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Gefen R, Garoufalia Z, Zhou P, Watson K, Emile SH, Wexner SD. Treatment of enterocutaneous fistula: a systematic review and meta-analysis. Tech Coloproctol 2022; 26:863-874. [PMID: 35915291 DOI: 10.1007/s10151-022-02656-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/20/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Enterocutaneous fistula (ECF) is an abnormal communication between the gastrointestinal tract and skin, with a myriad of etiologies and therapeutic options. Management is influenced by etiology and specifics of the ECF, and patient-related factors. The aim of this study was to assess overall success, recurrence, and mortality rates of treatment for ECF. MATERIALS A systematic search of PubMed and Google Scholar was performed through October 2021 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Case reports, reviews, animal studies, studies not reporting outcomes, had no available English text, included patients < 16 years old or those assessing other abdominocutaneous/internal fistulas were excluded. RESULTS Fifty-three studies, between 1975 and 2020, incorporating 3078 patients were included. Patient age ranged between 16 and 87 years with a male:female ratio of 1.14:1. ECF developed postoperatively in 89.4%. Other common etiologies were inflammatory bowel disease, trauma, malignancy, and radiation. At least 28% of patients had complex fistulae (reported in 18 studies). Most common fistula site was small bowel. In 34 publications, 62.4% (n = 1371) patients received parenteral nutrition. In 45 publications, 72.5% underwent surgery to treat the fistula. Meta-analysis revealed an 89% healing rate; recurrence rate after initial successful treatment was 11.1%, and mortality rate was 8.5%. In a subgroup of patients who underwent combined ECF takedown and abdominal wall reconstructions (n = 315), 78% achieved fascial closure, mesh was used in 72%, hernia, and fistula recurrence rates were 19.7% and 7.6%, respectively. CONCLUSIONS Treatment of ECF must be individualized according to specific etiology and location of the fistula and the patient's associated conditions.
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Affiliation(s)
- R Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Z Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - P Zhou
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - K Watson
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - S H Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - S D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Tatsuta K, Oshima T, Ishimatsu H, Hazama H, Ohata K. The successful management for long-term intractable enteroatmospheric fistula: A case report. Ann Med Surg (Lond) 2020; 57:253-256. [PMID: 32817789 PMCID: PMC7426484 DOI: 10.1016/j.amsu.2020.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 11/06/2022] Open
Abstract
Introduction Efficacy of open abdomen management with negative pressure wound therapy for enteroatmospheric fistula has been performed. But, few reports have shown its utility for enteroatmospheric fistula several years after onset. Presentation of case A 46 year-old woman underwent total colectomy due to total ulcerative colitis in her twenties. Three years before the onset of enteroatmospheric fistula, she underwent simple total hysterectomy for uterine smooth muscle tumor. Small bowel obstruction occurred early and a small bowel bypass was performed. However, she had sudden abdominal pain and was diagnosed with anastomotic leakage of small bowel bypass. Although antibiotic treatment was initiated, infection was difficult to control, and a midline abdominal incision was performed, followed by the formation of enteroatmospheric fistula. She declined early surgical intervention and started receiving home parenteral nutrition with antibiotic treatment. Although central vein management was continued, catheter infection became frequent. Hence, surgical intervention was planned 30 months after the formation of enteroatmospheric fistula. Two-stage abdominal wall reconstruction using open abdomen management with negative pressure wound therapy was planned. The definitive abdominal wall reconstruction was performed 14 days after the initial operation. Finally, she was discharged without reoperation. Discussion Enteroatmospheric fistula has no overlying soft tissue and no real fistula tract. Besides these complications, there were complications of the scarred abdominal wall from intestinal fluid exposure for 30 months. Conclusion The strategy using open abdomen management with negative pressure wound therapy for long-term enteroatmospheric fistula will have a good postoperative outcome with the same as early intervention. Negative pressure wound therapy is effective in postonset enteroatmospheric fistula. It repairs abdominal wall skin damage from 30-month intestinal fluid exposure. Open abdominal management was able to control infection in the perioperative period.
