Hari 5 days post adrenalectomy

[Planti]

Hellooo, I am new here, just found the forum when I ran out of answers from scholarly articles. Harrison aka Hari is a 12.5 yr old PWD, neutered male, sweetest Portie on the planet and best spooner. Diagnosed with Cushings December 2016 after about a year of symptoms, panting, night wakening, hyperphagia, dementia like symptoms/personality change and recent unlearning of proper potty rules. I had started looking for answers a year ago but none were found.
Early December, back to vet, Cushing's on history and physical, LLDT abnormal but not diagnostic of either Cushing's Disease or Syndrome, only a moderately elevated Alk Phos on Geriatric panel. So detailed US done ASAP and found enlarged Right Adrenal, normal Liver, Kidneys, Pancreas, Lungs (XRay).
Hari has been a healthy senior so far. I live in a semi rural area on Vancouver Island, feed raw food, filtered water, use natural cleaning stuff like vinegar and baking soda, big yard but don't use chemicals on lawn, avoid plastics, give some researched nutraceuticals and have avoided any unnecessary vaccinations. He was desexed at age one according to the breeders contract.
My vet is cautious but givenHari's relative health despite his age and the apparent lack of mets or other organ problems, we went to a large centre in Vancouver as soon as reasonably possible for consult with an experienced surgeon and he had surgery the following day. They repeated his bloodwork, US and CXR, did a bleeding time and crossmatched him in case. Their was still no evidence of mets.
The surgery went well as could be. He was stable metabolically during surgery, blood loss was controlled, no extra fluids/blood necessary, blood pressure okay. The incision was at first midline but had to be extended to the right under to get better access. The Right adrenal virtually popped when extraction was attempted.

My surgeon said she had seen this before and did not know why it would have happened, he did not receive any medications prior to surgery (I have seen report of necrosis due to mitotane and rare with trilostane). He had a couple of weeks of melatonin and about a week of melatonin plus lignans from Norwegian Spruce. Surgeon did not think that would have caused the problem. His left adrenal looked normal in size and consistency but of course presumed to be not functional.

They lavaged the retroperitoneum to try to suck up any errant cells and closed. He did very well post op, eating within 24, urine output normal, pain control with Fentanyl then oral acetaminophen. Started on oral pred 15 mg per day. Out of ICU at 48 hours post op and apart from some breakthrough pain day 3 has been managed on 325 mg Tylenol Q8h, or half q4h. First reduction of Pred to 12.5mg planned for 3 days from now.

He finally pooped day 4 and we made the 5 hour journey home by car and ferry today. We are all glad to be home.

So, my questions:
1. how have others CC pups fared post surgery?
2. things to watch for
3. reducing prednisone (should I switch to HC so ACTH can be measured?)
4. wound management suggestions, anyone tried Manuka Honey or BioGel by Anjon?
5. I will be making bone broth and continuing with melatonin, milk thistle and maybe adding Salvestrols after consultation with naturopathic vet (my regular vet knows about this and doesn't freak out). I am not totally out there as I am a human MD with research skills.

I am so sorry to see the pups who have passed from this nasty disease. Is there any question about routine desexing and adrenal stress causing more adrenal disease? Do we see more adrenal disease than in Europe where desexing is not as prevalent.

Sorry for so many questions. I am very impressed with what I have read so far, but I can't seem to access the Articles portion with my new membership.

Thank you, Lauren and Hari and his bff Woggly the PomxTasmanian devil

[WinstonTheWestie]

My Westie Winston had an adrenalectomy five months ago. Like Hari, he also had a tumor on his right adrenal gland. We had found the enlarged adrenal gland 18 months prior to surgery. It was stable in size for about a year, then between months 12 and 18 it doubled in size, so we pursued removal.

After surgery, Winston did very well. The surgeon told me if they survive the surgery they usually do well long-term, and she was right. Winston came home on day 2 or maybe 3, and by day 5 or 6 he seemed back to normal for the most part. He had no ill effects in the post-op or recovery period. He acts as if nothing has ever happened to him, and he is coping with life with one adrenal gland very well. He plays, we've traveled via airplane (him in the cabin with me), and by all accounts I do not regret the surgery.

I was told to watch closely for signs of pancreatitis (vomiting, diarrhea, not eating) for the first few days since the pancreas is so close to that area they were manipulating. I was also told to watch for signs of Addison's disease once we began to taper the prednisone. The gradual tapering allows the remaining adrenal gland (that was previously essentially 'shut off' due to the tumor) to become functional as you go. Things to watch for at that stage were lethargy, inappetance, vomiting, weakness, diarrhea.

