Applicability of an established management algorithm for destructive colon injuries after abbreviated laparotomy: a 17-year experience.J Am Coll Surg. 2014;218:636-641. [PMID: 24529811 DOI: 10.1016/j.jamcollsurg.2013.12.028]

Contemporary diagnosis and management of colorectal injuries: What you need to know

ABSTRACT

Colorectal injuries are commonly encountered by trauma surgeons. The management of colorectal injuries has evolved significantly over the past several decades, beginning with wartime experience and subsequently refining with prospective randomized studies. Colon injuries were initially nonoperative, evolved toward fecal diversion for all, and then became anatomic based with resection and primary anastomosis with selective diversion, and now primary repair, resection with primary anastomosis, and delayed anastomosis after damage-control laparotomy are all commonplace. Rectal injuries were also initially considered nonoperative until diversion came into favor. Diversion in addition to direct repair, presacral drain placement, and distal rectal washout became the criterion standard for extraperitoneal rectal injuries until drainage and washout fell out of favor. Despite a large body of evidence, there remains a debate on the optimal management of some colorectal injuries. This article will focus on how to diagnose and manage colorectal injuries. The aim of this review is to provide an evidence-based summary of the contemporary diagnosis and management of colorectal injuries.

Impact of Concomitant Traumatic Pancreatic and Colon Injuries on Outcomes

BACKGROUND

Colon and pancreatic injuries have both long been independently associated with intraabdominal infectious complications in trauma patients. The goal of this study was to evaluate the impact of concomitant pancreatic injury on outcomes in patients with traumatic colon injuries.

METHODS

Consecutive patients over a 3-year period who underwent operative management of colon injuries were identified. Patient characteristics, severity of injury and shock, presence and grade of pancreatic injury, and intraoperative packed red blood cell (PRBC) transfusions were recorded. Outcomes including intraabdominal abscess formation and suture line failure were collected and compared. Multivariable logistic regression analysis was then performed to determine the impact of concomitant pancreatic injury on intraabdominal abscess formation.

RESULTS

243 patients with traumatic colon injuries were identified. 17 of these also had pancreatic injuries. Patients with combined colon and pancreatic injuries were clinically similar to those with isolated colon injuries with respect to age, gender, penetrating mechanism of injury, admission lactate, ISS, suture line failure, and admission systolic blood pressure. Both intraabdominal abscess rates (88.2% vs 29.6%, P < .001) and intraoperative PRBC transfusions (8 vs 1 units, P = .004) were higher in the combined pancreatic and colon injury group. Multivariable logistic regression identified both intraoperative PRBC transfusions (odds ratio, 1.09; 95% confidence interval, 1.04-1.15; P < .001) and concomitant pancreatic injury (odds ratio, 14.8; 95% confidence interval, 3.92-96.87; P < .001) as independent predictors of intraabdominal abscess formation.

DISCUSSION

Both intraoperative PRBC transfusions and presence of concomitant pancreatic injury are independent predictors of intraabdominal abscess formation in patients with traumatic colon injuries.

Transforming the management of colon injury: Dr Timothy C Fabian - scholar, scientist, leader, and teacher

Dr Fabian and his colleagues have transformed the management of colon injury during a span of more than four decades. They have done so by following a patient-centered, rigorous, and dogged approach to improving patient care and standardizing care with a simplified and widely applicable algorithm. All non-destructive colon injuries are primarily repaired. Healthy patients without massive blood loss who have sustained destructive wounds are treated with resection and anastomosis without fecal diversion. Patients with coexisting significant medical conditions or those requiring greater than 6 units of packed red blood cell(PRBC) transfusions are treated with resection and fecal diversion. Following this simple algorithm has led to a low rate of anastomotic leak with minimal colon-related morbidity in penetrating and blunt colon trauma and in those patients requiring abbreviated laparotomy/damage control procedures. During his four decades in Memphis, Dr Fabian established, led, and developed a regional trauma system which transformed trauma care, significantly improving survival and minimizing disability of patients in the Memphis community and across the entire mid-South region. I was fortunate to be a trauma and surgical critical care fellow 30 years ago in Memphis. As a leader, Dr Fabian gave us the freedom to pursue our own interests and explore ideas with full academic freedom with only one caveat-always do the right thing for our patient. A general principle championed by Dr Fabian is that patient care is not a means to some other goal (academic, reputational, or financial); no, serving the patient's interests first is the reason we exist as surgeons and the reason why the trauma system exists. This human-centered approach was central to the Memphis approach to trauma care led by Timothy C Fabian and will live on in the work of those who are following his leadership.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.

