Management of colonic injuries in the setting of damage-control laparotomy: One shot to get it right

摘要

BACKGROUND: The optimal management of colonic injuries in patients requiring damage-control laparotomy (DCL) remains controversial. Primary repair, delayed anastomosis, or colostomy have all been advocated after DCL; however, some evidence suggests that colon-related complications are increased in patients with delayed primary fascial closure. We hypothesized that increased complications associated with colonic repair/anastomosis occur in those patients undergoing DCL who cannot achieve fascial closure on their initial reoperation. METHODS: A retrospective review of adult patients sustaining colonic injury between 2001 and 2010 who survived four or more days was performed. Patients were classified as having all their abdominal injuries managed during a single laparotomy (SL), DCL with complete treatment and fascial closure on the initial reoperation (DCL1), or DCL with open abdomen for more than two operations (DCL2). Data on postoperative complications and need for intervention were collected. Kruskal-Wallis analysis of variance was used to determine differences between groups. RESULTS: A total of 317 patients with colonic injuries were treated during the study period; 70 were excluded, leaving 247 patients as the study group. The group was primarily male (93%), with a mean age of 29 years. Ninety-two percent sustained penetrating injuries. Injury Severity Scores (ISSs) were similar between groups. Mean (SD) time for the DCL1 was 1.2 (0.6) days after injury and 4.1 (2.8) days for DCL2. Inability to achieve fascial closure by the time of the initial reoperation was associated with significant increase in intra-abdominal abscess (SL, 17% vs. DCL1, 31% vs. DCL2, 50%; p < 0.001) and anastomotic leaks (SL, 2% vs. DCL1, 2% vs. DCL2, 19%; p < 0.001). CONCLUSION: Primary repair or delayed anastomosis following DCL is feasible, with complication rates similar to SL when successful fascial closure is completed on the first post-DCL reoperation. However, if fascial closure is not possible on the second operation, patients should be treated with a stoma because there is an eightfold increase in the incidence of anastomotic leak. We believe that these data indicate that there is a single opportunity for reestablishing colonic continuity following DCL.