Article

Surgical management and outcome of dogs with primary spontaneous pneumothorax: 110 cases (2009-2019)

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Abstract

Objective: To describe surgical management and associated outcomes for dogs with primary spontaneous pneumothorax. Animals: 110 client-owned dogs with primary spontaneous pneumothorax that underwent surgical management. Procedures: Medical records at 7 veterinary teaching hospitals were reviewed. Data collected included signalment, history, clinical signs, radiographic and CT findings, surgical methods, intraoperative and postoperative complications, outcomes, and histopathologic findings. Follow-up information was obtained by contacting the referring veterinarian or owner. Results: 110 dogs were included, with a median follow-up time of 508 days (range, 3 to 2,377 days). Ninety-nine (90%) dogs underwent median sternotomy, 9 (8%) underwent intercostal thoracotomy, and 2 (2%) underwent thoracoscopy as the sole intervention. Bullous lesions were most commonly found in the left cranial lung lobe (51/156 [33%] lesions) and right cranial lung lobe (37/156 [24%] lesions). Of the 100 dogs followed up for > 30 days, 13 (13%) had a recurrence of pneumothorax, with median time between surgery and recurrence of 9 days. Recurrence was significantly more likely to occur ≤ 30 days after surgery, compared with > 30 days after surgery. Recurrence > 30 days after surgery was rare (3 [3%]). No risk factors for recurrence were identified. Conclusions and clinical relevance: Lung lobectomy via median sternotomy resulted in resolution of pneumothorax in most dogs with primary spontaneous pneumothorax. Recurrence of pneumothorax was most common in the immediate postoperative period, which may have reflected failure to identify lesions during the initial thoracic exploration, rather than development of additional bullae.

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Novel approaches and innovations in small animal thoracoscopy are being rapidly developed; this article aims to describe recent updates in commonly performed thoracoscopic procedures, including lung lobectomy, pericardiectomy and pericardial and cardiac neoplasia evaluation, chylothorax treatment, cranial mediastinal mass resection, persistent right aortic arch treatment, and management of pyothorax and primary spontaneous pneumothorax.
Chapter
Medical thoracoscopy is a term that gained popularity in the early 2000s to distinguish diagnostic thoracoscopy from video-assisted thoracoscopic surgery (VATS). The phrase diagnostic thoracoscopy is a fitting equivalent of medical thoracoscopy in the veterinary field, indicating endoscopic exploration of the pleural cavities for evaluation of pleural pathology, which may then lead to therapeutic intervention through VATS. The shape of the small animal thorax is dramatically different from that of humans. Thus, the primary indications for diagnostic thoracoscopy in small animals are non-chylous exudative or modified transudate pleural effusions and spontaneous pneumothorax. Preoperative thoracic imaging is critical when considering diagnostic thoracoscopy. Rigid endoscopes have historically been used for thoracoscopy; they carry the advantage of less image distortion and ease of use compared to flexible endoscopes. Careful manipulation of pulmonary parenchyma is required for diagnostic thoracoscopy. One of the major complications associated with diagnostic thoracoscopy includes failure to identify an underlying etiology.
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This review article will review treatment and prognosis of spontaneous pneumothorax in dogs and cats. The advantages of surgical and medical management in dogs and cats, as well as current treatment practices, including autologous blood pleurodesis and small-bore chest tubes, will be discussed.
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Objective: To evaluate reporting of surgical complications and other adverse events in clinical research articles describing soft tissue and oncologic surgery in dogs and cats. Study design: Systematic literature review. Sample: English-language articles describing soft tissue and oncologic surgeries in client-owned dogs and cats published in peer-reviewed journals from 2013 to 2016. Methods: CAB, AGRICOLA, and MEDLINE databases were searched for eligible articles. Article characteristics relevant to complications were abstracted and summarized, including reported events, definitions, criteria used to classify events according to severity and time frame, and relevant citations. Results: One hundred fifty-one articles involving 10 522 animals were included. Canine retrospective case series of dogs predominated. Ninety-two percent of articles mentioned complications in study results, but only 7.3% defined the term complication. Articles commonly described complications according to time frame and severity, but terminology and classification criteria were highly variable, conflicting between studies, or not provided. Most (58%) reported complications could have been graded with a published veterinary adverse event classification scheme, although common intraoperative complications were notable exceptions. Conclusion: Definitions and criteria used to classify and report soft tissue and oncologic surgical complications are often absent, incomplete, or contradictory among studies. Clinical significance: Lack of consistent terminology contributes to inadequate communication of important information about surgical complications. Standardization of terminology and consistency in severity scoring will improve comparative evaluation of clinical research results.
