Teknik Operasi Colotomy Dan Colectomy Pada Hewan - Ilmu Bedah Khusus Veteriner PDF [PDF]

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ILMU BEDAH KHUSUS VETERINER TEKNIK OPERASI COLOTOMY DAN COLECTOMY



DISUSUN OLEH: Varhan Dwiyan Indra



1809511044



Ferdy Olga Saputra



1809511050



Maharani Lisna Wulandari



1809511056



Kelas B



FAKULTAS KEDOKTERAN HEWAN UNIVERSITAS UDAYANA DENPASAR 2021



KATA PENGANTAR Puji syukur kami panjatkan atas kehadiran Tuhan Yang Maha Esa karena atas berkat dan rahmat-Nya kami dapat menyelesaikan tugas mata kuliah Ilmu Bedah Khusus Veteriner yang berjudul “Teknik Operasi Colotomy dan Colectomy” dengan sebagaimana mestinya. Penulisan tugas yang berjudul “Teknik Operasi Colotomy dan Colectomy” ini bertujuan untuk memenuhi tugas mata kuliah Ilmu Bedah Khusus Veteriner yang diberikan. Selain itu, penulisan tugas ini juga bertujuan untuk menambah wawasan dan pengetahuan pembacanya. Segala kritik dan saran sangat penulis harapkan demi kebaikan dari tulisan ini, dan tak lupa penulis ucapkan banyak terima kasih.



Denpasar, 16 Oktober 2021 Hormat kami,



Penulis



ii



DAFTAR ISI



KATA PENGANTAR ........................................................................................... ii DAFTAR ISI ......................................................................................................... iii DAFTAR GAMBAR ............................................................................................ iv BAB I PENDAHULUAN ...................................................................................... 1 1.1 Latar Belakang............................................................................................... 1 1.2 Rumusan Masalah ......................................................................................... 2 1.3 Tujuan ............................................................................................................ 2 1.4 Manfaat .......................................................................................................... 2 BAB II TINJAUAN PUSTAKA ........................................................................... 3 2.1 Terminologi ................................................................................................... 3 2.2 Indikasi .......................................................................................................... 5 2.3 Anestesi ......................................................................................................... 5 2.4 Preoperasi ...................................................................................................... 5 2.5 Operasi........................................................................................................... 2 2.6 Pascaoperasi .................................................................................................. 5 BAB III PENUTUP ............................................................................................... 6 3.1 Kesimpulan .................................................................................................... 6 3.2 Saran .............................................................................................................. 6 DAFTAR PUSTAKA ............................................................................................ 7



iii



DAFTAR GAMBAR Gambar 1. Large intestinal obstruction ................................................................... 3 Gambar 2. Jahitan kedua pada sero muskuler (colotomy) ...................................... 3 Gambar 3. Proses Colectomy .................................................................................. 5 Gambar 4. Ilustrasi pemotongan dan penjahitan kolon ........................................... 5



iv



BAB I PENDAHULUAN 1.1 Latar Belakang Kolostomi merupakan sebuah lubang yang dibuat oleh dokter ahli bedah pada dinding abdomen dengan tujuan untuk mengeluarkan feses. Lubang kolostomi akan muncul dipermukaan berupa mukosa kemerahan yang disebut dengan stoma. Kolostomi dapat dibuat secara permanen maupun temporer (sementara) yang disesuaikan dengan kebutuhan pasien. Komplikasi pada stoma yang dapat terjadi berupa obstruksi/penyumbatan yang diakibatkan oleh adanya perlengketan usus atau adanya pergeseran feses yang sulit dikeluarkan, stenosis akibat penyempitan lumen, prolap pada stoma akibat kelemahan otot abdomen, perdarahan stoma akibat tidak adekuatnya haemostasis dari jahitan batas mucocutaneus, edema jaringan stoma akibat tekanan dari hematoma peristomal dan pengkerutan dari kantong kolostomi, nekrotik stoma akibat cedera pada pembuluh darah stoma, dan retraksi/pengkerutan stoma akibat kantong stoma yang terlalu sempit/tidak pas untuk ukuran stoma dan akibat jaringan scar disekitar stoma. Berbeda dengan colostomy, Colectomy merupakan suatu tindakan bedah yang dilakukan untuk memotong sebagian kolon (colecomy subtotal) atau seluruh bagian colon (colectomy total) tergantung dari besar-kecilnya kerusakan pada kolon tersebut. Colectomy subtotal adalah prosedur bedah yang diindikasikan untuk kasus-kasus sembelit kronis non-responsif terhadap intervensi medis. Colectomy subtotal mempunyai tujuan untuk menghilangkan bagian colon yang mengalami kerusakan, sehingga menghasilkan feses yang lebih lembut, kotoran yang semisolid, yang kemudian dapat melewati pelvis yang mengalami penyempitan. Setelah tindakan operasi colectomy subtotal maupun colectomy total dilakukan, usus halus mengalami kompensasi, tinggi vili akan meningkat, begitu pula dengan ketinggian dan density enterocyte juga meningkat, feses biasanya menjadi lebih lembut pada 3 bulan pertama setelah operasi. Namun secara klinis, fungsi usus masih berada dalam keadaan normal.



1



1.2 Rumusan Masalah 1. Apa yang dimaksud dengan colotomy dan colectomy? 2. Apa saja indikasi colotomy dan colectomy? 3. Bagaimana anestesi colotomy dan colectomy? 4. Bagamana tindakan praoperasi colotomy dan colectomy? 5. Bagaimana teknik operasi colotomy dan colectomy? 6. Bagaimana tindakan pascaoperasi colotomy dan colectomy? 1.3 Tujuan 1. Untuk mengetahui apa yang dimaksud dengan colotomy dan colectomy. 2. Untuk mengetahui indikasi colotomy dan colectomy. 3. Untuk mengetahui bagaimana anestesi colotomy dan colectomy. 4. Untuk mengetahui bagamana tindakan praoperasi colotomy dan colectomy. 5. Untuk mengetahui bagaimana teknik operasi colotomy dan colectomy. 6. Untuk mengetahui bagaimana tindakan pascaoperasi colotomy dan colectomy. 1.4 Manfaat Manfaat dari penulisan paper ini adalah dapat bermanfaat bagi pembaca khususnya mahasiswa Fakultas Kedokteran Hewan dan dapat memahami mengenai Teknik operasi



Colotomy



Dan



Colectomy



dan



indikasi



penggunaanya. Selain itu diharapkan mampu menjadi referensi untuk penulisan selanjutnya.



2



BAB II TINJAUAN PUSTAKA 2.1 Terminologi Colostomy berasal dari kata “colon” dan “stomy”. Colon merupakan bagian dari usus besar yang memanjang dari sekum sampai rektum dan stomy yang dalam bahasa yunani diartikan sebagai stoma yang berarti mulut. Colostomy dapat diartikan sebagai suatu pembedahan dimana suatu pembukaan dilakukan dari kolon (atau usus besar) ke luar abdomen. Feses keluar melalui saluran usus yang akan keluar disebuah kantung (stoma) yang diletakan pada abdomen. Stoma yang terlihat pada dinding abdomen terdiri dari jaringan mukosa usus yang lembab, hangat dan mensekresikan sejumlah kecil mukus. Tidak seperti anus, stoma tidak mempunyai katup atau otot sehingga pengeluaran feses tidak bisa di kontrol karena berada di bawah pengaruh saraf tak sadar. Berbeda dengan colostomy, Colectomy adalah tindakan bedah yang dilakukan untuk memotong sebagian kolon (colecomy subtotal). Atau seluruh bagian colon (colectomy total) tergantung dari besar-kecilnya kerusakan pada kolon tersebut. Colectomy subtotal adalah prosedur bedah yang diindikasikan untuk kasus-kasus sembelit kronis non-responsif terhadap intervensi medis. Tujuan dari colectomy subtotal adalah untuk menghilangkan bagian colon yang mengalami kerusakan, sehingga menghasilkan feses yang lebih lembut, kotoran yang semisolid, yang kemudian dapat melewati pelvis yang mengalami penyempitan. Setelah colectomy subtotal atau total, usus halus mengalami kompensasi, tinggi vili akan meningkat, begitu pula dengan ketinggian dan density enterocyte juga meningkat, feses biasanya menjadi lebih lembut pada 3 bulan pertama setelah operasi. Namun secara klinis, fungsi usus masih berada dalam keadaan normal. Terdapat beberapa jenis Colostomy, yaitu: 1.



Colostomy Ascendens Colostomy jenis ini terletak pada sebelah kanan abdomen dan cairan yang dihasilkan sangat encer. Colostomy tipe ini jarang digunakan karena lebih sering dilakukan ileostomy pada cairan usus yang encer.



3



2.



Colostomy Transversum Colostomy transversum dilakukan pada pasien-pasien dengan diverticulus, penyakit inflamasi usus, keganasan (kanker), obstruksi usus, kecelakaan atau kelainan congenital. Colostomy jenis ini akan mengakibatkan feses keluar dari kolon sebelum sampai ke kolon descenden.



3.



Colostomy Descendens atau Sigmoid. Lokasinya terletak pada bagian kiri bawah abdomen dan merupakan jenis colostomy yang paling sering dilakukan. Feses yang dikeluarkan pada colostomy jenis ini lebih padat dibanding dengan feses pada colostomy transversum. Pengeluaran feses ini terjadi pada basis reguler dan intervalnya bisa diprediksi. Pergerakan usus terjadi setelah sejumlah feses terkumpul dalam usus yang terletak di atas tempat colostomy.



Beberapa tipe Colostomy: 1.



Colostomy Loop Jenis colostomy ini didesain sehingga baik segmen distal maupun proksimal usus terdapat pada permukaan kulit.



2.



Colostomy Double Barrel Pada colostomy double barrel, dibuat dua stoma yang terpisah pada dinding abdomen stoma bagian proksimal berhubungan dengan traktus gastrointestinal yang lebih atas dan akan menjadi saluran pengeluaran feses. Stoma bagian distal berhubungan dengan rectum. Colostomy double barrel termasuk jenis colostomy sementara. Colostomy double barrel mudah dan aman digunakan pada neonatus dan hewan kecil.



3.



Colostomy Devided Colostomy ini sering dibuat pada sigmoid pda karsinoma rectum yang tak dapat diangkat, sehingga karsinoma tersebut tidak teratasi oleh tinja.



4



4.



Colostomy Terminal Tipe ini dilakukan bila diperlukan untuk membuang kolon karena terlalu membahayakan bila dilakukan anastomosis yang memudahkan timbulnya sepsis. Kontinuitas dapat diperbaiki kemudian bila sepsis telah dapat diatasi dan kondisi penderita lebih baik.



5.



Sekostomi dengan Pipa (Tube) Sekostomi merupakan colostomy sementara. Berguna untuk dekompresi gas dalam usus. Sekostomi tidak cocok untuk diversi aliran feses. Saat ini sekostomi jarang digunakan karena stoma sering tersumbat oleh feses dan seringkali diperlukan irigasi untuk melancarkan.



2.2 Indikasi Colostomy dilakukan bila terjadi sumbatan (obstruksi), dan perforasi pada colon sehingga menghambat proses keluarnya feses dari dalam usus besar. Selian itu colostomy dapat dijadikan solusi untuk menangani kasus dekompersi usus dan colon berukuran kecil. Sementara bila terjadi kerusakan pada kolon baik akibat adanya tumor, kanker colon, kelainan kongenital, divertikulitis, megacolon, infeksi atau peradangan yang mengakibatkan rusaknya jaringan pada kolon, maka dilakukan colectomy. 2.3 Anestesi Anestesi yang dilakukan dalam operasi colostomy dan colectomy merupakan anestesi umum. Hewan diberi premedikasi atropin sulfat 0,025 % dosis 0,04 mg/kg BB (hewan). Apabila sudah berpengaruh, maka mukosa mulut tampak kering. Kemudian suntikan kombinasi xylazin 2% dan ketamin HCL 10% dosis 10-15 mg/kg BB secara intramuskuler sesuai dengan dosis. 2.4 Preoperasi Sebelum melakukan tindakan operasi terlebih dahulu dilakukan persiapan operasi. Adapun persiapan yang dilakukan adalah persiapan alat atau instrument bedah, persiapan ruangan operasi, persiapan pasien, dan persiapan operator.



