Trauma to Colon - Forum

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सर्जन

Trauma to Colon - Ärzteforum

Post#1 »

I have recently operated on a young man following a MVA. Exploratory
Laparotomy showed a tear in the sigmoid mesentry and a 4 cms area of
devascularized sigmoid. I had recently read the Practice management
Guidelines for trauma from the Eastern Association For the Surgery of
Trauma(EAST) published in the June issue of The Journal Of Trauma. In the
Guidelines for Colonic injury the recommendations are: Patients with
colon wounds that involve >50% of bowel wall or devascularization can
undergo resection and anastomosis if the patient is 1. haemodynamically
Stable. 2.no significant other disease. 3.have minimal associated
injuries 4.have no peritonitis. All the above were absent in this patient.
However I opted for A Hartmann Procedure, as the sigmoid was loaded with
Faeces,
My question is:
Would you perform a resection with primary anastomosis in such a situation?


User avatar
Surgeon

Re: Trauma to Colon - Ärzteforum

Post#2 »

Yes to the above question. We did so in the otherwise stable patients even before knowing what EAST is or was.

As you well know-"loaded colon" means nothing; time you stop being afraid off shit!

User avatar
Doctor Green

Re: Trauma to Colon - Ärzteforum

Post#3 »

I suppose that you meant that the patient was actually hemodynamically stable, had no significant other disease, etc. You chose a solid safe approach. An on-table antegrade bowel irrigation for a loaded left colon will need to set up an irrigation system with a big Foley into the appendiceal stump and large anesthesia-type hose for the exiting fluid, which needs to be continued till the outcome is clear. I will opt for Hartmann's, though.

John Dissector

Re: Trauma to Colon - Ärzteforum

Post#4 »

I would and have on innumerable occasions, as the evidence clearly
supports--why ask opinions when it is now out of the realm of opinion? Feces
in the colon are in no way a contraindication to primary anastomosis. The
real question is why YOU performed a colostomy, which has at least the same
level of complication, PLUS the added down side of consigning the patient to a
second operation. The state of the art demands that those who do
colostomies in this setting bear the burden of proof for that course, not the
other way around.

John Dissector

Re: Trauma to Colon - Ärzteforum

Post#5 »

Doctor Green wrote:I suppose that you meant that the patient was actually hemodynamically stable, had no significant other disease, etc. You chose a solid safe approach. An on-table antegrade bowel irrigation for a loaded left colon will need to set up an irrigation system with a big Foley into the appendiceal stump and large anesthesia-type hose for the exiting fluid, which needs to be continued till the outcome is clear. I will opt for Hartmann's, though.


Wrong! This is NOT the safer or wiser course, as the literature for the past
20 years clearly shows--Stone's original study challenging your unproven
concept was published in 1979, and the floodgates of info since then opened.
Please read the EAST guidelines, which include a comprehensive listing and
summary of the listing proving my assertion, something you can not provide to
prove your stance because it does not exist

Hans

Re: Trauma to Colon - Ärzteforum

Post#6 »

at last a medical topic to discuss - what a pleasure. However the answer is
simple YES. I would resect and primarily anastamose. I think the evidence
is pretty clear and the recommendations of the East surgical site well laid
out, (a lot of the pioneering work on colon injury was done in South
Africa - just thought I'd add this for the sake of national pride).
Actually I only don't do it in patients already developing SIRS, or at relap
if there has been a prior leaking anastamosis. If I didn't do this I would
be spending an awful lot of my time restoring Hartman's resections, thus
giving my patients an unnecessary long additional operation not without its
own risks. Why are you so frightened of a bit of faeces? There will be
plenty of it next to your anastamosis whether you do it now or closing your
Hartman's.

सर्जन

Re: Trauma to Colon - Ärzteforum

Post#7 »

you and others convinced me, and I am changing my position. I did not
say safer, I just said safe, though.

Stone and Fabian's study did actually exclude patients who had major
contamination. At that time, stool was considered contamination. Subsequent
studies, though, did not substantiate that. And, as I said, I am now
convinced, and a separate posting about that will follow.

सर्जन

Re: Trauma to Colon - Ärzteforum

Post#8 »

The discussions here lead me to change my choice the next time I encounter an injured colon "loaded" with stool, and I will go for the primary repair.

Although the EAST Practice Management Guidelines apply to "penetrating" intraperitoneal colon injuries, using the same in selected non-penetrating injury situations makes sense. And although the recommendation is level II (i.e. supported by class II or preponderance of class III data), it is clear to me that in major centers in Jacksonville, FL, Brooklyn, NY and South Africa this is the standard practice based on their extensive experience. I changing my practice for the benefit of my patients, and this means a lot to me.

Any words of advice about setting up for the ante-grade (3Dprograde) on-table colon lavage. I mean any practical points that are not covered in the literature?

User avatar
Resident

Re: Trauma to Colon - Ärzteforum

Post#9 »

My answer too is "yes" (and would have been not knowing the other
replies..).

At the department I work at, we have narrowed down the indication for
Hartmann's procedure considerably in the last 10 years (mainly "old" i.e. >
24hours purulent or fecal peritonitis!). One point in your favour is the
often underestimated blunt damage to the mesentery and the retroperitoneum
in such cases. But as others have already pointed out, feces alone is no big
problem as long as the anastomosis has a good vascular supply and is
completely tension-free.

Hans

Re: Trauma to Colon - Ärzteforum

Post#10 »

I'm not sure if any of these remarks are covered in the textbooks or not,
but I don't routinely do colonic lavage for colon injury. If I were to do
it I would mobilise the proximal end of my proposed anastamosis, hang it
over the side of the patient, put a Foley in the patients appendix stump and
irrigate into a bucket until clean effluent was obtained.
I do use it routinely in rectal injury below the peritoneal reflection where
a repair is very difficult. Here I put the patient in Lloyd Davies
supports, stick a big tube (anaesthetic tubing is great) in his rectum, or a
German medical student holding a proctoscope (whichever is more convenient
at the time) then having opened the belly, I bring out a loop sigmoid
colostomy via a small LIF incision, cannulate that with a big Foley, soft
bowel clamp proximally and irrigate with warm saline until medical student
reports all clear. Then I close up, put a prolene stitch round the distal
limb of my loop, (to make it defunctioning) open the stoma and that's it.
I don't routinely open the pararectal space, unless the injury is 24 or more
hours old, or an unusual amount of tissue damage, or looks like an abscess
or pelvic cellulitis developing.

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