Effect of carboxymethylcellulose and hyaluronate solutions on jejunal healing in horses

OBJECTIVE: To compare a double-layer inverting anastomosis with a single-layer appositional anastomosis, coated with either 1% sodium carboxymethylcellulose (SCMC) or 0.4% sodium hyaluronate (HA) solutions, in the small intestine of horses with respect to anastomotic healing and adhesion formation. ANIMALS: 18 adult horses. PROCEDURE: Midline celiotomy and end-to-end jejunal anastomoses were performed. In control group horses (n = 6), a double-layer inverting anastomosis coated with sterile lactated Ringer's solution was performed. In treatment group horses, a single-layer appositional anastomosis was performed that was coated with 1% carboxymethylcellulose solution (SAA + SCMC group horses, 6) or 0.4% hyaluronate solution (SAA + HA group horses, 6). An additional 500 mL of the respective treatment solution was applied to the jejunal serosal surface, and 2 jejunal serosal abrasion sites were created. Horses were euthanatized 10 days after surgery. Anastomoses and abdominal adhesions were evaluated grossly. Anastomotic healing was evaluated on the basis of bursting wall tension. RESULTS: Bursting wall tension was significantly greater in SAA + SCMC group horses, compared with control group horses. All intestinal segments failed at a point distant to the anastomosis. Significantly fewer adhesions were found at the abrasion sites of SAA + HA group horses, compared with control group horses. No differences were found in adhesion formation at the anastomotic sites among groups. CONCLUSIONS AND CLINICAL RELEVANCE: Coating a single-layer appositional jejunal anastomosis with SCMC or HA solutions does not adversely affect anastomotic healing. Application of 0.4% HA solution to the serosal surface of the jejunum significantly decreases the incidence of experimentally induced intra-abdominal adhesion formation in horses.     

Vaginourethroplasty as a salvage procedure for management of traumatic urethral rupture in a cat

This report describes a cat that suffered pelvic urethral rupture associated with multiple pelvic fractures. A vaginourethroplasty was performed as a salvage procedure, via intrapelvic anastomosis of the proximal urethra to the caudal vagina, following failure of a primary urethral anastomosis. Urinary diversion was achieved via tube cystostomy and a vagino-urethral catheter was maintained for 3 days postoperatively. Anterograde cystourethrography was performed at 7 days and 14 days postoperatively. Absence of contrast leakage from the vagino-urethral anastomosis was documented at 14 days postoperatively and the tube cystostomy was removed. An Escherichia coli urinary tract infection was treated following removal of the tube cystostomy and subsequent urine culture revealed no evidence of urinary tract infection. The cat retained normal urinary continence and elimination behaviour during the 7-month follow-up period. Vaginourethroplasty could be considered as a salvage option for management of traumatic pelvic urethral rupture in the neutered female cat.     

Successful surgical management of a perforating oesophageal foreign body in a cat

CASE PRESENTATION AND SURGICAL INTERVENTION: a 3-year-old cat was presented with a recent history of dysphagia and intermittent regurgitation. Radiography revealed a bony oesophageal foreign body at the level of the thoracic inlet. Endoscopic retrieval was attempted but resulted in severe dyspnoea due to the development of pneumomediastinum, pneumothorax and subcutaneous emphysema secondary to perforation of the oesophageal wall. Immediate surgical exploration was carried out. Extensive necrosis of the oesophagus resulting from the presence of the foreign body led to a decision to perform an oesophageal resection and anastomosis. CLINICAL RELEVANCE: this is the first clinical report of a cat treated successfully by oesophagectomy following oesophageal perforation due to an obstructive foreign body. The authors suggest that prompt surgical intervention, the ability to convert to a surgical procedure under the same anaesthetic as a non-surgical retrieval, placement of a gastrostomy tube and the availability of advanced anaesthetic and critical care support are important factors to consider when managing feline patients with a perforating oesophageal foreign body.     

