Surgery

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

florin48260278_10156282671250432_7554491919091367936_nDiana Anghelescu DVM

Georgiana Ciochina DVM

Florin Cristian Delureanu DVM, MRCVS, OCQ(V)

February 2022

 

 

Abstract

 

 

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

 

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

 

Signalment and history

 

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

 

Clinical examination and findings

 

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

 

Treatment

 

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

289288036_573537091005365_5412946589005750861_n

 

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

 

 

 

 

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

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

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

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

 

 

 

 

 

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

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

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

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

 

 

 

 

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

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

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

The following steps were used for both wounds:

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

Fig 5

Fig 5

Fig 6

Fig 6

 

 

 

 

 

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

 

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

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

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

 

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

 

Discussion

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

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

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

 

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

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

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

 

 

References:

 

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

Lateral Flank Approach for Ovariohysterectomy in Cats

Vladimir Stojanoski, DVM, Spec. surg. vet.

Irena Mandevska, DVM.

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

ABSTRACT

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

 

INTRODUCTION

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

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

 

MATERIAL AND METHODS

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

 

INDICATIONS

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

The mammary hyperplasia, also known as fibro adenomatous hyperplasia or mammary hypertrophy -fibroadenomal complex (Dolly Parton Syndrome) – image 1, represents a benign formation during estrous cycle or breastfeeding at cats that characterizes with fast abnormal growth of one or more mammary complexes (Hayden at all, 1981). As a choice of treatment its recommended to use ovariectomy or ovariohysterectomy, that results with regression of the mammary hyperplasia within a time period of 3-4 weeks (Wehrend and all, 2001). The use of this technique during lactation eliminates the occurrence of rupture of the mammary complexes triggered by a wound infection that appears as a complication by using the medial access of OVH.274135312_291687186401383_2989444432093713041_n

ADVANTAGES

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

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

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

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

CONTRAINDICATIONS

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

 

DISADVANTAGES

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

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

SURGICAL INTERVENTION

Anesthesia of the patient

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

Sedation/anesthesia in combination with midazolam:

  • Dexmeditomidin10 µg/kg i/m
  • Midazolam2mg/kg i/v and
  • Ketamine 2mg/kg i/v – slowly applicate till effect is achieved
    • For maintenance of anesthesia if needed Propofol is administered like a bolus of – 0,4mg/kg
    • Intubation and monitoring of breathing with Breathe Safe Respiratory Monitor (image 2).
      Image 2 - Breathe Safe Respiratory Monitor

      Image 2 – Breathe Safe Respiratory Monitor

      Instruments that are used for the procedure

      Standard set for sterilization: surgical gloves, surgical sterile sheet, surgical tweezers – Adison tissue, scalpel – No. 10, needle holder – Mayo Hager, hook (spay hook) for ovariohysterectomy, four surgical forceps – Mosquito forceps, surgical scissors – mayo scissor curved, four Backhaus towel clamps, surgical knife – No. 10, monofilament (Monosyn 3-0) resorptive threat, sterile gauze (image 3).

      Image 3 - Ovariohysterectomy kit

      Image 3 – Ovariohysterectomy kit

      Position of the patient

      By using the lateral “flank” access the patient could be positioned in right or left dorsal recumbence depending of the surgeons opinion. The access at the right side is preferred by some surgeons because it provides better access to more cranially anatomically placed ovary and because the omentum covers the viscera when it’s used a left sided access (Dorn &Swist, 1977). From our experience there aren’t any advantages whether a left or right sided access is used, but the left side is better because the dominant hand is used for easy manipulation with the suspensory ligament. The animal is placed in lateral position by fixing the limbs in their extension (Krzaczynski, 1974) – image 4.

      Image 4 - Lateral position with limbs fixed in extension

      Image 4 – Lateral position with limbs fixed in extension

      Surgical preparation

      The surgical field is being shaved by starting cranially from the last rib all the way down to the iliac bone in cranial-caudal direction and the transversal processes of the lumbar vertebrae, all the way down to the mammary complex in dorsal-ventral projection.

       

      Marking the incision

      The carving of the incision may be placed in dorsal-ventral or cranial-caudal direction, however by our experience we use the technique of cranial-caudal incision by which the incision is placed in one conceived central line, two fingers from the last rib, one finger from the transversal processes and two fingers from the iliac bone in diameter of 1-1,5 cm (image 5) depending on the size of the cat, estrus phase, or the presence of other possible complication factors.

