Ch 94 Rectum, anus + perineum Flashcards

Question

complications fistula

Answer 1

- fecal incontinence - urinary tract signs (uroliths) - wound dehiscence (tension or fecal contamination) - tenesmus, - obstipation, - rectal prolapse, - anal stenosis

Answer 2

Rare condition in which urine and faeces enter a common cavity and body opening (cloaca) Treatment of anogenital cleft in females is often successful. The anus is reformed ventrally, and tissues between the anus and vulva are reconstructed

Answer 3

- partial or anal prolapse, only anal mucos - complete or rectal prolapse, all layers of the rectum around the entire circumference protrude through the anal orifice as an elongated, cylindrical mass. - tissues become edematous, and spontaneous resolution of the condition becomes unlikely. - Prolapse usually occurs secondary to tenesmus from gastrointestinal (especially colorectal or anal) or urogenital disease - self-mutilation and trauma may occur with time Diagnosis - underlying reason for its development may be less evident. - distinguish rectal prolapse from a prolapsed intussusception > the instrument or finger can be passed easily (5 to 7 cm) between the rectal wall and prolapsed tissue treatment - manually with saline or lubricants. Topical 50% dextrose - purse-string suture is inserted at the mucocutaneous junction and tied loosely, place for 3 to 5 days to prevent recurrence - given laxatives such as lactulose. - colopexy - rectal resection and anastomosis - epidural comlications - incontinence, dehiscence, leakage, recurrence of the prolapse, and anorectal strictures

Answer 4

- Perianal gland tumors originate from the circumanal modified sebaceous glands - Cytology can confirm the hepatoid nature of the tumor, but differentiation between hepatoid adenoma and adenocarcinoma may be difficult - adenocarcinomas exhibit greater pleomorphism and staining characteristics. Invasion of tumor cells into the surrounding tissue is an important histologic criterion for malignancy - Enlarged sublumbar lymph nodes can be aspirated during a digital rectal exploration or via transabdominal ultrasonographic-guided aspiration.

Answer 5

- perianal or circumanal region, but they may also be found on the tail, prepuce, scrotum, inguinal region, thighs, and trunk - hormone dependent and can be stimulated by androgens or inhibited by estrogens. Therefore they regress after castration or following estrogen therapy - older entire male - Perianal adenomas are slow growing, may ulcerate and become infected, but they are not commonly fixed to the deeper tissue Tx - Castration may be the sole procedure required for intact males - large or diffuse lesions may redcue in size with castration, making subequent excision easier - Excision is curative in more than 90% (especailly in femles)

Answer 6

Perineal hernia (10%) Testicular tumours Hyperadrenocorticism (source of androgen for females)

Answer 7

- more common in intact male dogs and dogs weighing more than 35 kg, - often larger, firmer, locally invasive, fixed, and rapidly growing. - benign and malignant tumors are indistinguishable; therefore histologic sampling - Metastasis to the sublumbar lymph nodes occurs in 15% of cases - only prognostic factor identified for perianal adenocarcinoma is clinical stage - T3 and T4 (invasive tumor) have a median survival of 6 to 12.5 months. with metastasis is 7 months. tx - en bloc excision with or without anoplasty and excision of lymph nodes affected by metastasis - margin of 1 to 3 cm - tumor is reportedly relatively radioresistant - Electrochemotherapy has been used successfully for perianal adenomas and adenocarcinomas, with an objective response rate of 94% | ddx SCC, MM

Answer 8

- large intestine is most commonly affected, with 36% to 60% of intestinal tumors occurring there - More than 50% of colorectal tumors are malignant, - adenocarcinoma most common - leiomyoma and leiomyosarcoma, plasmacytoma, and carcinoids.

Answer 9

- benign adenomatous polyps - composed of branching lamina propria covered by an abnormal epithelial surface - single or multiple, raised, sessile, or pedunculated - rectum and anorectal junction - ddx leiomyomas, fibromas, plasmacytomas, ganglioneuroma - malignant transformation of benign lesions may occur - Polyps that invade the intestinal lamina propria and submucosa but not the basement membrane = carcinoma in situ - 41% of dogs developed recurrence of clinical signs, and 18% developed malignant transformation. dx - tenesmus, dyschezia, hematochezia, mucoid feces, painful defecation, - Most rectal tumors are located 3 to 8 cm from the anus - Abdominal and thoracic radiography, abdominal ultrasonography, and endoscopy - more than 50% of tumors are located in the middle portion of the rectum,74 endoscopic examination should be continued orad - biopsy? a superficial biopsy may not be able to differentiate between these tumor types Tx - 2-cm margin of excision to reduce recurrence - Local excision of adenomatous polyps is associated with a survival of 5 to 24 months - prolapse of the rectum through the anus - larger polyps and leiomyomas may require resection and anastomosis - Leiomyomas of the caudal rectum may be removed via a dorsal or lateral approach with submucosal resection.