Comparison of biofragmentable anastomosis ring and sutured anastomoses for subtotal colectomy in cats with idiopathic megacolon

OBJECTIVE: To report use of a biofragmentable anastomosis ring (BAR) device in cats with idiopathic megacolon (FIM) and compare outcome after subtotal colectomy with sutured colocolic anastomosis. STUDY DESIGN: Retrospective study. ANIMALS: Nineteen cats with megacolon. METHODS: Medical records (January 1990-January 2004) of cats treated surgically for idiopathic megacolon with sutured (SUT) or BAR anastomosis were retrieved and reviewed. Operative, short- and long-term complications, and survival times were recorded and Kaplan-Meier survival analysis used to assess outcome. RESULTS: There were 11 SUT and 8 BAR cats. One BAR cat had anastomotic dehiscence 36 hours after surgery. Mild serosal tearing during BAR insertion in 6 cats was corrected by suture reinforcement. One SUT cat developed anastomotic stricture at 32 days. Short-term complication rates at 3 and 7 days were 18% and 45% in the SUT group and 25% and 87.5% in the BAR group, respectively (P=.058). Two SUT cats had persistent loose stool consistency and were euthanatized 254 and 1661 days after surgery. One BAR cat had recurrence of constipation which was managed medically. Long-term complication rates were not significantly different between SUT and BAR (P=.61). The 1 and 4-year survival rates were 90% for SUT and 100% for BAR (P=.29). CONCLUSIONS: No difference was detected for short and long-term complication rates and survival times between SUT and BAR groups. CLINICAL RELEVANCE: The BAR device can be used for colocolic anastomosis in cats with idiopathic megacolon. Serosal tearing during BAR insertion was a common intraoperative complication. Regardless of anastomotic technique, survival outcome after colonic resection is excellent for cats with FIM.     

Use of atropine to reduce mucosal eversion during intestinal resection and anastomosis in the dog

OBJECTIVE: To determine whether atropine altered the degree of mucosal eversion during jejunal resection and anastomosis in the dog. STUDY DESIGN: Part I: Prospective, blinded, randomized, controlled study using a therapeutic dose (0.04 mg/kg systemic) of atropine. Part II: Prospective, unblinded, assigned, controlled study using a pharmacologic (0.04 mg/kg local arterial) dose of atropine. ANIMALS: Part I: Twenty-two young adult female Beagle dogs used during a nonsurvival third-year veterinary student surgical laboratory (small intestinal resection and anastomosis). Part II: Ten young adult female Beagle dogs used immediately after completion of a nonsurvival third-year veterinary student orthopedic surgical laboratory. METHODS: Part I: Dogs were randomly assigned to receive either atropine (0.04 mg/kg), or an equal volume of saline, given intramuscularly (premedication) and again intravenously prior to intestinal resection. Part II: In each dog, atropine (0.04 mg/kg)/saline was alternately given in the proximal/distal jejunum. RESULTS: Part I: There was no clinically or statistically significant difference between systemic atropine and saline solution on the degree of jejunal mucosal eversion after resection. Part II: There was a statistically significant decrease in jejunal mucosal eversion with atropine compared with saline solution when injected into a local jejunal artery. CONCLUSION: Systemic atropine (0.04 mg/kg) does not alter the degree of jejunal mucosal eversion during resection and anastomosis. Jejunal intraarterial atropine (0.04 mg/kg) reduced jejunal mucosal eversion during resection and anastomosis. CLINICAL RELEVANCE: The clinical usefulness and consequences of jejunal arterial atropine administration to reduce mucosal eversion remain to be determined.     

Urethral transitional cell carcinoma in a cat

A 15-year-old, male neutered cat was referred for investigation of dysuria. A retrograde urethrography was performed which showed two space-occupying masses within the lumen of the mid-to-proximal urethra. Exploratory coeliotomy revealed two urethral masses. Segmental urethrectomy was performed to resect the mass, and the lower urinary tract was reconstructed by vesico-urethral anastomosis. Histopathology showed the mass to be a transitional cell carcinoma with incomplete surgical margins. Tumour regrowth was suspected when dysuria was found approximately 318 days after surgery. Clinical signs were palliated by radiation using weekly fractions of 6 Gy for three weeks. The cat died of unknown causes 386 days postoperatively.     

