外伤性结肠破裂27例治疗体会

目的探讨创伤性结肠损伤的处理方法以及一期手术的安全性和有效性。方法回顾性分析2001年5月～2007年5月收治的27例结肠损伤病例的临床资料。结果本组病例合并多发伤患者21例。全部病例均经急诊手术,23例(85.2%)行一期手术,其中17例行单纯修补术,切口感染2例;6例行破裂结肠部分切除吻合术,吻合口漏1例,切口感染1例。4例(14.8%)行单纯近端结肠造口 局部引流术,切口感染1例。除1例因胸腹部严重复合伤死于MODS外,其余患者均痊愈出院。结论创伤性结肠损伤一期手术对绝大多数结肠损伤是安全可靠的,值得临床应用。     

6 Year Prospective Clinical Trial of Primary Repair Versus Diversion Colostomy in Colonic Injury Cases

Management pathway of colonic injury has been evolving over last three decades. There has been general agreement that surgical methods dealing with colonic injury did not affect the outcome but there are certain independent risk factors for complications. These risk factors are still not clear and studies are going on to specify these risk factors. The primary objective of this study was to demonstrate that primary closure of colonic injury without colostomy in selective patient is safe. This was a prospective study of 6 year duration. All the colonic injuries operated and divided into two groups: primary repair and colostomy. The criteria for exclusion of primary repair taken were; injury time >8 hour, patient need >4 unit of blood transfusion till surgery, devascularization injury of colon, any pre existing disease of bowel, any severe co morbid disease like uncontrolled diabetes mellitus, tuberculosis, malignancy etc. Both groups are analyzed by assessing complications with special emphasis on leak rate. Patients died within 72 hours of admission were excluded from study. Total 55 colonic injury cases operated and primary repair was done in 35 cases and colostomy in 20 cases. There was 1 mortality in colostomy group and no major morbidity in both groups. The complications in primary repair group were; 1 leak (treated conservatively), 5 wound infections 1 incisional hernia and 1 intra abdominal abscess. In colostomy group 8 cases of wound infections, 2 incisional hernias and 2 intra abdominal abscesses occurred. Primary repair of colon injuries can be safely done in selected patient.     

Primary repair of the colon: when is it a safe alternative?

Management of civilian colon injuries has clearly departed from the military directive advocating mandatory colostomy. The treatment of 228 colon injuries at the Denver General Hospital was reviewed to elucidate risk factors for colon-related complications and quantify the morbidity of available surgical treatment options. In our population, 68% of patients sustained gunshot wounds with a high percentage of severe colon injuries and associated abdominal organ damage. Primary repair was accomplished in 49% with 17% septic morbidity and 1% septic mortality rates. Colostomy was required in 36% with a cumulative septic morbidity of 48% and 2% septic mortality. The most common complications were abdominal abscess (12%), wound infection (7%), and fecal fistula (4%). Analysis of risk factors for colon-related morbidity showed that the Abdominal Trauma Index (ATI), colon injury severity, preoperative shock, and peritoneal contamination were most important. Synthesis of the treatment outcome and risk factor data yields a proposed management scheme for colon injuries that is based on the patient's hemodynamic status, colon injury severity, and ATI scores. Primary repair by either debridement and simple closure or resection with primary anastomosis is advocated for colon injuries in patients who are hemodynamically stable with an ATI score less than 25.     

Universal primary colonic repair in the firearm era.

All patients with colonic trauma treated at King Edward VIII Hospital, Durban, from August 1993 to May 1994 underwent primary repair of the colonic wound. They were evaluated prospectively to assess the mode of injury and outcome variables. Colonic injuries were sustained by 102 patients. These were inflicted by gunshots (62), stabs (22), shotguns (14), and blunt trauma (4). The transverse colon was injured most frequently (53). All shotgun injuries were multiple. Average time from admission to theatre was similar for shocked and non-shocked patients. Eighty-seven patients had simple closure (18 deaths) and 15 required resection and anastomosis (eight deaths). Ten patients died in the first 48 h, and 16 died subsequently owing to multiple-organ systems dysfunction. The mortality rates were stabs 9% (2), gunshots 27% (17), shotguns 50% (7), and 0% for blunt trauma. Septic morbidity was seen in 16 but was not related to breakdown of the colonic repair. Implementation of strategies to reduce preoperative time delays and use damage control principles for the management of massive trauma should be evaluated as methods of reducing mortality.     

