Sunday, November 15, 2009

What I did...

This is the final installment in my case study (see posts below).

In the end, I rehydrated the patient for 6 hours. He continued to be lethargic and depressed. I made the decision to go to surgery and see what we were facing.

When I opened him up, I found a massive liver tumor, as I suspected. It had not yet ruptured (as evidenced by the lack of fluid in the abdomen on ultrasound), but it was only days away from doing so. There were enormous pockets of necrosis and abscessation. As I was slowly and meticulously dissecting it away from the diaphragm (it had formed adhesions to the body wall and the diaphragm), I punctured the mass, and blood poured into the abdomen. I clamped it off and gave it time to clot, then continued working. During the surgery, my patient's blood pressure fell and fell and fell till it was in the basement. He received crystalloid boluses (NormR) followed by Hetastarch (colloid), and then a whole blood transfusion when his PCV was 14%. He also received dopamine intra-operatively to help keep his BP up.

An hour and 15 minutes later, the whole left side of the liver was out. The tumor enveloped all the lobes on the left side, and I had to remove it all. Everything else looked good, so I checked for bleeding, found none, lavaged the abdomen, and closed him up. There was no evidence of metastasis anywhere. Even the spleen looked happy.

We are 48 hours out from surgery, and he is slowly recovering. His kidney values are falling, but not as much as I would like. He is still nauseated and isn't able to eat. He is - however - able to move around his cage and go outside. His PCV is holding at around 24%.

The tumor will be sent for histopathology. In all likelihood, it will be read as a hepatocellular carcinoma - the most common malignant hepatic tumor of dogs. These are slow growing tumors that rarely metastasize and have a GREAT prognosis if not diffuse or metastatic (as this dog's wasn't). Prognosis is 4 years, and usually, the patient dies of something else unrelated to the cancer.

I am left with more questions than answers. I will never know if I did the right thing by going to immediate surgery. Should I have waited, fully rehydrated him, seen if he would stabilize more then taken him to surgery? Surgery was absolutely indicated for this little guy, otherwise, the tumor would have ruptured at some point in the near future causing a hemoabdomen. I know that. I just don't know if it should have been done that night, or if I should have treated his renal dysfunction for a week or more, than taken the tumor out.

Any thoughts?


Nicki said...

I don't think you can ever know, but as long as the patient does well, who cares? It's hard to learn to trust yourself bur sounds like you did great.

Hermit Thrush said...

Well, I hope this isn't the final installment. I'm dying to hear (and hope) that the little guy makes a complete recovery.

I think I would have done exactly what you did. I'm not terribly patient and once I had done some stabilization I would not have wanted to wait any longer because I would have worried the patient would go downhill again. I really don't think there is any way to know what is the right thing to do, are there any studies on this type of thing-- whether one tends to have a better outcome with going to surgery quickly or stabilizing for 24 hours first? If you hadn't gone to surgery it is always possible the mass would have ruptured and then you would have had a true emergency and he could have bled out even more easily. I'm impressed that you see such complex cases and that you are tackle them with aplomb. For someone in her first year as an emergency vet you are doing spectacularly. I can only imagine that things will get somewhat easier with time as your confidence builds and you develop more of a gut instinct on what to do with complicated cases based on what you've already seen and the outcomes you achieve with various treatments.
Way to go!

The Homeless Parrot said...

My little patient is alive and well 2 weeks post-operatively. He is eating feline w/d only...but we're not picky at this point. He is bright, happy, and alert. His owner is very happy...despite the enormous bill she racked up (even with her discount). I'd be quite proud of myself at this moment if I hadn't just lost a patient under anesthesia. Instead, I'm bummed and awake at 3:30am.