surgery

The use of vacuum assisted closure in the management of septic peritonitis – case report

 

1112Dr Robert Carst

Bucharest Romania

Pet Stuff veterinary hosptal

 

Introduction:

Septic peritonitis is an inflammatory condition of the peritoneum that occurs secondary to microbial contamination. Septic peritonitis may have a wide variety of clinical courses and outcomes, with high morbidity and mortality. The definitive diagnosis usually relies on the identification of toxic and/or degenerate neutrophils with foreign debris and/or intracellular bacteria in the peritoneal fluid. A thorough understanding of the treatment options and prognosis is crucial to decision making and comprehensive care.

 

Despite the numerous advancements in recent years, severe abdominal sepsis (with associated organ failure associated with infection) remains a serious, life-threatening condition with a high mortality rate in both veterinary and human medicine.

 

Vacuum Assisted Closure is a type of therapy used mainly for wound closure; it works by reducing atmospheric pressure on the wound bed.

In septic peritonitis the advantage of Vacuum Assisted Closure is that the system gently pulls fluids out of the abdomen, removes bacteria and helps clean the peritoneal cavity.

The system requires special dressing, a vacuum pump and various types of cycles can be used.

 

In septic peritonitis VAC therapy is used with an open abdomen technique. Open abdomen is a viable alternative to repeated laparatomy or continuous peritoneal lavage. The main advantages of open abdomen are prevention of intra-abdominal hypertension and abdominal compartment syndrome and early identification of intra-abdominal complications. Maintaining an open abdomen creates numerous management challenges – development of fistula and infection.

 

  1. Case presentation:

 

The patient is an 2 years and 6 months old American Staffordshire Terrier, intact female. She presented on September 14th for vomiting. The vomit persisted even after simptomatic treatment, so further investigation was recommended.

 

Initial blood tests were performed – cbc + biochemstry (attachment 1a, 1b 1c).

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On abdominal ultrasound (performed by my colleague, dr. Raluca Munteanu) – a jejunal foreign body with a diameter of 2.4 cm was diagnosed (attachment 2).1

 

Surgery was performed and a nut was retrieved from the patient’s jejunum; also, marked ischemia of the involved intestine was seen and it was decided to continue with an enterectomy of the affected area. 10 cm of jejunum were excised and a termino-terminal apositional suture was performed.

 

On September 15th the patient was discharged and treatment was continued with Amoxicilin + Clavulanic Acid, Metronidazole, Omeprazole and Sucralfat for the following 7 days.

 

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pic 3

Initially, the patient’s clinical evolution was positive, but on October 2nd she presented at the hospital for fecaloid vomit. An abdominal x-ray was performed and a gastric foreign body was detected (picture 3). An endoscopic retrieval was performed and a stone was removed from the patient’s stomach.

 

Patient was discharged with simptomatic treatment, but the vomiting relapsed on October 8th; new abdominal radiographs were performed, free peritoneal fluid and gas were detected and a laparatomy was recomended.

 

Pic 4

pic 4

General anaesthesia was induced according to standard protocol. An exploratory laparatomy was performed and multiple adherences were diagnosed (pic  4); at the point of the previous suture no leakage could be identified, but the intestine was distended with gas and fluid cranial to the enterectomy site.

 

 

 

 

 

 

 

 

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picture 6

Another enterectomy was performed, this time the excised part being approximately 60 cm of the jejunum. Duodenum and ileon were individualized and maintained (picture 6).

After copious peritoneal lavage (500 ml of sterile saline/kg) we decided to try VAC with an open peritoneum for septic peritonitis management. We used an VivanoMed® Abdominal Kit (attachment 7).6

The abdominal wall was sutured to the sponge in the VivanoMed® Abdominal Kit, the draining machine was attached to it and a leakage test was performed (video 1). In order to secure the abdomen a tie-over bandage was used to keep the VAC machine in place.

 

For the next 5 days continous pressure was applied at 40 mmHG. During the first 2 days, approximately 1 litre of septic fluid was drained. In the next 3 days, less and less fluid was obtained.133 134

On day 5, another surgical intervention was performed in order to change the usable parts of the VivanoMed® Abdominal Kit. The following 5 days, fluid collection was decreased and smears from it showed marked reduction of bacteria. On the 10th day no more bacteria could be identified in the peritoneal fluid.

 

On the 10th day, the abdominal kit was removed and routine abdominal closure was performed. Patient was discharged from the hospital and further evolution was good. On the 14th day recheck patient showed no more vomits, stool was normal and general status was good.

 

During VAC therapy – creatinine, BUN and albumin were monitored (attachment 8 and 9)98. Even though hypoalbuminemia persisted throughout the hospitalization period, there was no need for albumin suplementation as no peripheral oedema had developed.

 

  1. Discussion

 

Septic peritonitis is a complex process initiated most commonly by a bacterial focus, causing damage and inflammation of the primary and surrounding organs and usually culminating in circulatory shock, multiorgan failure and death. This process has been historically difficult to treat, with high mortality rates in both veterinary and human patients, despite aggressive medical and surgical treatment.

In this patient a deffinitive source for peritoneal infection could not be determined during later procedures; it is hypothesised that bacterial translocation could have occured secondary to increased permeability of the intestinal mucosa. It is also hypothesised that ingestion of the second foreing body (the gastric stone) was just a simptome of gastrointestinal disturbance.

During the 10 days of VAC treatment patient was hospitalized and closely monitored. Fluid production decreased after the first 2 days of treatment; on the last day no more fluid could be retrieved from the peritoneal cavity. Although the dog was managed with an open abdomen, no signs of pain or discomfort was seen. The patient managed to go out for walks with the VAC machine attached to the abdomen. Pain was controlled with buprenorphine – 10 mcg/kg every 12 hours. During the entire period antibiotherapy was continued and, after VAC placement, steroids (prednisone) were started at a dose of 1 mg/kg/24 h.

Even though in the first days after surgery the patient had developed a short bowel syndrome, on the 14th day recheck stools were back to normal. It is believed that the organism adapted to the shortened jejunum and digestion and absorbtion normalized.

At the time of publishing, the patient is doing well and is now back to presurgical weight and general status.

1111

Uterine prolapse in cats – tips & tricks

YordanovStoyanovYavor Stoyanov, DVM

Yordan Yordanov, DVM

Bomed Veterinary Clinic – Sofia

Uterine prolapse is a relatively uncommon complication of parturition, occurring infrequently in cats. Ekstrand and Linde-Forsberg reported it as accounting for 0.6% of the maternal causes of dystocia. The etiology of uterine prolapse is unknown in queens. The prolapse can be complete, with both horns protruding from the vulva, or limited to the uterine body and one horn. Uterine prolapse requires immediate attention. It is an obstetric emergency.

A 1-year-old female European Shorthair outdoor cat weighing 2.5 kg was presented to our clinic with 96h after parturition. Two days before presentation his caretaker saw “something like placenta to hanging behind the cat”.

On physical examination, the animal was alert, 38.3 °C and slightly dehydrated. The pulse and respiratory rate were both within normal ranges. The prolapse of the uterus was complete, with both horns protruding from the vulva. The exposed tissue was congested and slightly edematous with a few small areas of necrosis, and was covered with debris.

The exposed uterus was palpated to rule out the possible presence within it of any abdominal organs such as the urinary bladder.

Tips & Tricks. Ultrasound examination of the abdomen and the uterine prolapse can be performed to reveal the position of the urinary bladder and the intestine.

Tips & Tricks. Topical application of Manitol 10% can be performed to reduce the oedema in prolapsed tissue.

CBC and biochemical analysis were performed. CBC showed WBC 38.8 x109/l, HGB 89 g/l, HCT 0.265 l/l.  Other parameters of the biochemical analysis and packed cell volume were all normal in range.

After premedication with domitor/buprenorphine/ketamine, anesthesia was induced with propofol after preoxygenation. An endotracheal tube was inserted and anesthesia was maintained with isoflurane. Preoperative antibiotics: Cefazoline i.v. and enrofloxacine s.c.

The surgery was performed in two steps: first the replacement of the prolapsed horns and uterus and then ovariohysterectomy.Uterine prolaps Cat

Tips & Tricks. If the prolapsed organ is in very good condition and the cat is a valuable breeding animal you can try conservative treatment. Replacement, following by medical treatment Oxitocin (0.5-1.0 UI) and antibiotics. Complications may develop from minor laceration of the uterus to septicemia or uterine rupture.

Tips & Tricks. Do OHE! It is the safest option in this situation.

Tips & Tricks. OHE can be performed before reduction if the uterus is too contaminated or necrotic or ruptured.

In this reported case the uterus looked in good condition.

Gross debris was removed gently from the prolapsed organ by irrigation with hypertonic solution.

Then the uterus was reponeted carefully, starting from tip of the horns, one by one.

Tips & Tricks. Use some type of lubricant, like Vaseline.

Tips & Tricks. Oxytocin 0.5 IU can be administered directly in prolapsed tissue to facilitate uterine involution prior to replacement. Attention! Oxitocin make uterine tissue fragile.

Tips & Tricks. An episiotomy may be performed to assist uterine replacement.

Tips & Tricks. Cystocentesis may be performed before attempting to reposition the uterus.

Tips & Tricks. Use monofilament suture material, like PDS 2-0 for cervix ligatures. Polyfilament suture can cut the weakened uterine tissues like saw.

Apposition of vulvar lips was performed with a horizontal mattress pattern without tightening to allow vulvar discharge and normal urination.

This suture was removed after 24 h.

 

The queen recovered well. Postoperative treatment included the use of an Elizabethan collar and intravenous fluid therapy.

The day after surgery, the cat was alert, urinated normally and there was mild discharge from the vulva.

Antibiotic treatment for 5d amoxicillin/clavulanic acid -Synulox and Enrofloxacin.

Tips & Tricks. Postoperatively, urination should be monitored as swelling and pain can lead to urethral obstruction.

Conclusions

Although rare, uterine prolapse should be managed as an emergency. The treatment for uterine prolapse depends upon the severity of damage to the uterus. The prognosis following treatment for a uterine prolapse is guarded to good, depending on the timing of veterinary intervention.

 

Achieving primary closure on the proximal third of the tail after 4 cm mass removal in a dog

51559132_952390804967417_8511078558653743104_nFlorin Cristian Delureanu    

DVM, MRCVS

December 2019

Abstract

Defects located on the tail are challenging due to lack of skin. Second intention healing, skin grafts or random local flaps can be used as a treatment in this particular area. Primary closure can be used when small defects are present but risk of dehiscence and vascular compromise is very increased due to tension and tourniquet effect. In cats was described a perineal axial pattern flap used for covering a defect located on the proximal third of the tail. Also a “spiral closure technique” can be used to close small to medium size defects on the tail. The use of the advancement flap is usually the first choice in approaching the closure of defects if they can not be closed by undermining and suturing. This article illustrates the usage of advancement flap from the base of the tail for closing the surgical defect left after excision of a tumor located on the dorsal proximal third of the tail in a dog. No complications were noted after surgery and the tail maintained the normal function.

 

Case report

 

A 5 years old female neutered cross breed dog was admitted for assessment of a lump located on the tail. The owner was not sure for how long time the lump was in that place and how fast developed, was just recently observed on the tail.

