On opening the abdomen, large amounts of air whistled out of the abdominal cavity. Large amounts of gross fecal material and bloody ascites were found.
Intraoperative endoscopic rectal examination after rectal irrigation was done to evaluate the entire length of the rectum since the presence of perineal air suggested additional rectal injuries; however, there was no other damage. Primary repair of the perforation or anastomosis after bowel resection seemed dangerous under the circumstance of severe fecal contamination. The damaged segment of the bowel was resected with closure of the distal rectal stump and construction of an end sigmoid colostomy Hartmann procedure.
His follow-up period was completed without any complication and he was discharged 8 days after operation. Reversal of the colostomy was done after 8 weeks and the postoperative period was uneventful. Dozens of pneumatic colon injury cases have been reported since the first report by Stone in [ 1 ]. Case analysis often reveals unwise behavior.
Those cases not involving misbehavior usually occurred when employees used air hoses to dust off their clothing as in the present case. It is important to realize that this injury can occur without inserting the air hose into the anus. Colorectal injury can occur when the nozzle is merely placed near the anus, even when clothes are worn [ 2 , 3 ]. It took only 1 to 2 seconds to deliver enough air to cause major damage. Andrews, using compressed air to distend the intestine of a dog, found that normal intestine required a pressure of 0.
Burt showed that the average pressure needed to cause a full thickness tear in human gastrointestinal tracts is 0. It is far greater than the pressure needed for intestinal perforation. Highly compressed air is known to form a column that acts like a solid body forcing open the anal sphincter [ 4 ]. The funnel shaped anatomy of the buttock facilitates the air to concentrate around the anus and allows the easy delivery of air through the anus.
Clothes do not protect the force of compressed air as shown by the fact that almost all cases were fully dressed. The cecum, having the largest diameter in colon, is the most susceptible site for iatrogenic barotrauma and is explained by the law of Laplace where the tension in the wall is proportional to the radius of the lumen [ 6 ].
Meanwhile, most compressed air related injuries occur in the rectosigmoid region. Pneumatic injury is relatively rare in the anal canal and distal rectum since these parts are well supported by external structures and are anatomically straight.
The rectosigmoid region, having many flexures, is the first part of the colon to be struck by a column of air. Therefore, most reported injuries occur in the rectosigmoid junction, sigmoid colon, and sigmoid-descending junction [ 2 , 3 , 7 ]. However, colon perforation can occur in other sites including the transverse and ascending colon [ 8 , 9 ]. When a lage amount of gas is introduced into the peritoneal cavity, respiratory distress occurs due to increased intraabdominal pressure. The elemination of air using a large bore needle is a simple and effective method for relieving pneumoperitoneum tension and respiratory distress as shown in the present case.
After recovery from the initial shock, peritonitis due to fecal contamination should be checked for and treated immediately. The diagnosis is not difficult if the patient has a history of abdominal pain and distension after exposure to compressed air. On radiologic examination, a distended colon filled with air or a large amount of free air in the peritoneal cavity is observed.
Colon perforation itself should be treated according to the general principles of treatment for colon perforation. For the perforation of the colon, various types of treatment are possible from conservative management at colonoscopic damage to aggressive surgical treatment.
Surgical exploration should garner greater consideration in cases of compressed air induced colon injury with pneumoperitoneum since it accompanies fecal contamination, and preoperative evaluation of the extent of damage is difficult.
Conservative managemet would also be possible in mild cases of peritonitis. At the time of laparotomy, primary repair, segmental resection, with or without colostomy, can be performed depending on the extend of contamination. Primary repair or anastomosis after resection was not appropriate for the present case as the fecal contamination was severe and the bowel was edematous.
It should be remembered that a second operation might be necessary in cases of delayed colon perforation [ 9 ]. The prognosis has generally been favorable in recent years, although early collective reviews reported grave results [ 10 ]. The careless use of compressed air results in catastrophic results as shown in this case.
Therefore, workers handling compressed air should be made aware of the hazards before allowing them access. The potential dangers should be prominently displayed in writing in places where it is being used to minimize such accidents in the future. National Center for Biotechnology Information , U. Ann Surg Treat Res. Published online Jun Young Jin Park. Find articles by Young Jin Park.
Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding Author: Young Jin Park. This article has been cited by other articles in PMC. Abstract As the use of compressed air in industrial work has increased, so has the risk of associated pneumatic injury from its improper use. Keywords: Intestinal perforation, Rectum, Barotrauma. Open in a separate window. Air-gun used in the work place of patient animal feed factory.
Extensive pneumoperitoneum. High intraperitoneal air pressure can impede venous return and induce respiratory distress. Download chapters of the Compressed Air and Gas Handbook for free. The handbook is the authoritative reference source for general information about compressed air and for specific information about proper installation, use, and maintenance of compressors and pneumatic equipment.
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