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IN THIS NEWSLETTER:

Perianal Fistulas

IV Disc Disease


About the Veterinary Surgical Referral Center

Information for Professionals

Online Resources

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Newsletter, 1997 Vol. 3, Issue 4

With the Holiday Season upon us, our final newsletter of the year will be brief, as I know everyone has other things on their mind. We are thankful for the continued support you have shown us and we hope to continue to earn your trust and confidence. 

One of the more frustrating referral situations we have encountered, and one in which their may now be a "flicker of hope" for significant improvement, is the dog with perianal fistulas

Traditionally, perianal fistulas have been treated as a surgical disease, with an initial course of broad spectrum antibiotic being utilized to attempt to minimize the superficial infection invariably present. Antibiotic therapy alone has been universally unrewarding, and surgical procedures have variable efficacy depending upon the publication referred to. Surgical treatments range from chemical cautery, electrocautery fulguration of the lesions, cryosurgery, tail amputation, to excision of all diseased tissues combined with a rectal pull-through procedure. Recently, the use of ND:YAG laser ablation of fistulas has been reported. 

Success rates for all of these procedures have been in the range of approximately 80%, as reported in the literature. Depending on the technique used, variable complications can be expected ranging from rectal stricture (cryosurgery), to fecal incontinence (rectal pull-through). Visiting with other surgeons in practice has yielded the same conclusion we have arrived at in our practice: published success rates seem to be higher than what we are achieving clinically. This may be due to the fact that most published cases come from the university setting, where intensive postoperative care is available in the form of cheap student labor, or from the fact that many of these success rates are based upon study groups of relatively low sample size (N = 10-20). 

Recently, the medical treatment of perianal fistulas using cyclosporine has been reported (JAVMA, Vol 211, No. 10; 1249-1253). Improvement was seen after 4 weeks in most cases and 85% of dogs had healed in 16 weeks. The published dose of 5 mg/kg can be reduced by 1/2 in many cases with the same results. Reports from other surgeons have yielded similar promising success rates and hopefully we can now offer an alternative to surgical treatment for this condition. 

Best wishes for the upcoming Holidays 
 
 
 
Newsletter, 1997 Vol. 3, Issue 3

Another Oklahoma Summer is here, and many of you have been, or are planning a well-deserved vacation with family and/or friends. At this time of year, one of the last things of interest is "another piece of information overload" to assimilate and file. For this newsletter, we are going to digress from our previous format to some degree. 

As we all know, keeping current with all of the new applications and developments in veterinary medicine is a full-time job in itself. One of the individual decisions we all must make is where to concentrate our time and efforts in order to maximize our efficiency, and to do justice to our clientele. 

I personally am extremely grateful for the reception our surgical practice has received from you, and it is my sincere hope that you have benefited from our presence. A consequence of practice growth has been that we do not have the time to devote in some areas where we previously felt there was a need for service; specifically in the use of our fiberoptic endoscope. A personal decision I have made is to ask that cases no longer be referred for g.i. endoscopy. I do not feel that we are able to provide the level of excellence in this area that you and your clients deserve. With the availability of specialists in private practice within the state, and at the university, I would encourage you to utilize their expertise in this field. Purchase of an endoscope, attending a short course or two, and exposure to the procedure does not qualify one as an expert in endoscopy. Our surgical practice has grown to the extent that, even though we will continue to maintain our endoscope, it's primary use here will be for retrieval of esophageal and gastric foreign bodies and the occasional biopsy procedure. Endoscopy for internal medicine diagnostics should be referred elsewhere. 

To expedite treatment of patients and to provide more optimum management of referred cases, we would appreciate it if, when possible, a minimum database of bloodwork be submitted with the animal referred for surgery. Patients under five (5) years of age and in good health should have a hematocrit (Hct), BUN and ALT; animals older than five (5), or debilitated patients, should have a complete profile submitted. These can either be sent with the owner or faxed to our office (FAX 918-665-7089). 

Best wishes for the Summer 
 
Newsletter, 1997 Vol. 3, Issue 2

Spring is here, and it's time again to send out our quarterly newsletter. The response to our previous newsletters has been positive, and we hope you continue to enjoy them. Your comments and feedback are appreciated! 

