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Home , Colostomy, Ileostomy, Pararectal fossa, Rectal examination

CE Article #2

Rectocutaneous

Boel A. Fransson, DVM, PhD, DACVS a Washington State University

ABSTRACT: This article reviews the etiology, diagnosis, and treatment of rectal perforation and rectocutaneous in small animals. In addition, the literature regarding use of in small animals is reviewed, and comparative aspects of this procedure in humans and are presented. A case report of rectal perforation leading to rectocutaneous fistula formation in a dog and the use of in managing the case is presented.

ectal perforations carry the inherent risk thral or bladder perforation is more common in of introducing fecal material into the peri - dogs with pelvic fractures. 2,8 Other causes of rectal toneal cavity or the retroperitoneal space perforation include penetrating animal bites, 3,4 R 4–6 in the pelvic canal. In most species, septic peri - perineal herniorrhaphy or anal sacculectomy, tonitis and generalized septicemia develop rap - trauma from ingested foreign bodies or intralumi - idly if the is directly contaminated nal foreign bodies entering via the , iatrogenic by . Retroperitoneal fecal contamination tears during , improper use of may also lead to generalized in dogs and enema tubes, gunshot wounds , and stab wounds. 9 cats if clinical signs are not recognized and Most rectal perforations described in dogs and appropriately managed early .1,2 Another sequela cats occur within the most caudal 4 cm of the of rectal perforation is rectocutaneous fistula, .1,2,7 The rectum extends from the pelvic which has been described as secondary to trau - inlet cranially to the caudally. Cranial matic rectal injury 1,3,4 and to iatrogenic rectal per - to approximately the second caudal (coccygeal) foration from anal gland or perineal vertebra, the rectum is suspended from the ven - . 4,5 Rectal perforations and rectocutaneous tral aspect of the sacrum by the mesorectum, fistulas may be challenging to treat because they which forms the parietal peritoneum lining the are prone to complications such as dehiscence, pararectal fossa, a direct extension of the infection , and delayed healing, sometimes despite abdominal . 10 This more cranial early identification and repair. 1,2,6 part of the rectum is relatively mobile and dis - tensible and appears to be less prone to trau - ETIOLOGY matic penetration. However, at the level of the Rectal perforation in dogs and cats has been second caudal vertebra, the visceral peritoneum most frequently described in association with from the rectum reflects cranially to blend into pelvic fractures. 1,2,7 Overall , rec - the parietal peritoneum. Caudal to this point , tal tears are very rare (<1%) in the rectum is extraperitoneal and is more fixed pelvic trauma cases ,2 and ure - to the encircling muscle cuff forming the pelvic diaphragm. This less mobile area appears to be •Take CE tests a Dr. Fransson discloses that she has more susceptible to trauma. • See full-text articles been loaned equipment for research from Karl Storz and Rectocutaneous fistula is a potential compli - CompendiumVet.com AngioDynamics, Inc. cation of any rectal perforation, including peri -

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anal surgery. 11,12 However, to my knowledge, this disor - and der has been previously reported in only six small ani - Diagnostic Imaging mal cases. 1,3,4,7 The cause of the initial rectal perforation The physical examination of a dog with rectal perfo - in these animals was pelvic trauma ,1,7 an animal bite ,3,4 ration may reveal omentum herniated through a full - or perineal/anal surgery. 4 In all cases , the initial rectal thickness lesion into the rectum and protruding from perforations were surgically closed by experienced sur - the anus, 2 in which case the defect is readily apparent. In geons one or several times before dehiscence and subse - other cases , the defect is more obscure. A rectal exami - quent development of a fistulous tract. Reinforcement nation should be performed in any cat or dog with of the primary repair with a biceps muscle flap 1 or fas - trauma to the or perineal region. The tear in the cia lata graft 3 did not lead to a successful outcome. rectal mucosa may not be directly palpable, but the pres - ence of blood in the rectal lumen may be an indication DIAGNOSIS of full -thickness rectal wall trauma 2 and should lead to Clinical Signs further investigation. Rectal perforation is easily overlooked in a dog or cat In three of six cases of rectal perforation associated with severe pelvic and polysystemic trauma. 1,2,7 However, with pelvic fracture, the perforation was initially not early detection and treatment are imperative to avoid readily apparent on physical examination, and diagnosis complications, such as sepsis and repair failure, that predis - was delayed. 1,2,7 Subsequent retrospective examination of pose the patient to fistula formation. The first step is for pelvic radiographs revealed free gas in the perirectal soft

