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EQUINE VETERINARY EDUCATION


Equine vet. Educ. (2020) 32 (1) 54-56 doi: 10.1111/eve.13115


Correspondence


Letter to the Editor: Response to Dr Blikslager's letter on post- operative reflux


Thank you very much for giving me the opportunity to respond to the letter by A.T. Blikslager (Blikslager 2020) regarding my reviews in Equine Veterinary Education (Freeman 2018a) and in Equine Veterinary Journal (Freeman 2018b). I will limit my responses to small intestinal surgery, presumably the topic of interest. Dr Blikslager is correct that 22% of horses in the study


mentioned (Freeman et al. 2000) were euthanised intra- operatively, but then he incorrectly assumed that these cases reflect an inconsistency or redirection in my stance on pessimism. Many surgeons were involved in the study and few, if any, of these euthanised cases were mine; however, they did represent a pessimistic approach to small intestinal strangulation that has contributed to my current views. I do not subject the owner to intraoperative discussions about prognosis in small intestinal strangulations, except in catastrophes beyond dispute (see below), and believe this approach is not unethical, as implied. I suspect that Dr Blikslager’s realism could vary widely


across the broad spectrum of surgeons and might include pessimism in some cases. The owner of a horse that needs colic surgery knows that the horse has a life-threatening disease and might already be distraught and pessimistic, especially with old horses and even with previous veterinary advice (Ireland et al. 2011). Therefore, I believe that my role is not to promote or sustain this pessimism before or during surgery, but to give the horse every chance I can to save its life. I do not engage in intraoperative discussions with owners of horses with a primary small intestinal strangulation unless for a rare but undisputed catastrophe (e.g. ruptured stomach, uncontrollable haemorrhage from a portal vein). Rarely, an owner might request intraoperative euthanasia over resection and anastomosis during preoperative discussions but that is based on their own experiences or advice from others (Ireland et al. 2011). Dr Blikslager’s approach to “refining the prognosis at the


time of surgery” is likely to lead to an overly pessimistic assessment in my opinion. Many horses with severe ischaemic lesions can have a far more favourable outcome than expected, defying all prognostic indicators derived “in view of all the literature”. “All the literature” does not apply to all hospitals and all surgeons and, more importantly, to every horse. I believe that the owner should be spared a difficult intraoperative decision that lacks satisfactory guidelines and should instead be granted the benefit of a completed surgery. For example, red discoloration of peritoneal fluid is not a grave indicator of prognosis, contrary to what is stated in “the literature” (Van den Boom et al. 2010). It is very common in horses with small intestinal strangulation, most of which survive. Dr Blikslager is correct about numerical errors, but they are


his, not mine. The number of horses with post-operative ileus (POI) in the manuscript I cited (Blikslager et al. 1994) was 21%, as he stated, but that was for both small and large intestinal lesions. I was only interested in small intestinal cases, as stated in figure 2 (Freeman 2018a). According to table 1 in Dr


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Blikslager et al.’s paper (1994), 23 of 49 horses (47%) that had a small intestinal disease developed post-operative reflux (POR/POI), so the percentage I used was correct and in line with others he has published (Morton and Blikslager 2002; Fogle et al. 2008). I can assure Dr Blikslager that the numbers reported in figure 2 (Freeman 2018a) have been carefully checked for accuracy. The comment that I “picked apart the data” to find a


73% rate of POR in the paper by Fogle et al. (2008) implies that this information was not readily apparent. Actually, this percentage is prominently displayed in table 2 (Fogle et al. 2008) and to characterise this group as “only 33 horses” misses the point. These horses constituted a group over a specific time period (2003–2005) that followed the other 170 horses (1994–2002) in chronological order to provide an example of how the prevalence of POR appeared to increase over that interval (figure 2 in Freeman 2018a). This observation supports the objective of my commentary (Freeman 2018a) and contradicts the positive role that Dr Blikslager assigns to pharmacological management of complications (Blikslager 2009). I believe we need to consider the role of many factors in POR and my commentary was intended to address that. Dr Blikslager made an error in his “splitting of


percentages” in my jejunocecostomy paper (Freeman and Schaeffer 2010) that he could have avoided by reading the erratum for that paper (Freeman and Schaeffer 2011a). He interpreted the third row on our table 2 as evidence that 70% of the 10 horses with the stapled anastomosis had POR, whereas horses in that row actually had colic alone, POR alone, or both combined (Freeman and Schaeffer 2011a). In fact, 40% of horses in the stapled group had POR (with or without colic) as clearly stated in the first row of table 2 (Freeman and Schaeffer 2010). As Dr Blikslager correctly noted, but with the wrong numbers, when six horses with POR of 32 total (19%) in the jejunocecostomy study were merged with two other studies, the percentage of horses with POR dropped to 10%, largely because no horse in one of these studies developed POR (Freeman and Schaeffer 2011b). Dr Blikslager’s statement about repeat celiotomy provides


an example of pessimism. Repeat celiotomy is always expensive but so is prolonged medical treatment of POR. Contrary to what he suggests, repeat celiotomy is not “the key approach to POR” for me, but I do see targeted prevention of POR through specific surgical techniques and a reduced emphasis on the role of POI as critical (Freeman 2018a). Repeat celiotomy plays an important role in treating POR because a physical obstruction can contribute more to this complication (Bauck et al. 2017a) than Dr Blikslager recognises. His criticism should be tempered with awareness that repeat celiotomy (one or two) immediately terminated POR in 81% of cases in a recent study (Bauck et al. 2017a), despite the additional inflammation that a second surgery would inflict on the affected intestine. This response, the favourable short-term survival rate, and median survival time


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