Anorectal Injury Research Articles

A Rare Case of Anorectal Injury Communicating with the Back in a Child.

A Rare Case of Anorectal Injury Communicating with the Back in a Child.

WE1.5 Management of Anorectal trauma - A UK trauma centre based experience

Abstract Introduction and Aim The evidence base supporting the management of traumatic anorectal injuries is poor. Previous case series provide some general observations on management decisions. The aim of the current study was to describe the largest UK experience of anorectal trauma management from a national major trauma centre. Methods Retrospective review of prospective data, collected systematically as part of routine trauma practice locally, was performed. Data were extracted on mechanism of trauma, immediate hospital care, diagnostics and operative management. Outcome data were extracted, where available, from follow up. Data are presented descriptively in a case series format. Results 37 patients (35 male vs 2 female) presented with traumatic anorectal injury between March 2012 and December 2021. The median age was 34 (6–93), 20 (54%) were penetrating injuries (11 stabs, 5 GSW, 5 other) vs 17 (46%) blunt (13 RTA, 4 other). Median Injury severity score was 16. Of the 37 cases treated, there were 18 intra peritoneal (8 both intra and extra) vs 16 extra peritoneal injuries. 30 patients had defunctioning stoma (DS), 8 cases had primary repair (PR) (with or without DS). Mean length of stay was 27 days. 15 out of 37 have had GI continuity restored, out of which 13 had a water-soluble contrast study and 5 anorectal physiology preoperatively. Conclusions Traumatic anorectal injuries are uncommon within UK practice, affect predominantly young men and have high morbidity. In the majority of cases defunctioning stomas are still the mainstay of treatment. Primary repair of extraperitoneal injuries is a viable procedure.

Rectal avulsion associated with complex open pelvic fracture following rollover injury

Background: We present a rare case of complete rectal avulsion from the external anal sphincter complex associated with unstable pelvic ring disruption, including spinopelvic dissociation, following rollover by tractor. In the context of major pelvic trauma, evaluating for unstable bony, acute vascular, urethral and bladder injuries is essential. However, a detailed search for anorectal injury is also required by the reporting radiologist. Case Report: In this case report we highlight specific pelvic floor anatomy on CT, with a focus on gross morphology and the presence of peri-rectal free gas as primary evidence for injury. Secondary radiological evidence which should trigger the search for anorectal injury includes bony posterior pelvic ring disruption (sacrum or coccyx fractures) or associated Morel-Lavallee lesions. Conclusion: The presence of radiological abnormality should prompt direct clinical inspection for corroboration. Early recognition is crucial for joint colorectal and orthopaedic management and the avoidance of delayed pelvic sepsis, which may become intractable.

The Management of Perineal Trauma in Children.

Aims:This study aimed to evaluate the outcome of perineal trauma in children and to a define protocol for their management.Methods:It is a retrospective study of children who presented with perineal injury between August 2012 and December 2020. The patients were classified into three groups: Group-1 included children with perineal and genitourinary injuries; Group-2 included patients with perineal and anorectal injuries; and Group-3 included patients with perineal, genitourinary, and anorectal injuries. All patients underwent primary repair. Those with full-thickness anorectal injury underwent an additional covering colostomy, while urethral disruption was initially managed by a diverting suprapubic cystostomy (SPC).Results:A total of 41 patients were studied. Impalement injury (n = 11; 27%) and sexual abuse (n = 11; 27%) were the most common mechanisms of injury. Twenty (49%) patients had anorectal injuries with 10 (24%) each of partial-thickness and full-thickness injury. There were 24 (59%) genital injuries and five (12%) urethral injuries. One patient each developed anal and vaginal stenosis, both were managed with dilatation. One patient developed a rectovaginal fistula repaired surgically at a later date.Conclusion:Perineal injuries with resultant anorectal or genital damage require a careful primary survey. Following stabilization, an examination under anesthesia as a set protocol will help determine the treatment strategy. A colostomy is essential in the acute management of severe anorectal injuries to reduce local complications and preserve continence. Urethral injuries may warrant an initial diverting SPC in selected cases.

