Direct intraluminal closure of artificial grade four rectal tears in horses

Abstract

Iatrogenic rectal lesions are rare, but well known, and with lesions of third or fourth grade (according to ARNOLD et al. (1978a)) often fatally proceeding and, dreaded complications ofduring transrectal examinations of the abdominal organs in horses. References for the approach to the caretreatment of higher graded rectal lesions vary strongly and are based on case reports, small case series and few experimental studies. Due to the When contamination of the pelvic and abdominal cavity occurs, the chance of survival rate of the injured horse is critically decreases significantlyd. So aAll treatment proposals firstly demand an instant medical care of the lesion. Therefore the direct transrectal all layer suture of the injured rectal wall, using the specifically for this suture specialised modified Deschamps-needle is proposed, and in few cases successfully applied (HUSKAMP 1994). The intraluminal suture of the rectal wall, which is very difficult from a surgical point of view, has to be performed blindly and has to fulfil all requirements of other intestinal sutures. That is to say This means it has to feature absolute densityimpermeability, has to resist high pressure and has to have a high patency. In the context of the existing study, the question was investigated, if and to what extend such an operation can be performed in practice. Twenty-two immediately post mortem removed rectum and small colon specimens of horses of different age, sex and breed were clamped mounted in a phantom in an anatomically correct position. Afterwards an iatrogenic rectal lesion was simulated by applying a perforating fourth grade lesion from intra to extra luminal in with a length of 7,5 cm at the location which is most often described in the literature (dorsolateral in the rectal roof, intra peritoneal). Following that, it was attempted to close the lesion sightlessly with an intra luminal all layer suture using a modified extra long Deschamps-needle and a braided absorbable suture material metric 5. After confirming the secure closing by palpation (first criterion), the suture was tested for its capacity. It had to resist a pressure of a minimum of 60 mm Hg, simulated by using water filling (second criterion). The suture site had to hold a patency of > 85 % (third criterion) to be classified as a succeeded suture. Thisat means that such a suture could fulfil all requirements for the survival of a liveing horse. During suturing the following difficulties occurred: The intra luminal orientation byvia palpating the perforation edges proved to be very difficult. Because of that an exact placement of the individual sutures was hindered. For the same reason, the tissue trauma became worse. In addition, the wound's edges were ruptured, so more manipulation was needed to place additional sutures. An adjustment of the wound's edges against each other, which caused a formation of crinklesfolds, could not be avoided in every case. The described difficulties led to an expenditure of time. In 7 of 22 cases (31.8 %) the trial was discontinued after a minimum of 60 minutes, because the wound's edges ruptured repeatedly, so that an adequate wound closure was unachievable. Fifteen of the 22 sutured intestines (68.2 %) were palpated and classified as successful (first criterion). From this group, eight (8/15 = 53.3 %) cases did not fulfil both of the other criteria, pressure ≥ 60 mm Hg and patency ≥ 85 %. Another two palpatory successfully classified sutures (2/22 = 9.1 %) resisted a pressure of ≥ 60 mm Hg, but could not reach a patency of ≥ 85 %. The mean closing time for the 15 palpatory successfully classified cases was 94 ± 6.4 min. Five of 22 sutures (22.7 %) passed all three criteria and were classified as "successful" sutures. The given experimental conditions could not simulate the additional difficulties that occur during a suture in the field (agitation, defence of the animal, peristalsistic of the intestine, blood coagulation attached to the wound edges, lack of help and lack of an adequate fixation standhorse stocks). Conclusions:1. If an intra luminal rectal suture is palpated and classified as a successful suture, it can not be assumed that this is in fact a secure wound closure. Rather more than half of these sutures are expected to be insufficient or cause lumen narrowing. 2. Because of the manipulation withinin the rectum it suturing can result in a worsening of the situation, instead of a secure closure of the intestinal lesion. 3. Despite improved surgical experience due to the repeated trial management treatment there is a high need demand of time (app. 1.5 hours). High expenditure of time would cause additional problems on for patients and finally, only five of 22 of the intestinal sutures (just undershortly one quarter25%) could be classified as "successfully" sutured. 4. Because of the additional difficulties on living patients during suturing a rectal lesion in living patients, the emergency situation in the field would bring an even worse result (< 22,7 %). Due to For this reason and because of a not in every case avoidable contamination of the abdominal and pelvic cavity with intestinal bacteria, a poor survival rate of patients with higher graded rectal lesions must be assumed, if they are treated with the tested intestinal suture technique.