Vets on the Balkans - an online journal for veterinarians from the Balkans

8 years Vets on The Balkans Conference- “Vets for Cats” 2024

December 3, 2023

We are delighted to announce that in 11-12^th May 2024 will hold our next conference at Ramada Parc Hotel in Bucharest, Romania.

We will enjoy the knowledge of Dr Luca Ferasin, DVM PhD CertVC PGCert(HE) DipECVIM-CA (Cardiology) GPCert(B&PS) FRCVS, European (EBVS) and RCVS Recognised Specialist in Veterinary Cardiology and Dr Ana Nemec, DVM, PhD, Dipl. AVDC, Dipl. EVDC, Assist. Prof., in Veterinary Dentistry.

We will have 2 more guests, local veterinarians, Dr Teodoru Soare,DVM,PhD Senior Profesor – Veterinary Pathology and Dr Elena Nenciulescu DVM, MRCVS – Veterinary Dentistry.

Scientific Program:

11^th May

8:00-9:00 Registration and welcome coffee

9:00- A fresh approach to heart murmurs in cats.

Dr Luca Ferasin

9:45- Oral Tumors- staging and treatment options

Dr Ana Nemec

10:30-11:00- Coffee Break

11:00 -Is classification of feline cardiomyopathy truly useful?

Dr Luca Ferasin

12:30-13:30 Lunch

13:30-The most common oral tumors in cats

Dr Ana Nemec

14:45- Dr Teodoru Soare- Pathology

15:30-16:00 Coffee Break

16:00 -Clinical cases- presentations of local vets

12^th May

9:00-A practical approach to the fainting cat.

Dr Luca Ferasin

9:45- Biopsy is always indicated: non-neoplastic oral lesions in cats

Dr Ana Nemec

10:30-11:00- Coffee Break

11:00-Beyond furosemide. Current therapeutic options in feline cardiology

Dr Luca Ferasin

12:30-13:30 Lunch

13:30- Two poorly understood clasics-feline chronic stomatitis and tooth resorption

14:45- Dr Elena Nenciulescu- veterinary dentistry

16:00-Clinical cases- presentations of local vets

17:00-TOMBOLA

Soon will be opened and the registration, the price for both days is 100 euro.

Thank you to our general sponsors:

Hills

Pamas Trading

Taste of The Wild

Vet Pharma Distribution

Veteco

Boehringer Ingelheim

Because of them we will enjoy our meeting full of knowledge.

Soon we will come with more information

Ear tip vasculitis in a Bull Terrier dog – case report

October 21, 2023

Dr Giulia Nadasan-Cozma

Giu The Vet- veterinary clinic

Arad, Romania

Pacient data and history:

Name: Connor

Breed: Bull Terrier

Age: 2 years

Patient presented for a dermatological consult after a few days of bleeding from the auricular pinnae.

The owner noted that the onset was acute, the lesions appeared “ overnight” and the animal was bothered by them, and started scratching and bleeding.

Dermatological findings:

Vasculitis lesions are noted bilaterally on the apex of the pinnae consisting of alopecia, ulceration, crusting in different stages and necrosis that led to loss of tissue and altered the shape of the pinnal apex.

The crust comes off very easily and hemorrhage starts.

Lesions begin at the apical margins of the pinnae and spread along the concave surface.

Diagnosis:

A sample was performed by the impression smear technique and sent to the lab for cytology. The result was consistent with neutrophilic acute inflammation. In correlation with the clinical aspect, we had a strong suspicion of vascular damage, which may be caused by inflammatory or noninflammatory diseases, and often are idiopathic. The diagnosis is normally confirmed by histopathology but unfortunately the owner did not agree with the medical procedure.

Diferential diagnosis:

Proliferative thrombovascular necrosis of the pinnae is the dermatological diagnosis but to confirm this diagnosis, a biopsy and a histopathology exam is needed.

Ear tip ulcerative dermatitis can be another dermatological diagnosis.

Vaccine associated vasculitis can be another cause.

Vasculitis can be associated with coexisting disease like hypersensitivity disorders, food allergies, insect bites and many drugs administration, even dexamethasone or prednisone.

Given the note that Connor is an atopic dog, atopy itself can be the reason these lesions appeared because he was treated with prednisolone over an year because of his atopic syndrome and owner’s budget restraints.

Treatment and outcome:

After a long talk the owner chose surgery but in the end we managed to convince him to try medication for at least 14 days.

The following treatment options were offered:

1: Oclacitinib

Dosage: 0.5-0.6 mg/kg/12 h

1 tablet of 16 mg to be given BID 30-90 days according to the studies

Local topical Tacrolimus 0,1%
Pentoxifylline tablets, dosage 15mg/kg BID
Doxicycline tablets, 5 mg/kg BID
Niacinamide tablets 500 mg/dog TID, for 30-90 days, may not work.

Treatment with oclacitinib (Apoquel 16 mg) was started despite budget restraints and Connor started to get better by day 7.

The treatment lasted 7 weeks ( 49 days) until complete remission of lesions.

He continued with Apoquel 16 mg 1×1/24 h to control his atopic syndrome.

Conclusion:

Oclacitinib it is not typically used to treat vasculitis in dogs but should be included

among the therapeutic options for ear tip vasculitis if there are no signs of infection. Oclacitinib has immune modulatory effects on numerous cytokine-mediated inflammatory, autoimmune or immune-mediated diseases in dogs. This type of vascular damage of the pinna is sometimes idiopathic and is hard to find a definitive diagnosis without a histopathology exam.

References:

Silvia Colombo, Luisa Cornegliani, Antonella Vercelli, Alessandra Fondati – Ear tip ulcerative dermatitis treated with oclacitinib in 25 dogs: a retrospective case series (2021) – Veterinary Dermatology
Thelma Lee Gross, P. J. Ihrke, E.J. Walder, V.K.Affolter – Skin diseases of the dog and cat, 2nd Edition, 2020, Blackwell
Rosanna Marsella, Katherine Doerr, Andrea Gonzales,Wayne Rosenkrantz – Oclacitinib 10 years later: lessons learned and directions for the future

(2023) – J Am Vet Med Assoc.

William H. Miller Jr., Craig E. Griffin, Karen L. Campbell – Muller and Kirk’s Small animal dermatology, 7nd Edition, 2012, Elsevier

OSTEOMIELITIS OF THE MANDIBLE IN A 7-YEAR-OLD CAT -case report

July 15, 2023

Michel (Mihai) GUZU, DVM, Dipl EVDC, ADVETIA Small Animal Hospital, Vélizy-Villacoublay, France
Dr Mihai Guzu

Dr Elena Nenciulescu

Elena Carmen NENCIULESCU, DVM, MRCVS, PET STUFF Small Animal Hospital, Bucharest, Romania

Address correspondence to Dr Guzu: guzu@advetia.fr

History and Clinical Examination Findings

A 7-year-old 5.350 kg neutered male Domestic Shorthair cat was referred for loss of appetite and generalized weakness lasting for 10 days. The owners reported a short episode of hemorrhagic ptyalism (for 24 hours), accompanied by moans and chewing efforts. Previous injection 0.1 mg/kg and prescription 0.05 mg/kg of meloxicam PO, q 24 h, for 2 days only permitted minor transitory food intake improvement. On physical examination, the patient appeared mildly dehydrated (5%) and hyperthermic (39.4°C ). Halitosis with concurrent rostral mandibular swelling were noticed. The swelling was fluctuating, with pain elicited by palpation. A seeping sore spot was observed on the ventral aspect of the mandible (Figure 1).

Figure 1: Initial clinical presentation, with appearance of the rostral intermandibular region before (a) and after shearing of the area of the swelling

Moderate bilateral mandibular lymph node enlargement was noted on palpation. Examination on the awake patient was very uncomfortable and the cat only allowed a brief evaluation of the oral cavity. An inflammation of the gingiva surrounding the right mandibular second incisor and the right mandibular canine teeth (402 and 404) was otherwise reported. The remaining physical examination was within normal limits. Biochemistry profile and ionogram results were unremarkable and the FIV/FeLV SNAP test was negative. Complete blood count and serum biochemistry were within normal limits.

A 22G intravenous catheter was placed on the right cephalic vein. The patient was premedicated with methadone hydrochloride 0.2 mg/kg IV and dexmedetomidine 5 µg/kg IV. The patient was induced with propofol 2 mg/kg IV, a 4.5 oral endotracheal tube was placed and then isoflurane 1.5% at a 2L/min rate of oxygen was used for maintenance. Intraoral examination under general anaesthesia and dental charting revealed severe focal periodontitis involving the right mandibular second incisor and the right mandibular canine teeth, with concurrent absence of several incisor teeth. Lateral and occlusal intraoral radiographs were obtained. Selected radiographic views are provided (Figure 2).

