Veterinary Vertex
Veterinary Vertex is a weekly podcast that takes you behind the scenes of the clinical and research discoveries published in the Journal of the American Veterinary Medical Association (JAVMA) and the American Journal of Veterinary Research (AJVR). Tune in to learn about cutting-edge veterinary research and gain in-depth insights you won’t find anywhere else. Come away with knowledge you can put to use in your own practice – along with a healthy dose of inspiration to remind you what you love about veterinary medicine.
Veterinary Vertex
Understanding Perineal Hernia Recurrence in Dogs: Risks, Challenges, and Solutions
Discover the hidden complexities behind perineal hernia recurrence in dogs as we chat with Dr. Mandy Wallace and Abigail Hatch. Mandy and Abigail provide fascinating insights into the risks associated with hernia development and the challenges of fecal incontinence. Mandy and Abigail emphasize the crucial need for pet owner education. Their discussion offers a deep dive into the nuances of soft tissue surgery, contrasting it with the generally healthier cases found in orthopedic surgery, while sharing personal journeys that led them to this specialized field.
Our conversation also touches on the evolution of veterinary record-keeping, highlighting the shift from paper to electronic systems and how this impacts data collection for retrospective studies. Mandy and Abigail offer their perspectives on improving these practices, guided by their own experiences with scientific writing and mentorship. This episode promises a blend of serious insights and light-hearted moments with two passionate professionals in the veterinary world.
JAVMA article: https://doi.org/10.2460/javma.24.07.0487
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You're listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode we chat about how dogs neutered prior to perineal hernia or that developed fecal incontinence are at increased risk for perineal hernia recurrence. With our guests Mandy Wallace and Abigail Hatch.
Lisa Fortier:Welcome to Veterinary Vertex. I'm Editor-in-Chief Lisa Fortier, and I'm joined by Associate Editor Sarah Wright. Today we have Mandy and Abigail joining us, who are both on clinic, so we really, truly appreciate you taking time out of your busy day to be here with us today.
Mandy Wallace:Thank you so much for having us. We're excited to talk about the paper and have this opportunity to discuss it more.
Abigail Hatch:Yeah, we're really excited, thank you.
Sarah Wright:All right, let's dive right in. So, Abigail, your JAVMA article discusses how dogs neutered prior to perineal hernia happy or that develop fecal incontinence are at increased risk for perineal hernia recurrence. Please share with our listeners the background on this article.
Abigail Hatch:Yeah, of course. So, as you know, perineal hernias, they occur when that pelvic diaphragm muscles fail to support the rectal wall. They're usually seen in intact males, usually over five years of age, among many different breeds. Clinical signs usually associated with perineal hernias are swelling around the perineal region, constipation, tenesmus, strange area, and the main way to correct perineal hernias is through surgery. Treatment of choice is a perineal herniography and usually with the surgery, any post-operative complications that we typically see are surgical site infections, sciatic nerve injury, tenesmus and risk of reoccurrence, as well as fecal incontinence. There have been no previous studies to this date to determine any risk factors associated with these complications. So we decided to do this study where we looked at risk factors, two of the main ones fecal incontinence and risk factors associated with surgical site infection and recurrence. So we just kind of found some stuff, some interesting things.
Mandy Wallace:Yeah, and from a clinical perspective, you know, perinatal hernias are something that one of my mentors in my residency was very excited about and I got to where I really enjoyed doing the surgery, and so as a team we felt that, like Abigail said, we just really didn't have great resources that told us what the risk factors were that we could talk to owners about or to help us have better outcomes, and so that was our goal was to see can we have better outcomes with looking back through our cases and identifying potential things that we could do differently, or at least have things we could warn owners about?
Sarah Wright:And Abigail. What are the important take-home messages from this JAVMA article?