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Affiliation(s)
- Kyota Tatsuta
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Aoi-ku, Japan
| | - Takeshi Oshima
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Aoi-ku, Japan
| | - Hisato Ishimatsu
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Aoi-ku, Japan
| | - Hiroyuki Hazama
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Aoi-ku, Japan
| | - Ko Ohata
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Aoi-ku, Japan
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Fragkos KC, Thong D, Cheung K, Thomson HJ, Windsor AC, Engledow A, McCullough J, Mehta SJ, Rahman F, Plumb AA, Di Caro S. Adipose tissue imaging as nutritional predictors in patients undergoing enterocutaneous fistula repair. Nutrition 2020; 73:110722. [DOI: 10.1016/j.nut.2020.110722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 12/31/2019] [Accepted: 01/01/2020] [Indexed: 12/22/2022]
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Xu X, Ma Y, Yao Z, Zhao Y. Prevalence and Risk Factors for Pressure Ulcers in Patients with Enterocutaneous Fistula: A Retrospective Single-Center Study in China. Med Sci Monit 2019; 25:2591-2598. [PMID: 30964125 PMCID: PMC6476408 DOI: 10.12659/msm.913261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/20/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Prevalence and associated risk factors for pressure ulcers (PU) vary in different body areas and diseases. Few studies have focused on PU in patients with enterocutaneous fistula (ECF). The aim of the present study was to investigate the prevalence and risk factors for PU in patients with ECF. MATERIAL AND METHODS From January 2016 to June 2016, medical records of 140 patients with ECF who were transferred to the Enterocutaneous Fistula Treatment Center, Jinling Hospital, were reviewed and analyzed. The prevalence of PU was investigated. To evaluate the risk factors for PU in patients with ECF, 5 patients with PU before admission were excluded, and the remaining 135 patients were divided into 2 groups: the PU group and the non-PU group. The risk factors for PU were confirmed by multivariate logistic regression analysis of characteristics on admission. RESULTS There were 42 cases with PU (5 cases with PU before admission, 37 cases with PU in the treatment after admission), and the prevalence of PU in patients with ECF was 30%. In addition, Braden risk score <19 (OR=9.33, CI: 2.80-31.08, p<0.001); underweight (BMI<18.5) (OR=5.21, CI: 1.65-16.39, p=0.005); onset of duodenal fistula (OR=4.86, CI: 1.33-17.78, p=0.017); diabetes (OR=4.95, CI: 1.03-23.85, p=0.046); and APACHE II score (OR=1.34, CI: 1.04-1.72, p=0.019) were associated with PU. CONCLUSIONS The PU prevalence was 30% in patients with ECF. Braden risk score <19, underweight, onset of duodenal fistula, diabetes, and APACHE II score were risk factors for PU in patients with ECF.
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Bannon MP, Heller SF, Rivera M, Leland AL, Schleck CD, Harmsen WS. Reconstructive operations for enteric and colonic fistulas: Low mortality and recurrence in a single-surgeon series with long follow-up. Surgery 2019; 165:1182-1192. [PMID: 30929896 DOI: 10.1016/j.surg.2019.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/07/2019] [Accepted: 01/07/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence. METHODS Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas. RESULTS Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not. CONCLUSIONS With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.
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Affiliation(s)
- Michael P Bannon
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN.
| | - Stephanie F Heller
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN
| | - Mariela Rivera
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN
| | - Ann L Leland
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN
| | - Cathy D Schleck
- Division of Biostatistics and Informatics, Mayo Clinic, Rochester, MN
| | - William S Harmsen
- Division of Biostatistics and Informatics, Mayo Clinic, Rochester, MN
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A Systematic Review and Meta-analysis of Timing and Outcome of Intestinal Failure Surgery in Patients with Enteric Fistula. World J Surg 2018; 42:695-706. [PMID: 28924879 PMCID: PMC5801381 DOI: 10.1007/s00268-017-4224-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background The timing of intestinal failure (IF) surgery has changed. Most specialized centers now recommend postponing reconstructive surgery for enteric fistula and emphasize that abdominal sepsis has to be resolved and the patient’s condition improved. Our aim was to study the outcome of postponed surgery, to identify risk factors for recurrence and mortality, and to define more precisely the optimal timing of reconstructive surgery. Methods PubMed, Embase, and the Cochrane Library were systematically reviewed on the outcomes of reconstructive IF surgery (fistula recurrence, mortality, morbidity, hernia recurrence, total closure, enteral autonomy). If appropriate, meta-analyses were performed. Optimal timing was explored, and risk factors for recurrence and mortality were identified. Results Fifteen studies were included. The weighted pooled fistula recurrence rate was 19% (95% CI 15–24). Lower recurrence rates were found in studies with a longer median time and/or, at the minimum of the range, a longer time interval to surgery. Overall mortality was 3% (95% CI 2–5). Total fistula closure rates ranged from 80 to 97%. Enteral autonomy after reconstructive surgery, mentioned in four studies, varied between 79 and 100%. Conclusions Postponed IF surgery for enteric fistula is associated with lower recurrence. Due to the wide range of time to definitive surgery within each study, optimal timing of surgery could not be defined from published data.
