Use of a spiral rectal diaphragm technique to control anal sphincter incontinence in a cat

Michael Pavletic Department of Surgery, Angell Animal Medical Center, 350 S Huntington Ave, Boston, MA 02130.

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Matt Mahn Department of Surgery, Angell Animal Medical Center, 350 S Huntington Ave, Boston, MA 02130.

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Jean Duddy Department of Internal Medicine, Angell Animal Medical Center, 350 S Huntington Ave, Boston, MA 02130.

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Abstract

Case Description—A 10-year-old castrated male domestic shorthair cat was examined for a mass involving the right anal sac region.

Clinical Findings—The mass was diagnosed as a fibrosarcoma, and resulted in progressive tenesmus, requiring repeated resection.

Treatment and Outcome—Surgical removal of the fibrosarcoma was performed on 4 occasions, including complete resection of the anal sphincter muscles and portions of the rectum. A perineal urethrostomy was required during the third surgical procedure secondary to tumor invasion of the preputial tissues. To reduce involuntary loss of feces, the remaining rectal wall was rotated approximately 225° prior to surgical closure during the second, third, and fourth surgical procedures. This procedure created a natural spiral diaphragm within the rectal lumen. The elastic spiral barrier reduced inadvertent fecal loss and facilitated fecal distention of the terminal portion of the colon, allowing the patient to anticipate the impending passage of feces and to use the litter tray on a daily basis.

Clinical Relevance—With complete loss of the terminal portion of the rectum and anal sphincter muscles, spiraling the rectum created a deformable threshold barrier to reduce excessive loss of stool secondary to fecal incontinence. On the basis of the positive outcome in this patient, this novel technique may be a useful option to consider for the treatment of cats with loss of anal sphincter function.

Abstract

Case Description—A 10-year-old castrated male domestic shorthair cat was examined for a mass involving the right anal sac region.

Clinical Findings—The mass was diagnosed as a fibrosarcoma, and resulted in progressive tenesmus, requiring repeated resection.

Treatment and Outcome—Surgical removal of the fibrosarcoma was performed on 4 occasions, including complete resection of the anal sphincter muscles and portions of the rectum. A perineal urethrostomy was required during the third surgical procedure secondary to tumor invasion of the preputial tissues. To reduce involuntary loss of feces, the remaining rectal wall was rotated approximately 225° prior to surgical closure during the second, third, and fourth surgical procedures. This procedure created a natural spiral diaphragm within the rectal lumen. The elastic spiral barrier reduced inadvertent fecal loss and facilitated fecal distention of the terminal portion of the colon, allowing the patient to anticipate the impending passage of feces and to use the litter tray on a daily basis.

Clinical Relevance—With complete loss of the terminal portion of the rectum and anal sphincter muscles, spiraling the rectum created a deformable threshold barrier to reduce excessive loss of stool secondary to fecal incontinence. On the basis of the positive outcome in this patient, this novel technique may be a useful option to consider for the treatment of cats with loss of anal sphincter function.

A 10-year-old 4.1-kg (9-lb) castrated male domestic shorthair cat was examined at Angell Animal Medical Center with a firm 2-cm subcutaneous mass adjacent to the right anal sac that was recently noted by the owner. A CBC and serum biochemistry profile were within reference limits. Thoracic radiographs were negative for metastatic disease. Financial constraints precluded additional diagnostic testing. Surgical treatment was elected, and food was withheld from the patient for 12 hours prior to surgery.

Cefazolin sodiuma (20 mg/kg [9.1 mg/lb], IM) was administered 1 hour prior to surgery, and the patient was premedicated with hydromorphoneb (0.05 mg/kg [0.023 mg/lb, IM]) and metomidinec (0.2 mg/kg [0.1 mg/lb], IM), followed by induction of anesthesia with propofold (5.0 mg/kg [2.3 mg/lb], IV). The cat was intubated and anesthesia was maintained with isofluranee in oxygen. Lactated Ringer'sf solution was administered at a rate of 5.0 mL/kg/h (2.3 mL/lb/h) for the duration of the surgery. The surgical site was clipped of fur and prepared for surgery in a routine manner.

The right anal sac and adjacent growth were excised with 1-cm cutaneous and base margins. The patient recovered uneventfully from surgery. After surgery, the patient was maintained on cefazolin and buprenorphineg (0.005 mg/kg [0.0023 mg/lb], PO) until discharge from the hospital 48 hours after surgery. An oral suspensionh of amoxicillin and clavulanic acid (13.75 mg/kg [6.25 mg/lb], PO, q 12 h) was dispensed for 1 additional week. Sutures were removed 10 days after surgery.