I was told that opinions for when to consider rechecking ACTH after surgery differed between internists, but we were told to complete the prednisone taper over the course of 10-12 days and then once he was off of the prednisone, we would retest around day 14, which was also when his staples would come out. We completed the taper, and Winston had his ACTH which was very slightly low, but not so much that they wanted to continue giving him prednisone. He was fine after stopping the prednisone as well.

I did nothing special as far as incision care aside from the warm and cold compresses several times a day, as recommended by his surgeon. It is my understanding that manuka honey and such are good for open wounds and promoting granulation tissue but would be unlikely to be of benefit for a clean surgical incision, which heals within days in most cases. I would check with Hari's surgeon before applying anything to the surgical site, personally.

The biopsy results should tell you a lot about how closely you will need to watch Hari for tumor regrowth, metastasis, or new tumors arising from the 'burst' cells in the future. Do you have that back yet? Winston had a cortical adenoma...he had an ultrasound one month after surgery to get new 'starting place post-op' images and then three months later (4 months post-op) to check on things, and our next check is not until July. After that the internist just wants to see him on a yearly basis if things remain stable. I hope Hari does as well as Winston did. You both have already come a long way through the scary journey of adrenalectomy. The ladies here are very knowledgeable about ACTH testing and all of that, and we'll be eager to hear how he fares moving forward. Welcome to the forum!

[Squirt's Mom]

Hi and welcome to your and Hari!

I have a question and pray I am misreading something or have missed something in your post. You said -


Early December, back to vet, Cushing's on history and physical, LLDT abnormal but not diagnostic of either Cushing's Disease or Syndrome, only a moderately elevated Alk Phos on Geriatric panel. So detailed US done ASAP and found enlarged Right Adrenal, normal Liver, Kidneys, Pancreas, Lungs (XRay).

Was an adrenalectomy performed simply because the adrenal gland was enlarged?

Of everything you wrote (and thanks so much for the details so far) this is the most critical thing I see. It would help us a great deal if you would get copies of all the testing done prior to the surgery and post the abnormal results here along with the normal ranges and units of measurement for each abnormal value plus all comments on the US and the full results of the LDDS.

As for the Articles section - that showed up with our recent update and we don't know exactly why. ;) The information you are probably looking for can be found in our Helpful Resource section. http://www.k9cushings.com/forum/forumdisplay.php?10-Helpful-Resources-for-Owners-of-Cushing-s-Dogs

We have had several members who faced an adrenalectomy due to either a cortisol secreting tumor found with Cushing's or a Pheochromocytoma (not associated with Cushing's). You can use the Search feature above and it should help you locate those threads.

I'm glad you found us and look forward to learning more as time passes. Hopefully others will be along soon to chat with you as well. I pray Hari's recovery is swift and uneventful! Do be aware of changes that could indicate pancreatitis as that organ is persnickety and does not like to be disturbed at all...and often it is moved during abdominal surgeries.

Hugs,
Leslie

[flynnandian]

welcome here on the forum from us.
we do live in europe and i keep my dogs as natural as possible too.
that means raw food, no desexing, i do titer my dogs, so they only get their puppy vaccinations and sometimes at age 1, but after that the titers show they are protected for life.
no de- worming neccesary according to stool sample tests, no dentals because of raw food, and still i got 2 dogs with cushing's disease.
one of them died at age 10 3/4, the other one lived up to 14 1/2 years old.
i still own the sister of the last dog and she is almost 16 years old and has last seen a vet dec. 24th 2007.
so a very healthy line of dogs and still i had 2 cases of cushing's disease.
i hope harrison is a survivor. it is a tricky operation after all.

[Planti]

Hi Kellie,

Thanks so much for getting back to me and I am very glad that Winston is doing well. How old is Winston and did he have any other health concerns prior to surgery?
I do wonder about the high dose pred as he is still behaving as if he has hyper-adrenalcortisolism, which he has. This taper will not end until April the 4th. I will work closely with my vet to see if there is any possibility of reducing more quickly.

I had no suggestions of any compresses or other treatments but the staples and incision look fine so far.

The biopsy results won't be back for a couple of days. I am so hoping that Hari's tumour is an adenoma, as he had symptoms for a year and no sign of mets at surgery. The tumour dissolution is more worrisome.

My vet has some doubts about ACTH testing at all, says it is highly unreliable.

