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there are limitations in the lighting, the instruments available, the ability to control patient
positioning, and availability of adequate sedation, wh ich may prevent successful
attempts
5,21
and result in the FB being pushed further upward. The reported success rate
of bedside or ED attempts varied between 16% and 75%.
4
For these reasons, transanal
removal in the operating theater is more appropriate. Absolute contraindications for
the removal of rectal FB in the ED are (1) sharp objects, (2) high-lying FBs, (3) the presence
of complications,
2
(4) body pusher/body packer,27and (5) failed attempts at removal by
the ED physician.
2
The transanal removal of a rectal FB requires adequate anesthesia to obtain maximal
anal sphincter dilatation.
23,28,31
This may be obtained by local anesthesia, pudendal nerve
block, regional anesthesia, intravenous sedation or general anesthesia.
6
Local anesthesia
using 1% lidocaine with epinephrine or 0.5% bupivacaine, at a 2.5-cm radius around the
anus, is used to block inferior rectal nerve.
2,11
These may be added to intravenous sedation
to decrease anal spasm and improve exposure.
2,6,23
The lithotomy position using appro-
priate stirrup, with 30 degree head up (reverse Trendelenburg position),
32
is preferred to
allow pelvic floor relaxation and downward suprapubic or abdominal pressure by assistant.
2,12,23
Gentleness is required throughout the procedure to prevent colorectal perfora-
tion
31
and further injury to the anal sphincter. Direct visualization with endoscopes helps
to prevent iatrogenic injury.
11
Manual disimpaction is useful for the removal of bezoar.
13–15
Manual extraction while
asking the patient to bear down is al so possible.
3,32,33
Many instruments had been used to
bring an FB down, including (a) grasping instruments (long Kocher clamp, ringed
forceps,
2,6,34,35
Allis forceps,6rubber-shod clamps,28spoon, corkscrew,36obstetric
forceps,
11,31,37,38
and obstetric vacuum39), and (b) instruments to proximally drag down
the objects (Foley catheter,
2,9,11
endotracheal tube,2Sengstaken-Blakemore tube,2and
esophageal dilatation balloon).
1
These latter-mentioned catheters are inserted between
the FB and the rectal wall up beyond the proximal part of the FB. Then the balloon is
inflated to help in hooking the object while dragging it down toward the anus.
28
The balloon also reduces the vacuum that can be present with hollow objects, such as bottle,
glass, cup, with their open-end directed cephalad.
31
If the FB is an inflatable object,
aspiration to deflate it would allow transanal removal.
40
16.4.2 Endoscopic Removal
For high-lying
6
and sharp objects, removal should be performed under direct visualization
using endoscopy. Reported techniques are the use of anoscope and Magill forceps,
17
oper-
ation using a proctoscope/endoscope and a tenaculum,
8,28
and endoscopic removal using
biopsy forceps, polypectomy snare,
41
stone-extraction basket, esophageal dilatation
balloon,
28,42
gastrolith forceps,43and esophageal overtube44. Most rectal foreign bodies
are successfully removed transanally.
2,6
Success rates of 80%–90% have been reported
with the use of intravenous sedation (40%) and general anesthesia (43.3%).
45
Factors
for failure of transanal extraction include objects >10-cm long, hard or sharp objects,
204 ANORECTAL DISORDERS
migration to the sigmoid, and a duration of >2 days.
1,2,11
Fifty-five percent of FBs located
in sigmoid and 24% of FBs loc ated in rectum require laparotomy for removal.
6
After successful removal, proctosigmoidoscopy should always be performed to assess
mucosal tears, bleeding, bowel injury or any residual FB.
11
Iatrogenic perforation from
attempted removal occurs in <1% of cases.
27
If mucosal injury is seen, the patients should
be kept in the hospital for observation.
11
Observation for at least 24 h after the procedure
or until the next bowel movement is recommended.
6,27
If the extraction is simple, uncomplicated, and no mucosal injury seen, the patients should be observed at the ED for 2 h. If
there is no development of abdominal tenderness, distension, guarding, or fever, they can
be discharged.
27
In all cases, plain radiography should be acquired before discharging the
patient.
23
16.4.3 Minimally Invasive Transanal Removal
Transanal minimally invasive surgical technique (TAMIS) to remove rectal FB has been
reported.
46–50
A classic TAMIS port was used to remove high-lying candle stick46and
the metallic sheath of a Cuban cigar.