Oesophageal squamous cell carcinoma in two cats

Two cases of feline oesophageal squamous cell carcinoma are described. In both cases, diagnosis was achieved by radiography, endoscopy and cytology, and later confirmed by histology. One cat underwent oesophagectomy followed by end-to-end anastomosis, but died three days postsurgery; the second cat was euthanased after diagnosis.     

In vitro evaluation of an inverted end-to-end equine jejunojejunal anastomosis using skin staples

OBJECTIVE: To compare functional indices of end-to-end (EEA) jejunojejunal anastomosis using skin staples in horses with a 2-layer inverting hand-sewn technique. STUDY DESIGN: Experimental study. SAMPLE POPULATION: Jejunal segments from 8 fresh equine cadavers. METHODS: For each bowel segment, 2 EEA anastomoses were created: one 2-layer hand-sewn and one 1-layer using skin staples. Time for anastomosis creation was recorded and compared. Lumen diameter of each anastomosis was measured on digital radiographs after intraluminal instillation of contrast medium and inflation of the jejunal segments to 14 mm Hg. Anastomotic indices (a compensated measure of stoma diameter) and bursting pressure were determined. RESULTS: EEA jejunal anastomosis using skin staples was significantly faster than use of a 2-layer hand-sewn technique. Anastomotic index, a measure of lumen size, was significantly larger with the skin-staple technique; however, the bursting pressure of stapled anastomoses was significantly less than for the hand-sewn technique, but the values were well above those reported for other anastomotic techniques. CONCLUSIONS: An anastomotic technique using skin staples was easy to learn and perform, effective and faster, and mechanically comparable with a hand-sewn 2-layer technique. CLINICAL RELEVANCE: The staple technique could be beneficial in equine gastrointestinal surgery by reducing anastomosis time, although further in vivo studies are needed to establish clinical safety.     

In vitro evaluation of a closed-bowel technique for one-layer hand-sewn inverting end-to-end jejunojejunosotomy in the horse

OBJECTIVE: To report a technique for closed-bowel 1-layer inverting end-to-end jejunojejunal anastomosis in horses. STUDY DESIGN: Experimental study. SAMPLE POPULATION: Fresh cadaveric jejunal segments from 12 horses. METHODS: For each bowel segment a 1-layer closed and a 2-layer inverting end-to-end jejunojejunosotomy was created. Anastomosis construction time and anastomotic bursting pressure were measured and compared. RESULTS: Closed-bowel anastomosis was significantly faster to create than a 2-layer technique. Luminal narrowing (<30%) was similar with both techniques and comparable with other inverting techniques. Bursting pressure was significantly higher for the 2-layer technique, although all anastomoses resisted pressures higher than those reported for other jejunojejunal anastomosis techniques. CONCLUSIONS: A 1-layer hand-sewn, closed, inverting jejunojejunosotomy using a modified Doyen clamp was easy and faster to perform, and resulted in functional characteristics similar to, a 2-layer hand-sewn inverting technique. CLINICAL RELEVANCE: A closed, 1-layer inverting technique could be considered for equine jejunal anastomosis but requires in vivo evaluation before recommendation for clinical use.     

Simultaneous occurrence of inflammatory bowel disease and trichomonosis in a Maine coon cat

A 2-year-old, 4.2 kg, spayed female, Maine coon cat was referred to the veterinary hospital for evaluation of hyporexia, slow growth, and chronic, intermittent, mucoid, bloody, voluminous, and fetid diarrhea. The diarrhea had been observed since the cat was acquired from a cattery at 4 months of age; with acute worsening in the 5 d before presentation. Abdominal palpation revealed moderate pain. Ultrasonographic examination showed thickening of the jejunal wall and ileal loops, increased echogenicity of the jejunal mucosa, and enlargement of the jejunal and ileocolic lymph nodes. Histopathology of full-thickness intestinal biopsies showed moderate, diffuse, lymphoplasmacytic, erosive enteritis with hemorrhage and edema. Diffuse, lymphoplasmacytic, erosive colitis with mild, interstitial fibrosis and hemorrhage was also noted. The ileocecal lymph node biopsy showed eosinophilic lymphadenitis. Based on the immunohistochemical evaluation of intestinal samples with CD3 and CD79a antibodies, a diagnosis of lymphoma was ruled out. Fecal polymerase chain reaction testing was positive for Tritrichomonas foetus. Based on these results, inflammatory bowel disease and trichomonosis were diagnosed. Treatment for the cat included a hypoallergenic diet and an oral omega-3 fatty acid supplement, in conjunction with prednisolone, to manage the inflammatory bowel disease. Ronidazole was administered to target the Tritrichomonas foetus. The cat was clinically normal during a follow-up examination after 6 months of treatment.     

