Long-term outcomes of gastric bypass surgery in two Lusitano foals: Contemporary evidence for surgical decision-making. Short running title: Gastric bypass in foals: outcomes.

Long-term outcomes of gastric bypass surgery in two Lusitano foals: Contemporary evidence for surgical decision-making. Short running title: Gastric bypass in foals: outcomes. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 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Authors : Pablo Fernández Hernández 0000-0001-5445-1630 [email protected] , Marta Valero-González , Fernando Bulnes 0009-0001-3837-6324 , Noelia Venegas Chávez , Beatriz Fuentes Romero , Manuel Iglesias García , Joaquín Jiménez Fragoso 0000-0002-7127-6763 , Maria Martin-Cuervo , and Luis Ezquerra Calvo Authors Info & Affiliations https://doi.org/10.22541/au.176574269.94683198/v1 260 views 225 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Gastric outflow obstruction (GFO) occasionally requires surgical intervention in foals when medical management fails. Current literature lacks consensus on several surgical decisions, with most comprehensive reports dating back over a decade. Critical aspects—including jejunal loop orientation and necessity of jejunojejunostomy—remain debated among surgeons. Long-term data regarding complications, growth, and athletic performance are scarce. This case series documents the long-term outcomes of two Lusitano dressage foals that underwent bypass surgery for GFO, providing contemporary outcome data for specific surgical decisions where evidence remains limited. Two Lusitano foals underwent bypass procedures for GFO. Case 1: A 15-day-old orphan foal with pyloric stenosis underwent side-to-side gastrojejunostomy without jejunojejunostomy, with jejunal loop oriented left-to-right. Six years post-operatively, the horse performs dressage at a competitive level with normal growth and conformation. Case 2: A 12-hour-old foal underwent gastroduodenostomy; nearly three years later, it continues without complications. This series contributes recent outcome data for specific surgical decisions in bypass procedures. Both foals achieved favourable results. Left-to-right orientation gastrojejunostomy and without jejunojejunostomy worked perfectly. Importantly, extended follow-up documents the absence of long-term complications, normal growth, and athletic performance—critically needed information for surgical decision-making and owner communication regarding these uncommon, costly procedures. Title: Long-term outcomes of gastric bypass surgery in two Lusitano foals: Contemporary evidence for surgical decision-making. Short running title: Gastric bypass in foals: outcomes. Pablo Fernández Hernández 1,2*, Marta Valero González 1,3 , Fernando Bulnes Jiménez 1 , Noelia Venegas Chávez 1,3 , Beatriz Fuentes Romero 4 , Manuel Iglesias García 4 , Joaquín Jiménez Fragoso 3 , María Martín Cuervo 3 and Luis Javier Ezquerra Calvo 3 1 Veterinary Teaching Hospital, Universidad de Extremadura., Cáceres, 10003, Spain, 2 Universidad de Extremadura, Animal Medicine Department, MINVET Group., Cáceres, 10003, Spain. 3 Animal Medicine Department, MECIAN Group. Universidad de Extremadura., Cáceres, 1003, Spain. 4 Veterinary Teaching Hospital. Department of Veterinary Science. School of Biomedical and Health Sciences. Universidad Europea de Madrid., Villaviciosa de Odon, Madrid, 28670, Spain. Corresponding author + Pablo Fernández Hernández. DVM. PhD. ECVS-LA Resident. Veterinary Teaching Hospital, Universidad de Extremadura., Cáceres, Spain and Universidad de Extremadura, Animal Medicine Department, MINVET Group., Cáceres, Spain. Facultad de Veterinaria, Campus Universitario, Av. de la Universidad, s/n, 10003 Cáceres, España. E-mail: [email protected] , ORCID: https://orcid.org/0000-0001-5445-1630 Summary. Gastric outflow obstruction (GFO) occasionally requires surgical intervention in foals when medical management fails. Current literature lacks consensus on several surgical decisions, with most comprehensive reports dating back over a decade. Critical aspects—including jejunal loop orientation and necessity of jejunojejunostomy—remain debated among surgeons. Long-term data regarding complications, growth, and athletic performance are scarce. This case series documents the long-term outcomes of two Lusitano dressage foals that underwent bypass surgery for GFO, providing contemporary outcome data for specific surgical decisions where evidence remains limited. Two