The management of colon injuries by primary repair or colostomy

This retrospective study comprises 134 cases of penetrating colon injuries. In 92 cases the injury involved the left colon and in the remaining 42 the right colon. Death due to the colonic injury occurred in 1.5 per cent and the incidence of abdominal complications was 17.9 per cent. Patients treated by primary repair of the colon had less colon-related complications and a shorter hospital stay than patients treated by colostomy. Left and right colon injuries treated by primary repair had similar complication rates and hospital stay (P greater than 0.05). We believe that primary repair can safely be performed more frequently than is generally accepted. The site of colon injury, the presence of shock and the presence of multiple associated intra-abdominal injuries do not exclude primary repair. It is suggested that colostomy should be reserved for both left and right colon injuries with gross peritoneal contamination, extensive colonic damage, and large amount of hard faeces in the colon.     

Colonic resection in trauma: colostomy versus anastomosis

OBJECTIVES: The management of colonic trauma is well established for simple injuries with primary repair, and ileocolostomy for right-sided injuries that undergo colonic resection. Segmental colon resection for injuries to the left colon can be managed with either an end colostomy or primary anastomosis. A retrospective review was performed to evaluate the outcome and complications associated with colonic resection for trauma to determine the risk factors associated with anastomotic leakage. METHODS: A retrospective review included patients undergoing colonic resection for trauma. The patients were stratified into colostomy, ileocolostomy, and colocolostomy groups. Patient demographics and colon-related complications were collected. Comparison between the colostomy and colocolostomy groups was performed to determine the difference in outcome. The outcome of right-sided colon injuries managed by either an ileocolonic or colocolonic anastomosis was compared. Analysis was performed to identify the factors associated with an increased risk of anastomotic leakage. RESULTS: One hundred forty patients over a 66-month period were included in the analysis. Overall, 41% (57 of 140) of patients developed a colon-related complication; 28% (39 of 140) of patients developed an abscess. Overall, the anastomotic leak rate was 13% (7 of 56) in the colocolostomy group, 4% (2 of 56) in the ileocolostomy group. Right-sided colon injuries managed with a colocolonic anastomosis had a higher incidence of anastomotic leakage than ileocolonic anastomosis, i.e., 14 versus 4% respectively. Of the seven patients who developed a leak from a colocolonic anastomosis, two patients died (29%). Univariate analysis identified an Abdominal Trauma Index Score > or = 25 (p = 0.03) or hypotension in the emergency department (p = 0.001) to be associated with increased risk of developing an anastomotic leak from a colocolonic anastomosis. CONCLUSION: Colonic injuries that are managed with resection are associated with a high complication rate regardless of whether an anastomosis or colostomy is performed. Colonic resection and anastomosis can be performed safely in the majority of patients with severe colonic injury, including injuries to the left colon. For injuries of the right colon, an ileocolostomy has a lower incidence of leakage than a colocolonic anastomosis. For injuries to the left colon, there remains a role for colostomy specifically in the subgroups of patients with a high ATI or hypotension, because these patients are at greater risk for an anastomotic leak. The role of resection and primary anastomosis versus colostomy in colonic trauma requires further investigation.     

Outcome for delayed operation of penetrating colon injuries.

It has been stated that delay in operative repair of penetrating injuries to the gastrointestinal tract will result in a high rate of complications related to infection. To test this assertion, a group of patients with penetrating injuries to the colon were analyzed who had operative repair delayed (usually because of triage considerations) more than 6 hours after admission to the hospital. Nine hundred six patients who survived at least 48 hours after injury were divided into two groups. The immediate group of 769 patients was treated within 6 hours of admission and the delayed group of 137 patients was treated more than 6 hours after admission. The mortality for the immediate group was 4.0% vs. 1.5% for the delayed group. Colon-related infectious complications, defined as abscess or colon suture-line failure, occurred in 10% of the immediate group and 4.4% of the delayed group. To eliminate the effect of associated injuries, the group of patients with colon injuries only was analyzed separately. There was no mortality for 128 patients with colon injuries only operated on within 12 hours of injury, and the colon-related infectious morbidity rate was 3%. Eleven patients with colon injuries only were treated after 12 hours with a mortality of 9% and colon-related infectious morbidity of 18%. These data demonstrate that even patients with fecal contamination can have operative repair delayed for up to 12 hours without undue morbidity related to infection.     

