A bright sunny morning on Thursday, Sep 13, 2012. I went to the Surgery at 8.45 am as usual. Dr Daniel is in Langkawi yesterday. I handled his post-op cases including this Shih Tzu with complications of blocked bladder. As his mentor, I took over the case as it was too complicated for him, being a recent graduate, to handle.
In any case, every vet has his or her own approach to resolving a challenging post-operation problem and his was to stitch up the original urethrostomy so that the dog could pee from the normal penile opening when he took over the case around 5 days ago from the other vet who had done a bladder surgery. But after the bladder surgery, there was large swelling in the prepuce and scrotal sac and possibly in the left inguinal area but this was denied.
But the other vet said that the scrotal sac was filled with fluid as found out on ultrasound. As to whether the fluid was urine (from a damaged urethra at the bend of the urethra via difficult initial catherisation) or pus and blood or all 3, she said that ultrasound would not be able to by thdifferentiate. Ultrasound would indicate the presence of fluid. I did not ask if she had aspirated the scrotal sac. In any case, she had recommended a 2nd hole (2nd urethrostomy) to be opened up and closed the first hole which was obstructed with pus and fibrous tissue. The owner did not want another surgery costing $1,200 and so, the case came to Dr Daniel.
He did a castration (testicles abnormally small) and removed white fatty tissue in the swollen left inguinal area (size of 6 cm x 6 cm containing around 30 ml of blood + fluid aspirated daily for the past 4 days) as requested by the owner. I had asked him why he did it as this dog already had much complications of not being able to pee normally. He ought not have done it but the owner had asked for this service.
After his excision of the left inguinal area fat, fluid + blood of around 30 ml (aspirated daily) accumulate every day for the next 3 days. Why? What was it? The urine was passed via the cathether and did not contain blood. He irrigated the bladder daily and the dog was OK, till on Day 4 when the dog had fever and there was some tissues inside the urine passed out.
As he would be going on leave and in any case, this was such a complicated emotional expensive case (the owner having spent over $2000 on the blocked bladder surgery and more money on the earlier 2 related urinary stone surgeries, excluding expenses at Toa Payoh Vets, I took over the case. There is so much time spent on commuicating with the owner who visited every evening and this time spent are not billed though young vets don't realise it.
NO FURTHER LEAKAGE
Yesterday, from 10 am, I did a 2-hour surgery to cut off the hard scrotal sac and opened up the first urethra hole done by a vet some months ago. I extended the incision. My hypothesis is that the SC fluid in the left inguinal area could have come from the bladder via the leakage from the urethral opening (lst urethrostomy) which, though stitched up with 2 interrupted sutures, was found to still be opened in between the two stitches. The opening was around 3mm in length and I suspected the leakage over 24 hours would be from there into the SC area.
However the lab could NOT determine whether the SC fluid + blood sent by me was urine or not and so this part of the mystery could not be resolved.
The important thing is that the SC area should not again be filled with 30 ml of fluid + blood every morning as in the past 4 days leading to pain for the dog and fever on the 4th day before Dr Daniel left for Langkawi (ie. on Tuesday). My hypothesis is that the urethra further up, at the bend was damaged and caused pain during urination. Therefore the dog could not pee properly and the other vet had suggested a 2nd urethrostomy nearer to the bend and scrotal ablation (cut off the scrotal sac).
Where's the leak? Was it from the damaged urethra at the bend? This was most consistent with the filling up of the scrotal sac after the blocked bladder surgery and difficult catherisation of the urethra (the other vet said a cat catheter - smaller in diameter had to be used as it was difficult to catherise the urethra due to blockage by pus and fibrous tissue around the first hole). So, urine leaked into the scrotal sac which had two testicles. The testicles became smaller due to compression of the testicles by urine and blood from the urethra damage at the bend (ultrasound had been done to show fluid inside the scrotal sac, as said by the other vet.). Urine also back-flowed to the big left inguinal area where the mass of fat had been removed.
Therefore, in theory, if I extended the first hole, the urine leakage from the bend into the SC tissues into the scrotal sac (no fluid on needle aspiration yesterday. Filled with reddish brown hard tissues and pockets of pus, with testicles already removed by Dr Daniel 3 days ago).
