Post‐operative reflux – a surgeon's perspective

Abstract

Summary Post‐operative ileus (POI) is a well‐recognised complication of colic surgery that accounts for a high proportion of post‐operative deaths. Although much has been written about the pathophysiology and management of POI in horses, most studies seem to apply research findings to the clinical case without full regard for the clinical evidence. Although much attention has focused recently on the role of inflammation, this narrow focus might explain our failure to make important advances in managing horses with this complication. This commentary is offered to redirect our current thinking about POI away from an approach that predominantly emphasises a functional disorder and medical management, to one that addresses surgical prevention.

An update on equine post‐operative ileus: Definitions, pathophysiology and management

“…The term post-operative reflux (POR), proposed to describe solely the presence of reflux following surgery without any causal assumptions [20], includes both mechanical obstructions and functional motility inhibition as potential underlying mechanisms. In the interest of clarity, this review will focus on POI; namely, the functional inhibition of motility following abdominal surgery.…”

“…Minimisation of tissue handling is likely to have beneficial effects via reduced induction of inflammation within the muscularis [28,29,37]. However, the potential benefit of limiting the degree of intestinal manipulation in equine surgery must be weighed against the increased risk of POR associated with inadequate decompression of the SI which may result in kinking, and therefore obstruction, of distended SI loops [20]. Studies conducted in rodent models have clearly demonstrated an association between the force of manipulation and both the resulting inflammatory response and the delay in recovery of GIT motility [29].…”

“…Patients are recommended to initiate progressive mobilisation after abdominal surgery as early as the first day post-operatively, provided the level of analgesia is effective [120]. In horses, the reported benefits of early mobilisation are largely anecdotal; however, those that adapt and apply the human ERAS protocol to their equine post-operative cases instigate early mobilisation as one of the components of this approach [20].…”

Letter to the Editor: Bias in statistics or bias in equine veterinary medicine?

“…We agree that future studies with even randomisation into both resection and nonresection groups to account for this variable would be informative. Nonetheless, Dr. Freeman has previously indicated that horses in which SISO is not resected are arguably more critical patients to manage because of the known presence of ischaemic‐injured intestine , so it could be argued that more nonresected cases in the firocoxib group is an allocation bias against that group. The authors are aware of and have discussed prothrombotic side effects of COX‐2 inhibitors in human beings previously . Horses are not known to be susceptible to these prothrombotic side effects of COX selective NSAIDs, and no significant increase in such side effects (such as thrombosed jugular veins) were noted in horses on firocoxib in the present RCT. The authors were careful not to overstate the results indicating that ‘this RCT provides important preliminary evidence that firocoxib offers clinical benefits.’ In the letter by Dr Freeman, the bolded part of the statement was omitted to make a point not intended by the authors.…”

“…We agree that future studies with even randomisation into both resection and nonresection groups to account for this variable would be informative. Nonetheless, Dr. Freeman has previously indicated that horses in which SISO is not resected are arguably more critical patients to manage because of the known presence of ischaemic-injured intestine [2], so it could be argued that more nonresected cases in the firocoxib group is an allocation bias against that group. • The authors are aware of and have discussed prothrombotic side effects of COX-2 inhibitors in human beings previously [3].…”