Rectal Perforation Research Articles

NON-ACCIDENTAL INJURY: AN IMPORTANT CAUSE OF PAEDIATRIC MAJOR TRAUMA

Objectives & BackgroundTo establish the number of major trauma patients attending Bristol Royal Hospital for Children's Emergency Department with child protection concerns and suspected non- accidental injury (NAI). To identify...

The evaluation of rectal mucosal punch biopsy in the diagnosis of Hirschsprung's disease: a 30-year experience of 954 patients.

For 30years, we have consecutively performed rectal mucosal punch biopsy to diagnose Hirschsprung's disease. The aim of this study was to evaluate the safety of our technique. Patients with suspected Hirschsprung's disease who underwent punch biopsy, including our original "K-PUNCH" method using an S-moid forceps and non-specific blood-collecting tube at our department and branch hospital between April 1986 and March 2016 were included in the present study. Our punch biopsy technique is characterized by excellent visibility and a direct grasping sensation. The backgrounds and complications of the patients were retrospectively investigated. During this period, 954 patients (median age 4months; range 1day-73years) underwent punch biopsy. Although there were no cases of severe complications (i.e., rectal perforation, infection or full-thickness biopsy), one (0.1%) of the 954 cases in the early period showed liver dysfunction and required transfusion due to bleeding. In addition, inappropriate specimens were obtained in 37 patients (3.9%). Punch biopsy including the "K-PUNCH" method is considered safe and feasible and is associated with a low rate of complications and inappropriate specimen harvesting among patients of all ages. Comorbidities, including the potential for hemorrhage, should always be considered.

Perforated Rectal Diverticulum following Prostate Biopsy Resulting in Peri-Rectal Abscess and Sepsis

Background: Transrectal ultrasound guided prostate biopsy (TRUS-PB) is a common investigation for assessment of prostatic carcinoma. Loco-regional complications of TRUS-PB are uncommon and usually relate to infective processes from bacteria present in the rectum. We present a novel case of an abscess from a rectal diverticular perforation secondary to TRUS-PB to highlight this complication as a potential concern for this diagnostic modality. Methods: We present a 55-year-old male who underwent TRUS-PB for investigation of elevated prostate-specific antigen (PSA) (PSA 3.5ug/l). Three weeks following this procedure, at the hospital, the patient presented with septic shock requiring inotropic support. Computed tomography (CT) identified a contained rectovesical abscess anterior to the upper rectum. The patient required operative intervention as he failed to improve on conservative management. Histopathological assessment confirmed recent perforation through the anterior rectum via a rectal diverticulum. Results: Post-operatively, the patient recovered rapidly and was discharged day nine. The patient underwent a laparoscopic-assisted reversal of Hartmann's stoma approximately 8 mo after his initial operation.

Anorectal Manometry Causing Rectal Perforation: Can We Prevent This Rare Iatrogenic Complication?

