1. General and Trauma Surgery, University of São Paulo, Brazil
Colon Degloving Resulting From Seat Belt Syndrome - A Potentially Life-Threatening Injury
Couto Netto SD, Teixeira F, Menegozzo CAM, Junior D, Fontes B, Collet e Silva F, Bernini CO, Utiyama EM
General and Trauma Surgery, University of São Paulo, Brazil
INTRODUCTION Blunt abdominal trauma represents 5% of colon injuries, most frequently in the mobile segments of the colon. These injuries may compromise the bowel wall and/or mesentery. Of these, colonic deglovement associated with seat belt sign are quite rare. Mucosal ischemia and perforation may occur if not promptly identified [1]. These injuries results from thoracoabdominal compression against the seat belt causing shearing forces that tear de inner muscularis from the mucosa [2] . Delayed treatment may result in higher morbidity and mortality [1]. We report two cases of degloving colonic injuries as a result of seat belt syndrome after motor vehicle accident, one being a child. Both patients had the seat belt sign. Moreover, both were treated surgically with resection and primary anastomosis.
After stabilization, whole body CT showed ribs and sternum fractures, left pneumothorax, free abdominal fluid and mesenteric hematoma. After pleural drainage, he was take to the OR for emergency laparotomy. A 25cm-long degloving injury was found at the sigmoid, with no mucosal injury, 1L of blood and mesenteric bruising near the ileocecal valve. Resection and primary anastomosis was performed. His recovery was unneventful, with 2 days in the ICU, chest drain removal on day 5, and hospital discharge on day 10. Long-term follow-up revealed no complications.
CASE REPORTS
A 5-year-old female patient was involved in a lateral vehicel collision. She was seating in the back of the car wearing a two-point seat belt. She arrived both hemodinamically and neurologically intact, complaining of lower abdominal pain, and showing no peritonitis but the seat belt sign upon physical exam. FAST, and chest and pelvis X-rays, were negative but further evaluation with whole body CT scan showed free fluid.
She was taken to the Operating Room for a diagnostic laparoscopy. A 5cm degloving injury of the sigmoid was found, along with 300cc of blood in the abdominal cavity. The procedure was converted to a low-midline laparotomy, followed by sigmoidectomy with primary colonic anastomosis (Fig 1, 2, 3). Post-operative course was unneventful and she was discharged on the 7th post-operative day. Follow-up was also unneventful.
Figure 4
Figure 5
DISCUSSION
Colonic deglovement injuries as a result of blunt trauma are rare, specially in children. Diagnosis is seldom made preoperatively, despite the high sensitivity of CT scan in abdominal trauma [3]. They are often found incidentally during laparoscopy or laparotomy.
Surgery is indicated mainly in three situations: signs of peritonitis, free fluid on CT without visceral organ injury, and persist abdominal pain. A high index of suspicion is required, as delayed treatament results in higher mortality [1, 5].
Intraoperative decisions rely basically in the extent of the injury and the hemodynamically condition of the patient. Both of our patients had favorable conditions and successfully underwent primary anastomosis.
The presence of the seat belt sign warrants further evaluation of the patient with CT scan, since it suggests a high energy mechanism. Prompt identification of such scenarios can improve both morbidity and moratlity [4].
Figure 1
Figure 2
REFERENCES
Choi WJ, Management of Colorectal Trauma. J Korean Soc Coloproctol 2011;27(4):
Slavin RE, Borzotta AP. The Seromuscular Tear and Other Intestinal Lesions in the Seat Belt Syndrome: A Clinical and Pathologic Study of 29 Cases. The Am J of Forensic and Med Pathol 2002;23(3):
Griffin XL, Pullinger R. Are diagnostic peritoneal lavage or focused abdominal sonography for trauma safe screening investigations for hemodynamically stable patients after blunt abdominal trauma? A review of the literature. J Trauma 2007;62:
Keller MA, Blewett CJ. Traumatic sigmoid degloving injuries in the pediatric population. Am Surg. 2011;77:509-10
VanderKolk WE, Garcia VF. The use of laparoscopy in the management of seat belt trauma in children. J Laparoendosc Surg. 1996 Mar;6 Suppl 1:S45-9
Figure 3
The second patient was a 45-year-old male involved in a car accident, arriving with tachicardia and pallor, with abdominal and chest pain, and a seat belt sign. Pelvic X-ray showed a pubic stable fracture.