To ex-lap or not ex-lap?

RE: To ex-lap or not ex-lap?

Hannah Wynne Richards — Thu, 05 Nov 2015 16:24:05 GMT

I agree with Micheal. The primary aim must be to cure the animal, rather than necessarily always reach a diagnosis. That CPD was probably given my a university bod who had lost sight of the raisond'etre for our profession.

By far the best teacher I ever came across was the late Jim Pinsent. He had "The physician's prayer" pinned over his desk. Part of it went"Lord, let me not make the treatment of disease more grievous than endurance of the same".

If you're going to take multiple biopsys from grossly normal tissue;

a) you may still not get a diagnosis - because you've biopsied in the wrong place

b) you will increase post-op morbidity

c) you may increase post-op mortality

Like Anthony, where do you start (or finish) biopsying?

Wynne

RE: To ex-lap or not ex-lap?

grumpyoldman — Thu, 05 Nov 2015 16:12:42 GMT

[quote user="Anthony Todd"]If an animal is showing such signs that necessitate an ex-lap is it likely or even possible that there will not be macroscopic changes in organs or tissue that would make a biopsy a good idea?[/quote]

I used to think that ,but had a few duodenal biopsies from animals with chronic vomiting and diahorrea ,that looked grossly normal come back as small cell lymphoma , significantly the two lower illeo-jejunal were normal, and the mesenteric lymph nodes inflammatory . All of which makes you want to ring them and check sometimes ,ask for a 2nd op , and IHC for the clone involved.

RE: To ex-lap or not ex-lap?

Sue Knighton — Thu, 05 Nov 2015 15:44:30 GMT

Thanks Arlo! Looking forward to spending more time on the site. :)

And thanks to everyone else who has commented.

RE: To ex-lap or not ex-lap?

Sue Knighton — Thu, 05 Nov 2015 15:43:28 GMT

Yes, that's what I'm doing at present. :)

RE: To ex-lap or not ex-lap?

Anthony Todd — Tue, 03 Nov 2015 15:31:21 GMT

If an animal is showing such signs that necessitate an ex-lap is it likely or even possible that there will not be macroscopic changes in organs or tissue that would make a biopsy a good idea?

In other words, is a visibly or palpably negative ex-lap always subsequently negative thus making biopsies unnecessary?

Er, if not, where would you take your biopsy from?

RE: To ex-lap or not ex-lap?

Thomas Johnson — Tue, 03 Nov 2015 15:09:46 GMT

[quote user="Michael Woodhouse"]

From a simple negative ex lap I can't recall a single negative outcome. I would biopsy if I believed there was clinical need. I'm only biopsying a pancreas if I really, really have to. I try not to even touch it at ex lap.

[/quote]

My understanding was that the concerns over biopsying the pancreas, or even touching it, come from humans where this can trigger a marked pancreatitis, whereas in dogs and cats it's rare to see any complications after biopsying the pancreas, and I can't recall that I've noticed any additional problems after biopsying a pancreas.

RE: To ex-lap or not ex-lap?

Michael Woodhouse — Tue, 03 Nov 2015 14:53:04 GMT

[quote user="Sue Knighton"]I went to a CPD lecture last year on ex-laps where it was advised that even in a 'negative' ex-lap full thickness surgical biopsies of GIT should be taken (I think they also said liver and pancreas). Obviously this has increased risks associated. Does anyone have views on this? [/quote]

Yes, I believe it is invasive and potentially not needed. We know that opening the gut increases morbidity and mortality - there was a DC case a couple of years ago where risks of biopsy were not fully explained. Seemed to think a paper was quoted showing over 10% complication rate from biopsy.

RE: To ex-lap or not ex-lap?

Arlo Guthrie — Tue, 03 Nov 2015 14:48:32 GMT

[quote user="Sue Knighton"]This is the first time I've visited a forum and my first post[/quote]

That's made my day; think it's the first time anyone has said VetSurgeon was the place they posted their first ever forum post anywhere).

A very warm welcome! And yes, you've posted correctly :) (if you need it, full instructions here, which tell you how to use the quote button, forum rules etc.)

[quote user="Sorrel Proctor"]Wow, I'm exhausted after reading all that![/quote]

Laughed out loud.

RE: To ex-lap or not ex-lap?

Sorrel Proctor — Tue, 03 Nov 2015 14:29:04 GMT

Wow, I'm exhausted after reading all that! And I'm on the fence as to whether I'd have ex-lapped or waited with that history and that xray.

But re full thickness biopsies I have done them at a negative ex-lap for chronic signs but I've always chickened out when signs are acute. Just thinking about how much of a tit I'd feel if a dog with a bit of GE/ileus ended up with peritonitis because I was too scalpel-happy...

