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Colorectal Trauma

Colorectal Trauma

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Colorectal Trauma

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  1. Colorectal Trauma 12/15/10

  2. 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) >25 or multiple blood transfusions • In patients with destructive colon injuries requiring resection, reported incidence of abdominal complications is ~24%

  3. 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

  4. Epidemiology • Blunt trauma is uncommon • Most are partial thickness injuries • Only 3% are full-thickness perforations • Most are due to traffic accidents • Seatbeltsign 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 closedloop obstructions • Hematoma or contusion may present as delayed perforation • Left colon > Right colon > Transverse colon

  5. 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

  6. 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

  7. 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

  8. AAST Colon Injury Scale May be used for the calculation of the Injury Severity Score (ISS)

  9. 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 ‘70’s • 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

  10. Operative Management • Exteriorized repair (1970’s) • 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

  11. 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 >25 • Multiple blood transfusions • Associated medical illness

  12. 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

  13. Risk Factors for Complications • Multiple blood transfusions (>4 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 (>15) 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

  14. 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

  15. 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 (>10% vs 4%) • External fecal fistulas can be safely managed nonoperatively with low-residue diet • Local abscess can be drained percutaneously

  16. 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

  17. 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

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

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

  20. 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)

  21. 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