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Clinical exam
Imaging
Endoscopy
COLON 331
Bowel resection
Resection
Primary
anastomosis
Absolute indication
for surgery
Laparotomy
Repeat endoscopy
Resection
Stoma
No improvement
Second-look
laparotomy
FIGURE 66-2 Management of ischemic colitis. NPO, Nothing by mouth.
No indication
for surgery
NPO
Parenteral fluids
Antibiotics
Persisting or
worsening
symptoms
Symptomatic
improvement
Stricture
OUTCOME
e overall outcome of colonic ischemia is related to the severity of
the disease, the extent and region of colon aected, and the comorbidities of the patient. Determining the outcome of nonsurgically
managed ischemic colitis is dicult because of the varying severity of
the disorder. A 2012 meta-analysis evaluating 1049 patients showed
that colonic ischemia was managed nonoperatively in 80.3% of the
patients. Surgery was associated with 39.3% mortality, whereas the
ability to manage ischemia with supportive care was associated with
6.2% mortality. e higher mortality in the surgical group was a
reection of the greater severity of the disease. Lack of rectal bleeding, peritoneal signs, renal dysfunction, and right-sided ischemic
colitis correlated with severity of the disease, and right-sided disease
was most indicative of outcome. is series excluded patients aer
aorto-iliac surgery, for whom the mortality rates are higher in both
the supportive and surgical management arms. Interestingly, mortality associated with colectomy for colonic ischemia aer endovascular repair is higher than for ischemia that follows open surgery, even
though the rate of development of colonic ischemia is lower in the
former approach.
Right-sided colonic ischemia is associated with a vefold higher
need for resection and a twofold worse mortality. In a series of 273
cases of biopsy-proven colonic ischemia, 54.9% of the 71 patients
with isolated right-sided colonic ischemia as opposed to 10.9% of
the other patients needed surgery, and the mortality in the patients
with right-sided ischemia was 22.5% versus 11.9% in the other
patients.
In studies of the long-term follow-up of survivors, recurrence
rates were low (0 to 8.3%). In patients undergoing surgery, survival
was 63% at 2 years and 18% at 5 years. e only predictor of longterm survival aer surgery was the presence of mesenteric atherosclerosis and not the extent of the colectomy.
Restoration of intestinal continuity is high in patients with segmental ischemia who have undergone a resection with diversion.
Although most studies have low numbers, intestinal continuity was reestablished in 60% to 83% of patients, in contrast to patients with total
intestinal ischemia, who had a 33% restoration of intestinal continuity.
SPECIAL TOPICS
Ischemic Colitis after Aortic Surgery
e development of ischemic colitis aer abdominal aortic reconstructive procedures remains a challenging problem. It usually involves the
sigmoid colon and rarely the rectum. When postoperative colonoscopy is performed routinely on all patients, an incidence as high as
7% has been noted. When clinical criteria are used, the incidence is
only 1% to 2%. e risk of ischemic colitis is signicantly lower (0.5%
to 1.4%) aer endovascular repair. e mechanism of ischemia aer
endovascular repair is likely microembolization from the manipulation and dislodgment of atheroma or thrombus in the aneurysm sac
and not interruption of the inferior mesenteric artery (IMA).
e incidence of ischemic colitis aer repair of ruptured abdominal aortic aneurysms may be as high as 60%. Other risk factors
include prior colectomy (because of collateral interruption), hypogastric or mesenteric arterial occlusive disease, advanced age, and
preoperative hypotension. Patients with aneurysms may be at higher
risk than patients with occlusive disease because of better collateralization in the latter group. Upon preoperative arteriography, retrograde lling of the superior mesenteric artery (SMA) and the IMA
places the patient at a higher risk of postoperative ischemic colitis.
IMA reimplantation is important in such cases, as it is for patients
with severe bilateral hypogastric artery stenosis. On the other hand,
ManageMent of ColoniC isCheMia332
the presence of ow from the SMA to the IMA suggests that collateral colonic ow is adequate. If the IMA is found to be occluded or
severely stenosed, ligation is believed to carry little risk of ischemic
colitis. Ligation of the IMA should be carried out exactly at its origin
to avoid disruption of collateral pathways. Finally, aorto-bifemoral
bypass may decrease pelvic circulation if retrograde ow to the internal iliac vessels is not assured.
Several criteria have been proposed in an eort to predict which
patients might be at risk for postoperative ischemic colitis. Such
eorts are based on the assumption that direct colonic or pelvic
revascularization at the time of aortic reconstruction might lessen the
risk of postoperative ischemic colitis. Indeed, in one study in which
such aggressive revascularization was undertaken, the incidence of
endoscopically proved ischemic colitis was reduced to 3%, and all
cases were mild and nonfatal. Intraoperatively, the presence of IMA
back-bleeding does not guarantee protection from ischemic colitis.
However, the presence of an IMA stump pressure/systemic pressure
ratio greater than 0.4 has been reported to be associated with a low
likelihood of postoperative colonic ischemic aer IMA ligation.
