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.