Diagnostic Imaging Findings

Radiographic study of the mandible highlighted stage 4c dental resorptive lesions of 402 and 404 (Figure 3). Three root fragments of incisor teeth were noticed (301, 302, 401). An ill-defined bone proliferation with osteolysis involving the surrounding bone was associated with extrusion of the right mandibular canine tooth (404) and concurrent enlarged periodontal space. Cytological examination under light microscope of a transcutaneous fine needle aspirate of the lesion showed degenerated neutrophils, bacteria and some phagocytic activity.

fig 3

Figure 3: Surgical debridement (a) and immediate postoperative aspect of the advancement flap with passive drain in place (b). Followed: Histological analysis reports ulcerative gingivitis with severe chronic suppurative osteomyelitis and inclusion of intralesional bacterial colonies. During the control on day 5 after surgery dehiscence of several skin points is noted after removal of the drain. Open wound management with iterative hydrocolloid dressings was undertaken for an additional 14 days. Skin point removal was performed 27 days after the initial presentation (Figure 4).

Treatment and Outcome

Within the same general anesthesia, bilateral inferior alveolar nerve blocks (intraoral approach) were performed using a mixture of 0.2 ml lidocaine 2% and 0.8 ml bupivacaine 0.5%. The surgical procedure had 2 parts – an intraoral procedure (dental extractions and biopsy of the diseased mandibular bone) and an extraoral procedure (debridement and reconstruction of the skin). For the first part, with the patient in lateral recumbency 10 mm mucosal incision was performed over the alveolar ridge on the distal aspect of the mandibular canine teeth and was prolonged mesially within the sulcus of the mandibular incisor teeth with a #15c scalpel blade. A mucogingival envelope flap was lifted using a Chompret stripper and a Molt periosteal elevator. Simple extraction of the incisor teeth was performed with a 1.5 mm dental luxator used in a circumferential motion. An external alveolar ostectomy was then performed mesially to the mandibular canine teeth (304 and 404) with a round tungsten carbide burr under irrigation over 50% of the height of the roots. 304 and 404 were extracted using a 3 mm luxator. Curettage of the alveolar sockets and of the remodeled bone was performed using a 3 mm Volkman curette for specimen submission to histology. A minimal alveolar osteoplasty (alveoloplasty) using a round diamond burr under irrigation was eventually performed before closure of the defect with a simple interrupted pattern suture with 5/0 polyglecaprone 25, by moving the flap in translation. For the second part of the procedure, the patient was placed in dorsal recumbency. Clipping and antisepsis (with iodine soap and iodine) of the mandibular and cervical cranial area were carried out before surgical draping. The cutaneous and subcutaneous tissues were debrided over a 3 x 3 cm area, then the site was thoroughly rinsed with a 0.9% NaCl solution (Figure 2). Reconstruction of the defect was undertaken using a submandibular skin flap advanced rostrally. A multi-fenestrated drain was inserted and secured ventrally. A first intent closure of the wound was considered using a simple interrupted pattern suture nylon (Figure 3). Perioperative amoxicillin-clavulanic acid 20 mg/kg was administered by slow IV injection, as well as a postoperative injection of buprenorphine 20 μg/kg IV and meloxicam 0,1 mg/kg SC. Amoxicillin-clavulanic acid 12,5 mg/kg BID for oral relay over a 10 days course and oral meloxicam SID for 5 days were prescribed postoperatively. Placement of a buster collar was recommended during the entire convalescence period.

The patient recovered uneventfully after surgery.

Figure 4: Clinical aspect of the operating site during the control at 3 months after the procedure.

Discussion

Mandibular swellings may be associated with a fluid collection, such as a cyst, inflammatory seroma, hematoma or, in some cases, a subcutaneous abscess. Development of subcutaneous abscesses may be related with penetrating or migrating foreign bodies, bites or scratches incidents, especially from other cats. A dental etiology (endodontic and/or periodontal disease) must be considered whenever the location involves the oromaxillofacial area. Some local or systemic conditions (neoplastic, inflammatory, infectious, metabolic or endocrine) may trigger the condition. The differential diagnosis summarizing the main causes responsible for mandibular swellings is shown in Table 1.Main DDx of orofacial swellings in cats

The radiographic findings in this case mainly support the hypothesis of a secondary osteomyelitis with regional subcutaneous abscess due to periodontal-endodontic complications of resorptive lesions. The prevalence of dental resorptive lesions varies between 25 and 40% in the general feline population. This rate is as high as 60 to 70% in purebred cats and/or presented within a dentistry department (Girard, 2008 et 2010; Van Wessum et al, 1992). The condition combines heterogeneous, destructive and progressive lesions of the tooth, resulting in ankylosis and replacement of dentoalveolar structures by bony tissue (ghost tooth). The resorption mostly initiates at the level of the radicular cementum and progresses towards the root and/or the dental crown. Involvement of the dental crown is usually associated by a characteristic crenate-looking patching gingiva filling the enamel-dentinal defect corresponding to the progression of a granulation tissue. Many local conditions (e.g. lack of oral hygiene and development of periodontitis, tooth fracture with pulpitis, chronic gingivostomatitis, occlusal trauma) have been documented in the literature, and some systemic causes (e.g. genetic, nutritional) have been suggested as possible triggering factors in the development of the disease in the feline patient. The resulting pulpal exposure (pulpitis) and/or progression towards periodontitis may then be associated with an endodontic-periodontal lesion, significantly decreasing the oral health status. In those cases, an acute pain may sometimes be elicited by finger percussion of the jaw. A characteristic, but not specific jaw trembling reflex may then be observed. The earliest affected teeth statistically reported in the literature are the mandibular third premolars (307 and 407). (Ingham, 2001) However, all teeth may be involved, with progression towards a generalized disease possible in some individuals. Typical but non-pathognomonic presentation is possible in canine teeth (dental extrusion or occult root destruction). Several clinical and radiological classifications have been proposed by the American Veterinary Dental College (AVDC) in regard to the location and severity of the lesions. (DuPont, 2002) A similar condition has also been described in humans and dogs, but is slightly different from the feline presentation. (Heithersay, 2007; Kim, 2013; Nemec, 2012; Peralta, 2010) Despite many evoked tracks (traumatic, metabolic, infectious, nutritional or genetic), the etiology of the feline tooth resorption remains rather vague and no prophylactic approach is available to date. (Okuda & Harvey, 1992; Reiter, 2005; Girard, 2008) It seems that metabolism of vitamin D may play a key role in the odontoclastic activation process. (Booij-Vrieling, 2009)

When facing an oromaxillofacial swelling, it is important to consider the specificity of the area, in particular the proximity of oral, nasal, orbital, nodal, vasculo-nervous or salivary structures. Reclining the lips and tongue, allowing a more detailed inspection of the gingiva, vestibule, floor of the mouth, as well as the ventral and lateral aspects of tongue is therefore essential. Fine needle aspiration should be performed whenever possible as cytological examination could bring additional information that could further guide diagnostic and therapeutic approach. Evidence shows a favorable predictive value of about 69% even in case of neoplastic conditions. (Ghisleni, 2006) The histopathological examination remains cornerstone, in order to confirm the diagnosis given the high rate of secondary infection in or near the oral cavity. According to the information gathered during the clinical examination and the localization of the lesion, different diagnostic imaging tools could be considered. The conventional extraoral radiography has two major disadvantages compared to the dental radiography: superimposed images and lack of sensitivity in the exploration of dental conditions (Chapnik, 1989). The CT scan provides good information in regard to the extension of any swelling condition. However, only 42 to 57% of the dental resorptive lesions are diagnosed on the CT scan when compared to the intraoral radiography (Lang et al, 2016) Therefore, dental radiographs still constitute the gold standard imaging method to diagnose tooth resorption. New diagnostic imaging devices such as the cone-beam computed tomography scan (CBCT) might be an interesting alternative in the exploration of these dento-alveolar conditions in the future. (Naitoh et al, 2010 ; Soukup, 2015 ; Creanga, 2015)

Extraction of the affected tooth by resorptive lesions remains the treatment of choice. (DuPont, 2005) According to the topography of the lesions, conservative techniques (glass ionomer restoration) have historically been described in early forms, localized to the collar and dental crown. However, the outcome for those teeth remained poor, with inevitable progression of the disease in the majority of the cases. In advanced forms, with associated root ankylosis, and for which tooth extraction would be an additional trauma for healthy tissue (e.g. high risk of mandibular fracture), crown-root amputation may constitute an acceptable alternative. The use of dental rotary instruments is mandatory. However, this option remains controversial for FIV or FeLV positive patients, as potentially at high risk of osteomyelitis, and systemic infectious spread. Specific cases affected by internal or localized forms to the root apex may be eligible to standard root canal treatment +/- apicoectomy as in other species, but fast progression of the disease known in the feline patient is a negative prognostic factor and therefore extraction is the only therapeutic option.

