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Outcome after surgical and conservative treatments of canine peritoneopericardial diaphragmatic hernia: A multi‐institutional study of 128 dogs
Abstract
Objective:
To compare demographics and disease characteristics in dogs in which peritoneopericardial diaphragmatic hernia (PPDH) had been diagnosed and report outcomes after surgical treatment (ST) or conservative treatment (CT).
Study design:
Retrospective study.
Sample population:
One hundred twenty-eight dogs (91 ST, 37 CT) in which PPDH had been diagnosed.
Methods:
Medical records were reviewed for demographics, perioperative findings, and outcomes. Follow-up was obtained via telephone interview and email correspondence with owners and referring veterinarians. Baseline variables were compared between treatment groups.
Results:
Dogs treated surgically were younger (P < .001), more likely to be sexually intact (P = .002), more likely to have clinical signs from PPDH vs an incidental diagnosis (P < .001), and more likely to have other congenital abnormalities (P = .003) compared with dogs treated conservatively. Ninety-seven percent of ST dogs were discharged from hospitals. Intraoperative and postoperative complications were reported in 22% and 41% of dogs, respectively, although most complications were classified as low grade (75% and 83%, respectively). Follow-up was available in 87 dogs, at a median of 1062 days. Hernia recurrence was not reported in any surgically treated dog. The deaths of nine dogs (five ST, four CT) could be attributed to PPDH, and long median survival times were observed in both the ST and CT groups (8.2 and 5 years, respectively).
Conclusion:
Preoperative characteristics differed between dogs treated conservatively vs surgically. Surgical treatment was associated with low operative mortality, and both ST and CT dogs had good long-term survival.
Clinical significance:
A diagnosis of PPDH can confer a good long-term prognosis for both ST and CT dogs.
... PPDH have ≥ 1 liver lobe and occasionally the gallbladder herniated into the pericardial sac. 4,9 Sometimes cystic pericardial lesions are attached to the herniated liver or pedunculated stalk of remnant biliary epithelium. 6,8 Notably, histologic features of herniated and nonherniated liver lobes from animals with PPDH are infrequently described in the veterinary literature. ...
... 6,8 Notably, histologic features of herniated and nonherniated liver lobes from animals with PPDH are infrequently described in the veterinary literature. 5,7,9,14 Congenital central diaphragmatic hernias are also rare in dogs and cats and may be associated with congenital hiatal hernias. 15 Also, affected cats may have concurrent hepatobiliary disorders such as cholangitis and cholelithiasis. ...
... [28][29][30][31][32][33] Interestingly, coexistent congenital abnormalities including umbilical hernias, body wall defects, cardiac malformations, and skeletal anomalies are also reported in dogs and cats with PPDH or other congenital diaphragmatic hernias. 1,3,4,9,12,14 However, comparatively few reports 5,7,9,14,33 include a description of concurrent histologic features consistent with DPM. The presence of a DPM increases the lifelong risk for bacterial cholangitis and cholelithiasis, may permit evolution to a phenotype of congenital hepatic fibrosis, and may coexist with polycystic kidney disease (another DPM phenotype) that may cause progressive kidney dysfunction. ...
Objective:
To characterize the association between peritoneopericardial diaphragmatic hernia (PPDH) or congenital central diaphragmatic hernia (CCDH) and ductal plate malformations (DPMs) in dogs and cats.
Animals:
18 dogs and 18 cats with PPDH or CCDH and 19 dogs and 18 cats without PPDH or CCDH.
Procedures:
Evaluation of clinical details verified PPDH or CCDH and survival times. Histologic features of nonherniated liver samples were used to categorize DPM. Immunohistochemical staining for cytokeratin-19 distinguished bile duct profiles per portal tract and for Ki-67-assessed cholangiocyte proliferation. Histologic features of herniated liver samples from PPDH or CCDH were compared with those of pathological controls (traumatic diaphragmatic hernia, n = 6; liver lobe torsion, 6; ischemic hepatopathy, 2).
Results:
DPM occurred in 13 of 18 dogs with the proliferative-like phenotype predominating and in 15 of 18 cats with evenly distributed proliferative-like and Caroli phenotypes. Congenital hepatic fibrosis DPM was noted in 3 dogs and 2 cats and renal DPM in 3 dogs and 3 cats. No signalment, clinical signs, or clinicopathologic features discriminated DPM. Kaplan Meier survival curves were similar in dogs and cats. Bile duct profiles per portal tract in dogs (median, 5.0; range, 1.4 to 100.8) and cats (6.6; 1.9 to 11.0) with congenital diaphragmatic hernias significantly exceeded those in healthy dogs (1.4; 1.2 to 1.6) and cats (2.3; 1.7 to 2.6). Animals with DPM lacked active cholangiocyte proliferation. Histologic features characterizing malformative bile duct profiles yet without biliary proliferation were preserved in herniated liver lobes in animals with DPM.
Conclusions and clinical relevance:
DPM was strongly associated with PPDH and CCDH. Because DPM can impact health, awareness of its coexistence with PPDH or CCDH should prompt biopsy of nonherniated liver tissue during surgical correction of PPDH and CCDH.
