\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[T2A]{fontenc}
\usepackage[ngerman,greek,polish,english]{babel}



\usepackage{float}








\begin{document}

\title{The use of a vascularized pedicle jejunal graft as a treatment for
anastomosis dehiscence after transanal pull-trough, with a combined
approach, in two dogs.}



\author[1]{Ilaria Falerno}%
\author[1]{Francesco Collivignarelli}%
\author[1]{Massimo Vignoli}%
\author[1]{andrea paolini}%
\author[1]{Roberto Tamburro}%
\affil[1]{University of Teramo Faculty of Veterinary Medicine}%


\vspace{-1em}



  
  \date{June 14, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
A novel use of a jejunal graft for the successful repair of a colorectal
anastomotic dehiscence after a transanal pull-through procedure in two
dogs.%
\end{abstract}%



\sloppy


\textbf{Title page}

\emph{Title}

The use of a vascularized pedicle jejunal graft as a treatment for
anastomosis dehiscence after transanal pull-trough, with a combined
approach, in two dogs.

Authors

Ilaria Falerno, Francesco Collivignarelli, Massimo Vignoli, Andrea
Paolini, Roberto Tamburro

\emph{Affiliations}

University of Teramo, Faculty of Veterinary Medicine, 64100, Teramo,
Italy

\emph{Corresponding author:}

Francesco Collivignarelli

University of Teramo, Faculty of Veterinary Medicine

Localit\selectlanguage{ngerman}à Piano d'Accio SP 18, 64100, Teramo, Italy

Tel + 39 (0)861266835

Email:\emph{fcollivignarelli@unite.it}

\emph{Keywords:} jejunal, pull-through, colorectal, anastomosis
dehiscence.

\textbf{Key clinical message}

A pedicled jejunal graft was successfully used to treat a colorectal
anastomotic dehiscence, which

eliminated the tension on the anastomotic site.

\textbf{Abstract} A novel use of a jejunal graft for the successful
repair of a colorectal anastomotic dehiscence after a transanal
pull-through procedure in two dogs.

\textbf{Introduction}

Intestinal tumors represent 3\% of all canine tumors, with 36-60\% of
these affecting the large intestine.\textsuperscript{1--4} More than
50\% of colorectal tumors are malignant, with adenocarcinoma being the
most common type.\textsuperscript{1,5,6} Other malignancies of the
rectum include leiomyosarcoma, lymphosarcoma, hemangiosarcoma,
extramedullary plasmacytoma, mast cell tumor, melanoma, and
fibrosarcoma.\textsuperscript{3}

Adenocarcinoma can occur in many forms including nodular, pedunculated,
or annular constrictive.\textsuperscript{1,2} Single, pedunculated, or
polypoid tumors are reported to have a good prognosis after surgical
resection, whereas annular colorectal adenocarcinoma is associated with
the shortest survival time.\textsuperscript{1,7,8} Malignant tumors
require full-thickness resection with a recommended margin of at least
2-8 cm. The rectum may be exposed using a ventral, dorsal, lateral,
caudal, transanal, transcutaneous, or combined approach. The choice of
the approach is made according to the location, size, and type of
injury.\textsuperscript{1}

A transanal pull-through procedure is one of the most common surgical
approaches used to resect colorectal neoplasms.\textsuperscript{6} A
transanal pull-through or combined abdominal-transanal approach are
well-described procedures. The postoperative complications after rectal
amputation and anastomosis using a transanal pull-through procedure are
tenesmus,\textsuperscript{1,9,10} stricture
formation,\textsuperscript{1,9}
dehiscence,\textsuperscript{6,9}infection,\textsuperscript{9,10} and
fecal incontinence.\textsuperscript{1,9,10} Anastomotic dehiscence
usually occurs 3-5 days after surgery, can be fatal, and requires prompt
intervention.\textsuperscript{3} Numerous studies in the human and
veterinary literature have focused on the assessment of risk factors,
prophylactic measures, and approaches to repair the
dehiscence.\textsuperscript{11} A case report was recently published on
the use of a temporary end-on colostomy in a dog as a rescue technique
for the repair of an anastomotic dehiscence after a transanal-rectal
pull-through procedure.\textsuperscript{6} The use of a colostomy has
rarely been reported in veterinary medicine,\textsuperscript{6,7} likely
because animal owners may not appreciate the associated fecal
incontinence and postoperative care requirements.\textsuperscript{3}

