Improved Outcomes in Colon and Rectal Surgery part 39 docx

A single case series reported the successful treatment of 4 patients with slow-transit constipation without pelvic floor dyssynergy using biofeedback therapy 96; how-ever, two of the fou

determine which method is superior, a recent meta-analysis of

the available literature was used to compare the treatment

out-come using EMG vs pressure biofeedback.(87) EMG

biofeed-back was primarily used in 18 studies (442 subjects) with a mean

success rate (improved symptoms) of 70% Pressure biofeedback

training was used in 13 studies (275 subjects) with a mean success

rate of 78% These results showed a significantly better outcome

in patients with pressure biofeedback protocols Further

analy-sis compared intraanal to perianal EMG biofeedback and their

results showed no significant difference between the two

sub-groups (69% vs 72%, respectively) Overall, these data show

suc-cess rates ranging from 69 to 78%, regardless of which protocol or

what instrumentation is used; however, without controlled trials,

the optimal protocol for subjects with dyssynergic-type

constipa-tion remains unclear

The role of other factors on the outcome of biofeedback therapy

in patients with pelvic dyssynergy has been studied In one study,

the only predictor of successful outcome was the number of

ses-sions attended (5 or more) and whether the therapist discharged

the patient (63% success rate) rather than the patient terminating

treatment prematurely (25% success rate).(90) To date,

research-ers have not been able to identify any physiologic (manometry

and balloon expulsion test), anatomic (rectocele, intussusception,

or abnormal perineal descent), or demographic (age, gender,

duration of symptoms) variables that influence treatment

out-come; however, many investigators do suggest that

psychopathol-ogy may influence biofeedback treatment outcome Anxiety and

psychological distress are commonly associated with pelvic floor

dyssynergy One study showed that patients with pelvic floor

dys-synergic-type constipation or rectal pain showed a tendency to

use somatization as a defense mechanism to manage

psychologi-cal distress.(91) This pattern was not seen in a comparison group

of patients with fecal incontinence Others have suggested that

there may be a psychosomatic basis for chronic idiopathic

con-stipation, including pelvic floor dyssynergy.(92, 93) Studies have

reported up to 65% of constipated subjects were diagnosed with

various psychological disorders (94); however, there is significant

debate whether the psychopathology is a cause or a consequence

of dyssynergic constipation In a study of patients with

slow-tran-sit constipation without pelvic dyssynergy 60% of subjects had a

concurrent affective disorder, with 66% reporting having a previous

affective disorder.(95) Others have shown a high incidence of

sexual or physical abuse in patients suffering from constipation

Given these results, it is of no surprise that psychological treatment

for subjects with constipation is frequently recommended in

addi-tion to biofeedback therapy Establishment of an effective

psycho-therapeutic relationship may be critical for success

Biofeedback therapy has been used for the treatment of

slow-transit constipation A single case series reported the successful

treatment of 4 patients with slow-transit constipation without

pelvic floor dyssynergy using biofeedback therapy (96);

how-ever, two of the four patients continued to require laxative use

despite improved symptoms, and there was no objective

confirm-atory evidence (repeat colonic transit study) to support

physi-ologic improvement A recent study has compared the benefits

of biofeedback therapy in patients with slow-transit

constipa-tion to those with pelvic dyssynergia-type constipaconstipa-tion.(97) At

6 months, the dyssynergic group had greater satisfaction (71%

vs 8%), and more frequently reported ≥ 3 bowel movements per week (76% vs 8%) than the slow-transit group following a

5 weekly biofeedback sessions These data indicate that pelvic floor biofeedback benefits patients with pelvic floor dyssyner-gia, but not patients with slow transit constipation Biofeedback therapy has been suggested as the initial therapy for patients with outlet obstruction associated with pelvic floor dyssynergy This concept is supported by a recent randomized, controlled trial

of patients with pelvic floor dyssynergy where biofeedback was shown to be more effective than laxative therapy with PEG.(98) Further well designed prospective randomized controlled trials are necessary to establish biofeedback therapy as the primary treatment for patients with this condition