Answer 10

- adenocarcinoma is the most common malignant tumor of the rectum - Metastatic rates vary from 0% to 80%. - Leiomyosarcomas are locally invasive but slow to metastasize. Gastrointestinal stromal tumors (GISTs) are similar in histologic appearance > differentiated on IHC with CD117 - Lymphosarcoma, the most common rectal tumor in cats - Rectal lymphoma has a favorable prognosis, with an overall mean survival time of 1697 days tx - anal, ventral, dorsal, or lateral approach or a rectal pull-through technique may be used - Conservative resection of malignant lesions has been reported by multiple authors

Answer 11

1/3 incorrectly diagnosed Adenocarcinoma most common in dogs, LSA in cats

Answer 12

* Pedunculated * Cobblestone * Infiltrative (classic ‘napkin-ring’) Pedunculated and cobblestone have a good prognosis with surgical resection. Infiltrative/annular poor prognosis

Answer 13

* Adenomatous polyps - Leucocytosis * Eosinophilic masses - eosinophilia, neutrophilia, hypocholesterolaemia, hypoalbuminaemia * Leiomyosarcoma - hypoglycaemia * Secretory plasmacytomas - Hyperproteinaemia, monoclonal gammopathy

Answer 14

* NSAIDs * Immunosuppresive medications for inflammatory polyps * Pred and ivermectin (eosinophilic masses) * Chemotherapy (MST 2532d vs 70d for rectal lymphoma in dogs) * Orthovoltage irradiation (perforation and subsequent peritonitis possible SE) * Colostomy

Answer 15

- rectal polyps, carcinoma in situ, and leiomyomas is good if complete excision: 2 years or longer for polyp, 17% recurrence - malignant neoplasia is generally guarded - after surgery vary from 6 to 22 months - GIST 21 months - cats with complete excision of large intestinal adenocarcinoma is 138 days - mast cell tumors is 199 days

Answer 16

Pedunculated 32m Nodular or cobblestone 12m Annular 1.6m

Answer 17

Within the caudal 4cm leading to focal retroperitoneal infection

Answer 18

- asap sx associated with improved survival and is important in preventing rectocutaneous fistula development - Placement of drains and administration of broad-spectrum antimicrobials are indicated - caudal perforations and rectocutaneous fistula are explored from a perineal approach. - surgical wound is managed open, eventually healing by second intention. - temporary colostomy of rectal stenting (ETT) to provide fecal bypass of the rectum until local tissues heal | dx: identify free gas in the perirectal tissues on rads

Answer 19

- can occur dt surgery or secondary to proctitis, trauma, penetrating foreign bodies, perianal fistula, congenital malformations, or infiltrative or proliferative neoplastic lesions - Contrast radiography or CT can be useful in determining the exact location +/- biopsy - nonneoplastic cases may respond to bougienage or balloon dilation or intralesional triamcinolone - resection and rectal anastomosis

Answer 20

Sphincter-enhancing procedures - Semitendinosus muscle flap - Rotation of rectum 225 degrees before anastomosis - Implantation of polyester-impregnated silicone elastomer ring - Sartorius muscle transposition - Free neuromicrovascular transfer of latissimus dorsi medical - dietary change to a low-residue diet, use of opioids to slow transit time | due to reservoir incontinence or sphincter incontinence

Answer 21

- Apocrine gland adenocarcinoma is the most common tumor, represents 17% of all perianal tumors - readily obliterate the anal sac and invade surrounding soft tissues. - equal sex distribution - Spaniel breeds, particularly English Cocker Spaniels appear to be predisposed - higher frequency of certain major histocompatibility complex type II alleles in tumor-bearing dogs - ddx squamous cell carcinoma arising from the epithelial lining **tumor biology** - Expression of KIT (2.6% of tumors) and platelet-derived growth factor (PDGF)-β (19.5% of tumors) - cellular nucleus may help to predict biologic behavior: larger nuclei were seen in metastatic tumors as compared to nonmetastatic tumors - Expression of COX-2 in 100% of primary tumors and metastatic lesions, providing a biologic basis for the use of COX-2 inhibitors in this tumor type - lower expression of the adhesion molecule E-cadherin was associated with a shorter median survival time - paraneoplastic pseudohyperparathyroidism: secretion of a substance with biologic activity similar to PTH, resulting in persistent hypercalcemia