While the application of jejunal grafts is well-described in
humans,\textsuperscript{12--15} it is not frequently used in veterinary
medicine.\textsuperscript{16--18}

The aim of this report was to describe the application of a jejunal
graft and outcome for the repair of an anastomotic dehiscence after a
transanal pull-through procedure for colorectal carcinoma, in two
separate dog cases using a combined approach.

\textbf{Materials and Methods}

\emph{Case 1}

A 6-year-old, 12-kg, female mixed-breed dog underwent a transanal-rectal
pull-through surgery for adenocarcinoma of the colon.

Three days after surgery, the dog was presented to the Veterinary
Teaching Hospital of the University of Teramo with a history of weakness
and dysorexia. A physical examination showed evidence of tachypnea (44
breaths/min), mucosal pallor, abdominal pain, and hyperthermia (40.3
°C). Dehiscence of a previously placed anastomotic suture was suspected.
Digital rectal palpation confirmed the presence of a partial
ventral-left-lateral dehiscence of the colorectal anastomosis localized
approximately 1.5 cm from the anus. Laboratory findings showed mild
hypoalbuminemia (2.4 g/dL; reference range, 2.8-3.7 g/dL) and
leukocytosis (22 × 10\textsuperscript{3}/mm\textsuperscript{3};
reference range, 6-17 × 10\textsuperscript{3}/mm\textsuperscript{3}).
The packed cell volume was 39\% (reference range, 35-55\%), and total
protein level was 6.7 g/dL (reference range, 6-7.5 g/dL). Lateral and
dorsoventral abdominal radiographs showed decreased serosal surface
visualization with a ground-glass appearance in the caudal abdomen. The
ultrasound examination showed a moderate amount of free peritoneal fluid
with hyperechoic fat in the caudal abdomen. Fluid samples were collected
by ultrasound-guided abdominocentesis. Degenerate neutrophils and
vegetable material were found among the cytological findings.

The dog was hospitalized for surgical revision. During the
hospitalization, the dog received maintenance fluid therapy with
lactated Ringer's solution (4 mL/kg/h), methadone (0.2 mg/kg, every 4
hours, administered

according to the Glasgow pain scale), and metronidazole-spiramycin (10
mg/kg, every 12 hours, administered orally).

\emph{Case 2}

A 5-year-old, 33-kg, female golden retriever was referred to the
Veterinary Teaching Hospital for exercise intolerance, dyschezia,
tenesmus, and hematochezia. A colorectal surgery was performed 6 days
earlier using a transanal pull-through procedure for colorectal
carcinoma. A physical examination showed evidence of severe abdominal
pain, mucosal pallor, tachycardia (150 beats/min), and a rectal
temperature of 39.7 °C. Dehiscence of a previous colon surgery with
anastomosis was suspected. Digital intraluminal rectal palpation
confirmed the presence of a partial ventral dehiscence of the colorectal
anastomosis localized approximately 1 cm from the anus. Blood tests were
normal. An abdominal radiographic study in two orthogonal views and
abdominal ultrasonography findings were compatible with moderate
peritoneal effusion. After abdominocentesis, a cytological evaluation of
the fluid showed degenerate neutrophils and intracellular cocci.

