Intra-abdominal Complications after Surgical Repair of Small Bowel Injuries: An International Review

The impact of stapled compared to handsewn repair on anastomotic outcomes in trauma patients: a systematic review and meta-analysis

BACKGROUND

Approach to enteric anastomotic technique has been a subject of debate, with no clear consensus as to whether handsewn or stapled techniques are superior in trauma settings, which are influenced by unique perturbances to important processes such as immune function, coagulation, wound healing and response to infection. This systematic review and meta-analysis compares the risk of anastomotic complications in trauma patients with gastrointestinal injury requiring restoration of continuity with handsewn versus staples approaches.

METHODS

A comprehensive computer assisted search of electronic databases Medline, Embase and Cochrane Central was performed. Comparative studies evaluating stapled versus handsewn gastrointestinal anastomoses in trauma patients were included in this review. All anastomoses involving small intestine to small intestine, small to large intestine, and large intestine to large intestine were eligible. Anastomosis to the rectum was excluded. Outcomes evaluated were (1) anastomotic leak (AL) (2) a composite anastomotic complication (CAC) end point consisting of AL, enterocutaneous fistula (ECF) and deep abdominal abscess.

RESULTS

Eight studies involving 931 patients were included and of these patients, data from 790 patients were available for analysis. There was no significant difference identified for anastomotic leak between the two groups (OR = 0.77; 95% CI 0.24-2.45; P = 0.66). There was no significant improvement in composite anastomotic complication; defined as a composite of anastomotic leak, deep intra-abdominal abscess and intra-abdominal fistula, in the stapled anastomosis group (OR = 1.05; 95% CI 0.53-2.09; P = 0.90). Overall, there was limited evidence to suggest superiority with handsewn or stapled anastomosis for improving AL or CAC, however this was based on studies of moderate to high risk of bias with poor control for confounders.

DISCUSSION

This meta-analysis demonstrates no superiority improvement in anastomotic outcomes with handsewn or stapled repair. These findings may represent no effect in anastomotic outcome by technique for all situations. However, considering the paucity of information on potential confounders, perhaps there is a difference in outcome with overall technique or for specific subgroups that have not been described due to limited sample size and data on confounders. Currently, there is insufficient evidence to recommend an anastomotic technique in trauma.

Small bowel anastomosis in emergency surgery

BACKGROUND

Emergency laparotomy is associated with a high morbidity and mortality rate. The decision on whether to perform an anastomosis or an enterostomy in emergency small bowel resection is guided by surgeon preference alone, and not evidence based. We examined the risks involved in small bowel resection and anastomosis in emergency surgery.

METHODS

A retrospective study from 2016 to 2019 in a university hospital in Denmark, including all emergency laparotomies, where small-bowel resections, ileocecal resections, right hemicolectomies and extended right hemicolectomies where performed. Demographics, operative data, anastomosis or enterostomy, as well as postoperative complications were recorded. Primary outcome was the rate of bowel anastomosis. Secondary outcomes were the anastomotic leak rate, mortality and complication rates.

RESULTS

During the 3.5-year period, 370 patients underwent emergency bowel resection. Of these 313 (84.6%) received an anastomosis and 57 (15.4%) an enterostomy. The 30-day mortality rate was 12.7% (10.2% in patients with anastomosis and 26.3% in patients with enterostomy). The overall anastomotic leak rate was 1.6%, for small-bowel to colon 3.0% and for small-bowel to small-bowel 0.6%.

CONCLUSION

A primary anastomosis is performed in more than eight out of 10 patients in emergency small bowel resections and is associated with a very low rate of anastomotic leak.

Abdominal emergency surgery in patients with hematological malignancies: a retrospective single-center analysis

BACKGROUND

Hematologic patients requiring abdominal emergency surgery are considered to be a high-risk population based on disease- and treatment-related immunosuppression. However, the optimal surgical therapy and perioperative management of patients with abdominal emergency surgery in patients with coexisting hematological malignancies remain unclear.

METHODS

We here report a single-center retrospective analysis aimed to investigate the impact of abdominal emergency surgery due to clinically suspected gastrointestinal perforation (group A), intestinal obstruction (group B), or acute cholecystitis (group C) on mortality and morbidity of patients with coexisting hematological malignancies. All patients included in this retrospective single-center study were identified by screening for the ICD 10 diagnostic codes for gastrointestinal perforation, intestinal obstruction, and ischemia and acute cholecystitis. In addition, a keyword search was performed in the database of all pathology reports in the given time frame.

