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401

Turkish Journal of Trauma & Emergency Surgery

Original Article Klinik alma

Ulus Travma Acil Cerrahi Derg 2011;17 (5):401-406

Factors affecting morbidity in penetrating rectal injuries:

a civilian experience

Penetran rektal yaralanmalarda morbiditeye etkili faktrler: Sivil deneyim

Metehan GM, Murat KAPAN, Akn NDER,

Abdullah BYK, Sadullah GRGN, brahim TAYILDIZ

Presented at the 17th Turkish National Surgical Congress

(May 26-29, 2010, Ankara, Turkey).

Department of General Surgery, Dicle University Faculty of Medicine,Diyarbakr, Turkey.

2010 Ulusal Cerrahi Kongresinde szl bildiri olarak sunulmutur(26-29 Mays 2010, Ankara).

Dicle niversitesi Tp Fakltesi Genel Cerrahi Anabilim Dal,Diyarbakr.

Correspondence (letiim): Metehan Gm, M.D. Dicle University, Medical Faculty, Department of General Surgery, Diyarbakr, Turkey.Tel: +90 - 412 - 248 80 01 e-mail (e-posta):[email protected]

AMA

Rektal yaralanmalarn tedavi prensipleri sava deneyim-lerine dayanmaktadr. Sivil yaralanmalarda bu prensipleri

uygularken sivil rektal yaralanmalarn zelliklerini ve bu-

nun yannda morbiditeye etkili faktrleri bilmek gerekir.

GERE VE YNTEM

Ateli silah ve delici-kesici aletle rektal yaralanma olumu

29 hastann zellikleri deerlendirildi. Risk faktrlerini be-

lirlemek amacyla hastalar morbidite olanlar ve olmayan-

lar eklinde iki gruba ayrld (morbidite olan: Grup 1, mor-

bidite olmayan: Grup 2) ve faktrler gruplar arasnda kar-

latrld.

BULGULAR

iddetli fekal kontaminasyon, perianal veya gluteal yara-

lanma, travma tedavi intervali ve izole ekstraperitoneal ya-

ralanma olmas morbidite geliimi zerine etkili faktrler-

di. Hastanede kal sresi Grup 1de Grup 2 ile karlat-

rldnda anlaml derecede daha uzundu.

SONU

Rektal yaralanmalarla nadiren karlalmasna ramen,

morbidite ve mortalite oranlar yksektir. Risk faktrleri-

nin bilinmesi ve hastaya gre tedavi plan yaplmas teda-

vinin baars iin nemlidir. Zamannda tedavi edilen has-

talarda morbidite oran nemli lde azalmaktadr. Bu ne-

denle, doktorlarn yan sra hastalarn da rektal yaralanma

konusunda bilinli olmas gerekmektedir.

Anahtar Szckler: Ateli silah yaralanmalar; kolostomi; delici-kesici alet yaralanmalar; rektal yaralanma; rektal onarm.

BACKGROUND

The principles of the treatment of rectal injuries have beendetermined based on the experiences gained from military

injuries. While adopting these principles in civilian life, it

is essential to know the characteristics of civilian rectal in-

juries as well as the risk factors affecting morbidity.

METHODS

The characteristics of 29 inpatients who had been treat-

ed due to rectal injuries caused by gunshot wounds and

penetrating devices were evaluated. In order to determine

the risk factors, the patients were divided into two groups

regarding the presence of morbidity (Group 1, with mor-

bidity; Group 2, without morbidity) and compared.

RESULTS

Severe fecal contamination, perianal or gluteal injuries,

duration of trauma- treatment interval, and isolated extra-

peritoneal injury were signicant factors that affected the

development of morbidity. The length of hospital stay was

signicantly longer in Group 1 as compared to Group 2.

CONCLUSION

Although rectal injuries are rarely encountered, they carry

high morbidity and mortality. Awareness of the risk factors

and planning of a patient-based treatment are essential for

the success of the therapy. The rate of morbidity is substan-

tially decreased when patients are treated in time. Thus, the

awareness of both patients as well as physicians managing

trauma about rectal injuries should be increased.

