Treatment of penetrating duodenal injuries: primary repair vs. repair with decompressive enterostomy/serosal patch

We analyzed 60 patients with penetrating duodenal injuries (1972-1983) treated by two operative techniques: primary repair or anastomosis after debridement, and repair with decompressive enterostomy with or without serosal patch of jejunum. The two treatment groups were comparable in terms of severity of duodenal and associated injuries and clinical status of the patients. Morbidity was significantly higher (p less than 0.001) in the enterostomy/patch group and mortality was limited to that group. Our data suggest that debridement and primary repair of duodenal wounds is the treatment of choice and that the addition of decompressive enterostomy and/or serosal patch does not improve results and may contribute to morbidity and mortality.     

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.     

Exteriorized primary repair of colon injuries

Two classic approaches have been applied to the surgical management of colon injuries. One has been exteriorization of the injured segment. The other has been primary repair of the injury in selected cases. A compromise approach can be utilized when the risk of leakage is high in a primarily repaired segment of colon: exteriorization of the primarily repaired injury without colostomy. This technic has prevented the need for formal colostomy in 49 per cent of a group of thirty-seven patients who otherwise would have required colostomy. This approach appears to be a useful addition to the various procedures used for the treatment of penetrating injuries of the colon in civilian practice.     

Experimental evaluation of primary repair of colonic injuries.

To evaluate the management of colonic injuries, experimental models simulating acute injuries of the colon were studied utilizing New Zealand white rabbits. Seventy-nine rabbits underwent primary repair of colonic injuries in the presence of massive contamination and none showed any evidence of anastomotic leakage or breakdown. The fact that primary colonic repairs do heal even in the presence of infection suggests that breakdown of colonic anastomosis results from factors other than infection. Despite the absence of anastomotic leaks in this series, morbidity and mortality were high in those animals not given antibiotics. The high morbidity and mortality were due to peritonitis, intra-abdominal abscess, and wound infection, and were directly proportional to the length of time from colonic injury to repair. On the basis of this study, it is concluded that most isolated injuries of the colon can be closed primarily, if antibiotic therapy is begun immediately after injury and continued throughout the operative and postoperative periods.     

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.     

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.     

Further evaluation of colostomy in penetrating colon injury

Our objective was to compare, in a randomized prospective format, complication rates associated with primary repair versus fecal diversion in penetrating colon injury. During a 72-month period, 181 patients with penetrating colon injuries were entered in a randomized prospective study at an urban Level I trauma center. After intraoperative identification of colon injuries, patients were randomized to a primary repair or a diversion group. Randomization was independent of previously identified risk factors, including severity of colon injury, presence of hypotension, blood loss, extent of fecal contamination, and time from injury to operation. Five patients initially entered in the study protocol were removed because they died in the immediate postoperative period (< 24 hours). One hundred seventy-six patients were studied, of which 89 were randomized to primary repair and 87 to diversion. The average age in the diversion group was 26.4 years and it was 28.0 years in the primary repair group (P > 0.05). The average Penetrating Abdominal Trauma Index for the diversion group was 22.3, and it was 23.7 for the primary repair group (P > 0.05). There were 18 (21%) septic related complications in the diversion group and 16 (18%) in the primary repair group (P > .05). With respect to risk factors, complication rates were not higher in one study group versus the other. We conclude that, in the civilian population, all penetrating colon injuries should be managed with primary repair.     

Feasibility of endovascular repair in penetrating axillosubclavian injuries: a retrospective review

