Colon & Rectal Trauma

Scott R. Steele, MD
Chief, Colon & Rectal Surgery
Madigan Army Medical Center
Fort Lewis, WA

 
Introduction

The evolution of care for the patient with trauma to the lower gastrointestinal tract has seen major changes over the past few decades.  Present day wartime conflicts have again highlighted the controversy regarding proper management of the patient with traumatic colon and rectal injuries for both the military and civilian sectors.  Fortunately, high mortality rates have drastically fallen, mandatory stoma placement has seen increasing trend toward in-continuity management--especially in colon injuries--and the “4D’s” of divert, drain, direct repair, and distal washout for rectal trauma have been challenged.  In addition, damage control surgery has now made it into mainstream practice for the most severely injured patients with multi-system disease including colorectal trauma, and allowed both outcome evaluation and, more importantly, survival from injuries that previously resulted in death.  Yet, despite this evolution, considerable debate regarding proper diagnoses and care for the colorectal-injured patient persists for both the combat and civilian settings.  This update will discuss the progression of care for these patients as well as outcomes regarding the management for colon and rectal trauma.

Historical Perspectives

Although the initial report of a colonic injury occurred during biblical times when Ehud killed King Eglon (Book of Judges – Jud 3:21-22), it wasn’t until 1675 when Matthaeus Gotfried Purman of the Brandenburg Army was credited with the first repair of an intestinal injury.  Despite not knowing the soldier’s eventual outcome, we can surmise he did not do exceedingly well, as the primary repair of intestinal wounds, including colonic, up until the 1970s and 1980s was largely obsolete.  During the Civil War, most patients with colon and rectal injuries died, as in addition to the battlefield injuries themselves, secondary infection and sepsis largely led to the policy of expectant management.[1]  It wasn’t until World War I that larger scale outcome data was first available for these injuries, demonstrating mortality rates between 60-75% depending on injury location. [2]  Regardless of these dismal outcomes, the fact that a small but not insignificant percentage of people survived was astounding, especially considering the context of the time--no antibiotics, no fluid resuscitation, and significant delays in surgical management.  In part, this outcome improvement may reflect changing practice patterns that were ongoing, from watchful waiting early on to exploration and diversion late in the war.  As World War II evolved, following Ogilvie’s experience with British forces, the United States Surgeon General mandated either exteriorization or proximal stoma placement with an elective closure at a later date. [3] Remarkably, Ogilvie’s own series demonstrated that mortality rates were similar between primary repair and the diversion/exteriorization groups (53% vs. 59%).  Nonetheless, as time went on this change in surgical technique coincided with other advances--decreased evacuation time, more aggressive fluid resuscitation, improved antibiotics, and banked blood use--all leading to a significant decrease in overall mortality rates to 22-35%. [4, 5]  Based on this data, failure to perform either diversion technique was justification for a court martial. [6]  Diversion then remained the standard practice for the next 40-50 years, before finally the re-emergence of primary repair, when feasible, as the treatment of choice. [7-11]  Wartime series were slower to mimic the civilian trauma experience, but similarly demonstrated not all colorectal injuries required a colostomy, with equivalent morbidity and mortality rates following primary repair. [12-14]  Yet, colorectal injuries continue to be a source of not only significant morbidity and mortality, but also ongoing debate over the correct management strategy.  This may reflect, in part, surgeons comfort level with avoiding fecal diversion in an elective setting, but when faced with a large amount of destruction, multiple injuries, unstable patients, or a wartime environment, practice patterns change. 

Etiology & Patterns of Injury Incidence
Unfortunately it is difficult to determine the exact incidence of traumatic colon and rectal injuries.  The literature is scattered with either prospective trials or retrospective case series composed of a cohort of colorectal injured patients.  In general, wartime series have a higher incidence of colonic injuries at 5-10%, [15, 16] with a recent review of over 3,400 patients during Operation Iraqi Freedom finding colon and rectal injuries present in 5.1%. [17]  Most civilian series have found a slightly lower percentage, at between 1-3%.  Blunt trauma rates are even lower, as highlighted by a study of 2,632 hollow-viscus injury patients, where colorectal injuries occurred in only 0.3%. [18]  Similarly, Carillo and colleagues found a low incidence of 0.5% following blunt trauma, [19] while Ng et al., in a review of 1,367 blunt trauma patients found colonic injuries in 0.1%. [20]  Yet despite the low incidence, surgeons must retain a high index of suspicion to avoid the increased morbidity and mortality associated with a delayed or missed diagnosis.

