How much mandible can be removed?

RE: How much mandible can be removed?

Tim Charlesworth — Tue, 16 May 2017 11:30:16 GMT

NOthing to do with mandibles anymore but...

Dogs with spontaneous haemoperitoneum due to a splenic mass have an approx 70-80% risk of having malignant splenic neoplasia, the vast majority of which are haemangiosarcomas (HSA). Smaller and multiple masses (in these cases ie haemoperitoneum) are also more likely to be malignant.

We would never refuse to operate on a bleeding spleen unless we could demonstrate metastases but it is very important to assess these patients for spread before cutting them as the MST for splenic HSA is only approx 2 months and this is in the absence of any detectable mets at the time of surgery. I have plenty of dogs still going strong after splenectomy for haemoperitoneum - as always it's all about case selection.

Dog's don't need ongoing meds following splenectomy. Complications are always possible but you shouldn't get septic peritonitis unless there was an abscess or breach/failure of sterile technique.

RE: How much mandible can be removed?

Glenn Hodgson — Mon, 15 May 2017 22:31:22 GMT

We take out plenty of bleeding spleens each year. And euth a similar number.

Seen a couple that have metastasised into the wound prior to sutures out. Not good at all.

Seen many that have been haematomas, some infected and haemangiisarc looking. These dogs are delighted to be without their spleen. No noticeable immune compromise.

One interesting one that raised my eyebrows. A springer with clear mets on the liver. Assistant operated in the face of my skepticism... We are now 2 years post splenectomy and a chop protocol for the lymphoma later... One very lucky dog.

It's an educated gamble. I let the owners choose and am.happy to try. Pointing out exactly what happens if procedures don't 'go well' is also important and helpful. Eg. If this does not go well we fluffy could go through this big procedure and the associated pain and stress only to die on need euthanasia prior to recovering fully.

RE: How much mandible can be removed?

Linda Filshie — Mon, 15 May 2017 18:44:40 GMT

[quote user="Busybee"]

I had one 2 weeks ago, 11yr old labrador with no signs of hepatic spread but seeds throughout the mesentery. An intra-op phone call to the owners to warn of a guarded prognosis, but they wished to continue. They reported last week that the dog was the best she'd been for a long time.

A lot of what we do is all about quality not quantity of life.

[/quote]

Just curious- was she receiving analgesics post-sx that she wasn't before?

My personal "yes I'll consider splenectomy as long as these aren't gross mets" tale: 11 y old springer with vague GI signs and weight loss - large splenic mass and on ex-lap adhesions present suggestive of prior bleeds. Splenectomy and histo -> reactive hyperplasia, which was not what I was expecting. Dog did super for many months, with resolution of c/s. Lost to follow up when I left the practice. My point, in a rambling way, being that the body is a weird and wonderful thing and absolutes are absolutely () never helpful.

RE: How much mandible can be removed?

Busybee — Mon, 15 May 2017 18:27:56 GMT

It was my understanding - in both theory and practice - that you cannot distinguish a haemangioscaroma from a haematoma when faced with a bleeding mass on a spleen? Unless there's obvious metastatic spread elsewhere in the abdomen, how can you make that call? If you're a good ultrasound scanner, maybe you can pick all these up before you cut. If you can't? Do you cut? If all you can find is a bleeding splenic mass, don't you give these dogs a try?

My first splenectomy was an 11 yr old border terrier with a melon sized bleeding growth on his spleen. I very nearly abandoned the surgery as I felt it could end up hopeless, but we continued and now, 6 yrs later, the dog is 16yrs old and alive, though fading from co-morbidities. Surely a haematoma.

A lot of what we do is all about quality not quantity of life.

RE: How much mandible can be removed?

