General Thoracic Surgery: Staging, Resection, and Chest Tubes
General Thoracic Surgery - Staging, Resection, and Tubes
The exam rewards systematic staging and complication management. For non-small cell lung cancer, know TNM principles: tumor size and invasion determine T, ipsilateral hilar nodes are N1, ipsilateral mediastinal or subcarinal nodes are N2, and contralateral or supraclavicular nodes are N3. Mediastinal staging with EBUS-TBNA, mediastinoscopy, or PET-CT is essential before resection when nodes are enlarged or FDG-avid. Lobectomy with systematic nodal dissection remains the standard for fit patients with stage I–II disease; sublobar resection is acceptable for small, peripheral, predominantly ground-glass lesions or patients with limited reserve. For esophageal cancer, staging includes endoscopic ultrasound and PET-CT; neoadjuvant chemoradiation is standard for locally advanced disease. Chest tube traps: know the difference between an air leak and a bronchopleural fistula, avoid routine high suction after lobectomy, and recognize that a persistent leak beyond about 5 days changes management. Pneumothorax questions test whether the patient is stable and whether a pigtail catheter or operative intervention is needed.
Worked example/rule of thumb: a 2-cm peripheral ground-glass nodule in a patient with severe COPD may be treated with wedge or segmentectomy rather than lobectomy. Rule of thumb: stage the mediastinum before you resect - an unexpected N2 node changes the operation into induction therapy.