Figure 5: Stages of tooth resorption

When treating perioral wounds, choosing between first, second or even third intention healing strategies, the following must be taken into consideration: the size of the defect, the possible infection associated, the risk of tissue contraction, fibrosis and dehiscence, as well as more specific patient or systemic considerations. When infected, a surgical wound debridement with abundant sterile rinsing of the area should be considered first. It is generally accepted that leaving a wound heal by second intention is not recommended near a sphincter, or any orbicular muscle such as those constituting the lips due to the wound contraction associated, and possible restricted mobility. (Ishii & Byrne, 2009) Excessive tension should be avoided by proper use of reconstructive techniques and more specifically locoregional flaps described in the oromaxillofacial area. (Guzu et al, 2021) A random flap advanced rostrally using lateral releasing incisions and incremental subcutaneous dissection allows for simple reconstruction of the cutaneous defect in the intermandibular area. (Swaim in: Verstrate, 2012) Placement of walking sutures reduces the dead space between the flap and the underlying tissue while decreasing the tension on the wound. Depending on the different size and location of the defect, axial flaps (labial, angular oris), free cutaneous flaps, or even free vascularized flaps using microvascular anastomosis techniques are also appropriate surgical treatment options. (Tong & Simpson, 2012; Smith, 1991; Smeak, 1992; Bradford, 2011, Walsh & Gregory in: Verstraete, 2012) The survival of all those flaps does not rest on the presence of an underlying granulation tissue, but simply on the absence of major contamination. Drainage is generally recommended, in order to reduce the risk of fluid collection formation (hematoma, seroma, infection) which may compromise the vitality of the flap. (Wardlow & Lanz in: Tobias, 2012)

Conclusion:

Dental resorptive lesions constitute a potential source of discomfort, affecting approximately 30% of the cats in the general population. Early diagnosis and treatment remain particularly challenging for any practitioner. Despite many hypotheses regarding the initiating factors leading to its development, no preventive or conservative strategies are available to provide long-term control of the disease. Extraction of the affected teeth is the gold standard treatment, capable of slowing down the extension of the lesions to the adjacent teeth and preventing possible infectious complications. A better understanding of the mechanisms associated with the formation of dental resorptive lesions may improve its medical and surgical management in the future.

References

1. Verhaert L, Van Wetter C. Survey of oral diseases in cats in Flanders. Vlaams Diergeneeskd Tijdschr (2004) 73:331–40

2. Girard N, Servet E, Biourge V, Hennet P. Periodontal health status in a colony of 109 cats. J Vet Dent (2009) 26:147–55. doi:10.1177/089875640902600301

3. Girard N, Servet E, Biourge V, Hennet P. Feline tooth resorption in a colony of 109 cats. J Vet Dent. 2008 Sep;25(3):166-74.

4. Bilgic O, Duda L, Sánchez MD, Lewis JR.Feline Oral Squamous Cell Carcinoma: Clinical Manifestations and Literature Review. J Vet Dent. 2015 Spring;32(1):30-40.

5. Gracis M, Molinari E, Ferro S. Caudal mucogingival lesions secondary to traumatic dental occlusion in 27 cats: macroscopic and microscopic description, treatment and follow-up.J Feline Med Surg. 2015 Apr;17(4):318-28. doi: 10.1177/1098612X14541264. Epub 2014 Jul 7

Congenital pathology of duplicated ureter from left kidney with CKD in geriatric dog Chao – Chao

February 13, 2023

Dr Mila Kisyova

Dr. Mila Kisyova

veterinary clinics “Dobro hrumvane!”- Sofia, Bulgaria

Introducion

Normal anatomy of the kidneys:

The kidneys are paired, bean-shaped structures located in the retroperitoneal space directly beneath the sublumbar muscles. The cranial pole of the right kidney lies in the renal fossa of the caudate liver lobe and is located more cranially than the left kidney. The cranial pole of the left kidney lies lateral to the ipsilateral adrenal gland, which is closely associated with the cranial aspect of the left renal vessels. The left kidney is generally more mobile than the right kidney. Each kidney has a cranial and caudal pole and a ventral and dorsal aspect .

The concave surface of the kidney is located along the medial aspect and is called the hilus. The hilus is the location where the renal artery enters the kidney and the renal vein and ureter exit. Nerves and lymphatic vessels enter at the hilus as well. Anatomically, the renal vein is located more ventrally, and the renal artery is more dorsally. In an animal of normal body condition, the kidney is typically surrounded by a substantial amount of fat; this fat is maintained even in lean animals. In obese animals, the surrounding adipose tissue can virtually hide the kidney from view, making gross evaluation difficult.

Patophysiology of duplicated ureters:

Duplicated Ureter or Duplex Collecting System is a congenital condition in which the ureteric bud, the embryological origin of the ureter, splits (or arises twice), resulting in two ureters draining a single kidney. In the case of a duplicated ureter, the ureteric bud either splits or arises twice. In most cases, the kidney is divided into two parts, an upper and lower lobe, with some overlap due to intermingling of collecting tubules. However, in some cases the division is so complete as to give rise to two separate parts, each with its own renal pelvis and ureter. Double ureters from each kidney are very rare condition in dogs. They are drain separate renal collection systems from the same kidney and open separately into the urinary or genital tract. Given the embryological migration pattern of ureters, their termination sites are often ectopic.

*) https://www.researchgate.net/figure/Classification-of-urethral-duplication-in-dogs-based-on-the-classification-in-human_fig3_250044546

Duplex kidney formation: developmental mechanisms and genetic predisposition
Vladimir M. Kozlov, Andreas Schedl, iBV, Institut de Biologie Valrose, Equipe Labellisée Ligue Contre le Cancer, Université Cote d’Azur, Centre de Biochimie, UFR Sciences, Parc Valrose, Nice Cedex 2, 06108, France

Duplex systems can have a variety of phenotypes, and multiple classification systems have been proposed to categorise this pathology. In incomplete duplication, the two poles of a duplex kidney share the same ureteral orifice of the bladder. Such duplex kidneys with a bifid pelvis or ureter arise when an initially single UB bifurcates before it reaches the ampulla. This is likely caused by a premature first branching event that occurred before the ureter has reached the metanephric mesenchyme (MM). Much more frequent are complete duplications, which occur when two UBs emerge from the nephric duct (ND). In most cases, the lower pole of the kidney is normal and the upper pole is abnormal an observation explained by the fact that the ectopic ureteric bud (UB) frequently emerges anteriorly to the position of the normal UB and drives the formation of the upper pole of a duplex kidney. Inverted Y-ureteral duplication is a rare condition in which two ureteral orifices drain from a single normal kidney. Inverted Y-ureteral duplication is believed to be caused by the merging of two independent UBs just before or as they reach the kidney anlagen. A very rare H-shaped ureter has also been reported. Although the vast majority of cases involve a simple duplication, multiplex ureters with up to six independent buds have also been described. In some cases, the additional ureter or ureters are ectopic and fail to connect to the bladder or the kidney (blind ending ureter).

Report and history of the patient

We saw Jonh (11 years old, non-castrated, cryptorchid, chao- chao) for first time in our clinic for second opinion related to chronic kidney disease (CKD). He was diagnosed with chronic renal failure by colleagues about 2 years ago. Prior to our examination, he had been taking only food supplements (Irc Vet) and Renal Food. He had polyuria and polydipsia (PU/PD). The owners said that the urine was very light in colour. Sometimes Jonny had episodes with vomiting and lose of appetite. There was data for periodic blood tests with a tendency to increase the basic renal parameters (urea and creatinine). There was no ultrasound or other type of imaging examination.

