Colic Surgery Comes Down To Finances

We told Dr. Bill Hay that our readers tend to be highly experienced overall and pretty much know how to recognize colic (although we will have a future story discussing different types of colic). We asked him to tell us what he thinks most horseowners don’t realize and need to know in advance of making a decision about colic surgery, given his background as a surgeon at a referral hospital.

Is colic surgery the same for every type of colic’

When we talk about colic, we’re really saying, ”abdominal pain.” There are numerous causes of colic other than intestinal problems, but as a general rule, the horses we refer to as ”colics” have pain from the gastrointestinal system. One of the most important things for the owner to realize up front is that colic of the small intestine is a different problem and has a different prognosis than colic of the large intestine. Different parts of the intestine that have obstructions or twists have different chances of success and different time frames. Your veterinarian has to determine where the pain is coming from and how best to correct the situation. The layperson is only going to be able to recognize that the horse has abdominal pain. But that’s a critical part. The most important thing an owner can do is to know the horse and know when something’s not right.

Let’s say that an owner senses her horse isn’t quite right, but there are no major colic signs. Do your recommend that the owner give the horse Banamine and see what happens’

The owner who knows her horse well and recognizes a change in behavior — maybe something as simple as the horse not cleaning up his grain as he normally does — should pay close attention to see if there’s anything else that’s not right. Take his temperature, pulse and respiration. The horse’s behavior change may be unrelated to colic, such as having a virus starting and a mild fever. But from that point on, even a mild colic sign, such as the horse being quieter than usual or mild pawing or looking at his sides, is time to call your veterinarian and have an exam done. The biggest thing to know is that the colics that are seen by a veterinarian early on have the best outcome.

I prefer that my farm clients don’t give Banamine before I see the horse. That way I can examine the horse before he is responding to the medication and can best evaluate what’s really going on with him. I do ask the client to take the horse off hay right away but to make sure that the horse has access to water.

How often do you think people fail to recognize colic, thinking that a horse has ulcers’

We know there’s a high prevalence of ulcers in our sport horses, and we do often see mild colic signs with ulcers. Severe signs, like pawing, kicking at the belly and wanting to go down are probably not just ulcers. There’s also a high concern that low-grade pain from ulcers might predispose to more severe colic in the intestine. Your veterinarian can make an assessment as to whether the pain is from ulcers or something more involved. Ulcers can be easily diagnosed by gastroscopy.

After treating so many colic cases, you probably get an early hunch about which horses are going to need surgery. What do you look for’

It’s important to remember that over 90 percent of the time, horses get better on the farm. Only a small percentage of horses with colic need intervention at a referral center. But both situations look the same at the start. The hallmark sign that this isn’t the run-of-the-mill colic that’s going to get better on the farm is the horse with abdominal pain that persists beyond the veterinarian’s initial treatment, or the horse that responds initially to the treatment but then gets painful again. That’s when it’s decision time for the owner.

Talk to us about what decisions the owner is faced with.

The decision point for the owner happens if the horse is treated on the farm and either the veterinarian determines something’s not right or the horse is still painful or painful again. If a referral is a financial option, then that’s the time to do it. It’s strictly a financial decision for the owner. Not every horse has the benefit of receiving the financial investment involved with referral for treatment, but if it is an option for the owner and something they would do if needed, do it early.

The owner has to ask himself, ”What am I going to invest in additional therapy for this horse’” That doesn’t automatically mean surgery. You might get to the referral hospital and the doctor might say, ”Your horse is not painful, and he’s passed three piles of manure on the trailer ride. We’re just going to watch him.” Or the center might evaluate him and think that high-volume IV fluids might fix the problem. Then there’s a small percentage where the veterinarian is going to say, ”This is surgical right now, and we have to run.”

That sounds pretty immediate. What about the wait-and-see theory’

In human medicine, they refer to the ”critical hour” or the ”golden hour.” Treatment within an hour from when a trauma occurs often determines the outcome — life or death. Colic is a trauma to the horse. Their major shock organ is their intestine. If they have a severe colic, it’s a critical condition that can lead to all kinds of complications quickly. To say that we would intervene with every horse within an hour is unrealistic, but we have looked at large numbers of horses with severe colic, and we see a huge difference in outcome with horses that are evaluated and treated at a referral center within six hours.

That’s a much shorter time frame than most people usually think about. As horse people, we’re used to thinking about colic as something that we’re going to deal with over the next 12 hours or over the next day. What we’ve found from the horses who do need surgery — and I want to keep stressing that over 90% of the horses that colic are seen on the farm and do not need to go to a referral center — for the five to 10 percent of severe colics, referral-center evaluation and intervention in the first six hours dramatically increases the chance of survival. Unfortunately, the colics that have been going on for 12 and 24 hours have a much lower survival rate.

Given early intervention with large-colon conditions, the horse has a good chance of going back to doing what he was doing before. Large-colon problems where the bowel has not lost its blood supply have an 80-90% chance of the horse returning to his previous level of activity after surgery.

