Thoracoscopic treatment of bullous emphysema in 3 dogs
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Veterinary Surgery 32:524-529, 2003
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Thoracoscopic Treatment of Bullous Emphysema in 3 Dogs HERVE N. BRISSOT, BERNARD M. BOUVY, Dr Med Vet, MS,
Dr Vet, GILLES P. DUPRE, Dr Vet, Diplomate ECVS, Diplomate ECVS, Diplomate ACVS, and LAURENT PAQUET, Dr Med Vet
Objective—To report thorascopic partial lobectomy for treatment of bullous emphysema in dogs. Study Design—Prospective clinical study. Animals—Three dogs with spontaneous pneumothorax. Methods—Thoracoscopy without pulmonary exclusion was used to identify bulla. The thorascope was introduced into the thorax lateral to the xyphoid process, and instrument portals were made at different levels along the thoracic wall between the third and tenth intercostal spaces. The thorascope was passed through the mediastinum to view the opposite pleural cavity. After identification of bullae, the affected lung was excised using an endoscopic stapler, and the incision line was checked for air leakage. Thoracic drains were used for air aspiration for 2 days after surgery. Results—Bullae were confirmed histologically as emphysematous lesions. Lung inflation did not interfere with identification of bullae or with surgery. All dogs had full recovery without recurrence for 18 to 29 months after surgery. Conclusions—Identification and ablation of bulla can be performed thoracoscopically without pulmonary exclusion in dogs. Clinical Relevance—Thoracoscopy offers several advantages compared with thoracotomy for treatment and diagnosis of idiopathic pneumothorax, including ease of identification of bullae and reduced postoperative pain and morbidity. © Copyright 2003 by The American College of Veterinary Surgeons
PONTANEOUS pneumothorax is a nontraumatic closed pneumothorax in which the lung is the source of air accumulation.1 Previous retrospective studies assume that most spontaneous pneumothorax results from emphysematous disease and blebs, or bullae ruptures.2-11 When pleural drainage does not allow control of air accumulation, the definitive treatment is an explorative thoracotomy by an intercostal or a transsternal approach.2-6 If bullous lesions are discovered, lobectomy is performed. Pleurodesis has also been advocated as an adjunctive or sole treatment.3 Thoracoscopy has been previously used for diagnostic or therapeutic purposes, and thoracoscopic pericardectomy without pulmonary exclusion has been reported.4,12-17 Our objective was to report the use of thoracoscopy as a diagnostic tool for spontaneous
pneumothorax in 3 dogs and to describe thoracoscopic partial lobectomy without pulmonary exclusion. MATERIALS AND METHODS Dogs Three dogs referred between October 1999 and October 2001, for treatment of spontaneous pneumothorax, were included in this report.
Surgical Technique A nasal tube was placed on admission; oxygen was delivered at 50 mL/kg/min and continued until recovery from anesthesia. The thoracic cavity was evacuated by thoracocentesis and aspiration before induction of anesthesia. After premedication with diazepam (0.2 mg/kg intrave-
From the clinique Fregis, Arcueil, France. Address correspondence to Herve´ N.Brissot, DV, Clinique Fregis, service de chirurgie, 43, Ave Briand, 94110 Arcueil, France. © Copyright 2003 by The American College of Veterinary Surgeons 0161-3499/03/3206-0004$30.00/0 doi:10.1053/jvet.2003.50055
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Fig 2. Intrathoracic view during thoracoscopy of a bulla. Ll, lung lobe; b, bulla; Pp, parietal pleura.
Fig 1. Artistic representation of the placement of different thoracoscopic portals. Instrumental portals (p) are inserted between the 3rd and the 8th intercostal spaces (S). The thoracoscope (t) is inserted at the level of the 9th or 10th space.
