traumatic colon injury

Management of Management of Traumatic Colon Traumatic Colon

injuryinjuryGan Dunnington M.D.Gan Dunnington M.D.

Trauma ConferenceTrauma ConferenceStanford UniversityStanford University

7/24/067/24/06

Case ReportCase Report HPI: 16 yo boy involved in MVC as HPI: 16 yo boy involved in MVC as

restrained back seat passengerrestrained back seat passenger Trauma 97 – Report – ambulatory at scene, Trauma 97 – Report – ambulatory at scene,

c/o abd painc/o abd pain Airway intactAirway intact Breathsounds equalBreathsounds equal HR 76, BP 140/76, equal pulsesHR 76, BP 140/76, equal pulses GCS 15, MAE, AxOx3GCS 15, MAE, AxOx3 Impressive seatbelt sign, Large left flank Impressive seatbelt sign, Large left flank

eccymosis/fullnesseccymosis/fullness FAST negativeFAST negative CT – no solid organ injury, small amt free fluidCT – no solid organ injury, small amt free fluid

Case ReportCase Report

Hopital courseHopital course

Admitted to trauma for observation, Admitted to trauma for observation, pain control, spine consult for pain control, spine consult for question of compression fxquestion of compression fx

HD#4 develops tachycardia, HD#4 develops tachycardia, tachypnea, abd paintachypnea, abd pain

Hospital CourseHospital Course

OROR Exploratory laparotomy – midlineExploratory laparotomy – midline Suprafascial hematoma superiorlySuprafascial hematoma superiorly Devascularized portion of small bowel – Devascularized portion of small bowel –

8cm8cm Devascularized, necrotic, perforated Devascularized, necrotic, perforated

sigmoid colonsigmoid colon Minimal fecal contaminationMinimal fecal contamination

Large left flank hernia with hematomaLarge left flank hernia with hematoma

Hospital CourseHospital Course

Returned to ICU with open abdomen Returned to ICU with open abdomen for planned 2for planned 2ndnd look at fascia look at fascia

22ndnd look POD#2, fascia viable, bowel look POD#2, fascia viable, bowel healthy and fascia closed, skin left openhealthy and fascia closed, skin left open

Intermittent fevers post-op, but Intermittent fevers post-op, but currently doing well, tolerating diet, currently doing well, tolerating diet, stoma functioning, dispo planningstoma functioning, dispo planning

Plan colostomy reversal in approx 3 Plan colostomy reversal in approx 3 months, then will plan later lumbar months, then will plan later lumbar hernia repairhernia repair

Traumatic Colon InjuryTraumatic Colon Injury

Incidence: Incidence: 22ndnd most frequent injury in GSW most frequent injury in GSW 33rdrd most frequent in stab wounds most frequent in stab wounds Relatively infrequent after blunt trauma Relatively infrequent after blunt trauma

(2-5%)(2-5%) Morbidity – 20-35%Morbidity – 20-35% Mortality – 3-15%Mortality – 3-15%

Traumatic Colon InjuryTraumatic Colon Injury

Assessment:Assessment: Physical exam Physical exam

Peritoneal signsPeritoneal signs Rectal exam – blood Rectal exam – blood

is fairly sensitiveis fairly sensitive DPLDPL

X-ray, CTX-ray, CT GSW mandates GSW mandates

operationoperation

HistoryHistory Historically colon repair a failure until WWIHistorically colon repair a failure until WWI 1943 - Due to failure rate Major General W.H. 1943 - Due to failure rate Major General W.H.

Ogilvie mandated colostomyOgilvie mandated colostomy 1950’s –improvements in trauma care, and 1950’s –improvements in trauma care, and

surgeons began to challenge “diversion dogma”surgeons began to challenge “diversion dogma” 1979 – Stone and Fabian –prospective study 1979 – Stone and Fabian –prospective study

confirmed safety and efficacy of primary repair in confirmed safety and efficacy of primary repair in selected patientsselected patients

Exteriorization in 1960’s-70’s abandonedExteriorization in 1960’s-70’s abandoned 1980’s – present – greater move to primary 1980’s – present – greater move to primary

repairrepair

Risk factors for primary Risk factors for primary repairrepair

Delayed treatment (>12hrs)Delayed treatment (>12hrs) Prolonged shockProlonged shock Gross fecal contaminationGross fecal contamination >4-6 units PRBC’s transfused>4-6 units PRBC’s transfused Need for mesh to close abdominal Need for mesh to close abdominal

wallwall

Trauma grading scoresTrauma grading scores

Flint gradingFlint grading I – isolated colon, no shock, minimal I – isolated colon, no shock, minimal

contamination, minimal delaycontamination, minimal delay II – Through and through perforation, II – Through and through perforation,

laceration, moderate contaminationlaceration, moderate contamination III – severe tissue loss, III – severe tissue loss,

