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Hydrostatic rectosigmoid perforation: a rare personal watercraft injury
Journal of Pediatric Surgery (2011) 46, 402–404
www.elsevier.com/locate/jpedsurg
Hydrostatic rectosigmoid perforation: a rare personal watercraft injury Richdeep S. Gill a,⁎, Harshdeep Mangat b , David P. Al-Adra a , Mark Evans a a
Department of Surgery, University of Alberta, Edmonton, Alberta Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
b
Received 20 July 2010; revised 10 August 2010; accepted 15 August 2010
Key words: Personal watercraft; Jet-ski injury; Intestinal perforation; Rectal injury
Abstract Personal watercrafts (PWC), also known as jet skis, seadoos, and wave-runners have risen in popularity since their introduction in the 1970s. Hydrostatic rectal injury is a rare presentation of passengers thrown off a PWC. The perforation of the rectum is owing to the excessive hydrostatic force of water exerted through the anal canal. We present the first case of rectosigmoid perforation secondary to PWC hydrostatic injury in Canada. A 14-year-old female passenger presented to the pediatric trauma center with severe abdominal pain and blood per rectum following a fall off the back of a PWC at a local lake. Computed tomography of the abdomen and pelvis demonstrated a laceration in the anterolateral rectal wall at the rectosigmoid junction with associated free intra-peritoneal air and profuse free fluid. At exploratory laparotomy, a full thickness perforation was identified at the rectosigmoid junction. The rectum was oversewn as a Hartman pouch, and a proximal end colostomy was performed to divert the fecal stream. Management of traumatic pediatric rectal injuries involves detailed perineal examination with proctoscopy, and if warranted, exploratory laparotomy. Despite the rare occurrence of hydrostatic rectal perforations in Canada, it is a serious and potentially devastating injury. In the United States, the National Transportation Safety Board recommends wet suit bottoms for all pediatric PWC operators and passengers. In Canada, similar recommendations have not been made. The use of PWC in Canada is less common than in the US. However, it is steadily increasing, especially on local lakes. Education regarding potential injuries and prevention is recommended. © 2011 Elsevier Inc. All rights reserved.
Personal watercrafts (PWC) also known as jet skis, seadoos, and wave-runners have risen in popularity since their introduction in the 1970s. Currently, they are the only recreational boats in which the primary cause of death is blunt trauma, not drowning [1]. The most common injuries observed in children are lacerations and fractures [1]. Hydrostatic rectal injury is a rare presentation in passengers thrown from a PWC. It involves perforation of the rectum
owing to the hydrostatic force of water exerted through the anal canal. Previously, 5 children with rectal injury associated with PWC in the United States and one in Europe have been described [2-7]. Our study presents the first case of rectosigmoid perforation secondary to PWC hydrostatic water injury in Canada.
1. Case report ⁎ Corresponding author. Tel.: +1 780 709 7473; fax: +1 780 758 7049. E-mail address: [email protected] (R.S. Gill). 0022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.08.052
A14-year-old female passenger wearing a 2-piece swimsuit was transferred from a local community hospital
Hydrostatic rectosigmoid perforation
Fig. 1
403
Perianal ecchymosis (black arrow).
following a fall off the back of a PWC at a local lake. She was the third passenger on the PWC and fell backwards as the PWC accelerated to approximately 40 km/h. She stated that on impact she felt a rapid injection of pressure and water enter her rectum. The patient presented to the pediatric trauma centre with severe abdominal pain and blood per rectum. On physical examination, she was tachycardic with a distended tender abdomen. A hematoma measuring 5 × 5 cm was visualized on the right buttock adjacent to the anus (Fig. 1). Computed tomography of the abdomen and pelvis displayed a laceration in the anterolateral rectal wall at the rectosigmoid junction (Fig. 2) with associated free intraperitoneal air and profuse free fluid (Fig. 3). The patient was emergently taken to the operating room. Vaginal examination under anesthesia demonstrated an intact introitus and no vaginal injury. Sigmoidoscopy was performed up to 15 cm, after which insufflations were not attainable. At exploratory laparotomy, copious amounts of lake water and fecal matter were encountered upon entering the peritoneum. Lake
Fig. 3 Computed tomography of the abdomen demonstrating copious free fluid (white arrow).
debris and stool extended to both diaphragms. A full thickness perforation was identified at the rectosigmoid junction, which was oversewn as a Hartman pouch and a proximal end colostomy was created to divert the fecal stream. Closed suction drains were placed in the presacral space. The patient tolerated the procedure well and was taken to the pediatric surgical ward postoperatively. The patient's postoperative course was complicated by a wound infection that required opening and packing the skin incision. She also received systemic antibiotics. Six weeks later, she was readmitted with a presacral abscess that was drained operatively and once again started on antibiotics. At 4 months from her initial presentation, the colostomy was closed and intestinal continuity restored. The patient had subsequent return of her bowel function and is doing well at this time.