Prevention of ischemic colitis aer aortic surgery is important
because its development is associated with a very high mortality rate.
In a study of U.S. veterans in whom such a complication developed,
the overall mortality rate was 54%. Colectomy was required in two
thirds of patients, and in that subgroup, the mortality rate was 89%.
Mean hospitalization time was longer than 1 month aer the diagnosis of ischemic colitis was made. None of the patients displayed evidence of aortic gra infection in the immediate postoperative period.
Early recognition of postoperative ischemic colitis is important
so that supportive measures can be instituted. Warning symptoms
include bloody or guaiac-positive diarrhea, especially early aer surgery, increased uid requirements, fever of uncertain causes, unexplained leukocytosis or thrombocytopenia, abdominal distention,
and acidosis. Treatment is similar to that for ischemic colitis in other
patients, although the threshold for colectomy should be lower to
avoid possible perforation. Patients treated nonoperatively should
undergo exible sigmoidoscopy every other day to assess the status
of the disease. Patients who undergo surgery require a colectomy, vigorous abdominal irrigation, omental patch covering of the retroperitoneum, and long-term antibiotic coverage.
Colonic Ischemia after Cardiopulmonary Bypass
e development of colonic ischemia aer cardiopulmonary bypass
surgery, although uncommon, is a lethal complication that is oen
associated with sepsis and multiple organ failure. e incidence of
bowel ischemia in this circumstance ranges between 0.06% and 0.2%.
Mortality averages 76%.
Evaluation of critically ill postoperative cardiac patients is dicult
because they are oen connected to a ventilator and sedated. In the
presence of blood in the stools, hemodynamic instability, or cardiac
parameters suggesting sepsis, colonoscopy should be strongly considered. A colonoscopy can be performed with a bowel preparation
or aer proctoscopy and gentle enemas. Physicians are oen reluctant
to allow patients to undergo major abdominal surgery in the period
immediately aer cardiac surgery. However, surgical intervention per
se is not associated with a signicant increase in mortality.
Gastrointestinal mucosal ischemia aer cardiopulmonary bypass is
likely to be related to the low ow state of bypass and is maintained
by splanchnic vasoconstriction. Contributing factors include systemic
hypovolemia, hypotension, and hypothermia. Cardiopulmonary bypass
exposes the blood to abnormal surfaces, resulting in blood coagulation
abnormalities, alterations in cells and proteins, liberation of biologically active substances, and activation of the complement cascade. is
sequence of events results in a reduction of blood ow throughout the
intestinal microcirculation. However, long bypass times, postoperative
use of inotropes, which may induce splanchnic vasoconstriction, and
use of an intraaortic balloon pump act as cumulative insults.
Ischemic Colitis Associated with Colon Carcinoma and Obstructing Colon Lesions
Patients may have symptoms of colonic ischemic or symptoms related
to primary cancer. Acute ischemic colitis also may masquerade as
colonic carcinoma. A biopsy should prove denitive. Repeat interval
endoscopy will add further assurance.
Obstructing lesions, including diverticulitis, volvulus, fecal
impaction, and strictures from prior ischemic insults, operations, or
radiation therapy may cause diminished colonic blood ow as a result
of the profound eects of sustained increased intraluminal pressure.
Because the tension in the bowel wall is greatest in the cecum, it is
this part of the colon that is usually ischemic.
Total Colonic Ischemia
A rare fulminant form of colonic ischemia that involves all or
most of the colon and rectum has been identified in a few patients.
These patients present with a sudden onset of bleeding, fever,
severe diarrhea, abdominal pain, and tenderness, often with signs
of peritonitis. They have sustained systemic insults that render the
entire colon susceptible to ischemia. The clinical course typically
accelerates rapidly. Management of the condition, similar to that
for other forms of fulminating colitis, requires total abdominal
colectomy and ileostomy. Further clinical deterioration mandates proctoscopy to evaluate any ischemia that may involve the
rectum.
In an effort to determine the outcome of patients with ischemic colitis, we compared patients who had segmental disease
with patients who had total colonic ischemia. Forty-three consecutive patients with ischemic colitis were identified and were
grouped into those with segmental ischemic colitis and those with
total colonic ischemia. The mean age was 68.8 years; 28 of the 43
patients (65%) were men. The diagnosis was established by colonoscopy in 31 of 43 (72%) of the patients during admission for
an unrelated illness. Ischemic colitis developed after surgery in
6 (14%) of these 43 patients. Segmental colitis was present in 31
of 43 (72%), and 12 (35%) of these 31 patients were successfully
managed nonoperatively. In the patients with segmental colitis
who required surgery, the 30-day mortality rate was 22%. Among
12 of 17 (71%) with segmental ischemia treated by resection and
stoma, 9 (75%) underwent eventual stoma closure. All 12 patients
with total colonic ischemia required surgery, and 9 of the 12 (75%)
died. Total colonic ischemia carries a worse prognosis than segmental colonic ischemia.
