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Soft-Tissue Surgery: Case Study


The Case

When Sprout, a French Bulldog, wasSprout, French Bulldog, Ryan Hospital only a few weeks old, his owner, breeder Virginia Cowger knew something was very wrong. As much as he tried, Sprout couldn’t keep any food down.

When Mrs. Cowger brought the dog to her vet, Penn Vet alum Dr. Liz Bruce, VMD, in Easton, Maryland, Dr. Bruce suspected a persistent right aortic arch.

An abnormal development of the major blood vessels in the chest, a persistent right aortic arch results in constriction of the esophagus, and in some cases, the trachea. In other words, instead of developing behind the esophagus and/or the trachea, the major blood vessels, sit on top of these vital passages, thereby restricting the passage of food and/or air. This, in turn, results in dilatation of the esophagus, regurgitation, and, in some cases, aspiration pneumonia.

Puppies often start to show symptoms of distress at the time of weaning, when they are transitioned from liquid to solid foods. In Sprout’s case, his esophageal constriction was so severe that he could not even hold down liquids. At such a young age, this type of developmental malformation can be deadly. 

The Surgery

Sprout underwent surgery soon after the diagnosis was confirmed. With a larger dog, this surgery could have been laparoscopic, but because of Sprout’s size, the surgical team recommended a left fourth intercostal thoracotomy.

Thoracotomy, persistent right aortic archThis type of extensive, major surgery involves entering the space between the ribs, which means opening the chest cavity. Thoracotomies are thought to be one of the most difficult surgical incisions to deal with post-operatively, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading to atelectasis or pneumonia.

Historically, this approach has been very difficult on puppies because of their size and their ability to tolerate pain. However, due to advances in nerve block anesthesia and pain management medications, the Penn Vet team felt confident that they would be able to effectively manage Sprout’s surgery and subsequent pain level. With Mrs. Cowger’s approval, Sprout went into surgery.    

Once the existence of the persistent right aortic arch was confirmed, the constricting tissue band (ligamentum arteriosum) was cut to free the esophagus and allow for normal flow of ingesta through the esophagus. Because the esophageal changes can take time to reverse, a gastrostomy tube was placed as part of Sprout’s surgery. This tube allowed for bypass of the esophagus and direct feeding into the stomach, ensuring the puppy would receive all the nutrients he needed during recovery.

The Team

Sprout's team, Drs. Bruce, Wormser, Holt, and owner 

From left to right: Dr. Liz Bruce, VMD; Mrs. Cowger, owner; Sprout; Dr. Chloe Wormser, VMD; Dr. David Holt, BSc, Surgery Section Chief, Ryan Hospital

What Happened

Sprout developed severe aspiration pneumonia after the surgery. He stayed in the Ryan Hospital Intensive Care Unit so that Penn Vet’s critical care team could care him for around the clock. Within a short time, Sprout was breathing normally again and was gaining weight. Once his team determined he was stable, he was sent home with Mrs. Cowger to recover. And Sprout was sporting a tiny shirt to keep his gastrostomy tube in place.

Sprout was seen back at Penn Vet’s Ryan Hospital every couple of weeks after surgery. The surgeons were cautiously optimistic, as Sprout had been gaining weight. Mrs. Cowger started to feed Sprout orally in addition to his gastrostomy tube feedings, and Sprout was tolerating this well. Four weeks after surgery, his gastrostomy tube was removed.



However, shortly after, Sprout began to show signs of esophagitis (esophageal inflammation) including dehydration, weight loss, and regurgitation. He was therefore seen back at Penn Vet, and his gastrostomy tube was replaced. He bounced back quickly after this surgery and has since shown signs of significant improvement.

He has been gaining weight appropriately and is now eating readily on his own with no signs of recurrent regurgitation. The hope is that once Sprout is a little bigger, his gastrostomy tube can be removed permanently.