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Management of rectal injuries
Management
of R&tal Injuries CO!. GEORGE S. LAVENSON, Jr, MD,* US Army, Vietnam CO1 ARTHUR
Rectal wounds are among the most challenging injuries encountered by the surgeon.Virulent complications and high mortality are common and are invariably related to sepsis. The use of a diverting sigmoid colostomy, presacral drainage, and rectal repair when feasible was instituted during World War II and proved to be most effective in significantly reducing mortality which w&s associated with earlier methods of treatment [Z-3]. Unfortunately, a death rate exckeding 20 per cent has continued to result from rectal injuries in both civilian [4,5] and military casualties [6]. Furthermore, many patients have required prolonged hospitalization for the treatment of complications. Experience with rectal injuries in Vietnam suggested that fecal material remaining in the distal defunctionalized segment was an important factor in the production of sepsis. It seemed logical to assume that removal of feces from this segment, at the time of initial surgery, would prevent continued contamination and effect a reduction in morbidity and mortality. Accordingly, a group of patients with wounds of the rectum had washout of the distal defunctionalized segment added to the standard method of treatment. The purpose of this report is to present the results of treatment of rectal trauma with and without washout of the distal rectum and to offer our current recommendations for the management of
rectal injuries. Material and Methods Between July 1968 and August 1969 we were involved in the care of twenty-nine battle wounds involvihg the rectum. Twenty-fbur of the casualties were US servicemen and five patients were Vietnamese. Eighteen rectal injuries were treated before December 1968 and did From the Dffice of the Surgical Consultant, US Army, Vietnam. and the 24th Evacuation Hospital, Republic of Vietnam. Presented at the Forty-Second Annual Meeting of the Pacific Coast Surgical Association. Mexico City, Mexico. February 14-18. 1971. Present address: Department of Surgery. Wllliem Beaumont General Hospital, El Paso, Texas 79920. t Present address: Department of Surgery, Lettermen General Hospital. Presidio of San Francisco, California 94129. l
226
COHEN,
not have washout
MD,? US Army,
of the distal
Vietnam
rectum.
Ten casualties
with rectal wounds were treated after December 1,1968 and all had washout
of the distal
rectum
in addition
to
conventional operative treatment. In one instance, the extent of injury required abdominoperineal resection. Rectal trauma was suspected in all casualties with wounds of the lower abdomen, buttocks, perineum, and upper thigh. Rectal injury was also strongly considered in all wounds of the sacrum because of the high incidence of bone fragmerlts traversing the rectum. X-ray examination commonly failed to demonstrate either the bone fragments or the sacral fracture. All patients with suspected rectal injuries had preoperative rectal examination and sigmoidoscopy. Although rectal wounds were not uniformly vidualized, the presence of intraluminal blood in the absence of proximal colonic injury was considered postive evidence of rectal involvement. A Foley catheter was routinely pladd ii? the bladder and if hematuria was present, an excretory urogram and a cystogram were obtained. Preoperative neurosurgical evaluation was also indicated whenever injury to the dura of the spihal cord was suspected. All casualties in whom rectal injury was determined had exploratory laparotomy through a midline incision. Appropriate surgical management of the associated intraperitoneal injuries wa.s accomplished and intraperitoneal rectal wounds were repaired. In the majority of retroperitoneal recta1 injuries the pelvic peritoneum was incised, the presacral space was dissected bluntly down to the levators, as in a Miles resection, and the rectal injury, if visualized, was repaired. (Figure 1.) Penrose drains were then placed throughout the pelvis, under direct vision, and were brought to the exterior through a presacral stab wound. (Figure 2.) The ten patients treated after December 1, 1968 did have thorough washout of the distal bowel at the time of initial surgery. This was accomplished by passing copious amounts of saline solution through the defunctionalized segment until returns were clear. t b’igure 3. ) In some cases this technic also allowed identification of the extraperitoneal rectal defect. The pelvic peritoneum was then closed, and in all but one case, a completely diverting sigmoid colostomy was performed. All casualties received appropriate supportive measures, including whole blood replacement, repair of fluid and electrolyte deficits, appropriate antibiotics, and tetanus prophylaxis.
The American
Journal
of Sutzery
Rectal
Figure 1.
Presacral dissection.
Figure 2. Site of incision for presacral drains (inset). Placement of drains under direct vision.
