Ch 103 Lungs Flashcards

Question

Surgical Approaches (3)

Answer 1

Intercostal Thoracotomy - allows access to approximately one-third of the ipsilateral thoracic cavity and mediastinal structures. - radiograph can help determine the intercostal space that best - hilus of the lungs is located between the fourth or fifth intercostal space - thoracostomy drain is placed to establish negative intrapleural pressure and monitor the pleural space Median Sternotomy - allows access to the entire thoracic cavity - great vessels and bronchial hilus, are more difficult, - manubrium, xiphoid, or both should be left intact. - In dogs, pain, the degree of cardiopulmonary impairment, and complication rates with this approach are not different from those after intercostal Thoracoscopy - minimally invasive - surgical telescope, trocar-cannulas, a set of thoracoscopic surgical instruments, a light source, a video camera, and a video monitor. - Thoracoscopy does not require CO2 insufflation - performed through a transdiaphragmatic (subtotal pericardiectomy) or an intercostal approach (Lung lobectomy) - Cannulas should be inserted in the ventral two-thirds

Answer 2

Intercostal (4th-9th ICS) Transdiaphragmatic (Manubrium, 9th-10th ICS)

Answer 3

- Hypoplasia of one lung or lung lobe - tracheoesophageal and bronchoesophageal fistulas

Answer 4

- Cysts within parenchyma can be fluid filled or air filled and are covered by a respiratory epithelium - Blunt trauma to the chest with pulmonary contusion seems to be the most common cause - Lung bullae and blebs (pseudocysts) have no epithelial lining - Bullae are large and develop within parenchyma, and blebs are small between the parenchyma and visceral pleura - develop from traumatic rupture and coalescence of alveoli and are frequently secondary to obstructive lung disease - Bullae and cysts show similar complications of infection; abscessation; rupture, resulting in pneumothorax - may be underlying cause of **Spontaneous idiopathic pneumothorax** - sensitivity of CT scan is very poor (42% to 58%) for the diagnosis of the cause of a spontaneous pneumothorax - Conservative management by continuous intrathoracic drainage can be attempted for 2 to 3 days before partial or complete lobectomy is considered - Most dogs have lesions in the cranial lung lobes - bulla or bleb cannot be visualized, the thorax is filled with warm saline so that leaks can be identified - Kim 2023: 74 dogs > No adverse anesthesia events were found following CT anesthesia or repetitive anesthesia procedures.

Answer 5

Contrast oesophogram with water soluble iodine Toy-breeds and small terriers - primarily result from foreign bodies wedged into the esophagus - lung lobectomy and fistula closure.

Answer 6

E.Coli Klebsiella pneumoniae Staph Strep Pseudomonas Fusobacterium

Answer 7

- Consolidated lung lobe: from pneumonia secondary to a foreign body, bacterial or fungal infection, or parasites - Abscesses: thoracic penetrating wounds, vascular obstruction, or central necrosis of a pulmonary neoplasm > commonly result in pyothorax - plant awn frequently migrates into parenchymal - Thoracic radiographs aid in locating the involved region > alveolar pattern with air bronchogram - CT has been used to identify pulmonary foreign bodies Tx - Bronchoalveolar lavage should be performed to collect fluid from the diseased lung for cytology, culture, and sensitivity. - Appropriate antibiotics are administered for at least 2 to 3 weeks - pleural effusion is present, a thoracostomy tube - sternotomy is the approach of choice because it allows evaluation of both sides - partial or complete lobectomy is performed - if chronic restrictive pleuritis is present and prevents lung reexpansion > lobectomy - mortality rate was 20%

Answer 8

* Mortality 20% (14% if 1 lobe removed, 60% if three removed) * 54% of survivors has resolution of their pneumonia * MST 96m with resolution of pneumonia vs 10m

Answer 9

- localized or diffuse destructive lung disease that results in severe dilatation of large airways, accumulation of secretions, and recurrent infection - inflamed bronchial walls lose collagen and elastin elements, and a granulomatous reaction develops - manifests grossly as a prominent lump in the lungs. It induces atelectasis - can be associated with primary ciliary dyskinesis or be the result of chronic respiratory disease - prognosis is guarded; the median survival time of dogs treated for bronchiectasis is 16 months