Answer 22

100% Decreased expression of e-cadherin assoc with shorter survival 27% hypercalcaemia (20-90%)

Answer 23

- incidental finding on routine rectal in 7% to 39% of dogs - bilateral tumors have been reported, with an incidence of up to 10.5% at same time (or develop later in other side) - paraneoplastic: polyuria, polydipsia, lethargy, weight loss - FNA: polyhedral cells with uniform round nuclei and granular, light blue-gray cytoplasm - cytologic features of malignancy may be subtle staging - rectal examination, complete blood count, serum chemistry, urinalysis, and thoracic and abdominal imaging (radiography and ultrasonography, or CT) mets - metastatic sites: sublumbar lymph nodes, abdominal organs (particularly the liver and spleen), and lungs. - Metastasis to the lungs or bones is rare in the absence of sublumbar lymph node metastasis - metastasis at the time of presentation 36% to 96%. - volume of metastatic disease in these lymph nodes may be greater than the primary tumor - mets to lung 16-53% imaging - lymph node metastasis have more heterogeneous lymph nodes and bigger (>1cm suggest but not confirmed by histo) - MRI more sensetive particularly the sacral lymph nodes

Answer 24

- Hypercalcemia can result in acute renal failure and therefore must be treated before surgery - 0.9% saline promotes calciuresis and protects tubular epithelial cells, furosemide (2 mg/kg IV BID) Surgery - Surgical excision of the primary anal sac mass is currently the treatment of choice - surgery alone survival time of 16 to 18 months - multimodal tx offers better MST (sx, chemo, extirpation) l.n. extirpation - historically literature are conflicted - recently, appears to offer survival advanatge, as repeat removal increase MST - Complications after extirpation: severe hemorrhage, overflow urinary incontinence, and death Chemotherapy - theoretically indicated, given the high metastatic rate, but it is not clear which animals will benefit from this modality and what the most appropriate drugs and protocol - conflicting resuts re if improve MST - Excision of anal sac adenocarcinoma and metastatic lymph nodes is often marginal - cisplatin, carboplatin, doxorubicin, mitoxantrone, melphalan, chlorambucil, actinomycin D, piroxicam, epirubicin, prednisolone - chemo downstaged some dogs with large tumors to allow surgical excision, and palliated clinical signs of rectal obstruction in some dogs - Electrochemotherapy of an incompletely excised tumor, complete remission for more than 18 months. - toceranib resulted in a partial response in 25% and stable disease in 62.5%, radiation - may prolong survival and delay tumor regrowth - irradiation of the pelvic region can result in gastrointestinal perforation and death - sx chemo + raditation MST 956d

Answer 25

- The median survival times of dogs from three studies with a controlled treatment regimen (sx + expiration + chemo/radiation) were 17 to 31 months

Answer 26

* infection, 7% * tenesmus, * fecal incontinence 19% to 33% (more likely if anoplasty performed) * temporary urinary incontinence, * anal stenosis or stricture * local recurrence/lymph nodes 29% to 45% * Recurrence of hypercalcemia 35% to 50% (metastasis or regrowth)

Answer 27

Stage 1 - Tumour under 2.5cm, no mets. MST 40m Stage 2 - Tumour over 2.5cm, no mets. MST 24m Stage 3a - LN under 4.5cm. MST 15-16m Stage 3b - LN over 4.5cm. MST 10-11m Stage 4 - Distant mets. MST under 3m

Answer 28

* larger tumor size (>2.5 cm poorer prognosis, >5cm mets present in 86%) * lymph node metastasis, * distant metastasis * advanced clinical stage, * E-cadherin expression, * not performing surgery

Answer 29

- domestic shorthair (81%), Siamese cats may be predisposed. - hypercalcemia is rarely a feature - ulceration, sinus, fistulas, and purulent or hemorrhagic discharge more common in cats - mets only 15% of cats, outcome - 75% euthanized or died dt surgical complications (13%), clinical progression (15%), or local recurrence (35% to 41%) leading to impairment of defecation - prognosis is poor, with a median survival time of 3 months and 1-year and 1-year survival rates of 19% and 0%

Answer 30

- iatrogenic trauma to the external anal sphincter and caudal rectal artery and nerve should be avoided - blade and scissors, although the carbon dioxide laser has also been described - open, closed, modified