Endoluminal vacuum-assisted closure for penetrating rectal injury in a pediatric patient

Abstract Purpose Endoluminal Vacuum-assisted closure therapy (EVT) has been employed to assist in closure of rectal defects with high success rates. Most of the literature is focused on the use of EVT after anastomotic leaks, and has been limited in the pediatric population to esophageal defects. We describe a case report of the successful use of EVT in a penetrating rectal injury in a pediatric patient. Results The patient is a 15-year-old male who suffered a traumatic 6 cm full thickness penetrating anorectal injury, initially treated with fecal diversion, pre-sacral drainage, and distal rectal washout. He developed worsening pre-sacral abscess and was subsequently treated with EVT for 10 weeks with successful closure of the defect. Upon completion, he had restoration of intestinal continuity and maintained fecal continence. Conclusions EVT can be used to successfully manage penetrating rectal injuries in the pediatric population. This can avoid extensive surgical resection or permanent ostomy and help control sepsis.

Anorectal injury related to a personal watercraft: a case report and literature review

BackgroundDouche injury is a rare consequence of water recreation activities. Generally, this type of trauma occurs when people fall into the water in a sitting position during high-speed activities such as using a personal watercraft (PWC). Here, we report a rare case of anorectal injury caused by water jets from a PWC during sudden acceleration from rest.Case presentationA 21-year-old male passenger on a PWC fell off backward from the rear seat when the craft suddenly accelerated. He fell into the water in a supine position with his legs open, and the water jets of the PWC struck his perineum directly. Thereafter, bleeding from the anus was seen, and he was transferred to our hospital. On physical examination, there was a deep laceration interrupting the external anal sphincter in the posterior rectal wall. Abdominal computed tomography revealed a full-layer perforation of the posterior rectal wall and leakage of feces into the extraperitoneal space, but intraperitoneal free air was not seen. Laparoscopic sigmoid loop colostomy and primary suturing of the sphincter and mucosa were performed. He did not have any complications and was discharged from our hospital 16 days after the surgery. His anal function was almost perfectly preserved, and his diverting colostomy was closed 4 months later.ConclusionAnorectal injuries related to PWCs can occur not only while traveling at high speeds, but also when suddenly accelerating from rest. A diverting colostomy should be performed for this type of trauma. In these trauma cases, clinicians must suspect complex and life-threatening anorectal injuries early.

Diagnosing injuries caused by Indian wild boar: A case report

Wild boars are medium sized mammals commonly seen in Europe, Asia, North Africa and Greater Sun-da Island and India. Sus scrofa cristatus species is commonly seen in India. They are primarily nocturnal animal and are generally shy in nature, so incidences of attack by wild boar are rare. They are dangerous due to their razor sharp tusks, which can cause serious injuries. Wild boar attacks are under reported in the medical litera-ture. Attacks on humans by wild animals causing fatal injuries are not uncommon in rural and forest areas of India. This is the case of a 55-year-old male farmer who was assaulted from by an adult wild boar. Autopsy ex-amination revealed multiple penetrating injuries, bilateral rib fractures and an anorectal injury. Unlike the inju-ries inflicted by wild cats, canines and bulls, the hallmark of boar attack is the infliction of multiple penetrating injuries to the lower part of the body. As the victims of wild boar attack are usually recovered from rural forest areas, the investigating officers could be misled as to the nature of infliction of these multiple, fatal penetrating injuries to a possible homicide. This case is reported for its rarity, for the awareness of the possible injuries in such unnatural deaths, and for the factors predisposing to a boar attack. It is concluded that fatal penetrating injuries caused by this type of attack can be associated with extensive soft-tissue damage despite externally appearing to be simple puncture wounds. Keywords: Wild boar, penetrating injuries, anorectal injury

Regional Injury Classification and Treatment of Open Pelvic Fractures.

