So, welcome to this lecture on postoperative care of the colic patients. This talk will aim to take you through key sort of bits of current evidence about how we manage horses in the postoperative periods. It's not going to be a comprehensive review of absolutely everything, because it is actually a fairly big topic with quite a lot of scientific evidence within it.
But I thought I'd use this as an opportunity to just highlight some more recently undertaken scientific studies and demonstrate how these are informing our ways in which we look after the postoperative colic patients. So as an overview to the colic patients, our ultimate aim is to get the best outcome for our patients and their owners. And this is a sort of a fairly big sort of process that doesn't just involve our postoperative care.
It starts right from the time that the horse first starts to show signs of colic. And the horse owner and the vet, seeing that case are absolutely critical in achieving that best possible outcome together with all the other factors. And it's really important that owners are educated into what the signs of colic are and when to call their vets, and the owners and vets appreciate the potential need for surgery in those cases that are more severe.
And we always sort of cite that as being around about one in 10 colic cases in the general sort of equine sort of colic population, but probably the more critical cases would be around sort of 2 to 3 in 10 of those cases. So it's not an infrequent occurrence that a horse will potentially need referral to hospital facilities for further assessment and treatments. And obviously, that requires communications with the hospital team, and that decision whether the horse needs to go to surgery by a team who've got the appropriate surgical expertise, are able to perform anaesthesia to a high level and can perform the postoperative care.
And it really is a team-based approach from that early admission of horses into the clinic and a rapid decision as to whether a horse needs surgery or not. And one of the big sort of things that we try to encourage in our referring vets is you don't need to make a diagnosis of what type of lesion it might be. Sometimes with all the tools that we have in clinic facilities, what we find at surgery might be slightly different to what we were expecting.
But discussion with the owner at the same time that we're working horses up, ensuring that they understand the potential implications of a horse needing surgery for colic in terms of potential outcomes and costs. So then, of course, we have to get our colic case onto the operating table, and, you know, it's a fairly big job requiring a skilled team, not just of surgeons, but as I've already mentioned, anaesthetists, and obviously, a 24 hour servicesarcholic patients usually don't recognise the 9 to 5 normal working hours and out of hours surgeries are really common. And then you've got to factor in, not just surgery, but getting that horse back up and onto its feet and then into the recovery periods.
So we're gonna focus on postoperative care, but obviously there's an awful lot that goes into the potential outcome from factors that have already gone beforehand. And the reason why I spend quite a lot of time emphasising the importance of owners and vets and prompt referral for surgery. Is because we know that what we work with as that horse comes into the clinic will dictate what postop complications and outcomes we're going to get.
So this is work that we performed at University of Liverpool a number of years ago now, but still holds very true and has been replicated in other studies. So cardiovascular parameters such as heart rates and packed cell volume, provide a really good indicator. Likely survival and potential complications.
So as you can see here, as the horse's heart rate goes up, their chances of dying increase, and horses that are out with the normal ranges of packed cell volume also have reduced survival. So prompt surgery is, is, the, the key and getting horses to surgery whilst they are not, suffering from severe cardiovascular compromise. So factors that we have to consider, and this is where communication, particularly with horse owners, is really important, are the likely costs.
And it depends on various populations, whether you have a population of horse owners in which horses are likely to be insured, or horses where insurance isn't common, but especially in countries where their owners are used to paying for their own medical healthcare insurance and sometimes have a better understanding of likely costs incurred. So every situation is a bit different, but it's really important that owners know what they're getting themselves in for. And obviously for those insured cases, whether they're actually covered for surgery or not.
And it's also important that they have some idea about likely patient outcome, and that is based on, on evidence. And we know from studies that we've done looking at owner attitudes, we know that owners seek advice from a variety of sources, not always their vets, usually a bit of Googling and listening to their friends and what other people have encountered a sort of lay epidemiology. And it's important that, owners have an informed, idea of how likely an individual colic patient is to survive.
What potential morbidities they might suffer, and particularly for horses that where athletic function is an important part of their career, you know, sporting horses or even for pleasure horses, not just pasture pets, and owners need to know how likely that horse is to return to that prior or expected level of athletic function. So when we're dealing with the horse that's up and standing in the recovery box where owners have been happy for us to continue with surgery, we're then faced with a number of questions about how best to care for this horse. And there are lots and lots of options available to us.