Article
Objective To evaluate the long‐term outcome of video‐assisted thoracoscopic (VATS) thoracic duct ligation (TDL) and pericardectomy for treatment of chylothorax in dogs. Study design Multi‐institutional retrospective study. Animals Thirty‐nine client‐owned dogs. Methods Dogs were included if they had undergone a VATS TDL and pericardectomy and had at least 1‐year follow‐up or had died within 1 postoperative year. Medical records were evaluated, and recorded data included clinicopathological and diagnostic imaging results, surgical findings, complications, conversion rates, and long‐term resolution and recurrence rates. Results Thirty‐nine dogs met the inclusion criteria. Two dogs died intraoperatively; 1 was euthanized after severe restrictive pleuritis was diagnosed intraoperatively, and 1 underwent ventricular fibrillation and cardiac arrest during pericardectomy and could not be resuscitated. Conversion to an open approach was required in 1 of 39 (3%) dogs for TDL and 4 of 36 (11%) dogs for pericardectomy. Overall follow‐up time was median 38 months (range, 3‐115). Resolution of pleural effusion occurred in 35 of 37 (95%) dogs that survived the perioperative period. Late recurrence of pleural effusion was seen at 12, 12, and 19 months postoperatively in 3 of 35 (9%) dogs that survived the perioperative period and in which chylothorax had initially resolved. Conclusion Successful long‐term resolution of chylothorax was seen in a high proportion of dogs that underwent VATS TDL and pericardectomy, although late recurrence was sometimes seen. Clinical significance Video‐assisted thoracoscopic thoracic duct ligation and pericardectomy are highly successful in dogs with chylothorax. Future studies should evaluate whether pericardectomy is required in dogs without evidence of pericardial disease.
Article
Objective To determine the agreement between focused assessment with sonography for trauma (FAST) exams and computed tomography (CT) for the detection of pleural and peritoneal fluid and pneumothorax in animals that have sustained recent trauma. Design Prospective study. Setting University Teaching Hospital. Animals Thirteen dogs and 2 cats were enrolled into the study, with 10 having sustained blunt force trauma and 5 penetrating trauma. Interventions Abdominal FAST (AFAST) and thoracic FAST (TFAST) exams were performed by emergency room (ER) clinician or house officers and radiology house officers (radiology). TFAST evaluated for the presence of pneumothorax and pleural effusion, and AFAST evaluated for the presence of peritoneal effusion. A minimally sedated, full‐body CT exam was performed on each patient and interpreted by a board‐certified radiologist. The exams were performed in the same order for all patients: ER FAST, followed by radiology FAST, followed by CT, and operators were blinded to the results of the other exams. A kappa statistic was calculated to assess for agreement between the FAST exams and CT. Measurements and Main Results The median time to perform all 3 exams was 55 minutes (range 30–150 min). There was moderate to excellent agreement between AFAST and CT for detection of free peritoneal fluid (ER K = 0.82; radiology K = 0.53), fair to moderate agreement between TFAST and CT for detection of pleural free fluid (ER K = 0.53; radiology K = 0.36), and poor agreement between TFAST and CT for detection of pneumothorax (ER K = –0.06; radiology K = –0.12). Conclusions FAST exams reliably identify the presence of free fluid in the peritoneal and pleural cavities; however, TFAST is not a reliable method to diagnose pneumothorax in dogs and cats following trauma.
