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22
Colon and Rectal Trauma and Rectal
Foreign Bodies
Demetrios Demetriades and Ali Salim
Colon Injuries
The management of colon injuries has been one of the most
controversial issues in trauma and has undergone many radical changes in the last few decades. Despite the dramatic
reduction of colon-related mortality from about 60% during
World War I to about 40% during World War II to about 10%
during the Vietnam War and to lower than 3% in the last
decade, the colon-related morbidity remains unacceptably
high. The abdominal sepsis rate has remained at about 20% in
most prospective studies in the last decade (Table 22-1).
No other organ injury is associated with a higher septic
complication rate than colon. In some subgroups of patients
with colon injuries in the presence of Penetrating Abdominal Trauma Index (PATI) >25 or with multiple blood
transfusions, the incidence of intraabdominal sepsis has
been reported to be as high as 27%.
tive colon injuries requiring resection, the reported incidence
of abdominal complications is about 24%.
have attempted to identify risk factors for complications and
optimize the treatment.
7
In patients with destruc-
6
Many studies
Epidemiology
The vast majority of colon injuries are caused by penetrating
trauma. In American urban centers, firearms are by far the
most common cause of injury. In anterior or posterior abdominal gunshot wounds, the colon is the second most frequently
injured organ after the small bowel and it is involved in about
27% of cases undergoing laparotomy.
stab wounds, the colon is the third most frequently injured
organ after the liver and small bowel and an injury is found in
about 18% of patients undergoing laparotomy. In posterior
stab wounds, the colon is the most frequently injured organ
and is injured in about 20% of patients undergoing laparo-
10
tomy.
frequently affected segment. In stab wounds, the left colon is
the most frequently injured segment, probably because of the
predominance of right-handed assailants.
In gunshot wounds, the transverse colon is the most
8,9
In anterior abdominal
1–6
Blunt trauma to the colon is uncommon and is diagnosed in
about 0.5% of all major blunt trauma or in 10.6% of patients
undergoing laparotomy.
thickness and only 3% of patients undergoing laparotomy
have full-thickness colon perforations.
the most common cause of blunt colon injury. Deceleration
injuries may cause avulsion of the colon from the mesentery
resulting in ischemia but blowout perforations caused by transient closed loop formation may occur as well. Seatbelts
increase the risk of hollow viscous perforations and the presence of a seatbelt mark sign is a predictor of hollow viscous
injury. In rare cases, colonic wall hematoma or contusion may
result in delayed perforation several days after the injury. The
left colon is the most frequently injured segment followed by
the right colon and the transverse colon.
11,12
Most of these injuries are partial
11,13
Traffic trauma is
11
Diagnosis
The diagnosis of colon injury is almost always made intraoperatively. However, with the introduction of selective nonoperative management of penetrating abdominal trauma, there has
been a concern of missing colon injuries. This is particularly
important in penetrating injuries of the back because small
retroperitoneal colon injuries may not give early clinical signs.
A rectal examination may show blood in the stool, especially
in cases with distal colon or rectal injuries. A preoperative
erect chest film may show the nonspecific presence of free air
under the diaphragm. The colon can reliably be evaluated by
soluble enema studies or abdominal computed tomography
(CT) scan with soluble rectal contrast. Retroperitoneal gas or
contrast extravasation are diagnostic and an exploratory
laparotomy should be performed. Other investigations, such as
ultrasound or diagnostic peritoneal lavage have no role in the
evaluation of suspected colon injuries.
The preoperative diagnosis of colon injury after blunt
trauma can be a major challenge, especially if the patient is
unevaluable because of severe associated head injuries. The
diagnosis may be suspected by the presence of free gas or
thickened colonic wall on the routine abdominal CT scan. In
322
22. Colon and Rectal Trauma and Rectal Foreign Bodies 323
TABLE 22-1. Incidence of abdominal septic complications in colon
injuries (prospective studies)
Author No. of patients Abdominal sepsis (%)
1
George et al.,
Chappuis et al.,
Demetriades et al.,
Ivatury et al.,
Gonzalez et al.,
Demetriades et al.,
Overall 921 22
1989 102 33
2
1991 56 20
3
1992 100 16
4
1993 252 17
5
1996 114 24
6
2001 297 24
some cases, the diagnosis may be delayed by many days with
catastrophic consequences.
Intraoperatively, every paracolic hematoma caused by penetrating trauma should be explored and the underlying colon
should be evaluated carefully. Failure to adhere to this important surgical principle is a serious error with medical and legal
implications. Paracolic hematomas caused by blunt trauma
should not undergo routine exploration unless there is evidence of colon perforation.