5



•



Persiapan Alat dan Bahan Alat dan bahan yang digunakan dalam operasi ini antara lain:



•



1.



Scalpel



8.



Tampon



2.



Gunting



9.



Jarum



3.



Needle holder



10. Duk clem



4.



Pinset



11. Meja operasi



chirurgis



dan anatomis



12. Endotrakeal tube



5.



Mosquito forceps



13. Kateter



6.



Allis forceps



14. Tiang infuse



7.



Hemostasis



15. Tabung oksigen



forceps



16. Antiseptik.



Persiapan Ruang Operasi. Ruang



operasi



dibersihkan



menggunakan



desinfektan.



Sedangkan meja operasi didesinfeksi dengan menggunakan alkohol 70%. Penerangan ruang operasi sangat penting untuk menunjang operasi, oleh karena itu sebelum diadakanya operasi persiapan lampu operasi harus mendapatkan penerangan yang cukup agar daerah/site operasi dapat terlihat jelas. •



Persiapan Pasien (hewan). − Pemeriksaan Fisik: Sebelum operasi, terlebih dahulu lakukan anamnesa untuk memastikan riwayat kesehatan hewan. Kemudian lakukan pemeriksaan fisik dan laboratorium terutama pemeriksaan feses. − Urinasi dan defekasi: Untuk mencegah kontaminasi dari feses hewan atau urin, hewan dipuasakan sekurang-kurangnya 12 jam, setelah itu feses dan urin dikeluarkan. − Pemotongan Rambut: Untuk mencegah kontaminasi yang terjadi sebelum, atau saat pembedahan berlangsung seminimal mungkin, dapat dilakukan pemotongan rambut dengan cara memotong rambut pada daerah pembedahan.



6



•



Persiapan Operator (petugas yang akan melakukan operasi). Operator dan tim pembedahan yang terdiri dari dokter hewan harus siap secara fisik dan mental, memahami prosedur operasi, dan terampil, serta harus menjaga higiene agar tidak terjadi kontaminasi, seperti menggunakan alas kaki, masker, penutup kepala, baju operasi, sarung tangan, dll.



2.5 Operasi 1. Teknik Operasi Colotomy Berikut merupakan Teknik bedah colotomy untuk 2 macam tujuan, yaitu: a.



Untuk mengeluarkan obstruksi atau Eterolith •



Laparotomy di incisi pada ventral midline, dari umbilicus ke caudal diperlukan untuk eksplorasi abdomen, serta mengidentifikasi dan mengeluarkan enterolith.



•



Obstruksi biasanya terjadi di transverse kolon dan kolon kecil, operasi pengeluaran enterolith di bagian proksimal kolon kecil atau transverse kolon harus didahului sebelumnya dengan evakuasi ingesta dari kolon besar melalui enterotomy pada pelvic flexure untuk meminimalisir kontaminasi abdomen.



•



Selang air hangat kemudian dialirkan melalui rectum dan akan menggerakan enterolith kearah kolon dorsal, enterolith kecil dapat mengalir ke sisi enterotomy kemudian dikeluarkan enterolith yang lebih besar memerlukan enterotomy terpisah pada kolon dorsal kanan untuk pengeluaran enterolith yang mempunyai sisi rata atau bentuk polyhedral biasanya lebih dari satu pemeriksaan adanya enterolith tambahan pada kolon besar dan kecil sebelum menutup abdomen.



•



Enterolith pada kolon kecil harus dikeluarkan melalui enterotomy pada bagian kolon yang terkena.



•



Panjang irisan enterotomy pada pelvic flexure dan evakuasi pada kolon besar harus dilakukan sebelum enterotomy pada kolon kecil



2



akan meminimalisir ingesta masuk ke sisi enterotomy segera setelah masa operasi. •



Enterotomy kemudian ditutup dalam dua layer menggunakan benang yang dapat diserap dengan jarum taper.



•



Jahitan pertama dilakukan pada semua lapisan dinding usus dengan pola jahitan sederhana tunggal atau menerus. Jahitan kedua pada sero muskuler dengan pola jahitan lambert atau cushing.



Gambar 1. Large intestinal obstruction



Gambar 2. Jahitan kedua pada sero muskuler (colotomy) b.



Untuk Biopsi • Insisi dilakukan sepanjang tepian antisimetric. Untuk meminimalisir sentuhan pada sample biopsy kolon, jahitan dengan benang 4.0 monofilament dilakukan pada ketebalan penuh disekitar daerah yang perlu di biopsy. • Kemudian incisi berbentuk elips di buat disekitar jahitan untuk mengambil sample. • Mucosa yang tersisa dari lokasi pengambilan biopsy dapat diangkat dengan menggunakan gunting Metzenbaum yang tajam.



3



• Daerah sekitar luka kemudian di bersihkan dan dijahit dengan pola simple continuous atau interrupted menggunakan 3.0 atau 4.0 polydioxanone atau polyglyconate. • Bekas luka diperkuat dengan menyatukan omentum dengan serosa menggunakan benang absorbable monofilament 4.0. 2. Teknik Operasi Colectomy Operasi colectomy adalah tindakan bedah yang dilakukan untuk mengangkat sebagian segmen colon (colectomy subtotal) atau keseluruhan colon (colectomy total). •



Hewan dibaringkan secara lateral recumbency. Siapkan area yang akan dioperasi yaitu daerah datar pada flank sebelah kiri.



•



Buatlah insisi secara dorsoventral sekitar 4cm dari arah lateral muskulus (external abdominal obique, internal abdominal oblique, dan transversus abdominis muscles) dan masuk ke dalam cavum abdomen.



•



Potong bagian kolon yang diinginkan melalui insisi flank secara melingkar (longitudinal).



•



Ada 2 kemungkinan yang dapat dilakukan pada colectomy, yaitu dilakukan penjahitan pada sisa ujung proksimal dan ujung distal usus atau dibuatkan kantong (stoma) sebagai tempat penampungan feses.



•



Jahit secara melingkar permukaan serosa colon hingga ke musculus abdomen menggunakan 3-0 monofilament dengan benang absorbable (polydoxanone, polyglyconate, poliglecaprone 25).



•



Lengkapi dengan stoma dengan cara menjahit semua bagian dari dinding kolon yang terpotong hingga tepi insisi kulit menggunakan 3-0 atau 4-0 monofilamen absorbable.



•



Kemudian melalui ventral midline insisi diakukan colopexy (penyatuan kolon dengan dinding abdomen) dekat dengan stoma untuk mencegah terjadinya hernia.



•



Dilakukan pemasangan colostomy bag untuk pengumpulan feses. Perlu dilakukan penggantian colostomy bag dan kolon diirigasi secara teratur.



4



Gambar 3. Proses Colectomy



Gambar 4. Ilustrasi pemotongan dan penjahitan kolon 2.6 Pascaoperasi Secara garis besar, kedua proses pembedahan ini memiliki tindakan post operasi yang hampir sama, yaitu hewan dimonitor perkembangannya tiap 3 jam, pemberian antibiotik spectrum luas sampai 48 jam setelah operasi, Pemberian nonstreoidal anti-inflamasi, emberian cairan intravena (40-60 ml/kg), diberi minum air hangat beberapa jam setelah operasi harus diulang tiap setengah jam (maintenance : 20L/450 kg BB/hari), jangan diberi makan 12-24 jam pasca operasi, pakan dalam jumlah sedikit dapat diberikan sesegera mungkin jika hewan sudah mau makan dengan sendirinya, hewan yang sudah mau makan dapat diberi tambahan suplemen lemak tinggi untuk meningkatkan kalori, dan hewan dapat mulai exercise sedikit demi sedikit 30 hari setelah operasi.



5



BAB III PENUTUP 3.1 Kesimpulan Colostomy dapat diartikan sebagai suatu pembedahan dimana suatu pembukaan dilakukan dari kolon ke luar abdomen. Colectomy adalah tindakan bedah yang dilakukan untuk memotong sebagian kolon (colectomy subtotal) atau seluruh bagian kolon (colon total) tergantung dari besar kecilnya kerusakan pada kolon tersebut. Tujuan dari colectomy subtotal adalah untuk menghilangkan kerusakan, sehinga menghasilkan feses yang lebih lembut, kotoran yang semisolid, yang kemudian dapt melewati pelvis yang mengalami penyempitan. Setelah colectomy subtotal atau total, usus halus mengalami kompensasi, tinggi vili akan meningkat, feses biasanya menjadi lebih lembut pada 3 bulan pertama setelah operasi. Namun, secara klinis, fungsi usus masih berada dalam keadaan normal. 3.2 Saran Koreksilah paper ini, jika terdapat kesalahan kata dan kalimat yang disengaja maupun tidak sengaja serta kesalahan kami dalam pemahaman materi. Jika ada yang tidak dimengerti dari paper ini, penulis menyarankan untuk membaca teksbook dan jurnal mengenai Colotomy dan Colectomy.



6



DAFTAR PUSTAKA Barnes, Darren C. 2012. Subtotal colectomy by rectal pull-through for treatment of idiopathic



megacolon in 2 cats: case report. Can Veterinary J. United



Kingdom. Laikul A, Phetudomsinsuk K, Aumarm W, Sritrakul T, Prukudom S. 2010. Congenital Colonic



Atresia in Horse. Department of Large Animal and



Wildlife Clinical Sciences, Faculty of



Veterinary



Medicine.



Kasetsart University. Thailand. Ryan S, Seim H, Macphail C, Bright R, Monnet E. 2006. Comparison of biofragmentable



anastomosis ring and sutured anastomoses for



subtotal colectomy in cats with idiopathic



megacolon. Vet Surg.



Turek, B. and G. Verhoeven. 2008. Atresia coli in a foal: case report. Medycyna Wet. Adrin Ma’aruf. 2016. Teknik Operasi Colotomy Dan Colectomy pada Hewan. ”Bedah



Sistem



Digesti”.



MyDokterhewan.blogspot.com.



https://mydokterhewan.blogspot.com/2016/05/teknik-operasi-colotomydan-colectomy.html Barnes, Daren C. 2012. Subtotal colectomy by rectal pull-through for treatment of idiopathic megacolon in 2 cats. Canine Vet Journal. Vol 53: 780-782.



7



Case Report  Rapport de cas Subtotal colectomy by rectal pull-through for treatment of idiopathic megacolon in 2 cats Darren C. Barnes Abstract — Surgical management of idiopathic megacolon is described in 2 cats by a rectal pull-through with subtotal colectomy performed outside of the abdomen. This newly described technique facilitates access to the rectum for suturing an anastamosis without the need for pubic osteotomy and with minimal risk of abdominal contamination. Résumé — Colectomie subtotale par opération de Swenson-Bill pour le traitement d’un mégacôlon idiopathique chez 2 chats. La gestion chirurgicale du mégacôlon idiopathique est décrite chez 2 chats par une opération de Swenson-Bill avec une colectomie subtotale réalisée à l’extérieur de l’abdomen. Cette technique nouvellement décrite facilite l’accès au rectum pour la suture d’une anastomose sans devoir réaliser une ostéotomie pubienne et avec un risque minime de contamination abdominale. (Traduit par Isabelle Vallières) Can Vet J 2012;53:780–782



M



egacolon is defined as dilation of the colon which may occur as a congenital disease, an acquired condition due to neurological damage or mechanical obstruction of the colon, or frequently as an idiopathic condition in middle-aged to older cats (1). Medical management is aimed at increasing dietary fiber, fecal softening, lubrication, and promoting colonic motility (2). Subtotal colectomy is indicated with chronic constipation refractory to medical therapy or with obstructive disease (2–4). Bowel adaptation occurs following subtotal colectomy, with surgically treated cats producing feces at slightly increased frequency but with no significant difference in fecal volume or water content compared with normal cats (4,5). Hence surgically treated cats are reported to have an excellent prognosis, although patients in which the ileocolic junction is removed may produce softer stools in the long-term (6). A rectal pull-through technique has been described for excision of distal rectal lesions in dogs and cats, allowing surgical access without need for pubic osteotomy or extensive dissection of the perineum (7). The aim of this report is to detail use of the rectal pull-through technique for access to the entire colon for subtotal colectomy. Advantages of this technique include its speed, simplicity, ease of access for suturing an appositional anastamosis, and reduced risk of abdominal contamination.