Ischemic Proctosigmoiditis
Rectal ischemia is rare because the blood supply is derived from
three arteries with independent origins. Although rectosigmoid
ischemia is usually accompanied by more proximal colonic involvement, it may occur alone. A retrospective review of all patients diag
nosed as having colonic ischemia at the Mayo Clinic from 1976 to
1991 revealed 10 of 328 patients with ischemia of the rectosigmoid
extending to no more than 30 cm above the dentate line. Among
these 10 patients, 6 had chronic disease and 4 had an acute presentation. ese patients were predominantly elderly and had atherosclerosis. An identiable precipitating factor such as a major illness
or hemodynamic disturbance was identied in a number of these
patients. CT oen revealed rectal wall thickening, and angiography
demonstrated atherosclerosis of the aortoiliac vessels. e investigators concluded that, in contrast to generalized colonic ischemia,
patients with acute rectal ischemia oen have a clearly identiable cause. Conservative management fares well for acute disease,
but complications such as stricture or perforation may develop in
patients with chronic disease.
-
COLON 333
CONCLUSION
Ischemic colitis covers a wide range of disease severity and presentation. Mild, self-limiting ischemia can be diagnosed on colonoscopy, requires no treatment, and has no sequelae. Severe ischemic
colitis usually occurs in patients hospitalized for other reasons, and
the diagnosis requires an informed, astute, and attentive clinician.
Management depends on the severity and extent of the ischemia, the
presence of peritonitis, and the severity of the comorbid illness. Most
patients can be successfully managed nonoperatively with attention
to hemodynamic and respiratory support. Surgery is indicated for
patients whose condition deteriorates despite appropriate medical
intervention. Unfortunately, the mortality rate for severe ischemic
colitis remains high because of the associated comorbidities. Further investigation may concentrate on methods of preserving colonic
blood ow during aortic and cardiovascular surgery and cytoprotective measures for ischemia and reperfusion.
S u g g e S t e d R e a d i n g S
Bharucha AE, Tremaine WJ, Johnson CD, Batts KP. Ischemic proctosigmoidi-
tis. Am J Gastroenterol. 1996;91:2305–2309.
Boley SJ, Schwartz S, Lash J, Sternhill V. Reversible vascular occlusion of the
colon. Surg Gynecol Obstet. 1963;116:53–60.
Gandhi SK, Hanson MM, Vernava AM, etal. Ischemic colitis. Dis Colon Rec-
tum. 1996;39:88–100.
Higgins PDR, Davis KJ, Laine L. Systematic review: the epidemiology of is-
chaemic colitis. Aliment Pharmacol er. 2004;19:729–738.
Longo WE, et al. Ischemic colitis complicating abdominal aortic aneurysm
surgery in the U.S. veteran. J Surg Res. 1996;60:351–354.
Longo WE, Ward D, Vernava AM, Kaminski DL. Outcome of patients with
total colonic ischemia. Dis Colon Rectum. 1997;40:1448–1454.
Miller A, etal. Ischemic colitis aer endovascular aortoiliac aneurysm repair:
a 10-year retrospective study. Arch Surg. 2009;144:900–903.
O’Neill S, Yalamarthi S. Systematic review of the management of ischaemic
colitis. Colorectal Dis. 2012;14:e751–e763.
Perry RJT, Martin MJ, Eckert MJ, et al. Colonic ischemia complicating
open vs endovascular abdominal aortic aneurysm repair. J Vasc Surg.
2008;48:272–277.
Reissfelder C, etal. Ischemic colitis: who will survive? Surgery. 2011;149:585–
592.
Sotiriadis J, Brandt LJ, Behin DS, Southern WN. Ischemic colitis has a worse
prognosis when isolated to the right side of the colon. Am J Gastroenterol.
2007;102:2247–2252.
West BR, Ray JE, Gathright JB. Comparison of transient ischemic colitis with
that requiring surgical treatment. Surg Gynecol Obstet. 1980;151:366–368.
C R
T
Scott R. Steele and Eric K. Johnson
INTRODUCTION
It seems as if surgeons have always debated the “proper” treatment of
colorectal injuries, including the following issues:
• Whenshouldcontinuitybe restored,andwhenshoulddiver-
sion be implemented?
• Should le-sided colon injuries be treated dierently from
right-sided colon injuries?
• Aredrainsusefulinrectalinjuries?
• Shoulddirectrepairbeastandardcomponentofsurgicalman-
agement of rectal trauma?
• Isrectalwashoutahelpfuloraharmfulprocedure?
Answersto these seemingly straightforwardquestionsarecontro-
versial. Our goal in this chapter is to provide answers based on the
current evidence and experience.
ETIOLOGY
Colon and rectal trauma occurs in 0.1% to 15% of injured patients,
depending on the underlying mechanism of the injury and the
environmentin which it occurs.Similarto trauma in other organ
systems, the causes of colorectal trauma can be divided into blunt
andpenetrating.Hollow-viscusinjuriesarelesscommonaerblunt
force trauma than with penetrating wounds and typically occur only
withhigh-energytransfer.Assuch,theyareoen accompaniedby
concomitant abdominal, thoracic, neurologic, and orthopedic inju-
ries. Injury patterns also dier between civilian life and wartime.