nously [IV]) and morphine chlorhydrate (0.1 mg/kg subcutaneously), anesthesia was induced with sodium thiopental (8 mg/kg IV) and maintained with isoflurane in oxygen. A tidal volume of 10 to 15 mL/kg at a frequency of 10 to 12 inspirations/minute was controlled with a volumetric ventilator (Seneca, Dra¨ ger, 78190 Montigny le Bretonneux, France). Dogs were positioned in dorsal recumbency and monitored with an electrocardiogram, spirometer, pulse oximeter, and capnograph. The chest was clipped and prepared for aseptic surgery from the manubrium to the xyphoid process and to the dorsal third of the thoracic wall. A 10-mm 0° thoracoscope (Stryker Endoscopy, 93290 Tremblay en France, France) was connected to a video camera (Stryker Endoscopy) and to a light source (Quantum 4000, Stryker Endoscopy). Images were viewed on a video monitor and recorded. Operating instruments included endoscopic scissors (Tyco France, 78370 Plaisir, France) connected to an electrosurgical unit, endoscopic graspers (Tyco), irrigation-suction unit (Tyco), atraumatic Babcock forceps (Tyco), and surgical stapler device (endo-TA, 303.5, blue cartridge, Tyco). A 1-cm skin incision was made 3 cm lateral to the last sternebra at the junction between the costal arch and the xyphoı¨d process (Fig 1). A large hemostat forceps was introduced through the intercostal muscles and pleura into the chest. Next, a 10.5-mm trocar (Thoracoport, Tyco) was inserted into the thoracic cavity. Under thoracoscopic control, endoscopic atraumatic forceps were introduced through 2 separate portals (5 mm and 10.5 mm) located on the lateral side of the thorax between the
third and tenth intercostal spaces. After thorough thoracoscopic examination (Fig 2), the endoscopic Babcock forceps were used to manipulate the mediastinal and interlobar lungs surfaces. In all dogs, the thoracoscope was pushed through the ventral mediastinum to view the contralateral lung lobes. Once a bulla or bleb was observed, the affected lung region was grasped. An endoscopic stapler was introduced through the 10.5-mm portal, and a triple row (30 mm long) of 3.5-mm titanium staples was placed proximal to the lesion (Fig 3). The distal part of lobe containing the bulla or bleb was excised with endoscopic scissors and retrieved through the 10.5-mm portal. If observation of the dorsal part of lungs was poor, the dog was rolled slightly to the side until a complete inspec-
Fig 3. Intrathoracic view during thoracoscopy. A bulla (b) has been grasped by an endoscopic Babcock forceps (Eb). Partial lobectomy will be performed after closing an endoscopic stapler (As) over the lung lobe (Ll). Pp, parietal pleura.
THORACOSCOPIC TREATMENT OF BULLOUS EMPHYSEMA
tion could be achieved. If needed, a limited insufflation of carbon dioxide (3 cm water pressure) was used to create partial lung collapse and facilitate thorascopic lung manipulation. If a bulla was not identified, the thoracic cavity was filled with saline (0.9% NaCl) solution warmed to body temperature and checked for bubbles. After removal of the affected tissue, the lung wound was submerged in saline and checked for leakage. A large multifenestrated thoracic drain (Redon drain, 18 Fr; Dahlhausen, Koln, Germany) was then introduced under thorascopic control into the 5-mm portal and tunneled before entering the chest. Aspiration was maintained until negative pressure was obtained in the thoracic cavity. Closure of the portal holes was performed in a routine manner. Bupivacaine (2 mg/kg) was administered through the thoracic drain then the dogs were gently rolled from side to side to facilitate distribution of the bupivicaine within the thoracic cavity. Excised lung samples were submitted for histologic examination.
Postoperative Treatment Carprofen (4 mg/kg IV) was administered at the end of surgery and continued for 5 days orally (4 mg/kg once daily). Morphine (0.1 mg/kg SC, every 6 hours) was administered for 2 days to dog 3. Enrofloxacin (5 mg/kg, orally, once daily) was administered for 5 to 10 days. Thoracic drainage was performed as needed (every hour for the first 4 hours, then every 6 hours for the next 24 hours, and then every 12 hours until fluid or air production was ⬍1 mL/kg/d). Next, the drains were removed. A thoracic radiograph was taken before hospital discharge 24 hours after drain removal. Rest and leash walk were recommended for 1 month after surgery.
Follow-up Operative complications, postoperative recovery, and duration of postoperative thoracic drainage were recorded. Follow-up information was obtained by telephone interview.