Answer 10

- Blunt (rib fracture) or penetrating trauma> subsequent pneumothorax - lateral compression of the chest wall with a closed glottis, resulting in a rapid increase in airway pressure - iatrogenic - thoracic radiographs, patients with lung lacerations have pneumothorax Conservative Treatment - initial treatment of choice - Small lung lacerations usually resolve with the aid of thoracic drainage - supplemental oxygen delivery via cage, mask, or nasal - blood patch Sx - If intrapleural air does not resorb in 3 to 4 days, surgery is indicated - Median sternotomy - leaks can be detected by flooding the chest with warm sterile saline under IPPV - Lacerations are closed with a mattress pattern of absorbable 4-0 or 5-0 suture (interrupted Lembert) - mounted on Teflon pledgets to provide an adequate seal without tearing tissue - partial lung lobectomy - mainstem bronchus), the airway can be reapposed with simple interrupted sutures - thoracostomy tube

Answer 11

- large deep chested: lung lobe torsion can be spontaneous or occur secondary - Pugs, the condition is thought to be spontaneous - cause poorly understood but may result from partial collapse of the lung lobe, permitting increased mobility - lobe subsequently becomes severely congested and consolidated as fluid moves into the interstitial tissue and airways - Dogs can have an acute or chronic presentation - thoracocentesis is usually serosanguineous or chylous dx - RADS: Pleural effusion and lung consolidation - Changes in bronchial size are more readily noted on CT, all have abrupt terminations - Peripheral band sign on ultrasound Tx - Initial therapy is symptomatic and aimed at stabilization. - Lobectomy - To avoid release of inflammatory cytokines and endotoxins, they should not be untwisted. - Stapling equipment is preferred because it permits lobectomy with the lung in its torsed position - fair to guarded after lobectomy, with a survival rate of 50% - more favorable prognosis noted in Pugs

Answer 12

* Large dogs with deep narrow chests (right middle and left cranial) * Pugs (left cranial) * May be assoc with chronis resp disease, chylothorax, trauma, d-hernia, thoracic surgery, neoplasia

Answer 13

- Most primary lung tumors are malignant - respiratory dysfunction from lung infiltration or airway compression - Pulmonary hemorrhage or pneumothorax may occur with vessel or airway erosion - Primary or mets: develop hypertrophic osteopathy (paraneoplastic syndrome) - Cats can have “lung-digit” syndrome dx - Cats may have diffuse or multifocal primary lung tumors. - hilar lymph nodes should be evaluated on radiographs and CT - false-positive and false-negative result possible on CT - Complication rates after fine-needle lung aspiration include pneumothorax, hemoptysis, and death (reduced if ultrasound guided) - large neoplastic masses that affect the lobe periphery or the entire right middle or left cranial lung lobe > histiocytic sarcomas Sx - considered in animals with primary or metastatic neoplasia of the lung if the mass is a solitary

Answer 14

Carcinomas of bronchial or alveolar origin Hypertrophic osteopathy or lung-digit syndrome (17.9% of cats)

Answer 15

22-25g needle under u/s guidance DIagnostic in 80% (sen 77%, spec 100%)

Answer 16

* Clinical signs (545 vs 240d) * LN involvement (452 vs 26d) * Better prognosis for solitary, well-differentiated carcinoma less than 5cm in diameter * Malignant pleural effusion worse prognosis * SCC worse prognosis (50% survival 8m) In cats, degree of differentiation most prognostic - moderately differentiated 698d - poorly differentiated 75d

Answer 17

Continuous overlapping haemostatic, pneumostatic suture pattern (1-2 layers) Oversewn with simple continuous If relatively large bronchi and blood vessels are encountered, they are ligated individually

Answer 18

- distal two-thirds or less - sutured - stapled (TA) - Thoracoscopic (Endo GIA) - keyhole ( 3- to 7-cm intercostal thoracotomy)

Answer 19

Endo-GIA - 30-, 45- and 60mm cartridges - Open staple leg lengths 2.0, 2.5, 3.5, 4.8 - 2.5mm staples typically used for partial lung lobectomy - Can be inserted through a 12mm cannula

Answer 20

- preferred open surgical approach through a lateral intercostal thoracotomy -

Answer 21

Pulmonary ligament (pleural fold between the caudal edge of the hilus and the mediatinum)

Answer 22

- The arterial supply to the lobe is approached first - triple ligated with two encircling sutures and one transfixation - pulmonary vein is approached on the ventral or caudal side of the bronchus - bronchial suture line is tested for air leaks, uturing surrounding pleural and subpleural tissue over the end of the bronchus

Answer 23

Pre-placed horizontal mattress sutures Oversewn

Answer 24

TA-V3 TA55 with 3.5mm staples

Answer 25

Dogs weighing less than 10kg Mass over 8cm Three or four cannulas are required. If a cranial lung lobe is removed, cannulas are placed in the eighth or ninth intercostal space; if a caudal lung is resected, cannulas are placed in the fourth intercostal space. bag (e.g., EndoPouch) to facilitate retrieval of the specimen without thoracic wall contamination.

