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Mammectomy in Dogs

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Surgical stress and postoperative complications related to regional and radical


mastectomy in dogs

Article  in  Acta Veterinaria Scandinavica · June 2015


DOI: 10.1186/s13028-015-0121-3

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Horta et al. Acta Veterinaria Scandinavica (2015)7:34
DOI 10.1186/s13028-015-0121-3

RESEARCH Open Access

Surgical stress and postoperative


complications related to regional and radical
mastectomy in dogs
Rodrigo S. Horta, Mariana S. Figueiredo, Gleidice E. Lavalle, Mariana P. Costa, Rubia M. C. Cunha* and Roberto B. Araújo

Abstract
Background: Surgery is the treatment of choice for regional control of mammary neoplasms in female dogs.
Various surgical techniques may be used, as long as mammary gland anatomy, lymphatic drainage, and known
prognostic factors are respected. The purpose of this study was to compare surgical stress—including duration of
surgery, nociception and hematological changes—and postoperative complications in dogs undergoing regional
and unilateral radical mastectomy. Eighteen dogs were selected for each technique. Postoperative pain
(nociception), hematological changes, and postoperative complications were compared between the two groups.
Results: The group treated with radical mastectomy had a longer surgical duration, showed more intense
physiological changes, achieved higher scores on nociception scales, and experienced more postoperative
complications.
Conclusion: Compared to regional mastectomy, radical mastectomy was associated with longer surgical duration,
greater nociceptive stimulus, greater surgical stress, and higher incidence of postoperative complications in dogs.
Although evaluation of long-term results was not a goal of this study, it is suggested that postoperative recovery and
patient quality of life should be considered when choosing a surgical approach for treating mammary tumors in dogs.
Keywords: Dogs, Mammary neoplasms, Surgery, Pain, Regional mastectomy, Unilateral radical mastectomy

Background disadvantages of each surgical procedure have been thor-


Mammary gland tumors represent 42 % of all tumors in oughly debated [6]; however, to our knowledge, postop-
female dogs [1]. Despite many efforts to develop new erative aspects have not been considered.
treatment modalities, surgery remains the treatment of Although mastectomy is associated with a relative low
choice for most dogs with mammary tumors [1, 2]. Dif- morbidity, it is considered an invasive surgery that may
ferent surgical techniques may be applied to promote cause moderate to severe pain. Postoperative complications
local control of disease. The simplest and least invasive are common, especially when more aggressive surgical
procedure necessary to remove all nodules and adjacent techniques are used [7, 8].
lymphatic tissue should be selected [1]. In a prospective Aggressive procedures with extensive incisions and re-
study, MacEwen et al. [3] did not find differences in sections probably are associated with higher nociception
overall survival time and relapse rate when comparing and postoperative stress, compromising patient quality of
simple mastectomy and radical mastectomy in 144 dogs. life. Those often are performed as prophylactic surgeries
Nevertheless, some researchers have suggested perform- without an adequate clinical indication or evident benefits
ing aggressive procedures as a prophylactic measure to the patient [1, 2].
owing to the possibility of development of new lesions The purpose of this study was to compare surgical
in the remaining mammary tissue [4, 5]. Advantages and stress (including duration of surgery, nociception and
hematological changes) and postoperative complica-
tions in dogs undergoing regional and unilateral radical
* Correspondence: rubiamcc@gmail.com
Veterinary School, Universidade Federal de Minas Gerais - UFMG, Avenida
mastectomy.
Antônio Carlos, 6627, caixa postal 567, CEP 30161-970 Belo Horizonte, Brazil

© 2015 Horta et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Horta et al. Acta Veterinaria Scandinavica (2015)7:34 Page 2 of 10

