Strangulating obstruction of the small intestine by a fibrous band originating on the nephrosplenic ligament
Keywords
colic, horses, laparoscopy, nephrosplenic ligament, strangulating obstruction
Gandini Marco, Labate Federico, Rosso Augusta, Giusto Gessica
Department of Veterinary Sciences, University of Turin, 10095 Grugliasco TO, Italy Declarations
Source of funding: none Competing Interests
The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Declarations Section
The owners were informed and signed an informed consent form. Animal welfare was respected throughout the hospital stay.
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Abstract
During a laparotomy for colic symptoms in a 2-year-old male thoroughbred, a portion of approximately 7 meters of the jejunum was found entrapped in a fibrous band originating from the nephrosplenic ligament. The entrapped jejunum was necrotic and was removed. Two months after the first surgery, a laparoscopy was performed to close the
nephrosplenic space and it was possible to identify several fibrous bands bridging from the renal capsule to the splenic capsule and a fibrotic plate over the spleen. This is the first report of a strangulating obstruction of the jejunum in the nephrosplenic space and of fibrous bands bridging from the nephrosplenic ligament to the spleen. The fibrous bands were likely due to an inflammation caused by previous, multiple left dorsal displacements of the bowel, which resolved spontaneously.
Nephrosplenic entrapment, also known as left dorsal displacement of the large colon or reno-splenic entrapment, is a well-known pathology that presents as a non-strangulating displacement that usually involves the large colon. However, displacement of the small colon [1] and two cases involving the small intestine have been described [2].
This condition usually occurs when the left dorsal colon and the left ventral colon displace between the left abdominal wall and the spleen and move in a dorsal direction, dorsal to the spleen, becoming entrapped over the nephrosplenic ligament.
Nephrosplenic entrapment represents the cause of gastrointestinal colic in approximately 2.5–9% of colic cases. Geldings and Warmbloods are reported to be predisposed to this condition [3]. The depth of the nephrosplenic space can be a predisposing factor for entrapment. In fact, the lower the ligament attachment is on the medial margin of the spleen, the more likely the large colon is to become entrapped.
The present case report describes the pathological findings of a strangulating obstruction of the small intestine in the nephrosplenic space in a 2-year-old male thoroughbred. 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47
Clinical case presentation
A 2-year-old male Thoroughbred was referred to the Veterinary Teaching Hospital of the Department of Veterinary Sciences of the University of Turin with signs of abdominal pain for approximately 8 h. At the time of presentation, the horse had been in training for 6 months; during this time, there had been no noted episodes of colic. The horse had also not had colic episodes as a foal or as a yearling.
Vaccination and deworming were performed on a routine basis.
Examination
At presentation, the horse showed moderate signs of abdominal pain and was mildly depressedand dehydrated as evidenced by a PCV of 43% and Total Protein of 5.2 g/L. Its heart rate was 100 beats/min and respiratory rate 24 breaths/min; and its body
temperature was 37.8°C. Abdominal auscultation evidenced a decreased intestinal motility in all four abdominal quadrants. A secondary impaction of the large colon and a distended small intestine were found during rectal palpation. Due to the small intestinal distension, the nephrosplenic ligament could not be palpated. The passage of a nasogastric tube did not result in reflux. The horse was intravenously administered a bolus of 5 litres of
crystalloid solution, lactated Ringer’s (Ringer Lattato S.A.L.F.a).
Ultrasonography and abdominocentesis were not performed based on the rectal findings. Due to the presumed diagnosis of a small intestinal obstruction, an exploratory laparotomy was recommended.
Surgery
The horse was sedated with butorphanol (Nargesicb) and xylazine (Nerfasinb), and anaesthesia was induced with ketamine (KetaVetd) and diazepam (Ziapame) and maintained with isoflurane (Iso-Vetf) in oxygen. After aseptic preparation, a ventral midline exploratory laparotomy was performed. During exploration of the abdominal cavity, a portion of jejunum was palpated over the nephrosplenic ligament. Further evaluation 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75
the nephrosplenic space. The band was blindly cut with scissors deep in the abdomen and the entrapment was resolved. Upon exteriorisation of the small intestine, it was possible to identify a portion of necrotic distal jejunum approximately 7 meters long. The intestine was dark red/purple in colour, with a thick wall and necrotic odour (grade IV of the Freeman scale) [4]. This portion was resected and an end-to-end single layer (continuous Lembert) jejuno-jejunal anastomosis was performed. Due to a secondary impaction of the large colon, a pelvic flexure enterotomy was performed to empty its contents. No other abnormalities were found and the intestine was replaced in the abdomen and the abdominal incision closed in two layers.
The surgery lasted 3 h and the horse recovered uneventfully from anaesthesia approximately 1 h after extubation.
Follow-up
For approximately 12 h after surgery, the horse was mildly depressed, then it became alert and started drinking. Its hydration status was monitored via PCV and total protein trend (samples obtained every 4 h in the first three days). It was not deemed necessary to initiate fluid therapy. Intestinal motility was present in the immediate postoperative period, thus the horse was left to graze for 15–20 min every 4 h in the first postoperative day. Hay and a pelleted feed high in fibre and low in carbohydrates (PHC metabolicg) were
introduced in the second day, increasing the food ration day by day to meet the horse’s needs in 7 days. The post-operative treatments included ranitidine (Ranitidina S.A.L.Fa) (1.5 mg/kg IV q8) for 2 days, nadroparin calcium (Seleparianah) (40 U/kg SC q8h), flunixin meglumine (Meglufeni) (0.5 mg/kg IV q12h), ampicillin (Vetampliusj) (15 mg/kg IV q8h), and gentamicin (Aagentj) (6.6 mg/kg IV q24h) for 3 days.