ObjectivesTo propose the regional injury classification of open pelvic fracture and summarize the characteristics of its treatment.MethodsClinical data for 67 open pelvic fractures treated from January 2001 to December 2017 were retrospectively analyzed. There were 48 male and 19 female patients. The patients were aged from 12 to 68 years old, and their pelvic fractures were categorized according to Tile classification (type A: 23 cases; type B: 19 cases; type C: 25 cases). Main injury distribution: pubic perineum, 29 cases; ilioinguinal, 20 cases; and sacroiliac, 7 cases. There were 5 cases of ilioinguinal‐perineum and 6 cases of sacroiliac‐perineum injury. Based on the region of the injury, the mortality and combined injury of each group were observed. The relationship between regional injury groups and death was examined.ResultsFollowing active treatment, 28 patients died. The mortality rate was 41.8% (28/67), with 39 patients surviving. The average follow‐up time was 6 months (3 months to 1 year after discharge). Majeed pelvic fracture score: the score was excellent in 12 cases, good in 14 cases, fair in 9 cases, and poor in 4 cases; there was an excellent and good rate of 66.7%. Open pelvic fracture regional injury classification includes: the perineal type (type I); the ilioinguinal type (type II); the sacroiliac type (type III); and the composite type (type IV). All types were independent of each other, and the mortality of open pelvic fractures was positively correlated with this classification, with a correlation coefficient of 0.620 (P = 0.001 < 0.05; the difference was statistically significant). In this study, cystourethral injury, anorectal injury, and infection were the main combined injuries of type I. The type II and III injuries were mainly iliac vascular injuries. The main combined injuries of type IV were infection, injury of ilium vessels and its branches. There was a statistical difference among the combined injuries of each subtype (P = 0.001 < 0.05).ConclusionsThe criteria for regional classification were clear, the mortality of the four subtypes increased gradually, and the incidence of combined injury of each subtype varied. Each subtype had different therapeutic characteristics.

Regional injury classification and treatment of open pelvic fractures

Objective To propose a novel regional injury classification for open pelvic fractures and characterize its application in clinical treatment. Methods The clinical data of 67 open pelvic fractures were retrospectively analyzed which had been treated from January 2001 through December 2017 at Department of Orthopedics, Affiliated Hospital to Chengdu University. They were 48 males and 19 females, from 12 to 68 years of age (average, 34 years). According to the Tile classification, 23 cases were type A, 19 Type B and 25 Type C. Their main injuries were located at pubic perineum in 29 cases, at ilioinguinal region in 20, at sacroiliac region in 7, at ilioinguinal-perineum in 5 and at sacroiliac-perineum in 6. Our novel regional injury classification was proposed according to the assessment of soft tissue injuries at the Faringer regions. The mortalities and complications were compared between types of our regional injury classification to find associations between them. Results Despite active treatment 28 patients died, giving a mortality of 41.8% (28/67). Our regional injury classification grouped the open pelvic fractures into 4 types: perineal type (type Ⅰ), ilioinguinal type (type Ⅱ), sacroiliac type (type Ⅲ) and composite type (type Ⅳ). The mortalities for the 4 types were respectively 20.7% (6/29), 45.0% (9/20), 71.4% (5/7) and 72.7% (8/11). The mortality of open pelvic fractures was positively correlated with our classification (γ=0.620, P=0.001). Type Ⅰ mainly included cystourethral injury, anorectal injury and infection, type Ⅱ and Ⅲ injury to iliac vessels and Type Ⅳ injury to iliac vessels and infection. The incidences of complications for type Ⅲ (100.0%, 7/7) and type Ⅳ (100.0%, 11/11) were significantly higher than those for type Ⅰ (82.8%, 24/29) and type Ⅱ (85.0%, 17/20) (P<0.05). Conclusions Our regional injury classification gives clear criteria. The mortality increases gradually with the 4 types. The incidence of complications for each type varies and thus leads to different therapies. Key words: Pelvis; Fractures, open; Classification; Mortality; Treatment

