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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.
Évaluation clinique d’une anastomose jéjuno-iléale fermée, en un temps, agrafée, fonctionnelle et termino-terminale chez 5 chevaux. Cette étude décrit le résultat et les complications d’une anastomose jéjuno-iléale (AJI) fermée, en un temps, agrafée, fonctionnelle et termino-terminale (FTAFTT) chez des chevaux après la résection d’un petit intestin compromis. Les dossiers médicaux ont été examinés pour identifier tous les chevaux qui avaient subi une AJI FTAFTT durant une laparotomie exploratoire et déterminer les complications postopératoires et le résultat final. Les 5 chevaux qui ont été identifiés ont tous subi une AJI FTAFTT réussie avec résection de diverses quantités du jéjunum distal et de l’iléon proximal. Une occlusion intestinale postopératoire s’est produite chez 1 des 5 chevaux. Tous les chevaux ont survécu au moins 1 an après la chirurgie. Le temps de survie et l’incidence d’une occlusion intestinale postopératoire ont présenté une comparaison favorable avec les résultats publiés pour d’autres types de résection du petit intestin et d’anastomoses. Une AJI FTAFTT est une intervention chirurgicale viable pour corriger les lésions du jéjunum distal et de l’iléon proximal.
(Traduit par Isabelle Vallières)
The ileum comprises about 5% of the small intestine but is involved in approximately 50% of cases of small intestinal strangulation (1,2). Involvement of the ileum traditionally necessitates a jejunocecostomy (3) and there is ample clinical evidence that the use of jejunocecostomy is associated with increased morbidity and mortality compared with jeunojejunostomy (2,4–7). As an alternative to jejunocecostomy a jejunoileal anastomosis (JIA) may be created when lesions involving the ileum are encountered. A recent clinical study found no difference in survival and complication rates between jejunojejunostomy and jejunoileostomy (8).
Latimer et al (9) first reported on the use of linear stapling equipment to create a closed, one-stage, stapled, functional, end-to-end (COSFE) jejunojejunal anastomosis which was later validated in an in vitro study (10). However, there have been no reports on the clinical application of the COSFE anastomosis in horses.
We hypothesized that a COSFE JIA would provide an effective technique to create an anastomosis between the distal portion of the jejunum and proximal portion of the ileum. The purpose of this study is to report, for the first time, on the clinical application of a COSFE JIA.
Medical records of horses admitted to the University Veterinary Teaching Hospital for emergency abdominal exploratory surgery were reviewed. Horses that had undergone a COSFE JIA during emergency abdominal exploratory surgery performed from March 2006 to December 2007 were included in the study. Information obtained from the medical records included: signalment; pre-operative findings during physical examination; results of pre-operative complete blood cell count and biochemical analysis of serum; surgeon; intestinal lesion, including the location and length of small intestine resected; surgical time; postoperative treatments; postoperative complications; and day of discharge. Owners were contacted by telephone for post-discharge follow-up at 12 mo or later or the horse was examined at our hospital.
After the need for surgical exploration of the abdomen was established and informed consent from the owner was received, all horses received 2 L of hypertonic saline solution (7.2% NaCl IV bolus), potassium penicillin (Pfizerpen; Pfizer, New York, New York, USA), 22 000 IU/kg body weight (BW), IV, and gentamicin (6.6 mg/kg BW, IV). Flunixin meglumine (Flunixijet; Butler Schein Animal Health, Dublin, Ohio, USA), 1.1 mg/kg BW, IV was administered if the horse had not received a dose of this drug within the past 12 h. A tetanus toxoid booster (Fort Dodge Animal Health, Fort Dodge, Iowa, USA) was administered if the horse’s vaccination history was unknown or if the horse had not been administered tetanus toxoid within the past 12 mo.
The horses were anesthetized and placed in dorsal recumbency. The ventral aspect of the abdomen was prepared for surgery and the abdomen was explored through an incision created on the ventral midline. One horse undergoing repeat celiotomy had a ventral midline incision created cranial to the original celiotomy that had been performed 15 d previously. In 2 horses with scrotal herniation, the incarcerated small intestine was reduced through a ventral midline celiotomy and scrotal incision; then both testes were excised and the scrotal incisions were closed in routine fashion. The vaginal tunics were sutured as proximal as possible in order to prevent re-herniation.
