Dr. Phil Zeltzman’s Blog

Jake, an 11 year old Golden, had a long list of issues…

• A mass in his left anal sac, which was likely cancerous.
• A right-sided perineal hernia, because he was not neutered.
• An enlarged prostate, because he was not neutered.

He needed 4 separate surgeries to solve these issues:

• Removal of the anal sac mass.
• Repair of the perineal hernia.
• Abdominal surgery to deal with the prostate.
• A neuter.

That’s a lot for one older dog, and a long anesthesia.

That begged a critical question: was it safer to do everything under one anesthesia (and take a risk) or separate different surgeries under 2 separate anesthesia episodes (and take a risk)?

In other words, one very long anesthesia (possibly 2-3 hours) could be risky in an older dog. He could have a much longer recovery. Now, I’d be the first one to tell you that anesthesia is incredibly safe these days, but it makes sense that a longer anesthesia is riskier than a short anesthesia.

So the next question was: would 2 shorter anesthesia episodes, a few weeks apart, be safer?

And if we decided to separate the surgeries in 2 sessions, what should we do first and second?

I agonized over what to do.

I consulted with surgeon colleagues to brainstorm about the wisest approach.

It was a huge ethical & medical dilemma.

In the end, I decided not to gamble and perform 2 separate surgeries.

I had a long heart-to-heart with Jake’s owner. She understood the reasoning and was ready to get started.

Anesthesia 1:

We decided to perform everything on the “back end” during the first anesthesia.

• Right perineal hernia repair: a perineal hernia is a bizarre condition, most commonly found in non-castrated male dogs. The muscles that keep organs inside the belly become weaker. This can allow organs to slip through the pelvis and end up under the skin, on either side (or both) or the anus.

Below is a picture of the back end of another dog, Tommy, with a huge bulge on the right side of the anus. It contained the prostate & the bladder.

In other patients, the hernia can even contain intestines.

You can see Jake’s hernia in the X-ray below. The bulge in his back end is the hernia. In Jake’s case, it contained fat and a lot of fluid.

• Left anal sac mass: then we dealt with the tumor. It was tiny (2 mm, or less of a tenth of an inch), but most of the time, such masses are cancerous and aggressive. This was one of the reasons to perform the “back end” surgeries first: to get rid of presumed cancer ASAP. Sure enough, the biopsy came back as the classic cancer in an anal sac (adenocarcinoma). It was small enough that we got it all.

Jake has his family vet to thank for that. Not only did she find the tiny mass by doing a thorough exam (including a rectal exam), but she recommended surgery rather than procrastinating.

• Neuter: Then Jake was neutered. I also recommended removing his scrotum (the “sac”), for shall we say… cosmetic reasons…

Jake did great through anesthesia, and went home to recover over the following month.

Anesthesia 2:

One month later, Jake was back to normal and we performed the belly surgery to deal with the very large prostate found on ultrasound.

The prostate cannot be removed safely. We drained it by using a natural “drain” that lives in the belly, called the omentum. This thin membrane that floats in the belly is very rich in lymphatic vessels, and can drain pus and fluid from the prostate. This is called “omentalization.”

We also took biopsies of the prostate. The biopsy revealed that Jake’s condition was “benign prostatic hyperplasia,” along with multiple cysts. It can cause difficulty peeing, which is also the classic condition in older gentlemen…

In dogs, castration is the treatment of choice. The lack of testosterone causes the prostate to shrink over a few weeks.

This time again, Jake did great through anesthesia, and went home to recover over the following month.

Over 7 months after his first surgery, Jake is still doing great!

His owner was happy with the sequence of events, and with the end result: a happy, healthy, tail-wagging Golden!

If you would like to learn how we can help your pet with safe surgery and anesthesia, please contact us through www.DrPhilZeltzman.com
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Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Toto, an 8 year male terrier, had difficulty urinating. He was painful and struggled to pee, and not much urine came out despite his efforts.

