[Severe combined injury of the rectum and bladder in a child]. / Sochetannaya travma vnebryushinnoi chasti pryamoi kishki i mochevogo puzyrya u rebenka.

Traumatic anorectal injuries are rare in pediatric surgical practice. Only several similar cases are described in the world literature. This causes no generally accepted algorithms and tactics for these patients. We demonstrate successful surgical treatment of combined trauma of the rectum and bladder in a child. A 13-year-old boy was hospitalized after the child sat on the leg of an overturned chair. No evidence of penetrating abdominal injury was revealed. The boy underwent sigmoidoscopy under general anesthesia. We found a lacerated wound of anterior wall of the rectum measuring 1/3 of its diameter with damage to posterior wall of the bladder. Diagnostic laparoscopy revealed intact abdominal cavity. Wall defects were sutured (bladder wound was sutured during traditional cystotomy), and we formed protective separate double-barreled sigmostomy. In 3 months after discharge, the child was hospitalized for cystography and fistulography with subsequent closure of stoma. In long-term postoperative period (6 months), the quality of life is satisfactory. There is no pain and disturbances of urination.

Colonoscopic removal of an intrauterine device with rectal perforation: A case report.

RATIONALE: The intrauterine device is one of the effective, safe, convenient, economical, and reversible contraceptive methods. Although its contraceptive effect is definite, some female patients may experience complications such as expulsion, bleeding, and pregnancy with the device in place. Rectal perforation is one of the rare and serious complications, which can lead to complications such as abdominal infection and intestinal adhesions, severely affecting the quality of life of patients. PATIENT CONCERNS: A 34-year-old female was sent to the Department of Gastroenterology with noticeable left lower quadrant abdominal pain. She had presented with abdominal discomfort and anal tenesmus 1 year earlier. Two months ago, her abdominal pain had gradually worsened and she was presented to our hospital. DIAGNOSES: Investigations, including colonoscopy and computed tomography scan, had revealed an intrauterine device migrated and perforated into the rectum. INTERVENTIONS AND OUTCOMES: The patient underwent successful colonoscopic removal of the intrauterine device. She recovered well after the treatment. LESSONS: This case proves that endoscopic therapy can be considered the preferred method for removing intrauterine devices displaced into the digestive tract lumen.

Iatrogenic rectal perforation after coccygeal radiofrequency ablation.

Coccygodynia (pain of the coccygeal bone) can be treated locally with anti-inflammatory drugs, local steroid injections, surgical removal of the coccyx and, more recently, with radiofrequency thermal ablation. Complications, such as perforation of the colon, can occur as a consequence of the close relationship between the rectum and the sacrococcyx and with the heat from the thermal ablation expanding to the surrounding tissue causing delayed damage with severe consequences. The treatment of this complication requires the combined effort of the gastrointestinal surgeon as well as a gastroenterologist. In this case report, we describe the treatment of this complication and the clinical course after a perforation of the rectum due to thermal ablation of the coccyx to treat long-standing coccygodynia.

Rectal perforation after laser hemorrhoidoplasty: a case report.

This case report outlines the intricate management of rectal perforation following laser hemorrhoidoplasty in a 31-year-old female, leading to an acute abdomen, sepsis, and multiorgan failure. Urgent laparoscopic exploration and the establishment of a double-loop colostomy were undertaken, marking the beginning of a complex course characterized by relapsed pelvic sepsis. Laser hemorrhoidoplasty has gained widespread acceptance for its minimally invasive approach in treating hemorrhoids. Remarkably, to our knowledge, the case we present is the first major complication reported after laser hemorrhoidoplasty, likely attributed to collateral thermic and mechanical tissue damage.

To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study.

BACKGROUND: This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery. METHODS: A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS: In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment. CONCLUSION: When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Traumatismo anorrectal contuso. Reporte de un caso y revisión bibliográfica / Blunt anorectal trauma. Case reportand literature review

Introducción: El traumatismo anorrectal es una causa poco frecuente de consulta al servicio de emergencias, con una incidencia del 1 al 3%. A menudo está asociado a lesiones potencialmente mortales, por esta razón, es fundamental conocer los principios de diagnóstico y tratamiento, así como los protocolos de atención inicial de los pacientes politraumatizados. Método: Reportamos el caso de un paciente masculino de 47 años con trauma anorrectal contuso con compromiso del esfínter anal interno y externo, tratado con reparación primaria del complejo esfinteriano con técnica de overlapping, rafia de la mucosa, submucosa y muscular del recto. A los 12 meses presenta buena evolución sin incontinencia anal. Conclusión: El tratamiento del trauma rectal, basado en el dogma de las 4 D (desbridamiento, derivación fecal, drenaje presacro, lavado distal) fue exitoso. La técnica de overlapping para la lesión esfinteriana fue simple y efectiva para la reconstrucción anatómica y funcional. (AU)