Necrotizing fasciitis of cryptoglandular infection treated with multiple incisions and thread-dragging therapy: A case report

BACKGROUND

Necrotizing fasciitis is a fulminant necrotizing soft tissue disease with a high fatality rate. It always starts with impact on the deep fascia rapidly and might result in secondary necrosis of the subcutaneous tissue, fascia, and muscle. Thus, timely and multiple surgical operations are needed for the treatment. Meanwhile, the damage of skin and soft tissue caused by multiple surgical operations may require dermatoplasty and other treatments as a consequence.

CASE SUMMARY

Here, we report a case of 50-year-old male patient who was admitted to our hospital with symptoms of necrotizing fasciitis caused by cryptoglandular infection in the perianal and perineal region. The symptoms of necrotizing fasciitis, also known as the cardinal features, include hyperpyrexia, excruciatingly painful lesions, demonstration gas in the tissue, an obnoxious foul odor and uroschesis. The results of postoperative pathology met the diagnosis. Based on the premise of complete debridement, multiple incisions combined with thread-dragging therapy (a traditional Chinese medicine therapy) and intensive supportive therapies including comprising antibiotics, nutrition and fluids were given. The outcome of the treatment was satisfactory. The patient recovered quickly and achieved ideal anal function and morphology.

CONCLUSION

Timely and effective debridement and multiple incisions combined with thread-dragging therapy are an integrated treatment for necrotizing fasciitis.

Management of the injured bowel: preserving bowel continuity as a gold standard

BACKGROUND

Management of bowel traumatic injuries is a challenge. Although anastomotic or suture leak remains a feared complication, preserving bowel continuity is increasingly the preferred strategy. The aim of this study was to evaluate the outcomes of such a strategy.

METHODS

All included patients underwent surgery for bowel traumatic injuries at a high volume trauma center between 2007 and 2017. Postoperative course was analyzed for abdominal complications, morbidity and mortality.

RESULTS

Among 133 patients, 78% had small bowel injuries and 47% had colon injuries. 87% of small bowel injuries and 81% of colon injuries were treated with primary repair or anastomosis, with no difference in treatment according to injury site (p = 0.381). Mortality was 8%. Severe overall morbidity was 32%, and abdominal complications occurred in 32% of patients. Risk factors for severe overall morbidity were stoma creation (p = 0.036), heavy vascular expansion (p = 0.005) and a long delay before surgery (p = 0.023). Fistula rate was 2.2%; all leaks occurred after repairing small bowel wounds.

CONCLUSION

Primary repair of bowel injuries should be the preferred option in trauma patient, regardless of the site-small bowel or colon-of the injury. Stoma creation is an important factor for postoperative morbidity, which should be weighed against the risk of an intestinal suture or anastomosis.

Analysis of National Presentations of Surgical Case Series Discussions: What Matters to Surgeons?

BACKGROUND

Although the surgical case series is a useful study design for surgical disciplines, elements of its presentation have not been standardized with a widely accepted reporting guideline. Hence, case series may not include all components necessary for surgeons to best interpret their results. We aimed to determine core elements of case series through qualitative analysis of discussions after presentations at national meetings.

METHODS

Case series with accompanying discussions in three high-impact journals from 2010 to 2015 were analyzed with conventional content analysis. All interrogative sentences were selected for analysis and were classified by a redundant iterative process into descriptive categories and subcategories.

RESULTS

Two hundred twenty-one case series were identified, 56 of which included discussion transcripts. Four hundred seventy six unique interrogatives were classified into 4 categories and 13 subcategories. The main categories identified were "Application of Results to Patient Care," "Clarification of Study Methodology," "Facilitation of Author Insight," and "Request for Additional Study-Specific Data." The most frequent subcategories of inquiry pertained to the changes to current standard of care, clarification of study variables, and subgroup data and outcomes.