Methods discharge, patients were treated with cephalexin2 (30 mg/


Animal selection kg orally [VO]) every 12 h until 10 day after surgery.
Thirty-six female dogs of different breeds with a clinical All dogs were premedicated with acepromazine maleate3
diagnosis of mammary tumor were subjected to regional (0.05 mg/kg intramuscularly [IM]) and morphine sulphate4
mastectomy (18 dogs) or unilateral radical mastectomy (0.3 mg/kg, IM). Anesthetic induction was performed with
(18 dogs). Patients were excluded if they presented abnor- propofol5 (5 mg/kg, IV). After orotracheal intubation,
malities, such as anemia, azotemia, coagulation disorders, anesthesia was maintained with isoflurane6 in an inhalant
severe cardiac impairment, and pulmonary metastasis anesthesia machine with vaporizer and a semiclosed circuit
visible on thoracic radiographs, during preoperative exam- for dogs larger than 7 kg, and with a Rees-Baraka system
inations. Patients with solitary lesions were not included, for dogs smaller than 7 kg.
as they were subjected to nodulectomy, whenever lesion Immediately after surgery, each animal was medicated
was smaller than 1 cm, or to simple mastectomy, if the with morphine sulphate (0.2 mg/kg, IV) and meloxicam7
lesion size ranged through 1–3 cm. (0.2 mg/kg, IV). In the first 24 h, animals were kept in
The Ethics Committee on Animal Experimentation of the Veterinary Hospital, with compression bandages. An-
Universidade Federal de Minas Gerais, Brazil, approved this algesia was performed with tramadol chlorhydrate8
study (protocol number 23/2011) and the authorization for (3 mg/kg, IV) 6 h after surgery and every 8 h thereafter.
inclusion of each patient was obtained from its respective After discharge, patients were medicated with meloxicam9
owner with a free and informed consent form. (0.1 mg/kg, VO) every 24 h for 4 days and tramadol
chlorhydrate (3 mg/kg, VO) every 8 h for 5 days.
Surgical technique selection
Lesions on each mammary gland were identified properly Evaluation of surgical stress
and characterized according to size, adherences, necrosis, Patients were evaluated in 10 different times, including
and ulceration. Clinical staging (three-view thoracic radio- preoperative, transoperative, immediate, and late postop-
graphs and abdominal ultrasound) was performed for each erative periods. The first time was at the initial examin-
patient. When multiple nodules were present, the largest ation when the tumor was diagnosed (T1). This
lesion was considered for staging. happened approximately 10 day before surgery in a con-
Regional mastectomy was indicated for removal of ax- sulting room, in the presence of the owner. During the
illary or inguinal mammary lymphatic connections when preoperative period, patients were evaluated at three
a single lesion was larger than 3 cm. Cranial abdominal time points, as follows: T2, immediately before pre-
mammary gland was occasionally removed when per- medication; T3, 15 min after premedication; T4, five
forming regional mastectomy to achieve clean surgical min after induction and orotracheal intubation. During
margins or when lesions of 1–3 cm also were located in the transoperative period (T5), patients were evaluated
this gland. Radical mastectomy was performed when le- every 5th min, and their physiologic parameters were
sions > 3 cm were located on cranial abdominal gland. kept stable. During the immediate postoperative period
Regional and radical mastectomies also were performed (first 24 h), while they were still using compression
despite size of lesions when disperse nodules were bandages, patients were evaluated at three time which
present along the mammary tissue, in order to create were: T6, 2 h after surgery; T7, 12 h after surgery; T8,
one single surgical wound. An elliptical incision was 24 h after surgery. During the late postoperative period,
made around the mammary glands to be excised and animals were evaluated at two time points, according
subcutaneous tissue was dissected until exposure of to scheduled appointments: T9, 48 h after surgery,
muscle fascia. Major blood vessels were ligated, with a when compression bandages were removed and surgical
2-0 or 3-0 poliglecaprone suture, including superficial wound was evaluated; and T10, 10 day after surgery,
epigastric vessels, whenever inguinal mammary gland when stiches were removed.
was removed. Poliglecaprone also was used to advance Blood samples were drawn through jugular venipuncture
the skin toward the center of the defect with a walking su- at T2, T4, T6, and T8 to measure objective serum markers,
ture (2-0 or 0) and a subcuticular continous suture (3-0). invariably in the afternoon. Serum cortisol level was
Simple interrupted sutures were used to appose skin with assessed through chemiluminescence after blood storage in
a 3-0 monofilament nailon. Surgical duration was defined sterile tubes with clot activator, for as long as 24 h. A refer-
as the moment from surgical incision to conclusion of skin ence range of 1.0–6.0 mcg/dL was used [9]. Glycemia was
suture. Surgical wound was measured after conclusion of assessed, immediately after collection of whole blood, in a
procedure, in centimeters. portable Trackease Smart System (Trackease stripes)10. A
Antibiotic treatment was performed with sodium cepha- reference range of 70–110 mg/dL was used [9]. Samples
lothin1 (30 mg/kg intravenously [IV]) 30 min before and from T2 (before administration of any drugs) and T8 (24 h
after surgery and every 8 h during hospitalization. After after surgery) also were stored under refrigeration in sterile
Horta et al. Acta Veterinaria Scandinavica (2015)7:34 Page 3 of 10

tubes with EDTA (ethylenediamine tetraacetic acid) for as diastolic arterial pressure (DAP) and mean arterial
long as 4 h for hematological assessment. Complete blood pressure (MAP) reference ranges of 80–120 mmHg,
counts (CBC) were performed with Abacus Veterinary 60–80 mmHg and 65–96 mmHg, respectively were
Hematology Analyzer11. Differential leukocyte count and used [11]. When animals were in hospital cages during
morphologic evaluation of cells were performed in blood evaluation periods (T2, T6–T10), they were taken into
smears stained with panoptic12 under optic microscopy. a quiet room away from other animals for 5–10 min, so
Reference values in accordance with Jain [10] were used. that they could adapt before measurements. During T5,
Physiological parameters evaluated included heart rate, hemoglobin oxygen saturation was also measured with
respiratory rate, body temperature, and arterial pressure. a digital pulse oximeter.11
The first three parameters were assessed in all 10 evalu- For the postoperative nociception study (T6–T10), two
ation points. Reference ranges of 60–160 beats per mi- nociception evaluation scales were used. The University of
nute, 18–36 breaths per minute, and 37.5–39.2 °C, Colorado Scale, adapted from Hellyer et al. [12], consid-
respectively were used [11]. Non-invasive arterial pres- ered behavior changes and palpation response to an area
sure was assessed through oscillometric method with a of 2 cm2 around surgical wound, with a score from 0 to 4
Veterinary Digital Blood Pressure Device12 and a cuff (Fig. 1). The Postoperative Nociception Evolution Scale
with a width of 40 % limb circumference, positioned on was developed according to Malm et al. [13], and it con-
the middle third of the right radius. Arterial pressure was sidered five physiological nociception markers (objective)
evaluated on T1–T10 with patient on dorsal recumbency and five behavior markers (subjective), with a score from 0
during surgical procedure or in left lateral recumbency on to 26 (Table 1). For both scales, higher scores were associ-
other evaluation times. Values for each patient, in each as- ated with a greater nociception response. Because there
sessment time, were the result of an arithmetic average of was no intent to prove result repeatability, evaluations
three measurements. For systolic arterial pressure (SAP), were performed by a single trained person, as described by

