An international World Society of Emergency Surgery (WSES) panel developed GRADE-based recommendations across 17 PICO questions covering diagnosis, operative strategy, technical conduct, and perioperative management of adult colon and rectal trauma from blunt and penetrating mechanisms.
Primary repair or resection with anastomosis is preferred over routine diversion for most stable patients; selective diversion is reserved for persistent vasopressor dependence, inability to achieve fascial closure, or compounded physiologic derangement. CT combined with proctoscopy raises sensitivity for rectal injury to ~97%; stapled and hand-sewn anastomoses are equivalent; antibiotic prophylaxis should not exceed 24 hours; routine presacral drainage and distal rectal washout are not recommended.
Most supporting evidence is observational; prospective trials are lacking. The recommendations are consensus-harmonized, so individual GRADE certainty ratings range from low to very low for many questions.
Use a physiology-driven, selective approach to colorectal trauma: prioritize primary repair or anastomosis over routine diversion, limit antibiotics to 24 hours, and add proctoscopy to CT when rectal injury is suspected. Reserve fecal diversion for patients with persistent vasopressor dependence, failed fascial closure, or severe physiologic derangement—not simply based on the organ injured.
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