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Colorectal Trauma
SeanC.Glasgow andFiaYi
51
Colon Trauma Refer toAlgorithm
inFig. 51.1
A. Trauma to the colon is almost always the
result of penetrating mechanisms such as
stabbings or gunshot wounds, with the transverse colon being most prone to injury. The
diagnosis of blunt colonic trauma requires a
high-degree of suspicion. For either mechanism, CT scanning remains the most sensitive
test. Findings of extraluminal gas, signicant
free uid, bowel wall thickening, segmental
loss of contrast enhancement, contrast extravasation from the mesentery, or location adjacent to suspected bullet trajectory all suggest
a potential colon injury (Fig.51.2). Although
some patients with low-velocity penetrating
abdominal trauma may treated with serial
examinations or diagnostic laparoscopy,
patients with frank peritoneal signs or the
above CT ndings should undergo prompt
exploratory laparotomy following initial
resuscitation and evaluation.
B. While the Organ Injury Scale (Table 51.1)
offers precise classication, generally speak-
S. C. Glasgow (*)
Department ofSurgery, Washington University
School ofMedicine, St. Louis, MO, USA
e-mail: glasgows@wustl.edu
F. Yi
San Antonio Military Medical Center,
Houston, TX, USA
ing, colon trauma can be viewed as either
destructive or non-destructive. The latter
encompasses grade I and II injuries, and
includes serosal tears without lumen perforation, hematomas resulting from projectile cavitation, and simple perforations involving less
than half the circumference of the bowel wall.
Non-destructive wounds occur more commonly in low-velocity penetrating trauma.
C. Primary repair of non-destructive colon
wounds has been shown conclusively to be
safe and results in fewer infectious complications than routine fecal diversion. Importantly,
primary repair includes either simple suture
repair or resection with primary anastomosis.
Suture repairs are generally performed in two
layers, with the rst layer achieving approximation of healthy mucosa (limited debridement of wound edges may be indicated) and
the second layer of Lembert sutures ensuring
complete inversion of the closure.
Traditionally, left-sided colon trauma was
more frequently diverted than repaired relative to right-sided injuries. However, several
studies have shown no difference in leak or
complication rates based on anatomic area of
injury. The fundamental surgical aspects of
ensuring healthy, well-perfused, and tensionfree bowel in the repair remain key.
D. Destructive colon injuries often occur follow-
ing high-velocity penetrating trauma or major
deceleration mechanisms. These injuries will
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_51
393
394
S. C. Glasgow and F. Yi
Fig. 51.1 Algorithm for managing colon trauma. DCS damage control surgery, pRBC packed red blood cells,
hrs hours
Fig. 51.2 CT image showing extraluminal gas and bowel
wall thickening, suggestive of right-sided colonic injury
following transabdominal gunshot wound
always require at least segmental colon resection in order to control hemorrhage and fecal
spillage. Injury to multiple intra-abdominal
organs is likely. Initial steps following generous laparotomy are four-quadrant packing
with surgical sponges, careful clamping of
Table 51.1 Colon Injury Scale
Grade
I Hematoma Contusion or hematoma with
II Laceration Laceration <50% of
III Laceration
IV Laceration Transection of the colon
V Laceration Transection of the colon with
Colon injury scale, adapted from Moore etal.
Type of
injury Description
devascularization
Laceration Partial thickness, no
perforation
circumference
Laceration ≥50% of
circumference without
transection
segmental tissue loss
Vascular Devascularized segment
obvious bleeding vessels, and rapid closure of
open bowel injuries using Babcock clamps,
umbilical tape, or GIA staplers to control
contamination.
E. While there is no level I evidence supporting
the use of damage control surgical (DCS) techniques, the perceived benets of DCS following major abdominal trauma are clear. The
goals of DCS are to control active hemorrhage
51 Colorectal Trauma
395
and limit on-going gastrointestinal spillage in
a rapid manner, thereby allowing active resuscitation and correction of acid- base and coagulation disorders. After initial surgical measures,
the abdomen is closed temporarily using a
vacuum-type dressing and the patient is moved
to the intensive care unit for further care.
Reconstructive efforts such as enteric anastomoses are deferred until the patient is more
stable and typically performed at a second
operation in 24–48h after initial laparotomy.