Failure of biofeedback therapy poses a significant treatment problem as most patients do not improve with surgical interven-tion Division of the puborectalis muscle in the posterior midline has been reported in patients with intractable pelvic dyssynergy However, results are disappointing with very few patients obtain-ing any benefit from the procedure.(99) These data suggest that this procedure has no role in the treatment of patients with this condition Botulinum toxin injection has been proposed as an alternative therapeutic modality for these patients with refrac-tory pelvic floor dyssynergy Injection of the toxin is directed into the puborectalis muscle and external anal sphincter Symptom improvement was reported in up to 75% of patients with benefit lasting from 1 to 3 months Fecal incontinence was reported in 25% of patients, and was transient lasting only 1 to 3 months after injection.(100–101) Others have reported similar beneficial effects of botulinum toxin injection for dyssynergic-type con-stipation.(102) However, because the effects of the toxin wear off within 3 months of administration, repeated injections are necessary to maintain symptomatic improvement Furthermore, given the expense of this drug, this treatment modality should be reserved for those patients with severe symptomatic pelvic dys-synergia that has failed all other therapies

sURgeRY OPtiOns

Surgical intervention for functional constipation is limited to patients with documented severe slow-transit constipation that

is refractory to medical management Patient selection is criti-cal for success Minimal evaluation requires colon transit studies

to document slow-transit constipation, and pelvic floor physiol-ogy testing to rule out pelvic floor dysfunction Operative proce-dures performed for the treatment of slow-transit constipation include segmental colectomy, subtotal colectomy with ileosig-moid anastamosis, and total abdominal colectomy with ileorec-tal anastamosis Each procedure has its champions; however, the overwhelming body of literature indicates superiority of total abdominal colectomy with ileorectal anastamosis

Total abdominal colectomy with ileorectal anastamosis is the treatment of choice for patients with slow-transit constipation The anastamosis is usually performed in the proximal rectum

at or near the sacral promontory At this level, the anastamosis

is easier to perform, eliminates the risks associated with rectal mobilization, and bowel diameter does not limit the size of the anastomotic lumen.(103)

Timing of surgery is best decided by the patient, as this

sur-gery is an irreversible step in the treatment of constipation Most

patients are accepting of surgical intervention when all

conserva-tive measures have failed to result in an acceptable quality of life

In addition to standard operative risk for colectomy, patients

should be counseled that abdominal pain and bloating may

persist postoperatively even after normalization of bowel

fre-quency This is significant as a recent report showed that

persist-ent abdominal pain had the strongest correlation with quality of

life scores following colectomy in these patients.(104) Standard

bowel preparations may not be sufficient as many patients with

slow-transit constipation have one bowel-movement per week

and are already taking PEG products to assist with bowel

func-tion A clear liquid diet for 48 hours along with multiple enemas

and laxatives may be necessary to adequately evacuate the colon

and rectum of stool Perioperative antibiotics are given

accord-ing to current standards (intravenous) and physician preference

(oral) as described in Chapter 2

Overall success of total abdominal colectomy with ileorectal

anas-tamosis for slow-transit constipation is approximately 90%, and

reported rates of symptomatic improvement ranges from 50% to

100%.(104, 105) This variability may be the direct result of how

suc-cess after surgery is defined.(104) Many studies use patient satisfaction

as criteria for success; however, patient derived subjective assessment

is an inaccurate measurement of surgical outcome and likely varies

between patients and studies In a review of the literature evaluating

subtotal colectomy for slow-transit constipation, Knowles et al found

that only half of the 31 studies that documented success or satisfaction

reported the method of data acquisition.(19) Furthermore, in these

studies success rate was based on patient judgment in 14, on function

in 6, and on a combination of both in 5 Criteria used to assess

suc-cess or satisfaction was not reported in 6 studies Patient satisfaction

and gastrointestinal functional outcomes (i.e bowel-movement

fre-quency) do not correlate with quality of life.(104, 106) A recent report

showed a significant increase in bowel-movement frequency after

subtotal colectomy; however, the persistence of abdominal pain and

the development of postoperative incontinence or diarrhea adversely

affected quality of life scores.(104) The authors concluded that bowel

movement frequency alone does not provide an accurate assessment

of patient’s outcome This has led investigators to suggest the use of

standardized outcome measures such as questionnaire-based

proto-cols that assess quality of life.(106) These instruments should be used

along with postoperative complications, functional outcome measures

as well as gastrointestinal function to provide more uniform outcomes

measurement of operative success in these patients

Acute and long-term complications are significant and include

prolonged postoperative ileus, recurrent bowel obstruction,

abdominal pain and bloating, diarrhea, incontinence, and

recur-rent constipation, and are addressed in detail below These

fac-tors all affect quality of life scores with incontinence having the

greatest negative impact.(104) In fact, postoperative quality of

life assessment after total abdominal colectomy and ileorectal

anastamosis showed significantly decreased scores compared to

those of the general population (107); however, 93% of patients

that met selection criteria for total abdominal colectomy with

ile-orectal anastamosis for slow-transit constipation would undergo

colectomy again given the chance.(104)

