March 12, 2024

#116: Making Linear Foreign Body Surgery Less Scary And Getting Better Outcomes. With Dr Bronwyn Fullagar.

#116: Making Linear Foreign Body Surgery Less Scary And Getting Better Outcomes. With Dr Bronwyn Fullagar.
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Season 1

If you find surgery even remotely appealing, then chances are a good old intestinal foreign body removal ranks high on your list of favourites. But GI surgery can be a lot less fun when faced with a linear foreign body, and patient outcomes can be potentially be much worse.

This episode with specialist surgeon Dr. Bronwyn Fullagar is packed with invaluable insights to make your linear foreign body surgeries smoother, less scary, and increase your chances of success.

Dr. Bronwyn Fullagar is an Australian specialist surgeon based in the US. Her passion lies in sharing knowledge to elevate our skills as surgeons and promote our overall well-being. She does her teaching through speaking engagements, publications, through her role as Director of Surgical Education for the Veterinary Emergency Group, and with frequent appearances on the Vet Vault Clinical podcasts.

For more surgery with Dr Bron, plus access to 450+ more episodes in Small Animal Medicine, Surgery, and Emergency and Critical Care and our library of show notes, including this episode, go to vvn.supercast.com.

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If you ever remotely enjoy surgery, then I bet that the good old intestinal foreign body removal is high on a list of favorite surgeries to do.Not many things in our job.It's quite as satisfying and as immediately life savingly impactful as cutting a corncob or a stone or a large flesh colored men's G string out of a dog's Liam.
Yep, that really happened.But where GI foreign bodies become a lot less fun is when you open up the abdomen and you're faced with a very sad, very red, or even worse purple bunched up intestinal tract that is so tightly strung that you can't even lift it out of the abdomen.
Yep, of course I'm talking about those lovely linear foreign bodies.Nobody loves making ten small incisions into the gut to take out ten small bits of string or sock or flesh colored undies, or even worse, cutting out large sections of bowel from an already compromised GI tract.
Which is why I love this episode with surgeon Doctor Bronwyn Fullagar, which is just filled with Nuggets of wisdom on how to make your linear foreign body surgeries easier and more successful.Because the only thing worse than making 10 incisions into the GI tract to take out ten small bits of string is making any incision into the gut for a round two surgery after round one has gone to shed.
Doctor Bronwyn Fullagar is a specialist surgeon from Australia who practices in the US.She loves sharing her knowledge to help the rest of us become better, more confident surgeons and happier humans.If you want to hear more about Bron and her story, and about becoming a specialist surgeon, go back to episode 30, where we interviewed her.
On the podcast, Bronwyn shares her knowledge through his speaking, writing, and through a role as the Director of Surgical Education for the Veterinary Emergency Group or VEG, and through multiple episodes on the Vet Vault Clinical podcast.And this episode on how to make linear foreign body surgery less scary is from the very early days of the podcast.
I think back in episode four.We currently add episode 150, something on the surgery stream alone to put that in perspective, and this is still one of my favorites, which is why I wanted to share it with you.If you have not yet checked out our subscriber only clinical podcast, well why the hell no?
I can only assume that you have not heard about them, so let me tell you more.For our clinical podcasts, I interview specialists and ask them all of the questions that I've accumulated over my 20 RDA career about their topic of expertise, all the stuff that I used to or still get stuck on SO, updates on what's new, or sometimes a revision of important things that I've long since forgotten.
You're not going to find these podcasts if you search for them on your podcast player because access to them is through a paid subscription.Once you sign up for them at vvn.supercast.com, they will show up on your podcast layer of choice.Now you might ask yourself, why would I want to become a paid subscriber when Humid is sharing this stuff on here for free?
Well, first because on our subscriber only podcasts we have a vault.Get it of around 450 episodes in small animal medicine, surgery, and emergency and critical care with two new episodes released each week.So the stuff that you hear on here is just a drop in the Ocean 2nd subscribers get access to our beautifully crafted, very popular show notes so that you can refer back to the stuff that you've learned on the podcast when you see that case that makes you think.