Thanks again for your response and the good news about Winston, he looks very cute. Lauren

[Planti]

Hi Leslie,

His tests indicated that his cortisol was high and not suppressible but the numbers were all in the borderline area. He is pretty obviously Cushingoid physically with pot belly, loss of muscle mass, thin skin, ravenous, polyuria/polydipsia, poor dry coat and loss of hair, change of behaviour, panting, sleep disturbance and much more.

What I meant was that the tests were abnormal but they could not differentiate between pituitary or adrenal Cushings not that he did not have hypercortisolism.

I don't have all the tests in one spot but will post them when I catch my breath.

Many thanks for being there for us all, Lauren and Hari, woofing for his dinner.

[Planti]

Hiya, That is interesting to hear that your dogs despite not being desexed and having attention to diet, toxins and more still have Cushings. Sorry I meant to say that intellectually it is interesting but I do feel for you and your doggies.

What breed or breeds are your dogs? I am happy that they lived to senior years. I know that adrenalectomy will only make the last maybe 2 years of my Hari's life better. He is pretty strong so far. I only wish for him to regain his sense of play with his Airedale girlfriend. I live in a pretty idyllic place for dogs, near the sea, good air, happy vibes.

All best wishes, Lauren

[WinstonTheWestie]

Winston is 8 and 1/2 now. He has inflammatory bowel disease, atopy, and our internist thinks he has chronic pancreatitis though I don't really ever see signs of pancreatitis. We found his tumor incidentally during an ultrasound when we first diagnosed his IBD. It sounds like Harrison had a few more signs beforehand than Winston did, so perhaps that contributes to a need for a longer taper? I don't know if that matters or not. I definitely don't think it is wrong to discuss it with your vet, your internal medicine specialist (if you have one), and/or the surgeon, especially if Hari is having signs of iatrogenic Cushing's. We did cold compresses for 10-15 minutes (or as long as he'd let me, he was tender at first) 4x per day the first two days he was home then switched to warm (a dish cloth soaked in warm water placed in a zip-top bag) for about 5-7 more days. I admit they were less frequent as I went back to work.

[flynnandian]

Hiya, That is interesting to hear that your dogs despite not being desexed and having attention to diet, toxins and more still have Cushings. Sorry I meant to say that intellectually it is interesting but I do feel for you and your doggies.

What breed or breeds are your dogs? I am happy that they lived to senior years. I know that adrenalectomy will only make the last maybe 2 years of my Hari's life better. He is pretty strong so far. I only wish for him to regain his sense of play with his Airedale girlfriend. I live in a pretty idyllic place for dogs, near the sea, good air, happy vibes.

All best wishes, Lauren

hi lauren, flynn was a border collie and ian a shetland sheepdog mix.
flynn had all the symptoms in the book including the rare ones. he couldn't tolerate vetoryl because of arthritis.
ian had much less symptoms and tolerated vetoryl well.
they were sport/working dogs and i took them to the beach, forest etc. for long hikes.
living in a rural area too.
they never had steroids in their life or any other meds, so it was just bad luck i guess.
just look at how harrison is doing on the pred. maybe his other adrenal will kick in soon, so he doesn't need pred for a long time.
what kind of breed is harrison?

[molly muffin]

Hello and welcome. Vancouver Island, one of my favorite places in Canada, but not the greatest for pet emergencies perhaps.

I would recommend trying the compresses that Kellie mentioned. Her Winston had a very good recovery from his surgery. We are all very proud of her and Winston.

Having been on here and the Facebook group for quite a while, I would say that Europe, Australia, etc have a large ratio of occurrences of cushings in dogs, comparable with the side of population, but with sometimes less recourse for treatment than North America.

Hoping to hear of continued positive recovery for Hari.

[Planti]

Hi, Hari is a Portuguese Water Dog. Sorry I have not been online for a bit due to nursing duties. That is very bad luck about two dogs having Cushing's despite very good conditions.
Now almost 3 weeks from surgery and he is doing very well as far as healing. His staples are out (there was a very big incision), he has had one reduction in Prednisone but still acting like a dog who is on very high steroid (currently 7.5mg/d and he is about 28 kg). He is completely food obsessed and spends all his time standing in the kitchen looking at the counter as if food will jump off. He is not interested in playing. But he is interested in being petted, eating and drinking, peeing mostly in appropriate places and sleeping reasonably well. He has a benign tumour on his foot that he has bothered and made bleed so he has been with cone (tried everything else) for 3 weeks.
We hoped to postpone surgery on the tumour until he was on a lower dose of prednisone but it is a very fragile vascular tumour (cavernous hemangioma, but not a sarcoma). There is very scant information on these tumours online. The treatment is removal, with low rate of recurrence but given that he is on steroids and it is in a place where closure will be an issue it seems like a no win situation. Poor chance of healing whether he has removal or not.
I asked my vet, who is very good to prescribe Timolol drops to use topically as there are reports that infantile hemangiomas can stop growing and subside with this fairly risk free treatment. It does help it stop bleeding and with the eye of faith might be increasing the tissue growth around the margins.
My vet says there is no way to know if the other adrenal is kicking in.

