1
|
Wang K, Deng YX, Li KW, Wang XY, Yang C, Ding WW. Multiple portions enteral nutrition and chyme reinfusion of a blunt bowel injury patient with hyperbilirubinemia undergoing open abdomen: A case report. Chin J Traumatol 2022:S1008-1275(22)00139-0. [PMID: 36635154 PMCID: PMC10388244 DOI: 10.1016/j.cjtee.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/21/2022] [Accepted: 10/15/2022] [Indexed: 12/24/2022] Open
Abstract
Blunt bowel injury (BBI) is relatively rare but life-threatening when delayed in surgical repair or anastomosis. Providing enteral nutrition (EN) in BBI patients with open abdomen after damage control surgery is challenging, especially for those with discontinuity of the bowel. Here, we report a 47-year-old male driver who was involved in a motor vehicle collision and developed ascites on post-trauma day 3. Emergency exploratory laparotomy at a local hospital revealed a complete rupture of the jejunum and then primary anastomosis was performed. Postoperatively, the patient was transferred to our trauma center for septic shock and hyperbilirubinemia. Following salvage resuscitation, damage control laparotomy with open abdomen was performed for abdominal sepsis, and a temporary double enterostomy (TDE) was created where the anastomosis was ruptured. Given the TDE and high risk of malnutrition, multiple portions EN were performed, including a proximal portion EN support through a nasogastric tube and a distal portion EN via a jejunal feeding tube. Besides, chyme delivered from the proximal portion of TDE was injected into the distal portion of TDE via a jejunal feeding tube. Hyperbilirubinemia was alleviated with the increase in chyme reinfusion. After 6 months of home EN and chyme reinfusion, the patient finally underwent TDE reversal and abdominal wall reconstruction and was discharged with a regular diet. For BBI patients with postoperative hyperbilirubinemia who underwent open abdomen, the combination of multiple portions EN and chyme reinfusion may be a feasible and safe option.
Collapse
Affiliation(s)
- Kai Wang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Yun-Xuan Deng
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Kai-Wei Li
- The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, China
| | - Xin-Yu Wang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Chao Yang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Wei-Wei Ding
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China.
| |
Collapse
|
2
|
Destructive colon injuries requiring resection: Is colostomy ever indicated? J Trauma Acute Care Surg 2022; 92:1039-1046. [PMID: 35081597 DOI: 10.1097/ta.0000000000003513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
Collapse
|
3
|
Talving P, Chouliaras K, Eastman A, Lauerman M, Teixeira PG, DuBose J, Minei J, Scalea T, Demetriades D. Discontinuity of the Bowel Following Damage Control Operation Revisited: A Multi-institutional Study. World J Surg 2017; 41:146-151. [PMID: 27541027 DOI: 10.1007/s00268-016-3685-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Discontinuity of the bowel following intestinal injury and resection is a common practice in damage control procedures for severe abdominal trauma. However, there are concerns that complete occlusion of the bowel, especially in the presence of hypotension or edema that may result in ischemic bowel changes or increase bacterial or toxin translocation. METHODS This was a retrospective study from three Level-1 trauma centers. Included were trauma patients who required bowel resection and damage control. The study population was stratified into two groups based on the management for bowel injury: bowel discontinuity versus primary anastomosis. Outcomes included anastomotic leak, organ space infection, bowel ischemia, and mortality. RESULTS A total of 167 cases were included. In 84 cases, continuity of the bowel was established, and in 83, the bowel was left in discontinuity. The epidemiological, admission, and intraoperative physiological characteristics, the abdominal Abbreviated Injury Scale, type of intra-abdominal injury, and transfusion requirements were similar in the two study groups. The mortality was 8.3 % in the continuity group and 16.9 % for the discontinuity group (p = 0.096). On the crude bivariate and adjusted regression analyses, there was a higher rate of bowel ischemia at the take-back operation in the discontinuity group (p = 0.003 for the crude and p = 0.034 for the adjusted). The organ space infection and anastomotic leak rate were not significantly different between the study groups. CONCLUSIONS Discontinuity of the bowel following damage control operation is associated with a higher risk of bowel ischemia than in patients with anastomosis. Further prospective observational and randomized studies are warranted. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Peep Talving
- Division of Acute Care Surgery Trauma, Emergency Surgery and Surgical Critical Care), Department of Surgery, Keck School of Medicine, Los Angeles County + University of Southern California Medical Center, IPT-C5L100, 2051 Marengo Str. 90033, Los Angeles, CA, USA
| | - Konstantinos Chouliaras
- Division of Acute Care Surgery Trauma, Emergency Surgery and Surgical Critical Care), Department of Surgery, Keck School of Medicine, Los Angeles County + University of Southern California Medical Center, IPT-C5L100, 2051 Marengo Str. 90033, Los Angeles, CA, USA
| | - Alexander Eastman
- Division of Burn/Trauma/Critical Care at UT Southwestern Medical Center, The Trauma Center at Parkland, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Margaret Lauerman
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pedro G Teixeira
- Division of Acute Care Surgery Trauma, Emergency Surgery and Surgical Critical Care), Department of Surgery, Keck School of Medicine, Los Angeles County + University of Southern California Medical Center, IPT-C5L100, 2051 Marengo Str. 90033, Los Angeles, CA, USA
| | - Joseph DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joseph Minei
- Division of Burn/Trauma/Critical Care at UT Southwestern Medical Center, The Trauma Center at Parkland, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery Trauma, Emergency Surgery and Surgical Critical Care), Department of Surgery, Keck School of Medicine, Los Angeles County + University of Southern California Medical Center, IPT-C5L100, 2051 Marengo Str. 90033, Los Angeles, CA, USA.
