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Treatment of Caecal Impaction by Caecotomy in The Horse
B/". lIet ]. (1974), 130, 420
TREATMENT OF CAECAL IMPACTION BY CAECOTOMY IN THE HORSE By P.
HEKMATI AND H. SHAHRASBI
Large Animal Clinic, Faculty of Veterinary Medicine, University of T ehran
SUMMARY
Caecotomy was performed on nine sick horses in which the caecum was firmly impacted and medical treatmenfhad failed. The right flank was the approach used for laparotomy and the apex of the caecum for caecotomy. Evacuation of the caecal contents was performed by pulling the caecum out of the abdominal cavity and opening the apex of the organ. INTRODUCTION
With the continuing importance of horse practice, the indications for equine surgery likewise maintain their value and significance. Caecal impaction in horses is one of the conditions in which medical treatment does not produce satisfactory results. Consequently surgical removal of the caecal contents by caecotomy offers a potentially rewarding alternative. This paper shows that this operation can now be successfully performed, and the practicability and value of surgical interference on this organ of the horse can therefore now be assessed. A brief survey of the literature on abdominal surgery in the horse shows that as long ago as 1940, Farquharson reviewed this subject and although little detail is available he records that five out of six cases of "impaction" were successfully treated by surgery. Since then there has been very little published evidence to support the value of surgical treatment of impaction of the caecum. Bone et al. although they mention surgical correction for torsion and intusseption still treat impaction of the caecum medically with unrewarding results. Alexander & Donald (1949), Hickman (1950) and Milne & Horney (1960) give interesting and valuable information on the principles oflaparotomy in the horse. Chubar ( I953) records the successful surgical treatment of two cases of impaction of thecaecum in the horse, and Donald (I 950) records one unsuccessful endeavour. C LI N I CA L FINDINGS
All the affected animals showed symptoms of a mild colic. Pain was manifested by pawing and lying down. The bouts of pain appeared to be of moderate severity occurring at intervals of up to half an hour. There was anorexia, and faeces were passed infrequently. Intestinal motilty was markedly reduced. The right flank was distended and hard on palpation. By auscultation over the caecum there were no sounds except an occasional low rumble, replacing the
Fig .
2.
Fig. I. The opera ti ve an d incision sites . I mpacted caecum is pulled out from the a bdomen.
PLATE II
Fig. 3 (a). Evacuation of the impac ted caecum through a n incision made on its ap ex.
Fig. 3 (b) . The suture placed on th e wound of apex.
H ekmati a nd Shahrasbi, Br. vet .
J.
( 1974), 130, 5
CAECOTOMY IN THE HORSE
{21
active normal tinkling and bubbling borborygmi. The pulse rate was moderately increased but did not usually rise above 54 per minute. Examination of the mucous membranes revealed some congestion., In most cases rectal palpation revealed that the base of the impacted caecum could be palpated in the right flank extending from high up and passing downwards. The consistency of impaction varied from that of a soft loaf of bread to the hardness of a board. These degress of consistency contrased markedly with the normal fluctuating fluid state. OPERATIVE METHOD
Laparotomy was p erformed with paravertebral anaesthesia in a routine manner with the animal standing. Starting 6-7 inches below the tranverse processes of the lumbar vertebrae and 2- 3 inches behind and parallel to the last rib (Fig. I a, b) an incision 8-9 inches long was made through the skin and underlying muscle layers, fascia and peritoneum. In a highly dilated caecum, excess gas was released using a 14-gauge needle connected to a intravenous tube by inserting a needle into the wall of the caecum. The right hand and arm, which was smeared with a cream containing penicillin, was then introduced into the abdomen and directed to the most anterior-ventral part of it. While doing this the horses felt pain and were restless. By exploring the abdomen antro-ventrally the apex of the caecum was located lying chiefly on the abdominal floor, and it was then drawn gently out through the abdominal incision (Fig. 2, a, b). Caecotomy was then performed by making a 3-4 inch-long incision a t the tip of the organ through which the caecal contents were evacuated (Fig. 3, a, b). The contents were usually soft tendin"g towards hardness, dark coloured