MEDIASTINUM 1. Anatomy A. Compartments Mediastinal borders: thoracic inlet (superior ! diaphra"m (in#erior ! sternum (anterior ! spine (posterior !

! pleura (lateral Anterosuperior compartment is anterior to pericardium Contents include th$mus and "reat %essels Middle! or %isceral! compartment is bet&een anterior and posterior pericardial re#lections Contents include heart! phrenic ner%es! tracheal bi#urcation! ma'or bronchi! l$mph nodes (osterior! or para%ertebral! compartment is posterior to posterior pericardial re#lection Contents include esopha"us! %a"us ner%es! s$mpathetic chains! thoracic duct! descendin" aorta! and a)$"os*hemia)$"os 2. Mediastinal Conditions A. Mediastinal Emph$sema ((neumomediastinum Introduction o# air #rom esopha"us! tracheobronchial tree! nec+! or abdomen Causes include penetratin" or blunt trauma! or spontaneous mediastinal emph$sema (resents as substernal chest pain! crepitation! and pericardial crunchin" sound Ma$ result in tamponade Treat underl$in" cause, ma$ re-uire chest tube placement #or pneumothora. /. Mediastinitis 0ccurs in about 12 o# patients a#ter median sternotom$ 3is+ #actors include prolon"ed sur"er$ ! re4e.ploration! &ound dehiscence! shoc+! and use o# bilateral internal mammar$ arter$ "ra#ts in patients &ho are older or ha%e diabetes Acute mediastinitis is a #ulminant in#ectious process that spreads alon" the #ascial planes o# the mediastinum. In#ections ori"inate most commonl$ #rom esopha"eal per#orations! sternal in#ections! and orophar$n"eal or nec+ in#ections. Clinical si"ns and s$mptoms include #e%er! chest pain! d$spha"ia! respirator$ distress! cer%ical and upper thoracic subcutaneous crepitus! ele%ated 5/C! and tach$cardia. In se%ere cases! the clinical course can rapidl$ deteriorate to #lorid sepsis! hemod$namic instabilit$! and death. Thus! a hi"h inde. o# suspicion is re-uired in the conte.t o# an$ in#ection &ith access to the mediastinal compartments. A chest CT scan can be particularl$ help#ul in determinin" the e.tent o# spread and the best approach to sur"ical draina"e. Acute mediastinitis is a true sur"ical emer"enc$ and treatment must be instituted immediatel$ and must be

aimed at correctin" the primar$ problem! such as the esopha"eal per#oration or orophar$n"eal abscess. Another ma'or concern is d6ebridement and draina"e o# the spreadin" in#ectious process &ithin the mediastinum! nec+! pleura! and other tissue planes. Antibiotics! #luid resuscitation! and other supporti%e measures are important! but sur"ical correction o# the problem at its source and open d6ebridement o# in#ected areas are critical measures. Chronic Mediastinitis: Sclerosin" or #ibrosin" mediastinitis is a result o# chronic in#lammation o# the mediastinum! most #re-uentl$ as a result o# "ranulomatous in#ections such as histoplasmosis or tuberculosis. The process be"ins in l$mph nodes and continues as a chronic! lo&4"rade in#lammation leadin" to #ibrosis and scarrin". In man$ patients! the clinical mani#estations are silent. 7o&e%er! i# the #ibrosis is pro"ressi%e and se%ere! it ma$ lead to encasement o# the mediastinal structures! causin" entrapment and compression o# the lo&4pressure %eins (includin" the superior %ena ca%a and innominate and a)$"os %eins . This #ibrotic process can compromise other structures such as the esopha"us and pulmonar$ arteries. There is no de#initi%e treatment. Sur"er$ is indicated onl$ #or dia"nosis or in speci#ic patients to relie%e air&a$ or esopha"eal obstruction or to achie%e %ascular reconstruction. C. Mediastinal Hemorrhage Caused b$ trauma! aortic dissection! aneur$sm rupture! or sur"ical procedures Ma$ result in mediastinal tamponade! &hich is more insidious than pericardial tamponade Meticulous hemostasis and ade-uate chest tube draina"e &ill pre%ent this s$ndrome Spontaneous mediastinal hemorrha"e can result #rom mediastinal masses! altered coa"ulation status! and se%ere h$pertension
D. SVC Obstruction

Pathogenesis a E.trinsic compression o# S8C : 9radual S8C obstruction b In%asion o# S8C : 0bstruction de%elops rapidl$ c Thrombosis o# S8C : Acute obstruction d 8enous h$pertension and l$mphatic obstruction 4 all empt$ into the subcla%ian %eins Causes a /eni"n 1:2

 In#lammator$ 4 histoplasmosis! idiopathic #ibrosin" mediastinitis Iatro"enic 4 pacema+er electrode! h$peralimentation or other C8 line b Mali"nant ;:2 /roncho"enic! epidermoid <=4>:2 Small cell 1?4@:2 A$mphoma 1?4?:2 Symptoms and Signs S&ellin" #ace! nec+! arms Shortness o# breath! orthopnea! cou"h and chest pain su""est upper air&a$ obstruction 7oarseness! stridor! ton"ue s&ellin"! nasal con"estion 7eadaches! s$ncope and lethar"$ are caused b$ cerebral edema #rom %enous h$pertension S$mptoms &orse l$in" do&n! bendin" #or&ard S$mptoms o# cerebral or lar$n"eal edema is associated &itha reduced li#e e.pectanc$ o# about < &ee+s! demandin" ur"ent inter%ention Ca%al obstruction ma$ be the li#e4limitin" problem o# patients &ith underl$in" mali"nanc$ Diagnosis a Chest .4ra$ 3i"ht hilar mass 4 broncho"enic carcinoma Anterior mediastinal mass 4 l$mphoma Calci#ication 4 histoplasmosis b Simultaneous bilateral arm %eno"ram De#ines obstruction and collateral circulation Identi#ies thrombus c Computeri)ed a.ial tomo"raph$ Assessment o# mediastinum Determine patenc$ o# 'u"ular %eins Directed needle biops$ Radiation Therapy Since most cases due to mali"nanc$! nearl$ all patients recei%e radiation >:4;:2 relie%ed o# S8C S$ndrome =:2 o# patients relapse 3elapse occurs in beni"n disease as &ell, althou"h collaterals de%elop! thrombosis &ill continue to propo"ate and occlude these collaterals o%er time Medical Therapy Chemotherap$ #or l$mphomas and small cell carcinoma Diuretics and corticosteroids reduce cerebral edema Anticoa"ulants in selected cases to pre%ent clot propa"ation Thrombol$tic therap$ #or selected acute thrombosis Surgery

 Se%ere S8C S$ndrome associated &ith thrombosis o# ca%al tributaries and inade-uate collateral circulation S8C b$pass &ith composite auto"enous %ein "ra#ts <41? months a#ter onset in beni"n causes or #or palliation in mali"nant causes &ith se%ere or acute onset S8C s$ndrome M D!AST!"A# T$M%RS 1. #ocation Aesions are to some de"ree predictable Most common tumors are neuro"enic (?:2 ! th$momas (?:2 ! primar$ c$sts (?:2 ! l$mphomas (1@2 ! and "erm4cell tumors (1:2 Most are located in anterosuperior compartment (=B2 ! #ollo&ed b$ posterior (?<2 and middle (?:2 tumors Tumors and C$sts b$ Aocation Anterior Th$moma 9erm cell tumor A$mphoma 7eman"ioma (arath$roid adenoma Th$mic c$st Aipoma Aberrant th$roid A$mphan"ioma Middle Posterior Entero"enous c$st Neuro"enic ori"in Mesothelial c$st Neurenteric c$st A$mphoma A$mphoma Thoracic duct c$st 9ranuloma 7amartoma

A si"ni#icant portion (?=4B:2 o# mediastinal tumors are mali"nant Anterosuperior tumors are more li+el$ to be mali"nant! as are tumors o# patients bet&een the a"es o# 1: and B: Neuro"enic tumors and non47od"+inCs l$mphomas are the most common tumors in children 2. Clinical Presentation About t&o4thirds o# patients &ill ha%e s$mptoms at the time o# dia"nosis The absence o# s$mptoms is a reasonabl$ "ood indicator that a dia"nosed tumor is beni"n Most common s$mptoms include chest pain! cou"h! and #e%er Si"ns o# mechanical compression or in%asion o# mediastinal structures are more common &ith mali"nant tumors (araneoplastic s$ndromes are not uncommon and include Cushin"Cs s$ndrome! th$roto.icosis! h$pertension! h$percalcemia! h$po"l$cemia! diarrhea! and "$necomastia &. Diagnosis CD3 &ill locali)e the tumor and "i%e in#ormation on calci#ication and relati%e

densit$ o# the tumor CT scannin" identi#ies chest &all in%asion! multiple masses! and e.tension into spinal column M3I is more accurate #or %ascular in%ol%ement and intracardiac patholo"$ Echocardio"raph$ is use#ul #or patients &ith middle compartment tumors to locali)e bet&een intracardiac and pericardial tumors 9uided needle biops$ can ma+e a dia"nosis o# mali"nanc$ in >:4;:2 o# patients Mediastinoscop$*mediastinotom$ ma$ be necessar$ to ma+e a dia"nosis and establish resectabilit$ '. Thymoma A. Eeatures 3epresents ?:2 o# all mediastinal masses in adults (ea+ incidence is in @rd to =th decades o# li#e, rare in children /et&een 1= and <=2 o# th$momas are beni"n Ere-uentl$ associated &ith paraneoplastic s$ndrome! most commonl$ m$asthenia "ra%is M$asthenia "ra%is (circulatin" antibodies to acet$lcholine receptor is dia"nosed in @:4=:2 o# patients &ith a th$moma! and 1=2 o# m$asthenia patients &ill ha%e a th$moma Autoimmune reaction directed a"ainst the posts$naptic nicotinic receptors results in s+eletal muscle #ati"abilit$ and &ea+ness! especiall$ in a.ial muscles 4 Th$mectom$ leads to impro%ement or resolution o# s$mptoms o# m$asthenia "ra%is in onl$ about ?= percent o# patients &ith th$momas. In contrast! in patients &ith m$asthenia "ra%is and no th$moma! th$mectom$ results are superior: up to =: percent o# patients ha%e a complete remission and ;: percent impro%e. /4The dia"nosis ma$ be suspected based on CT scan and histor$! but ima"in" alone is not dia"nostic. CT4"uided ENA biops$ has a dia"nostic sensiti%it$ o# >= 2 and a speci#icit$ o# ;= 2. C$to+eratin is the mar+er that best distin"uishes th$momas #rom l$mphomas. In most patients! the distinction bet&een l$mphomas and th$momas can be made onCT scan! because most l$mphomas ha%e mar+ed l$mphadenopath$ and th$momas most #re-uentl$ appear as a solitar$ encapsulated mass. C. 0perati%e Techni-ue The de#initi%e treatment #or th$momas is complete sur"ical remo%al #or all resectable tumors, 3emo%e all anterior mediastinal tissue and an$ in%asi%e disease! includin" in%ol%ed lun"! pleura! pericardium! and S8C*innominate %ein Th$mic blood suppl$ arises #rom the internal mammar$ arteries 47i"her sta"es : debul+in"! radiotherap$ and chemotherap$ (ro"nosis is dependent on sta"e o# tumor! not on presence o# m$asthenia "ra%is

