Enemy at the Gates: Hypothermia, the underestimated anesthesia complication

denDr Denica Djiodjeva

Central Vet Clinic

Sofia, Bulgaria

Hypothermia is one of the most frequent and major anesthetic complications, occurring in at least 40% of patients. Unfortunately, too little attention is paid to this condition, which is associated with many pathophysiological changes that affect the patient before, during and after surgery. In a dog, hypothermia is considered a temperature below 37° C. As with prolonged procedures and operations, the risk increases. These are operations in which the abdominal cavity is open for a long time, in small animals under 2 kg, weak, cachectic, pediatric and geriatric patients.

Cat and dog lying on the snow in cold winter

Thermoregulation is a process in which the body strives to maintain a constant body temperature, regardless of external conditions, which ensures normal functioning of enzymes, coagulation and immune response. The normal physiological limits for a dog and a cat are 37.5˚ C to 39.2˚ C for a dog and 37.8˚ C to 39.5˚ C for a cat. For mild hypothermia, 37.0˚ C to 37.7˚ C is accepted; moderate, 35.8˚ C to 37.0˚ C ; severe, 33.6˚ C to 35.8˚  C ; and critical, less than 33.6˚ C or less. The normal body temperature (head and body) is about 38° C, and that of the peripheral parts is 2-4° C lower. Animals and humans, in addition to maintaining their body temperature within certain limits, can also produce it. Their body is conditionally divided into two parts, central (core), which generates heat, and peripheral, which regulates. The body’s regulatory mechanisms work to keep heat within normal limits. Under normal conditions, the production of heat is the result of the metabolic processes of the internal organs. When the blood passes through them, it warms up and reaches the periphery of the body through the cardiovascular system. The main organ that plays the role of a thermostat is the hypothalamus. When the blood passes through it, its temperature depends on what the body’s response will be in order to maintain the balance between heat gain and loss. From the hypothalamus, through afferent and efferent nerve pathways, vasoconstriction is induced, which occurs before the activation of other energy-consuming reactions, such as shivering. It is important to mention that the efferent response includes both types of regulation – behavioral and autonomic. Behavioral is the strongest response to rewarming, but requires awareness, which is absent during anesthesia. For this reason, the patient must rely on autonomic defense mechanisms, such as maintaining normal blood pressure, vasoconstriction, etc. When local anesthesia is used, vasoconstriction is reduced in the area, where it is administered and this increases heat loss. In addition to central thermoreceptors for heat and cold (in the hypothalamus, spinal cord, abdominal organs, brain stem, muscles), there are also peripheral ones in the skin.

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According to the second law of thermodynamics heat can only flow by temperature gradient from the body that is warmer towards the periphery or the environment that is colder, therefore, the body can never be heated from the periphery to the core which is usually warmer than the outside.

As already mentioned, when the animal is under anesthesia, the thermoregulatory mechanisms are blocked. Anesthesia slows down behavioral defense mechanisms, reduces metabolic needs, hypothalamic function and muscle tone. Heat loss begins within the first minutes of premedication because all sedatives and tranquilizers block the hypothalamus. The highest heat loss is during the first 20 minutes of induction, due to its distribution from the center to the periphery of the body. For this reason, it is very important to prevent heat loss at the beginning of the anesthesia, through various methods that will be mentiont later.images (4)

At first, the main mechanisms of heat loss are four.

 

Convection- This is one of the most common ways of losing heat, which occurs when body heat is dissipated into the surrounding space through the air. The larger the surface of the body, the greater the heat loss. In animals, hair greatly interferes with this mechanism and it is important, with a larger shaved area and an open abdominal cavity during prolonged surgery.         Conduction – occurs in direct contact of surfaces with different temperatures. For example, when lying on a cold operating table. This mechanism is especially important, when the patient is lying on a wet and cold surface.  Temp-4a-1140x778 (1)

Radiation- The transfer of heat from one surface (e.g. the body) to another without direct physical contact. Radiation is received from the sun by any object exposed to sunlight. The heat load from solar radiation,  can be significant in hot environments, where animals are exposed to sunlight for prolonged periods. When an animal is standing in bright sunlight, the amount of solar radiation absorbed may substantially exceed its own metabolic heat production.

Evaporation – evaporation of water at the surface of the body or respiratory tract results in heat loss and it’s approximately 22% of total body loss. 0.58 kilocalories of heat is lost for each gram of evaporated water. In human the evaporation is manifested like sweating but in animals due to the lack of sweat glands, it is expressed by panting. To prevent evaporation from the respiratory tract and a drop in body temperature during anesthesia, the oxygen flow can be reduced if this is compatible with the circuit used and the needs of the patient.

The main physiological disorders that occur with hypothermia are related to reduced liver metabolism, compromised cardiovascular system, reduced ventilation and oxygenation, compromised renal function, reduced cerebral flow. All these factors also influence the slower post-anesthesia recovery. In human medicine, there are many more studies on the subject and more specifically on the direct impact of hypothermia on the body. The most frequently observed are delayed pharmacokinetic and dynamics of anesthetics, impaired coagulation, a threefold increase in the risk of cardiac problems in high-risk patients, an increased likelihood of difficult wound healing and infection, leukocyte migration and suppression along with impaired phagocytosis and neutropenia.

When liver metabolism and enzyme systems are reduced, the metabolism of most anesthetics such as acepromazine, propofol is also impaired. As well as anesthetics can directly block the hypothalamus, such as acepromazine and morphine. Inhalational anesthetics are affected by hypothermia by increasing their solubility but not slowing their potency. They also reduce the intensity of shivering, as a mechanism to conserve heat. It has not been proven, whether that hypothermic patients may take longer to recover from anesthesia because of larger amounts of anesthetic that need to be exhaled. But it’s for sure known that propofol, as one of the most commonly used anesthetics, is also affected by body temperature, as for hypothermia with 3° C down, its plasma concentration increases by 30%. The only drug tested so far, which does not effect thermoregulatory responses, is midazolam. The vasodilator effect of most of the anesthetics surpasses physiological vasoconstriction, which supports thermoregulation. As with vasodilation, there is a large loss of heat that comes from the center of the body and is lost to the periphery.

The negative effect of hypothermia on coagulation and blood has three main factors. It affects – platelet function, coagulation enzyme function and fibrinolytic function. As a rule, hypothermia increases blood viscosity, which leads to deterioration of perfusion. For every 1° C decrease, the hematocrit rises by 2%. This accordingly leads to false results that can be interpreted as blood loss. Since the function of the enzyme systems is disturbed, this also affects blood clotting. PTT, PT increase significantly, there is temporary thrombocytopenia and reduced platelet function occur due to impaired synthesis of thromboxane B2. The morphology of the platelets  also changes. There is a hypothesis according to which hypothermia results in coagulopathy by reducing the availability of platelet activators. This hypothesis is supported by the following observations: (a) The generation of thrombin, a potent platelet agonist, decreases under hypothermic conditions, and (b) hypothermia results in the release of a circulating anticoagulant with heparin-like effects. (1)

Due to the vasoconstriction that occurs, the oxygenation of the tissues is reduced and hence their slower healing. Direct suppression of neutrophil function is also a factor influencing healing in addition to the immunosuppressive effect, reducing leukocyte migration, neutrophil phagocytosis and production of ILF 1, 2, 6 and TNF.

In order to avoid all complications of hypothermia, different methods are used for pre-during and post-operative warming of patients. Typically, in the preparation of the animal for surgery, towels are used to cover the table or the animal is wrapped. A heating pad is often placed on the surgical table. The use of fluid-warming devices, which largely support normothermia, is also appropriate. Various methods can be used such as putting socks on the paws, wrapping in bubble rap, placing hot water bottles, red infrared lamps. After surgery, the animal can be wrapped with a blanket and any of the methods of warming can be used. But some of the most effective methods of maintaining a normal body temperature are warm air devices and warm water beds. According to a study comparing several methods of warming and prevention of heat loss, warm air is the most effective. (2) In addition to all the listed methods, it is important to reduce the time of the operation, especially in longer abdominal operations. Avoiding placing animals on cold metal tables, warm operating room.