Abigail Hatch:So the important take-home message is just that letting owners know that dogs that are undergoing perineal hernia aphides. If they have a dog that had been previously castrated or neutered, they should just be told that. What we found is if they were neutered prior to a surgical correction of a perineal hernia, they are at an increased risk of having reoccurrence post-operatively. That's no reason to not get your dog neutered. We definitely want our dogs neutered out there, but it's just at least a talking point during that discussion pre-operatively to let owners know that the risk is a little bit higher. And then also, if patients develop fecal incontinence post-operatively, there is also an increased risk of recurrence. So just keeping your owners informed with all of these things.
Lisa Fortier:You may or may not know, I'm a equine orthopedic surgeon and I remember the day when I was like this is for me. I remember watching, as a student, somebody do arthroscopy and I thought that's the sexiest thing ever seeing all the cartilage and the bones and how the joints move together. So I'm curious from each of you what sparked your interest in yucky soft tissue surgery, like the perineal region. So, Abigail, how about we start with you? And then Mandy, love to hear what inspired you too.
Abigail Hatch:Yeah. So I guess to start like my interest at least in veterinary medicine. I was always that kid that just wanted to do vet med for some reason, like right from the get-go. And then I, at one of the practices, I worked at a specialty hospital prior to vet school and they had ER surgery cardiology, ophthalmology, all the things and I just I loved being in the OR, I loved watching emergency surgeries like GDVs and splenectomies and things like that and I just the intricacy and the soft tissue handling and everything it's I don't know, it's just so intriguing to me.
Lisa Fortier:Very cool. One of the things I do miss in orthopedic surgery there's not much medicine that goes. Most of them are pretty healthy right. Especially in what I do is sports medicine, so I do miss a little bit of the. We get plenty of emergencies but they're still usually healthy. So that that would be one part. I think soft tissue surgery would add to your puzzle.
Lisa Fortier:Putting together Mandy, how about you?
Lisa Fortier:Sorry.
Abigail Hatch:No, that's okay. No, I was like I was agreeing. There's a lot of case management. I'm currently on ortho for my rotations right now and, like you said, all of our patients are healthy and I do kind of
Mandy Wallace:Yeah, I completely agree. So, funny enough, I found an essay I wrote as a first year vet student where I said I wanted to be an orthopedic small animal surgeon in academia. And I reached most of those goals, except I switched roles there and so for me it's exactly what you said. I remember being a third-year vet student and on my surgery rotation walked into an open chest surgery and got to feel the beating heart, got to see the lungs moving, and it was this immediate, like I have to do this forever. So, I knew surgery was where I wanted to go.
Mandy Wallace:And as I progressed through the rest of vet school and internship and residency, I also really love internal medicine and so internal medicine was kind of almost like a secondary thing for me. And I realized in soft tissue surgery not only would I get to feel the beating heart on a fairly regular basis which I didn't think I could ever let go of but I also get to put those puzzle pieces together, really work through cases and see some really interesting things that just every day is kind of different on soft tissue. Every splenectomy is different, every foreign body is different, and so that's what really sparked my interest and keeps me excited about it.
Lisa Fortier:Excellent. Every time we do a manuscript of any sort, even if it's a retrospective study, we find things that we didn't expect. So was there anything in this study that you found surprising?
Abigail Hatch:I mean, I guess the fact that previously neutered animals having a higher risk of recurrence that was actually kind of surprising for me, just because always we talk about neuter your animals If they're not breeding it's better for their overall health. So just finding out the fact that it actually is a risk factor for one of our surgical complications, that was pretty interesting.
Lisa Fortier:Yeah, I thought that too, Mandy. How about you?
Mandy Wallace:I agree that that was really unexpected for us. We really didn't think that was the case, because we do recommend castration at the time of perinatal hernia repair and so most of the time they're already, they're still intact, and so when we found that, finding it really surprised us. I mean I couldn't probably couldn't have been more shocked that that was real and it was quite a large odds ratio. So we feel pretty confident that it is real. That was the most shocking thing. We also the fecal incontinence finding also shocked us. Honestly, we were shocked by both findings. We were. I think the thing that maybe surprised us more too is that we didn't find more risk factors for surgical site infection. So we thought starting antibiotics at the time of surgery would have decreased our surgical site infection risk, and that was not something that we found. So some of the non-findings were maybe just as shocking as the things we did find.
