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

Evaluation and Management of Traumatic Rectal Injury

Traumatic injury to the rectum is rare but associated with high morbidity and mortality. In recent years, diagnostic and treatment recommendations for these complex injuries have changed. While rare, it is critical for general surgeons to understand the basic principles of injury assessment, damage control, and definitive management of traumatic rectal injuries. This article reviews the literature regarding the evaluation and management of traumatic rectal injuries.

National estimates of intestinal ostomy creation and reversal for trauma

BACKGROUND

Intestinal ostomy creation after trauma is selectively indicated for destructive colon and rectal injuries. However, the nationwide rates of creation of ostomies for trauma and their reversal are not known. The objective of this study was to ascertain national estimates of trauma ostomy creation and reversal.

METHODS

Weighted analysis of Healthcare Cost and Utilization Project Nationwide Readmissions Database 2014 to 2015 was performed. Adult trauma patients (≥16 years) with a hollow viscus injury were included. Patients with preexisting ostomies and permanent ostomies and those who died within 48 hours of admission were excluded. Rates of ostomy creation and same admission ostomy reversal were calculated. Rates of postdischarge ostomy reversal were calculated using the Kaplan-Meier estimator. Multivariable Cox proportional hazards model was used to determine factors associated with postdischarge trauma ostomy reversal.

RESULTS

A total of 22,542 patients sustained a hollow viscus injury resulting in the creation of 2,145 ostomies (9.6%). The rate of same-admission ostomy reversal was 0.7% (n = 16). At 1, 3, 6, and 9 months, the cumulative stoma reversal rates were 0%, 7.6%, 31.0%, and 43.1%, respectively. The mean ± SD time from ostomy creation to reversal was 123 ± 6.7 days for those undergoing reversal. Injury Severity Score greater than 9 was significantly associated with ostomy nonreversal after discharge (hazard ratio, 0.41; 95% confidence interval, 0.26-0.66). Age, sex, insurance status, penetrating injury, Charlson Comorbidity Index, and hospital teaching status were not significantly associated with ostomy reversal.

CONCLUSION

The nationwide rate of ostomy creation after trauma is nearly 10%. At 6 months postinjury, only one third of patients had undergone ostomy reversal. Future study is needed to understand patient and provider-level factors associated with trauma ostomy reversal.

LEVEL OF EVIDENCE

Epidemiology, level III.

Assessing Risk and Related Complications after Reversal of Combat-Associated Ostomies

BACKGROUND

During the past decade of conflict, numerous patients with combat-associated injuries required the formation of an ostomy. However, outcomes in those patients undergoing ostomy reversal have yet to be analyzed. We review the experience and identify risk factors for complications after ostomy reversal in a series of patients with combat injuries at our military treatment facility.

STUDY DESIGN

A retrospective review of patients with combat-associated injuries managed with a diverting ostomy who underwent ostomy reversal at our military treatment facility during a 13-year period. Demographic and clinical data were collected for all patients and postoperative complications were identified. Multivariate analysis was performed to identify independent risk factors for complications after reversal. Complication rates were calculated for 90-day periods of time after ostomy creation and best-fit curve analysis was conducted.

RESULTS

Ninety-nine patients were identified who underwent ostomy reversal. Forty patients (40.4%) suffered a post-reversal complication. On multivariate analysis, older age (odds ratio 1.11/y; p = 0.038), severe perineal injury indication for diversion (odds ratio 4.37; p = 0.028), and increased time interval between ostomy creation and reversal (odds ratio 1.005/d; p = 0.037), were independently associated with postoperative complications. A cubic regression best fit quarterly complication rate data (R² 0.526; p < 0.001) and calculates a minimum complication rate for reversal 90 to 180 days after ostomy creation.

CONCLUSIONS

Ostomy reversal in patients wounded in combat is a major undertaking with a high complication rate. The finding of a shorter interval from ostomy creation to reversal independently associated with a reduction in complications provides a modifiable risk factor to guide future practice and potentially reduce complications. Our modeling suggests reversal in the 3- to 6-month time frame can have the lowest rate of complications. Future research to reduce complications is indicated, especially in older patients with perineal wounds.

Penetrating anorectal injuries in Jamaican children

PURPOSE

To discuss the presentation, management and outcomes of penetrating anorectal injuries at the Bustamante Hospital for Children.

METHODS

A retrospective review over an 11-year period (January 2001-December 2011) was undertaken. The data analysed were extracted from patients' case notes which were pulled based on the hospital's admission database.

