Anorectal Avulsion

SavageGlow · #1 ● 10-17-2024, 10:20 PM

A 29-years-old patient was admitted to the emergency room (ER) of the University hospital Hassan II of Fez after having an accident which resulted in a severe pelvic trauma. When the patient was admitted to the ER, he was agitated but conscious and hemodynamically stable with slightly discolored conjunctives.

The physical examination revealed a pulse rate of 90 beat per minute, a blood pressure of 110/80 mmHg, but there was no fever. Abdominal examination showed minimal tenderness in the hypogastria with a distended bladder. Urologic examination revealed urethral bleeding with a large scrotal scar. The perineal exam showed a big substance loss with complete anorectal avulsion due to the contraction of the elevator ani muscle (Figure 1). Laboratory data showed a white-blood cell count of 10 900/mm3, serum hemoglobin concentration of 10,4 g/dl with a normal blood platelet level (390,000/mm3), a blood urea of 0.45 g/l and a creatinine level of 10 mg/L. Hemostasis laboratory data, chemistry and serum lipase were within normal limits. So, being hemodynamic stable, the patient underwent chest X-ray. The latter was normal. The pelvic X-ray showed a right ischio pubic rami fracture (Figure 2). A contrast-enhanced computed tomography (CT) was performed and therefore showed a pelvic trauma with right ischio pubic rami fracture (Figure 3) as well as a fracture in the right transverse process of L5 and S1 sacral wing. CT scan also showed a right bladder effusion extending to the retro peritoneal area. Furthermore, there was a large inguinal hematoma measuring 10 x 4 cm and fusing along the right thigh. It was therefore associated with symphysis emphysematous soft tissue extending down to the scrotum the thing that resulted in a right scrotal pneumatocele (Figure 4). There was also free air in the perineum, the perirectal space and the right lateral abdominal wal (Figures 5, 6). No free abdominal fluid or air was detected.

The patient was taken to the operating room. Suprapubic cyst catheter was placed. During the perineal exam, the anorectal stump was hardly recognized among the injured tissues for it was retracted upward and ventrally making the distance between the anal canal and the perineal skin about 6 cm (Figure 7). A rectal washout was performed. Necrosectomy with several debridements as well as presacral irrigation were realized. The ano-rectal mucosa was closed at first; then the torn ends of the external sphincter were identified and sutured accurately. Presacral drainage was placed in the ischio rectal area by a passive drain and delbet lames (Figure 8). Finally the perineal skin was closed using good mattress sutures to build up the perineal body. A sigmoid loop colostomy was performed through an elective laparotomy in the left iliac fossa.

As far as the treatment is concerned, the patient was given an antibiotic regimen consisting of ciprofloxacin and metronidazole for two weeks. The postoperative course was unremarkable. Drainage was removed at the fifth day after surgery. Conservative treatment was undertaken for spine and rib fracture.

Anorectal Manometry was performed six months after surgery. The latter did not show any physiologic dysfunction except the length of the anal canal which was reduced to less than 2 cm (Figure 9). Sigmoidostomy closure was performed seven months after the surgery. Unfortunately, the evolution was marked by anal stenosis which required iterative dilatations. Nowadays, during 9 months of follow up, the patient is free of any symptoms since the very last dilatation