Key Words: Gunshot wounds; colostomy; penetrating injuries;rectal injuries; rectal repair.

doi: 10.5505/tjtes.2011.06936


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Ulus Travma Acil Cerrahi Derg

Penetrating trauma is the most common cause ofrectal injuries. In most cases, gunshot wounds accountfor 80%-85% of the cases. Other causes of rectal in-juries include stab wounds, blunt trauma, iatrogenicinjuries during surgery, foreign bodies, and sexualmisadventure.[1]

Although rectal injuries are rarely encountered,they are associated with high morbidity and mortalityrates.[2]The principles of the treatment of rectal inju-ries have been determined based on the experiencesgained from high-energy injuries during wartime.Since the injuries in civilian life are low-energy in-juries, direct adaptation of these principles to civilianinjuries has begun to be questioned. Awareness of thecharacteristics of civilian rectal injury cases as wellas the factors affecting morbidity and mortality willcontribute to improving the treatment approaches. Aspecic treatment method, including primary repair,diversion, presacral drainage, distal rectal washout,and antibiotherapy, or their combinations, should bedetermined for each patient by evaluating specic fac-tors, including the general status of the patient andconcomitant injuries, as well as local ndings, such asthe site and grade of rectal injury and the presence ofcontamination.[3]

Knowing which patients are likely candidates formorbidity in advance and close follow-up of these pa-tients are of great importance in determining the princi-ples of treatment. In the present study, the factors affect-ing morbidity in patients with rectal injury by gunshotor stab wounds in civilian life were investigated.

MATERIALS AND METHODSTwenty-nine inpatients, who had been treated

between 2000 and 2009 in the General Surgery Clinicof Dicle University due to rectal injuries caused bygunshot and stab wounds, were included in the study.The demographic characteristics of the patients, aswell as the trauma-treatment interval (TTI), length ofhospital stay, concomitant organ injuries, Injury Se-

verity Score (ISS), New Injury Severity Score (NISS),Revised Trauma Score (RTS), Trauma Injury Sever-ity Score (TRISS), fecal contamination, and therapymethods were retrospectively recorded from the hos-pital records. In order to determine the factors af-fecting morbidity, the patients were divided into twogroups regarding the presence of morbidity (Group 1,with morbidity; and Group 2, without morbidity), andthe data of these two groups were compared.

Statistical analyses were performed using the Sta-tistical Package for the Social Sciences (SPSS) ver-

sion 12.0 (SPSS, Inc., Chicago, IL, USA). Data arepresented as the meanstandard deviation or n (%).One-sample Kolmogorov-Smirnov test was used toevaluate the distribution of data. The differences be-

tween the subgroups were analyzed by chi-square orFishers exact and Mann-Whitney U tests. The corre-lations between variables were performed by Pearsonor Spearmens rank correlation analyses based on thedistribution of data. A value of p24 hours. The mean length ofhospital stay was 16.012.3 days (range: 5-51 days).Gunshot wounds accounted for 69.0% of the rectalinjuries. Grade 3 injury existed in 58.6% of the pa-tients. Extraperitoneal rectal injuries were present in19 patients (65.5%). In 12 patients, 13 complicationsoccurred. The general characteristics of the patientsare summarized in Table 1.

Of the patients, 62.1% had concomitant organ in-juries (Table 2). The most commonly associated in-jured organs were the intestine (31.0%) and bladder(27.6%). Medical therapy was administered to 1 pa-tient and primary repair was performed on 8 patients,whereas the remaining patients received ostomies.Of the 20 patients who received ostomies, loop co-

402 Eyll - September2011

Table 1. General characteristics of the patients

n %

Cause of trauma

Gunshot wound 20 69.0

Stab wound 9 31.0

Concomitant organ injury

Present 18 62.1

Absent 11 37.9

Causes of morbidity

Wound site infection 8 27.6

Ano-gluteal stula 2 6.9

Vesicorectal stula 1 3.4

Necrotizing fasciitis 2 6.9Grade of injury

I 1 3.4

II 10 34.5

III 17 58.6

IV 1 3.4

Site of injury

Extraperitoneal 19 65.5

Intraperitoneal 6 20.7

Extra+intraperitoneal 4 13.8

Therapy

Medical 1 3.4

Primary repair 8 27.6 Ostomy 20 69.0

TTI: Trauma-treatment interval; LOHS: Length of hospital stay; SD: Standard

deviation.


