Author

Stephen J. Birchard DVM, MS, Diplomate ACVS

Sunday, September 29, 2013

5 Ways To Become a Faster Surgeon



“Time is trauma!”  How many times have you heard that from the anesthesiologist or anesthesia technician monitoring your surgical patient? How does it make you feel when people comment on the length of your surgery; pressured, annoyed, even angry? All understandable reactions. But, there is a scientific basis for that cliché. The longer the tissues are exposed to the air the more likely to have complications such as excessive inflammation and infection.1 During my residency I was taught that for every hour the incision is open the rate of infection doubles.2 Studies on human hospitals have found the clinics with higher case loads tend to have fewer surgical complications than the slower ones.3

In the 19th century surgical speed was essential because surgery was done without anesthesia. Rapid surgery was necessary to decrease pain and mortality. Dr. Robert Liston was famous for being the fastest surgeon of his time. He could amputate a person’s leg in 2 and ½ minutes! But, occasionally his intent on being fast led to serious mishaps such as when he accidentally removed a man’s testicles while amputating his leg, and cutting off his assistant’s fingers during another lightening fast operation. There!

Thankfully in modern day surgery we have general anesthesia and other support systems to minimize morbidity and mortality and eliminate the need for 2 and ½ minute amputations. But prolonged surgery time still leads to increased postoperative problems for the patient and takes its toll on the surgeon. The longer the surgery takes the more likely you and your assistants will become stressed, tired, hungry, and have full urinary bladders. Tired surgeons become inefficient, less patient, and less meticulous. Decisions become more difficult and are made with less confidence. The surgeon loses focus and direction.

There is a also a stigma to being a slow surgeon. People, particularly non-surgeons, tend to judge surgical skill by how fast the surgeon is rather than by the hand skills or the ability to “think on your feet”. Its not always fair, but it happens.

Performing an operation swiftly is just one of many aspects of being a good surgeon and actually not the most important one. Speed in surgery is, although important, somewhat overrated. Patient evaluation, owner communication, and decision making before surgery are more important elements to good surgical practice. The decision making process involves a careful analysis of the patient, its owner, and the evidence based medicine that is relevant to your patient. The surgeon’s dedication to these principles trumps having hands that are a blur on the operating table.

Although being a speedy surgeon is not absolutely essential, the clinical evidence is clear that shorter operative times result in fewer postoperative complications. Here are 5 things you can do right now to reduce the time your surgical patients spend on the operating table:
  1. Have a plan. Base that plan on a thorough review of all aspects of the patient’s clinical presentation and status. Review the current literature for up to date information on the disorder and the surgical technique. Review anatomy and the steps involved in the procedure. Get advice from others before the surgery, not during. Discuss your plan with your support staff.
  2. Use good quality instruments and sutures. Have them ready in the operating room. Poor quality tools and materials lead to frustration, stress, and delays.
  3. Have an assistant surgeon. An assistant saves time by retracting, handing you instruments, cutting sutures, and keeping the instrument table organized. A lot of time is wasted searching for instruments when they are piled up like an anthill. Veterinary technicians love to scrub in and get close to the action! Let them do it!
  4. Use a simple continuous suture pattern to close the linea alba. Use polydioxanone or equivalent delayed absorbable suture for this tissue layer. This step alone could save 15-20 minutes of surgery time. A simple continuous pattern can also be used to close cystotomy incisions and  intestinal anastomoses. Closure of the skin with surgical staples will also save 15-20 minutes.
  5. Don’t force it. You can’t will yourself to be faster. Allow it to happen naturally as you gain experience and repetition with procedures. Experience is a wonderful teacher; you learn how to handle and dissect tissues effectively and atraumatically. Your hands will start to flow through the surgery with little wasted motion and less tissue manipulation. Live in the moment and enjoy it.

A clean, organized instrument table makes surgery
more efficient and less frustrating.

Simple continuous closure of the linea alba with PDS.

 Conclusion

Surgical skill is more about what’s between your ears than in your hands. Practice your technical skills and always strive to have better hands, but be a “thinking” surgeon. Learn from your mistakes, keep a positive outlook, and believe in yourself. Do that, and you will find surgery to be a very satisfying part of your veterinary career, and your patients will appreciate your knowledge and skill by having uncomplicated postoperative recoveries.

