Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Awesome. Ok, thanks everyone for coming. We really appreciate it. Um Very happy to introduce today. Our next speaker, he's gonna be covering the topic of cardiothoracic surgery. So today we have doctor Aja Pasig, he's a junior doctor. We have an undergraduate degree from Saint George's and a post graduate from Nottingham. Um He's someone who's shown a um continued interest in cardiothoracic surgery, which I'm glad to say has been reinforced after his f one rotations and he's given up his time today to do a talk for us. Um So, yeah, without further ado, I introduced Dennis, he's gonna be talking today about cardiothoracic surgery. Thank you, Josh. I have always a pleasure to be here uh to be invited to speak on this, er, cardiothoracic surgery installment of the Incision Teaching series. I hope you've enjoyed this series so far. I never learned a thing or two from the other speakers. Er, so as you said, my name is Denis. I'm one of the regional junior do ambassadors for the East Midlands region. And tonight, I'm hoping to cover some of the more relevant anatomy and physiology that relates to the common pathologies you in cardiothoracic surgery. So, namely coronary artery disease, var disease, lung cancer, pneumothorax, and pleural effusion. And of course, particularly when it's relevant to coronary artery disease and bowel disease, looking at bypass. And some of the main principles just before I continue consider a message in the chat that you can hear and see me in the slides as well. No, perfect. And as as Josh said, there'll be poll questions throughout just to enforce some of the learning and to hopefully make it as interactive as possible. So this first case um is a 59 year old male who presents to his GP, he has chest pain and shortness of breath on exertion. He describes the pain as a central chest pain that he feels like someone is sitting on his chest. It radiates to the left shoulder and came on suddenly when he was gardening, he tried processing all, but it didn't help at the time when recalled. And he says that you remember feeling sweaty, lightheaded. Um and he's also very concerned because his dad died of a heart attack in his sixties. Now as the F one or F two in the GP practice, um you take a thorough history and you find that he has hypertension type two diabetes, high cholesterol obesity, uh and some arthritis in the knee. He has a Rapi Metformin and atorvastatin. And as he tells you, his father died of M I his mom had diabetes. His grandfather had a stroke. He currently works as a builder and he smoked since he was 16. He was smoking 20 a day, but now he's cut to 10 a day and he drinks a few pints at the weekend in terms of his alcohol intake. Ok. So question number one in the poll is considering, um, his presentation, his past medical history as well as his family history. What is your top differential? So, for a, it's gastroesophageal reflux disease for B acute Coronary syndrome, C aortic dissection and D costochondritis. And I'll give you guys a minute just to answer that one. Yes. Ok. Ok. So I can see essentially it's either A or B with the majority going for the right answer, which is, um, A CS. But at this point, I think, especially when you're a medical student and then a junior doctor, you want to keep a broad differential in mind. Um, particularly for example, if you're about to clock this patient, if it's a night shift, if it's the weekend, you need to be bored at the beginning and all the relevant investigations. So therefore you systematically rule in or out depending upon what you find. Um, I'm glad all went for good because whilst it's unlikely and some patients actually think it's just reflux, they think it's a bit of heartburn. Um, they sort of put it down to maybe, um, something that we're eating at the time. Although in this case, it's not the case um and then they carry on. So this may be a first presentation, but this may also be um a repeated presentation of Angina. So a CS we classify into semi and semi unstable Angina, which I'll go to in a minute, it's unlikely to be able to have dissection because it's, you know, you haven't got that classic tearing pain that goes to the back, the character also the way the patient describes it and that there's no collapse, although the patients may not always collapse. Um in a dissection in terms of d costochondritis M SK pain. Again, if you're looking at the risk factors and the type of pain and the classic radiation, um it's unlikely to be D as well. Ok. So again, you're in the GP practice. So what is the next most appropriate investigation? So A is ECG B arrange for act an water, see echo or D coronary angiography? I'll give you guys a minute just to answer that way as well. Yeah. OK. The, the, the OK. OK. So again, the majority put the right answer, which was ECG and this is something that comes up in medical school exams particularly. Um, whilst at some point, you may do all of these exam, um, investigations if the patient needs to be admitted, particularly if they are to undergo further investigations and operations, it's the next most appropriate. So you go for the ECG because it's quicker, it's cheap and it's freely available. In primary care CT angiogram or water, you are unlikely to uh request at this point even later because it's unlikely to be a dissection, an echo which some of you went for um is good to look at the function. And if there are any rival abnormalities and particularly if this patient may, may not go to theater as part of the work up, they will most likely do an echo uh just to see if there are any incidental findings that they may be able to investigate. And then also at the same time, operate on um as the problem this patient may or may not have. So as we move on, we've done a few basic ops. So we can see that the patient is hypertensive, he's tachycardic, he that's normal borderline. Um high respirate, we draw some blood. Um So we can see hp is normal white cell count was normal as is electrolytes. Um But we can see that the DMA is elevated. Now, depending upon what you read, some journal papers can say that if it's less than at 5 45 50 you classify this as unstable angina. If it's above 5 45 50 then it's M I. Uh but again, this does vary depending upon where you work. Um The troponin is elevated. Uh So again, um in practice, depending upon the onset of symptoms and the local guidelines where you work, um you probably do troponins on admissions or admission and then 6 to 12 hours later. Um So usually as a rough guide, if it's less than 14, it's unlikely to have an M I. If it's 14 to 30 then you repeat the troponins three hours later. And then if they go up by seven or if the overall value isn't greater than 30 then it's a probable by M I. And then as you've seen from the ECG findings as well, uh The patient is tachycardic, there is no um axis deviation, no left bundle branch block and there is ST elevation that leads, we want to V five with a normal pr interval and normal QR S as well. OK. OK. So now that we have a bit of understanding in terms of his presentation, we've done some investigations. The next question is which of the following is the next most appropriate investigation to diagnose the underlying cause of the patient's presentation. I'll give you guys a minute just to on that one. OK. So again, the majority have got the answer right. Um We have around 60% for curry angiography, uh non femoral heart and they run 10% for CT angiograph for aorta and then 30% for echo. So the reason why I've put this question in is because this is the gold standard for um diagnosing uh coronary artery disease in the context of a again, you perform all of the others depending upon um if you want to work the patient up for theater. Um But gold chronography is the gold standard um for diagnosing coronary artery disease, it's just a bit of an insight. Um A semi for some reason know is complete occlusion. So, for criteria you need the ST elevation on the ECG and a raised intra an ente is partial occlusion. So you have ST depression or T wave inversion and an increased intrapontile vagina is partial occlusion. Uh which means that there's ST depression or T wave inversion without an increased in troponin. So, again, that's fairly popular in medical school examinations. Um So again, touching just on the ECG findings, you'd assume the patient is having a stomach. If there is new left bundle branch block and there's chest pain. And then again, this, depending upon your medical school, they would like to sometimes test um if they show you an ECG. So if you see ST elevation or greater one millimeter in two or more contiguous, which means the same territory, um limb leads or greater than two millimeters um in two or more leads in the same region for chest leads. Plus you also need to have ST depression in reciprocal