The majority of casualties were retained at the initial treatment center until their condition allowed for safe transportation to hospitals in Japan (US servicemen) or to local Province hospitals (Vietnamese). Results
The surgical procedure used for the treatment of rectal injury appeared to have a significant effect on the outcome. Measures employed and the resultant morbidity and mortality are listed in Table I. Seven patients received a divided sigmoid colostomy and presacral drainage as the sole treatment for the rectal injury. Distal washout and rectal repair were not performed. Two deaths occurred in this group. One patient had a massive perineal wound with extensive tissue damage and died of overwhelming sepsis on the fourth postoperative day. The second case had an associated dural wound which went unrecognized. The patient died of meningitis on the forty-eighth day, after he had weathered earlier drainage of a subphrenic abscess and nonoperative treatment of a bleeding stress ulcer. Major nonfatal complications developed in two additional patients. In one, a rectal fistula and osteomyelitis of the sacrum responded to treatment. A pelvic abscess and rectal fistula complicated the postoperative course of the other patient. In nine patients, treatment consisted of repair of the rectal wound, construction of a divided sigmoid colostomy and presacral drainage. Distal washout of the rectosigmoid was not performed. One patient in whom a pelvic abscess and a bleeding stress ulcer developed died of generalized sepsis. Complications occurred in six other patients. These included two rectal fistulas, a rectovesical
Volume 122, August 1971
Figure 3. washout.
A method
Injuries
of distal
fistula, two vesicocutaneous fistulas, osteomyelitis of the sacrum, and a bleeding stress ulcer. Washout of the distal rectal sigmoid was performed in two patients along with sigmoid colostomy and presacral drainage. The rectal injury was not repaired in either instance. In one case, loop colostomy was fashioned and incomplete fecal diversion produced a rectal fistula. No complications occurred in the second case. Eight casualties had washout of the distal rectosigmoid in addition to a divided sigmoid colostomy, rectal repair, and presacral drainage. All patients did well without a major complication. Resection of a completely shattered rectosigmoid with closure of the rectal stump and placement of TABLE
I
Morbidity
and Mortality of Operative
Numberof Patients
Morbidity
Colostomy Presacral drain
7
4
Colostomy Presacral drain 1 Rectal repair
9
7
Colostomy Presacral drain Distal washout t
2
1*
Colostomy Presacral drain Rectal repair Distal washout
a
0
Hartmann procedure
2
2
Abdominoperineal resection
1
0
Operation
Procedures
Mortality
* Nondivided colostomy performed.
227
Lavenson and Cohen
Comparison of Morbidity and Mortality with and without Washout of the Rectosigmoid
TABLE II
Number of Patients
Morbidity
Mortality
10 18
1 (10%) 13 (72.2%)
D (0%) 4 (22.2%)
Washout No washout
TABLE Ill
Complications
and Causes of Death
Data
Number
Complications: lntraperitoneal abscess Pelvic abscess Sepsis Rectal fistula Rectovesical fistula Vesicocutaneous fistula Stress ulcer Meningitis Osteomyelitis Causes of death: Sepsis Meningitis
a proximal end sigmoid colostomy (Hartmann procedure) was performed in two cases. The distal rectum was not washed out in either case. One patient died on the twenty-third postoperative day despite drainage of pelvic and multiple intra-abdominal abscesses. A large pelvic abscess, rectal fistula, and sacral osteomyelitis developed in the other casualty. One casualty presented with massive injury to the rectum and perineum and required abdominoperineal resection to effect adequate debridement. He recovered without complication. Four deaths were encountered among twentynine casualties with rectal wounds, yielding an over-all mortality of 13.8 per cent. Sepsis was the cause of death in each instance. These four patients did not have washout of the distal defunctionalized segment. Although no mortality occurred in the ten patients who did have distal washout, four deaths occurred in the eighteen casualties not TABLE IV
Associated Injury Small intestine Colon Liver Kidney Urinary bladder Chest Head Spinal cord Fracture
228
Injuries Number 11 4 1 1 7 1 1 2 7
with washout, resulting in a 22.2 per cent mortality for that group. Complications appeared in fourteen cases, 48.2 per cent of the over-all group of rectal injuries, and again, the complications in each case were related to sepsis.. Only one major complication occurred among patients who had cleansing of the distal segment, and this was associated with nondiverting loop colostomy. Complications did occur in thirteen (72.2 per cent) of those who did not have distal washout. The patient who required abdominoperineal resection is not included in the comparative morbidity rates. Table II compares the morbidity and mortality with and without washout of the distal rectosigmoid. The specific complications occurring in the fourteen patients with morbidity and in the four who died are listed in Table III. Associated injuries were almost equally distributed between the washout and nonwashout groups and are listed in Table IV. Four patients with associated bladder injuries were not treated with distal washout. Three patients had complications of the urinary tract repair. These included two vesicocutaneous and one rectovesical fistula. The fourth patient had no disruption of the bladder repair, and a rectal fistula and sepsis did develop. Three patients with associated bladder injuries who did receive distal washout had no disruption of the urinary tract repair. treated
Comments