The dog was hospitalized for surgical revision. During the
hospitalization, the dog received maintenance fluid therapy with
lactated Ringer's solution (4 mL/kg/h), methadone (0.2 mg/kg, every 4
hours, administered according to the Glasgow pain scale), and
metronidazole-spiramycin (10 mg/kg, every 12 hours, administered
orally).

\emph{Surgical procedure}

Each dog was slowly administered dexmedetomidine (1 \selectlanguage{greek}µ\selectlanguage{english}g/kg) and methadone
(0.2 mg/kg) intravenously. Anesthesia was induced intravenously with
propofol (initial bolus of 2 mg/kg over 60 seconds followed by
incremental bolus doses of 0.5 mg/kg) and maintained using isoflurane in
oxygen. A urinary catheter was placed and the metacarpal artery was
catheterized. The intraoperative blood pressure was monitored using both
invasive and noninvasive techniques. Cefazolin (22 mg/kg) was
administered intraoperatively at induction and every 90 minutes
thereafter. A loading dose of meloxicam (0.2 mg/kg) was administered
intravenously following induction. Intraoperatively, the dogs received a
loading dose of lidocaine (2 mg/kg) intravenously followed by lidocaine
CRI (33 \selectlanguage{greek}µ\selectlanguage{english}g/kg/min) and fluid therapy with lactated Ringer's solution
(6-7 mL/kg/h).

Each dog was positioned in dorsal recumbency, and both the ventral
abdomen and the perineal area were prepared for surgery. A ventral
midline abdominal approach was used, starting from the xiphoid to the
pubis, and showed a moderate amount of peritoneal effusion.

To increase the colorectal exposure, bilateral pubic and ischial
osteotomies were carried out. The division between the right and left
adductor muscles was incised sharply, taking care to stay exactly on the
midline to minimize the risk of hemorrhage. The adductor muscles were
then elevated subperiosteally from the pubis and ischium with a
0.25-inch Key periosteal elevator. Then, elevation was continued until
the obturator nerves and approximately two-thirds of the obturator
foramina were visible. The prepubic tendon was incised along the pubis
to the level of the proposed pubic osteotomy sites, and a 2-mm pin chuck
was used to drill two holes on either side of the four proposed
osteotomy sites. The osteotomies of the right and left pubis and ischium
were then created using a sagittal oscillating saw. The internal
obturator nerves were protected with a malleable retractor while the
osteotomies were performed. The internal obturator muscle was elevated
subperiosteally from the right pubis and ischium, allowing for the
resection of the central bony plate to the left. Upon increased
colorectal exposure, an anastomotic dehiscence was evident (Figure 1A).
Initially, the dehiscence was isolated by sterile gauze. Debridement and
primary closure of the colon and rectal stumps were attempted, which
resulted in tension upon closure. To decrease the tension on the
anastomosis, a jejunal grafting technique was utilized. A 5-cm segment
of healthy jejunum (Figure 1B), including the jejunal artery and vein,
were isolated and mobilized from the middle of the jejunum. The graft
donor site was closed using an end-to-end anastomosis with a 4-0
polydioxanone suture (PDS) in a simple, continuous appositional pattern
(Figure 1C). The pedicled jejunal segment was transposed to the
anastomotic site. Cranially, the rectal and jejunal stumps were sutured
in place using an end-to-end anastomosis with a 4-0 PDS in a simple
interrupted pattern (Figure 2A). The rectal portion was hard to scarify
and anastomose using this approach. The use of a transanal technique was
thus necessary. The jejunal caudal stump was closed with a 4-0 PDS using
a continuous Parker-Kerr inverting suture technique. A Doyenne clamp was
inserted through the anus into the abdomen by a second surgeon to pull
out the caudal jejunal stump through the anus (Figure 2B). The abdomen
was lavaged with 5 L sterile saline, and a Jackson Pratt drain was
placed in the peritoneal cavity and was closed without complications.
The dog was then positioned in sternal recumbency and the perineal
surgical field was prepared using an external operator. The jejunal
caudal stump was externalized using a Doyenne clamp, and the Parker-Kerr
suture was removed. A transanal-rectal-jejunal end-to-end anastomosis
was performed using a 4-0 PDS in a simple continuous appositional
pattern. The jejunal-rectal anastomosis was then replaced through the
anus (Figure 2C).

