The role of presacral drainage in the management of penetrating rectal injuries

Colon Injuries and Infectious Complications in Concurrent Gunshot-Related Fractures

INTRODUCTION

Concurrent colonic injury among patients with gunshot-related fractures presents a potential risk for infectious complications. We hypothesized that colon injuries are associated with more infectious orthopedic complications among gunshot victims with concurrent fractures.

MATERIALS AND METHODS

We reviewed trauma patients arriving at our level 1 trauma center from January 1, 2019 to May 31, 2022 who suffered any gunshot-related fracture and also underwent an exploratory laparotomy. Of these patients, those with colon injuries were compared to those without colon injuries. Baseline characteristics, including antibiotic regimens, were collected in addition to outcomes of length of stay, intensive care unit admission, ventilator requirement, and development of infectious orthopedic complications.

RESULTS

Overall, 56 of the 107 included patients had colon injuries. Age, sex, race/ethnicity, and Injury Severity Score were similar between groups. Of patients with colonic injuries, 16.1% received early, repeat dosing of broad-spectrum antibiotics, while only 3.9% of patients without colonic injuries received this antibiotic dosing (P = 0.04). Interestingly, only patients with colon injuries developed infectious orthopedic complications and none of the patients without colon injuries developed such complications (10.7% versus 0.0%, P = 0.03). All patients with orthopedic infections had infected pelvic fractures. Length of stay was 3 d longer in the colon injury group (P = 0.04). There was no difference in intensive care unit admission, ventilator requirement, or death.

CONCLUSIONS

Concurrent colon injuries among patients with gunshot-related fractures are associated with higher risk of infectious orthopedic complications, likely from direct spread of fecal contaminant. Early, broad-spectrum antibiotics may be associated with reduced infectious orthopedic complications.

Rectal Perforation During Pelvic Surgery

Rectal perforations during pelvic surgery are rare but serious complications. The occurrence of rectal involvement is generally lower than that of the involvement of other portions of the bowel. The urologic field is responsible for the majority of iatrogenic rectal injuries from pelvic surgery; general and gynecologic surgeries are prone to the occurrence as well, the latter especially in the case of rectal shaving for deep infiltrating endometriosis. Attention should be posed to the prevention of rectal injuries, especially in case of challenging or salvage procedures; some tricks may be recommended to avoid thermal and mechanical damages and to realize a safe dissection. Intraoperative detection of rectal injuries is of paramount importance; once confirmed, immediate management with the closure of the defect is recommended. In general, rectal injuries diagnosed after surgery are liable to significantly worse outcomes than those detected and managed intraoperatively.

Patient summary

Rectal perforation is a rare but possible complication of pelvic surgeries. The more challenging the procedure (ie, surgery for locally advanced tumors or after radiation therapy), the higher the risk of rectal lesion. Intraoperative management of the injury should be attempted, with direct repair of the defect with or without fecal diversion.

Contemporary management of rectal trauma - A South African experience

INTRODUCTION

The management of rectal trauma remains controversial. There are three modalities which have been used to manage these injuries; proximal diversion (PD), washout of the distal rectum (DRW) and presacral drainage (PSD). The EAST group tentatively advocate mandatory proximal diversion for extraperitoneal rectal injuries and omitting DRW or PSD. Other authors have suggested that diversion can be eschewed in patients with an intraperitoneal injury which can be primarily repaired. In light of all these controversies, this project set out to review our experience with rectal injuries over the last seven years with the objective of reviewing our use of PD, PSD and DRW.

METHODS

Patients aged greater than or equal to 15 years with rectal injuries during December 2012 to July 2019 were included. Patient demographics, mechanism of injury, management strategy (operative or non-operative), complications, patient residential status (urban or rural), hospital and intensive care duration of stay, and 30-day mortality rates were assessed.

RESULTS

During the study period, a total of 51 patients with a rectal injury were treated. There were 45 (88%) males and the median age was 29 (22-39) years. There were 7 (14%) blunt mechanisms, 41 (80%) penetrating mechanisms and 3 (6%) combined blunt and penetrating mechanisms. The median ISS was 13 (9-18). Of the 50 rectal injuries ultimately treated at our institution, there were 31 extraperitoneal and 14 intraperitoneal injuries. There were five combined intra and extraperitoneal injuries. A total of 21 rigid sigmoidoscopies and a single flexible sigmoidoscopy were performed. A total of 24 patients underwent a CT scan. There were 13 primary repairs and 45 PD. A single patient required a PSD. Of the 34 documented complications, 15 (44%) were related to sepsis and can be attributed to the rectal injury. The overall mortality rate was 11.8%.

CONCLUSIONS

Rectal injuries are associated with significant septic related morbidity and mortality. Although we have begun to avoid diversion in a small subset of patients with an intraperitoneal injury, we continue to perform PD for the vast majority of patients with a rectal injury. We do not perform DRW and PSD is used in highly selective cases.

Rectal trauma injuries: outcomes from the U.S. National Trauma Data Bank

BACKGROUND

There is a  lack of general consensus and a little published data regarding the management of trauma-related rectal injuries and outcomes. The aim of the present study was to evaluate the surgical management and corresponding outcomes for this patient cohort, using a nationwide trauma database.