Introduction: Anorectal trauma is a rare cause of consultation to the Emergency Department, with an incidence of 1 to 3%. It is often associated with life-threatening injuries, so it is essential to know the principles of diagnosis and treatment, as well as the initial care protocols for the polytrau-matized patient. Methods: We present the case of a 47-year-old man with a blunt anorectal trauma involving the internal and external anal sphincter, treated with primary overlapping repair of the sphincter complex and suturing of the rectal wall. At 12 months the patient presents good outcome, without anal incontinence. Conclusion: The treatment of rectal trauma, based on the 4 D ́s dogma (debridement, fecal diversion, presacral drainage, distal rectal washout lavage) was successful. Repair of the overlapping sphincter injury was simple and effective for anatomical and functional reconstruction. (AU)

Risk factors and management of iatrogenic colorectal perforation in diagnostic colonoscopy: a single-center cohort study.

BACKGROUND AND AIMS: Diagnostic colonoscopy plays a central role in colorectal cancer screening programs. We analyzed the risk factors for perforation during diagnostic colonoscopy and discussed the treatment outcomes. METHODS: We performed a retrospective analysis of risk factors and treatment outcomes of perforation during 74,426 diagnostic colonoscopies between 2013 and 2018 in a tertiary hospital. RESULTS: A total of 19 perforations were identified after 74,426 diagnostic colonoscopies or sigmoidoscopies, resulting in a standardized incidence rate of 0.025% or 2.5 per 10,000 colonoscopies. The majority (15 out of 19, 79%) were found at the sigmoid colon and recto-sigmoid junction. Perforation occurred mostly in less than 1000 cases of colonoscopy (16 out of 19, 84%). In particular, the incidence of perforation was higher in more than 200 cases undergoing slightly advanced colonoscopy rather than beginners who had just learned colonoscopy. Old age (≥ 70 years), inpatient setting, low body mass index (BMI), and sedation status were significantly associated with increased risk of perforation. Nine (47%) of the patients underwent operative treatment and ten (53%) were managed non-operatively. Patients who underwent surgery were often diagnosed with delayed or concomitant abdominal pain. Perforations of rectum tended to be successfully treated with endoscopic clipping. CONCLUSIONS: Additional precautions are required to prevent perforation in elderly patients, hospital settings, low BMI, sedated patients, or by a doctor with slight familiarity with endoscopies (but still insufficient experience). Endoscopic treatment should be actively considered if diagnosis is prompt, abdominal pain absent, and especially the rectal perforation is present.

Vegetating lesions that appear in the scar after neoadjuvant therapy for rectal tumors: tumor regrowth or benign neoplasm?

Introduction: After the diagnosis of neoplasm of the middle and distal rectum, patients are often submitted to oncological treatment by neoadjuvant therapy. At the end of this treatment, those patients who show complete clinical response can choose, together with their physician, to adopt the watch-and-wait strategy; although it implies lower morbidity for the patient, this strategy is dependent on strict adherence to treatment follow-up for the early identification of any future local injury. Materials and Methods: Survey of data from medical records and description, and discussion of case reports with a literature review in books and databases. Results: We report the case of a 73-year-old patient diagnosed with moderately differentiated adenocarcinoma of the middle rectum, Stage II (cT3bN0M0), who presented complete clinical response after undergoing treatment with neoadjuvant therapy. Together with the assistant team, the watch-and-wait strategy was chosen. During the follow-up, an endoscopic examination showed a vegetating at the proximal limit of the tumor scar. We chose to perform submucosal endoscopic dissection. The report of the anatomopathological examination evidenced a serrated adenoma with narrow margins free of neoplasia. Conclusion: Patient adherence to cancer treatment using the watch-and-wait strategy is essential for the early identification of new local lesions. After resection of the lesion identified in the tumor scar site as a neoplasm-free lesion, it is consistent to think that this lesion would be the origin of the neoplasm, given the adenomatous origin. (AU)

Laparoscopic synthetic mesh explantation after sacrohysteropexy.

