Blunt colonic injury--a multicenter review

Outcomes of Primary Repair and Anastomosis for Traumatic Colonic Injuries in a Tertiary Trauma Center

Background: Surgical management for traumatic colonic injuries has undergone major changes in the past decades. Despite the increasing confidence in primary repair for both penetrating colonic injury (PCI) and blunt colonic injury (BCI), there are authors still advocating for a colostomy particularly for BCI. This study aims to describe the surgical management of colonic injuries in a level 1 metropolitan trauma center and compare patient outcomes between PCI and BCI. Methods: Twenty-one patients who underwent trauma laparotomy for traumatic colonic injuries between January 2011 and December 2018 were retrospectively reviewed. Results: BCI accounted for 67% and PCI for 33% of traumatic colonic injuries. The transverse colon was the most commonly injured part of the colon (43%), followed by the sigmoid colon (33%). Primary repair (52%) followed by resection-anastomosis (38%) remain the most common procedures performed regardless of the injury mechanism. Only two (10%) patients required a colostomy. There was no significant difference comparing patients who underwent primary repair, resection-anastomosis and colostomy formation in terms of complication rates (55% vs. 50% vs. 50%, p = 0.979) and length of hospital stay (21 vs. 21 vs. 19 days, p = 0.991). Conclusions: Regardless of the injury mechanism, either primary repair or resection and anastomosis is a safe method in the management of the majority of traumatic colonic injuries.

Traumatic Acute Colonic Intramural Hematoma: A Rare Entity and Successful Expectant Approach

Acute intramural hematoma in colon is a rare presentation following trauma. There are reports in literature of acute colonic hematoma following trauma, warfarin intake and in patient with coagulation disorders. In traumatic acute colonic intramural hematoma, most of the reported cases were managed surgically. Very few cases were successfully managed conservatively. We present a case of 28-year-old male who presented to the surgical emergency after two days of road traffic accident. After relevant investigations, he was found to have intramural hematoma of ascending colon, which was managed conservatively.

Contemporary Trends and Outcomes of Blunt Traumatic Colon Injuries Requiring Resection

BACKGROUND

After traumatic injury, primary anastomosis after colon resection has overtaken ostomy diversion. Improved technology facilitating primary anastomosis speed and integrity may have driven this change. Trends in ostomy versus anastomosis have yet to be quantified, and recent literature comparing outcomes is incomplete.

METHODS

The National Trauma Databank (2007-2014) was queried for all blunt colon injuries requiring resection. Patients were dichotomized into study groups based on whether they underwent ostomy creation. Ostomy creation frequency was compared over time. After subgrouping patients by colon injury location, multivariate regression adjusted for baseline characteristics and evaluated the impact of ostomy on clinical outcomes.

RESULTS

A total of 13,949 colon injuries requiring colectomy were identified. Ostomy frequency did not vary by study year (P = 0.536). Univariate analysis showed that patients undergoing ostomy were older (median, 40 versus 32; P < 0.001) and more often had comorbidities (65% versus 56%; P < 0.001). Multivariate analysis showed that ostomy creation was significantly associated with lower mortality after sigmoid colon injury (odds ratio, 0.512; P = 0.011) and higher rates of unplanned reoperation after transverse colon injury (odds ratio, 3.135; P = 0.048). Across all colon injuries, ostomies were significantly associated with longer hospital length of stay, intensive care unit length of stay, and ventilator days.

CONCLUSIONS

Ostomy creation for colonic injury has reached an equilibrium trough. The impact of ostomy creation varies by not only clinical outcome but also injury location. Further study is needed to define the optimal surgical management for blunt colon injuries requiring resection.

Postoperative complications of intestinal anastomosis after blunt abdominal trauma

BACKGROUND

Intestinal disruption following blunt abdominal trauma (BAT) continues to be associated with significant morbidity and mortality despite the advances in resuscitation and management. We aim to analyze the management and postoperative outcomes of intestinal injuries secondary to blunt abdominal trauma.

METHOD

We retrospectively reviewed all adult patients with intestinal injuries who underwent laparotomy for BAT between December 2008 and September 2015 at Level I trauma center. Data included demographics, mechanism of injury, site (small and large intestine), type of repair, (enterorrhaphy and resection with anastomosis), type of anastomosis (hand-sewn or stapled anastomoses), need for damage control laparotomy, postoperative complications, and mortality. Data were analyzed and compared for postoperative complications.

