Management of Traumatic Colon

injury

www.gims-org.com
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
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
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
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 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
 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%
 Traumatic Colon Injury
• Assessment:
– Physical exam
• Peritoneal signs
• Rectal exam – blood is
fairly sensitive
• DPL
– X-ray, CT
– GSW mandates
operation
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’s-70’s abandoned
• 1980’s – present – greater move to primary repair
 Risk factors for primary repair
• Delayed treatment (>12hrs)
• Prolonged shock
• Gross fecal contamination
• >4-6 units PRBC’s transfused
• Need for mesh to close abdominal wall
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
• 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

Lewis et al. Ann Surg. 1989

Therapeutic options
• Two stage
– Repair and protective-ostomy
– 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
• 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.”
 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
Burch et al. Ann Surg. 1999 rate (approx 2%), cheaper,
faster
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
• 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
• 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 >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
• 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
• 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
• 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
• 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
• 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
• 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
• 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.
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?