must be carried out
with
urgency.
The immediate priorities must be protection of
the airway to the nonbleeding lung and
localization of the site
of haemorrhage preferably by bronchoscopy. Bronchoscopy has a high
yield when performed during active hemorrhage. Immediate control
of bleeding may be
achieved by local tamponade with a balloon-tipped
Fogarty catheter, use of a double-lumen
endotracheal tube, or
angiographically guided embolization. Surgical resection is
the preferred
definitive treatment for those who meet operative
criteria. On the other hand, those who lack
adequate pulmonary reserve are candidates
for embolization of sites with persistent bleeding.
In a study by Knott-Craig and colleagues, 36.4% of patients admitted with massive
haemoptysis who underwent medical therapy had a recurrent episode of haemoptysis within 6
months of hospital discharge. Almost one half of these recurrent episodes (45%) proved fatal.
When compared with the other therapy modalities, surgical resection is really a curative
solution to eliminate primary haemoptysis and its recurrences.
Thoracic Surgery: Answers
215
Bronchial artery embolization (embolotherapy) may be an effective alternative method.
However, it has some important complications. These include spinal cord syndromes,
mediastinal haematoma after subintimal aortic dissection, bronchial stenosis,
bronchoesophageal fistula, infarction of the bronchus, and transient cortical blindness.
Besides, embolotherapy may not be successful in 10% to 25% of patients.
References
Knott-Craig CJ, Oostuizen JG, Rossouw G, et al. Management and prognosis of massive
hemoptysis. Recent experience with 120 patients. J Thorac Cardiovasc Surg.
1993;105:394-7.
Erdogan A, Yegin A, Gürses G, et al. Surgical management of tuberculosis-related
hemoptysis. Ann Thorac Surg. 2005;79:299-302.
Mal H, Rullon I, Mellot F, et al. Immediate and long-term results of bronchial artery
embolization for life-threatening hemoptysis. Chest. 1999;115:996-1001.
3.12 Answer: C
Bronchiectasis refers to the permanent abnormal dilatation of
the central and medium
sized bronchi. This is due to a vicious
cycle of transmural infection and inflammation with
mediator release. Symptoms include chronic productive cough, wheeze,
and dyspnoea.
Infective exacerbations are associated with worsening
of symptoms and signs of pneumonia.
Haemoptysis can occur. However, amounts of blood are usually small, and serious
haemoptysis
requiring selective arteriography and embolisation or surgery
is rare.
Discharge of the patient in this vignette without definitive therapy is dangerous even if no
further bleeding occurs during the current admission, as conservative therapy has failed.
Prompt resection taking care to spare uninvolved lung tissue is indicated. Antibiotic therapy is
appropriate for a first episode of hemoptysis associated with bronchiectasis, but not the third.
There is no evidence of a fungal infection and hence anti-fungal chemotherapy is not
indicated. Bronchoscopy followed by bronchial artery embolization is an option, but one that
should be reserved for patients with significant medical compromise in whom operation is
contraindicated.
References
Kim DN, Lazarus AA. Management of bronchiectasis. Dis Mon. 2008;54:540-6.
Osaki S, Nakanishi Y, Wataya H, et al. Prognosis of bronchial artery embolization in the
management of hemoptysis. Respiration. 2000;67:412-6.
3.13 Answer: B
Massive hemoptysis is a potentially lethal condition that deserves to be investigated
thoroughly and brought under control promptly. The mortality rate depends mainly on the
underlying etiology and the magnitude of bleeding. Although the diagnosis of hemoptysis
may be established by chest radiograph, bronchoscopy is always indicated to determine or
confirm the source of the bleeding. Inserting a right endobronchial tube would allow
ventilation of the uninvolved lung but it would not impede bleeding from the involved lung.
Rigid bronchoscopy with insertion of a balloon occlusion catheter is most appropriate in
circumstances of exsanguinating hemorrhage. The rigid bronchoscope allows better suction
and thus greater ease in the placement of a balloon occlusion catheter until the patient can
Shahzad G. Raja
216
have further treatment. Intensive care unit observation, sedation, antitussive medication and
positioning in bed with the bleeding side down are used in patients who have stopped
bleeding. Angiography should be reserved for patients who are not suitable candidates for
operation, as the long term success rate is far inferior to resection. The described patient‘s
recent pulmonary function tests suggest adequate pulmonary reserve. In light of the
chronic/recurrent nature of his problem confirmatory bronchoscopy and pulmonary resection
is the best treatment.