METHODS

Rectal injuries and procedures performed over a 2-year period (2013 and 2014) were identified through ICD-9 clinical modification codes, from the United States National Trauma Data Bank. Patient factors, management variables, and outcomes were evaluated.

RESULTS

Of 1.7 million patients, 1472 (0.1%) sustained a rectal injury; 81% male, median age 30 years (range 16-89 years) and 60% due to penetrating trauma. Seven hundred and seventy-eight (52.8%) had an isolated extraperitoneal injury and 694 (47.2%) had isolated Intraperitoneal or combined intra- and extraperitoneal injuries. Overall, 726 patients (49.3%) underwent fecal diversion. Injuries following blunt trauma were associated with higher injury severity scores (ISS), lower stoma rates, longer hospital and intensive-care unit (ICU) stay, and higher mortality rates than penetrating trauma (all p ≤ 0.001). Patients with stoma formation had lower mortality than undiverted patients (8.6 vs. 4.0%, p < 0.001) despite a higher ISS and more intraperitoneal injuries, but longer hospital and ICU stay (all p ≤ 0.001). On multivariate regression analysis, older age, higher ISS, intraperitoneal injury, and return to the ICU were independently associated with higher rates of mortality, while stoma formation was associated with a lower mortality rate. For isolated extraperitoneal rectal injuries, 494 patients (63.5%) were managed by resection/repair without stoma and had significantly lower overall postoperative morbidity rates (12.7 vs. 30.2%, p = 0.009) and shorter hospital stay (14 vs. 23 days, p < 0.001), than those who underwent resection/repair + stoma (n = 284; 36.5%), despite no significant difference in ISS (29 vs. 27, p = 0.780). There was no significant difference in mortality.

CONCLUSIONS

Our results showed that trauma-related rectal injuries are rare and there is wide variation in their management. These data support a low threshold for stoma formation in patients with intraperitoneal or combined injuries, while suggesting that isolated extraperitoneal defects may be safely managed without fecal diversion.

Rectal Trauma: Evidence-Based Practices

The management of rectal trauma has often been lumped in with colon trauma when, in fact, it is a unique entity. The anatomic nature of the rectum (with its intra- and extraperitoneal segments) lends itself to unique circumstances when it comes to management and treatment. From the four Ds (debridement, drainage, diversion, and distal irrigation), the management of rectal trauma has made some strides in light of the experiences coming out of the recent conflicts overseas as well as some rethinking of dogma. This article will serve to review the anatomy and types of injuries associated with rectal trauma. A treatment algorithm will also be presented based on our current literature review. We will also address controversial points and attempt to give our opinion in an effort to provide an update on an age-old problem.

Management specificities for abdominal, pelvic and vascular penetrating trauma

Management of patients with penetrating trauma of the abdomen, pelvis and their surrounding compartments as well as vascular injuries depends on the patient's hemodynamic status. Multiple associated lesions are the rule. Their severity is directly correlated with initial bleeding, the risk of secondary sepsis, and lastly to sequelae. In patients who are hemodynamically unstable, the goal of management is to rapidly obtain hemostasis. This mandates initial laparotomy for abdominal wounds, extra-peritoneal packing (EPP) and resuscitative endovascular balloon occlusion of the aorta (REBOA) in the emergency room for pelvic wounds, insertion of temporary vascular shunts (TVS) for proximal limb injuries, ligation for distal vascular injuries, and control of exteriorized extremity bleeding with a tourniquet, compressive or hemostatic dressings for bleeding at the junction or borderline between two compartments, as appropriate. Once hemodynamic stability is achieved, preoperative imaging allow more precise diagnosis, particularly for retroperitoneal or thoraco-abdominal injuries that are difficult to explore surgically. The surgical incisions need to be large, in principle, and enlarged as needed, allowing application of damage control principles.

The management of penetrating rectal and anal trauma: A systematic review

INTRODUCTION

Traumatic injuries to the lower gastrointestinal tract (rectum and anus) have been largely reported in the military setting with sparse publications from the civilian setting. Additionally, there remains a lack of international consensus regarding definitive treatment pathways. This systematic review aimed to assess the current literature and propose a standardised treatment algorithm to aid management in the civilian setting.

METHODS

A systematic review of available literature from 1999 to 2016 that was performed. Primary endpoints were the assessment and surgical management of reported rectal and anal trauma.

RESULTS

Seven studies were included in this review, reporting on 1255 patients. 96.3% had rectal trauma and 3.7% had anal trauma. Gunshot wounds are the most common mechanism of injury (46.9%). The overwhelming majority of injuries occurred in males (>85%) and were associated with other pelvic injuries. Surgical management has substantially evolved over the last five decades, with no clear consensus on best management strategies.

CONCLUSION

There remains significant international discrepancy regarding the management of penetrating trauma to the rectum. Key management principals include the varying use of the direct primary closure, faecal diversion, pre-sacral drainage and/or distal rectal washout (rarely used). To date, there is sparse evidence regarding the management of penetrating anal trauma.