References

1. Manilich E, Vogel JD, Kiran RP, Church JM, Seyidova-Khoshknabi D, Remzi FH. Key factors associated with postoperative complications in patients undergoing colorectal surgery. Dis Colon Rectum. 2013 Jan;56(1):64-71.
2. Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am. 1980;60(1):27-40.
3. Talya Salz, Robert S. Sandler. The Effect of Hospital and Surgeon Volume on Outcomes for Rectal Cancer Surgery Clinical Gastroenterology and Hepatology 2008 6:11, pg 1185–1193

Acknowledgement

Thank you to my friend and mentor, Dr. Ronald M. Bright, for teaching me to be a thinking surgeon.

Friday, September 27, 2013

Case Outcome: Patriot the pitbull with acute vomiting


Based on Patriot's acute onset of vomiting and diarrhea, a palpable hard abdominal mass, and the mixed density opaque object on radiographs (Fig. 1-2), exploratory laparotomy was recommended to the owner.


Fig. 1: Lateral abdominal radiograph with opaque density (arrow)
Fig. 2: Ventrodorsal radiograph with opaque density. (arrow)

A ventral midline abdominal approach was performed. All structures were normal except for the ileo-ceco-colic area of the intestine. (Fig. 3-4)
Fig. 3: Ileo-ceco-colic area of intestine. The cecum was impacted with
firm material that was obstructing the ileum. (arrow)
The firm foreign body in the cecum and was manually massaged, fragmented, and moved into the colon. (Fig. 4) No incision in the cecum was necessary.
Fig. 4: Ileo-ceco-colic area after manually moving the foreign material into the colon.
Arrow indicates the now empty cecum.

Patriot made an uneventful recovery from surgery. He began eating and defecating normally several hours after surgery and was discharged 1 day postoperatively. One week after surgery the owner reported that he was doing well with no vomiting or diarrhea.

Comments

An interesting feature of this case was the severity of the vomiting even with a low (or distal) intestinal obstruction. The position of the foreign body on radiographs (cranial right abdomen) was consistent with a ileo-ceco-colic obstruction. The lack of intestinal dilation probably indicated a partial obstruction.  Ultrasonography or pneumocolon radiography would have been helpful to definitively localize the lesion.

Please post any questions or comments you have about this case either in the Comments box below or at: https://www.facebook.com/DrStephenBirchardVeterinaryCE

Thursday, September 26, 2013

What's Your Diagnosis and Treatment? Acute vomiting and diarrhea in a 3 year old pitbull.



Fig. 1: Patriot
Patriot is a 3-year-old male neutered 29 kg. pitbull that presented to Circle City Veterinary Specialty and Emergency Hospital with a history of acute vomiting and diarrhea.(Fig. 1) He had eaten bones 5 days ago and began vomiting 3 days prior to presentation.  He also had some episodes of diarrhea during this time.

On physical examination Patriot was bright and alert and slightly dehydrated. An egg sized firm movable mass was palpated in the mid-abdomen but otherwise his abdomen was soft and non-painful and no other abnormalities were found.

Complete blood count and serum chemistry profile were normal.

Lateral and ventrodorsal radiographs were obtained. (Figs. 2,3)
Fig. 2

Fig. 3

 What is your diagnosis?
 What is the next step for this patient?

Wednesday, September 25, 2013

Addendum to Linear Foreign Body Post; Look again at Fig 2a!

After reading yesterday's blog on linear foreign bodies, my friend Dr. Dave Biller (Head of Radiology at the College of Veterinary Medicine, Kansas State University) shared some valuable information and experience. At K State they routinely obtain left lateral abdominal radiographs for animals with a history of vomiting. This allows air to fill the pyloric antrum which may then outline a foreign body.

If you look closely at Fig 2a, you can see a foreign body in the pylorus. See the figure below with arrows pointing to the foreign body.



I honestly did not notice this until he pointed it out to me!

Yet another reason radiologists are such an important part of our profession. Thank you Dr. Biller!

Tuesday, September 24, 2013

Linear Foreign Bodies: One of the most sinister of all intestinal disorders


Fig. 1: String foreign body in the mouth of a cat

Linear intestinal foreign bodies can be serious and even life threatening. Besides causing intestinal inflammation and obstruction they can also cause multiple perforations at the mesenteric aspect of the bowel. Linear foreign bodies, such as string, fabric, and towels can involve only a few loops of bowel or they can extend from the stomach to the colon. If perforation has occurred the animal will develop septic peritonitis and rapidly deteriorate. Therefore surgery to remove linear intestinal foreign bodies should be considered urgent. In other words, “The sun should not set on a linear foreign body.”

