Perforated rectum - Forum

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A Doctor

Perforated rectum - Ärzteforum

Post#1 »

How would you manage this situation? You are called into the OR by a urologist, who is performing a radical prostatectomy. He states that all was going well, with the procedure nearly completed, when he noticed a 2.5 cm perforation of the anterior rectum. He had given the patient an enema pre-or and one dose of parenteral antibiotic. He wants you to treat the perforated rectum. This happened to one of my partners, who was called, and who rendered treatment. There was much discussion about the approach. I volunteered to get more input.


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Surgeon

Re: Perforated rectum - Ärzteforum

Post#2 »

This is not too uncommon a scenario, especially for perineal prostatectomies, and I've repaired more than a few such rectal perforations. A simple one layer oversew, I guess I wouldn't argue if you did it in 2 layers. Stop your perioperative antibiotics post-op. Any more than that and you are treating yourself more than any evidence could support you doing anything for the patient. We have yet to have a single problem with this approach.

Arizona

Re: Perforated rectum - Ärzteforum

Post#3 »

On a slightly related topic of traumatic rectal perforations, at the recent Las Vegas trauma conference (which is on my very lengthy to do list to summarize for the group), the consensus was that trying to do perineal presacral drainage of anterior rectal perforations was probably not helpful since these drains would not be anywhere near the anterior rectal injury and often do not even reach through the very tough Waldeyer's fascia to get anywhere near any other location of rectal injury.

Proctologist

Re: Perforated rectum - Ärzteforum

Post#4 »

This is relatively simple; repair it and don't worry too much. The rent was noticed, there was no or minimal contamination, no shock, no foreign body, etc. I would not even give a long course of antibiotics, 1 or 2 post op doses would be enough. Please don't tell me that this was handled with proximal diversion, pre sacral drains and a distal washout.

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Old surgeon

Re: Perforated rectum - Ärzteforum

Post#5 »

I was prepared for some complication, though not fecaluria--this indicates a tecnical problem, either your urologist nicked the bladder or somehow got into it--two suture lines in close proximity should have been avoided, as obviously they eroded--some tissue should have been put between the bladder and rectum if bladder was injured--that info was not given--this does NOT happen in the absence of bladder injury. Diversion even in retrospect was still not indicated, as it likely would not have prevented this problem--it only would have been discovered later when the colostomy was closed.

Scalpel

Re: Perforated rectum - Ärzteforum

Post#6 »

I guess we all just learned that doing the correct thing does not always result in the correct response by the patient. Anyway, back to our hero... Fecaluria, or its more popular first cousin, pneumaturia, obviously represent a fistula from somewhere in the bowel to somewhere in the urinary tract. With the history given a rectal to bladder fistula is the presumed cause. I say presumed because it has not been proven. If this patient came off the street with this problem he would undergo a detailed history and physical, a ct scan and probably a cysto and a BE or colonoscopy. A fistula caused by, lets say, diverticulitis, would be treated by a sigmoid colostomy, removal of the fistulous tract and closure of the bladder, WITHOUT any form of diversion. Is your patient sick? Is he septic? Does he have a peritoneal or retroperitoneal abscess? These have to be answered before I answer the question. Obviously if he is septic he needs to be drained and exteriorized. I would favor a end sigmoid colostomy; a loop would also do but is tough to bring up. At the later operation a repair of the bladder would be performed along with the further colectomy/ closure of colostomy. However, if your patient is more pissed off than sick (bad pun) than you might consider doing nothing for a few weeks other than giving him outpatient oral antibiotics to lessen the cystitis. Then a 1 stage resection/repair. I recognize that this is a somewhat radical approach, but I think it is correct. The only difference between your patient and the average patient with a diverticular fistula is that you know the exact day the damage was caused. You did the right thing, don't forget.

forceps

Re: Perforated rectum - Ärzteforum

Post#7 »

I have seen this before, with colovesical fistulae secondary to 'tics. A colostomy has been done, then taken down, only to have the fistula activate again. It has even happened when the fistula has been resected. A colostomy was done here after the discovery of fecaluria. I would not have diverted initially, but with some past experiences (I know--different process), and with what you say, I wonder if the colostomy will solve the problem now.

canadian

Re: Perforated rectum - Ärzteforum

Post#8 »

I would probably just suture it and be content with the single dose prophylactic antibiotics. I have had this happen on at least once with the urologist (same situation) and with the gynecologists. It works, at least sometimes. I do not see any information in your message that contradict a simple suture.

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