F. Many factors inuence the surgeon’s decision
on whether to perform DCS. These may
include: (a) metabolic derangement [e.g. hypothermia, pH<7.2, elevated INR or abnormal
thromboelastogram (TEG)], (b) injury-specic
factors such Injury Severity Scale (ISS) over
25, injury to multiple body regions, blast or
high-velocity wounds, (c) sustained hemodynamic instability or massive transfusion
requirement, (d) environment- specic factors
such as surgeon experience and institutional
capabilities. If DCS is selected, any colon
wounds should be expeditiously closed using
GIA or TA staplers to limit on-going peritoneal contamination. Limited peritoneal irrigation with warm saline is done to remove gross
fecal spillage. Segmental resection of clearly
necrotic or destroyed segments may be performed quickly. Active bleeding from the mesentery should be oversewn but is not an
absolute indication for colectomy at the initial
operation. No attempt at anastomosis or
ostomy should be made; the bowel may be
safely left in discontinuity for up to 72 h,
though a secondary evaluation at 12–24h is
often performed.
G. Largely based on extensive study from the
University of Tennessee in Memphis, major
co-morbidities and an intraoperative transfusion requirement greater than 6 units of
packed red blood cells (RBCs) have consistently been shown to increase anastomotic
leak in colon trauma patients (upwards of
40%). Although patient co-morbidities may
not be immediately known upon presentation
to the emergency room following trauma,
suspicion of cirrhosis, congestive heart failure, poorly controlled diabetes or other sig-
nicant disease should lead the surgeon to
favor fecal diversion. Signicant transfusion
requirement, whether due to intra-abdominal
or other hemorrhage, remains a contraindication for primary anastomosis out of concern
for hypoperfusion.
H. Assuming a relatively stable patient without
indication for DCS or major co-morbidities,
resection and primary anastomosis is a safe
option for destructive colon injuries. This
approach should be favored over fecal diversion due to lower rates of infectious complications. The anastomosis may be accomplished
in either a hand-sewn or stapled manner.
Proximal fecal diversion is not typically
employed or necessary, and drains should be
used selectively.
I. Fecal diversion remains a reasonable option
for destructive wounds in the setting of ongoing bleeding, signicant co-morbidities, or
prolonged “open abdomen” after initial
DCS.Unfortunately, trauma ostomies are frequently not reversed, with studies indicating a
50% permanent diversion rate. When indicated, colostomy or ileostomy (for right- sided
colon injuries) should be created through the
rectus sheath. Eversion of the bowel wall in a
Brooke manner aids with ostomy pouching
and is encouraged, even for colostomies. In
some instances, a loop colostomy may be useful (e.g., sigmoid colon injury with concurrent
complex open pelvic fracture), but most commonly end-stomas are created.
J. Early in the adoption of DCS, surgeons noted
that leak rates from colonic anastomoses performed during the second-look operation far
exceeded the rates of those created during
single laparotomy. Similarly, failure to
achieve fascial closure at the initial take-back
and prolonged “open abdomen” are risk factors for both intra-abdominal abscess and
anastomotic leak. Potential causes for these
worse outcomes include generalized bowel
wall edema, prolonged resuscitation requirements, and sepsis from fecal spillage or other
infectious sources. Collectively, the data suggest that performing a colostomy is safer for
patients in whom the abdominal fascia cannot
be closed within 48h of injury.
396
S. C. Glasgow and F. Yi
K. Under select circumstances, delayed primary
anastomoses of the colon may be created following DCS. The patient should be fully
resuscitated and other major intra-abdominal
injuries denitively treated (e.g., hepatic
embolization, vascular repairs). Additionally,
certain injury patterns may preclude safely
re-establishing colon continuity. For instance,
destructive colon wounds with concurrent
traumatic pancreatic disruption should be
treated with colostomy, regardless of other
factors.
Rectal Trauma Refer toAlgorithm in
Fig.51.3
A. Rectal trauma is almost always penetrating,
with gunshot injuries comprising a majority of these injuries and stabbings a smaller
portion. Blunt trauma is rarely a primary
cause of rectal injuries given the rectum’s
anatomic location within the pelvis, though
bony fractures in the pelvis can cause collateral injury to the rectum. The most com-
mon injury pattern associated with rectal
injury is anteroposterior compression pelvic fracture which has been seen in up to
75% of patients with blunt rectal injury.
Injuries can be classied as destructive vs.
non-destructive or more categorically using
the Organ Injury Scale (Table51.1). Rectal
injuries should also be described according
to the location of the trauma in relation to
the peritoneal reection (intra- vs.
extraperitoneal).