References
Serasli E, Kalpakidis V, Iatrou K, et al. Percutaneous bronchial artery embolization in the
management of massive hemoptysis in chronic lung diseases. Immediate and long-term
outcomes. Int Angiol. 2008;27:319-28.
Bruzzi JF, Rémy-Jardin M, Delhaye D, et al. Multi-detector row CT of hemoptysis.
Radiographics. 2006;26:3-22.
Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med.
2000;28:1642-7.
3.14 Answer: B
The diagnostic and therapeutic contributions of endoscopic procedures during the last
two decades have made instrumentation as the most common cause of esophageal perforation,
accounting for 59% of patients in recent series. Esophageal perforation during upper
endoscopy is estimated to occur at a frequency of 0.03%, compared with 0.11% during rigid
endoscopy. The more common sites of iatrogenic esophageal perforation are at the normal
anatomic narrowings of the esophagus. Perforation most often occurs in the hypopharynx or
cervical esophagus secondary to exertion of force in attempting to pass the endoscope through
the cricopharynx. The risk of esophageal injury also increases when therapeutic
manipulations are undertaking during endoscopic intervention. Perforation of the distal
esophagus is most frequently related to esophageal dilation performed for esophageal
strictures or achalasia. The incidence of distal esophageal rupture after pneumatic dilation for
achalasia ranges from 2% to 6%. Such a complication is often associated with previous
pneumatic dilation or the use of high inflation pressures.
Endoscopic sclerotherapy for esophageal varices leads to esophageal perforation in 1% to
3% of patients. The local necroinflammatory reaction after sclerosant injection contributes to
the transmural necrosis of esophageal wall. Avoidance of perforation may be achieved by
attempting to control the depth, volume, and concentration of injection to prevent extensive
and prolonged ischemia to the surrounding tissue.
Perforation of the esophagus can result from a variety of other forms of endoscopic
instrumentation. Iatrogenic esophageal perforation during transesophageal echocardiography
has been well documented with an incidence of 0.18%. Rarely, rupture of distal esophagus
may occur with improper placement and inflation of the gastric balloon of a Sengstaken-
Blakmore tube to control bleeding esophageal varices. Other forms of esophageal intubation
associated with perforation include nasogastric tube placement, endotracheal tubes,
endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound-guided
interventions.
Thoracic Surgery: Answers
217
References
Wu JT, Mattox KL, Wall MJ Jr. Esophageal perforations: new perspectives and treatment
paradigms. J Trauma. 2007;63:1173-84.
Brinster CJ, Singhal S, Lee L, et al. Evolving options in the management of esophageal
perforation. Ann Thorac Surg. 2004;77:1475-83.
Jones WG 2
nd
, Ginsberg RJ. Esophageal perforation: a continuing challenge. Ann Thorac
Surg. 1992;53:534-43.
3.15 Answer: D
The fundamental principles of management in esophageal perforation include elimination
of septic focus, provision of adequate drainage, augmentation of host defenses by antibiotics,
and maintenance of adequate nutrition. Therapeutic interventions aimed to achieve these
goals vary with the cause, location, and severity of the perforation, as well as the time interval
between perforation and intervention. The overall health status and physiologic reserve of the
patient, extent of associated injuries, and underlying esophageal pathologic findings are also
the critical determinants of successful therapy.
Primary repair is the preferred surgical treatment of choice in thoracic or abdominal
esophageal perforation. Successful outcome requires the debridement of necrotic tissue, full
exposure of the mucosal defect after longitudinal esophagomyotomy, and approximation of
mucosal and submucosal edges over a 40F to 46F bougie in a tension-free closure. Muscular
layer is then reapproximated using a running or interrupted absorbable suture technique. A
variety of vascularized autogenous tissues, including pleural flap, diaphragmatic pedicle graft,
omentum onlay graft, rhomboid and latissimus dorsi muscles, intercostals muscles, and
pericardial fat pad have been used to buttress the primary repair.
Brinster et al. reviewed published case series from 1990 to 2003, and found that the
overall mortality associated with esophageal perforation in 726 patients was 18%. Surgical
primary repair, with or without reinforcement, is the most successful therapeutic modality
with an averaged mortality of 12%. This is followed by esophagectomy with a mortality of
17%. In contrast, other surgical therapies are associated with a higher mortality rate. A
mortality of 24% was observed with the various exclusion and diversion procedures, and
drainage alone was associated with a mortality of 37%.
