This sporting dog’s life……

Given the seismic shift in the foundations of our lives and community in these COVID19 times, the eighth of March seems like a date from an ancient history class. However, it was the day of the 2020 Chester 10km Road Race. The first 10k that either I, or my son Finn had ever attempted! Important facts initially – my time was nine minutes faster than I had predicted, and quite respectable. Finn did the decent thing and let his old man finish first! What on earth has this to do with the world of Veterinary Surgery? When I run, my mind tends to drift off and given that I was pushing myself at about the 8km mark going uphill towards the city centre, I began to tick off my list of personal rugby-related injuries – from Achilles tendon tears, to sutured forehead and lip, subluxated shoulder, broken nose (twice – first time it was crooked and the second reset it!) and finally to a hip resurfacing procedure. As I ran, despite this extensive list, I decided that in a bizarre way I had dodged the proverbial bullet by avoiding a most common football and rugby injury – the ruptured cruciate ligament!

Known as an anterior cruciate ligament (ACL) injury in people, rupture of the cranial cruciate ligament (CCL) is incredibly common in dogs. In part this is because the average dog even if a canine couch potato, would be an accomplished amateur athlete in the human world. However, we frequently see the injury much more in some breeds of dog than others, particularly medium and large breeds, sometimes as young as eight months of age – a common patient is the Labrador Retriever.

The knee should only move in the manner of a hinge, but because it is often under stress through a range of angles from fully straight (extension) to bent (flexion), it contains an array of structures to combat these forces. Effectively the cranial cruciate ligament exists to keep the tibia (the shin bone) and the femur (the thigh bone) in a predictable position relative to one another. When the CCL is torn, partially or completely, then the tibia tends to slide forwards in respect to the femur. The resulting lameness varies from subtle, to the dog only touching its toes to the ground – due in part to the sense of instability as the patient tries to put weight through the leg, and in part to the inflammation and swelling in the joint. There are also two discs of cartilage between the femur and tibia which act to stabilise the bones rather like a chock behind a wheel. The inner one (the medial meniscus) is commonly damaged along with the cruciate ligament.

It is accepted that nearly all dogs will benefit from surgical treatment of a cruciate related lameness, however small dogs can make a reasonable recovery with rest, anti-inflammatories, then physiotherapy – although recovery time can be protracted. Surgical treatment of the injury is often the best option. Traditionally the instability within the knee was addressed by direct stabilisation using a variety of materials to replace the function of the ligament. These could be grafts of tissue harvested from the knee area, or synthetic material. These standard procedures served us well for many years, but it is recognised that these ligament replacements may stretch or fail completely leaving the knee joint unstable. Recovery can sometimes be quite protracted. We now recognise that we can neutralise the forces within the knee that drive the tibia forwards by altering the shape of the tibia itself. There are several procedures used by surgeons to accomplish this: TPLO (tibial plateau levelling osteotomy) and the TTA (tibial tubercle advancement) are the principle ones. It is also important to inspect and treat the medial meniscus, if damaged, at the time of surgery.

In the TTA, the front of the tibia where the patellar or knee-cap tendon attaches is moved forwards by a distance measured on digital radiographs. The bone is then held in place using a cage and screws, or a cage and plate. Although uncommon, complications can occur which can include infection, further damage to the meniscus, persistent instability or fracture.

While injury to the cruciate ligament in people or dogs is a serious occurrence, in the veterinary world as with human orthopaedics, surgical treatment performed by a surgeon experienced in the techniques can give great results and patients will often return to their sporting life!

Post operative radiograph of the TTA Rapid procedure (Tibial Tubercle Advancement)

Gastric dilation and torsion, or bloat in dogs and laparoscopic gastropexy – a preventative surgical procedure

Gastric dilation-volvulus (GDV) syndrome is a painful and life-threatening condition in which the stomach becomes hugely distended with gas and fluid and rotates on its axis, often through 1800 to 3600. Gross gastric dilation can occur without rotation of the stomach.