Rectal perforation may occur secondary to pelvic trauma or iatrogenically during perineal surgery. the veterinary practitioner to be alert to the fact that rectal tissue. The finding of small volumes of perirectal gas in tears are occasionally associated with pelvic fractures. a dog or cat with pelvic trauma must be considered sug - In pelvic trauma cases, the acute clinical signs of rectal gestive of rectal perforation. The analysis of pelvic radi - perforation (i.e. , pelvic canal pain and swelling ) may be ographs should include a meticulous evaluation of the obscured by hypovolemic shock or severe pain or perirectal soft tissue in addition to more readily appar - swelling from the pelvic fractures. 1,2,7 Rectal perforation ent bony lesions. in these cases can be identified by a meticulous physical No reports in the veterinary literature describe the examination and evaluation of diagnostic images. If value of advanced imaging or endoscopic examination in diagnosis is delayed beyond the first few hours after cases of rectal perforation. It is reasonable to believe that trauma, the initial clinical signs will include three-dimensional imaging using computed tomography and perineal swelling, often preceding clinical signs of or magnetic resonance imaging would allow easier exam - . 2,3 ination of the perirectal tissue compared with conven - In cases of iatrogenic rectal penetration or perforation , tional radiography. the initial clinical signs include , dys- The diagnosis of an established rectocutaneous fistula chezia , and pain or discomfort associated with defeca - in a dog or cat is usually more straightforward than that tion or rectal . 9 Perineal herniorrhaphy with of a recent rectal perforation because the drainage from inadvertent suture placement into the rectal mucosa may the fistulous tract shows fecal contamination. 1,3,4 cause tenesmus as an early clinical sign. If the offending suture is not removed, subsequent suture tract infection TREATMENT may lead to formation of a rectocutaneous fistula. 5,13 It is often stated that minor retroperitoneal rectal per - The clinical signs of a rectocutaneous fistula include forations can heal by second intention if adequate drainage of fecal material through the perianal defect 1,3,4,12 drainage is provided. 5,9,11 However, healing by second and pain and swelling associated with a perifistular intention was reported in only two of eight patients inflammatory reaction. with rectal perforation/rectocutaneous fistula that sur - (text continues on page 230)