Complex Perineal Trauma with Anorectal Avulsion

Introduction. The objective of this case report is to illustrate a severe perineal impalement injury, associated with anorectal avulsion and hemorrhagic shock. Results. A 32-year-old male patient was referred to our hospital for an impalement perineal trauma, associated with complex pelvic fracture and massive perineal soft tissue destruction and anorectal avulsion. On arrival, the systolic blood pressure was 85 mm Hg and the hemoglobin was 7.1 g/dL. The patient was transported to the operating room, and perineal lavage, hemostasis, and repacking were performed. After 12 hours in the Intensive Care Unit, the abdominal ultrasonography revealed free peritoneal fluid. We decided emergency laparotomy, and massive hemoperitoneum due to intraperitoneal rupture of pelvic hematoma was confirmed. Pelvic packing controlled the ongoing diffuse bleeding. After 48 hours, the relaparotomy with packs removal and loop sigmoid colostomy was performed. The postoperative course was progressive favorable, with discharge after 70 days and colostomy closure after four months, with no long-term complications. Conclusions. Severe perineal injuries are associated with significant morbidity and mortality. Their management in high volume centers, with experience in colorectal and trauma surgery, allocating significant human and material resources, decreases the early mortality and long-term complications, offering the best quality of life for patients.

Management of penetrating extraperitoneal rectal injuries: An Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

The management of penetrating rectal trauma invokes a complex decision tree that advocates the principles of proximal diversion (diversion) of the fecal stream, irrigation of stool from the distal rectum, and presacral drainage based on data from World War II and the Vietnam War. This guideline seeks to define the initial operative management principles for nondestructive extraperitoneal rectal injuries.

METHODS

A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding penetrating rectal trauma from January 1900 to July 2014. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included the management principles of diversion, irrigation of stool from the distal rectum, and presacral drainage using the GRADE methodology.

RESULTS

A total of 306 articles were screened leading to a full-text review of 56 articles. Eighteen articles were used to formulate the recommendations of this guideline.

CONCLUSION

This guideline consists of three conditional evidence-based recommendations. First, we conditionally recommend proximal diversion for management of these injuries. Second, we conditionally recommend the avoidance of routine presacral drains and distal rectal washout in the management of these injuries.

Colorectal trauma

The management of traumatic injuries to the colon and rectum has undergone a significant change since World War II. Penetrating injuries are the most common cause of trauma to the colon and rectum. Colon and rectal perforation after blunt trauma are uncommon but not rare. For years, colostomy formation was considered the only acceptable form of treatment for injuries penetrating the colonic mucosa. With the realization that dictums governing colonic injuries during military conflicts were, for the most part, not applicable to civilian injuries, the pendulum has swung from mandatory colostomy to immediate repair in the management of uncomplicated cases. Accompanying these changes in management together with improvement in perioperative care, trauma service and the use of more powerful antibiotics, a significant reduction of mortality rates to less than 5% has been seen in many centres. In the presence of other risk factors, for example multiple associated injuries, severe shock, Penetrating Abdominal Trauma Index (PATI) of more than 25, colostomy is still an option to be considered.

Penetrating pelvic trauma: Initial assessment and surgical management in emergency

Penetrating pelvic trauma (PPT) is defined as a wound extending within the bony confines of the pelvis to involve the vascular, intestinal or urinary pelvic organs. The gravity of PPT is related to initial hemorrhage and the high risk of late infection. If the patient is hemodynamically unstable and in hemorrhagic shock, the urgent treatment goal is rapid achievement of hemostasis. Initial strategy relies on insertion of an intra-aortic occlusion balloon and/or extraperitoneal pelvic packing, performed while damage control resuscitation is ongoing before proceeding to arteriography. If hemodynamic instability persists, a laparotomy for hemostasis is performed without delay. In a hemodynamically stable patient, contrast-enhanced CT is systematically performed to obtain a comprehensive assessment of the lesions prior to surgery. At surgery, damage control principles should be applied to all involved systems (digestive, vascular, urinary and bone), with exteriorization of digestive and urinary channels, arterial revascularization, and wide drainage of peri-rectal and pelvic soft tissues. When immediate definitive surgery is performed, management must address the frequent associated lesions in order to reduce the risk of postoperative sepsis and fistula.

Treatment of complex perineal trauma. A review of the literature

Perineal injuries are uncommon, but not rare. They may present a wide variety of injury patterns which demand an accurate diagnostic assessment and treatment. Perineal injuries may occur as isolated injuries to the soft tissues or may be associated with pelvic organ, abdominal or even lower extremity injury. Hence the importance to know in depth not only the anatomy of the perineum and its organs, but also the implications of the patient's hemodynamic stability on the decision making process when treating these injuries using established trauma guidelines. The purpose of this review is to describe the current epidemiology and clinical presentation of perineal injuries in order to provide specific guidelines for the diagnosis and treatment of both stable and unstable patients.

An unusual stab wound to the buttock

Stab wounds to the buttock are uncommon injuries that are rarely seen in surgical civilian practice. Although, the wound appears trivial, it may cause major life-threatening visceral and vascular injuries. Failure to detect these injuries may lead to serious morbidity and mortality. Herein, we report a patient with a single gluteal stab wound, which was initially sutured and treated conservatively. Two days later, patient developed fever, lower abdominal pain and tenderness with leakage of fecal material from the wound. Exploratory laparotomy revealed an extraperitoneal rectal perforation for which a Hartmann's procedure was performed. Computed tomography scanning is recommended as a diagnostic tool for stable patients having buttock stab wounds. Diverging colostomy is the standard surgical procedure for extraperitonal rectal injuries that cannot be properly visualized and repaired during a laparotomy. More evidence is needed to assess the fecal non-diversion approach in the treatment of these patients.