水上ジェットスキー推進装置の高圧水流による直腸肛門損傷の1例(A case of anorectal injury caused by the high pressure propulsion system of a water jet ski)

要旨 症例は18歳の男性。水上ジェットスキー（水上バイク）の後方座席に乗船し，加速した際に後方へ落水した。直後より腹痛，肛門痛，持続的な下血を認め，救急搬送された。初診時の肛門診察では6時方向に肛門から直腸にかけて約4cmの裂創があり，肛門は弛緩し，肛門収縮は認められなかった。腹部造影CTで腹腔内遊離ガス像と直腸周囲に造影剤の漏出を認めた。以上から水上ジェットスキー推進装置より噴出した高圧水流による直腸肛門損傷と診断し，緊急開腹術により腸管縫合術，人工肛門造設術，腹腔内ドレナージを施行した。術後は敗血症性ショックに陥ったがPMX–DHP（polymyxin B immobilized fiber column direct hemoperfusion），CRRT（continuous renal replacement therapy）によりショックから離脱し，術後経過は良好であった。第18病日の経肛門超音波検査で内肛門括約筋の不全断裂を認めたが，肛門収縮は残存していた。退院後は肛門括約筋訓練を行い肛門機能は徐々に回復し，受傷9か月後に人工肛門閉鎖術を実施した。水上ジェットスキーの高圧水流による直腸肛門損傷は稀であるが，出血や腹膜炎からショックに陥る場合がある。好発年齢である若年者の肛門機能に重篤な後遺症を残す可能性もあるため，早期より病態把握や肛門機能の評価を実施しなければならない。

Clinical Evaluation of a Novel Intrarectal Device for Management of Fecal Incontinence in Bedridden Patients.

The primary objective of the study was to evaluate the safety and efficacy of a stool management kit (SMK) for containment of fecal incontinence in hospitalized bedridden patients. A single-group quasi-experimental study. Twenty bedridden adults who had at least 1 episode of fecal incontinence in the prior 24 hours participated in the study. The study setting was the neurological unit of the All India Institute of Medical Sciences in New Delhi, India. The study was carried out in 2 phases. The device was placed in situ for up to 24 hours in 10 patients during phase I of the study and up to 120 hours in an additional 10 patients during phase II. Participants were assessed for anorectal injury and peripheral device leakage on a 4- to 6-hourly basis. Sigmoidoscopy was performed to evaluate for any mucosal trauma or alteration of anorectal pathology after retrieval of the device. The device was successfully placed in all patients following the first attempt to place the device; 80% of patients retained the device until planned removal. The SMK diverted fecal matter without anal leakage in 174 (93.5%) out of 186 assessment points in a group of 20 patients. The devices remained in situ for 21 ± 0.2 and 84.5 ± 38.9 hours during phase I and phase II, respectively. None experienced anorectal bleeding, sphincter injury, or mucosal ulceration with device usage. Post-device sigmoidoscopy revealed erythema at the site of diverter placement in 2 participants. Study findings suggest that the SMK successfully diverted liquid to semiformed fecal exudate without peripheral device leakage in 93.5% of bedridden patients. No serious adverse events occurred. Additional research is needed to compare its effectiveness with that of currently available intrarectal balloon devices.

