Authors : Emil Ofner, DVM
Marina Barižon, DVM
Small Animal Veterinary Clinic More, Šibenik, Croatia
Bronchial foreign body in feline patient – case presentation
Male cat ( 4.5 kg ) with chronic gingivitis-stomatitis-pharyngitis syndrome was admitted to our clinic because of aspiration of loose tooth 15 days ago. At that time, the owner told us that cat first started to cough suddenly and because of coughing he received antibiotics. After a course of antibiotics, cough started to decrease, but didn’t stop completely. Thorax x-rays done on next physical examination revealed tooth inside the lungs.
Case presentation :
At the time of admission cat was stable with no apparent breathing problems. The cat was afebrile and blood work revealed elevation in leukocyte number. On x-rays we could see that the tooth (premolar) was stuck somewhere in the right caudal lung lobe (Picture 1). The x-ray scan also demonstrates a radio opaque area around the tooth, which represents fluid filled dilated bronchi ( Picture 2).
Equipment and Methods :
After initial examination, we decided to do a bronchoscopy to attempt endoscopic tooth removal. After intubation Olympus fiberoptic paediatric bronchoscope (3.6 mm diameter) with 1.2 mm working channel was introduced into the trachea (Picture 3 and 4). In level of segmental bronchi of right caudal ( posterior ) lung lobe we located bronchus plugged with white thick purulent material. In order to liquify this purulent material for aspiration we first lavaged it with warm saline. After successful aspiration of pus tooth was finally revealed. Grasping of the tooth was done with 0.9 mm diameter alligator forceps (Picture 5 and 6). After removal of the tooth rest of the pus was aspirated.
In cats most aspirated foreign objects will get trapped in the right caudal lung lobe. In our opinion the reasons for that are difference in right and left lung volumes, diameter of principal bronchi and bronchial tree anatomy. In cats average diameter of left principal bronchus is 6.0 mm, while the average diameter of right principal bronchus is 7.34 mm. Also, because of bronchial tree anatomy in the cats bronchial pathway which leads to right caudal lung lobe is more straight in comparison to left lung bronchial tree anatomy.
Majority lung foreign bodies in cats will be trapped somewhere along the right bronchial three because of anatomical differences of right and left lungs.
Cats with chronic gingivitis-stomatitis-pharyngitis syndrome may have an increase chance in aspirating foreign objects. Sudden attack of cough in cats with gingivitis-stomatitis-pharyngitis syndrome maybe can be aspirated foreign object.
Authors : Emil Ofner, DVM
Ivica Ukić, DVM
Davor Crnogaća, DVM
Silvijo Tarasić, Eng; OLYMPUS d.o.o. Zagreb
Small Animal Veterinary Clinic More, Šibenik, Croatia
Key words : Gyrus PKS plasma SORD, Laparoscopic ovariectomy
Since the beginning of 2012 two hundred laparoscopic ovariectomyes with two – portal method was done in veterinary clinic More. The average body weight of female dogs was 25 kg. While no surgical problems were encountered in small and medium size dogs, overweight and obese patients demonstrated to be more challenging both for the surgeon and anesthesiologist. Because of problems encountered in large and obese female dogs, especially the difficulties of removing easily ovaries with large ovarian bursa, it was necessary to find new easier and faster way for removing such ovaries through laparoscopic portals without elongation of incision. That was reason for implementation of high frequency bipolar morcellator Gyrus PKS plasma SORD for fast removal of ovaries and its adherent burse in large and obese patients.
Materials and methods
All dogs were sedated using alpha-adrenergic agonists or acepromazine. Induction of anaesthesia was done with propofol. After intubation patients were maintained on isofluran. Analgesia during surgery was provided by constant–rate infusion (CRI) of fentanyl. Most patients were breathing spontaneously and ventilatory assistance was used if needed.
To facilitate ovary visualization laparoscopic positioner was used. Ovarian fixation for resection was done with a percutaneous needle technique. Resection of ovaries was done with bipolar forceps (Grus PKS) or ultrasonic knife (Ethicon). For large and obese female dogs removal of resected ovaries was done by bipolar high frequency Gyrus PKS plasma SORD morcellator.
A total of 200 laparoscopic two portal ovariectomies were done from the beginning of 2012. A body weight span of dogs was from 4.0 kg to 65 kg. The average body weight of female dogs was 25 kg. Of all dogs 29 % (58 dogs) were characterized large (above 30 kg) , overweight or obese (body condition score > 4) .
