Management of Traumatic Colon injury 11.05.10 PM

Management of Traumatic Colon injury 11.05.10 PM -...

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Unformatted text preview: Management of Management of Traumatic Colon injury Gan Dunnington M.D. Trauma Conference Stanford University 7/24/06 Case Report Case Report HPI: 16 yo boy involved in MVC as restrained back seat passenger Trauma 97 – Report – ambulatory at scene, c/o abd pain Airway intact Breathsounds equal HR 76, BP 140/76, equal pulses GCS 15, MAE, AxOx3 Impressive seatbelt sign, Large left flank eccymosis/fullness FAST negative CT – no solid organ injury, small amt free fluid Case Report Case Report Case Report Case Report Case Report Case Report Hopital course Hopital course Admitted to trauma for observation, pain control, spine consult for question of compression fx HD#4 develops tachycardia, tachypnea, abd pain Hopital course Hopital course Hospital Course 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 Hopital course Hopital course Hospital Course Hospital Course Returned to ICU with open abdomen for planned 2nd look at fascia 2nd look POD#2, fascia viable, bowel healthy and fascia closed, skin left open Intermittent fevers post­op, but currently doing well, tolerating diet, stoma functioning, dispo planning Plan colostomy reversal in approx 3 months, then will plan later lumbar hernia repair Traumatic Colon Injury Traumatic Colon Injury Incidence: 2nd most frequent injury in GSW 3rd most frequent in stab wounds Relatively infrequent after blunt trauma (2­5%) Morbidity – 20­35% Mortality – 3­15% Traumatic Colon Injury Traumatic Colon Injury Assessment: Physical exam Peritoneal signs Rectal exam – blood is fairly sensitive DPL X­ray, CT GSW mandates operation History History Historically colon repair a failure until WWI 1943 ­ Due to failure rate Major General W.H. Ogilvie mandated colostomy 1950’s –improvements in trauma care, and surgeons began to challenge “diversion dogma” 1979 – Stone and Fabian –prospective study confirmed safety and efficacy of primary repair in selected patients Exteriorization in 1960’s­70’s abandoned 1980’s – present – greater move to primary repair Risk factors for primary repair Risk factors for primary repair Delayed treatment (>12hrs) Prolonged shock Gross fecal contamination >4­6 units PRBC’s transfused Need for mesh to close abdominal wall Trauma grading scores Trauma grading scores Flint grading I – isolated colon, no shock, minimal contamination, minimal delay II – Through and through perforation, laceration, moderate contamination III – severe tissue loss, devascularization, heavy contamination Advantage – simplicity Disadvantage – does not factor in other injury Trauma grading scores Trauma grading scores Penetrating Abdominal Trauma Index – combined severity of injury to individual abd organs assessed operatively Disadvantage – does not take into account rest of body Lewis et al. Ann Surg. 1989 Trauma grading scores Trauma grading scores Lewis et al. Ann Surg. 1989 Therapeutic options Therapeutic options Two stage Repair and protective­ostomy Resection and stoma formation proximally Distal Hartmann’s or mucous fistula Exteriorization of repaired bowel – uncommon now One stage Simple suture repair Resection and primary anastamosis Anastamosis Anastamosis Stapled vs. Hand­Sewn Brundage et al. J trauma. 1999 Multicenter retrospective cohort design “anastamotic leaks and intra­abdominal abscesses appear to be more likely with stapled bowel repairs compared with sutured anastamoses in the injured patient. Caution should be exercised in deciding to staple a bowel anastomosis in the trauma patient.” Anastamosis Anastamosis Burch et al. Ann Surg. 1999 Burch et al. Ann of Surg. 1999. Prospective randomized trial of single­layer continuous vs. two layer interrupted intestinal anastamosis NB: Important to invert, 4­ 6mm seromuscular bites, 5mm advances, larger bites at mesenteric border Single layer – similar leak rate (approx 2%), cheaper, faster Studies Studies Review: Tzovaras et al. New Trends in Management of colon trauma. Injury. 2005 Fabian and Stone study criticized for excluding 48% before randomization 3 prospective studies – consecutive patients without exclusion criteria Studies Studies 3 prospective randomized trials comparing diversion to primary repair without exclusion criteria Tzovaras et al. New Trends in Management of colon trauma. Injury. 2005 Authors all conclude primary repair should be first treatment in civilian penetrating colon trauma Studies Studies Demetriades et al. ‘92 – prospective study of 100 GSW to colon Stewart et al. ’94 reviewed series of 60 pts who required resections Routine colostomy on all resections (16 pts) 37.5% abdominal septic complication rate 43 primary anastamosis, 17 with diversion Abdominal sepsis in 37% anastamosis, 29% diversion Leak in 14% total, 33% if >6U PRBC’s 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 Studies Studies Cornwell et al. ‘98 – prospective study of 27 pts requiring resection All had delay>6hrs, >6U prbc’s, or PATI>25 25pts had primary anastamosis, 2 with colostomy Abd septic complications in 20% anastamosis group, 2 leaks and both fatal Demetriades et al. ‘01– propective, multicenter on penetrating colon injuries requiring resection 22% complication with primary repair, 27% diversion 3 risk factors – severe fecal contam., >4U prbc, single agent abx Type of management did not affect complications Studies 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 Studies 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% Studies 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 EAST Guidelines EAST Guidelines Published in 1998 Level I Sufficient class I and class II data to support primary repair for nondestructive colon wounds(<50% bowel wall without devascularization), in the absence of peritonitis EAST Guidelines 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 EAST Guidelines 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 non­healing bowel injury BE not necessary to r/o cancer or polyps prior to colostomy closure for trauma patients who otherwise have no risk factors. Summary 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? ...
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