Chicago Metropolitan Trauma Society 4/15/2015 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.

Traumatic Colon Injury and Open Abdomen – Is anastomosis worth the risk? Greg Day MD Loyola University Medical Center

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 bilaterally

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 OR

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 resuscitation

Resuscitation In OR – 3L IVF, 12u PRBCs, 13u FFP, 2 Plt ICU Care – Hypoxemia resolved over next hours – Vasopressors weaned off – Acidosis resolved, base deficit cleared

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 later

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?

Colonic Anastomosis in Trauma

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?

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 normal

When is anastomosis appropriate? Difficult to study prospectively Most data at this time is retrospective in nature Why risk it? – Repeat operations incur high risk

-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 injury

68 Patients with DCS with colonic injury – 41 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 performed

Colon Anastomosis After Damage Control Laparotomy: Recommendations From 174 Trauma Colectomies Ott, 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 anastomosis

Colon Anastomosis After Damage Control Laparotomy: Recommendations From 174 Trauma Colectomies Ott, 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

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 abdomen

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.

Anticoagulation management after IVC ligation Harold Bach MD Loyola University Medical Center

AB 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 repaired

AB 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 exploration

AB 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.

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

Stabilized, taken back to OR PID #2 – Found 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

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

Abdominal IVC injuries Incidence – Penetrating 0.5-5% – Blunt 0.6-1% Mortality – 19%-66% in literature, widely reported around 40%

Rx: – Lateral venorrhaphy Patient stable Technically feasible Must have >25% luminal diameter remaining – IVC ligation Damage control

The first report of an IVC ligation was by Kocher (1883). Bilroth performed the procedure in – 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.

DeBakey et al reported the first large series of AVC injuries in – 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%.

It was also historically a procedure employed to halt the propogation of LE DVT prior to anticoagulation therapy.

Sequelae of IVC ligation In repaired IVC, recommend surveillance via US or CT Ligated IVC? Anticoagulation? Role of prophylactic fasciotomies?

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 - D

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 - E

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.