Thoracentesis indications. Thoracentesis, thoracostomy

Pyothorax in animals or thoracic empyema – inflammation of the pleura, characterized by the accumulation of purulent effusion in the chest cavity.

Pyothorax is the result of a bacterial or fungal infection of the pleural cavity. In most cases, pyothorax is characterized by a moderate to significant amount of pleural exudate.

In animals with pyothorax, many pathogens can be cultured, but there is a high frequency of diseases in which a single anaerobic pathogen is identified. Most often cultivated Bacteroides And Fusobacterium, and also Pasteurella multocida. Streptococci, staphylococci, and various species are also often found Corynebacterium, Clostridium, Enterobacteriacae, Mycoplasma and even some types of fungi.

The causes of purulent inflammation of the pleural cavity may be:

• penetrating wounds of the chest cavity,
• bacterial pneumonia,
• penetration of foreign bodies,
• perforation of the esophagus,
• spread of infections from the cervical or lumbar spine and mediastinum,
• hematogenous and lymphogenous spread of bacteria,
• perforation of the chest wall,
• osteomyelitis,
• inhalation of cereal awns and their subsequent migration into the bronchi and pleural space.

No reliable breed or gender predisposition to the development of pyothorax in small domestic animals has been identified. It is believed that young intact cats involved in fights and receiving chest wounds have an increased risk of developing pyothorax, however, recent research has shown that the most common cause of feline pyothorax is invasion through the lung microflora of the oropharynx. Adult dogs of large breeds (especially hunting dogs) may be predisposed to the development of pyothorax due to the increased frequency of inhalation of foreign plant material (plant spines) and the receipt of penetrating wounds to the chest. Cats with multiple housing may also be predisposed to pyothorax.

The course of the disease depends on the form and severity of the process. Secondary pleurisy can last for months and years (tuberculosis). Purulent and putrefactive pleurisy often ends in the death of the animal during the first decade of the disease.

Symptoms

Pyothorax often has an insidious course, and the appearance of clinical signs may not be evident for a long time. Clinical signs appear due to restrictive processes and include:

• inspiratory dyspnea,
• rapid shallow breathing,
• dyspnea (impaired frequency and depth of breathing, accompanied by a feeling of lack of air.),
• orthopnea (difficulty breathing when lying down).

Additional clinical signs are exercise intolerance, lethargy, anorexia and fever. Chronic or severe infection results in septic shock, dehydration, exhaustion, and hypothermia.

Features of clinical manifestations in dogs:

• depression, anorexia, fever;
• shortness of breath, shallow breathing, abdominal type;
• with dry pleurisy, pain in the intercostal spaces, friction noises coincide with excursions of the chest.
• with effusion pleurisy, splashing noises during auscultation, during percussion - horizontal dullness, regardless of changes in posture;
• body temperature rises by 1-1.5 ° C;

Features of clinical manifestations in cats:

• depression, decreased appetite;
• cyanosis of mucous membranes;
• temperature rises by 1-2°C;
• urine is brown with a foul odor, stool is dry;
• shortness of breath, frequent abdominal breathing;
• upon palpation, the animal becomes restless and groans;
• when a cat lies down, the chest is compressed, which interferes with breathing, so the cat is afraid to lie down;
• The slightest stress leads to a sharp deterioration of the condition.

Diagnostics

The diagnosis is made on the basis of a blood test, chest x-ray and thoracentesis results, followed by cytological and microbiological examination of the resulting fluid.

Laboratory examination reveals pronounced neutrophilic leukocytosis, degenerative shift to the left, anemia of chronic inflammation. Also, when examining blood and urine, signs of secondary infection of organs (hepatitis, pyelonephritis) may be revealed.

With thoracentesis, the effusion is not transparent, the color ranges from white to amber and red, the protein content is usually more than 3.5 g/dl. Cytological examination reveals a large number of degenerative neutrophils. Macrophages and reactive mesothelial cells are present in the effusion in varying quantities, depending on the causative agent and the chronicity of the pyothorax. Culture of effusion is indicated in all animals with pyothorax, but positive results are not always achievable, especially when infected with anaerobic organisms.

