Repeat Celiotomy-Current Status.

Repeat celiotomy can be lifesaving in horses with a surgically treatable postoperative obstruction, although guidelines for its use are lacking, except for uncontrollable postoperative pain. Overdiagnosis of ileus as the cause of postoperative obstruction could delay a second surgery so the disease progresses beyond a manageable level of severity. Although many horses respond favorably to repeat celiotomy, complications can be severe and life threatening, such as incisional infection and adhesions. Repeat celiotomy does not seem to exacerbate postoperative ileus, despite additional surgical manipulation. An important benefit of repeat celiotomy is termination of hopeless cases, thereby reducing cost and suffering.

Small Intestine Ultrasound Findings on Horses Following Exploratory Laparotomy, Can We Predict Postoperative Reflux?

Postoperative reflux (POR) is a well-recognized complication after colic surgery in horses, particularly when presenting small intestinal pathology. Even though much has been written about the pathophysiology and management of POR, additional clinical studies are needed to better understand and anticipate this complication. The aim of the study was to provide clinical evidence of ultrasound findings in the postoperative period (three days). The study is based on transcutaneous abdominal ultrasounds of the caudoventral abdomen during the postoperative period (three days), in 58 horses, presented for an exploratory laparotomy, and compared to 20 horses that underwent general anesthesia for an elective surgical procedure. Small intestine (SI) images and videos were analyzed for loop number, loop diameter, wall thickness, motility, and echogenic type of loop contents. Ultrasound findings of horses that had a large colon pathology were similar to those of the control group. Interestingly, horses that presented an SI pathology had significantly thicker SI walls, increased loop diameter, slower motility, and hypoechoic contents, particularly in horses that had undergone small intestinal resection and anastomosis. Although the number of horses that developed POR in our study was too small for statistical analysis, they all had the aforementioned ultrasonographic changes. Abdominal ultrasound, during the postoperative period (three days), was a useful method to identify horses with abnormal small intestinal parameters. Further investigation as to whether these parameters can be used to predict POR in a larger population is warranted.

Prevention and Treatment of Postoperative Complications in Equines / Prevención y tratamiento de complicaciones postoperatorias en equinos / Prevenção e tratamento de complicações pós-operatórias em equinos

Abstract Colic surgery is one of the most expensive procedures in equine clinics throughout the world. Although costs of surgery and anesthesia can be standardized to some extent, the cost of aftercare is less predictable. It can be altered considerably by the development of complications, such as surgical site infection, postoperative ileus, and formation of post-operative hernias, among others. Colic surgery places enormous demands on personnel, time, and resources. Nevertheless, it is a life-saving procedure. Complications increase cost through prolonged nursing care, technician salaries, extended treatment with antibiotics and other drugs, repeated laboratory analysis, and high-volume fluid therapy. Additional surgery, such as repeat celiotomy or repair of incisional complications, increases the costs considerably. Because none of these can be anticipated in most cases, a critical part of case management is a complete evaluation of expected and probable unexpected costs for the owner.

Resumen La cirugía de cólicos es uno de los procedimientos más costosos en la clínica de equinos en todo el mundo. Aunque los costos de la cirugía y la anestesia se pueden estandarizar hasta cierta medida, el costo de cuidado posterior es menos predecible y se puede alterar considerablemente mediante el desarrollo de complicaciones, tales como infección del sitio quirúrgico, ileus postoperatorio y formación de hernias postoperatorias, entre otros. La cirugía de cólicos le trae exigencias enormes al personal y requiere tiempo y recursos. Sin embargo, es un procedimiento que salva vidas. Las complicaciones aumentan el costo debido a que el cuidado de enfermería se prolonga, hay que pagar salarios a los técnicos, se amplía el tratamiento con antibióticos y otros medicamentos, hay que repetir análisis de laboratorio y se requiere terapia de fluidos con altos volúmenes. La cirugía adicional, como una celiotomía repetida o reparación de las complicaciones incisionales, aumenta los costos considerablemente. Como ninguno en la mayoría de los casos no se puede prever ninguna de estas cosas, una parte crítica del manejo de casos es la evaluación completa de los costos esperados y los probables no-esperados que cubrirá el propietario.

Resumo A cirurgia de cólica é um dos mais custosos procedimentos clínicas equinas ao redor do mundo. No entanto, os custos de cirurgia e anestesia possam ser padronizados até certo ponto, o custo dos cuidados posteriores é menos previsível e pode se alterar consideravelmente a causa de complicações, tais como infecção do local cirúrgico, íleo pós-operatório e formação de hérnias pós-operatórias, entre outras. A cirurgia de cólica impõe uma enorme demanda de pessoal, tempo e recursos, toda vez que é um procedimento que salva vidas. As complicações aumentam o custo por meio de cuidados prolongados de enfermagem, salários dos técnicos, tratamento prolongado com antibióticos e outros medicamentos, análises laboratoriais repetidas e fluidoterapia de alto volume. Cirurgias adicionais, como repetição de celiotomia ou reparo de complicações incisionais, aumentam consideravelmente os custos. Como nada disso pode ser previsto na maioria dos casos, uma parte crítica do gerenciamento de casos é a avaliação completa dos custos esperados e prováveis inesperados para o proprietário.