a nd with an offensive odour. After removal of the caecal contents and cleansing of the wound with normal saline, the incision was carefully stitched by closely placed continuous Lembert sutures, using No.2 chromic catgut. Oily pencillin was smeared on the caecal wound, the organ replace in the abdomen and the laparotomy wound closed. Post-operatively, water and food were reduced for the first 12 hours and antibiotics and parasympathetic stimulants were given. At the end of 10 to 12 hours the pulse rate was 60-78 per minute and respiration was rapid and thorasic. In seven out of nine horses treated the body temperature rose to 39·2°C. In the other two it rose from 37·8 °C to 38·7 °C. Evidence of peritonitis d eveloped in three horses; antibiotics were given for 1-2 days. Six of the nine horses recovered within 12- 17 days following the opera tion and they returned to work. The three which failed to recover were those with peritonitis; one was destroyed and two died. POST-MORTEM EXAM INATIO N
One horse was destroyed four weeks after operation. On post-mortem examination there was evidence of gross adhesions between the caecal and abdominal
BRITI SH VETERINARY J OURNAL, 130, 5
wall. Exudation and fibrinous deposits were observed in the peritoneal cavity and a chronic general peritonitis was present. It was difficult to identify the stitches which closed the caecal incision. In the two horses which died, post-mortem examination revealed exudation and fibrinous deposits in the peritoneal cavity, and fresh adhesions were present which were easily broken down. The exudate was purulent, forming a thick cheesy covering over most of the viscera. DIS CU SSION
Generally speaking, caecal impaction in the horse is recognjzed as a most intractable condition. The consistency of the impacted contents causes a degree of obstruction which is very difficult if not impossible to overcome by medical treatment. The degree of success which attends surgical removal of the caecal contents by performing right fl ank laparotomy and caecotomy through the caecal apex is recommended and seems to be well justified. The authors consider that two features of the operative procedure are of special importance, namely, the pulling of the caecum out through the laparotomy incision to preven t abdominal contamination by caecal contents, and the complete evacuation of caecal contents. In view of the high mortality rate caused by this condition and the very poor response to medical treatment, it appears that surgical treatment can provide a chance of saving these animals. REFE R EN CES
ALEXANDER, F. & DONALD, D. E. (1949). J. camp . Path. 59, 127 . BONE, j . F., CATCOTT, E. j., GABELL, A. A., JOHNSON, L. E. RILEY, W. F., JR. (1963). Equine Medicine and Surgery. Wheaton, Ill.: American Veterinary Publications Inc. CHUBAR, V. K . (1953). Veterinarba, ll/!oscow, 29, 46, quoted from an abst. in J. Am. vet . IVIed. Ass. 122, 234. DONALD, D . E. (1950). J. com}). Path. 60, 28. F.<\RQ.UHARSON, j. (1940). J. Am. vet. lv!ed. Ass. 97, 606. HICKMAN, j. (1950). Vet. Rec. 62, 132. MILNE, F. j . & HORNEY, F. D. (1960). Can. vet. J. 1, 524. (Accepted for publication 4 May 1973)
Traiternent de la non-evacuation caecale par caecotolnie chez Ie cheval (Hekrnati et Shahrasbi) Res 1Ul1e. On pratiqua une caecotornie chez neuf chevaux malades chez lesquels Ie caecum etait fermement rempli et chez qui Ie traitement medical avait echoue. Le Banc droit servit d'approche pour la laparotomie et Ie sommet du caecum pour la caecotomie. On effectua I'evacuation des contenus caecaux en sortant Ie caecum de la cavite abdominale et en ouvrant Ie sommet d e l'organe. Behandlung c o ecaler Koteinklernlnung durch Coecotolnie bei Pferden (Hekrnati und Shahras bi) Zusarnlnenfassung. Bei neun Pferden, deren Coecum mit eingeklemmtem Kot gefiillt war und bei denen Medikation erfolglos geblieben war, wurde eine Coecotomie vorgenommen.
CAECOTOMY IN THE HORSE Die Laparatornie wurde von der rechten Flanke aus vorgenommen und das Coecum an der Spitze geoffnet. Zur Entleerung seine Inhalts wurde es aus der Bauchhohle herausgezogen und an seiner Spitze eroffnet. TrataDliento de iUlpac cion cecal en al caballo Dlediante (HekDlati y Shahrasbi) ReSlUnen. Se efectuaron cecotomias en nueve caballos enfermos en los que el ciego estaba firmemente impactado; el tratamiento con medicamentos no habia surtido efecto. Las laparotomias se efectuaron en la ijada derecha, y el ciego se ataco por el apice. Se Jlevo a caba la evacuacion del contcnido del ciego sacandolo de la cavidad abdominal y abriendo el apice de dicho organo.
