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154. Colorectal Trauma

Emergent Care of the Victim of Colorectal Trauma

Introduction

  • Trauma Surgery vs. Elective Surgery
    • Trauma patients differ significantly from elective surgical patients.
      • Delay in presentation leads to adverse cascades of infection and shock.
      • Instability without preoperative optimization.
      • Need for rapid, decisive operation based on minimal information.
    • Surgeons must adapt principles to patients who have often lost significant blood volume.

Incidence of Colorectal Trauma

  • Blunt Colorectal Trauma
    • Rare but associated with high morbidity and mortality due to concomitant injuries.
    • Less than 1% incidence, with a mortality rate greater than 25%.
    • Common mechanisms:
      • Blunt force from compression or deceleration.
      • External penetrating injuries (gunshots, stab wounds).
      • Internal penetrating injuries (foreign bodies, iatrogenic causes).
  • Penetrating Colorectal Trauma
    • Colon is frequently injured in penetrating trauma.
      • Second most common organ injured by gunshots.
      • Third most common injured by stab wounds.
    • Rectal and distal sigmoid injuries are more common in penetrating trauma.
    • Associated injuries:
      • High incidence of genitourinary (GU) and osseous injuries.
      • Up to 25% of open pelvic fractures involve rectal injuries.

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Diagnosis of Colorectal Trauma

  • Challenges in Diagnosis
    • Often diagnosed during surgery for other emergent indications.
    • Peritonitis or unstable vital signs warrant immediate surgery without additional diagnostics.
    • Delay in diagnosis (>5 hours) increases mortality risk.
    • Early signs may be nonspecific or absent, especially in blunt trauma.
  • Physical Examination
    • Seat belt sign may raise suspicion.
    • Digital Rectal Examination (DRE)
      • Performed to detect wounds, foreign bodies, or blood.
      • Limited utility: may miss 100% of colon injuries and 66.7% of rectal injuries.
      • A positive DRE may justify operation; a negative DRE is inconclusive.
    • Anorectal Examination
      • Rigid or flexible sigmoidoscopy is useful (78% sensitivity).
      • Caution with insufflation to avoid exacerbating injuries.
    • Associated GU Injuries
      • Look for hematuria or blood at the meatus.

Imaging in Colorectal Trauma

  • Plain Radiographs
    • May show pneumoperitoneum, pelvic fractures, foreign bodies.
    • Nonspecific but can prompt further studies.
  • Focused Assessment with Sonography for Trauma (FAST)
    • Detects peritoneal fluid in unstable patients, indicating need for surgery.
  • Computed Tomography (CT)
    • Multidetector CT is crucial for stable patients.
    • Direct signs of bowel perforation:
      • Pneumoperitoneum, extravasation of contrast, bowel wall defects.
    • Indirect signs:
      • Bowel wall thickening, mesenteric stranding, free intraperitoneal fluid.
    • Pneumoperitoneum
      • High specificity (95%) but low sensitivity (25%).
    • Free Peritoneal Fluid
      • Lack of fluid has high negative predictive value for bowel injury.
    • Rectal Contrast-Enhanced CT
      • Useful but absence of extravasation doesn't exclude injury.

Treatment of Colorectal Trauma

Damage Control Laparotomy (DCL)

  • Goals:
    • Rapidly control bleeding.
    • Limit contamination.
  • Procedure:
    • Expeditious entry into the abdomen with wide exposure.
    • Control of hemorrhage and contamination.
    • Temporary abdominal closure if necessary.
  • Open Abdomen Challenges
    • Risk of infection, anastomotic leaks, fistulas.
    • Multiple operations increase risk of complications.
    • Early fascial closure (by day 5) reduces risk.

Damage Control Resuscitation (DCR)

  • Components:
    • Permissive hypotension before hemostasis.
    • Hemostatic resuscitation with balanced blood products.
    • Minimize crystalloids to prevent bowel edema.
    • Use of antifibrinolytics and coagulation factors.

Management of Colonic Injuries

  • Decision Factors
    • Mechanism of injury, hemodynamic stability, injury severity, transfusion volume, tissue destruction.
  • Treatment Options
    • Primary Repair
      • Preferred for nondestructive injuries.
      • Débridement and single-layer closure with seromuscular Lembert sutures.
    • Resection with Anastomosis
      • For destructive injuries where viable tissue remains.
      • Hand-sewn or stapled anastomoses based on surgeon's expertise.
    • Resection with Diversion
      • Considered when patient's condition doesn't tolerate potential complications.
      • Colostomy or diverting ileostomy may be lifesaving in selected patients.
  • Laparoscopic Approach
    • Possible in hemodynamically stable patients.
    • Requires institutional capability and surgeon expertise.
    • Reduced nontherapeutic laparotomies.

Vascular Injuries Associated with Colorectal Trauma

  • Management
    • Control hemorrhage early by clamping or packing.
    • Ligation of unnamed mesenteric vessels if necessary, with resection of compromised bowel.
    • Repair or shunting for injuries to major vessels like the superior mesenteric artery.
    • Avoid ligation of major vessels to prevent extensive bowel ischemia.
    • Therapeutic embolization may be considered for inferior mesenteric artery injuries.

Treatment of Anorectal Injuries

Pelvic Anatomy Considerations

  • Rectum Divisions:
    • Upper third: intraperitoneal, accessible via abdomen.
    • Middle third: partially peritonealized, challenging access.
    • Lower third: extraperitoneal, accessible via anus.
  • Blood Supply:
    • Superior rectal artery (from inferior mesenteric artery).
    • Middle rectal arteries (from internal iliac artery).
    • Inferior rectal arteries (from internal pudendal artery).
  • Adjacent Structures:
    • Ureters, iliac vessels, bladder, reproductive organs.
    • Important to avoid damage during surgical intervention.

Surgical Approach to Anorectal Injuries

  • Intraperitoneal Injuries
    • Managed similar to colon injuries.
    • Primary repair after débridement.
  • Extraperitoneal Injuries
    • Primary repair via transanal approach if accessible without extensive dissection.
    • Fecal diversion (colostomy) if injury is inaccessible or complex.
  • Presacral Drainage
    • Not routinely recommended.
    • Considered for large or destructive injuries at risk of abscess formation.
  • Surgical Techniques
    • Patient positioned in lithotomy.
    • Use of rigid or flexible sigmoidoscope.
    • Avoid extensive dissection to prevent damage to surrounding structures.
  • Associated Injuries
    • Genitourinary injuries may require coordinated management.
    • Keep repairs separate to prevent fistula formation.

Considerations for Distal Rectum and Anus

  • Sphincter Injuries
    • Require careful repair to preserve function.
    • Primary repair for simple injuries (e.g., obstetric tears).
    • Delayed overlapping sphincteroplasty for complex injuries.
    • Avoid wide débridement to prevent nerve damage.
  • Foreign Body Removal
    • Attempted under sedation in ED or under anesthesia in OR.
    • Techniques:
      • Relaxation of sphincter for easier extraction.
      • Use of Foley catheter to break vacuum seal.
    • Imaging before and after removal to detect perforations.
    • Observation post-removal to monitor for occult injuries.

Conclusion

  • Surgical Judgment is Critical
    • Individual patient factors and surgeon's experience dictate the best course.
  • Complications Reflect Severity
    • Septic complications often correlate with injury severity rather than treatment method.
  • Timely Intervention
    • Early diagnosis and prompt surgical management improve outcomes in colorectal trauma.

Note: These revision notes are based solely on the provided context and focus on the core concepts of emergent care in colorectal trauma, highlighting important keywords and explaining specific pathologies where mentioned.