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

Difference between delayed anastomosis and early anastomosis in damage control laparotomy affecting the infusion volume and NPWT output volume: is infusion restriction necessary in delayed anastomosis? A single-center retrospective analysis

Objectives

During temporary abdominal closure (TAC) with damage control laparotomy (DCL), infusion volume and negative-pressure wound therapy (NPWT) output volume are associated with the success and prognosis of primary fascial closure. The same may also hold true for anastomosis. The aim of this research is to evaluate whether the difference between early anastomosis and delayed anastomosis in DCL is related to infusion volume and NPWT output volume.

Methods

This single-center retrospective analysis targeted patients managed with TAC during emergency surgery for trauma or intra-abdominal sepsis between January 2011 and December 2019. It included patients who underwent repair/anastomosis/colostomy in the first surgery and patients who underwent intestinal resection in the first surgery followed by delayed anastomosis with no intestinal continuity.

Results

Seventy-three patients were managed with TAC using NPWT, including 19 cases of repair, 17 of colostomy, and 37 of anastomosis. In 16 patients (trauma 5, sepsis 11) with early anastomosis and 21 patients (trauma 16, sepsis 5) with delayed anastomosis, there was no difference in the infusion volume (p=0.2318) or NPWT output volume (p=0.7128) 48 hours after surgery. Additionally, there was no difference in the occurrence of suture failure (p=0.8428). During the second-look surgery after 48 hours, the anastomosis was further postponed for 48% of the patients who underwent delayed anastomosis. There was no difference in the infusion volume (p=0.0783) up to the second-look surgery between the patients whose delayed anastomosis was postponed and those who underwent delayed anastomosis, but there was a tendency toward a large NPWT output volume (p=0.024) in the postponed delayed anastomosis group.

Conclusion

Delayed anastomosis may be managed with the same infusion volume as that used for early anastomosis. There is also the option of postponing anastomosis if the planned delayed anastomosis is complicated.

Level of evidence

Therapeutic/Care Management, Level IV.

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.

Reinterventions after damage control surgery

Damage control has well-defined steps. However, there are still controversies regarding whom, when, and how re-interventions should be performed. This article summarizes the Trauma and Emergency Surgery Group (CTE) Cali-Colombia recommendations about the specific situations concerning second interventions of patients undergoing damage control surgery. We suggest packing as the preferred bleeding control strategy, followed by unpacking within the next 48-72 hours. In addition, a deferred anastomosis is recommended for correction of intestinal lesions, and patients treated with vascular shunts should be re-intervened within 24 hours for definitive management. Furthermore, abdominal or thoracic wall closure should be attempted within eight days. These strategies aim to decrease complications, morbidity, and mortality.

Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®

INTRODUCTION

Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma.

METHODS

Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene.

RESULTS

The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004).

CONCLUSION

DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

Use of REBOA in the universe of magical realism: a real-world review

While reading the novella “Chronicle of a Death Foretold” by the Colombian Nobel Laureate Gabriel García-Marquez, we were surprised to realize that the injuries sustained by the main character could have been successfully treated had he received modern trauma care in which REBOA may have been considered. This is a discussion of Mr. Nasar's murder to explore whether he could have been saved by deploying REBOA as a surgical adjunct to bleeding control and resuscitation. In reading García-Marquez's novel we noted the events that unfolded at the time of Santiago Nasar's murder. To contextualize the claim that Mr. Nasar could have survived, had his injuries been treated with REBOA, we explored and illustrated what could have done differently and why. On the day of his death, Mr. Nasar sustained multiple penetrating stab wounds. Although he received multiple stab wounds to his torso, the book describes seven potentially fatal injuries, resulting in hollow viscus, solid viscus, and major vascular injuries. We provided a practical description of the clinical and surgical management algorithm we would have followed in Mr. Nasar's case. This algorithm included the REBOA deployment for hemorrhage control and resuscitation. The use of REBOA as part of the surgical procedures performed could have saved Mr. Nasar's life. Based on our current knowledge about REBOA in trauma surgery, we claim that its use, coupled with appropriate surgical care for hemorrhage control, could have saved Santiago Nasar's life, and thus prevent a death foretold.