TREATMENT OF CAECAL IMPACTION BY CAECOTOMY IN THE HORSE By P.
HEKMATI AND H. SHAHRASBI
Large Animal Clinic, Faculty of Veterinary Medicine, University of T ehran
SUMMARY
Caecotomy was performed on nine sick horses in which the caecum was firmly impacted and medical treatmenfhad failed. The right flank was the approach used for laparotomy and the apex of the caecum for caecotomy. Evacuation of the caecal contents was performed by pulling the caecum out of the abdominal cavity and opening the apex of the organ. INTRODUCTION
With the continuing importance of horse practice, the indications for equine surgery likewise maintain their value and significance. Caecal impaction in horses is one of the conditions in which medical treatment does not produce satisfactory results. Consequently surgical removal of the caecal contents by caecotomy offers a potentially rewarding alternative. This paper shows that this operation can now be successfully performed, and the practicability and value of surgical interference on this organ of the horse can therefore now be assessed. A brief survey of the literature on abdominal surgery in the horse shows that as long ago as 1940, Farquharson reviewed this subject and although little detail is available he records that five out of six cases of "impaction" were successfully treated by surgery. Since then there has been very little published evidence to support the value of surgical treatment of impaction of the caecum. Bone et al. although they mention surgical correction for torsion and intusseption still treat impaction of the caecum medically with unrewarding results. Alexander & Donald (1949), Hickman (1950) and Milne & Horney (1960) give interesting and valuable information on the principles oflaparotomy in the horse. Chubar ( I953) records the successful surgical treatment of two cases of impaction of thecaecum in the horse, and Donald (I 950) records one unsuccessful endeavour. C LI N I CA L FINDINGS
All the affected animals showed symptoms of a mild colic. Pain was manifested by pawing and lying down. The bouts of pain appeared to be of moderate severity occurring at intervals of up to half an hour. There was anorexia, and faeces were passed infrequently. Intestinal motilty was markedly reduced. The right flank was distended and hard on palpation. By auscultation over the caecum there were no sounds except an occasional low rumble, replacing the
Fig .
2.
Fig. I. The opera ti ve an d incision sites . I mpacted caecum is pulled out from the a bdomen.
PLATE II
Fig. 3 (a). Evacuation of the impac ted caecum through a n incision made on its ap ex.
Fig. 3 (b) . The suture placed on th e wound of apex.
H ekmati a nd Shahrasbi, Br. vet .
J.
( 1974), 130, 5
CAECOTOMY IN THE HORSE
{21
active normal tinkling and bubbling borborygmi. The pulse rate was moderately increased but did not usually rise above 54 per minute. Examination of the mucous membranes revealed some congestion., In most cases rectal palpation revealed that the base of the impacted caecum could be palpated in the right flank extending from high up and passing downwards. The consistency of impaction varied from that of a soft loaf of bread to the hardness of a board. These degress of consistency contrased markedly with the normal fluctuating fluid state. OPERATIVE METHOD
Laparotomy was p erformed with paravertebral anaesthesia in a routine manner with the animal standing. Starting 6-7 inches below the tranverse processes of the lumbar vertebrae and 2- 3 inches behind and parallel to the last rib (Fig. I a, b) an incision 8-9 inches long was made through the skin and underlying muscle layers, fascia and peritoneum. In a highly dilated caecum, excess gas was released using a 14-gauge needle connected to a intravenous tube by inserting a needle into the wall of the caecum. The right hand and arm, which was smeared with a cream containing penicillin, was then introduced into the abdomen and directed to the most anterior-ventral part of it. While doing this the horses felt pain and were restless. By exploring the abdomen antro-ventrally the apex of the caecum was located lying chiefly on the abdominal floor, and it was then drawn gently out through the abdominal incision (Fig. 2, a, b). Caecotomy was then performed by making a 3-4 inch-long incision a t the tip of the organ through which the caecal contents were evacuated (Fig. 3, a, b). The contents were usually soft tendin"g towards hardness, dark coloured a nd with an offensive odour. After removal of the caecal contents