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CASE STUDY: Sam
Collaboration Breeds Successful Outcomes
By Jeff T. Stallings, DVM, DACVS
Winter 2017
Patient Name: Sam Mansfield

Age/Breed: 11-year-old MN Dachshund

Referred by: Leigh Rigler, DVM, Pasquotank Animal Hospital
History:  Sam presented to The COVE ER previously on multiple occasions with a variety of complaints and ongoing conditions including neck pain, cranial abdominal pain, suspected pancreatitis, intermittent pyrexia and anorexia, increased hepatic enzymes, probable cholangitis/cholangiohepatitis with recent concern regarding an emerging gall bladder mucocele, and with a history of seizures (10 years). He had been on or was still on a combination of the following medications: Denamarin, ursodiol, Cerenia, omeprazole, gabapentin, trazadone, phenobarbital, Clavamox, Baytril, metronidazole, and vitamin E. Additionally, a Royal Canin low-fat diet had been prescribed. On 9/6/17, Sam presented to Dr. Rigler at Pasquotank Animal Hospital with the complaint of exhibiting signs of discomfort when being picked up. Dr. Rigler detected abdominal pain on physical examination. Dr. Rigler felt that Sam did not have spinal pain. Dr. Rigler performed radiographs, a CBC, and a biochemical profile. There were no significant findings on radiographs, and other than an elevated ALP (1779 U/L), lab work was unremarkable. Maropitant, omeprazole, and gabapentin were dispensed, and a referral to The COVE was initiated.

Presentation at The COVE ER : Sam presented at The COVE with the same complaint of discomfort when picked up and intermittently stiffening as if in pain. Our board-certified critical care specialist, Dr. Jacqueline Nobles, initially evaluated Sam. The following findings were recorded: BAR, euhydrated, mm-pink, CRT-2 sec., TPR - WNLs, grade 3/6 holosystolic heart murmur, abdomen tense + cranial abdominal organomegaly, all else WNLs.

Diagnostics:  Abdominal U/S revealed the following abnormalities: the liver was enlarged and mottled. The gall bladder was distended with hyperechoic organized debris and no evidence of common bile duct distension; the right limb of the pancreas appeared enlarged.

Assessment:  Suspect chronic hepatopathy with emerging gall bladder mucocele +/- concurrent Cushing's disease. Dr. Nobles expressed concern about the gall bladder and discussed abdominal CT, exploratory surgery, or both as further diagnostic/therapeutic measures. A trial of Cerenia was agreed upon at this time with reevaluation if symptoms persist.

Representation to The COVE ER:  After a week of considering the options and no noticeable response to Cerenia therapy, Mrs. Mansfield brought Sam back to The COVE for a surgical consult. Traditional abdominal exploratory surgery with liver biopsies +/- cholecystectomy and laparoscopic exploratory surgery with liver biopsies +/- cholecystectomy were discussed in detail with Mrs. Mansfield. She elected to proceed with laparoscopic surgery for Sam.

Preoperative evaluation:  Since Sam was diagnosed with a heart murmur on a previous visit, a preanesthetic cardiac consult with The COVE's cardiologist, Dr. Merrilee Small, was recommended. Sam was diagnosed with compensated mitral valve endocardiosis. No treatment was deemed necessary. With the exception of elevated ALP and ALT levels, preoperative lab work was WNLs. A preoperative coagulation profile was WNLs.

Surgery:  Sam was anesthetized and prepped for aseptic laparoscopic surgery. The abdomen was insufflated and a four-portal laparoscopic array was established. The abdomen was explored and the liver was found to be diffusely light yellow and finely mottled. The right lobe of the pancreas was slightly erythematous and edematous. Five representative hepatic biopsies were obtained and submitted for histopathological evaluation. The gall bladder was distended and discolored with moderate enlargement of the proximal aspect of the cystic duct. Laparoscopic cholecystectomy was performed in standard fashion. Samples from the gall bladder were submitted for histopathology and C&S.

Post-op care: Sam recovered from anesthesia and surgery uneventfully. He remained hospitalized for monitoring for three days postoperatively. His cardiac status remained stable. Sam seemed relatively comfortable immediately upon recovering from anesthesia but was maintained on a fentanyl/lidocaine CRI for the rest of the day of surgery and that night. He was eating well, and we were able to transition him to oral medications the following day. Other than some mild bruising at the laparoscopic portal sites, there was virtually no morbidity associated with the surgical sites. Sam was discharged on the third postoperative day. The following medications were dispensed or continued as previously directed: Cephalexin, Tramadol, gabapentin, omeprazole, metoclopramide, sucralfate, phenobarbitol and Denamarin.

Follow-up:  Sam's biopsy results came back as follows: liver - moderate to marked, diffuse, hepatocellular vacuolar change with glycogen accumulation, biliary hyperplasia and lipogranulomas. Copper stain was negative for copper storage disease. Diagnostic testing for Cushing's disease is warranted based on these results. Gall bladder - cystic, mucinous hyperplasia and chronic moderate lymphoplasmacytic cholecystitis characteristic of gall bladder mucoceles. Sam returned for his two-week incisional evaluation and was reportedly doing very well at home with no persistence of the prior clinical syndrome. Subsequently, Sam was returned to the care of his primary veterinarian. 