Hemodynamically unstable pelvic fracture: A damage control surgical algorithm that fits your reality

Pelvic fractures occur in up to 25% of all severely injured trauma patients and its mortality is markedly high despite advances in resuscitation and modernization of surgical techniques due to its inherent blood loss and associated extra-pelvic injuries. Pelvic ring volume increases significantly from fractures and/or ligament disruptions which precludes its inherent ability to self-tamponade resulting in accumulation of hemorrhage in the retroperitoneal space which inevitably leads to hemodynamic instability and the lethal diamond. Pelvic hemorrhage is mainly venous (80%) from the pre-sacral/pre-peritoneal plexus and the remaining 20% is of arterial origin (branches of the internal iliac artery). This reality can be altered via a sequential management approach that is tailored to the specific reality of the treating facility which involves a collaborative effort between orthopedic, trauma and intensive care surgeons. We propose two different management algorithms that specifically address the availability of qualified staff and existing infrastructure: one for the fully equipped trauma center and another for the very common limited resource center.

Damage Control Surgery may be a Safe Option for Severe Non-Trauma Peritonitis Management: Proposal of a New Decision-Making Algorithm

BACKGROUND

Damage control surgery (DCS) has emerged as a new option in the management of non-traumatic peritonitis patients to increase survival in critically ill patients. The purpose of this study was to compare DCS with conventional strategy (anastomosis/ostomies in the index laparotomy) for severe non-traumatic peritonitis regarding postoperative complications, ostomy rate, and mortality and to propose a useful algorithm in the clinical practice.

METHODS

Patients who underwent an urgent laparotomy for non-trauma peritonitis at a single level I trauma center in Colombia between January 2003 and December 2018, were retrospectively included. We compared patients who had DCS management versus definitive initial surgical management (DISM) group. We evaluated clinical outcomes and morbidities among groups.

RESULTS

290 patients were included; 81 patients were treated with DCS and 209 patients underwent DISM. Patients treated with DCS had a worse critical status before surgery with higher SOFA score [median, DCS group: 5 (IQR: 3-8) vs. DISM group: 3 (IQR: 1-6), p < 0.001]. The length of hospital stay and overall mortality rate of DCS group were not significant statistical differences with DISM group. Complications rate related to primary anastomosis or primary ostomy was similar. There is not difference in ostomy rate among groups. At multivariate analysis, SOFA > 6 points and APACHE-II > 20 points correlated with a higher probability of DCS.

CONCLUSION

DCS in severe non-trauma peritonitis patients is feasible and safe as surgical strategy management without increasing mortality, length hospital of stay, or complications. DCS principles might be applied in the non-trauma scenarios without increase the stoma rate.

Damage Control Laparotomy: High-Volume Centers Display Similar Mortality Rates Despite Differences in Country Income Level

BACKGROUND

Comprehensive analysis of trauma care between high-, middle-, and low-income countries (HIC/MIC/LIC) is needed to improve global health. Comparison of HIC and MIC outcomes after damage control laparotomy (DCL) for patients is unknown. We evaluated DCL utilization among patients treated at high-volume trauma centers in the USA and South Africa, an MIC, hypothesizing similar mortality outcomes despite differences in resources and setting.

METHODS

Post hoc analysis of prospectively collected trauma databases from participating centers was performed. Injury severity, physiologic, operative data and post-operative outcomes were abstracted. Univariate and multivariable analyses were performed to assess differences between HIC/MIC for the primary outcome of mortality.

RESULTS

There were 967 HIC and 602 MIC patients who underwent laparotomy. DCL occurred in 144 MIC patients (25%) and 241 HIC (24%) patients. Most sustained (58%) penetrating trauma with higher rates in the MIC compared to the HIC (71 vs. 32%, p = 0.001). Between groups, no differences were found for admission physiology, coagulopathy, or markers of shock except for increased presence of hypotension among patients in the HIC. Crystalloid infusion volumes were greater among MIC patients, and MIC patients received fewer blood products than those in the HIC. Overall mortality was 30% with similar rates between groups (29 in HIC vs. 33% in MIC, p = 0.4). On regression, base excess and penetrating injury were independent predictors of mortality but not patient residential status.