leads. That's for um te so posterior ST I give you something, I'll touch on the slides after is you have ST depression in two more chest leads, that's V one to V four and you'll run half a millimeter of ST elevation in the typical posterior leads. That's V seven to V nine um an endemic, it's around half a millimeter. Again, I appreciate these are sort of random facts, but sometimes they do like to throw these in um in MC Qs. So you're on half a millimeter of ST depression in two more contiguous leads and one millimeter t of depression in leads with a positive uh QR S. So if we go with an angiogram, um so as you can see on the left hand side, we have an angiogram, which is essentially a cat technique where they go into the femoral artery and they inject a contrast dye with a serial of x rays. And then you can see live as the heart is beating as it, the dye flows into the coronaries, you can see it, there will be some occlusion. So I'm not sure how well it's showing. But the first picture on the left shows normal coronary arteries on the left hand side of the heart. The middle picture is uh normal coronary arteries on the right. And then the far right as you can see L ad stenosis um as labeled in the picture there to just to try to uh summarize the topics. Now, does anyone have any questions feel free to put something in the chats or you can uh meet your mic and ask correct? Yeah, I OK. So me one. No. So again, we've done an angiogram and we can see that this patient has 90% stenosis in the LD, 80 point stenosis in the circumflex and 75% stenosis in your left nodule. So, fairly significant triple vessel disease and some stenosis in the right coronary artery. Ok. Ok. So next question relates to anatomy. So which of the following regions uh of the heart is supplied by the left anterior descending artery. So A is left atrium and left ventricle. B is left and right ventricle and the anterior one third of the intraventricular septum C is left ventricle and D is left and right ventricle. And the posterior two thirds of the interventricular septum. I'll give you guys a minute for this one. Ok. So again, you guys pretty much smashed it. So the maturity 92% 1 for B. So the reason why the others aren't correct. So the left atrium and the left ventricle is supplied by the circumflex. And as you guys rightly said, the left and right ventricle and the anterior one third of the interventricular septum is supplied by the L ad the left ventricle is supplied by the left marginal and the left and right ventricle is supplied by the posterior two thirds. Uh the posterior interventricular artery supplies the left and right ventricle and the posterior two thirds of the interventricular septum. Any questions about that one? Yes. OK. To do some of the relevant anatomy. Um Usually in MC Qs in medical school, they tend to want you to link the ECG changes to the territory supplied by which of the um arteries that will then give you uh as a problem. So I like the first thing on the top left. I got teach me anatomy which shows you a very simple schematic. And that shows you that as the left and right coronary arteries arise from the aortic sinuses, they split into the left and right. Um And then you can see that the right arises from the anterior aortic sinus, which then runs into the right part of the atrium groove. Uh and it gives off the main branches of the right marginal and the posterior anteroventris branch, you then have the left coronary artery which is larger and shorter uh than the right. So that rises from the left posterior aortic sinus and then divides into the main branches of the anterior intraventricular artery. And the so again, just a bit of a summary, I appreciate it's quite a busy slide. But in medical school, they do like you to link uh particularly when they give you either the symptoms and then the E CG findings and then they want you to see which of the arteries is occluded or vice versa. So any questions in terms of the anatomy? Mhm So one question that comes up, particularly if you go to theater surgeons love to ask this is in terms of query dominance. So that's why I went um into the right coronary artery first because essentially coronary dominance means which coronary artery gives rise to the posterior interventricular artery. In that diagram, it's the right and that usually is so around 70 75% of current dominance is maintained by the right, but it can be the left. Um it's sort of 10 to 20%. And then when both the left and the right uh gives rise to the posterior interventricular artery that's known as codominance. No, it's ok. So now going back to our patients, we have a summary in terms of what he came in for our initial findings, we did an EKG, we did an angiogram. So we're fairly convinced that this is due to um fairly significant coronary artery disease. So the next question is which of the following is the most suitable for this patient in terms of treatment do be admitted for observation, medical management and lifestyle advice and then discharge, do admit for observation, medical management, lifestyle advice with cardiology. Follow up. Do we do a primary PCI with or without insertion of a stent or do you refer him to cardiac surgery for Corio artery bypass surgery? And again, I'll give you guys a minute interest. Still not on that one. Ok. Ok. Ok. So with this one, the majority of 53% went for primary PCI with stent. Uh 26% went for D which is the correct answer and around 20% went for B um observation, medical management, lifestyle with cardiology follow up. I'm glad it all went for a because we would get in trouble. So the reason why I did the question like this as the most suitable is depending upon patient characteristics. So this was an elderly patient with multiple comorbidities and wasn't suitable uh for bypass surgery, which I'll go into a minute in terms of the risks um of bypass. But why this patient would be more for bypass surgery as opposed to a stent is if we go back to, if you look at his and he has a fairly significant triple vessel disease, um He's very acute, he sort of short, short of breath and symptomatic, relatively speaking, he's quite young and whilst he does have comorbidities, uh he seems to fit in well, all things considered, he works as a builder. So fairly uh physically demanding job, you also need to plan in terms of um future intervention. So some stents can result in restenosis. Um But in this patient, with the extent of stenosis, you're more likely to offer him uh bypass surgery. So I've taken these points from the 2018 E se ex guidelines in terms of whether you do PCI um versus cage. So roughly, if you want to make it simple, uh this criteria usually is the left main stem stenosis. He has fairly significant l ad stenosis. Um They, they also have proximal stenosis. Um If it's 2 to 3 vessel disease, we haven't done an echo. But if there was low ejection fraction, um, you might want to also offer, um, CE PG plus also, if the patient has angina and if they'd come in before and we'd treated them medically, and if they are still symptomatic, um, then you'd be more, um, inclined to offer them from artery bypass surgery. So again, you can see that it's usually the extent of the stenosis, the number of vessels involved. And if there's late main stem disease, if he had fairly significant renal disease, we might be going against uh bypass surgery because some of the effects um on renal function. Um he has no recent stroke, um or larger virus diseases, a contraindication to dual antiplatelet therapy. Um And again, looking into age and likelihood of stent restenosis. If this was the same patient presenting at 75 then you're more likely to be inclined to offer PCI over cage. Um And he has sort of no chest deformity. Um At this point, we haven't assessed that we don't know if he has any poor quality or missing conduits. So when it comes to doing the grafts, um I'm not sure how much you guys know, but usually, um it's the left internal mammary artery to the left anterior descending. And the reason why we do that is because it results in around 90% patency at 10 years. Um Some patients may also have vein grafts. Um But that's again, in terms of the work up, you decide that after you've done all the pre examinations and an echo and then discuss this with the patient. So if you don't have any questions, uh based upon that matter, there was a bit of a even spread in terms of the answers. Um again, feel free to message in the chat or if you want to uh unmute and then we can discuss as to why this is a cabbage over a PC case. Ok. Mhm. Ok. So we'll go to the next question. So we decide to send this patient coronary artery bypass surgery. He is assessed and once the patient goes for coronary artery bypass surgery, um we establish so we open the chest, do a median Steny. Um And then the patient is given heparin before we start him on