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Surgical Repair and Management of Congenital Intestinal

Atresia in 68 Calves
SAEED AZIZI, DVM, DVSC, RAHIM MOHAMMADI, DVM, and IBRAHIM MOHAMMADPOUR, DVM
ObjectiveTo determine outcome and survival rate after surgical treatment of intestinal atresia,
gender predilection, and effect of rectal palpation on the cause of atresia coli in calves.
Study DesignProspective clinical study.
AnimalsNewborn calves (n68).
MethodsData collected were husbandry system, anamneses, physical examination ndings, sur-
gical treatments, and postoperative results. Calves with atresia ani, and with atresia coli et recti had
anal reconstruction and right ank colostomy, respectively. In midank colostomized calves, the
inner muscular layers were dissected to form a valve-like stoma.
ResultsOf 68 calves with intestinal atresia, 37 were treated surgically. Anal reconstruction was per-
formed in 21 calves with atresia ani with a long-term survival rate of at least 6 months with good con-
dition. Colostomy was performed in 14 calves with atresia coli and 1 with atresia coli et recti; survival
rate was 73%. The case morbidity rate for intestinal atresia was 13.8% and for atresia coli, 5.7% in
the hospital population. No gender predilection for occurrence of atresia ani and atresia coli was
identied. Palpation per rectum for early pregnancy diagnosis did not predispose to atresia coli.
ConclusionSurgical treatment of atresia ani through circular anal skin removal has a good prog-
nosis for survival. Colostomy is not an acceptable treatment from the calfs perspective because of
the resulting poor condition but the high survival rate is important to allow continued milk pro-
duction of the dam.
Clinical RelevanceEarly diagnosis, supportive treatment, and surgical correction are important in
management of atresia coli.
r Copyright 2010 by The American College of Veterinary Surgeons
INTRODUCTION
I
NTESTINAL ATRESIA as a congenital defect has
been reported in people and many domestic animals
including pigs, sheep, and calves.
16
In calves, this con-
genital abnormality is dened as complete occlusion of
intestinal lumen because of anomalous development of
the wall of intestine and has been identied involving the
rectum and/or anus
79
; colon
10,11
; ileum
7
; and jejunum.
8
Atresia ani is believed to be hereditary in cattle
7
and at-
resia jejuni is inherited as an autosomal recessive trait in
Swedish Highland and Jersey breeds
7,12
; however, inher-
itance of atresia coli remains controversial and incom-
pletely understood.
13
Atresia coli may occur secondary to
vascular insufciency of the developing colon in calves
and early pregnancy diagnosis in cattle by amniotic pal-
pation has the potential to damage the fetal intestinal
blood supply and disrupt organogenesis.
13,14
Our objectives were to determine the rate and gender
predilection for atresia coli, and association of rectal pal-
pation for early pregnancy diagnosis with atresia coli in
newborn calves. Outcomes and survival rate after surgical
treatment of intestinal atresia including atresia coli were
evaluated.
Corresponding Author: Dr. Saeed Azizi, DVM, DVSC, Iran and Food Animal Veterinary Clinic, Department of Clinical Sciences,
Faculty of Veterinary Medicine, Urmia University, PO Box 57155-1177, Urmia, Iran. E-mails: s.azizi@mail.urmia.ac.ir or sazizim
@gmail.com.
Submitted May 2008; Accepted January 2009
From the Iran and Food Animal Veterinary Clinic, Department of Clinical Sciences, Faculty of Veterinary Medicine, Urmia
University, Urmia, Sardasht, West Azerbyjan Province, Iran.
r
Copyright 2010 by The American College of Veterinary Surgeons
0161-3499/09
doi:10.1111/j.1532-950X.2009.00611.x
115
Veterinary Surgery
39:115120, 2010
MATERIALS AND METHODS
Calves with intestinal atresia (December 1994September
1996; April 2001March 2006) admitted for surgical treatment
were enrolled in this study. The case morbidity rate of intes-
tinal atresia was determined for the total hospital population
of newborn (o2-week-old) calves. Recorded data were breed,
husbandry system (range or small holders [free-stall inten-
sive]), type of breeding (articial insemination, natural mating
obtained from breeding record of dams raised under small
holder system and client declaration for range system), timing
of early pregnancy diagnosis by rectal palpation, anamneses,
physical examination ndings, surgical treatments, and post-
operative outcome.
