Thursday, September 6, 2012

1082. Blocked bladder case - urethrotomy twice


Today, Dr Daniel operated on a Shih Tzu who could not pass urine. Vet 1 and Vet 2 in another ractice had operated and made two "holes" in the lower part of the penis ie. urethrotomy. This case was referred to him by his brother as the dog could not urinate and the dog owner was his brother's friend.


I reviewed this case done by my associate vets and discovered that this 4-year-old Shih Tzu had been examined by Dr Vanessa on Oct 24, 2011. She confirmed bladder stones from X-rays and the cathether was blocked about 6 cm from tip of penis. She recorded that the owner "declined all treatment."

The infected areas were cleared. The urethral opening was stitched again and a catheter was passed through. "Pus in the penis," he said to me. "According to the book, the penile head should have been amputated." I said: "Normally I don't do it. Just open the urethra behind the os penis to let the urine flow out if the front part is completely blocked. Only in this case, there were complications of infections after surgery done by Vets 1 and 2."

As more new vet surgery text books are produced, there are new concepts. Amputation of the penile head, in my opinion, is unnecessary despite what the new vet surgery text books say. I mean, this amputation causes more pain and bleeding and I have done urethrotomy without the need to cut off the penile head and the dog was OK. "The only problem with urethrotomy is that the male dog leaks urine onto the floor and the owner does not like cleaning up," I replied to him.

In urethrotomy, the owner needs to take special nursing care as the area can close up due to infections and scarring. So Vet 2 did another urethrotomy. This gave complications as the dog could not urinate. Vet 3 proposed another opening of the urethra further back.

In conclusion, this case would be difficult to treat. In my opinion, the solution is to open up the first urethral stricture. It must be debrided and opened up to join the 2nd one. Both stitched up as one opening ventral. A catheter is to be placed for over 10-20 days for healing to take place. Not just 4 days and take out the catheter as the urethral opening will closed up and obstruct urine flow again!
       

 

Wednesday, September 5, 2012

1080. Retrospective study: Vaginal hyperplasia & Prolapse Type II in an old female chihuahua

"Very tired, not moving," the home-breeder said. "Not eating  1's for the past 9 days and vomit when given canned food." There was a red"tongue-like" tissue hanging from the backside of this 10-year-old female Chihuahua, fawn/white.

On Nov 18, 2011, he had consulted Vet 1 who noted "vaginal/uterine" prolapse and advised spay. She informed him there could be pyometra. She recorded that he declined blood testing. He did not want surgery as the vet warned of high anaesthetic risk. So he took some medication. However, his dog did not eat again. Four days had passed. Vet 1's Nov 19 blood test records showed elevated liver enzymes and marginal elevation of WBC (Total WCC 17.2). Her ultrasound showed mainly liver, gall bladder and kidney issues. Urine tests showed presence of glucose (3+), blood (4+), bacteria (2+), epithelial cells, WBC and RBC. However, in retrospective review today, of the differential count, neutrophils was 88% (high) and platelets 181 (200-500) was low.

The owner wanted non-surgical treatment. But there was none. Surgery was the option but highly risky as the dog had been sick for some days.

He wanted me to do the surgery which was done on Nov 27. I got a blood test done on Nov 25. This time the Total WCC was 33.2 (6-17), Neutrophils was 96%, platelets 14 (200-500).  NOW, the haemoglobin 5.3 (12-18) and red cell count 2.7 (5.5 - 8.5), Haematocrit 0.15 (0.37-0.55), MCV 55 (60-77) indicated severe anaemia too. Platelets are 14 - clotting problems exist now - dog unable to clot when the tissues are cut (see image of my report case).

CONCLUSION
1. Spaying the dog when she was young would not have caused this serious health problem.
2. Often the owner is not aware of the seriousness of the problems as the vet mentioned "high risk" and death likely.
3. The vet was not able to communicate the need for prompt surgery (1-2 days on Nov 19 , not wait longer) as delays would make survival very low.




Tuesday, September 4, 2012

1079. Follow up: Will my dog still have bleeding after spay?

Sunday Sep 2, 2012 was a busy day. So I did a spay of a fat SilkieXMaltese, 5 years old. This case was written earlier. Today, Tuesday, I phoned the owner to find out what happened after spay and to let them know the blood test results were OK.
"Why did your sister want the dog spayed?" I asked.
"My sister moved to a new apartment and did not want the furniture soiled by blood from the dog's heat," he said. "Also, mum is getting old and having to clean up the blood stains of heat would be too tiring for her."
Good reasons to spay a dog. I was intrigued to know why the sister asked me a few times and now the brother as to whether the dog would still have bleeding of heat after spay.

