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.     

Standing rectal and tail surgery.

A variety of rectal, perirectal, and coccygeal surgeries can be performed in the standing equine patient if appropriate chemical and physical restraints are available and adequate regional anesthesia can be achieved. Some rectal tears and most rectal prolapses, mass lesions, perirectal abscesses, rectal biopsies, and selected injuries of the tail can be managed without prohibitive difficulty. Severe injuries that compromise the small colon cranial to the peritoneal reflection may require flank laparotomy, midline celiotomy, or humane euthanasia to manage the disease process effectively and appropriately. The foremost perioperative consideration beyond the use of effective restraint is the management of tenesmus in horses with rectal tears or prolapses. Medications to control bowel motility, epidural anesthesia, antiinflammatory analgesics, and topical compounds adequate to soothe and lubricate inflamed rectal tissues are an important adjunctive therapy in the aftercare of these surgical patients. Of nearly equal importance is the requirement that a loose fecal consistency be maintained with laxative diets, psyllium, and mineral oil. Failure to maintain a loose consistency of stool after treatment of these conditions may lead to rectal impaction or incisional dehiscence and surgical failure.     

Management and Outcome of a Non-iatrogenic,Nearly Circumferential,Full-thickness Retroperitoneal Rectal Tear in a Horse

An 8-year-old Quarter Horse stallion presented to the Veterinary Teaching Hospital for evaluation of acute colic and a suspected rectal tear. Clinical examination revealed a nearly circumferential retroperitoneal full-thickness rectal tear. Exploratory laparotomy was performed, and medical management of the tear continued for 6 weeks. Multiple attempts at direct suturing of the tear were unsuccessful. Despite intensive medical management, the horse was not able to defecate, and the tear did not heal adequately, so the horse was humanely euthanized. Necropsy revealed complete obliteration of the muscular layers of the rectum with only a small area of rectal mucosa intact dorsally. There is limited information available on the management of circumferential rectal tears. Based upon this experience and other historical reports, a poor prognosis may be expected for circumferential full-thickness retroperitoneal rectal tears involving the ventral aspect of the rectum.     

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)     

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.     

Comparison of rectal mucosal cultures and fecal cultures in detecting Salmonella infection in horses and cattle

Bacteriologic cultures of 65 rectal mucosal samples and 335 fecal samples from 53 horses and 5 cattle shedding Salmonella were performed. Salmonella spp were isolated from 34 (52%) rectal mucosal samples, 21 (32%) concurrent fecal samples, and 150 (45%) total fecal samples. The use of rectal mucosal samples when compared with concurrently obtained fecal samples significantly (P less than 0.025) improved the ability to isolate Salmonella spp. Concurrent bacteriologic culture of rectal mucosal samples and fecal samples resulted in 39 (60%) isolations. Compared with a series of fecal samples, Salmonella was isolated significantly more often when rectal mucosa and feces were cultured concurrently. Salmonella was isolated from rectal mucosal samples when it was not isolated from feces.     

Oil Red O-positive lipid in peritoneal fluid from a horse with a rectal tear

A 4-year-old Quarter Horse mare was presented to the Texas A&M University Veterinary Medical Teaching Hospital for evaluation of a rectal tear. On initial evaluation, rectal palpation and colonoscopy revealed a grade IIIb rectal tear. Analysis of peritoneal fluid revealed a modified transudate. Preliminary supportive care included fluid therapy and mineral oil administration via nasogastric tube. Approximately 48 hours after presentation, a second abdominocentesis was performed, and cytologic examination of the fluid revealed a marked suppurative exudate. Round clear nonrefractile material observed within neutrophils and macrophages and in the background stained bright pink to red with Oil Red O, confirming the material as lipid, likely from leakage of mineral oil through the rectal tear. The condition of the mare deteriorated and euthanasia was elected due to the poor prognosis. At necropsy, gross and histologic findings included peritoneal effusion and a full-thickness rectal tear with transmural necrotizing pyogranulomatous colitis and fibrinous peritonitis. To the authors' knowledge, this is the first reported case of Oil Red O-positive lipid vacuoles in the peritoneal fluid of a horse from presumed leakage of mineral oil through a transmural rectal perforation. The frequency of this occurrence in horses is unknown, but it is important for cytopathologists to be familiar with the appearance and significance of lipid-type droplets in phagocytic cells in cytologic fluid analysis specimens.     