Withcombat zone experiences, in general, a higher incidence of
colonic injuries is reported (5% to 15%), whereas most civilian series
cite rates of less than 5%. Rectal injuries may occur as a result of a
direct injury from a projectile, as a result of bony fragments from
pelvic fractures, or via foreign body insertion. Finally, blast injuries,
suchasthoseseeninawarzoneorexplosion,arebecomingmore
commonplace and may result in damage to the colon or rectum
from either the pressure wave itself or from shrapnel caused by the
explosion.
DIAGNOSIS
Physical Examination
Assessment begins with a standard evaluation using Advanced
Trauma Life Support guidelines. Aer the primary survey and
concomitant resuscitation, a specic evaluation for colon and rectal injuries involves an abdominal examination with emphasis on
identication of injuries, exposed intra-abdominal contents, or
334
peritonitis that may mandate an urgent exploration (Fig. 67-1).
Rectal examination is performed to assess sphincter tone, presence
of blood, a high-riding prostate (i.e., a possible urethral injury), or
fragments that may indicate a bony injury to the rectal wall. Digital rectal examination (DRE) has had varying success in detecting
rectal injury. In a series of 77 patients who sustained penetrating
pelvic wounds, DRE was compared with rigid sigmoidoscopy.
Overall sensitivity for the detection of injury was higher with rigid
sigmoidoscopy (78% vs. 51%), with rates even higher for extraperitoneal (88%) versus intraperitoneal (58%) locations. is low
sensitivitywithDREhascausedsomeinvestigatorstoquestionits
utility as a part of the secondary evaluation; rather, they promote
reliance on a high index of suspicion using other clinical factors
such as the presence of gastrointestinal bleeding, urethral disruption, or spinal cord injury. Furthermore, DRE alone has had poor
correlation with determining the presence of concomitant injuries,
with one series reporting an accuracy of 23% (95% condence
interval [CI], 16% to 30%). Despite these concerns, DRE has little
downside, can demonstrate so tissue or sphincter injuries that
may need treatment (Fig. 67-2), and when combined with rigid
proctosigmoidoscopy, has the ability to identify injuries that otherwise may not be found with imaging alone. erefore, although a
negative examination doesn’t necessarily rule out an injury, a positive examination is critical, and surgeons should always have a high
index of suspicion for injuries.
Imaging
Imaging plays a major role in diagnosing colon and rectal injuries.
Similartootherhollow-viscusinjuries,perforationofthecolonor
intraperitoneal rectal wall may cause a pneumoperitoneum that is
best seen on an upright chest radiograph. In contrast, damage to
the extraperitoneal rectum or retroperitoneal portion of the colon
(such as that seen in ank stab wounds) may not demonstrate any
free air.
A focused assessment with sonography for trauma (FAST),
although not specic for colorectal trauma, may provide information
that can indicate a possible injury. Demonstration of intra-abdominal
free uid in the absence of a dened solid organ injury, especially
when it is more than trace pelvic uid, correlates with higher rates of
therapeuticlaparotomy aer blunttrauma is sustained. Other concomitant ndings such as a seat belt sign or a Chance-type spinal
fracture in this setting of free uid should lead to an even higher
degree of suspicion for an underlying clinically signicant visceral
injury. Ultrasonography also can be useful in perineal injuries to
conrm or identify suspected sphincter injuries (Fig. 67-3
to a tear during obstetric delivery, disruption of the external sphincter (Fig. 67-4) can be demonstrated by a lack of a continuous hyperechoic ring.
).Similar
FIGURE 67-1 Entry wound along the right nipple line (arrow) and
intraperitoneal fat visible along the right flank.
COLON 335
FIGURE 67-3 Rectal soft tissue injury.
FIGURE 67-2 Concomitant soft tissue injury of the left buttock.
(Courtesy Alec Beekley, MD.)
Computed tomography (CT) remains the mainstay of radiologic
testingforcolorectalinjuries.MostimagingpathwaysutilizeCTin
hemodynamically stable patients directly or aer identication of
freeuiduponFASTexamination.Sensitivities,specicities,negative
predictive value, and accuracy rates of greater than 95% have been
reportedinmanystudies.Withthewidespreadavailabilityofmulti-
row detector CT scans, scanning times have signicantly shortened,
and thin slicing has allowed demonstration of both direct bowel wall
damage and secondary signs of injury (i.e., free uid, inammation,
contrast extravasation, free air, and bony fragments). In addition, the
improved technology allows for evaluation of the tract of a projectile/bullet, which can provide some insight as to potential injuries
(Fig. 67-5, A-D). Various protocols are in place, including the use of
oral, rectal, and intravenous (IV) contrast material. In general, CT
of the head, chest, abdomen, and pelvis with IV contrast material
is used initially and permits identication of concomitant injuries.
