Colon injuries: new perspectives

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

Background

Far reaching sub-specialization tends to become obligatory for surgeons in most Western countries. It is suggested that exposure of surgeons to emergency laparotomy after trauma is ever declining. Therefore, it can be questioned whether a generalist (i.e., general surgery) with additional differentiation such as the trauma surgeon, will still be needed and can remain sufficiently qualified. This study aimed to evaluate volume trends and outcomes of emergency laparotomies in trauma.

Methods

A retrospective cohort study was performed in the University Medical Center Utrecht between January 2008 and January 2018, in which all patients who underwent an emergency laparotomy for trauma were included. Collected data were demographics, trauma-related characteristics, and number of (planned and unplanned) laparotomies with their indications. Primary outcome was in-hospital mortality; secondary outcomes were complications, length of ICU, and overall hospital stay.

Results

A total of 268 index emergency laparotomies were evaluated. Total number of patients who presented with an abdominal AIS > 2 remained constant over the past 10 years, as did the percentage of patients that required an emergency laparotomy. Most were polytrauma patients with a mean ISS = 27.5 (SD ± 14.9). The most frequent indication for laparotomy was hemodynamic instability or ongoing blood loss (44%).Unplanned relaparotomies occurred in 21% of the patients, mostly due to relapse of bleeding. Other complications were anastomotic leakage (8.6%), intestinal leakage after bowel contusion (4%). In addition, an incisional hernia was found in 6.3%. Mortality rate was 16.7%, mostly due to neurologic origin (42%). Average length of stay was 16 days with an ICU stay of 5 days.

Conclusion

This study shows a persistent number of patients requiring emergency laparotomy after (blunt) abdominal trauma over 10 years in a European trauma center. When performed by a dedicated trauma team, this results in acceptable mortality and complication rates in this severely injured population.

Management of Destructive Colon Injuries after Damage Control Surgery

After the World War II, fecal diversion became the standard of care for colon injuries, although medical, logistic, and technical advancements have challenged this approach. Damage control surgery serves to temporize immediately life-threatening conditions, and definitive management of destructive colon injuries is delayed until after appropriate resuscitation. The bowel can be left in discontinuity for up to 3 days before edema ensues, but the optimal repair window remains within 12 to 48 hours. Delayed anastomosis performed at the take-back operation or stoma formation has been reported with variable results. Studies have revealed good outcomes in those undergoing anastomosis after damage control surgery; however, they point to a subgroup of trauma patients considered to be "high risk" that may benefit from fecal diversion. Risk factors influencing morbidity and mortality rates include hypotension, massive transfusion, the degree of intra-abdominal contamination, associated organ injuries, shock, left-sided colon injury, and multiple comorbid conditions. Patients who are not suitable for anastomosis by 36 hours after damage control may be best managed with a diverting stoma. Failures are more likely related to ongoing instability, and the management strategy of colorectal injury should be based mainly on the patient's overall condition.

Primary repair for pediatric colonic injury: Are there differences among adult and pediatric trauma centers?

BACKGROUND

Management of colonic injuries (colostomy [CO] versus primary anastomosis [PA]) among pediatric patients remains controversial. The aim of this study was to assess outcomes in pediatric trauma patient with colonic injury undergoing operative intervention.

METHODS

The National Trauma Data Bank (2011-2012) was queried including patients with isolated colonic injury undergoing exploratory laparotomy with PA or CO with age ≤18 y. Missing value analysis was performed. Patients were stratified into two groups: PA and CO. Outcome measures were mortality, in-hospital complications, and hospital length of stay. Multivariate regression analysis was performed.

RESULTS

A total of 1151 patients included. Mean ± standard deviation age was 11.61 ± 2.8 y, and median [IQR] Injury Severity Score was 12 [8-16]; 39% (n = 449) of the patients had CO, and 35.6% (n = 410) were managed in pediatric trauma centers (PC). Patients with CO had a higher Injury Severity Score (P < 0.001), a trend toward lower blood pressure (P = 0.40), and an older age (P < 0.001). There was no difference in mortality between the PA and CO groups. However, patients who underwent PA had a shorter length of stay (P < 0.001) and lower in-hospital complications (P < 0.001). A subanalysis shows that, after controlling for all confounding factors, patients managed in PC were 1.2 times (1.2 [1.1-2.1], P = 0.04) more likely to receive a CO than those patients managed in adult trauma centers (AC). Moreover, there was no difference in mortality between the AC and the PC (P = 0.79).

CONCLUSIONS

Our data demonstrate no difference in mortality in pediatric trauma patients with colonic injury who undergo primary repair or CO. However, adult trauma centers had lower rates of CO performed as compared to a similar cohort of patients managed in pediatric trauma centers. Further assessment of the reasons underlying such differences will help improve patient outcomes.

