Case Presentation. Duane R. Monteith, MD Department of Trauma Surgery Kings County Hospital Center

Transcription

1 Case Presentation Duane R. Monteith, MD Department of Trauma Surgery Kings County Hospital Center

2 Case Presentation Admission Patient is a xx y/o male BIBEMS to KCHC ED s/p multiple GSWs to the abdomen. Vitals: BP 110/58 HR 104 RR18 Sat 100% (on RA) Pt assessed and resuscitated as per ATLS protocol.

3 Case Presentation Physical Exam Neuro: : GCS 15, A+Ox3. Chest: Clear and equal breath sounds bilaterally. Trachea midline. CVS: S1, S2 normal intensity. No JVD. Abd: : ND, generalized tenderness, soft. GSW to right AAL (superior to inguinal ligament), GSW to left flank/mal (just above iliac crest). Rectal: Normal tone, no gross blood. Extr: Neurovascularly intact x4. GSW to right shoulder.

4 Case Presentation History Patient states he was walking down the street when he was assaulted by several unknown males and heard several gunshots. PMHx / PSHx: : Denies. Meds: Denies. Social Hx: : Denies any ETOH/tobacco/ID.

5 Case Presentation Labs ABG: ph 7.33 / 42 / 87 / 21 / -33 / 97% Lactate: 2.5 Hb: : 11.6 UA: negative. U.Tox: : negative.

6 Case Presentation Radiology CXR

7 Case Presentation Radiology PXR

8 Case Presentation OR Findings Right chest tube placed: Approx. 150cc blood evacuated. Exploratory laparotomy: Approx. 250cc of blood and clots evacuated. No active bleeding noted. Patient remains hemodynamically stable.

9 Case Presentation Operative Course Grade I liver laceration (dome) with right diaphragmatic perforation (5mm): Scant oozing. Thrombin and Gelfoam applied. Proximal jejunum T-T T T injury: Segmental resection with stapled side-to to-side anastamosis. Left colon mid-portion T-T T T injury: Segmental resection with stapled side-to to-side anastamosis. Transverse colon mid-portion perforation: Debridement and hand-sewn primary closure.

10 Case Presentation Operative Course Stomach (anterior greater curvature) perforation: Debridement and stapled primary closure. Left diaphragm perforation (1cm): Primary closure of defect. Bullet found resting in omentum (LUQ).

11 Case Presentation Operative Course Total OR time: 5hrs Total in: 2.5L LR, 2U PRBC. EBL: 800cc. Labs (pre- and post-op): op): ABG: 7.33/42/87/21/-3/97% 3/97% 7.34/42/100/22/ /97% Lactate: Hb: :

12 Case Presentation Post-Operative Course (POD#0) Remains intubated,, admitted to SICU. Approx. 1hr post-op, op, pt begins to become hypotensive (80/40 s) and tachycardic (120 s). Bolused 4L LR with minimal effect. Urine output falls below 30cc/hr. Chest tube output minimal. H/H stable (13.1/ /39.4) Started on Levophed drip (followed by Vasopressin drip a 4hrs later). Abx changed from Zosyn to Primaxin, Amikacin and Vancomycin.

13 Case Presentation Post-Operative Course (POD#1) Weened off pressors. Urine output satisfactory. Extubated without complication. POD#3 Started on clear liquid diet. Broad-spectrum abx D/C ed ed.

14 Case Presentation Post-Operative Course (POD#4) Advanced to regular diet and tolerates. POD#5 Transferred to the floor.

15 Case Presentation Post-Operative Course (POD#8) Pt found to be tachycardic with increasing hypotension. Bilious drainage from midline wound noted. Pt is intubated and taken for CT of chest and abdomen. Pt is afebrile,, WBC 7.9, H/H 7.9/23.8, ABG: 7.42/36/363/24/-0.2/99%.

16 Case Presentation Post-Operative Course (POD#8) Pt taken to OR for exploratory laparotomy: Fecal peritonitis with multiple intra-loop abscesses and extensive adhesions secondary to inflammation/fibrinous fibrinous exudate. Left colon anastomosis with wide (3cm) staple-line line dehiscence. Remaining anastomoses intact. Left end-colostomy with Hartmann s. Abdomen copiously irrigated and left open.