Diagnosis

Animals with this type of foreign body usually present with acute vomiting and in some cases diarrhea. Lethargy and dehydration are common. Clinical signs are much more severe if septic peritonitis is present and can include signs of septic shock. Examination of the mouth in cats and less commonly dogs may reveal a string wrapped around the base of the tongue.(Fig. 1) Strings or other linear material may be seen protruding from the rectum. If a string is found around the tongue and also coming out of the rectum it is unwise to try to pull the string from either end.

Plain film abdominal radiographs show varying degrees of dilation and plication of the small intestine and in some cases bunching of the bowel in the abdomen. (Fig. 2-3) Gas pockets in the intestine that look like commas may be seen in the plicated areas. 
Fig. 2a: Lateral abdominal radiograph
of a dog with a linear intestinal foreign body.
Fig. 2b: Ventrodorsal radiograph of same dog in
Fig. 2a.
If a linear foreign body is suspected and an upper GI series is necessary to confirm the diagnosis, use a water-soluble contrast agent such as iohexol instead of barium because of the risk of leakage from intestinal perforations. Barium leakage into the peritoneal cavity worsens septic peritonitis by inhibiting phagocytosis of bacteria and causing a foreign body reaction. Ultrasound can be used to confirm the presence of the foreign body and plicated bowel and may also reveal peritoneal fluid that can be sampled and analyzed cytologically. Ultrasound has been shown to be superior to plain film radiography in diagnosing small intestine obstruction.1 Only 50% of dogs with linear foreign bodies showed intestinal dilation in that study.1
 
Fig. 3a: Lateral abdominal radiograph of a dog with a linear
foreign body. Less dilation of the bowel is seen compared to
dog in Fig. 2.

Fig. 3b: Ventrodorsal abdominal radiograph of same dog
as Fig. 3a. Note plicated duodenum (arrows)

Surgery

After a thorough abdominal exploratory, identify the affected areas of GI tract. (Fig. 4-5)
Fig. 4: Intestinal plication in same dog as Fig. 2 radiographs
Fig. 5: Intestinal plication in same dog as Fig. 3
If no foreign body is present in the stomach make the enterotomy in the middle of the plicated bowel. I find that many times the entire linear foreign body can be removed through one enterotomy if you patiently apply gentle traction on the foreign body while gradually releasing the plication of the intestine with your other hand or with the assistant’s help.(Fig. 6) Use suction and abdominal sponges to prevent peritoneal contamination.

Fig. 6: Linear foreign body removed through one enterotomy.
String foreign bodies in cats are usually present in the stomach and intestine. If so, begin with a gastrotomy to remove that portion of the string. (See previous blog on gastrotomy) Gently pull the foreign body through the gastrotomy in attempt to remove the intestinal portion as well. If that is not possible remove as much as possible and then cut the string and close the gastrotomy. Remove the remainder of the string through one or more enterotomy incisions. (Fig. 7)
Fig. 7: String foreign body in a cat being removed through
an enterotomy
Also, prior to performing the enterotomy attempt to milk the foreign material into one segment of the intestine to make it easier to remove via a single enterotomy. Multiple incisions in the gastrointestinal tract were one risk factor for higher mortality in a large study of dogs and cats with intestinal foreign bodies.2 

Perform resection and anastomosis of bowel that has been perforated. Do not try to simply close the perforations; the tissue is not healthy and normal healing is unlikely. Try to avoid multiple anastomoses of the bowel; if possible include all the perforations in one resected segment so that only 1 anastomosis results.

If bowel perforation is present obtain samples of peritoneal fluid for culture, flush the abdomen with copious amounts of sterile saline, and place a closed suction drain (e.g. Jackson-Pratt drain).

Postoperative Care

See blog on intestinal biopsy for routine care of intestinal surgery patients. Postoperative care of animals with peritonitis will be covered in a future post. Animals with linear foreign bodies have a guarded prognosis compared to discrete, non-linear foreign bodies.