Answer 31

- anal sac is excised without entering its lumen - sacs can be filled with: tape, suture material, anal sac gel, paraffin, silicone sealant, resin, dental acrylic, haemostat or 5- or 6-Fr Foley catheter - sac is tightly adhered to external anal sphincter muscle, necessitating elevation or transection modified closed technique (prpich 2024) - a circular incision was made around the anal sac duct,then extended in a caudolateral direction overlying the anal sac. The subcutaneous tissues were dissected away from thesac and duct, and the tumor, sac, and duct were excised enbloc in their entirety. The external anal sphincter was then reconstructed,

Answer 32

- permits visualization of the secretory lining of the anal sac to help ensure its removal - permits complete removal of the anal sac duct and orifice. - grooved director is inserted into the duct and anal sac - modification of the open technique, the incision over the sac is made only down to the haired area of the anus (less trauma to the external anal sphincter) Disadvantages - trauma to the external anal sphincter - risk infection from contamination by anal sac contents - risk of dissemination of tumor

Answer 33

- incidence of major complications low. - Minor complication 3.2% to 32.3% - one study more with open tehcnique Intraoperative complications - hemorrhage, - iatrogenic nerve trauma - laceration of the rectum. Short-term complications - scooting, - inflammation, bruising, seroma - infection (open, debridement and lavage, and antibiotic) - dehiscence - tenesmus, dyschezia, and constipation. - fecal incontinence 3.2% to 14.5% (bilateral sacculectomy, open technique, usually resolve within 10 days) Long-term complications 1.1% to 14.7% - licking of the surgery site, - fecal incontinence - sinus or fistula (anal sac or ductal remnants) - stricture formation incontinence is uncommon after unilateral surgery because reinnervation from the intact site will occur in a few weeks, but fecal incontinence that persists for more than 3 to 4 months after bilateral surgery is unlikely to resolve.

Answer 34

- characterized by single or multiple ulcerated sinuses or fistulous tracts that can involve up to 360 degrees of the perianal skin and subcutaneous tissues - middle-aged German Shepherd Dogs pathophysiology - cause of perianal fistula is not clear, theories including anatomic, endocrine, infectious, and immunologic causes. - anal sacs may only be involved secondarily. - bacterial contamination and infection may occur (E. coli, Staphylococcus aureus) - broad-based tail with low tail carriage - More recent evidence > immune-mediated cause of perianal fistula - histologically similar to those in humans with Crohn's disease - characterized by infiltration of large numbers of CD3+ T-lymphocytes, IgA- and IgG-secreting B-lymphocytes, and macrophages - responsive to various immunosuppressive drugs - Cyclosporine can suppress T-cell activation by blocking interleukin-2 (IL-2) expression directly

Answer 35

Cyclosporine - alone has resulted in resolution of lesions in 70% to 100% of dogs treated - a mean duration of 8.8 weeks - some patients may require low-dose cyclosporine as a lifelong treatment. - regular blood level monitoring should be performed to maintain cyclosporine doses within an appropriate therapeutic range - 5 mg/kg q12 hours, target range from 400 to 600 ng/mL - Anal sacculectomy and tract resection are performed in patients for lesions that do not resolve completely with cyclosporine treatment. - Ketoconazole is an antifungal agent that affects cyclosporine metabolism by inhibiting hepatic and intestinal cytochrome P-450 oxidase activity, resulting in increased blood cyclosporine concentrations pred - dietary management and a tapering dose of prednisone over 6 to 8 weeks resulted in complete resolution in one-third of dogs Tacrolimus - inhibitor of calcineurin, with immunosuppressive actions similar to cyclosporine but with 10 to 100 times the potency. - 80% resolution or can be used together or for maintenance following oral meds azathioprine-metronidazole - not cause complete resolution of perianal fistulas, decreases the severity and extent of lesions

Answer 36

- Complete excision of all fistulous or sinus tracts in the perianal area - concurrent bilateral anal sacculectomy is recommended. - partial or complete anoplasty may be necessary > Complete anoplasty should be performed only if owners are willing to accept incontinence. outcome - en bloch sx + sacculectomy: resolution of visible lesions in 29 of 33 (87.9%) dogs and resolution of clinical signs in 79.3% Complications - dehiscence, anal stenosis, fecal incontinence, flatulence, and recurrence of lesions.