So, in hypothesis, if I did the above surgery (extended the first urethrostomy and do scrotal ablation), the SC fluid inside the inguinal area should not be present.
At 9 am today, I checked the dog and took some images. The hypothesis was verified and there was no swelling. The dog was much happier in the behaviour that when he was turned upside down to examine his inguinal area and do dressing, he did not protest and cried loudly as in the past 4 days.
It was good news. I hope this article will help other vets with similar complications. Never open another hole in the urethra. Just unblock the first hole and extend it. Never suture the first urethra and hope it will close as it might not. In any case, a continuous inverting suture would be needed as in uterine or gastric closing, not interrupted sutures. In any case, this area was infected badly and so, it is doubtful that it would heal well, without stricture and causing obstruction again. A dye would reveal the urine leakage area but the owner would never pay for this and the other vet said she had done nothing wrong and why should her management pay for this test?
In practical terms, resolve the owner's dog complications at the least cost. It is easy for me to criticise.
Thursday, September 13, 2012
Wednesday, September 12, 2012
1088. Complications from 3 blocked bladder surgeries
This article shows that different vets may come to a surgical plan for complicatons of blocked surgery differently.
In summary, this 4-year-old Shih Tzu was seen by me as a puppy 4 years ago and treated twice for minor ailments. He had a blocked bladder some 7 months ago and was seen by my associate vet who diagnosed bladder stones after radiography. The owner took his dog to another vet for surgery as this vet was recommended. The vet made a hole in the urethra behind the os penis (lst urethrostomy) and the dog peed through it for the next 7 months. Then it had a blocked bladder with stones and was operated (lst cystostomy) by a vet in big vet practice 4 months ago. The dog developed same problems 3 weeks ago and the same practice operated to remove the stones from the bladder (2nd cystostomy).
However, the whole penis, prepuce and scrotum were swollen and after paying over $2,000, the owner was asked to pay $1,200 for another surgery to open a new hole in the urethra (2nd urethrostomy) as the dog could not pee properly. The owner would not want to spend more money since the stones were removed and X-ray after surgery showed no stones. He could not understand why there was a need for the $1,200 surgery to open another hole further back in the urethra and to close up the first hole done by the first vet.
The niece knew Dr Daniel and so the case came back to Toa Payoh Vets. The owner complained about a big swollen scrotal sac (which had fluid, according to the vet in the big vet practice, using ultrasound) and a large swelling of over the left inguinal area. Every day for the past 3 days, blood-tinged fluid of 30 ml would be aspirated from this inguinal area. Was it urine or not? Was it peritoneal fluid from a stitch breakdown in the linea alba of the 2nd bladder cystotomy or not?
I sent the SC fluid to the lab for analysis.
I took 2 hours this morning to cut off the infected scrotal sac, tied up the two inguinal rings, removed the two stitches of the original urethrostomy done by Dr Daniel who wanted to close it so that the dog could pee normally from the penile end. I discovered a 2 mm hole and so there could be leakage as well as from the bend of the urethra (only a small cathetheter could be passed through the bend, whereas a bigger one could pass through the penile urethra).
The uncle came again as in the past days, in the evening and asked for explanation. "It took 2 hours just to operate on this dog," I said. "The shorter the anaesthesia, the safer for the dog. No point being the best vet surgeon in the world if the done dies on the operating table due to a lengthy surgery," I advised him. He understood me. This case demanded a lot of communication and only by tomorrow morning will I know if the left inguinal area will swell again, as in the past 3 days.
The lab people phoned me and asked how to check whether the SC fluid is urine or not. "I presume you check for urea," I said. "Oh, you want the chemistry," the lab tech said.
In summary, this 4-year-old Shih Tzu was seen by me as a puppy 4 years ago and treated twice for minor ailments. He had a blocked bladder some 7 months ago and was seen by my associate vet who diagnosed bladder stones after radiography. The owner took his dog to another vet for surgery as this vet was recommended. The vet made a hole in the urethra behind the os penis (lst urethrostomy) and the dog peed through it for the next 7 months. Then it had a blocked bladder with stones and was operated (lst cystostomy) by a vet in big vet practice 4 months ago. The dog developed same problems 3 weeks ago and the same practice operated to remove the stones from the bladder (2nd cystostomy).
