Management of rectal injuries

Diagnosis, evaluation, and management of the various grades of rectal tears is discussed. Surgical techniques, which include direct closure, diverting colostomies, and placement of temporary rectal liners, are detailed. Also, rectal prolapses and various methods of repair are outlined.     

Rectal tears in the horse: a literature review

Rectal tears are a relatively rare complication of rectal palpation, mating, or dystocia, and idiopathic rectal perforation is an incidental finding. Rectal tears can be classified according to a 3 or a 4-grade system. This article describes medical and surgical treatment for rectal tears.     

A review of equine rectal tears and current methods of treatment

Rectal tears are a risk of rectal palpation during equine clinical examination and can be life‐threatening; prompt medical and surgical intervention is required to improve patient outcome. Depending on the degree of the tear, conservative treatment or surgical management may be warranted. Surgical management involves either direct suturing or faecal diversion techniques, such as colostomy or a temporary indwelling rectal liner. The prognosis for a horse with a rectal tear depends on size of the tear, grade and location of the tear, and time between occurrence and first aid measures.     

Rectal and Colonic Injury in the Llama Anatomic Considerations and Surgical Management in Four Llamas

Transrectal palpation in llamas can result in iatrogenic rectal and colonic injury. The purpose of this report is to define the caudal extent of the peritoneal cavity in llamas and to describe the surgical management of rectal or colonic injuries in four llamas. Measurements were made of six adult llamas during necropsy. The mean distance from the peritoneal reflection to the anus was 3.9 ± 0.1 cm (3.4 - 4.3 cm). Four llamas were examined for rectal or colonic perforations. One laceration was of partial thickness and three lacerations were of full thickness. Two of the defects were repaired by a transanal approach and two by celiotomy to facilitate removal of fecal debris and abdominal lavage. Successful repair of the rectal or colonic tears was achieved in all four llamas. Wound infection and incisional hernia occurred in both llamas that underwent celiotomy. Two llamas died 3 and 18 months later, and two llamas have survived 2 years. Rectal tears in llamas are accompanied by a high risk of peritoneal contamination, and primary closure is recommended. If fecal contamination of the abdomen has occurred, celiotomy is indicated to allow mechanical removal of fecal debris and peritoneal lavage.     

Surgical technique to repair grade IV rectal tears in post-parturient mares

Objective— To describe a surgical technique for repair of grade IV rectal tears after parturition in mares and to report outcome.
Study Design— Clinical report.
Animals— Horses (n=6) with grade IV rectal tears.
Methods— Mares were sedated and restrained in standing stocks. After caudal anesthesia and evacuation of feces from the rectum, the perineal region was aseptically prepared. Four stay sutures were placed through the external anal sphincter before vertical transection (12 o'clock). Caudal retraction of the tear was performed using Allis tissue forceps (5 mares) or stay sutures before accurate apposition of the tear margins with steel staples below the tissue forceps. The mucosal edges were then sharply dissected leaving ∼5 mm edges which were apposed in a single layer (2-0 poliglecaprone 25) before stapler release. In 1 mare, the rectal tear was identified and apposed using a 2-layer hand-sutured closure. Systemic antibiotics and anti-inflammatory agents were administered postoperatively (5 mares) and standing abdominal lavage performed (3 mares).
Results— Four mares survived long term and subsequently became pregnant. Immediately after surgical repair, 1 mare was anesthetized for exploratory celiotomy and abdominal lavage but fractured her pelvis during recovery from anesthesia and was euthanatized. A 2nd mare was euthanatized after 72 h because of severe diffuse peritonitis; however, the repair was still intact.
Conclusion— In standing mares, rectal tears can be exteriorized by prolapse through the anal sphincter after sphincterotomy and repaired in 2 layers with staples oversewn with a continuous suture pattern.
Clinical Relevance— Rectal tears occurring as a result of parturition can potentially be repaired efficiently using an oversewn stapled primary closure technique.     