During X-ray examination, due to the fact that the liquid has a high ability to absorb rays, a typical picture is observed. It is characterized by a sharp division of the projection of the entire pulmonary field into two parts, lower and upper. In the upper part, the shadows of the vertebrae and ribs stand out in contrast, and somewhat condensed root and pulmonary patterns are visible. The lower part of the chest is represented by a continuous, extensive, deeply intense and homogeneous darkening, the upper border of which has a horizontal and sharply contoured edge. Against the background of this uniform dense shading, formed due to pleural effusion, in contrast to pneumonic shading, not even the shadows of the ribs protrude. With extensive effusions, the cardiac silhouette is also not visible.

Treatment

The basis of treatment for pyothorax is drainage.

Once the diagnosis is made, a thoracostomy tube is placed through which periodic lavage is performed ( 2-3 times a day) with warm saline solution with aspiration of the contents an hour after administration. The introduction of antibiotics into the lavage solution does not provide any advantages over their systemic administration. The duration of lavage for pyothorax can take up to 5-7 days.

Supportive care is often necessary, including intravenous fluids and nutrition (via a nasal feeding tube or gastrostomy tube) to replace lost nutrients.

The final choice of antibiotic is made based on the results of the culture test, and a combination of antibiotics is prescribed while waiting for the results. It should be remembered that anaerobic microflora is not always determined by culture. The duration of antibiotic therapy for pyothorax is 4-6 weeks

If the condition does not improve, further investigation should be performed for underlying diseases (eg, feline leukemia virus, viral immunodeficiency, foreign body) or encapsulated abscesses in the lungs or pleura; they can develop as a result of insufficiently timely or insufficiently effective treatment. If an abscess is present, it must be opened after thoracotomy.

In animals with pyothorax, if conservative treatment is not effective, an attempt is made to identify and surgically correct the source of infection (foreign body, lung abscess, volvulus of the lung lobe). Surgical correction may also be indicated to resect the involved tissue and remove debris.

The prognosis for pyothorax is favorable. In animals treated only with systemic antibiotics without lavage, there is a high probability of recurrence of pyothorax. With the development of fibrinous pleurisy, the prognosis may not be favorable.

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A gentle technique for draining pathological cavities in the lungs by introducing drainage through a trocar has been used for a long time. Subsequently, this method was used mainly to treat patients with pulmonary tuberculosis, and then acute suppuration of the lungs, mainly abscesses. In the treatment of pulmonary gangrene, drainage through thoracentesis was rarely used. Thus, Gross (cited by A. Brunner, 1942) successfully treated 3 patients with pulmonary gangrene in this way, 3 of whom recovered, and in 1 a residual pulmonary cavity was formed. A. Brunner (1942) used drainage by thoracentesis in 2 patients with pulmonary gangrene to prepare for subsequent pneumotomy.

In the USSR, the method of drainage through thoracentesis in patients with abscesses and gangrene of the lungs was first used at the suggestion of I. S. Kolesnikov in the hospital surgical clinic of the Military Medical Academy named after. S. M. Kirov in 1968. Preliminary results of this treatment were presented in 1969 by L. S. Lesnitsky, and then summarized by him in his Ph.D. thesis (1970). Subsequently, numerous reports appeared on the use of this method in patients with pulmonary abscesses and only a few reports on the treatment of patients with pulmonary gangrene with thoracentesis and drainage. Thus, V. Vainrub et al. (1978), having achieved recovery in all 3 patients they observed with a limited form of pulmonary gangrene, propose drainage by thoracentesis in these cases as an alternative to lobectomy.

E. Cameron, J. Whitton (1977) used drainage through thoracentesis instead of lobectomy in 7 patients with limited and widespread forms of pulmonary gangrene caused by Friedlander's bacillus. A thick rubber drain was inserted into the decay cavity in the lung through the bed of the previously removed rib fragment. All patients recovered. P. M. Kuzyukovich (1978), who proposes drainage through thoracentesis as an independent method in such cases, also objects to lung resections in patients with a limited form of pulmonary gangrene. Of the 33 patients he observed, 14 recovered, in 6 the process became chronic. 13 patients died.

The results obtained cannot be considered satisfactory, especially since the transition of the process to a chronic form cannot be called success either. The advisability of using thoracentesis and drainage of lung cavities in patients with gangrene in order to prepare for resection was indicated by E. A. Wagner et al. (1980).

In the group of patients we observed, treatment of 23 patients with pulmonary gangrene began with drainage through thoracentesis. In 16 of them it was ineffective, and these patients subsequently underwent lung resection or pneumotomy. In 7 cases, drainage through thoracentesis was the only treatment method (Table 1).