Essential components in the management of rectal trauma have been emphasized in various reports [1,5,7-II]. Although absolute unanimity of opinion does not exist, there is general agreement that complete diversion of the fecal stream, dependent drainage, and repair of the rectal defect are necessary measures in treatment. Stress has also been placed on the need for early diagnosis and prompt onset of therapy [5]. The use of antibiotics is considered to be extremely important by some authors [1.2]. Only occasional mention and no emphasis have been given to the value of evacuating the defunctionalized rectosigmoid at the time of initial surgery [ 7,ll,lZ]. The inadequacy of established and accepted methods of care is affirmed by a mortality of over 20 per cent and a complication rate of over 72 per cent in this study. The latter figure closely approximates the experience of others [.21]. There is little question that presacral drainage has reduced the incidence of retroperitoneal sepsis by promoting excellent dependent drainage. How-
The American
Journal
of Surgery
Rectal Injuries
ever, pelvic abscesses are still encountered frequently. Divided sigmoid colostomy, designed to prevent continued contamination, fails in this assignment because of the fecal material already present in the rectum distal to injury. Residual material in the distal segment is likely to pass through snkall urecognized rectal defects, and bowel contents have been implicated in the disruption of repaired rectal wounds. This readily provides for the formation of rectal fistulas, the production of osteomyelitis, and the spread of sepsis from the levator area to the abdominal retroperitoneum. This study tends to confirm the value and the importance of adding washout of the distal rectosigmoid to the conventional management of rectal injuries. There were no deaths. among the ten casualties who were treated in this manner and the only major complication in the group receiving wa,shout occurred in a patient in wh,om a loop rather than a diverting sigmiod colostomy was employed. The contrast between the virtual absence of major morbidity and mortality when fecal material was removed from the rectum and the high incidence of deaths and serious complications when washout was not employed is striking. Based on this experience, we believe that certain points in our approach to the treatment of rectal injuries deserve emphasis. Injuries to the rectum should be highly suspect in all cases of regional penetrating trauma and in blunt trauma, particularly with pelvic fractures, and should be suspect as an iatrogenic consequence of sigmoidoscopy, rectosigmoid biopsy, and barium enema. In all such instances, rectal and proctoscopic examination is mandatory. The presence of blood in the rectosigmoid is usually indicative of rectal injury and prompt operative management must be planned. Adjacent organs and systems must be evaluated for possible involvement. At surgery, associated injuries must be repaired as indicated, a diverted sigmoid colostomy be constructed, wide blunt dissection of the presacral space be performed from above, rectal injuries repaired if feasible, and the distal segment completely cleared of all fecal material by saline lavage. Presacral drains are then placed within the pelvis under di,rect vision and passed to the outside through a presacral stab wound. Coccygectomy may or may not be necessary to provide adequate dependent drainage. Drains must never be placed through a sacral fracture. Some authors [11] have suggested ligation of the hypogastric artery to control massive pelvic bleed-
Volume122, August 1971
ing. Our experience indicates that this has little or no value and should be performed only when there is direct injury to the artery. Splitting of the pubic symphysis and direct hemostasis have been of value in an occasional case. In others, temporary packing was required to control hemorrhage. Debridement must be complete if additional morbidity is to be avoided. Massive injury to the retroperitoneal rectum and perineum may require abdominoperineal resection to effect adequate debridement and proper management of the injury. Summary
We have reviewed the management of twentynine casualties with rectal injuries terated in Vietnam. A high incidence of virulent complications and a 22.2 per cent mortality occurred in eighteen casualties treated by conventional means with a divided sigmoid colostomy, rectal repair when feasible, and presacral drainage. The complications and deaths were invariably related to pelvic sepsis. Distal washout to prevent continued contamination from fecal material remaining in the defunctionalized rectosigmoid was employed in ten casualties in addition to the conventional measures. This resulted in a striking reduction in complications and no mortality. We also stress the importance of prompt diagnosis, direct control of hemorrhage, proper management of associated injuries, and adequate debridement. References 1. Morgan CN: Wounds of the rectum. Surg Obstet - Gynec _ 81: 56, 1945. 2. Ogilvie Wti: Abdominal wounds in the western desert. Sum Gvnec Obstet 78: 225. 1944. 3. Taylor-Ed, Thompson JE: The early treatment and results thereof, of injuries of the colon and rectum. Int Abstr8urg 87: 209, 1948. 4. Vannix RS, Carter R, Hinshaw DB, Joergenson EJ: Surgical management of colon trauma in civilian practice. Amer J Surg 106: 364, 1963. 5. Wanebo HJ, Hunt TK, Mathewson C Jr: Rectal injuries. J Trauma 9: 712,1969. 6. Bowers WF: Surgical treatment in abdominal trauma: a comparison of results in war and peace. Milit Med 118: 9, 1956. 7. Ganchrow MI, Lavenson GS Jr, McNamara JJ: Surgical management of traumatic injuries of the colon -and rectum. Arch Sum 100: 515. 1970. a. Croce EJ, Johnson 7s: The management of war injuries of the intraperitoneal rectum. Ann Surg 122: 408, 1945. 9. Hurt LE: The surgical management of colon and rectal injuries in the forward areas. Ann Surg 122: 398, 1945. 10. Laufman H: The initial surgical treatment of penetrating wounds of the rectum. Surg- Gynec Obstet 82: 219. 1946. 11. Lung JA, Turk RP, Miller RE, Eiseman B: Wounds of the rectum. Ann Surg 172: 985, 1970.
