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

== Discussion ==

血管肉瘤是狗的常见肿瘤，约占所有非皮肤原发性恶性肿瘤的 5%[1] 血管肉瘤起源于血管内皮，已知会迅速转移[2-4] 常见的受累部位包括脾脏、右心房、皮下组织和肝脏[3-5] 血管肉瘤的常见并发症，无论位置如何，'''包括自发性出血和贫血'''[4] 这种类型的肿瘤与播散性肿瘤密切相关血管内凝血，血管肉瘤患者由于肿瘤内形成的异常血管的脆弱性，发生自发性出血的风险很高。心脏血管肉瘤的临床体征通常与心包积液和右侧充血性心力衰竭的体征有关，包括腹水、运动不耐受和呼吸困难[2] 体格检查的常见异常包括心音低沉、心动过速、黏膜苍白、股动脉搏动微弱、腹液波和呼吸困难[2,3]。


在本报告中描述的狗中，通过胸腔镜检查进行了心包次全切除术和右心房肿块切除术。胸腔镜检查以前被用作检查胸腔和获取活检标本的微创方法[6] 在人类医学中，胸腔镜检查被用于许多应用[7,8] 最近，人们对小动物的胸腔镜外科手术产生了兴趣，包括用于治疗心脏肿块出血或特发性心包积液的狗的次全心包切除术。一项研究[6] 涉及 13 只接受胸腔镜引导下心包切除术的肿瘤性或特发性心包积液狗，该研究的作者得出结论，这是一种可行的选择，与开胸术相比具有多项优势。没有发现麻醉并发症，13 只狗中只有 3 只出现手术并发症，包括膈神经横断、医源性肺撕裂伤和中度术中出血。12 只狗的恢复时间< 24 小时；1 只患有医源性肺撕裂伤的狗住院 36 小时[6] 这些结果[6] 和人类患者的结果[7-9] 表明，在正确选择的患者中，胸腔镜检查具有多种优势，主要优点是与开胸手术相比，手术的侵入性较小。胸腔镜手术的优点是切口部位小，不需要肋骨回缩。患者在手术后仍然需要放置胸腔造口管以允许从胸膜腔排出空气，但他们没有大切口的相关不适[10] 在之前的研究中[6] 涉及 13 只接受胸腔镜心包切除术的狗，报告的困难主要与所需视野的正确可视化有关。


狗心脏血管肉瘤的治疗可能包括药物和手术选择。许多患者在诊断时有转移的证据，这可能导致所有者选择姑息治疗，例如反复心包穿刺术，联合或不联合辅助化疗，而不是心包切除术和肿块切除术。在有转移性疾病证据的狗中，肿块切除术仅是姑息性的;因此，许多临床医生建议不进行切除肿块的次全心包切除术[3] 然而，最近一项针对 23 只接受正中胸骨切开术或侧开胸手术进行心包切除术和肿块切除术的狗的研究[3] 揭示了有希望的结果，23 只狗中有 20 只存活出院。


Hemangiosarcoma is a common neoplasm in dogs, representing approximately 5% of all noncutaneous primary malignant neoplasms.1 Hemangiosarcomas originate from vascular endothelium and are known to rapidly metastasize.2–4 Common sites of involvement include the spleen, right atrium, subcutaneous tissue, and liver.3–5 Common complications of hemangiosarcoma, regardless of location, include spontaneous hemorrhage and anemia.4 This type of neoplasm is strongly associated with disseminated intravascular coagulation, and patients with hemangiosarcoma are at high risk for spontaneous hemorrhage owing to the fragility of the abnormal vessels formed within the tumor. Clinical signs of cardiac hemangiosarcoma are generally related to pericardial effusion and signs of right-sided congestive heart failure, including ascites, exercise intolerance, and dyspnea.2 Common abnormalities on physical examination include muffled heart sounds, tachycardia, pale mucous membranes, weak femoral pulses, an abdominal fluid wave, and dyspnea.2,3

In the dog described in the present report, subtotal pericardiectomy and right atrial mass resection were performed by means of thoracoscopy. Thoracoscopy has been used previously as a minimally invasive way to examine the thoracic cavity and obtain biopsy specimens.6 In human medicine, thoracoscopy is being used for a number of applications.7,8 More recently, there has been interest in thoracoscopic surgical procedures in small animals, including subtotal pericardiectomy for the treatment of dogs with bleeding cardiac masses or idiopathic pericardial effusion. Authors of a study6 involving 13 dogs with neoplastic or idiopathic pericardial effusion that underwent thoracoscopic-guided pericardiectomy concluded that this was a viable option with several advantages over thoracotomy. No anesthetic complications were identified, and only 3 of the 13 dogs had procedural complications, including phrenic nerve transection, iatrogenic lung laceration, and moderate intraoperative bleeding. Recovery time was < 24 hours in 12 dogs; 1 dog with an iatrogenic lung laceration was hospitalized for 36 hours.6 These results6 and results from human patients7–9 indicate multiple advantages of thoracoscopy in properly selected patients, with the major advantage being the less invasive nature of the procedure when compared with thoracotomy. Thoracoscopic procedures have the advantage of small incision sites and do not require rib retraction. Patients still require placement of a thoracostomy tube after surgery to allow evacuation of air from the pleural cavity, but they do not have the associated discomfort of a large incision.10 In the previous study6 involving 13 dogs that underwent thoracoscopic pericardiectomy, reported difficulties were mainly associated with proper visualization of the desired field of view.