Bishop’s Stortford Veterinary Hospital, Rye Street, Bishop’s Stortford, Hertfordshire, CM23 2HA, UK. Address all correspondence to Mr. Darren Barnes; e-mail: [email protected] Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere. 780



Case descriptions Case 1 A 12-year-old, neutered male, Siamese cat was presented with a 9-month history of severe recurrent constipation, treated by increased dietary fiber intake, colonic stimulants, and fecal softeners (liquid paraffin; Vetway, York, UK: lactulose; Sandoz, Bordon, Hants, UK.) Despite medical management, bouts of obstipation continued requiring anesthesia for soapy water enemas. Previous chronic pancreatitis (diagnosed by elevated feline pancreatic lipase immunoreactivity) was managed with a low-fat diet. On physical examination the cat was bright, although dehydrated, with impacted feces palpable along the length of the distended colon. Rectal examination revealed no obstruction or narrowing of the pelvic canal. At exploratory celiotomy, a generally dilated and atonic colon was mobilized, a rectal pull-through maneuver was performed to the level of the ileocolic junction and subtotal colectomy was performed with colocolic anastamosis. The cat passed loose, formed stools by 4 d after surgery and then normal stools before the time of suture removal, with no subsequent constipation over the subsequent 6 mo.



Case 2 A 7-year-old, neutered male, British short-haired cat was presented, having vomited daily for the previous 3 wk, with ravenous appetite, weight loss, and obstipation. On physical examination the cat was dehydrated and a caudal abdominal mass (7 cm 3 4 cm 3 3 cm) was palpated. Radiographs demonstrated megacolon with solid fecal impaction, without pelvic narrowing. Following enemas and medical management with a high fiber diet, colonic stimulants, and fecal softeners (liquid paraffin; Vetway; lactulose; Sandoz), there was an immediate recurrence of the obstipation. CVJ / VOL 53 / JULY 2012



CA S E R E P O R T



Figure 1.  Pre-operative radiograph demonstrating megacolon.



Exploratory celiotomy revealed a dilated, atonic colon and cecum with a gross thickening of the wall of the distal descending colon. The colon was mobilized and a rectal pull-through maneuver was completed just beyond the ileocolic junction and a subtotal colectomy was performed with ileocolic anastamosis. The cat had diarrhea for 7 d after surgery and subsequently passed slightly soft but formed stools over the next 6 mo. Histopathology of the resected bowel revealed moderate colitis with reactive lymphoid tissue and focal ulceration of the mucosa.



Surgical management Pre-operative treatment. Following admission, food was withheld for 48 h. Soapy water enemas were used to remove fecal material 24 h prior to surgical investigation. Intravenous fluids were administered during hospitalization and metronidazole (Metronidazole; Marco Pharma, Roseburg, Oregon, USA), 10 mg/kg body weight (BW), intravenously (IV) q12h and amoxicillin/clavulanate (Augmentin; GlaxoSmithKline UK, Uxbridge, Middlesex, UK), 20 mg/kg BW, 3 times daily were administered during the immediate 24-h presurgical period. Surgery. After premedication with acepromazine (ACP; Novartis, Frimly, Camberly, UK), 20 mg/kg BW, and buprenorphine (Buprecare; Animalcare, Dunnington, York, UK), 20  mg/kg BW intramuscularly (IM), anesthesia was induced with propofol (Rapinovet; Intervet-Schering-Plough, Milton Keynes, UK) and maintained on oxygen and isoflurane (Isoflo; Abbott, Maidenhead, UK) following intubation. Patients were prepared aseptically in dorsal recumbency and a ventral midline celiotomy was performed from umbilicus to pubis allowing assessment of the gastrointestinal tract. The colon and cecum were inspected and mobilized from mesenteric attachments by sharp dissection with ligation of the left, middle 1/2 right branches of the colic artery and vein and vasa recta from the caudal mesenteric vessels to the region to be resected, taking care to preserve the cranial and caudal rectal vessels. Allis tissue forceps were passed per rectum with one hand then designated as “dirty” using a separate operation kit and clamped to the colonic wall mid-way along the portion to be ressected. The ileocolic junction was drawn gently into the pelvic canal (case 1) or beyond the anus (case 2) to allow resection of the affected colon guided by the “sterile” hand within the abdoCVJ / VOL 53 / JULY 2012



Figure 2.  Intra-operative photograph showing the anastamosis beyond the anus.



men. This procedure intussuscepted the bowel to be resected. The abdominal incision was closed with towel clamps and covered with a sterile drape. Subtotal colectomy was performed beyond the anus outside the abdomen. The intussuscepted bowel wall was progressively divided (mucosa to serosal on the external loop of bowel, serosal to mucosa on the inner loop) with layers of bowel wall being sutured together with 4-0 polydiaxanone (PDS*II; Ethicon, Johnson & Johnson Intl, St. Stevens-Woluwe, Belgium) in a simple interrupted appositional pattern progressively working around the lumen (7). Luminal disparity was managed by circumferential suturing making use of the elastic nature of the bowel wall, without the need for spatulation or partial closure of the larger lumen, facilitated by the concentric orientation of the lumina. This orientation aided visualization of the layering of the bowel wall for ease of suture placement. Two simple interrupted stay sutures were placed in the anastomosed segments at the 3 and 9 o’clock positions to prevent retraction of the intestine into the abdomen as transection of the bowel progressed. On completion of the anastamosis, the stay sutures were removed, the contaminated kit disposed of, and gloves replaced. The anastamosis was withdrawn into the abdomen by gentle traction on the ileum and inspected to ensure that the anastomosis was no longer intussuscepted and that the suture line was adequate. The mesentery was closed, the abdominal cavity was lavaged with warm 0.9% saline, and the anastamosis was covered with omentum before routine celiotomy closure. 781



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Post-operative treatment. Patients were hospitalized on intravenous fluids and buprenorphine (Buprecare; Animalcare) for 24 h after surgery with metronidazole (Metronidazole; Marco Pharma) and amoxicillin/clavulanate (Augmentin; GlaxoSmithKline UK) continued for 5 d. Food was offered immediately after surgery and fecal softeners and colonic motility drugs were discontinued. Initially the cats were fed a bland diet for 5 d, but subsequently both patients were managed on a standard complete cat food.



Discussion Conservative management of recurrent obstipation is frequently frustrating, time consuming, and expensive. Several surgical techniques have been described for management of megacolon in cats; however, subtotal colectomy is regarded as the surgical treatment of choice (1–6,8–10). An abdominal approach for resection is universally described with or without pubic osteotomy to improve access to the rectum, although this may not be greatly beneficial (2). A rectal pull-through technique has been described for excision of distal rectal lesions, allowing access without the need for pubic osteotomy or extensive dissection of the perineum (7). This report describes an abdominal approach to assess the extent of bowel for resection, release mesenteric attachments and ligate vascular supply to that portion of bowel planned for resection. An extensive rectal pull-through was then used to perform the subtotal colectomy outside the abdomen. These cases demonstrate mobilization and removal of the entire length of the large bowel to include the cecum if desired, sparing 1.5 cm of distal rectum to conserve fecal continence (7). In a long-term retrospective study, resection of the ileocolic junction resulted in no significant difference in recurrence in constipation, but was associated with cats producing significantly looser stools (6). Removal of the valve may result in small intestinal bacterial overgrowth, deconjugation of bile salts, and steatorrhea (11). Preoperative intestinal preparation with multiple enemas is regarded as ineffective and unnecessary to evacuate the large bowel with a conventional abdominal approach (9), but is necessary with this technique to allow intususseption of the bowel. In both cases detailed in this report soapy water enemas were performed 24 h prior to surgery. Both patients had been medically treated with fecal softeners prior to repeat presentation. Enemas to completely evacuate the colon were time consuming due to the degree of fecal impaction, but were readily achievable in these cases. In the author’s experience soapy water enemas are an effective means of manual evacuation of the colon both as a conservative treatment for constipation and in pre-operative preparation, as described in these 2 cases. Inability to adequately evacuate the colon prior to surgery may prove to be a potential limitation of the use of this surgical technique should soapy water enemas be ineffective or impractical. Previous reports detail an end-to-side anastamosis (1,5), spatulation of the proximal bowel (4,9), or partial closure of the proximal rectal stump (3) to deal with luminal disparity. These methods are not possible with this approach. Instead a simple appositional closure was used (8,10). Suturing in this pattern with a large luminal disparity was facilitated by the concentric orientation of the lumina to be anastamosed. 782



Other potential advantages of this technique include; speed, simplicity, and low risk of abdominal contamination, facilitating access to the operative site without the need for pubic osteotomy or special surgical equipment. Intraoperative technical difficulties in removal of the distal colon have been reported due to narrow pelvic canals in small cats and those with pelvic fracture malunion (3). This may result in inadequate resection or leakage from the anastamosis with a conventional abdominal approach. A 20% recurrence rate of constipation requiring further surgery was quoted in 1 text (6). These 2 reported cases did not have pelvic narrowing, but further evaluation of this technique may demonstrate an advantage in such cases. This report details 2 cases with a follow-up time of 6 mo; with time this technique may prove to be valuable. A controlled prospective study comparing the merits of this technique with the standard abdominal approach and treatment with a longer period of follow-up will be needed. Initial assessment of the technique is, however, encouraging. Subtotal colectomy is the surgical treatment of choice for feline idiopathic megacolon. The rectal pull-through technique described is a swift, simple modification of the previously reported technique, facilitating surgical access to the distal rectum for suturing an anastamosis without need for pubic osteotomy and minimizing the risk of abdominal contamination. The entire colon including ileocolic valve may be excised with this technique. Further work is required to critically compare this technique with a standard abdominal approach.



Acknowledgment The author thanks Dr. Rob Furneaux for his guidance and assistance in the preparation of this report. CVJ



References   1. Bright RM, Burrows CF, Goring R, Fox S, Tilmant L. Subtotal colectomy for treatment of acquired megacolon in the dog and cat. J Am Vet Med Assoc 1986;188:1412–1416.   2. Webb SM. Surgical management of acquired megacolon in the cat. J Small Anim Pract 1985;26:399–405.   3. Matthiesen DT, Scavelli TD, Whitney WO. Subtotal colectomy for the treatment of obstipation secondary to pelvic fracture malunion in cats. Vet Surg 1991;20:113–117.   4. Bertoy RW, MacCoy DM, Wheaton LG, Gelberg HB. Total colectomy with ileorectal anastomosis in the cat. Vet Surg 1989;18:204–210.   5. Gregory CR, Guilford WG, Berry CR, Olsen J, Pederson NC. Enteric function in cats after subtotal colectomy for treatment of megacolon. Vet Surg 1990;19:216–220.   6. Sweet DC, Hardie EM, Stone EA. Preservation versus excision of the ileocolic junction during colectomy for megacolon: A study of 22 cats. J Small Anim Pract 1994;35:358–363.   7. Anson LW, Betts CW, Stone EA. A retrospective evaluation of the rectal pull-through technique. Procedure and postoperative complications. Vet Surg 1988;17:141–146.   8. Kudisch M, Pavletic MM. Subtotal colectomy with surgical stapling instruments via a trans-cecal approach for treatment of acquired megacolon in cats. Vet Surg 1993;22:457–463.   9. Rosin E, Walshaw R, Mehlhaff C, Matthiesen D, Orsher R, Kusba J. Subtotal colectomy for treatment of chronic constipation associated with idiopathic megacolon in cats: 38 cases (1979–1985). J Am Vet Med Assoc 1988;193:850–853. 10. Ryan S, Seim H, 3rd, Macphail C, Bright R, Monnet E. Comparison of biofragmentable anastomosis ring and sutured anastomoses for subtotal colectomy in cats with idiopathic megacolon. Vet Surg 2006; 35:740–748. 11. Naveb F. Management of Short Bowel Syndrome. South Med J 1984; 77:484–488.