Lavenson and Cohen
12. Hughes LE: Penetrating injuries of the extraperitoneal rectum. Brit J Surg 56: 169, 1969.
Discussion
THOMASHUNT (San F,rancisco, Calif) : Penetration of the colon increases markedly the mortality and mor-, bidity of any injury. Penetration of the rectum is the most serious of all colonic injuries. Five factors seem to govern the outcome: (1) the extent of soft tissue trauma, be it in the area of the rectum or elsewhere, (2) the presence of associated injury such as that involving the bladder, bone, and the like, (3) the time lapse from injury to treatment, (4) the age and health of the patient, and (5) the degree of contamination. Several years ago Peter Hawley and I assessed the importance of some of these factors in the laboratory. We found that, by itself, bacterial contamination of colonic suture lines caused few intraperitoneal infections and no anastomotic leaks. The addition of tissue injury, well remote from the anastomosis, potentiated infection and led to a few anastomotic leaks. When we added sterilized stool to the bacterial contamination, we caused a large number of intraperitoneal infections and many anastomotic leaks. The authors suggest that distal washout and careful repair of the injury prevent stool leaks through undiscovered penetrations. I agree. I would add, however, that their patients have: (1) high velocity injuries with extensive tissue damage, (2) inevitable delays in treatment, and (3) extensive contamination. Under these circumstances, suture line breakdown is common. Distal washout, then, becomes a reliable assurance against continued stool contamination when the repair leaks. We know from civilian experience that one must place a diverting colostomy close to the spontaneous perforation. Otherwise, a column of stool merely waits to leak through the perforation, and intraperitoneal sepsis will probably occur. I am trying to develop the concept that suture line leaks are probably the result of intraperitoneal infection as frequently as they are the cause. Furthermore, postoperative leaks are frequently not in the suture line at all, but a short distance away. Cleaning the distal segment is messy and one tends to avoid it. However, removing foreign bodies (stool) is well worth the immediate risk of added contamination. The peritoneum can handle bacteria. It cannot handle repeated stool contamination. Our experience at the Cook County Hospital involves about twenty patients. We have had a 20 to 25 per cent mortality. Many of our patients were very old, and there was a great delay before many of them came to our attention. On the other hand, we did not have the problem of high velocity missile injuries. We used distal washout in some cases but not in all. Another important factor is the time before operation is performed. The ,recent experience from Cook County Hospital underscores this. In their experience, 230
morbidity and mortality soared if there was as much as four hours delay before operation. Distal washout seems like a small detail; yet, good surgery is made up of such small and important details. The authors certainly seem to have improved on a grim picture. Anyone who treats ten successive rectal injuries with only one major complication has obviously done something better than the rest of us have done in the past, CARLETONMATHEWSON,JR (San Francisco, Calif) : There is very little good that comes out of war; however, we have learned some important lessons in regard to the management of trauma. Doctor Cohen and his associates have brought us another important message with regard to injuries of the rectum. Injuries of this type are not easily overlooked when there is evidence of external trauma; however, in civilian life a large percentage are iatrogenic and often unrecognized, causing serious delay in management. The injury often does not become apparent until serious infection has taken place. In our experience, iatrogenic injury to the rectum after sigmoidoscopic examination or barium enema carries a high mortality, either because the injury appeared to be minor and colostomy was delayed or because the injury was unrecognized until sepsis intervened and colostomy was performed too late. It is important, therefore, that we recognize these injuries early and proceed immediately with diverting colostomy, presacral drainage, and washout of the distal segment. ARTHUR COHEN (closing) : Doctor Hunt has reiterated the essential components in the treatment of rectal injuries. These methods all evolved from the care of casualties during World War II and later in the treatment of isolated groups of civilian patients. Although we completely agree on the need for all these methods of treatment, our experience with the use of thorough and complete washout of the distal defunctionalized rectal segment has shown more dramatic results than have been achieved with any other modality. Our later experiences at more distant echelons of medical care made us disagree with Dr Hunt in his advocacy of placing the colostomy close to the site of injury. The frequent necessity for repeated operations and the increased incidence of infection make restoration of gastrointestinal continuity a procedure of great magnitude. If a Hartmann procedure is used initially, it can and has made for an extremely formidable operative procedure. Time did not permit us to mention the use of ligation of the hypogastric artery in treating hemorrhage with these injuries. Our own experience indicates that this procedure is of no value unless there is direct disruption of the artery itself. We are in complete agreement with Dr Mathewson’s statement that international conflicts bring forth new methods of treatment. I have frequently heard him mention that these new concepts are quickly and easily forgotten by each generation. The