Time for ovary resection and removal in small and medium size dogs was similar like in large and obese dogs when using PKS plasma SORD morcellator. For both groups surgical time in most of the cases was under 40 minutes. For dogs under 30 kg average time was 23.45 minutes, and for large and obese dogs average surgical time was 34 minutes.
Only one dog had a postoperative wound infection which was managed with antibiotics and in one dog (8 years old Alaskan Malamute) we couldn’t establish pneumoperitoneum because of huge deposits of intra-abdominal fat tissue so we proceeded to open laparotomy.
Veterinary laparoscopic ovaryectomy is traditionally done by three – portal method and we can call it a universal method for every type and size of the patient. But, it’s not as minimally invasive as two and single portal method.
Single portal laparoscopic ovariectomy is only method which is the not universal or ideal for every patient because of technical, intraoperative difficulties (especially in obese and large female dogs) mostly related to difficulty in viewing anatomical structures for precise surgical resection. Single portal ovariectomy in our opinion can be only ideal for small and medium size female dogs from 7 to 20 kg especially before the first heat (5-7 months old female dogs).
Two portal method has some disadvantages, but we can also call it universal method for every type and size of dog. The main deficiency of two portal method was difficult removal of large ovaries with its adherent burse thrue laparoscopic portals in obese and large breeds of dogs. Also, using a percutaneous needle technique in two portal method for fixation of ovaries in the abdomen makes them very often hidden behind its adherent bursa and difficult for viewing in order to do a precise disection to get a smaller tissue piece for easy extraction (Picture 1).
Ovaries with adherent bursa in large and obese female dogs by our own measurements can be over 6 cm in diameter. The traditional method for removal of large ovaries was an elongation of laparoscopic portals by scalpel No. 11. Unfortunately, if you are using threaded trocars (we use endotip trocar type) this can be little challenging. Also making portal larger by incision is abandoning basic principles of minimally invasive surgery and causes more intraoperative trauma. Size of elongated incisions of laparoscopic portals is getting close to standard open laparotomy incision size and then we can’t absolutely say that we did minimally invasive surgery.
Problem of removal of large ovaries in three portal method is not so important because the surgeon can easily use scissors and forceps to divide such ovaries intra-abdominal in two or more segments and take them out separately but that also lengthens operation time.
Removing ovaries with large ovarian bursa is very often time-consuming and elevates stress on the surgeon and its assistants, also lengthens anaesthesia time and increases risk for the patient.
Also, there are mortality risks in obese patients during and after laparoscopic surgery that are proportional to operative time which is often increased in these patients. Because of that operative time becomes very important factor (Table 1).
Taking into consideration things mentioned above, we tried to make two portal method easy and fast even in large and obese patients (> 30 kg) with large ovarian bursa making surgical time for resection and removal of both ovaries under 30 minutes.
To achieve this we started to use human gynaecological bipolar morcellator Gyrus PKS plasma SORD (SORD – solid organ removal device) and HF generator Gyrus G400 (Picture 2, 3 , and 4).
Main advantages when using Gyrus PKS plasma SORD are :
- easy to use (Plug and play)
- small diameter (12 mm / 15 mm)
- light (250 grams)
Main disadvantages are :
- single use instrument (can be reprocessed)
- smoke production (use of insufflators with the automatic smoke evacuation system resolves this problem)
Two portal laparoscopic ovariectomy using Gyrus PKS plasma SORD morcellator makes this method suitable for technically demanding ovariectmies especially in large and obese dogs. Difficult ovariectmies in these patients are done with minimal intraoperative trauma without elongation of laparoscopic portals and short period of time (up to 30 minutes). After 3 years using Gyrus PKS plasma SORD morcellator we can conclude that to us it’s become a crucial instrument in every two portal laparosopic ovariectomy of obese dogs. Using this instrument makes two portal laparoscopic ovariectomy universal, fast and safe especially in large and obese dogs. Only downside of using Gyrus PKS plasma SORD morcellator is its price.
