Evolution of the operative management of colon trauma

The impact of colon injuries on the outcome of gunshot wounds to the abdomen

PURPOSE

Factors predicting morbidity and mortality in patients with colon-related gunshot injuries and the management of these injuries are not always straightforward. This aimed to assess the impact of abdominal gunshot wounds with colonic injuries on patients' overall outcomes.

METHODS

This cross-sectional prospective observational study compared patients with colon injuries and without colon injuries. Data was collected from admission, theatre and postoperative care. Patients were recruited between 1 January 2020 and 20 October 2021.

RESULTS

Of 132 patients with abdominal gunshot injuries, 71 (54.0%) had colon injuries. The colon injury group had a higher incidence of laparotomy wound sepsis (p<0.0001), bullet exit wound infection (p<0.0001), tract necrotizing fasciitis (p<0.0001), relook laparotomies (p<0.0001) and a longer hospital stay (p<0.0001). Septicaemia (p=0.002) or anastomotic leak (p=0.041) was associated with a penetrating abdominal trauma index (PATI) ≥25. Most patients who developed tract necrotizing fasciitis did not have their tract debrided/ lavaged (p=0.004). The type of colon repair did not influence the length of hospital stay (p=0.688) or the development of a colon-related complication (p=0.578). Between 18 and 25 years (p<0.0001) and >2 organs injured (p=0.018) were associated with colon-related complications. Patients between 18 and 25 years were 4.748 times more likely to develop a colon-related complication (p=0.046).

CONCLUSION

Gunshot wounds to the abdomen with associated colonic injuries had a worse outcome with an increased risk of developing wound infections. There is no difference in the operative management of colonic injury. Patients between the ages of 18 and 25 years or >2 organs injured are more likely to develop a complication.

Complete transection of the descending colon following blunt abdominal trauma

We present the case of a man in his 30s who was crushed between two vehicles sustaining blunt trauma to his lower limbs and torso. The patient was in shock on arrival to the emergency department, and immediate resuscitation was given with massive transfusion protocol activation. Once the patient's haemodynamic status was stabilised, a CT scan revealed a complete colon transection. The patient was taken to the operating theatre where a midline laparotomy was performed, and the transected descending colon was managed with a segmental resection and handsewn anastomosis. The patient followed an unremarkable postoperative course, with bowels opening on day 8 postoperatively. Colon injuries are rare following blunt abdominal trauma, and a delay in diagnosis may lead to increased morbidity and mortality. As such, a low threshold for surgical intervention is recommended.

Transforming the management of colon injury: Dr Timothy C Fabian - scholar, scientist, leader, and teacher

Dr Fabian and his colleagues have transformed the management of colon injury during a span of more than four decades. They have done so by following a patient-centered, rigorous, and dogged approach to improving patient care and standardizing care with a simplified and widely applicable algorithm. All non-destructive colon injuries are primarily repaired. Healthy patients without massive blood loss who have sustained destructive wounds are treated with resection and anastomosis without fecal diversion. Patients with coexisting significant medical conditions or those requiring greater than 6 units of packed red blood cell(PRBC) transfusions are treated with resection and fecal diversion. Following this simple algorithm has led to a low rate of anastomotic leak with minimal colon-related morbidity in penetrating and blunt colon trauma and in those patients requiring abbreviated laparotomy/damage control procedures. During his four decades in Memphis, Dr Fabian established, led, and developed a regional trauma system which transformed trauma care, significantly improving survival and minimizing disability of patients in the Memphis community and across the entire mid-South region. I was fortunate to be a trauma and surgical critical care fellow 30 years ago in Memphis. As a leader, Dr Fabian gave us the freedom to pursue our own interests and explore ideas with full academic freedom with only one caveat-always do the right thing for our patient. A general principle championed by Dr Fabian is that patient care is not a means to some other goal (academic, reputational, or financial); no, serving the patient's interests first is the reason we exist as surgeons and the reason why the trauma system exists. This human-centered approach was central to the Memphis approach to trauma care led by Timothy C Fabian and will live on in the work of those who are following his leadership.

Laparoscopic treatment for colonic injuries following penetrating trauma: A feasible option in a surgical department of Sub-Saharan Africa

Introduction

The management of abdominal penetrating trauma remains complex. Between the risk of negative laparotomy and missed visceral injury, laparoscopy is a good alternative. We report 2 cases of abdominal penetrating trauma with colonic injury diagnosed and treated with laparoscopic approach.

