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Thoracic Curriculum

Index

History
Embryology and anatomy of lung and heart
Functional patient evaluation
Medical therapy of lung and cardiocirculatory functional disorders
Preoperative patient care
Anesthesiological management
Mechanical ventilation
ICU management
Postoperative care
Physiotherapy
Extracorporeal bypass, ECMO, blood management
Pain management
Diagnostic imaging techniques
Basic oncology
Molecular biology
Principles of medical therapy of cancer
Quality surveillance
Feedback and complication reporting
Statistics
Study design
Scientific writing
Thoracic incisions
Video-endoscopy basics
Neoplastic lung disease
Complications of lung resection
Infectious lung diseases
Pneumothorax
Lung transplantation
Functional lung disease
Congenital lung disease
Pericardium
Mediastinum
Diseases of the pleura
Trachea and larynx
Esophagus
Chest wall
Thoracic trauma
Diaphragm
Ethics - Practice - Outcome

Unit I - HISTORY

UNIT OBJECTIVE:
At the end of the unit the resident has knowledge of the historic development of cardio-thoracic surgery

Unit II - EMBRYOLOGY AND ANATOMY OF LUNG AND HEART

UNIT OBJECTIVE:
At the end of this unit the resident understands the embryology and the anatomy of lungs and heart and their relationships to adjacent structures.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands pulmonary and heart embryogenesis;
Understands the arterial, venous and bronchial anatomy of heart and lungs;
Understands the microscopic structures of heart and lungs;
Knows the surgical anatomy encountered;
Understands the lymphatic system of the lungs, the major lymphatic nodal station and lymphatic drainage routes of the lung segments.

CONTENTS:

Pulmonary parenchimal, vascular and stromal embryogenesis
Heart embryogenesis
Macroscopic and microscopic structures of heart and lung
Surgical anatomy of heart and lung5. Lymphatic system

Unit III - FUNCTIONAL PATIENT EVALUATION

UNIT OBJECTIVE:
At the end of this unit the resident understands lung function, interpretations of pulmonary gas exchange, mechanics of breathing, cardiac and circulatory function, performance status.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands lung function and interprets measurements of gas exchange and lung volume;
Understands the physiology of airway mechanics;
Knows the cardiologic assessment of the thoracic surgical patient;
Understands clinical evaluation and various scores of performance status.

CONTENTS:

Lung function
- Measurement of gas exchange (pulmonary diffusing capacity, arterial blood gases, acid base balance)
- Factors affecting pulmonary gas exchange (partition and distribution of ventilation; distribution of blood flow; relationship of ventilation and perfusion)
Mechanics of breathing
- Elastic properties of the lung and the chest wall
- Lung volume measurements
- Airflow resistance
Cardiac- circulatory function, performance status
- Cardiologic assessment of the thoracic surgical patient
- ECG
- Ultrasound
- Clinical evaluation
- Various scores of performance status (Karnofsky etc

Unit IV - MEDICAL THERAPY OF LUNG AND CARDIOCIRCULATORY FUNCTIONAL DISORDERS

UNIT OBJECTIVE:
At the end of this unit the resident understands medical therapy to treat specific clinical problems.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the action of drugs used as medical therapy of respiratory and cardiac diseases.

CONTENTS:

Medical therapy for COPD
B2agonist
Aminophyllinic
Steroids
Inhalatory bronchodilatators
Inotropic and antiarhytmic therapy

Unit V - PREOPERATIVE PATIENS CARE

UNIT OBJECTIVE:
At the end of this unit the resident understands the preoperative management of patients undergoing thoracic surgery.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the evaluation of clinical and diagnostic data;
Understands the assessment of the operative risk.

CONTENTS:

Patient and family information
Optimization of nutritional status
Evaluation and associated disorders (renal, hepatic etc)
Risk evaluation

Unit VI - ANESTHESIOLOGICAL MANAGEMENT

UNIT OBJECTIVE:
At the end of this unit the resident understands the physiology, methods and techniques of anesthesia in thoracic surgery.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the preoperative risk assessment and management;
Understands the action of drugs used in thoracic anesthesia;
Understands the technique of epidural analgesia;
Understands intraoperative monitoring, fluid management and blood transfusion.

CONTENTS:

Preoperative evaluation
Informed consent
Drugs
Epidural analgesia
Conduct of anesthesia (monitoring, one lung ventilation, blood and fluid replacement, high frequency jet ventilation)

Unit VII - MECHANICAL VENTILATION

UNIT OBJECTIVE:
At the end of this unit the resident understands the indications for mechanical support, device selection, methods for weaning the patients from support.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the indications for support with mechanical device;
Knows the management of various ventilation strategies;
Understands the principles of weaning patients from these devices;
Understands weaning strategies and postextubation pulmonary management;
Understands the principles of non invasive ventilation.