Early reports found that if the whole intraabdominal colon was not removed, symptoms often recurred.(108) In fact, results

of segmental colectomy have been disappointing with small series reporting up to 100% failure rate.(19) Reports of subtotal colectomy with ileosigmoid anastamosis resulted in an increased incidence of constipation and conversion to total colectomy was necessary in 50% of cases.(109) Other authors support this concept and cite increased incidence of constipation recurrence and persistence resulting in the need to reoperate to remove the remaining colon.(107, 110) Removal of the colon with preserva-tion of the cecum and ileocecal valve has been described; how-ever, long-term results were poor as maintenance of the cecal reservoir resulted in dilatation and recurrence of constipation symptoms.(111) Modifications of colonic transit studies using multiple ingestible markers and scintigraphic defecography have been used to determine segmental colonic inertia.(112) Although the validity of these techniques to determine segmental motility dysfunction has been questioned (113), these tests have been used

in recent studies to identify and successfully treat patients with segmental colonic inertia.(105, 114) In one study, 28 patients were treated with segmental resection with a median follow-up of

50 months.(114) Early failure with persistent or recurrent consti-pation occurred in 3 (11%) patients and required further surgery Patient satisfaction was reported in 23 (82%) patients; however, outcome was reported as excellent in 10 patients, good in 7, fair

in 7, poor in 4 If successful outcomes were assigned to the excel-lent and good category, the success rate would fall to 61% Again, variability in method to define success may play a factor in these results Another study evaluated 15 patients with slow-transit constipation classifying them into total colonic slow-transit (8 patients) and left slow-transit (7 patients) (105) Total abdominal colectomy or left colectomy was performed according to this clas-sification and resulted in improvement in symptoms (increased daily evacuations) in 8 (100%) and 6 (86%) patients, respectively The authors report that patients with left colonic slow-transit all had prolonged latency times and were treated with percutaneous nerve evaluation None received permanent implantation of the device, but it does raise the question as to whether colon transit studies were affected in these patients The weighted finding of prolonged latency times in patients with left colonic slow-transit

is interesting as sacral nerve stimulation has been successful for the treatment of slow-transit and dyssynergic-type constipation (115) Although segmental colectomy seems promising for the treatment of segmental colonic inertia, controlled data are lack-ing and further studies are needed to verify and support its use

In a small subset of patients with slow-transit constipation ile-ostomy may be necessary due to poor operative risk or in elderly patients with impaired continence

COMMOn COMPliCatiOns

Morbidity of colectomy in patients with slow-transit constipation includes several factors First, the direct risks of colon resection are related to the anastamosis (leak, stricture), infections (wound and intraabdominal abscess), bleeding, and anesthesia Mortality related

to colectomy in this group has been <1%.(103) Long-term compli-cations resulting from colectomy in patients with slow-transit con-stipation are significant, and have been shown to negatively impact

outcomes with decreased quality of life.(104) Common

complica-tions in this group of patients include recurrent bowel obstruction,

abdominal pain, diarrhea, incontinence, and recurrent

constipa-tion, and warrant further discussion Recurrence of constipation is

addressed in detail in the section to follow

In patients undergoing total abdominal colectomy with

ile-orectal anastamosis, the most frequently occurring complication

is small bowel obstruction The reported incidence ranges from

8 to 38% with surgical intervention required in up to 75%.(104,

110, 116) The etiology of obstruction is commonly attributed to

adhesions formed from the extensive colectomy; however, others

have reported findings of small bowel pseudo-obstruction due

to proposed neuropathic disorder of the myenteric plexus

affect-ing overall bowel motility.(104, 117, 118) A retrospective review

examined the incidence of postoperative complications

follow-ing subtotal colectomy with ileorectal anastamosis in 48 patients

with colonic inertia, 30 with Crohn’s disease, and 22 with either

Familial Adenomatous Polyposis, or other neoplasia.(119) Small

bowel obstruction occurred in 10 to 18% of each group, with

no significant difference between groups Others have reported

intestinal obstruction rates of 35% following total abdominal

colectomy for slow-transit constipation In this study, 33% of

patients had evidence of a delay in small bowel transit time

sug-gesting this disorder is not limited to the colon, but also affects

the small bowel Recent reviews have speculated that routine use

of antiadhesive agents such as Seprafilm® may reduce the

inci-dence of adhesion induced small bowel obstruction.(103)

