Professional Documents
Culture Documents
Blunt and Penetrating Injuries To The Anus and Rectum Are Uncommon
Blunt and Penetrating Injuries To The Anus and Rectum Are Uncommon
Considerable
debate remains regarding the optimal treatment of rectal injuries. Although intraperitoneal
rectal injuries can be treated similarly to colonic injuries, treatment options for
extraperitoneal injuries include fecal diversion with a colostomy, presacral drainage,
repair of the rectal defect, and distal rectal washout. Perineal injuries resulting in anal
sphincter disruption often occur with severe associated injuries. Small defects can be
repaired primarily, but extensive injuries often require diversion and sphincter reconstruction.
Tumpul dan luka tembus ke anus dan rektum jarang terjadi. Besar
Perdebatan masih mengenai pengobatan optimal cedera dubur. meskipun
intraperitoneal
cedera rectal dapat diperlakukan sama dengan cedera kolon, pilihan pengobatan
untuk
luka ekstraperitoneal termasuk pengalihan tinja dengan kolostomi, drainase
presacral,
perbaikan cacat dubur, dan washout dubur distal. luka perineum mengakibatkan
anal
gangguan sfingter sering terjadi dengan cedera terkait parah. cacat kecil bisa
diperbaiki terutama, tetapi cedera yang luas sering membutuhkan pengalihan
dan sfingter rekonstruksi.
Accidental blunt and penetrating injuries to the anorectumare
uncommon events. The relative protection offered by
the rectums position in the bony pelvis makes blunt injuries
particularly uncommon. Excluding iatrogenic, sex-related,
and foreign body injuries, the most common injury is a result
of a pelvic gunshot wound; however, even in the setting of
transpelvic gunshot wounds, penetrating injury to the rectumare
seen in a small minority of patients.1,2 Traumatic anal
sphincter injury can be from impalement or other penetrating
injury, or blunt trauma, including crush injury. The evaluation
and management of anorectal trauma are reviewed here.
Rectal Trauma
Initial Evaluation
The trauma victimmust first be assessed with attention to the
primary survey to ensure immediate life-threatening injuries
are stabilized. During the secondary survey, anorectal trauma
can be assessed and evaluated. When possible, obtaining
history related to the injury, associated symptoms including
abdominal and genitourinary symptoms, as well as baseline
bowel function and continence can be helpful. Particularly for
penetrating injuries, knowing the caliber and velocity of the
missile can help establish an understanding of the potential
injury.3 Physical examination begins with visual inspection,
including an assessment of entry and exit wounds in the
tumpul disengaja dan luka tembus ke anorectumare yang
peristiwa biasa. Perlindungan relatif ditawarkan oleh
posisi rektum dalam tulang panggul membuat luka tumpul
terutama jarang. Tidak termasuk iatrogenik, berhubungan dengan seks,
dan luka benda asing, cedera paling umum adalah hasilnya
dari luka tembak panggul; Namun, bahkan dalam pengaturan
luka tembak transpelvic, menembus cedera rectumare yang
terlihat di sebagian kecil anal Trauma patients.1,2
cedera sfingter bisa dari penyulaan atau penetrasi lainnya
cedera, atau trauma tumpul, termasuk cedera naksir. Evaluasi
dan pengelolaan trauma anorektal ditinjau di sini.
dubur Trauma
Evaluasi awal
The victimmust trauma pertama dinilai dengan memperhatikan
survei primer untuk memastikan cedera yang mengancam jiwa langsung
yang stabil. Selama survei sekunder, trauma anorektal
dapat dinilai dan dievaluasi. Bila mungkin, mendapatkan
sejarah terkait dengan cedera, gejala yang terkait termasuk
gejala perut dan genitourinary, serta dasar
fungsi usus dan kontinensia dapat membantu. khusus untuk
luka tembus, mengetahui kaliber dan kecepatan dari
rudal dapat membantu membangun pemahaman tentang potensi
injury.3 Pemeriksaan fisik dimulai dengan inspeksi visual,
termasuk penilaian dari luka masuk dan keluar di
penetrating trauma patient. Digital rectal examination
should also include an assessment of resting and squeeze
tone when feasible. The position of the prostatemay be noted
if urethral injury is suspected in the blunt trauma patient.
Although a part of nearly all secondary surveys, the digital
rectal exam probably has limited value in detecting injury.4,5
Adjuncts to the physical examination include imaging
studies and endoscopy. Bowel injuries can be challenging to
detect on computed tomography (CT).6 However, with newer
multidetector CT and appropriate use of oral, intravenous, and
rectal contrast, the diagnostic accuracy can be improved.7
Rigid proctoscopy or flexible proctosigmoidoscopy has generally
been considered to be a reliable tool to detect the presence
and location of an injury.8 It can be helpful in both blunt and
penetrating injuries.9,10 However, there is a risk of further
injury with the procedure, and it may not be necessary in the
setting of good-quality imaging or planned exploration. Although
there are frequently abnormal findings, it is unclear
whether the findings effectively guide management, ormerely
confirm findings already suspected.11
Rectal injuries can be classified according to the Rectum
Injury Scale from the American Association for the Surgery of
Trauma (AAST; see Table 1).12 Widespread use of classification
tools and registries has allowed for standardized data
collection and will improve data analysis.