Fig. 1 Postoperative nociceptive evaluation scale proposed by University of Colorado (adapted from Hellyer et al. [12])
Horta et al. Acta Veterinaria Scandinavica (2015)7:34 Page 4 of 10

Table 1 Postoperative nociceptive evolution scale (adapted Table 1 Postoperative nociceptive evolution scale (adapted
from Malm et al. [13]) from Malm et al. [13]) (Continued)
Patient: Record number: Date: Time: 20 to 50 % above preoperative 1
Category Observer Score value
• Behavior data: 50 to 100 % above preoperative 2
value
Mental state/Temperament Similar to state before surgery 0
100 % above preoperative value 3
Changed, but submissive 1
Respiratory rate 0 to 20 % above preoperative value 0
Changed but slightly friendly 1
20 to 50 % above preoperative 1
Changed, but distrustful 2 value
Changed, but aggressive 3 50 to 100 % above preoperative 2
Activity level/disposition Similar to level before surgery/ 0 value
feeding 100 % above preoperative value 3
Resting (in recumbency or standing) 1 Body temperature Normal temperature 0
or sleeping
Temperature below reference values 1
Restless 2
Temperature above reference values 1
Rolling or self-mutilating 3
Pupils Normal 0
Posture Recumbency, but rising when 0
stimulated, seating, or standing with Dilated 2
the head up
Excessive drooling Absent 0
Moving, seated, or standing with 1
Present 2
the head down
0 to 26 score; the higher the score, the greater the postoperative pain
Recumbency, but not rising when 2
stimulated
Protecting affected area (including 2 Slingsby and Water-Pearson [14] for cats and by Maticic
fetal position)
et al. [15], Moll et al. [16], and Kim et al. [17] for dogs.
Standing in prayer or arched 3 Rescue analgesia with intramuscular morphine injec-
posture
tion in a dosage of 0.3 mg/kg was used in patients that
Vocalization Does not vocalize 0 reached twelve or more points on the Postoperative
Slight vocalization when touched or 1 Nociception Evolution Scale.
changing position
Exaggerated vocalization when 2 Evaluation of postoperative complications
touched or changing position
According to protocols described in studies by Hedlund [7]
Spontaneous vocalization, stops 2 and Al-Asadi et al. [18], nine postoperative complications
when touched
were evaluated: posterior limb edema, hematoma, subcuta-
Continuous spontaneous 3
vocalization
neous emphysema, dehiscence, surgical wound contamin-
ation, bleeding, seroma, hyperesthesia, and allodynia.
Response to surgical No alteration 0
wound area palpation During the immediate postoperative period, patients
(2 cm) Slight discomfort, watchful to 1 were examined for these complications 2, 12, and 24 h
palpation, and looking at
manipulated area, but relaxed after surgery, matching nociception evaluation times T6,
abdominal wall T7, and T8, respectively. During late postoperative period,
Moderate discomfort, watchful to 2 complications associated with surgical procedure were
palpation, and looking at evaluated two days after surgery, in the 48 h follow-up ap-
manipulated area, but rigid
abdominal wall
pointment (T9) and 10 d after surgery, immediately before
suture removal (T10).
Immediate response with 2
movement and attempt to evade Posterior limb edema, hematoma, subcutaneous em-
painful stimulus physema and surgical wound dehiscence severity varied,
Immediate response with 3 so these four complications were classified as discrete,
vocalization, attempt to evade moderate, and intense. Posterior limb edema was classi-
painful stimulus, may act fied as discrete when it did not cause mechanical com-
aggressively
plications to the patient; moderate when it interfered
• Physiological data:
with patient ambulation; and intense when it prevented
Heart rate 0 to 20 % above preoperative value 0 patient ambulation. Hematoma and subcutaneous em-
physema were classified as discrete when restricted to
Horta et al. Acta Veterinaria Scandinavica (2015)7:34 Page 5 of 10

one spot in a 2-cm2 area around surgical wound; moderate criteria were reported as median and subjected to Mann–
when they occurred in more than one spot in a 2-cm2 area Whitney test to compare parcels and to Kruskal-Wallis
around surgical wound; and intense when they exceeded a (one-way analysis of variance), followed by Dunn’s
2-cm2 area around surgical wound. Dehiscence was classi- (non-parametric pairwise multiple comparisons proced-
fied as discrete, moderate, and intense when it occurred ure) post-hoc to compare subparcels. Behavior aspects
in < 10 %; ≥ 10 to < 30; and ≥30 % of the surgical wound, identified after T6 (without anesthetic drugs) resulted
respectively. in 144 observations (72 for each parcel). Frequency disper-
Other postoperative complications were accessed with- sion according to Postoperative Nociception Evolution
out an intensity classification. Wound contamination was Scale grading was analyzed with chi-squared test. CBC ob-
positive when purulent discharge was seen in the surgical servations and postoperative complications were similarly
wound. Seroma was positive when there was accumulation analyzed. Patients with mammary tumors presenting with
of serous liquid in the surgical wound. Peripheral and cen- adherences or ulceration were compared with patients who
tral sensitivity responses were distinguished according to underwent the same surgical technique, but without these
type of stimuli triggered. Hyperesthesia was evaluated ap- characteristics, using the same statistics model. To test and
plying a gentle pressure in the middle of a 2-cm² area assess association between studied variables in each parcel
around surgical wound. Allodynia was evaluated applying (Groups 1 and 2), Pearson correlations were used for para-
the same gentle pressure in the middle of a distant area metric data and Spearman correlations were used for non-
(between 5 and 6 cm) from surgical wound. parametric data. Significant correlations were considered
strong when they were present in over 49 % of the studied
Experiment design and statistical analyses population (r > 0.07), moderate when they were present in
A subdivided parcel design was conducted. Surgical pro- 9 to 49 % (0.3 < r < 0.07) and weak when they were present
cedures consisted of parcels, as regional mastectomy in less than 9 % of the population (r < 0.3).
was named Group 1 and unilateral radical mastectomy
was named Group 2. Evaluation periods were subparcels, Results
and each animal was considered an experiment unit or Group 1 patients were between 5 and 13 years old
repetition. Differences were considered statistically sig- (9.8 ± 2.4) and had a mean body weight of 9.6 kg.
nificant when P < 0.05. Group 2 patients were 6–14 years old (10.5 ± 1.9) and
Before comparison tests were used, parametric data was had a mean body weight of 11.3 kg. Statistical significance
tested for normalcy (Kolmogorov-Smirnov test) and ho- for each variable is represented in Table 2.
moscedasticity. Parametric data, with normal distribution Considering all surgical procedures performed in this
of probabilities and variance homogeneity, were reported study (n = 36), duration of surgery varied from 20 to
as mean and standard error, and subjected to analyses of 90 min (42 ± 14 min). Animals that underwent regional
variance, with Fisher’s test to compare parcels and Tukey mastectomy had a shorter procedure duration and a
test to compare subparcels. Non-parametric data and smaller surgical wound (35 ± 11 min and 11 ± 4 cm) than
values that did not meet normalcy and homoscedasticity those that underwent radical mastectomy (48 ± 16 min