Anorectal manometry (ARM) is considered a very safe procedure used to assess anorectal function. ARM induced rectal perforation is exceedingly rare with only 7 reported cases to date. Here, we report an unusual case of rectal perforation caused by ARM. Importantly, there are common features found in previous reports. We propose here an algorithm to help prevent this morbid complication. A 54-yearold Caucasian female with history of rectal adenocarcinoma status post low anterior resection, coloanal anastomosis, loop ileostomy, adjuvant chemoradiation, and rectovaginal fistula repair 3 years prior was referred for ARM as a routine evaluation before ostomy reversal. Gastrograffin enema was normal. Minor resistance was noted during manometry probe insertion. During maximal tolerable volume (MTV) measurement, a “pop” was heard when the balloon was insufflated to 190 cc and the patient experienced minor discomfort. Upon withdrawal, serosanguinous material was noted on the balloon. She tolerated the procedure well otherwise. However, she returned 8 hours later with worsening abdominal pain and chills. Physical examination showed moderate left lower abdominal tenderness without peritoneal signs. CT scan revealed contrast leakage and a large intrapelvic fluid collection, consistent with distal rectal perforation. Meropenem and vancomycin were initiated. CT-guided percutaneous drain was placed and yielded 210 mL of purulent fluid. Her overall clinical status improved with conservative management. Endoscopic evaluation at 3 months showed a completely healed scar just above coloanal anastomosis. She underwent an uneventful ileostomy reversal 4 months after the incident. This case underscores a rare but dreadful complication of ARM. A review of 8 reported cases, including ours, exhibited 3 common features; 1) blood on the balloon upon withdrawal or sudden drop in balloon pressure during insufflation, 2) lower abdominal pain during the procedure, and 3) history of rectal surgery. This triad should prompt an urgent evaluation as suggested in our protocol. We also propose to omit MTV measurement in high-risk patients undergoing routine pre-ostomy reversal evaluation. Risk factors include elderly, history of rectal surgery, and multiple co-morbidities. Conservative treatment can be offered in selected patients while endoscopic closure may be attempted when detected early. The need for surgical intervention should be discussed as a multidisciplinary team.Table 1: Published Data on ARM Causing Rectal PerforationFigure 1

Total laparoscopic sigmoid vaginoplasty.

To demonstrate step by step our technique for total laparoscopic sigmoid vaginoplasty. Surgical video tutorial. Academic medical center. Transgender women with penile hypoplasia or with a failed primary vaginoplasty and biological women with either acquired or congenital absence of a functional vagina. An original technique for total laparoscopic sigmoid vaginoplasty is shown on video. Surgery is performed via a simultaneous abdomino-perineal approach. The genital surgeon dissects the neovaginal cavity and performs a bilateral orchiectomy and shortening of the urethra. Out of penile and scrotal skin, a clitoro-vulvaplasty is created. Meanwhile, the laparoscopic surgeon mobilizes the sigmoid segment and transects it down to the base of the sigmoid arteries. The segment is guided in an iso-peristaltic way through the neovaginal tunnel on to the perineum. The distal staple line is opened and sutured in an exaggerated interdigitating fashion to the perineum and inverted penile skin. Length of the segment is measured with a transilluminated perspex dildo, after which the segment is stapled at the proper level. A neovaginopexy is performed on the promontory. Bowel continuity is restored with an intra-abdominal side-to-side oversewn stapled anastomosis. The patient provided written informed consent for the use of this video in this article. None. Given current literature, intestinal vaginoplasty is associated with low complication rates. Since 2008 our group performed 42 primary and 21 secondary procedures, mainly in transgender women, with at least 1year of clinical follow-up. Complications comprised three rectal perforations and two anastomotic leakages. These were addressed laparoscopically without long-term fistula formation. There were no conversions to laparotomy. Total laparoscopic sigmoid vaginoplasty is a feasible and safe procedure in the hands of an experienced team with the right infrastructure. It provides good surgical and functional results. In selected cases it is indicated for primary vaginoplasty, as well as for revision vaginoplasty.

Robot-Assisted Abdominoperineal Resection: Clinical, Pathologic, and Oncologic Outcomes.

