Colonic Trauma

Steven Brown

Powerpoint File

Colonic trauma may be penetrating or blunt; blast injury is essentially a special form of blunt injury. Low energy transfer penetrating wounds cause damage only along the missile track, whereas high energy transfer wounds cause distant damage. Blunt and blast trauma cause shear injuries with mural haematomas, which may perforate up to 2 weeks after injury (1).

Although the colon is the second most commonly injured organ in penetrating trauma fortunately such injury (particularly from gunshot wounds) is still unusual in UK practice. Blunt trauma (e.g. from RTI) is more frequently seen but rarely injures the colon. There is a plethora of experience of all types of abdominal trauma from some countries (e.g. USA and South Africa). Ideas from large trauma centres in these countries have recently questioned some surgical dogma in the diagnosis and management of these patients.

Diagnosis of colonic injury may be difficult and a high degree of suspicion is essential. Often injuries are identified at laparotomy performed for other injuries. In conservatively managed abdominal trauma, repeated examination, preferably by the same surgeon, is mandatory as subtle signs of peritonism may develop over several hours. If there is clinical suspicion of injury but no overt signs (or the patient is obtunded/unconscious) diagnostic investigations include CT, diagnostic peritoneal lavage, ultrasound scanning (FAST) or laparotomy (2-3). CT is particularly useful for back and flank stab injuries. Accuracy is high and may be increased with triple contrast. Laparoscopy may also have a role and may be carried out under local anaesthetic (4).

Treatment of stable patients with insignificant penetrating stab injuries still remains controversial. Management has evolved from prompt surgical exploration, towards more selective approaches (5). In contrast to stab wounds where intraperitoneal injury may not be present in 40%, gunshot wounds almost invariably cause injury and prompt surgery is advocated by most (but not all) centres.

A major change to surgical management of colonic injury is the concept that all civilian colon injuries can be repaired primarily rather than defunctioned (6-8). This avoids the extra morbidity and cost of a stoma. Combining all RCTs suggests a leak rate of < 1%. Small penetrating wounds can be closed with simple suture. Significant bowel injury requires resection and primary anastomosis. Of course factors may combine to dictate colostomy is safer (e.g. delayed diagnosis, severe contamination or persistent hypovolaemia). Occasionally there is severe compromise with haemorrhagic shock, hypothermia, coagulopathy and acidosis. Here damage control surgery is indicated. Haemostasis is secured. Simple suture may be carried out but large areas of damaged colon should be resected and ends stapled off pending relook laparotomy when physiological parameters are improved. Abdominal compartment syndrome may prompt laparostomy with stomas placed very laterally to avoid nursing problems.

It should be emphasised that many recent practice guidelines are based on evidence from high volume trauma centres in South Africa and the USA and care must be taken when applying them in UK, as the infrastructure within which they are framed varies significantly.

References

1. Garner J. Blunt and penetrating trauma to the abdomen. Surgery 2005;23:223-228.

2. Malhotra AK, Fabian TC, Katsis SB, Gavant ML, Croce MA. Blunt bowel and mesenteric injuries: the role of screening computed tomography. J Trauma. 2000;48(6):991-8

3. Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Scalea TM. Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy. AJR Am J Roentgenol. 2001 ;177(6):1247-56.

4. Bautz P. The trauma patient: critical decision making. When to explore the abdomen. A South African perspective. Trauma 2000;2:135-142.

5. Taviloglu K. When to operate on abdominal stab wounds. Scandinavian J Surg. 2002;91:58-61.

6. Cayten CG, Fabian TC, Garcia VF. Penetrating Intraperitoneal Colon Injuries - Eastern Association for the Surgery of Trauma (EAST) Trauma Practice Guidelines. 1998 http://www.east.org/tpg/chap4.pdf

7. Demetriades D, Murray JA, Chan L, et al; Committee on Multicenter Clinical Trials. American Association for the Surgery of Trauma. Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma. 2001;50:765-75

8. Conrad JK, F. K., Foreman ML, Gogel BM, Fisher TL, Livingston SA. Changing management trends in penetrating colon trauma. Dis Colon Rectum 2000;43:466-471.

Website

www.trauma.org

Acknowledgement

I am grateful to Major Jeff Garner RA (SpR Sheffield Teaching Hospitals) for his help and advice.