Colorectal Trauma

1. Colorectal Trauma Colorectal Conference St Luke’s-Roosevelt Hospital Department of Surgery Leslie Tyrie, PGY III 16 March 2006

2. 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

3. 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 – Etiology

4. Colorectal Trauma – H&P • Trauma algorithms • ABCs • History • Physical • Abdomen • Flank • Perineum • DRE – blood

5. 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

6. Operative Management • Options • Primary repair • Resection and anastomosis • Repair w/proximal diversion • Exteriorization • The Question • Proximal diversion of fecal stream • Prevent septic complications • Colon: anastomotic leak • Rectum: pelvic sepsis • Pelvic abscess

7. 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

8. 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

9. 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%

10. 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

11. Management of Colon Injuries • 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

12. The Exception: Damage Control • Cold • Coagulopathic • Acidotic • Resect if needed, no anastomosis • Planned second look

13. 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

14. 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

15. 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