(. #ymphoma 0%erall! l$mphomas are the most common mali"nanc$ o# the mediastinum. In about =: percent o# patients &ho ha%e both 7od"+in and non47od"+in l$mphoma! the mediastinum ma$ be the primar$ site. The anterior compartment is most commonl$ in%ol%ed! &ith occasional in%ol%ement o# the middle compartment and hilar nodes. The posterior compartment is rarel$ in%ol%ed. characteristic 7od"+inCs l$mphoma s$mptoms are chest pain a#ter alcohol consumption and c$clic (el4Ebstein #e%ers. Nodular sclerosin" and l$mphoc$te predominance #orms o# 7od"+inCs l$mphoma are the most common to cause mediastinal in%ol%ement. Chemotherap$ and*or radiation results in a cure rate o# up to ;: percent #or patients &ith earl$ sta"e 7od"+in disease! and up to <: percent &ith more ad%anced sta"es. Sur"er$ is indicated i# #ine4needle aspiration is inconclusi%e or to e%aluate residual mass a#ter chemotherap$.Sur"ical options include cer%ical mediastinoscop$! parasternal mediastinotom$! and thoracoscop$ ). *erm Cell Tumors Comprise 1=4?=2 o# anterior mediastinal masses Most common in children and $oun" adults Includes teratomas! teratocarcinomas! seminomas! embr$onal cell carcinomas! choriocarcinomas! and endodermal cell or $ol+4sac tumors Identical to "erm cell tumors ori"inatin" in the "onads! but are not metastatic lesions #rom primar$ "onadal tumors About <:2 are beni"n and B:2 are mali"nant 4 ENA biops$ alone ma$ be dia"nostic #or seminomas! usuall$ &ith normal serum mar+ers! includin" hC9 and AE(. In 1: percent o# seminomas! hC9 le%els ma$ be sli"htl$ ele%ated. ENA #indin"s! alon" &ith hi"h hC9 and AE( le%els! can accuratel$ dia"nose nonseminomatous tumors. I# the dia"nosis remains uncertain a#ter assessment o# ENA #indin"s and serum mar+er le%els! then core4needle biopsies or sur"ical biopsies ma$ be re-uired. An anterior mediastinotom$ (Chamberlain procedure or a thoracoscop$ is the most #re-uent dia"nostic sur"ical approach. A. (redominantl$ /eni"n Tumors Teratomas are comple.! multiple tissue element tumors S$mptoms are related to mechanical e##ects Simplest #orm is the dermoid c$st! &hich consists o# mostl$ dermal and epidermal tissue More comple. teratomas ma$ ha%e &ell4di##erentiated bone! cartila"e! ner%e! or "landular tissue Mali"nant tumors are di##erentiated upon histolo"ic identi#ication o# embr$onic

tissue /. Mali"nant Tumors Male predominance and most patients are s$mptomatic B:2 are seminomas and <:2 are nonseminomas (embr$onal cell! choriocarcinoma! $ol+4sac! and teratocarcinoma
Seminomas "on+seminomas

A,P-.+HC*

rare

;:2

Associated syndromes

none

Fline#elterCs! trisom$ >! =- deletion

Radiosensiti/ity

7i"h

Insensiti%e

Metastatic 0eha/ior

3emain intrathoracic

Ere-uentl$ disseminated

Treatment

3adiation

Cis4platinum chemotherap$

Remission

0%er >:2

C3 in ==4<:2! (3 in @:4@=2

(+year sur/i/al

=:4>:2

=:4<:2

3emission

C3Gcomplete

(3Gpartial

Initial sur"ical inter%ention t$picall$ onl$ #or dia"nosis due to hi"h radiosensiti%it$ o# seminomas and #re-uent metastatic disease in non4 seminomas Sur"ical resection a#ter induction o# chemotherap$ ma$ ha%e a role in non4 seminomatous tumors 1. ndocrine Tumors A. Intrathoracic Thr$oid >:2 are substernal e.tensions o# a cer%ical "oiter True intrathoracic th$roid (deri%es blood suppl$ #rom thoracic %essels comprises onl$ 12 o# all mediastinal tumors More common in &omen and in the <th to Hth decades! most are adenomas Usuall$ presents &ith tracheal or esopha"eal compression, th$roto.icosis is uncommon

 I41@1 scannin" should be done to identi#$ presence o# #unctionin" cer%ical th$roid tissue be#ore resectin" these tumors 3esect substernal e.tensions throu"h a cer%ical incision and true intrathoracic lesions throu"h the chest /. (arath$roid Most are adenomas and are #ound b$ the superior pole o# the th$mus due to common embr$o"enesis #rom the third branchial cle#t S$mptoms are usuall$ due to h$perparath$roid s$ndrome (arath$roid c$sts are not usuall$ hormonall$ acti%e 2. Primary Cysts A. /roncho"enic C$sts Most common primar$ c$sts in the mediastinum (=2 Arise #rom %entral #ore"ut and are usuall$ located in the subcarinal or ri"ht paratracheal re"ion T&o4thirds are as$mptomatic, s$mptoms include tracheobronchial or esopha"eal compression and in#ection #rom tracheobronchial communication Complete e.cision is recommended! e%en i# as$mptomatic! to pre%ent late complications /. Esopha"eal*Enteric C$sts Comprise @4=2 o# mediastinal tumors More common in children and tend to occur in the lo&er third o# the esopha"us D$spha"ia is the most common s$mptom CT scannin" is essential in patients &ith %ertebral anomalies to e%aluate #or possible spinal cord in%ol%ement (neuroenteric c$st A%oid endoscopic biops$! as this ma$ cause c$st per#oration and in#ection Complete e.cision is indicated, a thoracoscopic approach can be used #or unin#ected c$sts C. (leuropericardial C$sts Uncommon! classicall$ occur at the pericardiophrenic an"les! H:4>:2 on the ri"ht side Usuall$ as$mptomatic and ma$ communicate &ith the pericardium 9uided needle aspiration is the initial therap$ o# choice Sur"ical e.cision is indicated i# the c$st recurs or i# the dia"nosis is in doubt 13. "eurogenic Tumors A. Etiolo"$ and Dia"nosis Most posterior mediastinal masses are o# neuro"enic ori"in ;=2 o# these tumors in adults are beni"n and are usuall$ as$mptomatic In children! most neuro"enic tumors are mali"nant Classi#ied accordin" to cell ori"in, most arise #rom intercostal ner%e or s$mpathetic chain

!ntercostal ner/e Sympathetic ganglia

Paraganglia cells

Neuro#ibroma 9an"lioma (ara"an"lioma Neurilemoma 9an"lioneuroblastoma (pheochromoc$toma Neuro#ibrosarcoma Neuroblastoma

Neurilemomas are the most common and also called sch&annomas! arise #rom Sch&ann cells in intercostal ner%es. The$ are #irm! &ell4encapsulated! and "enerall$ beni"n. I# routine CT scan su""ests e.tension o# a neurilemoma into the inter%ertebral #oramen! M3I is su""ested to e%aluate the e.tent o# this IdumbbellJ con#i"uration. Such a con#i"uration ma$ lead to cord compression and paral$sis! and re-uires a more comple. sur"ical approach. It is recommended that most ner%e sheath tumors be resected. In children! "an"lioneuroblastomas or neuroblastomas are more common, there#ore all neuro"enic tumors should be completel$ resected. Neuro#ibroma. Neuro#ibromas ha%e components o# both ner%e sheaths and ner%e cells and account #or up to ?= percent o# ner%e sheath tumors. Up to B: percent o# patients &ith mediastinal #ibromas ha%e "enerali)ed neuro#ibromatosis (%on 3ec+lin"hausenKs disease . About H: percent o# neuro#ibromas are beni"n. Mali"nant de"eneration to a neuro#ibrosarcoma ma$ occur in ?=L@: percent o# patients. Neuro#ibrosarcomas carr$ a poor pro"nosis because o# rapid "ro&th and a""ressi%e local in%asion alon" ner%e bundles. Complete sur"ical resection is the mainsta$ o# treatment. The Diaphragm 1. Anatomy #ibromuscular structure composed o# a central tendinous portion and a peripheral muscular portion Muscular portion consists o# sternal! costal! and lumbar components Three ma'or openin"s: aortic (aorta! a)$"os %ein! thoracic duct ! esopha"eal (esopha"us! %a"us ner%es ! ca%al (I8C 3i"ht and le#t phrenic arteries arise #rom the abdominal aorta Additional arterial suppl$ #rom pericardiophrenic and musculophrenic arteries 8enous draina"e is %ia ri"ht and le#t phrenic %eins to the I8C, some draina"e to the le#t renal %ein as &ell 3i"ht and le#t phrenic ner%es suppl$ both sensor$ and motor inner%ation 2. Congenital Diaphragmatic Hernias A. /ochdale+Cs 7ernia 0ccurs posterolateral in the area o# the 1:th and 11th ribs throu"h the dome o# diaphra"m.

 ;:2 occur on the le#t ?:1 male to #emale incidence Usuall$ isolated and not associated &ith other con"enital de#ects T$picall$ mani#ests as acute respirator$ distress 4D. prenatal US CD3 demonstrates intestine in the thora. and shi#t o# mediastinal contents to the ri"ht Initial treatment includes N9 decompression! positi%e4pressure %entilator$ support! and sur"ical correction Approach le#t4sided de#ect throu"h the abdomen in order to e.plore #or malrotation and obstruction 3i"ht4sided de#ects are repaired throu"h a thoracotom$ (ostoperati%e mortalit$ can be as hi"h as =:2! mostl$ attributed to increased pulmonar$ %ascular resistance 4 (ro"nosis is related to the se%erit$ o# pulmonar$ h$poplasia. /. Mor"a"niCs 7ernia De#ect occurs in a subcostosternal location (anterior part b*& costal M sterna attachement Uncommon (less than @2 o# diaphra"matic hernias and usuall$ as$mptomatic 5ell de#ined hernia sac becomes s$mptomatic t$picall$ a#ter a"e B:! &hen obesit$! pre"nanc$! or trauma increases intraabdominal pressure The trans%erse colon is the most common or"an to herniate! and can present as an acute colonic obstruction 3epair is usuall$ per#ormed throu"h a upper midline incision C. Esopha"eal 7iatal 7ernia Con"enital de#ects causin" these hernias are uncommon in adults! but some neonates and in#ants ma$ ha%e re#lu. associated &ith an esopha"eal hiatal hernia T$pical s$mptoms are %omitin"! respirator$ complications! anemia! and #ailure to thri%e Dia"nosis rests on esopha"o"raph$! #luoroscop$! and p7 monitorin" Treatment is primaril$ medical, sur"er$ is indicated #or medical #ailure &. Tumors o4 the Diaphragm A. (rimar$ 3are tumors, c$sts are more common than in#lammator$ masses! &hich are more common than neoplasms E-ual M:E incidence, A4sided are sli"htl$ more common than 34sided tumors S$mptoms include pain! cou"h! d$spnea! and 9I s$mptoms CD3 and CT scan &ill locali)e the tumor The ma'orit$ o# neoplasms are beni"n (<:2 ! &hich are usuall$ c$sts

 Up to B:2 are mali"nant! usuall$ sarcomas Treatment includes e.cision and closure o# the diaphra"matic de#ect /. Metastatic Most neoplastic in%ol%ement o# the diaphra"m occurs #rom conti"uous e.tension o# nearb$ tumors The most common lesions arise #rom lun"! esopha"us! stomach! li%er! and the retroperitoneum Treatment is based on the primar$ tumor '. Traumatic Per4oration (enetratin" per#oration should be suspected &ith an$ thoracic in'ur$ belo& the le%el o# the nipples (=th ICS Most blunt hernias are caused b$ automobile accidents! and about ;:2 occur in the le#t hemidiaphra"m /lunt trauma de#ects are lar"e! usuall$ about 1:41= cm! and t$picall$ located in the posterior le#t hemidiaphra"m Stomach is the most commonl$ herniated or"an! #ollo&ed b$ spleen! colon! small bo&el! and li%er 3espirator$ insu##icienc$ is common earl$! &hile intestinal obstruction predominates later CD3 and CT scan &ill dia"nose most, barium contrast is contraindicated! as it can produce a total obstruction in this settin" Missed in'ur$ and dela$ed dia"nosis commonl$ leads to bo&el incarceration and obstruction Mortalit$ is relati%el$ hi"h (1=4B:2 due to hi"h incidence o# associated in'uries 3epair should be underta+en promptl$ &ith #ull e.ploration #or other in'uries 4 unless there is stran"ulation or bleedin" itKs best mana"ed at inter%al Ae#t4sided per#oration should be repaired throu"h the abdomen to allo& correction o# associated in'uries 3i"ht4sided per#orations ma$ re-uire thoracotom$ =4 Disorders o# inner%ations Durin" normal respiration! the brain stem sends action potentials to the third throu"h #i#th spinal le%els! &hich then "i%e o## dorsal rami that con%alesce to #orm the phrenic ner%es bilaterall$ Traumatic in'ur$ to the head or brain stem pre%ents ner%e si"nals #rom reachin" the phrenic ner%e. 9enerall$! in'uries that a##ect the brain and brain stem are catastrophic! &ith the chance o# sur%i%al bein" "rim. In'uries or disease processes that a##ect the respirator$ ner%ous impulse alon" its lon" course are &idel$ described. A number o# distinct entities! includin" trauma! spinal cord disorders! s$rin"om$elia! poliom$elitis! and di##erent motor neuron diseases! decrease the impulse o# stimuli to the cer%ical spinal cord. (eripheral phrenic ner%e in'uries result #rom dama"e to the ner%e alon" its path in

the cer%ical area or the thora.. A number o# clinical entities can a##ect the phrenic ner%e directl$! includin" trauma! open heart sur"er$ or thoracic sur"er$! chiropractic cer%ical spine manipulation! radiation therap$! dem$elinatin" diseases (e"! 9uillain4/arrN s$ndrome ! neoplasm! uremia! lead neuropath$! postin#ectious neuropathies! and man$ other processes

diaphra"matic pacer:is indicated in patients &ho ha%e chronic %entilator$ insu##icienc$ &ith normal ner%es! lun"s and diaphra"m This includes some -uadriple"ic patients and central al%eolar h$po%entilation Contraindications to pacin" are lo&er motor neuron d$s#unction! muscular d$stroph$! and e.tensi%e lun" disease

