Author

Stephen J. Birchard DVM, MS, Diplomate ACVS

Sunday, October 27, 2013

5 Safe Chew Toys that Veterinarians Give to Their Own Dogs and Cats

Veterinarians know what toys are safe for their pet to play with. As a follow up to the blog on what not to let your dog or cat chew on,  I asked several veterinarians and veterinary technicians to tell me what they consider acceptable toys for their own dogs and cats.* Here are the top 5 items they prefer:


The Classic Kong
Kong: The Kong products seem to top everyone’s list as  safe, durable, and fun toys for dogs. Fill the classic Kong with peanut butter and kibble, put it in the freezer overnight, and let your dog go to town. They even make a blue Kong that is radio-opaque so in the unlikely event that it is fragmented and eaten it will be visible on x-ray films.
Goughnut stick
Goughnuts: These durable toys are the favorite of some of the vets I asked. The interior of the sticks and other toys are red so that the owner can easily see if the toy has been damaged and needs to be taken away from the dog.
Kong Pajama Buddy

Kong Pajama Buddy: Fill these with catnip to make them an attractive toy for your cat. One vet told me her cat even takes them camping!

Orka Dog Toys: Like the Kong, these tough toys come in variable shapes and can be filled to treats to enhance and make them more interesting.

Busy Buddies: The Kibble Nibble toy is filled with dry dog kibble. Bits of kibble drop out as the dog rolls the toy around the floor. Warning: dogs get pretty good at efficiently getting the dry food to fly out of the toy, but at least they’re getting some exercise!

*Disclaimer: although these products are considered safer than other commonly used chew toys, supervision of your dog or cat when playing with or chewing on an item is highly recommended. Make sure to offer an appropriate size of toy that cannot be swallowed whole by your pet.

Saturday, October 19, 2013

Intestinal Anastomosis Made Simple: Description and Surgical Model Video


Intestinal resection and anastomosis is indicated for any bowel that is nonviable, neoplastic, perforated by a foreign body, intussuscepted, or has any other irreversible tissue damage. The principles of intestinal resection and anastomosis are:
- isolate the affected segment of intestine from the peritoneal cavity to prevent contamination
- keep the tissues moist and handle atraumatically
- use assistant’s fingers rather than forceps to occlude the bowel
- avoid excessively grabbing the intestine with thumb forceps and only grab the serosal layer
- remove all intestine that appears non-viable
- use a delayed absorbable, monofilament suture with a small swaged on needle (e.g. 4-0 PDS with an RB1 needle)
- take full thickness suture bites of the intestinal wall to assure penetration of the submucosa, which is the holding layer.
- wrap the anastomosis with the omentum after completion to seal the incision and provide blood supply and lymphatic drainage.

Technique

Fig. 1: The jejunal artery and vein are ligated
Expose the affected bowel and pack it off with moistened laparotomy sponges. Ligate the jejunal artery and vein supplying the intestine to be removed and also ligate the small vasa recti branches immediately adjacent to the mesenteric aspect of the intestine.(Figs. 1-2) 
Fig. 2: The vasa recti vessels have been ligated and the bowel is grasped with fingers
Divide the mesentery between jejunal vessel ligatures. Have the assistant place fingers on each side of the proposed incisions in the intestine to prevent leakage.

Place clamps on the bowel to be removed to prevent spillage of contents. Incise the bowel with a scalpel on each side of the segment to be removed. Angle the cuts away from the segment to insure good blood supply to the anti-mesenteric aspect of the intestine.(Fig. 3)
Use suction to gently remove material from the bowel lumen.  
Fig. 3: Lines indicate the angle of incisions to resect the indicated portion of intestine
Appose the two ends of the intestine and begin two sutures lines, one at the mesenteric aspect and one at the anti-mesenteric aspect.(Fig. 4) 
Fig. 4: Two lines of suture are placed in the ends of the intestine
Sutures are placed full thickness from serosa to mucosa on one side and mucosa to serosa on the other side. Place mosquito forceps on the free end of each suture after they are tied. The weight of these forceps helps to stabilize and align the anastomosis. Run one suture from top to bottom in a simple continuous pattern.1 (Fig. 5) 
Fig. 5: Suture from top to bottom simple continuous
Have the assistant maintain traction on the suture to prevent loosening, and use the suture needle to guide each loop of suture into place. At the end of the suture line, tie to the free end of the other suture.  Flip the bowel over and repeat on the other side. (Fig. 6)
Fig. 6: Flip the intestine over and suture the opposite side
Leak test the anastomosis by injecting 10-12cc of sterile saline into the anastomosis and gently massaging the fluid back and forth through the anastomosis. Place simple interrupted sutures as needed in leaking areas.