INTRODUCTION: In this video, we present a case of rectal and bladder injury, which occurred during laparoscopic mesh removal following sacrohysteropexy treated 6 months later with a laparoscopic pectopexy. METHODS: We present the case of a 66-year-old woman with a prolapse recurrence after sacrohysteropexy. During the laparoscopic explantation of the mesh, we detected a fixation of the mesh to the bladder and the rectum rather than a fixation to the vaginal walls. Consequently, bladder and rectal injuries occurred during the dissection and were diagnosed and repaired immediately. Due to bowel injury, the treatment of the prolapse was postponed. Six months later, a laparoscopic pectopexy was performed to avoid complications during the repeated dissection of the promontory. The postoperative recovery after the pectopexy was uncomplicated with no short-term prolapse recurrence or postoperative complications. CONCLUSION: Laparoscopy appears to be an efficient approach to mesh explantation. Futhermore, laparoscopic pectopexy seems to be a good approach to secondary prolapse reconstruction after sacrohysteropexy mesh explantation avoiding complications during repeated dissection of the promontory.

Incidence and Characterization of Rectal Complications From Fecal Management Systems.

BACKGROUND: Fecal management systems have become ubiquitous in hospitalized patients with fecal incontinence or severe diarrhea, especially in the setting of perianal wounds. Although fecal management system use has been shown to be safe and effective in initial series, case reports of rectal ulceration and severe bleeding have been reported, with a relative paucity of clinical safety data in the literature. OBJECTIVE: The purpose of this study was to determine the rate of rectal complications attributable to fecal management systems, as well as to characterize possible risk factors and appropriate management strategies for such complications. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a large academic medical center. PATIENTS: All medical and surgical patients who underwent fecal management system placement from December 2014 to March 2017 were included. MAIN OUTCOME MEASURES: We measured any rectal complication associated with fecal management system use, defined as any rectal injury identified after fecal management system use confirmed by lower endoscopy. RESULTS: A total of 629 patients were captured, with a median duration of fecal management system use of 4 days. Overall, 8 patients (1.3%) experienced a rectal injury associated with fecal management system use. All of the patients who experienced a rectal complication had severe underlying comorbidities, including 2 patients on dialysis, 1 patient with cirrhosis, and 3 patients with a recent history of emergent cardiac surgery. In 3 patients the bleeding resolved spontaneously, whereas the remaining 5 patients required intervention: transanal suture ligation (n = 2), endoscopic clip placement (n = 1), rectal packing (n = 1), and proctectomy in 1 patient with a history of pelvic radiotherapy. LIMITATIONS: The study was limited by its retrospective design and single institution. CONCLUSIONS: This is the largest study to date evaluating rectal complications from fecal management system use. Although rectal injury rates are low, they can lead to serious morbidity. Advanced age, severe comorbidities, pelvic radiotherapy, and anticoagulation status or coagulopathy are important factors to consider before fecal management system placement. See Video Abstract at http://links.lww.com/DCR/B698. INCIDENCIA Y CARACTERIZACIN DE LAS COMPLICACIONES RECTALES DE LOS SISTEMAS DE MANEJO FECAL: ANTECEDENTES:Los sistemas de manejo fecal se han vuelto omnipresentes en pacientes hospitalizados con incontinencia fecal o diarrea severa, especialmente en el contexto de heridas perianales. Aunque se ha demostrado que el uso del sistema de tratamiento fecal es seguro y eficaz en la serie inicial, se han notificado casos de ulceración rectal y hemorragia grave, con una relativa escasez de datos de seguridad clínica en la literatura.OBJETIVO:Determinar la tasa de complicaciones rectales atribuibles a los sistemas de manejo fecal. Caracterizar los posibles factores de riesgo y las estrategias de manejo adecuadas para tales complicaciones.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro médico académico de mayor volumen.PACIENTES:Todos los pacientes médicos y quirúrgicos que se sometieron a la colocación del sistema de manejo fecal desde diciembre de 2014 hasta marzo de 2017.PRINCIPALES MEDIDAS DE VALORACION:Cualquier complicación rectal asociada con el uso del sistema de manejo fecal, definida como cualquier lesión rectal identificada después del uso del sistema de manejo fecal confirmada por endoscopia baja.RESULTADOS:Se identificaron un total de 629 pacientes, con una duración media del uso del sistema de manejo fecal de 4,0 días. En general, 8 (1,3%) pacientes desarrollaron una lesión rectal asociada con el uso del sistema de manejo fecal. Todos los pacientes que mostraron una complicación rectal tenían comorbilidades subyacentes graves, incluidos dos pacientes en diálisis, un paciente con cirrosis y tres pacientes con antecedentes recientes de cirugía cardíaca emergente. En tres pacientes el sangrado se resolvió espontáneamente, mientras que los cinco pacientes restantes requirieron intervención: ligadura de sutura transanal (2), colocación de clip endoscópico (1), taponamiento rectal (1) y proctectomía en un paciente con antecedentes de radioterapia pélvica.LIMITACIONES:Diseño retrospectivo, institución única.CONCLUSIONES:Este es el estudio más grande hasta la fecha que evalúa las complicaciones rectales del uso del sistema de manejo fecal. Si bien las tasas de lesión rectal son bajas, pueden provocar una morbilidad grave. La edad avanzada, las comorbilidades graves, la radioterapia pélvica y el estado de anticoagulación o coagulopatía son factores importantes a considerar antes de la colocación del sistema de manejo fecal. Consulte Video Resumen en http://links.lww.com/DCR/B698.