Answer 26

cardiac arrest haemothaorax pulmonary hypertension pneumothorax incisional dehiscence

Answer 27

* Removal of 60% is fatal (acute pulmonary hypertension) - should remove a maximum of 50% acutely * Left lung 42% * Right lung 58% Dogs undergoing staged lobectomies over 6m period can survive with equivalent of 1.5 caudal lung lobes | can do left but not right actuely

Answer 28

* Decreased compliance, vital capacity and perfusion * Right ventricular hypertrophy and increased pulmonary vascular resistance and residual lung capacity

Answer 29

* Recruitment of physiologic reserves of diffusion capacity * Remodelling of existing alveoli-capillary structures * Growth of new alveoli-capillary unit

Answer 30

- Control of the branch of the main pulmonary artery (lobar artery) early reduces the chance of major hemorrhage - Lobar arteries 5 mm or larger should be stapled or oversewn - endotracheal tube cuff is deflated, the tube is advanced into the contralateral bronchus - first suture line is placed approximately 5 to 10 mm distal to the carina

Answer 31

Retrospective study. Animals: A total of 72 dogs and 15 cats. TA stapler was used in 83 (82.2%) and the SLL in 18 (17.8%) lung lobectomies. Intraoperative complications were identified in 14/101 lung lobectomies (13.9%), including intraoperative hemorrhage in 12/101 lobectomies (11.8%) and air leakage in 2/101 lobectomies (1.9%). Postoperative complications were identified in 12/87 cases (13.8%), including 4 (4.6%) catastrophic complications and 5 (5.8%) major complications. Self-ligating loop lung lobectomy provided a comparable alternative to stapled lung lobectomy. Further studies are needed to assess technique superiority. The SLLs improved resistance to airway leakage likely correlates with improved resistance to hemorrhage.

Answer 32

Retrospective. 61. Thoracoscopic resection of lung masses. (81%) carcinomas. Clean surgical margins (88%) Conversion to open (26%) > Larger tumor (≥ 5 cm) risk factor, presence of adhesions, OLV not tolerated All 61 dogs survived to discharge MST 311 days Tracheobronchial lymphadenopathy > shorter survival, margins + chemo were not. (85%) cases, one-lung ventilation (OLV) was used. Intraoperative complications (16%) Postoperative complications (8%) dogs prospective required to compare open and minimally invasive sx

Answer 33

Client-owned animals; 5 dogs and 5 cats Exfoliative cytology results were consistent with carcinoma in 4 dogs and lymphoma in 1 dog. A minor postprocedural complication was noted in 1 dog

Answer 34

Pleural effusion was present in nine cats at presentation. Fluid analysis confirmed chylothorax in three cats A diagnosis was made preoperatively in six cats Lung lobectomy was successfully performed in all cases. Based on clinical, diagnostic and lung histopathology findings, three cats had idiopathic and seven cats secondary LLT Postoperative complications occurred in six cats and lead to euthanasia or death in four cats Secondary LLT associated with underlying thoracic pathology was associated with high complication rates and poor outcomes. (effusions, carcinoma) Most reported LLTs in cats are of secondary aetiology (67%),2,5,7–18 in contrast to in dogs (24–38%).1,6,24

Answer 35

perioperative mortality 20/340 (5.9%) - pulmonary carcinoma 296/340 (87.1%) - MST 399d - 27.0% developed metastasis, 6.1% developed recurrence - MST by stage: I 663d; II 389d; III 361d; IV 273d - when sorted by clinical stage – adjuvant chemotherapy → no difference in MST - sarcoma 26/340 (7.6%) - histiocytic sarcoma MST 300d - adenoma 11/340 (3.2%) - pulmonary neuroendocrine tumour 5/340 (1.5%) - MST 498d - prognostic for survival: primary tumour size >5cm, pleural effusion, increasing mitotic count, distant metastasis, affected lymph nodes

Answer 36

The perforation site was identified in 21 of 22 (95.5%) dogs and involved the caudal lobes in 20 of 22 (90.9%) cases The perforation site was characterized as a soft tissue attenuating focus lying against an extensive pleural thickening in 21 of 22(95.5%) dogs.A grass awn was seen in 11 of 22(50%) dogs. The pneumothorax distribution and grass awn position consistently indicated the perforation side in this sample of dogs.