Colon Injury Scale
The American Association for the Surgery of Trauma
(AAST) developed a grading system for organ injuries in
order to have objective criteria for the classification of the
severity of the injury and enable reliable comparisons of
results. On the basis of the injury grade, an Abbreviated
Injury Score is assigned and may be used for the calculation
of the Injury Severity Score (ISS). The AAST Colon Injury
Scale is shown in Table 22-2.
Operative Management
Historical Perspective
The first guidelines regarding the management of colon
injuries were published by the United States Surgeon General
and mandated proximal diversion or exteriorization of all
colon wounds.
of the very high mortality of colorectal injuries during the
early years of World War II. The mortality in both civilian and
military reports exceeded 50%.
were not based on any scientific evidence, they were credited
TABLE 22-2. AAST Colon Injury Scale
Grade Injury description
I a) Contusion or hematoma without devascularization
II Laceration ≤50% of circumference
III Laceration >50% of circumference
IV Transection of the colon
V Transection of the colon with segmental tissue loss
14
This unusual directive was initiated because
15,16
Although these guidelines
b) Partial thickness laceration
for the significant reduction of mortality in the last years of
the war. However, during this period, many other major
changes in trauma care took place. Faster evacuation from the
battlefield and early definitive care, improved resuscitation
protocols, and introduction of penicillin and sulfadiazine
could all have contributed to the reduction of mortality. The
policy of mandatory colostomy for all colon injuries remained
the unchallenged standard of care until the late 1970s. Stone
17
and Fabian
reported the first major scientific challenge of
this policy in 1979. In a prospective, randomized study, which
excluded patients with hypotension, multiple associated
injuries, destructive colon injuries, and delayed operations,
the authors concluded that primary repair was associated with
fewer complications than colostomy. The exclusion criteria
were perceived as risk factors for anastomotic leak and were
absolute indications for diversion.
With mortality rates attributable to colon-related complications improving over the next few years, surgeons challenged
the validity of the “standard” contraindications for primary
repair or resection and anastomosis. A few prospective randomized studies with no exclusion criteria (class I evidence)
confirmed the safety of primary repair, at least in nondestructive colon injuries. Another alternative to primary repair or
colostomy was exteriorized repair, which was introduced in
the 1970s. With this technique, the sutured colon was exteriorized and observed for 4–5 days. If the repair remained intact
during this period of observation, the colon was returned to
the abdominal cavity. If the repair leaked, it was converted to
a loop colostomy.
18,19
The enthusiasm for this approach
waned in the 1980s because of the overwhelming evidence of
the superiority of primary repair.
In the 1990s and 2000s, primary repair became the standard
of care in most cases although there is still some skepticism by
many surgeons, especially in the presence of certain risk factors such as destructive colon injuries, severe contamination,
multiple injuries, and delays in treatment.
Nondestructive Colon Injuries
There is now enough class I evidence (prospective, randomized studies) supporting primary repair in all nondestructive
colon injuries (injuries involving <50% of the bowel wall and
without devascularization) irrespective of risk factors.
Chappuis et al.
exclusionary criteria concluded that primary repair should be
considered in all colon injuries irrespective of risk factors.
In another landmark study, Sasaki et al.
71 patients with colon injuries to either primary repair or
diversion, without any exclusionary criteria. The overall complication rate was 19% in the primary repair group and 36%
in the diversion group. In addition, the complication rate for
colostomy closure was 7%. The authors concluded that
primary repair is the method of choice of treatment of all
penetrating colon injuries in the civilian population despite
any associated risk factors for adverse outcome.
2
in a randomized study of 56 patients with no
20
randomized
324 D. Demetriades and A. Salim
Gonzalez et al.5published another important prospective, randomized study in 1996. The authors randomized 109 patients
to primary repair on diversion, independent of any risk factors.
The sepsis-related complication rate was 20% in the primary
repair group and 25% in the diversion group. In the presence
of certain risk factors, such as severe fecal contamination,
shock on admission, blood loss 1000 mL, or more than two
associated organ injuries, the diversion group had a higher
complication rate, although this difference did not reach statistical significance. Gonzalez et al.
21
continued their study
and the series increased to 176 patients with penetrating colon
injury. The study concluded again that in civilian trauma, all
penetrating colon injuries should be primarily repaired.
Overall, collective review of all available prospective, randomized studies (class I evidence) identified 160 patients with
primary repair and an incidence of 13.1% of abdominal sepsis complications. In the group of 143 patients treated with
diversion, the abdominal sepsis complication rate was 21.7%
(Table 22-3). In addition to the available class I evidence,
numerous prospective observational studies (class II evidence) demonstrated the superiority of primary repair over
diversion in nondestructive injuries.