CONTENTS:

Postoperative indications for support
Ventilator management strategies (control mode of ventilation; synchronized intermittent mandatory ventilation; pressure support ventilation; volume-cycled ventilation)
Weaning from ventilator
Non invasive ventilation

Unit VIII - ICU MANAGEMENT

UNIT OBJECTIVE:
At the end of this unit the resident understands the immediate post-anesthesiological and post-operative evaluation of the patient undergoing thoracic surgery.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands non invasive and invasive monitoring and circulatory management;
Understands the management of nutrition status through parenteral/enteral feeding;
Knows the prevention, diagnosis and medical treatment of infections which are either peculiar to the critical care unit or particularly difficult to diagnose in the critically ill;
Understands renal function, renal failure, indications and complications of dialysis.

CONTENTS:

Hemodynamic monitoring and management
Parenteral/enteral feeding
Control of ICU infections
Renal function and support

Unit IX - POSTOPERATIVE CARE

UNIT OBJECTIVE:
At the end of this unit the resident understands the management of all aspects of postoperative care.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the postoperative management of chest tubes and air leaks;
Understands postoperative complications and appropriate treatment;
Understands the diagnosis, treatment and pharmacologic management of secretion retention vs. fluid overload.

CONTENTS:

Management of chest tubes and air leaks
Postoperative hemorrhage (indication for reoperation) µ
Secretion retention vs. fluid overload

Unit X - PHYSIOTHERAPY

UNIT OBJECTIVE:
At the end of this unit the resident understands principles of preoperative and postoperative pulmonary rehabilitation.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the program structure and goal of preoperative pulmonary rehabilitation;
Understands patient evaluation for exercise capacity (6-minute walking test and exercise stress testing), supplemental oxygen requirement at rest and during exercise, inspiratory muscle function assessment;
Understands mechanism whereby pulmonary rehabilitation accomplishes the reversal in functional deterioration;
Understands postural drainage therapy to improve the mobilization of bronchial secretions after surgery;
Understands mechanics of the cough to remove retained secretions.

CONTENTS:

Preoperative physiotherapy
Postoperative physiotherapy

Unit XI - EXTRACORPOREAL BYPASS, ECMO, BLOOD MANAGEMENT

UNIT OBJECTIVE:
At the end of this unit the resident understands principles of mechanical circulatory support, oxygenators, techniques of extracorporeal bypass, indications for ECMO, device selection, patient management, methods for weaning the patient from support, and the use of blood component therapy to treat specific clinical problems.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the design and physiology of the various extracorporeal circuits;
Understands the types of tubing, filters, hemoconcentrators and perfusion solutions;
Understands the techniques for extracorporeal bypass;
Oversees the management of patients undergoing extracorporeal bypass;
Understands the indications for ECMO;
Understands the principles of weaning the patient from support;
Understands the requirements for anticoagulation and blood management;
Understands the methods used in blood component storage and measures taken to ensure a safe blood supply;
Understands the use of specific blood components;
Understands the operative and postoperative techniques to ensure blood conservation.

CONTENTS:

Extracorporeal bypass, ECMO
- Overview of mechanical circulatory support
- Circuit design
- Location
- Venovenous versus venoarterial bypass
- Indications for ECMO support
- Cannulation techniques
- Patient management
- Weaning
- Decannulation
- Follow up
Blood management
- Blood component therapy
- B. Indications for transfusion
- C. Autotransfusion
- D. Hemoconcentration
- E. Pharmacologic manipulation

Unit XII - PAIN MANAGEMENT

UNIT OBJECTIVE:
At the end of this unit the resident understands the management of acute and chronic pain after surgery and in inoperable patients.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands principles of analgesia during and after thoracic surgery;
Understands multimodal approach to pain control;
Knows the use of local and systemic analgesia;
Understands the beneficial effects in respiratory function and the diminishment of diaphragmatic dysfunction;
Understands the use of intermittent or continuous infusion in epidural local anesthesia.

CONTENTS:

Postoperative management of pain
Pain management in inoperable patients

Unit XIII - DIAGNOSTIC IMAGING TECHNIQUES

UNIT OBJECTIVE:
At the end of this unit the resident understands the use of diagnostic imaging techniques for evaluation of thoracic diseases, lung cancer staging, preoperative and postoperative functional evaluation.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the use of specific X-ray evaluation of thoracic diseases and the indications for contrast studies;
Understands indications for chest computed tomography and the use of various techniques for the evaluation of parenchimal and nonparenchimal lesions;
Understands the theory, techniques and clinical application of thoracic magnetic imaging;
Understands the use of ventilation/perfusion scanning to study the distribution of airflow and blood flow to the lungs preoperatively, postoperatively and in the evaluation of patients with suspected pulmonary embolysm.

