Soft palate and tonsil resection using PlasmaKnife dissector in dogs with brachycephalic obstructive airway syndrome – A novel technique

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Author-Emil-Ofner

Dr Emil Ofner

Authors : Emil Ofner, DVM
Marina Barižon, DVM
Mario Grubišić, DVM
Silvijo Tarasić, Eng; OLYMPUS d.o.o. Zagreb

Small Animal Veterinary Clinic More, Šibenik, Croatia

Key words : Brachycephalic syndrome, PlasmaKnife

Abstract

Brachycephalic obstructive airway syndrome is chronic, repetitive and life threatening disorder and because of that it often requires immediate surgical intervention. In literature, there are many described surgical techniques to treat different aspects of brachycephalic syndrome. The soft palate and tonsil resection using Gyrus PlasmaKnife dissector is a novel technique which is in our opinion ideal for every veterinary practice.

Introduction

Brachycephalic Obstructive Airway Syndrome (BOAS) is a complex chronic condition characterized by narrowing or collapse of the different airway passages. This disorder is hereditary and because of that associated with different breeds of dogs. Depending on general skull morphology dogs can have brachycephalic, mesaticephalic and dolichocephalic heads. Phenotypic selection in search for round heads and foreshortened nose in brachycephalic breeds of dogs resulted in loss of sagittal crest and a braincase longer than the facial bones. Rostral shortening of the skull in brachycephalic breeds, without paralell reduction in the associated soft tissues, results in disproportion causing abnormal airway resistance. These primary anatomic defects lead to secondary changes over time (Table 1). At the time of presentation, clinical sings can be mild, moderate or severe. All moderate and severe cases are accompanied with sleep difficulties, coughing, dyspnoea, gagging, retching and syncope. While moderate and severe cases need prompt surgical intervention only mild cases can be managed conservatively.

Patients and methods

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Last decade, there is a huge increase of pure breed dogs and breed related disorders in Dalmatia. Brachycephalic breeds which have round heads resembled those of human infants are becoming very popular. Among breeds presented with BOAS in our clinic overrepresented breeds are Pugs, French Bulldogs and Cavalier King Charles Spaniels.
Most patients in time of presentation have serious and life threatening symptoms. Because of that diagnostic procedure needs to be done quickly with skilled team. In Veterinary Clinic More all patients with BOAS are put under general anesthesia, intubated and after radiographic examination, laryngo-tracheo-bronchoscopy procedure with or without rhinoscopy is done. After a complete examination of upper and lower respiratory pathways we prepare surgical planning. In almost all situations we do a soft palate resection. If needed, vertical or horizontal external nares resection, tonsillectomy or everted laryngeal saccules excision is done also.
To clearly and precisely visualize the surgical site is critical in all surgical procedures involved in BOAS. Because of that, all patients should be positioned in sternal recumbency with maxilla resting on the perch and the mandible should be suspended by rolled gauze ventrally (Picture 1 ). If soft palate resection is going to be done all tissues extending mid to the caudal aspect of tonsillar crypt should be excised. The soft palate is grasped with Allis clamps, pulled rostrally and dissected with PlasmaKnife dissector (Picture 2). If tonsils are enlarged in order to clear out as much space as possible we also do unilateral or bilateral tonsillectomy.

Discussion

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Though in available literature, there are lots of papers about soft palate dissection we didn’t find anything about using PlasmaKnife dissector for soft palate and tonsil resection. Traditionally resection is done with sharp dissection using Metzenbaum scissors or monopolar electrocautery. Other reported techniques include bipolar sealing devices (LigaSure), laser or harmonic scalpel. Surgery time for soft palate resection was about 12 minutes for sharp dissection, and about 5 minutes for laser surgery.
PlasmaKnife dissector is triode-tipped bipolar instrument (Picture 3) which attaches to the Gyrus G3 WorkStation generator (Picture 4). It uses PlasmaCision technology that enables both simultaneous and sequential hemostatic sealing and cutting. PlasmaCision leverages the electricaly conductive properties of tissue fluid to form a tightly defined low temperature plasma field over the active pole of the triode tip. The instrument has two main modes of operation, PlasmaCision cut phase and pure coagulation phase. In cut phase a low-temperature plasma field precisely divides tissue and coagulates blood vessels. In pure coagulation phase tip delivers controlled radio frequency energy for sealing larger blood vessels ( Pictures 5 and 6). Tip design has both convex and flat surfaces. The convex part for pin point accurate dissection and flat surface provides maximum tissue contact for effective hemostasis along with a suction channel for blood and vapor (Picture 7). Switching between modes is done by foot pedal.
Surgical time for soft palate resection with PlasmaKnife dissector was average 63 seconds and 44 seconds for unilateral tonsillectomy. Realized time was about 10 times faster in comparison to traditional sharp dissection and 5 times faster comparing to laser surgery. Production of smoke and vapors was minimal and suction channel was not needed. Postoperatively, all dogs received local dexamethasone to reduce swelling (Picture 8). We didn’t have any postoperative complications.

Conclusion

PlasmaKnife dissector in combination with Gyrus G3 WorkStation generator is multi – functional instrument and provides versatility, efficiency, clean incisions, and hemostatic performance with minimal tissue damage.

Acknowledgments
Again, we are thankful to Mr. Silvijo Tarasić and Olympus d.o.o. Zagreb who recognized our enthusiasm and provided technical expertise that greatly assisted us in implementing new technology improvements in our practice.

Encephalitozoon cuniculi – associated Phacoclastic Uveitis with Second Glaucoma in Rabbit

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Dr Vesela Elenkova

Dr Vesela Elenkova – master scintific in veterinary ophthalmology and surgery, veterinary clinic “Eskovet”– Bulgaria, Sofia

Case presentation :

A nine month female rabbit presented for a right eye lesion of two weeks duration. There was cataract on the same eye from birth. The referring veterinarian had prescribed a course of topical and systemic antibiotics but it continued to deteriorate. The eye was become very painful. The lesion appeared as a whitish-yellow mass into the hyperemic iris, slightly protruding into the anterior chamber. There was a mature cataract formation and the pupil was mydriatic with no response to light. The intraocular pressure (IOP) of the affected eye was 40. On the other was 11and it was not clamped. Fluorescein staining was negative for corneal lesions on both eyes. On the ultrasound examination there was no changes into the posterior segment of the affected eye.

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The right eye of the rabbit with E.culiculi-assosiated lens-induced uveitis. Note the mature cataract, the large mass into the hyperemic iris and the midriatic pupil not responding to light. IOP is 40.

There was only seen the hyperechogenic lens and the lesion in the iris. The rabbit was in pain when touched and didn’t want to eat well.

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Ultrasound image of the eye. Note the hyperehogenic lens and the 7mm lesion behind the iris. The posterior chamber is not affected.

The patient history and appearance of the lesion were compatible with Encephalitozoon cuniculi-induced phacoclastic uveitis, and a tentative diagnosis was made. Other diagnostic defferentials included granuloma caused by Pasteurella or other bacterial infections, but they were unlikely considering cataract formation. Diagnostic included complete blood count, biochemical profile and serology testing.
The complete blood count and serum biochemical profile were within normal limits. The serum IgG-antibodies were not so high, but the IgM-antibodies indicate active infection in most cases. They bought are not indicative for utero infection.

We opted medical management. 12570932_1258201610860482_1705138233_nExcept of the antibiotic therapy (with enrofloxacin PO and ciprofloxacin eye drops), the treatment was continued with fenbendazole at 20 mg/kg PO q24h for 28 days. 12607270_1258201650860478_1726829549_nPrednisolone acetate ophthalmic drops were prescribed to treat the uveitis and dorzolamide hydrochloride and timolol maleate drops for the eye pressure.

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The left eye of the rabbit appeared unaffected

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After one week recheck. The iris is not so hyperemic and IOP is 6.

After 1-week recheck, the lesion had not changed, hyperemia was decreased, the IOP had become low – 6. There was no pain in the eye and the rabbit was doing well. The pupil still does not respond to light. After 2 weeks more, there was no change. The rabbit was in very good condition, but the vision in the right eye was compromised. Surgery might be necessary in the future depending on progression of the lesion, discomfort, and long term effects on the eye.

