To explore the clinical characteristics and treatment methods of colonic injury to improve the efficacy. Methods The clinical data of 81 patients with colonic injury admitted from 2004 to 2007 were retrospectively analyzed. Results: 81 patients were treated surgically, 74 cases (91%) were cured and 7 cases (0.08%) died. There were 75 cases (92%) of first-stage surgery, 6 cases (8%) of second-stage surgery, 2 cases of early return colostomy after injury, and 4 cases of late return colostomy.
Conclusion Phase I surgery for colonic injury is an ideal and feasible surgical method, but its indications must be strictly mastered; Phase II surgery can improve patients’ quality of life and shorten treatment time by early reduction of colostomy.
Colon injury is a relatively common clinical injury to abdominal organs, and its incidence accounts for 10%-22% of abdominal trauma [1]. 81 cases of colon injury admitted to our hospital between February 2004 and September 2007 are collected, and their characteristics and treatment are reported as follows.
I. Data and methods
1.1 General information
This group of 81 cases, including 74 male cases, 7 female cases, age 17 to 78 years old, including 44 cases of penetrating injuries, 37 cases of blunt injuries. Causes of injury: 36 cases of stab wounds, 8 cases of gunshot wounds, 24 cases of car accident wounds, 9 cases of impact wounds, 2 cases of high-pressure air wounds, and 2 cases of medical origin wounds.
1.2 Injury site and combined injury situation
There were 20 cases of ascending colon, 31 cases of transverse colon, 18 cases of descending colon and 12 cases of sigmoid colon. There were 47 cases of right hemicolectomy injury and 34 cases of left hemicolectomy injury.
There were 28 cases of simple colon injury, 53 cases of combined injury, including 16 cases of combined small bowel injury, 10 cases of spleen injury, 6 cases of liver injury, 3 cases of pancreatic injury, 5 cases of stomach injury, 2 cases of duodenal injury, 17 cases of omental or mesenteric injury, 1 case of diaphragm injury, 5 cases of chest injury, 2 cases of head injury, 3 cases of kidney injury, 2 cases of bladder injury, 4 cases of pelvic fracture, 6 cases of retroperitoneal hematoma, and 14 cases of combined 2 or more organ injuries in 14 cases.
1.3 Auxiliary examination
Diagnostic laparotomy was performed in 56 cases, including 30 cases with turbid non-coagulable blood fluid and 18 cases with purulent fluid, with a positive rate of 85%, and abdominal X-ray examination was performed in 36 cases, with free intra-abdominal gas signs seen in 24 cases, with a positive rate of 67%.
1.4 Grading of injury and abdominal cavity contamination
Colorectal injuries were graded according to the American OIS Committee, with 5 cases of grade I, 39 cases of grade II, 31 cases of grade III, 5 cases of grade IV, and 1 case of grade V. The degree of abdominal cavity contamination was graded according to Sakaki [3], with 10 cases of mild, 63 cases of moderate, and 8 cases of severe.
1.5 Treatment methods
First-stage surgery: 44 cases of simple sutured intestinal repair and 31 cases of resection anastomosis, totaling 75 cases (92%). Second-stage surgery: 6 cases of intestinal repair or resection anastomosis plus proximal colostomy, 2 cases of early reduction colostomy within 15 d after injury, and 4 cases of late reduction colostomy after 3 months after injury.
II. Results
In this group, 81 cases were treated surgically, 74 cases were cured (91%), 7 cases died (0.08%), the causes of death: 3 cases of serious multi-organ injury, 3 cases of abdominal and systemic infection, and 1 case of multi-organ failure. There were 75 cases of first stage surgery and 2 cases of postoperative complications of intestinal fistula, including 1 case of death due to severe abdominal infection.
III. Discussion
In recent years, due to colostomy, the application of antibiotics, early definitive surgery and other factors, the mortality rate after simple colon injury has been reduced to 4%-10%, but the complication rate is still as high as 15%-50%, the main reason for this is related to the characteristics of colon injury.