Wrap the anastomosis with the greater omentum by pulling it through the mesenteric opening and draping it around the intestine. Suture the omentum to itself and to the serosa of the bowel on the anti-mesenteric area. (Fig. 7-8) 
Fig. 7: Place the greater omentum through the mesenteric rent

Fig. 8: Wrap the omentum around the anastomosis and suture to itself and to the serosa of the intestine

References

1. Weisman DL, Smeak DD, Birchard SJ, Zweigart SL. Comparison of a continuous suture pattern with a simple interrupted pattern for enteric closure in dogs and cats: 83 cases (1991-1997). J Am Vet Med Assoc. 1999 May 15;214(10):1507-10.

Thursday, October 10, 2013

10 Things Your Dog or Cat Should Never Play With or Chew On


I have been a veterinary surgeon since 1984, so I’ve spent almost 30 years surgically removing objects lodged in the mouth, esophagus, stomach, and intestines from dogs and cats. A simple lesson I’ve learned from this experience is: when dogs and cats swallow something other than food, it can kill them. Here are 10 common items that can cause serious problems for your dog or cat:

Bones: That’s right, “A dog and his bone” are not a good combination. They love to chew them but if swallowed whole or in fragments they can lodge in the esophagus, intestine or rectum and cause severe problems. Substitute real bones with large nylon bones that they can’t break up or swallow.
A fish hook lodged in the esophagus of a dog. Surgical removal was required.
Fish hooks: Dogs and cats eat them because they taste like fish. Fish hooks are good at catching fish but will lodge in the mouth, esophagus, stomach, or intestine requiring either endoscopic or surgical removal.



Undergarments: Don’t ask why, but dogs love to eat our “unmentionables”. They get stuck in the stomach or intestine and if not removed quickly they can cause perforation of the bowel and life threatening infection.
Panty hose being surgically removed from the intestine of a dog.
Keep tampons out of reach too!
 
Corn cob in the intestine of a dog. 
Corn cobs: Dogs can swallow them whole and they will plug up the guts in no time.


Baby pacifiers: Kids and pets are usually a great combination, but keep an eye on pacifiers and bottle nipples. Dogs love them as appetizers.
 
A scarf being removed from the intestine of a dog.
Linear foreign bodies: socks, strings, towels, plastic bags, rug fragments: A kitten playing with a ball of yarn is cute, but not if kitty eats it. Strings wrap around cats’ tongues and can extend from there all the way to the large intestine. Dogs will eat all kinds of stringy materials. The foreign bodies will make the intestines bunch up and perforate and are an extremely serious problem. That string they use to tie up your Thanksgiving turkey? Guess who would love to eat it?
Radiograph of a dog with gravel in his stomach and intestine. 
Rocks: “If he chews it, he will swallow it.” Give your dog safer alternatives to satisfy his chewing desires. Don’t discard meat drippings on your gravel driveway.
 
Radiograph of a dog with a ball in his stomach
Balls: tennis balls, golf balls, rubber balls; anything that he can fragment or swallow, he will.  Playing ball with your retriever is fine but when the game is over, put the ball away.


Gorilla Glue: Dogs like the taste so they will eat the entire bottle. Then the glue rapidly expands and hardens and forms a mold of the inside of the stomach requiring surgical removal. Save yourself some money and your dog some pain and suffering by keeping this stuff away from him.
 
A large stick being removed from the chest cavity of a dog.
Sticks: Dogs love to chew them and run with them. Both are bad. Splinters from the sticks get jammed into their throat or esophagus and cause severe infection. Small splinters may migrate from the throat to remote areas of the body causing a chronic infection and draining tracts.

Conclusion: Keep risky items away from your pets. When you give your dog or cat something to play with, ask yourself: can he swallow this? If the answer is yes, take it away. Even when you give your dogs or cats a safe toy, supervise them. Talk to your veterinarian about safe chew toys for your pets. Your furry loved one will thank you by living a longer life.

Questions are welcome, and please share any experiences you've had that we can all learn from.

Monday, October 7, 2013

Intussusception in Dogs and Cats: How to Make Them Go Away and Not Come Back!



Fig. 1: Duodenal intussusception in a dog due to a leiomyoma
Many years ago I was operating on a puppy with severe enteritis that we suspected had an intussusception. While I was doing the abdominal exploratory, an intussusception developed in a segment of bowel while I was watching it. Since it was very acute, as in, just happening before my eyes, reducing it was easy. But I was amazed at how easily it occurred and I thought, what can we possibly do to prevent more of these from happening in this puppy? Also, what an odd thing this is for the bowel to do.

