Risk factors for colostomy in military colorectal trauma: A review of 867 patients

Analysis of outcomes of penetrating colonic injuries managed with or without fecal diversion

Traumatic colorectal injuries can be managed by either fecal diversion or primary repair / resection and anastomosis. We aimed to study differences in outcomes in adult patients managed with or without fecal diversion at time of initial operation. The National Trauma Databank (NTDB) was used to identify adult patients (ages 18-64 years) with penetrating colonic injuries for the years 2013-2015. We included patients with Injury Severity Score (ISS) of 9-24 excluding patients with concomitant extra-abdominal Abbreviated Injury Scale (AIS) score of 3 or more. Subjects arriving without signs of life, expiring in ER or with missing data were excluded. Data was collected for age, gender, vital signs on presentation, discharge disposition and length of stay (LOS). Patients were divided into two groups based on whether or not fecal diversion was performed within 1 day of presentation. Primary outcome assessed was in-hospital mortality and unplanned return to OR. Secondary outcomes were acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), deep vein thrombosis (DVT), pulmonary embolism (PE), pneumonia, organ surgical site infection (SSI), deep SSI, severe sepsis and unplanned intubation. Statistical analysis was conducted using SPSS for windows. P-value < 0.05 was considered statistically significant. Of 2,598,467 patients, 5344 (0.21%) sustained a penetrating colonic injury. 2339 (43.8%) patients met criteria for age, ISS, AIS, signs of life and ED outcome. 173 patients underwent fecal diversion within 24 h of presentation (Group 1) while 708 did not (Group 2). Patients with missing data were excluded leaving 162 patients in Group 1 and 657 patients in Group 2. Groups 1 and 2 were noted to be similar in terms of ISS (median of 10 in both), age (median of 31 vs 29 years), percentage of male patients (85.2% vs 87.8%; p = 0.44), mean systolic blood pressure (127 mmHg vs 126 mmHg; p = 0.54), mean pulse rate (95.4 vs 94.5; p = 0.60) and mean respiratory rate (20.4 vs 20.1; p = 0.56) respectively. Median LOS was 10 days in both groups. No statistically significant differences were found between groups 1 and 2 in the primary outcomes of in-hospital mortality (2.4% vs 3.5%; OR: 1.43; 95% confidence interval (CI): 0.49-4.20) or unplanned return to OR (4.3% vs 7.8%; OR: 1.86; 95% CI: 0.83-4.19). No statistically significant differences were noted between groups 1 and 2 in the secondary outcomes of AKI (3.7% vs 3.8%; OR: 1.03; 95% CI 0.41-2.55), ARDS (1.2% VS 1.7%; OR: 1.36; 95% CI 0.30-6.21), DVT (1.9% vs 4.0%; OR: 2.18; 95% CI 0.65-7.31), PE (1.9% vs 2.0%; OR: 1.07; 95% CI 0.30-3.80), pneumonia (4.9% vs 5.3%; OR: 1.08; 95% CI 0.49-2.38), organ SSI (3.7% vs 7.0%; OR: 1.96; 95% CI: 0.82-4.67), deep SSI (3.7% vs 4.4%; OR: 1.20, 95% CI 0.49-2.94), severe sepsis (3.7% vs 3.3%; OR: 0.90; 95% CI: 0.36-2.26) or unplanned intubation (1.9% vs 1.7%; OR: 0.90; 95% CI 0.25-3.27). Adult patients with penetrating colonic injuries with ISS 9-24 in the absence of serious extra-abdominal injury who undergo surgery within 24 h of presentation do not seem to derive a statistically significant benefit from fecal diversion in terms of post-operative complications and mortality. In more severely injured patients fecal diversion may continue to provide a benefit.

Gunshot injury to the colon by expanding bullets in combat patients wounded in hybrid period of the Russian-Ukrainian war during 2014-2020

BACKGROUND

A gunshot wound to the colon is a frequent injury in armed conflicts. An example of a high-energy modern weapon is hollow-point bullets, which is associated with increased tissue damage and lethal outcome. The aim of this study was to evaluate gunshot injuries to the colon in combat patients and to assess the difference in clinical features of patients with colon injuries by hollow-point versus shape-stable bullets.

PATIENTS AND METHODS

Analyses of clinical data were performed on 374 male soldiers from the Armed Forces of Ukraine with gunshot abdominal wounds with injury to the colon in East Ukraine between 2014 and 2020. Out of 374 injured, 112 (29.9%) patients were diagnosed with penetrating gunshot bullet wounds: 69/112 (61.6%) were injured by shape-stable bullets, and the hollow-point bullets injured 43/112 (38.4%) patients.

