1 Pneumonectomy in Dogs and Cats

2
3 Outcome after pneumonectomy in 17 dogs and 10 cats: A Veterinary Society of
4 Surgical Oncology Retrospective Study
5
6
7
8 Wavreille V1, Boston SE1, Souza C1, Ham K2, Chanoit G3, Rossetti D4, Takacs J5,
9 Milner R1
10
11
12

13 Department of Veterinary Clinical Sciences, College of Veterinary Medicine,

1

14 University of Florida, Gainesville, FL

15
16 2
Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Ohio
17 State University, Columbus, OH
18
19 School of Veterinary Sciences & Bristol CardioVascular, University of Bristol,
3

20 University of Bristol, Langford, UK

21
22 4
Small Animal Surgery Department, Centre Hospitalier Vétérinaire Frégis, Arcueil,
23 France
24
25 Department of Veterinary Clinical Sciences, College of Veterinary Medicine,
5

26 University of Pennsylvania, Philadelphia, PA

27
28

29
30
31
32
33
34
35
36
37
38

1
39 ABSTRACT
40 Objective: (1) To report signalment and outcome data from dogs and cats undergoing
41 pneumonectomy; and (2) to document presenting clinical signs, surgical
42 complications, histologic diagnosis, and postoperative complications.
43 Study Design: Retrospective, multicenter study.
44 Sample Population: Seventeen dogs and ten cats.
45 Methods: Signalment, clinical signs, side affected, surgical data, pre-operative
46 diagnostic tests (including complete blood count, serum biochemistry, cytological
47 diagnosis, chest radiographs and computed tomography), histopathologic diagnosis,
48 surgical complications, adjunctive therapy, and date and cause of death were collected
49 from records of dogs and cats that underwent pneumonectomy. Survival estimates,
50 and complication were assessed.
51 Results: Seventeen patients had a left-sided pneumonectomy performed (12 dogs
52 and 5 cats) and ten patients had a right-sided pneumonectomy (5 dogs and 5 cats).
53 Fourteen patients were diagnosed with neoplasia (52%). The overall incidences of
54 complications were 76% and 80% for dogs and cats, respectively. The incidences of
55 major complications were 41% and 50% for dogs and cats, respectively. Respiratory
56 complications (persistent pleural effusion, oxygen dependence, persistent increased
57 respiratory rate or coughing) were the most commonly reported complications. No
58 patients died or were euthanized intraoperatively or within the first 24 hours post
59 operatively. However, one dog (6%) and 2 cats (20%) died or were euthanized in the
60 first 2 weeks post-operatively.

61 Conclusion: Based on this small cohort, right and left pneumonectomy can be
62 performed with a relatively low perioperative mortality rate in dogs and cats, with
63 some animals experiencing prolonged survival.
64

2
65
66 INTRODUCTION

67

68 Pneumonectomy, defined as surgical excision of the entire left or right lung, is an

69 uncommonly performed procedure in veterinary surgery. A small number of reports

70 have described outcome after pneumonectomy in companion animals 1-4 and two of

71 these reports were not directly focused on the clinical outcome: one study 3 assessed

72 the impact of the procedure on the right-side of the heart and the second report was

73 focused on the anesthesia and perioperative management of a pneumonectomized

74 dog.4 Factors associated with perioperative mortality, complications or successful

75 outcome remain largely unknown in dogs and cats.

76

77 This procedure has also been reported in clinically normal research dogs. Because of

78 the differential in lung volume between the right and left lung, it has been reported

79 that removal of more than 60% of the lung volume can lead to potentially fatal

80 pulmonary hypertension.5,6 A left-sided pneumonectomy is considered to be better

81 tolerated as the left lung represent 42% of the lung volume. 6 It has also been

82 suggested that in some slow and progressive disease processes, a right

83 pneumonectomy is a possible treatment option because of compensation of the

84 remaining functional lung.2,6 Experimental studies performed in healthy dogs showed

85 increased pulmonary vascular resistance and right ventricular hypertrophy after left

86 pneumonectomy but pulmonary arterial pressure remained within the normal

87 reference range.7,8 There is also evidence of compensation via more efficient oxygen

88 transport across the alveoli after pneumonectomy exceeding 50% of the lung volume.

89 This has been explained by three principal mechanisms: recruitment of physiologic

3
90 reserves of diffusing capacity, remodeling of the existing alveolar-capillary network,

91 and new or regenerative alveolar-capillary growth.8-12

92

93 In contrast to veterinary medicine, outcome following pneumonectomy in humans is

94 reported in numerous studies.13-15 It is associated with a high morbidity and mortality

95 rate in people13. Three recent studies reported a 30 day mortality rate of 5.1%13, 14 and

96 5.7%15 in pneumonectomy patients operated for cancer. Rivera et al reported a

97 postoperative in-hospital mortality rate of 22.1% for pneumonectomy patients treated

98 for benign disease.13 In a recent review,16 morbidity rates between 25 to 60% were

99 reported. The primary indication for pneumonectomy in human medicine is the

100 treatment of lung cancer.13 In the 14 cases in the veterinary literature, seven were

101 treated for neoplasia.1-4

102

103 Because pneumonectomy is uncommonly performed in veterinary medicine,

104 information about the procedure, success-rate and complications are lacking.