Chest 5all Anomalies and Tumors Anatomy : The bon$ thora. consists o# 1? paired ribs! multiple cartila"es! and the sternum and cla%icles arran"ed about the thoracic %ertebrae. The ribs and sternum determine the si)e and shape o# the thoracic ca%it$. The upper se%en ribs (numbered 1 to H are true ribs because the$ articulate directl$ &ith the sternum b$ means o# cartila"es. The lo&er #i%e ribs (numbered > to 1? are #alse ribs, the$ do not directl$ connect to the sternum anteriorl$ but! in most cases! connect &ith the costocartila"e abo%e them. 3ibs 11 and 1? are #loatin" ribs. /eneath s+in and subcutaneous tissue! the bon$ thora. is co%ered b$ three "roups o# muscles: the primar$ and secondar$ muscles #or respiration and those attachin" the upper e.tremit$ to the bod$. The primar$ muscles include the diaphra"m and intercostal muscles. The intercostal muscles o# the intercostal spaces include the e.ternal! internal! and trans%erse or innermost muscles. Ele%en intercostal spaces! each associated numericall$ &ith the rib superior to it! contain the intercostals bundles (%ein! arter$! and ner%e that tra%el alon" the lo&er ed"e o# each rib The secondar$ muscles consist o# the sternocleidomastoid! the serratus posterior! and the le%atores costarum. The third muscle "roup attaches the upper e.tremit$ to the bod$. The pectoralis ma'or and minor muscles lie anteriorl$ and super#iciall$. (osterior super#icial musculature includes the trape)ius and latissimus dorsi. Deep muscles include the serratus anterior and posterior! the le%atores! and the ma'or and minor rhomboids. These super#icial and deep muscles help to hold the scapulae to the chest &all . In respirator$ distress! the deltoid! pectoralis! and latissimus dorsi muscles #orm a tertiar$ s$stem #or %entilator$ assistance throu"h #i.ation o# the upper e.tremities.

C0N9ENITAA DEE03MITIES 0E C7EST 5AAA 1. Pectus 6ca/atum (#unnel chest Most common con"enital sternal de#ormit$! occurrin" in 1 in B:: children. M:E B:1 E.cessi%e "ro&th o# lo&er costal cartila"e results in sternal depression Usuall$ causes a deeper depression on the ri"ht! pushin" heart to the le#t Con"enital &ith pro"ressi%e &orsenin" o%er time 3arel$ #amilial 2. Physiologic Mani4estations Usuall$ as$mptomatic Sub'ecti%e decrease in respirator$ reser%e &ith e.ercise Scoliosis and mitral %al%e prolapse ha%e been associated &ith pectus e.ca%atum Decreased ma.imal %oluntar$ %entilation and a mild restricti%e pattern on (ETs has been documented in some studies Decreased S8 and C0 durin" upri"ht e.ercise has also been demonstrated &. %perati/e !ndications Cosmetic correction is the most common reason (s$cho4social #actors! ho&e%er! ma$ be -uite limitin"! particularl$ in older children 3espirator$ insu##icienc$ and recurrent pulmonar$ in#ections /est results are obtained in patients bet&een the a"es o# @ and = '. %perati/e Techni7ue 3a%itch repair! Sternal e%ersion! (rosthetic implants 4repositionin" the sternum anteriorl$ b$ sternal osteotom$ 8. %ther De4ormities A. (ectus Carinatum( pi"eon chest More common in males (B:1 !a #amilial predisposition (@:2 and an association &ith scoliosis (1=2 and con"enital heart disease (?:2 are reported Usuall$ presents as anterior sternal displacement (protrusion &ith s$mmetric costal cartila"e conca%it$ 4 S$mptoms are uncommon but ma$ include e.ertional d$spnea or cardiac arrh$thmias. (ulmonar$ #unction tests and echocardio"raph$ are use#ul #or determinin" the e.tent o# cardiopulmonar$ compromise. Costal cartila"e resection "i%es e.cellent results L mobili)in" the sternum and allo&in" it to #all bac+ into place. Sur"er$ best le#t until late teens &hen #urther "ro&th o# chest &all is unli+el$ /. (olandCs s$ndrome rare! non#amilial disease o# un+no&n cause that occurs in 1 per @:!::: births.

The components o# the s$ndrome include absence o# the pectoralis ma'or muscle! absence or h$poplasia o# the pectoralis minor muscle! absence o# costal cartila"es! h$poplasia o# breast and subcutaneous tissue (includin" the nipple comple. ! and a %ariet$ o# hand anomalies. patients &ho present &ith absent ribs are considered candidates #or sur"ical repair. Althou"h a %ariet$ o# sur"ical techni-ues ha%e been described to correct this anomal$! an approach usin" a latissimus dorsi muscle #lap &ith autolo"ous rib "ra#ts to reconstruct the chest &all commonl$ is used. C. Sternal #issure Complete (thoracic ectopia cordis ! upper (cer%ical ectopia cordis ! or distal (thoracoabdominal ectopia cordis %arieties occur Narro& cle#ts can be closed primaril$ a#ter mobili)ation b$ obli-ue chrondotomies /roader cle#ts ma$ re-uire a prosthesis to a%oid compressin" the heart D. CantrellCs (entalo"$ Characteri)ed b$ a distal cle#t! omphalocele! diaphra"matic cle#t! pericardial de#ect! and con"enital heart de#ect (usuall$ 8SD or T0E 0ne4sta"e repair is usuall$ possible C7EST 5AAA TUM03S 1. !ncidence Comprise H4>2 o# all bon$ tumors Most primar$ chest &all tumors are mali"nant >=4;:2 occur in the ribs (=:2 mali"nant 1:41=2 occur in the sternum (;=2 mali"nant Male:#emale G ?:1 2. Clinical Presentation Slo&l$ enlar"in" mass e%entuall$ causes pain and presence o# mass (ain is more common in mali"nant tumors! but ?:4?=2 are as$mptomatic Tumors occur at an$ a"e and are more li+el$ to be mali"nant in older patients CD3 &ith rib detail #ilms and CT scan are usuall$ ade-uate and can e%aluate associated pulmonar$ nodules M3I distin"uishes ner%e and %ascular in%asion &. tiology Malignant Chondrosarcoma M$eloma .enign Eibrous d$splasia (B:2 Chondroma (@:2

0steo"enic sarcoma E&in"Cs sarcoma

0steochondroma Desmoid

'. Principles o4 Treatment E.cisional rather than incisional biops$ should be pe#ormed i# a primar$ chest &all tumor is suspected Eull thic+ness e.cision o# the tumor &ith 1 rib mar"in is necessar$, do not compromise resection to a%oid lar"e chest &all de#ect Aar"e tumors ma$ &arrant incisional biops$ Needle biops$ is best #or suspicious mets or m$eloma Sternal tumors should be treated b$ sternectom$ - 3econstruction Thoracic %utlet Compression Syndrome 1. De4inition Compression o# the subcla%ian %essels and brachial ple.us at the superior aperture o# the chest! most commonl$ a"ainst the #irst rib. 0ther terms #or this s$ndrome include scalenus anticus s$ndrome! costocla%icular s$ndrome! h$perabduction s$ndrome! cer%ical rib s$ndrome! and #irst thoracic rib s$ndrome. 2. Anatomy A. Sur"ical Anatom$ The #irst rib di%ides the cer%icoa.illar$ canal into a pro.imal space and a distal space (the a.illa Most neuro%ascular compression occurs in the pro.imal section! &hich consists o# the costocla%icular space and the scale trian"le Costocla%icular space boundaries: cla%icle (superior ! #irst rib (in#erior ! costocla%icular li"ament (anteromedial ! and scalenus medius*lon" thoracic ner%e (posterolateral Scalene trian"le boundaries: scalenus anticus (anterior ! scalenus medius (posterior ! and #irst rib (in#erior The subcla%ian %ein lies anteromedial to the scalenus anticus, the subcla%ian arter$ and brachial ple.us run posterolateral to this muscle /. Eunctional Anatom$ Certain mo%ements and position o# the arm and shoulder "irdle! as &ell as anatomic %ariations! can narro& the costocla%icular space or scalene trian"le Arm abduction rotates the cla%icle to&ard the #irst rib Arm h$perabduction pulls the neuro%ascular bundle around the coracoid process and head o# the humerus (oor shoulder posture lessens the an"le o# the sternocla%icular 'oint as the distal end o# the cla%icle OdroopsO Se%ere emph$sema or e.cessi%e muscular de%elopment causes abnormal li#tin" o# the #irst rib

 Anatomic %ariations narro& either the superior an"le or the base o# the scalene trian"le! producin" upper and lo&er t$pes o# compression s$ndromes! respecti%el$ &. tiology There are man$ #actors &hich can cause neuro%ascular compression at the thoracic outlet. /on$ abnormalities are present in about @:2 o# patients! and some o# these ma$ be %isuali)ed on plain chest .4ra$.
I. Anatomic Eactors Interscalene compression Costocla%icular compression Subcoracoid compression II. Con"enital Eactors Cer%ical rib 3udimentar$ #irst rib Scalene muscle abnormalities Eibrous bands /i#id cla%icle Eirst rib e.ostosis Enlar"ed CH trans%erse process 0moh$oid muscle abnormalities Anomalous trans%erse cer%ical arter$ (ost#i.ed brachial ple.us Elat cla%ice III. Traumatic Eactors Eractured cla%ice 7umeral head dislocation Upper thora. crush in'ur$ Sudden e##ort o# shoulder "irdle muscles C4spine in'uries*cer%ical spond$losis I8. Atherosclerosis

Cer%ical rib is presented b$ a #ibrous band ori"inatin" #rom Hth cer%ical %ertebra Minsertin" onto the 1st thoracic rib. It ma$ be as$mptomatic! but because the subcla%ian arter$M brachial ple.us course o%er it a %ariet$ o# s$mptoms ma$ occur. The lo&er trun+ o# the ple.us (mainl$ T1 is compressed leadin" to &astin" o# interossei and altered sensation in T1 distribution '. Clinical Presentation The character and pattern o# s$mptoms &ill %ar$ dependin" on the de"ree to &hich ner%es! blood %essels! or both are compressed A. Neuro"enic More #re-uent than %ascular compression (ain and paresthesias present in ;=2 o# patients True motor &ea+ness &ith atroph$ o# h$pothenar*interosseus muscles #ound in 1:2 Sensor$ #ibers lie on the outside o# the ner%e bundles and are the #irst to be

a##ected b$ compression S$mptoms usuall$ ha%e ulnar ner%e distribution (medial arm and hand! Bth and =th #in"ers (ain is insidious and in%ol%es nec+! shoulder! arm and hand Strenuous ph$sical e.ercise preciptates the s$mptoms! &ith arm in abduction and nec+ h$pere.tended /. 8ascular (ain is usuall$ di##use and associated &ith coldness! &ea+ness! and eas$ #ati"uabilit$ o# the hand and arm Unilateral 3a$naudCs phenomonen in about H.=2 o# patients! &hich can be precipitated b$ h$perabduction or carr$in" hea%$ ob'ects There ma$ be si"ns o# distal emboli)ation! poststenotic dilation or aneur$sm o# the subcla%ian arter$! or true arterial occlusion 8enous obstruction is much less common and is +no&n as Oe##ort thrombosisO or O(a"et4Schroetter s$ndromeO The a##ected arm is edematous! discolored! and aches (. Diagnosis A. Clinical maneu%ers (ositi%e #indin"s #or all tests include a decrease or loss o# the radial pulse! or reproduction o# s$mptoms Adson*scalene test: patient holds a deep inspiration! #ull$ e.tends nec+! and turns head to the side Costocla%icular test: shoulders dra&n in#eriorl$ and posteriorl$ 7$perabduction test: arm is h$perabducted to 1>: de"rees /. 3adiolo"ic tests CD3 and C4spine #ilms can detect cer%ical ribs and de"enerati%e chan"es Cer%ical CT should be per#ormed i# osteoph$tic chan"es and inter%ertebral space narro&in" are present An"io"raph$ is indicated #or a pulsatin" paracla%icular mass! absent radial pulse! or paracla%icular bruit C. Ulnar ner%e conduction %elocit$ (oints o# stimulation include the supracla%icular #ossa! middle upper arm! belo& elbo&! and &rist Normal %alue across the thoracic outlet is H? m*sec, an$ %alue less than H: m*sec indicates compression 8. Di44erential Diagnosis The di##erential dia"nosis #or thoracic outlet s$ndrome is -uite broad and includes neurolo"ic! %ascular! pulmonar$! cardiac! and esopha"eal disorders. Some o# the more common conditions include herniated cer%ical dis+! cer%ical