Military versus civilian
 Important differences remain between civilian and military trauma, nevertheless research and innovations in each realm can have a significant impact on the other.  Military trauma often involves high velocity weaponry, fragment wounds, increased associated injuries, burns, limited supplies and occasional remote locations.  Unlike the civilian sector, the more frequent need to transport injured soldiers on prolonged evacuation routes, without constant physician attention, may make diversion more of an attractive and practical option for those with combat-related colorectal injuries.  In addition, the combat surgeon must consider not only the anatomic injuries and patient physiology, but also the number and severity of other incoming casualties, the available resources such as blood products, and the length of postoperative observation required before evacuation to the next level of care.  Despite these differences, both arenas have experienced the evolution of colorectal trauma care being somewhat delayed by a history of dogmatic teaching, as well as anecdotal past experiences. [21]  As such, continued practice patterns in the face of literature pointing to the contrary have persisted.  Yet this appears to be slowly changing, as what was once considered standard management for rectal injuries (4 D’s), and mandatory stoma placement for colon injuries are no longer universally practiced in either the civilian sector or on the battlefield. [22]

Diagnosis
 Evaluation of the patient with colorectal trauma begins with standard ATLS primary and secondary surveys along with concomitant resuscitation.  Specific to this injury pattern, all patients should undergo abdominal examination to evaluate for sites of penetrating wounds or peritonitis mandating urgent exploration.  In addition, digital rectal examination (DRE) should be performed with a focus on sphincter tone, presence of blood, foreign objects or bony protrusion--especially in those patients with pelvic fractures.  Rigid proctoscopy should also be performed to evaluate for mucosal or full-thickness injury, as well as documenting the degree and extent of damage.  Yet, although DRE and proctoscopy can identify blood in up to 80-90% of cases, [23] the sensitivity is much lower at 33% for rectal injuries and 6% for all bowel injuries [24], and results in management alterations fewer than 5% of the time. [25, 26]  Upright chest radiograph may demonstrate free intraperitoneal air consistent with hollow-viscus perforation.  Ultrasound use via a focused assessment with sonography for trauma (FAST) may demonstrate free fluid and has been shown to be useful for both blunt and penetrating abdominal trauma, despite being non-specific for colorectal injuries. [27]  CT scan has become the predominant radiological test in many centers, having been shown to be effective in diagnosing colorectal injuries in hemodynamically stable patients with no immediate indication for laparotomy.  Shanmuganathan and colleagues demonstrated a 100% sensitivity, 96% specificity, 100% negative predictive value, and 97% accuracy in a study of 104 patients evaluating CT’s ability to identify peritoneal violation, or colonic, major vascular, or urinary tract injuries following penetrating trauma. [28]  In a follow-up prospective study of 200 patients, the same group confirmed their results with >95% sensitivity, specificity, and accuracy for both peritoneal violation and visceral injury. [29]  Finally, although not used as frequently, diagnostic peritoneal lavage (DPL) has shown sensitivities of 84-97% for detection of intestinal injury and should remain as a tool in the armamentarium of surgeons. [30, 31]

Laparoscopy
 Laparoscopy has evolving roles in both diagnosis and treatment in the realm of colorectal trauma.  For tangential injuries, those in which peritoneal penetration is indeterminate, or cases such as blood per rectum with no identifiable source, laparoscopy can help identify intraperitoneal injuries.  It also provides the additional ability to help identify more difficult to diagnose injuries (i.e., diaphragm) that may be concomitantly present, while avoiding the morbidity of a laparotomy.  In South Africa, one prospective protocol for penetrating low velocity extraperitoneal rectal gunshot wounds successfully used laparoscopic techniques to initially exclude any intraperitoneal damage, followed by creation of a sigmoid loop colostomy to divert stool away from the site of injury. [32, 33]  As surgeons continue to grow more facile with advanced laparoscopic techniques, minimally invasive management of traumatic injuries is likely to increase.
Management
Colonic Injuries
 Despite reports of negative laparotomy in 5.3 - 27% of abdominal gunshot wounds and up to 53% of stab wounds, penetrating abdominal injuries are still predominately managed with mandatory exploration. [34]  Yet the complications from unnecessary laparotomy must be weighed against the potential severe morbidity from missed injuries.  In general, options for management of colon injuries include primary repair, including resection and primary anastomosis (each +/- proximal diversion), and stoma formation, with exteriorization mentioned solely as a historical procedure.  This section will review the controversy and data surrounding each of these methods.