The management of penetrating rectal and anal trauma: A systematic review

INTRODUCTION

Traumatic injuries to the lower gastrointestinal tract (rectum and anus) have been largely reported in the military setting with sparse publications from the civilian setting. Additionally, there remains a lack of international consensus regarding definitive treatment pathways. This systematic review aimed to assess the current literature and propose a standardised treatment algorithm to aid management in the civilian setting.

METHODS

A systematic review of available literature from 1999 to 2016 that was performed. Primary endpoints were the assessment and surgical management of reported rectal and anal trauma.

RESULTS

Seven studies were included in this review, reporting on 1255 patients. 96.3% had rectal trauma and 3.7% had anal trauma. Gunshot wounds are the most common mechanism of injury (46.9%). The overwhelming majority of injuries occurred in males (>85%) and were associated with other pelvic injuries. Surgical management has substantially evolved over the last five decades, with no clear consensus on best management strategies.

CONCLUSION

There remains significant international discrepancy regarding the management of penetrating trauma to the rectum. Key management principals include the varying use of the direct primary closure, faecal diversion, pre-sacral drainage and/or distal rectal washout (rarely used). To date, there is sparse evidence regarding the management of penetrating anal trauma.

The management of colonic trauma in the damage control era

INTRODUCTION The purpose of this study was to audit our current management of colonic trauma, and to review our experience of colonic trauma in patients who underwent initial damage control (DC) surgery. METHODS All patients treated for colonic trauma between January 2012 and December 2014 by the Pietermaritzburg Metropolitan Trauma Service were included in the study. Data reviewed included mechanism of injury, method of management (primary repair [PR], primary diversion [PD] or DC) and outcome (complications and mortality rate). Results A total of 128 patients sustained a colonic injury during the study period. Ninety-seven per cent of the injuries were due to penetrating trauma. Of these cases, 56% comprised stab wounds (SWs) and 44% were gunshot wounds (GSWs). Management was by PR in 99, PD in 20 and DC surgery in 9 cases. Among the 69 SW victims, 57 underwent PR, 9 had PD and 3 required a DC procedure. Of the 55 GSW cases, 40 were managed with PR, 9 with PD and 6 with DC surgery. In the PR group, there were 16 colonic complications (5 cases of breakdown and 11 of wound sepsis). Overall, nine patients (7%) died. CONCLUSIONS PR of colonic trauma is safe and should be used for the majority of such injuries. Persistent acidosis, however, should be considered a contraindication. In unstable patients with complex injuries, the optimal approach is to perform DC surgery. In this situation, formal diversion is contraindicated, and the injury should be controlled and dropped back into the abdomen at the primary operation. At the repeat operation, if the physiological insult has been reversed, then formal repair of the colonic injury is acceptable.

Performance of primary repair on colon injuries sustained from low-versus high-energy projectiles

Among various reasons, colon injuries may be caused by low- or high-energy firearm bullets, with the latter producing a temporary cavitation phenomenon. The available treatment options include primary repair and two-stage management, but recent studies have shown that primary repair can be widely used with a high success rate. This paper investigates the differences in performance of primary repair on these two types of colon injuries. Two groups of patients who sustained colon injuries due to single gunshot wounds, were retrospectively categorized based on the type of bullet. Primary colon repair was performed in all patients selected based on the inclusion and exclusion criteria (Stone and Fabian's criteria). An almost absolute homogeneity was attained among the groups in terms of age, latent time before surgery, and four trauma indexes. Only one patient from the low-energy firearm projectile group (4%) developed a postsurgical complication versus nine patients (25.8%) from the high-energy group, showing statistically significant difference (p = 0.03). These nine patients experienced the following postsurgical complications: pneumonia, abscess, fistula, suture leakage, and one multiorgan failure with sepsis. Previous studies concluded that one-stage primary repair is the best treatment option for colon injuries. However, terminal ballistics testing determined the projectile's path through the body and revealed that low-energy projectiles caused considerably lesser damage than their high-energy counterparts. Primary colon repair must be performed definitely for low-energy short firearm injuries but very carefully for high-energy injuries. Given these findings, we suggest that the treatment option should be determined based not only on the bullet type alone but also on other clinical findings.

Surgical outcomes of a civil war in a neighbouring country

OBJECTIVES

The civil war in Syria began on 15 March 2011, and many of the injured were treated in the neighbouring country of Turkey. This study reports the surgical outcomes of this war, in a tertiary centre in Turkey.

