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Fields A, Salim A. Contemporary diagnosis and management of colorectal injuries: What you need to know. J Trauma Acute Care Surg 2024; 97:497-504. [PMID: 38595231 DOI: 10.1097/ta.0000000000004352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
ABSTRACT Colorectal injuries are commonly encountered by trauma surgeons. The management of colorectal injuries has evolved significantly over the past several decades, beginning with wartime experience and subsequently refining with prospective randomized studies. Colon injuries were initially nonoperative, evolved toward fecal diversion for all, and then became anatomic based with resection and primary anastomosis with selective diversion, and now primary repair, resection with primary anastomosis, and delayed anastomosis after damage-control laparotomy are all commonplace. Rectal injuries were also initially considered nonoperative until diversion came into favor. Diversion in addition to direct repair, presacral drain placement, and distal rectal washout became the criterion standard for extraperitoneal rectal injuries until drainage and washout fell out of favor. Despite a large body of evidence, there remains a debate on the optimal management of some colorectal injuries. This article will focus on how to diagnose and manage colorectal injuries. The aim of this review is to provide an evidence-based summary of the contemporary diagnosis and management of colorectal injuries.
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Affiliation(s)
- Adam Fields
- From the Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Van Zande J, Van Molhem Y. Transanal minimally invasive surgery approach for rectal impalement trauma with combined rectal and bladder perforation-a video vignette. Colorectal Dis 2024; 26:1456-1457. [PMID: 38688682 DOI: 10.1111/codi.16978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/12/2024] [Accepted: 03/09/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Jaro Van Zande
- Department of General Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst-Asse-Ninove, Aalst, Belgium
| | - Yves Van Molhem
- Department of General Surgery, Onze-Lieve-Vrouw (OLV) Hospital Aalst-Asse-Ninove, Aalst, Belgium
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Banks KC, Mooney CM, Alcasid NJ, Susai CJ, Mazzolini K, Browder TD, Victorino GP. Colon Injuries and Infectious Complications in Concurrent Gunshot-Related Fractures. J Surg Res 2024; 293:152-157. [PMID: 37774592 DOI: 10.1016/j.jss.2023.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION Concurrent colonic injury among patients with gunshot-related fractures presents a potential risk for infectious complications. We hypothesized that colon injuries are associated with more infectious orthopedic complications among gunshot victims with concurrent fractures. MATERIALS AND METHODS We reviewed trauma patients arriving at our level 1 trauma center from January 1, 2019 to May 31, 2022 who suffered any gunshot-related fracture and also underwent an exploratory laparotomy. Of these patients, those with colon injuries were compared to those without colon injuries. Baseline characteristics, including antibiotic regimens, were collected in addition to outcomes of length of stay, intensive care unit admission, ventilator requirement, and development of infectious orthopedic complications. RESULTS Overall, 56 of the 107 included patients had colon injuries. Age, sex, race/ethnicity, and Injury Severity Score were similar between groups. Of patients with colonic injuries, 16.1% received early, repeat dosing of broad-spectrum antibiotics, while only 3.9% of patients without colonic injuries received this antibiotic dosing (P = 0.04). Interestingly, only patients with colon injuries developed infectious orthopedic complications and none of the patients without colon injuries developed such complications (10.7% versus 0.0%, P = 0.03). All patients with orthopedic infections had infected pelvic fractures. Length of stay was 3 d longer in the colon injury group (P = 0.04). There was no difference in intensive care unit admission, ventilator requirement, or death. CONCLUSIONS Concurrent colon injuries among patients with gunshot-related fractures are associated with higher risk of infectious orthopedic complications, likely from direct spread of fecal contaminant. Early, broad-spectrum antibiotics may be associated with reduced infectious orthopedic complications.
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Affiliation(s)
- Kian C Banks
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California.
