scope camera

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September 2014 Case of the Month – Meet Tido!!!

Tido two weeks after surgery!!! You can't keep him down!!!

Tido two weeks after surgery!!! You can’t keep him down!!!

Meet Tido!!! Tido is a 6 1/2 year old West Highland White Terrier that came to us (Affiliated Veterinary Specialists – Orange Park) for a lower esophageal foreign body. He started showing signs of intermittent vomiting and regurgitation after swallowing his rawhide bone. Unfortunately, it became lodged in the portion of the esophagus that goes through his chest, just past his heart. Usually we can use a scope camera and remove the object without any incisions. The piece of rawhide was wedged in this area and was unable to be moved, so surgery was his only option.

This was the piece of rawhide that was lodged in Tido's esophagus. It was nearly 5cm in length!!

This was the piece of rawhide that was lodged in Tido’s esophagus. It was nearly 4cm in length!!

An incision was made in the chest and the large piece of rawhide was found in the esophagus just past the heart. An incision was made into the esophagus and the rawhide was removed. Surgery on the esophagus is a very delicate surgery. In this area we have big vessels (aorta) above the esophagus and the vena cava below. Just in front of the esophagus is the heart. Nearby, there are very important nerves (vagus) that course over the esophagus. Also, the esophagus has a harder time healing versus other areas of the gastrointestinal tract with a higher chance of stricture (narrowing due to scar tissue) formation.

View of the esophagus just past the heart.

View of the esophagus just past the heart.

After the rawhide was removed, the esophagus was closed in two layers and then a Vetrix Extracellular Matrix (ECM) sheet was placed. This will aid in healing by providing a scaffold for the tissue to heal and incorporate the bodies own stem cells to infiltrate the area. After the esophagus was closed, Tido’s chest was closed in a standard fashion.

Vetrix Extracellular Matrix placement over the esophageal incision.

Vetrix Extracellular Matrix placement over the esophageal incision.

Tido made an excellent recovery!!! He has been on a soft diet and no rawhides for him!!! In four weeks he should be able to resume his normal activity. At his two week recheck, you could never tell he had surgery. Way to go Tido!!!

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Frankie’s Journey: Part 2

Frankie relaxing before surgery.

After the diagnostics were performed (reviewed in the previous segment), a decision needed to be made as to which issue was to be addressed first. This is often a tough decision and must be made with the experience of your trusted veterinarian. My criteria consisted of which leg was most affected and the fact that I had already decided to address his hips with a total hip replacement. In my opinion (and supported clinically), a total hip replacement was a better option than other procedures available for canine hip dysplasia. Certain growth plates (centers of bone growth) need to be closed prior to performing a total hip replacement making the minimum age being around 10 months of age. This made our decision easier and the decision to address the elbows was made.

Surgery for his elbows was staged; the left elbow surgery performed on December 6, 2013 and the right elbow addressed on February 14, 2014 (Happy Valentine’s Day!). The time period in between was used for physical therapy and maximizing the results of the surgeries. Identical surgeries were performed on both elbows due to the similarity of the disease process occurring. An elbow arthroscopy was performed, which revealed the cartilage flap (osteochondritis dissecans (OCD)) and a fragmented coronoid process (FCP) The OCD flap was removed and the FCP segment was removed. The damaged bone under the OCD flap was removed with a shaver until healthy bone was present. Since the diseased area of the elbow was on the inside (medial) aspect a specialized procedure to displace weight to the central and outside (lateral) aspects was performed. This procedure is called a sliding humeral osteotomy (SHO). This procedure is fairly aggressive and involves a bone cut in the middle of the humerus bone and a plate/screws placed.

Below are images of the elbow arthroscopy showing both the OCD lesion and the FCP segment.

 

Noted the line in the cartilage outline a fragmented coronoid Process (FCP).

Noted the line in the cartilage outline a fragmented coronoid Process (FCP).

Note the underlying bone (pink). This is usually covered by cartilage, however the cartilage has become a flap.

Note the underlying bone (pink). This is usually covered by cartilage, however the cartilage has become a flap.

 

Following the elbow arthroscopy, the SHO procedure was performed. Below is a radiograph of the procedure.

Note the cut in the middle of the humerus and the shifting of the bone.

Note the cut in the middle of the humerus and the shifting of the bone.

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Brachycephalic Upper Airway Syndrome (BUAS) – diagnosis

Diagnostic testing:

In addition to direct visualization of structures it is wise to evaluate both the neck and chest. This is most commonly performed with radiographs (X-rays). Structures to evaluate include the oro/nasopharynx, trachea, lungs (for pneumonia, etc), and cardiac disease. If cardiac disease is suspected due to auscultation and radiographs, an echocardiogram is recommended. A complete blood count (CBC), chemistry and urinalysis should be performed prior to anesthesia to assess total body function and if your pet is a good anesthetic and surgical candidate.