METHODS

159 patients with civilian war injuries in Syria who were admitted to the General Surgery Department in the Research and Training Hospital of the Medical School of Mustafa Kemal University, Hatay, Turkey, between 2011 and 2012 were analysed regarding the age, sex, injury type, history of previous surgery for the injury, types of abdominal injuries (solid or luminal organ), the status of isolated abdominal injuries or multiple injuries, mortality, length of hospital stay and injury severity scoring.

RESULTS

The median age of the patients was 30.05 (18-66 years) years. Most of the injuries were gunshot wounds (99 of 116 patients, 85.3%). Primary and previously operated patients were transferred to our clinic in a median time of 6.28±4.44 h and 58.11±44.08 h, respectively. Most of the patients had intestinal injuries; although a limited number of patients with colorectal injuries were treated with primary repair, stoma was the major surgical option due to the gross peritoneal contamination secondary to prolonged transport time. Two women and 21 men died. The major cause of death was multiorgan failure secondary to sepsis (18 patients).

CONCLUSIONS

In the case of civil war in the bordering countries, it is recommended that precautions are taken, such as transformation of nearby civilian hospitals into military ones and employment of experienced trauma surgeons in these hospitals to provide effective medical care. Damage control procedures can avoid fatalities especially before the lethal triad of physiological demise occurs. Rapid transport of the wounded to the nearest medical centre is the key point in countries neighbouring a civil war.

The safety of primary repair or anastomosis in high-risk trauma patients

PURPOSE

There is currently not enough data regarding the management of bowel injury and the results of primary repair or resection and anastomosis in high-risk trauma patients. We aimed to determine whether there were any short-term (30 days) postoperative complications relevant to the primary reconstruction of such bowel injuries.

METHOD

In a retrospective study, all trauma patients who underwent a definite laparotomy after penetrating or blunt injury in our institution during the last decade were identified. The study group consisted of those who underwent primary repair or resection and anastomosis of the small or large bowel or both. Patients who died within 72 h of admission, who had only serosal injuries or who received resection and diversion, were excluded.

RESULTS

Seventeen of the trauma patients who were treated at our institution during the study period had bowel injuries. Thirteen fit our criteria. All of them had at least one risk factor, and 61.5% of them had at least three risk factors for anastomotic or suture line disruption. Overall, 35 repairs and anastomoses took place. Only one patient developed clinical anastomotic leakage, resulting in a fistula, which did not require re-operation.

CONCLUSION

Our study contributes to the controversial issue of post-traumatic bowel reconstruction in high-risk trauma patients, and suggests that primary reconstruction is feasible and can provide a good outcome.

Isolated abdominal trauma: diagnosis and clinical management considerations

PURPOSE OF REVIEW

The scope of the present study is to review the topics of initial assessment, diagnosis and clinical management of an isolated abdominal trauma.

RECENT FINDINGS

Progress in the management of trauma patients increasing survival includes a multidisciplinary approach involving multiple specialties at presentation. If immediate surgical intervention is needed, 'damage control' is the best option; if not, it has been proven that conservative management is superior to operative, in terms of survival for the majority of intraabdominal injury. 'Open abdomen' should be performed in major abdominal traumas when indicated. Early enteral feeding is beneficial, even in the presence of 'open abdomen'.

SUMMARY

Abdominal trauma is a complex injury; the multidisciplinary approach has made nonoperative management feasible and effective. When surgical intervention is needed, it should be performed in an orderly fashion, within the context of the overall management.

Rectal impalement injury through the pelvis, abdomen and thorax

Impalement rectal injuries with intraperitoneal organ injuries are rare. It is even rarer for such injuries to result in pelvic, abdominal and thoracic internal injuries. We present the case of a 39-year-old man who was admitted after an assault where a broken broomstick was inserted forcibly into his rectum. Surgery revealed penetration through the rectum, dome of the bladder, mesentery, liver and right lung. The patient survived following management by a multispecialty surgical team. Our literature review identified four similar cases with one fatality only. Prognosis seems to be good in these types of injuries provided there is an early presentation, the penetrating object is left in situ before the operation and, most importantly, an organised team approach to deal with the various injuries.

Safety of performing a delayed anastomosis during damage control laparotomy in patients with destructive colon injuries

BACKGROUND

Recent studies report the safety and feasibility of performing delayed anastomosis (DA) in patients undergoing damage control laparotomy (DCL) for destructive colon injuries (DCIs). Despite accumulating experience in both civilian and military trauma, questions regarding how to best identify high-risk patients and minimize the number of anastomosis-associated complications remain. Our current practice is to perform a definitive closure of the colon during DCL, unless there is persistent acidosis, bowel wall edema, or evidence of intra-abdominal abscess. In this study, we evaluated the safety of this approach by comparing outcomes of patients with DCI who underwent definitive closure of the colon during DCL versus patients managed with colostomy with or without DCL.