The extralevator approach to abdominoperineal resection is associated with a decreased incidence of rectal perforation and circumferential resection margin positivity translating to lower recurrence rates. The abdominoperineal resection, as such, is an operation associated with poorer outcomes in comparison with low anterior resections, and any improvements in short-term outcomes are likely to be related to surgical technique. Robot assistance in extralevator abdominoperineal resection has shown improvement in these pathologic outcomes. Because these are surrogate markers for local recurrence and disease-free survival, long-term survival data are needed to assess the efficacy of this robot-assisted technique, exclusively in a dedicated abdominoperineal resection cohort. We assessed the perioperative, pathologic, and oncologic outcomes of the robot-assisted extralevator abdominoperineal resection for rectal cancer. This study was a review of a prospective database of patients over a 5-year period. Procedures were performed in the colorectal division of a tertiary hospital from April 2007 to July 2012. Patients with rectal cancer were operated on robotically. Indications for abdominoperineal resection were low rectal cancers invading the sphincter complex or location in the anal canal precluding anastomosis. All patients received a robot-assisted extralevator abdominoperineal resection. Operative and perioperative measures, pathologic outcomes, and disease-free survival and overall survival were documented and assessed. Twenty-two patients (15 men) with a mean age of 65.5 years and mean BMI of 28.6 kg/m underwent robotic abdominoperineal resection. Circumferential resection margin was positive in 13.6%. There was 1 tumor/rectal perforation. At a mean follow-up of 33.9 months, overall survival was 81.8% with a disease-free survival of 72.7%. Local recurrence was 4.5%. This was a single-institution study with no comparative open or laparoscopic group. Robot-assisted abdominoperineal resection is safe, feasible, and oncologically sound with short-term and long-term outcomes comparable to open and laparoscopic surgery.

Current practice patterns of rectal suction biopsy in the diagnostic work-up of Hirschsprung's disease: results from an international survey.

The diagnosis of Hirschsprung's disease (HD) was revolutionized by the introduction of rectal suction biopsy (RSB), allowing specimens to be taken without general anesthesia on the ward or as an out-patient procedure. However, insufficient tissue samples are not uncommon, and subsequently histopathologists often remain reluctant to confirm the presence or absence of enteric ganglion cells merely on the basis of submucosal RSBs. The aim of this study was to evaluate the current usage of RSB in the diagnostic work-up of HD based on an international survey. A 15-item questionnaire was distributed among participants and faculty members at the 21st International Meeting of the Pediatric Colorectal Society. Eighty-seven pediatric surgeons from 30 countries completed the anonymous survey (response rate 70.2%), grouped into 68 (78.2%) staff surgeons and 19 (21.8%) trainees, with a median work experience of 18years (range 2-45years). Of these, 74 (85.1%) use RSB in the diagnostic work-up of patients with suspected HD, whereas 13 (14.9%) prefer open full-thickness biopsy under general anesthesia. In total, 47 (63.5%) respondents perform ≥20 RSBs (range 3-100 RSBs) per year. Five different RSB instruments were reported, the most common ones being rbi2 (65.0%), Solo-RBT (15.0%) and multipurpose suction biopsy kit (8.3%). Only 22 (29.7%) of the respondents use a defined negative suction pressure, with a median of 10mL air (range 6-25mL air). The most proximal reported biopsy site was located at a median of 2cm (range 1-15cm) above the pectinate line and a median of 2 (range 1-5) specimens are routinely taken, mainly from the posterior rectal wall. Insufficient tissue samples with need for repeat RSB were encountered in a median of 10% (range 0-40%). Most frequently used staining methods for rectal biopsies are hematoxylin/eosin (75.9%), acetylcholinesterase (73.6%), and calretinin (33.3%). Overall, 36 (48.6%) respondents had experienced RSB-related complications, including self-limiting rectal blood loss (n=28), persistent rectal bleeding requiring blood transfusion (n=9) and rectal perforation requiring surgical intervention (n=7). Although RSB is considered to be today's gold standard for the diagnosis of HD, many aspects of its current usage are lacking consensus. Therefore, a prospective multi-center study or larger global audit appears warranted to identify if the present survey reflects common surgical practice and to establish universal standards for RSB.

Late recurrence of a malignant hypoglycemia-inducing pelvic solitary fibrous tumor secreting high-molecular-weight insulin-like growth factor-II: A case report with protein analysis.