Metronidazole neurotoxicosis in two cats

Two cats were presented for neurological dysfunction from suspected metronidazole toxicity. One cat was receiving 111 mg/kg body weight per day of metronidazole for 9 weeks. After 9 weeks, the dose was increased to 222 mg/kg body weight per day, and 2 days later the cat began to experience progressive neurological signs that culminated in generalized seizures. The second cat was receiving metronidazole at a total dose of 58 mg/kg body weight per day for 6 months. This cat experienced acute onset of ataxia and alteration in mentation. Laboratory evaluations in both cases were without significant findings. The neurological signs in both cats resolved within days of initiating supportive therapy and withdrawal of the drug. This report describes the two cases and discusses the etiology of metronidazole neurotoxicosis.     

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.     

Total Colectomy with Ileorectal Anastomosis in the Cat

Total colectomy with end-to-end ileorectal anastomosis was performed in eight healthy adult cats. Hydration status, body weight, attitude, appetite, and stool consistency were monitored for 24 weeks. Ileal water absorption was determined at weeks 1, 6, 12, 18, and 24 using the double-lumen catheter intestinal perfusion technique with polyethylene glycol as the indicator substance. Bowel adaptation was evaluated by histologic morphometric analysis of full-thickness ileal biopsies taken at the time of total colectomy and at weeks 6, 12, 18, and 24. The anastomoses were examined at necropsy for evidence of leakage and development of strictures. All cats resumed normal activity in 48 hours and maintained or gained weight during the study. Small volumes of watery diarrhea were present immediately after surgery, but by week 1 all cats had a semi-solid nonformed stool. At month 2, three cats developed semi-solid formed stools. One cat had occasional perineal soiling and five cats had at least one episode of hematochezia. There was improvement in ileal water absorption in two cats, and there were significant increases in villus height, enterocyte height, and enterocyte density in all cats. Results of postmortem examination of the anastomosis showed no evidence of stricture in any cat.     

Hand‐assisted laparoscopic adhesiolysis of extensive small intestinal adhesions in a mare after breeding injury

In this article we report the course of disease in a mare following severe vaginal injury during natural cover. Although the genital injury healed completely, the mare developed extensive intra‐abdominal intestinal adhesions causing complete small intestinal obstruction 2 years after the incident. The adhesion was not accessible during initial emergency laparotomy and a standing, hand‐assisted laparoscopic adhesiolysis and jejuno‐jejunal end‐to‐end anastomosis were subsequently performed. The mare was subjected to euthanasia 10 weeks after surgery due to recurrence of abdominal pain. The pertaining literature is discussed in regards to this case.     

Closed One-Stage Functional End-to-End Jejunojejunostomy in Horses With Use of Linear Stapling Equipment

Objective—To use gastrointestinal linear stapling instrumentation to perform a closed one-stage functional end-to-end jejunojejunostomy in adult horses as an alternative to a stapled side-to-side jejunojejunostomy.
Study Design—Clinical outcome, anatomic and histological architecture, and anastomotic dimensions were determined at 2, 4, 8, 16, and 24 weeks postoperatively. Animals or Sample Population—18 adult horses.
Methods—The anastomosis and peritoneal cavity were inspected for adhesions. The diameter and circumference of the anastomosis and jejunum oral and aboral to the anastomosis were determined from digitized contrast radiographs and linear measurements. Healing of anastomotic sites was evaluated histologically.
Results—Three horses were euthantized in the immediate postoperative period. In the 15 surviving horses, there were no peritoneal adhesions or distortion of the anastomoses and stomas remodeled in an end-to-end fashion. The mean anastomotic staple line (7.48 cm) and mucosa (6.89 cm) diameters were significantly ( P < .05) larger than the mean jejunal diameter oral (6.03 cm) and aboral (6.01 cm) to the anastomosis. The mean anastomotic luminal circumference (13.61 cm) was significantly ( P < .01) larger than the mean oral (11.43 cm) and aboral (11.12 cm) jejunal circumference. Histologically, there was adequate mucosal and muscularis mucosae reapposition with a moderate degree of fibrosis and inflammation.
Conclusions —Closed one-stage functional end-to-end jejunojejunostomy resulted in an acceptable functional anastomosis.
Clinical Relevance —This technique appears to be an acceptable alternative to linearly stapled, side-to-side jejunojejunostomies performed in horses.     