Rectal impalement with bladder perforation: A review from a single institution

Context:

Impalement injuries of the rectum with bladder perforation have been rarely reported. Such lesions have been associated with increased postoperative morbidity. A well-conducted preoperative evaluation of the lesions tends to prevent such complications.

Aims:

To increase awareness about patients with rectal impalement that involve bladder injuries and to examine the significance of thorough clinical examination and complementary investigation for these patients’ management.

Materials and Methods:

Retrospectively, we identified three patients with rectal impalement and bladder perforation treated in University Hospital Hassan II, Fez, Morocco. We recorded the symptoms, subsequent management, and further follow-up for each patient. All available variables of published cases were reviewed and analyzed.

Results:

Evident urologic symptoms were present in only one patient. Bladder perforation was suspected in two other patients on the basis of anterior rectal perforation in digital exam. Retrograde uroscanner could definitely confirm the diagnosis of bladder perforation. Fecal and urine diversion was the basis of the treatment. No postoperative complications were noted. We have reviewed 14 previous reports. They are presented mainly with urine drainage through the rectum. Radiologic investigation (retrograde cystography and retrograde uroscanner) confirmed bladder perforation in 10 patients (71.4%). Unnecessary laparotomy was performed in six patients (42.8%). Fecal diversion and urinary bladder decompression using urethral catheter were the most performed procedures in bladder perforation [6/14 patients (42.8%)]. No specific postoperative complications were reported.

Conclusions:

A high index of clinical suspicion is required to make the diagnosis of bladder perforation while assessing patients presenting with rectal impalement. Meticulous preoperative assessment is the clue of successful management.

Care of the patient with anorectal trauma

Blunt and penetrating injuries to the anus and rectum are uncommon. Considerable debate remains regarding the optimal treatment of rectal injuries. Although intraperitoneal rectal injuries can be treated similarly to colonic injuries, treatment options for extraperitoneal injuries include fecal diversion with a colostomy, presacral drainage, repair of the rectal defect, and distal rectal washout. Perineal injuries resulting in anal sphincter disruption often occur with severe associated injuries. Small defects can be repaired primarily, but extensive injuries often require diversion and sphincter reconstruction.

Treatment of rectal war wounds

Treatment strategies for penetrating rectal injuries (PRI) in civilian settings are still not uniformly agreed, in part since high-energy transfer PRI, such as is frequently seen in military settings, are not taken into account. Here, we describe three cases of PRI, treated in a deployed combat environment, and outline the management strategies successfully employed. We also discuss the literature regarding PRI management. Where there is a major soft tissue component, repetitive debridement and vacuum therapy is useful. A loop or end colostomy should be used, depending on the degree of damage to the anal sphincter complex.

Anorectal avulsion: an exceptional rectal trauma

Anorectal avulsion is an exceptional rectal trauma in which the anus and sphincter no longer join the perineum and are pulled upward. As a result, they ventrally follow levator ani muscles. We present a rare case of a 29-years old patient who was admitted in a pelvic trauma context; presenting a complete complex anorectal avulsion. The treatment included a primary repair of the rectum and a diverting colostomy so as to prevent sepsis. Closure of the protective sigmoidostomy was performed seven months after the accident and the evolution was marked by an anal stenosis requiring iterative dilatations.

Rectal trauma in adults

Rectal trauma is associated with high rates of morbidity and mortality and generally affects young males due to its aetiology of violent crime and vehicular collision. Historically, management has followed principles derived from military practice, with faecal diversion, pre-sacral drainage and distal washout being mandatory. Civilian trauma studies examining management of colon and rectum injuries from the early 1950s identified major differences in the level of energy transfer between civilian and military wounds, given that the vast majority are penetrating in nature. This led to a re-evaluation of the necessity for these interventions for all rectal injuries. Current management depends on whether the injury is intra- or extraperitoneal, with those above the peritoneal reflection being readily accessible and amenable to treatment as for colon injury. Extraperitoneal injuries remain difficult to access and direct repair is usually impossible; the mainstay of treatment in most instances remains faecal diversion. The role of pre-sacral drainage and distal washout remains contentious in the realms of civilian rectal injury but retains a place in battlefield or other high-energy transfer rectal injuries where aggressive early management reduces septic complications. This article reviews the historical and current evidence for the management of both civilian and military extraperitoneal rectal injuries.

Anorectal avulsion: Management of a rare rectal trauma

INTRODUCTION

Traumatic injuries of the rectum are unusual even though their treatment is challenging and often lead to high morbidity and mortality rate.

PRESENTATION OF CASE

This paper reports a rare case of complete rectal avulsion with multiple fracture and hemoperitoneum treated with a multistep approach in our department.

DISCUSSION

The anorectal avulsion is a rare rectal trauma; only few reports are available. Treatment key points of rectal trauma are: direct repair, diverting stoma and sacral drainage.

CONCLUSION

We reported a case of anorectal avulsion with complete detachment of external sphincter muscle. A multidisciplinary approach was mandatory in this kind of lesions.

