Management of Colon and Rectal Injuries From Blunt and Penetrating Trauma: Evidence-Based Recommendations From the World Society of Emergency Surgery.

IMPORTANCE: Traumatic colon and rectal injuries generate wide practice variation across diagnosis, operative strategy, technical conduct, and perioperative care. Management has shifted from mandatory fecal diversion toward selective primary repair and physiology-guided reconstruction, but decision-making remains inconsistent. OBJECTIVE: To develop evidence-based recommendations for the diagnosis, operative strategy, technical conduct, and perioperative management of adult colon and rectal trauma. EVIDENCE REVIEW: An international World Society of Emergency Surgery panel prioritized 17 clinical questions in the format Population, Intervention, Comparator, Outcome across 3 domains (colon, rectum, and technical/perioperative considerations). For each question, designated authors performed structured literature reviews through early 2026; evidence was synthesized and recommendations were drafted with an assigned strength (strong or conditional) and certainty (high, moderate, low, or very low) using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach and then harmonized by consensus. Reporting followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) conventions. FINDINGS: Contrast-enhanced computed tomography (CT) anchors diagnosis but is a sensitive screening tool whose negative result does not exclude injury; specific signs (bowel wall discontinuity, extraluminal air, active mesenteric extravasation) warrant operation. For suspected rectal injury, CT is first-line, with adjunctive rigid or flexible proctoscopy raising combined sensitivity to approximately 97%; routine rectal contrast is not recommended. Primary repair or resection with anastomosis is preferred over routine diversion for most stable patients, including many traditionally deemed high risk; for low-grade injuries, primary repair alone is preferred over resection with anastomosis. Selective diversion is reserved for persistent vasopressor dependence after damage-control laparotomy, inability to achieve fascial closure at the first reoperation, or compounded physiologic derangement. Proximal diversion is the default for extraperitoneal rectal injury, and routine presacral drainage and distal rectal washout are not recommended. Stapled and hand-sewn anastomoses are equivalent; antibiotic prophylaxis should not exceed 24 hours; and early enteral nutrition is advised in selected patients. CONCLUSIONS AND RELEVANCE: These recommendations support a selective, physiology-driven approach to colorectal trauma, in which patient physiology, contamination, perfusion, and the ability to achieve fascial closure-rather than the injured organ or any single risk factor-guide management. Much of the supporting evidence remains observational, and prospective study is warranted.