Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?
Abstract
Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.
Authors
Downloads
Keywords
- Penetrating Combined Small and Large Bowel Injuries
- Damage Control Surgery
- Definitive Laparotomy
- Primary Anastomosis
- Deferred Anastomosis
- Ostomy.
- Injury Severity Score
- Laparotomy
- Anastomotic Leak
- Surgical Anastomosis
- Fistula
References
Cardi M, Ibrahim K, Alizai SW, Mohammad H, Garatti M, Rainone A, et al. Injury patterns and causes of death in 953 patients with penetrating abdominal war wounds in a civilian independent non-governmental organization hospital in Lashkargah, Afghanistan. World J Emerg Surg 2019;14:51. https://doi.org/10.1186/s13017-019-0272-z.
Parra-Romero G, Contreras-Cantero G, Orozco-Guibaldo D, Domínguez-Estrada A, del Campo J de JMM, Bravo-Cuéllar L. Abdominal trauma: Experience of 4961 cases in western Mexico. Cir y Cir (English Ed 2019;87:183–9. https://doi.org/10.24875/CIRU.18000509.
Bordoni PHC, dos Santos DMM, Teixeira JS, Bordoni LS. Óbitos por trauma abdominal: Análise de 1888 autopsias médico-legais. Rev Col Bras Cir 2017;44:582–95. https://doi.org/10.1590/0100-69912017006006.
González A, Vernza A, Velásquez L, Guerrero R, Fajardo D, Gómez E, et al. Laparotomía Rutinaria o Selectiva en Trauma Abdominal Abierto y Cerrado, Experiencia en el Hospital Universitario del Valle 1972 - 1974. Acta Médica Val 1976;7:97–100.
Oosthuizen G V., Kong VY, Estherhuizen T, Bruce JL, Laing GL, Odendaal JJ, et al. The impact of mechanism on the management and outcome of penetrating colonic trauma. Ann R Coll Surg Engl 2018;100:152–6. https://doi.org/10.1308/rcsann.2017.0147.
Nelson RL, Singer M. Primary repair for penetrating colon injuries. Cochrane Database Syst Rev 2009. https://doi.org/10.1002/14651858.CD002247.
Cullinane DC, Jawa RS, Como JJ, Moore AE, Morris DS, Cheriyan J, et al. management of penetrating intraperitoneal colon injuries: A meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2019;86:505–15. https://doi.org/10.1097/TA.0000000000002146.
Ahern DP, Kelly ME, Courtney D, Rausa E, Winter DC. The management of penetrating rectal and anal trauma: A systematic review. Injury 2017;48:1133–8. https://doi.org/10.1016/j.injury.2017.03.002.
Demetriades D, Murray JA, Chan L, Ordoñez C, Bowley D, Nagy KK, et al. Penetrating colon injuries requiring resection: Diversion or primary anastomosis? An AAST prospective multicenter study. J. Trauma - Inj. Infect. Crit. Care, vol. 50, Lippincott Williams and Wilkins; 2001, p. 765–75. https://doi.org/10.1097/00005373-200105000-00001.
Biffl WL, Kaups KL, Cothren CC, Brasel KJ, Dicker RA, Bullard MK, et al. management of patients with anterior abdominal stab wounds: A western trauma association multicenter trial. J Trauma - Inj Infect Crit Care 2009;66:1294–301. https://doi.org/10.1097/TA.0b013e31819dc688.
Velmahos GC, Demetriades D, Toutouzas KG, Sarkisyan G, Chan LS, Ishak R, et al. Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: Should routine laparotomy still be the standard of care? Ann Surg 2001;234:395–403. https://doi.org/10.1097/00000658-200109000-00013.
Ashley, Cance, Chen, Jurkovich, Napolitano, Riall, et al. ACS Surgery. 2012.
Gardner J. Blunt and penetrating trauma to the abdomen. Emerg Surg 2005;23:223–8. https://doi.org/10.1385/1-59259-886-2:095.
Moore EE, Feliciano D V, Mattox KL. Trauma. 2017.
Moore E, Cogbill T, Malangoni M, Jurkovich G, Champion H, Gennarelli T, et al. Organ injury scaling, II: pancreas, duodenum, small bowel, colon and rectum. J Trauma 1990;30:1427–9.
Velmahos GC, Degiannis E, Doll D. Penetrating Trauma. 2012. https://doi.org/10.1213/ane.0b013e3182572adb.
Advanced trauma life support (ATLS): 10th Edition. 2018. https://doi.org/10.1111/j.1365-2044.1993.tb07026.x.
Ordoñez CA, Parra MW, Serna JJ, Rodríguez H F, García AF, Salcedo A, et al. Damage Control Resuscitation : REBOA as the New Fourth pillar. Colomb Med 2020. https://doi.org/10.25100/cm.v51i4.4353.
Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJF, Scalea TM. Penetrating torso trauma: Triple-contrast helical CT in peritoneal violation and organ injury - A prospective study in 200 patients. Radiology 2004;231:775–84. https://doi.org/10.1148/radiol.2313030126.
Ordoñez CA, Parra MW, Holguín A, García C, Guzmán-Rodríguez M, Padilla N, et al. Whole-body computed tomography is safe, effective and efficient in the severely injured hemodynamically unstable trauma patient. Colomb Med 2020;51. https://doi.org/10.25100/cm.v51i4.4362.
