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Simcock J, Kuntz CA, Newman R. Externalized Ileocolic Anastomosis: Case Report. J Am Anim Hosp Assoc 2010; 46:274-80. [DOI: 10.5326/0460274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 6-year-old, spayed female Labrador retriever was presented 48 hours after an intestinal resection and anastomosis for management of a small intestinal foreign body. Abdominal ultrasound confirmed the presence of peritoneal effusion. Cytology of fluid collected by abdominocentesis revealed a large number of degenerate neutrophils with intracellular cocci. A diagnosis of septic peritonitis was made, presumably because of dehiscence of the anastomosis. Upon repeat exploratory celiotomy, the intestinal anastomosis (located 4 cm orad to the cecum) was found to be leaking intestinal contents into the abdomen. The distal ileum, cecum, and proximal colon were resected. An end-to-end, ileocolic anastomosis was performed and subsequently exteriorized into the subcutaneous space via a paramedian incision through the abdominal wall. The anastomosis was inspected daily for 4 days before it was returned to the abdomen and the subcutaneous defect was closed. Serial cytology of the peritoneal fluid, which was performed during this 4-day postoperative period, confirmed progressive resolution of peritonitis. The dog was discharged from the hospital 2 days following return of the anastomosis into the abdomen. Externalized intestinal anastomosis is used with good success in human medicine for repair of colonic injuries. In this case, externalization of the anastomosis permitted healing of the intestinal anastomosis in an environment isolated from the detrimental effects created by septic peritonitis. In addition, direct visualization of the anastomosis allowed assessment of healing. To our knowledge, this procedure has not been previously reported in companion animals.
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Affiliation(s)
- James Simcock
- Southpaws Specialty Surgery for Animals (Simcock), 3 Roper Street, Moorabbin, Victoria, 3189 Australia
- Southern Animal Emergency Centre (Kuntz, Newman), 248 Wickham Road, Highett, Victoria, 3190 Australia
- From the
| | - Charles A. Kuntz
- Southpaws Specialty Surgery for Animals (Simcock), 3 Roper Street, Moorabbin, Victoria, 3189 Australia
- Southern Animal Emergency Centre (Kuntz, Newman), 248 Wickham Road, Highett, Victoria, 3190 Australia
- From the
| | - Raquel Newman
- Southpaws Specialty Surgery for Animals (Simcock), 3 Roper Street, Moorabbin, Victoria, 3189 Australia
- Southern Animal Emergency Centre (Kuntz, Newman), 248 Wickham Road, Highett, Victoria, 3190 Australia
- From the
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Asfar SK, Al-Sayer HM, Juma TH. Exteriorized colon anastomosis for unprepared bowel: An alternative to routine colostomy. World J Gastroenterol 2007; 13:3215-20. [PMID: 17589900 PMCID: PMC4436607 DOI: 10.3748/wjg.v13.i23.3215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To see the possibility of avoiding routine colostomy in patients presenting with unprepared bowel.
METHODS: The cohort is composed of 103 patients, of these, 86 patients presented as emergencies (self-inflected and iatrogenic colon injuries, stab wounds and blast injury of the colon, volvulus sigmoid, obstructing left colon cancer, and strangulated ventral hernia). Another 17 patients were managed electively for other colon pathologies. During laparotomy, the involved segment was resected and the two ends of the colon were brought out via a separate colostomy wound. One layer of interrupted 3/0 silk was used for colon anastomosis. The exteriorized segment was immediately covered with a colostomy bag. Between the 5th and 7th postoperative day, the colon was easily dropped into the peritoneal cavity. The defect in the abdominal wall was closed with interrupted nonabsorbable suture. The skin was left open for secondary closure.
RESULTS: The mean hospital stay (± SD) was 11.5 ± 2.6 d (8-20 d). The exteriorized colon was successfully dropped back into the peritoneal cavity in all patients except two. One developed a leak from oesophago-jejunostomy and from the exteriorized colon. She subsequently died of sepsis and multiple organ failure (MOF). In a second patient the colon proximal to the exteriorized anastomosis prolapsed and developed severe serositis, an elective ileo-colic anastomosis (to the left colon) was successfully performed.
CONCLUSION: Exteriorized colon anastomosis is simple, avoids the inconvenience of colostomy and can be an alternative to routine colostomy. It is suitable where colostomy is socially unacceptable or the facilities and care is not available.
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Affiliation(s)
- Sami K Asfar
- Department of Surgery, Faculty of Medicine, Kuwait University and Mubarak Al-Kabeer Hospital, PO Box: 24923, Safat-13110, Kuwait.
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Abstract
PURPOSE This study was designed to develop treatment algorithms for colon, rectal, and anal injuries based on the review of relevant literature. METHODS Information was obtained through a MEDLINE ( www.nobi.nih.gov/entrez/query.fcgi ) search, and additional references were obtained through cross-referencing key articles cited in these papers. RESULTS A total of 203 articles were considered relevant. CONCLUSIONS The management of penetrating and blunt colon, rectal, and anal injuries has evolved during the past 150 years. Since the World War II mandate to divert penetrating colon injuries, primary repair or resection and anastomosis have found an increasing role in patients with nondestructive injuries. A critical review of recent literature better defines the role of primary repair and fecal diversion for these injuries and allows for better algorithms for the management of these injuries.
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Affiliation(s)
- Robert K Cleary
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan 48106, USA.
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Behrman SW, Bertken KA, Stefanacci HA, Parks SN. Breakdown of intestinal repair after laparotomy for trauma: incidence, risk factors, and strategies for prevention. THE JOURNAL OF TRAUMA 1998; 45:227-31; discusion 231-3. [PMID: 9715177 DOI: 10.1097/00005373-199808000-00005] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Breakdown of intestinal repair and enteric leakage after trauma laparotomy can have dire consequences. Factors contributing to these failures when stratified according to location of intestinal injury and method of repair were examined. METHODS We retrospectively reviewed all intestinal injuries occurring in a recent 2-year time span in adult patients surviving for more than 48 hours at a Level I trauma center. Data included Injury Severity Score, Abdominal Trauma Index score, site (stomach, duodenum, small and large intestine), and type of repair (enterorrhaphy vs. resection and anastomosis). Physiologic parameters within 48 hours of repair were assessed. Nonparametric analysis was used with significance assessed at the 95% confidence interval. RESULTS Two hundred twenty-two intestinal repairs in 171 patients were evaluated. All repairs but one were performed at the initial surgery. Eleven (5%) of these failed in 11 patients (6.4%)--four duodenum, four small bowel, and three colon--and were not recognized for an average of 15 days. Breakdown of repair occurred in patients with higher Injury Severity Scores and Abdominal Trauma Index scores (30 vs. 21 and 29 vs. 14, respectively; p < 0.001) and higher intraoperative blood and fluid administration (8.8 vs. 2.2 U and 11.5 vs. 5.1 L, respectively; p < 0.05). This was associated with longer intensive care unit and hospital stays (15.1 vs. 1.9 and 68.4 vs. 10.4 days, respectively; p < 0.001). All small bowel leaks occurred after resection and anastomosis versus enterorrhaphy (p < 0.05). All anastomotic breakdowns (four small bowel, one colon) occurred in the setting of massive blood and fluid administration versus those that did not leak (12.5 vs. 1.7 U and 12.7 vs. 5.8 L, respectively; p < 0.05). Four of 12 duodenal enterorrhaphies failed. All were associated with pancreatic injury versus none without (p < 0.05). The abdominal compartment syndrome occurred in three patients. In each case, breakdown of a small bowel anastomosis occurred. CONCLUSIONS (1) Stomach repair and small bowel and large-bowel enterorrhaphy may be safely accomplished in any setting. (2) Associated pancreatic injury is a risk factor for disruption of duodenorrhaphy. (3) In patients with massive blood and fluid administration, delay of bowel anastomoses should be considered. (4) Disruption of small bowel anastomoses is associated with abdominal compartment syndrome.
