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Colorectal trauma


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colorectal trauma: the things residents should know
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Colorectal trauma

  1. 1. Colorectal Trauma: The Things Residents Should Know Facebook: Happy Friday Knight 30th March, 2018 General Surgical Residency Program Thailand
  2. 2. • Introduction • Relevant Anatomy • General considerations – Antibiotics – Wound management • Colonic trauma – Classification – Destructive VS non-destructive injuries – Essential issues • Rectal trauma – “4Ds” – classification – Intraperitoneal VS extraperitoneal injuries • Iatrogenic colorectal injuries
  3. 3. Introduction • Radical changes of colorectal injuries management result in dramatic reduction of colon-related mortality from 60% during WWI to less than 3% in the last decade • However, abdominal sepsis after this trauma is about 20% • For rectal injuries, “4Ds” concept has been challenged
  4. 4. Introduction • The vast majority of colorectal injuries are due to penetrating trauma, usually firearms during war • Colonic injuries: – 2nd most common GSW after small bowel: transverse colon – 3rd most common abdominal stab wound after liver and small bowel: lt colon • Blunt trauma is uncommon – Most superficial – mechanisms: • Mesenteric tear and ischemic necrosis • Transient formation of closed loop and blowout perforation
  5. 5. Relevant Anatomy
  6. 6. Netter’s Atlas of anatomy.
  7. 7. Netter’s Atlas of anatomy.
  8. 8. Netter’s Atlas of anatomy.
  9. 9. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.
  10. 10. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.
  11. 11. Netter’s Atlas of anatomy.
  12. 12. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.
  13. 13. Collateral Communication Arteries • Arc of Buhler: celiac a to SMA • Arc of Riolan: meandering mesenteric artery: SMA to IMA • Marginal artery of Drummond: SMA to IMA
  14. 14.
  15. 15.
  16. 16. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.
  17. 17. Netter’s Atlas of anatomy. 0, 2, 4, 7, 11, 15 0 = anal verge 2 = dentate line 4 = anorectal ring 7 = lower to midrectum 11 = mid to upper rectum 15 = upper rectum to rectosigmoid junction
  18. 18. Netter’s Atlas of anatomy.
  19. 19. General Consideration • Antibiotics • Wound management
  20. 20. Antibiotics • Cover E.coli and B.fragilis • Enterococcus in early abdominal sepsis is controversial • Duration: 24-hr prophylaxis is at least as effective as prolonged prophylaxis for 3 – 5 days
  21. 21. Wound Management • Delayed primary closure for 3 -5 days postoperatively when fecal spillage
  23. 23. Diagnosis • Almost always made intraoperatively – Paracolic hematoma • Should be explored in penetrating trauma • Serial examination and CT scan evaluation – Free air – Free fluid – Thickening colonic wall – Contrast leak • Delayed peritonitis in ischemic necrosis from torn mesentery
  24. 24. Management of Colonic Trauma
  25. 25. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.
  26. 26. Colon Injuries • Nondestructive – < 50% circumferential – No devascularization – Grade II • Destructive – > 50% circumferential – Devascularization – At least grade III
  27. 27. Nondestructive Colon Injuries • There is now enough class I evidence supporting primary repair in all nondestructive colon injuries irrespective of risk factors.
  28. 28. Destructive Colon Injuries • Require segmental colonic resection • Primary anastomosis or diversion?
  29. 29. Risk Factors for Abdominal Complications after Colon Injuries • Sepsis rate higher than 20% • Most of risk factors failed scientific scrutiny: – Left versus Right colon injuries – Associated abdominal injuries – Shock – Blood transfusion – Fecal contamination – Time from injury to operation – Retained missiles – Skin closure
  30. 30. Left versus Right • Perception: anatomical differences between 2 sides of the colon? • It led to primary repair in right colon and colostomy in left colon • But no study demonstrates healing differences • Colocolostomy is found to be more leakage than ileocolostomy • Conclusion: – No differences – Right hemicolectomy is procedure of choice for rt colon injuries – Good blood supply is cornerstone for colon healing
  31. 31. Associated Abdominal Injuries • Although multiple injuries, the method of colon management does not affect the incidence of abdominal sepsis • presence of pancreatic or urine leaks is associated with increased risk of anastomotic failure
  32. 32. Shock • Although shock is not a contraindication for primary anastomosis, duration and severity of hypotension might be important factors that need further investigation
  33. 33. Blood Transfusion • Multiple transfusion (≥4U in 24 hrs) is most important risk factor on abdominal sepsis but management of colon did not differ in complication rates in this group of patients • It might be factor for anastomotic failure
  34. 34. Fecal Contamination • is important factor for abdominal sepsis but colon management does not influent septic complication rate
  35. 35. Time from Injury to Operation • Delayed operation increases risk of septic complications • Duration is not clear • Degree of contamination might be more important factor than duration
  36. 36. Retained Missiles • There is no evidence that retained bullets are associated with increased risk of local sepsis • Removal of the missiles does not reduce the risk of infection
  37. 37. Skin Closure • Associated with wound dehiscence
  38. 38. Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New york: Informa healthcare USA, 2007