Table 2 Statistical significance for different postoperative parameters between regional (Group 1) and radical (Group 2) mastectomy
Parameter Regional mastectomy Radical mastectomy Statistical
significance
Length of procedure 35 ± 11 min 48 ± 16 min P < 0.02
Wound surgical size 11 ± 4 cm 24 ± 7 cm P < 0.0001
Serum cortisol in T6 4.2 ± 2.3 mcg/dL 8.2 ± 5.3 mcg/dL P < 0.004
Glycemia in T6 145,7 ± 46,0 mg/dL 192,6 ± 61,1 mg/dL P < 0.01
Glycemia in T8 108,8 ± 22,2 mg/dL 121,8 ± 25,7 mg/dL P < 0.04
Systolic arterial pressure in T6 91,0 ± 15,7 mmHg 102,9 ± 24,4 mmHg P < 0.03
Postural disorders 88.9 % 98.5 % P < 0.02
Response to surgical wound palpation 83.3 % 97.2 % P < 0.05
Score in University of Colorado Scale (median) T6 (2), T7 (1), T8 (1), T9 (1) T6 (3), T7 (2), T8 (2), T9 (2) P < 0.05
Score in Postoperative Nociception Evolution Scale T6 (6,5), T7 (4,5), T8 (4,0) T9 (4,0), T6 (11,5), T7 (9,0), T8 (8,5), T9 (6,5), P < 0.05
(median) T10 (3,0) T10 (5,0)
Rescue analgesia 1/18 patients 10/18 patients P < 0.005
T6, 2 h after surgery; T7, 12 h after surgery; T8, 24 h after surgery; T9, 48 h after surgery; T10, 10 days after surgery
Horta et al. Acta Veterinaria Scandinavica (2015)7:34 Page 6 of 10

and 24 ± 7 cm), with P < 0.02 and P < 0.0001, respectively. identified after surgery only in the group that underwent
Correlation between these two variables was positive and radical mastectomy.
moderate (P < 0.0001; rP = 0.593). During the postoperative period (144 posture observa-
Non-invasive arterial blood pressure evidenced difference tions) alterations were seen in 88.9 % of Group 1 observa-
in SAP values during T6, with higher values in animals tions (83.3 % moving, sitting, or standing with head facing
subjected to radical mastectomy (P < 0.03). down and 5.6 % in recumbency not responding to stimu-
Mean concentrations of serum cortisol in each evalu- lus, protecting affected area) and 98.5 % of Group 2 obser-
ation for both groups are represented in Fig. 2. Difference vations (81.9 and 16.7 %, respectively). Animals that
between two groups was evidenced in T6, with lower underwent radical mastectomy had greater postural disor-
levels in animals that underwent regional mastectomy ders (P < 0.02). Responses to surgical wound palpation
(4.2 ± 2.3 versus 8.2 ± 5.3 mcg/dl), with P < 0.004 (Mann– were seen in 83.3 % of Group 1 observations (56.9 % with
Whitney). Concerning glycemia, animals subjected to rad- slight discomfort and relaxed abdominal wall and 26.4 %
ical mastectomy had higher glycemic values in T6 (Fisher, with moderate discomfort, tense abdominal wall, or im-
P < 0.01) and T8 (Fisher, P < 0.04). The results for those mediate response with an attempt to evade painful
parameters in T6 were not significantly correlated with stimulus). Responses to surgical wound palpation were
surgery duration, but with surgical wound extension seen in 97.2 % of Group 2 observations (29.2 % with
(P < 0.003, rS = 0.486 for serum cortisol, and P < 0.02, slight discomfort and relaxed abdominal wall; 61.1 %
rS = 0.380 for glycemia). with moderate discomfort, tense abdominal wall, or im-
Considering the number of patients with hematological mediate response with attempt to evade painful stimulus
abnormalities, there was a significant increase in leukocyte and 6.9 % with immediate reaction, vocalization, and
(P < 0.03) and neutrophil counts (P < 0.0002) for both attempt to evade painful stimulus, and indications that
groups in the postoperative period. A significant increase aggressiveness might be present). More intense responses
(P < 0.007) in neutrophil count, accompanied by right shift to surgical wound palpation were seen in animals that
(significant presence of hypersegmented neutrophils) was underwent radical mastectomy (P < 0.005).