1,3,4,22
In conclusion, there
is sufficient class I and II data to support routine primary
repair of all nondestructive colon injuries, irrespective of risk
factors for abdominal complications. No study has ever
shown that colostomy is associated with better results than
primary repair.
Despite the available scientific evidence, there is still some
skepticism about liberal primary repair and many surgeons
still consider colostomy as the procedure of choice in many
colon injuries. In a survey of 317 Canadian surgeons in 1996,
75% of them chose colostomy in low-velocity gunshot wounds
to the colon.
23
In another survey of 342 American Trauma
Surgeons, members of the AAST, a colostomy was the procedure of choice in 3% of colon perforations with minimal
spillage, in 43% of perforations with gross spillage, in 18% of
colon injuries involving >50% of the wall, and in 33% of cases
with colon transection.
24
It is obvious that old traditions still
have a significant role in modern trauma surgery.
Destructive Colon Injuries
Until recently, there was no sufficient class I or II data regarding the management of destructive colon injuries requiring
resection (loss of >50% of bowel wall or devascularization).
The available prospective, randomized studies included only
36 patients with colon resection and anastomosis. The overall
incidence of anastomotic leak was 2.5% and no deaths
occurred. All these studies recommended primary anastomosis
irrespective of the presence of any risk factors for abdominal
2,20,21
complications.
study on colon injuries by Cornwell et al.,
In a recent prospective but not randomized
7
there were 25
patients with destructive colon injuries treated by resection
and anastomosis and two patients treated by resection and
colostomy. All patients had a PATI >25 or were transfused
with >6 units of blood or the operation was delayed by >6
hours from the time of injury. There were two anastomotic
leaks (8%) and both were fatal. The study concluded that some
high-risk patients with destructive colon injuries might benefit
from diversion. Unfortunately, the study did not include
enough patients with diversion for comparison with the primary anastomosis group. There are two retrospective studies,
which included only destructive colon injuries requiring resection: Stewart et al.
25
analyzed 60 patients, 43 of whom were
managed by resection and anastomosis and 17 by diversion.
The overall anastomotic leak rate was 14% and in the subgroup of patients with blood transfusion >6 units, the leak rate
was 33%. The authors suggested that primary anastomosis
should not be performed in patients receiving massive blood
transfusions or in the presence of underlying medical illness.
Another retrospective study from Los Angeles analyzed the
complications in a series of 140 patients with destructive colon
injuries requiring resection.
26
The incidence of intraabdominal
sepsis was similar in the groups with primary anastomosis or
diversion. Univariate analysis identified Abdominal Trauma
Index >25 or hypotension in the emergency room to be associated with increased risk of anastomotic leak. The study suggested that a diversion procedure might be appropriate in these
high-risk subgroups of patients.
In summary, the available prospective, randomized studies,
which include only a small number of cases, recommend resection with anastomosis irrespective of risk factors. Two large retrospective studies advocate diversion in the subgroups of
patients with certain risk factors such as PATI >25, multiple
blood transfusions, or associated medical illness.
25,26
The
guidelines of the Eastern Association for the Surgery of
Trauma published in 1998
27
supported resection and primary
anastomosis in the subgroups of patients with destructive colon
injuries if they are a) hemodynamically stable intraoperatively,
b) have minimal associated injuries (PATI < 25, ISS < 25), c)
have no peritonitis, and d) have no underlying medical illness.
The guidelines suggest that patients with shock, significant
associated injuries, peritonitis, or underlying disease should be
managed with resection and colostomy.
27
However, these
TABLE 22-3. Primary repair versus diversion: prospective, randomized studies with no exclusion criteria
Primary Repair Diversion
Study No. of patients Abdominal septic complications (%) No. of patients Abdominal complications (%)
Chappuis et al.
Sasaki et al.
Gonzalez et al.
Total 160 21(13.1) 143 31(21.7)
2
20
21
28 4(14.3) 28 5(17.9)
43 1(2.3) 28 8(28.6)
89 16(18) 87 18(21)
22. Colon and Rectal Trauma and Rectal Foreign Bodies 325
guidelines were based on class III evidence. In their review of
the literature, there were only 40 patients in class I studies with
resection and anastomosis and the anastomotic leak rate was
2.5% and without mortality. In class II studies, there were only
12 patients who underwent resection and anastomosis and the
leak rate was 8.3% without mortality. In class III retrospective
studies, there were 303 patients with a leak rate of 5.2% and
three deaths (1%) as a result of the leak.