devascularization, heavy contaminationdevascularization, heavy contamination Advantage – simplicityAdvantage – simplicity Disadvantage – does not factor in Disadvantage – does not factor in

other injuryother injury


Penetrating Penetrating Abdominal Trauma Abdominal Trauma Index – combined Index – combined severity of injury severity of injury to individual abd to individual abd organs assessed organs assessed operativelyoperatively Disadvantage – Disadvantage –

does not take into does not take into account rest of account rest of bodybody

Lewis et al. Ann Surg. 1989


Lewis et al. Ann Surg. 1989

Therapeutic optionsTherapeutic options

Two stageTwo stage Repair and protective-ostomyRepair and protective-ostomy Resection and stoma formation proximallyResection and stoma formation proximally

Distal Hartmann’s or mucous fistulaDistal Hartmann’s or mucous fistula Exteriorization of repaired bowel – Exteriorization of repaired bowel –

uncommon nowuncommon now One stageOne stage

Simple suture repairSimple suture repair Resection and primary anastamosisResection and primary anastamosis

AnastamosisAnastamosis Stapled vs. Hand-SewnStapled vs. Hand-Sewn

Brundage et al. J trauma. Brundage et al. J trauma. 19991999

Multicenter retrospective Multicenter retrospective cohort designcohort design

““anastamotic leaks and anastamotic leaks and intra-abdominal intra-abdominal abscesses appear to be abscesses appear to be more likely with stapled more likely with stapled bowel repairs compared bowel repairs compared with sutured with sutured anastamoses in the anastamoses in the injured patient. Caution injured patient. Caution should be exercised in should be exercised in deciding to staple a deciding to staple a bowel anastomosis in the bowel anastomosis in the trauma patient.”trauma patient.”

AnastamosisAnastamosis Burch et al. Ann of Surg. Burch et al. Ann of Surg.

1999.1999. Prospective randomized Prospective randomized

trial of single-layer trial of single-layer continuous vs. two layer continuous vs. two layer interrupted intestinal interrupted intestinal anastamosisanastamosis

NB: Important to invert, NB: Important to invert, 4-6mm seromuscular 4-6mm seromuscular bites, 5mm advances, bites, 5mm advances, larger bites at mesenteric larger bites at mesenteric border border

Single layer – similar leak Single layer – similar leak rate (approx 2%), rate (approx 2%), cheaper, fastercheaper, fasterBurch et al. Ann Surg. 1999

StudiesStudies Review: Tzovaras et al. New Trends in

Management of colon trauma. Injury. 2005 Fabian and Stone study criticized for excluding Fabian and Stone study criticized for excluding

48% before randomization48% before randomization 3 prospective studies – consecutive patients 3 prospective studies – consecutive patients

without exclusion criteriawithout exclusion criteria

StudiesStudies 3 prospective randomized trials comparing 3 prospective randomized trials comparing

diversion to primary repair without exclusion diversion to primary repair without exclusion criteriacriteria

Authors all conclude primary repair should be first Authors all conclude primary repair should be first treatment in civilian penetrating colon traumatreatment in civilian penetrating colon trauma

Tzovaras et al. New Trends in Management of colon trauma. Injury. 2005

StudiesStudies Demetriades et al. ‘92 – prospective study of 100 GSW to Demetriades et al. ‘92 – prospective study of 100 GSW to

coloncolon Routine colostomy on all resections (16 pts)Routine colostomy on all resections (16 pts) 37.5% abdominal septic complication rate37.5% abdominal septic complication rate

Stewart et al. ’94 reviewed series of 60 pts who required Stewart et al. ’94 reviewed series of 60 pts who required resectionsresections 43 primary anastamosis, 17 with diversion 43 primary anastamosis, 17 with diversion Abdominal sepsis in 37% anastamosis, 29% diversionAbdominal sepsis in 37% anastamosis, 29% diversion Leak in 14% total, 33% if >6U PRBC’sLeak in 14% total, 33% if >6U PRBC’s

Murray et al ‘99– retrospective series of 140pts requiring Murray et al ‘99– retrospective series of 140pts requiring resectionresection 80% anastamosis, 20% diversion80% anastamosis, 20% diversion

Equal abdominal sepsis ratesEqual abdominal sepsis rates 4% leak ileocolic, 13% leak in colocolostomy4% leak ileocolic, 13% leak in colocolostomy

