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The colon is the second most commonly injured organ in penetrating trauma, but injury is rare in blunt trauma (2-5%). However rectal injuries are more common in blunt trauma, especially when associated with pelvic injuries. Diagnosis of these injuries may be difficult - especially in the unconscious or obtunded patient. Maintaining a high degree of suspicion is vital to avoid missing these injuries.
Case Presentation: Missed rectal injury
A 22 year old man presented to the trauma centre 3 days following a stab wound to the right buttock. He had initially been seen at another hospital where a 1.5cm wound to the outer aspect of the right buttock had been cleaned and stitched. He represented due to pain in the buttock and appearance of a 4cm black patch around the buttock wound. He had never complained of any rectal pain or bleeding.
Examination at the trauma centre included digital rectal examination and rigid sigmoidoscopy/proctoscopy, revealing some blood and pus and an injury to the lateral rectal wall. The patient was transferred immediately to the operating room for debridement of the buttock wound and defunctioning colostomy. On the operating table the nectroci patch on the buttock had expanded to approximately 8cm in diameter. Debridement was commenced but could not keep pace with the rapidly spreading necrotizinf fasciitis.
The patient eventually died on the operating table when it became apparent the sepsis had spread to include his upper and lower limbs.
Most colon injuries are identified at laparotomy performed for injury to other organs. Penetrating injury to the colon usually presents with peritonitis. This may develop over the course of a few hours and therefore serial physical examination is important for patients who are being managed non-operatively.
In patients where there is clinical suspicion of injury without overt signs, or clinical examination is impossible or unreliable (unconscious, intoxicated, spinal cord injury) then other modalities must be employed. The options are Computed Tomography (CT), Diagnostic Peritoneal Lavage (DPL) and Laparoscopy. Neither diagnostic peritoneal lavage nor laparoscopy will adequately evaluate the colon - especially the retroperitoneal colon.
Computed Tomography CT is rapidly becoming the investigation of choice for evaluating blunt abdominal trauma in the haemodynamically normal patient. Colonic injury is suggested by free extraluminal air, intra-peritoneal or retro-pertioneal free fluid, focal thickening of the bowel wall, bowel wall haematoma or intra-mural air. The most sensitive sign for penetrating injury however is the presence of a wound track leading up to bowel wall.
Scans should be viewed on both abdominal and 'bone' windows to increase the sensitivity for free air. The overall accuracy of CT for evaluating bowel injury is 82%, with a sensitivity of 64% and a specificity of 97%. There is little evidence to support the use of oral and rectal contrast for evaluation of these injuries, although at present most radiologists are more familiar with reading contrast enhanced CT scans.. CT may also be useful in excluding peritoneal violation and allowing early discharge rather than admission for observation.
A high index of suspicion for trauma is vital if injuries are not to be missed. In blunt trauma, rectal injuries are most commonly associated with pelvic fractures. Rectal examination should be performed on all pelvic injuries, looking for blood and bone fragments lacerating the rectal wall. If there is any doubt about the disagnosis, rigid sigmoidoscopy should be performed. When identified early and managed appropriately, open pelvic fractures have a mortality approaching that of closed injuries. However, in the presence of a missed rectal injury, the mortality may be as high as 50%.
Penetrating rectal injuries may be caused by injuries to the abdomen, thigh or buttock, as in the case presented. Again, any penetrating wound that may have injured the rectum should be fully evaluated with digital examination and proctoscopy/sigmoidoscopy. Even with these examinations it is possible to miss a significant rectal injury.
Evolution of the Management of Colon & Rectum injuries
Management of colonic injury has fluctuated over the past 100 years. During the first world war, the first papers describing large numbers of colonic injuries were published. The overall mortality from colonic injury was around 60%. At the time most injuries presented over 6 hours old, there were no antibiotics and intravenous fluid infusion was rare. Laparotomy was not universal for these injuries, and mobilisation of the colon was not routinely practiced.
By the end of the war most series were reporting favourable results with primary suture of simple colonic injuries, and suggesting that colostomy be reserved for more extensive trauma. However, in the early part of the second world war, and despite the previous evidence to the contrary, Ogilvie recommended colostomy for all colonic injuries. This was despite Ogilivie's own paper recording a mortality of 50% for primary repair compared to 59% for colostomy.
"The treatment of colon injuries is based on the known insecurity of suture and the dangers of leakage. Simple closure of a wound of the colon, however small, is unwarranted; men have survived such an operation, but others have died who would still be alive had they fallen into the hands of a surgeon with less optimism and more sense. Injured segments must either be exteriorized, or functionally excluded by a proximal colostomy." - W. H. Ogilvie. 1944
Adding to the call for colostomy was a publication from the Office of the Surgeon General of the United States in 1943 which mandated that all colonic injuries be treated by colostomy. By the end of the second world war, mortality from colon injuries was being reported at 5-20%. This was attributed to the use of colostomy, but again all series reporting both treatment methods had a lower mortality in the primary repair group. The use of colostomy for all colonic injuries continued into the Korean and Vietnam wars.