Any breed of dog may be affected but large and giant breeds are predisposed – Great Danes, German Shepherds, Gordon and Irish Setters, Bassett Hounds, Airedales, Wolfhounds, Weimeraners and Rottweilers to name a few. A study found that 18% of all Great Dane deaths were due to GDV (Evans and Adams 2010). The specific cause is unknown but several risk factors beyond breed have been identified (Glickman 2000); a high ratio between chest height and chest width (deep-chested individuals), increasing age, having a first-degree relative affected, speed of eating, using an elevated food bowl. Other factors affecting incidence include male gender, low body weight, eating one meal per day and a fearful or anxious temperament.

Dogs may present following a period of restless behaviour, non-productive retching and hypersalivation. They will have a dramatic and progressing distension of their abdomen. They may be pale, with a rapid heart rate, breathing difficulties and may be collapsed.

Stretching of the stomach wall, and twisting, compromises the blood flow to the wall, reducing oxygen supply which can lead to death of the tissue. The spleen, which is attached to the stomach, can undergo twisting or torsion as well, leading to similar effects. The dilated stomach compresses the vena cava. Compression of this vein reduces the return of blood to the heart from the abdomen and hind legs of the dog. The dilated stomach presses on the diaphragm reducing its movement and consequently the ability for the lungs to expand normally. The circulatory and respiratory effects lead to a reduced supply of blood and oxygen to tissues, resulting in shock and if untreated eventually death.

Treatment includes aggressive intensive care and fluid therapy to combat the fatal effects of shock, decompression and if necessary, de-rotation of the stomach. In some cases, removal of the spleen (splenectomy) or resection of part of the stomach (partial gastrectomy) is required. Even with prompt treatment mortality rates can be high – published results range from 10% (Brockman 1995) to 33% mortality (Mackenzie 2010). The prognosis is better where there is dilation but no twisting (Brockman 1995). However, where gastrectomy and splenectomy are required the mortality rate has been reported as high as 55% (Brourman 1996).

The incidence of gastric dilation and volvulus can be influenced by selective breeding and management of feeding – avoid stress at mealtimes, feed more than once per day, do not feed from a height, slow down rate of eating. A gastropexy is a surgical procedure where a permanent adhesion is created between the stomach and the body wall. It is performed for the prevention of a gastric dilation and volvulus (GDV) either in animals suffering from an episode of GDV or as a preventative procedure. Dogs treated for GDV with de-rotation of the stomach but no gastropexy had a recurrence rate of 50%, whilst those treated with a gastropexy had a rate of less than 5% (Glickman 1997). A study of five predisposed breeds (Great Danes, Irish Setters, Rottweilers, Standard Poodles and Weimeraners). Ward, M.P (2003) found a reduced lifetime risk of mortality ranging from 2.2-fold in Rottweilers to 29.6-fold in Great Danes.

There are several different open abdominal techniques to achieve a gastropexy, however these require significant exposure of the abdomen to achieve the result. There are also laparoscopic-assisted procedures where the surgeon uses a telescope and camera to identify and grasp the stomach before suturing to a reduced abdominal incision up to 6cm long. However, the gold standard procedure is to perform the procedure entirely laparoscopically. While this technique requires significantly more skill and experience on the part of the surgeon, in such hands the comfort of the patient and recovery rate are much enhanced.

Laparoscopic gastropexy should be considered in at risk breeds. The procedure can be performed as a single procedure in male dogs or at the time of ovariectomy ovariohysterectomy in females.

  1. Brockman, J.D., Washabau, R.J., Drobatz, K.J., (1995) Canine gastric dilation-volvulus syndrome in a veterinary critical care unit: 295 cases (1986-1992) Journal of the American Veterinary Medical Association 207: 460-464
  2. Brourman, J.D., Schertel, E.R., Allen, D.A. et al (1996) Factors associated with perioperative mortality in dogs with surgically managed gastric dilatation-volvulus: 137 cases (1988-1993) Journal of the American Veterinary Medical Association 208: 1855-1858
  3. Evans, K.M., Adams, V.J. (2010) Mortality and morbidity due to gastric dilation-volvulus syndrome in pedigree dogs in the UK. Journal of Small Animal Practice 51: 376-381
  4. Glickman, L.T., Glickman, N.W., Schellenberg, D.B., Raghavan, M., Lee, T.L. (2000a) Incidence of and breed-related risk factors for gastric dilatation-volvulus in dogs. Journal of the American Veterinary Medical Association 216: 40-45
  5. Glickman, L.T., Glickman, N.W., Schellenberg, D.B., Raghavan, M., Lee, T.L. (2000b) Non dietary risk factors for gastric dilatation-volvulus in large and giant breed dogs. Journal of the American Veterinary Medical Association 217: 1492-1499
  6. Mackenzie, G., Barnhart, M., Kennedy, S. et al (2010) A retrospective study of factors influencing survival following surgery for gastric dilatation-volvulus syndrome in 306 dogs. Journal of the American Animal Hospital Association 46: 97-102
  7. Ward, M.P., Patronek, G.J., Glickman, L.L. (2003) Benefits of prophylactic gastropexy for dogs at risk of gastric dilation-volvulus. Prev Vet Med 60: 319-329