Histologic examination of the mass excised at surgery demonstrated fibrosarcoma with a high mitotic index, within 3.0 mm of the inked excised tissue margin. The owner declined any further treatment options for this neoplastic condition. After surgery, the patient was defecating normally but subsequently returned to the hospital 7 months later when the owner noted tenesmus. Examination of the patient revealed a firm 2-cm-wide mass enveloping the circumference of the anus. A CBC and serum biochemistry profile were within reference limits. Fibrosarcoma recurrence was suspected, and the owner was informed that complete resection of this invasive mass could be problematic because fecal incontinence would be a sequela to aggressive removal of this mass, with wide margins encompassing the anal sphincter musculature and the terminal rectum. The owner reported that the cat was remarkably active and healthy, despite tenesmus, and elected to have the mass resected a second time.

After surgical preparation and anesthesia by means of the protocol used previously, the entire circumference of the anus and associated infiltrative tumor were resected with a 2-cm peripheral cutaneous surgical margin, including 5 cm of the terminal rectum. The remaining rectal cylinder was mobilized by gentle dissection. The rectum was then rotated 225° clockwise on its axis, creating a spiral diaphragm of the twisted rectal cylinder (Figure 1). A one-fourth–inch Penrose draini was looped over the rectum with dual-exit stab incisions. Simple interrupted 3–0 monofilament nylonj sutures were used to secure the rectal wall to the corresponding incised cutaneous border. Following surgery, a lubricated, gloved index finger could be inserted through this spiraled area with little effort. The Penrose drain was removed prior to departure of the patient 48 hours after surgery. A small area of dehiscence, noted at the time of suture removal, healed by second intention (Figure 2). The patient was maintained on the same regimen of postoperative medications as for the first surgery and was discharged from the hospital the following day.

Figure 1—
Figure 1—

Plastic model of the terminal portion of the rectum and colon. A—The blue band represents the sutured peripheral margin, and the inner red foam represents the rectal and colonic mucosa. Note the white cotton representing luminal contents. B—Clockwise rotation of the model at 90°, illustrating how the wall of the rectum and colon is forming a spiral diaphragm. C—Formation of a spiral diaphragm as the model is rotated over 180°.

Citation: Journal of the American Veterinary Medical Association 241, 6; 10.2460/javma.241.6.766

Figure 2—
Figure 2—

Appearance of the terminal portion of the colon in a 10-year-old castrated male domestic shorthair cat with a recurrent fibrosarcoma of the right anal sac region after suture removal. The patient had been treated with resection 7 months previously. The entire circumference of the anus and associated infiltrative tumor were resected with a 2-cm peripheral cutaneous surgical margin, including 5 cm of the terminal portion of the rectum. The remaining rectal cylinder was mobilized and the rectum was then rotated 225° clockwise on its axis, creating a spiral diaphragm of the rectal cylinder. The small area of dehiscence noted in this photograph healed by second intention.

Citation: Journal of the American Veterinary Medical Association 241, 6; 10.2460/javma.241.6.766

Histopathologic findings indicated the mass was classified as a leiomyosarcoma. During the ensuing months, the cat was periodically examined and the owner reported that the cat would occasionally drop a 2-cm-sized piece of stool on a daily basis. However, the cat would also consciously squat and pass a normal bowel movement in its paper-lined litter pan on a daily basis. Maintenance and upkeep of the cat were considered minimal by the owner.

Eight months later, the patient was again examined with tenemus. Circumferential recurrence of the mass was evident, with local invasion of the preputial area. Because of the cat's excellent health and quality of life at this point, the owner again elected to have the mass removed surgically. Resection was again performed with the same anesthetic and postoperative protocol, including a 2-cm surgical perimeter and an additional 3 cm of the terminal rectum. The remaining rectum and adjacent terminal colon were mobilized and surgically restored in the previous spiral configuration by means of the same technique (Figure 1). A standard perineal urethrostomy was also performed as a result of tumor invasion of the preputial tissues. The cat's recovery was uneventful, and the postoperative care was as previously noted. The owner declined histopathologic examination of the removed mass.