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.     

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.     

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.     

Medical examination of the digestive system relevant to purchase.

Routine examination of the digestive system relevant to purchase includes gross examination of the feces, auscultation of the abdomen, and examination of the oral cavity and teeth for verification of age and identification of any gross abnormality. Further examination is indicated only when there is a history of diseases such as colic, especially colic surgery, or esophageal obstruction. Special procedures that might be indicated, depending upon the history and findings on the routine physical examination, include rectal palpation of the abdominal viscera; endoscopic examination of the esophagus; abdominal paracentesis; radiographs of the teeth, esophagus, or abdomen; and transabdominal or transrectal ultrasound.     

Transmural rectal intestinal evisceration associated with parturition in a primiparous mare

A 6-year-old, primiparous standardbred mare was presented with a history of intestinal protrusion from the rectum shortly after parturition. A subacute grade IV rectal tear was diagnosed. The unusual nature of the tear led to speculation of a possible owner palpation accident. A grave prognosis was given and the mare was euthanized.     

Jejunocolic Anastomosis for the Surgical Management of Recurrent Cecal Impaction in a Horse

A 5-year-old Thoroughbred gelding with recurrent cecal impaction refractory to medical management was treated with a side-to-side jejunocolic anastomosis. Cecal impaction did not recur after surgery. The horse gained weight and performed successfully for 14 months, but experienced three episodes of mild abdominal pain between 14 and 20 months after surgery. Mild cecal gas distention and firm ingesta in the colon were detected on rectal examination. The horse's feces remained soft after surgery, except during the colic episodes when dry, firm feces were passed.     

Equine eosinophilic enterocolitis

A 4-year-old Morgan stallion was presented with a 9-week history of diarrhea. Biopsy of nodules in the rectal mucosa yielded a diagnosis of eosinophilic enterocolitis. Treatment with steroids was instituted and the feces firmed within 2 days. Continued treatment with oral prednisone kept the feces at a normal consistency for 4 months.     

Novel application of internal obturator and semitendinosus muscle flaps for rectal wall repair or reinforcement

Internal obturator and/or semitendinosus muscle flaps were used to reinforce primary appositional rectal wall repair in three dogs and one cat in this case series. All three dogs incurred rectal wall compromise during surgical excision of anal sac tumours. The cat sustained bite wounds to the perianal region resulting in abscessation and a rectal tear. Our results indicate that application of an internal obturator and/or semitendinosus muscle flap can reduce the risk of rectal wall dehiscence after primary repair, and consequently the risk of pararectal abscess or rectocutaneous fistula formation.     

Comparison of fecal samples collected per rectum and off the ground for estimation of environmental contamination attributable to beef cattle

OBJECTIVES: To determine whether sampling feces off the ground replicates prevalence estimates for specific pathogens obtained from fecal samples collected per rectum of adult cows, and to determine characteristics of feces on the ground (fecal pats) that are associated with subsequent identification of Campylobacter spp, Cryptosporidium parvum, and Giardia duodenalis. ANIMALS: A random sample of adult beef cattle from 25 herds located throughout California. PROCEDURE: 1,115 rectal and ground fecal samples were obtained. Samples were submitted for culture of Campylobacter spp and examined, using a direct fluorescent antibody assay, to detect C parvum oocysts and G duodenalis cysts. Characteristics of fecal pats, such as volume and consistency, were recorded. RESULTS: Prevalence of Campylobacter spp was 5.0% (20/401) for rectal fecal samples, which was significantly greater than prevalence determined for ground fecal samples (2/402; 0.5%). Most isolates were C jejuni subsp jejuni. Prevalence of C parvum was higher in rectal fecal samples (6/557; 1.1%) than in ground fecal samples (1/558; 0.2%), but this difference was not significant. Prevalence of G duodenalis did not differ for rectal (36/557; 6.5%) versus ground (26/558; 4.7%) fecal samples. CONCLUSIONS AND CLINICAL RELEVANCE: Evaluation of ground fecal samples may not accurately indicate the prevalence of Campylobacter spp or C parvum in cattle but may reflect prevalence of G duodenalis. Differences in prevalence estimates between the 2 methods suggest inactivation of pathogens in feces after cattle have defecated. Prevalence estimates generated by evaluation of ground fecal samples, however, may more accurately estimate environmental pathogen burden.     

