Perineal trauma & Anal Sphincter Injuries: Treatment Outcomes in Minia University Emergency Unit | ||||
Minia Journal of Medical Research | ||||
Volume 33, Issue 2, April 2022, Page 62-72 PDF (792.21 K) | ||||
Document Type: Original Article | ||||
DOI: 10.21608/mjmr.2022.252253 | ||||
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Authors | ||||
Ahmad N. Mohamed; Tohamy A. Tohamy; Doaa A. Saad Kamel; Mohamed Kh. Allah | ||||
General Surgery Department, Faculty of Medicine, Minia University | ||||
Abstract | ||||
Background: Fecal incontinence is a very distressing problem that affects quality of life and has social aspects. we aimed at reaching standardized and systematic lines of treatment to get the best results after perineal trauma and minimize the incidence of fecal incontinence. Methods: all patients we encountered that have acute perineal injury regardless of severity of the injury, mode of trauma , associated injuries, presence of anorectal injury. This study has been conducted in El-Minia university hospital, emergency unit including 32 patients in the period between March 2021 and December 2021. The main operative treatment applied in the study was immediate 1ry repair in the emergency setting using overlapping technique, with or without bowel diversion according to the evaluation of each individual case. The post-operative continence in the studied patients was assessed by a clinical score “modified Wexner score”, on a scale from 0 to 24 , with 0 means complete continence and 24 means complete incontinence. Results: the mean age of the study was 23.9±11.2. The continence score after 6 months was ranging between 0 and 9 , with majority of the cases were between 2 and 6. Conclusion: there are many factors that influence the treatment outcomes regarding anal continence including the mode of trauma, type and site of injury and the operative procedure. Primary repair of traumatic anal sphincter injury can be done in the emergency settings, unless there is severe and extensive destruction of the perineal soft tissue. Long term follow up of the patients with anal sphincter injury and the use of recent diagnostic modalities such as anal manometry and endoanal ultrasound can lead to more dependable and precise results about fecal incontinence. | ||||
Highlights | ||||
Conclusion According to the results of the present study; there are many factors that influence the treatment outcomes regarding anal continence. These factors include the mode of trauma, type and site of injury and the operative procedure.
Regarding site of injury; total sphincter injury or multiple injuries at different sites are the worst types in the degree of post-operative incontinence.
Fecal incontinence is a very distressing problem that affects quality of life and has social aspects. Aplan of treatment is tailored to each case individually according to the assessment of the severity and extent of the perineal injury, whether the perineal wound and sphincter injury could be primary repaired or not, and if there is a need for fecal diversion or not.
This study recommends that primary repair of traumatic anal sphincter injury can be done in the emergency settings, unless there is severe and extensive destruction of the perineal soft tissue. Fecal diversion is done selectively in case of presence of extensive soft tissue damage and association of anorectal or disabling injury.
Long term follow up of the patients with anal sphincter injury and the use of recent diagnostic modalities such as anal manometry and endoanal ultrasound can lead to more dependable and precise results about fecal incontinence. | ||||
Keywords | ||||
Perineum; Anorectum; Trauma; Fecal incontinence; overlapping sphinctroplasty | ||||
Full Text | ||||
Introduction Perineal injuries due to accidental traumas are not very common in the trauma and emergency settings, but not rare at the same time . And when we encounter such type of trauma, it needs to be managed according to clear, systematic guidelines taking in consideration the anatomical orientation among adjacent structure and possible associated injuries (1) The different aetiologies of perineal injures include iatrogenic causes such as haemo-rroidetomy, fistulctomy, fissurectomy and also during normal delivery. Blunt trauma is considered an infrequent cause of perineal and anorectal injury (5- 10%). This infrequent type of injury is usually caused by motor vehicle, motorcycle or pedestrian-vehicular accidents(2) One of the main morbidities that perineal and anorectal trauma casualties suffer from is fecal incontinence which could be disabling and devastating to the degree that permanent fecal diversion in some severe cases will be a reasonable option for patient satisfaction(3) Restoring normal and satisfactory bowel function and anal continence after such type of injuries are the primary outcome addressed in the present study, by which we can evaluate the competence and degree of success of our management. Patients and methods
This study has been conducted in El-Minia university hospital, emergency unit including 32 patients in the period between March 2021 and December 2021. All the patients had come to the E.R presented with perineal trauma of different aetiologies and modes of trauma. Inclusion criteria
3) All possible mechanisms of trauma (Blunt, penetrating, iatrogenic anal sphincter injuries and obstetric anal sphincter injuries)
Methodology Pre-operative preparations. - Primary survey according to ATLS protocol especially in polytrauma patients to ensure that immediate life-threatening injuries are stabilized. - Resuscitation and hemorrhage control. - Stabilization of the pelvis if fractures present. - During the secondary survey, perineal and anorectal trauma can be assessed and evaluated: 1- History taking: history related to the injury, associated symptoms including abdominal and genitourinary symptoms, as well as baseline bowel function and continence can be helpful. Particularly for penetrating injuries, knowing the caliber and velocity of the missile can help establish an understanding of the potential injury. 2- Physical examination: begins with visual inspection, including an assessment of the site of injury, corrugation of perianal skin, entry and exit wounds in the penetrating trauma patient and bleeding per anum or urethra. Palpation of the perineal region for assessing the depth of the injury and extent of tissue involvement. Digital rectal examination should also include an assessment of resting and squeeze tone when feasible and presence of a palpable sphincteric defect or anorectal tears. Examination under anesthesia in the operative theatre was done to all patients in lithotomy position and in some cases proctoscopy was used. - Exclusion of associated rectal, bowel and other organ injury through history, examination and available investigations. Laboratory investigation: The usual laboratory investigations in trauma patients were done including:
Imaging:
Operative procedure Variable operative procedures had been done according to the severity , extent of the injury and associated organ injuries. The procedure was performed in most of the cases under spinal anesthesia and only few needed general anesthesia in which exploratory laparotomy was planned or another surgical intervention was needed for associated injury. All patients received routine preoperative antibiotic prophylaxis (third generation cephalosporin). After Examination under anesthesia and thorough assessment of the injury were done, we chose the surgical treatment compatible with the severity and extent of injury.
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