And that's why we do have to put a little bit of consideration into what we're gonna do, because no one colic patient will be treated necessarily in the same way, or the outline might be Similar, it depends on many factors, and particularly the nature of the lesion that was causing the colic signs and how severe any systemic compromise was, and what we've had to do at surgery, for example, resection and anastomosis. And we face a number of challenges, in this, period. And this is a study that was presented at the International Collic Research symposium in 2017 and followed on from a previous, study in which there were some concerns about the ability and willingness of owners to pay for colic surgery.
And certainly, this was a follow-up study and recognised that there were increasing numbers of proportions of cases of colleagues that, weren't going to surgery, were being euthanized either before surgery or during surgery, and concerns about how economics was going to affect, owners being able to afford, or being willing to pay for horses to have colic surgery. And the current pandemic, obviously is a little bit of an unknown in terms of what effect this is either having currently or when the economic ramifications, you know, are are fully understood and how that affects our our whole owning population. And this was a study that was published in the vet records in 2019 and demonstrated for a UK situation, looking at the costs and the various insurance policies and for which I did an accompanying commentary on this.
And Quite concerningly, a number of insurance policies haven't really increased the level of cover that they provide for colic surgeries, and many didn't actually provide a full cover for the cost that an owner would incur for a horse undergoing colic surgery. And horses obviously have a finite value. It's a bit different to our small animal patients, our dogs and our cats, where they're not an economic factor like a cow or a sheep is for a farmer, but there's a much more of an emotional attachment and economics is perhaps less important.
And our horses fall somewhere in between that. So that will vary hugely for different horse owners. It may be purely an economic decision or the economics may come much lower down the line.
But overall, there are lots of different options for how we can manage horses postoperatively, but if we make those treatments so expensive, ultimately, fewer horse owners are going to be able to afford colic surgery, and there certainly doesn't look like there's a willingness for insurance company policies to cover those increased costs that some of these additional medications, you know, incur. So then, if we're going to keep colic surgery affordable, we have to take a logical approach to our post-op care of the colic patients. And I think taking an evidence based approach is by far the most appropriate way to decide what the evidence is for that post-operative treatment or management regime and the sort of the cost benefits associated with it.
And I'm sure many of you will be very aware of the pyramid of evidence, and I'll run through some of the studies, maybe some of the limitations for some of the evidence that we have for some things, we, we just don't have the quality of evidence to really be able to make a proper informed decision, to, you know, help us make those decisions about how to look after our postoperative colic patients. So I'm going to run through the key aspects of initial management, and some of you may be very familiar with looking after the postoperative colic patients. Some of you may be vets who send horses in for colic surgery or who are aware of colic surgery being done, but maybe don't quite appreciate some of the challenges or decisions, that we are faced with when deciding what to do for our patients.
So I'm going to run through each of these, aspects and just pull out some of the recent evidence and sort of current thoughts on best sort of practise based on current evidence. So monitoring of our postoperative colic patients is, is really important. There's no point in doing the surgery if then we're not going to be able to accurately assess how the patient's doing and get an idea when things are not quite going as planned.
So this is just an example of our monitoring sheets. And it's a really a sort of good tool, almost like a checklist, I guess, for making sure that we record all the key aspects of post-operative care that need to be recorded. But you can see by having the checks organised in columns, it's very easy for us to look at trends.
And trends are really important in the postoperative colic patient, in particular, for getting an idea that maybe things are going well, which is always good, or a little idea that maybe there's something not quite right going on and identifying it at the earliest possible stage. So, top horse, Barry Edwards, who's one of the key, sort of proponents of, evidence-based, sort of colic surgery and aftercare. This is a horse not long after surgery and looking very bright, looking for food and looking quite relaxed and happy, whereas you've got the one at the bottom, which was quite a sick horse, before referral that you can see has obviously been through the wars, has got, swellings above its periorbital area and is really looking a bit sorry for itself.
And so we have to make sure that we're monitoring a variety of things, not just the obvious things such as the surgical incision, but also the importance of things like catheter care and haematological and biochemical monitoring of cases as well. Pain scoring is an area that I think, has changed slightly within the last few years, and I think that will become increasingly, different in clinics and performing postoperative care. And I think subjectively, we kind of do this anyway.
We get an idea, our patient at the top is is hanging his head over the door, looking really quite cheerful and looking out for some food. So, subconsciously, we know that that pony is, you know, likely to be fairly pain free and hopefully progressing well after surgery. But, pain scoring provides us with a much more objective and consistent method of doing this, and particularly where different people are assessing horses and may not be as familiar with some of the more subtle changes in behaviour that might indicate that a horse is a little bit more painful than it should be.