References

1. Sharma A, Thompson MS, Scrivani PV, et.al. Comparison of radiography and ultrasonography for diagnosing small-intestinal mechanical obstruction in vomiting dogs. Vet Radiol Ultrasound. 2011 May-Jun;52(3):248-55
2. Hayes G. Gastrointestinal foreign bodies in dogs and cats: a retrospective study of 208 cases. J Small Anim Pract. 2009 Nov;50(11):576-83.

Sunday, September 22, 2013

Blog Updates: NSAID Vote Final Tally, What's Coming Next Week, And I Have Questions For You

Final tally on NSAID preferences:


Which NSAID do you prefer for your canine patients?


Of course this is not a scientifically designed poll but Rimadyl was the clear choice amoung those who voted.

Don't forget to vote on which GI surgeries you feel comfortable doing. I like to ask questions like this because it helps me "gauge" my audience and influences what content I present in future posts.

More Discussion of the Blogs

I'm trying to figure out a way to get more discussion going on the blog website. I receive very few comments on the website itself, although many people comment on my Facebook page. Is that because you have to have a Google account to comment on the blog site? If you would rather not post a comment on the blog website, one option would be for you to put your comment or question on the facebook page:
https://www.facebook.com/DrStephenBirchardVeterinaryCE
Then I could copy and paste the comment or question and my answer on the blog for everyone to see. Of course I would make it anonymous in case you don't want your name on it. Another option would be to email your question to me (stephenbirchard@gmail.com) and then I could post it on the blog website.
Either of these options sound OK? I would love your input.

How Can We Reach More People?

I would also love your input on how we can have the blogs reach more vets, techs, and students. Not that I'm unhappy with the number of page visits we're getting but I'm just not confident that we always get the desired exposure on facebook that we want. How can we share the Vet Key Points website so that we can get more "traffic" as they say. (in general I hate "business-speak" like that but it seems like a good word here.) Do you belong to any online veterinary groups that might be interested in the site? Let me know any ideas you have.

What's Coming Next Week?

Look for more discussion of intestinal surgery topics, some "What's Your Diagnosis" cases, one that I did at Circle City Veterinary Specialty Hospital just last week, and  I'm working on making a video, using a model, of intestinal resection and anastomosis.

So, stay tuned!

Friday, September 20, 2013

STEVE! I Got a Bitch in the Truck!



His name was Ray. He was a middle-aged dog breeder; show dog handler, and boarding kennel owner.  He was a regular customer of the practice I worked in right out of veterinary school.  He was a big, tall, gruff man.  He was hard of hearing so he shouted all the time and you had to shout back. He was honest and direct and he expected the same from everyone else. His dogs were boxers; the females were “bitches” and the males were “studs”. Typical lingo in the dog-breeding world.

He always let himself in the back door of the practice. It was a courtesy granted him by the owner of the practice since he’d been a client for so many years. He never had an appointment; he didn’t need one. It was like he was a member of the staff. He came in the mornings before appointments started, usually on Mondays. He would come in the door and very loudly proclaim to my boss: “Doc, I got a bitch in the truck! I need you to look at her!” Then he would go back to the pick-up and fetch the dog.

He called me Steve, and at first he wasn’t so sure what to think of this “wet behind the ears” new graduate. My boss told him I had potential, but he had to find out for himself. He asked me to help hold a boxer while “Doc” did a rectal exam. Of course the dog started to squirm, and Ray yelled at me: “What’s the matter son, can’t restrain an animal? Didn’t they teach you that in vet school?” I was humiliated but held my tongue, and held the dog tighter. I found out later he was testing me. I guess I passed the test since I took his criticism in stride. The honest truth was, Ray knew more about dogs than I did and he and I both knew it. He intimidated me but I didn’t let him see it because I thought he wouldn’t respect me.

Ray had just enough veterinary knowledge to have a pretty good idea what the diagnosis and treatment was going to be when he brought a dog in. But, he didn’t always get the terminology quite right. If one of his dogs was lame in the rear leg, it had a rupture of the “crucial” ligament. If a puppy had a lump around the umbilicus, it had a “Biblical” hernia. I didn’t dare correct his mistakes. Ray didn’t know pathophysiology or pharmacology, but he knew dogs.
Gradually he started to trust me and let me treat his treasured boxers. He once asked me to remove a small skin mass from the head of one of his dogs. He wouldn’t let me give anything other than a local anesthetic, not even a sedative. He said: “Steve, if I tell her to stay, she won’t move a muscle.” I took the mass off with her sitting up and she didn’t budge.