CONTENTS:

Diagnostic imaging techniques: X-ray
- Routine PA and lateral X-ray examination
- Supplementary radiographic views
- Specific X-ray evaluation of thoracic diseases
- Contrast studies (esophagus etc)
- Angiograms (PA, SVC etc)
Diagnostic imaging techniques: CT (various forms)
- Indications for chest computed tomography
- Technique (standard and helical computed tomography, intravenous contrast media, high resolution CT)
- Evaluation of parenchimal lesions
- Evaluation of nonparenchimal lesions
- Postoperative evaluation
Diagnostic imaging techniques: NMR, US
- Theory and technique
- Clinical application of thoracic magnetic imaging (anterior mediastinum, middle visceral compartment, paravertebral space, thoracic aorta, pulmonary vascular diseases, bronchial carcinoma, chest wall, pleural disease)
Diagnostic imaging techniques: Scans
- Ventilation-perfusion imaging in the preoperative functional evaluation
- Ventilation-perfusion imaging in the diagnosis of pulmonary embolysm
- Positron Emission Tomography

Unit XIV - BASIC ONCOLOGY

UNIT OBJECTIVE:
At the end of this unit the resident understands principles of cancer biology, etiology, theories of carcinogenesis, indication for neoadjuvant, adjuvant and primary chemotherapy, principles of combined radio and chemotherapy.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands mechanism and derivation of tumor cell types;
Understands influence of genetic background;
Understands the role of oncogenes and tumor suppressor genes in tumorgenesis
Understands selection, mechanism of action, dose, schedule and toxicity of various anticancer agents;
Understands ionizing radiations biochemical effects in the cells.

CONTENTS:

Basic oncology
Lung carcinogenesis
Genetic factors
Oncogene activation
Oncogenes mediating stimulation of growth
Tumor suppressor genes
General applications of chemotherapy (neoadjuvant, adjuvant, primary chemotherapy, combined radio and chemotherapy
Drugs
Adverse effects of ionizing radiations and biological basis of radiation therapy

Unit XV - MOLECULAR BIOLOGY

UNIT OBJECTIVE:
At the end of this unit the resident understands general principles of molecular biology of tumors.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands cell biology;
Understands the role of T cell in immune responses;
Understands the role of activation of oncogenes and growth factors, inactivation of tumor-suppressor genes and deletions of genes in mesothelioma initiation and growth;
Understands biology of esophageal cancer.

CONTENTS:

Cell biology
T cell-mediated immune responses
Pathology and molecular biology of mesothelioma
Biology of esophageal cancer

Unit XVI - PRINCIPLES OF MEDICAL THERAPY OF CANCER

UNIT OBJECTIVE:
At the end of this unit the resident understands the state of art of non small cell lung cancer chemotherapy, radiotherapy and other therapeutic approaches.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands patient eligibility and strategies in chemotherapy, and selection of drugs to be used in the treatment of individual patients;
Understands chemotherapy regimens in advanced disease;
Understands combined effects of chemotherapy and radiation therapy versus radiation therapy alone in inoperable or unresectable M0 disease;
Understands the role of cisplatin-ontaining regimens used in the neoadjuvant setting in locoregional advanced disease;
Understands the role of removal of bulk disease;
Understands single agents and combination chemotherapy, intensity, and duration of chemotherapy and new drug development for managing SCLC;
Knows indications and evaluations before radiation therapy;
Understands indications for surgical adjuvant radiation therapy in patients with involvement of regional lymph nodes (N1 or N2);
Understands the role of local- regional treatment for either operable or inoperable tumors, in diminishing or eliminating paraneoplastic effects, and relieving symptoms caused by primary tumors; understands timing, dose and volume of thoracic radiation, prophylactic cranial irradiation and newer fractionation schemes in treatment of small cell lung cancer;
Knows new development in gene therapy;
Understands specific and non-specific immunotherapeutic strategies for cancer treatment,
Understands principles and results of hyperthermia and radiofrequency ablation.