17 Case Presentation Post-Operative Course (POD#11-27) Pt returns to OR several times for abdominal washouts. Develops multiple enterotomies/fistulas with several failed attempts to adequately repair/drain the affected areas.

18 Case Presentation Post-Operative Course (POD#28) Pt progresses to MSOF secondary to sepsis. POD#30) Pt expires secondary to overwhelming sepsis and MSOF.

19 Management of Colon Injury in Trauma Duane R. Monteith, MD Morbidity and Mortality Conference April 7, 2006

20 Introduction Management of colon injuries has been a controversial field in trauma and has evolved tremendously with time. Highest abdominal septic complication in comparison to any other organ. Ranks 2nd to Small Bowel in Penetrating Trauma Mortality Rates: WWI: 60% WWII: 40% Vietnam: 10% Currently: 3% Demetriades D. Colon injuries: new perspectives. Injury, Int. J. Care Injured :

21 Demetriades D. Colon injuries: new perspectives. Injury, Int. J. Care Injured :

22 History (WWI) Surgeons in US & UK Advocated suturing of perforations Avoidance of Resection Proximal Colostomies may be beneficial for extensive injuries or those involving the descending colon High mortality rates 60% Laparotomy?, No Saline/Blood, No Antibiotics, Delay from injury to OR, Mobilization of colon not performed. Burch JM. 2004; Injury to the Colon and Rectum. In Ed/s Moore EE,, Feliciano DV, Mattox KL, Trauma New York. McGraw-Hill.

23 History (WWII) WH Ogilvie Based on his Expert Opinion Colostomy for treatment of all colon injuries In his series: Mortality 53% Primary Repair: (10/20) 50% Colostomy: (49/83) 59% Primary Repair in less severe trauma This approach removed clinical judgment and common sense from the treatment of colon injuries for decades to follow.

24 History In the US (1943) Many challenged the concept of Colostomy Korean & Vietnam War: Primary Repair lower mortality Multiple retrospective & prospective trials in the past 20 years Current practice: Controversy Diversion vs. Primary Repair??

25 History Many challenged the concept of Colostomy Korean & Vietnam War: Primary Repair lower mortality Multiple retrospective & prospective trials in the past 20 years Current practice: Controversy Diversion vs. Primary Repair??

26 Etiology Penetrating Injury Firearms ~ 75% Knives ~ 25% Transanal ~ 5% More likely to injure the Left Colon Right handed assailant Blunt Injury MVA Equally distributed along the colon

27 Treatment Primary Repair Simple suture/stapled repair Resection & Primary Anastomosis Diverting Colostomy/Ileostomy End ostomy Diversion proximal to primary repair site Exteriorization of Repair; Popular 1980s Desiccation serositis,, tension on repair, obstruction, edema and impaired blood supply

28 Treatment Concerns Primary Repair: Failure of Repair Internalized repair will leak Leaking Colon injury Intra-Abdominal infection Sepsis Increasing the patient s s risk of morbidity & mortality These complications are avoidable by creating a diverting colostomy or proximal diversion of the repair site.

29 Treatment Benefits Primary Repair Reduction of morbidity of the colostomy Hernia/ Prolapse/ / Retraction/ Necrosis/ Stenosis Reduction in cost associated with colostomy care Avoidance of the subsequent cost and morbidity associated with hospitalization for colostomy closure. $14,000 in 1990.

30 Grading Colon Injuries Flint system (1981) Grade 1 Isolated to colon Minimal contamination Hemodynamic stability Grade 2 Two wall Injury Moderate contamination Grade 3 * Severe tissue loss Devascularization Heavy contamination Hemodynamic instability Penetrating Abdominal Trauma Index (PATI) Grade 1 Serosal tear Grade 2 Single wall penetration Grade 3 <25% of wall involvement Grade 4 >25% of wall involvement Grade 5 * Segmental devascularization * Indicates destructive injuries

31 Grading Colon Injuries American Association for Surgery of Trauma (AAST) 1990 / Colon Injury Scale (CIS) Grade 1 Contusion, no perforation Grade 2 Laceration < 50% of circumference Grade 3 Laceration > 50% of circumference Grade 4 * Transection of Colon Grade 5 * Segmental devascularization & Tissue Loss * Indicates destructive injuries