All horses had COSFE JIA, using the stapling technique described by Latimer et al (9), involving resection of various amounts of distal jejunum and proximal ileum once their intestinal lesions had been anatomically corrected. Sodium carboxymethylcellulose (1 L) was applied to lubricate the small intestine serosal surface while the luminal contents were decompressed into the cecum. After decompression, the intestinal segment to be removed was isolated using an impervious drape. The arcuate mesenteric vessels perfusing the intestinal segment to be resected were ligated and transected using a proximal transfixation ligature of 2-0 polydioxanone sulphate (PDS, Ethicon; Johnson & Johnson, Somerville, New Jersey, USA) and 2 distal staples from a ligating/dividing stapler (LDS, Covidien, Mansfield, Massachusetts, USA) followed by sharp transection of the mesentery of the affected intestinal portion. The intestinal lumens approximately 10 cm proximal and distal to the site of resection were occluded with Penrose drains passed through the mesentery and tied. A Doyen clamp was placed at each margin of intestine to be transected and positioned such that the section of intestine to be resected was folded in half (Figure 1). Two seromuscular stay sutures were placed on the anti-mesenteric border, 1 approximately 2 cm adjacent to the loop of intestine to be resected and the other 10 to 12 cm towards the healthy intestine, to align the intestine to be anastomosed in an anti-peristaltic configuration.
A longitudinal stab incision was made into the lumen of each segment of healthy intestine at its antimesenteric border (Figure 2). A 100-mm, linear anastomotic stapler (ILA-100, Covidien) was used to connect the adjacent segments of intestine at their antimesenteric borders and fired to create 1 side of the stoma (Figure 3). A 90-mm linear stapler (TA-90, Covidien) was positioned diagonally to the 100-mm staple line, with the longer side being on the mesenteric aspect of the anastomosis and the shorter side slightly overlapping the antimesenteric staple line, and fired to finish the stoma (Figure 4). Before the 90-mm linear stapler was removed, the diseased intestine was sharply excised with a scalpel. The stoma was reinforced with a single cruciate suture of 2-0 polydioxanone sulfate at each end of the staple lines, but was not over-sewn. The mesentery was sutured with 2-0 polydioxanone sulfate in a simple continuous pattern. Once the anastomosis was complete (Figure 5), it was evaluated for patency and adequate seal, copiously lavaged with sterile physiologic saline solution, and replaced into the abdomen.
The abdomen was lavaged with 10 to 15 L of sterile physiologic saline. Ten million units of potassium penicillin, 1 g of gentamicin, and 20 000 units of sodium heparin (Hospira, Lake Forest, Illinois, USA) in 1 L of sterile physiologic saline and 1 L of sodium carboxymethylcellulose were instilled into the peritoneal cavity prior to closure of the abdominal incision which was closed routinely in 3 layers. An iodine-impregnated adhesive wound drape (Ioban; 3M, St. Paul, Minnesota, USA) was placed over the incision and removed after the horses recovered from anesthesia.
The horses were administered a second dose of potassium penicillin (22 000 IU/kg BW, IV) after 2 h of surgery. Before strangulated intestine was de-rotated, the horses received a bolus of polymixin B sulphate (The Upjohn Co., Kalamazoo, Michigan, USA) 6000 IU/kg BW, IV. The horses received plasma (2 to 4 L IV) and were administered a lidocaine hydrochloride (Vedco; Saint Joseph, Missouri, USA) CRI (loading dose of 1.3 mg/kg BW, IV followed by 0.05 mg/kg BW per min) during surgery.