RESULTS

A total of 56 patients were included in this study. Gastrointestinal perforation and intestinal obstruction occurred in 26 and 13 patients, respectively. Of those, 21 patients received a primary gastrointestinal anastomosis, and anastomotic leakage (AL) occurred in 33.3% and resulted in an AL-related 30-day mortality rate of 80%. The only factor associated with higher rates of AL was sepsis before surgery. In patients with suspected acute cholecystitis, postoperative bleeding events requiring abdominal packing occurred in three patients and lead to overall perioperative morbidity of 17.6% and surgery-related 30-day mortality of 5.9%.

CONCLUSION

In patients with known or suspected hematologic malignancies who require emergency abdominal surgery due to gastrointestinal perforation or intestinal obstruction, a temporary or permanent stoma might be preferred to a primary intestinal anastomosis.

[New treatment concepts for colonic injury after percutaneous nephrolithotomy]

Percutaneous nephrolithotomy (PCNL) has become the gold standard for the treatment of large kidney stones > 2 cm and stones in the lower calyces > 1.5 cm. Despite the miniaturization of instruments and the greater expertise of urologists, serious complications can still occur. One of the most dangerous complications is intestinal perforation. Current database analyses report colonic injury in 0.3-0.8% of all cases. These injuries can be treated with either conservative management with long-term drainage and parenteral nutrition, or an exploratory laparotomy with primary closure or creation of a colostomy becomes necessary. We present the case of a 53-year-old woman who underwent left-sided PCNL for a single kidney stone. After removal of the nephrostomy, feces leaked from the puncture channel. After literature research and an interdisciplinary case presentation, the decision was made in favor of an undescribed therapy concept for colon injury after PCNL. After taking laxatives, a colonoscopy was performed. The entry and exit points of the puncture were identified and were both treated with an OTSC® clip (InMedi, Langenhagen, Germany). Immediately after the intervention stool leakage via the puncture channel stopped and the patient was allowed to eat normally. A control sonography on the third day revealed minimal fluid retention in the retroperitoneum which did not require treatment. The patient was then discharged symptom-free.

The Effect of Epidermal Growth Factor on Anastomotic Leaks: An Experimental Study in Rats

INTRODUCTION

To investigate the effects of local epidermal growth factor (EGF) use on anastomotic healing during primary repair of anastomosis in rats with anastomotic leaks (AL).

METHODS

Thirty albino Wistar rats were divided into three groups. Anastomoses were performed in group 1 after colon transection. In groups 2 and 3, ALs were created with an incomplete colon anastomosis model. Relaparotomy was conducted on rats in groups 2 and 3 72 h after the first procedure. ALs of the rats were repaired with a primary suture in group 2 and with a primary suture and the application of submucosal EGF in group 3. All rats were sacrificed through cervical dislocation on the 6th day after the first procedure. Four-centimeter colonic segments containing 2-cm distal and proximal parts of the anastomotic lines of the subjects were resected. The primary outcome was anastomotic burst pressure (ABP). The secondary outcomes included limitation in inflammation, increased neovascularization, increased fibroblast activation and increased collagen synthesis.

RESULTS

The ABP value of group 2 was significantly lower than that of group 3 (P < 0.05). No significant difference was detected in the ABP value between group 3 and group 1 (P > 0.05). There was significantly less inflammatory cell infiltration in group 3 than in group 2 (P < 0.05). Collagen synthesis and neovascularization were significantly higher in group 3 than in group 2 (P < 0.05).

CONCLUSIONS

A single-dose of submucosal EGF applied to the AL line limited inflammation and stimulated neovascularization. It also had a positive effect on the strength of the anastomosis.

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.

Light-activated photosealing with human amniotic membrane strengthens bowel anastomosis in a hypotensive, trauma-relevant swine model

BACKGROUND

Gastrointestinal anastomotic leakage is a dreaded complication despite advancements in surgical technique. Photochemical tissue bonding (PTB) is a method of sealing tissue surfaces utilizing photoactive dye. We evaluated if crosslinked human amniotic membrane (xHAM) photosealed over the enteroenterostomy would augment anastomotic strength in a trauma-relevant swine hemorrhagic shock model.