CONTENTS:

Principles of chemotherapy
- Chemotherapy of non small cell lung cancer
  - Advanced (metastatic) disease
  - Inoperable or unresectable M0 disease: chemotherapy plus radiation therapy versus radiation therapy alone
  - Neoadjuvant therapy
  - Surgical adjuvant therapy
- Chemotherapy of small cell lung cancer
Principles of radiotherapy
- Evaluation before radiation therapy
- Surgical adjuvant radiation therapy
- Definite radiation therapy for inoperable squamous cell carcinoma, and large cell carcinoma of the lung
- Radiotherapy for Pancoast tumors, superior vena cava obstruction, treatment of scheletal and nervous metastases
- Radiotherapy for small cell carcinoma
Other approaches
- Gene therapy
- Immunotherapy
- Hyperthermia
- Radiofrequency ablation

Unit XVII - QUALITY SURVEILLANCE

UNIT OBJECTIVE:
At the end of this unit the resident understands the non-clinical elements of a thoracic surgical practise.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Knows the structure, responsibilities and requirements of managed care;
Understands the need for quality control systems.

Unit XVIII - FEEDBACK AND COMPLICATION REPORTING

UNIT OBJECTIVE:
At the end of this unit the resident understands

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Unit XIX - STATISTICS

UNIT OBJECTIVE:
At the end of this unit the resident understands the basic medical statistical concepts and the appropriate application of statistical tests to the problem.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the role of statistics in validating scientific inferences, including application of statistical tests commonly used in the thoracic literature, their limitations and deficiencies;
Understands the role of power, significance and sample size in interpreting data.

CONTENTS:

Date collection
Statistical analysis
Comparative analysis

Unit XX - STUDY DESIGN

UNIT OBJECTIVE:
At the end of this unit the resident is able to design a scientific approach to the solution of unsolved problem in thoracic surgery.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Knows how to develop and design a research proposal and complete the process of solving a problem critically;
Understands the scientific method as it applies to basic and clinical research;
Knows how to access the literature including computerized and conventional library search;
Understands the role of statistics in validating scientific inferences.

CONTENTS:

Scientific method
- Description of a researchable problem
- Formulation of a testable hypothesis
- Date collection and analysis
- Validation of a hypothesis using statistical methods

Unit XXI - SCIENTIFIC WRITING

UNIT OBJECTIVE:
At the end of this unit the resident understands the essential steps of the research process in preparing and submitting a manuscript for publication.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands how to define an analyzable problem or scientific question;
Understands assembling an appropriate literature review;
Understands synthesizing and analyzing available data;
Understands appropriate application of statistical tests to the problem;
Understands how to formulate an informed and insightful discussion;
Understands how to compares a properly constructed, critically reviewed bibliography or list of literature citations.

Unit XXII - THORACIC INCISIONS

UNIT OBJECTIVE:
At the end of this unit the resident understands the various types of surgical approaches to the chest.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands importance of a well-conceived incision;
Understands the advantages and limitation of each incision;
Knows anterior, lateral, posterior, posterolateral and other combined approaches to the chest

CONTENTS:

Posterolateral thoracotomy
Axillary thoracotomy
Anterior thoracotomy
Mediastinotomy
Mediastinoscopy
Cervicotomy
Various types of sternotomy
Transverse thoracosternotomy
Thoracoabdominal incisions
Special incisions (pancoast, thoracic inlet etc)

Unit XXIII - VIDEO-ENDOSCOPY BASICS

UNIT OBJECTIVE:
At the end of this unit the resident understands the general principles, indications, operative room setup, equipment and techniques for endoscopic surgery, has a working knowledge of the equipment.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands indications, contraindications and the goals of endoscopic procedures;
Knows the imaging system (monitors, miniaturized video-cameras, video recorder, video printers) mediastinoscopes, thoracoscopes (rigid and flexible), staplers, clip appliers, sutures, ports, disposable and reusable instruments;
Understands both argon beam coagulator (ABC) and laser;
Understands incisions and procedures.

CONTENTS:

Indications
Instruments
Techniques

Unit XXIV - NEOPLASTIC LUNG DISEASE

UNIT OBJECTIVE:
At the end of this unit the resident understands basic, evaluation, diagnosis and therapeutic options for patients with lung neoplasms.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands epidemiology and etiologically relevant factors in lung cancer;
Understands TNM system and its application to the diagnosis and therapeutic planning;
Understands non invasive and invasive procedures for staging of lung cancer;
Understands indications, complications and surgical techniques of standard resections for neoplastic and non-neoplastic disease;
Understands indications and technical aspects of surgical procedures for special circumstances;
Understands the role of VATS in neoplastic and non-neoplastic disease resections;
Understands the role of neoadjuvant and adjuvant therapy;
Understands evaluation, clinical features and treatment of carcinoid and solitary nodules;
Understands the indications for either medical or surgical treatment of pulmonary metastases.