American
Journal
of
SurEPry
of R&tal Injuries CO!. GEORGE S. LAVENSON, Jr, MD,* US Army, Vietnam CO1 ARTHUR
Rectal wounds are among the most challenging injuries encountered by the surgeon.Virulent complications and high mortality are common and are invariably related to sepsis. The use of a diverting sigmoid colostomy, presacral drainage, and rectal repair when feasible was instituted during World War II and proved to be most effective in significantly reducing mortality which w&s associated with earlier methods of treatment [Z-3]. Unfortunately, a death rate exckeding 20 per cent has continued to result from rectal injuries in both civilian [4,5] and military casualties [6]. Furthermore, many patients have required prolonged hospitalization for the treatment of complications. Experience with rectal injuries in Vietnam suggested that fecal material remaining in the distal defunctionalized segment was an important factor in the production of sepsis. It seemed logical to assume that removal of feces from this segment, at the time of initial surgery, would prevent continued contamination and effect a reduction in morbidity and mortality. Accordingly, a group of patients with wounds of the rectum had washout of the distal defunctionalized segment added to the standard method of treatment. The purpose of this report is to present the results of treatment of rectal trauma with and without washout of the distal rectum and to offer our current recommendations for the management of
rectal injuries. Material and Methods Between July 1968 and August 1969 we were involved in the care of twenty-nine battle wounds involvihg the rectum. Twenty-fbur of the casualties were US servicemen and five patients were Vietnamese. Eighteen rectal injuries were treated before December 1968 and did From the Dffice of the Surgical Consultant, US Army, Vietnam. and the 24th Evacuation Hospital, Republic of Vietnam. Presented at the Forty-Second Annual Meeting of the Pacific Coast Surgical Association. Mexico City, Mexico. February 14-18. 1971. Present address: Department of Surgery. Wllliem Beaumont General Hospital, El Paso, Texas 79920. t Present address: Department of Surgery, Lettermen General Hospital. Presidio of San Francisco, California 94129. l
226
COHEN,
not have washout
MD,? US Army,
of the distal
Vietnam
rectum.
Ten casualties
with rectal wounds were treated after December 1,1968 and all had washout
of the distal
rectum
in addition
to
conventional operative treatment. In one instance, the extent of injury required abdominoperineal resection. Rectal trauma was suspected in all casualties with wounds of the lower abdomen, buttocks, perineum, and upper thigh. Rectal injury was also strongly considered in all wounds of the sacrum because of the high incidence of bone fragmerlts traversing the rectum. X-ray examination commonly failed to demonstrate either the bone fragments or the sacral fracture. All patients with suspected rectal injuries had preoperative rectal examination and sigmoidoscopy. Although rectal wounds were not uniformly vidualized, the presence of intraluminal blood in the absence of proximal colonic injury was considered postive evidence of rectal involvement. A Foley catheter was routinely pladd ii? the bladder and if hematuria was present, an excretory urogram and a cystogram were obtained. Preoperative neurosurgical evaluation was also indicated whenever injury to the dura of the spihal cord was suspected. All casualties in whom rectal injury was determined had exploratory laparotomy through a midline incision. Appropriate surgical management of the associated intraperitoneal injuries wa.s accomplished and intraperitoneal rectal wounds were repaired. In the majority of retroperitoneal recta1 injuries the pelvic peritoneum was incised, the presacral space was dissected bluntly down to the levators, as in a Miles resection, and the rectal injury, if visualized, was repaired. (Figure 1.) Penrose drains were then placed throughout the pelvis, under direct vision, and were brought to the exterior through a presacral stab wound. (Figure 2.) The ten patients treated after December 1, 1968 did have thorough washout of the distal bowel at the time of initial surgery. This was accomplished by passing copious amounts of saline solution through the defunctionalized segment until returns were clear. t b’igure 3. ) In some cases this technic also allowed identification of the extraperitoneal rectal defect. The pelvic peritoneum was then closed, and in all but one case, a completely diverting sigmoid colostomy was performed. All casualties received appropriate supportive measures, including whole blood replacement, repair of fluid and electrolyte deficits, appropriate antibiotics, and tetanus prophylaxis.
The American
Journal
of Sutzery
Rectal
Figure 1.
Presacral dissection.
Figure 2. Site of incision for presacral drains (inset). Placement of drains under direct vision.
