Rectal Injuries

I. Introduction

Injuries to the rectum occur in up to 3% of civilian trauma and 5.1% in military-related trauma patients.¹ Understanding the anatomy of the rectum is critical to guiding trauma management. The rectum is the most posterior visceral organ in the pelvis, initiating at the rectosigmoid junction and terminating in the anal canal. In male patients, the rectum lies posterior to the bladder and prostate, separated by the rectovesical pouch. In female patients, the rectum is posterior to the vaginal canal and uterus, separated by the pouch of Douglas (rectouterine pouch). Both the rectovesical pouch and pouch of Douglas are the most inferior aspects of the peritoneum. As such, the rectum has both intraperitoneal and extraperitoneal components. The anterior and lateral walls of the proximal two-thirds of the rectum is intraperitoneal, while the posterior wall of the proximal rectum and the entirety of the distal third is extraperitoneal. A sagittal diagram from Weinberg et al demonstrates this delineation in a female patient.²

Weinberg JA, Fabian TC, Magnotti LJ, Minard G, Bee TK, Edwards N, Claridge JA, Croce MA. Penetrating rectal trauma: management by anatomic distinction improves outcome. J Trauma. 2006 Mar;60(3):508-13; discussion 513-14. doi: 10.1097/01.ta.0000205808.46504.e9. PMID: 16531847. Reproduced with permission.

Approximately 85% of all rectal injuries are secondary to gunshot wounds, with blunt trauma and stab wounds compromising the remainder of traumatic rectal injuries.¹ However, in military-related trauma, over 20% of rectal injuries are due to blast injuries.¹ Given the location of the rectum deep in the pelvis, traumatic rectal injuries are rarely seen in isolation, as the mechanism responsible would be high-velocity trauma to the pelvis. Rectal injury discovered in a trauma patient should raise suspicion for associated pelvic organ or vascular damage.¹

Historically, the management of rectal trauma stemmed from military trauma experience and typically included presacral drainage, distal rectal washout, debridement and diversion.^4,5,6 However, a study published in 1979 by Stone et al substantially changed management, and the subsequent decades have revealed management strategies with improved outcomes for both civilian and military rectal trauma injuries.^6,7

II. Clinical Presentation

Given the anatomical location of the rectum, diagnosis of rectal injuries in a trauma patient may be difficult. A high index of suspicion of injury for both rectal and potential adjacent injuries is crucial. Distal rectal injuries may present with external anal tears or visible trauma, or exquisite pain in the perianal region. Additionally, presentation of gross blood at the anus or on a digital rectal exam may be present. However, given that a digital rectal exam has a high-false negative rate of up to 67%, a lack of blood does not rule out injury.⁸

Rectal trauma, especially in the setting of high-velocity blunt trauma, can present in association with disruption of the bony pelvis. Specifically, trauma patients who present with a widened pubic symphysis have a three-fold increased risk of rectal trauma.⁹ Pelvic fractures should also raise concern for rectal injury.⁹ Given the proximity to the prostate, a high riding prostate or evidence of urogenital trauma may be concurrent with rectal trauma, and evaluation with a retrograde urethrogram is warranted. To summarize, rectal traumas rarely happen in isolation, therefore evaluation of a trauma patient with presumed rectal injuries should be evaluated for additional pelvic organ or vascular injury.³

III. Evaluation

In patients with suspected rectal injury, close examination of the perineum, anus, rectal vault, and prostate is warranted.¹⁰ A digital rectal exam should be performed in the secondary survey in trauma patients in which rectal injury is suspected.^3,11

If a pelvic x-ray demonstrates pelvic displacement or fracture, suspicion for concomitant rectal injury should be high. Hemodynamically stable patients who have sustained blunt trauma, and select patients who have sustained penetrating trauma, should ultimately undergo CT scan. Triple contrast CT scan (IV, oral, and rectal contrast) may be helpful for identification of colorectal injuries, if available.⁵ CT findings concerning for rectal injury include perirectal stranding, rectal wall thickening, rectal defect, retroperitoneal or intraperitoneal extraluminal gas or fluid.

