My case for Grand Rounds: a comedy of errors

I've been on Oncology this week, which has been an exhausted but informative and often fun rotation.

One storm cloud looming over my head, however, is the fact that I have my requisite Grand Rounds presentation this coming Friday.

Grand Rounds is a cruel vet school tradition wherein every senior student selects a case they've seen on clinics to present on a Friday morning sometime during the year. We are assigned a general topic for our presentation, typically the rotation that we have been on 2-4 weeks prior to our Grand Rounds date. This means that my topic is Oncology.

For Grand Rounds, you put together a 15-minute PowerPoint presentation discussing a case of interest to you. Then you get up in front of the junior lecture hall in the VTH, which is filled with other senior and junior vet students, nurses, and (most terrifyingly) clinicians.

Yes, that means that you have to give a presentation to basically the entire rest of the hospital, including the doctors who have been teaching you for the last 3+ years and working with you on clinics all year.

Okay, now that I'm done throwing up, I can finish typing.

The case I've selected for next week's Grand Rounds is a 13-year-old female Lab/Chow mix named Vega.

Vega has very dedicated, well-informed, responsible, and caring owners (no, I didn't say "obsessed," but maybe you get my drift...) who refer to her as their daughter. They have no human children or other pets, so Vega really is their only child.

On routine pre-anesthetic bloodwork prior to a dental cleaning 5 years ago, Vega's rDVM noted elevated liver enzymes. Vega had a battery of tests, including bile acids and liver biopsies, to try to discover the underlying cause of her elevated liver values, but everything came back normal. Vega's rDVM has managed her liver enzymes in the intervening period with a regimen of liver support drugs (ursodiol, SAMe, vitamin E) and a liver diet (Hill's l/d).

And Vega's done fine. She's had bloodwork monitored twice yearly, and her rDVM has noted elevations in a couple of Vega's liver values that sometimes fluctuate but have never gone back down to the normal range. Vega has never acted sick or shown any clinical signs of liver disease.

About 6 weeks ago, though, Vega went in for her 6-month geriatric wellness exam, and Vega's rDVM palpated a mass in the front part of Vega's abdomen. She repeated Vega's usual bloodwork, which was unchanged from her previous values, and recommended an abdominal ultrasound.

The ultrasound confirmed the abdominal mass and determined it to be about the size of a large orange, arising from a lobe of Vega's liver, and appearing to be solitary. Vega was referred to the vet school for an Oncology consultation and possible surgery.

Now, a lot of owners would hesitate at the thought of dropping $2-3K on anesthesia and abdominal surgery to remove a liver mass that might very well be an incidental finding in a 13 year old dog. However, Vega doesn't act her age -- if I hadn't known her age prior to meeting her, I'd have thought she was maybe 8 instead of 13. She's very fit and active, and otherwise totally healthy except for some arthritis which is under control. And though it's possible that Vega's liver tumor could be something benign that would never cause her a problem, there's also a possibility that it could be a vascular malignancy that could rupture suddenly and cause internal hemorrhaging, or some other type of malignancy that could spread elsewhere and make her sick if not excised. So, given the fact that Vega's owners didn't have much in the way of financial concerns, I can absolutely see their rationale for wanting to go to surgery.

Vega stayed in the hospital for a few hours with us on Thursday so we could repeat bloodwork and urinalysis (unchanged from her rDVM's labs a month earlier), run coagulation times (normal), check her blood type in case a transfusion was needed during or after surgery, and take chest x-rays (normal).

Vega went home on Thursday night and came back bright and early on Friday morning for surgery. She was anesthetized around 11:30 am and I was called to come shave her around noon. Given the fact that she has about 25 variably sized SQ and skin masses all over her body, and particularly on her abdomen, it was a remarkable challenge to have to try and clip her hair over and around the masses adequately to make her abdomen ready for surgery. She rolled into the OR around 12:15 pm.

Upon making our abdominal incision (difficult to find her midline due to her lumpiness!) we removed her falciform. The falciform is a very thick, fatty, gelatinous ligament that sits on the belly of the abdominal cavity and is often excised during abdominal surgery, simply because it isn't necessary to leave it in the dog and it gets in the way during surgery.

Immediately under Vega's falciform was her enormous tumor, popping right out at us. It was more grapefruit than orange-sized, and very ugly and vascular. Fortunately, it appeared to be growing on a stalk out of one of the 6 liver lobes, and the remaining liver did not appear to be involved.

Here comes Error #1: The surgeon elected to use a surgical stapler to cut off the tumor from its stalk. The way it works is that the stalk of the tumor is placed in the mouth of the stapler, the stapler is clamped down, and a double row of staggered small staples is automatically fired into the intervening tissue, effectively ligating the blood supply.

It works great.

Usually.

Unfortunately, it wasn't apparent that the stapler had misfired until the surgeon cut the tumor off of the stalk, released the stapler from the remaining stalk, and hemorrhage ensued.

In retrospect, the bleeding wasn't that bad. It certainly wasn't as bad as it would have been had none of the staples been placed as intended. But there was a heck of a lot of bleeding nonetheless, and significantly more than we'd have expected had the stapler functioned correctly.