Observations

The first patient was 15 years old, with no medical history and received at 3 h of a penetrating trauma by stabbing. Hemodynamic status was normal. An exploratory laparoscopy was performed. It objectified a penetration of the peritoneum on the left flank with an injury of the anti-mesenteric edge of the descending colon that was sutured. The second patient was 20 years old, with no history, who had a penetrating trauma of the left iliac fossa by stabbing. Arterial pressure was normal. He was received 6 h after the trauma. An exploratory laparoscopy objectified an injury of 2 cm located at the sigmoid colon which was sutured with a good evolution.

Conclusion

Laparoscopy in abdominal wounds is a good option in selected patients. It has a diagnostic and therapeutic importance in colonic injuries. The limits are represented by the possibility of unrecognized visceral lesions that can lead to additional morbidity.

Difference between delayed anastomosis and early anastomosis in damage control laparotomy affecting the infusion volume and NPWT output volume: is infusion restriction necessary in delayed anastomosis? A single-center retrospective analysis

Objectives

During temporary abdominal closure (TAC) with damage control laparotomy (DCL), infusion volume and negative-pressure wound therapy (NPWT) output volume are associated with the success and prognosis of primary fascial closure. The same may also hold true for anastomosis. The aim of this research is to evaluate whether the difference between early anastomosis and delayed anastomosis in DCL is related to infusion volume and NPWT output volume.

Methods

This single-center retrospective analysis targeted patients managed with TAC during emergency surgery for trauma or intra-abdominal sepsis between January 2011 and December 2019. It included patients who underwent repair/anastomosis/colostomy in the first surgery and patients who underwent intestinal resection in the first surgery followed by delayed anastomosis with no intestinal continuity.

Results

Seventy-three patients were managed with TAC using NPWT, including 19 cases of repair, 17 of colostomy, and 37 of anastomosis. In 16 patients (trauma 5, sepsis 11) with early anastomosis and 21 patients (trauma 16, sepsis 5) with delayed anastomosis, there was no difference in the infusion volume (p=0.2318) or NPWT output volume (p=0.7128) 48 hours after surgery. Additionally, there was no difference in the occurrence of suture failure (p=0.8428). During the second-look surgery after 48 hours, the anastomosis was further postponed for 48% of the patients who underwent delayed anastomosis. There was no difference in the infusion volume (p=0.0783) up to the second-look surgery between the patients whose delayed anastomosis was postponed and those who underwent delayed anastomosis, but there was a tendency toward a large NPWT output volume (p=0.024) in the postponed delayed anastomosis group.

Conclusion

Delayed anastomosis may be managed with the same infusion volume as that used for early anastomosis. There is also the option of postponing anastomosis if the planned delayed anastomosis is complicated.

Level of evidence

Therapeutic/Care Management, Level IV.

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.

Evolution of damage control surgery in non-traumatic abdominal pathology: a light in the darkness

Damage control surgery is based on temporal control of the injury, physiologic recovery and posterior deferred definitive management. This strategy began in the 1980s and became a formal concept in 1993. It has proven to be a strategy that reduces mortality in severely injured trauma patients. Nevertheless, the concept of damage control in non-traumatic abdominal pathology remains controversial. This article aims to gather historical experiences in damage control surgery performed in non-traumatic abdominal emergency pathology patients and present a novel management algorithm. This strategy could be a surgical option to treat hemodynamically unstable patients in catastrophic scenarios such as hemorrhagic and septic shock caused by peritonitis, pancreatitis, acute mesenteric ischemia, among others. Therefore, damage control surgery is light amid better short- and long-term results.

Penetrating colonic trauma and damage control surgery: Anastomosis or stoma?

BACKGROUND

The management of colon injuries in damage control surgery (DCS) remains controversial.

METHODS

A retrospective study investigating outcomes of penetrating colonic trauma in patients who survived beyond the initial repeat laparotomy (IRL) after DCS was performed. Patients over 18 years with penetrating colon injury and who underwent DCS from 2012 to 2020 were included from our electronic trauma registry. Demographic data, admission physiology and Injury Severity Score (ISS) were reviewed. Patients were classified into three groups: primary repair of non-destructive injuries at DCL, delayed anastomosis of destructive injuries at IRL and diversion of destructive injuries at IRL. Outcomes observed included leak rates, length of intensive care unit stay, length of hospital stay, morbidities, mortality and colon-related mortality.