... incidental and the patients were physiologically compensated, submitting them to surgery was considered an unnecessary risk, unlike other studies in which the herniorrhaphy technique was chosen, considered to be highly effective for solving the clinical condition. 5,8,9 Some studies compared surgical and conservative treatments, 9,16 and evidence showed that animals with DPPH that do not have clinical signs at the time of diagnosis can develop clinical signs at a later time. 9 Even so, surgical treatment is considered risky, and studies in the past stated that the survival rate after diagnosis may vary between 53% and 90%. ...
... 17 However, if the animal survives the immediate postoperative period (12-24 hours), the prognosis is excellent and the possibility of recurrence is uncommon. 18 Morgan et al. 16 performed a study with 128 dogs treated surgically or conservatively, and they observed 22% of intraoperative and 47% of postoperative complication rates, with a high rate of success and low operative mortality, but they still stated that additional studies are necessary to determine which dogs in this condition would benefit from surgical versus conservative treatment. ...
Congenital diaphragmatic peritoneopericardial hernia in dogs is attributed to a failure in the development of the transverse septum and may cause clinical signs. Its diagnosis is usually made through chest radiographic examination, where it is possible to detect cardiomegaly and the presence of abdominal organs in the pericardial sac. The aim of this study was to report two cases of peritoneopericardial hernia in asymptomatic bitches. The patients presented a lack of appetite and vomiting for different reasons, which led the veterinarians to request abdominal ultrasounds, which, in both cases, were suggestive of diaphragmatic peritoneopericardial hernia. In Case 1, a Doppler echocardiogram was also performed, and in Case 2, a contrast‐enhanced chest x‐ray confirmed the diagnosis. Although surgical treatment can be used, in the reported cases it was unnecessary. Therefore, the treatment chosen was conservative, maintaining the clinical follow‐up and keeping the patient's quality of life without surgical interventions.
... Based on the histopathology results and perfusion of the herniated liver on CT, the hepatic parenchyma incarcerated in a PPDH showed chronic liver changes, although the patient had no symptoms and abnormal blood work results. In a retrospective study of dogs with PPDH, histopathologic results of the herniated liver with grossly abnormal appearance were also hepatic or portal fibrosis [11]. To our knowledge, there are no imaging studies of altered perfusion in incarcerated liver in a PPDH. ...
... Large defects in the diaphragm can result in adhesions of abdominal organs to the pericardium and incarcerate of organs in the pericardium [12]. Dogs that received surgical treatment tended to show clinical signs associated with PPDH, and the herniation of liver was confirmed in 66% of them [11]. It has also been reported that herniation of the liver is associated with a poor prognosis in fetal congenital diaphragmatic hernia in human medicine, suggesting compression of the lung by the herniated liver, and increased size of defect in the diaphragm and disturbed regulation of liver growth [13]. ...
A 1-year-old male Persian cat was presented for castration. Liver incarcerated in a peritoneopericardial diaphragmatic hernia (PPDH) was diagnosed through pre-anesthetic tests. Multiple homogeneous hyperechoic nodules in the hepatic parenchyma were identified using ultrasound. The nodules showed decreased attenuation compared with normal hepatic parenchyma, and the herniated hepatic parenchyma showed increased arterial and decreased portal enhancement on computed tomography. From the histopathology, we diagnosed hydropic degeneration with portal fibrosis and myelolipoma. This report presents diagnostic imaging features of hepatic myelolipoma incarcerated in a PPDH in a cat. When perfusion of the hepatic parenchyma is altered, surgical treatment should be considered.
... Animals with PPDH often have other concurrent congenital abnormalities such as midline defects (e.g., umbilical hernia, cleft palate, sternal abnormalities) and cardiac defects (e.g., ventricular septal defects, subaortic stenosis, pulmonic stenosis, atrial septal defect) (4)(5)(6)(7)(8). Peritoneopericardial diaphragmatic hernia is commonly seen as a congenital abnormality in several animals of the same litter (6)(7)(8)(9). ...
... There are three classifications of the pentalogy of Cantrell. In class 1, patients have all five defects, patients with class 2 have four defects, including intracardiac and ventral wall anomalies, and patients with class 3, also known as the incomplete expression, have various combinations of abnormalities including a sternal defect (4,5). To date, in veterinary medicine, this classification does not exist. ...
Objective: This study aims to describe an unusual peritoneopericardial diaphragmatic hernia (PPDH) in an 8-month-old German shepherd dog, associated with a pericardial pseudocyst and coexisting severe pericardial effusion resulting in right-sided heart failure.
Case Summary: An 8-month-old, male, intact, German shepherd dog, was referred for ascites. Echocardiography revealed a severe pericardial effusion with a cyst-like structure within the pericardium and consequently decompensated right-sided heart failure. The ascites was secondary to right-sided heart failure (cardiac tamponade). Computed tomography (CT) of the thorax and abdomen was performed and showed PPDH with severe pericardial effusion and presence of a pericardial cyst-like structure; xyphoid cleft and Y-shaped seventh sternebra; and mild thickening along the cranioventral abdominal wall consistent with scar tissue from the previous umbilical hernia surgical repair. During surgery, the PPDH was corrected, and it was revealed that the remnant of the umbilical cord passed through it, into the pericardium. The cyst-like structure was successfully resected and sent for pathology. Histopathology showed signs of a chronic suppurative inflammation, with absence of a mesothelial or endothelial wall layer, thus consistent with a pseudocyst. Based on tomographic and surgical findings, it is suspected that the pseudocyst, together with the pericardial effusion, evolved by an inflammation of the remnant of the umbilical cord during the umbilical hernia surgical repair 1 month prior to presentation. The underlying PPDH most likely favored the development of the pericardial pseudocyst. However, due to prior antibiotic therapy initiated by the private vet, an infectious origin cannot be ruled out completely.