Is There Still a Place for Lidocaine in the (Postoperative) Management of Colics?

Intravenous lidocaine is widely used to prevent or treat postoperative ileus in horses. Clinical studies that support this approach are flawed and contradicted by others. Also, physical obstruction could be more important in causing postoperative reflux than postoperative ileus in the horse. The antiinflammatory properties of lidocaine and the role of inflammation from intestinal handling in the genesis of postoperative reflux are questionable. Because of cost and questionable efficacy of lidocaine, a well-designed clinical trial is required to support its continued use. However, lidocaine could be given to provide or enhance analgesia in selected cases with postoperative colic.

Has intravenous lidocaine improved the outcome in horses following surgical management of small intestinal lesions in a UK hospital population?

BACKGROUND: Perioperative lidocaine treatment is commonly used in horses that undergo surgical treatment of colic, to prevent or treat postoperative ileus and reduce the effects of intestinal ischaemia-reperfusion injury. However, its clinical efficacy has not been evaluated in a large population of horses undergoing small intestinal surgery. The aim of the current study was to evaluate whether systemic lidocaine administration reduced the prevalence, volume and duration of postoperative reflux and improved rates of survival following surgical treatment of small intestinal lesions. Data were collected as a part of two prospective studies investigating postoperative survival of surgical colic patients admitted to a UK equine referral hospital during the periods 2004-2006 and 2012-2014. Kaplan-Meier plots of cumulative probability of survival and the log-rank test were used to compare survival between horses that did or did not receive lidocaine. The Wilcoxon rank-sum test was used to compare the total reflux volume and duration of reflux between the groups. A multivariable Cox proportional hazards model was used to identify pre- and intraoperative risk factors for non-survival. RESULTS: Data from 318 horses were included in the final analysis. The overall prevalence of postoperative reflux was 24.5 %. This was significantly higher (34.8 %) in horses admitted in 2012-2014 compared to the 2004-2006 cohort (16.7). Perioperative lidocaine treatment had no effect on total reflux volume, duration of reflux or rates of postoperative survival nor was it a risk factor associated with altered postoperative survival. Variables identified to be associated with increased risk of postoperative mortality included packed cell volume on admission (hazard ratio [HR] 1.03 95 %, 95 % confidence interval [CI] 1.004-1.06, p = 0.024), heart rate on admission (HR 1.014, 95 % CI 1.004-1.024, p =0.008) and duration of surgery (HR 1.007, 95 % CI 1.002-1.01, p = 0.008). CONCLUSIONS: Lidocaine therapy had no effect on the prevalence of postoperative reflux, total reflux volume and duration of reflux nor did it have any effect on postoperative survival in horses undergoing surgical management of small intestinal disease for treatment of colic. There is a need for a well-designed multicentre, prospective randomised controlled trial to fully investigate the efficacy of lidocaine across different hospital populations.

Hospital variation in rates of acid-reducing medication use after laparoscopic sleeve gastrectomy.

BACKGROUND: Postoperative gastroesophageal reflux is one of the most important long-term complications of sleeve gastrectomy, the most common bariatric procedure. OBJECTIVE: To assess variation in hospital performance with laparoscopic sleeve gastrectomy using rates of acid-reducing medication use at postoperative 1 year. SETTING: Clinical registry of bariatric surgical patients at academic and community hospitals in Michigan. METHODS: We studied 2923 patients who underwent laparoscopic sleeve gastrectomy across 39 hospitals in the Michigan Bariatric Surgery Collaborative, 2007 to 2014. We compared risk- and reliability-adjusted rates of new-onset reflux-defined by new use of acid-reducing medication-across hospitals and in relation to surgical quality indicators (hospital procedure volume and 30-day complications). RESULTS: Overall, 20% of patients were newly taking acid-reducing medication at postoperative 1 year. Hospital rates of new medication use varied 3-fold, ranging from 10% (95% CI 7-15%) to 31% (95% CI 23-40%) of patients. Of the 2 hospitals with significantly lower rates of new medication use, 1 was high volume and 1 was medium volume. The 1 hospital with significantly higher rates was medium volume. Rates of acid-reducing medication use did not correlate with hospital volume or perioperative complications. CONCLUSION: Across Michigan hospitals, rates of new acid-reducing medication use at 1 year after laparoscopic sleeve gastrectomy varied widely and did not correlate with traditional quality indicators. Future research could explore differences in surgical technique to better understand the factors underlying variation in long-term outcomes after sleeve gastrectomy.