Iatrogenic colorectal perforation induced by anorectal manometry: Report of two cases after restorative proctectomy for distal rectal cancer

Abstract

There are no reports regarding perforation of the colorectum induced by anorectal manometry. We report two cases of colorectal perforation that occurred during manometry in the patients undergoing restorative proctectomy for distal rectal cancer. In the first patient, computed tomography showed an extraperitoneal perforation in the pelvic cavity and a rupture of the rectal wall. A localized perforation into the retroperitoneum was managed conservatively. In the second patient, a 3 cm linear colon rupture was detected above the anastomotic site. A primary closure of the perforated colon and proximal ileostomy were conducted, but the patient died 2 wk later. We hypothesize that the perforation induced by anorectal manometry may be associated with the relative weakening of the proximal bowel wall due to anastomosis, decreased compliance, and abnormal rectal sensation. We suggest that measurement of the maximum tolerable volume should not be routinely performed after restorative proctectomy for distal rectal cancer.

Colorectal Perforation After Anorectal Manometry for Low Anterior Resection Syndrome

“…An iatrogenic colorectal perforation related to ARM is a rare complication. Park et al [ 3 ] reported 2 cases; 1 patient who had undergone a LAR improved after only conservative treatment, but the other who had undergone a LAR following preoperative chemoradiotherapy died immediately after the emergency surgery. Jeong et al [ 4 ] reported 1 case, in which the patient had undergone a LAR following preoperative chemoradiotherapy and was treated by surgery after failure of conservative treatment resulting in colo-cutaneous fistula with abdominal fasciitis.…”

“…Both authors suggested that manometry should be performed with great care. Park et al [ 3 ] also insisted that the maximum tolerable volume should not be routinely measured for patients who had undergone a restorative proctectomy. In our institute, we perform ARM (Orion Platinum K003367, SRS Medical Systems, Billerica, MA, USA) on patients who present with severe LARS, who are intractable to loperamide, and whose qualities of life are markedly disturbed.…”

Orthopaedic Guide Wire Injury to Ileum in a Case of Fracture Neck of Femur

“…All the available data in this regard consist of sporadic case reports eliciting various modalities of iatrogenic bowel injuries like perforations secondary to surgical drains [1], flush ligation of umbilical stump in cases of exomphalos minor [2], terminal ileum perforation due to misplaced percutaneous suprapubic cystostomy [3], perforation of ileal conduit during loopography [4]. Iatrogenic large bowel perforations have also been reported especially after colonoscopy and barium enema [5] and after performing anal manometry in patients who have undergone restorative proctectomy [6].…”

Performing and analyzing high-resolution anorectal manometry

“…Dyssynergia should be suspected if at least two of the following are present: inability to contract abdominal muscles, inability to relax anal sphincter and/or puborectalis, paradoxical contraction of the anal sphincter or puborectalis, or absence of perineal descent 6 . Abnormal lesions and strictures should be noted and alternatives to manometry considered 7 . Any tenderness, presence of stool in the rectum, and any blood are noted.…”

“…Two iatrogenic colorectal perforations were reported, in a sample of 1501 ARM tests (0.13%). Both subjects had a history of rectal cancer resection 7 .…”