Epidemiology
2nd most commonly injured organ c Penetrating Trauma
75% GSW
20% Stab Wounds
5% Blunt
History
World War I
Wallace, 1917: 59% overall mortality
- Minimal experience - conservative approach by french and british at onset of WW1 --> 118,000 deaths --> changed to surgical approach in 1915
- No mobilization of colon, rare resuscitation or antibiotics, surgery was rarely < 6 hours after injury
Isolated SB Injuries – 66% Mortality
3 British Surgeons - Fraser, Wallace and Gordon-Taylor independently concluded at the end of WW1 that: 1. Most colon injuries treatable with primary suture; 2. Some benefit to proximal colostomies for extensive or descending colon injuries.
World War II (The 2 Edicts)
1943 - Ogilvie urges use of diverting ostomies
Mortality Rate 53%
–Primary Repair Mortality 50% (10/20)
–Colostomy Mortality 59% (49/83) (? sicker patients)
1943 - US Surgeon General order: All US armed forces with colon injuries sustained in battle, should be treated with diverting ostomy
End of WW II - Mortality: 5-30%
Reduction in Mortality Attributed to Increased Use of Ostomies
Established standard for >40 years
Factors Improving Mortality Rate in Colon Trauma
More Seasoned Surgeons
Improved Evacuation from the Front Line and Earlier Surgical Intervention
Safer Anesthesia
Use of Antibiotics
Availability of Blood Products
Fluid Resuscitation
Not Everything Which Makes Sense is True
- Through the end of WWII, every series of colon trauma patients in which both primary repair and ostomy formation were performed, demonstrated lower mortality c primary repair.
Colon Trauma - Re-evaluation
1951 - Woodhall and Ochsner
Management of 50 Civilian Trauma Pts c Colon Injuries
–Primary Repair Mortality 8.3% (2/24)
–Colostomy Mortality 35% (9/26)
Nonrandomized but Questioned Benefit of Routine Ostomy
Primary Closure vs. Ostomy 1979 - Stone and Fabian
Prospective, Randomized, Non blinded Study of 268 patients over 44 months
- LOS: primary repair 17 days; ostomy 22 days (33 w/ TD)
- Wound infection: primary repair 48%; ostomy 57%
- Abscess: 15%, 29%
Exclusion criteria: BP < 80/60; Blood Loss > 1000 ml; > 2 Abdominal Organ Systems Injured; Large Soft Tissue Loss; TTP > 8 Hours; Significant Fecal Soiling; Colon Injury requiring Resection (“Destructive”);
Meta-analysis of non-destructive civilian colon trauma
Mortality: PR 0.11%, Ostomy: 0.14%
Overall complications: PR: 14%; Ostomy: 30%;
Abscess: PR: 5%; Ostomy: 12%
Leak: PR: 2%; Ostomy 1-2%;
Nondestructive Colon Injuries
Presence of Previous 1st Column Exclusion Criteria associated c Abscess (but not leak) rates regardless of whether PR or Diversion done
1998 ETA Guidelines
Primary Repair for all Non-destructive Colon Trauma
Primary Repair of Low Risk Destructive Colon Trauma
Diversion for High Risk Destructive Colon Trauma
- 1. Shock requiring >6uPRBC; 2. Significant concurrent injuries; 3. Medical comorbidities
Recs for Destructive Injuries based on 52 cases available from Class 1 & 2 Studies: 3.8% leak rate with 0% mortality
Also Considered 303 cases from Class 3 Studies: 5% leak rate with 19% mortality
Risk for Leak appeared increased c:
- 1. Shock requiring >6uPRBC; 2. Significant concurrent injuries; 3. Medical comorbidities
Need for Prospective Study c Destructive Injuries Recognized
AAST Trial c Destructive Civilian Colon Trauma
Prospective Study involving 19 Centers
297 patients -->
--> 197 anastamosis: 22% CR morbidity, 0% mortality
--> 100 Diversion: 27% CR morbidity, 4% mortality
Lack of Randomization Compensated for c MV Analysis which confirmed no increased risk c Primary Anastomosis
Conclusion: PA should be considered in ALL civilian colon trauma
Damage Control Surgery
46 patients with penetrating abdominal trauma who required > 10 units of PRBC’s
10/13 patients underwent stapling-off of the colon injury and survived
1/9 patients underwent definitive therapy survived
Dictum: In damage control surgery, get out!
Delayed Primary Anastamosis
Ordonez C, et al. Is it feasible & safe to perform a deferred primary anastomosis in critically ill patients with severe secondary peritonitis? 2006 AAST presentation
23/26 underwent DPA c 3 fistulas (11.5%) & no mortality
Historical Control matched comparison c 34 DPA patients VS 78 Diversion pts
Equivalent outcomes
? Decreased ARDS rate in DPA pts (reflection of decreasing ARDS rates more recently seen overall?)
DPA after DC Surgery – the 2000-06 Wake Forest Experience
55 Destructive colon injuries --> 33 definitive procedure
--> 33 definitive procedure - 21 anastamosis, 12 ostomy
--> 22 damage control - 11 DPA (6 right, 4 left), 3 died early, 6 ostomy, 2 primary anastamosis
DPA after DC Surgery – the 2001-07 Alabama Experience
Problems c Alabama Experience
Excessive Re-looking
Ostomy M/M not inclusive of Takedown
DPA after DC Surgery – the Colorado Experience
309 Colon Injuries over 7 years -->
- 280 (91%) SL --> 278 (99%) PA (with 1 (0.3%) leak), 2 (1%) ostomy
- 29 DC --> 21 DPA (mean 2.6 days) (with 4 (17%) leaks), 4 ostomies, 4 early deaths
Columbian DPA Experience
Retrospective Review
2003-2009
Stapled or single layer running anastamosis
At 1st or 2nd take-back (within 72 hr)
We believe that a DA should be performed in all patients with DCI undergoing DCL, but is not recommended in patients with recurrent intra-abdominal abscesses, severe bowel wall edema and inflammation, or persistent metabolic acidosis. In these patients, a colostomy should be performed.
Colon Trauma – Current Management
Primary Repair
Damage Control Stapling + Delayed PR/A or ostomy
Combat Colon Trauma
High Velocity
Prolonged Transport
Limited Resources
Colon Trauma – SSTP Experience
16 patients c 21 Colon Injuries
Mean ISS 21 (4-34)
Mean 2.6 concurrent serious injuries (0-6)
RC – 5
TC – 10
LC – 3
SC - 3
Colon Trauma:
Non-Colon Complications
1 Empyema (Resection & Anastomosis Pt)
1 Wound Infection (DC Pt)
1 Traumatic Intubation (Primary Repair Pt)
Colon Injury Grading
Grade 1 - contusion or partial-thickness lac
Rx: observe or oversew
Grade 2 - Lac < 50% circumferential
Rx: close or resect and anastamosis
Grade 3 - Lac > 50% circumfrential
Rx: resect and anastamosis
Grade 4 - transection
Rx: resect and anastamosis
Grade 5 - transection with segmental loss or devascularized segment
Rx: resect and anastamosis