However, the whole penis, prepuce and scrotum were swollen and after paying over $2,000, the owner was asked to pay $1,200 for another surgery to open a new hole in the urethra (2nd urethrostomy) as the dog could not pee properly. The owner would not want to spend more money since the stones were removed and X-ray after surgery showed no stones. He could not understand why there was a need for the $1,200 surgery to open another hole further back in the urethra and to close up the first hole done by the first vet.
The niece knew Dr Daniel and so the case came back to Toa Payoh Vets. The owner complained about a big swollen scrotal sac (which had fluid, according to the vet in the big vet practice, using ultrasound) and a large swelling of over the left inguinal area. Every day for the past 3 days, blood-tinged fluid of 30 ml would be aspirated from this inguinal area. Was it urine or not? Was it peritoneal fluid from a stitch breakdown in the linea alba of the 2nd bladder cystotomy or not?
I sent the SC fluid to the lab for analysis.
I took 2 hours this morning to cut off the infected scrotal sac, tied up the two inguinal rings, removed the two stitches of the original urethrostomy done by Dr Daniel who wanted to close it so that the dog could pee normally from the penile end. I discovered a 2 mm hole and so there could be leakage as well as from the bend of the urethra (only a small cathetheter could be passed through the bend, whereas a bigger one could pass through the penile urethra).
The uncle came again as in the past days, in the evening and asked for explanation. "It took 2 hours just to operate on this dog," I said. "The shorter the anaesthesia, the safer for the dog. No point being the best vet surgeon in the world if the done dies on the operating table due to a lengthy surgery," I advised him. He understood me. This case demanded a lot of communication and only by tomorrow morning will I know if the left inguinal area will swell again, as in the past 3 days.
The lab people phoned me and asked how to check whether the SC fluid is urine or not. "I presume you check for urea," I said. "Oh, you want the chemistry," the lab tech said.
1087. Coincidence? Zhaobao article on dogs
After operating on the Shih Tzu with complicated problems, an old friend drove me to her office in People's Park. There I met her brother who said: "I read the Zhaobao. It was given free and I have never read Zhaobao. There, I read about you as a vet. I didn't know that dogs can get poisoned from eating grapes!"
I was surprised he read this newspaper and saw my interview. I don't read Zhaobao and so I did not know when the reporter would publish the article. It is rarely that I get interviewed and so this was much of a coincidence.
Another coincidence was that my old friend's dog had died of canine lymphosarcoma many years ago. Today, I met an old client who told me that her dog Sparky had passed away suddenly, due to tumours on her diaphragm, as she had surfed the net to find out.
"Did your Jack Russell recover from mouth ulcers after dental scaling?" I asked her. The dog had swollen lymph nodes on submandibular area.
"Yes," she said. "She ate and was normal in drinking, peeing and pooping. She just died 3 months later." It was nice to know she had a good quality of life.
What's so coincidental about the above. The lymphosarcomas of the two dogs and the Zhaobao incidents of the brother. Was there a message from the "datuk" above? My friend believes in the "datuk" and there are stories I had written some time ago in the powers of the "datuk".
I went back to the Surgery at 6 pm. The Shih Tzu was barking like mad which was a good sign. He had fever yesterday and pus in his urine.
I was surprised he read this newspaper and saw my interview. I don't read Zhaobao and so I did not know when the reporter would publish the article. It is rarely that I get interviewed and so this was much of a coincidence.
Another coincidence was that my old friend's dog had died of canine lymphosarcoma many years ago. Today, I met an old client who told me that her dog Sparky had passed away suddenly, due to tumours on her diaphragm, as she had surfed the net to find out.
"Did your Jack Russell recover from mouth ulcers after dental scaling?" I asked her. The dog had swollen lymph nodes on submandibular area.
"Yes," she said. "She ate and was normal in drinking, peeing and pooping. She just died 3 months later." It was nice to know she had a good quality of life.
