Management of Colon Wounds in the Setting of Damage Control Laparotomy: A Cautionary Tale

Weinberg, Jordan A.; Griffin, Russell; Vandromme, Marianne J.; Melton, Sherry M.; George, Richard L.; Reiff, Donald A.; Kerby, Jeffrey D.; Rue, Loring W.

doi:10.1097/ta.0b013e3181991ab0

Cited by 49 publications

(50 citation statements)

References 16 publications

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“…[15][16][17] Weinberg et al 15 demonstrated that primary repairs as well as resections with anastomoses in the setting of damage control techniques carried higher rates of complications, particularly leak and abscesses, compared with patients who underwent single laparotomy. 15 Other authors have shown that the leak rate in the setting of resection and anastomosis was over 4 times greater in patients managed with an open abdomen compared with single laparotomy, whereas results from the recent Western Trauma Association's multicenter trial showed a similar 4-fold risk for leak in patients whose abdomen was left open of >5 days. 16,17 Notably, a large portion of the 284 patients in the current study treated with DCS techniques likely met this criterion.…”

Section: Discussionmentioning

confidence: 99%

“…4,[10][11][12][13][14] Both primary colonic repair or resection with anastomosis carry increased morbidity in the wartime and civilian trauma setting, particularly when combined with DCS techniques. 10,[14][15][16][17] An initial step toward improving combat casualty care is understanding the wound and patient factors that correlate with colostomy creation. Ultimately, the aim is to optimize combat casualty care by minimizing potentially unnecessary ostomies without needlessly incurring more risk for the injured soldier.…”

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confidence: 99%

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Risk factors for colostomy in military colorectal trauma: A review of 867 patients

Watson¹,

Aden²,

Engel³

et al. 2014

Surgery

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Background. Limited data exist examining the use of fecal diversion in combatants from modern armed conflicts. Characterization of factors leading to colostomy creation is an initial step toward optimizing and individualizing combat casualty care. Methods. A retrospective review of the US Department of Defense Trauma Registry database was performed for all US and coalition troops with colorectal injuries sustained during combat operations in Iraq and Afghanistan over 8 years. Colostomy rate, anatomic injury location, mechanism of injury, demographic data, and initial physiologic parameters were examined. Univariate and multivariate analyses were conducted. Results. We identified 867 coalition military personnel with colorectal injuries. The overall colostomy rate was 37%. Rectal injuries had the highest diversion rate (56%), followed by left-sided (41%) and right-sided (20%) locations (P < .0001). Those with gunshot wounds (GSW) underwent diversion more often than blast injuries (43% vs 31% respectively, P < .0008). Injury Severity Score $16 (41% vs 30%; P = .0018) and damage control surgery (DCS; 48.2% vs 31.4%; P < .0001) were associated with higher diversion rates. On multivariate analysis, significant predictors for colostomy creation were injury location: Rectal versus left colon (odds ratio [OR], 2.2), rectal versus right colon (OR, 7.5), left versus right colon (OR, 3.4), GSW (OR, 2.0), ISS $ 16 (OR, 1.7), and DCS (OR, 1.6). Conclusion. In this exploratory study of 320 combat-related colostomies, distal colon and rectal injuries continue to be diverted at higher rates independent of other comorbidities. Additional outcomes-directed research is needed to determine whether such operative management is beneficial in all patients. (Surgery 2014;155:1052-61.)

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Risk factors for colostomy in military colorectal trauma: A review of 867 patients

Watson¹,

Aden²,

Engel³

et al. 2014

Surgery

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“…Our data are insufficient to draw any definitive conclusions but our experience suggests that delayed PR is an acceptable option if the patient's physiology has normalised completely. [18][19][20][21][22][23][24] Nevertheless, if there is persistent lactic acidosis and haemodynamic instability, then formal diversion remains the safest option. Continued collection of routine data as part of a trauma registry is needed to attempt to answer this question.…”

Section: Discussionmentioning

confidence: 99%

“…[18][19][20][21][22][23][24] Those with hypovolaemic shock, metabolic acidosis, systemic hypothermia and complex intra-abdominal injuries should be subjected to an abbreviated laparotomy. Both PR and formal PD are inappropriate in this setting, and it is highly likely that a significant proportion of the PD patients in this series may have been better served by a DC approach.…”

Section: Discussionmentioning

confidence: 99%

“…The principle of DC is to avoid all definitive surgery in the unstable patient at the initial operation, and to control bleeding and soiling in an abbreviated procedure. [18][19][20][21][22][23][24] The controversies in colonic trauma revolve currently around management of destructive colonic injuries, initial selection of cases for DC and (once a DC approach has been chosen) how to manage colonic injuries that have been temporised during the initial procedure. The purpose of this study was to audit our current management and outcomes of colonic trauma, to review our experience of colonic trauma in patients who underwent DC surgery and to produce a clinical algorithm for assisting with the management of these injuries.…”

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The management of colonic trauma in the damage control era

Shazi

Bruce

Laing

et al. 2017

annals

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INTRODUCTION The purpose of this study was to audit our current management of colonic trauma, and to review our experience of colonic trauma in patients who underwent initial damage control (DC) surgery. METHODS All patients treated for colonic trauma between January 2012 and December 2014 by the Pietermaritzburg Metropolitan Trauma Service were included in the study. Data reviewed included mechanism of injury, method of management (primary repair [PR], primary diversion [PD] or DC) and outcome (complications and mortality rate). RESULTS A total of 128 patients sustained a colonic injury during the study period. Ninety-seven per cent of the injuries were due to penetrating trauma. Of these cases, 56% comprised stab wounds (SWs) and 44% were gunshot wounds (GSWs). Management was by PR in 99, PD in 20 and DC surgery in 9 cases. Among the 69 SW victims, 57 underwent PR, 9 had PD and 3 required a DC procedure. Of the 55 GSW cases, 40 were managed with PR, 9 with PD and 6 with DC surgery. In the PR group, there were 16 colonic complications (5 cases of breakdown and 11 of wound sepsis). Overall, nine patients (7%) died. CONCLUSIONS PR of colonic trauma is safe and should be used for the majority of such injuries. Persistent acidosis, however, should be considered a contraindication. In unstable patients with complex injuries, the optimal approach is to perform DC surgery. In this situation, formal diversion is contraindicated, and the injury should be controlled and dropped back into the abdomen at the primary operation. At the repeat operation, if the physiological insult has been reversed, then formal repair of the colonic injury is acceptable.

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Stomas

Cheetham¹

2011

Contemporary Coloproctology

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Management of Colon Wounds in the Setting of Damage Control Laparotomy: A Cautionary Tale

Cited by 49 publications

References 16 publications

Risk factors for colostomy in military colorectal trauma: A review of 867 patients

Risk factors for colostomy in military colorectal trauma: A review of 867 patients

The management of colonic trauma in the damage control era

Stomas

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