The Case: Tied Up in Ribbons

Presentation

• 2-year-old spayed female, domestic shorthair cat presented for ribbon extending from mouth discovered 3 days earlier. The owner had cut ribbon short after unsuccessful attempts to remove it. It was not observed to have passed in the feces. Lethargic/inappetent; had coughed, gagged, and vomited once, a day earlier. No feces noted.

• No other significant medical history. Current core vaccinations (FVRCP/rabies). No heartworm preventive or flea/tick products used at home.

Physical Examination

• Recumbent/obtunded/estimated 7% to 8% dehydration

• Body temperature: 97.5⁰ F; pulse: 150 bpm; respiration: 48 bpm; body weight: 3.2 kg

Diagnostics

• CBC: ↑ band neutrophils (0.933 × 103/mcL)

• Serum biochemical analysis - Glucose: 430 mg/dL (range, 71–165) - Total bilirubin: 1.1 mg/dL (range, 0.0–0.3) - BUN: 83 mg/dL (range, 18–32) - Potassium: 6.5 mEq (range, 3.2–4.5) - Sodium: 139 mg/dL (range, 149–155) - Phosphorus: 13.1 mg/dL (range, 2.4–5.9) - Creatinine: 7.9 mg/dL (range, 1.0–1.80) - Chloride: 85 mEq (range, 116–123) - Calcium: 7.8 (range, 8.8–11.0) - Anion gap: 45.5 mEq (range, 15–24.6)

• Radiography/US - Obstructive linear foreign body from stomach into jejunum. Several jejunal loops containing obstructive linear foreign material. No evidence of perforation.     

TreatmentSurgery 1

• Exploratory celiotomy/gastrotomy/mid-jejunal enterotomy to remove ribbon. Gastrotomy/enterotomy closed and tested for leaks. Despite several darkened areas of mucosa, bowel was not resected due to patient instability under anesthesia. Postsurgical pulses throughout cranial GI tract stronger/more regular. Abdomen closed routinely.

• Anesthesia - Premedication: oxymorphone (0.03 mg/kg IV) - Induction/maintenance: ketamine (5 mg/kg)/ valium (0.20 mg/kg)/propofol to effect (5 mg), all IV, plus isoflurane inhalant

• Intraoperative treatment - Cefazolin (20 mg/kg) - Hetastarch (6.5 mL) - 0.9% NaCl (32 mL/hr) - Reflux occurred shortly after induction, suction performed - Dopamine (5 mcg/kg/hr) started 30 min after induction; dobutamine (5 mcg/kg/hr) started 60 min after induction; 0.9% NaCl bolus (64 mL/hr for 20 min)––all to address hypotension

• Postoperative treatment/instructions - Buprenorphine (0.02 mg/kg IV) - Meloxicam (0.34 mg SC once, 0.08 mg Q 24 H × 3 days) - Monitor incision for swelling/discharge/heat - Warm-pack incision Q 12–24 H, if tolerated - Return for suture removal/recheck in 7–10 days

Presentation 2

• Patient presented 8 days postop for urgent care (incisional swelling for 1 day and lethargy/ moderate inappetence for 2 days). E-collar had not been maintained at home; owner did not note licking at incision.

Physical Examination

• Quiet, alert, pale mucous membranes, thin body condition (3.03 kg)

• Estimated 5% dehydration

• Body temperature: 103.7⁰ F

• Pulse: 216 bpm

• Respiration: 60 bpm

• ~ 2 × 10 cm soft, fluctuant swelling beneath surgical incision, bi-lobed in distinct cranial and caudal regions. Clean uninflamed incision; no discharge; sutures intact

Diagnostics

• FNA of swelling: purulent discharge; cytology: numerous rods/degenerate neutrophils

• CBC- WBC: 18.060 × 103/mcL- Band neutrophils: 2.167 × 103/mcL- Basophils: 0.542 × 103/mcL

• Serum biochemical analysis- Glucose: 189 mg/dL (range, 71–65)- Albumin: 2.6 (range, 3.0–4.0)- Total bilirubin: 0.5 mg/dL (range, 0.0–0.3)- Sodium:145 mg/dL (range, 149–155)- Potassium: 4.7 mEq (range, 3.2–4.5)- Chloride: 115 mEq (range, 116–123)

• Radiography/ultrasound- Incisional cellulitis/suspected superficial abscess with focal gas. Hypomotile bowel/peritoneal inflammation consistent with peritonitis without evidence of dehiscence. Free peritoneal gas likely secondary to surgery

TreatmentSurgery 2

Upon removal of sutures, purulent material seeped from incision. Skin incision was opened; large quantity of purulent material removed by suction. Site lavaged thoroughly with warm sterile saline; necrotic material debrided. Communication with abdominal cavity found at abscess/multiple other sites. Further lavage; area packed with 4 × 4” gauze/sponges. Length of abdominal wall closure opened; wall was thickened/fibrous. Abdominal cavity lavaged with copious warm sterile saline. Previous enterotomy site examined, tested for leakage, determined to be intact. Length of intestinal tract explored; no sites of perforation. Abdomen closed with monofilament, antibiotic-impregnated suture. Surgical site was bandaged before recovery from anesthesia.

Postoperative treatment/instructions

• Meloxicam (0.34 mg, 0.23 mL) PO Q 24 H × 3 days

• Amoxicillin/sulbactam 100 mg IV Q 8 H × 3 days

• Removed bandage 24 hr postop

• Cold-packing of incision Q 12 H × 2 days

• Amoxicillin/clavulanic acid 62.5 mg PO Q 12 H × 10 days following IV antibiotics

• Monitor incision for dehiscence/further swelling

Outcome

• Culture/sensitivity of purulent material: β-hemolytic E coli sensitive to most antibiotics (resistant to clindamycin, erythromycin, oxacillin, penicillin)

• Incision healed; no further surgical complications

The Specialist's OpinionLinear foreign bodies are one of the most common causes of intestinal obstruction in cats. Conservative management may be successful if the foreign body does not become fixed at some point and peristalsis can propel it through the intestine. Patients should be closely monitored for signs of obstruction until the foreign body has been passed in the feces.

