Bitch spey closure

Re: Bitch spey closure

Anthony Todd — Sun, 30 Oct 2011 22:45:45 GMT

[quote user="Martin Atkinson"]

[quote user="Anthony Todd"]

What exactly was the disadvantage of chromic gut for all but the skin in dogs, and everything from uterus to skin in the cat?

[/quote]

I don't see any logic in why if you use it in the skin of the cat you don't use it in the skin of a dog. But to answer the question: all the (very few!) wound breakdowns that have occurred with my surgery have been when using catgut. Besides having a much lower tensile strength than any synthetic material it seems to have the ability to undo itself and disintegrate within 2-3 days in the presence of a wound infection. Both Vicryl and PDS hang on in there and reduce the risk of herniation.

[/quote]

We used cat gut in the skin 'cos we never saw them again and the gut dissolved eventually, sometimes lasting months.

And,er, I guess synthetics might last longer "in the presence of a wound infection" but, as my ops never got infected etc, etc, [sorry mate, but I just couldn't resist it]

Seriously though, it's so easy to blame the material for all sorts of unconnected complications.

Re: Bitch spey closure

Anthony Todd — Sun, 30 Oct 2011 22:35:12 GMT

[quote user="Julian Earl"]Err, I don't wish to be too pedantic but inflammation is a vital part of the inital stages of healing. No monocytes equals no healing.[/quote]

So all your skin incisions get all "inflamed" do they? Sorry, I should have said excessive inflammation, if you are going to include pedantically normal wound healing or adhesion as "inflammation".

We've been here before and, as I said in the last thread a year or so ago, if you got an experienced surgeon to do 100 spays with chromic gut and 100 spays with any synthetic the adhesion rate, "infection rate" wound breakdown, knot failure and all the other complications would be the same, probably very few.

The various choices shown in the survey show, to me, that preferred suture material and even suture pattern doesn't indicate superiority just choice or preconception probably influenced as much by advertising, the tendency to use what the medicos use, or a disaster in the dim and inexperienced past, as by any evidence.

In fact, apart from statistical niceties and red herrings regarding breaking strength we all should still be using chromic gut as far as the scientific evidence seems to suggest regarding adhesions.

We can't even agree on continuous versus single interrupted sutures, for heaven's sake!

Re: Bitch spey closure

Evelyn Barbour-Hill — Sun, 30 Oct 2011 19:38:54 GMT

[quote user="Anthony Todd"]I must point out again that chromic catgut was used for, what, 40 odd years[/quote]

Considerably more than that, surely? 140 years more like it?

Re: Bitch spey closure

Julian Earl — Sun, 30 Oct 2011 17:53:41 GMT

[quote user="Anthony Todd"]

Another thing is that, if you are trying to get healing [as in an incision] the last thing you want is an inflammatory response which leads to no healing at all, similarly infection. so why would you get an adhesion in this environment. I suppose minor haemorrhage forming initially a clot which attached to the nearest surface might do it?

[/quote]

Err, I don't wish to be too pedantic but inflammation is a vital part of the inital stages of healing. No monocytes equals no healing.

Re: Bitch spey closure

Anthony Todd — Sat, 29 Oct 2011 11:44:10 GMT

[quote user="David Beattie"]Perhaps adhesions post-OVH are more common than I previously thought [/quote]

I'm sure they are and the last of my quotes from the JAMA where he said "certain patients...." seemed to sum it up in that they just happen sometimes.

Apparently 93% of humans get some degree of adhesions after abdo. surgery.

I couldn't find any references which seemed to prove why they sometimes occurred,even in humans.

I must point out again that chromic catgut was used for, what, 40 odd years with no more problems than we seem to get now so I still feel that to condemn it outright doesn't seem to be supported by the evidence I found nor by history.

Re: Bitch spey closure

Anonymous — Sat, 29 Oct 2011 11:02:52 GMT

Thanks, Anthony, useful look at some of the literature.