105 Our aims in this retrospective, multi-institutional Veterinary Society of Surgical

106 Oncology (VSSO) study were: (1) to report signalment and outcome data from a

107 relatively large number of dogs and cats undergoing pneumonectomy; and (2) to

108 document presenting clinical signs, histologic diagnosis, potential prognostic factors,

109 and complications. We hypothesized that right and left pneumonectomies are not

110 associated with a poor outcome.

111

112

113

4
114 MATERIAL AND METHODS

115

116 This study was approved by the Veterinary Society of Surgical Oncology (VSSO)

117 research committee and was initiated by requesting case submissions from VSSO

118 members through the VSSO list-serve. Medical records from contributing institutions

119 were searched to identify dogs and cats that had had pneumonectomy. Inclusion

120 criteria for this study were dogs and cats underwent pneumonectomy between 2004

121 and 2014 for neoplastic and non-neoplastic causes. Cases were excluded if there was

122 not a histopathological diagnosis of the underlying disease and if a subtotal

123 pneumonectomy was performed, defined as preservation of one or more lung lobes on

124 the affected side. Data retrieved included: sex, breed, age, weight, clinical signs, side

125 affected, surgical data (including surgical approach, method for lobectomy, and

126 whether or not tracheobronchial lymph nodes were removed), preoperative diagnostic

127 tests (including complete blood count, serum biochemistry, cytologic diagnosis,

128 thoracic radiographs and computed tomography (CT), histopathologic diagnosis,

129 perioperative and postoperative surgical complications, reason for performing a

130 pneumonectomy if not planned prior to surgery, adjunctive therapy if any, and date

131 and cause of death. Animals were classified by the underlying disease as having

132 neoplastic or non-neoplastic disease as the reason for pneumonectomy. Complications

133 were classified in 2 groups: major and minor complications. They were also evaluated

134 as intraoperative and post-operative complications. Major intraoperative

135 complications were defined as complications necessitating direct surgical

136 management or cardiopulmonary resuscitation. Major complications were defined as

137 any complication that was life threatening (serious complications that could cause

138 death without urgent support), resulted in a second surgical procedure, death or

5
139 euthanasia. Minor complications were defined as self-limiting or medically managed

140 complications. Complications were also defined by the time-frame in which they

141 occurred, including intra-operative complications, and (within 14 days) and late

142 (greater than 14 days) post-operative complications. The overall incidence, severity

143 and time frame of complications was reported.

144

145 Statistical analysis

146 Statistical software (GraphPad Prism version 5.00 for Mac OS X, GraphPad Software,

147 San Diego California USA, www.graphpad.com) was used to generate descriptive

148 statistics and median survival time (MST). Survival time was defined as the time

149 between pneumonectomy and death. The cause of death was classified as either

150 disease‐related or non-disease related. Patients with an unknown cause of death were

151 presumed to have died from disease‐related causes. Patients that died because of non‐

152 disease related causes or were lost to follow up were censored for the survival

153 analysis. Kaplan–Meier survival plots as well as mean survival times and MSTs were

154 calculated.

155

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157

158

159

160

161

162

163

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164 RESULTS

165 Signalment

166 Seventeen dogs and ten cats met the inclusion criteria for this study (9 institutions

167 participated to this study). The median age of the dogs was 86 months (range, 3-164

168 months). There were seven male and ten female dogs. The median body weight of the

169 dogs was 22.6 kg [range, 0.8–52.4 kg] of various breeds (Table 1).

170

171 Of the ten cats, the median age was 84 months [range, 6–181 months]. There were 7

172 male and 3 female cats. Domestic short hair cats were the most common breed

173 represented (n=7). The median weight was 4.5 kg [range, 2.2–6.5 kg] (Table 2).

174

175 Presenting complaint

176 Most of the patients (21/27, 78%) presented with respiratory signs such as difficulty

177 breathing and/or coughing. All of the cats and 11 dogs presented for respiratory signs.

178 Five dogs (19%) were referred for non-specific clinical signs such as lethargy,

179 inappetence and exercise intolerance. For one dog, the lung mass was an incidental

180 finding, diagnosed on thoracic radiographs during staging for a cutaneous melanoma.

181

182 Pre-operative diagnostic tests

183 All patients had full serum biochemistry and complete blood count performed prior to

184 surgery. In one case, the results were not available for review. Leukocytosis was

185 reported in nine cases, with five of these cases (5/13, 38%) ultimately diagnosed with

186 non-neoplastic disease and four of these cases (4/14, 29%) diagnosed with neoplasia.

187 Albumin was decreased in seven cases (7/27, 26%), four of these cases were

188 diagnosed with non-neoplastic disease (4/13, 31%).

