Outcomes of Primary Repair and Primary Anastomosis in War-Related Colon Injuries

Platelet rich plasma effectiveness in bowel anastomoses: A systematic review

BACKGROUND

Anastomotic leak constitutes a major problem in abdominal surgery. Technical insufficiency, topical or systemic factors contribute to disrupted healing of the performed bowel anastomosis and result in anastomosis leakage, with detrimental effects on patient postoperative outcomes. Despite the investigation of several factors and the invention of protective materials, the ideal agent to prevent anastomotic leaks is yet to be determined.

AIM

To study the effect of platelet rich plasma (PRP) on the healing of bowel anastomoses.

METHODS

A systematic literature search was performed in PubMed, EMBASE, and Scopus databases to identify studies investigating the effect of PRP application on bowel anastomosis.

RESULTS

Eighteen studies were eligible with a total population of 712 animals including rats (14 studies), rabbits (2 studies) and pigs (2 studies). No postoperative complications were reported following PRP application. Fourteen out of 18 studies reported a statistically significant higher anastomosis bursting pressure in PRP groups compared to control either in healthy animals or animal models with underlying condition or intervention, such as intraperitoneal chemotherapy or peritonitis. Similar results were reported by ten studies in terms of tissue hydroxyproline levels. One study reported significant increase in collagen deposition in PRP groups. PRP application resulted in significantly decreased inflammatory cell infiltration in the presence of peritonitis or intraperitoneal chemotherapy (6 studies).

CONCLUSION

The application of PRP is associated with improved bowel anastomosis outcomes, especially in animal models having an underlying condition affecting the normal healing process. PRP application seems to augment the normal healing process under these circumstances. However, further studies are needed to investigate the potential role of PRP on bowel anastomosis healing, especially in clinical settings.

Meta-analysis on surgical management of colonic injuries in trauma: to divert or to anastomose?

BACKGROUND

Primary repair or resection with anastomosis (PR/A) has been gaining increasing recognition for traumatic colonic injuries, with the need for faecal diversion (FD) especially those of penetrating etiology being questioned. However, the role of PR/A in critically ill patients is still controversial with concerns pertaining to safety and anastomotic leak.

AIMS AND METHODS

We performed a systemic review of studies comparing outcomes of FD versus PR/A in traumatic colonic injuries. A systematic review was performed as per PRISMA guidelines utilizing three electronic databases: Pubmed, EMBASE, and Cochrane Library resources. Mortality and anastomotic leak rates are identified as the primary and secondary outcomes, respectively. Data extracted include mortality rates, type of surgical intervention, surgical complications, and need for DC (damage control) surgery.

RESULTS

Fourteen studies were identified comprising 11 retrospective, 2 prospective cohort and 1 randomized trial with a total of 2071 patients. Six studies included patients that underwent DC surgery. The overall mortality rate was 3.77% and was higher in the FD group compared to PR/A group (5.38% vs 2.49%, p = 0.07). 71.3% of patients underwent PR/A with an overall leak rate of 4.63%. There was no difference in intra-abdominal collections between the PR/A and FD groups. In the subgroup analysis, anastomotic leak rate was significantly higher in the DC group compared to non-DC group (16.7% vs 3.2%, p = 0.003).

CONCLUSIONS

This meta-analysis supports PR/A in stable patients with traumatic colonic injuries. FD should be considered in critically ill patients who require DC surgery as leak rates are significantly higher.

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.

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.

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.