The majority of casualties were retained at the initial treatment center until their condition allowed for safe transportation to hospitals in Japan (US servicemen) or to local Province hospitals (Vietnamese). Results
The surgical procedure used for the treatment of rectal injury appeared to have a significant effect on the outcome. Measures employed and the resultant morbidity and mortality are listed in Table I. Seven patients received a divided sigmoid colostomy and presacral drainage as the sole treatment for the rectal injury. Distal washout and rectal repair were not performed. Two deaths occurred in this group. One patient had a massive perineal wound with extensive tissue damage and died of overwhelming sepsis on the fourth postoperative day. The second case had an associated dural wound which went unrecognized. The patient died of meningitis on the forty-eighth day, after he had weathered earlier drainage of a subphrenic abscess and nonoperative treatment of a bleeding stress ulcer. Major nonfatal complications developed in two additional patients. In one, a rectal fistula and osteomyelitis of the sacrum responded to treatment. A pelvic abscess and rectal fistula complicated the postoperative course of the other patient. In nine patients, treatment consisted of repair of the rectal wound, construction of a divided sigmoid colostomy and presacral drainage. Distal washout of the rectosigmoid was not performed. One patient in whom a pelvic abscess and a bleeding stress ulcer developed died of generalized sepsis. Complications occurred in six other patients. These included two rectal fistulas, a rectovesical
Volume 122, August 1971
Figure 3. washout.
A method
Injuries
of distal
fistula, two vesicocutaneous fistulas, osteomyelitis of the sacrum, and a bleeding stress ulcer. Washout of the distal rectal sigmoid was performed in two patients along with sigmoid colostomy and presacral drainage. The rectal injury was not repaired in either instance. In one case, loop colostomy was fashioned and incomplete fecal diversion produced a rectal fistula. No complications occurred in the second case. Eight casualties had washout of the distal rectosigmoid in addition to a divided sigmoid colostomy, rectal repair, and presacral drainage. All patients did well without a major complication. Resection of a completely shattered rectosigmoid with closure of the rectal stump and placement of TABLE
I
Morbidity
and Mortality of Operative
Numberof Patients
Morbidity
Colostomy Presacral drain
7
4
Colostomy Presacral drain 1 Rectal repair
9
7
Colostomy Presacral drain Distal washout t
2
1*
Colostomy Presacral drain Rectal repair Distal washout
a
0
Hartmann procedure
2
2
Abdominoperineal resection
1
0
Operation
Procedures
Mortality
* Nondivided colostomy performed.
227
Lavenson and Cohen
Comparison of Morbidity and Mortality with and without Washout of the Rectosigmoid
TABLE II
Number of Patients
Morbidity
Mortality
10 18
1 (10%) 13 (72.2%)
D (0%) 4 (22.2%)
Washout No washout
TABLE Ill
Complications
and Causes of Death
Data
Number
Complications: lntraperitoneal abscess Pelvic abscess Sepsis Rectal fistula Rectovesical fistula Vesicocutaneous fistula Stress ulcer Meningitis Osteomyelitis Causes of death: Sepsis Meningitis
a proximal end sigmoid colostomy (Hartmann procedure) was performed in two cases. The distal rectum was not washed out in either case. One patient died on the twenty-third postoperative day despite drainage of pelvic and multiple intra-abdominal abscesses. A large pelvic abscess, rectal fistula, and sacral osteomyelitis developed in the other casualty. One casualty presented with massive injury to the rectum and perineum and required abdominoperineal resection to effect adequate debridement. He recovered without complication. Four deaths were encountered among twentynine casualties with rectal wounds, yielding an over-all mortality of 13.8 per cent. Sepsis was the cause of death in each instance. These four patients did not have washout of the distal defunctionalized segment. Although no mortality occurred in the ten patients who did have distal washout, four deaths occurred in the eighteen casualties not TABLE IV
Associated Injury Small intestine Colon Liver Kidney Urinary bladder Chest Head Spinal cord Fracture
228
Injuries Number 11 4 1 1 7 1 1 2 7
with washout, resulting in a 22.2 per cent mortality for that group. Complications appeared in fourteen cases, 48.2 per cent of the over-all group of rectal injuries, and again, the complications in each case were related to sepsis.. Only one major complication occurred among patients who had cleansing of the distal segment, and this was associated with nondiverting loop colostomy. Complications did occur in thirteen (72.2 per cent) of those who did not have distal washout. The patient who required abdominoperineal resection is not included in the comparative morbidity rates. Table II compares the morbidity and mortality with and without washout of the distal rectosigmoid. The specific complications occurring in the fourteen patients with morbidity and in the four who died are listed in Table III. Associated injuries were almost equally distributed between the washout and nonwashout groups and are listed in Table IV. Four patients with associated bladder injuries were not treated with distal washout. Three patients had complications of the urinary tract repair. These included two vesicocutaneous and one rectovesical fistula. The fourth patient had no disruption of the bladder repair, and a rectal fistula and sepsis did develop. Three patients with associated bladder injuries who did receive distal washout had no disruption of the urinary tract repair. treated
Comments
