Surgical management of colic Flashcards
List the indications for colic surgery
Severe, unrelenting pain
Recurrence of pain despite moderate – potent analgesia
HR >60bpm
Net reflux >2L
Deteriorating CV parameters
Reduced intestinal motility
Increased abdominal distension
Deteriorating peritoneal fluid values
Is a diagnosis needed for colic surgery?
No - evaluation just needs to determine if potential surgical or medical management is appropriate
List the common types colic requiring surgery
- Small intestinal Pedunculated lipoma
- Epiploic foramen entrapment
- Caecum
- Large colon displacement
- Large colon torsion
- Small colon
Describe how to initiate the referral process for colic cases
- Discussion with the owner / carer
- Start organizing transport
- Contact the referral centre
- Make sure owners know where they are going & how to contact the referral centre
- Get the horse to the centre as quickly as possible
- Contact the clinic if any delays / problems
What should be discussed with the owners when surgery for colic is needed
- Discuss your findings and why you feel that surgery may be needed
- Discuss the possible causes of colic and likely costs of surgery
- In insured cases, check that the horse / pony is covered for colic surgery
- Surgery might not be an option but owners should be provided with EVIDENCE-BASED INFORMATION ON WHICH THEY CAN MAKE AN INFORMED DECISION
- If referral is declined at this stage, owners should be aware of the potential consequences
List the various factors involved in an owners decision regarding colic surgery
- Financial (insurance)
- Existing health issues (e.g. laminitis / OA)
- Emotional (dead / ill relative)
- Previous experience (good or bad)
- Advice from friends / peers / you!
What needs to be discussed when contacting the referral contre?
- Most clinics are happy to discuss colic cases and possible causes / prognosis / cost
- Provide a succinct history and details of analgesia, results of repeat examinations etc
- Discuss possible costs / prognoses and any deposit required with the owner first
- Discuss analgesia and other therapies required e.g. passage of a nasogastric tube
- Give an ETA and contact details for the owner / transporter
Describe the steps needed in the initial assessment of surgical colic cases
- Quick and efficient: decision about whether urgent surgical intervention is needed
- may be painful on admission and potentially dangerous to manage
- Need to make sure examination is performed efficiently and properly (so it can be a very busy time for staff and students) and that owners may be very tired / upset at this stage (it can be quite a stressful time for all involved)
- Some cases may be relatively normal on admission and are admitted for medical treatment / further monitoring
Describe initial exploration in colic cases
- Midline abdominal incision in dorsal recumbency
- Essential to do a logical and thorough exploration
- Caecum exteriorized as the starting point
- Tracing of dorsal caecal band to ileum & exteriorization of small intestine, palpation of duodenum & distal ileum
- Exteriorisation of large colon: orientation correct, palpation of RVC and RDC
- Exteriorisation of small colon: palpation of transverse colon and down to rectum
- Palpation of non exteriorisable areas / organs: stomach, diaphragm, nephrosplenic space, spleen, liver, bladder and ovaries / uterus
How can you minimise trauma and inflammation when assessing the small intestine?
Fluids flushed on the intestine during handling, avoid drying out, trauma from swabs
How should you decided wether or not to resect the small intestine
- Key decision as this can have important consequences for the horses short and long-term outcome
- Early surgery helps to avoid the need for resection
- But leaving non-viable intestine in situ will lead to POR and potential need for repeat laparotomy
Name 3 mistakes that can occur during SI resections
Leakage
Mesenteric rent
Lumen too narrow – physical obstruction and POR
Which types of SI resection has been associated with increased risk of post operative colic and relaparotomy?
Jejujuno ileal anastomoses
What should be suspected as the cause in cases of ileal impaction or caecal intususseption?
High tapeworm burdens
How is intussusception treated?
May require resection on the caecum
When is a surgical bypass indicated for caecal impactions?
When there is evidence of poor caecal motility
What are the 4 common sources of primary large colon lesions?
Impactions
Displacements
Torsion
Enteroliths/sand
Lesions most commonly occur in which part of the large colon?