James Dunne — Sun, 14 May 2017 14:27:35 GMT

Re splenectomy: we have had 4/10 this year that were NOT malignancies and all animals have survived well. Out of the other 6, 2 were not haemangiosarcoma and are also alive and well. one of the other 4 is still alive 9 months down the line. I do not agree they come in having been moribund for a number of weeks. Many of them present peracutely and the decision to PTS is very straightforward. Comparing humans to dogs - my understanding is that the human spleen is more of an immune system reservoir and the dog spleen more of a blood volume reservoir for 'fight or flight', hence the different percentages of 'white spleen' vs 'red spleen' in humans vs dogs, so while it is an important immune system organ, its removal in a dog cannot be compared directly with removal in man. I agree that we all need to audit our cases and applaud you for doing so critically, but we all treat small numbers overall and may have very different patient populations. Judging one's peers on your own patient population may be unwise. Lastly, some ruptured splenic tumours will respond to conservative treatment without surgery - not my favourite option but on occasion it is worth trying rather than diving in with the knife.

RE: How much mandible can be removed?

Utlendigur — Sun, 14 May 2017 09:58:33 GMT

[quote user="David Mills"]Would people take the spleen out of this? Genuinely interested. 10yo lab. Collapsed. Heamabdomen. Obvious bust spleen on scan. No resp [/quote]

No resp = dead, so not sure why you'd remove a spleen

RE: How much mandible can be removed?

Gillian Mostyn — Sun, 14 May 2017 09:20:52 GMT

[quote user="David Mills"]It's personal ethics and nothing to do with protocol or money saving. It's just where I draw my line in the sand. [/quote]

Oh to be so cocksure of yourself. Must be nice.

I, however, find life is far more complicated and am constantly unsure of my decisions. I rarely get to have 'a line in the sand' because pets always have owners attached, whose opinions and requirements I have to take into consideration. I cannot tell an owner that all bleeding spleens are malignant, or that all dogs need PTS on presentation, because it simply isn't true.

RE: How much mandible can be removed?

David Mills — Sat, 13 May 2017 23:07:04 GMT

Would people take the spleen out of this? Genuinely interested. 10yo lab. Collapsed. Heamabdomen. Obvious bust spleen on scan. No resp issues.

RE: How much mandible can be removed?

David Mills — Sat, 13 May 2017 22:46:38 GMT

I've seen a few septic peritonitis, wound break down, slow recoveries (weeks) due to blood loss. You're removing a major immune system organ and huge blood reservoir. Because most animals are old we probably put slow recoveries down to age.

In humans following splenectomy most are on amoxicillin for the rest of their lives (functions slightly different in dogs vs himans).

Over and above all this I simply don't buy normal QoL argument. Most of these dogs come in for pts 2 months later with v/D for a few weeks and a waking great liver met and skinny as hell. Horrible way to go. But as you say we all make our decisions. Personally I can't support them.

RE: How much mandible can be removed?

Nicola Cole — Sat, 13 May 2017 22:36:44 GMT

Posting at the same time as David.

What terrible complications have you seen post-splenectomy?

RE: How much mandible can be removed?

Nicola Cole — Sat, 13 May 2017 22:34:55 GMT

[quote user="David Mills"]

I won't amputate osteosarcs, treat ATEs or remove bleeding splenic tumours. I'm not into dealing hope. I know others will, and I disagree strongly with them. I make owners aware of the options and what I'm willing to do. It both dismays and saddens me and I smile blackly at the gross hypocrisy in the profession at times.

[/quote]

I will offer spleen removal with splenic tumours if no apparent hepatic involvement. I advise that many are malignant and that may have already spread and that may not prolong things for long. I don't usually advise histo on them-because they either spread and present with signs or they don't!

Dogs usually recover very quickly from a splenectomy. I'd much rather give them an extra 6 months or whatever with a relatively quick procedure with very little post op recovery time (recovery time same as a bitch spay) then have a dog in weekly for chemo to extend (not cure!) their life span by a relatively short period.

Where do we draw the line in what is 'appropriate' and what isn't? Do we give the elderly cat with chronic renal failure a go, or do we say no we can't cure it so we're not treating? Depends very much on the individual cat surely?

I think the phrase 'gross hypocrisy in the profession' is a bit strong! There will be times when I don't agree with how far another vet has agreed to go with regards to treatment and sometimes when I think it is really wrong to go that far but unless it's causing a welfare issue then the line in the sand is different for us all.