Lusitano foals underwent bypass procedures for GFO. Case 1: A 15-day-old orphan foal with pyloric stenosis underwent side-to-side gastrojejunostomy without jejunojejunostomy, with jejunal loop oriented left-to-right. Six years post-operatively, the horse performs dressage at a competitive level with normal growth and conformation. Case 2: A 12-hour-old foal underwent gastroduodenostomy; nearly three years later, it continues without complications. This series contributes recent outcome data for specific surgical decisions in bypass procedures. Both foals achieved favourable results. Left-to-right orientation gastrojejunostomy and without jejunojejunostomy worked perfectly. Importantly, extended follow-up documents the absence of long-term complications, normal growth, and athletic performance—critically needed information for surgical decision-making and owner communication regarding these uncommon, costly procedures. Keywords : Horse, Sport Foal, Gastric outflow obstruction, Bypass procedure, Outcome. Introduction Gastric outflow obstruction (GFO) is a clinically relevant complication of gastroduodenal ulcer disease (GDUD) in suckling foals. GDUD-associated inflammation and scarring can lead to pyloric and/or duodenal stenosis, resulting in impaired gastric emptying (Coleman et al. 2009, Sánchez 2018). Medical management constitutes the first line of treatment for GFO; however, if medical treatment does not reverse clinical signs, surgical intervention is warranted. Foals with pyloric stenosis may develop serious developmental complications such as aspiration pneumonia, peritonitis, adhesion, and sudden death (Camacho-Luna et al. 2018, Vokes et al. 2023, Sykes 2024). The specific surgical procedure employed depends on the location of the obstruction: gastroduodenostomy or gastrojejunostomy (Sánchez 2018). Variations of these techniques have been described to reduce the risk of complications, including gastrojejunostomy combined with jejunojejunostomy and/or additional duodenojejunostomy (Orsini and Donawick 1986, Coleman et al. 2009). Currently, literature lacks consensus among authors; hence, critical surgical decisions—including jejunal loop orientation and necessity of jejunojejunostomy—remain debated (Zedler et al. 2009). Owing to the lack of high-quality evidence, some authors have suggested that, until more cases are documented, the decision regarding which surgical technique to employ may be best left to the surgeon’s discretion (Brabon et al. 2023). Current literature dates back over a decade (Zedler et al. 2009, Coleman et al. 2009), long-term outcomes are generally considered fair to guarded, and most studies focus on survival and, in racehorses, number of races and earnings, which may not be applicable in other disciplines (Zedler et al. 2009, Coleman et al. 2009, Blikslager and Wilson 2018). Importantly, long-term data regarding complications, growth, and athletic performance in sport horses are scarce, yet essential for owner counselling about these costly and infrequent procedures. Additionally, concerns persist regarding post-surgical development and recurrent gastrointestinal issues (Coleman et al. 2009). This case series documents the long-term outcomes of two Lusitano dressage foals that underwent bypass surgery for GFO, providing contemporary outcome data for specific surgical decisions where evidence remains limited, with focus on development, complications, and athletic performance over extended follow-up periods. Case History Case 1. An orphan male-Lusitano foal was admitted a few hours after birth, presenting clinical signs consistent with neonatal encephalopathy and sepsis. Following fifteen days of favorable clinical progress after medical treatment, the foal developed anorexia, bruxism, flow of milk from the nose, and ptyalism. Gastroscopy revealed the presence of diffuse glandular and non-glandular gastric ulcers and a constricted pylorus. Contrast radiography, realized via nasogastric tube with barium sulfate (8 ml/kg, 30% w/v), indicated delayed gastric emptying attributed to pyloric stenosis. Besides, in the radiological exam, a focal alveolar pattern, compatible with aspiration pneumonia, was observed (Figure 1). Subsequently, a medical treatment was initiated, which included the administration of antibiotics (sodium penicillin at 22000 UI/kg, IV, q 6 h, and amikacin at 25 mg/kg, IV, q 24 h), histamine type-2 receptor antagonists (ranitidine at 1.4 mg/kg IV, q 8 h), prokinetics (metoclopramide