Laparoscopic surgical technique for repair of rectal and colonic tears in horses: an experimental study

OBJECTIVE: To determine the efficacy of laparoscopic surgical techniques for repair of rectal lacerations in horses. STUDY DESIGN: Experimental study. ANIMAL OR SAMPLE POPULATION: Thirty-two segments of equine bowel placed in an equine pelvitrainer, 8 equine cadavers, and 3 normal horses. METHODS: In experiment 1, 3 laparoscopic intestinal-repair techniques were evaluated in an equine pelvitrainer: suturing with needle holders, with an automatic suture device, and stapling with a hernia stapler. In experiment 2, descending colon lacerations were sutured laparoscopically using needle holders in a pelvitrainer and in equine cadavers. In experiment 3, iatrogenic rectal lacerations were sutured laparoscopically with needle holders in horses under general anesthesia. These horses were evaluated for 7 days' postoperatively by clinical examination and blood and peritoneal fluid analysis. The horses were euthanatized 7 days' postoperatively and necropsied. The repaired colonic segments were collected for determination of bursting pressures, degree of luminal narrowing, and microscopic examination of the suture line. RESULTS: For the 3 techniques, there was no significant difference in repair time or degree of luminal narrowing, but bursting pressure was higher in segments repaired by use of needle holders or with the suture device. Colonic and rectal lacerations were sutured successfully with laparoscopic needle holders. No major complications were recorded. At necropsy, adequate healing was confirmed by a high bursting strength (>140 mm Hg) and by histologic examination. CLINICAL RELEVANCE: A novel laparoscopic method can be used to repair iatrogenic rectal lacerations in horses. Whether this method may be used for clinical cases of rectal tears must be investigated.     

Comparison of several combinations for anesthesia in rabbits.

Few safe and effective anesthesia regimens have been described for use in rabbits, partially because of the susceptibility of this species to sometimes fatal respiratory depression. Although inhalant anesthetics are generally safer than injectable anesthetics, their use may be limited by lack of equipment or facilities. This study was conducted to compare effects of several injectable anesthetics in rabbits on response to noxious stimuli, heart rate, respiratory rate, and rectal temperature. Six injectable anesthetic combinations were administered to rabbits: xylazine-ethyl-(1-methyl-propyl) malonyl-thio-urea salt (EMTU), ketamine-EMTU, xylazine-pentobarbital, xylazine-acepromazine-ketamine (XAK), ketamine-chloral hydrate, and ketamine-xylazine. All combinations induced a depression of respiratory rate. Although rectal temperature values were reduced to some degree in each group, the most profound hypothermia was induced by XAK. The combination that induced the longest duration of anesthesia was XAK. It was concluded that XAK was preferable for longer periods of anesthesia (60 to 120 minutes), although it induces severe hypothermia. For short periods of anesthesia, xylazine-pentobarbital, xylazine-EMTU, or ketamine-xylazine were deemed adequate; however, xylazine-EMTU induced the best survivability and consistency.     

Loop colostomy for management of rectal tears and small-colon injuries in horses: 10 cases (1976-1989).

Loop colostomy was performed in 10 horses as treatment for grade-III rectal tears (n = 6 horses), small-colon infarction (n = 2 horses), perirectal abscess and stenosis (n = 1 horse), and small-colon stricture (n = 1 horse). In 7 horses, the colostomy was constructed through a single incision low in the left flank, with closure of the incision around the stoma (single-incision technique). In 3 horses, 2 of which had colostomy performed as a standing procedure, the selected segment of small colon was placed from a flank incision into a separate, small incision low in the left flank (double-incision technique). Five horses underwent colostomy reversal (at 18 to 63 days) and 2 of these horses, both with grade-III rectal tears, recovered completely. Of 8 horses that did not survive, 6 died from the primary disease or associated complications. Technical problems associated with colostomy accounted for death of 2 horses. One horse had gastric rupture attributable to suture occlusion of the small intestine after colostomy reversal, and another horse had complications of incisional infection after repair of a peristomal hernia. Small-colon prolapse through the stoma necessitated premature reversal of the colostomy in a horse that was euthanatized because of worsening laminitis. Minor complications of the colostomy procedure were partial stomal dehiscence (n = 4 horses), partial dehiscence of the flank wound after colostomy reversal (n = 2 horses), and small ventral midline hernia after colostomy reversal (n = 1 horse). Loop colostomy may be of benefit to horses with rectal tears, provided it is done soon after the tear occurs.(ABSTRACT TRUNCATED AT 250 WORDS)     

