Clinical evaluation of a closed,one-stage,stapled, functional,end-to-end jejuno-ileal anastomosis in 5 horses

This study describes the outcome and complications in horses that had a closed, one-stage, stapled, functional, end-to-end (COSFE) jejuno-ileal anastomosis (JIA) following resection of compromised small intestine. Medical records were reviewed to identify all horses that had a COSFE JIA performed during exploratory laparotomy and to determine post-operative complications and final outcome. All 5 horses that were identified had successful COSFE JIA with resection of various amounts of distal jejunum and proximal ileum. Post-operative ileus occurred in 1 of the 5 horses. All horses survived at least 1 year after surgery. The survival times and incidence of post-operative ileus compared favorably with published results for other types of small intestinal resection and anastomoses. A COSFE JIA is a viable surgical procedure to correct lesions of the distal jejunum and proximal ileum.     

Differential survival in horses requiring end-to-end jejunojejunal anastomosis compared to those requiring side-to-side jejunocaecal anastomosis

REASONS FOR PERFORMING STUDY: Horses requiring different methods of intestinal anastomosis during equine colic surgery may have differences in mortality and morbidity. HYPOTHESES: Horses requiring side-to-side jejunocaecal anastomosis have a higher mortality and morbidity rate than those requiring end-to-end jejunojejunal anastomosis. Morbidity and mortality of handsewn vs. stapled side-to-side jejunocaecal anastomoses are not significantly different. METHODS: A prospective, nonrandomised, observational study was conducted. Clinical and surgical details were recorded during hospitalisation and survival data acquired by periodic telephone questionnaire. Differences in mortality and morbidity rate were evaluated by survival analysis. RESULTS: A total of 184 horses underwent end-to-end jejunojejunal anastomosis and 178 underwent side-to-side jejunocaecal anastomosis. Horses with a jejunocaecal anastomosis had a significantly higher mortality rate. The incidence of post operative colic in horses requiring side-to-side jejunocaecal anastomoses was greater than those requiring end-to-end jejunojejunal anastomoses. Within the group undergoing side-to-side jejunocaecal anastomosis there was no evidence of differential survival between horses with handsewn vs. stapled anastomoses. CONCLUSIONS: Mortality rate is higher in horses that have required side-to-side jejunocaecal anastomosis than in those that needed end-to-end jejunojejunal anastomosis; and post operative colic is more common after side-to-side jejunocaecal anastomosis. No difference in mortality was found between horses with handsewn and stapled side-to-side jejunocaecal anastomoses. POTENTIAL RELEVANCE: Surgeons should be aware of the increased mortality and morbidity in horses requiring side-to-side jejunocaecal anastomosis. Our finding of no difference in mortality between handsewn and stapled side-to-side jejunocaecal anastomoses justifies surgeons exercising personal preference in their selection of anastomosis method.     

Clinical assessment and outcome of three techniques for jejunal resection and anastomosis in horses: 59 cases (1989-2000)

OBJECTIVE: To compare postoperative complications, short- and long-term survival, and surgical times for hand-sewn end-to-end (EE), stapled functional end-to-end (FEE), and stapled side-to-side (SS) anastomotic techniques for jejunal resection in horses. DESIGN: Retrospective study. ANIMALS: 59 horses. PROCEDURE: Medical records were reviewed to obtain signalment, diagnosis, treatment, and outcome for horses that underwent jejunojejunostomy in our hospital. Only horses that recovered from anesthesia were included in the study. RESULTS: Among the 59 horses, there were 33 EE, 15 FEE, and 11 SS anastomoses. No difference was found in duration of surgery among the 3 techniques. The most common postoperative complications were colic episodes (56%), ileus (53%), diarrhea (20%), and adhesions (15%). Horses with SS anastomosis had a significantly shorter duration of postoperative ileus than the EE group did. No significant difference in duration of postoperative ileus was found among the other groups. No difference was found among the 3 anastomotic techniques in regard to survival rate at the time of discharge, 6 months after surgery, or 1 year after surgery. Overall survival rates after jejunal anastomosis were 88% at the time of discharge, 65% at 6 months after surgery, and 57% at > or = 1 year after surgery. CONCLUSIONS AND CLINICAL RELEVANCE: The hand-sewn EE, stapled FEE, and stapled SS anastomotic techniques should be considered equivalent methods for small intestinal anastomosis in the horse. However, the stapled SS technique may be preferred because of possible decreased duration of postoperative ileus.     