What's so coincidental about the above. The lymphosarcomas of the two dogs and the Zhaobao incidents of the brother. Was there a message from the "datuk" above? My friend believes in the "datuk" and there are stories I had written some time ago in the powers of the "datuk".
I went back to the Surgery at 6 pm. The Shih Tzu was barking like mad which was a good sign. He had fever yesterday and pus in his urine.
Tuesday, September 11, 2012
1086. Open pyometra Jack Russell - the old vet did it
"The old vet did it," the sister said when I asked about a pyometra surgery done on her JR in Nov 2011. I checked the records and it was I who did the surgery. As part of my succession plan, many cases are now handled by Dr Vanessa and Dr Daniel Sing. So, the old clients don't see me.
However I do consult in the mornings before 12 noon and am usually at the Surgery at 8.30 am. If I handle all the cases, the associate vets will have nothing to do and not gain the necessary experience over time. I do check every case handled by the associate vets and inform them of any matters to ensure a higher standard of veterinary medicine and surgery.
Associate vets have to understand that a more demanding and sophisticated clientele requires much more expertise of Toa Payoh Vets which has been established for over 30 years. Just treating coughs and colds is not the main focus of Toa Payoh Vets. Veterinary surgical skills are being built up.
However I do consult in the mornings before 12 noon and am usually at the Surgery at 8.30 am. If I handle all the cases, the associate vets will have nothing to do and not gain the necessary experience over time. I do check every case handled by the associate vets and inform them of any matters to ensure a higher standard of veterinary medicine and surgery.
Associate vets have to understand that a more demanding and sophisticated clientele requires much more expertise of Toa Payoh Vets which has been established for over 30 years. Just treating coughs and colds is not the main focus of Toa Payoh Vets. Veterinary surgical skills are being built up.
1085. Update on bladder stone complications Shih Tzu
Yesterday, the Shih Tzu had another 30 ml of fluid aspirated from under the left inguinal skin area as also the day before. Dr Daniel told me that the owner had given instructions to operate to find the source of the leak.
"It is not as simple as that," I advised Dr Daniel. "There is the legal aspect. If the dog dies, you get the blame although you can say that the dog was already leaking "abdominal fluid" every day. You need to advise the owner to contact the original vet operating on this dog and find out what was done. The dog was said to be hospitalised for 8 days after surgery there.
Today Sep 11, 2012, the Shih Tzu has high fever 41 deg C.
Monday, September 10, 2012
1084. Yellow pages advert for new vet surgery in Yangon
The advertisement must be attractive for a new vet clinic. As requested by a friend, I have the following concept for her advert. See webpage at:
http://www.sinpets.com/F6/20120906advert_yellow_pages_toapayohvets.htm
A friend requested my help to craft an advertisement for her new veterinary surgery in the yellow pages of Yangon for 2013. An example of an advertisement for the yellow pages. As there is no image of the Royal Asia Veterinary Surgery, I have used CAU Animal Clinic, Hong Kong and other images as an example of the layout as I don't have the actual images
http://www.sinpets.com/F6/20120906advert_yellow_pages_toapayohvets.htm
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 | Welcome To Veterinary Services of Yangon, Myanmar | |||||||||||||||||||||||||||
| Image of township | ||||||||||||||||||||||||||||
 | Image of clinic front (left) Logo. Royal Asia Veterinary Surgery is a full service small animal practice located in .....Yangon, Myanmar | |||||||||||||||||||||||||||
| Myanmar language of name of surgery here | We offer preventative care (including vaccinations, blood & urine tests for health screening), radiology, laboratory tests, dentistry, surgery (including sterilisation, tumour removal, Caesarean section, orthopedics, diagnosis and treatment of diseases in dogs, cats, rabbits, guinea pigs, hamsters, turtles, fishes and birds. We provide general veterinary care for your pets and hospitalisation facilities. | |||||||||||||||||||||||||||
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Sunday, September 9, 2012
1083. Sunday Sep 9, 2012's interesting cases
Sep 9, 2012
I went to Surgery at 8.30 am this Sunday to check on 2 in-patient cases - the urethrostomy Shih Tzu that still has a large SC swelling to the left of the penis and the old poodle with cement-grey teeth.