We got to be friends and I developed a tremendous amount of respect for him. He even referred clients to me for veterinary care and I referred people to him for boarding.  After I moved on to Ohio State he occasionally called me for advice about his dogs. Underneath that crusty exterior was a heart of gold.  He loved his boxers more than anything. He taught me so much about dogs, things I never learned in vet school.  He also taught me about the world of dog breeding and show handling.  It's a tough way to scratch out a living, I can tell you that. He was an amazing man and I will never forget him.

My friend Ray is gone now.  I spoke with his daughter Pat today; she is 71 years young and told me that Ray passed away 7 years ago. The boxers have passed on, and the boarding kennel is closed. But Ray’s legacy and his spirit live on, and I can still hear that booming voice:

“STEVE! I got a bitch in the truck!”

New Poll; which GI surgeries are you comfortable performing?


I put a new poll in the upper right hand corner of the website. I am very interested to see what everyone is comfortable doing in gastrointestinal surgery. Multiple answers can be selected.

Thanks!

Thursday, September 19, 2013

Enterotomy For Intestinal Foreign Bodies Including Surgical Video


Fig. 1 Corn cob foreign body in the intestine of a dog.
Make enterotomy incision at arrow.

Preoperative Care

Fluid therapy is a critical aspect of overall management of the intestinal surgery patient. Correct dehydration and provide maintenance needs with intravenous fluids (such as Lactated Ringers or other balanced electrolyte solution). Correct electrolyte abnormalities such as hypokalemia. Give colloids if the animal is hypoproteinemic or whole blood or packed cells if anemic.
                 
Prophylactic use of antibacterials is indicated since the intestine is contaminated. Broad-spectrum antibiotics are recommended such as one of the cephalosporins (cefazolin, 20 mg/kg IV) Begin the drug before surgery to insure adequate blood levels at the time of the operation. Do not continue the antibiotic postoperatively unless infection (e.g. peritonitis) is present.

Quietly recite the Halsted Chant to prepare yourself for the surgery. (See first blog in the VKP series.)

Surgical Technique for Enterotomy

See previous blog on Intestinal Biopsy for recommendations on instruments and sutures for intestinal surgery. Use meticulous, atraumatic technique and keep the tissues moist. Isolate the affected segment of bowel with moistened sponges and place stay sutures adjacent to the proposed incision.  Have an assistant use their fingers to occlude the bowel on each side of the enterotomy incision. Incise the intestine on the antimesenteric side close to the foreign body and in an area of intestine that is healthy, i.e. the area of bowel that is downstream from the foreign body. (Figs.1,2)
Fig 2: Fragment of rubber ball in the intestine of a dog.
Make enterotomy incision at arrow.


Fig 3: Rubber fragment removed


Use suction to control spillage and minimize contamination of the peritoneal cavity. Do not use electrocautery on the intestine for hemostasis. Extricate the foreign body from the intestine and remove it from the sterile field to avoid contamination. (Fig. 3)

Closure:

Close the intestine with 4-0 PDS, taper RB1 needle in a simple continuous pattern.  Be sure to do full thickness bites of the intestine (Fig. 4) to include the submucosa which is the holding layer.
Fig. 4: Full thickness suture bites of the intestinal wall are required
to be sure of including the submucosa.
Avoid excessively handling the full thickness bowel with thumb forceps even if you are using DeBakey forceps.  Have your assistant maintain tension on the suture line as you are taking the bites of tissues to keep it from loosening. Use the suture needle to guide each suture loop onto the incision to maintain even spacing. (See Video) After completing the simple continuous line, fill in any gaps with the same suture using a simple interrupted pattern. (Fig. 5)
Fig. 5: Completed enterotomy closure with simple continuous pattern
Leak test the incision as described in the blog on Intestinal Biopsy. Lavage the local tissues but not the entire abdomen unless there was gross spillage of intestinal contents or peritonitis is present. Place the omentum on the incision and tack it adjacent to each end of the incision. (The omentum helps seal the incision and provides blood supply and lymphatic drainage.)

See blog on Intestinal Biopsy for postoperative care.

Always save the foreign body and give it back to the owner when the animal is discharged from the hospital. Encourage them to provide safe chew toys for their animal to use.