METHODS

Yorkshire swine (40-45 kg, n = 14) underwent midline laparotomy and sharp transection of the small intestine 120 cm proximal to the ileocecal fold. Immediately following intestinal transection, a controlled arterial bleed was performed to reach hemorrhagic shock. Intestinal repair was performed after 60 minutes and autotransfusion of the withdrawn blood was performed for resuscitation. Animals were randomized to small intestinal anastomosis by one of the following methods (seven per group): suture repair (SR), or SR with PTB augmentation. Animals were euthanized at postoperative Day 28 and burst pressure (BP) strength testing was performed on all excised specimens.

RESULTS

Mean BP for SR, PTB, and native tissue groups were 229 ± 40, 282 ± 21, and 282 ± 47 mmHg, respectively, with the SR group statistically significantly different on analysis of variance (p = 0.02). Post-hoc Tukey all-pairs comparison demonstrated a statistically significant difference in burst pressure strength between the SR only and the PTB group (p = 0.04). All specimens in SR group ruptured at the anastomosis upon burst pressure testing, while all specimens in the PTB group ruptured at least 2.5 cm from the anastomosis.

CONCLUSION

Photosealing with xHAM significantly augments the strength of small intestinal anastomosis performed in a trauma porcine model.

Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties

BACKGROUND

Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties.

METHODS

Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals.

RESULTS

Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively.

CONCLUSIONS

Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high.

The Bucharest ESTES consensus statement on peritonitis

INTRODUCTION

Peritonitis is still an important health problem associated with high morbidity and mortality. A multidisciplinary approach to the management of patients with peritonitis may be an important factor to reduce the risks for patients and improve efficiency, outcome, and the cost of care.

METHODS

Expert panel discussion on Peritonitis was held in Bucharest on May 2017, during the 17th ECTES Congress, involving surgeons, infectious disease specialists, radiologists and intensivists with the goal of defining recommendations for the optimal management of peritonitis.

CONCLUSION

This document is an updated presentation of management of peritonitis and represents the summary of the final recommendations approved by a panel of experts.

Bowel and Bladder Injury Repair and Follow-up After Gynecologic Surgery

Bowel and bladder injuries are relatively rare, but there can be serious complications of both open and minimally invasive gynecologic procedures. As with most surgical complications, timely recognition is key in minimizing serious patient morbidity and mortality. Diagnosis of such injuries requires careful attention to surgical entry and dissection techniques and employment of adjuvant diagnostic modalities. Repair of bowel and bladder may be performed robotically, laparoscopically, or using laparotomy. Repair of these injuries requires knowledge of anatomic layers and suture materials and testing to ensure that intact and safe repair has been achieved. The participation of consultants is encouraged depending on the primary surgeon's skill and expertise. Postoperative care after bowel or bladder injury requires surveillance for complications including repair site leak, abscess, and fistula formation.

Intestinal Perforation Secondary to Pits of Jujube Ingestion: A Single-Center Experience with 18 Cases

BACKGROUND

Ingestion of jujube pits is a common clinical problem, which can be difficult to diagnose and life-threatening if accompanied with intestinal perforation and peritonitis. In this study, 18 cases of intestinal perforation caused by ingestion of jujube pits were reviewed and summarized to discuss the clinical characteristics, diagnosis and treatments.

METHODS

From 2012 to 2018, a total of 18 patients diagnosed as intestinal perforation due to ingested pits of jujube in our center were retrospectively reviewed and the manifestations, laboratory tests, imaging examinations and treatment strategies were summarized.

RESULTS

The patients comprised of 11 males and 7 females with an average age of 63.5 years. The main clinical manifestation was abdominal pain. Twelve patients (67%) presented to the emergency department with signs of localized peritonitis. CT imaging revealed positive findings in 17 (94%) patients. Conservative treatments were attempted in 3 patients, and the other 15 patients received emergency surgical exploration, where 7 patients had more than one perforation identified during surgery. Five patients were admitted in the surgical intensive care unit after surgery. The average length of stay of all 18 patients was 9.8 days (range 5-24 days).

CONCLUSION

Ingestion of jujube pits is a common clinical problem and potentially leads to intestinal perforation and peritonitis. CT imaging is the first imaging modality of choice. Patients with milder symptoms might be managed with cautious conservative treatment, and patients with more than one perforation can be identified during surgery.

Characteristics of Combat-Associated Small Bowel Injuries

INTRODUCTION

Although there are multiple studies regarding the management and outcomes of colonic injuries incurred in combat, the literature is limited with regard to small bowel injuries. This study seeks to provide the largest reported review of the characteristics of combat-associated small bowel injuries.