On general examination no abnormalities were detected. A 4 cm mass was identified on the dorsal aspect of the mid proximal third of the tail. The mass had round shape, located under the skin and well attached to the coccygeus muscle. On palpation, local temperature was normal, elastic-firm consistency, without local pain. No other abnormalities were detected. Fine needle aspirate was recommended and performed before surgery.

Cytologic interpretation: marked pyogranulomatous inflammation, epithelial proliferation, neoplasia probable and evidence of mineralization.

 

 

 

Surgical approach and suture technique

 

Surgical site was aseptically prepared and the patient was placed on the table in ventral recumbency. Before starting the procedure, another evaluation of the mass in relation to the skin located on sacro-coccygeal area but also with the skin which surrounds the mass was done. Before incision, the skin mobility was checked. In physiological position a small skin fold was observed cranially to the lump (Fig.1).

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Figure 1. Preoperative appearance of the sacrococcygeal area after surgical site preparation. The tumor have a spheric shape, is located in the proximal third area of the tail-dorsal aspect and have a wide base of implantation. At the base of the tail a small fold can be observed

A circular incision was performed 3mm distance from the mass. No.10 scalpel blade was used to create the skin incision and the dissection until the muscle was done with Metzenbaum scissors.

 

A thin capsule that surrounds the mass was discovered at the junction between it and the coccygeal muscle. At that point the dissection was performed with the scalpel blade until the end. Care was taken to avoid the major vassels of the tail( Fig 2, Aand B)

Figure 2. Intraoperative view of the tail. (A) Right lateral side before tumor excision and (B) left lateral side after full excision hightlights the intact lateral coccygeal veins (yellow and black arrows).

 

 

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Fig 2

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Fig 2

 

 

 

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Figure 3. Transverse section at the level of caudal vertebrae illustrates distribution of the muscles

The tail movements are coordinated by 6 pairs of muscles (12 muscles in total) that are distributed concentrically over the coccygeal vertebrae (Fig.3).

 

 

 

The vascular supply of the tail is composed by 2 lateral caudal veins and arteries located

on lateral sides and the median caudal artery and vein. In this case both caudal lateral veins were preserved. Minimal bleeding was present and the small blood vassels were ligated with 3/0 PGA. Two parallel lines extended from the proximal border of

the defect to the base of the tail were  made in the skin deep to the muscle. Meticulous dissection of the skin was performed with Metzenbaum scissors until the fold located at the base of the tail. The flap was elevated and advanced distally to cover the defect

(Fig.4 A). The flap managed to cover ¾ of the defect without tension. Undermining of the skin  located on the distal border was attempted to obtain the mobility that can help to cover the ¼ of the defect but faild. To obtain the maximum coverage, walking sutures were used to further advance the flap. The first bite went deep into the dermis and the second bite in the tendinous portion of the m.  sacrocaudalis dorsalis  lateralis (sacrococcygeus dorsalis lateralis).Few walking sutures were placed so that the tension is equally distributed (Fig. 4B).

Figure 4. Undermining and elevation of the skin flap. (A) Stay sutured were placed on the flap corners (yellow arrows) to manipulate the skin; (B) Closer wiev of the first walking suture. First bite (blue arrow) is inserted deep in the dermis and the second bite is inserted in the tendons of m. sacrocaudalis dorsalis lateralis (black arrow).

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Fig 4

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Fig 4

 

 

 

 

 

 

 

 

 

 

 

 

Nor following this procedure the primary defect has not been fully covered. In the end, horizontal mattres pattern (“U” shape) was used on the edge of the flap and full coverage was achieved under moderate tension (Fig.5).

 

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Figure 5. Dorsal aspect of the tail after final closure

 

Usually after advancing a flap “dog      ears” will result at the base. In this particular    case minimal “dog ears” were present. For a    cosmetic appearance and to preserve the soft     tissue, central suture technique was performed     on the lateral sides of the skin flap due to crescent    shaped defect. There are many ways to close up a crescent shaped defect but in this particular case central suture technique was chosen to avoid “dog    ears” removal. First simple interrupted suture was placed     in the middle of the defect and after, another  sutures in the middle of the two defects obtained   and so on until complete closure.

 

The central closure technique distributes the “dog ears” all along the sutures line in small increments (Fig.6a, 6b). In the end, the final aspect of the tail in relaxing position was changed due to advancement flap. The tail gain a curved up position (Fig.6).

Figure 6. Central suture technique. (a) Left lateral view of the tail illustrates no “dog ear” present at the base of the flap due to suture technique. The black line show the curved shape of the tail after the final closure. (b) Illustration of closure of crescent shape defect1.

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Fig 6

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Fig 6

 

 

 

 

 

 

 

 

 

 

 

Postoperative care 

 

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Figure 7. Postoperative view after bandage application

For protection, a soft padded bandage was      used to cover the surgical site, this being made up of  square gauze applied on top, fixed in place with an elastic band; Stirrups were applied over the gauze and  extended proximally to the base of the tail and Vetrap  was used as a last layer (Fig.7).

 

The patient was sent home with booster collar to prevent self trauma and 3 days of robenacoxib, also in the surgery day a NSAID injection was administered with the same nonsteroidal anti-inflammatory drug. Until the first recheck (3 days post surgery) the bandage has fallen due to excessive tail movement in 24 hours but the owner apply another one at home; Four days after surgery the patient present for the first recheck, on inspection the tail was less curved in compare with the day the surgery was performed and no complications were present. The owner reports the patient was comfortable at home after surgery, and did not show any changes in behavior. The same bandage was applied in the same manner and this time did not slip until the second visit.                 The patient has presented for sutures removal in day 10 aftert surgery . No postoperative complications were present and the tail was less curved upwords. One last visit was 34 days after surgery. Due to the weight of the tail, continous tension was applied on the skin over time and the natural position was regain (the processes of mechanical creep and stress relaxation) (Fig.8). The owner reptorts the patient was comfortable in all this period and does not seem to be disturbed by surgery.

Figure 8. Ventral (A) and right lateral (B) aspect of the tail after sutures removal – 10 days post surgery; (C) Dorsal view of the tail 34 days after surgery.

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Fig 8

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Fig 8

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Fig 8

 

 

Histopthologic result and prognosis

 

The mass (Fig. 9) was put into a containter with formol and sent to the lab for histopathologic examination. Pilomatricoma partially ruptured and mineralized, associated with moderate granulomatous inflammation. This is a benign tumour of the hair follicle, slow growing, non-invasive, and generally rarely metastasizes (malignant variant exists but is rare). was the diagnosis and clear margins were achieved and the prognosis is was good. Poodles, Schnauzers and Kerry Blue and Bedlington terriers may be predisposed.

 

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Treatment of massive brain compression in two dogs

1575875879547blobDr. Vladislav Zlatinov

Central Vet Clinic

Sofia, Bulgaria

 

Introduction

 

This is case series of two dogs with similar advanced brain compression. The aetiology was different, but in both cases there was gradual epidural compression, indeed allowing survival of the patients. The final size of the brain compression lesions in both dogs was impressive and was related to the delayed diagnostic process. Both dogs were successfully treated and followed in next few months post op. Different surgical approaches and techniques were applied, according to the specific needs.

These cases present interest because such large lesions are rarely met in practice, and may be considered untreatable by some veterinary clinicians.

 

 

Case 1

 

Referring Vet: Dr. Evgeni Evtimov

Corresponding authors Dr. Aglika Jordanova (Clinical pathology), Dr. Vladislav Zlatinov (Surgery),Dr Nikola Penchev( Anesthesia)

 

 

Felix, a 7 months old Collie dog was presented for treatment of progressively deteriorating central nervous system dysfunction.

 

The male puppy lives in an apartment; vaccinations and deworming are current, fed on regular dry food diet. Had been with his owner for a month, came from a breeder.

 

The clinical signs had started 3 weeks ago, with unclear manifestation- decreased appetite, lethargy, intermittent fever, unstable walk. The overall body condition of the patient had been appreciated as underdeveloped, and the owner reported the dog is not growing.

Felix had been initially consulted by the referring vet, who had started primary diagnostic and treatment steps. Biochemistry profile, CBC and vector diseases fast serology tests had been done- being normal/ negative, not revealing the specific cause of the condition. Symptomatic antibiotic treatment had been started, without significant improvement. NSAIDs resulted in temporary alleviation of the symptoms – body temperature back to normal, the dog was brighter.

At this point the dog was referred to us to investigate the possible cause of the condition, suspected to be endocrinological.

The dog was found to be lethargic, walking with head positioned low, no pain during head lifting, does not resist opening the jaws, wobbly gait, with normal proprioception of all 4 limbs. body temp.39.0C. The CBC was WNL. Total T4 was normal (16nmol/l). Radiography of limbs and vertebrae showed normal physeal growth for the dog’s age; thus excluding congenital hypothyroidism.

 

Cerebrospinal fluid collection and computer tomography study of the head were suggested, as the symptoms were assessed as central neurological. During the period of owner contemplation, trial course with corticosteroids had been applied. Short-term clinical improvement had been noticed, followed by further decline in the dog’s condition. A bulge on the left side of the head became visible.  After gradual progression of neurological symptoms- dull behaviour, mild head tilt, inactivity, the dog deteriorated profoundly to the status of stupor- severely depressed mental status, barely reacting to stimuli.

 

CT study of the head was performed 14 days after the initial examination at Central Veterinary Clinic (with no anaesthesia needed), revealing dramatic findings. Extensively grown soft tissue “mass” (vs thick fluid accumulation) was found over and under (extra and intracranially) the left parietal and occipital skull calvaria. The outside lesion was more heterogeneous, lobular like, under the temporal fascia. The internal part was homogenous, with clear fluid density, well encapsulated, caudally extending over cerebellar tentorium. It was causing a significant mass effect with compression of the left parietal and occipital cerebellar brain lobes. Dramatic lateral ventricular compression and a falx shift to the right was present.The skull bone in the area was hypertrophied, with aggressive periosteal reaction, mostly extra- cranially. In the cranial left parietal bone, a small concave defect was noticed on 3d reconstruction images.

Fine needle aspiration was done puncturing the extra cranial lesion area. Pus-like  fluid was obtained, cytologically tested, confirming suppurative process.

 

All these findings suggested the main differential diagnosis- massive epidural empyema (abscess), compressing the brain parenchyma and causing profound neurological deficit. The probable cause was bite wound on the head (<=concave defect on the parietal bone).

 

Surgical decompression was suggested and accomplished as an urgent procedure because of the fast deterioration of the patient.

 

Lateral approach to the skull was applied. An abscess cavity with intensively neo-vascularised capsule was found, just under the temporal fascia, Topographically it was within the temporal muscle tissue. After partial capsule resection and copious lavage, the soft tissues were undermined and reflected to expose the lateral (parietal) skull area. Next, rectangular  rostrotentorial craniectomy was accomplished using maxilo-facial mini oscillating saw. Skull sutures and the concave defect (bite area?) were used as reference landmarks to orientate the cuts. The skull bone in the area had reached 1 cm thickness. A fluid filled epidural (over dura mater) cavity was found. It was filled by thick bright yellow purulent fluid. After microbiology and pathohistology sampling, the pus was aspirated and the residual cavity copiously lavaged. Prompt haemostasis was applied, with minimum haemostatic materials left in place.