CVJ / VOL 53 / JULY 2012



Kasetsart Veterinarians vol. 20 No. 1. 2010



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Congenital Colonic Atresia in Horse Aree Laikul1, Kanittha Phetudomsinsuk1, Waraporn Aumarm2, Tepyuda Sritrakul3, and Sukumal Prukudom3



ABSTRACT The paper describes a case of atresia coli in a twenty hours old foal. Newborn foal was presented with signs of colic and absence of meconium staining following repeated enemas. The final diagnosis of atresia of the small colon was confirmed during laparotomy. The blind end of the small colon had a diameter of approximately 5 cm and 7 cm in length. The blind end of rectum was about 10 cm in length and attached with peritoneum in pelvic cavity. The anastomosis between the rectum and colon was incapacity. A new fecal opening was created at the left side of abdomen. The foal was making a good recovery without complications after surgery. Key words: colonic atresia, horse



INTRODUCTION Intestinal atresia in the horse is a rare occurrence (Cho and Taylor, 1986). The most commonly missing occurs in the colon (atresia coli) and in the rectum or anus (atresia recti or ani) of the horse. The defect occurs sporadically in most species. In horses and cattle it can be inherited, in 1



cattle it can be resulted from over-vigorous palpation of the fetus between 35 and 41 days gestation at pregnancy diagnosis (Blood et al., 2007). The etiology of intestinal atresia is unknown, but the condition could be resulted from a simple recessive gene, developmental arrest, or vascular compromise to the fetal gut resulting in ischemic necrosis of the affected intestinal portion. The most popular



Department of Large Animal and Wildlife Clinical Sciences, Faculty of Veterinary Medicine, Kasetsart University, Kamphaengsean, Nakorn-Pathom 73140, Thailand 2 Department of Small Animal Clinical Sciences, Faculty of Veterinary Medicine, Kasetsart University, Kamphaengsean, Nakorn-Pathom 73140, Thailand 3 Kasetsart University Veterinary Teaching Hospital, Kamphaengsean, Nakorn-Pathom , Kamphaengsean, Nakorn-Pathom 73140, Thailand



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theory regarding the pathologenesis of intestinal atresia is that of a vascular accident. The vascular accident is theorized to arrest growth and result in atrophy of a bowel segment which becomes the atresic segment (Santschi, 2002). The types of intestinal atresia are classified according to the tissue involved. In type1 atresia, or membrane atresia, a diaphragm or membrane occludes the intestinal lumen. Type2, or cord atresia, the proximal and distal blind ends are joined by a small cord of connective tissue, with or without mesentery. In type3, or blind-end atresia, the proximal and distal blind segment of colon are complete separated and the corresponding mesentery is absent. Type4 atresia involves multiple small-bowel atresias of any combination of types 1 to 3. This defect often takes on the appearance of a string of sausages because of the multiple lesions. (Jone and Modi, 2009). Foal with intestinal atresia are born normally. However, intestinal atresia clinical signs are recognized within the first 24-48 hours of life for signs of colic include depression, discomfort, failure to pass their mecomium, and abdominal distension (Young et al., 1992). The diagnosis should include a thorough history taking, clinical signs, physical examination, digital palpation or endoscopic examination and contrast radiography using barium enemas. Definitive diagnosis is made during exploratory laparotomy (celiotomy) (Schumacher, 2002). Surgical repair is recommended.



37



HISTORY AND PHYSICAL EXAMINATION A newborn Thoroughbred female (filly) foal was born normal. Fifteen hours after birth, foal had sign of colic with abdominal distension, no meconium passed per rectum. Local veterinarian examined and treated with transrectal intubation for enema, however enema tube could be passed only 15 cm from the end of rectum. The filly arrived at the Kasetsart university veterinary teaching hospital, Kamphaengsaen, Nakhonpathom in good condition showed light signs of colic and from time to time attempted to lie down. The rectal temperature was 38.4 °C. Other vital signs such as heart rate, respiration rate hydration status, capillary refilling time and gut sound were in normal range. The filly presented mild abdominal distention and had no meconium in the rectum. By rectal palpation, the presence of blind end of rectum also suggested atresia recti. Final diagnosis of atresia coli was confirmed during laparotomy.



TREATMENTS AND RESULTS Initial treatment of the symptoms included fluid therapy (Ringer lactate solution, 40% dextrose, amino acid infusion) and flunixin meglumine 1.1 mg/kg intravenous injection. Due to lack of rectum, surgical correction was performed. To do general anesthesia, xylazine hydrochroride 0.5 mg/kg intravenous was premedicated. Then, 1.5%



38



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isofurance was used to induce and maintenance of anesthesia. Midline laparoscopy was performed with the foal in dorsal recumbency. During the surgical exploration atresia coli was recognized. The blind end of the small colon had a diameter of approximately 5 cm, about 7cm in lenght (Figure 1). Side to side anastomosis between rectum and colon was incapable because rectum was very short and narrow, about 10 cm in length and positioned



at pelvic cavity. A new fecal opening (colostomy) was created at the left side of abdomen (Figure2). Eventually the foal was replaced to the recovery room. Flunixine meglumine 1.1 mg/kg was administered to alleviate the pain. Antibiotic therapy consisted of penicillin-streptomycin (long acting) 25 mg/kg intramuscular injection for 10 d. Recovery from anesthesia was well smooth and mucomium could pass through this opening (Figure 3).



Figure 1 Blind end atresia in a neonatal foal with absence of small colon, resulting in a complete obstruction of the bowel.



Figure 2 Colostomy procedures. A, Blind end of small colon is pulled through the lower body wall at the left side and B, cut the blind end to make the new opening. C, seromuscular edges are sutured to the subcutaneous fascia, and the mucosal edges are sutured the skin in a simpleinterrupted fashion



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39



Figure 3 Foal after surgery. A, foal is in dorsal recumbence with the laparotomy ventral midline closure and the new opening for the anus at the left side of the midline. B, after foal recovered, mucomium was throughout.



DISCUSSION This foal had type 3 atresia coli which blindends of colon was complete separated and the corresponding mesentery was absent. Surgery correction (colostomy) was needed to create an opening for the anus or to reconstruct the part of the rectum that was missing. The side to side anastomosis technique is of value but may dispose the horse to blind loop syndrome. However, colostomy was preferred for this case because blind ends of small colon and rectum are very short. The prognosis depends on which segment of the colon is absent but is generally poor because of the absence of a distal colon (Benamou et al., 1995; Santschi, 2002). It is likely that the condition is more complex and probably also involves other neurological dysfunctions. Literature describes a few cases which were treated surgically but none of the patients survived more than 18 months (Benamou et al., 1995; Cho and Taylor, 1986). The complications after surgery were anastomosis



rupture (Turek and Verhoeven, 2008) and recurrent colic. Surgery is sometimes impossible owing to the location of the problem. However, for this case, foal can survive after colostomy until now and recurrent colic is a complication of surgery. The horse is classified, based on the anatomy of the digestive tract as a non-ruminant herbivore. All true digestion is by enzymatic digestion and takes place in the fore gut ahead of the cecum. Microbial fermentation in the hindgut results in the production of volatile fatty acids which are an important nutrient source for the horse. The hindgut also serves as a reservoir of water and electrolytes which are vital to sustain exercise performance (Jackson, 2009). The rectum is continues the small colon at the pelvic inlet (Budras et al., 2003) and serves primarily as storage area for fecal product which has not been digested and then results in nervous stimulation and voiding of feces through the anus. An absent small colon would be affect further performances, however adjust nutrition will help these problems.



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As the atresia coli is a congenital condition the most important aspect in preventing it is to avoid using the parents of the affected foal for breeding purpose(Santschi, 2002). Congenital colonic atresia should be considered for neonatal foals with signs of acute colic including failure to pass their mecomium, and abdominal distension. Laparotomy is recommended for final diagnosis and treatment. Adjustment nutrition is an important post operative care to improve body condition and prevent recurrent colic.



REFERENCES Benamou, A., A.T. Blikslager and D. Sellon. 1995. Intestinal atresia in horses. Compend Cont Educ Pract Vet. 17: 1510-1517. Budras, K.D., W.O. Sack, and R. Sabine. 2003. Anatomy of the horse. 4th edn. Schlutersche. 64-65p. Blood, D.C., V.P. Studdert and C.C. Gay. 2007. Saunders Comprehensive Veterinary Dictionary, 3rd ed., Elsevier, St. Louis, Missouri, USA. Cho, D.Y. and H.W. Taylor.1986. Blind-end atresia coli in two foals. Cornell Vet. 76: 11-15.



Jackson, S.G. The digestive tract of the horsepractical considerations. Kentucky Equine Research, Inc., Kentucky, USA. October 29, 2009. From www.ker.com/library/advances/ 101.pdf Jones, B.A. and B.P. Modi. 2009. Intestinal Atresia, Stenosis, and Webs. October 29, 2009. eMedicine from http://emedicine.medscape. com/article/940615-overview. Santschi, E.M. 2002. Atresia recti and ani. edit by T. mair, T. divers, and N. ducharme. In Manual of equine gastroenterology. W.B. Saunders, Sydney, Toronto. 491-492p. Schumacher, J. 2002. Disease of the small colon and rectum. edit by T. mair, T. divers, and N. ducharme. In Manual of equine gastroenterology. W.B. Saunders, New York, USA. 299300p. Turek, B. and G. Verhoeven. 2008. Atresia coli in a foal: case report. Medycyna Wet. 64: 280-282. Young, R.L., R.L. Linford and H.J. Olander. 1992. Atresia coli in the foal: a review of six cases. Equine Vet J. 24: 60-62.



Veterinary Surgery 35:740–748, 2006



Comparison of Biofragmentable Anastomosis Ring and Sutured Anastomoses for Subtotal Colectomy in Cats with Idiopathic Megacolon STEWART RYAN, BVSc (Hons), MACVSc, HOWARD SEIM III, DVM Diplomate ACVS, CATRIONA MACPHAIL, DVM, Diplomate ACVS, RON BRIGHT, DVM, MS, Diplomate ACVS, and ERIC MONNET, DVM, PhD, Diplomate ACVS & ECVS



Objective—To report use of a biofragmentable anastomosis ring (BAR) device in cats with idiopathic megacolon (FIM) and compare outcome after subtotal colectomy with sutured colocolic anastomosis. Study Design—Retrospective study. Animals—Nineteen cats with megacolon. Methods—Medical records (January 1990–January 2004) of cats treated surgically for idiopathic megacolon with sutured (SUT) or BAR anastomosis were retrieved and reviewed. Operative, shortand long-term complications, and survival times were recorded and Kaplan–Meier survival analysis used to assess outcome. Results—There were 11 SUT and 8 BAR cats. One BAR cat had anastomotic dehiscence 36 hours after surgery. Mild serosal tearing during BAR insertion in 6 cats was corrected by suture reinforcement. One SUT cat developed anastomotic stricture at 32 days. Short-term complication rates at 3 and 7 days were 18% and 45% in the SUT group and 25% and 87.5% in the BAR group, respectively (P ¼ .058). Two SUT cats had persistent loose stool consistency and were euthanatized 254 and 1661 days after surgery. One BAR cat had recurrence of constipation which was managed medically. Long-term complication rates were not significantly different between SUT and BAR (P ¼ .61). The 1 and 4-year survival rates were 90% for SUT and 100% for BAR (P ¼ .29). Conclusions—No difference was detected for short and long-term complication rates and survival times between SUT and BAR groups. Clinical Relevance—The BAR device can be used for colocolic anastomosis in cats with idiopathic megacolon. Serosal tearing during BAR insertion was a common intraoperative complication. Regardless of anastomotic technique, survival outcome after colonic resection is excellent for cats with FIM. r Copyright 2006 by The American College of Veterinary Surgeons



accounts for 60–70% of reported cases,1 is believed to result from dysfunction of the colonic smooth muscle,2 although it is unknown if this is a primary or secondary effect. Medical management for FIM, typically a combination of fecal softeners, enemas, prokinetic agents and dietary modification, is generally unrewarding in the



INTRODUCTION



M



EGACOLON IN cats can be primary (idiopathic, congenital) or secondary (pelvic fracture malunion, neurologic dysfunction, rectal stricture or neoplasia) in cause. Feline idiopathic megacolon (FIM) which



From the Colorado State University Veterinary Medical Center, Fort Collins, CO. Presented in part at the ACVS Symposium, San Diego, CA, October 28th 2005. Address reprint requests to Dr. Stewart Ryan, BVSc (Hons), MACVSc, Colorado State University Veterinary Medical Center, 300 W. Drake Road, Fort Collins, CO 80523. E-mail: [email protected]. Received January 2006; Accepted July 2006 r Copyright 2006 by The American College of Veterinary Surgeons 0161-3499/06 doi:10.1111/j.1532-950X.2006.00218.x



