Rectal perforation injury following high pressure water penetrating trauma: a case report
Background: Injuries to the rectum and perineal regions secondary to jet-ski and watercraft vessels are uncommon and unique, presenting a potentially complicated clinical scenario. While this injury pattern has been described before, severity, intervention and hospital course has varied among cases¹. Additional descriptions of these trauma types may be necessary to establish a standardized approach to the treatment of such injuries.
Case information: The patient is a 16-year-old female with a past medical history of asthma that was a transfer from an outside medical facility. She presented following a trauma sustained after falling off a jet-ski. She reports being the third individual seated at the rear of the watercraft when the wake created by another vessel caused her to be thrown from the back. She states that she fell backwards onto the water being propelled from the back of the jet-ski and felt a sudden sharp burst of pain. She described her pain as moderate, located in the lower pelvis, radiating to her abdomen and back. The patient was brought to an outside hospital where she was found to have several small lacerations in the perianal region and rectal bleeding. On presentation to our institution approximately 8 hours after injury, she was neurologically intact (GCS 15), blood pressure 128/73, heart rate 120s, febrile 101.5F. Primary trauma survey was intact and the secondary survey revealed two small superficial lacerations at the anterior and posterior aspects of her anus, good sphincter tone, and malodorous dark rectal discharge mixed with blood. Abdominal examination revealed tenderness to palpation over the lower quadrants with guarding.
Given the above findings, the patient was taken to the operating room for surgical evaluation and treatment. She was placed in the lithotomy position and proctoscopy performed. Visualization was difficult secondary to a large amount of dark, watery anal discharge but a large posterior rectal defect was appreciated on examination, about 6 cm from the anal verge. The surgical team proceeded to perform a diagnostic laparoscopy which was converted to an exploratory laparotomy after confirmation of intra-abdominal extension of contaminated water. Upon evaluation of the pelvis, the presacral space was found to be dissected with underlying exposure of the sacrum and rupture of the retroperitoneum near the bifurcation of the aorta. Additionally, large amounts of contaminated water were found throughout the bilateral paracolic gutters and between the small bowel loops. The rectum also demonstrated a 5 cm anterior vertical serosal tear. Surgical intervention involved stapling and transection of the rectosigmoid junction leaving ~15cm rectal stump and providing colonic diversion, rectal serosal repair, abdominal washout, drain placement within the presacral space exiting the right lower abdominal quadrant, and temporary abdominal closure. She remained intubated and was admitted to the trauma surgical intensive care unit.
Planned takeback occurred 24 hours later. Proctoscopy was repeated with better visualization. The rectal defect was found to involve approximately 40% of the posterior circumference. The celiotomy was reopened and explored, no residual fluid collections were noted, all observed bowel was viable. The abdominal cavity and presacral space were irrigated once more and a second drain placed exiting the left lower abdominal quadrant. An end sigmoid colostomy was created and the abdominal fascia closed. A subcutaneous wound vacuum device was placed. The patient was extubated and returned to the ICU.
Postoperative care included empiric broad spectrum antibiotic coverage for freshwater organisms. The initial regimen included Levaquin and Flagyl for anaerobic/gram-negative bowel flora contamination and Clindamycin with Fluconazole for possible endemic organisms present within the water contamination. This antibiotic combination was continued from the time of admission until 24 hours after final closure when Clindamycin and Flagyl were discontinued. Intraoperative cultures resulted negative and all antibiotics were discontinued after a total of nine days.
On postoperative day fourteen, the patient began to experience intermittent fevers with moderately elevated leukocytosis. Computed tomography of the pelvis showed an abscess collection present within the presacral space. Interventional radiology was consulted for percutaneous drain placement. Drain cultures were taken and yielded a specimen positive for multi-drug resistant Staph epidermidis, Streptococcus viridans, and Gardnerella vaginalis, for which she was treated with Cefepime, Flagyl, and Vancomycin. On postoperative day nineteen, the patient continued to experience intermittent fevers. Repeat imaging of the pelvis showed an abscess collection present despite the surgical drains in place. The patient was returned to the operating room for surgical drainage. She was placed in the lithotomy position and proctoscopy was performed with the rectal defect irrigated with two liters normal saline to drain the presacral abscess. A large penrose drain was left in place through the defect. Antibiotic coverage was continued until the patient’s discharge to an ancillary facility.
Conclusions: The above case presents several points of interest. Rectal injuries and perforations from high pressure water exposure is an uncommonly reported incident and the subsequent management less defined. The initial approach to such an injury first requires recognition of the potential sequelae of the mechanism and appropriate evaluation of the patient’s clinical status. A prior case report acknowledged the benefits of a multimodal assessment with the use of imaging and non-operative interventions as warranted in hemodynamically stable patients in whom peritonitis was not present¹. For more severe cases, where further intra-abdominal involvement is suspected, imaging becomes more selected as surgical intervention will most likely be warranted.
Close examination of the entire perineal region should be performed, including both the genital and anal areas. Proctoscopy is beneficial in identifying the proximity and circumference extent of the rectal injury, which may be difficult to assess during laparotomy, especially if present on the posterior/retroperitoneal surface. Frequently, however, frank watery discharge is present in excess and impedes visualization of the injury. When intra-abdominal extension is likely, laparoscopy/laparotomy is indicated for presacral drainage. In the case above, exposure of this area showed a large dead space created by the pressure injury, denoting a difficult area to control surgically and subsequently abscesses occurred despite multiple drains in place. As commonly documented in previously reported cases, an end diverting colostomy was created. After adequate drainage and diversion, the rectal injury is allow to heal without attempts at primary closure². A colorectal consultation may be beneficial, both at the onset of treatment and for further long-term followup.
Empiric antibiotic coverage should be initiated to include specimens both present within the gastrointestinal tract and water source. Freshwater exposure includes Aeromonas, Edwardsiella, Erysipelothrix, Vibrio, and Mycobacterium species. A third or fourth generation cephalosporin, fluoroquinolone or clindamycin is appropriate for gram-negative coverage in addition to Vancomycin for gram-positive organisms. Metronidazole should be added for anaerobic coverage. Antibiotics can then be tailored once cultures have speciated³⁻⁴.
Multidisciplinary care is advantageous in a unique case such as this and should follow the tenants of safe surgical diversion and drainage. Awareness of rectal injuries associated with watercraft vessels can aid in prompt identification and effective management.
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Gill, Richdeep S. et al. Hydrostatic rectosigmoid perforation: a rare personal watercraft injury, Journal of Pediatric Surgery, Volume 46, Issue 2, 402-404
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