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     

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.     

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.     

Operative Management of Civilian Rectal Gunshot Wounds: Simpler Is Better

Extraperitoneal rectal gunshot wounds have been managed with a variety of methods from simple diverting colostomy to combinations of rectal repair, proximal diversion, transperitoneal or presacral drainage, and distal bowel irrigation techniques. Treatment methodology is chosen based on anecdotal experience, and there is no clear evidence that any technique is superior to the others. The objective of this study was to compare 3 methods of managing civilian extraperitoneal gunshot wounds. Retrospective analysis of 30 consecutive patients with extraperitoneal rectal gunshot wounds was undertaken. Patients were treated with 1 of these 3 techniques: (1) simple diverting colostomy without rectal repair (group A, 12 patients); (2) diverting colostomy and rectal repair (group B, 12 patients); and (3) diverting colostomy and presacral drainage without repair (group C, 6 patients). Injury, hospital course, and outcome data were compared. The 3 groups were similar in age, injury severity, admission hemodynamics, preoperative and intraoperative time, blood loss, fecal contamination, and associated injuries. The overall incidence of complications was 27% (8/27): 25% (3/12) in group A, 33% (4/12) in group B, and 17% (1/6) in group C (p= NS). Complications directly associated with the rectal injury were found in 2 cases (7%): 1 group A patient developed a vesicorectal fistula and 1 group B patient developed a rectocutaneous fistula. For 10 patients with both rectal and bladder injuries, the complication rates for groups A, B, and C were 50%, 20%, and 0%, respectively (p= NS). No patient died. In conclusion, diverting colostomy without rectal repair or drainage appears to be safe for the management of most civilian retroperitoneal rectal gunshot wounds. Additional surgical maneuvers may be required for combined rectal and urinary trauma or other complex rectal injuries. Sound surgical principles, tailored to the individual case, should overrule any unproven dogmas.     

Management of rectal injuries. Dogma versus practice

The current treatment of civilian rectal injuries stems from military practice. Five principles have evolved: 1) complete fecal diversion, 2) debridement and closure, 3) rectal stump irrigation, 4) presacral drainage, and 5) broad spectrum antibiotics. To assess our practice results, the records of 52 consecutive patients with rectal injury seen at Detroit Receiving Hospital from 1980-88 were reviewed. Etiologies were gunshot (40), shotgun (9), anal assault (2), and stab (1). There were no blunt injuries and no deaths. Treatment consisted of celiotomy (52), diverting colostomy (51), presacral drains (35), rectal stump irrigation (26), and primary closure (1). Broad spectrum antibiotics were administered in all patients. Despite lack of universal application of the "standard" principles, only five patients had postoperative complications and none were related to the rectal injury. Our results demonstrate that a single approach may not be justified, as excellent outcome was achieved with low morbidity and no mortality despite selective management. The universal application of colostomy, repair, irrigation, drainage, and antibiotics cannot be supported.     

Colostomy and drainage for civilian rectal injuries: is that all?

One hundred consecutive patients with injuries to the extraperitoneal rectum were treated over a ten-year period at an urban trauma center. The mechanisms of injury included firearms in 82 patients, stab wounds in 3 patients, a variety of other penetrating injuries in 10 patients, and in 5 patients the injuries resulted from blunt trauma. Treatment of the rectal injury was determined by the bias of the operating surgeon, the condition of the patient, and the magnitude of the rectal injury. Proximal loop colostomies were performed in 44 patients, diverting colostomies in 51 patients, Hartmann's procedure in 4 patients, and an abdominoperineal resection in 1 patient. Extraperitoneal rectal perforations were closed in 21 patients and the rectum was irrigated free of feces in 46 patients. Transperineal, presacral drainage was used in 93 patients. Infectious complications potentially related to the management of the rectal wound occurred in 11 patients (11%) and included abdominal or pelvic abscesses (4 patients), wound infections (6 patients), rectocutaneous fistulas (3 patients), and missile tract infections (2 patients). Four patients (4%) died as a result of their injuries. Of the therapeutic options available, statistical analysis revealed that only the failure to drain the presacral space increased the likelihood of infectious complications (p = 0.03); however, as it could not be determined with certainty that the use of, or failure to use, any particular therapeutic option had an effect on the risk of death. It is concluded that colostomy and drainage are the foundations of the successful treatment of civilian injuries to the extraperitoneal rectum. The use of adjuncts such as diverting colostomies, repair of the rectal wound, and irrigation of the rectum has little effect on mortality and morbidity.     

