Comparison of complications and long-term survival rates following hand-sewn versus stapled side-to-side jejunocecostomy in horses with colic

David E. Freeman Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana, IL 61802.

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 MVB, PhD, DACVS
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David J. Schaeffer Department of Biosciences, College of Veterinary Medicine, University of Illinois, Urbana, IL 61802.

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Abstract

Objective—To evaluate survival rate and complications after jejunocecostomy in horses with colic and to compare outcomes after hand-sewn versus stapled side-to-side jejunocecostomy.

Design—Retrospective cohort study. Animals—32 horses.

Procedures—Information was retrieved from medical records and through telephone calls on horses that had a hand-sewn or stapled side-to-side jejunocecostomy for treatment of colic, which was performed by or under the supervision of the same surgeon. KaplanMeier life table analysis was used to compare survival times and rates between horses that underwent a hand-sewn or stapled side-to-side anastomosis.

Results—32 horses met inclusion criteria; 22 underwent a hand-sewn anastomosis, and 10 underwent a stapled anastomosis. Horses in the stapled group had a significantly greater prevalence of postoperative colic and combined postoperative colic and reflux than horses in the hand-sewn group. In the hand-sewn group, repeated celiotomy was performed within the same hospitalization period for 3 of 22 horses; in the stapled group, 4 of 10 horses had repeated celiotomies. Hospital discharge rates (ie, short-term survival rates) were similar between horses in the hand-sewn group (20/22 horses) and those in the stapled group (9/10 horses). Long-term survival rates were similar for both groups, ranging from 5 to 126 months. Conclusions and Clinical Relevance—Short- and long-term results justify use of jejunocecostomy in horses. Despite similar survival rates between groups, horses that underwent a stapled anastomosis had significantly greater prevalences of postoperative complications than horses that underwent a hand-sewn anastomosis, suggesting that horses were sensitive to minor differences in anastomosis techniques.

Abstract

Objective—To evaluate survival rate and complications after jejunocecostomy in horses with colic and to compare outcomes after hand-sewn versus stapled side-to-side jejunocecostomy.

Design—Retrospective cohort study. Animals—32 horses.

Procedures—Information was retrieved from medical records and through telephone calls on horses that had a hand-sewn or stapled side-to-side jejunocecostomy for treatment of colic, which was performed by or under the supervision of the same surgeon. KaplanMeier life table analysis was used to compare survival times and rates between horses that underwent a hand-sewn or stapled side-to-side anastomosis.

Results—32 horses met inclusion criteria; 22 underwent a hand-sewn anastomosis, and 10 underwent a stapled anastomosis. Horses in the stapled group had a significantly greater prevalence of postoperative colic and combined postoperative colic and reflux than horses in the hand-sewn group. In the hand-sewn group, repeated celiotomy was performed within the same hospitalization period for 3 of 22 horses; in the stapled group, 4 of 10 horses had repeated celiotomies. Hospital discharge rates (ie, short-term survival rates) were similar between horses in the hand-sewn group (20/22 horses) and those in the stapled group (9/10 horses). Long-term survival rates were similar for both groups, ranging from 5 to 126 months. Conclusions and Clinical Relevance—Short- and long-term results justify use of jejunocecostomy in horses. Despite similar survival rates between groups, horses that underwent a stapled anastomosis had significantly greater prevalences of postoperative complications than horses that underwent a hand-sewn anastomosis, suggesting that horses were sensitive to minor differences in anastomosis techniques.

Jejunocecostomy is frequently indicated in surgical treatment of horses with small intestinal obstruction,1 but this surgery tends to be associated with a poor prognosis, compared with that of jejunojejunostomy,2–4 and with a greater likelihood of postoperative colic and repeat celiotomy.a In 1 study,2 20% of horses that had a jejunocecostomy had postoperative ileus, whereas no horse developed this complication after a jejunojejunostomy.2 Long-term survival rate for horses that had a side-to-side jejunocecostomy in 1 study3 was poorer than for a group of horses that had an end-to-end jejunojejunostomy. In 3 studies2,4,5 published in 2000 and 2002, survival rate until hospital discharge for horses that had jejunocecostomy was 71% to 76%, which was 11% to 15% lower than for horses that had a jejunojejunostomy. These results indicate a lack of improvement in success rates after this surgery since 1971, when the first report6 on this procedure in the American literature described a 67% survival rate at 1 year after surgery. Because of these problems with jejunocecostomy, some surgeons avoid jejunocecostomy when possible, with preference for a jejunoileostomy instead.7