I'm not suggesting that there is any evidence (there may be, I haven't looked) that in the dog the use of catgut ligatures during OVH is associated with more adhesions than the use of [insert favourite synthetic absorbable].

However, in the case I mentioned that was on my mind this week, I think the suture material (which happened to be catgut) was responsible for the formation of the adhesions as described rather than 'surgical error'. I do, however, also take Evelyn's point that lack of sterility may or may not have been a crucial factor - impossible to know.

But, to play devil's advocate, the evidence you quote does not convince me that catgut is not more likely to cause such adhesions than a synthetic absorbable which I might postulate to be less antigenic and less likely to induce inflammation.

[quote user="Anthony Todd"]

Well, David, I thought I was on for a hammering when I reached for Google but the first one was this;

http://www.ncbi.nlm.nih.gov/pubmed/8725827

which concluded as follows:

In dogs, the formation and strength of intentionally created abdominal adhesions are not increased by use of chromic catgut.

[/quote]

I don't feel this study design of 6 dogs looking to see if catgut was useful when one was trying to get adhesions from enteropexy procedures comments usefully on unintentional adhesions such as I'm suggesting occurred in the case I mentioned. Indeed I would wonder if its conclusion that: "Selection of chromic catgut suture for use in surgical procedures where adhesions are desired is unwarranted" is even a valid interpretation of the results: "No statistically significant difference in breaking strength was observed", but would need to see the full paper to determine what the statistical power of the study was. I can go into detail if you wish.

[quote user="Anthony Todd"]which said this [cows I know, but uteri, at least][/quote]

Those who deal with rabbits assure me catgut use is tantamount to negligence which would suggest to me that there may be significant species differences - I would be cautious on extroplating from bovine study to dogs, but looks like an interesting study.

[quote user="Anthony Todd"]

and then this, in the dog from:

Int. J. Morphol.,

28(4):1221-1225, 2010.

[/quote]

Available at: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0717-95022010000400037&lng=es&nrm=iso

This appears to be a replica of the first study mentioned (i.e. comparing polypropylene with chromic catgut to see if the former is as good or better for forming intentional adhesions in enteropexy). Interesting results though and authors clearly feel polypropylene causes a more impressive inflammatory response than chromic catgut.

[quote user="Anthony Todd"]Every surgeon of experience has been impressed by the fact that certain patients are apt to form extensive adhesions following the simplest operation, done under perfect aseptic conditions, while other patients fail to form adhesions no matter how much the traumatism, nor how imperfect the technic. He has also found that certain patients will seemingly withstand a great amount of sepsis, while others die from very slight infections.[/quote]

Perhaps adhesions post-OVH are more common than I previously thought (like the 50% of cows) and this poor dog was just unfortunate that they resulted in intestinal obstruction?

Re: Bitch spey closure

Anonymous — Sat, 29 Oct 2011 10:15:29 GMT

[quote user="alison howell"]I am quite surprised that people are still using nylon in the linea alba. [/quote]

So was I, but it does seem to be cheapest option, and I can't really think of any serious downsides compared to e.g. PDS? Obviously unlike PDS is not eventually absorbed, but is this a big problem?

Re: Bitch spey closure

Anonymous — Sat, 29 Oct 2011 10:04:45 GMT

[quote user="Evelyn Barbour-Hill"]Maybe he left the ends too long? Maybe the catgut was not sterile?[/quote]

As far as I could tell the amount of catgut appeared reasonable on the ovarian stumps.

The catgut not being sterile is certainly a possibility. Whether it was or not is impossible to know now. I don't know if I need incite the addition of bacteria to the foreign material to explain the inflammatory response and adhesions, but it may have been the case and may have been the critical factor without which the adhesions would not have formed?

Re: Bitch spey closure

Julian Earl — Sat, 29 Oct 2011 09:34:48 GMT

That's a very interesting and useful post Anthony. Five stars from me.