CONTENTS:

Basic
- Epidemiology and carcinogenesis
- Carcinogens agents
- Risk factors
- Screening tests
TNM system
- Non invasive staging
  - Chest X ray
  - Computed tomography
  - Abdominal US
  - Radionuclide bone scan
  - Sputum cytology
- Invasive staging
  - Fiberoptic bronchoscopy
  - Transthoracic needle aspiration
  - Video assisted thoracoscopy
  - Mediastinoscopy
  - Intraoperative staging
Standard resections
- Lobectomy
- Pneumonectomy
- Segmentectomy
VATS resections
- Operative strategies
- VATS in lung nodules surgery, emphysema and hemotorax
- Surgical complications of VATS (bleeding, air leaks and infection)
Special techniques
- Sleeve resections
- Pulmonary artery resections
- Sleeve pneumonectomy
- Pancoast
- Thoracic inlet
- SVC
- Thoracic wall infiltration
Induction therapy
Adjuvant therapy
Carcinoid
- Clinical features
- Diagnosis
- Typical and atypical carcinoid
- Treatment
Solitary nodules
- Clinical evaluation
- Radiographic assessment
- Transthoracic needle biopsy
- VATS
- Thoracotomy
Lung metastasis
- Symptoms
- Diagnosis
- Pathology
- Medical treatment
- Surgical treatment

Unit XXV - COMPLICATIONS OF LUNG RESECTION

UNIT OBJECTIVE:
At the end of this unit the resident understands postoperative minor, major, early and late complications.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands how to recognize the complications of pulmonary resection and their management;
Recognizes complications requiring operative treatment.

CONTENTS:

Bleeding
Prolonged air leak
Broncopleural fistula
Residual pleura space
Wound infection
Atelektasis
Infections
Secretions management
Respiratory failure

Unit XXVI - INFECTIOUS LUNG DISEASES

UNIT OBJECTIVE:
At the end of this unit the resident knows suppurative diseases and their diagnoses and operative and non-operative management.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the diagnostic procedures used to evaluate infectious lung diseases;
Understands pathophysiology, clinical diagnoses and treatment of the most common infectious lung diseases;
Understands the principles of surgical resection;

CONTENTS:

Pulmonary infections
- Aspergilloma
- Hydatide Cysts
- Pulmonary Tb
- Middle lobe syndrome (pathophysiology; diagnoses; treatment)
Bronchiectasis
- Clinical diagnoses
- Method of diagnoses
- Treatment
Lung abscess

Unit XXVII - PNEUMOTHORAX

UNIT OBJECTIVE:
At the end of this unit the resident understands classification, diagnosis and evolution of therapy for pneumothorax.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands classification of pneumothorax;
Understands physiologic changes secondary to pneumothorax;
Understands etiology, diagnosis, complication and management;
Understands indications for either surgical or non-surgical therapy;
Understands indications for surgery in primary spontaneous pneumothorax;
Understands emergence of the VATS versus open approach.

CONTENTS:

Etiology (spontaneous; traumatic; associated with bullae)
Diagnoses
Treatment (VATS vs open)

Unit XXVIII - LUNG TRANSPLANTION

UNIT OBJECTIVE:
At the end of this unit the resident understands indications, donor/recipient selection criteria, pre and postoperative management, operative techniques and complications, immunosuppressive therapy, short and long-term follow-up in lung transplantation.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the indications for lung transplantation and underlying diseases;
Understands the selection criteria and management of organ donor;
Understands technique for organ procurement and basic principles of lung preservation;
Understands recipient selection criteria;
Understands the management of immunosuppressive drugs and their side effects;
Knows the operative techniques for single and double lung transplantation;
Recognizes signs of rejection or infection;
Understands the role of short and long-term follow-up and endobronchial biopsy for detection and treatment of acute and chronic rejection;
Understands management of infectious and airway complications.

CONTENTS:

Basic
- Selection of recipient
- Indications (CF; emphysema; restrictive disease; PPH)
- Donor management
- Matching
- Organ harvesting
- Lung preservation
- Operative techniques
- Anesthesiological management
- Basic immunology
- Principles of immunosuppression
Postoperative care
- Ventilation
- Fluid management
- Sepsis prophylaxis (bacterial, viral, fungal infections)
Complications
- Early graft dysfunction
- Infection
- Pleural space complication
- Airway complication
- Rejection (monitoring and treatment)

Unit XXIX - FUNCTIONAL LUNG DISEASE

UNIT OBJECTIVE:
At the end of this unit the resident understands natural history, presentation and treatment of chronic obstructive lung disease and giant bullous emphysema.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands indications, pathophysiology and current surgical options in the management of bullous disease;
Understands rationale for LVRS;
Understands eligibility patient profile;
Understands patients selection criteria;
Understands preoperative medical management and pharmacotherapy;
Understands unilateral and bilateral operative approaches;
Understands the importance of adequate pain relief, early ambulation, chest physiotherapy and management of secretions in the postoperative period.

