EAST just published their newest practice management guideline, which pertains to rectal trauma. They sought to answer three questions that pertain to nondestructive penetrating trauma to the extraperitoneal rectum.
Trauma dogma from the 80′s and 90′s mandated that these injuries undergo three things: proximal diversion, distal rectal washout, and presacral drainage. The latter two have had waning interest over the intervening years, and questions have even been raised as to whether diversion is really necessary.
Practice Guideline Committee members at EAST performed a thorough and well documented review of the existing literature to determine what we really should be doing with these injuries.
Here are the factoids:
- Proximal diversion. The major fear that prompts surgeons to divert is the possibility of infectious complications in the area of the rectal injury itself, or death. The literature consisted of 14 papers, most of which were retrospective and observational. Although there was no difference in mortality (about 0%), the incidence of infections doubled in patients without diversion. The recommendation was that patients with these injuries receive a proximal diverting colostomy.
- Presacral drains. Only 17 papers addressed this question, and they were of low quality with few patients. There is not enough evidence to recommend this practice. And from a logistical standpoint, I could never figure out why this should work. The drain is placed in the presacral space, adjacent to the posterior rectum. How can this do anything for an anterior injury?
- Distal rectal washout. In the good old days, this was performed through the distal portion of the newly created colostomy. There were all kinds of fancy ways to do it, and it required converting to lithotomy position and stationing someone (hint: intern) with a bag or bucket to catch the effluent. Very messy and unpleasant. Only 13 papers addressed this practice, and could not convincingly demonstrate a benefit. Not recommended.
Some additional tips of my own:
- Do not violate the peritoneal reflection in the pelvis while doing the laparotomy. If the injury is isolated to the distal rectum, you will create a conduit for infection in the deep pelvis. You will have a hard time repairing an injury from above, especially in the usual narrow male pelvis. Don’t look at it; just let it heal on its own.
- Create a standard end colostomy. Surgeons argue that a loop colostomy is convenient because it may be possible to close it later without reopening the midline incision. This is not always the case, and the bridge that is necessary to keep the loop above the skin makes colostomy care very difficult. Patients frequently complain about smelly leaks.
Bottom line: EAST guidelines are helpful in figuring out what to do in certain clinical situations, but they do not provide detailed guidance. This guideline provided answers (as best they could) to just three questions about rectal trauma. They justify not doing things that most surgeons have not been doing for some time. But don’t try to talk yourself out of not doing the diverting colostomy.
Management of penetrating extraperitoneal rectal injuries: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma 80(3):546-551, 2016.