By Dr. Jonathan Mitelman and Barbara Kelly
Continued from part 18
When we last left Billy he had just had surgery to remove the lipomas under his front armpits.
Barbara: We are entering into a particularly difficult and even painful time for me to talk about.
Perhaps it is because the events have happened so recently, only a few short months ago. Or is it due to how Billy himself has struggled through this time, showing pain and more obvious discomfort than ever before.
He has remained the loving and devoted companion, but his high spirited presence dwindled, and appeared absent at times. I wasn't sure we would ever see that happy, forever tail wagging dog again.
Had this long and frustrating journey taken such a big toll on Billy?
We couldn't give up now, of that Dr. Mitelman and I were certain.
Dr. Mitelman: The excision of the now known as "benign" lipomas had been rather straightforward. However, what followed certainly was not.
The constant movement and friction associated with walking (with dachshunds, read rapid leg movement) meant no adherence of skin to structures below. Tacking down skin to muscle would invariably tear, so careful effort to minimize size and disrupt as little tissue beneath as possible was performed.
Despite this, a potential space was present where each lump used to be.
This resulted in fluid seeping into the space, creating a small pocket called a seroma.
Over a short couple of days, the swellings in each armpit enlarged. This was not the desired outcome.
Other causes leading to fluid accumulation in surgical pockets include leaking blood vessels, infection, suture reaction, residual unhealthy tissue, to name a few.
Barbara: Coming to the realization that we should "expect the unexpected" with Billy did not make this situation any easier to deal with. We had the relief of the original growths being deemed as benign on one hand, and now the fear that something else was going on in those areas on the other.
On a low-to-the ground, smooth haired guy such as Billy, those pockets of fluid build up looked very large, hanging dangerously close to rubbing on the pavement.
Dr. Mitelman: The fluid was distending the originally small surgical sites into larger ones. The greater the surface area of the internal wound, the longer the healing time.
It was deemed necessary to remove fluid to hasten healing, essentially shrinking the size of the beach ball so the inside surfaces would adhere. If nothing is done in these cases, the rate of healing is often slower, and the chance of incurring large amounts of scar tissue beneath the skin's surface is considerable.
We aseptically inserted a needle attached to a syringe directly into the fluid bulge and withdrew all of the fluid. The risks are minimal if done safely and sterile protocol is followed.
There is risk of introducing bacterial contamination into the wound site, so cases must be evaluated individually.
Barbara: This was the start of a period where second guessing my decisions often got the better of me. I was questioning my decision to remove the lumps, given what we were dealing with post-surgery.
For just over a week, we were at the clinic every second day to drain the seromas.
When I voiced my reservations to Dr. Samson, he assured me that the seromas would resolve eventually with the accumulated fluids lessening and being resorbed.
The lump removal was still the best decision for Billy's overall health and we would get through this together.
Dr. Samson was right. As suddenly as it appeared, the fluid build up finally stopped. Giving way to other issues.
Dr. Mitelman: During this time Billy had been battling a bacterial infection revealed through urine tests and cultures.
The results showed Enterococcus sp. that was resistant to many antibiotics.
Which one should we choose?
Those that he had in the past without ill effect were deemed ineffective by culture results, so we had to venture carefully (read anxiously) into uncharted territory.
The dog's reactions to a whole host of oral medications limited the array of available antibiotics to few deemed safe, or in Billy's parlance, some that haven't been tried on him before.
One in particular, a fluoroquinolone class of antibiotic, seemed a logical choice, only Billy's gut reacted adversely with lots of gurgling, diarrhea and inconsolable pacing.
But in a stroke of genius, this particular brand is available in injectible form. Billy tolerated a variety of other injections without ill effect (except for the allergy serum), so why not?
Barbara: Despite being administered correctly, Billy didn't react well to the injections. He cried and he hurt.
Those dreaded words, "We have never seen this happen before" were again spoken.
And to this day are echoed in my mind.
Perhaps one time was unlucky, should we try it again? We did try again, twice. And regretted it.
The area where the injection was given on Billy's left side was so painful to him that when I brushed against it he snapped at the air beside my hand. A warning to me of how badly that area must hurt as that reaction was not typical of the usually passive Billy.
At that point, I realized there would be no more of these injections given.
He absolutely needed an antibiotic, one that would take care of the worrisome urinary tract infection. But we would have to find another solution.