CONCLUSION

Use and survival of DCL for patients with severe abdominal trauma was similar between trauma centers in HIC and MIC settings despite increased penetrating trauma and less transfusion in the MIC center. While the results overall suggest no gap in care for patients requiring DCL in this MIC, it highlights improvements that can be made in damage control resuscitation.

[Management of traumatic intestinal injury of mass casualties]

While intestinal injury is relatively rare in blunt abdominal trauma, it is common in penetrating abdominal trauma. Intestinal injury cannot be detected effectively by computed tomography (CT); therefore penetrating abdominal injury or abdominal signs in blunt trauma require liberal indications for explorative laparotomy. In mass casualty situations patients with hemodynamic instability and abdominal signs should be prioritized for surgery. Besides intra-abdominal hemorrhage the major issue is septic complications due to intestinal perforation. The current surgical strategy should reflect the number of injured patients and the individual pattern of injuries. Damage control surgery is not an effective strategy to improve survival rates in severely injured patients or in mass casualty situations. Damage control surgery focuses on lifesaving procedures especially bleeding control and control of contamination. This includes an open abdomen strategy with later definitive repair and abdominal wall closure.

Progress and pitfalls in treatment of colorectal injury

Based on the previous experience of war wound treatment, the treatment of colorectal injury has been changing constantly. Also, since the 1980s, the progress of severe trauma treatment such as CT examinations and damage control strategies has had a profound impact on the treatment of colorectal injury. This article systematically reviews the clinical manifestations, imaging findings, and endoscopic examinations of colorectal injuries, and lists injury assessment pitfalls such as neglecting colorectal injury in blunt wounds, being misdirected by negative sign or supine X-rays, strict indications for laparotomy exploration, or intro-operative omission. The progress of emergency surgery such as staged surgery for colorectal injury, surgical way of colorectal injury during damage control strategy, and treatment of rectal injury in extraperitoneal section is also described in detail. In addition, the pitfalls for emergency treatment are described, including ignoring effects of massive crystal fluid resuscitation on colorectal anastomosis, attaching no importance on the technical points of the colonic injury operation, and performing improper suture for abdominal incisions.

Casualties of peace: an analysis of casualties admitted to the intensive care unit during the negotiation of the comprehensive Colombian process of peace

Background

After 52 years of war in 2012, the Colombian government began the negotiation of a process of peace, and by November 2012, a truce was agreed. We sought to analyze casualties who were admitted to the intensive care unit (ICU) before and during the period of the negotiation of the comprehensive Colombian process of peace.

Methods

Retrospective study of hostile casualties admitted to the ICU at a Level I trauma center from January 2011 to December 2016. Patients were subsequently divided into two groups: those seen before the declaration of the process of peace truce (November 2012) and those after (November 2012-December 2016). Patients were compared with respect to time periods.

Results

Four hundred forty-eight male patients were admitted to the emergency room. Of these, 94 required ICU care. Sixty-five casualties presented before the truce and 29 during the negotiation period. Median injury severity score was significantly higher before the truce. Furthermore, the odds of presenting with severe trauma (ISS > 15) were significantly higher before the truce (OR, 5.4; (95% CI, 2.0-14.2); p < 0.01). There was a gradual decrease in the admissions to the ICU, and the performance of medical and operative procedures during the period observed.

Conclusion

We describe a series of war casualties that required ICU care in a period of peace negotiation. Despite our limitations, our study presents a decline in the occurrence, severity, and consequences of war injuries probably as a result in part of the negotiation of the process of peace. The hysteresis of these results should only be interpreted for their implications in the understanding of the peace-health relationship and must not be overinterpreted and used for any political end.

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.

Discontinuity of the Bowel Following Damage Control Operation Revisited: A Multi-institutional Study

BACKGROUND

Discontinuity of the bowel following intestinal injury and resection is a common practice in damage control procedures for severe abdominal trauma. However, there are concerns that complete occlusion of the bowel, especially in the presence of hypotension or edema that may result in ischemic bowel changes or increase bacterial or toxin translocation.

METHODS

This was a retrospective study from three Level-1 trauma centers. Included were trauma patients who required bowel resection and damage control. The study population was stratified into two groups based on the management for bowel injury: bowel discontinuity versus primary anastomosis. Outcomes included anastomotic leak, organ space infection, bowel ischemia, and mortality.

