Sunday, August 25, 2013

1097. Script for intern - closed pyometra & uterine torsion in a very old Maltese


tpvets_logo.jpg (2726 bytes)TOA PAYOH VETS
toapayohvets.com

Date:   26 August, 2013  
 
Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits
 
A Risky Surgery - Closed Pyometra & Uterine Torsion in a very old Maltese  
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date:   26 August, 2013  
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129
 
Script for Intern

1.  HOOK: Video: Titled August 20, 2013, First Consultation at Toa Payoh Vets

A very old dog - 15 years old, Maltese, Female
                          Large swollen abdomen. Not eating.

"My dog has been gaining weight in the past 7 days," the slim lady owner in her late 50s said. "I could feel that she is heavier than before. After grooming, I saw a big lump on her left abdomen. She is not interesting in eating. What's wrong with her?"

Images of left & right side views, top view

2. OBJECTIVE OF VIDEO:  A "Be Kind To Pets" Vet educational video slide.

3. INTRODUCTION
 
August 20, 2013

Diagnosis:
"
Is she a spayed female dog?" I asked as many Singapore dog owners doctor-hop. My medical records showed 3 incidents of false pregnancy and advices to spay the dog went unheeded.

"She is my daughter's dog but now I have taken over. Over the years, my daughter did not think of spaying the dog," the mother said.

"When was the last heat?" I noted that this dog would have false pregnancy around August in the previous 3 episodes in the years I saw her during vaccination.

"None at all," the mother said. "She is so old and should be in menopause."

I palpated the large abdomen. The left side protruded a giant "sausage-like" mass which was painful. The dog her head turned to bite me.

"Your dog suffers from closed pyometra," I said quite confidently.  "The cervix had closed and so the pus and bacteria accumulated inside the womb, causing such a large swelling. The only solution is to operate to remove the womb which is now swollen with pus."
 CONFLICT 1 - Highly Risky Surgery
"My dog is so old. I don't want her to die on the operating table. Isn't there medication to cure her?"

"Antibiotics will give temporary relief for a few days," I said. "Your dog's health will deteriorate and she will die soon as the toxins spread to her whole body or the swollen uterus ruptures spilling out pus into her abdomen. Therefore, you have no choice but to get her operated."

CONFLICT 2 - Financial costs of tests for heartlanders
"Are you sure of your diagnosis?" she asked.
"Nearly 100%. To save you money, I have not recommended an X-ray and blood tests which will add around $300 to the medical costs. However, if you want them done, I will do it." The owner wanted the tests done.

X-Rays images x 2. The left swollen uterine horn can be seen (arrows).

Blood test image. No increase in total white cell count but the neutrophils have increased.

CONFLICT 3 - Chances of Death on the operating table.
A very old Maltese at 15 years equivalent to a 105-year-old woman. The blood test showed a very low creatinine level indicating that the kidney function was not normal. So anaesthesia could be fatal. "Less than 50% chances," I said to the owner. 

CONFLICT 4 - Procrastination of the owner. The owner is very fond of this dog and so could not decide. The daughter had her own family and so this dog is her companion. A highly risky surgery could mean death. 

She is from the baby-boomer generation that usually does not bother to do research on the internet for "closed pyometra." So she did not know that time is of the essence and any delay will lead to toxic damage to the kidneys and death from kidney.
failure.

"My dog started eating after your antibiotics," she said when I followed up to ask her to operate. It seems like hard-sell but it is in the interest of the dog and the owner. When vomiting from kidney failure starts, the owner will ask for the operation but then it will be too late.
CONFLICT 5 - Reputation of the veterinary surgery and vet.  Deaths on the operating table are extremely emotional events for the owner and the younger family members nowadays. Some owners post adverse comments on the internet forum when such incidents happen asking others to avoid the practice.

The owner came on August 21, 2013 for the surgery. A bright sunny day. "This high risky surgery is not one I look forward to and it must be done speedily," I told the owner. "Ask Dr Daniel to do it," she said. "I will do it myself," I said to her.

Old dogs do die on the operating table in all veterinary practices and I had my encounters. I hope that this old dog will not.  A positive mental attitude cannot overcome any weak old canine heart that may fail under anaesthesia.. 
CONFLICT 6 - A complicated surgery prolongs anaesthesia.

1. The left uterine horn has twisted (uterine torsion).
ILLUSTRATIONS


2. Red blood was present in the abdomen (haemoabdomen) indicating rupture of blood vessels.
ILLUSTRATIONS

3. Adhesions of the omental fat to the left uterine horn
wrapping around the uterus and connecting to the spleen, stomach and kidneys. This was unexpected as this was my first case of uterine torsion seen in my over 30 years of practice. 
ILLUSTRATIONS
 

All my past cases were over the last 30 years of practice were just swollen uterine bodies full of pus.

IMAGES OF 6 CASES OF CLOSED PYOMETRA WITH NO UTERINE TORSION IN OTHER DOGS
Reference:
http://www.bekindtopets.com/animals/20081201PG4_
Dog_Surgery_Anaesthesia_Female_Dog_Problems_
ToaPayohVets.htm

So, I expected this to be a routine surgery. I only had to be speedy and should complete the surgery in less than 30 minutes. When I opened the abdomen, a gigantic kidney-shaped "sausage" - the biggest you can find in the supermarket, popped out.

IMAGES OF REAL GERMAN SAUSAGES
& VIDEO CLIPS OF SURGERY

CONCLUSION
Speed, Accuracy & Completeness are 3 important factors in any surgery. In old dogs, time is of the essence as the old dog can die of heart failure as the anaesthesia is prolonged. This surgery from the inhalation of isoflurane + oxygen gas to last stitch took 68 minutes for a surgeon with over 30 years of experience.

It could be done in around 50 minutes if there were no complications of uterine torsion. In this rare case, I had to figure out what to do. The best would be to look for the cervical area and ligate it as the uterine body was also twisted. 

This case has a happy ending. The dog was hospitalised for 7 days as requested by the owner. She ate canned food on day 2 after surgery. Not all similar cases end happily. My best advice is to get your female dog spayed when she is young and healthy to avoid highly emotional stress when closed pyometra occurs. 
       
First consultation X-ray X-ray confirms Blood test & uterine torsion illustration
Gigantic kidney-shaped twisted left uterine horn  View of left uterine horn torsion Omental fat adhered to left uterus proves torsion A heavy weight of toxic pus is removed
IV drip video Post-op video of dog on Aug 26, 2013 Illustrations of haemoabdomen Surgery stitches image
Updates will be on this webpage:
www.sinpets.com/F5/20130826closed_pyometra
_uterine_torsion_old_Maltese.htm


More info at: Dogs or Cats
To make an appointment: e-mail judy@toapayohvets.com
tel: +65 9668-6469, 6254-3326
tpvets_logo.jpg (2726 bytes)Toa Payoh Vets
Clinical Research
Copyright © Asiahomes
All rights reserved. Revised: August 26, 2013

Toa Payoh Vets

No comments:

Post a Comment