查看狗的胸腔镜次全心包切除术和右心房肿块切除术的源代码

== 概述 ==

检查了一只 10 岁的 20.7 公斤（45.5 磅）绝育雌性柯基犬混合物，是否有 3 周的嗜睡和体重增加史。评估显示腹部膨大，可能存在脾脏肿块，腹部 X 线片显示明显腹腔游离液。病人被转诊到一家专科医院。


到达转诊医院后，这只狗很聪明，很警觉，反应灵敏。体格检查显示腹部膨大，血流波;在胸部听诊时听到低沉的心音。初始诊断性检查包括全血细胞计数、血清生化评估、胸部 X 线检查（右侧、左侧和腹背侧视图）、心电图以及胸部和腹部超声检查。


临床病理异常包括血小板减少症（167,000 血小板/μL;参考范围，200,000-500,000 血小板/μL）、低白蛋白血症（2.2 g/dL;参考范围，2.5-4.4 g/dL）、低蛋白血症（4.8 g/dL;参考范围，5.4-8.2 g/dL）和轻度高血糖（117 mg/dL;参考范围，60-110 mg/dL）。胸部 X 线片评估显示球状心脏轮廓。没有肿瘤性疾病的证据，肺野的影像学表现被认为在正常范围内。胸部超声检查提示心包积液，右耳廓附着 3.8 × 3.3 cm 的带蒂肿块。腹部超声检查显示肝脏充血，肝静脉和腹水扩张。脾脏和肾脏的超声检查无明显异常。初始心电图评估提示窦性心动过速，无室性搏动。


进行心包穿刺术，取出约 180 mL 出血液。由于患者举止安静，因此不需要镇静剂。术中偶有室性心动过速发作，心包穿刺术完成后2小时内偶见心室早搏。通过腹腔穿刺术获取腹液样本，并提交心包和腹液样本进行细胞学分析。心包积液由外周血和既往出血证据组成。观察到一些反应性间皮细胞，但没有肿瘤的证据。腹液被归类为具有非退行性中性粒细胞和反应性单核细胞的改良渗出物。狗在连续心电图监测下住院过夜;给予 50 mL/h （60 mL/kg/d [27.3 mL/lb/d]， IV） 和利多卡因 （100 μg/kg/min [45.5 μg/lb/min]， IV） 的平衡晶体液替代液a。这只狗在心包穿刺术后的第二天就出院了。出院前，与业主讨论了多种治疗方案，包括反复心包穿刺术和手术方案，例如姑息性心包切除术和心包切除术和肿块切除术。


一周后，狗被送回转诊医院进行胸腔镜心包切除术和右心房肿块切除术。主人报告说，这只狗在前一周在家里表现良好。用氢吗啡酮（0.05 mg/kg [0.023 mg/lb]，皮下注射）预先用药物，并用丙泊酚（5 mg/kg [2.3 mg/lb]，IV）和咪达唑仑（0.2 mg/kg [0.09 mg/lb]，IV）联合麻醉，并用异氟醚维持氧气。在麻醉诱导后，在手术开始前放置中心静脉导管（通过颈静脉）和动脉导管。手术开始前还进行了血型分析，发现狗的DEA 1.1阳性。手术前开始连续输注芬太尼（5 μg/kg/h，静脉注射）。头孢唑林（22 mg/kg [10 mg/lb]，静脉注射）在手术开始时给药。手术期间通过脉搏血氧饱和度、连续心电图和二氧化碳图对狗进行监测;用换能器测量动脉血压。在手术过程中进行手动通气，以控制肺部的整体充气，同时提供手术区域的充分可视化。


A 10-year-old 20.7-kg (45.5-lb) spayed female Corgi mix was examined for a 3-week history of lethargy and weight gain. Evaluation revealed a distended abdomen and possible splenic mass with free abdominal fluid evident on abdominal radiographs. The patient was referred to a specialty hospital.

On arrival at the referral hospital, the dog was bright, alert, and responsive. Physical examination revealed a distended abdomen with a fluid wave on ballottement; muffled heart sounds were heard during auscultation of the thorax. Initial diagnostic testing included a CBC, serum biochemical evaluation, thoracic radiography (right lateral, left lateral, and ventrodorsal views), electrocardiography, and thoracic and abdominal ultrasonography.