and cleansing of the wound with normal saline, the incision was carefully stitched by closely placed continuous Lembert sutures, using No.2 chromic catgut. Oily pencillin was smeared on the caecal wound, the organ replace in the abdomen and the laparotomy wound closed. Post-operatively, water and food were reduced for the first 12 hours and antibiotics and parasympathetic stimulants were given. At the end of 10 to 12 hours the pulse rate was 60-78 per minute and respiration was rapid and thorasic. In seven out of nine horses treated the body temperature rose to 39·2°C. In the other two it rose from 37·8 °C to 38·7 °C. Evidence of peritonitis d eveloped in three horses; antibiotics were given for 1-2 days. Six of the nine horses recovered within 12- 17 days following the opera tion and they returned to work. The three which failed to recover were those with peritonitis; one was destroyed and two died. POST-MORTEM EXAM INATIO N
One horse was destroyed four weeks after operation. On post-mortem examination there was evidence of gross adhesions between the caecal and abdominal
BRITI SH VETERINARY J OURNAL, 130, 5
wall. Exudation and fibrinous deposits were observed in the peritoneal cavity and a chronic general peritonitis was present. It was difficult to identify the stitches which closed the caecal incision. In the two horses which died, post-mortem examination revealed exudation and fibrinous deposits in the peritoneal cavity, and fresh adhesions were present which were easily broken down. The exudate was purulent, forming a thick cheesy covering over most of the viscera. DIS CU SSION
Generally speaking, caecal impaction in the horse is recognjzed as a most intractable condition. The consistency of the impacted contents causes a degree of obstruction which is very difficult if not impossible to overcome by medical treatment. The degree of success which attends surgical removal of the caecal contents by performing right fl ank laparotomy and caecotomy through the caecal apex is recommended and seems to be well justified. The authors consider that two features of the operative procedure are of special importance, namely, the pulling of the caecum out through the laparotomy incision to preven t abdominal contamination by caecal contents, and the complete evacuation of caecal contents. In view of the high mortality rate caused by this condition and the very poor response to medical treatment, it appears that surgical treatment can provide a chance of saving these animals. REFE R EN CES
ALEXANDER, F. & DONALD, D. E. (1949). J. camp . Path. 59, 127 . BONE, j . F., CATCOTT, E. j., GABELL, A. A., JOHNSON, L. E. RILEY, W. F., JR. (1963). Equine Medicine and Surgery. Wheaton, Ill.: American Veterinary Publications Inc. CHUBAR, V. K . (1953). Veterinarba, ll/!oscow, 29, 46, quoted from an abst. in J. Am. vet . IVIed. Ass. 122, 234. DONALD, D . E. (1950). J. com}). Path. 60, 28. F.<\RQ.UHARSON, j. (1940). J. Am. vet. lv!ed. Ass. 97, 606. HICKMAN, j. (1950). Vet. Rec. 62, 132. MILNE, F. j . & HORNEY, F. D. (1960). Can. vet. J. 1, 524. (Accepted for publication 4 May 1973)
Traiternent de la non-evacuation caecale par caecotolnie chez Ie cheval (Hekrnati et Shahrasbi) Res 1Ul1e. On pratiqua une caecotornie chez neuf chevaux malades chez lesquels Ie caecum etait fermement rempli et chez qui Ie traitement medical avait echoue. Le Banc droit servit d'approche pour la laparotomie et Ie sommet du caecum pour la caecotomie. On effectua I'evacuation des contenus caecaux en sortant Ie caecum de la cavite abdominale et en ouvrant Ie sommet d e l'organe. Behandlung c o ecaler Koteinklernlnung durch Coecotolnie bei Pferden (Hekrnati und Shahras bi) Zusarnlnenfassung. Bei neun Pferden, deren Coecum mit eingeklemmtem Kot gefiillt war und bei denen Medikation erfolglos geblieben war, wurde eine Coecotomie vorgenommen.
CAECOTOMY IN THE HORSE Die Laparatornie wurde von der rechten Flanke aus vorgenommen und das Coecum an der Spitze geoffnet. Zur Entleerung seine Inhalts wurde es aus der Bauchhohle herausgezogen und an seiner Spitze eroffnet. TrataDliento de iUlpac cion cecal en al caballo Dlediante (HekDlati y Shahrasbi) ReSlUnen. Se efectuaron cecotomias en nueve caballos enfermos en los que el ciego estaba firmemente impactado; el tratamiento con medicamentos no habia surtido efecto. Las laparotomias se efectuaron en la ijada derecha, y el ciego se ataco por el apice. Se Jlevo a caba la evacuacion del contcnido del ciego sacandolo de la cavidad abdominal y abriendo el apice de dicho organo.