Fig. 2 Graphic representation with mean values and standard deviation for serum cortisol (a), serum glucose (b), systolic arterial pressure (c), and
diastolic arterial pressure (d) at T2 (immediately before premedication), T4 (5 min after general anesthesia and orotracheal intubation), T5 (immediately
after orotracheal intubation), T6 (2 h after surgery), and T8 (24 h after surgery) in dogs undergoing regional (n = 18) and radical (n = 18) mastectomy.
Significant differences for serum cortisol (Mann–Whitney, P < 0.004), on T6; serum glucose, on T6 (Fisher, P < 0.01) and T8 (Fisher, P < 0.04); and systolic
arterial pressure, on T6 (Fisher, P < 0.03), are marked with stars
Horta et al. Acta Veterinaria Scandinavica (2015)7:34 Page 7 of 10

Patients that underwent radical mastectomy achieved 2 observation, but natural absorption and complete
higher scores on the University of Colorado Scale in resolution occurred in all cases within 3 to 5 days.
T6–T9 and T6–T10 in Postoperative Nociception Evolu- Hyperesthesia and allodynia were rare in this study.
tion Scale (P < 0.05). During 180 postoperative evalua- Prescribed analgesics and rescue analgesia were sufficient
tions, rescue analgesia was necessary for one patient to treat those sensitization reactions.
(only in one T6 evaluation) for the group that underwent
regional mastectomy, but for 10 patients (in 13 evalua- Discussion
tions, of which nine were in T6, two in T7 and two in Al-Asadi et al. [18] reported a mean duration of 50 min
T8) for the group that underwent radical mastectomy for surgical removal of mammary tumors, but they did
(P < 0.005). not differentiate among surgical techniques used. In this
Postoperative complications were diagnosed in 14 pa- study, animals that underwent regional mastectomy had
tients of each group (77.8 %), regardless of severity. The shorter procedure duration and smaller surgical wound.
number of postoperative complications diagnosed in In the present study, no significant changes in serum
each evaluation period according to surgical technique is levels of glucose and cortisol were seen immediately
specified in Table 3. Postoperative complications were after anesthetic induction (T4), indicating that animal
seen in 57.8 and 91.7 % of evaluations for Groups 1 and manipulation, including physical restraint, venipuncture,
2, respectively, in 180 evaluations (T6–T10). Therefore, drug administration, and orotracheal intubation did not
greater postoperative complications were observed in interfere with neuroendocrine and metabolic functions,
dogs that underwent radical mastectomy (P < 0.03). Pos- in accordance with observations of Church et al. [19]
terior limb edema was considered discrete in all observa- and Caldeira et al. [20]. Although Yoder and Wolf [21]
tions. Resolution occurred in three to seven days after reported association between duration of surgery and
treatment with hot dressings and moderate exercise. Nat- cortisol levels in postoperative period of dogs that
ural absorption and complete resolution of hematomas underwent nephrectomy, there was no correlation, in
also were seen in all cases within 3 to 8 days. Surgical this study, between those parameters, nor did we find an
wound dehiscence was considered moderate in 80 % (4/5) association between duration of surgery and glycemia.
of Group 2 observations, while it was considered discrete Nevertheless, cortisol and glycemia elevation at T6 were
in the remaining observations. Secondary intention moderately correlated with surgical wound extension,
healing was observed in all patients within 7 to 14 days, probably related to greater nociceptive effect triggered
with usage of saline lavage and sunflower oil bandages. by radical mastectomy. Peripheral and central nocicep-
Hematomas were discrete, but were considered moder- tive stimulation can increase release of cortisol [22–24].
ate in 37.5 % (9/24) of Group 1 observations, severe A hyperglycemic state also may be established in painful
and moderate in 15.8 % (3/19), and in 47.4 % (9/19) of situations owing to catabolic effect of cortisol and per-
Group 2 observations, respectively. Only three animals ipheral resistance to insulin, as described by Cunning-
presented discrete seroma in the inguinal region, with ham [25]. Decrease in these levels in the subsequent
spontaneous resolution within 3 to 4 d. Subcutaneous evaluation period (T8) indicates a reduction in central
emphysema was mostly discrete, except for one Group sensitization and a decrease in inflammatory reaction,

Table 3 Number of patients with postoperative complications in different times after regional (n = 18) and radical (n = 18)
mastectomy
Postoperative Group 1 Regional mastectomy Group 2 Radical mastectomy
complications
T6 T7 T8 T9 T10 Total T6 T7 T8 T9 T10 Total
Posterior limb edema 0 1 1 4 4 10 0 4 4 4 2 14
Hematoma 0 0 0 12 12 24 0 0 0 10 9 19
Dehiscence 0 0 0 1 2 3 0 0 0 1 4 5
Subcutaneous emphysema 0 0 1 1 0 2 2 0 0 1 1 4
Infection 0 0 0 5 4 9 0 0 0 6 9 15
Bleeding 0 0 0 1 0 1 0 0 1 0 0 1
Seroma 0 0 0 1 1 2 0 0 0 2 0 2
Hyperesthesia 1 0 0 0 0 1 0 1 1 1 0 3
Allodynia 0 0 0 0 0 0 1 1 1 0 0 3
Total 1 1 2 25 23 52 3 6 7 25 25 66
T6, 2 h after surgery; T7, 12 h after surgery; T8, 24 h after surgery; T9, 48 h after surgery; T10, 10 days after surgery
Horta et al. Acta Veterinaria Scandinavica (2015)7:34 Page 8 of 10