RESULTS

A total of 160 patients with bowel injuries were included with mean age of 33 years, and 95.6% were males. Injuries involving small bowel, colon, and combined small and large bowel were found in 57.5%, 33.1%, and 9.4%, respectively, with only two duodenal and one rectal injury cases. There were 46.3% patients underwent debridement and primary closure, while 53.8% required resection with anastomosis. Anastomoses were side-to-side stapled in 79.1%, hand-sewn in 14.0%, and combination in 7.0% of patients. The overall postoperative complications (17.5%) in terms of wound infection (n = 16), intra-abdominal abscess (n = 13), and anastomotic leak (n = 13). There were two deaths occurred because of bowel injury complications. Need for blood transfusion, high serum lactate, number of re-laparotomies, and mortality were significantly associated with postoperative complications. On multivariate regression analysis, serum lactate (OR 1.27; 95% CI 1.01-1.60; p = 0.04) was found to be the independent predictor of postoperative complications.

CONCLUSION

Repair of traumatic blunt bowel injury remains a surgical challenge.

Defining Outcomes after Colon Resection in Blunt Trauma: Is Diversion or Primary Anastomosis More Favorable?

Previous literature demonstrates the safety of primary repair in penetrating colon injury requiring resection, without the creation of a diverting ostomy. It is unknown whether a similar approach can be applied to patients with blunt colon injury. The aim of this study was to measure outcomes in patients who underwent colon resection with and without ostomy creation after blunt trauma injury to help direct future management. Using the National Trauma Data Bank for years 2008 to 2012, we identified patients with blunt trauma mechanisms who underwent colectomy. Patients were stratified into two groups: primary anastomosis and diversion with ostomy. Primary outcome was inpatient mortality. Secondary outcomes included length of stay and perioperative complications. All risk-adjusted analyses were performed using logistic regression with consideration of interactions. Five hundred eighty-one observations met our inclusion criteria. Baseline characteristics between the two groups were similar with the exception of age (37.3 vs 42.2 years, P < 0.001) and admission Glasgow coma score (13.2 vs 12.1, P = 0.002). Risk-adjusted mortality for the two groups was not statistically significant (2.3% vs 3.0%, P = 0.63); however, patients with primary anastomosis had a shorter length of stay (18.2 vs 28.1, P < 0.001), fewer days in the intensive care unit (10.9 vs 16.2, P < 0.001), and fewer ventilator days (10.5 vs 14.6, P = 0.01). In patients requiring colon resection after blunt trauma, mortality is not different for those who receive a primary anastomosis versus ostomy. Patients without diversion had shorter hospital stays, intensive care unit days, and ventilator days. These data support that primary anastomosis is safe in this patient population.

Colon Trauma: Evidence-Based Practices

Colon injury is not uncommon and occurs in about a half of patients with penetrating hollow viscus injuries. Despite major advances in the operative management of penetrating colon wounds, there remains discussion regarding the appropriate treatment of destructive colon injuries, with a significant amount of scientific evidence supporting segmental resection with primary anastomosis in most patients without comorbidities or large transfusion requirement. Although literature is sparse concerning the management of blunt colon injuries, some studies have shown operative decision based on an algorithm originally defined for penetrating wounds should be considered in blunt colon injuries. The optimal management of colonic injuries in patients requiring damage control surgery (DCS) also remains controversial. Studies have recently reported that there is no increased risk compared with patients treated without DCS if fascial closure is completed on the first reoperation, or that a management algorithm for penetrating colon wounds is probably efficacious for colon injuries in the setting of DCS as well.

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.

Colorectal trauma

The management of traumatic injuries to the colon and rectum has undergone a significant change since World War II. Penetrating injuries are the most common cause of trauma to the colon and rectum. Colon and rectal perforation after blunt trauma are uncommon but not rare. For years, colostomy formation was considered the only acceptable form of treatment for injuries penetrating the colonic mucosa. With the realization that dictums governing colonic injuries during military conflicts were, for the most part, not applicable to civilian injuries, the pendulum has swung from mandatory colostomy to immediate repair in the management of uncomplicated cases. Accompanying these changes in management together with improvement in perioperative care, trauma service and the use of more powerful antibiotics, a significant reduction of mortality rates to less than 5% has been seen in many centres. In the presence of other risk factors, for example multiple associated injuries, severe shock, Penetrating Abdominal Trauma Index (PATI) of more than 25, colostomy is still an option to be considered.

