Penetrating Colon Trauma - SUNY Downstate Medical Center · Penetrating Colon Trauma Author:...

PENETRATING COLON TRAUMA: THE CURRENT EVIDENCE Samuel Hawkins MD

www.downstatesurgery.org

CASE PRESENTATION 22M BIBEMS s/p multiple GSW ABCs intact Normotensive, non-tachycardic Secondary Survey:

4 truncal bullet holes L superior lateral scapula (posterior) T4-T5 level lateral to midline (posterior) L mid-flank (anterior) L mid-flank (posterior)

2 bullet holes proximal to L elbow joint Graze wound L mid-bicep


CASE PRESENTATION CONT. CXR negative Abd distended, tender EX LAP


CASE PRESENTATION CONT. Operative course

Crash laparotomy Full peritoneal exploration, no active bleeding

Identified mid-descending colon through-and-through with >50% circumference destruction

Segmental resection with GIA stapler L retroperitoneal exploration

Identified grade III renal laceration (inferior pole) Ureter explored and intact Posterior abdominal wall defect with no active bleeding or

hematoma


CASE PRESENTATION CONT. Operative course cont.

GU intraop consult Renorrhaphy with Surgicel and chromic Approximated Gerrota’s over repair

Repair of colon Stapled side-to-side functional end-to-end with GIA Repair of mesentery with interrupted silk

Copious peritoneal irrigation with NS JP drain left in L gutter Fascia closed, skin open Extubated, taken to PACU


CASE PRESENTATION CONT. Post-operative course

POD 0: foley out, clears, transferred to floor, CT scan



POD 0: foley out, clears, transferred to floor, CT scan POD 1: regular diet, L elbow XR neg POD 2: persistent skin bleeding from lap wound,

ligated POD 3: JP removed POD 4: Hb 9 6. Repeat Hb 8. No transfusion POD 5: Febrile to 101.8. WBC 8 POD 6: WBC 14. Abx, CT scan



POD 7: IR drainage of peri-nephric abscess; initial output 80cc purulent fluid

POD 10: Abx d/c’d, IR drain removed POD 11: Pt discharged home

Follow-up

None, pt somewhere in Georgia


QUESTIONS?


OUTLINE: PENETRATING COLON TRAUMA Anatomy and Epidemiology Historical perspective The Established Evidence Base “Textbook” Management Strategy What about Damage Control?


THE COLON (RECTUM ALSO SHOWN) Reabsorption of water and nutrients Transmission of waste Blood supply: SMA/SMV And IMA/IMV Intra- and Extraperitoneal Position Full of bacteria


COLON TRAUMA POPULATION STATS NDTB Data 2007-2009 6817 colon injuries (0.4%) 2839 vs 3039 B/P


COLON TRAUMA POPULATION STATS Penetrating abdominal

trauma 27% of laps for GSW 20% of laps for anterior

stab wounds


HISTORICAL PERSPECTIVE 1300 BCE: Ehud stabs King Eglon of Moab – dies

of Colon Injury – 100% mortality Civil War: Expectant Management – near 100%

mortality WWI: Primary Repair – 60%-75% mortality WWII: Surgeon General recommends

Exteriorization – 50% mortality…then 25%-35% mortality

Vietnam: no change – 10% mortality Notice the improvement! Likely many things. Then, in 1979….


1975-1979, all pts presenting to Grady in Atlanta with abdominal trauma requiring laparotomy

Randomization after initial resuscitation, explore lap and control of bleeding and GI spillage with discovery of colonic injury

Pts were randomized if they did not meet obligatory criteria

129 excluded, 139 randomized


1987-1990, all pts presenting to Charity Hospital in New Orleans with abdominal trauma requiring laparotomy

Randomization after initial resuscitation, explore lap and control of bleeding and GI spillage with discovery of colonic injury

ALL pts that met these criteria were randomized

N=56, 28 in each arm


10 18


All non-destructive wounds of the colon (<50% circumference) should be repaired primarily without diversion (Level I)

Destructive wounds can be managed with resection and primary anastomosis if patient: Is hemodynamically stable without evidence of shock Has no significant underlying disease Has minimal associated injuries (PATI <25, ISS <25) Has no peritonitis

Otherwise resection and colostomy (Level II)


Prospective non-randomized multi-institution (19) study

Inclusion criteria: colon resection for penetrating trauma surviving >72h

NO obligate ostomy criteria n = 297; 197 vs 100 PA/D Multivariate analysis…


Multivariate Analysis! Logistic Regression!


Predictors of abdominal complications are INDEPENDENT of repair technique

Conclusion: Colon injuries requiring repair should be treated with resection and primary anastomosis regardless of risk factors


2003


“Evidence Supports Primary Repair”


“TEXTBOOK ANSWER” Primary repair/primary anastomosis is preferred in

majority of cases, however… Indications for diversion include blood loss,

concomitant solid organ injury, fecal contamination, mechanism of injury, delayed repair, and patient age. An additional consideration is the subjective evaluation of the degree of bowel edema present at the time of anastomosis (Asensio 2008)

Consideration of colostomy creation is reserved for “high risk” patients with destructive injuries; such patients are defined as those with a high penetrating abdominal trauma index score (≥25), those with high transfusion requirements (greater than six units), and those in whom surgery is delayed. (Cameron 2014)


OPERATIVE PRINCIPALS 1. Completely define all injuries with proper

dissection. 2. Grade injuries according to severity. 3. Decide on type of repair: simple repair or resection

and repair with or without, you know, diversion. 4. Debride all devitalized tissue. 5. Resect bowel that has any evidence of ischemia. 6. Establish clean bowel edges in the area of repair. 7. Use absorbable suture if a stapling technique is not

employed. A second interrupted seromuscular layer may be added.

8. Repair lacerations transversely to avoid strictures. 9. Close mesenteric defects. 10. Irrigate peritoneal cavity with warm saline

solution.


WHAT WAS THE PATI OF THE PRESENTED PT?

A. Let me calculate it real quick B. I dunno…

25


PATI: PENETRATING ABDOMINAL TRAUMA INDEX



PATI = (RF x IE)duo + (RF x IE)panc…+ (RF x IE)min



• Retrospective Review • Penetrating abdominal injury in urban trauma center 1975-1979 • n= 108 stab wounds; n= 114 GSW

Stab Wounds GSW PATI <=25 5% 7% PATI >25 50% 46%


CONCLUSION www.downstatesurgery.org

Penetrating Colon Trauma - SUNY Downstate Medical Center · Penetrating Colon Trauma Author:...

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