spond$losis! and peripheral neuropathies ). Treatment (h$sical therap$ should be initiated in all patients Most patients &ith an UNC8 abo%e <: m*sec &ill impro%e &ith conser%ati%e therap$ Sur"ical inter%ention should be considered i# s$mptoms persist a#ter ph$sical therap$ and the UNC8 sho&s minimal or no impro%ement 1. %perati/e Techni7ue Al&a$s document preoperati%e neurolo"ic #indin"s Transa.illar$ #irst rib resection a%oids di%ision o# ma'or muscle "roups! ensures complete remo%al o# the #irst rib! and has the best cosmetic result 3emo%e the entire #irst rib! as an$ residual portion ma$ cause recurrence 2. Results Almost all patients &ill ha%e relie# &ith conser%ati%e therap$! &ith about =2 re-uirin" sur"er$ S$mptoms recur in about 1:2 o# patients Aess than ?2 &ill re-uire reoperation 13. Recurrent Thoracic %utlet Syndrome Pseudorecurrence occurs in patients in &hom a cer%ical rib or the second rib &as resected instead o# the #irst rib! or the #irst rib &as resected instead o# the causati%e cer%ical rib True recurrence occurs in patients in &hom the #irst rib &as incompletel$ resected or there &as e.cessi%e scar de%elopment around the brachial ple.us Pneumothora6 is the accumulation o# air &ithin the pleural space. (neumothoraces ma$ be spontaneous or occur secondar$ to a traumatic! sur"ical! therapeutic! or disease4 related e%ent. A pneumothora. compresses lun" tissue and reduces pulmonar$ compliance! %entilator$ %olumes! and di##usin" capacit$. These pathoph$siolo"ic conse-uences depend primaril$ on the si)e o# the pneumothora. and condition o# the underl$in" lun". I# air enters the pleural space repeatedl$ (as &ith inspiration and is unable to escape! positi%e pressure de%elops in the pleural space! causin" compression o# the entire lun"! shi#tin" o# the mediastinum and heart a&a$ #rom the pneumothora.! and se%ere respirator$ compromise &ith hemod$namic collapse. This situation is called a tension pneumothora. and re-uires immediate decompressi%e treatment. It ma$ be the se-uela o# a pneumothora. #rom man$ causes. A primar$ spontaneous pneumothora. occurs &ithout +no&n cause or e%idence o# di##use pulmonar$ disease or #rom subpleural blebs. A secondar$ spontaneous pneumothora. occurs as the result o# an underl$in" pulmonar$ process that predisposes to pneumothora.. Chronic obstructi%e pulmonar$ disease (C0(D !/ullous disease!C$stic #ibrosis!(neumoc$stis4related

con"enital c$sts!Idiopathic pulmonar$ #ibrosis (I(E !(ulmonar$ embolism! Catamenial ( lun" endometriosis And Neonatal. Iatro"enic pneumothoraces are common and ma$ be caused b$ thoracentesis! central %enous catheteri)ation! sur"er$! mechanical %entilation! or dia"nostic lun" biops$. And Traumatic (neumothora. : blunt or penetratin" trauma (atients &ith pneumothora. most commonl$ present &ith chest pain. It is o#ten sharp and pleuritic and ma$ lead to se%ere respirator$ embarrassment or become dull and persistent. D$spnea is the second most common s$mptom in patients &ith pneumothora.. Aess common s$mptoms include nonproducti%e cou"h and orthopnea. The dia"nosis o# primar$ spontaneous pneumothora. usuall$ is established b$ histor$ and ph$sical e.amination and con#irmed &ith chest radio"raph$. (atients are o#ten tall! thin men #rom ?= to B: $ears o# a"e. (h$sical #indin"s ma$ be normal i# the pneumothora. is less than ?=2. Characteristic ph$sical #indin"s include diminished chest e.cursion and h$perresonance on percussion o# the a##ected side. /reath sounds are diminished to absent. 3arel$! subcutaneous emph$sema ma$ be palpated or pneumomediastinum auscultated on cardiac e.amination. A pneumothora. usuall$ is seen on the standard posteroanterior chest radio"raph &ith displacement o# the %isceral pleura #rom the parietal pleura b$ air in the pleural space. The area appears h$perlucent &ith absent pulmonar$ mar+in"s. An end4e.pirator$ chest radio"raph ma$ appear to increase the si)e o# the pneumothora. because o# reduction in lun" %olume durin" #orced e.piration. 3eco"nition o# a pneumothora. ma$ be di##icult on portable supine or semirecumbent chest radio"raphs obtained in trauma or criticall$ ill patients because o# both the location o# the least dependent pleural spaces (anterior! subdiaphra"matic and associated radio"raphic #indin"s. (atients &ith bullous disease also ma$ ha%e chest radio"raphs that are di##icult to interpret, chest CT ma$ be use#ul in these situations. The routine use o# CT in patients &ith spontaneous primar$ pneumothora. is not &arranted because the con#irmation o# apical blebs does not chan"e treatment recommendations. The occurrence o# apical blebs and bullae in these patients has been #ound to be "reater than >=2 in most recent sur"ical series. The treatment o# a #irst4time spontaneous pneumothora. depends on the si)e o# pneumothora.! associated s$mptoms! and pulmonar$ histor$. Small pneumothoraces (P?:2 that are stable ma$ be monitored i# the patient has #e& s$mptoms. Eollo&4up o# a pneumothora. should include a chest radio"raph to assess stabilit$ &ithin ?B to B> hours. An uncomplicated pneumothora. should reabsorb at a rate o# appro.imatel$ 12 per da$. Indications #or inter%ention include pro"ressi%e pneumothora.! dela$ed pulmonar$ e.pansion! or de%elopment o# s$mptoms.

Moderate (?:2 to B:2 and lar"e (QB:2 pneumothoraces nearl$ al&a$s are associated &ith persistent s$mptoms that cause ph$sical limitations and re-uire inter%ention. Simple needle aspiration o# a pneumothora. ma$ relie%e s$mptoms and can promote -uic+er lun" ree.pansion. It also ma$ help to determine &hether the initial #istula that caused the pneumothora. has sealed or i# there is an on"oin" air lea+ that re-uires chest tube insertion. This method is carried out usin" a standard thoracentesis +it and either an e%acuated bottle or hand aspiration %ia a three4&a$ stopcoc+ and s$rin"e. The needle "enerall$ is placed either anteriorl$ or laterall$. The needle aspiration ma$ be repeated! or a chest tube or needle catheter*thoracic %ent draina"e s$stem ma$ be inserted. It pro%ides e.cellent mana"ement o# iatro"enic pneumothoraces a#ter central %enous access or lun" needle biops$. This approach conser%ati%el$ treats a sealed pneumothora. and identi#ies those &ith an acti%e air lea+ #or chest tube insertion. Emer"ent needle decompression #or tension pneumothora. is carried out on the a##ected side b$ placin" an 1>4"au"e needle or an"iocatheter into the hemithora. at the midcla%icular line in the second anterior intercostal space. This emer"enc$ maneu%er relie%es the tension created &ithin the thora.. It does not treat the pneumothora., subse-uent chest tube insertion is re-uired. Tube thoracostom$ (chest tube insertion and under&ater seal draina"e are the mainsta$s o# treatment #or spontaneous pneumothora.. Eull re4e.pansion o# the lun"! e%en in the presence o# a continuous lea+! usuall$ can be achie%ed &ith the application o# suction to the thoracostom$ draina"e s$stem. The classic location #or chest tube insertion is the same as #or emer"enc$ needle decompression because the tube can be inserted -uic+l$ and easil$ &ithout the need #or patient positionin". The pre#erred approach is throu"h the #ourth! #i#th! or si.th intercostal space in the mid4to4anterior a.illar$ line. This can be done under local anesthetic emplo$in" rib bloc+s or under intra%enous procedural sedation. The chest tube should be directed up&ard to the ape. o# the hemithora.. Care should be ta+en to a%oid the subcutaneous placement o# a chest tube. Di"ital pleural dilatation is recommended to con#irm entrance into the chest ca%it$! appreciate an$ adhesions! and allo& passa"e o# the chest tube &ithout need #or a st$let! &hich can cause dama"e to the lun" or other intrathoracic structures. Complications o# chest tube insertion #or pneumothora. are in#re-uent but include laceration o# an intercostals %essel! laceration o# the lun"! intrapulmonar$ or e.trathoracic placement o# the chest tube! and in#ection. 3e4e.pansion pulmonar$ edema is a rare complication that can be seen a#ter treatment o# a pneumothora.. Althou"h it is thou"ht to be secondar$ to a sudden increase in capillar$ permeabilit$! the e.act mechanism o# this increased permeabilit$ is un+no&n. Most cases ha%e been reported a#ter rapid lun" re4e.pansion. An air lea+ ma$ be present #or a %ariable amount o# time a#ter tube thoracostom$. Should the air lea+ persist #or more than H? hours or the lun" not completel$

re4e.pand! sur"ical inter%ention is &arranted. (rimar$ spontaneous pneumothora. tends to recur &ith increasin" #re-uenc$ a#ter each episode. The ris+ o# #irst4time recurrence is on the order o# ?=2 to @:2. Sur"er$ is recommended #or a recurrence or the de%elopment o# a contralateral pneumothora.. Sur"ical inter%ention #or a #irst4time pneumothora. is recommended in situations that include bilateral simultaneous pneumothoraces! complete (1::2 pneumothora.! pneumothora. associated &ith tension! and borderline cardiopulmonar$ reser%e and in patients in hi"h4ris+ pro#essions or acti%ities in%ol%in" si"ni#icant %ariations in atmospheric pressure! such as pilots or scuba di%ers. Sur"er$ #or complications o# pneumothora. (emp$ema! hemothora.! or chronic pneumothora. also is recommended in patients &ith #irst4time spontaneous pneumothora.. Sur"er$ #or primar$ spontaneous pneumothora. has e%ol%ed o%er recent $ears #rom open thoracotom$ (a.illar$ or posterolateral to a minimall$ in%asi%e %ideo4 assisted techni-ue . The sur"er$ carried out is identical! despite the di##erences in approach. Apical blebs are resected. The parietal pleura o%er the ape. o# the hemithora. can be remo%ed (pleurectom$ ! abraded (mechanical pleurodesis ! or treated &ith talc or tetrac$cline4li+e a"ents (chemical pleurodesis or poudra"e . The recurrence rate #or these procedures! per#ormed open or closed! is less than =2. Treatment options #or primar$ and secondar$ spontaneous pneumothora. are similar. 7o&e%er! patients &ith secondar$ pneumothora. "enerall$ are debilitated #rom a respirator$ standpoint and ma$ ha%e other si"ni#icant comorbid diseases. Treatment &ith tube thoracostom$ alone has a hi"h recurrence rate. E##ecti%e treatment must be indi%iduali)ed but should include chemical or sur"ical pleurodesis in combination &ith complete lun" ree.pansion and e##ecti%e sealin" o# air lea+s.

sophagus:
Anatom$ The esopha"us is a muscular tube that be"ins at the phar$n.! tra%els throu"h the thora. in the posterior mediastinum! and empties into the cardia o# the stomach. Superior third: Striated muscle onl$. Middle third: /oth striated and smooth muscle. In#erior third: Smooth muscle onl$. T&o sphincters are present &hich #unction as control points: Upper esopha"eal sphincter (UES pre%ents the passa"e o# e.cess air into the stomach durin" breathin". Ao&er esopha"eal sphincter (AES pre%ents the re#lu. o# "astric contents ACHA#AS!A DEEINITI0N Achalasia is the result o# a primar$ or secondar$ deran"ement o# the m$enteric ple.us! the net&or+ o# neurons in%ol%ed in the coordination o# "astrointestinal (9I motilit$. The resultin" d$spha"ia is due to three mechanisms:

