Anesthesia facilitates the extraction of rectal foreignbodies

I read with interest the contribution from Ahmed and Cummings1Ahmed A Cummings SA Novel endoscopic approach for removal of a rectal foreign body.Gastrointest Endosc. 1999; 50: 872-874Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar regarding the successful removal of a rectal foreign body. The authors are to be commended for devising an ingenious method of threading the “eye” at the end of a 28 cm, oblong object with a guidewire to pull the object out. The authors state that “a basic principle of management for a patient with a foreign body in the rectum is to avoid laparotomy and general anesthesia” and point out that “sedatives… were not administered” during this rather protracted and difficult procedure. I certainly agree that laparotomy (with or without colotomy) is a last resort for extraction of rectal foreign bodies; however, anesthesia is often an essential means of providing relaxation for these anxious and embarrassed patients. The authors recognize “spasm of the anal sphincter” as one of the obstacles in the safe extraction of rectal foreign bodies. Goldberg et al. note that “appropriate anesthesia, both to relax the patient and to totally relax the anal sphincter musculature, is usually necessary.”2Goldberg SM Gordon PH Nivatvongs S Essentials of anorectal surgery.in: JB Lippincott, Philadelphia1980: 291-307Google Scholar This can be accomplished with local, regional, or general anesthesia and is especially important for sharp objects, which may cause injury or perforation during extraction. Goligher3Goligher J Surgery of the anus, rectum and colon.in: 5th ed. Bailliere Tindall, London1984: 1119-1136Google Scholar notes that injury from irregular and sharp foreign bodies “is more likely to occur during unskilful [sic] attempts at removal.” Sohn and Weinstein4Sohn N Weinstein MA Foreign bodies of the rectum.in: Current therapy in colon and rectal surgery. BC Decker, Philadelphia1990: 105-107Google Scholar report that the use of endoscopes “in most cases…do not aid in their removal, but often displace the foreign body more proximally into the rectum, confounding its subsequent removal.” Of their 200 patients, laparotomy (without colotomy) was required only once to remove a 4-inch steel ball from the sigmoid colon. MacLeod5MacLeod JH A method of proctology.in: Harper & Row, Hagerstown, MD1979: 75-77Google Scholar suggests that “removal is best performed under general anesthesia with a relaxant, or with spinal anesthesia” and he also notes that “lithotomy is the best position for removal.” Indeed, the authors describe “bimanual manipulation under anesthesia” but only as a method to convert a high-lying object to a low-lying object to allow “transanal removal by direct endoscopic visualization with traction.” Indeed, the use of a brief, general anesthetic in the lithotomy position is an excellent initial approach and allows adequate relaxation, so that the object (especially oblong objects) may be pushed out with bimanual manipulation rather than pulled out, given the acknowledged difficulties with grasping these objects, pulling against a suction effect and finally traversing the acute anorectal angle (perhaps the most difficult part of extraction). Laparotomy is necessary only for bowel perforation or as a last resort for irretrievable objects. Therefore, the routine use of anesthesia should be encouraged as an appropriate and prudent adjunct to the extraction process, providing relaxation of the anal sphincter mechanism, so that foreign body removal may be achieved in a safe and expeditious manner, while avoiding injury to the rectum.