Surgical Management and Associated Complications of Penetrating Rectal Injuries Sustained in Iraq and Afghanistan

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1 MILITARY MEDICINE, 178, 11:1213, 2013 Surgical Management and Associated Complications of Penetrating Rectal Injuries Sustained in Iraq and Afghanistan MAJ Shaun R. Brown, MC USA; CPT Jonathan P. Swisher, MC USA; MAJ Luke J. Hofmann, MC USA; LTC Lisa C. Coviello, MC USA; LTC Kurt G. Davis, MC USA ABSTRACT Purpose: The aim of this study was to analyze the surgical management and associated complications of penetrating rectal injuries sustained in Operation Iraqi Freedom and Operation Enduring Freedom. Methods: A retrospective review was performed using the Joint Theater Trauma Registry. U.S. military personnel injured in Iraq and Afghanistan from October 2003 to November 2008 were included. The surgical management of rectal injuries was evaluated, specifically looking at the utilization of diversion with ostomy, distal washout, and presacral drainage. Complications were compared between the treatment groups. Results: 57 patients who sustained a penetrating rectal injury were included in this study. Surgical management included diversion and ostomy alone in 34 patients (60%), diversion and distal washout in 11 patients (19%), diversion and drainage in 8 patients (14%), and diversion, distal washout, and drainage in 4 patients (7%). Complications were identified in 21% of patients. There were no deaths in the study group. Logistical regression failed to show a correlation between postoperative complications with either distal washout ( p = 0.33) or presacral drainage ( p = 0.9). Conclusions: The majority of patients were successfully managed with fecal diversion alone, suggesting that drainage and distal washout may be unnecessary steps in the management of high-velocity, penetrating rectal injuries. INTRODUCTION The management of penetrating rectal injuries has evolved through numerous military conflicts. During the U.S. Civil War, penetrating abdominal injuries were often managed expectantly. 1 With experience gained during World War I there was an improvement in survival from penetrating rectal injuries, when surgeons first began performing fecal diversion with creation of an ostomy; however, the reported mortality was high at 50%. 2 The mortality rate decreased further to 30% during World War II with the introduction of transperineal presacral drainage. 3 With the addition of distal washout during the Vietnam War, there was a reported decrease in mortality associated with penetrating rectal injuries. 4 Knowledge gained through these conflicts lead the widely accepted doctrine that all penetrating rectal injuries required diversion, distal washout, and presacral drainage. 5 This practice continued for several decades until a growing body of literature questioned the utility of distal washout and presacral drainage for lower-velocity, penetrating rectal injuries Although the current literature supports diversion with ostomy alone in civilian trauma, the application of this management strategy to the higher velocity ammunition and blast injuries commonly encountered on the battlefield is untested. The aim of this study was to critically analyze the surgical management and postoperative complications of penetrating rectal injuries sustained by U.S. soldiers injured in Operation Iraqi Freedom and Operation Enduring Freedom. Department of Surgery, William Beaumont Army Medical Center, 5005 N Piedras Street, El Paso, TX doi: /MILMED-D METHODS This was an institutional review board approved retrospective analysis of rectal injuries sustained by U.S. soldiers in Iraq and Afghanistan from October 2003 to November Patients excluded from the study were those who failed to survive their initial operation, foreign nationals, or those patients with no available operative report for review. The surgical management of rectal injuries was analyzed, specifically looking at the utilization of diversion with ostomy, distal washout, and presacral drainage. Data were collected from the Joint Theater Trauma Registry (JTTR). The JTTR is a data repository that collects Department of Defense trauma-related data. JTTR is used to document patient information from the battlefield through each level of care, allowing real-time access to the patient s medical record. One of the goals of the JTTR is to create a research repository that supports the reduction of morbidity and mortality in military and civilian trauma patients. This registry has been used by several authors in recent literature for the purpose of conducting trauma research The JTTR was queried for patient demographics, injury characteristics, resuscitation fluid and blood product requirements during the initial operation, surgical management, and subsequent outcomes. The operative report for each patient was reviewed to accurately record the surgical management of the rectal injury, with specific interest in the utilization of diversion with ostomy, distal washout, and presacral drainage. For the purpose of this study, postoperative complications were defined as pulmonary embolus, bacteremia, urinary incontinence, septic shock, deep vein thrombosis, pneumonia, hernia, enterocutaneous fistula, fascial dehiscence, necrotizing soft tissue infections, intra-abdominal abscess, cardiac arrest, and death. Complications that occurred in the immediate MILITARY MEDICINE, Vol. 178, November