RE: How much mandible can be removed?

David Mills — Sat, 13 May 2017 22:28:41 GMT

Nice strawmanning

I've probably done about 50 since qualification. That's where my figures come from. Have you looked at yours recently?

Surgery is offered but I now refuse to do it unless it's a young dog without comorbidities (1/50). It's personal ethics and nothing to do with protocol or money saving. It's just where I draw my line in the sand.

I've seen some terrible complications following splenectomy. You're kidding yourself if you think it's a benign procedure. Still, nice moneymaker and chance to be a hero (for 1-3 months at least)

RE: How much mandible can be removed?

Gillian Mostyn — Sat, 13 May 2017 22:06:31 GMT

[quote user="David Mills"]My last one was 94% malignant. What was yours?[/quote]

My last one was malignant. I'd guess it had a maximum of 5 days of post op pain/discomfort, and then 3 months of normal QOL before starting to show signs of mets and subsequently needing PTS.

Most bleeding splenic tumours in dogs are malignant and I'd guess that I euthanase over 50% of cases on presentation. But to say all dogs should be euthanased and surgery not even offered as an option is ridiculous.

But if you euthanase them all you'll never be wrong, I guess. And the RSPCA will save some money.

RE: How much mandible can be removed?

Evelyn Barbour-Hill — Fri, 12 May 2017 17:20:45 GMT

[quote user="David Mills"] "did well".[/quote]

How about "lived happy, active, in good body condition and pain-free for over 18 months and died of something else"?

RE: How much mandible can be removed?

David Mills — Fri, 12 May 2017 17:05:51 GMT

[quote user="Tim Charlesworth"]Sorry if you misunderstood? [/quote]

Didn't misunderstand. The ct report was non committal but it sounds like leaning more towards mets. They may not be. My point was that they were likely to be. Dismissing imagers as "sitting on the fence" or going in harvesting lymph nodes is a triumph of hope over reality.

[quote user="Rob Davis"]I think by doing so you are doing a proportion of your patients a disservice.[/quote]

Thank you. Have you audited your outcomes beyond "did well". My last one was 94% malignant. What was yours?

RE: How much mandible can be removed?

Rob Davis — Thu, 11 May 2017 19:56:42 GMT

[quote user="David Mills"]I won't amputate osteosarcs, treat ATEs or remove bleeding splenic tumours. [/quote]

Fair enough. I will amputate osteosarcomas to improve quality of life after thorough discussion with the owners. They are generally immediately happier, and given that they generally have a good QOL, even if only for a relatively short period, I do not have a problem with this. I don't treat ATEs, I will remove bleeding spleens, again after discussion with owners. While some will succumb to mets after a short period, many do very well. I see no reason to have a rigid stance on not performing splenectomies on these patients. I think by doing so you are doing a proportion of your patients a disservice.

RE: How much mandible can be removed?

Tim Charlesworth — Thu, 11 May 2017 15:54:46 GMT

I don't think anyone advised operating on a dog with mets? My point was that many older dogs have small 2-3mm opacities within their lung fields that are not visible on radiographs hence asking for more information about their appearance. These nodules are often described as potential early metastases if there is a malignancy but they are often dismissed as incidental ("ditzels") by imagers if the thoracic CT is done for a reason other than a met-check. Sorry if you misunderstood?

RE: How much mandible can be removed?

David Mills — Thu, 11 May 2017 14:53:49 GMT

[quote user="Rob Davis"]

[quote user="David Mills"]This dog with mets should never be offered surgery. [/quote]

This dog doesn't necessarily have mets. If there were definite mets then obviously surgery would be a non-starter.

Do you offer amputation to osteosarcoma cases?

[/quote]

Of course it doesn't necessarily have mets. Just as a chest rad with cannon balls isn't necessarily mets. The only definitive answer is via histopathology. But we work on the balance of probability and what's more likely. We can't simply pick and choose our diagnoses to fit or defend our ethics.

RE: How much mandible can be removed?