I think I listened to a podcast on this, but I can't quite remember what they said.Our notes have grown into a searchable library or quick reference in its own right, and it's become my personal first line reference when I'm on the clinic floor.This is because it's not just a wordy textbook chapter, it is the up to date key tips and takeaways from some of the smartest, most experienced people in the field.
Third, members get exclusive access to spaces on the Red Vault network where you can ask questions and have discussions about the stuff that we're learning and you get to help us guide what content gets produced next.And lastly, ads.These public versions of the podcast will usually have some sort of advertising attached to them, like this message, whereas the subscriber feed will never have any ads.
So if you like what you hear on this episode and you do want to check out a full feed of clinical content, go and try it out for free for two weeks at VVN.That's VVN for vetvaultnetwork.supercast.com.OK, Doctor Bronwyn, Fullagar and Linear Intestinal Foreign Body Surgery.
Welcome back, everybody.We have Doctor Bronwyn talking to us about GI surgery again tonight, but we're diving into a unique one, one that can be a real challenge for both of us.We're talking about linear foreign bodies.Gerardo, you get lots of these, I take it.We get a lot of these.
We get ones which are sent across because clinicians don't want to tackle them, which is perfectly fine to be honest.I don't really want to tackle them either because like 40 to 50% of them have perfed already.So you're dealing with septic pernitis and maybe that's actually a good point to discuss about your decision making process between chopping them or not or referring them or not.
But I'm sure they will come up in the Chat Bronzer guru at this stuff, so I'm looking forward to hearing what she has to say.Brian, you see more complications from linear foreign bodies than you do with other intestinal surgery.Yeah.
And I think that's because like Gerardo said, they tend to be a bit more challenging than your standard solitary foreign body and that that's a lot more damage potentially done to the intestinal tract.And yeah, like like Gerardo just said, many more of them have perforated by the time you you do surgery.
And so that means that you're you need to do a resection of astomosis and that's a pretty technically challenging GI surgery.But yeah, I think they can be really manageable.You just need to kind of have a a technique or a set of steps that you take with them.So yeah, actually what you just said there was was really important about the decision making process to jump in.
So in my mind if you've never tackled linear foreign body or you've never done a resection astomosis or you don't have access to someone who's done at least a resection and astomosis.And I think that the, I don't know, you've got to be the gung ho, are prepared and read up and have a step by step process, but otherwise maybe if you if it's within referral distance and maybe in my mind that would be something you would consider referring.
Yeah, definitely.I think that's one of the main troubles that people find themselves in is they go in thinking, Oh yes, I know this cat ate a piece of string, or I know this dog ate a long piece of carpet.No problem.And then they get into surgery not expecting to have to do a resection.Ostomosis perhaps.
And then all of a sudden they're in surgery.Maybe they're by themselves or they don't have a ton of mentorship, but they're not so familiar with the procedure.And all of a sudden they're faced with one of the most challenging intestinal surgeries you know, you have to do.And I think that's when things can start to go a little bit sideways.So yeah, definitely.
Rule number one, I think is if you're going in to cut a foreign body that you suspect is linear, you need to be prepared to do a resection anastomosis.And that might mean having another person scrubbing with you.Would highly recommend that.And also hopefully having practice it a few times, maybe on cadavers or you've done a course or you have a mentor in the practice who's pretty familiar, who can guide you through it.
Because it is a surgery that it's pretty difficult to do for the first time if you're just reading it out of a textbook or you don't have a lot of support in your practice.So I'll start by I'll give you a few scenarios that I've encountered that scared the bejeevas out of me.Unexpected, a little bit lazay and you go in and you meet a few problems and you can maybe talk through how to deal with each of these.
So the first thing is where it's already damaged the intestinal tract.So you go in and there's this really freaking tight loop of the rope bound or string bound gut that you can hardly lift out of the abdomen.And on the mesenteric surface you have these multiple little black lines that just you just go, oh crap, are those alive or dead?
And a big challenge for me, there is decision making, what stays and what goes.The other thing that I've encountered is physically just getting it out exactly that.Sometimes it's so tight from that piece of linear foreign body that I can't properly lift it out, especially the ones where you have.It's anchored in the stomach.
One of my worst ones was a tennis ball that had half unravelled.So it was anchored in the stomach and then gone all the way through linear body halfway down.So you had to hold your denim and half this small intestine just bunched up into this tight little friggin ball.Third problem is access again is if it is in the jodenum because you can't lift the jodenum out as nicely as you can lower down the intestinal tract.