Standing surgery and procedures of the head

Although most surgical procedures of the head are technically easier to perform with the horse under general anesthesia, other factors will influence whether a surgical procedure is performed with the horse standing or recumbent under the influence of general anesthesia. The accessibility of the head lends itself to many standing surgical procedures if the proper combination of analgesia and physical and chemical restraint is used. Traumatic injuries of the head (lacerations, facial bone fractures, and oral fractures) may involve vital structures, and a thorough examination is indicated. Failure to treat a traumatic injury may result in facial deformity, bony sequestra, paranasal sinusitis, salivary-cutaneous fistula, cutaneous fistulas into a nasal passage or paranasal sinus, nasal septal deformities, and ocular dysfunction. Proper management of these injuries typically results in a cosmetic outcome because of the head's abundant blood supply. Other surgical procedures that can be performed in the standing horse include centesis and trephination of the paranasal sinuses, certain dental procedures, alar fold stabilization, and extirpation of epidermal inclusion cysts of the nasal diverticulum.     

THE MANAGEMENT OF RECTAL TEARS IN HORSES

Rectal trauma in horses is usually iatrogenic and carries a high mortality. Partial thickness tears heal without surgical assistance. Full thickness tears require surgical repair through the anus or a ventral laparotomy or, if these are not possible because of difficulty in gaining access to the tear in its usual site at the pelvic inlet, a diverting colostomy to allow the rectum to heal is necessary. This paper describes the management of 15 cases of rectal injury, only 3 of which survived. Two of these were partial thickness tears not treated surgically and the third had a temporary diverting colostomy.     

Repeated manual evacuation for treatment of rectal tears in four horses

Horses with tears that involve all layers of the rectum except the mesocolon (grade IIIb) have a poor prognosis for survival because of the difficulty in treating these wounds and the propensity for them to progress to full perforations (grade IV). Most treatments for grade-IIIb rectal tears involve surgery of some kind, but not all grade-IIIb rectal tears require surgical intervention. We report on 4 horses with grade-IIIb rectal tears that were evaluated via palpation per rectum and endoscopy. Two of 4 horses were admitted with signs consistent with shock and endotoxemia, and evaluation of all peritoneal fluid samples was indicative of nonseptic peritonitis. Horses were treated via administration of antibiotics and anti-inflammatory drugs and repeated manual evacuation of the terminal portion of the small colon and rectum. Treatment centered on preventing further enlargement of the rectal tear by eliminating the storage function of the terminal portion of the small colon and rectum. None of our horses had worsening of the original injury, and horses were discharged within 2 weeks of admission with full resolution of the rectal tear. Outcomes in the horses of our report indicate that repeated manual evacuation can be successful for treatment of horses with grade-IIIb rectal tears.     

Standing abdominal surgery.

Safe, effective surgery can be performed in the standing, conscious horse using a combination of mechanical and chemical restraint. Clear indications for performing standing abdominal surgery exist, but many procedures are best performed under general anesthesia. The preferred approach involves a modified grid incision of the left paralumbar fossa. Flank celiotomy allows the surgeon to thoroughly explore the abdominal cavity, but few structures can be exteriorized, and visibility of abdominal contents is poor. Indications for standing abdominal surgery include diagnosis of abdominal masses, drainage and biopsy techniques, correction of left dorsal displacement of the large colon, and evaluation of rectal injuries, and performing loop colostomy techniques, laparoscopy, removal of retained testicles, correction of uterine torsions, surgical embryo transfer, ovariectomy in normal mares, and some experimental procedures. Standing surgical techniques are most useful and appropriate for surgical exploration, to correct uterine torsions, and to perform loop colostomy and surgical embryo transfer techniques. Perioperative antimicrobial and antiinflammatory therapy is recommended. Mild discomfort and ventral incisional swelling after surgery are expected.     

Rectal tears in the horse: malpractice or an unfortunate accident?

