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Management of pediatric rectal trauma: A four-year ACS-TQIP database review
Omar Obaid1, Tania Torres-Ruiz2, Cory Criss1
1Department of Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
Insights
Pediatric rectal trauma is often managed non-operatively. When surgery is needed, primary repair is favored over diversion, with surgical technique not impacting outcomes.
Area of Science:
- Pediatric Surgery
- Trauma Surgery
- Colorectal Surgery
Background:
- Adult rectal trauma management has shifted towards primary repair, but pediatric data is limited.
- This study addresses the management and outcomes of pediatric rectal trauma nationwide.
Purpose of the Study:
- To assess the nationwide management strategies for pediatric rectal trauma.
- To evaluate the outcomes associated with different surgical techniques in pediatric rectal trauma.
- To identify predictors of management strategies and adverse outcomes.
Main Methods:
- Retrospective review of the American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) database (2017-2020).
- Inclusion of pediatric patients with rectal injuries (rectal-AIS≥2).
- Analysis of operative management (trans-anal repair, transabdominal repair, diverting colostomy, distal rectal washout, presacral drainage, resection) and diagnostic endoscopy, along with outcomes (infectious complications, return to OR, ICU admission, mortality, length-of-stay).
Main Results:
- 641 children were included; 57% managed non-operatively, 43% surgically.
- Primary repair was more common than fecal diversion (diverting colostomy, distal rectal washout, presacral drainage).
- Higher rectal AIS predicted diverting colostomy; age 6-12 and higher rectal AIS were associated with adverse outcomes.
Conclusions:
- This is the largest cohort study on pediatric rectal trauma, showing a trend towards selective non-operative management.
- Primary repair is the predominant surgical approach when intervention is necessary.
- Surgical technique was not independently associated with patient outcomes after adjusting for confounders.
Introduction:
Adult rectal trauma management has shifted away from fecal diversion, distal rectal washout (DRW) and presacral drainage (PSD) towards primary repair alone, but there is scarce data on children. This study aims to assess the nationwide management of pediatric rectal trauma, its outcomes, and the impacts of the surgical techniques described.
Methods:
Retrospective review of the ACS-TQIP database 2017-2020. Children with rectal injuries (rectal-AIS≥2) were included. Operative management included trans-anal repair (TAnR), transabdominal repair (TAbR), diverting colostomy (DC), DRW, PSD, and resection (LAR); endoscopy (Endo) was assessed as a predominantly diagnostic procedure. Outcomes included infectious complications, unplanned return to OR, unplanned ICU admission, mortality, and length-of-stay (LOS). Multivariate binary logistic regression analyses were performed to identify independent predictors of DC, and the effect of surgical techniques on outcomes.
Results:
641 children were included. Mean age was 11 ± 5 years, 62% were male, 65% were blunt injuries, and median ISS was 8 (IQR 4-16). Concomitant injuries included pelvic fracture (21%), small bowel (15%), and colon (15%). Overall, 43% of patients underwent operative intervention, while 31% underwent diagnostic endoscopy. Outcomes were: 2% infectious complications; 3% unplanned return to OR; 1% unplanned ICU admission; 3% mortality; 4 [2-8] days LOS. Higher rectal AIS was the only predictor of DC. Age 6-12 years (lower odds) and higher rectal AIS (higher odds) were independently associated with the composite adverse outcome.
Conclusion:
This is the largest cohort study of pediatric rectal trauma to date. The majority (57%) were managed non-operatively, consistent with a contemporary practice pattern of selective operative management. When surgery was pursued, primary repair was much more common than fecal diversion, DRW or PSD. The surgical technique was not independently associated with outcomes after adjusting for confounders.