cardiopulmonary bypass. The reason why that's given is to avoid thrombus formation in the circuit. So as the operation ends, the consultant asks the anesthetist to give an agent that reverses heparin. So which of the following reverses happening? Is it a Vitamin K Is it B protamine CFF P or D promine complex? I give you guys a minute. Ok. Most the answer it correct. So you have 65% of protamine, 25% for Vitamin K and 10% for prothrombin complex. So again, this is one of those factual recall questions. Um that is fairly niche. Um I know this came up one of the practice MRC S. So for post graduate members of the audience, this is one of those niche questions that you either know or you don't. Um And again, surgeons do like to test you on this, uh particularly if you shadow the perfusionist. So I'll go into the principles of bypassing a bit whether they do like to ask this question. So again, it's just fairly straight standard um factual recall. OK. So this is a fairly important principle. Um to understand as most operations um done, my cardic surgeons will involve an element of cardio bypass. Some of them may do OCA which is essentially beating heart, um open heart surgery, which takes a bit of a um degree of technical skill and depending upon if the patients um aren't suitable for bypass. So why do patients um need bypass or open heart surgery? So essentially um its role is to take over the function of the heart and lungs. So, in doing so, it essentially provides both circulatory and respiratory support. Now, it does that in order to deliver oxygen to and organs and also to provide emotionless and bloodless um field. So effectively, you provide oxygenation, uh ventilation, circulation, temperature control, which I'll go to in terms of the heat exchanger um and electrolyte balance. So, apart from um taking over the role of the heart, it also has to stop the heart from beating and also protect the heart um during bypass surgery. So to do this uh we give cardioplegia. Now, the reason why we do this again, um provides protection of the heart but also decompresses the heart. And the reason why we do this is to decrease the basal vein that creates. So, during that period of ischemia, the heart is protected and it allows the surgeon um to safely carry out whether it's um coronary artery bypass surgery or something like a valve repair, um oral placement or for example, if it's eye dissection as well, but that's uh going into hypothermic circulatory or rest, which is when they um reduce the temperature, even furthest they can go down to 18 degrees. Uh But that's beyond the scope um of this presentation in this particular patient. So in terms of the physiology, why some patients may or may not be suitable for bypass. Um because the tubes are non endothelial lined as the blood goes through and it goes back into the patient, we essentially induce a whole body um inflammatory response. And the reason why this is important is because in some patients, um it activates the contact system, the intrinsic and extrinsic pathway, the complement symptom system and the fibrinolytic pathways. Again, this is one of those niche things that the medical school I didn't really appreciate. And I thought, why do we need to know this? But in principles like this, you can see why it's important to know that. So what does that mean for the patient? Some patients are at an increased risk of developing A R DS. Um AK I, they can also have reduced contractility um after surgery. Um And then, because you can sometimes get protein induced uh pulmonary hypertension, they can have increased pulmonary resistance. So, in terms of uh the circuit set up, so as we said, before we give the patient heparin um and then they measure depending upon the act. So you run around 480 above. So that's the communication between the anesthetist um and the perfusionist. So once it's around 480 we also want to control the systolic BP. So you want to aim for around 90 to 100. And the reason why we do that is to reduce the risk of aortic dissection. So if you look at the top uh picture, which again is quite simple. But again, I think it's important to illustrate um the basic concepts. So once we've given in the heparin, we'd insert um the cannula. So you can see two there, the most common set up is an aortic atrial. So you have one cannula in the right atrium which then drains blood from the right atrium and then it goes through into the reservoir which is then going into the heat exchange as well. So once you've drained from the right atrium into the reservoir, um we propelled the blood um into the heating gas exchange and you can see that and then go through to an oxygenator as well. So we provide both gas exchange and then temperature control at this stage. Um And then as you see, there it goes into um another filter and then back into the patient. So at this point, we've established the circuit, but the next step is then to insert the cardioplegia solution. So at this point, um we then place the aortic cross clamp, as you can see in the bottom right now, the reason why this is important if we separate the systemic and the coronary circuits, we don't want mixing because once we give that potassium rich cardioplegic solution, we don't want this going into the systemic circulation. So as you can see there um in the bottom left, we can either give it antegrade which is into the aortic root, which is illustrated by the bottom right picture or we can give it retrograde, which is directly into the coronary sinus. Now, in some cases, we do that because if you see that there's aortic valve pathology, you may wanna do an aortic valve replacement as well as for example, the aortic root. So your access into the coronaries is affected, particularly if there's fairly significant aortic stenosis. So you have very small canals that you can give directly uh into the coronary sinuses. And again, once you've done this, depending upon surgeon preference, the length of the operation, you would then repeat by giving further doses around 20 to 30 minutes uh interval after you established uh cardiopulmonary bypass. So there was quite a bit to go through, see if you guys have any questions. Uh Let me know. So you put a question in the chat or if you wanna meet yourself. Um You can ask a question as well. I think of the question. Yeah, of course. So the reason why we use cardioplegia is both to arrest the heart, so to stop it from beating, but also to protect it. So when you have potassium rich solution, that's the one that essentially arrests the heart. But there are very other components with cardioplegia, we can give uh both in terms of temperature control to then stop the heart beating, but also to protect it. So the protection part is you reduce its basal metabolic rate. So its oxygen demand during the operation decreases to the point where you don't want to induce ischemia because obviously the heart is technically um without a blood supply. So we arrest it to stop it from beating. So the surgeon can do the operation, that's for the potassium. And then we provide there other um components to the cardioplegic solution that then protect the myocardium to stop it from um developing ischemia er during the operation. I hope that's answered your question. And again, we top it up throughout the operation. So it's not as if you give one dose. Um and then that's enough for the operation. You have to sort of keep giving cardioplegia um throughout the operation. And again, that depends on the length of the operation and also um surgeon preference as well. No worries. Thank you. Ok. So moving on to viral disease. So I'll give you a bit of an overview first and then we'll go into some of the more common um pathologies encounters. So they're fairly common in the general population. Around 2.5% of patients have some sort of viral disease um of varying severity and as they age, um obviously, the risk and prevalence increases around 10% in patients over 75. So as well, most patients, as you've seen with this one, we'll do a battery of tests. So chest x-ray and E CG because sometimes these may be found incidentally, a patient may come with an infection, they may develop af and then you do an echo and then somehow they have um mitral valve regurgitation, aortic stenosis or they may present acutely with symptoms such as shortness of breath, um chest pain, sickening or pulmonary edema. Now, with echo, right? Um Thank you for the question. So with that one, I'm not really sure just because with most operations, um we also get in the circuit as well. Um When you put a patient on bypass, um the non endothelial line circuit is in itself a risk factor for producing clots. So what you can also do is quickly reverse it so the patient can recover. Um And then with some of the effects of AD and AK I um by reversing um heparin, you can then also then um speed