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Affiliation(s)
- S W Behrman
- University Medical Center, University of California San Francisco, Fresno Medical Education Program, USA
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Baker LW, Thomson SR, Chadwick SJ. Colon wound management and prograde colonic lavage in large bowel trauma. Br J Surg 1990; 77:872-6. [PMID: 2203507 DOI: 10.1002/bjs.1800770809] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Between 1983 and 1987 prograde colonic lavage was prospectively evaluated in 389 patients with colon trauma. Predefined high risk patients had exteriorization of the primarily sutured colon. Intraperitoneal primary closure was otherwise used. Patients received prograde colonic lavage by random allocation. The healing exteriorized colon was interiorized 5-10 days after the initial surgery. The median age was 29 years and only 28 patients were women. Injuries were due to stab (316), gunshot (54), shotgun (10) or blunt trauma (9). Exteriorization of the primarily sutured colon was carried out in 217 patients of whom 101 had prograde colonic lavage. Twenty (9 per cent) died. Of the survivors, 150 (76 per cent) had their colon successfully interiorized and this rate was unaffected by prograde colonic lavage. Intraperitoneal primary closure was performed in 172 patients of whom 91 had prograde colonic lavage. Seven (4 per cent) died. Mortality was directly related to the number of associated injuries. Prograde colonic lavage, irrespective of the type of colonic wound management used, did not reduce the mortality rate, which was 7.2 per cent for those who had such lavage and 6.6 per cent for the rest. Prograde colonic lavage cannot therefore be recommended in colon trauma.
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Affiliation(s)
- L W Baker
- Department of Surgery, University of Natal, Durban, South Africa
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Abstract
The evaluation and management of colon injuries have recently undergone significant changes. The time-honored philosophy of conservative management by repair and diversion is giving way to a more aggressive approach, which includes primary repair of many injuries. The role of colostomy has been challenged by the need for additional operative procedures, patient disability, and rising hospital and medical costs. Based on the current literature, the authors have come to the following conclusions: 1. Primary repair is safe in carefully selected cases. 2. Colostomy should not be abandoned because of a fear of the morbidity associated with its closure. 3. The difference between injuries on the right and the left is questionable and probably not as significant as previously thought. 4. Exteriorized repair frequently requires conversion to colostomy and probably has little indication for use. 5. Short-term perioperative single-antibiotic coverage is sufficient. 6. Use of drains cannot be supported in most instances. 7. Wounds are best left open in patients with significant contamination. Surgical judgment remains the final arbiter in the decision process. These controversies and the debate generated have sharpened the guidelines for that judgment.