Spaying female dogs? Why? What? How?

Recently a lovely lady with a super young female dog appeared in my consult room wanting to know about laparoscopic spaying or neutering. She was a client at another practice but her vet, a friend of mine, had suggested she seek us out! It was great to speak to someone who had done a lot of research herself so I thought I’d write an article based around that conversation.

It has long been accepted that we should consider spaying or neutering female dogs. However, as it is a choice that we, as pet owners have to make, we should ask ourselves what the reasons for this are. Population control, avoidance of unwanted pregnancies is an obvious reason. Social reasons, the prevention of signs of a bitch coming in to heat – vaginal bleeding or being chased around the park by overly enthusiastic male dogs – again is straightforward. There are health benefits to your bitch which for some reason, we often forget about. The Royal Veterinary College (RVC) in London have a detailed disease surveillance programme, involving many veterinary practices and hence literally thousands of dogs. One of the simplest statistics to come from this is simply that neutered dogs live longer than entire or un-neutered ones. In the female dog we prevent ovarian and uterine cancers. Mature bitches who have never bred or who haven’t had a litter for many years can commonly develop a serious and potentially life-threatening womb infection, called a pyometra. Pyometra can be treated surgically but surely this is best prevented. If a bitch is spayed earlier in her life there is a dramatic reduction in the incidence of mammary carcinomas (breast cancer) in her later years. We see this in practice – many years ago, surgery for mammary tumours was frequently performed in the surgery, but now, with the majority of older females being spayed, we perform significantly fewer procedures. So we can argue that spaying your female dog is an important part of preventative health care.

So, we have decided to neuter our lovely female dog. What does this actually entail?

The traditional spay performed in the U.K. would be an ‘open’ surgical procedure. This means that the surgeon creates a wound in the abdomen, large enough to allow direct access for the fingers, hands and surgical instruments to the contents of the abdomen. The operation would usually involve the removal of both ovaries and the uterus. This is called an ovariohysterectomy (OVH). The alternative surgery involves the removal of only the ovaries (an ovariectomy or OVE). Surgical procedures can involve complications, however rare, and studies have shown no difference between OVH and OVE regarding the incidence of womb infections or incontinence.

Now we know just a little about what the neutering surgery entails do we have any other considerations? Well, yes!

Nowadays the choices available are further broadened by the development of Minimally Invasive Surgery (MIS) or laparoscopic assisted surgical techniques, sometimes called ‘keyhole surgery’. The range of surgeries we can perform laparoscopically mirrors that of human surgical practice. Neutering a female dog and removing retained abdominal testicles (which have a high risk of undergoing cancerous change) in a male dog, are surgeries that lend themselves to MIS. Rather than completely opening the body cavity we place surgical tubes (or cannula) between 5.5mm and 10mm in diameter through the abdominal wall to gain surgical access, using special scissors, forceps and sealing devices. The patient’s abdomen in inflated with carbon dioxide gas to create a space in which to perform the surgery. The whole procedure is viewed via a digital camera on a high definition monitor.

Is laparoscopic surgery better than open surgery? This is a question I am often asked. There is nothing wrong with traditional open surgery. It is safe and surgeons are well practiced with techniques and in fact when performing an MIS laparoscopic procedure we are always prepared to convert to an open procedure. What else could we do if our camera broke? However many studies in both the human field and Veterinary surgery have demonstrated lower complication rates with wound infection or haemorrhage, lower pain levels and a more rapid return to normal activity. A study in 2009 showed that female dogs undergoing OVH via an open procedure were 62% less active in the 24 hours after surgery, while those undergoing OVH laparoscopically were only 25% less active. Typically our patients are exercising normally a week after surgery.