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Factors affecting morbidity in penetrating rectal injuries

lostomy, Hartmanns colostomy and ileostomy wereperformed on 15 (75.0%), 1 (5.0%) and 4 (20.0%) pa-tients, respectively. Morbidity was recorded in 12 pa-tients (41.4%) (Group 1), whereas 17 patients (58.6%)had no morbidity (Group 2). No signicant differencewas determined between Groups 1 and 2 with respectto concomitant organ injury and the grade of injury(p=0.514 for both; Table 3). Ostomies were performedin 91.7% of the patients in Group 1 and 52.9% of thepatients in Group 2 (p=0.043). The rate of patientswith severe fecal contamination was signicantlyhigher in Group 1 compared to Group 2 (75.0% vs.35.3%, respectively; p=0.041). The rate of perianalor gluteal injuries was signicantly higher in Group1 than Group 2 (91.7%, p=0.032). No signicant dif-ference was determined between the groups in terms

of extraperitoneal rectal injuries (p=0.182), whereasintraperitoneal injuries were higher in Group 2 (52.9%vs. 8.3%, p=0.016; Table 3). The length of hospitalstay in Group 1 was signicantly longer than in Group2 (27 days vs. 8.2 days, p


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The principles of the treatment of rectal injuries havebeen determined based on the experiences gained fromhigh-energy injuries during wartime. Since the injuriesin civilian life are low-energy injuries, direct adapta-tion of these principles to civilian injuries has begun tobe questioned. In a recent study, the mortality rate wasreported to be 18% among 175 patients with colorectal

injuries who had been treated at the 31st Combat Sup-port Hospital during Operation Iraqi Freedom. Themortality rate among 3267 patients treated for otherreasons in the same hospital was 8% during the sameperiod of time.[4]The morbidity and mortality rates ina civilian rectal injury series have been reported to be6%-42% and 0%-10%, respectively.[5]In a more recentstudy performed on 19 civilian patients with extraperi-toneal rectal injuries, and 4 civilian patients with bothintra- and extraperitoneal rectal injuries, Shatnawi andBani-Hani[6]reported the morbidity and mortality ratesas 47.8% and 13%, respectively. In the present study,the overall morbidity and mortality rates were 41.4%and 3.4%, respectively. The morbidity rate for thosewith extraperitoneal rectal injuries was 47.8%.

In the present study, the fact that no mortality wasdetermined in patients treated in time indicated theefcacy of the treatment modalities used in the man-agement of patients with rectal injuries. Mortality oc-curred in only one patient in whom an extraperitonealrectal injury had been recognized after the develop-ment of necrotizing fasciitis during the emergent op-eration in the orthopedics clinic. Unless rectal injuries

are diagnosed and treated properly, they can lead tohigh-risk injuries. Rectal injuries cannot be noticeddue to the anatomic localization of the area if they arenot examined carefully.[6] A digital rectal examina-tion should be performed in patients with gross rectalblood, wounds in close proximity, pelvic fractures, in-juries to the genitourinary tract, and lower abdominalpain or tenderness, which suggest the possibility of arectal injury.[6]A proctosigmoidoscopic examinationshould be performed in case of any suspicious nd-ings, and sphincter tone must be checked during the

examination. A negative digital rectal examinationdoes not exclude the diagnosis of rectal injury. There-fore, further examinations should be performed incases of suspected rectal injuries, including cystoure-

thrograms, abdominal and pelvic X-rays, water-solu-ble contrast studies, peritoneal lavage, and computedtomography (CT) scanning.[2]

In the treatment of extraperitoneal rectal injuries,a diverting colostomy has been accepted as the stan-dard therapy by many authors.[7-9]It has been reportedthat extraperitoneal rectal injuries can be safely treatedwith fecal diversion alone, particularly in low-veloci-ty trauma.[10,11]Bostick et al.[7]reported that no septiccomplications were observed in any of the cases thatunderwent loop colostomies. Demirba et al.[12]veri-ed the therapeutic approach consisting of a divert-ing colostomy (by performing a loop colostomy on allpatients), distal rectal washout and presacral drainagein the treatment of ano-rectal gunshot injuries. In thepresent study, a loop colostomy was performed in 15of the patients who had undergone ostomies; 1 patientunderwent Hartmanns procedure for technical rea-

sons, and in 4 patients, the rectum was primarily re-paired and an ileostomy was performed.

