RECTAL TRAUMA - MANAGEMENT BASED ON ANATOMIC DISTINCTIONS

Principles of rectal wound management, including routine diversion, in jury repair, presacral drainage and distal washout, evolved from World War II and the Vietnam conflict and have been questioned in recent ye ars. We believe significant confusion arises because of imprecise defi nition of injury location relative to retroperitoneal involvement. Our 5-year experience with penetrating rectal injuries at a Level I traum a center was analyzed. Injuries to the anterior and lateral surfaces o f the upper two-thirds of the rectum were classified as intraperitonea l (IP, serosalized), and those of the posterior surface extraperitonea l (EP, no serosa); injuries to the lower one-third were EP. A total of 58 injuries were managed (92% gunshot wounds). Of these, 16 were IF, and 42 had some EP component. Ten patients underwent repair without di version (6 IF, 4 EP); there were no leaks. Ten septic complications oc curred in the remaining population: 2 necrotizing fasciitis, 5 abdomin al abscess, and 3 presacral infections (PIs) (2 presacral abscesses an d 1 wound tract infection). PI is the only complication that can be sp ecifically associated with EP rectal injuries relative to management; as associated injury confounds interpretation of the other complicatio ns. The operative management in the 38 patients with diverted EP wound s with respect to presacral infection (PI) demonstrated the following: repair injury (n = 10), 0 PI versus no repair (n = 28), 3 PI (P = 0.5 5); washout (n = 33), 2 PI versus no washout (n = 5), 1 PI (P = 0.35); presacral drain (n = 30), 1 PI versus no drain (n = 8), 2 PI (P = 0.1 1). We conclude that most IP injuries can be managed with primary repa ir. EP wounds to the upper two-thirds of the rectum should usually be repaired. EP wounds to the lower one-third, which are explored and rep aired, do not require drainage. EP wounds that are not explored should be managed with presacral drainage to minimize the incidence of presa cral abscess.