RESULTS

More severe hemorrhagic shock stages were in patients injured by hollow-point bullets: shock stages III-IV was in 25 (58.1%) patients injured by the hollow-point bullets vs. 17 (24.6%) patients injured by shape-stable bullets (p = 0.0004). Left colon parts were more frequently injured as compared to the right colon side or transverse colon: 21 (48.8%) patients were injured by the hollow-point bullets (p < 0.0001), and 41 (59.4%) patients were injured by the shape-stable bullets (p = 0.032). A significant difference was identified for the frequent injury to the middle colon within the entire cohort (p = 0.023). Patients injured by the hollow-point bullets demonstrated a higher frequency of 3-5 areas of colon gunshot defects, which was detected in 18 (41.8%) patients injured by hollow-point bullets and none with shape-stable bullets injury (p = 0.0001). Colon Injury Scale (CIS) IV was detected in 7 (16.3%) patients injured by the hollow-point bullets as compared to 2 (2.9%) patients injured by shape-stable bullets (p = 0.011). Colostomy was performed in 14 (69%) patients injured by shape-stable bullets and in 12 (27.9%) patients injured by hollow-point bullets (p > 0.05). 15 (35%) patients died after injury by the hollow-point bullet, whereas 9 (13%) patients after damage by the shape-stable bullets (p = 0.0089).

CONCLUSIONS

All patients should be suspected to have an injury by bullet with expanding properties in case of penetrating abdominal injury (absent of outlet wound) and careful revision of the abdomen must be performed to identify possible multiorgan injury as well as multiple gunshot defects of the intestine.

[Treatment of victims with mine-explosive injuries]

OBJECTIVE

To study the incidence and structure of combat gunshot surgical trauma received during the 2^nd Karabakh War and to analyze the results of treatment of these victims.

MATERIAL AND METHODS

We analyzed surgical treatment of 60 victims with combat gunshot surgical trauma received during the 2^nd Karabakh war. In 25 (41.7%) victims, injury occurred as a result of mine-explosive trauma. These victims were divided into 3 groups depending on mechanism of mine-explosive injury. The 1^st group included 7 (28%) patients who received mine-explosive injury due to indirect (propelling) effect of blast wave. The 2^nd group included 14 (56%) victims in whom mine-explosive injury was caused by non-contact (distant) impact of mine fragments. The 3^rd group consisted of 4 (16%) patients whose mine-explosive injuries were caused by direct impact of explosion factors on various anatomical areas. Patients were also ranked into 3 groups depending on the nature and severity of mine-explosive injury: wounded with isolated injuries (n=16, 64%), wounded with concomitant injuries (n=2.8%), wounded with combined and multiple injuries (n=7, 28%).

RESULTS

Most patients underwent organ-sparing procedures. Resections were performed only in 4 cases (splenectomy - 3, nephrectomy - 1). Postoperative complications developed in 23 (38.3%) wounded (suppuration of postoperative wounds - 13, post-traumatic pleuritis - 5, clotted hemothorax - 2, subphrenic abscess - 1, phlegmon of perineum and perianal region - 2). Mortality rate was 1.7%.

CONCLUSION

Timely sorting and evacuation of victims, early qualified surgical care and correct postoperative management with monitoring of vital functions can improve the results of treatment of victims with mine-explosive trauma. Autologous skin grafting for extensive defects and closure of colostomy with restoration of colon continuity were essential in rehabilitation of these patients.

Practice Implications from the WCET® International Ostomy Guideline 2020

GENERAL PURPOSE

To introduce the 15 recommendations of the International Ostomy Guideline (IOG) 2020, covering the four key arenas of education, holistic aspects, and pre- and postoperative care; and to summarize key concepts for clinicians to customize for translation into their practice.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Analyze supporting evidence for the education recommendations in the IOG 2020.2. Identify a benefit of the International Charter of Ostomate Rights.3. Distinguish concepts related to pre- and postoperative ostomy-related care.4. Select a potential barrier to IOG 2020 guideline implementation.

Ostomy Usage for Colorectal Trauma in Combat Casualties

INTRODUCTION

The role for diverting ostomy as a method to help reduce morbidity and mortality has been well established in the combat trauma population. However, factors that influence the type of ostomy used and which ostomies become permanent are poorly studied. We examine patterns of ostomy usage and reversal in a large series of combat trauma patients.

