Extraperitoneal Rectal Injuries Research Articles

CONTEMPORARY DIAGNOSIS AND MANAGEMENT OF COLORECTAL INJURIES: WHAT YOU NEED TO KNOW.

Colorectal injuries are commonly encountered by trauma surgeons. The management of colorectal injuries has evolved significantly over the past several decades, beginning with wartime experience and subsequently refining with prospective randomized studies. Colon injuries were initially nonoperative, evolved towards fecal diversion for all, then became anatomic based with resection and primary anastomosis with selective diversion, and now primary repair, resection with primary anastomosis, or delayed anastomosis after damage control laparotomy are all commonplace. Rectal injuries were also initially considered non-operative until diversion came into favor. Diversion in addition to direct repair, presacral drain placement, and distal rectal washout became the gold standard for extraperitoneal rectal injuries until drainage and washout fell out of favor. Despite a large body of evidence, there remains debate on the optimal management of some colorectal injuries. This article will focus on how to diagnose and manage colorectal injuries. The aim of this review is to provide an evidence-based summary of the contemporary diagnosis and management of colorectal injuries.

Faecal diversion remains central in the contemporary management of rectal trauma–Experience from a major trauma centre in South Africa

IntroductionThis paper provides an overview of a single centre's experience with rectal injury over a decade. It hopes to use this data to provide context to our current approach to managing these injuries in the civilian setting. The StudyAll patients with rectal trauma were identified from the Hybrid Electronic Medical Registry (HEMR). ResultsDuring the study period, a total of 88 patients with rectal injuries were admitted to Grey's Hospital in Pietermaritzburg. There were 80 (91 %) males and 8 (9 %) females. The median age was 31 (15–63) years. There were 9 (10 %) blunt mechanisms, 76 (86 %) penetrating mechanisms and 3 (4 %) combined blunt and penetrating mechanisms. Gunshot wounds accounted for the majority of sustained rectal trauma (71 %). There were 57 (65 %) extra-peritoneal injuries, 24 (27 %) intraperitoneal injuries and 7 (8 %) combined injuries. The grade of injury, according to the AAST grading system, was as follows, AAST 1: 16 (18 %), AAST 2: 63 (72 %), AAST 3: 7 (8 %), and AAST 4: 2 (2 %). Pre-sacral drainage and distal rectal washout were not performed. Almost all (55/57) of the extra-peritoneal rectal injuries were managed with proximal diversion (PD). There were five primary repairs (PR) performed in the extra-peritoneal rectal injury cohort. In four of these cases, this was accompanied by a PD. Of the 24 intraperitoneal rectal injuries, 15 underwent PR, of which 11 were performed in conjunction with PD. In total, 20 intraperitoneal rectal injuries underwent PD. All seven combined rectal injuries underwent PD, and three of the combined rectal injuries underwent PR with PD. There was urogenital tract associated morbidity in 8 %, gastrointestinal tract related morbidity in 8 % and septic complications in 11 %. ConclusionRectal trauma is still associated with a high rate of rectal/urogenital and infection related morbidity. Although pre-sacral drainage and distal stump washout have been largely abandoned in civilian practice, faecal diversion currently remains the cornerstone of the management of rectal trauma in our environment. Although there was a low rate of intra-abdominal septic complications in patients who had undergone diversion, this needs to be balanced against the low rate of stoma reversal.

Surgical management of colorectal injury in war.

The rate of colorectal trauma is 5-10 % in modern war conflicts. The most common causes include gunshots or shrapnel injuries; the contusion-laceration mechanism occurs in sporadic cases in the war zone. Despite modern surgical procedures, however, it is associated with a high rate of morbidity, especially if it is not diagnosed and treated in time. Surgical management is specified by simple scoring schemes - the colon injury scale, rectal injury scale and the Flint grading system. Colonic resection with primary or delayed anastomosis is not associated with a higher risk of complicated healing and is nowadays preferred over the construction of terminal stomas. These are indicated only for cases with severe hemodynamic instability in traumatic-hemorrhagic or septic shock with severe diffuse peritonitis. Trauma to the intraperitoneal segment of the rectum is treated in the same way as trauma to the colon. An extraperitoneal rectal injury without soft tissue devastation can be treated with or without a transanal suture. On the contrary, devastating injuries to the rectum including the pelvic soft tissues should be primarily controlled with a stoma with delayed reconstruction. Presacral drainage or rectal stump lavage are no longer recommended.