MATERIALS AND METHODS

The Department of Defense Trauma Registry was queried for U.S. Armed Forces members who sustained hollow viscus injuries in the years 2007-2012 during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Concomitant injuries, procedures, and complications were delineated. Fisher's exact test was used to analyze the relationship of bowel injury pattern to rates of repeat laparotomy, fecal diversion, and complications.

RESULTS

One hundred seventy-one service members had small bowel injuries. The mean age was 25.8 ± 6.6 yr with a mean injury severity score of 27.9 ± 12.4. The majority of injuries were penetrating (94.2%, n = 161) as a result of explosive devices (61.4%, n = 105). The median blood transfusion requirement in the first 24 h was 6.0 units (interquartile range 1.0-17.3 units). The most frequent concomitant injuries were large bowel (64.3%, n = 110), pelvic fracture (35.7%, n = 61), and perineal (26.3%, n = 45). Fifty patients (29.2%) had a colostomy, and nine patients (5.3%) had an ileostomy; 62.6% (n = 107) of soldiers underwent more than one laparotomy. The mortality rate was 1.8% (n = 3). The most common complications were pneumonia (15.2%, n = 26), deep vein thrombosis (14.6%, n = 25), and wound infection (14.6%, n = 25). The need for repeat laparotomy and fecal diversion was found to be significantly associated with injury pattern (p = 0.00052 and p < 0.0001, respectively).

CONCLUSION

We found that two-thirds of service members with small bowel injuries also had a large bowel injury. One-third of the patients required diversion and two-thirds had more than one laparotomy. The pattern of bowel injury significantly affected the need for repeat laparotomy and fecal diversion.

Hollow viscus injuries: predictors of outcome and role of diagnostic delay

INTRODUCTION

Hollow viscus injuries (HVIs) are uncommon but potentially catastrophic conditions with high mortality and morbidity rates. The aim of this study was to analyze our 16-year experience with patients undergoing surgery for blunt or penetrating bowel trauma to identify prognostic factors with particular attention to the influence of diagnostic delay on outcome.

METHODS

From our multicenter trauma registry, we selected 169 consecutive patients with an HVI, enrolled from 2000 to 2016. Preoperative, intraoperative, and postoperative data were analyzed to assess determinants of mortality, morbidity, and length of stay by univariate and multivariate analysis models.

RESULTS

Overall mortality and morbidity rates were 15.9% and 36.1%, respectively. The mean length of hospital stay was 23±7 days. Morbidity was independently related to an increase of white blood cells (P=0.01), and to delay of treatment >6 hours (P=0.033), while Injury Severity Score (ISS) (P=0.01), presence of shock (P=0.01), and a low diastolic arterial pressure registered at emergency room admission (P=0.02) significantly affected postoperative mortality.

CONCLUSION

There is evidence that patients with clinical signs of shock, low diastolic pressure at admission, and high ISS are at increased risk of postoperative mortality. Leukocytosis and delayed treatment (>6 hours) were independent predictors of postoperative morbidity. More effort should be made to increase the preoperative detection rate of HVI and reduce the delay of treatment.

Intestinal perforation secondary to ingested foreign bodies: a single-center experience with 38 cases

OBJECTIVE

The aim of this study is to report our experience with patients with intestinal perforation secondary to ingested foreign bodies (FBs) who were treated surgically at our institution.

METHODS

Between 2001 and 2015, a total of 38 pediatric patients with the diagnosis of intestinal perforation secondary to FBs were retrospectively reviewed.

RESULTS

The series comprised 22 males and 16 females. The average age of the patients was 1.9 years. A definitive preoperative history of the ingestion of FBs was obtained for only eight patients. Crying and abdominal pain were the main clinical manifestations. Perforation repair was performed in 29 patients (76.3%), while enterostomy was utilized in five patients (13.2%) and enterectomy in four patients (10.5%). Five perforations occurred in the large intestine, and 33 perforations occurred in the small intestine with the most common site being the distal ileum. Of the 38 FBs recovered, 26 were food objects, while non-food objects were found in 12 patients. All patients recovered well, except one patient with an intestinal obstruction from adhesions that occurred approximately 1 month after discharge.

CONCLUSIONS

Clinical performance of intestinal perforation secondary to FBs in children is atypical. Most perforations occur in the small intestine. Primary perforation repair is safe and effective, and better outcomes can be achieved.

Can Human Recombinant Epidermal Growth Factor Improve Ischemia and Induce Healing of Anastomosis in an Experimental Study in a Rabbit Model?

