Letter

Removing rectal foreign bodies: is the ventouse gender specific?

MJA 1998; 169: 670-671

After an uneventful induction of anaesthesia, the surgeon proceeded to try to remove the "bottle top". However, it was soon obvious to him that he was not looking at a bottle top, but rather at the bottom of a glass bottle approximately 5 cm in diameter.

Attempts to remove it with fingers, assisted by abdominal pressure, very similar to bimanual pelvic examination of the female pelvis, were unsuccessful. The surgeon was considering proceeding to laparotomy, with the aim of pushing the bottle up into the sigmoid colon and then opening the abdomen and retrieving it.

However, the general practitioner anaesthetist, also trained in advanced obstetrics, suggested the possible use of the ventouse. The surgeon agreed, but, having no experience in the use of the ventouse, invited the GP to perform the procedure. The management of the anaesthesia was handed over.

A small disposable plastic ventouse cup (Mityvac 0044M) was gently inserted through the already lax anus and manipulated onto the bottle. The rim was checked for trapped rectal mucosa. After three attempts to seal, suction was successfully applied. The rim was then checked again for mucosa and gentle traction applied. The bottle descended easily and delivered per rectum with no obvious trauma to the anus. The surgeon then checked for mucosal tears by sigmoidoscopy. There were none, and the patient was discharged the following day.

I describe this case to illustrate two points. Firstly, that general surgeons may find a use for, and possibly adapt, the well-tried ventouse cup for delivery of foreign bodies per rectum. It would be advisable to have some obstetric training to learn how to avoid the dangers of mucosal entrapment. The advantages of the suction cup are that it will mould to the object and that it doesn't increase the diameter of the foreign body.

Secondly, that the multiskilled rural GP still has a place in medicine, and can occasionally bring expertise from one area to another to benefit the patient.

Richard P G Mackinnon
Rural General Practitioner, Crystal Brook, SA 5523
Email: rmackinnATpirie.mtx.net.au

Comment: The above tale of clinical cunning is an excellent illustration of the need for lateral thinking in certain situations. The particular clinical problem described has been with us for some time and is seen all over the world. It is relatively common, and requires a sensitive, meticulous and skilfully taken history, a professional physical examination, and diagnostic imaging (usually x-rays, occasionally ultrasound or computed tomography) before a careful plan based on knowledge and experience is formulated. However, a marked degree of modification or even innovation, depending on the particular object to be removed and the clinical circumstances, is often used. Not infrequently, careful trial and error (and luck) are factors in the outcome.

A quick scan of the literature confirms the diverse and international nature of the problem and of its solutions. A German report tells of an apple wrapped in cellophane, unable to be retrieved until coagulated intermittently by argon laser. The Indian gastroenterology journal tell us of screwing out carrots, removing needles and whisky bottles.¹ A series from Athens reports success with obstetric forceps in 40% of cases, while highlighting the importance of negating the proximal vacuum suction effect caused by traction on the foreign body, especially smooth, round ones like bottles (see Figure 1). This is commonly done by gently passing a well-lubricated Foley-type urinary catheter up past the object to break the air seal.²

An overview of cases from California and London reminds us that, although foreign bodies can be removed in the emergency department in about two out of three cases, some 10% still require a laparotomy and a diverting colostomy to remove the object or to treat bowel perforation.

Only one case report (which claimed to be a world's first) described the use of an obstetric vacuum extractor.³ As in the case described above, this report also emphasised the practical issues of ensuring that no mucosa is trapped and the need for follow-up sigmoidoscopy to check for mucosal damage or perforation.

The case described above also illustrates the element of surprise when what we are led to expect from the history is nothing like what we really have to deal with (see Figures 2 and 3). As 80% of these events occur for sexual stimulation and 10% involve sexual assault,⁴ it is understandable that there may be an initial reluctance to tell the truth. At all times, before and after the extraction, extra effort must be made by all staff to show a confidential, sensitive and caring attitude to a patient who is deeply embarrassed and often in great discomfort.

Gordian Fulde
Director, Emergency Department, St Vincent's Hospital
Victoria Street, Darlinghurst, NSW 2010

1. Vashist MG, Arora AL, Salil. Screwing a carrot out of the rectum [letter]. Ind J Gastroenterol 1997; 16: 120.
2. Kouraklis G, Misiakos E, Dovas N, et al. Management of foreign bodies of the rectum: report of 21 cases. J Roy Coll Surg Edin 1997; 42: 246-247.
3. Johnson SO, Hartranft TH. Nonsurgical removal of a rectal foreign body using a vacuum extractor. Report of a case. Dis Colon Rectum 1996; 39: 935-937.
4. Cohen JS, Sackier JM. Management of colorectal foreign bodies. J Roy Coll Surg Edin 1996; 41: 312-315.

Acknowledgment: Figures 2 and 3 were kindly provided by Dr T O'Connor, Colorectal Surgeon, St Vincent's Hospital, Sydney.

©MJA 1998
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