47
A single incision laparoscopic surgery (SILS) port
has been used to extract a polished jar,
48
a plastic cigar case,49and the cap of baby’s bot-
tle.
50
A modification was to use the laparoscopic port for transanal access47to overcome
the cost of TAMIS instruments and a SILS port, and to avoid additional injury from the
40-mm rigid TAMIS proctoscope.
47
Either of these advanced transanal techniques means
the operator has direct vision of the nature of the FB, multi-instruments, and a clear postremoval examination.
48
16.4.4 Operative Removal
A laparoscopic attempt to push the FB distally to allow transanal removal is recommended
for smooth objects that could not be removed transanally.
1,6,51
If laparoscopic milking
fails, laparotomy is required.
6
Laparotomy milking to allow transanal removal can be tried
first. Colotomy is needed to remove objects with unfavorable orientation, size (large),
shape,
1,6
and hard or sharp-edge objects,30such as a bull horn,52needle,53or broken
glass.
54
If colonic laceration is less than one-third to half the circumference, the bowel tissue is fresh, and there is absence of gross peritoneal contamination, the wound can be
primarily repaired.
6,28,52,55
A diverting colostomy should be performed in cases with
delayed presentation, gross fecal contamination,
7
signs of abdominal sepsis, hemody-
namic instability,
6
presence of large perforation,1abscess,56or pressure ischemic necro-
sis.
1
Bowel resection may be required when the perforation has caused severe tissue
damage.
25,57,58
After repair or resection of the injured bowel, additional procedures
include distal bowel cleansing and drainage of the presacral space where necessary.
1
In
the presence of acute perforation after transanal removal of FB, total laparoscopic repair
has been successfully performed.
59,60
Other additional procedures may be required to cor-
rect complications such as interna l fistula, rectovesicle, rectovaginal,
19,45,61
perianal
Chapter 16 • Foreign Body and Anorectal Trauma 205
fistula,
10,45
pelvic abscess,45and anal stricture.62If sphincter injury occurs, surgical repair
should be delayed.
6
Additional anal function tests and anal ultrasound may be perfor-
med to help in the planning of treatment.
23,45
A delay of at least 3 months is been
recommended.
23
Fig. 16.1 summarizes the approach to rectal FB. It is important to keep medical pho-
tographs of the retrieved rectal FB for both clinical records and medicolegal reasons, especially in cases of assault and child abuse.
1
Patients with psychological disorders and the
victims of sexual assault or child abuse should be referred for psychological evaluation
and counseling.
1,4
FIG. 16.1 Management of rectal foreign body.
206 ANORECTAL DISORDERS
16.5 Ingested FB, Body Packer, Body Pusher
For the FB that has been ingested and moved down to the colon beyond the ileocecal valve
without signs of complication, the watchful waiting protocol has been a recommendation.
12,28
This is advised even for sharp objects, as blunt end tends to turn down toward
anal direction.
28
An initial plain abdominal radiography to identify the nature and location
of the object should be performed. A barium enema may be used for suspected or known
radiolucent FB.
28
Then daily radiographs to document progression of the FB are
acquired.
12,28
A high-fiber diet, bulk laxative, or mineral oil may be used but not
cathartics.
28
The classic indications for surgery include (1) presence of signs of obstruction, bleeding, or perforation; (2) a blunt FB that is retained in the ileoc ecal region for >2 weeks; and
(3) a sharp FB that has not progressed over a 3-day period.
2,28,63
Currently, a colonoscopic
approach may be the procedure of choice to remove retained FB in the colon that failed to
progress after 3 days.
16,63
Surgery should be reserved for patients with FB-associated complications and in whom colonoscopic retrieval may lead to damage to the organ of passage.
63
Ribas et al. reported a 87.6% rate of successful spontaneous passage of FB with
9.2% requiring endoscopic retrieval, and 3.1% requiring surgical treatments.
63
“Body packing” is a method of concealing illicit drugs within the body where the drugs
are.
12,64
Body packers usually packed their drugs carefully to withstand transit through the
GI tract.
12,64
Thus these drugs are securely wrapped with condoms or balloons in multiple
layers.
12
“Body stuffing” is typica lly performed in a quick manner by the drug dealers or
users when encountering officers of the law. Thus drugs are loosely wrapped.
12
The term
“body pushing” is used if drugs are inserted into the body orifice. Various cavities, such
as rectum, vagina, gluteal fold, fat fold, umbilicus, ear, colostomy, and prepuce, have been
reported.
