Discontinuity of the Bowel Following Damage Control Operation Revisited: A Multi-institutional Study

A decade long overview of damage control laparotomy for abdominal gunshot wounds

PURPOSE

Over the last three decades, damage control laparotomy (DCL) has become important in the management of abdominal gunshot wounds (GSW). This paper reviews the experience of a single institution over a decade with the use of DCL for GSW of the abdomen.

METHODS

Longitudinal data (2013-2022) was collected from the Hybrid Electronic Medical Registry database to identify all patients with an abdominal GSW over the study period. The data was stratified based on patients who underwent DCL and those who did not. Descriptive analysis was completed to summarise the raw data. Univariate and multivariate analysis was completed to identify variables associated with undergoing DCL.

RESULTS

There were 135 patients (32%) who underwent DCL and 290 patients (68%) who did not. Colonic, small bowel, mesenteric, hepatic, pancreatic and intra-abdominal vessel injuries were associated with the need for DCL (P<0.05). In total, 85 of the 135 (63%) patients who underwent DCL required more than one damage control technique. There were 45 (33%) mortalities in the DCL group compared to 16 mortalities (6%) in the non-DCL group (P<0.001).

CONCLUSION

One third of patients who underwent a laparotomy following a gunshot wound to the abdomen had a DCL. The indications for DCL include both physiological criteria and injury patterns. DCL is associated with significant morbidity and mortality. Efforts need to be directed towards refining the indications for DCL in this group of patients to prevent inappropriate application of this potentially lifesaving technique.

Proximal protective diverting ostomy following colon anastomosis for penetrating trauma may not be protective: A matched cohort study

INTRODUCTION

Despite the shift toward liberal primary anastomosis in penetrating colon injuries, some surgeons recommend a protective diverting ostomy (DO) proximal to the anastomosis. This study evaluates the effect of DO on outcomes in patients undergoing colon resection and anastomosis following penetrating trauma.

METHODS

The TQIP database (2013-2018) was queried for penetrating colon injuries undergoing colectomy and anastomosis. Patients receiving DO were propensity matched to patients without diverting ostomy (woDO) (1:3). Outcomes were compared between groups.

RESULTS

After matching, 89 DO patients were analyzed. The DO group had more surgical site infections (32 ​% vs. 21 ​%; p ​< ​0.05) and longer hospital stay (20 [13-27] vs. 15 [9-25]; p ​< ​0.05) compared to the woDO group. Mortality and unplanned operations were similar between groups.

CONCLUSIONS

Diverting ostomy after colon resection and anastomosis is associated with increased infectious complications without decreasing unplanned operations or mortality. Its routine role in penetrating colon trauma needs reassessment.

Gastrointestinal Discontinuity After Emergency Laparotomy

During laparotomy, patients requiring intestinal resection may be temporarily left in gastrointestinal discontinuity (GID). We performed this study to determine predictors of futility for patients initially left in GID after emergency bowel resection. We divided the patients into 3 groups: never restored continuity and died (group 1), restored continuity and died (group 2), and restored continuity and survived (group 3). We compared the 3 groups for differences in demographics, acuity at presentation, hospital course, laboratory data, comorbidities, and outcomes. From a total of 120 patients, 58 patients died and 62 survived. We identified 31 patients in group 1, 27 patients in group 2, and 62 patients in group 3. On multivariate logistic regression, only lactate (P = .002) and use of vasopressors (P = .014) remained significant to predict survival. The results of this study can be used to identify futile situations which can direct end-of-life decisions.

Destructive colon injuries requiring resection: Is colostomy ever indicated?

BACKGROUND

The management of destructive colon injuries requiring resection has shifted from mandatory diverting stoma to liberal use of primary anastomosis. Various risk criteria have been suggested for the selection of patients for primary anastomosis or ostomy. At our center, we have been practicing a policy of liberal primary anastomosis irrespective of risk factors. The purpose of this study was to evaluate the colon-related outcomes in patients managed with this policy.

METHODS

This retrospective study included all colon injuries requiring resection. Data collected included patient demographics, injury characteristics, blood transfusions, operative findings, operations performed, complications, and mortality.

