International Wound Journal ISSN 1742-4801

CASE REPORT

Use of self-expanding covered stent and negative pressure wound therapy to manage late rectal perforation after injury from an improvised explosive device: a case report M Tahir Ozer1 , Ali K Coskun1 , Huseyin Sinan2 , Mehmet Saydam2 , Emin O Akay3 , Subutay Peker1 , Gokhan Ogunc4 , Sezai Demirbas1 & Yusuf Peker1 1 Department of General Surgery, Gulhane Military Medical Academy, Ankara, Turkey 2 Department of General Surgery, Ankara Mevki Military Hospital, Ankara, Turkey 3 Department of Urology, Gulhane Military Medical Academy, Ankara, Turkey 4 Department of Criminology, Ankara Police Department, Ankara, Turkey

Key words Blast injuries; High-energy perineal trauma; Stents; Vacuum-assisted closure; Wound care Correspondence to MT Ozer, MD Department of General Surgery Gulhane Military Medical Academy Ankara 06018 Turkey E-mail: [email protected]

doi: 10.1111/iwj.12287

Ozer MT, Coskun AK, Sinan H, Saydam M, Akay EO, Peker S, Ogunc G, Demirbas S, Peker Y. Use of self-expanding covered stent and negative pressure wound therapy to manage late rectal perforation after injury from an improvised explosive device: a case report. Int Wound J 2014; 11 (suppl. 1):25–29 Abstract Blast injuries, caused by explosions accompanied by high-pressure waves, produce tissue damage in the acute period, followed in the later period by circulatory disorders due to vascular endothelial damage and related tissue necrosis. Blunt rectal perforation is rare and difficult to diagnose. In the acute period following blast pelvic injuries, the main objectives are to stop bleeding, minimise contamination and preserve the patient’s life. The patient in this report had major vascular injuries, severe pelvic injury and, in the later period, rectal perforation because of vascular endothelial damage caused by the blast effect. Our aim was to treat the patient conservatively because of his poor general condition. We placed a self-expanding covered stent (SECS) into the rectum and then applied negative pressure wound therapy (NPWT; V.A.C.® Therapy, KCI) to the pelvic region and perirectal area. At the end of the treatment, the rectal perforation was closed, and the patient was discharged with healing. In this article, we discuss the novel use of an SECS with NPWT and review related literature.

Introduction

A mine explosion causes a blast wave or ‘blast overpressure’, which is a sudden increase in air pressure over normal atmospheric pressure (1). Acute traumatic injuries are expected as a result of the blast effect of explosions; however, late visceral injuries and necrosis may also occur as a result of vascular endothelial injuries (2). Blast injuries cause decreased microcirculation, which can result in a great deal of necrosis. Pressure injuries such as these to the pelvic region can intensify through a variety of mechanisms, causing rectal contusions, the initiation and propagation of cell-mediated pathways of injury and ischaemia of the rectal wall. Ischaemia occurs from circulatory disorders caused by damage to the vascular endothelia. Blunt rectum perforation is rare and difficult to diagnose. In the acute period, the main objective is to preserve the patient’s life. Secondary objectives are to ensure limb function and restore urinary and intestinal integrity as much as possible.

When encountering patients with these injuries, the first step is to control bleeding. The next step is to eliminate perineal contamination, which may require urinary and intestinal diversion (3,4). After necrotic tissue is debrided and infection is controlled, reconstruction procedures are begun.

© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd

Key Messages

• in this case report, a self-expanding covered stent (SECS) and negative pressure wound therapy (NPWT) were used to treat a blunt rectal perforation, which developed because of vascular endothelial damage and related tissue necrosis after a blast injury • the impact of rock pieces projected by the blast of an improvised explosive device resulted in widespread destruction of the intrapelvic soft tissue, pelvic fractures and a full-thickness laceration of the membranous urethra

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Managing late rectal perforation using SECS and NPWT

• perforation of the anterior wall of the rectum due to blast endothelial injuries developed days after the initial operation; however, because of the patient’s condition, non-operative treatment was necessary • SECS placement stopped the faecal contamination, and NPWT was applied to promote granulation tissue formation • in this patient, the novel use of SECS and NPWT facilitated closure of the rectal perforation and aided wound healing

