Management of colorectal injuries during operation iraqi freedom: patterns of stoma usage

Rectal damage control: when to do and not to do

Rectal trauma is uncommon, but it is usually associated with injuries in adjacent pelvic or abdominal organs. Recent studies have changed the paradigm behind military rectal trauma management, showing better morbidity and mortality. However, damage control techniques in rectal trauma remain controversial. This article aims to present an algorithm for the treatment of rectal trauma in a patient with hemodynamic instability, according to damage control surgery principles. We propose to manage intraperitoneal rectal injuries in the same way as colon injuries. The treatment of extraperitoneal rectum injuries will depend on the percentage of the circumference involved. For injuries involving more than 25% of the circumference, a colostomy is indicated. While injuries involving less than 25% of the circumference can be managed through a conservative approach or primary repair. In rectal trauma, knowing when to do or not to do it makes the difference.

Article Commentary: Evolving Colon Injury Management: A Review

The colon is the second most commonly injured intra-abdominal organ in penetrating trauma. Management of traumatic colon injuries has evolved significantly over the past 200 years. Traumatic colon injuries can have a wide spectrum of severity, presentation, and management options. There is strong evidence that most non-destructive colon injuries can be successfully managed with primary repair or primary anastomosis. The management of destructive colon injuries remains controversial with most favoring resection with primary anastomosis and others favor colonic diversion in specific circumstances. The historical management of traumatic colon injuries, common mechanisms of injury, demographics, presentation, assessment, diagnosis, management, and complications of traumatic colon injuries both in civilian and military practice are reviewed. The damage control revolution has added another layer of complexity to management with continued controversy.

Ostomy Usage for Colorectal Trauma in Combat Casualties

INTRODUCTION

The role for diverting ostomy as a method to help reduce morbidity and mortality has been well established in the combat trauma population. However, factors that influence the type of ostomy used and which ostomies become permanent are poorly studied. We examine patterns of ostomy usage and reversal in a large series of combat trauma patients.

METHODS

We performed a retrospective review of combat casualties treated at our continental U.S. military treatment facility from 2003 to 2015. All patients who underwent ostomy formation were included. Clinical and demographic factors were collected for all patients including the type of ostomy and whether or not ostomy reversal took place. Patients were grouped and analyzed based on ostomy type and by ostomy reversal.

RESULTS

We identified 202 patients who had ostomies created. End colostomies were most common (N = 149) followed by loop colostomies (N = 34) and end ileostomies (N = 19). Casualties that underwent damage control laparotomy (DCL) were less likely to have a loop colostomy created (p < 0.001). Ostomy reversal occurred in 89.9% of patients. There was no difference in ostomy reversal rates by ostomy type (p = 0.080). Presence of a pelvic fracture was associated with permanent ostomy (OR = 3.28, p = 0.019), but no factor independently predicted a permanent ostomy on multivariate analysis.

DISCUSSION

DCL and a severe perineal injury most strongly influence ostomy type selection. Most patients undergo colostomy reversal, and no factor independently predicted an ostomy being permanent. These findings provide a framework for understanding the issue of fecal diversion in the combat trauma population and inform military surgeons about injury patterns and treatment options.

Rectal Trauma: Evidence-Based Practices

The management of rectal trauma has often been lumped in with colon trauma when, in fact, it is a unique entity. The anatomic nature of the rectum (with its intra- and extraperitoneal segments) lends itself to unique circumstances when it comes to management and treatment. From the four Ds (debridement, drainage, diversion, and distal irrigation), the management of rectal trauma has made some strides in light of the experiences coming out of the recent conflicts overseas as well as some rethinking of dogma. This article will serve to review the anatomy and types of injuries associated with rectal trauma. A treatment algorithm will also be presented based on our current literature review. We will also address controversial points and attempt to give our opinion in an effort to provide an update on an age-old problem.