  39. 39. Colon Leaks • 2.2 – 6.6% leaks • Resection and anastomosis is significantly higher leak than simple repairs • Colocolostomies are at higher risk to leak more than ileocolostomies • Multiple blood transfusions, severe contamination, and multiple associated injuries were not identified as independent risk factors for anastomotic leak. • If leaks: nonoperatively: adequate drainage and low-residual diet
  40. 40. Technical Tips • Control bleeding • Adequate mobilization of injured segment and careful inspection of retroperitoneal wall • Paracolic hematoma due to penetrating trauma should be explored to rule out perforation • In blunt trauma,no need for routine exploration of paracolic hematomas, unless there is a strong suspicion for an underlying perforation • Gently squeeze for occult injuries
  41. 41. Technical Tips • Ureters should always be identified in case of Rt or Lt colon injuries • Beware of splenic flexure – Weak point – Don’t pull it too hard to cause splenic capsular tear • Adequate debridement of all penetrating wounds • Anastomosis under tension-free and good blood supply • One-layer anastomosis is as safe as a two-layer anastomosis
  43. 43. Diagnosis • Peritonitis  lack in extraperitoneal rectal injuries • DRE • Rigid proctosigmoidoscopy • CT scan with or without rectal contrast
  44. 44. Management • Intraperitoneal rectal injuries – as colon injuries  primary repair • Extraperitoneal rectal injuries: 4Ds – Debridement – Presacral drainage – Distal rectal washout – Diversion: ostomy
  45. 45. Diversion • The Hartmann’s procedure should be reserved for patients with extensive destruction of the rectum • Routine colostomy has been challenged • Lesion at too low to repair from transabdominal approach and too high to suture transanally can be done by diverting colostomy without suturing of the perforation
  46. 46. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013.
  47. 47. Presacral Drainage • Routine use of presacral drains cannot be supported
  48. 48. Surgery for Victims of War (ICRC, 1998, 225 p.)
  49. 49. Distal Rectal Washout • No role
  50. 50. Technical Tips • Lithotomy • Look for bladder and iliac vessel injuries and repair separately by using omentum • In complex anorectal injuries with pelvic fracture: hemostasis with sigmoid colostomy • Massive rectal bleeding can be controlled by embolization, if not, pack • Rarely, APR may be only option to control bleeding or sphincter cannot be repaired
  51. 51. Iatrogenic Colorectal Injuries
  52. 52. Gynecologic Procedures • Dilatation and curettage can lead to perforation • Both total abdominal and vaginal hysterectomy can lead to perforation and fistulization • Intrauterine devices erode peritoneal cavity and subsequently to colon
  53. 53. Anorectal Procedures • Simple procedures like surgery for hemorrhoids, fissure, fistula can cause stenosis or incontinence
  54. 54. Urologic Procedures • Percutaneous nephrostomy: colon perforation • Perineal prostatectomy, suprapubic prostatectomy, or transurethral resection of the prostate can be associated with injury of the adjacent rectum
  55. 55. Neurosurgical and Orthopedic Procedures • During inserting VP shunt • During internal fixation of hip fracture when the nail being too deep and injures the rectum
  56. 56. Endoscopically Induced Trauma
  57. 57. Rigid Proctosigmoidoscopy • Most: near peritoneal reflection of rectosigmoid • Factors associated with perforation included – blind introduction beyond the anal margin, – reinsertion of the obturator to overcome spasm – injudicious use of long cotton-tipped applicators – the attempted forceful dilatation of rectal strictures with the proctosigmoidoscope
  58. 58. • Common sense to decrease perforation rate: – perform the examinations gently – obtain biopsies judiciously – insufflate minimally Rigid Proctosigmoidoscopy
  59. 59. Fiberoptic Sigmoidoscopy and Colonoscopy • Major complications of colonoscope is hemorrhage and perforation • During diagnostic: abrasion of laceration (unusual) – During slide-by technique especially when tip is entrapped: rectosigmoid, midsigmoid, and the angle created by the junction of the descending colon and the sigmoid colon – When tip is introduced to large diverticulum – Dilatation of the stenosis – Overstretching the fixed segment by looping scope
  60. 60. • Therapeutic: snare polypectomy (most common) – From hot biopsies or snare polypectomy with full- thickness burn and necrosis – Treating sessile polyp is even greater risk, to minimize: Taking <2.0-cm pieces of a sessile polyp and coagulating them in short two-second bursts, allowing cooling periods Fiberoptic Sigmoidoscopy and Colonoscopy
  61. 61. • Explosion – During electrocautery – During argon plasma coagulation – Mannitol bowel preparation – Thegases should be evacuated from the colon and rectum by suctioning the lumen before any kind of electrical or laser coagulation – If explodes, monitor signs and symptoms and obtain film abdomen for free air Fiberoptic Sigmoidoscopy and Colonoscopy
  62. 62. • Silent perforation – Air in retroperitoneum – Ileus is the most common symptom – It can be treated nonoperatively, primary repair, or primary anastomosis Fiberoptic Sigmoidoscopy and Colonoscopy
  63. 63. Rectal Thermometer • In newborn • During measuring temperature • 50% of perforation occur at <3cm from anal verge
  64. 64. Therapeutic Enema • Unison? • Installation of wrong liquid • Insertion of enema tip • Majority is anterior wall • Extraperitoneal perforation can cause abscess, fistula, or severe hemorrhage.