Discussion

Encephalitozoon cuniculi (E. cuniculi) is a protozoal parasite. The parasite primarily affects rabbits, but cases have been reported in sheep, goats, dogs, cats, monkeys, guinea pigs, foxes, pigs and humans. It is a recognized zoonosis, but the zoonotic risk seems to be minimal to healthy individuals observing basic hygiene and to date there have been no reported cases of direct transmission from a rabbit to a human. However, those individuals who are immunosuppressed should implement strict hygiene and if possible avoid animals suspected or confirmed of being infected with E. cuniculi. Spores are shed in infected animals’ urine and transmission is usually by ingestion of contaminated food or water, or less commonly by inhalation of spores. Transmission from mother to young (transplacental) also occurs so that offspring are born infected. Most of the time, these organisms do not cause any obvious clinical disease. When E. cuniculi reach nerve tissue, rabbits can experience neurologic impairment, characterized by partial or complete paralysis, loss of coordination, seizures and head tilting.
E.cuniculi-assosiated phacoclastic uveitis is recognized in rabbits. There is no sex predisposition and the condition is often seen in younger rabbits. The mechanism by which the protozoan causes cataract is unclear in detail, but its lifecycle gives clues as to aetiopathogenesis of cataract. Passage of parasite between adult and young happen in utero with the parasite circulating in the fetus and sometimes ending up residing in the developing lens. The parasite migrates through the anterior lens capsule causing liberation of lens protein into the iris and anterior chamber and subsequent development of lens-induced uveitis, however, the posterior chamber usually remains unaffected. Normally this uveitis presents as a white-yellow mass in or near the pupil, sometimes with neovascularisation rendering it red or pink.
Serum ELISA antibody titers are helpful in making a diagnosis, however, serology only indicates past exposure and is not diagnostic of or necessarily correlated with clinical disease and infection. Immunofluorescence assay and polymerase chain reaction (PCR) testing of tissue, urine and feces samples, as well as cerebrospinal fluid and removed lens material. These test looks for antigens, unlike serology, which test for antibodies. Simultaneous testing of IgG and IgM-specific antibodies can give an indication of infection status because IgM antibodies indicate active infection. If transmission is transplacental, bought IgG and IgM antibodies may be low.
In this cases treatment options include antiprotozoal medication, topical corticosteroids for the uveitis, surgery to remove the affected lens and granuloma if it is possible. The other option is enucleation, but it is not common if the eye is functional, because it is unlikely to eradicate the infection. In other cases the eye may atrophy without surgery (phthisis bulbi).

Conclusion

E.cuniculi-assosiated phacoclastic uveitis should be always suspected for rabbits presenting with ocular lesions and uveitis and oral antiprotozoal medications are always recommended, as affected rabbits may develop infection in the brain and encephalitis, that can lead to death.

CHIARI-LIKE MALFORMATION AND SYRINGOMYELIA

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Dr Ates Barut, DVM, PhD

Dr Ates Barut, DVM, PhD

Owner of Small Animal Veterinary Clinic PETCODE

 

Introduction

We can describe Chiari-like Malformation as an overcrowded and narrow caudal occipital fossa and cervicomedullar junction due to a congenital developmental malformation of caudal occipital bone. Disease is similar to Chiari Type I disease in humans and therefore named as «chiari like malformation» in dogs.

Chiari-like malformation is a hereditary condition and first described in king charles cavalier spaniels and altough several other small breeds can become effected king charles cavaliers are the most common breed effected by the disease.
The other reported breeds are; Griffon, Miniature poodle, Yorkshire terrier, Maltese, Chihuahua, Bichon frise, Staffordshire terrier, Pug, Shih Tzu, Dachsund, Pincher, French bulldog, Jack Russel Terrier, Pekingese and Boston terriers.
Affected patients has a kind of cerebellar compression and narrowing around foramen magnum and cervicomeduller junction.

Patho-physiology

Bony compression, progresive meningeal hypertrophy and dural fibrosis cause; several different neurological dysfunction like cerebellovestibuler disfunction, cervical myelopathy, seizure activity, syringomyelia, ventricle dilatation and hydrocephalusPicture1Picture2Picture4

Although in humans almost all chiari malformation patients has some degree of cerebellar herniation , in dogs cerebellar herniation is not that common and this is the main difference between these 2 species. Caudal occipital malformation syndrome is a genetic deformation of the mesoderm of caudal occipital bone causing cerebellar compression and herniation.
In normal dogs CSF move from cerebral subarachnoid space to cervical spinal subarachnoid space through foramen magnum in every sistom and diastol in a pulsative manner.


Compression and partial obstruction caused by Chiari malformation disturb CSF flow in both ways but because of high systolic pressure push CSF to central canal of cervical spinal cord and produce a cavity with this hammer effect. Valsa maneuras like barking and coughing, make sudden changes in intrathorasic and intraabdominal pressure which cause epidural venous distention and fast fluid acumulation to the cavity. Because of spinal epidural vein distention and compression in cervicomedullar junction syringomyelia cavity continue to enlarge gradually.Picture5Picture6Picture7Picture9
Herniated cerebellum increase the amount of obstruction , CSF flow and fluid accumulation. CSF will flow from intrcranial cavities to cervical region easier but can not come back again.

Symptoms and clinical presentation

Presentetion of the disease is different from patient to the other. The first signs can be seen from 5-6 months to 9-10 years.Picture17Picture18Picture19
The disease can cause several different neurological signs.

We can list the possible symptoms as; cervical hyperaesthesia, scratching( air scratchig or phantom scratching)

, facial rubbing, air licking, fly catching, tail chasing, vocalization, pain reaction during atlantoxipital palpation., cervical myelopathy, fore leg paresis characterized by lower motor neurons, multifocal CNS dysfunction, torticollis, scoliosis, seizure activity.
Pain due to or seconder to syringomyelia is a very important symptom and it happens because of the damage on the dorsal horn of spinal cord.

It usually happens Because of the hypersensitivity due to the damage on spinothalamic pathways and/or dorsal horn neuronsPicture20Picture23Picture24Picture27
Abnormal sensitivity in head, shoulder, neck, axillar and sternal regions is prominent in several patients with syringomyelia but pain severity is not directly correlated with the amount of the fluid inside the spinal cord. Pain is most common in king charles cavaliers and usually more dominant in one side.
Scratching is another very common sign in king charles cavaliers and stress, excitement or a touch to the neck stimulate or increase sctraching. Some dogs has a scratch point and react to a simple touch to this point. The scratching style usually without touching the body is also unique and that is why named as air scratching or phantom scratching.


In some severe cases the patients can have cervical myelopathy, cerebellovestibüler dysfunction and multifocal central nervous system dysfunction. In these cases severe neck pain, strabismus, head tremor and nystagmus can be observed. Loss of muscle tone due to asimetric innervation of paraspinal muscles can cause opusthotonus.

Some patients with chiari-like malformation can have seizures but pathogenesis is not so clear. This rare condition can be related with impaired cerebellar functions because cerebellum has an inhibitoric effect on seizure activity.

The most common neurological and physical examination finding is atlanto-occipital pain and increased sensitivity on pin point palpation on atlanto-occipital joint.Picture28Picture29

Magnetic resonans imaging is the only way for exact and definitive diagnosis of chiari-like malformation and syringomyelia. T2 and T1 weightened midsagital and transversal images of
the foramen magnum, caudal occipital fossa and cervical spinal cord will show syringomyelia.

We can describe magnetic resonans imaging findings as a narrow subarachnoid space in cervicomedullar junction, occipital bone compression on caudal cerebellum, rostral movement of caudal cerebellum, syringomyelia, cerebellar herniation from foramen magnum and kinked appearance of caudal medulla.

Lateral vetricle dilatation is a very common sign but hydrocephalus is a possible but rare condition.

Treatment

Most of the patients with syringomyelia can spend their whole lives with mild neurological symptoms without any need for medical or surgical treatment. Life quality is the main concern for treatment decision. Patients with obvious neurological signs and pain and non-responsive to pain managment therapies are candidates for surgery. Patients with mild symptoms and pain or non-responsive to pain medication are candidates for medical treatment.

Non-steroidal antinflamatoric medications are not effective against neurologic pain. In severe cases pain can be manage just by some anticonvulsants like gabapentin( 10mg/kg tid) or pregabalin (2-4 mg/kg bid). Last researches showed that omeprazol decrease cerebrospinal fluid production and can be used in some patients but some studies done in rats showed that long term use can cause hypergastrinemia and increase the risk of stomach cancer.

The other medicatios can be used to depress the clinical signs of syringomyelia are; acetozalamide, furosemide, corticosteroids, and phenobarbital. Another promising medication for neurologic pain is palmitoylethanolamide (pea) nad can be effective in several syringomyelia patients.

Surgical treatment is indicated in patients with worsening neurological signs and unresponsive pain. Aim of the surgery is to reorganize cerebrospinal fluid flow pathways and decrease the abnormal CSF in side the central nervous system by decompressing cerebellum. For this aim “Foramen magnum decompression” is indicated by a suboccipital craniectomy and partial dorsal laminectomy of first cervical vertebra that enlarge foramen magnum .

Foramen magnum decompression window limits and borders are so important. A small window will be effectless and a large window can cause atlanto-occipital instability or excessive bleeding in a very sensitive area which can cause life treating situations. Lateral borders of the window are atlantooccipital joints and lateral vertebral foramens of atlas , rostral borders are midpoint of the distance between protuberentia occipitalis and dorsal border of foramen magnum, caudal border is ¾ of atlas. Durotomy and marsupilization of dura to the muscular structures around the foramen magnum window is the common procedure but cerebrospinal fluid leakage can cause an inflamation and this inflamation can lead severe soft tissue thickening which can cause compression in the area. Altough durameter is firmly attached to the bony structures in atlantoaccipital region carefull dissection can be done without duratomy to prevent csf leakage.

Foramen magnum decompression will reorganize cerebrospinal fluid flow but the present fluid and the syringomyelia cavity will remain which means the present symptoms will continue most of the time. Foramen magnum decompression is most effective against pain which is the most common indication of surgical treatment.

To drain the present syrinx in syringomyelia cavity “syringosubarachnoid shunt application” is the most effective and popular method. Approach to spinal cord with a dorsal laminectomy where the syrinx cavity is most prominent has to be done first. After a “T” shaped duratomy placement of a shunt in 1-1.2mm thickness from syrinx cavity to subarachnoid space has to be performed to complete the procedure.

