Management of Anorectal Injuries in Children: An Eighteen-Year Experience

Abstract

Anorectal injuries (ARI) are rare in childhood and yet occur due to sexual abuse and firearm injuries in developed countries. The labeling of ARI remains controversial in spite of a number of divergent reports over the past decade. We evaluated the surgical indications for primary repair of ARI without stoma, and also the potential risk factors affecting morbidity and mortality in children with ARI. Between 1983 and 2001, 41 children were diagnosed as ARI in our institution due to blunt or penetrating trauma. There were 17 male and 24 female patients. Causes of anorectal injury were blunt injuries in the majority of cases (56 %). Vagina and extremity fractures were the organs most frequently associated with ARI. There was isolated ARI in 49 % of cases. Intraperitoneal organ injury was found in 3 patients (7 %). The distribution of injury location according to the classification of ARI in our children was as follows: 10 % in G I, 32 % in G II, 51 % in G III, and 10 % in G V. Primary repair without colostomy was performed in 51 % of cases. Primary repair and diversion of faecal stream by loop colostomy was required in 20 (49 %) patients. Postoperative septic complications occurred in 29 % of cases. Some potential risk factors such as trauma mechanism and associated organ injury were not significantly correlated to postoperative septic complications, while other risk factors such as mode of treatment, time of operative intervention and contamination were significantly related to postoperative septic complications (p < 0.05). The sensitivity of trauma scoring systems for the estimation of postoperative complication occurrence was significant for ISS (p < 0.05) and ARI score (p < 0.05). The relative risk of developing a postoperative septic complication was higher than 2 for patients with ARI grade III, ISS > 15, primary repair + colostomy group, and time of operative intervention > 8 hours. A child in the colostomy + primary repair group died on the first postoperative day from rapidly progressing septicaemia and multiple organ failure (2.4 %). The management of ARI can be carried out by primary repair procedure without colostomy in the majority of cases if the needed selectivity is established.

The Management of Perineal Trauma in Children

“…had a higher incidence in boys contrary to the studies by Bakal et al ., Oztürk et al ., and Sogut et al . [ 1 2 3 4 5 6 7 8 ] Anorectal injuries were the most common injuries following trauma to the perineal area which was consistent with Hashish, Vincent et al ., and Black et al . [ 1 7 8 ] From our study, no specific reason for this predominance could be deduced.…”

“…quoted sexual abuse and firearm injuries as the most common. [ 1 3 4 ] Fall from height was the most common injury in studies by Bakal et al ., Samuk et al ., and Sogut et al . [ 2 5 6 ] We found impalement injuries and sexual abuse as the most common mechanisms of perineal injury in our study similar to Vincent et al .…”

Management of child victims of acute sexual assault: Surgical repair and beyond

“…Hence, diverting colostomy is often performed for management of penetrating rectal injuries. [45] Extensive perianal lacerations are repaired at the same time to reapproximate the sphincter muscle mechanism as much as possible. Otherwise, there is eminent danger of the sphincter muscle fibers getting retracted or being devascularized with healing by fibrosis and suboptimal results of delayed repairs.…”

“…Otherwise, there is eminent danger of the sphincter muscle fibers getting retracted or being devascularized with healing by fibrosis and suboptimal results of delayed repairs. Oztürk et al , [4] have described relative risk > 2 of developing a postoperative septic complication for patients with injury severity score ISS > 15. No major septic complications (other than fever) occurred in our study though the average ISS of our study population was 17; probably because of thorough on-table distal loop washouts and regime of postoperative wound irrigations under sedation using antiseptic solution.…”

“…The details of their AGI and surgical reconstruction are presented in the current study. Repair [4] of their injuries was done under general anesthesia [2] within 4-6 h of presentation to our center. The procedure done was as follows:…”