PURPOSE

Anastomotic leaks following intestinal operations may cause devastating effects on patients. Ischemia may also occur at the intestinal walls in the presence of strangulations. In this study, we examined the effects of human recombinant (Hr)-epidermal growth factor (EGF) given at a single intramural dose into the intestinal walls and daily intraperitoneal cavity on ischemia and the healing process of anastomosis.

MATERIALS AND METHODS

Sixteen male New Zeland white rabbits were randomly divided into four groups (n = 4 in each group). In Group 1, two different segments of ileum were identified and, then, transected and the free ends were sutured each other. In the other groups, ischemia was induced by ligating the mesenteric vascular arcade. After the ischemic induction, Group 2 received intramural injections of %0.9 saline, Group 3 received intramural injections of a single dose of EGF, and Group 4 received intramural and intraperitoneal injections of EGF. Bursting pressures and tissue hydroxyproline levels were analyzed. Necrosis, fibroblastic activity, collagen deposition and neovascularization were also studied.

RESULTS

The mean levels of bursting pressures in Group 4 (148.6 ± 25.3 mmHg) were higher than Group 2 (70 ± 21.5 mmHg) (p = 0.001). The mean level of bursting pressures was not statistically significant between Group 1 (170.1 ± 35 mmHg) and Group 4 (p = 0.073). Hydroxyproline levels in Group 2 were lower than Groups 3 and 4. There was a statistically significant difference in the mucosal ischemia, mucosal healing and degree of adhesion, but not in the mural anastomotic healing among the groups.

CONCLUSIONS

Intramural injection with daily intraperitoneal administration of low-dose EGF enhances the bursting pressure and collagen accumulation in ischemic anastomosis, improving many histological variables associated with ischemic intestinal anastomosis.

Percutaneous damage control with self-expanding foam: pre-hospital rescue from abdominal exsanguination

Non-compressible intra-abdominal hemorrhage results in significant morbidity and mortality in contemporary trauma medicine. Regrettably, many deaths from non-compressible hemorrhage are attributable to potentially survivable injuries. A self-expanding polyurethane foam has been developed for rapid, percutaneous damage control of exsanguinating abdominal hemorrhage, for patients not expected to survive to definitive surgical care. Foam intervention creates a temporary, commensal, hemostatic environment within the abdominal cavity. This tropism away from exsanguination physiology creates a hemostatic bridge such that the patient may reach definitive surgical intervention. This review article summarizes the existing literature characterizing the safety and efficacy of this intervention, along with a study in recently deceased patients that enables dose translation from animal models to human beings.

Chronic safety assessment of hemostatic self-expanding foam: 90-day survival study and intramuscular biocompatibility

BACKGROUND

Noncompressible hemorrhage is a significant cause of preventable death in trauma, with no effective presurgical treatments. We previously described the efficacy and 28-day safety of a self-expanding hemostatic foam in swine models. We hypothesized that the 28-day results would be confirmed at a second site and that results would be consistent over 90 days. Finally, we hypothesized that the foam material would be biocompatible following intramuscular implantation.

METHODS

Foam treatment was administered in swine following a closed-cavity splenic injury. The material was explanted after 3 hours, and the animals were monitored to 28 days (n = 6) or 90 days (n = 4). Results were compared with a control group with injury alone (n = 6 at 28 days, n = 3 at 90 days). In a separate study, foam samples were implanted in rabbit paravertebral muscle and assessed at 28 days and 90 days relative to a Food and Drug Administration-approved polyurethane mesh (n = 3 per group).

RESULTS

All animals survived the acute phase of the study, and the foam animals required enterorrhaphy. One animal developed postoperative ileus and was euthanized; all other animals survived to the 28-day or 90-day end point without clinically significant complications. Histologic evaluation demonstrated that remnant particles were associated with a fibrotic capsule and mild inflammation. The foam was considered biocompatible in 28-day and 90-day intramuscular implant studies.

CONCLUSION

Foam treatment was not associated with significant evidence of end-organ dysfunction or toxicity at 28 days or 90 days. Remnant foam particles were well tolerated. These results support the long-term safety of this intervention for severely bleeding patients.

