Division of Colorectal Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA.
Mailman School of Public Health, Columbia University, New York, NY, USA.
Tech Coloproctol. 2018 Nov;22(11):847-855. doi: 10.1007/s10151-018-1856-4. Epub 2018 Sep 27.
There is a lack of general consensus and a little published 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.
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.
Of 1.7 million patients, 1472 (0.1%) sustained a rectal injury; 81% male, median age 30 years (range 16-89 years) 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 p ≤ 0.001). 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 p ≤ 0.001). 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.
Our results showed that trauma-related rectal injuries are rare and there is wide 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.
目前对于创伤相关直肠损伤的处理以及相关结局，尚未达成普遍共识，相关数据也较为匮乏。本研究旨在通过全国性创伤数据库，评估该患者群体的手术处理方式和相应结局。
通过 ICD-9 临床修正代码，从美国国家创伤数据库中确定 2013 年和 2014 年期间发生的直肠损伤和手术。评估患者因素、处理变量和结局。
在 170 万患者中，1472 例（0.1%）发生直肠损伤；81%为男性，中位年龄 30 岁（范围 16-89 岁），60%为穿透性损伤。778 例（52.8%）为单纯腹膜外损伤，694 例（47.2%）为单纯腹膜内或联合腹膜内外损伤。总体而言，726 例（49.3%）患者行粪便转流。钝性创伤后直肠损伤与更高的损伤严重程度评分（ISS）、更低的造口率、更长的住院和重症监护病房（ICU）住院时间以及更高的死亡率相关，与穿透性创伤相比（均 p≤0.001）。造口患者的死亡率低于未转流患者（8.6%比 4.0%，p<0.001），尽管 ISS 更高，腹膜内损伤更多，但住院和 ICU 住院时间更长（均 p≤0.001）。多变量回归分析显示，年龄较大、ISS 较高、腹膜内损伤以及返回 ICU 与死亡率升高独立相关，而造口形成与较低的死亡率相关。对于单纯腹膜外直肠损伤，494 例（63.5%）患者行切除/修复术而未造口，其总体术后并发症发生率显著较低（12.7%比 30.2%，p=0.009），住院时间更短（14 天比 23 天，p<0.001），与行切除/修复术+造口（n=284；36.5%）的患者相比，尽管 ISS 无显著差异（29 分比 27 分，p=0.780）。两组死亡率无显著差异。
本研究结果表明，创伤相关直肠损伤较为罕见，其处理方式存在较大差异。这些数据支持对腹膜内或联合损伤患者施行造口术的低门槛，而提示单纯腹膜外缺损可安全地不进行粪便转流处理。
