Rectal trauma injuries: outcomes from the US National Trauma Data Bank

BackgroundThere is a lack of general consensus and a littlepublished data regarding the management of trauma-related rectal injuries and outcomes. The aim of the present study was to evaluate the surgical management and corresponding outcomes for this patient cohort, using a nationwide trauma database. Methods Rectal injuries and procedures performed over a 2-year period (2013 and 2014) were identified through ICD-9 clinical modification codes, from the United States National Trauma Data Bank. Patient factors, management variables, and outcomes were evaluated. Results Of 1.7million patients, 1472 (0.1%) sustained a rectal injury; 81% male, median age 30years (range 16-89years) and 60% due to penetrating trauma. Seven hundred and seventy-eight (52.8%) had an isolated extraperitoneal injury and 694 (47.2%) had isolated Intraperitoneal or combined intra- and extraperitoneal injuries. Overall, 726 patients (49.3%) underwent fecal diversion. Injuries following blunt trauma were associated with higher injury severity scores (ISS), lower stoma rates, longer hospital and intensive-care unit (ICU) stay, and higher mortality rates than penetrating trauma (all p0.001). Patients with stoma formation had lower mortality than undiverted patients (8.6 vs. 4.0%, p<0.001) despite a higher ISS and more intraperitoneal injuries, but longer hospital and ICU stay (all p0.001). On multivariate regression analysis, older age, higher ISS, intraperitoneal injury, and return to the ICU were independently associated with higher rates of mortality, while stoma formation was associated with a lower mortality rate. For isolated extraperitoneal rectal injuries, 494 patients (63.5%) were managed by resection/repair without stoma and had significantly lower overall postoperative morbidity rates (12.7 vs. 30.2%, p=0.009) and shorter hospital stay (14 vs. 23 days, p<0.001), than those who underwent resection/repair+stoma (n=284; 36.5%), despite no significant difference in ISS (29 vs. 27, p=0.780). There was no significant difference in mortality. Conclusions Our results showed that trauma-related rectal injuries are rare and there iswide variation in their management. These data support a low threshold for stoma formation in patients with intraperitoneal or combined injuries, while suggesting that isolated extraperitoneal defects may be safely managed without fecal diversion.