Hemimandibulectomy

Re: Hemimandibulectomy

Malcolm Ness — Thu, 24 Jan 2013 16:56:55 GMT

[quote user="Michael Woodhouse"]

quick GA and dog back to eating normally.

What should I do? Kill them? Refuse to treat the dog palliatively?

[/quote]

?? offered a partial mandibulectomy or maxillectomy. Single procedure, dog back eating quickly. Admittedly prob less profitable than 6 debulkings but has the advantages of better pain control and the potential of a cure. Most such operations are relatively straight forwards and within the capabilities of a careful surgeon who is willing to take the time to read up or discuss with an experienced colleague and perhaps practice on a cadaver.

Re: Hemimandibulectomy

Evelyn Barbour-Hill — Thu, 24 Jan 2013 14:00:57 GMT

[quote user="Pynadath George"]One of my last patients while doing Maxfax was begging me just to have a teaspoon of tea. It was very early on and we had informed him he wasn't allowed to eat or drink using his mouth just yet.[/quote]

How long post-op are they not allowed to use their mouths – and why? Seriously interested.

[quote user="Michael Woodhouse"]

[quote user="Evelyn Barbour-Hill"]

While I think of it, with regard to oral tumours:

Please don't "debulk." Or at least (I do understand the constraints of practice) if you must debulk it once, when it grows again please don't debulk it again.

[/quote]

So what about these dogs that have a mass so large it is interfering with eating, but the dog has good QOL and there is no prospect of radical surgery?

I have 'debulked' masses maybe half a dozen times 1-2 months in-between - quick GA and dog back to eating normally.

What should I do? Kill them? Refuse to treat the dog palliatively?

[/quote]

Well, OK. You know what a reasonable person I am. The point is, each time you "debulk" you are just delaying. You are reducing, very possibly destroying, the chances of curative surgery. I speak from depressing experience.

Why would there be no prospect of radical surgery? Unless the cancer was already advanced so very far that it was "beyond ", as they say round here, which would be a different kettle of fish.

Re: Hemimandibulectomy

Mark Hedberg — Thu, 24 Jan 2013 10:59:30 GMT

Plus, after a good anaesthesia, your mouth is probably dry as an old boot!

Re: Hemimandibulectomy

Michael Woodhouse — Thu, 24 Jan 2013 10:48:11 GMT

[quote user="Evelyn Barbour-Hill"]

While I think of it, with regard to oral tumours:

Please don't "debulk." Or at least (I do understand the constraints of practice) if you must debulk it once, when it grows again please don't debulk it again.

[/quote]

So what about these dogs that have a mass so large it is interfering with eating, but the dog has good QOL and there is no prospect of radical surgery?

I have 'debulked' masses maybe half a dozen times 1-2 months in-between - quick GA and dog back to eating normally.

What should I do? Kill them? Refuse to treat the dog palliatively?

Re: Hemimandibulectomy

Pynadath George — Thu, 24 Jan 2013 06:04:25 GMT

[quote user="Evelyn Barbour-Hill"]

They worry in humans, firstly because it affects speech and secondly because of the extraordinary importance of facial appearance in people. But the late Prof. Ernest Gray, many years curator of the Hunterian Museum, had a mandible missing for many more years. It just made his speech a little hard to follow. The story he used to tell was that he had the mandible removed and his surgeon was planning to replace it with a piece of rib later. However the surgeon died before he could do this, and Ernest never bothered to get another.

[/quote] Absolutely. In humans it's extremely debilitating. Sometimes the patients die due to suicide due to the psychological damage. One of my last patients while doing Maxfax was begging me just to have a teaspoon of tea. It was very early on and we had informed him he wasn't allowed to eat or drink using his mouth just yet.

Re: Hemimandibulectomy

Evelyn Barbour-Hill — Thu, 24 Jan 2013 02:13:49 GMT

While I think of it, with regard to oral tumours:

Please don't "debulk." Or at least (I do understand the constraints of practice) if you must debulk it once, when it grows again please don't debulk it again.

Re: Hemimandibulectomy

Evelyn Barbour-Hill — Thu, 24 Jan 2013 02:08:47 GMT

[quote user="Hanna Bennett"]

we did one of these last week, 2yo sprocker with acanthomatous epulis which was invading into the mandible. eating normally within 24 hours post op. i do think good pre op discussions are important as owners can be shocked at their appearance immediately post op, but as in this case alternative was euth in the next few months in an otherwise healthy young dog, mandible removed just in front of lower carnassials. also think dog personality plays a part.

[/quote]

Nice one. But an osteosarcoma would require removal of the entire affected mandible (in my opinion). Patience and planning are required.Still very acceptable cosmetically.