METHODS

We performed a retrospective chart review of patients with penetrating DCI during 2003 to 2009. Severity of injury, surgical management, and clinical outcome were assessed.

RESULTS

Sixty patients with severe gunshot wounds and three patients with stab wounds were included in the analysis. DCL was required in 30 patients, all with gunshot wounds. Three patients died within the first 48 hours, three underwent colostomy, and 24 were managed with DA. Thirty-three patients were managed with standard laparotomy: 26 patients with primary anastomosis and 7 with colostomy. Overall mortality rate was 9.5%. Three late deaths occurred in the DCL group, and only one death was associated with an anastomotic leak.

CONCLUSIONS

Performing a DA in DCI during DCL is a reliable and feasible approach as long as severe acidosis, bowel wall edema, and/or persistent intra-abdominal infections are not present.

Management of colorectal trauma

Although the treatment strategy for colorectal trauma has advanced during the last part of the twentieth century and the result has improved, compared to other injuries, problems, such as high septic complication rates and mortality rates, still exist, so standard management for colorectal trauma is still a controversial issue. For that reason, we designed this article to address current recommendations for management of colorectal injuries based on a review of literature. According to the reviewed data, although sufficient evidence exists for primary repair being the treatment of choice in most cases of nondestructive colon injuries, many surgeons are still concerned about anastomotic leakage or failure, and prefer to perform a diverting colostomy. Recently, some reports have shown that primary repair or resection and anastomosis, is better than a diverting colostomy even in cases of destructive colon injuries, but it has not fully established as the standard treatment. The same guideline as that for colonic injury is applied in cases of intraperitoneal rectal injuries, and, diversion, primary repair, and presacral drainage are regarded as the standards for the management of extraperitoneal rectal injuries. However, some reports state that primary repair without a diverting colostomy has benefit in the treatment of extraperitoneal rectal injury, and presacral drainage is still controversial. In conclusion, ideally an individual management strategy would be developed for each patient suffering from colorectal injury. To do this, an evidence-based treatment plan should be carefully developed.

Surgical intensive care unit--the trauma surgery perspective

PURPOSE

This review addresses and summarizes the key issues and unique specific intensive care treatment of adult patients from the trauma surgery perspective.

MATERIALS AND METHODS

The cornerstones of successful surgical intensive care management are fluid resuscitation, transfusion protocol and extracorporeal organ replacement therapies. The injury-type specific complications and unique pathophysiologic regulatory mechanisms of the traumatized patients influencing the critical care treatment are discussed.

CONCLUSIONS

Furthermore, the fundamental knowledge of the injury severity, understanding of the trauma mechanism, surgical treatment strategies and specific techniques of surgical intensive care are pointed out as essentials for a successful intensive care therapy.

Primary repair of colon injuries: clinical study of nonselective approach

BACKGROUND

This study was designed to determine the role of primary repair and to investigate the possibility of expanding indications for primary repair of colon injuries using nonselective approach.

METHODS

Two groups of patients were analyzed. Retrospective (RS) group included 30 patients managed by primary repair or two stage surgical procedure according to criteria published by Stone (S/F) and Flint (Fl). In this group 18 patients were managed by primary repair. Prospective (PR) group included 33 patients with primary repair as a first choice procedure. In this group, primary repair was performed in 30 cases.

RESULTS

Groups were comparable regarding age, sex, and indexes of trauma severity. Time between injury and surgery was shorter in PR group, (1.3 vs. 3.1 hours). Stab wounds were more frequent in PR group (9:2), and iatrogenic lesions in RS group (6:2). Associated injuries were similar, as well as segmental distribution of colon injuries. S/F criteria and Flint grading were similar.In RS group 15 primary repairs were successful, while in two cases relaparotomy and colostomy was performed due to anastomotic leakage. One patient died. In PR group, 25 primary repairs were successful, with 2 immediate and 3 postoperative (7-10 days) deaths, with no evidence of anastomotic leakage.

CONCLUSIONS

Results of this study justify more liberal use of primary repair in early management of colon injuries.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN94682396.

Deferred primary anastomosis versus diversion in patients with severe secondary peritonitis managed with staged laparotomies

BACKGROUND

There is inconclusive data on whether critically ill individuals with severe secondary peritonitis requiring multiple staged laparotomies may became eligible candidates for deferred primary anastomoses (DPA). We sought to compare a protocol for DPA against a protocol for diversion in severely ill critical patients with intra-abdominal sepsis.