Video

The video is short but demonstrates some important principles of tissue handling that were mentioned in the text above.

Tuesday, September 17, 2013

Intestinal Biopsy: When, and How?


Fig. 1: Intestinal segment from a dog with chronic diarrhea.
Note dilated lymphatics and whitish plaques in the mesentery.
Histopathology of biopsy samples revealed lymphangiectasia.

You are in the middle of an abdominal exploratory on a dog with chronic vomiting and diarrhea. You were REALLY hoping to find a foreign body but no such luck. The only abnormality is some thickened intestine with what looks like some dilated lymphatics and a couple of small whitish nodules just under the serosa.(Fig. 1) You know you should obtain a full thickness biopsy of that intestine but how will you do it, will it heal without complications and will you be able to sleep at night worrying about it?

Indications

Biopsy of the intestine is indicated for a variety of reasons. Chronic vomiting or diarrhea of unknown etiology, chronic hypoproteinemia of intestinal origin, and suspected intestinal neoplasia are all disorders that may require a full thickness intestinal biopsy for definitive diagnosis. A classic indication for full thickness biopsy is to differentiate between inflammatory bowel disease and lymphosarcoma in cats. Surgical biopsies were found to be preferred over endoscopic biopsies in one study of 22 cats.1

Instruments

Certain surgical instruments are helpful for performing meticulous and atraumatic intestinal surgery. Suction is mandatory to help prevent spillage of intestinal contents. Use DeBakey thumb forceps to handle the bowel instead of Brown-Adson or Adson forceps.(Fig.2) 
Fig. 2
Handle the bowel very gently and avoid grabbing the full thickness of the intestine to minimize trauma. Be sure to have 4-0 PDS suture with the R-B1 taper needle. Skin biopsy punches, size 4mm-6mm, will also be necessary. One last thing, be sure to have plenty of sterile blue towels just in case you decide to take pictures of the affected area of intestine.  (See Fig. 1; my former students and residents will understand that strange statement.)

Surgical Technique

Isolate the segment of intestine to be sampled with moistened sponges and place stay sutures on the anti-mesenteric surface. Make a small elliptical incision in the antimesenteric aspect of the intestine using a #15 scalpel blade and Metzenbaum scissors. (Fig. 3) 
Fig. 3: Biopsy of the intestine using scalpel.
An initial stab incision can be made and then the tissue sample trimmed out with scissors. Alternatively, my preferred technique is to use a 4, 5, or 6 mm skin biopsy punch to obtain the tissue sample.(Fig. 4-5)
Fig. 4: Intestinal biopsy using a biopsy punch.
Fig. 5
While holding the intestine with one hand gently place the punch on the antimesenteric side of the bowel and twist it while pushing toward the lumen to make the full thickness cut. It is usually possible to feel when the punch has completely cut through the bowel wall and is in the lumen. Take care not to cut the mesenteric side as well. After pulling out the punch sometimes the tissue sample remains attached to the bowel by a small amount of mucosa and will require trimming it out with Metzenbaum scissors. Occasionally the sample may actually drop into the lumen and out of sight. Gently squeezing the bowel will bring the sample back out through the incision.

Close the biopsy site with 4-0 PDS in a simple interrupted or simple continuous fashion taking full thickness bites of the intestine.(Fig. 6)
Fig. 6: Closure of biopsy incision after scalpel incision.
Polypropylene (4-0) can be used in animals that may have delayed healing. Punch biopsy incisions generally require 2 or 3 simple interrupted sutures.(Fig. 7) These small incisions can be closed either longitudinally or transversely depending on surgeon preference.
Fig. 7: Closure of biopsy incision after punch technique.
Perform a leak test by occluding the bowel on both sides of the sampled area and injecting 5-10cc of sterile saline. Massage the segment to see if any saline leaks out through the incision and place additional sutures if necessary.

To provide a thorough evaluation of the intestinal disorder obtain samples from the duodenum, jejunum, and ileum. Obtain the duodenal sample from the distal duodenum to avoid injuring either the major or minor duodenal papillae. 


Postoperative Care

Postoperatively provide the standard care for a GI surgical patient, i.e., analgesics, intravenous fluids until eating and drinking, prophylactic antibiotics given only during the perioperative period, and famotidine and sucralfate. The famotidine and sucralfate can be continued for several days postoperatively.