Postoperative persistence of abdominal pain and alteration in

bowel function are significant issues that adversely affect quality

of live A recent retrospective review on quality of life after

subto-tal colectomy for slow-transit constipation showed that

abdomi-nal pain was persistent in 41% of patients, diarrhea in 52%, and

incontinence in 45%.(104) Collectively, these factors had the

strongest correlation with quality of life survey, and the

devel-opment of incontinence had the most negative impact on the

score As mentioned above, the high rate of persistent abdominal

pain after surgery warrants detailed counseling of the patients

regarding expectations and outcomes Patients must be aware

that normalization of bowel frequency may not relieve them of

their pain Diarrhea following total abdominal colectomy with

ileorectal anastamosis is not uncommon with reported incidence

ranging from 0 to 46%.(104) This is not surprising as the colon

is effective at water absorption and is responsible for desiccating

the stool Over time intestinal adaptation occurs and normalizes

consistency and frequency of the stool, with more than 90% of

patients having either solid or semisolid stools by 6 months.(120)

During the intestinal adaptation period, diarrhea is treated with

fiber, motility agents (loperamide, diphenoxylate and atropine

sulfate), and binders (cholestyramine) to reduce bowel frequency

The incidence of postoperative incontinence has been reported

in 0% to 52% of patients with a mean of 14%.(104) Intractable

diarrhea, especially in the setting of fecal incontinence, may

require conversion to a permanent ileostomy

ReCURRenCe

It is clear that colectomy for refractory constipation has

demon-strated successful outcomes for total abdominal colectomy with

ileorectal anastamosis in 89 to 100% after appropriate preop-erative workup, including colon transit study, defecography, and anorectal physiology tests.(19) Therefore, the greatest assurance

to success in the operative treatment of constipation starts with appropriate patient selection

Recurrence or persistence of constipation following colectomy has been reported to occur in up to 33% of patients.(104) Patients with combined slow-transit constipation with pelvic floor dyssynergy are less likely to result in successful outcomes after surgery Outcomes

in patients undergoing surgery for slow-transit constipation with or without pelvic floor dyssynergy have been compared.(121) The pres-ence of pelvic floor dysfunction significantly decreased success rates from 78% to 56% It has been shown that slow-transit constipation with associated pelvic floor dyssynergia can be treated initially with biofeedback therapy followed by surgery with similar improvement

in outcomes such as median stool number per day, spontaneous stools, laxative use, and quality of life.(107)

Patients with slow-transit constipation are believed to have a glo-bal neuropathic disorder of the myenteric plexus that affects colonic motility.(117) It has been proposed that this neuropathic disorder may extend proximal into the small bowel, or even the entire gas-trointestinal tract resulting in a global gasgas-trointestinal motility dis-order (panenteric inertia) Failure to identify these patients may be

a reason for early recurrence of constipation or even the high inci-dence of postoperative bowel obstruction Preoperative evaluation

of whole gastrointestinal transit should be performed in all patients undergoing surgery for slow-transit constipation Successful iden-tification of these patients should raise question as to whether they will benefit from colectomy If this entity is identified after surgery, conversion to an ileostomy may be required

Finally, recurrence of constipation may be a direct result of incomplete colonic resection Segmental colectomy, ileosigmoid anastamosis, and preservation of the cecum and ileocecal valve with cecorectal anastamosis are all associated with a higher inci-dence of constipation recurrence or persistence Surgical failure

in these patients frequently requires reoperation for conversion

to ileorectal anastamosis

In patients with recurrent constipation after colectomy, workup

is directed at the issues addressed above First, anatomic evalu-ation of the remaining rectum should be performed Flexible signoidoscopy is adequate and can be performed in the office after two Fleets enemas Special attention is made to the anastamosis as stric-ture formation will result in constipation In the absence of organic disease, pelvic floor physiology testing is repeated to determine the presence of pelvic floor dyssynergia Presence of this condition requires biofeedback therapy to improve symptoms and outcome Upper gastrointestinal small bowel follow trough and other tests of whole gut transit will determine whether panenteric inertia is present

In these patients, persistent constipation and pseudo-obstruction are difficult to manage and may require end ileostomy A careful review of the original operative report will provide evidence as to whether adequate colectomy was performed Complimentary tests such as colon transit studies (radiopaque markers or scintigraphy) and gastrografin enema (avoid barium if constipation is significant) will help determine if there is residual dysmotile colon remaining Persistent constipation with evidence of residual colon may require completion colectomy with ileorectal anastamosis

sUMMaRY

Constipation is a common and complex polysymptomatic

clini-cal disorder that has multiple etiologies Successful treatment

requires careful workup and patient selection A careful history

and physical exam are the first step Many medical conditions

and medications can cause constipation, and correction of these

disorders can improve symptoms Anatomic evaluation of the

colon to rule out neoplasia, stricture, and other organic disease

is required When these secondary causes of constipation are

excluded, a functional chronic constipation exists Functional

constipation consists of three overlapping subtypes including

slow-transit constipation, dyssynergic defecation, and mixed

dis-orders Initial therapy for all patients includes dietary and lifestyle

modification with and without laxatives Persistent constipation

that is refractory to medical management requires further testing

The tests obtained will vary depending on the patients history,

surgeons experience, and testing availability Colonic motility is

determined by colon transit studies such as radiopaque markers

or scitigraphic defecography Pelvic floor function and physiology

is determined by anal manometry, balloon expulsion test,

defec-ography, and electromyography Isolated slow-transit

constipa-tion is successfully treated with total abdominal colectomy with

ileorectostomy Lesser operations result in poor outcome with a

high incidence of reoperation Before surgery global

gastrointes-tinal motility should be assessed as the presence of panenteric

inertia can negatively impact outcomes Pelvic floor dyssynergia

is treated with biofeedback therapy to improve pelvic muscle

coordination for defecation Surgical therapy has poor results

and should be discouraged The combination of slow-transit

constipation and pelvic floor dyssynergia are more complex

Optimal outcomes require successful treatment of pelvic floor

dysfunction with biofeedback therapy before surgery

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 Colorectal trauma

S David Cho, Sharon L Wright, and Martin A Schreiber

Challenging Case

A 23-year-old man sustained a through and through gun shot

wound to the left lower abdomen The patient was mildly

hypoten-sive on arrival to the emergency room, but responded to

admin-istration of 2 L of normal saline The abdominal exam reveals

the bullet holes and moderate tenderness The rectal exam was

normal Chest and abdominal radiographs were normal except

for markers at the gunshot wounds, electrolytes and hemoglobin

levels were normal After administration of a second generation

cephalosporin and a type and cross for blood, the patient was

taken to the operating room for an abdominal exploration The

only injury found was a lateral injury to the mid sigmoid colon

There was minimal stool contamination of the lower abdomen

Case management

The colonic wound edges were debrided and the colon was

repaired primarily with a two layer suture closure The abdomen

was copiously irrigated The laparotomy wound was closed and

the patient received one dose of antibiotics postoperatively

introduCtion

The management of traumatic colon injury has been the

sub-ject of much debate and has evolved considerably over the past

century During World War I, primary repair was practiced for

all colon injuries, with a resultant mortality in excess of 60%

(1, 2) Civilian series reported similar results, with LoCicero and

colleagues reporting a 67% mortality rate from 1927–1942.(3)

The mortality rate dropped to approximately 30% during World

War II (2) at a time when several changes in management were

introduced Most notably, Ogilvie (4) described exteriorization

of colon injuries, leading to the practice of mandatory colostomy,

which reduced mortality to about 45%.(4) Mortality dropped

further during the Korean and Vietnam conflicts, to about 10%

(1), which many attributed to the standardization of

colos-tomy The thinking at that time was that diversion of the fecal

stream and avoiding an anastomosis would greatly reduce

infec-tious complications.(5) The specter of infection was particularly

ominous during a time when antibiotics had just been

intro-duced Many combat surgeons did not have significant training

in managing colon injuries, high-velocity wounds, or operating

under conditions of resource constraint and combat triage,

dur-ing which follow-up of an anastomosis would be difficult.(4, 6)

