3.Management of Traumatic Colon Injury
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Transcript of 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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Trauma grading scores
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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Trauma grading scores
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?