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Initial management and outcome of modern battlefield anal trauma
Sean C Glasgow1, Thomas A Heafner, J Devin B Watson
11Department of Surgery, Saint Louis University, St. Louis, Missouri 2US Air Force Center for Sustainment of Trauma & Readiness Skills, St. Louis, Missouri 3Department of Surgery, San Antonio Military Medical Center, Ft. Sam Houston, Texas 4US Army Institute of Surgical Research, Ft. Sam Houston, Texas 5Audie L. Murphy Veterans Hospital, San Antonio, Texas.
Background:
Despite the potential for morbidity and permanent lifestyle alteration, few reports exist examining traumatic injury to the anal canal, particularly among modern-day combatants.
Objective:
The aim of this study was to document the incidence, initial surgical management, and long-term outcomes of wartime anal trauma.
Design:
This study is a retrospective review.
Data Sources:
Data were compiled from multiple electronic medical record systems, including the Department of Defense Trauma Registry, the Patient Administration Systems and Biostatistics Activity, and the Armed Forces Health Longitudinal Tracking Application.
Settings:
Combatants were treated at military treatment facilities with surgical capability during the wars in Iraq and Afghanistan, 2003 through early 2011.
Patients:
All US and coalition combatants sustaining trauma to the anal canal or sphincter musculature were included.
Main Outcome Measures:
The quantification of incidence, the evaluation of initial treatment approach, and the determination of clinical and surgical factors correlating with restoration or preservation of GI tract continuity were the primary outcomes measured.
Results:
Anal trauma occurred in 46 combatants, predominantly from blast injury (76.1%). Most (36, 78.2%) underwent fecal diversion. Concurrent severe systemic or intra-abdominal injuries correlated with colostomy creation. Acute anoplasty was attempted in 11 patients (23.7%) but did not influence eventual colostomy reversal. Among 33 US personnel, the permanent colostomy rate was 30.3%. Concurrent injury to the abdomen strongly predicted long-term colostomy (p = 0.009), along with hypogastric arterial ligation (p = 0.05) and pelvic fracture (p = 0.06).
Limitations:
This study was limited by the potential underdiagnosis of anal injury and the restricted follow-up of non-US personnel.
Conclusions:
Other injuries besides anal trauma typically have guided the decision for fecal diversion, and acute anal repair has rarely been indicated. The majority of patients with anal trauma regained normal GI continuity, although certain pelvic injuries increased the likelihood of permanent colostomy.