Stepwise surgical management of rectal foreign bodies: a multicenter operative case series and systematic review

Most rectal foreign bodies (RFBs) are removed non-operatively; operative management after failed transanal extraction remains poorly standardized. We describe a multicenter series of surgically managed RFBs and a systematic review of case series to quantify how often abdominal access avoids opening the bowel.

All patients who underwent operating-room extraction of an RFB at three institutions over 5 years (2019-2023) were reviewed; bedside and endoscopy-suite removals were not captured, so the cohort represents surgically managed RFBs. The review (PubMed/MEDLINE, Embase, Scopus, Web of Science; Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020; retrospective registration) included case series of five or more patients in any language, with extracted values checked against primary reports wherever available and source-level qualifications documented explicitly; all included series were appraised item by item with the Joanna Briggs Institute Critical Appraisal Checklist for Case Series.

In total, 22 patients (19 men; median age 49 years) were included, all self-inserted. Fourteen were managed transanally or by transanal minimally invasive surgery (TAMIS) (transanal 12, TAMIS 2) and eight by an abdominal approach (five open, two hand-assisted laparoscopic, and one laparoscopic); two minimally invasive attempts were converted. Two proximal objects were delivered per anum by milking without a deliberate bowel incision. Of the other six abdominal cases, three underwent resection, two required deliberate extraction enterotomies that were closed primarily, and one pre-existing contained perforation was managed by lavage and primary repair without diversion; a stoma was formed in three, all with perforation. There were no deaths. Abdominal cases more often involved objects above the rectosigmoid junction (7/8 vs. 2/14) and perforation (4/8 vs. 0/14), but not larger objects; all comparisons were exploratory and unadjusted. The review included 60 series from 26 countries (1976-2026). Among the 42 series that explicitly distinguished milking from bowel opening, 64 of 181 abdominal procedures were completed by milking without an enterotomy. Post-extraction endoscopy was performed in 0%-100% of patients across series.

A stepwise, organ-preserving strategy-transanal or TAMIS extraction, then laparoscopic or hand-assisted milking, and then enterotomy, with resection and stoma reserved for perforation with severe injury or contamination-was executable in this cohort. In the published series that record the distinction, abdominal access did not entail opening the bowel in approximately one-third of procedures.