Contrast this to the small-intestine twist that progressed to the point where the bowel was dead because it didn’t get intervened early enough, and you’ve had to remove 20 feet of small bowel, your chance of the horse going home drops to the 50-60% category. It’s important t o note that the horse that has been this critical also has a higher complication rate. That could be a need for additional surgery or a chronic colic that requires special diet.

That’s why I really stress the time. We’ve had horses with a specific condition that leads to the blood supply to the small bowel being cut off, and we’ve had them on the table within three hours of starting colic. The horses recovered beautifully and went back to full work. Take the same condition in a horse that got a couple of doses of Banamine before it came in. They didn’t realize the severity of the problem initially, and it went to surgery more than six hours after onset of colic, ending up with 20 feet of bowel removed. Not only is the bill a lot higher, there’s a lower chance of success.

Of course, we know that finances play a part, but we’re surprised to hear you say that surgery — if it’s needed — is a financial decision.

I stress to my clients that they should have a plan of what they will do with a severe colic before it happens. If you want to provide more treatment than you can afford, look into insurance. Major medical insurance is one of the best bargains in the insurance industry. General estimates, when a horse is referred to a center for high-volume fluid therapy and intensive care medical therapy, range between $1,500 and $3,000 for full intensive management of a medical colic. That includes IV-therapy, 24-hour monitoring, nursing care, and bloodwork.

If surgery is needed, there’s a large range depending on the facility and the part of the country, but ballpark costs for anesthesia, surgery and the expected five to seven days of aftercare runs $5,000 to $8,000, depending on the severity and barring complications.

If a horse has a large-bowel condition, it’s usually much less expensive than a small intestinal problem where bowel has to be removed. I think it would help people to realize that early intervention in a lot of these large-bowel conditions can prevent having to go to surgery. If you have colon displacement, which is a common cause of colic from the colon, where the colon is displaced, gassed up, and half twisted but not a full twist, early fluid therapy can resolve a lot of those without surgery. I’m convinced that those where fluid and therapy is delayed have a higher chance of progressing to the point where they will need surgery. So I look at medical therapy as a way to prevent surgery, but if surgery is needed, you’re there and have a much higher chance of success. That goes back to the critical hour.

An owner considering surgery may wonder if his horse is a good surgical risk.

Any healthy horse has a good chance of coming through surgery these days. We’ve done colic surgery on 30-year-old horses and have had them recovery beautifully, though there’s no doubt that horses 20 years and younger are more likely to survive some complications. They are in general hardier. With advances in anesthesia and the monitoring of horses under anesthesia, there’s no reason that a healthy horse in his 20s can’t survive the risk and stress of surgery if it’s performed early, before he’s very sick. More importantly, the owner has to determine whether they want to invest in colic surgery for their 25-year old horse. That’s an owner decision, not a veterinarian decision.

I can tell you the story of a 30-year-old Quarter Horse who had a severe colic that didn’t respond to medical therapy on the farm and was referred to the hospital. The owners wanted to do everything they could. The horse went to surgery and recovered, and lived at least four more years.

As a surgeon, I never talk a client into spending money on surgery that they don’t want to spend, and I try to never make anyone feel bad if they don’t choose to have surgery. We are here to provide a service, but if it doesn’t make financial sense for the horse to have surgery but it makes sense to have fluids, we try hard that way. If it doesn’t work, we put him down, rather than having him suffer.

It’s important to know that, early in the colic, it’s a financial decision. I don’t believe in the thought process that ”I don’t want to put him through it.” Don’t limit your treatment of colic because you don’t want to put the horse through the stress. If you financially want to do everything possible, intervene early, get medical treatment early, and if necessary, go to surgery early. If on the surgery table, the surgeon determines that there’s a poor prognosis, you can always make a humane decision then.

What do you find is the biggest ”A-ha!” when you’re talking with people about colic surgery’

The need to move fast surprises people. There’s a large left-over-from-the-past idea that you only do colic surgery when nothing else is working and the horse is about to die. That dates back to the years when not many horses lived through colic. In the ’70s, the survival rate from colic surgery was low. But with advances in anesthesia and surgical techniques, and with early recognition, the outcomes are so much better.

A lot of people are surprised at the level of intensive care that can be provided in a referral center, for instance, that we have ventilators that breathe for horses while they’re asleep or that we can support horses with intravenous nutrition.

When people call friends to ask their advice, friends often say, ”It’s just not worth it.” But they’re not looking at current facts.

The No. 1 thing I tell owners is that they should have a plan before colic happens, and tell your veterinarian what you’d want done. If you happen to be on a cruise and your farm sitter finds your favorite horse down and rolling at 6 a.m. when she comes to feed — you have no time. If it takes them three hours to find you and decide what you want to do, it may be too late. A lot of veterinarians maintain a file on clients that says what they want done if the client can’t be reached.

I also remind people that not all colics can be prevented, but many can. We rarely see colic surgery due to parasite problems any more, for instance, and that’s a credit to improvements in deworming and management. Good care and early intervention when there’s a problem have saved or at least improved the lives of countless horses over the years.

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