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Lauro A, Cirocchi R, Cautero N, Dazzi A, Pironi D, Di Matteo FM, Santoro A, Faenza S, Pironi L, Pinna AD. Surgery for post-operative entero-cutaneous fistulas: is bowel resection plus primary anastomosis without stoma a safe option to avoid early recurrence? Report on 20 cases by a single center and systematic review of the literature. G Chir 2017; 38:185-198. [PMID: 29182901 DOI: 10.11138/gchir/2017.38.4.185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND A review was performed on entero-cutaneous fistula (ECF) repair and early recurrence, adding our twenty adult patients (65% had multiple fistulas). METHODS The search yielded 4.098 articles but only 15 were relevant: 1.217 patients underwent surgery. The interval time between fistula's diagnosis and operative repair was between 3 months and 1 year. A bowel resection with primary anastomosis was performed in 1.048 patients, 192 (18.3%) underwent a covering stoma: 856 patients (81.7%) had a fistula takedown in one procedure. RESULTS The patients had 14.3% recurrence and 13.1% mortality rate. In our experience 75% were surgically treated after a period equal or above one year from fistula occurrence: surgery was very demolitive (in 40% remnant small bowel was less than 100 cm). We performed a bowel resection with a hand-sewn anastomosis (95%) without temporary stoma. In-hospital mortality was 0% and at discharge all were back to oral intake with 0% early re-fistulisation. CONCLUSIONS Literature supports our experience: ECF takedown could be safely performed after an adequate period of recovery from 3 months to one year from fistula occurrence. In our series primary repair (bowel resection plus reconnection surgery without temporary stoma) avoided an early recurrence without mortality.
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Tonolini M, Magistrelli P. Enterocutaneous fistulas: a primer for radiologists with emphasis on CT and MRI. Insights Imaging 2017; 8:537-548. [PMID: 28963700 PMCID: PMC5707219 DOI: 10.1007/s13244-017-0572-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/22/2017] [Accepted: 08/24/2017] [Indexed: 12/16/2022] Open
Abstract
Abstract Enterocutaneous fistulas (ECFs) represent abnormal communications between the gastrointestinal tract and the skin. Nowadays, the majority (~80%) of ECFs develops secondary to abdominal surgeries; alternative, less common causes include chronic inflammatory bowel diseases (IBD) such as Crohn’s disease, tumours, and radiation enteritis in descending order of frequency. These rare disorders require thorough patient assessment and multidisciplinary management to limit the associated morbidity and mortality. This pictorial review includes an overview of causes, clinical manifestations, complications and management of ECFs. Afterwards, the imaging appearances, differential diagnoses, and therapeutic options of post-surgical, IBD-related, and malignant ECFs are presented with case examples. Most of the emphasis is placed on the current pivotal role of CT and MRI, which comprehensively depict ECFs providing cross-sectional information on the underlying postsurgical, neoplastic, infectious, or inflammatory conditions. Radiographic fistulography remains a valid technique, which rapidly depicts the ECF anatomy and confirms communication with the bowel. The aim of this paper is to increase radiologists’ familiarity with ECF imaging, thus allowing an appropriate choice between medical, interventional, or surgical treatment, ultimately resulting in higher likelihood of therapeutic success. Teaching Points • Enterocutaneous fistulas may complicate abdominal surgery, sometimes Crohn’s disease and tumours. • The high associated morbidity and mortality result from sepsis, malnutrition and metabolic imbalance. • The multidisciplinary management of ECFs requires thorough imaging for correct therapeutic choice. • Radiographic fistulography rapidly depicts fistulas and communicating bowel loops in real-time. • Multidetector CT and MRI provide cross-sectional information on fistulas and underlying diseases.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
| | - Paolo Magistrelli
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy
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Leang YJ, Bell SW, Carne P, Chin M, Farmer C, Skinner S, Wale R, Warrier SK. Enterocutaneous fistula: analysis of clinical outcomes from a single Victorian tertiary referral centre. ANZ J Surg 2016; 88:E30-E33. [PMID: 27452814 DOI: 10.1111/ans.13686] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 05/16/2016] [Accepted: 05/21/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Enterocutaneous fistulas (ECFs) are complex and can result in significant morbidity and mortality. The study aimed to evaluate ECF outcomes in a single tertiary hospital. METHODS A retrospective study of all patients treated with ECF between the period of January 2009 and June 2014 was conducted. Baseline demographic data assessed included the primary aetiology of the fistula, site of the fistula and output of the fistula. Outcomes measures assessed included re-fistulation rate, return to theatre, wound complications, fistula closure rate and death over the study period. RESULTS A total of 16 patients with ECF were recorded within the study period. Mean age of the patient cohort was 55.8 ± 11.8 years with a female predominance (11 females, 5 males). Primary aetiology were Crohn's disease (31%), post intra-abdominal surgery not related to bowel neoplasia (50%) and post intra-abdominal surgery related to bowel neoplasia (19%). Majority of the fistulas developed from the small bowel (75%) and had low output (63%). Operative intervention was required in 81% of patients with an overall closure rate of 100%. Median operations required for successful closure was 1.15 operations. Mean duration between index operation and curative operation was 8 ± 12.7 months. CONCLUSION Appropriate bundle of care (perioperative care, surgical timing and surgical technique) can produce excellent results in patients with ECF.
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Affiliation(s)
- Yit J Leang
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephen W Bell
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Carne
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Martin Chin
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Chip Farmer
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Steward Skinner
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Roger Wale
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
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Chamberlain M, Dwyer R. Reducing pre-operative length of stay for enterocutaneous fistula repair with a multi-disciplinary approach. BMJ QUALITY IMPROVEMENT REPORTS 2016; 4:bmjquality_uu204075.w1773. [PMID: 26734355 PMCID: PMC4645886 DOI: 10.1136/bmjquality.u204075.w1773] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/12/2015] [Indexed: 11/06/2022]
Abstract
Pre-operative assessment of complex surgical patients can be a lengthy process, albeit essential to minimise complication rates. In a tertiary referral unit specialising in the surgical repair of entercutaneous fistulas, a baseline audit revealed an average in-patient length of stay of 30.1 days, mainly caused by poor co-ordination between specialities. After the introduction of a weekly multi-disciplinary team meeting and the formalisation of a patient pathway, this admission length was reduced to 5.7 days (p<0.01), resulting in significant savings to the department.
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Affiliation(s)
| | - Rebecca Dwyer
- University College London Hospitals NHS Foundation Trust, UK
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Barba M, Barrett E, Cesar F, Caldwell F, Schumacher J. Management of enterocutaneous fistula associated with an umbilical hernia in a two‐year‐old horse. VETERINARY RECORD CASE REPORTS 2013. [DOI: 10.1136/vetreccr-2013-000014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Marta Barba
- Department of Clinical SciencesCollege of Veterinary MedicineAuburn UniversityAuburnAL36849USA
| | - Elizabeth Barrett
- Department of Clinical SciencesCollege of Veterinary MedicineAuburn UniversityAuburnAL36849USA
| | - Fernanda Cesar
- Department of Clinical SciencesCollege of Veterinary MedicineAuburn UniversityAuburnAL36849USA
| | - Fred Caldwell
- Department of Clinical SciencesCollege of Veterinary MedicineAuburn UniversityAuburnAL36849USA
| | - John Schumacher
- Department of Clinical SciencesCollege of Veterinary MedicineAuburn UniversityAuburnAL36849USA
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