| | - Colin M Mooney
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Nathan J Alcasid
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Cynthia J Susai
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Kirea Mazzolini
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Timothy D Browder
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Gregory P Victorino
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
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Schellenberg M, Koller S, de Moya M, Moore LJ, Brown CVR, Hartwell JL, Inaba K, Ley EJ, Keric N, Peck KA, Fox CJ, Rosen NG, Weinberg JA, Coimbra R, Martin MJ. Diagnosis and management of traumatic rectal injury: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2023; 95:731-736. [PMID: 37405856 DOI: 10.1097/ta.0000000000004093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Affiliation(s)
- Morgan Schellenberg
- From the Division of Acute Care Surgery, Department of Surgery (M.S., K.I., M.J.M.),; Division of Colorectal Surgery, Department of Surgery (S.K.), University of Southern California, Los Angeles, California; Division of Acute Care Surgery, Department of Surgery (M.d.M.), Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Acute Care Surgery, Department of Surgery (L.J.M.), University of Texas-Houston Medical Center, Houston; Division of Acute Care Surgery, Department of Surgery (C.V.R.B.), Dell Medical School, University of Texas at Austin, Austin, Texas; Division of Acute Care Surgery, Department of Surgery (J.L.H.), University of Kansas Medical Center, Kansas City, Kansas; Division of Acute Care Surgery, Department of Surgery (E.J.L.), Cedars-Sinai Medical Center, Los Angeles, California; Division of Acute Care Surgery, Department of Surgery (N.K.), Banner University Medical Center, Phoenix, Arizona; Division of Acute Care Surgery, Department of Surgery (K.A.P.), Scripps Mercy Hospital, San Diego, California; Division of Vascular Surgery, Department of Surgery (C.J.F.), R. Cowley Adams Shock Trauma Center, Baltimore, Maryland; Division of Pediatric General and Thoracic Surgery, Department of Surgery (N.G.R.), Children's Hospital, Cincinnati, Ohio; Division of Acute Care Surgery, Department of Surgery (J.A.W.), St. Joseph's Medical Center, Phoenix, Arizona; and Division of Acute Care Surgery, Department of Surgery (R.C.), Riverside University Health System Medical Center, Riverside, California
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Mouradian GP, Lake Z, Winfield R. Rectal necrosis in the setting of critical illness and burn. Trauma Case Rep 2023; 47:100886. [PMID: 37654702 PMCID: PMC10466907 DOI: 10.1016/j.tcr.2023.100886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2023] [Indexed: 09/02/2023] Open
Abstract
The rectum is an anatomically protected and well vascularized structure. Injury to the rectum is usually the result of penetrating perineal mechanisms or reported scalding enemas. Here, we report a case of isolated rectal necrosis following a 72 % total body surface area burn that resulted from a motor vehicle crash. The patient's rectal injury was managed with open resection, left in discontinuity and ultimately expired. In presenting this case, we hope to share an unusual development in a patient with critical illness and guide future care.
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Affiliation(s)
- Gregory P. Mouradian
- The University of Kansas Medical Center, Department of Surgery, 3901 Rainbow Blvd, Mail Stop 2005, Kansas City, KS 66160, USA
| | - Zoe Lake
- The University of Kansas Medical Center, Department of Surgery, 3901 Rainbow Blvd, Mail Stop 2005, Kansas City, KS 66160, USA
| | - Robert Winfield
- The University of Kansas Medical Center, Department of Surgery, 3901 Rainbow Blvd, Mail Stop 2005, Kansas City, KS 66160, USA
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Severe anorectal injury secondary to jet ski accident: An important and increasing mechanism of injury. Trauma Case Rep 2022; 42:100703. [PMID: 36262775 PMCID: PMC9573912 DOI: 10.1016/j.tcr.2022.100703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Traumatic injuries from jet ski-related accidents have increased in incidence over the past few decades. Anorectal injuries are uncommon but typically arise from high-speed jet ski accidents. We present a case of a severe anorectal injury from a fall off the back of an accelerating jet ski. Case report This case reports on the presentation, operative findings and management of a 22-year-old female with major internal and external anal sphincter disruption sustained via an unusual traumatic mechanism. Operative findings identified a complete internal and external anal sphincter disruption at the 1 and 7 O'clock positions and extra-peritoneal rectal perforation. Washout, suture repair and an end-colostomy were performed. Conclusion Understanding the potential severity of injury from the insult mechanism is paramount to triaging and managing trauma patients. Although this case describes an inconspicuous mechanism, the resulting trauma is significant and should prompt consideration in future cases. In addition, the article describes an approach to the repair of such injuries and the difficult decision relating to the role and type of defunctioning colostomy to protect any possible missed injuries in a complex traumatic environment, and in the protection of the anorectal repair.
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Martínez-Hincapié C, Sierra-Jaramillo JI, Carvajal-López A, Santiago Salazar-Ochoa S, Posada-Moreno P, Llano-Herrera M. Trauma de recto penetrante: revisión de tema. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Extraperitoneal rectal trauma in a patient with multiple gunshot wounds: A case report and literature review. Trauma Case Rep 2021; 36:100554. [PMID: 34825043 PMCID: PMC8605271 DOI: 10.1016/j.tcr.2021.100554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/22/2022] Open
Abstract
Penetrating rectal trauma is an uncommon presentation, particularly in centres with low rates of trauma, and requires a high index of suspicion to identify and treat. Management of penetrating rectal trauma has evolved over several decades and previously included proximal diversion, distal rectal washout, and presacral drainage as the primary surgical maneuvers to reduce mortality. Recently, a more conservative approach has been adopted, as the applicability of combat experience to the civilian setting has been questioned. In this report, a case of extraperitoneal rectal injury in a patient with multiple gunshot wounds provides a backdrop for literature review and discussion of the modern diagnostic and management approaches to penetrating rectal trauma.
