Medical Management of LDAs

Re: Medical Management of LDAs

Alan Tevendale — Thu, 23 Sep 2010 08:27:44 GMT

Phil makes a very good point that many cows that have obvious primary causes will often respond to medical management. At BCVA congress last year there were some interesting discussions on LDAs. Mr Aggers (the pump and fluids man) talked about the use of 20-40 litres of fluids - they reportedly 'cured' 20 out of 22 LDAs with medical tx - obviously a very small and probably completely unscientific study. It does make the point however that medical tx can certainly be at least an aid in the overall tx of any LDA.

Previous points on the reduced success rates of toggling versus surgery I'm not totally convinced on though. Another study presented at BCVA congress showed little difference in success rates between any of the surgical options - toggling or otherwise. Again this was only one study. I think most of it comes down to what the individual vet is used to doing. I know vets who claim 90-95% success with toggling and others who only achieve 60%. Personally I believe that the more invasive surgical options are likely to be more effective but who am I to alter the opinions of the profession.

Re: Medical Management of LDAs

Phil Elkins — Mon, 02 Aug 2010 11:29:36 GMT

[quote user="Michael Woodhouse"]

I have tried medical management and unless the cow has a major obvious cause (eg toxic metritis AND a DA) then I'm not sure I've cured one medically with or without metoclopramide!

[/quote]

This is a very good point. I have cured (or more likely a cure has been incidental) many DAs that are secondary to an obvious cause. All DAs are secondary anyway but I mean obvious primary ongoing causes rather than the tail end of a uterine infection or lameness still being present. As a general rule, pyrexic cows are not operated on that day. They would be given appropriate antibiosis (usually a Cephalosporin), NSAIDs, 20-40 litres of oral fluids together with propylene glycol and one of the Selekt range of pumping products as appropriate (fresh cow has a lot of Ca in it) +/- maxolon depending on degree of immotility. they will then be rechecked the next day. Of those with relatively low volume, ventral displacements, I would estimate that between 40 and 60% are not displaced the next day and do not redisplace with contuining therapy.

Other than pyrexic animals, I would generally always recommend surgery (not toggling, the cost issue if far outweighed by the reduced success rate) and would recommend either the paramedian approach as recommended by Michael, or a right sided only approach with a forward pyloropexy rather than an omentopexy at a site in the last intevertebral space away from the primary incision.

Re: Medical Management of LDAs

Michael Woodhouse — Sun, 25 Jul 2010 13:34:43 GMT

[quote user="Julian Earl"]It is also beneficial to get the plastic "button" to prevent the suture cutting in to the abdominal wall afterwards. I can't remember the price but it is negligible in the grand scheme of things.[/quote]

£9.86 for 6. I agree it's an insignificant cost. Should get some and give it a try.

[quote user="Julian Earl"]I think that the main advantage of toggling is that it can be done immediately rather than going back to the farm at a later time or date by which time the cow may have deteriorated somewhat. [/quote]

I agree - so long as she is well. Sunken eyed and toxic with metritis I prefer to manage medically first.

Re: Medical Management of LDAs

Julian Earl — Sun, 25 Jul 2010 10:41:52 GMT

[quote user="Michael Woodhouse"]

The trocar, stylet and handle are £29.97 and the toggles £7.20 each. You need to search "TROCAR FOR GRYMER STERNER" for the kit. This is Dunlops list price before any discount excluding VAT.

I have tried medical management and unless the cow has a major obvious cause (eg toxic metritis AND a DA) then I'm not sure I've cured one medically with or without metoclopramide!

I have used toggles and I have operated. In my hands I would say toggles are 75-80% effective. My preferred surgical technique is paramedian and this way I would say success was around 95%.

If the cow is worth it - I operate, if money is an issue I toggle. I would always operate as a first choice, bear in mind it now cost more than £80 to dispose of a dead cow, we don't charge that to toggle a cow (and it covers a lot of the cost of the op!)

[/quote]

It is also beneficial to get the plastic "button" to prevent the suture cutting in to the abdominal wall afterwards. I can't remember the price but it is negligible in the grand scheme of things.

I think that the main advantage of toggling is that it can be done immediately rather than going back to the farm at a later time or date by which time the cow may have deteriorated somewhat.

Re: Medical Management of LDAs

Michael Woodhouse — Thu, 28 Jan 2010 23:41:38 GMT

Let us know how you get on. I have put a reference in the other displaced abomasum thread of a blow by blow reference for paramedian if it's any help.

The hardest part is when you get an abomasum so full of fluid and gas that you can't pick it up to get the stitches in. Remember your anatomy and if there's omentum around it you're looking at rumen not abo! every now and again you have to go fishing for it, but it tends to be just where you open the skin. I fix the abomasum parallel to the incision with 3 large catgut sutures, not in the abdominal incision.

Good luck!

Re: Medical Management of LDAs

Vikki Halliday LLB — Thu, 28 Jan 2010 21:46:43 GMT

[quote user="Rachael Mather"] I need to put a case forward to the practice to try toggles and paramedian sx[/quote]

Good for you, go for it, and if you need any more advice you know where we are!

Vik

Re: Medical Management of LDAs

Rachael Mather — Thu, 28 Jan 2010 21:39:58 GMT

Thanks for all your messages, think I need to put a case forward to the practice to try toggles and paramedian sx as they seem to do metoclopramide/prorumen or the flank approach, and most farmers seem to be reluctant to go for surgery straight off. Thanks for your offer Michael, but unfortunately I'm in Devon. I actually watched a few and did one paramedian approach as a student and would be fairly happy doing one, provided I had the assistance to get the cow in position, which is prob most likely prob in our practice; that and convincing farmers of the new-fangled approach!