Immediate Versus Delayed Repair of Destructive Bowel Injuries in Patients with an Open Abdomen

Trauma surgeons frequently encounter destructive bowel injuries. The timing of the repair of the bowel injury should be performed in patients with planned open abdomen management and second-look laparotomy has not been specifically addressed. Our primary objective was to determine if there was a significant difference in the incidence of major complications between immediate and delayed repair among patients with traumatic bowel injuries and planned open abdomens. This was a retrospective cohort study of adult patients with traumatic bowel injuries treated between 2001 and 2011 and who underwent laparotomy and were left with an open abdomen with a planned second operation. Pediatric patients (age less than 15 years) and patients who died in the first 24 hours of admission were excluded. The primary exposure of interest was dichotomously defined based on either definitive repair of the bowel injury during the initial trauma operation (immediate) or definitive repair during a subsequent surgery (delayed). Major complications were defined as enterocutaneous fistula, dehiscence, and abscess. Ninety-two patients met study eligibility. Of these, 50 (54%) underwent immediate bowel repair. Univariate analysis suggested no significant differences in the proportion of major complications between the two groups. After adjusting for Injury Severity Score, penetrating injury, initial base deficit, and presence of colon injury, there was no statistical difference in incidence of major complications between the two groups. Patients undergoing immediate versus delayed repair of traumatic bowel injuries and who are left with an open abdomen have comparable outcomes in terms of major complications.

Colon diversion versus primary colonic repair in gunshot abdomen with penetrating colon injury in Libyan revolution conflict 2011 (a single center experience)

PURPOSE

The objective of this study is comparing colon diversion versus primary repair in penetrating colon gunshot injuries.

METHODS

A retrospective study of 63 cases of gunshot abdomen with penetrating colon injury were admitted to Al-jalla Hospital in 2011 in Benghazi, Libya. After surgical intervention, these patients were observed for any postoperative complications.

RESULTS

During the study period, 63 eligible patients included, 62 (98.4%) were males and 1 (1.6%) was female. And the mean age was 29.24 years. Eighteen patients had an injury on the right side of the colon, while 16, 6, 11, 6, 2, 3, and 1 patients had an injury on the transverse, left, sigmoid, rectum, right transverse, left transverse, and total colonic injury, respectively. In the first group, 23 patients (36.5%) was treated with colon diversion, (2 with Hartmann's operation, 21 with loop colostomy). In the second group, 40 patients (63.4 %) was treated with primary repair. Eighteen (28.5%) with right hemicolectomy, 5 (7.9%) with transverse colon resection and anastomosis, and 17 (26.9%) with simple repair. We evaluate the rate of postoperative complication and compare the postoperative morbidity between both groups.

CONCLUSION

In our study, there was no significant statistical difference between types of operations and rate of complications (P = 0.18). We could not see any advantage of the diversion over the primary repair. To reduce risk of the psychological trauma, complications of colostomy, unnecessary repeated hospitalization, decrease of economic cost, and complications of stoma revision operation, we should consider that the primary repair of penetrating colon injuries is an acceptable alternative method of treatment over the colostomy.

Initial management and outcome of modern battlefield anal trauma

BACKGROUND

Despite the potential for morbidity and permanent lifestyle alteration, few reports exist examining traumatic injury to the anal canal, particularly among modern-day combatants.

OBJECTIVE

The aim of this study was to document the incidence, initial surgical management, and long-term outcomes of wartime anal trauma.

DESIGN

This study is a retrospective review.

DATA SOURCES

Data were compiled from multiple electronic medical record systems, including the Department of Defense Trauma Registry, the Patient Administration Systems and Biostatistics Activity, and the Armed Forces Health Longitudinal Tracking Application.

SETTINGS

Combatants were treated at military treatment facilities with surgical capability during the wars in Iraq and Afghanistan, 2003 through early 2011.

PATIENTS

All US and coalition combatants sustaining trauma to the anal canal or sphincter musculature were included.

MAIN OUTCOME MEASURES

The quantification of incidence, the evaluation of initial treatment approach, and the determination of clinical and surgical factors correlating with restoration or preservation of GI tract continuity were the primary outcomes measured.

RESULTS

Anal trauma occurred in 46 combatants, predominantly from blast injury (76.1%). Most (36, 78.2%) underwent fecal diversion. Concurrent severe systemic or intra-abdominal injuries correlated with colostomy creation. Acute anoplasty was attempted in 11 patients (23.7%) but did not influence eventual colostomy reversal. Among 33 US personnel, the permanent colostomy rate was 30.3%. Concurrent injury to the abdomen strongly predicted long-term colostomy (p = 0.009), along with hypogastric arterial ligation (p = 0.05) and pelvic fracture (p = 0.06).

