Management of anorectal injuries in children: an eighteen-year experience.

Abstract

Anorectal injuries (ARI) are rare in childhood and yet occur due to sexual abuse and firearm injuries in developed countries. The labeling of ARI remains controversial in spite of a number of divergent reports over the past decade. We evaluated the surgical indications for primary repair of ARI without stoma, and also the potential risk factors affecting morbidity and mortality in children with ARI. Between 1983 and 2001, 41 children were diagnosed as ARI in our institution due to blunt or penetrating trauma. There were 17 male and 24 female patients. Causes of anorectal injury were blunt injuries in the majority of cases (56 %). Vagina and extremity fractures were the organs most frequently associated with ARI. There was isolated ARI in 49 % of cases. Intraperitoneal organ injury was found in 3 patients (7 %). The distribution of injury location according to the classification of ARI in our children was as follows: 10 % in G I, 32 % in G II, 51 % in G III, and 10 % in G V. Primary repair without colostomy was performed in 51 % of cases. Primary repair and diversion of faecal stream by loop colostomy was required in 20 (49 %) patients. Postoperative septic complications occurred in 29 % of cases. Some potential risk factors such as trauma mechanism and associated organ injury were not significantly correlated to postoperative septic complications, while other risk factors such as mode of treatment, time of operative intervention and contamination were significantly related to postoperative septic complications (p < 0.05). The sensitivity of trauma scoring systems for the estimation of postoperative complication occurrence was significant for ISS (p < 0.05) and ARI score (p < 0.05). The relative risk of developing a postoperative septic complication was higher than 2 for patients with ARI grade III, ISS > 15, primary repair + colostomy group, and time of operative intervention > 8 hours. A child in the colostomy + primary repair group died on the first postoperative day from rapidly progressing septicaemia and multiple organ failure (2.4 %). The management of ARI can be carried out by primary repair procedure without colostomy in the majority of cases if the needed selectivity is established.