up the recovery. Um So again, that's not something actually I looked up so I can get back to you if you will leave me some of your details. Um because also I'm not sure in terms of the length how long it would take uh for the heparin to metabolize normally after the surgery, which I think is mostly related due to time. Um but also helping the patient recover um immediately after the operation. So you can then monitor them uh in the acute coronary unit in intensive care rather. So that's to answer your question. But if not, I'm happy to uh get in touch after. Um OK, so in terms of the more common ones, we have mitral regurge. So in exams, actually, I remember when I was um on my cardiology placement and the card said, just remember aortic stenosis and mitral regurge in finals, that's essentially what's going to come up. Um But of course, I'll go through uh both of them today. So the symptoms um are fairly generic and again, up until you do the echo, you don't really know. Um, they may have complications. Af and then again, I said, coincidentally, you might do investigations like an echo uh to find that they have v pathology. But in terms of medical management, so again, depending upon the severity, uh both of the disease and patient symptoms, but sometimes patient choice, it will then influence um which you use in terms of management. So if you go medical management, we're mainly looking at symptomatic relief and also managing but also optimizing their comorbidities if they are to go for surgery, in terms of surgery timing and the type of intervention again is guided by the severity um of the viral pathology, but also patient symptoms. So you can go for a catheter based technique such as Tavi. So that's transcatheter, aortic valve implantation. Um for patients with aortic stenosis MitraClip again, is something used uh for mitral regurgitation. And then we have open heart surgery and increasingly minimally invasive and robotic surgery. So remember I was on my elective um and I saw a patient who had aortic stenosis. He came in and we did all the exams, did an echo and he was offered surgery. Now, the patient declined because he said, well, it's not that bad. Um I this open heart surgery nonsense sounds a bit too scary for me and I'd rather avoid it if I can, which is fair enough because some patients when you tell them you have to put you on bar, bar, stop the heart and then all the risks associated with it. Most of them don't really want the operation. But the trouble is if you wait and then they develop increasing shortness of breath and then some of the complications as a result of that, such as heart failure, that operation becomes a lot more challenging, even if it's the same pathology. And then you're looking at some of the more minimally invasive techniques which depending upon which term you read, the long term success um is variable. Um And then also for the patient as well, in terms of symptomatic relief, um it's always better when you can get in and particularly for things like aortic stenosis because particularly when you can open um the aortic root and then take out all of the calcifications or most of it, that's definitely more preferable um of why I'm biased um than doing a minimally invasive technique. But again, if they present, um can you short of breath, you do the echo and then you find you have chronic kidney disease, very common disease, severe CO PD, you look at their performance status as well, doing open heart surgery, even if it improves their symptoms may not be the wise choice because you have to think about the effects of bypass. So the whole system inflammatory response, if they have chronic kidney disease, the effects of their kid or their kidneys afterwards and how they recover um post bypass. So, going into the next question, so you have a 67 year old female uh that presents with this neural exertion, um increasing fatigue, particularly when she does the shopping and looking after her grandchildren, she's noticed her legs becoming more swollen over the last year when you auscultate, you hear a pansystolic murmur over the apex which radiates to the left axilla and as loudest heard on expiration. So which of the following is the likely underlying cause? Is it a mitral stenosis b mitral regurgitation. C aortic stenosis or D aortic regurgitation. Yeah, I'll give you guys a minute just to answer that one. Yeah. Ok. So the majority is 71% but for the correct answer, which is mitral regurgitation. So again, when looking at medical school exams, um essentially it's aortic stenosis, mitral regurge, pansystolic for um mitral regurge. And then the next question will tell you what aortic stens it is. I'll get it away there. Um uh over the apex and also radiation to the left axilla is a classic sign. So it's something you just need to know. Um And it's a favorite of um medical final exams. So going into mitral regurg, so as the name suggests, regurgitation essentially is an incompetent valve which leads um to retrograde blood flow through the mitral valve. Um from the left ventricle back up into the left atrium. It's the more most common v abnormity worldwide. And then in terms of what causes it. So it's classified into primary or secondary. And again, I'd recommend uh particularly when you're either presenting to seniors or when you're sort of clarifying what you think is the cause and then the management always classifying them into a cause. OK. Yep. Thank you for the question, Sam. Um So yes, you can do. So we'll get into that in terms of um robotic um CABG. So laparoscopy is abdominal surgery. If it's um thoracic, it will be thoracoscopy. So they can go in through the site again, depending upon um particularly when it comes to the mitral. I'll get into that later. Yeah, you can do uh minimally invasive heart surgery. So usually the uh standard is open heart surgery. So your media stott toy establish bypass, you can also then do without bypass, which is off cab. And then increasingly now, uh there are minimally invasive uh lateral thoracotomy. So it's a mini thoracotomy that goes into the um right hand side from depending upon which valve you're going into. And then now we're going into robotic surgery, which is kind of the latest advancement. It's more prominent in thoracic surgery. Um cardiac surgery again, just because of the complications with bypass and you need a sort of, if things go wrong, you need to access the chest very quickly. Uh So if the patient encounters bleeding, if you can't reach into and obviously think about the delicacy of um bypass grafting and how tiny the economy vessels are, you need very advanced instruments that can then give you that field of vision, but also with dexterity um and the ability to then go into and do the uh particularly the bottom ends. Um And then you're getting into more complex. You know, if you're trying to do off pump, um, meaning invasive surgery with the heart beating and you're going in from the side, you need that field of you. But also if things do go wrong in terms of bleeding, you need quick access to the chest. So that's again, you're looking at the conversation with the patient, how risky the operation is. If it's just a single vessel, if you do, for example, a lemur to led, so you don't need do the top and you just do the bottom end cos it goes off the left subclavian, you can then do that. Um But again, that's more advanced and few centers um offer that you, you think about also the profile of the surgeons. Um But again, I think King's College do that in London. Um But yeah, it's, it's definitely increasing. I think both specialties are heading towards that way. So in my center, actually, um we have two robots. Now, one, you can have a training robot where you can actually sit down, you can have a 3d image of what's actually happening. So you have the surgeons field division. Um But because obviously thoracic thoracic surgery is more way more simpler, but the access points is more natural and then also with the operations that they do, they have to go in as deep um in terms of some of the vessels. So if you encounter complications, um it's a lot easier to than just uh increase the incision and then go in and then either do a vats or you can do a thoracotomy. So I hope that makes sense. Um So going into the courses, we can classify them um in terms of primary or secondary. So the primary course is something related to the structure uh within the valve itself or the surrounding structures um around the. Um Yes. Yeah, Davinci. So we have one in Nottingham. Um I think there's another company that does them. So I think with the ones we have in Nottingham, um we have a Da Vinci that's used by Thoracic, I think upper gi as well. So it's not sort of um exclusive to your thoracic surgery because these robots are quite expensive. Um And then you get into the whole point in terms of