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Surgical Management of Enterocutaneous Fistula in a Mare
CLINICAL TECHNIQUES Surgical Management of Enterocutaneous Fistula in a Mare Vandana Sangwan, MVSc,a Jitender Mohindroo, MVSc, PhD,b Kiranjeet Singh, MVSc, PhD,b Mulinti Raghunath, MVSc, PhD,b and Shashi Kant Mahajan, MVSc, PhDb
ABSTRACT Enterocutaneous fistulas are reported to be sequelae of congenital umbilical hernia or penetrating trauma to the equine patient’s abdomen. An enterocutaneous fistula is considered to be the least common clinical presentation in a horse with incarcinated umbilical hernia, and may be life-threatening if not managed timely. This case report describes an enterocutaneous fistula in a mare as a sequela to congenital umblical hernia. The mare had an uneventful recovery after surgical repair and delivered a healthy foal on subsequent followup. The report highlights the need to repair congenital umbilical hernias (regardless of the size), if they do not resolve by the age of 6 to 12 months. Keywords: Mare; Surgery; Enterocutaneous fistula; Richter’s hernia; Enterotomy
INTRODUCTION Small congenital umbilical hernias are often diagnosed in young horses. Usually they resolve spontaneously and do not require surgical intervention. However, it has been reported that small umbilical hernias (1 cm diameter) later develop into an enterocutaneous fistula.1 The length of time of the entrapment of the intestinal loop within the hernia ring can determine the long-term prognosis. Sometimes, the intestinal loop is not irreducibly entrapped in the hernia and may occasionally return to the abdomen and not be fatal. If the length of time of entrapment is long (days to months), it may lead to a bowel perforation and the development of septic peritonitis.1 This case report From the Department of Teaching Veterinary Clinical complex, Guru Angad Dev Veterinary and Animal Sciences University, Punjab, Indiaa; and Department of Veterinary Surgery and Radiology, Guru Angad Dev Veterinary and Animal Sciences University, Punjab, Indiab. Reprint requests: Jitender Mohindroo, MVSc, PhD, Department of Veterinary Surgery and Radiology, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana, Punjab, India. 0737-0806/$ - see front matter Ó 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jevs.2010.04.011
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describes the successful surgical treatment of an enterocutaneous fistula in a young mare.
CASE PRESENTATION A 2-year-old mare was presented to the Veterinary Teaching Hospital with an open wound on the ventral abdomen. Green-colored ingesta was leaking from the wound. The history revealed the presence of a small umbilical hernia since birth. However, during the last 15 days, a softtissue swelling was observed by the owner along the entire ventral abdomen, extending up to the cranial thorax. The mare was treated by the local veterinarian; the swelling reduced in size but the firm mass, next to the umbilicus, persisted. The firm mass eventually ruptured 2 days before presentation and ingesta was seen draining from the wound. Physical examination confirmed this to be an enterocutaneous fistula. The mare was otherwise clinically healthy, although it had a reduced appetite. There was no history of abdominal pain since birth. The mare was prepared for exploratory surgery. General anesthesia was induced using xylazine, 1.1 mg/kg intravenously (IV) as a preanesthetic, followed by ketamine, 2.2 mg/kg IV for induction. The mare was intubated, using a 20-mm cuffed endotracheal tube, and maintained on halothane and oxygen inhalation anesthesia. The mare was positioned in dorsal recumbency, and an aseptic preparation of the surgical site and an en bloc resection of the firm mass including the skin wound was performed. The ruptured portion of the intestine (jejunum) was separated from the body wall using blunt dissection. The mesenteric side of the affected intestine was considered healthy (Fig. 1), but a wedge-shaped section of the affected antimesenteric portion of the intestine was resected and closed in a single layer using Schmieden’s suture pattern (Fig. 2) by using #2 Polygalactin 910. The resected and sutured intestine was thoroughly lavaged using normal saline solution and returned to the abdomen. The abdominal wound was closed with simple interrupted sutures using #1 Polygalactin 910 and #1 Polyamide. The skin wound was closed with #1 Polyamide using simple interrupted sutures. The mare had an uncomplicated anesthetic recovery within 20 minutes of discontinuing
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Figure 1. An affected intestine after separating from the abdominal wall. The mesenteric portion of the intestine is healthy.
