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Leziuni traumatice ale colonului - factori ce influeneaz
decizia chirurgical
Introducere: Acest studiu evalueaz tendinele moderne de
tratament chirurgical a leziunilor traumatice de colon ntr-un
centru de traum de nivel I, prin prisma creterii ncrederii n
procedeele de reparare primar.
Material i metod: Studiul nostru retrospectiv evalueaz
rezultatele obinute n cazul a 116 pacieni cu leziuni
traumatice colonice operai n Spitalul Clinic de Urgen
Bucureti, prin prisma unora din cei mai utilizai parametri care
pot influena decizia chirurgului catre unul din procedeele de
reparare primara sau colostomie.
Rezultate: Leziunile colonice au survenit mai frecvent ca
urmare a contuziilor abdominale (65%). Leziuni asociate
intraabdominale au survenit n 85 de cazuri. Repararea primar
a fost utilizat preponderent n 95 de cazuri (82%), iar colostomia n numai 21 de cazuri (18%). Parametrii care au
influenat decizia chirurgical au fost: prezena ocului, gradul
contaminrii peritoneale, gradul leziunii colonice (GLC) i
valoarea Indicelui Traumatic Abdominal (ITA). Procedeele de
reparare primar au avut o morbiditate de 7% comparativ cu
14% n cazul colostomiei, ITA avnd rol predictiv.
Mortalitatea general a fost de 19%.
Concluzii: Repararea primar, prin sutur primar sau rezecie
i anastomoz, este o metod sigur de rezolvare a majoritii
Corresponding author:
Abstract
Background: This study sought to evaluate current trends in
surgical management of colon injuries in a level I urban
trauma centre, in the light of our increasing confidence in
primary repair.
Methods: Our retrospective study evaluates the results of 116
patients with colon injuries operated at Bucharest Clinical
Emergency Hospital, in the light of some of the most
commonly cited factors which could influence the surgeon
decision-making process towards primary repair or colostomy.
Results: Blunt injuries were more common than penetrating
injuries (65% vs. 31%). Significant other injuries occurred in
85 (73%) patients. Primary repair was performed in 95
patients (82%). Fecal diversion was used in 21 patients
(18%). Multiple factors influence the decision-making
process: shock, fecal contamination, associated injuries and
higher scores on the Abdominal Trauma Index (ATI) and
Colon Injury Scale (CIS). Colon related intra-abdominal
complications occurred in 7% of patients in whom the
colon injury was closed primarily and in 14% of patients in
whom a stoma was created, ATI having a predictive role in
their occurrence. The overall mortality rate was 19%.
Conclusions: Primary repair of colon injuries, either by primary
suture or resection and anastomosis, is a safe method in the
management of the majority of colonic injuries. Colostomy is
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Introduction
The recommended surgical treatment for colon trauma has
undergone major changes in the last decades. There are
various choices for colon injuries surgical repair but they can
be grouped in two categories: primary repair (suture repair or
resection and anastomosis) and diversion with colostomy
formation at the time of injury. Surgeons decision for one
surgical procedure or another is influenced by a vast array of
factors, yet there still are disagreements as to which of these
factors is most significant. The dilemma over choosing the best
medical procedure based on a series of parameters has been
largely assessed in the specialized literature by means of
retrospective and prospective analysis, meta-analysis and by
literature review. Despite a relatively general consensus which
stands for using primary repair procedures in colon injuries in
civilan practice, there are yet authors warning against the
dogmatic use of the latter mentioned ones (1). The present
paper evaluates the results obtained in the case of 116 patients
with traumatic colon injuries, operated in the Bucharest
Clinical Emergency Hospital, and it is based on the most
frequently used parameters that could influence the surgeons
decision towards one of the primary repair or colostomy
procedures.
Results
Of 116 patients undergoing operation for colonic injury, 95
underwent primary repair, while for the rest of the 21 cases,
colostomy has been chosen.
Primary repair methods have been mostly used (82%),
colonic injuries of 84 patients (88.5%) being primary sutured,
whereas for 11 cases (11.5%) colon resection followed by
anastomosis was chosen.
Methods of diversion of the faeces, generically registered
as colostomy have been performed in only 18% of the cases
- 21 patients. Most of the cases were represented by
Hartmann colectomy (14 cases), followed by exteriorization
of the colonic lesion as ostomy (4 cases) and primary suture
with diverting Maydl colostomy (3 cases). Exteriorized repair
was not used in our study.
The surgical attitude in Bucharest Clinical Emergency
Hospital has been oriented towards primary repair methods
for colon injuries. The method of surgical management was
at the liberty of the operating surgeon.
In the selected group, the male/female ratio was 5/1
while the mean patient age was 41 (with a range of 8 to
88 years), scarcely lower in cases of primary repair- 39
years old compared to the cases where colostomy has
been used-46 years old. These differences are not statistically significant and have not influenced the surgical
decision towards one method or another.