2 TABLE I. TABLE II. Demographic Information for Patients Included in This Study Mean ± Standard Patient Demographics Deviation Age (Years) 25.1 ± 5.1 ISS 27.6 ± 11.7 Systolic Blood Pressure (mm Hg) ± 30.3 Crystalloid Transfusion (ml) ± Colloid Transfusion (ml) ± Packed Red Blood Cell Transfusion (Units) 6.3 ± 13.8 Fresh Frozen Plasma Transfusion (Units) 3.5 ± 8.2 Mechanism of Penetrating Rectal Injuries Mechanism of Injury Number of Patients (%) Gunshot Wound 27 (47) Improvised Explosive Device 24 (42) Mortar/Rocket 4 (7) Rocket Propelled Grenade/Grenade 2 (4) postoperative period, and those that occurred after the patient was transferred to a higher echelon of care, were captured within this database and reviewed. The patients were stratified into four groups 1 4 based on the surgical management of their rectal injury. Group 1 included patients who underwent diversion with ostomy alone, group 2 included diversion along with distal washout, group 3 included diversion along with presacral drainage, and group 4 included diversion along with distal washout and presacral drainage. Demographic information included age, injury severity score (ISS), presenting systolic blood pressure, and initial operative resuscitation requirements (crystalloid, colloid, packed red blood cells, and fresh frozen plasma). Logistical regression analyzed the possible effects of these parameters on the surgical management between these cohorts. In addition, the postoperative complications were analyzed for each treatment group. The possible relationship between surgical management and postoperative complication was evaluated using logistical regression. The univariate logistic regression analysis was used to evaluate for the possible association of distal washout and presacral drainage on the presence/absence of complications. For the purpose of this study statistical significance was set at a p < RESULTS Sixty-two patients who sustained a rectal injury were initially identified. Five patients with injuries confined to the serosa, requiring only primary repair, were excluded. A total of 57 patients who sustained a penetrating extraperitoneal rectal injury were included for analysis. Patient demographics are depicted in Table I. The mechanism of injury for most patients was a high-velocity gunshot wound or blast injury from an improvised explosive device (Table II). Review of the operative reports revealed that all patients in this cohort received diversion with ostomy. The analysis of surgical management revealed that 34 (60%) patients received diversion with ostomy alone (Fig. 1). Diversion combined with distal washout was performed in 11 patients (19%), and diversion with presacral drainage was used in 8 patients (14%). Only 4 patients (7%) received all three procedures (diversion, drainage, and distal washout). Distal washout was only performed in 15 patients (26%), whereas presacral drains were placed in only 12 patients (21%). Postoperative complications were identified in 12 (21%) patients who sustained a penetrating rectal injury. Five patients had 2 complications, and two patients had 3 complications (Fig. 2). No complications were observed in patients who underwent presacral drainage. The most common complication in the study group was pneumonia followed by FIGURE 1. Surgical management of penetrating rectal injuries sustained in combat MILITARY MEDICINE, Vol. 178, November 2013

3 FIGURE 2. Surgical management and associated number of complications. septic shock and bacteremia (Table III). No deaths were identified in the study group. There was no statistically significant difference in regard to age, ISS, mechanism of injury, or level of treatment facility between the surgical groups. However, the majority of patients received their definitive therapy at a Combat Support Hospital (CSH). In addition, there was no difference in regard to fluid (crystalloid/colloid) or blood product requirements during the initial operation between the surgical groups. Logistical regression failed to show statistical significance between these parameters and the surgical management of rectal injuries. Logistical regression was used to evaluate the potential relationship between distal washout and presacral drainage on the presence or absence of a complication. The development of one or more complications was set as a dependent variable versus distal washouts and presacral drainage. The results of this logistical regression failed to show a relationship between the performance of distal washout (p = 0.33) or presacral drainage ( p = 0.9) and the subsequent development TABLE III. Complications Following Surgical Management of Penetrating Rectal Injuries Complication Number of Patients (%) Pneumonia 8 (14) Sepsis 6 (11) Bacteremia (Without Sepsis) 3 (5) Cardiac Arrest 3 (5) Hernia 2 (4) Pulmonary Embolus 2 (4) Necrotizing Fasciitis 1 (2) Urinary Incontinence 1 (2) Intra-Abdominal Abscess 1 (2) Deep Vein Thrombosis 1 (2) Enterocutaneous Fistula 0 Fascial Dehiscence 0 Death 0 of a postoperative complication. Therefore, both presacral drainage and distal washout were not associated with a reduction in postoperative complications. DISCUSSION The delivery of combat casualty care poses numerous challenges including austere conditions, prolonged evacuation times, and multiple simultaneous casualties involving complex polytrauma patients. The wartime surgeon is often faced with injuries sustained from high-velocity ammunition and explosive ordinances. These challenges along with previous wartime experience have resulted in the traditional military doctrine of drainage, diversion, and distal washout for all penetrating rectal injuries. 5 However, the current literature shows an evolution in the management of penetrating rectal injuries with an emphasis for a more conservative approach. The traditional practice of presacral drainage uses an incision between the coccyx and anus with development of a space between the sacrum and rectum to provide dependent drainage. 