Are there any disadvantages to laparoscopic surgery? Learning laparoscopic surgery has a steep learning curve but as with all things with experience the procedure become straight forward. The procedure is more expensive performed laparoscopically because of the high cost of equipment and the extensive training required. However for reasons of reduced post operative pain and a much reduced return to normal activity, laparoscopic surgery offers a good alternative to traditional open surgical neutering.

Dugie Gemmill is the Clinical Director, and principal surgeon in his own Veterinary practice on the Wirral, with an interest in laparoscopic surgery and orthopaedics. He has been performing laparoscopic surgery for over eight years and as well as offering the procedures in his own practice, also operates at certain practices in North Wales.

Dog Blood Transfusion and Donation

Very recently here at Parkside we found ourselves trying to save an increasingly critical patient. A lovely black Labrador bitch developed a disease called immune mediated haemolytic anaemia – her own immune system no longer recognized her red blood cells and was producing antibodies to destroy them. A normal red blood cell count or PCV in a dog is between 37% and 61%. Bess’s PCV had fallen to 18% in twenty four hours. We faced a terrible clinical dilemma as she urgently required a blood transfusion.

In 2007 thewp_20150607_001 Pet Blood Bank came into being in the UK, a not-for-profit organization supplying blood products within the UK for veterinary use. In 2013 the Pet Blood Bank supplied over 3000 units of blood products to the UK veterinary profession.

To be concise, the presence of this organization saved Bess’ life! Within four hours of contacting the PBB we had three units of packed red blood cells ready for her.The transfusion in combination with round the clock care from our dedicated nursing team saved lovely Bess.

As with human blood transfusions, blood comes in different types. It is important to match donated blood with the recipient’s blood type to reduce the risk of transfusion reactions, which can be life threatening. Canine blood types are described as ‘dog erythrocyte antigens’ (DEA) and there are eight DEA systems in the dog; 1.1, 3, 4, 5, 6, 7 and 8. DEA 1.1 is regarded as the most significant in relation to serious transfusion reactions. There are commercial blood type test kits for DEA 1.1 which means that practicing vets can easily ascertain a patient’s type.

Dogs are either DEA 1.1 positive where the 1.1 antigen is present or DEA 1.1 negative where it is not. The Pet Blood Bank reports that 70% of dogs are DEA 1.1 positive. It is important to realise this for two reasons. Firstly the supply of DEA 1.1 negative blood is more limited as there are fewer donors. Secondly, as DEA 1.1 negative blood can be given to positive recipients we must minimise this to preserve the available stocks of the rarer type. Blood typing in the veterinary practice is very important. It also appears that certain breeds have a higher probability of being DEA 1.1 negative.

Packed red blood cells can be stored for up to 42 days at 4oC +/- 2oC, but it can be easily deduced that blood donors are as important to the veterinary and pet owning worlds as they are to human medicine. The Pet Blood Bank uses a network of volunteer practices as donation centres, using their facilities to collect blood from blood donor dogs.

Certain breeds appear to have a predisposition to being DEA 1.1 Negative blood. These are listed below. As there is a higher demand for DEA 1.1 Negative blood, the PBB tries to encourage more donor owners with these breeds to register their dog onto a blood donation programme. These breed are;

Airedales                                                              parkside-final-logos-dog-alone

American Bulldog

Boxers

Doberman

English Bull Terriers

Flat Coated Retrievers

German Shepherdspet-blood-blank-logo

Greyhounds

Lurchers

Mastiffs various breeds

Pointer (English)

Weimaraners

Just as in human blood donation, there are certain criteria that a dog must meet to enable safe blood donation.

The dog must:

1. Be aged between 1 and 8 years

2. Weigh over 25kgs – 55lbs lean bodyweight

3. Be in good general health

4. Be up to date with vaccinations – dogs cannot give blood up to 14 days after their annual booster vaccination

5. Not be taking certain medications – see exclusions information

6. Have no history of heart murmur, seizures or fainting episodes

7. Have no history of travel abroad

8. Have not received a blood transfusion

9. Have a good temperament and be able to lie quietly for a tummy rub for 5-10 minutes while blood is donated. Click here to see a video of a donor giving blood.