The mechanism of injury has influenced the type of
surgical intervention (Fig. 1).
In blunt abdominal trauma with colon injuries (75 cases),
primary repair has been used in most of the cases (85.3%,
p=0.0032): primary suture in 55 cases and resection with
anastomosis in 9 cases. Colostomy has been used in 14.7%:
exteriorization of the lesion in 3 cases and Hartmann
colectomy in 8 cases.
For penetrating abdominal wounds (36 cases) the primary
repair/ colostomy ratio was 83.3%/16.7% and it is very similar
to the one in blunt abdominal trauma; however, by looking
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Table 1.
Intervention type
Primary repair
(n = 95)
Colostomy
(n = 21)
Shock +
37 cases (39%)
ATIm = 20
11 cases (52%)
ATIm = 26
Politrauma case
56 cases (59%)
10 cases (48%)
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patients - 26%), wound infection (8 patients - 30%) and extraabdominal complications (6 patients - 22%). Among the 89
patients with ATI < 25, 14 suffered complications (15.7%):
colon-related intra-abdominal complications (3 patients
3.5%), wound infection (8 patients - 9%) and extra-abdominal
complications (6 patients 6.7%).
By interpreting the results of our study one can conclude
that ATI may represent a predictive feature for morbidity, as
patients with ATI values >25 have a three times higher risk
for complication occurrence, compared to patients with an
ATI <25. Moreover, considering complications for cases
with CIS grade IV or V and ATI >30, the colon resection
must be followed by colostomy, not by anastomosis.
Overall mortality was 19.6% close to literature data, which
varies between 2% and 16% (9, 10). Mortality rate was double
for colostomy (31.2%) compared to primary repair (17.4%) but
the conclusion must be carefully evaluated considering the fact
that diversion was applied to politraumatized patients with
colon injuries grade IV or V, with severe fecal contamination,
factors with negative consequences. Half of the politraumatized
patients with hospital in-take shock died. The number of
deaths was extremely high for grade IV and V colon injuries,
irrespective of the surgical solution (primary repair - 75%,
colostomy - 83%), as a result of exsanguination or severe
neurologic trauma, all within the first 24 hours. The analysis of
deaths based on ATI values shows a 2.5 times higher
mortality in cases with ATI > 25 (55.5%) compared to ATI <
25 (21.3%).
Discussion
The high number of studies analysing surgical treatment
options in colon trauma shows present controversies on this
issue. It was in 1998 when Curran and Borzotta (10) analysed
27 retrospective studies with a total number of 2964 cases of
traumatic colon injury; in the same year, Eshragi (11) quotes
seven prospective studies which analyse primary repair
procedures compared to colostomy. Even though there is no
absolute consensus, most of the research papers which
approach the topic conclude that primary repair should be
used in traumatic colon injuries.
It was during World War II when colostomy was chosen
as the standard method for solving colon wounds (12). Thus,
the only options were exteriorization of the injured
segment as a stoma, resection and colostomy or repair of the
injury with proximal colostomy. Primary repair gained
popularity as surgeons began to understand the differences
between military and civilian injuries. (13).
The policy of mandatory colostomy applied to the end of
the 70s, was challenged in 1979 when Stone H.H. and Fabian
T.C. (14) published the first prospective randomized trial
involving 268 patients. Mandatory colostomy was performed
in patients who had: preoperative shock, hemorrhage >1000
ml blood, more than two intra-abdominal organs injured,
severe fecal contamination, delay of more than 8 hours to
operation, colonic injury requiring resection, massive loss of
soft tissue. The remaining patients were randomized to either
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658
Conclusions
Surgery of trauma has permanently evolved during centuries ,
reorganisig itself in our days in order to cope with the modern
injuries. (22) The goal of this study was to determine the
preferences regarding the management of colon injuries of the
surgeons from a level I trauma center Bucharest Clinical
Emergency Hospital. Factors that can influence intraoperative
decision towards primary repair or diversion were evaluated as
well as the influence of the surgical procedure on the patients
prognostic. The results of this study suggested that the surgical
choice in colon injuries should be:
Colostomy, when:
- the mechanism of injury is a gunshot wound, endolumenal or iatrogenic;
- shock at hospital admission;
- severe fecal contamination;
- CIS grade IV or V with ATI > 30.
Primary repair, when:
- the mechanism of injury is a blunt or stabbed abdominal wound;
- the patient is hemodynamically stable, with no shock
at admission;
- mild or moderate fecal contamination;
- CIS grade I, II or III with ATI < 25;
- CIS grade IV, V with ATI < 30 (Resection and
anastomosis).
Thus, the information provided by the awareness of injury
mechanism, shock presence, peritoneal contamination level,
colon injury severity (CIS) in association with the complexity
of abdominal trauma (ATI), can represent objective criteria for
choosing the surgical solution.
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