METHODS

A retrospective cohort study was performed examining 112 patients admitted through an ICU between 2002 and 2006, with diagnosis of secondary peritonitis and managed with staged laparotomies whom required small- or large-bowel segment resections. Patients were categorized and compared according to the surgical treatment necessitated to resolve the secondary peritonitis (DPA versus diversion). Outcome measures were days on mechanical ventilation, days required in ICU, days required in hospital, incidence of fistulas/leakages, acute respiratory distress syndrome (ARDS), and mortality.

RESULTS

There were 34 patients subjected to DPA and 78 to diversion. Fistulas/leakages developed in three patients (8.8%) with DPA and four patients (5.1%) with diversion (p = 0.359). ARDS was present in 6 patients (17.6%) with DPA and 24 patients (30.8%) with diversion (p = 0.149). There were 30 patients (88.2%) with DPA and 65 patients (83.3%) with diversion discharged alive (p = 0.51). There were not statistical significant differences between groups among survivors regarding hospital length of stay, ICU length of stay, and days on mechanical ventilation.

CONCLUSIONS

We did not find significant differences in morbidity or mortality when we compared DPA versus diversion surgical treatment. It is feasible to perform a primary anastomosis in critically ill patients with severe secondary peritonitis managed with staged laparotomies.

Independent Predictors of Treatment Modality for Penetrating Colon Injury

BACKGROUND AND AIMS

We aimed to evaluate the independent factors of the treatment of penetrating colon injuries in a teaching and research hospital in light of some of the most commonly cited considerations affecting the decision as to whether to perform primary repair or divert.

METHODS

Hospital records of patients between January 2004 and January 2007 were reviewed retrospectively. Fifty-seven patients were included and divided into two groups. Group A consisted of patients (n = 43) who had primary repair or resection and anastomosis, and Group B consisted of patients (n = 14) who had diverting colostomy. The degree of fecal contamination was assessed by reviewing the detailed operative dictation. The type of colon injury, as determined from the colon injury scale (CIS) of the American Association for the Surgery of Trauma (AAST), and the penetrating abdominal trauma index (PATI) were recorded.

RESULTS

Age, sex, presence of shock on admission, location of the injury, and colon-related or non-colonrelated complications between the two groups were not significant. Stab or gunshot injury, operation time, degree of fecal contamination (grade 1/2/3), transfusion, PATI score, hospital stay, and associated organ injury were significantly different in the two groups (p < 0.05).

CONCLUSION

Despite the fact that CIS, fecal contamination, transfusion, PATI and delayed operation affect the decision about the procedure, primary repair can be performed safely on patients with penetrating colon injuries.

Massive colonic haematoma following blunt trauma sustained playing rugby

A case is presented of a 24-year-old man who sustained a forceful blow to the right side of the abdomen during a tackle while playing rugby union. The patient was thought to be "winded" and could not play on. He sought medical attention several hours later at the local hospital where initial evaluation revealed mild right iliac fossa tenderness with no signs of peritonism and clinical parameters showed haemodynamic stability. Subsequent ultrasound and CT evaluation revealed a large haematoma involving the caecum and ascending colon. Emergency right haemicolectomy with primary anastomosis was performed to remove the large haematoma within the intact colonic wall. He was observed in the high dependency unit and was discharged after 7 days following an uneventful postoperative course. He continues to make significant progress some 3 months later and a full return to contact sport is being proposed within 9-12 months.

[Current situation of colorectal trauma]

Mortality from colorectal trauma decreased from the end of the 19th Century, when death was the rule, to the 21st Century, when mortality is 5%. The greatest advances were produced during wars, mainly due to improved transport conditions, antisepsis, advances in operating and anesthetic techniques, the management of fluids, blood and blood products, the use of antibiotics, exteriorization of wounds, and the use of colostomy. Injuries to the anus, rectum and colon are infrequent. Their prevalence is difficult to establish because they can be caused by several factors. In Spain, the most frequent causes are traffic accidents and iatrogenic lesions, while in America the most common causes are stab or gunshot wounds. Although the etiology of these injuries is diverse, two major groups of colorectal trauma can be established: accidental injuries and iatrogenic trauma. Clinical symptoms vary, ranging from abdominal, pelvic, perianal or anal pain, sometimes associated with rectorrhagia, to peritonismus or shock. Diagnosis is based on physical and rectal examination and laboratory, radiological, and endoscopic investigations. Laparoscopy can also be used on occasions. Treatment should be individualized, depending on the patient's history, current status, the time elapsed since injury, the status of the injured intestine, the degree of fecal contamination, associated lesions, and the surgeon's experience.