Primary repair versus diversion
 Although suggested by Woodhall and Ochsner in 1951, [5] Stone and Fabian’s classic article in 1979 signified the beginning of a paradigm shift in the management of penetrating colon injuries.  Despite mandating an “obligatory colostomy” for 129 patients with either shock, blood loss >1000 ml, more than 2 intra-abdominal organs injured, significant peritoneal contamination, delay > 8 hours after injury, destructive colon wounds, or major abdominal wall loss, they found equivalent rates of infection (48% vs. 57%, P>0.05) and mortality (1.5% vs. 1.4%, P>0.05) in 139 patients randomized to primary repair versus colostomy over a 44 month period, respectively. [7]  Since then, the civilian trauma literature has demonstrated successful primary repair in as many as 73-81% of these injuries, [6, 35] and 11-72% of military series. [15-17, 36]  Unfortunately, the majority of these series were retrospective in nature, potentially confounded by the inherent biases that accompany these types of studies.  It wasn’t until 1991 that another prospective trial was performed by Chappuis and colleagues involving 56 patients with penetrating colon injuries randomized to either primary repair or diversion. [37]  Despite prior studies demonstrating various risk factors associated with increased complications following primary repair, management of the colonic injury in this study was independent of the number of associated injuries, transfusion requirement, degree of fecal contamination, or hemodynamic stability on presentation.  Septic complications were similar between the two groups (primary 21.4% vs. diversion 17.9%), including no cases of anastomotic leak in the primary repair cohort.  Other authors in this period demonstrated primary repair was both safe and avoided the additional morbidity associated with stoma construction and eventual takedown. [38-40]  In addition, destructive wounds and those cases with concomitant shock, excess blood loss, fecal contamination or multiple organ injuries appeared to convey no benefit from diversion, [41] though some authors still recommended stoma placement for high risk patients. [42]  Even the Eastern Association for the Surgery of Trauma (EAST) practice management guidelines for colon injuries from 1998 suggesting colostomy is associated with improved outcomes for those patients with destructive colon wounds with PATI > 25, significant comorbidities, or hemodynamic instability was derived from mainly class III and limited class II data. [43]  So, despite the improved methodology with Chappuis’ study and comparable results found in an emerging body of literature supporting primary repair, these articles were criticized secondary to small patient numbers and potential for confounding bias.  Ten years later Demetriades and colleagues attempted to change this via a multi-center prospective trial involving 19 trauma centers that included 297 patients with destructive colon injuries requiring resection, of which two-thirds were managed by primary repair. [44] (Demetriades)  Colon-related mortality was significantly lower in the primary repair group (0% vs. 4%, P=0.012), with no difference in colon-related complications (22% vs. 27%, P=0.373).  The authors found that although the presence of severe fecal contamination, transfusion of greater than 4 units of packed red cells within the first 24 hours, and single agent antibiotic prophylaxis were all independently associated with increased complications, this was irrespective of the management of the colonic injury.  Thus, if patients developed complications, it was not dependent on whether or not they were diverted or repaired primarily.  It should be noted that this was not a randomized study, as the method of colon wound management as well as the antibiotic use and duration was left to the discretion of the attending surgeon.  Therefore, as a large observational study with class II data, only Level II recommendations could be made.  Despite these limitations, it was a significant improvement in more than numbers alone, and provided further insight as to the relative safety of primary repair of these injuries.

 Since then Adesanya and Ekanem similarly found no difference in outcome in the two methods in their retrospective review of 60 penetrating colonic injuries over a ten-year period. [45]  Furthermore, Singer and Nelson followed with a meta-analysis and subsequent Cochrane Review of all prospective randomized trials from 1966-2001, identifying only five studies to meet inclusion criteria.  Overall they found no difference in mortality between primary repair versus diversion, although total complications (odds ratio [OR]=0.28; 95 percent confidence interval [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 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 significantly favored primary repair. [46, 47]  Other groups have since attempted to refine and standardize management of these injuries.  Miller and colleagues had previously demonstrated that preoperative or intraoperative transfusion of more than 6 units of packed red blood cells or those patients with severe comorbid disease developed suture line failure more often following primary anastomosis (42% vs. 3%). [48]  Even more concerning, one-third of those patients sustaining a leak died.  Based on this data, the authors found it imperative to identify those patients at risk and developed a clinical pathway such that presence of either of these two conditions would prompt an end colostomy, while those without either risk factor would undergo resection of the destructive injury with primary anastomosis. [6]  Using this algorithm they were able to decrease their anastomotic leak and abscess rate, lower colon-related mortality, and all while performing fewer stomas.
 