When we took Johnny’s case, we initially did a complete abdominal ultrasound and new blood tests:

1. Creatinine	456.20 mmol/L	44.30-138.40 mmol/L
2. Urea	26.32 mmol/L	3.00-8.00 mmol/L
3. ALP	272.59 U/L	10.60-109.00 U/L
4. Na	141.60 mmol/L	140.30-153.90 mmol/L
5. K	6.26 mmol/L	3.50-5.10 mmol/L
6. P	2.10 mmol/L	1.00-2.00 mmol/L
7. Albumin	31.37 g/L	25.80-39.70 g/L
8. Glucose	3.95 mmol/L	3.40-6.00 mmol/L
9. Bilirubin Total	5.07 mmol/L	0.00-5.10 mmol/L
10. Bilirubin Direct	3.05 mmol/L	0.00-3.60 mmol/L
11. ALT	31.33 U/L	8.50-109.00 U/L
12. AST	29.30 U/L	8.90-48.50 U/L

Abdominal Ultrasound:

We started a standard echo-screening and the prostatic gland was normal, the bladder too. And after that on the left abdomen near the left kidney we saw a big, elongated, strange formation with anechoic fluid with a diameter of about 3 cm. The left and right kidneys had a good ultrasound density. Three small cysts were found in the cortex of the left kidney. There was no evidence of pyeloectasis or hydronephrosis. The corticomedullary border was good. This finding may be a pathologically altered testis, cystic formation, or pathological /duplicate/ ureter. During the first ultrasound examination, the dog was fed, so we decided to repeat the examination on an empty stomach. For the next echo screening Jonny was on a 12- hour fasting diet but the ultrasound finding is the same as the previous examination – the strange formation after the left kidney was there with the same size and shape. After performing the second ultrasound examination, we had suspicion for duplicate ureter. In order to be definite in the diagnosis, it necessary to perform computed tomography (CT).

After the new blood tests we started a new supplements – Ipakitine/Rubenal 300/Renassense/IrcVet. But Jonny didn’t feel very well. After some days we made a new blood tests. Before that we had spoken with the owners about the ultrasound finding and we decided to do a CT and see what the exact cause of this strange ultrasound finding.

Rusults of the CT:

2-B

3-C

4-D

5-E

6-F

Images:

1-A – little arrows are the bought normal ureters (left and right), big arrow „А“ – duplicate/ectopic left ureter

2-B – big arrow „А“ – duplicate left ureter

3-C – little arrows are cranial and caudal renal medula, big arrow „А“ – duplicate/ectopic left ureter draining the cranial pole of the kidney

4-D – А“ – duplicate/ectopic left ureter, about 3 cm wide along entire length

5-Е – normal right kidney

6-F – Left kidney, big arrow „А“ – duplicate/ectopic left ureter

*) the photos are provided by colleagues from the CVK (Central Vet Clinic, Sofia)

Тhe conclusion of the computed tomography is the left kidney has a slightly enlarged pelvis. Two ureters originating from the left kidney are found. The ureter, originating from the left kidney, has greatly increased dimensions – a width of about 3 cm along its entire length. Before entering the bladder, it turns ventrally and then dorsally. The other ureter of the left kidney begins in the normal anatomical position and drains into the bladder in the area of the trigone. Both kidneys have no tomographic evidence of hydro/pyelonephrosis.

This kind of pathology of the urogenital system in dogs is very rare. In this case it was an incidental finding because for 11 years the patient had never previously undergone additional ultrasound examinations. Certainly, this rare pathology is directly related to the rapidly progressing renal failure.

Due to the rapidly progressing renal failure, deteriorated general condition and the age of the patient, surgical intervention could not be performed. Jonny’s prognosis is very poor.

Sourses:

„Urethral duplication in a dog: case report [Duplicação uretral em cão: relato de caso] R. Stedile, E.A. Contesini, S.T. Oliveira, C.A.C. Beck, E.C. Oliveira, M.M. Alievi, D. Driemeie, M.S. Muccillo Faculdade de Veterinária – UFRGS Av. Bento Gonçalves, 9090 91540-000 – Porto Alegre, RS „
„Duplex_kidney_formation_Developmental_mechanisms_a.pdf– in humans“
Atlas of Small Animal CT and MRI by Erik Wisner, Allison Zwingenberger ,

March 2015

Four-dimensional CT excretory urography is an accurate technique for diagnosis of canine ureteral ectopia (Tobias Schwarz, Nick Bommer, Maciej Parys, Florence Thierry, Jonathan Bouvard, Jorge Pérez-Accino, Jimmy Saunders, Maurizio Longo – onlinelibraly.wiley.com)

WSAVA Alerts to Emerging ‘Canine Welfare Crisis’ Caused by the Popularity of Short-Nosed Breeds

January 29, 2023

Veterinarians around the world are warning about an emerging canine welfare crisis caused by the rapidly increasing number of short-nosed (brachycephalic) dogs. These dogs can have exaggerated anatomical features that can seriously affect their health and well-being. The most concerning of the health issues they face is Brachycephalic Obstructive Airway Syndrome (BOAS).

The Hereditary Disease Committee (HDC) of the World Small Animal Veterinary Association (WSAVA) has produced an educational video highlighting the problems that BOAS can cause in brachycephalic breeds, including French bulldogs, English bulldogs, and pugs. During the video, members of the WSAVA HDC and other experts explain how the appearance of short-nosed breeds has been affected by breeding for extreme and exaggerated anatomical conformation. While dogs which snore or pant are considered cute by some, the experts point out that these traits are not normal and that the dogs are, in fact, struggling to breathe. Many short-nosed dogs require surgery to survive and have a significantly shorter lifespan than other dogs.

Speaking during the video, Dr Peter Sandøe, Director of the Centre for Companion Animal Welfare at the University of Copenhagen, says: “With French bulldogs now the most popular breed in many countries and with English bulldogs and pugs also very popular, the number of affected dogs is increasing dramatically. Selective breeding for an exaggerated short nose has created dogs whose health, in many cases, is compromised for the sake of perceived ‘cuteness’. It is simply unethical to breed dogs which struggle to breathe.”

The WSAVA Hereditary Disease Committee is calling on all stakeholders – breeders, owners, veterinarians, media, regulators, and others – to work together to improve the welfare of these breeds going forward, and change perceptions of what ‘healthy’ looks like in these dogs.

It urges them to work together on health-focused breeding initiatives to produce dogs with less exaggerated anatomical features so that BOAS and other related health issues are not passed on. The selective breeding which caused these problems in the first place, can return these breeds to better respiratory health by selecting for more moderate anatomical conformation and for normal breathing. Many kennel clubs have instituted Respiratory Function Grading (RFG) to screen prospective breeding dogs against BOAS. If RFG screening is not available, prospective breeding dogs should be able to go on a brisk three-minute walk without laboring to breathe. If they cannot do this, they should not be used for breeding.

The need for a united approach is reinforced by WSAVA HDC member Dr Monique Megens, who contributes to the video explaining that brachycephalic dogs are bred – legally and illegally – around the world and transported across borders so a global approach is the only way to make progress.

The 17-minute video, available in several languages, also features contributions from:

Dr Jerold Bell, Chair of the WSAVA HDC, Cummings School of Veterinary Medicine, Tufts University, USA
Dr Åke Hedhammar, WSAVA HDC member, Senior Professor in Internal Medicine at the University of Agricultural Sciences, Uppsala, Sweden
Dr Jane Ladlow, Clinical Lead of the BOAS Research Group, Cambridge University, UK

Dr Bell said: “Breeders did not purposefully select for dogs with impaired breathing but there is no doubt that breeding to create dogs with ever shorter muzzles has created serious health issues in these breeds.

“We hope our video will help educate breeders, owners, and all of those involved in or influencing the breeding and care of short-nosed dogs. We also hope it will give them useful advice on the steps they can take to help as we work together to resolve a serious welfare issue. All dogs deserve to live healthy lives. We must not let them down.”

The video can be seen here: https://bit.ly/3HmL5fk

The WSAVA represents more than 200,000 veterinarians worldwide through its 115 member associations and works to enhance standards of clinical care for companion animals. Its core activities include the development of WSAVA Global Guidelines in key areas of veterinary practice, including pain management, nutrition and vaccination, together with lobbying on important issues affecting companion animal care worldwide.

The WSAVA Hereditary Disease Committee aims to facilitate clinician diagnoses, treatment and control of hereditary diseases and genetic predispositions in dogs and cats, thereby improving the health of patients now and in future generations.

Latest WSAVA Global Pain Management Guidelines Launched

November 7, 2022

Updated recommendations and resources for pain assessment and management to support veterinary teams now available

An updated set of Global Guidelines for the Recognition, Assessment and Treatment of Pain, which incorporate advances in knowledge and novel evidence, have been launched by the World Small Animal Veterinary Association’s (WSAVA’s) Global Pain Council (GPC) during its annual World Congress in Lima, Peru. WSAVA association member representatives gave enthusiastic support to the new Guidelines, with many signing up to support the GPC’s pledge to improve pain management in companion animals.