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long-term, and total or subtotal colectomy, with or without preservation of the ileocolic valve, is the recommended definitive treatment. After subtotal colectomy, anastomosis can be achieved with sutures, staples, or a biofragmentable anastomotic ring (BAR; Valtract, US Surgical Corporation, Norwalk, CT; Fig 1). A single layer, simple interrupted, appositional sutured anastomosis has a low complication rate and is considered the current standard of care in veterinary surgery. A transcecal approach using an end to end anastomosis stapling instrument (EEA; US Surgical Corporation) to create an inverting anastomosis has been reported to yield an excellent outcome in cats with FIM3; although the technique was associated with post operative bleeding in 2 cats and produces an additional staple line in the cecum. The BAR was developed by Hardy et al in 19854,5 to create a sutureless, inverted anastomosis for enterectomy and colonectomy in human patients.4,5 The BAR is composed of 87.5% polyglycolic acid and 12.5% barium sulfate. Inclusion of barium sulfate allows fragmentation and elimination of the BAR to be monitored radiographically. The BAR is available in a range of external diameters (25 , 28 , 31 , 34 mm) and closed gap widths (1.5 , 2.0 , 2.5 mm) to accommodate different intestinal lumen diameters and wall thicknesses. One potential advantage of the BAR compared with stapling equipment is that it can be placed without an additional incision in the gastrointestinal tract or by retrograde introduction through the anus. BAR has been compared experimentally with sutured anastomosis after subtotal colectomy in young normal cats.6 Fragmentation occurred in a predictable



manner 10–12 days after implantation and with BAR passage in the stool 2–5 days later without clinical signs. To our knowledge, there are no reported studies of BAR use in cats with FIM. It is unknown if idiopathic megacolon has an influence on anastomotic healing after subtotal colectomy; however, the complication rate after subtotal colectomy and sutured anastomosis is very low.7,8 Because the BAR device is expelled relatively early during anastomosis healing, recommending use of the BAR device in these cats may be a potential concern. Thus, we conducted a retrospective study to report use of the BAR device in cats clinically affected by FIM to determine if there were any differences in operative, short- and long-term complication rates, clinical outcome, and survival by comparing these cats to a group of similarly affected cats that had sutured colocolostomy. Our null hypothesis was that there would be no difference in measured variables between the 2 anastomotic methods. MATERIAL AND METHODS Inclusion Criteria Medical records (January 1990–January 2004) from a university teaching hospital and a referral practice were reviewed for cats that had surgical treatment for megacolon. Presumptive diagnosis of FIM was made based on historical findings, clinical signs, poor response to medical therapy, clinical examination findings, and preoperative abdominal radiography. Cats were included if they had subtotal colectomy and colocolic anastomoses either by hand-suture (SUT) or use of a BAR device (BAR). A minimum follow-up of 4 months after surgery was required. Cats were excluded if the ileocolic valve was removed, if there was gastrointestinal tract neoplasia, or if it was determined that megacolon was secondary in nature.



Data Retrieval Retrieved data were signalment, duration of clinical signs before surgery, previous medical treatment, anastomosis type (for sutured anastomosis [SUT], suture type, size, and pattern were recorded; for BAR, the external diameter and inner gap width of the BAR were recorded), preservation or removal of the ileocolic valve, primary surgeon training level, and any operative, short- or long-term complications. Histologic findings were recorded if excised colon tissue was submitted for histopathology. Information on short- and long-term complications, and survival after surgery was obtained from either the medical record or telephone interview of the owner or referring veterinarian.



Surgical Technique Fig 1. Valtract biofragmentable anastomosis ring (BAR) device with insertion tool.



The decision to use the BAR device or suture was made before surgery. All BAR cases were performed by one surgeon



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(E.M.). Informed consent was obtained from clients before use of the BAR. Preoperative bowel preparation to remove feces from the colon was not performed. Either intravenous (IV) cefoxitin (22 mg/kg; 17 cats) or a combination (2 cats) of enrofloxacin (5 mg/kg IV) and amoxicillin (22 mg/kg IV) was administered before surgery and repeated every 90 minutes during surgery. Subtotal colectomy was performed after ventral midline celiotomy using a previously reported technique6,8,9 by a board-certified surgeon or a resident under direct supervision. BAR Anastomosis. The BAR device was used according to manufacturer’s instructions and as described by Hardy et al4 and Huss et al6 Briefly, after isolating the affected colon, a 2–0 or 3–0 monofilament non-absorbable pursestring suture was placed across the colon just aboral to the cecum using a Furness clamp (Fig 2; US Surgical Corporation). A straight swaged needle was used for suture passage through the Furness clamp.3,6 The colon was then resected distal to the pursestring suture using the clamp as a guide. Another pursestring suture was placed in the terminal colon
2–3 cm proximal to the pelvic brim and the colon resected proximal to the second pursue string suture. The pursestring sutures were inspected to ensure that they engaged the colon correctly. The BAR device was introduced into the lumen of the orad segment of colon with the aid of a holding device and the pursestring suture tied securely against the internal barrel of the BAR device (Fig 3A). The smallest external diameter (25 mm) BAR device with a 1.5 mm gap width was used in all cats. If the colonic lumen was too small to accept the BAR,
1 mL papaverine (Papaverine HCl 30 mg/mL, Bedford Laboratories, Bedford, OH) was applied topically to relax the



colonic wall smooth muscle and facilitate device insertion. After BAR insertion into the aboral colonic segment, the second purse string suture was secured (Fig 3B). The caps of the BAR device were digitally snapped shut from the serosal surface which engaged the full thickness of the colon to create an inverting anastomosis (Fig 3C). The anastomosis was carefully inspected to ensure circumferential serosa to serosa contact. At the discretion of the surgeon, an additional partial or complete continuous seromuscular suture was used to seal the anastomosis if serosal splitting occurred (Fig 3D). Sutured Anastomosis. The affected colonic section was removed and an end to end anastomosis using a single layer appositional closure of either monofilament absorbable or non-absorbable material in either a simple interrupted or continuous pattern was used. In all cats, the mesenteric defect was sutured closed. The abdomen was lavaged with warmed 0.9% saline (NaCl) solution and then the celiotomy closed.



Outcome Operative, or short- and long-term postoperative complications were recorded. Short-term postoperative (within 2 weeks) complications were determined from the time after surgery to when first noted in the medical record. Long-term complications were defined as occurring between 2 weeks after surgery and death or follow-up time. Complications were further categorized as major or minor. Major complications were defined as those requiring general anesthesia and surgical intervention, or resulted in euthanasia. Minor complications were defined as those that responded to medical or conservative therapy. Survival was defined as time (days) from surgery to either follow-up or death. If the cat was dead at follow-up, the reason for death was determined and recorded as related or not related to FIM or colectomy.



Data Analysis



Fig 2. Intraoperative image of Furness clamp use for purse string placement.



Variables for the BAR and SUT groups were compared with a Fisher’s exact test for categorical data and ANOVA for continuous data. Results were reported as mean  SEM. Kaplan–Meier actuarial survival analysis was used to compare short- and long-term complication rates and survival time between groups. If complications were related to FIM or surgery, the cat was uncensored for short- and long-term complication rate analysis. If death was related to FIM or surgery, the cat was uncensored in the survival analysis. A cat lost to follow-up, alive at the time of study, or dead for unrelated cause was censored for the survival and long-term complication rate analysis. A log-rank test was used to compare median complication rates and survival times. Power calculations were determined for comparisons between the BAR and SUT groups for short and long-term complication rates and survival time.10 A P value  .05 was considered significant for all tests. Statistical analysis was performed with a statistical software package (JMP IN 5.1, SAS Institute Inc. Cary, NC).



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Fig 3. (A) Insertion of biofragmentable anastomosis ring (BAR) device into orad colon segment with aid of positioning device. A purse string suture has been used to invert the colon wall to the level of the central barrel of BAR. (B) BAR positioned intraluminally and secured with 2 purse string sutures. BAR is still in the open position. Note smaller orad and larger aborad colon segments. Serosal tearing was minimal (2–3 mm) and was located in the inverted tissue. (C) BAR has been digitally closed to create inverting anastomosis. (D) A continuous seromuscular oversew suture was used to repair serosal tearing during BAR insertion.



RESULTS Twenty seven cats with a presumptive diagnosis of megacolon that had surgical treatment were identified; 19 met the inclusion criteria. Twelve cats (8 BAR, 4 SUT) were from the university teaching hospital and 7 cats (all SUT) were from the referral practice. Thus, there were 11 SUT cats (5 female spayed, 6 male castrates) and 8 BAR (2 female spayed, 6 male castrates; P ¼ .63). The most common breed was the domestic short hair (n ¼ 7); breeds represented by 2 cats were: domestic long hair, Manx, Persian, and Russian Blue. No difference in mean age at surgery was detected (SUT ¼ 9.70  1.10 years; range, 4.2–14.23 years; BAR ¼ 9.60  1.3 years; range, 1.30–14.67 years; P ¼ .98). All cats had a history of chronic constipation and had undergone various medical and dietary therapies before surgery. Multiple enemas had been performed in 7 BAR and in all SUT cats, lactulose was administered to 6 BAR and 8 SUT cats, and cisapride was administered to all BAR and 8 SUT cats. There was no difference in duration of signs before surgery for SUT (2.60  0.70 years) and BAR groups (2.30  0.80 years; P ¼ .74). Abdominal radiographs taken preoperatively in all cats confirmed



presence of a dilated colon with fecal impaction, consistent with megacolon. Surgery The primary surgeon (EM, RB, HS) was a boardcertified surgeon for 16 cats (8 SUT, 8 BAR) and a supervised resident (2 residents) for 2 cats (2 SUT). Sutured Anastomosis. A single layer, appositional, end to end colocolic anastomosis was used in all cats; 10 cats had a simple interrupted pattern and 1 cat a simple continuous pattern. The cat with a continuous suture pattern developed a stricture at the anastomosis 32 days after surgery. Suture materials were all monofilament, either 3–0 (n ¼ 8) or 4–0 (n ¼ 3) size and either absorbable (polydioxanone, n ¼ 8; polyglyconate, n ¼ 2) or nonabsorbable (polypropylene, n ¼ 1). Two SUT cats had additional procedures performed at subtotal colectomy. One had 2 attempts at EEA stapling before sutured anastomosis was performed, and 1 had an enterectomy and end to end anastomosis for removal of granulomatous disease in the jejunum. BAR Anastomosis. Mild longitudinal serosal tearing (2–3 mm in length, 1–2 tears) after BAR insertion



prompted use of an additional partial (1 cat) or complete (5 cats) continuous seromuscular reinforcing suture (3–0 polydioxanone, 2 cats; 4–0 polydioxanone, 4 cats) to prevent further tearing. Histopathology Histopathology was available for 10 cats (2 SUT, 8 BAR). No specific abnormalities suggesting an underlying cause for megacolon were detected. Changes either were non-specific and consistent with mild colitis (mild increase in number of goblet cells, flattening of mucosa), or the colon was considered within normal limits. Submucosal and myenteric ganglia were noted to be within normal limits for number and histomorphology. Complications No major intraoperative complications occurred in the SUT group. Difficulty inserting the BAR occurred in 6 cats resulting in mild serosal tearing and use of a seromuscular oversew suture. Topical papaverine was used in 3 BAR cats to relax the smooth muscle and dilate the lumen to allow easier BAR insertion; no oversew was required for 2 of these cats. All cats recovered uneventfully and were hospitalized for a minimum of 2 days after surgery. Short-Term Complications. Twelve cats had complications. Short-term complication rates at 3 and 7 days were 18% and 45% for SUT and 25% and 87.5% for BAR, respectively (P ¼ .058, power ¼ 0.40; Fig 4). Minor complications (11 cats) were anorexia (n ¼ 6; 1 SUT, 5 BAR), anemia (3; 1 SUT, 2 BAR), and vomiting (2; 1 SUT, 1 BAR). One BAR cat had a major short-term complication: dehiscence occurred 36 hours after surgery causing septic peritonitis and the need for surgical intervention. One-third to one-half of the distal part of the anastomosis was not engaged between the BAR caps. The BAR device was removed and the colon anastomosed by simple interrupted suture reinforced by a serosal patch. This cat (not included in SUT after the second surgery) was discharged from the hospital and had no long-term complications. Postoperative body temperature 439.51C did not occur in any cat during hospitalization except the dehiscence case. Long-Term Complications. Six cats (4 SUT, 2 BAR) had long term complications. One and 4-year complication rates were both 41% for SUT and 25% for BAR (P ¼ .61; power ¼ 0.524; Fig 5). The most frequent minor long-term complication was continued soft stool consistency beyond 12 weeks (4 SUT, 1 BAR). Two SUT cats with persistent soft stool consistency had resolution of clinical signs with empirical treatment for inflammatory bowel disease; however, definitive diagnosis of inflamma-