Synergistic Effect of Combined Hollow Viscus Injuries on Intra-Abdominal Abscess Formation

The strong association between penetrating colon injuries and intra-abdominal abscess (IAA) formation is well established and attributed to high colon bacterial counts. Since trauma patients are rarely fasting at injury, stomach and small bowel colony counts are also elevated. We hypothesized that there is a synergistic effect of increased IAA formation with concomitant stomach and/or colon injuries when compared to small bowel injuries alone. Consecutive patients at a level one trauma center with penetrating small bowel (SB), stomach (S), and/or colon (C) injuries from 1996 to 2012 were reviewed. Logistic regression determined associations with IAA, adjusting for age, gender, Injury Severity Score (ISS), admission Glasgow Coma Score, transfusions, and concurrent pancreas or liver injury. A total of 1518 patients (91% male, ISS = 15.9 ± 8.4) were identified: 496 (33%) SB, 231 (15%) S, 288 (19%) C, 40 (3%) S + SB, 69 (5%) S + C, 338 (22%) C + SB, and 56 (4%) S + C + SB. 148 (10%) patients developed IAA: 4 per cent SB, 9 per cent S, 10 per cent C, 5 per cent S + SB, 22 per cent S + C, 13 per cent C + SB, and 25 per cent S + C + SB. Multiple logistic regression demonstrated that ISS, 24 hour blood transfusions, and concomitant pancreatic or liver injuries were associated with IAA. Compared with reference SB, S or S + SB injuries were no more likely to develop IAA. However, S + C, SB + C, and S + C + SB injuries were significantly more likely to have IAA. In conclusion, combined stomach + colon, small bowel + colon, and stomach, colon, + small bowel injuries have a synergistic effect leading to increased IAA formation after penetrating injuries. Heightened clinical suspicion for IAA formation is necessary in these combined hollow viscus injury patients.

Surgical outcomes of a civil war in a neighbouring country

OBJECTIVES

The civil war in Syria began on 15 March 2011, and many of the injured were treated in the neighbouring country of Turkey. This study reports the surgical outcomes of this war, in a tertiary centre in Turkey.

METHODS

159 patients with civilian war injuries in Syria who were admitted to the General Surgery Department in the Research and Training Hospital of the Medical School of Mustafa Kemal University, Hatay, Turkey, between 2011 and 2012 were analysed regarding the age, sex, injury type, history of previous surgery for the injury, types of abdominal injuries (solid or luminal organ), the status of isolated abdominal injuries or multiple injuries, mortality, length of hospital stay and injury severity scoring.

RESULTS

The median age of the patients was 30.05 (18-66 years) years. Most of the injuries were gunshot wounds (99 of 116 patients, 85.3%). Primary and previously operated patients were transferred to our clinic in a median time of 6.28±4.44 h and 58.11±44.08 h, respectively. Most of the patients had intestinal injuries; although a limited number of patients with colorectal injuries were treated with primary repair, stoma was the major surgical option due to the gross peritoneal contamination secondary to prolonged transport time. Two women and 21 men died. The major cause of death was multiorgan failure secondary to sepsis (18 patients).

CONCLUSIONS

In the case of civil war in the bordering countries, it is recommended that precautions are taken, such as transformation of nearby civilian hospitals into military ones and employment of experienced trauma surgeons in these hospitals to provide effective medical care. Damage control procedures can avoid fatalities especially before the lethal triad of physiological demise occurs. Rapid transport of the wounded to the nearest medical centre is the key point in countries neighbouring a civil war.

The safety of primary repair or anastomosis in high-risk trauma patients

PURPOSE

There is currently not enough data regarding the management of bowel injury and the results of primary repair or resection and anastomosis in high-risk trauma patients. We aimed to determine whether there were any short-term (30 days) postoperative complications relevant to the primary reconstruction of such bowel injuries.

METHOD

In a retrospective study, all trauma patients who underwent a definite laparotomy after penetrating or blunt injury in our institution during the last decade were identified. The study group consisted of those who underwent primary repair or resection and anastomosis of the small or large bowel or both. Patients who died within 72 h of admission, who had only serosal injuries or who received resection and diversion, were excluded.

RESULTS

Seventeen of the trauma patients who were treated at our institution during the study period had bowel injuries. Thirteen fit our criteria. All of them had at least one risk factor, and 61.5% of them had at least three risk factors for anastomotic or suture line disruption. Overall, 35 repairs and anastomoses took place. Only one patient developed clinical anastomotic leakage, resulting in a fistula, which did not require re-operation.