Problems associated with jejunocecostomy have been explained by loss of a valve between small intestine and cecum, which could combine with cecal hydrostatic pressure and contractions to force cecal contents into the jejunum.8,9 Such reflux could act as a functional obstruction to small intestinal emptying. After jejunocecostomy, all remaining small intestine is subjected to preoperative distention, which could delay return of function10 and impair ability to overcome reflux of cecal contents. Although horses that need a jejunocecostomy might have a more severe primary intestinal lesion than horses that require other types of anastomoses, this was not confirmed by the results of 1 study.2 Other complicating factors for jejunocecostomy are remaining devitalized ileal stump and mesentery1 and postoperative obstruction by stomal edema.11 Some surgeons believe that the latter problem can be avoided in a side-to-side jejunocecostomy by creating a larger stoma than is possible with the end-to-side technique.11,12 When both techniques were compared in clinically affected horses, 83% of horses with a side-to-side jejunocecostomy were discharged from the hospital, compared with 37% that had an end-to-side jejunocecostomy.12 The latter technique also necessitated more repeat celiotomies to correct kinking of the intestine atthe anastomosis, adhesions, impaction, intussusception of the anastomosis, and volvulus.12

Findings in a recent study3 indicate that hand-sewn and stapled side-to-side jejunocecostomy have similar results over the long term and that surgeons were justified in using personal preference for selecting the type of anastomosis technique for jejunocecostomy.3 However, the possibility that postoperative complications might be different between the 2 methods was not examined in that study.3 Despite the pessimism concerning the use of jejunocecostomy, our personal experiences with this procedure suggest that such a reputation might not be warranted. Therefore, the purpose of the study reported here was to examine the outcome after side-to-side jejunocecostomy in horses clinically affected with colic and to compare hand-sewn versus stapled anastomosis methods on complications and survival rate. A critical element in the design of this study was to standardize the techniques as much as possible and to examine the effects over a longer follow-up period than described previously.

Materials and Methods

Case selection—Medical records of horses that recovered from anesthesia and surgery2,13 for small intestinal lesions at the University of Illinois and the University of Florida from June 1994 to February 2005 were reviewed. Data from the medical records of horses were included in this study if the following criteria were met: surgery was performed by or under the supervision of the first author (DEF) and involved a hand-sewn or stapled side-to-side jejunocecostomy, and jejunocecostomy was the first procedure performed during the period of hospitalization.

Procedures—In addition to information from the medical records, specific surgical data from all horses with small intestinal lesions were collected to generate a data set for surgical treatment of these diseases. These data included lengths of intestine resected and a viability index, which is the product of intestinal length (in meters) and a viability grade from I to V (ie, grades I to III for viable intestine and grades IV and V for nonviable intestine), as described previously.14

Short-term survival was defined by discharge of a horse from the hospital alive, and data on long-term outcome and complications were obtained at various intervals by telephone follow-up with owners. Information on severity and prevalence of colic after hospital discharge was sought specifically in all phone conversations with owners. The end date for long-term data collection was May 2009.

Surgery—After the strangulation was corrected, the strangulated mesentery was resected and gathered, as described previously.8 After this step, the entire small intestine was completely decompressed of fluid and gas through a transverse enterotomy in the strangulated intestine, after it had been mobilized far from the surgical field.8 Nonviable small intestine was resected as described.8 The transected ileum was closed with a Parker-Kerr technique oversewn with a Cushing pattern, leaving as short a segment of ileal stump as possible.8 As much cecum was exteriorized as possible, and a longitudinally oriented pouch of cecal wall midway between the dorsal and medial cecal bands was elevated with Babcock forceps. This portion of cecal wall was as close to the cecal base as possible, proximal to the attachment of the cecocolic fold.