So there's a really nice review article that was published in equine Veterinary Education. And I think increasingly, not just in the field of equine colic surgery, but also in orthopaedics and doing post crustration in in Other aspects of surgery. This recognition that, a horse's facial expression and this so-called pain face can be really good indicators as to how painful a horse is feeling, and some of those subtle signs that otherwise might be missed.
So it's a really, really nice article that goes through. A variety of of pain scores. And a number of these have been validated and published.
I've picked just a couple here. There's a variety of pain scores that, as I said, have been validated and some of the ones that are just coming out at the moment. So I don't think it necessarily matters what score, what pain score that you use, but I think using a pain score in itself is a really useful thing and should be part of monitoring of alcoholic patients postoperatively.
And that ties in quite nicely with our decisions around analgesia, because obviously, we want our patients postoperatively to be as pain-free as possible. And flunix and melamine, various surveys have demonstrated and I suppose the textbooks as well, would usually recommend this is the standard analgesic, postoperatively. However, it is a a non-selective COX1 and COX-2 inhibitor.
And there is some evidence that that activity may be detrimental to gastrointestinal or renal function and also may not be conducive to recovery of the intestinal mucosa. So, selective COX-2 inhibitors have been proposed as a better alternative, and these include meloxicam and ferrooxo. And it's really good to see, if you think about that pyramid of evidence, that we've got some randomised controlled trials, albeit they're not massive ones, but they do provide, you know, fairly high quality evidence of the potential usefulness of these medications.
So there was a study published a number of years ago, and by the team at the Royal Veterinary College, looking at Maloxam in comparison to Flu Nixon. And actually, there was no difference in outcome between meloxicam and Flunixin but Flunixin provided better analgesia. So that is perhaps the reason why meloxicam, you know, hasn't become a universally utilised NSAID in postoperative analgesia for the colic case.
And some recent work performed in the United States of America looked at for a cocky and has shown some beneficial, effects on selected markers and, and this was looking at horses following small intestinal strangulating lesions. So in the future, it may be that we use different non-steroidals. But again, I think larger studies are needed, and these studies, I think, need to show some true benefits in, in outcome because costs have to be considered.
And, you know, the costs of these are much greater than our traditional NSAIDs, then obviously, we need to have the evidence base to justify those associated costs, depending again on what the relative cost is. So it's like cost benefits coming into our decision making again. Continuous rate infusions are something that, I think overall, has become more widely used sedative protocols, but for analgesia as well, and they can be considered.
And in general, opiates are generally avoided due to their, effects on detrimental effects on gastrointestinal motility, and, other analgesics such as lidocaine, which I'll, I'll come on to further on in this presentation. But I think one important thing to remember is that our postoperative colic patients, in general, should be reasonably comfortable following surgery. It might be that some cases we know that there is, for example, a compromised large colon following a large colon vulvullus, where we know that likely reperfusion injury is going to result in maybe a period of increased pain.
But continuous or increasing pain is a concern in our postoperative colic patients. So, before reaching for, much more potent analgesics, we might need to consider why that horse is painful, other things that we might need to consider. Whether horse has got a, a severely distended stomach, for example, or whether we've got evidence that there's something else going on in the abdomen, such as haemorrhage, or, .
Evidence of adhesion formation, and in those cases, we might need to think about relaparotomy at an earlier rather than later stage. 24 hours of intensive care with fluids and additional analgesics, again, can be quite expensive. So early relaparotomy might be a more economic and potentially more humane option, particularly if the horse really doesn't stand a chance of of recovering long term.
So we've thought about analgesia and sort of looking at pain, and then we need to think about use of antimicrobials with the main aim to avoid some of the complications associated with potentially septic peritonitis, which is actually uncommon as a sort of a clinical entity, and obvious concerns about development of surgical site infection at the laparotomy incision. And as you'll all be aware, antimicrobial use is a, is a huge, and very important, part of responsible responsible antimicrobial use. We have a responsibility not just to our veterinary patients, but to our fellow human beings.
And it's quite scary when you look at the impact that predictions for antimicrobial resistance is going to have in the future. And certainly, organisations such as the World Health organisation, really, you know, want us to take that on board and as a veterinary profession, it is important that we use our antimicrobials appropriately and responsibly. So depending again which country you're based in, in the UK, you'll be aware of guidelines such as Protect me by the British Equine Veterinary Association, but other organisations worldwide have also provided antimicrobial use guidelines as well.
