Published online Aug 16, 2022. doi: 10.12998/wjcc.v10.i23.8406
Peer-review started: April 12, 2022
First decision: May 9, 2022
Revised: May 18, 2022
Accepted: July 6, 2022
Article in press: July 6, 2022
Published online: August 16, 2022
Acute iatrogenic colorectal perforation (AICP) is a serious adverse event, and immediate AICP usually requires early endoscopic closure. Immediate surgical repair is required if the perforation is large, the endoscopic closure fails, or the patient's clinical condition deteriorates. In cases of delayed AICP (> 4 h), surgical repair or enterostomy is usually performed, but delayed rectal perforation is rare.
A 53-year-old male patient underwent endoscopic submucosal dissection (ESD) at a local hospital for the treatment of a laterally spreading tumor of the rectum, and the wound was closed by an endoscopist using a purse-string suture. Unfortunately, the patient then presented with delayed rectal perforation (6 h after ESD). The surgeons at the local hospital attempted to treat the perforation and wound surface using transrectal endoscopic microsurgery (TEM); however, the perforation worsened and became enlarged, multiple injuries to the mucosa around the perforation and partial tearing of the rectal mucosa occurred, and the internal anal sphincter was damaged. As a result, the perforation became more complicated. Due to the increased bleeding, surgical treatment with suturing could not be performed using TEM. Therefore, the patient was sent to our medical center for follow-up treatment. After a multidisciplinary discussion, we believed that the patient should undergo an enterostomy. However, the patient strongly refused this treatment plan. Because the position of the rectal perforation was relatively low and the intestine had been adequately prepared, we attempted to treat the complicated delayed rectal perforation using a self-expanding covered mental stent (SECMS) in combination with a transanal ileus drainage tube (TIDT).
For patients with complicated delayed perforation in the lower rectum and adequate intestinal preparation, a SECMS combined with a TIDT can be used and may result in very good outcomes.
Core Tip: In this case, the diagnosis of perforation was delayed, the nearby rectal mucosa and internal anal sphincter were extensively damaged. Rectoscopic or laparoscopic repair was difficult. The alternative approach is proximal enterostomy and subsequent stoma reversal. but the patient refused. The perforation was in the lower rectum, the bowel was well prepared. The treatment could be successful as long as the leakage of intestinal contents into the abdominal cavity were prevented, the wound was protected from contamination. The self-expanding covered mental stent covers the perforation, promotes repair and prevents the stenosis, and the transanal ileus drainage tube drains the intestinal contents. The combination achieved the goals.