Colonic injuries are commonly addressed during exploration
for GSWs and stab wounds to the abdomen.
Many factors must be taken into account regarding the management of
these injuries including the extent of the injury, hemodynamic stability of the
patient, amount of resuscitation required, and additional co-morbidities. Injuries are divided into non-destructive or
destructive injuries. Traditionally,
destructive injuries affect greater than 50% of the colon wall and are not
amendable to primary repair. Less severe
injuries can be closed primarily. With
destructive injuries, once the affected colon is resected, a decision has to be
made regarding how GI continuity will be restored. If the ends can be brought together easily
with no tension and a good blood supply is palpated, a hand-sewn or stapled
anastomosis can be completed. In
elective colorectal surgery, research has demonstrated that these two methods
are equally safe with limited amounts of complications, however there is still
controversy in trauma literature with several retrospective studies
demonstrating that a stapled anastomosis has an increased leak rate and
increased tendency for intra-abdominal abscess formation. Some may choose to protect the anastomosis
with a proximal ostomy, however this has not been shown to decrease the rate of
complications. The alternative would be
to bring up an ostomy with a mucous fistula or Hartman’s. This is the preferred method in a patient
with a large resuscitation requiring greater than 6 U PRBCs, hypotension, other
significant abdominal injuries, large stool spillage, or significant
comorbities
In the era of damage control or abbreviated laparotomy, many
times there is a delay between the original resection and final management of
the GI tract. Patients that do require
a large resuscitation, have significant other injuries or large amounts are
spillage tend to fall into this group. At
the initial operation, severely damaged bowel is resected, the GI tract is left
in discontinuity and the abdomen is left open.
Patient is taken to the ICU, allowed to recover and have their
physiologic state optimized before return to the OR. The few retrospective studies that have
looked at this subgroup have demonstrated that an anastomosis is safe when the
patient returns to the OR, however there maybe a slightly increased risk of
anastomotic leak or intra-abdominal abscess especially if the patient requires
an open abdomen for greater than 5 days.
Further research in this area is required to determine the best
management guidelines for this subgroup.
SOURCES:
1. Brundage SI et al. Stapled versus sutured
gastrointestinal anastomoses in the trauma patient: A multicenter trial. The
Journal of Trauma. 2001; 51(6):1054-1061.
2. Sharpe JP et al. Adherence to a simplified management
algorithm reduces morbidity and mortality after penetrating colon injuries: A
15- year experience. J Am Coll Surg. 2012; 214(4):591-597.
3. Georgoff P et al. Colonic injuries and the damage control
abdomen: does management strategy matter. Journal of Surgical Research. 2013;
181:293-299.
from Dr. Purvi Patel
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