METHODS

We performed a retrospective review of combat casualties treated at our continental U.S. military treatment facility from 2003 to 2015. All patients who underwent ostomy formation were included. Clinical and demographic factors were collected for all patients including the type of ostomy and whether or not ostomy reversal took place. Patients were grouped and analyzed based on ostomy type and by ostomy reversal.

RESULTS

We identified 202 patients who had ostomies created. End colostomies were most common (N = 149) followed by loop colostomies (N = 34) and end ileostomies (N = 19). Casualties that underwent damage control laparotomy (DCL) were less likely to have a loop colostomy created (p < 0.001). Ostomy reversal occurred in 89.9% of patients. There was no difference in ostomy reversal rates by ostomy type (p = 0.080). Presence of a pelvic fracture was associated with permanent ostomy (OR = 3.28, p = 0.019), but no factor independently predicted a permanent ostomy on multivariate analysis.

DISCUSSION

DCL and a severe perineal injury most strongly influence ostomy type selection. Most patients undergo colostomy reversal, and no factor independently predicted an ostomy being permanent. These findings provide a framework for understanding the issue of fecal diversion in the combat trauma population and inform military surgeons about injury patterns and treatment options.

Characteristics of Combat-Associated Small Bowel Injuries

INTRODUCTION

Although there are multiple studies regarding the management and outcomes of colonic injuries incurred in combat, the literature is limited with regard to small bowel injuries. This study seeks to provide the largest reported review of the characteristics of combat-associated small bowel injuries.

MATERIALS AND METHODS

The Department of Defense Trauma Registry was queried for U.S. Armed Forces members who sustained hollow viscus injuries in the years 2007-2012 during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Concomitant injuries, procedures, and complications were delineated. Fisher's exact test was used to analyze the relationship of bowel injury pattern to rates of repeat laparotomy, fecal diversion, and complications.

RESULTS

One hundred seventy-one service members had small bowel injuries. The mean age was 25.8 ± 6.6 yr with a mean injury severity score of 27.9 ± 12.4. The majority of injuries were penetrating (94.2%, n = 161) as a result of explosive devices (61.4%, n = 105). The median blood transfusion requirement in the first 24 h was 6.0 units (interquartile range 1.0-17.3 units). The most frequent concomitant injuries were large bowel (64.3%, n = 110), pelvic fracture (35.7%, n = 61), and perineal (26.3%, n = 45). Fifty patients (29.2%) had a colostomy, and nine patients (5.3%) had an ileostomy; 62.6% (n = 107) of soldiers underwent more than one laparotomy. The mortality rate was 1.8% (n = 3). The most common complications were pneumonia (15.2%, n = 26), deep vein thrombosis (14.6%, n = 25), and wound infection (14.6%, n = 25). The need for repeat laparotomy and fecal diversion was found to be significantly associated with injury pattern (p = 0.00052 and p < 0.0001, respectively).

CONCLUSION

We found that two-thirds of service members with small bowel injuries also had a large bowel injury. One-third of the patients required diversion and two-thirds had more than one laparotomy. The pattern of bowel injury significantly affected the need for repeat laparotomy and fecal diversion.

Historical Perspectives on Colorectal Trauma Management

The authors discuss the history and evolution of management of traumatic wounds to the colon and rectum, summarizing early management parallel with the history of armed conflict followed by the increase in research and management interest by civilian centers in the post-Vietnam era. They explore the strong opinions of the early thought-leaders such as DeBakey and Ogilvie, detailing factors that may have impacted their views. The current literature on optimal management of both colon and rectal trauma is reviewed, including the contentious debate over which patients may benefit from diversion. Current organ injury staging and clinical practice guidelines are also reviewed, as well as lessons learned by the U.S. military in recent conflicts in Iraq and Afghanistan. Understanding of the evolution of colon and rectal trauma management, as well as the current literature, will help surgeons in their decision-making and management of these challenging injuries.

Traumatic colorectal injuries in children: The National Trauma Database experience

PURPOSE

We sought to utilize a nationwide database to characterize colorectal injuries in pediatric trauma.

METHODS

The National Trauma Database (NTDB) was queried for all patients (age≤14years) with colorectal injuries from 2013 to 2014. We stratified patients by demographics and measured outcomes. We analyzed groups based on mechanism, colon vs rectal injury, as well as colostomy creation. Statistical analysis was conducted using t-test and ANOVA for continuous variables as well as chi-square for continuous variables.

