Irzal Fahrizal

Colorectal Trauma
The colon the 2nd most common injury

in penetrating trauma, but injury is rare

in blunt trauma (2-5%).
Rectal injuries are more common in blunt
trauma, especially with pelvic injuries.
Diagnosis may be difficult - especially in
the unconscious or obtunded patient.
Maintaining a high degree of suspicion is
vital to avoid missing these injuries.

Colorectal Trauma - History

During the first world war, the overall

mortality from colonic injury was

around 60%.
At the time most injuries presented
over 6 hours old, there were no
antibiotics and intravenous fluid
infusion was rare.
Laparotomy was not universal for these
injuries, and mobilization of the colon
was not routinely practiced

Colorectal Trauma - History

Second world war, Ogilvie 1944

recommended colostomy for all colon

injuries
By the end of the second world war,
mortality from colon injuries : 5-20%.
The use of colostomy for all colonic injuries
continued into the Korean and Vietnam
wars.
After the second world war, civilian trauma
mortality for primary repair 8.3%,
mortality for colostomy 35%

Diagnosis - Colon Injuries

Most colonic injuries are identified at

laparotomy performed for injury to

other organs.
Penetrating injury to the colon usually
presents with peritonitis.
This may develop over the course of a
few hours serial physical
examination is important for patients
who are being managed nonoperatively.

Diagnosis - Colon Injuries

In clinical suspicion of injury without

overt signs, or clinical examination is

impossible or unreliable (unconscious,
intoxicated, spinal cord injury) then:
Computed Tomography (CT),
Diagnostic Peritoneal Lavage (DPL)
Laparoscopy.

Neither diagnostic peritoneal lavage nor

laparoscopy will adequately evaluate

the colon - especially the
retroperitoneal colon.

Diagnosis
Ascending colon laceration:
Ultrasound and CT imaging

CT Scan for Colon Injury

CT investigation of choice in the

haemodynamically normal patient.

Colonic injury is suggested by
free extraluminal air
intra-peritoneal or retro-peritoneal free

fluid,
focal thickening of the bowel wall,
bowel wall haematoma or intra-mural air.

The overall accuracy of CT is 82%,

sensitivity 64% and specificity 97%.

Colon Injury

Female patient with right-sided colon

perforation. Axial CT through the abdomen

shows focal gas bubbles (red arrow) and
an extraluminal fluid collection (blue
arrow) adjacent to the contrast-filled colon.

CT Colonography
Transverse CT

image shows
perforation of the
rectum at CT
colonography in
84-yearold woman.
The sigmoid colon
shows
diverticulosis
(arrows), and air
(*) is seen round
the rectum. The
patient was
treated
conservatively.

Diagnosis Rectal Injury

A high index of suspicion for trauma is

vital if injuries are not to be missed.

In blunt trauma, rectal injuries are
most commonly associated with pelvic
fractures.
Rectal examination should be
performed on all pelvic injuries,
looking for blood and bone fragments
lacerating the rectal wall.

Diagnosis Rectal Injury

If there is any doubt about the

diagnosis, rigid sigmoidoscopy

should be performed.
When identified early and managed

appropriately, open pelvic fractures

have a mortality approaching that of
closed injuries. However, in the
presence of a missed rectal injury,
the mortality may be as high as 50%.

Diagnosis Rectal Injury

Penetrating rectal injuries may be

caused by injuries to the abdomen,

thigh or buttock.
Any penetrating wound that may have
injured the rectum should be fully
evaluated with digital examination and
proctoscopy/sigmoidoscopy.
Even with these examinations it is
possible to miss a significant rectal
injury.

Management Colon Injury

Almost all civilian

colon injuries can be

repaired primarily

Small penetrating wounds simple suture

Larger bowel injury resection &

anastomosis.
Repair is with a single-layer, continuous,
extra-mucosal, monofilament suture.

Primary Repair vs Diverting

Colostomy
Debate continues, but shifted in favor

of PR
Meta-analysis: PR has fewer
complications
DC:
Social implications, poor quality of life
Needs reoperation for reanastomosis
Only for severe local anatomic conditions

(extremely edematous or obviously

Maxwell
RZ, Fabian TC. Current
management
compromised
vascular
supply)of colon trauma.
World J Surg 27: 632, 2003.

Primary Repair

Feliciano DV, Mattox KL, Moore EE. Trauma. McGrawHill,

6thed, 2008.

Resection &Ileocolostomy

Feliciano DV, Mattox KL, Moore EE. Trauma. McGrawHill,

6thed, 2008.

Handsewn vs Stapled
Anastomosis
Meta-analysis 1233 patients from 9

RCTs: mortality, overall dehiscence,

stricture, anastomotic hemorrhage,
reoperation, wound infection: 622
stapled, 611 manual.
No difference in outcome
Choice should be on convenience,
cost,
and training
Lustosa SA, Matos D, Atallah AN, et al: Stapled vs handsewn metho

for colorectal anastomosis surgery. Cochrane Database of Systemat

Reviews 3: CD003144, 2001.

One vs Two Layer

Anastomosis
No difference in anastomotic leaks

between the two techniques

One layer was faster by ten minutes,
patients discharged from the hospital
2 days earlier (wider lumen, less
edema at anastomosis faster
resumption of bowel activity)

Burch JM, Franciose RJ, Moore EE, et al. Single-layer continuous vers
Two-layer interrupted intestinal anastomosis: A prospective random
Trial. Ann Surg 321: 832, 2000.

Single layer running suture

Feliciano DV, Mattox KL, Moore EE. Trauma. McGrawHill,

6thed, 2008.