April 2008 COMPENDIUM 226 CE Rectocutaneous Fistulas

Management of a Rectocutaneous Fistula in a Dog byTemporary Colostomy

History and Presentation site of the colostomy—a flat area without skin folds in the A 59.4-lb (27-kg), 4-year-old, male castrated Karelian dorsal flank region (Figure A )— was planned with the dog bear dog was referred to the Washington State University awake in normal standing position. A circular skin incision Veterinary Teaching Hospital (WSUVTH) for a rapidly 4 cm in diameter was made and the underlying abdominal growing soft tissue sarcoma located in the right perineal wall musculature separated rather than incised to gain region. The mass was surgically resected, leading to a small entrance into the . The rectal perforation that was surgically repaired during the was exteriorized, and a rod created from three 90-mm same procedure. Five days after the first surgery, the per - Lubra plates wired together was passed through the meso - ineal area was surgically reexplored because of fecal colon and sutured in a vertical position in the subcutis and drainage from the incision, and a 1-cm rectal defect was to the underlying muscle fascia. The seromuscular layer of sutured and reinforced with porcine intestinal submucosa the exteriorized colon was sutured to the subcutaneous tis - (Vet BioSISt, Cook Biotech Inc., West Lafayette, IN). An sue. A 4-cm antimesenteric longitudinal enterotomy was 18-fraction course of radiation therapy was started 14 days performed and the mucosa sutured to the skin with simple after the second surgery and was completed after 23 days. interrupted sutures. Care was taken to allow the mucosa to Two weeks after the last radiation treatment, the local vet - evert over the skin edges to create a “nipple-like” protru - erinarian diagnosed a rectocutaneous fistula located in the sion in an attempt to minimize fecal contact with the skin previous surgical field. The dog returned to WSUVTH for (Figure B ). surgical repair through an anal approach. Four days after the colostomy procedure, the perineal inflammation had decreased significantly and the rectocu - Treatment and Outcome taneous fistulous tracts were surgically resected. The previ - One week after the third surgery, the dog returned to ously identified rectal wall defects were sutured from the WSUVTH because of severe pain during defecation and perineal approach, and an internal obturator muscle flap drainage of fecal material from the perineal area. A recto - was used to reinforce the repair and support the rectal wall. cutaneous fistula was again located in the center of the On the 32 nd day after colostomy creation, the colon was previous perineal incision. Results of a complete blood sharply dissected from the skin and , and count, biochemistry profile, and urinalysis were within the longitudinal enterotomy was closed in a transverse normal limits. Subcutaneous administration of amikacin direction. The lumen of the colon aborad to the (20 mg/kg once daily) was instituted, and the dog was sub - was mildly atrophied. One centimeter of the skin and sub - sequently monitored by daily urinalysis. and cutis surrounding the stoma was resected, the area was rectal examination revealed two defects in the right ventro - lavaged, and the muscle layers, subcutis, and skin were lateral rectal wall, 1 cm and 3 cm cranial to the anus, closed in separate layers. The dog recovered without com - respectively. Two days later, a left flank diverting colostomy plications and was discharged the following day with the was performed, as described by Hardie and Gilson .6 The recommendation to feed a liquid diet for 2 days and then

Figure A. The planned colostomy site . A flat area Figure B. The colonic mucosa is allowed to evert over without folds in the left dorsal flank region was chosen . the skin edge in an attempt to minimize fecal contact with the skin.

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a low-residue diet in gradually larger portions over the of the mass showed spindle-shaped cells consistent with next 10 to 14 days. local recurrence of the sarcoma. The owners elected Four doses of doxorubicin were administered 3 weeks euthanasia. apart, starting 4 weeks after the colostomy reversal. After the first treatment, the dose was decreased from 29 mg/m 3 to 25 Stoma Care mg/m 3 because of a decrease in the white blood cell count. The stoma was kept patent for 32 days, during which a At the time of each chemotherapy administration, the rec - low-residue diet was fed. During this time, a two-piece tum was palpated and no masses or defects were noted. flange-and-bag system was used (Figures C and D), with Approximately 4 months after the last chemotherapy the opening in the flange cut to a diameter of 45 mm. The dose, the dog returned to WSUVTH with pain on defe - adhesive backing on the flange did not provide a secure cation. A mass 3 cm in diameter was palpated in the area attachment, so additional adhesive was applied to the of the previous rectal wall defects. Abdominal ultra - peristomal area and adhesive tape was used to secure the sonography showed no evidence of metastasis and a edge of the flange (Figure E ). colonic wall within normal limits. Fine-needle aspiration The stoma care and the products used for the colostomy (Box continues on page 230)

Figure C. An example of a two-piece flange and bag Figure D. The flange and bag in place over the system. colostomy.

Figure E. After multiple trials with different adhesive Figure F. Skin excoriation at its peak 12 days after strategies, the owners applied elastic tape as well as colostomy. adhesive to extend the time between flange changes.

April 2008 COMPENDIUM 230 CE Rectocutaneous Fistulas

Management of a Rectocutaneous Fistula in a Dog byTemporary Colostomy (continued)

