PO.42.

ANORECTAL INJURIES IN CHILDREN: TREATMENT GUIDELINES

Kakar M., Lobaceva J., Mezale O., Canarelli J.P., Engelis A., Petersons A.(Latvia)

INTRODUCTION
Perineal traumatic injuries are not very common in children. The management of perineal trauma
in children is very challenging in absence of standardized well defined guidelines. The purpose is
to demonstrate two centres, 4 patients case report is to compare the results & evaluate the
treatment guidelines.
MATERIAL & METHODS
I Case: UPJV University Hospital, Amiens (France). 15- yr old boy was brought to the
emergency ward after he had fallen on his bicycle handlebar after a jump. Immediate CT showed
the handlebar entering the left scarpa crossing the pelvis to the skin of the right buttock with no
perforation of intraperitoneal organs. The boy was rushed to the operating room. A foleys
catheter was placed preoperatively due to the suspicion of bladder rupture. An exploratory
enlarged laparotmy upto the inguinal wound was performed to clear any intraperitoneal injury.
The exploration of the pelvis revealed a crossing wound of the anterior and the posterior faces of
the bladder as well as extraperitoneal. The bladder was closed in 2 layers around the foleys
cathether. The rectum was diverted with lateral sigmoid colostomy without repairing the rectal
injuries. The patient was discharged successfully without any serious complications.
II Case: UPJV University Hospital, Amiens (France). 10- yr. old girl was transported from
peripheral hospital to the emergency with a picture of peritonitis with fever and vaginal bleeding,
the anamnesis revealed that while jumping into a brook in sitting position she impaled herself on
a wooden branch in the stream. CT scan defined the position length & thickness of the wooden
branch and perforation in the peritoneal cavity. It entered the anus and passed through the
anterior wall of the rectum, vagina and uterus. Immediately was rushed to operation- median
laparotmy. The foreign body was evacuated and fragmented uterus sutured and drained the rectal
wound was not closed and a sigmoid loop colostomy was performed. A recto-vaginal fistula was
detected after 6 weeks during the closure of the colostomy. A vaginoscopy revealed fragment of
the branch persisting which was removed successfully but 5 weeks later, second opacification
showed a persistant fistula. An MRI revealed 5X
3 mm fistula. Planned scheduled closure of the fistula in 4 months after the accident. In 6
months after the accident total colostomy closure was performed successfully without any
consequences.
III Case: University Childrens Hospital, Riga (Latvia). 10- yr old boy was brought to the
emergency with a diagnose of Vulnus lacerate perinei sin, anamnesis revealed that while jumping

from a tree and overlooking fell on a sharp wooden stick. Visually, a lot of bruises on both the
legs, perineal wound approx. 4-5 cm. checking with the finger revealed that one canal is along
the pelvis 8-10 cm and second enter the rectum. Immediately laparotomy with colostomy and
closure of the rectal wound as the wound was more than 7 cm large and drainage was performed.
After 2 weeks rectoscopy was performed to examine the rectal wound and 3 weeks after the first
surgery colostomy closure was performed. The hospital stay was uneventful and discharged
without complications.
IV Case: University Childrens Hospital, Riga (Latvia). 9 yr old boy was rushed to the
emergency with diagnose of Vulnus lacerate perinei dx, anamnesis showed while sitting on the
chair with a broken leg unknowingly got 3X1 cm deep wound ventral to the anal canal. The
surgeon on duty in emergency performed the primary closure of the wound and drainage. On the
4 th day due to unsuccessful closure and discharge from the wound a rectoscopy was performed
and observed 10 cm in the pararectal canal a 15 mm rectal wall damage. Immediately
Lapraotomy with colostomy with drainage was performed. 3 months after the first operation a rediagnostic rectoscopy was performed and planned colostomy closure was done. The patient was
discharged with no futher uneventful events.
CONCLUSION
The current standard guidelines in the treatment of severe anorectal injuries in children remain
fecal diversion colostomy, wound drainage, and broad spectrum antibiotics. The authors
emphasize extensive diagnostic investigation specially rectoscopy on admission. The prognosis
of penetrating perineal and transanal injuries in childhood is good, even in cases with severe
anorectal damage, when standard about mentioned guidelines are followed.