Answer 37

- weakness and separation of the components of the pelvic diaphragm - permits deviation and dilatation of the rectum and caudal protrusion of various abdominal organs - evator ani is the most common muscle atrophied - most common location is caudal perineal hernia

Answer 38

- pelvic diaphragm = principal structure of the perineum, including the levator ani, coccygeus muscles, perineal fascia, and the external anal sphincter. - levator ani muscle: two portions, iliocaudalis and pubocaudalis - coccygeus muscle: strap-like, lies lateral and cranial to the levator ani - external anal sphincter: surrounds the anal canal - internal obturator muscle, - sacrotuberous ligament: fibrous band from ischiatic tuberosity > sacrum - superficial gluteal muscle internal pudendal artery, vein, and nerve course caudomedially over the dorsal surface of the internal obturator muscle - caudal rectal nerve = innervate external anal sphincter.

Answer 39

- almost exclusively in older intact males, who constitute 83% to 93% of cases, - Pekingese, Boston Terriers, Corgis, Boxer Dogs, Poodles - cause of the condition still remains unclear and is likely to be multifactorial - association between perineal hernia and nontraumatic inguinal hernia has also been identified, suggesting a common pathogenesis 1. **Rectal Abnormalities** (deviation, dilatation, and diverticulum > likely consequence rather than cause, excessive straining may weaken pelvic diaphragm) 3. **Androgens** (predisposition of intact males, castration may help prevent recurrence from 43% to 23%) 4. **Gender-Related Anatomic Differences** (female have larger, broader, and stronger levator ani muscles, longer rectal attachment; larger sacrotuberous ligaments) 5. **Relaxin** (alters connective tissue components, greater expression of relaxin receptors in hernai dogs, produced in prostate gland) 6. **Prostatic Disease** (25% and 59% concurrent, may result in chronic straining and recurrence, castration may help) 7. **Neurogenic atrophy** (levator ani and coccygeus muscles, suggestive of a neurogenic myopathy, unknown if primary or secondary condition) | primarily testicular neoplasia in 69.7% of dogs

Answer 40

Prostate gland is the primary site of relaxin synthesis Muscles of pelvic diaphragm with perineal hernia has higher expression of relaxin receptors 25-59% of dogs with perineal hernia have concurrent prostatic disease, 69.7% have testicular abnormalities

Answer 41

- unilateral or bilateral perineal swelling, straining to defecate, and constipation - associated with obstruction, incarceration, or strangulation of herniated organs (bladder, or intestine) - Dysuria and stranguria with prostatic disease or bladder retroflexion - unilateral (47% to 66%) or bilateral, with the right side being more commonly affected Bladder Retroflexion - unable to urinate > retroflexion into the hernia may have occurred. - in 20% to 29% - azotemia and metabolic derangements > relieve the obstruction is indicated (U-cath or centesis) - FNA fluid can confirm urine (2x serum Ure/crea) - positive contrast retrograde urethrocystogram may be required - presence of urinary bladder retroflexion has no effect on the complication rate - literature confincted weather pexy makes difference to recurrence diagnosis - digital rectal examination may reveal a loss of the normal pelvic diaphragm and the presence of pelvic or abdominal viscera within the hernia. - ID unilateral or bilateral disease - abdominal radiography and ultrasonography (prostate dz, intrapelvic mass etc)

Answer 42

dietary management, stool softeners, periodic evacuation of feces by digital removal or with the use of warm soapy enemas - lactulose (0.5 to 1.0 mL/kg q8-12h, adjusted so that the animal is producing two or three soft formed stools a day) or methylcellulose and psyllium preparations.

Answer 43

* Traditional herniorrhaphy * Internal obturator muscle transposition * Superficial gluteal muscle transposition * Semitendinosus muscle transposition * Prosthetic implants * Biomaterials (Porcine SIS, Porcine dermal collagen, autologous fascia) * Organopexy (colopexy, cystopexy, vas deferensopexy)

Answer 44

- Patients that present with incarcerated or strangulated small intestine, however, require emergency abdominal exploration - catheterization or bladder decompression - Broad-spectrum perioperative antibiotics - Epidural analgesia Sx - With most herniorrhaphy techniques, an incision is made over the hernia - Gentle, firm pressure is used to replace herniated organs through the muscular defect - dog can either be repositioned for a standard approach or castrated from a perineal approach

Answer 45

-diaphragm is reconstructed by placement of sutures between the external anal sphincter and the levator ani or coccygeus muscles and internal obturator muscle ventrally - If significant atrophy is present, the sacrotuberous ligament can be used as the lateral component - Both absorbable and nonabsorbable suture have been advocated - suture placement through the rectal wall is avoided. - urethra lies just ventral to the rectum - sutures placed through sacrotuberus ligament, rather than around it, to avoid inclusion of the caudal gluteal vessels and sciatic nerve.