Clinicopathologic abnormalities included thrombocytopenia (167,000 platelets/μL; reference range, 200,000 to 500,000 platelets/μL), hypoalbuminemia (2.2 g/dL; reference range, 2.5 to 4.4 g/dL), hypoproteinemia (4.8 g/dL; reference range, 5.4 to 8.2 g/dL), and mild hyperglycemia (117 mg/dL; reference range, 60 to 110 mg/dL). Evaluation of thoracic radiographs revealed a globoid cardiac silhouette. There was no evidence of neoplastic disease, and the radiographic appearance of the lung fields was considered within normal limits. Thoracic ultrasonography indicated pericardial effusion with a 3.8 × 3.3-cm pedunculated mass attached to the right auricle. Abdominal ultrasonography revealed congestion of the liver with dilatation of the hepatic veins and ascites. Ultrasonographic appearance of the spleen and kidneys was unremarkable. Evaluation of an initial ECG indicated sinus tachycardia with no ventricular beats.

Pericardiocentesis was performed, and approximately 180 mL of hemorrhagic fluid was removed. Sedation was not required because of the patient's quiet demeanor. There were occasional episodes of ventricular tachycardia during the procedure, and an occasional premature ventricular complex was seen up to 2 hours after pericardiocentesis was completed. A sample of abdominal fluid was obtained via abdominocentesis, and the pericardial and abdominal fluid samples were submitted for cytologic analysis. The pericardial fluid consisted of a combination of peripheral blood and evidence of prior hemorrhage. Some reactive mesothelial cells were seen, but there was no evidence of neoplasia. The abdominal fluid was classified as a modified transudate with nondegenerative neutrophils and reactive mononuclear cells. The dog was hospitalized overnight with continuous ECG monitoring; balanced crystalloid replacement fluida at 50 mL/h (60 mL/kg/d [27.3 mL/lb/d], IV) and lidocaine (100 μg/kg/min [45.5 μg/lb/min], IV) were administered. The dog was discharged from the hospital the day after pericardiocentesis. Prior to discharge, multiple treatment options were discussed with the owner including repeated pericardiocentesis and surgical options such as palliative pericardiectomy and pericardiectomy with mass resection.

A week later, the dog was returned to the referral hospital for thoracoscopic pericardiectomy and right atrial mass resection. The owner reported that the dog had been doing well at home during the preceding week. The dog was premedicated with hydromorphone (0.05 mg/kg [0.023 mg/lb], SC), and anesthesia was induced with a combination of propofol (5 mg/kg [2.3 mg/lb], IV) and midazolam (0.2 mg/kg [0.09 mg/lb], IV) and was maintained with isoflurane in oxygen. A central venous catheter (via the jugular vein) and an arterial catheter were placed after anesthesia had been induced, prior to commencement of surgery. Blood typing was also performed before the start of surgery, and the dog was found to be DEA 1.1 positive. A continuous rate infusion of fentanyl (5 μg/kg/h, IV) was started before surgery. Cefazolin (22 mg/kg [10 mg/lb], IV) was administered at the start of surgery. The dog was monitored during surgery by use of pulse oximetry, continuous ECG, and capnography; arterial blood pressure was measured with a transducer. Manual ventilation was performed during surgery to control overall inflation of the lungs while providing adequate visualization of the surgical field.


将狗置于背卧位，并创建了一个膈下门户以插入 5 毫米胸腔镜。肋间门户在第五肋间隙双侧创建。解剖纵隔组织以允许心包可视化。切开心包，在膈神经腹侧建立一个 6 cm 的窗口。当心包被打开时，少量血液被释放到胸膜腔中。使用胸腔镜器械识别并切除右侧耳廓肿块，包括一个 45 毫米长的线性吻合器和 3.5 毫米的吻合器。放置胸腔造口管，并常规闭合胸腔。吸入胸腔造瘘管直至获得负压，然后通过胸腔造口管将布比卡因（2mg/kg [0.9mg/lb]）输注到胸膜腔中。


从麻醉中恢复是例行公事。将狗连接到连续心电图监护仪，并在手术后的前 2 小时内通过紧密贴合的面罩给予补充氧气。术后治疗包括静脉注射含电解质的等渗液体（50 mL/h）;连续输注芬太尼（2 至 5 μg/kg/h，静脉注射）、氯胺酮（2 μg/kg/min，静脉注射）和利多卡因（35 μg/kg/min [15.9 μg/lb/min]，静脉注射）;和头孢唑林的静脉给药（22 mg / kg，IV q 8 h）。在手术后的第一个小时内，每 15 分钟抽吸一次胸腔造口管，然后每小时抽吸一次，直到连续 4 小时内没有获得液体或空气。此后，每 6 小时吸入一次管子过夜。为了辅助疼痛控制，利多卡因（1 mg/kg [0.45 mg/lb]，胸腔内）和布比卡因（1 mg/kg，胸腔内）在管抽吸后每 6 小时通过胸腔造口管给药。


