Management of Traumatic Colon injury

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Management of Traumatic Colon injury

• Gan Dunnington M.D.
• Trauma Conference
• Stanford University
• 7/24/06

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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

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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
• HD4 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 for planned 2nd
  look at fascia
• 2nd look POD2, 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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Traumatic Colon Injury

• Assessment
• Physical exam
• Peritoneal signs
• Rectal exam blood is fairly sensitive
• DPL
• X-ray, CT
• GSW mandates operation

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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 surgeons
  began to challenge diversion dogma
• 1979 Stone and Fabian prospective study
  confirmed safety and efficacy of primary repair
  in selected patients
• Exteriorization in 1960s-70s abandoned
• 1980s present greater move to primary repair

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Risk factors for primary repair

• Delayed treatment (gt12hrs)
• Prolonged shock
• Gross fecal contamination
• gt4-6 units PRBCs transfused
• Need for mesh to close abdominal wall

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Trauma grading scores

• Flint grading
• I isolated colon, no shock, 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

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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
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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 retrospective cohort design
• anastamotic leaks and intra-abdominal 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.

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Anastamosis

• Burch et al. Ann of Surg. 1999.
• Prospective randomized trial of single-layer
  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

Burch et al. Ann Surg. 1999
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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

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Studies

• 3 prospective randomized trials comparing
  diversion to primary repair without exclusion
  criteria
• Authors all conclude primary repair should be
  first treatment in 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 gt6U 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 pts
  requiring resection
• All had delaygt6hrs, gt6U prbcs, or PATIgt25
• 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., gt4U prbc,
  single agent abx
• 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(lt50 bowel wall without devascularization),
  in the absence of peritonitis

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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
• SuturegtStapled for trauma?