diversion by enterostomy earlier in the disease process would decrease the number of surgical procedures needed for reso - lution. However, the owners need to be aware and capable of the level of postoperative care associated with an enteros - tomy. The maintenance of temporary enterostomy in dogs has varied from 9 days 1 to 3.5 weeks 6 in previously reported cases of rectal perforation or rectocutaneous fistula. In this case, radiation therapy of the pelvic canal had been per - formed, which can impair local wound healing after repair of a rectal defect. a A slightly longer time (32 days) for colostomy maintenance was used to ensure adequate healing of the rectocutaneous fistula repair. In cases of cancer-related rectal obstruction, have been used for up to 7 months .6 Compared with humans and horses, complications appear to be sparse and mild in dogs. 1,3,6,15,20,21,23,24 Skin exco - Figure G. After modification of the stoma care, including riation is the most commonly reported complication. 3,6 skin protection with diaper rash ointment, the excoriation However, the number of enterostomies reported in small improved and resolved (day 32 after colostomy ). animals is limited, and general conclusions regarding com - plications should be made with caution. (Box continued from page 227) In the case reported here, the enterostomy significantly period are summarized in Table 1. Skin excoriation decreased the dog’s pain associated with defecation. At a occurred from day 4 and peaked at day 12 (Figure F ) after later interview, the owners expressed that they did not stoma creation. After some modification of skin care, the regret the decision to have the colostomy procedure per - skin excoriation diminished and was healed completely by formed because of the increased quality of life obtained the week before colostomy reversal (Figure G ). for their dog, despite the short survival time after treat - ment. However, they also acknowledged the effort associ - Discussion ated with stoma care and indicated that they would not Rectocutaneous fistulas are, fortunately, rare in veterinary have been able to proceed with a permanent colostomy. medicine. However, as illustrated by this case and others, aMorgenstern L, Sanders G, Wahlstrom E, et al. Effect of preoper - treatment is often difficult and may require multiple surgical ative irradiation on healing of low colorectal anastomoses. Am J procedures. 1,3 It is possible that more frequent use of fecal Surg 1984;147(2):246-249.

(continued from page 225) vived the perioperative period. 1–4,7 Both of these cases both cases requiring fecal diversion, the time from per - required fecal diversion by colostomy or foration to primary repair exceeded 1 week, and rectocu - before a successful outcome was achieved. 1,3 The size of taneous fistulas had developed. 1,3 the defect appears to have little impact on the outcome In three cases reported by Schiller and colleagues ,4 of the case. In six cases in which rectal defect sizes were primary repair was attempted several times. After multi - reported, the defects ranged from 2 mm in diameter to ple repair failures with formation of rectocutaneous fis - 1–3,7 20 × 40 mm, with a median length of 17.5 mm. In tulas, the cranial aspect of the defect was anastomosed one of the two cases that ultimately required fecal diver - to the anus, which led to a successful outcome. How - sion to heal, the rectal perforation was only 2 mm in ever, clinical signs, defect size and location , and time to diameter. 1 repair in these dogs were not well described. 4 This tech - Time to primary repair appears to be of greater nique has also been suggested by Matthiesen and Mar - importance than defect size. In two of three cases suc - retta 12 for the management of rectocutaneous fistulas cessfully managed by primary repair without fecal diver - secondary to perineal . sion, the rectal defects were closed within 24 hours of If the patient presents with clinical signs of general - occurrence .2 In the third case, primary repair was carried ized sepsis from retroperitoneal rectal perforation, stabi - out on the sixth day after trauma. However, lavage of the lization before anesthesia and surgery is imperative. pelvic canal and treatment with intravenous broad -spec - Fluid therapy to correct hydration status and colloid trum antibiotics had been instituted 3 days earlier. 7 In osmotic pressure is necessary, as are intravenous broad -

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Table 1. Care of theTemporary Colostomy in the Reported Case Procedure Frequency Equipment a Comments Bag changes Twice daily or Disposable or reusable (Figure C) • Use gloves to protect hands from intestinal after bowel colostomy bag bacteria. movement • Reusable bag requires cleaning and drying Used here : b before reuse ; fecal material characteristics • Sur-fit Natura drainable pouch (“stickiness”) may make reusing bags • Sur-fit Natura closed-end pouch b difficult. I recommend having both types available. Do not lose the bag clip if using a reusable bag.