Here are the reported findings on this dog after spaying.
Day 1. Sep 2, 2012. Spayed in the morning. Went home at around 1 pm.
                                 Evening, the dog could not sleep properly as she needed to rest her head on her two front paws but the e-collar was obstructing. She paced. After the owner took out the e-collar, she was OK. Not eating except when given cheese (ate a bit).  Slept sideways.

Day 2. Sep 3, 2012. Morning. Walking and barking. Able to eat. Jumped on chairs.

Day 3. Sep 4, 2012 (today). Morning. Normal. Not wearing e-collar. Monitored. Plaster with blood - not able to replace with new one. Dog ran away.

CONCLUSION
No tolfedine painkillers (oral) were prescribed. A tolfedine and baytril injection were given post-op.
Fast recovery. Could possibly be due to small skin incision of around 2 cm in length and no surgical complications like peritonitis? In most of my spay cases, the female dog is normal on Day 3, as in this case.

1078. Follow up: Will my dog still have bleeding after spay?

Sunday Sep 2, 2012 was a busy day. So I did a spay of a fat SilkieXMaltese, 5 years old. This case was written earlier. Today, Tuesday, I phoned the owner to find out what happened after spay and to let them know the blood test results were OK.
"Why did your sister want the dog spayed?" I asked.
"My sister moved to a new apartment and did not want the furniture soiled by blood from the dog's heat," he said. "Also, mum is getting old and having to clean up the blood stains of heat would be too tiring for her."
Good reasons to spay a dog. I was intrigued to know why the sister asked me a few times and now the brother as to whether the dog would still have bleeding of heat after spay.

Here are the reported findings on this dog after spaying.
Day 1. Sep 2, 2012. Spayed in the morning. Went home at around 1 pm.
                                 Evening, the dog could not sleep properly as she needed to rest her head on her two front paws but the e-collar was obstructing. She paced. After the owner took out the e-collar, she was OK. Not eating except when given cheese (ate a bit).  Slept sideways.

Day 2. Sep 3, 2012. Morning. Walking and barking. Able to eat. Jumped on chairs.

Day 3. Sep 4, 2012 (today). Morning. Normal. Not wearing e-collar. Monitored. Plaster with blood - not able to replace with new one. Dog ran away.

CONCLUSION
No tolfedine painkillers (oral) were prescribed. A tolfedine and baytril injection were given post-op.
Fast recovery. Could possibly be due to small skin incision of around 2 cm in length and no surgical complications like peritonitis? In most of my spay cases, the female dog is normal on Day 3, as in this case.

1077. Email advices regarding eye tumour






Dear Dr Sing,

My pet maltese is diagnosed with malignant high grade anaplastic mast cell tumor. A first operation was performed to remove a tumor from her left thoracic flank. The histological report revealed that there is no margin of tumor-free tissue along the deepest border.


Two months after the surgery, a new lump developed on the right neck and was surgically removed. An ultrasound abdo scan also showed that the cancer has metastasized to the spleen.


She began her first chemotherapy: Prednisolone and Vinblastine (8 sessions; 4 x weekly, 4 x biweekly). Her second chemotherapy: Palladia was on for two weeks and interrupted due to a swollen right eye lid.


We seek a vet with special interest in ophthalmology today and she was definite that the swollen eyelid is a malignant tumor, without doing any biopsy. Surgically removal of the entire eye is the only option but the tumor is likely going to reappear. My pet is given a prognosis of 3 weeks.


Aside from the swollen right eyelid, she is still a very active pet and has good appetite. The tumor in the eyelid has pushed her eyeball to the side and looking very uncomfortable. She is given Prednisolone for now.


After doing some research online, most commented that eyelid tumor is benign.


Given that my pet is still in good spirits, I am not willing to put her down in any case. However, the unwelcome tumor in the eyelid seems like an time-ticking tumor. It is getting more inflamed as each day passes.


EMAIL REPLY FROM DR SING DATED AUG 24, 2012

I will be back from HK on Friday aug 24. It will be best to tel me 96686468 on Sat 10am. Most likely eye tumor is malignant.



Monday, September 3, 2012

4000. Educating the rabbit owner about his rabbit abscess

If a vet wants to build up his reputation and expertise, he has to review his cases, esp. challenging ones and must be able to communicate in the layman's language.

I heard a new graduate telling the owner he wants a "history" of the panting dog. To the owner, "history" means nothing.