Following peer-review, the new Guidelines have been published by the Journal of Small Animal Practice (JSAP), the WSAVA’s official scientific journal, and are available for free download from the WSAVA website and from the JSAP website.

A key feature of the Guidelines is an emphasis on the use of pain scales for the assessment of acute and chronic pain in companion animals. They provide guidance, for instance, on selecting the most effective pain assessment tool based on the condition of the patient and scientific evidence, with links to relevant tools also provided.

In terms of pain management, the Guidelines take into account novel evidence regarding the efficacy and safety of both drug and non-drug therapies. For example, they evaluate the performance of new pharmaceuticals, including monoclonal antibodies, or those with new delivery systems, and evidence regarding the use of cannabinoids for chronic pain. They also discuss the use of non-drug therapies, including acupuncture – evidence of efficacy of which has increased in certain pain conditions. The Guidelines also stress that euthanasia should always be considered in cases where pain cannot be effectively managed and quality of life is poor.

Greater attention is paid to the role of emotions on the perception of pain in the Guidelines. It is now recognized that fear and stress can increase the perception of pain in animals so the document includes recommendations as to how to improve the experience of hospitalized patients, as well as giving advice to support the welfare of animals living with chronic pain and primarily managed by their caregivers at home.

The format of the Guidelines has been enhanced for this version to increase the accessibility of information with an increased use of visuals and graphics. Links to recommended tools are provided, as well as links to videos and additional resources for those wanting to further their knowledge.

A priority for the WSAVA is to provide Guidelines that are globally relevant. For the GPC, this means supporting veterinarians in regions with restricted access to analgesic drugs in working around the limitations they face. To help them, the Guidelines offer tiered protocols and highlight the role of local anesthetic techniques that don’t require additional training, together with the role of non-drug therapies to manage pain such as cold/ice therapy and the provision of a comfortable and safe environment to patients. They also discuss the importance of nursing and supportive care.

The Guidelines are currently available in English with translation into Spanish, Portuguese, Chinese and other languages underway.

Commenting on the launch of the updated Global Guidelines for the Recognition, Assessment and Treatment of Pain, Dr Bea Monteiro, GPC Chair, said: “Pain management is an area of veterinary medicine in which knowledge and understanding has expanded dramatically in recent years. Members of the GPC have worked tirelessly to pull together these latest WSAVA Guidelines, which now provide the most comprehensive and state-of-the-art resource available to support veterinary professionals, wherever in the world they are in practice.

“With animal sentience now legally recognized in many countries and jurisdictions, veterinary health professionals have a medical and ethical duty to mitigate suffering to the best of our ability. Despite the advances in pain management, pain still occurs more commonly than it is treated. We hope that these Guidelines will help colleagues understand the importance of pain management for patient health and welfare and that they will commit to:

Frequently assess pain in every patient
Taking measures to prevent pain and other negative emotions (such as fear and anxiety)
Treat pain using drug or non-drug therapies.”

The work of the GPC is generously supported by Zoetis.

“At Zoetis, we are committed to ongoing innovation, and we have long history of providing medications, tools/resources and educational initiatives to help veterinarians diagnose and manage pain in pets more effectively,” said Dr Mike McFarland, chief medical officer at Zoetis. “Pain has broad negative impacts on an animal’s health, causes suffering and lowers quality of life. Because we know that pain can lower quality of life and disrupt the important human-animal bond which benefits people and the pets they love, it’s important to ensure veterinarians around the world have access to solutions that can help better diagnose and alleviate pain in animals.”

The goal of the WSAVA Global Pain Council, comprising a team of global experts, is to create a global environment for companion animals in which pain is considered as the fourth vital sign and addressed appropriately. Its first Global Guidelines were published in JSAP in 2014 and have been downloaded from its website 53,000 times.

West Nile Virus detection in Ural owl

October 16, 2022

Dr Plamen Kirov

(case report)

Dr. Plamen M. Kirov, DVM,

Anamaria Manolea, A.S.P.A.D.A. Timisoara – Romania

Introduction

West Nile Virus (WNV) is a single strained RNA virus from the genus Flavivirus. It was discovered for the first time in 1937 in Uganda, causing zoonotic West Nile fever in affected animals and humans. The natural host for the virus are birds, mostly corvids(crows, ravens, and blue jays) and raptors. The disease is vector-borne and distributed by mosquitoes. It is discovered that 80% of the cases are asymptomatic, 20% become symptomatic, and mortality in birds could reach between 20 and 60%. It is agreed that the disease is a considerable factor in corvids population reduction. The mosquitoes transmit the virus by feeding infected blood and then transiting it to uninfected ones. Raptors can get infected by consuming infected chicks or birds. Between humans, the virus can be transmitted by blood or organ transfer, vertically, but not via direct contact.

Clinical signs can vary widely from non to death, with a high dependency on the species affected. Of the mammals only humans and horses show clinical signs – WNV was detected in many domestic and wild mammals, but no cases of the disease were registered. Birds with WNV demonstrate neurological signs – tremors, weakness, loss of coordination, head tilt, lethargy, blindness, and characteristic position of the legs at death.

Balkan countries by having long periods of hot weather and the presence of a lot of water sources (rivers, lakes, marshes, etc.) are the perfect environments for mosquitoes from Aedes(incl. Tiger mosquito) and Calex spp.

Clinical case

An adult Ural owl (Strix uralensis) was found by people in a passing car on rural road in Lugoj area (Timis county). The bird was in lethargic state, with difficult breathing and incoordination of movements of legs and wings.

Physical examination

During the physical examination no feather or tegument abnormalities or signs of trauma were found. Body temperature was elevated to +42oC. The bird was lethargic with difficulties to walk. The appetite appeared to be normal. Clinical diagnostic tests From the bird were taken a venous blood sample from the brachial vein, fecal, and nasopharyngeal probes. Using a panel of tests, bacterial and parasitic diseases were excluded. Since cases of WNV are detected annually in Romania and neighboring countries (Serbia and Hungary), the virological panel included West Nile Virus testing. The results obtained using epitome-binding ELISA, with a sensitivity rate of 98% for WNV antigen, are shown in Table 1.

Table 1

From the obtained results we concluded that the bird is in acute state of West Nile fewer. After consulting with the local veterinary authority, the bird was kept in enclosed environment and treated with Meloxicam per os. We did a second test after a week and another one week later. The third test went negative by showing an absence of viral antigen in the three samples – nasopharyngeal, fecal, and blood. Besides the negative results and complete recovery of the bird, it was transferred to a sanctuary where will remain for a few months and eventually released back into nature in 2023

One Medicine, One Love, One Hope

September 7, 2022

Dr Denica Djodjeva

Blue Cross Veterinary Clinic

Sofia, Bulgaria

I was extremely impressed with my visit to Fitzpatrick Referrals , UK. I initially visited the Soft Tissue Surgery and Oncology Hospital in Guilford. My colleague from Bulgaria, Ivan Kalmukov, who is a graduating resident in surgery and a great guy, had informed everyone about my visit. I am extremely grateful to him, for that, because otherwise without his help my visit would not have taken place.

On the first day, I was greeted by the surgical specialists, who showed me around the hospital and helped me going deeper in the working environment there. They introduced me to a large part of the team. Since my main professional interests are anesthesiology and critical care, I was also introduced to the head of anaesthesia – Daisy. She is a very nice young lady and immediately engaged me with blood gas analysis problems to solve. From day one, I was already aboard. Unfortunately, there were not so many procedures and operations, but for me it was perfect, because I had time to orient myself in the environment and get to know the team. In the following days, the things continued in another direction and I was able to feel the workload of the clinic. In between the many duties and busy workload, everyone talks calmly, without unnecessary emotions and fulfills their duties. In general, a pleasant working atmosphere. I was left with the impression of a great team in which everyone helps each other and has each other’s back. Needless to say, the professionalism with which all operations and procedures are performed.

The attitude they have towards the animals is great and my question “Don’t the dogs bite here?” was completely unnecessary. Collars and other protective devices were only used for very aggressive animals. Each one of them was spoken to calmly and there was always a person next to him to reduce the stress of the unfamiliar environment and people. In the postoperative period, each patient is strictly monitored and waited until is completely recovered from anaesthesia. After that, it is accompanied to thd e waror goes to see the owners, who are already waiting for him in one of the consult rooms.

In my last days, I was able to visit and the other referral centre, for Orthopedics and Neurosurgery in Godalming. I participated in every procedure closely related to my interests in anesthesia and there was always someone to explain everything about it to me. Unfortinately I was not allowed to practice, because I am not a licensed veterinarian in the UK. In my last days, I attended many operations during which I saw some innovative practices, one of which was on a cat with fractured vertebrae. My colleague Ivan was one of the surgeons. The next day, the animal was already walking.

