SciELO - Scientific Electronic Library Online

 
vol.23 suppl.1Transanal endoscopic operation: a new proposalComparison of colon-cleansing methods in preparation for colonoscopy - Comparative efficacy of solutions of mannitol, sodium picosulfate and monobasic and dibasic sodium phosphates author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

Share


Acta Cirúrgica Brasileira

Print version ISSN 0102-8650On-line version ISSN 1678-2674

Acta Cir. Bras. vol.23  suppl.1 São Paulo  2008

http://dx.doi.org/10.1590/S0102-86502008000700017 

17-CLINICAL RESEARCH
ORIGINAL ARTICLE
ALIMENTARY TRACT

 

Surgical treatment of traumatic cloaca1

 

Tratamento cirúrgico da cloaca pós-trauma

 

 

Roberta Lages das MercêsI; Paulo Henrique PisiI; Antônio Balestrim FilhoI; Thiago Agostini BragaI; José Joaquim Ribeiro da RochaII; Omar FéresII

IMD, Resident, Division of Coloproctology, Departament of Surgery and Anatomy, Ribeirão Preto Faculty of Medicine, University of São Paulo, Brazil
IIPhD, Professor, Division of Coloproctology, Departament of Surgery and Anatomy, Ribeirão Preto Faculty of Medicine, University of São Paulo, Brazil

Correspondence

 

 


ABSTRACT

PURPOSE: To assess the functional results of surgical treatment of traumatic cloaca by a technique including reconstructive plastic surgery of the perineal body and of the rectovaginal septum using the puborectal and external sphincter muscles.
METHODS: Six female patients were submitted to surgical treatment for correction of the cloaca over a period of 5 years (2002 to 2007). Loop sigmoidostomy was parformed in two patients. The mean duration of symptoms before surgical treatment was 97.5 months (4 months to 36 years), mean patient age was 36 years (17 to 58 years) and the follow-up period was 14.6 months (6 months to 2 years).
RESULTS: Five patients (83.3%) regained fecal and flatus continence and one patient had flatus incontinence.
DISCUSSION:
Surgical treatment yields good results, is safe and involves low rates of complications.

Key words: Traumatic Cloaca. Fecal Incontinence. Reconstruction of The Rectovaginal Septum/Sphincteroplasty.


RESUMO

INTRODUÇÃO: A causa mais comum da cloaca é o trauma obstétrico. O objetivo desse trabalho é avaliar os resultados do tratamento cirúrgico empregando-se plástica reconstrutiva do corpo perineal e do septo reto vaginal.
MÉTODOS: Foram operadas seis mulheres, num período de 5 anos (2002-2007). Sigmoidostomia em alça foi realizada em duas pacientes. O tempo médio de duração dos sintomas no pré-operatório foi de 97,5 meses (4 meses a 36 anos), a faixa etária média foi de 36 anos (17-58) e o período de seguimento foi de 14,6 meses (6 meses – 2 anos).
RESULTADOS: Cinco pacientes (83,3%) recuperaram a continência anal para fezes e flatos e uma paciente permaneceu com incontinência para gases.
DISCUSSÃO:
O tratamento cirúrgico da cloaca pós-trauma apresentou bons resultados, sendo considerado um procedimento seguro, com baixo índice de complicação.

Descritores: Cloaca Traumática. Incontinência Fecal. Reconstrução Parcial de Septo Retovaginal/Esfincteroplastia.


 

 

Introduction

Traumatic cloaca is caused by the anterior loss of the sphincter apparatus and of the perineal body, resulting in a common opening for the rectum and vagina. The most common cause is obstetrical trauma resulting from episiotomies that lead to third and fourth degree perineal lacerations, with destruction of the external and internal sphincter apparatus and of the perineal body.1 The incidence is approximately 0.003% of all vaginal deliveries, is more common at first delivery and more prevalent in the presence of median episiotomies, forceps deliveries, and large weight infants.2,3 The symptoms consist of flatus and fecal incontinence, causing serious social, sexual ad psychological problems for the patients.2 One of the surgical techniques for the correction of the cloaca includes reconstructive plastic surgery of the perineal body and of the rectovaginal septum using the puborectal muscle and the external sphincter (Figure 1-8).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Methods

Over a period of 5 years (2002 to 2007), 6 patients were submitted to surgical treatment for correction of the cloaca using the technique described in the abstract. All patients were submitted to preoperative anterograde colon preparation and to antibiotic treatment. Loop sigmoidostomy was performed in two patients. The mean duration of symptoms before surgical treatment was 97.5 months (4 months to 36 years), mean patient age was 36 years (17 to 58 years) and the follow-up period was 14.6 months (6 months to 2 years). The cause of the cloaca was a normal delivery with 3rd and 4th degree perineal laceration in 3 patients, a motorcycle accident with fracture of the pelvis and perineal laceration in one patient, fistulotomies on the anterior midline in one patient, and perineoplasty performed by a gynecologist in one. In all patients with obstetrical trauma, primary suture of the sphincter and skin had been performed by the obstetrician in the delivery room.