Proctoscopy should be performed in stable patients that have imaging findings suggestive of a rectal injury or for those with a negative CT but high clinical suspicion.^{3,5, 6} Retrospective data from the American Association for the Surgery of Trauma (AAST) Contemporary Management of Rectal Injuries Study group demonstrated that in 106 patients with grade II – V injuries, only 34% of patients had positive CT findings (i.e. rectal injury, perirectal stranding, rectal wall thickening), whereas 94% had positive rigid proctoscope findings, such as blood, mucosal abnormalities, or laceration.¹² The combination of CT and proctoscopy demonstrated a sensitivity of 97%.¹²

Rectal injuries are graded by the AAST Organ Injury Scales for Recum.¹³ The grading is as follows:

• Grade I: Hematoma or contusion without devascularization or partial thickness laceration
• Grade II: Laceration < 50% circumference
• Grade III: Laceration > 50% circumference
• Grade IV: Full-thickness laceration with extension into the perineum
• Grade V: Devascularized segment

These injuries can subsequently be described as either non-destructive (less than 50% of rectal circumference) or destructive (greater than or equal to 50% rectal circumference).

IV. Management

Initial management of a trauma patient with suspected rectal injuries should include the primary and secondary survey and stabilize the patient as indicated. If the primary and/or secondary survey have signs of rectal injury, it is critical to evaluate for other concomitant injuries in the pelvis given likelihood of adjacent organ or vascular damage as described above. If primary and secondary surveys have signs of rectal injury and the patient is otherwise hemodynamically stable, plan for proctoscopy in the operating room.³ However, for hemodynamically unstable patients with peritonitis or signs of rectal injury, exploratory laparotomy should be performed first.  The patient should be positioned in lithotomy to allow for intraoperative rigid proctoscopy. 

For patients proceeding to the operating room, preoperative IV prophylactic antibiotics for enteric coverage should be administered to decrease risk of postoperative surgical site infection. Cefazolin (2g IV if <120kg, 3g IV if ≥120kg) plus metronidazole 500mg IV or alternatively a second-generation cephalosporin such as cefoxitin 2g IV or cefotetan 2g IV can be given.  Preoperative antibiotics should be continued at a minimum for 24 hours post-operatively, with continuation for four days total if evidence of significant intra-abdominal spillage is found.^5,10

All patients with suspected rectal injury should undergo proctoscope evaluation; in unstable patients, this can be performed once the patient has been resuscitated.¹⁰ Findings suggestive of rectal injury include submucosal hematoma, intraluminal clot or hematoma, and luminal defect. Obtaining insufflation when performing preoperative sigmoidoscopy is critical for optimum evaluation. Excess insufflation increases the risk of fecal contamination from concurrent injuries or impair subsequent abdominal exploration, while lack of sufficient insufflation may result in missed rectal injuries.⁵ Proctoscopy can be challenging intraoperatively in trauma patients, who often have high fecal burden in the rectum, which limits visualization.  Having suction and irrigation available can be helpful.

Operative management of rectal trauma is dictated by the anatomy of the rectum, specifically the distance of the injury from the anal verge and whether the injury is intraperitoneal or extraperitoneal.

Intraperitoneal non-destructive rectal injuries are managed with a parallel algorithm as colonic injuries. Non-destructive lesions (grade I, II and selected III ) should be managed with primary repair. Primary repair should include debridement of all unhealthy and devascularized tissue. Repair of the defect or anastomosis after resection can be performed in either a two-layer closure (via inner full thickness closure with absorbable 3-0 suture and outer seromuscular closure with interrupted 3-0 silk in Lembert fashion) or in a one-layer closure with continuous running full-thickness suture with absorbable monofilament suture (or interrupted full thickness 4-0 silk) depending on surgeon preference. ^5,20

Intraperitoneal destructive rectal injuries (selected grade III, grade IV and V) should be managed with primary repair if adequate mesenteric blood supply is present.^5,21 Primary repair should not be performed in patients who required greater than 6 units of transfused blood or have comorbidities that would impair wound healing; in these patients, diversion is warranted.^15,22-25 In addition, if associated with perineal injury or an open book pelvic fracture, fecal diversion with proximal colostomy is indicated.^5,6 For patients who do require ostomy formation, a loop colostomy is recommended  to aid for ease of reversal, which can occur typically within 6-8 weeks of creation.^5,20 Colostomy using a loop of sigmoid brought up to the left lower quadrant of the abdomen is preferred.²⁰

Extraperitoneal rectal injuries are managed based on anatomical constraints. If the injury is accessible transanally, primary repair may be appropriate.²⁷ If the lesion is inaccessible transanally, proximal diversion is likely warranted.^2,5,27 Notably, a small prospective study demonstrated that for non-destructive penetrating extraperitoneal injuries, non-operative management with healing by secondary intention was feasible, though larger scale studies are needed to validate this management strategy.²⁸

