Colorectal TraumaColorectal Conference

St Luke’s-Roosevelt HospitalDepartment of Surgery

Leslie Tyrie, PGY III16 March 2006

Colorectal Anatomy Right Colon, Left Colon, Rectum Blood supply

SMA, IMA vs. inf. mesenteric/int. iliacs/pudendal art.

Function Dehydration, storage, defecation

Bacterial content Increases as more distal to stomach 60% dry weight stool = bacteria

Intraperitoneal and retro/extraperitoneal components

Right and left colon morbidity / mortality outcomes the same

Colon vs. Rectum Proximal vs. distal to

peritoneal reflection

Colorectal Trauma – Etiology COLON Penetrating

>85% 1/3 penetrating abdominal injuries GSW > SW > shotgun > iatrogenic

> misc Blunt

MVA, ped struck, falls Multiple injuries

Delayed presentation

RECTUM Penetrating

Majority GSW Impalement / straddle injuries Iatrogenic Foreign body

Blunt Pelvic fractures

Disruption of pubic symphysis Spicules

Scrape injuries Drag over pavement s/p motorcycle

accident

Trauma to perineum High index suspicion

Colorectal Trauma – H&P Trauma algorithms

ABCs

History Physical

Abdomen Flank Perineum DRE – blood

Colorectal Trauma – Studies CT SCAN

Blunt Abdominal and Penetrating Flank Triple contrast

DPL Abdominal trauma Will not evaluate retroperitoneum Bacteria / vegetable matter suggestive

FAST Abdominal trauma Repeatable Non invasive Will not evaluate retroperitoneum

Rigid Proctosigmoidoscopy

Exploratory Laparotomy

Operative Management Options

1. Primary repair2. Resection and anastomosis3. Repair w/proximal diversion4. Exteriorization

The Question Proximal diversion of fecal stream

Prevent septic complications Colon: anastomotic leak Rectum: pelvic sepsis Pelvic abscess

Grading Score for Colon Injury AAST Colon Injury Scale (CIS)

I – serosal injury II – single wall injury III – < 25% wall involvement

IV – > 25% wall involvement V – circumferential wall, vascular injury, or both

Destructive vs. Nondestructive wounds

Colon Trauma – Historical Perspective“Ephud put forth his left hand, and took

the sword from his right thigh and thrust it into his belly… and the dirt came out.”

– book of Judges in the Old Testament

Suggestive of early penetrating colon trauma

However no treatment or outcome is discussed

Historical Perspective (cont) American Civil War

Non operative management of penetrating abdominal wounds Mortality 90%

WWI Diverting colostomy is preferable in extensive wounds Primary repair was attempted Mortality 59%

WWII US Surgeon General Thomas Parren Jr. mandated

colostomy for all colon injuries sustained in battle Inexperienced war-time surgeons High-energy, high-velocity injuries Delay in care Transfer soon after initial management

Mortality to 5-20%

Historical to today After WWII… Colostomy remained standard of care However, civilian ≠ military trauma

Less destructive Delay to definitive care short Resuscitation administered quickly Newer antibiotic prophylaxis Postoperative supervision available

Non Destructive Wounds (CIS I – III) Stone and Fabian et al 1979 Primary repair or resection + anastomosis

Destructive wounds (CIS IV – V) Demetriades et al 2001

no difference, or improved outcomes w/ primary repair

Patients at risk for anastomotic breakdown Immunocompromised patients Transfusion > 6 units Likely increased

Shock Other traumatic injury > 2 Delay of operation

Traditionally diverting colostomy New data resection + primary anastomosis One strict contraindication, delay > 12 hrs

Management of Colon Injuries

The Exception: Damage Control Cold Coagulopathic Acidotic

Resect if needed, no anastomosis Planned second look

Management of Rectal Injuries Intraperitoneal

Like colonic injuries Primary repair

Extraperitoneal Diversion

End vs. loop colostomy Drainage

Closed or open drainage of presacral space Tranverse incision anococcygeal raphe into subcutaneous tissue Lateral dissection on each side of raphe to avoid transsection of coccygeal attachments to access

presacral space Penrose or JP drainage

Repair If feasible, avoid unnecessary dissection > 1cm unless involving GU tract then repair w/interposition patch

Distal Washout Washout of rectal stump No proven benefit For highly contaminated wounds and extensive devitalization

Towards primary and definitive care w/out DDR,DW In rare cases, APR

Considerations Antibiotics

No proven regimen 24 hours w/2nd generation

cephalosporin is accepted Colostomy Reversal

Traditionally 3 months New data suggests if signs of

improvement may consider reversal at 2 weeks

Avoid 2 – 6 weeks BE not necessary

Unidentified rectal trauma, ongoing symptoms

Conclusions Colon Trauma

Primary repair, resection + primary anastomosis Exceptions destructive injuries w/risk factors

Shock, delay to management, associated organ injury, transfusion requirement, co-morbid disease

Rectal Trauma Intraperitoneal

Like colonic injuries Extraperitoneal

Diversion and presacral drainage Antibiotics

2nd gen ceph x 24 hrs periop