2. Discussion
Fig. 2 Computed tomography of pelvis demonstrating air outside the rectal wall (white arrows).
According to the American Academy of Pediatrics, the popularity and availability of PWC has increased dramatically over the last decade. Contrary to PWC operators, most PWC passengers are younger than 18 years [8]. The most common mechanism of injury comprising approximately 70% of pediatric injuries occurs from blunt trauma. This is related to collision with another vessel or stationary objects [9]. Personal watercraft–associated rectal injuries are exceedingly rare, with 6 reported cases described in the literature [2-7]. Rectal injuries are the result of forceful propulsion of water by PWC. The increased pressure at the rectum overcomes the anal sphincter resistance resulting in a burst of fluid in the rectum, which acts
404 more like a solid, leading to perforation and significant intra-abdominal contamination. The phenomenon of hydrostatic injury has been described in water-skiing and waterslide injuries [10-14] resulting in vaginal lacerations and perforations. Management of traumatic pediatric rectal injuries involves detailed perineal examination with proctoscopy and if warranted, exploratory laparotomy. Descottes et al [3] describe a child in whom failure to assess for extraperitoneal rectal injury resulted in multiorgan failure and death. Repair of the full thickness rectal perforation remains an option. However, we agree with previous reports that fecal diversion with loop or end colostomy, although conservative, is safe and effective initial operative management. This should be combined with wide drainage of the presacral space and thorough irrigation of the contaminated abdominal cavity. Despite the rare occurrence of hydrostatic induced rectal perforations in Canada, it is a serious and potentially devastating injury. Therefore, safety guidelines and education are needed. In the United States, the National Transportation Safety Board recommends wet suit bottoms for all pediatric PWC operators and passengers. In Canada, similar recommendations have not been made. The use of PWC in Canada is less common than the United States, however, is steadily increasing, especially on local lakes. Education regarding potential injuries and establishing prevention guidelines is recommended. Furthermore, the addition of a device that automatically shuts off the PWC, as a passenger is dislodged, may help prevent hydrostatic rectal injures [2,15].
R.S. Gill et al.
References [1] Personal watercraft use by children and adolescents. American Academy of Pediatrics. Committee on Injury and Poison Prevention. Pediatrics 2000;105(2):452-3. [2] Morrison DM, Pasquale MD, Scagliotti CJ. Hydrostatic rectal injury of a jet ski passenger: case report and discussion. J Trauma 1998;45(4):816-8. [3] Descottes B, Lachachi F, Moumouni I, et al. Rectal injury caused by personal watercraft accident: report of a case. Dis Colon Rectum 2003;46(7):971-3. [4] Parsons DP, Kahn HA, Isler JT, et al. Rectal injury caused by a personal watercraft accident: report of a case. Dis Colon Rectum 1999;42(7):959-60. [5] Philpott JM, Ng PC, Wixon CL, et al. Rectal blowout by personal watercraft water jet: case report and review of literature. J Trauma 1999;47(2):385-8. [6] Goldberg J, Horan C, O'Brien LM. Severe anorectal and vaginal injuries in a jet ski passenger. J Trauma 2004;56(2):440-1. [7] Szmytkowski J, Dabrowiecki S, Makuch-Burzynska M. Unusual rectal injury by personal watercraft. J Trauma 2007;62(2):551. [8] Jones CS. Children and personal watercraft: injury characteristics and potential countermeasures. Inj Prev 1998;4(1):61-2. [9] Rubin LE, Stein PB, DiScala C, et al. Pediatric trauma caused by personal watercraft: a ten-year retrospective. J Pediatr Surg 2003;38(10):1525-9. [10] Gray HH. A risk of waterskiing for women. West J Med 1982;136(2): 169. [11] Kizer KW. Medical hazards of the water skiing douche. Ann Emerg Med 1980;9(5):268-9. [12] Perlman SE, Hertweck SP, Wolfe WM. Water-ski douche injury in a premenarcheal female. Pediatrics 1995;96(4 Pt 1):782-3. [13] Eder M, Bjelic-Radisic V, Luschin-Ebengreuth G, et al. Vaginal laceration in a premenarcheal girl after sliding down a water chute. Eur J Obstet Gynecol Reprod Biol 2010;150(1):103-4. [14] Kosola S, Rouhe H, Molander P. Vaginal water pressure injury. Duodecim 2010;126(2):181-2. [15] Eberhart-Phillips J, Fielder J, Reeder A. Jet-ski injuries in New Zealand. N Z Med J 1998;111(1067):215-6.