Colon injuries in children

BACKGROUND/PURPOSE: Colonic injuries are rare in childhood, but when they do occur, they are mostly associated with penetrating abdominal injuries. The primary repair of colon injuries without stoma is still controversial within surgical experience, and the potential risk factors affecting morbidity and mortality is not sufficiently known. METHODS: Between 1985 and 1997, 34 children presenting with traumatic colonic perforations were reevaluated by analyzing the relationship between the overall morbidity and mortality and the potential risk factors. RESULTS: Of the 34 children in the case study, 27 boys and 7 girls, there were 7 (21%) isolated colonic injuries. The remaining 27 (79%) patients showed colonic injuries most frequently associated with the small bowel, the liver, and the bladder. Localization of injury was distributed thus: 21% in the right colon, 29% in the transverse colon, and 50% in the left colon. Primary repair, with or without intestinal resection, was performed in 27 (79%) of the patients. In total, postoperative complications occurred in 10 (29%) of the patients. Risk factors such as age, abdominal contamination, and associated abdominal organ injuries were found significant in these complications, however, the mechanism of injury, shock, blood transfusion, and localization of injury were not correlated significantly to postoperative complications. "'Flint's Colon Grading System" was used to ascertain the sensitivity of trauma scoring systems for postoperative complications. CONCLUSION: Colonic wounds can be repaired primarily without the need of colostomy in the majority of cases in children when the required selections are established.     

Independent predictors of morbidity and mortality in blunt colon trauma

We sought to determine the impact of (1) grade of the colon injury, (2) the formation of an ostomy, and (3) associated injuries on outcomes such as morbidity and mortality after blunt colon injuries. We retrospectively reviewed 16,814 cases of blunt abdominal trauma. Patients with colonic injuries were selected and charts reviewed for demographic, clinical, and outcomes data. Injuries were grouped by the Colon Injury Scale (grades I-V). Independent risk factors of morbidity included spine and lung injuries, as well as increased age. A higher grade of colon injury trended toward a significant association with intra-abdominal complications. Independent risk factors of mortality included liver, heart, and lung injuries, as well as intracerebral blood and female gender. The grade of colon injury, the formation of an ostomy, and management of the colon trauma did not independently predict increased intra-abdominal complications, morbidity, or mortality. These results indicate that patients afflicted with blunt colon trauma experience a high rate of morbidity and mortality from associated injuries and or increased age. Treatment regimens directed at these factors will be most helpful in reducing the high morbidity and mortality after blunt colon trauma. Factors such as ostomy formation and management strategy are not associated with increased morbidity or mortality after blunt colon trauma.     

Comparison of penetrating injuries of the right and left colon.

Controversy still exists whether penetrating injuries of the right colon have more favorably than those to the left. The importance of the issue rests in the operative management. This is a review of 50 cases of penetrating injuries of the right colon and 55 of the left treated at our institution from 1975 to 1980. The two patient groups were similar with respect to mechanism of injury, presence of shock at admission, degree of fecal contamination, severity of injury, and the percentage of cases with associated intra-abdominal injuries. The number of patients managed by primary repair or resection (52 vs. 45%), repair or resection with exteriorization (20 vs. 22%), and colostomy (28 vs. 33%) were also comparable in right versus left injuries. The treatment of right colon injuries resulted in 32% morbidity rate and 2% mortality rate, and that of left sided injuries 33% morbidity and rate of 4% mortality rate. These findings indicate that, despite known anatomic and physiologic differences, penetrating trauma to the right and left colon should be managed similarly.     

Randomized clinical trial to determine if delay from time of penetrating colonic injury precludes primary repair

BACKGROUND: There is often a delay of more than 12 h in transferring patients with penetrating colonic injury from outlying hospitals to a regional referral centre. The aim of this prospective study was to determine whether primary suture of a penetrating colonic injury in the presence of delayed presentation, shock, peritoneal contamination or associated injuries leads to increased morbidity and mortality rates. METHODS: Patients with penetrating colonic injuries were randomized to primary closure or colostomy. Patients were compared with regard to interval from injury to operation, associated injuries, duration of operation, postoperative complications and hospital stay. RESULTS: Two hundred and forty patients were seen over a 69-month period. The interval from injury to operation ranged from 3 to 56 h, and was similar in the two treatment groups. Postoperative complications were similar in the two groups but there were significant differences in operation time (mean(s.d.) 127.1(45.8) min for primary repair and 142.3(43.0) min for colostomy; P = 0.009) and length of hospital stay (mean (range) 9 (6-56) versus 26 (13-64) days respectively; P < 0.001). CONCLUSION: Delay from time of penetrating colonic injury is not a contraindication to primary repair. :     

