Management of colorectal injuries: A Western Trauma Association critical decisions algorithm

Blunt and Penetrating Injury to the Bowel: A Review

Traumatic injuries to the small and large bowel are common and can be highly morbid. Identifying these injuries, especially in stable patients who suffer blunt trauma, can be challenging. It is critical that traumatic bowel injuries are diagnosed in a timely fashion as delays in diagnosis and treatment are associated with worse outcomes. The literature outlining the management of traumatic bowel injuries is mostly comprised of retrospective data and case reports/series. We have compiled the existing literature and relevant guidelines into a single resource for providers who care for traumatically injured patients.

Contemporary diagnosis and management of colorectal injuries: What you need to know

ABSTRACT

Colorectal injuries are commonly encountered by trauma surgeons. The management of colorectal injuries has evolved significantly over the past several decades, beginning with wartime experience and subsequently refining with prospective randomized studies. Colon injuries were initially nonoperative, evolved toward fecal diversion for all, and then became anatomic based with resection and primary anastomosis with selective diversion, and now primary repair, resection with primary anastomosis, and delayed anastomosis after damage-control laparotomy are all commonplace. Rectal injuries were also initially considered nonoperative until diversion came into favor. Diversion in addition to direct repair, presacral drain placement, and distal rectal washout became the criterion standard for extraperitoneal rectal injuries until drainage and washout fell out of favor. Despite a large body of evidence, there remains a debate on the optimal management of some colorectal injuries. This article will focus on how to diagnose and manage colorectal injuries. The aim of this review is to provide an evidence-based summary of the contemporary diagnosis and management of colorectal injuries.

Primary Repair Versus Resection for AAST Grade I and II Colon Injuries: Does the Type of Repair Matter?

INTRODUCTION

The management of traumatic colon injuries has evolved over the past two decades. Recent evidence suggests that primary repair or resection over colostomy may decrease morbidity and mortality. Data comparing patients undergoing primary repair versus resection are lacking. We sought to compare the outcomes of patients undergoing primary repair versus resection for low-grade colon injuries.

METHODS

A retrospective review of all patients who presented with American Association for the Surgery of Trauma grade I and II traumatic colon injuries to our Level I trauma center between 2011 and 2021 was performed. Patients were further dichotomized based on whether they underwent primary repair or resection with anastomosis. Outcome measures included length of stay data, infectious complications, and mortality.

RESULTS

A total of 120 patients met inclusion criteria. The majority of patients (76.7%) were male, and the average age was 35.6 ± 13.1 y. Most patients also underwent primary repair (80.8%). There were no statistically significant differences between the groups in arrival physiology or in injury severity score. Length of stay data including hospital length of stay, intensive care unit length of stay, and ventilator days were similar between groups. Postoperative complications including pneumonia, surgical site infections, fascial dehiscence, the development of enterocutaneous fistulas, and unplanned returns to the operating room were also all found to be similar between groups. The group who underwent resection with anastomosis did demonstrate a higher rate of intra-abdominal abscess development (3.1% versus 26.1%, P < 0001). Mortality between both groups was not found to be statistically significant (7.2% versus 4.3%, P = 0.4) CONCLUSIONS: For low-grade (American Association for the Surgery of Trauma I and II) traumatic colon injuries, patients undergoing primary repair demonstrated a decreased rate of intra-abdominal abscess development when compared to patients who underwent resection with anastomosis.

Faecal diversion remains central in the contemporary management of rectal trauma-Experience from a major trauma centre in South Africa

INTRODUCTION

This paper provides an overview of a single centre's experience with rectal injury over a decade. It hopes to use this data to provide context to our current approach to managing these injuries in the civilian setting.

THE STUDY

All patients with rectal trauma were identified from the Hybrid Electronic Medical Registry (HEMR).