The present study reports a case of recurrent malignant pelvic solitary fibrous tumor (SFT) that induced non-islet cell tumor hypoglycemia via high-molecular-weight insulin-like growth factor-II in a 72-year-old male patient. The tumor recurred ~12 years after the complete resection of the original mass. The recurrent tumor, which had directly invaded the left ureter and perirectal fat tissue, could not be completely excised due to its fragility and adhesiveness. At 13 days post-surgery, the patient presented with rectal perforation, and an urgent rectal resection and colostomy was performed. Neither recurrence of the tumor nor hypoglycemic symptoms were observed 9 months after the surgery. High molecular weight insulin-like growth factor-II was detected in the serum and tumor specimens by western blot analysis and immunohistochemistry. The present case report suggests that certain SFTs can relapse even ≥10 years after a presumed complete resection of the primary tumor, and that performing a safe and complete resection of these tumors can be challenging, due to their adhesiveness or physical presentation; therefore, the indications for surgery should be considered with caution.

Clinical Characteristics and Management of Neovaginal Fistulas After Vaginoplasty in Transgender Women.

To describe our experience and results obtained in the management of neovaginal fistulas after vaginoplasty as gender reassignment surgery in transgender women. A retrospective study was performed of 1,082 transgender women who underwent 1,037 primary and 80 revision vaginoplasty procedures between 1990 and 2015. Thirty-five women underwent both primary and later revision vaginoplasty at our institution. Patient, clinical, surgical, and outcome characteristics were reviewed. We treated 25 (2.3%) patients for 13 rectoneovaginal, 11 urethroneovaginal, and one pouch-neovaginal fistulas. Patients undergoing revision vaginoplasty were at higher risk of rectoneovaginal fistula development (0.8% compared with 6.3%, P<.01, odds ratio 8.6, 95% confidence interval 2.7-26.9). Of 23 intraoperatively identified and oversewn rectal perforations, four (17.4%) patients developed a rectoneovaginal fistula. In four patients, fecal diversion was achieved through temporary colostomy or ileostomy with direct (n=1) or delayed (n=3) fistula closure. In six patients, urethroneovaginal fistula arose after a complication such as meatal stenosis. Two patients underwent temporary suprapubic cystostomy for urinary diversion. In most patients, fistulectomy and primary closure or a local advancement flap was sufficient to treat the fistula. Neovaginal fistulas are uncommon after vaginoplasty. Symptoms of neovaginal fistulas are comparable with those of vaginal fistulas. In most patients, the diagnosis can be made based on symptoms and physical examination alone. It seems that a complicated course (eg, intraoperative rectal perforation or meatal stenosis) predisposes for fistula formation. Surgical repair of neovaginal fistulas is associated with few intraoperative and postoperative complications and does not seem to impair neovaginal function.

INTRAPERITONEAL RECTAL PERFORATION PRESENTING AS FETAL ASCITES – A RARE OCCURRENCE

Spontaneous perforation of the rectum presenting as fetal ascites is an extremely rare occurrence. We report the case of an infant where antenatally detected fetal ascites was attributable to intraperitoneal rectal perforation. Investigations directed to identify common causes of this condition did not reveal any aetiology. Patient underwent surgical colostomy formation on day two of life, which was reversed at six weeks of age. We suggest that meconium ascites and peritonitis should be considered as differential diagnoses in fetuses with ascites and, if the neonate requires a laparotomy, the rectal area should be thoroughly inspected to exclude this entity.

The transrectal single-port laparoscopic radical prostatectomy in a cadaver model.