Table 1

Drainage of lung cavities through thoracentesis in patients with pulmonary gangrene

The essence of the method is to insert a drainage tube into the destructive cavity through a trocar after preliminary puncture of the abscess and thoracentesis of the chest wall. The technique for draining pulmonary abscesses through thoracentesis was developed in our clinic by L. S. Lesnitsky. It is described in detail in the monograph by I. S. Kolesnikov and V. S. Vikhrnev “Lung Abscesses” (1973).

To ensure a constant supply of pus through the drainage, the latter can be left open under a thick cotton-gauze bandage that absorbs pus, or connected to another drainage tube lowered under water according to Bulau-Petrov. You can also use vacuum drainage with a slight vacuum not exceeding 1.96-2.94 kPa (20-30 cm of water column). It must be emphasized that the large vacuum created in the destructive cavity can provoke arrosive bleeding.

The most important element of drainage of purulent cavities by thoracentesis is their systematic sanitation through a drainage tube with antiseptic solutions. After administering the first portion of the solution, the patient’s reaction can be used to judge the condition of the bronchi draining the abscess. If the bronchi are patent, a cough immediately appears and the patient coughs up purulent sputum and the injected solution. If the cough does not appear, then the bronchi are obstructed. In this case, the syringe is disconnected from the drainage, the patient is asked to cough, after which the injected solution along with pus flows out through the drainage. About 200 ml of solution is used in fractional portions during one wash. Rinsing the cavity should continue until the last portions of the solution flowing through the drainage become transparent and do not contain pus. The patient's condition should be monitored and if he becomes tired or dizzy, he should stop rinsing the cavity.

The effectiveness of the treatment can be judged both by changes in the patient’s well-being and condition, and by data from laboratory and radiological studies. Often in the first days after surgery, the amount of sputum released when coughing increases, which indicates restoration of the patency of the draining bronchi. If within 5-7 days the amount of purulent discharge through the drainage decreases and its character changes, the amount and character of the sputum decreases (often initially smelly and thick, it gradually becomes more liquid, mucopurulent, and then odorless mucous), the temperature decreases body and the general condition of the patient improves, then drainage by thoracentesis can be considered effective and it is advisable to continue it.

Lack of improvement in general condition, persistent fever, copious discharge of purulent sputum, ongoing pathological changes in leukocytes, and radiologically determined fluid level in the cavity where the drainage is located determine the need for more extensive drainage - pneumotomy or resection. It is dangerous to persist in treating patients with pulmonary gangrene by drainage using thoracentesis, since the process in the lung may begin to progress and the most favorable moment for performing the operation will be missed.

If the course of the process is favorable, the drainage can be removed as soon as the body temperature and the composition of leukocytes are normalized, the separation of purulent sputum and pus through the drainage stops, and an X-ray examination will establish the disappearance of inflammatory infiltration in the circumference of the cavity, its size will decrease and there will be no horizontal fluid level in it , as can be seen in the above observation.

Patient Z., 61 years old, was admitted to the clinic on August 13, 1968 with complaints of weakness, pain in the right half of the chest, cough with purulent sputum up to 150 ml per day. She became acutely ill 1 month ago after hypothermia. After 1 week, with a diagnosis of influenza, she was hospitalized in the therapeutic department, where right-sided upper lobe lobar pneumonia was initially diagnosed. The patient was treated with morphocycline, but the condition did not improve, a foul odor appeared when breathing, and then purulent-putrefactive sputum.

Upon admission to the clinic, the condition was serious. High fever (up to 38.5 C). Severe pallor of the skin and exhaustion of the patient were noted. Pulse 120 per minute, rhythmic, satisfactory filling. Blood pressure 18/12 kPa (135/90 mm Hg). A shortening of the percussion sound was noted over the right lung, and during auscultation, weakened breathing with an amphoric tinge and numerous moist rales were heard. Blood test: Hb 90 g/l, er. 3.1.10 to 12 degrees/l, l. 8.4 10 to the 9th power/l, p. 19%, p. 58%, lymph. 15%, e. 1%, mine. 7%. Total protein 50 g/l. A/G 0.4.