Ordoñez C, Pino L, Badiel M, Sanchez A, Loaiza J, Ramirez O, et al. The 1-2-3 approach to abdominal packing. World J Surg 2012;36:2761–6. https://doi.org/10.1007/s00268-012-1745-3.
Du Bose JJ, Scalea TM, Brenner M, Skiada D, Inaba K, Cannon J, et al. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). vol. 81. 2016. https://doi.org/10.1097/TA.0000000000001079.
Reva VA, Matsumura Y, Hörer T, Sveklov DA, Denisov A V., Telickiy SY, et al. Resuscitative endovascular balloon occlusion of the aorta: what is the optimum occlusion time in an ovine model of hemorrhagic shock? Eur J Trauma Emerg Surg 2018;44:511–8. https://doi.org/10.1007/s00068-016-0732-z.
Ordoñez CA, Rodríguez F, Orlas CP, Parra MW, Caicedo Y, Guzmán M, et al. The critical threshold value of systolic blood pressure for aortic occlusion in trauma patients in profound hemorrhagic shock. J Trauma Acute Care Surg 2020;89:1107–13. https://doi.org/10.1097/TA.0000000000002935.
Ditzel RM, Anderson JL, Eisenhart WJ, Rankin CJ, DeFeo DR, Oak S, et al. A review of transfusion- And trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg 2020;88:434–9. https://doi.org/10.1097/TA.0000000000002570.
Skube ME, Mallery Q, Lusczek E, Elterman J, Spott MA, Beilman GJ. Characteristics of Combat-Associated Small Bowel Injuries. Mil Med 2018;183:e454–9. https://doi.org/10.1093/milmed/usy009.
Roberts DJ, Stelfox HT, Moore LJ, Cotton BA, Holcomb JB, Harvin JA. Accuracy of Published Indications for Predicting Use of Damage Control During Laparotomy for Trauma. J Surg Res 2020;248:45–55. https://doi.org/10.1016/j.jss.2019.11.010.
Weinberg JA, Croce MA. Penetrating Injuries to the Stomach, Duodenum, and Small Bowel. Curr Trauma Reports 2015;1:107–12. https://doi.org/10.1007/s40719-015-0010-2.
Weale R, Kong V, Buitendag J, Ras A, Blodgett J, Laing G, et al. Damage control or definitive repair? A retrospective review of abdominal trauma at a major trauma center in South Africa. Trauma Surg Acute Care Open 2019;4:1–5. https://doi.org/10.1136/tsaco-2018-000235.
George MJ, Adams SD, McNutt MK, Love JD, Albarado R, Moore LJ, et al. The effect of damage control laparotomy on major abdominal complications: A matched analysis. Am J Surg 2018;216:56–9. https://doi.org/10.1016/j.amjsurg.2017.10.044.
Urbanavičius L. How to assess intestinal viability during surgery: A review of techniques. World J Gastrointest Surg 2011;3:59. https://doi.org/10.4240/wjgs.v3.i5.59.
Siddharth BR, Keerthi MSS, Naidu SB, Venkanna M. Penetrating Injuries to the Abdomen: a Single Institutional Experience with Review of Literature. Indian J Surg 2017;79:196–200. https://doi.org/10.1007/s12262-016-1459-0.
Ordoñez CA, Pino LF, Badiel M, Sánchez AI, Loaiza J, Ballestas L, et al. Safety of performing a delayed anastomosis during damage control laparotomy in patients with destructive colon injuries. J. Trauma - Inj. Infect. Crit. Care, vol. 71, 2011, p. 1512–8. https://doi.org/10.1097/TA.0b013e31823d0691.
Cleary RK, Pomerantz RA, Lampman RM. Colon and rectal injuries. Dis Colon Rectum 2006;49:1203–22. https://doi.org/10.1007/s10350-006-0620-y.
Demetriades D, Murray JA, Chan LS, Ordoñez C, Bowley D, Nagy KK, et al. Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: a multicenter study. J Trauma 2002;52:117–21. https://doi.org/10.1097/00005373-200201000-00020.
Naumann DN, Bhangu A, Kelly M, Bowley DM. Stapled versus handsewn intestinal anastomosis in emergency laparotomy: A systemic review and meta-analysis. Surg (United States) 2015;157:609–18. https://doi.org/10.1016/j.surg.2014.09.030.
Burlew CC, Moore EE, Cuschieri J, Jurkovich GJ, Codner P, Crowell K, et al. Sew it up! A western trauma association multi-institutional study of enteric injury management in the postinjury open abdomen. J Trauma - Inj Infect Crit Care 2011;70:273–7. https://doi.org/10.1097/TA.0b013e3182050eb7.
Loftus TJ, Efron PA, Bala TM, Rosenthal MD, Croft CA, Walters MS, et al. The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy. J Trauma Acute Care Surg 2019;86:670–8. https://doi.org/10.1097/TA.0000000000002170.
![](https://colombiamedica.univalle.edu.co/colombiamedica311/public/journals/1/article_4425_cover_en_US.jpg)
Copyright (c) 2021 Universidad del Valle
![Creative Commons License](http://i.creativecommons.org/l/by-nc/4.0/88x31.png)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The copy rights of the articles published in Colombia Médica belong to the Universidad del Valle. The contents of the articles that appear in the Journal are exclusively the responsibility of the authors and do not necessarily reflect the opinions of the Editorial Committee of the Journal. It is allowed to reproduce the material published in Colombia Médica without prior authorization for non-commercial use