Surgical treatment of anorectal injuries.

W retrospectively studied 40 patients who were admitted to our department with anorectal trauma during 1996-2004. There were 36 male and 4 female patients with a mean age of 24 + 5.35 (range 20-36 years). We analyzed the injury severity score (ISS) and abbreviated injury scale (AIS) recorded for each patient at the time of admission. The mean ISS was 13.2 + 7.1 (range 4-38). Mean age was 24 + 5.35 years (range 20-36). Five patients (12.5%) suffered blunt abdominal trauma, 2 (5%) had stab injury, 8 (20%) were injured with low-velocity bullets, 14 (35%) were injured with high-velocity bullets, 10 (25%) had shrapnel injury and one (2.5%) suffered from a shotgun injury. Twenty-five patients (62.5%) had hemorrhagic rectal discharge. In the operating room, each patient underwent rigid rectosigmoidoscopy under general anesthesia. Isolated rectal injury was detected in 5 patients (12.5%). The associated organ injuries are shown in Table 1. Four out of 11 intraperitoneal rectal injuries were repaired primarily while resection approach was applied to the remaining 7. Prophylactic ostomy was not carried out in 3 out of 4 primarily repaired patients. Two of these 4 cases were stab injuries while the remaining 2 were pistol injuries. One patient for whom an ostomy was applied, had a pistol injury leading to collateral ileum and bladder trauma. In 5 cases where resection was applied, intestinal passage was maintained by end colostomy and Hartman procedure. Of these 5, 2 patients had colorectal anastomosis. In these patients, proximally located prophylactic ostomy aimed to protect the colorectal anastomosis. There were 10 combined intra and extra-peritoneal injuries. These injuries were located between the transition region of intra-peritoneal and extra-peritoneal rectum. Eight of these injuries were treated with resection, 2 were primarily repaired. Primarily repaired injuries were caused by either a pistol injury or a blunt trauma. Only one of the 2 primarily repaired patients had prophylactic ostomy. Nine of 19 extra-peritoneal injuries involved the anal canal and rectal sphincter. Four of 19 extra-peritoneal injuries were treated by primary suturation; 2 of which were caused by blunt trauma while others were injuries involving low-velocity gunshot incidents. Sphincter injuries were operated with an overlap type, and rectal injury sites were sutured through whole layer. Diverting ostomy was applied to 2 of the primarily repaired patients with an overlap sphincter repairs. Fifteen patient injuries involved the anal canal and perineum, or the site of injury was classified as “difficult injury region to reach,” for which we did not use any repair or resection, but a diverting ostomy with debridement and local washout was preferred. Two of the patients with anal canal and sphincter injuries were treated with primary closure, while 5 patients were treated with local wound care and dressing only. In these 5, the integrity of the anal canal and rectum was maintained although the full function was not. However, patients were nearly satisfied with the continence obtained following the surgery. We have performed primary rectal repair operations in 10 patients. Six of them, for whom we preferred not to use a protective colostomy, had a rectal AIS between 2-3, and their ISS ranged between 4-17 with an average ISS of 7.5 + 3.5. We performed a diverting ostomy in 4 patients whose ISS was over 17 and they had other accompanying injuries. Distal rectal irrigation was carried out for all patients with rectal injury in order to provide mechanical cleaning. Pre-sacral drainage was carried out for each patient with an injury located to the combined intra and extra peritoneal site or below the pelvic peritoneum. Eight out of 29 pre-sacral drainage procedures were performed transabdominally while a perineal incision between coccyx and anus was required for 21 patients. To secure safety of colorectal or coloanal anastomoses, and primary repairs, loop ileostomy was performed when needed. In patients with additional Table 1 Associated organ injuries.