www.elsevier.com/locate/jpedsurg
Hydrostatic rectosigmoid perforation: a rare personal watercraft injury Richdeep S. Gill a,⁎, Harshdeep Mangat b , David P. Al-Adra a , Mark Evans a a
Department of Surgery, University of Alberta, Edmonton, Alberta Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
b
Received 20 July 2010; revised 10 August 2010; accepted 15 August 2010
Key words: Personal watercraft; Jet-ski injury; Intestinal perforation; Rectal injury
Abstract Personal watercrafts (PWC), also known as jet skis, seadoos, and wave-runners have risen in popularity since their introduction in the 1970s. Hydrostatic rectal injury is a rare presentation of passengers thrown off a PWC. The perforation of the rectum is owing to the excessive hydrostatic force of water exerted through the anal canal. We present the first case of rectosigmoid perforation secondary to PWC hydrostatic injury in Canada. A 14-year-old female passenger presented to the pediatric trauma center with severe abdominal pain and blood per rectum following a fall off the back of a PWC at a local lake. Computed tomography of the abdomen and pelvis demonstrated a laceration in the anterolateral rectal wall at the rectosigmoid junction with associated free intra-peritoneal air and profuse free fluid. At exploratory laparotomy, a full thickness perforation was identified at the rectosigmoid junction. The rectum was oversewn as a Hartman pouch, and a proximal end colostomy was performed to divert the fecal stream. Management of traumatic pediatric rectal injuries involves detailed perineal examination with proctoscopy, and if warranted, exploratory laparotomy. Despite the rare occurrence of hydrostatic rectal perforations in Canada, it is a serious and potentially devastating injury. In the United States, the National Transportation Safety Board recommends wet suit bottoms for all pediatric PWC operators and passengers. In Canada, similar recommendations have not been made. The use of PWC in Canada is less common than in the US. However, it is steadily increasing, especially on local lakes. Education regarding potential injuries and prevention is recommended. © 2011 Elsevier Inc. All rights reserved.
Personal watercrafts (PWC) also known as jet skis, seadoos, and wave-runners have risen in popularity since their introduction in the 1970s. Currently, they are the only recreational boats in which the primary cause of death is blunt trauma, not drowning [1]. The most common injuries observed in children are lacerations and fractures [1]. Hydrostatic rectal injury is a rare presentation in passengers thrown from a PWC. It involves perforation of the rectum
owing to the hydrostatic force of water exerted through the anal canal. Previously, 5 children with rectal injury associated with PWC in the United States and one in Europe have been described [2-7]. Our study presents the first case of rectosigmoid perforation secondary to PWC hydrostatic water injury in Canada.
1. Case report ⁎ Corresponding author. Tel.: +1 780 709 7473; fax: +1 780 758 7049. E-mail address: [email protected] (R.S. Gill). 0022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.08.052
A14-year-old female passenger wearing a 2-piece swimsuit was transferred from a local community hospital
Hydrostatic rectosigmoid perforation
Fig. 1
403
Perianal ecchymosis (black arrow).
following a fall off the back of a PWC at a local lake. She was the third passenger on the PWC and fell backwards as the PWC accelerated to approximately 40 km/h. She stated that on impact she felt a rapid injection of pressure and water enter her rectum. The patient presented to the pediatric trauma centre with severe abdominal pain and blood per rectum. On physical examination, she was tachycardic with a distended tender abdomen. A hematoma measuring 5 × 5 cm was visualized on the right buttock adjacent to the anus (Fig. 1). Computed tomography of the abdomen and pelvis displayed a laceration in the anterolateral rectal wall at the rectosigmoid junction (Fig. 2) with associated free intraperitoneal air and profuse free fluid (Fig. 3). The patient was emergently taken to the operating room. Vaginal examination under anesthesia demonstrated an intact introitus and no vaginal injury. Sigmoidoscopy was performed up to 15 cm, after which insufflations were not attainable. At exploratory laparotomy, copious amounts of lake water and fecal matter were encountered upon entering the peritoneum. Lake
Fig. 3 Computed tomography of the abdomen demonstrating copious free fluid (white arrow).
debris and stool extended to both diaphragms. A full thickness perforation was identified at the rectosigmoid junction, which was oversewn as a Hartman pouch and a proximal end colostomy was created to divert the fecal stream. Closed suction drains were placed in the presacral space. The patient tolerated the procedure well and was taken to the pediatric surgical ward postoperatively. The patient's postoperative course was complicated by a wound infection that required opening and packing the skin incision. She also received systemic antibiotics. Six weeks later, she was readmitted with a presacral abscess that was drained operatively and once again started on antibiotics. At 4 months from her initial presentation, the colostomy was closed and intestinal continuity restored. The patient had subsequent return of her bowel function and is doing well at this time.