New or Unique Information Provided: There are a few case reports describing PPDH and/or pericardial pseudocysts in veterinary patients, but the current case report is unique, since it describes PPDH associated with a pericardial pseudocyst and coexisting severe pericardial effusion resulting in cardiac tamponade. As far as the authors know, such a case has not been described in veterinary medicine before.
... Hérnia diaframática em cães refere-se à protrusão de órgãos abdominais para a cavidade torácica através de uma falha no diafragma, a musculatura responsável pela separação dessas cavidades (MORGAN et al., 2020). Esta condição pode ser classificada como congênita ou adquirida, sendo que ambas têm consequências significativas para a saúde do animal (DEVEREUX; SCHARF, 2023). ...
Neste estudo, investigou-se hérnias diafragmáticas em cães, com o intuito de entender melhor e aprimorar a abordagem dessa condição. Foram avaliados casos atendidos no Hospital Veterinário da Uniube ao longo de 17 anos. A hérnia diafragmática foi a variante mais comum de hérnia canina, afetando principalmente cães jovens e sem raça definida. Os sintomas predominantes estavam relacionados ao sistema respiratório, incluindo dispneia e abafamento de sons torácicos. Exames radiográficos e ultrassonográficos se mostraram eficazes para o diagnóstico, revelando a perda da cúpula diafragmática e a presença de órgãos abdominais no tórax, frequentemente envolvendo o fígado. Além disso, a hérnia diafragmática muitas vezes se associou a lesões graves, como fraturas e traumas cranioencefálicos e raquimedulares, complicando o tratamento e impactando o prognóstico. A taxa de mortalidade foi elevada, podendo ocorrer antes, durante ou após a cirurgia. Esse estudo fornece informações valiosas para compreender melhor a hérnia diafragmática canina e melhorar os cuidados clínicos nesses casos
The diaphragm serves as a physical barrier between the pleural and peritoneal cavities. Innervation of the diaphragm is via the phrenic nerve, which arises from the fifth to seventh cervical nerves. Herniation of abdominal contents through the diaphragm may be a result of either a congenital or a traumatic event. Respiratory and cardiac functions are altered after a traumatic diaphragmatic hernia, resulting in reduction of oxygen delivery. Diaphragmatic hernia should always be suspected for a dog or cat following trauma. Thoracic and abdominal radiography is recommended for confirming the diagnosis of a diaphragmatic hernia. Pathogenesis is attributed to a failure of normal development of the septum transversum, the embryologic structure that forms the ventral portion of the diaphragm. The principles of medical stabilization and surgical treatment are similar to those for traumatic diaphragmatic hernias.
A 7‐month‐old, male, entire Weimaraner was referred for surgical repair of a peritoneopericardial diaphragmatic hernia. Thoracic radiographs confirmed a peritoneopericardial diaphragmatic hernia and showed a vesicular emphysema pattern, suggestive of lung lobe torsion. Herniorrhaphy to repair the peritoneopericardial diaphragmatic hernia was performed, and exploratory median sternotomy revealed a torsion of the right middle lung lobe, as well as complete atelectasis of the right caudal lung lobe. Lung lobectomies were performed, and an autologous pericardial flap was used to repair the diaphragmatic defect. A second operation was required because of the suspicion of active bleeding. It was discharged after 6 days of hospitalisation. It is our hypothesis that peritoneopericardial diaphragmatic hernia contributed to the lung lobe torsion due to alterations in the spatial dimensions of the thoracic cavity. Lung lobe torsion has been previously associated with traumatic diaphragmatic herniation in dogs and cats, and has also been reported in a cat with a congenital peritoneopericardial diaphragmatic hernia and chylothorax.
Objective:
(1) To adapt and apply the Clavien-Dindo (aCD) postoperative complication grading system to dogs experiencing complications following a single orthopedic procedure. (2) To compare the reliability of the Clavien-Dindo system to the Cook complication grading system.
Study design:
Retrospective study.
Sample population:
Sixty-eight client-owned dogs.
Methods:
Scenarios derived from complications following TightRope stabilization of the stifle and shoulder were graded by four ACVS-boarded surgeons using two systems; the Cook 3-point scale and the aCD 5-point scale. Because the aCD system distinguishes complications from outcomes ("sequelae" or "failure to cure"), two data sets were created: one with (n = 76) and without (n = 67) inclusion of "sequelae" and "failure to cure" cases. Interobserver reliability was evaluated using intraclass correlation coefficient (ICC) calculations.
Results:
Seventy-six scenarios from 68 records were evaluated. The ICC of the aCD system was 0.620 consistent with moderate reliability. The reliability of the Cook system was good, with an ICC of 0.848. Exclusion of cases with "sequelae" or "failure to cure" resulted in excellent reliability of the aCD system (ICC = 0.975) and good reliability of the Cook systems (ICC = 0.857).
