Sutured end-to-end and stapled side-to-side jejunal anastomoses in the horse

Use of Polyamide (Nylon) Cable Ties for Vascular Ligation of Healthy Equine Jejunal Mesentery

Jejunal vascular ligation is an essential step in performing jejunojejunostomy. Hand sewn ligation is typically used and can increase operative time with long sections of bowel to be removed. Nylon cable ties (NCT) have been used for vascular ligation in horses but are yet to be investigated for application on the mesenteric vasculature of the gastrointestinal tract. Our objective was to evaluate the efficacy and short-term safety of NCT jejunal mesenteric vessel ligation in healthy horses. Eight healthy adult horses underwent midline celiotomy. A segment of jejunal mesentery was identified (≥4 arcades). Briefly, three fenestrations (proximal, middle, distal) were made 5–10 mm apart adjacent to the first and last vascular arcade to be ligated. Two sterilized NCT were passed to encircle the mesentery through the proximal and middle fenestrations, separated by intact mesentery. NCT were closed tightly and the vascular pedicle transected with Mayo scissors through the distal fenestration. Jejunojejunostomy was then performed and the mesentery sutured closed. The number of vascular arcades and time to ligate using NCT were recorded. At 2 weeks, horses underwent repeat celiotomy to assess the healing of the NCT ligation site and an equal number of vascular arcades were hand sewn double ligated using 2-0 Polyglactin 910 as a timed comparison. NCT mesenteric ligation was significantly faster than hand sewn methods (P < 0.01). Effective hemostasis was achieved in all cases. There was no evidence of local infection or adhesions at 14 days post-operatively. Further investigation in the long-term effects in horses as well as horses with strangulating jejunal lesions are needed for clinical application.

Comparison of one-layer Utrecht pattern with two-layer (simple continuous/Cushing) pattern for jejunojejunostomy in healthy horses in vivo

OBJECTIVE

To compare end-to-end jejunal anastomoses with a one-layer (Utrecht) and two-layer (simple continuous/Cushing) patterns.

STUDY DESIGN

Experimental study.

ANIMALS

Eight healthy adult horses.

METHODS

Jejunal end-to-end anastomoses were performed in randomly assigned one-layer or two-layer patterns. Horses were recovered from surgery and monitored for complications. At 14 days, the opposite pattern was performed (cross-over design) prior to euthanasia. Duration of closures was compared between patterns. Serosal width was measured before harvesting anastomotic sites from the first procedure. Luminal diameter was measured, and sections were collected for histological evaluation of heating after routine and immunohistochemical staining.

RESULTS

One-layer closure was faster (716 ± 86 s) than two-layer closures (1136 ± 111 s). Postoperative complications were minimal. No difference was detected in lumen size between groups. The lumen was reduced by 18% after one-layer and 15% after two-layer closures (p = .34). Serosal adhesions to the mesentery without clinical evidence of obstruction were observed in two horses with two-layer closure. Histopathological scores for inflammation, infection, and healing did not differ between groups.

CONCLUSION

Jejunal anastomosis with one-layer Utrecht technique was about 7 min faster and led to similar luminal reduction and histological healing scores as two-layer jejunojejunostomies.

CLINICAL SIGNIFICANCE

The outcomes of one-layer Utrecht jejunojejunostomies in healthy horses justify clinical evaluation of this technique.

Ex Vivo Comparison of a UV-Polymerizable Methacrylate Adhesive versus an Inverting Pattern as the Second Layer of a Two-Layer Hand-Sewn Jejunal Anastomosis in Horses: A Pilot Study