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Affiliation(s)
- P J Huber
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas
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Nelken N, Lewis F. The influence of injury severity on complication rates after primary closure or colostomy for penetrating colon trauma. Ann Surg 1989; 209:439-47. [PMID: 2930290 PMCID: PMC1493972 DOI: 10.1097/00000658-198904000-00009] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The management of penetrating colon injury has been frequently debated in the literature, yet few reports have evaluated primary closure versus diverting colostomy in similarly injured patients. Diverting colostomy is the standard of care when mucosal penetration is present, but primary closure in civilian practice has generally had excellent results, although it has been restricted to less severely injured patients. Because the degree of injury may influence choice of treatment in modern practice, various indices of injury severity have been proposed for assessment of patients with penetrating colon trauma. As yet, however, there has been no cross-comparison of repair type versus injury severity. A retrospective study 76 patients who sustained penetrating colon trauma between January 1, 1979 and December 31, 1985 and who survived for at least 24 hours was conducted. Different preferences among attending surgeons and a more aggressive approach to the use of primary closure during the years of study led to an essentially random use of primary closure and diverting colostomy for moderate levels of colon injury, with mandatory colostomy reserved for the most serious injuries. Primary closure was performed in 37 patients (three having resection and anastomosis), and colostomy was performed in 39 patients. Severity of injury was evaluated by the Injury Severity Score (ISS), Penetrating Abdominal Trauma Index (PATI), and the Flint Colon Injury Score. Complications and outcome were evaluated as a function of severity of injury, and primary closure and colostomy were compared. Demographic profiles of the two groups did not differ regarding age, sex, mechanism of injury, shock, or delay between injury and operation. The mortality rate was 2.6% for each group. Major morbidity, including septic complications, occurred in 11% of the patients of the primary closure group and in 49% of those of the colostomy group. When PATI was less than 25, the Flint score was less than or equal to 2, or when the ISS was less than 25, primary closure resulted in fewer complications than did colostomy. Of the injury severity indices examined, the PATI most reliably predicted complications and specifically identified patients who whose outcome would be good with primary repair. These results suggest that the use of primary closure should be expanded in civilian penetrating colon trauma and that, even with moderate degrees of colon injury, primary closure provides an outcome equivalent to that provided by colostomy. In addition, the predictive value of the PATI suggests that it should be included along with other injury severity indices in trauma data bases.
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Affiliation(s)
- N Nelken
- Department of Surgery, University of California San Francisco, San Francisco General Hospital 94110
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Abstract
Colorectal injury remains a source of significant morbidity and mortality. Gunshot and stab wounds are the most common etiologic agents. Diagnosis is usually established on clinical grounds. For the purposes of management, the large bowel can be considered as colon and rectum. Minor colon injuries can be repaired primarily; management of major colon injuries or injuries associated with multiple organ involvement, significant blood loss, or massive contamination should be individualized. Diversion or exteriorization remains the gold standard of treatment when there is any doubt. Rectal injury should be repaired when feasible and diverted and the presacral space drained. Distal rectal washout is of proven merit. Antibiotics provide an important adjunct to therapy. They should be initiated early (preoperatively), ended quickly (12 to 72 hours postoperatively), and provide a broad spectrum of coverage. The treatment of established infection should be guided by bacterial culture. Postoperatively, aggressive support is important for a good outcome. The significant incidence of complications even in the face of optimal management demands continued vigilance and aggressive intervention by the operating surgeon.
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Abstract
During a 5 year period, 137 patients who sustained intraperitoneal colon injuries were retrospectively analyzed. One hundred fourteen were considered for evaluation. The method of colon wound management and infectious complications thought to be secondary to the colon wound were reviewed. These patients were admitted to the trauma service and underwent exploratory laparotomy for their injuries. The penetrating abdominal trauma index, as well as other risk factors, were evaluated for their efficacy in predicting potential complications associated with the colon wound. Sixty-four percent of patients were managed by primary closure, 27 percent by end colostomy or end ileostomy, and 9 percent by exteriorization of the injury. The complication rates for these categories were 18, 42, and 40 percent, respectively. There were no significant differences in complications in terms of location and mode of injury. This review confirms that the presence of shock, transfusion (4 or more units), significant contamination, and associated injuries (evaluated by the penetrating abdominal trauma index) contribute to the development of complications. There were no disruptions of the suture line in the primary closure group. We believe that infections and septic complications are secondary to the original injury to the colon and not related to the method of repair. Primary repair of all colon wounds not requiring resection may be feasible. Prospective evaluation of that approach is indicated.
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Affiliation(s)
- S M George
- Department of Surgery, University of Tennessee School of Medicine, Memphis
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Demetriades D, Rabinowitz B, Sofianos C, Prümm E. The management of colon injuries by primary repair or colostomy. Br J Surg 1985; 72:881-3. [PMID: 4063755 DOI: 10.1002/bjs.1800721110] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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