The patient continued to do well, as reported by the owner, over the next 11 months, at which time the cat was reexamined with tenesmus secondary to tumor recurrence. Palliative surgical resection of the invasive mass and tail amputation were performed in conjunction with spiraling the terminal colon for a third time (Figure 1). The patient recovered from the surgical procedure without incident, but was reexamined with rapid recurrence of the neoplasm 6 weeks later, and the cat was euthanized.

Discussion

Fecal continence is the ability to retain fecal content, perceive the rectum is full, and determine appropriate defecation.1 Continence is the result of complex interactions involving smooth muscles, striated muscles, and the intrinsic-extrinsic neurons innervating these tissues.1 Innervation to the anorectum is similar to that of the colon: there is a well-defined enteric nervous system consisting of a myenteric and submucosal plexus. This portion of the autonomic nervous system controls the sensory, integrative, and motor neurons that characterize the functions of the rectum and anus.1 Innervation of the anus is more complex: the pelvic plexus (sacral branches of the pelvic nerve) provides parasympathetic fibers that are excitatory to the rectum and inhibitory to the internal anal sphincter. Reciprocally, sympathetic fibers arising from the hypogastric nerves of the caudal mesenteric ganglion cause relaxation (inhibitory effect) of the rectum and contraction (excitatory effect) of the internal anal sphincter. Relaxation of the internal and external anal sphincters in conjunction with rectal contraction allows the patient to defecate.1

Fecal or anal incontinence is the failure of the anal sphincter to prevent involuntary expulsion of liquid, solids, or gas from the lower bowel.1–3 There are 2 major types of fecal incontinence: reservoir incontinence and sphincter incontinence.1–3 Reservoir incontinence results from a failure of the large bowel to adapt to and contain the contents of the colorectum.2 As a result, patients with reservoir incontinence have issues associated with capacity (volume), compliance, and motility. Colorectal irritability causes an increased urge to defecate. These patients can sense the imminence of defecation and have the ability to control the anal sphincter. However, control is overcome by the overwhelming urge to defecate.1–3

By contrast, sphincter incontinence is a failure of the sphincteric mechanisms to resist the propulsive forces of the rectum, resulting in the involuntary passage of feces. Sphincter incontinence can be secondary to spinal injury or disease or damage or destruction of the external pudendal nerves (second and third sacral nerves or first coccygeal nerve) supplying the anal sphincter musculature (neurogenic sphincter incontinence). It may also be the result of injury to or loss of the external anal sphincter muscles (nonneurogenic sphincter incontinence).2 Damage or degeneration of the levator ani and coccygeus muscles may contribute to fecal incontinence: both muscle groups compress the tail against the dorsal rectal wall and anal canal, inhibiting stool passage. Conversely, elevation of the tail during voluntary defecation facilitates the evacuation of feces.2 The internal anal sphincter is important in maintaining the resting pressure of the anal canal. This muscle layer also may be important in guarding against the elimination of small amounts of liquid stool. The external anal sphincter plays a greater role in maintaining continence with elevation of pressure and distention of the rectum.2

Damage to the nerve supply and sphincter can be the result of direct trauma including bite wounds.2,3 Most surgical cases of fecal incontinence in veterinary medicine are associated with the resection of the anal sacs bilaterally in dogs, with subsequent damage to the innervation, anal sphincter muscles, or both. This surgical complication is most commonly noted in smaller dogs. Interestingly, experimental division of the external pudendal nerves caused complete incontinence in two-thirds of the dogs, but partial continence was present in the remaining one-third of the animals.2 Anatomic studies4 have noted that the pudendal nerve may not be the sole source of innervation to the external anal sphincter. Nerve fibers can travel as direct branches from the sacral nerve roots or can travel as fibers separate from the caudal rectal branch of the pudendal nerve. The thinner cranial portion of this muscle may receive innervation from motor neurons originating in the medial horn of spinal segments S2–S3 The thicker caudal portion is innervated by cell bodies located in the ventrolateral horn of spinal cord segments S1-S2. Pudendal neurectomy denervates that portion of the sphincter innervated by the cells in the ventrolateral horn, but not the cells in the medial horn.4

The autonomic peripheral nerves (pelvic plexus) innervate the lateral rectal walls. Damage to the pelvic plexus or pelvic nerves can interfere with the conscious sensation of rectal fullness: 20% of cats with dysautonomia display fecal incontinence.1,2 Other neurologic conditions can contribute to fecal incontinence. Cauda equina syndrome can result in loss of anorectal sensation and motor control of the continence muscles.1–3 In some instances, CNS injuries (spine, brainstem, or midbrain injuries) can interfere with the continence reaction or the animal's conscious or subconscious reinforcement of the reaction. Reinforcement is important when rectal pressure markedly begins to exceed the pressure in the anal canal.2