Management of Destructive Colon Injuries after Damage Control Surgery

After the World War II, fecal diversion became the standard of care for colon injuries, although medical, logistic, and technical advancements have challenged this approach. Damage control surgery serves to temporize immediately life-threatening conditions, and definitive management of destructive colon injuries is delayed until after appropriate resuscitation. The bowel can be left in discontinuity for up to 3 days before edema ensues, but the optimal repair window remains within 12 to 48 hours. Delayed anastomosis performed at the take-back operation or stoma formation has been reported with variable results. Studies have revealed good outcomes in those undergoing anastomosis after damage control surgery; however, they point to a subgroup of trauma patients considered to be "high risk" that may benefit from fecal diversion. Risk factors influencing morbidity and mortality rates include hypotension, massive transfusion, the degree of intra-abdominal contamination, associated organ injuries, shock, left-sided colon injury, and multiple comorbid conditions. Patients who are not suitable for anastomosis by 36 hours after damage control may be best managed with a diverting stoma. Failures are more likely related to ongoing instability, and the management strategy of colorectal injury should be based mainly on the patient's overall condition.

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.

Tannin-based adhesive for protection of colonic anastomosis in the open abdomen

This study was aimed to evaluate the effect of tannin acid- polyethylene glycol (TP) adhesive on the wound healing process of primary colonic anastomosis in the open abdomen (OA). Adhesion strength test, degradation and hemostatic ability of TP were investigated. In a rat model, after standard colonic anastomoses, rats were divided into three groups: OA group; OA + FG (fibrin glue) group; OA + TP group. Five days after surgery, body weight, anastomotic bursting pressure (ABP), and histology of anastomotic tissue were evaluated. Performance of adhesion strength and hemostatic ability of TP was better than that of FG. The weight of TP decreased by over 50% after 11-day incubation. All rats survived well after surgery. Compared to OA group and OA + FG group, OA + TP group showed a significant improvement in body weight, ABP and healing state. Application of TP adhesive, used as an auxiliary treatment of colonic anastomosis operation, improved the wound strength and promoted the anastomotic healing after OA.

The management of colonic trauma in the damage control era

INTRODUCTION The purpose of this study was to audit our current management of colonic trauma, and to review our experience of colonic trauma in patients who underwent initial damage control (DC) surgery. METHODS All patients treated for colonic trauma between January 2012 and December 2014 by the Pietermaritzburg Metropolitan Trauma Service were included in the study. Data reviewed included mechanism of injury, method of management (primary repair [PR], primary diversion [PD] or DC) and outcome (complications and mortality rate). Results A total of 128 patients sustained a colonic injury during the study period. Ninety-seven per cent of the injuries were due to penetrating trauma. Of these cases, 56% comprised stab wounds (SWs) and 44% were gunshot wounds (GSWs). Management was by PR in 99, PD in 20 and DC surgery in 9 cases. Among the 69 SW victims, 57 underwent PR, 9 had PD and 3 required a DC procedure. Of the 55 GSW cases, 40 were managed with PR, 9 with PD and 6 with DC surgery. In the PR group, there were 16 colonic complications (5 cases of breakdown and 11 of wound sepsis). Overall, nine patients (7%) died. CONCLUSIONS PR of colonic trauma is safe and should be used for the majority of such injuries. Persistent acidosis, however, should be considered a contraindication. In unstable patients with complex injuries, the optimal approach is to perform DC surgery. In this situation, formal diversion is contraindicated, and the injury should be controlled and dropped back into the abdomen at the primary operation. At the repeat operation, if the physiological insult has been reversed, then formal repair of the colonic injury is acceptable.

Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting

Introduction

Exsanguination following trauma is potentially preventable. Extremity tourniquets have been successfully implemented in military and civilian prehospital care. Prehospital control of bleeding from the torso and junctional area’s remains challenging but offers a great potential to improve survival rates. This review aims to provide an overview of potential treatment options in both clinical as preclinical state of research on truncal and junctional bleeding. Since many options have been developed for application in the military primarily, translation to the civilian situation is discussed.

Methods

Medline (via Pubmed) and Embase were searched to identify known and potential prehospital treatment options. Search terms were|: haemorrhage/hemorrhage, exsanguination, junctional, truncal, intra-abdominal, intrathoracic, intervention, haemostasis/hemostasis, prehospital, en route, junctional tourniquet, REBOA, resuscitative thoracotomy, emergency thoracotomy, pelvic binder, pelvic sheet, circumferential. Treatment options were listed per anatomical site: axilla, groin, thorax, abdomen and pelvis Also, the available evidence was graded in (pre) clinical stadia of research.