Dilemma of Blunt Bowel Injury: What are the Factors Affecting Early Diagnosis and Outcomes

Blunt bowel and mesenteric injury (BBMI) is frequently a difficult diagnosis at initial presentation. We aimed to study the predictors for early diagnosis and outcomes in patients with BBMI. Data were collected retrospectively from the database registry between January 2008 and December 2011 in the only Level I trauma unit in Qatar. Patients with BBMI were divided into Group A (surgically treated within 8 hours) and Group B (treated after 8 hours). Data were analyzed and χ2, Student's t test, and multivariate regression analysis were performed appropriately. Among 984 patients admitted with blunt abdominal trauma (BAT), 11 per cent had BBMI with mean age of 35 ± 9.5 years. Polytrauma and isolated bowel injury were identified in 53 and 42 per cent, respectively. Mean Injury Severity Score (ISS) was higher in Group A in comparison to Group B (18 ± 11 vs 13 ± 8; P = 0.02). Presence of pain and seatbelt sign ( P = 0.02) were evident in Group B. Hypotension ( P = 0.004) and hypothermia ( P = 0.01) were prominent in Group A. The rate of positive Focused Assessment Sonography for Trauma was greater in Group A ( P = 0.001). Among operative findings, bowel perforation was more frequent in Group B ( P = 0.04), whereas mesenteric full-thickness hematoma was significantly higher in Group A. Pelvic fracture was more frequent finding in Group A ( P = 0.005). The overall mortality rate was 15.6 per cent. In patients with BAT, the presence of abdominal pain, hypotension, ISS greater than 16, hypothermia, pelvic fracture, and mesenteric hematoma might help in early diagnosis of BBMI. Moreover, base deficit and mean ISS were independent predictors of mortality. Delayed operative interventions greater than 8 hours increased morbidity rate but had no significant impact on mortality.

Traumatic injury to the colon and rectum in Scotland: demographics and outcome

AIM

An analysis of a multi-centred database of trauma patients was performed.

METHOD

The study used data from a prospective multi-centre trauma database containing details of 52 887 trauma patients admitted to participating Scottish Hospitals over an 11-year period.

RESULTS

Three hundred and forty (0.64%) of 52 887 trauma patients (284 male) with colorectal injuries were identified; 43.9% of colorectal injuries occurred following blunt trauma and 56.1% following penetrating injury. Patients in the latter group were younger, had less haemodynamic compromise and were less likely to die than those with blunt trauma (P < 0.01). The overall mortality rate was 25.6% and after rectal injury it was 21.2% (P > 0.05). Female gender, increased age, road traffic accidents and those admitted as a result of a blunt traumatic injury were associated with increased mortality. Age > 65 years (P = 0.01), increasing injury severity score (ISS) at presentation (P < 0.001), haemodynamic compromise (P = 0.045) and decreased Glasgow Coma Score (GCS) (P < 0.001) had the strongest independent associations with mortality.

CONCLUSION

Colorectal injury after trauma has a high morbidity. Clinical features associated with death allow stratification of mortality risk.

Management of colorectal trauma

Although the treatment strategy for colorectal trauma has advanced during the last part of the twentieth century and the result has improved, compared to other injuries, problems, such as high septic complication rates and mortality rates, still exist, so standard management for colorectal trauma is still a controversial issue. For that reason, we designed this article to address current recommendations for management of colorectal injuries based on a review of literature. According to the reviewed data, although sufficient evidence exists for primary repair being the treatment of choice in most cases of nondestructive colon injuries, many surgeons are still concerned about anastomotic leakage or failure, and prefer to perform a diverting colostomy. Recently, some reports have shown that primary repair or resection and anastomosis, is better than a diverting colostomy even in cases of destructive colon injuries, but it has not fully established as the standard treatment. The same guideline as that for colonic injury is applied in cases of intraperitoneal rectal injuries, and, diversion, primary repair, and presacral drainage are regarded as the standards for the management of extraperitoneal rectal injuries. However, some reports state that primary repair without a diverting colostomy has benefit in the treatment of extraperitoneal rectal injury, and presacral drainage is still controversial. In conclusion, ideally an individual management strategy would be developed for each patient suffering from colorectal injury. To do this, an evidence-based treatment plan should be carefully developed.