Stoma cleaning Twice daily or • Long-handled cotton -tipped • Use gloves to protect hands from intestinal after bowel applicators bacteria. movement • Cotton makeup pads • Oil- or petroleum -based skin protection • Saline products tend to mix with the fecal content • Triple antibiotic ointment and may be difficult to dissolve with water - • Diaper rash ointment based products . Cleaning may be more effective using the skin protection product Used here: rather than water or saline. • Desitin original c • Neosporin original c

Skin protection After each • Triple antibiotic ointment Apply with cotton -tipped applicators to the cleaning • Diaper rash ointment skin (not colonic mucosa) exposed to fecal material. Used here: • Desitin original c • Neosporin original c

Flange change Every 2 –4 days • Flange (Figure C) • Flange removal may require sedation, • Adhesive especially if the adhesive irritates the skin. • Wide elastic adhesive tape • In the case presented here, Skin-Bond was irritating the skin and difficult to remove ; Used here: the owners chose to use Stomahesive around • Sur-fit Natura Stomahesive wafer b the inner perimeter of the flange and 6 × 6- in , 4- in flange adhesive tape (Figure E) to secure the • Sur-fit Natura Stomahesive flexible remainder of the flange. wafer, 5 × 5- in, 2¼ -in flange b • Adhesive remover is available but was not • Stomahesive paste b used in this case. • Skin-Bond d • Elastikon c

Protection of Daily • Stockinette A 6-inch stockinette conforms well to the appliances • T-shirt trunk and minimizes downward displacement of the flange/bag. For added protection during walks and travel , a tight T-shirt can be worn over the stockinette. aThe product information is strictly for products used in this case report and is not an exhaustive list of available products. bConvaTec, Princeton, NJ cJohnson & Johnson Consumer Companies, New Brunswick, NJ dSmith & Nephew, Largo, FL; this product has since been discontinued by the manufacturer. spectrum antibiotics. In addition, adequate drainage of thesia and subsequent primary repair or fecal diver - the perineal area with or without wound lavage is sion .1,3,7 Septic must be ruled out in these important to successfully stabilize these cases for anes - animals by abdominocentesis, diagnostic peritoneal

April 2008 COMPENDIUM 232 CE Rectocutaneous Fistulas

Suspicion of rectal perforation

Rectal examination Diagnostic imaging shows perirectal gas

Minor defect: Extent of (<2 mm in diameter) Large defect or suture penetration defect unknown (>2 mm)

Endoscopy Remove offending suture Stabilize animal and Diagnostic imaging Begin antibiotic therapy proceed to primary Diagnostic perineal lavage Establish drainage repair without delay Surgical exploration

Inflamed fragile Failure of primary Formation of tissue with high risk repair/formation of Successful healing rectocutaneous fistula for failure rectocutaneous fistula

Consider Primary repair Fecal diversion of Consider fecal diversion by colostomy/ defect to anal mucosa.* by colostomy/jejunostomy jejunostomy

Figure 1. An approach to the patient with suspected rectal perforation. *Surgical technique described by Schiller and colleagues. 4 lavage , or surgical abdominal exploration. Adequate after exteriorization of the intestinal segment and either drainage can be achieved by open wound management transverse transection of the intestinal segment, creating of the perirectal tissues, using wet-to-dry bandages .1,3 an end enterostomy, or enterotomy, creating a loop A management approach to cases of suspected rectal enterostomy. 15 perforation is depicted in Figure 1. In humans, minimizing the bulk and odor of the fecal effluent is of great concern , and is often TEMPORARY FECAL DIVERSION preferred over colostomy for this reason. 16 The overall BY ENTEROSTOMY complication rate appears to be fairly similar between Comparative Medicine ileostomy and colostomy. 17,18 Complications after any In human medicine, temporary fecal diversion by enterostomy are very frequent ; the most common include colostomy has been used for more than 200 years and skin excoriation, appliance leakage, stoma retraction , and remains a common and important treatment option for small . 15 Small bowel obstruction is com - many colorectal diseases. 14 Indications include colorectal mon after both creation and closure of a loop ileostomy. or other obstructing cancer ; severe inflammatory dis - The obstruction is most commonly a result of intraabdom - ease ; pelvic , perineal, or perianal sepsis, including rectal inal adhesions following the , but in some perforation ; and major large intestinal resection and instances , disuse atrophy of the distal intestinal limb, lead - anastomosis (coloanal or ileoanal ). 15 An anastomosis ing to a narrowing diameter, is believed to play a role. 15 A between the skin and intestinal mucosa can be achieved complication more commonly associated with ileostomy