at 0.1 mg/kg, IV, q 6 h), anti-ulcer medications (omeprazole at 0.8mg/kg, IV, q 24h), lactase (150 U/kg, PO, q 2 h), analgesia (butorphanol at 0.05 mg/kg IV, q 4 h) and glucosaline fluid therapy IV (Ringer Lactate, 5-2,5 % glucose). This medical therapy was combined (until the decision of surgery) with 200mL of artificial milk q 2h, given that the medical treatment did not result in the reversal of clinical signs within four days, an exploratory laparotomy was subsequently performed. The foal, after emptying the stomach, was premedicated with sodium penicillin (22000 UI/kg, IV), amikacin (25 mg/kg, IV), and flunixin meglumine (1.1 mg/kg, IV). Abdominal exploration revealed a severe thickening of the pylorus and duodenum. Based on these findings, a gastrojejunostomy was performed (Blikslager and Wilson 2018). Stay sutures were placed in the anastomosis site in the stomach. An 8-9 cm segment of the proximal jejunum, approximately 20 cm aboral to the duodenocolic ligament, was aligned from left to right (oral to aboral), with a relatively avascular region of the caudal ventral aspect of the stomach (Figure 2). Side-to-side gastrojejunostomy was performed by first suturing the jejunum, slightly off the anti-mesenteric site, to the stomach. First, jejunum was sutured to the stomach with 3/0 USP polyglyconate using a continuous Lembert pattern. Full-thickness incisions, 7-8 cm in length, were made into the stomach and jejunum parallel to the first suture line. The cut edges of the stomach and jejunum were then apposed using a full-thickness simple continuous pattern in two halves. This was subsequently oversewn with a continuous serosal Lembert pattern utilizing a 3/0 USP polyglyconate (Zedler et al. 2009) (Figure 3). The resulting side-to-side anastomosis produced an average stoma length of 6–7 cm. Additionally, jejunojejunostomy was not performed. ††slugcomment: Draft version Outcome After surgery, a medical treatment was continued, which included the administration of antibiotics (sodium penicillin at 22000 UI/kg, IV, q 6 h and amikacin at 25 mg/kg, IV, q 24 h), histamine type-2 receptor antagonists (ranitidine at 1.4 mg/kg IV, q 8 h), prokinetics (metoclopramide at 0.1 mg/kg, IV, q 6 h), anti-ulcer medications (omeprazole at 0.8mg/kg, IV, q 24h), and anti-inflammatories (flunixin meglumine (1.1 mg/kg, IV, q 12h) combined with intensive vigilance and progressive artificial milk feeding VO (100 ml q 2h progressively until 3 L q 6h). During this period, the foal developed a right congenital indirect scrotal hernia, which was managed with repeated manual reduction. Aspiration pneumonia responded favourably with medical treatments established, without respiratory or systemic signs. The antibiotics, prokinetics, and anti-inflammatories were suppressed 9, 8, and 7 days (respectively) after surgery; histamine type-2 receptor antagonists and anti-ulcer medications were maintained until the end of hospitalization. Finally, the foal was discharged from the hospital two months post-surgery, and the extended hospitalization was the owner’s decision. Six years later, the horse is being utilized for dressage and demonstrates a good level of performance. Throughout this time, it has not exhibited any growth delays or episodes of colic, and is comparable in size and conformation to other foals of the same age on the farm. ††slugcomment: Draft version Case 2. A 12-hour-old male Lusitano foal was admitted presenting with difficulty suckling. During the first 24 hours, the foal was able to suckle and exhibited a good affinity for its mare; however, it also displayed signs of moderate dehydration and nasogastric reflux. The foal was treated conservatively with antibiotics (sodium penicillin at 22000 UI/kg, IV, q 6 h, and amikacin at 25 mg/kg, IV, q 24 h), prokinetics (metoclopramide at 0.1mg/kg, IV, q 6 h), anti-ulcer medications (omeprazole at 0.8mg/kg, IV, q 24h), analgesia (meloxicam at 0.6 mg/kg) and intravenous glucosaline fluid therapy. Despite these medical interventions, the clinical signs did not improve. Gastroscopy did not reveal gastric ulcers, while contrast radiology indicated delayed gastric emptying due to pyloric stenosis (Figure 4). ††slugcomment: Draft version Treatment The foal received the same premedication as the case 1. During abdominal exploration, a severe thickening of the pylorus was noted. Based on these findings, a gastroduodenostomy was performed (Blikslager and Wilson 2018). After an omentectomy and