[Gastrointestinal and mesenteric injuries in the trauma patient: incidence, diagnosis delay and prognosis]

BACKGROUND

Gastrointestinal and mesenteric injuries (GIMI) are uncommon in trauma patients, and their diagnosis are often delayed. Our aims were to determine the reliability of CT scan in our centre, and to assess the clinical significance of a delayed diagnosis.

MATERIALS AND METHOD

Retrospective analysis of cases confirmed at laparotomy. Patients were identified at the Severe Trauma Registry of Gregorio Marañón University General Hospital, between 1993 and 2006.

RESULTS

We found 105 (16.6%) GIMI out of 632 patients with abdominal trauma, in a Registry with 1495 severe trauma cases included. A total of 46% had blunt injuries. The mean injury severity score (ISS) and new ISS (NISS) were 20 and 25, respectively. There were 9 (8.5%) deaths, 4 of which were unexpected. A CT scan was performed in 56 (53%) cases, and only in 37 there were signs suggestive of a GIMI. In another 43 (41%) patients an urgent laparotomy was indicated because of positive clinical findings or instability. Surgery was delayed for more than 8 hours in 21 (20%) patients, the most common reason being a false negative result in the CT scan.

CONCLUSIONS

The overall incidence of GIMI was high in our centre (31% due to penetration and 10.7% blunt trauma). Several factors, such as the initial lack of symptoms, a low diagnostic sensitivity of the CT scan (34% false negatives), and the non-surgical management of solid organ injuries, have contributed to a delayed diagnosis and treatment in one out of each five patients in our series, but this has not led to a significant increase in septic complications in this group.

Massive Rectal Hemorrhage from the Middle Hemorrhoidal Artery after Blunt Perineal Trauma Without Pelvic Fracture

BACKGROUND

Severe pelvic hemorrhage after blunt trauma without bony fracture has been reported occasionally, and clinical presentation as a delayed massive rectal bleeding is very rare.

CASE STUDY

The case of an 86-year-old woman with massive rectal bleeding 12 h after mild blunt perineal trauma is presented. Physical examination revealed an extensive perineal hematoma and a 2-cm laceration in the posterior rectal wall. Pelvic CT scan revealed a large mesorectal hematoma causing extrinsic compression of the rectal lumen. No bony fracture was observed. Selective arteriography was then performed showing hemorrhage resulting from the right middle hemorrhoidal artery, branch of the internal pudendal artery. Transcatheter embolization of coils successfully controlled the bleeding. However, the patient developed a respiratory distress syndrome and renal failure with no response to the treatment and she died 3 days later.

CONCLUSION

This report is unique not only for the unusual association of pelvic hemorrhage and rectal injury after blunt trauma without pelvic fracture but also because of the clinical presentation as a massive rectal bleeding. Undoubtedly, the delayed diagnosis and treatment, 12 h after the trauma, contributed to the fatal outcome.

Colon and rectal injuries

PURPOSE

This study was designed to develop treatment algorithms for colon, rectal, and anal injuries based on the review of relevant literature.

METHODS

Information was obtained through a MEDLINE ( www.nobi.nih.gov/entrez/query.fcgi ) search, and additional references were obtained through cross-referencing key articles cited in these papers.

RESULTS

A total of 203 articles were considered relevant.

CONCLUSIONS

The management of penetrating and blunt colon, rectal, and anal injuries has evolved during the past 150 years. Since the World War II mandate to divert penetrating colon injuries, primary repair or resection and anastomosis have found an increasing role in patients with nondestructive injuries. A critical review of recent literature better defines the role of primary repair and fecal diversion for these injuries and allows for better algorithms for the management of these injuries.