Anorectal Injury Caused by Falling Backward from a Jet Ski: A Case Report

Anorectal Injury Caused by Falling Backward from a Jet Ski: A Case Report

Pathophysiology of late anorectal dysfunction following external beam radiotherapy for prostate cancer

Background. Patients treated with external beam radiotherapy (EBRT) may suffer from long-term anorectal adverse effects. The purpose of the present study was to assess long-term functional and structural anorectal changes in patients previously treated with EBRT for prostate cancer and to suggest the mechanism behind the development of the adverse effects.Material and methods. Our previously proposed RT-induced anorectal dysfunction (RT-ARD) score, developed with the intention to survey anorectal dysfunction was used to identify patients with and without anorectal symptoms. Among 309 patients surveyed with the questionnaire, we chose 23 patients with the highest RT-ARD score and 19 patients with the lowest RT-ARD score. They were investigated by multimodal rectal sensory stimulation, standard anal physiological tests. Changes of the rectal mucosa were assessed by flexible sigmoidoscopy and graded by the Vienna Rectoscopy Score (VRS).Results. The mean follow-up time was 3.8 (range, 2.8; 8.6) years in patients with high RT-ARD and 3.8 (range, 2.6; 5.9) in patients with low RT-ARD. Endoscopic evaluation revealed higher VRS scores in patients with high RT-ARD compared to patients with low RT-ARD (p = 0.002). Patients with high RT-ARD had increased rectal sensory response to distension manifested both as volume (p = 0.006) and cross-sectional area (p = 0.04), and they had reduced maximum anal resting pressure assessed by anal manometri (p = 0.02).Conclusions. Long-term anorectal symptoms correlate to changes in anorectal biomechanical properties and rectal mucosal injury. Our data suggests that RT-induced long-term anorectal dysfunction is multifactorial caused by injury of the rectal mucosa and the internal anal sphincter combined with increased rectal sensitivity and reduced rectal functional capacity.

A Case of Emphysema which Spread through the Mediastinum from an Anorectal Injury Caused by a Personal Watercraft Accident

A Case of Emphysema which Spread through the Mediastinum from an Anorectal Injury Caused by a Personal Watercraft Accident

Anorectal injury in pelvic blast

The signature injury of the Afghanistan campaign has, amongst other things, included an increased incidence of destructive anorectal injury. There is no significant body of evidence about this type of...

A Rare Case of Anorectal Injury with Ruptured Bladder and Rectum but Normal Anal Sphincter

Anorectal injuries are rare in children. These injuries mostly occur with two major mechanisms; 1) sexual abuse, and 2) penetrating trauma. Coincident injury of rectum and bladder following anorectal trauma has been rarely reported. Here, we describe an anorectal injury in a 15-year-old boy due to falling off a tree leading to anorectal trauma by a stick. After the trauma, the patient experienced hematuria and generalized abdominal pain and tenderness. In anal area inspection, anal sphincter was intact and there were no evidences of trauma. The patient underwent anoscopy and exploratory laparotomy and omentum was extruded. The patient was treated by repair of lacerations and retraction of omentum.

Fulminant Intra-Abdominal Sepsis after Stapled Hemorrhoidectomy

Stapled hemorrhoidectomy (SH) is a modern approach for the management of hemorrhoids that can provoke life-threatening complications such as fulminant sepsis. Case report and review of the pertinent English-language literature. A 23-year old man being treated with SH for third-degree hemorrhoids developed fulminant intra-abdominal sepsis as the result of a rectal injury during the operation. An exploratory laparotomy was performed. The rectal injury was sutured, and a temporary sigmoid loop colostomy was constructed. Anorectal injury during SH can provoke serious sepsis, which the surgeon must confront promptly and aggressively.

