Faecal diversion remains central in the contemporary management of rectal trauma – Experience from a major trauma centre in South Africa

• Published in: Injury 2024-01, Vol.55 (1), p.111110, Article 111110
• Main Authors: J, Tan, VY, Kong, J, Ko, JL, Bruce, GL, Laing, W, Bekker, V, Manchev, DL, Clarke
• Format: Article
• Language: English
• Subjects: Faecal Diversion; General Surgery; Rectal injury; Trauma
• ISSN: 0020-1383; 1879-0267; 1879-0267
• DOI: 10.1016/j.injury.2023.111110

•Primary repair is increasingly being used to manage rectal injuries, however, faecal diversion remains the main stay of rectal trauma management in our environment.•Rectal injuries are associated with high levels of morbidity such as sepsis and urogenital complications. This paper provides an overview of a single center's experience with rectal injury over a decade. It hopes to use this data to provide context to our current approach to managing these injuries in the civilian setting. All patients with rectal trauma were identified from the Hybrid Electronic Medical Registry (HEMR). During the study period, a total of 88 patients with rectal injuries were admitted to Grey's Hospital in Pietermaritzburg. There were 80 (91%) males and 8 (9%) females. The median age was 31 (15-63) years. There were 9 (10%) blunt mechanisms, 76 (86%) penetrating mechanisms and 3 (5%) combined blunt and penetrating mechanisms. Gunshot wounds accounted for the majority of sustained rectal trauma (71%). There were 57 (65%) extra-peritoneal injuries, 24 (27%) intraperitoneal injuries and 7 (8%) combined injuries. The grade of injury, according to the AAST grading system, was as follows, AAST 1: 16 (18%), AAST 2: 63 (72%), AAST 3: 7 (8%), and AAST 4: 2 (2%). Pre-sacral drainage and distal rectal washout were not performed. Almost all (55/57) of the extra-peritoneal rectal injuries were managed with proximal diversion (PD). There were five primary repairs (PR) performed in the extra-peritoneal rectal injury cohort. In four of these cases, this was accompanied by a PD. Of the 24 intraperitoneal rectal injuries, 15 underwent PR, of which 11 were performed in conjunction with PD. In total, 20 intraperitoneal rectal injuries underwent PD. All seven combined rectal injuries underwent PD, and three of the combined rectal injuries underwent PR with PD. There was urogenital tract associated morbidity in 8%, gastrointestinal tract related morbidity in 8% and septic complications in 11%. Rectal trauma is still associated with a high rate of rectal/urogenital and infection related morbidity. Although pre-sacral drainage and distal stump washout have been largely abandoned in civilian practice, fecal diversion currently remains the cornerstone of the management of rectal trauma in our environment. Although there was a low rate of intra-abdominal septic complications in patients who had undergone diversion, this needs to be balanced against the low rate of stoma reversal.