justifying them. So they're very expensive and you have to look at the outcomes for the patient as well. You have some old school surgeons that say, why would you use a robot when you can use an open approach? If things go wrong, you have the access point. But then when you speak to patients and then you sort of counsel them in terms of, if we do the operation, you're gonna have a scar this big or a tiny scar. That's when um you sort of make that decision in collaboration with them. Um I've spoken to a few consultants that are sort of very head on in terms of using just either open or vats. Um And then in Cambage, you can also use a mini um uh stenotomus. So it's only the top part. For example, if you want to operate on the aortic root, you can just do a mini steno. That's the top part. You'd have to do the full uh steno that again for the patient in terms of cosmesis. Um but also complications in terms of uh spinal wound infections, but obviously the bigger the wound, the higher chances of infections. So I hope that has answered your question. Um So again, going into the causes, so we then go to secondary causes. So there's actually nothing wrong with the valve itself. It's just over time, you have myxomatous degeneration or in developing countries. Um Rheumatic heart disease is still the most common cause. They going some of the ps er the physiology. So as a result of the retrograde blood flow into the left atrium, you increase the preload of the left ventricle during diastole. Now, during um going into the uh physiology that's expressed by the starting equation, you then have a left ventricular stroke volume that's increased to compensate, which then means that the left ventricle is dilated and then the annulus, which is essentially what um keeps the integrity of the vital mouth is then widened. So, when patients present to you, um there are features of heart failure, so shortness of breath, um and some of them may say when I sleep, I need a few pillows to prop me up because I just can't, um, get a good sort of intake of breath and some of them may wake up grasping for air, opening the windows at night. And that's sort of paroxysmal nocturnal dis, you know. So again, as the question, uh, previously illustrated an examination, it's not always textbook in reality, but you'll hear a pansystolic murmur over the apex which then goes into the left axilla in terms of management. Um Again, it's depending upon which paper you read. There's a paper that I read that looked at all the various um medications, patients have high BP and all the other comorbidities. Ace inhibitors and alb can potentially reduce the regurg volume and the left ventricular size in primary um mitral regurgitation, which then you hope would um decrease progression. But again, the evidence is very limited, you can also give them loop diuretics. So if they have sort of edema um to then offload the fluids to help them um with the shortness of breath. But really depending upon the severity. If they're sort of moderate to severe, you're looking at either mitral clip, which is sort of the equivalent um for mitral valve surgery. And then as we touched earlier, you can either have open heart surgery, um or minimally invasive surgery. So any questions on that one? Ok. So we'll go to the next slide. So again, I hope this illustrates uh the previous questions. Um So if you look at the top left, that's the module clip. Again, it's a catheter based technique. The top right is an open mitral valve replacement. So you can either replace the whole valve or you can do a repair which is the bottom left. So it's usually um an annuloplasty ring, which is that white ring, you can see and you can suture the valve and then just to answer the many invasive questions, you can then see the open approach versus the robotic approach. So again, it's usually such as preference. Um I think those are up and coming. Surgeons are being trained increasingly um in really invasive techniques. But the advantage of the open approach, as I said earlier is your axis is better in terms of vision, it's better um the techniques in terms of bypass that well established. And if you have complications, it's much easier to then um correct during the operation on the right, you can see a robot. So usually you have depending upon um your sight in terms of the technique that you're using how many holes you have while you're operating, you usually have 3 to 4 ports. And then the surgeon has a console where essentially they sit down and it's sort of wrapped around, it's a sort of 40 image when they can use. Um And they get 4360 degree um in ability with the instruments So that's the benefit of a robotic um technique is you have better vision. And also it's with a hand, you're sort of limited in terms of um the amount of degrees you can turn your hand and depending upon the access point, um if there's two or three of you, all of these things lead to an increased um operative time. Um But with a robot, you have 40 vision, it's again, if I would urge you guys, um, what don't we do? Slow? Yeah, exactly. So, and that, I think that's one of the reasons why um if you look at old school surgeons and the ones up and coming, they'd use what they've been taught to justify their technique. So they will sort of backwards, rationalized and say yes. But if I use a robot, I can see everything and it's easier and the old school surgeons will say yes. But if you use a robot, something happens by the time you mess around with redoing the robot cos it takes a bit of time cos that picture doesn't really illustrate how big the robot is and how big the arms are and you're sort of all the way from the operative operative table and you're des as well. So all of these things play a factor. Say if you encounter bleeding and you can't see it. I mean, even the vision, even if the fuel vision is great, you still wanna get in quickly and solve the problem, which I think is the reason why, particularly in cardiac surgery, they've been hesitant to, um, use robots. Whereas in thoracic, it's a lot more common and definitely um improving in terms of both the training for junior surgeons, but also some of the senior surgeons as well. Um I think in my center there's at least one day where it's just a robot. Um, and obviously that will be increasing in use as the up and coming trainees. Um I would urge anyone who is either in a center nearby or if you have an elective um to see it because it's really cool. The field division is amazing. Um But again, depending upon the indication, the severity of the pathology of encountering and also the patient as well, if you think about patients with um increased BMI, that may be one of the issues in terms of getting access. But again, as you rightly say, you need to think about the likelihood of complications and what to do. So that's why you have a plan in place. But thank you for the question. I hope that's um answered your question, he conscious of time. So if we go on to the next question, 0 65 your man that presents with apologies. I think it's been cut off. Um So on a scortation, you have to say it will be shortness of breath. Um On a quotation, you hear mid systolic ejection murmur that's heard over the right side of the sternal edge, second, intercostal space that radiates to both carotid arteries. So which of the following is the likely underlying cause? So, a marl stenosis B mitral regurgitation, C aortic stenosis or D aortic regurgitation. I sort of gave it away um in the previous explanation. So I won't give you guys that much time for this one. OK. So pretty much everyone got aortic stenosis, which is the correct answer. So again, just the question stan will pretty much um tell you what the answer is. Um And this is just one of those factual recall questions that medical school finals love. And remember it's either aortic stenosis or mitral regurge. So going into aortic stenosis, um so again, it's age related calcification. Um you can have a congenital bica aortic uh valve that then will present with symptoms um later on in life and to mitral regurge in developing countries. Rheumatic heart disease is a common cause. So in terms of the physiology, you'll get reduced blood flow from the left ventricle, which would then lead to increased resistance and then hypertrophy of the left ventricle to maintain the stroke volume over time, the left in interval will and eventually decompensate and then you get patients with heart failure. So, going into the patient that I saw in clinic um at the time he wasn't very symptomatic. So to him, it didn't really make sense to undergo open heart surgery for something that yeah, was short of breath, but he put it down to getting older. Um, but if you ignore it over time, you will then develop heart failure and that shortness of breath will be significant and not just on exertion but going into the