Although there were inexperienced colleagues, they always found support in dealing with daily tasks and everyone celebrated their small victories.

During this one week, I learned a lot, I saw the high level of medicine that is being worked on, and I hope I will be able to apply this to my work in Bulgaria or at least some part of it. I am extremely happy for this opportunity and am very grateful to Ivan for helping to make this happen. My experience at both hospitals was a once in a lifetime. I hope I am wrong and have the opportunity to visit them again.

Management of chronic non-healing wounds over the calcaneal tuberosity in a Sphinx cat

July 2, 2022

Diana Anghelescu DVM

Georgiana Ciochina DVM

Florin Cristian Delureanu DVM, MRCVS, OCQ(V)

February 2022

Abstract

Wounds that fail to heal through the normal healing phases in a routine timely manner are classed as chronic wounds. Factors like improper nutrition, hypovolemia, anemia, infection, excessive motion and endocrinopathies contribute to delay wound healing. The patient presented with chronic bilateral wounds over the calcaneal extremities without progression after approximately two months of conservative management consisting of local bandaging techniques. Therefore, a surgical approach was used to close both defects. In order to achieve closure of these particular lesions, a single releasing incision was utilized. After surgery the patient was hospitalized for 10 days and a “donut type” bandage was used to minimize the local trauma. The sutures were removed at 21 days after surgical intervention.

Key words: Chronic wound, “donut-type” bandage, calcaneal extremities.

Signalment and history

A six months old Sphinx cat weighing 2.1 kg was brought for a second opinion in december 2021 because of non-healing wounds at the calcaneal extremities. It was not clear the cause of these lesions but the owner noted a slowly progression of the wounds in approximately one month. At the initial veterinary practice the patient was locally treated with an antibacterial-steroid based ointment which was applied twice a day and a light bandage to cover the wounds. Afterwards, the owner was advised to improve the comfort of the home environment to prevent further trauma. There was no improvement noted after this treatment.

Clinical examination and findings

At the time of presentation, the wounds from both calcaneal extremities were quite similar in appearance. In terms of depth, a full thickness skin defect was present measuring approximately 1cm diameter. The wound from the left side presented mild moisture and small amount of slough was covering the surface while the wound from the right side was covered by a dry crust. There was no local pain and or purulent discharge and no bone exposure. A concurrent parasitic otitis was found during examination.

Treatment

Cytological examination of the lesions revealed a mild superficial bacterial infection along with an inflammatory response. The options of conservative and surgical management were discussed with the owner. Initially the owner opted for second intention healing. The bacterial infection was treated locally using chlorhexidine gluconate solution 0.02% daily for three days followed by application of medical grade Manuka gel covered by a light protective bandage. A recommendation of daily bandage changes was made for the first three days until the first recheck. An Elizabethan collar was recommended to prevent self-trauma but the owner declined. An otic swab confirmed the presence of Otodectes Cynotis and the patient received one dose of lotilaner for the parasitic infection and daily ear cleansing with clorhexidine with TRIS-EDTA for 2 weeks.

Fig.1 Left (A) and right (B) calcaneal lesions. There is no marginal reepithelialisation and the wound margins are not inflamed. The left defect present a chronic pale granulation tissue and the right lesion is covered by a dry crust.

At the first check-up the lesions were considerably larger but also the owner reported that the patient managed to remove the bandages during the night. Moderate amount of slough was present on both defects and mild moisture was present (Figure 2).

Fig.2 Left (A) and right (B) calcaneal wounds. There is an increase in size of both wounds and the wound edges present mild inflammation.

At this moment a “dounut-type” bandage with hydrogel representing the contact layer for the next ten days was recommended (Figure 3). This type of bandage was ment to prevent against any further trauma and the hydrogel to help by wound debridement and keeping a moist environment. The the bandage was changed every three days.

Fig.3 Donut Type bandage. A “donut” pad was made by rolling long strip of cotton in a circular manner and was applied over the bony proeminence. The “donut” was fixed in place with padding gauze and tape.

At the ten days recheck there was no more slough or necrotic areas over the wounds but was no improvement in terms of size or granulation tissue quality. The surgical intervention was recommended at this state and the owner accepted.

Complete blood work, including a CBC and a biochemistry panel, was done before surgery. The results were within reference levels. The patient underwent general anesthesia using dexmedetomidine (4.5mcg/kg IM) and methadone (0.18 mg/kg IM) as premedication followed by induction with propofol (6mg/kg IV) and maintenance with isoflurane and oxygen.

After wound bed preparation, the local skin assessment was performed aiming to obtain a robust and tension free closure. The assessment involved manipulation of the skin that surround the defects but also the skin from the nearby area (Figure 4). More skin was available proximal to the hock, medial and lateral compared with other areas. The options of surgical closure taken in consideration were: undermining, tension-relieving techniques in form of single releasing incision, Z-plasty, V-Y plasty and transposition flap from the lateral or medial aspect of the distal tibia. Initially undermining of the wound edges was performed and closure was attempted but there was too much tension. A single releasing incision was the option used to close these particular wounds.

Fig.4 Caudal view of the right hock. A manual manipulation of the skin that surround the wound is perform.

The following steps were used for both wounds:

Initially the fibrotic thickened wound edge was removed and undermining was performed around in a circular manner (Figure 5). A 2cm parallel incision with the wound was made approximately 2cm dorsally and 1cm medial on the medial aspect of the distal tibia (Figure 6). Undermining was performed in a cranio-caudal direction connecting the incision with the wound bed. The skin was advanced into the defect and 3/0 monofilament in a simple interrupted suture pattern was used for closure (Figure 7).

Fig 5

Fig 6

The medial donor defect was left to heal by second intention. The surgical site was covered by a “donut-type” bandage placed over the hock and a nonadherent dressing over the new defect.

After surgery the patient was hospitalized in a padded room the same “donut” bandage but polyurethane foam was used as a contact layer over the new defects and the closed wound was not covered with any dressings. The bandage was changed every 3 days. The new defects ressolved within 8 days and no complications were noted at the surgical site.

Fig.7 Medio-caudal view of the right hock. The final appearance of the wound after closure.

The cat was discharged after 10 days and was sent home with the same bandage until the suture material was removed. In day 14 and 21 the sutures were removed an Elizabethan collar was appied to prevent self-trauma at home for the next 4 days. At the last recheck both hocks presented with normal scar tissue and no local discomfort. The owner reported that after the collar was removed the cat was not interested in her previously affected areas.

Discussion

The present case report describes the conservative and surgical approach of two symmetric chronic non-healing wounds associated with the calcaneal tuberosity together with the macroscopic description of the lesions.

Fig.8 Caudal view left (A) and right (B) calcaneal extremities four days after suture removal.

The patient was presented with a history of more than four weeks of non-healing wounds at both calcaneal extremities. We treated conservatively with specific dressings and bandaging techniques for another two without improvement. Hence, a surgical intervention was recommended.

To achieve the maximum skin advancement the purposed skin incision was planned to be perpendicular to the wound. The reason why the releasing incision was performed slightly proximally to the defect and not perpendicular to it was to avoid exposure of the medial malleolus of the tibia which was sharp and was not covered by robust soft tissue. Therefore, this extremity could represent another pressure point exposed.

In order to minimise the chances of self-trauma, the patient was hospitalised in a soft padded room. The “donut” type bandage was still used for another 10 days. A follow up recheck four days post suture removal was made to make sure there are no post-operative complications. There was a normal scar tissue formed and no local discomfort present functional deficits (Figure 8).

References:

Michael M. Pavletic– Atlas of Small Animal Wound Management and Reconstructive Surgery, Fourth edition, 2018 John Wiley & Sons, Inc;
Nicole J. Buote, DVM, DACVS-SA- Updates in Wound Management and Dressings, Veterinary Clinics of North America: Small Animal Practice 2021 Elsevier Inc;
Theresa Fossum- Small Aminal Surgery 5^th Edition, April 2018, Elsevier Inc;
Steven F. Swaim, Walter C. Renberg, Kathy M. Shike- Small Animal Bandaging, Casting, and Splinting Techniques, Iowa State University Press, United States 2011;
Baranoski, S, Ayello, EA. 2016. Wound Care Essentials: Practice Principles, 4th ed. New York: Wolters Kluwer;
Hunt TK, Williams H. 1997. Wound healing and wound infection. Surg Clin N Am 77:587–606.
Bryant RA, Nix DP. 2016. Acute and Chronic Wounds: Current Management Concepts, 5th ed. St. Louis: Elsevier Inc.