X-ray of 08/14/68 shows a huge destructive cavity with a wide level of fluid, occupying almost the entire upper lobe of the right lung. On August 15, 1968, the cavity was drained by thoracentesis from the subclavian fossa (Fig. 1), during which about 300 ml of thick pus was simultaneously removed. After washing the cavity in the lung through drainage during the 1st night, the patient coughed up another 300 ml of thick pus mixed with blood. The bandages and bedding were soaked with pus. During sanitation, small sequestration of lung tissue emerged through the drainage over several days. During the first 5 days after drainage, the daily amount of sputum decreased and amounted to 200, 150, 100, 50 and 30 ml, respectively. On the 6th day, the patient’s condition improved: she had an appetite and “it became easier to breathe.” Body temperature returned to normal after a week. The radiograph after 9 days (Fig. 2) shows a decrease in the cavity’s size, the absence of fluid in it, and the drainage is located at the base of the cavity. The drainage was removed after 2 weeks. The patient was discharged with a dry residual cavity. For 1½ years she felt well, the dry residual lung cavity was preserved.

Rice. 1. Gangrene of the upper lobe of the right lung in the stage of a giant abscess, the cavity of which was drained by thoracentesis

Rice. 2. A large dry cavity in the upper lobe of the right lung, remaining after evacuation of pus and necrotic areas of the lung through a drainage tube.

There were few complications after drainage by thoraconcentesis in the analyzed group of patients. Mild subcutaneous emphysema in the area of ​​the drainage tube was observed in all patients. In only one case, drainage was complicated by phlegmon of the soft tissues of the chest wall.

As can be seen from table. 1, drainage of the lung cavity through thoracentesis in 16 patients was not effective enough; they were subjected to repeated operations. In only 2 patients, after sanitation, the condition improved, in 4, the effect of drainage was questionable, and in 10, drainage by thoracentesis had no effect. The reasons for this were the progression of lung gangrene, the presence of multiple cavities of destruction and large sequestration of lung tissue.

Drainage through thoracentesis was the only treatment method in 2 patients with widespread and 5 with limited forms of pulmonary gangrene. 6 people were discharged from the clinic. In 5 patients, huge lung cavities with fluid levels formed after purulent-putrefactive decay of necrotic areas of lung tissue (lung gangrene in the stage of a giant abscess) were drained. Sanitation of cavities through drainage was effective, and patients were discharged with dry residual lung cavities. One patient died with bilateral pulmonary gangrene, which developed against the background of agranulocytosis and bronchial asthma. Her condition was extremely serious, and she could not have endured any other surgical intervention.

Analysis of the results of treatment of pulmonary gangrene by drainage by thoracentesis led to the conclusion that as an independent method it can be used only in patients with large destructive cavities containing pus or small sequestra that have not yet been rejected. In the latter cases, it seems advisable to administer proteolytic enzymes through the drainage to accelerate the lysis of dead areas of lung tissue.

Drainage by thoracentesis can also be used for the purposes of detoxification and accelerating the emptying of pus through the bronchi in those patients where resection and even pneumotomy pose a great risk to the patient’s life. The use of drainage of lung cavities through thoracentesis to prepare for resection is unjustified due to the risk of complications and the formation of a thoracic fistula, the elimination of which usually requires a small, but undesirable surgical intervention in conditions of acute purulent infection.

Kolesnikov I.S., Lytkin M.I., Lesnitsky L.S.

Lung gangrene and pyopneumothorax

(pleurocentesis) is a procedure in which the pleura is punctured through the intercostal space in order to divert and aspirate pathological contents (or), normalize respiratory function, and also to diagnose the contents.

Transudate effusions arise from decreased plasma and result from decreased plasma oncotic pressure and increased hydrostatic pressure. The most common causes are metastasis in the chest cavity, kidney and liver pathologies.

Exudate effusions are formed under the influence of local pathological or surgical processes, causing an increase in capillary patency and subsequent exudation of intravascular components. There are many reasons for this: neoplasms, pulmonary embolism, dry pleurisy, etc.

The nature and volume of pleural effusions and the amount of air are determined by the doctor using an x-ray of the chest cavity and directly during thoracentesis in a dog or cat.

Indications

The main indications for thoracentesis are the presence of air, large pleural effusions, or pleural effusions of any size in the pleural space that cause difficulty breathing.

Contraindications and complications

A contraindication to thoracentesis in animals is increased bleeding, but if there is a sufficiently large amount of blood in the pleural space, respiratory failure may occur. Then the doctor weighs the risks and decides whether this procedure is necessary now. If the case is not an emergency, then there is time to adjust blood clotting.

It is necessary to warn owners about possible complications of the procedure - lung injury.