1. Nonperistaltic contrations ?. Incomplete rela.ation o# the AES a#ter s&allo&in" @. Increased restin" tone o# the AES SI9NS AND SRM(T0MS D$spha"ia #or both solids and li-uids 3e"ur"itation o# #ood Se%ere halitosis (due to the decomposition o# sta"nant #ood &ithin the esopha"us DIA9N0SIS Aateral upri"ht chest .4ra$ (CD3 ma$ re%eal a dilated esopha"us and the presence o# airL#luid le%els in the posterior mediastinum. /arium s&allo& &ill re%eal the characteristic distal birdKs bea+ si"n due to the collection o# contrast material in the pro.imal dilated se"ment and the passa"e o# a small amount o# contrast throu"h the narro&ed AES. Esopha"eal motilit$ stud$ &ill con#irm nonperistaltic contractions! incomplete AES rela.ation! and increased AES tone. Esopha"oscop$ is indicated to rule out mass lesions or strictures! and to obtain specimens #or biops$. T3EATMENT Medical mana"ement: Dru"s that rela. the AES such as nitrates or calcium channel bloc+ers Sur"ical mana"ement: Endoscopic dilatation or esopha"om$otom$ &ith #undoplication Esopha"om$otom$: Esopha"us is e.posed %ia transthoracic (le#t thoracotom$ ! transabdominal! thorascopic! or laparoscopic techni-ue. The tunica muscularis o# the esopha"us is incised distall$! &ith e.tension to the AES. Complete di%ision o# the AES necessitates the addition o# an antire#lu. procedure such as Nissen @<:S #undoplication or partial #undoplication. Endoscopic dilatation: Ao&er success rate and a hi"her complication rate .In%ol%es insertin" a balloon or pro"ressi%el$ lar"er si)ed dilators throu"h the narro&ed lumen! &hich causes tearin" o# the esopha"eal smooth muscle and decreases the competenc$ o# the AES. C0M(AICATI0NS 3is+ o# s-uamous cell carcinoma is as hi"h as 1:2 in patients &ith lon"4standin" achalasia (1= to ?= $ears . (atients ma$ also de%elop pulmonar$ complications such as aspiration pneumonia! bronchiectasis! and asthma! due to re#lu. and aspiration. D!,,$S S%PHA* A# SPASM 9D S: DEEINITI0N DES is a disorder o# un+no&n etiolo"$ that! li+e achalasia! in%ol%es a d$s#unction o# the m$enteric ple.us. It ma$ be a primar$ disease process! or it ma$ occur in

association &ith re#lu. esopha"itis! esopha"eal obstruction! colla"en %ascular disease! and diabetic neuropath$. Spasm occurs in the distal t&o thirds o# the esopha"us and is caused b$ uncoordinated lar"e4amplitude contractions o# smooth muscle. SI9NS AND SRM(T0MS D$spha"ia #or both solids and li-uids. Chest pain similar to that seen in m$ocardial in#arction (MI : Acute onset o# se%ere retrosternal pain that ma$ radiate to the arms! 'a&! or bac+. The chest pain ma$ occur at rest! or it ma$ #ollo& s&allo&in". The de"ree o# chest pain depends on the duration and se%erit$ o# the contractions. No re"ur"itation (unli+e achalasia . DIA9N0SIS /arium s&allo& ma$ re%eal the characteristic Icor+scre&J appearance o the esopha"us. This appearance is due to the ripples and sacculations that are %isible due to uncoordinated esopha"eal contraction. /arium s&allo& ma$ be entirel$ normal! ho&e%er! because the esopha"us ma$ not be in spasm at the time o# the stud$. In contrast to achalasia! the AES appears its normal diameter. Esopha"eal manometr$ studies &ill re%eal the presence o# lar"e! uncoordinated! and repetiti%e contractions in the lo&er esopha"us. Alternati%el$! manometr$ ma$ appear normal &hen the patient is as$mptomatic. Esopha"oscop$ should be per#ormed to rule out mass lesions! strictures! or esopha"itis. T3EATMENT Nitrates or calcium channel bloc+ers to decrease AES pressure. Sur"ical treatment %ia esopha"om$otom$ is not as success#ul in relie%in" s$mptoms as it is #or achalasia and is there#ore not recommended unless pain or d$spha"ia are se%ere and incapacitatin" ,%R !*" .%D! S !" TH % S%PHA*$S All manner o# #orei"n bodies ha%e become arrested in the oesopha"us. /utton batteries ma$ be a troublesome problem in children. The most common impacted material is #ood! and this usuall$ occurs abo%e a si"ni#icant patholo"ical lesion .(lain radio"raphs are o#ten use#ul #or #orei"n bodies! but modern denture materials are not al&a$s radiopa-ue. A contrast e.amination is not usuall$ re-uired and onl$ ma+es endoscop$ more di##icult. Eorei"n bodies that ha%e become stuc+ in the oesopha"us should be remo%ed b$ #le.ible endoscop$ usin" suitable "raspin" #orceps! a snare or a bas+et. I# the ob'ect ma$ in'ure the oesopha"us on &ithdra&al! an o%ertube can be used! and the endoscope and ob'ect can be &ithdra&n into the o%ertube be#ore remo%al.

/utton batteries can be a particular &orr$ as the$ are di##icult t "rasp! and it is temptin" to push them on into the stomach. 7o&e%er! an e.hausted batter$ ma$ rapidl$ corrode in the "astrointestinal tract and is best e.tracted. A multi&ire bas+et o# the t$pe used #or "allstone retrie%al nearl$ al&a$s &or+s. An impacted #ood bolus &ill o#ten brea+ up and pass on i# the patient is "i%en #i))$ drin+s and con#ined to #luids #or a short time. The cause o# the impaction must then be in%esti"ated. I# s$mptoms are se%ere or the bolus does not pass! it can be e.tracted or bro+en up at endoscop$. S%PHA* A# P R,%RAT!%" %R R$PT$R DEEINITI0N Iatro"enic or patholo"ic trauma to the esopha"us! &hich ma$ result in lea+a"e o# air and esopha"eal contents into the mediastinum. Carries a =:2 mortalit$. ETI0A09R Iatro"enic: 0#ten occurs in an alread$ diseased esopha"us. Comprises =:LH=2 o# cases o# esopha"eal rupture. Endoscop$! Dilatation! /la+emore tubes! Intubation o# the esopha"us! N9 tube placement /oerhaa%e s$ndrome: A #ull4thic+ness tear. 9enerall$ occurs in the relati%el$ &ea+ le#t posterolateral &all o# distal esopha"us. Due to: Eorce#ul %omitin"! Cou"h! Aabor! Ai#tin"! Trauma Mallor$L5eiss s$ndrome: A partial4thic+ness tear. Usuall$ occurs in the ri"ht posterolateral &all o# the distal esopha"us and results in bleedin" that "enerall$ resol%es spontaneousl$. Due to #orce#ul %omitin". Eorei"n bod$ in"estion: 0b'ects usuall$ lod"e near anatomic narro&in"s: Abo%e the upper esopha"eal sphincter Near the aortic arch Abo%e AES SI9NS AND SRM(T0MS Se%ere! constant pain in chest! abdomen! and bac+ D$spha"ia D$spnea Subcutaneous emph$sema Mediastinal emph$sema heard as a Icrunchin"J sound &ith heartbeat (7ammonKs crunch DIA9N0SIS CD3: Ae#t4sided pleural e##usion! mediastinal or subcutaneous emph$sema Esopha"o"ram &ith &ater4soluble contrast: Sho&s e.tra%asation o# contrast 0ther studies: Endoscop$! computed tomo"raph$ (CT ! and thoracentesis (chec+ #luid #or lo& p7 and hi"h am$lase T3EATMENT Sur"ical repair o# #ull4thic+ness tears.

Ninet$ percent o# partial4thic+ness tears resol%e &ith N9 decompression and "astric la%a"e. The remainin" 1:2 re-uire sur"ical repair ("astrotom$ . 7emostasis is achie%ed #ollo&in" primar$ closure o# the esopha"eal mucosa &ith sutures. !nstrumental per4oration Instrumentation is b$ #ar the most common cause o# per#oration. Modern instrumentation is remar+abl$ sa#e. Pre/ention o4 per4oration is 0etter than cure (er#oration related to dia"nostic upper "astrointestinal endoscop$ is unusual &ith an estimated #re-uenc$ o# about 1:B::: e.aminations. (er#oration can occur in the phar$n. or oesopha"us! usuall$ at sites o# patholo"$ or &hen the endoscope is passed blindl$. A number o# patient4related #actors are associated &ith increased ris+! includin" lar"e anterior cer%ical osteoph$tes! the presence o# a phar$n"eal pouch and mechanical causes o# obstruction. (er#oration ma$ #ollo& biops$ o# a mali"nant tumour. (atients under"oin" therapeutic endoscop$ ha%e a per#oration ris+ that is at least 1: times "reater than those under"oin" dia"nostic endoscop$. The oesopha"us ma$ be per#orated b$ "uide&ires! "raduated dilators or balloons! or durin" the placement o# sel#4e.pandin" stents. The ris+ is considerabl$ hi"her in patients &ith mali"nanc$. Dia"nosis o# instrumental per#oration In most cases! a combination o# technical di##iculties and an inter%entional procedure should lead to a hi"h inde. o# suspicion. 7istor$ and ph$sical si"ns ma$ be use#ul pointers to the site o# per#oration. Cer%ical per#oration ma$ result in pain localised to the nec+! hoarseness! pain#ul nec+ mo%ements and subcutaneous emph$sema. Intrathoracic and intra4 abdominal per#orations! &hich are more common! can "i%e rise to immediate s$mptoms and si"ns either durin" or at the end o# the procedure! includin" chest pain! haemod$namic instabilit$! o.$"en desaturation or %isual e%idence o# per#oration. 5ithin the #irst ?B hours! patients ma$ additionall$ complain o# abdominal pain or respirator$ di##iculties. There ma$ be e%idence o# subcutaneous emph$sema! pneumothora. or h$dropneumothora.. In some patients! the dia"nosis ma$ be missed and reco"nised onl$ at a late sta"e be$ond ?B hours! as une.plained p$re.ia! s$stemic sepsis or the de%elopment o# a clinical #istula. (rompt and thorou"h in%esti"ation is the +e$ to mana"ement. Care#ul endoscopic assessment at the end o# an$ procedure combined &ith a chest D4 ra$ &ill identi#$ man$ cases o# per#oration immediatel$. I# not reco"nised immediatel$! then earl$ and late suspected per#orations should be assessed b$ a &ater4soluble contrast s&allo&. I# this is ne"ati%e! a dilute barium s&allo& should be considered. A CT scan can be used to replace a contrast s&allo& or as an ad'unct to accuratel$ delineate speci#ic #luid collections.

Treatment o4 oesophageal per4orations (er#oration o# the oesopha"us usuall$ leads to mediastinitis. The loose areolar tissues o# the posterior mediastinum allo& a rapid spread o# "astrointestinal contents. The aim o# treatment is to limit mediastinal contamination and pre%ent or deal &ith in#ection. 0perati%e repair deals &ith the in'ur$ directl$! but imposes ris+s o# its o&n, non4operati%e treatment aims to limit the e##ects o# mediastinitis and pro%ide an en%ironment in &hich healin" can ta+e place. The decision bet&een operati%e and non4operati%e mana"ement rests on #our #actors. These are: 1 the site o# the per#oration (cer%ical %s. thoracoabdominal oesopha"us , 2 the e%ent causin" the per#oration (spontaneous %s. instrumental , & underl$in" patholo"$ (beni"n or mali"nant , ' the status o# the oesopha"us be#ore the per#oration (#asted and empt$ %s. obstructed &ith a sta"nant residue . It #ollo&s that most per#orations that can be mana"ed nonoperati%el$ occur in the conte.t o# small instrumental per#orations o# a clean oesopha"us &ithout obstruction! &here lea+a"e is li+el$ to be con#ined to the nearb$ mediastinum at &orst

9eneral "uidelines #or non4operati%e mana"ement include: T pain that is readil$ controlled &ith opiates, T absence o# crepitus! di##use mediastinal "as! h$dropneumothora. or pneumoperitoneum, T mediastinal containment o# the per#oration &ith no e%idence o# &idespread e.tra%asation o# contrast material, T no e%idence o# on4"oin" luminal obstruction or a retained #orei"n bod$. The principles o# non4inter%entional mana"ement in%ol%e h$peralimentation! pre#erabl$ b$ an enteral route! naso"astric suction and broad4spectrum intra%enous antibiotics. Sur"ical mana"ement is re-uired &hene%er patients: T are unstable &ith sepsis or shoc+, T ha%e e%idence o# a hea%il$ contaminated mediastinum! pleural space or peritoneum,