Emil Ofner DVM, Veterinary Clinic More
Authors : Emil Ofner, DVM
Davor Crnogaća, DVM
Ivica Ukić, DVM
Silvijo Tarasić, Eng; OLYMPUS d.o.o. Zagreb
Small Animal Veterinary Clinic More, Šibenik, Croatia
Key words : esophageal stricture, balloon dilatation, regurgitation
Many diseases can cause esophageal stricture formation. Strictures in dogs are most frequently caused by foreign objects trapped in esophagus. The easiest way to diagnose and treat esophageal strictures is with flexible gastroscopes. Although there are lots of ways to dilate stricture, through the scope method, using esophageal balloon catheter is simple and safe method enabling direct visualisation of whole procedure.
Post-traumatic esophageal strictures in small animals are relatively rare problems. Most common cause of post – traumatic esophageal strictures is foreign body entrapment in the esophagus. Also, post – traumatic endoluminal strictures can be caused by caustic material ingestion or as a complication of esophageal surgery. In all of these situations damage of esophageal wall layers causes local inflammation with production of fibrous connective tissue. Local fibrosis or scar formation causes reduction of esophageal diameter thus causing stricture. Common symptoms of esophageal strictures are : regurgitation, salivation, dysphagia and ptyalism. Treatment is usually dilatation with balloon catheters or different types of cylindrical tubes called bogies (Table 1).
Case presentation :
Female, 9 years old West Highland White Terrier was brought to our clinic because of chronic regurgitation that lasted for four weeks. Prior to this, dog ingested bones and vomited them after five days. She could drink water and take liquid food. Solid food was regurgitated immediately after ingestion. Rectal temperature was normal but she lost 0.84 kg of body weight. Complete blood count and biochemistry values were normal. Radiographic examination didn’t reveal any cause of regurgitation. At this point we decided to do a flexible endoscopy examination of esophagus, which revealed 4 mm diameter stricture in distal part of thoracic esophagus.
Management and Outcome :
Dog was put under general anesthesia and intubated. Olympus GIF Q10 flexible gastroscope with 2.8 mm working channel was introduced into esophagus. After this, Olympus SWIFT balloon catheter (model BE – 6 ) was introduced through the working channel into the stricture ( through the scope method ). To generate force for stricture dilatation, catheter was expanded using saline and hand held Swift pump, two times for duration of two minutes. Steroid ( tramcinolone 40 mg / ml ) diluted with saline 1 : 2 was injected submucosally in three places around the stricture ( Pictures 1 to 5 ). After procedure, we prescribed omeprazole ( 1 mg / kg PO q24h ) for 7 days. After three weeks whole procedure was repeated. On next check-up dog regained normal body weight and was eating solid food without any problems.
From a biomechanical perspective, all types of dilators ( balloons and bougies ) generate two types of forces on esophageal wall, radial stretch force which is responsible for dilatation and unwanted longitudinal shear force which can cause esophageal perforation ( Table 1 ).
Through the scope balloon dilatation of esophageal strictures is an easy and relatively safe procedure. Stricture dilatation occurs because saline filled balloon transfers radial stretch force on esophageal wall. Complications like esophageal preforation rarely occur when using balloon catheters because of low longitudinal shear force. Mean shear force of balloon catheters is 1,44 N. Low shear force of balloon catheters is associated with significantly lower risk for perforation.
When using other types of dilators like bougies, in theory perforations are more likely to occur because of strong radial and shear forces.Bougies involve passing long rigid instrument ( rigid cylindrical tube ) through the stricture blindly or by endoscopic guidance. Advancing bougie through stricture generates radial force which causes dilatation of stricture, but it also generates strong shear force which can cause perforation. Mean shear force when using bougies is 16,92 N for Maloney type and 6,92 N for Savary – Gilliard bougie.
Steroid injection prior or after dilatation improves outcome because it’s decreasing scar formation and need for repeated dilatations. Most cases will need repeated procedure in three weeks. If the dog is eating normally after 3-4 weeks it probably wont need new dilatation procedure.
After procedure, anti-acids are prescribed to reduce potentially negative effect of gastric acid on new scar formation. Use of proton pump inhibitors like omeprazole is recommended because of better effect than H2 receptor antagonists ( ranitidine, famotidine ).
We are thankful to Mr. Silvijo Tarasić and Olympus d.o.o. Zagreb who provided technical expertise that greatly assisted us in implementing new technology improvements in our practice.
1. Adamama-Moraitou KK, Rallis TS, Prassinos NN, Galatos AD. Benign esophageal stricture in the dog and cat: A retrospective study of 20 cases. Can J Vet Res. 2002 Jan;66(1):55-9.