Discussion

As a result chiari-like malformation and syringomyelia is one of the most important breed predispositions of veterinary medicine and although the disease is reported in several other breeds it creates a very important clinical problem among king charles cavalier population. Most of the patients with syringomyelia can live whole their lives with very mild symptoms within a normal life expectancies but some patients will have cervical myelopathy, cerebellovestibüler dysfunction and multifocal central nervous system dysfunction. Pain and life quality is the main concern and criteria for treatment. Patients with obvious neurological signs and pain and non-responsive to pain managment therapies are candidates for surgery. Foramen magnum decompression and syringo-subarachnoid shunt application are the two surgical procedures described to reorganize normal cerebrospinal fluid flow and drain syrinx from its cavity.

Through the scope balloon dilatation of post-traumatic esophageal stricture in dog – case report

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Author Emil Ofner

Emil Ofner DVM, Only sky’s the limit

Emil Ofner DVM, Veterinary Clinic More

Authors : Emil Ofner, DVM
Davor Crnogaća, DVM
Ivica Ukić, DVM
Silvijo Tarasić, Eng; OLYMPUS d.o.o. Zagreb

Small Animal Veterinary Clinic More, Šibenik, Croatia
Key words : esophageal stricture, balloon dilatation, regurgitation

Abstract :

Many diseases can cause esophageal stricture formation. Strictures in dogs are most frequently caused by foreign objects trapped in esophagus. The easiest way to diagnose and treat esophageal strictures is with flexible gastroscopes. Although there are lots of ways to dilate stricture, through the scope method, using esophageal balloon catheter is simple and safe method enabling direct visualisation of whole procedure.

Introduction :

Table 1

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Post-traumatic esophageal strictures in small animals are relatively rare problems. Most common cause of post – traumatic esophageal strictures is foreign body entrapment in the esophagus. Also, post – traumatic endoluminal strictures can be caused by caustic material ingestion or as a complication of esophageal surgery. In all of these situations damage of esophageal wall layers causes local inflammation with production of fibrous connective tissue. Local fibrosis or scar formation causes reduction of esophageal diameter thus causing stricture. Common symptoms of esophageal strictures are : regurgitation, salivation, dysphagia and ptyalism. Treatment is usually dilatation with balloon catheters or different types of cylindrical tubes called bogies (Table 1).

Case presentation :

Picture 1

Picture 1. Olympus BE – 6 esophageal balloon catheter and hand held saline pump

Female, 9 years old West Highland White Terrier was brought to our clinic because of chronic regurgitation that lasted for four weeks. Prior to this, dog ingested bones and vomited them after five days. She could drink water and take liquid food. Solid food was regurgitated immediately after ingestion. Rectal temperature was normal but she lost 0.84 kg of body weight. Complete blood count and biochemistry values were normal. Radiographic examination didn’t reveal any cause of regurgitation. At this point we decided to do a flexible endoscopy examination of esophagus, which revealed 4 mm diameter stricture in distal part of thoracic esophagus.

Management and Outcome :

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Picture 2. Esophageal stricture

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Picture 3. Through the scope method of introducing balloon catheter into stricture

Dog was put under general anesthesia and intubated. Olympus GIF Q10 flexible gastroscope with 2.8 mm working channel was introduced into esophagus. After this, Olympus SWIFT balloon catheter (model BE – 6 ) was introduced through the working channel into the stricture ( through the scope method ). To generate force for stricture dilatation, catheter was expanded using saline and hand held Swift pump, two times for duration of two minutes. Steroid ( tramcinolone 40 mg / ml ) diluted with saline 1 : 2 was injected submucosally in three places around the stricture ( Pictures 1 to 5 ). After procedure, we prescribed omeprazole ( 1 mg / kg PO q24h ) for 7 days. After three weeks whole procedure was repeated. On next check-up dog regained normal body weight and was eating solid food without any problems.

Discussion :

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Picture 4. Expanding balloon catheter with saline

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Picture 5. Triamcinolone application

From a biomechanical perspective, all types of dilators ( balloons and bougies ) generate two types of forces on esophageal wall, radial stretch force which is responsible for dilatation and unwanted longitudinal shear force which can cause esophageal perforation ( Table 1 ).
Through the scope balloon dilatation of esophageal strictures is an easy and relatively safe procedure. Stricture dilatation occurs because saline filled balloon transfers radial stretch force on esophageal wall. Complications like esophageal preforation rarely occur when using balloon catheters because of low longitudinal shear force. Mean shear force of balloon catheters is 1,44 N. Low shear force of balloon catheters is associated with significantly lower risk for perforation.
When using other types of dilators like bougies, in theory perforations are more likely to occur because of strong radial and shear forces.Bougies involve passing long rigid instrument ( rigid cylindrical tube ) through the stricture blindly or by endoscopic guidance. Advancing bougie through stricture generates radial force which causes dilatation of stricture, but it also generates strong shear force which can cause perforation. Mean shear force when using bougies is 16,92 N for Maloney type and 6,92 N for Savary – Gilliard bougie.
Steroid injection prior or after dilatation improves outcome because it’s decreasing scar formation and need for repeated dilatations. Most cases will need repeated procedure in three weeks. If the dog is eating normally after 3-4 weeks it probably wont need new dilatation procedure.
After procedure, anti-acids are prescribed to reduce potentially negative effect of gastric acid on new scar formation. Use of proton pump inhibitors like omeprazole is recommended because of better effect than H2 receptor antagonists ( ranitidine, famotidine ).

Acknowledgments :

We are thankful to Mr. Silvijo Tarasić and Olympus d.o.o. Zagreb who provided technical expertise that greatly assisted us in implementing new technology improvements in our practice.

References :
1. Adamama-Moraitou KK, Rallis TS, Prassinos NN, Galatos AD. Benign esophageal stricture in the dog and cat: A retrospective study of 20 cases. Can J Vet Res. 2002 Jan;66(1):55-9.
2. Leib MS, Dinnel H, Ward DL, Reimer ME, Towell TL, Monroe WE. Endoscopic balloon dilation of benign esophageal strictures in dogs and cats. J Vet Intern Med. 2001 Nov-Dec;15(6):547-52.
3. Harai BH, Johnson SE, Sherding RG. Endoscopically guided balloon dilatation of benign esophageal strictures in 6 cats and 7 dogs. J Vet Intern Med. 1995 Sep-Oct;9(5):332-5.
4. McLean GK, LeVeen RF. Shear stress in the performance of esophageal dilation: comparison of balloon dilation and bougienage Radiology. 1989 Sep;172(3 Pt 2):983-6.
5. ASGE Technology Committee, Siddiqui UD, Banerjee S, Barth B, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Tokar JL, Wang A, Rodriguez SA. Tools for endoscopic stricture dilation. Gastrointest Endosc. 2013 Sep;78(3):391-404. doi: 10.1016/j.gie.2013.04.170.

 

 

PETCODE Veterinary Hospital on the Balkans….. is it real?

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PETCODE ANIMAL HOSPITAL; where our dreams came true

Just before starting to make our new  animal hospital I asked my collegues to write me about their dreams. I was not wondering what we can do,  I was wondering  about a small animal practioner’s dreams . It is not easy to understand the meaning of these dreams for a vet working  in Germany, Holland or England but I am sure you can understand  how important this is for us. In countries like Turkey or in Balkans, there is always some thing is absent while we are practicing. I asked the same question to some of my patient owners. I was sure that as the people who love their pets they would also have dreams about a perfect hospital.  I knew that it was impossible to make a perfect hospital  but I believed that all these dreams will guide us  to create a close one.IMG_1122IMG_1125

After I collected all these notes from my friends  I read them may be a hundred  times. I saw that some of my friends  was dreaming about wider and bigger spaces to practice, some of them was dreaming about high technologies  like MRI and CT, some about a better laboratory and etc. The list was so long but we did our best to make them true one by one. Of course we could not manage to make them all but we are still on work and continue .That is why I am not calling PetCode as  “the perfect animal hospital” I am calling us as “The hospital where the dreams come true.”

Now I will try to tell you about Petcode, the sum of  our dreams.IMG_1121IMG_1123

Our Petcode Animal Hospital is serving  in a 1400 square meter building and it is physically  the biggest animal hospital in Turkey. We are using 2 different entrance and 3 separate parts in Petcode. In polyclinics section you can find our account office, secretary and information desk, pharmacy, a wide waiting room with different waiting areas  for dog  and cat owners, two examination rooms for dogs and two examination rooms for cats, physical therapy and rehabilitation service with a hydrotherapy pool, hemodialysis unit, pet coiffeur and meeting room. In hospital section we have emergency entrance, emercency waiting and examination room, computered radiography, colored doppler ultrasonography, electrocardiography and office rooms, hospitalization section, central examination room for hospitalized patients, reanimation rooms,  oral health and dentistry unit, surgery preperation room, half sterile room and full sterile operation room. You can enter our hospital’s third section  with our elevator and here you can find computered tomography, restaurant  and, changing rooms for our staff, laudry and storage.IMG_1124

In PetCode Animal Hospital we believe that  “ Cats are not small dogs ” and  with  this policy we divided our wide waiting room  to 2 parts,  one is for dog owners and the other  is for cat owners. There are 4 routine examination rooms in our hospital and 2 of them is for cats and 2 for dogs. Dogs are never alouded to enter cat examination rooms just to reduce the stress of cats. We have special hiding places in our cat examination rooms so when they jump and escape from the examination table we never try to catch them because we already know  where they will enter.