Re: Bitch spey closure

Judith Joyce — Sat, 29 Oct 2011 09:21:32 GMT

Anthony,

How dare you!

Just when debate is lapsing into an argument with unsupported anecdote and personal prejudice starting to fly, you spoil it all by going all scientific on us.

Malcolm N

Re: Bitch spey closure

Anthony Todd — Sat, 29 Oct 2011 06:21:16 GMT

[quote user="David Beattie"]If the suture wasn't the guilty party, explain to me, Anthony, what caused the adhesions around each area of catgut ligature?[/quote]

Well, David, I thought I was on for a hammering when I reached for Google but the first one was this;

http://www.ncbi.nlm.nih.gov/pubmed/8725827

which concluded as follows:

In dogs, the formation and strength of intentionally created abdominal adhesions are not increased by use of chromic catgut.

and then this:

http://www.ncbi.nlm.nih.gov/pubmed/8367842

which said this [cows I know, but uteri, at least]

A caesarean section was performed in 202 cows for the first time. The uterus of 103 of these cows was sutured with Vicryl (7 metric) and the uterus of 99 cows was sutured with plain catgut (9 metric). The cows were randomly allotted to the two groups. All cows were rectally examined to diagnose adhesions between the uterus and the surrounding tissue five weeks post partum. Adhesions were found in 50% of the cases. There were no differences in the number of adhesions and the severity of the adhesions between the catgut and the Vicryl group (Table 1).

but then this in rats showed that plain gut caused more adhesions of the peritoneum than nylon but was complicated by the deliberate addition of infection and the fact that if you didn't suture the peritoneum you got even fewer adhesions....

and then this, in the dog from:

Int. J. Morphol.,

28(4):1221-1225, 2010.

which concluded:

SUMMARY: The gross and histologic patterns of abdominal adhesions formed by the use of chromic catgut and polypropylene

suture materials were evaluated in dogs. Gross and histologic examinations did not reveal significant difference (p>0.05) in the degree of

adhesions observed at enteropexy sites in both suture materials. The use of polypropylene with superior suture qualities should be

considered instead of chromic catgut for procedures in which adhesion is desired in the dog.

which seems to suggest that I may be doing not too bad although the SUMMARY last sentence reads illogically??

But then this, from a firm that has stopped making catgut sutures:

It is undeniable that the extent of research and evidence for swapping the old Catgut sutures for a more beneficial synthetic absorbable suture is starting to pile up. Perhaps it may be time to join the advancement highway of suture material progression, and say goodbye to Catgut for good.

which might just be based on market factors and forces rather than any hard evidence?

As far as the causes of adhesions in the cited anecdote this seems to sum it up from:

JAMA.1913;61(22):1952-1957. doi:10.1001/jama.1913.04350230006003

Every surgeon of experience has been impressed by the fact that certain patients are apt to form extensive adhesions following the simplest operation, done under perfect aseptic conditions, while other patients fail to form adhesions no matter how much the traumatism, nor how imperfect the technic. He has also found that certain patients will seemingly withstand a great amount of sepsis, while others die from very slight infections.

without going into the causes, and certainly no mention of suture material at all, David.

Re: Bitch spey closure

vs0u — Fri, 28 Oct 2011 21:52:26 GMT

[quote user="David Beattie"]Incidentally, the midline linea alba incision appeared to have healed (I've never had the chance to have to re-incise through one of these so soon before, so was surprised how quickly seemed to have healed and re-gained what appeared to be perfectly adequate strength in 10 days in this young bitch; it was closed with simple continuous nylon for the record.)[/quote]

I am quite surprised that people are still using nylon in the linea alba.