RESULTS

A total of 287 colon injuries were identified, 101 of whom required resection, forming the study population. The majority (63.4%) were penetrating injuries. Furthermore, 16.8% were hypotensive on admission, 40.6% had moderate or severe fecal spillage, 35.6% received blood transfusion of >4 U, and 41.6% had Injury Severity Score of >15. At index operation, 88% were managed with primary anastomosis and 12% with colon discontinuity, and one patient had stoma. Damage-control laparotomy (DCL) with temporary abdominal closure was performed in 39.6% of patients. Of these patients with DCL, 67.5% underwent primary anastomosis, 30.0% were left with colon discontinuity, and 2.5% had stoma. Overall, after the definitive management of the colon, including those patients who were initially left in colon discontinuity, only six patients (5.9%) had a stoma. The incidence of anastomotic leaks in patients with primary anastomosis at the index operation was 8.0%, and there was no colon-related mortality. The incidence of colon anastomotic leaks in the 27 patients with DCL and primary anastomosis was 11.1%, and there was no colon-related mortality. Multivariate analysis evaluating possible risk factors identified discontinuity of the colon as independent risk factor for mortality.

CONCLUSION

Liberal primary anastomosis should be considered in almost all patients with destructive colon injuries requiring resection, irrespective of risk factors.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

A contemporary prospective review of 205 consecutive patients with penetrating colon injuries

BACKGROUND

Management of colon injuries has significantly evolved in the recent decades resulting in considerably decreased morbidity and mortality. We set out to investigate penetrating colon injuries in a high-volume urban academic trauma center in South Africa.

METHODS

All patients with penetrating colon injuries admitted between 1/2015 and 1/2018 were prospectively enrolled. Data collection included demographics, injury profile and outcomes. Primary outcome was in-hospital mortality. Secondary outcome was morbidity.

RESULTS

Two-hundred and five patients were included in the analysis. Stab and gunshot wounds constituted 18% and 82% of the cases, respectively. Mean age was 28.9 (10.2) years and 96.1% were male. Median injury severity score (ISS) and penetrating abdominal trauma index (PATI) were 16 (9-25) and 19 (10-26), respectively. A total of 47.8% of the patients had a complication per Clavien-Dindo classification. Colon leak rate was 2.4%. Wound and abdominal organ/space infection rate was 15.1 and 6.3%, respectively. Overall in-hospital mortality was 9.3%. Risk factors for mortality were higher ISS and PATI, shock on admission, need for blood transfusion, intra-abdominal vascular injury, damage control surgery, and extra-abdominal severe injuries.

CONCLUSIONS

Contemporary overall complication rate remains high in penetrating colon injuries, however, anastomotic leak rate is decreasing. Colon injury associated mortality is related to overall injury burden and hemorrhage rather than to colon injuries.

[Management of traumatic intestinal injury of mass casualties]

While intestinal injury is relatively rare in blunt abdominal trauma, it is common in penetrating abdominal trauma. Intestinal injury cannot be detected effectively by computed tomography (CT); therefore penetrating abdominal injury or abdominal signs in blunt trauma require liberal indications for explorative laparotomy. In mass casualty situations patients with hemodynamic instability and abdominal signs should be prioritized for surgery. Besides intra-abdominal hemorrhage the major issue is septic complications due to intestinal perforation. The current surgical strategy should reflect the number of injured patients and the individual pattern of injuries. Damage control surgery is not an effective strategy to improve survival rates in severely injured patients or in mass casualty situations. Damage control surgery focuses on lifesaving procedures especially bleeding control and control of contamination. This includes an open abdomen strategy with later definitive repair and abdominal wall closure.

The Trump Effect: With No Peer Review, How Do We Know What to Really Believe on Social Media?

Social media is a source of news and information for an increasing portion of the general public and physicians. The recent political election was a vivid example of how social media can be used for the rapid spread of "fake news" and that posts on social media are not subject to fact-checking or editorial review. The medical field is susceptible to propagation of misinformation, with poor differentiation between authenticated and erroneous information. Due to the presence of social "bubbles," surgeons may not be aware of the misinformation that patients are reading, and thus, it may be difficult to counteract the false information that is seen by the general public. Medical professionals may also be prone to unrecognized spread of misinformation and must be diligent to ensure the information they share is accurate.