CONCLUSION

Our study contributes to the controversial issue of post-traumatic bowel reconstruction in high-risk trauma patients, and suggests that primary reconstruction is feasible and can provide a good outcome.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

A review of posttraumatic bowel injuries in ibadan

Background. Bowel injuries are a leading cause of morbidity and mortality following trauma. Evaluating patients who sustained abdominal trauma with bowel injury may pose a significant diagnostic challenge to the surgeon. Prompt recognition and timely intervention is necessary to improve outcome. Aim. This study was undertaken to evaluate treatment and outcome of patients with bowel trauma. Methods. A 5-year retrospective study of all patients presenting with abdominal trauma requiring surgical intervention seen in the UCH Ibadan, Nigeria was undertaken. Results. There were 71 patients (59 males and 12 females). The majority of cases (70%) occurred between the 3rd and 5th decades of life. Some 37 patients (52%) sustained blunt abdominal injury, while 34 patients (48%) sustained penetrating abdominal injury. There were 27 patients with bowel injuries (38%). Isolated bowel injuries occurred in 19 patients (27%). The most common surgical operation performed was simple closure. There were 3 deaths in patients with bowel injuries. Conclusion. Most cases of bowel injury can be managed by simple closure, a technique that is not so technically demanding for surgeons in less-developed countries. This study has also incidentally identified a “rule of six” for patients with bowel injuries and abdominal trauma.

Enterocutaneous fistulas in the setting of trauma and critical illness

One of the most devastating complications to develop in the general surgical patient is an enterocutaneous fistula (ECF). Critically ill patients suffering trauma, thermal injury, infected necrotizing pancreatitis, and other acute intraabdominal pathology are at unique risk for this complication as well. By using decompressive laparotomy for abdominal compartment syndrome and leaving the abdomen open temporarily for other acute processes, survival in some instances may be improved. However, the exposed viscera are at risk for fistulization in the presence of an open abdomen, a newly defined entity termed the enteroatmospheric fistula (EAF). The purpose of this article is to describe the epidemiology of ECF in the setting of trauma and critical illness, nutrition in injured/critically ill patients with ECF, pharmacologic adjuncts to decrease fistula effluent, wound care, surgical management of the EAF/ECF, and techniques for prevention of these dreaded complications in patients with an open abdomen.

WSES consensus conference: Guidelines for first-line management of intra-abdominal infections

Intra-abdominal infections are still associated with high rate of morbidity and mortality.A multidisciplinary approach to the management of patients with intra-abdominal infections may be an important factor in the quality of care. The presence of a team of health professionals from various disciplines, working in concert, may improve efficiency, outcome, and the cost of care.A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bologna on July 2010, during the 1st congress of the WSES, involving surgeons, infectious disease specialists, pharmacologists, radiologists and intensivists with the goal of defining recommendations for the early management of intra-abdominal infections.This document represents the executive summary of the final guidelines approved by the consensus conference.

Gastrointestinal perforation and the acute abdomen

The acute abdomen accounts for up to 40% of all emergency-surgical hospital admissions and is considered in the differential in the more than 7 million visits to the emergency department annually for abdominal pain in the United States. A large percentage of these cases are secondary to perforation or impending gastrointestinal perforation. Gastrointestinal perforation causes considerable mortality and usually requires emergency surgery.Rapid diagnosis and treatment of these conditions is essential to reduce the high morbidity and mortality of late-stage presentation. Successful treatment requires a thorough understanding of the anatomy, microbiology, and pathophysiology of this disease process and in-depth knowledge of the therapy, including resuscitation,antibiotics, source control, and physiologic support.

Fatores preditivos de morbimortalidade no trauma de intestino delgado

OBJETIVO: Os objetivos deste estudo foram avaliar o diagnóstico e o tratamento das lesões de intestino delgado e determinar os fatores que influenciaram a morbimortalidade. MÉTODO: Estudo retrospectivo incluindo 410 pacientes com lesão de intestino delgado operados entre janeiro de 1994 e dezembro de 2004. Os dados coletados incluíram: mecanismo de trauma, métodos diagnósticos, tempo transcorrido até a intervenção cirúrgica, grau das lesões, índices de trauma, conduta cirúrgica (sutura ou ressecção e anastomose), morbidade (especialmente fístula) e mortalidade. A comparação entre os grupos foi feita usando os testes de Fisher e Yates. RESULTADOS: O mecanismo de trauma foi penetrante em 321 pacientes (78,3%) e fechado em 89 (21,7%). Houve mais pacientes tratados cirurgicamente com intervalo maior que 6 horas após o trauma no grupo trauma contuso se comparados com trauma penetrante (p<0,05). Sutura da lesão foi feita em 52,2% dos pacientes e ressecção e anastomose em 46,8%, e ambos procedimentos apresentaram a mesma incidência de fístula (4,7%). A morbidade foi de 35,1%. A incidência de fistula foi maior nos pacientes submetidos à laparotomia com mais de 12 horas após o trauma quando comparados com aqueles operados com menos de 12 horas (8,3% vs. 4,3%; sem diferença estatística), mas isto não foi fator determinante para maior mortalidade. A mortalidade foi de 13,7% e foi relacionada com escores de gravidade mais elevados. CONCLUSÃO: A lesão de intestino delgado é freqüente após o trauma abdominal, sendo mais comum nos traumas penetrantes. O diagnóstico desta lesão após trauma fechado pode ser difícil, com demora para o tratamento cirúrgico. A ocorrência de fistula não esteve relacionada aos seguintes fatores analisados: mecanismo de trauma, tempo transcorrido entre o trauma e a operação, conduta cirúrgica, lesões intra-abdominais associadas ou gravidade das lesões. A mortalidade esteve relacionada com lesões associadas.