RE: To ex-lap or not ex-lap?

Sue Knighton — Tue, 03 Nov 2015 14:02:32 GMT

Hi. This is the first time I've visited a forum and my first post so hope I've got the protocol right! Thanks for an interesting and useful discussion.

There has been a lot of talk about the relatively low risk of an ex-lap.

I went to a CPD lecture last year on ex-laps where it was advised that even in a 'negative' ex-lap full thickness surgical biopsies of GIT should be taken (I think they also said liver and pancreas). Obviously this has increased risks associated. Does anyone have views on this?

RE: To ex-lap or not ex-lap?

Thomas Johnson — Fri, 16 Oct 2015 08:44:00 GMT

[quote user="Martin Atkinson"]

did you perform a CPL Thomas and what did the pancreas look like at ex lap?

[/quote]

I didn't perform check his Spec cPL, and the pancreas looked normal at ex-lap.

RE: To ex-lap or not ex-lap?

Martin Atkinson — Thu, 15 Oct 2015 15:54:28 GMT

[quote user="Robin Grimmer"]Isn't it a bit young for pancreatitis? Right breed, but I thought middle-aged and older[/quote]You're probably right it was just an idiopathic gastro-enteritis but never say never. I think pancreatitis is a lot more common than recognised and many dogs probably have subclinical bouts which get ignored as 'a bit of an off day'. I would not put any age limit on it. Having diagnosed a 6 month old dog with Addisons with very non-specific symptoms which even the RVC didn't believe I always look outside the box.

RE: To ex-lap or not ex-lap?

Robin Grimmer — Thu, 15 Oct 2015 12:37:24 GMT

[quote user="Martin Atkinson"]

I know (unlike me!) I've come to this party late so I have the benefit of hindsight but the history wouldn't have been enough for me to ex-lap. I don't have ultrasound or flexible endoscopy so I might have given BIPS with a view to repeating radiographs next day but the gas is mostly in the colon and stomach which doesn't scream intestinal obstruction. A chewed up ball wouldn't give me enough evidence that there might be an FB - it was chewed up after all. Given the anterior abdominal pain and the fact it was a cocker spaniel which IME are predisposed to pancreatitis I would have followed that diagnostic route/treatment plan. I know a -ve CPL doesn't rule out pancreatitis and +ve one doesn't rule out an intestinal obstruction but it would have been enough to divert me away from further investigation at this stage. I confess I haven't read every subsequent post in detail but did you perform a CPL Thomas and what did the pancreas look like at ex lap?

I don't know why people have a issue with Cerenia in suspected obstruction cases, it acts centrally and has no prokinetic effect and is useful to alleviate the symptoms to give more thinking space and time for the patient to recover on its own.

[/quote]

Isn't it a bit young for pancreatitis? Right breed, but I thought middle-aged and older.

RE: To ex-lap or not ex-lap?

Martin Atkinson — Thu, 15 Oct 2015 10:00:35 GMT

RE: To ex-lap or not ex-lap?

mariette asselbergs — Wed, 14 Oct 2015 21:37:37 GMT

YES, it has been a while that I have enjoyed Vetsurgeon because a lot of debates and contributions seemed so predictable and therefor sort of boring. But this thread has been very interesting and I have certainly learnt from it, from everybody who contributed that is.

Mariette

PS And now I can even "officially" claim it as CPD, thanks Arlo!

RE: To ex-lap or not ex-lap?

Nicola Cole — Wed, 14 Oct 2015 20:55:38 GMT

Hi Thomas,

My emphasis definitely wasn't aimed at you and I did worry once I'd written it that it may come across harsh on you and that wasn't my intention at all. I just get fed up with how these very valuable threads get overrun...

I was going to write a 'thank you for starting this thread' post to you because I do genuinely think they are very valuable, especially to discuss and get other views on what different people will do on what is a common presentation. More clinical cases like these where we can discuss then someone can present the outcome would be brilliant!

RE: To ex-lap or not ex-lap?

Thomas Johnson — Wed, 14 Oct 2015 17:57:47 GMT

[quote user="Nicola M"]

I disagreed with the SPECIFIC comment that in THIS CASE, ex lap was the BEST option.

IN MY OPINION it wasn't and IN MY OPINION was unnecessary. The reason that I think it was unnecessary was because the gas distribution did not fit with requiring an instant ex lap, and it is my opinion that one simple further test (barium) would have clarified things further. It turned out that THIS dog did not need surgical correction of its problem. However, if someone had decided on an ex lap as the diagnostic tool in this case then that is their choice and it is a perfectly viable option-but in my opinion was not the BEST option.