stay sutures were conducted, the proximal duodenum, located oral to the entrance of the common bile duct, was aligned with an adjacent relatively avascular region of the stomach just oral to the pylorus using a 3/0 USP polyglyconate. The anastomosis was completed in the same fashion as described for case one, resulting in a stoma measuring 2.5-3 cm between the stomach and the duodenum. Outcome After surgery, the medical treatments established were continued, and it started with an intensive vigilance plan and progressive introduction of maternal feeding. Five days post-surgery, the foal experienced a mild episode of diarrhoea, which was treated with di-tri-octahedral smectite, without any associated complications. A culture and an ELISA test detect Criptosporidium parvum, Rotavirus, Clostridium y E. Coli. The antibiotics, and anti-inflammatories were suppressed 21, and 11 days (respectively) after surgery; anti-ulcer medication was maintained until the end of hospitalization. The foal was discharged from the hospital one month after the surgery. Nearly three years after the surgery, the foal has not exhibited any growth delays or episodes of colic and is comparable in size and conformation to other foals of the same age on the farm. Discussion This case series enhances the understanding of long-term outcomes, regarding growth, development, and athletic performance of Lusitano foals undergoing a bypass procedure for the treatment of GFO. Additionally, these cases provide updated information on specific surgical technical details, as the most recent comprehensive reports were published over a decade ago and are predominantly limited to Thoroughbred foals. In both cases, the initial line of treatment implemented was medical therapy (Blikslager and Wilson 2018, Camacho-Luna et al. 2018, Vokes et al. 2023). However, recent evidence increasingly supports early surgical intervention in GFO due to the substantial risk of secondary complications, particularly aspiration pneumonia (Sykes 2024). The timing of surgical decision-making remains critical, as aspiration pneumonia significantly impacts prognosis: in one study, three of four foals presenting with pneumonia at admission died following bypass surgery, whereas all foals that developed pneumonia post-operatively survived (Orsini and Donawick 1986). Despite favorable clinical progress in our cases, such complications may negatively impact both survival and long-term athletic performance (Ainsworth et al. 1998, Ainsworth et al. 2000, Treloar et al. 2012). These considerations underscore the importance of prompt surgical intervention when medical management fails, particularly in valuable sport foals. According to the most recent literature, gastrojejunostomy should be performed only when the stenosis involves the duodenum, because gastroduodenostomy is associated with fewer complications. There is no clear consensus among authors regarding best practice in the bypass technique. Recently, modified Heineke-Mikulicz pyloroplasty has been described as an alternative to the bypass procedure in three foals with pyloric stenosis. This technique could be a successful procedure in specific and selected cases, though further investigation is needed regarding outcomes and complications of this technique (Kent et al. 2020). In cases of stenosis involving de duodenum, some authors recommend performing a concurrent jejunojejunostomy with gastrojejunostomy to prevent loop syndrome and avoid duodenal reflux-induced gastritis (Orsini and Donawick 1986, Zedler et al. 2009). Nevertheless, jejunojejunostomy may create potential space for intestinal incarceration and increase the risk of jejunal volvulus. Additionally, it could prolong surgical time and present technical challenges (Brabon et al. 2023). In the case presented, gastrojejunostomy was performed without jejunojejunostomy, with no evident adverse effects observed. We believe further research is necessary to justify the routine use of jejunojejunostomy (Zedler et al. 2009, Coleman et al. 2009, Brabon et al. 2023). Regarding the orientation of the jejunal loop, previous reports have recommended orienting the anastomosis with the oral segment of the jejunum directed toward the right and the aboral segment toward the left (Orsini and Donawick 1986, Campbell-Thompson et al. 1986). However, based on anatomical considerations aimed at reducing potential complications, we propose, according to some authors, that orienting from left to right (oral to aboral portions of the jejunum) may decrease the likelihood of complications and improve long-term outcomes (Zedler et al. 2009, Coleman et al. 2009). In this manner, the normal orientation of the most proximal portion of the jejunum is maintained, with the oral segment on the left side of the abdomen and the aboral segment on the right side, thereby avoiding a mesenteric fold and intestinal kinking (Zedler et al. 2009, Coleman et al. 2009). For foals undergoing exploratory laparotomy, it is essential to consider that surgical celiotomy adversely affects athletic performance in Thoroughbred foals, particularly in sucklings (Santschi et al. 2000). However, this information has yet to be evaluated in other breeds or disciplines. In the present cases, both Lusitano foals demonstrated normal growth and development compared to contemporaries on the same farm with no signs of pain, weight loss, or performance limitations. Furthermore, these foals achieved a competitive level of dressage performance appropriate for their age. These favourable outcomes were achieved in one case using gastrojejunostomy without jejunojejunostomy and left-to-right jejunal loop orientation. Whilst some previous studies have described similar technical approaches in Thoroughbred foals (Zedler et al. 2009, Coleman et al. 2009, Brabon et al. 2023), consensus regarding optimal surgical technique remains incomplete, and long-term athletic outcomes beyond racing performance have not been well documented. Our case series extends existing outcome data to warmblood-type sport horses, providing valuable prognostic information for bypass procedures in non-Thoroughbred athletic populations. Long-term prophylactic anti-ulcer therapy has been widely recommended following bypass surgery (Furr 2017, Gillen 2024). In the largest study of foals undergoing bypass procedures, anti-ulcer drugs were administered for an average of 25 days, although gastric perforations occurred months after discontinuation (Zedler et al. 2009). In humans, extended postoperative treatment has been shown to reduce ulcer incidence (Kang et al. 2016), however, optimal duration in foals remains uncertain, with recommendations ranging from 30 days to lifelong therapy (Coblijn et al. 2014, Sykes 2021). In our cases, anti-ulcer medication was not prescribed at discharge, and given the lack of evidence in foals, we suggest an individualized rather than routine approach to prophylactic treatment following bypass surgery. Although this case series includes only two clinical cases, it provides valuable outcome data for bypass procedures in sport horses, which remain infrequently performed and challenging to study due to limited case numbers. ††slugcomment: Draft version Conclusions Gastrojejunostomy without jejunojejunostomy, using left-to-right jejunal orientation, or gastroduodenostomy resulted in excellent long-term outcomes in both Lusitano sport foals with GFO, both achieving competitive dressage performance at six and nearly three years post-operatively. These cases provide contemporary surgical technical data for specific bypass surgical decisions in non-Thoroughbred sport horses. Importantly, extended follow-up documents the absence of long-term complications, normal growth, and athletic performance—critically needed information for surgical decision-making and owner communication. This study contributes scarce evidence surrounding this uncommon surgical intervention in equine practice. Declarations Acknowledgements The authors would like to thank the referring veterinary surgeons who referred the cases and the hospital team for the support provided. Funding information This work was supported by the Junta de Extremadura and co-financed by the European Union: grant number GR24079 to the Animal Medicine and Surgery Research Group (CTS041) and grant number GR24094 to the Veterinary Internal Medicine Research Group (CTS061). Conflict of interest statement No conflicts of interest have been declared. Ethics Statement Client-owned horses were admitted to the hospital for routine care, therefore no ethical approval was required. All the procedures were performed in accordance with the highest standards of veterinary care. The owners gave full consent for publication. References Ainsworth, D.M., Eicker, S.W., Yeagar, A.E., Sweeney, C.R., Viel, L., Tesarowski, D., et al. (1998) Associations between physical examination, laboratory, and radiographic findings and outcome and subsequent racing performance of foals with Rhodococcus equi infection: 115 cases (1984-1992). javma 213, 510–515.Ainsworth, D.M., Erb, H.N., Eicker, S.W., Yeagar, A.E., Viel, L., Sweeney, C.R. and Lavoie, J.