COMPENDIUM April 2008 234 CE Rectocutaneous Fistulas

than with colostomy is the high output of liquid or semi - distal limb with 20 L of warm water was believed to liquid efflux , leading to dehydration and electrolyte distur - reduce the distal limb atrophy in the other study. 24 One bances. 15,19 Colostomy is associated with a higher frequency case of small bowel obstruction caused by for - of intestinal prolapse than is ileostomy. 20,21 mation between jejunum and abdominal wall was High body mass index, inflammatory bowel disease , noted. 23 and old age have repeatedly been shown to be risk fac - tors for enterostomy complications; 15 immunosuppres - Enterostomy in Small Animals sive treatment, diabetes , and surgeon inexperience are Only eight clinical cases of enterostomy in dogs have less consistently cited .15 A significantly decreased risk for been reported. 1,3,6,27 The indication for enterostomy was complications has been noted if an enterostomal thera - rectal obstruction associated with cancer or cancer treat - pist is involved in the treatment of stoma patients. 22 The ment in four cases 6,27 ; rectal perforation in three cases ,1,3,6 role of the enterostomal therapist in counseling the of which rectocutaneous fistula developed in two patient preoperatively, determining the stoma location , cases 1,3 ; and temporary colostomy to protect the surgery and educating the patient in the care of the stoma and site after rectal resection and anastomosis in one case .6 appliances is extremely important . Most of the dogs (five of eight) were treated by left Colostomy has also been reported as being of benefit flank colostomy through either a loop colostomy (four in horses with rectal tears. 23,24 In horses, rectal tears tend dogs )6 or end colostomy (one dog )27 ; ventral loop to occur in the peritoneal segment of the rectum or colostomy, 6 left ventrolateral end colostomy ,1 and right- descending colon and are often incurred iatrogenically sided end jejunostomy were used in one dog each .3

If identified late, a rectal perforation may lead to generalized sepsis or rectocutaneous fistula formation. during rectal palpation .23,25 Patients with incomplete In a case series of five dogs reported by Hardie and tears have excellent survival rates after conservative Gilson ,6 the first dog underwent a ventral colostomy. management with antibiotics, antiinflammatories , and This dog experienced fecal leakage into the peritoneal stool softeners .26 Tears extending to the serosa or meso - cavity, generalized sepsis , and multiple failure. The colon or through all layers are considered high grade authors speculated that the ventral location caused ten - and are potentially fatal because the risk for septic sion on the suture line , leading to the failure , and the peritonitis is high unless immediate treatment is insti - subsequent cases were managed by a left flank colostomy tuted. 23,24,26 Colostomy has been previously recom- using a colostomy rod to minimize tension on the stoma mended as the preferred treatment of high -grade tears site. The complications in the four surviving dogs mainly in which more than 25% of the rectal circumference is consisted of skin excoriation and appliance -related prob - torn. 25 However, the complication rates associated with lems. In two of the four dogs , the primary disease colostomy or its reversal have been high, reaching 84% process allowed reversal of the colostomy , and despite in two available studies. 23,24 In these studies, only one of mild atrophy of the distal colonic limb , no further com - the 12 horses that survived the initial 3 postoperative plications occurred at the incision site or in gastrointesti - days recovered without complications. The most com - nal function. 6 In a case of end colostomy reported by mon complications included partial dehiscence of the Tobias, 1 no complication related to the stoma occurred. stoma during anesthesia recovery (eight of 12 horses ), In this case , a “cuff” of colonic mucosa was created before partial dehiscence of the paralumbar incision after anastomosis of the mucosa to the skin to prevent fecal reversal (six of 11) , peristomal hernia (two of 12), and contamination of the skin, and the stoma was left open stomal prolapse (two of 12). 23,24 In addition, severe atro - and unbandaged. 1 In the most recent case reports of phy of the distal colonic limb, leading to impaction and enterostomy, a temporary end jejunostomy 3 and a perma - obstruction of the colon adjacent to the reversed stoma nent left flank end colostomy 27 were created , and the site, was observed in one study .23 Daily lavage of the only complications noted included skin excoriation 3,27