symptoms in terms of and the orthopnea and the paroxysmal nocturnal dyspnea over time, it can definitely impact their quality of life. Um, I was just on call so I did a six and seven day week this week just gone. And there was a patient with heart failure and they were treating the heart failure, but they really couldn't get on top of um just the amount of fluid and those sort of reduced um left ventricular function. Um So to the point where he was bed bound and their quality of life, particularly in the end stages really isn't that pleasant. Um So again, it's important to counsel patients on the trajectory of the disease and the likelihood of it progressing into more significant symptoms. And when they're at that stage where it's not really that bad, they can't foresee that. So again, this is very important as a clinician to then counsel them and say yes, the symptoms aren't that bad now, but later on, it might get to the point where your s your symptoms are even worse. But what we can do is limited based upon all the other factors in terms of their comorbidities. So in terms of their symptoms they'll have with, they'll come with exertional dyspnea, angina and syncom fee. And in the questions that you highlighted, they'll have an ejection systolic murmur in the aortic region. Well, sometimes again, this is where medical finals they like to throw in these textbook presentations, but they may not be the case in practice with a slow rising pulse and a narrow pulse pressure. Sometimes you might only get just that last bit. Um in the question, then without the um classic ejection systolic murmur. So again, management, we have either medical or surgical when most patients you want to control their BP. This is where ACES and A BS have a role. You can also apparently with A BS reduce left ventricular mass and slow the progression of the calcification. Um beta blockers have a negative inotropic effect. Um But then you can just use them in low doses for af and hypertension. Um use BS with caution. So again, with the risk of hypertension, um aggravating the heart failure diuretics can lead to potentially low cardiac output um with arterial hypertension and peripheral hyperperfusion. So in terms of the surgical options, we essentially have either tt um or surgical repair or replacement. So as you can see that the top left is your open um aortic valve replacement. So that's called a parachute technique. Um You usually get quite a good view if you're at the top end of the table. Uh And then the right is your catheter based tabby technique. So again, when it comes to counseling patients, patients, if you're looking at a mechanical valve, um if they're younger, just because of the lifespan of the valve. So if you have a mechanical valve, it will essentially outlive the patient. Um whereas a tissue valve has a large span of 10 to 15 years, the only obviously uh implication is in terms of anticoagulation. So usually um lifelong um warfarin after initially being on Heparin. Whereas if you have a tissue valve, um you don't need anticoagulation. So just before we go into the next case, um any questions on any of the cardiac related pathologies, I'm just conscious um of the time. Ok. Ok. So going on to our second case. So you're a 63 year old female who presents with recurrent chest infections and shortness of breath on exertion. This has been ongoing for the past six months. Her GP wrote for her to provide a two week wait suspected cancer line way pathway. As he noted, she had lost weight over the last three months and has a few episodes of hemoptysis. The respiratory team that she was referred to, organized an X ray and saw her in clinic. She was referred to the thoracic surgeons after the chest X ray showed a peripherally located white gray mass in the left lung in terms of the pro. So she has esophagus, high cholesterol and reflux. She's atorvastatin omeprazole in gascon her father was a coal miner, uh, who was also a lifelong smoker and he died of lung cancer. Um, she works as a cleaner. Um, she smoked 20 per day since 17, has a try to cut down and is currently smoking 10 a day. Um, she's a social drinker and lives at home with her husband. So, taking those factors into account in terms of the presentation, um, the initial investigations and family history. The next question is, what is the next most appropriate investigation bearing in mind we've already done an X ray. So is it a CT scan? BPE CT C endobronchial ultrasound biopsy or D bronchoscopy with or without biopsy? Give you guys a minute for that one. The OK. So the majority just went for a CT scan, um which is the correct answer. You have 30% CT scan, 20% pet ct, 20% EBUS and then 26% bronchoscopy and biopsy. So we'll go into the case and explain why um one or the other. So the next question is the CT scan that she goes on to have shows a left sided peripheral lesion that's highly suspicious of malignancy. She has a further pet CT. Um and then the surgical resection with biopsy is recommended by the MDT. So then which of the following types of lung cancer is the patient most likely to have. So think about the gender, think about the risk factors. Think about the location of the cancer. And that would usually, um, give you some kind of idea of the answer. I'll give you guys a minute. Ok. Ok. So 43% were for small cell or 47. Now it's going up, um B1 for squamous cell, 17% were for adenocarcinoma and then t went for large cell. So 0% had uh T as the ons. So this is where you need to, this is just a factual question and it could be a couple. So she's a smoker. So yes, A B and C could also be uh the answer. Um We then look at the location. So if I go back, OK, the key is in the location. So if I just give me a second peripheral located white grade mass in the lung and we go back the only one that's most, I mean, there's two large carcinoma but that's very rare and it's not likely to be in this patient. Um But again, she's a female, she's a smoker and it's a peripherally located lesion. Any questions on that one? No. Ok. So let me one. Um So again, looking at lung cancer. So in the UK, I'm not sure depending upon where you are in the world, but we now have um a lung cancer screening program we're expected to find and pick up a lot more um cancers than previously. These fro rates are still quite poor. Um So it's the third most common uh in western countries and the most common cause of cancer related deaths, the five year survival rates are quite bad. So 16%. Um and we don't know why, but survival in females are higher than males. And unfortunately, it causes around 2 million deaths worldwide each year. So you classify them uh based upon small c or um so apologies, I think this is a little bit incorrect. Um So it can either be small cell in 15 to 20% or non small cell in 80 to 85%. Um So small cells originate from neuroendocrine cells. Um They develop centrally in their main bronchus and have a strong solution with your smoking. So again, you look at the um risk factors and then you tie it up to the patient history in terms of their social history, they tend to grow quickly and metastasize rapidly uh compared to the small cell lung cancer. Uh squamous cells also develop essentially with a strong association with smoking. Adenocarcinoma developed peripherally. Um And then also they're associated with smoking and more common in women. So, again, going back to our question, uh looking at the demographics um and the risk factors, you can also have carcino that are mainly central. Uh And that's the only one that isn't associated with smoking. And then you have large cells, that's why it wasn't large cell in the previous one because they're found throughout the lung. Um So the risk factors, as you might imagine is smoking in 90% of lung cancers um are diagnosed in smokers. You can also have um occupational exposure, asbestos or heat on gas um and radiation depending upon um where you work or what part of the world um you live in. So the top left, we can see a CT chest and an axial view showing us the left envelope adenocarcinoma. And this is a, you do a pet CT, it's usually as a staging um scan once it's confirmed and usually recommended um by the MDT. So, surgeons like to look at these um preoperatively um to give them an idea of where they're going into. Um And then on the bottom left, you can see a squamous cell carcinoma uh in the left upper lobe. Yes. OK. So some of the features um and how the patients might present. It's again dependent upon the type of lung cancer where it is um if it's primary or not and the extent of metastases if there are any. So if they're localized, the patients will present with a cough hemoptysis, um and shortness of breath. If it's fairly advanced, patients may have unintentional weight loss, uh feel increasingly tired. Um and then depending upon the type of cancer. So it's more sort of