Technique

The technique for performing thoracentesis in dogs and cats is as follows. The procedure is most often carried out without sedation or local sedation, it is not painful and is well tolerated by animals. At the same time, oxygen is supplied. However, with aggressive or very restless patients, it is sometimes necessary to resort to sedatives.

Thoracentesis requires sterile needles of 18–22 diameters, 20 ml syringes, an infusion system, a three-way tap or hemostatic clamp, and a vessel for collecting fluid.

Thoracentesis is usually performed in the 7th–8th intercostal space on the right side (this is the safest area for inserting needles) or in the area of ​​maximum fluid accumulation. The position of the animal depends on the type of pathology. Thus, if there is air in the chest cavity, the animal is placed on its side and the puncture is made dorsally, and in the presence of fluid - in a standing, sitting or chest position, and the puncture is made ventrally. The injection site is carefully trimmed and treated with an antiseptic solution.

The puncture is carried out along the cranial edge of the rib, since there are intercostal vessels and nerves on the caudal edge.

The needle is inserted into the pleural space with a cut towards the lungs and parallel to the chest wall to avoid injury to the lung tissue. Aspiration of the contents is carried out while it is possible to remove fluid through the system, and is carried out with slight negative pressure to prevent the lung tissue from being sucked into the needle. It is usually not possible to completely remove content.

Thoracentesis is performed 1–3 times; if fluid collects again, it is recommended to apply

Thoracentesis or puncture of the pleural cavity is a medical procedure that involves puncturing the pleura (the membrane around the lung) through the intercostal space in order to diagnose the contents or evacuate the pathological contents of the pleural cavity to normalize respiratory function. Otherwise, this procedure is called thoracentesis.

Pathological contents of the pleural cavity may be:

— Transudate (non-inflammatory effusion) - fluid accumulating in the cavity due to impaired blood and lymph circulation. The formation of transudate occurs without inflammatory tissue changes. The most common causes of its formation include: heart failure, kidney and liver pathologies, and the process of metastasis in the chest cavity.

— Exudate - a liquid released into tissues or body cavities from small blood vessels during the inflammatory process. There are many reasons for its formation: pneumonia, pulmonary embolism, pleurisy, neoplasms, infectious diseases, etc.

The nature and volume of the pathological contents of the pleural cavity is determined by the doctor as a result of an x-ray examination, as well as directly during thoracentesis.

In what cases is a thoracentesis necessary?

• Thoracentesis is necessary in case of severe respiratory failure, which can develop in the following cases:
  • Acute injury accompanied by increasing pulmonary edema.
  • Chronic lung diseases.
  • Pleurisy (inflammation of the serous membranes covering the lungs and forming the pleural cavity, accompanied by the accumulation of exudate of various types).
  • Pneumothorax is the accumulation of air in the pleural cavity. Occurs as a result of chest injury or as a complication of treatment.

In cats, severe respiratory failure is observed when already 50 ml of liquid or air accumulates.

• Thoracentesis for diagnostic purposes to remove free fluid for analysis.

What is the significance of thoracentesis?

The pleural cavity is sealed and negative pressure is constantly maintained in it. This ensures a tight fit between the surface of the lungs and the pleura, allowing the lungs to fill with air. The normal breathing process occurs. When fluid (inflammatory exudate or non-inflammatory transudate, lymphatic effusion, blood) or air appears in the pleural cavity (for example, during injury), the pressure in the pleural cavity becomes positive and the normal breathing process is disrupted.

Thoracentesis removes fluid or air that is preventing the lungs from expanding. The ability of the lungs to fill with air is restored. The patient's condition with severe respiratory failure has stabilized.

Thoracentesis also has diagnostic value. Thanks to it, it is possible to determine the nature of the pathological contents of the lungs and recommend an appropriate set of therapeutic measures.

What are the contraindications for thoracentesis?

A contraindication for thoracentesis is coagulopathy - a blood clotting disorder. However, in case of severe respiratory failure, the procedure is performed, regardless of possible risks, for health reasons.

If the case is not an emergency, the doctor has time to adjust hemostatic parameters using vitamin K injections or blood plasma transfusions.

How is thoracentesis performed?

This procedure is usually well tolerated by animals and is performed without general anesthesia. In most cases, local anesthesia is sufficient. Sedatives are used if the patient is overly agitated or aggressive, or if there is a risk of worsening respiratory distress.