Resection and anastomosis of small intestine during colic can lead to adhesions and recurrent colic. Several methods are available to reduce the rate of adhesions in the postoperative period, such as the use of serosal barriers. Surgical glues form a smooth surface, are fast to apply, and could reduce surgery time when performing anastomosis. A recently developed UV-polymerizable methacrylate adhesive (UV-PMA) is designed to anchor into the biological tissues' top surface offering sealant and a smooth cover over the anastomosis site. This adhesive was used ex vivo on fifteen samples of equine jejunum as the second layer of a two-layer anastomosis (1L-UV-PMA group) and compared to a two-layer anastomosis (simple continuous pattern covered with a Cushing pattern; 2L-CT group), in terms of feasibility, bursting strength pressure (BSP), luminal diameter reduction (LDR), and time of construction. Data were analysed using a paired t-test or a chi²-test (P < 0.05). The results showed no statistical difference in BSP, LDR, or any mode of failure between the two anastomosis types. However, the glue anastomosis formed a tunnel-like anastomosis and shredded under pressure, before apparition of leakage, preventing its usage in clinical cases with this methodology. It was concluded that modification of the technique is warranted before testing in clinical cases. A preprint of a former version of the manuscript is available on researchsquare.com, which was not conducted to print and publication after peer reviewing. Since then, the manuscript has been modified to this current version.

Ex vivo comparison of the biomechanical properties of hand-sewn and stapled jejunoileal anastomoses in horses

OBJECTIVE

To compare bursting strength, construction time, and anastomotic dimensions of 4 jejunoileal anastomotic techniques.

STUDY DESIGN

Experimental ex vivo study.

ANIMALS

Adult horses (n = 12).

METHODS

Jejunoileal anastomoses were constructed from harvested ileal and distal jejunal segments using a single-layer Lembert technique (1HS), double-layer simple continuous/Cushing technique (2HS), stapled side-to-side technique (SS), or stapled functional end-to-end technique (FEE). Anastomotic construction time was recorded. Bursting pressures (BP), bursting wall tension (BWT), percentage of mean anastomotic luminal diameter reduction, percentage of luminal diameter reduction relative to adjacent ileal and jejunal diameters and stomal length, were calculated.

RESULTS

FEE had the shortest construction time. BP of 1HS and 2HS was significantly higher than FEE and SS (P < .001), which were not different from each other (P = .67). There were no significant differences in BP (P = .25) and BWT (P = .21) between 1HS and 2HS. Mean luminal diameter reduction was less for 1HS (25.1%) than for 2HS (34.8%), however, not statistically different (P = .12). Luminal diameter reduction relative to ileal diameter was significantly less for 1HS (15.2%) than for 2HS (28.47%; P = .012). Luminal diameter reduction relative to jejunal diameter was less for 1HS (32.4%) than 2HS (44.6%) but not statistically different; P = .07). Stomal length was significantly larger for SS (9.93 cm) than FEE (7.32 cm; P = .0002).

CONCLUSION

1HS and 2HS jejunoileal anastomosis are equal in strength; however, 1HS results in less relative luminal diameter reduction. SS and FEE have comparable strength but fail at significantly lower BPs than hand-sewn jejunoileal anastomoses.

In vitro comparison of V-Loc™ versus Biosyn™ in a one-layer end-to-end anastomosis of equine jejunum

OBJECTIVE

To compare a unidirectional barbed suture (V-Loc™) to its suture material equivalent (Biosyn™) in a single-layer end-to-end anastomosis of equine jejunum.

STUDY DESIGN

Experimental in vitro study.

ANIMALS

Jejunal sections from adult horses (n = 5) without gastrointestinal disease.

METHODS

Jejunal end-to-end anastomoses (n = 9) were performed for each group (V-Loc™, Biosyn™) with a continuous Lembert pattern with an interruption every 120°. Anastomosis construction time, luminal diameter, and number of suture bites were recorded. Anastomosis constructs were distended with fluid at 1 L/min until failure. Location and intraluminal pressure at failure were recorded and all measurements were compared between groups.

RESULTS

V-Loc™ anastomoses were significantly faster to perform (13.1 ± 0.35 minutes) when compared to the Biosyn™ group (15.6 ± 0.72 minutes; P = .0004). No differences were observed for anastomotic index or number of suture bites. V-Loc™ anastomosis constructs had a significantly decreased bursting pressure (160 ± 11.6 mmHg) compared to Biosyn™ constructs (184 ± 16.9 mmHg; P = .01).

CONCLUSIONS

V-Loc™ allowed faster construction time and did not cause a decreased anastomosis luminal diameter when compared with Biosyn™. V-Loc™ had a decreased bursting strength compared with Biosyn™, albeit well above pathologic pressures encountered clinically. Use of V-Loc™ may be beneficial for decreasing the amount of exposed suture material because of the absence of knots after construction and has the potential to result in decreased adhesions.