BACKGROUND: Penetrating injuries to the axillary and subclavian vessels are a source of significant morbidity and mortality. Although the endovascular repair of such injuries has been increasingly described, an algorithm for endovascular versus conventional surgical repair has yet to be clearly defined. On the basis of institutional endovascular experience treating vascular injuries in other anatomic locations, we defined an algorithm for the management of axillosubclavian vascular injuries. Subsequently, a near decade long experience with the management of axillosubclavian vascular injuries was retrospectively analyzed, so as to more accurately assess the true feasibility of endovascular treatment in these patients. METHODS: We defined a management algorithm that included (1) indications, (2) relative contraindications, and (3) strict contraindications for the endovascular repair of axillosubclavian vascular injuries. Anatomic indications for endovascular repair were restricted to relatively limited axillosubclavian injuries (pseudoaneurysms, arteriovenous fistulas, first-order branch vessel injuries, intimal flaps, and focal lacerations). Relative contraindications for endovascular repair included injury to the axillary artery's third portion, substantial venous injury (eg, transection), refractory hypotension, and upper extremity compartment syndrome with neurovascular compression. Strict contraindications to endovascular repair included long segmental injuries, injuries without sufficient proximal or distal vascular fixation points, and subtotal/total arterial transection. Within the context of these definitions, we retrospectively reviewed 46 noniatrogenic subclavian and axillary vascular injuries in 45 patients identified by a prospectively maintained computer registry during a 9-year period. Presentations were reviewed concurrently by two endovascular surgeons, and potential candidates for endovascular management were defined. RESULTS: Among 46 total case presentations and among the 40 patients who maintained vital signs on presentation, 17 were potentially treatable with endovascular therapy. Among the cohort of 40 presentations, the most common contraindications to endovascular therapy were hemodynamic instability (n = 10), vessel transection (n = 7), and no proximal vascular fixation site (n = 3). CONCLUSIONS: Despite growing enthusiasm for endovascular repair of injuries to the axillary and subclavian vessels, realistic clinical presentation and anatomic locations restrict the broad application of this technique at present. In our experience, less than but approaching 50% of all injuries encountered could be addressed with an endovascular approach. This percentage will increase during the upcoming decades if the endovascular technologies available in hybrid endovascular operating rooms uniformly improve.     

Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries

Background

General surgeons’ recent familiarity with advanced laparoscopic techniques have rendered laparoscopy feasible safely in the trauma setting. Traditionally high rates of nontherapeutic laparotomies also contribute to this increased interest. This study was undertaken to determine the predictive value and accuracy of diagnostic laparoscopy (DL) in evaluation of penetrating thoracoabdominal trauma.

Methods

Entry criteria included thoracoabdominal gunshot (GSW) or stab wounds (SW) in otherwise hemodynamically stable patients. A high index of suspicion for either hemoperitoneum, peritonitis, or diaphragmatic injury was required for inclusion. All patients underwent DL in the operating room followed by standard laparotomy. The findings of the two evaluations were compared.

Results

Twenty-four patients were included in the study. Twenty males and 4 females with an average age of 34 years made up the group. Violation of the peritoneal cavity was present in 21 cases and absent in 3. No intraabdominal injuries were found during laparotomy in the latter three cases without peritoneal violation. The specificity and positive predictive value were 100% for lesions of the diaphragm, liver, spleen, pancreas, kidney, and hollow viscus. The sensitivity was highest for liver and spleen injuries (88%), followed by diaphragmatic injuries (83%), pancreas and kidney injuries (50%), and lowest for injuries of hollow viscus (25%). The negative predictive value was 95, 99, 91, and 57%, respectively, for these organs.

Conclusions

DL could have avoided unnecessary laparotomy in 38% of cases in this study. There were no complications related to laparoscopy. The greatest value of DL in penetrating thoracoabdominal injuries is in the evaluation of peritoneal violation, diaphragmatic, and upper abdominal solid-organ injuries. It is not ideal for predicting hollow viscus injuries.     

Biomechanical evaluation of augmented and nonaugmented primary repair of the anterior cruciate ligament: an in vivo animal study

Purpose

The purpose of this study was to evaluate in a sheep model the biomechanical performance of augmented and nonaugmented primary repair of the anterior cruciate ligament (ACL) following transection at the femoral end during a 12-month postoperative observation.

Methods

Forty sheep were randomly assigned to nonaugmented or augmented primary ACL repair using a polyethylene terephthalate (PET) band. At two, six, 16, 26 and 52 weeks postoperatively four sheep in each group were sacrificed and biomechanical testing performed.

Results

Compared with nonaugmented primary ACL repair, the PET-augmented repair demonstrated superior biomechanical results from 16 weeks postoperatively onwards in terms of anterioposterior (AP) laxity, tensile strength and ligament stiffness. The augmentation device works as a stress shield during the ligament healing process. The nonaugmented ACL repair also resulted in ligament healing, but the biomechanical properties were at a significantly lower level.

Conclusion

These results support the previously reported histological findings following augmented primary ACL repair. This animal study on the healing capacity of the ACL may provide some important contributions to how primary healing in certain types of ruptures can be achieved.