7
189

190 Thoracic radiographs were performed in 25 (93%) cases. Computed tomography (CT)

191 was performed for 15 cases (56%). Among these 15 cases, lesions involving the entire

192 right or left lung lobe were described for 7 cases (47%). For the remaining 8 cases,

193 extension of the lesion was limited to a part of the lung (left cranial lung lobe, left

194 caudal lung lobe or right cranial and middle lung lobes) but for 3 cases (cases 6, 17

195 Table 1 and case 1, Table 2), the mass was described in close association with the

196 hilus. For one case, a foreign body was identified (case 16, Table 1). Compression of

197 the right lung by a thoracic wall mass causing increased density of the right lung lobes

198 was described for one case (case 14, Table 1) on CT. Between 2004 and 2009, a third

199 of the patients (3/9) had a CT prior surgery, whereas 2/3 of patients (12/18) had a

200 preoperative CT between 2009 and 2014.

201

202 Pneumonectomy

203 Seventeen patients had a left-sided pneumonectomy performed and ten patients had a

204 right-sided pneumonectomy. A lateral thoracotomy was employed in 22 patients at the

205 4th to 6th intercostal space. The intercostal space was not recorded in one patient that

206 had a lateral thoracotomy. A median sternotomy was performed in five patients, for

207 left (n=4) or right (n=1) pneumonectomy. A thoracic wall resection (6th and 7th ribs)

208 combined with a right-sided pneumonectomy was performed in one case (case 14,

209 Table 1). One case was a completion pneumonectomy for a pulmonary abscess as the

210 right cranial lung lobe had been partially removed for treatment of a spontaneous

211 pneumothorax 2 months previously (case 17, Table 1). Hemostasis and pneumostasis

212 were achieved with a surgical stapler alone in 16 cases (56%) (thoraco-abdominal

213 stapling device n=15, gastrointestinal anastomosis device n=1). A hand suture ligation

8
214 technique was used in four cases. A combination of surgical stapler and hand suture

215 ligation was used in three cases and a combination of a surgical stapler and hemoclips

216 was used in one case. Hemoclips alone were used for one case (case 3, Table 2). For 2

217 cases, the surgical technique was not recorded.

218

219 For eight cases, the pneumonectomy was unplanned. The reported reason for

220 performing an unplanned pneumonectomy was unexpected consolidation of the other

221 lung lobes (case 13 and 9, Table 1), unexpected diffuse disease (expanding to the

222 entire right or left lung) (case 2 Table 1 and case 1, Table 2), presence of adhesions

223 between the mass/affected lung lobes and the other lung lobes (case 6, 16 and 17,

224 Table 1), or pulmonary involvement of a chest wall mass (case 14, Table 1).

225

226 Tracheobronchial lymph nodes were removed and submitted for histopathology in six

227 cases (22%, 4 dogs and 2 cats) and sampled via intraoperative fine needle aspiration

228 for cytology in one case (4%, one cat). This cytology was consistent with reactive

229 lymphoid hyperplasia. Histopathology reports were available for 2 dogs and revealed

230 sinus histiocytosis with multifocal pyogranulomatous inflammation for one dog

231 diagnosed with a chronic hemorragic pleuritis (case 16, Table 1) and metastasis of

232 pulmonary carcinoma for the other dog (case 15, Table 1).

233

234 Surgical complications and outcome

235 Dogs – Intraoperative complications

236 Intraoperative complications were recorded in 5 cases (29%). Two cases had major

237 complications (12%) and included hemorrhage (n=1) and cardiac arrest (n=1). Minor

238 complications occurred in 3 dogs (18%) and included: hypotension (n=2) and

9
239 hypothermia (n=2). One case developed both hypothermia and hypotension. The case

240 that developed hemorrhage received a blood transfusion during the procedure. The

241 patient that developed cardiac arrest was resuscitated successfully. Intra-operative

242 death was not reported.

243

244 Dogs – Early Postoperative Complications (0-14 days)

245 Early postoperative complications were recorded in 12 cases (71%). Four cases had

246 major complications (24%) and included persistent pleural effusion (n=2), oxygen

247 dependence (n=2) and cardiac arrest (n=1). Minor complications occurred in 12 cases

248 (71%) and included: anemia (n=3), anorexia (n=2), regurgitation/vomiting (n=2),

249 coughing (n=2), hypertension (n=1), hypotension (n=1), hypothermia (n=1),

250 tachycardia (n=1), second degree atrioventricular block (n=1), phlebitis (n=1), nausea

251 (n=1), hypoglycemia (n=1), incisional infection (n=1), persistent increased respiratory

252 rate (n=1), infection pressure sores right front leg (n=1), and suspected immune

253 mediated vasculitis (n=1). The dog that developed cardiac arrest at day 10 post

254 operatively died (case c1, Table 1) in the hospital. This young dog (3 months old) was

255 diagnosed with a marked, severe, bronchopneumonia with pulmonary necrosis and

256 abscess formation. The bacterial culture revealed Bortella bronchiseptica.