Article
Objective To describe the operative findings and clinical outcome in dogs undergoing video-assisted thoracic surgery (VATS) for treatment of spontaneous pneumothorax and pulmonary bullae. Study DesignMulti-institutional retrospective case series. AnimalsDogs (n=12) with spontaneous pneumothorax and/or pulmonary bullae. Methods Medical records (2008-2013) were reviewed for signalment, clinical signs, diagnostic imaging, surgical and histopathologic findings, and outcome in 12 dogs that had VATS for treatment of spontaneous pneumothorax and pulmonary bullae. In particular, conversion to median sternotomy and surgical success were evaluated. ResultsTwelve dogs had initial VATS for spontaneous pneumothorax and/or pulmonary bullae. Conversion to median sternotomy because of inability to identify a parenchymal lesion/leak was necessary in 7 (58%) dogs. VATS without conversion to median sternotomy was performed in 6 (50%) dogs. Successful surgical outcomes occurred in 5 (83%) dogs that had conversion to median sternotomy, and in 3 (50%) dogs that had VATS without conversion to median sternotomy. Conclusions Exploratory thoracoscopy was associated with a high rate of conversion to median sternotomy because of inability to identify leaking pulmonary lesions in dogs with spontaneous pneumothorax and pulmonary bullae. Failure to convert to a median sternotomy may be associated with recurrent or persistent pneumothorax.
Article
IntroductionThe aim of this study was to compare the diagnostic performances of multi-detector computed tomography (MDCT) reconstruction at two different slice thicknesses (1 mm, ‘high resolution’ vs. 5 mm, ‘routine’) with respect to the detection of blebs and bullae (BBs) in patients with primary spontaneous pneumothorax (PSP).Methods Thirty-one patients underwent wedge resection of BBs (29 unilateral and 2 bilateral) for PSP from January 2010 to January 2013. Two observers assessed the presence and locations of BBs independently using high-resolution CT (HRCT) and routine CT reconstruction, and compared the sensitivities of each reconstruction method for BB detection using operative findings as a standard reference. In addition, the number of BBs in each CT image set was recorded and inter-observer agreements were evaluated.ResultsSensitivity for the detection of BBs was significantly better for HRCT than routine CT (97.0% vs. 63.6% for observer 1 and 94.0% vs. 57.6% for observer 2, respectively, both P-values < 0.001). On a per-bleb and a per-bulla basis, inter-observer agreements regarding BBs by HRCT were good and very good (k = 0.66 and 0.94, respectively) and superior to those determined by routine CT (k = 0.59 and 0.60, respectively).Conclusion Different slice thickness reconstructions influence the diagnostic efficacy of MDCT for the detection of BBs in patients with PSP. High-resolution thin slice CT reconstruction was found to have a significantly greater sensitivity than routine thicker slice thickness reconstruction for the detection of BBs.
Article
Objective: To describe clinicopathologic features of dogs that underwent lung lobectomy for resection of primary lung tumors via video-assisted thoracoscopic surgery (VATS) or open thoracotomy (OT) and to compare short-term outcomes for dogs following these procedures. Design: Retrospective cohort study. Animals: 46 medium- to large-breed dogs with primary lung tumors. Procedures: Medical records of dogs that underwent a lung lobectomy via VATS (n = 22) or OT (24) for resection of primary lung tumors between 2004 and 2012 were reviewed. Dogs were included if they weighed > 10 kg (22 lb) and resection of a primary lung tumor was confirmed histologically. Tumor volumes were calculated from preoperative CT scans where available. Surgical time, completeness of excision, time in the ICU, indwelling thoracic drain time, postoperative and total hospitalization time, incidence of major complications, and short-term survival rate were evaluated. Results: VATS was performed with a 3-port (n = 12) or 4-port (10) technique and 1-lung ventilation (22). In 2 of 22 (9%) dogs, VATS was converted to OT. All dogs survived to discharge from the hospital. There were no significant differences between the VATS and OT groups with regard to most variables. Surgery time was significantly longer for VATS than for OT (median, 120 vs 95 minutes, respectively). Conclusions and clinical relevance: In medium- to large-breed dogs, short-term outcomes for dogs that underwent VATS for lung lobectomy were comparable to those of dogs that underwent OT. Further studies are required to evaluate the effects of surgical approach on indices of postoperative pain and long-term outcomes.