RESULTS

A total of 167 cases were included. In 84 cases, continuity of the bowel was established, and in 83, the bowel was left in discontinuity. The epidemiological, admission, and intraoperative physiological characteristics, the abdominal Abbreviated Injury Scale, type of intra-abdominal injury, and transfusion requirements were similar in the two study groups. The mortality was 8.3 % in the continuity group and 16.9 % for the discontinuity group (p = 0.096). On the crude bivariate and adjusted regression analyses, there was a higher rate of bowel ischemia at the take-back operation in the discontinuity group (p = 0.003 for the crude and p = 0.034 for the adjusted). The organ space infection and anastomotic leak rate were not significantly different between the study groups.

CONCLUSIONS

Discontinuity of the bowel following damage control operation is associated with a higher risk of bowel ischemia than in patients with anastomosis. Further prospective observational and randomized studies are warranted.

LEVEL OF EVIDENCE

III.

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.

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.

Damage control surgery: use of diagnostic CT after life-saving laparotomy

Damage control surgery (DCS) is a limited exploratory laparotomy that is performed in unstable trauma patients who, without immediate intervention, would acutely decompensate. Patients usually present with shock physiology and metabolic derangements including acidosis, hypothermia, and coagulopathy. Delayed medical correction of these metabolic derangements leads to an irreversible state of coagulopathic hemorrhagic shock and inevitable patient demise. Therefore, once a patient meets DCS criteria, a limited exploratory laparotomy is performed to stabilize life-threatening injury and expedite initiation of medical resuscitation in the intensive care unit (ICU). The surgeon plans to return to the operating room for definitive surgical treatment once the patient is hemodynamically stabilized and the metabolic derangements have been corrected. DCS patients are frequently sent to the ICU with an open abdomen and purposefully retained surgical equipment. The lack of response to resuscitation efforts, persistent hypotension, tachycardia, and/or the development of sepsis are common indications for this patient population to undergo CT imaging. The indications and findings of multi-detector CT (MDCT) in patients post-DCS have not been thoroughly evaluated in the radiology literature. A radiologist's knowledge of the DCS protocol and pre-imaging surgical interventions helps optimize the MDCT protocol. This enhances the radiologist's ability to evaluate for failure of surgical interventions performed prior to imaging and to search for injuries in areas that were not explored or that were missed during the initial surgical exploration.

Atypical gunshot wound: Bullet trajectory analyzed by computed tomography

INTRODUCTION

Gunshot injuries are a result of a bullet or projectile fired from a weapon that penetrates the body. Homicide, suicide, and occasionally, accidental events are a significant cause of firearm-related injuries. In rare cases, the damage from the gunshot injury can be masked due to an atypical bullet trajectory.

PRESENTATION OF CASE

A 63-year-old male was found with a gunshot wound to the anterior left knee. Computed tomography (CT) scans revealed a bullet track extending from the anterior aspect of the left knee that traveled cephalad subcutaneously and entered into the peritoneal cavity, perforating the distal descending colon. The bullet was found to be at rest adjacent to the spleen and posterior chest wall, with no injury to the lungs, kidneys or the spleen. The patient required a sigmoid colectomy with descending colostomy and was subsequently discharged home without any complications.

DISCUSSION

Intra-abdominal organ damage from a gunshot wound to the distal limb is a rare occurrence. Atypical gun shot wounds, such as this case, have the potential for multiple issues including: delayed diagnostic tests, inaccurate radiological readings, and inappropriate medical management.

CONCLUSION

If an abnormal trajectory is maintained, it is possible for a bullet to traverse half the length of the body without the patient realizing it. Accurate CT analysis and quick decisions in surgical and medical management are critical takeaways to provide quality care to patients with these injuries.

The influence of the risk factor on the abdominal complications in colon injury management

INTRODUCTION

The management of colon injuries has distinctly evolved over the last three decades. However, trauma surgeons often find themselves in a dilemma, whether to perform a diversion or to perform a primary repair. The purpose of this study is to evaluate risk factors in colon injury management and their influence on abdominal complications.