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and a disparity between the proximal and distal intestinal 17. Williams NS, Nasmyth DG, Jones D, et al. De-functioning stomas—a prospective controlled trial comparing loop ileostomy with loop transverse limb diameter, prohibiting an end-to-end anastomosis at colostomy. Br J Surg 1986;73(7):566-570. 3 reversal. 18. Silva MA, Ratnayake G, Deen KI. Quality of life of stoma patients —tempo - rary ileostomy versus colostomy. World J Surg 2003;27(4):421-424. CONCLUSION 19. Hallbook O, Matthiesen P, Leinskold T, et al. Safety of the temporary loop ileostomy. Colorectal Dis 2002;4(5):361-364. Early detection and treatment of rectal perforation is 20. Law WL, Chu KW, Choi HK. Randomized clinical trial comparing loop the preferred method to avoid formation of rectocuta - ileostomy and loop transverse colostomy for faecal diversion following total neous fistulas. If a fistula is established and its size or mesorectal excision. Br J Surg 2002;89(6):704-708. location precludes the use of local repair techniques, an 21. Gooszen AW, Geelkerken RH, Hermans J, et al. Temporary decompression enterostomy for fecal diversion may be indicated in com - after colorectal surgery randomized comparison of loop ileostomy and loop colostomy. Br J Surg 1998;85(1):76-79. bination with primary repair or healing by second inten - 22. Duchesne JC, Wang YZ, Weintraub SL, et al. Stoma complications: a tion. Enterostomies in small animals appear to be multivariate analysis. Am Surg 2002;68(11):961-966. associated primarily with mild complications such as skin 23. Blikslager AT, Bristol DG, Bowman KF, Engelbert TA. Loop colostomy for excoriation and mild atrophy of the aborad bowel seg - treatment of grade-3 rectal tears in horses: seven cases (1983-1994). JAVMA ment. Stoma care is intensive, and owner education and 1995;207(9):1201-1205. commitment are imperative for a successful outcome. 24. Freeman DE, Richardson DW, Tulleners EP, et al. Loop colostomy for man - agement of rectal tears and small-colon injuries in horses: 10 cases (1976- 1989). JAVMA 1992;200(9):1365-1371. REFERENCES 25. Watkins JP, Taylor TS, Schumacher J, et al. Rectal tears in the : an 1. Tobias KM. Rectal perforation, rectocutaneous fistula formation, and entero - analysis of 35 cases. Equine Vet 1989;21(3):186-188. cutaneous fistula formation after pelvic trauma in a dog. JAVMA 26. Arnold JS, Meagher DM, Lohse CL. Rectal tears in the horse. J Equine Med 1994;205(9):1292-1296. Surg 1978;2(2):55-61. 2. Lewis DD, Beale BS, Pechman RD , et al. Rectal perforations associated with 27. Kumagai D, Shimada T, Yamate J, et al. Use of an incontinent end-on pelvic fractures and sacroiliac fracture-separations in four dogs. JAAHA colostomy in a dog with annular rectal adenocarcinoma. J Small Anim Pract 1992;28(2):175-181. 2003;44(8):363-366. 3. Chandler JC, Kudnig ST, Monnet E. Use of laparoscopic assisted jejunos - tomy for fecal diversion in the management of a rectocutaneous fistula in a dog. JAVMA 2005;226(5):746-751. ARTICLE #2 CE TEST 4. Schiller AG, Helper LC, Knecht CD. Repair of rectocutaneous fistulas in the CE dog. JAVMA 1967;150(7):758-759. This article qualifies for 2 contact hours of continuing 5. Matthiesen DT. Diagnosis and management of complications occuring after education credit from the Auburn University College perineal herniorrhaphy in dogs. Compend Contin Educ Pract Vet 1989;11(7):797. of Veterinary Medicine. Subscribers may take 6. Hardie EM, Gilson SD. Use of colostomy to manage rectal disease in dogs. individual CE tests or sign up for our annual Vet Surg 1997;26(4):270-274. CE program . Those who wish to apply this credit to 7. Muir P. Rectal perforation associated with pelvic fracture in a cat. Vet Rec fulfill state relicensure requirements should consult their 1998;142(14):371-372. respective state authorities regarding the applicability 8. Selcer BA. Urinary tract trauma associated with pelvic trauma. JAAHA of this program . CE subscribers can take CE tests online 1982;18(5):785-793. and get real-time scores at CompendiumVet.com . 9. Niebauer GW. Rectoanal disease. In : Bojrab MJ , ed . Disease Mechanisms in Small Animal Surgery . Philadelphia: Lea & Febiger ; 1993:271-284. 10. Evans HE, Christensen GC. Miller’s of the Dog . 2nd ed. Philadel - 1. Rectal perforation or tear is seen in fewer than phia: WB Saunders; 1979:484-492. ____ of small animal cases with pelvic trauma. 11. Aronson L. Rectum and anus. In: Slatter D , ed. Textbook of Small Animal Sur - a. 1% c. 10% gery . 3rd ed. Philadelphia: WB Saunders ; 2003:682-708. b. 5% d. 20% 12. Matthiesen DT, Marretta SM. Diseases of the anus and rectum. In: Slatter D , ed . Textbook of Small Animal Surgery . 2nd ed. Philadelphia: WB Saunders; 2. Other than vehicular trauma, etiologies for rec - 1993:627-645. tal perforation that have been reported in small 13. Houlton JEF. Surgical treatment of perineal hernia in dogs. Vet Annu 1983;23:208-213. animals include a. animal bites. 14. Cataldo PA. Intestinal stomas : 200 years of digging. Dis Colon Rectum 1999;42:137-142. b. iatrogenic injury in association with perineal hernior - 15. Kaidar-Person O, Person B, Wexner SD. Complications of construction and rhaphy. closure of temporary loop ileostomy. J Am Coll Surg 2005;201(5):759-773. c. iatrogenic injury in association with anal sacculec - 16. Fasth S, Hulten L. Loop ileostomy a superior diverting stoma in colorectal tomy. surgery. World J Surg 1984;8(3):401-407. d. all of the above