| |
Collapse
|
4
|
Ke J, Wu W, Lin N, Yang W, Cai Z, Wu W, Chen D, Wang Y. A novel method for multiple bowel injuries: a pilot canine experiment. World J Emerg Surg 2017; 12:44. [PMID: 28932257 PMCID: PMC5602872 DOI: 10.1186/s13017-017-0155-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 08/29/2017] [Indexed: 12/30/2022] Open
Abstract
Background Intestinal ligation is the cornerstone for damage control in abdominal emergency, yet it may lead to bowel ischemia. Although intestinal ligation avoids further peritoneal cavity pollution, it may lead to an increased pressure within the bowel segments and rapid bacterial translocation. In this study, we showed that severed intestine could be readily reconnected by using silicon tubes and be secured by using rubber bands in a canine model. Methods Adult Beagle dogs, subject to multiple intestinal transections and hemorrhagic shock by exsanguination, randomly received conventional ligation vs. silicon tubes reconnecting (n = 5 per group). Intestinal transections were carried out under general anesthesia after 24-h fasting. The abdomen was opened with a midline incision. The small intestine was severed at 50, 100, and 150 cm below the Treitz ligament. Hemorrhagic shock was established by streaming blood from the left carotid artery until the mean arterial pressure reached 40 mmHg in 20 min. Fluid resuscitation and surgery began 30 min after the establishment of hemorrhagic shock. Severed intestines were ligated or connected with silicon tubes. Definitive repair was conducted in subjects surviving for at least 48 h. Results Operation time was comparable between the two groups (39.6 ± 8.9 vs. 36.6 ± 7.8 min in ligation and reconnecting groups, respectively; p = 0.56). The time spent in managing each resection was also comparable (4.6 ± 1.1 vs. 3.8 ± 0.84 min; p = 0.24). Blood loss (341.2 ± 28.6 vs. 333.8 ± 34.6 ml; p = 0.48), and fluid resuscitation within the first 24 h (1676 ± 200.6 vs. 1594 ± 156.5 ml; p = 0.46) were similar. One subject in the ligation group was sacrificed at 36-h due to severe vomiting that led to aspiration. Four remaining dogs in the ligation group received definitive surgery, but two out of four had to be sacrificed at 24-h after definitive repair due to imminent death. All five dogs in the reconnecting group survived for at least a week. Radiographic examination confirmed the integrity of the GI tract in the reconnecting group. In both groups, plasma endotoxin concentration increased after damage control surgery, but the increase was much more pronounced in the ligation group. Microscopic examination of the involved segment of the intestine revealed much more severe pathology in the ligation group. Conclusion The current study showed that the reconnecting resected intestine by using silicon tubes is feasible under emergency. Such a method could decrease short-term mortality and minimize endotoxin translocation.
Collapse
Affiliation(s)
- Jun Ke
- Department of Gastroenterology, Dongfang Hospital, Xiamen University, Fuzhou, Fujian 350025 China
| | - Weihang Wu
- Department of General Surgery, Dongfang Hospital, Xiamen University, Fuzhou, Fujian 350025 China
| | - Nan Lin
- Department of General Surgery, Dongfang Hospital, Xiamen University, Fuzhou, Fujian 350025 China
| | - Weijin Yang
- Department of General Surgery, Dongfang Hospital, Xiamen University, Fuzhou, Fujian 350025 China
| | - Zhicong Cai
- Department of General Surgery, Dongfang Hospital, Xiamen University, Fuzhou, Fujian 350025 China
| | - Wei Wu
- Department of General Surgery, Dongfang Hospital, Xiamen University, Fuzhou, Fujian 350025 China
| | - Dongsheng Chen
- Department of Anesthesiology, Dongfang Hospital, Xiamen University, Fuzhou, Fujian 350025 China
| | - Yu Wang
- Department of General Surgery, Dongfang Hospital, Xiamen University, Fuzhou, Fujian 350025 China
| |
Collapse
|
5
|
Martin MJ. Editorial to accompany "Intraintestinal drainage as a damage control surgery adjunct in a hypothermic traumatic shock swine model with multiple bowel perforations". J Surg Res 2014; 192:59-61. [PMID: 25151467 DOI: 10.1016/j.jss.2014.07.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 07/10/2014] [Accepted: 07/18/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Matthew J Martin
- Department of Surgery, Madigan Army Medical Center, Tacoma, Washington.
| |
Collapse
|