care of the patient with anorectal trauma

8/19/2019 Care of the Patient With Anorectal Trauma

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Care of the Patient with Anorectal TraumaDaniel O. Herzig, MD 11Department of Surgery, Dige ti!e Health Center " #night Cancer$n titute, Oregon Health an% Science &ni!er ity, Portlan%, OregonClin Colon 'ectal Surg ()1(*(+ (1)-(1 .A%%re for corre pon%ence an% reprint re/ue t Daniel O. Herzig,

MD, Department of Surgery, Dige ti!e Health Center " #night Cancer$n titute, Oregon Health an% Science &ni!er ity, 101 S Sam 2ac3 onPar3 '%., 45(( A, Portlan%, O' 67( 6 8e5mail herzig%9oh u.e%u:.O;<ecti!e On completion of thi article, the rea%er houl%;e a;le to ummarize the management of anorectal trauma.Acci%ental ;lunt an% penetrating in<urie to the anorectumareuncommon e!ent . The relati!e protection o=ere% ;ythe rectum> po ition in the ;ony pel!i ma3e ;lunt in<urieparticularly uncommon. ?@clu%ing iatrogenic, e@5relate%,an% foreign ;o%y in<urie , the mo t common in<ury i a re ultof a pel!ic gun hot woun%* howe!er, e!en in the etting of tran pel!ic gun hot woun% , penetrating in<ury to the rectumare

een in a mall minority of patient . 1,( Traumatic analphincter in<ury can ;e from impalement or other penetrating

in<ury, or ;lunt trauma, inclu%ing cru h in<ury. The e!aluationan% management of anorectal trauma are re!iewe% here.'ectal Trauma$nitial ?!aluation

The trauma !ictimmu t r t ;e a e e% with attention to theprimary ur!ey to en ure imme%iate life5threatening in<urieare ta;ilize%. During the econ%ary ur!ey, anorectal traumacan ;e a e e% an% e!aluate%. hen po i;le, o;taininghi tory relate% to the in<ury, a ociate% ymptom inclu%inga;%ominal an% genitourinary ymptom , a well a ;a eline;owel function an% continence can ;e helpful. Particularly forpenetrating in<urie , 3nowing the cali;er an% !elocity of themi ile can help e ta;li h an un%er tan%ing of the potentialin<ury. Phy ical e@amination ;egin with !i ual in pection,inclu%ing an a e ment of entry an% e@it woun% in thepenetrating trauma patient. Digital rectal e@amination

houl% al o inclu%e an a e ment of re ting an% /ueezetone when fea i;le. The po ition of the pro tatemay ;e note%if urethral in<ury i u pecte% in the ;lunt trauma patient.Although a part of nearly all econ%ary ur!ey , the %igitalrectal e@am pro;a;ly ha limite% !alue in %etecting in<ury. B,+A%<unct to the phy ical e@amination inclu%e imaging

tu%ie an% en%o copy. owel in<urie can ;e challenging to%etect on compute% tomography 8CT:. Howe!er, with newermulti%etector CT an% appropriate u e of oral, intra!enou , an%rectal contra t, the %iagno tic accuracy can ;e impro!e%. 7'igi% procto copy or Ee@i;le procto igmoi%o copy ha generally;een con i%ere% to ;e a relia;le tool to %etect the pre encean% location of an in<ury. 0 $t can ;e helpful in ;oth ;lunt an%penetrating in<urie . 6,1) Howe!er, there i a ri 3 of furtherin<ury with the proce%ure, an% it may not ;e nece ary in the

etting of goo%5/uality imaging or planne% e@ploration. Althoughthere are fre/uently a;normal n%ing , it i unclearwhether the n%ing e=ecti!ely gui%e management, ormerelycon rm n%ing alrea%y u pecte%. 11'ectal in<urie can ;e cla i e% accor%ing to the 'ectum$n<ury Scale from the American A ociation for the Surgery of

Trauma 8AAST* ee FTa;le 1 :. 1( i%e prea% u e of cla i cationtool an% regi trie ha allowe% for tan%ar%ize% %atacollection an% will impro!e %ata analy i .Management of 'ectal $n<urie