Major complications were classified as a dehiscence of one or both of
the anastomotic sites and severe rectal bleeding, whereas minor
complications were classified as tenesmus, leakage, diarrhea, and fecal
incontinence.

\emph{Postoperative management}

Postoperatively, both dogs were hospitalized in the intensive care unit.
They were maintained on lidocaine CRI (33 \selectlanguage{greek}µ\selectlanguage{english}g/kg/min) for 24 hours and
received maintenance fluid therapy with lactated Ringer's solution (3-4
mL/kg/h), metronidazole-spiramycin (10 mg/kg, every 12 hours,
administered intravenously for 5 days), cefazoline (22 mg/kg, every 12
hours, administered intravenously for 8 days), meloxicam (0.1 mg/ kg,
every 24 hours, administered intravenously for 4 days), and methadone
(0.15 mg/kg, every 4 hours, administered intravenously, according to the
Glasgow pain scale). Pain scoring was performed every 2 hours and the
dogs resumed oral feeding the day after surgery with four small meals
per day of gastrointestinal canned food.

The mean urinary output was 2.5 mL/kg/h in Dog 1 and 3 mL/kg/h in Dog 2,
with the urinary output continuously monitored for 4 days after surgery.
Postoperative serial ultrasound examinations were performed to monitor
for abdominal effusion and peritoneal reaction.

\textbf{Results}

Self-limiting diarrhea was observed for 3 days following surgery in both
dogs.

The drains were removed, from both dogs, 4 days after the surgery
following a decreased peritoneal effusion. By 10 days after surgery, the
wound sutures were removed.

The dogs were discharged 5 days after surgery with normal vital
parameters and organic function, and with an absence of peritoneal
effusion. Wet food was recommended for the following two weeks. A
follow-up examination, including complete blood count, serum
biochemistry profile, rectal palpation, and abdominal ultrasound, was
performed 20 and 40 days after surgery, and were followed by interviews
with the owners 1 year after surgery. No complications were highlighted
at any follow-up. A physical examination showed normal vital parameters,
absence of abdominal pain, and no signs of wall discontinuity by rectal
palpation. The absence of peritoneal effusion was detected by an
ultrasound exam. During the telephone interviews, the owners were each
asked about the general status, appetite, frequency of defecation, and
episodes of incontinence of their dog. Notably, a total recovery was
reported by the owners.

The surgical time was 120 min for case 1 and 145 min for case 2.

In both dogs, the intraoperative mean arterial pressure never fell below
65 mmHg, and no major postoperative complications were observed in
either surgery. Self-limiting diarrhea was observed for 3 days after
surgery; however, the surgical procedure was successful and allowed for
the resolution of clinical signs.

\textbf{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,\textsuperscript{1,9,10} rectal
bleeding,\textsuperscript{1,9,10} rectal
stricture,\textsuperscript{1,9}suture dehiscence,\textsuperscript{6,9}
and transient or permanent fecal incontinence.\textsuperscript{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\%).\textsuperscript{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.\textsuperscript{9} The incidence of dehiscence increases
with resections greater than 6 cm,\textsuperscript{1,6,19}usually
occurring 3 to 5 days after surgery during the lag phase of the healing
process.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{16} The
most common jejunal grafting procedures involve the reconstruction of
pharyngolaryngectomy defects\textsuperscript{14}. Additionally,
tracheal, duodenal, esophageal,\textsuperscript{12,15} and urethral
replacements have been performed with acceptable results and risks of
complications related to the grafting sites.\textsuperscript{13}

In small animals, reports of jejunal grafting are less frequent.
Brourman et al\emph{.} 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.\textsuperscript{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 dog\textsuperscript{16} and
Bensignor et al. subsequently described this technique in
detail.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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
tumors\textsuperscript{2,5,8} and represents a possible postoperative
complication after the transanal pull-through
procedure.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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, colostomy\textsuperscript{6,7} 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 dog\textsuperscript{6};
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.\textsuperscript{6} Other
complications reported in the literature include prolapse of the stoma
and skin irritation.\textsuperscript{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.

