From:
Bruce Williams, DVM
Date: 2001-07-11 00:02:00 UTC
Subject: Re: Vets: Need advice on difficult adrenal case (vascular
surgery, caval ligation, cryosurgery, etc.) -- PLEASE HELP!
--- In Ferret-Health-list@y..., "Alicia D. Beth" <alicia@b...> wrote:
> Hello to all ferret-lovers,
>
> This post is lengthy, but we are in a bit of a dire situation and
would
> appreciate absolutely *any* feedback...
>
> One of my ferrets, Florian, is an altered male silver-mitt who just
turned
> 3. Since about December 2000, my husband and I have suspected an
adrenal
> problem, due to a tiny bit of hair loss at the tip of his tail (no
other
> symptoms). After 3 trips to our veterinarian (and 5 normal glucose
> levels), an adrenal panel indicated that our suspicions were
> well-founded. On Monday (7/2/01), Florian went in for what we
thought
> would be an adrenalectomy. While in surgery, the vet called me to
let me
> know that Florian has a tumor in a very precarious place on the
right
> adrenal (nothing on the left and no insulinoma that we know
> of). Apparently, the tumor is wrapped around his vena cava and may
even be
> invading it. The vet offered me 3 choices. He could:
>
> 1. attempt to remove the entire tumor (he suggested a very high
risk of
> hemorrhage and/or death).
> 2. de-bulk the tumor (he suggested a high risk of hemorrhage/death
even
> with this option).
> 3. biopsy the tumor and refer Florian to a vascular microsurgeon.
>
> Our vet suggested that the safest and best chance for Florian was
option
> #3, so this is what we chose to do. In the end, our vet was not
even able
> to biopsy the tumor, as he thought it too risky to even attempt
since the
> tumor is buried under the adrenal, wrapped around the vena cava,
and all
> *approachable* tissue appeared normal.
>
> 1. Is traditional vascular surgery the best/safest route, or should
we
> pursue someone who might be able to perform a caval ligation,
cryosurgery,
> or some other procedure?
> 2. I understand that caval ligation is only possible if collateral
> circulation has been established, so we would need to find a
veterinarian
> in our area (Austin, Texas) who is experienced in identifying
whether this
> has happened. Any ideas on how to go about doing that? Would it
ever be
> the case that we should *wait* for collateral circulation to
develop before
> attempting surgery?
> 3. How accepted a procedure is cryosurgery? If we decided to go
that
> route, what are our chances of finding an experienced cryosurgeon
in our
> area? And how would we go about finding one?
> 4. Is anyone aware of any other medical/surgical options that would
give
> Florian a good chance for life? We're open to absolutely *any*
> suggestions, and we'd love to hear as many perspectives as possible
(either
> on- or off-list).
Dear Alicia:
If your vet suggested that there was a good chance of extensive
hemorrhage inthis case, then it is probably best that he did not
proceed. A man has to know his limitations, and it is far better
that he pulled out rather than to perform a risky procedure.
As a general rule - in these cases, caval ligation is often of
benefit. In some cases, caval blockage of only 50% may be enough to
develop an adequate level of collateral circulation. However, this
is a salvage operation, and is associated with about a 15%
mortality. There is little way to determine whether adequate
collateral circulation has occurred before the cava is ligated - it
is based on an educated assessment of the situation and knowing that
there are few other options.
Cryosurgery is another possibility - the use of the cryoprobe is
associated with less risk than a scalpel blade when used in proximity
to the cava - vessels are relatively resistant to the freezing
technique. However, with this procedure, there is a higher chance
that the malignancy will not be completely removed, especially if it
goes around and under the cava.
The use of a vascular microsurgeon may be another viable way to
approach the problem - these specialists are generally not available
to all, necessitating the use of the other techniques.
You can't fault your vet for knowing when to call in the cavalry - I
know you and Florian all want the best outcome for this surgical
procedure.
With kindest regards,
Bruce Williams, DVM