SHIH TZU WITH URETHROSTOMY
Crying in pain when handled. Large SC swelling over 6 cm x 6 cm caudal to the incision to remove bladder stones done by the other vet. Over 20 ml of blood-tinged fluid was aspirated with a syringe by Dr Daniel. "It can't be urine," Dr Daniel said when I suggested it could be urine from the urethrostomy hole closed by him using skin sutuers.
"The catheter shows yellow urine without blood."It is possible that it is urine mixed with blood of the SC swelling."
"The SC swelling has only fat," said Dr Daniel who excised it earlier and neutered the dog as requested by the owner.
"It could be abdominal fluid," I said. "A stitch breakdown in the linea alba where the vet did the bladder surgery. What you saw under the skin was the subcuticular suturesd which had broken down at one part. The vet would have incised the skin parallel to the penis. Then he or she would have shifted the penile shaft to one side and then incise the linea allba to take out the bladder to remove the urinary stones. What you removed earlier were the stitch breakdown of the SC continuous sutures to close the skin. There were no over the skin sutures as some vets prefer to impress the owner with this method. Unfortunately, part of the continuous sutures broke down and you had to re-stitch to close up the skin. But you did not see the linea alba stitch because the penis would have been relocated back to its original midline position covering it.
"If there is the break of stitching in this linea alba, the left SC area would swell again with fluid, just like yesterday. You have to inform the owner of this incident." The owner was uncontactable and so he was not informed.
Struvite management by diet ought to be started soon. "The dog vomited all the SD diet yesterday," Dr Daniel said to me. "80% of the old diet plus 20% of the SD diet should be given originally," I explained. "Some dogs don't eat SD immediately as it tastes different." Will have to follow up. This seems to be a more complicated case than it appears. If the linea alba stitching had come undone, another operation needed to be done to close it. The big SC swelling on the left inguinal area apparently appeared after the other vet had done the bladder stone removal. Got to verify with the owner.
Send fluid for examination," I said to Dr Daniel.
POODLE WITH CEMENT-GREY TEETH
"The blood test showed a very high total WCC and low platelets, suggesting a high bacterial infection. That is why the dog stopped eating for 2 days and your wife quickly brought her for treatment. I thought she would die, being so thin. But she is eating now, after the IV drip and medication." This was good news for his wife who is overseas.
Cement-grey teeth? Really as grey as cement as you would see from the images.
"The most likely cause of bacteria would be from the mouth - the rotten teeth," I said. "They need to be removed."
"But the other vet we consulted 2 years ago said the dog would die under anesthesia and so we did not do any dental work," the husband visited the dog this morning. "The dog keeps drooling and has bad breath,"
CIRCUM-ANAL TUMOUR IN A MALE SPITZ
"I don't think the old vet can operate," the man said his dogs' anal area had a lump which bleeds. It was originally small and the wife could squeeze out the pus. But it kept growing bigger.
"So, I come to Toa Payoh Vets."
"The vet would usually refer cases to one particular practice," I said.
"Yes," the gentleman with his wife and daughter near him said." I don't like the practice this old vet refers me to.
"It is a case of circum-anal tumour," I said. "It needs to be removed as it seems to be growing bigger, now it being 5x5x3 cm. I will operate with Dr Daniel," I said. "As it is infected, it is best excised 2 days later. Otherwise the wound will not heal well."
SURGICAL APPROACH
"What is your surgical approach?" I asked. "It is a big tumour and if you have high tension, your ordinary stitching of the big gap will break down."
I asked him to draw and illustrate his treatment plan. As the dog was on a drip, I could not get to see it to sketch the surgical approach. Dr Daniel drew something. "Best is to use Z-plasty in this region and cut 1 cm away from the tumour edge, if possible," I said. "If you try to stitch the big hole in the usual way, you will find stitch breakdown."
I drew the surgical plan, advising electro-surgery and the Z-plasty (see image). Mentoring needs loads of patience.
