A 2-year-old, 2.5-kg neutered male Yorkshire terrier presented to Ohio State University for vomiting, abdominal discomfort, anorexia, lethargy, and abnormal behavior.
History. The dog had previously undergone gastrotomies and a duodenojejunal resection to remove numerous foreign bodies. During the second surgery, an extrahepatic portocaval shunt was also identified and an ameroid constrictor was placed. Two days later, intestinal dehiscence occurred, causing peritonitis. The intestinal site was resected and reanastomosed with a modified simple continuous pattern using 4-0 polypropylene (Prolene, www.ethicon.com). The dog recovered uneventfully and was released 3 days later.
Physical Exam & Diagnostics. The dog's clinical signs developed 6 months after the second surgery and had been present for 2 days prior to presentation. Physical examination revealed pain in the cranioventral abdomen with palpation of a firm object. The complete blood count and serum biochemical profile were unremarkable. Bile acids were close to normal limits.
- What are your initial thoughts on the cause of the abdominal pain?
- What diagnostics should be performed?
- What are other methods of closure for intestinal resection and anastomosis?
- Which techniques cause the least morbidity?
- What type of suture should be used for intestinal surgery?
Foreign body, adhesions surrounding the previous anastomosis site, viral enteritis, dietary indiscretion, and hepatic encephalopathy
Diagnostics. Initial abdominal radiographs were normal. The next day, the dog began to eat and less pain was observed. Radiographs were repeated and revealed 3 circular granular opacities, 1 to 2 cm in diameter (Figure 1), which were believed to be fecal matter in the ascending colon. The dog continued to improve and was released.
Figure 1. Ventrodorsal radiograph of the abdomen. Note 3 circular granular opacities (arrows) identified to the right of midline in the cranial quadrant.
Three days later, the dog returned for vomiting, anorexia, and depression. Cranial abdominal pain was elicited and radiographs revealed granular opacities. A gastrointestinal barium contrast study revealed a partial obstruction in the region of the opacities (Figure 2). The cause of the obstruction was suspected to be a foreign body, a stricture from the previous anastomosis, or an intussusception.
Figure 2. Ventrodorsal radiograph of the abdomen during a barium contrast study revealed a partial obstruction in the descending duodenum/proximal jejunum in the region of these opacities (arrows).
Treatment. Exploratory celiotomy was performed and 2-cm round foreign bodies with slight plication were palpated just distal to the previous anastomosis site. Enterotomy revealed firm, solid fecal balls in the lumen surrounding a blue monofilament suture (Figure 3). The polypropylene suture from the previous resection and anastomosis was anchored in the mesenteric side of the anastomosis,1 and the remainder of the continuous line was free in the lumen of the small intestines. Fecaliths had formed around the suture, causing a functional partial linear obstruction. The suture and fecaliths were removed, and the enterotomy closed with 4-0 polypropylene in a modified simple continuous pattern.
Figure 3. Intraoperative image obtained during surgery showing the fecaliths surrounding the suture line tethered at the mesenteric side of the original continuous suture line.
The dog was released the following day and returned for suture removal 2 weeks later, when he was doing very well. He was lost to further follow-up.
The author thanks Dr. Daniel Smeak, Colorado State University, for helping with the preparation and imaging for this manuscript.
Did You Answer...
• Intussusception, foreign body, adhesions surrounding the previous anastomosis site, viral enteritis, dietary indiscretion, and hepatic encephalopathy are differentials.
• Survey abdominal radiographs and initial fasting are appropriate. If there are no clinical signs, a food trial should be performed. If clinical signs return, consider repeated radiographs, abdominal ultrasonography, or a barium series. Caution: A barium study in a vomiting animal carries risk for aspiration pneumonia. There is also concern in an animal with a potential intestinal perforation; if a perforation is noted, the abdomen is lavaged with copious fluids to dilute the barium.
• Simple appositional interrupted suture is most common. Others include use of skin staples or simple appositional, everting, inverting, or crushing techniques.
• The single-layer, approximating technique produces less luminal narrowing than double-layer closure.1-3 Modified simple continuous pattern minimizes mucosal eversion, provides better serosal apposition and primary intestinal healing, and also induces less adhesion formation than the simple interrupted approximating techniques.The modified simple continuous and simple interrupted technique are both currently considered acceptable.4,5
• I recommend using monofilament absorbable suture for the modified simple continuous pattern. Monofilament suture travels through tissue with less chatter or resistance than multifilament, and the absorbable nature is recommended because it dissolves before creating such problems as occurred in our patient. Multifilament suture can also lead to wicking of intestinal contents. Gut should be avoided at all times.
VOMITING & POSTSURGICAL PAIN IN A DOG • Susanna Hinkle Schwartz
1. Intestines. Ellison GW. In Bojrab MJ (ed): Current Techniques in Small Animal Surgery, 4th ed-Baltimore: Williams & Wilkins, 1998, pp 245-254.
2. End-to-end anastomosis in the dog: A comparison of techniques. Ellison GW. Compend Contin Educ Pract Vet 3:486-495, 1981.
3. End-to-end approximating intestinal anastomosis in the dog: A comparative fluorescein dye, angiographic and histopathologic evaluation. Ellison GW, Jokinen MP, Park RD. JAAHA 18:729-736, 1982.
4. Comparison of a continuous suture pattern with a simple interrupted pattern for enteric closure in dogs and cats: 83 cases (1991-1997).Weisman DL, Smeak DD, Birchard SJ, et al. JAVMA 214:1507-1510, 1999.
5. Prevalence of small intestinal dehiscence and associated clinical factors: A retrospective study of 121 dogs. Allen DA, Smeak SD, Schertel ER. JAAHA 28:70-76, 1992.
A comparison of single layer suture patterns for intestinal anastomosis. Bennett RR. JAVMA 157:2075-2080, 1970.
Evaluation of anastomoses of small intestine in dogs: Crushing versus noncrushing suturing techniques. Bone DL, Duckett KE, Patton CS, et al. Am J Vet Res 44:2043-2048, 1983.
Simple interrupted approximating technique for intestinal anastomosis. DeHoff WD, Nelson W, Lumb WV. JAAHA 9:483-489, 1973.
Single layer everted intestinal anastomosis. Ott BS, Doyle MD, Greenwald KA. JAVMA 153:1742-1753, 1968.
Foreign body attachment to polypropylene suture material extruded into the small intestinal lumen after enteric closure in three dogs. Milovancev M, Weisman DL, Palmisano MP. JAVMA 225:1713-1715, 2004.
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