The operati!emanagement of rectal in<urie ha e!ol!e%witha com;ination of urgical %ogma, per onal a%!ice of #eywor%F anuF rectumF traumaF anorectal trauma



F e@traperitoneal rectaltraumaF anal phincter traumaA; tract lunt an% penetrating in<urie to the anu an% rectum are uncommon. Con i%era;le%e;ate remain regar%ing the optimal treatment of rectal in<urie . Although intraperitonealrectal in<urie can ;e treate% imilarly to colonic in<urie , treatment option for

e@traperitoneal in<urie inclu%e fecal %i!er ion with a colo tomy, pre acral %rainage,repair of the rectal %efect, an% %i tal rectal wa hout. Perineal in<urie re ulting in analphincter %i ruption often occur with e!ere a ociate% in<urie . Small %efect can ;e

repaire% primarily, ;ut e@ten i!e in<urie often re/uire %i!er ion an% phincter recon truction.$ ue Theme Trauma, owelO; truction, an% Colorectal?mergencie * Gue t ?%itor, Ste!en D.Mill , MD.Copyright ()1( ;y Thieme Me%icalPu;li her , $nc., Se!enth A!enue,Iew Jor3, IJ 1)))1, &SA.

Tel K18(1(: +0B5B (.DO$ http LL%@.%oi.orgL1).1)++L 5)) (51 (6 61.$SSI 1+ 15))B .(1)e@perience% urgeon , an% well5controlle% clinical tu%ie .Hi torically, there ha!e ;een fewhigh5/uality tu%ie to gui%e%eci ionma3ing, lea%ing to %ogma an% per onal5e@perienceinEuence%management %eci ion . ictim of penetratingrectal in<urie , particularly ol%ier , were more li3ely thannot to %ie fromtheir in<ury until routine u e of colo tomywaman%ate% for ;attle el% in<urie in 16B0. 1 The u e of apre acral %rain wa popularize% a;out the ame time, an%the importance of %i tal rectal wa hout wa e ta;li he%%uring the ietnam ar. 1B Di!er ion, %rainage, an% wa houtcontinue to ha!e a place in themanagement of rectal trauma,although much more %ata e@i t to%ay to upport the option of primary repair for intraperitoneal in<urie , omi ion of %rainan% %i tal wa hout, an% a!oi%ance of primary repair of e@traperitoneal in<urie in mo%ern management.

A recent y tematic re!iew of the literature from 16 + to()1) i%enti e% 1)0 accepta;le article on colon an% rectaltrauma, with !ery few of the e e@amining rectal trauma inparticular. 1+ The ;e t %ata a!aila;le were from mall retro pecti!e

tu%ie with hea!y election ;ia , an% only onepro pecti!e ran%omize% trial of B0 patient . Currently a!aila;le%ata can help gui%e %eci ion ma3ing, howe!er. Nir t,there i ample e!i%ence that primary repair of colon in<urie iappropriate in electe% patient . 1 Current ?a tern A ociationfor the Surgery of Trauma gui%eline cite that non%e tructi!ein<urie in!ol!ing +) of the ;owel wall can ;erepaire%. Nor %e tructi!e ormore e@ten i!e in<urie , re ectionan% ana tomo i can ;e performe% in the etting of hemo%ynamic

ta;ility, a; ence of comor;i%itie , minimal a ociate%in<urie , an% no peritoniti . The e ame gui%eline may apply

to intraperitoneal rectal in<urie .Howe!er, there remain con i%era;le contro!er y regar%ingthe management of e@traperitoneal rectal in<urie . Necal%i!er ion i pro;a;ly the lea t contro!er ial, although thereare tu%ie upporting either routine %i!er ion or electi!eomi ion of a %i!erting colo tomy for e@traperitoneal rectalin<urie . A ca e5control trial e@amining treatment option fore@traperitoneal in<urie omitte% %i!er ion in the tu%y ca e ,an% compare% the outcome to hi torical control . 17 Theynote% no igni cant %i=erence in mor;i%ity after omitting%i!er ion. Howe!er, a cohort tu%y comparing matche%group of patient with e@traperitoneal in<urie foun% that%i!er ion without repair re ulte% in the fewe t complication .10 Another tu%y upport the concept that %i!er ion ithe mo t important of the inter!ention a!aila;le. 16