Surgical colic in racing endurance horses

A retrospective study was performed of horses that developed colic during endurance racing, and subsequently required surgery. Fifteen horses met the inclusion criteria, of which 13 (87%) had small intestinal volvulus. Nine of the 15 horses (60%) had a small intestinal resection and anastomosis performed. Post operative ileus, particularly in those horses that had a resection performed, was a common complication. Eleven of the 15 (73%) survived, and 4 (27%) have since raced.     

Modified functional end-to-end stapled intestinal anastomosis: technique and clinical results in 15 dogs

OBJECTIVES: To evaluate the use of a gastrointestinal anastomosis (GIA) stapling device to perform small intestinal anastomosis in the dog. METHODS: A retrospective study to evaluate the use of a GIA stapling device to perform small intestinal anastomosis in 15 dogs. RESULTS: Reasons for intervention included dehiscence of a previous enterotomy (four of 15), intestinal neoplasia (five of 15), vascular compromise (three of 15), intussusception (two of 15) and foreign body (one of 15). The mean time taken to perform the anastomosis was 7.7 minutes (range five to 12 minutes). No operative complications were recorded and all dogs recovered from the surgery. Major (two dogs) and minor (six dogs) short-term complications of pyrexia and anorexia were recorded in six dogs. In five of these, the cause was considered to be related to a pre-existing peritonitis. One dog was euthanased five months postoperatively for a multi-centric recurrence of intestinal lymphoma. Six month follow-up confirmed an unremarkable and complete recovery in all remaining dogs. No major or minor long-term complications were recorded in any individual. CLINICAL SIGNIFICANCE: A modified stapled functional end-to-end intestinal anastomosis holds merit and should be considered a viable alternative to other stapled and sutured anastomosis techniques.     

Modelling long-term survival of horses following surgery for large intestinal disease

REASONS FOR PERFORMING STUDY: Large intestinal diseases are an important cause of equine colic that require surgical management, but there is little published information about long-term survival of such cases. OBJECTIVES: To identify variables associated with post operative mortality and to develop a model for post operative survival following surgery for large intestinal disease. METHODS: Clinical data and long-term follow-up information from 275 horses undergoing surgery for large intestinal disease were used. A multivariable, Cox proportional hazards model for post operative death was developed and the fit of the model evaluated. RESULTS: The continuous variables age, heart rate and packed cell volume (PCV) were associated positively with the risk of post operative death, as were the categorical variables resection (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.2-5.1) and relaparotomy (OR 3.5, 95% CI 1.4-8.4). CONCLUSIONS: In the population studied, the probability of post operative survival following surgery for large intestinal disease was associated with the cardiovascular parameters heart rate and PCV on admission, age of the horse and whether it underwent resection or relaparotomy. POTENTIAL RELEVANCE: The prognosis for post operative survival for horses with large intestinal disease may be improved by early surgery, prior to the development of cardiovascular compromise. Surgeons should be aware that increasing age, resection of large colon and relaparotomy are all associated with a worsening prognosis for survival.     

