An Assignment on

Affections of the Anal Glands and their Surgical Management

Submitted to: Dr. Manoj Kumar Shah Lecturer Department of Surgery and Pharmacology IAAS, Rampur campus, Chitwan

Submitted by: Suraj Subedi B. V. Sc & A.H, 9th semester Roll no: 29 IAAS, Rampur campus, Chitwan

April, 2011

ANATOMY
The anal glands (anal sacs) are specifically paranal sinuses formed by paired invaginations of the inner cutaneous zone between the internal and external anal sphincter muscles. The external anal sphincter is innervated solely by the caudal rectal nerves. These nerves branch from the pudendal nerves in the ischiorectal fossa and enter the external anal sphincter at the caudolateral aspect of the muscle bilaterally, ventral to the anal orifice and in close proximity to the anal sacs. In the dog, the anal sac ducts open in the lateral margin of the anus at the anocutaneous junction, approximately at the 4- and 8-oclock positions. In dogs, the anal sacs are completely surrounded by external anal sphincter muscle fibers and are difficult to see during closed sacculectomy. The anal sacs and ducts are lined with squamous epithelium, with primarily apocrine glands and a few sebaceous glands embedded in the epithelium. In the cat, the ducts open in a more lateral position, and the anal sacs contain a more even distribution of sebaceous and apocrine glands. These anatomic differences may account for the low occurrence of anal sac disease in cats compared with dogs. The exact function is unknown, although their putrid contents may play a role in social communications, sexual attraction, and delineation of territory by releasing pheromones. They also play a role in defense in skunks and stripe-necked mongooses. AFFECTIONS OF THE AN AL GLAN DS The anal glands affections are of 4 types. They are: a. Impaction b. Cellulitis c. Abscess d. Neoplasm

A diagnosis of anal sac disease can be made on the basis of the history and physical examination. Common clinical signs in these patients are scooting, licking and biting of the anal areas and tail base, discomfort in sitting, painful defecation and tenusmus. Draining tracks may also be seen if anal sac has ruptured. In a normal dog, anal sac secretion is clear to pale brown. In patients with impacted anal sacs, the anal sacs are swollen and non-painful and secretions are viscous and pasty brown or grayish brown. Enlarged anal sacs are readily palpable through the skin. Anal sacculitis and abscess are common sequels to chronic impaction. Patients with anal sacculitis often have pain on physical examination and may be febrile; secretions may be copious and greenish yellow or yellowish white with flecks of blood. Before rupture, the skin overlying and abscess can become edematous, erythrematous and painful. A purulent, hemorrhagic discharge may be observed, cellulitis and draining tracks may be present. In cats, an abscess associated with anal sac disease is differentiated from a bite wound.

In neoplasia of anal sac, Perineal swelling and dyschezia and a unilateral anal sac mass is occasionally found, rarely bilateral. Severe neoplastic cases may result perineal edema, erythrema and fistula formation. Differential diagnosis has to be made with Vaginitis, Proctitis, Ectoparasites, Endoparasites, Flea allergy, Perianal fistulae, Perianal tumor, Urinary tract or perivulvar infections in the female etc. CONSE RV AT IVE THE RAPY     Manual expression of anal sac contents. Anal sac irrigation with saline or dilute antiseptic. Intraductal instillation of a corticosteroid antibiotic preparation. Oral broad-spectrum antibiotics for cellulitis or abscessation.

PREOPE RAT IVE MAN AGE MENT If an anal sac mass is detected on digital rectal examination, dogs should be evaluated for metastases. Anal sac tumors frequently spread to sublumbar lymph nodes and, less often, lungs. Paraneoplastic syndrome associated with some anal sac adenocarcinomas results in persistent hypercalcemia and secondary renal failure. Therefore, ionized or total calcium, phosphorous, BUN, and creatinine concentrations and urine specific gravity should be measured in dogs with anal sac masses. Dogs with anal sacculitis should be evaluated for allergies or other causes of dermatitis. Cellulitis from anal sac rupture should be treated with antibiotics and analgesics until inflammation is resolved. Focal abscesses should be drained and lavaged. The anal sacs are gently flushed with water or saline and the perineal region is clipped and prepped. The animal is placed in a perineal position over the padded end of a surgery table. The tail should be pulled up and forward with tape. General anesthesia is attained by administration of parenteral or inhalation agent with prior medication. Because of compression of the viscera on the diaphragm, respirations should be assisted while the animal is in the perineal position.

