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      Date:   12 September, 2011  
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Buying Time For An Old Companion - Circum-anal tumours - Part 1
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 09 June, 2009
Upd
ate:  12 September, 2011
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First Consultation in June 2009

3 years ago, the first veterinarian consulted said, "Don't operate. This dog would die before the tumour grows to a large size as he is an old dog." The man in his 50s went home.

A year later, he consulted another veterinarian in another practice as the tumour had grown bigger in size. The second veterinarian said, "Don't operate. The dog is old and may die under general anaesthesia."

6 months ago, the tumours to the left of the anus grew enormously to become the half the size of a tennis ball. The dog licked the tumours. The bacteria multiplied in the open sores of the tumour. The smell of stinking flesh and oozing blood overwhelmed the air inside the apartment. Unbearable smell of rotting flesh. Blood drops stained the floor as the old companion rubbed his backside vigorously and frequently on the floor to relieve his pain and itchiness.  The man decided that it was time to put the 11-year-old male Shih Tzu to sleep. Euthanasia by lethal injection.

"No," his grown up children objected strenuously. "Why should the old dog die just because he had a large tumour?"

The son-in-law was working opposite my Surgery. So that was how I got to see this case in June 2009.

"The dog is very thin," I had a premonition that this dog was going to die during anaesthesia . "He should be in good condition at his age. Therefore, he may not be able to take the long general anaesthesia and will die on the operating table."

"He used to be chubby. My children just would not permit me to get the vet to euthanase him," the man in his 50s said.

High risk anaesthesia cases usually die on the operating table. I could understand that the first two veterinarians were not keen to operate on the old dog. At that time, the perianal (circum-anal) tumours were much smaller.

News about deaths on the operating table spread like wild fire and kill the hard-earned reputations faster than lethal injections. It is up to the owner to seek a veterinarian who will operate. But inertia in this old companion led to the explosive growth of the perianal (circum-anal) tumours.

"I will try to fatten the dog for 3 days before I operate," I said to the man. "Your Shih Tzu has high fever. The cause would be bacterial infections from this large tumour."

"OK," the man accepted the risks and the poor surgical outcome. I had a bad feeling about this case. At 11 years of age and in a poor body condition, being very thin. My premonition was telling me to reject this case. All vets will get deaths on the operating table at one time or another. But this case had a high probability of death and ought to be rejected to save a hard-earned veterinary reputation that could be bad-mouthed by the owner whenever a dog dies on the operating table.

I put the dog was put on an IV drip and antibiotics for the first 24 hours. He ate little. His fever went down 36 hours later. He licked his tumour hoping it would disappear by continual licking.

He was likely to have a perianal (circum-anal) adenocarcinomas. Fast growing. Usually present in a non-neutered male dog. 

Anaesthesia
On day 3, I started the surgery with a negative mental attitude and a heavy heart for this old companion who had endured so much pain and rejections by two veterinarians who did not want to risk their reputations operating on him.

I injected 0.2 ml of Zoletil 50 IM. The dog started to look skywards as his wry neck forced him to turn his head at 90 degrees to his body. Torticollis like chickens suffering from the viral Newcastle Disease is an effect of Zoletil injection.

The reason I used Zoletil was that xylazine caused vomiting and hypotension. This dog was very old and in poor condition. Therefore I placed my bets on Zoletil being safer for this old companion.

The dog's neck twisted sideways and was tetanic. So the gas mask to knock him down with 5% isoflurane gas could not be placed properly and comfortably into this nose. Even if he was anaesthesized, it would be extremely difficult to lift up his head upright and intubate. What's the solution?

This is why a knowledge of veterinary pharmacology comes in. Zoletil has this side effect on dogs and I seldom use it for sedation. Zoletil also cause great excitement in cats when given alone. The cats dash here and there inside the crate. I saw one rabbit behaving similarly.

The reason I used Zoletil was that it would be a safer drug for this aged dog.
His neck remained twisted to the side. What to do now? His tongue had gone maroon red. Dark red.

The solution was to give him atropine 0.5 ml IM. Will it work? After 2 minutes, the dog's neck muscles relaxed and I could mask him properly. He had no profuse salivation unlike one case I did earlier. 99% of the time, I use xylazine as I had been using it for more than 20 years. Zoletil is
not a new drug and is very good for topping up as an injectable anaesthetic in dogs where there is no general anaesthestic gas facilities.

But now we are talking about sedation. The dog had this side effect of "Torticollis" if you don't give atropine 5 minutes before Zoletil or at the same time.

In this case, the atropine injection given later put the dog back to normal. So, I started intubation when the dog fell asleep under isoflurane gas delivered in the gas mask.

Everything should be routine, I thought. My premonition was not justified. 

Just as I had inserted the endotracheal tube, a large amount of bubbles and fluid flowed out of the endotracheal tube. As if the lungs had lots of water. This was unexpected and never encountered in xylazine sedation and induction in my past twenty years. Vomitus from the stomach sometimes happened during xylazine sedation on the operating table. But clear bubbly water from the lungs started shooting out fast and furiously. That was dangerous.