Essential components in the management of rectal trauma have been emphasized in various reports [1,5,7-II]. Although absolute unanimity of opinion does not exist, there is general agreement that complete diversion of the fecal stream, dependent drainage, and repair of the rectal defect are necessary measures in treatment. Stress has also been placed on the need for early diagnosis and prompt onset of therapy [5]. The use of antibiotics is considered to be extremely important by some authors [1.2]. Only occasional mention and no emphasis have been given to the value of evacuating the defunctionalized rectosigmoid at the time of initial surgery [ 7,ll,lZ]. The inadequacy of established and accepted methods of care is affirmed by a mortality of over 20 per cent and a complication rate of over 72 per cent in this study. The latter figure closely approximates the experience of others [.21]. There is little question that presacral drainage has reduced the incidence of retroperitoneal sepsis by promoting excellent dependent drainage. How-
The American
Journal
of Surgery
Rectal Injuries
ever, pelvic abscesses are still encountered frequently. Divided sigmoid colostomy, designed to prevent continued contamination, fails in this assignment because of the fecal material already present in the rectum distal to injury. Residual material in the distal segment is likely to pass through snkall urecognized rectal defects, and bowel contents have been implicated in the disruption of repaired rectal wounds. This readily provides for the formation of rectal fistulas, the production of osteomyelitis, and the spread of sepsis from the levator area to the abdominal retroperitoneum. This study tends to confirm the value and the importance of adding washout of the distal rectosigmoid to the conventional management of rectal injuries. There were no deaths. among the ten casualties who were treated in this manner and the only major complication in the group receiving wa,shout occurred in a patient in wh,om a loop rather than a diverting sigmiod colostomy was employed. The contrast between the virtual absence of major morbidity and mortality when fecal material was removed from the rectum and the high incidence of deaths and serious complications when washout was not employed is striking. Based on this experience, we believe that certain points in our approach to the treatment of rectal injuries deserve emphasis. Injuries to the rectum should be highly suspect in all cases of regional penetrating trauma and in blunt trauma, particularly with pelvic fractures, and should be suspect as an iatrogenic consequence of sigmoidoscopy, rectosigmoid biopsy, and barium enema. In all such instances, rectal and proctoscopic examination is mandatory. The presence of blood in the rectosigmoid is usually indicative of rectal injury and prompt operative management must be planned. Adjacent organs and systems must be evaluated for possible involvement. At surgery, associated injuries must be repaired as indicated, a diverted sigmoid colostomy be constructed, wide blunt dissection of the presacral space be performed from above, rectal injuries repaired if feasible, and the distal segment completely cleared of all fecal material by saline lavage. Presacral drains are then placed within the pelvis under di,rect vision and passed to the outside through a presacral stab wound. Coccygectomy may or may not be necessary to provide adequate dependent drainage. Drains must never be placed through a sacral fracture. Some authors [11] have suggested ligation of the hypogastric artery to control massive pelvic bleed-
Volume122, August 1971
ing. Our experience indicates that this has little or no value and should be performed only when there is direct injury to the artery. Splitting of the pubic symphysis and direct hemostasis have been of value in an occasional case. In others, temporary packing was required to control hemorrhage. Debridement must be complete if additional morbidity is to be avoided. Massive injury to the retroperitoneal rectum and perineum may require abdominoperineal resection to effect adequate debridement and proper management of the injury. Summary
We have reviewed the management of twentynine casualties with rectal injuries terated in Vietnam. A high incidence of virulent complications and a 22.2 per cent mortality occurred in eighteen casualties treated by conventional means with a divided sigmoid colostomy, rectal repair when feasible, and presacral drainage. The complications and deaths were invariably related to pelvic sepsis. Distal washout to prevent continued contamination from fecal material remaining in the defunctionalized rectosigmoid was employed in ten casualties in addition to the conventional measures. This resulted in a striking reduction in complications and no mortality. We also stress the importance of prompt diagnosis, direct control of hemorrhage, proper management of associated injuries, and adequate debridement. References 1. Morgan CN: Wounds of the rectum. Surg Obstet - Gynec _ 81: 56, 1945. 2. Ogilvie Wti: Abdominal wounds in the western desert. Sum Gvnec Obstet 78: 225. 1944. 3. Taylor-Ed, Thompson JE: The early treatment and results thereof, of injuries of the colon and rectum. Int Abstr8urg 87: 209, 1948. 4. Vannix RS, Carter R, Hinshaw DB, Joergenson EJ: Surgical management of colon trauma in civilian practice. Amer J Surg 106: 364, 1963. 5. Wanebo HJ, Hunt TK, Mathewson C Jr: Rectal injuries. J Trauma 9: 712,1969. 6. Bowers WF: Surgical treatment in abdominal trauma: a comparison of results in war and peace. Milit Med 118: 9, 1956. 7. Ganchrow MI, Lavenson GS Jr, McNamara JJ: Surgical management of traumatic injuries of the colon -and rectum. Arch Sum 100: 515. 1970. a. Croce EJ, Johnson 7s: The management of war injuries of the intraperitoneal rectum. Ann Surg 122: 408, 1945. 9. Hurt LE: The surgical management of colon and rectal injuries in the forward areas. Ann Surg 122: 398, 1945. 10. Laufman H: The initial surgical treatment of penetrating wounds of the rectum. Surg- Gynec Obstet 82: 219. 1946. 11. Lung JA, Turk RP, Miller RE, Eiseman B: Wounds of the rectum. Ann Surg 172: 985, 1970.