CONTENTS:

Bullectomy
- Standard technique of bullectomy
- Video assisted blebectomy and bullectomy
- External drainage of a bulla
LVRS
- Selection of patients
- Preoperative assessment
- Surgical access and lung resection
- Postoperative management
- Results

Unit XXX - CONGENITAL LUNG DISEASE

UNIT OBJECTIVE:
At the end of this unit the resident understands embryology, pathology and principles of management of congenital lung abnormalities.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Recognizes clinical features of various congenital lung anomalies and understands diagnostic studies, indications for and appropriate treatment.

CONTENTS:

Bronchogenic cysts
Congenital cystic adenomatoid malformation
Sequestration (intralobar, extralobar)
Pulmonary dysplasia
Congenital lobar emphysema
Congenital pulmonary vascular malformations

Unit XXXI - PERICARDIUM

UNIT OBJECTIVE:
At the end of this unit the resident understands recognition of pericardial disease and invasive and non invasive tests to patient management.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands etiology and pathophysiology of acute and constrictive pericarditis;
Understands etiology, pathophysiology and surgical options for diagnostic and therapeutic evacuation of pericardial effusion;
Understands congenital anomalies and pericardial neoplasms;
Understands various operative approach to pericardium.

CONTENTS:

Pericarditis
Pericardial effusion
Pericardiocentesis
Techniques of pericardiectomy
Cysts
Tumors

Unit XXXII - MEDIASTINUM

UNIT OBJECTIVE:

At the end of this unit the resident understands embryology and anatomy of the mediastinum; radiological investigation, diagnosis and treatment of benign and malignant masses.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the embryologic development of structure within the mediastinum;
Understands the anatomic boundaries of the mediastinum and the structures found within each region;
Understands radiologic assessment of the mediastinum;
Understands signs and symptoms associated with mediastinal abnormalities;
Understands various open surgery procedures and VATS approach to the mediastinum;
Understands clinical-pathological features of thymoma;
Understands diagnosis and the role of surgery, radio and chemotherapy in the treatment of thymoma;
Understands medical and surgical therapeutic options for patients with myasthenia gravis;
Understands clinical presentation, radiologic investigation and treatment of mediastinal cysts and esophageal duplications;
Understands classification, diagnosis and treatment of thymic tumors;
Understands presentation, diagnostic evaluation, staging, surgical and non-surgical treatment and prognosis of thymic carcinoma;
Understands classification of mediastinitis and knows anatomic relationship and fascial planes of the mediastinum, related to the spread of infection leading to mediastinitis.

CONTENTS:

General
- Embryology
- Anatomy
- Imaging
- VATS approach
Thymoma
- Invasive
- Non invasive
- Clinical and radiological presentation
- Diagnoses
- Treatment
Myasthenia gravis
Bronchogenic cysts
- Pathology
- Clinical presentation
- Radiological investigation
- Treatment
Enteric cysts
- Tumors
- Thymic carcinomas
- Tumors of neuroendocrine cell origins
- Tumors of germ cell origins
- Tumors of lymphoid origin
- Tumors of adipose tissue
- Metastatic tumors of the thymus
Mediastinities
Acute
Chronic

Unit XXXIII - DISEASES OF THE PLEURA

UNIT OBJECTIVE:
At the end of this unit the resident understands the benign and malignant abnormalities of the pleura, pleura effusions, and the evalutation and treatment of pleural disease.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands physiology of pleural fluid exchange, the types of pleural effusions, their evaluation and treatment;
Understands clinical features, diagnosis and management of empyema with and without bronchopleural fistula;
Understands indications for invasive diagnostic studies and indications for surgical treatment after initial drainage procedures;
Understands pathology, biologic behaviour, natural history, clinical and radiological presentation, diagnosis and staging of mesothelioma;
Understands indications for treatment options for mesothelioma (surgery, irradiation, chemotherapy, immunotherapy, combination of these modalities).