I've I've really struggled with some of those where it's stomach anchored and then the jodenum's all bunched up.How do you access that?I feel like there was a fourth, but I'll stick to those 3.Yeah, that's a lot.That's a lot of questions already, I think.Adding any life advice as well on that right.
So like #5, how do I comply this human being?Relationship advice.Well, I think I'll stick, I'll stick to to linear foreign bodies, but maybe a future episode.So in answer to your, I think all of those questions can be answered in in sort of the series of steps that I would take.
So a few key ways that linear foreign body surgery is different to other foreign body surgery for me.And I think one of the first ones that's really important is usually when you do foreign body surgery, we're taught to do a full abdominal explore prior to taking the foreign body out.So you know, you look at the stomach and the intestines, the liver and the bladder and the spleen and everything.
And then after you've done all that, then you start taking out the foreign body and the linear foreign bodies are entirely different.So if I go into an abdomen and the intestines are all placated and and they're all bunched and I can't move them, I don't even touch the intestines to begin with.The last thing I want to do is start manipulating them and have the string tear through the mesenteric border.
So it's really difficult to assess intestinal viability when they're all bunched.So usually #1 port of call is identify where the foreign body is anchored and release the anchoring.That's number one before you do an explorer, before you assess viability, anything else.
And so in in a dog with your tennis ball analogy, that's most likely going to be in the pyloris and in a cat you're most likely to find a string under the tongue.Not all dogs and cats, obviously.Read the textbook, but I would say especially for dogs, the vast majority of these are going to be anchored at the pyloris.
So step number one will be gastronomy and release the foreign body.So in in your tennis ball case, you would cut the piece of unraveling right below the tennis ball and remove the tennis ball, Check the rest of the stomach for material, close the gastrotomy and let the fluff from the tennis ball of a string of the tampon or whatever your foreign body happens to be.
Let that start sliding down the duodenum, so allow it to make its way into the small intestine and then once you've got the foreign body into the duodenum.The good thing about dog foreign bodies is because they tend to eat carpet, toys, you know, women's hygiene products, all those sort of things.
They're pretty easy to feel.They don't tend to eat needles and threads, dogs, as a general rule.Sometimes they do, but usually not.They usually eat something large that you can feel.And so then you can start to milk the foreign body down the small intestine and relieve the placations really gently.And at that point you've got a much better chance of assessing viability and and accessing what you need to access in the small intestine.
Hey, cool.I've I've my experience has been otherwise a little bit because sometimes I've found it pretty hard to get to the stomach.So sometimes the only thing I've been able to do is release the aboral anchor or you call it anchor or the aboral kind of bit that's been pushed pushed along and it's and that's given me enough space to kind of unravel it a little bit take the pressure off and then get get into the stomach.
So I've always tried to get into the stomach and sometimes I just haven't been able to like get enough exposure.And then when you get in there, I think one thing that's really helpful is like passing the stomach tube, because often they're full of fluidy stuff that spills everywhere once you once you start exteriorizing the stomach, once you start cutting up in the stomach, is there any, is there any tips there?
I suppose, like for those ones which are bunched up and they're all kind of like a bundle of intestine looking disgusting.Yeah, I think so.My, my best foreign body, linear foreign body story, the one that I have a big photo of and all my PowerPoints on this topic is a dog, a Labrador, that ate his bandage.
And so he essentially ate an entire role of conforming, you know, the stretchy conforming gauze, we call it fling in North America.And so it's an elastic.So it had not only was it a linear foreign body, but it was, it was an elastic linear, foreign body.So his entire intestinal tract was just, you know, you can just imagine the placations, it was great.
But I think I've never had issues accessing the stomach.So if you're having trouble, you probably need to make your incision more cranial.So your skin incision can extend over the base of the xiphoid cartilage and you can extend your linear Alba incision over the xiphoid as well and remove the falsiform.
And then I find putting some stay sutures in the stomach really helpful before you make your gastrotomy and then those days.So just we can pull the stomach quarterly and eventually so upwards towards you and then you can get some lap sponges around the stomach and pack it off and then after that make your gastrotomy.
