IMAGES FOR SURGEONS
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 41 months following rectopexy, 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 were 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
Fig. 1. Axial computerized tomogram image of the pelvis showing perforation of posterior rectal wall with extraluminal gas. ANZ J Surg 86 (2016) 412–419
approximately 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. © 2014 Royal Australasian College of Surgeons
Images for surgeons
Perforation may occur from one of three mechanisms: direct impaling trauma, over‐inﬂation 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. 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 B, Gilmour RF. The enema continence catheter in spina biﬁda: successful bowel management. J. Pediatr. Surg. 1987; 22: 271–273. 2. Emmanuel AV, Krogh K, Bazzocchi G et al. Consensus review of best practice of transanal irrigation in adults. Spinal Cord 2013; 51: 732–738. 3. Christensen P, Krogh K, Buntzen S, Payandeh F, Laurberg S. Long‐term outcome and safety of transanal irrigation for constipation and fecal incontinence. Dis. Colon Rectum 2009; 52: 286–292.
4. Paran H, Butnaru G, Neufeld D, Magen A, Freund U. Enema‐induced perforation of the rectum in chronically constipated patients. Dis. Colon Rectum 1999; 42: 1609–1612. 5. Nakamura H, Iyoda M, 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: 707–710. 6. Biering‐Sørensen F, Bing J, Berggreen P, Olesen GM. Rectum perforation during transanal irrigation: a case story. Spinal Cord 2009; 47: 266–267. 7. PatientsVille.com. Adverse events and reactions involving rectal catheters. [Cited 22 Mar 2014.] Available from URL: http://patientsville.com/ devices/rectal‐catheter.htm 8. Christensen P, Krogh K. Transanal irrigation for disordered defecation: a systematic review. Scand. J. Gastroenterol. 2010; 45: 517–527.
Sameer Memon, FRACS Ian P. Bissett, MD, FRACS Department of Surgery, Auckland City Hospital, Auckland, New Zealand doi: 10.1111/ans.12680 Correction added on 21 May 2015, after initial online publication. A duplicate of this article was published under the DOI 10.1111/ ans.12761. This duplicate has now been deleted and its DOI redirected to this version of the article.
Knotted multi‐length ureteric stents: a case series Ureteric stents are commonly used in urology to relieve ureteric obstruction or to protect a ureteric anastomosis or injury. Haematuria, urinary tract infection, stent migration, encrustation, fracture and ureteric erosion/ﬁstula are among the reported complications. Ureteric stents can be either ﬁxed length or multi‐length with no reported difference in stent‐related symptoms between these types.1 Fixed length stents can be customized to each patient, adhering to the optimum length ratio, demonstrated to be 104% of the length of the ureter.2 Multi‐length stents place a larger coil in the renal pelvis and bladder and are favoured in many units as they can be reliably used by all grade of staff and are easier to order and stock, possibly reducing costs. The increased length of coil is usually of little consequence, although it can produce some rare and difﬁcult complications. Knotted stents have been increasingly reported, particularly with very long ﬁxed length (28 cm in men and 26 cm in women) and multi‐length stents, exposing these patients to unnecessary and potentially morbid surgical procedures.3–7 We present four cases where the proximal ends of multi‐length stents were knotted, without calciﬁcation, resulting in difﬁcult removal. (1) A 65‐year‐old man presented with right loin pain secondary to a 6‐mm right ureteric calculus. A 24–32 cm multi‐length 4.8Fr stent was inserted as an emergency prior to deﬁnitive removal of the stone with ureteroscopy at four weeks. At the second procedure, the stent knotted and fractured. The proximal third was retained. This could not be removed via © 2014 Royal Australasian College of Surgeons
retrograde ureteral access and required staged percutaneous antegrade removal (Fig. 1) and a 4‐day admission. (2) A 68‐year‐old woman sustained a right ureteric injury at the pelvic brim during laparoscopic excision of a gastrointestinal stromal tumour and bilateral salpingo‐oophorectomy. A 24– 32 cm multi‐length 4.8Fr ureteric stent was sited to manage this partial injury at the time. After 6 weeks, the stent could not be removed due to a knot in the proximal end. A rigid ureteroscopy was successful in accessing the knot, which was fragmented by holmium laser. All fragments were removed endoscopically. (3) A 55‐year‐old woman underwent elective ﬂexible ureteroscopy and incomplete removal of right renal calculi. A 22– 30 cm 6Fr multi‐length JJ stent was sited at the end of the procedure. Six weeks later, she was brought back for completion surgery. The stent was unable to be removed due to a knot proximally (Fig. 2). This was accessed with a rigid ureteroscope and divided with holmium laser. All fragments, and subsequent residual stones, were successfully removed. (4) A 59‐year‐old male underwent an elective ﬂexible ureteroscopy and holmium laser fragmentation of a 9‐mm left lower pole renal calculus. Although the stone was successfully fragmented, there was difﬁculty on routine insertion of a 22– 30 cm multi‐length 4.8Fr stent over a Sensor (Boston Scientiﬁc, MA, USA) wire at the end of the procedure. On