Sarah Wright:So, now that you've completed this study, Abigail, what are the next steps for future research on this topic study Abigail?
Abigail Hatch:What are the next steps for future research on this topic? So I guess, going off of our two main points that we found, the first being that if they were previously neutered the risk of recurrence is higher, I think it would be interesting to look at like what age they were neutered at, like compared to the time of surgery, and see if there is a association with if they were neutered earlier, does that increase their risk? Or if they were neutered closer to surgery time, does that increase their risk? As far as fecal incontinence goes, I think maybe looking at how long the fecal incontinence lasted postoperatively to see if there's any association with length of time and incontinence and risk factor or recurrence.
Abigail Hatch:Excuse me.
Lisa Fortier:Go a little off script. If the dog was neutered a length of time and I don't know what it is in dogs when their testosterone becomes T zero would you consider testosterone supplementation before fixing them? Or is it to an emergent surgery, like who we need to fix this? We can't wait to get their T up.
Mandy Wallace:Yeah, that's a great question. So typically not emergency um. On rare occasions it is so if they have the bladder um is retroflex and they're obstructed or if they're really just unable to defecate um despite medical management. But typically we wouldn't consider it a true emergency. So I think that's something that we could consider is to see if we could determine if length of time made a difference or if we could determine if there were receptors in that area that really truly responded to this testosterone. I think that could be a possible idea that would potentially keep them from having a recurrence.
Lisa Fortier:Awesome
Sarah Wright:Sounds like another project. Yeah, exactly so anyone listening? You contact Abigail and Mandy so lately you've been talking about like emerging technologies and like the veterinary space, and one of those is AI. So, Abigail, do you see a role for AI in this area of research?
Abigail Hatch:Specifically for perineal hernias? Not sure I'm sure there is, but I guess, with it being a retrospective study, I definitely think there's. A AI would definitely be useful. The amount of medical records I went through to get all of the information and charting and everything it was a lot and I know that AI there's a lot of tools out there now to like search through medical records, search for specific information, so I think that would be very helpful to minimize, maybe even like human error when looking through medical records. They might catch some things, cause I know we mentioned that as part of one of possible errors in our manuscript as well Just human error, we're all humans, but yeah, so I think AI would definitely be helpful in looking through all of those things.
Lisa Fortier:I remember my first retrospective study and being appalled at what was missing from medical records, and especially, I'm old enough that we transitioned from paper to paper, electronic. And then you switch medical record systems and you're like, well now, where did that go? So, for me at least, in my research animals, it inspired me to rethink what we're asking on those medical records. Right, you shouldn't. If you were a lawyer and you got sued and there's a blank space because you didn't comment on the integratory system, right, did that cross your mind like, wow, we need a better physical exam form.
Abigail Hatch:Um, I don't necessarily know. With physical exam one spot I noticed a lot like not a lot of missing information, but like I would have to dig for it with our anesthesia records because it's all handwritten um, and I had not taken my anesthesia rotation at the time yet, so I had not been through all of that and there was just often times where I'm like trying to figure out what was given, how long the patient was under anesthesia, sometimes the post-op time wasn't recorded, things like that. So when I was on anesthesia I was very, very laser focused to get all that information. So maybe on that aspect we could maybe improve a little bit. But I think everything else was pretty much there, most of the time.
Sarah Wright:Yeah, we had those same handwritten forms too, and I did my anesthesia rotation as well during vet school and I agree, definitely some room for improvement, for sure, yeah.
Abigail Hatch:And it's very easy to miss things because there's so much going on. So, it's not anyone's fault, but that's at least if there was maybe a online way to do everything. But we'll see.