Rob Davis — Thu, 11 May 2017 09:00:11 GMT

[quote user="David Mills"]This dog with mets should never be offered surgery. [/quote]

This dog doesn't necessarily have mets. If there were definite mets then obviously surgery would be a non-starter.

Do you offer amputation to osteosarcoma cases?

RE: How much mandible can be removed?

David Mills — Wed, 10 May 2017 23:18:22 GMT

[quote user="Tim Charlesworth"]

Hi Rob, how big were the lung nodules? Small "ditzels" are very common on thoracic CT as are pulmonary osteomata etc so not all nodules are metastatic. The imagers love sitting on the fence about them but I wouldn't necessarily rule out surgery based on this alone. If the owners were keen for surgery then you could rescan the thorax in a month or so and see if there is any progression of these nodules if clinically suspicious of mets. We would also "harvest" the regional lymph nodes (retropharyngeal, parotid and submandibular) for histo before considering radical mandibulectomy but I appreciate that this is a second procedure but, as has already been said, it's only reasonable to consider surgery of this kind if it is performed with curative intent.

Best of luck,

Tim

[/quote]

Just because we can doesn't mean we should.

Genuinely shocked by this thread.

Interesting some of those the most vocal are those bemoaning bad dog breeding.

Do the haters on here offer valve replacements for all their mitral valve patients replacements? Exactly. This dog with mets should never be offered surgery.

RE: How much mandible can be removed?

Rob Davis — Wed, 10 May 2017 16:33:29 GMT

[quote user="Tim Charlesworth"] how big were the lung nodules?[/quote]

From the report: There is a focal area of consolidation on dorsal in the left cranial lung lobe and multiple irregular marginated small (max 5mm) hypodense cavitary lesions in the caudal subsegment of the cranial lung lobe and the caudal left lung lobe. One single 3mm I diameter mineral dense nodule can be seen in the right caudal lung lobe.

And:

The pulmonary lesions can be incidental small bullae/blebs although they are fairly irregular but it cannot be ruled out that those represent an unusual appearance of metastases. The single nodule can according to the density represent a pulmonary osteoma or an early metastasis. The focal consolidation is an unspecific finding: consider focal atelectasis, neoplastic infiltrate, brosis, focal inflammation.

I have discussed all of this at length with the owners and they have decided (sensibly in my opinion) not to pursue surgery. The dog is comfortable at present, no instability (so as Evelyn says it's academic whether or not there is actually a fracture).

Many thanks again for the opinions.

RE: How much mandible can be removed?

Tim Charlesworth — Wed, 10 May 2017 13:57:20 GMT

Best of luck,

Tim

RE: How much mandible can be removed?

Evelyn Barbour-Hill — Wed, 10 May 2017 01:11:34 GMT

[quote user="Rob Davis"] I am not convinced that there is a fracture, despite the CT report. It looks to me as though the rostral cortex is still intact but there is significant bone loss on the lingual aspect giving the appearance of a fracture in some views. [/quote]

If there is no displacement, no mobility without excessive force and no detectable extra pain at this spot, it hardly matters whether there is a theoretical "pathological fracture" or not. In my opinion.

RE: How much mandible can be removed?

James Laidlaw — Tue, 09 May 2017 22:04:59 GMT

I did watch in horror one day as a man walked into surgery with a dog that had its tongue hanging down its neck like some kind of circus side-show, thinking it was my next appointment to fix. However he was the "bird-man" to collect wildlife that had been brought in to us and his dog had had the entire mandible removed. Was a super happy dog and a messy eater/drinker, but amazing how well it had adapted. Not sure I would recommend it personally, but we all know how well animals can cope with seemingly massive obstacles!

RE: How much mandible can be removed?

Rob Davis — Tue, 09 May 2017 16:59:26 GMT

James and Evelyn, thank you for your opinions. I will have a chat with the owners and we will probably go for palliative care only. I am not convinced that there is a fracture, despite the CT report. It looks to me as though the rostral cortex is still intact but there is significant bone loss on the lingual aspect giving the appearance of a fracture in some views.