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Yi-Xiong
Zheng, Li Chen, Si-Feng Tao, Ping Song, Shao-Ming Xu, Department of
Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang
University, Hangzhou 310009, Zhejiang Province, China
Correspondence to: Dr. Yi-Xiong Zheng, Department of Surgery,
Second Affiliated Hospital, School of Medicine, Zhejiang University,
Hangzhou 310009, Zhejiang Province,
China. zyx_xxn@hotmail.com
Telephone: +86-571-87783580
Received: 2006-10-11
Accepted: 2006-10-28
Abstract
AIM: To retrospectively evaluate the preoperative diagnostic
approaches and management of colonic injuries following blunt abdominal
trauma.
METHODS: A total of 82 patients with colonic injuries caused by
blunt trauma between January 1992 and December 2005 were enrolled. Data
were collected on clinical presentation, investigations, diagnostic
methods, associated injuries, and operative management. Colonic
injury-related mortality and abdominal complications were analyzed.
RESULTS: Colonic injuries were caused mainly by motor vehicle
accidents. Of the 82 patients, 58 (70.3%) had other associated injuries.
Laparotomy was performed within 6 h after injury in 69 cases (84.1%),
laparoscopy in 3 because of haemodynamic instability. The most commonly
injured site was located in the transverse colon. The mean colon injury
scale score was 2.8. The degree of faecal contamination was classified
as mild in 18 (22.0%), moderate in 42 (51.2%), severe in 14 (17.1%), and
unknown in 8 (9.8%) cases. Sixty-seven patients (81.7%) were treated
with primary repair or resection and anastomosis. Faecal stream
diversion was performed in 15 cases (18.3%). The overall mortality rate
was 6.1%. The incidence of colonic injury-related abdominal
complications was 20.7%. The only independent predictor of complications
was the degree of peritoneal faecal contamination (P = 0.02).
CONCLUSION: Colonic injuries following blunt trauma are
especially important because of the severity and complexity of
associated injuries. A thorough physical examination and a combination
of tests can be used to evaluate the indications for laparotomy. One
stage management at the time of initial exploration is most often used
for colonic injuries.
© 2007 The WJG Press. All rights reserved.
Key words: Colonic injuries; Blunt trauma; Operation; Faecal
stream diversion; Rretrospective study
Zheng YX, Chen L, Tao SF, Song P, Xu SM. Diagnosis and management of
colonic injuries following blunt trauma. World J Gastroenterol 2007;
13(4): 633-636
http://www.wjgnet.com/1007-9327/13/633.asp
INTRODUCTION
Although the colon is often injured in case of penetrating abdominal
trauma, a significant proportion of colonic injuries caused by road
accidents is a grossly destructive blunt type associated with damage to
multiple organs[1-3]. The diagnosis and management of blunt colon
injuries are still debatable. The aim of this retrospective study was to
evaluate the preoperative diagnostic methods and management of colonic
injuries following blunt abdominal trauma.
MATERIALS AND METHODS
Subjects
All patients with colonic injuries caused by blunt trauma presenting to
the Emergency Center of the Second Affiliated Hospital of School of
Medicine of Zhejiang University between January 1992 and December 2005
were enrolled. The criterion for inclusion in the study was full
thickness perforation of colon injuries requiring surgical repair. Data
were collected on clinical presentation, investigations, diagnostic
methods, associated injuries, operative management, morbidity and
mortality.
Haemodynamic status was determined based on their heart rate and
systolic blood pressure (BP) on admission. A systolic BP equal to or <
90 mmHg on admission was interpreted as haemodynamic instability or
presence of shock. The time from injury to operation was recorded. The
site of colon injury (right colon defined as the right of the middle
colic vessels, left colon the left of the vessels) and major associated
injuries of the head, thorax, pelvis, axial skeleton, major blood
vessels and long bones were recorded.
