Retrieval Of Rectal Foreign Bodies

doi:10.1111/j.1744-1633.2007.00376.x

Case report

Retrieval of rectal foreign bodies: A difficult case Yue-Sun Cheung, John Wong, Wilson W.C. Ng, Tak-Lap Tam, Micah C.K. Chan and Paul B.S. Lai* Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China.

Foreign body in the rectum is not an uncommon condition encountered by general surgeons. Endoscopic retrieval can be attempted but may not always be successful. A small proportion of patients require an operation under general anaesthesia. There is no well-defined guideline for proper management of rectal foreign body. We report a rare case (a 10-inch rectal vibrator) in which colonoscopic retrieval failed and, subsequently, extraction under general anaesthesia was required. The literature was reviewed for an optimum method of removal. Key words: colonoscopy, colorectal surgery, foreign body, surgery.

Introduction Foreign body in the gastrointestinal (GI) tract is a common problem encountered by general surgeons. Endoscopy is a well-established diagnostic and therapeutic method for retrieval of foreign bodies in the upper GI tract.1 For retained foreign bodies in the colorectal region, the role of colonoscopic removal is less well defined. We report a case of rectal foreign body where colonoscopic retrieval failed and removal under general anaesthesia (GA) was required.

Case report A 48-year-old man was admitted 12 h after introduction of a 10-inch vibrator into his rectum. He complained of lower abdominal pain with a small amount of per-rectal bleeding on admission. His vital signs were stable and abdominal examination did not reveal any peritonism or palpable mass. Digital rectal examination revealed a hard cylindrical object with a smooth circular base impinging onto the posterior wall of the rectum about 8 cm from the anal verge. Anal tone was laxed. Third-degree haemorrhoids were also noted. Abdominal radiograph showed an opacity corresponding to the battery unit of the vibrator (Fig. 1). There were no dilated bowels to suggest intestinal obstruction and there was no evidence of bowel perforation. His haemoglobin level was normal, and there was no leucocytosis. *Author to whom all correspondence should be addressed. Email: [email protected] Received 13 June 2006; accepted 3 November 2006.

Colonoscopy under sedation was attempted initially for retrieval of the vibrator (Fig. 2). Various types of snares and forceps were used to try to catch the distal end of the vibrator. However, none of them were able to achieve an engagement tight enough for removal. Subsequently, the patient was put in the lithotomy position in the operating theatre under general anaesthesia. With adequate muscle relaxation, the proximal part of the foreign body could be felt around the umbilical region. Through the anus, the distal end was grasped with a pair of sponge-holding forceps and trans-anal removal was successful with some assistance of trans-abdominal pressure. The foreign body was a 10-inch cylindrical vibrator made of hard rubber (Figs 3,4). No colonic damage was noted on sigmoidoscopy. The patient was discharged 2 days afterwards with no specific complaints.

Discussion Foreign body in the rectum can be caused by anal eroticism, concealment of illegal drugs, attentionseeking behaviour, assault, accident and occasionally retained ingested foreign bodies.2,3 A host of different foreign bodies with various sizes and shapes have been described, including glass bottles, aerosol cans, light bulbs, corn cobs, vibrators, hosepipes, primus stoves, and packets of marijuana.2–4 It can be diagnosed by history, physical examination (mainly by digital rectal examination) and confirmed by plain abdominal radiographs. The condition can be classified according to the level with respect to the rectosigmoid junction. Low-lying foreign bodies are those

Surgical Practice (2007) 11, 162–164 © 2007 The Authors Journal compilation © 2007 College of Surgeons of Hong Kong

Retrieval of rectal foreign bodies

Fig. 1. Abdominal radiograph showing the battery unit of the vibrator. The outline of the entire vibrator can actually be seen on careful examination. There was no evidence of intestinal obstruction or perforation.