Survival and complication rates in 300 horses undergoing surgical treatment of colic. Part 3: Long-term complications and survival

REASONS FOR PERFORMING STUDY: Few studies have evaluated long-term survival and complication rates in horses following surgical treatment of colic, making it difficult to offer realistic advice concerning long-term prognosis. OBJECTIVE: To review the complications occurring after discharge from hospital and survival to >12 months after surgery of 300 horses undergoing exploratory laparotomy for acute colic. Pre-, intra- and post operative factors that affected long-term complications and long-term survival were assessed. METHODS: History, clinical findings, surgical findings and procedures and post operative treatments of 300 consecutive surgical colic cases (1994-2001) were reviewed. Long-term follow-up information was retrieved from case records and telephone enquiries from owners. RESULTS: The long-term (>12 months) survival rate for 204 horses discharged after colic surgery and for which follow-up information was available was 84%. The most common complication after discharge was colic, affecting 35.1% of horses following a single laparotomy. Colic was most common in horses that had had small intestinal obstructions, bowel resection or post operative ileus. Abdominal adhesions were most common in horses that presented with severe colic due to strangulation of small intestine. Ventral hernia formation occurred in 8% of horses, and was most common in horses that had had post operative wound drainage or infection. CONCLUSIONS: This study identified various factors that appear to predispose horses to long-term complications after colic surgery. POTENTIAL RELEVANCE: Further evaluation of strategies that might reduce the incidence of such complications are needed; in particular, the value of intraperitoneal heparin should be evaluated, and procedures designed to reduce the rates of wound drainage and infection assessed.     

Gastric and small intestinal ileus as a cause of acute colic in the post parturient mare

REASONS FOR PERFORMING STUDY: Ileus (functional obstruction of aboral gastrointestinal transit) is an uncommon cause of gastrointestinal dysfunction and colic in the horse. A number of specific conditions have been previously reported in association with ileus. This report describes the recognition of primary gastric and small intestinal ileus of undetermined cause in a series of post parturient mares. OBJECTIVES: To describe the clinical features, treatment and outcome of a series of episodes of primary gastric and small intestinal ileus. METHODS: A retrospective study was performed of colic episodes seen in an equine practice in Newmarket, UK over a 6 year period (2002-2007). RESULTS: Seventeen episodes of gastric and small intestinal ileus were identified, which occurred in 15 horses. All episodes occurred in post parturient mares. No previously reported cause of ileus was identified in any of the episodes. Fifteen of the 17 episodes received medical treatment (medical support and nasogastric decompression) and, in addition, surgical decompression was performed in 9 episodes. Two mares were subjected to euthanasia before treatment due to the presence of gastric rupture and the remaining 13 mares survived with a follow-up period of at least 10 months. Two mares suffered a further episode of gastric and small intestinal ileus, one 4 days and the other 2 years after the initial episode. CONCLUSIONS: Gastric and small intestinal ileus of, as yet, unknown aetiology appears to be a potential cause of acute colic in the post parturient mare. The outcome following treatment by decompression is good.     

Comparison of a continuous suture pattern with a simple interrupted pattern for enteric closure in dogs and cats: 83 cases (1991-1997).

OBJECTIVE: To describe and compare a simple continuous suture pattern with a simple interrupted pattern for enterotomy closure or end-to-end intestinal anastomosis. DESIGN: Retrospective study. ANIMALS: 58 dogs and 25 cats that underwent enterotomy or intestinal resection and anastomosis. PROCEDURE: Signalment, surgical procedure, suture pattern, suture material, confirmation of dehiscence, and follow-up were reviewed. Groups were compared by procedure (anastomosis or enterotomy) and by suture pattern. RESULTS: 57 animals underwent continuous closure; 26 had interrupted closure. Only polydioxanone or polypropylene suture materials were used. Overall, 81 (98%) animals had no signs of intestinal dehiscence and survived > 2 weeks. Two animals had confirmed dehiscence after foreign body removal, 1 of 57 (2%) after continuous closure, and 1 of 26 (4%) after interrupted closure. CLINICAL IMPLICATIONS: The simple continuous closure pattern is an acceptable alternative to simple interrupted closure for small intestinal anastomosis or enterotomy closure.     