And it's all about weighing up the the benefits in terms of preventing a surgical site infection or peritonitis versus those negative effects. So I've mentioned about the broader impact of antimicrobial resistance. One of the other important things to consider is the potential detriment to our actual colic patients.
And this is a study that was done a few years ago now, but demonstrates really nicely why Any use of systemic antimicrobials needs to be considered carefully because it does have an impact on the intestinal, the gut microbiome and some quite profound effects that can take a number of weeks to actually resort back to the normal distribution and bacterial communities within the the large intestine. And most textbooks will, or sort of historic textbooks will advocate broad spectrum approach, predominantly use of penicillin and gentamicin for a standard sort of 5 day period. And that sort of use of that 5 day period has been questioned more recently.
And even within the the human field, evidence for duration of antimicrobial use in some aspects is a is a little bit unclear. But a study done again with the Royal Veterinary College team, compared to antimicrobial regimes, a sort of 5 versus a 3 day period, and found that there was absolutely no benefit in using that longer time period over a 3 day or 72 hour periods to prevent incisional infections. Other studies are potentially looking at 24 versus 72 hour periods of administration and certainly for a horse in which surgery has been relatively clean without need to do any enterotomy, that, you know, it's a a a reasonable thought to think that 24 hours of antimicrobial use might be sufficient.
And, some of the studies have sort of, have looked at, other factors that result in increased sort of duration of antimicrobial use or horses being put back on antimicrobial use. And I think they provide some interesting, additional information. For example, this study, performed at the new Bolton centre.
Looked in the USA, looked at factors that predicted infection and what was associated with infection. And the key sort of finding was that if a horse is pyrexic in the early post-operative periods, it doesn't necessarily mean that there is impending infection and the need to continue antimicrobials or put them back on antimicrobials. So I think in the future, it will be important for us to get a better evidence base together so that we can actually format some.
Fairly robust guidelines about antimicrobial duration and when to change or put horses on back on antimicrobials and other potential options for management of, for example, surgical site infections, for example, topical antimicrobial therapies. OK, so coming on to use of fluids, more broadly, what we're trying to do is provide some cardiovascular support to our patients. And for a number of horses, oral fluids won't be .
Indicated they want a period of sort of rest of that gut. And in horses who were already compromised prior to surgery, providing that extra cardiovascular support is important. And usually crystalloids, but on occasions may warrant use of colloids, plasma or or whole blood.
I'm not going to go into that for the purposes of this presentation. But just to highlight the importance of, of monitoring for the need for fluids, so looking at factors, cardiovascular parameters such as pack cell volume and total protein, together with heart rates, but also some of the very Common sense and easy to measure things, you know, simply looking at whether the horse is urinating or not, and potentially measurement of electrolytes or other systemic markers such as lactates and serum amyloid A. So this is a an area where there is a little bit of debate around optimal duration and sort of timing of intravenous fluids.
And I think it's an area that, again, in the future, there is a need for for more work to be done. I thought this study done at the bottom was quite interesting because one of the theories was that potentially overloading horse's guts, causing sort of got edoema might predispose to post-operative ileus. And in fact, that postoperative reflux, that wasn't the case.
As we sort of see clinically, postoperative reflux developed at around about 20 hours postoperatively and was more likely in those horses that had initial high pack cell volumes or high pack cell volumes after the 1st 24 hours. But interestingly, as well, they found that overload of IV fluids or electrolytes and abnormalities were not associated with the likelihood of post-op reflux. Some factors that I might, I think might become a little bit more important in the future is maybe a better understanding of some aspects around cardiac function that maybe are under-recognized in horses and certainly electrolyte disturbances, something to be suspicious of in a horse that doesn't seem to have parameters, for example, an elevated heart rate that doesn't tie in with the clinical picture.
And, actually some interesting work that's that's ongoing that demonstrates that actually some fairly significant cardiovascular changes can occur without necessarily recognising that when performing our, our standard postoperative checks. Some other factors that are slightly more practical sort of factor rather than necessarily more evidence-based, but, thinking of our unique patients in that our horse or equine. Patients do not have the ability to vomit.
So the challenge for us is equine clinicians looking at looking after colics pre and postoperatively is to make sure that we avoid the risk of gastric rupture through a horse having acute gastric distention. And they can be some of the most disappointing cases to to deal with. And certainly the ones that I worry about are horses where you identify a fairly large secondary gastric impaction at surgery.