Thus, despite a preponderance of evidence supporting primary repair, this continues to be an ongoing debate with heated opinions on each side.  Although there remains a lack of class I and paucity of class II data to base management strategies on, it seems primary repair of penetrating colon injuries is likely as safe as diversion, especially for non-destructive colon injuries.  Destructive colon injuries are also likely amenable to resection and anastomosis, although some evidence suggests colostomy should be considered in patients with significant co-morbidities, hemodynamic instability, and those with multiple associated injuries.  The largest study, though non-randomized, suggests that these factors play an independent role in the development of complications apart from the method of colon repair. 

Risk factors for anastomotic leak
 In simplest terms, the overriding goal remains to repair the damaged segment of colon and avoid the increased morbidity and mortality associated with an anastomotic leak or infectious complications, regardless of the method of repair.  Anastomotic leak rates following primary repair in civilian trauma range from 1-15%, [48-51] with a large retrospective review of 2,964 patients demonstrating a leak rate of 2.4%. [14]  On average, military series have slightly higher leak rates. [15, 17, 52]  As above, multiple risk factors have been associated with the development of anastomotic leaks following primary repair, with the most common including severe fecal contamination, shock, excessive blood loss, multiple transfusions, concomitant intrabdominal organ injuries, and delayed presentation/surgery. [7, 53]  In addition, the degree of colon injury (destructive versus non-destructive) has been identified as a potential indication for diversion due to a higher risk for anastomotic breakdown. [50]  Yet, Demetriades’ multicenter trial included only destructive wounds, demonstrating no difference in leak rate between the two methods of repair. [44]  Similarly, Miller and colleagues in subgroup analysis of their destructive injuries showed no difference in colon-related complications or death. [6]  Of the other major risk factors listed above, only hemodynamic instability or shock has consistently been associated with increased overall infectious complications (although not specifically anastomotic leak), with prolonged hypotension being a predictor of mortality as well. [54]  Finally, the actual technique of primary anastomosis has also been evaluated to determine its impact on anastomotic leak.  Demetriades and colleagues in a separate prospective non-randomized trial of 217 patients found no difference in overall colon-related complications between stapled versus handsewn (26.6% vs. 20.3%, P=0.3) or anastomotic leak rate (6.3% vs. 7.8%, P=0.69), respectively. [55]  Thus, although some have been associated with both infectious and non-infectious complications, no risk factors have consistently been demonstrated to be specific for anastomotic leak following primary repair, especially with non-destructive wounds. 

Right versus left colon
 There remains a perceptual difference between the ideal management of left and right-sided colonic injuries, despite what the literature would suggest.  Thompson and colleagues compared right and left colonic injuries in a retrospective review of 105 patients in 1981, finding similar rates of primary repair, morbidity and mortality. [56]  Burch and colleagues review of over 1,000 patients throughout the 1980s showed that in addition to simple primary repair of colon injuries, resection of the right colon and primary repair following destructive injuries is acceptable. [8] Since then, surgeons have increasingly felt that primary repair is equally safe and effective regardless of the injury location.  In a survey of 449 trauma surgeons regarding their preferred management for different types of colonic injuries, 98% chose primary repair for at least one type of injury, and 30% stated they would never use a colostomy, regardless of the location of the injury. [57]  Yet evaluation of how surgeons are actually practicing shows a continued difference in management amongst injury locations for both the military and civilian sector as well.  Adesanya and colleagues managed right colon wounds by primary repair in 69% versus only 12% of left colon wounds, despite no eventual difference in morbidity or mortality. [45]  Similarly, Murray and associates used fecal diversion in only 22% (6/27) of right colon injuries versus 39% (22/57) of left sided injuries (P<0.05). [58]  Miller et al., specifically evaluated patients with destructive colonic injuries, which they defined by need for resection, and found increased use of diversion with a left versus right colon injury (38% vs. 18.5%). [6]  This discrepancy was largely secondary to their clinical pathway that called for mandatory diversion with either a large transfusion requirement or significant medical co-morbidities—thus having these present more often in left sided injuries.  On the contrary, Fealk and associates found comparable use of primary repair in right-sided versus left-sided colon injuries (55% vs. 48%; P=0.52). [59]  Thus, there may be commonly held perception that left colon injuries are associated with worse outcome and therefore are more often treated with diversion.  In our review of the OIF experience, there was a definite trend, albeit not statistically significant, in rates of diversion with left colon versus right colon injuries (36% vs. 19%, P=0.07). [17]  Unfortunately, the mere nature of many studies makes it difficult to determine the exact reasons for this discrepancy in the absence of randomized prospective trials.  Possible explanations apart from surgical dogma include surgeons’ fears of worse outcomes associated with primary repair in the face of higher injury severity to the bowel (i.e., destructive versus small tangential wounds), higher bacterial soilage with left sided injuries, significant resuscitation requirements, or more severe associated injuries. 