Extensive resection of neoplasms involving the external and internal sphincter muscles can result in sphincter incontinence secondary to muscle loss as well as compromise to its innervation. From our clinical experience, partial incontinence is usually maintained with unilateral loss of the sphincter muscles; complete loss of this musculature will result in complete anal incontinence.4 This is in contrast to unilateral loss of the innervation to the anal sphincter, in which renervation can occur to the muscle from the contralateral side to help maintain complete control of continence.5

With complete anal incontinence, fecal matter is randomly released. As residue accumulates in the lower bowel, periodic peristaltic contraction moves the colonic contents into the rectum. Without a soft tissue barrier, feces will escape from the patient either at rest or during ambulation. The firmness of the feces can play a role in the severity of stool loss: soft stool escapes more readily than firm stool. Dietary control includes the use of low-residue diets. This can be combined with pharmacologic treatment (diphenoxylate hydrochloride or loperamide hydrochloride) to prolong the transit time of bowel contents, thereby increasing water resorption of the feces.2 Another alternative is to preemptively induce defecation with daily warm water enemas. Inflation of a Foley catheter inserted into the rectum also can be used to induce involuntary fecal evacuation. Both measures can be used by a dedicated owner to prompt evacuation in an appropriate area, thereby reducing incidental loss of stool on a daily basis.2 The cat of the present report was maintained on a normal commercial diet alone. Clinical reports6,7 pertaining to the surgical management of anal incontinence involved 2 dogs rendered incontinent after bilateral anal sacculectomy. In both cases, a strip of fascia lata was used to create a sling beneath the terminal rectum, with its ends either sutured to the lateral tail muscles bilaterally or secured over the tail base.6,7 When applied under slight tension intraoperatively, the lower rectal wall is partially elevated, reducing the size of the anal orifice while creating a partial retaining wall comprised of the elevated lower rectal wall. Fecal material must accumulate sufficiently for it pass over this threshold barrier formed. Both studies6,7 had good results with fascia lata banding. However, long-term follow-up is lacking and occasional subconscious loss of stool was not reported.

A subsequent study4 investigated the use of strips of a polyester impregnated silicone band in research dogs after bilateral pudendal nerve neurectomy. These elastomeric bands were implanted around the circumference of the retained external anal sphincter muscle. Tension was adjusted so that the 1-cm band snuggly tightened around the proximal interphalangeal joint of an assistant's index finger. Research dogs were followed up for up to 3 months and were able to pass stools without the use of stool softeners or enemas.4 This elastic banding technique controlled the loss of stool by forming a distensible circumferential barrier to fecal passage. Other techniques suggested for managing fecal incontinence in dogs include the use of a semitendinosus muscle flap for improving sphincter incompetence,8 pudendal nerve anastomosis to help create a neosphincter,9 and transposition of an electrically stimulated sartorius muscle.10 Veterinary clinical studies to determine the efficacy of these techniques is lacking, which is most likely due to the relative paucity of clinical cases and the unwillingness of many owners to pursue surgical management for their incontinent pet.

In the patient of the present report, aggressive resection of the invasive neoplasm necessitated removal of the anus and terminal rectum. An attempt at performing one of the previously described fascial or synthetic banding techniques would have best been postponed as a second surgical procedure because of the increased fecal contamination associated with tumor resection in this case. The spiral diaphragm technique was easily implemented in this patient without the need to repeatedly harvest and implant a strip of the fascia lata. More bold measures at muscle-nerve repair or replacement of the external anal sphincter must also be tempered with the probability of tumor recurrence negating any positive outcome achieved.

The potential use of the spiral diaphragm technique was assessed by the author (MP) in cadaver specimens (unpublished data). This was our first clinical opportunity to assess its efficacy in a cat. Cats are ideally suited for this novel option because of their unique anatomy, compared with dogs. We have noted the relative ease at mobilizing the rectum in cats, compared with dogs, facilitating the exteriorization the rectum and terminal colon.

After the second, third, and fourth surgeries, the owner reported that the cat's stool varied from firm to loose, with the patient being maintained on a standard commercially available diet. The cat occasionally released a small amount of stool (nickel sized [2 cm], 1 to 3 times daily) when ambulating in the house. However, the cat did consciously posture to have a normal bowel movement on a daily basis. The owner confined the cat to a room with linoleum flooring to facilitate the occasional clean-up required. During the 26 months encompassing this report, the owner remained pleased with the overall results and noted the cat was in excellent health after quickly recovering from each surgical procedure.