inhalation anesthesia. Postoperative care included intravenous fluids, lactated Ringer’s solution (15 L), and 5% dextrose in normal saline (5 L) daily for 3 consecutive days, 2 g ampicillin and 2 g cloxacillin q 12 hours for 7 days IV, 20 mL (100 mg/mL) gentamicin q 12 hours for 5 days intramuscularly (IM), 5 g metronidazole q 12 hours IV for 3 days, and 15 mL meloxicam IM once a day (OD) for 3 days. Oral intake, except water, was restricted for 3 days postoperatively. The mare passed normal feces on the first day after surgery. The mare was discharged from the hospital on day 4 postsurgery, with recommendations for soft green grass diet for the next 15 days. Surgical wound healing progressed uneventfully and skin sutures were removed on day 14 postsurgery. Three months rest was advised for the mare before return to her normal farm routine. Follow-up 18 months after surgery revealed the mare to be healthy and she had delivered a healthy foal during this period.
DISCUSSION The development of enterocutaneous fistulae is the least common clinical presentation for an incarcinated umbilical hernia.1,2 This report describes a case of a partial or Richter’s hernia which developed into an enterocutaneous fistula. Saunders Medical Dictionary3 defines a Richter’s hernia as an incarcinated or strangulated hernia in which only part of the circumference of the bowel is involved. For an enterocutaneous fistula to develop, the bowel must remain entrapped long enough to undergo ischemic necrosis and subsequent leakage of bowel contents into the subcutaneous tissue.1 A similar history and clinical findings were recorded in this reported case. Another important feature of this case was the absence of colic even though a portion of the bowel may have been entrapped for as long as 15 to 20 days. Earlier reports1,2,4
Figure 2. Enterotomy closed using Schmieden’s suture pattern.
also mention that colic was not a consistent sign of umbilical hernia or an enterocutaneous fistula. The possible reasons may be the lack of complete intestinal blockage and entrapping only the antimesenteric part of the intestine. Therefore, the mesentery of the affected bowel may not be under tension causing abdominal pain. The combination of xylazine and ketamine was satisfactory for the induction of general anesthesia and endotracheal intubation in the mare. No adverse effects of the anesthetic combination was observed and the mare showed a rapid and uncomplicated anesthetic recovery.5 This case was successfully treated by using an en bloc resection of the body wall.2 The compromised bowel was resected in a wedge-shaped manner referred to as a segmental resection. In cases in which ischemic and necrosed bowel is limited and confined to a small area of intestine, a wedge resection or segmental resection can be performed.6 Schmieden’s suture pattern is an inverting-suture pattern encompassing all layers of the bowel and can be easily and effectively used in intestinal surgery.7 Earlier studies also report closure of small intestinal enterotomy wounds using various inverting-suture patterns with synthetic absorbable suture material such as Polygalactin 910.8
CONCLUSION Clinical examination and history assisted in the correct diagnosis in this case. Enterocutaneous fistula can be successfully treated surgically provided the compromised part of the intestine is confined to the body wall and has not contaminated the peritoneal cavity. The authors recommend surgical repair of congenital umbilical hernias if they do not spontaneously resolve by 6 to 12 months of
336
age.1 This mare was a successful broodmare 3 months after surgery and delivered a foal 11 months later.
V Sangwan et al Vol 30, No 6 (2010)
5. Hall LW, Clarke KW. Anaesthesia of the horse. In: Hall LW, Clarke KW, eds. Veterinary anaesthesia, 9th ed. London, UK: ELBS 1991:217–224. 6. Rose J, Rose EM, White NA II. Subtotal resection and anastomosis of
REFERENCES
the ascending colon. In: White NA, Moore JN, eds. Current tech-
1. Baxter GM. Umbilical enterocutaneous fistula. Compend Equine Ed
niques in equine surgery and lameness, 2nd ed. Philadelphia, PA: W
2007;2:96–99. 2. Bristol DG. Enterocutaneous fistulae in horses: 18 cases (1964–1992). Vet Surg 1994;23:167–171. 3. Dorland’s medical dictionary for health consumers. Philadelphia, PA:
B Saunders Company 1998:283. 7. Kumar A, Kumar A. Suture material and techniques. In: Tyagi RP, Singh J, eds. Ruminant surgery, 1st ed. New Delhi, India: CBS Publishers and distributers 1993:78.
W.B. Saunders 2007. 4. Markel MD, Pascoe JR, Sams AE. Strangulating umbilical hernias
8. Mcllwraith CW, Robertson JT, Turner AS. Enterotomy techniques
in horses: 13 cases (1974–1985). J Am Vet Med Assoc 1987;190:
Turner’s equine surgery: advanced techniques, 2nd ed. Cambridge,
692–694.
