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      Date:   21 September, 2011  
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Buying Time For An Old Companion - Circum-anal tumours - Part 2
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 09 June, 2009
D
ate:  21 September, 2011
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129

First Consultation in June 2009
Circum-anal tumours - Jun 2009. Two vets had not wanted to perform the surgery, probably forecasting that the dog would die of old age anyway. However, the old dog outlived the growing tumours and caused lots of maintenance in the house as blood splattered all over the floor every day.  

Update in February 2010

I did not phone the owner to get the dog neutered as this would seem like being a desperado trying to tout for business.  In the interest of the old dog, I should do it but I did not.  He barely survived the anaesthesia in June 2009 and I don't want to risk my reputation operating on a very high-risk case. The chances of survival were so overwhelming low that it would be best for me not to seek such cases as human emotions on a dead dog after surgery are very high.

The owner consulted me 8 months later. The tumours recurred and grew with a vengeance. With a heavy heart, I did the surgery. This time the owner did come back for neutering. An anti-androgenic injection was given. The owner did not return for the second injection. The surgery is presented below:   
Left perineal tumour excised but recurs. Owner ignores it till now. Toa Payoh Vets  Perineal tumours. Shih Tzu, 12 years. Toa Payoh Vets Perineal tumours. Shih Tzu, 12 years. Toa Payoh Vets
As the dog was about to die during the first anaesthesia, not all circum-anal tumours were excised.   Circum-anal tumours - Jun 2009 If I had persisted in continuing the surgery when the dog's anaesthetic signs indicated imminent cardiac failure, the dog would have died. A second surgery should be done one month later when the dog has better health. However, the owner did not return.
Perineal tumours being excised. Electro-incision. Shih Tzu, 12 years. Toa Payoh Vets Perineal tumours being excised. Electro-incision. Shih Tzu, 12 years. Toa Payoh Vets Perineal tumours being excised. Electro-incision. Shih Tzu, 12 years. Toa Payoh Vets
The other circum-anal tumours had explosive growths 8 months after the first surgery. Electro-incision was initiated. Electro-surgery was used for skin incision and is of no further use in this case as the tumours were wide-spread and not in discrete lumps. Surgery in aged dogs must be completed fast in order to reduce risk of anaesthetic deaths. 
Perineal tumours being excised. Electro-incision. Shih Tzu, 12 years. Toa Payoh Vets Perineal tumours being excised. Electro-incision. Shih Tzu, 12 years. Toa Payoh Vets Perineal tumours excised. Shih Tzu, 12 years. Toa Payoh Vets
A bloody operation. Almost all the subcutaneous tumour and cells were excised.     No histopathology was done to save the owner money. Neutering would be done 2 weeks later.  Stitch breakdown is common in this case. The wounds were cleaned daily by the owner at home.

Update in June 2010

I did not follow up on this case as I expected a very poor prognosis. I expected that the dog would have recurrence again. The owner did not come for a second anti-androgen injection which is highly recommended to reduce any growth of circum-anal tumours.

circum-anal, perianal tumours male intact shih tzu old dog, toa payoh vets singapore Again I should have phoned him to come for the injection. I did not want to tout for business and I did not phone him. Recession had set in and I could understand that the two surgeries had cost the owner over $1,000.

On a fine sunny afternoon of June 4, 2010, the son-in-law phoned me as the dog had facial itchiness and infections. "How's his backside?" I asked the son-in-law who had phoned me for an appointment. "Very good. No tumours have grown." This was excellent news. I just would not believe him.

As he was busy, I offered to drive to his apartment to get the dog. His mother would bring the dog in a crate down to the void deck. My assistant Mr Saw would pick him up, put him in a crate and return to my car while I was waiting at the road-side. "Has he got perianal tumours?" I asked Mr Saw as he approached me. "No, Doctor" he said. I could not believe him. The tumour had recurred since the first operation in Jun 2009 and now he told me that there was no recurrence. How could that be? It was not logical.

Indeed, his backside looked normal. He bites people and so Mr Saw and I had to be very careful when we handle him.  

Advices:
It was only 4 months after the second surgery. The logical scientific explanation is that the dog had been neutered. This deprived the circum-anal tumours of testosterone which fueled its growth. It is a known fact that neutered dogs rarely suffer from circum-anal tumours and therefore this dog had no further recurrence. Cause and effect. Neuter and no circum-anal tumours recurring as compared to the first June 2009 surgery. The owner had complied with veterinary instructions to get the dog neutered after the 2nd surgery in Feb 2010. Therefore, the dog benefited in having a high quality of life by having a pain-free normal backside. However 4 months is too early to come to a conclusion as it takes 5 years to know whether the tumour (most likely malignant) will recur. It would likely recur if it was malignant.

The anal area should be examined weekly and the anti-androgen injections given when the tumours recur. Compliance may be difficult as almost all owners leave the backside alone unless the dog is licking it or blood drips onto the floor. 