Intussusception is telescoping of one bowel segment into another and usually occurs at the ileo-ceco-colic junction in dogs and in the jejunum in cats.1 (Figs. 1-2) Intussusception occurs secondary to other disease processes such as parvovirus enteritis, parasites, linear foreign body, or even neoplasia (e.g. ileo-ceco-colic tumors or duodenal tumors as in Beetle, the subject of a previous blog). One study in cats found that the most common causes of intussusception in older cats were inflammatory bowel disease and intestinal lymphosarcoma.1 These primary diseases probably cause changes in motility that causes one segment of bowel to telescope into an adjacent segment. The ileo-ceco-colic region in dogs is a common area of intussusception since the ileum is smaller in diameter than the colon.
Fig. 2: Ileo-colic intussusception in a dog
If not treated promptly, the intussusceptum (the portion of bowel inside the intussuscipiens) will become strangulated and necrotic. (Fig. 3) Intestinal resection and anastomosis is necessary in intussusceptions that are irreducible, have resulted in damage to the bowel, or are associated with an invasive neoplasm.
Fig. 3: Resected ileo-colic intussusception in a dog. The
intussuscipiens has been opened to show the intussusceptum.

Diagnosis

Intussusception causes acute intestinal obstruction and should be suspected in any dog or cat with acute vomiting and diarrhea especially if a movable, sausage shaped mass is palpable in the abdominal cavity. The mass is usually painful on palpation. Animals with known primary intestinal disease such as inflammatory bowel disease or infectious enteritis should be considered predisposed to intussusception and diagnostics preformed to rule it out.

Plain film radiographs typically reveal evidence of bowel obstruction with intestinal dilation particularly of the portion of the jejunum just upstream from the obstruction. Ultrasound can provide further evidence of intussusception by revealing the telescoped intestinal segment and a target like appearance on cross section of the affected area. (Fig. 4)
Fig. 4:Ultrasound of a dog with an intussusception. In this cross section of the affected
intestine note the layered intestinal walls creating a target appearance. (arrows)
Upper GI contrast study or barium enemas are additional methods to demonstrate the intussusception by outlining the intussusceptum as a filling defect within the bowel. (Fig. 5)
Fig. 5: Barium enema of a dog with an ileo-colic intussusception showing
a distinct filling defect within the ascending and tranverse colon
.

Treatment

Intussusception is a surgical emergency since it causes intestinal obstruction and strangulation of intestine. Fluid and electrolyte abnormalities should initially be treated and abdominal exploratory performed promptly after diagnosis.

Perform a thorough exploratory of all abdominal organs and attempt to indentify any predisposing disorders such as foreign body or neoplasm. Find the intussusception and isolate it from the peritoneal cavity with sponges. Attempt to reduce the intussusception by gently pulling on the intussusceptum. Pushing the intussusceptum out of the intussuscepiens by massaging it may also help.

Carefully examine the intestine and determine if it is viable. Inability to reduce the intussusception and finding non-viable intestine are indications for resection and anastomosis. Luminal disparity may make anastomosis challenging especially if the ileum is being sutured to the colon. Incising the antimesenteric aspect of the smaller sized intestine will enlarge the lumen to allow it to match up (more on this when we discuss subtotal colectomy for megacolon in cats).

Surgical plication of the intestine is a method to help prevent recurrence of intussusception.2,3 Plicate the bowel in gentle or “lazy” loops using serosal sutures to maintain the orientation. (Figs. 6,7)
Fig. 6: Surgical plication of the small intestine to prevent intussuception.
(from Bright RM. Surgery of the intestine. Saunders Manual of Small Animal
Practice
. Birchard and Sherding, editors. Elsevier, 2006, pg. 742.) 
Studies of the efficacy of plication are mixed and one study found complications associated with the technique. I usually will plicate just the local area of bowel by making 2-3 loops rather than doing the entire small intestine. Plication is particularly important if the intussusception was only reduced and not resected. 
Fig. 7: Several loops of bowel have been plicated with 4-0 polypropylene.
The sutures are only placed through the serosal layer or slightly deeper but are
not full thickness.
Always submit the resected intestine for histopathology to identify any underlying diseases. Other than plication, medically prevent recurrence of intussusception by indentifying and treating the etiology. Postoperative care is otherwise similar to that described for intestinal biopsy and enterotomy.

References

1. Jamie M. Burkitt; Kenneth J. Drobatz; H. Mark Saunders; Robert J. Washabau. Signalment, history, and outcome of cats with gastrointestinal tract intussusception: 20 cases (1986–2000) J Am Vet Med Assoc 2009;234:771–776

2. Oakes MG, Lewis DD, Hosgood G, Beale BS. Enteroplication for the prevention of intussusception recurrence in dogs: 31 cases (1978-1992. J Am Vet Med Assoc. 1994 Jul 1;205(1):72-5.
3. Applewhite AA, Hawthorne JC, Cornell KK. Complications of enteroplication for the prevention of intussusception recurrence in dogs: 35 cases (1989-1999. J Am Vet Med Assoc. 2001 Nov 15;219(10):1415-8.





Sunday, October 6, 2013

Final thoughts on suture patterns for linea alba closure including what size suture to use. Also results of GI surgery procedures poll.