And and yeah, like Gerardo said, a lot of these animals will have really full stomachs.And so either passing a stomach tube before you do gastrotomy and also having the suction available to you once you've done the gastrotomy because you can expect a sort of fountain of gastric juices to come out.
And I think one other thing to do with really full stomachs is these patients offering her a huge aspiration risk on induction.So having like really rapid intubation and then a oragastric tube at induction can be really helpful as well.Yeah, and that's some pretty good points there.
I think one thing that people find a little bit scary is cutting to the xyphoid.Like sometimes the xyphoid's hanging out, but any tips there on how far you can cut through without all of a sudden going into the diaphragm?No you don't.You don't need to cut through the xiphoid.So the linear Alba will extend Ventral to the xiphoid.
You can have your scissor between the xiphoid and the external rectus.And yeah, you can cut to the base of the xiphoid.I think if you're if you're ventral to the xiphoid, so on top of it as you're looking down, then the xiphoid will protect you from the diaphragm.Does that make sense?So the diaphragm will attach underneath or dorsal to the xiphoid process.
So definitely you need to be aware of of the diaphragm and don't you know don't into the chest.That's not not great.But honestly once if you can put your Balfour retractor in and just visualize the stomach then you can get some stay sutures in the stomach.The stomach is a really elastic organ and so it's possible to use those stay sutures to put a little bit of tension on it to get it eventually and and out from under the ribs where you can see it.
So I I don't think there should be a scenario where you can't access the stomach because the intestines are in the way.So I I would still advocate for releasing the foreign body from the stomach because otherwise you might make an extra intestinal anteronomy that you don't need to.Yeah, yeah, would.
Would depending on the viability right?Would you try to milk it a little bit orally first to see not not first, but as part of the process and see because I've actually done the gastrotomy and being able to make one incision, remove the anchor that was stuck in a pylorus and then able then to pull the whole thing back slowly just by kind of like milking it.
Yeah, sometimes.Sometimes you get lucky.So once you're in the stomach, if the material is, you know, moving really easily, and if it's very smooth material and not causing any trauma to the intestine, and if it's probably only in the duodenum, then sometimes you get lucky and you can pull it out of the stomach for sure.
But I would say the majority of times I would advocate, if in doubt, milk it abhorally rather than risk tearing the small intestine, because it's always better to have to make an extra end derotomy than to have to do a resection anastomosis that you hadn't planned on.
Hey, while we're on the topic of clinical content, I wanted to tell you about two events that I'll be attending and doing some live podcasting from.Both of these are organized by my friend and also regular podcast guest Doctor Dave Collins and his vets on tour conferences where we combine learning and fun.
In both these cases, it's no fun.The first one is in Wanaka in New Zealand from 12th to 16th of August.Now, if you haven't been to Wanaka, wow.Even if you don't like skiing, the hiking and the scenery is more than enough motivation to find an excuse to go there.
And this conference is a pretty good excuse.This year's clinical content is focused on surgery, anaesthesia and cardiology, with stellar speakers on topics like updates on desexing, BOA surgery, anaesthesia, emergencies, sedation protocols, feline heart failure, arrhythmias, to name just a few.
Then I'll hopefully be joining the Vets On Tour crew again in Fiorano in Japan on 18 to 25 of January 2025 for more snow fun, more learning and podcasting, and probably a fair amount of sake and amazing food.Davis just confirmed that our very own Bronwyn will be one of the speakers for that event.
He's also created a special vet vault special.If you register before the end of April for Wanaka or before the end of May for Japan, and you tell Dave that you heard about the conferences on the vet vault, he will give you 10% off your conference registration fee.He'll also let you choose his outfit for the Notorious vets on to a fancy dress party.
Perhaps he can wear the leather miniskirt that I wore last year, which sounded like a hilarious idea, but not that clever if you consider that we were, after all, in cold enough weather for it to snow.So tell Dave Hubert sent you and you'll get your 10% off.Hope to see you there.OK, back to Bronwyn and sad guts with strings in them.
So one question.I've never started at the stomach, probably because I've never actually asked.I just sort of bumbled my my own technique.I I I generally would start with a if you have a long one that goes stomach past the Jidenum and quite a way down just beyond the Jidenum.