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Tarasconi A, Perrone G, Davies J, Coimbra R, Moore E, Azzaroli F, Abongwa H, De Simone B, Gallo G, Rossi G, Abu-Zidan F, Agnoletti V, de'Angelis G, de'Angelis N, Ansaloni L, Baiocchi GL, Carcoforo P, Ceresoli M, Chichom-Mefire A, Di Saverio S, Gaiani F, Giuffrida M, Hecker A, Inaba K, Kelly M, Kirkpatrick A, Kluger Y, Leppäniemi A, Litvin A, Ordoñez C, Pattonieri V, Peitzman A, Pikoulis M, Sakakushev B, Sartelli M, Shelat V, Tan E, Testini M, Velmahos G, Wani I, Weber D, Biffl W, Coccolini F, Catena F. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg 2021; 16:48. [PMID: 34530908 PMCID: PMC8447593 DOI: 10.1186/s13017-021-00384-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy.
| | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA, USA
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Francesco Azzaroli
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Hariscine Abongwa
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Belinda De Simone
- Department of Metabolic, Digestive and Emergency Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, Poissy, France
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Giorgio Rossi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M.Bufalini Hospital, Cesena, Italy
| | - Gianluigi de'Angelis
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Nicola de'Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Bari, Ital - Université Paris Est, UPEC, Creteil, France
| | - Luca Ansaloni
- Department of Emergency and general Surgery, Pavia University Hospital, Pavia, Italy
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Alain Chichom-Mefire
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| | - Salomone Di Saverio
- General surgery 1st unit, Department of General Surgery, University of Insubria, Varese, Italy
| | - Federica Gaiani
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Mario Giuffrida
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Andreas Hecker
- Department of General & Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Michael Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Carlos Ordoñez
- Department of Surgery, Fundacion Valle del Lili - Universidad del Valle, Cali, Colombia
| | | | - Andrew Peitzman
- University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, PA, USA
| | - Manos Pikoulis
- 3rd Department of Surgery, National & Kapodistrian University of Athens, Athens, Greece
| | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Plovdiv, Bulgaria
| | | | - Vishal Shelat
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Edward Tan
- Department of Surgery, Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mario Testini
- Academic Unit of General Surgery "V. Bonomo" Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Imtiaz Wani
- Government Gousia Hospital, Srinagar, Kashmir, India
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walter Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Fausto Catena
- General, Emergency and Trauma Surgery Dept., Bufalini Hospital, Cesena, Italy
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McKnight GHO, Yalamanchili S, Sanchez-Thompson N, Guidozzi N, Dunhill-Turner N, Holborow A, Batrick N, Hettiaratchy S, Khan M, Kashef E, Aylwin C, Frith D. Penetrating gluteal injuries in North West London: a retrospective cohort study and initial management guideline. Trauma Surg Acute Care Open 2021; 6:e000727. [PMID: 34395917 PMCID: PMC8311336 DOI: 10.1136/tsaco-2021-000727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background Penetrating gluteal injuries (PGIs) are an increasingly common presentation to major trauma centers (MTCs) in the UK and especially in London. PGIs can be associated with mortality and significant morbidity. There is a paucity of consistent guidance on how best to investigate and manage these patients. Methods A retrospective cohort study was performed by interrogating prospectively collected patient records for PGI presenting to a level 1 MTC in London between 2017 and 2019. Results There were 125 presentations with PGI, accounting for 6.86% of all penetrating injuries. Of these, 95.2% (119) were male, with a median age of 21 (IQR 18–29), and 20.80% (26) were under 18. Compared with the 3 years prior to this study, the number of PGI increased by 87%. The absolute risk (AR) of injury to a significant structure was 27.20%; the most frequently injured structure was a blood vessel (17.60%), followed by the rectum (4.80%) and the urethra (1.60%). The AR by anatomic quadrant of injury was highest in the lower inner quadrant (56%) and lowest in the upper outer quadrant (14%). CT scanning had an overall sensitivity of 50% and specificity of 92.38% in identifying rectal injury. Discussion The anatomic quadrant of injury can be helpful in stratifying risk of rectal and urethral injuries when assessing a patient in the emergency department. Given the low sensitivity in identifying rectal injury on initial CT, this data supports assesing any patients considered at high risk of rectal injury with an examination under general anesthetic with or without rigid sigmoidoscopy. The pathway has created a clear tool that optimizes investigation and treatment, minimizing the likelihood of missed injury or unnecessary use of resources. It therefore represents a potential pathway other centers receiving a similar trauma burden could consider adopting. Level of evidence 2b.