Problems with colostomy closure
Colostomy construction has not been shown to be protective from initial septic complications.  In fact, Dente and colleagues demonstrated that creation of a stoma or penetrating abdominal trauma index (PATI) >30 were the two independent risk factors associated with the development of trauma-related infections (defined as abdominal abscesses, peritonitis, wound infections, missile tract infections and fistulas) in a retrospective review of 311 patients. [60]  Additional morbidity and even mortality are present following colostomy reversal, which are often not accounted for in the original study.  Complications range from inadvertent enterotomies, fistula, abscess, and anastomotic leaks to more minor morbidities such as urinary tract infection, pneumonia, ileus, and wound infections.  Thal and Yeary reviewed 137 patients undergoing colostomy closure following traumatic injuries and found a morbidity rate of 10.2%, with no difference in complication rates between early and late closure. [61] Similarly, Taheri and colleagues found a 9.1% intra-abdominal and 3.6% wound infection rate in a study of 110 patients. [62]  Other authors have found slightly higher complication rates including Bulger (17%), [63] Miller (37%), [6] and Berne (55%). [64]  Although often not considered, these factors should be kept in mind intra-operatively when determining which operation to perform.

Damage control surgery
In order to avoid the lethal triad of hypothermia, coagulopathy, and acidosis, surgeons have now readily adopted the practice of damage control surgery.  After accomplishing the initial objectives of controlling hemorrhage and preventing further contamination, the patient can be re-warmed, metabolic derangements corrected, fully resuscitated, and then brought back to the operating room for the definitive surgical procedure.  This application of damage control surgery has expanded to the patient with colon and rectal pathology both in the elective setting [65] and following trauma.  Miller and colleagues evaluated 11 patients undergoing delayed primary anastomosis following an initial damage control procedure, finding similar anastomotic leak rate (0% vs. 5%), abscess rate (36% vs. 24%), and colon related-death rate (9% vs. 0%; all P > 0.05) as those undergoing immediate primary repair. [66]  In the future, the decision to perform diversion versus primary repair may become easier, as initial stabilization can be performed followed by re-evaluation in the next 24-36 hours to determine the appropriate surgical procedure.  Damage control surgery, for both civilian and combat injuries, may hopefully then lead to decreased mortality and morbidity rates with less need for diversion.

Rectal InjuriesSimilar to colonic injuries, the management of both civilian and military penetrating rectal injuries has seen a dramatic shift in the last few decades. [21, 54]  Since Lavenson and Cohen’s article regarding their experiences in the Vietnam War purporting the benefits of diverting stoma, distal rectal washout, presacral drainage, and rectal repair (when feasible), this has remained the standard management for rectal trauma. [67]  However, these edicts of rectal injury treatment have been questioned not only in the civilian literature, [68] but in recent military conflicts as well. [22]  Confounding the issue, however, the data on rectal trauma has been less extensive than colon injuries, and almost exclusively consists of class III data or very small series.  Stone and Fabian’s sentinel paper advocating primary repair excluded 48% of their initial study population, including rectal injuries, providing some doubt as to widespread applicability of their findings to the patient with rectal trauma. [7]  Others have emphasized how mechanisms involved in this injury pattern often cause damage not only to the rectum, but major adjacent systems as well.  Thus, more traditional aggressive management with diversion, repair, distal washout, and drainage may seem to be more of a conservative or safe approach.  In a series of 28 patients undergoing damage control surgery for penetrating pelvic injuries, of the 43% who sustained extraperitoneal rectal injuries, half experienced associated major vascular injuries, and 43% incurred associated urological injuries. [69]  Moreover, over one-third of the patients with rectal and vascular injuries died within one week, highlighting the devastation and increased mortality associated with this injury complex. 