I do one releasing cut and it sort of booms and it recoils back to the stomach and the other way around.But I love your idea.But in my head I'm thinking, well, if you've got all that tension and you've got this thing trying to pull out of the stomach, how easy is it to actually access it or pull it far enough back through the stomach or into the stomach so that you can actually snip that?
Or is it like I I would worry that pulling on it is going to put even more tension on that strangulated bit of intestine.Is that a challenge or is it not?Am I making this up?Not usually.So yeah that this is one of the big take home messages of the podcast I think is to release the anchor first before you start making entorotomy.
So I I'm going to, I'm going to say it again maybe I'm just lucky but I as yet have never had to make more than one entorotomy in a dog with a linear foreign body SO1 gastronomy 1 entorotomy, foreign bodies out in a dog.And I think that's because if you release it in the stomach first then you only need to make one entorotomy.
And so that like the number of holes in the intestine you make is directly proportional to the right of complication.So if you can minimize the number of entorotomies, it'll minimize your surgical time, but it also minimizes your risk of of dehiscence.So in the stomach, yeah, you don't want to pull the foreign body too hard.
And so I'll position my gastronomy not over the pyloris, like you don't want to put it over that muscular part of the stomach, 'cause that increases the complication rate.But just just our end to the pyloris.So different kind of spot to what you would do for a standard gastronomy and having your stay sutures kind of towards the pyloris helps with that too.
And so then I'll just lift the foreign body up enough that I can get my scissor underneath it and cut.And sometimes I'm even cutting blind.So in the case of your tennis ball, you know, you've got your tennis ball grasped inside your Allis tissue faucets, and you've got your scissors in the other hand, and you just kind of snip underneath it.And then often times, you know, the fluff of the tennis ball or whatever it is just disappears down, you know, into the intestine.
And that's fine.Off it goes.And then check the rest of the stomach, make sure there's nothing else in there, and then close the stomach so you don't have stuff spilling everywhere.And then start the milking, milking process down the intestine.And then in most cases that have not perforated, you'll just carry on milking very, very gently down to sort of the mid jejunum or wherever the rest of the firing body happens to be.
And then at that point, pick a nice healthy spot and make one interotomy and pull the whole thing out.I'm almost excited for my next linear foreign body, this.Sounds so much.Easier.Podcast done.Podcast done.Yeah.No, I've got a couple questions.
One is about deciding when to respect anastomos, but I'm sure that's Oh yeah, that's later laid down the track.But what about Kitty cats?Kitty cats, where you you, you, you find it on the tongue and you just pull it right.That's.I'm sure that's what you just pull it out.Yeah, great idea.Oh yeah, obviously not.
Obviously not, because I was laughter there.OK.Yeah.So cats, yeah, cats are a bit different.So if you have your cat that has a linear foreign body and maybe you've done a really thorough physical exam and you found the string under the tongue and you're awake cat, my take would be to leave, you know that your cat's clinical, it's been vomiting, it's got this linear foreign body.
So you're gonna recommend surgery, so wait until surgery before cutting that stream.Because the difference in cats is that they tend to eat really, really thin thread, like foreign bodies, like thread with, with or without needles.And so that is really hard to palpate in an intestine, particularly thickened intestines.
They're quite different to dogs in what they eat and where it's anchored.And so generally, let's say we've got the textbook cat that has a under the tongue foreign body.Then we'll go into surgery, do our open up the the abdomen and you'll see the placated intestines and same thing as dogs.
Before we do the full explore, we're gonna release the foreign body.But in cats, often what I'll do before releasing it is I will make one enterotomy at a level where I think the intestine's relatively healthy and I'll grasp the foreign body with a little hemostat.
So being really careful not to pull on the foreign body, just grasp it and it'll be sitting there at the mesenteric border and then once I've got hold of it, so I'm not going to lose it, then I'll get somebody the anesa test or the the nurse or technician helping out to cut it under the tongue.
And at that point, you'll be able to get the foreign body that was in the mouth out through that one interotomy.And then depending on how much foreign body is left abarad to where your hemostat is grasping it, maybe you'll be able to milk it back and get it all out of that one entorotomy.