[Surgical management of abdominal injury]

PURPOSE

Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury.

METHODS

Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine.

RESULTS

Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this.

DISCUSSION

Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.

To close or not to close, that is one of the questions? Perceptions of Trauma Association of Canada surgical members on the management of the open abdomen

BACKGROUND

The optimal abdominal closure in critically ill surgical/trauma patients remains controversial with a wide variety of commonly employed techniques. We sought to evaluate clinical equipoise by surveying Canadian surgeons regarding the use of temporary abdominal closure strategies in damage control and emergency situations.

METHODS

A structured mixed-mode (Website and paper), scenario-based questionnaire was developed by members of the Canadian Trauma Trials Collaborative and directed to surgical members of the Trauma Association of Canada (TAC).

RESULTS

The overall response rate was 84% (86 out of 102). In resuscitated hemodynamically stable trauma patients, 42% (29 out of 69) of respondents elected to primarily close an "extremely tight" abdominal cavity while only 23% (16 out of 70) would primarily close the same patient when physiologic exhaustion (Damage control (DC) conditions-hypothermia, acidosis, and coagulopathy) supervened. Although the majority reported preference for temporizing abdominal closures [73% (51 out of 70) non-DC, 75% (52 out of 69) DC] when the fascia was physically impossible to close; the reported primary use of mesh in these situations was quite high [24.6% (17 out of 69) non-DC, 24% (16 out of 69) DC], including a reported 7% (5 out of 69) nonabsorbable mesh usage in a contaminated octogenarian abdomen.

CONCLUSION

Reported opinions suggest an overall appreciation for markers of "Damage Control," although clinical equipoise exists regarding the preferred technique and a frequent early use of mesh. These results highlight the necessity for further research but suggest challenges in defining a common standard for multicenter trials.

Spill Your Guts! Perceptions of Trauma Association of Canada Member Surgeons Regarding the Open Abdomen and the Abdominal Compartment Syndrome

BACKGROUND

To survey surgeon opinion regarding the management of the open abdomen (OA) and abdominal compartment syndrome (ACS) to assess current practice and direct future prospective clinical studies.

METHODS

Opinions of self-designated trauma, general, pediatric, and vascular surgeons belonging to the Trauma Association of Canada (TAC), were surveyed through a mixed-mode (mail and Web based) questionnaire.

RESULTS

Among 102 eligible candidates, 86 (84%) responded; 83% did regular trauma call, 45% regular critical care call being a separate call 79% of the time; 79% worked in centers serving >500,000 people; the median year of practice entry was 1997. There was no standard definition of what constituted an "open abdomen", preferred time for re-operation, or preferred method for alternate fascial closure, although 90% reported having not closing the fascia after a trauma laparotomy. Being "physically unable" was reported as an indication twice as often as objective measures of airway or bladder pressures. The decision to proceed with OA was reported as rarely or never being made preoperatively by 78% of respondents. None reported an institutional policy regarding OA. Eighty-four percent reported (re)opening an abdomen for primary ACS, 46% for secondary ACS, 28% for tertiary ACS. Self-assessed familiarity for the ACS was 6/7 on a Likert scale. Physical examination was reported as a diagnostic criterion for ACS by 66%, and used to screen by 21% of respondents.

CONCLUSIONS

There is no consensus regarding definition, functional indications, or management of an open abdomen in the perceptions of Canadian trauma providers despite a high self reported level of familiarity with the abdominal compartment syndrome. This is an area of practice with potential and requirements for further multi-center study.