Fig. 2. Colonoscopic view of the bottom end of the vibrator located 8 cm from the anal verge.

located inside the rectal ampulla, whereas high-lying foreign bodies lie at or above the rectosigmoid junction.2–4 This classification has been used as a general rule to guide the method of retrieval.4,5 For uncomplicated low-lying foreign bodies, transanal extraction can be achieved by digital manipulation or using various grasping forceps through proctoscopy, anal retractor or rigid sigmoidoscopy. If vacuum is built up proximal to the foreign body preventing its extraction, a Foley catheter could be passed proximal to it to overcome the negative pressure.4 As anal spasm can hold the foreign body away from anus, adequate relaxation is often needed. In difficult

Fig. 3.

Vibrator.

Fig. 4.

Circular base of the vibrator.

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cases, extraction may require complete relaxation of anal sphincters by local, regional or even general anaesthesia.2,4 For high-lying foreign bodies, trans-anal extraction can still be successful, but they are more likely to require a GA. In a review by Lake et al.5 consisting of 87 patients, the level of the foreign body was the only significant predictor of failed bedside removal. Foreign bodies located in the sigmoid region were 2.25-fold (1.1–4.4, 95% confidence interval) more likely than those located in the rectum to require removal under GA. Seventeen out of 23 patients (74%) in the anaesthetic group could be managed without laparotomy. In the remaining eight patients, five required a colotomy, two patients had a repair of the perforation and only one foreign body could be extracted trans-anally. For patients presenting with frank peritonitis, laparotomy is mandatory to remove the foreign body, repair

Surgical Practice (2007) 11, 162–164 © 2007 The Authors Journal compilation © 2007 College of Surgeons of Hong Kong

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the perforation and perform surgical lavage. A diverting stoma may sometimes be needed. In the present case, removal by colonoscopy under sedation was not successful as the patient was not fully relaxed and no endoscopic instrument was able to grasp the vibrator tightly enough. It was only under GA that we could pass a strong grasping forceps through the anus. Although there are reports using colonoscopy to remove rectal foreign bodies, one may find that the endoscope itself may actually displace the foreign body more proximally making removal even more difficult.6 In a case report by Ahmed and Cummings,7 the foreign body had an eye-hook at the bottom end, such that an endoscopic guidewire could be passed though the eye to hold the object for extraction. In light of this case, it might be advisable for the designer of rectal vibrators to incorporate an eye-hook at the bottom end, so that even if it was accidentally inserted too deeply into the rectum, trans-anal removal could be achieved slightly more easily. In conclusion, rectal foreign bodies should be managed in a well-organized manner. Most of them can be removed trans-anally without a laparotomy. However, the surgeons should always be prepared for retrieval under GA in the operating room. Informed

consent should at least include a possible laparotomy and a stoma. A ‘push-and-pull’ two-hand technique may facilitate retrieval if the foreign body has migrated intra-abdominally. Commercially available vibrators could be been better designed (e.g. with an eye-hook at the bottom end) in order to facilitate retrieval in cases of over penetration.

References 1. Eisen GM, Baron TH, Dominitz JA et al. Guideline for the management of ingested foreign bodies. Gastrointest. Endosc. 2002; 55: 802–6. 2. Clarke DL, Buccimazza I, Anderson FA et al. Colorectal foreign bodies. Colorectal Dis. 2005; 7: 98–103. 3. Cohen JS, Sackier JM. Management of colorectal foreign bodies. J. R. Coll. Surg. Edinb. 1996; 41: 312–15. 4. Kingsley AN, Abcarian H. Colorectal foreign bodies. Management update. Dis. Colon Rectum 1985; 28: 941–4. 5. Lake JP, Essani R, Petrone P et al. Management of retained colorectal foreign bodies: predictors of operative intervention. Dis. Colon Rectum 2004; 47: 1694–8. 6. Sohn N, Aronoff JS. Rectal foreign bodies. In: Fazio VW, Church JM, Delaney CP (eds). Current Therapy in Colon and Rectal Surgery, 2nd edn. Philadelphia: Elsevier Mosby, 2005; 149–51. 7. Ahmed A, Cummings SA. Novel endoscopic approach for removal of a rectal foreign body. Gastrointest. Endosc. 1999; 50: 872–4.

Surgical Practice (2007) 11, 162–164 © 2007 The Authors Journal compilation © 2007 College of Surgeons of Hong Kong