2. Leib MS, Dinnel H, Ward DL, Reimer ME, Towell TL, Monroe WE. Endoscopic balloon dilation of benign esophageal strictures in dogs and cats. J Vet Intern Med. 2001 Nov-Dec;15(6):547-52.
3. Harai BH, Johnson SE, Sherding RG. Endoscopically guided balloon dilatation of benign esophageal strictures in 6 cats and 7 dogs. J Vet Intern Med. 1995 Sep-Oct;9(5):332-5.
4. McLean GK, LeVeen RF. Shear stress in the performance of esophageal dilation: comparison of balloon dilation and bougienage Radiology. 1989 Sep;172(3 Pt 2):983-6.
5. ASGE Technology Committee, Siddiqui UD, Banerjee S, Barth B, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Tokar JL, Wang A, Rodriguez SA. Tools for endoscopic stricture dilation. Gastrointest Endosc. 2013 Sep;78(3):391-404. doi: 10.1016/j.gie.2013.04.170.
Laparoscopic surgery is a minimally invasive surgery, a technique that allows the intervention to be performed by using multiple small abdominal incisions. Specialized camera with fiber-optical fibers (laparoscope) is introduced through one of these portals in order to allow visualization of the internal contents of the abdomen. Similarly, through other portals surgical instruments necessary for the intervention are inserted into the abdominal cavity.
Laparoscopic surgery at ‘IVA VET’ clinic is performed by the team of experts. ‘IVA VET’ surgical team (picture 1.) utilizes advanced technology for the prophylactic, diagnostic, and therapeutic surgical procedures.
The most common type of surgery performed using minimally invasive technique is ovariectomy. This procedure is performed to prevent unwanted offspring, and to reduce the risk of infections and cancers of the female reproductive tract. Compared with traditional open ovariohysterectomy, laparoscopic ovariectomy is technically less complicated and time-consuming. Further, in a study published in the 2005 Journal of the Veterinary Medical Association has been documented that laparoscopic surgery diminishes pain, reduces the risk of hemorrhage and speeds recovery times up to 65%. In table 1. are presented laparoscopic surgery advantages over traditional open surgery.
The most common reasons for laparoscopic intervention are:
• Diseases causing acute or chronical pain in abdominal or pelvic cavity.
• Visualization of miscellaneous growths and patches in abdominal cavity, and collection of various samples (biopsy) for pathohistological examination.
• Ovariectomy and ovariohysterectomy
• Determining possible causes for free fluid accumulation in abdomen.
• Cancer staging for specific tumors.
• Surgical removal of tumors or organ invaded by tumor.
Laparoscopic procedures in abdomen cavity:
• Ovariohysterectomy (in this procedure both, ovaries and uterus are removed)
• Ovariectomy (spay), only the ovaries are removed
• Sterilization of male dog
• Cancer and cystic kidney surgery
• Hernia Repair
• Ultrasound guided percutaneous sampling (biopsy) of abdominal organs
• Surgery of polycystic ovaries
• Gastropexy (Bloat/GDV Prevention)
• Removal of various tumor masses
Animal owners should expect the following procedures to be preformed during the preparation for the laparoscopic intervention:
1. General physical examination to determine animal health status.
2. Laboratory blood analysis (1.Blood chemistry panel—Used to evaluate organ function, electrolyte status, hormone levels, and more; 2.Complete blood count—Gives us information on hydration status, anemia, infection, clotting ability, and the ability of the immune system to respond to disease)
3. Laboratory urine analysis (Checks the condition of the urinary and genital tracts and screens for conditions such as diabetes, liver disease, and Cushing’s disease)
4. Abdominal ultrasound (enabling a partial examination of the abdominal cavity- A non-invasive, real-time, moving picture of your pet’s abdomen, chest and heart)
Contraindication for Laparoscopic surgery
Conditions in which conventional surgical intervention is obviously indicated
Obesity (obscure the view of many organs)
Poor patient condition
Poor clotting time
Patient body weight <2 kg (instrument size)
Patient that is a poor anesthetic risk or an extreme surgical risk
Patient preparation before surgery
Owners should withhold food for 6-12 hours (over night) before surgery.
Anesthesia for laparoscopic surgery
Laparoscopic surgery is routinely performed in general anesthesia.
Laparoscopic Surgery Procedures in general
Preoperative preparation of patient
Empty urinary bladder for a better visualization of the abdominal cavity and to minimize the danger of tapping. Position the patient. Aseptically prepare the surgical field in the standard fashion.