Treatment of cardiac hemangiosarcoma in dogs may include medical and surgical options. Many patients will have evidence of metastasis at the time of diagnosis, which may lead owners to opt for palliative treatments, such as repeated pericardiocentesis with or without adjunct chemotherapy, instead of pericardiectomy and mass resection. In dogs with evidence of metastatic disease, mass resection is only palliative; therefore, many clinicians recommend subtotal pericardiectomy without mass resection.3 However, a recent study3 of 23 dogs that underwent median sternotomy or lateral thoracotomy for pericardiectomy and mass removal revealed promising results, with 20 of the 23 dogs surviving to discharge from the hospital.


辅助化疗方案以前曾用于患有血管肉瘤的狗，但结果喜忧参半。据报道，基于多柔比星的方案具有中等疗效，但不包括多柔比星的方案对血管肉瘤的狗疗效有限或没有疗效[5] 在一项仅限于患有心脏血管肉瘤的狗的研究中[3]，未经化疗的大规模切除后的平均生存时间为 46 天，而同样接受辅助化疗的狗的平均生存时间为 164 天。


据我们所知，这是第一份关于胸腔镜次全心包切除术和狗右心房肿块切除术的报道。本报告中的患者术后住院时间较短，无重大麻醉或手术并发症。我们患者手术的成功可能至少部分与外科医生在胸腔镜和微创外科手术方面的经验有关。安全地进行此类手术需要大量的培训和经验以及专业设备，在转诊患者进行类似治疗时应考虑这些因素。这只狗在大规模切除后的生存时间为 177 天，这与之前一项接受大规模切除和辅助化疗的右心房血管肉瘤狗的研究[3] 的平均生存时间相似。这些结果表明，对于患有右心房血管肉瘤的狗，胸腔镜肿块切除术可能是开胸术的可行替代方案。胸腔镜右心房肿块切除术的可能并发症与通过开胸术切除的肿块切除术相似，包括切除部位出血、心律失常和疼痛[3] 胸腔镜检查特有的并发症包括手术野可视化差和需要开胸手术的不受控制的出血。然而，在本报告中描述的狗中，没有出现这些并发症。在手术过程中可以看到完整的肿块，并且在肿块底部周围放置线性吻合装置没有发现任何问题。


Adjuvant chemotherapy protocols have been used previously in dogs with hemangiosarcoma with mixed results. Doxorubicin-based protocols reportedly have moderate efficacy, but protocols that do not include doxorubicin have had limited or no efficacy in dogs with hemangiosarcoma.5 In a study3 limited to dogs with cardiac hemangiosarcoma, mean survival time after mass resection without chemotherapy was 46 days, whereas mean survival time was 164 days for dogs that also received adjuvant chemotherapy.

To our knowledge, this is the first published report of a thoracoscopic subtotal pericardiectomy and right atrial mass resection in a dog. The patient in this report had a short postoperative hospitalization time and had no major anesthetic or operative complications. The success of the procedure in our patient was likely related, at least in part, to the experience of the surgeon in thoracoscopic and minimally invasive surgical procedures. Considerable training and experience and specialized equipment are required to safely perform this type of surgery, and these factors should be considered when referring a patient for similar treatment. Survival time in this dog after mass resection was 177 days, which was similar to mean survival time in a previous study3 of dogs with right atrial hemangiosarcoma that underwent mass resection and adjuvant chemotherapy. These results suggest that thoracoscopic mass resection may be a viable alternative to thoracotomy in dogs with right atrial hemangiosarcoma. Possible complications of thoracoscopic right atrial mass resection are similar to those associated with mass resection via thoracotomy and include bleeding from the resection site, cardiac arrhythmia, and pain.3 Complications unique to thoracoscopy include poor visualization of the surgical field and uncontrolled hemorrhage necessitating thoracotomy. However, in the dog described in the present report, none of these complications developed. The complete mass could be visualized during the procedure, and no problems were noted with placement of the linear stapling device around the base of the mass.

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