257

258 Dogs – Late Postoperative Complications (>14 days)

259 Late postoperative complications were recorded in 6 cases (38%). Three cases had

260 major complications (19%) and included persistent pleural effusion (n=1),

261 degradation of the clinical status leading to euthanasia due to persistent pleural

262 effusion and suspected carcinomatosis (n=1), and draining tract on the cranial aspect

263 of the sternum (n=1) that led to surgical removal of a sternal sequestrum. Minor

10
264 complications occurred in 3 cases (19%) and included: coughing (n=2), vomiting

265 (n=1) and exercise intolerance (n=1). One case developed vomiting and coughing.

266

267 Overall, complications were recorded in 13 dogs (76%). Seven cases had major

268 complications (41%) and 12 cases had minor complications (71%). Three dogs with a

269 right pneumonectomy (60%) and 4 dogs with a left pneumonectomy (33%) had

270 major complications.

271

272 Cats – Intraoperative complications

273 Intraoperative complications were recorded in 2 cases (20%). One case had a major

274 complication (10%), and was hemorrhage. Minor complication (10%) occurred in one

275 case, and was hypotension. The case that developed hemorrhage received a blood

276 transfusion during the procedure. Intra-operative death was not reported.

277

278 Cats – Early Postoperative Complications (0-14 days)

279 Early postoperative complications were recorded in 8 cases (80%). Four cases had

280 major complications (40%) and included persistent pleural effusion (n=1), tension

281 pneumothorax (n=1), need for assisted ventilation (n=1), oxygen dependence (n=1),

282 and deterioration of the clinical status leading to euthanasia (n=2) (both cases were

283 treated for major respiratory complications). Minor complications occurred in 8 cases

284 (80%) and included: anemia (n=5), regurgitation/vomiting (n=1), anorexia (n=2),

285 hypoalbuminemia (n=1), fever (n=1), hypotension (n=1), diarrhea (n=1) and

286 persistent increased respiratory rate (n=1).

287

288 Cats – Late Postoperative Complications (>14 days)

11
289 Late postoperative complications were recorded in 3 cases (43%). One case had a

290 major complication (14%), and was persistent pleural effusion. Minor complications

291 occurred in 2 cases (29%) and included: coughing and regurgitation/vomiting.

292

293 Overall, complications were recorded in 8 cats (80%). Five cases had major

294 complications (50%) and 8 cases had minor complications (80%). Three cats with a

295 right pneumonectomy (60%) and 2 cats with a left pneumonectomy (40%) had major

296 complications.

297

298 Cytological and histological outcome

299 Pre-operative cytology was performed in 18 cases (67%). Non-diagnostic results and

300 neoplasia were diagnosed in 4 cases each (22%). Of the cases diagnosed with

301 neoplasia on cytology, four had a neoplastic diagnosis confirmed on histopathology.

302 Suppurative or septic suppurative inflammation was reported for the remaining ten

303 cases (56%). Of the cases that had a preoperative cytological diagnosis that was

304 inflammatory or infectious, seven had this diagnosis confirmed on histopathology and

305 three were ultimately diagnosed with neoplasia.

306

307 Fourteen patients (52%) were diagnosed with neoplasia on histopathology: 10 dogs

308 and 4 cats. Ten cases were diagnosed with pulmonary adenocarcinoma (6 dogs and 4

309 cats), one dog with a chest wall chondrosarcoma, one dog with bronchogenic

310 adenoma, one dog with metastasis of an oral squamous cell carcinoma, and one dog

311 with metastasis of a cutaneous myxoid soft tissue sarcoma.

312 An infectious process (including pneumonia, bronchopneumonia, or pulmonary

313 abscess) was diagnosed in 6 dogs and 5 cats. Among these, a foreign body was

12
314 identified for 2 cases. Only two cases were diagnosed with non-infectious disease.

315 These included a cat with severe chronic pleuritis associated with atelectasis,

316 pulmonary artery medial hypertrophy, eosinophilic arteritis, periarteritis, and focal

317 arterial mineralization; and a dog with a cranial left lung lobe torsion associated with

318 complete consolidation of the caudal left lung lobe.

319

320 Adjuvant therapy

321 Six (43%) of 14 animals diagnosed with neoplasia were treated with adjuvant

322 chemotherapy. Protocols varied based on the histological diagnosis and clinician’s

323 preference. Of animals that received chemotherapy, four had pulmonary

324 adenocarcinoma, one had metastasis from a previously excised cutaneous myxoid soft

325 tissue sarcoma, and one had metastasis from a previously excised oral squamous cell

326 carcinoma.

327

328 Clinical Outcome

329 The MST for dogs was 156 days (range, 3-3839 days). The MST for cats was not

330 reached (mean=424 days).

331 No patients died or were euthanized intraoperatively or within the first 24 hours post

332 operatively. However, one dog (6%) and 2 cats (20%) died or were euthanized in the

333 first 2 weeks post-operatively and one cat was lost to follow-up during this time

334 frame.

335

336

337

338

13
339 DISCUSSION

340 This study provides further information on signalment, clinical signs, peri-operative

341 complications, underlying diagnosis, outcomes, and survival times of 17 dogs and 10

342 cats undergoing pneumonectomy. This procedure is technically feasible with a

343 relatively high overall incidence of complications, but a prolonged survival time.

