Wednesday, August 21, 2013

1093. Script for intern: Abscess: Closed pyometra & uterine torsion in an old Maltese

Wednesday August 21, 2013 was a bright sunny morning with blue skies and white clouds unlike yesterday when there was haze from the burning and slashing smoke in the forests of Sumatra. (Video). 

The lady owner brought the 15-year-old Maltese with a large left abdominal swelling for around 7 days to Toa Payoh Vets for surgery.

She had wanted to wait till tomorrow as she was busy. "Any further delay will result in the Maltese being toxic and decreasing her chance of survival on the operating table. Your dog had started eating yesterday because she was given antibiotic injection on Monday and is on antibiotic medication. So she felt better but this is only a respite from a painful death from septicaemia and toxaemia

"Her health will deteriorate as the left swollen uterine body is over-distended with pus and is going to burst like a swollen dam if you procrastinate. It may rupture and spill toxic contents into the abdomen, killing the dog painfully (Video of dog at first consultation at Toa Payoh Vets on Monday August 20, 2013. Subtitled "First consultation on Monday Aug 20, 2013").

During the first consultation, the lady asked about the chances of survival during the anaesthesia and surgery. "Less than 50%," I estimated. "The dog may just die on the operating table. The blood test showed a very low creatinine level which means that the kidneys are not functioning normally (image blood collection and blood tubes). The dog is very old and the heart and blood vessels may be weak due to old age.

This informed consent of risks of anaesthesia caused the owner much concern for some reasons. "What am I supposed to do?" she asked me. "What will you advise? Your professional advice."

"You have no choice but to take the risk and operate. I had advise you to spay her when she was younger and had false pregnancy, this situation would not occur."
"She is my daughter's dog and so there was no decision to spay her. Now I am taking care of her."

The elderly slim lady had wanted proof that the dog was correctly diagnosed as closed pyometra and so I got X-rays done. These confirmed a large left uterine swelling (X-ray images) in addition to the blood test. The blood test did not show an abnormal increase in total white cell count as is common in pyometra but the neutrophils were higher (image of blood test report)), showing that the body was mobilising the anti-bacterial cells. 

The cervix had closed and so the pus was not discharged from the vagina (illustration). So the left uterine horn accumulated more and more pus, swelling to a formidable size of the largest sausage ever seen in the supermarket.  This is a case of closed pyometra and surgery to remove it is the only chance for her to recover." It seems like hard sell as I followed up with this owner whose dog had come for vaccination and dental work since 2005 (image of treatment).

Video of Singapore scenes as 2 days passed (Monday to Wednesday) as the owner could not decide.
The owner arrived at 11 am.
"To be frank with you, I don't like to do such surgeries," I said to the owner as I re-examined the dog. The dog wanted to bite when her abdomen was touched. This was very painful.
"It is such a high anaesthetic risk. The dog may just die in the middle of surgery possibly due to heart failure as she is equivalent to 105 years old person and the heart will not be that strong as a younger dog."

"This surgery needs to be completed very fast." I implied that a faster surgery would reduce the aneasthetic exposure duration and therefore lowering the risk of death. 

"Let Dr Daniel do it," the owner probably misconstrued that a fast operating surgeon is not good for her dog as surgery would not be complete. Speed, Accuracy & Completeness are essential for good surgery. But in this very old dog, speed is predominant. Of course, Accuracy & Completeness are also important. For a speedy surgery, an older vet will be speedier owing to more years of experience. So, I decided to do it.

The old dog was an IV drip. Then she was given isoflurane + oxygen gas by mask. She was intubated. The surgery threw up some surprises as this was a case of closed pyometra and uterine torsion of the left uterine body. Images.

Haemoabdomen - This case - Red blood >300 ml was seen inside the abdomen when I made an insicion into the linea alba. Where's the source of bleeding?  "Peritonitis?" Dr Daniel said.

A brown kidney shaped structure 50% as big as a man's clenched fist was first seen. Monstrous size.   "Could this be a kidney with a large tumour?" I asked. Yet it was loose and free to move about unlike the usual fixed kidney. "It is uterine torsion," Dr Daniel said.

Omental sealed structure. The omental fat wrapped around this structure making it difficult to isolate it and take it out.  The fat seemed to have glued to this structure. What to do? I clamped with 2 artery forceps and cut in between. This separated the structure from other organs like spleen and stomach.

Spleen has splenic abscess (see video).

UPDATE ON AUG 24, 2013
3rd day. OK as she is eating all food. Owner came with adult daughter yesterday to visit as I had complained that the daughter did not visit the rabbit which was originally her pet.Will stay for 7 days as she will jump at home, causing stitch breakdown.



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