For the hand-sewn technique, the distal end of the healthy jejunum was transected and closed with a Parker-Kerr technique oversewn with a Cushing pattern with 2-0 polydioxanone. Then, interrupted sutures of 3-0 polydioxanone were used to attach each end of a 9- to 10-cm segment of the distal portion of the jejunum in side-to-side fashion to the pouch of cecum, with the oversewn end of the jejunum directed toward the cecal base. A continuous Cushing pattern with 3-0 or 2-0 polydioxanone was placed on the far side (furthest from the surgeon) of the proposed line for the stoma for approximately 9 to 10 cm and tied at each end. The jejunum and cecum were each incised about 5 mm parallel to that suture line to create a stoma in each segment that ended on the jejunum close to the oversewn end. A full-thickness simple continuous pattern apposed the far edges of the cecum and jejunum inside the row of the Cushing pattern. To complete the near side of this suture line (closest to the surgeon), a continuous Lembert pattern was used with minimal inversion. This layer was then oversewn with a continuous Cushing pattern to complete the anastomosis, with a stoma of approximately 7 to 8 cm. All suture lines were interrupted at the proximal and distal ends of the stoma. The free edge of mesentery was sewn to the cecum, then to the ileocecal fold, ending at the oversewn end of the ileum and the previously gathered mesentery.

For the stapled anastomosis, the same steps were completed as already described, except that the transected end of the jejunum was not oversewn before it was attached in side-to-side fashion to the cecal wall with stay sutures. A longitudinal 2-cm-long stab incision was made in the cecal wall immediately proximal to the end of the jejunum, and a staplerb was inserted through this stab incision and the open end of the jejunum to create a stapled anastomosis (Figure 1). The open end of the jejunum was closed with 3-0 polydioxanone in a Cushing pattern that started at the mesenteric attachment until the remaining opening was the same size as the stab incision in the cecum (Figure 2). One edge of the jejunal opening was sutured to 1 edge of the stab incision in the cecum with a simple continuous pattern. This was repeated on the other side, thereby creating an end-to-side anastomosis between the antimesenteric half of the jejunum and the stab incision in the cecum. These suture lines created a Y-shaped closure, with the divergent ends of the Y attaching the cecum to the jejunum (Figure 3). These suture lines were then oversewn with a Cushing pattern, and the final stoma length was approximately 11 cm. The staple lines were not oversewn, but interrupted Lembert sutures of 3-0 polydioxanone were placed at 3, 6, and 9 o'clock positions around the staple line. Mesenteric closure was completed as for the hand-sewn technique.

Perioperative care—Intraoperative abdominal lavage, intra-abdominal administration of carboxymethylcellulose, postoperative prophylactic administration of lidocaine, and prophylactic prokinetic drugs were not given to any horse, and no other techniques were used that have been described specifically for prevention of abdominal adhesions and reperfusion injury. Routine postoperative treatment included IV administration of balanced polyionic fluids at 50 to 100 mL/kg (23 to 45 mL/lb) daily for 24 hours or longer, depending on findings on laboratory and clinical assessments. Shortly before surgery and for 3 days after surgery, all horses received penicillin G potassium (22,000 U/kg [10,000 U/lb], IY q 6 h), gentamicin (6.6 mg/kg [3 mg/lb], IV, q 24 h), and flunixin meglumine (1.1 mg/kg [0.5 mg/lb], IY q 12 h) and were monitored postoperatively as described.2 Horses were fed small amounts of hay starting at 18 to 24 hours after surgery, and this was gradually increased over the next 48 to 72 hours.2

Figure 1—
Figure 1—

Diagram of the method of stapled side-to-side jejunocecostomy used in this study. The stapling instrument is inserted maximally (shaded) through the open end of the jejunum (a) and a separate stab incision in the cecum (b), proximal to the open end of the jejunum. The perspective is from the horse's left side, with the head to the right and the cecum reflected caudally. The jejunum is occluded with a Penrose drain and attached to the cecum with stay sutures (one placed at the open end and the other placed further proximally). Saline (0.9% NaCl) solution-soaked laparotomy sponges to isolate the anastomosis have been omitted for clarity. c = Ileocecal fold. d = Cecocolic fold.

Citation: Journal of the American Veterinary Medical Association 237, 9; 10.2460/javma.237.9.1060

Figure 2—
Figure 2—

Diagram of a close-up view of the stapled anastomosis used in this study. The open end of the jejunum has been closed by suture from the mesenteric side to point “a” so the remaining opening in the jejunum is the same size as the stab incision in the cecum. The side of the cecal incision (b) is sutured to the corresponding side of the jejunum (b'), and the opposite sides of the cecum and jejunum are apposed in a separate suture line. c = Stapled portion of the stoma. d = End of the staple line. e = Ileocecal fold. See Figure 1 for orientation.

