Foreign Body Surgery: What You Need to Know
October 23, 2012
They say cats are finicky about what they eat, but that is not what we see in emergency! Elastics, needles and thread, you name it! Dogs are known to be mooch pooches, garbage guts, and canine chewers so it is no surprise that we see dogs with everything but the kitchen sink down the hatch!
Surgery to remove foreign material (we term this foreign bodies) is necessary when the pet has eaten something and it cannot be vomited up nor passed through the guts. Material can get lodged in the esophagus, or retained in the stomach or stick anywhere along the intestines, though if it can reach the large intestine, usually it will pass out.
Though ingested foreign material is the most common reason for surgery, note that foreign material can be introduced elsewhere. Needle stuck in the roof of the mouth or throat, impalement on a stick or fence, entering through the body wall into chest or abdomen, thorns or glass in the feet, and inhaled material all can trigger a need for surgical removal!
Here we will present a typical foreign body removal surgery for a cat. Meet Mustachio Whiskerpad, who has eaten a sewing needle with about 18”-24” of thread attached (the owner thinks). He is normally a playful young kitty, and is almost a year old, which is a typical age for foreign body ingestion – often the patients are quite young. The loop of thread is stuck under his tongue and the other end of the thread is coming out his rear end! The needle is seen by X-ray to be in the small intestine, and the intestines have become plicated, like an accordion. The tension on the thread has caused the intestines to continue contracting hard to try to clear the thread, so they contract until the small intestine is all bunched up. Poor Mustachio Whiskerpad! He is repeatedly vomiting, not eating, dull in attitude, and now is dehydrated and painful in his abdomen.
Before surgery can take place, Mustachio Whiskerpad must be stabilized. While bloodwork is done to check his electrolytes and metabolic balance, his cell counts and organ function, some potent pain medicine and intravenous fluids are started pre-op to stabilize the cat. His white cell count is up and some toxic changes are present so there is concern his thread may be cutting through the delicate wall of the intestine. Any leakage of gut contents will worsen his prognosis. Abdomen infection (peritonitis) is a potentially life-threatening complication.
As soon as Mustachio Whiskerpad is relatively stable, he is whisked into the prep area. After receiving a sedative, he is induced for general anesthesia via an intravenous agent, becomes unconscious and a breathing (ET) tube is placed in the windpipe (trachea) to allow close monitoring and for administration of gas anesthesia with oxygen. The string is cut under the tongue to release pressure on the string from the front end. His whole abdomen underside is shaved and “prepped” with sterilizing solution to allow for a large incision. With linear foreign bodies, it is difficult to tell in advance how may incisions will need to be made into the digestive tract and a large incision is made so that good visualization of, and access to the entire abdomen is possible.
Once the surgeon dons mask, cap and scrubs his or her hands carefully, the sterile gown and gloves are carefully placed on and the sterile surgical pack is organized for surgery. Sterile surgical drapes are put in place, and a waterproof layer is used to guard the abdomen contents from any possible gut leakage. The skin and body wall are incised and the abdomen explored for signs of peritonitis, and other organs quickly surveyed. When infection is suspected, a sterile sample for a culture and antibiotic sensitivity will be taken and sent to the laboratory. Whiskerpad is showing minimal changes – that is lucky! A sample is taken and the task of removing the string and needle begins. Any tissue exposed to the outside is kept moist with warm sterile saline.
A small cut is made at each point along the tract to allow removal without too much tension being applied since the risk of the thread cutting through the gut remains until it is removed. Mustachio Whiskerpad is in need of 4 incisions, one in the stomach and three in the small intestine, and the sewing needle comes out of one of these without complication. Each spot is carefully stitched closed with absorbable sutures, and checked for leakage. Without opening the large intestine, the surgeon gently milks the soft stool there to the back end and the surgery assistant confirms the last part of the string is out the back end. Omentum is wrapped around the cut intestines to help healing.
Sometimes foreign bodies put pressure on the wall of the small intestine, causing it to die off, or a thread or string may have cut all the way through the intestine wall and in those cases, a piece of the small intestine may need to be cut out and removed (resected).
Once the intestine is closed the surgeon changes to a fresh pair of gloves and a new surgical pack and rinses the abdomen out with sterile warmed saline solution. The incision is closed in three layers—body wall, subcutaneous, and the final layer is placed, either subcuticular just under the skin, or skin sutures.
When Mustachio wakes up, he is closely watched and vitals are monitored carefully until he is up and around. The ET tube is removed when the anesthesia plane becomes light. This is the time a top up of pain therapy is done if he has not been on a continual infusion. He stays at the hospital long enough to ensure that food is going in and staying down, and all vitals are stable, and he is comfortable.
Sometimes sharp foreign bodies like needles will migrate out of the intestine, stomach or esophagus and travel around in the body tissues. I have seen cases where the needle is in the neck sitting beside the jugular vein, in the chest cavity, and in the body wall muscle layer! M. Whiskerpad is lucky and recovery is uneventful, as is the healing. His caregiver will be locking away the sewing kit from now on!
Complications can vary, and may include anesthetic problems, blood pressure problems, gut stasis, infection, sometimes with suture line breakdown (dehiscence). If peritonitis is severe, abdominal drain tubes may be used to allow the infection to continue to drain out of the abdomen. Healing problems may occur if Mustachio Whiskerpad is allowed to stress the incision by excess jumping and running post-op. It can be tough to keep cats quiet post-op since we cannot tell them to sit-stay!
The surgery process is the same for dogs. Staples may be used to close the skin layer to speed up closing time.
Here are a few interesting foreign body cases (note some examples are graphic so if you are sensitive, do not read on)
Dog eats carpet, socks, garbage, plastic bags, and hard plastic toy pieces – all found at one removal! The pile filled up a half of a bucket...
Dog eats baby pacifiers, 35 of them – all taken out of the stomach. Could not be seen on plain X-rays, but visible on barium swallow. Barium is a liquid used to contrast items that do not show up well on X-rays (paper, plastic, wood, and cloth do not show up well on plain X-rays).
Dog has metal fence post through chest (did not make it over the fence when jumped) – firemen and owners cut the fence post from the fence with a torch to get dog released!
Dog has stick through belly, exiting up near his tail (jumped onto sharp stick in the woods)
Dog messes with chain saw and has cuts up the front of him, including one right where the jugular vein is, but thankfully, a bit deeper than the wound!
Dog chases axe during a swing while owner is chopping wood, gets axe impaled into skull
Cat gets tooth impaled in eye socket
Cat swallows fishing lure with full hook and fishing line still on it! Gets stuck in the back of the throat
Dog swallows caregiver’s diamond ring – it is found in the stomach
Dog swallows all of the charcoal pieces from the hibachi after the burgers are done, and it has cooled, filling his entire digestive tract with greasy charcoal barely chewed.