Sarah Wright:For sure In the future.
Sarah Wright:That's why we asked that question and, for those of you just joining us, we're discussing what veterinarians should know before performing a perineal hernia appy and a dog after a prior castration with our guests Mandy and Abigail.
Lisa Fortier:Abigail, you talked just a few minutes ago about that you hadn't done your anesthesia rotation, so maybe it made it a little more difficult to start with the record review. How did all the other training in your previous work prepare you to finish this manuscript?
Abigail Hatch:So I've been very fortunate to be a part of a lot of research experiences throughout both my undergrad and my time here in vet school, so I feel like seeing multiple types of projects and things like that throughout my career has helped me be better prepared for this manuscript. I also took a lot of scientific writing courses in undergrad. We were lucky enough to have those at the university where I went and I think that helped strengthen my scientific writing. And of course, I also had great mentorship from Dr Wallace, which is key when you're writing a manuscript so.
Lisa Fortier:We love hearing that mentorship's alive and well. How about you, Mandy? How is your experience built on helping Abigail and really getting this to the finish line?
Mandy Wallace:For sure. Well, Abigail made it easy. She's fantastic, very on top of things, very detail oriented, trusted that she was able to get through those records and really trusted her data that she found, so that she made it easy to be her mentor. She always has, since she was a first year vet student.
Mandy Wallace:For me, I think the more retrospective studies that I do, maybe the better I get at refining what we need to get out of those records. And so I think at first you record so many data points that it almost gets exhausting instead of really focusing down on, okay, what are known or thought risk factors for recurrence, what are known or thought risk factors for surgical site infection, and really being able to pare those things down. And so I think you know, as the years go on, the more retrospectives we do, we get a little bit better every time at just narrowing it down, really focusing what we're looking for and, in focusing that, making sure that we're not getting some data that just really it doesn't make sense. You know, focusing on the things that do make sense from the prior literature, and I think that's an area that you get better at over time.
Lisa Fortier:Yeah, very good advice. I'm going to go off script for just a second. Abigail, are you a student still?
Abigail Hatch:I am. I'm a fourth year student.
Lisa Fortier:Awesome. Okay, back on script. Oh well, off script. But I think this is really cool that we have Abigail, fourth-year a veterinary student, not only completing the study but again getting it across the finish line. And I hope you guys know about our journal awards. Do you know about the awards we give out? Oh, Mandy knows, yay. So, for the listeners, we're the only, probably only journal I know veterinary or human and we give out four awards for JAVMA and AJVR, for students, interns and residents, for manuscripts. So, we really hope this is a really important article for our listeners and our practitioners. So, we really hope you self-nominate.
Sarah Wright:Yeah, I think Mandy submitted. You submitted some nominations last year. Is that correct Bird?
Mandy Wallace:I did. I've been fortunate. We've had some interns and residents and students get this award and it means so much to them. I really appreciate y'all doing that, because they all work so hard and there's not a lot of recognition for that hard work because it's hard to be a student and writing a paper and it's hard to be an intern or resident writing a paper, and so I just it really is always so exciting for them, it's exciting for us because we get to see them be recognized. So I really appreciate y'all doing that. I think it's it's awesome to to get to highlight their hard work.
Lisa Fortier:Yeah, we're really, really proud to do it. The other, we train student reviewers and associate editors as well, and, as the editor-in-chief, I had the privilege of presenting to the House of Delegates just last week, Sarah, maybe.
Sarah Wright:Last week, yeah!
Lisa Fortier:and advise them of the things that our journals are doing that nobody else is, because we really believe in the future of our profession.
Sarah Wright:So, we're really excited Now going back to your manuscript, so this next set of questions is going to be really important for our listeners. The first one is going to be more centered around the veterinarian's perspective. So, Abigail, what is one piece of information the veterinarian should know before performing a perineal when you're happy and a dog after a prior castration?
