Chicago Metropolitan Trauma Society4/15/2015

• Discussion objectives– Management of penetrating renovascular trauma– Colonic anastomosis after damage control

laparotomy – Is it worth the risk? – Anticoagulation management strategies after IVC

injuries requiring ligation of IVC.

Traumatic Colon Injury and Open Abdomen – Is anastomosis worth the risk?

Greg Day MDLoyola University Medical Center

Patient - CC

• Presentation– 22 y/o Male s/p stab to the left flank– Primary Survey• Airway – intact, shallow respirations• Breathing – Bilateral breath sounds• Circulation – tachycardic 120s, hypotensive to 70’s,

weakly palpable femoral pulses bilaterally

Patient CC

• Secondary Survey– Pertinent findings

• Neuro – Awake, alert, responsive to questions – c/o abd pain• Abd – Left flank stab approx 3cm in length, active bleeding

from site, digital probe beyond fascia• No other injuries noted

• Resuscitation– CVC placed– Massive transfusion protocol activated– First units of blood transfusing while going to OR

Operative and Hospital Course

• Operative Findings– Large hemoperitoneum, Grade V injury to left renal

hilum. Descending colon injury >50% circumference.

– Colon resected, left in discontinuity– Left nephrectomy performed. – Procedure complicated by cardiac arrest

• ACLS x20 minutes – ROSC

– Abdomen packed, abthera placed and patient to ICU for resuscitation

Resuscitation

• In OR– 3L IVF, 12u PRBCs, 13u FFP, 2 Plt

• ICU Care– Hypoxemia resolved over next 24-36 hours– Vasopressors weaned off– Acidosis resolved, base deficit cleared

Hospital Course

• Return to OR POD 2 for abdominal washout, primary colonic anastomosis and replacement of vac

• POD 5 – return to OR for fascial closure• POD 8 – Patient with stool from midline wound –

return to OR for resection of anastomosis, end colostomy

• Patient Discharged to home three weeks from injury• Stoma reversed successfully 6 months later

Prior to Colonic Anastomosis

• Pt Base deficit had cleared• Vasopressors were off• Transfusion requirements post op were

minimal• Bowel appeared viable

• Why was it not successful?

Colonic Anastomosis in Trauma

Colon Anastomosis in Trauma

• 1979 Stone/Fabian found that in the stable patient, primary repair can be performed safely at initial operation without diversion

• This was subsequently confirmed with following studies with primary anastomosis also Seeing good results

• How then does the open Abdomen affect your ability to perform an anastomosis?

Damage Control Laparotomy

• “Damage Control” – Procedures and skills used to maintain/restore the watertight integrity, stability or offensive power of a warship.

• Damage Control Surgery – limit surgery to essential interventions – Control hemorrhage, limit enteric contamination

• Decision to perform damage control– Clinical decision– Objective signs

• Temp < 35C• pH <7.2• Base Deficit - > 15mmol/L• INR > 50% of normal

When is anastomosis appropriate?

• Difficult to study prospectively• Most data at this time is retrospective in

nature• Why risk it?– Repeat operations incur high risk

- 78 Damage Control Laparotomy with colon injury – 61 analyzed

- Findings- 16% leak rate of those patients receiving anastomosis

- In comparison to 1-3% leak rate in non damage control surgery- Leaks – longer ICU stay, decreased likelihood of fascial closure- Risks for Leaks

- Older Age - Failure to close fascia in five days

- This study also had 2/10 leaks in a defunctionalized anastomosis- Question then – does proximal diversion help in trauma setting?- Anastomotic breakdown is suggested to be more related to physiology

of severe injury

• 68 Patients with DCS with colonic injury– 41 with anastomosis, 27 diverted

• Leak = suture line disruption or EC fistula

– Leak rate – DCS compared to Non-DCS• 17%-6%

– When comparing leak vs no leak• No difference in transfusion requirement, anastomosis technique

– They did find significant difference in leak rate in those patients with vasopressor use between DC and operation when anastomosis was performed

Colon Anastomosis After Damage Control Laparotomy: Recommendations From 174 Trauma Colectomies

Ott, Mickey M. MD; Norris, Patrick R. PhD; Diaz, Jose J. MD; Collier, Bryan R. DO; Jenkins, Judith M. MSN; Gunter, Oliver L. MD; Morris, John A. Jr. MD

• Goal to compare leak rates between open abd pts and those primarily closed at first operation

• 174 patients with DCS with colonic injury– 58 with fecal diversion, 116 with colonic

anastomosis

Colon Anastomosis After Damage Control Laparotomy: Recommendations From 174 Trauma Colectomies

Ott, Mickey M. MD; Norris, Patrick R. PhD; Diaz, Jose J. MD; Collier, Bryan R. DO; Jenkins, Judith M. MSN; Gunter, Oliver L. MD; Morris, John A. Jr. MD

How should we proceed?