In vitro comparison of a single-layer (continuous Lembert) versus two-layer (simple continuous/Cushing) hand-sewn end-to-end jejunoileal anastomosis in normal equine small intestine

OBJECTIVES

To compare in vitro physical and mechanical characteristics of 1-layer and 2-layer end-to-end jejunoileostomy.

STUDY DESIGN

In vitro experimental study.

ANIMALS

Adult horses (n = 6).

METHODS

Harvested equine jejunum and ileum was used to create 1- and 2-layer end-to-end jejunoileostomy specimens. Construction time, bursting pressure, and relative lumen diameter (anastomosis diameter expressed as a percentage of the lumen diameter of adjacent jejunum and ileum) were compared. Construction time and relative lumen diameters were compared using a paired t-test. Bursting pressure for anastomoses and control jejunal segments were compared using a repeated-measure ANOVA. Statistical significance was set at P < .05.

RESULTS

Mean (± SEM) construct completion times were shorter for 1 layer (21 ± 0.91 minutes) than 2 layers (26.71 ± 1.16 minutes; P = .005). Relative lumen diameters (percentage of jejunal diameter) were larger for 1 layer (77.67 ± 4.46%) than for 2 layers (69.37 ± 2.8%; P = .035). There were no significant differences in bursting pressures between the 2 groups and the control jejunum (P =.155) or relative lumen diameters (percentage of ileal diameter; P =.118).

CONCLUSIONS

One-layer jejunoileostomy can be created in a shorter time and maintain a larger anastomosis luminal diameter without compromising maximum bursting pressure when compared to 2-layer jejunoileostomy.

Differential survival in horses requiring end-to-end jejunojejunal anastomosis compared to those requiring side-to-side jejunocaecal anastomosis

REASONS FOR PERFORMING STUDY

Horses requiring different methods of intestinal anastomosis during equine colic surgery may have differences in mortality and morbidity.

HYPOTHESES

Horses requiring side-to-side jejunocaecal anastomosis have a higher mortality and morbidity rate than those requiring end-to-end jejunojejunal anastomosis. Morbidity and mortality of handsewn vs. stapled side-to-side jejunocaecal anastomoses are not significantly different.

METHODS

A prospective, nonrandomised, observational study was conducted. Clinical and surgical details were recorded during hospitalisation and survival data acquired by periodic telephone questionnaire. Differences in mortality and morbidity rate were evaluated by survival analysis.

RESULTS

A total of 184 horses underwent end-to-end jejunojejunal anastomosis and 178 underwent side-to-side jejunocaecal anastomosis. Horses with a jejunocaecal anastomosis had a significantly higher mortality rate. The incidence of post operative colic in horses requiring side-to-side jejunocaecal anastomoses was greater than those requiring end-to-end jejunojejunal anastomoses. Within the group undergoing side-to-side jejunocaecal anastomosis there was no evidence of differential survival between horses with handsewn vs. stapled anastomoses.

CONCLUSIONS

Mortality rate is higher in horses that have required side-to-side jejunocaecal anastomosis than in those that needed end-to-end jejunojejunal anastomosis; and post operative colic is more common after side-to-side jejunocaecal anastomosis. No difference in mortality was found between horses with handsewn and stapled side-to-side jejunocaecal anastomoses.

POTENTIAL RELEVANCE

Surgeons should be aware of the increased mortality and morbidity in horses requiring side-to-side jejunocaecal anastomosis. Our finding of no difference in mortality between handsewn and stapled side-to-side jejunocaecal anastomoses justifies surgeons exercising personal preference in their selection of anastomosis method.

Evaluation of a laparoscopic technique for collection of serial full-thickness small intestinal biopsy specimens in standing sedated horses

OBJECTIVE

To assess a technique for laparoscopic collection of serial full-thickness small intestinal biopsy specimens in horses.

ANIMALS

13 healthy adult horses.

