Thursday, September 26, 2013

Update: Sebaceous adenoma in the old Husky's right eye

Focus: Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits
Anaesthetic death worries for an old Siberian Husky     Dr Sing Kong Yuen, BVMS (Glasgow), MRCVSDate:   27 September, 2013   toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129
 
Sep 15, 2013
Dear Dr Sing Kong Yuen 
We – my wife Pri and I - have been at your clinic half a year ago with our two Huskies. Cleo - 6 years old, the male Husky, had strained his back legs muscles, but slowly he can run again after you had advised us what to do and how to treat him. It is still not perfect, but we get him there.
Our female Husky Al, now 9 years old,  has at her right upper eye-lid an abscess since some years (please see image), but we get the impression it is growing and causes her some problems, because sometimes she is scratching it and the eye ball is inflamed.
We hope it is not malignant. Nonetheless we think it must be removed now somehow.
Therefore we are asking you to get us an appointment for Friday, 20th September, at any time, but best would be in the morning. We are prepared to take all the time it would need to stay with Al at your clinic. Please get us your answer by email.
Thank you for your attention and I am looking forward to hear from you soon.
With warm regards
EMAIL FROM DR SING DATED SEP 16, 2013

Thank you for your email. Pl bring Al in at around 11am on Friday.
Surgery and anaesthesia will be done using electro-surgery in the afternoon. She goes home at around 6 pm after recovery from anaesthesia. No food and water after 10 pm the night before.
Please note that old dogs undergoing anaesthesia are at risk of death from anaesthesia. In most cases, there are no deaths if the dog is healthy and the surgery is short duration as in this case. The dog will be examined before surgery as there is inflammation and infection in the eye.  Pl give antibiotic eye drops for at least 3 days before surgery as I don't advise operating on an infected area.
 
 
REPLY TO EMAIL FOR SURGERY APPOINTMENT
 
Sep 16, 2013
Hi
Thank you for your email. Pl bring the Husky  in at around 11am on Friday Sep 20, 2013.
Surgery and anaesthesia will be done using electro-surgery in the afternoon. She goes home at around 6 pm after recovery from anaesthesia. No food and water after 10 pm the night before.
Please note that old dogs undergoing anaesthesia are at risk of death from anaesthesia. In most cases, there are no deaths if the dog is healthy and the surgery is short duration as in this case. The dog will be examined before surgery as there is inflammation and infection in the eye.  Pl give antibiotic eye drops for at least 3 days before surgery as I don't advise operating on an infected area.


EMAIL REPLY TO OWNER DATED SEP 16, 2013

Thank you for your energetic response. I am sorry that I do not permit all clients to be present at the surgery as I need to focus 100% on the anaesthesia of old dogs and thereby not getting anaesthetic deaths due to distractions or conversations.

In addition, the surgery room is small and you are welcome to inspect it.

The whole process takes around 30 minutes including pre-op preparation. It may take longer if there are complications like cardiac emergencies in which I have to revive the patient. With the owner present, there will be much emotional distress when such emergencies occur and distract me from my resuscitation of the patient. No vet can assume that the old dog will not have any cardiac or respiratory emergencies during anaesthesia and surgery and so it is best that the owner not be present.

In my younger days, I permited one lady to watch her hamster being operated for a small tumour as she requested. She fainted at the sight of blood when I excised the tumour. From that experience, I do not permit any owner to be present at surgery. Pl accept my apologies.

The dog needs to recover fully from anaesthesia and this takes around 2-4 hours for old dogs. That is why you pick the dog at around 6 pm.  

Sep 19, 2013

Dear Dr Sing
This afternoon we have been at your clinic and discussed with Dr Daniel the operation of Al’s eye lid tumour, he took a blood sample and checked her general health which should be OK.

 
Everything is clear and we fully trust to be in good hands due to your experience. However, having in mind yours and Dr Daniel's repeatedly mentioned remarks that Al could die due to the anaesthesia, even afterwards, you may understand that we are still concerned that the worst could happen to our precious dog Al.