with reduced influence in neuroendocrine and metabolic morphine-lidocaine-ketamine, during inhalant anesthesia
responses, as noted by Fox et al. [26]. and after surgery should be considered in animals under-
Higher values of SAP in animals undergoing radical going radical mastectomy to improve trans- and post-
mastectomy is probably secondary to sympathetic nervous operative analgesia [38].
system activation and shows a larger nociceptive response Behavior signs observed in both scales may be related to
in animals undergoing radical mastectomy [24, 27, 28]. patient emotional disorders, such as anxiety, fear and ex-
In this study, a significant increase in neutrophil counts citement [13]. Similarly, physiological parameters may also
was seen after surgery in the group that underwent radical be influenced by patient emotional status and drugs admin-
mastectomy, although a greater number of dogs showed istered [13, 36]. A specific marker to evaluate nociception
neutrophilia after surgery in both groups, as previously de- and pain in animals does not yet exist; however, association
scribed [22, 29, 30]. Hypersegmentation of neutrophils of several objective and subjective markers could be the
(right neutrophil shift) identified in post-operative samples most reliable method for evaluating pain [24, 36].
for Group 2 is a result of increased neutrophil nucleus Post-operative complications were relatively common in
maturation. This is probably related to increased level of dogs that underwent mastectomy in this study but were
serum steroid, a condition that prolongs circulating time more frequent in the radical approach. Posterior limb
and decreases neutrophil migration [30, 31]. This was not edema was mainly related to inguinal lymph node removal
a common finding for Group 1, which experienced less causing inguinal drainage impairment [7, 18]. Subcutane-
surgical trauma, followed by reduced stress response. ous emphysema was related to removal of mammary tissue
General behavior disorders in dogs may be associated adhered to subcutaneous tissue [7]. According to Hedlund
with painful experiences and include temperament mod- [7], canine mammary glands have an extensive blood sup-
ifications, activity level, posture, enhanced abdominal ply and a complex mammary tissue lymphatic drainage
muscle tonus, and attempt to protect the affected area that might favor development of hematomas and seromas.
[13, 32–35]. In this study, these disorders were more fre- In this study, the choice not to use electrocautery and the
quent in patients that underwent radical mastectomy. usage of compressive bandages for 48 h after surgery may
Arched or praying posture (score 3) was not identified be related to reduced incidence of seroma [7, 39].
in any of the observations, probably due to rescue anal- There was no intent, in this study, to report long-term
gesia. According to Hardie [35], extremely painful expe- results. Previous data about disease control and overall
riences might be necessary for expression of obvious survival in dogs with mammary tumors are conflicting,
nociceptive behaviors. As demonstrated in this study, but few studies have evaluated surgical stress triggered
surgical wound palpation might elicit different reactions by different techniques. Stratmann et al. [5] found a
depending on individual features, intensity of pain, dis- greater probability of new ipsilateral tumor development
comfort or stress [13, 24, 32, 35, 36]. Severe reactions in noncastrated bitches undergoing regional mastectomy.
with attempts to bite the observer were seen only in ani- Although a correlation was found between histological
mals that underwent radical mastectomy and suggest types, a detailed histological classification was not per-
greater postoperative pain [13, 24, 35]. formed. As demonstrated by MacEwen et al. [3], a recent
The University of Colorado Scale showed evolution of study advocated less aggressive surgical procedures ac-
nociception or discomfort in animal postoperative cording to clinical features such as staging, number and
period, without considering physiological parameters, size of lesions, presence of adherences, and tumor site.
and evaluating only behavior features. The University of Dogs in this study were not spayed and there was no dif-
Colorado Scale is simple to administer but not very ference in new tumor development, disease-free interval,
sensitive, given that it has only four categories. In contrast, or overall survival [40]. Prophylactic surgery by means of
Postoperative Nociception Evolution Scale is the result radical mastectomy obviously can prevent new mammary
of behavior and physiological (heart rate, respiratory neoplasm development in the future [8]. However, it is an
rate, body temperature, pupil dilation and salivation) invasive procedure that might result in surgical stress and
parameters. postoperative complications, as demonstrated in this
Rescue analgesia was used for patients that achieved 12 study. In addition, it is not proven yet that dogs with his-
points—representing a score below 50 % of the scale—in tory of malignant mammary tumor have greater risk of de-
the Postoperative Nociception Evolution Scale. This was veloping new mammary neoplasms [8, 40]. Empiric risk
done to avoid underestimating patient pain, because the may be reduced by regular re-examination and prompt
decision to use rescue analgesia was based on a subjective intervention if a new mass is found [40].
method that has not been validated [37]. Postoperative
pain was more easily controlled in Group 1 patients. This Conclusions
suggests that continuous infusion of low-dose analgesic Radical mastectomy resulted in longer surgical duration,
combinations, such as fentanyl-lidocaine-ketamine or greater nociceptive stimulus, surgical stress, and higher
Horta et al. Acta Veterinaria Scandinavica (2015)7:34 Page 9 of 10