  65. 65. Barium Enema • Both intra and extraperitoneal perforation • By both direct penetration of enema tip and overinflation • Others include formation of barium granulomas within the rectal wall, necrotizing proctitis, and barium embolism • Most perforations are ruptures through ulcers, neoplasms, diverticula, hernias, inflammatory bowel disease, or other areas of disease and from biopsied
  66. 66. Barium Enema • Combination of barium and feces are fatal complication  severe inflammatory response • Management: – Antibiotics and resuscitation – Remove barium: resection and diversion may be necessary – Prevention: (i) keeping the ‘‘head of pressure’’ of the barium <1 m, (ii) not overinflating the balloon, (iii) keeping the balloon tip minimally inserted (iv) deferring the barium enema in patients who have recently undergone a biopsy or polypectomy of the colon or rectum
  67. 67. Obstetric Trauma • CPD with vaginal delivery can cause anorectal trauma including anal sphincter system – Episiotomy decreases incidence of third degree laceration involved anal sphincter • Rectovaginal fistula may be caused from pressure necrosis: forceps delivery, midline episiotomies
  68. 68. Irradiation-Induced Proctitis • Acute and chronic phase – Acute: edema, inflammation, erythema, and friability of the rectal mucosa – Chronic: granulation tissue, fibrosis, and telangiectasia • Indications for colostomy were – excessive bleeding – radiation necrosis of the rectum – fistulization to the vagina, bladder, or bowel – obstruction caused by stenosis from radiation
  69. 69. • Other treatment – Adequate hydration and antidiarrheals – Oral and enama sucralfate – Sulfasalazine – Argon plasma coagulation – Topical formalin Irradiation-Induced Proctitis
  70. 70. Ingested Foreign Body • Rare • Perforation, abscess formation, obstruction, hemorrhage
  71. 71. Foreign Bodies and Sexual Trauma • Any object in anorectum used to be for sexual stimulation: vibrators, plastic phalluses, cucumbers, baby powder cans, balls, bottles, flashlights, screwdrivers, thermometers. • Embarrassment and pain • Plain radiograph is essential to identify size and number, but radiolucent objects may not be visualized
  72. 72. Sexual and Child Abuse • Boys more than girls
  73. 73. Unusual Perforation • Impact feces (stercoral perforation) • Spontaneous perforation with pre-existing disease: neoplasm, diverticular disease, IBD
  74. 74. Repair of Anal Sphincter Injury • Primary repair is acceptable unless extensive injury that colostomy is required • Delay repair is preferable if critical • Polyglycolic (dexon) acid or polyglactin (vicryl) sutures should be used instead of permanent sutures to prevent chronic suture sinuses
  75. 75. Removal of Foreign Bodies • Appropriate relaxation and sedation to relax anal sphincter • Goal is to remove object per anus with intact sphincter, but sometimes performing an internal anal sphincterotomy or opening external sphincter muscles to allow extraction of large foreign bodies may be necessary and must be repaired later • Lubrication and lithotomy position are helpful
  76. 76. Removal of Foreign Bodies • Obstetric forceps, foley catheter, padded pliers, plaster of paris with a string or clamp inside, SB tube, and proctoscope can be used to remove objects • After removal, proctosigmoidoscope should be performed to check bleeding or perforation
  77. 77. Padded pliers
  78. 78. Plaster of paris
  79. 79. Removal of Foreign Bodies • Regional anesthesia may be performed if local removal fails • Explore laparotomy is the last choice – For upper rectum and rectosigmoid – Surgeon will try milking and removing through anus – If fails, colotomy will be required – If perforation, it can be large contusion ,contamination, and too deep to exteriorize so resection or even diversion are recommended
  80. 80. References Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 3rd ed. New york: Informa healthcare USA, 2007. Mattox KL et al. Trauma. 7th ed. McGraw-Hill Medical, 2013. Netter’s Atlas of anatomy. Penetrating Abdominal Trauma, Prophylactic Antibiotic Use in. J Trauma. 73(5):S321-S325, November 2012