PATIENTS AND METHODS

This is a prospective study conducted at a national level I trauma center in Tirana, Albania from January 2009 to December 2012. The data with respect to demographics, physiological risk factors, intraoperative findings, and surgical procedures were collected. Colonic injury-related morbidity and mortality were analyzed. Multivariate logistic regression analysis was performed by assessing the influence of risk factors on abdominal complications.

RESULTS

Of the 157 patients treated with colon injury, was performed a primary repair in 107 (68.15%) of the patients and a diversion in the remaining 50 (31.85%). The mean PATI was 18.6, while 37 (23.6%) of patients had PATI greater than 25. The complications and their frequencies according to the surgical technique used (primay repair vs diversion respectively) includes: wound infections (9.3% vs 50%), anastomotic leak (1.8% vs 8.7%), and intra-abdominal abscess (1.8% vs 6.5%). The multivariate analysis identified two independent risk factors for abdominal complications: transfusions of 4 units of blood within the first 24 hours (OR = 1.2 95% CI (1.03 - 1.57) p =0.02), and diversion (OR = 9.6, 95% CI 4.4 - 21.3, p<0.001).

CONCLUSION

Blood transfusions of more than 4 units within the first 24 hours and diversion during the management of destructive colon injuries are both independent risk factors for abdominal complications. The socioeconomic impact and the need for a subsequent operation in colostomy patients are strong reasons to consider primary repair in the management of colon injuries.

Not all intestinal traumatic injuries are the same: a comparison of surgically treated blunt vs. penetrating injuries

PURPOSE

Traumatic intestinal injuries are less common with blunt compared to penetrating mechanisms of trauma and blunt injuries are often associated with diagnostic delays. The purpose of this study is to evaluate differences in the characteristics and outcomes between blunt and penetrating intestinal injuries to facilitate insight into optimal recognition and management.

METHODS

A retrospective analysis of trauma admissions from January 2009 to June 2011 was performed. Patient demographics, ISS, early shock, injury type, timing to OR, blood loss and transfusions, surgical management, infections, EC fistulas, enteric leaks, LOS and mortality were compared.

RESULTS

Demographics - There was 3866 blunt admissions and 966 penetrating admissions to our level II trauma centre (Total n=4832) during this interval. The final study group comprised n=131 patients treated for intestinal injuries. Blunt n=54 (BI) vs. penetrating (PI) n=77. Age was similar between the groups: (BI 34 SD 12 vs. PI 30 SD 12). Comorbid conditions were similar as were ED hypotension and blood transfusions. Blunt mechanisms had higher ISS; BI (20 SD 14) vs. PI (16 SD 12), p=0.08 and organ specific injury scales were higher in blunt injuries. Operative Management - Time to operation was higher in BI: (500 SD 676min vs. PI 110 SD 153min, p=0.01). The use of an open abdomen technique was higher for BI: n=19 (35%) vs. PI: n=5 (6%), p=<0.001, as well as delayed intestinal repair in damage control cases. Outcomes - Anastomotic leaks were more prevalent in BI: n=4 (7%) vs. PI: n=2 (3%), p=0.38. Enteric fistulas were: (BI n=8 (15%), vs. PI n=2 (3%), p=0.02). Surgical site infections and other nosocomial infections were: (BI n=11 (20%) vs. PI n=4 (5%), p=0.02), (BI n=11 (20%) vs. PI n=2 (3%), p=0.002), respectively. Hospital and ICU LOS was: (BI=20 SD 14 vs. PI=11 SD 11, p=0.001), (BI=10 SD 10 vs. PI=5 SD 5, p=0.01) respectively. These differences were reflected in higher hospital charges in BI.

CONCLUSIONS

Blunt and penetrating intestinal injury patterns have high injury severity. Significant operative delays occurred in the blunt injury group as well as, anastomotic failures, enteric fistulas, nosocomial infections, and higher cost. These features underscore the complexity of blunt injury patterns and warrant vigilant injury recognition to improve outcomes.

The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper

The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.

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.

