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      Anorectal avulsion: an exceptional rectal trauma

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          Abstract

          Anorectal avulsion is an exceptional rectal trauma in which the anus and sphincter no longer join the perineum and are pulled upward. As a result, they ventrally follow levator ani muscles. We present a rare case of a 29-years old patient who was admitted in a pelvic trauma context; presenting a complete complex anorectal avulsion. The treatment included a primary repair of the rectum and a diverting colostomy so as to prevent sepsis. Closure of the protective sigmoidostomy was performed seven months after the accident and the evolution was marked by an anal stenosis requiring iterative dilatations.

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          Colon and rectal injuries.

          R Lampman, K Cleary, A Pomerantz (2006)
          This study was designed to develop treatment algorithms for colon, rectal, and anal injuries based on the review of relevant literature. Information was obtained through a MEDLINE ( www.nobi.nih.gov/entrez/query.fcgi ) search, and additional references were obtained through cross-referencing key articles cited in these papers. A total of 203 articles were considered relevant. The management of penetrating and blunt colon, rectal, and anal injuries has evolved during the past 150 years. Since the World War II mandate to divert penetrating colon injuries, primary repair or resection and anastomosis have found an increasing role in patients with nondestructive injuries. A critical review of recent literature better defines the role of primary repair and fecal diversion for these injuries and allows for better algorithms for the management of these injuries.
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            The role of presacral drainage in the management of penetrating rectal injuries.

            M E Falimirski, R. González, M R Holevar (1998)
            To compare in a randomized, prospective manner infectious complication rates associated with presacral drainage versus no drainage in the presence of penetrating rectal injury. During a 45-month period, 48 patients with penetrating rectal injuries were entered into a randomized, prospective study at an urban Level I trauma center. The patients were randomized to a presacral drainage group or a nondrainage group. Randomization was performed after detection of the rectal injury. Forty-four injuries were identified by proctoscopy (92%), with the rest detected intraoperatively or by physical examination. All patients with rectal injuries were included regardless of age, associated injuries, time from injury to operation, blood loss, severity of rectal injury, other abdominal organs injured, or hemodynamic stability. Rectal injuries were defined as those injuries to the large bowel distal to the peritoneal reflection. All rectal injuries underwent fecal diversion, and all drainage was accomplished using closed Jackson-Pratt drainage. Forty-eight patients were studied, of whom 25 were randomized to no drainage and 23 were randomized to presacral drainage. The average age for the nondrainage group was 21.9 years, and the average age for the presacral drainage group 26.0 years. The average Penetrating Abdominal Trauma Index score was 34.3 for the nondrainage group and 32.4 for the presacral drainage group. There were two (8%) septic complications (one perirectal and one perivesical abscess) associated with the rectal injuries in the presacral drainage group. The abscesses in the drainage group resolved after computed tomography-guided drainage. There was one (4%) septic complication (rectocutaneous fistula) in the nondrainage group, which was associated with a retained missile fragment. The fistula resolved after bedside percutaneous removal of the missile fragment. We conclude that presacral drainage for penetrating rectal injuries has no effect on infectious complications associated with the rectal injuries.
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              Is fecal diversion necessary for nondestructive penetrating extraperitoneal rectal injuries?

              Ahmed Hassan, Jennifer Gonzalez, Erle C. Ellis … (2006)
              Current management of penetrating extraperitoneal rectal injury includes diversion of the fecal stream. The purpose of this study is to assess whether nondestructive penetrating extraperitoneal rectal injuries can be managed successfully without diversion of the fecal stream. This study was performed at an urban Level I trauma center during a 28-month period from February 2003 through June 2005. All patients who suffered nondestructive penetrating extraperitoneal rectal injuries were managed with a diagnosis and treatment protocol that excluded fecal stream diversion. Patients were placed in one of two management arms based upon clinical suspicion for intraperitoneal injury. In the first arm, patients with suspicion for rectal injury and a positive clinical examination for intraperitoneal injuries were delivered to the operating room for exploratory laparotomy. Proctoscopy was performed before exploratory laparotomy. Extraperitoneal rectal injuries were left to heal by secondary intention. Intraperitoneal rectal injuries were repaired primarily. Patients did not receive fecal diversion or perineal drainage. In the second management arm, patients with a negative clinical examination for intraperitoneal injury and wounding agent trajectory suspicious for rectal injury underwent diagnostic peritoneal lavage (DPL), cystography, and proctoscopy in the emergency room. Positive DPL or cystography warranted laparotomy as above. Patients with positive proctoscopy alone were admitted and placed on a clear liquid diet. Barium enema was performed 5 to 7 days postinjury for all rectal injuries with diets advanced accordingly.A matched historic control group of rectal injury patients who underwent fecal diversion was compared with the nondiversion protocol group. Patients from both groups were matched for penetrating abdominal trauma index (PATI), age and mechanism of injury. There were 14 consecutive patients diagnosed with penetrating rectal injury placed in the nondiversion management protocol. Of these, 9 (64%) patients in the nondiversion group required laparotomy. The average age in the diversion historical control group was 30.5 years and 29.3 years in the nondiversion group. The average PATI in the diversion group was 15.3 and 16.1 in the nondiversion protocol group. The average length of stay for the diversion and nondiversion groups was 9.8 days (range, 7-15) and 7.2 days (range, 4-10), respectively. There were no complications associated with rectal injuries in either group. Nondestructive penetrating rectal injuries can be managed successfully without fecal diversion. Randomized prospective study will be necessary to assess this management method.
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                Author and article information

                Contributors
                Karim Ibn majdoub Hassani
                Said Ait laalim
                El Bachir Benjelloun
                Imane Toughrai
                Khalid Mazaz
                Journal
                Journal ID (nlm-ta): World J Emerg Surg
                Journal ID (iso-abbrev): World J Emerg Surg
                Title: World Journal of Emergency Surgery : WJES
                Publisher: BioMed Central
                ISSN (Electronic): 1749-7922
                Publication date Collection: 2013
                Publication date (Electronic): 7 October 2013
                Volume: 8
                Page: 40
                Affiliations
                [1 ]Department of Surgery, School of Medicine and Pharmacy of Fez, Sidi Mohammed Ben Abdellah University, BP: 1893; Km2.200, Route de Sidi Hrazem, Fez 30000, Morocco
                Article
                Publisher ID: 1749-7922-8-40
                DOI: 10.1186/1749-7922-8-40
                PMC ID: 3852814
                PubMed ID: 24094142
                SO-VID: efc1a57a-6873-4ff4-9343-b13fa6b1a426
                Copyright © Copyright © 2013 Ibn majdoub Hassani et al.; licensee BioMed Central Ltd.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 13 April 2013
                Date accepted : 15 September 2013
                Categories
                Subject: Review

                ScienceOpen disciplines: Surgery
                Keywords: anorectal avulsion,rectal trauma,surgical management
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: anorectal avulsion, rectal trauma, surgical management

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