“Physical Therapy and Rehabilitation”(FTR)  is one of the most popular branches in veterinary medicine all over the world. The high percentage of geriatric animals among the pet population,and the important  tendency of dogs and cats to obesity is increasing the risk of osteoarthritis. Osteoarthritis  creates the main need for physical therapy and rehabilitation in most cases. The increasing  number of advanced surgeries we are performing  is also increasing the demand of patient owners for a better and faster recovery period. So physical therapy and rehabilitation is becoming more and more popular every year and of course we made a big investment  for FTR in PetCode. Our hospital has a hydrotherapy pool supported with a lifting crane for paraplegic animals. We have a  gait analysis system which shows given weight to each extremity quantitatively . Our treadmil, electrotherapy, therapeutic ultrasound, laser therapy and laser acupunture systems are the other feautures of Petcode FTR service.

Petcode Hemodialysis Service is the only hemodialysis  chance for dogs  in Turkey so patients with kidney failure and differenttoxications are coming to us everywhere from Turkey. Of course keeping a chronic renal failure patient alive just with hemodialysis is so expensive and not efficient and logical most of the time but we are mostly helping acute renal failure patients successfuly. Our hemodialysis machine is just suitable for patients over 15kg and we are performing peritoneal dialysis for our smaller dogs and cats.IMG_3087

According to American Animal Hospital Association veterinary dentistry creates the biggest income for every small animal practice in USA and in Petcode we made a serious  investment for veterinary dentistry. We are not only performing tartar cleaning and teeth extractions we are also using intraoral cameras, taking x-rays,  performing fillings, coverings and implants.

In PetCode we are  closing our polyclinic section everyday at 20.00 but emergency entrance is open for the rest of the night with an on duty veterinarian and a veterinary technician. When we had a surgical emergency we always call all our surgical team and perform the surgery.IMG_7684

During day time all our staff  pass the hospital section  door with a card reader. Our patient owners are not alouded to enter to the hospital section by themselves and even for visiting for their patiens we always guide them. They can pass to hospital section just with special plastic overshoeses, galoshes.

Because of our huge street animal population Turkey is a heaven for all kinds of infection diseases and in  PetCode we are fighting with hospital infections seriously. We are using hepafilters in all risky points, all our cages are made from chrome-nickel steel  for better disinfection, and they all have full glass doors to prevent the spread of infections via splashig, coughing, sneezing. We keep patients with infectious diseases in an isolated room. We are always  trying to obey high standart disinfection and sterilization rules everywhere in the hospital.

Oxygen is life and in PetCode we produce our own oxygen with a very special system and we safely use this oxygen in our anesthesia machine, intensive care units and everywhere in our hospitalization section.IMG_0549IMG_1831

Our hospitalization service has 4 sections.  We keep our patients with all kinds of infectious diseases in our infectious disease room. Our staff enter this room with special outwear. There is a special antibacterial plastic curtain in the entrance of this room which keep the infections inside and we are using special hepafilters  for the ventilation  so that possible infections are not entering to the general ventilation system  of the hospital. When we have patients that we are not sure about their health and vaccination status we keep them in cages in our  quarantinedepartment until we feel sure that they do not carry any kind of infectious disease to our other visitors. In our regular hospitalization section we have 2 parts and of course one is for dogs and the other one is for cats. All these parts are openning to a central examination room and we carry our patients here for their regular applications.

In PetCode we are able to perform almost all kind of surgeries. We are doing a lot of brain and spinal surgeries,total hip replacements,  tuberositas tibia advancements, tuberositas tibia transpozitions, eksteranl fixators, vertebral stabilisations, ventriculoperitoneal and syringosubarachnoid shunts,  different types of reconstructive and oncological surgeries, and eye surgeries including phacoemulsifications. All these advanced surgical procedures  give us a big responsibility as well.

. If you are planning to perform that sort of sophisticated and advanced surgical procedures , of course just good surgical skills are not enough for these plans. You need experience, a good team, perfect medical equipment and a very sterile surgical room.FullSizeRender

That is why Petcode  brought  “Full sterile operation room term”  to Turkey.  We enter to our operation room through a half sterile room always with head caps and masks. Floor surface of our operation room is made from esd conductive, antistatic and antibacterial material. Our walls are covered with chrome- nickel steel  because bacterial contamination of this material is  diffucult and disinfection is always easy. IMG_6016IMG_6010Ventilation of this room is special because air is entering to the room through hepafilters and a system always aspirates the dirty air inside the room again through hepafilters so there is always positive pressure inside the room and air entrance is limited even we are openning our doors during enterance. Our surgical room is also full of state of art medical equipments that allow us to perform all kind of surgeries.

Petcode is the one and only private animal hospital that has  its own computered tomography machine in Turkey. With the help of our  three dimentional reconstruction programmes we use,  we are able to obtain very high qualified images almost compatible with high field  magnetic resonans images so we can diagnose several  neurological and oncological problems easily.1424295_1650399288567012_3625160114951452674_n1497350_1650399538566987_593934141063559119_n

As you can see, PetCode Animal Hospital is the biggest investment done for small animal practice in Turkey  but we are still dreaming about a perfect animal hospital with our  lives coded to animal love,and veterinary medicine.

PERITONEAL DIALYSIS IN A SPHYNX CAT WITH ACUTE RENAL AND LIVER FAILURE

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Dr Bogdan Vitelaru

Bogdan Alexandru VIŢĂLARU

University of Agronomic Sciences and Veterinary Medicine of Bucharest, 59 Mărăşti Blvd, District 1, 011464, Bucharest, Romania, Phone: +4021.318.25.64, Fax: + 4021.318.25.67, Email: alexandrumv@yahoo.com

Corresponding author email: alexandrumv@yahoo.com

Abstract

A 11-year-old 3.1 kg, castrated, female Sphinx cat was referred to the Clinic of the Faculty of Veterinary Medicine Bucharest for acute onset vomiting, loss of appetite, anorexia, faintness, sharp breath, inability to exercise, oliguria and lethargy. Results from a complete blood (cell) count (CBC), serum chemical profile, and urinalysis submitted at that time were abnormal. The patient had hyperglycaemia (Glu-164mg/dl), acute renal failure (Crea-3.4mg/dl, BUN-117mg/dl) and acute liver failure (ALT-744U/L, TBIL-11.8mg/dl). The ALKP was 155U/L. The rectal temperature was 37,4ºC, the patient presented anaemic mucous membranes, mild dehydration (persistent skin fold thickness 2-3 seconds) and slight sensitivity to palpation in the renal lanyard. The established treatment consisted in peritoneal dialysis, rehydration and electrolyte balance, parenteral nutrition. We used PD4 peritoneal dialysis Dianeal 200 ml (1000ml / sqm). The patient was submitted to intravenous fluidotherapy with 5% Dextrose, Sodium Chloride 0.9 %, Aspatofort, Ondansetron, Metoclopramide and Duphalyte, CRI for 18 days. Abdominal ultrasound showed bile duct obstruction, abundant sludge in the gallbladder and mild modification in kidneys. Recommendation for oral treatment: Ipakitine bid, Azodyl bid and kidney diet food. The patient started to eat voluntary after 8 days of treatment. TBIL went up to 23.3mg/ml after the first 7 days and then started to decrease until it reached 0.9mg/dl at the end of the parenteral treatment. BUN and Creatinine values decreased to normal after the first 7 days of peritoneal dialysis and parenteral treatment. Peritoneal dialysis therapy plays an important role in renal failure in cats, especially in the elderly and weighing up to 10 kg. Elevated levels of creatinine and urea, hyperkalemia, hyper phosphatemia, or metabolic acidosis which do not yield to treatment can be solved using peritoneal dialysis. It also has a good effect in acute liver failure, cleaning the high levels of bilirubine.

Key words: peritoneal, dialysis, creatinine, urea, bilirubine

INTRODUCTION

Peritoneal dialysis is a technique whereby infusion of dialysis solution into the peritoneal cavity is followed by a variable dwell time and subsequent drainage. During peritoneal dialysis, solutes and fluids are exchanged between the capillary blood and the intraperitoneal fluid through a biologic membrane, the peritoneum. Inadequate renal function leads to disturbance in the removal of the extra fluid and waste products. It removes the waste product and extra fluid from the body in renal failure in small animal practice. Peritoneal dialysis is more accessible, more affordable and easier to administer to the small animal patient. The most common indication for peritoneal dialysis in cats is acute renal failure (ARF). Peritoneal dialysis is an important therapeutic tool for mitigating clinical signs of uraemia and giving the kidneys time to recover in cats with acute kidney injury when conventional therapy is no longer effective (Bhatt et al., 2011).
Peritoneal dialysis is a modality of renal replacement therapy that is commonly used in human medicine for treatment of chronic kidney disease and end-stage kidney failure. Peritoneal dialysis uses the peritoneum as a membrane across which fluids and uremic solutes are exchanged. In this process, dialysate is instilled into the peritoneal cavity and, through the process of diffusion and osmosis, water, toxins, electrolytes, and other small molecules, allowed to equilibrate (Cooper and Labato, 2011).
Peritoneal dialysis uses the peritoneum as a semi permeable layer for dialysis in which excess water, ions and solute in the blood pass through a semi permeable membrane to sterile solution which is known as dialysate via diffusion, osmosis and filtration. The three-layered peritoneal membrane consists of 1) themesothelium, a continuousmonolayer of flat cells, and their basement membranes; 2) a very compliant interstitium; and 3) the capillary wall, consisting of a continuous layer of mainly non-fenestrated endothelial cells, supported by a basement membrane. The mesothelial layer is considered to be less of a transport barrier to fluid and solutes, including macromolecules, than is the endothelial layer (Clough and Michel, 1988). Solute transport rates are assessed by the rates of their equilibration between the peritoneal capillary blood and dialysate. The ratio of solute concentrations in dialysate and plasma at specific times during the dwell signifies the extent of solute transport. Creatinine and urea clearance rates are the most commonly used indices of dialysis adequacy in clinical settings. Contributions of residual renal clearances are significant in determining the adequacy of dialysis (Flessner et al., 1985).