A surgeon makes one initial incision (picture 3.) commonly in the navel area. Then, a small needle is inserted through this incision, through which carbon dioxide gas can be pumped into the abdomen to inflate it allowing for better visualization of the abdomen’s contents. Pressure in abdomen (picture 4.) must not be higher than 15 mm Hg (maintain the abdominal insufflation pressure at 12 to 15 mm Hg). If pressure in abdomen is higher, patient respiration will be impeded.
Next, a laparoscope is inserted through one of the incisions. The camera illuminates the interior of the abdomen and transmits high-quality, magnified images to a video screen in the operating room, allowing for precise maneuvering. After that, surgeon can begin with organ examination. If required, more incisions are made on abdomen to insert instruments (basic equipment and instruments required to perform laparoscopic surgery in dogs and cats are listed in table 2.), and perform the surgery or/and sample collections (biopsy). Once the procedure is completed, the carbon dioxide is let out of the abdomen and the incisions are closed using stitches or clips.
Any collected tissue or liquid sample during laparoscopic surgery will be sent for further pathohistological examination. Results of those analyses can be expected few days after the procedure.
Postoperative recovery after the laparoscopic surgery is much faster, safer and less stressful for your animal companion.
Duration of laparoscopic surgery
Depending on the complexity of procedure, laparoscopic surgery can last anywhere from half an hour to several hours.
Three portal laparoscopic cat sterilization performed by cutting both ductus deferens without testicle extraction:
A seven month old half-breed cat named Lion (picture 1.) was presented to our clinic “IVAVET” for the sterilization. The patient’s caring owner wanted to know which surgical procedure would provide safer, less stressful and easier recovery to her loving animal companion. In addition, she wanted to know if there is any possibility to perform sterilization without removing testicales, thus Lion’s aesthetic appearance could stay undisrupted. Therefore, we thoroughly presented to her all possible solutions and recommended laparoscopicaly performed sterilization achieved by cutting both vas deferens without need to remove gonads.
Aim of this minimally invasive surgery is cutting the tubes (ductus deferens) that transport sperm from the testicles to the penis, without removing gonadal glands. By cutting these tubes permanently sterile animal retain hormonal balance due to kept ability to produce testosterone. Moreover, after this procedure there will be no need for any kind of special diet.
The patient’s owner accepted our advice so we obtained a signed permission form to perform laparoscopic sterilization, including permission to convert to an open procedure, should it be necessary.
General physical examination and laboratory analysis indicated Lion’s good health condition confirming him as ideal candidate for laparoscopic intervention. Examination revealed a slightly elevated body weight (3.9 kg).
Patient and instrument preparation for laparoscopic surgery
Discarding our professional advice the owner fed her cat night before surgery. Consequently, cat vomited food, luckily for us before surgery took place. We prepared and sterilized all instruments (picture 2.), and put them on instrument table near operating.
Anesthesia was achieved with appropriate dose of the domitor/ketamidor combination. We use this combination during surgery because it provides a suitable anesthesia for cats characterized by rapid induction, good muscle relaxation, good analgesia and bradycardia. During anesthesia our nonsterile assistant monitor all patient vital functions, instruments and keep connecting cables outside of patient sterile zone.
Patient was restrained in dorsal recumbency on positioner that has been securely attached to the surgery table, and the surgical field was aseptically prepared in the standard manner for all abdominal operations (picture 3.).
Next to the umbilicus we made a small skin incision (1 cm), trough which we placed the Veress needle. While placing the Veress needle we were very vigilant in order to avoid damage to internal abdominal content (especially spleen or liver). After penetrating the abdomen we attached the insufflation line to the Veress needle (picture 4.), turned the carbon dioxide gas on and started insufflation to establish pneumoperitoneum.
After that, we removed the Veress needle and in the same port we placed primary trocar through which we inserted laparoscope with a video camera and light source. After initial exploration with laparoscopic camera we placed two more lateral secondary ports (picture 5). Through this ports secondary trocars were placed, lateral to the primary trocar and halfway between the umbilicus and pubis. We used these two secondary ports to insert required instruments and to make easier access to the vas deferens.
