Recovery from Surgery with Cushings

[Mark W.]

Hi, my name is Mark and my dog has had Cushings for some time. He has done well with using medication to keep it under control and is living normally with it. The problem we face now is he has cancer on one of his anal glands. The good news is it can be removed as we caught it quick, the bad news is the vet told us with the Cushings he may not recover from the surgery. Literally went with 50/50! What I’m I to do? My question is for anyone who has had somewhat of a similar experience and had a surgery performed. I obviously wouldn’t base all my decision on that information, but maybe it could help.
Thanks to any who respond.

[molly muffin]

Hello and welcome to the forum.

Some questions first, where are his cortisol levels at now? How is his Blood Pressure? Have they done any clotting tests on him?
Have they done an ultrasound to see if any lymph nodes are enlarged or if there has been any spreading to the prostrate? How is his temperature?

I know that is a lot of questions to start off, but it's sort of the things you will want to know in order to make a decision about surgery going forward.

I am also going to copy/paste a questionaire that one of our members made up for when someone is facing adrenal surgery. It does however, pertain to any surgeries in the more generalized areas, so some things for you to think about and to discuss with the surgeon.


Part I - Questions to ask when considering if surgery is an option for your dog’s adrenal tumour:
1. What type of tumour do you suspect, ?functional, ?non-functional, pheochromocytoma, benign, metastatic
2. Expected life span for my dog in a normal situation. If your dog is close to, at or past his expected lifespan for his breed is surgery going to be of any benefit?
3. Prognosis for my dog if we treated medically i.e. with Cushings medications. AND if we do not proceed with surgery how long do you think it would be before the tumour started adversely affecting his quality of life?
4. If he is miserable now, does the benefit of potentially risky surgery outweigh his current quality of life?
5. Are there any other health problems that could impact on a positive surgical outcome, for example: if your dog is overweight or has heart, BP, liver, kidney or lung conditions
6. Is there any sign of tumour spread – imaging should be done, including ultrasound and on advice of specialists either CT or MRI to check whether there is local invasion around the tumour, into blood vessels including vena cava or spread further away in the body to lungs etc
7. Surgeon recommendations – would he/she do it for their own dog?
8. Psychological impact for the owner: It is important to understand this is risky surgery, sadly current guidelines indicate 1:5 dogs do not make it, and some recommendations are not even that high. Can you accept it if your dogs dies during or in the postoperative recovery period surgery? This is where it is important to weigh up whether the benefit of your dog being fully cured is worth the risk of possibly losing him.
9. Financially – can you afford it? Find out estimate of costs.
10. Hopefully this will not happen, but if your dog collapses, e.g his heart stops either during his surgery or afterwards what emergency measures should be undertaken, do you want your dog to have CPR, how far are you (the owner) willing to go for your dog to be saved in such circumstances

Part II - Surgery has been recommended as treatment for your dogs adrenal tumour, here are a few suggestions on what questions you should ask your surgeon:
1. Are you board certified? How many operations of this type have you done? What complications have you experienced? What were the outcomes?
2. Please explain to me how you will do the surgery, which part would likely give you the most trouble? Will you be doing the actual surgery or a resident in a teaching situation? If so, is their close supervision?
3. Will there be a specialist anaesthetist available for the surgery?
4. If it hasn’t been done, do we need a CT/MRI scan to look at the tumour more closely to check for vena cava involvement or any other tumour spread?
5. What are the risks associated with this surgery, including
• Bleeding (including trauma to blood vessels or other organs during surgery)
• clots
• Blood pressure or heart problems such as arrhythmias
• pancreatitis
• pneumonia
• kidney failure
• infection
• wound problems
• bowel problems
• anaesthetic risks
• adrenal insufficiency or electrolyte abnormalities
• death (sorry but you have to ask that risk too)
6. If we proceed with surgery does my dog need preoperative treatment with Cushing’s meds, antihypertensive if high blood pressure is a problem – phenoxybenzamine recommended preoperatively for dogs with pheochromocytoma, anticoagulants or anything else?
7. How will you treat to prevent clots postoperatively?
8. What would you do if you found anything else during the surgery i.e. nodules in other organs e.g. spleen, opposite adrenal, liver, kidney. Would you remove them and what are the risks associated when doing additional abdominal surgery together with adrenalectomy
9. How long will it take and when will you contact me so I know all is OK, when can I visit after surgery?
10. How will the postoperative period go, how long would you anticipate he would need to stay in hospital? How will we manage pain?
11. What monitoring would be needed, e.g. heart monitoring, oxygen levels in the postoperative period
12. If your dog has an adrenocortical tumour affecting cortisol production will he need to be on steroids following surgery and for how long?
13. If there are problems when I take him home, who do I contact? Hopefully the surgical team until all is stable. with some questions to ask the surgeon:

[Harley PoMMom]

Hi Mark,

Welcome to you and your boy! I'm not a vet, so this is just my opinion, if your boy's Cushing's is under control I see no reason why this surgery can not be performed, but it may take him longer to heal. Did the vet explain his reasons for that 50/50 survival rate?