These concepts became incorporated into civilian settings as well

and became the standard for at least 30 years Other innovations

during this period included the introduction of antibiotics, and

improvements in transport, surgical devices, critical care, and

resuscitation (2, 5, 7, 8) that may well have been responsible for

the improvements in survival Despite these factors, colostomy

remained the standard of care for the first three-quarters of the

twentieth century

This practice was first successfully challenged by the landmark work of Stone and Fabian (9) in 1979, when they published the results of their randomized trial of primary repair without diver-sion versus colostomy in 268 patients with colon injuries They noted a similar wound infection rate, and a significantly lower peritoneal infection rate with primary repair (15% vs 29%) Their overall complication rate was 1% for primary repair and 10% for colostomy Further, they noted an increase in hospital length of stay of approximately 6 days in the colostomy group Although the study excluded more severely injured patients, it was the first to provide evidence that colostomy was not manda-tory in all cases Based on this work, a growing body of evidence contributed to a shift toward primary repair of traumatic colon injury during the 1980s and 1990s

Currently, primary repair, defined as a single-staged operation establishing bowel continuity (either by direct suture repair or resection and anastomosis) without proximal diversion, is being increasingly used for most colon injuries in civilian settings.(10, 11) The military conflict in Iraq and Afghanistan has both rein-vigorated the debate between primary repair and diversion, and has brought new perspectives to this issue Clearly, optimal treat-ment depends not on the uniform application of one technique

or the other, but depends on sound judgment and an understand-ing of the current evidence

epidemiology

Colon injury occurs in 30% of abdominal gunshot wounds and 5% of stab wounds, and is the second most common intraabdominal organ injury in civilian penetrating trauma (12) Penetrating mechanisms cause 85–95% of colon injuries

in civilian practice.(6, 13–16) In contrast, in a recent review

of colon injuries sustained by American soldiers in Operation Iraqi Freedom over a 2-year period, 71% of injuries were caused

by improvised explosive devices (IED) and 24% were caused by gunshot wounds Blunt injury is rare, with colon involvement

in 0.2% of trauma admissions but 20–30% of blunt hollow viscus injuries.(17) Motor vehicle crashes and traffic accidents account for the majority of blunt colorectal injuries.(18, 19) Approximately 80–90% of colon injuries in civilian settings are nondestructive.(20)

While mortality has dropped in recent decades to <3% (21, 22), morbidity has remained high Colon related complications have been consistently reported in 15–30% of cases since 1979 (9, 14, 23–27)

preoperative assessment

The initial assessment of any trauma patient always begins with the ABCs (airway, breathing, and circulation) and adherence to Advanced Trauma Life Support (ATLS) principles including the primary and secondary surveys, rapid treatment of immediately

life-threatening injuries, establishment of appropriate

intrave-nous access, and administration of fluids or blood products when

appropriate

In cases of severe injury accompanied by marked physiologic

derangement, most notably the ‘lethal triad’ (acidosis,

hypo-thermia, and coagulopathy) (28) of trauma, the principles of

damage control surgery are applicable These include rapid

tri-age, abbreviated laparotomy, and return to the intensive care unit

(ICU) for rewarming and correction of acidosis and

coagulopa-thy Intraoperatively the abdomen is packed, massive hemorrhage

is controlled, and injured bowel is stapled off and left in

disconti-nuity if necessary In 12 to 24 hours the patient is brought back to

the operating room at least once for reexploration and definitive

repair.(29)

Diagnosis

The diagnosis of bowel injury is notoriously difficult Colon

inju-ries are primarily diagnosed intraoperatively.(30) However,

diag-nostic techniques warrant a brief discussion

physiCal exam

Peritoneal signs in the abdominal trauma victim are most often

caused by hollow viscus injury However, physical exam may be

dif-ficult to perform in the multisystem trauma patient Intoxication,

traumatic head injury, or distracting injuries may obviate a

reli-able physical exam

The “seat belt sign” has been described as a physical exam

find-ing that predicts bowel injury The classic findfind-ing is ecchymosis of

the anterior abdominal wall secondary to the compressive force

of the lap belt (Figure 35.1a) It is associated with a more than

doubled (2.9%) relative risk of bowel injury.(31) Flexion

distrac-tion injuries of the thoracolumbar spine, termed “Chance

frac-tures”, also should raise suspicion for blunt bowel injury.(32)

Diagnostic peritoneal lavage

Diagnostic peritoneal lavage (DPL) is a rapid and inexpensive

test to evaluate the intraperitoneal contents and it remains a

diagnostic option in patients with suspected abdominal injury Via an open or closed technique, the abdominal cavity is lavaged with 1 L of isotonic solution, then aspirated and tested for evi-dence of intraabdominal injury In blunt trauma, DPL is con-sidered positive if 10 mL of blood is aspirated before instillation

of lavage fluid Microscopic criteria for a positive DPL in blunt trauma include more than 100,000 red blood cells (RBCs)/mm3

or 500 white blood cells/ mm3 The criteria for a positive DPL

in penetrating trauma are much less standardized and vary from more than 1,000 RBCs/mm3 to gross aspiration of >10 cc of blood In both blunt and penetrating trauma, presence of bile, amylase, bacteria, or particulate matter should indicate visceral injury and need for laparotomy The accuracy of DPL is 92% to 98%, as reported by the Eastern Association for the Surgery of Trauma guidelines.(33)

Otomo et al (34) posited new criteria specifically designed to diagnose intestinal injuries using DPL Due to the fact that hemo-peritoneum is not necessarily an indication for operation, they considered the DPL positive when there was a relative increase in the WBC count compared to the RBC indicating peritoneal irrita-tion They prospectively evaluated 250 patients with blunt abdomi-nal trauma In addition to other criteria, when the RBC count in the lavage fluid was greater than 10 × 104/mm3), then the DPL was considered positive when the WBC count exceeded the RBC count/150 They report that these criteria have a diagnostic sensi-tivity of 96.6% and specificity of 99.4% for intestinal injury Advantages of DPL include rapidity, higher sensitivity, lower cost, and immediate performance and interpretation Unlike computed tomography, performance of DPL does not require transfer to a noncritical area The major disadvantages are a 1%

to 3% risk of iatrogenic intraperitoneal injury and the high sen-sitivity of the test, which may lead to nontherapeutic laparoto-mies.(33) The utility of DPL has significantly decreased in the era of nonoperative management of solid organ injuries and it

is primarily used in unstable trauma patients with an unknown source of hemorrhage However, DPL may diagnose hollow vis-cus injuries that are missed by other modalities There are relative contraindications to the performance of a DPL which include pregnancy, obesity, and prior celiotomy Lastly, DPL is primarily

of value if the abdominal injury is intraperitoneal If the injury is confined to the extraperitoneal colon and rectum, DPL may not identify these injuries

Ultrasound

Focused abdominal sonography for trauma (FAST) is now a com-monly used modality in the initial diagnostic management of abdominal trauma FAST has been used as a screening modality for patients with blunt trauma to determine which stable patients should undergo further diagnostic imaging with CT scanning It has also been used in hemodynamically unstable patients to rap-idly determine presence of intraperitoneal fluid and the need for immediate surgery analogous to the use of gross blood on DPL

In FAST, the ultrasound probe is used to serially evaluate the pericardium, Morison’s pouch (hepatorenal space), splenorenal recess, and the pouch of Douglas (retrovesical portion of the intraperitoneal cavity) for free fluid A small amount of physi-ologic fluid is occasionally seen in the pelvis, but anything more

Figure 35.1a Seat-belt sign The patient was involved in a roll-over motor vehicle

crash.