Das Abdominaltrauma

Blunt abdominal trauma is much more frequent than penetrating abdominal trauma in Europe. As a consequence of improved quality of computed tomography, even complex liver injuries are increasingly being treated conservatively. However, missed hollow viscus injuries still remain a problem, as they considerably increase mortality in multiply injured patients. Laparoscopy decreases the rate of unnecessary laparotomies in perforating abdominal trauma and helps to diagnose injuries of solid organs and the diaphragm. However, the sensitivity in detecting hollow viscus injuries is low and the role of laparoscopy in blunt abdominal injury has not been defined. If intra-abdominal bleeding is difficult to control in hemodynamically unstable patients, damage control surgery with packing of the liver, total splenectomy, and provisional closure of hollow viscus injuries is of importance. Definitive surgical treatment follows hemodynamic stabilization and restoration of hemostasis. Injuries of the duodenum and pancreas after blunt abdominal trauma are often associated with other intra-abdominal injuries and the treatment depends on their location and severity.

Hollow viscous injury in the pediatric patient

Injuries to the gastrointestinal tract account for 1% to 15% of intraabdominal injuries in children. Most hollow visceral injuries occur following some form of blunt trauma and motor vehicle accidents remain the most common mechanism of injury. The diagnosis of blunt intestinal injury is difficult and often delayed. Current imaging modalities are imprecise and contribute to delay. Delay is associated with morbidity and mortality in both children and adults, but the length of delay remains controversial. The purpose of this review is to examine the current diagnosis and management of hollow visceral injury in children.

Independent Predictors of Morbidity and Mortality in Blunt Colon Trauma

We sought to determine the impact of (1) grade of the colon injury, (2) the formation of an ostomy, and (3) associated injuries on outcomes such as morbidity and mortality after blunt colon injuries. We retrospectively reviewed 16,814 cases of blunt abdominal trauma. Patients with colonic injuries were selected and charts reviewed for demographic, clinical, and outcomes data. Injuries were grouped by the Colon Injury Scale (grades I–V). Independent risk factors of morbidity included spine and lung injuries, as well as increased age. A higher grade of colon injury trended toward a significant association with intra-abdominal complications. Independent risk factors of mortality included liver, heart, and lung injuries, as well as intracerebral blood and female gender. The grade of colon injury, the formation of an ostomy, and management of the colon trauma did not independently predict increased intra-abdominal complications, morbidity, or mortality. These results indicate that patients afflicted with blunt colon trauma experience a high rate of morbidity and mortality from associated injuries and or increased age. Treatment regimens directed at these factors will be most helpful in reducing the high morbidity and mortality after blunt colon trauma. Factors such as ostomy formation and management strategy are not associated with increased morbidity or mortality after blunt colon trauma.

Colon Injury after Blunt Abdominal Trauma: Results of the EAST Multi-institutional Hollow Viscus Injury Study

BACKGROUND

Blunt injury to the colon is rare. Few studies of adequate size and design exist to allow clinically useful conclusions. The Eastern Association for the Surgery of Trauma Multi-institutional Hollow Viscus Injury (HVI) Study presents a unique opportunity to definitively study these injuries.

METHODS

Patients with blunt HVI were identified from the registries of 95 trauma centers over 2 years (1998-1999). Patients with colon injuries (cases) were compared with blunt trauma patient undergoing a negative laparotomy (controls). Data were abstracted by chart review.

RESULTS

Of the 227,972 patients represented, 2,632 (1.0%) had an HVI and 798 had a colonic/rectal injury (0.3%). Of patients diagnosed with HVI, 30.2% had a colon injury. No physical findings or imaging modalities were able to discriminate colonic injury. Logistic regression modeling yielded no clinically useful combination of findings that would reliably predict colonic injury. In patients undergoing laparotomy, presence of colon injury was associated with a higher risk of some complications but not mortality. Colon injury was associated with increased hospital (17.4 vs. 13.1, p < 0.001) and intensive care unit (9.7 vs. 6.9, p = 0.003) length of stay. Almost all colon patients (92.0%) underwent laparotomy within 24 hours of injury.

CONCLUSION

Colonic injury after blunt trauma is rare and difficult to diagnose. No diagnostic test or combination of findings reliably excluded blunt colonic injury. Despite the inadequacy of current diagnostic tests, almost all patients with colonic injury were taken to the operating room within 24 hours. Even with relatively prompt surgery, patients with colon injury were at significantly higher risk for serious complications and increased length of stay. In contrast to small bowel perforation, delay in operative intervention appears to be less common but is still associated with serious morbidity.