An exam and X-rays revealed that he had stones in the bladder. The blockage was caused by smaller stones that were formed in the bladder, then were small enough to go down into his urethra. The urethra is the tube that goes from the bladder to the penis. The small stones lined up in the urethra like a string of (deadly) pearls.

Can you spot all stones?

Here is the same X-ray with the bladder (2 ovals at the top) & urethral stones (oval at the bottom) circled.

The easy part was to perform bladder surgery (aka cystotomy) to remove the big stone and a few small ones.

Here is the big bladder stone:

The hard part was to push the tiny, spiky stones from the urethra back into the bladder, from which they can easily be removed.

If that doesn’t happen because the stones are literally stuck in the urethra, then a second surgery needs to be done to create a new, larger opening in the urethra (aka a urethrostomy). This can be done successfully, but we always try to avoid it.

Because I know that my readers and subscribers are sensitive souls, I can’t explain exactly how the stones are moved from the urethra into the bladder. Let’s just say that we use sterile saline under pressure. As a reminder though, the patient is under general anesthesia during surgery!

It was an amazing surgery. Initially, the stones didn’t bulge at all.
We kept pushing more and more sterile saline – nothing.
Then all of a sudden, 3 small stones came out.
After multiple other unsuccessful attempts, another 2 stones came out.
The whole team was watching and cheering as my nurse and I struggled to push these stubborn stones back into the bladder.
So we continued to fight for Toto.

Little by little, stone by stone, we managed to move all of the stones into the bladder.
Toto didn’t need a urethrostomy after all.
Surgery was a success!

Here are the small urethral stones:

Toto was eventually able to go home, where he had to rest very strictly for 3 weeks. He had to wear a plastic cone around his head to prevent him from licking the incision. He recovered smoothly and has been happily urinating ever since surgery. He was switched to a special food to try to prevent the stones from coming back.

A few weeks after surgery, the stone analysis results confirmed the suspicion of “calcium oxalate” stones, i.e. they were made of calcium. So Toto had to eat that special diet exclusively for the rest of his life.

Toto’s surgery was truly challenging. It took a lot of effort, but in the end, the fight was worth it.

I just checked on Toto. Four years after surgery, he’s still peeing like a champion!

If you would like to learn how we can help your pet with safe surgery and anesthesia, please contact us through www.DrPhilZeltzman.com

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Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

“You should be prepared for this puppy to die.”

This is the terrifying advice Novakai’s owner was given.
Novakai, a cute 7 month old Pitbull, did have a big problem in her mouth.
A cleft palate divided the entire roof of her mouth in two halves.
This gap allowed food to go from her mouth into her nose.

PICTURES BELOW ARE GRAPHIC AND ARE NOT FOR THE FAINT OF HEART.

All of the pictures below show the inside of the roof of the mouth, with Novakai on her back.

Puppies with a cleft palate cannot nurse properly, so they don’t grow as much as the rest of the litter. They are typically the “runt.”
Those who survive eventually can have discomfort, a reluctance to eat and drink, difficulty breathing, and ongoing infections. After all, the nose is not supposed to be full of milk or food…
His amazingly dedicated owner wrote: “Novakai was tube-fed until she was about 5 months old. At that time, small amounts of soft kibble were offered. Sadly, most of it would come back out of her nose. So she stayed on a pureed diet until she turned 7 months.”

The only good solution is surgery to reconstruct the hard and the soft palate.
The hard palate is the front portion of the roof of the mouth. It’s hard because there is bone behind it.
The soft palate is the back part of the roof of the mouth. It’s soft because there is no bone behind it.
Suturing one side of the defect to the other does not work. It is doomed to fail. The tissue is just too tight. So one solution is to rob (tissue) from Peter to give to Paul.

PICTURES BELOW ARE GRAPHIC AND ARE NOT FOR THE FAINT OF HEART.

After creating incisions in the hard palate, we created 2 “flaps” or bands of tissue. Then it became easier to stitch one to the other, in the middle of the roof of the mouth.
This left an area on each side where the bone is literally exposed.
Amazingly, those healthy areas progressively heal with new tissue.

