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Treatment of Equine Gastric Impaction by Gastrotomy R

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Treatment of Equine Gastric Impaction by Gastrotomy R EQUINE VETERINARY EDUCATION / AE / april 2011 169 Case Reporteve_165 169..173 Treatment of equine gastric impaction by gastrotomy R. A. Parker*, E. D. Barr† and P. M. Dixon Dick Vet Equine Hospital, University of Edinburgh, Easter Bush Veterinary Centre, Midlothian; and †Bell Equine Veterinary Clinic, Mereworth, UK. Keywords: horse; colic; gastric impaction; gastrotomy Summary Edinburgh with a deep traumatic shoulder wound of 24 h duration. Examination showed a mildly contaminated, A 6-year-old Warmblood gelding was referred for treatment of 15 cm long wound over the cranial aspect of the left a traumatic shoulder wound and while hospitalised developed scapula that transected the brachiocephalicus muscle a large gastric impaction which was unresponsive to and extended to the jugular groove. The horse was sound medical management. Gastrotomy as a treatment for gastric at the walk and ultrasonography showed no abnormalities impactions is rarely attempted in adult horses due to the of the bicipital bursa. limited surgical access to the stomach. This report describes The wound was debrided and lavaged under standing the successful surgical treatment of the impaction by sedation and partially closed with 2 layers of 3 metric gastrotomy and management of the post operative polyglactin 910 (Vicryl)1 sutures in the musculature and complications encountered. simple interrupted polypropylene (Prolene)1 skin sutures, leaving some ventral wound drainage. Sodium benzyl Introduction penicillin/Crystapen)2 (6 g i.v. q. 8 h), gentamicin (Gentaject)3 (6.6 mg/kg bwt i.v. q. 24 h), flunixin 4 Gastric impactions are rare in horses but, when meglumine (Flunixin) (1.1 mg/kg bwt i.v. q. 12 h) and 5 encountered, may carry a grave prognosis. Medical tetanus antitoxin (7500 iu subcut) were administered and management is the preferred first line therapy and involves the horse admitted for observation. gastric lavage via nasogastric tube (Barclay et al. 1982). Approximately 24 h later, signs of colic were noted This technique may be unsuccessful in more severe cases consisting of the horse spending long periods in lateral prompting the use of surgical methods such as transgastric recumbency and faecal output was reduced. The horse lavage and massage during laparotomy (Honnas and was quiet, alert and responsive with a heart rate of 40 Schumacher 1985). Gastrotomy as a treatment for gastric beats/min, respiratory rate 12 breaths/min and rectal 6 impactions is described in foals (Blikslager and Wilson 2006; temperature 37.8°C. Hyoscine butylbromide (Buscopan) Coleman et al. 2009) and smaller breeds (Clayton-Jones (80 mg i.v.) was administered to aid rectal examination et al. 1972; Owen et al. 1987) while discrete Persimmon which revealed formed faeces in the rectum and marked concretions have also been successfully removed via caudal and ventral displacement of the spleen which lay gastrotomy (Kellam et al. 2000). Removal of large immediately cranial to the pelvic brim. Passage of a impactions is rarely attempted in larger adult horses due to nasogastric tube yielded no reflux and 5 l of electrolytes the limited surgical access to the stomach. This report were administered. Food was withheld and the previously describes the successful surgical treatment of a large described antimicrobial therapy was continued along with gastric impaction in a large breed of horse by gastrotomy flunixin meglumine (1.1 mg/kg bwt i.v. q. 24 h). and the post surgical complications encountered. By the following day there was little change in clinical parameters and gastroscopy identified a large mass of Case report impacted food material in the stomach. Transabdominal ultrasonography revealed the stomach wall to be visible History and case details over a greater number of intercostal spaces than normal and the spleen to be displaced ventrally and caudally. A 6-year-old Warmblood gelding, weighing 552 kg, Using a nonfenestrated nasogastric tube and a stomach presented to the Dick Vet Equine Hospital, University of pump, the stomach was repeatedly lavaged with warm water in an attempt to soften and remove the impacted *Corresponding author email: [email protected] material via the nasogastric tube but little gastric contents © 2011 EVJ Ltd 170 EQUINE VETERINARY EDUCATION / AE / april 2011 were retrieved by this method. The horse was kept on wood shavings (its usual bedding material), allowed ad libitum water and starved in an attempt to allow the impacted material to be passed into the intestines. The horse remained bright throughout a period of complete starvation for 7 days during which time a muzzle was placed as it was noted that the horse was consuming shavings. After 7 days, trickle