Management of civilian extraperitoneal rectal injuries

Trauma de recto penetrante: revisión de tema

Introducción. En la actualidad, el trauma de recto continúa siendo una situación clínica compleja y temida por ser potencialmente mortal. Su detección y manejo temprano es la piedra angular para impactar tanto en la mortalidad como en la morbilidad de los pacientes. Hoy en día, aun existe debate sobre la aproximación quirúrgica ideal en el trauma de recto y las decisiones de manejo intraoperatorias se ven enormemente afectadas por la experiencia y preferencias del cirujano. Métodos. Se realizó una búsqueda de la literatura en las bases de datos de PubMed, Clinical Key, Google Scholar y SciELO utilizando las palabras claves descritas y se seleccionaron los artículos mas relevantes publicados en los últimos 20 años; se tuvieron en cuenta los artículos escritos en ingles y español. Discusión. El recto es el órgano menos frecuentemente lesionado en trauma, sin embargo, las implicaciones clínicas que conlleva pasar por alto este tipo de lesiones pueden ser devastadoras para el paciente. Las opciones para el diagnóstico incluyen el tacto rectal, la tomografía computarizada y la rectosigmoidoscopia. El manejo quirúrgico va a depender de la localización, el grado de la lesión y las lesiones asociadas. Conclusión. El conocimiento de la anatomía, el mecanismo de trauma y las lesiones asociadas permitirán al cirujano realizar una aproximación clínico-quirúrgica adecuada que lleve a desenlaces clínicos óptimos de los pacientes que se presentan con trauma de recto.

Penetrating injury caused by a long iron bar: A case report

Foreign bodies that strike the body with their long edges can cause severe problems. From the hospitalization of the patients to the removal of the foreign body and from surgery to follow-up, working as a team in a well-organized manner is necessary. In the present research, we present our experience, including the hospitalization, initial assessment by the emergency team, examination, and treatment plan, of a pediatric patient who had a 12-m long iron bar that traversed from the right side of the anus to the loin; this impalement happened while the patient was sliding through a snow-covered street, and the patient had to wait on the snow until the fire department arrived and cut the iron bar.

Single-Contrast CT for Detecting Bowel Injuries in Penetrating Abdominopelvic Trauma

OBJECTIVE

Many centers advocate use of triple-contrast (IV, oral, and rectal) CT for assessing hemodynamically stable patients with penetrating abdominopelvic trauma. Enteric contrast material has several disadvantages, leading our practice to pursue use of single-contrast (IV) CT. We conducted a retrospective review of electronic medical records at our institution to assess the accuracy of single-contrast CT for diagnosing bowel injuries in cases of penetrating abdominopelvic trauma.

MATERIALS AND METHODS

We retrospectively reviewed patients who presented to our emergency department between January 1, 2004, and March 1, 2014, with penetrating abdominopelvic trauma, underwent an abdominopelvic CT, and had surgery performed thereafter. We reviewed pertinent emergency department records for details regarding the site of injury, the number of injuries per patient, and the type of weapon used. We correlated CT reports with operative notes for presence and sites of bowel injury.

RESULTS

A total of 274 patients (median age, 27 years old) met our inclusion criteria; 77% had sustained gunshot wounds (GSWs). CT showed bowel injury in 173 cases; surgery revealed bowel injury in 162 cases. CT had 142 true-positive, 31 false-positive, 81 true-negative, and 20 false-negative cases, resulting in sensitivity of 88%, specificity of 72%, positive predictive value of 82%, and negative predictive value of 80% for detecting bowel injuries. CT had the highest sensitivity and specificity in patients with multiple GSWs (94% and 79%, respectively) and those with injuries to the stomach and rectum.

CONCLUSION

Single-contrast CT can show bowel injuries in patients with penetrating abdominopelvic trauma with accuracy comparable with that reported for triple-contrast CT.

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.

Penetrating injury of the vagina, bladder and omentum in a woman with 5 months gestation: case report and review of the literature

Intra-peritoneal bladder and visceral injuries from impalement of the perineum in women are exceedingly rare. This kind of injury has not been previously reported in a pregnant woman. The evaluation and surgical management of a pregnant woman is a challenging surgical problem. Preoperative evaluation of the uterus and fetus is balanced with minimal use of radiographic studies. Multiple organs can be damaged with this type of injury, necessitating careful evaluation and operative planning. We report a rare case of transvaginal impalement injury with through-and-through bladder rupture and intra-peritoneal injury in a 5 months pregnant woman. We discuss diagnostic and management strategies and review the literature.

