Introduction

The majority (80%) of rectal injuries occur as a result of firearm injuries. This is followed by blunt traumas, which are responsible for 10% of rectal injuries, and cutting/penetrating injuries, which account for 5%. Treatment for rectal injuries can sometimes be a prolonged process.^1,2 Vacuum-assisted therapy is a method that facilitates wound healing in cases of difficult or late-healing wounds and recurrent injuries. Particularly in chronic or infected wounds with limited circulation, the method increases local blood flow by 3- to 4-fold, thus accelerating the formation of granulation tissue.^3,4,5 Therefore, we used a vacuum-assisted system to promote defect closure and provide definitive therapy in our patient with lower rectal injury and perforation. In this study, we evaluate this treatment approach and its outcomes.

Case Report

A 43-year-old male patient suffered rectal and bladder injury as a result of a firearm injury and underwent emergency bladder repair with sigmoid colonic colostomy in his home country in September 2015. During follow-up, urine and intestinal contents were observed to be exiting the incision site, and the patient was admitted for another surgery. The site of urine leakage and the suspected site of cecum injury were identified in cystography, and a diverting ileostomy was opened 30 cm from the ileocecal junction. After about 1.5 months of follow-up, it was observed that urine was exiting the incision site via a urinary fistula. The patient was referred to our center for bilateral percutaneous nephrostomy. On physical examination, the patient had colostomy and ileostomy in the left and right lower quadrants. Following bilateral nephrostomy, the amount of urine exiting the incision site decreased. Contrast abdominal tomography revealed fluid collection extending from the bladder to the pararectal area and an abscess cavity in the presacral region containing gas bubbles (Figure 1). The abscess was treated by placing a percutaneous drainage catheter and administering antibiotics. During treatment, urine stopped leaking from the incision site and the nephrostomies were closed, the patient began urinating normally, and clinical and radiological signs of the abscess cavity completely resolved. The patient was discharged after 4 months of therapy. Three months later, the patient returned for colostomy closure. Follow-up intravenous + oral contrast abdominal tomography revealed a 71x34 mm abscess cavity in the presacral area and a rectal defect (Figure 2).

Colonoscopy revealed a fistula connecting to the posterior wall 5 cm from the anus. The opening was approximately 5 mm in diameter and was leaking purulent discharge (Figure 3). The patient was admitted for surgery. With the patient in the jackknife position, a 4 cm transverse incision was made posterior to the anus and continued toward the presacral region. The abscess cavity was drained, necrotic tissues were debrided, and the cavity was washed with antiseptic solutions. The presacral area was then closed with a vacuum-assisted abdominal sponge closure using fibroblast growth factor-containing collagen and changed intermittently (Figure 4, 5). Following 10 sessions of vacuum-assisted therapy in operating-room conditions, abdominal tomography showed that granulation tissue had completely filled the abscess cavity and the fistula connection was no longer present (Figure 6). The patient underwent a final procedure to close the diverting ileostomies and colostomy. No postoperative complications were observed and the patient was discharged after 8 days.

Discussion

Rectal injuries may be caused by firearms (80%), blunt trauma (10%), transanal foreign bodies (6%), and cutting/penetrating instruments (3%).^1,2,6 McGrath et al.⁷ emphasized that in rectal injuries, the intraperitoneal and extraperitoneal parts of the rectum should be treated differently because they follow different clinical courses. They reported that, as with colon injuries, the intraperitoneal part of the rectum can be treated by primary repair within the first 8 hours; the lower rectum can be repaired if accessible, but presacral drainage and diversion are necessary if it is not accessible. This approach has become increasingly used in recent years.

In contrast, primary repair is not generally accepted for extraperitoneal rectal injuries. For injuries in this part of the rectum, primary repair with sutures was performed in 2.5-37% of the cases in the literature, with fecal diversion used in most of those cases. Although colostomy alone has been proposed as sufficient for lower rectal injuries, many authors have reported successful primary closure of injuries that can be accessed with minimal dissection and are not high-risk.^7,8,9,10,11 The generally accepted principles of rectal injury treatment are fecal diversion, debridement and primary repair, rectal irrigation, presacral drainage, and wide-spectrum antibiotic therapy.¹² As vacuum-assisted therapy has never been used in extraperitoneal rectal injuries, we wanted to demonstrate the effectiveness of this system in our patient.

Vacuum-assisted therapy is an effective way to promoting healing and reducing healing time for wounds that are difficult to treat, slow to heal, or have recurrent infection. In vacuum-assisted therapy, negative pressure is applied to a certain area of the wound surface in order to accelerate healing. Contraction is provided at and around the wound surface due to the mechanical stress applied by the synchronous system, and significant reduction in wound surface area is achieved. In addition, the secretions and edema encountered during the treatment of such infected wounds can be eliminated, reducing their deleterious effects on wound healing and accelerating the healing process.^13,14,15

Although vacuum-assisted therapy has been primarily used for injuries involving superficial tissue defects like burns, pressure sores, and diabetic wounds, in recent years it has also been utilized in orthopedic infections with severe soft tissue defects and in oncologic surgery.^16,17

The use of regional vacuum-assisted therapy for this purpose provides many advantages. The most significant of these is that the secretions which often indicate deep wound infection and extensive soft tissue necrosis are absorbed and removed from the wound.^17,18

Schaffzin et al.¹⁹ and Cresti et al.²⁰ reported favorable results using vacuum-assisted therapy in patients with severe hydradenitis debridement, Fournier’s gangrene, excision of the mucinous adenocarcinoma of the anal canal, and large and complex perineal wound after abdominoperineal resection.

This property of vacuum therapy also assisted us in the management of tissue edema and secretion in our patient’s wound. By preventing the formation of a dead space, a clean, dry surgical wound site was achieved. Increasing local circulation also accelerated the formation of granulation tissue. With vacuum-assisted therapy, both the fistula and defect closed completely. The colostomy and ileostomy were closed and the patient was discharged.

Treatment approach is critical in extraperitoneal distal rectal injuries. Primary repair is ineffective. Therefore, vacuum-assisted therapy should be considered to facilitate the closure of defects and fistula.

Ethics

Informed Consent: Consent form was filled out by the participant.

Peer-review: Internally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: E.Z., M.Ç., Concept: E.Z., M.Ç., Design: E.Z., M.Ç., Data Collection or Processing: E.Z., S.M., M.Ç., Analysis or Interpretation: E.Z., S.M., E.S., Literature Search: E.Z., E.E., Writing: E.Z., S.M.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.