[/quote]

Thank you for your comments Nicola, and to others who have also contributed to this thread. I know your emphasis isn't aimed at me. I started this thread because although I was happy with the outcome, in that the dog is no longer vomiting, and I am happy to use an ex-lap as a diagnostic tool if necessary, I did wonder if I could have got to the same outcome without having operated on the dog. This thread has given me food for thought, and I may use barium more often in the future, though will still be happy to ex-lap if I'm in any doubt.

RE: To ex-lap or not ex-lap?

Nicola Cole — Wed, 14 Oct 2015 17:19:46 GMT

Right, I don't know why I'm coming back on this but you've baited me-apparently me not wanting to go around in a circular argument is throwing my toys out of the pram. Not at all. The reason I mentioned about not carrying on with this line of conversation is because unfortunately some threads, especially the ex lap threads, seem to deteriorate into ' this is the only way to do things' by the person who shouts the loudest...or shouts most times about it.

I disagreed with the SPECIFIC comment that in THIS CASE, ex lap was the BEST option.

i also do not agree that a quick ex lap is the solution to EVERY diagnostic challenge, because in my opinion it is not always indicated. Yes, it decreases your risk of missing something and it allows you to sleep at night rather than worrying over night about a case-but to be fair I try not to be in a position that I'm going to 'worry over the weekend' whether a dog has a FB. My answer wasn't 'don't do an ex lap and let the dog rot over the weekend'!, it was to do a very simple, very quick contrast X-ray in this specific case.

There are plenty of cases where I will go straight to ex lap (ie based on palpation) and plenty of cases where based on history and a plain radiograph I will go straight to ex lap. I am more than happy to use an ex lap as a diagnostic procedure, whether it be to open up and see what's in there, or to take biopsies or whatever. I am certainly not ex lap aversive and having spent a large proportion of my years in practice in a practice that does not have an ultrasound machine I will often go for an ex lap where someone else may lean towards ultrasound etc first. and I explain to owners it is a diagnostic procedure by itself.

I have (probably very annoyingly) put certain words in capitals in the hope that certain posters will actually bother to read the emphasis. If they have actually read the post rather than reading what they want it to say it should be clear that I am not contradicting myself/writing conflicting posts-I treat each case individually and if I think a certain case requires a little more work up then I will do it; just like if I think a case needs to go straight to ex lap I wouldn't hesitate.

RE: To ex-lap or not ex-lap?

Anthony Todd — Wed, 14 Oct 2015 16:22:54 GMT

[quote user="Nicola M"]But it wasn't the 'best' choice in this case-as it wasn't necessary![/quote]

I do just love it when posters make a sweeping and not too sensible statement and then throw their rattle out of the pram.

Applying your argument the dog should should just have had fluids and pain relief...

Conflicts a bit with your earlier post too viz:

With this gas distribution ie. restricted to distally (except stomach) I would barium (same day, no delay) but prepare owner for possibility of ex lap (again, same day). If gas was more proximallay I would ex lap.

P.s. Also I presume it's been done but I would double check for anything blocking on rectal (as on v-d the gas seems to stop suddenly...although doesn't have same cut off on lateral).

Actually I was going to suggest the PS in your earlier post but it was a very old diagnostic technique [ do vets still take temperatures or do you have to send the patient to the lab now?].

So manual rectals should be abandoned but, even you, might concede that a barium enema might be going too far.....

There dear, you can have your rattle back [sorry, couldn't resist]

RE: To ex-lap or not ex-lap?

Michael Woodhouse — Wed, 14 Oct 2015 15:04:23 GMT

[quote user="Nicola M"]But it wasn't the 'best' choice in this case-as it wasn't necessary![/quote]

Are we saying that an ex lap has no merit in the workup of these cases? It is only of value when something surgically correctable is found? I quite profoundly disagree with that viewpoint. You know exploratory surgery is still undertaken on people where there is a seemingly endless budget for work up and testing.

These dogs with GI signs are going to fall into one of three categories:

Requiring surgical correction of the condition - testing is just establishing the need to cut
Non specific signs, that require (surgical) biopsies to reach a disgnosis
Non surgical conditions that would resolve with just medical management/supportive treatment

If working with limited budget, then early cutting can save money - if the animal falls into category 1 or 2 then the diagnosis is reached and the problem resolved/diagnosed. If category 3 then you have a rule out sensitivity that must be as close to 100% as you can get (with good technique). Diagnostics are expensive. Time in the hospital is expensive.

If we didn't think we could ethically manage the pain and discomfort from a simple laparotomy, then we shouldn't be spaying bitches! This is bread and butter stuff.

Depends what you need to do in a 30 minute ex lap. If you are talking from first cut to last stitch then easy. If you are talking from giving a pre med, GA, clip, scrub etc then not a hope in hell.

