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Contemporary management of rectal injuries at Level I trauma centers: The results of an American Association for the Surgery of Trauma multi-institutional study

Brown, Carlos, V.R., MD; Teixeira, Pedro, G., MD; Furay, Elisa, MD; Sharpe, John, P., MD; Musonza, Tashinga, MD; Holcomb, John, MD; Bui, Eric, MD; Bruns, Brandon, MD; Hopper, H., Andrew, MD; Truitt, Michael, S., MD; Burlew, Clay, C., MD; Schellenberg, Morgan, MD; Sava, Jack, MD; VanHorn, John; Eastridge, PA-C,, Brian, MD; Cross, Alicia, M., MD; Vasak, Richard, MD; Vercruysse, Gary, MD; Curtis, Eleanor, E., MD; Haan, James, MD; Coimbra, Raul, MD; Bohan, Phillip, MD; Gale, Stephen, MD; Bendix, Peter, G., MDthe AAST Contemporary Management of Rectal Injuries Study Group

Journal of Trauma and Acute Care Surgery: February 2018 - Volume 84 - Issue 2 - p 225–233
doi: 10.1097/TA.0000000000001739
AAST 2017 Podium Paper
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INTRODUCTION Rectal injuries have been historically treated with a combination of modalities including direct repair, resection, proximal diversion, presacral drainage, and distal rectal washout. We hypothesized that intraperitoneal rectal injuries may be selectively managed without diversion and the addition of distal rectal washout and presacral drainage in the management of extraperitoneal injuries are not beneficial.

METHODS This is an American Association for the Surgery of Trauma multi-institutional retrospective study from 2004 to 2015 of all patients who sustained a traumatic rectal injury and were admitted to one of the 22 participating centers. Demographics, mechanism, location and grade of injury, and management of rectal injury were collected. The primary outcome was abdominal complications (abdominal abscess, pelvic abscess, and fascial dehiscence).

RESULTS After exclusions, there were 785 patients in the cohort. Rectal injuries were intraperitoneal in 32%, extraperitoneal in 58%, both in 9%, and not documented in 1%. Rectal injury severity included the following grades I, 28%; II, 41%; III, 13%; IV, 12%; and V, 5%. Patients with intraperitoneal injury managed with a proximal diversion developed more abdominal complications (22% vs 10%, p = 0.003). Among patients with extraperitoneal injuries, there were more abdominal complications in patients who received proximal diversion (p = 0.0002), presacral drain (p = 0.004), or distal rectal washout (p = 0.002). After multivariate analysis, distal rectal washout [3.4 (1.4–8.5), p = 0.008] and presacral drain [2.6 (1.1–6.1), p = 0.02] were independent risk factors to develop abdominal complications.

CONCLUSION Most patients with intraperitoneal injuries undergo direct repair or resection as well as diversion, although diversion is not associated with improved outcomes. While 20% of patients with extraperitoneal injuries still receive a presacral drain and/or distal rectal washout, these additional maneuvers are independently associated with a three-fold increase in abdominal complications and should not be included in the treatment of extraperitoneal rectal injuries.

LEVEL OF EVIDENCE Therapeutic study, level III.

From the Dell Medical School (C.V.R.B., P.G.T., E.F.), University of Texas at Austin, Austin, Texas; University of Tennessee Health Science Center (J.P.S.), Memphis, Tennessee; Baylor College of Medicine (T.M.), Houston, Texas; University of Texas Health Science Center at Houston (J.H.), Houston, Texas; University of California San Francisco—East Bay (E.B.), Oakland, California; R. Adams Cowley Shock Trauma Center (B.B.), Baltimore, Maryland; Vanderbilt University (H.A.H.), Nashville, Tennessee; Methodist Health System (M.S.T.), Dallas, Texas; University of Colorado—Denver Health (C.C.B.), Denver, Colorado; University of Southern California (M.S.), Los Angeles, California; MedStar Washington Hospital Center (J.S.), Washington, DC; Legacy Emmanuel Medical Center (J.V.H.), Portland, Oregon; University of Texas Health Science Center San Antonio (B.E.), San Antonio, Texas; University of Oklahoma (A.M.C.), Oklahoma City, Oklahoma; Harbor-UCLA Medical Center (R.V.), Los Angeles, California; University of Arizona (G.V.), Tucson, Arizona; University of California Davis (E.E.C.), Sacramento, California; Via Christi Health (J.H.), Wichita, Kansas; University of California San Diego (R.C.), San Diego, California; Oregon Health and Science University (P.B.), Portland, Oregon; East Texas Medical Center (S.G.), Tyler, Texas; and Brigham and Women’s Hospital (P.G.B.), Boston, Massachusetts.

Submitted: August 29, 2017, Revised: October 31, 2017, Accepted: November 1, 2017, Published online: November 15, 2018.

This was presented at the 76th Annual Meeting of the American Association for the Surgery of Trauma, September 13–16, 2017, Baltimore, Maryland.

Address for reprints: Carlos V. R. Brown, MD, Trauma Services, Dell Seton Medical Center, University of Texas at Austin, 1500 Red River St, Austin, TX 78701; email: CVRBrown@ascension.org.

© 2018 Lippincott Williams & Wilkins, Inc.