Value of distal colon washout in civilian rectal trauma--reducing gut bacterial translocation.

Recent experience with civilian rectal trauma challenges the military dictum advocating routine distal colon washout. Opponents contend that septic morbidity is not influenced by perioperative removal of feces from the rectosigmoid region. In an effort to elucidate this issue, we reviewed 27 consecutive patients sustaining extraperitoneal rectal trauma over the past 5 years. One patient, exsanguinating from abdominal vascular injury, was excluded from further analysis. In the remaining 26 patients, rectal injury was due to gunshot wound in 16 (62%), pelvic fracture in 8 (31%), and stab wound in 2 (7%). The mean Revised Trauma Score was 6.9 $pM 0.4, Abdominal Trauma Index 20.9 $pM 8.1, and Injury Severity Score 28.6 $pM 11.0. Proximal colostomy was done in all patients and presacral drains were placed in 23 (88%). Broadspectrum antibiotics were administered for a minimum of 5 days. Thirteen (50%) of the group underwent intraoperative washout of the distal rectosigmoid colon, dictated by attending surgeon's preference; the other half did not. These two groups were otherwise comparable with respect to injury mechanism, shock on arrival, rectal wound severity, associated injuries, and perioperative blood transfusions. Major complications were greater in the nowashout versus washout groups: pelvic abscess, 46% vs. 8%; rectal fistulae, 23% vs. 8%; and sepsis, 15% vs. 8%. The single death (4%) occurred in the nowashout group. Although based on a small group of patients, these trends imply that distal colon washout reduces septic morbidity following civilian rectal trauma. This benefit is greatest for injuries due to pelvic fractures and high-energy gunshot wounds. Ultimate resolution of the distal colon washout controversy demands a multicenter prospective randomized trial.