RESULTS

Over the study period a total of 14 children presented with penetrating anorectal injuries. The medical records for one child were missing. The mean age at presentation was 6 years. Impalement by a metal spike was the mechanism of injury in 12 children, with one case of sexual assault. Three of the children had associated urogenital injuries. Ten rectal injuries were extraperitoneal. Five of the 13 cases (38 %) were managed with a colostomy-average time to closure was 6 months. There was one case of perineal wound infection and dehiscence. There was no mortality.

CONCLUSION

Selective fecal diversion in the form of a sigmoid loop colostomy is a safe and acceptable management option for children with penetrating anorectal injuries. The perineal wound itself can be closed primarily except in cases of delayed presentation.

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.

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.

Same admission colostomy closure: a prospective, randomised study in selected patient groups

BACKGROUND

Despite a recent trend towards primary repair, colostomy still has an important place in the management of different colorectal pathologies. Timing of colostomy closure is a debatable issue among general surgeons. We carried out a prospective, randomised study to compare the outcome after same admission colostomy closure (SACC) and conventional delayed colostomy closure (CDCC) in patients with predominantly traumatic injury of the large bowel.

METHODS

Sixty patients, the majority with traumatic colorectal pathologies, were prospectively randomised to SACC [30 patients, 23 men, mean age 27.9 +/- 9.7 (range, 18-65) years] or (CDCC) [30 patients, 24 men, mean age 28.6 +/- 10.6 (range, 18-63) years]. All colostomies were closed using an intraperitoneal closure technique. Pre-operative data and post-operative outcomes were collected and analysed.

RESULTS

A total of seven patients (23.3%) with SACC developed complications compared with eight patients (26.6%) having CDCC (p = 0.83). The mean hospital stay (p < 0.01), as well as the overall cost (p < 0.001), were significantly less in the SACC group.

CONCLUSIONS

Same admission colostomy closure is a safe and cost-effective technique for colostomy closure in selected groups of patients.

Fechamento precoce das colostomias em pacientes com trauma do reto: um estudo prospectivo e casualizado

Foi feito um estudo prospectivo e casualizado de 35 pacientes portadores de colostomias devido a lesões traumáticas do reto admitidos no Hospital Jõao XXIIII no período de novembro de 1994 a junho de 1997. O objetivo foi avaliar os resultados do fechamento precoce das colostomias nestes pacientes. Após o atendimento inicial, os pacientes foram sorteados de acordo com o número do registro de admissão em dois grupos: os do grupo 1 (N = 14) foram submetidos ao fechamento precoce da colostomia programado para o 10º dia pós-operatório do tratamento da(s) lesão(ões) e os do grupo 2 (N = 21) submetidos ao fechamento tardio da colostomia, programado para oito semanas após a operação inicial. Nos dois grupos, o restabelecimento do trânsito intestinal somente foi realizado após o fechamento da lesão retal confirmado por um estudo radiológico contrastado. Houve um predomínio de pacientes jovens, do sexo masculino e vítimas de traumatismo penetrante. Todos eram portadores de uma colostomia em alça. A taxa global de complicações após o fechamento das colostomias foi de 25,7%, com a infecção de ferida operatória sendo a complicação mais freqüente (17,1%). No grupo 1, as complicações ocorreram em 35,7% dos casos e, no grupo 2, em 19,1% (p = 0,423). A análise dos resultados permitiu-nos concluir que a taxa de complicações, a duração da operação para o fechamento da colostomia e o tempo total de permanência hospitalar não apresentaram diferenças significantes entre os dois grupos. Os pacientes submetidos ao fechamento precoce (grupo 1) permaneceram apenas 10 dias em média com a colostomia, enquanto nos pacientes do grupo 2 a média de permanência com a colostomia foi de 66,3 dias (p< 0,001 - Teste de Kruskal-Wallis). Baseados nestes resultados, concluímos que os pacientes portadores de colostomias utilizadas para o tratamento de lesões traumáticas do reto e que não apresentem complicações da operação inicial, poderão ser submetidos ao seu fechamento a partir do 10ºDPO da operação inicial.

Análise das complicações pós-operatórias em decolostomias

Este estudo teve como objetivo analisar a ocorrência de complicações em pacientes submetidos à colostomia e reconstrução do trânsito intestinal. Para isto, estudou-se 56 pacientes, com idade média de 39 anos, sendo 37 homens e 19 mulheres. As principais indicações para a colostomia foram ferimento por arma de fogo (35%), doença diverticular perfurada (12,5%) e câncer colo-retal (12%). O tipo de colostomia mais realizado foi terminal (70%), com utilização do sigmóide em 71,4% dos casos. O tempo médio de permanência da colostomia foi de 5,5 meses. A reconstrução do trânsito foi realizada através de anastomose término-terminal em 85,7% dos pacientes, através de síntese mecânica com stapler circular em 5 pacientes ou manual em 51 pacientes. Observou-se taxa de complicações de 25%, sendo as mais frequentes a infecção de parede (35,7%), as fístulas (28,6%) e a hemorragia digestiva baixa (21,4%). Conclui-se que a reconstrução do trânsito intestinal não está isenta de riscos cirúrgicos e apresenta taxas consideráveis de complicações pós-operatórias, sendo que a infecção continua a ser um dos maiores desafios existentes neste procedimento.