Pre acral %rainage ha ;een well e ta;li he% ince orl%ar $$. Although tu%ie are plit with ome howing a ;ene tan% ome not, there ha not ;een conclu i!e e!i%ence of harm



with %rainage. The only pu;li he% ran%omize% trial a%%re ethi /ue tion. Norty5eight patient were tu%ie% an% no impro!ementwa foun% with the u e of a pre acral %rain,although it remain po i;le that the trial wa un%erpowere%.() Analy i of current %atawoul% ugge t that the %eci ioncoul% ;e in%i!i%ualize% placing a %rain in patient at high ri 3for a; ce an% eptic complication , an% omitting it in ituation

where igni cant a%%itional %i ection an% %i ruptionof normal ti ue woul% ;e re/uire% to place a %rain.Primary repair of the rectal in<ury can ;e accompli he% if aminimal amount of %i ection i re/uire%, i.e., the repair can;e %one tran anally or the repair can ;e %one while repairinggenitourinary tructure with pel!ic e@po ure. (1Ninally, %i tal rectal wa hout remain contro!er ial. $t wapopularize% after a 1671 report of outcome in ietnam

howing u; tantial re%uction in %eath an% infectiou complication .1B hen originally popularize%, there were farfewer option for ;roa%5 pectrum anti;iotic , an% it ha;een ugge te% that the pattern of in<ury in ietnam mayha!e ;een one of the rea on for the large ;ene t. To%ay, therei ome ugge tion that wa hout may tre the repair orwor en the in<ury, an% it i falling out of fa!or.

The pre ence of hoc3 or hemo%ynamic in ta;ility i a ri 3factor for failure of all ;ut the mo t con er!ati!e proce%ure .$n the e patient , a minimum of %i!er ion alone houl% ;econ i%ere%, with a%%itional treatment in%i!i%ualize%. 1 ,((

Anal Traumalunt an% penetrating in<urie to the perineum can cau e

%i ruption of the anal phincter an% can ha!e u; tantialmor;i%ity. ecau e of the high rate of concurrent pel!icin<ury, particularly pel!ic fracture in ;lunt trauma !ictim ,it i imperati!e that or%erly e!aluation an% re u citation ;eun%erta3en at the initiation of care, ;eginning with theprimary ur!ey to i%entify an% treat imme%iately life5threateningcon%ition . ( -(+ Once ta;ilize%, a e ment %uring the

econ%ary ur!ey will i%entify perineal an%Lor anal in<urie .Often, the e patient nee% early operati!e inter!ention for

Ta;le 1 'ectum $n<ury Scale of the American A ociation for the Surgery of TraumaGra%e Q Type of $n<ury De cription of $n<ury$a Hematoma Contu ion or hematoma without %e!a cularization$; 4aceration Partial5thic3ne laceration$$ 4aceration 4aceration +) of circumference$$$ 4aceration 4aceration R +) of circumference$ 4aceration Null5thic3ne laceration with e@ten ion into the perineum

a cular De!a cularize% egmentSource A%apte% from Moore et al. 1(

Q A%!ance one gra%e for multiple in<urie up to gra%e $$$.Clinic in Colon an% 'ectal Surgery ol. (+ Io. BL()1(Care of the Patient with Anorectal Trauma Herzig (11

ta;ilization of the pel!i or treatment of intraa;%ominalin<urie . $n the e ituation , performing a thorough a e mentof the perineal in<ury, procto copy, creation of a %i!erting

colo tomy, an% uprapu;ic catheter placement houl% ;econ i%ere% at the initial trip to the operating room. De;ri%ementof non!ia;le ti ue i e ential to pre!ent ep i , an%

ome author recommen% %aily trip to the operating roomfor la!age an% %e;ri%ement for the r t %ay . ( ,( $n the

etting of minor %i ruption , primary repair can ;e con i%ere%after clear ti ue !ia;ility ha ;een e ta;li he%. (7 Suchan approach can al o ;e <u ti e% from the re ult from aprimary repair for an o; tetric in<ury* therefore, in %eci%ingto procee% with uch an approach, the amount of repair to ;eun%erta3en houl% ;e on par with what woul% ;e e@pecte%from an o; tetric in<ury. (0More e@ten i!e in<urie houl% ;e manage% with %re ingchange an% pre!ention of infectiou complication 8 FNig. 1 :.Once the perineum ha fully heale%, the %egree of phincter