It is advisable to warm up by 1-2° C per hour and under constant monitoring, because complications can occur from trivial burns to more serious systemic complications. Some of the underestimated ones are the so-called “afterdrop”, in which, despite the warming, the temperature of the animal continues to fall. This is caused by the return of cold blood from the peripheral limbs to the body, which makes it difficult to reach a normal temperature. It is important in such moments to warm up the body (chest, abdomen), and not the extremities. Afterdrop can cause deterioration of physiological parameters, cardiac arrhythmias and arrest.

Rewarming shock is very unknown and underestimated complicaton, which manifests itself in a sudden vasodilation with following drop in blood pressure and cardiac output. This results in increased metabolic demands and increased perfusion requirements. In this regard, there may also be areas of impaired perfusion that are hypoxic and lactate begins to form. During rewarming, these areas are reperfused and lactate re-enters normal oxidative pathways, consuming oxygen in the process. Because of the rewarming acidosis that has occurred, appropriate fluid therapy may be considered. Shivering is a normal response of the body, with which it tries to normalize its temperature, but on the other hand, it can also lead to additional complications, because additional oxygen consumption is needed and this can cause additional hemodynamic instability. The suppression of shivering by neuromuscular blockade is an effective method for decreasing O2 consumption. This method has been described in some human studies. (3) Monitoring during the warm-up should include as many indicators as possible, such as saturation, blood pressure, ECG, lactate, glucose.images (1)

Short term result after Integrated Tanscutaneous Amputee Prosthesis for hock joint neoplasia

1575875879547blobCorresponding author:

Dr. Vladislav Zlatinov

Central Vet Clinic – Sofia

E-mail: doctorzlatinov@gmail.com

 

 

 

 

Introduction

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Synovial cell sarcoma is the most common joint tumor in dogs. It is a malignant neoplasm arising from mesenchymal cells outside the synovial membrane of joints and bursas1 . In dogs, synovial cell sarcomas usually occur in large breeds, with a predisposition for flat-coated and golden retrievers1,2 . Middle-aged dogs are most commonly affected, and there is no sex predilection. Synovial cell sarcomas usually involve the larger joints, but any joint can be affected.

Other joint tumors reported in dogs include fibrosarcoma, myxoma, malignant giant cell tumor of soft tissue and others. Recently, histiocytic sarcomas have been reported in the periarticular tissue of large appendicular joints3 .

Synovial cell sarcomas are locally aggressive with a moderate-to-high metastatic potential, depending on histologic grade. The average survival time with SCS is around 30 months, which is significantly better prognosis compared to the most common canine neoplasia- osteosarcoma.

 

Limb amputation is recommended for treatment of the SCS tumor because local recurrence is significantly lower compared to marginal resection.

In the recent years, an amputation alternative- limb sparing procedure, was developed. The first animal case (2008) with integrated prosthesis included bilateral tibial stem implantation4. The more recent procedure ITAP (Integrated Tanscutaneous Amputee Prosthesis)-Stanmore Implants Worldwide Ltd, UK, is demanding technique that consists of low limb amputation and  metal stem medullary canal insertion, aiming long term bone-implant integration. Suggested period for this integration has been suggested to be 6 weeks5. This is the most vulnerable period that demands high degree of implant stability, allowing bone tissue ingrowth into the implant micropores.  Once stable implant- stem fixation occurs, an external limb prosthesis attachment gives the opportunity for weight baring and some degree of limb functional recovery.

 

 

 

 

Abstract

 

This case report presents the short term functional result after application of ITAP technique in a five years old golden retriever. The dog’s tarsal joint was affected by synovial sarcoma. Custom manufactured implant with rigid locking plate fixation was developed. The goal of the implant design was solid fixation allowance of immediate weight baring, even before the stem integration. The follow up period of the case is 3 months post operatively. The patient revealed very good pain free limb function, starting almost immediately after the amputation.

 

Case report

 

A 5 years old male Golden retriever dog, weighting 39 kg was presented at Central Vet Clinic – Sofia. The owner reported low grade lameness with the left hind leg, lasting for more than one month and badly responding to NSAIDs.

 

 

Clinical examination

 

We did a thorough clinical exam, revealing normal over-all condition, moderate obese body score, choleric temperament. We found mild (II/IV) left hind leg weight baring lameness. Thickening of the left hock joint was noticed. Mildy decreased ROM with mild pain were appreciated in the affected joint.

 

 

Diagnostics

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Orthogonal radiographs of the left hock revealed diffuse intrinsic joint swelling. We found aggressive bone lysis areas (mostly severe at distal fibula)  and moderate aggressive periosteal reaction (mostly affecting the tarsal bones). No abnormalities were detected on preoperative 3-view thoracic radiographs, abdominal ultrasound, echocardiography, and blood tests.

 

Fine- needle aspirates were taken. Cytology revealed numerous clusters of plump, oval to spindloid cells often with moderate cellular atypia. Considering this , the signalment and the imaging findings, a diagnosis of joint sarcoma was suggested.

 

A decision for limb sparing surgery by low trans-tibial amputation and integrated limb prosthesis (ITAP) was made.

 

Implant planing and manufacturing

 

A cusv 1tom-made ITAP implant was manufactured using CNC machinery with additional welding process. Medical titanium (grade 4) was used for the production. The implant desired shape and size of the was predetermined using only radiographs. The straight shape and straight medullary canal made the design simple enough, so no necessity for  computer tomography imaging and planning was found.  The ITAP implant components included a 7 mm (rough surface) intramedulary stem, 3, 5 mm locking plate part, drilled titanium collar (flange) and most distally smooth 8 mm titanium rod (outside part). Locking 4 mm screws were produced corresponding to the plate locking mechanism.

 

A custom made exoprostheis was manufactured using combination of plastic polymer, rubber and metal elements. The length was conformed (with mild underestimation) to the natural foot size. Angulation of 135 degree of was planned to mimic the natural hock joint position. Shock absorbing (spring) design was developed.

 

Comment:

The titanium flange role is the reduction of epithelial downgrowth and good soft-tissue integration.

Anesthetic protocol

 

Premedication with Medetomidine and Butorphanol was used, followed by Propofol induction. The maintenance was sustained by Isoflurane and Ketamin drop in the fluid sack. Epidural block with Ropivacaine was provided just before the surgery.

 

Cimicoxib (Cimalgex) was prescribed for 7 days post op. No opioids were used in the recovery period.

 

 

Surgical technique

 

For the surgical intervention, the dog was positioned in dorsal recumbency. After macroscopic evaluation, transverse sharp dissection of  soft tissues, covering the distal tibial dyapihis was done. Four centimetres distance proximally from the edge of the tarsal lump was aimed. Muscles tendons (including common calcaneal tendon) were severed. A strict haemostasis by electrocautery and ligation of the main blood vessels was achieved. Minimally invasive approach (bone tunnelling) was used for the insertion of the plate element under the soft tissue on the medial side. Mild contouring of the proximal plate part was needed to fit the tibia shape. No canal drilling was needed- the stem part was impacted quite easily into the soft bone marrow tissue. Gentle axial hammering ensured good bone to flange contact.

Muscle tendons and crural fascia free ends were sutured to the special designed flange holes. After gentle subcutaneous fat debridement the skin edges were sutured over the flange surface. Special attention was emphasised so the circular skin defect was closed with an “appropriate” tension- no skin abundance, but also with no excessive tension on the stitches.