[Damage control surgery: an update]

The damage control surgery is a widely accepted concept today among abdominal trauma specialists when it comes to the severely traumatized. In these patients, the death is due, in most cases, to the installation of the lethal triad (hypothermia, coagulopathy and acidosis) and not the inability to repair the serious initial damage. In this review, the authors address the lethal triad in its three phases and emphasize the measures taken to prevent them, as well as discussing the indication and employment of damage control surgery in its various stages. Restoring the physiological status of the patient in the ICU, so that he/she can be submitted to final operation and closure of the abdominal cavity, another challenge in severe trauma patients, is also discussed.

Current concept of abdominal sepsis: WSES position paper

Although sepsis is a systemic process, the pathophysiological cascade of events may vary from region to region.

Abdominal sepsis represents the host’s systemic inflammatory response to bacterial peritonitis.

It is associated with significant morbidity and mortality rates, and is the second most common cause of sepsis-related mortality in the intensive care unit.

The review focuses on sepsis in the specific setting of severe peritonitis.

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.

Damage control - trauma care in the first hour and beyond: a clinical review of relevant developments in the field of trauma care

INTRODUCTION

Trauma provision in the UK is a topic of interest. Regional trauma networks and centres are evolving and research is blossoming, but what bearing does all this have on the care that is delivered to the individual patient? This article aims to provide an overview of key research concepts in the field of trauma care, to guide the clinician in decision making in the management of major trauma.

METHODS

The Ovid MEDLINE(®), EMBASE™ and PubMed databases were used to search for relevant articles on haemorrhage control, damage control resuscitation and its exceptions, massive transfusion protocols, prevention and correction of coagulopathy, acidosis and hypothermia, and damage-control surgery.

FINDINGS

A wealth of research is available and a broad range has been reviewed to summarise significant developments in trauma care. Research has been categorised into disciplines and it is hoped that by considering each, a tailored management plan for the individual trauma patient will evolve, potentially improving patient outcome.

Nutritional support in patients following damage control laparotomy with an open abdomen

INTRODUCTION

Damage control laparotomy (DCL) and the open abdomen have been well accepted following either severe abdominal trauma or emergency surgical disease. As DCL is increasingly utilized as a therapeutic option, appropriate management of the post-DCL patient is important. Early caloric support by enteral nutrition (EN) in the critically ill patient improves wound healing and decreases septic complications, lung injury, and multi-system organ failure. However, following DCL, nutritional strategies can be challenging and, at times, even daunting.

CONCLUSIONS

Even though limited data exist, the use of early EN following DCL seems safe, provided that the patient is not undergoing active resuscitation or the bowel is not in discontinuity. It is unknown as to whether EN in the open abdomen reduces septic complications, prevents enterocutaneous fistula (ECF), or alters the timing of definitive abdominal wall closure. Future investigation in a prospective manner may help elucidate these important questions.

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.

Experiencia en dos hospitales de tercer nivel de atención del suroccidente de Colombia en la aplicación del Registro Internacional de Trauma de la Sociedad Panamericana de Trauma

OBJETIVO: Describir la experiencia en la implementación de un Sistema de Registro de Trauma (SRT) en dos hospitales en Cali, Colombia. MÉTODOS: El SRT incluye información prehospitalaria, hospitalaria y estatus de egreso del paciente. Cada hospital tiene una estrategia para la captura electrónica de datos. Se presenta un análisis descriptivo exploratorio durante un piloto de tres meses. RESULTADOS: Se han registrado 3293 pacientes, 1626(49.4%) del Hospital Público y 1613(50.6%) en el Privado. 67.2% fueron hombres; edad promedio 30,5±20 años, 30,5% menores de 18 años. Mortalidad global 3,52 %. Causa más frecuente de consulta fueron las caídas (33,7%); 11.6% fueron heridas por arma de fuego, la mortalidad en este grupo fue del 44.7%. CONCLUSIÓN: Se determinaron las necesidades para la implementación del SRT y los mecanismos para darle continuidad. El registro se convierte en una fuente de información para el desarrollo de la investigación. Se identificaron las causas de consulta, morbilidad y muerte por trauma que permitirá una mejor planeación de los servicios de urgencias y del sistema regional de trauma con el fin de optimizar y de reducir los costos de atención. A partir de este sistema de información de trauma se podrán plantear los ajustes indispensables para rediseñar el sistema de trauma y emergencias del suroccidente colombiano.

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.