The impact of mechanism on the management and outcome of penetrating colonic trauma

Introduction In light of continuing controversy surrounding the management of penetrating colonic injuries, we set out to compare the outcome of penetrating colonic trauma according to whether the mechanism of injury was a stab wound or a gunshot wound. Methods Our trauma registry was interrogated for the 5-year period from January 2012 to December 2016. All patients over the age of 18 years with penetrating trauma (stab or gunshot) and with intraoperatively proven colonic injury were reviewed. Details of the colonic and concurrent abdominal injuries were recorded, together with the operative management strategy. In-hospital morbidities were divided into colon-related and non-colon related morbidities. The length of hospital stay and mortality were recorded. Direct comparison was made between patients with stab wounds and gunshot wounds to the colon. Results During the 5-year study period, 257 patients sustained a colonic injury secondary to penetrating trauma; 95% (244/257) were male and the mean age was 30 years. A total of 113 (44%) sustained a gunshot wound and the remaining 56% (144/257) sustained a stab wound. Some 88% (226/257) of all patients sustained a single colonic injury, while 12% (31/257) sustained more than one colonic injury. A total of 294 colonic injuries were found at laparotomy. Multiple colonic injuries were less commonly encountered in stab wounds (6%, 9/144 vs. 19%, 22/113, P < 0.001). Primary repair was more commonly performed for stab wounds compared with gunshot wounds (118/144 vs. 59/113, P < 0.001). Patients with gunshot wounds were more likely to need admission to intensive care, more likely to experience anastomotic failure, and had higher mortality. Conclusions It would appear that colonic stab wounds and colonic gunshot wounds are different in terms of severity of the injury and in terms of outcome. While primary repair is almost always applicable to the management of colonic stab wounds, the same cannot be said for colonic gunshot wounds. The management of colonic gunshot wounds should be examined separately from that of stab wounds.

EXTERIORISATION OF INTESTINAL STOMA AS A RESULT OF INTESTINAL CANCER DISEASE

Among diseases of the 21st century, intestinal tumours are frequently mentioned. Colon cancer is a serious and growing health problem not only in Poland, but also in the world. As the most common result of fighting for one's own health and often even life is the consent to the intestinal stoma. Intestinal stoma is made by exteriorisation of the preserved intestinal end by abdominal incision outside the abdominal cavity, the incision of the mucous membrane and suturing it to the skin. The three main groups of indications for exteriorisation of stoma are: (a) inflammatory disease of intestines, (b) colitis, rectal and colonic trauma, (c) colorectal cancer. Properly exteriorised stoma on the large intestine should be located on the smooth surface of the skin away from the navel, hip bone, skin folds, scars and also at least 4 cm away from the main surgical cut. Patients should see the fistula well because it is the basis of proper self-care. Dermatological complications are the most common complication of stoma and occur in nearly 80% of patients. It comes to them as a result of irritation of the skin by the intestinal contents that come out of it and causes inflammation. This is usually the result of incorrect stoma care or improper use of stoma equipment. Despite medical advances towards minimizing invasive procedures and limiting the severity of the disease, the problem of the great stress experienced by every person undergoing surgical treatment is still valid and relevant to the outcome of the whole therapy. Choosing intestinal stoma is one of the most stressful treatments, so in this case, not only medical care but also psychological over the patient seems to be a priority.

The management of colonic trauma in the damage control era

INTRODUCTIONThe purpose of this study was to audit our current management of colonic trauma, and to review our experience of colonic trauma in patients who underwent initial damage control (DC) surgery.METHODSAll patients treated for colonic trauma between January 2012 and December 2014 by the Pietermaritzburg Metropolitan Trauma Service were included in the study. Data reviewed included mechanism of injury, method of management (primary repair [PR], primary diversion [PD] or DC) and outcome (complications and mortality rate).ResultsA total of 128 patients sustained a colonic injury during the study period. Ninety-seven per cent of the injuries were due to penetrating trauma. Of these cases, 56% comprised stab wounds (SWs) and 44% were gunshot wounds (GSWs). Management was by PR in 99, PD in 20 and DC surgery in 9 cases. Among the 69 SW victims, 57 underwent PR, 9 had PD and 3 required a DC procedure. Of the 55 GSW cases, 40 were managed with PR, 9 with PD and 6 with DC surgery. In the PR group, there were 16 colonic complications (5 cases of breakdown and 11 of wound sepsis). Overall, nine patients (7%) died.CONCLUSIONSPR of colonic trauma is safe and should be used for the majority of such injuries. Persistent acidosis, however, should be considered a contraindication. In unstable patients with complex injuries, the optimal approach is to perform DC surgery. In this situation, formal diversion is contraindicated, and the injury should be controlled and dropped back into the abdomen at the primary operation. At the repeat operation, if the physiological insult has been reversed, then formal repair of the colonic injury is acceptable.

Changing patterns in the management of Colonic Trauma

Recent prospective studies have recommended primary repair for all colonic trauma. We evaluate the changing patterns given these recommendations and assess our results of primary repair. This prospective study was conducted on 63 patients with colonic trauma received over a year from July 2000 to June 2001. Morbidity was defined as failure of a primary repair, abscess, fistula, wound dehiscence, sepsis, and organ failure. Primary repairs were performed in 28 patients and colostomy was done in 35 patients. Prolonged mean hospital stay and more incidences of postoperative complications occurred in colostomy group. It was therefore, concluded that primary repair of colon should be adapted as a standard procedure. Colostomy should be reserved for patients with a prolonged delay to surgery, severe blood loss, and gross faecal contamination or associated with multiple organ injuries.