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Dr. Phil Zeltzman

Are You Haunted By Negative Exploratories?

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A few years ago, I wrote an article entitled “No such thing as a negative exploratory.”* Shortly thereafter, I received an amazing email from a colleague on the other side of the world.

Dr. Andreane Daigle, who practices in Queensland, Australia, shared with me a story about an exploratory laparotomy she performed on a vomiting nine-year-old dog after x-rays revealed a possible foreign body. When she went in, however, she found nothing.

“Ohhhh, how disappointed and angry at myself was I, when all I found was an erythemic small intestine,” she wrote. “The client now has a bill of about 2K because of my lack of confidence… If I would have just waited another day, maybe none of that would have happened… So I was hoping you could guide me with your experience. What questions do you ask yourself? How do you decide to go to surgery?”

Wow, what an incredible email!

My reply was:

Hi Andreane,

I think that what you did is fine. This has nothing to do with confidence.

However, it has to do with the art of veterinary medicine, rather than pure science.

Sitting on a suspected FB can be a recipe for disaster, so I can’t possibly recommend it. On Monday, the intestine may be fine, and an enterotomy may be enough. On Tuesday, the intestine may be so angry that an R & A is necessary. And on Wednesday, the dog may perforate and end up with septic peritonitis!

So earlier intervention is usually preferred… but not always. I have a hard time believing that waiting another day would have changed much to the health of the intestine… but your biopsy will confirm that.”

A week later, the biopsy results confirmed that this 9-year-old jack Russell had IBD.

Young Andreane had made the right decision after all.

Still, as I wrote in the original article*, there should be no such thing as a negative exploratory. If you don’t find anything grossly abnormal or fixable or removable, then you should at least take multiple biopsies and submit them to the lab.

Of course, saying “you should” is a diplomatically correct way to say that you must…

At a minimum, biopsies should include the stomach, the duodenum, the jejunum (maybe 2 levels), and very importantly the ileum, often forgotten but a common site for IBD. Depending on the specific situation, you may also need biopsies of the liver, pancreas, mesenteric lymph nodes etc.

You may have heard this saying: “If you don’t have negative exploratory laparotomies, you’re not doing enough of them.” In other words, a negative exploratory laparotomy is perfectly acceptable. I respectfully disagree with this philosophy. A laparotomy can be negative if you throw your hands up in the air, cuss a few times, and close the patient on the spot. But it will not be a negative exploratory until you take and submit a bunch of biopsies.

When should we consider an exploratory laparotomy? By definition, when we are not 100 % convinced about the diagnosis. Arguably, this could be when a patient presents with:

  • Unexplained and unresolved hematemesis or melena.
  • Chronic weight loss of unknown origin.
  • A history of eating foreign bodies, especially in puppies and kittens
  • A history of eating foreign bodies, especially in older patients – a classic suggestion for IBD.
  • A questionable barium study.
  • A penetrating injury to the abdomen, such as a gunshot wound.
    Unexplained and unresolved gastric or intestinal distension with no radiographic or ultrasonographic evidence of obstruction.
  • A focal intestinal lesion seen on ultrasound, such as a mass or disrupted layers.
  • An increase in bilirubin without a logical explanation.
  • When partial thickness GI biopsies taken via endoscopy do not provide answers that may be provided by full thickness GI biopsies performed surgically. Studies show that surgical biopsies are more reliable than endoscopic samples because of the difference in depth.

If you are still in doubt based on the history, the physical exam, blood work and X-rays, ultrasound is a great, non-invasive modality to guide you. The secret: ultrasound should be performed and read by well-trained individuals.

What are the consequences of “closing” a patient after a negative exploratory without taking (and submitting) biopsies?

Here are at least 4 consequences:
1. We (still) cannot document whether or not there is GI or some other abdominal disease.
2. The patient, who may (still) be debilitated, may need to have another anesthetic episode to have endoscopic or surgical biopsies harvested.
3. You may need to admit to a disgruntled internist (or surgeon) that you didn’t take biopsies!
4. And you need to have the same tricky discussion with an unhappy client.

Over a year later, I asked Andreane for permission to use her name for this story. In her approval email, she wrote:

“Interesting timing, I was talking about you to my colleague 2 days ago. I had a cat with GI signs and I wanted to do a laparotomy. He was telling me to wait… but I thought of you and went in yesterday… I found an obstruction due to chicken necks.”

Way to go Andreane!

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.

* “No Such Thing As a Negative Exploratory”. Veterinary Practice News. Published March 2nd, 2010.

When Everyone Knows It’s Cancer

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Many patients never get the surgery they need because veterinarians or owners assume that a mass is cancerous. Worse: countless pets are euthanized based on the same assumption.