And it's not uncommon that These gastric impactions can develop. For example, a horse that suddenly develops a right dorsal displacement or a colon volvulus, where they've actually got a fairly full stomach at the time that the lesion develops and there's obstruction to duodenal outflow. So, it's routine in our clinic that if we, we always palpate the stomach at surgery, and if there is an impaction or any amount of gastric distention, we're normally quite aggressive with trying to Lavage, and sometimes quite thick contents that can take repeated efforts at lavage to try and avoid the risk of the stomach rupturing, which can happen up to 48 and 72 hours postoperatively.
So, careful clinical monitoring is important, and multiple studies have highlighted the horses that are at greatest risk of developing gastric distention due to postoperative reflux due to a period of ileus or inability for the small intestine to function normally. So those cases would include small intestinal resections. For example, horses that have had marked prior small small intestinal distention, if, for example, they've had a small intestinal obstruction intraluminate.
And, something that's changed, I think, over the last few years is not just the utilisation of abdominal ultrasonography in our preoperative workup, of the colic case, and in particular, it's usefulness for identifying normal or abnormal small intestinal motility, particularly in the cranial abdomen, which obviously can't be felt on rectal examination. But also, it's a really useful tool in the post-operative patients. And this is a paper that is just about to be published in equine Veterinary Education.
And there's another study as well that's looked at duodenal motility. And ultrasound does provide a good predictor of those horses that are likely to subsequently go on and develop postoperative reflux. So, lack of duodenal contractions or reduced duodenal contractions on day one would be one of the key predictors for that.
So in those horses where we're worried about postdocvilius, we then have to make the decision about whether we're going to utilise prokinetics or not. And there are a variety of pro-kinetics that are available. The evidence base for those and costs, does need to be considered, and there's a nice review article, that, that goes through these quite nicely for those of you who are interested.
And one of the sort of the big debates over the last few years, has been in those horses that do reflux postoperatively, is it injury indeed true physiological postoperative bias or not? And, we know a lot more about the path of physiology and management, and including medical strategies to manage them. But, one of the, sort of viewpoints is that actually it might not be just as simple as a true physiologic postopativevilius.
And it is one of the reasons why we more commonly use the term postoperative reflux now rather than postop blius, because actually, the retrieval of greater than expected volumes of fluid from a horse's stomach could be for a variety of reasons, of which postoperative ileus only forms a part of those. And we have to consider, whether there's actually a mechanical obstruction actually preventing, the small intestine from emptying normally. So, if you've got a mechanical obstruction that is due to a surgical technique that's been performed, and that obviously is particularly relevant to horses who've had a small intestinal resection, that horse that reflexes for many days.
We maybe shouldn't just be thinking very narrowly about it being a physiological reason, but actually questioning whether we need to potentially revise an anastomosis or think about other reasons why a mechanical obstruction has developed. So lidocaine is one of the the drugs that has been proposed to be used for postoperative reflux. And I'm sorry, this is a very busy slide, but demonstrates that there is a little bit of evidence out there, but maybe not enough to fully answer our question.
So thinking back to that pyramid evidence, the top two studies are surveys, and they actually come very low down on the evidence base because they're opinion-based and not always based on the results of rigorous scientific studies. And there are some randomised controlled trials, these two studies here, but very small, low powered studies that suggested that lidocaine did have some benefits in postoperative reflux. And a retrospective study, which again suggested a potential benefit, but had multiple biases and actually very few horses not actually receiving some form of prokinetic.
And a study that we did where we looked at horses before and after lidocaine was actually used in our hospital population actually demonstrated no effect on the outcome. So it led us to sort of question whether, you know, using this medication, which is actually quite expensive, you know, can we justify that, when sometimes we have horses being euthanized because an owner simply run out of money. And a recent review article that was published in 2019 would tend to corroborate those sort of conclusions from looking at the literature and the the need, because of its costs, and a bit of unknowns about its efficacy to actually conduct a clinical trial, to, you know, get better evidence that's higher up that pyramid.
So, we are actually leading a multi-center, a blinded study, a randomised control trial looking at lidocaine versus saline to prevent post-operative reflux. This trial, is, is ongoing and is sponsored by the Horus. So, Hopefully at some stage, we'll have a greater evidence base on which we can say whether lidocaine is justified because of the benefits it has or whether those associated costs are not warranted, given any lack of benefits.
So it's a bit of an unknown still, but hopefully we'll have some more evidence in the future to inform us better. OK. So, hopefully, when our horse has either not developed postoperative reflux or has finished refluxing, we need to think about supporting the getting nutrition back into the enteral system.
