A fatal anal impalement.

Dear Editor,

Anal impalements are infrequent injuries, and generally involve only gastrointestinal, urinary or genital pelvic structures. They are rarely fatal. Only one previous fatal case was reported in the literature in 1995.[1] We report a rare case of fatal impalement, to our knowledge, the second one to be ever described in the literature.

A 63-year-old man was admitted to the emergency department after an accident occurred in his garden. He presented a trans-anal impalement by a metallic rod [Figure 1] and a complex wound in the left-side thoracic wall [Figure 2]. On arrival, consciousness was preserved despite the low blood pressure. The only immediate therapy started was fluid resuscitation. Unfortunately, the patient died for a severe hemorrhagic shock.

Figure 1

Entrance penetrating wound

Figure 2

Exit penetrating wound with a severe lesion in the leftside sub-clavicular region

Anal-perineal impalements are infrequent and potentially life-threatening injuries. Mortality rates are related to the severity of the trauma. Treatment requires a wide colo-proctological surgical expertise. A similar nonfatal case involving rectum, bladder, mesentery, liver, and right lung was recently published in 2012.[2] Most of the other reported cases are case series of pediatric patients victim of sexual abuse.[3] The surgical treatment of anal-perineal impalement can be problematic when serious vascular lesions have been caused, or multiple organs are involved; besides, uncomfortable sequelae such as urinary incontinence, anal sphincter dysfunction, and colonic diversion are frequent.[4]

Our case highlights how complex the management of an anal impalement can be when the pelvis, abdomen, and thorax are involved simultaneously. For a correct management of such kind of lesions, a multidisciplinary approach to deal with the various injuries is needed, and the penetrating object must not be displaced until the surgical procedure has not begun. Novel approaches have been suggested, for example, in a recent case, authors report the successful implementation of a laparoscopic approach for a pediatric impalement injury.[5]