Another colonic injury - Forum

[Hans]

The issue of colonic injury was discussed some days ago, but... :

A 29 year old otherwise healthy male was admitted after falling with his motorcycle at pretty high speed.

He was alert, GCS 15, no airway problem, no breathing problem, hemodynamically stable all the way.

His injuries : abdominal ( will be discussed below ), closed fracture radius - ulna (rt) and open fracture of the mandible without major tissue loss. No other injuries.

Abdomen : there was diffuse bruising of the abdominal wall and very mild abdominal tenderness. Pelvic X-rays : fracture of left anterosuperior spine.

CT scan of the abdomen : blood around the liver, spleen, lt. paracolic gutter, pelvis ( small amounts in all these locations ), no obvious injury of the liver, spleen, kidneys, pancreas and retroperitoneum. Contusion of the lt side of the abdominal wall near the fractured ASIS, but only a small hematoma.

During diagnostic work up the abdomen distended and the tenderness increased also, so we took him to OR ( he should arrive there anyway for the other two injuries - his forearm and mandibular fracture ). Intraoperative findings :

1.about 500-600 cc of blood in the abdomen, as described on CT.
2. There was a 4 cm long tear in the meso of the sigmoid colon with a circumferential irregular tear of the serosa and muscularis - about 4-5 cm long leaving an intact mucosal cuff.
3. At the medial border of the cecum - tear of the medial coalesced meso, about 5 cm wide with two longitudinal serosal tears of the cecum, one lateral and one medial, parallel to each other and some 7-8 cm long, with a dark bluish color in the medial wall.
Both lesions - 2. and 3. did not look suitable to any other repair except resection.
4. There was another 2-3 cm long tear in the mesenterium, 30 cm proximal from the ileocecal valve, without bleeding and with viable adjacent bowel.
5. No other injury ; no fecal contamination ; no gross active bleeding; stable patient.
What would you do next ?

[Surgeon]

Your guy is stable; no evidence of other significant intra-abdominal
injuries. I would resect what requires resection and anastomose- as many
anastomoses as required. You probably ask us whether we would go for a
sort of a subtotal colectomy and ileo-distal sigmoid anastomosis. I do not
know- without being in that abdomen.

BTW: it took me 5 minutes to read and re-read your case report. Brevity
is a recipe for obtaining larger input from members.

[Proctologist]

I have often wondered why so many of us
continue to do things that are clearly established as inferior. I am not
talking about ignoramii, I am talking about surgeons like Isma, who are
well read, and can qoute the JT June article.

I have often thought of the reason, and I think I know it now. Let me
share my new insight with you: These surgeons are prudently doing what is
safer for them, not what is in the best interest of their patient.

Take the case in question. It is clear that either way you may get a
complication. Contrary to what surgeon is implying, stool in the bowel does
not GUARANTY that there would be no leak . We simply know that there
are FEWER complications with primary anastomosis than with the combined
hartman/closure method, not that there are none.

Now suppose Isma had done a primary anastomosis and the patient had a
leak, and died of peritonitis or required multipe operations for salvage.
It is likely that the majority of surgeons around him, including his
superiors and hospital administrators, do not subscribe to for-surgeons.com, don't
know the color of the cover of the JT, and have never seen the EAST web
site, if they know what a web site looks like.

Conseqently, at M&M or at an internal audit, Isma would have been
crucified. It matters not that he will bring a bunch of papers begining
with Stones paper to prove his point, it will be totally ignored.

He would be judged as lacking surgical judgement. We all will loud his
action, but in Isama's environment (and mine) our vote doesn't count.

In contrast, if he does a Hartman procedure, and there are complications,
they will be dismissed as insignificant technical problems.

Only those of us who practice in major University centers, or who are
lucky to be surrounded by academically oriented and enlightened surgeons
can afford to do what is best for the patient. When Han says that
Isma chose a safe course, he is right. Isma chose a safe course for
himself, and so would Han, I suppose.

BTW, the 50% circumferential limit for primary repair is from Burch papers. If you look at the data, it is not altogether clear why he chose that number.

[Noro]

No--he is wrong! Penalizing the patient by doing what is NOT in that
patient's interests--which we all agree is the case here--is WRONG. As soon
as one starts putting their interests ahead of the patient. they have started
down that slippery slope to schlock medicine--and once you start down, it gets
harder and harder to get back

[الجراح]

You make it sound like someone really made a disasterous decision and did a
horrible mistake. It is not wrong while in the OR for one to use one's best
judgement and apply a procedure that used to be safe in one's own hands,
till you discuss with others and know what they also do. And it is good to
come out of the OR and post a question to see if there is a
better practice. The guidelines that everyone quotes here after all address
penetrating trauma in particular and not blunt trauma (although I realize
that same have been practiced for comaparble cases of blunt trauma. Good to
learn). The whole idea is not to be merely satisfied with what you used to
do. Needless to say we are all in this e-mail list because we want to
improve, and seek the opinion of experts like yourself and of the other
colleagues.

[الجراح]

I am now convinced that primary rapair/anastomosis would be the
preferred procedure and the first choice. My next similar patient will enjoy
having that procedure. My decision is not based on people around me. My
role, as your and everyone's, is to improve our services, and this may take
a political struggle (what else doesn't anyway?). We all want to do the
right thing for our patients.

[Old surgeon]

You've given us all a great and sobering insight into the average
community of general surgeons--it stinks, and my hat off to you for
functioning with such diligence and competence despite these brutal
efforts to threaten you and bring you down to their level of the
jerks and hacks they obviously are--it is so transparent that these
threats and pressures arise from their own insecurities in the face
of your excelllent grasp of surgical principles, and that you
threaten them and their own practices--if they would only spend half
the effort they use to threaten you on simply reading and educating
themselves, everyone would be better off--We should not be surprised
at the public's growing mistrust of us given how widespread is this
thuggery, which casts a bad image over all of us--they're the ones
who should be run out of town