-P. (2000) Effects of pulmonary abscesses on racing performance of horses treated at referral veterinary medical teaching hospitals: 45 cases (1985–1997). javma 216, 1282–1287.Blikslager, A.T. and Wilson, D., A. (2018) Stomach and duodenum. In: Equine surgery, 5th edition., Eds.: J.A. Auer and A.E. Fürst, Elsevier, St. Louis, MO. pp 499–503.Brabon, A., Labens, R., Ramachandran, A., Dart, A. and Dowling, B. (2023) Gastrojejunostomy as a treatment for gastric outflow disorders in four adult horses. Aust Veterinary J 101, 302–307.Camacho-Luna, P., Buchanan, B. and Andrews, F.M. (2018) Advances in diagnostics and treatments in horses and foals with gastric and duodenal ulcers. 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Equine Veterinary Journal 32, 32–36.Sykes, B. (2024) Gastroduodenal ulcer syndrome and ileus in the foal. Section II. In: Equine Neonatal Medicine, 1st ed., Eds.: D.M. Wong and P.A. Wilkins, Wiley. pp 442–448.Sykes, B.W. (2021) A free ride: Is long‐term omeprazole therapy safe and effective? Equine Veterinary Education 33, 556–560.Treloar, S.K., Dhand, N.K. and Muscatello, G. (2012) Rhodococcus equi pneumonia and future racing performance of the Thoroughbred. Journal of Equine Veterinary Science 32, S16–S17.Vokes, J., Lovett, A. and Sykes, B. (2023) Equine gastric ulcer syndrome: an update on current knowledge. Animals 13, 1261.Zedler, S.T., Embertson, R.M., Bernard, W.V., Barr, B.S. and Boston, R.C. (2009) Surgical treatment of gastric outflow obstruction in 40 foals. Veterinary Surgery 38, 623–630. Figure legends Figure 1. Toraco-abdominal radiographic images in right lateral decubitus of barium-contrast exam of the stomach, at (A) 1 hour and (B) 2 hours after de barium ingesta, showing delayed gastric emptying caused by pyloric stenosis. There is an area with increased radiopacity with an alveolar pattern in the caudoventral lung region (arrows). Figure 2. Anatomical illustration of gastrojejunostomy showing left-to-right jejunal loop orientation (oral to aboral direction). S: stomach, J: jejunum, L: left and R: right. Figure 3. Figure 3. (A) The cut edges of the stomach (S) and jejunum (J) are visible following the full thickness incision made in both structures. (B) The side-to-side anastomosis has been completed. Figure 4. Toraco-abdominal radiographic images in right lateral decubitus of barium-contrast exam of the stomach, at (A) 0 hour and (B) 4 hours after de barium ingesta, showing delayed gastric emptying caused by pyloric stenosis Information & Authors Information Version history V1 Version 1 14 December 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Equine Veterinary Education Keywords bypass procedure gastric outflow obstruction horse outcome sport foal Authors Affiliations Pablo Fernández Hernández 0000-0001-5445-1630 [email protected] Universidad de Extremadura Facultad de Veterinaria View all articles by this author Marta Valero-González Universidad de Extremadura Facultad de Veterinaria View all articles by this author Fernando Bulnes 0009-0001-3837-6324 Universidad de Extremadura Facultad de Veterinaria View all articles by this author Noelia Venegas Chávez Universidad de Extremadura Facultad de Veterinaria View all articles by this author Beatriz Fuentes Romero Universidad Europea de Madrid SLU View all articles by this author Manuel Iglesias García Universidad Europea de Madrid SLU View all articles by this author Joaquín Jiménez Fragoso 0000-0002-7127-6763 Universidad de Extremadura Facultad de Veterinaria View all articles by this author Maria Martin-Cuervo Universidad de Extremadura Facultad de Veterinaria View all articles by this author Luis Ezquerra Calvo Universidad de Extremadura Facultad de Veterinaria View all articles by this author Metrics & Citations Metrics Article Usage 260 views 225 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Pablo Fernández Hernández, Marta Valero-González, Fernando Bulnes, et al. Long-term outcomes of gastric bypass surgery in two Lusitano foals: Contemporary evidence for surgical decision-making. Short running title: Gastric bypass in foals: outcomes.. Authorea . 14 December 2025. DOI: https://doi.org/10.22541/au.176574269.94683198/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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