The optimal puncture site is selected depending on the results of an X-ray examination of the chest cavity. In case of atypical or heterogeneous distribution of the contents of the pleural cavity and in emergency cases, the puncture site is determined individually. Typically, thoracentesis is performed at the level of the seventh or eighth intercostal space on the right side. This is the safest place to insert needles. The position of the animal is determined individually - sitting, standing, lying down.

The needle insertion site is trimmed and sterilely processed.

The following is used as auxiliary equipment:

1) Butterfly or brownie catheter (intravenous catheter):

— 18-20 G for dogs of medium and large breeds weighing more than 10 kg,

— 20-22 G for small breed dogs and cats.

2) Three-way valve.

3) Syringes 10-50 ml depending on how much air or liquid is expected.

4) A container for collecting pleural fluid.

If it is necessary to obtain diagnostic material, the contents are sucked out with a syringe and transferred to a test tube or onto a glass slide.

Before starting the procedure, the skin must be moved to the side. At the end of the thoracentesis, the skin will return to its place and cover the entrance to the needle.

The needle or trocar is inserted first perpendicular chest wall to pierce the skin. Then, in order to get into the pleural cavity and avoid injury to the lung, it is moved parallel chest wall along the cranial (thick) edge of the rib, because On the caudal (sharp) edge there are intercostal vessels and nerves. The puncture depth ranges from 3 to 6 cm depending on the size of the animal. If necessary, a needle or catheter is secured to the chest using sutures and tape. To prevent air from entering, the inlet is sealed with Vaseline or aseptic ointment.

The absence of resistance indicates that the needle has entered the pleural cavity. It should be emptied slowly to avoid lung collapse (collapsing of the lung and preventing it from breathing). To do this, the rubber tube through which liquid or air is evacuated is clamped with hemostatic tweezers. You should not try to remove all the liquid, because... its remains are easily absorbed, unless of course we are talking about purulent pleurisy. In case of purulent pleurisy, the cavity must be washed with an aseptic solution 2-3 times until the sucked liquid becomes clear.

If clinical signs of respiratory failure recur, thoracentesis is performed again. After 3 or more repetitions, drainage is indicated. Drainage is also indicated in cases where it is difficult to evacuate viscous liquid through the needle. If a drain is installed, it must be protected with a bandage or collar to limit the animal's access to the puncture site.

At the end of the procedure, the skin is pressed against the chest wall and the trocar (needle) is removed. The wound is smeared with iodine and sealed with a piece of sterile bandage.

What complications can result from thoracentesis?

Possible complications include:

- Lung damage.

— Damage to the liver, spleen, heart sac or large vessels.

— Infection of the puncture site or pleural cavity if the rules of asepsis and antisepsis are not followed.

— Violation of the tightness of the pleural cavity and, as a consequence, impairment of respiratory function.

- Possible self-harm by animals.

Thoracentesis is a procedure that requires certain skills and abilities. But if it is carried out in compliance with all the rules, complications rarely occur.

If your pet has breathing problems, our experienced, highly qualified specialists at the Doctor Eye and Oh clinic will always help him! Your task is to bring your pet to the clinic on time, without hoping that it will “go away on its own.”

One of the problems in veterinary medicine in cats and dogs is diseases of the chest cavity, in which free fluid accumulates, resulting in respiratory failure and hemodynamic disturbances.

One of these diseases is chylothorax– pathological accumulation of lymph in the chest cavity.

Chylothorax has clinical, radiological and pathomorphological features of the manifestation of pathology similar to other types of diseases in which effusion occurs in the pleural cavity, a displacement of the mediastinum is created and an obstacle to the normal expansion of the lungs.

Among exudative pleurisy in cats and dogs, chylothorax ranges from 0.7 to 3%, and neoplastic and viral manifestations range from 12 to 64%.

There are several etiological and pathogenetic factors leading to the development of the disease.

Trauma is a rare cause chylothorax in cats and dogs, the thoracic duct is quickly restored, and effusions resolve without treatment within 10-15 days.

Chylothorax may occur due to diffuse lymphatic abnormalities, including intestinal lymphangiectasia or generalized lymphangiectasia with subcutaneous lymphatic leakage.

Dilatation of lymphatic vessels (thoracic lymphangiectasia) with exudation of lymph into the chest cavity may be a reaction to increased lymph formation in the liver or lymphatic pressure due to increased venous pressure.