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Affiliation(s)
- Gerard Hywel Owen McKnight
- Institute of Naval Medicine, Royal Navy, Gosport, UK.,Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | - Seema Yalamanchili
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK.,Division of Surgery and Cancer, Imperial College London Faculty of Medicine, London, UK
| | | | - Nadia Guidozzi
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | | | - Alex Holborow
- Department of Radiology, Swansea Bay University Health Board, Swansea, UK
| | - Nicola Batrick
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | | | - Mansoor Khan
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | - Elika Kashef
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | - Chris Aylwin
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | - Dan Frith
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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11
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Saldarriaga LG, Palacios-Rodríguez HE, Pino LF, Hadad AG, Capre J, García A, Rodríguez-Holguín F, Salcedo A, Serna JJ, Herrera MA, Parra MW, Ordoñez CA, Kestenberg-Himelfarb A. Rectal damage control: when to do and not to do. Colomb Med (Cali) 2021; 52:e4124776. [PMID: 34188328 PMCID: PMC8216057 DOI: 10.25100/cm.v52i2.4776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/21/2021] [Accepted: 05/13/2021] [Indexed: 11/11/2022] Open
Abstract
Rectal trauma is uncommon, but it is usually associated with injuries in adjacent pelvic or abdominal organs. Recent studies have changed the paradigm behind military rectal trauma management, showing better morbidity and mortality. However, damage control techniques in rectal trauma remain controversial. This article aims to present an algorithm for the treatment of rectal trauma in a patient with hemodynamic instability, according to damage control surgery principles. We propose to manage intraperitoneal rectal injuries in the same way as colon injuries. The treatment of extraperitoneal rectum injuries will depend on the percentage of the circumference involved. For injuries involving more than 25% of the circumference, a colostomy is indicated. While injuries involving less than 25% of the circumference can be managed through a conservative approach or primary repair. In rectal trauma, knowing when to do or not to do it makes the difference.
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Affiliation(s)
- Luis Guillermo Saldarriaga
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Helmer Emilio Palacios-Rodríguez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Jessica Capre
- Fundación Valle del Lili, Department of Surgery, Division of Colorectal Surgery , Cali, Colombia
| | - Alberto García
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | | | - Alexander Salcedo
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Colorectal Surgery , Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Michael W. Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Carlos A. Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
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12
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Chen MZ, Daniel E. Unusual case of rectal perforation. ANZ J Surg 2021; 91:E782-E783. [PMID: 33885230 DOI: 10.1111/ans.16896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Michelle Zhiyun Chen
- Department of General Surgery, The Northern Hospital, Melbourne, Victoria, Australia
| | - Eric Daniel
- Department of General Surgery, The Northern Hospital, Melbourne, Victoria, Australia
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13
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Hashmi ZG, Dalton MK, Sheikh SS, McCarty JC, Salim A, Haider AH. National estimates of intestinal ostomy creation and reversal for trauma. J Trauma Acute Care Surg 2021; 90:459-465. [PMID: 33617196 DOI: 10.1097/ta.0000000000003022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Zain G Hashmi
- From the Center for Surgery and Public Health, Department of Surgery (Z.G.H., M.K.D., J.C.M., A.S., A.H.H.), Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (Z.G.H.), Sinai Hospital of Baltimore, Baltimore, Maryland; Department of Surgery (S.S.S.), University of Alabama at Birmingham, Birmingham, Alabama; Department of Surgery (J.C.M.), St. Elizabeth's Medical Center, Boston, Massachusetts; and Medical College (A.H.H.), Aga Khan University, Karachi, Pakistan
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14
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Contemporary diagnosis and management of traumatic rectal injuries. SURGERY IN PRACTICE AND SCIENCE 2021. [DOI: 10.1016/j.sipas.2020.100024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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15
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James JD, Agarwal H, Kumar V, Kumar A, Hemachandran N, Gupta A. Traumatic Arterio-Enteric Fistula-A Report of 2 Cases With Review of Literature. Vasc Endovascular Surg 2021; 55:631-637. [PMID: 33622189 DOI: 10.1177/1538574421994413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Traumatic arterio-enteric fistula is predominantly seen after penetrating trauma with only 21 reported cases documented in the past 25 years. They may present in an acute or delayed manner with upper or lower gastrointestinal bleed. A detailed clinical examination with requisite imaging can help in detecting such injuries. CASE DESCRIPTION Case 1: A 20-year-old gentleman, presented with penetrating stab injury to the gluteal region with bleeding per rectum. Imaging revealed evidence of injury to the inferior rectal artery which was found to be communicating with the extraperitoneal portion of the rectum. He was managed with a combination of endovascular and open surgery with a successful outcome. Case 2: A 29-year-old gentleman, presented in a delayed manner 2 weeks after a gunshot wound to the gluteal region, which was managed operatively in another hospital. He developed a massive lower gastrointestinal bleed 2 weeks after presentation. Imaging revealed evidence of a pseudoaneurysm of the inferior gluteal artery which had a fistulous communication with the gastrointestinal tract leading to bleeding. It was managed by endovascular techniques successfully. CONCLUSION Arterio-enteric fistulas following trauma are rare phenomena and they need a high index of suspicion for diagnosis. Once diagnosed, they can be managed based on their location and patient physiology by interventional techniques, surgery, or a combination of the two.
