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Department

General Surgery

Position/Job Title

PGY-3 Resident

Description

Introduction: Rectal necrosis is a rare phenomenon given profound collateral circulation. This carries significant morbidity and mortality. We present a case of acute rectal necrosis that is managed conservatively with surgical drainage. Case Description: A 53-year-old female with a history of peripheral arterial disease status post aorto-bifemoral bypass who presented in the emergency room with altered mental status and hypotension. She subsequently developed peritonitis prompting emergent surgical exploration. Her colon and rectum were noted be ischemic with patchy areas of necrosis. She underwent a total abdominal colectomy with an end ileostomy. The rectum was stapled at the rectosigmoid junction at peritoneal reflection and a drain was left in the pelvis. Repeat CT scan demonstrated breakdown of rectal staple line but no further intervention was required. She had a prolonged stay in the intensive care unit with a complicated postoperative course. Following her discharge, she was seen in the office and was recovering well. Discussion: Acute rectal necrosis can often be managed conservatively in the acute setting without the need for surgical resection. Wide drainage is essential to prevent abdominal sepsis. In addition, optimization of postoperative nutritional status is essential to promote healing and improve outcomes. Current evidence does not support the superiority of rectal resection, as it is associated with significant morbidity and mortality related to extent of the resection. However, in situations with frankly gangrenous rectum with concurrent pelvic sepsis there is no alternative to definitive source control in these patients. Conclusion: Acute rectal necrosis can occur in patients with severe atherosclerotic disease and hypoperfusion. Surgical resection is not always the best option, and can be managed conservatively with drainage and antibiotics. Resection should be reserved for patients with features of gangrene and pelvic sepsis with the understanding that this carries significant morbidity. Lessons Learned: Conservative management and drainage are an appropriate treatment for acute rectal necrosis.

Publication Date

4-15-2025

Keywords

Henry Ford Jackson Hospital Research Symposium, surgery, case report

A Case of Unresectable Necrosis

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