MATERIALS AND METHODS

An 11-year-old, 3.1 kg, castrated, female Sphinx cat was referred on November the 10th 2014 to the Clinic of the Faculty of Veterinary Medicine Bucharest for acute onset vomiting, loss of appetite, anorexia, faintness, sharp breath, inability to exercise, oliguria and lethargy. The physical examination revealed that the patient was anorexic, lethargic, had inability to exercise and a pronounced yellowish colour of skin and mucosa. Results from a complete blood cell count (CBC), serum chemical profile, and urinalysis submitted at that time were abnormal. The rectal temperature was 37.4ºC the patient presented slight sensitivity to palpation in the renal lanyard. Abdominal ultrasound showed mild modification in kidneys. The established treatment consisted in peritoneal dialysis, rehydration and electrolyte balance, parenteral nutrition. The patient was also submitted to intravenous fluidotherapy with 5% Dextrose, Sodium Chloride 0.9%, Aspatofort, Ondansetron, Metoclopramide and Duphalyte, CRI (Kushwaha and Singh, 2008).

RESULTS AND DISCUSSIONS

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Fig 1

The patient was presented with abnormal blood biochemistry values in the first day. The patient had hyperglycemia – Glucose – 164 mg/dl (reference range 71-159 mg/dL), acute renal failure (Creatinine – 3.4 mg/dl – reference range 0.8-2.4 mg/dL, BUN – 117 mg/dl – reference range 16-36 mg/dL) and acute liver failure (ALT – 744 U/L – reference range 12-130 U/L, TBIL – 11.8 mg/dl – reference range 0.0-0.9 mg/dL). The ALKP was 155 U/L – reference range 14-111 U/L. The rectal temperature was 37.4ºC, the patient presented yellow anaemic mucous membranes, mild dehydration (persistent skin fold thickness 2-3 seconds) and slight sensitivity to palpation in the renal lanyard.
Abdominal ultrasound showed mild modification in kidneys. Recommendation for oral treatment: Ipakitine bid, Azodyl bid and kidney diet food.
The established treatment consisted in peritoneal dialysis, rehydration and electrolyte balance, parenteral nutrition. We used PD4 peritoneal dialysis Dianeal 200 ml (1000 ml/sqm) after placing the peritoneal catheter and after we managed to accommodate the patient with the peritoneal distension. Aseptic technique is imperative for the peritoneal dialysis (the use of surgical scrub and sterile surgical technique during catheter placement, as well as the use of sterile gloves, disinfectants, and the careful handling of dialysate fluids, catheters, and catheter line during dialysis), (Thornhill, 1981). The catheter enters the abdomen on midline at the level of the umbilicus and it is directed caudally and positioned in the lower pelvis (Figure 1).

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Fig 2

The patient was also submitted to intravenous fluidotherapy with 5% Dextrose, Sodium Chloride 0.9%, Aspatofort, Ondansetron, Metoclopramide and Duphalyte, CRI.
On 11th of November 2014, the first day of treatment, the patient was presented with 37.5°C body temperature and we started administrating fluidotherapy IV in a volume set at 30 ml per hour twice a day: Dextrose 5% 15 ml, Sodium Chloride 0.9% 30 ml, Aspatofort 1 ml and subcutaneous Emeset 0.4 ml. Peritoneal dialysis was performed infusing 200 ml Dianeal PD4 (1000 ml/sqm) and we collected 130 ml after 4 hours of dwelling (Figure 2).

On the next two days we used the same protocol of peritoneal dialysis and we managed to recover this time 160-180 ml after 4 hours. The fluidotherapy remained the same, 30 ml/h and the temperature dropped at 37°C. On the 13th of November the blood tests showed: Glu 196 mg/dL (reference range 71-159 mg/dL), BUN decreased to 73 mg/dL (reference range 16-36 mg/dL), and the creatinine decreased at a normal value of 1.6 mg/dL (reference range 0.8-2.4 mg/dL). The transaminaze ALT and ALKP also decreased: ALT 509 U/L (reference range 12-130 U/L), ALKP 121 U/L (reference range 14-111 U/L) but the total bilirubin (TBIL) increased at 18.4 mg/dL (reference range 0.0-0.9 mg/dL). The pancreatic lipase dropped at 59 U/L (reference range 100-1400 U/L).
On November the 14th, the patient presented hyperthermia (40.2°C) and we performed a second abdominal ultrasound exam where we noticed the bile duct obstruction and abundant sludge in the gallbladder. The IV fluidotherapy was modified to: Dextrose 10% 7.5 ml, Sodium Chloride 0.9% 50 ml, Aspatofort 2 ml, Duphalyte 15 ml and Metoclopramide 0.3 ml twice a day. The same protocol of peritoneal dialysis have been used and we managed to recover 160-180 ml after 4 hours. We followed the same treatment for the next two days and the temperature decreased at 39.2°C. On the 16th of November we performed a complete blood count which shown granulocytosis and thrombocytosis which indicated mostly an infection corroborated with a kidney disease. The following days the temperature dropped at 38.4°C and we administered, at a constant-rate of infusion of 20 ml per hour for 12 hours per day, Dextrose 10% 30 ml, Sodium Chloride 0.9% 200 ml, Aspatofort 8 ml, Duphalyte 15 ml and Metoclopramide 2 ml.
On the 18th we run biochemistry blood tests and the results were quite remarkable: BUN, creatinine and glucose came back to normal reference rates. Glu 120 mg/dL (reference range 71-159 mg/dL), BUN decreased to 33 mg/dL (reference range 16-36 mg/dL), and the creatinine maintained at a normal value of 2.0 mg/dL (reference range 0.8-2.4 mg/dL). The only parameters which remain high were ALT, TBIL and GGT. ALT was 469 U/L (reference range 12-130 U/L), TBIL decreased to 5.8 mg/dL (reference range 0.0-0.9 mg/dL) and GGT decreased to 10 U/L (referance range 0-1 U/L). The same protocols of peritoneal dialysis have been used and we managed to recover 180 ml after 4 hours.
We followed the same treatment for the next four days and the temperature went back to a normal value of 38.4°C. On the 21st of November we run biochemistry blood tests and the ALT decreased to 387 U/L (reference range 12-130 U/L), TBIL decreased to 3.5 mg/dL (reference range 0.0-0.9 mg/dL) and GGT decreased to 8 U/L (reference range 0-1 U/L). The same protocols of peritoneal dialysis have been used and we managed to recover 180 ml after 4 hours. On the 21st of November, our patient presented appetite for the first time and eat voluntary. From this moment it started to eat every two hours renal diet and drink by herself. We decided to stop the peritoneal dialysis, the peritoneal catheter was removed and dialysis was discontinued. The patient’s condition has improved significantly (Table 1).

We followed the same venous treatment for the next seven days and the temperature maintained at a normal value of 38.4°C. On the 28th of November we run biochemistry blood tests and BUN was 46 mg/dL (reference range 16-36 mg/dL) and all the other parameters maintained in normal ranges of value. The patient’s condition has improved significantly

Parameter 10.11 13.11 18.11 21.11 28.11
Glucose
(71-159 mg/dL) 164 196 120 129 94
BUN
(16-36 mg/dL) 117 73 33 34 46
Creatinine
(0.8-2.4 mg/dL) 3.4 1.6 2.0 1.7 1.4
ALT
(12-130 U/L) 744 509 469 367 109
GGT
(0-1 U/L) 0 15 10 8 0
TBIL
(0.0-0.9 mg/dL) 11.8 18.4 5.8 3.5 0.9

We decided to discontinue the venous treatment and we recommended oral treatment: Ipakitine bid, Azodyl bid and kidney diet food.
In comparison with the literature, the decrease in BUN and creatinine were quite remarkable, the BUN decreasing from 117 mg/dL to 33 mg/dL in eight days and the Creatinine from 3.4 mg/dL to 1.6 mg/dL in three days.

CONCLUSIONS
Peritoneal dialysis therapy plays an important role in renal failure in cats, especially in the elderly and weighing up to 10 kg. Elevated levels of creatinine and urea, hyperkalemia, hyper phosphatemia, or metabolic acidosis which do not yield to treatment can be solved using peritoneal dialysis. It also has a good effect in acute liver failure, cleaning the high levels of bilirubine.