The severity of colon injury was graded according to the
colon injury scale (CIS) score[4]. CIS score was definited as follows:
grade 1: contusion and serosal tear without devascularization, grade 2:
laceration of less than 50% of the wall, grade 3: laceration of 50% or
greater of the wall, grade 4: 100% transection of the wall, and grade 5:
complete transection with tissue loss and devascularization, an advanced
grade for multiple injuries to the colon. The degree of faecal spillage
(the gross extent of intra-abdominal faecal contamination) was
categorized as mild: stool contamination on local or one quadrant,
moderate: stool contamination on 2 to 3 quadrants, and severe: stool
contamination on all four quadrants[5].
Methods
All patients were resuscitated and received intravenous antibiotics in
the emergency room. The discretion of operative options was based on
Stone’s exclusion factors for primary repair[6] and surgeons’
experience. The outcome variables of the study included colonic
injury-related mortality and abdominal complications (anastomotic leak,
intra-abdominal abscess or peritonitis, and colon obstruction or
necrosis, if it was judged to be directly related to the colonic
trauma).
Statistical analysis
All analyses were carried out by SPSS 12.0 statistical software.
Independent predictors for colostomy and post-operative complications
were determined by entering potential confounders into a multivariate
stepwise (backward elimination) logistic regression. Variables
considered in the model for colostomy included age, mechanism of injury,
shock on admission, CIS, degree of peritoneal faecal contamination,
location of colon injury, and associated intra-abdominal injury. P <
0.05 was considered statistically significant.
RESULTS
Demographic data
A total of 82 patients were included in this study. There were 77 males
(93.9%) and 5 females (6.1%). Their age ranged 15-67 years with a mean
of 37.6 years. Colonic injury was found in 57 patients (69.5%) due to
motor vehicle accidents, in 18 (22.0%) due to building accidents, in 6
(7.3%) due to criminal assault, and in 1 (1.2%) due to burst injury.
Clinical presentation
Abdominal signs could not be detected in 8 cases (9.8%) because of head
injuries, intoxication or sedation. Seventy patients (94.6%) had
moderate to severe abdominal tenderness, 18 (24.3%) had diffuse
peritonism, 23 (28.0%) had shock on admission. In addition, hematuria
was found in 12 patients (14.6%), paraplegia in 2 (2.4%), aerocele of
scroticles in 2 (2.4%) patients. Plain abdominal radiograph was
performed to find pneumoperitoneum and intestinal obstruction in 54
patients. Diagnostic peritoneal lavage (DPL) or paracentesis was
performed in 65 cases, which was positive in 43 cases (noncongested
blood in 20 cases, pus in 23 cases). Abdominal ultrasonography (US) and
computed tomography (CT) were performed in 58 and 10 cases respectively.
Among them, 12 were diagnosed as gastrointestinal injury with
intraperitoneal free fluid.
Associated injuries
Fifty-eight patients (70.3%) were found to have one or more associated
injuries (Table
1). The most commonly associated intra-abdominal injury occurred
in the small bowel (51.2%), followed by in the speen, liver, and kidney.
Multiple colonic wounds were observed in 4 cases (4.9%), Isolated colon
injury in 20 cases (24.4%). The range of intra-abdominal organs injured
was 1-4, with a mean of 2.3.
Timing and indications for laparotomy
Seven patients (8.5%) underwent immediate laparotomy (< 2 h after
injury), 4 for severe peritonitis and 3 due to haemodynamic instability.
Laparotomy was performed between 2 h and 6 h after injury in 62 cases
(75.6%). Of them, 33 had a laparotomy because of abdominal signs with
evidence of peritonitis at admission or during observation, 35 because
of positive DPL or paracentesis. Eighteen (51.4%) of these patients had
more than one significant intra-abdominal injury. An abdominal CT scan
or US imaging with diagnostic or suspicious findings was the main reason
for laparotomy in 15 cases (18.3%). Colonic injuries were found in 2
patients at diagnostic laparoscopy (Figure
1).