Use of laparoscopic-assisted jejunostomy for fecal diversion in the management of a rectocutaneous fistula in a dog

A 2-year-old female Siberian Husky was referred for evaluation of a rectocutaneous fistula of unknown etiology. On evaluation, a rectal tear and an associated perivulvar abscess and draining tract were identified. Several attempts were made to repair the rectocutaneous fistula and associated rectal tear. Primary repair and fascia lata graft repair failed. Successful management was achieved via a laparoscopic-assisted end-on jejunostomy for fecal diversion, and the wound healed readily by second intention. During the period of hospitalization, the dog lost a considerable amount of weight. Particular care should be taken regarding fluid therapy, administration of antimicrobials, and adequate nutrition in patients with rectocutaneous fistulas. Overall, the use of laparoscopic-assisted end-on jejunostomy for fecal diversion in the management of rectocutaneous fistulas in dogs appears to be feasible; end-on or loop jejunostomy may also be an option for the treatment of other diseases of the distal portion of the gastrointestinal tract.     

Temporary indwelling rectal liner for use in horses with rectal tears

A temporary indwelling liner was surgically installed in 17 horses with grade III or grade IV rectal tears. The rectal tears of 9 of the horses healed. The remaining 8 horses developed peritonitis as a result of peritoneal contamination before surgery, a change in grade of the tear, or material failure.     

Anastomoses of intestinal tract as a sequela to rectal stricture in swine.

Rectal stricture with anastomoses of colon and/or small intestine to a spherical dilatation of the descending colon proximal to the stricture was observed in six swine. In three of these swine, feces bypassed most of the colon in passage from the small intestine to the dilated colon. Rectal stricture with an anastomosis of a loop of colon to the rectal stricture was observed in one pig where feces bypassed much of the stricture.     

Isolation of shiga-toxigenic Escherichia coli O157 from hide surfaces and the oral cavity of finished beef feedlot cattle

OBJECTIVE: To determine whether viable shiga-toxigenic Escherichia coli (STEC) O157 could be isolated from hide surface locations and the oral cavity of finished beef feedlot cattle. DESIGN: Within-animal prevalence distribution survey. ANIMALS: 139 finished cattle in 4 pens in a feedlot in Nebraska; prevalence of fecal STEC O157 shedding ranged from 20 to > 90%. PROCEDURE: Samples were collected from 7 sites from each animal: feces, oral cavity, and 5 hide surface locations (lumbar region, ventral aspect of the neck, ventral abdominal midline [ventrum], dorsal thoracic midline [back], and distal aspect of the left hind limb [hock]). RESULTS: Viable STEC O157 were isolated from the oral cavity or 1 or more hide surfaces of 130 cattle, including 50 fecal isolation-negative cattle. Site-specific prevalence of STEC O157 was 74.8% for oral cavity samples, 73.4% for back samples, 62.6% for neck samples, 60.4% for fecal samples, 54.0% for flank samples, 51.1% for ventrum samples, and 41.0% for hock samples. Only 5 cattle tested negative for STEC O157 at all 7 sites. Multiple correspondence and cluster analyses demonstrated that bacterial culture of feces, oral cavity samples, and back samples detected most cattle with STEC O157. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that viable STEC O157 may be isolated from the oral cavity, multiple hide surfaces, and feces of a high percentage of fed beef cattle and that bacterial culture of feces alone generally underestimates the percentage of fed beef cattle from which STEC O157 can be isolated.