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Immediate post op care

 

Preventive antibiotic therapy (Amoxcillin calvulonic acid) and NSAIDs (Cimalgex) was prescribed for 7 days

 

A Modified Robert Jones bandage was applied over the amputee stump. The bandage was removed after three days and the exoprosthesis was attached, with similar soft bandage applied around the stump.

 

 

Strict cage rest with very short leash walks was emphasised in the immediate post op period.

 

A recheck radiograph at six weeks post op demonstrated solidly homogenous bone-implant contact area, suggesting osteointegration in process.

 

 

 

 

 

 

 

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Pathohistology diagnosis

 

“Moderate differentiated synovial cell sarcoma.”

 

Atypical spindle shaped cells with indistinct borders and variable amounts of eosinophilic fibrillar cytoplasm and stroma. The long term prognosis is good but still variable.

 

 

 

 

 

Functional result

 

The dog revealed very good comfort after the procedure, with immediate weight baring. Light protective bandage was used to cover the distal stump area and prosthesis for two months post op. The followed period (within 3 months) revealed very fast and pain free limb usage with milld lameness (II/V)

 

Leash walk 6 day  post op.

 

 

Going for a walk 14 day  post op.

 

2 months  post op

 

 

 

3 months  post op

 

CONCLUSION

 

Locking plate ITAP design can provide adequate stability needed for implant osteointegration, while early limb usage is allowed. The role of shock absorbing exoprosthesis for success is unclear. This fast functional recovery can make the ITAP procedure more attractive and better accepted by the owners of pets that need similar limb sparing surgeries. Further investigations may demonstrate ITAP complications variabilities (ratio) and long term results.

 

 

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.

 

 

 

 

Degenerative Mucinotic Mural Folliculitis in cat – first case in Bulgaria

IVDr. Ivelina Vacheva, DVM
Central Vet Clinic, Sofia, Bulgaria
ESVD member, BAVD bord member

Introduction

Degenerative Mucinotic Mural Folliculitis (DMMF) is a rare, poorly understood syndrome in cats, defined as an inflammatory reaction pattern. It is characterized by inflammation of the hair follicle, atrophy degeneration and mucin production. The inflammatory reaction, takes place on the follicle wall, primarily affecting the external sheath of the hair above the follicular isthmus. However it can also affect the infundibulum or the bulbar portion of the hair follicle.
Literature (incl. case studies) regarding feline DMMF is sparse. It can be briefly summarized as follows: All described cases are in middle aged to older cats, the majority of which are male, with no information on breed predisposition. The most characteristic features are: Alopecia of the face, head and neck and in a later stage affecting the body and limbs. Pruritus, if present, is mild to very intense. The diagnosis is confirmed by biopsy and subsequent histopathological examination.

Case Study

Mila is an approximately 1,4 years old spayed female cat. She used to be a stray cat, until a lady, regularly

1_1 Mila before the onset of her skin problem

pic 1-1

1_2 Mila before the onset of her skin problem

pic 1-2

feeding her, noted dramatic changes to the cat’s fur. The lady temporarily adopted the cat and took her to several veterinarians. The lady provided shelter to about 20 other cats. According to the owner all cats were treated monthly with Broadline (Merial).
Picture 1.1, 1.2 Mila before the onset of her skin problem

 

2_1 hypotrichosis of the face

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2_2 hypotrichosis of the distal parts of the limbs

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First signs were: hypotrichosis of the face (pic. 2.1) and subsequent minor hypotrichosis of the distal parts of the limbs (pic. 2.2)
The cat’s skin condition gradually worsened. She showed progressive hypotrichosis, and alopecia, with severe pruritus. She was seen by a veterinarian and treated with Synulox (Zoetis) orally for 20 days, which reduced the inflammatory signs. Later she was seen by another veterinarian and underwent the following treatments (in a period of 3-4 months):
Pulse therapy (7 days of medication, 7 day break etc.) with oral itraconazole 5mg/kg q24h. Without good response.
Purina Pro Plan veterinary diets HA Hypoallergenic, for two months.
Ivermectin 0.3mg/kg q24h orally for 10 days.
According to the owner, the cat’s skin condition worsened. Described signs included: Pruritus, hypotrichosis, alopecia, skin hyperpigmentation and presence of scales and crusts.
The cat was admitted to our hospital for a second opinion. As as side note: Once admitted to our clinic, the lady signed the cat over to a local charity Redom.
Picture 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The cat presented with the following signs:

  • Symmetrical alopecia of the face and head. The skin had a thickened and swollen appearance.
  • Severe pruritus (9/10 – 10/10)
  • Hypotrichosis and alopecia of the entire body.
  • Hyperpigmentation, scales and crusts covering the dorsum.
  • Very passive and apathetic.
  • According to the owner the animal is not feeling well, has an increased water intake and softer stools, with more frequent defecation than usual.

 

 

 

 

 

 

 

 

Differential diagnoses (several)
Demodicosis; Notoedrosis
Feline atopic syndrome (allergies)
Feline sebaceous adenitis
Dermatophytosis
Degenerative mucinous mural folliculitis
FIV / FeLV
Thymoma-associated exfoliative dermatitis in cats
Lymphoma

The cat was hospitalized for further diagnostics and treatment was started, while waiting for the results of histopathology.
Results of clincial exam and diagnostic tests:
Skin scrape, hair plaque, tape strip: All negative for Demodex and Notoedres mites.
Tape strip cytology: Epithelial cells, but no neutrophils or Malassezia.
The ears have brown ear wax; Cytology – only epithelial cells, no Malassezia and no Otodectes cynotis.
CBC: WBC HH 58.24×109/L(5-19,5); NEU 25×109/L(2-12,5); LYM 16×109/ L; MONO 7,21 x109/L (0,15-1,7); EOS 8,58×109/L (0,1-0,79); BASO 0,13 x 109/L (0-0,1).
Blood Biochemistry: All parameters within normal range.
TT4= 18 nmol/l (10-80).
Urine: pH 7; PRO 30 mg/dl; GLU, KETO, UBG, BIL and BLOOD negative. No sediment.
Abdominal Ultrasound: Except for slightly enlarged inguinal lymph nodes, the other abdominal organs were unremarkable.
Chest radiographs: Bronchial pattern, possible cause could be lung worms. (Picture 4)
Fecal flotation: Negative
Bearman: Negative
PCR (antigen) Assays: FCoV, FIV, FeLV, Toxoplasma gondii and Giardia ALL negative.
Skin biopsy: Histopathology results below.
Lymph node biopsy: Histopathology results below.

Therapy

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5_1 The cat is licking and biting her legs and tail as well as scratching her neck

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Picture 5 (5.1-5.4): The cat is licking and biting her legs and tail, as well as scratching her neck.

Intravenous fluids: Ringer’s lactate solution 10 ml/h for 5 days. Antibiotics: Ceftriaxone 30 mg/kg IV q12h and Enrofloxacin 5 mg/kg SC q24h for 14days each. Anti-parasitic: Fenbendazole 50 mg/kg PO q24h for 5 days. Antihistamine: Diphenhydramine 1,5 mg/kg SC q24h for 2 weeks. Continuation of Purina Pro Plan veterinary diets HA Hypoallergenic and supplementing this with 4 drops YuMEGA cat (omega-3, -6, -9 fatty acids) once daily. A single application of dexamethasone 0,25 mg/kg SC, resulted in a major reduction of the pruritus!

