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Improved Outcomes in Colon and Rectal Surgery part 41

Improved Outcomes in Colon and Rectal Surgery part 41. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | improved outcomes in colon and rectal surgery Table 35.8 Traditional steps in the management of rectal injury. 20 Perineolithotomy position Management of concomitant injuries Debridement Proximal diversion Remove foreign bodies Presacral drainage Distal rectal washout Repair injury if possible Repair sphincters if possible External wound drainage Broad spectrum antibiotics Skin left open Table 35.9 Modified steps in management of rectal injury. Perineolithotomy position Management of concomitant injuries Debridement Intraperitoneal injury Extraperitoneal injury Primary repair Diversion Diversion if destructive injury Loop colostomy Selective presacral drainage preferred Repair if easily accessible Repair sphincters if possible Selective external wound drainage Broad spectrum antibiotics Skin left open 96 108 Given the relative ease of the procedure and subsequent reversal a loop colostomy is recommended 100 102 103 if solely for the purpose of diversion in rectal injury while an end colostomy is performed if there are other indications such as associated colonic injury. Extraperitoneal injuries can be treated without repair unless they are easily accessible or uncovered in the course of treating other injuries. 96 102 103 108 There is some evidence to support this principle. Gonzalez et al. 111 implemented a protocol for the management of extraperitoneal rectal injury without fecal diversion presacral drainage or distal irrigation in patients with nondestructive penetrating injury. Although they had no mortality or infectious complications the series included only 14 patients making these results difficult to generalize. Interestingly in all 14 patients a barium enema was performed and demonstrated complete healing by postinjury day 10 demonstrating the rapid healing capacity of the rectum likely due to its rich blood supply. Abdominoperineal resection has been described in the setting of traumatic rectal injury 102 but should be regarded as an extraordinary .