A fenestrated drain tube was inserted into the empyema  cavity and under the soft tissues. The temporal fascia and the skin were closed routinely over the defect. The drain tube was connected to active vacuum suction system.

Intense post op care was applied in the next 12 hours- blood pressure monitoring and correction with vasopressors, fluid infusion, pain control, i.v. antibiotic therapy. The patient started to improve slowly but steadily- the mental status improved within 24 hours, and the dog was able to stand up on the second day after the surgery. On the fourth day it was stable enough to be discharged from the clinic (still with the active vacuum drainage). The last was removed on the 7th day.  Ultrasound examination rechecks was done on the 10th and 14th days, excluding new fluid accumulation.

 

The microbiology culture test result was negative, but no anaerobic isolation media was available. Just in case of not detected anaerobic infection- 3 weeks course with Clindamycin was prescribed.

The pathology report confirmed the the diagnosis of pyo-granulomatous inflammation with no neoplastic tissue present.

 

Eventually, Felix did full recovery with no infection relapses within the follow up period of 4 months.

 

Case 2

 

Referring Vet: Dr. Milena Pancheva

 

Dr. Vladislav Zlatinov (Surgery), Dr. Antoan Georgiev (Anaesthesia).

 

 

 

Beki, 4 years old female Dalmatian was referred for consultation, regarding the possible treatment  of a huge intra-cranial mass.

The dog had a long history of slowly progressing vestibular signs and eventually obvious ataxic walking  Unfortunately the owners had ignored the problem for several months (> 7 m), because of the mild clinical presentation in the beginning and the good overall condition of the patient. Recently the dog deteriorated- difficult to keep balance during walking and eating. Two seizures  and nocturnal hyper excitement activities were also demonstrated.The dog had already computer tomography study of the head, revealing huge cranial mass. An opinion about euthanasia was already suggested to the owners. Empirical therapy with steroids and antibiotics was already applied before the achievement of the correct diagnosis.

 

During our neurological examination we found: normal mental status and vision, normal cranial and limb segmental reflexes; the menace response reflexes were decreased; body posture revealed broad-based stance. The patient demonstrated obvious ataxia. It was defined as cerebellar one, presented by hypermetria and  swaying, mild intentional head tremors.

We analysed the CT study and found: large hyper-dense oval mass, starting from the region of the occipital bone and engaging the cerebellar tentorium. The mass was protruding extensively into the brain cavity, eccentrically to the right side. Bone lysis and infiltration was evident in the right occipital nuchal area and also cranial to the right nuchal crest. Severe cerebellar compression in cranio-ventral direction was evident. Less severe compression of the occipital cerebral lobes (without lateral vetntricular displacement) was also found.

Despite the large size of the mass, we suggested moderate malignancy of the lesion- smooth, encapsulated margins, homogenous density. Bone neoplasia (osteosarcoma and multilobular osteochondrosarcoma) or meningioma were the most probable diagnosis. Slow progression of mass, made the osteosarcoma less probable. The bone involvement is not typical for meningiomas. Multilobular tumors usually has similar imaging features as presented in the case. Their excision offer good opportunity for long-term tumor control, so a surgical decompression and mass removal was suggested and accomplished in Beki’s case.

 

We approached the skull caudo- laterally, undermining and retracting the overlaying temporal fascia and neck muscles. The tumor mass was found protruding from the bone through osteolysed right occipital and parietal bones.  Using speed burr we created large combined occipital and caudal-lateral craniotomy. Excessive bleeding from the right transverse sinus was anticipated but fortunately not found, because of possible gradual vein obliteration. Despite this, during gradual enlargement of the craniotomy, special precautions was taken not damage the ipsilateral left one.

After exposure the cranium, we attempted to determine the mass borders. The tumor was originating from the cranium bone not invading (just compressing) the nervous tissue. Because of the huge size, en block resection was far from possible, so slow “debulking” mass removal was started.  The brain meninga (dura mater) was not affected by the neoplasia, so tissue direction was amenable.

 

Diffuse, moderate but constant bleeding was met through the whole process of removal small partial tumour masses. Haemostatisis was achieved using Cellulose blood clot inducing products (Surgicel mesh) and intermittent gentle compression. Copious lavage was applied during the whole surgery.

 

To complete the mass removal was a laborious procedure, taking itself about an hour. Finally, immediately  after the decompression a visible brain tissue re-expansion was noticed. After prompt haemostatis (using bone wax and Surgicel materials), the residual craniotomy defect was covered with apposition of the soft tissues over it.

 

In the next 24 h post op period, the dog was was given opioid analgesia, anti-inflammatory doses of steroids and anti oedematous osmotic agent (Manitol).

Indeed, Beki started to recover surprisingly fast- eating on the 12 h post op (on the video). For about 48 h she showed exaggerated ataxia, with difficulties in walking, but the coordination started to improve fast. The patient was discharged from the clinic on the third day pos op, walking reasonably well. Harness supported leash walks were recommended.

No physiotherapy was applied in the recovery time, because the patient coordination improved to normal on the 10th days pos surgery.

 

Patohystology evaluation of the tumor was done. The results was Multi lobular bone tumor. This is a low malignant, well differentiated neoplasia. In short term it can be controlled successfully by surgical resection. Slow reoccurrence could be expected, also long term metaplasia to more aggressive osteosarcoma.

 

Recheck of the patient revealed condition undistinguishable from normal. The follow up period till now is 3 months.

 

 

 

 

Persistent right aortic arch

Presentation1Tsvetan Ivanov, Dimitar Ivanov, Vladi Kirilov – veterinary clinics “Dobro hrumvane!”- Sofia, Bulgaria

 

  1. Introduction:

The persistent right aortic arch (PRAA) is vascular ring which is formed by the aortic arch on the right side, with ligamentum arteriosum dorsolaterally, and pulmonary artery on the left and ventrally. This ring compresses the esophagus and trachea, which leads to swallowing difficulty. This malformation is with genetic prevalence and represents  error in embryogenesis of the dog. In 95% of the cases of this vascular ring anomaly, a constricting band prevents solid foods from passing to the stomach which prevents the puppy from thriving well.  In the remaining 5% of cases, a bizarre anomaly of the vessels is present (double aortic arch and aberrant subclavian artery), which may be difficult to correct and may not have a good prognosis.pic 1

 

 

 

 

 

 

Signs of this condition usually become apparent shortly after weaning, when a puppy begins eating semi-solid or solid food.  While milk will slide down nicely, bulky foods will “jam up” in the esophagus, leading to a stretched structure and the inability to get food down, hence the symptom known as regurgitation. Regurgitation involves the puppy producing undigested food and mucus through the mouth with no effort; the pup tilts its head down and the food and mucus simply roll out.  By contrast, vomiting is an active process, meaning there are abdominal contractions (heaving) and a retching noise when food and mucus are expelled out the mouth.

Often complication of the regurgitation is aspiration pneumonia (AP), which leads to poor prognosis for the patient.

The standart therapy is surgical and is with good prognosis if there is no signs of AP. Before the surgery CBC and blood chemistry is required – WBC is important to rule out infection and the level of blood sugar should be in the reference values. The surgery can be open thoracotomy or thoracoscopy – the goal is to ligate and resect the fibrous annulus.

 

  1. Patient report

The patient is 2 months old german shepherd dog with history of vomiting after eating, according to the owners, but there is no problems with water drinking. The dog have diarrhea but is in good overall condition. When the dog sleeps there is strange noises from his neck and there is visible peristaltic waves in the level of 1-st rib.

We perform CPV/CCV/Giardia and the result was negative. The CBC and blood chemistry shows no difference from the reference values.

pic 2

pic 2

Then we made x-ray of the chest: pic 2

 

 

 

 

 

 

 

 

Because of the typical sign of the chest, we performed and BaSO4 examination, and this was the result:pic 3

pic 3

pic 3

So our diagnosis is PRAA with no signs of AP. We performed surgery on the next day – it was open thoracotomy with ligation of the annulus.

Differentiation of the fibrous ring:

pic 4 pic 5 pic 6

 

 

 

 

 

 

 

 

 

 

 

 

It’s was administrated antibiotics, pain killers, sedatives and assisted feeding. We didn’t use thoracic tube after the surgery.

On the fourth day after the surgery, the dog was discharged. Three months after the surgery the owners still make assisted feeding, but the dog is not vomiting and is in good condition.

Wound management part 2: The approach of traumatic wounds

 

 

51559132_952390804967417_8511078558653743104_nFlorin Delureanu

DVM, MRCVS

March 2017

 

Introduction

From a general point of wiev, a traumatic injury is defined as a physical damage caused by an external factor. Even if we talk about a road traffic accident, a burn or projectile injuries, all of them represents a trauma for the body. Because the first part of this series described the physiologic process of healing and how can wounds be recognized according to the phase in which they are, the second part will highlight how wounds can be addressed.

Initial assessment of the patient

Due to various types of trauma, the patient should be treated according to the requirements. The patient can be unstable after a road traffic accident, after a fighting with another dog or can be bright, alert if superficial lesions are present (patients that develop wounds due to scratching). If the patient is not stable the plan must be focused first on stabilization by checking the major function (A- airway, B- breathing, C-cardiovascular, etc) followed by a good pain control and assess the life-threatening injuries. In an emergency situations is recommended to cover the wounds with sterile gauze or another type of sterile material to provide haemostasis and to protect against another contaminants that are considered already present in the wound.

Evaluation of the wound

When the patient became comfortable, a wound evaluation must be performed. There are some factors that can help the surgeon to take a decision regarding the local management. Therefore, the following should be considered:

  • the degree of contamination;
  • when the injury took place;
  • the degree of tissue ischaemia;
  • the amount of tissue loss;
  • type of wound (burn, snake bite, etc).

About the length of time between the production of the trauma and the presentation of the patient to the clinic and the degree of contamination, wounds are classified as clean, clean-contaminated, contaminated and infected (see details in part1).               Because every injury has as a result blood loss, the tissue exposed may have different aspect and can help with the prognosis. The first aspect of the wound may be misinterpreted due to colour and integrity of the surrounding tissues. Many times the skin is crushed due to a powerfull trauma and just small superficial wounds may be present. If at first presentation the skin looks normal and the small wounds have a clean aspect and the trauma happend in less than 4-6 hours not every time will be a good ideea to do a primary closure. Some wounds may have good viability but because the tissues are crushed can develop necrosis and some wounds may have an ischaemic aspect but if the surrounding tissues are not traumatised the evolution can be favorable. As a conclusion, not every time a primary closure will be a wright decision, sometimes wounds need 2-4 days to “settle” depending of the type of trauma.                The amount of tissue loss will guide the surgeon to use specific dressings according to depth and length if second intention healing will be elected.               Regarding wound type, some specific considerations must be taken. For example, bite wounds should be explored whereas for an early frostbite wound the patient must be rewarmed first.

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Fig1. Basic wound management in six simple steps (Atlas of Small Animal Wound Management and Reconstructive Surgery, 4th Edition Michael M. Pavletic, April 2018

As an approach, wounds can be managed by closure (primary closure, delay primary closure, secondary closure already described in part 1) or can be left for second intention healing.