in<ury can ;e a e e% ;y en%o onography, concentric5nee%leelectromyography, an%manometry. Patient with a phincter%efect can con i%er o!erlapping phincteropla ty. (6 Simple



repair can potentially ;e treate% without %i!er ion. (7?@ten i!e in<urie an% in<urie that cau e lo of ner!efunction to the phincter may re/uire phincter replacement.Option inclu%e placement of an arti cial ;owel phincter oru e of a gracilopla ty. The arti cial ;owel phincter i ane=ecti!e olution if ucce ful implantation can ;e achie!e%*the nee% to remo!e the %e!ice %ue to infection remain

common an% it i unclear whether tho e with a faile% %e!iceha!e wor e function a a re ult of the attempte% implantation.)- ( Gracilopla ty ha al o ;een hown to ;e an e=ecti!eolution if a ucce ful recon truction can ;e o;taine%.

Howe!er, perioperati!e mor;i%ity an% long5term %ura;ilityremain i ue . B A mall ingle5center pro pecti!e tu%ycomparing the arti cial ;owel phincter to gracilopla ty forfecal incontinence lightly fa!ore% the arti cial ;owel phincter,;ut complication were common in ;oth group . +

Conclu ionlunt an% penetrating in<urie to the rectum an% anu are

uncommon, ;ut often ha!e e!ere a ociate% in<urie . Attentionto life5threatening in<urie an% ta;ilization i the r tpriority. Nor rectal in<urie , the optimal management i notuni!er al, an% con i%era;le <u%gment nee% to ;e e@erci e% topro!i%e in%i!i%ualize% care. Anal in<urie are often a ociate%with e!ere pel!ic in<urie . $f phincter repair i not a%e/uate,recon truction with a gracilopla ty or an arti cial ;owel

phincter i po i;le.'eference1 Thoma DD, 4e!i on MA, Dy3 tra 2, en%er 2S. Management of rectal in<urie . Dogma !er u practice. Am Surg 166)*+ 80:+)7-+1)( Duncan AO, Phillip TN, Scalea TM, Maltz S , Atweh IA, SclafaniS2A. Management of tran pel!ic gun hot woun% . 2 Trauma1606*(681): 1 +-1 B)

urch 2M, Neliciano D , Matto@ #4. Colo tomy an% %rainage forci!ilian rectal in<urie i that all Ann Surg 1606*()68+: ))- 1),%i cu ion 1)- 11B Porter 2M, &r ic CM. Digital rectal e@amination for trauma %oee!ery patient nee% one Am Surg ())1* 78+: B 0-BB1

+ ? po ito T2, $ngraham A, 4uchette NA, et al. 'ea on to omit %igitalrectal e@am in trauma patient no nger , no rectum, no u efula%%itional information. 2 Trauma ())+*+68 : 1 1B-1 16

utela ST, Ne%erle MP, Chang P2, et al. Performance of CT in%etection of ;owel in<ury. A2' Am 2 'oentgenol ())1*17 81:1(6-1 +7 An%er on S , Soto 2A. Anorectal trauma the u e of compute%tomography can in %iagno i . Semin &ltra oun% CT M' ())0*(68 : B7(-B0(0 Nry 'D. Anorectal trauma an% foreign ;o%ie . Surg Clin Iorth Am166B*7B8 : 1B61-1+)+6 Nerraro N2, 4i!ing ton DH, O%om 2, Swan #G, McCormac3 M, 'u h

N 2r. The role of igmoi%o copy in the management of gun hotwoun% to the ;uttoc3 . Am Surg 166 *+68 : +)- +(1) 'o G4, Do%% O, 4ipham 2C, Camp;ell 2#. 'ectal perforation inun ta;le pel!ic fracture the u e of Ee@i;le igmoi%o copy. $n<ury())1* (81: 7- 0

11 Mangiante ?C, Graham AD, Na;ian TC. 'ectal gun hot woun% .Management of ci!ilian in<urie . Am Surg 160 *+(81: 7-B)1( Moore ??, Cog;ill TH, Malangoni M, 2ur3o!ich G2. Scaling y temfororgan peci c in<urie . A!aila;le at http LLwww.aa t.orgLli;raryLtraumatool Lin<ury coring cale .a p@. Acce e% March ((, ()1(1 Of ce of the Surgeon General of the Army. Circular letter no. 170.