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Affiliation(s)
- Joses Dany James
- Division of Trauma Surgery and Critical Care, Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Harshit Agarwal
- Department of Trauma & Emergency, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India
| | - Vignesh Kumar
- Department of Trauma Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| | - Atin Kumar
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Naren Hemachandran
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Amit Gupta
- Division of Trauma Surgery and Critical Care, Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, Delhi, India
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16
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Chen MZ, Tay YK, Gan S. Waterjet rectal injury. ANZ J Surg 2020; 91:E425-E427. [PMID: 33186485 DOI: 10.1111/ans.16444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Michelle Zhiyun Chen
- Department of Surgery, Macquarie University Hospital, Sydney, New South Wales, Australia.,Department of Surgery, St George Hospital, Sydney, New South Wales, Australia
| | - Yeng Kwang Tay
- Department of Surgery, St George Hospital, Sydney, New South Wales, Australia.,Department of Surgery, Monash Hospital, Melbourne, Victoria, Australia
| | - Steven Gan
- Department of Surgery, St George Hospital, Sydney, New South Wales, Australia
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17
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Haut ER. Eastern Association for the Surgery of Trauma (EAST) practice management guidelines and the perpetual quest for excellence. J Trauma Acute Care Surg 2020; 89:1-10. [PMID: 32251261 DOI: 10.1097/ta.0000000000002709] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Elliott R Haut
- From the Division of Acute Care Surgery, Department of Surgery, Department of Anesthesiology and Critical Care Medicine, and Department of Emergency Medicine, Johns Hopkins University School of Medicine; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine; and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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18
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Melland-Smith M, Chesney TR, Ashamalla S, Brenneman F. Minimally invasive approach to low-velocity penetrating extraperitoneal rectal trauma. Trauma Surg Acute Care Open 2020; 5:e000396. [PMID: 32426526 PMCID: PMC7228675 DOI: 10.1136/tsaco-2019-000396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/12/2019] [Accepted: 12/08/2019] [Indexed: 11/20/2022] Open
Abstract
Unlike intraperitoneal colorectal injuries, the standard of care for extraperitoneal rectal trauma includes a diverting colostomy due to relative inaccessibility of these injuries for primary repair. New technologies to enhance access to the extraperitoneal rectum have gained increasing use in benign and malignant rectal disease. We present two cases of low-velocity penetrating extraperitoneal rectal trauma. In both cases, a transanal minimally invasive surgery (TAMIS) approach was used to access, and primarily repair, full-thickness rectal lacerations. These patients were successfully managed without a colostomy and without complication. TAMIS enables access to distal rectal injuries, facilitating primary repair and bringing the management of extraperitoneal rectal injuries in line with intraperitoneal injuries, with the potential to avoid fecal diversion.
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Affiliation(s)
| | - Tyler R Chesney
- General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shady Ashamalla
- General Surgery, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Fred Brenneman
- General Surgery, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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19
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Uchino H, Kong V, Elsabagh A, Laing G, Bruce J, Manchev V, Clarke D. Contemporary management of rectal trauma - A South African experience. Injury 2020; 51:1238-1241. [PMID: 32127200 DOI: 10.1016/j.injury.2020.02.121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/20/2020] [Accepted: 02/23/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The management of rectal trauma remains controversial. There are three modalities which have been used to manage these injuries; proximal diversion (PD), washout of the distal rectum (DRW) and presacral drainage (PSD). The EAST group tentatively advocate mandatory proximal diversion for extraperitoneal rectal injuries and omitting DRW or PSD. Other authors have suggested that diversion can be eschewed in patients with an intraperitoneal injury which can be primarily repaired. In light of all these controversies, this project set out to review our experience with rectal injuries over the last seven years with the objective of reviewing our use of PD, PSD and DRW. METHODS Patients aged greater than or equal to 15 years with rectal injuries during December 2012 to July 2019 were included. Patient demographics, mechanism of injury, management strategy (operative or non-operative), complications, patient residential status (urban or rural), hospital and intensive care duration of stay, and 30-day mortality rates were assessed. RESULTS During the study period, a total of 51 patients with a rectal injury were treated. There were 45 (88%) males and the median age was 29 (22-39) years. There were 7 (14%) blunt mechanisms, 41 (80%) penetrating mechanisms and 3 (6%) combined blunt and penetrating mechanisms. The median ISS was 13 (9-18). Of the 50 rectal injuries ultimately treated at our institution, there were 31 extraperitoneal and 14 intraperitoneal injuries. There were five combined intra and extraperitoneal injuries. A total of 21 rigid sigmoidoscopies and a single flexible sigmoidoscopy were performed. A total of 24 patients underwent a CT scan. There were 13 primary repairs and 45 PD. A single patient required a PSD. Of the 34 documented complications, 15 (44%) were related to sepsis and can be attributed to the rectal injury. The overall mortality rate was 11.8%. CONCLUSIONS Rectal injuries are associated with significant septic related morbidity and mortality. Although we have begun to avoid diversion in a small subset of patients with an intraperitoneal injury, we continue to perform PD for the vast majority of patients with a rectal injury. We do not perform DRW and PSD is used in highly selective cases.