Rachael

Re: Medical Management of LDAs

Hannah Wynne Richards — Thu, 28 Jan 2010 10:21:55 GMT

I can't give an opinion , one way or the other, about toggles-they didn't exist when I last did cattle work!!!!!!!!!!!!!!!!!!!!!!!!!. I would be very doubtful if medical management alone would be successful (even if combined with rolling, but not fixing ), once the abomasum was actually displaced-medical management could be useful if a VERY obsevant farmer called you at the abomasal atony stage, and certainly calcium is a good idea.

This thread, and the one on LDA surgery make me feel very old -fashioned, as , if I was still doing cattle work, I would like a 2nd surgeon, and the bilateral approach-don't tell me, not economically feasible now !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Wynne

Re: Medical Management of LDAs

Michael Woodhouse — Wed, 27 Jan 2010 23:09:19 GMT

[quote user="Vikki Halliday"]I'd agree with what you say in the main, however I think i't a bit less scary to toggle as new graduate, and if the farm really isn't big enough to swing a cat, perhaps sterility and assistance will be an issue?

[/quote]

Not wanting to argue, but I find the opposite!

For a paramedian op I cast the cow and administer chloral hydrate (60g in 400ml IV). I will ofen cast and position the cow with me and 1 helper (need to be able bodied!). I cast the cow next to a 5 bar gate and turn her upside down and tie the legs to the gate.

For a toggle I usually don't sedate the cow. Really you need 2 assistants one each side to steady the cow in addition to the vet! I tried sedating them but any delay in getting the cow upside down makes it harder as the gas escapes.

Either technique it is best to have someone show you the first time. Any friends local who could show you? If you were local to me you are welcome to tag along!

Re: Medical Management of LDAs

Vikki Halliday LLB — Wed, 27 Jan 2010 22:55:50 GMT

[quote user="Michael Woodhouse"]

The trocar, stylet and handle are £29.97 and the toggles £7.20 each. You need to search "TROCAR FOR GRYMER STERNER" for the kit. This is Dunlops list price before any discount excluding VAT.

[/quote]

Ok so I was a bit out in price!

I'd agree with what you say in the main, however I think i't a bit less scary to toggle as new graduate, and if the farm really isn't big enough to swing a cat, perhaps sterility and assistance will be an issue?

Re: Medical Management of LDAs

Michael Woodhouse — Wed, 27 Jan 2010 22:52:42 GMT

The trocar, stylet and handle are £29.97 and the toggles £7.20 each. You need to search "TROCAR FOR GRYMER STERNER" for the kit. This is Dunlops list price before any discount excluding VAT.

I have tried medical management and unless the cow has a major obvious cause (eg toxic metritis AND a DA) then I'm not sure I've cured one medically with or without metoclopramide!

I have used toggles and I have operated. In my hands I would say toggles are 75-80% effective. My preferred surgical technique is paramedian and this way I would say success was around 95%.

Re: Medical Management of LDAs

Vikki Halliday LLB — Wed, 27 Jan 2010 21:09:23 GMT

[quote user="Rachael Mather"] none of our farmers have enough room to roll a cow![/quote]

I think that's Boll@cks! Did that come from the farmers themselves or from the vets in the practice making excuses for not doing the procedure? ALL farms must have a straw pen somewhere, as they are required by law to have appropriate accomodation for pre and post calving cows in the winter.

I cannot believe therefore that they don't have a calving pen!

Seriously in spite of the other response, the toggles are easy to use, require minimal training or risk compared to a manual LDA replacement by laparotomy, and effectively prevent it next year when the farmer fails to listen to your advice re dry cow management. ( Which they will, and of course then try and blame the vet for the problem returning............)

At the risk of upsetting people, why don't you ask your boss if you can buy the kit and use it yourself, ( therefore no financial outlay for the practice and probably cost the same as a couple of Saturday nights in the pub), and so long as you follow the principles correctly, you will amaze the farmers, surprise your boss, and have him buying kits for all the large animal vets!

http://www.ldatogglesuture.com/Purpose.html

This is the site giving you the info on using the kit, and from memory it costs between £80-£100 for the initial puchase of the trochars,(please anyone correct me if I'm wrong on the proce but I am at home and don't have access to the catalogue) and the toggles themselves can be stainless steel or more recently I have used plastic ones.

I think anyone who puts a new graduate in a position of having to deal with LDA's should provide them with this kit and training in using it. I certainly don't agree with trying to medically manage them when there is a cost effective low risk surgical procedure available.

Good luck!

Vikki

Re: Medical Management of LDAs

Andrew Kent — Wed, 27 Jan 2010 19:20:39 GMT

Hi Rachael,

Hope all is good with you.

Have to say in my hands medical management of LDA's was a waste of time. Tried the approach you outlined on a few cases where surgery wasn't an option +/- buscopan but never with much success. I always found the best bet was to get in and fix them surgically asap.

Did a few toggles but again never found it to be very successful, I think you either love them or hate them.

Andy

Re: Medical Management of LDAs

Rachael Mather — Wed, 27 Jan 2010 19:00:43 GMT

Thanks for your advice Vicki, no-one in my practice uses toggles - apparently none of our farmers have enough room to roll a cow! I shall try the suggestion again though!

Re: Medical Management of LDAs

Vikki Halliday LLB — Tue, 26 Jan 2010 23:15:57 GMT

Hi Rachel,

At the risk of upsetting more old fashioned practitioners, I have never had any reservation in treating LDA's with a "toggle" procedure. I would hesitate to recommend solely medical management as in my experience they rarely get any better without appropriate manual replacement, and with a toggle, you and a farmer can roll and replace an LDA in about 15 mins, without the risk of abdominal surgery. the kits are not that expensive, and saved my bacon on a few occasions!

More important I think to concentrate on prevention and advice re appropriate dry cow management.

Vikki