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.

Rectum perforation after broomstick impalement in a 17-year-old: case report and review

Impalement injuries are uncommon, especially in the pediatric population. Because of the rarity of these injuries, physicians may have difficulty recognizing and treating impalement injuries appropriately. Clinical findings are sometimes innocuous, but can be life threatening. Therefore, evaluation of suspected impalement injury should involve careful history and thorough physical examination, even if there is no evidence of trauma to the perineum. We report a very rare case of rectum perforation after transanal introduction of a broomstick with almost no clinical findings. Impalement injuries are difficult to recognize, and severity may not be reflected by their external appearance. To diagnose these injuries in time, it is important to use a well-organized workup.

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.

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.

The significance of penetrating gluteal injuries: an analysis of the Operation Iraqi Freedom experience

BACKGROUND

Although penetrating gluteal injuries rarely are life-threatening, the risk for concomitant injury to regional anatomic structures warrants additional evaluation. We analyzed factors affecting the management and outcomes of these injuries.

METHODS

Retrospective analysis of prospectively collected data from the 31st Combat Support Hospital during Operation Iraqi Freedom over a 16 month period.

RESULTS

From 3442 patients, 115 patients (3.3%) suffered penetrating gluteal injuries. They were predominately male (98%) with a mean injury severity score of 13. Mortality was 6% (n = 7). Primary mechanisms of injury were improvised explosive devices (41%) and gunshot wounds (59%). Associated injuries were present in 57% of patients [orthopedic (35%), abdominal (29%), rectal (25%), vascular (21%), genitourinary (14%), pulmonary (11%), sphincter (9%)]. Overall, 76% required surgical management, with 14% developing postoperative complications. In total, 27 patients (24%) required stoma placement. Gunshot wounds were associated with through and through injuries (43% vs 6%, p < 0.01), rectal injury (35% vs 11%, p < 0.05), and stoma placement (32% vs 11%, p < 0.05). Blast injuries were associated with a higher mean transfusion requirement (11 vs 6 units, p < 0.05), increased length of stay (14 vs 9 days, p < 0.05), and traumatic brain injury (24% vs 6%, p < 0.05). Independent predictors of a need for stoma placement were gunshot wounds (odds ratio = 10, p < 0.05) and injury severity score greater than 20 (odds ratio = 27, p < 0.01).

CONCLUSIONS

Penetrating gluteal injuries are associated with significant damage to local structures. Gunshot wounds carry a higher risk of injury to the rectum and stoma placement, whereas blast injuries are associated with less local injury and more multisystem trauma.

Outcomes and management of rectal injuries in children

In the pediatric population, rectal injuries usually occur as a result of motor vehicle collisions. There has been an increased interest in selective diversion of rectal injuries in adults and increased utilization of laparoscopy both as a diagnostic and therapeutic adjunct. The aim of the study was to review our institutional experience with rectal injuries to determine if there was a subset of patients who could be managed with selective diversion. The medical records of children admitted with a rectal injury to Hospital for Sick Children, Toronto, over the last 20 years (1984-2004) were retrospectively reviewed. Data abstraction included patient demographics, mechanism of injury, injury severity score, associated injuries, presenting symptoms, methods of diagnosis, treatment and resultant complications. Nine patients with rectal injuries were identified. The average injury severity score (ISS) was 19.3. Two patients with penetrating injuries underwent laparoscopy. Laparoscopy was able to define the intraperitoneal extension of injuries and guide the colostomy. Primary repair without a diverting colostomy was performed in 3 patients (2 intraperitoneal and 1 extraperitoneal injury) without complications. Based on the limited sample size, one should avoid making any definitive recommendations but, it appears, primary repair without fecal diversion can be performed safely in select children in spite of a longer time to surgery. Laparoscopy may be used for the immediate management of the penetrating trauma patient to rule out intraperitoneal extension, repair a perforation and guide the colostomy if necessary.

[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.