Diagnostic and therapeutic aspects of rectal trauma. Blunt versus penetrating

In the last 6 years, nine patients with blunt and 16 with penetrating rectal injuries were treated at University Hospital, Jacksonville, Florida. Blunt trauma was caused by vehicular accidents in seven patients and crush injuries in two. Penetrating rectal trauma was due to gunshot wounds in ten patients and foreign body insertion in six. All patients with blunt injury had bright red rectal bleeding, which led to diagnostic sigmoidoscopy. Rectal injury was identified at sigmoidoscopy in 12 patients who had penetrating wounds and at laparotomy in four patients. Thirteen patients who had penetrating rectal trauma had injury to only the rectum or to one additional organ. In contrast, all patients who had blunt rectal trauma had at least three associated injuries. In the penetrating group, 13 patients were treated by colostomy and mucus fistula; three patients with mucosal injury were managed nonoperatively. The only death occurred in a patient whose rectal injury was initially missed. Patients who had blunt rectal trauma were managed with colostomy and mucus fistula. Three patients died postoperatively, two of pelvic bleeding and one of head injury. Hemodynamic stabilization, colostomy and mucus fistula, presacral drainage, and rectal washout constitute proper treatment of patients with blunt or penetrating rectal trauma. Because of the greater number and severity of associated injuries, morbidity and mortality are higher after blunt rectal trauma.     

Anorectal avulsion: an unusual rectal injury

Traumatic injuries to the rectum although uncommon can result in virulent complications and even death. Diverting colostomy, presacral drainage, distal wash out and rectal repair, when feasible, have become the standard treatment for rectal injuries. We report an unusual case of rectal injury resulting in anorectal avulsion from skin and surrounding tissues.     

Management of rectal injuries

We have reviewed the management of twentynine casualties with rectal injuries terated in Vietnam. A high incidence of virulent complications and a 22.2 per cent mortality occurred in eighteen casualties treated by conventional means with a divided sigmoid colostomy, rectal repair when feasible, and presacral drainage. The complications and deaths were invariably related to pelvic sepsis. Distal washout to prevent continued contamination from fecal material remaining in the defunctionalized rectosigmoid was employed in ten casualties in addition to the conventional measures. This resulted in a striking reduction in complications and no mortality. We also stress the importance of prompt diagnosis, direct control of hemorrhage, proper management of associated injuries, and adequate debridement.     

严重骨盆骨折合并毗邻脏器损伤的救治

目的探讨严重骨盆骨折合并毗邻脏器损伤的急诊处理方法。方法对14年中收治的79例严重骨盆骨折合并毗邻脏器损伤患者的资料做回顾性分析。结果骨盆大出血行髂内动脉结扎术33例、栓塞术8例;膀胱造口和后期尿道重建35例、尿道会师术7例;腹膜外直肠伤做结肠造口并骶前引流13例、一期修补4例;腹膜内结直肠伤一期手术19例、结肠造口3例。死亡率9％(7／79),主要死于休克和合并伤。共发生并发症7例：直肠膀胱瘘4例、右髂总动脉血栓形成1例、胸伤后急性呼吸窘迫综合征(ARDS)1例、截瘫1例,除截瘫均治愈。结论迅速准确的诊断治疗是成功的关键。髂内动脉断血术配合骨盆外固定支架的使用、膀胱造口和乙状结肠近端造口,是危重患者急诊治疗时常采用的有效方法。     

Management of rectal trauma

A 9 year review of rectal trauma was conducted. Forty-seven patients had major rectal trauma requiring diversion. Twenty-seven percent of patients presented in shock. Routine perioperative antibiotics were administered. Ninety-five percent of patients had positive findings on digital rectal examination or proctoscopy. There were 91 associated injuries. Rectal injuries were repaired in 19 patients. The absence of repair had no influence on postoperative morbidity or length of hospital stay. Ninety-five percent of patients had presacral drainage. One patient had distal rectal irrigation. Both loop and divided colostomies were utilized with no difference in morbidity or hospital stay. There were no deaths. Proctoscopy is essential in patients with wounds in proximity to the rectum. Diversion and presacral drainage for rectal injury is associated with a low mortality and acceptable morbidity. Rectal washout does not appear to be essential in civilian rectal injuries.     

Management of severe pelvic fracture associated with injuries of adjacent viscera

everepelvicfractureassociatedwithinjuriesofadjacentviscerahasahighmortality .Thefirst”goldenhour”aftertraumashouldbegrasped ,sincethemanagementinthishourcandeterminegreatlywhetherthecritically injuredvictimcouldsurvive .Inthispaper ,theexperienceintheemergencymanagementofsuch patientsisreviewedinordertoimprovethetherapeuticoutcome .METHODSSeventyninepatientswithseverepelvicfractureassociatedwithinjuriesofadjacentvisceratreatedinourDepartmentfromJanuary 1990toDecember 2 0 0 3werereviewedr…     

COLORECTAL INJURY: WHERE DO WE STAND WITH REPAIR?