Lavenson and Cohen
12. Hughes LE: Penetrating injuries of the extraperitoneal rectum. Brit J Surg 56: 169, 1969.
Discussion
THOMASHUNT (San F,rancisco, Calif) : Penetration of the colon increases markedly the mortality and mor-, bidity of any injury. Penetration of the rectum is the most serious of all colonic injuries. Five factors seem to govern the outcome: (1) the extent of soft tissue trauma, be it in the area of the rectum or elsewhere, (2) the presence of associated injury such as that involving the bladder, bone, and the like, (3) the time lapse from injury to treatment, (4) the age and health of the patient, and (5) the degree of contamination. Several years ago Peter Hawley and I assessed the importance of some of these factors in the laboratory. We found that, by itself, bacterial contamination of colonic suture lines caused few intraperitoneal infections and no anastomotic leaks. The addition of tissue injury, well remote from the anastomosis, potentiated infection and led to a few anastomotic leaks. When we added sterilized stool to the bacterial contamination, we caused a large number of intraperitoneal infections and many anastomotic leaks. The authors suggest that distal washout and careful repair of the injury prevent stool leaks through undiscovered penetrations. I agree. I would add, however, that their patients have: (1) high velocity injuries with extensive tissue damage, (2) inevitable delays in treatment, and (3) extensive contamination. Under these circumstances, suture line breakdown is common. Distal washout, then, becomes a reliable assurance against continued stool contamination when the repair leaks. We know from civilian experience that one must place a diverting colostomy close to the spontaneous perforation. Otherwise, a column of stool merely waits to leak through the perforation, and intraperitoneal sepsis will probably occur. I am trying to develop the concept that suture line leaks are probably the result of intraperitoneal infection as frequently as they are the cause. Furthermore, postoperative leaks are frequently not in the suture line at all, but a short distance away. Cleaning the distal segment is messy and one tends to avoid it. However, removing foreign bodies (stool) is well worth the immediate risk of added contamination. The peritoneum can handle bacteria. It cannot handle repeated stool contamination. Our experience at the Cook County Hospital involves about twenty patients. We have had a 20 to 25 per cent mortality. Many of our patients were very old, and there was a great delay before many of them came to our attention. On the other hand, we did not have the problem of high velocity missile injuries. We used distal washout in some cases but not in all. Another important factor is the time before operation is performed. The ,recent experience from Cook County Hospital underscores this. In their experience, 230
morbidity and mortality soared if there was as much as four hours delay before operation. Distal washout seems like a small detail; yet, good surgery is made up of such small and important details. The authors certainly seem to have improved on a grim picture. Anyone who treats ten successive rectal injuries with only one major complication has obviously done something better than the rest of us have done in the past, CARLETONMATHEWSON,JR (San Francisco, Calif) : There is very little good that comes out of war; however, we have learned some important lessons in regard to the management of trauma. Doctor Cohen and his associates have brought us another important message with regard to injuries of the rectum. Injuries of this type are not easily overlooked when there is evidence of external trauma; however, in civilian life a large percentage are iatrogenic and often unrecognized, causing serious delay in management. The injury often does not become apparent until serious infection has taken place. In our experience, iatrogenic injury to the rectum after sigmoidoscopic examination or barium enema carries a high mortality, either because the injury appeared to be minor and colostomy was delayed or because the injury was unrecognized until sepsis intervened and colostomy was performed too late. It is important, therefore, that we recognize these injuries early and proceed immediately with diverting colostomy, presacral drainage, and washout of the distal segment. ARTHUR COHEN (closing) : Doctor Hunt has reiterated the essential components in the treatment of rectal injuries. These methods all evolved from the care of casualties during World War II and later in the treatment of isolated groups of civilian patients. Although we completely agree on the need for all these methods of treatment, our experience with the use of thorough and complete washout of the distal defunctionalized rectal segment has shown more dramatic results than have been achieved with any other modality. Our later experiences at more distant echelons of medical care made us disagree with Dr Hunt in his advocacy of placing the colostomy close to the site of injury. The frequent necessity for repeated operations and the increased incidence of infection make restoration of gastrointestinal continuity a procedure of great magnitude. If a Hartmann procedure is used initially, it can and has made for an extremely formidable operative procedure. Time did not permit us to mention the use of ligation of the hypogastric artery in treating hemorrhage with these injuries. Our own experience indicates that this procedure is of no value unless there is direct disruption of the artery itself. We are in complete agreement with Dr Mathewson’s statement that international conflicts bring forth new methods of treatment. I have frequently heard him mention that these new concepts are quickly and easily forgotten by each generation. The
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