Radical prostatectomy is the most commonly used and most effective treatment for localized prostate cancer; however, this treatment modality is not without disadvantages. After describing the first technique of radical perineal prostatectomy, several techniques, including open, laparoscopic, and robotic retropubic radical prostatectomy were developed and preferred in the treatment of patients. The desire for reproducible, minimally invasive surgery, which reduces complication rates and maximizes cosmetic outcomes, is met by natural orifice transluminal endoscopic surgery (NOTES).[1] Akca et al.[2] revealed that radical prostatectomy may be performed using a transrectal NOTES route. The authors state that transrectal radical prostatectomy is technically feasible in the cadaver model and the transrectal NOTES route provides good exposure and easy access to the posterior surface of the prostate. Anatomy dissection studies using human cadavers are valuable to show surgeons exactly what is intended for them to see without the risk of disrupting the integrity of the cadaver.[3] We would like to congratulate the authors for an ethical cadaver study of a new treatment modality and for finding a cost-effective model to explore the feasibility of the technique. Rectal injury or rectal perforation is one of the most important complications in radical prostatectomy, and the frequency of this complication varies from 0% to 11% in the literature.[4] Additionally, a recent study showed that rectal perforation is an important cause of litigation in cases of radical prostatectomy in the United States of America, and this complication represents 40 % of all cases of negligence in the performance of radical prostatectomy surgery.[5] Even though the authors state that a meticulous repair of rectal mucosa makes this procedure less morbid than an inadvertent unrecognized rectal injury, a living human study may show that prolonged retraction on the rectal wall in the single port procedures can damage the viability of rectal tissue. Opening the gastrointestinal system can cause several complications, including sepsis and even death. Thus, concerning the motto ‘primum nil nocere’, an innovative technique should be experienced by using fundamental anatomical principles. Humphreys et al.[6] introduced another innovative surgical technique called NOTES radical prostatectomy for localized prostate cancer via a transurethral approach. This technique has the same advantages as transrectal NOTES radical prostatectomy, such as minimal invasiviness and improved cosmetic outcomes, with the lack of potential risks seen rectal injury. Nevertheless, the study by Akca et al.[2] is noteworthy, important, and will guide researchers in finding the best type of approach for radical prostatectomy surgery.

Case Report: Rectal perforation during CT colonography.

Introduction Computer tomography colonoscopy (CTC) is an increasingly prevalent procedure for the investigation of colorectal symptoms, or as a component of colorectal cancer screening. It is considered a low risk procedure, however colonic perforation is a recognized significant complication. Case Report We report the case of an 81-year-old female patient who underwent CTC after failed optical colonoscopy as part of routine colorectal cancer screening. Perforation of the rectum with surrounding pararectal air was confirmed on CTC. The patient had minimal symptoms and was treated successful non-operatively with bowel rest and antibiotics. Conclusion Perforation sustained during CTC is an uncommon complication. The incidence of perforation during CTC is still lower than that during optical colonoscopy. In the absence of significant abdominal signs and symptoms, this rare complication may be successfully managed non-operatively.

Pneumothorax, pneumomediastinum, pneumoperitoneum and extensive subcutaneous emphysema resulting from endoscopic mucosal resection secondary to colonoscopy: A case report.

Rectal perforation is an unusual complication of therapeutic colonoscopy. The present study reports the case of a patient with a rare manifestation of pneumothorax, pneumomediastinum, pneumoperitoneum and extensive subcutaneous emphysema that resulted from an endoscopic mucosal resection following a colonoscopy of the rectum. Only 3 cases of colonic perforation and 1 case of rectal perforation have been described previously, of which the clinical diagnoses and treatments were varied, and no results of follow-up studies were reported. In the present study, dyspnea and neck swelling were acute signs of extraluminal air that resulted from rectal perforation. Computed axial tomography was an effective diagnosis method, and is recommended for the early recognition of colorectal perforation. Appropriate management and a close follow-up are crucial for optimal results.

Central neuraxial blocks: Complacency begets complications.

Central neuraxial blocks: Complacency begets complications.

A Patient with Rectal Perforation Caused by an Industrial Air Compressor

A Patient with Rectal Perforation Caused by an Industrial Air Compressor

A Case of Rectal Perforation without Organic Disease After Upper Gastrointestinal Radiography

A Case of Rectal Perforation without Organic Disease After Upper Gastrointestinal Radiography

A case of rectal perforation without organic disease by x-ray examination of the upper gastrointestinal tract.

A case of rectal perforation without organic disease by x-ray examination of the upper gastrointestinal tract.