手术完成后 1 小时和 2 小时进行动脉血气分析。手术后 1 小时，O2 分压的肺泡-动脉梯度为 14 mm Hg（参考限值，< 15 mm Hg）;Pao2 和 Paco2 均在参考限值范围内。术后2小时，肺泡-动脉梯度、动脉pH值、Pao2、Paco2均在参考限值范围内。一夜之间，中心静脉压、动脉血压和连续心电图结果均在参考范围内。


手术后的第二天早上，这只狗很聪明，很警觉，反应灵敏。当时的体格检查显示肋间切口部位有一些轻微的渗出物，该部位被扩大以允许切除肿块，但其他方面结果并无明显异常。此时停止了对中心静脉压、动脉血压和心电图的连续监测。PCV为40%，总蛋白浓度为5.5 g/dL。停止监测前立即中心静脉压为 1 cm H2O。胸腔造口术插管被移除，因为一夜之间没有液体或空气通过管子吸入;最终剂量的利多卡因和布比卡因在取管前胸腔内给药。


这只狗在手术后的第二天继续表现良好。下午中午停止静脉注射头孢唑林、芬太尼、氯胺酮和利多卡因，口服曲马多（4 mg/kg [1.8 mg/lb]，PO，每 8 小时一次）以进一步控制疼痛。当晚晚些时候，这只狗出院了，并指示主人在14天后将其送回，进行后续检查和取出订书钉。


右心房肿块的组织学检查显示 2 级血管肉瘤，边缘不完全，主治病理学家表示肿瘤复发或转移的风险很高。当获得组织病理学检查结果时，这只狗被转介到内科讨论化疗方案。直到手术后 22 天，业主才安排与内科医生的初步咨询。


The dog was positioned in dorsal recumbency, and a subdiaphragmatic portal was created for insertion of a 5-mm thoracoscope. Intercostal portals were created bilaterally at the fifth intercostal space. Mediastinal tissues were dissected to allow for visualization of the pericardium. The pericardium was incised, and a 6-cm window was established ventral to the phrenic nerves. A small amount of bloody fluid was released into the pleural space as the pericardium was opened. The right auricular mass was identified and excised at its junction with the atrium by use of thoracoscopic instruments, including a 45-mm-long linear stapler with 3.5-mm staples.b The mass was removed via enlargement of one of the intercostal portal incisions and submitted for histopathologic examination. A thoracostomy tube was placed, and the thorax was closed routinely. The thoracostomy tube was aspirated until negative pressure was obtained, and bupivacaine (2 mg/kg [0.9 mg/lb]) was then infused into the pleural cavity via the thoracostomy tube.

Recovery from anesthesia was routine. The dog was connected to a continuous ECG monitor, and supplemental oxygen was administered for the first 2 hours after surgery via a tight-fitting face mask. Postoperative treatments included IV administration of isotonic fluids containing electrolytes (50 mL/h); continuous rate infusions of fentanyl (2 to 5 μg/kg/h, IV), ketamine (2 μg/kg/min, IV), and lidocaine (35 μg/kg/min [15.9 μg/lb/min], IV); and IV administration of cefazolin (22 mg/kg, IV q 8 h). The thoracostomy tube was aspirated every 15 minutes for the first hour after surgery and then hourly until no fluid or air was obtained over a continuous 4-hour period. Thereafter, the tube was aspirated every 6 hours overnight. For adjunctive pain control, lidocaine (1 mg/kg [0.45 mg/lb], intrapleurally) and bupivacaine (1 mg/kg, intrapleurally) were administered through the thoracostomy tube every 6 hours after tube aspiration.

Arterial blood gas analyses were performed 1 and 2 hours after the completion of surgery. One hour after surgery, the alveolar-arterial gradient in partial pressure of O2 was 14 mm Hg (reference limit, < 15 mm Hg); Pao2 and Paco2 were within reference limits. Two hours after surgery, the alveolar-arterial gradient, arterial pH, Pao2, and Paco2 were all within reference limits. Central venous pressure, arterial blood pressure, and results of a continuous ECG were all within reference limits overnight.