Laparoscopic procedure was observed on video monitor placed in the operating room so that all team members could supervise whole procedure.First, in inguinal area we located left ductus deferens, using laparoscope. Second, with grasping forceps we elevated previously located left ductus deferens (as much as it was possible, look at picture 8.), inserted through one of the secondary ports. Third, through other secondary port we inserted bipolar forceps with an electro generator and coagulated one small place on the left ductus deferens. Finally, after removing bipolar forceps we used same port to insert scissor forceps and transect left ductus deferens. We have done the same process on the right ductus deferens.
We thoroughly checked for any bleeding or tissue damage before removing all instruments (picture 6.). After intrabdominal administration of antibiotics, deflating abdomen and removing trocars we sutured all ports using 3-0 thread for cats, in standard manner.
Lion was released home within a few hours after surgery. He didn’t show any signs of pain or altered general condition. We prescribed a postoperative analgesic for three days and instructed owner to return in a week for recheck.
Laparoscopic vasectomy performed by cutting tubes is more challenging for a surgeon but for the patient is undeniable better due to faster recovery time, decreased stress and pain, improved visualization, undisrupted hormonal balance and last but not the least important unchanged aesthetic appearance of your animal companion.
Constantin Ifteme , DVM
Small Animal Veterinary Clinic Blue Vets in Bucharest , Romania
The gastro-esophageal intussusception is an acute pathological state, caring a grave prognostic. It appears as an intussusception of a part or the whole stomach in the distal esophageal area.
The causes and mechanisms are not well known, but it appears that the main predisposing factors involved are: the laxity of the esophageal hiatus, esophageal hipomotility and megaesophagus.
I will try to be as thorough as possible in these few lines. The case had more than one medical complaints, rarely encountered and diagnosed in veterinary medicine, but fairly interesting for us, surgeons.
Kino is a 5 year old Berger Blanc Suisse patient known for his gastro-esophageal pathology. He was diagnosed at the age of 6 months with congenital megaesophagus. A few months later he was diagnosed endoscopically with ulcerative gastritis cause by Helicobacter (diagnosed on cytology). He suffered three interventional endoscopies – one for removing a foreign body and the other two for dilating the hypertrophic cardiac sphincter with an achalasia balloon.
From when he was first diagnosed with megaesophagus, Kino received antisecretory, antiemetic and prokinetic treatment, and he was fed blended food from a vertical surface.
At this time, Kino’s clinical signs were far worse than all the other appointments in the clinic. The owner complained he had been vomiting and regurgitating after drinking water for no less than 40 times in the past 12 hours.
• Poor general state
• Mild dyspnea
• Purulent nasal discharge
• Mild hyperemia of the mucous membranes
• CRT > 5sec
• Severe dehydration 10%
• Crackles on pulmonary auscultation
• Weak pulse
• BP 8/5
• Body temperature 38,7
Abdominal palpation was unrewarding. The patient was cachectic, weighing 25kg (low under the breed standard bodyweight of 40kg).
We drew bloods for a complete blood count, biochemistry and a electrolyte count and set up a peripheral iv line for fluids and symptomatic medication.
The blood work showed:
• Slightly decreased HCO3 due to the hypovolemic shock
• Blood pH level 7,46
• Mild increase of BUN and Creatinine levels due to dehydration
• Mild hypoalbuminemia due to the esophageal pathology
• Leukocytosis with high Neutrophil, Monocyte and Basophil counts
• Mildly increased platelet counts
Based on the clinical signs and the results of the blood work we suspected an acute inflammatory / septic process, but we couldn’t figure out the primary cause of these severe symptoms.
We then recommended an ultrasound examination and x-rays. The A-FAST abdominal ultrasound we couldn’t see the stomach and spleen.
The x-rays showed an increased opacity in the thoracic segment of the esophagus (most likely food content). Furthermore, another increased, oval, well defined opacity was noticed in the caudal area, next to the cardiac sphincter. The measurement was 179mm/89mm. The lungs also presented an increased interstitial pattern.
During this time Kino was on CRI with: Ringer fluid and Duphalyte and received antiemetic and antisecretory medication (maropitant and pantoprazole). He also received antibiotic therapy with ceftriaxone.
His clinical signs did not improve whatsoever during the first 12-15 hours since admission in the clinic. Moreover, he was now vomiting blood.
The clinical signs and the tests results pointed out a presumptive diagnosis of gastro-esophageal intussusception and aspiration pneumonia.
Once the owners signed the consent form, we had the patient sedated with butorphanol and midazolam for the surgical preparation.
