Contemporary management of rectal trauma - A South African experience.

Abstract Introduction The management of rectal trauma remains controversial. There are three modalities which have been used to manage these injuries; proximal diversion, washout of the distal rectum (DRW) and presacral drainage (PSD). The EAST group tentatively advocate mandatory proximal diversion for extra-peritoneal rectal injuries and omitting DRW or PSD. Other authors have suggested that diversion can be eschewed in patients with an intra-peritoneal injury which can be primarily repaired. In light of all these controversies, this project set out to review our experience with rectal injuries over the last seven years with the objective of reviewing our use of proximal diversion, PD and DRW. Methods Patients aged greater than or equal to 15 years with rectal injuries during December 2012 to July 2019 were included. Patient demographics, mechanism of injury, admission vital signs, clinical laboratory data, management strategy (operative or non-operative), number and type of blood product transfusions, duration of time from injury to admission, complications, patient residential status (urban or rural), hospital and intensive care duration of stay, and 30-day mortality rates were assessed. Results During the study period, a total of 51 patients with a rectal injury were treated. There were 45 (88%) males and the median age was 29 (22-39) years. There were 7 (14%) blunt mechanism, 41 (80%) penetrating mechanisms and 3 (6%) combined blunt and penetrating mechanisms. The median ISS was 13 (9-18). Of the 50 rectal injuries ultimately treated at our institution, there were 31 extraperitoneal and 14 intraperitoneal injuries. There were five combined intra and extra peritoneal injuries. A total of 21 rigid sigmoidoscopies and a single flexible sigmoidoscopy were performed. A total of 24 patients underwent a CT scan. There were 13 primary repairs and 45 proximal diversions. Of the 34 documented complications, 15 (44%) were related to sepsis and can be attributed to the rectal injury. The overall mortality rate was 11.8%. Conclusions Rectal injuries are associated with significant septic related morbidity and mortality. PSD is used in highly selective cases. Almost all extra-peritoneal injuries undergo proximal diversion and are not repaired. All intra-peritoneal injuries are repaired and a select group are not diverted.