Equis ISSN 2398-2977

Rectum: trauma - management and repair

Synonym(s): Rectal liner

Contributor(s): Prof Gary M Baxter, Timothy Mair, Graham Munroe

Introduction

Initial management
  • First aid and prompt referral/treatment is of paramount importance to prognosis.
  • Early assessment of degree and extent of damage is indicated.
  • Epidural anesthesia   Anesthesia: epidural  may be necessary to reduce peristalsis and tenesmus. This can be achieved using lidocaine   Lidocaine  , but xylazine   Xylazine  may be preferred as it causes less ataxia and weakness.
  • Alternatively oral propantheline bromide can be used to reduce straining, or 25-50 ml lidocaine can be administered with an equal volume of saline or lubricant as an enema.
  • Gentle removal of any feces from rectum is advised.
  • Packing from cranial to the damaged area to the anus with povidone-iodine-soaked swabs   Povidone-iodine  or cotton wool helps prevent further contamination of peritoneum/retroperitoneal space.
  • A purse string suture or towel clamp must then be placed in the anal sphincter to prevent passage of swabs.
  • Broad spectrum antibiotics should be promptly instituted   Therapeutics: antimicrobials  .
  • A non-steroidal anti-inflammatory drug with anti-endotoxin activity such as flunixin meglumine   Flunixin meglumine  or ketaprofen/vedaprofen   Ketoprofen  is also useful.
  • Starvation should be instituted.
  • Medical therapy +/- laxatives usually adequate for Grade 1 tears.
  • No treatment required for Grade 2 tears.
  • Surgical repair of >Grade 2 rectal tears   Rectum: tear  .
  • Four surgical techniques:
    • Suturing.
    • Temporary rectal liner.
    • Loop colostomy.
    • End colostomy.
  • Selection of technique dependent upon location, severity and age of injury and presence/absence of peritonitis   Abdomen: peritonitis  .
  • Medical/conservative therapy of Grade 3 and 4 tears also possible.

Uses

  • Surgical treatment of >Grade 2 rectal tears   Rectum: tear  .
  • Non-visual direct suturing is a useful treatment alone for tears involving 50% or less of the circumference of the rectal lumen, and tears that have very small perforations of the serosa.
  • Non-visual direct suturing is an adjunct only for extensive grade 3 and grade 4 tears.

Advantages

Suturing
  • Simple, inexpensive standing procedure.
  • Non-visual technique requires minimal equipment.
  • Can prevent progression of a rectal tear   →   higher grade   →   fecal contamination of abdomen   →   peritonitis   Abdomen: peritonitis  .
  • Partial closure can prevent distraction of wound edges.
    Temporary indwelling rectal liner
  • Prevents fecal contamination during healing process.
  • Loop colostomy and end colostomy; diverts feces away from tear during healing process.

Disadvantages

Suturing
  • Access is difficult - often sutures have to be placed 'blind' using feel per rectum.
  • Special long-handled instruments may be required.
  • Laparotomy may be required.
  • A diverting procedure, eg temporary indwelling rectal liner or colostomy   Colostomy  , should follow suturing to reduce fecal passage over damaged tissues during healing.

Requirements

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Preparation

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Procedure

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Aftercare

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Outcomes

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Prognosis

  • Guarded: depends upon site, age and severity of tear and promptness of medical and surgical treatment.
  • Poor: Grade 4 tears can be rapidly fatal.
  • 60-75% survival with rectal suturing.

Further Reading

Publications

Refereed papers

  • Recent references from PubMed and VetMedResource.
  • Eastman T G et al (2000) Treatment of grade 3 rectal tears in horses by direct suturing per rectumEquine Vet Educ 12 (1), 32-34 VetMedResource.


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