PROCEDURES

In the ex vivo portion of the study, sections of duodenum and jejunum obtained from 6 horses immediately after euthanasia were divided into 3 segments. Each segment was randomly assigned to the control group, the double-layer hand-sewn closure group, or the endoscopic linear stapler (ELS) group. Bursting strength and bursting wall tension were measured and compared among groups; luminal diameter reduction at the biopsy site was compared between the biopsy groups. In the in vivo portion of the study, serial full-thickness small intestinal biopsy specimens were laparoscopically collected with an ELS from the descending duodenum and distal portion of the jejunum at monthly intervals in 7 sedated, standing horses. Biopsy specimens were evaluated for suitability for histologic examination.

RESULTS

Mean bursting strength and bursting wall tension were significantly lower in the ELS group than in the hand-sewn and control groups in both the duodenal and jejunal segments. Use of the hand-sewn closure technique at the biopsy site reduced luminal diameter significantly more than use of the stapling technique. In the in vivo part of the study, all 52 biopsy specimens collected during 26 laparoscopic procedures were suitable for histologic examination and no clinically important perioperative complications developed.

CONCLUSIONS AND CLINICAL RELEVANCE

Laparoscopic collection of serial full-thickness small intestinal biopsy specimens with a 45-mm ELS may be an effective and safe technique for use in healthy adult experimental horses.

Surgical Stapling Devices in Veterinary Medicine: A Review

OBJECTIVES

To review indications, benefits, and complications of surgical stapling in animals.

STUDY DESIGN

Literature review.

RESULTS

Benefits and complications of surgical stapling depend on the procedure performed. Use of surgical staplers does not improve wound strength but may decrease surgical time.

CLINICAL RELEVANCE

In patients at significant risk for intraoperative contamination or morbidity from prolonged anesthesia time, use of stapling devices should be considered.

In Vitro Evaluation of an Inverted End-to-End Equine Jejunojejunal Anastomosis Using Skin Staples

OBJECTIVE

To compare functional indices of end-to-end (EEA) jejunojejunal anastomosis using skin staples in horses with a 2-layer inverting hand-sewn technique.

STUDY DESIGN

Experimental study.

SAMPLE POPULATION

Jejunal segments from 8 fresh equine cadavers.

METHODS

For each bowel segment, 2 EEA anastomoses were created: one 2-layer hand-sewn and one 1-layer using skin staples. Time for anastomosis creation was recorded and compared. Lumen diameter of each anastomosis was measured on digital radiographs after intraluminal instillation of contrast medium and inflation of the jejunal segments to 14 mm Hg. Anastomotic indices (a compensated measure of stoma diameter) and bursting pressure were determined.

RESULTS

EEA jejunal anastomosis using skin staples was significantly faster than use of a 2-layer hand-sewn technique. Anastomotic index, a measure of lumen size, was significantly larger with the skin-staple technique; however, the bursting pressure of stapled anastomoses was significantly less than for the hand-sewn technique, but the values were well above those reported for other anastomotic techniques.

CONCLUSIONS

An anastomotic technique using skin staples was easy to learn and perform, effective and faster, and mechanically comparable with a hand-sewn 2-layer technique.

CLINICAL RELEVANCE

The staple technique could be beneficial in equine gastrointestinal surgery by reducing anastomosis time, although further in vivo studies are needed to establish clinical safety.

Comparison of One-Layer (Continuous Lembert) Versus Two-Layer (Simple Continuous/Cushing) Hand-Sewn End-to-End Anastomosis in Equine Jejunum

OBJECTIVE

To evaluate single and double layer end-to-end anastomosis in equine jejunum.

STUDY DESIGN

Experimental in vitro study.

ANIMALS

Mid-jejunal sections from 12 adult horses without gastrointestinal disease.

METHODS

Jejunal end-to-end anastomoses were performed by a continuous Lembert pattern or a simple continuous pattern oversewn with a Cushing pattern. Jejunal segments were distended with fluid at 1 L/min, and intraluminal pressure at failure, and mode of failure were recorded. Bursting pressure and bursting wall tension were calculated. Anastomosis construction time and degree of luminal reduction were recorded. Results- Single layer anastomoses were constructed in less time than 2-layer anastomoses. Both anastomotic techniques resulted in luminal reduction compared with control tissue; however, the reduction was smaller with a 1-layer continuous Lembert anastomosis. No differences were noted in bursting pressure or bursting wall tension between groups.

CONCLUSIONS

Anastomosis using a 1-layer continuous Lembert pattern resulted in a larger stoma, was faster to perform, and as strong as a 2-layer anastomosis.