Transanal Minimally-Invasive Surgery (TAMIS): Experience with No Closure of the Rectal Defect

Abstract Background In transanal minimally-invasive surgery (TAMIS), the closure of the rectal defect is controversial, and endoluminal suture is one of the most challenging aspects. The goal of the present study is to evaluate the short- and medium-term complications of a consecutive series of patients with extraperitoneal rectal injuries who underwent TAMIS without closure of the rectal defect. Materials and Methods A prospective, longitudinal, descriptive study conducted between August 2013 and July 2019 in which all patients with extraperitoneal rectal lesions, who were operated on using the TAMIS technique, were consecutively included. The lesions were: benign lesions ≥ 3 cm; neuroendocrine tumors ≤ 2 cm; adenocarcinomas in stage T1N0; and adenocarcinomas in stage T2N0, with high surgical risk, or with the patients reluctant to undergo radical surgery, and others with doubts about complete remission after the neoadjuvant therapy. Bleeding, infectious complications, rectal stenosis, perforations, and death were evaluated. Results A total of 35 patients were treated using TAMIS without closure of the defect. The average size of the lesions was of 3.68 ± 2.1 cm (95% confidence interval [95%CI]: 0.7 cm to 9 cm), their average distance from the anal margin was of 5.7 ± 1.48 cm, and the average operative time was of 39.2 ± 20.5 minutes, with a minimum postoperative follow-up of 1 year. As for the pathologies, they were: 15 adenomas; 3 carcinoid tumors; and 17 adenocarcinomas. In all cases, the rectal defect was left open.The overall morbidity was of 14.2%. Two patients (grade II in the Clavien-Dindo classification) were readmitted for pain treatment, and three patients (grade III in the Clavien-Dindo classification) were assisted due to postoperative bleeding, one of whom required reoperation. Conclusion The TAMIS technique without closure of the rectal defect yields good results, and present a high feasibility and low complication rate.

Contemporary diagnosis and management of traumatic rectal injuries

Abstract Rectal injuries are rare but potentially devastating injuries that are frequently associated with penetrating pelvic trauma or blunt pelvic fractures. Management principles for these injuries have gone through major paradigm shifts over time. Recently, large-scale civilian studies have been completed, providing valuable insight on best-practice strategies for contemporary trauma populations. The diagnosis of rectal injuries is accomplished with a combination of computed tomography (CT) scanning and rigid proctoscopy. Because the rectum is comprised of two distinct anatomic segments, the intra- and extraperitoneal rectum, management principles for rectal injuries are unique. Intraperitoneal rectal injuries are managed as colonic injuries, with small injuries primarily repaired and larger injuries resected. Extraperitoneal injuries are repaired primarily via a trans-anal approach, if feasible, and otherwise are managed with proximal diversion alone. Complications seen after rectal injuries include infection, strictures, and fistulae. The most provocative questions about rectal injuries that are currently unanswered relate to the possibility of nonoperative management for penetrating extraperitoneal rectal injuries and to the optimal timing of colostomy reversal after proximal diversion for extraperitoneal injuries.

Minimally invasive approach to low-velocity penetrating extraperitoneal rectal trauma.

Unlike intraperitoneal colorectal injuries, the standard of care for extraperitoneal rectal trauma includes a diverting colostomy due to relative inaccessibility of these injuries for primary repair. New technologies to enhance access to the extraperitoneal rectum have gained increasing use in benign and malignant rectal disease. We present two cases of low-velocity penetrating extraperitoneal rectal trauma. In both cases, a transanal minimally invasive surgery (TAMIS) approach was used to access, and primarily repair, full-thickness rectal lacerations. These patients were successfully managed without a colostomy and without complication. TAMIS enables access to distal rectal injuries, facilitating primary repair and bringing the management of extraperitoneal rectal injuries in line with intraperitoneal injuries, with the potential to avoid fecal diversion.