References
Wu JT, Mattox KL, Wall MJ Jr. Esophageal perforations: new perspectives and treatment
paradigms. J Trauma. 2007;63:1173-84.
Brinster CJ, Singhal S, Lee L, et al. Evolving options in the management of esophageal
perforation. Ann Thorac Surg. 2004;77:1475-83.
Jones WG 2
nd
, Ginsberg RJ. Esophageal perforation: a continuing challenge. Ann Thorac
Surg. 1992;53:534-43.
3.16 Answer: C
Tracheoinnominate fistula (TIF) is a rare but often fatal complication of tracheostomy.
Surgery is the necessary, definitive, and life-saving treatment of TIF. An awareness of the
potential of TIF as a complication in patients with tracheostomy tubes and a high index of
suspicion even before significant bleeding is important to recognize and stabilize the patient
with TIF. The mortality rate approaches 100% without urgent surgery as opposed to 20%
Shahzad G. Raja
218
with early recognition and proper management. Once massive hemorrhage occurs, mortality
is 15% to 25%. TIF usually occurs with newer tracheostomy tubes, those placed from 2 days
to 18 months before the hemorrhage, with 72% of TIF presenting within the first 3 weeks.
The innominate artery is the most commonly involved vessel, but fistula formation after
tracheostomy placement can also involve the common carotid artery, the innominate vein, the
inferior thyroid artery, the internal mammary artery, or the aortic arch. The risk factors
attributed to fistula formation involve mechanisms that either damage the tracheal wall or
prevent adequate healing. These risk factors include long-term ventilation, high ventilatory
peak pressures, poorly fitted or malaligned tracheostomy tubes, low-lying tracheostomy sites
typically below the third tracheal ring, and previous tracheal resections. Fistula formation has
been attributed to high cuff pressures, and it is recommended that the pressure in the
tracheostomy cuff remain less than 20 mm Hg because tracheal blood flow is impaired at
pressures greater than 22 mm Hg. An important observation in the pediatric population is the
presence of an abnormally high-positioned innominate artery which can predispose to fistula
formation. Another known risk factor that may contribute to the formation of the TIF in
stroke patients is neurological spasticity with abnormal arching of the neck, resulting in
increased pressure from the cannula against the anterior tracheal wall. Other associated risk
factors that impede wound healing include sepsis, stoma infection, steroid use, radiation
therapy, and malnutrition.
TIF can present in 1 of 2 ways: a sentinel bleed or acute massive hemorrhage.
Approximately half to two thirds of patients with TIF present with massive hemorrhage, and
when this occurs, the proper diagnosis is usually made. When vascular erosion presents as a
sentinel bleed, however, the proper diagnosis requires a high index of suspicion.
Approximately one third to one half of TIF patients will have a history of a sentinel
tracheostomy bleed within minutes to weeks before the massive hemorrhage. Jones and
associates recommend that patients with tracheostomies longer than 48 hours with bleeding in
excess of 10 mL be given the diagnosis of TIF and treated accordingly until proven otherwise.
Often, the sentinel bleed will spontaneously stop. Easy controllability of bleeding does not
rule out the diagnosis of TIF. The patient may have a history of a pulsating tracheostomy
cannula, but this occurs in only approximately 5% of cases. Patients may complain of vague
chest discomfort before bleeding, but rarely are these complaints severe enough to cause them
to seek medical attention.
If massive haemorrhage occurs, the goal is temporary stability to transfer the patient to
the operating room. Overinflating the tracheostomy tube cuff can be successful in temporarily
stopping the bleeding in 85% of cases.
References
Thorp A, Hurt TL, Kim TY, et al. Tracheoinnominate artery fistula: a rare and often fatal
complication of indwelling tracheostomy tubes. Pediatr Emerg Care. 2005;21:763-6.
Gasparri MG, Nicolosi AC, Almassi GH. A novel approach to the management of
tracheoinnominate artery fistula. Ann Thorac Surg. 2004;77:1424-1426.
Deguchi J, Furuya T, Tanaka N, et al. Successful management of tracheo-innominate artery
fistula with endovascular stent graft repair. J Vasc Surg. 2001;33:1280-1282.
Wright CD. Management of tracheoinnominate artery fistula. Chest Surg Clin N Am.
1996;6:865-873.