a hington, DC Of ce of the Surgeon General of the Army** 16B01B 4a!en on GS, Cohen A. Management of rectal in<urie . Am 2 Surg1671*1((8(: (( -( )Nigure 1 An impalement in<ury cau e ;oth anal phincter %i ruptionan% the po i;ility of rectal in<ury. 8$mage courte y of 2ennifer atter ,MD, Department of Surgery, Oregon Health an% Science &ni!er ity,Portlan%, Oregon. All right re er!e%.:Clinic in Colon an% 'ectal Surgery ol. (+ Io. BL()1((1( Care of the Patient with Anorectal Trauma Herzig1+ Steele S',May3el 2A, 2ohn on ?#. Traumatic in<ury of the colon an%rectum the e!i%ence ! %ogma. Di Colon 'ectum ()11*+B86:

110B-1()11 Pa /uale M, Na;ianTC. Practice management gui%eline for traumafrom the ?a tern A ociation for the Surgery of Trauma. 2 Trauma



1660*BB8 : 6B1-6+ , %i cu ion 6+ -6+717 Gonzalez 'P, Merlotti G2, Hole!ar M'. Colo tomy in penetratingcolon in<ury i it nece ary 2 Trauma 166 *B18(: (71-(7+10 elmaho GC, Gomez H, Nala;ella A, Demetria%e D. Operati!emanagement of ci!ilian rectal gun hot woun% impler i ;etter.

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Trauma 1660*B+8B: + - 1(1 4e!ine 2H, 4ongo ?, Pruitt C,Mazu 3i 2?, ShapiroM2, Durham 'M.Management of electe% rectal in<urie ;y primary repair. Am 2Surg 166 *17(8+: +7+-+70, %i cu ion +70-+76(( Shatnawi I2, ani5Hani #?. Management of ci!ilian e@traperitonealrectal in<urie . A ian 2 Surg ()) *(681: 11-1( #u% 3 #A, Mc ueen MA, oeller G', No@ MA, Mangiante ?C 2r,Na;ian TC. Management of comple@ perineal oft5ti ue in<urie . 2

Trauma 166)* )86: 11++-11+6, %i cu ion 11+6-11 )(B #u min 3y '?, Sh;ee; $, Ma3o G, olan% 2P. lunt pel!iperinealin<urie . An e@pan%e% role for the %i!erting colo tomy. Di Colon'ectum 160(*(+80: 707-76)(+ Maull #$, Sachatello C', ?rn t C . The %eep perineal laceration-anin<ury fre/uently a ociate% with open pel!ic fracture a nee% for

aggre i!e urgical management. A report of 1( ca e an% re!iewof the literature. 2 Trauma 1677*1786: 0+- 6( #u% 3 #A, Hanna M#. Management of comple@ perineal in<urie .

orl% 2 Surg ()) *(780: 06+-6))(7 Critchlow 2N, Houlihan M2, 4an%olt CC, ein tein M?. Primary

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) Mun%y 4, Merlin T4, Ma%%ern G2, Hiller 2?. Sy tematic re!iew of afety an% e=ecti!ene of an arti cial ;owel phincter for faecal

incontinence. r 2 Surg ())B*618 : +- 7(1 Par3er SC, Spencer MP, Ma%o= 'D, 2en en 44, ong D, 'othen;erger

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e@ner SD, aeten C, ailey ', et al. 4ong5term ef cacy of %ynamicgracilopla ty for fecal incontinence. Di Colon 'ectum ())(*B+8 : 0)6-010

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+ Ortiz H, Armen%ariz P, DeMiguel M, Solana A, AlV ', 'oig 2 .Pro pecti!e tu%y of arti cial anal phincter an% %ynamic gracilopla tyfor e!ere anal incontinence. $nt 2 Colorectal Di ()) *108B: B6- +BClinic in Colon an% 'ectal Surgery ol. (+ Io. BL()1(Care of the Patient with Anorectal Trauma Herzig (1

care of the patient with anorectal trauma

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