REFERENCES
Bhatt, R. H., Suthar, D. N., 2011, Peritoneal dialysis in acute renal failure in canines: A review. J. R. UkaniVet. World, Vol.4(11): 517-521
Clough, G. and Michel, C. C., 1988. Quantitative comparisons of hydraulic permeability and endothelial intercellular cleft dimensions in single form capillaries. J Physiol ; 405:563–576.
Cooper, R. L. and Labato, M. A., 2011. Peritoneal dialysis in veterinary medicine. 41(1):91-113.
Flessner, M. F., Dedrick, R. L. and Schultz, J. S., 1985. Exchange of macromolecules between peritoneal cavity and plasma. Am J Physiol ; 248: 15.
Kushwaha, R., Singh, N., 2008. Peritoneal dialysis în animals – A review. The Internet Journal of Veterinary Medicine. Volume 7 Number 1.
Stojimirovici, B.; Trbojevic-Stankovic, J., 2007. Animal models în peritoneal dyalisis, Scand. J. La. Anim, Sci. Vol. 34, No 4
Thornhill JA. 1981. Peritoneal dialysis în the dog and cat: an update. Compend Cortin Educ Prac Vet, 3, 20-34

 

Dr Valentin Nicolae….The most special person on The Balkans!

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Dr Valentin Nicolae

Who is Dr Valentin Nicolae? Let’s people say this:

1.Dr Wolfgang Dohne

Vice president of FECAVA
Owner of  Virginia Water Veterinary Clinic

 

He has been at his association’s FECAVA director for many years and I always found him very pleasant and approachable.

With his help the Romanian association has progressed a lot over the last 10 years and his association is now running a very successful annual congress.

Valentin very much enjoys the social side of FECAVA and is a surprisingly good dancer.

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Senior President of AMVAC

Both he and Robert Popa are outstanding representatives of their association.

2.Dr Robert Popa

Vice president of AMVAC/RoSAVA

Owner of O&R veterinary clinic

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Valentin

Dear Valentin! You are that kind of persons who never gives up. You had a dream to make a a decent veterinary association in Romania and you did it. You were the first, you were the leader, sometimes the dictator but you never ever avoid to take responsibilities. No mater that it was a good thing, when it is easy, or a bad thing, when is the moment of truth of for real leaders. It will always be a pleasure to shake your hand, have nice talk in a beautiful environment, near a good glass of wine. Thank you my friend and keep going!

3. Dr Tache Epure

The president of Romanian Feline Medicine Society

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Valentin

Valentin I’ve known for many years, before AMVAC site to represent something veterinary medicine in our country. Charismatic personality made him noticed which I had meetings at various congresses, conferences or Work-shops related to pets, but also the great value professional after … which is currently on a human quality is excellent but a young spirit, always searching for new. Generous with colleagues and friends but especially young doctors who always showed them everything he knows, and many of them now being competitors, doctor Nicholas stands today as a true thought leader, always consistent, punctual and good organizer.

3.Dr Sinziana Radulescu

The President of Hemopet Blood Bank

There are some people that you meet and then your whole world changes forever. I think this is actually a popular subject for essays in English tests: write an essay about a person that changed your life! Although this is not an English test, it still feels like that’s what I’m doing here.

I remember being so young and naïve with no clue on how a carrier in veterinary medicine should look like. I was so proud of being part of the biggest veterinary event in the country: AMVAC/RoSAVA International Congress. I will never forget Dr. Nicolae Valentin’s words: “It takes a lot of passion and a fair amount of craziness to make this possible.” I understood right then, whatever it is that you do, it takes passion and a fair amount of craziness if you want to do great things.

“See, all of this here is possible thanks to you!” he used to tell us, a bunch of 2nd year vet students who knew nothing about life. I did not completely understand then, but I understand now the power of leadership. If small animal veterinary medicine in Romania had only one leader – Dr. Nicolae Valentin would be the one. He can bring people together to share his passion and craziness until perfection is achieved. He would ask for your help and you would feel grateful he did. He would give others credit while he would stay humble and smile.

On top of all this, Dr. Nicolae Valentin is one of the first vets to go abroad and bring the world back to Romania through his small animal clinic in Ploiesti. “My prices are not low, I have to admit. If clients are not able to afford them I will gently recommend them to go to my competition, where they would still get good service. But our prices are the product of all the things we have learned and all of the investments we’ve made to keep our medical services at this standard. And this is something I care too much about.” What a valuable business lesson, don’t you think?

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SRDV

I feel the luckiest person in the world to have met him and worked with him to achieve a common purpose: make the veterinary world in Romania a better place. His influence will always guide my actions: Think big. Be passionate. Be crazy. Stay humble. Work hard. Do the impossible! 

5.Svetlina Aleksandrova, DVM, Member of ESVD

     Owner of Lightvet Veterinary Clinic

We met a couple of years ago in Budapest and my first impression of him as a positive, kind and very dynamic person stays the same for years. Now I can add that he is a real treasure as a friend, as a vet and as a part of our society!12189380_428904733970157_5303852493900633428_o

6.Dr Rares Capitan DVM, resident ECVD

Owner of Veterinary Clinic Regatul Animalelor

Dr. Nicolae is more then a role model, he is full of inspiration. I have known him since I was in 9th grade in high school and the experience I gained in his clinic has followed me throughout my career. I believe that most of the successful vets in his town and more have worked in his clinic for a period of time, either during their university years or at the beginning of their career. Most important to me was his strong nice character, good heart, high professionalism, charisma, and his interaction with people.

7.Dr Daniela Enache,DVM,M.Sc.,PhDS

member of the team Vets on The Balkans

Few years ago, a new world was opened to all Romanian veterinarians with the contribution of an optimistic, proactive veterinarian and his team. Being a professional and loving his job, Dr. Valentin Nicolae, dedicated with enthusiasm his time to big and interesting projects from which AMVAC is one of them, but as well he started also a successul activity in his own clinic. By organizing several veterinary events for the vets from everywhere, dr Valentin Nicolae showed to all that continuing education is an useful and important part of our job, who complete the clinical activity. For me, dr Valentin Nicolae is an extraordinary example: a wonderful veterinarian with successful career, a trusted friend who helps you unconditionally and who will never disappoint you, finding solutions for any situation

I’m very happy to be part of the world that he created! Thank you for all!!!12322532_1640029786270629_4467346060229231885_o

8.Dr Luba Gancheva, DVM, M. Sc. Infection diseases, PhDS

The main editor of Vets on The Balkans

Dr Valentin Nicolae…. hm…He changed my life! He was the person who invited me first time in Romania and now I am living in this country! Who is he? All the words will be not enough to describe his personality! He is real leader, the best organizer, wonderful vet , but when you look at his eyes the you can understand who is Valentin. So much goodness in one soul ! THANK YOU that I met you and I can be a part of your professional road and not only!

9. Dr Gizem Taktak

TSAVA director for FECAVA and WSAVA

Owner of  Ataşehir PatiSev Veteriner Kliniği

When I first saw him with a pleasent smile and thought about what I will going to talk in long way trip. And on our way I saw very polite and open person if he can not speak fluent english. I am very happy to meet him and find my father in Romania. 1397077_761534410585943_5276769957689416636_o

Dr Nikoleta Novak- veterinarian, mother, writer…. successful lady on the Balkans

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My dog Rasha and me

Dr Nikoleta Novak

1.Who is Nikoleta Novak?

Nikoleta is…
Nature lover. Social bee. Passionate reader. Wise Owl for close friends. Open-minded.. “Half-full glass” type of a person…
Apart from that Nikoleta is veterinary surgeon working in Veterinary Clinic Novak dealing with cardiology cases, but also seeing first-opinion cases and doing some soft tissue surgery.
She is also a mother of two girls, a writer of children’s books and the owner of a dog, cat and 55 years old tortoise.

2.Do you think is hard to be professional in veterinary medicine on the Balkans nowadays?

ESAVS cardio course Luxenburg

ESAVS cardiology course in Luxenburg

When one of my friends, who is also a vet, first time visited England, he said : “This is a Disneyland for a vet!” For veterinary practice on Balkans nobody will say such a thing. Here you need to struggle with lots of problems, drawbacks, lack of medicines ,equipment, different mentality of clients… On the other hand, being a vet on Balkans is more challenging. You need to think differently, to look for solutions outside the textbooks, be ready to be a service provider both for your clients and for your equipment, even if you are not a creative person you are forced to become imaginative and resourceful …

3.Why you didnt leave your country? (vet like you has many opportunity to do this)

EHO workshop with June Boon in Italy

Ultrasound workshop with June Boon in Italy

big patients1

working

One part of you really wants to be in Disneyland. Me and my former husband set and passed RCVS exam (exam set by British Royal College of Veterinary Surgeons) and became their members which means we could work in the U.K or other E.U. countries. (Serbia is not part of the EU). The whole of our staying in the U.K. and the exam itself was a great experience for us and we enjoyed every moment of it, even very hard studying . But then it was a life decision: starting a new life in the U.K. or going back home and continue the life we left. We decided to go back and never regretted this decision. Why? There is a list of reasons, but for me probably the strongest one was a family. On the other hand it is not the same if you are just visiting Disneyland and if you live in it.

4.What do you think about the level of veterinary medicine on the Balkans?

It is getting better and better, but still we all have to put much more effort and more work. We need to educate both ourselves and our clients.

5.You are a writer of children’s books. I read some of them.They are amazing. Tell us more about this part of your life?

2015 book fair anouncment for my novel promotion

2015 book fair anouncment for her novel promotion

cover4

one of her books

Belgrade book fair - my dog as a character in one of my picuter books

Belgrade book fair – her dog as a character in one of her picuter books

My new novel and the main character

Her new novel and the main character

Visting Children's book fair

Visting Children’s book fair

Since I was a child I loved to read and write. I even wrote my first picture book before starting school. It was about animals of course (smiling). Throughout my life I was a keen reader but the only things I wrote were professional articles. Then by lots of connected coincidences I was contacted by a children’s book publishing house “Pčelica” (www.pcelica.rs). They asked me to write a manual for children about pets. And that’s how it all started. Now I have three serials of eight picture books each, one manual and most recently, a novel published by “Pčelica”. So all together, I have 25 books published. I managed to connect my three loves together: love for children, for animals and for books – as I write books for children and most of the characters are animals. In my books I try to show children how amazing animals are, and to evoke love for animals in them, but I also do address some important human values, dilemmas and problems, on children’s level of understanding of course.

