Complete Evisceration of the Small Intestine through a Perianal Wound as a Result of Suction at a Wading Pool Mauricio Gomez-Juarez, PhD, Pedro Cascales, MD, Damian Garcia-Olmo, MD, Fernando Gomez-Juarez, PhD, Servando Usero, PhD, Pascual Capilla, PhD, Emilio Garcia-Blazquez, PhD, and Francisco Anderica, PhD J Trauma. 2001;51:398 –399. D amage of the pelvic floor can be caused by a variety of mechanisms, and transanal evisceration resulting from barotrauma is unusual. 1–4 The frequency of lesions caused by suction from drains in swimming pools and aquatic parks is increasing, probably as a result of increases in aspi- ration pressures at such installations and inadequate security measures. 3–6 To our knowledge, perineal nontransanal evis- ceration caused by suction has not previously been described. We present a case of evisceration of the entire small intestine through a perianal wound caused by suction from a drain, with severe intra-abdominal lesions. The patient survived but with an extreme case of short-bowel syndrome, which neces- sitated parenteral nutrition even on his return home from the hospital. CASE REPORT While playing in a community wading pool, a 16-year- old boy sat on an uncovered drain. He was trapped by the suction pressure on his perineum from the opening of the drain. He was released from the drain only when the vacuum pump had been turned off. The strong suction pressure rup- tured his pelvic floor, and his small intestine was observed to be protruding from the perineum. Vigorous resuscitation of the patient was required and, on initial examination at the hospital, he presented in shock with evisceration of the entire small intestine through a perianal wound (Fig. 1). After prompt preparation, the patient underwent surgery under general anesthesia. The perineum, eviscerated intes- tine, and abdomen were prepared aseptically and celiotomy was performed. About 200 mL of free sanguineous fluid was present, with little active bleeding and no fecal soilage. There was a long rectal tear that extended from above the peritoneal re- flection to within 5 cm of the anal orifice. The anal canal was undamaged. The entire small intestine, which had become totally separated from the mesentery, protruded through the perianal wound. Stripping of the transverse mesocolon with signs of colonic ischemia was also noted. The reduction of the viscera was reached via combined abdominal and perineal approaches, and complete resection of the nonviable entire jejunum and ileum was performed. The third portion of duodenum was subsequently anasto- mosed to the cecum. Segmentary resection of 20 cm of transverse colon with end-to-end anastomosis was required. The damaged portion of the rectum was resected and a Hartmann pouch established along with an end-sigmoid colostomy. Finally, the pelvic floor was reconstructed with verification of the integrity of anal sphincters. After surgery, intensive care and parenteral nutrition were required. No surgical complications were apparent in the early postoperative period, and on the seventh postoper- ative day, oral intake was tolerated with a functioning colos- tomy. On the 15th postoperative day, the transit time from mouth to colostomy was 4.5 hours. The patient was dis- charged from the hospital with a home parenteral nutrition program and enteral nutrition ad libitum. Six months later, colostomy stools were almost normal, and good anal-sphinc- ter function was verified by anorectal manometry. A recto- colic anastomosis was performed. The patient was continent to stools and gases, tolerating oral intake. However, home parenteral nutrition through a central venous catheter remained necessary to maintain ap- propriate weight gain. The frequency of defecation remained between two and four depositions per day. DISCUSSION One of the less frequent causes of damage to the pelvic floor is barotrauma. 1–4 Transanal suction of abdominal or- gans occurs when the perineal region is subjected to a strong negative pressure from the outside, with rectosigmoidal per- foration and evisceration. 3–6 To our knowledge, complete perineal nontransanal evisceration of the small intestine caused by suction has not previously been described. In our patient, barotrauma produced a lineal tear in the pelvic floor, without destruction of the anal sphincters but with evisceration of the entire small intestine through a per- ineal wound. Thus, the patient had normal anal-sphincter function. Because of the large resection, absorption of nutri- Submitted for publication July 10, 2000. Accepted for publication August 29, 2000. Copyright © 2001 by Lippincott Williams & Wilkins, Inc. From the Department of General Surgery (M.G.-J., P.C., D.G.-O., S.U., P.C., E.G.-B., F.A.) and the Pharmacology and Nutrition Unit (F.G.-J.), Albacete General Hospital, Albacete, Spain. Address for reprints: Pedro Cascales-Sanchez, MD, Hospital General de Albacete, c/ Hnos. Falco s/n, 02006 Albacete, Spain; email: pcascales@hgab.insalud.es. CASE REPORT The Journal of TRAUMA  Injury, Infection, and Critical Care 398 August 2001