incidence of postoperative complications when compared 2. Sorenmo K. Canine mammary gland tumors. Vet Clin North Am Small Anim
with regional mastectomy in dogs. Although it was not Pract. 2003;33:573–96.
3. MacEwen EG, Harvey HJ, Patnaik AK, Mooney S, Hayes A, Kurzman I, et al.
the aim of this study to evaluate long-term results, canine Evaluation of the effect of levamizole and surgery on canine mammary
mammary tumor surgical treatment should be based on cancer. J Biol Response Modif. 1985;4:418–26.
lymphatic drainage, number and size of lesions, and estab- 4. Gilbertson SR, Kurzman ID, Zachrau RE, Hurvitz AI, Black NM. Canine
mammary epithelial neoplasms: biological implications of morphologic
lished prognostic factors. Disregard of these criteria may characteristics assessed in 232 dogs. Vet Pathol. 1983;20:127–42.
result in potentially unnecessary aggressive surgical proce- 5. Stratmann N, Failing K, Richter A, Wehrend A. Mammary tumor recurrence
dures. Each patient should be individually assessed and in bitches after regional mastectomy. Vet Surg. 2008;37:82–6.
6. Fergunson RH. Canine mammary gland tumors. Vet Clin North Am Small
directed for each surgical technique, taking into account Anim Pract. 1985;15:501–11.
the postoperative recovery and patient quality of life. 7. Hedlund CS. Cirurgia dos sistemas reprodutivo e genital. In: Fossum TW,
Hedlund CS, Johnson AL, Shulz KS, Seim HB, Willard MD, Bahr A, Carrol
GL, editors. Cirurgia de pequenos animais. 3rd ed. Rio de Janeiro:
Endnotes Elsevier; 2008. p. 702–74.
1
Cefariston®, Ariston, Morón, Buenos Aires, Argentina. 8. Polton G. Mammary tumours in dogs. Irish Vet J. 2009;62:50–6.
2 9. Nelson RW, Turnwald GH, Willard MD. Endocrine, metabolic and lipid
Cefalexina, Medley, Campinas, São Paulo, Brazil.
3 disorders. In: Willard MD, Tvedten H. Filadélfia, editors. Small Animal
Acepran®, Vetnil, Louveira, São Paulo, Brazil. Clinical Diagnosis by Laboratory Methods. 4th ed. St. Louis, W.B. Saunders;
4
Dimorf®, Cristália, São Paulo, São Paulo, Brazil 2004. p. 165-207.
5
Fresofol 1 %®, Fresenius Kabi Brasil Ltda, Campinas, 10. Jain NC. Comparative hematology of common domestic animals. In:
Essentials of Veterinary Hematology. 1st ed. Philadelphia: Lea & Febiger;
São Paulo, Brazil 1993. p. 19–53.
6
Isothane® 100 ml, Baxter Hospitalar Ltda., Santo Amaro, 11. Feitosa FLF. Exame físico geral ou de rotina. In: Feitosa FLF, editor.
São Paulo, Brazil. Semiologia Veterinária: A arte do diagnóstico. 2nd ed. São Paulo: Roca;
7 2008. p. 77–102.
Maxicam®, Ourofino Agronegócio, Cravinhos, São Paulo,
12. Hellyer PW, Uhrig SR, Robinson NG. Canine Acute Pain Scale and Feline
Brazil. Acute Pain Scale. Fort Collins CO: Colorado State University Veterinary
8
Cloridrato de Tramadol, União Química Farmacêutica Medical Center; 2006.
Nacional S/A, Jabaquara, São Paulo, Brazil. 13. Malm C, Savassi-Rocha PR, Gheller VA, Oliveira HP, Lamounier AR, Foltynek V.
9 Ovario-histerectomia: estudo experimental comparativo entre as abordagens
Meloxivet®, Duprat, Rio de Janeiro, Rio de Janeiro, laparoscópica e aberta na espécie canina. II – Evolução clínica pós-operatória.
Brazil. Arq Bra Med Vet Zootec. 2005;57:162–72.
10
Trackease Smart System – Accumed, Duque de Caxias, 14. Slingsby LS, Water-Pearson AE. Postoperative analgesia in cat after
ovariohysterectomy by the use of carprofen, ketoprofen, meloxicam or
Rio de Janeiro, Brazil. tolfenamic acid. J Small Anim Pract. 2000;41:447–50.
11
Abacus Veterinary Hematology Analyzer, Diatron, 15. Maticic D, Stejskal M, Pecin M, Kreszinger M, Pirkic B, Vnuk D, et al.
São Paulo, São Paulo, Brazil. Correlation of pain assessment parameters in dogs with cranial cruciate
12 surgery. Vet Arhiv. 2010;80:597–609.
Veterinary Digital Blood Pressure Device, Contec 16. Moll X, Fresno L, García F, Prandi D, Andaluz A. Comparison of
Medical Systems Co., Qinhuangdao, China. subcutaneous and transdermal administration of buprenorphine for
pré-emptive analgesia in dogs undergoing elective ovariohysterectomy.
Competing interests Vet J. 2011;187:124–8.
The authors declare that they have no competing interests. 17. Kim YK, Lee SS, Suh EH, Lee L, Lee HC, Lee HJ, et al. Sprayed intraperitoneal
bupivacaine reduces early postoperative pain behavior and biochemical
Authors’ contributions stress response after laparoscopic ovaryhisterectomy in dogs. Vet J.
RH performed study design, participated in all surgeries and post-operative 2011;191:188–92.
evaluations, performed statistical analysis, and drafted the manuscript. MF 18. Al-Asadi RN, Al-Keledarm NAR, Al-Kadi KK. An Evaluation of mastectomy
participated in all post-operative evaluations and helped draft the manuscript. for removal of mammary glands tumors in bitches. Bas J Vet Res.
GL conceived the study, participated in its design and coordination, performed 2010;10:141–52.
all surgeries, and helped draft the manuscript. MP participated in all 19. Church DB, Nicholson AI, Ilkiw JE, Emslie DR. Effect of non-adrenal illness,
post-operative evaluations, performed the hematological analysis, and anaesthesia and surgery on plasma cortisol concentrations in dogs. Res Vet
helped draft the manuscript. RC revised the manuscript and helped with Scien. 1994;56:129–31.
statistical analysis and data interpretation. RB conceived the study, participated 20. Caldeira FMC, Oliveira HP, Melo EG, Martins C, Vieira MS, Silva CN. Cortisol
in its design and coordination, and helped draft the manuscript. All authors sérico e glicemia em cadelas tratadas com tramadol e submetidas à
have read and approved the final manuscript. ovário-histerectomia. Cienc Rural. 2006;36:155–60.
21. Yoder B, Wolf Jr JS. Canine model of surgical stress response comparing
Acknowledgements standard laparoscopic, microlaparoscopic, and hand-assisted laparoscopic
The study was funded by a research grant from CNPq (Conselho Nacional de nephrectomy. Urology. 2005;65(3):600–3.
Desenvolvimento Científico e Tecnológico). The authors would like to thank 22. Bush BM. White Blood Cells (WBCs). In: Bush BM, editor. Interpretation of
FEPMVZ (Fundação de Estudo e Pesquisa em Medicina Veterinária e laboratory results for small animals clinicians. 1st ed. Iowa: Blackwell
Zootecnia) and Hermes Pardini Laboratory for their contribution. Publishing; 1991. p. 132–95.
23. Lamont LA, Traquilli WJ, Grimm KA. Physiology of pain. Vet Clin North Am
Received: 27 October 2014 Accepted: 14 June 2015 Small Anim Pract. 2000;30:703–28.
24. Hellyer PW, Robertson SA, Fails AD. Pain and its management. In: Tranquilli
WJ, Thurmon JC, Grimm KA, editors. Lumb & Jones’ veterinary anesthesia
References and analgesia. 4th ed. Iowa: Blackwell Publishing; 2007. p. 31–57.
1. Sorenmo KU, Worley DR, Goldschimidt MH. Tumors of the Mammary Gland. In: 25. Cunningham JG. O sistema endócrino. In: Cunningham JG, editor.
Withrow SJ, Vail DM, Page RL, editors. Withrow & MacEwen’s small animal Tratado de fisiologia veterinária. 3rd ed. Rio de Janeiro: Guanabara
clinical oncology. 5th ed. Philadelphia: W.B. Saunders; 2013. p. 538–56. Koogan; 2004. p. 333–49.
Horta et al. Acta Veterinaria Scandinavica (2015)7:34 Page 10 of 10