344 Among the 14 cases of pneumonectomy previously described in the veterinary

345 literature,1-4 seven were treated for neoplasia. This ratio is consistent with the present

346 study, with 52% of the cases (14 cases) diagnosed with neoplasia, including 10 cases

347 of pulmonary adenocarcinoma.

348

349 Computed tomography was performed in only 56% of the cases. During the second

350 half of the study accrual period, the use of preoperative CT scans increased, with two-

351 thirds of cases having a preoperative CT after 2009 compared to one-third of cases

352 between 2004-2009. This difference is likely due to the increased availability of this

353 imaging modality and the recognition by veterinary surgeons that CT is extremely

354 useful in staging and surgical planning of lung disease. In our opinion, CT scan

355 should be used for surgical planning and staging in all cases where a lung lobectomy

356 or pneumonectomy is being considered. Sensitivity of CT for correctly assessing

357 tracheobronchial lymph nodes (TBLN) status was 83%, and specificity was 100% in a

358 recent retrospective clinical series.17 Ballegeer et al.18 also described a CT protocol

359 and some cut off values to better assess the TBLN.

360

361 Assessment of the complete lung field or TBLN may influence the surgical plan and

362 the willingness of the owner to proceed with surgery as cases with positive TBLN for

363 metastatic disease are associated with a shorter survival time.17,19,20

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364 The TBLN were assessed in only 7 patients in the present study (cytologically in one

365 patient and histopathologically in 6 patients). Three groups of tracheobronchial lymph

366 nodes are located around the tracheal bifurcation and are usually the primary site of

367 lymphatic metastasis for pulmonary neoplasms.21 Surgical removal of the

368 tracheobronchial lymph nodes can be challenging because of their location at the

369 pulmonary hilus in close association with the heart and major neurovascular

370 structures. An unstable patient during the procedure may also preclude extirpation of

371 the lymph nodes. The current recommendation is to palpate them and to perform a

372 biopsy if enlarged.22 However, the principal authors of this study recommend biopsy

373 of the lymph nodes systematically as normal size lymph nodes can be positive.17,18, 23

374

375 Surprisingly, only half (47%) of the CT studies report described involvement of the

376 entire left or right lung. Involvement of more than one lung lobe was a good indicator

377 for pneumonectomy. Among the remaining cases, only 3 cases presented with a lesion

378 in close association with the hilus, a location that precluded a single lung lobectomy.

379 Four cases presented some adhesions that led to the need for a pneumonectomy. In

380 these cases, CT was not very accurate for detection of adhesions and pneumonectomy

381 was not planned based on CT. It is important to consider pneumonectomy as a

382 potential procedure for complicated lung lobectomy or very extensive disease.

383

384 Pulmonary
385 lymphatics
15
386 drain into 3
387 groups of
388 tracheobronchial
389 lymph nodes
390 (TBLN)
391 located around
392 the tracheal
393 bifurcation,
394 1

16
395 and are the
396 primary
397 site of lymphatic
398 metastasis for
399 pulmonary
400 neoplasms.
401 Assessment of
402 TBLN for
403 metastatic disease
404 is an important
17
405 predictor of
406 outcome in dogs
407 with primary
408 bronchoalveolar
409 carcinoma ,
410 2–4
411 but TB LN are
412 very challenging
413 to access for

18
414 percutaneous
415 preoperative fine
416 needle aspiration
417 or biopsy
418 because of their
419 location at the
420 pulmonary hilus,
421 dorsal to the
422 heart, and
423 intimately
19
424 associated wi th
425 major
426 neurovascul ar
427 structures.
428 Because of this, it
429 is currently
430 recommended
431 that
432 when lung tumor
433 excision is
20
434 performed, as
435 part of the
436 surgical
437 procedure TBLN
438 should be
439 palpated and
440 biopsied if
441
442
enlarged
An intercostal approach between the 4th and 6th ribs was the most common approach

443 for pneumonectomy in the present series. This approach allows for good exposure to

444 the hilus and direct access to the TBLN. Hemostasis and pneumostasis were achieved

445 with a stapling device in more than half of the cases. Use of stapler is associated with

446 rapid application and minimal complications 24,25 and it is now, in the authors opinion,

447 the preferred technique used for lung lobectomy/pneumonectomy. For one case,

21
448 hemoclips were used for hemostasis and pneumostasis. This surgical technique is not

449 described for pneumostasis and is usually not recommended for hemostasis of large

450 vessels because of the risks associated with loosening of the hemoclips. 26 However,

451 this cat did not present any peri or post-operative complications.