Answer 46

Advantages over the traditional: - reduces tension sutures (and distortion of the external anal sphincter) - additional muscular tissue and blood supply that may help improve healing and prevent breakdown. - internal obturator muscle incised caudal lateral border, elevated from the ischium - prevent damage to the obturator nerve and artery - internal obturator tendon can be transected to provide greater dorsal elevation (care damage to the sciatic nerve) - muscle is then transposed dorsally and medially to fill in the hernial defect - all herniorrhaphy sutures are preplaced before tying - suture is placed from the muscle flap's lateral edge and tendon to the coccygeus and external anal sphincter muscles.

Answer 47

- tendon of the superficial gluteal muscle is isolated below the biceps muscle and cut at its insertion on the trochanter - still has attachments to the sacrum, sacrotuberous ligament, and gluteal fascia > reflected over and sutured to the external anal sphincter - care preserve the nerve and blood supply of the superficial gluteal muscle - **modification** > superficial gluteal tendon of insertion is transected, and the muscle is rotated 45 degrees. allows closure of the defect dorsolaterally, but closure of the ventral defect is more challenging. - Simultaneous transposition of the internal obturator and superficial gluteal muscles

Answer 48

- salvage procedure when other techniques have failed or for repair of ventral hernias - relatively superficial, has a consistent blood supply, is expendable because of synergistic muscles - transposed dorsally 180 degrees to fill a hernia on the ipsilateral side - transposed 90 degrees to fill a contralateral hernia with a ventral defect. - semitendinosus muscle is exposed and isolated - caudal gluteal artery and vein, which are the major blood vessels to the proximal half of the muscle - transected at its midbelly69 or closer to the stifle if more length is needed - longitudinally and bluntly split into two parts and the medial half used to repair contralateral side - sutured to the sacrotuberous ligament, coccygeus, external anal sphincter, and internal obturator muscle - When the entire muscle is used, physical bulk of the muscle in the perineal region may make closure of the skin difficult

Answer 49

- Polypropylene and polypropylene-poliglecaprone mesh - accommodate a significantly higher load when longitudinal cords oriented parallel to the tension axis - approach is similar to that described for a traditional herniorrhaphy - preplaced sutures - modification > secured to the ischium via three holes drilled - suture sinuses the most significant complication - recurrence rate of 9.1%, with no long-term complication

Answer 50

porcine small intestinal submucosa (SIS) - regeneration of site-specific tissues, is resistant to infection, and promotes tissue ingrowth - sheet of four-ply SIS - found to be as strong as normal pelvic diaphragm and internal obturator transposition - few clinical reports porcine dermal collagen - used to augment a traditional herniorrhaphy. - success rate was 59.3% autogenous fascia lata - Fascia lata and the vaginal tunic - less risk for immunologic rejection, foreign body reaction, or formation of a nidus of infection - as primary repair, produced a strong repair with no evidence of recurrence - Lameness associated with the donor site

Answer 51

- mixed results: some studies not show cystopexy or colopexy results in a lower rate of complications - may be performed laparoscopically. Cystopexy - to prevent bladder retroflexion - performed at apex or between the right bladder neck and right lateral abdominal body wall - use is contraversial colopexy - reduce the rectal diameter by reconstructing the normal tubular shape - diminishing the accumulation of feces, and to prevent caudal migration - adjunct to the management of complicated hernias vas deferensopexy - relocates the enlarged prostate gland and bladder from the pelvic canal and improves fixation of the colon via the coloprostatic fascia - vas deferens is identified on each side and retrieved from the inguinal canal. - craniocaudal tunnel created under the transversus abdominis muscle at the level of the bladder apex - vas deferens is pulled in a caudal to cranial direction through the tunnel - used successfully in conjunction with perineal herniorrhaphy Complications - Tenesmus with or without evidence of recurrence is the most common complication

Answer 52

- recommend for patients with bilateral or complicated perineal hernias. - Complicated = rectal dilatation, prostatic disease, retroflexed bladder or those that are recurrent - initial surgery: laparotomy > colopexy and/or cystopexy + castration. - hernia repair is scheduled 2 to 7 days after - (93%) had an improved quality of life. complications - urine dribbling (37%) - tenesmus (44%) - wound complications (17%) - hernia recurrence (10%).