Laparoscopic closure of the nephrosplenic space was suggested and performed 7 days after the exploratory laparotomy. The horse was then discharged 12 days after the first surgery. 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105
Laparoscopy
After clinical examination and laboratory tests aimed to assess the haematological status, the horse was placed in stocks and preoperative antibiotics and analgesia were
administered (procaine benzylpenicillin 8000 U/kg IM, dihydrostreptomycin 8 mg/kg IM ((Repenj), and flunixin meglumine (Meglufeni) 1.1 mg/kg IV). A detomidine (Dertonervink) constant rate infusion was initiated [5] and the left paralumbar fossa was aseptically prepared for surgery. After draping and local anaesthesia, three trocars were placed in order to perform a laparoscopic closure of the nephrosplenic space, as previously described [6].
After insertion of the laparoscope, a series of fibrous bands bridging from the renal capsule to the splenic capsule were evident. In addition, a fibrous plaque on the medial border of the spleen, just dorsal to the nephrosplenic ligament attachment, was evident (Fig. 1). A continuous barbed suture was placed between the perirenal fascia and dorsal edge of the spleen to close the nephrosplenic space as previously described [6].
The trocars were then removed and the abdominal fascia and skin were sutured. The horse recovered uneventfully and was discharged three days later. A telephone follow-up was performed with the owners 8 months after the laparoscopy and revealed that the horse was in training and had not shown any signs of colic since the surgery.
Discussion
Nephrosplenic entrapment of the small intestine has previously been described in horses, although the two reported case related to non-strangulating obstructions.
The case described in this manuscript differs from the previous cases for two reasons. Firstly, it involves fibrous bands present in the nephrosplenic space, and secondly, it resulted in strangulation of a jejunal segment.
During the laparotomy, it was possible to palpate by hand several fibrous bands between the nephrosplenic ligament and the spleen. The presence of these bands was confirmed at laparoscopy, as well as the presence of a fibrous band on the medial aspect of the spleen. 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133
ultimately resulted in the formation of the fibrous plaque on the spleen and the formation of fibrous bridges across the nephrosplenic space.
Although the fibrous band could have been a consequence of the inflammation caused by the small intestinal entrapment, we hypothesised that the fibrous bands were a
consequence of inflammation caused by repeated previous nephrosplenic entrapments which were not clinically evident. Similar bands were found by Moll et al. between the spleen and abdominal wall after multiple left colon displacements [7]. The authors also suggest that this might be similar to events occurring after epiploic foramen entrapment, where the epiploic foramen can be obliterated by fibrous structures. [8].
Fibrous bands are a type of adhesion found in several species, including horses [7, 9, 10, 11], which might lead to small intestinal obstructions, although they have been rarely reported in horses. They can form either after a previous surgery or not [12, 11], although in humans, it seems that solitary fibrous bands are more common in patients that had not undergone a previous surgery, suggesting that other factors might predispose to adhesion formations [11].
Closure of the nephrosplenic space can be used to reduce the incidence of recurrence of nephrosplenic entrapment. Indications for this procedure include a horse that has
experienced either two episodes of suspected nephrosplenic entrapment of the large colon which were resolved with medical management, or a horse that experiences one episode of nephrosplenic entrapment which is resolved with surgical intervention [13]. However, consideration should be given to the possibility that multiple large colon dislocations, resolved medically, could result in the same condition described in this case report, ultimately leading to small intestine strangulation. Or, as suggested for humans, other factors should be investigated in the formation of solitary fibrous bands in the absence of previous surgery [11].
To the authors’ knowledge, this is the first report of nephrosplenic entrapment of the small intestine resulting in strangulation, and resection and anastomosis of the jejunum. In addition, this case records the presence of fibrous bands located in the nephrosplenic space, which can potentially lead to intestinal strangulation.
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To date, closure of the nephrosplenic space has been proposed for recurrence of medically corrected left dorsal displacement of the large colon, or after a single episode surgically corrected nephrosplenic entrapment in order to prevent further large colon entrapment [13]. This report describes an occurrence that differs from previously described pathologies prevented by nephrosplenic space ablation. Small intestinal strangulation by fibrous bands in the nephrosplenic space should be considered in horses with signs of small intestinal strangulation. The potential for this particularly pathology to occur highlights the benefits of performing laparoscopic closure of the nephrosplenic space.
Manufacturers’ addresses
a. S.A.L.F. S.p.a Laboratorio Farmacologico, Cenate Sotto (BG), Italy b. Acme s.r.l., Cavriago (RE), Italy
c. Produlab Pharma B.V., Raamsdonksveer, Netherland d. Intervet Productions S.r.l, Aprilia (LT), Italy
e.CENEXI, Lempedes, France
f.Piramal Critical Care Limited, Drayton, United Kingdom. g. Mangimificio Palazzetto, Asti, Italy
h. Italfarmaco S.p.a., Milano, Italy i. IZO S.r.l., Brescia, Italy
j. Fatro S.p.a., Ozzano Emilia (BO), Italy
k. Produlab Pharma B.V., Raamsdonksveer, Netherland
Figure Legends
Figure 1: Appearance of the nephrosplenic space at laparoscopy. The fibrous band causing the strangulating obstruction is shown by the circle. This was transected during the procedure. 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191
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