Pelvic flexure
Describe a pelvic flexure enterotomy
- Removal of LC contents assists correction of torsions / displacements and can confirm sand colic
- Want to minimise reduction in the luminal diameter following closure
How can you assess the viability of the large colon?
- Colour
- Thickness of wall
- Motility
- Change in the above following correction of the torsion
How is a large colon torsion treated surgically?
Pexy to the body wall
Resection
Name 4 conditions in the small colon that need to not be missed
- Impaction
- Lipoma
- Volvulus
- Mesocolon tears
Describe abdominal closure following colic surgery
- Various suture materials and methods of closure
- Careful closure of the linea alba essential to minimise the chance of acute abdominal dehiscence
- Debate over need to close subcutaneous layer and some surgeons advocate closure of the peritoneum
How is postoperative pain assessed?
Pain scoring
- Subjective / objective
- Pain face
- Scoring systems
Describe post-op analgesia following colic surgery
- Flunixin meglumine most commonly used
- Other NSAIDs may be used: meloxicam
Describe post-op cardiovascular support following colic surgery
Crystalloids +/- colloids +/- plasma / whole blood
Monitoring
- PCV / TP
- Heart Rate
- Urination
- Electrolytes / acid base status
+/- Lactate
+/- SAA
What is a critical part of post colic surgery care to prevent gastric rupture?
Gastric lavage/decompression
Describe post-op nutrition following treatment for LI displacements
- Offered free choice water within 3 hours
- Offered feed within 3 hours of surgery
- Mostly fed handfuls of forage initially
List some post operative complications following colic surgery
Surgical site infection
Incisional dehiscence
Post-op colic
Post-op reflux
Adhesions
Diarrhoea
SIRS/endotoxaemia
Jugular thrombophlebitis
When would a possible relaparotomy be discussed with the owners?
- Persistent / increasing signs of pain
- Suspicion of abdominal haemorrhage / intestinal leakage
- Persistence of large quantities of reflux not decreasing beyond 48-72h
How can the risk of surgical site infections be reduced?
- Local wound management (e.g. cleansing around the site with hydrogen peroxide 1.5%, topical dressings)
- Good hospital protocols re. environmental sampling & infection control e.g. hand hygiene
What are the aims of the international colic surgery audit
- To document prevalence of different lesions, duration of survival and complication rates
- To improve the quality of care for colic patients: comparison of clinical performance with local, national and international standards = benchmarking
- To provide data about changing trends
- To identify areas of good practice / potential targets for improvement in care = audit cycle
Describe what needs to be discussed with owners at post hospital discharge following colic surgery
- Communication with owner and horse’s usual veterinary surgeon regarding aftercare and likely complications
- Post operative colic
- Incisional healing and timing of suture removal
- Rehabilitation strategy
Describe a suitable rehabilitation strategy following colic surgery
- 6-8 weeks box rest with in-hand walking 2-3 times per day
- 8 weeks turnout in a small yard /paddock
- Normal turnout and gradual return to normal exercise over 6-8 weeks
When would preventative surgical procedures for colic be considered?
In certain types of colic to reduce the likelihood of recurrence and performed as a scheduled preventive surgical procedure
Same some colic types that may indicate preventative surgical treatement
Epiploic foramen entrapment
Left dorsal displacement
Diaphragmatic hernia / mesenteric rent
Recurrent large colon displacements
Describe the long term prognosis following colic surgery
- Survival to hospital discharge for horses recovered from general anaesthesia is around 74-85%
- Highest rate of death in the first week
- Lower but continued rate of mortality from 7-120 days
Name 3 factors that contribute to the likelihood of post-op complications
- Initial lesion
- Surgical procedure performed
- Post-op complications encountered
Describe athletic function following colic surgery
There is no reason why horses cannot return to their previous function provided
Very good – excellent prognosis for return to athletic function
What is the most significant factors in maximising a horses chance of survival following colic surgery?
Early referral of the horse