But more commonly, because that thread is often embedded in the wall of the intestine, sometimes pulling on it can do more harm than good.So in those cases, if I can't get it all out, then before I release the one hemostat, I'll make a second entorotomy and grasp it at the 2nd entorotomy and then cut the string and pull half out from 1 entorotomy and half out from the other entorotomy.
Does that make sense?Sounds like you need to be Who's Spider Man's Arch enemy?Doctor.Doctor Och or something.Like, let's go back to actually your first mantra on me.So let's say when you're saying you're pulling it, you're not necessarily pulling it though, but you're kind of teasing the intestine that's aboral.
So towards the rectum kind of off it is, is as opposed to actually pulling it?Yeah, so you're right.So minimal pulling.So for the 1st, instead of a judgement call, like if I've got a cat whose entire J Junum is just completely placated with what we think is a is a really thin string foreign body.
And in some of these cats, honestly, the string is anchored in their mouth and some of it's dangling out their anus, like they've literally got the string all the way through them.And so in those cats, I know that I'm going to have to make usually more than one entronomy.So the first one will be kind of in say the early J Junum or the distal duodenum.
And that goal of that one is just to remove the string that used to be in the mouth.So I'm mainly removing the string from or add to the way the hemostat is.And then the second enterectomy will be sort of mid J Junum say.And that one we're going to grasp the string and then we're grasping it first because once you've cut it and these cats, you can't feel the foreign body.
So you don't want to sort of lose it and wonder, like, did I get it all out or not?You want to know where it is.So before cutting it, you'll grasp another little piece of it.And then if you're lucky, yeah, you'll be able to sort of milk the intestine over the foreign body and get it out through that, that second enterotomy.And if not, you'll have to make another enterotomy, really small.
And these enterotomies only need to be tiny, right?Like a centimeter or less long, because all we're trying to get out is tiny string.I'm picturing you've got at.At points you will have multiple hemis that's clicked on to bits of string with small little interactive is still open.Is that?
Am I understanding that correctly?OK.Cool.Yeah, yeah.And in cats, like my top tip for cat intestinal surgery, especially if you're by yourself, is to sterilize some Bobby pins, like the kind that you put in your hair or that some people put in their hair and.
Feed that to the cat and then.Right, so the the Bobby pins act in place of doyen forceps.So they are really a traumatic little intestinal clamps.And so, rather than having multiple assistance with their fingers on the intestine to prevent spillage, you just put little Bobby pins on either side of where you want to make your androtomies.
Really, They're not too tight.No, no.Works really well.Really a traumatic.I can show you a picture if you want, but yeah, that that that works.It works really well in cats because they've got such tiny and cute little intestines.And the nice thing about that is that often the string, it's possible to still pass the string even though you've got a a Bobby pin on it because the string is so tiny.
So yes, you sometimes will have more than one inch rotomy open in a cat, and that's why they're quite different to dogs.Like some cats eat the standard they eat different things that you can feel that are anchored in the stomach, and then those ones you just treat like a dog.But this is kind of the this is the cat that ate the string that's gone.
That's a very thin string.You might need to make multiple Anderotomies.That's brilliant, man.Love it.OK, Brian, now I'm cheering because I've got my foreign body out and I think I'm a hero.And then I look at that intestinal tract and you look at that mesenteric surface and you see those little black dots every couple of centimeters.
That's tough one for me.Do you always cut those out?Do you wait and see?What do you, how do you handle those ones?Yeah, that's a very challenging part of surgery.I think usually if you've managed to get your farm body out without dragging it along the mesenteric borders, you've managed to do as minimal damage as possible.
Only if you're very, very unlucky will there be perforations or non viable parts all along the intestine.More often, at least more often, at least in dogs, they'll just be maybe one little area.And I guess the way I assess viability in those cases, if there's a perforation, even if it's just a small one, if there is a hole, it needs a resection anastomosis.
So you know, sorry that this needs to be done.If there's kind of purplish regions, then I guess it's a it's really a judgement call.Usually I'll watch and see if things improve over time.So you give it, you know, 10 minutes.Sometimes I use that time to close my enterotomy incision.