Conclusion:
The aCD grading system was less reliable than the Cook system when evaluating all cases but more reliable when evaluating cases of complications excluding "sequelae" and "failures to cure".
Clinical significance:
The Cook grading system is reliably good in grading postoperative complications in dogs. The aCD system can also be used to assess postoperative complications with excellent reliability but is less reliable when distinguishing complications from other postoperative outcomes.
Two peritoneopericardial hernias (PPDH) repaired laparoscopically are reported. Both PPDHs were approached with the dog in dorsal recumbency. Herniated organs (gallbladder and 2 liver lobes in Case 1 and omental fat in Case 2) were dissected and reduced. Hernias were closed in a 2-layer horizontal mattress pattern using 2-0 polyester (Case 1), and in a single-layer simple continuous pattern using 0 barbed polyglyconate (Case 2). Reduction and herniorrhaphy were achieved without conversion. Moderate to severe systemic hypotension was observed in both dogs which responded rapidly to reducing abdominal insufflation. Ten- and 7-month follow-up confirmed good clinical outcome in both dogs.
Case summary
A 7-month-old intact female Maine Coon presented with a 2-week history of vomiting. A peritoneopericardial diaphragmatic hernia (PPDH) and a mass arising from the cardia, protruding into the gastric lumen, were diagnosed using a combination of ultrasound and CT. An exploratory gastrotomy revealed a circumferential, irregular, ulcerated mass involving the submucosal layer of the cardia. This mass was excised by partial-thickness resection of the gastro-oesophageal wall. The PPDH was corrected and a gastrostomy feeding tube was placed under the same anaesthetic. Histopathologically, the most characteristic feature of this mass was a submucosal fibroplasia associated with marked ulceration and granulation tissue. No infectious or neoplastic cells were identified. The affected region of the gastric wall appeared narrowly excised. Resolution of clinical signs was achieved until the cat was lost to follow-up 12 months postoperatively.
Relevance and novel information
This is the first report of the surgical management of an oesophagogastric mass in a cat with a concurrent PPDH and no other underlying disease. A benign fibrous mass should be considered as a differential diagnosis of an oesophagogastric mass in feline patients with PPDH. While medical and surgical options are debated for the management of PPDH, symptomatic patients with a concurrent oesophagogastric mass are legitimate candidates for surgical herniorrhaphy to prevent further complications. Based on this case, prognosis can be considered good if surgical resection is complete.
Peritoneopericardial diaphragmatic hernia (PPDH) is a congenital defect allowing communication between the peritoneal cavity and the pericardial sac, through which abdominal organs may herniate into the pericardial space. The condition can be asymptomatic or symptomatic, and if symptomatic, accompanied mostly with nonspecific gastrointestinal or respiratory clinical signs. A 2‐year‐old, male, neutered mixed breed dog was referred due to fever, lethargy and decreased food intake over the last 2 weeks. Abdominal ultrasound was performed and a transposition of abdominal organs into the thoracic cavity was suspected. Further diagnostic imaging confirmed PPDH with herniation of the gall bladder and spleen into the pericardial sac. The dog underwent surgery for hernia repair. Severe pneumopericardium subsequently complicated by pericardial effusion developed postoperatively. Both complications resolved without intervention. The dog never showed signs of haemodynamic instability or cardiac tamponade.
The diaphragm is a musculotendinous plate separating the thoracic from the abdominal cavity. The lumbar part of the diaphragm is formed by the right and left crura between which the aortic hiatus is enclosing the aorta, the azygos and hemiazygos veins, and the thoracic duct. Peritoneopericardial diaphragmatic hernia (PPDH) is an uncommon form of congenital hernia in which abnormal formation or fusion of the septum transversum during embryological development leads to incomplete separation of the peritoneal and pericardial cavities. Thoracoscopic herniorrhaphy usually requires one-lung ventilation or pneumothorax with CO 2 at low-pressure capnoperitoneum. In diaphragmatic hernia capnoperitoneum insufflation entails hypertensive pneumothorax with potential for hemodynamic and cardiorespiratory complications. Postoperative care is similar to that for other laparoscopic procedures if the pleural space is not breached and pericardial evacuation was performed intraoperatively. Laparoscopic surgery is an excellent modality for the treatment of inguinal hernias involving various organs and intraperitoneal structures.
Peritoneoperikardijalna dijafragmatska hernija predstavlja urođenu komunikaciju osrčja i trbušne šupljine. Javlja se s prevalencijom od 0,02 do 0,05 %, čineći najčešću prirođenu anomaliju srca i dijafragme u pasa. U članku je opisan prikaz slučaja mužjaka shi tzua starog 12 godina zaprimljenog na Kliniku za kirurgiju, ortopediju i oftalmologiju, Veterinarskog fakulteta Sveučilišta u Zagrebu, u kojeg je dijagnosticirana peritoneoperikardijalna hernija te je učinjena herniorafija. Pacijent je s Klinike otpušten nakon pet dana poslijeoperacijske skrbi, a četiri mjeseca nakon zahvata je stabilno.
A 6-year-old intact male pug dog was referred to the Atlantic Veterinary College veterinary teaching hospital for a surgical consultation after survey radiographs taken by the referring veterinarian led to a tentative diagnosis of a peritoneal-pericardial diaphragmatic hernia. Computed tomography of the thorax and abdomen prior to surgery further characterized the lesion and aided in surgical planning. Surgical correction of the defect was achieved via primary herniorrhaphy. The patient was discharged and was reported to be doing well 7 months after surgery.
