Management options in penetrating rectal injuries.

A retrospective analysis of 54 patients (1976-1989) with penetrating rectal injuries was carried out to evaluate the options in management. The diagnosis was made on proctosigmoidoscopy in 39 patients and at laparotomy in 15. Three patients died within 24 hours from extensive associated trauma (Abdominal Trauma Index [ATI] 39.2). In the remaining 51 patients, rectal wound repair was performed in seven patients, four without proximal colostomy (mean ATI 16.5) and three with colostomy (mean ATI 24.8) without complications. Colostomy and presacral drainage with or without repair were employed in 43 patients. Twenty-one of these patients had rectal washout in addition. The other 22 patients did not have this procedure. The incidence of pelvic abscess in these two groups, who had comparable mean ATI, was identical (4.7% and 4.5%, respectively). One other patient with an extraperitoneal rectal injury had a colostomy alone without presacral drainage and subsequently developed pelvic abscess. The overall incidence of abscess was three of 51 patients or 5.8%. There were no late deaths from sepsis. It is concluded that colostomy (loop or end) and presacral drainage are the most important components of rectal injury management. Small and isolated rectal or rectosigmoid perforations may be repaired primarily without fecal diversion. The value of distal rectal irrigation remains to be proven, but it may be indicated in high-energy injuries of the rectum.