In view of the lack of large prospective studies in the literature, the AAST sponsored a prospective multicenter study to
evaluate the safety of primary anastomosis or diversion and
identify independent risk factors for colon-related complications in patients with destructive colon injuries requiring
resection.
6
The study included 297 patients with penetrating
injuries requiring colon resection (rectal injuries were
excluded) that survived at least 72 hours. The overall colonrelated mortality was 1.3% (four deaths) and all deaths
occurred in the diversion groups (P = .01). The overall incidence of abdominal complications was 24% and the most
common complication was an intraabdominal abscess (19%
of patients) followed by fascia dehiscence (9%). The incidence of anastomotic leaks was 6.6%. Multivariate analysis
identified three independent risk factors for abdominal complications: severe fecal contamination, >4 units of blood
transfusions within the first 24 hours, and single-agent antibiotic prophylaxis. If all three risk factors were present, the incidence of abdominal complications was about 60%, if any two
factors were present the complications rate was 34%, if only
one factor was present this figure was about 20%, and with no
risk factors it was 13%. The method of colon management,
delay of operation >6 hours, shock at admission, site of colon
injury, PATI >25, ISS >20, or associated intraabdominal
injuries were not found to be independent risk factors. In a
second analysis, the group of patients with primary anastomosis was compared with the group with diversion, using
multivariate analysis which controlled for PATI >25, transfusion >6 units of blood, >6 hours’ delay of operation, shock at
admission, and severe fecal contamination. These factors
have been described in previous studies as significant risks for
abdominal complications. With colon diversion serving as
reference (RR 1.00) for comparison, the adjusted relative risk
of primary anastomosis was exactly the same (1.00).
In a similar analysis according to subgroups with ileocolostomy, colocolostomy, ileostomy, and colostomy, the
adjusted relative risk of abdominal complications was similar.
In another analysis, all patients were classified into either a
high-risk group (if any of the following factors was present:
hypotension at admission, blood transfusions >6 units, delay of
operation >6 hours, severe peritoneal contamination, or PATI
>25) or a low-risk group if the above factors were not present.
These risk factors are considered by many surgeons as strong
indications for diversion. The colon-related mortality in the
high-risk patients was 4.5% (4 of 88 patients) in the diversion
group and no deaths in the 121 patients who underwent primary
anastomosis (P = .03). Multivariate analysis showed that the
adjusted relative risk of abdominal complication in patients
with primary anastomosis or diversion was similar, in both the
low-risk and high-risk patients (Table 22-4). There was a trend
toward shorter intensive care unit and hospital stay in the primary anastomosis group. The study concluded that “In view of
these findings and the fact that colon diversion is associated
with worse quality of life and requires an additional operation
for closure, colon injuries requiring resection should be managed by primary repair, irrespective of risk factors.”
6
Damage
control procedures with abdominal packing and temporary closure of the abdominal wall with a prosthetic material pose a
special dilemma regarding the management of destructive
colon injuries. No studies have ever addressed this issue and the
existing practices are based on personal beliefs and experience.
The authors advocate primary anastomosis because of the theoretical disadvantages of having a colostomy, which is an open
source of fecal material, near an open abdomen. The only conditions for which there is agreement for colostomy are the presence of severe colon edema or a questionable blood supply of
the colon. In these situations, at least theoretically, a diversion
procedure might be a safe option.
Risk Factors for Abdominal Complications
The abdominal complication rate in colon injuries is very
high, with a sepsis rate of about 20% (Table 22-1). In destructive colon injuries requiring resection, the prospective AAST
colon resection study of 298 patients recorded an overall
incidence of 24% of abdominal complications. Many studies
attempted to identify risk factors for complications and on the
basis of these risks to modify the treatment.
Left Versus Right Colon Injuries
For many years and until recently, there was an anecdotal perception that left colon injuries are associated with a higher
risk of anastomotic leaks and septic complications than right
T
ABLE 22-4. AAST colon resection study: comparison of abdominal complications between primary anastomosis and diversion in high- and
low-risk patients
Patient population abdominal complications (%) complications (%) Adjusted relative risk (95% CI) P value
All patients 22 27 0.81 (0.55–1.41) .69
Low-risk patients
High-risk patients
*
High-risk patients were those with PATI >25 or severe fecal contamination or 6 hours from injury to operation or transfusion of >6 units of blood pre-/intra-
operatively systolic blood pressure ≤90 mm Hg. Low-risk patients were those without any of the above risk factors.