Sometimes a combination of two factors is noted: an increase in lymph volume and a decrease in drainage into the venous collectors.

Possible causes of chylothorax are neoplasms in the cranial part of the mediastinum (lymphosarcoma, thymoma), fungal granulomas, venous thrombosis and congenital anomalies of the thoracic lymphatic duct.

In most animals, despite careful examination, the underlying cause of chylothorax remains unclear (idiopathic chylothorax).

Diagnosis and choice of treatment methods for sick animals with chylothorax still remains an urgent and difficult task.

In the domestic literature there is very little material devoted to the clinic, diagnosis (morphology), conservative and surgical treatment of chylothorax in dogs and cats.

Late diagnosis of the disease, and the existing tactics of an exclusively conservative approach to treatment of chylothorax with pronounced clinical manifestations, it leads to prolongation of the pathological process, the result of which will be the development of irreversible changes in the pleura of the lung (fibrosing pleurisy).

Standard methods of conservative (thoracentesis, anti-inflammatory therapy) and surgical (thoracoabdominal, thoracovenous drainage, pleurodesis, thoracic duct ligation) are currently promising methods for treating this pathology, but success (relapse-free course) is 40–60%.

The purpose of the work is to evaluate the results of surgical treatments for chylothorax using various methods.

Materials and methods. The material consisted of 60 animals (cats) diagnosed with chylothorax, and which were subjected to surgical treatment in the period from 2002 to 2010. Surgical treatment included: ligation of the thoracic lymphatic duct n-13, pleuroperitoneal shunting n-9, ligation + pleurodesis n-25.

In 13 animals, diagnostic thoracoscopy revealed fibrosing pleurisy and surgical treatment was refused.

All animals were subjected to clinical and additional diagnostic methods.

The clinical method of the study involved the collection of anamnestic data on the timing and duration of manifestations of breathing disorders.

Particular attention was paid to visual assessment of the external manifestations of disturbances in the respiratory movements of the chest, the degree and type of shortness of breath.

Clinical manifestations of the disease at almost all stages were characterized by: difficulty breathing and shortness of breath - the main symptom of effusion into the pleural cavity. Dry non-productive cough.

Additional research methods included thoracentesis, radiography, morphological examination of the material obtained from the chest cavity, clinical and biochemical blood tests, ECG, ECHO CG, and thoracoscopy.

X-ray examination of animals

X-ray examination of the chest cavity was performed using two mutually perpendicular projections, lateral and direct (dorso-ventral).

Typically, the x-ray picture was characterized by total darkening with characteristic signs of the presence of fluid in the chest cavity and caudo-dorsal displacement of the caudal lobes of the lungs. The shadow of the heart silhouette is partially or completely erased, the usual sharp angles of the costophrenic junction are absent (Fig. 1a, b).

Thoracentesis and differential morphological examination

Thoracentesis (pleural puncture) was performed for diagnostic and therapeutic purposes.

Pleural puncture was performed in the 7-8th intercostal space along the line of the osteochondral junction on the left and right, focusing on the cranial edge of the next rib.

After pleural puncture, the pathological contents of the pleural cavity were evacuated and subjected to subsequent examination.

In case of chylothorax, transudate was determined to be milky white or mixed with a small amount of blood. During centrifugation, the exudate generally did not form a sediment (the sediment is represented by blood elements); a biochemical study indicated a large amount of triglycerides characteristic of chylothorax.

Separately differentiated from pseudochylous effusions (rarely found in animals) by the content of cholesterol and triglycerides.

All punctures from the pleural cavity were subjected to microscopic cytological examination, where purulent and neoplastic processes were excluded.

Thoracoscopy was performed under general anesthesia for detailed visualization of the condition of the lungs and neoplasms in the cranial mediastinum. (Fig. 2).
Surgical treatment

Surgical treatment of chylothorax involved surgical intervention under conditions of general anesthesia and artificial ventilation, both open and endoscopic (thoracoscopy).

Pleuroperitoneal (passive) shunting Operation stages:

3. Using a linear approach from the middle of the chest in the caudal direction to the umbilical region, the skin, subcutaneous tissue, and muscles were dissected. An entrance to the thoracic region was provided through the angle of the diaphragm in the area of ​​the xiphoid process. The perihepatic space was freed from adipose tissue and omentum. Silicone drainage was implanted to the communication between the chest and abdominal cavities, followed by fixation of the drainage in the tissues of the diaphragm. The surgical wound was sutured in layers (Fig. 3 a, b).

