How to manage a small lesion or foreign body?

Management of Small Anorectal Foreign Bodies

For a small anorectal foreign body with bowel perforation and limited peritoneal contamination, primary suture repair is appropriate only if the perforation is small and recent, the colonic tissues appear healthy and well-vascularized, and the perforation edges can be approximated without tension. 1

Initial Assessment and Imaging

• Obtain anteroposterior and lateral plain X-rays of chest, abdomen, and pelvis first to identify the foreign body's position, size, shape, and detect pneumoperitoneum 2
• Perform focused history and complete physical examination to assess for peritonitis, hemodynamic instability, and signs of perforation 2
• Delay digital rectal examination until after X-ray acquisition to prevent accidental injury from sharp edges 2
• Do not routinely order laboratory tests if there are no signs of perforation or peritonitis 2
• If perforation is suspected, obtain CBC, serum creatinine, and inflammatory markers (C-reactive protein, procalcitonin, lactates) before surgery 1

Treatment Algorithm Based on Clinical Presentation

If Hemodynamically Unstable or Signs of Perforation

• Do not attempt transanal extraction - proceed immediately to emergent laparotomy with damage control surgery 1, 2
• Resuscitate with IV fluids and initiate broad-spectrum antibiotics according to intra-abdominal infection guidelines 1

If Hemodynamically Stable Without Perforation

• Attempt bedside transanal extraction as first-line therapy for low-lying objects 1, 2
• Use pudendal nerve block, spinal anesthesia, intravenous conscious sedation, or general anesthesia to relax the anal sphincter and improve success rates 1
• For high-lying objects above the rectosigmoid junction, attempt endoscopic extraction as first-line therapy 1

If Transanal/Endoscopic Extraction Fails

• Proceed to surgical approach using a "step-up" technique 1
• Start with laparoscopic downward milking if skills and equipment are available 1
• Proceed to colotomy only when milking/transanal extraction fails 1

Management of Small Perforations

Primary suture repair is the preferred approach for small, recent perforations when specific conditions are met: 1

• The perforation must be small and recent 1
• Colonic tissues must appear healthy and well-vascularized 1
• Perforation edges can be approximated without tension 1
• Limited peritoneal contamination is present 1

When Primary Suture is Not Feasible

• In clinically stable patients without risk factors for anastomotic leakage, perform resection with primary anastomosis with or without a diverting stoma 1
• In critically ill patients or those with extensive peritoneal contamination and risk factors for anastomotic leakage, perform a Hartmann's procedure 1

Post-Extraction Management

• Perform proctoscopy or flexible sigmoidoscopy after removal to evaluate bowel wall integrity, identify mucosal lacerations, detect supernumerary fragments, and rule out perforation 1, 2

Antibiotic Therapy

• Do not routinely use antimicrobial therapy in patients without signs of perforation 1
• Administer broad-spectrum antibiotic therapy according to intra-abdominal infection guidelines if hemodynamic instability or perforation is present 1

Critical Pitfalls to Avoid

• Objects migrating into the sigmoid colon increase operative intervention risk 2.25-fold 1, 2
• If drug concealment is suspected, avoid any maneuver that could disrupt drug packages due to life-threatening overdose risk 1, 2
• Never delay surgical treatment to perform imaging investigations in hemodynamically unstable patients 1