Re: Bitch spey closure

Evelyn Barbour-Hill — Fri, 28 Oct 2011 21:36:01 GMT

[quote user="David Beattie"]

[quote user="Anthony Todd"]How on earth this could be blamed on the suture material is beyond me; talk about being at the scene, so must be the guilty party.....[/quote]

The surgery was performed by a 5 year graduated vet competent in routine ovariohysterectomy. I wasn't watching the original neutering procedure, but I find it hard to see how one could incompetently apply single ovarian catgut ligatures in a 12kg 1y5m thin lurcher cross??

The bitch was in early stages of pregnancy (accidently mated approx 3 weeks previously) and the uterine stump had been oversewn with catgut - so I could consider that atypical and if the adhesions had been there alone perhaps implicated surgical technique, but to have marked adhesions in all 3 areas of catgut ligatures seems rather suspcious on this isolated occasion of a suture reaction.

If the suture wasn't the guilty party, explain to me, Anthony, what caused the adhesions around each area of catgut ligature?

[/quote]

Maybe he left the ends too long? Maybe the catgut was not sterile?

Re: Bitch spey closure

Evelyn Barbour-Hill — Fri, 28 Oct 2011 21:33:05 GMT

[quote user="Martin Atkinson"] Besides having a much lower tensile strength than any synthetic material[/quote]

That's not really very significant. Yes, any given size of catgut has a lower breaking strain than the same size of Vicryl. But, as we all found when changing from catgut to Vicryl in any particular situation, that just means you can use Vicryl that is two sizes lower than the catgut you were using. Where you use 3/0 gut, you use 5/0 Vicryl, for instance.

Re: Bitch spey closure

Robin Grimmer — Fri, 28 Oct 2011 20:08:31 GMT

I have always used simple interrupted vicryl in the linea alba and in 20 years of vetting have never had a wound breakdown.

It's always worked for me so I see no reason to change.

I am a fan of 4m vicryl for ligating the ovarian pedicles in large dogs. It's great - you can pull it as tight as you like and it won't break unlike catgut.

Re: Bitch spey closure

Anonymous — Fri, 28 Oct 2011 19:39:52 GMT

[quote user="Anthony Todd"]How on earth this could be blamed on the suture material is beyond me; talk about being at the scene, so must be the guilty party.....[/quote]

If the suture wasn't the guilty party, explain to me, Anthony, what caused the adhesions around each area of catgut ligature?

Re: Bitch spey closure

Mark Hedberg — Fri, 28 Oct 2011 19:02:43 GMT

[quote user="Clive Ansell"]

[quote user="Mark Hedberg"]

I was informed by the practice I work at that continuous sutures in midlines were not allowed and VDS wouldn't defend it if something happened.

[/quote]

I don't accept that for a minute.

I was taught at vet school by an RCVS recognised specialist that simple continuous midline sutures were his preferred method, and that is what he advised we routinely use

As a final year student I managed to partially close the Linea alba of a Shire horses with simple continuous vicryl, under the watchful eye of the Late Prof Edwards. If that was ok, it is certainly fine with me.

>50% in this poll are using continuous sutures, therefore if it is accepted norm within the profession it could not be seen as negligent in any way.

I have never had a single midline wound breakdown in 15 years using continuous sutures. (he says touching something wooden with fingers crossed)

[/quote]

I happen to agree with you - my previous job before that I did continuous suture (catgut, even!) exclusively and it worked fine. It came down to me not being particularly fussed if my boss wanted me to use interrupteds. I wasn't particularly bothered enough to ring VDS and ask. Yes, it's lazy, but it seemed a bit pointless to pick a fight with the boss over something as minor as suture. :)

Re: Bitch spey closure

Martin Atkinson — Fri, 28 Oct 2011 18:25:56 GMT

[quote user="Anthony Todd"]

What exactly was the disadvantage of chromic gut for all but the skin in dogs, and everything from uterus to skin in the cat?

[/quote]

Re: Bitch spey closure

Rob Loxley — Fri, 28 Oct 2011 15:48:00 GMT

[quote user="Anthony Todd"]

What exactly was the disadvantage of chromic gut for all but the skin in dogs, and everything from uterus to skin in the cat?