Contemporary management of rectal trauma - A South African experience

IntroductionThe management of rectal trauma remains controversial. There are three modalities which have been used to manage these injuries; proximal diversion (PD), washout of the distal rectum (DRW) and presacral drainage (PSD). The EAST group tentatively advocate mandatory proximal diversion for extraperitoneal rectal injuries and omitting DRW or PSD. Other authors have suggested that diversion can be eschewed in patients with an intraperitoneal injury which can be primarily repaired. In light of all these controversies, this project set out to review our experience with rectal injuries over the last seven years with the objective of reviewing our use of PD, PSD and DRW. MethodsPatients aged greater than or equal to 15 years with rectal injuries during December 2012 to July 2019 were included. Patient demographics, mechanism of injury, management strategy (operative or non-operative), complications, patient residential status (urban or rural), hospital and intensive care duration of stay, and 30-day mortality rates were assessed. ResultsDuring the study period, a total of 51 patients with a rectal injury were treated. There were 45 (88%) males and the median age was 29 (22-39) years. There were 7 (14%) blunt mechanisms, 41 (80%) penetrating mechanisms and 3 (6%) combined blunt and penetrating mechanisms. The median ISS was 13 (9-18). Of the 50 rectal injuries ultimately treated at our institution, there were 31 extraperitoneal and 14 intraperitoneal injuries. There were five combined intra and extraperitoneal injuries. A total of 21 rigid sigmoidoscopies and a single flexible sigmoidoscopy were performed. A total of 24 patients underwent a CT scan. There were 13 primary repairs and 45 PD. A single patient required a PSD. Of the 34 documented complications, 15 (44%) were related to sepsis and can be attributed to the rectal injury. The overall mortality rate was 11.8%. ConclusionsRectal injuries are associated with significant septic related morbidity and mortality. Although we have begun to avoid diversion in a small subset of patients with an intraperitoneal injury, we continue to perform PD for the vast majority of patients with a rectal injury. We do not perform DRW and PSD is used in highly selective cases.

Rectal trauma injuries: outcomes from the U.S. National Trauma Data Bank.

There 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. 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 1.7million 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 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 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.

Management of Post-Traumatic Posterior Rectal Pouch Through a Posterior Approach

Proximal fecal diversion is the treatment of choice in the cases of extra-peritoneal rectal injuries that are not amenable for primary repair due to their distant location or high grade. The posterior approach enables complete excision of well-defined abscess cavities that communicate with the rectal lumen with full-thickness repair of the rectal defect. An important privilege of pouch excision through the posterior approach was the preservation of rectal reservoir and the sensation that would have been compromised if proctectomy with coloanal anastomosis was alternatively performed.

Management of penetrating extraperitoneal rectal injuries: An Eastern Association for the Surgery of Trauma practice management guideline.

The management of penetrating rectal trauma invokes a complex decision tree that advocates the principles of proximal diversion (diversion) of the fecal stream, irrigation of stool from the distal rectum, and presacral drainage based on data from World War II and the Vietnam War. This guideline seeks to define the initial operative management principles for nondestructive extraperitoneal rectal injuries. A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding penetrating rectal trauma from January 1900 to July 2014. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included the management principles of diversion, irrigation of stool from the distal rectum, and presacral drainage using the GRADE methodology. A total of 306 articles were screened leading to a full-text review of 56 articles. Eighteen articles were used to formulate the recommendations of this guideline. This guideline consists of three conditional evidence-based recommendations. First, we conditionally recommend proximal diversion for management of these injuries. Second, we conditionally recommend the avoidance of routine presacral drains and distal rectal washout in the management of these injuries.

Is Ostomy Still Mandatory in Rectal Injuries?

The aim of this study was to compare the outcomes of the treatment methods of ostomy and primary repair in rectal injuries. A total of 63 patients with rectal injury who had been treated at Dicle University Hospital between 2000 and 2011 were retrospectively reviewed. To determine the outcomes of the treatment methods, the patients were divided into 2 groups (ostomy group: patients who underwent ostomy plus primary repair; repair group: patients who only underwent primary repair) and compared. The patients included 51 men and 12 women. A total of 44 patients underwent ostomy, whereas 19 patients underwent primary repair. No morbidity was detected in either group with grade II intraperitoneal rectal injury. The outcomes of the patients with grade II intraperitoneal and extraperitoneal rectal injury were similar. In the treatment of patients with low-grade rectal injuries, primary repair can be preferred to ostomy.