Anterior and lateral upper two-thirds rectal woundsare intraperitoneal and should be treated similar to co-lon injuries. Anterior lower one-third and posteriorlower two-thirds rectal injuries are extraperitoneal andcan be managed by primary repair on a case-by-casebasis.[2]Some authors have suggested that primary re-pair without diversion is feasible in selected patients.[13-15]In a study involving 30 patients with extraperi-toneal rectal injuries, Levine et al.[15] suggested that

primary repair without fecal diversion could be con-sidered in patients without major associated injurieswhen they were treated within 8 hours of injury andhad rectal injury scores (RIS) 2. However, the repairof extraperitoneal rectal perforations is not alwaystechnically feasible, and there is very little evidenceto support the primary repair of these injuries.[11]Fecaldiversion without primary repair is a safe proceduredue to the anatomic considerations and technically dif-cult dissections. Those who advocate fecal diversionhave suggested that the incidence of septic complica-

tions is less with diversion and have also shown thatthe incidence of stoma closure is associated with ac-ceptable morbidity.[16]Primary repair is recommend-ed in only one-half of the cases with extraperitoneal


Table 5. The correlation coefcients between the studied variables

Number of COI TTI ISS RTS NISS

Grade 0.430* -0.185 0.905** -0.200 0.780**Number of COI -0.405* 0.613** -0.353 0.800**TTI -0.150 0.093 -0.436*ISS -0.194 0.851**RTS -0.406**p


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rectal injuries if it is possible to locate the wound.[7]The success rate of primary repair in a civilian serieshas been reported to be higher as compared to a mili-tary series.[4]Bostick et al.[7]performed primary repairto 32.1% of 28 extraperitoneal rectal injury cases. Inthe present study, primary repair or medical treatment

were performed on 9 (31%) of the cases. Burch et al.

[5]

reported that colostomy and drainage were success-ful in the treatment of civilian rectal injuries, whereasadditional procedures, such as diverting colostomies,rectal wound repairs and rectal irrigation had minimaleffects on morbidity and mortality.

In the present study, the TTI was 8 hours in 8 pa-tients, while it was >24 hours in 5 of these patients. Ofthe 5 patients, the reason for the delay was misdiagno-sis in 2 patients, and ignorance and embarrassment in3 patients. Owing to the fact that those with trans-anal

rectal injuries in particular are admitted late due tosocial reasons, complications associated with woundinfections are likely to be encountered more often.[17]Shatnawi and Bani-Hani[6]reported an associationbetween wound infections and a treatment delay >6hours. The duration of the TTI also increases the rateof fecal contamination. In addition to enhancing thetechnical capabilities, the awareness of patients andphysicians about rectal injuries should be increased inan effort to shorten the TTI.

In the present study, the majority of the patients

without morbidity (88.2%) were in the group with ashorter TTI (16, RTS 10 units, and not applying rectal irrigationare effective factors in the development of pelvic ab-scesses.[20] Bostick et al.[7] did not report any septiccomplications in 28 patients, including those in whompresacral drainage was not performed (n=3).

In the present study, fecal contamination, perianal

or gluteal injuries, the duration of the TTI, and isolatedextraperitoneal injuries were signicant factors affect-ing the morbidity rate. The length of hospital stay wassignicantly longer in Group 1 compared to Group 2.

Factors affecting morbidity in penetrating rectal injuries

Cilt - Vol.17 Say - No.5 405

Group 2

17

0

Lenghtofhospitalstay(days)

10

20

30

40

50

60

Group 1

12

Fig. 1. The association of morbidity with the length ofhospital stay.


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The development of morbidity prolongs the lengthof hospital stay in addition to its negative effects onhealth. Levy et al.[21] reported the length of hospitalstay to be 21 days (range: 10 days to 4 months) in ci-vilian extraperitoneal rectal injury cases. The lengthof hospital stay in the present study ranged from 5-51days and was 27.012.4 days on average in Group 1.The length of hospital stay was signicantly longer inGroup 1 than in Group 2 (Fig. 1).

In conclusion, a TTI >8 hours, the presence of peri-anal or gluteal injuries and the presence of fecal con-tamination were signicant factors that affected thedevelopment of morbidity in penetrating rectal inju-ries. A positive correlation was demonstrated betweenthe grade of injury and the number of concomitantinjured organs and NISS, whereas there was a nega-tive correlation with the TTI. It was concluded that amore severe clinical entity facilitates the early initia-tion of treatment and a decrease in morbidity. In orderto diagnose and treat in time, the awareness of bothpatients and physicians about rectal injuries should beincreased. Primary repair is adequate in those present-ing within 8 hours with low-grade injuries but withoutfecal contamination, accompanying perianal defectsand sphincter injuries and concomitant organ andsystem injuries. If the above-mentioned features donot present, ostomy should be included in the currenttreatment. Distal washout and presacral drainage maybe applied in selected cases.

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