Performance of a digital rectal examination (DRE) alone is not a reliable indicator of
rectal trauma. Recent trauma literature
reported the clinical reliability and signicance of DRE compared to other clinical
indicators (OCI) as part of the primary and
secondary survey. Abnormalities on DRE are
half as likely to identify a rectal injury compared to OCIs. DRE does provide useful
information regarding anal sphincter tone
which may alter surgical plans. Overall, the
recommendation is for combined CT and
proctosigmoidoscopy in determining presence of a rectal injury.
Fig. 51.3 Algorithm for managing rectal trauma
51 Colorectal Trauma
397
B. The proximal portion of the intraperitoneal
rectum is anatomically identied by the
splaying of the teniae coli. The distal extent is
considered to be at the peritoneal reection.
The extraperitoneal portion is the distal
remainder down to the anal canal. The rectal
injury scale (Table51.1) is largely similar to
the colon injury scale.
C. Identifying and distinguishing rectal injuries
often requires high clinical suspicion in the
context of the mechanism of injury combined
with diagnostic and physical examination.
Intraperitoneal rectal injuries will often manifest similarly to colon injuries with the ndings of free air, extraluminal air, unexplained
intra-abdominal uid, and oral or rectal contrast extravasation. Because of the extraperitoneal nature of the distal rectum, injuries are
often difcult to identify and can be missed.
Multi-detector computed tomography (CT) is
useful in detecting penetrating injuries to the
rectum, with the most sensitive nding being
the presence of a trajectory to the bowel and
the most specic being contrast extravasation
or the identication of a clear mural defect in
the wall of the rectum.
D. The surgical management of rectal injuries
takes into consideration a few other factors
besides the extra/intraperitoneal location of
the injury, such as hemodynamic stability and
concurrent injuries. In most instances, the
best treatment is direct repair for rectal injuries involving <25% of the rectal circumference, or resection with primary anastomosis
for more destructive injuries. These repairs
have shown lower infection and wound complication rates compared to fecal diversion.
Fecal diversion proximal to a repair may be
considered, especially in patients with multiple co-morbidities that may impair anastomotic healing (e.g., atherosclerosis, cirrhosis,
malnutrition).
E. Distal rectal injuries that are accessible dur-
ing laparotomy should be repaired primarily
in conjunction with proximal fecal diversion,
although there is some evidence to suggest
that diversion is not mandatory in all patients.
Recent EAST practice management guidelines conditionally recommend diversion
while acknowledging the low quality of supporting data. Diversion is best accomplished
with a loop stoma (colon or ileum). Every
attempt at restoring rectal continuity should
be made during the initial presentation, since
re-operating for end-colostomy reversal several months after distal rectal trauma is quite
difcult. However, prolonged efforts at repair
of extraperitoneal injuries in unstable patients
should be avoided.
F. Grossly devitalized ischiorectal and perineal
tissue should be debrided. Distal rectal washout likely has no inuence on outcome,
although large fecal burden should be alleviated to avoid stercoral ulceration. Presacral
drains are to be used judiciously. Such drains
are only useful when they communicate with
the rectal injury; healthy tissue planes should
not be disturbed simply to place a presacral
drain. Fecal diversion is best performed by
loop sigmoid colostomy.
Suggested Reading
Aihara R, Blanseld JS, Millham FH, et al. Fracture
locations inuence the likelihood of rectal and
lower urinary tract injuries in patients sustaining pelvic fractures. J Trauma Acute Care Surg.
2002;52:205–8.
Bosarge PL, Como JJ, Fox N, etal. Management of pen-
etrating extraperitoneal rectal injuries: an Eastern
Association for the Surgery of Trauma practice
management guideline. J Trauma Acute Care Surg.
2016;80:546–51.
Esposito TJ, Ingraham A, Luchette FA, etal. Reasons to
omit digital rectal exam in trauma patients: no ngers,
no rectum, no useful additional information. J Trauma
Acute Care Surg. 2005;59:1314–9.
Moore EE, Cogbill TH, Malangoni MA, et al. Organ
injury scaling, II: pancreas, duodenum, small bowel,
colon, and rectum. J Trauma Acute Care Surg.
1990;30(11):1427–9.