64
Cocaine and heroin are the most commonly concealed drugs.12However, there
have been reports of the smuggling of medication for future usage
64
and the hiding of
“clean”urine at body temperature for use in drug-screen evasion has also been described.
65
The main problem for the body packer, body stuffer, and body pusher is the toxicity of the
drugs if the wrap is damaged. Death after rupture of a packet has been found in 56% of
cases.
66
The presentation of “body packer syndrome” includes seizures, sympathomimetic
symptoms, anxiety, dilated pupils, diaphoresis, tachycardia, and hypertension, or other
drug-specific symptoms.
12,66
If illicit drug concealment is suspected, history taking may
be unreliable.
12
Plain radiograph will demonstrate 85%–90% of ingested drug packets,
but may not be able to identify radiolucent
67
or small numbers of drug packets.12Plain
CT scan may be useful.
67
In a nonurgent situation a barium-enhanced radiography may
be used when plain film is not diagnostic.
12
Emergency treatment for the syndrome
includes antidotes, cardiopulmonary support, and a medical toxicologist consultation.
12
In this situation the best treatment is surgical.66An asymptomatic body packer may be treated conservatively to allow the spontaneous evacuation of the packets.
66
Laxatives may be
used.
66
Administration of activated charcoal (1 g/kg) and performing continuous whole-
bowel irrigation with polyethylene glycol had been recommended.
12
Chapter 16 • Foreign Body and Anorectal Trauma 207
16.6 Anorectal Injury
Rectal trauma is uncommon and accounts for 0.1%–1.1% of all colorectal injuries.
11
There
is high prevalence in young male.
11
Colorectal trauma is generally classified into blunt and
penetrating trauma.
68
According to etiologies, Roberson et al. classified anorectal injury
into six subgroups: (1) gunshot wounds, (2) major impalements, (3) minor impalements,
(4) iatrogenic injuries, (5) blunt injuries (crush or blast), and (6) FB injuries.
69
Eighty percent of colorectal trauma comprise penetrating injuries (mostly shooting), 6.2% are blunt
injuries, and 2.5% are iatrogenic injuries.
11,68
Other causes of penetrating injury include
sex-related rectal FB insertion (discussed in the previous section) and perineal impalement.
11,70
Perineal impalement can be caused by (1) the intentional insertion of a FB into
the rectum during homicidal, psychiatric, or sexual acts, or (2) accidentally falling or running into sharp objects.
70
This is usually associated with severe vascular and other visceral
organ injuries. Blunt injury of the rectum is uncommon due to the protection of the pelvic
bones.
70
However, injur y may occur in the setting of severe pelvic fractures.70Iatrogenic
injury can occur during diagnostic and therapeutic procedures involving the anorectum
and pelvic organs, such as therapeutic colonoscopy, and gynecological procedures for
treatment of endometriosis, pelvic inflammatory disease, and myomectomy.
70,71
The American Association for the Surgery of Trauma (AAST) has developed a grading
system for rectal injury (
Table 16.2).
72
A recent study of rectal injuries showed that 32%
were intraperitoneal, 58% were extraperitoneal, and 9% were combined: grades I-28%;
II-41%, III-13%, IV-12%, V-5%.
73
16.6.1 Clinical Assessment
All trauma patients should be initially managed according to the Advanced Trauma Life
Support (ATLS) principles.
68
A targeted history includes abdominal/genitourinary symp-
toms, baseline bowel function/continence, and mechanism of injury.
70
After primary survey, resuscitation and stabilization, a complete secondary survey should then be
performed to assess pelvic fractures, perineal or transpelvic penetration, and bleeding
of the urethral meatus or per rectum.
11,68
Abdominal examination is important to look
for signs of peritonitis and to locate the possible site of injury.
11,68
The site and number
Table 16.2 Rectal Injury Grading System of Hematoma (the American Association for
the Surgery of Trauma)
2,10,69
Grade I Hematoma: contusion or hematoma without devascularization
Laceration: partial thickness laceration
Grade II Laceration <50% circumference
Grade III Laceration "50% circumference
Grade IV Full-thickness laceration with extension to the perineum
Grade V Devascularized segment
208 ANORECTAL DISORDERS
of penetrating injuries to the abdomen and back, and seat belt signs (in road-traffic accidents) should be noted.
70
DRE is essential to assess anal sphincter tone (sensitivity 37%)
and to identify rectal wall injury (sensitivity 33%), rectal FB, gastrointestinal bleeding (sensitivity 5%), and signs of potential pe lvic fractures,
11,68
for example, position of prostate
71
and perineal ecchymosis. If rectal injury is suspected, a rigid proctosigmoidoscopy is
mandatory.