Gastrointestinal stents are defined as stents deployed within the stomach, small bowel, colon and rectum. The placement of a stent in the colon was first introduced by Dohmoto in 1991 (5). There are two major indications for placement of a gastrointestinal self-expanding covered stent (SECS) to treat rectal obstruction: pre-operative decompression and palliation of advanced malignancy (6). Another important application for the placement of stents is for treating anastomotic colorectal strictures (7). Additional applications for placement are anastomosis leakage and oesophageal perforation. In this case, we used an SECS and negative pressure wound therapy (NPWT; V.A.C.® Therapy, KCI, San Antonio, TX) to treat blunt rectal perforation due to a mine explosion. Our purpose is to discuss the management of complicated rectal injuries with respect to the effectiveness of SECS and NPWT and to provide a review of the literature.

Figure 1 Left iliofemoral artery bypass with synthetic graft.

Case report

Rock pieces projected by an improvised explosive device (mine) hit a 22-year-old male in the left inguinal area, causing perforation that progressed to the superior retroperitoneal region. The rock scraped the bladder neck and ruptured the membranous urethra and left iliac artery and vein. Initial inspection revealed widespread destruction of the intrapelvic soft tissue, pelvic fractures and a full-thickness laceration of the membranous urethra. There was no rectal perforation, but we saw an area of impaired circulation on the anterior and left anterolateral face of the rectum. We did not perform rectal resection because of the patient’s poor medical condition. We undertook damage control surgery, which included sigmoid diversion because of destruction of the intrapelvic soft tissue, cystostomy, bilateral internal iliac artery ligation, left iliac vein ligation, left iliofemoral artery bypass with synthetic graft (Figure 1) and four-quadrant fasciotomy of the left lower extremity. A Foley catheter was placed between the membranous urethra and the prostate under direct vision (Figure 2). Penile and scrotal hypoperfusion were observed on the first postoperative day; reperfusion was provided by undoing the bilateral internal iliac artery ligation. Rebleeding was not observed. On the fifth postoperative day, we had to perform left leg disarticulation from the hip joint because of hypoperfusion and necrosis in the left leg. The pulses of the dorsalis pedis artery were palpable, but the microcirculation was nonfunctional. A skin graft taken from the amputated leg was used for grafting the defect on the other leg. Three days later, there was 26

Figure 2 Foley catheter placement.

foul-smelling purulent leakage from the disarticulation stump (Figure 3). Enlarging the incision revealed perforation of the left anterior wall of the rectum because of blast endothelial vascular injuries, and the surgical field was found to be contaminated with stool (Figure 4). Because the patient’s hemodynamic status was not suitable for low anterior resection (due to sepsis-related multiorgan failure, septic shock and pulmonary problems), we decided to place an SECS into the rectum to stop the faecal contamination and apply NPWT to promote rapid healing. In the operating room, under general anaesthesia, application of the stent was performed transanally under hand guidance, while at the same time overseeing the procedure through the left limb amputation stump incision. The SECS fully covered the rectal perforation area, and the contamination completely ceased (Figure 5). We secured the SECS with sutures to the anal verge because of peristaltic movements of the intestines (Figure 6). Contamination regressed after the procedure. NPWT was applied at continuous −125 mmHg, and the foam dressing was

© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd

M. T. Ozer et al.

Managing late rectal perforation using SECS and NPWT

Figure 5 The self-expanding covered stent completely covered the perforation, stopping the contamination.

Figure 3 Purulent leakage from the disarticulation stump.

Figure 6 Sutures were used to secure the self-expanding covered stent to the anal verge.

