The Crucial Facts You Must Remember About Intestinal Surgery

If your feline patient is vomiting more than twice a month, keep these 3 articles on intestinal surgery in mind.

When suturing an animal's small intestine, a veterinarian must be sure to carefully appose the various tissue layers.

dr. phil zeltzman

Originally published in the January 2015 issue of Veterinary Practice News

Vomiting Cats

Most cat owners and many colleagues probably consider regular vomiting to be normal in a cat. Yet cats vomiting more than twice a month should be worked up rather than treated with benign neglect.

Statistically, about half have inflammatory bowel disease (IBD) and about half have intestinal cancer. Such is the revolutionary conclusion of a recent study by Dr. Gary Norsworthy, et al., at the Alamo Feline Health Center in San Antonio.1 Dr. Norsworthy reported his study in the January 2014 issue of Veterinary Practice News.

An ultrasound was performed on 74 cats that presented for vomiting, diarrhea or weight loss. Also included in the study were 26 cats that went to the hospital for a yearly exam. Those 26 cats were all considered healthy by their owners in spite of ongoing vomiting or diarrhea. Weight loss was the most common sign, present in 70 percent of the cats, sometimes without vomiting or diarrhea.

In all 100 cats, ultrasounds revealed that the small intestine was thicker than normal. All cats had full-thickness surgical biopsies. Endoscopic biopsies provide partial thickness biopsies, which may not reveal the disease’s extent. In other words, one may miss the diagnosis with endoscopic biopsies because they involve only the mucosal layer. Additionally, access to most of the small intestine is not possible because of the limited length of endoscopes.

Surgical biopsies (i.e. performed via celiotomy), however, offer several benefits: harvesting full-thickness biopsies of all levels of the small intestine; performing a thorough laparotomy; taking biopsies of enlarged lymph nodes; removing segmental intestinal disease.

Pathology results were as follows in Norsworthy’s 100 cats:

  • One cat had no significant findings.
  • 49 cats had chronic enteritis. Those cats were 1 to 16 years old, with a mean age of 10.
  • 46 cats had lymphoma. These cats were 1 to 18 years old, with a mean age of 12. n Four had other types of intestinal cancer: three mast cell tumors and one adenocarcinoma.

Even though the age ranges look similar, a statistical difference existed between the two groups. Cats with chronic enteritis tended to be younger—under 8 years old—and cats over 8 tended to have either enteritis or intestinal cancer.

Conclusions from the study:

  • Weight loss was the most common sign, sometimes without vomiting or diarrhea. About 70 percent of cats presented with weight loss. Conclusion: Weigh cats at every visit.
  • Any cat presented with vomiting, diarrhea or weight loss should ideally have an abdominal ultrasound to measure the thickness of the intestine. If measurements reveal increased thickness, then surgical biopsies are indicated.
  • The most important conclusion: Vomiting more than twice a month is not normal in cats.

dr. phil zeltzman

Normal and thickened jejunum section in a 10-year-old cat with lymphoma.

 

dr. phil zeltzman

When suturing an animal's small intestine, a veterinarian must be sure to carefully appose the various tissue layers.

Save the Mucosa

After resection and anastomosis of the small intestine, it is important to carefully appose the various tissue layers, from the serosa to the mucosa. This ensures primary healing, a quicker return of tensile strength and fewer complications, such as leakage and adhesions.

Meanwhile, the mucosa has a sneaky tendency to evert during suturing. This eversion is due to contraction of the smooth muscle layer. Trimming the stubborn mucosa with scissors may not be ideal, because the mucosa, which after all is there for a reason, acts as a seal, which decreases leakage.

Techniques that help reposition the mucosa in the intestinal lumen include using:2

  • Dedicated forceps or sterile cotton swabs to push the mucosa.
  • The Gambee suture pattern, which was created to avoid mucosal eversion.
  • A simple continuous, rather than a simple interrupted, pattern.

Prefer a Continuous

The authors of a now-classic study3 showed that a simple continuous suture pattern helps decrease mucosal eversion and provides more accurate apposition of the tissue layers when suturing the small intestine after resection and anastomosis (R&A). Additional benefits include a quicker closure, shorter anesthesia time and significantly less foreign material (i.e. sutures) left in the patient. To avoid a purse-string effect if the suture is too tight, two sutures are used rather than one.

One knot is preplaced at the mesenteric border and one at the anti-mesenteric border (see box for a light modification). A 3- to 4-cm-long strand of suture material (polydioxanone) is tagged with a hemostat and used as a stay suture. The continuous suture is started on the mesenteric side, along one side of the intestine, up to the knot on the anti-mesenteric side. The intestine is flipped over.

The second continuous suture is now placed on the opposite side of the intestine, down to the mesenteric side. Tissue bites are full thickness. They are placed about 3 mm apart and 3 mm from the edge of the intestine. Each suture line is then tied to the short stay sutures.

This concept was put to the test on R&A patients, which were followed on average over two years. The results were considered excellent.

Modifying the Suture

I slightly modified the simple continuous suture. Because the mesenteric aspect of the small intestine is the hardest to suture, and because it is therefore the most likely to dehisce, I prefer the following steps:

  • I preplace the two sutures on the mesenteric side of the intestine.
  • I tie each knot, leaving 3- to 4-cm-long stay sutures as described in the article.
  • I place one simple continuous on one side, up to the anti-mesenteric aspect of the intestine.
  • I do the same on the other side.

These minor modifications allow a more secure placement of the initial knots on the mesenteric aspect on the intestine.

References

  1. GD Norsworthy, et al. “Diagnosis of chronic small bowel disease in cats: 100 cases (2008-2012).” JAVMA 2013, Vol 243, N 10, p. 1455-1461.
  2. M. Agrodnia, et al. “Use of atropine to reduce mucosal eversion during intestinal resection and anastomosis in the dog.” Vet Surg. 2003, Vol 32, N 4, p. 365-370.
  3. DL Weisman, et al. “Comparison of a continuous suture pattern with a simple interrupted pattern for enteric closure in dogs and cats: 83 cases (1991-1997).” JAVMA 1999, Vol 214, N 10, 1507-10.
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