[Planti]

Hi Sharlene,
Thank you for your welcome and your wishes and yes, Hari is so far a surgical success but not sure his QoL is any better or different than before. Indeed it is a fair bit worse due to the tumour on his foot and the cone that ate New York. It has to be enormous so he can't reach his foot, and that means he can't eat or drink without help, and I think it is depressing him. I am with him except for short trips to gather provisions.
Though the tumour is benign it is vascular and bleeds a lot. A topical beta blocker timolol has been shown in human babies to cause reduction in hemangioma growth and occasionally to produce remission after a few weeks, though those tumours generally grow for a while and then spontaneously regress and disappear at age 3-4years or so. The literature I can find on canine hemangiomas that are not sarcomas is extremely meagre. What I can find it that they are typically locally invasive of tissue which I think makes it likely to heal very poorly with a local excision.
Have you ever heard of this sort of vascular tumour appearing in Cushing's pups? Interesting that those places have lower rates of desexing too I think.
The connection to Cushings is that his post op Prednisone is interfering with healing, and will interfere if and when we try to resect. I thought that he was a little more like his pre Cushing's self, but have to say that no, he is still completely food driven and cognitively dull as before.
I moved to Comox about 13 years ago but am from BC originally and don't regret moving to a more rural location. Lovely place to live. I have a good vet, though he is quite clear when he would rather refer to a bigger centre. We don't have a full time open vet emergency but my vet has a call schedule and they will come in for emergencies. There is some availability of CT and there is a very good Ultrasonographer who can be booked, but that is not an emergency service.
Where in the world are you situated? Where on the Island (note the capital letter it was done without thought) have you been?
Thanks for being there. Lauren

[molly muffin]

Hi Lauren, I'm in Mississauga, Ontario (next door to Toronto) My mother in law lived in Victoria until recently when she moved here to be closer to us as she gets older. My Brother in Law still lives in Victoria though and I have friends there and work colleagues.

No I haven't heard of any speicific vascular tumor like what Hari has. It might be unrelated to the cushings in fact.

Are you reducing the prednisone? I think that the predinsone needs to be reduced on a schedule, as was discussed earlier with Kellie. And then testing to see if his adrenal gland can produce on it's own. The prednisone has to be decreased so that the other gland actually does start to kick in. A follow up ACTH once pred is removed will determine if the gland is working.

If it never kicks in then a move to Dex would be an option.

You want him off the pred so that the surgery can be done, with him off prednisone.

Poor guy to go through so much. I had a golden retreiver that had such horrible allergies (since age 2) she was on prednisone all her life, and no one told me anything about introgenic cushings, which she had, but I was just told, side effect of the prednisone. Anyway, she had hematomas in her ears, so bad, and so often, that she lived in a cone it felt like. Off and on for years. Many surgeries, it was horrible that girl, she would definitely figure out a way to get around and do whatever she wanted with that cone on or not. Would any of the soft cones work?

[Planti]

Re: Update on Hari the PWD. Hari turned 13 on May 22. He has done very very well. The tumour on his toe, we named Timmy and he was very difficult to heal as it was vascular but benign. I put Timolol on it as that is supposed to shrink hemangiomas on babies and it worked I think. Anyway the tumour shrank to a nubble that was barely palpable and did not need surgery. His prednisone was tapered and gone by end of February and his remaining adrenal making sufficient cortisol. He may have had a bit of a stroke during surgery or recovery because he is a bit wobblier than before, so much so that vet thought he might have Degenerative Myelopathy. However, with physio he has regained some muscle rather than deteriorating further and has even played with another dog, something not seen in almost 2 years.
He has not regained his lovely coat it is dry and scant, and he has very dry flakey skin, more so than ever before. His appetite remains very good, too good in fact and his loss of manners persists. I have to remove the knobs from the gas stove as he jumps up and turns on the gas!
His personality is more like his former self and I feel like one lucky dog mom.
Thanks so much for this forum and the love of dogs, Lauren

[Squirt's Mom]

What a great update, Lauren! SO glad your sweet boy has recovered so much of himself.