I'll look at it and I'll think, I'm not sure about this, but hey, I'll put some sutures in the enterotomy and kind of that gives me 10 minutes of waiting time.And then I'll lavage the abdomen and give it some time to reperfuse and then I'll go back and take another look.And a lot of the time things have improved in that time, in which case you know good news and especially if there's some peristalsis and the colour's getting better and and you can sort of palpate and if you don't feel any thin regions then it's probably going to be probably going to be OK.
But if you've got black or Gray patches or any holes, then then unfortunately you have to do your your resection anastomosis.OK.That's true.Because some people go and they look at it and they're like, oh, there's all this stuff's bunched up and they go, oh, how much you need to chop out first.
But the the first step is always relieving and removing the resection.The the the foreign body in the second is resection astomosis.Yeah, yeah.So I'll always, even in cases where it's perforated and I and I know I can, you know the septic periconitis that's fluid in the abdomen, I think of this is really bad news.
I'll still release the foreign body first.So in a dog that'll be the gastrotomy, release it from the stomach, milk it down.And then sometimes in those cases if things are are really bad and and there's multiple perforations, then you know, you can remove the foreign body along with the piece of intestine.
But more often I'll take out the foreign body, bion and deronomy, even if it's perforated, just 'cause it gives me a better idea of what the intestine actually looks like.And then in those cases, I won't spend time closing the enterotomy, 'cause I know that, you know, we have to do a resection of stamosis.But I'll at least get the foreign body out and still give the rest of the intestine some time.
Because I think sometimes people, if they make, if you make a judgement call really early in your surgery, particularly if your patients still say dehydrated or hypertensive and you haven't given it time after you've taken out the foreign body, just declare itself, then you might end up being a bit too aggressive with your resection anastomosis.
You know you want to take out enough but not too much.That's kind of where a bit of experience comes in.But I think giving a little bit of time before making the final call of what needs to to be removed is helpful.So.So removing from pyloris to like iliacollic junction is not advisable.
Pointing the colon to the pyloris is not good.Generally goes poorly the the bile duct would be most unhappy with that option.That's a half a joke, but it wasn't a total joke.But why do you use a?Discussion now about how much can you chop out?
OK, we'll answer that First, how much can you chop out before you start getting uncomfortable?So in terms of developing short bowel syndrome that'll happen in dogs once you start taking, well it's sort of a rough number but 7075% of the small intestinal length and especially if for some reason you need to resect the ileocecocolic.
So I think you know if I've, if I'm in surgery and there's a a serious issue with multiple parts of the small intestine, then I might give the owners a call and chat about that.But you know it's short bowel syndrome.If the ileocecocolic junction is intact and you have a committed owner and say the duodenum is intact so that that papilla with the bile duct and the pancreatic duct that's intact, then with a committed owner and a change in diet and some adaptation with time those dogs can still lead a reasonable quality of life but they'll need dietary changes and sometimes vitamin B12, cob albumin supplements and and the owners need to be prepared.
But for the first you know month or two the dog will probably have diarrhea as they adapt.So I I would say that's rare though that's a rare situation where you need to remove that much intestine.So if you're if you're feeling like in in practice you're removing 75% of the small intestine sort of most, most of the time then that I I would say that you probably need to re reassess how you're evaluating viability, but yeah I yeah.
And then back to Gerardo's comment about duodenum de colon duodenum, If you're in there and there is a perforation in the duodenum, how do you deal with that one?I have actually had that before.Yeah, wow, you're you're quite unlucky.
So in those situations.It's because I was yanking on it.I was yanking, yanking on it.Yeah, because because the duodenum is pretty well because the meso duodenum anchors the duodenum pretty well to the the body wall.It's got that duodenum colleague ligament quarterly.It's obviously attached to the stomach cranially.
So it's pretty uncommon in linear foreign bodies to get a perforation at the duodenal papilla, which is fortunate.But yeah, sometimes it does happen.So options there, I think that that's yeah all the options involve kind of complicated surgeries is.
That beyond the scope of this podcast.Probably beyond the scope of the podcast just because it involves pretty complicated rerouting procedures, but I I think, you know, really, really gentle handling of the intestine is so important with linear foreign bodies.And yeah, a lot of a lot of the time, although things might look catastrophic when you get in there, maybe actually things are just kind of bruised and nothing's perforated yet.