Pathophysiology and management of bowel and mesenteric injuries due to blunt trauma

Injuries to the bowel and mesentery are uncommon in blunt trauma and rarely occur in isolation. Delay to diagnosis has a significant impact on morbidity and mortality. The literature tends to focus on the diagnosis of hollow viscus and mesenteric injury, with little written on its management. Studies are usually retrospective with a paucity of comparative trials. The use of computerized tomography (CT) scanning in blunt abdominal trauma has overshadowed other reports. Early-generation scanners had a relatively poor sensitivity in detecting bowel-related injuries, but the CT scan is now the primary modality for imaging stable patients. However radiological signs can be subtle and should be regarded as complementary to meticulous clinical assessment.

The seromuscular tear and other intestinal lesions in the seatbelt syndrome: a clinical and pathologic study of 29 cases

The authors describe the clinical and pathologic findings in 29 patients with injuries from motor vehicle accidents. The seromuscular tear (SMT), the hallmark intestinal injury of the seatbelt syndrome, is an unambiguous lesion similar in all segments of bowel and is caused by a tear that separates the inner muscularis from the submucosa. It is characterized by (1) a wedge that strips the submucosa from the inner circular muscle; (2) a bending retraction of the torn muscularis toward the uninvolved bowel wall; (3) mucosal-submucosal fold effacement, causing the mucosa-submucosa bridge spanning the tear to become paper thin; and (4) the vulnerability of this bridge to ischemia that in 35% of the tears studied culminated in incipient or frank perforations and/or gangrene. Large SMTs, particularly the circumferential degloving type, are most prone to develop these complications. These findings militate against the idea that the SMT is a trivial lesion. The SMT occurred in 90% of patients in this report and accounted for 65% of all intestinal lesions. Seventy-three percent of the tears developed in the colon, and one third of all SMTs occurred in the sigmoid colon. Two thirds of all intestinal and mesenteric injuries clustered in three sites: the ileocecal region, the sigmoid colon, and the jejunum. Perforations were the principal lesion in the jejunum and SMTs at the other two locations. Ninety percent of patients experienced two or more intestinal lesions. This suggests the simultaneous action of different traumatic mechanisms on the bowel and its mesenteries in seatbelted persons who are in motor vehicle accidents.

Intra-abdominal gastrointestinal tract injuries following blunt trauma: the experience of an Australian trauma centre

AIMS

The aim of the study was to use the extensive experience of an Australian Level I trauma centre to develop guidelines for diagnosis and management of significant gastrointestinal tract injuries (GITIs).

METHODS

This was a retrospective study of 74 patients admitted to Westmead Hospital between 1985 and 1996 who had sustained major gastrointestinal tract (GIT) injuries following blunt trauma. The patients were identified from the trauma unit database. Clinical information was retrieved from the database and augmented by a review of the medical records.

RESULTS

Motor vehicle accidents were responsible for 55 (92%) admissions. Laparotomy was performed as a result of a positive diagnostic peritoneal lavage in 26 (35.1%) patients, abdominal signs in 20 (27%), diagnostic findings on computed tomography in 19 (25.7%), haemodynamic instability in eight (10.8%) and a positive contrast study in one (1.4%) patient. There was a total of 95 injuries: one gastric (1.1%), eight duodenal (8.4%), 64 small bowel (67.3%), two appendiceal (2.1%), 19 colonic (20%) and one rectal (1.1%). Thirty day mortality was 23% (17 patients). Seven (9.5%) patients died within 24h of injury, three (4.1%) of which were directly related to the GIT. Ten (13.5%) patients died within 2 weeks of admission, three (4.1%) of which were attributable to the GIT. Thirty day GIT morbidity was 29.7% (22 patients). The development of GIT morbidity was significantly related to a delay to laparotomy of more than 24h (P=0.036) and tachycardia on presentation (P=0.023). Associated injuries, injury severity scores (ISS) and age did not significantly impact on GITI related morbidity and mortality.

DISCUSSION

Major GITIs are associated with a high mortality due to the severity and complexity of associated injuries. Morbidity from GITIs correlates to delays in diagnosis and management.

Traumatic 'degloving' of the colon in blunt abdominal injury

We describe two cases of traumatic 'degloving' of the colon in blunt abdominal trauma. This is an extremely rare injury with the potential to present late. The mechanism of injury appears to be a combination of focal blunt abdominal trauma associated with a shearing force. The potential diagnostic dilemma posed by colonic 'degloving' is outlined and following review of the literature we conclude that CT scanning is the most reliable way of detecting such injuries, if emergency laparotomy is not indicated.