LIMITATIONS

This study was limited by the potential underdiagnosis of anal injury and the restricted follow-up of non-US personnel.

CONCLUSIONS

Other injuries besides anal trauma typically have guided the decision for fecal diversion, and acute anal repair has rarely been indicated. The majority of patients with anal trauma regained normal GI continuity, although certain pelvic injuries increased the likelihood of permanent colostomy.

Epidemiology of modern battlefield colorectal trauma: a review of 977 coalition casualties

BACKGROUND

Traumatic injuries to the lower gastrointestinal tract occur in up to 15% of all injured combatants, with significant morbidity (up to 75%) and mortality. The incidence, etiology, associated injuries, and overall mortality related to modern battlefield colorectal trauma are poorly characterized.

METHODS

Using data from the Joint Theater Trauma Registry and other Department of Defense electronic health records, the ongoing Joint Surgical Transcolonic Injury or Ostomy Multi-theater Assessment project quantifies epidemiologic trends in colon injury, risk factors for prolonged or perhaps unnecessary fecal diversion, and quality of life in US military personnel requiring colostomies. In the current study, all coalition troops with colon or rectal injuries as classified by DRG International Classification of Diseases-9th Rev. diagnosis and Abbreviated Injury Scale (AIS) codes in the Joint Theater Trauma Registry were included.

RESULTS

During 8 years, 977 coalition military personnel with colorectal injury were identified, with a mean (SD) Injury Severity Score (ISS) of 22.2 (13.2). Gunshot wounds remain the primary mechanism of injury (57.6%). Compared with personnel with colon injuries, those with rectal trauma sustained greater injury to face and extremities but fewer severe thoracic and abdominal injuries (p < 0.005). Overall fecal diversion rates were significantly higher in Iraq than in Afghanistan (38.7% vs. 31.6%, respectively; p = 0.03), predominantly owing to greater use of diversion for colon trauma. There was little difference in diversion rates between theaters for rectal injuries (59.6% vs. 50%, p < 0.15). The overall mortality rate was 8.2%. Notably, the mortality rate for patients with no fecal diversion (10.8%) was significantly greater than those with fecal diversion (3.7%, p < 0.0001).

CONCLUSION

Military personnel sustaining colon or rectal trauma continue to have elevated mortality rates, even after reaching surgical treatment facilities. Furthermore, associated serious injuries are commonly encountered. Fecal diversion in these patients may lead to reduced mortality, although prospective selection criteria for diversion do not currently exist. Future research into risk factors for colostomy creation, timing of diversion in relation to damage-control laparotomy, and quality of life in veterans with stomas will produce useful insights and help guide therapy.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Historical and current trends in colon trauma

The authors discuss the evolution of the evaluation and management of colonic trauma, as well as the debate regarding primary repair versus fecal diversion. Their evidence-based review covers diagnosis, management, surgical approaches, and perioperative care of patients with colon-related trauma. The management of traumatic colon injuries has evolved significantly over the past 50 years; here the authors describe a practical approach to the treatment and management of traumatic injuries to the colon based on the most current research. However, management of traumatic colon injuries remains a challenge and continues to be associated with significant morbidity. Familiarity with the different methods to the approach and management of colonic injuries will allow surgeons to minimize unnecessary complications and mortality.

Rectal trauma in adults

Rectal trauma is associated with high rates of morbidity and mortality and generally affects young males due to its aetiology of violent crime and vehicular collision. Historically, management has followed principles derived from military practice, with faecal diversion, pre-sacral drainage and distal washout being mandatory. Civilian trauma studies examining management of colon and rectum injuries from the early 1950s identified major differences in the level of energy transfer between civilian and military wounds, given that the vast majority are penetrating in nature. This led to a re-evaluation of the necessity for these interventions for all rectal injuries. Current management depends on whether the injury is intra- or extraperitoneal, with those above the peritoneal reflection being readily accessible and amenable to treatment as for colon injury. Extraperitoneal injuries remain difficult to access and direct repair is usually impossible; the mainstay of treatment in most instances remains faecal diversion. The role of pre-sacral drainage and distal washout remains contentious in the realms of civilian rectal injury but retains a place in battlefield or other high-energy transfer rectal injuries where aggressive early management reduces septic complications. This article reviews the historical and current evidence for the management of both civilian and military extraperitoneal rectal injuries.