CLINICAL RELEVANCE

Use of a 1-layer continuous Lembert pattern for jejunojejunosotomy may be beneficial by decreasing anastomosis time and produce a larger stoma than a 2-layer anastomosis.

In Vitro Evaluation of a Closed-Bowel Technique for One-Layer Hand-Sewn Inverting End-to-End Jejunojejunosotomy in the Horse

OBJECTIVE

To report a technique for closed-bowel 1-layer inverting end-to-end jejunojejunal anastomosis in horses.

STUDY DESIGN

Experimental study.

SAMPLE POPULATION

Fresh cadaveric jejunal segments from 12 horses.

METHODS

For each bowel segment a 1-layer closed and a 2-layer inverting end-to-end jejunojejunosotomy was created. Anastomosis construction time and anastomotic bursting pressure were measured and compared.

RESULTS

Closed-bowel anastomosis was significantly faster to create than a 2-layer technique. Luminal narrowing (<30%) was similar with both techniques and comparable with other inverting techniques. Bursting pressure was significantly higher for the 2-layer technique, although all anastomoses resisted pressures higher than those reported for other jejunojejunal anastomosis techniques.

CONCLUSIONS

A 1-layer hand-sewn, closed, inverting jejunojejunosotomy using a modified Doyen clamp was easy and faster to perform, and resulted in functional characteristics similar to, a 2-layer hand-sewn inverting technique.

CLINICAL RELEVANCE

A closed, 1-layer inverting technique could be considered for equine jejunal anastomosis but requires in vivo evaluation before recommendation for clinical use.

Prevention and treatment of gastrointestinal adhesions

As with many aspects of clinical medicine, there is yet to be a single or definitive cure for postoperative adhesion formation. Current methods of prevention target risk factors predisposing horses to adhesion formation. Systemic pharmacologic therapies, such as antimicrobials, nonsteroidal anti-inflammatory drugs, Salmonella antiserum, and hyperimmune plasma, help to reduce abdominal inflammation and minimize the effects of endotoxemia. Intra-abdominal or systemic heparin aids in enhancing peritoneal fibrinolysis. Prokinetic therapy promotes early postoperative return of intestinal motility, minimizing the propensity for adhesion formation between apposing adynamic segments of intestine. Mechanical separation of potentially adhesiogenic serosal and peritoneal surfaces is commonly achieved with use of abdominal lavage, protective coating solutions, and barrier membranes. Ongoing and future research is directed toward a better understanding of the local effects of intestinal trauma and the corresponding response of the fibrinolytic system. Recognition of horses at high risk for adhesion formation helps to guide the equine surgeon to an appropriate perioperative and intraoperative plan for adhesion prevention, including good surgical technique and a combination of adjunct therapies.

A comparison of the mechanical strength of two stapled anastomosis techniques for equine small intestine

OBJECTIVE

To compare bursting strength, time of construction, and cost of a closed one-stage, stapled functional end-to-end jejunojejunostomy (FEE) with a stapled side-to-side jejunojejunostomy (STS).

STUDY DESIGN

Experimental, randomized block design.

ANIMALS

Seven adult horses without gastrointestinal disease.

METHODS

The jejunum was isolated, and three FEE, three STS, and three control segments were created in each horse using a randomized block design. Anastomosis time was recorded. The intraluminal pressure at failure and mode of failure were recorded. Length at failure was measured on digitized images. Bursting pressure (BP), bursting wall tension (BWT), anastomosis time, and cost were compared.

RESULTS

Control jejunal segments were stronger (P < or = .0001) in bursting strength and bursting wall tension (P < or = .0001) than either anastomosis type; no difference was found between anastomosis types for either variable. Functional end-to-end jejunojejunostomy was significantly quicker and less costly than STS (P < or = .0001).

CONCLUSIONS

Mechanically there were no significant differences between the FEE and STS techniques. The FEE technique maintained the physiologic direction of peristalsis of the segments, required less tissue manipulation, and was faster and more economical to create.

CLINICAL RELEVANCE

The FEE is a clinically viable technique.

