Management Of Penetrating Rectal Injuries
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.
Management of Penetrating 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.
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.
A trial by Gonzalez et al treated 14 patients with nondestructive, penetrating extraperitoneal rectal injury without fecal diversion and reported no complications or mortality.36Extrapolation from nontrauma data would suggest the viability of nondiversion for rectal trauma. Penetrating, extraperitoneal rectal injuries are analogous to a supralevator abscess that is drained trans-anally, allowing preferential drainage into the rectum. Similarly, patients with rectal tumors undergoing full-thickness excision via trans-anal minimally invasive surgery do not require fecal diversion for successful healing.3738Definitive management algorithms regarding fecal diversion for extraperitoneal rectal injuries remain lacking, pending an appropriately designed clinical trial.
The treatment of rectal trauma comes with multiple nuances and potentially devastating outcomes if managed incorrectly. Correctly and most efficiently identifying injuries, and treating them appropriately lead to the best overall patients outcomes. This activity reviews the evaluation and treatment of rectal traumas and highlights the role of the interprofessional team in evaluating and treating patients with this condition.
Objectives:Identify the etiology of blunt and penetrating rectal trauma.Summarize treatment considerations for patients with blunt and penetrating rectal trauma.Review the classic history and presentation associated with rectal trauma. Explain the importance of collaboration and communication amongst an interprofessional team to accurately diagnose, treat, and manage rectal injuries in a trauma scenario.Access free multiple choice questions on this topic.
In 1979 Stone and Fabian published the first randomized prospective trial comparing primary repair and diversion; this marked the evolution of the management of colorectal injuries. Over the next two decades, multiple studies reinforced that primary repair or resection and anastomosis was the standard of care for most colorectal injuries, and extraperitoneal rectal injuries should have management with selective fecal diversion.
The majority of rectal injuries are secondary to penetrating trauma, excluding iatrogenic, sex-related, and foreign body injuries. Gunshot wounds compose 85 to 90% and stab wounds approximately 5%. Approximately 5 to 10% are secondary to blunt trauma of which 1 to 2% are associated with pelvic fractures, most specifically anterior-posterior compression.[4][5][6][7]
The incidence of rectal trauma in civilian trauma centers is 1 to 3%, and in recent military conflict, up to 5%. The military rectal wounds involve much higher velocity weaponry, blast injuries, fragmentations, and burns.[8]
Decision making for management of rectal injuries has as its basis intraperitoneal and extra-peritoneal zones and the Rectum Injury Scale of the American Association for the Surgery of Trauma (image attached below).[9]
The primary survey is designed to identify immediate life-threatening injuries quickly. Therefore, the universal approach has been established by the ATLS to follow the following in specific order: airway maintenance, breathing (ventilation), circulation (including hemorrhage control), disability (neurologic status), and exposure. Airway assessment and management have the highest priority of any injured patient irrespective of mechanism or wound location.[10] This cannot be overemphasized, to first secure or ensure a patent airway, before proceeding methodically, in appropriate order through the ATLS protocol.
During the primary survey, complete exposure of the patient is essential, as is to roll the patient potentially to both sides, as to not overlook penetrating injuries that may not be easily identifiable when lying in a supine position. The assessment includes an examination of the perineum, buttocks, and lower gluteal, anal, or groin folds (as is vital to examine the patients back, flanks, and axilla).
Recognition of rectal injuries requires a high level of suspicion in those evaluating any patient with a penetrating wound. This suspicion should increase with any identification of penetrating wounds to the lower abdomen, pelvis, perineum, buttocks, or thighs. Penetrating wounds should be counted and marked (one approach is a simple paper clip gets taped adjacent to the penetration site) to help physicians hypothesize missile projection. If the count is an odd number of penetrating wounds, the physician should have heightened suspicion that a foreign body may remain in the victim.