GI Surgery Poll

Here is the final tally on which gastrointestinal surgeries the participants feel comfortable doing:

Which of these surgeries do you feel comfortable doing? (multiple answers are accepted)

The results were about what I was expecting. 
I know that the complicated part of this is that you frequently do not know until you are in the abdomen which procedure will be necessary. Also, sometimes it is difficult to determine if a segment of intestine is viable or not and should be removed. Remember the basic criteria for viability: color, blood supply, peristalsis, and temperature. Also, it can be helpful to first remove a foreign body and then give the bowel a few minutes to see if its color improves. In the end it comes down to a judgement call that you have to make.
Also remember, when in doubt . . . cut it out!
Septic peritonitis requires intensive care, is expensive, and has a high mortality rate. So, not surprising that most people find it a difficult disorder to treat.

Closure of the Linea Alba

There's one day left on the suture pattern poll but barring a huge change in the final day it appears that simple continuous pattern is the winner! Of the comments posted on my Facebook page, 12 of 13 people said they prefer simple continuous. I routinely use a simple continuous pattern with PDS and use the following sizes:
  • - cats and small dogs: 3-0 
  • - medium size dogs: 2-0
  • - large dogs: 0
Obviously these are general guidelines and can be modified for dogs that are extremely active or athletic. In dogs with significant healing issues such as Cushing's disease, on chemotherapy, or hypoproteinemia I substitute polypropylene for the PDS but still use the same sizes.
See Ethicon's website for more information about their sutures:http://www.ethicon.novartis.us

What's in Store For Next Week?

We'll continue with intestinal topics such as more on intussusception, subtotal colectomy in cats, and risk factors for intestinal incision dehiscence. I'm also working on a video of simple continuous closure of intestinal anastomosis using a surgical model. Any other GI topics you are interested in?

Stay tuned!

Friday, October 4, 2013

"Beetle": A Jack Russell Terrier With An Unusual Intussusception


Fig. 1: Beetle
Beetle is a 10-year-old male neutered Jack Russell Terrier (Fig. 1) who had been lethargic and anorexic for the past 2-3 days. On physical examination Beetle was quiet but alert and had pale mucous membranes, 5% dehydration, 3/6 systolic cardiac murmur, and dark tarry stool on rectal examination. His right eye was very small and avisual with chronic corneal changes. His abdomen was tense and painful with a possible cranial abdominal mass present. Thoracic auscultation revealed a 3/6 systolic murmur. Rectal examination revealed dark, tarry stool.

Complete blood count and serum chemistry profile revealed of PCV of 18% and serum albumin 2 g/dl. A coagulagram was performed and was within normal limits.

Because of the possible abdominal mass and melena an abdominal ultrasound was performed and showed evidence of an intussusception. (Fig. 2)
Fig. 2: Ultrasound of a dog with an intussusception (not Beetle but similar). In this cross section of the affected
intestine note the layered intestinal walls  creating a target appearance. (arrows)
Abdominal exploratory was recommended to the owner. (Fig. 3)
Fig. 3: Beetle being aseptically prepared for abdominal exploratory.
A ventral midline abdominal exploratory was performed and revealed a duodenal intussusception and nodular fibrotic changes in the pancreas. (Fig. 4) 
Fig. 4: Duodenal intussusception in Beetle
The intussusception was easily reduced manually. A movable intraluminal mass was palpated and was exposed with a longitudinal incision in the antimesenteric aspect of the duodenum. (Fig. 5) 
Fig. 5: Duodenal enterotomy revealed an intraluminal mass. 
The pedunculated mass was 2cm in length and was locally excised by removing the full thickness area of bowel to which the mass was attached. (Fig. 6-7) 
Fig. 6: The duodenal mass was localized and pedunculated.
Fig. 7: The excised duodenal mass and attached intestine.
The intestinal incision was closed with 4-0 PDS in a simple continuous pattern.(Fig. 8)
Fig. 8: The closed duodenal incision. 
 The abdominal incision was closed routinely.

Beetle did well and was discharged from the hospital 2 days postoperatively. Skin staples were removed 10 days postoperatively. Histopathology of the duodenal mass showed a leiomyoma that was completely excised. Beetle was seen by referring veterinarian 1 year later and was doing very well.

Discussion

This is a very unusual case because the intussusception was in the duodenum rather than the more common (in dogs) ileo-ceco-colic area and it was secondary to a benign neoplasm. Also, Beetle did not present for vomiting but was anorexic and anemic due to bleeding from the duodenal mass. We performed a more conservative local full thickness tumor resection rather than a full intestinal resection and anastomosis because of the location of the mass (duodenum) and our suspicion that it was a benign tumor.

Have you seen a similar case? Post any questions or comments you have either here in the blog comments box or at: