Chicago Metropolitan Trauma Society
4/15/2015
• Discussion objectives
– Management of penetrating renovascular trauma
– Colonic anastomosis after damage control
laparotomy – Is it worth the risk?
– Anticoagulation management strategies after IVC
injuries requiring ligation of IVC.
Traumatic Colon Injury and Open
Abdomen – Is anastomosis worth
the risk?
Greg Day MD
Loyola University Medical Center
Patient - CC
• Presentation
– 22 y/o Male s/p stab to the left flank
– Primary Survey
• Airway – intact, shallow respirations
• Breathing – Bilateral breath sounds
• Circulation – tachycardic 120s, hypotensive to 70’s,
weakly palpable femoral pulses bilaterally
Patient CC
• Secondary Survey
– Pertinent findings
• Neuro – Awake, alert, responsive to questions – c/o abd pain
• Abd – Left flank stab approx 3cm in length, active bleeding
from site, digital probe beyond fascia
• No other injuries noted
• Resuscitation
– CVC placed
– Massive transfusion protocol activated
– First units of blood transfusing while going to OR
Operative and Hospital Course
• Operative Findings
– Large hemoperitoneum, Grade V injury to left
renal hilum. Descending colon injury >50%
circumference.
– Colon resected, left in discontinuity
– Left nephrectomy performed.
– Procedure complicated by cardiac arrest
• ACLS x20 minutes – ROSC
– Abdomen packed, abthera placed and patient to
ICU for resuscitation
Resuscitation
• In OR
– 3L IVF, 12u PRBCs, 13u FFP, 2 Plt
• ICU Care
– Hypoxemia resolved over next 24-36 hours
– Vasopressors weaned off
– Acidosis resolved, base deficit cleared
Hospital Course
• Return to OR POD 2 for abdominal washout,
primary colonic anastomosis and replacement of
vac
• POD 5 – return to OR for fascial closure
• POD 8 – Patient with stool from midline wound –
return to OR for resection of anastomosis, end
colostomy
• Patient Discharged to home three weeks from
injury
• Stoma reversed successfully 6 months later
Prior to Colonic Anastomosis
• Pt Base deficit had cleared
• Vasopressors were off
• Transfusion requirements post op were
minimal
• Bowel appeared viable
• Why was it not successful?
Colonic Anastomosis in Trauma
Colon Anastomosis in Trauma
•
1979 Stone/Fabian found that in the stable patient,
primary repair can be performed safely at initial
operation without diversion
• This was subsequently confirmed
with following studies with
primary anastomosis also
Seeing good results
• How then does the open
Abdomen affect your ability
to perform an anastomosis?
Damage Control Laparotomy
• “Damage Control” – Procedures and skills used to
maintain/restore the watertight integrity, stability or
offensive power of a warship.
• Damage Control Surgery – limit surgery to essential
interventions – Control hemorrhage, limit enteric
contamination
• Decision to perform damage control
– Clinical decision
– Objective signs
•
•
•
•
Temp < 35C
pH <7.2
Base Deficit - > 15mmol/L
INR > 50% of normal
When is anastomosis appropriate?
• Difficult to study prospectively
• Most data at this time is retrospective in
nature
• Why risk it?
– Repeat operations incur high risk
- 78 Damage Control Laparotomy with colon injury – 61
analyzed
- Findings
- 16% leak rate of those patients receiving anastomosis
-
In comparison to 1-3% leak rate in non damage control surgery
- Leaks – longer ICU stay, decreased likelihood of fascial closure
- Risks for Leaks
-
Older Age
Failure to close fascia in five days
- This study also had 2/10 leaks in a defunctionalized
anastomosis
- Question then – does proximal diversion help in trauma setting?
- Anastomotic breakdown is suggested to be more related to
physiology of severe injury
• 68 Patients with DCS with colonic injury
– 41 with anastomosis, 27 diverted
• Leak = suture line disruption or EC fistula
– Leak rate – DCS compared to Non-DCS
• 17%-6%
– When comparing leak vs no leak
• No difference in transfusion requirement, anastomosis technique
– They did find significant difference in leak rate in those
patients with vasopressor use between DC and operation
when anastomosis was performed
Colon Anastomosis After Damage Control Laparotomy:
Recommendations From 174 Trauma Colectomies
Ott, Mickey M. MD; Norris, Patrick R. PhD; Diaz, Jose J. MD; Collier, Bryan R. DO; Jenkins, Judith M. MSN;
Gunter, Oliver L. MD; Morris, John A. Jr. MD
• Goal to compare leak rates between open abd
pts and those primarily closed at first
operation
• 174 patients with DCS with colonic injury
– 58 with fecal diversion, 116 with colonic
anastomosis
Colon Anastomosis After Damage Control Laparotomy:
Recommendations From 174 Trauma Colectomies
Ott, Mickey M. MD; Norris, Patrick R. PhD; Diaz, Jose J. MD; Collier, Bryan R. DO; Jenkins, Judith M. MSN;
Gunter, Oliver L. MD; Morris, John A. Jr. MD
How should we proceed?