Results

Identified treatment options were wound clamps, injectable haemostatic sponges, pelvic circumferential stabilizers, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), intra-abdominal gas insufflation, intra-abdominal self-expanding foam, junctional and truncal tourniquets. A total of 70 papers on these aforementioned options was retrieved. No clinical reports on injectable haemostatic sponges, intra-abdominal insufflation or self-expanding foam injections and one type of junctional tourniquets were available.

Conclusion

Options to stop truncal and junctional traumatic haemorrhage in the prehospital arena are evolving and may offer a potentially great survival advantage. Because of differences in injury pattern, time to definitive care, different prehospital scenario’s and level of proficiency of care providers; successful translation of various military applications to the civilian situation has to be awaited. Overall, the level of evidence on the retrieved adjuncts is extremely low.

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.

Performance of primary repair on colon injuries sustained from low-versus high-energy projectiles

Among various reasons, colon injuries may be caused by low- or high-energy firearm bullets, with the latter producing a temporary cavitation phenomenon. The available treatment options include primary repair and two-stage management, but recent studies have shown that primary repair can be widely used with a high success rate. This paper investigates the differences in performance of primary repair on these two types of colon injuries. Two groups of patients who sustained colon injuries due to single gunshot wounds, were retrospectively categorized based on the type of bullet. Primary colon repair was performed in all patients selected based on the inclusion and exclusion criteria (Stone and Fabian's criteria). An almost absolute homogeneity was attained among the groups in terms of age, latent time before surgery, and four trauma indexes. Only one patient from the low-energy firearm projectile group (4%) developed a postsurgical complication versus nine patients (25.8%) from the high-energy group, showing statistically significant difference (p = 0.03). These nine patients experienced the following postsurgical complications: pneumonia, abscess, fistula, suture leakage, and one multiorgan failure with sepsis. Previous studies concluded that one-stage primary repair is the best treatment option for colon injuries. However, terminal ballistics testing determined the projectile's path through the body and revealed that low-energy projectiles caused considerably lesser damage than their high-energy counterparts. Primary colon repair must be performed definitely for low-energy short firearm injuries but very carefully for high-energy injuries. Given these findings, we suggest that the treatment option should be determined based not only on the bullet type alone but also on other clinical findings.

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.

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.

Primary repair or fecal diversion for colorectal injuries after blast: a medical review

Blast injury is a frequent cause of injury during armed conflicts, and the force of a blast can cause closed colorectal injury and perforation.1 After identification of a blast-related colorectal injury, the surgical options are primary repair or fecal diversion with the option for secondary repair. This structured review was conducted to determine which patients could be treated with primary repair (PR) or with fecal diversion. The review method followed the Prisma Statement method for medical systematic review. All data from the relevant articles were collected in a single database. Articles took into account wars in Bosnia, Iraq and Afghanistan from January 1993 through November 2012. The review was limited due to lack of reported data, hence qualitative analysis was the main review method. The review showed that for patients who do not have associated intra-abdominal injuries (diaphragm, stomach, pancreas, spleen, or kidney) or hemodynamic instability, PR did not result in an increase of complications or mortality.

Protection of colonic anastomosis with platelet-rich plasma gel in the open abdomen

BACKGROUND

Although evidence for colonic anastomosis in the damage control abdomen continues to accumulate, anastomotic leak is common and associated with greater morbidity. The purposes of our study was to evaluate the effect of platelet-rich plasma (PRP) gel on the healing of colon anastomosis and anastomotic strength in the open abdomen.

METHODS

PRP was prepared by enriching whole blood platelet concentration from healthy rat. In the rodent model, standard colonic anastomoses followed by closure of abdomen (Control; n=10) and anastomoses followed by open abdomen (OA; n=10) were compared to PRP-sealed anastomoses in open abdomen (OA+PRP; n=10). One week after surgery, body weight, anastomotic bursting pressure, hydroxyproline concentration, and histology of anastomotic tissue were evaluated.