The CBC was repeated the next day, but did not show significant changes. However the CBC 48h after hospitalization did: WBC HH 44.8×109/L(5-19,5); NEU 19,5 x109/L (2-12,5); LYM 14,12 x109/L; MONO 1,96 x109/L (0,07-1,36); EOS 9,12 x109/L (0,06- 1,93); BASO 0,05 x109/L (0-0,1).
Clinically no evidence of polydipsia!
The charity agreed on taking biopsies (and subsequent histopathology) of the skin, spleen and enlarged lymph node.
Results – Histopathology
Spleen and inguinal lymphnode biopsy
(Dimitra Psalla, DVM, PhD)
Histopathological findings:
Spleen: Multifocally white pulp is composed of atypical round cells with distinct cell borders, scant to moderate amphophilic cytoplasm, round to ovoid nuclei with finely stippled chromatin and one large basophilic nucleolus. There is moderate pleomorphism and mitoses average 1 per HPF. Multifocally red pulp is infiltrated by small numbers of neutrophils.
Inguinal lymphnode: Focal presence of atypical cells similar to those described above. Lymphnode is infiltrated by few neutrophils.
Diagnosis :Spleen and inguinal lymphnode: Infiltration by atypical round cells (accompanied by neutrophilic inflammation)
Comments: The diagnosis of lymphoma cannot be confirmed since the distribution of the atypical cells is limited on the white pulp and the pleomorphism is not high. This population could reflect a hyperplastic conditionas well.

Skin Biopsies – face, lateral body and dorsum
(Dimitra Psalla, DVM, PhD)
Histopathological findings:
There is moderate irregular acanthosis that extends to follicular infundibula and is accompanied by mild spongiosis. Follicular isthmuses are severely infiltrated by the lymphocytes, histiocytes, neutrophils, and few eosinophils and multinucleated giant cells and the inflammatory infiltration is extending to the infundibulum. Parts of the follicular wall are widened due to accumulation of mucin (clear/basophilic spaces). Follicular atrophy is moderate to severe; normal anagen hair follicles are interspersed, particularly in less inflamed lesions. Moderate numbers of lymphocytes, histiocytes, neutrophils, and plasma cells surround hair follicles and infiltrate the superficial dermis. The histopathological features are similar in all the examined samples.
Diagnosis and Comments : The histopathological findings are compatible with the “Degenerative mucinotic mural folliculitis in cats”.

6 DMMF 1

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6 DMMF 3

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6 DMMF 2

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Picture 6 (6.1-6.3 pictures) Dimitra Psalla, DVM, PhD
Severely infiltrated Follicular isthmuses by the lymphocytes, histiocytes, neutrophils, and few eosinophils and multinucleated giant cells. Inflammatory infiltration is extending to the infundibulum. Accumulation of mucin. Follicular atrophy is moderate to severe. Moderate numbers of lymphocytes, histiocytes, neutrophils, and plasma cells surround hair follicles and infiltrate the superficial dermis.

Therapy continuation following the histopathology results:

The cat was started on oral prednisolone 3 mg/kg q24.Tapering off the prednisolone after 75% of the skin lesions had resolved and switching to cyclosporine, to avoid longer term adverse effects of corticosteroid treatment.

 

 

 

7_1 One week after the start of prednisolone

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Picture 7(7.1-7.3 pictures) – One week after the start of prednisolone.

Supportive therapy included: Once weekly bathing with Clorexyderm ICF shampoo (4% chlorhexidine); Ectoparasite treatment with Stronghold plus (Zoetis) every 4 weeks; Purina Pro Plan veterinary diets HA Hypoallergenic and supplementing this with 4 drops YuMEGA cat once daily.

To stop the cat from reaching her skin and further self-mutilation, caused by the severe pruritus she was experiencing, she was dressed in a suit. She readily excepted the suit and wore it without any problem.

8_1 Two weeks after the start of prednisolone

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Picture 8(8.1-8.3 pictures)Two weeks after the start of prednisolone.
Fur started regrowing on her head, body and legs.

There was a significant reduction in skin hyperpigmentation, scaling and crusting on the dorsum.
Gradually the pruritus decreased and the cat became more friendly, more active and was no longer apathetic.

After 3 weeks the prednisolone was tapered off gradually to an anti-inflammatory dose. (The oral prednisolone was decreased with 0.5 mg/kg every 5days, reaching 0,5 mg/kg q24h and finally after 5 days set on 0,5 mg/kg q48h).
Once the prednisolone dosage of 0,5 mg/kg q48h was reached, the cat was started on cyclosporine (suspension) 5mg/kg PO q24h simultaneously, for a duration of 10 days. Then the prednisolone was discontinued and the cyclosporine dosage increased to 7 mg/kg PO q24h.

9-1 Four weeks after the start of prednisolone

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Picture 9(9.1-9.5 pics.)Four weeks after the start of prednisolone.
Mila is much livelier and her fur is regrowing. However there are moments she is intensively licking herself, causing new skin lesions.

 

 

 

 

 

 

 

 

 

 

 

 

10_1 Two weeks after start of cyclosporin

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Picture 10(10.1-10.3 pics.)Two weeks after start of cyclosporin.
Mila while on cyclosporine – visibly improved. No more alopecia, no longer itchy and no new skin lesions.

 

 

 

 

 

 

 

 

11 Three weeks after start of cyclosporin-1

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11 Three weeks after start of cyclosporin-2

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11 Three weeks after start of cyclosporin-3

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11 Three weeks after start of cyclosporin-4

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11Three weeks after start of cyclosporin-6

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Picture 11(11.1-11.6 pics.)Three weeks after start of cyclosporin.
Mila was feeling much better and was discharged after 12 weeks of inpatient care. She was now being cared for in a single-cat foster home. After discharging Mila she was monitored and followed up closely.
Mila was discharged and after two weeks came for her first check-up.

 

 

 

 

 

 

 

 

12 -1 2 weeks after discharging

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Picture 12 (12.1-12.4 pics.) Mila 2 weeks after discharging.

The cat progressed steadily, with normal fur regrowth on head, body, legs and tail. The skin of the dorsum was still very scaly.
The following supportive therapy was continued and slightly modified: Weekly washing with Clorexyderm 4% shampoo (ICF) , directly followed by washing with Allermyl (Virbac) shampoo. Topical treatment with Dermoscent Spot-on once weekly was added to the treatment protocol. Feeding Purina Pro Plan veterinary diets HA Hypoallergenic, but no longer supplementing with YuMEGA cat.

 

 

 

 

 

 

 

13_1 Mila in her foster home

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13_2 Mila in her foster home

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Picture 13(13.1-13.2 pics.) Mila in her foster home. Mila 8 weeks after discharging

The supportive therapy was continued and oral cyclosporine was reduced to 5 mg/kg q48h for another 2 months.
Her skin and coat were looking great and she was no longer itchy. She became active, friendly and very social.

 

 

 

Case Follow- up
Seven months after her last check-up Mila presented with dyspnoe. Diagnostics showed thoracic effusion and severe anemia. Thoracentesis was performed and she had several blood transfusions. However she didn’t improve. Feline Infectious Peritonitis was suspected. Eventually the decision was made to euthanize her.

Acknowledgments

I am particularly grateful for the cooperation with Dr. Rania Farmaki, Dp.ECVD, DVM and Dr. Dimitra Psalla, DVM, PhD. They provided me with invaluable advice and supported me throughout this difficult but interesting case. I would also like to thank the local charity Redom for their excellent care, trust and financial support. Finally, I wish to thank all my colleagues from the Central Veterinary Clinic in Sofia (Bulgaria) for their assistance.

REFERENCES:
Degenerative mucinotic mural folliculitis in cats- Gross TL, Olivry T, Vitale CB, Power HT. Vet Dermatol. 2001;12(5):279-8
Lymphocytic mural folliculitis and pancreatic carcinoma in a cat Remo Lobetti (Journal of Feline Medicine and Surgery 2015, 17 (6): 548-50)
Thymoma associated with exfoliative dermatitis in a cat. Jacqueline Vallim Jacobina Cavalcanti1, Mariana Pereira Moura1 and Fabio Oliveira Monteiro2 (Journal of Feline Medicine and Surgery 2014, Vol. 16(12) 1020– 1023)
First Case of Degenerative Mucinotic Mural Folliculitis in Brazil- Reginaldo Pereira de Sousa Filho, Veronica Machado Rolim, Keytyanne de Oliveira Sampaio, David Driemeier, Marina Gabriela Monteiro Carvalho Mori da Cunha, Fernanda Vieira Amorim da Costa
An anatomical classification of folliculitis-Gross LG, Stannard AA, Yager JA. Veterinary Dermatology. 1997;8147-156.