Second intention healing occurs when a wound is left to heal by contraction and epithelialization. All wounds can be left to heal by second intention but this process may fail at a point or may end without providing a functional outcome. There are some reasons why not every time a complete healing by second intention (especially large wounds and in high motion area-joints, axillary, inguinal) is not recommended: the granulation tissue is very fragile and easly abraded; wound contraction, sometimes excessive, may impede normal function.

Some wounds may fail to completely reepithelialize. Open wound management is indicated in dirty, traumatized, contaminated wounds in which cleansing and debridement is necessary.

Wound preparation – cleansing

To prevent further contamination of the wound in the time of cleaning, all equipement must be sterile. Prior to application of topical treatments, the wound bed must be properly prepared. Initially the wound must be protected with a sterile lubricant (eg. K-Y sterile gel) or sterile gauze soaked in warm saline. After protection, the hair that surrounds the wound must be clipped. The hair represent one of the main foreign body that can imped wound healing in a clean wound. Next, lavage the wound with a proper solution under 7-8 psi to remove the surface contaminants and in the end dry the skin surrounding the wound. This may facilitate the adhesion of the dressing and also will prevent maceration of the skin if the wound is highly exudative.

  • Wound lavage: many lavage solutions are availabile. Most popular are
fig 2

Fig.2 Basic kit for wound lavage composed by seringe, 3 way-stop cock, 18G needle, intravenous tube and 500ml bag of sterile saline.

clorhexidine, betadine, Ringer’s and sterile saline. A study from human medicine compared tap water with sterile saline for wound irrigation and showed no difference in occurance of infection. Clorhexidine is availabile in many concentrations (4%, 2%, 0,5%) but for open wounds 0,05%  solution should be used. To obtain this concentration, 25ml of clorhexidine 2% must be mixed with 1liter bag of solution. Betadine may be a good option to use in wounds located on the face, particulary near eyes because clorhexidine have very toxic effect if will get in contact with the eyes. Betadine also must be diluted to a proper concentration (0,1%-1% solution). To obtain this solution, 1-10ml of 10% betadine must be mixed with 1 liter bag of solution. As a comparation, clorhexidine is not activated by anorganic matter while as betadine is inactivated by anorganic matter such as blood or exudate. Also a 0,01% clorhexidine gluconate with tris-EDTA solution was described for wound lavage. This combination help lyse Pseudomonas aeruginosa, Escherichia coli, and Proteus vulgaris. Recently polyhexanide/betaine (Prontosan), a solution or gel containing 0.1% of the antimicrobial agent polyhexanide and 0.1% of the surfactant betaine was described as a lavage solution in wounds with good results.

 

One of the key of this procedure is not necessarily the type of solution used, but the amount used. A copious lavage of 500-1000ml is recommended. The ideal pressure of 7-8 psi can be provided by different systems. The most cheapest way is to use an 18G needle, a 3 way stop cock, saline bag, 35-60ml seringe and an intravenous tube. Pressure cuff also can be attached to the solution bag and 300mm Hg pressure can be maintained to provide 7-8 psi in the time of lavage. If the pressure is too high, the healthy tissue can break; if the pressure is under 7-8 psi the surface contaminants may not be removed completely.

After cleansing, if the wound is not considered contaminated, primary closure is indicated. Most of traumatic wounds need also debridement.

54437071_1199173830241222_8271066268505735168_n

Fig. 3 Wet to dry bandage applied on a wound located on the ventral aspect of the metatarsal area in a cat as a nonselective form of debridement

Debridement: can be selective or nonselective. Usually chronic wounds needs debridement but also fresh wounds which present devitalized tissue. Surgical and mechanical debridement are considered nonselective forms. For surgical debridement different surgical instruments can be used (scalpel, scissors, etc.) and adherent bandages (wet-to-dry / dry-to-dry) are used for mechanical debridement.

 

Surgical debridement must be performed in layers, step by step until the necrotic/ devitalized tissue has been removed and blood can be visible from the wound edges or from the bed. An en block surgical debridement can be performed but this can be limited due to location and size. The wound margins should be closed with suture material or towel clamps can be applied for a temporary closure and after the entire wound is excised, including a margin of healthy tissue. Wound irrigation is also considered a nonselective debridement.There is no strong evidence that cleansing wounds increases healing or reduces infection, but it is almost universally recommended.

Three forms of selective debridement are described: enzymatic, autolytic, biosurgical/ biotherapeutic.

 

 

  • Enzymatic debridement – includes proteolytic enzymes that break down the necrotic
54408491_1829146833855841_342684561395679232_n

Fig.4 An example of ointment with papain and urea used for enzymatic debridement

tissue. Papain, trypsin, chymotripsin, fibrinolysine, collagenase, urea are the most common enzymes used for enzymatic debridement. Castor oil, balsam of Peru, desoxyribonuclease are also described.

 

As an advantage, they will not damage healthy tissue. This type of debridement is used less and less nowadays in wound management because is less effective and needs a long period of time to have the proper effect. Surgical debridement may facilitate enzymatic debridement.

  • Autolytic debridement – is the most preferate selective debridement. Is less painfull in

compare with the other types. This method involves maintaining a moist environement on the wound so that natural enzymatic “phenomens” can take place. Hydrogels, hydrocolloids and foams are very common used to support autolytic debridement and will be described later as moisture retentive dressings. Due to their high osmolarity, honey and sugar can also be used also for autolytic debridement. They attract the fluid and will keep a moist environement.

 

  • Biosurgical debridement – refers to usage of maggots (Lucilia Sericata, Phaenicia

Sericata) and have and FDA approval since 2004. The maggots produce enzymes that dissolve the necrotic tissue and don’t interact with healthy tissue, that’s why the debridement is selective. They are applied in the wound as larva stage (4-7 days of life) and can be left in place 3-4 days. At the moment of application the larvae have 2-3 mm and in 4 days grow until 10-15mm. The optimal activity of the maggots depends on the wound pH. They don’t survive in an acidic environment. An 8.5 pH in the wound is preffered. Each maggot may consume up to 75mg of necrotic tissue every day. They cannot penetrate dry necrotic tissue or eschar therefore are not indicated for this situation.

 

 

Moisture retentive Dressings (MDR’s)

Transepidermal water loss represents the the amount of fluid lost by the normal skin. In humans with intact skin the transepidermal water loss is 4–9 g/m2/h. In partial and full-thickness wounds the water loss increase up to 90 g/m2/h. Dressings that have a low moisture vapor transmission value, less than 35 g/m2/h, are considered moisture retentive. In humans was found that the dressing with a water vapor transmission rate of 2028.3 ± 237.8 g/m2/24h was able to maintain an optimal moisture content for the proliferation and regular function of epidermal cells and fibroblasts in a three-dimensional culture model.                The process of wound healing can be accelerated by a moist environment. MDR’s retain water and hydrate the tissue and facilitate natural autolytic debridement. All wounds need to be covered with a specific dressing to maintain a proper moisture until full epithelialization otherwise the granulation tissue will get dry and eschar will occur. MDR’s are availabile on the market in various sizes, shapes, thicknesses, with or without adherent margins. They must be applied on top of the wound as a first layer and after can be covered with the second (absorbent layer) and third layer (protective layer).

55521004_2192459434348788_3535934312941617152_n

Fig.5 Lateral view of a polyurethanic foam. Noticed the convex shape that the foam acquired after beign moistened. Due to this particularity this dressing have a good contact with the wound bed.

Polyurethane foams: is a porous nonadherent dressing that can be used in moderate to high exudative wounds. It absorb several times it’s weight. Is recommended to be used in sterile wounds and regularly must be changed every 3-5 days. With time, the period in which the dressing must be kept in place will change according to the amount of exudate. Some articles described that can be used also over infected wound bed but must be changed every 24 hours.

 

Can or cannot have adhesive borders and does not transform in gel. It is contraindicated in wounds with low exudate and not recommended in areas with bony proeminence because is very soft and cannot protect the damaged area. In compare with hydrocolloids and alginates, foams are less effective for autolytic debridement.

Alginates (calcium alginate): have high absorbtive properties. It absorbs 20-30 times its weight in fluid. In contact with the exudate, alginates transforms in gel. Is derived from brown seaweed and is recommended in high exudative wounds. It promotes haemostasis and Ca2+ stimulates macrophages and fibroblast activity. Is not recommended to be used in low exudative wounds.

55491724_2245338905729035_4329870188817154048_n

Fig.6 Calcium alginate appearance. Left picture represents calcium alginate sheet applied on dorsal and ventral aspect of metatarsal area in a cat with a degloving injury after surgical debridement; Right picture represents the aspect of calcium alginate 24 hours later in the same patient; Note the transformation from dry fibers in gel and the proximal area in which the dressing was absorbed (yellow arrow).

54434198_813769725659050_4294598044776660992_n

 

 

 

 

 

 

 

 

 

 

 

 

 

As a presentation form, alginates are used in flat sheets and can be applied even in narrow cavities. On the market alginates can be found in combination with silver, zinc or honey.

Hydrogels: are indicated in low exudative wounds. They donate fluid to wound but can also absorbe it. Can be found in two presentation forms-sheet and gel. Contains 60-95% water and the cooling effect may decrease pain. Is not indicated in high exudative wounds because maceration can occur. Overgranulation has been reported after usage of hydrogels in excess. In cavitary wounds the gel form is inficated due to better contact. Hydrogels can also be used to soak the dry necrotic tissue.

54419121_304340596894037_5926477775199272960_n

Fig.7 Left picture describes hydrogel sheet used on the lateral aspect of digit IV in a dog with and abrasion wound. The wound had partial epithelialization and a small area with granulation tissue and the level of exudate was low. In the right picture gel shaped hydrogel is placed on Primapore.

55597519_2356707577946837_6316435894865756160_n

Various forms of hydrogels combinations are availabile: with hyaluronic acid, alginate, collagen, etc. Can be left in place 3-4 days in non-infected wounds. They are permeable to gas and water and have proven to be a less effective bacterial barrier than occlusive dressings.

 

 

 

 

 

Hydrocolloids: have in composition may constituents like sodium arboxymethylcellulose,

gelatin, pectin, and polyisobutylene. Gelatin, pectin, elastomers, alginates, silver, and other materials can be added to these substrates. In contact with exudate it transform in gel and maintain a moist environment. Hydrocolloids are indicated in wounds with low to moderate exudate.

Sheets, powder and paste are the form of presentation. In compare with alginates, foams and hydrogels, the contact face of hydrocolloids is adherent but just on the skin, not on the granulation bed. Regarding permeability, hydrocolloids are semi-permeable to water vapour and oxygen but not permeable to bacteria and other contaminants. Is not recommended in infected wounds. May cause overgranulation.

54514139_356556011613436_3825262809151700992_n 54798374_375870166339962_7150276900298948608_n 54433025_262213321326943_64787537255727104_n

 

 

 

 

 

 

 

Fig. 8 Different aspects of hydrocolloid dressing. (a) Fresh hydrocolloid applied on a mild exudative wound in a dog; the dressing have is brown and opaque. (b) View of the dressing 5 days after application on the dorsal metacarpal area in cat. Note the brown dark colour that hydrocolloid achieved. (c) Dressing removal in the same patient in the same day. Note the yellow, gelly and bright aspect due to granulation bed contact.