RESULTS

There were 534 pediatric patients who sustained colorectal trauma. The mean ISS was 15.6±0.6 with an average LOS of 8.5±0.5days. 435 (81.5%) were injured by blunt mechanism while 99 (18.5%) were injured by penetrating mechanism. There were no differences between age, ISS, complications, mortality, LOS, ICU LOS, and ventilator days between blunt and penetrating groups. Significantly more patients in the penetrating group had associated small intestine and hepatic injuries as well as underwent colostomies. Patients with rectal injuries (25.7%) were more likely to undergo colonic diversion (p<0.0001), but also had decreased mortality (p=0.001) and decreased LOS (p=0.01). Patients with colostomies (9.9%) had no differences in age, ISS, GCS, transfusion of blood products, and complications compared to patients who did not receive a colostomy. Despite this, colostomy patients had significantly increased hospital LOS (12.1±1.8 vs 8.2±0.5days, p=0.02) and ICU LOS (9.0±1.7 vs 5.4±0.3days, p=0.02).

CONCLUSION

Although infrequent, colorectal injuries in children are associated with considerable morbidity regardless of mechanism and may be managed without fecal diversion.

LEVEL OF EVIDENCE

III.

STUDY TYPE

Epidemiology.

Traumatic colonic injuries in Westmead Hospital – A paradigm shift in management over 10 years

Methods

Patients were identified via the prospectively collected trauma registry at Westmead Hospital from 2003 to 2013. Fifty-seven patients initially identified with a proven diagnosis of penetrating colonic injury had their medical records reviewed. Excluded in the study are patients who had rectal injuries or serosal tears of the colon. Patient characteristics, mechanisms of injury, treatment course and complications were analysed. Extent of colonic injury was graded of using American Association for the Surgery of Trauma scalings.

Results

A total of 55 patients were then included in the study. Primary repair of colon injuries was the most common method used (63.6%, n = 35) followed by resection and primary anastomosis (21.8% n = 12), diverting colostomy (14.3%, n = 5) and non-operative management (5.5%, n = 3). There was a higher rate of diversion in the earlier time period (2003–2007) when compared to the later time period (2008–2013), p = 0.03. Over the 10-year period, there was no significant difference with regards to complications among groups, particularly intra-abdominal complications.

Conclusion

From 2003 to 2013, there is a shift of management of penetrating colonic injuries from diversion to resection and primary anastomosis to that of primary repair. Primary repair of colonic injuries is a safe option and is associated with low morbidity. It should be considered as a valid tool in the armamentarium of today’s surgeon.

Complex Perineal Trauma with Anorectal Avulsion

Introduction. The objective of this case report is to illustrate a severe perineal impalement injury, associated with anorectal avulsion and hemorrhagic shock. Results. A 32-year-old male patient was referred to our hospital for an impalement perineal trauma, associated with complex pelvic fracture and massive perineal soft tissue destruction and anorectal avulsion. On arrival, the systolic blood pressure was 85 mm Hg and the hemoglobin was 7.1 g/dL. The patient was transported to the operating room, and perineal lavage, hemostasis, and repacking were performed. After 12 hours in the Intensive Care Unit, the abdominal ultrasonography revealed free peritoneal fluid. We decided emergency laparotomy, and massive hemoperitoneum due to intraperitoneal rupture of pelvic hematoma was confirmed. Pelvic packing controlled the ongoing diffuse bleeding. After 48 hours, the relaparotomy with packs removal and loop sigmoid colostomy was performed. The postoperative course was progressive favorable, with discharge after 70 days and colostomy closure after four months, with no long-term complications. Conclusions. Severe perineal injuries are associated with significant morbidity and mortality. Their management in high volume centers, with experience in colorectal and trauma surgery, allocating significant human and material resources, decreases the early mortality and long-term complications, offering the best quality of life for patients.

Treatment of complex perineal trauma. A review of the literature

Perineal injuries are uncommon, but not rare. They may present a wide variety of injury patterns which demand an accurate diagnostic assessment and treatment. Perineal injuries may occur as isolated injuries to the soft tissues or may be associated with pelvic organ, abdominal or even lower extremity injury. Hence the importance to know in depth not only the anatomy of the perineum and its organs, but also the implications of the patient's hemodynamic stability on the decision making process when treating these injuries using established trauma guidelines. The purpose of this review is to describe the current epidemiology and clinical presentation of perineal injuries in order to provide specific guidelines for the diagnosis and treatment of both stable and unstable patients.