University of Groningen Management of rectal foreign bodies Koornstra, Jan J.; Weersma, Rinse K. Published in: World Journal of Gastroenterology DOI: 10.3748/wjg.14.4403 IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2008 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Koornstra, J. J., & Weersma, R. K. (2008). Management of rectal foreign bodies: Description of a new technique and clinical practice guidelines. 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For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 29-09-2021 Online Submissions: wjg.wjgnet.com World J Gastroenterol 2008 July 21; 14(27): 4403-4406 [email protected] World Journal of Gastroenterology ISSN 1007-9327 doi:10.3748/wjg.14.4403 © 2008 The WJG Press. All rights reserved. CASE REPORT Management of rectal foreign bodies: Description of a new technique and clinical practice guidelines Jan J Koornstra, Rinse K Weersma Jan J Koornstra, Rinse K Weersma, Department of INTRODUCTION Gastroenterology & Hepatology, University Medical Centre Groningen, University of Groningen, Groningen RB 9700, Intentional or unintentional insertion of rectal foreign The Netherlands bodies is not uncommon and often poses a serious Author contributions: Koornstra JJ and Weersma RK were challenge on the clinician. Objects can be inserted for responsible for the design of the paper and patient care and diagnostic or therapeutic purposes, or self-treatment of wrote the manuscript; Koornstra JJ performed the systematic anorectal disease, by criminal assault and accident or, literature search. most commonly, for sexual purposes. Most patients with Correspondence to: Dr. Jan J Koornstra, Department of rectal foreign bodies present to the emergency room Gastroenterology & Hepatology, University Medical Centre Groningen, University of Groningen, PO Box 30001, Groningen usually after efforts to remove the object at home. Many RB 9700, The Netherlands. [email protected] endoscopic and surgical techniques to remove rectal Telephone: +31-50-3613354 Fax: +31-50-3619306 foreign bodies have been described in the literature and Received: April 9, 2008 Revised: May 10, 2008 the reported variety in foreign bodies is as large as the [1-46] Accepted: May 17, 2008 number of techniques used to remove them . The Published online: July 21, 2008 descriptions in the available literature are anecdotic and consist largely of case reports or case series[1-46]. In this report, a novel endoscopic technique to remove rectal foreign bodies using a pneumatic dilatation Abstract balloon normally used in achalasia patients is presented. A number of techniques have been described to In addition, a systematic review of the literature was remove rectal foreign bodies. In this report, a novel performed for non-operative methods to remove foreign endoscopic technique using a pneumatic dilatation bodies from the rectum. These results are summarized balloon normally used in achalasia patients is and a practical flow chart is presented to guide the presented. In addition, a systematic review of the clinician in his or her treatment decisions. literature was performed for non-operative methods to remove foreign bodies from the rectum. These CASE REPORT results are summarised, presented as a practical at-a- glance overview and a flow chart is offered to guide A 19-year-old man presented at the emergency the clinician in treatment decisions. The design of the department, 12 h after insertion of a high pressure flow chart was based on the aims to treat the patient container with tanning spray into his rectum. A plain preferably on an outpatient basis with minimally abdominal radiograph (Figure 1) showed the container invasive techniques and if possible under conscious in the rectosigmoid region. There were no signs of sedation rather than general anaesthesia. perforation. A flexible sigmoidoscopy was performed under conscious sedation. The object was located © 2008 The WJG Press. All rights reserved. just above the rectosigmoid junction. The container could not be extracted by bimanual manipulation. Key words: Foreign body; Rectum; Rectal; Removal; An attempt to remove the object with conventional Review endoscopic instruments, such as polypectomy snares, was unsuccessful. Peer reviewer: Fabio Pace, Professor, “L. Sacco” University The sigmoidoscope could be passed alongside the Hospital, Via G. B. Grassi, 74, Milano 20157, Italy foreign body to its proximal end. A guide wire was left behind with the sigmoidoscope removed. Subsequently, Koornstra JJ, Weersma RK. Management of rectal foreign a 40 mm pneumatic dilatation balloon (Rigiflex®, bodies: Description of a new technique and clinical Boston Scientific), normally used in achalasia patients, practice guidelines. World J Gastroenterol 2008; 14(27): was inserted over the guide wire and inflated just above 4403-4406 Available from: URL: http://www.wjgnet. the container (Figure 2). For safety purposes, the com/1007-9327/14/4403.asp DOI: http://dx.doi.org/10.3748/ sigmoidoscope was reintroduced alongside the catheter wjg.14.4403 of the balloon to allow endoscopic visual control of www.wjgnet.com 4404 ISSN 1007-9327 CN 14-1219/R World J Gastroenterol July 21, 2008 Volume 14 Number 27 Figure 1 Plain abdominal radio- Figure 3 The removed container. graph showing the foreign body impacted in the rectosigmoid. Figure 2 Lateral view X-ray: perforation? Yes of abdominal radiograph No depicting the foreign body with the achalasia balloon Position foreign body relative to rectosigmoid junction inflated just above the container. Below Above Digital extraction Bimanual extraction Failed Failed Conscious Endoscopic extraction (+ accessories) sedation Failed Endoscopic and/or fluoroscopic guided balloon extraction the distal end of the container in the rectum. Gentle traction was exerted on the balloon catheter, and the Failed container was successfully removed under fluoroscopic Anal dilation and manual or forceps extraction and endoscopic control (Figure 3). Regional Failed spinal or general DISCUSSION Laparotomy anesthesia A large number of surgical and non-surgical techniques -Anal delivery have been described to remove rectal foreign bodies[1-46]. -Colotomy -Perforation repair Our case illustrates that for removal of foreign bodies retained in the rectosigmoid, extraction with a pneumatic dilatation balloon, inflated above the foreign body, may Figure 4 Algorithm for the removal of a colorectal foreign body. be an elegant and safe alternative when conventional techniques fail. Our technique has not been described before as revealed by a systematic review of the always be aware of the possibility of a large bowel literature. We performed a systematic PubMed search perforation and perform radiological investigations. from 1966 to present, using the search terms ‘rectal’, Plain abdominal radiography or water soluble contrast ‘rectum’, ‘colorectal’, ‘foreign’, ‘bodies’ and ‘endoscopic’. enemas may be helpful. An abdominal X-ray will also Only reports in English were included. The results of provide information on the localization of the foreign the systematic search of the literature, specified for the body, whether it is below or above the rectosigmoid type of foreign body, are summarized in Table 1[1-36]. junction. If perforation of the bowel has occurred, Table 1 also summarizes endoscopic techniques and immediate laparotomy is warranted. If there are no signs non-endoscopic techniques for removing foreign bodies. of perforation, several management approaches can be In addition to the reports presented in the Table 1, tried. Our aim was to treat the patient on an outpatient several case series have been published without detailed basis with minimally invasive techniques and preferably information on the techniques used to remove various under conscious sedation instead of general anaesthesia. foreign bodies[18,22,25,37-46]. First, digital removal of the object should be An algorithm was provided to guide the clinician attempted, if necessary with the patient at different in his or her treatment decisions, partly based on positions. If this approach fails, one can try bimanual the methods presented in the Table 1 (Figure 4). We manipulation. The next step is the insertion of an included only those methods most commonly used and endoscope with subsequent attempts to grasp the excluded rare treatment variants.