PROPORTION COMPLICATION FREE



BIOFRAGMENTABLE ANASTOMOSIS RING IN CATS 1.0 0.9



P = 0.058



0.8 0.7 SUT



0.6



+



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BAR



+



10



14



0.1 0.0 2



3



4



5



6



7



8



9



11 12 13



TIME (Days)



Fig 4. Survival curves for short-term complication rate. þ , censored data; ’, uncensored data.



tory bowel disease was not made in either cat. The other minor long-term complication was recurrent constipation in 1 BAR cat. On abdominal radiographs there was mild dilation of the remaining colon 17 days after surgery. This cat had 1 enema and was treated with lactulose, dietary modification, and cisapride. After 1.5 years of daily treatment with lactulose, stool consistency and regular defecation could be maintained with dietary therapy alone. One SUT cat had a major long-term complication that required surgery. This cat developed a stricture at the anastomosis site that caused tenesmus and constipation. A continuous, single layer suture pattern (3–0 polyglyconate) was used at initial surgery and at 32 days, an end to side anastomosis was performed with a stapling instrument (Endo GIA and TA30 stapler, US Surgical Corporation).



COMPLICATION FREE PROPORTION



744



1.0



+



0.9



BAR



0.8



+



0.7



++ +



+



+ +



+



+



0.6



+



0.5



+ SUT



0.4 0.3 0.2



P = 0.608



0.1 0.0 0



365



730



1095



1460



1825



2190



TIME (Days)



Fig 5. Survival curves for long-term complication rate. þ , censored data; ’, uncensored data.



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+



PROPORTION SURVIVING



1.0 0.9 0.8



++ + + ++ +++ + +



+



+ BAR



0.7



+



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+ SUT



0.5 0.4 0.3 0.2



P = 0.292



0.1 0.0 0



365



730



1095



1460



1825



2190



TIME (Days)



Fig 6. Survival curves for survival after surgery. þ , censored data; ’, uncensored data.



Outcome Follow-up was available on all cats; 12 cats were still alive. Median follow-up time was not significantly different between SUT (525 days) and BAR group (1041 days; P ¼ .27). Five cats died or were euthanatized for reasons unrelated to either FIM or complications related to subtotal colectomy. One SUT cat was euthanatized for fecal incontinence and persistent soft stool consistency 254 days after surgery. One SUT cat was euthanatized for persistent soft stool consistency 1661 days after surgery. One and 4-year survival rates were both 90% for SUT and 100% for BAR (P ¼ .29; power ¼ 0.16; Fig 6).



DISCUSSION A BAR device could be used for colocolic anastomosis after subtotal colectomy in cats clinically affected with idiopathic megacolon. Intraoperative complications were more frequent with BAR compared with a group of cats with FIM that had sutured anastomoses, however these were mostly minor and addressable at the time of surgery. Short- and long-term complication rates and survival times were not affected by use of the BAR compared with sutured anastomoses. Outcome after surgical treatment for idiopathic megacolon with either anastomotic technique was excellent. Subtotal colectomy can be considered curative for idiopathic megacolon. In human patients, reported operative complication rates with BAR range from 4 to 17% and are higher than for sutured anastomoses.11,12 Complications related to BAR include mucosal or serosal tearing, failed pursestring application, and bowel lumen too small for the BAR.6,11



745



Serosal tearing after BAR insertion was the only intraoperative complication we observed. Tearing was longitudinal and affected the inverted part of the colon. In 6 cases, a continuous seromuscular oversew suture was used to prevent further tearing where serosal tearing occurred. This technique has been described in a human clinical trial11 and the BAR manufacturers recommend placing interrupted Lembert seromuscular sutures using absorbable monofilament sutures in deficient areas of the anastomosis.13 When serosal tearing did not occur, oversew of the anastomosis was not performed and no adverse effects were seen. Serosal or mucosal tearing was mostly caused by a large device size relative to the colonic lumen diameter. Huss et al6 reported that in cadaveric normal cats oral colonic segment dimensions were marginal for insertion of a 25 mm BAR. Indeed, the oral colonic lumen was significantly smaller than the aboral lumen and more difficulty was encountered with BAR insertion in the oral segment. Kurdisch and Pavletic3 reported that, in cats with acquired megacolon, 25 mm circular staple cartridges could be used in 13 of 15 cats by a transcecal insertion route. We used the smallest available BAR (25 mm external diameter with a 1.5 mm gap size) based on the experience of Huss et al.6 Use of the BAR is limited to colocolic anastomosis as the 25 mm external diameter is too large for the feline terminal ileum, precluding its use for ileocolostomy. After transection, colonic wall smooth muscle spasm leads to reduced lumen diameter which exacerbates difficulty of BAR insertion. Relaxation of colonic smooth muscle and lumen dilation can be used to facilitate BAR insertion,6 by warm saline irrigation, IV glucagon,5,14 topical 1% lidocaine, use of a water soluble sterile lubricant, insertion of ovoid sizing devices,3 manual dilation by forceps,6 and use of a Foley catheter balloon.6 We used the spasmolytic papaverine topically in 3 cats to relax the colonic smooth muscle. The lumen dilated within seconds of topical application. In 2 cats, BAR insertion was uneventful after papaverine use and in 1 cat mild serosal tearing still occurred. Further investigation of the use of papaverine for this purpose is warranted. Postoperative dehiscence occurred in 1 BAR cat less than 36 hours after surgery. At the second surgery, the colon was partially free (one-third to half the circumference) from the distal BAR cap; failure of the pursestring suture was the most likely cause of anastomotic failure. Correct purse string suture placement is important for BAR anastomosis.5 Application of the Furness clamp and pursestring suture before colon transection reduces the risk of colon retraction within the clamp and inadequate pursestring purchase3,6 Failure may also have occurred because of lack of colon compression by the BAR. As noted, we used a 1.5 mm gap BAR; however, in this



746



BIOFRAGMENTABLE ANASTOMOSIS RING IN CATS



young cat the gap may have been too wide to adequately hold the colon wall. It is of interest that this cat only had a partial seromuscular oversew although the location of the oversew relative to the site of dehiscence was not recorded. Short-Term Complications Short-term complications occurred more frequently in the BAR group than the SUT group. These complications were mostly minor (anorexia, anemia) and were successfully managed with medical treatment. These complications in BAR cats may have resulted from inflammatory reaction and necrosis of the inverted colonic wall within the device. Increased body temperature and anorexia occurred postoperatively in 2 normal cats after BAR anastomosis between 7 and 15 days after surgery.6 Hyperthermia resolved with passage of the BAR. We did not observe hyperthermia in any of our BAR cases during hospitalization, but we cannot rule out that hyperthermia did not occur as the cats were at home during the expected BAR fragmentation period. Soft stool consistency is an expected outcome after subtotal colectomy as the terminal ileum adapts to increase water absorption,15–17 so we did not classify soft stool consistency within the first 2 weeks as a short-term complication. Fecal consistency is expected to change to soft-formed stools by 12 weeks postoperatively.9,16,17 Long-Term Complications Recorded long-term complications in both groups were similar to those previously reported. Complications occurred within the first year after surgery and were generally minor in nature. Recurrent constipation has been reported as a frequent (7–45%) long-term complication after sutured subtotal colectomy.9,16 BAR use results in retention of a longer colonic segment than in SUT which might increase the risk of recurrent constipation in cats with idiopathic megacolon. Only 1 BAR cat had recurrent constipation and this was managed with an enema, lactulose, cisapride, and dietary modification. Stricture formation is a reported complication after colonic anastomosis.9 For sutured anastomoses, a single layer, simple interrupted, appositional suture pattern with monofilament absorbable or non-absorbable suture material is recommended for colonic anastomoses because 2-layer, crushing or inverting suture techniques are associated with an increased rate of stricture formation in dogs and cats.18 The BAR might increase risk of stricture formation. It produces an inverting anastomosis with reduction in luminal diameter and also induces an inflammatory reaction at the anastomosis site,6,19 because



the entrapped tissue and pursestring sutures necrose and slough into the lumen, freeing the ring caps for expulsion. However, Huss et al6 reported no difference in granulation tissue, mucosal regeneration, or inflammation at the anastomosis site or distant inflammation between SUT and BAR anastomosis in normal cats. Similarly in comparative experimental studies in pigs and dogs, equivalent histological healing, with alignment of layers occurred by 16 days in most anastomoses performed by suture, staple, or BAR.4 Luminal diameter reduction was greater with BAR or stapled anastomosis than sutured anastomosis in dogs but gradually increased during the first 6 months.19 None of the BAR cats but 1 SUT cat developed stricture at the anastomosis site. Interestingly, this was the only cat that had a simple continuous pattern used for anastomosis. Long-term, persistent soft-stool consistency occurred in 4 SUT cats and none of the BAR cats. Two cats responded to empirical treatment for inflammatory bowel disease, although this diagnosis was not confirmed. One cat was euthanatized at owner request 254 days after surgery because fecal incontinence was associated with the soft stool consistency. The other cat was euthanized 1661 days after surgery with the owner citing chronic soft-stool consistency as the reason for euthanasia. Colon Healing Although not evaluated in this report, it is of interest to consider comparative findings of healing after colon anastomosis with BAR or SUT. Colonic anastomoses have reduced collagen synthesis and greater collagen degradation compared with small intestinal anastomosis because of increased levels of collagenase produced under the influence of tissue inhibitor of metalloproteinases.20–22 Anastomotic strength is reliant on the sutures, staples, or anastomotic devices during early (0–6 days) healing. Experimentally in dogs, bursting/leak pressure for BAR was lower, but not significantly so, than SUT anastomoses at 3 and 4 days and was equivalent to SUT by 7 days.19,23 Bursting pressures were greater for SUT than BAR anastomoses and both approached normal colonic bursting pressure by day 28. Wound breaking strength was significantly lower for BAR anastomosis at 4 and 7 days compared with sutured and stapled anastomosis but equivalent from 14 days onward.19 Study Limitations We acknowledge several limitations to our study. Its retrospective nature over a 14-year period at 2 hospitals with various surgeons introduces many variables and potential biases that cannot be controlled. During that period some improvements in technique, especially with



RYAN ET AL



BAR, occurred. Cases were not randomized to treatment groups, so surgeon bias in case selection is possible. Also owner recollections of postoperative complications, especially short-term complications, can be misleading in assessing complication rates. No radiographs were performed to document rate of degradation of the BAR device or document degree of luminal reduction. In our study power was 40.4 for the complications rates. The power was low most likely because of the low case numbers. Although we analyzed comparative data, small sample sizes limited the power of our tests and therefore the strength of our conclusions. Ideally, a randomized clinical trial with larger population sizes comparing the 2 anastomotic methods should be done in cats affected by FIM. Outcome Overall short- and long-term complication rates, and survival times were not significantly different for BAR and SUT anastomoses. The difference between survival rates for the 2 techniques was only 10% at 4 years, which is likely not biologically significant. However, the shortterm complication rate was higher in the BAR group and was considered biologically important. The difference in long-term complication rates between groups was only 6%. Even if differences were to become statistically significant with more cases, it would likely not be biologically significant. Our results suggest the eventual outcome was similar in both BAR and SUT cats and that BAR offers no distinct advantage over sutured anastomosis. The intraoperative complication rate was higher with the BAR, but most complications were minor. BAR anastomoses are limited to colocolic anastomoses because of device size; a smaller sized BAR is not currently available. Our study did corroborate that regardless of anastomotic technique, outcome after colonic resection is excellent for cats with medically unresponsive idiopathic megacolon. ACKNOWLEDGMENTS The authors wish to acknowledge Dr. Adrienne Gwin, DVM for her assistance with the medical record search and follow-up information obtained for this study.