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Affiliation(s)
- Hayaki Uchino
- Department of Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Victor Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.
| | | | - Grant Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - John Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Vassil Manchev
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Department of Surgery, University of KwaZulu Natal, Durban, South Africa.
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20
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Concomitant bladder and rectal injuries: Results from the American Association for the Surgery of Trauma Multicenter Rectal Injury Study Group. J Trauma Acute Care Surg 2020; 88:286-291. [PMID: 31343599 DOI: 10.1097/ta.0000000000002451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Combined traumatic injuries to the rectum and bladder are rare. We hypothesized that the combination of bladder and rectal injures would have worse outcomes than rectal injury alone. METHODS This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004 to 2015 traumatic rectal injury patients who were admitted to one of 22 participating centers. Demographics, mechanism, and management of rectal injury were collected. Patients who sustained a rectal injury alone were compared with patients who sustained a combined injury to the bladder and rectum. Multivariable logistic regression was used to determine if abdominal complications, mortality, and length of stay were impacted by a concomitant bladder injury after adjusting for cofounders. RESULTS There were 424 patients who sustained a traumatic rectal injury, of which 117 (28%) had a combined injury to the bladder. When comparing the patients with a combined bladder/rectal injury to the rectal alone group, there was no difference in admission demographics admission physiology, or Injury Severity Score. There were also no differences in management of the rectal injury and no difference in abdominal complications (13% vs. 16%, p = 0.38), mortality (3% vs. 2%, p = 0.68), or length of stay (17 days vs. 21 days, p = 0.10). When looking at only the 117 patients with a combined injury, the addition of a colostomy did not significantly decrease the rate of abdominal complications (14% vs. 8%, p = 0.42), mortality (3% vs. 0%, p = 0.99), or length of stay (17 days vs. 17 days, p = 0.94). After adjusting for cofounders (AAST rectal injury grade, sex, damage-control surgery, diverting colostomy, and length of stay) the presence of a bladder injury did not impact outcomes. CONCLUSION For patients with traumatic rectal injury, a concomitant bladder injury does not increase the rates of abdominal complications, mortality, or length of stay. Furthermore, the addition of a diverting colostomy for management of traumatic bladder and rectal injury does not change outcomes. LEVEL OF EVIDENCE Level IV; prognostic/therapeutic.
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21
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Management of colorectal injuries: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2019; 85:1016-1020. [PMID: 29659471 DOI: 10.1097/ta.0000000000001929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Pfählungsverletzungen und rektale Fremdkörper. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-0614-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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23
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Ebeling PA, Clark C, Erwin D, Beale K, Dent DL. Femoral Head Dislocation into the Rectum Following Blunt Trauma. Cureus 2019; 11:e4596. [PMID: 31309021 PMCID: PMC6609309 DOI: 10.7759/cureus.4596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Traumatic hip dislocations require prompt diagnosis and treatment to prevent avascular necrosis of the femoral head. This injury is further complicated when there is an ipsilateral femur fracture. Here, we present what is likely the first reported case of a patient with traumatic hip dislocation and ipsilateral femur fracture with transrectal displacement of the femoral head. The patient presented to a level one trauma center in 2006 as a transfer from another facility after being thrown from a pickup truck. Upon initial evaluation, a foreign body was palpated in the rectum. Computed tomography (CT) imaging showed that the right femoral head was lodged within the pelvis. In the operating room, an exploratory laparotomy was performed, and anoscopy confirmed the placement of the femoral head within the rectal lumen. The femoral head was extracted from the rectum transanally. The operation was abbreviated, as the patient became hemodynamically unstable, and he was taken to the intensive care unit. He returned to the operating room the following day for a repeat washout and proximal diversion. Despite numerous orthopedic procedures and operative washouts, he ultimately underwent a right hip disarticulation. Physicians should be aware that intracorporeal femoral head displacement is possible in select patients who have experienced a high-energy trauma mechanism. This is a complicated, highly morbid injury that poses various management challenges to orthopedic and acute care surgeons.
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Affiliation(s)
- Peter A Ebeling
- Surgery, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Clarence Clark
- Surgery, Morehouse School of Medicine and Grady Memorial Hospital, Atlanta, USA
| | - Dylan Erwin
- Surgery, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Katherine Beale
- Surgery, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Daniel L Dent
- Surgery, University of Texas Health Science Center at San Antonio, San Antonio, USA
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24
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Behrenbruch C, Read D, Hayes I. Use of the GelPoint Path access channel for rectal trauma. ANZ J Surg 2019; 89:E589-E590. [PMID: 30690846 DOI: 10.1111/ans.14997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/04/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Corina Behrenbruch
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David Read
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Colorectal Surgery Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ian Hayes
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Colorectal Surgery Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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25
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Schroll RW. Management of some extra-peritoneal rectal injuries without fecal diversion may be feasible, but high-quality evidence is still needed. Tech Coloproctol 2018; 22:829-830. [PMID: 30523514 DOI: 10.1007/s10151-018-1902-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 11/28/2022]
Affiliation(s)
- R W Schroll
- Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave, #8622, New Orleans, LA, 70112, USA.