Because the colon is full of feces, containing a large number of bacteria, once the intestinal tube rupture, it is easy to contaminate the abdominal cavity, causing serious infection, and ascending and descending colon is more fixed, interposition organs, easy to miss after the injury and lead to retroperitoneal infection; in addition, the colon wall is thin, poor blood circulation, weak healing ability, high pressure in the colon cavity, postoperative intestinal flatulence often occurs and cause complications such as rupture of the suture or anastomosis.
The diagnosis of typical colonic injury is not difficult and is mainly based on medical history, abdominal physical examination, diagnostic laparotomy, abdominal X-ray, hematological examination, and laparoscopy.
However, due to the diversity of colonic injury, insidiousness, as well as the multiple complications of other intra-abdominal organ injuries, and therefore often masked by bleeding, peritonitis, shock, etc.; coupled with the current auxiliary tests are of limited help in the localization and diagnosis of colonic injury, and the preoperative diagnosis can be confirmed less, the current diagnosis of colonic injury is still mainly dependent on abdominal exploration, how to correctly diagnose colonic injury at an early stage, even before the emergence of abdominal contamination, and timely surgery is still for clinicians. How to correctly diagnose colonic injury at an early stage, even before the emergence of abdominal contamination, and operate in a timely manner is still a challenge for clinicians.
The principles of colon injury management are early surgery, removal of necrotic intestinal segments, thorough flushing of the abdominal cavity and adequate drainage, and the specific use of phase I or phase II surgery is still controversial. The main common surgical methods are direct repair or resection and anastomosis of the injured intestinal segment in the first stage and colostomy or external placement in the second stage, and later on, rejection. In our group, there were 75 cases of phase I surgery, accounting for 92%, but 2 cases of postoperative intestinal leakage occurred, both of which were elderly patients, aged over 70 years, and one of them died due to severe abdominal infection.
Therefore, we believe that the following principles should be strictly followed for one-stage surgery.
1, preoperative shock is not heavy, blood loss is less than 20% of normal blood volume;
2, definitive surgery within 6-8h after injury;
3, mild abdominal contamination;
4, less than or equal to 2 visceral injuries;
5, no extensive abdominal wall tissue defects;
6, colonic injury is relatively limited, can be closed in one phase, the injury does not involve the mesentery;
7, age less than 60 years. Although the second-stage surgery has the disadvantages of increasing the patient’s pain and requiring reoperation, most scholars now believe that the principle of “Damage Control Surgery (DCS)” should be followed first for rescuing patients with severe trauma. Therefore, for those who do not have the above-mentioned conditions for the first-stage surgery of colon injury, they should adopt the second-stage surgery.
In this group, there are 6 cases of second-stage surgery, among which 2 cases were treated with early colostomy within 15 d after the injury, and the patients were cured. Therefore, we believe that early return is a measure to reduce the patient’s pain and promote rapid recovery, but should strictly grasp the indications, mainly for the first operation without serious complications, good postoperative recovery, good general condition, no abdominal wall incision infection, barium enema or enteroscopy, etc. to confirm the wound has healed on the distal and proximal side of the colon.
Control of infection is another major means of treating colonic injury, which often leads to abdominal infection and peritonitis due to contamination of the abdominal cavity with colonic contents after colonic injury, and Poret reported an infection rate of 26%. In this group of patients, antibiotics were used before or during surgery, thorough debridement was made during surgery, and a large amount of saline plus antibiotic solution was used for abdominal lavage, adequate drainage was placed after surgery, and strong, broad-spectrum antibacterial drugs were applied intravenously after surgery, but there were still three cases of death due to serious abdominal infection or secondary systemic infection that could not be controlled.
In conclusion, simple colonic injury is not immediately life-threatening, but untimely and inappropriate treatment can lead to serious consequences. When combined with other organ injuries, the principle of life-saving first should be followed, and the operation should be simple and reliable without pursuing one-stage surgery or two-stage surgery. In addition, adequate intraoperative abdominal drainage and attention to perioperative management are also one of the important measures in the treatment of colonic injury.