Answer 53

- most common = caudal hernia > tissue protrudes between external anal sphincter, levator ani, and internal obturator muscles. sciatic perineal hernia - sacrotuberous ligament can be sutured to the coccygeus and levator ani dorsal perineal hernia - coccygeus muscle should be sutured to the levator ani muscle. ventral perineal hernia - a new perineal body crated by suturing the two levator ani muscles together - closed with a semitendinosus muscle transposition - urinary catheter should be placed to avoid urethral damage

Answer 54

- rectal examination is performed to confirm the rectal wall is appropriately supported and that sutures have not been placed through it. - A low-residue diet and stool softener

Answer 55

* SSI 6-43% (dt poor aseptic technique, excessive dissection, fecal contamination, uture penetration) * wound dehiscence 0-29% * Faecal incontinence 0-33%, permanent 10-15% (unilateral should have reinnervation) * Sciatic nerve injury - less than 5%. (injury is evident immediately after recovery. If permanent - talocrural arthrodesis, long digital extensor muscle transfer to vastus lateralis, amputation) * Urinary tract complications - 0-15% (bladder atony, incontinence, inadvertent placement of sutures through the urethra > prolonged stretching of the detrusor muscle or damage to the nerve and blood, transient or permanent) * Tenesmus 4-43% (colopexy worsen?) * Rectal prolapse 0-17% * Recurrence 0-70% (10-48 traditional, 0-36 internal obturator, 36 superficial glut)

Answer 56

- difficult to compare the complication rates between studies overall - 29% to 61% traditional herniorrhaphy - 19% to 45% internal obturator - 15% to 58% superficial gluteal technique recurrence - 10-48% traditional - 0-36% (11%) internal obturator - 36% superficial glut - 12.5% internal obturator + mesh Factors affect recurrence include surgeon experience, surgical technique, previous surgical repairs, amount of tension, ongoing predisposing factors, and whether the animal is neutered or intact.

Answer 57

Larger proportion are female Bilateral disease more common Perineal swelling less common (22.5%) - most unkpwn cause, some had recent perineal urethrostomy (25% of cats), megacolon, perineal masses - no association between surgical failure and type of surgical technique, - Complications following surgery are reported to be less common in the cat

Answer 58

retrospective Non-neoplastic dz 23 of 35 (66%) dogs bilateral AGASACA seven of 35 (20%) dogs 9% intraoperatively (tumour capsule disruption) and 14% postoperatively (SSI) comparable to those reported for unilateral anal sacculectomy alone liptak 2016 (not published) 8.4% incidence of bilateral AGASACA with around half of those patients presenting with the contralateral anal sac tumour at a later stage prospective study would be beneficial in investigating the true incidence of incidental bilateral AGASACA and determining the consequences of this phenomenon

Answer 59

Prospective. perineal hernia with fascia lata vs internal obturator: 66 dogs recurrence rate was 8.8% obturator and 10.3% facia lata Fecal incontinence 3 dogs (EIOM = 1; FLG = 2) resolving by 3mths. long-term: urinary incontinence 1 dog 6% (FLG). rectum dilated in ~ 90% @ 12-month follow-up, Dogs received lactulose ~ 70% of cases did not close facia harvest > decreased tension and discomfort.

Answer 60

Retrospective multicentric cohort study West Highland White Terrier (WHWT) breed The overall median time to recurrence was not reached after 2000 days. The overall estimated median survival time was 1640 days. larger polyps were significantly associated with a shorter time of polyp recurrence The polyps were removed using the pull-out method in 45/58 dogs (78%), endoscopic diathermy resection in 7/58 dogs (12%), and colectomy in 6/58 dogs (10%). nsaid distant metastasis in 3 dogs Recurrence might have been underestimated in our study because half of dogs were monitored for recurrence using only clinical sign

Answer 61

lympadenectomy and metastasis to the iliosacral lymphocentrum are negative prognostics indicators. There was concordance between intramual and perimural techniques for the sentinel lymph node identified in 50% of cases. A sacral lymph node was identified as sentinel in three of eight dogs (37.5%)

Answer 62

Retrospective case series obturator muscle to cover the ventral aspect of the perineal hernia and the superficial gluteal muscle to cover the dorsal aspect of the hernia No recurrence of clinical signs or rectal deviation was observed (16mths). Five dogs developed a superficial minor partial necrosis of the T-shaped incision and two had surgical site infections.