Re: Hemimandibulectomy

Hanna Bennett — Wed, 23 Jan 2013 20:47:35 GMT

Re: Hemimandibulectomy

David Mills — Tue, 22 Jan 2013 15:54:03 GMT

[quote user="Utlendigur"]

Thanks for all the information. I suppose because the face is so important to humans that there's an instinctive fear of doing anything that will affect the facial area in a big way. Having not seen one I felt I didn't have the information to advise the owner properly, but the responses are a lot more positive than I was expecting. Nb isn't it ALP rather than AST that's important prognostically in osteosarcoma?

Thanks again - really helpful

[/quote] Correct, alp not ast, apologies.

Re: Hemimandibulectomy

Bibs — Tue, 22 Jan 2013 15:47:08 GMT

Thinking more about it, i think for me it's one of those operations where equipment makes life much easier. Apart from the oscillating saw, I used a monopolar cut and coag machine to do most of my incising. That's probably why I found things reasonably tidy and not that brutal at all. We also had bone wax on hand to ram into the mandibular canal to stop bleeding but in the end the electrocautery sorted the bleeding and we didn't need it.

I think if all I had was a hack saw blade and a scapel I would not be too keen.

Just some more thoughts.

Re: Hemimandibulectomy

Bibs — Tue, 22 Jan 2013 14:45:52 GMT

I did a cheiloplasty in my case but I did find that it partially broke down after. Maybe was due to slightly too much tension. Didn't seem to cause any major issues though.

Re: Hemimandibulectomy

Evelyn Barbour-Hill — Tue, 22 Jan 2013 13:48:03 GMT

[quote user="Elizabeth Billimore"] To be honest the dog looked really good post op and from a distance didn't look any different. [/quote]

Yep. On a little hairy dog – well, any hairy dog – there's not much to see unless you look deliberately. On a shorthaired dog with a finely-tuned head, like a Labrador maybe, it's more obvious to see, but still not ugly. The nuance of "disfiguring" is rather that there is a very unpleasant ugliness, which I say is rarely the case.

A certain amount of cheiloplasty is usually part of the surgery, in my opinion. It has to be judged nicely and one should err on the side of slackness I suppose.

I'd always place an oesophagostomy tube in a cat, but I wouldn't do this automatically for a dog: it seems unnecessary.

Re: Hemimandibulectomy

Utlendigur — Tue, 22 Jan 2013 13:46:26 GMT

Thanks again - really helpful

Re: Hemimandibulectomy

Malcolm Ness — Tue, 22 Jan 2013 13:33:27 GMT

[quote user="Lucy Fleming"]Similar to the debate about amputation of limbs affected with osteosarcoma[/quote]

Osteosarcoma of the axial skeleton tends to have a better prognosis than long bone osteosarcoma to the extent that appropriate excision is often curative.

Re: Hemimandibulectomy

Bob Russell — Tue, 22 Jan 2013 12:39:10 GMT

Our one and only hemi-mandibulectomy died from an unrelated neoplasm many years later. Owner was happy with the result!

Re: Hemimandibulectomy

Lucy Fleming — Tue, 22 Jan 2013 12:07:06 GMT

[quote user="Elizabeth Billimore"]

The dog was a yorkie that had a really nasty mandibular fracture nonunion following a dog bite to the head months previously, so she might have responded so well because she was in pain before hand (old fracture repair swinging in the breeze and dog screaming when trying to eat).

[/quote]

I think this is an important point... the procedure itself as pain relief. Removal of a destructive bony lesion - though obviously there is post-op pain to be managed - likely to lead to a pain-free outcome when healed. Similar to the debate about amputation of limbs affected with osteosarcoma, and whether or not that is associated with increased survival times.

Re: Hemimandibulectomy

Bibs — Tue, 22 Jan 2013 11:54:23 GMT

I have done one of these where pts was the other option. I am a GP and then had about 4-5 years small animal expereince.

My experience was good, however I had the support of a friendly in house referral vet who didn't mind talking me through it and being around if I had problems. I also borrowed their oscillating saw. The surgery wasn't too difficult but like everything else, if it's new to you it is difficult. I remeber having to be careful of the salivary ducts and you need to be ready to deal with bleeding from the mandibular blood vessels.

I used a nerve block and morphine (pre-med and post op) for pain relief. The dog had a feeding tube placed but we didn't need it post op apart from the first 24 hours or so as the dog was keen to eat on her own.

I talked the owners through it and showed them pictures from books of other dogs that had had the procedure. To be honest the dog looked really good post op and from a distance didn't look any different. I have some pictures somewhere.

I used the case for a report for my GPCert(SAS). I'll dig it out and see if there is any more info I could give you. I don't have long term information as I've need seen the dog since it's post op checks. Maybe I should try find the client and ring them to see how the dog is now.

Re: Hemimandibulectomy

Malcolm Ness — Tue, 22 Jan 2013 11:01:00 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Utlendigur"]what do the owners feel about the result?[/quote]

Extremely happy. Live healthy dog, happy and eating, even cosmetic change not that obvious.