Dr. Mitelman: If we could turn back the clock we would.
Billy would frequently twitch and stare at his flanks where the small volume of injectible antibiotic had been administered. His level of agitation and unease grew.
Tramadol and gabapentin took some of the edge off, but his gut reacted adversely to other anti-inflammatory medications. As sore as a dry throat without a lozenge. Pity didn't perform well as a remedy either.
Three weeks following these injections, Barbara started to notice small, firm, log shaped bulges beneath the skin of Billy's flanks.
Barbara: On a smooth coated dog such as Billy, a lump beneath the skin is obvious to the eye. First one, then two, then a third.
My reaction can be summed up in one word, "panic".
Heart pounding, probably to outsiders I was bordering on hysteria at times. Something was very wrong. These lumps appeared quickly and seemed to be growing with fury.
Dr. Mitelman: What were they? They enlarged up to 1/2 inch (1.2 cm) wide and two inches (5 cm) long and appeared to coincide with the injection sites administered three weeks earlier.
That's strange. I have never had this happen before with this particular antibiotic. Given the temporal relationship to the injection, it was assumed the tissue had reacted to the antibiotic itself.
What concerned us most was the firmness.
Was there more than just inflammation, could tumor development have been induced?
I was worried about Billy developing a
fibrosarcoma, a rapidly growing and destructive tumor.
Each of the three sites was inspected with ultrasound and sampled by fine needle aspirate. All three sites revealed either normal or reactive fat, but one site showed reactive fibrocytes (cells that make scar tissue) with possible atypia.
The last word was frightening.
Though it is common to find fibrocytes in previously insulting and currently healing tissue, the line between normally functioning fibrocytes and cancerous fibrocytes can be blurred.
I wanted those masses out. Post haste.
Barbara: At that point, my venture into "second guessing" my decisions was put on hold. Billy was going into surgery, again.
There would be plenty of time for that second guessing to resume later.
***
The Kingston Road Animal Hospital, and its founder Dr. Morris Samson, are celebrating the clinic's 25th anniversary this year. VETSToronto, the veterinary emergency trauma service, is housed in this location in the Beach area of Toronto.
The hospital is a full service emergency/after hours/critical care facility that provides around the clock care. There is a doctor on site 24/7/365. Owners Dr. Samson and Dr. Mitelman oversee all cases, providing continuity of care.
Referrals from other hospitals are examined, stabilized and treated, then returned to their regular clinic. Follow ups are done with both the referring veterinarians and the pet's owners.
As a full service hospital we have the following:
- on site ultrasound
- on site endoscopy
- laser and orthopedic surgery
- emergency/critical care specialists, internal medicine specialists, and surgeons on call
A full listing of diagnostics and additional services is available on our website, www.vetstoronto.com
www.vetstoronto.com
www.vetstoronto.com/blog
www.facebook.com/vetstoronto
Twitter. @vetstoronto & @iambillysmom
Ask Dr. Mitelman vetsdrjm@gmail.com
Further reading:
Shedding light on laser surgery
Related articles:
When A Small Sore Turns Into A Catastrophe: Billy's Story (Part I)
Life-threatening Infection Resolves; All Is Good? Billy's Story (Part II)
What Is Going On With Billy's Skin? Billy's Story (Part III)
The Plot Thickens: Billy's Story (Part IV)
I've Never Seen That Before: Billy's Story (Part V)
Billy's Diagnosis Still Unknown: Billy's Story (Part VI)
Neuronal Ceroid Lipofuscinosis (NCL)? Billy's Story (Part VII)
Time To Make A New Plan: Billy's Story (Part VIII)
Atopic Dermatitis? Billy's Story (Part IX)
It Is Not Neuronal Ceroid Lipofuscinosis But What Is It Then? Billy's Story (Part X)
My Dog Has A Gut Of Steel, Doesn't He? Billy's Story (Part XI)
Feeling As Though Running Out Of Options: Billy's Story (Part XII)
Fighting Fire With Fire Backfires: Billy's Story (Part XIII)
A Second Endoscopy: Billy's Story (Part (XIV)
Staying The Course: Billy's Story (Part XV)
Fewer And Fewer Solutions Left: Billy's Story (Part XVI)
When The Only Consistent Feature Is Inconsistency: Billy's Story (Part XVII)
What Is Behind The Fast-Growing Lipoma? Billy's Story (Part XVIII)