 

 

Miscellaneous dressings

Honey – called also natural dressing, they are composed by glucose, fructose, sucrose, maltose, amino acids, vitamins, minerals and enzimes. Honey is the most popular product used as a topical treatment for wounds; have an antimicrobial effect due to low pH (3-4.5 ), release of small amounts of hydrogen peroxide or the presence of methyglyoxal. Honey promotes autolytic debridement and reduce oedema due to high osmolarity. It was demonstrated that honey have effect against a multitude of bacteria including Pseudomonas spp., MRSA and E. coli. Composition of honey does vary according to the geographical source. Many types of honey are availabile, from raw honey to medical grade. Manuka honey (Leptospermum scoparium) that originates from New Zealand is the most common used in humans and animals for wound care. Medical grade Manuka honey is recommended despite raw honey because raw honey may contain bacteria and fungal contaminants including anaerobic spore‐forming organisms. Recently was developed a new type of honey was developed which is not manuka honey. SurgihoneyRO is an antimicrobial wound gel utilising bioengineered honey to deliver Reactive Oxigen and is superior to Manuka honey. It cames in a variety of form such as gels, sheets, in combination with alginates or simple gauze. Honey is recommended in wounds that needs debridement and is not recommended to be applied over the granulation tissue. Despite the multitude of benefits, the quality of the evidence is variable.

Silver dressings– should be used when infection is suspected. Has been shown that silver ions have an antibacterial effect in contact with the exudate. Because silver ions are activated by a moist environment, is not indicated to be used in wounds with moderate-to-low exudate. There are some evidence that suggest delay healing if silver dressings are used in acute wounds. Is available as gel, sheets, impregned in alginates, foams and hydrocolloids and can be left in contact with the wound up to 7 days. Silver is a broad-spectrum antimicrobial agent that is effective against bacteria, fungi, viruses, and yeast. It has also been proven to be active against MRSA and vancomycin-resistant enterococci (VRE) when used at an appropriate concentration. Silver destroy bacteria due to multiple mechanisms: disrupts bacterial cell walls, inactivates bacterial enzymes, and interferes with bacterial DNA synthesis. Therefore bacterial resistance has yet to be documented, although reports of isolated Escherichia coli and Pseudomonas aeruginosa have shown resistance to silver in vitro.  Despite the benefits, some articles concluded that is still a lack of evidence about usage of topical silver and silver dressings for treatment of infected or contaminated chronic wounds.

Collagen dressing: are available in different forms such as granules, powders, sheets, pastes, gels. The collagen from these products derived from bovine, porcine, equine, piscean or avian source. Collagen has been widely used in cosmetic surgery, as a healing aid for burn patients for reconstruction of bone. Is the main structural protein in the extracellular space. Is resistant against bacteria and in this way it helps to keep the wound sterile. Platelets interact with the collagen to make a hemostatic plug. Collagen based dressings need a secondary dressing layer to maintain a moist environment. Products that contain collagen promotes angiogenesis and stimulates fibroplasia. Recently, usage of Tilapia skin fish in veterinary medicine and blue shark skin in human medicine for burns were described with promising results.

Silicone dressings– are used mainly in humans to reduce the hypertrophic scar. The mechanism of action of silicone dressings is not fully understood. It is believed that silicone due to occlusive effect, decrease the oxygen of the tissue until anoxia, environment in which fibroblasts cannot have a normal function and undergo apoptosis. In humans has been shown to help reduce trauma and pain. Silicone dressings were tested in rabbits, rats and horses. Silicone dressings are nontraumatic and the contact surface is adherent but just on the skin surrounding, not to the granulation bed. A comparison between silicone dressing and silicone gel in a controlled trial for treatment of keloids and hypertrophic scar. Compared to the untreated controls, all of the measured parameters including scar size and induration were reduced in both silicone and nonsilicone-treated groups. In 2005, silicone dressing was used with good outcomes in horses with exuberant granulation tissue. In 2017, a review of silicone gel sheeting and silicone gel for the prevention of hypertrophic scars and keloids concluded that was statistical significance in the effectiveness of both of them but most of the trials had poor quality with high or uncertain risk of biases.

Borate glass nanofiber – was developed in 2010 by human engineers and is recognized to have regenerative properties on bones and soft tissues due to stimulation of angiogenesis and osteogenesis. Two borate glasse with (1605) or without (13-93B3) CuO and ZnO were studied along with the silicate-based glass, 45S5 for the potential effect on vascular endothelial growth factor. The study demonstrate that silicate glass is inferior to borate glass. Copper and zinc ions together with calcium, phosphorus, magnesium, etc., stimulate the proliferation of human endothelial and osteoblast-like cells, promote angiogenesis, and stimulate vascular endothelial

growth factor secretion. Osteogenesis is encouraged because the fibers convert to hydroxyapatite.

54523641_367624424087613_5827889279115722752_n

Fig.9 Borate based glass nanofiber. Macroscopic aspect, “cotton-candy” like (left picture) and electron microscopy (right picture).

In 2017, borate glass nanofiber was evaluated for treatment of full thickness wounds in six dogs. The study had many criteria: wound cause and location, type and duration of previous wound management, time to granulation tissue formation, time to complete wound healing, subsequent procedures if applicable, outcome, and complications associated with treatment. With a “cotton candy” aspect and soft texture, the borate glass can be applied to any defect, even in deep wounds can be packed. Is not expensive and did not require hospitalization. A veterinary product was developed and is available (RediHeal) for cats, dogs and horses. Because promotes bone growth, the product can be packed also in the defect which result after dental extraction. After application, the fibers degrades at a controllable rate and release ions.

 

Wet-to-dry Vs MDR’s

 

·         Wet to dry bandages: first they overhydrate and after dessicate the wound bed. As

a result, cells involved in the healing process will lose their function. Because is a nonselective debridement form, when wet to dry bandages are removed normal cells (WBCs, macrophages, granulation tissue) are pulled off with the surface contaminants. The environmental bacteria can penetrate the gauze.

 

Because is adherent, in the time of removal will be not comfortable for the patients due to pain sensation. Small gauze fibers can remain in the wound bed, will act as a foreign body and will extend the inflammatory phase. They are not expensive but if are used as a sole treatment for wounds, the cost may increase semnificatively due to delay healing and daily replacement.

 

·         Moisture retentive dressings: during the inflammatory phase, support selective

54437443_2574715225903155_8136169536241008640_n

Fig.9 Characteritics of an ideal dressing

autolytic debridement and promote healing because will keep a moist environment. They are nonadherent and nonpermeable for bacteria  so the infection rate is lower in compare with wet to dry bandages. They also require replacement every 3-6 days (depends on the product and the wound appearance) therefore decrease the costs for total wound care. Because MDRs are occlusive or semioclusive in nature, they decrease the pH and oxygen tension in wound and, as a result, WBCs are attracted, angiogenesis and collagen formation are stimulated and inhibit bacteria. MDRs are comfortable  not painfull for the patient when are removed from the wound bed. Also they prevents dessication and necrosis.

There is no dressing that meets all the conditions and cannot be considered that one is better than the other. The aim is to use the correct dressing according to the needs of the wound. Therefore, the physiology of wound healing needs to be understood. As an example, even if gauze (wet-to-dry) have many negative consequences, it can be used for debridement as part of wound management and is very effective but contraindicated in the proliferative phase while calcium alginate (MDRs) is less effective and can dessicate the wound bed when is applied on dry wounds.

 

Regarding moisture, a simple general rule is considered: exudative wounds need dressing that will absorb the fluid and dry wounds need dressings that will deliver moisture. It is detrimential to assess the volume and the appearance of the exudate each time the bandage is changed. A wound with a favorable evolution will produce less and less exudate with a clear clear aspect.

Alternative therapies

 

            Wounds have different behavior and the evolution depends on many factors (localization, degree of contamination, size, etc.). In particular situations, wounds may not heal by second intention or they may decrease in size in the time of treatment but in some cases the proliferation may stop. If surgical closure cannot be achieved, alternative therapies may be considered. As an example, vaccum assisted closure (negative pressure therapy), laser therapy or platelet-rich plasma (PRP) should be considered.

Wound management part 1: the healing process and recognition of wound healing stages

51559132_952390804967417_8511078558653743104_nFlorin Delureanu

DVM, MRCVS

Romania

 

Section A

The physiology of the healing process

The most largest organ of the body is the skin. The skin acts like a barrier between the body and environement. Composed by 3 layers (epidermis, dermis, subcutis) and associated adnexa, the skin is a complex organ with many functions and properties: thermoregulation, motion and shape, environmental protection, storage (vitamins, electrolytes, fat, etc.), immunoregulation, sensory perception, secretion, excretion, etc.

Following trauma, the skin is the first organ to undergo changes. A wound represent a disruption in the continuity on anatomical structure with deterioration of the physiological function. There are several criteria for wound classification:

–                by the time that has passed since wound production: acute or chronic;

–                by the thickness of the skin layer that has been injured: full-thickness or partial thickness;

–                by the degree of contamination:

·                clean wounds – made under aseptic conditions (surgical wounds), in which it does not penetrate into the chest cavity, gastrointestinal, genitourinary tract;

·               clean contaminated wounds – in which the respiratory, gastrointestinal, or                            genitourinary tract is entered with minimal contamination;

·               contaminated wounds – wounds with a major break in sterile technique, open traumatic wounds less than 4-6 hours old with inflammatory process without purulent discharges;

·               infected wounds – traumatic wounds with purulent discharges or perforated viscera, more than 6 hours old.

 

After trauma, when the patient shows up in the clinic, it must be stabilized initially. If haemmorage is present, the wounds need to be bandaged with sterile gauze to stop bleeding, and emergency treatment should be initiated according to the patient’s needs. If it is not an emergency and the patient comes to the clinic with an older wound, after obtaining the complete anamnesis and examining the wound, formation of an initial plan of treatment is necessary. Thereby, depending on the type of wound, the approach differs. Four types of wound closure are described:

–                 primary closure, called also healing by first intention represents immediate closure of a fresh wound. This category includes recent traumatic wounds and surgical wounds.

  • delayed primary closure is indicated when the injured tissue have questionable viability or infection is suspected. The closure is delayed 3-5 days in which time the wound is assessed with proper dressings. Also delay closure offers time for proper drainage and the inflammation will decrease. Approximately 5 days after wounding fibroplasia, cytokines and macrophages will protect the wound against infection and closure can be performed. This type of closure is done before granulation tissue formation.

–                 secondary closure is performed after granulation tissue formation. Usually 5-10 days after injury; this type of closure is indicated when necrotic tissue persists and need to be debride many times, when inflammation is prolonged or when signs of infection are still present

.-                healing by second intention represents healing by granulation, contraction and re-epitelisation. This method is applicable for next types of wounds:

·                    moderate to large wounds in young animals that are located on trunk. Kittens and puppies have a fast rate of healing;

·                    wounds located in areas where the closure may create a “tourniquet effect“ (commonly on distal limbs). In this situation the circulation is compromised

;·                    infected wounds and those who presents questionable tissue viability;

·                    wounds that are closed under tension and dehiscence will occur.

How do wounds heal?