fairly common in terms of um presenting with Mets. So, if there's this metastases um in the brain, they'll present with a change in personality. Um and mood, if it in the liver, they'll present with a vague abdominal pain. Um And then if mass to the bone, they may have pain. Um and pathological fractures and adrenal glands is one of the more common, the other common sites um where lung cancer tends to metastasize um depending upon again where it is if it invades within the media structure. So the picture on the left of my colleagues from teach me surgery.com has shown you um if it's a pancreas tumor in terms of where it would invade, so you can develop Horner Syndrome. Um So it's your ptosis miosis and on hidrosis. If it's phrenic nerve involvement, you will then have diaphragmatic paralysis. If it's the recurrent laryngeal nerve patients may present with hoarseness in voice and then you can see some facial swelling uh in a patient with SVC syndrome. Any questions on that one before I carry on? Ok. Uh So in terms of investigations, you do the basic bloods in terms of FB CCR P using these and bone profile. Again, just to give you um a basic overview of the patient and if they have any underlying infections um or electro abnormalities that you might want to correct, as we said in this uh patient chest X ray is the most common initial investigation. Um And then you can have a contrast CT S to characterize the lesion check if there are any lymph nodes that are involved. And then if there's any local invasion. So usually, usually a pet CT for non small cell um lung cancer or a CT of your pelvis, most likely for uh small cell lung cancer because most patients tend to present uh with metastases. And then depending upon if you suspect um brain mets, you might also order a CT pet scan. So most patients will, then once they've been seen in primary care and then in clinic, um by expiratory physician will then be discussed. And an MDT, so that's where we determine in terms of factors whether or not um the patient is likely to benefit from surgery if they also need um adjuvant chemo or radiotherapy. And then we discuss with them in terms of the prognosis. Um So at this point in time, surgery remains the only definitive option. Um So depending upon the location of um the cancer, again, this is where we go into the classification, but also the surgical approach that will then influence whether or not you do um a vat or an open procedure. You can then again, depending upon where the lesion is go more targeted. So you rarely do a pneumonectomy. It's sort of, I don't think I've ever seen one in practice. Um Most likely patients will either go a lobectomy or if it's a more peripheral lesion, you can do a word resection, um or a segmentectomy and just going into the chat in terms of um whether or not you do open vats or rats, most centers are heading towards that surgery. Um Again, just because of the EIS um you still have a good uh field of vision. Um And then now, depending upon which center you work in robotic assisted surgery, um is becoming increasingly more common. Got it. So just an overview. Um you can. So the top left is a two port of that set up. Um Some surgeons can use three. But there are others that also do a uni portal um where you can essentially get all the instruments into one, the bottom left shows you the view. So I've assist in a few of these cases. Um And depending upon where the cancer is, sometimes it can be quite awkward to get some of the structures uh particularly if patients have had prior surgeries or if you're undergoing chemoradiotherapy that involves um in adhesions forming. And sometimes it's actually quite tricky because you can't see, as you can see with the instruments, they are sort of gently maneuvering as you get some of the um structures and sometimes they can be hidden behind adhesions. So that's where um as we touched on earlier, you need to prepare to potentially open up um to a thoracotomy if you um encounter some bleeding, that's uncontrollable, the picture on the right. So as we increasingly move to a more minimally invasive approach, um there's also currently a debate actually in thoracic whether whether resection or segmentectomy are um the best approach for patients with borderline lung function or patients with significant morbidities, um depending upon the location, the patients comorbidities and choice in terms of whether or not they prefer. And that's an open approach that gives you an idea um in terms of some of the smaller incisions, and then the approach is depending upon where the cancer is located um and how they'll proceed in terms of the operations. So just before we carry on, do you guys have any questions? Um in terms of the va set up or uh the approaches that you'd use in lung cancer surgery? Yes. Ok. So, moving on to the next slide. Um So just to finish up, we've got pneumothorax. So again, this is fairly common in terms of I'm currently working in respiratory. Um and as a junior, particularly if patient goes into A&E, um you'd be expected to clock them and then depending upon what you find um sated scene as if it's something of potential pneumothorax. So getting into the definition, so the pneumothorax is the presence of air within the pleural cavity. So it's usually down to a defect um on the lung surface itself or a damage to the chest wall in certain traumatic cases. So the reason why it develops is the natural poor seal that's there, whereby you have the normal negative pressure that aids the lung expansion is lost, which then stops lung expanding as it should do. And it can either result in a partial or a total lung collapse. As always, we want to classify them. So you can either have a spontaneous pneumothorax, which is then further classified into primary or secondary depending upon if there's an underlying cause. Um If there isn't, then it's a primary, if there is, it's a secondary. Um and then you can have a traumatic. So either if it's a trauma or you can also have the AIC case, it's either case in my finals of a central line insertion. And they presented to you with symptoms, essentially um attention in your thorax. And they asked you what is the most likely um cause of the patient's symptoms? So, going into uh the features, so shortness of breath is predominantly what patients will present with and depending upon the location and the severity um of the pneumothorax. And if they have any preexisting respiratory conditions, um that will vary in severity. So, on a quotation, you will see reduced breast sounds, but again, depending upon um how symptomatic the patient is, you may or may not pay, um there'll be hyperresonance um and reduced chest expansion if a patient develops a tension pneumothorax. Um again, you probably see this um as them being increasingly hypoxic could be tachycardic and hypertensive. Um and in very severe cases, they may have distended neck veins, um and a trachea that deviates away uh from the affected side. So, going into some imaging. So, usually you go for a chest X ray um alongside doing the a uh at examination. So you want to make sure the patient is safe first, particularly if it's a tension pneumothorax, you don't want to kind of wait until um you have an X ray to do something about it. So you use an x-ray to determine the location size and any obvious um mediastinal shift or perhaps any preexisting um respiratory cause, you may not always need act. Um But when the patient has um underlying Lyme disease, or particularly if you want to then proceed on to surgery later, you want sort of characterize what the underlying cause is the severity and if the patient needs intervention. So on my ward, we had a patient that was stepped down from critical care. Um He was there for, I think about 50 days and he developed a small apical pneumothorax, but he had underlying lung disease. Um and it wasn't fairly symptomatic. So we left it and it resolved uh spontaneously um over the course of I think four or five days. So you don't always need to intervene. What's changed in terms of the guidelines is if the patient is symptomatic or not. So usually before it was the size of the um you know, the right drug going into in the next slide. But remember these days, it's mostly related to um how stable the patient is and if they're symptomatic, so going into management So, if it's a primary spontaneous pneumothorax, if again, it's asymptomatic or small and by small. So to measure the pneumothorax, it's at the level of the hilum and you measure the edge of the line markings to the um, chest wall. So if it's large, it's greater than two centimeters, small, less than two centimeters. But again, these days, it's mainly um guided by patient symptoms. So in primary spontaneously, thorax where there isn't an underlying cause. So think of your uh tall slim male that's usually a smoker. Um You admit to