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Date:   18 November, 2008
Focus: Small animals - dogs, cats, hamsters & rabbits
*10 a.m - 5 p.m (Mon - Sun, except Sat). Dr Sing Kong Yuen. By Appointment Only.

*6 p.m - 10 p.m (Mon - Fri). 10am - 5pm (Sat). Dr Jason Teo. House-
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Appointment preferred.
Tel: 6254-3326, 9668-6469
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9668-6469, 6254-3326
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Toa Payoh Vets Clinical Research
Making veterinary surgery alive
to a veterinary student studying in Australia
using real case studies and pictures

Case Written: Nov 18, 2008
Veterinary Surgery
- Chicken Bone stuck in the gullet and the stomach - Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS 

"What are the chances of survival on the operating table?" the lady owner wiped her reddened eyes. Her Maltese had swallowed a chicken wing and had emergency night consultation at Vet 1. Surgery was quoted at $1,000. I estimated that Vet 1's fees would go up to $2,000 - $3,000, inclusive of the emergency night consultation and medication.

3 X-rays of the lateral view of the stomach by Vet 1 showed a chicken humurus (forearm) bone mostly in the oesophagus (gullet) and partly in the stomach. "Why did vet 1 take 3 X-rays of the same view?" I asked her as I was puzzled.

To see whether the bone had moved into the stomach".  Would the bone move, given time? I doubt it as the end inside the gullet was much larger in diameter. In any case, the dog vomited around 40 ml of white frothy saliva onto my consultation table twice and wanted to vomit more. This 12-year-old was in poor health. Heart disease was bad enough. She had gum disease (large plaques encasing teeth) and infection of the womb (pyometra). 

There was no time to wait for the bone to move into the stomach. But what are her chances of survival on the operating table? I said, "Due to her old age, her heart disease, infection of the womb, fever and general poor ill, I would give her a 5%".

I prefer not to operate on high risk anaesthetic cases as no good will ever comes out of it if the dog dies on the operating table.      

But her friend had referred her to me as I was once a horse veterinarian. "If you can operate on a horse which is such a large animal, you can operate on a dog," the lady said.

It was difficult situation for the owner too. If the dog was not operated, the dog would die a painful death from continuous vomiting, fever and starvation as food could no longer pass into the stomach. If her dog was operated a 5% chance of survival was not good enough. She took some pictures of her dog with her camera phone.   

1. No injectable sedatives or anaesthetics were used so as not to depress the cardio-respiratory system. There are good injectable anaesthetics but they require topping up to achieve surgical anaesthesia.

2. Was it possible to scope and take out the chicken bone from the mouth and gullet? A flexible scope with a forceps to grip the bone?  If there was such a scope, it would cost a lot of money. Here, the owner wanted the least cost surgery.

3. How to get the bone out then? The bone was trapped by the gastro-esophageal sphincter muscle. Would it be possible to pull it out of the gullet via the sphincter? Would there be traumatic injury and bleeding to the sphincter?

4. What surgical approach would be used? There was only one simple approach - via the stomach. I could not feel the bone on palpation of the stomach. Therefore, it must be sticking into the stomach by a short length only. X-rays showed it was around 1/4 inside the stomach.

PROBLEM 1. Difficult Airway/Aspiration Risk

Isoflurane gas by mask was given. When the dog was sleepy, I opened her mouth to intubate. Her epiglottis was covered by white foamy saliva. It was like a smoke screen. No opening of the epiglottis could be seen and therefore I could not put in the endotracheal tube and therefore could not maintain the surgical anaesthesia with gas.

"Too much saliva make intubation impossible," I said to my assistant Aung. "What is the solution?"

Revert to the use of injectable anaesthetic? This seemed to be the only choice. Injectable anaesthetic would be very risky as there was no rapid means of reversal should the dog's heart fail.

Aung was ready to get the injectable anaesthetic.

"Wait," I said. "I will hang the dog upside down, slap her chest to get the chicken bone to drop out."  I held the Maltese by her hind legs and slap her thorax 4 times.

Aung looked at me in surprise and probably wondering whether I had gone nutty. No chicken bone would ever drop out just like that. It was just physiologically impossible. Aung was a serious man. He seldom talked more than necessary to me but he said, "It is not possible to get the bone out this way."

Hanging the Maltese upside down was to get the frothy saliva out of the epiglottis and out of the mouth. But I did not tell Aung and so he really thought that I had intended to get the chicken humurus bone out by simply hanging the dog upside down.

The difficult airway/aspiration risk problem was resolved. The saliva was gone and I was able to intubate the dog.

PROBLEM 2. Chicken bone's end was larger inside the oesophagus than inside the stomach (see X-ray).
Would pulling the chicken bone out traumatise the gastro-esophageal sphincter? 

"Can the chicken bone be split into 2 long halves?" I tested Aung who had a big passion for veterinary medicine and surgery. Aung must have thought I was nutty again and shook his head. The bone end inside the stomach was felt. The problem was that it was a smaller diameter than the end inside the gullet. Would pulling it out via the stomach damage the sphincter and cause bleeding?

The dog must be trying to vomit out the bone end inside the stomach but the sphincter would not permit it as it tightened round the bone.

From my horse medicine, I used anti-spasmodic drugs for impaction colic. 30 minutes before surgery, I had given this dog an anti-spasmodic injection so as to relax the sphincter muscle. Antibiotic was given too.  

I put the artery forceps into the stomach incision, felt and gripped the end of the bone and pulled it out at one go. The bone came out easily. 2 pieces of meat came out too and I was careful not to let them contaminate the peritonium by removing them fast.

The gastric mucosa was purplish as I sutured it with an inverted continuous suture. Some blood flow to it must have been cut off, otherwise it should be pinkish. Fortunately, there was no delay in the surgery. Two inverted continuous suture closed the stomach wall. The dog woke up in a daze but was all right. 

The dog had no problem during anaesthesia. Her tongue was a healthy pink colour. She went home at day 6 after surgery. Once home, she was active and ran to greet her owners when they come home from work. So she started to pant.

She was warded on day 8 for observation and treatment of her heart disease. She was still bleeding from the pyometra infection and had this bleeding for at least 3 months. The only cure was surgery to spay her.

I feel that another veterinarian should do the spay as it is not good as this dog may die on the operating table. And chances are very high that she would die. Why should I tempt fate a second time?

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