The role of primary repair for colonic injuries in wartime

BACKGROUND: The study reviewed an experience of selective primary repair for penetrating colonic injuries incorporating a number of procedures during the 1992-1995 Bosnia-Herzegovina conflict. METHODS: Of 5370 casualties, 259 (4.8 per cent) had injuries to the colon. The patients were divided into two groups: those who had primary repair and those who needed a colostomy. The patients' records were reviewed to determine the cause of injury (explosive weapons or bullets), the position and type of colon injury, associated injuries, the surgical procedure(s) done, complications related to the colonic wound or its management, and mortality. RESULTS: Some 122 (47.1 per cent) patients had primary colonic repair and 137 (52.9 per cent) had a colostomy. One hundred and fifty (57.9 per cent) were injured by explosive weapons, 108 (41.7 per cent) had bullet wounds and one (0.4 per cent) a stab injury. Associated injuries were seen in 249 (96.1 per cent) patients. Complications related to the colonic wound or its management developed in 27 per cent of patients after primary repair and 30 per cent after colostomy. Mortality rates were 8.2 per cent and 7.2 per cent, respectively. CONCLUSION: Primary repair was a safe and effective treatment for penetrating colonic injuries during war.     

Management of blunt and penetrating colon injuries.

The records of 28 patients with traumatic colon injuries (TCI) were retrospectively reviewed. Sixteen patients (57%) with 17 TCI had blunt trauma, whereas 8 patients (29%) experienced penetrating trauma. Four TCI were from intraluminal injury. Blunt trauma commonly involved the left colon, whereas penetrating trauma usually involved the right or transverse colon. Fifty-nine percent of the blunt TCI were treated with primary repair, including resection and primary anastomosis, as were 88% of the penetrating TCI. Shock, transfusion requirement of more than 4 units, contamination, and associated injuries did not necessarily preclude primary repair. One of 16 patients (6%) who underwent primary repair developed morbidity related to the colon injury. The morbidity rate for the colostomy group was 13% (1 of 8). The mortality rate was 13% in the patients who experienced external trauma (3 of 24). Two of these deaths were related to severe head injury and chest injury, respectively. These data represent a much higher proportion of blunt injuries to the colon than is reported in the literature. The low rate of morbidity for all patients treated by primary repair tends to support the more liberal trend toward this technique for both blunt and penetrating TCI.     

Abdominal injuries in the war wounded of Afghanistan: a report from the International Committee of the Red Cross Hospital in Kabul.

This report is from the hospital opened by the International Committee of the Red Cross, in Kabul, which receives acute war-wounded patients from the Afghanistan conflict. Of more than 1000 operations carried out by the New Zealand team in a 6-month period, there were 70 laparotomies for penetrating wounds. These injuries were dealt with by established surgical techniques. The main area of controversy was the management of colonic wounds where the recent trend away from mandatory colostomy was followed by good results. Selective primary repair was achieved in 16 of 27 patients with colonic injury with no mortality and minimal morbidity. The right colon was considered particularly favourable for primary anastomosis. The overall mortality rate for all laparotomies was 13 per cent, with injuries to the liver, major veins and rectum particularly being fatal. There were eight negative laparotomies.     

Experimental evaluation of ileal patch in delayed primary repair of penetrating colon injuries: An animal study

Primary repair of traumatic colonic perforation is progressively gaining acceptance as the best method of management. However, when delayed, the risk of infection-related complications may increase. Here, we present a new method of repairing colon perforation in the presence of peritonitis. Acute colon injury was simulated in 22 German shepherd dogs. The dogs were randomly divided into two groups of 11 and after 24 hours they were operated on. The perforations were repaired by subserosal suture technique. In the first group (group A), ileal patch was used. In the other group (group B), the colon was closed by debridement and anastomosis. After 6 weeks, the repairs were assessed on the basis of survival, gross and histological assessments. Nine (82%) dogs in group A and six (56%) in group B survived. Ileal patch utilization significantly decreased the mortality rate (p < 0.05). The cause of death in two group A dogs and five group B dogs was peritonitis and intra-abdominal abscess formation. None of the surviving dogs showed evidence of anastomotic leakage or breakdown. Small bowel patch used in primary repair of colon injury in the presence of peritonitis may decrease the risk of postoperative infection-related complications and the mortality rate.     