And equine nutrition, again, I think is something where we don't have much of an evidence base, and again, there's a lot of opinion. But not always the ability to, have the scientific evidence to, to help them inform us any better. So this is a a study that's literally again just been published which looked at opinions of diplomats of various colleges.
To look at how, sorry, cases are managed. And again, it's possibly not a surprise looking at these results, that these tie in often with what is suggested in in textbooks, but obviously isn't universally accepted by all. And I think large intestinal displacements are a particular group where actually these horses are generally returned to feed and water more quickly.
But it's interesting looking at those results there, not, not always. And we know that small intestinal strangulating lesions, one of the theories being that you want to rest the gut. Again, how people manage them is a bit different, and together with small colon lesions and lesions affecting the secum.
So, it's sort of interesting to see how people, are feeding horses after surgery, but, that is, again, not necessarily always based on on true evidence that's out there and it's just, based on, on opinions. And I think this again is an area that's going to receive a lot more attention, and the gut microbiota is something that is really huge within the human research fields. We know that the gut microbiome doesn't just have effects on the gut itself, but it has effects on, immune function, for example, as well.
And, within the horse, we're just starting to understand what, what is normal and, and what is abnormal. And when we're thinking about the horses intestine, these are my, my pair. They were out in the snow, last week enjoying the sunshine, but thinking about what our horses are designed, to do, what they're designed to to eat on in the wild.
So it's no surprise when you think about the different weather conditions and the different feedstuffs that are horse grazing, that there are changes in, in those. So there are several microbiome, studies, and I'd say increasing numbers of these coming into the equine literature. And, by knowing what's normal, we can then focus on, on what's abnormal.
And again, this might give us a better idea of why some forms of colic develop in, in the first place. And a study that again has very recently been published, shows that there are changes in the faecal microbiota during hospitalisation, and those differ between different types of colic and and in particular, some of the the large colon lesions and in horses that have had colic for a longer duration. The problem with these studies is that they're really expensive to perform.
The data that you get is really complex and quite challenging to interpret. But hopefully, as more of these studies are done in different populations, then we might be able to build up a bigger picture with the ultimate aim, I guess, of not just informing us about how to manage horse's nutrition in the post-operative period, but potentially in trying to prevent colic from occurring. OK, so just running on to some some other post-operative complications.
There are, there are a number of these that we have to consider whilst we're sort of doing our routine care. And again, a study that was published in in 2016, is a sort of a review of the the evidence as it was then, and a summary of those. So I'm not going to run through this in a in a huge amount of detail, but the studies that have been published give us a good idea as to the likelihood of those complications being identified.
And they do vary between different populations. So in the next few slides, I'm going to focus a little bit on surgical site infection, post-operative colic. But we always have to take in mind, take into account when we're thinking about prevalence of the population that that we're looking at, because, for example, adhesions, this is a population of horses undergoing repeat laparotomy.
So the prevalence would be expected to be much lower in the general equine surgical population. And I think there are some interesting differences. So, for example, why our studies in the USA where obviously different types of surgical lesions might be more likely to occur and could be associated with changes in the large colon microbiome.
I think it's interesting to see how some of these complications change between those different populations. So surgical site infection would probably be the most common and potentially could be quite problematic. Fortunately, acute total evisceration of dehiscence of the suture line is is uncommon, but certainly infection of the laparotomy incision is is one of the most common complications we're going to encounter in these horses.
And I'm not going to run through all the the studies that have gone beforehand, but multiple risk factors have been identified. And actually, this is one of the areas of veterinary medicine in which I think there's some of the highest quality evidence utilising. Randomised studies has been published and that's great because it gives us a really good idea of some of the consistent risk factors that we know are likely to cause surgical site infection and ways to prevent them.
And we have a very good understanding of some of the organisms that might be isolated in horses, and again, those differ on hospital population. So I guess one of the consistent messages coming out is that For hospitals, it's really important that sampling of horses with surgical site infections is performed and that you have monitoring for multi-drug resistant pathogens and and and patterns in pathogens identified in clinics to get an idea of of what pathogens you're dealing with and thinking about biosecurity and relevant control measures. Things like consideration of hand hygiene and disinfection protocols.