6. Tell us more about your project “Blue dog” ?

blue dog part of the team

Blue Dog -part of the team

Blue Dog workshop

Blue Dog workshop

Blue dog is an European project designed to promote the education of children in their relationships with dogs  . The first resouce was the interactive CD-ROM with its printed parent guide. This was well received in scientific circles. However, promoting a prevention message to the public proved to be challenging in Serbia but also in all other countries which are participating in the program.
As a member of the Blue Dog team in Serbia. I really do enjoy working with children but all the other issues connected with it (writing projects, raising money for it etc.) I personally find hard to deal with. That’s why the Blue Dog team needs to have people with different knowledge and skills involved in it’s work.
In Serbia we had lots of workshops and other kind of activates in preschools, schools and different public happenings designed to teach the children safe behavior towards dogs and to promote and spread the Blue Dog project idea.

7. What do you think about “Vets on The Balkans” ?

my girls and our dog

her girls and her dog!

I read the interview you had with our colleague Nikola Bunevski, and I think he said it perfectly; “Sharing is caring. Vets on the Balkans can serve that purpose””Vets on Balkans” is really a great idea and I do wish you all the best on this exciting and high-minded mission.

 

The team of Vets on The Balkans would like to express their gratitude to this brilliant veterinarian from The Balkans and we are proud to have her as a colleague and friend!

 

Dr Nikoleta Novak

 

Nikoleta Novak BVSc MRCVS, surgery specialist, graduated in 1995 from the Faculty of Veterinary Medicine, University of Belgrade. She attained her surgery specialist degree in 1997. From 2000-2002 she expanded her professional knowledge in Great Britain, mostly in Cambridge veterinary school.
Nikoleta has been a Member of the Royal College of Veterinary Surgeons (MRCVS) since 2002. More recently, she obtained three parts of ESAVS certificate in Small Animal Cardiology, and continuing to expand her knowledge in the veterinary cardiology area by attended June Boon’s Echocardiography courses in Belgrade and Italy, over the past few years. She has attended more than 50 various continuing education programs, congresses, symposia, workshops, round tables, professional meetings beside those where she was involved as an organiser.

Nikoleta was a member of the Scientific and Professional Committee of Serbian Association of Small Animal Practicioneres (SASAP). as well as a member of the Editorial Board of the SASAP Bulletin for eight years.

She works Small Animal Veterinary Clinic – Veterinary Clinic “Novak” ; which is an institution that provides general and specialized veterinary medicine and surgical services for small animals.

Nikoleta is the leader of the Blue Dog Project in Serbia. (European project on safe behavior between children and dogs).

In 2010 Nikoleta wrote a short manual for children “Let’s learn about pets” for the publishing house “Pčelica” . Continuing this successful partnership, she published 3 serials of 8 picture books each, and most recently a novel for older children.

Laparoscopic surgery in IVAVET clinic

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Picture 1.Expert team at IVAVET clinic, Belgrade, Serbia.

Picture 1.Expert team at IVAVET clinic, Belgrade, Serbia. In front from right to left are Ivan Jevtić, DVM, and doctor specialist for laparoscopic surgery, owner and the main surgeon at IVAVET clinic. Next to him is Marija Pavlović, DVM, intern at IVAVET clinic. Behind from left to right are Biljana Jevtić, VT and owner at IVAVET clinic. Next to her is Radenko Savić, DVM, doctor specialist for intern medicine in small animals at IVAVET clinic.

Laparoscopic surgery is a minimally invasive surgery, a technique that allows the intervention to be performed by using multiple small abdominal incisions. Specialized camera with fiber-optical fibers (laparoscope) is introduced through one of these portals in order to allow visualization of the internal contents of the abdomen. Similarly, through other portals surgical instruments necessary for the intervention are inserted into the abdominal cavity. Table 1.

Laparoscopic surgery at ‘IVA VET’ clinic is performed by the team of experts. ‘IVA VET’ surgical team (picture 1.) utilizes advanced technology for the prophylactic, diagnostic, and therapeutic surgical procedures.

Picture 2. A Tissue appearance after laparoscopically performed surgery.

Picture 2. is presented tissue appearance after laparoscopically performed surgery.

Picture 2. B Tissue appearance after traditional open surgery.

Picture 2 is presented tissue appearance after traditional open surgery

The most common type of surgery performed using minimally invasive technique is ovariectomy. This procedure is performed to prevent unwanted offspring, and to reduce the risk of infections and cancers of the female reproductive tract. Compared with traditional open ovariohysterectomy, laparoscopic ovariectomy is technically less complicated and time-consuming. Further, in a study published in the 2005 Journal of the Veterinary Medical Association has been documented that laparoscopic surgery diminishes pain, reduces the risk of hemorrhage and speeds recovery times up to 65%. In table 1. are presented laparoscopic surgery advantages over traditional open surgery.

 

The most common reasons for laparoscopic intervention are:

• Diseases causing acute or chronical pain in abdominal or pelvic cavity.
• Visualization of miscellaneous growths and patches in abdominal cavity, and collection of various samples (biopsy) for pathohistological examination.
• Ovariectomy and ovariohysterectomy
• Determining possible causes for free fluid accumulation in abdomen.
• Cancer staging for specific tumors.
• Surgical removal of tumors or organ invaded by tumor.

Laparoscopic procedures in abdomen cavity:
• Ovariohysterectomy (in this procedure both, ovaries and uterus are removed)
• Ovariectomy (spay), only the ovaries are removed
• Sterilization of male dog
• Cancer and cystic kidney surgery
• Hernia Repair
• Ultrasound guided percutaneous sampling (biopsy) of abdominal organs
• Surgery of polycystic ovaries
• Gastropexy (Bloat/GDV Prevention)
• Removal of various tumor masses

Pre-operative assessment
Animal owners should expect the following procedures to be preformed during the preparation for the laparoscopic intervention:
1. General physical examination to determine animal health status.
2. Laboratory blood analysis (1.Blood chemistry panel—Used to evaluate organ function, electrolyte status, hormone levels, and more; 2.Complete blood count—Gives us information on hydration status, anemia, infection, clotting ability, and the ability of the immune system to respond to disease)
3. Laboratory urine analysis (Checks the condition of the urinary and genital tracts and screens for conditions such as diabetes, liver disease, and Cushing’s disease)
4. Abdominal ultrasound (enabling a partial examination of the abdominal cavity- A non-invasive, real-time, moving picture of your pet’s abdomen, chest and heart)
Contraindication for Laparoscopic surgery
Absolute contraindications

 Diaphragmatic hernia
 Septic peritonitis
 Conditions in which conventional surgical intervention is obviously indicated

Relative contraindications

 Obesity (obscure the view of many organs)
 Poor patient condition
 Ascites

 Poor clotting time
 Patient body weight <2 kg (instrument size)
 Patient that is a poor anesthetic risk or an extreme surgical risk

Patient preparation before surgery
Owners should withhold food for 6-12 hours (over night) before surgery.
Anesthesia for laparoscopic surgery
Laparoscopic surgery is routinely performed in general anesthesia.
Laparoscopic Surgery Procedures in general
Preoperative preparation of patient
Empty urinary bladder for a better visualization of the abdominal cavity and to minimize the danger of tapping. Position the patient. Aseptically prepare the surgical field in the standard fashion.

Surgery

Picture 3. First incision in naval area

Picture 3. First incision in naval area

A surgeon makes one initial incision (picture 3.) commonly in the navel area. Then, a small needle is inserted through this incision, through which carbon dioxide gas can be pumped into the abdomen to inflate it allowing for better visualization of the abdomen’s contents. Pressure in abdomen (picture 4.) must not be higher than 15 mm Hg (maintain the abdominal insufflation pressure at 12 to 15 mm Hg). If pressure in abdomen is higher, patient respiration will be impeded.

 

Next, a laparoscope is inserted through one of the incisions. The camera illuminates the interior of the abdomen and transmits high-quality, magnified images to a video screen in the operating room, allowing for precise maneuvering. After that, surgeon can begin with organ examination. If required, more incisions are made on abdomen to insert instruments (basic equipment and instruments required to perform laparoscopic surgery in dogs and cats are listed in table 2.), and perform the surgery or/and sample collections (biopsy). Once the procedure is completed, the carbon dioxide is let out of the abdomen and the incisions are closed using stitches or clips.Table 2.

 

Picture 4. Laparoscopic equipment

Picture 4. Laparoscopic equipment

Postoperative procedures
Any collected tissue or liquid sample during laparoscopic surgery will be sent for further pathohistological examination. Results of those analyses can be expected few days after the procedure.
Postoperative recovery after the laparoscopic surgery is much faster, safer and less stressful for your animal companion.
Duration of laparoscopic surgery
Depending on the complexity of procedure, laparoscopic surgery can last anywhere from half an hour to several hours.