Extra- versus intraperitoneal location
 It is important to differentiate the location of the rectal injury, though similar controversy regarding the utility and need for proximal diversion versus primary repair exists with both sites.  As in other benign disease processes, trauma to the intraperitoneal rectum is often treated like colonic injuries.  On the other hand, extraperitoneal rectal injuries occur within the fixed pelvis.  Here visceral and vascular structures are located in close proximity to one another, and are at significant risk for concomitant injury from either the inciting object or the pelvic injury causing secondary damage.  Unlike injuries located above the peritoneal reflection, these patients are more often treated with upfront fecal diversion.  Younger age and presumably better overall health does not seem to play a role in the treatment strategy, as a study of 53 pediatric-aged penetrating colorectal injured patients demonstrated all rectal injuries were treated with a colostomy, whereas 62% of the colon injuries were repaired primarily. [70]  Similarly, in a study from the late 1980s of 100 consecutive patients with injuries to the extraperitoneal rectum, 100% were treated with colostomy, with a resultant pelvic sepsis rate of 11% and overall mortality rate of 4%. [71]  The authors concluded that all patients with this injury should be diverted.  In another study of 28 patients sustaining extraperitoneal rectal injuries, all patients underwent diversion with no deaths.  The authors again felt that these injuries should all be managed with stomas and presacral drainage, although there was no need for primary repair of the injury itself. [72]  Hence, the management of pelvic and low rectal injuries tends to be more consistent across both the military and civilian sectors. 
 
Yet as time has evolved, some have questioned the need for a different practice pattern between the two locations.  Even dating back to the late 1970s, Haas and Fox treated 3 patients with penetrating injuries to the extraperitoneal rectum non-operatively without any complications. [73]  Burch and colleagues noted successful non-operative management may be possible, although proper patient selection is difficult, and this “is not recommended” for these injuries. [72]  Others have felt the degree of injury plays a major role in determining the extent of surgery required.  Gonzalez and colleagues evaluated whether the practice of diversion and drainage for nondestructive wounds (defined as <25% of the total circumference) of the extraperitoneal rectum is always necessary. [74]  In a prospective protocol of 14 injuries, after exclusion or repair of intraperitoneal injuries, all extraperitoneal rectal injuries were allowed to heal by secondary intention without diversion or drainage.  Patients were instead treated with a regimen of 24 hours of antibiotics, clear liquid diet, and follow-up barium enema in 5-7 days.  The authors found no complications associated with the rectal injury itself, with a single intraabdominal abscess developing as a result of a cecal injury, and concluded that routine diversion and drain placement is unnecessary for non-destructive wounds.
 
Thus, although treatment options range from any combination of proximal diversion, primary repair, presacral or transperitoneal drainage and/or distal washout, there remains disagreement regarding which regimen is best.  Like colon injuries, specific surgical procedures should be tailored to the patient depending on not only the degree of rectal injury, but also on their hemodynamic status and concomitant injuries.  Yet, questions remain as to how aggressively to pursue these injuries.  This is especially evident with regards to the need for direct repair of the rectal injury.  Velmhamos and colleagues in a retrospective study of 30 extraperitoneal gunshot wounds found similar rates of complications whether or not the injury site was repaired. [75]  Other authors have attempted to further substratify the location of the extraperitoneal injuries in attempt to determine appropriate management.  McGrath and associates used the anatomical boundaries of the serosalized surface to distinguish intraperitoneal versus extraperitoneal. [76]  The same group then went on to develop a pathway for full thickness penetrating rectal injuries such that intraperitoneal rectal injuries were treated with primary repair, and extraperitoneal rectal injuries were divided based on the anatomic location of the injury.  Proximal two-thirds and accessible distal one-third extraperitoneal rectal injuries were managed with direct repair and “selective” fecal diversion, while inaccessible distal extraperitoneal injuries were treated with diversion and presacral drainage.  Selective proximal diversion for the upper two-thirds injuries was left to the discretion of the surgeon, based on the complexity of the wound and overall clinical status of the patient.  Using this pathway in comparison to their prior near uniform use of colostomy and drainage, overall infectious complications were reduced from 31 to 14% (P<0.05), along with a 2% intra-abdominal or presacral abscess rate versus prior rate of 12%. [77]  Thus, although based on somewhat limited data, when proximal diversion is performed, direct repair of the rectal injury is likely not needed.  Whether direct repair is needed in the absence of proximal diversion is still left to question, although evidence again suggests that it is not.  Of more concern may be exploration of these often difficult injuries, depending on the location, leading to prolonged surgery, excess blood loss, and ultimately higher morbidity.    
 