CONTENTS:

Basic
- Physiology of pleural fluid exchange
- Effusions
- Chylothorax
- Haemothorax
Parapneumonic emphyema
- Clinical features
- Diagnosis
- Management
Postsurgical emphyema
- General principles of treatment
- Empyema post-pneumonectomy
- Muscle flap closure of the postpneumonectomy empyema
Mesothelioma
- Epidemiology and incidence
- Pathology
- Clinical and radiological presentation
- Diagnosis
- Staging
- Surgical treatment
- Medical treatment

Unit XXXIV - TRACHEA AND LARYNX

UNIT OBJECTIVE:
At the end of this unit the resident understands anatomy, physiology of the trachea and larynx, and applies finding of radiography and endoscopy to patient care; the resident also understands operative and non operative management of neoplasms affecting the trachea.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Knows operative approach to the trachea techniques of mobilization;
Understands etiology, presentation, diagnosis and management of acquired tracheal stictures and tracheo-esophageal fistulas;
Understands the methods of airway management;
Knows various types of stents and tracheostomy tubes;
Understands principles of tracheal surgery, release maneuvers, laryngotracheal resection and reconstruction of the upper and lower trachea;
Understands the types, histology, clinical presentation and surgical and endoscopic treatment of tracheal neoplasms;
Knows the indications for and the use of radiotherapy and chemotherapy.

CONTENTS:

Basic
- Anatomy
- Function
- Imaging
Bronchoscopy
- Flexible
- Rigid
Tracheostomy
- Mini, standard, endoscopic
- Mediastinal tracheostomy
Endotracheal therapy
- Dilatation
- Stenting
- Laser
Technique of resection
- Surgical approaches
- Anatomic mobilization
- Reconstruction of the upper and lower trachea
Benign stenosis
- Posttherapeutic stenosis
- Postintubation stenosis
Tracheoesophageal fistula
- Clinical presentation
- Diagnosis
- Treatment
- Complications
Tumors
- Benign tumors
- Malignant primary tumors
- Secondary malignant tumors
- Diagnoses
- Surgical treatment
- Endoscopic management
- Radiation therapy

Unit XXXV - ESOPHAGUS

UNIT OBJECTIVE:
At the end of this unit the resident understands the anatomy, physiology, and embryology of the esophagus and the diagnostic tests of normal and abnormal function; understands the types and causes of acquired abnormalities and the appropriate treatment; understands benign and malignant esophageal neoplasms and the various forms of treatment.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the embryology, anatomy, innervation, and vascular supply of the esophagus and adjacent structures;
Understands the physiologic function of the esophagus and pharynx, and the diagnostic tests;
Understands the indications and technique of diagnostic endoscopy of the esophageal diseases;
Understands the principles of endoluminal therapies;
Understands the pathophysiology, histology, complications, and diagnosis of esophageal reflux;
Understands the indications and principles of anti-reflux operations;
Understands the clinical presentation, causes, diagnosis, and treatment of paraesophageal hernias, mobility disorders, and perforation of the esophagus;
Understands the indications, methods, and the operative approaches for benign and malignant esophageal diseases;
Understands the role of laparoscopic and thoracoscopic procedures in the treatment of benign disorders, in staging of esophageal cancer, and esophageal dissection and esophagectomy;
Understands pros and cons of differing resection techniques for esophageal cancer;
Understands the principles of patient management after esophageal resection;
Understands the presentation and management of complications of esophageal operations;
Understands the role of surgical pallation and multimodality therapy for locally advanced esophageal cancer;
Knows the long term results.

CONTENTS:

Basic
- Embryology
- Anatomy
- Physiology
Functional tests
- 24 hour esophageal pH monitoring
- Motility studies
Diagnostic endoscopy
- Indications and technique
- Diseases of the esophagus
Endoluminal therapies
- Malignant obstruction
- Barrett’s esophagus
- Esophageal varices
Benign esophageal disorders
- Reflux
  - Antireflux mechanism and pathogenesis of reflux
  - Esophagitis and its complications
  - Diagnosis
  - Medical and surgical treatment
- Diverticula
- Achalasia
- Stenosis
- Hernias
- Perforation
Cancer of the esophagus
- Basic
  - Staging
  - Preoperative evalutation
- Surgical techniques
  - odified Heller esophagomiotomy
  - Resection of the esophagus
  - Replacement of the esophagus with stomach, colon and jejunum
  - Free intestinal transfer techniques in reconstruction of the esophagus
- Perioperative care
- Complications
  - Infection
  - Fistula
  - Anastomotic complications
- Surgical pallation
  - Palliative esophageal resection
  - Esophageal bypass
  - Esophageal dilatation
  - Esophageal intubation
  - Gastrostomy and jejunstomy
  - Laser procedures
- Multimodality therapy
  - Radiotherapy treatment with curative intent
  - Brachiterapy
  - Postoperative radiation therapy
  - Combination of radiation therapy and chemotherapy
  - Palliative radiation therapy
- Long term results
VATS surgery
- Laparoscopic procedures
  - Fundoplication
  - Miotomy and fundoplication
  - Epiphrenic diverticulum
  - Paraesophageal hernia repair
  - Collis-Nissen fundoplication
- Thoracoscopic procedures
  - Staging for esophageal cancer
  - Esophageal dissection and esophagectomy
  - Leiomyoma resection
  - Heller myotomy
  - Belsey fundoplication
  - Epiphrenic diverticulum

