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 (). 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.
Figure 1 Damaged distal jejunum and proximal ileum after incarceration in the epiploic foramen prior to resection and anastomosis using a closed one-stage stapled functional end-to-end technique. The long white arrows point to the Doyen intestinal forceps occluding (more ...)
A longitudinal stab incision was made into the lumen of each segment of healthy intestine at its antimesenteric border (). 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 (). 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 (). 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 (), it was evaluated for patency and adequate seal, copiously lavaged with sterile physiologic saline solution, and replaced into the abdomen.
Stab incisions are created while the intestinal segment is held up to prevent leakage of intestinal content and contamination of the surgical field.
Figure 3 Application of the linear stapler (ILA 100, white arrow) for creation of the stoma; one arm is inserted into the jejunum and the other into the ileum. The long black arrows points to the stay sutures while the short black arrow points to the doyen forceps. (more ...)
Figure 4 Application of the TA 90 stapler (vertical white arrow) to the intestinal segment that is about to be removed (horizontal black arrow) including the area in which the stab incisions (vertical black arrow) were made for linear stapler application. The (more ...)
A completed closed one-stage stapled functional end-to-end jejuno-ileal anastomosis.
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 . 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 . 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.