Sharpe JP, Magnotti LJ, Weinberg JA, etal. Adherence to
a simplied management algorithm reduces morbidity
and mortality after penetrating colon injuries: a 15-year
experience. J Am Coll Surg. 2012;214(4):591–7.
Yamamoto R, Logue AJ, Muir MT. Colon trauma:
evidence-based practices. Clin Colon Rectal Surg.
2018;31(1):11–6.
Endometriosis
BidhanDas andMichaelJ.Snyder
52
Refer toAlgorithm inFig. 52.1
A. As most women have endometriosis conned
to the pelvis, the most common presentations
of endometriosis are related to dysmenorrhea, pelvic pain, and infertility. Pain is the
most common symptom of endometriosis,
affecting 80% of patients who were subsequently diagnosed with the disease.
Symptoms are related to the depth of penetration of the lesion, the type of lesion, and its
location. Dyspareunia is usually a symptom
of more advanced endometriosis and noted
just prior to menstruation. This pain is correlated to xation of the pelvic organs.
Chronic noncyclic pelvic pain is associated
with perineural inammation and uterosacral
ligament involvement with endometriosis.
The cause of pain from endometriosis is
unclear and may be related to the cyclic
growth and increase in visceral pressure of
the capsule surrounding the endometrial
implant. Bowel involvement is associated
with 12–37% cases of endometriosis, and the
degree and symptomatology vary relative to
the area affected. The rectosigmoid is
involved in over 70% of patients, and this
B. Das (*) · M. J. Snyder
Department of Surgery, McGovern Medical School,
The University of Texas Health Science Center at
Houston, Houston, TX, USA
e-mail: Bidhan.b.das@uth.tmc.edu
presentation can cause change in bowel habits, tenesmus, or even rectal bleeding.
Colonic endometriosis, however, can present
with obstructive symptoms and can be difcult to differentiate from other causes of
large bowel obstruction.
B. The true prevalence of endometriosis is
unknown. There is to date no noninvasive
screening test, and retrospective population
studies estimate 6.2% of premenopausal
women have endometriosis. Additionally,
that prevalence may be increased due to
widespread use of exogenous estrogens and
increasing obesity. The pathogenesis of
endometriosis is very controversial, with
beliefs that endometriosis is a result of transtubal regurgitation of menstrual blood, lymphatic spread, and hematogenous spread.
C. Physical examination may be normal, but a
careful bimanual and rectal examination is a
necessity and could reveal nodularity or
induration in the uterosacral ligaments or the
cul-de-sac of Douglas. Ovarian masses may
be felt, and retroversion of the uterus may be
noted as a sign of advanced disease.
D. Laboratory evaluation may demonstrate a
modest rise in CA-125, but only in moderate
to severe cases of endometriosis, thus the
nding lacks both sensitivity and specicity.
E. Noninvasive testing is of little value in the
diagnosis of endometriosis. Advanced disease
can be seen on barium enema studies, which
can reveal a narrow lumen (Fig. 52.2).
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_52
399
400
B. Das and M. J. Snyder
Fig. 52.1 Algorithm for endometriosis. GnRH-A gonadotropin-releasing hormone analogue
52 Endometriosis
Fig. 52.2 Barium enema demonstrating narrowing of
proximal rectum with cul-de-sac of Douglas
endometrioma
Endoscopy may show stenosis, a mass, or
polypoid lesion with advanced disease. Bluish
submucosal discoloration can be seen as well.
In our experience one example of locally
invasive rectosigmoid disease is rectal tethering seen by an expert proctoscopist using an
ofce rigid proctosigmoidoscopy. Endorectal
ultrasound can be useful if physical examination is concerning for cul-de-sac involvement
of the rectum. Endorectal ultrasound in limited studies has been shown to have a high
specicity and high sensitivity for the need of
intestinal resection in the setting of cul-de-sac
involvement. In recent years MRI has been
considered one of the best noninvasive
modalities for imaging suspected endometri-
401
Fig. 52.3 Deep inltration of an endometrial implant at
the level of the rectosigmoid
osis. Colorectal involvement is strongly suspected with a disappearance of the fat plane
between the rectum and the vagina, loss of the
hypointense signal of the anterior bowel wall
on T2-weighted images, and a contrast
enhanced mass on T1-weighted images
involving the bowel wall. This modality
depends on the hemorrhage that occurs in
endometrial implants and has a sensitivity
and specicity between 78% and 98%.
F. Diagnosis of endometriosis usually requires
direct visual inspection, and the gold standard of diagnosis is both visual and tactile
evaluation of the abdomen and pelvis.