Abigail Hatch:So in dogs that undergo surgical correction of their perineal hernias, I do think it's important to keep that association that dogs neutered prior to surgery are at a 4.4 times greater chance of recurrence postoperatively. Again, like I said earlier that's not to tell your patients do not get neutered, because we do want our patients neutered out there.
Abigail Hatch:But it's a very important point to have with your owners during that discussion and make that very clear that it does unfortunately increase their risk of recurrence postoperatively.
Sarah Wright:and then, on the other side of the relationship, what's something that these pet owners should know?
Abigail Hatch:Yeah, so, since we looked at recurrence being one of the major complications and we found some risk factors associated with recurrence, I think just informing owners on what clinical signs and symptoms you would see if their pet had recurrence postoperatively, so they would know when to look for veterinary help, and those clinical signs would be similar to what we mentioned before, like constipation, perineal swelling, strange area, et cetera.
Lisa Fortier:Fantastic, really really good take-home points and nice succinctly stated. So thank you, of course. Thank you, guys Again. As we wind down, we ask a fun question of each of you. Mandy, this is going to be a tough one. Sarah and I have a hypothesis for this question, but really curious what your answer is. When you complete a puzzle, do you begin with the interior, do you do a middle section, middle section by color, or do you do the exterior border pieces first?
Mandy Wallace:Yes, that's it. That's a great question. So I do the exterior border pieces first. So I, because I feel like I can see the edges, so it allows me to get going. However, I do get a little distracted and so if I find pieces that look like they go together, I'll have little separate islands of pieces that I found that kind of go together at the same time. So I may make little piles or that, but I try to get the exterior border first.
Lisa Fortier:All right, You're fitting our biomorph. So we we predict that surgeons do the exterior and medicine folks do the interior. So you are, you're the perfect hybrid.
Mandy Wallace:That is funny. Oh, I love that.
Lisa Fortier:We're going to actually do a retrospective on this answer.
Mandy Wallace:I love that.
Lisa Fortier:And then maybe when we're interviewing folks right, and you should like, would you have a student come into your office? You could have like a half done puzzle and then like see where they gravitate towards and you're like I know what your career is.
Mandy Wallace:I love that.
Lisa Fortier:And, Abigail, for you, even though you're a fourth year veterinary student, what is the oldest or the most interesting item on your desk or in your desk drawer?
Abigail Hatch:So I don't know how interesting it would be for everyone else, but it means a lot to me. At my desk back home I have my sister. When I went off to college she hand painted this like ceramic fish and I've kept it on my desk throughout college, throughout vet school, and it's just something that if I'm having a rough day it kind of reminds me of home. Family's really important to me. So it may seem kind of small and just oh, it's a little ceramic fish on your desk but it's something that kind of eases me if I'm stressed studying for exams or when I'm writing a lot of discharges for patients on clinics and things like that. It just kind of keeps me grounded and reminds me of where I came from and stuff.
Lisa Fortier:That's very awesome. Maybe when you get back home you can send us a selfie of you and what's your fish's name.
Abigail Hatch:I didn't name it. I should have
Lisa Fortier:Fishy.
Abigail Hatch:Fishy.
Lisa Fortier:Do you pet it like a worry stone?
Abigail Hatch:No, I have not. It's very smooth, so I mean I guess I could. That would actually probably like. The smoothness would probably be calming as well.
Sarah Wright:But Very cool. Thank you both so much. We appreciate you being here today chatting with us, and also for submitting your manuscript to JAVMA.
Abigail Hatch:Yeah, thank you for having us. It's been so much fun talking to you guys.
Mandy Wallace:Yes agreed.
Mandy Wallace:Thank you, we really appreciate it and thanks for highlighting our paper and to our listeners.
Sarah Wright:You can read Mandy and Abigail's article in JAVMA. I'm Sarah Wright with Lisa Fortier. Be on the lookout for next weeks episode.