RESULTS All dogs were polypneic and had labored breathing on admission. Bilateral pneumothorax was identified by thoracic radiography in all dogs. Cavitary or cystic lesions were not detected. In dog 2, bullae were also not identified by computed tomography. Thoracoscopy permitted localization and definitive diagnosis of bullous lesions. After partial lobectomy, parenchymal stapling was effective, and no air leakage was detected from the staple lines. Surgical time ranged from 60 to 90 minutes. Drains were maintained for 2 days in each
dog; no air was aspirated after the initial 6 hours. Microscopy of resected lung tissue confirmed bullous emphysema; no neoplastic lesions were observed. Dog 1 A 9-year-old, male, mixed breed (23 kg) dog was admitted after 11 days of chest drainage. Two bullae were identified at the periphery of the caudal aspect of the left and right cranial lung lobes. No complications occurred. The dog died 24 months later from unrelated, acute renal failure. Dog 2 A 6-year-old, female, Siberian husky (30 kg) dog was admitted for conservative treatment by aspiration through a chest tube for 6 days. Pneumothorax resolved after 4 days, but, on radiographic examination at 1 week, recurrent pneumothorax was identified, and surgery was recommended. A bulla was identified at the periphery of the right middle lobe. No complications were observed. At 29 months, the dog was doing well. Dog 3 A 6-year-old, female, German shepherd (31 kg) dog was admitted after 10 days of chest drainage. Carbon dioxide insufflation (3 cm H2O pressure) was performed to facilitate inspection of the lung surfaces. A bulla was identified in the right cranial lobe. The bulla was located at the end of the lobe but was surrounded by a thick layer of normal parenchyma. Two cartridges of staples were necessary to encompass all involved lung tissue. Swelling around the chest tube and dehiscence of the portals occurred 2 days after surgery. There was subcutaneous cellulitis, which was managed by local wound treatment and antibiotic administration. It resolved within 5 days. In addition to bullous emphysema, the resected tissue had bronchopneumonia and pleuritis. At 18 months, the dog was doing well. DISCUSSION Using thoracoscopy, we were able to scan readily the pleural surface of the lung for bullous lesions. Because these dogs had bilateral pneumothorax without radiographic evidence of bullae, we initially inserted the endoscope on the left side. If lesions were
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not evident, we fenestrated the ventral mediastinum and passed the endoscope to the opposite side to view the pleural surface of the opposite lung. When lesions were not evident, the thoracic cavity was filled with saline solution to identify lung regions with air leakage. After the lesion was identified, instruments designed for endoscopic surgery were used for partial lobectomy. Previous reports have described open chest surgery to identify bullous disease or identify the source of air leakage.2-6 Clinical management of spontaneous pneumothorax by repeated thoracocentesis followed by chest tube aspiration has a poor prognosis (25% to 100% recurrence), so surgical treatment is recommended.2-6 This requires exploratory thoracotomy, recognition of the affected tissue, and partial lobectomy.2-11 For generalized emphysematous disease, no curative treatment is known, and, in most cases, euthanasia is warranted.6-10 Both median sternotomy and intercostal thoracotomy have been reported as surgical approaches for spontaneous pneumothorax; however, when preoperative lesion lateralization is unknown, a median sternotomy is preferred. Some authors have recommended a bilateral intercostal approach.2-6 In humans, partial or complete pleurodesis18,19 is routinely used as an adjunctive treatment to partial lobectomy to prevent recurrence. These procedures are now routinely performed thoracoscopically.18,20 Thoracoscopy compares favorably with an “open chest” procedure because patients have less morbidity, less pain, quicker recovery, and shorter hospitalization.21-24 In small animals, the value of pleurodesis to limit recurrence of spontaneous pneumothorax has been questioned.2-4 Mechanical abrasion or talc slurry pleurodesis do not effectively obliterate the pleural space in dogs.25 Although thoracoscopic talc slurry may produce a better pleurodesis than mechanical abrasion,20 the efficacy of pleurodesis to control emphysematous pneumothorax in dogs has not been clinically established, and partial lobectomy remains the treatment of choice. The typical radiographic pattern of bullous disease has been described as a cystic hyperlucent zone at the margins of lung lobes.1-11 Radiographic identification of bullous disease has been reported in 5% to 50% of cases.2-5 Typically, serial radiographs over several days are necessary to diagnose bullous disease. Pulmonary scintigraphy, bronchoscopy, or a bubblegram technique (instillation of contrast