Each calf was examined by a standard procedure and data
recorded. Diagnosis was obvious when the anus was absent.
In these calves, there was a pronounced protrusion of the
perineal region with deep palpation of abdomen. Diagnosis
was conrmed performing lateral plain radiography of ab-
dominal and pelvic regions. Intestinal gas was evident and
outlining a membrane within the perineal region. If abdominal
palpation failed to protrude the perineal region, right ank
exploratory laparotomy was performed to determine the an-
atomic intestinal malformation. In calves with a normal anus
and rectum and no history of defecation, tenesmus, and ab-
dominal distention, successful passage of a small tube per
rectum ruled out the diagnosis of atresia recti only. Plain or
barium contrast enema radiography and right ank explor-
atory laparotomy were performed for a denitive diagnosis.
Severely dehydrated, toxemic, recumbent, and hypother-
mic calves, where surgery was not considered useful, were
slaughtered and intestinal abnormalities were diagnosed at
necropsy. If intestinal tissue necrosis, adhesion, ileus, or per-
sistent membranes were found during exploratory laparo-
tomy, calves also had necropsy.
Surgical Techniques
Anal reconstruction. Each calf was administered supportive
uid therapy based on clinical ndings before and during sur-
gery. The calf was positioned in sternal recumbency with the
hind limbs directed toward the edge of the surgery table and
the hind feet hanging down. The perineum was inltrated with
45 mL 2% lidocaine, and after routine aseptic preparation of
the surgical eld, a cruciate incision, (2.5 2.5cm), was
made through the skin and subcutaneous tissue at the site
where the anus would normally be located. Incision ends were
connected to create a circular defect (2.53.0 cm diameter).
Careful blunt dissection was used to locate the rectal pouch,
which was secured to the skin edge with 4 full-thickness sutures
of 1 silk, then the rectum was incised and its mucosa was
sutured to the skin with simple interrupted sutures of 1 silk.
If there was a rectovaginal stula, a cruciate skin incision
was made at the site corresponding to the anus and a circular
ap was removed and the rectal pouch located. Then another
skin incision in a horizontal plane was made on, or just near,
the upper commissure of vulva. Blunt dissection was extended
cranial to the stula trying to maintain maximum thickness to
the rectal oor until the edges of the stula were freed. Any
remaining meconium was evacuated. Nonpenetrating inter-
rupted Lembert sutures (2-0 chromic catgut) were preplaced
transversely to create a rectal oor. Similarly, a vaginal roof
was created using the pattern vertically. All sutures were tied
individually. The skin was closed with simple interrupted su-
tures (1 silk).
15
Finally, the rectal pouch was sutured to the
skin as described earlier.
After evacuation of the rectum and cleaning of the surgical
wound, oxytetracycline spray (Vetaque, Animal Health Divi-
sion, Tehran, Iran) was applied to the region. In warm sea-
sons, insect repellent spray was also used. Procaine penicillin
(20,000 U/kg intramuscularly [IM]) and dihydrostreptomycin
(10 mg/kg IM) were administered for 3 days. A single dose of
vitamin AD
3
E (Razak Laboratories, Tehran, Iran) was ad-
ministered IM. Cleaning and irrigation of the surgical wound
with povidone iodine (0.7% aqueous solution) was performed
3 times daily for 5 days. Sutures were removed at 1214 days.
Other Intestinal Malformations. Right midank colostomy
was performed in calves with atresia recti and/or coli, if no
visible lethal malformations were identied during exploratory
laparotomy. After corrective uid therapy, unixin meglumine
(1.1mg/kg intravenously) was administered. The calf was po-
sitioned in left lateral recumbency and an inverted L-block in
the right ank performed with inltration of 2% lidocaine.