Management of Rectal Injuries
The operativemanagement of rectal injuries has evolvedwith
a combination of surgical dogma, personal advice of
penetrasi pasien trauma. pemeriksaan colok dubur
juga harus mencakup penilaian beristirahat dan pemerasan
nada jika memungkinkan. Posisi prostatemay yang dicatat
jika cedera uretra dicurigai pada pasien trauma tumpul.
Meskipun bagian dari hampir semua survei sekunder, digital
dubur mungkin memiliki nilai terbatas dalam mendeteksi injury.4,5
Tambahan berarti untuk pemeriksaan fisik termasuk pencitraan
studi dan endoskopi. luka usus dapat menantang untuk
mendeteksi pada computed tomography (CT) 0,6 Namun, dengan yang lebih
baru
multidetector CT dan penggunaan yang tepat dari mulut, intravena, dan
Sebaliknya dubur, akurasi diagnostik dapat improved.7
proctoskopi kaku atau proctosigmoidoscopy fleksibel memiliki umumnya
telah dianggap sebagai alat yang handal untuk mendeteksi keberadaan
dan lokasi dari injury.8 Hal ini dapat membantu dalam kedua tumpul dan
menembus injuries.9,10 Namun, ada risiko lebih lanjut
cedera dengan prosedur, dan mungkin tidak diperlukan di
Pengaturan pencitraan berkualitas baik atau eksplorasi direncanakan. Meskipun
ada temuan sering tidak normal, tidak jelas
apakah temuan efektif membimbing manajemen, ormerely
mengkonfirmasi temuan sudah suspected.11
cedera dubur dapat diklasifikasikan menurut Rektum yang
Cedera Skala dari Asosiasi Amerika untuk Bedah
Trauma (Aast; lihat Table 1) 0,12 Meluasnya penggunaan klasifikasi
alat dan pendaftar telah memungkinkan untuk data standar
pengumpulan dan akan meningkatkan analisis data.
Manajemen Cedera rektal
The operativemanagement cedera rectal memiliki evolvedwith
kombinasi dogma bedah, saran pribadi
experienced surgeons, and well-controlled clinical studies.
Historically, there have been fewhigh-quality studies to guide
decisionmaking, leading to dogma and personal-experienceinfluenced
management decisions. Victims of penetrating
rectal injuries, particularly soldiers, were more likely than
not to die fromtheir injury until routine use of colostomywas
mandated for battlefield injuries in 1948.13 The use of a
presacral drain was popularized about the same time, and
the importance of distal rectal washout was established
during the VietnamWar.14 Diversion, drainage, and washout
continues to have a place in themanagement of rectal trauma,
although much more data exist today to support the option of
primary repair for intraperitoneal injuries, omission of drains
and distal washout, and avoidance of primary repair of
extraperitoneal injuries in modern management.
A recent systematic review of the literature from 1965 to
2010 identified 108 acceptable articles on colon and rectal
trauma, with very few of these examining rectal trauma in
particular.15 The best data available were from small retrospective
studies with heavy selection bias, and only one
prospective randomized trial of 48 patients. Currently available
data can help guide decision making, however. First,
there is ample evidence that primary repair of colon injuries is
appropriate in selected patients.16 Current Eastern Association
for the Surgery of Trauma guidelines cite that nondestructive
injuries involving < 50% of the bowel wall can be
repaired. For destructive ormore extensive injuries, resection
and anastomosis can be performed in the setting of hemodynamic
stability, absence of comorbidities, minimal associated
injuries, and no peritonitis. These same guidelines may apply
to intraperitoneal rectal injuries.
However, there remains considerable controversy regarding
the management of extraperitoneal rectal injuries. Fecal
diversion is probably the least controversial, although there
are studies supporting either routine diversion or selective
omission of a diverting colostomy for extraperitoneal rectal
injuries. A case-control trial examining treatment options for
extraperitoneal injuries omitted diversion in the study cases,
and compared the outcome to historical controls. 17 They
noted no significant differences in morbidity after omitting
diversion. However, a cohort study comparing matched
groups of patients with extraperitoneal injuries found that
diversion without repair resulted in the fewest complications
ahli bedah yang berpengalaman, dan studi klinis terkendali dengan baik.
Secara historis, telah ada penelitian berkualitas fewhigh untuk membimbing
pengambilan keputusan, yang mengarah ke dogma dan pribadiexperienceinfluenced
keputusan manajemen. Korban menembus
Conclusion