Discussion
This report describes the use of a vascularized pedicled jejunal graft as a treatment for anastomotic dehiscence after a transanal pull-through procedure using a combined approach.
Complications following rectal pull-through procedures are tenesmus,1,9,10 rectal bleeding,1,9,10 rectal stricture,1,9suture dehiscence,6,9 and transient or permanent fecal incontinence.1,9,10 In the literature, the incidence rates reported for each of these complications are highly variable. In a study of 74 cases,78% of patients undergoing a transanal pull-through procedure developed at least one postoperative complication; fecal incontinence was the most common complication recorded (57%), followed by diarrhea (43.2%), tenesmus (31.1%), stricture formation (21.6%), rectal bleeding (10.8%), constipation (9.5%), dehiscence (8.1%), and infection (5.4%).9 Of the six dogs with anastomotic dehiscence, one developed septic peritonitis, three developed pararectal abscesses, and two had mild incisional dehiscence that healed after a second procedure. The dog with septic peritonitis was euthanized, and the cases of pararectal abscesses were resolved with surgical and medical management.9 The incidence of dehiscence increases with resections greater than 6 cm,1,6,19usually occurring 3 to 5 days after surgery during the lag phase of the healing process.3
The current treatment for suture dehiscence after a transanal-rectal pull-through procedure is a temporary end-on colostomy with meticulous daily stoma management and 60 days of hospitalization.6 Initial management using a human fecal collection bag was ineffective; after 90 days, a second surgery was performed to resect the stoma and recanalize the intestine with a colonic end-to-end anastomosis. Dermatitis and stoma management were the major complications described in the aforementioned study. Although the procedure was successful, it required extensive postoperative management by the dog’s owner.6
In humans, several types of jejunal and ileal grafts (pedicled, augmented, free segment, or a combination of these) have been used for the reconstruction of large anatomical defects.16 The most common jejunal grafting procedures involve the reconstruction of pharyngolaryngectomy defects14. Additionally, tracheal, duodenal, esophageal,12,15 and urethral replacements have been performed with acceptable results and risks of complications related to the grafting sites.13
In small animals, reports of jejunal grafting are less frequent. Brourman et al. described a successful repositioning of an obstructed ureter using an ileal graft in a cat. Additionally, ileal grafting has proven to be an effective rescue technique for the treatment of severe ureteral impairments where a primary repair is not possible or has failed.20
Moreover, Massie et al. reported the innovative use of a vascularized pedicled jejunal graft for the successful repair of a large circumferential duodenal perforation in a dog16 and Bensignor et al. subsequently described this technique in detail.17
Previously, Ziaian et al. showed how the jejunal pedicled flap and jejunal serosal patch techniques were effective in closing large duodenal defects in dogs; they obtained better histological results using the jejunal pedicled flap than using the jejunal serosal patch.18
In these studies, no complications related to the use of the grafts were found. Possible described complications related to the use of jejunal grafts include the formation of stenosis and vascular thrombosis; dysmotility problems have also been reported.16
None of these complications were clinically or ultrasonographically detected in our patients. Further, no tension or obstruction of the vascular pedicle was detected intraoperatively due to the great mobility of the mesentery. No postoperative complications such as tenesmus, leakage, dehiscence, and fecal incontinence were observed.
The risk factors for anastomotic dehiscence and leakage include septic peritonitis, hypoalbuminemia, and intraoperative hypotension.21
Preoperatively, both dogs showed evidence of peritoneal effusion with degenerative neutrophils and bacteria upon cytological evaluation for anastomotic dehiscence of a previous colorectal surgery. Intraoperatively, the dehiscence was corrected by eliminating the suture under tension, washing the abdomen with 5 L sterile saline, and inserting a Jackson Pratt drain prior of closure. A broad-spectrum antibiotic therapy was also administered.
Diarrhea is a common finding associated with intestinal tumors2,5,8 and represents a possible postoperative complication after the transanal pull-through procedure.9 In both cases, only diarrhea was observed for 3 days following surgery. Furthermore, post-surgical diarrhea is significantly associated with the length of the resected rectal segment compared to the body weight.9 Other possible explanations are a decrease in the rectal area available for the absorption of water from the stool before elimination and the establishment of a condition similar to short bowel syndrome or hypermotility syndrome, similar to that observed in humans, which can cause transient postoperative diarrhea.9
Therefore, the use of the pedicled jejunal graft allowed for the resolution of the colorectal dehiscence without major complications, and eliminated the tension that the anastomotic site was previously subjected to.
To date, colostomy6,7 is the only surgical technique described as an alternative to euthanasia for the treatment of colorectal anastomotic dehiscence after a transanal pull-through procedure. Recently, Cinti et al. reported a case of a temporary end-on colostomy as a rescue technique to repair an anastomotic dehiscence after a transanal pull-through procedure in a dog6; the procedure allowed for fecal diversion, with the aim of reducing tension on the anastomotic site and allowing for the healing of the distal colorectal area. In that study, dermatitis and stoma management were the major complications described.6 Other complications reported in the literature include prolapse of the stoma and skin irritation.7 Although the procedure was successful, it required extensive postoperative management by the dog’s owner.
In our study, we used a pedicled jejunal graft to successfully treat a colorectal anastomotic dehiscence, which eliminated the tension on the anastomotic site. Moreover, the entire procedure is a single surgical solution that did not require extensive postoperative care by the owners. Therefore, the pedicled jejunal graft technique represents a novel and effective alternative for the repair of colorectal anastomotic dehiscence after a transanal pull-through procedure. Larger studies are needed to investigate the effectiveness and risks of complications associated with this novel surgical procedure.