INTESTINAL SURGERY: NEW APPROACHES TO OLD PROBLEMS

Ronald M Bright, DVM MS DACVS VCA-Veterinary Specialists of Northern Colorado Loveland, CO . HEALING CHARACTERISTICS OF THE BOWEL For the first 4-5 days following surgery on the bowel (enterotomy, end-to-end anastomosis), there is no intrinsic strength and the bowel is supported primarily by suture. The small intestine regains 75% of its strength within 14 days of injury. Large bowel heals more slowly, taking 21 days to regain 75% of its original strength. THE ROLE OF THE SURGEON The surgeon is largely responsible for ensuring a successful outcome in intestinal surgery. Hypoproteinemia, suture selection, needle choices, etc., are important considerations but appear to be less important than gentle tissue handling, preservation of the blood supply, strict asepsis, a tensionless suture line and meticulous placement of sutures. Increased risks of leakage following intestinal surgery include surgical removal of foreign bodies, presence of infection at the time of surgery (peritonitis) and enterotomies vs. anastomoses. Interestingly, enterotomies are associated with a higher rate of dehiscence and leakage peritonitis. Suture selection today is made easier by the availability of first-rate suture material. Monofilament absorbable sutures are very close to being the ideal suture material. Polypropylene is also acceptable but be careful when using this for continuous suture patterns as some recent case reports describe problems with intestinal obstruction. With the advances that have been made in needles and suture materials, I dont believe there is ever any indication for using anything but a swaged-on needle. Silk and chromic gut should be considered obsolete. The size of the suture material for intestinal surgery in dogs and cats, regardless of size, should be limited to 3/0 or 4/0. Acceptable needles include taper-cut, reverse-cutting or taper point. The author prefers the RB-1 needle, which is available on most sutures. Sutures should always incorporate the submucosa layer and to ensure this always happens, contact with the lumen is necessary. Any attempt to prevent going into the lumen may compromise the procedure because the submucosa may not be engaged. This is a serious technical error, which will likely lead to dehiscence of the bowel repair. Packing off segments of bowel with a saline-soaked towel or laparotomy pads will act as a barrier to contamination of the entire peritoneal cavity. Intestinal contents should be milked away from the site of incisions where appropriate. This will decrease the amount of spillage of intestinal contents. Following surgery, the surgical site should be gently irrigated with warm saline and suctioned dry. Routine irrigation of the entire abdomen is discouraged unless there is gross contamination outside of the isolated area of packed off bowel or if there is peritonitis present upon entering the abdomen. I like to thoroughly irrigate the subcutaneous layer after linea Alba closure as well. There are a number of factors that assist in minimizing failure of the intestinal repair: 1. 2. 3. 4. 5. 6. 7. 8. 9. careful manipulation of the bowel aimed at preserving its blood supply tension-free closures of enterotomy incisions or anastomoses selection of proper sutures which excludes chromic gut or silk suture use of suture that is not too large for delicate intestinal surgery precise and discriminating use of electrocautery sharp dissection whenever possible careful suture placement that approximates tissue gently Correct use of perioperative antimicrobial prophylaxis begin feeding the animal within 18-24 hours of he surgery if possible

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PERIOPERATIVE ANTIMICROBIAL PROPHYLAXIS I prefer a simple approach to the use of antibiotics during the perioperative period. Ideally, the antibiotic chosen should always be given intravenously to achieve maximum plasma/tissue levels at the time of incising into the bowel. It has been shown that the optimum time to give the drug is approximately 20-30 minutes prior to surgery. Giving the drug more than 2 hours after the initiation of surgery will diminish the benefit of giving perioperative antibiotics.