Novakai recovered smoothly after anesthesia and surgery, and went home.
She had to stay quiet for one month, without any chew toys or hard food to protect the stitches and the surgery area.
Thankfully, the mouth has an amazing ability to heal. Think of when you bite your tongue or the inside of your cheek. It hurts at first, but then it heals within days.
Novakai needed a bit longer than that, but the end result was rather impressive as you can see below.
One month after surgery, we examined her mouth under sedation to assess the surgery site.

Thankfully, 100% of the surgery area had healed nicely.
Novakai’s owner concludes: “Today she is healthy, happy and very active. The surgery was a great success. She weighs in at a nice 60 lb. We are very pleased with the surgery. We knew the risk was 50-50. My family and I are all very happy that she turned out as well as she did.”

If you would like to learn how we can help your pet with safe surgery and anesthesia, please contact us through www.DrPhilZeltzman.com 

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

www.DrPhilZeltzman.com

Eve’s story is a bit unusual because her owner is the one who figured out her diagnosis!!!

Dr. Google led her to one of my blogs about laryngeal paralysis (or “lar par”).

Her recently adopted dog Eve, a 10 year old Lab, “definitely checked all the boxes.”

Eve’s owner remembers: “She has always had the “old lady bark.” As the warmer weather approached, she was panting a lot more. Her activity tolerance plummeted. She’d walk 2-5 miles when we first adopted her. But now she couldn’t even do 0.5 mile in the warmer temperatures.”

Her condition was really serious. “She was struggling when breathing, even just to go outside to potty. It was so hot and humid. Any little physical activity had her panting. Right before surgery, she came in stridorous and truly struggling. Her tongue was purplish. It really scared me.”

After doing her research, she “knew that it was a degenerative condition, and Eve would eventually suffocate to death.”

She continues: “I felt bad for her – a senior dog – going through surgery, but I was hopeful that she would feel better after recovery.”

Laryngeal paralysis (or “lar par”) is a serious and stressful condition where the larynx (or voice box) doesn’t allow enough oxygen to flow into the lungs.

It mostly occurs in older and senior dogs, most commonly Labs over 10 years of age. It can also happen in young dogs, and other breeds.

We scheduled Eve for an exam under light sedation, followed by surgery if the diagnosis were confirmed.

Sure enough, the exam confirmed lar par.

The goal of surgery (a “tie back” procedure) is to open up the larynx with two permanent nylon sutures.

Anesthesia and surgery were uneventful.

When Eve woke up from anesthesia, her breathing was slow and quiet.

She went home on the same day.

Here is a step-by-step summary of her progress, as told by her owner.

As you read those, please remember that every patient is different, and the improvement in breathing may vary from patient to patient.

• 2 weeks postop: “Eve had her staples removed today and did very well in the car. Appetite is great. She clears her throat upon getting up from sleeping, and after taking a drink of water. She’s tolerating being outside on the deck in the evenings, when it’s cooler (she used to want to go back inside).”
• 3 weeks postop: “Eve is doing very well. She clears her throat at the usual times. She is more alert and silly since stopping the pain medication. It’s going to be an interesting 5 weeks keeping her calm!!!”
• 4 weeks postop: “Eve is doing AMAZING!”
• 6 weeks postop: “Eve is acting like a puppy! So good to see.”
• 8 weeks postop: “WE MADE IT!! Eve is doing awesome! She’s like a puppy. Happy, alert and wanting to play.

After 2 months of rest and TLC, Eve could resume her Labrador life…

For once, I didn’t take a video before and after surgery.

You can watch this short video as it is very similar to Eve’s experience:

www.youtube.com/watch?v=fy7dWlAVqnM

What’s the moral of the story?

Lar par is a very stressful condition, both for the dog and the owner. Surgery is the best option to open up the airway and allow more oxygen to get to the lungs. Thankfully, in the vast majority of patients, results are good and patients can resume a pretty normal life.