Learn and Travel-Dr Renata Jelic from Serbia in Central Vet Clinic in Sofia, Bulgaria

 

53835429_2559867640708543_1925608025490456576_nDr Renata Jelic from Serbia has done her externship in Central Vet Clinic in Sofia, Bulgaria

learn and travel

 

 

 

 

Lets see what she said about it:

 

“I would like to start by thanking Dr. Luba Gancheva and Vets on The Balkans for giving me a wonderful opportunity to spend a week in one of the best veterinary clinic on the Balkans. received_625044874599015Together with my colleague I was warmly welcomed by Dr. Ranko Georgiev, the head of Central Veterinary Clinic in Sofia, a great expert and an exceptional man who provided accommodation for us and, more importantly, gave us free access to all parts of his clinic. And what a clinic it is. It spreads on three levels, all well organized and fully equip, in order to provide the best possible comfort and care for pet patients. Dr. Georgiev when out of his way to make sure that I used my time efficiently, constantly encouraging me to ask and participate. His help is immeasurable. Central Veterinary Clinic is the best vet clinic I ever had a chance to be a part of, even for a short while. One week is certainly not enough to experience and learn all that the great and professional staff was willing to teach me, but the knowledge and experience gained will sure help me improve as a veterinarian. One vet that I would like to give a special thanks to is Dr. Hristina Shukerova,received_555494404860695 received_2472585622815978 a person I spend most time with. She was always there for all my questions, she answered them professionally but with a touch of human emotion which made me fell as a part of the group, as a part of their team. As Dr. Shukerova’s field of expertise is cardiology, a field I wish to specialize in, she was able to help me greatly improve my knowledge in this area of veterinary practice. I will conclude this short look back on my week spent at Central Veterinarian Clinic in Sofia by sending my love and lots of smiles to all the staff working in this clinic, with a special big “Thank you” to Dr. Ranko Georgiev, Luba Gancheva and Vets on The Balkans for making this externship possible.”received_398377974256240 received_445330466039904

We would like to express our gratitude to Dr Ranko Georgiev and the whole team of Central Vet clinic for make this possible!

 

Learn and Travel- New Story

20181207_125741Dr Cristian Badineci from Bucharest Romania, with the kindly support of Pamas Trading has done his internship in Central Vet Clinic in Sofia, Bulgaria. Let him tell us more about it:

 

I had the chance to attend a one-week internship in December 2018 at the Central Vet Clinic in Sofia. I recently heard of the Vets on The Balkans project from colleagues sharing the same passion: Cardiology. Thus, with the help of organizers Luba Gancheva and Pamas Trading 12814393_1673705086236432_1339900710371625092_nI managed to come to Bulgaria to meet wonderful people.

The clinic is located in an area with green spaces, next to a zoo. I had a warm welcome and attention from Dr. Ranko Georgiev, who presented his colleagues and the tour of the clinic. It has a reception hall, a corridor to the large workroom. On the right corridor there are 3 consulting rooms, and on the left 3 imaging rooms. One for radiology and two for ultrasound. Also on the ground floor there are 2 surgical halls. In the basement there are the admissions stations, the meeting room.During my time here, I attended various cases of general medicine, emergency and surgery, but most of the time I spent in the cardiology department with Dr Marin Buckov, Dr Hristina Shukerova and Dr Ranko Georgiev. I have remarked their dedication to this discipline as well as vast experience in cardiology. They participated in numerous workshops and international congresses. I have witnessed many cases, both common like PS and AS, DCM, MVD, HCM, and distinguished, such as a Labrador with Cor Triatriatum Dextrum, a Jack Russell with Revers PDA. cor triatriatum dextrum24246_103549239687374_288378_nAs far as cardiology is concerned, in the clinic can be made specialized consultations and any kind of interventions for solving cardiac diseases in dog, cat and exotic animals. Performing the necessary investigations in a timely manner, Those in critical situation are interned, stabilized and monitored. There are always staff checking out the clinical signs and administering the medication.During my time at the clinic I was impressed by the qualities of this team. I have met respect and common sense both towards people, animals and love for medicine. I witnessed an emergency in which a small dog was sprouted by a wild boar and had an open chest wound and internal haemorrhage. He arrived in hypovolemic shock. They quickly organized a mini intervention team and stabilized the puppy in 30 minutes. 5 people quickly took clinical signs, performed intubation, artificial respiration, 2-member venous approach, restored volley, stopped bleeding. In 15 minutes the surgery room was ready, and the surgery team performed the closing of torax. The next morning, this dog was barking and eating like nothing happened.I was impressed by a doctor who received a chinchilla with kidney failure. The animal was in critical condition since receiving had serious prognosis and died, but this doctor did not stop for 2 hours trying to save it.After this experience I can hardly wait to get back in our practice and apply the new working methods learned here. I attach some pictures of Dr. Ranko‘s interesting cardiology cases to which I have attended. I am very greatfull for this experience.

 

Vets on The Balkans express their gratitude to Centra Vet Clinic and Dr Ranko Georgiev for being part of Learn and Travel and as well to Pamas Trading for the strongly support as always!

LEARN AND TRAVEL….. NEW STORY! Dr Matei Alexandru at Central Vet clinic in Bulgaria

46520505_355142141909610_6510054373484134400_nDr Matei Alexandru from 3vet Original Project Clinic in Bucharest, Romania has done his externship at Central Vet Clinic in Sofia, Bulgaria. What he said about it:

 

Central  Veterinary  Clinc – Sofia – October /November 2018

To go to certain places you need friends, and sometimes you will find friends simply by hitting them in while you’re going through life. A rumor, a link and a helping hand at the right time if you know how to accept them will open your world. Luba, I met her through a rumor, my colleague Stefan made my connection and my helping hand came from Pamas Trading .12814393_1673705086236432_1339900710371625092_n And I accepted the challenge but a bit different from what was initially planned.

At first I was asked what I liked and I answered –  Soft tissues surgery… when I got there I was asked again – What do you like? And I answered – ALL and I had the opportunity to see ALL at the clinic in Sofia .

I saw a waiting room full of people that was held by three receptionists. I went to three meeting rooms on a long hallway leading to the triage / urgent reception area, and in one corner a lab with all of a dedicated man surrounded by books. I went back through two ultrasound halls and stopped in a radilogy room used to its maximum value.46504093_1954656381506155_1879230126814658560_n 46506316_504219466756165_6529017598988779520_n 46507462_343922266187577_8073384407227957248_n 46507771_738542649840914_4496201851145814016_n 46508584_2175589452709070_1243322865311285248_n 46513483_369877663752364_467199421403103232_n 46514154_1186951701472334_2597444006979829760_n 46514502_259039121427825_8745223588467965952_n

Many surgeons can be operated at once and I have enjoyed the idea and the fact that each surgeon has an anesthesiologist who will do his job very well, the surgeon being strictly focused on the surgical side. I have attended and participated in routine and to more complicated operations (new or older fractures remedies, chronic cases without hope of resolution). Through the hard work of dedicated people ,animals with no hope of healing, resumed their lives, and I have learned new things.

In the clinic everywhere is always a line. A line on which doctors walks and split  the chaos of order. I tested my own skin because I tended to go into the surgery  without a mask … it was a good lesson.