Clinical relevance

I     

Clinical study of penetrating thoracic injuries

During the 13-year period ending in December 1987, 39 patients (pts) of penetrating thoracic injuries were treated. Thirty-five pts (89.7%) were male, and the age range was 21 to 56 years with average of 38.7 years. Thirty-one pts (79.5%) sustained stab wounds and eight (20.5%) had gun-shot wounds. 5 pts died in all (2 pts with stab wounds, 3 with gun-shot wounds). The wounds were limited on chest wall in 14 pts, and penetrated to thorax in 25. In these pts with penetrating wounds, lung injuries were found in 18, heart in 7 and esophagus in 1, respectively. Twenty-one pts had multiple injuries, and abdominal injuries were found in 20 pts (95.2%), limbs in 7 (33.3%), and neck in 2 (9.5%). All 5 dead pts had multiple injuries. Prognoses were fair in cases of simple chest wall injuries or lung injuries. In the cases of lung injuries, thoracotomy was performed in 8 pts (44.4%) and tube thoracostomy in 10 (55.6%). Thoracotomy was performed for massive bleeding (over 600 ml/1-2 hours) (6 cases) and the sites of the injuries suspecting of heart injuries (2 cases). Two pts undergoing tube thoracostomy and one pt done thoracotomy died, but the causes of the death were not related to lung injuries. Regarding the heart injuries, the injured sites were left ventricle in 1, right ventricle in 1, right atrium in 2, and pericardium in 3. All the 7 pts were in shock on arrival. In these pts with heart injuries, all the wounds were in and near the Sauer's danger zone. In all pts, emergent thoracotomy was performed, and 5 pts could be saved (mortality 28.6%). As the risk factors, heart injuries, multiple injuries, and gunshot injuries were noticed with mortality of 28.6%, 23.8%, and 37.5%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of three methods for managing penetrating colon injuries.

Although primary intraperitoneal repair of selected penetrating colon injuries is a feasible method of treatment, injudicious use of this method, especially in wounds of the right colon, led to increased morbidity, in the group of 90 patients studied. Colostomy may be avoided in selected patients by using primary repair with exteriorization of the injured segment. The technique described is a reliable compromise which protects the patient from the danger of intraperitoneal suture line disruption and possibly avoids the inconvenience and morbidity of formal colostomy. Since exteriorized primary repair has been a safe, effective method of managing gunshot wounds of the colon in selected patients, we advocate its increased use.     

幼儿指深屈肌腱损伤不同时期修复后的疗效比较

目的　比较幼儿 区肌腱损伤后早期和择期修复的功能恢复情况。方法　对同期住院行早期和延期修复 区屈肌腱损伤的幼儿 14例和 9例 ,术后随访 3个月～ 1年 ,平均 4个月。采用 Strick-land评定标准进行功能评价。结果　早期修复组功能恢复优良率达 78.3 % ,延期修复功能恢复率为4 9.7%。结论　幼儿 区指屈肌腱损伤后早期修复效果明显好于延期修复者。     

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.     

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.     

Canadian Association of General Surgeons evidence based reviews in surgery. 12. Primary repair for penetrating colon injuries.

Objective: To determine if the treatment of penetrating colonic injury must include fecal diversion at or proximal to the injury, to avoid sepsis and mortality. Data source: Studies were identified by searching MEDLINE 1966–2001, the Cochrane Controlled Trials Registry and EMBASE. Study selection: Studies were included if they were randomized controlled trials comparing outcomes of primary repair versus fecal diversion in the management of penetrating colon injuries; 5 studies were identified. Outcome measures: Operative mortality, total complications, total infectious complications, intra-abdominal infections, abdominal infections excluding dehiscence, and wound complications including and excluding dehiscence. Penetrating abdominal trauma index (PATI) and length of stay were included when available. Results: PATI did not significantly differ between groups; neither did mortality (odds ratio [OR] 1.7, 95% confidence interval [CI] 0.51–5.66). However, total complications (OR 0.28, CI 0.18–0.42), total infectious complications (OR 0.41, CI 0.27–0.63), intra-abdominal infections (OR 0.59, CI 0.38–0.94), abdominal infections excluding dehiscence (OR 0.52, CI 0.31–0.86) and wound complications including (OR 0.55, CI 0.34–0.89) and excluding dehiscence (OR 0.43, CI 0.25–0.76) all significantly favoured primary repair. Conclusions: Primary repair of penetrating colon injuries is as safe as fecal diversion and has a lower complication rate.