A first generation cephalosporin, such as cefazolin, would be an acceptable choice, except for its poor coverage against important anaerobes such as Bacteroides fragilis. Anaerobes greatly outnumber aerobes in the distal small bowel, colon, and rectum. My preference is cefoxitin, a second-generation cephalosporin, because it provides excellent coverage against all of the pathogens we are likely to encounter with bowel surgery in small animals. HOW MUCH BOWEL CAN BE RESECTED? For decades, we have been taught that removing more than 50-60% of the small intestine results in short bowel syndrome (SBS). Animals with SBS typically have a number of nutritional and metabolic derangements that often lead to death. Malabsorbtion, weight loss, intractable diarrhea and fluid and electrolyte abnormalities are the most important concerns related to SBS. SBS, although talked about a lot in veterinary medicine, has only been reported in 7 dogs No cases involving cats has been described. A recent study 1 provides us with information involving 13 dogs and 7 cats that had an average of 68% of the small intestine removed most often related to foreign bodies. The range was 5090%. Seventeen of the animals were discharged from the hospital. Median survival time was 828 days. In 12/15 animals where long-term follow-up was available, the outcome was considered good. In this report, the percentage of bowel resected did not have a significant impact on survival time and outcome. ANASTOMOSES TECHNIQUES The anastomosis of two segments of bowel should be kept simple. Everting and inverting patterns are generally unacceptable in companion animals. Disruption of the blood supply especially during the critical postoperative days of 1-5 influences my decision to avoid these suture patterns. The simple interrupted or continuous appositional patterns are excellent in preserving the blood supply. Most surgeons today prefer a simple-interrupted or continuous appositional suture patterns. Appositional suture patterns when used in intestinal anastomoses should be limited to the adult dog and cat. LUMEN DISPARITY Lumen disparity associated with an intestinal resection usually requires some form of correction. Various methods are available including spatulation of the smaller bowel segment, cutting the small diameter segment of bowel at a sharp angle, or suturing the lumen of the larger bowel until its diameter matches that of the other segment. Optimal control of correcting lumen disparity in my hands is best achieved using the lumen-decreasing technique. OMENTAL OR SEROSAL PATCHING TECHNIQUES 2 Omental or jejunal serosal patching (using a segment of jejunum) should be used to augment primary suture lines or, in some instances, as a full-thickness patch. I recommend a wraparound omental patch on all of my anastomoses or enterotomies. I now employ a skin stapler for quick and safe placement of the wraparound patch being careful to avoid major mesenteric vessels. The jejunal serosal patch is used when a more substantial augmentation of an enterotomy or anastomosis is required, i.e., when infection is present at the time of surgery or if there are some minor concerns about viability of the bowel following an enterotomy or end-to-end anastomosis. The segment of bowel that is most difficult to resect and reestablish bowel continuity with an end-to-end anastomosis is the proximal duodenum. This is an ideal site where partial resection of a lesion can be accomplished and the bowel integrity restored using a segment of jejunum as a full thickness patch. This is also an area where a patch using a peritoneal-musculature flap can be utilized. FOREIGN BODIES Linear foreign bodies (LFBs) are most often seen in the cat but in my more recent experiences, I have seen it be comparable in incidence to the dog. The average age of cats seen with thread +/needle was 2.7 years in one study. The needle is involved in less than 10% of the cases. The effect of a linear foreign body initially results in partial obstruction. The pathogenesis of the obstruction results from the object becoming fixed somewhere cranially in the GI tract, most notably under the tongue or within the pylorus. Normal smooth muscle contraction of the small intestine continues to propel the object aborally but due to its fixation, it will begin to do serious damage to the mesenteric border of the bowel. Continuing peristalsis against the pressure of the fixed linear object will eventually result in a perforation of the gut with leakage and peritonitis quickly following. This provides us with a huge incentive to diagnose and treat this problem as soon as possible. Historically, the owner will recall (but not always) seeing the cat/dog playing with thread or string and may even notice it being missing shortly after the cat becomes ill. Dogs are less helpful in this regard since the source of their linear foreign body is so varied. Vomiting with regularity combined with

anorexia and depression are the most common signs seen with LFBs. Weakness and dehydration may eventually result from vomiting. Some melena or blood-tinged stool may be seen. On physical examination, some degree of dehydration is usually detected. The base of the tongue may reveal a loop of string/thread. In cats, approximately 50% of the time the LFB is found tethered under the tongue. The anus should also be examined for the presence of string. Abdominal palpation will often reveal tenderness and a bunching up effect of the small bowel in the cranial abdomen. The diagnosis relies on the history and physical examination findings combined with diagnostic imaging. Abdominal radiography will usually reveal a pleated pattern sign and multiple gas bubbles eccentrically appearing throughout the affected loops. Barium contrast studies will reveal shortening of the bowel and eccentric pleating throughout the bowel. Sometimes the linear object can be seen after the barium clears portions of the bowel because it retains some of the barium contrast material. Also, look closely at serial films and youll notice that the position of the bowel remains fixed on successive films. Early peritonitis may also be verified by the loss of serosal detail. In 14% of the time radiography may be of no help in the diagnosis of LFB. Ultrasound would then be indicated to help confirm the diagnosis. Surgery is the recommended treatment. If the string is under the tongue, it can be cut (same with string protruding from the anus) and occasionally this will alleviate the signs. Conservative management in one study (cutting the sublingually positioned string) was successful in 9 or 24 cats. A gastrotomy combined with multiple enterotomies is the traditional method of removing LFBs. However, I prefer a technique described by Anderson that describes the possible removal of a linear object with a gastrotomy alone or combined with limited enterotomies (usually only one). The LFB is sewn to a red rubber tube cut to a length of approximately 12-13 cm starting at the closed tip end of the tube. The catheter is passed through the pylorus with the foreign body attached to it and is gently massaged throughout the bowel until the placations are relieved. It can either be passed completely through the bowel and be retrieved by an assistant from the anus, or it is removed through a single enterotomy incision. Although you may be tempted to primarily close a rent or tear in the mesenteric side of the bowel that may be present, I prefer to resect that segment. If perforation and peritonitis are present at the time of surgery, then the prognosis is considerably worse for the patient. This again stresses the need for a prompt and accurate diagnosis and subsequent surgery. BIOPSIES Intestinal biopsies may be necessary to assist in the diagnosis of bowel disease. A longitudinal incision with a side-to-side closure or a longitudinal incision followed by a transverse closure are acceptable biopsy techniques I believe in keeping it simple, i.e., longitudinally oriented biopsies with side-to-side closure. We now routinely close these enterotomy incisions with a continuous suture pattern starting and ending just beyond the margins of the incision. REFERENCES 1. Gorman SC, Freeman,LM, Mitchell,SL, Chan DL. Extensive small bowel resection in dogs and cats. J Amer Vet Med Assoc 2006: 228: 403-407 2. Crowe D T The serosal patch: Clinical use in 12 animals, Vet Surg 1984:13: 29-34 9