      Image 5 - Ready surgical field and appropriate location of incision for a left lateral access (left dashed line: location of the last rib; right dashed line: location of the iliac crest

      Image 5 – Ready surgical field and appropriate location of incision for a left lateral access (left dashed line: location of the last rib; right dashed line: location of the iliac crest

      Surgical technique

      The incision of the skin for the lateral “Flank” access can made in cranial caudal direction paying attention for avoiding the superficial blood vessels. The subdermal tissue must be cut with separating scissors (image 6). The abdominal muscles should be separated from the subdermal tissue and by using a forceps or scissors an incision must be made separately on every layer of the lateral abdominal muscles. When the abdomen is opened its important to fixate the abdominal muscle with a forceps, or the thumb, to maintain the control over the abdominal wall. The ovary or the uterine horn should be placed right under the incision.

      Image 6 - Subcutaneous separation

      Image 6 – Subcutaneous separation

      The horn is pulled out by using  (image 7 top).

      Image 7 - Spay hook (top) and extraction of the horn of the uterus (bottom)

      Image 7 – Spay hook (top) and extraction of the horn of the uterus (bottom)

      20210528_102125 After the extraction of the horn and sighting the ovary, with the help of a forceps the ovary is fixated with the suspensory ligament (image 7 bottom). At older and obese cats the ovary is surrounded by adipose tissue, which requires prolonging the incision of the abdominal wall to achieve better visibility of the surgical field. After fixating the ovary/ligament the blood vessel is being ligated by placing two ligatures also used at the medial ventral access. The wide ligament (including the surrounding ligament) should be blindly separated parallel to the uterine artery at the level of the bifurcation of the uterus. After that, the uterine horn should be lifted to reveal the bifurcation and the contra lateral  horn of the uterus, after which by using the hook the horn is lifted to a level of visibility of the contra lateral ovary, which is fixated with a forceps to the suspensory ligament. Because this ligament is on the opposite side it is harder to pull it out, and because it is shorter, it should be torn bluntly or be cut by scissors, and the rest of the procedure is the same as the other ovary. Then the both horns are pulled out until the bifurcation is visible. The both horns are being ligated twice near the bifurcation and are cut off 0,5 cm over the second ligature.

      The visualization of the contra lateral ovary and horn of the uterus could be difficult to acquire through the small incision, but because the ipsilateral ovary is spotted right beneath the incision, by pulling out the horn all the way to the bifurcation, the contra lateral horn is pulled out by a hook, so is the contra lateral ovary. For easy visualization of the contra lateral ovary, the duodenum (left lateral “Flank” access) or the descendent colon (right lateral “Flank” access) are used to push dorsally the small intestine with the spay hook, simultaneously we pull the abdominal wall ventrally, and by doing so the visibility of the contra lateral ovary is bigger (image 8).

      Image 8 - Extraction of the ovaries

      Image 8 – Extraction of the ovaries

      Image 8 - Extraction of the ovaries

      To visualize the bifurcation of the uterus, by using the spay hook the small intestine and the bladder should be pulled in cranial and ventral direction simultaneously pulling the abdominal wall caudally, by doing so the uterine body lies dorsally of the bladders neck (image 9).

      The abdominal wall at cats is closed by using a continuous suture, embracing  the three layers of abdominal muscles. The skin is closed with a routine intra dermal suture, and by doing so, the extraction of the suture threads postoperatively is unnecessary (image 10).

      Image 10 - Closing the skin wound by placing an intradermal suture

      Image 10 – Closing the skin wound by placing an intradermal suture

      20210528_103512

      Postoperative care and analgesia

      The postoperative care by using the lateral “Flank” access is nothing special, nor is necessary stationary observing postoperatively, so the patient could be checked out the very same day. The observation is done from distance and there is no need of bringing the patient back for a control. We used a single dose of NSAIL analgesic – meloxicam 0,2 mg/kg i/v.

       

      RESULTS AND DISCUSION

      In this study for ovariohysterectomy were involved 500 adult female cats at the age of 6 months to 9 years, with bodyweight of 2,5-5 kg. (Domestic and feral) which were electively brought to the clinic, which covers all the world known high standards of working in veterinary medicine.

      The owners and volunteers in charge were informed of the whole process both verbally and in writing detailed description of the procedures and in this publication, their personal data isn’t mentioned and they remained completely anonymous.

