Rectal Trauma

Excerpt

The treatment of rectal trauma has undergone a significant evolution over the past 80 years. Most of these changes have paralleled the history of wartime conflict. During World War II, Sir William H. Ogilvie, who was the Consultant Surgeon to the East African Force in 1941, mandated that all colorectal wounds be managed by exteriorization. This remained dogma in post - world war civilian surgery. During the Vietnam conflict, pre-sacral drainage and distal rectal washout were popularized, completing the four D's dogma (debridement, diversion, drainage, and distal rectal washout.)

In 1979 Stone and Fabian published the first randomized prospective trial comparing primary repair and diversion; this marked the evolution of the management of colorectal injuries. Over the next two decades, multiple studies reinforced that primary repair or resection and anastomosis was the standard of care for most colorectal injuries, and extraperitoneal rectal injuries should have management with selective fecal diversion.

In 1994 a study by Stewart et al. looked retrospectively at patients with destructive wounds of the colon. They found a 14% leak rate with primary anastomosis. With sub-analysis, patients with underlying chronic illness and requiring greater than four units of packed red blood cells within 24 hours had a leak rate of 42%, and a third of the leaks died.