Single layer running suture

Feliciano DV, Mattox KL, Moore EE. Trauma. McGrawHill, 6 thed, 2008.

Single layer running suture

Feliciano DV, Mattox KL, Moore EE. Trauma. McGrawHill,

6thed, 2008.

End vs Loop Colostomy

Colostomy for trauma almost never

permanent minimizing the morbidity

of the operation for reconnection is
essential.
Loop (but totally diverting) colostomy
should be preferred whenever possible
Can be by stapling, suturing or tying off
the distal lumen
Hartmanns pouch is an alternative
method

Loop colostomy

Feliciano DV, Mattox KL, Moore EE. Trauma. McGrawHill,

6thed, 2008.

Hartmanns procedure

Feliciano DV, Mattox KL, Moore EE. Trauma. McGrawHill,

6thed, 2008.

Linear stapler

Feliciano DV, Mattox KL, Moore EE. Trauma. McGrawHill,

6thed, 2008.

Drainage vs No Drainage
3 meta-analyses routine drainage

is unnecessary
(all meta-analyses on elective colon
surgery, applicability for trauma is
unknown)
In trauma, usually spillage of fecal
material
Recommendation: peritoneal drain,
Urbach DR, Kennedy ED, Cohen MM . Ann Surg 229: 174, 1999.
Jesus
EC, et al. after
Cochrane24-48
Databasehours
for Systematic Reviews 4: CD0021
remove

Petrowsky H, Demartines N, Rousson V, et al. Ann Surg 240: 1074, 20

Management Colon Injury

The leak rate for primary repair is around

1%.
Patients at risk of anastomotic breakdown:
Significant diagnosis delay (24 hours)
Hypovolaemic
Reduced gut perfusion in the perioperative

period.

If long delay in diagnosis or treatment,

repair and proximal colostomy MAY be the

preferred option, though each case should
be managed individually

Management Colon Injury

Abdominal compartment syndrome

is a frequent sequelae of shock and

hypoperfusion open abdomen
If colostomies must be placed they

should be brought out far more

laterally than their usual position,
away from the wound edges.

Management Colon Injury

Patients who are in haemorrhagic

shock, and are (or soon will be)

hypothermic, coagulopathy and
acidotic
damage control procedure

Management Rectal Injury

Rectal injuries above the peritoneal

reflection can be treated as colonic

injuries and repaired primarily.
Extraperitoneal rectal injuries should

be repaired primarily if possible.

Management Rectal Injury

The rectum can be mobilised to allow

repair, and posterior wall injuries

repaired through an anterior wound
or colotomy
Do not repair an anterior wound
without examining the posterior
rectal wall
Some low rectal injuries can be
repaired trans-anally

Management Rectal Injury

Where the position of the injury

precludes repair a proximal, diverting

colostomy should be performed.
The options here are
loop colostomy,
loop with distal stoma closed,
a colostomy and mucus fistula
Hartmann's procedure.

Management Rectal Injury

Pre-Sacral Drainage
Drainage of the pre-sacral space used to
be a routine procedure for all rectal
injuries. However, a propective randomised
trial of 48 patients by Gonzalez in 1998
showed a lower complication rate without
presacral drainage (8% with drainage, 4%
without).
Pre-sacral drainage probably still has a
place in high-energy blunt trauma, pelvic
fractures and where there is delayed repair
of injuries.

Presacral drainage

Feliciano DV, Mattox KL, Moore EE. Trauma. McGrawHill,

6thed, 2008.

Management Rectal Injury

Distal Washout
Washout of the distal rectal stump has also
been routinely practiced, no supporting
evidence
May reduce faecal load in the rectum, but may
also force faecal material out of a rectal
laceration.
McGrath & Fabian (1998): no difference in
pelvic infection rates, with and without distal
washout.
Distal washout to military injuries where
soldiers are often constipated and where
surgical procedures are performed after some
delay.

Management Rectal Injury

Combined Genito-urinary Injuries
a significantly higher complication
rate than isolated rectal injuries.
Complications are increased by

distal rectal washout,

no presacral drainage,
repair of a rectal injury,
prolonged supra-pubic drainage and
failure to adequately separate the GI
and GU injuries.

Guidelines for the

management of Colon &

Rectal
Trauma

Haemorrhagic Shock.
Hypothermia - Coagulopathy
Acidosis
Damage Control Procedure

Control Haemorrhage
Rapid primary suture of small wounds.
Transect & close (stapler) more
extensive injuries for later repair.
Avoid colostomy.

Guidelines for the

management of Colon &

Rectal Trauma
Colon:

Primary repair.
Consider colostomy if >24 hours post

trauma.

Guidelines for the

management of Colon &

Rectal Trauma

Rectum:
Primary Repair if:
Intra-peritoneal rectal injury.
Extra-peritoneal rectal injury that can be

mobilised intra-peritoneally or repaired

trans-anally.
No pre-sacral drainage
No distal washout.

Guidelines for the

management of Colon &

Rectal
Trauma
Rectum:
Proximal diverting loop colostomy

if:

More extensive rectal injury.

Position makes repair impossible.
Pre-sacral drainage if high-energy, blunt

trauma or delayed surgery

No distal washout.

Hartmann's Procedure if:

Severe extra-peritoneal rectal injury.

Colon injury
YES

YES

NO

NO

*Damage control op, blood transfusion >6 units, multiple associated abdom
severe bowel edema, suboptimal vascular supply to resected margins

Extraperitoneal Rectum
Injury

Thank You