452

453 In this study, complications occurred in 76% and 80% of dogs and cats, respectively.

454 The incidences of major complications were 41% and 50% for dogs and cats,

455 respectively. No patients died or were euthanized intraoperatively or within the first

456 24 hours post operatively. However, one dog (6%) and two cats (20%) died or were

457 euthanized in the first 2 weeks post-operatively. In humans, pneumonectomy is also

458 associated with high morbidity. In a recent study reporting 5975 human patients,

459 complications were reported in 53% of patients with benign disease and 39% of

460 patients with neoplastic disease.13 In that study, the postoperative in-hospital mortality

461 rates were 22.1% and 5.1% for patients with benign and malignant disease,

462 respectively.13 Considering these high morbidity and mortality rates, this type of

463 surgical procedure is considered a salvage procedure in humans. 13 The incidence of

464 complications in this study were similarly high: the surgical team and the owners need

465 to be prepared for these potential life threatening complications that will prolong

466 hospitalization and increase costs.

467

468 Complications in respiratory, cardiac and gastrointestinal function are the reported

469 complications associated with pneumonectomy in small animals.2,3 In the present

470 study, respiratory complications (persistent pleural effusion, oxygen dependence,

471 persistent increased respiratory rate or coughing) were the most commonly reported

472 complications. Gastrointestinal complications were uncommon and self-limiting: 4

22
473 cases (2/17 dogs and 2/10 cats) presented some regurgitation/vomiting and one case

474 (one cat) with diarrhea. The duration of the clinical signs was short (24-48 hours).

475 Previously reported by Liptak et al.2 as a potential complication, esophageal

476 dysmotility was not reported in this study.

477 Atrial fibrillation and varying degrees of atrioventricular (AV) block are common

478 cardiac complications following lung lobectomy or pneumonectomy 3. In the study

479 performed by Kocaturk et al.3, one dog died within 7 days of pneumonectomy due to

480 complete AV block. Based on these findings, Kocaturk et al recommended pre and

481 postoperative cardiac evaluation of dogs undergoing lung resection. In the present

482 study, only one case presented a second-degree AV block (one dog) within 24 hours

483 after surgery.

484 In humans, numerous negative prognostic factors have been reported after

485 pneumonectomy: age greater than 65 years, underweight body mass index category,

486 American Society of Anesthesiologists score of 3 or greater, right laterality of the

487 procedure, performance of an extended pneumonectomy, or absence of systematic

488 lymphadenectomy.14 Despite being the largest study reporting clinical outcome after

489 pneumonectomy in the veterinary literature, the low numbers reported here precluded

490 significant statistical analysis and determination of prognostic factors.

491

492 Right pneumonectomy was not associated with a high mortality rate in this study.

493 This is clinically important because the current veterinary literature suggests that

494 right-sided pneumonectomy is not recommended due to the risk of fatal pulmonary

495 hypertension6 even if this procedure was successful for few patients. 2,3 Likely the

496 reason that right-sided pneumonectomy was well-tolerated in these clinical patients

23
497 compared to reports in clinically normal dogs is that these patients had significant

498 disease in the affected lung and this likely led to a period of accommodation in these

499 patients, allowing them to tolerate right or left sided pneumonectomy. Pulmonary

500 hypertension and the inability to adjust to right-sided pneumonectomy remains a

501 potential complication of a pneumonectomy. However, this procedure should be

502 considered in affected patients, regardless of the side affected.

503

504 Limitations
505
506 Limitations of our study include the retrospective nature of the data collection, and

507 variations in surgical technique, tumor staging, perioperative management, and

508 postoperative follow-up routines between institutions. The physiologic impact of the

509 pneumonectomy on the lung or heart function was not assessed: spirometric analysis

510 of ventilatory function or echocardiography was not performed before or after

511 surgery. These tests may help to anticipate the complications 3, the outcome or to

512 identify a potential risk factor. The limited numbers of patients also precluded more

513 advanced statistical analysis.

514

515 Conclusion

516 Pneumonectomy is an uncommon procedure, which is most commonly executed via a

517 lateral thoracotomy, using a TA stapling device. The incidence of complications is

518 relatively high for this procedure, but risk factors were not identified. Right-sided

519 pneumonectomy was not associated with a high mortality rate and side affected

520 should not influence the decision whether or not to perform this procedure in patients

521 with extensive disease requiring pneumonectomy.

522 ACKNOWLEDGMENTS

24
523 We thank Veterinary Society of Surgical Oncology (VSSO) members support for this

524 study and especially Drs. Julius Liptak, Michelle Oblak, David Dycus, Stan Veytsman

525 and Mirae Wood for case submission.

526

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547 REFERENCES

25
548 1. Madewell, B. R., Nyland, T. G. and Weigel, J. E: Regression of hypertrophic
549 osteopathy following pneumonectomy in a dog. Journal of the American Veterinary
550 Medical Association 1978;172:818-821
551
552 2. Liptak JM, Monnet E, Dernell WS, et al: Pneumonectomy: four case studies and a
553 comparative review. J Small Anim Pract. 2004;45:441-447
554
555 3. Kocatürk M, Salci H, Yilmaz Z, et al: Pre- and post-operative cardiac evaluation of
556 dogs undergoing lobectomy and pneumonectomy. J. Vet. Sci. 2010; 11:257-264