6
Primary anastomosis: Diversion: abdominal
*
*
13 8 1.26 (0.21–8.39) .82
28 30 0.90 (0.53–1.40) .67
326 D. Demetriades and A. Salim
colon injuries. This perception was based on theoretical reasons (different anatomy and blood supply, higher concentration of bacteria, and poorer healing properties in the left
colon) rather than clinical evidence. This perception led surgeons to advocate liberal primary repair of right colon
wounds and colostomy in left colon wounds. However, no
clinical or experimental study has ever demonstrated any
healing differences between the two sides of the colon or any
evidence that the two anatomic sides should be treated differently. Experimental work in baboons, which have very similar anatomy and bacteriology with humans, showed no
difference of the healing properties between the right and left
28
colon.
right colon and a 10-cm segment of left colon and primary
anastomosis, without any mechanical or chemical preparation
The study involved resection of a 10-cm segment of
FIGURE 22-2. Breaking strengths of the right and left colon are similar (values in N/mm
2
).
of the colon. The healing of the anastomosis was assessed at
autopsy 7 days postoperatively (leak, local abscess), mechanically by measuring the breaking strength of the anastomosis,
and biochemically by measuring the hydroxyproline concentrations at the anastomotic site. The study showed identical
healing properties of the two sides of the colon.
28
In another study using the same model, one of the authors
evaluated the effect of hypovolemia (blood loss of 20 mL/kg)
not affect the incidence of abdominal sepsis.
ies have suggested that the creation of an ostomy in these highrisk patients may independently contribute to abdominal
30
sepsis.
The current class I and II literature supports primary
repair or resection and anastomosis in patients with severe or
multiple associated abdominal injuries.
3,5–7,30
Some stud-
on healing of the left and right sides of the colon and again no
differences were found
29
(Figures 22-1 and 22-2).
Shock
Associated Abdominal Injuries
Earlier studies suggested that multiple or severe associated
intraabdominal injuries (PATI >25) are associated with a high
incidence of septic complications and they were considered as
contraindications for primary repair of the colon.
was considered even more critical in destructive colon injuries
and was suggested as indication for diversion.
class I and II studies have shown that although multiple associated intraabdominal injuries are significant risk factors for
intraabdominal sepsis, the method of colon management does
4,7
This factor
26,27
However,
There is now sufficient class I and II evidence that preoperative or intraoperative shock is neither an independent risk
factor for abdominal sepsis nor a contradiction for primary
colon repair or anastomosis.
3,5,6
Blood Transfusions
Multiple blood transfusion (>4 units of blood within the first
24 hours) has been shown to be a major independent risk fac-
6,30
tor for abdominal septic complications.
In a large prospective AAST study of 297 patients with penetrating destructive
colon injuries requiring resection, blood transfusion was the
most critical independent factor for abdominal sepsis [adjusted
relative risk (RR), 2.0; 95% confidence interval (CI),
1.31–2.83; P = .001].
6
However, the method of colon management did not influence the complication rate in this group of
patients and primary anastomosis was recommended.
6
Injury Severity Score
The ISS is not an independent risk factor for abdominal sepsis and high ISS (>15) is not a contraindication for primary
repair or anastomosis.
3,6
Fecal Contamination
FIGURE 22-1. Hydroxyproline concentrations (biochemical marker of
wound healing) are similar in both sides of the colon (values in μg/mg).
Severe fecal contamination of the peritoneal cavity is a major
independent risk factor for abdominal sepsis.
1,6,11,26,30,31
This
finding led some studies to suggest that the presence of severe
contamination should be a contraindication for primary repair
22. Colon and Rectal Trauma and Rectal Foreign Bodies 327
or anastomosis.
1,11,31,32
However, all prospective, randomized
studies and recent large prospective observational studies
have shown that the method of colon management in this
group of patients does not influence the septic complication
rate and recommended primary repair or anastomosis.
2,5,6
Specific Associated Abdominal Injuries
There is class III evidence that the combination of colon
injuries with pancreatic or ureteric injuries is associated with
33,34
an increased incidence of septic complications.
However,
there is no evidence that the presence of any of these injuries
is a contraindication for primary repair or anastomosis.
6
Time from Injury to Operation
The length of delay of surgical repair over which the septic
complication rate increases is not well defined. Some studies
suggest >6 hours whereas others >12 hours as the critical
delays associated with an increased risk of infections.
7,22,26,35
seems that the degree of contamination is much more important than the delay in surgical management and the time delay
in itself should not be used as a criterion for primary repair or
diversion. In a prospective study of 297 destructive colon
injuries, the incidence of abdominal complication was 11.4%
(4/35) in the group of patients with preoperative time >6 hours
and 26.1% in patients with times <6 hours. Multivariate analysis failed to identify time delay as an independent risk factor.