Traumatic injury of the colon and rectum: the evidence vs dogma

BACKGROUND

The treatment of traumatic injuries to the colon and rectum is often driven by dogma, despite the presence of evidence suggesting alternative methods of care.

OBJECTIVE

This is an evidence-based review, in the format of a review article, to determine the ideal treatment of noniatrogenic traumatic injuries to the colon and rectum to improve the care provided to this group of patients. Recommendations and treatment algorithms were based on consensus conclusions of the data.

DATA SOURCES

A search of MEDLINE, PubMed, and the Cochrane Database of Collected Reviews was performed from 1965 through December 2010.

STUDY SELECTION

Authors independently reviewed selected abstracts to determine their scientific merit and relevance based on key-word combinations regarding colorectal trauma. A directed search of the embedded references from the primary articles was also performed in select circumstances. We then performed a complete evaluation of 108 articles and 3 additional abstracts.

MAIN OUTCOME MEASURES

The main outcomes were morbidity, mortality, and colostomy rates.

RESULTS

Evidence-based recommendations and algorithms are presented for the management of traumatic colorectal injuries.

LIMITATIONS

Level I and II evidence was limited.

CONCLUSIONS

Colorectal injuries remain a challenging clinical entity associated with significant morbidity. Familiarity with the different methods to approach and manage these injuries, including "damage control" tactics when necessary, will allow surgeons to minimize unnecessary complications and mortality.

Management of colorectal trauma

Although the treatment strategy for colorectal trauma has advanced during the last part of the twentieth century and the result has improved, compared to other injuries, problems, such as high septic complication rates and mortality rates, still exist, so standard management for colorectal trauma is still a controversial issue. For that reason, we designed this article to address current recommendations for management of colorectal injuries based on a review of literature. According to the reviewed data, although sufficient evidence exists for primary repair being the treatment of choice in most cases of nondestructive colon injuries, many surgeons are still concerned about anastomotic leakage or failure, and prefer to perform a diverting colostomy. Recently, some reports have shown that primary repair or resection and anastomosis, is better than a diverting colostomy even in cases of destructive colon injuries, but it has not fully established as the standard treatment. The same guideline as that for colonic injury is applied in cases of intraperitoneal rectal injuries, and, diversion, primary repair, and presacral drainage are regarded as the standards for the management of extraperitoneal rectal injuries. However, some reports state that primary repair without a diverting colostomy has benefit in the treatment of extraperitoneal rectal injury, and presacral drainage is still controversial. In conclusion, ideally an individual management strategy would be developed for each patient suffering from colorectal injury. To do this, an evidence-based treatment plan should be carefully developed.

Current management of large bowel injuries and factors influencing outcome

BACKGROUND

Colonic and intra-peritoneal rectal injuries may be managed by primary repair and extra-peritoneal rectal injuries by diverting colostomy. This study was undertaken to document our experience with this approach and to identify factors which might impact on outcome.

PATIENTS AND METHODS

Prospective study of all patients treated for colon and rectal injuries in one surgical ward at King Edward VIII hospital, Durban, over a 7-year period (1998-2004). Demographic data, clinical presentation, findings at laparotomy and outcome were documented.

RESULTS

Of 488 patients undergoing laparotomy, 177 (36%) had injuries to the colon and rectum with age 29.8+/-10.9 years. Injury mechanisms were firearms (118) stabs (54) and blunt trauma (5). Delay before laparotomy was 10+/-9.3 h. Complication and mortality rates were 36% and 17%, respectively. 68 patients (38%) required ICU management. Shock on admission and increased transfusion requirements were associated with a significantly increased mortality. Patients with delay < or = 12 h before laparotomy had a higher mortality rate than those with delay >12 h. The mortality rate increased with the number of associated injuries and it was higher the higher the Injury Severity Score (ISS); it was similar for stabs, firearms and blunt trauma. Hospital stay was 9.5+/-9.2 days.

CONCLUSION

We reaffirm that primary repair is appropriate for colonic and intra-peritoneal rectal injuries and that extra-peritoneal rectal injuries require diverting colostomy. Shock on admission, increased blood transfusion requirements, associated organ injury and severity of the injury were associated with high mortality.

Combined penetrating injury of the perineum and abdominal viscera

This is a rare presentation. A farmer aged 52 years old was brought to the emergency service of Government District (Doon) Hospital in the late evening having significant bleeding per rectum. He had injured his perineum on a sharp wooden stick during a fall near a tube well. The wooden stick had been extracted by his relatives, which had resulted in profuse bleeding. The patient was managed with intravenous crystalloids and rushed to the operating theatre for examination under analgesia. Blood transfusion was arranged and the wound explored under general anaesthesia. The patient had unusual associated visceral injuries as well as sphincter, rectum, urinary bladder, ileal loop and mesentery injuries. The injured bowel, mesentery, urinary bladder and rectum were repaired with diversion of the upper pelvic colon. In addition, debridement of the perineal wound with rectal sphincter repair was performed and the presacral space drained. The colostomy was closed after 3 months, and the patient survived and is continent.

Colonic trauma: indications for diversion vs. repair

INTRODUCTION

The management of colonic trauma has evolved considerably over the past several decades. An appreciation of best-evidence practices is paramount to the optimal management of these injuries.