I pulled out the endotracheal tube promptly. My assistant, Mr Saw quickly lifted the dog by the back legs with the dog's head downwards. He slapped the chest to get all the lung water out of the lungs. Mr Saw was very prompt and experienced.

Now, what should I do? My bad feeling about this case had returned. It was no wonder that the other two veterinarians did not want to touch this case. Should I abort the surgery now?

Abortion meant death for this dog as the perianal (circum-anal) tumours were badly infected and had many big holes due to continual licking and traumatic damage from the floor. The dog needed help. This was his last opportunity to live as the pressure from the man in his 50s to euthanase him would increase.

Gas mask anaesthesia
I put a big breed gas mask to fit the head of this Shih Tzu. The mask had a see-through wall and I could see the colour of the tongue. The Shih Tzu breathed heavily. Soon he felt asleep. His tongue colour was now reddish.

The surgery commenced. Nothing eventful. The tongue colour started to fade. From red to bluish and then half blue and half white. I monitored the anaesthesia very carefully as gas mask anaesthesia was not as efficient as intubation.

The surgery needed to be completed faster. 30 minutes had passed. The tongue started to whiten. Any more anaesthetic gas would stop the heart beating. The dog's heart would. A cardiac emergency. What to do now? There was no endotracheal tube now to give emergency oxygen as the tube had been filled with pulmonary fluid earlier and I had taken it out.

What was the reason for the tongue to turn white in colour?

I pressed the chest hard with my palms to stimulate the heart to pump. An external cardiac resuscitation using hand pressure. To get the heart to beat so that blood could circulate. The breathing had slowed considerably.

This was the twilight zone. Between life and death. Should anaesthesia be given at all? If not, the dog might feel the pain and struggled during the final stages of tumour removal. If yes, the dog's heart might fail. A dead dog on the operating table was not welcome by the owner. What decision should I make?

What would you do? You had a few seconds to decide.

I took away the gas mask and the assistant continued cardiac massage. The dog was in deep comatose sleep. His pupils had dilated 70% wide. At death's door. He did not now experience pain. He was going to die.

For the next 5 minutes and it seemed it was an eternity, the large skin defect after removal of the gigantic tumour was stitched. As fast as possible.

"Abort the surgery," I said to my team. "The 5 smaller satellite tumours around his anus would not be removed today. It is better to have a live dog rather than a dead one."

Post-operation

The dog was conscious. So it was good news. The inside of the cheek was snow white. The tongue and gums had pale tinges of pink. Very light pink. The dog was awake.

I gave an I/V drip now. Hartman's Solution I/V drip was not given during surgery as the dog had an I/V drip for 24 hours prior to surgery.

I injected one vial of Lasix into the IV drip. Baytril antibiotics were also given into this I/V drip. The inside of the cheek was still snow white. Why? The dog was alive and conscious. 50 ml of the glucose was also given.

The dog was put in the crate. He barked and barked at me. Glucose had revived him. I was surprised at his vigorous barking. This old dog was at death's door and now he was so busy and noisy. As if he was communicating to me. To say that he was very much alive. That he beat the odds. Never harbour negative mental thoughts. 

Going home
After 7 days of nursing, I sent the dog home. His stitches had held up for 2 days only. His 5 tumours appeared to have shrunk 20%.

I would not like to operate on him again. Yet, if he could be neutered, it might be possible that the 5 perianal (circum-anal) tumours might not grow fast.

"You are buying time for this dog," I said to the good son-in-law who discovered my surgery by proximity to his office. How much time? It is hard to say. If only the dog had been operated on when the perianal (circum-anal) tumours were small. In this case, two vets did not want to operate on him and the owners did not seek out a vet who would perform the surgery. I advised neutering some 2 weeks later. The owner did not return.

Advices to owners
Singapore flowers, Toa Payoh VetsOwners will need to be proactive and take tumours seriously in their beloved old companion dogs. This dog was much younger at that time and the tumour could be easily removed. Neutering is highly recommended as this tumour is said to depend on the male hormone testosterone to thrive and grow. Neutered male dogs seldom suffer from perianal tumours in old age.

Some vets don't like to tarnish their reputation with surgeries on old dogs. Some vets do not want to do surgery as it is very difficult to close the big wound after excision of the tumour.

It is up to the owners to do their homework and find a veterinarian who will operate on small circum-anal tumours. In this case, there was a second opinion which was similar to the first - "Don't operate. The dog would die before the tumour would grow bigger." Unfortunately for the two good-intentioned vets, the tumours outlived the dog in the sense that the dog was still alive as the tumours grew by leaps and bounds, like a tsunami wave, causing daily bleeding soiling the apartment.  

In conclusion, owners had to be proactive as regards their personal health as well as that of their dog. Large tumours cost over $1,000 in veterinary fees as they require lots of time and medication. Always get small tumours (less than 1 cm in diameter) operated by our vet early. If your vet is not so keen on the surgical excision of circum-anal tumours, seek other vets. You will save a lot of money if you just be proactive.
 

Update in February & June 2010

circum-anal, perianal tumours male intact shih tzu old dog, toa payoh vets singapore Buying Time For An Old Companion - Circum-anal tumours - Part 1
Circum-anal tumours - Feb & Jun 2010 - Part 2

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