IV DISC DISEASE

Spinal cord problems, in particular thoracolumbar intervertebral disc herniations, continue to be a major part of our practice. Frequently asked is how best to handle the acute herniation which is typically seen in the dachshund and dachshund-type breed of dog. The following are our recommendations for treatment based upon clinical signs: 
 

  • PAIN ONLY - CAGE REST FOR 3 WKS IF POSSIBLE. Cautious use of anti-inflammatory medications. Avoid corticosteroid use.
  • PAIN W/ ATAXIA - HOSPITALIZATION; SINGLE DOSE CORTICOSTEROIDS. CAGE REST FOR 3 WEEKS. If these dogs remain static or are becoming more ataxic over time, we recommend myelography +/- decompressive surgery. If they respond to conservative management, prophylactic fenestration or laser disc ablation can be considered to prevent future recurrence.
  • PARETIC - (DOG IS DOWN BUT RETAINS VOLUNTARY MOTOR MOVEMENT) IV SOLU-MEDROL (15-30 MG/KG OVER 30 MINUTES) MYELOGRAM + DECOMPRESSIVE SURGERY
  • PARALYSIS - SAME AS PARETIC DOG. Paralysis with or without the presence of deep pain sensation is an indication for immediate surgical intervention. Conventional wisdom previously held that dogs which were "down" for longer than 48 hours were not good surgical candidates. Although true that we tend to see better results the sooner we are able to intervene surgically, many surgeons are now stretching the timetable out to one week and still seeing beneficial results from mass removal in the paralyzed patient.
There is now good evidence which points to the fact that many of the dogs with signs of back pain alone have a significant amount of spinal cord compression (JAVMA 1996:209;1275-1279). It is rational in light of these findings to offer myelography and definitive decompressive surgery in these cases as an option to the owner. Although many dogs which are painful only will respond to conservative management, the owner should be cautioned that there is a high rate of recurrence of clinical signs with conservative management. 

SOLU-MEDROLR

Solu-MedrolR (methylprednisolone sodium succinate) seems to be more effective in spinal cord injury when given acutely than Solu-Delta-CortefR (prednisolone sodium succinate). Solu-Medrol can be ordered directly through your local pharmacy, or many mail order supply pharmacies carry this Upjohn product. I have found Amerisource Health Services (800-477-7119) to be a convenient source for ordering Solu-Medrol. 

DEXASONE-SP

Although not as good a choice as either Solu-Medrol or Solu-Delta-Cortef, Dex-SP can be given alternatively in the acute spinal case at high doses. I use from 2.2 to 6.6 mg/kg i.v. as an initial dose. 

HOPEFULLY some of this will be new or useful to you in your management of these cases. As medicine is continually changing and updating with new advances, our recommendations in the future may also change! 
 
 
Newsletter, 1997 Vol. 3, Issue 1

The New Year is upon us and we hope that everyone had a Happy Holiday Season. Many people have expressed a desire to continue to receive our newsletters, which we try and send out quarterly. Usually, we confine issues to a single topic but I thought this newsletter, we might deviate from the usual format and mention several items of potential interest. Some will be old news to you while hopefully some will be new and something that might find a use in your practice. 

On the equipment side of things, Pulse Oximeters are becoming standard in monitoring patients under anesthesia, with several companies marketing products for the veterinary sector. We have been using the Nonin model and have been extremely pleased with it. There are other companies making these and I would urge you to check with your colleagues and see what they are using, and their experiences with different models before purchasing one. 

Another new piece of equipment we are evaluating is the BoneBiter tissue anchor system. This unique system allows you to anchor suture in the medullary cavity securely with a biocompatible, stainless steel tissue anchor. If you are interested in this, the manufacturer of this is Androcles, PO Box 1795, Warsaw, IN 46581. 

We are also evaluating a Cannulated Screw Set made by Synthes. This unique system allows placement of a K-wire, with drilling, tapping and insertion of the screw directly over the wire and will allow more precise fixation of small fragments. 

A new drug on the market which you will be hearing about is RimadylR (carprofen), a non-steroidal anti-inflammatory approved for use in dogs. Colleagues who have been using this drug, getting it out of England prior to FDA approval here, have been extremely pleased with it's use in degenerative joint disease for pain relief as well as for postoperative use. The major benefit over other NSAID's is the lack of g.i. side effects, even with prolonged use (up to 5 years!). See your Pfizer representative about this product. 

We thought it would be interesting to look at our caseload from last year to see what the majority of cases being referred were. It is not surprising that orthopedic and neurological cases predominate. Our breakdown of cases operated upon in the top 4 categories was: 
 

     
    Knees
    Cruciates
    50
    MPL's 
    26
    Thoracolumbar Discs1
    Myelogram & Decompress
    50
    Misc. Orthopedics:
    Fractures
    60
    Hips
    21
    Elbows
    15
    Shoulders
    3
    Soft Tissue:
    77
This is not an all-inclusive list, but is representative of the cases your colleagues are referring. 

In our practice, the majority of neurological cases seen exhibit either severe pain, proprioceptive deficits, or some degree of paralysis. The overwhelming majority of surgeons in the American College of Veterinary Surgeons feel that myelography and decompression of these cases is warranted. Thoracolumbar disc fenestration alone is not indicated, nor an appropriate method of treating those patients. 

Endoscopy and radiographic consultations are availiable. While we are glad to provide radiographic evaluation prior to referral of a case, it has become cost-prohibitive for us to bear the cost of return mail. For that reason, we are currently charging a modest fee for radiographic evaluation on cases which are not subsequently referred; we would encourage you to pass that charge on to your clients as a consultation fee. 

Best wishes for the New Year!