Diversion is recommended in patients with associated pelvic fractures or concomitant vascular injuries with ability to compromise rectal blood flow.²⁹ In addition, extensive dissection of the extraperitoneal distal rectum should be avoided given the potential for iatrogenic injury and diversion should be performed. Proximal diversion should be performed with a loop sigmoid colostomy as described above. Accepted approaches included both laparoscopic and open, though with consideration to overall injury burden and surgeon preference.^20.27

Retained foreign bodies to the rectum usually result in extraperitoneal injuries. Following removal of the object, either at bedside or in the operating room, evaluation for rectal injury should be performed with rigid proctoscopy or flexible sigmoidoscopy. Patients that are otherwise hemodynamically stable and do not have a full-thickness injury can proceed with non-operative management including a period of observation.^{27 30} However, if a full thickness injury has occurred operative management based on anatomic location should be pursued.

In general, presacral drainage and distal rectal washout for extraperitoneal injuries should be avoided. ^19,20,27 Though initially thought to decrease the risk of pelvic sepsis, presacral drains have demonstrated variable to no benefit in recent studies.^2,5,19,31 Despite this, presacral drainage may be indicated in patients with complex injuries that include disruption of the pelvic musculature.³⁰ Extraperitoneal wounds with significant presacral contamination that cannot be explored may benefit from presacral (retrorectal) drainage.² If a presacral drain is warranted, drains should be placed with the patient in lithotomy. Posterior to the anus, a curved incision should be made and blunt dissection used to develop the presarcal space to the level of the sacrum. A penrose drain may be placed in the presacral space and sutured to the skin. Removal of the drains should be performed beginning on postoperative day 4.²⁰

Rectal washout was also initially believed to reduce incidence of morbidity secondary to sepsis¹⁴, yet subsequent studies have demonstrated no morbidity benefit.^3,5,29,31 In fact, patients with extraperitoneal injuries that underwent rectal washout have increased complications.¹⁹

Primary skin closure is not advised after repair of rectal injury if significant intra-peritoneal feculent contamination is present, but may be considered otherwise.^5,10 Loosely stapling skin with placement of gauze wicks between staples is appropriate. Incisional wound vacs (i.e vacuum-assisted wound closure device) can be employed.

V. Postoperative Management

After rectal injury repair, antibiotics should be continued postoperatively. For intraperitoneal injuries, 24 hours of antibiotics postoperative is typically sufficient.²⁷ However, for extraperitoneal injuries, duration may be extended to 3-5 days postoperatively.²⁷ Antibiotics should include both enteric aerobic and anaerobic coverage, as per above. Patients should be monitored closely for surgical site infections, stoma complications (retraction, prolapse, skin irritation, stenosis), perianal sepsis, and presacral abscess.²¹

VI. Complications

Complications of traumatic rectal injuries have been reported in nearly half of rectal wartime trauma patients.³² The most common cause of death in patients with colorectal injuries is exsanguination from concomitant mesenteric injury.¹⁰ The second most common cause of death is sepsis. ¹⁰

Complications from repair of traumatic rectal injuries include wound infections, wound dehiscence, stenosis, and the development of fistulas. Infections can include wound infection, abscess, formation, and necrotizing soft tissue infection and perineal sepsis. Abscess formation can be managed with CT-guided drainage if possible.¹⁰ Risk of wound infection can be reduced by leaving the skin open with closure via secondary intention or placement of a negative-pressure wound therapy device.^5,10,27 Patients with pelvic fractures are also at high risk of postoperative infection, which can be mitigated with diversion as described above.²⁷ Fistulas that develop in these settings tend to be low output. If a patient is otherwise hemodynamically stable, without evidence of sepsis, these fistulas can be managed nonoperatively and patients can continue with PO intake.

VII. Summary

• Penetrating trauma is the most common mechanism of rectal injury. Blunt trauma is usually associated with significant disturbance to the pelvis.
• Rectal trauma rarely happens in isolation, therefore evaluation of a trauma patient with presumed rectal injuries should be evaluated for additional pelvic organ or vascular injury.
• Evaluation for rectal injury should include digital rectal examination, pelvic x-ray, CT imaging with triple contrast if available, and proctoscopy
• Intraperitoneal injuries should be repaired primarily, unless the patient requires greater than 6 units of red blood cell transfusion or has comorbidities associated with poor wound healing.
• Patients with intraperitoneal injuries and concurrent pelvic fractures may benefit from loop colostomy formation for temporary fecal diversion.
• Extraperitoneal injuries that are accessible transanally can be repaired primarily. If inaccessible, diversion with loop colostomy is recommended.
• Rectal washout is generally not beneficial.
• Management of the skin is based on the extent of fecal contamination of the peritoneal cavity.

VIII. References

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