Rectal trauma in adults

Rectal trauma is associated with high rates of morbidity and mortality and generally affects young males due to its aetiology of violent crime and vehicular collision. Historically, management has followed principles derived from military practice, with faecal diversion, pre-sacral drainage and distal washout being mandatory. Civilian trauma studies examining management of colon and rectum injuries from the early 1950s identified major differences in the level of energy transfer between civilian and military wounds, given that the vast majority are penetrating in nature. This led to a re-evaluation of the necessity for these interventions for all rectal injuries. Current management depends on whether the injury is intra- or extraperitoneal, with those above the peritoneal reflection being readily accessible and amenable to treatment as for colon injury. Extraperitoneal injuries remain difficult to access and direct repair is usually impossible; the mainstay of treatment in most instances remains faecal diversion. The role of pre-sacral drainage and distal washout remains contentious in the realms of civilian rectal injury but retains a place in battlefield or other high-energy transfer rectal injuries where aggressive early management reduces septic complications. This article reviews the historical and current evidence for the management of both civilian and military extraperitoneal rectal injuries.

Unusual extraperitoneal rectal injuries: a retrospective study.

Rectal injuries, which are rarely encountered because of the anatomic characteristics, occur due to penetrating traumas. In the current study, we aimed to present experiences gleaned from our clinic concerning rarely encountered unusual rectal injuries, including those cases presented for the first time. Eleven patients who had been treated for unusual rectal injuries in the General Surgery Clinic of Dicle University between 2004 and 2011 were retrospectively reviewed. The reasons for rectal injuries included foreign bodies in four cases, sexual intercourse in three cases, iatrogenic injuries in two cases, electric shock in one case, and animal horns in one case. All cases had extraperitoneal rectal injuries and all injuries were grade 2 injuries, except for the electrical burn. Primary repair was adequate for the treatment of six patients. Four patients underwent primary repair and ostomy, whereas one of the patients underwent debridement and an ostomy. The patients recovered without complications, except for one patient with sphincter insufficiency. The results of the current study suggested that primary repair is adequate in the patients with low-energy injuries and early presentation, whereas an ostomy is required for those with late presentation and for those with high-energy and destructive injuries.

Surgical management of colorectal injuries: colostomy or primary repair?

Several factors have been considered important for the decision between diversion and primary repair in the surgical management of colorectal injuries. The aim of this study is to clarify whether patients with colorectal injuries need diversion or not. From 2008 to 2010, ten patients with colorectal injuries were surgically treated by primary repair or by a staged repair. The patients were five men and five women, with median age 40 years (20-55). Two men and two women had rectal injuries, while 6 patients had colon injuries. The mechanism of trauma in two patients was firearm injuries, in two patients was a stab injury, in four patients was a motor vehicle accident, in one woman was iatrogenic injury during vaginal delivery, and one case was the transanal foreign body insertion. Primary repair was possible in six patients, while diversion was necessary in four patients. Primary repair should be attempted in the initial surgical management of all penetrating colon and intraperitoneal rectal injuries. Diversion of colonic injuries should only be considered if the colon tissue itself is inappropriate for repair due to severe edema or ischemia. The role of diversion in the management of unrepaired extraperitoneal rectal injuries and in cases with anal sphincter injuries is mandatory.

Management of Colorectal Trauma

Although the treatment strategy for colorectal trauma has advanced during the last part of the twentieth century and the result has improved, compared to other injuries, problems, such as high septic complication rates and mortality rates, still exist, so standard management for colorectal trauma is still a controversial issue. For that reason, we designed this article to address current recommendations for management of colorectal injuries based on a review of literature. According to the reviewed data, although sufficient evidence exists for primary repair being the treatment of choice in most cases of nondestructive colon injuries, many surgeons are still concerned about anastomotic leakage or failure, and prefer to perform a diverting colostomy. Recently, some reports have shown that primary repair or resection and anastomosis, is better than a diverting colostomy even in cases of destructive colon injuries, but it has not fully established as the standard treatment. The same guideline as that for colonic injury is applied in cases of intraperitoneal rectal injuries, and, diversion, primary repair, and presacral drainage are regarded as the standards for the management of extraperitoneal rectal injuries. However, some reports state that primary repair without a diverting colostomy has benefit in the treatment of extraperitoneal rectal injury, and presacral drainage is still controversial. In conclusion, ideally an individual management strategy would be developed for each patient suffering from colorectal injury. To do this, an evidence-based treatment plan should be carefully developed.