SELECTED ANESTHETIC PROTOCOL FOR USE IN THE ANIMAL Species Dog Premedication Induction Maintenance Isoflurane or Halothane

Atropine :0.02-0.04 mg/kg, iv, im, Thiopental : 10-12 mg/kg sc Profolol : 4-6 mg/kg Glycopyrrolate: 0.005-0.011 mg/kg Administration iv iv, im, sc Oxymorphone: 0.05-0.1 mg/kg sc or im Atropine :0.02 mg/kg or Glycopyrrolate: 0.005-0.011 mg/kg iv, im, sc with 0.01 mg/kg IV, with ketamine and diazepam

Cat

Diazepam (0.27 mg/kg) plus Isoflurane ketamine (5mg/kg) iv or Thiopental :10-12 mg/kg iv Halothane

SURGICAL MAN AGE MENT Anal sacs can be removed by an open or closed technique. The closed technique, where the sac is left intact, should be performed in animals with anal sac tumors and in ferrets and other species that have particularly odoriferous secretions. Identification of the sac can be facilitated by inserting something into the sac to make it larger and more firm. Options include umbilical tape, a Foley catheter, or a gel that hardens after infusion. Alternatively, an instrument or cotton tipped applicator swab can be left in the duct and sac during dissection. In cats, the anal sacs are more readily apparent. The open technique is easier to perform if the surgeon has small fingers or the anal sacs are large. With closed or open techniques, dissection should be as close to the sac as possible to reduce the chance of injury to the caudal rectal artery and nerve and to minimize trauma to the external anal sphincter. Resected tissue should be inspected to make sure the anal sac has been completely removed. SURGICAL TECHNIQUE : CLOSED AN AL SACCULECTOMY 1. Insert a groove director, cotton - tipped applicator swab, Kelly haemostatic forceps, or 5 or 6 French latex or silicone balloon - tipped (e.g., Foley catheter) through the duct into the anal sac. a. If a Foley catheter is used, insert the catheter through the duct until the entire balloon is in the sac. Inflate the balloon with 1 to 2 ml of sterile saline until it is the size of the normal sac. If necessary, place a suture around the duct and catheter to prevent the catheter from backing out as the balloon is inflated. b. If a rigid instrument is used, angle the tip of the instrument so that the anal sac is forced caudally and superficially (toward the surgeon).

2. Make a 2 to 3 cm vertical curvilinear skin incision. The incision should be 1 to 2 cm lateral to the anus and centered over the tip of the probe or catheter balloon. 3. Dissect the subcutaneous tissues away from muscle fibers overlying the sac. 4. Maintain caudal rotation and traction on the sac with the probe or another instrument. a. Grasp the exposed apex of the anal sac with an Allis tissue forceps. Retract the sac caudally, pulling gently so that the tissues do not tear. b. Alternatively, insert one jaw of a Kelly forceps into the duct and gland once the caudal aspect of the sac is exposed. Clamp the forceps shut to provide a handle for sac manipulation. 5. Using iris or Metzenbaum scissors, dissect external anal sphincter muscle fibers off the sac, working from the sac apex toward the duct. a. Insert the scissors under the muscle fibers without penetrating the sac. b. Spread the fibers parallel to the sac wall so that the glistening, grayish white surface of the sac is exposed. c. Transect any large muscle fiber attachments, cutting close to the sac. Leave as much muscle as possible. d. Alternately dissect along all sides of the gland until the entire sac is exposed. 6. Dissect the duct from the perianal tissues. 7. Ligate and transect the duct at its junction with the anus. 8. Flush the surgical site with sterile saline if contamination occurs. 9. Appose transected muscle and subcutaneous tissues with interrupted sutures of 3 - 0 rapidly absorbable, synthetic suture. 10. If desired, place skin sutures or cover the incision with tissue glue.