within the pleural space and observation of bubbles under fluoroscopy) have also been recommended.1,8 We were unable to identify bullae on thoracic radiographs but did not take serial radiographs. In human medicine, tomodensitometric examination is used to detect and localize bullae.21,22 CT scan was performed on dog 2, but we were unable to detect a bleb or bulla. When bullae cannot be detected by radiography or CT scan, thoracoscopy can be used as a diagnostic tool.4,12 In small animals, thoracoscopy has been used diagnostically and therapeutically.4,12-17 In dogs, good observation of all thoracic strucures can be obtained by thoracoscopy.14,16 Most thoracoscopic procedures have been described in conjuction with pulmonary exclusion. Pulmonary exclusion requires selective intubation or specially designed endotracheal tubes to ventilate selectively one main stem bronchus.14-16,26 Single lung ventilation has minimal adverse effect on cardiopulmonary function in healthy anesthetized dogs26; however, we are unaware of similar studies conducted on dogs with abnormal cardiovascular or ventilatory status, such as pneumothorax. We previously reported that thoracoscopic examination and thoracoscopic pericardectomy were feasible without pulmonary exclusion in a dog positioned in dorsal recumbency.12 In our experience, when there is bullous disease, bullae are more readily visible when both lungs are ventilated. The thoracoscope allowed inspection of most of the lung surface without need for pulmonary exclusion. We passed the thorascope through the mediastinum to explore the controlateral hemithorax and found that, in dorsal recumbency, rolling the dog slightly from side to side facilitated complete inspection of the most dorsal parts of both lungs from a single portal. The lack of lung exclusion and pulmonary motion do not interfere with detection of the bullae.12,13 Because exploration of both sides of the thoracic cavity was necessary, selective intubation would need to be repeated on the contralateral bronchus to faclitate examination of the contralateral thoracic cavity. Therefore, the technique that we describe has several advantages over conventionnal thoracoscopic techniques because preoperative lateralization of the bullae and selective intubation are not necessary. If observation needs to be improved in the absence of pulmonary exclusion, carbon dioxide insufflation (maximum pressure: 3 to 5 cm H2O) under capnographic control
THORACOSCOPIC TREATMENT OF BULLOUS EMPHYSEMA
can induce limited lung collapse to facilitate lung manipulation.13 We performed throracoscopic partial lobectomies with 3.5-mm staple cartridges (Endo-TA, 30-3.5, Tyco). This staple size enabled us to adequately compress and seal the parenchyma of medium to large dog’s lungs.22,27 It has been reported that thoracoscopic pericardectomy caused less postoperative pain and morbidity than “open” pericardectomy in dogs.13,28,29 Pain scores and blood cortisol concentrations were significantly different between both procedures in the first postoperative hours. In humans, thoracoscopy allows an earlier return to normal spirometric and gasometric levels.21,29 It is also believed that pain and scar tissue after a thoracotomy may affect thoracic wall compliance.21,29 We did not perform pain scores, but these 3 dogs recovered an early normal appetite, normal locomotion, and breathing and were able to rest comfortably. Surgical time ranged from 60 to 90 minutes, which compares favorably with our surgical time for median sternotomy and partial lobectomy. With further thorascopic experience, we believe that the operative time could be shortened.12 Previous studies2-5 on spontaneous pneumothorax in dogs have reported fair to good results, with a 3% to 25% risk of recurrence after surgery. Our dogs recovered quickly and fully and had no signs of recurrence at 18 to 29 months. Spontaneous pneumothorax is an emergency condition in dogs that may lead to death from tension pneumothorax. Early recognition and early air evacuation are critical. Spontaneous air effusion is always associated with an underlying pulmonary disease, bullae or bleb rupture being the most ferequent cause. Thoracoscopy facilitated accurate diagnosis and treatment of the bullous disease and, based on our expereince, can be performed without need for pulmonary exclusion.
10. 11. 12.
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