Lets not forget that we are potentially increasing morbidity by delaying an animal that will eventually require surgery by running endless tests. By NOT operating we are potentially causing harm, losing gut viability etc.

Personally I take each case on its merits, but to somehow suggest that an ex lap is ever 'not in the animal's best interests' is likely to be flawed thinking. This is going to come back and bite you on the arse when your 'negative' radiographs, 'negative' scan, 'negative' bloods dog dies of peritonitis......

RE: To ex-lap or not ex-lap?

Nicola Cole — Wed, 14 Oct 2015 14:01:05 GMT

[quote user="Anthony Todd"]

[quote user="Nicola M"]Yes, an ex lap should pick up everything....but in some circumstances is completely unnecessary[/quote]

Very true, but as I said:

In this case, history of the rubber toy [and anything small enough to swallow?], signs, and X-ray made it the best choice without the risk of delay.

You could say the same, even for Xray, ultrasound, and barium in some GI cases. ie totally unnecessary.

[/quote]

But it wasn't the 'best' choice in this case-as it wasn't necessary!

and I know the reply I get will be going over the same old ground so I am going to gracefully bow out.....

RE: To ex-lap or not ex-lap?

Anthony Todd — Tue, 13 Oct 2015 23:34:53 GMT

[quote user="Nicola M"]Yes, an ex lap should pick up everything....but in some circumstances is completely unnecessary[/quote]

Very true, but as I said:

In this case, history of the rubber toy [and anything small enough to swallow?], signs, and X-ray made it the best choice without the risk of delay.

You could say the same, even for Xray, ultrasound, and barium in some GI cases. ie totally unnecessary.

RE: To ex-lap or not ex-lap?

Anthony Todd — Tue, 13 Oct 2015 23:27:33 GMT

[quote user="Kate Richardson"]So how much does a 'quick ex lap' cost the owner?[/quote]

Probably much less than all the GAs, tests, consults etc

.[quote user="Kate Richardson"]Do you still hospitalise it afterwards and if so for how long?[/quote]

Nah, owners usually give better aftercare, certainly back in the day when "hospitalisation" was not common. and dog can come back twice daily, that's if the Exlap was negative, obviously.

[quote user="Kate Richardson"]And really- 30 minutes???[/quote]

Yep, probably less, [not me I hasten to add] as I said, quickest, neatest, most sympathetic surgeon I ever saw.

Er, mind you his consults were even quicker.....

A very quick surgeon asked him to do a C/S while he watched, so he did, and the "learner" said "can you do the next one slower so I can see what you did"....

RE: To ex-lap or not ex-lap?

Nicola Cole — Tue, 13 Oct 2015 20:37:06 GMT

[quote user="Anthony Todd"]

I said "others" not "everybody"....

Are you sure a barium study would have picked up a slowly necrotising bowel or even a twist before it was too late?

An ex-lap should pick up everything.

[/quote]

Yes, an ex lap should pick up everything....but in some circumstances is completely unnecessary (in my opinion).

In this circumstance I can completely see why some people would go straight to ex lap and some would barium and I wouldn't have a problem with either of those two approaches. However, in this particular circumstance (in hindsight), an ex lap wasn't required. Equally, this dog could have had a FB, and again, either method (ie image then STRAIGHT to ex lap if FB confirmed or just straight to ex lap) if FB not palpable are both perfectly viable options in my opinion. And I completely agree that if we delay an ex lap and a FB is present then more problems can be caused-and that has to influence the decision made. But by doing a very simple quick, extra test to confirm means that some unnecessary ex laps would be avoided.

In general (not specifically about this case)-Doing a quick extra, cheap, test (if palpation and a plain radiograph does not give the answer) does not make someone wrong, or a 'modvet' or too reliant on new techniques! I guess what I'm objecting to is the blanket generalisation that ex laps are such a brilliant diagnostic technique-they are, but are overkill in quite a few circumstances. Not quite the same, but a bit like saying lets echo every single cat with a heart murmur, just in case.

I think I'd be a bit put out if I was poorly and taken straight to ex lap without doing a couple of tests first!

p.s. I am more than happy to use an ex lap as the main/only (if palpation indicates) diagnostic procedure when indicated.

RE: To ex-lap or not ex-lap?

Gillian Mostyn — Tue, 13 Oct 2015 18:40:13 GMT

[quote user="Michael Woodhouse"]Does anyone have a single bad outcome from a simple ex lap?[/quote]

Depends how you define 'bad outcome'. All my 'negative' ex laps have woken up....and either recovered from or died of the actual problem. But I'm sure they all had more pain due to my procedure. (I am happy to admit that ALL my abdominal surgeries cause some degree of pain! Obviously I use analgesia as required.)