CommentarySam's case is an example of how primary care veterinarians, emergency doctors/staff, and specialists can work together to achieve a successful outcome. The use of minimally invasive, laparoscopic surgical technique provided excellent visualization and access to the areas of interest and allowed the procedure to be performed in a way that was associated with a more rapid and pain-free patient recovery.
TECH TIP: Keeping Regurgitation At Bay
By Rachel Franklin, LVT and Brandy Sinclair, LVT
I ntraoperative and postoperative regurgitation is a menace to veterinarians and their patients. Patients that regurgitate can develop esophagitis, esophageal strictures, dysphagia, odynophagia, and aspiration pneumonia.

Regardless of the vast quantity of data gathered, no one factor or effective treatment plan has been identified for regurgitation, but several factors have been linked to higher incidences. Patient factors include obesity, high anxiety, longer hospital stay, and prolonged fasting.

It has also been found that certain procedures have a higher association with causing regurgitation: most commonly, orthopedic and laparoscopic procedures. Although it is not clearly understood why orthopedic patients have a higher likelihood for regurgitation, it is justifiably understood in laparoscopic procedures. The explanation is as follows. During laparoscopy, the abdomen is insufflated with carbon dioxide to a pressure of 8mmHg. The pressure on the stomach can push gastric contents into the esophagus and oropharynx. Since insufflation is unavoidable, preventive therapy and treatment is crucial if regurgitation is identified, in order to prevent its associated complications.

At The COVE, we have implemented medical therapy and minor adjustments in patient positioning that have helped reduce our incidence of intraoperative and postoperative regurgitation.
 
Medical Therapy
  • Omeprazole: 1mg/kg PO the night before surgery.
    • Omeprazole must be given on an empty stomach because it requires an acidic pH to take effect. Typically, owners find this easy to administer at bedtime.
  • Trazodone (anxiolytic): 5-7 mg/kg PO, given at home 1hr prior to leaving the house.
  • Maropitant (Cerenia): 1mg/kg IV or SQ, premedication.
  • Metoclopramide (Reglan): 0.4mg/kg (up to 1mg/kg) IV, premedication.
  Patient Positioning
  • Keep the patient's head elevated above its stomach at all times.
    • At induction, hold the patient's chin rather than letting it lay its head down during the induction process.
    • Use towels as pillows to prop up the patient's head, both during prep and while on the operating table.
    • If inversion of the table does not inhibit the surgeon's ability, invert the table slightly so that the patient's head rests on an incline.
    • When transferring the patient, be conscious of the head, and focus on keeping it supported.
    • Upon recovery, towels or blankets can be stacked to keep the patient on an incline.
If regurgitation occurs despite all efforts:
  • Always verify that the endotracheal cuff is properly inflated.
  • Utilizing suction, flush the esophagus and oropharynx with tap water until the fluid being removed is clear.
  • Institute a metoclopramide CRI at 1-2 mg/kg/day or repeat metoclopramide 0.4mg/kg IV q8hr.
  • Continue the patient on oral medication for 3-5 days postoperatively:
    • Sucralfate: ½ to 1g PO TID. Slurry the medication in tap water prior to administration. Give on an empty stomach.
    • Metoclopramide: 0.4 mg/kg PO TID.
    • Omeprazole: 1mg/kg PO SID. Give on an empty stomach.
    • Maropitant: 2 mg/kg PO SID. 
COVE News
Did You Know?
COVE News
Meet our Critical Care Specialist Jacqueline Nobles, DVM, DACVECC
 

Your emergency and critical care patients deserve the very best.

A Monroeville, Alabama native, Dr. Nobles has started and expanded two large specialty hospitals in Oklahoma and Florida. She is honored to join The COVE and continue to serve our exceptional community of veterinarians and pets. We are confident you will enjoy her expertise, kindness, and steadfast dedication to patient and client care.
The COVE offers Minimally Invasive Surgery (MIS)

In cases where surgery is required, we always look for options that will cause the least amount of pain and provide the quickest recovery option for our patients. In a minimally invasive procedure, small incisions are made and used as passageways for a laparoscope or endoscope , which are tiny fiber optic video cameras. Working from the images provided from the scope, special instruments are then passed through other openings and operated by remote control to perform the necessary procedure.

Benefits to your patients:
  • Smaller incisions
  • Quicker recovery time
  • Less pain
  • Less scarring
  • Lower risk of infection
  • Reduced blood loss
We offer MIS for:
  • Laparoscopy: Abdominal and pelvic surgery
  • Thoracoscopy: 
    Lung/chest surgery
  • Arthroscopy: Joint surgery
Would you like to learn more? 
Please call us anytime!
If you missed hearing our practice manager, Danielle Russ, speak at CVC in December, then you can check her out at VMX (formerly NAVC) in Orlando in February 2018!


We know you'll enjoy her presentations on:
  • Feline Heartworm Disease: the H.A.R.D. part
  • Blood Pressure Monitoring in practice
  • ECGs: Minding your Ps and Qs
  • 7 Deadly Sins of Vet Tech turned Manager 
Click here for registration information.

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