Tissue continuity is restored by the healing process. This biologic process begin immediately after injury or incision. Wound healing is a complex process that comprise three phases: inflammation and debridement, proliferation (repair), maturation and remodeling. All these three stages overlap and have a different duration.

Ø              Inflammatory and debridement phase.

After wounding, to avoid exsanguination hemostasis occur. Following the breakdown of blood vessels, endotheline is produced and along with other mediators (serotonin, bradykinin, catecholamines, histamine, prostaglandins) cause contraction of muscle within the vessel walls and hemorage is stopped by vasoconstriction. After 5-10 minutes, vasodilation occur. An increased blood flow to the wound bed and extravasated fluid in the wound will be present. Subsequent vasodilation, leukocyte migration starts (neutrophils and monocytes). At this point the wound will have the classic aspect of inflammation: swelling, elevated local temperature, erythema, pain. In early inflammatory phase the neutrophils predominate and in late inflammatory phase they decrease and monocytes predominate.

The main cells: –endothelial cells: neoangiogenesis-provides oxygen and nutrients to the tissue;

–macrophages and neutrophils: debridement, phagocytosis of bacteria

and other pathogens.

 

  • Proliferative (repair) phase. About 4-6 days later, after wound debridement, the wound enters in repair phase. This stage lasts from day 5 until day 20 but can be longer and depends on many factors: wound size, location, age, health, etc. Four stages are included in the proliferative phase: angiogenesis, fibroplasia, contraction and epitelisation. The aspect of the wound will change in this phase from red to pink and the quantity of exudate will decrease. This phase is predominated by macrophages, fibroblasts, endothelial and epithelial cells. Due to platelet-derived groth factor (PDGF) and transforming growth factor (TGF-β), fibroblasts migrate in the wound from surrounding tissue. As a response to PDGF
    type III collagen is synthesized by fibroblasts. After 7-14 days, TGF-β increase synthesis of type I collagen. Collagen afford strength to connective tissue. There are more than 20 types of collagen. Type I collagen is present in unwounded dermins in 80% and type III collagen in 20%. Finally, due to TGF-β1, fibroblasts are transformed into myofibroblasts and wound contraction begin. Contraction increases with a speed of approximately 0.6 to 0.8 mm/day. As a response to epidermal growth factor (EGF) and TGF-α proliferation of epithelial cells begin. Epitelisation continue until complete epidermal thickness. The growth rate of the granulation tissue is 0.4 – 1mm/ day. The granulation tissue is very fragile in consistency and act as a barrier to infection.
  • Maturation and remodeling phase. In the last phase of wound healing remodelling and strengthening of collagen take place. Care must be taken at the beginning of this phase because the scar tissue new formed is very thin and fragile and need few weeks until will gain a proper strength. Due to a changing in collagen type (only 10% of type III collagen present in the scar tissue) rigidity rise and the matrix becomes more stiff. Though, the final scar tissue will not achieve the elasticity and strength of a normal tissue. The maximum strength will be approximately 70 % – 80%. Usually this phase starts 3 weeks after wounding and continue until 1 year.

Figure 1. Illustration of approximate time of wound healing stages. Inflammatory phase last between 0-6 days,

52115600_1963395883709645_7962708292625498112_n

Fig 1

repair phase 4-25 days and maturation and remodelling phase 21 days to months. Overlapping of healing stages is represented by the green triangles.

 

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Fig 2

  Figure 2. Illustration of cell distribution in the time of healing;

 

Conditions that delay or impede wound healing

 

Factors who are involved in this process are grouped into several categories:¨             Host factors: hypoproteinemia (malnutrition); age (wounds in elderly patients have a longer healing time compared to young patients); internal organ disfunctions (Cushing Syndrome- excess circulation of glucocorticoids, liver diseases – clotting factor deficiencies, diabetes mellitus, uraemia, hypothyroidism), obesity, immune disfunction, viral diseases (FeLV/FIV), cancer, coagulopathies, self trauma;¨             External factors: infection, foreign bodies (environmental – grass awns, soil; surgical  metal plates, drains), radiation therapy, long surgical time and hypoperfusion;¨             Medication: chemotherapy, glucocorticoids, NSAID, anticoagulants, cytotoxic solution used for lavage; ¨             Mechanical factors: motion, tension, pressure (from bandage).

 

 

Section B

 

In which stage of healing we are?

In order to choose an appropriate treatment method (closure or dressing) it is necessary to recognize the phases of wound healing. Some specific aspects should be considered: macroscopic appearance (infection, contamination, blood, inflammation), time elapsed from wound appearance, amount of exudate, wound size, tissue viability, wound margins. This section will illustrate wound details in different phases of healing.

Figure 3. Ventral view of abdomen of a cat during     Figure 4. Approximate 1 hour old wound located on

spay, midline approach; This is a surgical clean        the left front leg, between digit IV and digit V. Small

wound.                                                                                amount of  unclotted blood and early inflammation

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Fig 3

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Fig 4

 

 

 

 

 

 

 

 

 

 

 

 

Figure 5. (a)Lateral view of digit V of  left hind in a 6 years old paraplegic female dog. Healthy

granulation tissue is present 9 days post dressings treatment. Mild exudate was present following the

removal of the bandage . (b)The same pacient 18 days after wounding; a nearby photograph was made to highlight the presence of epithelisation present at the wound edge (black arrows). The white color at the

center of the wound represents the reflection of the camera light. (c) Maturation phase- complete

epithelisation present in day 44 post dressing treatment.

51800949_234522520832342_3353788615388823552_n

Fig 5

51617023_2173831566010944_4981136923385921536_n

Fig 5

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Fig 5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 6. Dorsal view of the right paw of the hind limb in a cat;

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Fig 6

The deglowing wound shows necrotic tissue, foreign materials devitalised tissue and mild exudate; High local tempreture was present on palpation. The infected wound was debride surgically, treated with dressings and later a full thickness mesh graft was applied. The cat disappeared from home for 2 weeks.

 

 

Figure 7. Left latera view of a 4 years old male Yorkshire beign bitten by a dog; Second intention healing

from the beginning until the end was chosen. Granulation tissue is in the middle followed by epithelisation

51573064_655797781507474_8977494285964279808_n

Fig 7

and obvious wound contraction after 4 weeks of treatment with dressings.

 

 

OSTEOCHONDROSARCOMA- SURGERY

43715598_336141656947602_6782174039545741312_n(CASE REPORT)

DR LUCIAN FODOR HAPPY PET TIMISOARA-ROMANIA

Introduction:

Osteochondrosarcoma is an uncommon tumor that generally arises from the skulls of dogs (cranium, orbit, zygomatic arch, mandible, and maxilla) and can occasionally arise from the pelvis, ribs, and os penis. These tumors have a characteristic appearance on radiographs, CT, and MRI: generally the borders of the tumor are sharply demarcated with limited lysis of the adjacent bone, with a coarse granular density throughout. A popcorn-like appearance with stippled and heavily calcified or ossified regions has been described on survey radiographs.

Clinical signs are generally based on location and extent of the lesion; ranging from a palpable, fixed, and firm mass to pain on mouth opening for tumors involving the mandible and zygomatic arch, exophthalmos with infraorbital lesions, and neurologic abnormalities for tumors involving the cranium.

43950478_167475047490012_2226512029793910784_n

Fig 2

43514688_913495158846702_418217810473254912_n

Fig 1

43734015_173106753553540_5169187062804381696_n

Fig 3

Cara, a one year unsterilized mallinois female bitch, from the age of 7 months beggin to develop in the fronto-parietal region a globular formation(fig.1-2-3)

 

.She came to our unity with neurological manifestations, ataxia, deviation, refusal to rise from the bottom, bilateral midriasis.

Blood analyzes where in optimal parameters. After performing the CT, a giant extra and intra-cerebral form was noticed, being the imaging feature of the osteocondrosarcoma. (Fig.4-5)

43759528_484990658670865_14835555774758912_n

Fig 4

43788744_241906113168260_7429289207186587648_n

Fig 5

After consulting with the owner we decided surgery.

It was performed a large, circular craniotomy with a safety margin of one cm. The formation did not adhere to dura mater, only compressing the brain. (Fig. 6-7-8-9)43828104_267060260621234_1089416852607598592_n 43727747_1873646689408833_5453387625761079296_n

T43828915_108324666763855_6959109323293196288_n 43750703_2206611569596014_4590836245717843968_nhe bone reconstruction was accomplished with Collapat, a substrate of bone based on hydroxyapatite and collagen. (Fig.10)

Concluzion:

Post operator evolution was good, 48 hours after the surgery the patient was recovered neurologically(Fig11). At six (Fig12)and 12 months post surgery,(Fig.13) Cara feels good, fully recovered.

 

 

Full thickness mesh graft in a cat with degloving wound – case presentation

22264908_689114241295076_1764003733_n

Delureanu FlorinCristian

Dr Delureanu FlorinCristian

Veterinary Center Otopeni

Bucharest, Romania

 

 

Introduction

An ample loss of skin with underlying tissue and exposure of deep components (eg. tendons, ligaments, bones) define a degloving injury. This kind of wounds are most frequent seen on the distal limbs, medial tarsus/ metatarsus. The main cause of deglowing wounds is car accident, special when the animal is dragged or pushed by a moving car. In all of the cases bacteria and debris are present in the wound.

Free grafts are described as a piece of skin detached from an area of the body and placed over the wound. There are two tipes of free grafts when we talk about graft thickness: full thickness (epidermis and entire dermis); partial/split thickness (epidermis and a variable portion of dermis). Skin grafts are using when exist a defect that cannot be closed by skin flaps or direct apposition. Two factors influence skin graft survival: revascularization and absorbtion of the tissue fluid.

Case report

A 4 years old female shorthair cat, weighting 3,25kg was presented to our clinic. Before that, the owner was at another clinic for consult and he was disappointed because they recommended euthanasia or amputation of the limb. Besides, the first vet treated the cat with Amoxi+Clavulanic Acid and Nekro Veyxym. The owner said that she went missing for about 10 days.

Clinical examination

IMG_6649

Picture 1. Dorsal aspect of the metatarsal wound Deep tissue is affected; low to moderate discharge is present.

IMG_6644

Picture 2. Ventral aspect of the wound; Note the big swelling and the holes at the base of the fingers (red arrows)

IMG_6645

Picture 3. Deep wound with circular aspect, approximate 1,5cm diameter located near saphenous vein

After a thorough clinical exam we found that all was normal excepting the degloving injury. The back right leg was affected. There was a massive inflammation with infection and a lot of debris on the dorsal surface of metatarsal area and ventral, above metatarsal pad. On the dorsal surface of metatarsal area (Picture 1). Besides, also in the ventral area, another wond proximal to the metatarsal pad and 3 deep holes was identified at the base of second, third and fourth finger (Picture 2). It could be distinguished the chronic aspect. A third lesion was registrated on the same leg, in the medial aspect of the thigh. This wound was deep with a circular shape (Picture 3). We estimated that the lesion occurred about two weeks ago. We register pain and high local temperature after palpation. The cat was stable, normothermic, with normal color on mucous membrane, CRT 3seconds and normal superficial lymph nodes.