RESULTS

All rats survived surgery and had no signs of anastomotic leakage. Compared with the control and PRP group, OA group exhibited a significant decrease in body weight, anastomotic bursting pressure, hydroxyproline concentration, and collagen deposition. No significant difference was detected in these variables between the PRP group and the control group.

CONCLUSION

PRP gel application prevented delayed anastomotic wound healing after open abdomen, which suggested that anastomotic sealing with PRP gel might improve outcome of colonic injuries in the setting of open abdomen.

Management of colonic injuries in the setting of damage-control laparotomy: one shot to get it right

BACKGROUND

The optimal management of colonic injuries in patients requiring damage-control laparotomy (DCL) remains controversial. Primary repair, delayed anastomosis, or colostomy have all been advocated after DCL; however, some evidence suggests that colon-related complications are increased in patients with delayed primary fascial closure. We hypothesized that increased complications associated with colonic repair/anastomosis occur in those patients undergoing DCL who cannot achieve fascial closure on their initial reoperation.

METHODS

A retrospective review of adult patients sustaining colonic injury between 2001 and 2010 who survived four or more days was performed. Patients were classified as having all their abdominal injuries managed during a single laparotomy (SL), DCL with complete treatment and fascial closure on the initial reoperation (DCL1), or DCL with open abdomen for more than two operations (DCL2). Data on postoperative complications and need for intervention were collected. Kruskal-Wallis analysis of variance was used to determine differences between groups.

RESULTS

A total of 317 patients with colonic injuries were treated during the study period; 70 were excluded, leaving 247 patients as the study group. The group was primarily male (93%), with a mean age of 29 years. Ninety-two percent sustained penetrating injuries. Injury Severity Scores (ISSs) were similar between groups. Mean (SD) time for the DCL1 was 1.2 (0.6) days after injury and 4.1 (2.8) days for DCL2. Inability to achieve fascial closure by the time of the initial reoperation was associated with significant increase in intra-abdominal abscess (SL, 17% vs. DCL1, 31% vs. DCL2, 50%; p < 0.001) and anastomotic leaks (SL, 2% vs. DCL1, 2% vs. DCL2, 19%; p < 0.001).

CONCLUSION

Primary repair or delayed anastomosis following DCL is feasible, with complication rates similar to SL when successful fascial closure is completed on the first post-DCL reoperation. However, if fascial closure is not possible on the second operation, patients should be treated with a stoma because there is an eightfold increase in the incidence of anastomotic leak. We believe that these data indicate that there is a single opportunity for reestablishing colonic continuity following DCL.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Abdominal blast injuries: different patterns, severity, management, and prognosis according to the main mechanism of injury

PURPOSE

To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury.

METHODS

A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS.

RESULTS

Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties.

CONCLUSIONS

The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.

Applicability of an established management algorithm for destructive colon injuries after abbreviated laparotomy: a 17-year experience

BACKGROUND

For more than a decade, operative decisions (resection plus anastomosis vs diversion) for colon injuries, at our institution, have followed a defined management algorithm based on established risk factors (pre- or intraoperative transfusion requirements of more than 6 units packed RBCs and/or presence of significant comorbid diseases). However, this management algorithm was originally developed for patients managed with a single laparotomy. The purpose of this study was to evaluate the applicability of this algorithm to destructive colon injuries after abbreviated laparotomy (AL) and to determine whether additional risk factors should be considered.

STUDY DESIGN

Consecutive patients over a 17-year period with colon injuries after AL were identified. Nondestructive injuries were managed with primary repair. Destructive wounds were resected at the initial laparotomy followed by either a staged diversion (SD) or a delayed anastomosis (DA) at the subsequent exploration. Outcomes were evaluated to identify additional risk factors in the setting of AL.