Diagnostic Peritoneal Lavage
Diagnostic peritoneal lavage (DPL), although not specic for
colorectal injuries, may provide insight regarding a potential intraabdominal injury when it is used in select cases. Identication of
FIGURE 67-4 Blunt perineal injury with partial sphincter disruption.
bowel contents, gross blood, or bile is an indication for exploration.
Weoccasionallynd DPLuseful inindeterminatecases(e.g.,when
freeuidofanunknownsourceisidentiedwithFASTand/orCT)
or in situations in which when resources are limited (e.g., in a combat
environment) in patients without a denitive indication for surgery.
Laparoscopy
Laparoscopy is another useful modality for both the diagnosis and
treatmentof abdominal injuries. As with DPL, laparoscopyis not
specic for colorectal trauma. However, laparoscopy provides a minimally invasive approach to determine whether any intra-abdominal
injuries are present, such as those with free uid or blood per rectum with no identiable source, along with tangential injuries in
whichperitonealinjuryisinquestion.Historically,penetrationofthe
anterior fascia has been an indication for a standard open operative
exploration; however, in 25% to 60% of such cases, ndings of the
exploration were negative. Prospective series have shown that laparoscopy decreases the rate of nontherapeutic laparotomy from 59%
to0%aerstabwoundstotheabdomen.Laparoscopyisalsoauseful
method to determine occult diaphragm injuries in penetrating thoracoabdominal wounds. Laparoscopy has been combined with DPL
Colon and ReCtal tRauma336
AB
A
C D
FIGURE 67-5 A, Computed tomography (CT) demonstrating the missile tract from a gunshot to the back that tracked retroperitoneally. Arrows
mark the bullet track as visible by the air in the soft tissue on CT. B, Flank hematoma on physical examination. C, An intraoperative, retroperitoneal
hematoma identified on a CT scan. D, Mobilized colon without any injury.
techniquestodeterminewhetherafullexplorationisneeded.Finally,
laparoscopy provides the opportunity for surgeons with appropriate
experience and expertise to treat identied injuries in select cases.
Resection and anastomosis, primary repair of an injured segment of
bowel, ligation of bleeding vessels, and stoma creation are all possible
with a minimally invasive approach for surgeons skilled in perform-
ingadvancedlaparoscopictechniques.
TREATMENT
Although the nonoperative management of abdominal and pelvic
trauma, including penetrating injuries, has gained supporters as
experience has grown, this chapter will focus on operative treatment.
Itisimportanttorecognizethatalthoughnonoperativemanagement
has been successful in some clinically stable patients with the use of
high-quality imaging and reliable (repeatable) examination, these
patients are a highly select group without injury to the gastrointestinal tract, and thus nonoperative management should not be considered the standard of care.
Colon Injuries
Treatment of colon injuries has evolved signicantly during the past
several decades, with increasing acceptance of performing primary
repair or resection and primary anastomosis (with or without proximal diversion). Historically, any colonic injury mandated a stoma,
eitherviatheinjuryitself(byexteriorization)orproximaltotheinjury.
Exteriorization,whetherviatheinjuredsegmentorthroughutilization
of a tube, has essentially no role in present-day management. e use
of diversion versus primary repair remains somewhat contentious. In
theseminal1979studybyStoneandFabian,139patientswithcolonic
injurywererandomizedtoprimary anastomosis(withoutdiversion)
versus colostomy, with ndings of similar rates of infection (48% vs.
57%, P >.05) and mortality (1.5% vs. 1.4%, P >.05). Closer examination
of this cohort reveals 129 patients who underwent a mandatory colostomy because of shock, estimated blood loss greater than 1000 mL,
injury of more than two intra-abdominal organs, destructive wounds,
extensive peritoneal contamination, or a delay of more than 8 hours in
presentation.Severalprospectiveseriessincethenhavedemonstrated
notonlyequivalentbut superior outcomes(asuccessrateof73%to
85% in civilian series and 11% to 72% in military series) with primary
anastomosiscomparedwith diversion.Septic complications(10%to
34%), including anastomotic leak (0 to 10%), also have been similar
in both cohorts. In a 2003 Cochrane meta-analysis of all ve prospec-
tive randomized trials from 1966 to 2001, no dierence was found
in mortality between primary repair and diversion, although total
complications (odds ratio [OR], 0.28; 95% CI, 0.18-0.42), total infectious complications (OR, 0.41; 95% CI, 0.27-0.63), abdominal infections including dehiscence (OR, 0.59; 95% CI, 0.38-0.94), abdominal
infections excluding dehiscence (OR, 0.52; 95% CI, 0.31-0.86), wound
Suspected injury to the colon
COLON 337
If need for damage
control procedure —
perform
ICU care, rewarm,
resuscitate
Back to OR for
definitive
treatment
Immediate indication
to go to OR
Colon injury
Nondestructive
injury
Primary repair Resection
Consider Hartmann or anastomosis
and proximal diversion
Stable for further evaluation
present
Destructive
injury
Shock, transfuse
>4 units, comorbidities
Yes No
Anastomosis
Examination,
FAST, plain films,
Positive
labs, CT
Negative
Observe
Injuries in the military setting and those secondary to high-energy transfer may be more likely to require resection. This
should be taken into consideration when managing these individuals. Level 3 data indicate a higher rate of anastomotic
leakage in this population. Individual variations may be required, and nothing should replace proper surgical judgment.
