Rectal Trauma

It seems as though the focus of every pre-op conference is a stoma takedown for a known or presumed rectal injury.  Therefore, below is a short review of how we identify and treat rectal injuries – hint: not all require a stoma.

Most rectal trauma results from penetrating injury often times secondary to a GSW to the buttocks and/or pelvis with blunt trauma accounting for ~5% of patients usually related to a pelvic bone fracture.  Regardless of mechanism, a basic understanding of rectal anatomy is required  as it will influence the clinical presentation and surgical treatment options.  Of particular importance is the distinction between intraperitoneal and extraperitoneal rectal injuries such that the posterior 2/3 and lower 1/3 of the rectum circumferentially are devoid of peritoneal serosa and may not present with the findings of abdominal peritonitis or ‘free air’ on x-ray. 

Clinical presentation/diagnosis requires a high degree of suspicion based on mechanism or associated injury of nearby structures such as the bladder, urethra or pelvic bones.   During the secondary survey, one must examine for peritonitis and not overlook a careful examination of the perineum, inner thighs, buttocks and external anus for gunshot or stab wounds.  A digital rectal exam (DRE) is mandatory to identify retained foreign bodies or gross blood however, a negative DRE does not exclude injury.  If suspicion is high, a rigid proctoscopy must be performed, usually in the OR.  Besides obvious rectal injury, blood on proctoscopy is a positive indicator of rectal injury and subsequent visualization of the injury itself is not required.  CT can be helpful but only after the above exams and in a stable patient.   

Treatment of traumatic rectal injury has evolved from wartime experience where the traditional surgical treatment dictum included the four ‘D’s:  direct repair, drain, divert and distal washout.   Current treatment options are based more on anatomic location, extent of injury and patient stability.  Penetrating intraperitoneal rectal injuries are treated similar to colon injuries with data, including a recent Cochrane review, demonstrating that primary repair/anastomosis is now the accepted standard of care without the need for a stoma. (1,2)  The exception are patients who present in shock, massive hemorrhage requiring >6 units of blood, those with a delayed presentation or with gross fecal spillage who may still undergo a primary repair but often with a diverting stoma.  Stapled or handsewn anastomosis does not seem to affect post-operative complication rates.  (3)    

Extraperitoneal rectal injuries are usually ‘low’ in the pelvis and thus difficult to identify, access and repair during laparotomy.   Therefore, the traditional treatment is stoma diversion with presacral drainage.  While diversion with an end or loop colostomy remains the standard treatment, the role for presacral drainage has been challenged with prospective data suggesting no difference in outcome. (4)

1.  Demetriades, D., et al. Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma. 2001; 50(5): 765-75.

2.  Nelson, R, Singer, M. Primary repair for penetrating colon injuries. Cochrane Database Syst Rev. 2003; (3): CD002247.

3.  Demetriades, D., et al. Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: a multicenter study. J Trauma. 2002; 52(1): 117-21.

4.  Gonzalez, RP., et al. The role of presacral drainage in the management of penetrating rectal injuries. J Trauma. 1998; 45(4): 656-61.

from Dr. Michelle Cowan