MATERIALS AND METHODS

Literature review of pertinent clinical literature regarding the management of colonic trauma was performed.

RESULTS

Based on available level I evidence, primary repair of all colorectal injuries should be attempted, irrespective of associated risk factors. Diversion should only be considered if the colonic tissue itself is deemed inappropriate for repair, as in the setting of prohibitive edema or questionable perfusion of the tissues. Diversion does remain the standard of care for the management of extra-peritoneal rectal injuries, although this practice is under active investigation.

CONCLUSION

Level 1 evidence has failed to demonstrate that routine proximal diversion, once considered the standard of care for the treatment of all colorectal trauma, affords benefit for victims of the injuries. While utilization of these practices may prove beneficial in select circumstances, the routine utilization of proximal diversion for the treatment of colorectal injuries is unwarranted.

Civilian Extraperitoneal Rectal Gunshot Wounds: Surgical Management Made Simpler

BACKGROUND

Rectal injuries are associated with significant morbidity and mortality. Controversy persists regarding routine presacral drainage, distal rectal washout (DRW), and primary repair of extraperitoneal rectal injuries. This retrospective review was performed to determine the outcome of rectal injuries in an urban trauma center with a high incidence of penetrating trauma where a non-aggressive surgical approach to these injuries is practiced.

METHODS

The records of all patients with a full-thickness penetrating rectal injury admitted to the Trauma Center at Groote Schuur Hospital over a 4-year period were reviewed. These were reviewed for demographics, injury mechanism and perioperative management, anatomical site of the rectal injury, associated intra-abdominal injuries and their management. Infectious complications and mortality were noted. Intraperitoneal rectal injuries were primarily repaired, with or without fecal diversion. Extraperitoneal rectal injuries were generally left untouched and a diverting colostomy was done. Presacral drainage and DRW were not routinely performed.

RESULTS

Ninety-two patients with 118 rectal injuries [intraperitoneal (7), extraperitoneal (59), combined (26)] were identified. Only two extraperitoneal rectal injuries were repaired. None had presacral drainage. Eighty-six sigmoid loop colostomies were done. Two (2.2%) fistula, one rectocutaneous, and one rectovesical, were recorded. There were nine (9.9%) infectious complications: surgical site infection (4), buttock abscess (1), buttock necrosis (1), pubic ramus osteitis (1), septic arthritis (2). No perirectal sepsis occurred.

CONCLUSIONS

Extraperitoneal rectal injuries due to low-velocity trauma can be safely managed by fecal diversion alone.

Immediate postoperative complications of combined penetrating rectal and bladder injuries

BACKGROUND

Combined penetrating trauma involving the rectum and bladder has been associated with increased postoperative morbidity. Specific complications resulting from these injuries include colovesical fistula, urinoma, and abscess formation.

METHODS

A retrospective review of Temple University Hospital trauma database was performed. Patients were categorized by having an isolated rectal (n = 29), isolated bladder (n = 16), or combined injury (n = 24). Records were reviewed for sex, age, site of injury, location of rectal and bladder injuries, operative intervention, fistula formation, urinoma formation, abscess formation, time to urinary catheter removal, length of intensive care unit stay, and length of hospital stay.

RESULTS

Patient sex and age did not differ significantly between groups, nor was there a significant difference in location of rectal injury between groups. Presacral drainage was utilized in all patients with extraperitoneal injuries. Fecal diversion was performed in all patients, except two with intraperitoneal rectal injuries. Omental flap interposition between rectal and bladder injuries was utilized in one patient. No significant difference was noted in immediate postoperative complications between groups including fistula, urinoma, and abscess formation. However, all cases of colovesical fistula (n = 2) and urinoma (n = 2) formation were noted in those patients with rectal and posterior bladder injuries.

CONCLUSIONS

Combined rectal and bladder injuries were not associated with an increase in immediate postoperative complications compared with isolated rectal and bladder injuries. However, postoperative fistula and urinoma formation occurred only in patients with a combined rectal and posterior bladder injury. Consequently, these patients may benefit from omental flap interposition between injuries to decrease fistula and urinoma formation.

Is fecal diversion necessary for nondestructive penetrating extraperitoneal rectal injuries?

BACKGROUND

Current management of penetrating extraperitoneal rectal injury includes diversion of the fecal stream. The purpose of this study is to assess whether nondestructive penetrating extraperitoneal rectal injuries can be managed successfully without diversion of the fecal stream.

METHODS

This study was performed at an urban Level I trauma center during a 28-month period from February 2003 through June 2005. All patients who suffered nondestructive penetrating extraperitoneal rectal injuries were managed with a diagnosis and treatment protocol that excluded fecal stream diversion. Patients were placed in one of two management arms based upon clinical suspicion for intraperitoneal injury. In the first arm, patients with suspicion for rectal injury and a positive clinical examination for intraperitoneal injuries were delivered to the operating room for exploratory laparotomy. Proctoscopy was performed before exploratory laparotomy. Extraperitoneal rectal injuries were left to heal by secondary intention. Intraperitoneal rectal injuries were repaired primarily. Patients did not receive fecal diversion or perineal drainage. In the second management arm, patients with a negative clinical examination for intraperitoneal injury and wounding agent trajectory suspicious for rectal injury underwent diagnostic peritoneal lavage (DPL), cystography, and proctoscopy in the emergency room. Positive DPL or cystography warranted laparotomy as above. Patients with positive proctoscopy alone were admitted and placed on a clear liquid diet. Barium enema was performed 5 to 7 days postinjury for all rectal injuries with diets advanced accordingly.A matched historic control group of rectal injury patients who underwent fecal diversion was compared with the nondiversion protocol group. Patients from both groups were matched for penetrating abdominal trauma index (PATI), age and mechanism of injury.

