Surgery of the anus (Proceedings)

Perianal fistula is a specific disease of the canine characterized by ulcerating fistulous tracts, often with a malodorous purulent discharge around the anal orifice. The tracts are usually infected and filed with chronic inflammatory tissne. The extremely severe and chronic cases the tracts may extend to the lumen of the rectoanal canal, becoming true fistulas.

This disease is most commonly seen in the German shepherd with a few cases reported in Setters and Retrievers. Dogs of either sex can be affected and there seems to be some age correlation with older dogs, over seven years, being most often affected.

Etiology

Although the etiology of this disease is not clear, many possibilities have been advanced. The conformation of the German shepherd may be a predisposing factor in that the broad-based tail is held close to the anal region and thus maintains a film of fecal material and anal sac secretion over the perianal region. This conformation and the poor ventilation afforded by such tail carriage may provide a suitable environment for establishment of infection of circumanal glands, hair follicles, and other glands in the perianal region.

This conformation and. the poor ventilation afforded by such tail carriage may provide a suitable environment for establishment of infection of circumanal glands, hair follicles, and other glands in the perianal region, and thus abscessation fistulization. This author feels the deep folds just inside the anus also play a major role in this disease and lead to collection of feces in rectal glands and resulting fistulous tracts.

Many of the dogs affected may also have a generalized skin problem and be hypothyroid; some may also have poor T-cell function. Thus some suspect that perianal fistulas are an expression of generalized skin and systemic problems.

The anal sacs have been shown to be only secondarily involved in the disease process.Statistically, anal disease is seen less frequently in German Shepherds. However, the infection can spread to deeper structures which can eventually canse severe problems for the dog. One of these structures is the external anal sphincter, which plays a vital role in fecal continence; rarely do the tracts extend to the bowel lumen.

Clinical presentation and diagnosis

The primary clinical signs associated with perianal fistulas are tenesmaus, constipation and dyschezia with licking and biting of the anal area. Weight loss, anorexia, lethargy and diarrhea may occur as the disease progresses. In severe cases there will be a copious, foul-smelling mucopurulent discharge in the perianal area and mild fecal incontinence. Occasionally, rectoanal hemorrhage will occur.

Diagnosis is made by direct visual examination of the perianal area, revealing the fistulous lesions, which vary according to the chronicity of the disease. It is important to differentiate this disease from primary anal sac disease, which has lead to abscessation and fistula formation. Anal sac disease is rare in German Shepherds and other large breed dogs. The lesions associated with anal sac disease are found generally over the anal sac area, while perianal fistula lesions can be found 360 degrees around the anus. Perianal adenocarcinomas will also have ulceration and fistulization in this area; however, on palpation the perianal gland tissue around the anus will be considerably thickened. A biopsy may be necessary to differentiate the two.

The severity of the disease is correlated with the extensiveness of the lesion, the amount of scar tissue that has been laid down and the length of time the disease has been allowed to progress. Ulceration and necrosis of the skin in the perianal region is often seen; the lesions may extend two to five centimeters from the anus and further in severe cases. The fistulous tracts may be seen extending deep into the tissue and may contain hair and fecal material. Microscopically, these tracts are lined by chronic granulation tissue or stratified squamous epithelium growing in from the skin. In severe cases the formation of fibrous tissue around the anus may prevent easy dilation of the anal orifice and result in stricture and fecal impaction.

Rectal examination is essential and may have to be performed under anesthesia. An assessment should be made of the depth of the lesions, extent of circumferential involvement and any degree of anal stricture that may be present due to the chronicity of the disease, These factors affect the extensiveness of the surgical intervention and prognosis for the case.

Post-operative care entails administration of antibiotics lincocin (10 mg/lb. BID) for 5 days and a low residue diet such as I/D to maintain a low bulk diet and a soft stool without diarrhea. 2 tablespoons Metamucil is added to the feed daily, as needed, to help prevent diarrhea or constipation. The dog should be walked daily and problems with defacation noted. Re-examinations  are required to ensure that the healing process is advancing properly and that complications have not arisen, however, it is imperative not to raise the tail too high when examining the incision to prevent stressing the incision with resulting incision breakdown.

At the University of Missouri Veterinary Teaching Hospital we ran a retrospective study on the perianal fistula repairs, which were performed from 1973-1983 and found several interesting results. Our success rate was 62% for one surgical procedure and the overall success rate for one or more surgical procedures was 75%. But as was mentioned before, we have a much higher success rate if the cases are presented closer to their inception. For instance, we were successful on 78% of the mild cases after just one procedure, in comparison to 53% of the severe cases, although the pull-through technique showed good success with the severe cases with a final success rate of 73%.

The complications that may occur with this procedure are: incision dehiscence (usually on the 4th or 5th post-operative day), or fecal incontinence. Incontinence can be transient, and often continence returns after 2-3 weeks, if incontinence is permanent, there is little that can be done. Stricture can be handled by doing anasplasty. Dehiscence is resutured after a granulating bed develops. Cleansing the dehisced wound twice daily with tepid water from a hose keeps the wound clean and promotes granulation. The incidence of post- operative complications increases with severity of the disease.

In conclusion, perianal fistula is a disease that can be successfully corrected with a rectal pull-through. Although the procedure is not 100% successful, veterinarians can offer a relatively good chance to the animal. Clients should be made aware of the clinical signs elicited with this disease and urged to consult their veterinarian on the proper care.