Rectovaginal fistula following colectomy with an end-to-end anastomosis stapler for a colorectal adenocarcinoma

An 11-year-old, female neutered Labrador retriever was presented with a micro-invasive differentiated papillar adenocarcinoma at the colorectal junction. A colorectal end-to-end anastomosis stapler device was used to perform resection and anastomosis using a transanal technique. A rectovaginal fistula was diagnosed two days later. An exploratory laparotomy was conducted and the fistula was identified and closed. Early dehiscence of the colon was also suspected and another colorectal anastomosis was performed using a manual technique. Comparison to a conventional manual technique of intestinal surgery showed that the use of an automatic staple device was quicker and easier. To the authors' knowledge, this is the first report of a rectovaginal fistula occurring after end-to-end anastomosis stapler colorectal resection-anastomosis in the dog. To minimise the risk of this potential complication associated with the limited surgical visibility, adequate tissue retraction and inspection of the anastomosis site are essential.     

Clinical assessment and outcome of a single-layer technique for anastomosis of the small intestine in horses

In order to assess postoperative outcome in horses undergoing end-to-end anastomosis of the small intestine, performed using a one-layer technique, 15 horses that underwent exploratory coeliotomy, resection of the small intestine and end-to-end anastomosis using a continuous Lembert pattern were studied. Information on the age, breed, sex, diagnosis, treatment, complications and outcome of each case were obtained from medical records. Follow-up information was obtained via telephone conversations with clients and trainers. Five of the horses had short-term postoperative complications: one had postoperative ileus (POI), colic and peritonitis, one had POI and colic, two had POI only and one had diarrhoea only. A second exploratory coeliotomy was recommended in two of the 15 horses (13 per cent). The short-term survival rate, defined as survival up to the time of discharge from the hospital, was 93.3 per cent (14 of 15 horses). The long-term survival rate, defined as survival for at least 12 months after the surgery, was 84.6 per cent (11 of 13 horses followed up).     

Evaluation of a vessel-sealing device for small intestinal resection and anastomosis in normal horses

OBJECTIVES: To compare arterial bursting pressure after vessel closure using a vessel-sealing device (LigaSure Atlas Laparoscopic Sealer/Divider Instrument; Valleylab, Boulder, CO), a ligate-and-divide stapling device (LDS), and 2-0 polydioxanone suture. To evaluate the LigaSure Atlas as a method for ligation of the mesenteric vasculature during small intestinal resection in normal horses. STUDY DESIGN: Experimental study. ANIMALS: Part A: jejunal segments from 19 horses. Part B: 6 horses, aged 1 to 18 years, weighing 330 to 509 kg. METHODS: Part A: Jejunal segments with mesenteric vessels were collected from 19 horses. After closure by 1 of 3 methods (LigaSure Atlas, LDS, 2-0 polydioxanone) arteries were cannulated, and bursting pressure was measured by incrementally increasing intraluminal pressure until failure. Part B: Six horses had jejunal resection and anastomosis using a vessel-sealing device (LigaSure Atlas) to provide hemostasis of the mesenteric vasculature. Horses were monitored clinically for 4 weeks. RESULTS: Part A: Mean +/- SEM bursting pressure after 2-0 polydioxanone ligation (1,014.50 +/- 279.05 mm Hg) was significantly greater than mean bursting pressure after LigaSure (554.25 +/- 228.79 mm Hg), which was significantly greater than the mean bursting pressure after LDS (373.25 +/- 183.69). Part B: No major operative or postoperative hemorrhage occurred after application of the LigaSure Atlas for sealing and transecting mesenteric vasculature during small intestinal resection in normal horses. CONCLUSIONS: The LigaSure Atlas appears to be a safe method for hemostasis of the mesenteric vasculature during small intestinal resection in normal horses. CLINICAL RELEVANCE: Benefits of the LigaSure Atlas vessel-sealing device include reduced time required to provide hemostasis, acceptable arterial bursting pressure, no remaining foreign material, and no risk for ligature slippage. In our experience, use of the LigaSure Atlas during small intestinal resection and anastomosis in horses is safe for ligation of vessels less than or equal to 7-mm diameter.     