Citation: Journal of the American Veterinary Medical Association 237, 9; 10.2460/javma.237.9.1060

Figure 3—
Figure 3—

Diagram of the completed stapled anastomosis used in this study. Notice that the blind end of the jejunum has been partly closed to point “a” and then attached to each side of the stab incision in the wall of the cecum (b and b'). The broken and intact heavy lines are suture lines and the finer broken and intact lines are staple lines, which were not oversewn. The shaded area (c) is the stoma created by a combination of suture closure and stapling instruments, between points “a” and “d” With “a” at the 12 o'clock position, individual Lembert sutures are shown at the 6 and 9 o'clock positions around the staple line and a similar suture (not shown) is used at the 3 o'clock position. e = Ileocecal fold. See Figure 1 for orientation.

Citation: Journal of the American Veterinary Medical Association 237, 9; 10.2460/javma.237.9.1060

Statistical analysis—Each horse was regarded as a single unit of observation. A t test of the means was used for continuous data (length of intestine resected, viability index, and admitting heart rate) after normality was justified by the Anderson-Darling and Shapiro-Wilk tests, and homogeneity of variances was verified by the Levene test. For nonparametric data (days of hospitalization and duration of colic), a Kruskal-Wallis test was used. A 2-tailed test of the difference between 2 binomial proportions with exact 2 × 2 contingency tables was used to test other differences, with a value of P < 0.05 considered significant. The Kaplan-Meier survival probabilities were determined for both types of anastomosis after recovery from anesthesia, and the Tarone-Ware, Mantel, and Breslow-Gehan methods were used to detect differences in survival rates between groups. For long-term analyses, the follow-up period ended at the horse's death (regardless of cause), time of lost contact because of sale of horse or owner move, and last recorded date that the horse was still alive. All these analyses were performed with statistical programs.c,d The mortality rate from colic after hospital discharge was determined as the number of deaths from colic per horse-year (total accumulated years of follow-up), and the incidence density for colic after hospital discharge was recorded as number of colic episodes per horse-year (total accumulated years of follow-up).13,15

Results

Thirty-two horses met the inclusion criteria; 22 underwent a hand-sewn anastomosis, and 10 underwent a stapled anastomosis. Seventeen of these horses were included in a broader study2 on outcome and postoperative ileus after different types of small intestinal surgery. The first author (DEF) performed 18 of 22 hand-sewn anastomoses and 9 of 10 stapled anastomoses and supervised residents throughout the entire resection and anastomosis in the remainder of the surgeries. The 2 methods for jejunocecostomy were not applied in a random fashion; their use was distributed among the horses in the study so that a stapled anastomosis was performed in groups of 1 to 4 horses separated by groups of 1 to 10 horses that underwent a hand-sewn anastomosis. The method for anastomosis was selected on the basis of availability of staples or the need to teach both methods to residents and not on any perceived surgical needs of each horse. In 1 horse in the hand-sewn group, the ileum was necrotic to the ileocecal junction and was amputated at that level by use of blind application of a stapler.e

There was no difference in ages between the 2 groups (Table 1). Of the 22 horses with a hand-sewn anastomosis, 9 (41%) had a strangulating lipoma, 5 (23%) had strangulation in the epiploic foramen, 7 (32%) had miscellaneous strangulating lesions, and 1 (5%) had an impaction at a jejunocecostomy that had been performed with staples at another clinic 2 years earlier. The impaction appeared to have started in a blind pouch of jejunum that extended about 6 cm distal to the stoma. Of the 10 horses with a stapled anastomosis, 5 had a strangulating lipoma, 4 had strangulation in the epiploic foramen, and 1 had proliferative enteropathy caused by Lawsonia intracellularis.

Table 1—

Preoperative and intraoperative data of 32 horses with colic that underwent hand-sewn or stapled side-to-side jejunocecostomy.

VariableHand-sewn group (n = 22)Stapled group (n = 10)
Age (y)
 Mean ± SD12.8 ± 6.312.4 ± 6.7
 Range0.08-260.75-28
Duration of colic (h)*
 Mean ± SD11.63 ± 5.5113.60 ± 5.18
 Median98
Heart rate (beats/min)
 Mean ± SD75.11 ± 29.460 ± 15.8
 Range36-120 40-88
Intestine resected (feet)
 Mean ± SD13 ± 6.6813.8 ± 6.6
 Median1113.5
Intestine resected (m)
  Mean ± SD  
  Median 3.35 4.11
Viability index
  Mean ± SD16.8 ± 9.617.3 ± 10.0
  Median14.314.9

Information was available for only 16 horses in the hand-sewn group and 5 horses in the stapled group for duration of colic before surgery.

