SURGERY


these concerns and have revealed improved ap- proaches to management of cases that might require repeat celiotomy.3,16,18 From this review, impor- tant findings have emerged, such as improved guide- lines for selecting repeat celiotomy, discovery of lesions that can be overlooked, effective surgical treatment of intestinal complications that led to re- peat celiotomy, and improved short- and long-term survival rates compared with previous reports. This discussion does not relate to large intestinal surgery, because repeat celiotomy is rarely required for this surgery during the same hospitalization period. Jejunoileostomy is rarely used in the au- thors’ hospital, so there is no data on this procedure, although it is associated with a high rate of repeat celiotomy.6


2. Guidelines for Repeat Celiotomy


Selection criteria for repeat celiotomy have not been well described in the literature and have not been defined relative to segment of intestine and proce- dure performed. Another reason for lack of guide- lines is the failure of most studies to distinguish on clinical or laboratory findings the difference between POR caused by a physical obstruction or POI. Part of the reason for this failure is that there are no distinguishing features and true POI might be less common in horses than most reports would sug- gest.19 The other reason is the tendency to group all intestinal segments together in most large retro- spective studies, including incisional complications with intra-abdominal complications.1 The guidelines used for horses that had surgery


for small intestinal disease were predominantly based on the following: horses with POR, postoper- ative colic (POC), or both that do not improve within the first 48 hours after onset of clinical signs are candidates for repeat celiotomy. This differs from previous reports1–15 that relate time of repeat celiot- omy to the end of the first surgery, not to the onset of clinical signs, which the authors regard as a far more clinically relevant timeline. The definition of POR used in this review was any reflux after sur- gery and the inability to eat small handfuls of hay without reflux.19


3. Client and Referring Veterinarian Discussions


In this hospital, owners and referring veterinarians are informed that repeat celiotomy might be re- quired as soon as complications develop. Although this might seem premature, it is better than surpris- ing them with this option when days of fruitless medical therapy have passed and all financial re- sources have been drained. It also prevents the delay in decision-making that might lead to a poor outcome through adhesions and a decline in the horse’s metabolic status. A successful outcome af- ter repeat celiotomy can allow the horse to start eating, shorten the interval for fluid therapy, and shorten its hospital stay.


402 2018  Vol. 64  AAEP PROCEEDINGS In a recent study,18 repeat celiotomy was per-


formed between 11–120 hours after the first sur- gery, the upper end of the range produced by an owner that requested prolonged medical treatment before repeat celiotomy. This horse was eutha- nized under anesthesia because of extensive adhe- sions, secondary to prolonged obstruction by a shortened mesentery that kinked the anastomosis. The median duration of post-operative reflux (POR), POC, or both in this study was only 16.5 hours before repeat celiotomy.18 In horses with POC, the severity of pain shortened the duration between first and second surgery significantly, evidence that this complication can be severe enough to hasten the decision to do a repeat celiotomy.


4. Intraoperative Findings


In horses that had a small intestinal strangulation treated by resection and jejunojejunostomy at the first surgery,18 findings at second surgery included inadvertent anastomotic rotation by the surgeon, impacted anastomosis, ischemic mucosa at the anas- tomosis (Figs. 1A and 1B), leaking anastomosis, and mechanical kinking of the anastomosis caused by an excessively shortened mesentery (Fig. 2). In horses that had a jejunocecostomy at the first surgery,16 findings at repeat celiotomy included im- pacted anastomosis (Fig. 3), hemorrhage from the ileal stump, continued necrosis of the ileum or adja- cent cecum, small intestinal volvulus at the stoma, right dorsal displacement of the large colon, cecal distention, and serositis with or without fibrinous adhesions attributed to leakage because the anasto- motic staple lines were not oversewn. Lesions at repeat celiotomy apparently not related


to an anastomosis included adhesions, small colon wrapped around the small intestine, jejunal infarct, impacted gastric antrum, small intestinal disten- sion, jejunal stricture, a missed lesion, and small intestinal volvulus. No horse had evidence of dif- fuse peritonitis at the second surgery, although some had serositis and fibrin in the area immedi- ately adjacent to those anastomoses suspected of leaking.


5. Corrective Surgical Procedures


In horses originally treated by jejunojejunostomy in a recent study,18 the majority of them (9/11; 82%) were treated at the repeat celiotomy by revision of the original anastomosis and manual decompres- sion of distended small intestine. For horses with strangulating small intestinal lesions that did not have a resection at the first surgery, 4/8 were treated with resection and anastomosis at repeat celiotomy, with the rest undergoing simple manual decompression.18 In one horse that had two repeat celiotomies, POR ceased after the second one, which involved removal of dehydrated contents from the large colon through an enterotomy and manual de- compression of the small intestine.18


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