Mass Removal in an Aged Patient

DoveLewis Surgeon Ashley Magee, DVM, DACVS reviews a case of an elderly Dachshund that presented to the ER for a facial mass removal.

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A 14-YEAR-OLD MALE DACHSHUND was presented to DoveLewis' ER for evaluation of a large mass over the right eye (figure 1). The mass was present as a small nodule for a year, but over the past 6 months, it started growing rapidly, ruptured through the skin and started intermittently bleeding. The patient was previously evaluated by the primary care DVM and antibiotics and pain medication were prescribed. Surgical removal of the mass was recommended but the client was financially unable to pursue further treatment. At the time of evaluation at DoveLewis, the patient was having trouble holding his head up due to the size of the mass and appeared to be painful and pruritic. The clients had used up previously prescribed pain medications. Thanks to generous donors, we were able to offer a palliative procedure to relieve his suffering and allow him good quality of life.

 

Figure 1: Although the clients sought veterinary care, they did not have the means to pursue surgery to remove the mass. What began as small nodule became a large, ulcerated mass causing significant discomfort.

 

On exam, the patient was quiet and responsive with a pain score of 2/5. A 10-12 cm pink fleshy mass was present over the right eye and appeared to be originating from a 4 cm skin pedicle (figure 2). The mass exhibited purulent odorous discharge and evidence of prior bleeding. Other physical exam findings included mature cataracts bilaterally (the mass could be elevated to allow brief exam of OD), a soft heart murmur (grade 2/6), significant dental disease, and thin body condition (4/10). Mass removal was recommended along with appropriate preanesthetic diagnostic tests and biopsy/culture. An IV catheter was placed and the patient was sedated with maropitant 1 mg/kg, methadone 0.3 mg/kg, midazolam 0.2 mg/kg and propofol 3-5 mg/kg to allow intubation. Patient was maintained on oxygen and propofol titrated to maintain sedation for the procedure. 

 

Figure 2: Closer examination of the mass showed evidence  of infection.

 

With the eyes protected, the skin around the mass was clipped then prepared with povidone iodine. The skin at the base of the mass was infiltrated with 2 mg/kg lidocaine, then final preparation and aseptic draping was performed. A doyen forcep was placed across the base of the pedicle, and the skin pedicle and interposing subcutaneous tissue was sharply transected just above the clamp and the mass was removed. (figure 3). Several large vessels were identified and ligated with 3-0 Maxon. The site was lavaged and then closed in two layers resulting in a 5-6 cm incision over the right eye (figure 4). The patient recovered smoothly and was discharged later that day with pain medication and empiric antibiotic therapy. Follow-up two weeks later revealed the patient had recovered well and was able to spend the holiday season with his family in comfort (figure 5).

 

Figure 3: Mass after surgical removal.

 

Figure 4: Patient immediately post-op.

 

Figure 5: Patient 2 weeks post-op and healing comfortably.

 

THIS CASE ILLUSTRATES that geriatric dogs with surgical disease can be managed successfully with a relatively simple treatment plan in selected patients. While diagnostics such as CBC, clinical chemistry, urinalysis, thoracic radiographs, cardiac ultrasound, wound culture and biopsy would have been ideal for this patient, they were unattainable due to severe financial restrictions. When a thorough physical examination did not elucidate any distinct contraindications to anesthesia other than the heart murmur, an anesthetic plan designed to provide maximum safety (IV catheter, secured airway) and minimal cardiovascular effects (oxygen, local anesthesia, titrated propofol, full agonist opioid) was implemented and used successfully to remove the mass. While it is possible that, if malignant, this mass may re-occur as relatively conservative margins were taken (1-1.5 cm); this was done to minimize surgical time and potential wound healing complications by leaving ample skin for a tension free closure. In this geriatric patient, the object of surgery was palliative as it was clearly affecting his quality of life, and the clients were without the means for a more intricate surgery or follow-up.

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