Hollow Viscus Injury:

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Hollow Viscus Injury The Evil that Lurks
Within(the Abdomen)
Sinai Hospital Dept of Surgery Trauma
Conference March 23, 2005 Case David
Hernandez Algorithm Michele Manahan Management
Dorry Segev
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Case Presentation
Initial Presentation
Previously healthy 4 year old boySeatbelt-restrai
ned MVC passenger 3/2/04Airway intact, no
respiratory distress.Hemodynamically
stable.Interactive. No abdominal pain. No
n/v.Supraumbilical ecchymosis.Head CT, Abdo CT
3/2 morning - negative.To PICU for observation.
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Case Presentation
Initial Observation
Developed fever in PICU.Abd still soft,
nondistended, nontender.Tachycardic. Hypoactive
bowel sounds.Repeat CT 3/2 evening free fluid
and free air.
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Case Presentation
Operative Findings
Exploratory laparotomy.Soiled ascites.Fibrinous
exudate on serosal surfaces of bowel.Serosal
tear distal ileum, oversewn.1 cm by 0.7 cm full
thickness hole in left colon.Primary repair 4-0
vicryl.Copious irrigation.Primary closure
including skin.Returned to PICU.
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Case Presentation
Postoperative ICU Course
Profoundly septic.Fluid seeking.Febrile.Vasopre
ssors for 36 hours.Significant abdominal wall
erythema.Extubated POD 2.Transferred to floor.
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Case Presentation
Postoperative Course
Persistent fevers.Broad spectrum abx.Bowel rest
/ TPN.Bilious vomiting. CT 3/8 minimal
undrainable fluid collections.
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Case Presentation
Continued Postop Course
Vomiting subsided. Diet advanced and
tolerated.Defervesced. Abx continued while in
hospital.CT 3/12 shown small loculated
abscesses.CT 3/16 not shown near-complete
resolution.
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Case Presentation
The Saga Continues
Discharged home POD 14.Well at home for
several days, low grade temps.Spiked another
fever 4 days after discharge.Seen in ER,
tolerating diet, benign abdomen.CT minimal
undrainable collections.Discharged home from ER.
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Diagnosis
Penetrating abdominal trauma Blunt abdominal
trauma Diagnostic Workup Indications for
Laparotomy
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Diagnosis
Penetrating Abdominal Trauma

• Immediately to OR if
• Diffuse abdominal tenderness
• No diffuse tenderness but hemodynamically labile
  without other injuries
• No diffuse tenderness, hemodynamically stable,
  left or right anterior thoracoabdominal injury
• Laparoscopy

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Diagnosis
Penetrating Abdominal Trauma

• Hemodynamically stable
• Observe stab wounds
• Consider CT in gun shot wounds and act
  accordingly

• Hemodynamically labile
• DPL
• If positive, to OR
• Resuscitation

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Diagnosis
Blunt Abdominal Trauma

• Immediately to OR if
• Diffuse abdominal tenderness

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Diagnosis
Blunt Abdominal Trauma

• Hemodynamically stable
• FAST (Focused Abdominal Sonogram for Trauma) AND
• CT
• Act according to findings

• Hemodynamically labile
• FAST
• If positive, to OR
• DPL
• If positive, to OR
• Resuscitation