Simplified Management of Low-Energy Projectile Extraperitoneal Rectal Injuries

Since minimally invasive approach for fecal diversion in low-velocity extraperitoneal rectal injuries (EPRI) has a lower morbidity than open, and since computed tomography (CT) scan is helpful in ruling out concomitant intraperitoneal injuries (IPI), we utilized both modalities to simplify management of such injuries. Retrospective review of stable patients with EPRI, treated with laparoscopic assisted diversion, after a CT scan, compared with patients with similar injuries that had a negative laparotomy and a colostomy. The laparoscopy group had a shorter length of stay (3 +/- 2 days versus 7 +/- 2 days), earlier return of bowel function (3 +/- 2 days versus 5 +/- 2 days) and fewer infectious complications. If the CT scan was negative for IPI, none were found on open exploration or laparoscopy. If IPI are ruled out with a preoperative CT scan, laparoscopy-assisted colostomy is safe and less morbid.

Clinical treatment of open pelvic fractures associated with anorectal injury

Objective To investigate the clinical treatment of open pelvic fractures associated with anorectal injury. Methods We retrospectively reviewed the medical data of 19 patients who had been treated at our department between October 1998 and October 2008 for open pelvic fractures associated with anorectal injury. By Tile classification, there were 1 type A, 5 type B and 13 type C. Three cases suffered from intraperitoneal rectal injury, 11 from extraperitoneal rectal injury and 5 from injury to the anal canal. Their treatment was carried out in 4 steps. First, emergency resuscitation to rescue life and control massive hemorrhage; second, sigmoid colon ostomy and debridement to handle anorectal injury; third, management of the pelvic fracture; fourth, later wounds management. Resnits No death occurred in this group. All the 19 patients were followed up for 12 to 48 (average, 18) months. The anorectal injury was cured in 18 cases and improved in 1 case. According to the Majeed evaluation, the outcome of pelvic fractures was excellent in 3 cases, good in 11, fair in 4, and poor in 1. The good to excellent rate was 73. 7%. The wounds healed at one or two stages after grafting and flap transfer in 18 eases. Conclusion C, oed outcome of open pelvic fractures associated with anorectal injury may result from timely emergency resuscitation, aggressive manage-ment of anorectal injury and proper management of pelvic fractures by orthopaedists in cooperation with spe-cialists from other disciplines. Key words: Pelvis; Fractures, open; Rectum; Anal canal

Current management of large bowel injuries and factors influencing outcome

Background Colonic and intra-peritoneal rectal injuries may be managed by primary repair and extra-peritoneal rectal injuries by diverting colostomy. This study was undertaken to document our experience with this approach and to identify factors which might impact on outcome. Patients and methods Prospective study of all patients treated for colon and rectal injuries in one surgical ward at King Edward VIII hospital, Durban, over a 7-year period (1998–2004). Demographic data, clinical presentation, findings at laparotomy and outcome were documented. Results Of 488 patients undergoing laparotomy, 177 (36%) had injuries to the colon and rectum with age 29.8 ± 10.9 years. Injury mechanisms were firearms (118) stabs (54) and blunt trauma (5). Delay before laparotomy was 10 ± 9.3 h. Complication and mortality rates were 36% and 17%, respectively. 68 patients (38%) required ICU management. Shock on admission and increased transfusion requirements were associated with a significantly increased mortality. Patients with delay ≤12 h before laparotomy had a higher mortality rate than those with delay >12 h. The mortality rate increased with the number of associated injuries and it was higher the higher the Injury Severity Score (ISS); it was similar for stabs, firearms and blunt trauma. Hospital stay was 9.5 ± 9.2 days. Conclusion We reaffirm that primary repair is appropriate for colonic and intra-peritoneal rectal injuries and that extra-peritoneal rectal injuries require diverting colostomy. Shock on admission, increased blood transfusion requirements, associated organ injury and severity of the injury were associated with high mortality.