I went to Surgery at 8.30 am this Sunday to check on 2 in-patient cases - the urethrostomy Shih Tzu that still has a large SC swelling to the left of the penis and the old poodle with cement-grey teeth.
SHIH TZU WITH URETHROSTOMY
Crying in pain when handled. Large SC swelling over 6 cm x 6 cm caudal to the incision to remove bladder stones done by the other vet. Over 20 ml of blood-tinged fluid was aspirated with a syringe by Dr Daniel. "It can't be urine," Dr Daniel said when I suggested it could be urine from the urethrostomy hole closed by him using skin sutuers.
"The catheter shows yellow urine without blood."It is possible that it is urine mixed with blood of the SC swelling."
"The SC swelling has only fat," said Dr Daniel who excised it earlier and neutered the dog as requested by the owner.
"It could be abdominal fluid," I said. "A stitch breakdown in the linea alba where the vet did the bladder surgery. What you saw under the skin was the subcuticular suturesd which had broken down at one part. The vet would have incised the skin parallel to the penis. Then he or she would have shifted the penile shaft to one side and then incise the linea allba to take out the bladder to remove the urinary stones. What you removed earlier were the stitch breakdown of the SC continuous sutures to close the skin. There were no over the skin sutures as some vets prefer to impress the owner with this method. Unfortunately, part of the continuous sutures broke down and you had to re-stitch to close up the skin. But you did not see the linea alba stitch because the penis would have been relocated back to its original midline position covering it.
"If there is the break of stitching in this linea alba, the left SC area would swell again with fluid, just like yesterday. You have to inform the owner of this incident." The owner was uncontactable and so he was not informed.
Struvite management by diet ought to be started soon. "The dog vomited all the SD diet yesterday," Dr Daniel said to me. "80% of the old diet plus 20% of the SD diet should be given originally," I explained. "Some dogs don't eat SD immediately as it tastes different." Will have to follow up. This seems to be a more complicated case than it appears. If the linea alba stitching had come undone, another operation needed to be done to close it. The big SC swelling on the left inguinal area apparently appeared after the other vet had done the bladder stone removal. Got to verify with the owner.
Send fluid for examination," I said to Dr Daniel.
POODLE WITH CEMENT-GREY TEETH
"The blood test showed a very high total WCC and low platelets, suggesting a high bacterial infection. That is why the dog stopped eating for 2 days and your wife quickly brought her for treatment. I thought she would die, being so thin. But she is eating now, after the IV drip and medication." This was good news for his wife who is overseas.
Cement-grey teeth? Really as grey as cement as you would see from the images.
"The most likely cause of bacteria would be from the mouth - the rotten teeth," I said. "They need to be removed."
"But the other vet we consulted 2 years ago said the dog would die under anesthesia and so we did not do any dental work," the husband visited the dog this morning. "The dog keeps drooling and has bad breath,"
CIRCUM-ANAL TUMOUR IN A MALE SPITZ
"I don't think the old vet can operate," the man said his dogs' anal area had a lump which bleeds. It was originally small and the wife could squeeze out the pus. But it kept growing bigger.
"So, I come to Toa Payoh Vets."
"The vet would usually refer cases to one particular practice," I said.
"Yes," the gentleman with his wife and daughter near him said." I don't like the practice this old vet refers me to.
"It is a case of circum-anal tumour," I said. "It needs to be removed as it seems to be growing bigger, now it being 5x5x3 cm. I will operate with Dr Daniel," I said. "As it is infected, it is best excised 2 days later. Otherwise the wound will not heal well."
SURGICAL APPROACH
"What is your surgical approach?" I asked. "It is a big tumour and if you have high tension, your ordinary stitching of the big gap will break down."
I asked him to draw and illustrate his treatment plan. As the dog was on a drip, I could not get to see it to sketch the surgical approach. Dr Daniel drew something. "Best is to use Z-plasty in this region and cut 1 cm away from the tumour edge, if possible," I said. "If you try to stitch the big hole in the usual way, you will find stitch breakdown."
I drew the surgical plan, advising electro-surgery and the Z-plasty (see image). Mentoring needs loads of patience.
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