Morgan Schellenberg1, Carlos V R Brown2, Marc D Trust3, John P Sharpe4, Tashinga Musonza4, John Holcomb5, Eric Bui6, Brandon Bruns7, H Andrew Hopper8, Michael S Truitt9, Clay C Burlew10, Kenji Inaba3, Jack Sava11, John Vanhorn12, Brian Eastridge13, Alisa M Cross14, Richard Vasak15, Gary Vercuysse16, Eleanor E Curtis17, James Haan18, Raul Coimbra19, Phillip Bohan20, Stephen Gale21, Peter G Bendix22. 1. LAC+USC Medical Center, University of Southern California, Los Angeles, California. Electronic address: morgan.schellenberg@med.usc.edu. 2. Dell Medical School, University of Texas at Austin, Austin, Texas. 3. LAC+USC Medical Center, University of Southern California, Los Angeles, California. 4. University of Tennessee Health Science Center, Memphis, Tennessee. 5. University of Texas Health Science Center at Houston, Houston, Texas. 6. University of San Francisco-East Bay, Oakland, California. 7. R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland. 8. Vanderbilt University, Nashville, Tennessee. 9. Methodist Health System, Dallas, Texas. 10. Denver Health Medical Center, University of Colorado, Denver, Colorado. 11. MedStar Washington Hospital Center, Washington, District of Columbia. 12. Legacy Emanuel Medical Center, Portland, Oregon. 13. University of Texas Health Science Center San Antonio, San Antonio, Texas. 14. University of Oklahoma, Oklahoma City, Oklahoma. 15. Harbor-UCLA Medical Center, Los Angeles, California. 16. University of Arizona, Tucson, Arizona. 17. University of California Davis, Sacramento, California. 18. Via Christi Health, Wichita, Kansas. 19. University of California San Diego, San Diego, California. 20. Oregon Health and Science University, Portland, Oregon. 21. East Texas Medical Center, Tyler, Texas. 22. Brigham and Women's Hospital, Boston, Massachusetts.
Abstract
BACKGROUND: Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. METHODS: Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). RESULTS: After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. CONCLUSIONS: Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.
BACKGROUND: Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion. METHODS: Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative). RESULTS: After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management. CONCLUSIONS: Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.