RESULTS

There were 14 consecutive patients diagnosed with penetrating rectal injury placed in the nondiversion management protocol. Of these, 9 (64%) patients in the nondiversion group required laparotomy. The average age in the diversion historical control group was 30.5 years and 29.3 years in the nondiversion group. The average PATI in the diversion group was 15.3 and 16.1 in the nondiversion protocol group. The average length of stay for the diversion and nondiversion groups was 9.8 days (range, 7-15) and 7.2 days (range, 4-10), respectively. There were no complications associated with rectal injuries in either group.

CONCLUSIONS

Nondestructive penetrating rectal injuries can be managed successfully without fecal diversion. Randomized prospective study will be necessary to assess this management method.

Pediatric anorectal impalement with bladder rupture: case report and review of the literature

Rectal impalement involves foreign body trauma to the anus or rectum resulting in intra- or extraperitoneal rupture. Evaluation of suspected rectal impalement injury involves careful history and physical examination. Ruling out rectal perforation in patients with reported impalement is critical even if there is no evidence of trauma to the perineum. There are few reports on pediatric impalement and only 1 reported case of pediatric rectal impalement with bladder rupture. We report a rectal impalement with extraperitoneal bladder injury in a 12-year-old boy and review the literature on treatment of these injuries.

[Penetrating injuries to the pelvis]

As criminality and weapon use increase, general and military surgeons are increasingly confronted with penetrating pelvic injuries both at home and on peacekeeping missions. Penetrating injuries to the iliac vascular axis are associated with considerable mortality, and thus the majority of these emergency patients arrive in a state of deep hypovolemic shock. Concomitant bowel injuries are present in one of five cases, resulting in contamination of the damaged area. Surgical options are simple lateral repair, ligation of the veins, temporary shunt insertion, and prosthetic graft interposition in the injured artery. In extremis ligation of the common or external iliac artery may be the only option to save the patient's life. Surgeons must be aware that damage control surgery and related methods may be needed early on to enable patient survival.

[Perianal and rectal impalement injuries]

Perianal impalement injuries with or without involvement of the anorectum are rare. Apart from a high variety of injury patterns, there is a multiplicity of diagnostic and therapeutic options. Causes of perianal impalement injury are gunshot, accidents, and medical treatment. The diagnostic work-up includes digital rectal examination followed by rectoscopy and flexible endoscopy under anaesthesia. We propose a new classification for primary extraperitoneal perianal impalement injuries in four stages in which the extension of sphincter and/or rectum injury is of crucial importance. Therapeutic aspects such as wound treatment, enterostomy, drains, and antibiotic treatment are discussed. The proposed classification encompasses recommendations for stage-adapted management and prognosis of these rare injuries.

Colon and rectal injuries

PURPOSE

This study was designed to develop treatment algorithms for colon, rectal, and anal injuries based on the review of relevant literature.

METHODS

Information was obtained through a MEDLINE ( www.nobi.nih.gov/entrez/query.fcgi ) search, and additional references were obtained through cross-referencing key articles cited in these papers.

RESULTS

A total of 203 articles were considered relevant.

CONCLUSIONS

The management of penetrating and blunt colon, rectal, and anal injuries has evolved during the past 150 years. Since the World War II mandate to divert penetrating colon injuries, primary repair or resection and anastomosis have found an increasing role in patients with nondestructive injuries. A critical review of recent literature better defines the role of primary repair and fecal diversion for these injuries and allows for better algorithms for the management of these injuries.

[Current situation of colorectal trauma]

Mortality from colorectal trauma decreased from the end of the 19th Century, when death was the rule, to the 21st Century, when mortality is 5%. The greatest advances were produced during wars, mainly due to improved transport conditions, antisepsis, advances in operating and anesthetic techniques, the management of fluids, blood and blood products, the use of antibiotics, exteriorization of wounds, and the use of colostomy. Injuries to the anus, rectum and colon are infrequent. Their prevalence is difficult to establish because they can be caused by several factors. In Spain, the most frequent causes are traffic accidents and iatrogenic lesions, while in America the most common causes are stab or gunshot wounds. Although the etiology of these injuries is diverse, two major groups of colorectal trauma can be established: accidental injuries and iatrogenic trauma. Clinical symptoms vary, ranging from abdominal, pelvic, perianal or anal pain, sometimes associated with rectorrhagia, to peritonismus or shock. Diagnosis is based on physical and rectal examination and laboratory, radiological, and endoscopic investigations. Laparoscopy can also be used on occasions. Treatment should be individualized, depending on the patient's history, current status, the time elapsed since injury, the status of the injured intestine, the degree of fecal contamination, associated lesions, and the surgeon's experience.