Article
Objective: To determine the sensitivity, positive predictive value, and interobserver variability of CT in the detection of bullae associated with spontaneous pneumothorax in dogs. Design: Retrospective case series. Animals: 19 dogs with spontaneous pneumothorax caused by rupture of bullae. Procedures: Dogs that had CT for spontaneous pneumothorax caused by rupture of bullae confirmed at surgery (median sternotomy) or necropsy were included. Patient signalment, CT protocols, and bulla location, size, and number were obtained from the medical records. Computed tomographic images were reviewed by 3 board-certified radiologists who reported on the location, size, and number of bullae as well as the subjective severity of pneumothorax. Results: Sensitivities of the 3 readers for bulla detection were 42.3%, 57.7%, and 57.7%, with positive predictive values of 52.4%, 14.2%, and 8.4%, respectively, with the latter 2 readers having a high rate of false-positive diagnoses. There was good interobserver agreement (κ = 0.640) for correct identification of bullae. Increasing size of the bulla was significantly associated with a correct CT diagnosis in 1 reader but not in the other 2 readers. Correct diagnosis was not associated with slice thickness, ventilation protocol, or degree of pneumothorax. Conclusions and clinical relevance: Sensitivity and positive predictive value of CT for bulla detection were low. Results suggested that CT is potentially an ineffective preoperative diagnostic technique in dogs with spontaneous pneumothorax caused by bulla rupture because lesions can be missed or incorrectly diagnosed. Bulla size may affect visibility on CT.
Article
Background This retrospective, single-center study was designed to assess our management strategy based on blebs detection on the initial CT scan. Methods Children younger than aged 18 years presenting with a primary spontaneous pneumothorax (PSP) between 2000 and 2007 in a University Children’s Hospital (hospital Armand Trousseau, Paris, France) were included in this study. Results Twenty-five children who presented with PSP were included. The mean age was 14.2 ± 1.9 years, and the sex ratio was 2.1. There was no significant difference between patients with or without blebs with regard to the anthropomorphic data or the side of the pneumothorax. Six patients had recurrence, which, in most cases, was a grade 1 pneumothorax. Fourteen (56%) children showed blebs on CT scan, which was ipsilateral or bilateral in 13 cases and contralateral in 1 case. Eleven of these children had surgery, and all the remaining patients (n = 3) had recurrence. All the patients, except one, presenting blebs on the preoperating CT scan, showed blebs on the subsequent surgery (predictive positive value = 92%), and the CT-scan sensibility for blebs was 75%. Conclusions In children, blebs detection on CT scan has a good sensitivity and may be a useful tool to determine the indication of lung surgery to prevent PSP recurrence.
Article
A severity grading system is essential to reporting surgical complications. In 1992, we presented such a system (T92). Its use and that of systems derived from it have increased exponentially. Our purpose was to determine how well T92 and its modifications have functioned as a severity grading system and to develop an improved system for reporting complications. 129 articles were studied in detail. Twenty variables were searched for in each article with particular emphasis on type of study, substitution of qualitative terms for grades, grade compression, and cut-points if grade compression was used. We also determined relative distribution of complications and manner of presentation of complications. T92 and derivative classifications have received wide use in surgical studies ranging from small studies with few complications to large studies of complex operations that describe many complications. There is a strong tendency to contract classifications and to substitute terms with self evident meaning for the numerical grades. Complications are presented in a large variety of tabular forms some of which are much easier to follow than others. Current methods for reporting the severity of complications incompletely fulfill the needs of authors of surgical studies. A new system-the Accordion Severity Grading System-is presented. The Accordion system can be used more readily for small as well as large studies. It introduces standard definition of simple quantitative terms and presents a standard tabular reporting system. This system should bring the field closer to a common severity grading method for surgical complications.