• Trauma patients who require damage control operations are under more physiologic stress

• Markers of transfusion requirements, acidosis, temperature, and vasopressor requirements are surrogates to prove their stressed state

• It is these factors one must consider when discussion anastomosis after a patient has an open abdomen

How has the literature helped

• Patients with massive transfusion requirements, left sided colon injuries and vasopressor requirements should most often be diverted

• Consideration of anastomosis beyond those factors remains a clinical judgment call.

Anticoagulation management after IVC ligation

Harold Bach MDLoyola University Medical Center

AB 2767036

• 22 y/o male involved in altercation at a bar• Sustained GSW to abdomen, mid-epigastric

region

• Unstable at OSH (Level II trauma center), so taken immediately to OR

• Liver injury attempted to be repaired

AB 2767036

• Upon arrival to trauma bay, patient intubated and sedated

• PRBC transfusing• HR 115 BP 140 systolic

• Abdomen open and packed

• Taken back to OR for exploration

AB 2767036

• At OR, diagnosed injuries included:– shredded IVC, – multiple areas of bleeding from IVC side branches

and side branches of aorta, – aorta without obvious injuries, – injury to lumbar vertebral body, – supraceliac aortic clamping time 50 minutes.

• Procedures included:– Damage Control Exploratory laparotomy, – ligation of infrarenal IVC, – packing of liver with Vicryl mesh, – packing of abdomen, – Abdomen left open with Bogota closure

• Taken back to ICU for resuscitation

AB 2767036

• Stabilized, taken back to OR PID #2– Found to additionally have a pancreatic head

injury and small bowel serosal injury

– Reexploration of recent laparotomy, – removal of packing, – abdominal washout, – placement of drains to retroperitoneum, – abthera vac placement

AB 2767036

• Returned to OR 2x more, eventually closed with feeding jejunostomy tube placed

• Post op course complicated by patient self-discontinuing retroperitoneal drains requiring IR replacement

• Began on coumadin, discharged home

AB 2767036

Abdominal IVC injuries

• Incidence– Penetrating 0.5-5%– Blunt 0.6-1%

• Mortality– 19%-66% in literature, widely reported around

40%

• Rx:– Lateral venorrhaphy• Patient stable• Technically feasible• Must have >25% luminal diameter remaining

– IVC ligation• Damage control

• The first report of an IVC ligation was by Kocher (1883).• Bilroth performed the procedure in 1885.

– These were for iatrogenic injuries to during surgery for malignant disorders in two patients.

– Both of these patients demised. • The first record of an infrarenal vena caval ligation with a

successful outcome was by Bottini.• Detrie reported the first survivor after a suprarenal

ligation.• By 1949 there were 136 reports of caval ligations in the

literature.

• DeBakey et al reported the first large series of AVC injuries in 1978. – 301 patients who had been identified with caval

injuries / 30 years. – The majority (234) were treated with repair while

only 32 received caval ligation. – Initial mortality rates in the 1950’s approached

100%.

• It was also historically a procedure employed to halt the propogation of LE DVT prior to anticoagulation therapy.

Sequelae of IVC ligation

• In repaired IVC, recommend surveillance via US or CT

• Ligated IVC?• Anticoagulation?• Role of prophylactic fasciotomies?

Questions:

• What are the EAST guidelines on treatment with anticoagulation after ligation of the infrarenal IVC?

• A) 3 months therapeutic anticoagulation• B) 6 months therapeutic anticoagulation• C) lifetime anticoagulation• D) there are no guidelines for treatment

Answer - D

Question

• Current guidelines suggest that patients with a destructive colon injury can undergo resection and primary anastomosis if

• A – There is no evidence of shock• B – Minimal underlying disease• C – Minimal associated injuries• D – There is no peritonitis• E – All the above are present

Answer - E

Question

• True/False : In penetrating renovascular trauma, preliminary vascular control decreases blood transfusions, decreases rate of nephrectomy and decreases blood loss.

Answer – False – Preliminary vascularControl has no impact on the above.