A very important part of the diagnostic workup performed just before surgery is the oral examination. One way to evaluate the upper airway is endoscopy of both the larynx and esophagus. This will provide a very thorough evaluation of the soft palate, ventricles and laryngeal function.

Direct visualization is the most common way of diagnosing the associated factors of the brachycephalic dog. The nares are narrower than a normal dog and the airflow is distorted.  For a sedated oral exam, the patient is typically anesthetized (light plane of anesthesia). Evaluating the laryngeal function in these dogs is very important in differentiating laryngeal paralysis from laryngeal collapse.

The mainstay of treatment for BUAS remains surgical, however some medical measures can also be taken. When considering medical management, it is important to focus on factors that can cause worsening of the signs, such as weight loss and allergies. Other factors to consider are housing the patient in a cool environment, avoiding the use of neck leads, decreased activity levels and the use of gastroprotectants for any concurrent vomiting or regurgitation.

 

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Happy Holidays

I want to take a moment to thank everyone for their continued interest and support of this blog. Your continued support has meant a lot to me and allowed me to continue to post various topics. I want to wish everyone Happy Holidays during this joyous time of the year! I wish you all the best in the New Year too! Keep your pets safe throughout this time, but definitely spoil them (we want them to ring in the New Years without any ailments)! Please continue to follow this blog!

Seasons Greetings!!

Kevin

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Minimally Invasive Surgery – Thoracoscopy

Thoracoscopy is the use of a rigid scope to evaluate the thoracic cavity. Typically this is performed in either dorsal recumbency (on their back) or lateral recumbency (on side) and involves an average of 3 portals. These patients typically experience a marked decrease in pain post-operatively when compared to a lateral thoracotomy or median sternotomy (open chest procedures).

Indications for thoracoscopy are as follows (not limited to): exploration of the thoracic cavity, pleural effusion of unknown origin, idiopathic pericardial effusion, lung resection, vascular ring anomaly, biopsies of the chest cavity, lymph node biopsy, pyothorax evaluation, etc. When appropriate, the major advantage is patient comfort, decreased morbidity, and in many cases better visualization. One of the most common reasons for thoracoscopy is pericardial effusion. This can be idiopathic, neoplastic or inflammatory. Therapy for pericardial effusions could include a pericardial window which can be done via thoracoscopy. Common risks with this procedure are as follows: herniation of the heart, fibrosis of the window, and continued hemorrhage.

Results of thoracoscopic pericardial windows are usually very successful when performed in the appropriate patient. It can provide long-term resolution in patients with idiopathic effusion and inflammatory disease. Quality of life can be improved in cases with cancer.

Overall, thoracoscopic procedures are increasing in popularity. The thought of being able to address surgical problems with minimal incision versus using large invasive incisions is very attractive. Please feel free to discuss these options with your veterinarian or veterinary surgeon.

Pericardial window being performed with Ligasure.

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Minimally Invasive Surgery – 1

I hope everyone is having a great weekend! The next series of topics is join got focus on minimally invasive procedures. This is of particular interest of mine. There are multiple implications of this terms, I am going to focus on laparascopy, thoracoscopy and arthroscopy.

As medicine advances in both the human and veterinary world, we are starting to do more with less. What I mean is that through smaller incisions and better technology we address more and more surgical problems. The benefit of this is shorter hospital stays, decreased complication rte, decreased infection rates, and decreased soft tissue trauma and post-surgical pain. We are very lucky to have all this new technology available to us.

Here is a definition of the terms:

Laparascopy: Abdominal surgery being performed with a scope/camera via a small portal incision. Multiple other portals are made to introduce instruments. All procedures are performed within the abdominal cavity. Laparoscopic-assisted means that part of the procedure is done with cameras within the body cavity and part is done via small incisions outside of the abdomen.

Thoracoscopy: Same definition as above, however this pertains to the chest or thorax. This is a very useful modality and is used to treat various cardiac, pulmonary (lung) and esophageal problems.

Arthroscopy: Same definition as above, however this is performed on the joints. This is a very common use in veterinary medicine and is thought to be the gold standard in joint evaluation. The most common joints evaluated through this are the elbows, shoulders and knees, however the wrists (carpi), ankles (hocks/tarsi), and hips can be evaluated. Just think, if you have an ACL injury, it is very common for you to have your knee scoped, why not your best friend?