Colostomy Closure: Impact of Preoperative Risk Factors on Morbidity

The objective of this study was to stratify patients for colostomy closure into risk categories according to preoperative variables. This was a retrospective case series. Median follow-up was 82 months. A tertiary care academic medical center was the setting for this study. A study sample of 155 consecutive patients who underwent colostomy closure at a single institution between 1985 and 1995 were included in this study. The following preoperative variables were analyzed: indication for colostomy fashioning; age; gender; American Society of Anesthesiology (ASA) class; presence of cardiac, renal, or pulmonary dysfunctions; presence of diabetes mellitus; and immunosuppression. The occurrence of adverse outcome, as evidenced by postoperative morbidity and mortality, was used as the main outcome measure. Complications occurred in 49 patients (31.6%), including a 1.3 per cent mortality. There was a trend of increasing morbidity with increasing ASA class. The single factor that showed a statistically significant increase in morbidity was the presence of diabetes (P = 0.036). Predicted probabilities of complications for patients with ASA HI with renal disease was 31 per cent, increased to 47.9 per cent if cardiac disease was also present and to 77 per cent with the addition of diabetes. The presence of diabetes carries an independent risk factor for adverse outcome in colostomy closure. This study provides information about stratification of postoperative risk based on commonly available preoperative variables. In the majority of cases, colostomy closure seems to carry a very acceptable complication rate. In selected patients with multiple preoperative risk factors, the morbidity becomes significantly higher.

Impalement and anorectal injuries in childhood: a retrospective study of 12 cases

BACKGROUND/PURPOSE

Because of the small numbers of impalement and anorectal injuries in childhood, a standardized therapeutic approach is necessary to avoid major complications. On the basis of a retrospective analysis of 12 children with such injuries treated from 1986 to 1996 in our department, the authors tried to establish guidelines for their treatment.

METHODS

Additional therapeutic problems and main complications are elucidated after meticulous analysis of three selected cases.

RESULTS

In two cases of anorectal impalement and a primary colostomy, no complications occurred. However, in three cases involving anorectal injury a primary fecal diversion was not performed, making a secondary colostomy necessary afterwound infection.

CONCLUSIONS

The current standard principles in the treatment of severe anorectal injuries in children are fecal diversion, wound drainage, and broad spectrum antibiotics. A primary reconstruction in cases of impalement can be recommended only after exclusion of anorectal injury.

Anorectal disorders

Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.

Early closure of colostomies in trauma patients--a prospective randomized trial

BACKGROUND

Most traumatic colon injuries can be repaired primarily, but a colostomy may still be required for severe colonic or rectal injury. The current trend is to reverse the colostomy early, rather than to wait the traditional 3 months before closure.

METHODS

Forty-nine patients with colostomies after abdominal trauma were entered into the study. All patients had undergone a contrast enema in the second postoperative week to assess distal colon healing. Patients were excluded from early closure for nonhealing of the bowel injury, unresolving wound sepsis, or an unstable condition. We then compared the outcome of the remaining 38 (77.6%) patients allocated to either an early or a late colostomy group in a controlled, prospective, randomized trial.

RESULTS

We found no significant difference in morbidity between the two groups, with an overall complication rate of 26.3%. Technically the early closure of colostomies was far easier than late closure and required significantly less operating time (p = 0.036) and with less intraoperative blood loss (p = 0.020). The closure of end colostomies was more time consuming, both early (p < 0.001) and late (p < 0.001) and caused more bleeding (p < 0.001 and p < 0.001, respectively). Total hospitalization was marginally shorter overall for early closure, but late closure of end colostomies resulted in prolonged hospitalization (p = 0.023).

CONCLUSIONS

The early closure of colostomies and the use of loop colostomies whenever possible are recommended as both safe and beneficial for patients with colonic injury after trauma. Contraindications for early closure include nonhealing distal bowel, persistent wound sepsis, or persistent postoperative instability.

Anorectal trauma and foreign bodies

The causes of rectal trauma are many and varied. The most frequent cause is iatrogenic. Treatment depends on the severity of the injury; and the accurate assessment of the injury is essential. Rectal foreign bodies are either ingested or inserted through the anus. Foreign bodies usually can be extracted by nonsurgical methods but appropriate technique is required to avoid rectal or sphincteric laceration.