Rectal injuries

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Slide 1 : GUN SHOT RECTAL INJURIES AHMED A. KANDIL, MD,PhD. CONSULTANT SURGEON SHIFA HOSPITAL P.N.A.
Slide 2 : INTRODUCTION GUN SHOT RECTAL INJURIES ARE UNCOMMON. THEY ARE THE SOURCE OF SIGNIFICANT MORBIDITY AND MORTALITY.
Slide 3 : DIFFICULTIES IN MANAGEMENT OF RECTAL INJURIES ARE DUE TO:- 1. ANATOMY OF THE RECTUM. 2. CONTROL OF PELVIC HAEMORRHAGE. 3.MULTIPLICITY OF ASSOCIATED INJURIES. 4.PREVENTION AND MANAGEMENT OF POST-OPERATIVE SEPSIS.
Slide 4 : COMPONENTS OF TREATMENT OF G.S.R. INJURIES: 1. FECAL DIVERSION. 2. PRESACRAL DRAIN. 3. RECTAL WOUND REPAIR. 4. DISTAL RECTAL WASHOUT.
Slide 5 : CAUSES OF PROGRESS IN MANAGEMENT OF G.S.R. INJURIES: 1. SKILLS IN DIAGNOSIS. 2. IMPROVEMENT IN RESUSCITATION. 3. ADVANCE IN ANESTHESIA. 4. USE OF ANTIBIOTICS.
Slide 6 : AIM OF WORK THE PURPOSE OF THIS STUDY IS TO PRESENT OUR CLINICAL EXPERIENCE IN MANAGEMENT OF GUN SHOT RECTAL INJURIES.
Slide 7 : PATIENTS AND METHODS IT IS A RETROSPECTIVE STUDY FROM SHIFA HOSP. IT WAS BETWEEN 1989 AND 1994. 28 PATIENTS WERE INCLUDED (23 M & 5 F). RANGE OF AGE FROM 11-52 YEARS (MEDIAN 21.4 YEARS) ALL PATIENTS RECEIVED FULL THICKNESS RECTAL INJURIES. TWO PATIENTS DIED IN FIRST 24 H. WERE EXCLUDED.
Slide 8 : RECTAL INJURY W AS SUSPECTED WHEN: 1. PRESENCE OF PENETRATING INJURIES IN THE BUTTOCKS, PERINEUM, OR PELVIC REGION. 2. PRESENCE OF BLEEDING PER RECTUM WITHOUT PROXIMAL COLONIC INJURIES.
Slide 9 : DIAGNOSIS WAS CONFIRMED BY:- P.R. EXAMINATION PROCTOSIGMOIDSCOPY AND SEEING A RECTAL WOUND. BOTH, AND PRESENCE OF BLOOD IN THE RECTUM.
Slide 10 : STEPS OF MANAGEMENT:- 1. RESUSCITATION WHEN NEEDED. 2. FOLEY CATHETER, ROUTINELY. 3. EXPLORATION VIA LOW MEDLINE INCISION. 4. I.V. ANTIBIOTICS. 5. MANAGEMENT OF ASSOCIATED INJURIES.
Slide 11 : 5. COLOSTOMY ( LOOP OR DIVIDED). 6. REPAIR OF RECTAL WOUND IF FEASIBLE. 7. PRESACRAL DRAINING . 8. DISTAL RECTAL WASHOUT.
Slide 12 : TREATMENT MODALITIES
Slide 13 : RESULTS Time between injury and operation did not exceed 5 h. 4 patient (15.4%) were shocked on arrival. 5 patient (19.2%) had positive findings on P.R. 13 patient(50%) had positive proctoscopic exam. findings. In 8 patients blood on proctoscopy was the only indication for surgery.
Slide 14 : 23 patients had associated injuries
Slide 15 : 11 patient had complications
Slide 16 : CLOSURE OF COLOSTOMY COLOSTOMIES CLOSURE WERE PERFORMED AFTER THE PATIENTS RECOVERED COMPLETELY FROM THEIR INJURIES
Slide 17 : CONCLUSION 1. P.R. alone and /or proctosigmoidscopy should be performed when rectal injury is suspected. 2. It is wise to treat the patient as if he has rectal injury when blood present on P.R or proctosigmoidscopy even if rectal perforation can not be identified.
Slide 18 : 3. Intrapperitoneal rectal injury can safely closed without diversion. 4. Colostomy and pre sacral drainage are essential component in treatment of rectal injuries. 5. Properly constructed loop colostomy can provide complete fecal diversion.
Slide 19 : 6. Repairs of rectal wounds are preferable, but it is unnecessary to dissect the rectum just for closure of the rectal wounds unless there are associated injuries which necessitate pelvic dissection. 7. Distal rectal washout is not an essential step in the treatment of rectal injuries, but may be performed according to the preference of the surgeon if the patient is stable at the end of the operation.
Slide 20 : THANK YOU DEPARTMENT OF SURGERY SHIFA HOSP. GAZA - PNA

 


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