Yet not all are in favor of a “less is more” approach for extraperitoneal injuries.  In a retrospective review of 23 patients with full thickness rectal injuries, assorted regimens of drainage (n=11), distal washout (n=6), primary closure of the wound (n=17) and diversion (n=15) were used. [78]  Despite these different treatments, 11/23 developed complications including pelvic sepsis (22%) and an overall 13% mortality rate.  Though the authors made no recommendations on the use of colostomy, they did conclude that regardless of the treatment employed, these remain significant injuries with a high morbidity rate.  Others have been even more forceful, as Duncan and colleagues in a retrospective review of colorectal injuries from Operation Iraqi Freedom found all rectal injuries were managed via diversion, finding no leaks in this small cohort. [79]  The authors concluded that in this setting of high velocity weaponry, injury severity, and complex issues involved within the combat arena, colostomy should continue to have a prominent role in these patients.

Drain versus no drain
Presacral drain usage, either via the traditional transperineal or abdominal routes, continues to be both taught and practiced clinically, especially for those patients with extraperitoneal rectal injuries.  Regardless of the method of placement, proponents cite the need for proper positioning adjacent to the injury to adequately drain the presacral area.  Using this technique, Armstrong and associates demonstrated a reduction of pelvic infections by 50% with the use of transperineal drainage in a series of combat related wounds. [80]  Even Burch and colleagues in 1989 stated that “the one adjunct about which there is almost unanimous agreement is the need for drainage of the presacral space.” [72]  However, as is the case with the other components of traditional management, drain use has been questioned.  Levy and colleagues reviewed 26 cases of extraperitoneal rectal injuries, and although emphasizing the need for proximal diversion, felt that presacral drainage and distal washout were not mandatory components to successful management. [81]  Navsaria and associates retrospectively reviewed 92 patients with 118 rectal injuries.  Although 86/92 were managed with proximal diversion, none had presacral drains.  Despite the lack of drainage, they found only two patients acquired fistulas and only 10% incurred infectious complications, with no patients developing pelvic/perirectal sepsis. [82]  Steinig and Boyd also reviewed their 10-year experience of 22 patients with extraperitoneal injuries, of which 20 received a colostomy and 12 had a distal washout.  In comparing the 12 without drainage and 8 with presacral drains, there was no difference in infectious complications. [83]  Yet the retrospective nature of these studies made it difficult to determine the exact role of drainage in the prevention of infectious complications.  Gonzalez and colleagues attempted to further evaluate this question when they prospectively randomized patients with rectal injuries to no drain or presacral drain with closed suction JPs.  Although all were managed with diversion, infectious complications occurred in only 1 (4%) of the 25 patients managed without a drain (rectocutaneous fistula) versus two (8%) of the 23 patients with a drain (perirectal (1) and perivesical (1) abscess).  The authors concluded that presacral drainage has no impact on reducing infectious complications. [84]  Finally, McGrath and colleagues felt that presacral drainage was only necessary in those extraperitoneal injuries that were inaccessible and not able to be explored in order to decrease the incidence of presacral abscess.  [77]  Thus, while the degree to which drain placement prevents infectious complications remains unknown, its use is likely to be minimal based on the best available class of data.  In addition, there remains minimal evidence evaluating drainage use following high velocity mechanisms and blunt trauma where local injury may be more extensive.

Role of distal washout 
Those that advocate distal rectal washout highlight the need to clear the defunctionalized rectum of the stool that can be a persistent source of sepsis through what is in many cases an open wound in the rectal wall.  Shannon and colleagues evaluated this in a retrospective review of 26 extraperitoneal rectal injuries for which half the patients were treated with distal washout, presacral drains in 88%, and all had proximal colostomy in place. When comparing the no-washout group with those that underwent distal washout, major complications were greater in the no-washout group (pelvic abscess, 46% vs. 8%, fistula 23% vs. 8%; sepsis 15% vs. 8%, P<0.05).  Though a small non-randomized review, the authors felt that washout leads to a decrease in overall septic morbidity, possibly through decreasing gastrointestinal bacterial translocation. [85]  Opponents claim that feces remaining in the rectal vault bear no influence on the rate of sepsis, but in washing out this area stool and bacteria are forced into tissue planes that would not have otherwise been disturbed.  Tuggle and Huber were some of the first to question the utility of rectal washout, as only 1 of there 27 patients had distal rectal irrigation with no increase in morbidity compared to those that were advocating its use. [86]