26. Fox SM, Mellor DJ, Lawoko CR, Hodge H, Firht EC. Changes in plasma
cortisol concentrations in bitches in response to different combinations of
halothane and butorphanol, with or without ovariohysterectomy. Res Vet
Sci. 1998;65:125–33.
27. Conzemius MG, Hill CM, Sammarco JL, Perkowski SZ. Correlation between
subjective and objective measures used to determine severity of
postoperative pain in dogs. J Am Vet Med Assoc. 1997;210:1619–22.
28. Holton LL, Scott EM, Nolan AM, Reid J, Welsh E. Relationship between
physiological factors and clinical pain in dogs scored using a numerical
rating scale. J Small Anim Pract. 1998;39:469–74.
29. Väisänen M, Lilius EM, Mustonen L, Rekallio M, Kuusela E, Koivisto M, et al.
Effects of ovariohysterectomy on canine blood neutrophil respiratory burst:
a chemiluminescence study. Vet Surg. 2004;33(5):551–6.
30. Stockham SL, Scott MA. Leucócitos. In: Stockham SL, Scott M, editors.
Fundamentos de Patologia Clínica Veterinária. 2nd ed. Rio de Janeiro:
Guanabara Koogan; 2011. p. 45–89.
31. Raskin RE, Latimer KS, Tvedten H. Leukocyte disorders. In: Willard MD,
Tvedten H, editors. Small animal clinical diagnosis by laboratory methods.
4th ed. Philadelphia: W.B. Saunders; 2004. p. 63–91.
32. Haskins SC. Postoperative analgesia. Vet Clin North Am Small Anim Pract.
1992;22:353–6.
33. Hellyer PW, Gaynor JS. Acute postsurgical pain in dogs and cats. Comp
Cont Educ Pract. 1998;20:140–53.
34. Mathews KA. Pain assessment and general approach to management. Vet
Clin North Am Small Anim Pract. 2000;30:729–55.
35. Hardie EM. Reconhecimento do comportamento doloroso em animais. In:
Hellebrekers LJ, editor. Dor em animais. São Paulo: Manole; 2002. p. 49–68.
36. Dobromylskyj PA. Pain assessment. In: Flecknell P, Waterman-Pearson A,
editors. Pain management in animals. 1st ed. London: W.B. Saunders;
2000. p. 53–79.
37. Pohl VH, Carregaro AB, Lopes C, Garlet C, Marques JS. Correlação entre as
escalas visual analógica, de Melbourne e filmanetos de Von Frey na
avaliação da dor pós-operatória em cadelas submetidas à
ovariossalpingohisterectomia. Cienc Rural. 2011;41:154–9.
38. Bednarski RM. Dogs and cats (anesthesia, analgesia, and immobilization of
selected species and classes of animals). In: Tranquilli WJ, Thurmon JC,
Grimm KA, editors. Lumb & Jones’ veterinary anesthesia and analgesia. 4th
ed. Iowa: Blackwell Publishing; 2007. p. 705–15.
39. Vitug AF, Newman LA. Complications in breast surgery. Surg Clin North Am.
2007;87:431–51.
40. Horta RS, Lavalle GE, Cunha RMC, Moura LL, Araújo RB, Cassali GD. Influence
of surgical technique on overall survival, disease free interval and new
lesion development interval in dogs with mammary tumors. Adv Breast
Cancer Res. 2014;3:38–46.

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