557 4. Anagnostou TL, Pavlidou K, Savvas I, et al: Anesthesia and Perioperative

558 Management of a Pneumonectomized Dog. J Am Anim Hosp Assoc. 2012
559 27;48:145-149
560
561 5. Nelson, AW: Lower respiratory system, in Textbook of Small Animal Surgery. (ed
562 2) Ed D. Slatter. W. B. Saunders, Philadelphia, 1993 pp 777- 804
563
564 6. Tobias KA, Johnston SA: Lungs, in Veterinary Surgery: Small Animal, 2012 (ed 1)
565 pp1766-1768
566
567 7. Hsia CC, Carlin, JI, Cassidy SS, et al: Hemodynamic changes after
568 pneumonectomy in the exercising foxhound. Journal of Applied Physiology. 1990 69,
569 51-57
570
571 8. Tronc, F, Grégoire, J, Leblanc P, et al: Physiologic consequences of
572 pneumonectomy: consequences on the pulmonary function. Chest Surgery Clinics of
573 North America. 1999; 9, 459-473
574
575 9. Davies P, McBride J, Murray GF, et al: Structural changes in the canine lung and
576 pulmonary arteries after pneumonectomy. Journal of Applied Physiology. 1982;53,
577 859-864

578 10. Carlin, JI, Hsia CC, Cassidy SS, et al: Recruitment of lung diffusing capacity with
579 exercise before and after pneumonectomy in dogs. Journal of Applied Physiology.
580 1991;70, 135-142

581 11. Hsia CC, Herazo LF, Fryder-Doffey F, et al: Compensatory lung growth occurs in
582 adult dogs after right pneumonectomy. Journal of Clinical Investigation. 1994;94,
583 405-412

584 12. Nelson AW, Monnet E: Lungs, in: Textbook of Small Animal Surgery (ed 3) Ed
585 D. Slatter. W. B. Saunders, Philadelphia. 2003 pp 880-889

586 13. Rivera C, Arame A, Pricopi C, Riquet M, Mangiameli G, Abdennadher M, et al.

587 Pneumonectomy for benign disease: indications and postoperative outcomes, a
588 nationwide studydagger. Eur J Cardiothorac Surg. 2014; 48(3):435-440
589

590 14. Stolz AJ, Harustiak T, Simonek J, et al: Pneumonectomy for non-small cell lung
591 cancer: predictors of early mortality and morbidity. Acta Chir Belg. 2014;114(1):25-
592 30

26
593
594 15. Thomas PA, Berbis J, Baste J-M, et al: Pneumonectomy for lung cancer:
595 contemporary national early morbidity and mortality outcomes. The Journal of
596 Thoracic and Cardiovascular Surgery. 2015;149(1):73–82

597 16. Groth SS, Burt BM, Sugarbaker DJ. Management of Complications After
598 Pneumonectomy. Thorac Surg Clin. 2015;25(3):335-48
599
600 17. Paolini MC, Adams WM, Dubielzig RR, et al: Comparison of results of computed
601 tomography and radiography with histopathologic findings in tracheobronchial lymph
602 nodes in dogs with primary lung tumors: 14 cases (1999-2002). J Am Vet Med Assoc.
603 2006;228(11):1718–22

604 18. Ballegeer EA, Adams WM, Dubielzig RR, et al: Computed tomography
605 characteristics of canine tracheobronchial lymph node metastasis. Vet Radiol
606 Ultrasoun. 2010;22;51(4):397–40321.

607 19. McNiel EA, Ogilvie GK, Powers BE, et al: Evaluation of prognostic factors for
608 dogs with primary lung tumors: 67 cases (1985-1992). J Am Vet Med Assoc.
609 1997;211(11):1422–7

610 20. Poulton GA, Brearley MJ, Powell SM, et al: Impact of primary tumor stage on
611 survival in dogs with solitary lung tumors. J Small Anim Pract 2008;49:66–71
612
613 21.Evans HE, Howard E, DeLahunta A : The lymphatic system, in Miller’s anatomy
614 of the dog (ed 4). Philadelphia, PA, Saunders, 2013, pp 545-550

615 22. Martano M, Boston S, Morello E, et al: Respiratory tract and thorax, in Kudnig
616 ST, Seguin B, in Veterinary surgical oncology. Chichester, UK, Wiley Blackwell,
617 2012, pp 303

618 23. Langenbach A, McManus PM, Hendrick MJ, et al: Sensitivity and specificity of
619 methods of assessing the regional lymph nodes for evidence of metastasis in dogs and
620 cats with solid tumors. J Am Vet Med Assoc. 2001;218(9):1424–8

621 24. Hess JL: Use of mechanical staples in veterinary thoracic surgery. J Am Anim
622 Hosp Assoc 1979;15:569

623 25. LaRue SM, Withrow SJ, Wykes PM: Lung resection using surgical staples in dogs
624 and cats. Vet Surg 1987;16:238–240
625
626 26. Tobias KA, Johnston SA: Suture material, tissue staplers, ligations devices, and
627 closure methods, in Veterinary Surgery: Small Animal, 2012 (ed 1) pp197

