Contents of trauma-list digest, Vol 24, Issue 46

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Caesar and Newton

I agree with Caesar - however, that should not stop one from doing a sigmoidoscopy; if you can exclude a full thickness injury one can watch the patient; afterall no-one likes a stoma! As to extensive mobilisation and repair of an accessable injury (proximal five cm of extraperitoneal rectum); I would not do a stoma if I can repair the injury; indeed the three cases like that this past year all did well. Treat it as you would for a primarily repaired colonic injury if it is early post injury.

Having said that, I still prefer to only do a loop stoma and leave the rectum to heal by secondary intention, closure being performed after 8-12 weeks after a "loopogram" to exclude sinusses / fistulae / stricturing (0/30+ cases recently). I do not believe in washouts as the rule (maybe if there is gross solid faecal matter), neither has our unit used pre-sacral drains for the last 10 years!

Just for the record - we see around 1-2 extraperitoneal penetrating rectal injuries per month (GSW low velocity - as with our colleagues in Cape Town = Navsaria, and JHB = Degiannis)

Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
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ATLS and DSTC instructor
Intern program Coordinator: Surgery
Program Manager: Emergency Medicine (U.S.)
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-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of djinmori.alp
Sent: Wednesday, June 29, 2005 3:59 AM
To: trauma-list
Subject: Re:Contents of trauma-list digest, Vol 24, Issue 46



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> Rigid proctoscopy in the setting of gross blood per rectum is highly
> over-rated and irrelevant in this scenario, and only wastes time. 
> More often than not the rectum will be full of blood and dfecal
> matter, adding nothing to the equation - you already know that there's
> an injury. At the exploratory laparotomy the level of the rectal
> injury should be easy to determine simply by mobilizing the rectum to
> the level of the peritoneal reflection and even beyond, and closely
> inspecting it. If the rectal injury is proximal to this point, repair
> it and divert. If too distal into the pelvis for access, just divert
> the colon proximally. No distal rectal washout, no presacral or
> pelvic drains.
> 
> CM Ursic
> Sydney

Hi Dr. Ursic

I desagree of your opinion about rigid proctoscopy.
The question is, what about extraperitoneal or intraperitoneal rectal injuries.
I suppose that if you have one more information about it, it could be moe according to "to do no further harm"...Or you mean that we must to explore all the extraperitoneal rectal injuries?
Thanks.

Newton Djin Mori
djinmori at terra.com.br
Surgical Emergency Surgery of Hospital das Clinicas of Sao Paulo University 
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