Singapore flowers, Toa Payoh VetsNever harbour negative mental thoughts when you encounter challenges in life. They suppresses your own immune system and cause you to fail in life. Adopt a positive mental attitude when you operate on circum-anal tumours in the old dog.

COPY OF A REPORT IN MY BLOG.
http://2010vets.blogspot.com/2010/06/95-perianal-tumours-in-dog.html
In the afternoon of June 3, 2010, I had taken out the files of the old Shih Tzu with gigantic perianal tumours and gave a review of this case to a new intern who was a Junior College Year 2 student from Raffles Institution.

I had driven back to the surgery with an old Shih Tzu that had large perianal tumours excised by me four months ago. However his tumours had not recurred, so the old illustrations in my case sheets would be the only way to educate her. I do illustrate my surgical cases for review and to give to my clientele to educate them and their families.




For the benefit of readers, the tumour case is described at:
Buying Time For An Old Companion - Cicum-anal (perianal) tumours in a male Shih Tzu

http://www.sinpets.com/dogs/20100533perianal_circum_anal_tumours_dogs_ToaPayohVets.htm


Jun 2009. Surgery aborted as the dog went into cardiac failure. Only the largest tumour was excised.
To continue surgery would be very foolish as no owner wants a dead dog with a completed surgery




Feb 2010. Dog came with larger tumours





Jun 2010. No recurrence of circum-anal tumours for the past 4 months after excision, neutering and an anti-androgenic injection. So is he fully cured?

Weekly monitoring of the anal area during bath-time will be ideal and any small tumours be resected or reduced by an anti-androgenic injection. But which owner would remember to do the weekly checking for perianal tumours?
"I have not seen many cases of perianal tumours as they predominantly occur in male un-neutered dogs," I said to the intern. The old Shih Tzu I drove back in my car now had a normal backside and so I could not show her the real thing. "Perianal tumours, also know as circum-anal tumours seldom present themselves in neutered male dogs or female dogs. Many Singapore dogs are sterilised as dog licence fees are much lower. This is why there are so few cases."

In the evening, I visited a veterinary surgery whose founder is an old colleague of mine during our employment by the Primary Production Department (PPD), Singapore. The PPD is now called the AVA (Agri-Food and Veterinary Authority.

 "How many cases of perianal tumours have you seen?" I asked the founder's son who was on duty. His mum had not been in good health and was not in the practice.

The son would be at least 30 years old. I could remember him as a 10-year-old running around in his mum's surgery when I was doing locum some two decades ago. Now he is a young father and have to bear the responsibilities of taking over the practice.

On this fine evening, I was shocked to see that he had both sides of his head shaved bald, leaving a central high turf of hair bleached brown. I could never imagine he would be this fashionable when he was half my height during his childhood days.

The son said: "I don't see many cases. There is one 10-year-old Alsatian in the Army having this anal problem. The Army would not send it for treatment and I donated some of my cream for the dog."

"Is the dog suffering from anal fistulas? Or circum-anal tumours? Why don't you get him treated?" I asked.

"The Army takes a long time to decide on treatment," the son said. "There are many considerations before a sick dog can be sent to the vet for treatment. The Army sends their dogs to two veterinary practices if necessary."

"Why don't you ask the Army to send the old dog to me for surgery?" I asked him. "I will charge $100 for everything to be done." The son who was doing reservist duties in the Singapore Armed Forces Provost Unit's Dog Company. I was a veterinarian in charge of the health of guard dogs and tracker dogs in this Dog Company when I was doing my National Service in the early 1970s and am concerned about the health of this old guard dog.

"It is not so easy to send a sick dog to the vet for treatment," the son said. "The Army has to be careful of expenditure and has to justify."

This is a sad state of affairs as Singapore is a developed country and a retired guard dog's painful backside does not get treatment.

One can be idealistic but in reality, any complaint from me to the Commanding Officer would likely lead to euthanasia of the old dog. For $100, a retired dog's life is terminated by the bureaucracy. But which is worse? Suffering from a painful backside daily but being alive or death by lethal injection? Has the dog any choices? Is there public funding for such cases for retired army dogs?  There must be a fund to treat retired military dogs. In the meantime, I have to store away my idealism by keeping quiet. Rocking the boat will mean death of this dog as I doubt that the Army would even organise transport to get the dog treated for free.

At the surgery, I borrowed the son's new thick cat medicine book "Problem-based Feline Medicine" by Jacquie Rand, Edition 2007. I wanted to read more about a condition in cat where the mucous membranes of the cat's fauces are swollen and edematous. This surgery had many stray cat cases and this was why I came to ask the founder and her son about one case I encountered recently. It was an immune disease as prednisolone reduced the swelling by 50% the next day.