In the diagnostic assessment of a trauma patient, bedside ultrasonography in the form of the focused assessment with sonography for trauma (FAST) examination is considered standard of care. This diagnostic modality allows the operator to perform evaluations simultaneously during the primary of the initial assessment, as outlined above. Of the four views, the suprapubic location with visualization of the pelvic cul de sac requires inspection with a concern of penetrating rectal trauma. The presence of fluid in this window may indicate intra-abdominal hemorrhage, hollow viscus injury, hemoperitoneum, or ascites. A threshold of at least 200mL of fluid is necessary for the detection of fluid within the intra-abdominal cavity. Most recently, a FAST exam is noted to have a sensitivity of 69.8% and a specificity of 92.1%.[11] Positive findings in a stable patient can be evaluated further with CT. In contrast, positive findings in an unstable patient necessitate the surgeon to take the patient to the operating room for emergent abdominal exploration.
Prio practice was that all patients where there was a concern of penetrating rectal injury should undergo a digital rectal exam during the secondary trauma survey; this, however, has raised controversy and recently been called into question. Digital rectal examination is, however, not supported due to low sensitivity, approximately 51% of this test being inadequate to effectively rule out injury, coupled with significant risk for enlargening rectal perforation with a blind examination.[12][13][14][15] The physician, however, may attempt to directly visualize rectal injury with a higher yield modality, such as intraoperative examination with proctosigmoidoscopy. A senior-level physician who is familiar with proctosigmoidoscopy should perform this exam. If the location of the injury is not identifiable, blood seen on rigid proctosigmoidoscopy has been determined to have a sensitivity as high as 90% for the diagnosis of rectal injury.[16]
For the hemodynamically stable patient, the rectal injury is repaired based on the anatomy of the wound.[19] The rectum is partially intraperitoneal (anterior and lateral surfaces of the upper two-thirds, and partly extraperitoneal (posterior surface, and circumferential lower one-third). The management of intra-peritoneal wounds is the same as colon injuries. Primary repair with or without proximal diversion. The patient should also receive broad-spectrum antibiotics covering gram-negative and anaerobes for 24 hours. If the injury is nondestructive (less than 50% of the circumference of the intraperitoneal rectum), it can undergo repair. If the wound is destructive (greater than 50% circumferential involvement), the rectum requires resection to viable, healthy tissue and re-anastomosed.
Over the last several decades, there have been multiple studies showing that fecal diversion is not necessary, except in the setting of various transfusion requirements or hypotension. In 1979 Stone and Fabian performed a randomized prospective trial comparing primary repair of colon injuries versus colostomy creation and found equivalent infection (48% vs. 57% p>0.05) and mortality rates (1.5% vs. 1.4% p>50). This historical study revolutionized the management of colorectal trauma. In 2001, the American Association for the Surgery of Trauma conducted a prospective multicenter study on penetrating colon injuries, comparing diversion or primary repair. This study demonstrated lower mortality in the primary repair arm (0% vs. 1.3%).[9] A 2009 Cochrane review examined six randomized trials on colon injuries comparing primary repair versus fecal diversion from 1975 to 2002. [20] This also revealed a significantly lower rate of wound complication and infection with primary repair.
In 2006, Gonzalez did a trial of 14 patients with nondestructive rectal trauma without fecal diversion and had no complications or mortality.[26] If one compares nondestructive rectal injuries in the non-trauma world, such as draining pelvic abscess of the rectum, excising rectal tumor trans-anally, or draining supra levator abscess via the rectum, none of these procedures require a fecal diversion.[27][28]
For destructive extraperitoneal rectal trauma (greater than 50% circumferential involvement), associated pelvic fractures, or concomitant vascular injuries that can compromise the blood supply to the rectum causing anastomotic failure; fecal diversion would be a safe alternative. With regards to presacral drainage and distal washout, these procedures were established during the Vietnam Conflict and published in 1971 by Lavenson and Cohen. Over the past several decades, there have been numerous studies demonstrating no benefit in presacral drainage or distal rectal washout. For extraperitoneal rectal injuries, there is controversy over fecal diversion, presacral drainage, and distal rectal washout. The Eastern Association of the Surgery of Trauma (EAST) recently published guidelines on fecal diversion for extraperitoneal rectal trauma despite finding the quality of evidence to be weak, and conditionally recommended proximal diversion.[20] The Eastern Association of the Surgery of Trauma practice management guidelines on nondestructive penetrating extraperitoneal rectal injuries also conditionally recommended not performing rectal washout or pre-sacral drainage.[20] 041b061a72