All horses received the following postoperative treatments: balanced polyionic intravenous fluid (Normosol-R, Abbott Laboratories, North Chicago, Illinois, USA) at 1 to 2 L/h for at least 2 d; a CRI of lidocaine (0.05 mg/kg BW per min, IV) for at least 2 d; flunixin meglumine (1.1 mg/kg BW, IV, q12h initially for 2 d, then 0.55 mg/kg BW, IV, q12h for at least 2 d); and polymixin B (6000 IU/kg in a 1 L saline IV bolus BID for at least 2 d after surgery). The horses continued to receive potassium penicillin (22 000 IU/kg BW, IV, q6h) and gentamicin (6.6 mg/kg BW, IV, q24h) for 5 d. Additional antimicrobial drugs, based on results of culture and sensitivity, were administered to horse 1 [chloramphenicol palmitate (Bimeda, Lesueur, Minnesota, USA), 50 mg/kg BW, PO, q8h for 14 d], and horse 5 [enrofloxacin (Baytril, Bayer HealthCare, Shawnee, Kansas, USA), 10 mg/kg BW, PO, q24h for 14 d] for treatment of incisional infections.
Additional treatments administered to some of the horses included: DMSO (Domoso, Fort Dodge Animal Health) (horses 1, 2, and 5: 20 mg/kg BW in 1 L saline IV bolus, q12h) and sodium heparin (horses 1, 3, and 4: 20 000 IU, SQ, q8h). Abdominal bandages were placed on horses 1 and 5 during hospitalization. The bandages consisted of sterile absorbent cotton padding next to the incision secured by elastic adhesive tape (Elasitkon; Johnson & Johnson, New Brunswick, New Jersey, USA) or an equine hernia belt (CM™ Equine Hernia Belt; Norco, California, USA).
The horses were allowed access to water within 12 to 18 h after surgery and were provided small amounts of feed at 18 to 48 h after surgery. Initially, alfalfa leaves and small amounts of grass hay or small amounts of complete, pelleted feed were fed every 3 to 4 h. The quantity and particle size of feed were gradually increased daily until the horses were allowed to eat hay free choice (usually by 5 to 7 d after surgery). The horses were hand-walked and allowed to graze for short periods at 24 to 36 h after surgery.
Five horses that underwent abdominal exploration between 2007 and 2008 because of suspected small intestinal strangulation met the study criteria. The horses’ signalment and intestinal lesions, including the location and estimated lengths of intestine resected, are presented in Table 1. Resected intestine included proximal portions of the ileum and the distal portions of the jejunum; length of intestine removed ranged from 1 to 6 m and included 10 to 30 cm of the ileum. All resections and anastomoses were performed by 1 surgeon (GK) with at least 1 surgical assistant. Total surgical times (first incision to last suture placement) ranged from 135 to 285 min with a mean of 210 min.
Horse 1 experienced several postoperative complications, including hemoperitoneum, salmonellosis (Salmonella cultured from feces), persistent fever and incisional infection by methicillin-resistant Staphylococcus aureus extending laterally into the rectus abdominis muscle.
Horse 2 was the only horse that experienced postoperative ileus (POI; defined as production of gastrointestinal reflux > 2 L/h following surgery). The entire length of small intestine of this horse was severely distended during surgery prior to decompression. This horse produced gastrointestinal reflux for 5 d after surgery and was treated by intravenous administration of yohimbine (Yobine; Lloyd Laboratories, Shenandoah, Iowa, USA), at 0.25 mg/kg BW in 1 L physiologic sterile saline IV bolus TID, beginning on day 3 after surgery until intestinal ileus had resolved on day 5. Horse 2 intermittently displayed signs of mild abdominal pain for 4 d after surgery, developed mild dyspnea, caused by pleural effusion and pnuemothorax, and thrombophlebitis of the left jugular vein.
The scrotum of horses 3 and 4 became swollen 2 d after the horses were castrated during surgery to reduce an inguinal hernia. The swelling resolved in both horses after the sutured scrotal, incision was opened to permit drainage. Horse 5 developed an incisional infection of its caudal ventral midline incision, experienced hemoperitoneum, and a low-grade fever for 3 d after surgery.
All horses were discharged from the hospital. None of the horses had had recurrence of colic at the time of follow-up which was at least 14 mo (range: 14 to 20 mo, median: 15 mo) after surgery. Duration of survival at the time of follow-up is shown in Table 1. Horses 2, 3, 4, and 5 returned to their previous level of activity within 6 mo after surgery and horse 1 resumed exercise only 15 mo following surgery, due to the owner’s concern about body wall strength.