RESULTS

We identified 149 patients: 33 (22%) patients underwent primary repair at initial exploration, 42 (28%) underwent DA, and 72 (49%) had SD. Two (1%) patients died before re-exploration. Of those undergoing DA, 23 (55%) patients were managed according to the algorithm and 19 (45%) were not. Adherence to the algorithm resulted in lower rates of suture line failure (4% vs 32%, p = 0.03) and colon-related morbidity (22% vs 58%, p = 0.03) for patients undergoing DA. No additional specific risk factors for suture line failure after DA were identified.

CONCLUSIONS

Adherence to an established algorithm, originally defined for destructive colon injuries after single laparotomy, is likewise efficacious for the management of these injuries in the setting of AL.

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.

Colonic injuries and the damage control abdomen: does management strategy matter?

BACKGROUND

The optimal management of colon injury patients requiring damage control laparotomy (DCL) is controversial. The objective of this study was to assess the safety of colonic resection and anastomosis versus fecal diversion in trauma patients requiring DCL.

METHODS

Patients with traumatic colon injuries undergoing DCL between 2000 and 2010 were identified by the database and chart review. Those who died within 48 h were excluded. Patients were divided into two groups: those undergoing one or more colonic anastomoses with or without distal colostomy (group 1) and those undergoing colostomy only or one or more colonic anastomoses with a protecting proximal ostomy (group 2). Variables were compared using Wilcoxon rank sum, χ2, or Fisher exact tests as appropriate.

RESULTS

Sixty-one patients were included (group 1, n=28 and group 2, n=33). Fascial closure rates (group 1, 50% versus group 2, 61%; P=0.45), hospital length of stay (29 versus 23 d; P=0.89), and in-patient mortality (11% versus 12%; P=1.0) were similar between groups. There were a total of 11 anastomotic leaks, five of which were related to non-colonic enteric repairs. Colonic anastomosis leak rates were 16% overall (six of the 38 patients), 14% in group 1 (four of the 28 patients), and 20% in group 2 (two of the 10 patients). Compared with patients who did not leak, patients who leaked had a higher median age (37 versus 25 y; P=0.05), greater likelihood of not achieving facial closure before post-injury day 5 (18% versus 2%; P=0.003), and a longer hospital length of stay (46 versus 25 d; P=0.003).

CONCLUSIONS

Outcomes after colonic injury in the setting of DCL were similar regardless of the surgical management strategy. Based on these findings, a strategy of diversion over anastomosis cannot be strongly recommended.

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.

Safety of performing a delayed anastomosis during damage control laparotomy in patients with destructive colon injuries

BACKGROUND

Recent studies report the safety and feasibility of performing delayed anastomosis (DA) in patients undergoing damage control laparotomy (DCL) for destructive colon injuries (DCIs). Despite accumulating experience in both civilian and military trauma, questions regarding how to best identify high-risk patients and minimize the number of anastomosis-associated complications remain. Our current practice is to perform a definitive closure of the colon during DCL, unless there is persistent acidosis, bowel wall edema, or evidence of intra-abdominal abscess. In this study, we evaluated the safety of this approach by comparing outcomes of patients with DCI who underwent definitive closure of the colon during DCL versus patients managed with colostomy with or without DCL.

METHODS

We performed a retrospective chart review of patients with penetrating DCI during 2003 to 2009. Severity of injury, surgical management, and clinical outcome were assessed.

RESULTS

Sixty patients with severe gunshot wounds and three patients with stab wounds were included in the analysis. DCL was required in 30 patients, all with gunshot wounds. Three patients died within the first 48 hours, three underwent colostomy, and 24 were managed with DA. Thirty-three patients were managed with standard laparotomy: 26 patients with primary anastomosis and 7 with colostomy. Overall mortality rate was 9.5%. Three late deaths occurred in the DCL group, and only one death was associated with an anastomotic leak.

CONCLUSIONS

Performing a DA in DCI during DCL is a reliable and feasible approach as long as severe acidosis, bowel wall edema, and/or persistent intra-abdominal infections are not present.

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.