[/quote]

There are suture materials that are stronger, last longer, cause less tissue reaction etc. etc.?
That's not to say that gut closure hasn't had and will continue to have its successes and fans, but obviously most feel there are better options these days?

Re: Bitch spey closure

Mark Holmes — Fri, 28 Oct 2011 14:47:05 GMT

Its usually just the knot that cause those, and I find if you bry the knot deep they don't happen. Aberdeen knots have substantially less thread in them and help prevent them also.

Re: Bitch spey closure

Anthony Todd — Fri, 28 Oct 2011 14:44:15 GMT

[quote user="Evelyn Barbour-Hill"]Sorry, but I'm putting it down to either bad surgical technique[/quote]

Yeah, but I'm just for the above.

How on earth this could be blamed on the suture material is beyond me; talk about being at the scene, so must be the guilty party.....

Re: Bitch spey closure

Evelyn Barbour-Hill — Fri, 28 Oct 2011 14:24:29 GMT

[quote user="David Beattie"]

Just one anecdote, and I'm sure there are are plenty similar for synthetic absorbable usage, but I saw my first case of serious adhesions secondary to catgut ligatures on a routine ovariohysterectomy this week - so it doesn't appear just to be theoretical...

About 10 days post-spay and intestinal obstruction present radiographically with appropriate signs.

Ex.lap:

Uterine stump adhesed to bladder and 2 x loops of jejunum

Right ovarian stump adhesed to pancreas and kidney

Left ovarian stump adhesed to kidney and 2 x loops of jejunum, with a third secton of jejunum corkscrewing through adhesions and this was the obstruction.

I'm definitely puting that one down to the catgut that had been used.

[/quote]

Sorry, but I'm putting it down to either bad surgical technique or to an individual quirk of the patient.

Re: Bitch spey closure

Clive Ansell — Fri, 28 Oct 2011 12:16:08 GMT

[quote user="Mark Hedberg"]

I was informed by the practice I work at that continuous sutures in midlines were not allowed and VDS wouldn't defend it if something happened.

[/quote]

I don't accept that for a minute.

I was taught at vet school by an RCVS recognised specialist that simple continuous midline sutures were his preferred method, and that is what he advised we routinely use

>50% in this poll are using continuous sutures, therefore if it is accepted norm within the profession it could not be seen as negligent in any way.

I have never had a single midline wound breakdown in 15 years using continuous sutures. (he says touching something wooden with fingers crossed)

Re: Bitch spey closure

Anne Seawright — Fri, 28 Oct 2011 12:02:50 GMT

Anthony: I meant too late (it was after midnight) for technical issues (with my ability to post, for some reason what was in my screen was not being posted and I was getting frustrated at myself). I was just trying to share the reference people had previously discussed suggesting no difference between interrupted and continuous.

Re: Bitch spey closure

Anonymous — Fri, 28 Oct 2011 11:59:17 GMT

[quote user="Anthony Todd"]What exactly was the disadvantage of chromic gut for all but the skin in dogs[/quote]

About 10 days post-spay and intestinal obstruction present radiographically with appropriate signs.

Ex.lap:

Uterine stump adhesed to bladder and 2 x loops of jejunum

Right ovarian stump adhesed to pancreas and kidney

Left ovarian stump adhesed to kidney and 2 x loops of jejunum, with a third secton of jejunum corkscrewing through adhesions and this was the obstruction.

I'm definitely puting that one down to the catgut that had been used.

Incidentally, the midline linea alba incision appeared to have healed (I've never had the chance to have to re-incise through one of these so soon before, so was surprised how quickly seemed to have healed and re-gained what appeared to be perfectly adequate strength in 10 days in this young bitch; it was closed with simple continuous nylon for the record.)

PS - Is there a special issue with catgut usage in skin in dogs that I don't know about?