Site and nature of injuries
A total of 87 colonic injuries were found in 82 patients. The most often
wounded site was located in the transverse colon (32 cases, 36.8%). The
right colon injury was found in 21 cases, the descending colon injury in
16, the sigmoid colon injury in 13, and the intraperitoneal rectum
injury in 5. The mean CIS score was 2.8 ± 1.2. The degree of faecal
contamination was classified by the operating surgeon as mild in 18
cases (22.0%), moderate in 42 (51.2%), severe in 14 (17.1%), and unknown
in 8 (9.8%).
Management and prognosis
Therapeutic options were considered: two-stage management for those with
any type of faecal stream diversion, while one stage management for
those undergoing primary repair of the injured colon with or without
anastomosis. The successful rate for colonic wounds without diversion
was 81.7% (67 cases). Primary repair was undertaken in 37 cases with
resection and primary anastomosis in a further 30 cases. Two-stage
operation was performed in 15 cases (18.3%): repair and protective
ostomy in 11 cases, exteriorisation of the repaired bowel in 3 cases,
Hartmann’s operation in 1 case. The overall mortality rate was 6.1%
(5/82). The overall incidence of colonic injury-related abdominal
complications was 20.7% (17/82). The most common complications were
anastomotic leak (12 cases), intra-abdominal abscess (10 cases), wound
infection (12 cases) and colon obstruction or necrosis (4 cases). The
only independent predictor of complications was the degree of peritoneal
faecal contamination (P = 0.02). There was no significant correlation
between age, mechanism of injury, shock on admission, location of colon
injury, therapeutic options and outcome in terms of morbidity and
mortality.
DISCUSSION
Injuries of the hollow viscera are far less common in blunt abdominal
trauma than in penetrating abdominal trauma. Blunt abdominal trauma
accounts for approximately 5% to 15% of all operative abdominal
injuries[3,7]. The majority of colonic injuries caused by penetrating
trauma are dominant[1-3,5]. Nevertheless, in our experience about 6.5%
of patients with blunt trauma at admission had injuries to the colon and
rectum, which is slightly higher than the reported 5%[8]. Despite their
infrequence, traumatic blunt injuries to the colon are extremely
destructive and generally associated with damage to multiple organ
systems, making diagnosis and treatment difficult. It was reported that
delayed management of colonic injuries results in a high incidence of
morbidity[9]. Therefore, further researches on guidelines for the
diagnosis and surgical management of colonic injuries following blunt
trauma are especially important.
No clinical investigations are available to compare with
gastrointestinal tract injuries. Moreover, clinical assessment can be
unreliable in patients following blunt trauma due to distracting
injuries, head and spinal cord injuries, and shock. Less than 50% of
gastrointestinal tract injuries resulting from blunt trauma are reported
to have sufficient clinical findings to indicate the need for
laparotomy[10]. In this study, 3 patients with unstable haemodynamics
undergoing immediate laparotomy (< 2 h) showed marked evidence for
abdominal injury. The other 4 patients with gross abdominal distension
and marked tenderness were also immediately operated. In 6 patients
presented within two hours, abdominal signs were vague at initial
evaluation but became marked over a few hours at a repeated examination.
The finding of abdominal signs in the other 27 cases presented between
two and six hours after trauma resulted in laparotomy. Tenderness or
other abdominal findings were usually apparent within 24 h.
Physical examination and diagnostic tests can be used to
evaluate patients with blunt abdominal trauma, including DPL, US, CT,
and diagnostic laparoscopy. Speed and efficiency are important factors
in the performing such tests[3]. It is reported that peritoneal lavage
cell count may also be useful in early detection of hollow viscus
injury[11,12]. Although DPL is sensitive in identifying haemoperitoneum
and associated hollow viscus injury, it has been criticised for its
higher rate of non-therapeutic laparotomy (NTL) and inconvenience in
practice[12]. In this study, the presence of positive DPL or
paracentesis was an important clinical finding. The routine use of
diagnostic celiocentesis to detect possible intra-abdominal injuries in
cardiovascularly stable patients has been used to differentiate between
injuries that require a therapeutic laparotomy and those that do
not[13]. Suspicious diagnosis of gastrointestinal tract injuries was
indicated in 35 cases in this study. However, the diagnostic rate of
colonic injuries by DPL or celiocentesis was decreased over the study
period, which may be due to the increased use of imaging techniques to
assess haemodynamically stable trauma patients.