My boy, Harley, had 3 teeth extractions that were performed at one sitting, and this was when his Cushing's was not controlled, he sailed right through this surgery with flying colors, no complications at all. Harley's vet did state that they would be doing things a bit different with him since the Cushing's was not controlled: like pushing more fluids before, during, and after surgery; using a different kind of anesthesic that's not as hard on a dog with some type of illness, I believe it was Propofol. I realize Harley's case is much different than your furbaby's, however I just wanted to share some of the things that Harley's vet did do.

I am so happy to hear that your furbaby's treatment has and is going so well, this kind of news will bring hope to our members who are on this new journey with their pups.

Would you mind sharing some information regarding your boy's Cushing's history? When was his most recent ACTH stimulation test done and could you post those results? What medication is he taking for the Cushing's? Does he have the adrenal or pituitary type of Cushing's? How are his symptoms?

I am sorry for the reasons that brought you here but sure glad you found us.

Hugs, Lori

[Haleth]

Hello Mark, I cannot speak to this specific surgery, but my Haleth did experience serious abdominal surgery: one lobe of her liver was removed to take care of a malignant tumor that had burst. We had our surgery done by a specialist surgeon at a referral centre as it was difficult and she was in a very bad way. The regular vets I go to practice minor surgery, but if, say, Haleth's wonky gall bladder also ruptured, we would go back to the surgeons at the referral centre who are trained to do challenging surgeries like the one your pup may undergo. If the vet you spoke to was the equivalent of a GP, I would suggest asking to be referred to a surgeon as well as an IM specialist if you don't have one yet. Is there a university vet centre or referral clinic in your area that you can be referred to? Someplace with an ICU and trained staff just for the ICU? Haleth had to spend at least a couple days in the ICU because of the expected heart and bp fluctuations before being transferred to a normal "ward". I say this not to scare you, because Hallie came out of that situation and is still with is a year and a half later, but to show that you will want a surgeon experienced in abdominal surgeries at the very least and that if critical care is warranted, the ideal is to have critical care specialists and monitoring 'round the clock. Please don't assume your pup will need ICU care; that would be something to ask a surgeon who knows what to expect. To give you an idea of the specialists involved, here's the website of the emergency/referral centre that did such a tremendous job: http://vectoronto.com/services/surgery/ (for ICU see the menu)

[molly muffin]

I absolutely agree that a board certified surgeon who has done many of the else surgeries with good outcomes and the doing it in a top facility with ICU if needed is absolutely the only way to go. I wouldn't personally use anything other than that.

[Mark W.]

Thanks to all or responding. He is 12 years old and has been on medication since 2010/2011. He is 100% symptom free since with regular testing and medication. He sleeps more than normal, but acts fine otherwise, even some playtime, and we have kids 5 and 8 year old so, he is in good shape under the conditions. The cancer seems to have been caught very early and was called very aggressive. They said that with Cushings the surgery would be a big deal. They may playing it safe a bit, I don't know, but I am leaning toward the surgery as he seems to be strong enough for it. I will definitely ask about their expertise and qualifications, thanks and will check back.

[Mark W.]

I'm glad you guys have had good luck helping your dogs deal with this disease. Maverick gets 10 mg trilostane twice a day and is 20 pounds. That dosage has been consistent for years. His symptoms were wetting the floor uncontrollably, and I think pituitary. It has been expensive but I won't do it another way.

[molly muffin]

That is great that he has done so well on the same dose for years. Yes, it is definitely an expensive disease.

I do worry about that aggressive remark. With aggressive cancers situations can change very quickly. When do you see the surgeon and have to make a decision?

[molly muffin]

Mark, I just wanted to check in and see if you had a consult with the surgeon or what is going on with that?
I wouldn't wait too long since they have termed it aggressive to get it looked into.