[/quote]

or "extremely disfiguring"

I am not disputing the entitlement to an opinion. However, if this opinion is given professionally, then there is a duty to make sure that the client does not assume that it is a fully informed and well-experienced opinion, unless it actually is. Clients quite reasonably assume that their vet knows what they are talking about unless the vet explains the limits of their experience and expertise.

Re: Hemimandibulectomy

Clive Ansell — Tue, 22 Jan 2013 10:53:21 GMT

I would be happy for the procedure to go ahead, in the light of a biopsy to confirm a diagnosis and the absence of any evidence of metastases. I would be less keen if it were an aggressively malignant tumour.

I have never carried this out, but referred cases have had good results with good recoveries. If referral is not an option I would certainly do it, but would practice first on a cadaver.

Re: Hemimandibulectomy

Clive Ansell — Tue, 22 Jan 2013 10:47:07 GMT

[quote user="David Mills"]

It's an amputation like most others - brutal, bloody and somewhat Crimean in nature.

[/quote]

Speak for yourself. my amputations are carefully planned and executed surgical procedures with skill, precision and haemostasis

Re: Hemimandibulectomy

Michael Woodhouse — Tue, 22 Jan 2013 10:34:57 GMT

[quote user="Malcolm Ness"]Was it because he didn't support the relatively uninformed speculation of other posts?[/quote]

No red star from me, but I don't think I'd have something so disfiguring done to my dog, however fond I am of her.

We're all entitled to our own opinions.

Re: Hemimandibulectomy

Malcolm Ness — Tue, 22 Jan 2013 08:14:37 GMT

What Evelyn says reflects my experience.

The red-starring is sad. An experienced individual reports his experience (which, in fact is entirely in keeping with the published literature and the views of all other experts that I know) and gets red-starred. Was it because he didn't support the relatively uninformed speculation of other posts?

Re: Hemimandibulectomy

KathW — Tue, 22 Jan 2013 06:48:54 GMT

My last boss did a couple over the years (GP normal good general skills ) As Evelyn says they did fine and owners + dogs v happy. Beofre the 1st op I was a bit concerned about how they would be/cope but now wouldnt hesitate to recommend the op if needed - subject to all Evelyn's excellent advice of course.

Re: Hemimandibulectomy

Evelyn Barbour-Hill — Tue, 22 Jan 2013 00:38:15 GMT

[quote user="Utlendigur"]Has anyone any experience of this?[/quote]

Yes lots.

[quote user="Utlendigur"]do they manage ok?[/quote]

They manage very well indeed.

[quote user="Utlendigur"]what do the owners feel about the result?[/quote]

Extremely happy. Live healthy dog, happy and eating, even cosmetic change not that obvious.

[quote user="Utlendigur"] any problems to be aware of.[/quote]

You mean post-op problems? Not much. Any oral op means dribbling for a little bit afterwards, of course. After healing, maybe, maybe not. The surgery of course includes a cheiloplasty to reduce this possibility. Perhaps the tongue lolling out – I don't see that as a major consideration. The dog may take a few days to adapt to a new style of eating.

It's very satisfying to catch such a cancer early and be able to offer curative surgery. So often they are too advanced before treatment is sought.

Like many operations there has to be lots of analgesia afterwards. That's hardly a problem. I'd keep in hospital maybe just one night as a rule, depending mostly on the owner's capabilities: dogs recover more quickly at home, assuming they are fit to go home.

The most I have ever taken was the whole of one mandible and the rostral part of the other as far as the second premolar. That dog had some trouble for maybe a fortnight or three weeks, as the "free" remaining mandible would swing to the lateral side of the maxillary teeth and get trapped there. That ceased as the tissues stabilised and the dog became accustomed to the new state. He had to eat a little messily, with a sort of sideways scoop action, but he ate fine and the owner was very happy.

[quote user="Utlendigur"]Is it something that is feasible for a experienced GP vet to do or a referral only job?[/quote]

That would depend on the experienced GP's levels of experience, expertise, skill, knowledge and equipment.

Of course you would want to do the usual checks, blood profile, radiography etc. that you would do with a cancer anywhere.

[quote user="David Mills"]It's an amputation like most others - brutal, bloody and somewhat Crimean in nature[/quote]

And, er, no it's not commonly done nowadays under chloroform with a big knife that the surgeon wipes on his apron between patients.

[quote user="Michael Woodhouse"]This is one operation that sits very uncomfortably with me.[/quote]

Why?

[quote user="Utlendigur"](although I can think of others like maxillectomy that find even more uncomfortable)[/quote]

Why?

Re: Hemimandibulectomy

Busybee — Tue, 22 Jan 2013 00:05:35 GMT

I'm afraid I can't offer much information and I'm sure the experts will be along soon, but I saw a 12 year old spaniel last week who had had a hemimandibulectomy at the age of 6 due to a tumour of some sort (done at previous vets). Has lived a pretty much normal life since except he has very little temporal muscle mass on that side. Came in for an unrelated problem.