Colorectal Trauma

Presentation Transcript

Colorectal Trauma Colorectal Conference St Luke's-Roosevelt Hospital Department of Surgery Leslie Tyrie, PGY III 16 March 2006

Colorectal Anatomy Right Colon, Left Colon, Rectum Blood supply SMA, IMA versus inf. mesenteric/int. iliacs/pudendal workmanship. Work Dehydration, stockpiling, crap Bacterial substance Increases as more distal to stomach 60% dry weight stool = microorganisms Intraperitoneal and retro/extraperitoneal parts Right and left colon grimness/mortality results a similar Colon versus Rectum Proximal versus distal to peritoneal reflection

COLON Penetrating >85% 1/3 infiltrating stomach wounds GSW > SW > shotgun > iatrogenic > misc Blunt MVA, ped struck, falls Multiple wounds Delayed introduction RECTUM Penetrating Majority GSW Impalement/straddle wounds Iatrogenic Foreign body Blunt Pelvic cracks Disruption of pubic symphysis Spicules Scrape wounds Drag over asphalt s/p bike mischance Trauma to perineum High file doubt Colorectal Trauma – Etiology

Colorectal Trauma – H&P Trauma calculations ABCs History Physical Abdomen Flank Perineum DRE – blood

Colorectal Trauma – Studies CT SCAN Blunt Abdominal and Penetrating Flank Triple complexity DPL Abdominal injury Will not assess retroperitoneum Bacteria/vegetable matter suggestive FAST Abdominal injury Repeatable Non obtrusive Will not assess retroperitoneum Rigid Proctosigmoidoscopy Exploratory Laparotomy

Operative Management Options Primary repair Resection and anastomosis Repair w/proximal redirection Exteriorization The Question Proximal preoccupation of fecal stream Prevent septic difficulties Colon: anastomotic hole Rectum: pelvic sepsis Pelvic ulcer

Grading Score for Colon Injury AAST Colon Injury Scale (CIS) I – serosal damage II – single divider harm III – < 25% divider association IV – > 25% divider contribution V – circumferential divider, vascular harm, or both Destructive versus Nondestructive injuries

Colon Trauma – Historical Perspective "Ephud set forth his left hand, and took the sword from his correct thigh and push it into his gut… and the soil turned out." – book of Judges in the Old Testament Suggestive of early entering colon injury However no treatment or result is talked about

Historical Perspective (cont) American Civil War Non agent administration of infiltrating stomach wounds Mortality 90% WWI Diverting colostomy is ideal in broad injuries Primary repair was endeavored Mortality 59% WWII US Surgeon General Thomas Parren Jr. ordered colostomy for all colon wounds maintained in fight Inexperienced war-time specialists High-vitality, high-speed wounds Delay in care Transfer not long after starting administration Mortality to 5-20%

Historical to today After WWII… Colostomy stayed standard of care However, regular citizen ≠ military injury Less dangerous Delay to conclusive care short Resuscitation directed rapidly Newer anti-toxin prophylaxis Postoperative supervision accessible

Management of Colon Injuries Non Destructive Wounds (CIS I – III) Stone and Fabian et al 1979 Primary repair or resection + anastomosis Destructive injuries (CIS IV – V) Demetriades et al 2001 no distinction, or enhanced results w/ primary repair Patients at hazard for anastomotic breakdown Immunocompromised patients Transfusion > 6 units Likely expanded Shock Other traumatic harm > 2 Delay of operation Traditionally  occupying colostomy New information  resection + essential anastomosis One strict contraindication, delay > 12 hrs

The Exception: Damage Control Cold Coagulopathic Acidotic Resect if necessary, no anastomosis Planned second look

Management of Rectal Injuries Intraperitoneal Like colonic wounds Primary repair Extraperitoneal Diversion End versus circle colostomy Drainage Closed or open seepage of presacral space Tranverse cut anococcygeal raphe into subcutaneous tissue Lateral dismemberment on each side of raphe to stay away from transsection of coccygeal connections to get to presacral space Penrose or JP waste Repair If plausible, keep away from pointless analyzation > 1cm unless including GU tract  then repair w/mediation fix Distal Washout of rectal stump No demonstrated advantage For profoundly tainted injuries and broad devitalization Towards essential and authoritative care w/out DDR,DW In uncommon cases, APR

Considerations Antibiotics No demonstrated regimen 24 hours w/2 nd era cephalosporin is acknowledged Colostomy Reversal Traditionally 3 months New information proposes if indications of change may consider inversion at 2 weeks Avoid 2 – a month and a half BE a bit much Unidentified rectal injury, progressing manifestations

Conclusions Colon Trauma Primary repair, resection + essential anastomosis Exceptions dangerous wounds w/hazard elements Shock, deferral to administration, related organ damage, transfusion prerequisite, co-sullen malady Rectal Trauma Intraperitoneal Like colonic wounds Extraperitoneal Diversion and presacral seepage Antibiotics 2 nd gen ceph x 24 hrs periop