\textbf{Authors contribution}

All authors were involved in drafting the article. IF, FC and RT
critically revised the manuscript. RT approved the final version to be
submitted for publication.

All of the authors have read and approved the final manuscript.

\textbf{Ethical approval}

No ethical approval has been required for this study as it was not
experimental. A written informed consent has been taken beforehand form
the owners.

\textbf{Funding information}

No sources of funding were declared for this study.

\textbf{Acknowledgments}

We would like to thank BioScience Writers
(\emph{www.biosciencewriters.com}) for English language editing

\textbf{Conflict of interest statement}

The authors declare no conflict of interests related to this report.

\textbf{References}

1. Morello E, Martano M, Squassino C, et al. Transanal Pull-Through
Rectal Amputation for Treatment of Colorectal Carcinoma in 11
Dogs.\emph{Vet Surg} . 2008;37(5):420-426.
doi:10.1111/j.1532-950X.2008.00404.x

2. Spu\selectlanguage{polish}ż\selectlanguage{english}ak J, Ciaputa R, Kubiak K, et al. Adenocarcinoma of the posterior
segment of the gastrointestinal tract in dogs -- clinical, endoscopic,
histopathological and immunohistochemical findings. \emph{Pol J Vet Sci}
. 2017;20(3):539-549. doi:10.1515/pjvs-2017-0066

3. Baines SJ, Aronson LR. Rectum, anus, and perineum.
In:\emph{Veterinary Surgery: Small Animal} . Elsevier Saunders;
2018:1783-1827.

4. White RAS, Gorman NT. The clinical diagnosis and management of rectal
and pararectal tumours in the dog. \emph{J Small Anim Pract} .
1987;28(2):87-107. doi:10.1111/j.1748-5827.1987.tb05974.x

5. Danova NA, Robles-Emanuelli JC, Bjorling DE. Surgical Excision of
Primary Canine Rectal Tumors by an Anal Approach in Twenty-Three
Dogs.\emph{Vet Surg} . 2006;35(4):337-340.
doi:10.1111/j.1532-950X.2006.00154.x

6. Cinti F, Pisani G. Temporary end-on colostomy as a treatment for
anastomotic dehiscence after a transanal rectal pull-through procedure
in a dog. \emph{Vet Surg} . 2019;48(5):897-901. doi:10.1111/vsu.13152

7. Kumagai D, Shimada T, Yamate J, Ohashi F. Use of an incontinent
end-on colostomy in a dog with annular rectal adenocarcinoma. \emph{J
Small Anim Pract} . 2003;44(8):363-366.
doi:10.1111/j.1748-5827.2003.tb00169.x

8. Prater MR, Flatland B, Newman SJ, Sponenberg DP, Chao J. Diffuse
annular fusiform adenocarcinoma in a dog. \emph{J Am Anim Hosp Assoc} .
2000;36(2):169-173. doi:10.5326/15473317-36-2-169

9. Nucci DJ, Liptak JM, Selmic LE, et al. Complications and outcomes
following rectal pull-through surgery in dogs with rectal masses: 74
cases (2000--2013). \emph{J Am Vet Med Assoc} . 2014;245(6):684-695.
doi:10.2460/javma.245.6.684

10. Anson LW, Betts CW, Stone EA. A Retrospective Evaluation of the
Rectal Pull-through Technique Procedure and Postoperative
Complications.\emph{Vet Surg} . 1988;17(3):141-146.
doi:10.1111/j.1532-950X.1988.tb00292.x