5 Several authors have shown a lack of evidence supporting the continued use of presacral drainage in management of penetrating rectal injuries. 7,8,19 The argument against the necessity of presacral drainage is the lack of evidence that this procedure offers any advantage in regard to infection or mortality. 8 The most convincing article supporting this argument was a prospective study including 48 patients, which showed that presacral drainage had no impact on septic complications in the management of penetrating rectal injuries. 7 In our study none of the patients who received presacral drainage had an observed complication. However, this procedure was only performed in 12 patients and logistical regression failed to show significance. Admittedly, this lack of significance may be related to the small patient number and lack of power. Distal washout was implemented during the Vietnam War with the rationale that washing out the remaining fecal debris would prevent further pelvic contamination. Several MILITARY MEDICINE, Vol. 178, November

4 authors question this practice because of the concern that this technique actually forces fecal material into the injured tissues exacerbating rather than alleviating contamination. 6,9,20 Despite the growing body of literature questioning the utility of presacral drainage and distal washout, there is less debate that diversion of the fecal stream is a necessary step in the management of penetrating rectal injuries. 19,21 There are several options for fecal diversion to include the creation of a loop sigmoid colostomy, or an end colostomy with a Hartmann pouch. With the advent of laparoscopic surgery, a new approach to rectal injuries has been described. Navsaria et al 22 showed that rectal injuries could be successfully managed with diagnostic laporoscopy to rule out an intra-abdominal injury, followed by a laparoscopically placed loop sigmoid colostomy for diversion. Laparoscopy is not yet an option in the austere environment. The results of this study show that the paradigm shift in the surgical management of rectal injuries is being reflected on the battlefield. Although all of the patients included in this study underwent diversion with ostomy, the majority of patients received diversion with ostomy alone. Although both loop sigmoid colostomy and end colostomy were used in this cohort, all patients received an open operation. Distal washout was performed in only 26% of patients, and presacral drains were placed in only 21% of patients. Interestingly, the historical military doctrine of diversion, drainage, and distal washout was used in only 7% of the patients in this cohort. Postoperative complications were identified in 21% of the patients. None of the patients who underwent presacral drainage developed a complication. However, there was no statistical correlation between the surgical management of the rectal injury and the development of a postoperative complication. The majority of these patients were successfully managed without presacral drainage or distal washout. Furthermore, it appears that additional injuries along with the presenting physiologic parameters and resuscitation requirements of the patient had no impact on the surgical management of the rectal injury. No deaths were identified following the initial operation for patients included in this study. Although this may seem surprising given the mechanism of injuries and ISS of this cohort, the care delivered on the battlefield has improved substantially since earlier wartime experience with penetrating rectal injuries. Eastridge et al 12 evaluated the mortality of injured U.S. soldiers after being evacuated to either a Forward Surgical Team or CSH. Of the 2,617 injured soldiers who had survived to be admitted to a Forward Surgical Team or CSH, only 77 patients subsequently died of their wounds. The advent of surgical teams placed closer to the battlefront and the implementation of a sophisticated trauma center, combined with the utilization of individual body armor, has lead to a decrease in the mortality commonly associated with previous wars. 12 Limitations of this study include those inherent to a retrospective review. Although there was no statistical significance between the treatment groups in regard to postoperative complications, the overall clinical outcomes of this cohort are unknown. Specifically, the long-term quality of life and potential fecal incontinence of these severely injured patients was not evaluated. Additional studies are necessary to examine the impact that diversion and presacral drainage may have on the patients overall quality of life following a penetrating rectal injury. CONCLUSION Current surgical literature continues to question the historical military doctrine of diversion, distal washout, and presacral drainage for the management of penetrating rectal injuries. The majority of patients in this cohort were successfully managed without presacral drainage or distal washout. The failure of drainage and distal washout to correlate with a reduction in postoperative complications suggests that these may be unnecessary steps in the management of penetrating rectal injuries. The results of this study adds to the growing body of literature supporting a more conservative approach to penetrating rectal injuries, and shows that this approach is now being applied on the battlefield with similar results. REFERENCES 1. Loria FL: Historical aspects of penetrating wounds of the abdomen. Surg Gynecol Obstet 1948; 87(6): Wallace C: A study of 1200 cases of gunshot wounds of the abdomen. Br J Surg 1916; 4: Ogilvie WH: Abdominal wounds in the Western Desert. 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