Management of civilian extraperitoneal rectal injuries

OBJECTIVE

The mortality and morbidity of rectal injuries are highly unsatisfactory. We retrospectively reviewed our experience with rectal injuries to draw some practical guidelines for management of such injuries.

METHODS

The medical records of all patients diagnosed at our hospitals with full-thickness rectal injuries between 1994 and 2003 were retrospectively reviewed.

RESULTS

Full-thickness rectal injuries were identified in 23 patients; 19 patients had extraperitoneal injuries and four had both intra- and extraperitoneal injuries. The mean age was 33.5 years (range, 5-73 years). The mechanism of injury was penetrating in 11 patients, blunt in six, impalement in three and iatrogenic in three. Injuries were closed primarily in 17 patients, with variable combinations of adjunct procedures. Eight patients were treated without colostomy. Drainage and rectal washout were performed in 11 and six patients, respectively. Overall, 11 patients developed complications, including eight wound infections and five pelvic septic complications related to the rectal injury. Four of the five pelvic septic complications and all three deaths occurred in patients with shock, at least two associated-organ injuries and more than 6 hours' delay in treatment.

CONCLUSION

Rectal injuries are serious additive mortality and morbidity factors in multi-injured patients. Regardless of treatment modality, wound infection is associated with shock at presentation and more than 6 hours' delay in treatment.

Penetrating rectal trauma: management by anatomic distinction improves outcome

BACKGROUND

Controversy persists regarding the optimal management of penetrating rectal injuries, specifically with respect to the routine application of diversion and presacral drainage. Our previous experience suggested that management decisions based on precise anatomic characterization of injury relative to retroperitoneal involvement might improve outcome. A clinical pathway was developed and implemented. Patients managed by the pathway (PATH) were compared with the previous study (PREV, n=58) to determine the impact of the clinical pathway on outcome.

METHODS

Consecutive patients with full-thickness penetrating rectal injury subsequent to the development of the pathway were evaluated. Intraperitoneal rectal injuries (IP) were treated with primary repair. Injuries to the proximal two-thirds and accessible distal one-third of the extraperitoneal rectum (EP) were treated with repair and selective fecal diversion. Inaccessible distal EP injuries were treated with diversion and presacral drainage. Infectious complications (wound infection, bacteremia, intraabdominal abscess, retroperitoneal abscess) were compared between the PATH and PREV groups.

RESULTS

In all, 54 patients were identified. Demographics, injury severity, and preventive antibiotics (24-hour) were similar between groups. Overall infectious complication rate was 13% in the PATH group versus 31% in the PREV group (p<0.05). There was a zero incidence of retrorectal abscess in the PATH group versus 11% of the total complications in the PREV group.

CONCLUSIONS

Implementation of the pathway resulted in a significant decrease in infectious morbidity. Management by anatomic distinction allows for omission of colostomy in most IP injuries and select EP injuries, while diminishing the risk of retrorectal abscess in EP injuries with the judicious application of presacral drainage.

Diagnostic laparoscopy and diverting sigmoid loop colostomy in the management of civilian extraperitoneal rectal gunshot injuries

Background

This prospective study reviews the management of isolated civilian extraperitoneal rectal gunshot injuries using a protocol of diagnostic laparoscopy and abdominal wall trephine diverting loop colostomy, without laparotomy, distal rectal washout and presacral drainage.

Methods

Patients admitted to the trauma unit at Groote Schuur Hospital between January 2000 and December 2002 with a rectal injury were evaluated. A rectal injury was confirmed by digital rectal examination and proctosigmoidoscopy. Missile peritoneal violation was excluded by diagnostic laparoscopy. Normal laparoscopy was followed by creation of a diverting sigmoid loop colostomy through an abdominal wall trephine, without a laparotomy. No distal rectal washout or presacral drainage was performed.

Results

Of the 104 patients admitted with 106 rectal injuries, 20 (19·2 per cent) qualified for inclusion in the study. All had sustained low-velocity gunshot injuries of which 18 exhibited a transpelvic trajectory. Diagnostic laparoscopy was normal and a trephine diverting loop sigmoid colostomy was performed in all 20 patients. No pelvic sepsis occurred. Two patients developed rectocutaneous fistulas, both of which resolved without surgical treatment. Nineteen stomas have since been closed.

Conclusion

Low-velocity gunshot injuries isolated to the extraperitoneal rectum can be managed safely by laparoscopic exclusion of intraperitoneal missile penetration and diverting sigmoid loop colostomy, without laparotomy, distal rectal washout or presacral drainage

Pathophysiology and management of bowel and mesenteric injuries due to blunt trauma

Injuries to the bowel and mesentery are uncommon in blunt trauma and rarely occur in isolation. Delay to diagnosis has a significant impact on morbidity and mortality. The literature tends to focus on the diagnosis of hollow viscus and mesenteric injury, with little written on its management. Studies are usually retrospective with a paucity of comparative trials. The use of computerized tomography (CT) scanning in blunt abdominal trauma has overshadowed other reports. Early-generation scanners had a relatively poor sensitivity in detecting bowel-related injuries, but the CT scan is now the primary modality for imaging stable patients. However radiological signs can be subtle and should be regarded as complementary to meticulous clinical assessment.