At the time of hospital admission.

Viability index is the product of length of intestine resected (m) and viability grade, which was IV or V on a scale of I to V.

Duration of colic prior to surgery was not recorded for all horses, but for those for which this information was available, there was no significant difference between that of horses in the hand-sewn group and stapled group (Table 1). The heart rates at admission were similar between horses in the hand-sewn group and stapled group. Also, there were no significant differences between lengths of intestine resected and the viability index between the 2 groups. There was no significant difference in the days of hospitalization (mean ± SD) between horses in the hand-sewn group (7.9 ± 2.4) and stapled group (7.7 ± 1.15). Short-term survival rate (ie, discharge from hospital alive) was similar for both groups (Table 2), but horses in the stapled group had a significantly greater prevalence of postoperative colic and combined postoperative colic and reflux than horses in the hand-sewn group (P < 0.05 for all comparisons).

Table 2—

Results of analysis of postoperative data from 32 horses with colic that underwent hand-sewn (n = 22) or staplec (10) side-to-side jejunocecostomy.

VariableNo. of horses in hand-sewn group (%) 
Postoperative reflux2/22 (9)4/10 (40)
Postoperative colic2/22 (9)a6/10 (60)b
Postoperative colic and reflux4/22 (18)a7/10 (70)b
Repeated celiotomy3/22 (14)4/10 (40)
Survived to hospital discharge20/22(91)9/10 (90)
Colic after hospital discharge*2/18 (11)4/9 (44)

All these colic episodes led to death or euthanasia, except for 1 horse in each group.

This information could not be obtained for horses in this group.

Different superscript letters within a row indicate significant (P> 0.05) differences between groups for these data.

Although strangulation in the epiploic foramen appeared to be overrepresented in horses in the stapled group, this lesion did not have a significant effect on postoperative complications or mortality rate. In the stapled group, 2 of 4 horses with strangulation in the epiploic foramen had a postoperative complication and all survived to discharge, whereas all 5 horses with a lipoma in this group developed a complication and 1 died during hospitalization. Numbers were too small to allow statistical analysis of effect of the primary surgeon on outcome, but no horse in either group developed a complication or died in the hospital when a resident had performed the anastomosis under supervision of the first author (DEF).

In the hand-sewn group, a repeat celiotomy was performed within the same hospitalization period for 3 horses (Table 2), 1 with colic caused by the small colon being wrapped around the small intestine, another because of colic from small intestinal volvulus at the stoma, and the third because of postoperative reflux and abdominal distention. The last 2 horses died, 1 because of postanesthetic myopathy and the other from colitis. The latter developed severe postoperative diarrhea after the first surgery, followed by abdominal distention and postoperative reflux that were attributed at the second surgery to fluid distention of the cecum and large colon, with reflux of cecal contents into the small intestine. Although a typhlotomy and colotomy improved the clinical condition of the horse dramatically for 24 hours after the second surgery, the signs then recurred and the owner agreed to have the horse euthanatized.

In the stapled group, 3 horses had 1 repeat celiotomy and 1 had 2 repeat celiotomies (Table 2); all 4 were discharged from the hospital. Causes of postoperative colic in the horse that had 2 repeat surgeries were right dorsal displacement of the large colon (1 surgery) and cecal distention (1 surgery). Causes of postoperative colic (with or without reflux) that necessitated repeat celiotomy in the other 3 horses were serositis in the distal portion of the jejunum and cecum in 1 horse, the same condition but more diffuse and with fibrinous adhesions from the jejunum to the body wall and large colon in another horse, and postoperative ileus in the third. In the 3 horses with serositis, intra-abdominal lavage at the second surgery with approximately 20 L of warmed lactated Ringer solution and lysis of abdominal adhesions (1 horse) resolved their clinical signs. One horse with a stapled side-to-side jejunocecostomy was recovering without problems when the horse developed acute colic at 4 days after surgery, associated with signs of severe endotoxemia and copious fluid drainage from its abdominal incision. A ruptured viscus was suspected, and the horse was euthanatized but a necropsy was not performed.

