Providing surgical care for rectal wounds

Kim I.Yu.¹, Panov V.V.¹, Musailov V.A.^{2, 3}, Sychev D.A.¹, Abdurakhmanov R.F.³

Introduction. Over the past decades, due to the constant conduct of local wars and armed conflicts, gunshot fragmentation and mine explosion wounds have become dominant in injury surgery. Modern combat gunshot injury is characterized by combined and multiple injuries of various anatomical areas, a high frequency of purulent-septic complications, persistent disability and high mortality. Despite the improvement of modern means of armor protection, there is no tendency to decrease the category of penetrating pelvic wounds with damage to the rectum, which can be attributed to extremely severe both in the course of the pathological process and difficult to diagnose, which requires further study of this pathology.

Objective: to study the frequency and localization of rectal wounds, features of diagnosis and treatment at the stage of providing qualified surgical care, options and sequence of surgical interventions, early complications.

Materials and methods: a prospective analysis of the provision of surgical care for rectal wounds to patients admitted to advanced medical organizations and to the surgical hospital of FGKU “1602 EKG” of the Ministry of Defense of the Russian Federation from the area of a Special military operation was carried out. At the same time, medical documentation was studied, including primary medical records, protocols of performed surgical interventions of previous stages of medical care. The analyzed group of wounded belongs to the same age group, with the same conditions of military service, life and nutrition, which increases the representativeness of the results obtained.

Results: The rectal injury Scale (AAST) was used in the work. The degree of injury was determined either based on the data from the protocols of surgical interventions of previous stages of medical care, or intraoperatively when performing programmatic relaparotomies. The vast majority of the wounded (86.4%) were admitted to the stage of providing qualified medical care in the first day from the moment of injury. The proportion of shrapnel wounds (88.2%) prevailed over bullet wounds (11.8%). In the absolute majority of cases, the localization of the inlet was located in the gluteal region (61.7%). The multiple nature of the injuries, combined with injuries to other organs and systems, was recorded in 87.6% with intraperitoneal injuries, in 85.5% with extraperitoneal localization. At the same time, damage to the small intestine (23.1%) and pelvic bones (19.0%) was most often noted in combination with injury to the intraperitoneal rectum, colon (15.2%), with extraperitoneal localization, respectively, the bladder (54.1%), pelvic bones (27.3%). The tactics of simultaneous surgical treatment were used everywhere in 48.3%, and multi–stage surgical treatment in 51.7%. In the surgical treatment of rectal wounds of both localizations, in 92.0% of cases, the formation of an unloading stoma was performed. In 8.0% of cases, the discharge stoma did not form, the operation ended with suturing of the rectal wound. In 0.8% of cases, the failure of the distal stump of the rectum was noted, in 3.4% — the development of intrathase phlegmon. There have been cases of late diagnosis of isolated rectal wounds of extraperitoneal localization, due to poor clinical data, short periods of stay at the stages of medical evacuation. In 1.7% of cases, the onset of death was noted against the background of progression of intrathase phlegmon, sepsis, and multiple organ failure.

Conclusion: rectal wounds, especially those of extraperitoneal localization, occupy not a leading, but an important place in the structure of combat surgical trauma. Timely detection of damage to the rectum, determination of optimal surgical tactics, allows you to avoid or reduce the risk of purulent septic complications. The main tactical tasks for rectal wounds should be considered: stopping passage through the rectum, washing the distal colon, draining the cellular spaces of the pelvis in case of extraperitoneal injuries.

1. Aliyev SA, Aliyev TG. Surgical treatment of gunshot wounds of the chest and abdomen. Bulletin of the National Medical and Surgical Center named after N.I. Pirogov. 2023; 18(3): 51-57. (In Russ.) doi: 10.25881/20728255-2023-18-3-51.

2. Denisov AV, Badalov AV, Kraynyukov PE. The structure and nature of modern combat surgical trauma. Military Medical Journal. 2021; 342(9): 12-20. (In Russ.) doi: 10.52424/00269050-2021-342-9-12.

3. Trishkin DV, Kryukov EV, Chuprina AP. et al. Methodological recommendations for the treatment of combat surgical trauma. St. Petersburg: Military Medical Academy named after S.M. Kirov, 2022. 373 р. (In Russ.)

4. Esipov AV, Sukhorukov AL, Musailov AV. The magnitude and structure of isolated limb wounds in modern local conflicts. 2023; 344(3): 33-39. (In Russ.) doi: 10.52424/00269050-2023-344-3-33.

5. Clemens MS, Peace KM, Yi F. Rectal Trauma: Evidence-Based Practices. Clin Colon Rectal Surg. 2018; 31(1): 17-23. doi: 10.1055/s-0037-1602182.

6. Kitaev AV, Stolyarzh AB, Hayrapetyan AT. The experience of treating gunshot wounds of the pelvis with damage to the rectum Coloproctology. 2016; 1(55): 94. (In Russ.)

7. Matieva EV, Totikov VA. Khestanov. The experience of surgical treatment of patients with gunshot wounds of the rectum. Topical issues of medical law, biomedical ethics and patient safety: Materials of the interregional scientific and practical conference. Vladikavkaz, April 20-21. 2017: 130-132. (In Russ.)

8. Totikova EV, Totikov VZ, Khestanov AK. Tactics of treatment of gunshot wounds of the rectum. Coloproctology. 2019; 3(69): 91. (In Russ.)

9. Alisov PG. Defects in the treatment of gunshot wounds of the abdomen. Clinical pathophysiology. 2021; 27(3): 3. (In Russ.)

10. Trishkin DV, Kryukov EV, Chuprina AP. et al. Methodological recommendations for the treatment of combat surgical trauma. St. Petersburg: Military Medical Academy named after S.M. Kirov, 2022. 373 р. (In Russ.)

11. Samokhvalov IM, Badalov VI, Kryukov EV, et al. Military field surgery: Textbook. — M.: GEOTAR-Media, 2023. (In Russ.) doi: 10.33029/9704-8037-3-MFS-2023-1-568.

12. Svetlichny EV, Muradyan KR, Gerasimenko OS, Kotikov MA, Gaida YI, Enin RV. The use of ultrasound imaging in the removal of foreign bodies in gunshot wounds. 2018; 24(4): 101-104. (In Russ.) doi: 10.26641/2307-0404.2018.4.

13. Faguy K. Imaging foreign bodies. Radiol Technol. 2014; 85(6): 655-678.

14. Jaruwattanachaikul S, Boonyasatid P, Kanlerd A. Management of Rectal Injury. The Thai Journal of Surgery. 2023; 44(2): 46-53.

15. Lavenson GS, Cohen A. Management of rectal injuries. Am J Surg. 1971; 122(02): 226-230.