Article
Advantages of thoracoscopic lobectomy include less postoperative pain, shorter hospitalization, and improved delivery of adjuvant chemotherapy. The incidence of postoperative complications has not been thoroughly assessed. This study analyzes morbidity after lobectomy to compare the thoracoscopic approach and thoracotomy. By using a prospective database, the outcomes of patients who underwent lobectomy from 1999-2009 were analyzed with respect to postoperative complications. Propensity-matched groups were analyzed based on preoperative variables and stage. Of the 1079 patients in the study, 697 underwent thoracoscopic lobectomy, and 382 underwent lobectomy by means of thoracotomy. In the overall analysis thoracoscopic lobectomy was associated with a lower incidence of atrial fibrillation (P = .01), atelectasis (P = .0001), prolonged air leak (P = .0004), transfusion (P = .0001), pneumonia (P = .001), sepsis (P = .008), renal failure (P = .003), and death (P = .003). In the propensity-matched analysis based on preoperative variables, when comparing 284 patients in each group, 196 (69%) patients who underwent thoracoscopic lobectomy had no complications versus 144 (51%) patients who underwent thoracotomy (P = .0001). In addition, thoracoscopic lobectomy was associated with a lower incidence of atrial fibrillation (13% vs 21%, P = .01), less atelectasis (5% vs 12%, P = .006), fewer prolonged air leaks (13% vs 19%, P = .05), fewer transfusions (4% vs 13%, P = .002), less pneumonia (5% vs 10%, P = .05), less renal failure (1.4% vs 5%, P = .02), shorter chest tube duration (median of 3 vs 4 days, P < .0001), and shorter length of hospital stay (median of 4 vs 5 days, P < .0001). Thoracoscopic lobectomy is associated with a lower incidence of major complications, including atrial fibrillation, compared with lobectomy by means of thoracotomy. The underlying factors responsible for this advantage should be analyzed to improve the safety and outcomes of other thoracic procedures.
Article
To compare results of surgical versus nonsurgical treatment of spontaneous pneumothorax in dogs. Retrospective study. 64 dogs with pneumothorax without any history of antecedent trauma. Information on signalment, thoracic radiographic findings, treatment, histologic findings, and outcome was obtained from the medical records. Signalment of affected dogs was compared with signalment of a control population of 260 dogs examined by the emergency service for reasons other than pneumothorax during the study period. Siberian Huskies were overrepresented in the case population, compared with the control population of dogs examined by the emergency service for other reasons. Twenty-eight dogs were treated without surgery (ie, thoracocentesis or tube thoracostomy with or without cage rest), and 36 were treated with surgery. Information regarding final outcome was available for 33 dogs treated with surgery (median follow-up time, 485 days) and 15 dogs treated without surgery (median follow-up time, 366 days). Dogs that underwent surgery had significantly lower recurrence (1/30) and mortality (4/33) rates, compared with dogs treated without surgery (6/12 and 8/15, respectively). A definitive diagnosis was obtained for 38 dogs, including 34 of 36 dogs undergoing surgery; 26 had bullous emphysema and 4 had neoplasia. Two dogs developed spontaneous pneumothorax secondary to migration of plant foreign bodies. Results suggest that recurrence and mortality rates for dogs with spontaneous pneumothorax managed surgically were significantly lower than rates for dogs managed by nonsurgical means alone. Early surgical intervention is recommended for definitive diagnosis and treatment of dogs with spontaneous pneumothorax.
Article
Spontaneous pneumothorax caused by pulmonary blebs and bullae was diagnosed in 12 dogs based on history, clinical examination, thoracic radiographs, surgical findings, and histopathological examination of resected pulmonary lesions. Radiographic evidence of blebs or bullae was seen in only one dog. None of the dogs responded to conservative treatment with thoracocentesis or thoracostomy tube drainage. A median sternotomy approach was used to explore the thorax in all dogs. Pulmonary blebs and bullae were resected with partial or complete lung lobectomy. Ten of the dogs had more than one lesion, and seven of the dogs had bilateral lesions. The cranial lung lobes were most commonly affected. Histopathology results of the blebs and bullae were consistent in all dogs and resembled lesions found in humans with primary spontaneous pneumothorax. None of the dogs developed recurrence of pneumothorax. Median follow-up time was 19 months. The outcome following resection of the pulmonary blebs and bullae was excellent.
Article
To report thorascopic partial lobectomy for treatment of bullous emphysema in dogs. Prospective clinical study. Three dogs with spontaneous pneumothorax. 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. 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. Identification and ablation of bulla can be performed thoracoscopically without pulmonary exclusion in dogs. 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.