[tweetthis]Many pets never get the surgery they need because we assume a mass is cancerous.[/tweetthis]

Lump removalIt’s not uncommon for a referring veterinarian to call me in (I’m a traveling surgeon) to perform surgery on a patient with a “tumor in the spleen” or “spleen cancer.” I tend to call it a “mass in the spleen” until proven otherwise by a pathologist. Understandably, some clients often don’t want to put their (often older) pet through surgery if it’s likely to be cancer. But that’s obviously a decision based on their family vet’s assumption.

The truth is, it sometimes doesn’t even matter if a mass is benign or cancerous. A benign mass can cause some very annoying signs depending on where it is located:

– A large, benign mass in the rectum can prevent a dog from defecating.

– A large, benign mass pushing on the trachea can cause severe difficulty breathing.

– A large, benign mass in the armpit can prevent a dog from using the leg normally.

These masses may have been benign, but they still caused some significant signs that dramatically affected the pet’s quality of life.

We recently did surgery on three patients. “Everybody” involved was convinced that they had cancer. But their owners just loved their pet too much and couldn’t put them to sleep without at least the benefit of surgery – and a biopsy.

Max* is a 13-year-old male Sheltie. X-rays revealed a large mass in the spleen. Based on the way it looked on ultrasound, the mass was believed to be malignant. Taking an ultrasound-guided biopsy of the spleen is possible, but it can be risky: the mass can rupture and bleed out. In addition, the biopsy can cause spreading or “seeding” of cancer cells.

Despite the odds, Max’s owner was interested in surgery. The mass was the size of a cantaloupe (in a Sheltie!), and looked really “ugly” (this is secret vet code for “Wow, this oughta be cancer”). Max recovered uneventfully. One week later, the biopsy came back as… benign! The mass was a myelolipoma, essentially a benign fatty tumor. Max is now expected to have a normal quality of life and a normal life expectancy.

Jake* is a 12-year-old male Cocker who had difficulty urinating. Ultrasound showed a large mass in his bladder. Bladder masses are much more often cancerous than benign. His owner elected to have the mass removed anyway. We took Jake to surgery and removed about one-third of his bladder! One week later, the biopsy came back as… benign! The mass was a leiomyoma, a benign tumor of the muscle. Jake should have a normal life expectancy and a normal quality of life.

BENIGN sweat gland cyst in the tail of a 9 year old Labrador
BENIGN sweat gland cyst in the tail of a 9 year old Labrador

Praline*, a 9-year-old Labrador had a pretty big mass under the tail. She was referred for tail amputation, since the mass was thought to be cancer. For some reason – call it a gut feeling – I wasn’t too thrilled to do that, and of course neither was the owner. So we agreed to remove the mass only.  After cutting into the mass after surgery, it appeared dark, so I was concerned it could be a malignant melanoma. One week later, results came back: the mass was benign!  It was a cyst in a sweat gland. Again, this mass will not affect the patient’s life span, and Praline got to keep her tail!

So what is the moral of the story? Be humble and “never assume”…

[tweetthis]Does this pet have cancer? “Be humble and never assume”[/tweetthis]

I am perfectly aware that the diagnosis could just as easily have been “bad.” In fact, it was supposed to be, based on experience and statistics. But here are three older dogs, in the later part of their lives. They all were statistically “supposed” to have cancer. But these loving owners, willing to provide the best possible care for their pet, were not going to give up without a fight.

In fact, out of countless patients who did have cancer, I don’t remember a single pet owner ever regretting choosing surgery over euthanasia, no matter how little extra time we bought. The goals of tumor removal are to obtain a diagnosis, improve the patient’s quality of life (e. g. being able to urinate or defecate or breathe), increase life span, and decrease future risks (e.g. by preventing internal bleeding after a spleen mass bursts).

Think these are miraculous exceptions?

Far from that. It happens all the time. Within the past few weeks, we had Prince*, the 15-year-old cat with a huge liver “cancerous” mass which turned out to be a multitude of benign cysts. And Leo*, the 12-year-old Italian Greyhound with a huge “cancerous” tumor on the thigh, which report showed a perfectly benign fatty tumor (lipoma). And Frank*, a 12-year-old Doxie with a “cancerous” tumor on the ankle, that came back a ruptured benign cyst. The list could go on…

Over the years, I have become much more cautious when a pet owner asks me what I think a tumor is – benign or malignant. I simply answer that “I don’t have microscopic vision,” and that I just don’t know. Some clients hate this answer, but I would rather remain humble, than give a client unnecessarily poor odds or false hopes.

In the case of Max, Jake and Praline, three extremely dedicated owners were rewarded with an excellent outcome and hopefully many more happy years with their dogs.

 [tweetthis]What happens when veterinarians call it “cancer” and are wrong?[/tweetthis]

Clinical photo credit Phil Zeltzman: BENIGN sweat gland cyst in the tail of a 9-year-old Labrador

* The stories are real, but patient names have been changed to protect their privacy.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.