Answer 37

Mild bleeding was the main complication (58 of 75; 77%) of endoscopic removal, which was successful in 67 of the 84 (80%) cases.

Answer 38

,Bronchial collapse was also more common in dogs with brachycephalic conformation, which is in agreement with the previously published literature.

Answer 39

lesions that have heterogenous contrast enhancement, additional pulmonary nodules, and wall thickness > 40 mm at their thickest point, it would be reasonable to consider malignant neoplastic disease higher

Answer 40

Retrospective. thoracoscopic-assisted lung lobectomy in dogs. 30. Twelve intraoperative complications 6 conversion to open > adhesions (2), too big (2), O2 desaturation (1). One lung ventilation was successful in 4 / 7 27% post complications > 1 x thromboembolic event mortality 9 dogs, MST 168 days facilitate the excision of larger pulmonary lesions or to treat smaller dogs, in which a thoracoscopic excision may be technically more challenging.

Answer 41

Nine patients underwent a TL approach and 3 underwent TAL. In those that underwent TL, conversion to an intercostal thoracotomy was performed in 4 out of 9 dogs 1 died Conversion rates were higher than those historically reported for dogs undergoing thoracoscopic lung lobectomy for primary lung tumors.

Answer 42

Cadaveric anatomical study. The lateral vein varied in its location, The pulmonary ligament attached to the ALL in a caudally pointing apex on the dorsal process of the lobe. Medial and lateral extensions of the ALL parenchyma were found. The ALL was most easily accessed by a right lateral thoracotomy at the sixth intercostal space

Answer 43

(90%) dogs underwent median sternotomy, Recurrence was significantly more likely to occur ≤ 30 days after surgery, recurrecnt rate 3% Lung lobectomy via median sternotomy resulted in resolution of pneumothorax in most dogs with primary spontaneous pneumothorax 2-year and 5-year survival rates were 90%. reflected failure to identify lesions during the initial thoracic exploration, rather than development of additional bullae. Failing to divide the xiphoid may severely limit the surgeon’s ability to visualize the entirety of the accessory lung lobe,

Answer 44

Retrospective. treatment of idiopathic lung lobe torsion in 80 cases pugs 47.5% considered primary 77%, secondary 21%, and unknown 2% Postoperative complications 14%. Overall, 95% of dogs survived to discharge Primary associated with a longer survival (median not reached) compared with secondary 921 days Six (11%) dogs died or were euthanized for causes related to their secondary LLT

Answer 45

Percutaneous MWA of pulmonary nodules was technically feasible in two dogs without major complications Liptak et al9 reported a median survival time of 487 days for 36 dogs that underwent limb amputation, single-agent cisplatin therapy, and lung lobectomies to remove metastatic lesions.

Answer 46

Two- and 5-year survival rates were 88.4% and 83.5%, respectively. There was recurrence in 14 of 99 dogs (14.1%)

Answer 47

None of the samples leaked below 25 cm H2O, which is well above the physiologic airway pressure. extent of collateral damage was approximately 2.7 mm in all specimens. The maximum physiologic airway pressure is considered to be 20 cm H2O (Santini et al. 2006). Currently partial lung lobectomy is routinely performed with staplers, resulting in median leak pressures of 25.5 cm H2O for thoraco-abdominal-stapled biopsies

Answer 48

Sample population: Thirty cadaveric canine lung lobes and 5 client-owned dogs. endoloop Results: Two stapled and 4 sutured bronchial stumps leaked at supraphysiological pressures >15 mm Hg. One stapled bronchial stump failed at a physiological airway pressure (5 mm Hg). None of the PLL lobectomies leaked. The incidence of bronchial stump failures did not differ among techniques (P = .15). Lung lobectomy was performed successfully with the PLL in 5 clinical cases with no intraoperative or postoperative complications; median follow-up time was 6 months.

Answer 49

In situ cadaveric study. LigaTie or a TA Animals: Ten feline cadavers. cranial lung lobes only. Airway pressures were tested to a maximum pressure of 40 cmH2O. Lung lobectomies were consistently performed at the hilus only when the LigaTie was used. Lung lobectomies were less likely to leak when performed with the LigaTie rather compared with TA staples. Clinical significance: The LigaTie may be an effective alternative

Ch 103 Lungs Flashcards

(75 cards)