This is the first report that describes the clinical use of a COSFE JIA when resection of the distal jejunum and/or proximal ileum is indicated. The incidence of morbidity related to the gastrointestinal tract associated with this technique is comparable to that for horses that underwent small intestinal resection and anastomosis (7,11,12). All horses were discharged, and most importantly, all 5 horses had successful long-term outcomes.
Although the COSFE anastomotic technique is not commonly used to create small intestinal anastomoses in horses, we believe that it offers significant advantages compared with other anastomotic techniques. A notable advantage is the large stoma created initially that has been shown, in jejunojejunal anastomoses, to remodel within 6 mo to become slightly larger in diameter than the surrounding intestine (9). Although the intestinal segments are aligned in an anti-peristaltic manner after a COSFE anastomosis has been completed, the anastomosis remodels within 16 wk to become isoperistaltic (9). Creating a large, functional stoma is advantageous because a potential complication of small intestinal anastomosis is impaction at the site of the anastomosis. Horse 5 developed an impaction at its previous COSFE JJA, the anastomosis appeared functional in the second surgery and the horse did not show any problem related to its COSFE JIA.
Another significant advantage of the COSFE is that, similar to other stapled techniques, it decreases the risk of abdominal contamination because the intestinal lumen is only exposed through 2 stab incisions. In contrast to other stapled anastomotic techniques, neither the staple lines nor the stab incisions are over-sewn. Rather the staple lines are re-enforced with an interrupted suture at each end to prevent the staple line from “unzipping.” In the original description by Latimer et al (9), a simple interrupted suture was placed at each end of the staple line; however, in that study the authors expressed concern that when the intestinal wall is thick the staples may not be secure enough. Since the ileum has a thicker wall we elected to reinforce the anastomosis with a cruciate suture at each end. By not over-sewing, the risk of intussusception is decreased, the intestine is handled less, and the time required to create the anastomosis is shortened. Note that the technique used in this study (COSFE) is different from the functional end-to-end (FEE) technique that was reported to be complicated by intussusception (12,13). The technique used in these studies entails over-sewing the intestinal edges and, according to Semovolos et al (12), the fact that this is not performed in COSFE may make COSFE less susceptible to this complication.
The rate of short-term complications, including hemoperitoneum (2/5) and incisional infection (2/5), is high in this study; however, we did not see these complications when using COSFE JJA in other clinical cases and thus we do not believe these complications are related to the anastomosis technique but more to the specific cases. The incidence of POI (20%, 1/5 horses) experienced in this small group of horses was similar to those in other studies that have reported incidences of POI ranging from 14% to 53% after resection and anastomosis of the small intestine (7,8,11,12). The only horse (horse 2) that suffered POI in this study had severe, extensive small intestinal distension prior to decompression during surgery; this has been shown to cause ischemia and edema that can lead to POI (14). Therefore, the POI experienced by horse 2 could be attributed to the pre-operative small intestinal distension rather than anastomosis dysfunction.
Decreased surgical time during abdominal exploration has been shown to decrease post-operative morbidity and mortality (6,15). Although mean surgery time in this study was long (210 min), surgery time can be greatly reduced once familiarity with the procedure is established. In this study, surgery time decreased from 285 min at the first surgery to 135 min at the final surgery. In addition, Bickers et al (10) demonstrated a significant decrease in time to create a COSFE compared with a stapled side-to-side anastomosis.
This report describes the short-term outcomes and postoperative complications in 5 horses that underwent a COSFE JIA during emergency exploratory laparotomy. Only 1 horse experienced POI and all horses were alive with no recurrence of colic at least 14 mo after surgery. In our opinion, creating a COSFE JIA is a practical, safe, and effective technique that may be used to correct lesions involving the distal portion of the jejunum and the proximal portion of the ileum.
The authors express their gratitude to the referring veterinarians and clinical staff for their invaluable contribution to the success of these cases. We also thank Dr. Jim Schumacher for his critical reading of the manuscript. CVJ
Presented in part at the 2009 American College of Veterinary Surgery Symposium in Washington, DC. The study was conducted at the University of Tennessee.
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