Figure 4 Perforation of anterior wall of the rectum due to blast endothelial injuries.

changed every 3 days (Figure 7). The SECS was removed after 2 weeks. Two weeks after the procedure, there was no evidence of surgical site infection, and another operation was performed to create a Foley-guided anastomosis between the membranous urethra and the prostate. After 2 months, examination determined that the rectal perforation and the skin defect on the amputation stump were completely healed (Figure 8). Six months later, colonoscopic examination showed that the rectal injury had healed completely (Figure 9). The current status of the patient includes a nonfunctional anal sphincter, an amputated left inferior extremity and sigmoidal diversion, but he remains alive. Discussion

This case presentation presents a method for treating late rectal perforations that has never been previously used and has no similar example in the literature. We believe that it is possible that results in this case may be applicable to other emergency

Figure 7 Placement of negative pressure wound therapy foam dressing in the wound.

surgical treatments. Blunt trauma of the anorectum is less frequent than penetrating trauma. The colon is more vulnerable than the rectum to blunt trauma because the rectum is protected by its extraperitoneal pelvic localisation and its rich blood supply (8). Rectal injuries caused by mines, hand grenades and rifle shots have a high incidence of complications and wide

© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd

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Managing late rectal perforation using SECS and NPWT

Figure 8 Two months postoperation, rectal perforation and the skin defect on the amputation stump were completely healed.

Figure 9 Complete healing was confirmed 6 months after the rectal injury.

tissue loss. The mortality rate ranges from 6% to 21%, and the complication rate is 60% (9). During the past 15–20 years, placement of an SECS has become the major endoscopic method for relieving malignant colonic obstruction and managing microleakage of anastomoses, both as a palliative measure and as a temporary treatment before elective surgery (10). The published data confirm that in experienced hands, stent placement is the preferred option for malignant obstruction (11). Notably, most studies have found a very low rate of mortality related to SECS complications (12). The major SECS complication is perforation (13,14). In general, perforations occurring after stent placement could have been caused by iatrogenic technical factors; however, these complications occur mostly in a colorectum that has a severe angulation deformity or long stenotic segment. Our patient’s injury was located at the middle rectum with no angulation deformity or stenosis. We managed insertion of the stent easily in the region, and at the end of the 28

process, the perforation area was covered fully with the SECS and the NPWT dressing. The main reason for placing the SECS in our patient was its ability to produce dilation. We believed that isolation of the perforated area was very important to facilitate successful wound healing. The combination of NPWT and stent application did result in healing for our patient. NPWT is used in the treatment of wounds at high risk of contamination and for which dressing changes are difficult. The pelvic and perineal areas are probably the regions where it is most difficult to avoid bacterial contamination. Therefore, special techniques are needed to secure the areas that undergo surgical repair, and NPWT has been considered as one of the best solutions for overcoming problems such as contamination in these areas (15,16). This technique allows continuous drainage from the contaminated area and maintains a moist wound environment. NPWT has been reported to increase the formation of granulation tissue on the wound surface (resulting in improved microperfusion), increase partial oxygen pressure in the tissue and reduce bacterial colonisation (17,18). Our earlier study (2), and also the study by Schaffzin et al. (19), demonstrated that at the end of NPWT, wound care was facilitated and healing was accelerated. These advantages led to earlier wound closure, early skin grafting and earlier hospital discharge (19). Leininger et al. reported their experiences with the use of NPWT for war injuries. Because these wounds involve a large amount of devitalised and contaminated tissues, they have a high risk of wound contamination and infection (20). The same issues applied to our patient. Our idea in placing the stent in the rectum was to disassociate the wound and the perforation area. The role of NPWT was to close the perforation area and promote healing of the wound by the creation of active granulation tissue. The use of SECS and NPWT allowed us to perform earlier membranous urethra and prostate anastomosis, and the benefits of NPWT allowed use of the stent in this unusual manner. In conclusion, in this case, the novel use of an SECS with NPWT was a reasonably safe and effective procedure for treating complicated and contaminated pelvic injuries with rectal perforation. However, more of these procedures are needed in order to appraise the long-term outcomes and confirm the efficacy of this unusual approach. Conflicts of Interest

Dr MTO presented as a faculty member during the 2013 International Surgical Wound Forum (ISWF), an annual educational event sponsored by Kinetic Concepts, Inc. (KCI). His article is part of a KCI-funded educational supplement based on 2013 ISWF faculty presentations about wound care strategies using Negative Pressure Wound Therapy. KCI assisted with the editorial review of the manuscript. Drs AKC, HS, MS, EOA, SP, GO, SD and YP state no conflict of interest and no financial relationship with KCI. References 1. Mayorga MA. The pathology of primary blast overpressure injury. Toxicology 1997;121:17–28.