StudiesStudies Cornwell et al. ‘98 – prospective study of 27 Cornwell et al. ‘98 – prospective study of 27

pts requiring resectionpts requiring resection All had delay>6hrs, >6U prbc’s, or PATI>25All had delay>6hrs, >6U prbc’s, or PATI>25 25pts had primary anastamosis, 2 with colostomy25pts had primary anastamosis, 2 with colostomy Abd septic complications in 20% anastamosis Abd septic complications in 20% anastamosis

group, 2 leaks and both fatalgroup, 2 leaks and both fatal Demetriades et al. ‘01– propective, Demetriades et al. ‘01– propective,

multicenter on penetrating colon injuries multicenter on penetrating colon injuries requiring resectionrequiring resection 22% complication with primary repair, 27% 22% complication with primary repair, 27%

diversiondiversion 3 risk factors – severe fecal contam., >4U prbc, 3 risk factors – severe fecal contam., >4U prbc,

single agent abxsingle agent abx Type of management did not affect complications Type of management did not affect complications

StudiesStudies

Hudolin et al. Br. J Surg. 2005– Role of Hudolin et al. Br. J Surg. 2005– Role of primary repair of colon injuries in wartimeprimary repair of colon injuries in wartime 5370 casualties – 259 (4.8%) with colon injuires5370 casualties – 259 (4.8%) with colon injuires

122 had primary repair, 137 had colostomy122 had primary repair, 137 had colostomy 58% explosive, 42% gsw, 1pt had stab wound58% explosive, 42% gsw, 1pt had stab wound Associated injury in 96%Associated injury in 96%

Complications in 27% primary repair, 30% Complications in 27% primary repair, 30% colostomycolostomy

Mortality 8% and 7% respectivelyMortality 8% and 7% respectively Conclusion – primary repair safe and effective Conclusion – primary repair safe and effective

treatment for colon injuries during wartreatment for colon injuries during war

StudiesStudies

Adedoyin et al. – 60 pts over 10 yrsAdedoyin et al. – 60 pts over 10 yrs No difference in outcome of primary No difference in outcome of primary

repair vs. colostomyrepair vs. colostomy Colostomy closure related morbidity Colostomy closure related morbidity

21%, mortality 5%21%, mortality 5%

StudiesStudies

Multiple studies show no difference in Multiple studies show no difference in complication rates between right and left complication rates between right and left colon injuries repaired primarilycolon injuries repaired primarily

Eshraghi N et al. J Trauma. 1998Eshraghi N et al. J Trauma. 1998 Survey of trauma surgeons AAST membersSurvey of trauma surgeons AAST members 30% never diverted, 1% always diverted30% never diverted, 1% always diverted High velocity GSW only indication where High velocity GSW only indication where

majority divertedmajority diverted Negative correlation between surgeon age and Negative correlation between surgeon age and

preference for anastamosispreference for anastamosis Lower volume surgeons preferred diversionLower volume surgeons preferred diversion

EAST GuidelinesEAST Guidelines

Published in 1998Published in 1998 Level ILevel I

Sufficient class I and class II data to Sufficient class I and class II data to support primary repair for support primary repair for nondestructive colon wounds(<50% nondestructive colon wounds(<50% bowel wall without devascularization), bowel wall without devascularization), in the absence of peritonitisin the absence of peritonitis


Level IILevel II Patients with penetrating Patients with penetrating

intraperitoneal colon wounds which are intraperitoneal colon wounds which are destructive can undergo resection and destructive can undergo resection and primary anastomosis if they are:primary anastomosis if they are: Hemodynamically stable without shockHemodynamically stable without shock Have no significant underlying diseaseHave no significant underlying disease Have minimal associated injuriesHave minimal associated injuries Have no peritonitisHave no peritonitis


Level IILevel II Patients with shock, underlying disease, Patients with shock, underlying disease,

significant associated injuries, or peritonitis significant associated injuries, or peritonitis should have destructive colon wounds managed should have destructive colon wounds managed by resection and colostomyby resection and colostomy

Colostomies after trauma can be closed within 2 Colostomies after trauma can be closed within 2 weeks if contrast enema is performed in distal weeks if contrast enema is performed in distal colon if no unresolved sepsis, instability, nor colon if no unresolved sepsis, instability, nor non-healing bowel injurynon-healing bowel injury

BE not necessary to r/o cancer or polyps prior BE not necessary to r/o cancer or polyps prior to colostomy closure for trauma patients who to colostomy closure for trauma patients who otherwise have no risk factors.otherwise have no risk factors.

SummarySummary

Colon trauma carries significant Colon trauma carries significant morbidity and mortalitymorbidity and mortality

Choice of diversion vs. primary repair Choice of diversion vs. primary repair should be individualized to situationshould be individualized to situation

Move towards more primary repairs and Move towards more primary repairs and resections with anastamosis without resections with anastamosis without colostomycolostomy

Right colon = Left colon for managementRight colon = Left colon for management Suture>Stapled for trauma?Suture>Stapled for trauma?

traumatic colon injury

Documents

trauma care

blunt trauma

j trauma

trauma grading scoreslewis

bowel healthy

bowel anastomosis

frequent injury

efficacy of primary