MA: Blackwell 1998:324.
(surgery of gastrointestinal tract). In: Cann C, ed. Mcllwraith and
ABSTRACT Enterocutaneous fistulas are reported to be sequelae of congenital umbilical hernia or penetrating trauma to the equine patient’s abdomen. An enterocutaneous fistula is considered to be the least common clinical presentation in a horse with incarcinated umbilical hernia, and may be life-threatening if not managed timely. This case report describes an enterocutaneous fistula in a mare as a sequela to congenital umblical hernia. The mare had an uneventful recovery after surgical repair and delivered a healthy foal on subsequent followup. The report highlights the need to repair congenital umbilical hernias (regardless of the size), if they do not resolve by the age of 6 to 12 months. Keywords: Mare; Surgery; Enterocutaneous fistula; Richter’s hernia; Enterotomy
INTRODUCTION Small congenital umbilical hernias are often diagnosed in young horses. Usually they resolve spontaneously and do not require surgical intervention. However, it has been reported that small umbilical hernias (1 cm diameter) later develop into an enterocutaneous fistula.1 The length of time of the entrapment of the intestinal loop within the hernia ring can determine the long-term prognosis. Sometimes, the intestinal loop is not irreducibly entrapped in the hernia and may occasionally return to the abdomen and not be fatal. If the length of time of entrapment is long (days to months), it may lead to a bowel perforation and the development of septic peritonitis.1 This case report From the Department of Teaching Veterinary Clinical complex, Guru Angad Dev Veterinary and Animal Sciences University, Punjab, Indiaa; and Department of Veterinary Surgery and Radiology, Guru Angad Dev Veterinary and Animal Sciences University, Punjab, Indiab. Reprint requests: Jitender Mohindroo, MVSc, PhD, Department of Veterinary Surgery and Radiology, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana, Punjab, India. 0737-0806/$ - see front matter Ó 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jevs.2010.04.011
334
describes the successful surgical treatment of an enterocutaneous fistula in a young mare.
CASE PRESENTATION A 2-year-old mare was presented to the Veterinary Teaching Hospital with an open wound on the ventral abdomen. Green-colored ingesta was leaking from the wound. The history revealed the presence of a small umbilical hernia since birth. However, during the last 15 days, a softtissue swelling was observed by the owner along the entire ventral abdomen, extending up to the cranial thorax. The mare was treated by the local veterinarian; the swelling reduced in size but the firm mass, next to the umbilicus, persisted. The firm mass eventually ruptured 2 days before presentation and ingesta was seen draining from the wound. Physical examination confirmed this to be an enterocutaneous fistula. The mare was otherwise clinically healthy, although it had a reduced appetite. There was no history of abdominal pain since birth. The mare was prepared for exploratory surgery. General anesthesia was induced using xylazine, 1.1 mg/kg intravenously (IV) as a preanesthetic, followed by ketamine, 2.2 mg/kg IV for induction. The mare was intubated, using a 20-mm cuffed endotracheal tube, and maintained on halothane and oxygen inhalation anesthesia. The mare was positioned in dorsal recumbency, and an aseptic preparation of the surgical site and an en bloc resection of the firm mass including the skin wound was performed. The ruptured portion of the intestine (jejunum) was separated from the body wall using blunt dissection. The mesenteric side of the affected intestine was considered healthy (Fig. 1), but a wedge-shaped section of the affected antimesenteric portion of the intestine was resected and closed in a single layer using Schmieden’s suture pattern (Fig. 2) by using #2 Polygalactin 910. The resected and sutured intestine was thoroughly lavaged using normal saline solution and returned to the abdomen. The abdominal wound was closed with simple interrupted sutures using #1 Polygalactin 910 and #1 Polyamide. The skin wound was closed with #1 Polyamide using simple interrupted sutures. The mare had an uncomplicated anesthetic recovery within 20 minutes of discontinuing
Journal of Equine Veterinary Science Vol 30, No 6 (2010)
V Sangwan et al Vol 30, No 6 (2010)
335
Figure 1. An affected intestine after separating from the abdominal wall. The mesenteric portion of the intestine is healthy.
inhalation anesthesia. Postoperative care included intravenous fluids, lactated Ringer’s solution (15 L), and 5% dextrose in normal saline (5 L) daily for 3 consecutive days, 2 g ampicillin and 2 g cloxacillin q 12 hours for 7 days IV, 20 mL (100 mg/mL) gentamicin q 12 hours for 5 days intramuscularly (IM), 5 g metronidazole q 12 hours IV for 3 days, and 15 mL meloxicam IM once a day (OD) for 3 days. Oral intake, except water, was restricted for 3 days postoperatively. The mare passed normal feces on the first day after surgery. The mare was discharged from the hospital on day 4 postsurgery, with recommendations for soft green grass diet for the next 15 days. Surgical wound healing progressed uneventfully and skin sutures were removed on day 14 postsurgery. Three months rest was advised for the mare before return to her normal farm routine. Follow-up 18 months after surgery revealed the mare to be healthy and she had delivered a healthy foal during this period.