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Management
Overview of Specific Injuries StomachSmall
BowelColon Duodenal and rectal omitted from this
discussion(too complex for my small brain)
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ManagementStomach
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ManagementStomach
Gastric Injury Scale
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ManagementStomach
Exposure
GE jxnDivide L triangular ligament,mobilize L
lobe of liver(watch vagus, anomalous L
hepaticin gastrohepatic ligament) FundusShort
gastrics(to get high on fundus) Posteriordivide
gastrocolic ligament along greater
curvature(dont injure transverse mesocolon /
middle colic)
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ManagementStomach
Operative Treatment
In an anterior hole is discovered, search for a
second oneGreater curvature, lesser curvature,
posterior can hide holes Air insufflation
through NG tube Gastrotomy and internal
inspection Also look for nearby
injuriesPresident William McKinley, 1901GSW to
abdomenSuccessful repair of multiple gastric
woundsLived for 8 days (mortality was gt80 at
this time)BUT pancreatic injury missed (this
did not happen at Hopkins)
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ManagementStomach
Operative Treatment
Grade I, II Two layer primary closure Inner
running licked vicryl (hemostatic) Outer
interrupted seromuscular silkGrade III Primary
hand-sewn or stapled closure Attention to
avoidance of GE or pyloric stenosisGrade IV
Proximal or distal gastrectomy Bilroth I or II
reconstruction May require roux-en-Y Based on
other injuries found
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ManagementSmall Bowel
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ManagementSmall Bowel
Small Bowel Injury
Much less common in blunt than penetratingNonethe
less, 3rd most common blunt abdominal
injuryMechanism Crushing of bowel against
the spine Sudden deceleration sheering of the
bowel from its mesentery at a fixed point
Bursting of pseudo-closed-loop from sudden
increase in intraluminal pressure
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ManagementSmall Bowel
Small Bowel Injury Scale
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ManagementSmall Bowel
Treatment Grade I
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ManagementSmall Bowel
Treatment Grade II
Transverse closure preferred (if possible)
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ManagementSmall Bowel
Treatment Grade III
No difference in hand-swen vs. stapled (Witzke, J
Trauma, 2000)No difference in 1 vs. 2-layer
anastomosis (Burch, Ann Surg, 2000)
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ManagementSmall Bowel
Treatment Grade IV
Damage ControlCan staple both ends, control
other intra-abdominal damage, resuscitate in ICU,
and return to OR in 24-48 hrs for delayed primary
anastomosis(Carillo, J Trauma, 1993)
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ManagementSmall Bowel
Treatment Grade V
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ManagementSmall Bowel
Postoperative Care
24 hrs perioperative abx if this is the only
injuryNG decompression until ileus resolves
Multi-injured patients have slower return of
bowel fxn Can decompress stomach if jejunal
feeds used (Am Surg 1996) Moderately to
severely injured patients (ISS between 16 and 25)
do better with enteral feeds started 24-48 hrs
postop (Moore, Ann Surg, 1992, many other
papers)High risk of abscess (10-20), almost
always drain percutaneously10 postop bowel
obstruction, wait 10-14 days and r/o abscess by
CT scan before re-exploring (Pickleman, Ann Surg,
1989)
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ManagementColon
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ManagementColon
Historical Notes Backwards as Usual
Gordon-Taylor G. Br J Surg 1942.Most colonic
injuries can be fixed primarily, avoid resection,
proximal colostomies possibly for extensive
injury or descending colon injury. 50
Mortality.Ogilvie WH. Surg Gynecol Obstet
1944.Colostomy for colon injuries. 60
Mortality.Led to Circular Letter 178, Office of
the Surgeon General of the United States,
mandating colostomy for all colonic
injuries.Improvement in postoperative care
towards the end of WWII led to 5-20 mortality,
credited incorrectly to use of colostomy.Woodhal
l, Ochsner. Surgery 1951. Re-introduced primary
repair.
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ManagementColon
Colonic Injury Scale
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ManagementColon
Intraoperative Diagnosis
Injuries distributed evenly throughout the
colon Sometimes even difficult to diagnose
intra-operativelyExplore allBlood staining /
hematoma on colonic wallInjured mesentery in
proximity to colonic wall (may even need to
divide one or two terminal mesenteric vessels for
exposure)Mobilize all colon in injured
areasFollow trajectories if possibleMilk
luminal contents through areas of suspicion
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ManagementColon
Suture Repair
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ManagementColon
Resection and Primary Repair
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ManagementColon
End colostomy
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ManagementColon
Exteriorization
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ManagementColon
Factors Determining Optimal Tx
Shock (preoperative BP lt 80/60)Hemorrhage (blood
loss gt 1L)Multiorgan injury (gt2 organ
systems)Significant peritoneal soilageDelayed
operation (gt8 hrs post injury)Nonviable colon
(wall destruction or ischemia)Major loss of
abdominal wall (close range blast
injury)Location of injury (distal vs. proximal
to middle colic)
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ManagementColon
Sample Algorithm
Resection required?
NO
YES
Suture Repair
Proximal to MCA?
YES
NO
Resection and ileocolostomy
Evaluate Local ConditionsResection and
Colocolostomy vs. Hartmanns
39
Literature
Recent Literature Review Controversies Pediatric
Trauma
40
Literature
Williams, Watts, Fakhry. Colon Injury after
Blunt Abdominal Trauma Results of the EAST
Multi-institutional Hollow Viscus Injury Study. J
Trauma. 2003 55906-912.