Lateral Flank Approach for Ovariohysterectomy in Cats

March 18, 2022

Vladimir Stojanoski, DVM, Spec. surg. vet.

Irena Mandevska, DVM.

Animal Care Clinic, Clinic for surgery, oftalmology andstomatology, Bitola, Macedonia

ABSTRACT

The ovariohysterectomy is a routine procedure which is recommended primary for control of the population of cats. Until now there are various access techniques that are described in the literature for the ovariohysterectomy(OVH) at cats. In this study of ovariohysterectomy, 500 adult female cats at the age of 6 months to 9 years with bodyweight of 2,5-5 kg, were covered. In OVH a small lateral accessed cut is made which minimizes the presence of bleeding during incision, easy access and extraction of the ovaries and the horns of the uterus is obtained during the procedure, also minimization of postoperative complication, shorten the time of the surgical procedure (give or take 20 minutes per intervention), also the healing of the wound and the pain threshold postoperative, all this examined by Feline grimace scale fact sheet(Evanelista at all 2019) are significantly smaller. 96% of the clinics in the USA apply the “Flank” lateral access for OVH at cats, but in our region this technique is still not well known though the benefits of it are greater, in contrast to other techniques of OVH at cats.

INTRODUCTION

The managing of the population of domestic cats is a global issue which raises the question of the individual wellbeing of the cats (Roberts et all, 2015). OVH is a routine procedure that is recommended as the best method in controlling the population of cats (Levy et all, 2003). Traditionally, OVH is made by medial ventral or lateral “Flank” access which in the world and also our region is still not accepted as a routine everyday technique. Because of the positive feedback, the lateral “Flank” access for OVH at cats is more and more applied in the world.

The left side of incision was preferred in the start of applying the lateral “Flank” access (McGarthet all, 2004) and also many incisions were applied in horizontal and vertical direction of the abdominal oblique muscles in OVH at cats (Hogue, 1991). Generally, at the start of the application of this technique, the length of the incision was 2-3cm м (McGrath et all, 2004; Coe et all, 2006; Rana, 2007; Kiani et all, 2014). In comparative studies Ghanawat and Mantri (1996), Shuttleworth and Smythe (2000), Coe et all, (2006) and Rana (2007) reported significantly smaller incision with the lateral “Flank” access 1-1,5 cm compared to the medial ventral access. Examining the technique and comparing the suturing of the skin with skin and intradermal sutures a conclusion was gained that the healing of the wound with intradermal suture is way quicker and the discomfort of the patient is greatly reduced. Also by applying this technique the time needed for wound healing is shortened, the trauma of the abdominal muscles is way smaller because the incision is lateral, the pressure over the wound and the incision is greatly reduced.

MATERIAL AND METHODS

In this study were covered 500 female adult cats, the youngest older than 6 months and the oldest younger than 9 months. All patients undergone: general clinical examination, blood test and ultrasonography for confirmation of pregnancy. Every cat that did not showed deviations in the clinical examination, blood test also were not pregnant was included in this study. Every cat was preoperatively deprived of food 12-24h and water 6h. At all patients a venous path was established, a venous anesthesia was applied, also intubated and a breathing monitoring was used thanks to a Breathe Safe Respiratory Monitor. During the procedure a NaCl0.9% infusion was applied in dose of 20ml/kg/h. The surgical field was shaved by a shaving machine with No. 40F knife, and also disinfected by 4% chlorhexidine. Also the surgical field was covered by surgical covers (sheets) with dimensions of 45-45cm, a surgical knife 10 was used and as a surgical thread we used monofilament Monosyn 3-0. We used the general surgical set for sterilization (with spay hook), sterilized by the method of dry sterilization. Postoperatively as an analgesic a single dose of NSAID – meloxicam 0.2mk/kg i/v was applied.

INDICATIONS

One of the most common indication for implementing this access is sterilizing of breastfeeding cats and also sterilizing cats with hyperplasia of the mammary glands. When the OVH is made during lactation it’s a better choice to use the lateral “Flank” access rather than the medial ventral access because the occurrence of dermal and subdermal heamorrhagia is very rare almost unnoticeable, also swelling, infection and discharge of the mammary gland are absent. Besides that, by using the lateral “Flank” access in cats during lactation, there is no disorder in the function of the mammary gland, so these patients can continue the breastfeeding postoperative the next day.

The mammary hyperplasia, also known as fibro adenomatous hyperplasia or mammary hypertrophy -fibroadenomal complex (Dolly Parton Syndrome) – image 1, represents a benign formation during estrous cycle or breastfeeding at cats that characterizes with fast abnormal growth of one or more mammary complexes (Hayden at all, 1981). As a choice of treatment its recommended to use ovariectomy or ovariohysterectomy, that results with regression of the mammary hyperplasia within a time period of 3-4 weeks (Wehrend and all, 2001). The use of this technique during lactation eliminates the occurrence of rupture of the mammary complexes triggered by a wound infection that appears as a complication by using the medial access of OVH.

ADVANTAGES

The advantages of the lateral “Flank” access to OVH at cats includes the possibility to over watch the surgical wound from distance and reducing the potential to eviscerate due to dehiscence of the wound sutures (Dorn & AS, 1975; Krzaczynski, 1974; Miller &Zawistowski, 2012). These advantages are very important while working with wild, feral and homeless, scared animals or animals whose owner is not always capable to transport the patient back to the clinic/ambulance. The capability for these animals to be brought back for routine control postoperative is very limited, thus very often, observing from distance is necessary.

The lateral “Flank” access allows visual assessment of the wound without manipulating with the patient, which is not the case by using the ventral-medial access.

Evisceration of the abdominal organs or dehiscence of the sutures are very uncommon because the forces of gravity using the lateral “Flank’ access are weaker than using the ventral-medial access (Dorn & AS, 1975; Krzaczynski, 1974; Miller &Zawistowski, 2012; Janssens&Janssens, 1991). In addition, the overlapping of the oblique abdominal muscles helps keeping the integrity of the abdominal wall, which makes the possibility of such complications to occur very small.

With the lateral access, the ipsilateral ovary and the horn of the uterus is spotted right under the incision, which makes them very easy to locate. This shortens the time, normally needed to locate the ovary during the ventral-medial access, thus shortens the time needed for the whole operation.

CONTRAINDICATIONS

Contraindications of the lateral “Flank” access includes: distension of the uterus respectively gravity or pyometra, overweight or patient younger than 12 weeks (Dorn & AS, 1975; Krzaczynski, 1974; Janssens&Janssen,s 1991; Dorn &Swist, 1977). Some authors describe the risk of visual scar or imperfections of the color and fur growth of the operation field (Janssens&Janssens, 1991). At patient that are highly gravid or have a uterine distension/pyometra, the lateral “Flank” access is not recommended because we do not have a clear access to manipulate with the uterus. If the gravity or pyometraare identified by accident, the lateral “Flank” access is extended for relieved extraction of the uterus. However, extending the incision can increase the risk of muscle trauma or potential bleeding, undermining the primary advantages of the lateral “Flank” access during OVH (Salmeri at all, 1991).

DISADVANTAGES

The primal disadvantage of the lateral “Flank” access is the limited visual exposure in occurrence of possible complications (Dorn & AS 1975; Krzaczynski, 1974; Janssens&Janssens, 1991; Dorn &Swist, 1977).

The second important concern is that when a cat is brought, but it’s unknown if the same cat has undergone a OVH, the surgical scar is small and the point of incision is not always typical to be made at the same location, even if it’s made on the same side of the previous incision, in contrast to the medial ventral access where the incision is typically spotted on exact location respectively under the umbilicus along the linea alba (Miller &Zawistowski, 2012). This could lead to an unnecessary surgical intervention if the surgeon is not aware of the possibility that the lateral “Flank” access might have been used for OVH. Therefore, when the lateral “Flank” access is used, it is necessary to mark the cat that is operated, like tattooing of the umbilicus or linea alba along the abdomen, or by incising the tip of the left ear at the homeless or feral cats (Miller &Zawistowski, 2012).

SURGICAL INTERVENTION

Anesthesia of the patient

Ovariohysterectomy is a routine surgical procedure by which in this study is used an intravenous anesthesia.