T ha%e &idespread intrapleural or intraperitoneal e.tra%asation o# contrast material. Eor patients re-uirin" sur"er$! the choice rests bet&een direct repair! the deliberate creation o# an e.ternal #istula or! rarel$! oesopha"eal resection &ith a %ie& to dela$ed reconstruction. Direct repair is pre#erred b$ man$ sur"eons i# the per#oration is reco"nised earl$ (&ithin the #irst BL< hours and the e.tent o# mediastinal and pleural contamination is small. A#ter 1? hours! the tissues become s&ollen and #riable and less suitable #or direct suture. (rimar$ repair is inad%isable &ith late presentation and in the presence o# &idespread mediastinal and pleural contamination. These patients tend to be more ill as a result o# the dela$! and the aim o# treatment should be to achie%e &ide draina"e &ith the creation o# a controlled #istula and distal enteral #eedin". This can usuall$ be achie%ed b$ placin" a T4tube into the oesopha"us alon" &ith appropriatel$ located drains and a #eedin" 'e'unostom$. In unusual circumstances! #or instance &ith e.tensi%e necrosis #ollo&in" corrosi%e in"estion! emer"enc$ oesopha"ectom$ ma$ be necessar$. 0esopha"ostom$ and "astrostom$ should be per#ormed &ith a %ie& to dela$ed reconstruction. sophageal Atresia and Tracheoesophageal ,istula Esopha"eal atresia (EA is a con"enital interruption or discontinuit$ o# the esopha"us resultin" in esopha"eal obstruction. Tracheoesopha"eal #istula (TEE is an abnormal communication (#istula bet&een the esopha"us and trachea. EA ma$ be present &ith or &ithout a TEE. Alternati%el$! a TEE can occur &ithout EA. The incidence and ran"e o# anatomic %ariants are depicted in Ei"ure

The pre%alence o# EA*TEE is ?.< to @ per 1:!::: births and &ith a sli"ht male predominance. The etiolo"$ o# the disturbed embr$o"enesis is presentl$ un+no&n. 3ou"hl$ one third o# in#ants &ith EA*TEE ha%e lo& birth &ei"ht! and t&o thirds o# in#ants ha%e associated anomalies. There is a nonrandom! nonhereditar$ association o# anomalies in patients &ith EA*TEE that must be considered under the acron$m 8ATE3 (vertebral! anorectal! tracheal! esopha"eal! renal or radial limb . Another acron$m that is commonl$ used is 8ACTE3A (vertebral! anorectal! cardiac! tracheal! esopha"eal! renal! limb . The dia"nosis o# EA should be entertained in an in#ant &ith e.cessi%e sali%ation alon" &ith cou"hin" or cho+in" durin" the #irst oral #eedin". A maternal histor$ o#

pol$h$dramnios is o#ten present. In a bab$ &ith EA and TEE! acute "astric distention ma$ occur due to air enterin" the distal esopha"us and stomach &ith each inspired breath. 3e#lu. o# "astric contents into the distal esopha"us tra%erses the TEE and spills into the trachea! resultin" in cou"h! tach$pnea! apnea! or c$anosis. The presentation o# isolated TEE &ithout EA ma$ be more subtle and o#ten be$ond the ne&born period. In "eneral! these in#ants ha%e cho+in" and cou"hin" associated &ith oral #eedin". The inabilit$ to pass a naso"astric tube into the stomach o# the neonate is a cardinal #eature #or the dia"nosis o# EA. Inabilit$ to pass a naso"astric tube in an in#ant &ith absent radio"raphic e%idence #or "astrointestinal "as is %irtuall$ dia"nostic o# an isolated EA &ithout TEE (#i"ure A . 0n the other hand! i# "as is present in the "astrointestinal tract belo& the diaphra"m! an associated TEE is con#irmed ( #i"ure / . These simple rules pro%ide the correct dia"nosis in most cases.

0ccasionall$! a small amount o# isotonic contrast ma$ be "i%en b$ mouth to demonstrate the le%el o# the pro.imal EA pouch and*or the presence o# a TEE! but this israrel$ necessar$. In #act! the ris+ o# aspiration &ith studies o# this t$pe is "enerall$ hi"h. The immediate care o# an in#ant &ith EA*TEE includes decompression o# the pro.imal EA pouch &ith a sump4t$pe o# tube placed to continuous suction. This pre%ents spillo%er o# oral secretions into the trachea. The presence o# the TEE ma$ be li#e threatenin" because positi%e pressure %entilation ma$ be inade-uate to in#late the lun"s! since air is directed into the TEE %ia the path o# least resistance. The sur"ical treatment #or the most common EA*TEE in%ol%es an 3i"ht e.trapleural thoracotom$ throu"h the Bth intercostal space &ithin a da$ or t&o o# birth. The #istula is di%ided and the tracheal side o%erse&n. The oesopha"eal ends are then anastomosed.

A bronchoscop$ should be done prior to the thoracotom$ to identi#$ the relati%e site o# the #istula! e.clude the presence o# a second #istula! and delineate the bronchial anatom$. In patients &ith pure EA! the "ap bet&een the t&o esopha"eal ends is #re-uentl$ &ide! thus pre%entin" a primar$ anastomosis in the ne&born period. In these patients! the traditional approach is to per#orm a cer%ical esopha"ostom$ #or draina"e o# oral secretions and insertion o# a "astrostom$ #or enteral #eedin". An esopha"eal replacement usin" the stomach! small intestine! or colon is then per#ormed at about 1 $ear o# a"e. The mortalit$ o# EA*TEE is directl$ related to the associated anomalies! particularl$ cardiac de#ects and chromosomal abnormalities. In the absence o# these #actors! sur%i%al o# ;:2 to ;=2 is e.pected.U1@V (ostoperati%e complications uni-ue to EA*TEE include esopha"eal motilit$ disorders! "astroesopha"eal re#lu. (9E3 anastomotic stricture! anastomotic lea+ and tracheomalacia S%PHA* A# CARC!"%MA E(IDEMI0A09R Esopha"eal cancer causes rou"hl$ 1L?2 o# all cancer4related deaths. In the United States! each $ear there are rou"hl$ si. ne& cases per 1::!::: population, in other re"ions o# the &orld such as Asia! the incidence o# esopha"eal carcinoma is much hi"her. Most cases occur in patients o%er the a"e o# =:. Males are a##ected three times more #re-uentl$ than #emales. 3ISF EACT03S Alcohol Tobacco Diets hi"h in nitrites or nitrosamines Esopha"eal disorders such as achalasia! chronic esopha"itis! and (lummerL 8inson s$ndrome. SI9NS AND SRM(T0MS 9radual de%elopment o# d$spha"ia! #irst #or solids and later #or both solids and li-uids (mechanical d$spha"ia . Anore.ia de%elops as s&allo&in" becomes more pain#ul. Decreased (0 inta+e results in pro#ound &ei"ht loss! eas$ #ati"abilit$! and &ea+ness. (h$sical e.am earl$ in the disease course ma$ be entirel$ normal. 5ith ad%anced disease! the patient &ill appear cachectic! and supracla%icular l$mphadenopath$ ma$ be present. DIA9N0SIS /arium s&allo& ma$ re%eal the presence o# a mass. Chest .4ra$ ma$ re%eal hilar l$mphadenopath$.

Esopha"eal duodenoscop$ (E9D is use#ul to both %isuali)e the mass and to retrie%e specimens #or biops$. CT scan o# the thora. is use#ul to de#ine the e.tent o# disease and thereb$ determine appropriate treatment. T3EATMENT Most patients &ho are s$mptomatic at the time o# dia"nosis ha%e ad%anced! &idespread disease! &ith multiple metastases present to the li%er! lun"s! pleura! and l$mph nodes. As a result o# this! P B:2 o# patients &ill be candidates #or Icurati%eJ sur"er$. E%en &hen sur"er$ is an option! response is poor, there#ore! treatment #or esopha"eal carcinoma is mostl$ palliati%e. (ostoperati%e complications are common, Q ?:2 o# patients &ill de%elop #istulae or abscesses and respirator$ complications. 3adiation therap$ can shrin+ the tumor! resultin" in at least temporar$ relie# #rom obstructi%e s$mptoms. 0ther options include endoscopic laser therap$! endoscopic dilatation and stent placement! or placement o# a "astrostom$ or 'e'unostom$ tube. S%PHA* A# D!; RT!C$#A DEEINITI0N 0utpouchin" o# the esopha"eal mucosa that protrudes throu"h a de#ect in the tunica muscularis. Ma$ be either a true di%erticulum! in%ol%in" all three la$ers o# the esopha"us! or a #alse di%erticulum! in%ol%in" onl$ the mucosa and submucosa. Characteri)ed b$ its location: (har$n"oesopha"eal (Wen+erKs di%erticulum ! midesopha"eal! or epiphrenic. (har$n"oesopha"eal and epiphrenic di%erticula are called pulsion di%erticula! since the$ are caused b$ increased esopha"eal pressure, the$ are #alse di%erticula. Midesopha"eal di%erticula are traction di%erticula and are true di%erticula. SI9NS AND SRM(T0MS (har$n"oesopha"eal t$pe is the most li+el$ to be s$mptomatic. T$pical s$mptoms include d$spha"ia! halitosis! re"ur"itation o# #ood eaten hours to da$s earlier! cho+in"! and aspiration. Midesopha"eal di%erticula are usuall$ as$mptomatic. Epiphrenic di%erticula ma$ cause d$spha"ia and re"ur"itation or ma$ be entirel$ as$mptomatic. DIA9N0SIS /arium s&allo& &ill re%eal the presence o# all t$pes o# di%erticula. T3EATMENT Treatment o# Wen+erKs di%erticulum is recommended to relie%e s$mptoms and to pre%ent complications such as aspiration pneumonia or esopha"eal per#oration.

The most common procedure is a cer%ical esopha"om$otom$ &ith resection o# the di%erticulum. Midesopha"eal di%erticula are resected in the occasional incidence o# a #istulous connection bet&een the di%erticulum and tracheobronchial tree. Epiphrenic di%erticula ma$ be treated %ia resection and esopha"om$otom$ %ia a le#t thoracotom$ approach. Pleural 44usions (leural e##usion re#ers to an$ si"ni#icant collection o# #luid &ithin the pleural space. Normall$! The mo%ement o# #luid across the pleural membranes is complicated but in "eneral is "o%erned b$ Starlin"Ks la& o# capillar$ e.chan"e. This su""ests that the #lu. o# #luid is controlled b$ the balance o# both oncotic and h$drostatic pressures &ithin the pleural capillaries and pleural space. there is an on"oin" balance bet&een the lubricatin" #luid #lo&in" into the pleural space and its continuous absorption. /et&een = and 1: A o# #luid normall$ enters the pleural space dail$ b$ #iltration throu"h micro%essels suppl$in" the parietal pleura. The net balance o# pressures in these capillaries leads to #luid #lo& #rom the parietal pleural sur#ace into the pleural space! and the net balance o# #orces in the pulmonar$ circulation leads to absorption throu"h the %isceral pleura. Normall$! 1=L?: mA o# pleural #luid is present at an$ "i%en time. E%en a small imbalance o# accumulation and absorption o# pleural #luid &ill lead to the de%elopment o# a pleural e##usion. The mechanisms o# this imbalance include (1 increased h$drostatic pressure! (? increased ne"ati%e intrapleural pressure! (@ increased capillar$ permeabilit$! (B decreased plasma oncotic pressure! and (= decreased or interrupted l$mphatic draina"e. Appro.imatel$ @:: mA o# #luid is re-uired #or the de%elopment o# costophrenic an"le bluntin" seen on an upri"ht chest radio"raph. At least =:: mA o# e##usion is necessar$ #or detection on clinical e.amination.(leural e##usions are classi#ied as either transudates or e.udates based on #luid protein and lactate deh$dro"enase (AD7 concentrations. Transudati%e e##usions occur as the result o# a chan"e in #luid balance in the pleural space it is protein poor ultra#iltrates o# plasma that occur because o# alterations in the s$stemic h$drostatic pressures or colloid osmotic pressures!0n "ross %isual inspection! a transudati%e e##usion is "enerall$ clear or stra&4colored. E.udati%e e##usions su""est the disruption or inte"rit$ loss o# pleura or l$mphatics. it is protein4rich pleural #luid collections that "enerall$ occur because o# in#lammation or in%asion o# the pleura b$ tumors. 9rossl$! the$ are o#ten turbid! blood$! or purulent. 9rossl$ blood$ e##usions in the absence o# trauma are #re-uentl$ mali"nant! but ma$ also occur in the settin" o# a pulmonar$ embolism or pneumonia. An e##usion is considered e.udati%e i# it meets an$ one o# the #ollo&in" criteria: 4 (leural #luid protein*serum protein "reater than :.= 4 (leural #luid AD7*serum AD7 "reater than :.<