The purpose of this technique is to create a message and the possibility of outflow of chylous exudate into the abdominal cavity, where it is subsequently absorbed and lymph is recirculated in the body.

Pleurodesis

Operation stages:

1. Fixing the animal on its back.

2. Treatment of the surgical field using generally accepted methods.

3. A mini-access in the area of ​​the xiphoid process is used to access the chest cavity; depending on the stage of the pathological process, partial pleurectomy or targeted treatment with chemicals is carried out under endoscopic control.

The purpose of this surgical intervention is to create adhesive inflammation of the lungs in an expanded state.

Open ligation of the thoracic lymphatic duct

Operation stages:

1. Fixation of the animal in a lateral position.

2. Treatment of the surgical field using generally accepted methods.

3. Access was made to the chest cavity on the left or right in the area of ​​the 8-10 intercostal space with layer-by-layer dissection of tissue (skin, subcutaneous tissue, muscles). After access to the chest cavity, surgical access to the abdominal cavity was carried out nearby, a part of the mesentery and intestine was isolated for the purpose of lymphography using a visceral lymphatic collector.

4. Lymphography was performed with a 1% solution of methylene blue with a volume of no more than 0.5 ml injected into the lymphatic vessel. The contrast agent entered the lumbar cistern and stained the thoracic lymphatic duct (Fig. 4a, b).

Under visual control, a ligature made of non-absorbable suture material Prolene 4-0, 5-0 was applied to the visible thoracic lymphatic duct through the access of the thoracic cavity. The surgical wound was sutured in layers.

The purpose of this technique was to stop the flow of lymph through the thoracic lymphatic duct into the chest cavity.

Closed ligation of the thoracic lymphatic duct

Unlike open ligation, closed method involves ligation of the thoracic lymphatic duct using the endoscopic method (thoracoscopy) without wide access to the chest cavity (Fig. 5a, b, c).

Thoracic duct ligation and pleurodesis

This type of surgical intervention involves the simultaneous use of two of the above-described techniques - ligation and pleurodesis.

The purpose of this technique is to combine two methods: stopping the flow of lymph through the thoracic lymphatic duct into the chest cavity and creating an adhesive inflammation of the lung and parietal pleura. After which the lung assumes a straightened position in the chest cavity, and in cases of recurrent chylothorax, the possibility of its collapse is reduced. The risk of respiratory failure is sharply reduced.

We used open and endoscopic ligation of the thoracic lymphatic duct.

Postoperative treatment included monitoring the possible consequences of thoracic surgery. Conducting a course of antibiotic and anti-inflammatory therapy. The course of antibiotic therapy was five days, the sutures were removed on the tenth day, after endoscopic manipulation on the third.

Result and discussion

In assessing the results of treatment, great importance was given to data from subsequent clinical observation of operated animals over a period of ten days to one and a half years. (see table).

Results and methods of surgical treatment. Table

The criteria were not only the clinical condition, but also radiographic methods (Fig. 6a, b.).

The prognosis for chylothorax, according to many authors, is extremely restrained. When choosing treatment methods, they study the cause of the disease and begin treatment with conservative therapy methods; in the absence of positive results, they proceed to surgery. We have not achieved long-term positive drug treatment in any animal.

In our opinion, the beginning of surgical treatment is rather arbitrary, and the timing of the development of fibrosing pleurisy is unpredictable. In some cases, we noted the development of fibrosing pleurisy two to three weeks after the onset of clinical signs and did not see them after five months of the disease (video, Fig. 7).

According to our observations, the isolated method of ligation of the thoracic lymphatic duct recurred in six cases; in two animals, repeated surgical intervention was performed to the extent of ligation and pleurodesis (Fig. 8a, b).

The surgical method of bypassing the chest and abdominal cavity was usually complicated by catheter occlusion after surgery. Another disadvantage is the reverse flow of contents when using valveless catheters.

The most effective method was a combination of ligation and pleurodesis. The rehabilitation period was slightly reduced in animals that underwent endoscopic ligation using thoracoscopic techniques when applying a ligature to the thoracic lymphatic duct.

Conclusions. According to our observations, true chylothorax in cats does not respond to conservative therapy. The presented results of surgical methods for treating chylothorax in cats allow us to draw conclusions about the need for surgical treatment. The use of combined surgical methods makes it possible to achieve complete or long-term remission of the disease.

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