12,68
The sensitivity of rigid proctosigmoidoscopy in the detection of extraper-
itoneal rectal injury is nearly 100%.
12,68
Plain radiograph is sensitive for detecting pneu-
moperitoneum and may detect radiopaque FBs.
11,70
CT is sensitive in diagnosing
pneumoretroperitoneum and visceral organ injury with a sensitivity and specificity of
100% and 96%, respectively. Negative predictive values were 100% .
68
CT scan is the gold
standard in detecting rectal injury. The triple contrast technique, including oral rectal and
intravenous water-soluble contrast, should be used.
11
The management of rectal injury has been developed using the experiences of wartime injury, which includes both high-energy devastating wounds and civilian injury,
which tends to be less serious.
68,70,74
The direct repair of the injury, diversion, distal rectal
washout, and drainage of presacral area
68,70,74
are based on 4Ds-principals and the surgeons tailor their treatment according to the level and extent of injury, other associated
injuries, and the patient’s status.
75
Primary repair or primary resection with anastomosis
is feasible for nondevastating, stable patients with intraperitoneal rectal injury.
74,75
Proximal diversion after primary repair is considered on a case-by-case basis taking into
account the severity of the injury, if there is multiple-trauma, if there has been transfusion,
the resuscitation requirements, the amount of tissue destruction, and the patient’s underlying disease.
74
Closure of a colostomy is usually performed after 3–6 months.
70
Primary repair of extraperitoneal rectal injury may involve extensive pelvic dissection
and should be attempted only if the site is easily accessible.
68,70
After repair, proximal
diversion should be performed without the need of presacral space drainage.
74
For inaccessible extraperitoneal rectal injury, proximal diversion with presacral drainage is more
appropriate to prevent pelvic infectious complications.
68,70,74,75
Distal rectal washout
should be performed for destructive wounds.
75
Besides evolution in surgical technique,
advances have been made in resuscitation techniques, antibiotic use, critical care, and
trauma systems.
74
These factors also have had important roles in patient outcomes, which
have guided clinical practice.
16.7 Perineal Injury
Perineal, including the anal sphincter complex, injury may be associated with blunt or
penetrating pelvic trauma. The ATLS approach for correction of life-threatening conditions is a priority. Associated pelvic fracture and genitourinary system injury should
be identified and managed accordingly. Disruptive anal sphincter injury associated
with multiple injury and unstable vital signs is not suitable for immediate repair and
may require fecal diversion.
75
Immediate anal repair is rarely indicated.68In the stable
patient and examination under anesthesia is performed to assess the degree of injury.
Chapter 16 • Foreign Body and Anorectal Trauma 209
Proctosigmoidoscopy should be performed to identify possible rectal injury. Devitalized
tissue is debrided and wound irrigation and open wound care are performed, together
with administration of antibiotics.
70,74
Repeated exploration/debridement and lavage
may be performed.
70
Delayed anal sphincter evaluation with endo anal ultrasound, anorectal manometry, and pudendal nerve terminal motor latency may be performed when
the patient recovered from the life-threatening conditions. Anal sphincter repair/reconstruction and/or tissue coverage are planned accordingly.
70,74
Colostomy closure can
be performed after continence is ensured.
74
Morbidity from anorectal trauma is mostly from infectious complication (18.8%).
68
Overall in-hospital mortality was 5.9% for rectal trauma and 4.3% for anal trauma.
Increased mortality rates were found in those who had no diverting stoma compare to
those who received a stoma (10.8% vs 3.7%, P <.0001).
68
A permanent colostomy rate of
30.3% has been reported.
68
16.8 Conclusion
Anorectal FB is a subtype of anorectal trauma that is not uncomm on. Due to its sensitive
etiology, a careful clinical approach and systematic management, involving emergency
physician, radiologist, endoscopist, surgeon, anesthetist, and psychiatrist, are necessary
for the successful removal and prevention of recurrence. When the presence of illicit drugs
is suspected a medical toxicologist should be notified. A trauma patient is approached
initially according to the ATLS principle. Anorectal trauma is assessed in the secondary
survey. The surgical approach is tailored to location, injury grading, associated injury,
and the patient’s condition. If the injured site is assessible, primary repair can be performed with or without proximal diversion. Proximal diversion and presacral drainage
is used for nonassessible extraperitoneal rectal injury.
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