This cat presented in a very debilitated state with an obstructive GI problem. Obstructive diseases often result in overgrowth of the intestinal flora and may significantly alter the types of bacteria normally seen. Although cefazolin is commonly used in GI surgery, given the obstructive pattern and the condition of the patient, the use of an antibiotic or antibiotic combination with broader spectrum of activity (ie, covering all 4 quadrants) may have been more appropriate. A single agent such as cefoxitin that provides such added coverage might have been a better choice in this case.

Discoloration of the intestinal wall and mucosal ulceration is common with both linear and nonlinear foreign bodies. As long as the segment is determined to be viable and no perforations are found, resection is generally unnecessary. Such areas of mucosal ulceration can predispose to bacterial translocation so this patient could be at increased risk for peritonitis despite the fact that there was no evidence of perforation and the surgical sites were tested for leaks after closure.

Techniques for LavageIsolating the affected areas during surgery is important in minimizing contamination. Ideally, local lavage of the gastrotomy and enterotomy incisions would be performed so that the lavage fluid is immediately aspirated and not spread throughout the wound. If the infection originated in the subcutaneous tissues in this case, then contamination likely occurred during the procedure and was not removed by adequate lavage intraoperatively.

Early surgical intervention decreases morbidity and mortality in cases of peritonitis. Complete exploration of the abdomen was warranted given the results of the diagnostic workup. Since no evidence of perforation/dehiscence was found, closure of the abdomen following copious lavage seems to be the most appropriate course of action. On the other hand, an argument could be made for leaving the subcutaneous tissue open for reassessment and additional wound lavage, especially if culture and sensitivity results were not immediately available.

Eric R. Pope, DVM, MS, DACVS, is professor of Small Animal Surgery and section head of Small Animal Clinical Sciences at Ross University School of Veterinary Medicine. A general surgeon, Dr. Pope focuses his research interest on wound management and reconstructive surgery, surgical oncology, and minimally invasive techniques for thoracic and abdominal surgery. He has authored or coauthored 50 publications in referred journals and numerous book chapters, serves on the editorial review board of several journals, and speaks widely at international and national meetings. Having earned his DVM from Auburn University, Dr. Pope joined a small animal practice in Jacksonville, Florida; then returned to Auburn University to complete a surgery residency and Master of Science degree program. He served on the faculty of the University of Tennessee and University of Missouri before joining the staff at Ross University in 2007.

The Generalist's OpinionThis cat’s disease state was quickly identified and appropriate surgical treatment instituted. When complications ensued, the problem was again appropriately identified and treated. Some steps that could have been taken to lessen potential complications were additional surgical safeguards against infection and a more careful approach to NSAID use.

Linear Foreign BodiesThe presence of a linear foreign body in itself increases the risk for infection. Linear objects lodged in the intestinal tract are different from other obstructive objects, as they can “saw” through the inner mucosal layer in areas other than those accessed surgically, which can be difficult to detect. Intestinal viability was appropriately assessed in this case as evidenced by the findings of the second surgery. Even if the intestine had not been completely compromised, it is conceivable that sufficient damage to the mucosa had occurred to cause bacterial leakage across the gut wall. In addition, multiple incisions into the gastrointestinal tract compound the risk for bacterial contamination.

Antibiotics in SurgeryA good safeguard against potential surgical contamination is to administer a dose of antibiotics either preoperatively or intraoperatively, a step that was taken here. There is a clear benefit to perioperative use of antibiotics but postsurgical use of antibiotics is controversial. This is true both in human and veterinary medicine as various studies have produced conflicting results. Different factors that account for the risk for postsurgical infection include age, preexisting illness, degree of wound contamination, duration of anesthesia, hypothermia, preanesthetic surgical site preparation, surgical suite air quality, number of people in the surgical suite, and surgical skill. All these factors should be considered when deciding whether a more aggressive use of antibiotics is indicated. Given the fact that this was a linear foreign body and the fact that reflux occurred during the procedure, postsurgical antibiotics would have been a reasonable consideration. Lavage of the abdomen after any gastrointestinal procedure is an additional safeguard that can be taken to lessen the chance of a postoperative infection and would also have been of benefit in this case.

NSAIDs in CatsThe cat was presented with elevated renal values, and it is not evident that aggressive measures were taken to correct these. Meloxicam was prescribed for postoperative pain, which did not result in any problems in this case. Even if renal values had resolved at the point of discharge, however, meloxicam was not the best choice as it has been associated with a risk for renal toxicity in cats. Although meloxicam is still approved in Europe for oral use, there is a black box warning on the packaging in the United States barring oral administration to cats. It is recommended to avoid this drug in cats beyond a single subcutaneous injection.

Barak Benaryeh, DVM, DABVP, is the owner of Spicewood Springs Animal Hospital. He graduated from University of California–Davis School of Veterinary Medicine in 1997 and completed an internship in Small Animal Medicine, Surgery, and Emergency at University of Pennsylvania. Dr. Benaryeh has also taught practical coursework to first-year veterinary students and was a primary veterinary surgeon for the Helping Hands Program, which trains assistance monkeys for quadriplegic people. Dr. Benaryeh is certified by the American Board of Veterinary Practitioners in Canine and Feline Practice.