The morning following surgery, the dog was bright, alert, and responsive. Physical examination at that time revealed some mild oozing from the intercostal incision site that was enlarged to allow mass removal, but results were otherwise unremarkable. Continuous monitoring of central venous pressure, arterial blood pressure, and the ECG was discontinued at this time. The PCV was 40%, and total protein concentration was 5.5 g/dL. Central venous pressure was 1 cm H2O immediately prior to discontinuation of monitoring. The thoracostomy tube was removed because no fluid or air had been aspirated through the tube overnight; final doses of lidocaine and bupivacaine were administered intrapleurally just prior to tube removal.

The dog continued to do well the day after surgery. Intravenous administration of cefazolin, fentanyl, ketamine, and lidocaine was discontinued by midafternoon, and oral administration of tramadol (4 mg/kg [1.8 mg/lb], PO, q 8 h) was instituted for further pain control. The dog was discharged later that evening with directions that the owners return it 14 days later for a follow-up examination and staple removal.

Histologic examination of the right atrial mass revealed a grade 2 hemangiosarcoma with incomplete margins, and the attending pathologist remarked that there was a high risk of recurrence or metastasis of the tumor. The dog was referred to the internal medicine department for discussion of chemotherapy options when the results of histopathologic testing were obtained. The initial consultation with the internist was not scheduled by the owners until 22 days after surgery.


在肿块手术切除后 35 天开始用多柔比星治疗（30 mg/m^2，IV，每 3 周一次，共 5 剂）。进行全血细胞计数，并在每次给予多柔比星之前'''测量 PCV 和总蛋白浓度'''。每次结果都在参考限度内。在给予第二剂多柔比星之前，由于在给予第一剂多柔比星后出现恶心和呕吐的迹象，狗预先用'''马罗匹坦柠檬酸'''（1 mg/kg，SC）服药，并开具'''甲氧氯普胺'''（0.24 mg/kg [0.11 mg/lb]，PO，q 8 h）。相同的治疗方案用于随后的每次剂量的多柔比星。唯一报告的其他并发症是每次服用阿霉素后嗜睡 1 至 2 天。在用阿霉素治疗期间，狗的体重保持稳定，主人报告说狗在家里表现良好。


化疗结束后约50天（即手术后169天），狗被送回医院，主人主诉 2 至 3 天在兴奋和呼吸困难时咳嗽。这只狗在其他方面表现良好，食欲良好，活动水平正常。体格检查中发现的'''异常包括呼吸急促'''和'''刺耳的肺音'''。'''心脏听诊结果无明显异常'''。胸甲线检查显示'''所有肺野均有弥漫性粟粒状结节'''，与'''转移性血管肉瘤'''一致。泼尼松（1mg / kg，q 24小时，PO）用于缓解咳嗽。八天后，这只狗被重新检查，有咳嗽加重、呼吸急促和呼吸受损导致无法舒适睡眠的病史。当时，主人选择了对狗实施安乐死，因为生活质量下降和转移性疾病的证据。没有进行尸检。


Treatment with doxorubicin (30 mg/m2, IV, every 3 weeks, for a total of 5 doses) commenced 35 days after surgical resection of the mass. A CBC was performed, and PCV and total protein concentration were measured before each dose of doxorubicin was administered. Results were within reference limits each time. Before the second dose of doxorubicin was administered, the dog was premedicated with maropitant citratec (1 mg/kg, SC) because of signs of nausea and vomiting that had developed following administration of the first dose of doxorubicin, and metoclopramide (0.24 mg/kg [0.11 mg/lb], PO, q 8 h) was prescribed. This same treatment protocol was used for each subsequent dose of doxorubicin. The only other complication reported was lethargy for 1 to 2 days after administration of each dose of doxorubicin. The dog's weight remained stable during treatment with doxorubicin, and the owner reported that the dog was otherwise doing well at home.

Approximately 50 days after the conclusion of chemotherapy (ie, 169 days after surgery), the dog was returned to the hospital with a chief complaint by the owner of a 2- to 3-day history of coughing when excited and labored breathing. The dog had otherwise been doing well, with a good appetite and normal activity level. Abnormalities noted on physical examination included tachypnea and harsh lung sounds. Results of cardiac auscultation were unremarkable. Thoracic radiography revealed diffuse miliary nodules throughout all lung fields, consistent with metastatic hemangiosarcoma. Prednisone (1 mg/kg, q 24 h, PO) was prescribed for palliation of the cough. Eight days later, the dog was reexamined with a history of a worsening cough, tachypnea, and an inability to sleep comfortably owing to respiratory compromise. The owners elected euthanasia of the dog at that time because of a declining quality of life and evidence of metastatic disease. A necropsy was not performed.

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