Luckily, the surgeon remained very calm, and directed me to retract the abdominal wall and apply pressure to the hemorrhage while she obtained some additional materials to help start clotting and clamp off the bleeding vessels. There were about 10 minutes of panic, though, when multiple surgery nurses rushed in to assist us, and a flood of about 6 anesthesia personnel ran in to help the student anesthetist monitor blood pressure and heart rate, administer additional fluids, and get ready to send someone to the pharmacy to pick up some blood for a transfusion.

In the end, no transfusion was needed, and Vega'a anesthesia actually remained quite uneventful. The thing is, the liver is a very vascular organ, since its job is to filter toxins out of the blood. Tumors anywhere in the body tend to be very vascular, since they can produce factors that stimulate the growth of extra blood vessels to feed themselves; liver tumors are exceptionally vascular. Though this complication ended well, it could have been much worse and might even have led to Vega bleeding out.

Okay. Bleeding under control. Surgeons' and my heart rates were dropping back down to some semblance of normal.

Here comes Error #2: An important part of an abdominal surgery (other than something elective, like a spay) is to perform an explore of all of the abdominal organs, whether you expect them to be abnormal or not. As part of Vega's abdominal explore, we noted that one of her remaining liver lobes had a slightly abnormal appearance. The surgeon collected a biopsy sample, and placed it on a small piece of sterile paper on the instrument table. Unfortunately, she did not immediately hand the biopsy sample off to a surgery nurse to place in a formalin container, as is usually done with tissue samples, and we all forgot about the sample. It was presumably thrown away with all of the wrappers and packaging from everything needed for Vega's surgery -- but when I "got" to go hunting for it in the trash about an hour later, it was nowhere to be found. Oops.

Anyway, the rest of Vega's abdominal explore was fine. We closed her up, then transported her to CCU where she woke up slowly but normally, and proceeded to return to her usual neurotic behavior -- panting, pacing, barking, and generally trying to destroy everything in her kennel. The poor CCU staff were apparently rather irritated by this (and understandably so), since she received 5 doses of IV sedatives during the night (which reportedly did nothing to alter her behavior), and she was eventually shut up in an oxygen cage on room air, which did nothing to stop her barking but did at least dull the sound so it was almost inaudible in the room.

Vega's owners received a surgery and hospitalization estimate that included a second night's stay in the hospital if needed, since arrhythmias and pain are not uncommon complications of a surgery like this and are best dealt with in a hospitalized setting. However, Vega experienced no arrhythmias, seemed nonpainful, and clearly expressed to us that she was ready to be discharged, so we arranged a dismissal time for 9 am on Saturday.

I met with Vega's owners at 9 am and went through her dismissal instructions -- her pain medications and their side effects, how to care for and monitor her surgical incision, activity restrictions, etc. It all went well, and I advised them it would be a few minutes while I went to CCU to unplug Vega from all of her lines and monitoring, remove her IV catheters, and remove the bandage that had been placed over her incision so it would stay clean in the hospital.

Well, it turns out that the surgery nurses have gotten some new brand of extra-mega-super adhesive to get the bandages to stick onto the skin around the incisions, because Vega threw a tantrum when we tried to remove her bandage. It was really an all-out drama-queen hissy-fit, complete with howling, moaning, and thrashing, even when we were just gently restraining her and not even touching her bandage.

I should explain what the bandage looks like. It's a long, thin, flat strip of what looks like cotton padding, about 2 inches wide, laid down along the length of her abdominal incision (which goes from her sternum to her pelvis). A piece of clear plastic (which looks like plastic wrap) is placed over the cotton layer, and extends about an inch and a half onto the skin on either side of the bandage. An adhesive is sprayed onto the skin around the incision as well as onto the outside of the cotton bandage, to affix the clear plastic to the skin around the incision as well as to the outside of the bandage.

Since we couldn't easily peel or pull the plastic layer off Vega's skin (even with the help of adhesive remover wipes), the surgeon decided to very carefully cut into the cotton layer in the center of the bandage, overlying the incision. Her goal was to cut out the cotton layer (which was not affixed to the skin) and just leave the plastic layer around the edges to fall off on its own.

Error #3: Unfortunately, while cutting into the middle of the cotton layer, the surgeon accidentally cut some of the skin sutures from Vega's abdominal incision.

Luckily, not many of the sutures were lost, and we only had to replace 2 or 3 stitches in order to re-secure the suture line. But, it still meant a lot more drama from Vega, as well as more time that her poor anxious owners spent up front waiting for us to bring her out, and there's the pesky little fact that the skin likes to bleed a lot when poked with a needle, so there was still a little blood that appeared to be coming from Vega's incision (though it wasn't) by the time her owners saw her.

All in all, none of the "oops"es were major or complicated Vega's recovery. Her liver mass shows every sign of being consistent with a hepatocellular carcinoma, a tumor type for which complete surgical excision is essentially curative. We won't have biopsy results until Monday or Tuesday, but we're hopeful that it won't be something worse than that.

Now what's left for me is to put together my Grand Rounds presentation. I have some really cool pictures that were taken of Vega's abdomen and tumor during surgery. Once we have the histopath back and have confirmed that it's hepatocellular carcinoma, I'll do a little more research, but until then I'm ready to sleep for awhile!