After aseptic preparation, a 1012 cm skin incision was made
in the right midank and the external abdominal oblique
muscle incised. The internal abdominal oblique and transverse
muscles were bluntly dissected in the direction of their bers
and the peritoneum incised. This modied grid incision po-
tentially creates a valve-like effect upon closure of the layers.
After systematic abdominal exploration, the proximal blind
end of the colon was exteriorized and anchored to peritoneum
and abdominal muscles in the middle of the mid ank incision,
equidistant from both ends of the laparotomy incision, in a
circular fashion using simple nonpenetrating interrupted 1
chromic catgut sutures. Then, the upper and lower parts of the
abdominal wall incision were closed in layers. The blind end of
the colon was incised and after evacuation of meconium and
irrigation of the region with warm normal saline (0.9% NaCl)
solution, the intestinal wall was anchored to the skin using
simple interrupted (1 silk). After surgery, procaine penicillin
(20,000 U/kg) and dihydrostreptomycin (10 mg/kg) were ad-
ministered IM for 5 days and 2 doses of vitamin AD
3
E were
injected IM 5 days apart. Balanced electrolyte (ORS powder,
Damyaran Arak Vet Pharmaceutical Co., Saveh, Iran) was
administered orally if required. Calves were hand fed. The
surgical wound was cleaned and irrigated using povidone io-
dine (0.7% solution, 3 times daily for 5 days) and skin sutures
were removed at 1214 days.
Jejunostomy was performed using the same procedure de-
scribed for colostomy in 1 calf with a brous cord in distal
segment of jejunum.
Outcome
Follow-up information was obtained 2 weeks after surgery
to determine immediate surgical complications (e.g., wound
116 SURGICAL REPAIR OF CONGENITAL INTESTINAL ATRESIA IN CALVES
dehiscence, suture abscess, local infection) and at 6 months for
evaluation of weight gain, stricture of created anus, prolapse
of the colostomy opening, and air suction of the colon. The
short-term survival rate of treated calves was obtained
through hospital discharge and conrmed at 2448 hours af-
ter surgical intervention by phone conversation. All recovered
calves were recommended to be raised for fattening. The long-
term survival rate after 6 months was obtained by follow-up
information.
Data Analysis
For the study period, affected calves were compared with
similarly aged calves of the general hospital population to
determine gender predilection for atresia ani and atresia coli
using w
2
-test. Survival rate of colostomized calves were com-
pared with that of calves with anal reconstruction using
Fishers exact test. Po.05 was considered signicant.
RESULTS
Of 492 newborn calves admitted to the hospital, 68
calves had intestinal atresia during the study period. Age
of the calves ranged from 4 hours to 18 days old (mean,
3.5 days). The frequency and location of intestinal mal-
formations and gender distribution of affected calves are
shown in Table 1. The case morbidity rate of intestinal
atresia was 13.8% in the admitted calves. The case mor-
bidity rate of atresia coli with and/or without co-existing
intestinal anomalies (atresia coli et recti, atresia coli et
recti et ani) was 5.7%.
Fifty-two calves were Holstein-native cross (30 males,
21 females, 1 hermaphrodite) and 16 calves were native,
local unregistered breed (10 males, 6 females). No gender
predilection for atresia ani (P.68) or atresia coli
(P.33) was identied. Survival rate for colostomized
calves (73%) was signicantly lower (P.019) than for
calves with anal reconstruction (100%). For 7 native
calves with atresia coli, conception resulted from natural
mating and in 21 Holstein-native cross calves with atresia
coli from articial insemination. In the other 40 calves,
conception of the dam was resulted from natural mating
in native (9 cows) and articial insemination in Holstein-
native cross (31) cows.
Atresia ani with or without other intestinal malfor-
mations was diagnosed by the owners at 1 day (4 calves),
2 days (25), and 24 days (29) after birth; otherwise, the
abnormality was detected in our hospital (10 calves). Age
of calves at admission that had anal reconstruction were
1 day (n4), 2 days (12) and 3 days (5) whereas for
14 colostomized calves, ages were 3 days (n4), 4 days
(4), 510 (5), and 18 days (1). Most affected calves were
reported to have nursed normally immediately after birth.