Since the 1990s, most series have demonstrated no significant advantage to distal washout in civilian rectal trauma.  McGrath’s series found no difference in presacral infections in 33 patients managed with distal washout (2/33) versus no washout (1/5), p=0.35. [77]  Even Burch’s series of 100 consecutive extraperitoneal rectal injuries, although strongly advocating the use of both colostomy and drainage, felt that direct repair of the wound and distal irrigation had little effect on morbidity and mortality. [72]  Ivatury retrospectively reviewed 54 patients with penetrating rectal injuries, of which 43 patients had colostomy and presacral drainage.  In 21 of these patients distal washout was included, but the incidence of pelvic abscess was no difference from those 22 without washout (4.7 vs. 4.5%, respectively).  Whereas they felt diversion and drainage is imperative, they questioned the value of distal rectal irrigation. [87]  So although limited prospective data has addressed this issue, it appears that distal washout has no significant protective effect on the prevention infectious complications.

Antibiotic Use 
Unfortunately infectious issues have plagued colon and rectal trauma throughout time. [88]  Sources include not only the initial injury itself resulting in wound and deep space contamination, but also subsequent development of nosocomial infections that may result during long-term care.  In order to fully address infectious processes secondary to traumatic mechanisms, multiple tenets must be implemented.  First is early aggressive debridement or resection of any grossly necrotic tissue present, as well as leaving the skin open or partially open in most cases in attempt to lessen surgical site infection.  The importance of early administration of intravenous antibiotics cannot be emphasized enough.  Historical data from civilian trauma centers have demonstrated that postoperative infectious complications can range from 30% with any intraabdominal injury, and up to 70% when the colon is injured and antibiotics are administered postoperatively versus 11% when given preoperatively. [89]  In addition, even with preoperative dosing, Thadepalli in colleagues in 1973 highlighted the need for broad spectrum antibiotics to reduce the risk of postoperative infection from 27% to 10% with the addition of anaerobic coverage. [90]  In a recent review of all combat injuries, a multidisciplinary panel recommended that implementation of broad spectrum antibiotics to include anaerobic activity should be instituted upon arrival following identification of the hollow viscus injury, and continued for 24 hours after definitive control of all gross spillage. [91]  In the civilian sector, the current Eastern Association for the Surgery of Trauma (EAST) guidelines for the prophylactic antibiotic use in penetrating trauma currently recommends a single preoperative dose with broad spectrum aerobic and anaerobic activity for only 24 hours after finding sufficient Class I and II data. [92]  Duration longer than 24 hours has also not been to shown to decrease surgical or non-surgical infectious complications, even in prospective randomized studies, [93, 94] including high risk injuries such as colonic injuries or significant degree of intrabdominal injuries. [95]

Conclusions & Recommendations
In summary, colorectal injuries remain a challenging clinical entity associated with significant morbidity.  Familiarity with the different methods to approach and manage these injuries, including “damage control” tactics when necessary, will allow surgeons to minimize unnecessary complications and mortality.  Evolution in the care along with extensive outcomes research over the past few decades has demonstrated that almost all civilian and military colon injuries can be repaired primarily with a low anastomotic leak rate that appears to be independent of the method of repair.  Rectal injuries, although often complex and associated with injuries to adjacent organ systems, have similarly seen a rise in successful primary repair for those located intraperitoneally.   Extraperitoneal rectal injuries, while still most often managed with the use of diverting colostomies, have also been shown to be amenable to avoidance of proximal diversion in select patients--especially those in the upper extraperitoneal rectum.  Further prospective trials with increasing experience and outcome data is necessary prior to definitive recommendations.  Adjuncts to management for rectal injury including distal washout and presacral drainage, despite the potential for a continued role in high velocity and complex injuries, appear to have no significant impact in decreasing the septic complications from this injury complex.  Direct repair of extraperitoneal rectal injuries also does not seem to significantly reduce infectious complications.  Finally, antibiotics should be instituted as quickly as possible, have activity against aerobic and anaerobic pathogens, and initially limited to 24 hours following control of all gross contamination, with further use only directed against a known infection. 

 
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