32 Evidence for Primary Repair Stone & Fabian (1979): 268 pts First Prospective Randomization Exclusion Criteria Mandating Diversion (129 pts) Empirically Derived Risk Factors on 48% of pt pool Hypotension (BP < 80/60) Fecal Soilage Delay in time from injury to operation (> 8 hrs) Blood loss > 20% of blood volume (> 1 L) High # of associated injuries (More than 2) Destructive colon injuries Demetriades D. Colon injuries: new perspectives. Injury, Int. J. Care Injured :

33 Evidence for Primary Repair Stone & Fabian (1979): 268 pts First Prospective Randomization 139 pts underwent randomization 67 Primary Repair 72 Diversion Results Immediate mortality rates were identical between the 2 groups. Patients with primary closure had lower abdominal complication rates (1% vs. 10%) when compared to colostomies. Incidence of abdominal abscesses was significantly higher in the colostomy group. Demetriades D. Colon injuries: new perspectives. Injury, Int. J. Care Injured :

34 Evidence for Primary Repair Subsequent Studies Destructive & Non-Destructive colon wounds in conjunction with PATI / FSS / ISS Statistical Analysis to identify independent risk factors predictive of poor outcome regardless of treatment: Blood Loss & Solid Organ Injury Fecal Contamination & Mechanism of Injury Age Burch JM et al. Evaluation of the treatment of injured colon in the 1980s. Arch Surg :979-85

35 Evidence for Primary Repair Subsequent Studies Colostomy doubled the rate of adverse outcomes Prospective study of 252 patients: Ivatury et al. Severity of injury PATI >25 & the presence of colostomy as significant independent risk factors for intra-abdominal abdominal sepsis. Association of abdominal abscess with high PATI score reflects severity of trauma & not the use of primary repair. Curran TJ et al. Complications of Primary Repair of Colon Injury: : Literature Review of 2,964 Cases. Am J Surg :

36 Evidence for Primary Repair Suture Line Failure: First Arm of the Study: Primary Repair vs. Resection & Colostomy Second Arm of the Study: Primary Repair Primary Suture Repair vs. Resection & Anastomosis 93% treated by primary suture repair with only one suture line failure Location of injury not a factor in determining therapy George SM, Fabian TC et al. Primary Repair of colon wounds. A prospective trial in nonselected patients. Ann Surg :728-34

37 Evidence for Primary Repair Primary Repair: Standard in non military setting 4 yrs later, George recognized a subset of pts with massive transfusions or with pre-existing existing conditions 42% incidence of Anastomotic failure George SM, Fabian TC et al. Primary Repair of colon wounds. A prospective trial in nonselected patients. Ann Surg :728-34

38 Colostomy in Penetrating Colon Injury: Is It Necessary? University of Illinois: (38 months) Prospective Randomization of 109 patients Primary Repair: Debridement & Closure OR Segmental Resection & Anastomosis Diversion: Debridement & Closure of perforations with proximal loop colostomy Exteriorization of the injury as loop colostomy Resection & proximal stoma Gonzalez RP et al. Colostomy in Penetrating Colon Injury: Is it Necessary? J Trauma (2):

39 Colostomy in Penetrating Colon Injury: Is It Necessary? University of Illinois: Statistics # of Patients Age Injury to operation ED to operation Gunshot Wound Stab Wound LOS Diversion minutes 89.9 minutes days Primary Repair minutes 90.3 minutes days Gonzalez RP et al. Colostomy in Penetrating Colon Injury: Is it Necessary? J Trauma (2):

40 Colostomy in Penetrating Colon Injury: Is It Necessary? University of Illinois: Distribution of Sites Gonzalez RP et al. Colostomy in Penetrating Colon Injury: Is it Necessary? J Trauma (2):

41 Colostomy in Penetrating Colon Injury: Is It Necessary? University of Illinois: Associated Intraabdominal Injuries Gonzalez RP et al. Colostomy in Penetrating Colon Injury: Is it Necessary? J Trauma (2):