Variable decrease in appetite, signs of colic and depres-
sion followed after 24 hours. Clinical signs became pro-
gressively worse with abdominal distention.
In calves with atresia ani, tenesmus was evident a few
hours after birth and they usually were dehydrated with a
distended abdomen. In simultaneous percussion and
auscultation of the abdomen ping and splashing
sounds were usually heard. Calves with atresia ani were
diagnosed based on absence of an anus, tenesmus, and
subsequent protrusion of the perineal region. In calves
with a normal anus and/or rectum that had malformation
in the colon and orad part of intestine, diagnosis was
based on presence of blood-tinged yellow mucus on dig-
ital rectal palpation and radiography. Exploratory
laparotomy was performed to conrm the anomalies.
Of 68 calves, 37 were treated surgically either by anal
reconstruction (n21), colostomy (15), or jejunostomy
(1). In 8 calves with atresia ani, other congenital abnor-
malities (e.g., absent tail, microphthalmia) were also
identied (Table 2). Sixteen calves with atresia ani had
anal reconstruction and all calves recovered without
dehiscence; suture abscesses occurred in 2 calves. All
calves were still alive 6 months after surgery with normal
weight gain and without evidence of anal stricture.
Twenty-eight calves had segmental atresia of ansa
distalis and/or ansa spiralis portions of ascending colon
(Table 1); 18 had right ank exploratory laparotomy and
4 of these were slaughtered because of adhesion and ne-
crosis of the atretic ends. Colostomy was performed on 14
calves; 4 died 1 day after surgery and 10 calves recovered.
Table 1. Sites of Intestinal Congenital Malformations and Gender
Distribution in 68 Calves
Malformation Site Number Male/Female (%)
Single Anus 12/12 (16.5/16.5)
Rectum 1/1 (1.4/1.4)
Colon 18/10 (26.0/15.0)
Jejunum 1/0 (1.4/0.0)
Multiple Anus and rectum 4/2 (5.5/3.0)
Anus, rectum, and colon 3/2 (4.0/3.0)
Rectum and colon 2/0 (3.0/0.0)
Table 2. Congenital Abnormalities Observed in the 8 Calves with
Atresia Ani
Abnormalities
Anal
Reconstruction
Surgical Correction
of Abnormality
Male/
Female
Absent tail
microphthalmia
Successful Successful 1/0
Absent tail staggering
gait
None None 2/0
Agenesis of urethra and
vulva
None None 0/1
Absent tail
rectovaginal stulation
Successful Successful 0/2
Rectovaginal
stulation
Successful Successful 0/2
117 AZIZI, MOHAMMADI, AND MOHAMMADPOUR
Calves recovered from surgery were alive at follow-up
(6 months) but had reduced growth rate and were in sub-
optimal health status. However, from an owner perspec-
tive, the outcome was favorable because of continued
milking and well being of family. No other clinical com-
plications were identied and survival rate of calves with
atresia coli was 71% (10/14). At necropsy, of the other
10 calves with colonic atresia, there was extensive intes-
tinal gas and uid accumulation, necrosis of the cecum
and proximal blind end of colon, adhesions and diffuse
peritonitis.
On necropsy, of 1 calf with segmental atresia of rec-
tum, hermaphroditism and hypospadias were identied.
Another calf with rectal atresia was slaughtered and a
brous cord was found rather than a rectum. Two calves
with atresia recti had persistent sphincter. In 1 calf while
performing right ank exploratory laparotomy, a brous
cord in distal portion of the malformed jejunum was
found; this calf had right ank jejunostomy but died 1
day after surgery.
In 6 calves with atresia ani et recti, diagnosis was
based on clinical examination and radiography and in 5
calves with atresia ani, recti, and coli, diagnosis was based
on radiographic ndings, exploratory laparotomy, and
necropsy.
Two calves had atresia of the rectum and colon. In 1,
abdominal distention was not clinically obvious and in
right ank exploratory laparotomy, membrane atresia of
rectum and descending colon was diagnosed. The other
calf was colostomized and follow-up information showed
the calf was alive with reduced growth rate compared
with herd mates.