Retained Missiles
Missiles, which passed through the colon and remained
lodged in the tissues, are not associated with increased risk of
local sepsis and they should be removed only if it is technically easy and does not prolong the operation. In a study of 84
patients with gunshot wounds of the colon, the bullet
remained in the body in 40 and was removed in 44. The incidence of local septic complications was 5% in patients with
retained bullets and 7% in those without.
36
Anatomic Location of Colon Injury
There is a plethora of classes I, II, and III evidence that the incidence of complications is similar in right and left colon injuries.
Temporary Abdominal Wall Closure
Damage control laparotomy and temporary abdominal wall
closure with prosthetic material seem to be associated with
increased incidence of abdominal septic complications. The
crude relative risk of abdominal sepsis in patients with temporary abdominal wall closure has been reported to be 2.12
(1.32–3.40) (P = .005) in a study of 297 of destructive colon
injuries requiring resection. However, multivariate analysis
failed to identify this method as independent risk factor.
There is no literature addressing the optimal management of
colon injuries in this group of patients. The authors prefer
primary repair or resection and anastomosis, to avoid a
colostomy near an open abdomen.
Anastomotic Leaks
Colon leaks remain the most serious complication in repaired
or anastomosed colons. The overall incidence of suture line
failures is fairly low. In a collective review of 35 prospective
or retrospective studies with 2964 primary repairs, Curran
reported 66 (2.2%) leaks.
534 patients with colon repair or resection and anastomosis,
there were 17 (3.2%) leaks.
and anastomosis is significantly higher than in simple repairs.
In a collective review of 362 patients with resection and anastomosis, the overall incidence of anastomotic leak was
37
5.5%.
In another large retrospective study of 112 patients
with penetrating or blunt colonic injuries treated by resection
and primary anastomosis, Murray et al.
of 9%. In a more recent multicenter prospective study of 197
It
patients with penetrating colon injuries who underwent resection and primary anastomosis, the leak rate was 6.6%.
The risk factors for anastomotic leak are not well defined.
It seems that colocolostomies are associated with a higher
incidence of anastomotic leaks than ileocolostomies. Murray
26
et al.
reported a leak rate of 4% in 56 patients with ileo-
colostomies and 13% in 56 colocolostomies. Univariate
6
analysis identified PATI >25, > 6 units of blood transfusion,
and hypotension in the emergency room as risk factors for
anastomotic leak. A multicenter prospective AAST study
reported a leak rate of 4.2% for ileocolostomies and 8.9% in
colocolostomies.
6
out multiple blood transfusions, severe contamination, and
multiple associated injuries. No significant independent risk
factors could be identified.
The prognosis of anastomotic leaks is usually good and
most of the patients can safely be managed nonoperatively
with low-residue diet. In most cases, the leak results in a fecal
fistula, which heals spontaneously within a few days. In other
cases, the leak results in a local abscess, which can be drained
percutaneously. However, in some patients, the colonic leak
causes severe intraabdominal sepsis and a proximal diversion
procedure may be required. Curran and Borzotta
deaths in a collective series of 66 patients with repair leaks.
However, Murray et al. reported two colon-related deaths in a
group of 10 patients with anastomotic leak. The AAST multicenter study reported no deaths in the 13 patients with anastomotic leaks. The overall mortality attributable to colon
leak-related complications in a collective review of 3161
trauma patients treated with primary repair or resection and
anastomosis was only 0.1%.
In summary, colonic leaks occur more often in patients
with colocolostomies than patients with ileocolostomies. Exter-
6
nal fecal fistulas can safely be managed nonoperatively with
low-residue diet. Localized abscesses are best drained
6,37
In prospective studies including
6,37
The leak rate after resection
26
reported a leak rate
The leaks occurred in patients with or with-
37
reported no
6,37
6
328 D. Demetriades and A. Salim
percutaneously by interventional radiology and the ensuing fecal
fistula almost always closes spontaneously. Reexploration of the
abdomen and creation of fecal diversion with or without resection of the leaking colon should be reserved only for patients
with generalized peritonitis or failed percutaneous drainage.
Technique of Colon Repair
In nondestructive injuries, repair of the injured colon should
be performed after debridement of the perforation. This step
is critical in gunshot wounds and failure to debride may result
in breakdown of the suture line. In destructive injuries, resection to normal and well-perfused edges should be performed
and the anastomosis should be tension free. The method of
anastomosis, hand-sewn or stapled, does not influence the
incidence of abdominal complications or leak rate and it
should be surgeon’s preference. In a prospective AAST study
of 207 patients with penetrating destructive injuries who
underwent resection and anastomosis, 128 cases were managed by hand-sewn and 79 cases by stapled anastomosis. The
incidence of anastomotic leak was 7.8% and 6.3%, respectively. Multivariate analysis adjusting for blood transfusions,
degree of fecal contamination, and antibiotic coverage
showed identical complication rates (stapled anastomosis
adjusted RR = 0.99).
anastomosis may be beneficial although no study has ever
evaluated its role in colonic anastomosis in trauma. Further
protection of the anastomosis with adjacent omentum is
recommended whenever possible. It is the practice of the
authors to apply fibrin glue and cover the anastomosis with
omentum in all cases with resection and anastomosis.