Background:
The teratogenic effects of immunomodulatory and certain antimicrobial therapies are described in small rodents and humans. While the described teratogenic effects in small rodents have been extrapolated to make conclusions about its use in the pregnant dam, teratogenic effects of prednisone and doxycycline have not yet been reported in the dog. Here we report and describe midline defects observed in a litter of golden retriever puppies exposed to mid-gestational immunosuppressive and antimicrobial therapy.
Case presentation:
Twenty-one days into gestation, the dam of a litter of eight golden retriever puppies was administered prednisone, doxycycline, and tramadol as treatment for immune-mediated polyarthritis. The individuals in the litter were subsequently diagnosed with a variety of midline defects and congenital cardiac defects. This case series describes the variety of identified defects and presents a descriptive account of complex congenital abnormalities that are likely secondary to teratogenic effects of one or more drugs administered during gestation. The available puppies, dam, and grand dam underwent thorough physical examination, complete echocardiogram, and where indicated, advanced imaging with various surgical corrections when possible. Numerous midline congenital defects and congenital heart disease were identified in the puppies evaluated. Ultimately 5 of 8 puppies born to the dam were presented for thorough evaluation. The midline defects include: gastroschisis (1), peritoneopericardial diaphragmatic hernias (4, PPDH), umbilical hernia (4), unilateral cryptorchidism (1 of 4 males), cleft palate (1), renal agenesis (1), renal abnormalities (1), sternal and vertebral abnormalities (3), remnant liver lobe (1) and malformations consistent with ductal plate malformations with congenital hepatic fibrosis (1). The congenital cardiac defects include: ventricular septal defect (4, VSD) and subaortic stenosis (4, SAS). The presence of greater than one congenital defect was noted in all 5 of the dogs evaluated. Surgical correction was necessary for PPDH in 4 puppies. Medical intervention was recommended for congenital cardiac disease in 1 puppy.
Conclusion:
This case report is the first to describe midline defects in dogs that have been exposed to immunomodulatory therapy during gestation. A causative relationship between mid-gestational immunomodulatory exposure and midline defects cannot be proven, however, this case supports a clear association and provides case-based evidence to support its avoidance when possible.
BACKGROUND:
Standardized reporting of intraoperative adverse events is important to enhance transparency. To the best of our knowledge, there is no validated definition and classification of intraoperative complications.
METHODS:
We conducted a two-round Delphi study to develop a definition and classification of intraoperative complications. Experts were contacted by email and sent a link to the online questionnaire. In a pilot study, two independent raters applied the definition and classification in a sample of 60 surgical interventions of low, intermediate, and high complexity and evaluated practicability. Interrater agreement of the classification was determined (raw categorical agreement, weighted kappa, and intraclass correlation).
RESULTS:
In the Delphi study, 40 of 52 experts (77 % return rate) from 14 countries took part in each round. The Delphi study resulted in a comprehensive definition of intraoperative complications as any deviation from the ideal intraoperative course occurring between skin incision and skin closure. The classification foresees four grades depending on the need for treatment (no need, grade I; need for treatment, grade II) and the severity of the complication (life-threatening/permanent disability, grade III; death, grade IV). The pilot study showed good practicability (6 on a 7-point scale) and a high raw agreement of 87 %, a weighted kappa of 0.83 [95 % confidence interval (CI) 0.73-0.94] and an intraclass correlation coefficient of 0.83 (95 % CI 0.73-0.90).
CONCLUSIONS:
While the Delphi process enabled to develop definitions and classification of intraoperative complications by severity, further research including a multicentre international full-scale validation needs to be conducted with the ultimate goal to contribute to standardized reporting in surgical practice and research.
Background. Morbidity is a cornerstone assessing surgical treatment; nevertheless surgeons have not reached extensive consensus on this problem. Methods and Findings. Clavien, Dindo, and Strasberg with coauthors (1992, 2004, 2009, and 2010) made significant efforts to the standardization of surgical morbidity (Clavien-Dindo-Strasberg classification, last revision, the Accordion classification). However, this classification includes only postoperative complications and has two principal shortcomings: disregard of intraoperative events and confusing terminology. Postoperative events have a major impact on patient well-being. However, intraoperative events should also be recorded and reported even if they do not evidently affect the patient's postoperative well-being. The term surgical complication applied in the Clavien-Dindo-Strasberg classification may be regarded as an incident resulting in a complication caused by technical failure of surgery, in contrast to the so-called medical complications. Therefore, the term surgical complication contributes to misinterpretation of perioperative morbidity. The term perioperative adverse events comprising both intraoperative unfavourable incidents and postoperative complications could be regarded as better alternative. In 2005, Satava suggested a simple grading to evaluate intraoperative surgical errors. Based on that approach, we have elaborated a 3-grade classification of intraoperative incidents so that it can be used to grade intraoperative events of any type of surgery. Refinements have been made to the Accordion classification of postoperative complications. Interpretation. The proposed systematization of perioperative adverse events utilizing the combined application of two appraisal tools, that is, the elaborated classification of intraoperative incidents on the basis of the Satava approach to surgical error evaluation together with the modified Accordion classification of postoperative complication, appears to be an effective tool for comprehensive assessment of surgical outcomes. This concept was validated in regard to various surgical procedures. Broad implementation of this approach will promote the development of surgical science and practice.