Three portal laparoscopic cat sterilization performed by cutting both ductus deferens without testicle extraction:

 

Case report

Picture 5. Patient, seven months old cat named Lion

Picture 5. Patient, seven months old cat named Lion

Case description:
A seven month old half-breed cat named Lion (picture 1.) was presented to our clinic “IVAVET” for the sterilization. The patient’s caring owner wanted to know which surgical procedure would provide safer, less stressful and easier recovery to her loving animal companion. In addition, she wanted to know if there is any possibility to perform sterilization without removing testicales, thus Lion’s aesthetic appearance could stay undisrupted. Therefore, we thoroughly presented to her all possible solutions and recommended laparoscopicaly performed sterilization achieved by cutting both vas deferens without need to remove gonads.

Aim of this minimally invasive surgery is cutting the tubes (ductus deferens) that transport sperm from the testicles to the penis, without removing gonadal glands. By cutting these tubes permanently sterile animal retain hormonal balance due to kept ability to produce testosterone. Moreover, after this procedure there will be no need for any kind of special diet.

The patient’s owner accepted our advice so we obtained a signed permission form to perform laparoscopic sterilization, including permission to convert to an open procedure, should it be necessary.
Clinical finding
General physical examination and laboratory analysis indicated Lion’s good health condition confirming him as ideal candidate for laparoscopic intervention. Examination revealed a slightly elevated body weight (3.9 kg).

Patient and instrument preparation for laparoscopic surgery
Discarding our professional advice the owner fed her cat night before surgery. Consequently, cat vomited food, luckily for us before surgery took place. We prepared and sterilized all instruments (picture 2.), and put them on instrument table near operating.

Surgery

Picture 6. Basic sterilized instruments

Picture 1. Basic sterilized instruments

Picture 7. Cat position during procedure

Picture 2 Cat position during procedure

Anesthesia was achieved with appropriate dose of the domitor/ketamidor combination. We use this combination during surgery because it provides a suitable anesthesia for cats characterized by rapid induction, good muscle relaxation, good analgesia and bradycardia. During anesthesia our nonsterile assistant monitor all patient vital functions, instruments and keep connecting cables outside of patient sterile zone.
Patient was restrained in dorsal recumbency on positioner that has been securely attached to the surgery table, and the surgical field was aseptically prepared in the standard manner for all abdominal operations (picture 3.).

Next to the umbilicus we made a small skin incision (1 cm), trough which we placed the Veress needle. While placing the Veress needle we were very vigilant in order to avoid damage to internal abdominal content (especially spleen or liver). After penetrating the abdomen we attached the insufflation line to the Veress needle (picture 4.), turned the carbon dioxide gas on and started insufflation to establish pneumoperitoneum.

Picture 8. The Veress needle

Picture 4. The Veress needle

After that, we removed the Veress needle and in the same port we placed primary trocar through which we inserted laparoscope with a video camera and light source. After initial exploration with laparoscopic camera we placed two more lateral secondary ports (picture 5). Through this ports secondary trocars were placed, lateral to the primary trocar and halfway between the umbilicus and pubis. We used these two secondary ports to insert required instruments and to make easier access to the vas deferens.

Picture 9. A. Three trocars are visible (one primary, two lateral secondary

Picture 5. A.

Picture 9. B. Primary trocar with inserted Laparoscope with video camera and light source.

Picture5 B

Picture 11. A. Removing of instruments, after successful intervention

Picture 6 Removing of instruments, after successful intervention

Picture 11. B. Small portals left after removal of laparoscopic equipment.)

Picure 6 Small portals left after removal of laparoscopic equipment.)

Laparoscopic procedure was observed on video monitor placed in the operating room so that all team members could supervise whole procedure.First, in inguinal area we located left ductus deferens, using laparoscope. Second, with grasping forceps we elevated previously located left ductus deferens (as much as it was possible, look at picture 8.), inserted through one of the secondary ports. Third, through other secondary port we inserted bipolar forceps with an electro generator and coagulated one small place on the left ductus deferens. Finally, after removing bipolar forceps we used same port to insert scissor forceps and transect left ductus deferens. We have done the same process on the right ductus deferens.

We thoroughly checked for any bleeding or tissue damage before removing all instruments (picture 6.). After intrabdominal administration of antibiotics, deflating abdomen and removing trocars we sutured all ports using 3-0 thread for cats, in standard manner.

 

Postsurgical treatment
Lion was released home within a few hours after surgery. He didn’t show any signs of pain or altered general condition. We prescribed a postoperative analgesic for three days and instructed owner to return in a week for recheck.
Conclusion

Picture 12. Secondary ports sutured. Primary still not, but will be also sutured).

Picture 7 Secondary ports sutured. Primary still not, but will be also sutured).

Picture 10. Ductus deferens elevated with grasping forceps (instrument on the left) and coagulated with bipolar forceps (instrument on the right) on the same place where it will

Picure 8 Ductus deferens elevated with grasping forceps (instrument on the left) and coagulated with bipolar forceps (instrument on the right) on the same place where it will

Laparoscopic vasectomy performed by cutting tubes is more challenging for a surgeon but for the patient is undeniable better due to faster recovery time, decreased stress and pain, improved visualization, undisrupted hormonal balance and last but not the least important unchanged aesthetic appearance of your animal companion.

THE USE OF CONTINUOUS REMIFENTANIL ANALGESIA DURING GENERAL ANAESTHESIA IN ORTHOPEDIC PROCEDURES

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12346841_10208357516479226_277332268_nVet TommyDVM Goran Tomišić1, DVM Olgica Derota1, DVM Davor Ninković2
Veterinary clinic Tommy1, Veterinary clinic Radionica2, Belgrade, Serbia

Introduction

On the basis of long term use of continuous infusion of fentanylindifferent orthopedic procedures (pelvic, front and hind leg fractures, cruciate ligamentrepair and spinal surgery), we wanted toexplore the effects ofremifentanil, considering that they belong to the same group of opioid analgesics. Moreover,remifentanil is not widely used as fentanil in small veterinary practice. All surgical interventions were performed underisoflurane general anesthesiaandpremedication with medetomidine (intwenty six cases) and acepromazine (in sixteen cases). All patients were in good general condition (28 dogs and 14cats), age of six months toten years with no history of other diseases. Analgesic effect of remifentanil was extremely powerful and has directly decreased isoflurane MAC. Based on ourresultswe can concludethatremifentanilis powerfulanalgesicwith very short duration.

Based on the extended use of continuous infusion with the syringe pump of fentanyl (CRI) in different orthopedic procedures, the effects of clinical efficacy ofremifentanilas analgesic for these procedures which are very demanding in terms of analgesia. Surprisingly, given that they belong to the same group of the opioid analgesics, we have expected to obtain similar results to the effect of analgesia, side effects and speed of recovery from anesthesia. In fact, the continuous application in adminstering the drug has created remarkable savings in the reduction of the quantities used, as opposed to either timed dosage of remifentanil or the classic or CRI fentanyl application.

Materials and Methods

During surgery wewere not able to use artificial ventilation under general anesthesia. Each patient has received premedication with atropine at a dose of 0.02-0.05 mg/kg with the aim of prevention of bradycardia.Furthermore, the premedicationdrugs used, weremedetomidine at a dose of 10mcg/kg (0.01 ml/kg) for dogs and 50 mcg/kg (0.05 ml/kg)for cats and acepromazinefor both dogs and cats, at a dose of 0,06 mg/kg. Propofol was used for induction in a range from 1 to 4 mg/kg.After intubation was administered, continuous infusion of remifentanil which was followed by a significant decrease in the percentage of the isoflurane anesthetic in the range of
0.5% to 1,5 %.The dose of CRIremifentanil was in a range from0.4 to 0.1 mcg /kg /min, which is comparable to the recommended dose of fentanyl is 0.2 mcg /kg /min.During anesthesia monitoring analgesia was continuously matched to the frequency of heart rate, frequency and volume of respiration, arterialblood pressure and oxygenation of tissues(4).Forty two different orthopedic operations were carried out under this anesthetic protocol without visibleproblems on monitored parameters.

Results

12363956_10208357516239220_1054842213_oThe tables(Table 1. and Table 2.) show the varying concentration of Isoflurane in CRI administered remifentanil vs fentanyl.
In 28 dogs, the remifentanil dosage from 0.1 to 0.4mcg/kg/min (M=2.357, SD=1.062). Average concentration of Isofluranebeing 1.036% (M=1.036, SD=.470).
In 18 cats, at the same dosage level of remifentanil gave 0.92% of isoflurane (M=.920, SD=.275).
In comparison with our previous experiences with fentanyl (dosage being 0.2 mcg/kg/min, M=2.000, SD=.000), that was averaging 1.4% isoflurane in 30 dogs (M=1.400, SD=.000) to 1.2% isoflurane in 16 cats (M=1.200, SD=.000), the usage of remifentanil gives 0.37% (t=-4.248, df=56, py0.01) lower consumption of isoflurane in dogs and 0.28% (t=-4.067, df=29, p<0.01) in cat.

12356300_10208357562600379_671735595_oThe effect of analgesia was markedly potent, having direct impact on the decrease ofisoflurane in 60 % of MAC|(1). Recovery is easy and tree times as fast than if we had used fentanyl. The length of the surgical procedure did not affect the stability of the patient. When we used remifentanil CRI with propofol for induction of anesthesia, nausea and vomiting were nearly non-existent. In addition to the low frequency heart rate,there were no significant hemodynamic changes in the circulation. In some (11 dogs) patients, mild defecation was observed.