38
Application of fibrin glue around the
injuries infrequent, and exposure difficult. The rectum varies
in length from 12 to 15 cm, with only the upper two-thirds
anteriorly and the upper one-third laterally covered by peritoneum (intraperitoneal rectum). The lower third of the rectum completely lacks peritoneal covering (extraperitoneal
rectum) which makes exposure and repair of injuries difficult.
Finally, the rectum is easily accessible from the anus, with the
anterior peritoneal reflection only approximately 6 cm from
the anal verge. This results in a not uncommon finding of
intraperitoneal injury from rectal foreign bodies.
Epidemiology
For the various anatomic reasons, injuries to the rectum occur
infrequently, and are usually the result of penetrating trauma.
In most series, gunshot and shotgun wounds account for
80%–85% of injuries, and stab wounds for 3%–5%.
39,46,47
The
incidence of rectal trauma is low, with most series describing
relatively few injuries. In a series of 59 patients with gunshot
wounds to the buttocks, only 3.4% had rectal injuries.
48
In
another series of 192 patients with gunshot wounds to the
back, 2.6% had a rectal injury.
9
Interestingly, in a series of
309 anterior abdominal gunshot wounds, and a series of 37
transpelvic gunshot wounds, no rectal injuries were identified, reiterating the infrequency of this injury.
8,49
Other causes include iatrogenic injuries from urologic and
endoscopic procedures, sexual misadventure, and anorectal
foreign bodies. Blunt trauma accounts for 5%–10% of cases,
and is usually the result of pelvic fractures or impale-
39,42,46,47,50
ment.
2% of all pelvic fractures.
Rectal injuries have been reported in nearly
51
Diagnosis
Rectal Injuries
The management of rectal trauma has undergone many
changes in the same manner as colon injuries, with many of
the principles of management evolving from wartime experiences. The mortality related to rectal trauma has decreased
dramatically from 67% during World War I down to today’s
civilian reports of 0%–10%.
which was as high as 72% during the Vietnam War, is now as
44,45
low as 10%.
The mainstay of management, developed
from lessons learned from combat experiences, has remained
controversial and includes: 1) diversion of fecal stream, 2) distal rectal washout, 3) presacral drainage, and 4) debridement
and closure of wounds when possible. Because of the paucity
of class I and class II data, no consensus has been achieved
with respect to the optimal management of rectal trauma.
Anatomy
The anatomy of the rectum makes it difficult to apply the
principles of colon trauma management. The majority of the
rectum is completely surrounded by the bony pelvis, making
39–44
Likewise, the morbidity,
The diagnosis of intraperitoneal rectal injury, similar to colonic
injuries, is almost always made intraoperatively. Extraperitoneal
rectal injuries may not always be as obvious. A high index of suspicion is necessary with both blunt and penetrating mechanisms
to avoid missing an injury. The cornerstone for diagnosing an
extraperitoneal injury is the combination of a digital rectal examination and rigid proctoscopy. In most series, the diagnostic
accuracy of the digital rectal examination and rigid proctoscopy
ranges from 80% to 95%.
rate of the two has been reported to be as high as 31%.
39,44,47,52–54
However, the false-negative
40
For this
reason, any suggestion of a rectal injury, even with a normal
rectal and proctoscopic examination, should prompt further
evaluation. In hemodynamically stable patients with a mechanism suspicious for a rectal injury (gluteal, perineal, and
transpelvic gunshot wounds, pelvic fractures, and foreign body
insertion), a digital rectal examination and a rigid proctoscopy
must be performed and in the appropriate cases further evaluation by means of a contrast study should be considered.
Rectal Organ Injury Scale
The grading system developed by the AAST for rectal injuries
(Table 22-5) is similar to that of colonic injuries (Table 22-2).