42 Colostomy in Penetrating Colon Injury: Is It Necessary? University of Illinois: Complications 11 in Primary Repair vs. 13 in Diversion Group Intra-Abdominal Abscess Wound Dehiscence Intra-Abdominal Abscess & Wound Dehiscence Peristomal Abscess Enterocutaneous Fistula Peristomal Gangrene Gonzalez RP et al. Colostomy in Penetrating Colon Injury: Is it Necessary? J Trauma (2):

43 Colostomy in Penetrating Colon Injury: Is It Necessary? University of Illinois: Complications Hemodynamic Instability Primary Repair: 3/15 complications Diversion:6/11 complications Fecal Contamination (moderate & severe spillage) Primary Repair: 45% Diversion: 33% Gonzalez RP et al. Colostomy in Penetrating Colon Injury: Is it Necessary? J Trauma (2):

44 Colostomy in Penetrating Colon Injury: Is It Necessary? University of Illinois: Complications Re-Operations: Patients requiring formal re- exploration of the abdomen or surgical closure of a wound dehiscence. PATI: Primary Repair Group: 55% Diversion Group: 62% >25: 18 (39%) in Diversion group 7 complications >25: 29 (29%) in Primary repair group 6 complications Gonzalez RP et al. Colostomy in Penetrating Colon Injury: Is it Necessary? J Trauma (2):

45 Colostomy in Penetrating Colon Injury: Is It Necessary? University of Illinois: Complications Hypotension in 26 patients Primary Repair had less complications than Diversion Fecal Contamination Does not impact septic complication rate Mortality 2 in Primary Repair: Colonic repair intact 1 in Diversion: Parastomal herniation with Gangrene Gonzalez RP et al. Colostomy in Penetrating Colon Injury: Is it Necessary? J Trauma (2):

46 Colostomy in Penetrating Colon Injury: Is It Necessary? University of Illinois: Conclusion Primary Repair is as successful as diversion, even in patients with previously identified exclusion criteria. Incidence of septic complications not greater in Primary Repair Group. Primary Repair with lower overall complication rate. PATI > 25 Risk for complications Patients suffering penetrating colon injury should undergo primary repair. Gonzalez RP et al. Colostomy in Penetrating Colon Injury: Is it Necessary? J Trauma (2):

47 Penetrating Colon Injuries Requiring Resection: Diversion or Primary Anastomosis? An AAST Prospective Multicenter Study Large Multicenter Trial: 19 Trauma Centers USC, LA County TC, UC Davis, Layola, Univ Loma Linda, Shock Trauma, Johns Hopkins, Univ Pennsylvania, Harbor View TC, Jackson-Memorial, Univ Louisville, and Others Investigators: Demetrio Demetriades Edward E. Cornwell III Rao R. Ivatury Ernest E. Moore Demetriades D et al. Penetrating Colon Injuries Requiring Resection: Diversion ion or Primary Anastomosis? An AAST Prospective Multicenter Study. J Trauma :

48 AAST Prospective Multicenter Study Methods: This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. Demetriades D et al. Penetrating Colon Injuries Requiring Resection: Diversion ion or Primary Anastomosis? An AAST Prospective Multicenter Study. J Trauma :

49 AAST Prospective Multicenter Study 297 patients fulfilled the criteria for inclusion and analysis. 197 patients (66.3%): Primary Anastomosis 100 patients (33.7%): Diversion The overall colon related mortality: 1.3% (4 deaths in the diversion group, no deaths in the primary anastomosis group). Colon related abdominal complications occurred in 24% of all patients Primary repair 22%; Diversion 27% Demetriades D et al. Penetrating Colon Injuries Requiring Resection: Diversion ion or Primary Anastomosis? An AAST Prospective Multicenter Study. J Trauma :

50 AAST Prospective Multicenter Study Demetriades D et al. Penetrating Colon Injuries Requiring Resection: Diversion ion or Primary Anastomosis? An AAST Prospective Multicenter Study. J Trauma :

51 AAST Prospective Multicenter Study Multivariate analysis including all potential risk factors identified three independent risk factors for abdominal complications: Severe fecal contamination, Transfusion of > 4 units of blood within the first 24 hours Single-agent antibiotic prophylaxis. 2 gm Mefoxin The type of colon management was not found to be a risk factor. Demetriades D et al. Penetrating Colon Injuries Requiring Resection: Diversion ion or Primary Anastomosis? An AAST Prospective Multicenter Study. J Trauma :

