Intraoperative photograph of a small intestinal intussusception in a three‐year‐old female spayed German Shepherd. The dog had surgery one month ago for an intussusception and reintussuscepted at the site of the previous intestinal resection and anastomosis. No enteroplication was performed at the initial surgery. Note areas of devitalized bowel as well as multiple serosal tears of the intussuscipiens.
Source: Reproduced with permission from L.R. Aronson, University of Pennsylvania, Philadelphia, PA, USA, 2014.
In previous reports involving intussusception in 88 dogs, 72 (82%) required resection and anastomosis due to necrosis of involved intestine and/or inability to manually reduce the affected bowel [25]. Laparoscopic management of intussusception has been reported in pediatric patients [26, 27]. In a series of 22 children, 91% were managed entirely laparoscopically, while 2 patients required conversion to open laparotomy. In this series, 46% of patients underwent a bowel resection [26]. In veterinary medicine, use of laparoscopy to identify bowel loops affected by an intussusception and then perform extra corporeal resection and anastomosis has been documented [28, 29]. Another reported method for reduction in an experimental setting has been described using laparoscopic assisted pneumatic reduction. An intussusception was experimentally created in 27 dogs and under laparoscopic observation, CO2 was insufflated into the rectum and the bowel was successfully reduced with grasping forceps in 94% of the dogs [27].
Although the majority of cases require surgical intervention, spontaneous reduction of intestinal intussusception is known to occur in people [30] and has been reported in dogs [31]. In these dogs, clinical signs and imaging were consistent with intussusception but were not confirmed on exploratory laparotomy. Additionally, the duration of clinical signs in these dogs was shorter (median two days), and on ultrasound examination, the intussusception was smaller in diameter and shorter in length, compared with those dogs in which surgery confirmed the presence of an intussusception. It is suggested that analgesia or general anesthesia may allow for relaxation and spontaneous reduction of an intussusception, so it may be advisable to repeat imaging after induction of anesthesia but prior to abdominal exploration.
After reduction or resection of the intussusception, enteroplication may reduce the incidence of future occurrence (Figure 6.7). This procedure is performed by arranging the small intestine in gentle loops side by side from the duodenal colic ligament to the level of the ileum. Adjacent loops of intestine are sutured together, engaging the submucosa [32]. Enteroplication has also been reported using cyanoacrylate tissue adhesive in a series of cats but was reportedly associated with adverse clinical signs and was therefore not recommended for clinical use [33]. In a series of 31 dogs, intussusception reoccurred in 6 of 22 dogs without enteroplication but 0 of 9 dogs that underwent enteroplication, suggesting that enteroplication decreases the probability of reoccurrence with no apparent adverse effects [34].
Complications of enteroplication have been reported and include intestinal volvulus, intestinal perforation with abscess formation, as well as peritonitis [35–38]. To investigate the complications and reoccurrence rates, a study of 35 dogs found that there were no significant differences in the rate of intussusception reoccurrence between patients that did or did not undergo enteroplication; however, there were life‐threatening complications related to enteroplication. The authors reported 3 of 16 dogs (19%) that underwent enteroplication required a second surgery to address complications, including obstruction of foreign material and strangulation of bowel through enteroplicated loops [21]. A retrospective evaluation of surgically addressed intussusceptions in cats revealed that enteroplication may not prevent recurrence of intussusception in that species. In that study, functional ileus immediately postoperatively and 11 months after surgery were attributed to enteroplication, although there was no evidence for causality, as etiologies for ileus are varied and multifactorial [7].
Figure 6.7 Intraoperative photograph of enteroplication. A resection and anastomosis was performed before enteroplication.
Figure 6.8 Resected segment of intestine submitted for histopathologic analysis from a four‐year‐old, male castrated Shih Tzu that was evaluated for an acute onset of vomiting, lethargy, and anorexia for three days and a one‐day history of hematochezia. The dog was diagnosed with an intussusception based on physical examination and an abdominal ultrasound. At surgery, an approximately 10‐cm segment of jejunum was invaginated upon itself. A resection and anastomosis was performed. Final histopathology revealed mild lymphoplasmacytic enteritis, but no masses or apparent cause for the intussusception.
Source: Reproduced with permission from T. Donovan.
Following removal of the resected section of intestine, it is advisable to submit the section for histological examination (Figure 6.8). In a study of the histopathology reports of 49 animals (31 dogs and 18 cats) with intussusception, histopathology was able to detect abnormalities that may have contributed to intussusception in 47% of cases [39]. If biopsy specimens from additional segments of bowel (other than the resected segment) were also submitted, a potential contributing histological finding was documented in 85% of patients. The most common underlying abnormality in dogs was found to be inflammatory disease, while cats were significantly more likely to have neoplastic lesions [39].
Postoperative Care and Complications
Following surgery, patients should be closely monitored with respect to hydration, perfusion, comfort level, electrolyte and acid–base status. Electrolytes and acid–base parameters should be evaluated once daily, and potentially more frequently, depending on the degree of derangements preoperatively. Opioid analgesia is important not only for patient comfort but may play a role in preventing reoccurrence of intussusception. In a study of dogs undergoing renal transplantation, the rates of intussusception dropped from 17% to 3% in dogs receiving butorphanol in the postoperative period [40]. It is hypothesized that opioids increase the tone of the intestines, as well as the amplitude of the non‐propulsive contractions that may decrease local bowel wall inhomogeneity and segmental ileus [41]. Patients may experience nausea and regurgitation postoperatively, which can be managed with antiemetics and gastric acid reducers, such as proton pump inhibitors (pantoprazole, esomeprazole, omeprazole) or H2‐blockers (famotidine). Prokinetic agents, such as metoclopramide and erythromycin or azithromycin, should be considered if ileus and enteral feeding intolerance are suspected or documented.
Initiation of feeding is begun as patients are alert and awake, usually within 12 hours following surgery. A significant number of dogs with gastroesophageal intussusception may have persistent regurgitation and significant esophageal dilation following repair, which may require elevated feeding [8]. In debilitated patients, or those remaining anorectic, nutritional support should be provided. Early enteral nutrition (within 24 hours of surgery) in children undergoing GI resection was associated with lower rates of complications, shorter hospitalization time and quicker postoperative GI function recovery [42]. This has not been corroborated in dogs, but studies did report on benefits of early enteral nutrition (within 48 hours of admission) in dogs with pancreatitis where it has been shown to decrease GI intolerance and expedite voluntary intake in dogs with pancreatitis [43]. A nasogastric tube is the least invasive method of enteral nutrition that does not require anesthesia for placement and may be a simple way of providing the patient's nutritional needs during