References

Sarah E. Evans, DVM; Jennifer J. Bonczynski, DVM, DACVS; John D. Broussard, DVM, DACVIM; Eveline Han, VMD, DACVIM; Keith E. Baer, DVM, DACVP
Comparison of endoscopic and full-thickness biopsy specimens for diagnosis of inflammatory bowel disease and alimentary tract lymphoma in cats. J Am Vet Med Assoc November 1, 2006, Vol. 229, No. 9, Pages 1447-1450

Monday, September 16, 2013

What Is The Topic for Our Next Series of Blogs?

Linear intestinal foreign body in a dog.

What's our next topic?

The Figure is a hint. Our new topic is intestinal surgery of all kinds: biopsy, enterotomy, resection and anastomosis, subtotal colectomy, omental and serosal patches, foreign bodies, neoplasia, and intussusception. Also, risk factors for intestinal dehiscence and peritonitis. There is a lot to talk about and we will cover it all!

Stayed tuned.

Reminders: 

Take the Stomach Quiz if you haven't already, and make your choice of your preferred NSAID in the poll on the upper right hand side of the blog.
Only 31 have voted so far . . . come on, work with me people!

Quiz on Stomach Key Points (Don't Worry, Its Open Book!)


Stomach Key Points Quiz

1. Chronic pyloric hypertrophic gastropathy:
                 a. is common in brachycephalic dogs
                 b. is seen in young dogs
                 c. is a form of acquired pyloric disease
                 d. is best treated by pyloromyotomy
                 e. c and d are correct
2. What is the “holding” or strongest histologic layer of the stomach:
     a. serosa
     b. muscularis
     c. submucosa
     d. mucosa
                 e. mucous lining
3. The source(s) of stomach gas in gastric dilatation-volvulus is(are):
                  a. swallowed air
                  b. bacterial fermentation
                  c. carbon dioxide diffusing from capillaries
                  d. necrosis of tissue allowing anaerobic bacteria to proliferate and release gas
                  e. all of the above
4. The preferred method of pyloroplasty for CHPG is:
                  a. Heineke-Mikulitz
                  b. Fredet-Ramstedt
                  c. P to G pyloroplasty
                  d. Y to U pyloroplasty
                  e. Bilroth II
5. On a right lateral abdominal radiograph of a dog with GDV, the stomach looks like a:
      a. Football helmet
      b. Smurf hat
      c. Tri-corner hat
      d. Sponge Bob Square Pants
      e. None of the above
6. NSAID induced perforating gastric ulcers in dogs usually occur in the:
      a. fundus
      b. lesser curvature of cardia
      c. greater curvature of the body
      d. lesser curvature of the pyloric antrum
      e. duodenum
7. NSAIDs can cause gastric ulcers by:
      a. mucosal irritation
      b. reduced prostagladin production
      c. delayed mucosal healing
      d. decreased gastric blood flow
      e. all of the above
8. In the VKP described incisional pyloroplasty, the incision in the stomach was in:
     a. the gastric fundus, perpendicular to the long axis of the stomach
     b. the gastric body, parallel to the long axis of the stomach
     c. the pylorus
     d. the pyloric antrum, parallel to the long axis of the stomach
     e. the pyloric antrum, perpendicular to the long axis of the stomach
9. GDV dogs can present in shock usually because:
     a. gastric distension causes decreased blood flow through the caudal vena cava
     b. gastric distension causes decreased blood flow through the aorta
     c. thrombosis of the aorta
     d. myocardial depressant factor released by the pituitary gland
     e. hemorrhage from the liver
10. True or False: CHPG stands for: Chronically and Horrendously Passing Gas
                 False

Answer Key: 

1. c; 2. c; 3. a; 4. d; 5. b, 6. d, 7. e, 8. e, 9. a, 10. F

Sunday, September 15, 2013


As a follow up to the last blog, I posted a question for my colleagues concerning use of NSAIDs in dogs. I was interested in which drugs they prefer and if they have had any cases that developed gastric ulcers. Thirteen people responded and offered a variety of experiences. Several cases of gastric ulcers were described but not associated with one particular drug. Some NSAIDs not labeled for use in animals were administered by owners without the advice of their veterinarian to patients that subsequently developed ulcers. Some of the veterinarians even had gastric ulcers develop in their own dogs while administering appropriately labeled drugs.