• Trauma patients who require damage control
operations are under more physiologic stress
• Markers of transfusion requirements, acidosis,
temperature, and vasopressor requirements
are surrogates to prove their stressed state
• It is these factors one must consider when
discussion anastomosis after a patient has an
open abdomen
How has the literature helped
• Patients with massive transfusion
requirements, left sided colon injuries and
vasopressor requirements should most often
be diverted
• Consideration of anastomosis beyond those
factors remains a clinical judgment call.
Anticoagulation management
after IVC ligation
Harold Bach MD
Loyola University Medical Center
AB 2767036
• 22 y/o male involved in altercation at a bar
• Sustained GSW to abdomen, mid-epigastric
region
• Unstable at OSH (Level II trauma center), so
taken immediately to OR
• Liver injury attempted to be repaired
AB 2767036
• Upon arrival to trauma bay, patient intubated
and sedated
• PRBC transfusing
• HR 115 BP 140 systolic
• Abdomen open and packed
• Taken back to OR for exploration
AB 2767036
• At OR, diagnosed injuries included:
– shredded IVC,
– multiple areas of bleeding from IVC side branches
and side branches of aorta,
– aorta without obvious injuries,
– injury to lumbar vertebral body,
– supraceliac aortic clamping time 50 minutes.
AB 2767036
• Procedures included:
– Damage Control Exploratory laparotomy,
– ligation of infrarenal IVC,
– packing of liver with Vicryl mesh,
– packing of abdomen,
– Abdomen left open with Bogota closure
• Taken back to ICU for resuscitation
AB 2767036
• Stabilized, taken back to OR PID #2
– Found to additionally have a pancreatic head
injury and small bowel serosal injury
– Reexploration of recent laparotomy,
– removal of packing,
– abdominal washout,
– placement of drains to retroperitoneum,
– abthera vac placement
AB 2767036
• Returned to OR 2x more, eventually closed
with feeding jejunostomy tube placed
• Post op course complicated by patient selfdiscontinuing retroperitoneal drains requiring
IR replacement
• Began on coumadin, discharged home
Abdominal IVC injuries
• Incidence
– Penetrating 0.5-5%
– Blunt 0.6-1%
• Mortality
– 19%-66% in literature, widely reported around
40%
• Rx:
– Lateral venorrhaphy
• Patient stable
• Technically feasible
• Must have >25% luminal diameter remaining
– IVC ligation
• Damage control
• The first report of an IVC ligation was by Kocher (1883).
• Bilroth performed the procedure in 1885.
– These were for iatrogenic injuries to during surgery for
malignant disorders in two patients.
– Both of these patients demised.
• The first record of an infrarenal vena caval ligation with
a successful outcome was by Bottini.
• Detrie reported the first survivor after a suprarenal
ligation.
• By 1949 there were 136 reports of caval ligations in the
literature.
• DeBakey et al reported the first large series of
AVC injuries in 1978.
– 301 patients who had been identified with caval
injuries / 30 years.
– The majority (234) were treated with repair while
only 32 received caval ligation.
– Initial mortality rates in the 1950’s approached
100%.
• It was also historically a procedure employed
to halt the propogation of LE DVT prior to
anticoagulation therapy.
Sequelae of IVC ligation
• In repaired IVC, recommend surveillance via
US or CT
• Ligated IVC?
• Anticoagulation?
• Role of prophylactic fasciotomies?
Questions:
• What are the EAST guidelines on treatment
with anticoagulation after ligation of the
infrarenal IVC?
• A) 3 months therapeutic anticoagulation
• B) 6 months therapeutic anticoagulation
• C) lifetime anticoagulation
• D) there are no guidelines for treatment
Answer - D
Question
• Current guidelines suggest that patients with a
destructive colon injury can undergo resection
and primary anastomosis if
• A – There is no evidence of shock
• B – Minimal underlying disease
• C – Minimal associated injuries
• D – There is no peritonitis
• E – All the above are present
Answer - E
Question
• True/False : In penetrating renovascular
trauma, preliminary vascular control
decreases blood transfusions, decreases rate
of nephrectomy and decreases blood loss.
Answer – False – Preliminary vascular
Control has no impact on the above.