Background: The chief danger of colonic injury is sepsis resulting from faecal spill. Primary repair is now well established in the USA, particularly for penetrating injuries, in up to 81% of patients. However, in Australia, highly destructive blunt trauma forms a larger proportion of injuries, and the purpose of this study was to determine if there are any contrasts in the management of these patients. Method: A retrospective survey was undertaken over the past 20 years of all of the patients with full-thickness colorectal injuries presenting at the three major hospitals which receive multi-trauma patients in Brisbane. Results: Of 112 patients 114 sustained full-thickness colorectal injuries. Forty patients had penetrating injuries, 41 had blunt injuries and 33 had iatrogenic injuries. Primary repair or resection and anastomosis was performed in 39% of patients with colonic injuries and the leak rate was 8%. Exteriorized repairs had a 67% leak rate. A colostomy was used in 58% of patients. The mortality for penetrating injuries was zero. The mortality for blunt colonic injuries was 17% and for iatrogenic injuries was 7% but for blunt rectal injuries was 50%. The overall mortality was 10%. Colostomy closure had a 20% morbidity but no mortality. Conclusions: In the absence of shock, associated injuries, or gross faecal soiling primary repair or resection with anastomosis may be considered. For blunt injury, colostomy is still usually indicated, often with resection. For iatrogenic injury, when seen early, primary repair can be performed. We do not recommend exteriorized repair. Extraperitoneal rectal injuries require proximal colostomy and distal washout, with drainage where appropriate. Blunt devitalizing injury is relatively more common in Australia than in the USA and therefore there is less indication here for primary repair. Colostomy remains an important consideration in operative management.     

Radiation-Induced Rectal Cancer Originating from a Rectocutaneous Fistula: Report of a Case

This report describes a patient with radiation-induced rectal cancer with an unusual history. A 51-year-old man was admitted in 2000 because of ichorrhea of the skin on the left loin. The patient had received irradiation for a suspicious diagnosis of a malignant tumor in the pelvic cavity in 1975. A subcutaneous abscess in the right loin appeared in 1989, and rectocutaneous fistula was noted in 1992. Moreover, radiation-induced rectal cancer developed in 2000. Plain computed tomography and magnetic resonance imaging of the pelvis demonstrated a presacral mass and tumor in the rectum. Finally, we diagnosed the presacral mass to be an abscess attached to the center of the rectal cancer. The rectum was resected by Miles operation and a colostomy of the sigmoid colon was also performed. Many cases of radiation-induced rectal cancer have been reported. However, this is a rare case of radiation-induced rectal cancer originating from a presacral abscess and rectocutaneous fistula.     

结直肠损伤的手术治疗：附125例报告

目的:探讨结直肠损伤的手术治疗和围手术期处理。 方法:回顾性分析19年间收治的125例结直肠损伤患者的临床资料。结果:结肠和腹膜内直肠破裂69例中，初期缝合或切除吻合56例（81.16 %），行造口术11例，“损伤控制外科”术式2例。腹膜外直肠破裂18例中，14例行乙状结肠近端造口并骶前引流，4例一期修补未造口;其余38例非全层损伤患者，均做简单修补。全组死亡8例（6.40 %），6例术中、1例术后死于失血性休克，1例术后5 d死于胸腔感染。术后并发症包括局部感染6例、粘连性肠梗阻1例，均治愈。 结论:多数结肠和腹膜内直肠损伤可一期手术，应配合围手术期正确使用抗生素尤其甲硝唑。腹膜外直肠伤应分期手术，为阻断远端污染，应行乙状结肠近端造口而不选择襻式造口。     

Same admission colostomy closure (SACC). A new approach to rectal wounds: a prospective study.

OBJECTIVE: The purposes of this project were to study the healing of protected rectal wounds (RWs) using contrast enemas (CEs) and to establish the safety of same admission colostomy closure (SACC) in terms of colostomy closure (CC) and rectal wound-related outcomes, for selected patients with radiologically healed RWs. SUMMARY BACKGROUND DATA: Traditional treatment of RWs has included a diverting colostomy that is closed 2 or more months later during a readmission. METHODS: All patients admitted with a rectal injury were entered into this prospective study, treated with a diverting colostomy and presacral drainage, and managed according to a postoperative protocol that included a CE per anus to detect healing of the RW. Patients with no leaking on their first CE, no infection, and anal continence underwent SACC. RESULTS: From 1990 to 1993, 30 consecutive patients had rectal injuries, 90% of which resulted from gunshot wounds. The first CE was performed in 29 patients 5 to 10 days after injury. In this group, 21 patients did not and 8 did have leakage from their RWs. The proportions of RWs radiologically healed at 7 and 10 days after injury were 55.2% and 75%, respectively. Sixteen patients with a normal CE underwent SACC 9 to 19 days after injury (mean, 12.4 days). There were two fecal fistulas (2 of 7; 28.6%) after simple suture closure, none (0 of 9) after resection of the stoma with end-to-end anastomosis, and no RW-related complications after SACC. The mean hospitalization time was 17.4 days. CONCLUSIONS: The following conclusions were drawn: (1) CE confirmed healing of RWs in 75% of patients by 10 days after injury; (2) 60% of patients with RWs were candidates for SACC, and 53% were discharged with their colostomies closed; (3) SACC was performed without complications in 87.5% of patients with radiologically healed RWs; and (4) there were no RW-related complications after SACC.     