22. Colon and Rectal Trauma and Rectal Foreign Bodies 329
TABLE 22-5. AAST Rectal Organ Injury Scale
Grade Injury description
I a) Contusion or hematoma without devascularization
II Laceration ≤50% of circumference
III Laceration >50% of circumference
IV Full-thickness laceration with extension into the perineum
V Devascularized segment
b) Partial-thickness laceration
Operative Management
Historical Perspective
The history of rectal trauma parallels that of colon trauma
with much of the early management principles evolving from
lessons learned from wartime experiences. Mortality from
rectal gunshot wounds was as high as 67% in World War I and
the early part of World War II, until the Army Surgeon
General mandated colostomy for fecal diversion for all colon
and rectal injuries.
decreased to 35%.
which appeared to bring the mortality down further to approximately 5%.
39,56
series demonstrated satisfactory results with colostomy and
presacral drainage.
more destructive injuries were encountered, colostomy and
presacral drainage alone was found to be inadequate. Rectal
repair and distal rectal washout were added to the management and was associated with improved results.
war civilian studies demonstrated acceptable results when
colostomy, rectal repair, presacral drainage, and distal irrigation were all used.
that also demonstrated acceptable results when only
colostomy and presacral drainage were used.
there is no acceptable gold standard for the treatment of rectal injuries, because most studies have been unable to demonstrate any advantage of the various treatment options.
Intraperitoneal Injuries
With no class I or class II data present regarding the management of intraperitoneal rectal injuries and limited class III
data that combines both extraperitoneal and intraperitoneal
injuries, it is difficult to make a conclusion regarding management. However, several studies do indicate that injuries to
the intraperitoneal rectum can be managed similar to left
colon injuries with primary repair without the need for
colostomy.
43,47,52,54,61
was found in these series when primary repair without
colostomy was performed. The authors’ program advocates
primary repair in this group of patients.
Extraperitoneal Injuries
As previously mentioned, there is no agreement in terms of
the optimal management of extraperitoneal rectal injuries,
14,39,55
55
Retrorectal drainage was added in 1943,
Subsequently, the mortality
Shortly after World War II, several civilian
57,58
During the Vietnam War, in which
45
Early post-
40,59
Interestingly, there were other studies
42,56,60
Presently
No increase in abdominal complications
but the mainstay of treatment has included four main
components: 1) fecal diversion with colostomy, 2) presacral
drainage, 3) distal rectal washout, and 4) repair of the injury
when possible. Each will be addressed separately below.
Fecal Diversion with Colostomy
Since World War II, the mainstay of management of extraperitoneal injuries has been proximal colostomy.
only controversial aspect has been whether to perform a loop
colostomy versus an end colostomy. Some argue that a
loop colostomy does not offer complete fecal diversion, whereas
proponents of loop colostomy argue that a properly constructed
loop colostomy will function as a true diverting colostomy with
the benefit of simple construction and rapid closure.
62
Rombeau et al.
demonstrated that a properly constructed loop
colostomy, supported by a solid rod above the level of the skin,
achieves complete fecal diversion. The authors believe that the
type of colostomy should be dictated by the operative findings.
Extensive destruction of the rectum that requires a resection
may best be served with a Hartmann’s procedure, whereas
injuries that are not repaired or require limited dissection may be
addressed by a loop colostomy.
Recently, there have been reports of primary repair without
fecal diversion in selected extraperitoneal rectal
injuries.
46,47,52,54,63
In a series of 30 patients with extraperitoneal rectal injuries, five were transanally repaired without
fecal diversion and no subsequent morbidity.
injuries right at the peritoneal reflection, or injuries encountered with minimal dissection, may also be primarily repaired
without the need for colostomy.
54
39,42,43,50,52–54
39,52
47
Similarly,
The
In fact,
Presacral Drainage
Presacral drainage was added to the armamentarium in World
War II, because it was thought to decrease the pelvic sepsis
52,64
rate.
showing a benefit with its use,
ies failing to show any benefit.
secutive patients with extraperitoneal injuries from the
authors’ institution, no benefit with the use of presacral drains
was found.
recommended its use for most injuries.
recently by a randomized, prospective trial evaluating the
importance of presacral drainage.
23 randomized to presacral drainage and 25 randomized to no
drainage, no difference in pelvic sepsis was encountered. This
represents the first and only class I study involving rectal
injuries. Although it was a study with relatively few patients,
it convincingly demonstrated that the addition of presacral
drainage is unnecessary. The authors have completely abandoned the use of presacral drainage several years ago. It
involves an additional procedure and dissection into an uninvolved space. The drains that are placed often become malpositioned or malfunction. Most importantly, there is no proof
that it improves outcome.
It has remained controversial, with many studies
39,40,42,52,65
43,46,53,54,66
53
Despite the conflicting data, many authors still
67
whereas other stud-
In a series of 30 con-
54
This was challenged
In a series of 48 patients,
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