CONCLUSIONS

We determined major themes of inquiry that reflected core elements surgeons use to evaluate case series for relevance and applicability to their own practice. Discussants frequently questioned how the study's results changed the author's standard of care. Specifically encouraging surgical case series authors to comment on changes they made to their practice as a result of their findings would allow the surgical audience to quickly assess potential clinical applicability.

Progress and pitfalls in treatment of colorectal injury

Based on the previous experience of war wound treatment, the treatment of colorectal injury has been changing constantly. Also, since the 1980s, the progress of severe trauma treatment such as CT examinations and damage control strategies has had a profound impact on the treatment of colorectal injury. This article systematically reviews the clinical manifestations, imaging findings, and endoscopic examinations of colorectal injuries, and lists injury assessment pitfalls such as neglecting colorectal injury in blunt wounds, being misdirected by negative sign or supine X-rays, strict indications for laparotomy exploration, or intro-operative omission. The progress of emergency surgery such as staged surgery for colorectal injury, surgical way of colorectal injury during damage control strategy, and treatment of rectal injury in extraperitoneal section is also described in detail. In addition, the pitfalls for emergency treatment are described, including ignoring effects of massive crystal fluid resuscitation on colorectal anastomosis, attaching no importance on the technical points of the colonic injury operation, and performing improper suture for abdominal incisions.

Evolution of the operative management of colon trauma

For any trauma surgeon, colon wounds remain a relatively common, yet sometimes challenging, clinical problem. Evolution in operative technique and improvements in antimicrobial therapy during the past two centuries have brought remarkable improvements in both morbidity and mortality after injury to the colon. Much of the early progress in management and patient survival after colon trauma evolved from wartime experience. Multiple evidence-based studies during the last several decades have allowed for more aggressive management, with most wounds undergoing primary repair or resection and anastomosis with an acceptably low suture line failure rate. Despite the abundance of quality evidence regarding management of colon trauma obtained from both military and civilian experience, there remains some debate among institutions regarding management of specific injuries. This is especially true with respect to destructive wounds, injuries to the left colon, blunt colon trauma and those wounds requiring colonic discontinuity during an abbreviated laparotomy. Some programs have developed data-driven protocols that have simplified management of destructive colon wounds, clearly identifying those high-risk patients who should undergo diversion, regardless of mechanism or anatomic location. This update will describe the progression in the approach to colon injuries through history while providing a current review of the literature regarding management of the more controversial wounds.

Factors affecting morbidity and mortality in traumatic colorectal injuries and reliability and validity of trauma scoring systems

Background and aim

This study aims to determine the factors that affect morbidity and mortality in colon and rectum injuries related with trauma, the use of trauma scoring systems in predicting mortality and morbidity.

Patients and methods

Besides patient demographic characteristics, the mechanism of injury, the time between injury and surgery, accompanying body injuries, admittance Glasgow coma scale (GCS), findings at surgery and treatment methods were also recorded. With the obtained data, the abbreviated injury scale (AIS), injury severity score (ISS), revised trauma score (RTS) and trauma-ISS (TRISS) scores of each patient were calculated by using the 2008 revised AIS.

Results

Of the patients, 172 (88.7 %) were male, 22 (11.3 %) were female and the mean age was 29.15 ± 12.392 (15–89) years. The morbidity of our patients were 32 % and mortality were 12.4 %. ISS (p < 0.001), RTS (p < 0.001), and the TRISS (p < 0.001) on mortality were found to be significant. TRISS (p = 0.008), the ISS (p < 0.001), the RTS (p = 0.03), the trauma surgery interval (TSI, p < 0.001) were observed to have significant effects on morbidity.

Regression analysis showed that the ISS (OR 1.1; CI 95 % 1.01–1.2; p = 0.02), the RTS (OR 0.37; CI 95 % 0.21–0.67; p = 0.001) had significant effects on mortality. While the effects of TSI (OR 5.3; CI 95 % 1.5–18.8; p = 0.01) on morbidity were found to be significant.

Conclusion

Predicting mortality by using scoring systems and close postoperative follow up of patients in the risk group may ensure decreases in the rates of morbidity and mortality.