子宮脱と肛門からの小腸脱出を同時に伴った特発性直腸穿孔の1例

症例は75歳，女性．早朝，排便時に肛門からの脱出感を自覚し近医を受診したところ，子宮脱と肛門から小腸脱出を認めたため，当科外来へ緊急搬送となった．診察上，子宮脱と肛門から小腸が1m以上にわたり脱出していた．子宮は容易に還納できたが，脱出した小腸は絞扼され暗赤色調であり，還納を試みるも激しい疼痛により不可能であった．直腸穿孔による小腸脱出を疑い緊急手術を施行した．術中所見は直腸前壁に約8cmの縦走裂孔を認め，その穿孔部を通じて回腸が経肛門的に脱出していた．速やかに回腸を還納した後，直腸穿孔部を単純縫合閉鎖した．脱出した回腸にも壊死による穿孔を認めたため縫合閉鎖し，双孔式S状結腸人工肛門を造設して手術を終了した．術後経過は良好で第29病日に退院となった．

Endoscopic Vacuum Therapy in Colorectal Surgery

IntroductionEndoscopic vacuum therapy (EVT) has been established in Germany for the treatment of anastomotic leakage after rectal resection. Continuous or intermittent suction and drainage decrease bacterial contamination, secretion, and local edema promoting perfusion and granulation at the same time. However, data for use and long-term results of EVT in colorectal surgery are still scarce and are often limited by short-term follow-up. ObjectivesHere, we aimed at analyzing the treatment spectrum and long-term outcome of EVT for defects of the lower gastrointestinal tract. MethodsThis is a retrospective single-center analysis of EVT for defects of the lower gastrointestinal tract of different etiology in 41 patients over a time period of 8 years (2007–2015) with a mean follow-up of 36 (2–89) months. ResultsIn total, 426 polyurethane sponges were placed in lower GI defects of 41 patients (31 male, 10 female) with a median age of 70 years (range, 29–91). Most frequent indications for EVT were anastomotic leakage after rectal resection (n = 20), Hartmann’s stump insufficiency (n = 12), and rectal perforation (n = 3). The median number of sponge insertions was six (range, 1–37) with a mean changing interval of 3 days (range, 1–5). Median time of therapy was 20 days. A successful vacuum therapy with local control of the septic focus was achieved in 18 of 20 patients (90 %) with anastomotic leakage after rectal resection and in nine of 12 patients with a Hartmann’s stump insufficiency. In 15 of 19 (79 %) patients with a diverting stoma, take-down after successful treatment was possible. Median time to closure was 244 days (range, 152–488 days). ConclusionTo our knowledge, this retrospective observation of EVT application for rectal lesions represents the largest patient series in literature. EVT has earned its indication in complication management after colorectal surgery and can achieve a successful control of a local septic focus in the majority of patients.

The application of OTSC clamping system to perforation closure of gastrointestinal tract(with video)

Objective To investigate the application and therapeutic effects of OTSC clamping system on perforation closure of gastrointestinal tract. Methods A total of 21 cases of gastrointestinal perforation or digestive tract fistula patients underwent OTSC closure.The perforation tissue was drawn into the transparent cap with grasping forceps, and then the rake holder was released. Results OTSC was successfully performed in 1case of tracheoesophageal fistula, 1 case of esophageal perforation, 12 cases of gastric perforation, 2 cases of duodenal perforation, 1 case of ileocecal valve perforation, 1 case of colon perforation, 3 cases of rectum perforation. Nineteen cases of perforation were iatrogenic and 2 chronic perforation. The diameter of perforation was 0.3-4.0 cm, with mean diameter being(1.6±0.8) cm. No intraoperative hemorrhage, delayed bleeding or deaths occurred. Conclusion OTSC clamping system is safe, effective new technology and worth clinical recommendation to gastrointestinal perforation or fistula. Key words: Endoscopy; Intestinal perforation; Wound closure techniques