 

 

 

 

 

 

 

Radiograph of the affected back limb

pirpi

Picture 4a

pirpi1

Picture 4b

Two x-ray views was made to eliminate bone changes or foreign bodies (Picture 4a, Picture 4b).

Picture 4a, 4b- Specialist describe: Suspected slight thickening of phalanges cortical 1 fingers 3-4 and gently bending them. Soft tissue swelling of the tibio-tarso-metatarsian region.

 

 

 

 

 

 

 

Approach 

DSC08924

Picture 5a

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Picture 5b

After evaluation, the initial recommendation include a good wound management under anesthesia. Before surgical debridment (Picture 5a, 5b), culture was done.

Picture 5a and Picture 5b – Dorsal and ventral aspect of the lesions after surgical debridment

 

Next, wound lavage was initiated with one bag of 500 ml of worm saline (the most easy way to deliver fluids on the wound is to connect the saline bag with a administration set to the syringe and needle with a 3-way stop cock a large amount of liquid is needed to be effective).

DSC08936

Picture 6. Wound closure by simple interrupted suture.

Finally, this first stage ends with a wet to dry bandage. A primary wound closure was performed for the lesion placed on the medial aspect of the thigh (Picture 6), after intensive cleaning, removal of foreign bodies and dead skin .

Empirically the cat receive Cefquinome until the result arrive and for pain management we administered Tramadol 3mg/kg and Meloxicam 0,1-0,2mg/kg. The cat recover well after anesthesia.

 

 

 

Culture result

One day before performing surgery, we recived the culture result. Streptococcus canis (++++) was identified and was sensible to many antibiotics. Amoxicilin+Clavulanic Acid (Synulox) was initiate for general therapy and chloramphenicol ointment (Opticlor-Pasteur) for local therapy.

Next, a full thickness mesh graft was used on the dorsal aspect of the limb due to the length and depth of the wound and the other wound was left for healing by second intention, both being protected by bandages. In the next 10 day the limb wounds was treated in the same manner. Removal of bacteria, granulation tissue formation and the beginning of epithelization were supported by next bandages as follows: ·

Day 1 – wet-to-dry bandage was used after surgical debridment. (this kind of bandages adhere to the wound and remove the little layer of dead tissue when we take off). Soaked in warm saline 1-2 minutes before removing, they were changed after 24hours one to the other. Cotton gauze was the primary contact-layer of the bandage.

  • Day 2 and day 3
    24.06.2017

    Picture 7a Fresh Sorbalgon is applied on both wounds. This dressing can absorb 20-30 times its weight in fluid, stimulate fibroblast and macrophage activity.

    DSC08981

    Picture 7b Calcium alginate dressing must be changed when the fibres transforms in gel.

– moisture retentive dressing (MDR) – calcium alginate (Sorbalgon-Hartmann) was the primary contact-layer. It is good to use when it exist high exudate like in our patient (Picture 7a, 7b).

 

 

 

  • Day 4,6 and day 9
IMG_6726

Picture 8. Hydrocolloid is indicated because he stimulate granulation and epitelisation and have a good autolytic debridment

– moisture retentive dressing (MDR) – hydrocolloid (Hydrocoll-Hartmann) was the primary contact-layer because the discharge decreased (Picture 8).

 

 

 

 

 

Describing surgical procedure:

IMG_6747

Picture 9. The wound is refreshed by removing the new epithelium formed around the whole wound

Preoperative surgical site preparation: The cat was placed in left lateral recumbency, with the wound exposed. The limb was clipped entirely and povidone iodine and alcohol was used for aseptic surgery. Sterile warm saline 0.9% was use for wound lavage. Meanwhile a colleague prepare the donor site in the same manner- lower cranio-lateral thorax (right side). Almost 1mm of epithelium that has started to grow from the wound edges over the granulation tissue was removed using a thumb forceps and a no. 10 scalpel blade (Picture 9). A perpendicular incision was made right at the edge of haired skin with epithelium. The wound was incised all around and after that the epithelium was removed by advancing the scalpel blade under the epithelium around

the wound. Then, undermining was performed around the wound edges. A fragment of sterile surgical drape was used over the wound to get the exact shape. The drape “pattern” was placed to the donor area.

 

 

To maintain the wound moist, i placed over it a cotton gauze moistened in warm sterile saline 0.9% while the graft is transferred.

IMG_6755

Picture 10. The donor site-removing the skin; black arrow show the direction of the hair groth.

IMG_6769

Picture 11a. Skin from dorsal thorax is advanced

IMG_6778

Picture 11b. Simple interrupted suture is used for skin closure.

The direction of hair groth was marked with a black arrow above the donor site so that the direction of the hair groth on the graft will be the same as the hair groth direction on the skin surrounding the wound. After that, the margins of the drape “pattern” was traced on the skin. The skin of the donor bed was incised with No.10 scalpel balde and removed using thumb forceps and Metzenbaum scissors (Picture 10). The defect left after removing the graft was primary closed by undermining and advancing the skin edges with walking sutures using 3-0 monofilament absorbable suture material and finally the skin was sutured in a simple interrupted suture manner using 2-0 monofilament absorbable suture (Picture 11a, 11b).

 

 

 

 

 

 

 

 

 

 

Preparing the graft

IMG_6762

Picture 12. Final aspect of the skin graft after removal

IMG_6774

Picture 13. The skin is stretched on the receiving bed so the incisions made in it expand.

The dermal side of the graft was placed on a polystyrene board with a thickness of 10cm covered with a sterile drape and after that we fixed and stretched with 21G needles. The subcutaneous tissue was removed from the graft. Next, made parallel incisions was made in the graft, 0.5-0.7cm long and apart (Picture 12). At the end, the graft was placed on the granulation bed and sutured with 4-0 monofilament nonabsorbable suture in a simple interrupted suture manner. Additional tacking suture was placed to ensure the expansion of the mesh incision and allow the fluid drainage (Picture 13).

 

 

Choosing the right bandage after grafting and aftercare

DSC09086

Picture 14. Grassolind is ointment free of medication, broad mesh, air permeable and exudate; impregnated with neutral ointment. Ointment contain petroleum jelly, fatty acid esters, carbonate and bicarbonate diglycerol, synthetic wax.

It is important to use a nonadherent primary dressing. My initial choise was Grassolind (Hartmann), is sufficiently porous to allow easy passage of exudate from the wound surface, preventing maceration of surrounding tissue (Picture 14). The ventral metatarsal wound maintain hydrocolloid dressing (Hydrocoll-Hartmann) as primary layer. After that, a thin layer of chloramphenicol oinment (Opticlor-Pasteur) was used all around both wounds and over the graft.

DSC09091

Picture 15. Note that the “half clamshell” is extended with approximately 1cm toward fingers (red arrow) so the leg does not touch the ground

Over the first dressings was applied 5cmx5cm compress (Medicomp-Hartmann) and a roll gauze was the second layer. After a few laps of gauze stirrups was placed to secure the bandage in place. Extemporaneous half “clamshell” splint (Picture 15) was made from plastic material wich was curved in such a way that the limb was fixed in semi flexion. The splint is a little bit longer than the extremity of the pelvic limb (“toe-dancing” position), thus provide a maximum relief pressure. In the proximal area, under the splint, I put cotton to prevent pressure injuries on the caudal aspect of the thigh. Applied from proximal to distal and with moderate tension, elastic warp was the final protective layer of the bandage and it was secured at the proximal end with tape.

 

 

 

 

Changing bandages

The bandage was changed in day 1, 3, 5, 7 and 10 post op. In day 10 the suture material was removed from the graft and from the donor site. From day 17 to day 29 hydrogel (Hydrosorb-Hartmann) was used as primary bandage layer and the bandage was changed from 4 to 4 days. In day 29 no discharge was present in the bandage; the wound was completely healed and 0,2-0,4 mm of hair was present in the center of the graft.

20773274_1778379115510021_928059671_o

Picture 16. Delayed healing on day 45 – epitelization stopped at this level.

20170918_112707

Picture 17b. Honey improve wound nutrition, promotes the granulation tissue and epithelization, reduce inflammation and edema. Also it has a wide antibacterial effect.

20170918_112216

Picture 17a. DTL laser type is alaser light emitting diode in the red field (wavelength 650 nm) and infrared (wavelength 808 nm) of the light spectrum with next clinical effect: anesthetic effect; decreases edema and inflammation; activates microcirculation; stimulates wound healing; improves tissue trophicity; reflexogenic effect.

A delayed healing occurred at the wound in the ventral region (Picture 16). From day 29 to day 59 epithelization has advanced very hard and granulation tissue has captured an appearance of ulcer (in this time the wound was asepseptic prepared and hydrocolloid and hydrogel was used as primary layer bandage and without the splint). In day 59 the wound was refreshed on the surface with a scalpel blade and laser therapy (Picture 17a) and medical Manuka honey (Picture 17b) was used daily for 14 days. After that, a complete healing was reached.

 

 

 

 

 

 

 

Illustrating wounds evolution after surgery

 

Day 1

IMG_6795IMG_6797

 

 

 

 

 

 

 

 

 

Day 11

 

IMG_6873 IMG_6879

 

 

 

 

 

 

 

Day 28

IMG_4671 IMG_4677

 

 

 

 

 

 

Day 35

DSC09254 DSC09263

 

 

 

 

 

 

 

 

 

Day 49

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Day 11 after honey and laser therapy

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 Day 16 after honey and laser therapy

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Comparing day 1 and after 3 Months

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20170928_190228

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Resection of a chest wall mass- surgical technique and peri-operative analgesia

12959354_10153530931267960_1853416198_o-200x300

Dr Vladislav Zlatinov

Corresponding authors :

Dr. Vladislav Zlatinov, Dr. Aglika Yordanova (Clinical pathologist), Dr. Nadejda Petrova (Anaesthetist)

 

Central Veterinary Clinic

Chavdar Mutafov str, 25 B, Sofia, Bulgaria

 

Introduction

 

Rib tumors are uncommon in small animals. Osteosarcoma (OSA) is the most common (73%). Other types include chondrosarcoma (CSA), fibrosarcoma (FSA), hemangiosarcoma (HSA).

Rib tumors tend to occur in large breed dogs and the usual location is in the costo-chondral junction. Radiographic changes include lysis, sclerosis, or a mixture of lytic and blastic patterns. Intra-thoracic invasion of adjacent pericardium and lung lobes is relatively common, so CT scans are recommended to determine the location and extent of the tumor, planning of the surgical resection, and clinical staging for pulmonary metastasis1.

 

Chest wall resection is recommended treatment for the rib tumors 2. The surgical approach is the identical to intercostal thoracotomy, but caudal and cranial margins include a minimum of one intercostal space and rib, while ventral and dorsal margins should be a minimum of 2 cm from the tumor.  Because of the large defect present, a need for autogenous and/or prosthetic reconstruction techniques is often necessary. Autogenous reconstruction techniques include the latissimus dorsi and external abdominal oblique muscles, and diaphragmatic advancement following resection of caudal rib tumors 3. Prosthetic reconstruction with non-absorbable polypropylene mesh, alone or in combination with autogenous techniques, is recommended for large defects. Autogenous reconstruction is preferred in humans because of a high complication rate associated with prosthetic mesh, such as infection and herniation. These complications are rarely reported in dogs following chest wall reconstruction with prosthetic mesh. Up to six ribs can be resected without affecting respiratory function in dogs 4.