feeding of haylage (approximately 0.5 kg q. 4 h) was introduced. Mild colic signs persisted, including occasional periods of lateral recumbency and teeth grinding. Intestinal sounds remained normal or mildly reduced in all quadrants. Haematology and clinical chemistry examinations 4 days post admission were within normal limits. Repeated gastroscopy and gastric lavage under mild sedation with romifidine (Sedivet)6 (20 mg i.v.) was performed at 2 day intervals during the 11 day period but retrieved little solid material; 5 l of oral electrolytes were administered after each lavage. Visual inspection by gastroscopy revealed no change in the consistency of the stomach contents Fig 1: Visualisation of the enlarged stomach (black arrow) protruding to the level of the laparotomy incision. The edge of the while daily ultrasonography revealed no obvious change spleen can be seen caudal to the stomach (white arrow). in the size of the impaction. Faecal output was reduced with intermittent scant soft faeces passed. During this period, the shoulder wound initially developed some local emphysema and drainage but then healed well with antimicrobial therapy being discontinued after 7 days. Treatment and outcome Because of the failure of the gastric impaction to respond to medical treatment along with continued signs of abdominal pain, surgical evacuation of the stomach was attempted on Day 13 of hospitalisation. Sodium benzyl penicillin, gentamicin and metronidazole7 (15 mg/kg bwt per os q. 8 h) were administered prior to surgery. Following premedication with romifidine (Sedivet) (0.1 mg/kg bwt i.v.), general anaesthesia was induced with ketamine (Vetalar)8 (2.2 mg/kg bwt i.v.) and diazepam9 (100 mg/kg bwt i.v.) and maintained with inhaled sevofluorane 10 11 (Sevoflo) ; morphine sulphate (120 mg i.v.) was also Fig 2: Four partial thickness Polyglactin stay sutures have been administered as analgesia during surgery. The animal was placed in the greater curvature of the stomach to allow later placed in dorsal recumbency and a midline laparotomy elevation of the gastrotomy wound edges. made originating just caudal to the xiphoid process and extending approximately 30 cm caudally. The enlarged 15 cm linear gastrotomy incision created, exposing the stomach (c. 60 cm diameter) and spleen were gastric contents that consisted of slightly moist wood immediately visualised (Fig 1) and routine exploration of shavings overlying dry masticated forage. Initial attempts the remaining abdominal contents was unremarkable. to manually remove the contents showed them to be Four 4 metric Polyglactin 910 stay sutures with a 2–3 cm loose and they fell apart during removal, causing some bite were placed c. 10 cm apart and also c.10cmon contamination of the immediate surgical area including each side of the proposed gastrotomy incision site on the the loose packing drapes and exposed serosa. greater curvature where the distended stomach was In order to minimise further contamination, 2 closest to the laparotomy incision (Fig 2). The stay sutures overlapping saline soaked drapes were placed 10 cm were placed through the serosa, muscularis and within the gastrotomy site to form a funnel and kept in submucosa of the greater curvature of the stomach to position with simple transfixing sutures through the drapes later allow elevation of the edges of the gastrotomy site and stomach wall. The other ends of these drapes lay and help reduce abdominal contamination. The outside the laparotomy incision on the edge of the surrounding area was packed with sterile drapes and a abdomen. The stomach contents were then manually © 2011 EVJ Ltd EQUINE VETERINARY EDUCATION / AE / april 2011 171 at the hospital post small intestinal enterotomy, followed by the introduction of small soft oat breakfast cereal feeds offered every 4 h for 24 h. Soaked grass nuts were then introduced every 4 h for a further 48 h prior to the introduction of increasing amounts of haylage reaching normal levels at 6 days post operatively. A variety of clinical complications were evident in the immediate and later post operative period. Colic signs were not seen post operatively but at 24 h the horse was quiet and displayed mild bruxism. Three days post operatively, the horse developed pyrexia (39.2°C) and increased digital pulses in all 4 feet and infection was noted at the cranial aspect of the laparotomy incision with serosanguinous discharge and diffuse, painful ventral oedema. Abdominal ultrasonography revealed small pockets of turbid fluid within the abdomen consistent with Fig 3: Impacted ingesta consisting of wood shavings and semi-dry peritonitis; abdominal paracentesis was not performed. forage recovered during gastrotomy. Gut sounds remained good throughout this period and the pyrexia had fully resolved by 8 days with the horse removed in large handfuls
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