Management and Outcomes of Traumatic Colon Injury in Civilian and Military Patients

Divergent injury patterns may indicate the need for differing strategies in combat and civilian trauma patients. This study aims to compare outcomes of colon injury management in these two populations. Parallel retrospective reviews were conducted comparing warfighters (n = 59) injured downrange and subsequently transferred to the United States with civilians (n = 30) treated at a United States Level I trauma center. Patient characteristics, mechanisms of injury, treatment course, and complications were compared. The civilian (CP) and military (MP) populations did not differ in Injury Severity Score (MP 20 vs CP 26; P = 0.41). The MP experienced primarily blast injuries (51%) as opposed to blunt trauma (70%; P < 0.01) in the CP. The site of colon injury did not differ between groups ( P = 0.15). Initial management was via primary repair (53%) and resection and anastomosis (27%) in the CP versus colostomy creation (47%) and stapled ends (32%) in the MP ( P < 0.001). Ultimately, the CP and MP experienced equivalent continuity rates (90%). Overall complications (MP 68% vs CP 53%; P = 0.18) and mortality (MP 3% vs CP 3%; P = 0.99) did not differ between the two groups. The CP and MP experience different mechanisms and initial management of colon injury. Ultimately, continuity is restored in the majority of both populations.

Difficult decisions in the surgical care of military casualties with major torso trauma

Testing and difficult decision-making is a sine qua non of surgical practice on military operations. Better pre-hospital care protocols, reduced evacuation timelines and increased scrutiny of outcome have rightfully emphasised the requirement of surgeons to "get it right, first time and every time" when treating patients. This article addresses five contentious areas concerning severe torso trauma, with relevant literature summarised by a subject matter expert, in order to produce practical guidance that will assist the newly deployed surgeon in delivering optimal clinical outcomes.

Traumatic injury of the colon and rectum: the evidence vs dogma

BACKGROUND

The treatment of traumatic injuries to the colon and rectum is often driven by dogma, despite the presence of evidence suggesting alternative methods of care.

OBJECTIVE

This is an evidence-based review, in the format of a review article, to determine the ideal treatment of noniatrogenic traumatic injuries to the colon and rectum to improve the care provided to this group of patients. Recommendations and treatment algorithms were based on consensus conclusions of the data.

DATA SOURCES

A search of MEDLINE, PubMed, and the Cochrane Database of Collected Reviews was performed from 1965 through December 2010.

STUDY SELECTION

Authors independently reviewed selected abstracts to determine their scientific merit and relevance based on key-word combinations regarding colorectal trauma. A directed search of the embedded references from the primary articles was also performed in select circumstances. We then performed a complete evaluation of 108 articles and 3 additional abstracts.

MAIN OUTCOME MEASURES

The main outcomes were morbidity, mortality, and colostomy rates.

RESULTS

Evidence-based recommendations and algorithms are presented for the management of traumatic colorectal injuries.

LIMITATIONS

Level I and II evidence was limited.

CONCLUSIONS

Colorectal injuries remain a challenging clinical entity associated with significant morbidity. Familiarity with the different methods to approach and manage these injuries, including "damage control" tactics when necessary, will allow surgeons to minimize unnecessary complications and mortality.

Battlefield trauma, traumatic shock and consequences: war-related advances in critical care

Over the course of history, while the underlying causes for wars have remained few, mechanisms of inflicting injury and our ability to treat the consequent wounds have dramatically changed. Success rates in treating war-related injuries have improved greatly, although the course of progress has not proceeded linearly. From Homer's Iliad to the Civil War to Vietnam, there have been significant improvements in mortality, despite a concurrent increase in the lethality of weapons. These improvements have occurred primarily as a result of progress in three key areas: management of wounds, treatment of shock, and systems of organization.