628

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 Age at
Weight Side Intra-operative and early
Case Breed Sex surgery Approach Diagnosis Outcome
(Kg) affected complications
(Months)
Oxygen dependence
Cardiac arrest
1 Yorkshire Terrier FI 0.81 3 Left 4th ICS Anemia, anorexia Diffuse pneumonia
(10 days)
Hypoglycemia, cardiac arrest
Bronchogenic pulmonary Euthanasia
2 WHWT MC 11.6 86 Left 5th ICS None
adenocarcinoma (156 days)
Bronchioalveolar Euthanasia
3 Bernese mountain FS 25.4 100 Left Not recorded None
carcinoma (30 days)
Died
4 Scottish Terrier FS 8.1 91 Left 5th ICS Infected pressure sores SCC (metastasis)
(33 days)
Persistent pleural effusion Pulmonary Euthanasia
5 Weimaraner MC 52.4 108 Left 5th ICS
Incisional infection adenocarcinoma (960 days)
Hypothermia
6 Dachshund MC 8.6 24 Left 5th ICS Bronchogenic adenoma Alive
Hypotension, coughing
Suspected immune mediated High grade STS Euthanasia
7 Labrador Retriever MC 34 132 Left 5th ICS
vasculitis (metastasis) (87 days)
Persistent pleural effusion Bronchioalveolar Euthanasia
8 English Cocker MI 13 163 Left 5th ICS
Coughing carcinoma (15 days)
9 Pug FS 9 77 Left 5th ICS None Lobe torsion Alive
Chronic septic eosinophilic
10 Rottweiler FI 32.6 17 Right 5th ICS None Alive
bronchitis
Papillary pulmonary
11 Mixed breed FS 22 148 Right 5th ICS Hemorrhage, AV block Alive
adenocarcinoma
Primary pleuritis,
12 Boxer MC 11.4 5 Left MS Hypotension, anemia Unknown
pneumonia
13 Golden Retriever FS 32 60 Left 4th ICS Hypertension Pleuropneumonia Alive
Phlebitis, vomiting
Hypothermia Died
14 Mixed breed FS 23.1 144 Right 5th ICS Chondrosarcoma
Anorexia, tachycardia (54 days)
Died
15 Mixed breed FS 33.3 164 Left 4th ICS Regurgitations Pulmonary Carcinoma
(96 days)
Cardiac arrest
Chronic septic hemorragic
16 Springer Spaniel MC 18.1 54 Right MS Oxygen dependence Alive
pleuritis
Anemia, increased RR
17 Rottweiler mixed FS 26 62 Right 6th ICS None Pulmonary abscess Alive
629

28
630 Table 1: Breed, sexe (MC=male castrated, MI=male intact, FI=female intact,

631 FS=female spayed), weight, age at surgery, side of procedure, surgical approach

632 (ICS=intercostal space, MS=median sternotomy), intra-operative and early

633 complications encountered (RR=respiratory rate, AV=atrioventricular), final

634 diagnosis (SCC=squamous cell carcinoma, STS=soft tissue sarcoma) and outcome

635 (days represent time between surgery and death) of the 17 dogs.

29
 Age at
Weight Side Intra-operative and
Case Breed Sex surgery Approach Diagnosis Outcome
(Kg) affected early complications
(Months)
Tension pneumothorax
Papillary/Acinar Euthanasia
1 DSH MC 5.7 181 Left 6th ICS Hemorrhage
Adenocarcinoma (2 days)
Anemia
2 DSH MC 2.2 6 Left MS Anemia Pulmonary abscess Unknown
Accidental death
3 DSH MC 6.5 84 Left 6th ICS None Pulmonary abscess
(580 days)
Pulmonary adenocarcinoma Died
4 Ragdoll FS 2.9 138 Right 5th ICS None
Bronchopneumonia (345 days)
Hemorrhage
5 Main Coon MC 5.68 102 Right 5th ICS Anorexia Pulmonary adenocarcinoma Unknown
Diarrhea
6 DSH MC 3.8 12 Left MS Fever, Anemia Severe chronic pleuritis Unknown
Hypotension
Euthanasia
7 DSH FS 3.3 161 Right 6th ICS Ventilator dependent Pulmonary adenocarcinoma
(1 day)
Anemia
Persistent pleural
8 DSH MC 4.65 18 Right 6th ICS effusion Pneumonia and pleuritis Alive
Increased RR
Oxygen dependence Granulomatous
9 DSH FS 3.89 84 Left MS Alive
Hypotension, anemia bronchiopneumonia
10 Bengal MC 4.5 9 Right 5th ICS Anorexia, vomiting Bronchopneumonia Alive
636

30
637 Table 2: Breed (DSH=domestic short hair), sexe (MC=male castrated, MI=male

638 intact, FI=female intact, FS=female spayed), weight, age at surgery, side of

639 procedure, surgical approach (ICS=intercostal space, MD=median sternotomy), intra-

640 operative and early complications encountered (RR=respiratory rate), final diagnosis

641 and outcome (days represent time between surgery and death) of the 10 cats.

642

643

31