Rectal perforation following transanal irrigation A 57-year-old woman with a background of lifelong functional constipation and pelvic floor insufficiency was referred with obstructed defecation. Defecating proctogram showed high-grade internal rectal intussusception, which was treated with ventral mesh rectopexy. Post-operatively, the patient complained of ongoing constipation and transanal irrigation with the Peristeen Anal Irrigation system (Peristeen Coloplast A/S, Humlebaek, Denmark) was trialled for symptom management. During the first attempt at irrigation, the patient noticed pelvic pain and developed a fever. A computerized tomogram identified a rectal perforation (Fig. 1) with retroperitoneal emphysema. Rigid sigmoidoscopy and laparotomy confirmed a posterior rectal perforation associated with extraperitoneal inflammation extending to the anterior mesorectum, which was initially drained by an incision in the mesorectal fascia just above the point of mesh fixation. An ultralow anterior resection, colon J-pouch and loop ileostomy was performed and the Prolene mesh was excised with the specimen (Fig. 2). The patient made an uneventful recovery and had her ileostomy closed 2 months later, following which she described a deterioration of her continence. Histology confirmed a posterior rectal perforation with no underlying pathology. Transanal irrigation was first reported as an effective treatment for incontinence in children with spina bifida in 1987.1 Since then it has been successfully applied as a treatment for selected patients with disordered defecation of neurogenic, functional or post-surgical aetiology.2,3 The Peristeen irrigator allows daily evacuation of the left colon by tap water enema administered through a disposable rectal balloon catheter by the patient in the home environment. The most serious potential complication of this device is rectal perforation. The Peristeen irrigator has been commercially available for over 10 years and a recent long-term (median 21 months) follow-up study of 348 patients reported two bowel perforations in approximately

Fig. 1. Axial computerized tomogram image of the pelvis showing perforation of posterior rectal wall with extraluminal gas.

© 2014 Royal Australasian College of Surgeons

110 000 procedures (perforation risk 0.0002% per procedure).3 As each patient performs many irrigations, the per-patient risk is considerably higher (0.4% in the above series), although as perforation is most likely to occur in the first few months of use, the perforation rate is not directly cumulative.2 Rectal perforation following use of irrigation enemas is well documented.4,5 A literature review revealed one published case of rectal perforation related to Peristeen irrigation;6 however, an internet search revealed 14 device adverse event reports over a 16-month period documenting perforation requiring intervention, suggesting this complication may be more common.7 In many of the reports reference is made to the instructions for use which state that ‘special caution must be shown if the patient has had underlying diseases or treatments leading to weakening of the bowel’ including ‘previous abdominal or anal surgery, cancer in the abdominal or pelvic region, or diverticular disease or obstruction’, including severe constipation. In one report a history of surgery for rectal prolapse was noted. Others have listed a history of long-term steroid medication use and radiotherapy to the pelvis as relative contraindications.2 As Peristeen irrigation is frequently used as a last option before colostomy in patients with functional bowel disorders, many patients will have had previous surgery or have coexisting diverticulosis as a manifestation of long-standing dysfunction. In several of the adverse event reports perforation occurred in the first few irrigation procedures, probably because of underlying bowel pathology. This has led to some advocating for a low threshold for flexible endoscopy before starting the treatment.8

Fig. 2. Excised rectum with attached mesh from prior ventral rectopexy. Forceps within incision created in anterior mesorectum to drain mesorectal collection.

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Perforation may occur from one of three mechanisms: direct impaling trauma, overinflation of the balloon or exaggerated hydrostatic pressure during water instillation.2 The patient in the case we report had multiple previous pelvic operations for pelvic floor dysfunction as well as underlying functional pathology. Despite this, the perforation did not occur at an area of pathological weakness and given its location, impaling by the catheter tip is the most likely reason for the perforation. Scar tissue and anterior rectal fixation from attachment of the mesh may have resulted in a relatively immobile rectum, which may have increased the risk of perforation from this mechanism. The perforation occurred after the first irrigation event despite the patient being well educated prior to use by a nurse specialist, suggesting poor technique was not a contributing factor. The risk of perforation from transanal irrigation may be higher than reported and patients and clinicians need to be aware of this potentially serious complication and its associations.

References 1. Shandling BG, Gilmour RF. The enema continence catheter in spina bifida: successful bowel management. J. Pediatr. Surg. 1987; 22: 271–3. 2. Emmanuel AVKK, Bazzocchi G, Leroi AM et al. Consensus review of best practice of transanal irrigation in adults. Spinal Cord 2013; 51: 732–8.

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3. Christensen PKK, Buntzen S, Payandeh F, Laurberg S. Long-term outcome and safety of transanal irrigation for constipation and fecal incontinence. Dis. Colon Rectum 2009; 52: 286–92. 4. Paran HBG, Neufeld D, Magen A, Freund U. Enema-induced perforation of the rectum in chronically constipated patients. Dis. Colon Rectum 1999; 42: 1609–12. 5. Nakamura HIM, Sato K, Kitazawa K. Retrograde hydrostatic irrigation enema-induced perforation of the sigmoid colon in a chronic renal failure patient before colonoscopy. J. Int. Med. Res. 2005; 33: 707–10. 6. Biering-Sørensen FBJ, Berggreen P, Olesen GM. Rectum perforation during transanal irrigation: a case story. Spinal Cord 2009; 47: 266–7. 7. Adverse Events and Reactions Involving Rectal Catheters. [Cited 22 Mar 2014.] Available from URL: devices/rectal -catheter.htm 8. Christensen PKK. Transanal irrigation for disordered defecation: a systematic review. Scand. J. Gastroenterol. 2010; 45: 517–27.

Sameer Memon, FRACS Ian P. Bissett, MD, FRACS Department of Surgery, Auckland City Hospital, Auckland, New Zealand doi: 10.1111/ans.12761

© 2014 Royal Australasian College of Surgeons

Rectal perforation following transanal irrigation.

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