For the specific comments go to this link: https://www.facebook.com/DrStephenBirchardVeterinaryCE?ref=hl

Add your own experience and clinical preferences to the discussion by posting a comment. 

Also, vote on which NSAID you prefer to prescribe by selecting an item in the poll seen in the upper right side of the blog page. (If viewing the blog on your mobile phone, switch to "web version" to see the poll on the page.)





Friday, September 13, 2013

NSAID Induced Gastric Ulcers in Dogs


Fig 1: Perforating gastric ulcer of the pyloric antrum (arrow)

Non-steroidal antinflammatory drugs (NSAIDs) that are labeled for dogs have markedly improved management of chronic pain. However NSAIDs make the stomach more prone to ulceration by several mechanisms including mucosal irritation, reduction in prostaglandin production, decreasing gastric blood flow, and interfering with repair of superficial injury to the mucosa. This is a well-established phenomenon in humans and animals. A clinical study in dogs many years ago found that the most common causes of non-neoplastic ulcers in dogs were NSAIDS and hepatic disease.1  In the past few years, most likely due to widespread and chronic use of NSAIDS in dogs, we have seen an alarming number of dogs with perforating gastric ulcers. Ulcers have been associated with multiple drugs and in some cases due to more than one type of NSAID being used concurrently or a NSAID used with a corticosteroid drug.
Fig 2: The forceps is demonstrating the full thickness ulcer

Diagnosis

The dogs with perforating gastric ulcers present with variable signs that include vomiting, anorexia, lethargy, and abdominal pain. Abdominal radiographs frequently show pneumo-peritoneum and loss of serosal detail. (Fig. 3) Emergency abdominal exploratory is indicated.
Fig 3:Right lateral abdominal radiograph of a dog with
pneumoperitoneum. Note the intraabdominal air visible under the
crura of the diaphragm. (arrows) Radiograph courtesy of Dr. David Biller
Kansas State University College of Veterinary Medicine

Surgery

The perforating ulcers tend to be located at the lesser curvature of the pyloric antrum very close to the pylorus. (Fig. 1-2) Inflammation and omental and serosal adhesions are commonly found on the affected area.  Generalized peritonitis is usually present with serosal inflammation and peritoneal effusion.

After performing a complete surgical exploratory attention is focused on the ulcer. Adhesions are removed and the edges of the ulcer are debrided. The edges of the ulcer tend to be very thickened and friable. This resected tissue is saved and submitted for histopathology to rule out malignancy. Samples of peritoneal fluid are submitted for culture and sensitivity.
Fig 4: Closure of gastric ulcer using a local full thickness flap.
To close the ulcer I have found it helpful to develop a full thickness local advancement flap of pyloric antrum and move it to the site of the defect. (Fig. 4) Closure is with 3-0 or 4-0 PDS in a simple interrupted pattern.  A Jackson-Pratt (closed suction) drain is placed in the abdomen to remove fluid and is left in place for several days.  Postoperative intensive care is required for management of the peritonitis including fluid therapy, nutritional therapy, antibiotics, and gastric antacids and protectants.

Prevention

Prevention of this potentially life threatening complication of NSAID administration should be considered for all dogs and cats receiving these drugs.

Recommendations to prevent gastric ulcers secondary to NSAIDS:

  • Allow a “wash-out” period of 3-5 days when changing from 1 NSAID to another;
  • Never prescribe more than 1 NSAID at a time;
  • Never administer a NSAID and a corticosteroid at the same time 2;
  • Avoid using NSAIDs in dogs with gastrointestinal disease or after gastrointestinal surgery of any kind;
  • Avoid using NSAIDs in dogs with mast cell tumors (histamine release by the tumor can cause gastrointestinal irritation);
  • Avoid administering NSAIDs to animals that are anorexic.

 References

Stanton ME, Bright RM. Gastroduodenal ulceration in dogs. Retrospective study of 43 cases and literature review. J Vet Intern Med. 1989 Oct-Dec;3(4):238-44.

Boston SE, Moens NM, Kruth SA, Southorn EP. Endoscopic evaluation of the gastroduodenal mucosa to determine the safety of short-term concurrent administration of meloxicam and dexamethasone in healthy dogs. Am J Vet Res. 2003 Nov;64(11):1369-75.