Fatores preditivos de infecção no trauma de cólon

Este trabalho procurou avaliar fatores preditivos de infecção no trauma de cólon e sua validade epidemiológica. Durante 24 meses, 160 pacientes com trauma de cólon foram estudados prospectivamente em um centro de trauma, onde foram analisados possíveis fatores de risco para complicações infecciosas como a idade, o mecanismo de trauma, a topografia da lesão, o Colon Organ Injury Scale (CIS), o Abdominal Trauma Index (ATI), a presença de choque, a técnica cirúrgica empregada, o grau de contaminação e o intervalo de tempo entre o trauma e a cirurgia. Como complicações infecciosas foram consideradas: infecção da ferida cirúrgica, abscesso intra-abdominal, abscesso retroperitoneal, peritonite e deiscência de sutura colônica. A análise estatística dos dados foi feita por Regressão Logística Múltipla. No grupo estudado, 152 pacientes eram do sexo masculino, a idade média foi de 27,8 ± 12 anos, 104 ferimentos foram produzidos por arma de fogo, 38 por arma branca e 18 foram contusos, sendo de 18 ± 9 o ATI médio. A análise dos fatores de risco para infecção mostrou que o grau de contaminação fecal, o escore CIS, o tempo decorrido entre o trauma e a cirurgia e a faixa etária correlacionaram-se com complicações infecciosas neste estudo. Com base nesses resultados foi traçado um perfil do paciente de risco para infecção no grupo estudado: homem, mais de 35 anos, com trauma abdominal penetrante, com Cis > 3 e contaminação fecal moderada ou grande, submetido à cirurgia após mais de três horas do trauma.

Complications of primary repair of colon injury: literature review of 2,964 cases

OBJECTIVE

To evaluate the safety and efficacy of primary repair of colon injuries.

MATERIALS AND METHODS

A literature review was made of 35 publications containing 5,400 colon injuries in retrospective and prospective studies.

RESULTS

There were 62 (2.4%) failures in 2,627 primary repairs based on surgeon discretion or absence of risk factors. In prospective series of 337 patients repaired without exclusionary criteria, there were 4 (1.2%) suture line failures (P = not significant). In prospective randomized trials without exclusionary criteria, 127 primary repairs had less morbidity compared with 109 diverted patients (P <0.02). The leak rate after resection and anastomosis (5.5%) is greater than after simple suture of perforation (1.4%; P <0.001). The 66 colon repair leaks were treated by conversion to colostomy or led to fistulae that usually healed spontaneously. A preponderance of failed repairs occurred in the setting of multiple injuries or comorbid conditions.

CONCLUSIONS

Penetrating and blunt colon injuries in civilian practice are safely managed by primary repair, but colostomy may still be advised in selected cases.

Hollow visceral injury and blunt trauma

BACKGROUND

The incidence of hollow viscus injury (HVI) after blunt trauma (BT) is variable, and differences between children and adults have not been well described. The purpose of this study is to determine the age-group-related incidence and characteristics of BT-associated HVI as well as the clinical markers and consequences of delayed diagnosis.

METHODS

A 9-year trauma registry review of all patients with HVI.

RESULTS

A large sample of patients (19,621) with BT were evaluated (2,550 < or = 14 years old; 17,070 > 14 years old). One hundred thirty-nine of 17,070 (0.8%) adults had HVI compared with 27 of 2,550 (1%) children. HVI occurred more frequently in the duodenum in children (11 of 27) compared with adults (17 of 139) (p < 0.05). Among patients with abdominal wall ecchymosis, 13.5% of children had HVI compared with 10.6% of adults. Delays in diagnosis of HVI occurred in 9 of 27 children compared with 10 of 139 adults (p < 0.0 5). Delayed diagnosis was associated with increased abdominal septic complications in both children (4 of 9) and adults (2 of 10) compared with diagnosis at presentation (p < 0.05).

CONCLUSION

HVI occurs with a similar low frequency in both children and adults. Duodenal injuries are more common in pediatric BT patients. Abdominal wall ecchymosis is associated with increased HVI but is less predictive of HVI than previously described. Contrary to previous reports, delays in diagnosis are associated with increased morbidity.

