Colorectal Trauma

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Colorectal Trauma

• 12/15/10

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Colon injuries

• No other organ injury associated with a higher
  septic complication rate
• Incidence can approach 27
• In patients with colon injuries with Penetrating
  Abdominal Trauma Index (PATI) gt25 or multiple
  blood transfusions
• In patients with destructive colon injuries
  requiring resection, reported incidence of
  abdominal complications is 24

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Epidemiology

• Vast majority caused by penetrating trauma
• GSW
• Second most commonly injured organ in A/P GSW
• Involved in about 27 of cases undergoing
  laparotomy
• Transverse colon most frequently involved
• KSW
• Most frequently injured organ in posterior stab
  wounds
• Involved in 20 of laparotomies
• Third most commonly injured organ in anterior
  stab wounds
• Involved in 18 of cases undergoing laparotomy
• Left colon most frequently involved

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Epidemiology

• Blunt trauma is uncommon
• Most are partial thickness injuries
• Only 3 are full-thickness perforations
• Most are due to traffic accidents
• Seatbelt sign is a predictor of hollow viscous
  injury
• Deceleration injuries can cause avulsion of the
  mesentery leading to ischemia
• Blowout perforations can occur due to transient
  closed loop obstructions
• Hematoma or contusion may present as delayed
  perforation
• Left colon gt Right colon gt Transverse colon

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Diagnosis

• Mostly made at the time of surgery
• Rectal exam may show blood in the stool if distal
  colon or rectum are injured
• CXR may show free air
• Gastrograffin enema or CT with rectal contrast
  probably the best way to evaluate the colon
  radiographically
• Retroperitoneal gas or contrast extravasation are
  diagnostic
• Ultrasound and DPL have no role in diagnosing
  colon injuries

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Diagnosis

• May be more difficult with blunt trauma
• Especially with associated head trauma
• Free gas or thickened colon wall on CT may raise
  suspicion
• Diagnosis may be delayed with catastrophic
  consequences

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Paracolic Hematomas

• Every paracolic hematoma caused by penetrating
  trauma should be explored and the underlying
  colon evaluated carefully
• Those caused by blunt trauma should not undergo
  routine exploration unless there is evidence of
  perforation

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AAST Colon Injury Scale
Grade Injury description
I Contusion or hematoma without devascularization Partial thickness laceration
II Laceration 50 of circumference
III Laceration 50 of circumference
IV Transection of the colon
V Transection of the colon with segmental tissue loss
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Operative Management

• During WW II, first published guidelines mandated
  proximal diversion or exteriorization of all
  colon wounds
• Significantly reduced mortality in the last years
  of the war
• Remained unchanged until late 70s
• Stone and Fabian reported that primary repair was
  associated with fewer complications than
  colostomy
• Exclusion criteria (hypotension, multiple
  associated injuries, destructive colon injuries,
  and delayed operations) were considered risk
  factors for anastomotic leak and were absolute
  indications for diversion

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Operative Management

• Exteriorized repair (1970s)
• Sutured colon was exteriorized and observed for
  4-5 days
• If repair remained intact, in was delivered back
  into abdomen
• If it leaked, it was converted to loop colostomy
• Still skepticism by many that primary repair is
  safe

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Operative Management

• Nondestructive colon injuries
• May be safely managed with primary repair,
  irrespective of risk factors
• Destructive colon injuries
• Resection and primary repair is considered
  standard
• Exception is small subgroup of patients with
  certain risk factors
• Hemodynamic instability
• PATI gt25
• Multiple blood transfusions
• Associated medical illness

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Risk Factors for Complications

• Sepsis rate of about 20
• Complication rate of 28 in destructive lesions
• No difference in healing of R vs L sided injuries
• Shock is neither risk factor for sepsis nor
  contradiction for primary repair or anastamosis
• Multiple associated intraabdominal injuries are
  significant risk factor for intraabdominal sepsis
  
• Method of management does not affect incidence
• Some studies have shown an ostomy may contribute
  to sepsis

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Risk Factors for Complications

• Multiple blood transfusions (gt4 units/24 hrs) is
  a major risk factor for septic complications
• Fecal contamination is major risk factor for
  sepsis
• Injury severity score is not a risk factor and
  high scores (gt15) are not contraindication for
  primary repair or anastomosis
• Time from injury to operation may result in more
  contamination, which seems to be more important
  than actual time period

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Risk Factors for Complications

• Retained missiles are not associated with
  increased risk of infection
• Should be removed only if technically easy and
  does not prolong surgery
• Colostomies may want to be avoided in open
  abdomens

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Anastomotic Leaks

• Most dreaded complication, but incidence fairly
  low (2.2--9)
• Leak rate after resection and anastomosis is
  higher than simple repair
• Risk factors are not well defined
• Higher for colocolostomies (gt10 vs 4)
• External fecal fistulas can be safely managed
  nonoperatively with low-residue diet
• Local abscess can be drained percutaneously

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Techniques

• Debridement of perforation
• To normal, well-perfused edges
• Anastomosis tension-free
• Hand-sewn or stapled anastomosis is surgeon
  preference
• Protect anastomosis with omentum
• Consider fibrin glue

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Rectal Trauma

• Usually result from penetrating trauma
• GSW 80-85
• KSW 3-5
• Uro, Gyn, endoscopic procedures
• Sexual misadventure
• Anorectal foreign bodies
• Blunt trauma accounts for 5-10
• Pelvic fractures, impalement

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Diagnosis

• Extraperitoneal injuries may not be obvious
• Digital rectal exam and proctosigmoidoscopy

Grade Injury Description
I Contusion or hematoma without devascularization Partial-thickness laceration
II Laceration 50 of circumference
III Laceration 50 of circumference
IV Full-thickness laceration with extension into the perineum
V Devascularized segment
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Operative Management

• Parallels colon trauma
• Diversion with colostomy
• Presacral drainage
• Not recommended
• Distal rectal washout
• Not recommended
• Repair of injury

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Operative Management

• Rarely, APR has been described for severe
  bleeeding, massive tissue loss, or
  devascularizing injuries
• With concomitant injuries of genitourinary tract,
  both injuries should be closed and separated with
  well-vascularized tissue (omentum)

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Rectal Foreign Bodies

• Most can be safely removed in the ED (75)
• Small percentage require laparotomy with colotomy
  for extraction(8)
• Only independent risk factor was sigmoid location
• Signs of peritonitis should prompt emergent trip
  to OR
• Otherwise, bedside retrieval or sedation in OR
  with transanal extraction should be attempted
• If unsuccessful, laparotomy may help maneuver
  into rectum
• Colotomy may be necessary for retrieval

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