2. Discussion
Fig. 2 Computed tomography of pelvis demonstrating air outside the rectal wall (white arrows).
According to the American Academy of Pediatrics, the popularity and availability of PWC has increased dramatically over the last decade. Contrary to PWC operators, most PWC passengers are younger than 18 years [8]. The most common mechanism of injury comprising approximately 70% of pediatric injuries occurs from blunt trauma. This is related to collision with another vessel or stationary objects [9]. Personal watercraft–associated rectal injuries are exceedingly rare, with 6 reported cases described in the literature [2-7]. Rectal injuries are the result of forceful propulsion of water by PWC. The increased pressure at the rectum overcomes the anal sphincter resistance resulting in a burst of fluid in the rectum, which acts
404 more like a solid, leading to perforation and significant intra-abdominal contamination. The phenomenon of hydrostatic injury has been described in water-skiing and waterslide injuries [10-14] resulting in vaginal lacerations and perforations. Management of traumatic pediatric rectal injuries involves detailed perineal examination with proctoscopy and if warranted, exploratory laparotomy. Descottes et al [3] describe a child in whom failure to assess for extraperitoneal rectal injury resulted in multiorgan failure and death. Repair of the full thickness rectal perforation remains an option. However, we agree with previous reports that fecal diversion with loop or end colostomy, although conservative, is safe and effective initial operative management. This should be combined with wide drainage of the presacral space and thorough irrigation of the contaminated abdominal cavity. Despite the rare occurrence of hydrostatic induced rectal perforations in Canada, it is a serious and potentially devastating injury. Therefore, safety guidelines and education are needed. In the United States, the National Transportation Safety Board recommends wet suit bottoms for all pediatric PWC operators and passengers. In Canada, similar recommendations have not been made. The use of PWC in Canada is less common than the United States, however, is steadily increasing, especially on local lakes. Education regarding potential injuries and establishing prevention guidelines is recommended. Furthermore, the addition of a device that automatically shuts off the PWC, as a passenger is dislodged, may help prevent hydrostatic rectal injures [2,15].
R.S. Gill et al.
References [1] Personal watercraft use by children and adolescents. American Academy of Pediatrics. Committee on Injury and Poison Prevention. Pediatrics 2000;105(2):452-3. [2] Morrison DM, Pasquale MD, Scagliotti CJ. Hydrostatic rectal injury of a jet ski passenger: case report and discussion. J Trauma 1998;45(4):816-8. [3] Descottes B, Lachachi F, Moumouni I, et al. Rectal injury caused by personal watercraft accident: report of a case. Dis Colon Rectum 2003;46(7):971-3. [4] Parsons DP, Kahn HA, Isler JT, et al. Rectal injury caused by a personal watercraft accident: report of a case. Dis Colon Rectum 1999;42(7):959-60. [5] Philpott JM, Ng PC, Wixon CL, et al. Rectal blowout by personal watercraft water jet: case report and review of literature. J Trauma 1999;47(2):385-8. [6] Goldberg J, Horan C, O'Brien LM. Severe anorectal and vaginal injuries in a jet ski passenger. J Trauma 2004;56(2):440-1. [7] Szmytkowski J, Dabrowiecki S, Makuch-Burzynska M. Unusual rectal injury by personal watercraft. J Trauma 2007;62(2):551. [8] Jones CS. Children and personal watercraft: injury characteristics and potential countermeasures. Inj Prev 1998;4(1):61-2. [9] Rubin LE, Stein PB, DiScala C, et al. Pediatric trauma caused by personal watercraft: a ten-year retrospective. J Pediatr Surg 2003;38(10):1525-9. [10] Gray HH. A risk of waterskiing for women. West J Med 1982;136(2): 169. [11] Kizer KW. Medical hazards of the water skiing douche. Ann Emerg Med 1980;9(5):268-9. [12] Perlman SE, Hertweck SP, Wolfe WM. Water-ski douche injury in a premenarcheal female. Pediatrics 1995;96(4 Pt 1):782-3. [13] Eder M, Bjelic-Radisic V, Luschin-Ebengreuth G, et al. Vaginal laceration in a premenarcheal girl after sliding down a water chute. Eur J Obstet Gynecol Reprod Biol 2010;150(1):103-4. [14] Kosola S, Rouhe H, Molander P. Vaginal water pressure injury. Duodecim 2010;126(2):181-2. [15] Eberhart-Phillips J, Fielder J, Reeder A. Jet-ski injuries in New Zealand. N Z Med J 1998;111(1067):215-6.