Torsion and volvulus of the transverse and descending colon in a German shepherd dog

A German shepherd dog was presented two months after surgery for correction of acute gastric dilatation volvulus. The dog had been diagnosed with exocrine pancreatic insufficiency. Radiographs revealed marked gaseous distension of one loop of intestine with a generalised increase in intestinal gas content. A 360 degrees anticlockwise rotation of the descending and transverse colon, around the longitudinal axis of the mesocolon, was diagnosed at exploratory coeliotomy. The transverse and descending colon appeared uniformly necrotic and an end-to-end colo-colic resection and anastomosis was performed. The dog initially made satisfactory postoperative progress but was euthanased on the third postoperative day after it developed an intestinal intussusception.     

Risk factors associated with development of postoperative ileus in horses.

OBJECTIVE: To determine risk factors associated with development of postoperative ileus in horses undergoing surgery for colic. DESIGN: Case-control study. ANIMALS: 69 horses that developed ileus after surgery for colic and 307 horses that did not develop postoperative ileus. PROCEDURE: Signalment, history, clinicopathologic data, treatment, lesions, and outcome were obtained from medical records. RESULTS: Variables associated with increased risk of postoperative ileus included age > 10 years, Arabian breed, PCV > or = 45%, high serum concentrations of protein and albumin, anesthesia > 2.5 hours' duration, surgery > 2 hours' duration, resection and anastomosis, and lesions in the small intestine. Enterotomy reduced the risk of postoperative ileus. After multivariate logistic regression, the final model included the variables Arabian breed, PCV > or = 45%, lesion type, duration of surgery (> 2 hours vs < or = 2 hours), and pelvic flexure enterotomy. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that by evaluating certain factors, horses at increased risk of postoperative ileus may be recognized before the condition develops. Preventative treatment and early intervention may be instituted in these horses. Shortening surgery time and performing an enterotomy may decrease the probability of horses developing postoperative ileus.     

Equine gastrointestinal motility research: where we are and where we need to go

Equine gastrointestinal motility is a central issue in cases of equine colic, post operative convalescence and alimentary conditions encountered in practice. There are significant syndromes of intestinal dysmotility in the horse such as obstructive disorders and post operative ileus that are still poorly understood. This review describes the various areas of research that aim to elucidate the pathogenesis of intestinal hypo- or hypermotility by research methods, which include studies at the cellular level, and those that employ in vitro or in vivo techniques of evaluating the physiology and mechanical means of ingesta transit through the alimentary tract. The review discusses future directions for studies which will hopefully lead to better understanding and appropriate measures for diagnosis, therapy and prevention of ileus and other motility disorders.     

Intussusception in 12 cats

The medical records of 12 cats presented with intussusception and diagnosed at the University of Sydney Veterinary Teaching Hospital and the Sylvania Veterinary Hospital were reviewed. Eleven cats were less than one year old at the time of diagnosis. No breed or sex predilections were determined. The most consistent clinical signs were anorexia (83 per cent), weight loss (83 per cent) and a palpable abdominal mass (92 per cent). Vomiting (58 per cent) and diarrhoea (50 per cent) were seen less frequently in these cats compared with the reported incidence of these signs in dogs. In 10 cats the intussusception was corrected surgically. Manual reduction was successful in three of the cats but six required end-to-end anastomosis following intestinal resection and in one cat a typhlectomy was performed. Postoperative ileus complicated recovery in three cases. Recurrence of the intussusception at a different site occurred in two of these cases. One cat with recurrence of intussusception died and the cat with ileus but not recurrence was euthanased one month after the original surgery.     

Jejunal Intussusception: A Complication of Functional End-to-End Stapled Anastomoses in Two Ponies

Jejunojejunal intussusception occurred after jejunal resection and stapled functional end-to-end anastomosis in two pony mares. In both mares, the lead point of the intussusception was the stapled functional end-to-end (FEE) anastomosis. The stapled free ends of jejunum were oversewn with an inverting suture pattern. A possible explanation for development of the intussusception was the acute angle created in the intestine by the FEE anastomsis. This angulation may have impaired flow of ingesta causing motility changes that predisposed the site to intussusception. Because the oversewn blind intestinal ends acted as the lead point for formation of the intussusception, it may be inadvisable to oversew the stapled anastomotic ends.     