Clinical assessment and outcome of three techniques for jejunal resection and anastomosis in horses: 59 cases (1989-2000)

OBJECTIVE

To compare postoperative complications, short- and long-term survival, and surgical times for hand-sewn end-to-end (EE), stapled functional end-to-end (FEE), and stapled side-to-side (SS) anastomotic techniques for jejunal resection in horses.

DESIGN

Retrospective study.

ANIMALS

59 horses.

PROCEDURE

Medical records were reviewed to obtain signalment, diagnosis, treatment, and outcome for horses that underwent jejunojejunostomy in our hospital. Only horses that recovered from anesthesia were included in the study.

RESULTS

Among the 59 horses, there were 33 EE, 15 FEE, and 11 SS anastomoses. No difference was found in duration of surgery among the 3 techniques. The most common postoperative complications were colic episodes (56%), ileus (53%), diarrhea (20%), and adhesions (15%). Horses with SS anastomosis had a significantly shorter duration of postoperative ileus than the EE group did. No significant difference in duration of postoperative ileus was found among the other groups. No difference was found among the 3 anastomotic techniques in regard to survival rate at the time of discharge, 6 months after surgery, or 1 year after surgery. Overall survival rates after jejunal anastomosis were 88% at the time of discharge, 65% at 6 months after surgery, and 57% at > or = 1 year after surgery.

CONCLUSIONS AND CLINICAL RELEVANCE

The hand-sewn EE, stapled FEE, and stapled SS anastomotic techniques should be considered equivalent methods for small intestinal anastomosis in the horse. However, the stapled SS technique may be preferred because of possible decreased duration of postoperative ileus.

Use of a hyaluronate membrane for jejunal anastomosis in horses

OBJECTIVE

To compare the outcomes of double-layer inverting anastomosis (DIA), single-layer anastomosis (SLA), and single-layer anastomosis combined with a hyaluronate membrane (SLA+HA-membrane) with respect to stomal diameter, adhesion formation, surgery time, and anastomotic healing in horses.

ANIMALS

18 adult horses.

PROCEDURE

Midline celiotomy and end-to-end anastomoses were performed. In control horses (n = 6), DIA was performed; in treated horses, SLA was performed (6) or SLA+HA-membrane was performed (6). Horses were euthanatized 21 days after surgery. Abdominal adhesions were evaluated grossly and histologically. Stomal diameters were measured ultrasonographically and compared with adjacent luminal diameters. Anastomotic healing was evaluated histologically for fibrosis and inflammation, tissue alignment, and inversion. Surgery times were recorded for the anastomotic procedure and compared among groups.

RESULTS

There were significantly more adhesions in the SLA group, compared with the DIA and SLA+HA-membrane groups. Reduction in stomal diameters in the DIA group was significantly greater than the SLA and SLA+HA-membrane groups. Surgery times for the DIA group were significantly greater than the SLA and SLA+HA-membrane groups. Histologic findings of fibrosis, inflammation, and mucosal healing were similar among groups. There was significant tissue inversion in the DIA group, compared with the 2 treatment groups. Tissue alignment was not different among groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Use of a SLA+HA-membrane was an effective small intestinal anastomotic technique. This technique was faster to perform and resulted in a larger stomal diameter, compared with the DIA technique and significantly fewer perianastomotic adhesions, compared with the SLA technique.

Closed one-stage functional end-to-end jejunojejunostomy in horses with use of linear stapling equipment

OBJECTIVE

To use gastrointestinal linear stapling instrumentation to perform a closed one-stage functional end-to-end jejunojejunostomy in adult horses as an alternative to a stapled side-to-side jejunojejunostomy.

STUDY DESIGN

Clinical outcome, anatomic and histological architecture, and anastomotic dimensions were determined at 2, 4, 8, 16, and 24 weeks postoperatively.

ANIMALS OR SAMPLE POPULATION

18 adult horses.

METHODS

The anastomosis and peritoneal cavity were inspected for adhesions. The diameter and circumference of the anastomosis and jejunum oral and aboral to the anastomosis were determined from digitized contrast radiographs and linear measurements. Healing of anastomotic sites was evaluated histologically.