FIGURE 67-6 Colon injury algorithm. C T, Computed tomography; FAST, focused assessment with sonography for trauma; ICU, intensive care unit;
OR, operating room. (Modified from Steele SR, Maykel JA, Johnson EK. Traumatic injury of the colon and rectum: the evidence vs dogma. Dis Colon Rectum.
2011;54:1184-1201.)
complications including dehiscence (OR, 0.55; 95% CI, 0.34-0.89), and
wound complications excluding dehiscence (OR, 0.43; 95% CI, 0.25-
0.76) all signicantly favored primary repair.
Stratifyingcoloninjuriesbythedegreeofinsultisalsohelpfulwhen
selecting management. Nondestructive injuries include wounds such
as tangential, through-and-through, or puncture-type injuries where
nodevascularizationispresentandlessthan50%ofthewallisinjured.
Destructive injures in which a signicant portion (>50%) of the colon
wallisdamagedordevascularizedoenarebesttreatedwithresectionof
that segment and either anastomosis or the Hartmann procedure. is
classication may assist in determining which operation to perform,
27%, P
=.373).Severefecalcontamination,transfusionofmorethan4
units of packed red blood cells within the rst 24 hours, and single-agent
antibiotic prophylaxis were all independently associated with increased
complications; however, outcomes were not dependent on the method of
colon management. Nonetheless, there is little to replace the judgment of
the surgeon at the time of the operation. Diversion still plays a role in the
management of colon injuries, and consideration for proximal diversion
or end colostomy should be given with the presence of risk factors such
as those previously listed or especially with any technical issue that may
compromise the integrity of the anastomosis and result in a higher rate
of anastomotic leakage (Fig. 67-6).
especially when considering the concomitant clinical condition. In 2003,
Maxwell and Fabian, who stratied cases by the presence or absence
of destructive wounds, recommended diversion for nondestructive
wounds only when there was a delay in presentation for more than 12
hours or in the setting of signicant fecal contamination. For destructive
wounds, these researchers recommended stoma placement for a delay
of more than 6 hours, signicant fecal contamination, or hypotension.
Other researchers have since adjusted these recommendations following
the multicenter trial by Demetriades and colleagues that involved 297
patientswithdestructivewoundsonly.Althoughthetreatmentwasnot
randomized,approximately two thirdsunderwent primary anastomo-
sis, with lower colon-related mortality in the primary anastomosis group
(0% vs. 4%, P = .012) and similar colon-related complications (22% vs.
Damage Control
Damage control surgery entails upfront control of hemorrhage and
prevention of further gastrointestinal contamination, followed by
aggressive rewarming, resuscitation, and stabilization (typically in
the intensive care unit) prior to returning to the operating room
for the denitive surgical procedure. Instituted to avoid the “lethal
triad of death”—hypothermia, coagulopathy, and acidosis—dam-
age control surgery is now commonplace in both the elective set-
tingandaertrauma.Althoughtheprincipleshaveledtosignicant
improvement in outcomes across surgical disciplines, including those
with colon and rectal trauma, it is important to consider that higher
Colon and ReCtal tRauma338
FIGURE 67-7 Open abdomen after an initial damage control proce-
dure. The patient was taken back to the operating room and underwent an end colostomy, and the abdomen was left open.
leakage rates, ventral hernias, and colon-related complications have
been reported in patients undergoing damage control laparotomy
followed by resection and anastomosis compared with patients who
underwent primary repair or resection and colostomy. Yet, although
the controversy regarding primary repair/resection and anastomosis
versus diversion continues, damage control surgery has provided a
useful tool in the surgeon’s armamentarium for select patients, and
it has dramatically improved outcomes when used appropriately. In
addition,aeraninitialdamagecontrollaparotomyandappropriate
resuscitation, a nonurgent decision can be made regarding whether
restoration of continuity or diversion is the most appropriate option
when the abdomen is re-evaluated (Fig. 67-7).
Rectal Injuries
Overview
Surgicaldogmaduringthepreviousseveraldecadesdictatedtheutilization of the “4 D’s” for any rectal injury—Diversion, Direct repair, Drainage, and Distal washout. In part, this approach was based on sound
logic;however,itwasalso based on small, typicallylow-qualityretrospective studies that melded various strategies and components of the
4D’sinreportingtheiroutcomes.Althoughtheliteraturehasadearth
ofhigh-qualityevidenceuponwhichtobaserecommendations,several
take-home points are still possible. First, diversion still plays a prominent and primary role in the successful treatment of most signicant
rectal injuries. In addition, intraperitoneal (i.e., upper) rectal injuries
can be managed in a manner similar to that used with colonic injuries.