Follow-up information was obtained for all horses by phone call, except for 2 Thoroughbred mares that were lost to follow-up through owner change or move. Survival data for both these mares were obtained through breeding and produce records from the Jockey Club Information Systems.

After discharge from the hospital, 10 of 20 horses in the hand-sewn group died. Four of these horses were euthanatized for nongastrointestinal diseases such as arthritis, neurologic disease, fractured cervical vertebra, and tooth removal complications; 2 died as a result of old age; and 1 died of an unknown cause. None of these horses was necropsied. Of the remaining 3, 1 horse was readmitted to the clinic 19 months after surgery with colic and the owner requested euthanasia. At necropsy, this horse had diffuse small intestinal distention without any evidence of ischemia and the anastomosis was 15 cm long, larger than the size most likely produced at surgery. Stomal and distal jejunal dilatation was considered the cause of small intestinal distention and colic in this horse. This horse had no abdominal adhesions. A foal that underwent resection of 80% of the small intestine was euthanatized without necropsy 5 months after surgery because of severe weight loss. One horse was euthanatized because of weight loss at 36 months after surgery. This horse had a jejunocecostomy to correct strangulation from an adhesion to a jejunoileostomy performed previously; in the 2 surgeries combined, the horse had a total of 6.4 m (21 feet) of small intestine removed. A necropsy was not performed.

Figure 4—
Figure 4—

Kaplan-Meier survival curves comparing the proportion of horses surviving over time that underwent hand-sewn (solid line; n = 22) or stapled side-to-side jejunocecostomy (broken line; 10). Known deaths from colic after hospital discharge are recorded for horses in the stapled (solid arrows) and hand-sewn group (open arrow). Vertical ticks on each line indicate times when a horse was lost to further follow-up or was censored. The graphs end at the times when the 2 horses with the longest follow-up periods died.

Citation: Journal of the American Veterinary Medical Association 237, 9; 10.2460/javma.237.9.1060

After discharge from the hospital, 6 of 9 horses in the stapled group died. Two of these horses died as a result of old age. Another horse was euthanatized for reasons not specified but not related to surgery and had no abdominal adhesions at necropsy. The remaining 3 horses in the stapled group died of colic. Two of these horses each had a single bout of colic, without any preceding episodes: one at 32 months after surgery and the other at 98 months. The former was readmitted to the hospital and euthanatized at the owner's request. At necropsy, a lipoma that was not evident on exploration of the entire small intestine at the first surgery was found to have strangulated the jejunum at the anastomosis but there were no abdominal adhesions. Incidental findings were stomal enlargement and dilatation of the distal portion of the jejunum. The third horse in the stapled group that died of colic had survived 124 months after surgery without any problems but then developed a 1-month history of colic and weight loss. The cause of death was not specified.

According to the Kaplan-Meier survival estimates, the long-term survival rate was similar for horses undergoing either type of anastomosis (Figure 4). For the 5 horses that had more than 1 surgery during the single hospital visit and survived to discharge, long-term survival time was for a period of 60 to 126 months, and only one of these horses had a known episode of colic after hospital discharge. Number of deaths from colic/horse-year after hospital discharge for the hand-sewn group, stapled group, and both groups combined were 0.011, 0.055, and 0.027, respectively. Number of colic episodes/horse-year after hospital discharge in the hand-sewn group, stapled group, and both groups combined were 0.024, 0.110, and 0.058.

Discussion

Results of this study indicated that there was no significant difference in survival rates between horses that underwent a hand-sewn side-to-side jejunocecostomy, compared with horses that underwent a stapled side-to-side jejunocecostomy (Figure 4). However, the survivalcurve for horses in the stapled group did appear to be better than that for horses in the hand-sewn group before the survival rate decreased to approximately 50%. This difference is possibly an artifact caused by small and unequal sample sizes. Although the survival rates in the study reported here are similar to those described previously,3 horses with the stapled anastomosis were significantly more likely to develop a postoperative complication, manifested as postoperative colic alone or combined with reflux (Table 2). Although colic and reflux are common complications after small intestinal surgery,5 findings in our study underscore the potential role of surgical factors in their development and the fact that these should be investigated. In the study reported here, selection of hand-sewn or stapling methods was based on the assumption that these methods would provide comparable results, contrary to what the results seem to indicate.

