3.Management of Traumatic Colon Injury

8/9/2019 3.Management of Traumatic Colon Injury

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Management of Traumatic Colon

injury

www.gims-org.com


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Case Report

HPI: 16 yo boy involved in MVC as restrained backseat passenger

Trauma 97 Report ambulatory at scene, c/o abdpain Airway intact Breathsounds equal

HR 76, BP 140/76, equal pulses

GCS 15, MAE, AxOx3

Impressive seatbelt sign, Large left flankeccymosis/fullness

FAST negative

CT no solid organ injury, small amt free fluid


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Case Report


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Case Report


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Case Report


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Hopital course

Admitted to trauma for observation, pain

control, spine consult for question of

compression fx

HD#4 develops tachycardia, tachypnea, abd

pain


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Hopital course


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Hospital Course

OR

Exploratory laparotomy midline

Suprafascial hematoma superiorly

Devascularized portion of small bowel 8cm

Devascularized, necrotic, perforated sigmoid colon

Minimal fecal contamination

Large left flank hernia with hematoma


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Hopital course


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Hospital Course

Returned to ICU with open abdomen forplanned 2nd look at fascia

2nd look POD#2, fascia viable, bowel healthy

and fascia closed, skin left open Intermittent fevers post-op, but currently

doing well, tolerating diet, stoma functioning,

dispo planning Plan colostomy reversal in approx 3 months,

then will plan later lumbar hernia repair


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Traumatic Colon Injury

Incidence:

2nd most frequent injury in GSW

3rd most frequent in stab wounds

Relatively infrequent after blunt trauma (2-5%)

Morbidity 20-35%

Mortality 3-15%


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History

Historically colon repair a failure until WWI

1943 - Due to failure rate Major General W.H. Ogilvie

mandated colostomy

1950s improvements in trauma care, and surgeonsbegan to challenge diversion dogma

1979 Stone and Fabianprospective study

confirmed safety and efficacy of primary repair inselected patients

Exteriorization in 1960s-70s abandoned

1980s present greater move to primary repair


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Risk factors for primary repair

Delayed treatment (>12hrs)

Prolonged shock

Gross fecal contamination >4-6 units PRBCs transfused

Need for mesh to close abdominal wall


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Trauma grading scores

Flint grading

I isolated colon, no shock, minimalcontamination, minimal delay

II Through and through perforation, laceration,moderate contamination

III severe tissue loss, devascularization, heavycontamination

Advantage simplicity

Disadvantage does not factor in other injury


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Penetrating Abdominal

Trauma Index

combined severity of

injury to individual abdorgans assessed

operatively

Disadvantage does not

take into account rest ofbody

Lewis et al. Ann Surg. 1989


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Lewis et al. Ann Surg. 1989


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Therapeutic options

Two stage

Repair and protective-ostomy

Resection and stoma formation proximally

Distal Hartmanns or mucous fistula

Exteriorization of repaired bowel uncommon

now

One stage Simple suture repair

Resection and primary anastamosis


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Anastamosis

Stapled vs. Hand-Sewn Brundage et al. J trauma.

1999

Multicenter retrospectivecohort design

anastamotic leaks andintra-abdominal abscessesappear to be more likelywith stapled bowel repairscompared with suturedanastamoses in the injuredpatient. Caution should beexercised in deciding tostaple a bowel anastomosisin the trauma patient.


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Anastamosis

Burch et al. Ann of Surg.1999.

Prospective randomizedtrial of single-layer

continuous vs. two layerinterrupted intestinalanastamosis

NB: Important to invert, 4-6mm seromuscular bites,

5mm advances, larger bitesat mesenteric border

Single layer similar leakrate (approx 2%), cheaper,faster

Burch et al.Ann Surg. 1999


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Studies

3 prospective randomized trials comparing diversion toprimary repair without exclusion criteria

Authors all conclude primary repair should be first treatmentin civilian penetrating colon trauma

Tzovaras et al. New Trends in Management of colon

trauma. Injury. 2005


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Studies

Demetriades et al. 92 prospective study of 100 GSW to colon Routine colostomy on all resections (16 pts)

37.5% abdominal septic complication rate

Stewart et al. 94 reviewed series of 60 pts who required resections

43 primary anastamosis, 17 with diversion Abdominal sepsis in 37% anastamosis, 29% diversion

Leak in 14% total, 33% if >6U PRBCs

Murray et al 99 retrospective series of 140pts requiring resection 80% anastamosis, 20% diversion

Equal abdominal sepsis rates 4% leak ileocolic, 13% leak in colocolostomy


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Studies

Cornwell et al. 98 prospective study of 27 ptsrequiring resection All had delay>6hrs, >6U prbcs, or PATI>25

25pts had primary anastamosis, 2 with colostomy

Abd septic complications in 20% anastamosis group, 2leaks and both fatal

Demetriades et al. 01 propective, multicenter onpenetrating colon injuries requiring resection 22% complication with primary repair, 27% diversion

3 risk factors severe fecal contam., >4U prbc, single agentabx

Type of management did not affect complications


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Studies

Hudolin et al. Br. J Surg. 2005 Role of primary repair

of colon injuries in wartime

5370 casualties 259 (4.8%) with colon injuires

122 had primary repair, 137 had colostomy 58% explosive, 42% gsw, 1pt had stab wound

Associated injury in 96%

Complications in 27% primary repair, 30% colostomy

Mortality 8% and 7% respectively Conclusion primary repair safe and effective treatment

for colon injuries during war


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Studies

Adedoyin et al. 60 pts over 10 yrs

No difference in outcome of primary repair vs.

colostomy

Colostomy closure related morbidity 21%,

mortality 5%


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Studies

Multiple studies show no difference in complication

rates between right and left colon injuries repaired

primarily

Eshraghi N et al. J Trauma. 1998 Survey of trauma surgeons AAST members

30% never diverted, 1% always diverted

High velocity GSW only indication where majority diverted

Negative correlation between surgeon age and preference

for anastamosis

Lower volume surgeons preferred diversion


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EAST Guidelines

Published in 1998

Level I

Sufficient class I and class II data to support

primary repair for nondestructive colon

wounds(


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EAST Guidelines

Level II

Patients with penetrating intraperitoneal colon

wounds which are destructive can undergo

resection and primary anastomosis if they are: Hemodynamically stable without shock

Have no significant underlying disease

Have minimal associated injuries

Have no peritonitis


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EAST Guidelines

Level II

Patients with shock, underlying disease, significant

associated injuries, or peritonitis should have destructive

colon wounds managed by resection and colostomy

Colostomies after trauma can be closed within 2 weeks if

contrast enema is performed in distal colon if no

unresolved sepsis, instability, nor non-healing bowel injury

BE not necessary to r/o cancer or polyps prior to

colostomy closure for trauma patients who otherwise have

no risk factors.


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Summary

Colon trauma carries significant morbidity and

mortality

Choice of diversion vs. primary repair should

be individualized to situation

Move towards more primary repairs and

resections with anastamosis without

colostomy

Right colon = Left colon for management

Suture>Stapled for trauma?

3.Management of Traumatic Colon Injury

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