I saw smile, confidence and knowledge and felt the strength of a team. I have received the required information without retention, I have debated cases and I was involved in a differential diagnosis … I have seen desperately recovered cases but also the last breaths of patients for whom nothing could be done.46518652_2331664727053218_7447802504802205696_n 46519168_502253150292970_4750675781510758400_n

I have known dedicated doctors only for overnight patients focused on continuous monitoring, I have communicated with specilalists on exotic animal ,cardiology, ophthalmology, internal medicine, reproduction, neurochirurgia, orthopedics, dermatology, endoscopy, oncology … and I was pleasantly impressed of their level of knowledge and the fact that they want to share whit their colleagues the informations without asking for anything in return.I have been invited into their world for a short time to be witness at high-quality veterinary business build on trust and respect. Thank you Ranko Georgiev for accepting me in your house.46485905_349823095794080_9038427446554132480_n

LEARN AND TRAVEL…..New story!

44621748_2183879854956768_4110182779130478592_nDr Jelena Micic has done he externship in Central Vet Clinic in Sofia Bulgaria. Let her share with us:

“Thanks to Vets on the Balkans and Luba Gancheva, I had a chance to spend time from 14th do 22nd October this year at a great Central Veterinary Clinic in Sofia, Bulgaria.

The clinic is amazing, with everything that you think you might need for veterinary medicine. Great place, which has stationary, x-ray, two amazing ultrasound machines, great laboratory, operating rooms, 24h service etc. and above all, experts in all fields of veterinary medicine, team that is not only made of great doctors but great people. First of all, I would like to thanks Dr Ranko Georgiev, who is amazing cardiologist with huge experience and unselfish of giving his knowledge to others. Open to all my questions and willing to answer all of them and explain everything from echocardiography, cardiology, x-ray and also abdominal ultrasound. As I started to write about cardiology, I had chance to meet Dr Marin Buchkov, a young doctor, who works alongside Dr Georgiev and probably is a future of Bulgarian cardiology. Now, about abdominal ultrasound that I am professionally interested in, I have to thanks Dr Miroslav Genov, expert in reproduction and Dr Kaloyan Voichev, who had patience for all of my questions and luckily I will attend at least one of his ultrasound workshops in the future. 44702825_443237652867945_6189133321910353920_n

Also, I saw some interesting cases in ophthalmology thanks to Dr Janica Dencheva. Interesting part of my externship was meeting Dr Gergana Georgieva and Dr Melinda De Mul, who are interested in exotic animals. Even I don’t have so much contact with these kind of pets, they explained me a lot of cases and give chance to see, for example, an ultrasound exams and x-rays of exotic. Also I had chance to see and learn from Dr Yordan Stoyanov, Dr Nadia Mihalopoulou and Dr Yordan Yordanov. Special thanks to (of course also great doctors) Dr Tome Peychinovski, dermatologist and ultrasonographer and Dr Iva Dimitrievska, who spend her free day for tour of Sofia with me , and gave me that privilege to meet their family and spend the beautiful day with them. 44797808_534785090279383_5473703989302263808_n

There wasn’t just work. We also spend very pleasant night out with delicious food, drink and talks, speaking in Bulgarian, Macedonian, Serbian and English. Contacts that I made during this stay at the clinic are, hopefully, something that will last for a long time. I was really lucky to have opportunity for this externship, thanks once again to Dr Luba Gancheva and great invention, Vets on the Balkans.”24246_103549239687374_288378_nlearn and travel

Learn and Travel with Vets on The Balkans…. vets speak about it!

30706127_1869730476410629_6001501177299075072_n Dr Ivana Jovandin, veterinarian from Serbia, attened our education program Learn and Travel with Vets on The Balkans. She did her externship at Central Vet Clinic in Sofia, Bulgaria. Let her tell more about it:

 

Thanks to Vets from Balkan and Luba Gancheva, I had a chance to spend a week in April at a great Central Veterinary Clinic in Sofia, Bulgaria. The clinic is spacious, well equipped and the place where you can see the “state of art” veterinary medicine, and colleagues who work there are exceptional in various fields and together make a great team that is capable of finding the best solutions even for the most serious and difficult situations. It was a special pleasure to get to know and spend time with Dr. Melinda De Mul and Dr. Georgina Georgieva who work with exotic animals that I am professionally interested in. 30741558_1869730456410631_4343028306459754496_nIt was great to exchange our experiences, since in Serbia number of colleagues who are interested in exotic animals is very low. In addition to the work that is closely related to the profession, it was extremely useful to see the organization of work in such a large team where every person knew their task at all times, and everything was managed in order to provide better quality prevention, diagnostics and therapy of pets. Although the time I spent at the clinic was short, it will serve as motivation to strive to improve myself constantly, since the knowledge I got from working there with my colleagues is the experience that cannot be measured. 30712306_1869730686410608_5926180383073763328_nThe acquaintances and contacts made during the stay at the clinic are also something that is invaluable and something that will last for a long time. Enriched with this wonderful and unique experience, I believe that I have moved in the direction of what we all strive for, and that is to be, above all, better people and only then better veterinarians. And that’s why I am so thankful to Dr. Ranko Georgiev, Luba Gancheva and Vets from Balkan on everything!30688606_1864092660307744_6888695709592190976_n

Transplantation of ipsilateral canine ulna as a vascularized bone graft for treatment of distal radial osteosarcoma

12959354_10153530931267960_1853416198_o-200x300

Dr. Vladislav Zlatinov,

Corresponding author :

Dr. Vladislav Zlatinov,

Central Veterinary Clinic

Chavdar Mutafov str, 25 B, Sofia, Bulgaria

E-mail: zlatinov_vet@yahoo.com

 

 

Abstract

 

This case report describes the successful use of a vascularized cortical autograft from the ipsilateral ulna in limb-sparing surgery for the treatment of distal radial osteosarcoma. A pancarpal arthrodesis with two orthogonal plates was performed to stabilize the site. No implant failure and local tumor recurrence were observed in the 6 months post operative period. Excellent limb function was achieved within 6 weeks after surgery; no external support (coaptation) were used during the post operative period. Excellent perceived quality recovery, was reported by the dog’s owners, compared to their preliminary outcome expectations.

 

Introduction

 

Osteosarcoma (OSA) is the most common primary bone tumor in dogs, most commonly affecting the distal radius. Current treatment protocols-Fig.1 are based on a combination of surgery (limb amputation or limb sparing surgery) and adjuvant chemotherapy. Palliative therapies like- Stereotactic radiation or Percutaneous

Fig.1

Fig.1 Osteosracoma treatment algorithm

Cementoplasty therapy are rarely applied with limited success 1,2.

 

 

 

 

 

 

 

 

 

 

 

Recently, numerous publications suggest that the Limb-sparing surgery is a viable alternative to limb amputation in selected cases, especially indicated if there is pre-existing orthopedic or neurological disease or if owners are resistant to limb amputation 3,4,5,6.

 

 

Limb- sparing consists of removing the segment of bone involving the primary tumor and using internal or external fixation to the remaining bones with or without segmental bone replacement, resulting in a salvaged functional limb 7. Limb- salvage procedures

have been described in the distal aspect of the radius, proximal humerus, distal tibia, and proximal femur in dogs with OSA, but the salvage surgery of the distal aspect of the radius has produced the most favorable results. This is mainly because pancarpal arthrodesis is well tolerated by dogs, not like fusion of other joints. Importantly – the prognosis for survival is the same with amputation or limb- sparing, unless an infection is present, in which case the average survival is prolonged.

 

Candidates for limb sparing

 

Good surgical candidates are dogs with OSA confined to the bone, with minimal extension into adjacent soft tis­sue and involving less than 50% of the bone length. The extent of bone involvement is most accurately determined by using computed tomog­raphy and is overestimated by radiography, nuclear scintigraphy, and magnetic resonance imaging 8. Pathologic fracture is a relative contraindication for limb-sparing because of tumor seeding into adjacent soft tissue, although the risk of local tumor recurrence can be re­duced by use of preoperative chemo­therapy or radiation therapy.

