Casos Dificiles qu Necesitan Soluciones Ingeniosas
Sometimes we face cases that require not only our medical knowledge about anatomy and physiology, but also our creativity. I will describe some of these cases with the hope that this information might be helpful to save other patients.
Jumbo
An 11-year-old male Labrador was presented at the clinic after having been treated twice in a 15 days period for gastric dilatation without volvulus that were managed by orogastric intubation that successfully solved the problem; gastropexy was not performed. A complete blood count, renal and hepatic profile and an abdominal ultrasound were performed; the only abnormal finding at presentation was a mild gastric inflammation on the ultrasound. Omeprazole 20 mg/24 h and domperidone, as well as small feeding the dog 4 times-a-day were prescribed at that time.
Eight days later, the dog was presented for massive gastric dilatation without volvulus. The patient was intubated in order to protect the airway and an orogastric intubation was performed; immediately, relief was obtained with the extraction of gas, a few food pills and a small amount of water.
The patient was scheduled for an endoscopy in order to find out if there were any anatomic abnormalities that should be surgically treated and for a gastropexy. There were no remarkable endoscopic findings. Abdominal exploration and gastropexy were performed at the same anesthetic procedure, no anatomic abnormalities that could be impeding the stomach outflow were found on the stomach or surrounding organs. Gastropexy was performed by incisional technique.
Forty-eight, eighty-one and ninety-eight days later the dog held other episodes of massive gastric dilatation that required percutaneous gastric centesis as well as induction and orogastric intubation.
Different tests were performed in order to rule out possible underlying causes of impaired gastric motility. Myasthenia gravis was ruled out by acetylcholine receptor Ab-Myasthenia Gravis (905), a complete lipid profile, TSH and T4, glycemia and urine analysis were performed, all of them were within normal values.
Thirty-six days after the last massive gastric dilation, the patient developed three episodes that required induction and orogastric intubation within 21 hours, the idea of a permanent gastric tube to be able to evacuate the gas in the event of dilatation was presented to the owner as an alternative to euthanasia.
A left lateral gastrostomy tube was placed without the aid of an endoscope; a permanent gastropexy was also performed. The patient was put under general anesthesia and the left flank area was prepared for aseptic surgery. A large-bore, plastic tube was orally placed into the stomach. A small skin incision was performed on the dorsal paralumbar fossa a few centimeters caudally from the last rib; the subcutaneous tissues and abdominal muscles were bluntly dissected to expose the stomach wall. The orogastric tube was localized and held stable in order to place 2-0 PDS uninterrupted sutures from the stomach serosal wall to the body wall to firmly pexy the stomach in place to avoid or diminish the chances for peritoneal contamination with stomach contents. An 11-scalpel blade was used to puncture the stomach wall by punching the blade into the lumen of the orogastric tube. The gastric mucosa was suture to the skin to create a permanent gastric fistula. The stoma was only wide enough to pass a 14-French gastric feeding tube (GFT). The GFT was placed into the lumen of the stomach, the bulb was inflated with 15 ml of sterile saline and gentle traction was placed on the GFT to bring it against the stomach wall. The holding GFT device was then sutured to the skin. The dog was sent home 24 hours later on normal oral feeding.
Since the procedure, the patient was normally orally fed 4 times a day. Every time that bloat was perceived by the owner, the cap of the feeding tube was removed and gas was released. Depending on stress circumstances and other not totally comprehended factors, the dog did not require any assistance for days but sometimes required unbloating 3 or 4 times a day.
Skin fold dermatitis developed under the GFT holding device 7–10 days after the surgery, the stitches were removed and the skin was locally treated with an antiseptic. The gastric tube holding device was not sutured into place again, but tape butterfly was created at the middle length of the tube and sutured to the skin.
Jumbo had survived 2.5 years when he died of a recurrent oral melanoma. During that period, the GFT was changed 7 times after the lumen bulb broke. Tube changes were performed with the patient awake after careful lubrication of the tip; the bulb was then filled with water and pulled against the stomach wall.
The only complication he presented was the eventual development of dermatitis folds around the stoma which were treated with local and occasionally systemic antibiotics.
Cáceres
It is a female feline that was less than one month old and weighed 95 g at the time of submission with bilateral fail chest, open pneumothorax and emphysema as a result of trauma bite.
This patient required thoracic surgery to repair its right and left costal wall. The challenge was its size and the need for mechanical ventilation during the surgical procedure.
Since the 2.5-endotracheal tube, which is the smallest, was large for her trachea, it raised the problem about what to use as a substitute. We opted for a 14G IV catheter which almost completely obliterated the tracheal lumen. To adapt it to the inhalation anesthesia circuit or Ambu we can do one of two things. The first is to directly connect the catheter to a 2.5-endotracheal tube adapter and this to the anesthesia circuit. The second option is to connect the catheter to a 2.5–3 cc syringe, take out the plunger adapting in this site a 7–7.5 endotracheal tube adapter.
The next challenge was to avoid alveolar trauma during mechanical ventilation. For this purpose, it is important to perform a high-frequency low-volume technique, avoiding the volu and baro trauma to keep SaO2>95%.
We surgically prepared both hemithoraxes and proceeded to surgical repair. To achieve negative intrathoracic pressure, we usually place a thoracotomy connected to a continuous suction system; we keep them for 24 hours in average. In this patient we placed a chest tube in each hemithorax. We used a trade system in the form of an accordion that is meant to collect fluids from skin wounds.
If those small suction systems are not available we can use a 10- or 20-ml syringe; what we do to transform them into a continuous suction system is to remove the plunger and make a hole with a needle at the junction of the base of the plunger with the syringe body. We secure the syringe to the chest tube, we generate the negative pressure and then we place the needle through the hole that we had previously created so that the plunger cannot go back and a permanent suction is achieved.
This patient was subsequently placed in an oxygen cage and was discharged 36 h later.
Sandokan
It was a 10-year-old mixed-breed dog that was presented 15 days after having a surgical procedure to repair a traumatic rupture of the pelvic urethra. The patient had a urethral catheter, fever and uroperitoneum with an ultrasound image compatible with an abscess at the vesico-urethral junction. During the surgical approach we found that the urethra was not repaired and there was no identifiable urethral tissue from the urinary bladder to the pelvic diaphragm. At this time a permanent suprapubic cystostomy was proposed.
Unfortunately due to the abscess, no urethral sphincter healthy tissue was present. The necrotic tissue was removed and the bladder mucosa and serosa at this site were apposed to close the bladder closure at this end. Then an incision was made in the ventral wall of the bladder and a similar one on the abdominal wall in the left lower quadrant. The bladder serosa was sutured to the abdominal wall and the mucosa was sutured to the skin so as to create a permanent stoma. A 14-G Foley catheter was placed and the balloon was inflated, then it was connected to a urine collection bag.
An internal pocket was built in the dog sweater to hold the collection bag. This patient had a 2-year survival with periods in which the owners preferred not to place the catheter; unfortunately, this caused skin urinary irritation and secondary infection. The catheter was changed numerous times by a simple procedure in which the new lubricated one was introduced through the stoma and the mushroom was filled with fluids. This technique of bypassing urine through the abdominal wall can be used temporarily to derive urine as an emergency procedure until the surgeon who is able to repair the pelvic urethra arrives and as described here, as a permanent long-term solution in a patient that otherwise would have died.