REFERENCES 1. Bertoy RW: Megacolon in the cat. Vet Clin North Am Small Anim Pract 32:901–915, 2002 2. Washabau RJ, Stalis IH: Alterations in colonic smooth muscle function in cats with idiopathic megacolon. Am J Vet Res 57:580–587, 1996



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3. Kudisch M, Pavletic MM: Subtotal colectomy with surgical stapling instruments via a trans-cecal approach for treatment of acquired megacolon in cats. Vet Surg 22:457–463, 1993 4. Hardy TG Jr., Pace WG, Maney JW, et al: A biofragmentable ring for sutureless bowel anastomosis. An experimental study. Dis Colon Rectum 28:484–490, 1985 5. Hardy TG Jr., Aguilar PS, Stewart WR, et al: Initial clinical experience with a biofragmentable ring for sutureless bowel anastomosis. Dis Colon Rectum 30:55–61, 1987 6. Huss BT, Payne JT, Johnson GC, et al: Comparison of a biofragmentable intestinal anastomosis ring with appositional suturing for subtotal colectomy in normal cats. Vet Surg 23:466–474, 1994 7. Holt D, Johnston D: Idiopathic megacolon in cats. Comp Contin Educ Pract Vet 13:1411–1417, 1991 8. White RN: Surgical management of constipation. J Feline Med Surg 4:129–138, 2002 9. Rosin E, Walshaw R, Mehlhaff C, et al: Subtotal colectomy for treatment of chronic constipation associated with idiopathic megacolon in cats: 38 cases (1979–1985). J Am Vet Med Assoc 193:850–853, 1988 10. Markel MD: The power of a statistical test. What does insignificance mean? Vet Surg 20:209–214, 1991 11. Corman ML, Prager ED, Hardy TG Jr., et al: Comparison of the Valtrac biofragmentable anastomosis ring with conventional suture and stapled anastomosis in colon surgery. Results of a prospective, randomized clinical trial. Dis Colon Rectum 32:183–187, 1989 12. Bubrick MP, Corman ML, Cahill CJ, et al: Prospective, randomized trial of the biofragmentable anastomosis ring. The BAR Investigational Group. Am J Surg 161:136–142, 1991; discussion 142–143 13. US Surgical Instructions for Valtract Biofragmentable Anastomosis Ring, US Surgical, Norwalk, CT, 2000 14. Moseson MD, Hoexter B, Labow SB: Glucagon, a useful adjunct in anastomosis with a stapling device. Dis Colon Rectum 23:25, 1980 15. Gregory CR, Guilford WG, Berry CR, et al: Enteric function in cats after subtotal colectomy for treatment of megacolon. Vet Surg 19:216–220, 1990 16. Sweet DC, Hardie EM, Stone EA: Preservation versus excision of the ileocolic junction during colectomy for megacolon: a study of 22 cats. J Small Anim Pract 35:358–363, 1994 17. Bertoy RW, MacCoy DM, Wheaton LG, et al: Total colectomy with ileorectal anastomosis in the cat. Vet Surg 18:204–210, 1989 18. Holt D, Brockman D: Large intestine, in Slatter DH (ed): Textbook of Small Animal Surgery (ed 3). Philadelphia, PA, Saunders, 2003, pp 665–682 19. Maney JW, Katz AR, Li LK, et al: Biofragmentable bowel anastomosis ring: comparative efficacy studies in dogs. Surgery 103:56–62, 1988 20. van der Stappen JW, Hendriks T, de Boer HH, et al: Collagenolytic activity in experimental intestinal anastomoses. Differences between small and large bowel and evidence for



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the presence of collagenase. Int J Colorectal Dis 7:95–101, 1992 21. Hesp WL, Hendriks T, Schillings PH, et al: Histological features of wound repair: a comparison between experimental ileal and colonic anastomoses. Br J Exp Pathol 66:511–518, 1985



22. Chowcat NL, Savage FJ, Lewin MR, et al: Direct measurement of collagenase in colonic anastomosis. Br J Surg 77:1284–1287, 1990 23. Bundy CA, Jacobs DM, Zera RT, et al: Comparison of bursting pressure of sutured, stapled and BAR anastomoses. Int J Colorectal Dis 8:1–3, 1993



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Original paper



Atresia coli in a foal – case report BERNARD TUREK, GREGORY VERHOEVEN* Department of Clinical Science, Veterinary Faculty, Warsaw Agricultural University, Nowoursynowska Street 166, 02-787 Warsaw *Al Khalediah Equine Hospital, Kingdom of Saudi Arabia



Turek B., Verhoeven G.



Atresia coli in a foal – case report Summary The paper describes a case of atresia coli in a new born foal. Final diagnosis of atresia of the small colon was confirmed during laparoscopy. The blind end of the small colon was distended and had a diameter of approximately 7 cm. Rectum was very short and narrow. Length about 5 cm and diameter about 6-7 mm. Side to side anastomosis between the rectum and colon was performed. Recovery from anesthesia was uneventful. Six hours after the surgery patient was very painful and died 2 hours later. During post mortem examination ruptured of anastomosis site was found. Keywords: horse, foal, atresia coli



New born foals can at rare times suffer from a very uncommon condition known as atresia coli (3). This disease is characterized by an incomplete digestive tract, due to part of the colon being missing (7). The missing part can vary in size from a few centimeters to the complete atresia of the large and or small colon. Other malformations, such as atresia recti and ani, can occur simultaneously with atresia coli (2-4). The condition itself is most probably congenital and some scientist conjecture that a loss of blood supply induces atrophy and even sometimes atresia of the affected digestive tract segments (1, 3, 5, 6). Case history The foal presented to the hospital was 11 hours old. A local veterinery surgeon had sent the patient to the hospital for lack of meconium and signs of colic. The filly arrived in the hospital in poor condition showing light signs of colic and from time to time attempted to lie down. Its rectal temperature was 38.4 Celsius degree and mild abdominal distention was observed. Some blood was found during rectal examination. Hematology revealed; red blood cells – 6.8 103/mm3, white blood cells 13.6 103/mm3, hemoglobin 11.1 g/dl, hematocrit 45%. Blood biochemistry shown elevated levels of total protein: 9 g/dl, and albumin below the normal range: 1.9 g/dl. Provisional diagnosis established an impaction of the meconium. The lack of meconium in the rectum and the presence of blood also suggested atresia recti and atresia coli. Final diagnosis of atresia coli was confirmed during laparoscopy. Initial treatment of the symptoms included fluid therapy (ringer lactate, 40% dextrose, amino acid infusion) and



painkillers (methamizol, butorphanol and detomidine). The treatment also consisted of anti-ulcer drugs such as oprazol, and antacids such as aluminum hydroxide. Due to the lack of positive results of the treatment and the presence of continuous pain it was decided that surgery should be performed. Medline laparoscopy was performed on the foal in dorsal recumbence (fig. 1). The first step was to remove the umbilical remnants (fig. 2). During surgical exploration atresia coli was recognized. The blind end of the small colon was distended and had a diameter of approximately 7 cm (fig. 3). The rectum was very short and narrow, about 5 cm in length and with a diameter of about 6-7 mm (fig. 4). Side to side anastomosis between the rectum and colon was performed (fig. 5) following which the mesentery was sutured (fig. 6). Eventually the foal was replaced to the recovery box (fig. 7). Recovery from anesthesia was uneventful. Flunixine meglumine 1.1 mg/kg was administered to alleviate the pain. Antibiotic therapy consisted of ceftifour sodium 5 mg/kg and gentamycin 6.6 mg/kg. Six hours after surgery the patient was in great pain and died 2 hours later. Post mortem examination revealed the ruptured site of anastomosis.



Discussion Foals affected by atresia coli usually begin to show clinical signs within the first 48 hours of life (2, 3, 5, 7). At the beginning they seem to be generally in good condition but are unable to pass the meconium. Later the foals show signs of abdominal pain and abdominal distension. In general, establishing a diagnosis is difficult and is usually confirmed during exploratory laparoscopy



Medycyna Wet. 2008, 64 (3)



281



Fig. 2. Umbilical remnants



Fig. 1. Foal in dorsal recumbency



Fig. 3. The blind end of the small colon



Fig. 4. Short and narrow rectum



or necropsy (1-4). The most consistent finding during physical examinations is the absence of meconium staining following repeated enemas. Sometimes the blind end of the rectum can be recognized by palpation. Proctoscopy can be a useful procedure in establishing a diagnosis. Radiography can be helpful – particularly with contrast (oral or retrograde barium contrast enema studies, or both). Atresia coli should be differentiated from lethal white syndrome and



Fig. 5. Anasomosis side



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Medycyna Wet. 2008, 64 (3)



the suture failed. As the atresia coli is a congenital condition the most important aspect in preventing it is to avoid using the parents of the affected foal for breeding (5, 6). The mother of the presented foal experienced the same problem with 2 previous foals which died a few days after delivery, but unfortunately necropsy was not performed in their cases. References



Fig. 6. Mesentery suturing



1. Anderson W. I., King J. M., Rothwel J. T.: Segmental atresia of the transverse colon in a foal with concurrent equine herpes virus-1 infection. Cornell Vet. 1987, 77, 119-121. 2. Benamou A., Blikslager A. T., Sellon D.: Intestinal atresia in horses. Compend. Cont. Educ. Pract. Vet. 1995, 17, 1510-1517. 3. Cho D. Y., Taylor H. W.: Blind-end atresia coli in two foals. Cornell Vet. 1986, 76, 11-15. 4. Lopez M. J., Wilson D. G., Nicoll R. G., Cooley A. J.: What is your diagnosis? Atresia of a portion of the large colon. J. Am. Vet. Med. Assoc. 1997, 15, 211. 5. Santschi E. M.: Atresia coli, [in:] Manual of Equine Gastroenterology. Saunders W. B., Sydney, Toronto 2002, 486-488. 6. Santschi E. M.: Atresia recti and ani, [in:] Manual of Equine Gastroenterology. Saunders W. B., Sydney, Toronto 2002, 491-492. 7. Young R. L., Linford R. L., Olander H. J.: Atresia coli in the foal: a review of six cases. Equine Vet. J. 1992, 24, 60-62. Autor’s address: dr Bernard Turek, ul. Jutrzenki 6, Ustanów, 05-540 Zalesie Górne, Poland; e- mail: [email protected]



Fig. 7. Foal after the surgery in the recovery box



meconium impaction, both of which can coexist with atresia coli. The prognosis depends on which segment of the colon is absent but is generally poor because of the absence of a distal colon (2, 5). It is likely that the condition is more complex and probably also involves other neurological dysfunctions. The only successful treatment is surgery and its main goal is to reconstruct the prolongation of the intestine. Literature describes a few cases which were treated surgically but none of the patients survived more than 18 months (2, 3, 5). Surgery is sometimes impossible owing to the location of the problem. Why, in the above described case, did the anastomosis site rupture a few hours post surgery? The simplest explanation can be that difficulties were experienced during suturing due to extensive differences between the diameters of the rectum and colon. Another important factor to be considered is the short length of the fragment of the remaining rectum. These circumstances meant that it was extremely difficult to make an anastomosis between the very narrow and short rectum and the much bigger colon. The large differences between the anastomosised fragments of the intestines created huge pressure during the progression of ingesta and this could be the main reason why



TEKNIK OPERASI COLOTOMY DAN COLECTOMY Kelompok 3: Varhan Dwiyan Indra Ferdy Olga Saputra Maharani Lisna Wulandari Kelas B



1809511044 1809511050 1809511056



Terminologi Colostomy merupakan suatu pembedahan dimana suatu pembukaan dilakukan dari kolon ke luar abdomen Colectomy merupakan tindakan bedah yang dilakukan untuk memotong sebagian kolon (colecomy subtotal). Atau seluruh bagian colon (colectomy total)



Indikasi COLOSTOMY



• Obstruksi • Perforasi pada kolon • Dekompresi usus • Colon berukuran kecil



COLectomy



• Tumor • Kanker colon • Kelainan kongenital • Diveertikulitis • Megacolon • Infeksi atau radang



Anestesi Premedikasi Atropin sulfat 0.025% dosis 0.04 mg/kg BB secara SC



Anestesi Umum Xylazine 2% dan ketamin HCL 10% dosis 10-15 mg/kg BB secara IM



Persiapan alat dan bahan



Preoperasi Sebelum melakukan tindakan operasi terlebih dahulu dilakukan persiapan operasi. Adapun persiapan yang dilakukan adalah:



Persiapan ruang operasi



Persiapan pasien



Persiapan operator



Operasi 1. Teknik Operasi Colotomy a. Untuk mengeluarkan obstruksi atau eterolith Laparotomy di incisi pada ventral midline, dari umbilicus ke caudal diperlukan untuk eksplorasi abdomen, serta mengidentifikasi dan mengeluarkan enterolith. Obstruksi biasanya terjadi di transverse kolon dan kolon kecil, operasi pengeluaran enterolith di bagian proksimal kolon kecil atau transverse kolon harus didahului sebelumnya dengan evakuasi ingesta dari kolon besar melalui enterotomy pada pelvic flexure untuk meminimalisir kontaminasi abdomen.