4 (leural #luid AD7 1.<H times normal serum (absolute pleural AD7 le%el is "reater than t&o4thirds o# the normal upper limit #or serum tiology o4 Transudati/e 44usions 14Con"esti%e heart #ailure ?4Cirrhosis @4Nephrotic s$ndrome B47$poalbuminemic conditions =4Eluid retention*o%erload <4(ulmonar$ embolism H4Aobar collapse >4 Mei"sK s$ndrome /eni"n transudati%e e##usions tend to be #ree #lo&in" and la$er dependentl$. /eni"n! nonin#ectious! pleural e##usions should be drained completel$ b$ thoracentesis #or dia"nosis. Treatment o# beni"n pleural e##usions is directed to&ard treatment o# the underl$in" disease . i# recurrent : repeated thoracocentesis ! Tube thoracostom$ or thoracoscopic draina"e &ith or &ithout chemical pleurodesis(do.$c$cline! talc tiology o4 6udati/e 44usions 14 Malignant: /roncho"enic carcinoma,Metastatic carcinoma ,A$mphoma Mesothelioma, (leural adenocarcinoma ?4 Infectious: /acterial*parapneumonic,Emp$ema,Tuberculosis, Eun"al, 8iral.(arasitic @4 Collagen-Vascular Disease Related:3heumatoid arthritis,5e"enerKs "ranulomatosis! S$stemic lupus er$thematosus! Chur"4Strauss s$ndrome B4 Abdominal/Gastrointestinal Disease Related: Esopha"eal per#oration ,Subphrenic abscess,(ancreatitis*pancreatic pseudoc$st,Mei"sK s$ndrome =4 Ot ers: Ch$lothora., Uremia, Sarcoidosis,(ost coronar$ arter$ b$pass "ra#tin", (ost irradiation,Trauma,DresslerKs s$ndrome,(ulmonar$ embolism &ith in#arction, Asbestosis related I# an e.udati%e e##usion is su""ested b$ criteria ! #urther dia"nostic studies ma$ be help#ul. I# total and di##erential cell counts re%eal a predominance o# neutrophils (Q =: percent o# cells ! the e##usion is li+el$ to be associated &ith an acute in#lammator$ process (such as a parapneumonic e##usion or emp$ema! pulmonar$ embolus! or pancreatitis . A predominance o# mononuclear cells su""ests a more chronic in#lammator$ process (such as cancer or tuberculosis . 9ramKs stains and cultures should be obtained! i# possible &ith inoculation into culture bottles at the bedside. (leural #luid "lucose le%els are #re-uentl$ decreased (P <: m"*dA &ith comple. parapneumonic e##usions or mali"nant e##usions. C$tolo"ic testin" should be done on e.udati%e e##usions to rule out an associated mali"nanc$. C$tolo"ic dia"nosis is accurate in dia"nosin" o%er H: percent o# mali"nant e##usions associated &ith adenocarcinomas! but is less sensiti%e #or mesotheliomas (P 1: percent ! s-uamous cell carcinomas (?: percent ! or l$mphomas (?=L=: percent . I# the dia"nosis remains uncertain a#ter draina"e and #luid anal$sis! thoracoscop$ and direct biopsies are indicated.

Tuberculous e##usions can no& be dia"nosed accuratel$ b$ increased le%els o# pleural #luid adenosine deaminase (abo%e B: U per A . (ulmonar$ embolism should be suspected in a patient &ith a pleural e##usion occurrin" in association &ith pleuritic chest pain! hemopt$sis! or d$spnea out o# proportion to the si)e o# the e##usion. These e##usions ma$ be transudati%e! but i# an associated in#arct near the pleural sur#ace occurs! an e.udate ma$ be seen. I# a pulmonar$ embolism is suspected in a postoperati%e patient! most clinicians &ould obtain a spiral CT scan. Mali"nant (leural E##usion Mali"nant pleural e##usions are the second most common e.udati%e e##usi%e process ma$ occur in association &ith a %ariet$ mali"nancies! most commonl$ lun" cancer! breast cancer! and l$mphomas!o%arian cancer dependin" on the patientKs a"e and "ender. Mali"nant e##usions are e.udati%e and o#ten tin"ed &ith blood. An e##usion in the settin" o# a mali"nanc$ means a more ad%anced sta"e, it "enerall$ indicates an unresectable tumor! &ith a mean sur%i%al o# @L11 months. 0ccasionall$! beni"n pleural e##usions ma$ be associated &ith a broncho"enic NSCAC! and sur"ical resection ma$ still be indicated i# the c$tolo"$ o# the e##usions is ne"ati%e #or mali"nanc$. An important issue is the si)e o# the e##usion and the de"ree o# d$spnea that results. S$mptomatic! moderate to lar"e e##usions should be drained b$ chest tube! pi"tail catheter! or 8ATS! #ollo&ed b$ instillation o# a sclerosin" a"ent. /e#ore sclerosin" the pleural ca%it$! &hether b$ chest tube or 8ATS! the lun" should be nearl$ #ull$ e.panded. (oor e.pansion o# the lun" (because o# entrapment b$ tumor or adhesions "enerall$ predicts a poor result. The choice o# sclerosant includes talc! bleom$cin! or do.$c$cline. Success rates o# controllin" the e##usion ran"e #rom <:L;: percent! dependin" on the e.act scope o# the clinical stud$! the de"ree o# lun" e.pansion a#ter the pleural #luid is drained! and the care &ith &hich the outcomes &ere reported. mpyema Emp$ema is a p$o"enic or suppurati%e in#ection o# the pleural space. Emp$emas are the most common e.udati%e t$pe o# pleural e##usion. The$ ma$ be classi#ied into three cate"ories based on the chronicit$ o# the disease process. The acute phase ( e6udati/e phase is characteri)ed b$ pleural e##usion o# lo& %iscosit$ and cell count. The transitional or 4i0rinopurulent phase! &hich can be"in a#ter B> hours! is characteri)ed b$ an increase in &hite blood cells in the pleural e##usion. The e##usion is turbid! be"ins to loculate! and is associated &ith #ibrin deposition on %isceral and parietal pleurae and pro"ressi%e lun" entrapment. The organi<ing phase or chronic phase occurs a#ter as little as 1 to ? &ee+s and is associated &ith an in"ro&th o# capillaries and #ibroblasts into the pleural rind and ine.pansile lun".

An emp$ema ma$ occur 0y direct contamination o# the pleural space throu"h &ounds o# the chest (trauma or sur"er$ ! 0y hematolo"ic spread (bacteremia or sepsis ! 0y direct e.tension #rom lun" parench$mal in#ection (parapneumonic or postpneumonic ! 0y rupture o# an intrapulmonar$ abscess or in#ected ca%it$! or 0y e.tension #rom the mediastinum (esopha"eal per#oration or subphrenic abscess. Most o#ten! emp$emas are the result o# a primar$ in#ectious process in the lun". 7istoricall$! these in#ections &ere commonl$ due to Streptococcus or Pneumococcus pneumoniae, toda$ "ram4ne"ati%e and anaerobic or"anisms are common causes o# emp$ema. Tuberculous emp$ema has had a recent resur"ence. (neumonias caused b$ S. aureus! E. coli! Pseudomonas! and anaerobes are the most li+el$ to result in emp$ema Most patients &ith acute or transitional phase emp$ema present &ith s$mptoms o# their primar$ lun" in#ection (cou"h! #e%er! sputum production ! #ollo&ed b$ s$mptoms o# pleural e##usion (pleuritic chest pain and d$spnea and s$stemic illness (anore.ia! malaise! and s&eats . Ee%er #rom emp$ema can be %er$ hi"h. (ersistent #e%er a#ter resolution o# pneumonia is suspicious #or emp$ema. 5ithout inter%ention! a septic course &ill ensue. Chest radio"raph$ demonstrates a pleural e##usion, chest CT ma$ demonstrate a complicated e##usion &ith loculations and a hetero"eneous appearance to the e##usion.
mpyema 4luid characteristics p7 P H.: 9lucose P B: m"*dA AD7 Q 1::: IU*dA (ositi%e 9ram stain (ositi%e culture (=:2 Speci#ic "ra%it$ Q 1.:1> 5/C Q =:: cells*mm@ (rotein Q ?.= "*dA

Treatment o# emp$ema is dependent on its phase but in%ol%es the identi#ication and s$stemic treatment (antibiotics o# the causati%e or"anism and complete draina"e o# the pleural space. In the acute and earl$ #ibrinopurulent phases! complete thoracentesis can be both dia"nostic and therapeutic i# the e##usion is drained entirel$. The prior administration o# antibiotics ma$ lead to a sterile tap! but 9ram stain (or"anisms ! cell count (pol$morphonuclear leu+oc$tic predominance in bacterial emp$ema and l$mphoc$tic predominance in tuberculous emp$ema ! chemistries (protein! AD7! am$lase! and "lucose ! and p7 (PH.@ all can be use#ul in ma+in" the dia"nosis. Tube thoracostom$ ma$ be indicated #or pleural draina"e i# thoracentesis #ails or the emp$ema has pro"ressed be$ond its earliest sta"es. Chest tube insertion! ho&e%er! can be ine##ecti%e i# the emp$ema has become loculated or or"ani)ed .

8ATS emp$ema draina"e &ith earl$ pleural dNbridement has the added ad%anta"e o# more complete pleural draina"e b$ %isuali)in" and brea+in" do&n loculations. Eull lun" e.pansion and the pre%ention o# complications is the "oal o# the procedural inter%ention. 0ccasionall$! radiolo"icall$ "uided catheter draina"e can be a use#ul ad'unct to these sur"ical procedures. Thoracotom$ &ith dNbridement or #ormal decortication in later4sta"e emp$ema is reser%ed #or treatment #ailures &ith persistent sepsis. Complications o# emp$ema include empyema necessitans (spontaneous decompression o# pus throu"h the chest &all ! chronic emp$ema (&ith entrapped lun" and pulmonar$ restricti%e disease ! osteom$elitis or chondritis o# the ribs or %ertebrae! pericarditis! mediastinitis! the de%elopment o# a bronchopleural #istula! or disseminated in#ection o# the central ner%ous s$stem. Complications are best treated &ith prompt complete pleural draina"e and dNbridement o# in#ected tissues. Aon"4term (< &ee+s or more antibiotic therap$ is re-uired. Nutritional optimi)ation pla$s an important role in treatment. Chronic emp$ema is the result o# #ailure to reco"ni)e or properl$ treat acute pneumonia or acute emp$ema! or #ailure (or incompleteness o# earlier inter%ention! and usuall$ is associated &ith lun" entrapment b$ a thic+ pleural peel or #ibrothora.. This process can be"in as earl$ as 1 to ? &ee+s and as late as < &ee+s a#ter the onset o# the acute illness. Chronic emp$ema can mimic other s$stemic illnesses &ith s$mptoms o# anore.ia! &ei"ht loss! and lethar"$. Debilitation is both a contributin" #actor to and an end result o# this disease. Anemia is a common si"n. 5ith chronic emp$ema! chest radio"raph$ demonstrates opaci#ication o# the a##ected hemithora.! particularl$ laterall$ and in#eriorl$! &here thic+ened pleura abuts compressed lun". The interspaces are narro&ed! and the hemithora. becomes contracted. CT o# the chest is use#ul #or de#inin" the e.tent o# pleural thic+enin" and the e.act location o# the emp$ema ca%it$ and to rule out other associated parench$mal disease. The open sur"ical approaches #or chronic emp$ema include %ariations o# an open thoracostom$ &ith rib resection or #ull thoracotom$ &ith emp$ema e%acuation and lun" decortication. The appropriate procedure depends on the patientKs o%erall status and comorbidities. 0pen draina"e in%ol%es remo%al o# a portion o# a rib or ribs at the most dependent portion o# the emp$ema ca%it$. The pus is e%acuated. This space can then be drained &ith a tube! pac+ed &ith dressin"s (thoracic &indo& ! irri"ated! or lined &ith a mobili)ed s+in #lap to pre%ent closure (Eloesser #lap . 0pen draina"e usuall$ allo&s the ca%it$ to constrict and e%entuall$ obliterate itsel#! althou"h this can ta+e man$ months. Dela$ed muscle #lap closure o# the space ma$ be an option in selected patients. Emp$ema e%acuation and decortication is indicated #or relati%el$ $oun" patients &ho are in other&ise "ood health and &ithout si"ni#icant underl$in" lun" parench$mal disease. 3esection o# the thic+ened peel or corte. o%er the chest &all and lun" permits e.pansion o# chronicall$ collapsed lun". 3esolution o#