Extraperitoneal rectal injuries, which we will primarily address in the
following sections, should be further stratied by location because of
the close proximity of adjacent vascular, bony, and genitourinary structures. Finally, the degree to which the other components of the 4 D’s
(other than diversion) play a role in the successful treatment of rectal
trauma, if any, is unknown and likely variable (Fig. 67-8).
Diversion
Whenencounteringa rectalinjury,in additiontothe location, the
degree and extent of trauma must be determined. Full-thickness,
midrectalinjuriesareobviouslyvastlydierentfromasmallpuncture
just above the dentate line and should be approached accordingly.
In general, any signicant extraperitoneal rectal injury should be
approached with a stoma—typically an end colostomy. Diverting the
fecal stream allows removal of the persistent incoming bacterial load
and should be considered with signicant perineal or sphincter injuriesaswell.Withastomainplace(withorwithoutother4-Dcomponents), pelvic sepsis rates range between 11% to 33% and overall
mortality is less than 7%, with both rates typically higher in a military setting. Diversion also should be considered in the context of the
patient’s clinical condition and associated injuries. Concomitant multisystem organ damage, including the rectum, has been demonstrated
in up to 50% of patients who sustain severe pelvic injuries in a combat
environment. For nonmilitary surgeons, similar injury patterns can
bedemonstratedaerhigh-energy explosionssuchasanindustrial
accident or terrorist bombing. Although successful nondiversion
strategies for nondestructive rectal injuries have been reported, it is
not common practice and, in general, should be avoided.
Direct Repair
Even with the use of diversion, debate remains about the utility of
closureof rectal wounds. Similar to a transanal excision of a low-
lying rectal tumor, extraperitoneal wounds do not necessarily have
tobe closed. Several authorshavereported no dierence in pelvic
sepsis rates with and without closure of the wall defect, with no rectal
injury-related mortality. Upper wounds, even below the peritoneal
reection,areoeneasilyrepaired,asarelow-lyingwounds,typically
from a transgluteal or transanal penetrating injury. Using a selective
approach, infectious complications range from 2% to 35%, with difculty in the heterogeneity of the treatment strategies and degree of
the injuries themselves. Despite the limited evidence, direct repair
does not appear to be necessary with the use of diversion, and extensive time and dissection in the operating room to repair these injuries
should likely be avoided.
Drainage
Pelvic drainage of rectal injuries can be accomplished through a
transabdominal or perineal approach. Proponents of presacral drainage cite the ability to provide a route of egress for contaminated uid
and blood to ultimately allow the space to collapse, especially in cases
where no direct repair has been performed. Opponents note that, as
traditionally taught, this procedure may open up planes that are not
aectedforlittleprovenbenet.Interestingly,thewidespreaduseof
presacraldrainsinthissettingcanbetracedbacktotheVietnamWar,
at which time a small retrospective study reported a twofold reduc-
tioninpelvicinfectionswiththeuseofdrains.Sincethen,drainage
has become a routine part of management strategy of extraperito-
nealinjuriesdespitelimitedevidencedemonstratingitseectiveness.
In fact, several authors have noted that drains are not a necessary
component of treatment for these wounds, especially when diversion
is employed; they cite infectious complication rates of less than 15%
withorwithoutuseofdrains.Similartodirectrepair,thedegreeto
which drainage prevents infection is undetermined and is likely to be
minimal at best, especially with the use of diversion. Yet, with large
destructive wounds, pelvic cavities, and increased serosanguineous
drainage that may be a source for bacterial (and abscess) proliferation, a short trial of drainage may be warranted.
Distal Washout
Clearing the rectum of the residual stool via distal rectal washout
constitutes the nal “D” in traditional rectal trauma management.
Advocatesbelievethatdistalwashoutwillremoveapotentialsource
of pelvic abscess, especially in light of the fecal diversion that normally accompanies it. Distal rectal washout can be accomplished in
severalways,althoughmosttechniquesinvolveusinga device such
as a large rectal proctoscope to hold open the sphincter complex to
Trauma with possible rectal injury
eN
COLON 339
If need for damage
control procedure—
perform
ICU resuscitation,
rewarm
Back to OR for
definitive treatment
Destructive DestructiveNondestructive Destructive Nondestructiv
Resection
No shock, etc
Anastomosis
Immediate OR
indication
Intraperitoneal
Shock,
transfusion
Consider
Hartmann or
anastomosis and
proximal
diversion
Rectal injury; determine
location and extent
injury
Primary
Repair
Presence of shock, need for transfusion of 4 units or more of blood products, degree of
contamination, time from injury, patient comorbidities, and nature and extent of associated
injuries should all be taken into consideration. Shock and transfusion requirement have
been associated with anastomotic leakage and septic complications in some studies.