Article
To evaluate use of computed tomography (CT) of the lungs, compared with conventional radiography, for detection of blebs and bullae associated with spontaneous pneumothorax in dogs. Retrospective case series. 12 dogs with spontaneous pneumothorax. Medical records were reviewed, and information was collected that included signalment, body weight, initial owner complaint, laboratory findings, radiographic findings, CT findings, medical and surgical treatment, histologic findings, complications, duration of hospitalization, and final outcome. Radiographs were excellent for identifying pneumothorax (sensitivity, 100%) but poor for identifying the underlying cause (bullae or blebs); these were identified in radiographs of only 2 of 12 dogs. Computed tomography allowed identification of bullae or blebs in 9 of 12 dogs. Ten of the 12 dogs were treated via surgery, and 17 affected lung lobes were identified. Four of the 17 affected lobes were identified via radiography. Thirteen of the 17 affected lobes were identified via CT; however, 1 lobe was incorrectly identified as the right caudal lobe instead of the right cranial lobe. Results suggested that CT is better than radiography for identifying the underlying causes of spontaneous pneumothorax.
Article
To evaluate the factors influencing the short-term (<14 days) outcome of thoracic surgery in dogs. A retrospective review of 98 dogs undergoing thoracotomy over a five-year period was undertaken. A pre-operative diagnosis was achieved in 69 per cent of cases. Intrathoraic neoplasia had the lowest pre-operative diagnosis rate (5.5 per cent). Mortality rates of 21 per cent were recorded and were significantly higher for intrathoracic neoplasia (50 per cent) and significantly lower for persistent ductus arteriosus (7.4 per cent) and vascular ring anomaly (0 per cent). Median sternotomy was the preferred approach for pyothorax (85 per cent) and penetrating thoracic injuries (66 per cent). Intercostal thoracotomy was the preferred approach for all other diseases. Postoperative complications occurred in 39 per cent of cases. Wound complications were more common for pyothorax (45 per cent) and following median sternotomy (71 per cent). Thoracic drains were placed in 77 per cent of cases and complications were recorded in 23 per cent. Pyothorax and chylothorax had thoracic drains maintained for significantly longer periods of time. Longer thoracic drain duration was correlated significantly with increased complication rates. The short-term outcome following thoracic surgery is influenced by diagnosis. The thoracic approach is determined by intrathoracic disease, but may influence outcome by affecting the incidence of postoperative wound complications. The risk of thoracic drain complications increases with drain duration, which is influenced by the underlying disease. Drains should be maintained for the minimal amount of time possible.
Article
Spontaneous pneumothorax (SPTX) is a relatively common condition. In patients with SPTX, CT has been advocated to identify blebs and bullae (BB) to help in management planning. The study was designed to assess our experience with CT evaluation for underlying BB in children with SPTX as compared to normal controls. Forty-three children (mean age 16 years, range 13-19 years) with 50 SPTX events with both chest radiographs and CT scans were reviewed. CT findings were compared with those seen in 29 age- and gender-matched controls without SPTX. The parameters evaluated included size, number, location, and ipsi-/contralateral BB; apical lines; and surgical correlation. In the study group, BB were identified in 14 imaged events (28%) (size 2.5-45 mm, one to six BB) with contralateral BB in 11 of the 14 (78.6%). All BB were confined to the apices. BB were sometimes difficult to differentiate from "apical lines"--a suspected normal variant seen in 28 imaged events (56%). Of blebs seen at surgery, 59% were identified on CT, and there were no false-positive CT findings. In the control group, no BB were identified but "apical lines" were seen in eight children (28%). BB were seen by CT in 28% of imaged events in children with SPTX and were always confined to the apices. When present, BB were commonly bilateral (78.6%). BB should not be confused with "apical lines," which were not only seen in 56% of imaged events in the SPTX group but also in 28% of the normal controls.
Use of computed tomography for evaluation of lung lesions associated with spontaneous pneumothorax in dogs: 12 cases
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Long-term outcome of video-assisted thoracic duct ligation and pericardectomy in dogs with chylothorax: a multi-institutional study of 39 cases
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Thoracoscopic treatment of bullous emphysema in 3 dogs
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