In both groups combined, 7 of 32 (22%) horses had repeat celiotomy, which is more than the 9.6% to 10.6% reported for all colic surgeries13,16 and the 12% reported for all small intestinal surgeries5 but is less than the 28% reported previously for jejunocecostomy alone.a Of the 8 repeat celiotomies performed in this study, arguably only 4 were truly indicated on the basis of the surgical findings. However, clinical findings that preceded repeat celiotomy were of sufficient severity to represent a marked deviation from the expected postoperative course and the response of these horses to medical treatment was unsatisfactory.

Any potential confounding factors that would explain the difference in performance between the 2 types of anastomoses were not evident in our study, and both groups seemed equivalent on the basis of duration of colic signs and heart rate at the time of admission (Table 1). Although duration of surgery was not examined, all surgeries were completed or supervised by an experienced surgeon, which should have ensured some consistency in time between the 2 groups. The small number of horses in which the anastomosis was completed by a resident had no postoperative complications, although this is the group most likely to have had the longer surgeries. Also, the stapling technique without oversew theoretically provided the greatest benefit from time savings. The viability index provided some measure of the severity of intestinal damage within groups because it is a product of length of intestine resected and a viability grade, which was either IV or V in all strangulated segments on a scale of I to V14 It therefore represented a measure of damage to mucosal surface area, which should have determined the severity of the disease. In most horses with strangulating lesions, the ileum was involved but had less severe changes than the affected section of jejunum. In only 1 horse was the ileum judged to be so severely necrotic that it had to be resected to the level of the ileocecal junction by a blind technique with the stapling instrument.4

None of the horses in this study was subjected to a preoperative or intraoperative selection process that could have interfered with the equivalence of the 2 groups or improved the results after jejunocecostomy. The only factors that were discussed during surgery with the owner as reasons for euthanasia were preoperative rupture with contamination of the peritoneal cavity and resection of so much small intestine that the horse would be at risk for short bowel syndrome. On the basis of a previous report,2 the first author (DEF) used a length limit of 70% for resection of the small intestine, which was exceeded with fatal consequences in a foal in this study. Also, euthanasia was not offered as an option during surgery on the basis of the severity of ischemic damage and the type of anastomosis required, such as the need for jejunocecostomy versus jejunojejunostomy.

The method chosen for stapled side-to-side jejunocecostomy in this study is different than that described in standard textbooks,1,17 and the results should therefore not be applied to other stapling methods. The stapling method described was chosen because it allowed full insertion of the stapling instruments to maximize stoma size and it avoided the need to create a separate stab incision in the jejunum proximal to the stapled stoma. Location of the stab incision plays a critical role in placement and size of the stoma. For example, if the stab incision is too far from the blind end of the jejunum, a blind pocket of jejunum will be created distal to the anastomosis. If the stab incision is placed too close to the blind end of the jejunum, an insufficient length of instrument can be inserted distally to maximize stoma size. Despite the proposed advantages, the type of stapled anastomosis used in this study is not recommended on the basis of our results, and future studies should examine the more traditional stapling methods.

The findings at repeat celiotomy did not explain why there was such a difference in performance between the 2 versions of the same anastomosis. However, mild to moderate serositis on intestine close to and distant from the stapled anastomosis in 2 horses suggested the possibility of some minor leakage of intestinal contents in these horses, although a point of leakage could not be found. An oversew of the staple line should prevent this complication. Another possibility was unimpeded reflux of cecal contents into the jejunum with the stapled method, largely because it created a bigger stoma than the hand-sewn technique. Reflux of cecal contents into the jejunum might also have been favored by the Y-shaped suture line between the blind end of the jejunum and the cecum because that configuration appeared subjectively to open the stoma at the most distal end (Figure 3). Also, the hand-sewn anastomosis would be expected to provide some rigidity around the stomal margins that could act as a barrier to cecal reflux, especially if the margins became edematous.

