Highlights from #AASTAnnualMeeting - What to do with Colon injury in Damage Control Laparotomy?

The group at New Jersey Medical School looked at  repair vs diversion in patients with colon injuries and Damage Control Laparotomy.  They recommend primary repair/anastomosis only if the fascia can be closed at the first take-back.  Otherwise, the patient should be diverted.

MANAGEMENT OF COLONIC INJURIES IN THE SETTING OF DAMAGE CONTROL LAPAROTOMY – ONE SHOT TO GET IT RIGHT.

Devashish J. Anjaria* MD, Timothy M. Ullmann BA, Robert F. Lavery MA, David H. Livingston* MD, UMDNJ - New Jersey Medical School

Introduction: 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 colonic related complications are increased in patients with delayed primary fascial closure We hypothesized that increased complications associated with colonic repair/anastomosis occurs in those patient undergoing DCL who cannot achieve fascial closure on their initial reoperation.

Methods: A retrospective review of all patients sustaining colonic injury between January 1, 2001 and August 31, 2010 who survived ≥ 4 days. Patients were classified as having management of abdominal injuries during either a single laparotomy (SL), DCL with complete treatment and fascial closure on the initial reoperation (DCL1), or DCL with open abdomen for greater than 2 operations (DCL2). Data was collected on post operative complications and need for intervention. Kruskal-Wallis ANOVA was used to determine differences between groups.

Results: 317 patients were treated with colonic injuries, 70 were excluded due to incomplete charts, leaving 247 patients included in the study. The group was primarily male (93%) with a mean (± SD) age of 29 ± 9 years. 92% sustained penetrating injuries. Injury severity scores were similar between groups. Mean 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 intraabdominal abscess and anastomotic leaks (Table).

	SL (n = 179)	DCL1 (n = 42)	DCL2 (n = 26)
ISS	18 ± 10	15 ± 9	19 ± 11
Wound infection	6% (11)	14% (6)	12% (3)
Abdominal abscess	17% (30)	31% (13)	50% (13)*
Fistula	1.1% (2)	2.4% (1)	7.7% (2)
Anastomotic leak	2.2% (4)	2.4% (1)	19% (5)*
IR drainage	7% (12)	12% (5)	19% (5)
Unplanned reoperation	15% (27)	31% (13)	---

*p < 0.01 vs. SL

The primary reasons for the unplanned reoperations were intra-abdominal sepsis, peritonitis and/or fascial dehiscence. 19 (73%) patients in DCL2 never achieved complete fascial closure and required split thickness or full thickness skin coverage.

Conclusion: Primary repair or delayed anastomosis after 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 as there is an 8 fold increase in the incidence of anastomotic leak. We believe that these data indicate that there is a single opportunity for reestablishing colonic continuity after DCL.