Value of distal colon washout in civilian rectal trauma--reducing gut bacterial translocation

Recent experience with civilian rectal trauma challenges the military dictum advocating routine distal colon washout. Opponents contend that septic morbidity is not influenced by perioperative removal of feces from the rectosigmoid region. In an effort to elucidate this issue, we reviewed 27 consecutive patients sustaining extraperitoneal rectal trauma over the past 5 years. One patient, exsanguinating from abdominal vascular injury, was excluded from further analysis. In the remaining 26 patients, rectal injury was due to gunshot wound in 16 (62%), pelvic fracture in 8 (31%), and stab wound in 2 (7%). The mean Revised Trauma Score was 6.9 +/- 0.4, Abdominal Trauma Index 20.9 +/- 8.1, and Injury Severity Score 28.6 +/- 11.0. Proximal colostomy was done in all patients and presacral drains were placed in 23 (88%). Broad-spectrum antibiotics were administered for a minimum of 5 days. Thirteen (50%) of the group underwent intraoperative washout of the distal rectosigmoid colon, dictated by attending surgeon's preference; the other half did not. These two groups were otherwise comparable with respect to injury mechanism, shock on arrival, rectal wound severity, associated injuries, and perioperative blood transfusions. Major complications were greater in the no-washout versus washout groups: pelvic abscess, 46% vs. 8%; rectal fistulae, 23% vs. 8%; and sepsis, 15% vs. 8%. The single death (4%) occurred in the no-washout group. Although based on a small group of patients, these trends imply that distal colon washout reduces septic morbidity following civilian rectal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)     

Primary repair of the colon: when is it a safe alternative?

Management of civilian colon injuries has clearly departed from the military directive advocating mandatory colostomy. The treatment of 228 colon injuries at the Denver General Hospital was reviewed to elucidate risk factors for colon-related complications and quantify the morbidity of available surgical treatment options. In our population, 68% of patients sustained gunshot wounds with a high percentage of severe colon injuries and associated abdominal organ damage. Primary repair was accomplished in 49% with 17% septic morbidity and 1% septic mortality rates. Colostomy was required in 36% with a cumulative septic morbidity of 48% and 2% septic mortality. The most common complications were abdominal abscess (12%), wound infection (7%), and fecal fistula (4%). Analysis of risk factors for colon-related morbidity showed that the Abdominal Trauma Index (ATI), colon injury severity, preoperative shock, and peritoneal contamination were most important. Synthesis of the treatment outcome and risk factor data yields a proposed management scheme for colon injuries that is based on the patient's hemodynamic status, colon injury severity, and ATI scores. Primary repair by either debridement and simple closure or resection with primary anastomosis is advocated for colon injuries in patients who are hemodynamically stable with an ATI score less than 25.     

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.     

A new approach to extraperitoneal rectal injuries: laparoscopy and diverting loop sigmoid colostomy

BACKGROUND: Current management of extraperitoneal rectal injuries involves a laparotomy and diversion of the fecal stream. In this study, we review our experience with laparoscopy and diverting loop sigmoid colostomy without laparotomy in the management of these injuries. METHODS: All patients admitted to the trauma unit at Groote Schuur Hospital between January 1995 and May 2000 with a rectal injury were evaluated. The presence of a rectal injury was confirmed by rectal examination and proctosigmoidoscopy. Intraperitoneal injuries were excluded by laparoscopy. Only patients who did not have intraperitoneal injuries were included in the study. The patients were then managed with a diverting loop sigmoid colostomy created through an abdominal wall trephine without laparotomy. RESULTS: Ten patients were included in the study. In eight patients, laparoscopy excluded intraperitoneal injuries. All 10 patients had a diverting loop sigmoid colostomy fashioned. There were no complications related to either the rectal injury or colostomy. Nine stomas have since been closed. CONCLUSION: In patients with isolated extraperitoneal rectal injuries, laparoscopic exclusion of intraperitoneal injuries, followed by a diverting loop sigmoid colostomy, is a feasible option.