Civilian Extraperitoneal Rectal Gunshot Wounds: Surgical Management Made Simpler

Rectal injuries are associated with significant morbidity and mortality. Controversy persists regarding routine presacral drainage, distal rectal washout (DRW), and primary repair of extraperitoneal rectal injuries. This retrospective review was performed to determine the outcome of rectal injuries in an urban trauma center with a high incidence of penetrating trauma where a non-aggressive surgical approach to these injuries is practiced. The records of all patients with a full-thickness penetrating rectal injury admitted to the Trauma Center at Groote Schuur Hospital over a 4-year period were reviewed. These were reviewed for demographics, injury mechanism and perioperative management, anatomical site of the rectal injury, associated intra-abdominal injuries and their management. Infectious complications and mortality were noted. Intraperitoneal rectal injuries were primarily repaired, with or without fecal diversion. Extraperitoneal rectal injuries were generally left untouched and a diverting colostomy was done. Presacral drainage and DRW were not routinely performed. Ninety-two patients with 118 rectal injuries [intraperitoneal (7), extraperitoneal (59), combined (26)] were identified. Only two extraperitoneal rectal injuries were repaired. None had presacral drainage. Eighty-six sigmoid loop colostomies were done. Two (2.2%) fistula, one rectocutaneous, and one rectovesical, were recorded. There were nine (9.9%) infectious complications: surgical site infection (4), buttock abscess (1), buttock necrosis (1), pubic ramus osteitis (1), septic arthritis (2). No perirectal sepsis occurred. Extraperitoneal rectal injuries due to low-velocity trauma can be safely managed by fecal diversion alone.

Is Fecal Diversion Necessary for Nondestructive Penetrating Extraperitoneal Rectal Injuries?

Current management of penetrating extraperitoneal rectal injury includes diversion of the fecal stream. The purpose of this study is to assess whether nondestructive penetrating extraperitoneal rectal injuries can be managed successfully without diversion of the fecal stream. This study was performed at an urban Level I trauma center during a 28-month period from February 2003 through June 2005. All patients who suffered nondestructive penetrating extraperitoneal rectal injuries were managed with a diagnosis and treatment protocol that excluded fecal stream diversion. Patients were placed in one of two management arms based upon clinical suspicion for intraperitoneal injury. In the first arm, patients with suspicion for rectal injury and a positive clinical examination for intraperitoneal injuries were delivered to the operating room for exploratory laparotomy. Proctoscopy was performed before exploratory laparotomy. Extraperitoneal rectal injuries were left to heal by secondary intention. Intraperitoneal rectal injuries were repaired primarily. Patients did not receive fecal diversion or perineal drainage. In the second management arm, patients with a negative clinical examination for intraperitoneal injury and wounding agent trajectory suspicious for rectal injury underwent diagnostic peritoneal lavage (DPL), cystography, and proctoscopy in the emergency room. Positive DPL or cystography warranted laparotomy as above. Patients with positive proctoscopy alone were admitted and placed on a clear liquid diet. Barium enema was performed 5 to 7 days postinjury for all rectal injuries with diets advanced accordingly.A matched historic control group of rectal injury patients who underwent fecal diversion was compared with the nondiversion protocol group. Patients from both groups were matched for penetrating abdominal trauma index (PATI), age and mechanism of injury. There were 14 consecutive patients diagnosed with penetrating rectal injury placed in the nondiversion management protocol. Of these, 9 (64%) patients in the nondiversion group required laparotomy. The average age in the diversion historical control group was 30.5 years and 29.3 years in the nondiversion group. The average PATI in the diversion group was 15.3 and 16.1 in the nondiversion protocol group. The average length of stay for the diversion and nondiversion groups was 9.8 days (range, 7-15) and 7.2 days (range, 4-10), respectively. There were no complications associated with rectal injuries in either group. Nondestructive penetrating rectal injuries can be managed successfully without fecal diversion. Randomized prospective study will be necessary to assess this management method.