But if you start pulling on things or or you're not super careful, then potentially things can.You can make things worse and make things harder for yourself.So.I've got a question.So do you do 2 resections on ostomosis or one resection on ostomosis?
If you have two two distinct and and geographically separated areas of perforation, yeah.Yeah, tackle.That one, so the fairly uncommon scenario I think, but yeah, if I had two separate areas then I would and there was a reasonable amount of intestine in between them.
Well, depending on the size of dog, but I'd be more inclined to do 2 separate resection anastomosis.And if you remember the way the small intestine gets its blood supply, there's the jejunal artery that's a branch of the cranial mesenteric artery that runs instead of those fan shaped mesenteric blood vessels.
If you make sure that you're ligating the blood vessels really close to the intestine, so you're maintaining as much as possible the collateral circulation to the adjacent pieces of intestine, does that make sense?So in those scenarios it's helpful to have either hemoclips or a ligosure rather than hand like any because you obviously have to do more ligations.
But if you preserve the blood supply as much as you can, then you should be able to do 2 resection and astomoses.But if the two perforations are really close together or it's a really big dog with a lot of intestine, then you can do them in one.So I think it's very case dependent.
I've got one more question.Bron once SO colleague and I didn't watch the whole surgery, but he had a technique where he he went in possibly in the stomach and actually attached a little bit of rubber tubing or like something artificial and tied it onto the foreign body. close up the whole but big enough that you can clearly feel it.
And then use that to just thread thread the whole thing.And I think he threaded it all the way to the colon and pulled it out.Yeah.So that's another technique for particularly caps.So particularly foreign bodies where you can't easily feel the foreign body and the foreign body is also small enough that it's gonna make it through the intestinal tract and through the iliocecoccolic valve without too much issue.
So works best for skinny, thin foreign bodies and foreign bodies that are pretty soft.So ones that are not going to cause trauma.But yeah, definitely.So in those cases you can do either a a gastrotomy or an enterotomy depending on where the foreign body is lodged.So in the case of a cut under the tongue, say, you might do a gastrotomy and then once you've grasped the string, release it from under the tongue.
And then, yeah, tie the string to a little bit of red rubber catheter like urinary catheter tubing.And then close your gas pterodomy.And then you feed the catheter tubing very gently, melt it all the way down the intestinal tract.And sometimes if things are unplaccated nicely, then you can get it all the way through the ileostic hycolic valve.
I think the issue sometimes in cats is that the string is so firmly embedded in the wall of the intestine that it doesn't feed nicely.But certainly it's one option and it's there's even a paper I think describing that they call it the red rubber catheter technique.But yeah, it's another kind of trick that can be helpful for sure.Then you.Got to Then you got to ask your nurse to like look under the drapes and and and get ready for some cat poop in the rubber rubber catheter as you're trying to push it to the coal.
Line.Otherwise you just cut into the colon and pull it out, yes.You have you not listened to any of that podcast?Yeah, yeah, yeah.I think I thought of one other thing I wanted to touch on, and that was just briefly the post op care for linear foreign bodies.
So I'm not sure if you've noticed this, Gerardo, but linear foreign bodies usually are sicker than standard pharmodies and after surgery, because their intestine has been so, you know, it's really gone through the wring or it's been bunched up.And then often times they've also had a resection anastomosis.
The poor old myenteric plexus has been thoroughly confused.And so all those normal nerve impulses that would travel down the intestine causing peristalsis have been temporarily switched off.And so that patients will have really wicked ileus after surgery.And so for these guys, I love putting a nasogastric tube in them for after surgery.
So that means that we can suction residual and RC fluid out of the stomach and we can start feeding them from day one because many of them most I would say would not eat straight after surgery And then also putting them on a prokinetic like metachlorphromide straight after surgery.So more aggressively treating them medically in the post op period because it would be the exception rather than the rule that a patient with a linear foreign body would just wake up the next morning and have a Full breakfast.
That would be unusual, I would say.Awesome.Thank you so much, Bronwyn.That's full of pills of wisdom and make a pill necklace.Bron, thank you so much.That's epic.I can't wait for the next one.Hey guys, just a quick reminder about our specialist support space.
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Dr Bronwyn Fullagar