Overall, the survival rate in the colostomized calves (10
atresia coli, 1atresia recti et coli) was 73% (11/15). Short-
term follow-up showed no wound dehiscence and inci-
sional infections in colostomized calves except for a few
suture abscesses in 3 calves. Prolapse of the colostomy
opening and air suction of the colon were not observed in
long-term follow-up; however, growth rates were reduced
compared with herd mates.
DISCUSSION
The case morbidity rate of intestinal atresia and atresia
coli in this study were 13.8% and 5.7%, respectively. We
are unaware of any other reports documenting the rate of
these abnormalities in the calves; however, the case mor-
bidity rate of intestinal atresia in calves in our region may
be even higher because calves of little value are not re-
ferred for surgery and uncomplicated cases, atresia ani,
are often corrected surgically in practice. The rate of in-
testinal atresia in calves-at-risk of 2 herds in 1 study was
6.9%.
16
We found no gender predilection for atresia ani or
atresia coli. Likewise, Constable
11
found no signicant
correlation between gender and occurrence of atresia coli,
but Martens
17
without statistical analysis of the distribu-
tion of the sexes, stated most of their calves (76%) with
intestinal atresia were male.
Atresia ani in calves was an obvious clinical nding
and easily diagnosed by owners 1 or 2 days after birth. In
contrast, early diagnosis of intestinal malformations in
calves with normal anus and rectum was much more
difcult and calves usually were referred with abdominal
distention and inability to pass feces. In calves with these
abnormalities, physical examination and radiographic
(plain or barium enema) ndings are necessary to conrm
diagnosis. Ultrasonography might be useful but ndings
are not pathognomonic.
17
Constable
11
did not identify
signicant correlation between blood gas values or leu-
kocyte counts and nal outcome of calves with atresia.
Denitive diagnosis of the congenital intestinal abnor-
malities is made by right ank exploratory laparotomy.
For anal reconstruction, we used local inltration an-
esthesia rather than epidural anesthesia because persis-
tent tenesmus facilitated exteriorization of the rectal
pouch during surgery, so applying pressure to the anks
to protrude the rectal pouch was unnecessary. Surgical
correction of anal atresia was successful in all calves
which is consistent with other reports.
8,17
Anal recon-
struction using different techniques with subsequent stric-
ture formation from wound contraction has been
discussed
8
; however, we did not observe anal stricture
when using circular anal skin removal. Atresia ani with or
without other anomalies such as congenital rectovaginal
stulae, absent tail, and microphthalmia can be treated
surgically without undesirable results.
We found that survival of colostomized calves were
signicantly different from calves that had anal recon-
struction, perhaps because a diagnosis of atresia ani was
easier to make and these calves were admitted earlier than
those with atresia coli. This may explain why none of the
calves with atresia ani were euthanatized on admission
whereas 22% (4/18) of calves with atresia coli were
euthanatized at surgery because of advanced peritonitis.
To prevent prolapse after colostomy, suturing the
proximal blind end of the colon as high as possible in
the right ank is recommended; however, one disadvan-
tage of this technique is more extensive contamination of
the ank that must be cleaned regularly.
7
We attempted
creating a valve-like stoma in the midank to preserve
luminal microenvironment of the intestines and to
enhance weight gain in the colostomized calves. We did
not observe infection at the surgical site and intestinal
prolapse did not occur.
Colostomy in 1 calf with segmental atresia of rectum
and ansa ditalis portion of ascending colon was successful.
118 SURGICAL REPAIR OF CONGENITAL INTESTINAL ATRESIA IN CALVES
Colostomy was performed based on Jangs
18
recommen-
dation and our study supports the view that colostomy is
an unacceptable permanent treatment of atresia coli from
the calfs perspective. We preferred colostomy to intestinal
anastomosis because survival rate of colostomy is higher
and live calf, regardless of its condition, is very important
to the cow to allow continue milking for wellbeing of
family.
