Choice of treatment methods in extraperitoneal injuries of the rectum

From experience in the treatment of 202 patients with extraperitoneal injury to the rectum, the authors suggest that the choice of the method of management should be based on strict consideration for the etiology, the degree of injury to the rectal wall, the location of the injury, and the presence of early and late-term complications. Various methods of treatment are recommended depending on the character of the injury. Treatment in this case must be strictly individual. Thoroughness of surgical debridement, timely formation of colostomy, and correct choice of the time for plastic operations are also very important. With adherence to the suggested conditions for the choice of the method of treatment good results were produced in all patients.     

Successful management of trifurcation injuries

Vascular injuries to the distal popliteal artery and its primary division(s) (trifurcation) combined with fracture(s) were analyzed for the years 1978 to 1983 at the Charity Hospital of Louisiana at New Orleans and Tulane Medical Center affiliates. This article does not include reports of isolated popliteal artery injuries. Thirty-six male patients with a mean age of 24 (16 to 47) years experienced 20 tibiofibular fractures and 16 tibial plateau fractures. Twenty-four injuries were secondary to penetrating trauma; the remaining 12 vascular injuries were the result of blunt trauma. All patients were angiographed preoperatively, resuscitated, treated with tetanus toxoid and antibiotics, and brought to the operating room in an average of 95 (30 to 244) minutes from entry to the emergency departments. Eight (22%) definitive below-knee amputations (BKA) (six [17%] with blunt trauma) and 28 (78%) reconstructive procedures were done initially. Twenty-four of the 28 (86%) patients had associated venous injury; 16 were repaired. Twenty of the 28 (71%) patients received fasciotomies There were eight late amputations in addition to the eight early definitive BKA; five secondary to related neurologic injury. Twenty of the 28 (71%) patients had successful repair of their arterial injury and total rehabilitation.     

Perforations of the extraperitoneal rectum during barium enema

Rectal injuries during barium enema are uncommon but not unusual complications. Radiologists and surgeons must be able to recognize them, as early diagnosis is essential for effective treatment. The Authors discuss various aspects of problems arising from rectal perforation, and report their experience on seven cases.     

Social injuries of the rectum

Eleven patients with injuries of the rectum and sigmoid colon secondary to the insertion of the clenched fist are presented. Six patients sustained mucosal lacerations of the rectum and four patients had rectosigmoid perforations requiring laparotomy. One patient sustained a severe sphincter laceration producing complete anal incontinence. The management of these conditions is discussed.     

Successful atrial caval shunting in the management of retrohepatic venous injuries

Over a 3-year period, 519 patients underwent laparotomy for liver injuries. Nine (2 percent) required insertion of an atrial caval catheter to control hemorrhage from perihepatic venous injuries. In three cases, the shunt arrested the hemorrhage, allowing successful surgical repair of the venous injuries. From a careful analysis of our experience, we have identified common errors made in shunt placement, developed a modified atrial caval catheter, and have simplified the surgical technique for insertion.     

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.     

Neoplasia of the extraperitoneal rectum and anus. The perineal dilemma

A retrospective analysis was undertaken of 113 patients with biopsy-proven neoplasia of the extraperitoneal rectum and anus occurring between 1970 and 1975. Common initial symptoms included bleeding, constipation, and diarrhea; colon obstruction was the initial symptom in only ten cases. Adenocarcinoma occurred in 90 per cent of cases while lesions such as epidermoid cancer, carcinoid, and melanoma were encountered rarely. Operative treatment consisted of abdominoperineal resection (APR) in 60 cases, colostomy alone in 26 cases, anterior resection 13 cases, and electrocoagulation in four cases. Ten patients refused operative therapy. Of patients undergoing APR, 7 per cent died in the perioperative period. Postoperative morbidity included infection, impotence, bladder dysfunction, and perineal complications. The single most important factor contributing to this high morbidity was perineal wound management: 34 patients managed by the open method sustained a 47 per cent complication rate while the 26 patients with closed and adequately drained wounds had only a 15 per cent complication rate.     

Foreign bodies and injuries of the rectum

Personal experience of 33 cases of foreign rectal bodies introduced transanally with or without associated lesions is reported. After examining the principles of diagnosis, stress is laid on therapy and personal experience and it is suggested that more energy should be applied to extracting the foreign body transanally even using more or less deep anaesthesia, so avoiding the need for abdominal surgery.     

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     

Surgical treatment of extraperitoneal rectal and perineal injuries

The aim of this study was to analyse the results of the treatment of extraperitoneal rectal and perineal injuries for 153 patients. All the patients were examined according to the scheme. Therapeutic-diagnostic algorithm was developed for perineal, anal, rectal injuries. Wide opening and drainage of the wound was used. The method allows to avoid colostomy and its subsequent operative closing in extraperitoneal injury of the rectum. The method of surgical treatment is recommended in extraperitoneal rectal and perineal injuries.