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3. Most rectal perforations in dogs and cats occur 10. The most commonly reported complication of within ______cm of the anus. enterostomy in dogs is a. 1 c. 3 a. atrophy of the orad bowel segment. b. 2 d. 4 b. intestinal prolapse through the stoma. c. skin excoriation. 4. Rectal perforation should be suspected in a dog d. dehydration and electrolyte imbalance due to high or cat with pelvic trauma that efflux from the stoma. a. develops melena. b. demonstrates pain on rectal palpation. c. is showing free perirectal gas on radiographs. d. presents in shock.

5. Which statement regarding rectal perforations in dogs is true? a. Only defects larger than 1 cm are clinically significant. b. Early repair appears to be important for successful outcome. c. Healing by second intention has proven to be highly successful. d. Primary repair should not be attempted.

6. In humans, ileostomy is often preferred over colostomy for fecal diversion because a. ileostomy is associated with fewer complications. b. the bulk and odor of the effluent are less offensive. c. small bowel obstruction has not been associated with ileostomy. d. dehydration and electrolyte abnormalities due to high -volume efflux are more common with colostomy.

7. Risk factors for complications with enterostomy in humans include a. high body mass index . b. inflammatory bowel disease . c. old age . d. all of the above

8. Which statement regarding colostomy in horses is false ? a. Low complication rates have been seen in clinical studies. b. Colostomy has been recommended for high-grade rec - tal tears involving >25% of the rectal circumference. c. Stoma dehiscence often occurs during recovery from anesthesia. d. Small bowel obstruction has been reported as a com - plication.

9. _____ is the most commonly reported enteros - tomy technique in dogs . a. Left flank loop colostomy b. Right flank end jejunostomy c. Left flank end colostomy d. Ventral loop colostomy

COMPENDIUM April 2008