 

 

Limb sparing techniques

 

Historically, the most commonly performed limb sparing technique for the distal radial site involved the use of an allograft (donor from an individual of the same species) to replace the bone defect created by segmental bone excision 9- Fig.2. Although the limb function is good to excellent in about 80% of dogs with the allograft technique, the complication rate is substantial. The most common complications include infection, implant related problems, and local recurrence. Infection rate is reported to be up to 60%, implant failure in up to 50% as well. Even more, there are practicality issues for the regular application of the allograft technique- time consuming and costly maintenance of a bone bank. Recently,  there is a new alternative for graft purchasing from a commercial source on a case by case basis.

Fig.2

Fig.2 Allograft limbs spring surgery

 

It’s not surprising that alternative limb-sparing methods are being investigated. Reported grafting techniques include pasteurized/ irradiated autografts, endoprosthesis, vascularized ulnar transposition graft (roll-over technqique), free microvascular ulnar autograft.

 

Nevertheless the technical evolution of the available techniques, all of them are still often associated with a high complication rate including infection, construct failure, and tumor recurrence. The longitudinal or transverse bone transport osteogenesis has the advantages to lower the aforementioned complications but still have limitation for routine implementation in the practice 10, 11.

The advantages and disadvantages of the recent innovative techniques are shortly summarized below.

 

Fig.3

Fig.3 Endoprosthesis limb salvage procedure

The most prominent advantage of the endoprosthesis limb salvage (Fig.3) is the simplicity compared to the other grafting techniques; consequently it is time-saving. Decreasing the surgery time may suggest lower infection ration.  Unfortunately this was not proved by the clinical experience with the currently commercially available endoprosthesis.

 

 

A recent study 4, comparing the results of  Cortical Allograft and Endoprosthesis techniques, suggested  surgical infection of 60 and 55% of the cases, respectively. The use of a large volume of implants and foreign material has been proposed as a cause. More over in the same study, long term implant failure occurred in 40% of the treated dogs.

A positive remark in the paper is the good (subjectively) limb function, reported in the stable phases or in non-complicated cases.

 

Fig.4

Fig.4 Ulnar roll-over salvage technique

A more biologic friendly technique- ulnar roll-over – Fig.4 was resently reported with good results, despite limb shortening of up to 24 % 3,12,13. The distal ulna is osteotomized, rolled into the radial defect, and secured with a bone plate and screws. With this technique the preservation of the caudal interosseous artery and vein and a cuff of the deep digital flexor, abductor pollicis longus, and pronator quadratus muscles are important for maintaining viability of the transplanted ulna.

 

 

Theoretically, using a vascularized bone graft could reduce the gross incidence of complications compared to an allografts or endoprothesis. Vascularized bone is more resistant to infections, to the extent that vascularized cortical autografts have been used to treat osteomyelitis. Also the use of a viable graft may preserve biomechanical properties over allografts. Whereas the allograft may resorb and become weaker over time, the ulnar graft may maintain its physical properties or even hypertrophy and healing with the host bones.

However, the statistics reports are controversial, with no clear proof for substantially better outcomes. One study shows no statistically different infection (45%) and implant failure (55%) ratio. Probably the presence of a viable graft does not address all other factors predisposing to infection (poor soft tissue coverage, immunosuppression from neoplasia and chemotherapy, and use of orthopedic implants). The other complication problem- implant failure, sounds as  a surgeon’s skills dependent issue. For example one of the major complication in the mentioned study has been fracture of the remaining radius in cases of great length resection (>57%), which could be just consequence of suboptimal plate length or screws number and distribution.

Importantly, the roll-over technique demands sufficient length of the distal ulna to be preserved, but local recurrence was not increased compared to other limb- sparing techniques.

Microvascular anastomosed bone transfer was used in the presented case. This is a routine procedure in the limb sparing surgeries in human patient, but rarely applied technique in veterinary medicine, nevertheless, the vascular supply of the distal ulna has been , studied, described and successfully used experimentally and clinically 14,15.

In this technique, a more substantial middiaphysis segment of the ipsilateral ulna, with its source artery and vein (the common interosseous) is harvested and transpositioned, with a blood supply restored by vascular anastomosis to a neighboring artery and vein, once the graft is in its new position. The surgical technique is described further in the text. The concept is the same as the ulnar roll-over but, with the advantages of stronger cortical ulnar graft used, more mobile graft and  a chance for full distal ulnar resection. The disadvantages of this procedure are the need for a specially trained and equipped microvascular team and the prolonged surgical time.

Longitudinal bone transport osteogenesis

 

Fig.5

Fig.5 Longitudinal bone transport osteogenesis

This is a specific application of distraction osteogenesis, which has been used successfully in dogs for replacement of large segmental defects of the distal aspect of the radius and tibia after tumor resection. This is a process whereby healthy, detached bone segment is sequentially moved across an adjacent segmental osseous defect forming new regenerate bone in the distraction gap -Fig.5.The regenerate bone is highly vascular and resistant to infection.

The results following the procedure have been very encouraging, with good orthopedic function and no reported infections. Disadvantages of the bone transport osteogenesis procedure is the significant amount of time required to fill the defect after tumor removal (up to 7 months). This often leads to owner compliance issues (distracting the apparatus two to four times per day), also pin-tract drainage and loosening, difficulty in docking the intercalary bone onto the radial carpal bone.

Fig.6

Fig.6 Transverse Ulnar Bone Transport Osteogenesis

A recent modification –Transverse Ulnar Bone Transport Osteogenesis, has been reported 16- Fig.6. The technique substantially decrease distraction times. In one case report,  distraction of the ulnar transport segment across the 84 mm longitudinal segmental radial defect, was completed in 23 days.

 

 

 

Case report

 

 

A 9-year-old female Rottweiler dog (43 kg) was referred to our practice with a 3- weeks history of left forelimb lameness with an gradual onset and an unknown origin. The dog was been previously prescribed NSAIDs with temporary effect. During our examination we found weight-bearing lameness II/V. Physical and orthopedic examination revealed distal radial swelling on the left forelimb, with pain on extension of the carpal joint.

 

Fig.7

Fig.7 Orthogonal limb radiograph

Orthogonal radiographs were achieved, revealing vast osteolytic (relatively smooth margins) area in the  distal radius, with no apparent lesions in the distal ulna- Fig.7

 

 

Based on the history, signalment, lesion location, and radiographic findings, a primary bone tumor was suspected.

Fig.8

Fig.8 Thoracic X ray

No abnormalities were detected on preoperative 3-view thoracic radiographs, abdominal ultrasound, echocardiography, and blood tests- Fig.8. The Alkaline Phosphatase (AP) value was 195 U/L- in the upper limit but still within the reference range for the breed.

Treatment options were discussed with the owners:

 

-conservative palliative treatment

-amputation and chemotherapy

-limb-sparing surgery in conjunction with chemotherapy;

 

The owners chose the last  course of treatment but insisted on preoperative histologic confirmation of the suspected diagnosis.

 

Fig.9

Fig.9 Pathological fracture of the cranio-distal cortex

After short anesthesia and minimal invasive approach, tissue biopsy sample was retrieved and send for analysis. Ten day later the the suspicious of osteosarcoma neoplasia was confirmed. The histologist comments were: moderately aggressive OSA with low mitotic figures. Meanwhile the dog showed acute lameness deterioration, related to a pathological fracture of the cranio-distal cortex of the radius, following the biopsy procedure- Fig.9.

 

A limb sparing procedure (roll-over vs. free vascularized) grafting was planned.