RESULTS

During the study period, a total of 88 patients with rectal injuries were admitted to Grey's Hospital in Pietermaritzburg. There were 80 (91 %) males and 8 (9 %) females. The median age was 31 (15-63) years. There were 9 (10 %) blunt mechanisms, 76 (86 %) penetrating mechanisms and 3 (4 %) combined blunt and penetrating mechanisms. Gunshot wounds accounted for the majority of sustained rectal trauma (71 %). There were 57 (65 %) extra-peritoneal injuries, 24 (27 %) intraperitoneal injuries and 7 (8 %) combined injuries. The grade of injury, according to the AAST grading system, was as follows, AAST 1: 16 (18 %), AAST 2: 63 (72 %), AAST 3: 7 (8 %), and AAST 4: 2 (2 %). Pre-sacral drainage and distal rectal washout were not performed. Almost all (55/57) of the extra-peritoneal rectal injuries were managed with proximal diversion (PD). There were five primary repairs (PR) performed in the extra-peritoneal rectal injury cohort. In four of these cases, this was accompanied by a PD. Of the 24 intraperitoneal rectal injuries, 15 underwent PR, of which 11 were performed in conjunction with PD. In total, 20 intraperitoneal rectal injuries underwent PD. All seven combined rectal injuries underwent PD, and three of the combined rectal injuries underwent PR with PD. There was urogenital tract associated morbidity in 8 %, gastrointestinal tract related morbidity in 8 % and septic complications in 11 %.

CONCLUSION

Rectal trauma is still associated with a high rate of rectal/urogenital and infection related morbidity. Although pre-sacral drainage and distal stump washout have been largely abandoned in civilian practice, faecal diversion currently remains the cornerstone of the management of rectal trauma in our environment. Although there was a low rate of intra-abdominal septic complications in patients who had undergone diversion, this needs to be balanced against the low rate of stoma reversal.

Multiple portions enteral nutrition and chyme reinfusion of a blunt bowel injury patient with hyperbilirubinemia undergoing open abdomen: A case report

Blunt bowel injury (BBI) is relatively rare but life-threatening when delayed in surgical repair or anastomosis. Providing enteral nutrition (EN) in BBI patients with open abdomen after damage control surgery is challenging, especially for those with discontinuity of the bowel. Here, we report a 47-year-old male driver who was involved in a motor vehicle collision and developed ascites on post-trauma day 3. Emergency exploratory laparotomy at a local hospital revealed a complete rupture of the jejunum and then primary anastomosis was performed. Postoperatively, the patient was transferred to our trauma center for septic shock and hyperbilirubinemia. Following salvage resuscitation, damage control laparotomy with open abdomen was performed for abdominal sepsis, and a temporary double enterostomy (TDE) was created where the anastomosis was ruptured. Given the TDE and high risk of malnutrition, multiple portions EN were performed, including a proximal portion EN support through a nasogastric tube and a distal portion EN via a jejunal feeding tube. Besides, chyme delivered from the proximal portion of TDE was injected into the distal portion of TDE via a jejunal feeding tube. Hyperbilirubinemia was alleviated with the increase in chyme reinfusion. After 6 months of home EN and chyme reinfusion, the patient finally underwent TDE reversal and abdominal wall reconstruction and was discharged with a regular diet. For BBI patients with postoperative hyperbilirubinemia who underwent open abdomen, the combination of multiple portions EN and chyme reinfusion may be a feasible and safe option.

Management of Intra-abdominal Traumatic Injury

Traumatic injuries occur from unintentional and intentional violent events, claiming an estimated 4.4 million lives annually (World Health Organization). Abdominal trauma is a common condition seen in many trauma centers accounting for roughly 15% of all trauma-related hospitalizations (Boutros and colleagues 35) and is associated with significant morbidity and mortality. Following the concepts of Damage Control Resuscitation can reduce mortality drastically. Ultrasound, computed tomography scans, and routine physical examinations are used to make prompt diagnoses, trend injuries, and recognize deterioration of clinical status. Clear, effective, and closed-loop communication is essential to provide quality care.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.