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Colorectal TraumaColorectal Conference
St Luke’s-Roosevelt HospitalDepartment of Surgery
Leslie Tyrie, PGY III16 March 2006
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
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
Colorectal Trauma – H&P Trauma algorithms
ABCs
History Physical
Abdomen Flank Perineum DRE – blood
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
Operative Management Options
1. Primary repair2. Resection and anastomosis3. Repair w/proximal diversion4. Exteriorization
The Question Proximal diversion of fecal stream
Prevent septic complications Colon: anastomotic leak Rectum: pelvic sepsis Pelvic abscess
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
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
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%
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
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
The Exception: Damage Control Cold Coagulopathic Acidotic
Resect if needed, no anastomosis Planned second look
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
Considerations Antibiotics
No proven regimen 24 hours w/2nd 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
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
2nd gen ceph x 24 hrs periop
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