Colorectal Trauma
Colorectal Conference
St Luke’s-Roosevelt Hospital
Department of Surgery
Leslie Tyrie, PGY III
16 March 2006
Colorectal Anatomy
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Right Colon, Left Colon, Rectum
Blood supply
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Function
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SMA, IMA vs.
inf. mesenteric/int. iliacs/pudendal art.
Dehydration, storage, defecation
Bacterial content
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Increases as more distal to stomach
60% dry weight stool = bacteria
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Intraperitoneal and
retro/extraperitoneal components
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Right and left colon morbidity /
mortality outcomes the same
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Colon vs. Rectum
Proximal vs. distal to
peritoneal reflection
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Colorectal Trauma – Etiology
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COLON
Penetrating
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>85%
1/3 penetrating abdominal injuries
GSW > SW > shotgun > iatrogenic
> misc
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Blunt
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MVA, ped struck, falls
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RECTUM
Penetrating
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Multiple injuries
Majority
GSW
Impalement / straddle injuries
Iatrogenic
Foreign body
Blunt
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Delayed presentation
Pelvic fractures
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Scrape injuries
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Disruption of pubic symphysis
Spicules
Drag over pavement s/p motorcycle
accident
Trauma to perineum
High index suspicion
Colorectal Trauma – H&P
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Trauma algorithms
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ABCs
History
Physical
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Abdomen
Flank
Perineum
DRE – blood
Colorectal Trauma – Studies
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CT SCAN
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DPL
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Blunt Abdominal and Penetrating Flank
Triple contrast
Abdominal trauma
Will not evaluate retroperitoneum
Bacteria / vegetable matter suggestive
FAST
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Abdominal trauma
Repeatable
Non invasive
Will not evaluate retroperitoneum
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Rigid Proctosigmoidoscopy
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Exploratory Laparotomy
Operative Management
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Options
1.
2.
3.
4.
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The Question
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Primary repair
Resection and anastomosis
Repair w/proximal diversion
Exteriorization
Proximal diversion of fecal stream
Prevent septic complications
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Colon: anastomotic leak
Rectum: pelvic sepsis
Pelvic abscess
Grading Score for Colon Injury
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AAST Colon Injury Scale (CIS)
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I – serosal injury
II – single wall injury
III – < 25% wall involvement
IV – > 25% wall involvement
V – circumferential wall, vascular injury, or both
Destructive vs. Nondestructive wounds
Colon Trauma – Historical Perspective
“Ephud put forth his left hand, and took
the sword from his right thigh and
thrust it into his belly… and the dirt
came out.”
– book of Judges in the Old Testament
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Suggestive of early penetrating colon
trauma
However no treatment or outcome is
discussed
Historical Perspective (cont)
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American Civil War
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WWI
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Non operative management of penetrating abdominal wounds
Mortality 90%
Diverting colostomy is preferable in extensive wounds
Primary repair was attempted
Mortality 59%
WWII
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US Surgeon General Thomas Parren Jr. mandated
colostomy for all colon injuries sustained in battle
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Inexperienced war-time surgeons
High-energy, high-velocity injuries
Delay in care
Transfer soon after initial management
Mortality to 5-20%
Historical to today
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After WWII…
Colostomy remained standard of care
However, civilian ≠ military trauma
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Less destructive
Delay to definitive care short
Resuscitation administered quickly
Newer antibiotic prophylaxis
Postoperative supervision available
Management of Colon Injuries
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Non Destructive Wounds (CIS I – III)
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Stone and Fabian et al 1979
Primary repair or resection + anastomosis
Destructive wounds (CIS IV – V)
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Demetriades et al 2001
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no difference, or improved outcomes w/
primary repair
Patients at risk for anastomotic breakdown
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Immunocompromised patients
Transfusion > 6 units
Likely increased
 Shock
 Other traumatic injury > 2
 Delay of operation
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Traditionally  diverting colostomy
New data  resection + primary anastomosis
One strict contraindication, delay > 12 hrs
The Exception: Damage Control
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Cold
Coagulopathic
Acidotic
Resect if needed, no
anastomosis
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Planned second look
Management of Rectal Injuries
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Intraperitoneal
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Like colonic injuries
Primary repair
Extraperitoneal
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Diversion
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End vs. loop colostomy
Drainage
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Closed or open drainage of presacral space
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Tranverse incision anococcygeal raphe into subcutaneous tissue
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Lateral dissection on each side of raphe to avoid transsection of coccygeal attachments to access
presacral space
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Penrose or JP drainage
Repair
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If feasible, avoid unnecessary dissection
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> 1cm unless involving GU tract  then repair w/interposition patch
Distal Washout
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Washout of rectal stump
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No proven benefit
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For highly contaminated wounds and extensive devitalization
Towards primary and definitive care w/out DDR,DW
In rare cases, APR
Considerations
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Antibiotics
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No proven regimen
24 hours w/2nd generation
cephalosporin is accepted
Colostomy Reversal
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Traditionally 3 months
New data suggests if signs of
improvement may consider reversal
at 2 weeks
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Avoid 2 – 6 weeks
BE not necessary
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Unidentified rectal trauma, ongoing
symptoms
Conclusions
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Colon Trauma
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Primary repair, resection + primary anastomosis
Exceptions destructive injuries w/risk factors
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Rectal Trauma
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Intraperitoneal
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Like colonic injuries
Extraperitoneal
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Shock, delay to management, associated organ injury,
transfusion requirement, co-morbid disease
Diversion and presacral drainage
Antibiotics
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2nd gen ceph x 24 hrs periop