Rectal tears are a relatively rare complication of rectal palpation, mating or dystocia, and idiopathic spontaneous occurrence of rectal perforation has also been described. Rectal tears have been classified in a three or a four-grade system. Immediate recognition of the fact that a tear has been made and prompt action will improve the horses chance of survival, and is the best defence of the veterinarian against legislation. There is no clear explanation why rectal tears sometimes occur. A questionnaire of the Netherlands Equine Veterinary Association revealed that rectal tears occurred both to inexperienced veterinarians and to very experienced colleagues, working with or without a probe for ultrasonography. In the opinion of the authors, the approach in the legislation of rectal tears should be that a rectal tear is only considered 'malpractice' if the veterinarian obviously acted carelessly. However, this would create the ridiculous situation that it seems better for the veterinarian-client relationship when the veterinarian confesses to 'careless' rectal palpation. This point needs further clarification, and perhaps an 'insurance of the horse for rectal palpation' will be the solution. Further, retrospectively over the last ten years, the problem is often not 'making a rectal tear', but 'lacking recognition of making a tear'. Whenever a rectal tear is suspected, the veterinarian must assess its severity, discuss the problem openly with the owner and apply appropriate treatment including referral.     

Rectal tears in the horse: two case reports

Rectal tears occur incidentally and often have a poor prognosis. Early recognition of the problem and adequate therapy determine the outcome. The history, clinical examination, therapy, and outcome of two horses with grade IIIb and grade IV rectal tears are discussed.     

Rectal tears in the horse: an analysis of 35 cases

The records of 35 horses with Grade 3 or 4 rectal tears, presented to the Veterinary Medical Center at Texas A & M University over a five year period, were reviewed. Grade 3 tears were sub-classified according to whether the remaining tissue was serosa (Grade 3a) or mesorectum (Grade 3b). Five horses were destroyed on presentation and 30 were treated by primary suture closure (8 horses), faecal diversion alone (9 horses) or in combination with suture closure (11 horses) and packing of the tear with medicated gauze sponges (two horses). Faecal diversion was achieved with a temporary indwelling rectal liner (TIRL) in 19 horses and colostomy in one. Survival was related to classification of the tear, efficacy of first aid measures administered at time of injury and method of treatment. Seventy-four per cent of horses with Grade 3a tears and 44 per cent of those with Grade 3b tears survived. Grade 4 tears had a grave prognosis. Horses given adequate first aid before admission had a better survival rate. With proper patient selection, primary closure of the tear with sutures yielded excellent results. In horses which were not candidates for suture closure alone, a combination of faecal diversion and suturing gave better results than faecal diversion only. In addition, selected horses were treated successfully by packing the rectal tear with gauze sponges. The results demonstrate the value of a TIRL to divert faeces and appropriate first aid measures in treating rectal tears.     

Long-Term Outcome in 44 Horses with Stifle Lameness After Arthroscopic Exploration and Debridement

Objective— To (1) examine the outcome in horses with osteoarthritis or intra‐articular soft tissue injuries of the stifle after arthroscopic exploration and debridement and (2) to determine any imaging or surgical findings that may influence prognosis. Design— Case series. Animals— Horses (n=44) with lameness referable to the stifle, diagnosed with osteoarthritis, meniscal tears, or other intra‐articular soft tissue injuries based on arthroscopic examination. Methods— Medical records of horses with stifle lameness that had arthroscopic exploration were reviewed. Horses with osteochondrosis lesions, intra‐articular fractures, or osseous cyst‐like lesions were excluded. Pertinent case information was analyzed and short‐ and long‐term outcome was assessed. Results— There was no association between radiographic score and surgery score. Diagnostic ultrasound had a sensitivity of 79% and a specificity of 56% for identifying meniscal injuries. Follow‐up information was available for 35 horses; 23 horses (60%) improved after surgery, 16 (46%) became sound, and 13 (37%) returned to their previous level of function. A negative association was observed between age and degree of preoperative lameness and outcome. More severe changes observed on preoperative radiographs were also negatively associated with prognosis. No horses with grade 3 meniscal tears improved postoperatively and increasing meniscal pathology was negatively associated with return to previous function. A weak association between surgery grade and outcome was also observed. Degree of chondral damage, location of primary pathology, and microfracture techniques had no effect on outcome. Conclusions— Advanced horse age, severe lameness and preoperative radiographic changes, and presence of large meniscal tears are associated with a negative postoperative outcome for horses with stifle lameness. Appearance of the articular surface at surgery appears to be an inconsistent prognostic indicator. Clinical Relevance— Some horses with extensive cartilage damage may return to athletic function after arthroscopic debridement and lavage. A more pessimistic prognosis may be given to older horses, those with more severe preoperative lameness, and those with severe radiographic changes or large meniscal tears.     

