Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

Abstract

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

Reinterventions after damage control surgery

“…Furthermore, other studies have reported that complications such as leakage, enterocutaneous fistula, or surgical site infection do not have a frequency higher if the patient underwent definitive or abbreviated management 9 , 26 . In addition, there is not a difference regarding complications rate between patients undergoing deferred anastomosis or deferred diversion 11 , 27 , 28 .…”

“… Definitive anastomosis should be performed as soon as possible, a maximum of 24-48 hours after intestinal ligation to avoid septic complications 24 - 28 . Duodenal reconstruction should be performed during the first 48 hours after the index surgery.…”

“…Definitive anastomosis should be performed as soon as possible, a maximum of 24-48 hours after intestinal ligation to avoid septic complications 24 - 28 .…”

“…Otras experiencias han reportado que la frecuencia de complicaciones tales como filtración, fistulas entero cutáneas o infección del sitio operatorio no varía si el paciente es sometido a un manejo intestinal diferido, comparado con aquellos pacientes en que es posible un manejo definitivo 9 , 26 . Igualmente, no hay diferencia en los pacientes sometidos a anastomosis diferida vs ostomías diferida 11 , 27 , 28 .…”

“… Realizar la anastomosis lo antes posible, máximo 24-48 horas luego de la ligadura intestinal para evitar las complicaciones sépticas 24 , 28 . La reconstrucción del duodeno se debe realizar en las primeras 48 horas después de la primera cirugía inicial 29 , 30 .…”