OBSTETRIC INJURY OF THE RECTUM WITH INTACT ANAL SPHINCTER - TWO CASE REPORTS.

Background: Injury of the rectum with intact anal sphincter is an extremely rare but very serious complication of vaginal delivery. It is also called a "buttonhole" tear. Case: We present two cases of "buttonhole" tear/injury. Results: In one case, the injury was recognized at the time of delivery and adequately treated. In the other case the injury was not diagnosed on time and the patient was treated for complications on the 6th postpartal day. Conclusion: The consequences for the wellbeing of young mothers with perineal injury can be serious and affect social and sexual aspects of their lives. Adequate surgical treatment and postoperative care assure optimal results and prevent long term complications such as fistulas or fecal incontinence.

Traumatic rectovaginal fistula after sexual intercourse following a non-consensual anal penetration: a case report and a review of the literature.

Rectovaginal fistulas are rare genital lesions, often due to obstetric causes. More rarely they are a consequence of sexual intercourse. We present the case of a 36-year-old woman who presented to a gynecological emergency department with pelvic pain and feces coming from the vagina. This symptomatology appeared after non-consensual anal intercourse following consensual penile vaginal penetration. She was treated for a perforation of the rectovaginal septum. On the basis of our results, we reviewed the cases published in the literature, with a summary of the elements that may favor the appearance of this lesion, such as "virginity", obstetrics and gynecological history, or coitus position, its classification by size and localization, and the therapeutic indications (suture repair of the wall or a colostomy). Better knowledge of this type of lesion would improve the practice of forensic pathologists for screening and management.

Rectal damage control: when to do and not to do.

Rectal trauma is uncommon, but it is usually associated with injuries in adjacent pelvic or abdominal organs. Recent studies have changed the paradigm behind military rectal trauma management, showing better morbidity and mortality. However, damage control techniques in rectal trauma remain controversial. This article aims to present an algorithm for the treatment of rectal trauma in a patient with hemodynamic instability, according to damage control surgery principles. We propose to manage intraperitoneal rectal injuries in the same way as colon injuries. The treatment of extraperitoneal rectum injuries will depend on the percentage of the circumference involved. For injuries involving more than 25% of the circumference, a colostomy is indicated. While injuries involving less than 25% of the circumference can be managed through a conservative approach or primary repair. In rectal trauma, knowing when to do or not to do it makes the difference.

El trauma de recto es poco frecuente, pero generalmente se asocia a lesiones de órganos adyacentes en la región pélvica y abdominal. Estudios recientes han cambiado los paradigmas del manejo tradicional derivados del trauma militar, mostrando mejores resultados en la morbilidad y mortalidad. Sin embargo, las técnicas de control de daños en el trauma rectal aún son controvertidas. El objetivo de este articulo es proponer el algoritmo de manejo del paciente con trauma rectal e inestabilidad hemodinámica, según los principios de la cirugía de control de daños. Se propone que las lesiones del recto en su porción intraperitoneal sean manejadas de la misma manera que las lesiones del colon. Mientras que el manejo de las lesiones extraperitoneales del recto dependerá del compromiso de la circunferencia rectal. Si es mayor del 25% se recomienda realizar una colostomía. Si es menor, se propone optar por el manejo conservador o el reparo primario. Saber que hacer o que no hacer en el trauma de recto marca la diferencia.

Gastrointestinal perforation secondary to COVID-19: Case reports and literature review.