Physical examination,
rigid proctoscopy, CT scan
OR
Extraperitoneal
injury
Consider low Hartmann
vs. diversion alone
Presacral drainage, distal washout, and direct repair can be used at the
discretion of the operating surgeon. These methods cannot be recommended
across the board given the lack of evidence supporting their use and benefit.
Positive
(visualized injury)
Diversion
alone
Combined Injury
Consider low
Hartmann
Negative
Observe
ondestructive
Direct repair
if possible
with proximal
diversion
FIGURE 67-8 Rectal injury algorithm. ICU, Intensive care unit; OR, operating room. (Modified from Steele SR, Maykel JA, Johnson EK. Traumatic injury of
the colon and rectum: the evidence vs dogma. Dis Colon Rectum. 2011;54[9]:1184-1201.)
permit egress of stool and either proximal or distal irrigation of fecal
matter. Opponents note that in the presence of a rectal injury, the
irrigation will force stool into tissue planes (i.e., presacral or mesorectal) that otherwise would not come in contact with a large bolus
of feces, thus increasing the chances of infection. Limited data are
available to support (or refute) its utility, although several series have
demonstrated that diversion alone, without any distal washout, is not
associated with an increase in pelvic septic complications.
explorationareoenwarranted.Intheoperatingroom,alaparotomy
with removal of the foreign body and determination of the extent and
locationoftheinjuryshouldbeperformed.Similarto the concepts
presentedpreviously,theinjurymayrequireresection/repairwithor
without diversion. For stable patients with a suspected extraperito-
neal rectal injury, a CT scan may provide added information regard-
ingthedegreeandlocationoftheinjury.esepatientsoenrequire
anexaminationaerinductionofanesthesia,endoscopy,andforeign
body removal with or without repair or diversion as stated with other
Rectal Foreign Bodies
Iatrogenic or self-induced injury to the rectum via a foreign body
mayresult frommany dierent objects. It is important to keep in
mind the character (i.e., size, shape, andconsistency) of the incit-
ing item, which may play a primary role in the method used for its
removal. e most important initial step in the evaluation of these
patients is to determine whether a perforation of the rectum/sigmoid colon has occurred. e history and physical examination may
help identify peritonitis, which typically mandates surgical exploration, whereas plain abdominal lms may demonstrate free air, signifying a hollow viscous injury. If a perforation into the peritoneal
cavity is present, immediate resuscitation, antibiotics, and surgical
extraperitoneal rectal injuries.
For clinically stable patients with no signs of perforation, seda-
tionremainsthekeytoremoval.Adequaterelaxationviaconscious
sedation,andoenananalblockwithalocalanesthetic,canbeper-
formed in the emergency department or operating room to aid in
foreignbody removal. Weuse Xylocaine1%with epinephrine and
bupivacaine 0.5% with epinephrine in a 50:50 mix for a circum-
ferentialanal block. Wealso favor using high lithotomywith stir-
rups to permit use of concomitant abdominal pressure to facilitate
downward displacement of the foreign body toward the anus, when
required.Careshouldbetakentoavoidtraumatothesphinctercom-
plex; gentle dilation with two to three ngers will aid in this maneu-
ver.Althoughforcepsorclampsoccasionallymayberequired,oen
Colon and ReCtal tRauma340
digital extraction is the safest and most reliable method for removal.
Otherdescribed techniquesincludeendoscopic snares, Foley catheter placement above the object to pull it out, and installation of air
above the object to “break the vacuum seal” created by the rectal wall.
Once the object is removed, endoscopy and plain lms can aid in
conrming the absence of a perforation and evaluating the status of the
rectalwall(i.e.,ischemiaandnoresidualforeignbody).Althoughmost
objects may be safely removed transanally, a transabdominal approach
utilizingdirectpalpation/milkingoftheobjecttotheanusoracolostomymayberequired.Inmostcasesacolostomymaybeavoided,but
thesurgeon’sjudgmentisrequiredtomakethisdecisionbasedonthe
clinical condition of the patient and the rectum at the time of removal
of the object. Finally, it is important to consider the patient’s mental
condition following this episode, especially in cases of assault, and
mental health consultation should be considered as needed.
S u g g e S t e d R e a d i n g
Cleary RK,PomerantzRA, Lampman RM. Colon and rectal injuries. Dis Co-
lon Rectum. 2006;49(8):1203–1222.
Demetriades D, Murray JA, Chan L,etal.Penetratingcoloninjuriesrequir-
ingresection: diversionor primary anastomosis? An AAST prospective
multicenter trial. J Trau ma. 2001;50:765–775.
GlasgowSC,SteeleSR, Duncan JE, Rasmussen TE. Epidemiology of modern
battleeld colorectal trauma: a review of 977 coalition casualties. J Trauma
Acute Care Surg.2012;73(6suppl5):S503–S508.
Goldberg JE, Steele SR. Rectal foreign bodies. Surg Clin North Am.
2010;90(1):173–184.
SteeleSR, Maykel JA, Johnson EK. Traumatic injury of the colon and rectum:
the evidence vs dogma. Dis Colon Rectum. 2011;54(9):1184–1201.