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2. Ozer MT, Coskun AK, Ozerhan IH, Ersoz N, Yildiz R, Sinan H, Demirbas S, Kozak O, Uzar AI, Cetiner S. Use of vacuum-assisted closure (VAC) in high-energy complicated perineal injuries: analysis of nine cases. Int Wound J 2011;8:599–607. 3. Jeffery SL. Advanced wound therapies in the management of severe military lower limb trauma: a new perspective. Eplasty 2009;9:266–77. 4. Labler L, Trentz O. The use of vacuum assisted closure (VAC) in soft tissue injuries after high energy pelvic trauma. Langenbecks Arch Surg 2007;392:601–9. 5. Dohmoto M. New method: endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endosc Dig 1991;3:1507–12. 6. Baron TH, Harewood GC. Enteral self-expandable stents. Gastrointest Endosc 2003;58:421–33. 7. Fiori E, Lamazza A, De Cesare A, Bononi M, Volpino P, Schillaci A, Cavallaro A, Cangemi V. Palliative management of malignant rectosigmoidal obstruction. Colostomy vs. endoscopic stenting. A randomized prospective trial. Anticancer Res 2004;24:265–8. 8. Lo SK. Metallic stenting for colorectal obstruction. Gastrointest Endosc Clin N Am 1999;9:459–77. 9. Keighley MR. Injuries to the colon and rectum. In: Keighley MR, Williams NS, editors. Surgery of the anus, rectum and colon. London: WB Saunders Company, 1993:1867–925. 10. Lepsenyi M, Santen S, Syk I, Nielsen J, Nemeth A, Toth E, Thorlacius H. Self-expanding metal stents in malignant colonic obstruction: experiences from Sweden. BMC Res Notes 2011;4:274. 11. Beck DE. Endoscopic colonic stents and dilatation. Clin Colon Rectal Surg 2010;23:37–41.

Managing late rectal perforation using SECS and NPWT

12. Ptok H, Marusch F, Steinert R, Meyer L, Lippert H, Gastinger I. Incurable stenosing colorectal carcinoma: endoscopic stent implantation or palliative surgery? World J Surg 2006;30:1481–7. 13. Mainar A, De Gregorio Ariza MA, Tejero E, Tobio R, Alfonso E, Pinto I, Herrera M, Fernandez JA. Acute colorectal obstruction: treatment with self-expandable metallic stents before scheduled surgery – results of a multicenter study. Radiology 1999;210:65–9. 14. Han YM, Lee JM, Lee TH. Delayed colon perforation after palliative treatment for rectal carcinoma with bare rectal stent: a case report. Korean J Radiol 2000;1:169–71. 15. Braakenburg A, Obdeijn MC, Feitz R, van Rooij IA, van Griethuysen AJ, Klinkenbijl JH. The clinical efficacy and cost effectiveness of the vacuum-assisted closure technique in the management of acute and chronic wounds: a randomized controlled trial. Plast Reconstr Surg 2006;118:390–400. 16. Scherer SS, Pietramaggiori G, Mathews JC, Prsa MJ, Huang S, Orgill DP. The mechanism of action of the vacuum-assisted closure device. Plast Reconstr Surg 2008;122:786–97. 17. Labler L, Oehy K. Vacuum sealing of problem wounds. Swiss Surg 2002;8:266–72. 18. Mullner T, Mrkonjic L, Kwasny O, Vecsei V. The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum sealing technique. Br J Plast Surg 1997;50:194–9. 19. Schaffzin DM, Douglas JM, Stahl TJ, Smith LE. Vacuum-assisted closure of complex perineal wounds. Dis Colon Rectum 2004;47:1745–8. 20. Leininger BE, Rasmussen TE, Smith DL, Jenkins DH, Coppola C. Experience with wound VAC and delayed primary closure of contaminated soft tissue injuries in Iraq. J Trauma 2006;61:1207–11.

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Use of self-expanding covered stent and negative pressure wound therapy to manage late rectal perforation after injury from an improvised explosive device: a case report.

Blast injuries, caused by explosions accompanied by high-pressure waves, produce tissue damage in the acute period, followed in the later period by ci...
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