Lung Disease/GERD

SUGGGESTED READINGS LUNG DISEASE/ GERD

1. Current Surgical Diagnosis and Treatment, 12th Edition, Ch. 18.
2. Current Surgical Diagnosis and Treatment, 12th Edition, pages 462-466

OBJECTIVES LUNG DISEASE/ GERD

1. List common benign and malignant tumors of the chest wall.

2. What are the tests to differentiate transudative fluid from exudative fluid in the patient with pleural effusions?

3. What is etiology and usual management of a lung abscess? How does this differ from an empyema.

4. What is the differential diagnosis of a mass in anterior, middle, or posterior mediastinum?

5. What is the management of a patient with a thymic mass? What is the association between thymomas and myasthenia gravis?

6. What are the different histologic classifications of lung cancer and how do they differ? Which one is the most common?

7. What is the significance of N2 nodal disease in non-small cell lung cancer (NSCLC) and how is this evaluated?

8. What are possible diagnoses and evaluation options for the patient with the CXR finding of an asymptomatic solitary pulmonary nodule (SPN)?

9. How does one evaluate adequate pulmonary function in the patient who needs surgical resection?

10. Discuss the molecular biology and immunology of lung cancer. Discussion should focus upon the role of oncogenes.

11. Vascular endothelial growth factors have become important areas of research in ischemic heart disease as well as carcinogenesis. Describe in general terms what these growth factors and their potential roles.

12. Describe the anatomical and physiological factors predisposing to reflux esophagitis.

13. Describe the symptoms of reflux and discuss the diagnostic procedures used for confirmation.

14. List the indication for operative management of esophageal reflux and discuss the physiologic basis for the anti-reflux procedure utilized.

CASE HISTORIES LUNG DISEASE

1. A 56-year-old white male is found to have a 2 cm solitary pulmonary nodule in the periphery of the left lower lobe on a routine preoperative chest x-ray for an inguinal hernia repair. The patient has been a lifelong resident of Illinois, and has no history of TB exposure, cough, hemoptysis, dyspnea, or chest pain. He has smoked one pack of cigarettes per day for the last 40 years. He has no other significant medical problems. His only significant surgical history includes a cholecystectomy seven years ago. Physical examination and initial laboratory studies are entirely normal.

2. A 52-year-old white male presents with recent onset of hoarseness, cough and streaky hemoptysis. A chest x-ray reveals a 5 cm mass in the left lower lobe with a left sided pleural effusion. What is the plan for evaluation of this patient?

3. A 28-year-old white male presents with recent fever, a ten pound weight loss and a mediastinal mass on his chest x-ray. What is the differential diagnosis? How do you evaluate his mass?

4. A 33-year-old female presents with a sudden onset of sharp right-sided chest pain and dyspnea. A chest x-ray reveals a 50% pneumothorax on the right side. She states that she had a similar episode on the same side approximately two years ago, which was treated with a chest tube. How do you advise her?

CASE HISTORIES GERD

1. BF is 52-year-old female with a long history of “heartburn. She was evaluated by a gastroenterologist three years ago and was told that she had reflux and was prescribed an H2 blocker. Unfortunately, she has not had the money to purchase the medication so she has not taken it in eight months. She says that drinking a glass of milk before going to bed sometimes helps her symptoms. Currently her symptoms include moderate substernal chest pain between meals, at night, and sometimes after she eats a very large meal. The pain usually lasts an hour or two. It is particularly bad at night when she is sleeping, although she has found that if she sleeps on three pillows, the discomfort is improved. Often, she awakens in the middle of the night with a brackish taste in the back of her mouth. About once every two weeks, she awakens with spasmodic coughing “like something went down the wrong tube.” Her vital signs and physical exam are perfectly normal. Because of the prolonged symptoms, you send her to a gastroenterologist for upper endoscopy. A week later you receive a call that there is a concerning abnormality of the mucosa at the GE junction.

• What is the most likely abnormality that was seen and what is its etiology?
• What is the underlying problem leading to this abnormality?
• What would you expect if this problem were left untreated?
• What confirmatory tests are useful in diagnosing GERD?
• What abnormalities would you expect to see on these studies?
• What are the medical options for GERD?
• At what point do you consider a surgical option?
• What is the physiologic goal of the surgical procedure usually utilized for GERD?

2. A 55-year-old man complains of several years of severs heartburn. In the past year, his symptoms were partially relieved by proton pump inhibitors, but now he also has some dysphagia. He does not smoke, and drinks alcohol rarely. His physical exam is remarkable only for some mild obesity. What are the strengths and drawbacks of the diagnostic modalities: Barium swallow, EGD, CT scan, endoscopic ultrasound, esophageal manometry and pH monitoring? Barrett’s esophagus and adenocarcinoma of the GE junction are diagnosed. How would you stage this patient, and how would staging affect your treatment recommendations? If he has surgical resection with negative margins and 2 out of 14 positive lymph nodes, what is his prognosis?

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