Objectives
To investigate whether dogs undergoing laparoscopic ovariectomy might have a lower overall and wound‐healing complication rate than those undergoing an open surgical approach.
Materials and Methods
A retrospective study of dogs that underwent laparascopic or open surgical ovariectomy between January 1, 2013 and January 1, 2018 by the same team of similarly experienced surgeons using standard practice anaesthetic, theatre and perioperative protocols. General complications were described and graded using the Clavien‐Dindo system. Complication rates were compared between the two groups of dogs. Wound complications were further subdivided using the U.S. Centers for Disease Control guidelines.
Results
According to the Clavien‐Dindo system, 46 of 106 (44%) dogs undergoing open ovariectomy developed a complication. Thirty dogs (28.3%) had wound healing complications, the majority of which were minor and self‐limiting. Superficial site infections occurred in 50 (5%) cases and deep surgical site infections in one dog (1%). Incisional herniation occurred in four (4%) cases. Thirty‐one (20%) of 154 dogs undergoing laparoscopic ovariectomy developed a complication. Seventeen (11%) developed wound healing complications, most of which were minor; five (3%) developed superficial surgical site infections and none had deep surgical site infections. Incisional herniation occurred in none of the laparoscopic cases.
Clinical Significance
The rates of overall and wound healing complications were lower for the laparascopic group than the open surgical group in this non‐randomised study. Laparoscopy might be considered preferable for ovariectomy in dogs but confirmation requires a randomised trial.
The subject
A 5-month-old 15 Kg Dogue de Bordeaux was diagnosed with peritoneopericardial diaphragmatic hernia (PPDH). Four of the five other littermate puppies presented to another practice were diagnosed with the same condition. Only one puppy was unaffected.
Topicality and strong points
For all affected dogs, medical history was unremarkable except for poor growth. Diagnosis was established by thoracic radiography in all 5 dogs. The dog managed at the authors’ institution underwent surgical treatment for management of PPDH with the diaphragmatic defect closed using a transverse abdominal muscle flap. Long-term telephone follow-up performed one year and half after surgery was considered excellent in this dog.
Perspectives and projects
This report may support the suspicion of a presumed inherited condition or a familial predisposition in this breed although a teratogenic effect during pregnancy could not be excluded. Because some animals with PPDH may be asymptomatic their entire lives, a familial screening is recommended when one dog of the litter is affected with this condition.
A 4 mo old spayed female golden retriever was presented with a peritoneopericardial diaphragmatic hernia (PPDH) that was diagnosed during neutering. Echocardiography revealed a fluid-filled structure and parts of the liver in the pericardial cavity. Computed tomography confirmed the existence of the PPDH and the herniation of the right medial liver lobe and the gallbladder. Cystic masses were observed in the pericardial and the peritoneal cavities, possibly communicating through the PPDH. A median laparotomy revealed a single lobulated cystic lesion extending into both the pericardial and peritoneal cavities through the PPDH. Because of the nonviable aspect of some parts of the liver parenchyma, the gallbladder was dissected from the fossa, and the central division of the liver was resected. A cholecystopexy was performed on the diaphragm to limit gallbladder mobility. The PPDH was closed in the standard fashion. Histopathology of the cystic structure was compatible with a pericardial pseudocyst. Two months postoperatively, the dog was healthy, and the results of blood biochemistry and abdominal ultrasonography were normal. A pericardial pseudocyst can be associated with a PPDH in young dogs. Moreover, cholecystopexy appears to be a safe and effective method of limiting gallbladder mobility after resection of the central hepatic division.
Objective:
Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time.
Patients and methods:
A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide.
Results:
The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons.
Conclusions:
The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
OBJECTIVES
To report the complication rate for bilateral closed anal sacculectomy in the dog and to evaluate potential risk factors for the development of postoperative complications. To identify breed groups at risk of requiring anal sacculectomy.METHODSA retrospective review of medical records of dogs undergoing bilateral closed anal sacculectomy between 2003 and 2013.RESULTSSixty-two dogs were included in the study of which 32·3% developed mild and self-limiting complications including 14·5% dogs that experienced postoperative defaecatory complications. No dog developed permanent faecal incontinence. Dogs less than 15 kg bodyweight were more likely to develop postoperative complications. Dogs that used gel to distend the anal sac were more likely to have postoperative complications than those that did not. Previous abscess formation, recurrent disease and pretreatment with antibiotics had no significant effect on postoperative complication rates. Cavalier King Charles spaniels and Labrador-type dogs were over-represented within this study population.CLINICAL SIGNIFICANCEAnal sacculectomy is a safe procedure with a relatively high rate of short-term but self-limiting, minor, postoperative complications. Smaller (<15 kg) dogs are more likely to experience postoperative complications but the risk of permanent faecal incontinence is low.