Both our dogs are like children to us. That’s why we are still reading everything about this surgery and found the below article of a dog clinic from Washington D.C.

May we ask you, what is your opinion regarding  local anaesthesia after drug sedation and the described “freezing” of the wound? Please forgive us our nervousness.

QUOTE
:

2.   EYELID TUMORS. Older dogs commonly develop eyelid tumours (cancer). As in humans, cancer can be either benign or malignant. Fortunately, eyelid tumours in dogs are usually benign and do not spread to distant tissues. However, eyelid tumours do slowly or quickly grow, and can destroy the structure of the eyelid, in addition to rubbing on the eye. It is usually best to remove them when they are still small.
Eyelid tumours are treated by surgical removal. While there are many different surgical procedures possible, most eyelid tumours in old dogs can be removed at Animal Eye Care without requiring general anaesthesia. The patient is given a sedative, and then a local eyelid anaesthetic is given to numb the eyelid. The tumour is removed and the site frozen with liquid nitrogen (cryosurgery) to kill any remaining tumour cells. Tumour cells are usually very sensitive to freezing, and normal eyelid tissue is more resistant. After surgery, the eyelid margin turns pink (de-pigmentation), but usually re-pigments within 4 months.
EMAIL REPLY FROM DR SING DATED SEP 19, 2013
I can understand your concerns as the dog is old and thank you for your research in the article on eyelid tumour removal by one vet practice which claims that general anaesthesia is risky and the practices claims that it uses sedation and local anaesthesia to avoid the risks. Sedation is used at that practice and it does carry risks too. Even local anaesthesia has risks of adverse reactions.  

As the surgery, sedation and general anaesthesia with isoflurane gas is very short (<5 30="" and="" are="" at="" based="" be="" blood="" br="" case="" chances="" death="" dog="" dogs="" don="" dying="" electro-surgical="" examination="" excision="" experience="" general="" have="" he="" healthy="" i="" if="" in="" is="" low.="" minute.="" minutes.="" minutes="" my="" not="" of="" old="" on="" operating="" over="" procedure="" risk="" short..="" since="" so="" surgical="" t="" table="" test="" the="" this="" tumour="" very="" when="" will="" years="">
Sedation and local anaesthesia can be used as an alternative to remove the eyelid tumour. It is hard to achieve full pain relief if sedation is not given at full dose.

In my case, sedation is given at 50% of the dose and the isoflurane gas given for <5 3="" achieves="" analgesia.="" and="" br="" complete="" completely="" dog="" excised="" eyelid="" in="" is="" less="" minutes="" movement="" no="" pain="" properly="" s="" seconds.="" than="" the="" tumour="" with="">
Isoflurane gas is very safe and many times, I have used it solely for over 100 Caesarean sections of dogs stressed out by the breeder's delay in seeking prompt surgery. Those dogs were operated WITHOUT sedation using just isoflurane gas anaesthesia. None died from the anaesthesia.

Of course they were younger dogs but they were under considerable stress. In brief, old dogs with very short surgical procedures and anaesthesia ,<15 30="" died="" experience="" have="" in="" minutes="" my="" not="" of="" on="" operating="" over="" p="" past="" practice.="" table="" the="" years="">
I hope the above provides a satisfactory explanation. It is best not to research too much the technical aspects of anaesthesia to get worried. Chances of your dog surviving are excellent as your dog is eating normally and is active. The surgery to remove the eyelid tumour will be over in 3 seconds and I normally don't even inform some owners about anaesthetic risks as the risks are minimal if I assess they are worried.        
Best wishes. 
Dear Dr Sing 
Thank you so much for your comprehensive answer to our concerns! Appreciated. 
Now we feel much more calm and relaxed and can sleep better.
Finally, we do hope that the tumour is not malignant which the analysis will show later. 
Good night, and see you tomorrow.
With warm regards
UPDATE AS AT SEP 25, 2013

I operated on the husky on Sep 20, 2013 with Dr Daniel doing the anaesthesia and Niang assisting. The wife was present during IV sedation as this dog was "nervous" if the wife was not around during sedation. I asked my assistant Niang to tie a tourniquet using the infusion drip tubing looped over the elbow. However, the cephalic vein could not be seen as the dog was quite plump. "Clip the hair around the cephalic vein to see it," suggested Niang. "No," I said as that would not be good for the dog's appearance.