Sedation/anesthesia in combination with midazolam:

Dexmeditomidin10 µg/kg i/m
Midazolam2mg/kg i/v and
Ketamine 2mg/kg i/v – slowly applicate till effect is achieved
- For maintenance of anesthesia if needed Propofol is administered like a bolus of – 0,4mg/kg
- Intubation and monitoring of breathing with Breathe Safe Respiratory Monitor (image 2).
  Image 2 – Breathe Safe Respiratory Monitor
  
  Instruments that are used for the procedure
  
  Standard set for sterilization: surgical gloves, surgical sterile sheet, surgical tweezers – Adison tissue, scalpel – No. 10, needle holder – Mayo Hager, hook (spay hook) for ovariohysterectomy, four surgical forceps – Mosquito forceps, surgical scissors – mayo scissor curved, four Backhaus towel clamps, surgical knife – No. 10, monofilament (Monosyn 3-0) resorptive threat, sterile gauze (image 3).
  
  Image 3 – Ovariohysterectomy kit
  
  Position of the patient
  
  By using the lateral “flank” access the patient could be positioned in right or left dorsal recumbence depending of the surgeons opinion. The access at the right side is preferred by some surgeons because it provides better access to more cranially anatomically placed ovary and because the omentum covers the viscera when it’s used a left sided access (Dorn &Swist, 1977). From our experience there aren’t any advantages whether a left or right sided access is used, but the left side is better because the dominant hand is used for easy manipulation with the suspensory ligament. The animal is placed in lateral position by fixing the limbs in their extension (Krzaczynski, 1974) – image 4.
  
  Image 4 – Lateral position with limbs fixed in extension
  
  Surgical preparation
  
  The surgical field is being shaved by starting cranially from the last rib all the way down to the iliac bone in cranial-caudal direction and the transversal processes of the lumbar vertebrae, all the way down to the mammary complex in dorsal-ventral projection.
  
  Marking the incision
  
  The carving of the incision may be placed in dorsal-ventral or cranial-caudal direction, however by our experience we use the technique of cranial-caudal incision by which the incision is placed in one conceived central line, two fingers from the last rib, one finger from the transversal processes and two fingers from the iliac bone in diameter of 1-1,5 cm (image 5) depending on the size of the cat, estrus phase, or the presence of other possible complication factors.
  
  Image 5 – Ready surgical field and appropriate location of incision for a left lateral access (left dashed line: location of the last rib; right dashed line: location of the iliac crest
  
  Surgical technique
  
  The incision of the skin for the lateral “Flank” access can made in cranial caudal direction paying attention for avoiding the superficial blood vessels. The subdermal tissue must be cut with separating scissors (image 6). The abdominal muscles should be separated from the subdermal tissue and by using a forceps or scissors an incision must be made separately on every layer of the lateral abdominal muscles. When the abdomen is opened its important to fixate the abdominal muscle with a forceps, or the thumb, to maintain the control over the abdominal wall. The ovary or the uterine horn should be placed right under the incision.
  
  Image 6 – Subcutaneous separation
  
  The horn is pulled out by using (image 7 top).
  
  Image 7 – Spay hook (top) and extraction of the horn of the uterus (bottom)
  
  After the extraction of the horn and sighting the ovary, with the help of a forceps the ovary is fixated with the suspensory ligament (image 7 bottom). At older and obese cats the ovary is surrounded by adipose tissue, which requires prolonging the incision of the abdominal wall to achieve better visibility of the surgical field. After fixating the ovary/ligament the blood vessel is being ligated by placing two ligatures also used at the medial ventral access. The wide ligament (including the surrounding ligament) should be blindly separated parallel to the uterine artery at the level of the bifurcation of the uterus. After that, the uterine horn should be lifted to reveal the bifurcation and the contra lateral horn of the uterus, after which by using the hook the horn is lifted to a level of visibility of the contra lateral ovary, which is fixated with a forceps to the suspensory ligament. Because this ligament is on the opposite side it is harder to pull it out, and because it is shorter, it should be torn bluntly or be cut by scissors, and the rest of the procedure is the same as the other ovary. Then the both horns are pulled out until the bifurcation is visible. The both horns are being ligated twice near the bifurcation and are cut off 0,5 cm over the second ligature.
  
  The visualization of the contra lateral ovary and horn of the uterus could be difficult to acquire through the small incision, but because the ipsilateral ovary is spotted right beneath the incision, by pulling out the horn all the way to the bifurcation, the contra lateral horn is pulled out by a hook, so is the contra lateral ovary. For easy visualization of the contra lateral ovary, the duodenum (left lateral “Flank” access) or the descendent colon (right lateral “Flank” access) are used to push dorsally the small intestine with the spay hook, simultaneously we pull the abdominal wall ventrally, and by doing so the visibility of the contra lateral ovary is bigger (image 8).
  
  Image 8 – Extraction of the ovaries
  
  To visualize the bifurcation of the uterus, by using the spay hook the small intestine and the bladder should be pulled in cranial and ventral direction simultaneously pulling the abdominal wall caudally, by doing so the uterine body lies dorsally of the bladders neck (image 9).
  
  The abdominal wall at cats is closed by using a continuous suture, embracing the three layers of abdominal muscles. The skin is closed with a routine intra dermal suture, and by doing so, the extraction of the suture threads postoperatively is unnecessary (image 10).
  
  Image 10 – Closing the skin wound by placing an intradermal suture
  
  Postoperative care and analgesia
  
  The postoperative care by using the lateral “Flank” access is nothing special, nor is necessary stationary observing postoperatively, so the patient could be checked out the very same day. The observation is done from distance and there is no need of bringing the patient back for a control. We used a single dose of NSAIL analgesic – meloxicam 0,2 mg/kg i/v.
  
  RESULTS AND DISCUSION
  
  In this study for ovariohysterectomy were involved 500 adult female cats at the age of 6 months to 9 years, with bodyweight of 2,5-5 kg. (Domestic and feral) which were electively brought to the clinic, which covers all the world known high standards of working in veterinary medicine.
  
  The owners and volunteers in charge were informed of the whole process both verbally and in writing detailed description of the procedures and in this publication, their personal data isn’t mentioned and they remained completely anonymous.
  
  The choice of anesthetic protocol and the analgesia in the postoperative period, depends on the procedure and the health status of the patient, including both acute and chronic diseases.
  
  Even though there is no standard surgical access to ovariohysterectomy at cats, generally the ventral medial access dominates, in contrast to the lateral “Flank” access, which technique is less preferred (Bartels, 1998; Slatter, 2003).
  
  The complexity to identify the subcutaneous adipose tissue and the internal and external oblique muscle and the peritoneum, during this access did not showed as a problem, so did the identification of the anatomical position of the ovaries and the uterus.
  
  The risk of remaining ovarian tissue is rather often complication during ovariohysterectomy at cats, so is loosening of the ovarian ligatures during operation, which however doesn’t result with significant loss of blood (James at all, 2021). These intra operational complications didn’t showed as a problem with the application of the “Flank” lateral access in this study, considering the high level of competence and experience of the main surgeon, as is the use of modern materials for ligation and the use of modern surgical techniques as for ligating the ovaries and the
  
  uterus and as for the fascia of mm. rectus abdominis.
  
  By choosing the lateral “Flank” access to ovariohysterectomy at cats, there is lower degree of licking the wound, swelling and lower incidence of complications: bleeding of wound 0,5%, dehiscence of the wound 2%, infections of the wound 2,5% in the postoperative period (image 11).
  
  Even though there is no general opinion for which procedure is better and it’s not used as a routine procedure, the lateral “Flank” access to ovariohysterectomy at cats in this study provede positive effect in veterinary surgeons during the intra and postoperative process, lower costs of material, so is the greater satisfaction of the owners and the comfort of the patients in the healing period.
  
  Also the tress hold of pain during the lateral “Flank” access is very low, examined by Feline grimace scale fact sheet (Evanelista at all, 2019) by which a single dose of NSAID – meloxicam 0,2 mg/kg i/v is enough.
  
  CONCLUSION
  
  The lateral access in this study showed as better by the personnel that took place in the operations and the owners/fosters of patients because of the shorter operation time (
  
  generally the difference is 10-15 minutes quicker), smaller surgical incision (1-1,5 cm), eased anatomical locating of the ovaries and uterus, quicker healing of the wound (2-4 days), smaller degree of wound opening (2%), together with the better response of the patient during awakening from anesthesia and in the postoperative period.
  
  Saving the amount of time for the procedure (around 20 minutes per procedure), the minimal incision for performing the procedure, the shortened time for wound healing in contrast to the standard medial ovariohysterectomy, the tress hold of pain postoperatively is way lower in contrast to the standard medial technique, the postoperative complications are very rare (infection of the wound, dehiscence of the sutures, postoperative bleeding and pain at the animal itself.