Colon trauma: Royal Melbourne Hospital experience

Background: Recent studies from the USA and South Africa suggest that primary repair or resection and primary anastomosis have become the recommended treatment for most traumatic colon injuries. The aim of the present review is to determine the applicability of these studies to the urban Australian setting. Methods: All patients with colon injuries operated on at the Royal Melbourne Hospital from March 1989 to March 1999 were identified. Data were collected by a retrospective chart review. Results: A total of 20 patients sustained 26 injuries to the colon. Blunt injuries were more common than penetrating injuries (14 vs 6). Significant other injuries occurred in 15 patients. Colostomies were performed in four patients. The overall mortality rate was 10%. There were no anastomotic leaks. Primary repair or resection and primary anastomosis were not associated with any increase in intra‐abdominal complications. Conclusion: Evidence from large trauma centres supporting primary repair or resection and primary anastomosis is also applicable to regions that have a low rate of traumatic colon injury.     

Blunt colonic injury--a multicenter review.

During the past decade there has been a shift in the management of injuries of the colon to primary repair without a protective diverting colostomy. Unfortunately, reports concerning this practice contain relatively few patients with blunt trauma and it is unclear whether the principles established for penetrating injury should be applied in the setting of blunt colon injury. A retrospective review of 54,361 major blunt trauma patients admitted to nine regional trauma centers from January 1, 1986, through December 31, 1990, was conducted. Statistical analysis of the data collected regarding 286 (0.5%) of these patients who suffered colonic injury revealed: (1) injury to the colon is found in more than 10% of patients undergoing laparotomy following blunt trauma; (2) available diagnostic modalities are unreliable in detecting isolated colonic pathology; (3) primary repair of full-thickness injuries or resection and anastomosis may be safely performed without diversion; (4) gross fecal contamination is the strongest contraindication to primary repair. Further, delay of surgery, shock, and the timing of antibiotic administration were not associated with significantly increased morbidity.     

Primary repair of colon injuries in a developing country

Because there are several specific disadvantages to a colostomy in a developing country, primary repair for colon injury was electively performed. Sixty-one consecutive patients with colon injury were seen between 1978 and 1989 and 57 of these (93 per cent) underwent primary repair. In four a colostomy was constructed. Emergency repair was carried out regardless of site or mode of injury, presence of hypotension or peritoneal contamination. There was one death unrelated to anastomotic complications and one anastomotic leakage. The faecal fistula closed spontaneously in 4 weeks. The wound infection rate was 10 per cent. These data support the emerging view that primary repair of colon injury is the management of choice.     

Colostomy closure after colon injury: a low-morbidity procedure

One justification for expanding the indications for primary repair of colonic injuries is the high morbidity classically associated with colostomy closure. Our impression that this morbidity is overstated prompted us to review our experience with closure of colostomies constructed for treatment of colon trauma for the 5-year period 1979-1984. During this period 75 colostomies created for treatment of colorectal injuries were closed. Complications were frequent after colostomy creation, but few could be attributed to the colostomy. Following colostomy closure, however, complications were infrequent (5%) and generally minor. If morbidity of colostomy closure is cited as a factor justifying expanded indications for primary repair of colon injuries, current morbidity rates should be borne in mind.     

The injured colon.

Controversy continues regarding the initial management of civilian colon injuries. The main issues are the safety of colostomy versus the desirability of primary repair and the role of exteriorized repair. From 1979 through 1984, 727 patients with injuries to the colon were treated at a large urban trauma center. Ninety-seven per cent of injuries were caused by penetrating wounds. Ten patients died in the operating room prior to repair of the colon wound. For patients who survived long enough to have their injury treated, 52.4% were treated by primary repair, 32.9% were treated with colostomies, and 14.6% were treated with exteriorized repair. Of the factors that have been stated to influence decision making, the extent of the colon injury was the most important. Location, number, and type of associated injuries, fecal contamination, and shock were less important. However, none of these latter factors mandated performance of a colostomy. The overall mortality rate for the series was 9.9%. Forty-one out of 70 deaths occurred within the first 48 hours and were due to shock and hemorrhage. The mortality rate for primary repair was significantly lower than that for colostomies (p less than 0.01). The presence of shock and age greater than 40 were significant factors influencing mortality (p less than 0.01). Mortality also was directly related to the number and type of associated abdominal injuries. Abdominal abscess also occurred significantly less often in patients treated with primary repair than in those with colostomies (p less than 0.01). The use of exteriorized repair was successful in avoiding colostomy in 59% of patients. Primary repair can be performed with minimal morbidity and mortality and should be the mainstay of treatment for civilian colon injuries.