52 AAST Prospective Multicenter Study Comparison of primary anastomosis with diversion using multivariate analysis adjusting for: Above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome. Demetriades D et al. Penetrating Colon Injuries Requiring Resection: Diversion ion or Primary Anastomosis? An AAST Prospective Multicenter Study. J Trauma :

53 AAST Prospective Multicenter Study Conclusion In view of these findings and the fact that colon diversion is associated with worse quality of life and requires an additional operation for closure, primary injuries for colon injuries requiring resection should be considered, irrespective of risk factors. Demetriades D et al. Penetrating Colon Injuries Requiring Resection: Diversion ion or Primary Anastomosis? An AAST Prospective Multicenter Study. J Trauma :

54 Outcomes Most common cause of death Exsanguination not related to colon injury Second most common cause of death Sepsis and MOSF Mortality from this is < 5% Remain consistently higher in patients treated with colostomies as opposed to primary repair. Burch JM. 2004; Injury to the Colon and Rectum. In Ed/s Moore EE,, Feliciano DV, Mattox KL, Trauma New York. McGraw-Hill

55 Outcomes Infectious Complications: Intra-abdominal abdominal abscess occurs in 5 15% Colostomy > Primary Repair Suture Line Failure: (Fecal Fistulas) Occur 1-2% 1 of patients with Primary Repair Very Rare in Diverted patients Burch JM. 2004; Injury to the Colon and Rectum. In Ed/s Moore EE,, Feliciano DV, Mattox KL, Trauma New York. McGraw-Hill

56 Current Recommendations Level I evidence: A standard of primary repair: nondestructive colon wounds Involvement of < 50% of the bowel wall without devascularization) ) colon wounds in the absence of peritonitis Level II evidence: Penetrating colon wounds which are destructive > 50% of the bowel wall or devascularization of a bowel segment may undergo resection & primary anastomosis Hemodynamic Stability, Low PATI scores < 25, absence of peritonitis Cayten CG, Fabian TC et al. EAST Practice Parameter Workgroup for Penetrating Colon Injury. Patient Management Guidelines For Penetrating Intraperitoneal Colon Injuries Eastern Association for the Surgery of Trauma.

57 Current Recommendations Level II evidence: Penetrating colon wounds which are destructive > 50% of the bowel wall or devascularization of a bowel segment should undergo resection & diverting colostomy Hemodynamic instability, High PATI scores > 25, presence of other organ injuries, presence of peritonitis. Cayten CG, Fabian TC et al. EAST Practice Parameter Workgroup for Penetrating Colon Injury. Patient Management Guidelines For Penetrating Intraperitoneal Colon Injuries Eastern Association for the Surgery of Trauma.

58 References Curran TJ et al. Complications of Primary Repair of Colon Injury: Literature Review of 2,964 Cases. Am J Surg :42-47 Burch JM et al. Evaluation of the treatment of injured colon in the 1980s. Arch Surg : Demetriades D. Colon injuries: new perspectives. Injury, Int. J. Care Injured : Pasqulae M, Fabian TC et al Ad Hoc Committee on practice Management Guideline Development. J Trauma : George SM, Fabian TC et al. Primary Repair of colon wounds. A prospective trial in nonselected patients. Ann Surg : Moore EE et al. Penetrating Abdominal Trauma Index. J Trauma :439 Gonzalez RP et al. Colostomy in Penetrating Colon Injury: Is it Necessary? J Trauma (2): Demetriades D et al. Penetrating Colon Injuries Requiring Resection: Diversion or Primary Anastomosis? An AAST Prospective Multicenter Study. J Trauma : Maxwell RA, Fabian TC et al. Current Management of Colon Trauma. World J Surg : Burch JM. 2004; Injury to the Colon and Rectum. In Ed/s Moore EE, Feliciano DV, Mattox KL, Trauma New York. McGraw-Hill Cayten CG, Fabian TC et al. EAST Practice Parameter Workgroup for Penetrating Colon Injury. Patient Management Guidelines For Penetrating Intraperitoneal Colon Injuries Eastern Association for the Surgery of Trauma.