Effect of carboxymethylcellulose and a hyaluronate-carboxymethylcellulose membrane on healing of intestinal anastomoses in horses

OBJECTIVE: To evaluate the effect of sodium carboxymethylcellulose (SCMC) or a hyaluronate-carboxymethylcellulose membrane (HA membrane) on healing of the small intestine in horses. ANIMALS: 18 healthy adult horses. PROCEDURE: Midline celiotomy and 2 jejunal resection-and-anastomosis surgeries were performed. In treated horses, SCMC (n = 6) or a HA membrane (6) was applied to the jejunum to cover the anastomosis. There were 6 untreated control horses. Horses were euthanatized 10 days after surgery. For each horse, 1 anastomosis was used for histologic examination, and the second was used to determine intestinal bursting strength. Intestinal bursting tension, serosal granulation tissue, serosal fibrin deposition, and width of the fibrous seal at the anastomosis were compared among groups. RESULTS: 3 control horses had adhesions associated with the anastomosis, but none of the treated horses had adhesions associated with the anastomosis. Mean thickness of fibrin deposited on the serosal surfaces for the SCMC and HA-membrane groups was significantly less than that for control horses. Mean thickness of serosal granulation tissue, width of fibrous seal between inverted musculature, inflammatory cell infiltrate scores, and bursting tension did not differ significantly among groups. CONCLUSIONS AND CLINICAL RELEVANCE: Use of SCMC or application of a HA membrane to small intestinal anastomoses in horses resulted in fewer adhesions and decreased fibrin deposition, and it did not adversely affect anastomotic healing. In horses at increased risk for intra-abdominal adhesions, SCMC or application of HA membranes may decrease the frequency of adhesions without adversely affecting healing of small intestinal anastomoses.     

Use of recombinant human factor VIIa in 2 patients with postoperative noncompressible,abdominal hemorrhage

Objective

To describe the clinical presentation, clinical course, and successful management of noncompressible, abdominal hemorrhage with recombinant human factor VIIa (rFVIIa) in 2 postoperative patients.

Case Summary

A 14-year-old neutered female Border Terrier and a 9-year-old neutered male domestic shorthair were treated with rFVIIa to treat noncompressible abdominal hemorrhage in the postoperative period. The dog presented for a septic abdomen following endoscopic intestinal biopsies 10 days prior and was found to have a jejunal perforation along with a fractured liver lobe and hepatic lymphoma at the time of exploratory laparotomy. The cat presented for a spontaneous hemoabdomen associated with hepatic amyloidosis. Clinically significant hemorrhage occurred in the perioperative and postoperative period and both patients received massive transfusions and antifibrinolytic therapy. Despite these interventions, the patients continued to have ongoing abdominal hemorrhage and surgical attempts at hemostasis were not attempted due to the friable nature of the liver at the time of surgery. Both patients received rFVIIa intravenously every 3 hours at a dose between 70 and 90 μg/kg as indicated by the clinical picture, which subsequently decreased transfusion requirements.

New or Unique Information Provided

This case report describes the use of rFVIIa in a cat and a dog with severe, noncompressible abdominal hemorrhage in combination with standard hemostatic interventions.     

Successful treatment of feline pancreatitis using an endoscopically placed gastrojejunostomy tube

A cat with pancreatitis, diagnosed using abdominal ultrasonography, fine-needle aspirate cytopathology, and increased concentration of serum trypsin-like immunoreactive substance, was treated successfully using jejunal alimentation provided through a percutaneous gastrojejunostomy tube. This method of jejunal feeding is less technically difficult, less stressful for the patient, and has fewer complications than surgically placed jejunostomy tubes. Nutritional support with jejunal feeding is superior to total parenteral nutrition, as it maintains gut integrity, decreases septic complications, and may reduce exogenous insulin requirements. The methods of tube insertion and maintenance, and the physiological advantages over other feeding methods are described.     