sepsis (earl$ and impro%ement in pulmonar$ #unction (late are the e.pected results o# this sur"er$. 0#ten! e.trapleural resection o# the parietal pleura is necessar$. 0ccasionall$! pleuropneumonectom$ is indicated in emp$ema &ith underl$in" destro$ed lun" (tuberculosis or bronchiectasis . Chylothora6 the accumulation o# l$mph &ithin the pleural space. The incidence o# ch$lothora. ma$ be increasin"! because the number o# thoracic sur"ical procedures and chest traumas continues to rise. Ch$lothora. characteristicall$ is mil+$ &hite #luid that contains a hi"h concentration o# emulsi#ied #ats (tri"l$cerides! ch$lomicrons and a l$mphoc$tic predominance on cell count. 7o&e%er! dependin" on the nutritional and dietar$ status o# the patient! the e##usion can be onl$ sli"htl$ cloud$ or e%en clear. Ch$lothora. occurs &hen the contents o# the thoracic duct empt$ into the pleural space. It is more common on the le#t side because o# the anatom$ o# the thoracic duct. The underl$in" causes o# ch$lothora. are numerous 14 !raumatic "C est and #ec$%: /lunt! (enetratin" ?4 Iatrogenic: Catheteri)ation! particularl$ subcla%ian %enous! (ostsur"ical! E.cision o# cer%ical*supracla%icular l$mph nodes! 3adical AN dissections o# the nec+ !3adical AN dissections o# the chest! Esopha"ectom$! Aobectom$ or pneumonectom$! Mediastinal tumor resection! Thoracic aneur$sm repair! S$mpathectom$! Con"enital cardio%ascular sur"er$ @4 #eo&lasms: A$mphoma! Aun" cancers! Esopha"eal cancers! Mediastinal mali"nancies! Metastatic carcinomas B4 Infectious: Tuberculous l$mphadenosis! Mediastinitis! Ascendin" l$mphan"itis =4 Ot er: A$mphan"ioleiom$omatosis. 8enous thrombosis! Congenital S$mptoms o# ch$lothora. ma$ mimic the e##ects o# a pleural e##usion (d$spnea! chest pain! #ati"ue ! be attributable to underl$in" disease (in#ectious or neoplastic causes ! or ma$ be the result o# chronic metabolic e##ects o# a thoracic duct lea+ (loss o# #at! protein! antibodies! and #at4soluble %itamins . Aosses in #luid %olume ma$ be lar"e (Q@ A*da$ and produce hemod$namic instabilit$ i# not ade-uatel$ replaced. A#ter dia"nosis! mana"ement o# a ch$lothora. consists initiall$ o# tube thoracostom$ draina"e (chest tube insertion &ith complete lun" re4e.pansion and supporti%e measures such as a lo&4#at or #at4#ree diet supplemented b$ medium4chain tri"l$cerides and a""ressi%e #luid! electrol$te! and nutritional replacement or correction. 0#ten! these measures are enou"h to promote closure o# the thoracic duct pleural #istula. I# the ch$lothora. is caused b$ mali"nanc$! primar$ treatment o# the neoplasm ma$ be necessar$. 3adiation therap$ to the mediastinum has been use#ul in mana"in" ch$lothora. secondar$ to l$mphoma.

Conser%ati%e measures #or the treatment o# ch$lothora. "enerall$ are maintained #or 1 to ? &ee+s. I# the ch$lous e##usion has not responded to this mana"ement! sur"ical inter%ention is indicated. The most common procedures are li"ation o# the thoracic duct or mass li"ation o# tissue at the diaphra"matic hiatus ("enerall$ throu"h a ri"ht thoracotom$ or direct closure o# the duct in'ur$. Instillation o# oli%e oil or cream %ia naso"astric tube at the time o# sur"er$ can help to identi#$ the duct and area o# lea+a"e. 3arel$! pleurectom$ and pleurodesis are use#ul ad'uncts to these other sur"ical procedures or recalcitrant ch$lothora.. Most recentl$! minimall$ in%asi%e techni-ues #or thoracic duct obliteration %ia cisterna ch$li cannulation ha%e been championed b$ inter%entional radiolo"ists. #ung a0scess : A p$o"enic pneumonia de%elops! causin" locali)ed suppuration &ith parench$mal destruction! results in a solitar$ or dominant ca%it$ measurin" at least ? cm in diameter. There is central necrosis o# lun" tissue! &hich then li-ue#ies and communicates &ith the bronchial tree. This partial internal draina"e results in the classic ca%it$ &ith an air4#luid le%el. 2. tiology A. Aspiration Aocation: predilection #or the posterior se"ment o# the 3UA! the superior se"ment o# the 3AA! and the AAA /acteriolo"$: anaerobes and aerobes /. (ost4pneumonic Aocation: an$ se"ment! ma$ be in multiple se"ments /acteriolo"$: In communit$4ac-uired pneumonia! the causati%e bacteria are predominantl$ "ram4positi%e , in hospital4ac-uired pneumonia! <:LH: percent o# the or"anisms are "ram4ne"ati%e include Klebsiella pneumoniae! Haemophilus influenzae! (roteus species! Pseudomonas aeruginosa! Escherichia coli C. Endobronchial obstruction Neoplasms and #orei"n bodies can result in distal in#ection and abscess #ormation Classi#ication : 14 primar$ lun" abscess occurs! #or e.ample! in immunocompromised patients (as a result o# mali"nanc$! chemotherap$! or an or"an transplant! etc. ! in patients as a result o# hi"hl$ %irulent or"anisms incitin" a necroti)in" pulmonar$ in#ection! or in patients &ho ha%e a predisposition to aspirate orophar$n"eal or "astrointestinal secretions. ?4 Secondar$ lun" abscess occurs in patients &ith an underl$in" condition such as a partial bronchial obstruction! a lun" in#arct! or ad'acent suppurati%e in#ections (subphrenic or hepatic abscesses . &. Clinical Presentation

A. S$mptoms Ee%er! chills! se%ere producti%e cou"h! hemopt$sis! d$spnea and copious #oul smellin" sputum! #ati"ue! malaise! &t loss /. Si"ns Tach$pnea! consolidation! local chest &all tenderness! leu+oc$tosis (>1=!::: cells*mm@ ! Complications : such as massi%e hemopt$sis! endobronchial spread to other portions o# the lun"s! rupture into the pleural space and de%elopment o# p$opneumothora.! or septic shoc+ and respirator$ #ailure are rare in the modern antibiotic era. '. Diagnosis CD3: pneumonitis pattern earl$! #ollo&ed b$ densit$ or mass &ith a relati%el$ thin4&alled ca%it$ and air4#luid le%el! indicatin" a communication &ith the tracheobronchial tree. CT scan is use#ul to clari#$ the dia"nosis &hen the radio"raph is e-ui%ocal! to help rule out endobronchial obstruction! and to loo+ #or an associated mass or other patholo"ic anomalies.Aca%itatin" lun" carcinoma is #re-uentl$ mista+en #or a lun" abscess. /acteriolo"ical*#un"al e%aluation: aerobic! anaerobic! #un"al! T/ all important /ronchoscop$ is indicated to rule out obstructin" #orei"n bodies or neoplasms and can pro%ide draina"e and to obtain uncontaminated cultures b$ bronchoal%eolar la%a"e. (. Treatment S$stemic antibiotics are the mainsta$ o# therap$. Eor communit$4 ac-uired in#ections secondar$ to aspiration! li+el$ patho"ens are orophar$n"eal streptococci and anaerobes. (enicillin 9! ampicillin! or amo.icillin are the main therapeutic a"ents! but a X4lactamase inhibitor or metronida)ole should be added to co%er the increasin" pre%alence o# "ram4ne"ati%e anaerobes that produce X4 lactamase. Clindam$cin is also a primar$ therapeutic a"ent. Eor hospital4ac-uired in#ections! Staph$lococcus aureus and aerobic "ram ne"ati%e bacilli are common or"anisms o# the orophar$n"eal #lora. (iperacillin or ticarcillin &ith a X4lactamase inhibitor (or e-ui%alent alternati%es pro%ide better co%era"e o# li+el$ patho"ens. The duration o# antimicrobial therap$ is %ariable: 1L ? &ee+s #or simple aspiration pneumonia and @L1? &ee+s #or necroti)in" pneumonia and lun" abscess. Sur"ical draina"e o# lun" abscesses is uncommon because draina"e usuall$ occurs spontaneousl$ %ia the tracheobronchial tree. Indications #or inter%ention include #ailure o# medical therap$, an abscess under tension, an abscess increasin" in si)e durin" appropriate treatment, contralateral lun" contamination, an abscess lar"er than BL< cm in diameter, necroti)in" in#ection &ith multiple abscesses! hemopt$sis! abscess rupture! or p$opneumothora., and inabilit$ to

e.clude a ca%itatin" carcinoma. E.ternal draina"e ma$ be accomplished &ith tube thoracostom$! percutaneous draina"e (not candidates #or standard sur"ical inter%ention ! or sur"ical ca%ernostom$. Sur"ical resection is re-uired in #e&er than 1: percent o# lun" abscess patients.( Aobectom$ is t$picall$ re-uired &hen resection is in order! as se"mentectom$ is o#ten not possible and pneumonectom$ rarel$ necessar$ /30NC7IECTASIS 1. De4inition Chronic bronchial dilatation &ith parench$mal in#ection and in#lammator$ reaction. There are three t$pes: c$lindrical! %aricose! and saccular*c$stic. 2. tiology Ac-uired in#ection is the most common cause! t$picall$ &hen occurrin" in childhood. 0ther ac-uired causes include bronchial obstruction and scarrin" Con"enital causes include c$stic #ibrosis! Farta"enerCs s$ndrome! %arious immunode#icienc$ disorders! and bronchopulmonar$ se-uestration T$picall$ a##ects the basal se"ments o# the lo&er lobes &. Clinical presentation 3ecurrent pneumonia! persistent cou"h! copious #oul smellin" sputum 7emopt$sis is common in adults but rare in children '. Diagnosis CD3 usuall$ demonstrates nonspeci#ic #indin"s! althou"h a hone$comb pattern ma$ be #ound /acteriolo"ic studies t$picall$ return H. influenza! E. coli! and Klebsiella as the causati%e a"ents Chest CT &ith #ine cuts has replaced broncho"raph$ as the test o# choice /ronchoscop$ can help locali)e the process! rule out obstructin" lesions! and pro%ide pulmonar$ toilet (. Treatment Medical therap$ is the primar$ approach! usin" antibiotics! humidi#ication! bronchodilators Sur"ical inter%ention is indicated #or #ailure o# medical mana"ement! persistent s$mptoms! recurrent pneumonias! and hemopt$sis The ideal sur"ical candidate has unilateral disease con#ined to one lobe! usuall$ lo&er Most patients! ho&e%er! ha%e bilateral disease! and sur"er$ should be reser%ed #or locali)ed disease! operatin" on the &orst side #irst Malignant Mesothelioma
rare neoplasm that arises #rom mesothelial cells linin" the parietal and %isceral pleura and can present in a locali)ed or di##use manner. The locali)ed %ariant (solitar$ #ibrous

tumor is %er$ uncommon and usuall$ presents as a &ell4de#ined! encapsulated tumor that is not associated &ith e.posure to asbestos. T$picall$! the lesions are dia"nosed as an as$mptomatic mass on a chest radio"raph. Complete sur"ical resection is the treatment o# choice. ! The di##use %ariant presents as a locall$ a""ressi%e tumor commonl$ associated &ith asbestos e.posure (H=2 .A lon" latenc$ period bet&een asbestos e.posure and the de%elopment o# the disease has been reported.Althou"h smo+in" alone is not a reported ris+ #actor! other #actors such as radiation therap$ and %arious occupational e.posures ha%e been implicated.In the late 1;;:s an association bet&een simian %irus B: (S8 B: and mesothelioma &as in%esti"ated. Mali"nant mesotheliomas

ha%e a male predominance o# ?:1! and are most common a#ter the a"e o# B:. Clinical presentation. Most patients present &ith d$spnea and chest pain. 0%er ;: percent ha%e a pleural e##usion. chest radio"raph$ demonstrates pleural
thic+enin" &ith or &ithout pleural e##usion. Chest CT and M3I are particularl$ e##ecti%e in determinin" the presence o# ad%anced disease! such as transdiaphra"matic in%ol%ement or mediastinal or"an in%asion. Thoracentesis is dia"nostic in less than 1: percent o#

patients. Ere-uentl$! a thoracoscop$ or open pleural biops$ &ith special stains is re-uired to di##erentiate mesotheliomas #rom adenocarcinomas. 0nce the dia"nosis is con#irmed! cell t$pes can be distin"uished (e.".! epithelial! sarcomatous! and mi.ed . Epithelial t$pes are associated &ith a more #a%orable pro"nosis! and in some patients lon"4term sur%i%al ma$ be seen &ith no treatment. Sarcomatous and mi.ed tumors share a more a""ressi%e course. Sur"ical Mana"ement Sur"ical options include palliati%e pleurectom$ or talc pleurodesis &ith impro%ed local control and a modest impro%ement in short4term sur%i%al. More radical sur"ical approaches (such as e.trapleural pneumonectom$ #ollo&ed b$ ad'u%ant chemotherap$ and radiation ha%e an increased morbidit$ rate, moreo%er! the mortalit$ rate e.ceeds 1: percent in all but the most e.perienced centers.