Selang air hangat kemudian dialirkan melalui rectum dan akan menggerakan enterolith kearah kolon dorsal, enterolith kecil dapat mengalir ke sisi enterotomy kemudian dikeluarkan enterolith yang lebih besar memerlukan enterotomy terpisah pada kolon dorsal kanan untuk pengeluaran enterolith yang mempunyai sisi rata atau bentuk polyhedral biasanya lebih dari satu pemeriksaan adanya enterolith tambahan pada kolon besar dan kecil sebelum menutup abdomen.



Lanjutan … Enterolith pada kolon kecil harus dikeluarkan melalui enterotomy pada bagian kolon yang terkena. Panjang irisan enterotomy pada pelvic flexure dan evakuasi pada kolon besar harus dilakukan sebelum enterotomy pada kolon kecil akan meminimalisir ingesta masuk ke sisi enterotomy segera setelah masa operasi. Enterotomy kemudian ditutup dalam 2 layer menggunakan benang yang dapat diserap dengan jarum taper.



Gambar 1. Large intestinal obstruction



Jahitan pertama dilakukan pada semua lapisan dinding usus dengan pola jahitan sederhana tunggal atau menerus. Jahitan kedua pada sero muskuler dengan pola jahitan lambert atau cushing. Gambar 2. Jahitan kedua pada sero muskuler (colotomy)



b. Untuk Biopsi •



Insisi dilakukan sepanjang tepian antisimetric. Untuk meminimalisir sentuhan pada sample biopsy kolon, jahitan dengan benang 4.0 monofilament dilakukan pada ketebalan penuh disekitar daerah yang perlu di biopsy.



•



Kemudian incisi berbentuk elips di buat disekitar jahitan untuk mengambil sample.



•



Mucosa yang tersisa dari lokasi pengambilan biopsy dapat diangkat dengan menggunakan gunting Metzenbaum yang tajam.



•



Daerah sekitar luka kemudian di bersihkan dan dijahit dengan pola simple continuous atau interrupted menggunakan 3.0 atau 4.0 polydioxanone atau polyglyconate.



•



Bekas luka diperkuat dengan menyatukan omentum dengan serosa menggunakan benang absorbable monofilament 4.0.



2. Teknik Operasi Colectomy • •



Gambar. Proses Colectomy



• • • •



Gambar. Ilustrasi pemotongan dan penjahitan kolon



•



•



Hewan dibaringkan secara lateral recumbency. Siapkan area yang akan dioperasi yaitu daerah datar pada flank sebelah kiri. Buatlah insisi secara dorsoventral sekitar 4cm dari arah lateral muskulus (external abdominal obique, internal abdominal oblique, dan transversus abdominis muscles) dan masuk ke dalam cavum abdomen. Potong bagian kolon yang diinginkan melalui insisi flank secara melingkar (longitudinal). Ada 2 kemungkinan yang dapat dilakukan pada colectomy, yaitu dilakukan penjahitan pada sisa ujung proksimal dan ujung distal usus atau dibuatkan kantong (stoma) sebagai tempat penampungan feses. Jahit secara melingkar permukaan serosa colon hingga ke musculus abdomen menggunakan 3-0 monofilament dengan benang absorbable (polydoxanone, polyglyconate, poliglecaprone 25). Lengkapi dengan stoma dengan cara menjahit semua bagian dari dinding kolon yang terpotong hingga tepi insisi kulit menggunakan 3-0 atau 4-0 monofilamen absorbable. Kemudian melalui ventral midline insisi diakukan colopexy (penyatuan kolon dengan dinding abdomen) dekat dengan stoma untuk mencegah terjadinya hernia. Dilakukan pemasangan colostomy bag untuk pengumpulan feses. Perlu dilakukan penggantian colostomy bag dan kolon diirigasi secara teratur.



Pascaoperasi Secara garis besar, kedua proses pembedahan ini memiliki tindakan post operasi yang hampir sama, yaitu hewan dimonitor perkembangannya tiap 3 jam, pemberian antibiotik spectrum luas sampai 48 jam setelah operasi, Pemberian nonstreoidal anti-inflamasi, emberian cairan intravena (40-60 ml/kg), diberi minum air hangat beberapa jam setelah operasi harus diulang tiap setengah jam (maintenance : 20L/450 kg BB/hari), jangan diberi makan 12-24 jam pasca operasi, pakan dalam jumlah sedikit dapat diberikan sesegera mungkin jika hewan sudah mau makan dengan sendirinya, hewan yang sudah mau makan dapat diberi tambahan suplemen lemak tinggi untuk meningkatkan kalori, dan hewan dapat mulai exercise sedikit demi sedikit 30 hari setelah operasi.



Terima kasih



TEKNIK OPERASI COLOTOMY DAN COLECTOMY Kelompok 3: Varhan Dwiyan Indra Ferdy Olga Saputra Maharani Lisna Wulandari Kelas B



1809511044 1809511050 1809511056



Terminologi Colostomy merupakan suatu pembedahan dimana suatu pembukaan dilakukan dari kolon ke luar abdomen Colectomy merupakan tindakan bedah yang dilakukan untuk memotong sebagian kolon (colecomy subtotal). Atau seluruh bagian colon (colectomy total)



Indikasi COLOSTOMY • Obstruksi • Perforasi pada kolon • Dekompresi usus • Colon berukuran kecil



COLectomy • Tumor • Kanker colon • Kelainan kongenital • Diveertikulitis • Megacolon • Infeksi atau radang



Anestesi Premedikasi Atropin sulfat 0.025% dosis 0.04 mg/kg BB secara SC



Anestesi Umum Xylazine 2% dan ketamin HCL 10% dosis 10-15 mg/kg BB secara IM



Persiapan alat dan bahan



Preoperasi Sebelum melakukan tindakan operasi terlebih dahulu dilakukan persiapan operasi. Adapun persiapan yang dilakukan adalah:



Persiapan ruang operasi



Persiapan pasien



Persiapan operator



Operasi 1. Teknik Operasi Colotomy a. Untuk mengeluarkan obstruksi atau eterolith Laparotomy di incisi pada ventral midline, dari umbilicus ke caudal diperlukan untuk eksplorasi abdomen, serta mengidentifikasi dan mengeluarkan enterolith. Obstruksi biasanya terjadi di transverse kolon dan kolon kecil, operasi pengeluaran enterolith di bagian proksimal kolon kecil atau transverse kolon harus didahului sebelumnya dengan evakuasi ingesta dari kolon besar melalui enterotomy pada pelvic flexure untuk meminimalisir kontaminasi abdomen. Selang air hangat kemudian dialirkan melalui rectum dan akan menggerakan enterolith kearah kolon dorsal, enterolith kecil dapat mengalir ke sisi enterotomy kemudian dikeluarkan enterolith yang lebih besar memerlukan enterotomy terpisah pada kolon dorsal kanan untuk pengeluaran enterolith yang mempunyai sisi rata atau bentuk polyhedral biasanya lebih dari satu pemeriksaan adanya enterolith tambahan pada kolon besar dan kecil sebelum menutup abdomen.



Lanjutan … Enterolith pada kolon kecil harus dikeluarkan melalui enterotomy pada bagian kolon yang terkena. Panjang irisan enterotomy pada pelvic flexure dan evakuasi pada kolon besar harus dilakukan sebelum enterotomy pada kolon kecil akan meminimalisir ingesta masuk ke sisi enterotomy segera setelah masa operasi. Enterotomy kemudian ditutup dalam 2 layer menggunakan benang yang dapat diserap dengan jarum taper.



Gambar 1. Large intestinal obstruction



Jahitan pertama dilakukan pada semua lapisan dinding usus dengan pola jahitan sederhana tunggal atau menerus. Jahitan kedua pada sero muskuler dengan pola jahitan lambert atau cushing. Gambar 2. Jahitan kedua pada sero muskuler (colotomy)



b. Untuk Biopsi •



Insisi dilakukan sepanjang tepian antisimetric. Untuk meminimalisir sentuhan pada sample biopsy kolon, jahitan dengan benang 4.0 monofilament dilakukan pada ketebalan penuh disekitar daerah yang perlu di biopsy.



•



Kemudian incisi berbentuk elips di buat disekitar jahitan untuk mengambil sample.



•



Mucosa yang tersisa dari lokasi pengambilan biopsy dapat diangkat dengan menggunakan gunting Metzenbaum yang tajam.



•



Daerah sekitar luka kemudian di bersihkan dan dijahit dengan pola simple continuous atau interrupted menggunakan 3.0 atau 4.0 polydioxanone atau polyglyconate.



•



Bekas luka diperkuat dengan menyatukan omentum dengan serosa menggunakan benang absorbable monofilament 4.0.



2. Teknik Operasi Colectomy • •



Gambar. Proses Colectomy



• •



• • Gambar. Ilustrasi pemotongan dan penjahitan kolon



• •



Hewan dibaringkan secara lateral recumbency. Siapkan area yang akan dioperasi yaitu daerah datar pada flank sebelah kiri. Buatlah insisi secara dorsoventral sekitar 4cm dari arah lateral muskulus (external abdominal obique, internal abdominal oblique, dan transversus abdominis muscles) dan masuk ke dalam cavum abdomen. Potong bagian kolon yang diinginkan melalui insisi flank secara melingkar (longitudinal). Ada 2 kemungkinan yang dapat dilakukan pada colectomy, yaitu dilakukan penjahitan pada sisa ujung proksimal dan ujung distal usus atau dibuatkan kantong (stoma) sebagai tempat penampungan feses. Jahit secara melingkar permukaan serosa colon hingga ke musculus abdomen menggunakan 3-0 monofilament dengan benang absorbable (polydoxanone, polyglyconate, poliglecaprone 25). Lengkapi dengan stoma dengan cara menjahit semua bagian dari dinding kolon yang terpotong hingga tepi insisi kulit menggunakan 3-0 atau 4-0 monofilamen absorbable. Kemudian melalui ventral midline insisi diakukan colopexy (penyatuan kolon dengan dinding abdomen) dekat dengan stoma untuk mencegah terjadinya hernia. Dilakukan pemasangan colostomy bag untuk pengumpulan feses. Perlu dilakukan penggantian colostomy bag dan kolon diirigasi secara teratur.



Pascaoperasi Secara garis besar, kedua proses pembedahan ini memiliki tindakan post operasi yang hampir sama, yaitu hewan dimonitor perkembangannya tiap 3 jam, pemberian antibiotik spectrum luas sampai 48 jam setelah operasi, Pemberian nonstreoidal anti-inflamasi, emberian cairan intravena (40-60 ml/kg), diberi minum air hangat beberapa jam setelah operasi harus diulang tiap setengah jam (maintenance : 20L/450 kg BB/hari), jangan diberi makan 12-24 jam pasca operasi, pakan dalam jumlah sedikit dapat diberikan sesegera mungkin jika hewan sudah mau makan dengan sendirinya, hewan yang sudah mau makan dapat diberi tambahan suplemen lemak tinggi untuk meningkatkan kalori, dan hewan dapat mulai exercise sedikit demi sedikit 30 hari setelah operasi.



Terima kasih