RESULTS

Out of 584 patients with penetrating colonic trauma, 89 (15%) underwent DCS. After exclusions, 74 patients were analysed. Mean age was 32.8 years (SD 12.5); 67 (91%) were male. Mechanism of injury was gunshot in 63 (85%) and stab 11 (15%) patients. Seventeen patients underwent primary repair at DCS, of which one leaked. Twenty patients underwent delayed anastomosis at IRL. Of these, five (25%) developed leaks. Mortality was significantly higher for those with an anastomotic leak compared to those without (p < 0.001). Thirty-seven patients were diverted at IRL. Overall mortality (p = 0.622) and colon-related mortality (p = 0.592) were not significantly different across groups.

CONCLUSION

Delayed anastomosis at IRL following DCL was associated with a leak rate of 25% in this study. When anastomotic leak did occur, it was associated with significant mortality. Delayed anastomosis should only be undertaken in highly selected patients.

Delayed presentation of an isolated sigmoid Colon injury following blunt abdominal trauma: A case report with review of literature

Introduction and importance

Isolated Colon injury due to blunt abdominal trauma is very rare. Due to lack of a definitive diagnostic method; it's very challenging to detect such injury and this will lead to delay in treatment and subsequently resulting in high morbidity and mortality. The current literature is relatively sparse concerning the management of blunt colon injuries.

Case presentation

Here, we report a case of a 17-year-old male patient with isolated sigmoid injury presented 5 days after MVC. He underwent sigmoid resection and end colostomy followed by reversal 6 weeks later. Currently, the patient is disease-free with a completely healed wound.

Conclusion

The purpose behind this paper is to raise clinical suspicion regarding delayed presentation of blunt abdominal trauma and it effect on operative decision, so that timely diagnosis and proper management could be carried out. And to discuss the applicability of the defined management algorithm for penetrating colon injury on delay blunts colonic injury.

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Isolated Colon injury due to blunt abdominal trauma is very rare and its very challenging to detect.

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We have found that only few cases have been reported for Delayed Presentation Of An Isolated Colonic Injury Following Blunt Abdominal Trauma.

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The purpose of this report is to discuss surgical management in light of our experience.

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We believe that the defined management algorithm for penetrating colon injury can’t be applied to delay injury as in this case the colon are more vulnerable which increases risk of post-operative complication.

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Additional research is needed to completely define the patient population that benefits from fecal diversion after delayed blunt colon injury requiring resection.

National estimates of intestinal ostomy creation and reversal for trauma

BACKGROUND

Intestinal ostomy creation after trauma is selectively indicated for destructive colon and rectal injuries. However, the nationwide rates of creation of ostomies for trauma and their reversal are not known. The objective of this study was to ascertain national estimates of trauma ostomy creation and reversal.

METHODS

Weighted analysis of Healthcare Cost and Utilization Project Nationwide Readmissions Database 2014 to 2015 was performed. Adult trauma patients (≥16 years) with a hollow viscus injury were included. Patients with preexisting ostomies and permanent ostomies and those who died within 48 hours of admission were excluded. Rates of ostomy creation and same admission ostomy reversal were calculated. Rates of postdischarge ostomy reversal were calculated using the Kaplan-Meier estimator. Multivariable Cox proportional hazards model was used to determine factors associated with postdischarge trauma ostomy reversal.

RESULTS

A total of 22,542 patients sustained a hollow viscus injury resulting in the creation of 2,145 ostomies (9.6%). The rate of same-admission ostomy reversal was 0.7% (n = 16). At 1, 3, 6, and 9 months, the cumulative stoma reversal rates were 0%, 7.6%, 31.0%, and 43.1%, respectively. The mean ± SD time from ostomy creation to reversal was 123 ± 6.7 days for those undergoing reversal. Injury Severity Score greater than 9 was significantly associated with ostomy nonreversal after discharge (hazard ratio, 0.41; 95% confidence interval, 0.26-0.66). Age, sex, insurance status, penetrating injury, Charlson Comorbidity Index, and hospital teaching status were not significantly associated with ostomy reversal.

CONCLUSION

The nationwide rate of ostomy creation after trauma is nearly 10%. At 6 months postinjury, only one third of patients had undergone ostomy reversal. Future study is needed to understand patient and provider-level factors associated with trauma ostomy reversal.

LEVEL OF EVIDENCE

Epidemiology, level III.

Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma

BACKGROUND

Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT.

METHODS

The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed.

RESULTS

A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC.

CONCLUSIONS

MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL.

LEVEL OF EVIDENCE

Level III Prognostic.

Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013–2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88–6.69) (OR: 11.24; 95% CI: 8.53–13.95), more time spent in ICU (2.73; 1.70–3.76) (7.98; 6.10–9.87), and increased risk for surgical site infection (1.32; 1.03–1.68) (2.54; 1.71–3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.