A systematic description of the history, clinical and radiographic signs, and clinical sequelae in 13 dogs and four cats with congenital peritoneopericardial diaphragmatic hernia (CPDH) seen over ten years is presented. The predominant signs were gastrointestinal and respiratory. The animals were 8 weeks to 10 years old. Eight of the 13 dogs were male; the four cats were female. Weimaraners were 30.8 percent of the affected dogs, but only 1.1 percent of the hospital population during the ten years reviewed. There were concurrent umbilical hernias in four dogs, congenital heart disease in two dogs, and sternal deformities in six dogs and one cat. Twelge of the 13 dogs and two of the four cats had survey radiographs. Superimposed diaphragmatic and caudal heart borders were seen in nine of the 12 dogs and both cats. Abnormal soft-tissue gas or double soft-tissue densities in the pericardial sac were seen in 11 of the 12 dogs and the two cats. Upper gastrointestinal studies, pneumoperitoneography, thoracic tomography, and right ventricular angiography were special studies used to evaluate CPDH. Surgical correction was successful in nine of 11 dogs; signs remained in two dogs. The longest postoperative survival was 6.5 years. A 14-week-old English Setter without surgical correction of its CPDH or pulmonic stenosis was free of clinical signs of either disease for 2.5 years. Twenty-five reports of CPDH from 1960 to 1979 are reviewed.
Objective:
To determine clinical findings and outcomes for cats and dogs with peritoneopericardial diaphragmatic hernia (PPDH) treated surgically or nonsurgically.
Design:
Retrospective case series.
Animals:
28 dogs and 30 cats.
Procedures:
Medical records for cats and dogs evaluated at 1 of 2 veterinary teaching hospitals were reviewed, and data regarding clinical signs, diagnostic and surgical findings, and outcome were evaluated.
Results:
Prevalence of PPDH in the 2 hospitals during the study period was 0.025% (0.062% and 0.015% for cats and dogs, respectively); PPDH was an incidental finding for 13 (46.4%) dogs and 15 (50.0%) cats. Other congenital abnormalities were identified in 16 (571%) dogs and 7 (23.3%) cats (most commonly umbilical hernias, abdominal wall hernias cranial to the umbilicus, or sternal anomalies). Thirty-four (58.6%) animals underwent surgical repair of PPDH; 27 (79.4%) of these animals had a primary diagnosis of PPDH. Detection of clinical signs of PPDH (primary diagnosis) and intestines in the pericardial sac were significantly associated with surgical treatment. Short-term mortality rate for surgically treated animals was 8.8% (3/34). Clinical signs associated with PPDH resolved in 29 (85.3%) of surgically treated animals. No significant differences were detected between dogs and cats or between surgically and nonsurgically treated animals regarding long-term survival rate.
Conclusions and clinical relevance:
Results of this study indicated animals with clinical signs of PPDH were more likely to undergo surgery than were animals without such signs. Herniorrhaphy was typically effective for resolution of clinical signs. Long-term survival rates were similar regardless of treatment method. Surgical or nonsurgical treatment of PPDH may be appropriate for animals with or without clinical signs, respectively.
The records of 31 cats and eight dogs undergoing surgical correction of peritoneopericardial diaphragmatic hernia (PPDH) from 2000 through 2007 were reviewed. Weimaraners and long-haired cats of varying breeds, particularly Maine Coon cats, appear to be at higher risk of PPDH. Presenting complaints were most commonly related to the respiratory and gastrointestinal tracts in both dogs and cats, although respiratory signs were more prevalent in cats, and gastrointestinal signs were more common in dogs. The most common herniated organs were liver, gallbladder, and small intestine. Mortality associated with surgical repair of PPDH in cats and dogs was low in the first 2 weeks postoperatively, and prognosis for return to normal function was excellent. Peri-and postoperative complications were typically minor and self-limiting.
The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients', nurses', and doctors' perception.
Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication.
We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test).
This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as "minor or major" should be removed from the surgical literature.
Four Collie littermates had multiple cardiac and diaphragmatic anomalies. Ventricular septal defect was found in 3, pulmonic stenosis in 2, atrial septal defect in 1, mitral regurgitaion in 1, and pericardial diaphragmatic hernia in 3. Five additional littermates died within 72 hours of birth but were not necropsied. On the basis of available evidence, it was believed that the defects were congenital but not hereditary.
Lack of uniform reporting of negative outcomes makes interpretation of surgical literature difficult. We attempt to define and classify negative outcomes by differentiating complications, sequelae, and failures. Complications and sequelae result from procedures, adding new problems to the underlying disease. However, complications are unexpected events not intrinsic to the procedure, whereas sequelae are inherent to the procedure. Failures are events in which the purpose of the procedure is not fulfilled. We propose a classification of complications based on four grades: Grade I complications are alterations from the ideal postoperative course, non-life-threatening, and with no lasting disability. Complications of this grade necessitate only bedside procedures and do not significantly extend hospital stay. Grade II complications are potentially life-threatening but without residual disability. Within grade II complications a subdivision is made according to the requirement for invasive procedures. Grade III complications are those with residual disability, including organ resection or persistence of life-threatening conditions. Finally, grade IV complications are deaths as a result of complications. To illustrate the relevance of the classification, we reviewed 650 cases of elective cholecystectomy. Risk factors for development of complications were determined, and the classification was also used to analyze the value of a modified APACHE II as a preoperative prognostic score. Both supported the relevance of the proposed classification. The advantages of such a classification are (1) increased uniformity in reporting results, (2) the ability to compare results of two distinct time periods in a single center, (3) the ability to compare results of surgery between different centers, (4) the ability to compare results of surgical versus nonsurgical measures, (5) the ability to perform adequate metaanalysis, (6) the ability to identify objective preoperative risk factors, and (7) the ability to establish preoperative prognostic scores.