observation and then discharge if it's a primary spontaneous and if it's symptomatic or large. So again, we go to that two centimeter as a rough guide, you perform needle decompression if necessary. Um And then use a chest drain if there's no um further improvement, if it is a secondary spontaneous or you have underlying lung disease, um If it's small, then you meet the for observation. Um And then depending upon how they progress in terms of their symptoms, you have a low threshold uh to perform needle decompression. And then if it's secondary spontaneous, if it's symptomatic or large, then you go straight to a chest drain as you would do in a traumatic, um your thorax that isn't tensioning. Whereas if it's traumatic and it's tensioning, you perform immediate needle decompression or a finger thoracostomy. So that prior, um if you were to a chest drain, again, if there's no resolvement, so Thank you so much for your question. So we promise uh asymptomatic what happens? Ok. Yeah. So what you would then repeat the chest X ray. Um Give them advice in terms of certain occupations like deep sea diving, uh and flights. And then you also bring them in um usually to clinic depending upon again, the severity you can repeat the chest X ray. Um So you keep them uh monitored, repeat the X ray usually um the day after and you're guided by their symptoms. Um And then you discharge them um with safety net advice and depending upon where you work, you might then um bring them in to repeat chest X ray 4 to 6 weeks time. Um again, guided by uh your local center. So with the patient that I saw actually, um it was a apical pneumo flu on the right hand side and the patient was completely asymptomatic. Um Initially, I remember that I was seeing it and I immediately ordered a CT scan just because he had um underlying lung disease. And I discussed this with a consultant um because it was going over the weekend, we were thinking if the patient deteriorates, um would we need to intervene? So this was secondary, but I think it's quite relevant to your question. Um You'd prepare if the patient needs to be um sort of intervention with either um needle thst or um a chest drain. Uh But usually there is love on their own. Um, you can also use TALP. Um, so again, that sort of irritates the poor lining. But again, that's more, um, in terms of they're symptomatic and your procedure surgery. So I hope that answers your question. And also again, in these patients, particularly if it's, uh, probably asymptomatic, they're most likely to be your stereotypical, uh, to thin male. That's a smoker. So, again, this is where lifestyle advice, um, comes into hand. Yeah, as much as I guess most people here, probably a surgical background, they want to intervene. Sometimes it's better just to kind of give the patient lifestyle advice um and make sure that they sort of don't do the things that make uh recurrence more likely. Ok. So just to finish on pleural effusions, uh I'm currently on respiratory and I've seen quite a few of these. Um it's a favorite of examiners as well, particularly when it comes to uh classification. So definition is the accumulation of fluid um in the plural space. So you can either classify them as exudative or transudative and that's guided by uh the protein content. So once we diagnose it as an exudative, we use lights criteria. Again, in clinical practice, it's usually um you do take a sample um and then send it for cytology analysis and that's how you classify them um later on. So we'd like to come to you again, this probably comes up in some form or another um in medical school findings. So I appreciate it's the most interesting fact to learn, but it's definitely necessary um particularly when it comes to if it influences patient management, um when it comes to your presentation. So shortness of breath, uh there'll be pain depending upon severity of the pleural fusion. So when you percuss, no dullness um of the effusion, there'll be reduced breath sounds obviously with the collection. Um And then depending upon if it's very severe, although this is quite rare, um you'll get tricky deviation away from the effusion. So again, this is one of those um med school final exams that you love to throw in. Um As a question whether it deviates to or way uh poor effusion. OK. So in terms of investigations, um we have chest X ray is pretty much uh the most common um approach. You can always see uh blunting of the costophrenic angles. There might be fluid in the lung fins. And what you can see there on the X ray is a meniscus. So that's the upwards curve where it meets the chest wall and the mediastinum. And again, just as a sort of context in terms of whether you're a medical student or a junior doctor, always have a systematic approach when you present X ray. So one thing you can get from geeky medics, um something I like to use is ripe at E so ripe is rotation, inspiration, projection and exposure and then at E is your airway, uh chest breathing diaphragm and everything else you can use. So I remember there was another patient who presented acutely. Um If you want to insert a drain, you can use an ultrasound um or act if you want an ir um guided chest drain in surgeon, um Usually for smaller e fusions, you would then go and identify the course first. You don't always have to uh insert a drain. But if you want to make sure you're quite thorough in terms of understanding the cause. Um So you want to analyze the LDH cell count protein ph glucose and get some micro. Um because again, you want to make sure you treat it properly uh to stop it recurring. And as you'll see in a minute when they recur or when they get infected, you get some fairly significant presentations. So in terms of management, if it's a smaller effusion, that's asymptomatic, you go for conservative. Um ideally, you want pleural aspirate just because you can then diagnose. Um and in some cases, it will provide symptomatic relief. Um and then you can set a chest string for larger effusions. So, if it's large, persistent or infected, you would then refer to thoracic surgeons. So I've assisted on a few of these cases. Um as you can see in the bottom, right, it doesn't look pleasant. So this is a left sided uh empyema. So when a pleural fusion becomes infected, it's termed an empyema and usually this is when thoracic surgeons get involved and depending upon the severity, um and other factors such as patient b these operations are very tricky. So the reason why is because when it's significant, the lung will then be adhered to the chest wall. So as you try and gain access, um for a vat probe, it's quite dangerous because you want to sort of go slowly um to not damage the lung. And then, even once you get in, it's very difficult to sort of peel the lung off and get as much of the um infected matter away from the lung. And even then you can be there for hours. I remember there was an operation, I was assisting for about 3 to 4 hours. We got most of it out. But again, it's very rare to get a complete sort of decortication, which is why once patients are then um operated on, they're on an extended course of antibiotics for 4 to 6 weeks because the chance of recurrence is very high. Um And then depending upon what you find intraoperatively, um you'll then speak to micro um and get the appropriate antibiotics to ensure there's no recurrence. But also for a patient uh symptomatically, it's important. So usually it's IV antibiotics, I think for at least a week or two. And then you'd either keep them in or discharge them uh to complete a 4 to 6 week course um of antibiotics. So, any questions on pleural effusions. Ok. I appreciate I've won over by quite a bit. Hence why I was a bit of a rush in the end. But thank you guys for joining us. I hope you've learned a lot. Um Thank you for the questions. It was very interactive. Um And hopefully we'll see you for the next installment. So thank you very much. It was a pleasure. Yeah. Thank you, Dennis for hosting. I really enjoyed that. I definitely learned a lot. So I really appreciate the you taking your time out today to get that talk. If you have any questions, please free to um put it in the chat or if you want, I'm more than happy to discuss a particularly heparin question. I'm actually quite interested in terms of the absorption um after the by. But thank you very much guys. It was a pleasure and also make sure you guys can feed out the feedback form as well. Um We are collecting them. So if you reach the minimum, I think, which I believe is six talks and we feed out the feedback forms. You can get a certificate with the CPD Accreditation for um each point for each um talk you've attended. So, yeah. Um Thanks so much Dennis. Thanks everyone for attending that wraps up this week's um talk and like you mentioned earlier, I hope you guys stay tuned for next week's version and take care