Laparoscopy is often the initial approach to
patients under suspicion of endometriosis
and allows a detailed examination of the
entire abdomen and pelvis with mobilization
of both ovaries to evaluate the pelvic peritoneum with uterine manipulation to allow
complete evaluation of the cul-de-sac of
Douglas. The extent of endometriosis can be
documented using a codied form to classify
endometriosis. Classication systems currently do not assess the needs of the colorectal surgeon, however. There is no uniform
type of endometrial lesion; lesions often
change color or consistency over time;
lesions in the cul-de-sac of Douglas often are
desmoplastic, with depths of invasion that
are often hard to assess laparoscopically
(Fig.52.3).
G. Many centers now report the use of robot-
assisted laparoscopy as a technique to visual-
402
B. Das and M. J. Snyder
ize smaller lesions of the pelvis while also
offering initial methods of treatment and a
multimodal platform for both gynecologist
and colorectal surgeon. We agree that this
modality has promise; however, given the
broad-ranging phenotypical presentation, we
do not feel it has yet to replace open surgery
in every presentation. The improved ergonomic dexterity of the robotic platform may
well offer better diagnostic laparoscopy for
the initial assessment of endometriosis, given
the ability to have a stable view deep into the
pelvis with a modicum of mobilization and a
steady three-dimensional camera. Yet miliary
pelvic disease may sometimes only be appreciable with tactile feedback, while lesions
that are at the base of the appendix or on the
distal ileum are often missed by all but the
trained colorectal surgeon.
H. Treatment can be either medical or surgical
or a combination thereof. However, medical
therapy is purely for symptoms and largely
for pelvic pain.
I. Oral contraceptives can be used to manage
pelvic pain and dyspareunia by creating a
pseudo-pregnancy with hyperhormonal
amenorrhea to suppress the pituitary and ovaries, ultimately resulting in resorption of
endometrial implants. Although limited in
usage, this type of medical therapy offers
advantages in that it avoids surgical intervention in a patient with contraindications (extensive adhesions, highly comorbid conditions).
J. GnRH-a is also a potent agent in the reduc-
tion of endometriosis symptoms. The synthetic hormone is administered in the
mid-luteal phase of the menstrual cycle over
a period of six months. Results are variable
but impressive with complete response in
symptoms in over 50% of women with laparoscopic follow-up demonstrating signicant
decrease in the size of the lesions in the
majority of patients.
K. The major goal of surgery in endometriosis
patients is complete excision of endometrial
implants while preserving ovarian function.
Additionally, many techniques have been
employed to reduce adhesion formation,
including postoperative steroid therapy,
lavage with collagenase gels, and transient
laparoscopic placement of temporary spacers
in the pelvis. In most major centers of surgical treatment of endometriosis, these patients
are approached in concert with gynecologists
to completely remove all gross disease.
Exploratory laparotomy is the gold standard
to diagnose and to classify endometriosis,
and it allows complete evaluation with tactile
feedback for complete extirpation.
L. Many gynecologists utilize vaporization via
electrocautery or CO
laser, to remove endo-
2
metrial implants, but both modalities are
notable for delayed iatrogenic injury.
M. We recommend full mechanical and antibi-
otic bowel preparation as well as prophylactic antibiotics with positioning in the
low-lithotomy position for access to both
vagina and rectum for instrumentation. We
liberally utilize ureteral stents to facilitate
dissection of the ureters as well as dissection
of lesions from the ureters.
N. A decision for colonic resection is under-
taken with three major indications: (a) full
thickness decit from lesion excision that
would ultimately require repair that is too
extensive to be sutured (b) lesions that impact
the function of the bowel
(c) mesenteric dissection that could create
ischemia. Surgical techniques for resection
during endometriosis are not standardized, so
comparison of literature cannot be performed. Additionally, as popularity of the
robotic platform has grown, there are centers
that design a multidisciplinary approach
completely around a robot-assisted laparoscopic approach.
O. Small bowel and appendiceal endometriosis
is uncommon and often hard to correlate
symptomatically. Recurrent pain, bloating,
and occasional change in bowel habits are all
thought to accompany such a presentation.
Appendiceal implantation is treated with
appendectomy, while small bowel endometriosis treatment is determinant upon the size
and location of the lesion. Smaller lesions
may be amenable to wedge/disc excision and