Near circumferential retroperitoneal rectal tear in a pony

A 13-year-old, 370-kg, Appaloosa gelding with mild colic of 4 days' duration was found to have a near circumferential retroperitoneal rectal tear. Accumulation of feces at the site of the repair had created a large perirectal cavity. Removal of feces and cleansing of the perirectal cavity were performed daily. Sutures were placed to stabilize, but not reappose, the torn ends of the rectum. The perirectal cavity filled with granulation tissue, and the rectal tear healed.     

Meniscal injury following initial cranial cruciate ligament stabilization surgery in 26 dogs (29 stifles)

OBJECTIVE: To describe clinical signs, arthroscopic findings, and outcome in a group of dogs undergoing second look arthroscopy for the treatment of meniscal tears following original surgery to correct a CCL deficient stifle joint. METHODS: The medical records of 26 dogs from the Veterinary Teaching Hospital at Texas A&M University and the Veterinary Orthopedic Center (Round Rock, Texas) that had second look arthroscopy for lameness following an original surgical procedure were reviewed. Pre-operative clinical findings, 2nd look arthroscopic findings and owner assessed outcome were documented. RESULTS: Postliminary bucket handle tears of the medial meniscus were detected in 22 (75.9%) cases. Other postliminary meniscal injuries included frayed caudal horn tears of the medial meniscus 6 (20.7%), and longitudinal tears of the lateral meniscus 1 (3.4%). An audible or palpable click was present in 27.6% of cases. An improvement or resolution of lameness was reported in 96.5% of cases reported. In conclusion, tears of the medial meniscus are a significant cause of lameness in dogs subsequent to surgery for cranial crucial ligament ruptures. Increased lameness or acute onset of lameness after surgery for cranial crucial rupture is a consistent finding. In rare cases, a palpable or audible click will be appreciated. Arthroscopic evaluation and partial meniscectomy improve or resolve lameness in the majority of cases. CLINICAL SIGNIFICANCE: Sudden or increased lameness in dogs with historical CCL stabilization surgery should be evaluated and treated arthroscopically for postliminary meniscal injury if another cause for lameness can not be determined.     

Pain management and regional anesthesia for the dental patient

Current standards of care in veterinary medicine dictate an adequate level of pain control for our patients. Effective pain control uses a proactive, multimode approach that starts with preoperative medications, includes the anesthetic protocol selected, and continues into the postoperative period. A basic understanding of the physiology of pain assists in selecting those agents and modalities best suited for individual patients. Analgesic drug selection and local anesthesia are both integral parts of pain control when performing surgery in the oral cavity. Local (regional) anesthesia plays an important part in the pain control of oral surgical patients. Regional anesthetic techniques are used for many common oral procedures, including extractions, periodontal flap surgery, treatment of traumatic injuries of the oral cavity, tumor removal, palatal surgery, periodontal therapy, and root canal therapy. This presentation will cover strategies for analgesia and the techniques and materials used in local/regional anesthesia in the oral cavity. Anatomic landmarks and guidelines for effective regional blocks will be covered.     

Association of meniscal injury to joint space width on standard tibial plateau leveling osteotomy lateral radiographic projections of the canine stifle

Up to 70% of dogs with cranial cruciate ligament tears have concurrent meniscal injury, and these injuries can increase the risk of developing osteoarthritis and persistent lameness. Studies assessing joint space width on knee radiographs in people have indicated associations between joint space width and meniscal injuries. The aim of this prospective analytical study was to determine if there was an association between stifle joint space width on three different radiographic projections (the standard tibial plateau leveling osteotomy projections and a standing lateral projection) and meniscal injuries identified at surgery in dogs. There was a significant association between dogs with a meniscal tear and the corresponding joint space width on standard tibial plateau leveling osteotomy lateral radiographic projections (P‐value = .0028). Based on receiver operator characteristic curve analysis, joint space widths measuring less than 3.43 mm may indicate a meniscal tear, with a corresponding 89.5% specificity and 40.5% sensitivity in dogs weighing 31 kg. Joint space narrowing is seen with meniscal tears in dogs, and radiography may be a noninvasive way to identify meniscal tears prior to surgery.