We are unaware of reports describing the etiopatho-
genesis of these intestinal abnormalities completely. Jubb
and Kennedy
19
stated that atresia of ileum in Swedish
highland calves and atresia jejuni in Jersey calves are he-
reditary. Atresia coli was thought to be homozygous re-
cessives for a defective allele in Holstein calves.
17
However, Johnson
14
concluded nonhereditary cause of
atresia coli and stated that atresia of colon in cattle is
developed early in embryonic life and results from vas-
cular insufciency to the developing spiral colon. Vascu-
lar development and extensive spiraling of the colon
occurs during organogenesis (days 1245 of gestation) in
the fetus.
20,21
Also, Holstein-Friesian cattle may be ge-
netically predisposed to atresia coli, possibly because
their developing colon grows at a faster rate and/or to a
greater extent than that in other cattle breeds.
22
It has
been stated that amniotic palpation per rectum for early
diagnosis of pregnancy in cattle has the potential to dis-
rupt organogenesis
16
and when performed before day 42
of gestation, it consistently is associated with intestinal
atresia.
23
Brenner
16
noted when the early pregnancy di-
agnosis by amniotic vesicle palpation was applied, intes-
tinal atresia was associated with it in a frequency-
dependent manner.
Most Holstein-native cross dairy cows were kept un-
der range conditions in our region.
24
Based on herd re-
cords, no palpation per rectum had been performed when
the dam was pregnant. Rectal palpation for early preg-
nancy diagnosis is routinely performed during 5560 days
after articial insemination in dams kept under intensive
system in Iran.
25
Even in small-holder intensive system,
practitioners are not allowed to diagnose pregnancy by
rectal palpation earlier than mentioned because dairy
men assume it results in abortion. Our results indicated
palpation per rectum for early pregnancy diagnosis was
not a prerequisite for atresia coli which supports the
ndings of Constable.
22
Survival rate, dened as survival of calves allowed to
recover from anesthesia, is reported to range from 0%
17
to 4%
7
for colostomy procedure; however, we achieved a
6-month survival rate of 73% albeit with calves doing less
well than their peers. The reduced growth rate after co-
lostomy is presumably because of failure in post ruminal
fermentation and reduced absorption of hind gut fer-
mentation products. Comparatively, procedures that re-
store intestinal continuity using different type of colocolic
anastomosis resulted in survival rate ranging from of
43% to 71%.
2,8,11,26
The presumed advantage of surgical
resection and anastomosis to restore intestinal continuity
is preservation of more tissue for normal absorption and
thus lower rate of poor doer. In our region, survival of a
calf for 6 months, even in suboptimal condition, is desired
because calf near native dam is necessary for the owner of
the cow to allow continued milking for the familys well-
being. In those situations higher survival rate offered by
colostomy makes the procedure well worth its consider-
ation. When calf growth potential is desired, colocolos-
tomy would be desirable even if long-term survival rate is
perhaps lower.
Successful jejunocecostomy in 2 calves with jejunal
atresia has been reported with 1 calf dying suddenly 7
months after surgery and 1 alive, 1 year after surgery;
both calves grew well but had sporadic diarrhea.
27
The 1
calf with a jejunal anomaly that we treated, died 1 day
after jejunostomy.
Constable
11
and others
28
have reported that me-
conium impaction is rare in calves so it could be confused
with atresia coli.
11
Impaction of meconium was diag-
nosed in 1 calf based on case history, clinical ndings,
and radiography and resolved with mineral oil adminis-
tration. Although rare, meconium impaction should be
considered in differential diagnosis of colonic congenital
abnormalities in neonatal calves.
We concluded that surgical treatment of atresia ani in
calves has a good prognosis. A circular anal skin removal
technique should be considered for anal reconstruction in
atresia ani to minimize stricture formation. Seemingly,
surgical treatment of atresia coli by colostomy allows
reasonable short-term survival but generally with reduced
growth rate and is not a recommended treatment if the
calf has nancial value. Colostomy treatment of atresia
coli is acceptable if survival rate of the calf is the sole goal
to allow the dam to continue milking. Early diagnosis,
supportive treatment, and surgical correction are impor-
tant in management of atresia coli in calves.
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