• 227,972 blunt trauma patients retrospectively
  reviewed from 95 trauma centers over 2 years
  (1998-9). 2,632 (1) with viscus injury (798
  colonic).
• No findings on exam, imaging, or in logistic
  regression model could discriminate injury to the
  colon

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Literature
Williams, Watts, Fakhry. Colon Injury after
Blunt Abdominal Trauma Results of the EAST
Multi-institutional Hollow Viscus Injury Study. J
Trauma. 2003 55906-912.
Diagnostic Modalities (sensitivity/specificity)
42
Literature
Williams, Watts, Fakhry. Colon Injury after
Blunt Abdominal Trauma Results of the EAST
Multi-institutional Hollow Viscus Injury Study. J
Trauma. 2003 55906-912.
Complications
43
Literature
Fakhry, Watts, Luchette. Current Diagnostic
Approches Lack Sensitivity in the Diagnosis of
Perforated Blunt Small Bowel Injury (SBI). J
Trauma. 2003 54295-306.

• 227,972 blunt trauma patients retrospectively
  reviewed from 95 trauma centers over 2 years
  (1998-9). 2,632 (1) with viscus injury (2,457
  small bowel). Only 25 had transmural injuries
  (others were hematomas, serosal tears).
• Higher morbidity (13.4 vs. 28.9) and mortality
  (13.8 vs. 19.0) in patients with SBI,
  independent of injury mechanism, controlling for
  ISS.

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Literature
Fakhry, Watts, Luchette. Current Diagnostic
Approches Lack Sensitivity in the Diagnosis of
Perforated Blunt Small Bowel Injury (SBI). J
Trauma. 2003 54295-306.

• Early detection (lt24h vs. gt24h) fewer overall
  and infectious complications (abscess, sepsis,
  wound dehiscence, plt0.05). Mortality with repair
  lt24hrs 4 vs. 15 for delayed repair.
• No combination of findings in logistic
  regression model yielded appreciable sensitivity
  and specificity. Best one was abd tenderness,
  peritoneal signs, and free fluid on CT without
  solid organ injury 56.1 sensitivity, 94.4
  specificity.

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Literature
Fakhry, Watts, Luchette. Current Diagnostic
Approches Lack Sensitivity in the Diagnosis of
Perforated Blunt Small Bowel Injury (SBI). J
Trauma. 2003 54295-306.
Mechanisms
46
Literature
Fakhry, Watts, Luchette. Current Diagnostic
Approches Lack Sensitivity in the Diagnosis of
Perforated Blunt Small Bowel Injury (SBI). J
Trauma. 2003 54295-306.
Diagnostic Findings( with perf, with nonperf
SBI, with no SBI)
47
Literature
Demetriades, Murray et al. Penetrating Colon
Injuries Requiring Resection Division or Primary
Anastomosis? J Trauma. 2001 50765-775.

• AAST Prospective Multicenter Study, 19 centers,
  2 years (1998-2000). 297 patients enrolled 197
  primary, 100 diversion.
• Non-randomized -gt surgeons choice.
• Colon-related Mortality 4 diversion, 0
  primary Colon-related Morbidity 27
  diversion, 22 primary Not statistically
  significant

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Literature
Demetriades, Murray et al. Penetrating Colon
Injuries Requiring Resection Division or Primary
Anastomosis? J Trauma. 2001 50765-775.