Clinical treatment of open pelvic fractures associated with anorectal injury

Objective To investigate the clinical treatment of open pelvic fractures associated with anorectal injury. Methods We retrospectively reviewed the medical data of 19 patients who had been treated at our department between October 1998 and October 2008 for open pelvic fractures associated with anorectal injury. By Tile classification, there were 1 type A, 5 type B and 13 type C. Three cases suffered from intraperitoneal rectal injury, 11 from extraperitoneal rectal injury and 5 from injury to the anal canal. Their treatment was carried out in 4 steps. First, emergency resuscitation to rescue life and control massive hemorrhage; second, sigmoid colon ostomy and debridement to handle anorectal injury; third, management of the pelvic fracture; fourth, later wounds management. Resnits No death occurred in this group. All the 19 patients were followed up for 12 to 48 (average, 18) months. The anorectal injury was cured in 18 cases and improved in 1 case. According to the Majeed evaluation, the outcome of pelvic fractures was excellent in 3 cases, good in 11, fair in 4, and poor in 1. The good to excellent rate was 73. 7%. The wounds healed at one or two stages after grafting and flap transfer in 18 eases. Conclusion C, oed outcome of open pelvic fractures associated with anorectal injury may result from timely emergency resuscitation, aggressive manage-ment of anorectal injury and proper management of pelvic fractures by orthopaedists in cooperation with spe-cialists from other disciplines. Key words: Pelvis; Fractures, open; Rectum; Anal canal

Severe anorectal injury caused by a jet ski accident: report of a case

We report a case of severe anorectal injury caused by a jet ski accident. An 18-year-old girl riding on the back of a craft fell backward from the seat when the craft was suddenly accelerated. Her buttocks closely opposed the water jet nozzle of the craft as she entered the water. Afterward, she had severe perianal and abdominal pain. Two posterior anorectal tears were observed on physical examination. An abdominal CT scan revealed free air and ascites in the abdominal cavity and presacral space. A perforation of the anterior rectal wall was detected during an emergency operation. The perforated rectal wall and posterior sphincter muscles were sutured and a diverting sigmoid colostomy was made. She was discharged from our hospital 24 days after the surgery without any complication. Her diverting colostomy was closed six months later. Her anal function was almost perfectly preserved. Reports of severe traumatic injuries caused by jet ski accidents are increasing. Hence, wearing of a wet suit is recommended for not only the driver but also passengers during personal watercraft operation. Injury prevention education and government regulation for the drivers should also be considered to avoid traumatic injury from jet skis.

Genital and Anal Injuries Requiring Surgical Repair in Females Less Than 21 Years of Age

Study Objective The injuries of sexually abused and assaulted girls seldom require surgical repair, and genital and anal injuries due to other causes appear to require repair uncommonly. We sought to determine the causes of genital and anorectal injuries requiring surgical repair in relation to such variables as injury sites and severity. Design Retrospective study Setting A large tertiary care children's hospital Participants Forty-four girls less than 21 years of age who required surgical repair of genital injuries between June 1986 and April 2007 were identified. Main Outcome Measures Information collected included the victims' ages, trauma mechanisms, and sites and severity of injuries. Results Injuries requiring repair of the genital and anal areas were uncommon in the 20 year period of this study. Although most injuries were due to straddle and impalement mechanisms, sexual abuse or assault was identified in 25% of the girls. The remaining 11% were victims of motor vehicle accidents. Straddle/impalement injuries involved only the external genitalia, vestibule, perineum, or posterior fourchette of 21 of the 28 girls (76%) with those injuries. The injuries of 9 of the 11 sexually abused/assaulted girls (82%) also involved the hymen, vagina, anus, or rectum. Injuries due to sexual abuse/assault and motor vehicle accidents (MVA) had average severity scores of 2.1 and 2.2, respectively, while straddle injuries had an average severity score of 1.4. (Exact Pearson chi-square P < 0.003.) The ages of the girls were unrelated to the severity of their injuries. Conclusions Although straddle/impalement was the most commonly found mechanism of genital and anorectal injury requiring surgical repair, sexual abuse or assault was identified in 25% of the girls. Sexual abuse and assault should always be considered and assessed appropriately when such injuries are found. Consultation of a social worker or child abuse specialist may be appropriate, especially when injuries clearly not due to an MVA involve the vagina or anorectum. A suspicion of sexual abuse or assault should be reported to the legally mandated state agency in accordance with the laws of state.