Jejunal incarceration by an omental tear in a dog.

A 2-year-old male mixed-breed dog was examined after being hit by a car, and exploratory celiotomy revealed jejunal incarceration through an omental tear. The affected intestinal segment was distended and black, and had small serosal tears. Clinical signs of disease and hematologic, serum biochemical findings during surgery were consistent with concurrent diagnosis of sepsis. The dog responded to supportive treatment and resection of the affected intestinal segment by jejunal end-to-end anastomosis.     

Post operative neutrophilic inflammation in equine small intestine after manipulation and ischaemia

REASONS FOR PERFORMING STUDY: Post operative ileus (POI) remains an important cause of post operative morbidity and mortality in the horse. However, clinical progression of naturally occurring cases of POI in both horse and man does not entirely support the 'neurogenic' hypothesis as the sole mechanism of POI; and the hypothesis that inflammation plays a major role at 12-24 h after surgery requires validation. HYPOTHESIS: An inflammatory infiltrate in the muscularis externa and myenteric plexus of equine jejunum is present 18 h following a period of ischaemia. METHODS: Samples of normal jejunum, jejunum from the proximal resection margins of clinical cases and jejunum obtained 18 h after 1 or 2 h ischaemia or manipulation alone were evaluated for neutrophil infiltration. Samples obtained 18 h after surgery were additionally evaluated for leucocyte activation using calprotectin immunohistochemistry. Results were evaluated by ANOVA and P < 0.05 was considered significant. RESULTS: Significant neutrophilic inflammation was identified in the samples from the proximal resection margins of clinical cases compared to uninjured jejunum. In experimental cases, neutrophilic inflammation appeared to be increased further by 18 h and was identified through all intestinal layers, particularly in the serosa, fascial planes around circular and longitudinal muscle fibres, and myenteric plexus. This elevated level of neutrophilic inflammation was mirrored by an increased number of calprotectin-positive cells in these intestinal layers, indicating leucocyte activation. CONCLUSIONS: Significant neutrophilic inflammation occurs in equine jejunal myenteric layers 18 h after surgery. POTENTIAL RELEVANCE: This neutrophilic inflammation coincides with the clinical time point at which POI is identified and may indicate that inflammatory pathways, rather than solely neurogenic pathways, are responsible for POI in the horse.     

Survival rates for horses undergoing stapled small intestinal anastomosis: 84 cases (1988-1997)

OBJECTIVE: To determine whether location and type of small intestinal anastomosis and other variables were associated with short- and long-term survival rates in horses undergoing stapled small intestinal anastomosis. DESIGN: Retrospective study. ANIMALS: 84 horses that underwent small intestinal anastomosis. PROCEDURE: Medical records from 1988 to 1997 were examined for horses that underwent stapled small intestinal anastomosis. Horses were allotted into 4 groups: jejunojejunostomy (n = 27), jejunoileostomy (11), jejunoileocecostomy with small intestinal resection (20), and jejunoileocecostomy without small intestinal resection (26). Survival rates and other variables were determined. RESULTS: Horses that underwent jejunoileocecostomy without resection had a significantly higher survival rate at all intervals than did horses in the other 3 groups. At 180 and 365 days after surgery, horses that underwent jejunojejunostomy had a significantly lower survival rate than those that underwent jejunoileocecostomy with intestinal resection. Horses that underwent jejunoileocecostomy with intestinal resection had a significantly higher survival rate at 1 year, compared with the combined jejunojejunostomy and jejunoileostomy groups. Preoperative heart rate was inversely associated with survival rate. Overall survival rates at discharge and 1 year were 81 and 56%, respectively. For horses that underwent small intestinal resection, survival rates at discharge and 1 year were 65 and 47%, respectively. CONCLUSIONS AND CLINICAL RELEVANCE: Horses that underwent anastomosis of the small intestine to the cecum without resection had the highest survival rate, compared with horses that required intestinal resection. In some instances, resection and anastomosis involving the cecum had better prognosis than resections involving 2 segments of the small intestine.