Thoracic surgery in small animals is considered a painful procedure, resulting in alterations in pulmonary function and respiratory mechanics. Appropriate analgesic protocol may improve outcomes. Systemic administration of opioids and NSAIDs, intercostal and intrapleural blocks, and epidural analgesia are among the most common options for pain management after thoracic surgery in small animals 5.

 

 

Case report

 

A 10 years old male pitbull dog, weighting 24 kg was presented to us. The owners had been to three veterinary consultations before, the chief complaint being lameness at the right front limb. The cause was suggested to be a “lump” on the right thoracic wall. Based on an X- rays study and clinical examination, so far the owners were discouraged to pursue the further surgical treatment, because the procedure was supposed to be too aggressive and painful. The dog was prescribed palliative NSAIDs therapy.

 

 

Clinical examination

 

Fig1

Fig.1

We did a thorough clinical exam, revealing normal behaviour, good over-all body condition; signs of multiple joint arthritic diseases were found- elbows and stifles decreased ROM and capsules thickening. On the right cranio- ventral thoracic wall we found protruding, egg- size oval mass, widely and firmly connected to the rib cage (Fig.1).

 

 

 

Diagnostics

 

Radiograph of the right elbow revealed advanced elbow arthritic changes.

Fig 2

Fig.2

Additionally, orthogonal thoracic radiographs (+ oblique one) were done, demonstrating large infiltrating mass, with heterogenous lytic and proliferative mineralised pattern, originating at the costo-chondral junction of the 4-th rib (Fig.2).

 

 

 

 

 

unnamed

Fig.3

A fine needle aspiration was done and evaluated (Fig.3).

The pathologist remarks:

“Clusters of  fusiform mesenchymal cells, with obvious signs of malignancy- pleomorphism, increased anisokaryosis and anisocytsosis, basophilia, multinucleated cells . Occasional osteoclasts, macrophages and neutrophils were noted. No osteoid/chondroid was found in the examined material. The tumor was classified as malignant mesenchymal– fibrosarcoma, chondrosarcoma or osteosarcoma.”

 

 

Fig4

Fig.4

A computer tomographic study was accomplished and the mass’s margins investigated carefully. A mineralised tumor centre (from the distal third of the 4-th rib) was found; also soft tissue aggressive expansion in the neighbour intercostal spaces -3-th and 5-th. Typically for the chest wall masses, there was an eccentric growth- the 2/3 of the mass volume protruding into the throracic cavity, extruding the pulmonary parenchyma and contacting the heart on the right side. No lung metastases were noticed on the scans (Fig.4, video 1).

 

Complete blood work was done and found normal. Including normal Alkaline Phosphatase level, considered favorable prognostic factor.

 

After a discussion with the owner, a decision for surgical resection was made.

 

 

Anesthetic protocol

 

Premedication with Medetomidine and Butorphanol was used, followed by Propofol induction. The maintenance was sustained by Isoflurane and Ketamin drop in the fluid sack.

 

Peri-operative analgesia, Anesthetists remarks

 

fig 5

Fig.5

fig 6

Fig.6

The thoracic wall resection is considered very painful procedure, so a corresponding analgesic strategy was built and applied. A continuous post operative segmental epidural analgesia application was provided. T13—L1 epidural puncture (by Tuohy needle), was done and an epidural set catheter (B. Braun) was inserted till the 5-th thoracic vertebra(Fig.5-6). The catheter was safely attached and maintained for 48 h post op, during the patient’s stay in the clinic. The agent delivered through, was Levobupivacain (0,5 %), one 1ml every 4 hours, including pre op.

 

 

After the mass removal, a soaker catheter was sutured at the ribs resection edges; another one was applied between the skin and muscle flap, covering the defect. Both catheters were connected to an elastomeric pump (B. Braun), delivering locally 5 ml/h of 1% Lidocain for 96h (including outpatient period) post operatively.

 

The rationale behind additional soaker catheters was to suppress maximally the nociception transfer, including the sensation through the non- blocked cervical spinal nerves. Also we contemplated- removal of epidural catheter at the time of discharge, but leaving the delivery pump, providing residual local analgesia.

 

Cimicoxib (Cimalgex) was prescribed for 10 days post op. No opioids were used in the recovery period.

 

 

 

Surgical protocol (surgeon remarks)

 

Fig7

Fig.7

Fig 8

Fig 8

Fig 9

Fig 9

fig10

Fig10

After macroscopic mapping and drawing, a rectangular shaped, full thickness (skin, muscle, ribs and pleura) en bloc excision was done (Fig.7).  This included partial ostectomy of 3-th, 4-th and 5-th ribs. Caudal intercostal thoracotomy was performed first, permitting evaluation of the intrathoracic extent of the tumor. Special attention was applied at the proximal approach to ligate safely the three intercostal arteries and veins. No visceral lung pleural or pericardium adhesion were noticed. Careful electrocautery haemostasis was done at the muscles’ cut edges.  The removed mass was macroscopically evaluated for “clean” margins, and a reconstruction of the large defect was preceded (Fig.8). A double (folded) polypropylene mesh (SURGIPRO®TYCO) was sutured to the wound edges, using simple interrupted pattern (3-0 PDS material). A latissimus dorsi muscle flap was advanced to cover and “seal” the defect (Fig.9). The air content was evacuated with aspirator on the final closure; no chest drain was left in the thorax. Two soaker catheters were applied in the wound; the skin was closed by double pedicle advanced flap technique and simple interrupted pattern (Fig.10).

 

 

 

 

Post operative care and follow up

 

 

 

Fig 11

Fig. 11

The dog’s chest was loosely bandaged; the elastomeric pump and epidural catheter were securely fixed to the body(Fig.11). I.v. antibiotics and fluid support was continued for 24 hours post op.

Provided very effective local analgesia- the dog revealed excellent comfort immediately after the surgery (video 2,3,4). We paid special attention to any pain signs- excessive vocalization, hyper-excitement, panting, tachycardia, behavior abnormalities, etc. No such were present and the patient started eating the next day after surgery; it was discharged 48 after the procedure. No ambulation deficits were seen with the Levobupivacain application. The elastomeric pump was removed on the 4-th day. Mild to moderate serosanguineous discharges from the wound were present for 10 days after the surgery.

On the 14 days recheck the wound was healed and the sutures were removed; the patient showed excellent clinical recovery (Fig.12).

 

 

 

 

Discussion

 

 

The surgical excision is considered the first treatment of choice for malignant rib tumors, but a question about the long term prognosis and rationale behind an aggressive surgery could be raised. As mentioned above, the most common rib tumors are osteosarcomas (OS)  and chondrosarcomas(CS). They have quite different prognosis- OS is rarely cured, whereas CS could be cured with surgery alone. Dogs with osteosarcoma that have elevation of the Alkaline phosphatase level have a much lower median survival times 6. Chemotherapy significantly increases the survival of dogs with rib OS- from a few months to about 9.5 months. Roughly survival time is increased 4 times with chemotherapy + radical resection, compared to surgery alone. Chondrosarcomas have a very good chance to be cured with surgery alone with median survival times exceeding 3 years. The other common type -fibrosarcoma and hemangiosarcoma have intermediate metastatic potential between the other two. Survival times ranging from 120-450 days with chest wall resection alone 7.

 

Dealing with motivated owners, a patient in good general health, with normal AP, and need for moderately large rib case resection size, we found good indications for tumor removal without preliminary histological verification. We suggested acceptable life expectancy in the worst tumor type scenario (the option for chemotherapy was available). While respecting previous vets’ opinions, we took into consideration the stated in the literature fact that dogs tolerate removal of a large portion of the rib cage very well.

 

Despite all this encouraging decision making facts, we would have fought ethical issues in a scenario we weren’t able to provide sufficient peri-operative analgesia of the patient. Except the ethical side, the pain associated with thoracoectomies may have potentially lethal consequence for the patient cardiopulmonary status after surgery. A thoracoectomy requires a very painful excision, involving multiple muscle layers, rib resection, and continuous motion as the patient breathes. Sub-optimal management of pain has major respiratory consequences. Inspiration is limited by pain, which leads to reflex contraction of expiratory muscles, and consecutively to diaphragmatic dysfunction (decreased functional residual capacity and atelectasis, hypoxemia).Treatment of acute post-thoracotomy pain is particularly important not only to keep the patient comfortable but also to minimize pulmonary complications 8.

 

In the veterinary literature there are suggestion for various types of analgesia provided after thoracotomies-  intercostal blocks, intrapleural lidocaine, incisional pain soaker catheters9; systemic agents as NSAIDs, opioids, NMDA antagonists (ketamine),etc. There is plenty of space for objective evidence based studies, proving the best analgesic protocol, yet.

In the presented case we applied sophisticated but uncommon noxious stimulus blockage strategy. The thoracic epidural catheter insertion is technically demanding procedure but it is very powerful tool for both intra and post operative pain control 10. Even more, it allows even preemptive pain blockage. So-called preemptive analgesia is intended to prevent the establishment of central sensitization caused by surgery induced injuries. Evidence from basic research has indicated that analgesic drugs are more effective if administered before, rather than after, a noxious stimulus.  Human studies report that the area of post-thoracotomy pain is more discrete and largely restricted to the site of surgery. Hence, any benefit of preemptive epidural analgesia is, theoretically, more apparent in thoracic surgery than in abdominal surgery.

 

It is interesting if the present tumor or the arthritic elbow lesions caused the primary clinical sign- front right leg lameness. Lameness of the forelimb had been described with costal tumors, located within the first four ribs 11. Possible mechanism is pain translation to the nerves to the limb, mechanical interference with movement or invasion into the muscles of the forelimb. After the surgical excision the owners reported lameness disappearance, supporting the tumor as the real cause.

 

 

CONCLUSIONS

 

Excision of malignant chest wall masses could be very successful. It is feasible to achieve clean cut margins; large residual wall defects could be managed with combined reconstruction techniques. Never mind the aggressive character of the procedure, an excellent patient comfort should be achieved with a combination of thoracic epidural and local wound nerve nociception blockage, as in this case.

 

 

Comments:

 

Just before the submission of this case report the histopathology result was received. It concluded:

 

Mass, originating from spindeloid to pleomorphic cells, highly cellular. The cells were round, organized in bundles and solid formations. There was moderate to marked anisokaryosis and anisocytsosis; mitotic figures frequently present, multifocally there is osetoid production.

 

Diagnosis: Malignant pleomorphic neoplasia, suspicious for osteosarcoma.

 

Long term prognosis:

 

In the case, no local recurrence is expected because of the wide margins excision. Generally the median survival time (MST) for dogs with rib OSA is 90-120 days with surgery alone and 240-290 days with surgery and adjunctive chemotherapy, and death is caused by distant metastases.  Age, weight, sex, number of ribs resected, tumor volume, and total medication dose do not influence survival disease-free interval 12.

 

A chemotherapy protocol is already being contemplated:

Carboplatin 300mg/sq.m.; 4 treatments q 21 days (Withrow and MacEwen Small Animal Clinical Oncology,2007)

 

 

If available, the long term result and the survival time of the patient will be followed and shared through the journal.