INTRODUCTION: Corona virus disease-2019 (COVID-19) presents primarily with respiratory symptoms. However, extra respiratory manifestations are being frequently recognized including gastrointestinal involvement. The most common gastrointestinal symptoms are nausea, vomiting, diarrhoea and abdominal pain. Gastrointestinal perforation in association with COVID-19 is rarely reported in the literature. PATIENT CONCERNS AND DIAGNOSIS: In this series, we are reporting 3 cases with different presentations of gastrointestinal perforation in the setting of COVID-19. Two patients were admitted with critical COVID-19 pneumonia, both required intensive care, intubation and mechanical ventilation. The first one was an elderly gentleman who had difficult weaning from mechanical ventilation and required tracheostomy. During his stay in intensive care unit, he developed Candidemia without clear source. After transfer to the ward, he developed lower gastrointestinal bleeding and found by imaging to have sealed perforated cecal mass with radiological signs of peritonitis. The second one was an obese young gentleman who was found incidentally to have air under diaphragm. Computed tomography showed severe pneumoperitoneum with cecal and gastric wall perforation. The third case was an elderly gentleman who presented with severe COVID-19 pneumonia along with symptoms and signs of acute abdomen who was confirmed by imaging to have sigmoid diverticulitis with perforation and abscess collection. INTERVENTIONS: The first 2 cases were treated conservatively. The third one was treated surgically. OUTCOME: Our cases had a variable hospital course but fortunately all were discharged in a good clinical condition. CONCLUSION: Our aim from this series is to highlight this fatal complication to clinicians in order to enrich our understanding of this pandemic and as a result improve patients' outcome.

Rectal perforation after aquablation of the prostate: lessons learned the hard way.

INTRODUCTION: Transurethral resection of the prostate and open prostatectomy have been the standard of care for the surgical treatment of benign prostatic obstruction (BPO) over decades. New emerging techniques for the surgical management of BPO have been currently introduced, but might be associated with new, unusual complications. METHODS: We herewith report on two patients with a rectal perforation after aquablation treatment of BPO. RESULTS: In the first case, the diagnosis was made 2 days after the aquablation procedure due to unspecific postoperative symptoms. A complex combined open/endoscopic repair of the defect was carried out thereafter. As a consequence, a rectoscopy was routinely performed since then following each aquablation procedure. In the second case, intraoperative rectoscopy after uneventful aquablation revealed the rectal perforation. The perforation was clipped immediately with an over the scope-clip by colonoscopy. CONCLUSIONS: These two cases of a rectal perforation after aquablation of the prostate demonstrate an unusual complication and its complex management. Diagnostic delay complicates its treatment. Therefore, immediate rectoscopy should be performed routinely after the aquablation procedure.

Clinical Presentation, Treatment, and Challenges in the Management of Child Sexual Assault at a Tertiary Care Referral Center in India.

BACKGROUND: Child Sexual Assault (CSA) is not an uncommon but an under-reported crime. Along with social and psychological critical issues, there are multiple challenges faced by the surgical team for the treatment of complex perineal injuries associated with CSA. This study was conducted to find clinical presentation and management of CSA along with its problems and challenges encountered by the pediatric surgical team. MATERIALS AND METHODS: This was a retrospective study from 2010 to 2019, conducted in the department of pediatric surgery at a tertiary referral center. All-female patients with a definitive history of sexual assault were included in the study. RESULTS: Seven patients fulfilled the inclusion criteria and the mean age was 5.3 years. After a primary survey, all patients were taken up for examination under anesthesia (EUA). Three patients were managed by the primary repair of the wound and did well during follow-up. Four patients had grade 4 perineal injury and required stage reconstruction. As a first stage, repair of rectal tear, vaginal tear, and the perineal body reconstruction was done along with diversion colostomy. One patient required redo repair of the perineal body and one had developed a rectovaginal fistula. Three patients completed all stages and they are fully continent. CONCLUSION: The spectrum of injuries varies widely in CSA and more chances of high-grade perineal injuries in children due to distinctive local anatomy. EUA is crucial to assess the extent of the injury and to decide the course of management. Meticulous anatomical repair and diversion stoma is the key for successful complex repair and excellent long-term outcomes in terms of continence for the severe grade of perineal injuries.

Thulium laser to endoscopically manage a rectal erosion and intraluminal mesh migration after ventral rectopexy.

Rectal erosions after ventral rectopexy (VR) is an uncommon but challenging adverse event and can be associated with partial migration of the mesh into the intestinal cavity. Re-do surgery is difficult and often provides colostomy and/or anterior rectal resections. However, no alternative solutions are described in the available literature. An 82-year-old woman presented to our hospital for rectal erosion and intraluminal migration of the mesh placed at a 1-year laparoscopic VR. We performed an innovative totally endoscopic approach, using thulium laser and two endoscopes, that led to a successful removal of the mesh. The described mini-invasive technique can be an effective alternative to surgery in tertiary referral centres.