After the second world war, civilian surgeons started reporting their experience with colonic injuries. Again, primary repair was associated with better outcomes. Woodhall & Oschner reported an 8.3% mortality for primary repair compared with 35% mortality for colostomy. More evidence supporting primary repair emerged over the next decades. In the past 2 decades there are been several prospective studies and randomised control trials supporting primary repair in most cases of penetrating colonic injury.
Management of Colon Injuries
Almost all civilian colon injuries should be repaired primarily
Small penetrating wounds can be closed with simple suture. More significant bowel injury should be treated with resection and anastomosis. Repair is with a single-layer, continuous, extra-mucosal, monofilament suture.
Over the past 2 decades there have been several prospective randomised controlled trials comparing primary repair with colostomy formation. All have shown either no difference, or improved outcomes with primary repair (usually in terms of hospital stay and complication rates). The leak rate for primary repair is around 1%.
Analysing subsets, there is no evidence to support routine use of colostomy for colonic injuries, whether left or right colon, blunt or penetrating, simple suture or resection. Primary repair is also cheaper, especially when factoring into account the complications of colostomy closure.
Patients at risk of anastomotic breakdown are those in whom diagnosis has been delayed significantly (24 hours), and those who are in shock and have reduced gut perfusion in the perioperative period. Where there is a long delay in diagnosis or treatment, repair and proximal colostomy MAY be the preferred option, though each case should be managed on its own merits.
Patients who are in haemorrhagic shock, and are (or soon will be) hypothermic, coagulopathy and acidotic should have a damage control surgery procedure. Once control of haemorrhage is achieved, management of gastrointestinal injury is limited to the control of sepsis. Small wounds may be sutured primarily, but larger areas of damaged colon should be excised and the ends tied or stapled closed. Repair and restoration of intestinal continuity is reserved for a subsequent operation.
Abdominal compartment syndrome is a frequent sequelae of shock and hypoperfusion. The presence of a colostomy in these patients can be disastrous. In the worst case, the abdomen may swell and the colostomy retract into the peritoneal cavity. Even without this, the wound management of an open abdomen with a nearby colostomy can be extremely challenging. If colostomies must be placed they should be brought out far more laterally than their usual position, away from the wound edges.
Management of Rectum Injuries
Rectal injuries above the peritoneal reflection can be treated as colonic injuries and repaired primarily.
Extraperitoneal rectal injuries should be repaired primarily if possible. The rectum can be mobilised to allow repair, and posterior wall injuries repaired through an anterior wound or colotomy. (Do not repair an anterior wound without examining the posterior rectal wall). Some low rectal injuries can be repaired trans-anally.
Where the position of the injury precludes repair a proximal, diverting colostomy should be performed. The options here are loop colostomy, loop with distal soma closed, a colostomy and mucus fistula or a Hartmann's procedure. A well-fashioned loop colostomy is usually preferred, is adequate in diverting the faecal stream away from the repair and is easily closed. The central spur should be above the level of the skin to allow complete diversion.
Where there is more extensive damage to a significant portion of the rectal wall, or the injury is complex, a Hartmann's procedure (proximal colostomy and closed, intra-peritoneal distal end) is probably warranted.
Drainage of the pre-sacral space used to be a routine procedure for all rectal injuries. However, a propective randomised trial of 48 patients by Gonzalez in 1998 showed a lower complication rate without presacral drainage (8% with drainage, 4% without). Similarly McGrath and Fabian in 1998 also found no difference in presacral infection rates comparing patients with and without presacral drainage.
Pre-sacral drainage possibly still has a place in high-energy blunt trauma, pelvic fractures and where there is delayed repair of injuries.
Washout of the distal rectal stump has also been routinely practiced, but there is no supporting evidence for the procedure. Although it may reduce faecal load in the rectum, it may also force faecal material out of a rectal laceration. McGrath & Fabian in 1998 found no difference in pelvic infection rates comparing those patients with and without distal washout. Distal washout may be more applicable to military injuries where soldiers are often constipated and where surgical procedures are performed after some delay.
Combined Genito-urinary Injuries
Combined rectal and genito-urinary injuries have a significantly higher complication rate than isolated rectal injuries. Complications are increased by distal rectal washout, no presacral drainage, repair of a rectal injury, prolonged supra-pubic drainage and failure to adequately separate the GI and GU injuries.
Hypothermia - Coagulopathy - Acidosis
- Damage Control Procedure
- Control Haemorrhage
- Rapid primary suture of small wounds.
- Transect & close (stapler) more extensive injuries for later repair.
- Avoid colostomy.
Primary repair. Consider colostomy if >24 hours post trauma.
Primary Repair if:
- Intra-peritoneal rectal injury.
- Extra-peritoneal rectal injury that can be mobilised intra-peritoneally or repaired trans-anally.
- No pre-sacral drainage
- No distal washout.
Proximal diverting loop colostomy if:
- More extensive rectal injury.
- Position makes repair impossible.
- Pre-sacral drainage if high-energy, blunt trauma or delayed surgery
- No distal washout.
Hartmann's Procedure if:
- Severe extra-peritoneal rectal injury.
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