A few years ago, I wrote an article entitled “No such thing as a negative exploratory.”* Shortly thereafter, I received an amazing email from a colleague on the other side of the world.
Dr. Andreane Daigle, who practices in Queensland, Australia, shared with me a story about an exploratory laparotomy she performed on a vomiting nine-year-old dog after x-rays revealed a possible foreign body. When she went in, however, she found nothing.
“Ohhhh, how disappointed and angry at myself was I, when all I found was an erythemic small intestine,” she wrote. “The client now has a bill of about 2K because of my lack of confidence… If I would have just waited another day, maybe none of that would have happened… So I was hoping you could guide me with your experience. What questions do you ask yourself? How do you decide to go to surgery?”
Wow, what an incredible email!
My reply was:
I think that what you did is fine. This has nothing to do with confidence.
However, it has to do with the art of veterinary medicine, rather than pure science.
Sitting on a suspected FB can be a recipe for disaster, so I can’t possibly recommend it. On Monday, the intestine may be fine, and an enterotomy may be enough. On Tuesday, the intestine may be so angry that an R & A is necessary. And on Wednesday, the dog may perforate and end up with septic peritonitis!
So earlier intervention is usually preferred… but not always. I have a hard time believing that waiting another day would have changed much to the health of the intestine… but your biopsy will confirm that.”
A week later, the biopsy results confirmed that this 9-year-old jack Russell had IBD.
Young Andreane had made the right decision after all.
Still, as I wrote in the original article*, there should be no such thing as a negative exploratory. If you don’t find anything grossly abnormal or fixable or removable, then you should at least take multiple biopsies and submit them to the lab.
Of course, saying “you should” is a diplomatically correct way to say that you must…
At a minimum, biopsies should include the stomach, the duodenum, the jejunum (maybe 2 levels), and very importantly the ileum, often forgotten but a common site for IBD. Depending on the specific situation, you may also need biopsies of the liver, pancreas, mesenteric lymph nodes etc.
You may have heard this saying: “If you don’t have negative exploratory laparotomies, you’re not doing enough of them.” In other words, a negative exploratory laparotomy is perfectly acceptable. I respectfully disagree with this philosophy. A laparotomy can be negative if you throw your hands up in the air, cuss a few times, and close the patient on the spot. But it will not be a negative exploratory until you take and submit a bunch of biopsies.
When should we consider an exploratory laparotomy? By definition, when we are not 100 % convinced about the diagnosis. Arguably, this could be when a patient presents with:
- Unexplained and unresolved hematemesis or melena.
- Chronic weight loss of unknown origin.
- A history of eating foreign bodies, especially in puppies and kittens
- A history of eating foreign bodies, especially in older patients – a classic suggestion for IBD.
- A questionable barium study.
- A penetrating injury to the abdomen, such as a gunshot wound.
Unexplained and unresolved gastric or intestinal distension with no radiographic or ultrasonographic evidence of obstruction.
- A focal intestinal lesion seen on ultrasound, such as a mass or disrupted layers.
- An increase in bilirubin without a logical explanation.
- When partial thickness GI biopsies taken via endoscopy do not provide answers that may be provided by full thickness GI biopsies performed surgically. Studies show that surgical biopsies are more reliable than endoscopic samples because of the difference in depth.
If you are still in doubt based on the history, the physical exam, blood work and X-rays, ultrasound is a great, non-invasive modality to guide you. The secret: ultrasound should be performed and read by well-trained individuals.
What are the consequences of “closing” a patient after a negative exploratory without taking (and submitting) biopsies?
Here are at least 4 consequences:
1. We (still) cannot document whether or not there is GI or some other abdominal disease.
2. The patient, who may (still) be debilitated, may need to have another anesthetic episode to have endoscopic or surgical biopsies harvested.
3. You may need to admit to a disgruntled internist (or surgeon) that you didn’t take biopsies!
4. And you need to have the same tricky discussion with an unhappy client.
Over a year later, I asked Andreane for permission to use her name for this story. In her approval email, she wrote:
“Interesting timing, I was talking about you to my colleague 2 days ago. I had a cat with GI signs and I wanted to do a laparotomy. He was telling me to wait… but I thought of you and went in yesterday… I found an obstruction due to chicken necks.”
Way to go Andreane!
The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of the DrAndyRoark.com editorial team.
* “No Such Thing As a Negative Exploratory”. Veterinary Practice News. Published March 2nd, 2010.