      The choice of anesthetic protocol and the analgesia in the postoperative period, depends on the procedure and the health status of the patient, including both acute and chronic diseases.

      Even though there is no standard surgical access to ovariohysterectomy at cats, generally the ventral medial access dominates, in contrast to the lateral “Flank” access, which technique is less preferred (Bartels, 1998; Slatter, 2003).

      The complexity to identify the subcutaneous adipose tissue and the internal and external oblique muscle and the peritoneum, during this access did not showed as a problem, so did the identification of the anatomical position of the ovaries and the uterus.

      The risk of remaining ovarian tissue is rather often complication during ovariohysterectomy at cats, so is loosening of the ovarian ligatures during operation, which however doesn’t result with significant loss of blood (James at all, 2021). These intra operational complications didn’t showed as a problem with the application of the “Flank” lateral access in this study, considering the high level of competence and experience of the main surgeon, as is the use of modern materials for ligation and the use of modern surgical techniques as for ligating the ovaries and the

      uterus and as for the fascia of mm. rectus abdominis.

      By choosing the lateral “Flank” access to ovariohysterectomy at cats, there is lower degree of licking the wound, swelling and lower incidence of complications: bleeding of wound 0,5%, dehiscence of the wound 2%, infections of the wound 2,5% in the postoperative period (image 11).

      Even though there is no general opinion for which procedure is better and it’s not used as a routine procedure, the lateral “Flank” access to ovariohysterectomy at cats in this study provede positive effect in veterinary surgeons during the intra and postoperative process, lower costs of material, so is the greater satisfaction of the owners and the comfort of the patients in the healing period.

      Also the tress hold of pain during the lateral “Flank” access is very low, examined by Feline grimace scale fact sheet (Evanelista at all, 2019) by which a single dose of NSAID – meloxicam 0,2 mg/kg i/v is enough.

      CONCLUSION

      The lateral access in this study showed as better by the personnel that took place in the operations and the owners/fosters of patients because of the shorter operation time (

      generally the difference is 10-15 minutes quicker), smaller surgical incision (1-1,5 cm), eased anatomical locating of the ovaries and uterus, quicker healing of the wound (2-4 days), smaller degree of wound opening (2%), together with the better response of the patient during awakening from anesthesia and in the postoperative period.

      Saving the amount of time for the procedure (around 20 minutes per procedure), the minimal incision for performing the procedure, the shortened time for wound healing in contrast to the standard medial ovariohysterectomy, the tress hold of pain postoperatively is way lower in contrast to the standard medial technique, the postoperative complications are very rare (infection of the wound, dehiscence of the sutures, postoperative bleeding and pain at the animal itself.

       

Vaginal tumor in a dog

Case history and clinical findings

 

mirela miroslavDr. Mirela Marinova DVM, EVSSAR member , MVC Bulgaria

Dr. Miroslav Genov DVM, PhD, EVSSAR member, MVC Bulgaria

 

A 14 kg, 13-year-old female cocker spaniel for truffle hunting was examined for a swelling in the perineal region. As informed by the owner the bitch had given birth once in the past and was in heat two months ago. The swelling appeared one year ago, but had enlarged aggressively the previous month. The dog had been facing difficulty defecating.pic 1 pic 2

Clinical examination revealed palpable little dense masses in the mammary glands. The swelling turned out to be a firm vaginal mass compressing the colon.

CBC and biochemistry profile showed no changes.  An ultrasound showed no accumulation of fluid, the ovaries were normal, the bitch was in anoestrus.

Owner was recommended surgical removal of the mass with episiotomy and castration.

 

The patient was prepared in advance for vaginectomy in case  removal of the mass with episiotomy was impossible.

 

Surgical procedure

Episiotomy was performed for examination of the masses. We started removing them consecutively with an electrosurgical knife. Their location was beneath the mucosa and were removed easily without loss of wall integrity. A part of the vaginal mucosa was hyperplastic so it was also removed. The urethra was unaffected. The vagina was sutured and it’s normal structure was restored.

The second part of the surgery was ovariohysterectomy. No changes in the ovaries and uterine were visualized.