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26
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Affiliation(s)
- Lawrence Lee
- Department of Surgery, McGill University Health Centre, Montreal, Quebec
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27
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Rectal trauma injuries: outcomes from the U.S. National Trauma Data Bank. Tech Coloproctol 2018; 22:847-855. [PMID: 30264196 DOI: 10.1007/s10151-018-1856-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 09/12/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND There is a lack of general consensus and a little published data regarding the management of trauma-related rectal injuries and outcomes. The aim of the present study was to evaluate the surgical management and corresponding outcomes for this patient cohort, using a nationwide trauma database. METHODS Rectal injuries and procedures performed over a 2-year period (2013 and 2014) were identified through ICD-9 clinical modification codes, from the United States National Trauma Data Bank. Patient factors, management variables, and outcomes were evaluated. RESULTS Of 1.7 million patients, 1472 (0.1%) sustained a rectal injury; 81% male, median age 30 years (range 16-89 years) and 60% due to penetrating trauma. Seven hundred and seventy-eight (52.8%) had an isolated extraperitoneal injury and 694 (47.2%) had isolated Intraperitoneal or combined intra- and extraperitoneal injuries. Overall, 726 patients (49.3%) underwent fecal diversion. Injuries following blunt trauma were associated with higher injury severity scores (ISS), lower stoma rates, longer hospital and intensive-care unit (ICU) stay, and higher mortality rates than penetrating trauma (all p ≤ 0.001). Patients with stoma formation had lower mortality than undiverted patients (8.6 vs. 4.0%, p < 0.001) despite a higher ISS and more intraperitoneal injuries, but longer hospital and ICU stay (all p ≤ 0.001). On multivariate regression analysis, older age, higher ISS, intraperitoneal injury, and return to the ICU were independently associated with higher rates of mortality, while stoma formation was associated with a lower mortality rate. For isolated extraperitoneal rectal injuries, 494 patients (63.5%) were managed by resection/repair without stoma and had significantly lower overall postoperative morbidity rates (12.7 vs. 30.2%, p = 0.009) and shorter hospital stay (14 vs. 23 days, p < 0.001), than those who underwent resection/repair + stoma (n = 284; 36.5%), despite no significant difference in ISS (29 vs. 27, p = 0.780). There was no significant difference in mortality. CONCLUSIONS Our results showed that trauma-related rectal injuries are rare and there is wide variation in their management. These data support a low threshold for stoma formation in patients with intraperitoneal or combined injuries, while suggesting that isolated extraperitoneal defects may be safely managed without fecal diversion.
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Abstract
The authors discuss the history and evolution of management of traumatic wounds to the colon and rectum, summarizing early management parallel with the history of armed conflict followed by the increase in research and management interest by civilian centers in the post-Vietnam era. They explore the strong opinions of the early thought-leaders such as DeBakey and Ogilvie, detailing factors that may have impacted their views. The current literature on optimal management of both colon and rectal trauma is reviewed, including the contentious debate over which patients may benefit from diversion. Current organ injury staging and clinical practice guidelines are also reviewed, as well as lessons learned by the U.S. military in recent conflicts in Iraq and Afghanistan. Understanding of the evolution of colon and rectal trauma management, as well as the current literature, will help surgeons in their decision-making and management of these challenging injuries.
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Affiliation(s)
- Joshua A Tyler
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, Maryland.,Division of Colon and Rectal Surgery, Department of General Surgery, Keesler Medical Center, Biloxi, Mississippi
| | - David R Welling
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, Maryland.,Department of Anatomy, Uniformed Services University of the Health Science, Bethesda, Maryland
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29
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Abstract
The management of rectal trauma has often been lumped in with colon trauma when, in fact, it is a unique entity. The anatomic nature of the rectum (with its intra- and extraperitoneal segments) lends itself to unique circumstances when it comes to management and treatment. From the four Ds (debridement, drainage, diversion, and distal irrigation), the management of rectal trauma has made some strides in light of the experiences coming out of the recent conflicts overseas as well as some rethinking of dogma. This article will serve to review the anatomy and types of injuries associated with rectal trauma. A treatment algorithm will also be presented based on our current literature review. We will also address controversial points and attempt to give our opinion in an effort to provide an update on an age-old problem.