SURGICAL TECHNIQUE : OPEN AN AL S ACCULECT OMY 1. Insert one blade of a straight sharp scissors through the duct into the anal sac. 2. Tilt the scissors so the tips point caudally (toward the surgeon), forcing the anal sac superficially. 3. Close the scissors to cut skin, sub cutis, external anal sphincter muscle, and anal sac wall simultaneously. Remove the scissors. 4. Identify the shiny, grayish white lining of the anal sac to determine its borders. Enlarge the sac opening as needed to expose the entire surface. 5. Attach three or four mosquito hemostats to the edge of the sac. Space the hemostats evenly around the sacs circumference. 6. Insert the tip of your non-dominant index finger into the open sac. Grasp one or two hemostats in the palm of the same hand to keep the sac on your finger. 7. Rotate the finger and sac caudally to expose the lateral surface of the anal sac and overlying muscle fibers. 8. With a no. 15 blade, gently transect the muscle fibers at their attachments to the sac. a. Hold the scalpel handle in a pencil grip. b. Use small paint brush strokes to transect the fibers at their sac attachments. c. Continue to rotate the sac caudo-medially to expose and tense the muscle fibers. d. Alternately dissect along all sides of the gland until the entire sac wall has been freed. 9. With scissors or a blade, dissect along the duct and transect it at skin level. 10. Close as described above.

POSTOPE RAT IVE CONSIDE RATIONS Elizabethan collars may be required to prevent self - trauma. Potential complications include hemorrhage, infection, dehiscence, draining tracts, stricture, fecal incontinence, and persistence of clinical signs. If the incision dehisces, the wound should be flushed and the patient should be treated with systemic antibiotics. Broad-spectrum antibiotic therapy continued for 1 week. The open wound is allowed to heal by second intention. Draining sinus tracts may develop if secretory lining is left during dissection. Affected animals are treated with antibiotics and hot packing until cellulitis and swelling resolve. The tract is then dissected to its origin and the offending tissue is removed. Resected tissue can be submitted for histological evaluation to verify that anal gland tissue was present. Skin sutures are removed after 10-15 days. COMPLICAT IONS Short-term postoperative complications of anal sacculectomy include hemorrhage, wound infection, and tenusmus or dyschezia. Postoperative hemorrhage can be minimized with meticulous intraoperative hemostasis. In case of hemorrhage, controlling with cold compress and acepromazine can be done. Tenusmus or dyschezia may be associated with local infection or inflammation. Flushing with sterile saline solution or dilute disinfectant like povidone-iodine solution or chlorhexidine solution and a broad-spectrum antibiotic parenterally. Long- term postoperative complications of anal sacculetomy include fecal incontinence, chronic fistula and anal stricture. All of these can be minimized with careful intraoperative surgical procedures. Fecal incontinency caused due to trauma to external anal sphincter or damage to the caudal recti branch of the pudendal nerve is rare. If the damage is unilateral, the anal sphincter should reinnervate from the contralateral nerve in 4 to 6 weeks, restoring continence. Incontinence may also occur if the external anal sphincter is damaged from excessive dissection. Incontinence that persists longer than 4 months is unlikely to resolve. Chronic fistula is usually seen due to incomplete resection of the anal sac. Surgical exploration and resection of any residual tissue are required to resolve this complication. Anal stricture may require surgical correction, additionally with stool softeners and periodic bougienage. In dogs with allergies or other generalized dermatologic conditions, clinical signs of scooting and excessive perineal grooming may persist unless the underlying etiology can be treated. Dogs with sub lumbar lymphadenopathy secondary to metastatic disease may require lymph node removal to resolve hypercalcemia or constipation. BIBLIOGRAPHY

Bojrab, M.J. 1998. Current Techniques in Small Animal Surgery, Williams and Wilkins, USA. pp. 283-286 Foster & Smith. Anal Glands (Sacs): Impactions, Infections & Abscesses in Dogs, Accessed on: 27 April, 2011 in http://www.peteducation.com/article.cfm?c=2+2090&aid=510 Harari, J. 2004. Small Animal Surgery Secrets, Elsevier, Philadelphia, Pennsylvania. pp. 183-185 Slatter, D. 2002. Textbook of Small Animal Surgery, WB Saunders, Philadelphia. Vol.1, pp: 697701