• Only 3 independent risk factors for abdominal
  complications 1. Severe fecal contamination (RR
  1.71) 2. Transfusions gt4 U PRBC within first 24
  hrs (RR 2.0) 3. Single agent abx prophylaxis (RR
  1.75)
• NOT type of repair
• Multivariate analysis (adjusting for above 3
  factors), no statistically significant difference
  in outcome

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Literature
Demetriades, Murray et al. Penetrating Colon
Injuries Requiring Resection Division or Primary
Anastomosis? J Trauma. 2001 50765-775.
Factors (Primary repair, Diversion)
Outcomes (Primary repair, Diversion)
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Literature
Demetriades, Murray et al. Penetrating Colon
Injuries Requiring Resection Division or Primary
Anastomosis? J Trauma. 2001 50765-775.
High Risk Patients Only(gt6 hrs from injury,
severe contamination, high ISS, gt6 U PRBC,
hypotensive on arrival)
Outcomes (Primary repair, Diversion)
none of the above were statistically significant
51
Literature
Velmahos, Demetriades, et al. Selective
Nonoperative Management in 1,856 Patients with
Abdominal Gunshot Wounds. Ann Surg. 2001
234(3)395-403.

• 8 year period at one trauma center, 1856
  patients seen with abdominal GSW. 1405 anterior.
  451 posterior.
• 792 managed nonoperatively (34 anterior, 68
  posterior).
• Exclusion criteria peritonitis, hemodynamic
  instability, unreliable exam

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Literature
Velmahos, Demetriades, et al. Selective
Nonoperative Management in 1,856 Patients with
Abdominal Gunshot Wounds. Ann Surg. 2001
234(3)395-403.

• 4 progressed to delayed laparotomy only 61
  needed even this laparotomy 0.3 had
  complications related to delay of
  operation (abscess, pneumonia, ileus)
• Cost analysis routine laparotomy 47 would
  have been unnecessary 3560 hospital days
  saved 10 million saved

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Literature
Velmahos, Demetriades, et al. Selective
Nonoperative Management in 1,856 Patients with
Abdominal Gunshot Wounds. Ann Surg. 2001
234(3)395-403.
Laparotomies (Anterior, Posterior GSW)
54
Literature
Velmahos, Vassiliu, et al. Wound management
after colon injury A prospective randomized
trial. Am Surg. 2002 68(9)795-801.

• Two years (1998-2000) two groups 1. 48
  patients in a randomized trial 2. Prospective
  evaluation at surgeon discretion
• Univariate, multivariate analysis to identify
  independent risk factors for wound infection,
  dehiscence, and necrotizing soft tissue infection

55
Literature
Velmahos, Vassiliu, et al. Wound management
after colon injury A prospective randomized
trial. Am Surg. 2002 68(9)795-801.

• Two years (1998-2000) two groups 1. 48
  patients in a randomized trial 2. Prospective
  evaluation at surgeon discretion
• Univariate, multivariate analysis to identify
  independent risk factors for wound infection
• Wound infection can lead to dehiscence and
  necrotizing soft tissue infection

56
Literature
Velmahos, Vassiliu, et al. Wound management
after colon injury A prospective randomized
trial. Am Surg. 2002 68(9)795-801.

• Wound infection rate Randomized Closed 65
  Open 36 Nonrandomized Closed 29 Open 15
• Independent risk factors for wound
  infection Primary closure (OR 5.5) Colectomy
  (OR 3.4) Intra-abdominal infection (OR 5.3)

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Literature
Canty, Canty, Brown. Injuries of the GI Tract
from Blunt Trauma in Children A 12-year
Experience at a Designated Pediatric Trauma
Center. J Trauma. 1999 46234-240.
Single center. 11,592 children evaluated. 79 with
blunt GI tract injury.
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Summary
Diagnosis of hollow viscus injury is difficult,
challenges even modern diagnostic modalities, and
requires a high degree of suspicionNonoperative
management is still possible but requires
compulsive patient monitoringOutcomes improve
if the evil that lurks within the abdomen is
diagnosed and treated early
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You see what you look for Stephen Sondheim