There is fairly limited evidence about the use of antimicrobials in horses with surgical site infections unless they're systemically ill. And as I mentioned when considering the use of antimicrobials, I think there's a a sort of a a body of evidence that would suggest that actually most horses don't need to go back on systemic antimicrobials, but that local wound management may be sufficient and actually not change the ultimate outcome, which I'll come on to discuss in a couple of slides. And as I've already mentioned, I think it's really important that hospitals that are looking after postopative colic patients do have hospital protocols and perform routine sampling, not just of surgical site infections, but the environments and have strategies for infection control.
And as I've mentioned, lots of studies have been done in this area and we're Sometimes, I'm beginning to understand a little bit more about, what, causes surgical site infection, but, somewhat frustratingly, there isn't always a consistent effect in, in studies, and it probably is a multifactorial . Problem, and, and so something as simple as what type of dressing we apply is probably not the single answer. It's dependent on lots of things, such as how systemically compromised the patient is.
We've seen a seasonal effect, but also, a nice recent study has identified potential. Implication of body mass index and some preliminary data that we have would suggest that horses with increased thickness of retroperitoneal fat are also at increased risk. Post-operative colic is another one of our challenges, and again, it's been an area where quite a few studies have looked at the evidence and and sort of the debate about how soon you should go back in to perform repeat laparotomy in the colic patient that isn't progressing as expected.
And and the most common indication for that is the horse that is demonstrating evidence of postopative colic. And again, these studies provide hospitals with a better idea of those horses that are the ones to look for and to monitor more carefully. Those horses in which owners should be warned of the potential for postop colic and the potential need for repeat laparotomy.
And then the potential findings that repeat laparotomy and likely outcomes, and in general, sadly, repeat laparotomy, particularly if horses have adhesions or septic peritonitis identified isn't a necessarily good prognosis. But for other horses, if it's it's a case of decompressing small intestine alone, the prognosis for those horses may be much better. So overall, we've got some evidence there about how to how to look after our postoperative colic patients, but I think we always need to be looking at how can we we do it better.
And in human medicine, clinical governance is a really important part of patient outcomes, and that's something that I think is becoming much more important and focused on within the veterinary profession. And in medical care, it is a fairly mandatory thing that hospitals and doctors are expected to to go through. And for example, this is just an example of the National Emergency laparotomy audit, I suppose colic in people that outlines likely outcomes and areas for improvement in people undergoing emergency laparotomy in the UK.
And colic has been identified as an ideal area for performing audits, looking for areas that we need to improve our colic outcomes, and actually, a lack of benchmarks. So what is expected for for different clinics and different populations. Because actually, if you look at the literature, the information that we have is actually from a relatively small number of hospitals worldwide.
So by having a better idea of of what's going on, we can judge ourselves against others and see whether we're doing average or better or or worse than than might be expected. So we're leading an international colic surgery audit at present, which looks to document different lesions, duration of survival and complication rates, and to try and develop these benchmarks that clinics worldwide can use to to monitor their patient outcomes following colic surgery. Looking at data about changing trends and, you know, potentially for those clinics that have identified areas of good practise, looking at demonstrating that good practise or potential targets for improvement in care, so this so-called audit cycle.
And just in case you're wondering whether that's a pedunculated lipoma, that's where the logo comes from. If you're if you're wondering what that funny little yellow dot in the middle is, it's meant to be a lipoma. So this is the website.
If you go to www.international audit.com, we've, we're ongoing with data at the moment.
The deadline is the 31st of March for 2021 for collection of the data. But beyond this time, this is a toolkit available for all clinics worldwide, so they can record their data. You'll be given a a login and passwords, and you can generate your own clinic audit reports and download your own clinic data as well.
So the website's got all the information needed and if you would like to register, just email the colleague address shown at the bottom of the screen. OK, so finally, we've got a horse that we're looking to discharge from the hospital. And it's really important that owners and vets are aware of the likely aftercare and and outcomes and certainly postopative colic and incisional complications would be the main main ones on the list.
So informing them of, you know, any, suspected, problems with incisional healing or that are anticipated and when to remove stitches, and the strategy for rehabilitation. And so, on the screen, I've just put the, the, common strategy for horses following colic surgery. Think, areas that we might see a little bit more focus on in the future is thinking about the diets and the transition from not just hospital feeding, but also those changes in the microbiome that might have actually proceeded and been responsible for that colic episode.
As I've also myself, who's had a horse on box rest, I think sometimes with our vets and maybe surgeons shoes on, we don't always appreciate just how challenging it can be for horse owners, keeping a horse on on box rest as well. And, how we rehabilitate our patients. And I think this is a really interesting study.