Eve’s owner JP concludes: “Overall, our experience was phenomenal. Your instructions, genuine concern and willingness to be available with our worries was so great. Your nurse was also amazing. It was very comforting to know that you were only a call away.”

Here is a short video of the amazing Eve at the end of a 10 minute walk, 2 months after surgery.

If you would like to learn how we can help your pet with safe surgery and anesthesia, contact us through www.DrPhilZeltzman.com

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified
www.DrPhilZeltzman.com

Wiggles, a 12 year old Terrier, recently had surgery at a colleague’s practice.

Her problem?

She had mammary (breast) tumors.

Before that, my colleague (wisely) recommended to take chest X-rays to make sure that if it were cancer, nothing had spread to the lungs.

This is considered standard of care, meaning this is the right thing to do in modern practice.

For whatever reason – financial, lack of trust, poor understanding, miscommunication – I am not here to judge – the owner declined the X-rays.

So Wiggles had surgery to remove the tumors.

Everything went well. She recovered smoothly and went home.

I came to that hospital a couple of days after that do perform surgery on a totally different patient.

As I walked through the kennel, I was rather surprised to hear a dog actively struggling to breathe, and clearly suffering.

Of course, having a really hard time seeing a pet struggle, I inquired about her, and this is how I learned the whole story I shared above.

While I was performing surgery, the nurses did the only reasonable thing to do: they took chest X-rays on Wiggles.

Here is one of them below.

Do you see anything abnormal?

Here is the X-ray again, this time with red lines around the areas of interest.

Well, I am sad to say that each mass or nodule or tumor inside a red circle is a sign of metastasis (or spreading) of breast cancer to the lungs.

No need to wait for the biopsy to come back.

Wiggles had cancer.

Terminal cancer.

The suspicion is that she was OK before surgery, and anesthesia and surgery pushed her body “over the edge.” We call this phenomenon “decompensation.”

After a probably unpleasant discussion about the new findings and the dire situation with her family vet, the owner elected humane euthanasia.

I tend to only write about happy stories and optimistic outcomes in this blog. I feel that there is enough misery in the world. I don’t need to add more sadness, drama and negativity.

So why did I choose to write about the sad story of Wiggles?

Because she and her family went through a lot, medically, financially and emotionally, and it all could have been avoided.

I don’t say this to make her owners feel bad – I feel terrible for them.

I decided to share this story with the hope that at least, it doesn’t happen to one of my clients or readers.

Now, of course, the other cautionary tale is that ALL of this could have all been prevented by spaying this poor pup before her 1st heat.

I realize this is controversial for some, so please hold the hate mail.

Don’t believe the ridiculous things you hear and read.

The ONLY way to prevent mammary tumors is to spay a female – dog or cat – before their 1st heat.

Unlike what you will read elsewhere, this is not based on dogma, or brainwashing, or made-up facts, but based on science – the only thing I believe in.

And keep in mind that this is coming from a vet who hardly ever spays a dog. I’m a surgeon, so I tend to do the fancier surgeries.

I truly don’t have a bone in this fight.

My hope is to help prevent other pets and their families from going through the horror of breast cancer.

Here are some undeniable scientific facts:
. Over 25% of non-spayed female dogs will develop breast or mammary tumors!
. The risk of a dog having mammary tumors is 0.05% if a female is spayed before the first heat.
. The risk goes up to 8% after their first cycle.
. Then it shoots up to 26% after their second heat.
. If a dog is spayed after 2 years of age, then there is no more protection against breast tumors.
. However, it will protect her against other conditions, including pyometra (an infected uterus – a deadly condition). This is the reason why most vets typically recommend spaying before the 1st heat cycle.
. In dogs, approximately 50% of mammary tumors are benign and 50% are cancerous
. In cats, 90% of mammary tumors are cancerous, so spaying is even more important!

I hope one pet lover learn from this sad story.

Even if only one pet is spared, then this blog will be more than worth it.

If you would like to learn more about how your pet can have safe surgery and anesthesia, contact us through www.DrPhilZeltzman.com

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified
www.DrPhilZeltzman.com