After the castration, careful visual inspection of the uterine stump and the vagina led us to a big mass in the pelvic cavity that compressed the colon.  The abdominal cavity was opened caudally to pecten ossis pubis and the uterine stump was pulled cranially. The mass was localised at pars cervicalis. After it’s removal the vaginal wall was sutured.

pic 4 pic 5 pic 6 pic 7 pic 8

Post-operative period

The recovery was smooth.  Control of the urine bladder was kept and normal defecating restored.

The postoperative edema disappeared in 2 weeks.

 

Diagnosis

A part of the resected mass was send to laboratory for histopathological diagnosis resulting vaginal polyps- benign non-neoplastic proliferations of well differentiated fibrous tissue, covered by regularly structured hyperplastic epithelium.

 

 

Vaginal tumors

Tumors of the female reproductive tract are divided in two categories: arising from the ovaries and those derived from the tubular genitalia.

Genital tract tumours are usually seen in medium-aged (mean age 10 years) non-spayed dogs. Vulvar tumors in dogs are rare- 2,5% of all canine tumors with 70% of them being benign.

 

https://www.youtube.com/watch?v=SHCML_LI2pw

 

https://www.youtube.com/watch?v=Dsg-ClVJPpY

Tumors of mesenchymal origin, leiomyomas, fibroleiomyomas and fibromas occur most commonly. Leiomyosarcomas, lipomas, mastocytomas, adenocarcinomas, squamous cell carcinomas occur much less frequently. Transmissible venereal tumors (that spreads during coitus)  can also appear  in dogs. Transitional cell carcinoma of the urinary tract occasionally extend into the vagina and vestibule. Metastasis to the vagina is extremely rare.

 

Smooth muscle tumors and polyps of the tubular part of the genital system are common in the bitch. The growth of many of these benign tumours is associated with the ovarian secretion of oestrogen. Therefore, unless the bitch is receiving exogenous oestrogens, it is very unusual to find them in an spayed animal. Leiomyomas appear to be steroid-hormone dependent-  around 56% of them have estrogen receptors and 84% express progesterone receptors.  This type of tumor is associated with estrogen secreting tumors or ovarian follicular cysts. Spontaneous regression has been observed after castration or treatment with progesterone receptor antagonist.

About 85% of leiomyomas occurring in the reproductive tract in the bitch arise from the vagina, vestibule and vulva. Boxers are predisposed.

 

Benign vaginal tumours may present as either extraluminal or intraluminal forms. Extraluminal are usually well encapsulated and their growth results in a noticeable perineal swelling. Intraluminal tumours tend to be attached to the wall of the vestibule or vagina. The are often ovoid and firm. Sometimes they can protrude from the vulva. Large intraluminal tumours may become traumatized, oedematous and infected and their appearance may be similar to that of vaginal hyperplasia. Sometimes  with the development of the tumour mammary gland tumours, ovarian cysts and cystic endometrial hyperplasia can be seen simultaneously.

Benign tumours can reach 10-12 cm in diameter. When it’s small the consistency is fleshy, but as it develops it becomes firm and hard  due to increase in connective tissue ( so called “fibroid”). Small vaginal masses are are asymptomatic unless protruded form the vulva and they can only be discovered by coincidence during vaginal inspection.

 

Clinical signs include bulging of the perineum, dysuria, stranguria, haematuria, vulvar bleeding and discharge, faecal tenesmus, constipation. Usually there are no changes in the CBC.  Radiographs of the caudal abdomen may suggest the presence of vaginal tumor but will not be enough for a definitive diagnosis or it’s location. Endoscopy is an excellent way to visualize the vaginal mucosa and the presence of polyps. Histological examination is considered to be the gold standard in determining the type of the tumor. Surgical resection with ovariohysterectomy ( reduces the risk ot recurrence) provide great outcomes for patients. Digital vaginal and rectal examinations are performed monthly to monitor for tumor recurrence.