It requires a lot of time to process the X-ray image so that the rabbit owner understands the pathology of the rabbit's impacted molar and bone infection as shown in the images below:






Sunday, September 2, 2012

1075. KPI for a fat dog spay by Dr Sing. Sunday Sep 2, 2012's interesting cases

Sunday Sep 2, 2012. Sunny day, blue skies

Myths
Three dog owners told me today:
1. Dog at 5 years old, if neutered, will develop prostate cancer
2. Dog at 11 years old. Too old to neuter to prevent urine marking. I checked the health. Has heart disease now. So, anaesthesia not advised.
3. Dog, 4 years old. If spayed, will still get heat bleeding. "This is not possible," I said."Unless the vet leaves behind some ovarian tissue after spay."

I took over the spaying of this overweight Maltese X, at 9.15 kg,  as Sunday is a busy day and I can spay faster, due to more years of experience. Still, I pray not to get fat dogs.

A.  10am  Sedation with D + K at 50%. Dom = 0.18ml  Ketamine = 0.23ml IV.
B.  10.28 am  Isoflurane gas first given
C.  11 am Isoflurane gas stopped
D.  10.34 am First skin incision
E.  11.02 am  Completion of stitching

Lots of oily fat. Hooked 2nd attempt.
10.42 am Left ovary hooked out
10.48 am Right ovary hooked out.
10.51 am Uterine body pulled out
10.55  am  Uterine body ligated twice at 2 locations
10.56 am  Linea alba stitched
11.02 am End of stitching.

12 noon  Dog alert and goes home.

E-D = 28 minutes
E-A = 62 minutes (includes dental scaling before spaying). Therefore, excluding dental scaling, just for spay, E-A should be lesser.
SPAY TIPS FOR YOUNG VETS
1. The incision started 1.5 cm from the umbilical scar.
2. Ensure ovaries are exposed thoroughly including at least 5 mm of the ovarian suspensory ligament. Incise anteriorly 5mm more if you find difficulty in pulling out the ovary or can't access the suspensary ligament. In this dog, I was able to pull out the whole ovary and my finger could feel at least 5 mm of the suspensory ligament.

3. NICK INSTEAD OF RUPTURING THE SUSPENSORY LIGAMENT AS ADVISED BY THE PROFESSORS.
What to do with this suspensory ligament. I know the professors in the University may say "snap" it off with the finger by pulling hard to break it. The danger in fat dogs and small breed is that the force may break the whole ovarian ligament including the ovarian blood vessels, leading to profuse bleeding.
3.1 I use the scalpel blade and nick off the taut suspensory ligament on the dorsal side at around 2 mm depoth. A young vet asked me whether I would also nick off the ovarian blood vessels with the scalpel. My answer is no if you just nick at the taut ligament. You can feel it very tight when you pull out the ovary and at the tight area, use the scalpel to nick it. For big breeds, you can feel this tight ligament. I also nick it in big breeds.

4. TRANSFIXING SUTURE.  The professors advise transfixing the uterine body. Now, the theory is great but in practice, the uterine body of a small breed like the Maltese or even this fat Maltese X Silkie is less than 8 mm in width. Transfixing ligature may rupture this uterine body as there is not much space. In this dog, I ligate the uterine body 2 times at 2 locations.
5. PROFUSE BLEEDING SEEN.  If you incise the linea alba correctly and not the muscles, you seldom get profuse bleeding. I don't separate the omental fat surrounding the length of the uterine horn in this fat dog. Some vets will pull off the omental fat before ligating the uterine body and in big breeds, this may need to be done. In small breeds, I don't do it and ligate it together with the uterine body. Hence two ligatures at 2 locations. Profuse bleeding may come from omental blood vessels and it can be very alarming, as the body fills with flowing blood.

In cases where bleeding is non-stop, even when swabs are used, it is necessary to extend the incision to look for the bleeder and to save the dog from bleeding to death. There is no choice. Sometimes, the dog is on heat and the omental vessels are fragile and bleed easily. If the vet does NOT clamp the omental fat from the uterine horn area but just bursting it away with fingers before ligating the uterine body, there may be alarming profuse bleeding.

5. NO. OF SUTURE PACKETS
I used one packet of PDS 2/0. The last bit was to suture one horizontal mattress suture on the skin.     

In conclusion, for the young vet, keep spaying simple by:
1. Making a large skin incision of over 4 mm. It is unlikely you can do a 2 cm incision and so don't try till you know the best location.    
2. Try not to use fanciful stitching. Simple interrupted stitches x 3 (in this dog where the linea alba is around 2.5 cm long) and one horizontal mattress suture for the skin. No subcuticular or hidden sutures to impress the owner. Efficiency (short surgery, accuracy, speed and completion) rather than take your sweet time to do a spay.