Answer 63

AGASACA massive (> 5 cm), 28 dogs. Retrospective. (68%) iliosacral lymph node extirpation, including 17 of 18 (94%) dogs with suspected nodal metastasis preoperatively (18%) grade 2 intraoperative complications (rectal perforation 10%) (36%) postoperative complications >> No permanent fecal incontinence, tenesmus, or anal stenosis. MST was 671 days (37%) Local recurrence 19 > adjuvant chemotherapy, radiation, or both (not associated with PFI or OS) Dogs with lymph node metastasis at surgery were more likely to develop new/progressive lymph node metastasis and distant metastasis > -ve prognostic for PFI but not overall survival larger primary tumors > greater incidence of metastatic disease, majority of dogs (64.3%) had stage 3 disease at the time of surgery. (53.6%) of dogs in this cohort were hypercalcemic preoperatively.

Answer 64

with modified internal obturator muscle transposition 34 had bilateral The complicationrate was low, however, one cat experienced a major postoperative complication: rectal prolapse short-term postoperative tenesmus which resolved in nine of 12 (75%). good outcome (74%) (10%) had fair outcomes five of 31 (16%) had a poor outcome. Of the five cats with a poor outcome, two required subtotal colectomy to manage clinical signs related to megacolon can result in good owner-assessed longterm outcome.

Answer 65

Retrospective. Internal obturator dorsal recumbency in 23 dogs 18 abdominal pexy procedures, castration, or both No intraoperative complications SSI 4 dogs persistent urinary incontinence 2 dogs recurrence 4 dogs 17% > lowest no prior hernia repair or organ pexy

Answer 66

Transanal submucosal resections of benign and malignant epithelial rectal masses. Retrospective 93 dogs Recurrence (21%), 12/20 recurrent masses treated with repeat submucosal resection. MST not reached. The 1-,2-, 5-year carcinomas were 95%, 89%, and 73% overall survival was longer for benign tumors Recurrence was more likely incomplete margins (P = .023) were present. Recurrence was associated with an increased risk of death Presurgical biopsies > consistent with definitive diagnosis in (64.3%).

Answer 67

Retrospective sacrotuberous ligament in perineal herniorrhaphy 47 dogs No major complications or recurrence increased risk of complications > age and tx of recurrent PH All sutures in one maneuver placed around only the proximal half of ligament > further away from nerve/vessels.

Answer 68

free the origin and insertion of the ipsilateral SGM Flaps were used successfully to repair ventral perineal hernias in three dogs.

Answer 69

One hundred sixteen tumours from 107 dogs were included. There was moderate agreement between maximal dimension of the primary tumour measured by CT compared to formalin-fixed tissue and digital palpation. There was no significant difference in median maximum dimension between the measurement methods. primary tumour size (>2.5cm), tumour-stage and vascular invasion are strong predictors of metastasis at presentation.

Answer 70

3 dog and 1 cat three dogs sustained compromise of the rectal wall during excision of anal sac adenocarcinoma Polydioxa none (2 M) was used to suture the cranial, lateral and caudal mar gins of the internal obturator muscle to the seromuscular layer of the rectum in a simple interrupted pattern has the potential to promote rectal wall healing, reducing the risk of pararectal abscess formation

Answer 71

AGASACA in cats: 30 cases 36% recurrence at a median of 96 days Incomplete tumor margins > risk factors for recurrence and death. Median survival time 260 days, suggesting that wide margins should be obtained whenever possible chemo/radiation no obvious benefit sugery offers longer MST (no sx 90d)

Answer 72

Median survival time was 1,237 days. Seven dogs had tumor recurrence and 9 dogs developed metastatic disease dogs with early-stage nonmetastatic ASACA generally had a favorable outcome following surgical removal of the primary tumor alone. Routine rectal examination may be a simple and useful method for detection of dogs with early-stage ASACA.

Answer 73

Observational clinical retrospective study. Animal population: Forty-seven median of 364 days of follow-up (range 156–2156 days). Only one dog (2.2%) developed local recurrence concern that normal anal gland secretions in a dog with AGASACA may seed the entire duct with neoplastic cells. This concern forms the basis of our hypothesis that complete excision of the sac and duct, which does not occur in the traditional closed technique, would result in a lower local recurrence rate. Postoperative complications were reported in 15 dogs (31.9%) and were considered minor in 14 dogs (93.3%) and major in one dog (6.7%). Mean survival time for the 20 dogs that were deceased as of November 1, 2022 was 521 days (range 156–1409 days) and the median survival time was 388 days. Abdominal lymph node extirpation was performed in five dogs (10.6%), though 11 suspected to have l.n. mets

Ch 94 Rectum, anus + perineum Flashcards

(100 cards)