DISCUSSION The development of enterocutaneous fistulae is the least common clinical presentation for an incarcinated umbilical hernia.1,2 This report describes a case of a partial or Richter’s hernia which developed into an enterocutaneous fistula. Saunders Medical Dictionary3 defines a Richter’s hernia as an incarcinated or strangulated hernia in which only part of the circumference of the bowel is involved. For an enterocutaneous fistula to develop, the bowel must remain entrapped long enough to undergo ischemic necrosis and subsequent leakage of bowel contents into the subcutaneous tissue.1 A similar history and clinical findings were recorded in this reported case. Another important feature of this case was the absence of colic even though a portion of the bowel may have been entrapped for as long as 15 to 20 days. Earlier reports1,2,4
Figure 2. Enterotomy closed using Schmieden’s suture pattern.
also mention that colic was not a consistent sign of umbilical hernia or an enterocutaneous fistula. The possible reasons may be the lack of complete intestinal blockage and entrapping only the antimesenteric part of the intestine. Therefore, the mesentery of the affected bowel may not be under tension causing abdominal pain. The combination of xylazine and ketamine was satisfactory for the induction of general anesthesia and endotracheal intubation in the mare. No adverse effects of the anesthetic combination was observed and the mare showed a rapid and uncomplicated anesthetic recovery.5 This case was successfully treated by using an en bloc resection of the body wall.2 The compromised bowel was resected in a wedge-shaped manner referred to as a segmental resection. In cases in which ischemic and necrosed bowel is limited and confined to a small area of intestine, a wedge resection or segmental resection can be performed.6 Schmieden’s suture pattern is an inverting-suture pattern encompassing all layers of the bowel and can be easily and effectively used in intestinal surgery.7 Earlier studies also report closure of small intestinal enterotomy wounds using various inverting-suture patterns with synthetic absorbable suture material such as Polygalactin 910.8
CONCLUSION Clinical examination and history assisted in the correct diagnosis in this case. Enterocutaneous fistula can be successfully treated surgically provided the compromised part of the intestine is confined to the body wall and has not contaminated the peritoneal cavity. The authors recommend surgical repair of congenital umbilical hernias if they do not spontaneously resolve by 6 to 12 months of
336
age.1 This mare was a successful broodmare 3 months after surgery and delivered a foal 11 months later.
V Sangwan et al Vol 30, No 6 (2010)
5. Hall LW, Clarke KW. Anaesthesia of the horse. In: Hall LW, Clarke KW, eds. Veterinary anaesthesia, 9th ed. London, UK: ELBS 1991:217–224. 6. Rose J, Rose EM, White NA II. Subtotal resection and anastomosis of
REFERENCES
the ascending colon. In: White NA, Moore JN, eds. Current tech-
1. Baxter GM. Umbilical enterocutaneous fistula. Compend Equine Ed
niques in equine surgery and lameness, 2nd ed. Philadelphia, PA: W
2007;2:96–99. 2. Bristol DG. Enterocutaneous fistulae in horses: 18 cases (1964–1992). Vet Surg 1994;23:167–171. 3. Dorland’s medical dictionary for health consumers. Philadelphia, PA:
B Saunders Company 1998:283. 7. Kumar A, Kumar A. Suture material and techniques. In: Tyagi RP, Singh J, eds. Ruminant surgery, 1st ed. New Delhi, India: CBS Publishers and distributers 1993:78.
W.B. Saunders 2007. 4. Markel MD, Pascoe JR, Sams AE. Strangulating umbilical hernias
8. Mcllwraith CW, Robertson JT, Turner AS. Enterotomy techniques
in horses: 13 cases (1974–1985). J Am Vet Med Assoc 1987;190:
Turner’s equine surgery: advanced techniques, 2nd ed. Cambridge,
692–694.
MA: Blackwell 1998:324.
(surgery of gastrointestinal tract). In: Cann C, ed. Mcllwraith and