Chicago Metropolitan Trauma Society - PowerPoint Presentation

Slide1

Chicago Metropolitan Trauma Society4/15/2015

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. Slide2

Traumatic Colon Injury and Open Abdomen – Is anastomosis worth the risk?

Greg Day MD

Loyola University

Medical CenterSlide3

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 bilaterallySlide4

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 ORSlide5

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 resuscitationSlide6

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 clearedSlide7

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 laterSlide8

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? Slide9

Colonic Anastomosis in TraumaSlide10

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?Slide11

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 normalSlide12

When is anastomosis appropriate?

Difficult to study prospectively

Most data at this time is retrospective in nature

Why risk it?

Repeat operations incur high riskSlide13

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 injurySlide14

68 Patients with DCS with colonic injury41 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 performedSlide15

Colon Anastomosis After Damage Control Laparotomy: Recommendations From 174 Trauma ColectomiesOtt

, 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 anastomosisSlide16

Colon Anastomosis After Damage Control Laparotomy: Recommendations From 174 Trauma ColectomiesOtt

, 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. MDSlide17

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 abdomenSlide18

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. Slide19

Anticoagulation management after IVC ligation

Harold Bach MD

Loyola University Medical CenterSlide20

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 repairedSlide21

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 explorationSlide22

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.Slide23

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 2767036Slide24

Stabilized, taken back to OR PID #2Found 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 2767036Slide25

Returned to OR 2x more, eventually closed with feeding jejunostomy tube placed

Post op course complicated by patient self-discontinuing retroperitoneal drains requiring IR replacement

Began on

coumadin

, discharged home

AB 2767036Slide26

Abdominal IVC injuries

Incidence

Penetrating 0.5-5%

Blunt 0.6-1%

Mortality

19%-66% in literature, widely reported around 40%Slide27

Rx:Lateral venorrhaphy

Patient stable

Technically feasible

Must have >25% luminal diameter remaining

IVC ligation

Damage controlSlide28

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. Slide29

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%. Slide30

It was also historically a procedure employed to halt the

propogation

of LE DVT prior to anticoagulation therapy.Slide31

Sequelae of IVC ligation

In repaired IVC, recommend surveillance via US or CT

Ligated IVC?

Anticoagulation?

Role of prophylactic

fasciotomies

?Slide32

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 - DSlide33

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 - ESlide34

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. Slide35