On complete sedation, the patient was gently aspired with the surgical vacuum to prevent the worsening of the preexisting clinical signs (aspiration pneumonia)
We induced the patient with propophol and preceded the endoscopic examination with a large caliber Olympus video-endoscope, commonly used for digestive tract procedures. We found large quantities of liquid and purulent discharge in the respiratory tract (larynx, trachea and bronchi), which we completely aspired. We then had the patient intubated and anesthetized with isoflurane.
The next step was the endoscopic examination of the esophagus where we vacuumed a mixed liquid and food content, found in large quantities. In the lumen of the distal esophageal area we could see the gastric mucosa.
The gastric mucosa presented with hyperemia and small ischemic areas. We tried to endoscopically reposition the stomach in the abdominal cavity, but with no results.
The third step of the procedure was the exploratory laparatomy with diagnostic and curative intend. Upon examination we noticed the mispositioning of the stomach and partly the spleen.
We repositioned the stomach and the spleen by gently pulling the duodenum until we saw the antral area and continued with gentle pulling of the stomach until we achieved continuity of all the digestive segments.
The cardiac and the fundic areas of the stomach showed inflammation and the gastric mucosa was hypertrophic. No ischemic lesions were noticed due to prolonged stasis. We also assessed this finding during the post-interventional endoscopy. The spleen was partly torsed in a small region, near the splenic head.
We continued exploring the abdominal cavity and found a lax area near the diaphragmatic hiatus, which had contributed significantly to the “herniation” of the stomach in the mediastinum and ultimately in the esophagus – therefore Kino was also diagnosed with hiatal hernia.
We reduced the hernia by placing resorbable sutures near the diaphragmatic pillars. During this procedure, we placed a large caliber oral-gastric tube (12mm) in the lumen of the esophagus to prevent any potential strictures.
We continued the surgery with a gastropexy, placing sutures from the gastric antrum area to the right abdominal wall, next to and including the 12th rib.
Finally, at the end of the laparatomy, we “washed” the abdominal cavity with saline at body temperature (38 degrees C) and then aspirated the content with the surgical vacuum.
We ended the procedure with a tracheobronhical lavage and aspiration with saline at body temperature.
The final endoscopic examination of the superior digestive tract, esophagus and stomach showed that the pathological changes had been reversed and the prognosis in this case is favorable.
During anesthesia, the patient’s vitals were:
• spontaneous breathing: 8-10 rpm
• sinusal cardiac rhythm
• heart rate 90 bpm
• blood pressure 11/8
• Oxygen saturation 98%-100%
• Rectal temperature at the end of the surgery: 36,50C
Postoperative the patient received:
• Pain medication – fentanyl
• NSAIDs – meloxicam
• Antibiotics – a triad with ceftriaxone, enrofloxacine and metronidazole
• IV fluids: with isotonic solutions and duphalyte
• Parenteral feeding with peripheral kabiven
• Antisecretory medication – pantoprazole and ranitidine
• Injectable multivitamins
Postoperatively we restricted food for 48 hours, followed by prebiotics administration and highly protein canned food. We will remove the sutures 10-12 days following surgery.
The following exams will be necessary following surgery:
• Complete blood count, serum biochemistry and electrolyte count
• Thoracic X-rays
• Barium X-rays
• Endoscopic examination of the: bronchi (taking samples for cytology, bacteriology and mycology) and the digestive tract.
The gastro-esophageal intussusception is a major surgical emergency, having severe clinical signs, irreversible with conservative therapy and caring a grave prognosis.
The endoscopic examination and the x-rays are the most important tests for a definitive diagnosis.
If the simple x-rays are inconclusive, barium x-rays will show a esophageal obstruction.
The treatment is surgical and it requires repositioning the stomach in the abdominal cavity, gastropexy and rectifying the hiatal hernia. The endoscope can also be used curatively in the treatment of small gastro-esophageal intussusceptions by blowing air in the esophagus.
• Gastric wall necrosis
• Splenic torsion
• Circulatory collapse
Authors- DVM Constantin Ifteme – The Veterinary Endoscopic and Digestive Tract Surgery Center, Bucharest
Associate Professor Cristian Daniel M.D.,Ph.D. – UMF Carol Davila Bucharest
Blue Vets team – The Veterinary Endoscopic and Digestive Tract Surgery Center, Bucharest