On the basis of our clinical experience, patients with incontinence secondary to surgery (bilateral anal sac resection) or traumatic tail avulsion injuries have greater random loss of fecal material, compared with results reported for this patient after rotation of the terminal rectum. In dogs, involuntary loss of fecal material is most notable when the patient is active or during episodes of barking or coughing. In those cases, the patients do not posture for a bowel movement, which is likely because fecal retention and distention of the terminal rectum and colon do not occur. It was surprising to note that the cat of the present report retained the conscious ability to have a normal bowel movement. This may be explained by the stimulation of sufficient intact sensory fibers in the wall of the remaining rectum and terminal colon; with sufficient accumulation of feces anterior to the spiral diaphragm, the patient could detect the impending passage of stool, prompting it to use the litter pan.

Circulation to the terminal colon and rectum is similar in the dog and cat.11,12 The caudal mesenteric artery gives rise to the left colic artery supplying the descending colon. A second vascular branch from the caudal mesenteric artery, the cranial rectal artery, travels distally to supply the rectal wall, anastomosing with the middle and caudal rectal arteries.11,12 The middle rectal artery arises from the prostatic artery or the vaginal artery; the caudal rectal artery arises from the internal pudendal artery.12 As the rectum and colon were progressively twisted intraoperatively, the color of the exposed mucosa and the bleeding incised border remained unchanged. Whereas initial rotation of the rectum at 180°created a spiral diaphragm, an additional 45° of twist (225° total) was performed to offset the natural elasticity of the rectum and regional skin. This better assured that a twist of at least 180° was achieved to form the spiral diaphragm. Limiting the spiral to 225° would prompt the question of whether rotating the terminal rectum an additional amount would further improve fecal retention. The primary concern was progressive circulatory compromise if the bowel was rotated 270° or beyond. In the patient of the present study, the spiral formed improved stool retention without creating a more rigid barrier to stool passage.

The owner's decision not to pursue chemotherapy or radiation therapy as possible adjunctive forms of treatment permitted long-term assessment of the patient undergoing surgery alone to manage this neoplasm. The cat did remarkably well for over 2 years after the first surgical procedure was performed. Unfortunately, the tumor became more aggressive in the latter stages of the patient's life, necessitating euthanasia. Further clinical studies are required to determine the long-term efficacy of this novel technique, although the results in this patient are encouraging.

a.

Novaplus, Sandoz Inc, Princeton, NJ.

b.

Hydromorphone HCl, Baxter Healthcare Corp, Deerfield, Ill.

c.

Midazolam, Novaplus, Hospira Inc, Lake Forest, Ill.

d.

Propofol, Abbott Animal Healthy, North Chicago, Ill.

e.

Isoflurane USP, Halocarbon Products Corp, River Edge, NJ.

f.

LR USP, Hospira Inc, Lake Forest, Ill.

g.

Buprenorphine HCl, Hospira Inc, Lake Forest, Ill.

h.

Clavamox, Pfizer Animal Health, NY.

i.

Latex Penrose Tubing, Kendall, Mansfield, Mass.

j.

Monosof, Tyco/United States Surgical, Norwalk, Conn.

References

  • 1.

    Zoran DL. Rectoanal disease. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 6th ed. Philadelphia: Elsevier Saunders, 2005;14081410, 14191420.

    • Search Google Scholar
    • Export Citation
  • 2.

    Guilford WG. Fecal incontinence in dogs and cats. Compend Contin Educ Pract Vet 1990; 12:313326.

  • 3.

    Washabau RJ, Brockman DJ. Recto-anal disease. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 4th ed. Philadelphia: WB Saunders, 1995;14081409.

    • Search Google Scholar
    • Export Citation
  • 4.

    Dean PW, O'Brien DP, Turk MAM, et al. Silicone elastomer sling for fecal incontinence in dogs. Vet Surg 1988; 17:304310.

  • 5.

    Aronson L. Rectum and anus. In: Slatter D, ed. Textbook of small animal surgery, 3rd ed. Philadelphia: WB Saunders, 1993;701.

  • 6.

    Lumb WV. Surgical treatment of fecal incontinence. J Am Anim Hosp Assoc 1976; 12:666.

  • 7.

