K J Gash1,2, K Suradkar1,2, R P Kiran3,4. 1. Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA. 2. Mailman School of Public Health, Columbia University, New York, NY, USA. 3. Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA. rpk2118@cumc.columbia.edu. 4. Mailman School of Public Health, Columbia University, New York, NY, USA. rpk2118@cumc.columbia.edu.
Abstract
BACKGROUND: There is a lack of general consensus and a little published data regarding the management of trauma-related rectal injuries and outcomes. The aim of the present study was to evaluate the surgical management and corresponding outcomes for this patient cohort, using a nationwide trauma database. METHODS: Rectal injuries and procedures performed over a 2-year period (2013 and 2014) were identified through ICD-9 clinical modification codes, from the United States National Trauma Data Bank. Patient factors, management variables, and outcomes were evaluated. RESULTS: Of 1.7 million patients, 1472 (0.1%) sustained a rectal injury; 81% male, median age 30 years (range 16-89 years) and 60% due to penetrating trauma. Seven hundred and seventy-eight (52.8%) had an isolated extraperitoneal injury and 694 (47.2%) had isolated Intraperitoneal or combined intra- and extraperitoneal injuries. Overall, 726 patients (49.3%) underwent fecal diversion. Injuries following blunt trauma were associated with higher injury severity scores (ISS), lower stoma rates, longer hospital and intensive-care unit (ICU) stay, and higher mortality rates than penetrating trauma (all p ≤ 0.001). Patients with stoma formation had lower mortality than undiverted patients (8.6 vs. 4.0%, p < 0.001) despite a higher ISS and more intraperitoneal injuries, but longer hospital and ICU stay (all p ≤ 0.001). On multivariate regression analysis, older age, higher ISS, intraperitoneal injury, and return to the ICU were independently associated with higher rates of mortality, while stoma formation was associated with a lower mortality rate. For isolated extraperitoneal rectal injuries, 494 patients (63.5%) were managed by resection/repair without stoma and had significantly lower overall postoperative morbidity rates (12.7 vs. 30.2%, p = 0.009) and shorter hospital stay (14 vs. 23 days, p < 0.001), than those who underwent resection/repair + stoma (n = 284; 36.5%), despite no significant difference in ISS (29 vs. 27, p = 0.780). There was no significant difference in mortality. CONCLUSIONS: Our results showed that trauma-related rectal injuries are rare and there is wide variation in their management. These data support a low threshold for stoma formation in patients with intraperitoneal or combined injuries, while suggesting that isolated extraperitoneal defects may be safely managed without fecal diversion.
BACKGROUND: There is a lack of general consensus and a little published data regarding the management of trauma-related rectal injuries and outcomes. The aim of the present study was to evaluate the surgical management and corresponding outcomes for this patient cohort, using a nationwide trauma database. METHODS: Rectal injuries and procedures performed over a 2-year period (2013 and 2014) were identified through ICD-9 clinical modification codes, from the United States National Trauma Data Bank. Patient factors, management variables, and outcomes were evaluated. RESULTS: Of 1.7 million patients, 1472 (0.1%) sustained a rectal injury; 81% male, median age 30 years (range 16-89 years) and 60% due to penetrating trauma. Seven hundred and seventy-eight (52.8%) had an isolated extraperitoneal injury and 694 (47.2%) had isolated Intraperitoneal or combined intra- and extraperitoneal injuries. Overall, 726 patients (49.3%) underwent fecal diversion. Injuries following blunt trauma were associated with higher injury severity scores (ISS), lower stoma rates, longer hospital and intensive-care unit (ICU) stay, and higher mortality rates than penetrating trauma (all p ≤ 0.001). Patients with stoma formation had lower mortality than undiverted patients (8.6 vs. 4.0%, p < 0.001) despite a higher ISS and more intraperitoneal injuries, but longer hospital and ICU stay (all p ≤ 0.001). On multivariate regression analysis, older age, higher ISS, intraperitoneal injury, and return to the ICU were independently associated with higher rates of mortality, while stoma formation was associated with a lower mortality rate. For isolated extraperitoneal rectal injuries, 494 patients (63.5%) were managed by resection/repair without stoma and had significantly lower overall postoperative morbidity rates (12.7 vs. 30.2%, p = 0.009) and shorter hospital stay (14 vs. 23 days, p < 0.001), than those who underwent resection/repair + stoma (n = 284; 36.5%), despite no significant difference in ISS (29 vs. 27, p = 0.780). There was no significant difference in mortality. CONCLUSIONS: Our results showed that trauma-related rectal injuries are rare and there is wide variation in their management. These data support a low threshold for stoma formation in patients with intraperitoneal or combined injuries, while suggesting that isolated extraperitoneal defects may be safely managed without fecal diversion.
Authors: Patrick L Bosarge; John J Como; Nicole Fox; Yngve Falck-Ytter; Elliott R Haut; Heath A Dorion; Nimitt J Patel; Amy Rushing; Lauren A Raff; Amy A McDonald; Bryce R H Robinson; Gerald McGwin; Richard P Gonzalez Journal: J Trauma Acute Care Surg Date: 2016-03 Impact factor: 3.313
Authors: Quinton Hatch; Marlin Causey; Matthew Martin; Douglas Stoddard; Eric Johnson; Justin Maykel; Scott Steele Journal: Surgery Date: 2013-08 Impact factor: 3.982