RESULTS

Three horses were euthantized in the immediate postoperative period. In the 15 surviving horses, there were no peritoneal adhesions or distortion of the anastomoses and stomas remodeled in an end-to-end fashion. The mean anastomotic staple line (7.48 cm) and mucosa (6.89 cm) diameters were significantly (P < .05) larger than the mean jejunal diameter oral (6.03 cm) and aboral (6.01 cm) to the anastomosis. The mean anastomotic luminal circumference (13.61 cm) was significantly (P < .01) larger than the mean oral (11.43 cm) and aboral (11.12 cm) jejunal circumference. Histologically, there was adequate mucosal and muscularis mucosae reapposition with a moderate degree of fibrosis and inflammation.

CONCLUSIONS

Closed one-stage functional end-to-end jejunojejunostomy resulted in an acceptable functional anastomosis.

CLINICAL RELEVANCE

This technique appears to be an acceptable alternative to linearly stapled, side-to-side jejunojejunostomies performed in horses.

Surgery of the small intestine

Although earlier reports describe a poor prognosis for small intestinal surgery in the horse, there is growing evidence that the short-term survival rate can exceed 80%. In addition to advancements in surgery and aftercare, early referral contributes considerably to the improved prognosis. Surgical procedures that restore anatomic and physiologic continuity to close to normal can minimize postoperative complications. Jejunojejunostomy carries a better prognosis than jejunocecostomy, probably because the latter involves anastomosis between two intestinal segments with dissimilar functions. Careful technique can reduce the prevalence of complications, such as postoperative ileus and serosal adhesions.

Instrumentation and techniques in equine gastrointestinal surgery

Recent advances in abdominal surgical techniques in the horse have resulted in improved survival rates and reduced postoperative morbidity. The development of abdominal surgical procedures in horses has paralleled the development of safe anesthetic protocols and innovative technological advancements in humans. Irrespective of the species, the application of sound surgical principles is still the foundation of surgical intervention. This article describes recent advances in equine gastrointestinal surgical techniques. The availability and application of innovative intestinal surgical devices and their specific uses in equine gastrointestinal surgery are also described.

Jejunal intussusception: a complication of functional end-to-end stapled anastomoses in two ponies

Jejunojejunal intussusception occurred after jejunal resection and stapled functional end-to-end anastomosis in two pony mares. In both mares, the lead point of the intussusception was the stapled functional end-to-end (FEE) anastomosis. The stapled free ends of jejunum were oversewn with an inverting suture pattern. A possible explanation for development of the intussusception was the acute angle created in the intestine by the FEE anastomosis. This angulation may have impaired flow of ingesta causing motility changes that predisposed the site to intussusception. Because the oversewn blind intestinal ends acted as the lead point for formation of the intussusception, it may be inadvisable to oversew the stapled anastomotic ends.

Comparison of a biofragmentable intestinal anastomosis ring with appositional suturing for subtotal colectomy in normal cats

A subtotal colectomy was performed on 12 normal adult cats using an interrupted apposing suture pattern of monofilament polyglyconate (n = 6) or a biofragmentable intestinal anastomosis ring (Valtrac, Davis and Geck Company, Danbury, CT) (n = 6) composed of polyglycolic acid and barium sulfate. Abdominal radiographs were made daily, beginning 10 days after surgery, to determine fragmentation rates of the anastomosis ring. The cats were euthanatized 30 days after surgery, and a gross and histopathological evaluation of anastomotic healing and stricture formation was performed. The technique for implantation of the anastomosis ring was easy to learn and required only two purse string sutures to complete. Intraoperative complications associated with the anastomosis ring were minor, and included problems with purse string suture placement, small serosal tears, and spasms of the colon that reduced the lumenal diameter. There were no intraoperative complications in the cats with sutured anastomoses. Postoperative recovery was uneventful in all cats. The anastomosis rings fragmented 12.2 +/- 1.1 days (mean +/- standard deviation [SD]) after implantation and passed in the stool 3.8 +/- 1.9 days later without clinical signs in five of six cats. There were no statistically significant differences between the time required to perform the anastomosis (P = .348), postmortem gross anastomosis grades (P = .088), or percent of lumenal stricture (P = .178) between the two groups. Histologically, the only significant differences were an increased muscular inversion in the anastomoses performed using the fragmentable ring (P = .039) and an increased muscular eversion in the sutured anastomoses (P < .001) compared with normal colonic architecture.