should be considered abnormal and should prompt either

opera-tive exploration or further investigation

FAST has a sensitivity of 42% to 63%, a specificity of 98% to

100%, a positive predictive value of 67% to 100%, negative

pre-dictive value of 93% to 98%, and an accuracy of 92% to 98%

(33–40) Its advantages include rapidity, easy repeatability, its

noninvasive nature, the absence of radiation exposure, and low

cost Disadvantages to FAST are interobserver variability and

the fact that hollow viscus injuries may not be associated with

an adequate volume of free intraabdominal fluid to be diagnosed

by FAST

Computed tomography

Computed tomography (CT) scanning of the abdomen and

pel-vis is the procedure of choice for the evaluation of the

hemody-namically stable blunt trauma patient.(33) It is recommended in

patients with equivocal physical exam findings, multiple injuries,

and neurologic injury

Abdominal CT has a sensitivity of 64% to 88%, specificity of

97% to 99%, and an accuracy of 82% to 99% for the

diagno-sis of hollow viscus injury.(41, 42) Disadvantages include high

cost, radiation exposure, and the need to transport patients to the

radiology suite

Signs of bowel trauma seen on CT include mesenteric

strand-ing, free intraperitoneal fluid in the absence of solid organ injury,

extraluminal air or contrast material, and bowel wall thickening

(43) Figure 35.1b demonstrates these findings Improvements

in CT technology have led to increasing sensitivity of CT in the

detection of the more subtle signs of injury to the bowel

Laparoscopy

Laparoscopy has been evaluated in the diagnosis of

intraabdomi-nal injury in a selected group of trauma patients as a method to

evaluate penetrating injuries Potential advantages include

avoid-ing nontherapeutic laparotomy and diagnosavoid-ing and treatavoid-ing blunt

bowel injuries that are otherwise missed by imaging techniques

In patients with penetrating abdominal trauma, stable vital signs,

intact sensorium without evidence of raised intracranial pres-sure, and absence of contraindications for pneumoperitoneum, Ahmed et al found that exploratory laparoscopy is safe and accu-rate in the diagnosis of penetrating abdominal injuries, and iden-tified those injuries that necessitated open repair.(44) In their study, they report avoiding nontherapeutic exploratory laparo-tomy in 75% of their patients The authors describe laparoscopy

as having the advantage of identifying injuries to the peritoneum, diaphragm, mesentery and omentum

Mitsuhide et al (45), prospectively evaluated the use of diag-nostic laparoscopy in conjunction with CT scan in patients with blunt abdominal injury Diagnostic laparoscopy was performed

in hemodynamically stable patients who had either local peri-toneal signs and indirect CT signs (bowel thickening or isolated intraperitoneal fluid), an increase in abdominal pain or tender-ness, or intraperitoneal fluid increased on serial CT scan A total

of 25 laparotomies were performed in 399 patients, 14 based on physical exam or CT findings and another 11 after laparoscopy

In total, 17 laparoscopic examinations were completed and 10 injuries were repaired Thus, in these 399 patients, laparoscopy detected 1 mesenteric laceration and 7 bowel injuries that were not diagnosed on CT scan There were no nontherapeutic lapa-rotomies, and 7 laparotomies were avoided They concluded that laparoscopy can prevent nontherapeutic laparotomy and delayed diagnosis in patients with suspected blunt bowel injury

Risks of laparoscopy in trauma patients include tension pneu-mothorax upon CO2 insufflation, which can be decreased by limiting initial insufflation pressures to 8 mmHg.(45) Other risks include hypotension following insufflation secondary to intra-vascular volume depletion, and gas embolism in patients with intraabdominal solid viscus injury

Injury scales

In the effort to standardize assessment of traumatic injuries and potentially predict outcomes, a number of scoring systems have been published While these scales do not attempt to replace sound judgment, experience and individualization of treatment, they are useful as a common means of assessment and commu-nication amongst surgeons caring for patients with these inju-ries The three most commonly used in association with colonic injury are briefly discussed here

Flint and colleagues (16) described three grades of colonic injury (Table 35.1), derived from a series of 137 patients Interestingly, this report appears to have been at least in part generated by the discussion begun by Stone and Fabian (9) just 2 years earlier The aim of their study was to determine if selection of candidates for primary repair could be based on the severity of colon injury They noted an increase in mortality from 4% to 25% between injury grades 1 and 3, and no complications for grade 1 versus a 31% complication rate for grade 3 injury Although no statistics were reported, the authors concluded that primary repair was safe for injury grade 1, while colostomy was the procedure of choice for grades 2 and 3

Moore and co-workers proposed a Penetrating Abdominal Trauma Index (PATI) in 1981.(46) These authors cited a need for

an injury severity index that specifically addressed intraabdomi-nal injury, one that focused on morbidity rather than mortality,

Figure 35.1b CT scan of a patient with colon injury who demonstrated a

“seat-belt” sign Note the presence of free fluid (arrow) consistent with blood in the

abdominal cavity Of note, this patient did not have a solid organ injury raising

suspicion of a hollow viscus injury.