US is convenient, cheap and noninvasive. A positive study is
defined as evidence of free fluid or solid-organ parenchymal injury.
Abdominal CT is also useful in the diagnosis of abdominal injuries as it
accurately delineates solid organ injuries and retroperitoneal lesions.
While some advocate limiting imaging tests to evaluation of patients
with DPL-positive results and haemodynamic stability, US and CT remain
the preferred tool in the evaluation of blunt abdominal trauma[3,14].
The accuracy of abdominal US for evaluating blunt abdominal trauma is
comparable to the reported accuracy[15]. However, only 10 out of the 58
scans in our study could diagnose intra-abdominal gastrointestinal tract
injuries with 5 being suspicious of a significant intra-abdominal
injury. Some patients with free fluid but no evidence of a solid viscus
injury might presumably be overlooked.
Although the role of laparoscopy in abdominal trauma is
controversial[16], diagnostic laparoscopy has been introduced in our
emergency center. Its indications have expanded from identifying the
causative pathology of acute abdominal pain to avoidance of unnecessary
laparotomies, treatment of intra-abdominal lesions, and can be used as a
resource for evaluating blunt abdominal trauma. Diagnostic laparoscopy
was performed in 2 cases in our study and some direct indications for
colonic injuries (such as faecal spillage, colon rupture) were found in
both cases. Take together, the indications for laparotomy were
determined according one of the following findings: haemodynamic
instability with reasonable clinical suspicion of an intra-abdominal
cause, positive abdominal signs, positive DPL, positive diagnostic
imaging and abdominal finding by laparoscopy.
The management of colonic injuries has changed significantly from
‘‘faecal diversion dogma’’ to primary repair[2,3]. Although several
studies showed that diversion is not mandatory, additional
considerations in management should be taken into account regarding
grossly destructive colon injuries. In our study, mild, moderate and
severe faecal contamination was found in 22.0%, 51.2%, and 17.1% of
patients, respectively at laparotomy. In 15 patients (18.3%), primary
laparotomy was terminated before the completion of definitive surgery
(abbreviated laparotomy or damage control).
It was reported that the mortality of colonic injuries have
declined to 2%-12%[1,3,17]. Primary closure or resection and anastomosis
can be used in patients with colonic injury. The results are generally
favorable, due to the advances in intensive care techniques and
antibiotic therapy. Primary repair reduces operation and postoperative
complications, avoids a second operation, stoma complications, and the
financial burden related to colostomy care. A number of factors have
been traditionally accepted to be associated with higher mortality and
morbidity of primary colonic repair. It was reported that patients
should be excluded from primary repair in the presence of shock, major
blood loss, > two organs injured, faecal contamination higher than
‘mild’, delay of repair > 8 h and destructive wounds of the colon or
abdominal wall requiring resection[6]. The grade of colonic injuries
trends to be independently associated with intra-abdominal
complications. In our study, the overall mortality rate was 6.1%.
Although neither grade of injury nor ostomy formation demonstrated a
significant impact on morbidity, peritoneal faecal contamination has
shown its significant predictive value for complications. We advocate
that peritoneal faecal contamination should be thoroughly removed during
operation to reduce postoperative abdominal septic morbidities. There
was no difference between patients with primary repair and faecal stream
diversion. However, other organ injuries must be kept in mind. Colostomy
may be indicated due to unusual conditions, such as intramural hematomas
causing compression ischemia and delayed perforation, mesenteric
hematomas causing vascular compression with subsequent infarction, and
perforations in omentum or other surrounding organs[3]. All together,
the decision for a primary anastomosis, especially after segmental
resection in the descending colon, should be individualized according to
the injuries in different patients.
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S- Editor Wang J L- Editor Wang XL
E- Editor Lu W
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