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Affiliation(s)
- Michael S Clemens
- Division of Colon and Rectal Surgery, San Antonio Military Medical Center, Sam Houston, Texas
| | - Kaitlin M Peace
- Division of Colon and Rectal Surgery, San Antonio Military Medical Center, Sam Houston, Texas
| | - Fia Yi
- Division of Colon and Rectal Surgery, San Antonio Military Medical Center, Sam Houston, Texas
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30
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The utility of presacral drainage in penetrating rectal injuries in adult and pediatric patients. J Surg Res 2017; 219:279-287. [DOI: 10.1016/j.jss.2017.05.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/15/2017] [Accepted: 05/17/2017] [Indexed: 11/24/2022]
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31
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Hardcastle TC. Regarding: Systematic review of rectal injury management, Injury 48: 1133-1138]. Injury 2017; 48:2372. [PMID: 28789778 DOI: 10.1016/j.injury.2017.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 07/30/2017] [Indexed: 02/02/2023]
Affiliation(s)
- Timothy Craig Hardcastle
- Inkosi Albert Luthuli Central Hospital and University of KwaZulu-Natal Dept of Surgery 800 Vusi Mzimela Rd, Mayville, Durban, 4058, KZN, South Africa.
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32
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Ahern DP, Kelly ME, Courtney D, Rausa E, Winter DC. The management of penetrating rectal and anal trauma: A systematic review. Injury 2017; 48:1133-1138. [PMID: 28292518 DOI: 10.1016/j.injury.2017.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 02/27/2017] [Accepted: 03/02/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic injuries to the lower gastrointestinal tract (rectum and anus) have been largely reported in the military setting with sparse publications from the civilian setting. Additionally, there remains a lack of international consensus regarding definitive treatment pathways. This systematic review aimed to assess the current literature and propose a standardised treatment algorithm to aid management in the civilian setting. METHODS A systematic review of available literature from 1999 to 2016 that was performed. Primary endpoints were the assessment and surgical management of reported rectal and anal trauma. RESULTS Seven studies were included in this review, reporting on 1255 patients. 96.3% had rectal trauma and 3.7% had anal trauma. Gunshot wounds are the most common mechanism of injury (46.9%). The overwhelming majority of injuries occurred in males (>85%) and were associated with other pelvic injuries. Surgical management has substantially evolved over the last five decades, with no clear consensus on best management strategies. CONCLUSION There remains significant international discrepancy regarding the management of penetrating trauma to the rectum. Key management principals include the varying use of the direct primary closure, faecal diversion, pre-sacral drainage and/or distal rectal washout (rarely used). To date, there is sparse evidence regarding the management of penetrating anal trauma.
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Affiliation(s)
- Daniel P Ahern
- Department of Colorectal Disease, St. Vincent's University Hospital, Ireland.
| | - Michael E Kelly
- Department of Colorectal Disease, St. Vincent's University Hospital, Ireland
| | - Danielle Courtney
- Department of Colorectal Disease, St. Vincent's University Hospital, Ireland
| | - Emanuele Rausa
- Department of Colorectal Disease, St. Vincent's University Hospital, Ireland
| | - Des C Winter
- Department of Colorectal Disease, St. Vincent's University Hospital, Ireland
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33
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Gwak J, Lee MA, Yu B, Choi KK. Rectal Injury Associated with Pelvic Fracture. JOURNAL OF TRAUMA AND INJURY 2016. [DOI: 10.20408/jti.2016.29.4.201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jihun Gwak
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Min A Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Byungchul Yu
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Kang Kook Choi
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
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34
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Complex Perineal Trauma with Anorectal Avulsion. Case Rep Surg 2016; 2016:4830712. [PMID: 27891285 PMCID: PMC5116523 DOI: 10.1155/2016/4830712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/13/2016] [Accepted: 10/18/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction. The objective of this case report is to illustrate a severe perineal impalement injury, associated with anorectal avulsion and hemorrhagic shock. Results. A 32-year-old male patient was referred to our hospital for an impalement perineal trauma, associated with complex pelvic fracture and massive perineal soft tissue destruction and anorectal avulsion. On arrival, the systolic blood pressure was 85 mm Hg and the hemoglobin was 7.1 g/dL. The patient was transported to the operating room, and perineal lavage, hemostasis, and repacking were performed. After 12 hours in the Intensive Care Unit, the abdominal ultrasonography revealed free peritoneal fluid. We decided emergency laparotomy, and massive hemoperitoneum due to intraperitoneal rupture of pelvic hematoma was confirmed. Pelvic packing controlled the ongoing diffuse bleeding. After 48 hours, the relaparotomy with packs removal and loop sigmoid colostomy was performed. The postoperative course was progressive favorable, with discharge after 70 days and colostomy closure after four months, with no long-term complications. Conclusions. Severe perineal injuries are associated with significant morbidity and mortality. Their management in high volume centers, with experience in colorectal and trauma surgery, allocating significant human and material resources, decreases the early mortality and long-term complications, offering the best quality of life for patients.
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