11. Ellison GW. Complications of Gastrointestinal Surgery in Companion
Animals. \emph{Vet Clin North Am Small Anim Pract} . 2011;41(5):915-934.
doi:10.1016/j.cvsm.2011.05.006

12. Bax NMA, van der Zee DC. Jejunal pedicle grafts for reconstruction
of the esophagus in children. \emph{J Pediatr Surg} .
2007;42(2):363-369. doi:10.1016/j.jpedsurg.2006.10.009

13. Patricio J, Silveira L, Falc\selectlanguage{ngerman}ão F. {[}Reconstruction of the urethra
by free jejunal graft{]}. \emph{Chir Memoires Acad Chir} .
1994;120(5):231-233.

14. Perez-Smith D, Wagels M, Theile DR. Jejunal free flap reconstruction
of the pharyngolaryngectomy defect: 368 consecutive cases. \emph{J Plast
Reconstr Aesthetic Surg JPRAS} . 2013;66(1):9-15.
doi:10.1016/j.bjps.2012.08.033

15. Gaur P, Blackmon SH. Jejunal graft conduits after
esophagectomy.\emph{J Thorac Dis} . 2014;6 Suppl 3:S333-340.
doi:10.3978/j.issn.2072-1439.2014.05.07

16. Massie A, McFadden M. Vascularized pedicle jejunal graft for closure
of large duodenal defect in a dog. \emph{Can Vet J} . 2016;57:5.

17. Bensignor T, Rault A, Dubrez J. Duodenal repair with a jejunal
pedicle graft. \emph{J Visc Surg} . 2018;155(2):141-145.
doi:10.1016/j.jviscsurg.2018.02.008

18. Ziaian B, Hosseinzadeh M, Nikravesh B, et al. Assessing two methods
of repair of duodenal defects, jeujenal serosal patch and jejunal
pedicled flap, (an experimental animal study). \emph{J Pak Med Assoc} .
2014;64(8):4.

19. Anderson GI, Mckeown DB, Partlow GD, Percy DH. Rectal Hesection in
the Dog A New Surgical Approach and the Evaluation of Its Effect on
Fecal Continence. \emph{Vet Surg} . 1987;16(2):119-125.
doi:10.1111/j.1532-950X.1987.tb00922.x

20. Brourman JD. Successful replacement of an obstructed ureter with an
ileal graft in a cat. \emph{J Am Vet Med Assoc} . 2011;238(9):1173-1175.
doi:10.2460/javma.238.9.1173

21. Davis DJ, Demianiuk RM, Musser J, Podsiedlik M, Hauptman J.
Influence of preoperative septic peritonitis and anastomotic technique
on the dehiscence of enterectomy sites in dogs: A retrospective review
of 210 anastomoses. \emph{Vet Surg} . 2018;47(1):125-129.
doi:10.1111/vsu.12704

\textbf{Legends}

Figure 1. Celiotomy in a 6-year-old, 12-kg, female, mixed-breed dog.
Anastomotic dehiscence of the previous colorectal site (A).
Exteriorization and choice of a healthy 5-cm jejunal segment to be
grafted (B). Isolation of the jejunal segment, including the jejunal
artery and vein, and end-to-end anastomosis of the graft donor site with
a 4-0 polydioxanone suture using a simple interrupted pattern.

Figure 2. Combined transanal-abdominal surgical procedure in a
6-year-old, 12-kg female mixed-breed dog. A Doyenne clamp was inserted
through the anus into the abdomen by a second surgeon to grasp the
closed, free end of the jejunal graft (A) and pull it out through the
anus (B). A transanal-rectal-jejunal end-to-end anastomosis using a 4-0
polydioxanone suture using a simple continuous appositional pattern and
replacement (C).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/fig/fig}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/fig-2/fig-2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