 

Results

During the immediate postoperative period a patient presented a subcutaneous seroma with spontaneous drainage and without local infection. On the 15th postoperative day one patient developed infection of the surgical wound and was treated with a systemic antibiotic and local hygiene. In another patient, a subcutaneous fistulous pathway persisted after local healing and was treated by fistulotomy on the occasion of reconstitution of intestinal transit. In the two patients submitted to colostomy, reconstitution of intestinal transit was performed 8 weeks after the initial surgery, without complications. Five patients became continent for solid feces and flatus and one patient continued to present flatus incontinence.

 

Discussion

In most cases, traumatic cloaca is caused by perineal lacerations secondary to vaginal deliveries or episiotomies. Although most of these injuries are primarily corrected by obstetricians still in the delivery room, some cases are unsuccessful due to complications such as hematomas, infections, repair under tension, and lack of intestinal preparation.2 Due to the local inflammatory process, an interval of at least 3 months should be allowed between delivery and surgical correction. Transit bypass with colostomy usually is not necessary and is reserved for selected cases. In most published series, the patients develop satisfactory flatus and fecal continence after surgical correction.1-3 The few patients who continue to have incontinence for liquid feces or flatus may benefit from a program of perineal exercises or biofeedback therapy.3 The patient should avoid vaginal delivery after future pregnancies.1-4

Surgical treatment yields good functional results, is safe and presents low rates of complications. Most patients regain flatus and fecal continence.

 

References

1. Corman ML. Anal incontinence following obstetrical injury. Colon & Rectal Surgery 5th ed., 2005; p 381-9.         [ Links ]

2. Herand Abcarian, Charles P. Orsay, Russell K. Pearl, Richard L. Nelson, Susan C. Briley. Traumatic cloaca. Dis Colon Rectum 1989; 32:783-7.         [ Links ]

3. Venkatesh KS, Ramanujam P. Surgical treatment of traumatic cloaca. Dis Colon Rectum 1996; 39: 811-6.         [ Links ]

4. Khanduja KS, Yamashita HJ, Wise WE Jr., Aguilar PS, Hartmann RF. Delayed repair of obstetric injuries of the anorectum and vagina: a stratified surgical approach. Dis Colon Rectum 1994;37: 344-9.         [ Links ]

 

 

Correspondence:
Omar Féres, PhD
Department of Surgery and Anatomy
Faculty of Medicine of Ribeirão Preto, University of São Paulo
14.048-900 Ribeirão Preto, São Paulo, Brazil
Phone: +55 16 3602-2509
feresomar@netsite.com.br

Conflite of interest: no
Financial source: no

 

 

1. Study performed in the Division of Coloproctology, Department of Surgery and Anatomy, Ribeirão Preto Faculty of Medicine, University of São Paulo, Brazil.

 

 

Comments:

The loss of voluntary evacuation control is a condition greatly upsetting to the quality of life. Incapacity of fecal contention, that is, the involuntary loss of feces and gas, or the impossibility to eliminate feces and/or gas in an adequate place and time, although not a life threatening disease, is a physical and psychological aggression to the individual resulting in progressive isolation and alterations in the body image, self-esteem and identity. The present study, although having a small casuistry, should be published not only for the importance of the theme, but also for showing in a didactic manner the technical steps employed in sphincteral reconstruction and for calling attention to an avoidable post-partum complication. Greatly experienced world centers have published casuitics with 20-25 cases, thus, in comparison the brazilian experience should be considered good. The article was written according to the journal rules with a clear and objective introduction. Surgical techniques were described in detail and the results and discussion are pertinent. Literature references follow journal recommendations.

Ricardo Luiz Santos Garcia

MD, Fellow PhD degree, Division of Coloproctology, Department of Surgery and Anatomy, Ribeirão Preto Faculty of Medicine, University of São Paulo, Brazil.

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License