 

Twenty minutes before the skin incision high segmental epidural analgesia wad accomplished at the level of T11, infusing 2 ml of 0,25 % Levobupivacian solution and positioning the patient in left lateral recumbency for 10 minutes- Fig. 10.

 

 

Fig.10

Fig.10 Segmental epidural analgesia

Fig.11

Fig.11 Sternal recumbency

 

 

 

 

 

 

 

For the surgical intervention, the dog was positioned in sternal recumbency- Fig 11. , facilitating  a dorsal approach to the radius and carpus. Careful tissue examination was done during the sharp dissection of  the distal soft tissues. Caudally, the tumor was closely attached to the distal ulna. Thus, the tumor was not dissected caudally to avoid contamination. A decision for a more extending distal ulnar resection was made. This prevented the option for roll-over technique more advanced free vascularized transfer was prepared.

The extensor carpi radialis muscle was transected proximal and distal to the tumor; the common and lateral digital extensor tendons were spared. An oscillating saw was used in both radial and ulnar osteotomies. The level of the transverse osteotomy of the radius, 2 cm proximal to the tumor, was determined on radiographs and confirmed appropriately intraoperatively. The ulna was osteotomized at lower level, just over the overlapping zone with the radius. The radius was disarticulated at the antebrachiocarpal joint and the tumor removed en bloc with the distal ulna. The length of the resected radial segment was 10 cm, including the 2-cm free margins (this represented 45% of the total radial length). The whole radio-ulnar segment was stored in 10 % formalin solution for later histologic analysis-Fig.12 and 13

 

Fig.12

Fig.12

Fig.13

Fig.13

 

 

 

 

 

After tumor removal the limb sparing was continued with cartilage debridement from the carpal and metacarpal bones , accomplished by using a speed burr drill; several penetrating drill holes were created in dorsal surface of the radial carpal bone.

The resected radial bone segment was measured and a second ulnar osteotomy performed proximally using a separate blade to match the length of removed radial bone minus 1,5 cm. The proximal ulnar osteotomy was performed above the level of the radial osteotomy while identifying and carefully dissecting the caudal interosseous artery and vein.The last were a-traumatically clamped and transected as proximal as possible, preserving as much as possible of the vessel length.The muscle attachments of the abductor pollicis longus, ulnar head of the deep digital flexor, and pronator quadratus were kept intact onto the periosteum of the distal aspect of the ulna.

The ulnar graft was transposed into the radial defect and the proximal end of the common interosseal artery (<2  mm) was anastomosed to a distal branch of the median artery. The anastomosis was accomplished with the use of magnification (10x) with surgical microscope and fine jewelers forceps- Fig.14 and 15. General principles of end-to-end vascular anastomosis were followed- atraumatic handling, distance of 0,5- 1 mm from the vascular wound’s edge, the regular suture distance, etc. Five interrupted sutures (8-0 nylon) were used to seal the anastomosis. The total ischemic time of the bone graft was about 60 minutes.

Fig.14

Fig.14 Microscope- assisted arterial anastomosis

Fig.15

Fig.15

 

 

 

 

 

 

 

 

The microanastomosis success was confirmed by identification of a active blood flow present in the graft’s tissues and the distal end of the interosseal artery (video 1 ).  The corresponding vein was not anastomosed, but its end was left free in the surrounding soft tissues. The distal artery ending was ligated.

 

 

After the anastomosis, the procedure was finished by stabilization of the bone graft by long plate, engaging from the distal metacarpal bones to the proximal radius, on the cranio-dorsal surface. We used hybrid 4,5 mm plate (Mikromed, human series) allowing fixation with 4,5 mm screw proximally, 3,5 mm in the middle area (free graft) and divergent 2,7 mm screws in the III and IV metacarpal bones. A second orthogonal plate 3,5 mm reconstructive locking (Mikromed) was applied laterally, fixating the proximal radius to the fifth metacarpal bone- Fig.16 and 17. Copious cancellous bone graft (from proximal humerus) was retrieved and stacked at the level of all osteotomy gaps.

Fig.16

Fig.16

Fig.17

Fig.17

 

 

 

 

 

 

 

 

 

 

After copious wound lavage and before closing of the surgical wound, the implants were covered by Gentamycin impreganted bovine collagen sponges (Gentacoll- resorb). The goal of the last was infection prevention. A soaker catheter was also inserted along the full length of the surgical wound. Subcutaneous tissue and skin were closed routinely. After skin suturing, the leg was bandaged  with modified Robert -Jones bandage for the next 12 hours. The soaker catheter was attached to elastomeric pump, delivering 1 % Lidocain solution – 5 ml/h, for the next 3 days.

 

 

Post operative care

 

 

Postoperative analgesia consisted of: local Lidocain flash block delivery by the elastomeric pump (36 h) , Butorphanol  (0.3 mg/kg, every 6 h, i.v.) and meloxicam (0.1 mg/kg /24h ,s.c.).

 

Fig.18

Fig.18

Cryotherapy (frizzed towels compresses) was applied every 4 hours for the  next 48 h- Fig. 18

 

Cephazolin (20 mg/kg/8 h, i.v.) was applied for 3 days post op.

 

 

On the third post operative day -the dog was discharged, with oral Cimalgex (Cimicoxib, 2 mg/kg/day) for 14 days. Oral amoxicilin clavulonic acid  (12,5 mg/kg/12h) was administered for 2 weeks and exercise was restricted to short walks on a leash for 12 weeks. The dog was re-examined regularly- every 14 days, including the visits for the chemotherapy sessions.

 

Chemotherapy protocol

 

Fig.19

Fig.19

The histopathological diagnosis of the excised bone confirmed a grade II fibroblastic osteosarcoma (OSA)– Fig. 19. Surgical resection was considered complete with no evidence of neoplasia at joint compartment.

 

Fig.20

Fig.20 Carboplatin

A single agent protocol -carboplatin (300 mg/m2)- Fig. 20,  was planned and applied every 3 wk for a total of 5 treatments. The first treatment was started 2 weeks after surgery. A CBC was taken 2 weeks after and just before each carboplatin administration; serum biochemistry was performed every 2 months. There was no evidence of gastrointestinal upset, renal failure or  myelosupression after chemotherapy. The AP levels were always in the reference range.

 

 

 

 

Clinical recovery and Follow up

 

 

Lameness progressively improved from toe-touching (one day after surgery) to full weight-bearing with only slightl visible lameness- 6 weeks post op. No external coaptation was applied during the recovery period- Fig.21, Video 2- 3.

 

 

 

Fig.21

Fig.21 Three weeks post op

Fig.22

Fig.22 Six months post op

Fig.23

Fig.23 After lateral plate removal

 

 

 

 

 

 

 

 

 

 

 

 

 

Six months post op the limb function was appreciated as excellent, without any significant changes on limb palpation- Fig.22. Video 4. Orthogonal radiographs were taken, showing proximal bone fusion; distally the bone was superimposed by the lateral plate. No signs of construct failure were observed. A decision for dynamisation was made and the lateral plate was removed, revealing radiographically the bony structure under it. It showed good bone density and excellent graft fusion (primary), proximally and distally. Further segment hypertrophy is expected by the increased load sharing.

 

 

 

 

 

CONCLUSIONS

 

The limb sparing surgery could be a viable option for treating distal radial OSA in properly selected cases. With the innovative alternatives, the widely accepted approach to canine OSA – limb amputation treatment, should not be applied as “default treatment” in each case.  Case to case individual approach may provide the pets and their owners more fare attitude. Excellent functional results of the limb may be achieved by a complex (but single stage) surgical segment resection and appropriate bone reconstruction and rigid fixation. The use of free vascularized bone graft is a manageable option and an alternative to ulnar-roll over in cases of distal ulnar tumor engagement or vast radial segments resection, where solid vascular bone grafting is demanded.IMG_6122