It's a fairly small study, and it does have some biases. It wasn't a randomised study. But I think it does provide some initial preliminary evidence of the potential usefulness of physiotherapy exercises, and it seems intuitive and a common sense approach to take, to undertake exercises where you can start to develop a horse's core muscles.
In this paper, they started this at 4 weeks postoperatively delaying this at 8 to 8 weeks if the horses had a surgical site infection. And this was a 4 week programme of of exercises. And then finally, just to finish off this talk, you know, we're always looking to prevent recurrence.
And adhesions is a big topic in itself, you could spend an entire talk on, on adhesions. But we know that abdominal surgery is a risk factor for, for, potential colic episodes and, particularly where small intestinal surgery is undertaken. And sadly, some horses, such as those with a large colon vulus or epiple framing entrapments, we know from survival studies have a generally poorer postoperative outcome.
But the prevent potential for recurrence does depend on the type of colic. So, obviously, if you've got a lipoma or some form of congenital band where those lesions are removed at surgery, we're very unlikely to get a sort of recurrence certainly in the first few years after surgery. And the advent of laparoscopic techniques to repair mesenteric defects that can't be repaired at the time of surgery due to their location.
Provides a, a really useful way of, of, minimising the risk of colic recurrence. Those that are a bit more challenging are those large colon lesions and epiloic frame and entrapments. Just before we come on to the surgery, you know, people, or horse owners always ask me about probiotics.
I think the evidence base out there isn't particularly strong, but if we're thinking about those large colon lesions and minimising the risk of recurrence, I think, again, there is a need for, for further studies to, to look at those and . I think it is quite a complex story, given, you know, that we're understanding more about the complexities of the intestinal microbiome and how it does vary between horses. So for large colon disorders, we certainly know that right dorsal displacement and left dorsal displacement can recur.
And so, one of those discussions with with owners, again, dependent on use of the horse and economics, will be whether we, you know, the, the likelihood of recurrence, particularly if it's a second recurrence, merits of colonic pexy, closure of the necrosplenic space, for left dorsal displacements. Potentially large colon resection in some cases, or whether we have to think broader and whether, for example, use of steroids, if we think that there might be an inflammatory underlying problem may be may be warranted. And I think this is an area that we don't understand an awful lot about and hopefully over the next few years, more studies will look at.
I think this is a really exciting, sort of technique that's been developed by the team at, Ghent, together with other collaborators, but, an increasingly performed technique to place a mesh in the epiloic frame and. To reduce the chances of a recurrence of epi frame and entrapment. So I can see on the left, the mesh being placed under laparoscopic guidance, and on the right of the screen, the formation of adhesions sufficient to stop bowel re-entering that .
Ramen. And this was has been very methodically and rigorously appraised and was first designed to be used for electro closure of the frame and and following initial post-optic convalescence after, you know, a minimum of 4 weeks. But actually, they have subsequently, performed this during initial laparotomy and some horses and other workers, have also, performed, some recent studies, demonstrating its safety.
Finally, we're just looking at incisional complications. They are problematic and may merit further surgery. There's some weak evidence about the use of belly bands, but certainly they can be helpful, certainly in preventing any trauma to a hernia, and there are various surgical techniques to repair hernias by placing meshes.
And when thinking about our outcomes, and again, lots of studies are sort of ongoing, I suppose all part of that sort of audit and and outcomes and benchmarks. But I think something that horse owners don't always appreciate. They see colic surgery as being something bad, but actually, when you look at the evidence from horses that have undergone surgery in multiple no American and European populations, actually, the likelihood of them returning to athletic activities is very high, and owner satisfaction very high as well.
Pictured is desert orchid, a very well known racehorse that had a very extensive small intestinal resection that went very back to competing at a high level again. So I think it's one of the things that again, it's important for us to educate owners about. All right, so that's a sort of a rattle through a variety of challenges and sort of strategies that we employ in looking after the postoperative colic patient because that aspect of care is, is one important.
It's not the sole important part, but it is a key part of of management of the colic case. I think it's really important that we do take a pragmatic approach and think about the evidence for use of particular therapies, particularly those that really add to the treatment costs, because ultimately, an owner may not be able to afford them, . And thinking of, you know, our own performance and how we do things and our outcomes and how we can improve them, and the need for clinics to perform regular clinic audits, to identify those areas in which they are working at and areas of good practise or areas for improvement.
And above all, as I hope I've demonstrated, getting that colic patient to surgery at an early stage before they've become very cardiovascularly compromised or where we need to remove intestine is really important. So thank you very much for your time.