Penn radiologist and veterinarian collaborate to treat dog with rare condition

It took an interventional radiologist from the Hospital of the University of Pennsylvania and a veterinary surgeon in Conshohocken to perform a first-of-its-kind procedure on a 2-year-old pit bull to correct a rare condition that is also found in humans.

In August, Victoria Bary noticed something off about Jefferson, a rescue from Providence Animal Center in Delaware County.

"His stomach looked weird," said Bary, of Williamstown, N.J.

Worried he could have bloated or twisted intestines, Bary and her fiance, Michael Mroczek, took the pup to their veterinarian, where fluid was found in Jefferson's chest cavity. After a round of tests, they were told that Jefferson had chylothorax, a rare chronic condition caused when fluid from the lymphatic system leaks into the pleural cavity, the space between the chest wall and the lungs.

The lymphatic system is a network of vessels and lymph nodes that runs throughout the body and is part of the immune system. It absorbs and transports chyle, a milky liquid made up of fat and lymph fluid from the digestive system. That liquid was collecting in Jefferson's chest.

When the fluid builds up, the pressure can cause breathing problems — something Jefferson was beginning to experience. The couple consulted with Ron Ben-Amotz, a surgeon with Veterinary Specialty & Emergency Center (VSEC) in South Philadelphia. Jefferson would need expensive and invasive surgery to correct the problem, Bary was told.

The couple were trying to figure out how to pay for their upcoming wedding and honeymoon as well as the life-saving, $10,000 surgery when Ben-Amotz called back with an interesting proposal: Maxim Itkin, an interventional radiologist at HUP who performs a similar, less invasive procedure on his human patients, would help Jefferson.

The condition can be congenital or caused by an injury, or  can occur spontaneously, Itkin said.

With Itkin's help, the recovery would be much faster, and the cost would be cut in half, Ben-Amotz said.

"I was in a bit of a shock, honestly," Bary said. "How often does someone get a world-renowned doctor from Penn to help your dog?"

As it turns out, Ben-Amotz and Itkin are good friends.

Ben-Amotz knew Itkin had successfully corrected Jefferson's condition in both adults and babies. Itkin's patients travel to Philadelphia from across the globe for the procedure, in which he inserts a catheter through the abdomen into the main lymphatic duct to the area of the leak and closes it with a medical-grade glue.

But with canine patients, a veterinarian performs a six-hour surgery, in which the chest cavity of the dog must be opened to fix the leak.

Ben-Amotz called Itkin to "see if [Jefferson] was a good candidate" for the minimally invasive procedure. The two talked about the dog's condition while watching their kids play football in the backyard and then again over Thanksgiving dinner a few weeks later, he said.

Ben-Amotz said he had already removed fluid from Jefferson four times — once, nearly a half-gallon.

Itkin was in. It is not his first time helping with a veterinary case. He has also performed a tumor-ablation procedure on a rabbit, he said.

Collaboration between physicians and veterinarians has been going on for at least a century in the Philadelphia area. Dentists have fixed broken teeth in large zoo animals, oncologists weigh in on animal cancer, and veterinarians have helped poison-control centers track down anti-venom to treat snake bites.

In 2017, a Thomas Jefferson University Hospital obstetrician helped deliver a baby gorilla at the Philadelphia Zoo.

On Wednesday, the two doctors met at VSEC Conshohocken to perform the groundbreaking procedure.

If it worked, it would be a game-changer for veterinarians, said Ben-Amotz.

The small operating room was packed not only with equipment but more than a dozen interns, residents, technicians, staff, and other veterinarians who came to watch.

"I've never seen an OR this crowded before," Ben-Amotz said.

The plan was to thread a guided wire and catheter through Jefferson's groin area into the main lymphatic duct and up to the area of the leak. A small platinum coil would then be maneuvered into position to inject a medical-grade glue, similar to the product that is used to close small wounds.

Itkin maneuvered an ultrasound probe across Jefferson's groin to guide him as he threaded the wire into the lymph node.

"The lymph nodes are beautiful, better than a human," Itkin noted.

On a nearby monitor, the doctors tracked the progress of the wire using fluoroscopy, a type of imaging that allows the doctors to see the X-ray in real time. At times, the only sound in the packed room was the steady beep of the heart monitors attached to Jefferson.

"We punctured the sternum, and we're in the thoracic duct," said Ben-Amotz.

There was some last-minute improvising: The end of a bulb syringe was cut in half to use as a small sterile mixing bowl for the glue.

When the glue was in, Itkin pulled out the wires. The procedure was over in less than an hour.

For his part, Jefferson did very well overnight and was ready to go home by Thursday morning, Ben-Amotz said.

"He almost escaped from the cage. He was ready to go," he said. "It was like we didn't do anything."

As a precaution, a special pleural port was placed under the dog's skin to make it easier to drain if fluid does collect. It can be accessed with a needle and without anesthesia. In a few weeks, if there are no complications, the port will be removed, Ben-Amotz said.

Jefferson will have to take it easy until his next appointment in about 10 days.

"I think he will recover very quickly from this," Ben-Amotz said.