"You didn't tighten the tourniquet sufficiently," I lifted up the tubing. "I can put two fingers under it."

Niang said: "You do it yourself." This behaviour was not good for a young man and I had counselled him before as other employers would have terminated his services if he cannot control his mood when his job incompetencies are pointed out on the spot.

Dr Daniel palpated for the cephalic vein with his finger while Niang still gripped the elbow area of the right leg. The wife was present all the while. Dr Daniel inserted the needle in the region of the cephalic vein and drew blood into the syringe at the first prick. He injected the sedative of Domitor + Ketamine according to my formula and at 50%. I told the wife that it was OK for her to leave her dog now.

She left the room and the driver drove the couple home. The couple  had been waiting since 11 am for Dr Daniel who started work at 12.30 pm. They had first consulted Dr Daniel and so they just would not want to leave the dog alone till it was time to operate and so waited patiently in the waiting room. Usually I ask the owner to bring in the dog at 11 am so that the dog would settle down but this couple wanted to wait.
The eyelid tumour was large and I made a large electro-excision so as to have a wider margin in case it is a malignant tumour. "You are cutting off too big an area," Dr Daniel commented as I took a pair of blunt-edge scissors to trim off the jagged edge and undermine the  skin before stitching with 3 interrupted sutures of 3/0 absorbable sutures. The wound was large, around 2 cm at the base of the triangle  (see image below) and Dr Daniel must be wondering how I would be able to stitch up the wound.

Overall, the isoflurane gas + O2 was given for 24 minutes. This was not a 5-minute surgery as the tumour had expanded as you can see in the images. The dog survived and that was what the owner wished for. So it was a happy ending.

A vet in another practice had told the owners earlier that there was no need to operate such a small eyelid tumour. But it grew bigger and bigger and the dog started scratching the eyelid. So, the owner decided to operate. However, I had to get "informed consent" which meant letting them be aware of the anaesthetic risk of dying and this just was worrisome to the couple. "Eyelid tumours are best removed when they are very small," I said. "Your first vet may not like surgery and so advised to leave it alone. Some vets just don't like to perform surgery and prefer medical cases. You probably encountered one such personality."
It was great that there was a happy ending and the dog would be on a diet. "No more beef jerkys from Italy," I saw the owner eating such treats (air-dried) that were a specialty in the province of Italy and sharing with his Huskies. His wife said it was too salty.
 
Another surgical approach is such that the apex of the triangle is uppermost as contrasted to this approach where the apex was at the eyelid margin
     
UPDATE ON SEP 27, 2013

Histology reports indicated that this eyelid tumour is a sebaceous adenoma. I phoned the owner on Sep 26, 2013. He is happy that it is not malignant and asked me to email to him the lab report. The dog is still wearing the e-collar and is normal and I presume, eating jerkys from Italy.

Many Singaporean pet owners are worried about anaesthetic deaths and so small tumours get ignored till they become massive and irritating the dog, causing bleeding with blood soiling the floors and painful cries and infections.

As this dog's eyelid tumour was large, it took around 24 minutes of general anaesthesia to complete the surgery.  The dog was not given Antisedan reversal as the owner wanted her to wake up slowly. Usually I gave the antidote to get the dog to wake up early so as to restore the body systems to normal earlier.  

Surgery with general anaesthesia causing death on the operating table frightens away many owners from treating their dogs. The risk is there but is very low if the old dog is healthy. See video of a 15-year-old Maltese operated at
https://www.youtube.com/watch?v=7c_QNAHP3wY
https://www.youtube.com/watch?v=P54Q6NZgK7w

 
Updates will be on this webpage:
www.sinpets.com/F6/20130920
anaesthetic_risk_old_Husky.htm

More info at: Dogs or Cats
To make an appointment:
e-mail judy@toapayohvets.com
tel: +65 9668-6469, 6254-3326
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