 

 

References:

  • Jane M. Dobson and B. Duncan X. Lascelles, BSAVA Manual of Canine and Feline Oncology, Third Edition, 17: 257-259
  • David E. Noakes, Timothy J. Parkinson, Gary C.W. England, Arthur’s Veterinary Reproduction and Obstetrics, 9th Edition, 5: 649-651
  • Robert Klopfleisch, Veterinary oncology, 5: 141-143
  • Linda G. Shell, DVM, DACVIM, Tanya Gustafson DVM, Vaginal/Vulvar Neoplasia
  • B. Kand and D.L. Holmberg, Department of veterinary anesthesiology, radiology and surgery, Western College of Veterinary Medicine, Univeristy of Saskatchewan, Case Report: Vaginal leiomyoma in dog
  • Tuli Dey, Bhajan Chandra Das, Syed Imran, Mohammed B. Bostami, Bibek C. Sutradhar, Sonnet Poddar, University ot Veterinary medicine, Bangladesh, Case report: Surgical Management of Canine Vaginal Leiomyoma of a bitch

Suture material reactions: fistulas and granulomas. Review of several clinical cases

tetDr Tetiana Khramova

Veterinary Surgeon at Khramova STS Soft tissue surgery
 Kyiev, Ukraine

 

Complications on unabsorbable suture materials are not widespead in the countries where absorbable suture material or tissue sealing with electrocautery or Ligasure devices are used. But it’s still seen as a consequence of using unabsorbable multifilament suture material. It is considered, that such reactions arise because of lack of sterility during the surgery, and bacteria forming biofilms on the sutures as a result. As a reaction from the body granulomas form around the sutures and lately they might cause formation of fistulas. The most common surgeries when we can see such complications are bitch spays.

 

Periods of time, when fistula(s) form can be quite different. From my personal experience it can happen a cuople of weeks after the surgery, but it also happens as late as several years after spaying. The longest period in my practice was 10 years after the surgery.

 

The clinical appearance is usually typical: owners notice fistula(s) on the abdomen or lateral parts of the pet with exudate or pus. Rarely it can be just a painful skin inflammation on the flank without actually a fistula there. A lot of dogs demonstrate unwillingness to run and jump without any obvious lameness. Another clinical sign can be pollakiuria in the cases when granuloma forms around the uterus stump.

 

The tentative diagnosis can be made via clinical appearance. But in all the cases it’s mandatory to perform an ultrasound of the abdomen in order to check all the possible granulomas, that can be asymptomatic. The areas of interest during the ultrasound are caudal poles of the kidneys and uterus stump.  It’s quite important to check whether the ureters are involved in the granulomas, as it makes the case much more complicated. CT can be much more useful in checking the organ involvement and planning the surgery.

The fistula on the flank iscompletely resolved after surgery The granuloma adherent to the kidney. The omentum is also involved The granuloma and sutures inside

The СBСs are usually unremarcable or with signs of inflammation. In cases where granulomas have formed around the ureters the patient can show signs of azotemia (post-renal) and we will see high urea and creatinine in biochemistry panel.

 

The only possible option to treat the patient is surgical removal of the granulomas with the suture material inside or just the suture material from the ventral body wall. The therapeutic approach: using antimicrobials, flushing and draining the fistulas can help for some period of time, but then the problem will arise again.

The hydronephrotic kidney (caused by granuloma) The removed granuloma The suture material and the absess around it on the uterus stump (adherent with the bladder and intestines) The uterus stump adherent to the bladder The uterus stump granuloma on the ultrasound

The surgical approach to such cases is always the same: remove all the sutures from the body wall (often with a part of it in case of severe inflammation and thickening) and remove all the sutures and granulomas from the abdomen via middle-line laparotomy. Nevertheless, a lot of such surgeries are quite complicated because granulomas tend to be firmly connected with kidneys and it’s mandatory to remove them without injury of the kidneys. Another problem can be to free the ureter from the granuloma without breaking it or sometimes you have to reimplant them to the bladder or partly resect. It can be quite tricky to remove the granuloma from the uterus stump as they tend to be firmly connected with the dorsal part of the bladder. Sometimes other organs can be involved like omentum and intestines that leads to partial resection.

 

In severe cases you can observe hydronephrosis because of the mechanical compression of the ureter, and in such cases the kidney must be removed.

 

After removing granulomas it’s important to check whether all the suture material has been removed, and to flush and suture the peritoneum. The actual absesses around the sutures are quite rare.

 

After closing the abdomen don’t forget to check and flush and maybe drain if nessesary all the fistulas.  If you have removed all the implants, the fistulas will resolve in about a week.

 

The prognisis in such cases depends on how much all the other organs (kidneys, ureters, bladder) are involved in granulomas, so it can vary from excellent to grave.

 

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).

10

 

 

 

 

 

 

 

 

 

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.

 

2

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.