Five littermate Cocker Spaniels were born with concomitant pericardial, diaphragmatic, caudal sternal, and cranioventral abdominal wall defects. Three of the 5 pups had ventricular septal defects. A sixth pup with a cranioventral abdominal wall defect died 4 days after birth. No history of teratogen exposure was reported, and none of the pups from previous litters of the dam was affected. Each pup underwent successful surgical correction (without median sternotomy) of the diaphragmatic and cranial abdominal wall defects when they were 10 to 12 weeks old. The ventricular septal defects were not corrected. In 2 of 3 pups with ventricular septal defects, thoracic radiography 6 months after surgery revealed moderate generalized cardiomegaly. All pups were healthy one year after surgery.
The clinical diagnosis and successful surgical correction of a congenital peritoneo‐pericardial diaphragmatic hernia in a 4‐week‐old Dachshund puppy is described. The surgical approach used was a ventral transverse thoracotomy with transverse sectioning of the sternum.
Résumé. Bases du diagnostic et description d'une intervention correctrice pour une hernie diaphragmatique péritonéo‐péricardique congénitale chez un chiot basset de 4 semaines. La voie d'abord était une thoracotomie ventrale transversale avec section transversale du sternum.
Zusammenfassung. Die klinische Diagnose und die erfolgreiche chirurgische Korrektur eines angeborenen peritoneo‐pericardialen Zwerchfellbruchs bei einem 4 Wochen alten Dackel werden beschrieben. Chirurgisch wurde der Weg einer ventralen transversalen Thoractomie mit transversaler Sektion des Sternums eingeschlagen.
To document the incidence and outcome of complications in the department of surgery.
Retrospective study.
District hospital, The Netherlands.
7455 patients operated on between 1 January 1993 and 31 December 1995.
Documentation and outcome of complications (defined as "every unwanted development in the illness of the patient or in the treatment of the patient's illness that occurs in the clinic").
1078 complications were recorded after 8130 operations (13%), 337 (33%) of which had no long term effects. 175/1078 (16%) required reoperation, and in 134 of these (77%) an error in management or surgical technique was responsible for the complication. 6 patients were irreversibly harmed and of the 141 patients who died, 11 had evidence of some sort of error.
Audit of complications is necessary to improve practice in a surgical department, and weekly morbidity and mortality meetings are a good opportunity for learning about them.
A two-year-old cat with episodic dyspnea was diagnosed with an intrapericardial cyst via two-dimensional echocardiography. The cyst directly compressed the right ventricle, resulting in cardiac tamponade. Centesis of the cyst was performed to reduce tamponade prior to surgery. At surgery, a large, fluid-filled cystic structure was found within the pericardium. The cystic structure was continuous with a pedicle of liver that passed through a small peritoneopericardial diaphragmatic hernia. Surgical resolution was achieved by median sternotomy, midline pericardotomy, resection of the cyst, and diaphragmatic herniorrhaphy.
Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time.
A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide.
The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons.
The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
To determine long-term outcome of cats treated conservatively or surgically for peritoneopericardial diaphragmatic hernia (PPDH).
Retrospective study.
67 cats with PPDH.
Medical records of cats with a diagnosis of PPDH made from 1987 through 2002 were reviewed. Information regarding long-term outcome was obtained from owners.
Prevalences of PPDH in domestic longhair and Himalayan cats were significantly greater and prevalence of PPDH in domestic shorthair cats was significantly lower than prevalence of PPDH in the hospital cat population over the 15-year study period. Historical problems most commonly related to the respiratory and gastrointestinal tracts. Peritoneopericardial diaphragmatic hernia was the primary diagnosis in 40 cats and an incidental finding in 27 cats. One cat died prior to arrival at the Veterinary Medical Teaching Hospital. Thirty-seven of 66 cats were treated surgically, and 29 were treated conservatively. The postoperative mortality rate was 14%. Postoperative complications developed in 29 of 37 cats, the most common of which was hyperthermia. Two of 22 conservatively treated cats had progression of clinical signs necessitating surgical intervention or resulting in death. Owner satisfaction with treatment choice and long-term outcome was rated as very satisfied by 88% of owners of surgically treated cats and 68% of owners of conservatively treated cats.
Cats with overt clinical signs attributable to PPDH are good candidates for surgical herniorrhaphy. Postoperative complications may develop but are generally minor and self-limiting. Long-term outcome of cats treated conservatively or surgically was rated as very good by most owners.
Congenital cranioventral abdominal wall, caudal sternal, diaphragmatic, pericardial and intracardiac defects in cocker spaniel littermates
- J R Bellah
- D L Whitton
- G W Ellison
- L Phillips
Bellah JR, Whitton DL, Ellison GW, Phillips L. Congenital
cranioventral abdominal wall, caudal sternal, diaphragmatic,
pericardial and intracardiac defects in cocker spaniel littermates. J Am Vet Med Assoc. 1989;194:1741-1746.
Congenital peritoneopericardial diaphragmatic hernia in a dog
- G R Bolton
- S Ettinger
- J C Rousch