Incidence and significance of free fluid on abdominal computed tomographic scan in blunt trauma

OBJECTIVE

To determine the incidence and significance of free fluid on abdominal CT in blunt trauma.

DESIGN

Retrospective chart review.

METHODS

All blunt trauma patients with an abdominal computed tomographic scan from August of 1993 to December of 1995 were identified from the trauma registry at a Level 1 trauma center. A total of 1,159 computed tomographic scans were performed; records of 18 patients were excluded for incomplete records. Official reports of computed tomographic scans were reviewed for free fluid, solid organ injury, bladder injury, and pelvic fracture.

RESULTS

Free fluid without solid organ injury was found in 3% (34 of 1141). Laparotomy was performed because of free fluid in 13 patients. There were six small bowel injuries and one diaphragm injury for a therapeutic laparotomy rate of 54%. Ten patients had trace free fluid and did not undergo laparotomy; none had a missed small bowel injury.

CONCLUSIONS

The presence of more than trace amounts of free fluid without solid organ injury in patients with blunt trauma is a strong indication for exploratory laparotomy. Patients with isolated trace amounts of free fluid can be safely observed.

Posttraumatic retroperitoneal rupture of the right colon simulating a retroperitoneal hematoma

OBJECTIVE

This case illustrates the diagnostic problems encountered in a patient with posttraumatic retroperitoneal abscess caused by perforation of the posterior wall of the cecum, simulating a retroperitoneal hematoma. Because standard diagnostic techniques failed to make early diagnosis, delayed laparotomy and right colectomy with primary repair were performed. The mechanism of the lesion is uncertain but could be a compressive force and direct injury to the cecum by the seat belt.

CONCLUSION

Blunt colonic injuries are rare and difficult to diagnose. Septic signs are unexpected in case of posttraumatic retroperitoneal hematoma and should suggest the diagnosis of retroperitoneal colonic perforation.

The influence of personal blast protection on the distribution and severity of primary blast gut injury

Primary blast injuries have been recognized since World War I when the most significant reported injury was to the lung. The prevalence of injury to tissues containing air was underlined by the frequency of gut blast injury in underwater explosions mostly reported during World War II. Gut injury is the most likely cause of mortality after the more immediate effects of pulmonary primary blast injury. Effective protection has been achieved for lungs exposed to short duration external blast waves by the placement of stress wave decouplers on to the thoracoabdominal wall in a pig model, thus modifying the energy coupled into the body. A combination of two densities of glass-reinforced plastic plate and Plastazote foam (GRP/PZ) effectively eliminated pulmonary injury in 17 protected animals, compared with the production of severe blast lung in nine unprotected animals (p < 0.001). Partial pulmonary protection was achieved using a plasticized lead and plastazote foam decoupling combination (PbPVC/PZ) in a further group of 10 animals. Peak incident overpressures were not significantly different in any group. Small bowel contusions were highly significantly reduced in the GRP/PZ groups when compared with unprotected animals and with PbPVC protected animals (both p < 0.001); no significant reduction was observed in the summed colonic contusion size in any protected group. Intestinal perforations were also highly significantly reduced in both GRP/PZ groups (p < 0.001). Primary pulmonary blast injury and probably small bowel injury are caused by the propagation of coupled stress waves within the body. Elimination of these injuries implies prevention of stress wave propagation. Because colonic injury was not prevented by the same protection, a different mechanism for the injury is suggested: transmission and propagation of shear waves. These findings have important implications for blast protection and the clinical management of primary blast casualties.

Multicentre study of surgical complications of colonoscopy

A total of 196 records of colonoscopic surgical complications were reviewed during a 12-year period. Perforation (183 patients) and haemorrhage (11) were the two main complications. Diagnosis of perforation was delayed in 58 per cent of patients. The sigmoid colon was the site of perforation in 72 per cent with evidence of peritoneal contamination in 59 per cent. Postoperative mortality rate of perforation was 12 per cent and was significantly related to a past history of medical disease and size of perforation. Postoperative morbidity rate was 43 per cent. There were two deaths after colostomy closure. The overall mortality rate of colonoscopic perforation requiring an emergency surgical procedure reached 14 per cent. Haemorrhage always occurred after endoscopic polypectomy; the postoperative course was uneventful in these patients.