 

 

 

 

 

 

 

 

5

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

Tension pneumoperitoneum due to spontaneous gastric perforation in cat

MetodievStoyanovBorislav Metodiev, DVM       Yavor Stoyanov, DVM

Bomed Veternary Clinic, Sofia

Pneumoperitoneum refers to accumulation of gas within abdominal cavity, resulting from a perforated hollow viscus, penetrating wounds or bacterial peritonitis. Emergency condition of massive pneumoperitoneum compromise cardiorespiratory function, known as pneumoperitoneum, has been reported in humans. In veterinary medicine, there are also a few similar cases.

This study reports a case of a cat that developed tension pneumoperitoneum secondary to gastric perforation. The cat was treated with emergency abdominocentesis, followed by laparotomy.Pneumoperitoneum

A 10 years old British shorthair spayed female cat Tara (2.8 kg) was presented with a remarkable abdominal distention. Three months ago, the cat was operated because of suspected alimentary lymphoma. A part of small intestine and caecum was removed. Histology confirmed large cell lymphoma. Tara was started on chlorambucil and prednisolone protocol. Regular control examinations showed only decreased appetite and one or two times weekly vomiting. The last examination was two days before pneumoperitoneum, and ultrasonography was unremarkable.

At the time of admission, the cat was in good condition except respiratory distress, with huge ballooned, tympanic abdomen. Abdominal US showed only gas. Emergency needle abdominocentesis was performed, and about 300 ml air was aspirated. Than was performed X-ray. The abdominal radiograph showed distended by air abdominal wall, compressed viscus, displaced to thoracic cavity diaphragm. There was no evidence for free fluid in abdominal cavity. Subcutaneously was small amount of air, leaked after the needle aspiration. Second abdominocentesis was performed, and about 400 ml air was aspirated. The aspirated gas had no odor or admixtures.

On the next day, the cat was rehydrated, and a laparotomy was performed. Mild peritonitis was found with a small almond of yellowish ascites. The small intestines were empty, in the large intestines there were some faeces. The site of previously enter anastomosis was perfect. There was no evidence of leaking from the gut or any visible evidence of recurrence of lymphoma. A 6-8 mm perforation was found at the gastric fundus. The stomach, liver margin and omentum were mildly adhered. Other portions of stomach wall looked visually and palpably normal. After blunt dissection of the adhered liver and omentum, the gastric perforation was closed with interrupted sutures. Materials from stomach wall for cytology and from free fluid for microbiology were taken. Abdominal cavity was flushed with 0.9% warm saline and closed in a routine manner. Cytology did not show atypical cells, or any suspect for alimentary lymphoma. Microbiology was unremarkable.

Reported common causes for pneumoperitoneum in small animals include abdominal surgery, gastrointestinal perforation and bacterial peritonitis. In cats pneumoperitoneum also has been reported as complication after endoscopic biopsy or gastrostomy tube replacement. Most of these cases have not shown severe abdominal distention, necessitating emergency decompression.

The exact cause of gastric perforation in this cat is unknown. We suspect local weakness of gastric wall due to iatrogenic factors. Chlorambucil or prednisolone, or combination of these two medicaments may cause damage of mucosa and weakness in the walls of GI tract.

Necessity of therapeutic emergency abdominocentesis due to spontaneous pneumoperitoneum in cats has been emphasized only in few previous reports.

 

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).

78346759_2393783297549969_4542870446093107200_n

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).

 

 

78561561_811151145981832_8931977240468520960_n

Fig 2

78657130_445332022812163_8031162679685021696_n

Fig 2

 

 

 

78752190_487893868488710_7100718041469550592_n

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).

78594361_612991579480291_9147111151597780992_n

Fig 4

78549079_616311509109836_2261091335480016896_n

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).

 

79927998_540517130128091_7459387826895847424_n

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.

78602084_2532339577037341_5783121099822727168_n

Fig 6

78472698_420094512229176_6802791841071628288_n

Fig 6

 

 

 

 

 

 

 

 

 

 

 

Postoperative care 

 

78494333_842587132825425_8327883441676746752_n

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.

79332501_2589065501380609_2151178324896907264_n

Fig 8

78544522_559002944920035_7174581029305319424_n

Fig 8

78534452_1841938695949689_3873558410725163008_n

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.

 

78526523_712125492614617_692359963749646336_n 79379385_2591131814455479_8179800034531868672_n

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.

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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
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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).

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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.

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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).

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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.

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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.

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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.

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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.

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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

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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.