The name of the condition is plasmacytic-lymphocytic stomatitis/faucitis. My case was severe faucitis as the cat did not have inflammation of the tongue or gums. What a name for vet students or even vets to remember.

"Where's Dr Sing?" the receptionist said in a loud voice. I was sitting on the sole chair at the waiting area to her left but she could not see me. She had phoned a young couple to come to the surgery me after asking me how much I charged for surgery to excise the circum-anal tumours.

The couple had been to another vet since this surgery did not provide this service. The fees quoted was over a $1,000 and the couple must have sought the advice of the receptionist who asked me about my fees since I was present.

"Didn't you talk to the vet about the cost of over $1,000 perianal surgery?" I asked the couple.

"No," the young-looking wife whom I estimated to be in her 30s said. "A driver sent our dog to the vet." She looked young as contrasted to her husband who has many silvery grey hairs.

"Veterinary costs are now higher as many younger vets are more careful about litigation and demand blood testing prior to surgery." I said. "My generation appears backwards as we would have simply operated. However, nowadays, in a litigious society, there is no strong defence against professional negligence if the dog dies under anaesthesia if blood tests have not been done."

I asked the wife about the size of the tumour and to illustrate on a piece of paper. It was around 2-cm in diameter and was located below the tail and above the anus. This is a very difficult area to do surgery as there will be insufficient skin to stitch up. No wonder the founder did not want to perform this challenging task.

The continuous dripping of blood from the backside of their old Husky had caused the couple much distress. "Did you talk to the vet about the breakdown costs of over $1,000 for the surgery?" I asked the couple.
"No blood test will be done for the fee quoted by Dr Sing," the receptionist interjected. "I will not send the excised tumour for histopathology to check whether it is cancerous," I said to the couple. "That would bring down a few hundred dollars of veterinary costs."
"Blood test is important to screen the health of the dog before surgery. If the dog dies under anaesthesia, the owner may complain that the blood tests ought to have been done so that they would know the risks involved before surgery. The owner may sue the vet." I explained to the couple.
Blood tests would be useful as they can tell the vet that the dog is having a serious bacterial or viral infection or a liver or kidney disorder. Treatment would be done first if the health screening showed abnormality. A complete blood test would normally cost around $200.

"Is the Husky neutered?" I asked. "She has been spayed," the wife said. I had been presumptuous. This was a female dog. Perianal tumours are rare in females dogs but this was one of them. The world of veterinary medicine and surgery is full of surprises everyday.

"Get your dog's infected backside treated at this surgery first," I advised grooming, clipping of the backside and Baytril antibiotics for 6 days. "Otherwise the wounds will not heal well." The receptionist took out the case card and recorded what needed to be done. She calculated the cost and gave a fee estimate. This was the most efficient veterinary receptionist I had met and was definitely an asset to the founder of this practice. Knowing what to do and not wasting time is rare in many young receptionists. This receptionist was able to create loyalty in the founder's clientele from the way she cared about this customer by solving their problem. She must have overheard my conversation about perianal tumours with the founder's son as the door of the consultation room was open to the reception and knew what to do.
Sometimes the chemistry between a new vet and the prospective clientele is good and this was the case after several minutes of discussion and preparation for the surgery. This is important. The wife offered to shake my hands with me before she left.

There was a young girl in pink overalls working in this surgery. Her pink apron was unusual as I seldom see veterinary receptionist in pink. A slim quiet girl who would be learning from this receptionist on how to do things. I was introduced to her after her Miniature Schnauzer's bladder stone were removed by the son at my surgery (Toa Payoh Vets) some three years ago.

The son had operated on the dog. This was his first urinary stone removal surgery and his mum had asked me for assistance. So I was his mentor. See:
Mentoring a younger vet

Now three years later, the Schnauzer is OK and has no bladder stones although he has been eating dry dog food. "Are you feeding dry dog food to your dog?" I asked the girl in pink in a serious voice. She nodded: "Dr ... said it was OK." I was surprised that this Miniature Schnauzer did not get a recurrence of urinary stones despite being fed dry dog food after surgery and for the past three years.

"It is best not to as the bladder stones may recur unless the dry food is meant for dogs with urinary stones," I said to the young graduate.

There seems to be a high staff retention rate in this surgery. "Girls who left to work in banks would come back during Saturdays to work," the receptionist announced to me with maternal pride and to say that the founder was very caring about her staff.

I was most impressed with the management of the founder. It is hard to retain staff nowadays as many Singaporeans have lots of choices and are picky.

Good service helps to retain and grow clientele too. I was most impressed with this receptionist as she knows what to do to solve a client's problem on behalf of her employer without the need of prompting and reminders. She is worth her weight in gold. Gold prices are high and she is worth at least 80 kg worth of gold.


Photos and updates at:
http://www.sinpets.com/dogs/20100533perianal_circum_anal_tumours_dogs_ToaPayohVets.htm
 

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