The long-term survival rates in this study (Figure 4) and the prevalence of colic episodes after hospital discharge (Table 2) compared favorably with results from previous reports.3,13,16 Although necropsy findings were not available for most horses that died, there was no evidence of abdominal adhesion formation in any of the horses that had necropsy, including those that died of colic. In addition, some horses died of colic at a time long after discharge and without any known preceding bouts of colic, whereas problems from abdominal adhesions typically develop earlier in the postoperative course.18,19 Also, the pattern of survival time after discharge was different from that typically associated with a high rate of deaths in the early postoperative period, as would be expected with abdominal adhesions.18,19

Number of deaths from colic/horse-year after discharge from the hospital in the hand-sewn group (0.011), stapled group (0.055), and both groups combined (0.027) compared favorably with those reported by Proudman et al13 (0.044) for all horses undergoing all types of colic surgery and those reported by Tinker et al15 (0.025) for all causes of death. Number of colic episodes/horse-year after discharge from the hospital in the hand-sewn group (0.024), the stapled group (0.11), and both groups combined (0.058) were less than reported by Proudman et al13 (0.55) for all horses undergoing colic surgery and similar to the value reported by Tinker et al15 (0.1) for all horses in farms enrolled in a prospective study on colic incidence and mortality rate. Although the data on mortality rates in our study can be compared with results from other studies, the postoperative colic data probably underestimate the true prevalence of this complication because their collection relied on owner recall over long periods and even years after the horse's death in some instances. In other studies,13,15 more frequent and more structured methods of data collection were used to record incidences of colic and would be expected to give more accurate information. Nonetheless, all owners contacted in this study gave the impression that recurrent colic was not a prominent or prevalent feature throughout their horses’ lifetimes after surgery and they were satisfied that the quality of life for their horses was excellent after surgery.

Although the number of horses included in this study was too small to draw definite conclusions, horses that had 1 or more repeat celiotomies during the same hospitalization period did not seem more prone to postoperative colic than others, which is contrary to what would be expected on the basis of available evidence.5,13,16 All survived without colic for 60 to 126 months, and one of the longest survivors that died as a result of old age was in this group. Both horses that had serositis close to the anastomosis at repeat celiotomy, including the horse with fibrinous abdominal adhesions, lived to ages consistent with their life expectancies. Possibly, the nature of the findings at repeat celiotomy was mild enough in these horses that they would be expected to have a minimal effect on outcome.

Reasons for higher survival rates in our study than reported previously2,4,5 for jejunocecostomy cannot be determined. In a 2000 study by Freeman et al,2 the short-term survival rate was 76% for jejunocecostomy. However, many surgeons with different amounts of experience were involved in that study2 and most of the horses that died had avoidable technical errors. Specific guidelines were followed in an attempt to improve the surgical outcome,20 particularly complete decompression of the small intestine through an enterotomy. The alternative, decompression into the cecum, could favor postoperative cecal distention, with reflux of cecal contents into the jejunum and absorption of endotoxin from contents of the strangulated jejunum. Although many surgeons recommend a large stoma for this anastomosis,11,12 we try to limit the stoma to a size similar to the lumen of the distal portion of the jejunum in the belief that this size stoma should facilitate jejunal emptying into the cecum without increasing the risk of cecal reflux into the jejunum. Another consequence of a large stoma is transection of a proportionately greater number of circular muscle fibers in the jejunum, which could diminish peristalsis through that segment and predispose to progressive dilatation and obstruction.21,22 Stomal and distal jejunal dilatation were evident in 1 horse in each group that returned with colic and were considered the cause of severe small intestinal distention and colic in 1 horse. Also, placing the stoma as close to the cecal base as possible should theoretically reduce the contribution of intracecal hydrostatic pressure to cecal reflux into the jejunum.9,20

Based on the results of this study, jejunocecostomy should be selected when indicated, despite the impression that this procedure is fraught with a poor prognosis for survival in the short and long term. However, the difference in findings between the hand-sewn and the staple techniques for side-to-side jejunocecostomy would suggest that, even when the surgery is performed under similar conditions, a minor difference in technique can affect a horse's risk of postoperative complications. These complications have the potential to increase duration of hospitalization, postoperative care, and total cost of treatment, even if they do not affect survival rates.

a.

Pankowski RL. Small intestinal surgery in the horse: a review of ileo and jejunocecostomy (abstr). J Am Vet Med Assoc 1987; 190:1608.

b.

ILA 100, Covidien, Mansfield, Mass.

c.

Systat12, Systat Inc, Richmond, Calif.

d.

StatXact8, Cytel Inc, Cambridge, Mass.

e.

TA 90, Covidien, Mansfield, Mass.

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