Hypothermic Storage of Feline Kidneys for Transplantation: Successful Ex Vivo Storage Up to 7 Hours

Objective—To describe the effect of hypothermic storage on transplanted feline kidneys.
Study Design—Kidneys were stored in University of Wisconsin (UW) sodium gluconate (n = 3) or phosphate-buffered sucrose (n = 5) solutions before transplantation.
Animal Population—Eight cats with renal failure and seven normal cats as kidney donors.
Methods—Kidneys were perfused through the renal artery with cold (10°C) storage solution and immersed in the solution on ice until transplantation.
Results—Mean ex vivo storage time was 4.8 ± 0.36 hours (range, 3.5 to 7 hours). Seven recipient cats survived surgery. Five of the cats had decreased serum creatinine concentrations from a mean of 8.2 mg/dL (range, 4.0 to 15.8 mg/dL) preoperatively to 1.7 mg/dL (range, 1.3 to 2.2 mg/dL) within 4 days of surgery. In one cat, serum creatinine concentration dropped from 15.1 to 3.7 mg/dL in 3 days, but the cat developed a ureteral stricture that required revision. One graft did not function, and the cat died on day 19. The mean postoperative survival time of cats that were discharged from the hospital (n = 6) was 254 days (range, 49 to 717 days) at the time of this report. Long-term renal function (>60 days postoperatively; n = 5) was excellent with mean serum creatinine concentrations of 1.6 ± 0.15 mg/dL.
Conclusions—Hypothermic storage is feasible for short-term preservation of feline kidneys.
The maximal length of feasible storage remains unknown.
Clinical Relevance—Hypothermia protects against ischemia-induced nephron loss during ex vivo manipulation of the allograft and allows longer safe vascular anastomosis times. Short-term hypothermic storage also provides time to accommodate modifications in scheduling or anesthetic management of the recipient operation.     

One percent sodium carboxymethylcellulose prevents experimentally induced abdominal adhesions in horses

OBJECTIVE--To evaluate the efficacy of 1% sodium carboxymethylcellulose (SCMC) for prevention of experimentally induced abdominal adhesions in horses. STUDY DESIGN--Prospective, controlled, experimental study. ANIMAL POPULATION--Twelve healthy adult horses. METHODS--The effect of 1% SCMC on adhesion formation was evaluated in 12 healthy horses by using an established model of serosal trauma to induce intraabdominal adhesions. After ventral median celiotomy, 2 separate areas of the jejunum were abraded, and three 2-0 chromic gut sutures were placed in each abraded area. Jejunal resection and end-to-end anastomosis was performed at 2 sites distant to the abrasion sites. In treated horses (n = 6), 2 L of 1% SCMC was applied to the intestine before and after intestinal manipulation. In control horses (n = 6), 2 L of saline solution were applied to the intestine before and after surgical manipulation. All horses were euthanatized 10 days after surgery, and the abdominal cavity was evaluated for adhesion formation. The frequency of intraabdominal adhesions between groups was compared with a chi-square test. Statistical significance was set at P <.05. RESULTS--All control horses had intraabdominal adhesions. Fibrous adhesions were associated with both jejunal abrasion sites in 5 control horses. Fibrous adhesions were also associated with 1 or both jejunal anastomotic sites in 5 control horses. Only 1 treated horse developed adhesions at the jejunal abrasion sites, and no adhesions were present at the anastomotic sites in the treated horses. There were significantly fewer adhesions in the SCMC treatment group compared with the control group (P <.05). CONCLUSION--In this experimental model, application of 1% SCMC reduced the frequency of intraabdominal adhesions at areas of serosal abrasion and at jejunal anastomotic sites. CLINICAL RELEVANCE--In horses at an increased risk for developing intraabdominal adhesions after intestinal surgery, the use of 1% SCMC during celiotomy may decrease the frequency of adhesion formation.