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

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Presentation on theme: "Colorectal Trauma Colorectal Conference St Luke’s-Roosevelt Hospital Department of Surgery Leslie Tyrie, PGY III 16 March 2006."— Presentation transcript:

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

2 Colorectal Anatomy Right Colon, Left Colon, Rectum Blood supply SMA, IMA vs. inf. mesenteric/int. iliacs/pudendal art. Function Dehydration, storage, defecation Bacterial content Increases as more distal to stomach 60% dry weight stool = bacteria Intraperitoneal and retro/extraperitoneal components Right and left colon morbidity / mortality outcomes the same Colon vs. Rectum Proximal vs. distal to peritoneal reflection

3 Colorectal Trauma – Etiology COLON Penetrating >85% 1/3 penetrating abdominal injuries GSW > SW > shotgun > iatrogenic > misc Blunt MVA, ped struck, falls Multiple injuries Delayed presentation RECTUM Penetrating Majority GSW Impalement / straddle injuries Iatrogenic Foreign body Blunt Pelvic fractures Disruption of pubic symphysis Spicules Scrape injuries Drag over pavement s/p motorcycle accident Trauma to perineum High index suspicion

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

5 Colorectal Trauma – Studies CT SCAN Blunt Abdominal and Penetrating Flank Triple contrast DPL Abdominal trauma Will not evaluate retroperitoneum Bacteria / vegetable matter suggestive FAST Abdominal trauma Repeatable Non invasive Will not evaluate retroperitoneum Rigid Proctosigmoidoscopy Exploratory Laparotomy

6 Operative Management Options 1. Primary repair 2. Resection and anastomosis 3. Repair w/proximal diversion 4. Exteriorization The Question Proximal diversion of fecal stream Prevent septic complications Colon: anastomotic leak Rectum: pelvic sepsis Pelvic abscess

7 Grading Score for Colon Injury AAST Colon Injury Scale (CIS) I – serosal injury II – single wall injury III – < 25% wall involvement IV – > 25% wall involvement V – circumferential wall, vascular injury, or both Destructive vs. Nondestructive wounds

8 Colon Trauma – Historical Perspective “Ephud put forth his left hand, and took the sword from his right thigh and thrust it into his belly… and the dirt came out.” – book of Judges in the Old Testament Suggestive of early penetrating colon trauma However no treatment or outcome is discussed

9 Historical Perspective (cont) American Civil War Non operative management of penetrating abdominal wounds Mortality 90% WWI Diverting colostomy is preferable in extensive wounds Primary repair was attempted Mortality 59% WWII US Surgeon General Thomas Parren Jr. mandated colostomy for all colon injuries sustained in battle Inexperienced war-time surgeons High-energy, high-velocity injuries Delay in care Transfer soon after initial management Mortality to 5-20%

10 Historical to today After WWII… Colostomy remained standard of care However, civilian ≠ military trauma Less destructive Delay to definitive care short Resuscitation administered quickly Newer antibiotic prophylaxis Postoperative supervision available

11 Non Destructive Wounds (CIS I – III) Stone and Fabian et al 1979 Primary repair or resection + anastomosis Destructive wounds (CIS IV – V) Demetriades et al 2001 no difference, or improved outcomes w/ primary repair Patients at risk for anastomotic breakdown Immunocompromised patients Transfusion > 6 units Likely increased  Shock  Other traumatic injury > 2  Delay of operation Traditionally  diverting colostomy New data  resection + primary anastomosis One strict contraindication, delay > 12 hrs Management of Colon Injuries

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

13 Management of Rectal Injuries Intraperitoneal Like colonic injuries Primary repair Extraperitoneal Diversion End vs. loop colostomy Drainage Closed or open drainage of presacral space Tranverse incision anococcygeal raphe into subcutaneous tissue Lateral dissection on each side of raphe to avoid transsection of coccygeal attachments to access presacral space Penrose or JP drainage Repair If feasible, avoid unnecessary dissection > 1cm unless involving GU tract  then repair w/interposition patch Distal Washout Washout of rectal stump No proven benefit For highly contaminated wounds and extensive devitalization Towards primary and definitive care w/out DDR,DW In rare cases, APR

14 Considerations Antibiotics No proven regimen 24 hours w/2 nd generation cephalosporin is accepted Colostomy Reversal Traditionally 3 months New data suggests if signs of improvement may consider reversal at 2 weeks Avoid 2 – 6 weeks BE not necessary Unidentified rectal trauma, ongoing symptoms

15 Conclusions Colon Trauma Primary repair, resection + primary anastomosis Exceptions destructive injuries w/risk factors Shock, delay to management, associated organ injury, transfusion requirement, co-morbid disease Rectal Trauma Intraperitoneal Like colonic injuries Extraperitoneal Diversion and presacral drainage Antibiotics 2 nd gen ceph x 24 hrs periop


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