    Leeds EB, Renegar WR. A modified fascial sling for the treatment of fecal incontinence-surgical technique. J Am Anim Hosp Assoc 1981; 17:663667.

    • Search Google Scholar
    • Export Citation
  • 8.

    Doust R, Sullivan M. Semitendinosus muscle transfer flap for external anal sphincter incompetence in a dog. J Am Vet Med Assoc 2003; 15:13851387.

    • Search Google Scholar
    • Export Citation
  • 9.

    Sato T, Konishi F, Kanazawa K. End-to-side pudendal nerve anastomosis for the creation of a new reinforcing anal sphincter in dogs. Surgery 2000; 127:9298.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Konsten J, Baeten CG, Havenith MG, et al. Canine model for treatment of faecal incontinence using transposed and electrically stimulated sartorius muscle. Br J Surg 1994; 81:466469.

    • Search Google Scholar
    • Export Citation
  • 11.

    Hudson LC, Hamilton WP. Atlas of feline anatomy for veterinarians. Philadelphia: WB Saunders Co, 1993;161163.

  • 12.

    Evans HE. Miller's anatomy of the dog. 3rd ed. Philadelphia: WB Saunders Co, 1993;655657.

  • Figure 1—

    Plastic model of the terminal portion of the rectum and colon. A—The blue band represents the sutured peripheral margin, and the inner red foam represents the rectal and colonic mucosa. Note the white cotton representing luminal contents. B—Clockwise rotation of the model at 90°, illustrating how the wall of the rectum and colon is forming a spiral diaphragm. C—Formation of a spiral diaphragm as the model is rotated over 180°.

  • Figure 2—

    Appearance of the terminal portion of the colon in a 10-year-old castrated male domestic shorthair cat with a recurrent fibrosarcoma of the right anal sac region after suture removal. The patient had been treated with resection 7 months previously. The entire circumference of the anus and associated infiltrative tumor were resected with a 2-cm peripheral cutaneous surgical margin, including 5 cm of the terminal portion of the rectum. The remaining rectal cylinder was mobilized and the rectum was then rotated 225° clockwise on its axis, creating a spiral diaphragm of the rectal cylinder. The small area of dehiscence noted in this photograph healed by second intention.

  • 1.

    Zoran DL. Rectoanal disease. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 6th ed. Philadelphia: Elsevier Saunders, 2005;14081410, 14191420.

    • Search Google Scholar
    • Export Citation
  • 2.

    Guilford WG. Fecal incontinence in dogs and cats. Compend Contin Educ Pract Vet 1990; 12:313326.

  • 3.

    Washabau RJ, Brockman DJ. Recto-anal disease. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 4th ed. Philadelphia: WB Saunders, 1995;14081409.

    • Search Google Scholar
    • Export Citation
  • 4.

    Dean PW, O'Brien DP, Turk MAM, et al. Silicone elastomer sling for fecal incontinence in dogs. Vet Surg 1988; 17:304310.

  • 5.

    Aronson L. Rectum and anus. In: Slatter D, ed. Textbook of small animal surgery, 3rd ed. Philadelphia: WB Saunders, 1993;701.

  • 6.

    Lumb WV. Surgical treatment of fecal incontinence. J Am Anim Hosp Assoc 1976; 12:666.

  • 7.

    Leeds EB, Renegar WR. A modified fascial sling for the treatment of fecal incontinence-surgical technique. J Am Anim Hosp Assoc 1981; 17:663667.

    • Search Google Scholar
    • Export Citation
  • 8.

    Doust R, Sullivan M. Semitendinosus muscle transfer flap for external anal sphincter incompetence in a dog. J Am Vet Med Assoc 2003; 15:13851387.

    • Search Google Scholar
    • Export Citation
  • 9.

    Sato T, Konishi F, Kanazawa K. End-to-side pudendal nerve anastomosis for the creation of a new reinforcing anal sphincter in dogs. Surgery 2000; 127:9298.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Konsten J, Baeten CG, Havenith MG, et al. Canine model for treatment of faecal incontinence using transposed and electrically stimulated sartorius muscle. Br J Surg 1994; 81:466469.

    • Search Google Scholar
    • Export Citation
  • 11.

    Hudson LC, Hamilton WP. Atlas of feline anatomy for veterinarians. Philadelphia: WB Saunders Co, 1993;161163.

  • 12.

    Evans HE. Miller's anatomy of the dog. 3rd ed. Philadelphia: WB Saunders Co, 1993;655657.

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