Unit XXXVI - CHEST WALL

UNIT OBJECTIVE:
At the end of this unit the resident understands the anatomy of chest wall and congenital abnormalities, including those leading to thoracic outlet syndrome; the resident also understands acquired abnormalities and neoplasms of the chest wall, indication and operative approach for resection, various methods of reconstruction, and stabilization of the chest wall.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the diagnosis of primary and metastatic chest wall tumors;
Knows the types of chemotherapy and radiotherapy (induction and adjuvant therapy) of chest wall tumors and the indications for preoperative and postoperative therapy;
Knows methods of reconstruction with major musculo-cutaneous flaps and omental transposition;
Knows the indications for and methods of prosthetic reconstruction of the chest wall defects.
Knows the correct application of prosthetic materials;
Recognizes pectus excavatum and pectus carinatum, and understands possible physiologic disturbances;
Understands the indications for the operative treatment of congenital chest wall abnormalities;
Understands the etiology, evaluation, differential diagnosis, and diagnostic criteria for thoracic outlet syndrome;
Knows the operative and nonoperative management of thoracic outlet syndrome.

CONTENTS:

Chest wall resection and reconstruction
- Indications for resection
- Omental transposition for chest wall reconstruction
- Muscles flaps
  - a. Latissimus dorsi
  - b. Pectoralis major
  - c. Serratus anterior
  - d. Rectus abdominis
- Reconstruction with prothesis
Congenital anomalies
- Pectus excavatum
  - Etiology and incidence
  - Pathophysiology
  - Pulmonary and cardiovascular studies
  - Surgical treatment
- Pectus carinatum
  - Etiology
  - Surgical repair
- Thoracic inlet syndrome
  - Anatomic consideration
  - Signs and symptoms
  - Diagnosis
  - Therapy

Unit XXXVII - THORACIC TRAUMA

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands evaluation of patients with blunt or penetrating chest wall injury;
Understands the physiology and mechanics of operative drainage of the thoracic cavity;
Understands the operative and non-operative management of chest wall injuries;
Understands the pathophysiology of flail chest;
Understands the clinical presentation and radiologic findings of tracheobronchial injury;
Understands the principles of airway management;
Understands the management of tracheobronchial and pulmonary injuries.

CONTENTS:

Chest wall
- Rib fractures
- Flail chest
- Traumatic asphyxia
- Sternal fractures
- Penetrating chest wall wounds
Pulmonary and tracheobronchial
- Emergency approach
- Airway control
- Pneumothorax
- Haemothorax
- Pulmonary contusion
- Penetrating injury
- Bronchial laceration
- Tracheal injury

Unit XXXVIII - DIAPHRAGM

UNIT OBJECTIVE:
At the end of this unit the resident understands the anatomy, physiology and embryology of the diaphragm and its relationship to adjacent structures; the resident also understands congenital and acquired diaphragmatic anomalies, their pathologic effects, and the diagnosis and treatment of these conditions.

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the embryologic origin of the diaphragm;
Understands the anatomy of the diaphragm and adjacent structures;
Understands the neural and vascular supply of the diaphragm and the pathologic consequences of injury;
Understands the presentation of diaphragmatic rupture and associated injuries;
Understands the etiology, diagnosis, and treatment of diaphragmatic paralysis;
Understands the etiology, physiologic consequences, diagnosis, and indications for operative repair of congenital and acquired diaphragmatic hernias;
Understands the primary and secondary tumors of the diaphragm and their management;
Understands the reconstructions methods of the diaphragm.

CONTENTS:

Embryology and anatomy of the diaphragm
Diaphragmatic function, paralysis and eventration
Hernias
Tumors

Unit XXXIX - ETHICS - PRACTICE - OUTCOME

LEARNER OBJECTIVES:
Upon completion of this unit the resident:

Understands the ethical components of surgical practice;
Understands clinical database and outcome analysis in surgical practice;
Understands critical pathways and cost-benefit analysis in clinical decision-making, and clinical outcome;
Understands organizational structures and mechanics of solo practice, group specialty practice, multispecialty practice, and academic practice;
Knows the structure and differences of European Health Care organizations responsibilities and requirements of managed care, capitation payment, contractual agreements, physician-hospital organizations, and independent practice agreements;
Knows the medico-legal aspects of surgical practice;
Understands the time constraints imposed by the responsibilities of practice and the need for effective time management.

CONTENTS:

Foundamental elements of ethical practice
Clinical database and outcome analysis
Cost factors and clinical outcome
Practice arrangements
External economic forces
Medico legal factors
Time arrangement

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