Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
J Surg Res. 2013 May;181(2):293-9. doi: 10.1016/j.jss.2012.07.011. Epub 2012 Jul 25.
The optimal management of colon injury patients requiring damage control laparotomy (DCL) is controversial. The objective of this study was to assess the safety of colonic resection and anastomosis versus fecal diversion in trauma patients requiring DCL.
Patients with traumatic colon injuries undergoing DCL between 2000 and 2010 were identified by the database and chart review. Those who died within 48 h were excluded. Patients were divided into two groups: those undergoing one or more colonic anastomoses with or without distal colostomy (group 1) and those undergoing colostomy only or one or more colonic anastomoses with a protecting proximal ostomy (group 2). Variables were compared using Wilcoxon rank sum, χ2, or Fisher exact tests as appropriate.
Sixty-one patients were included (group 1, n=28 and group 2, n=33). Fascial closure rates (group 1, 50% versus group 2, 61%; P=0.45), hospital length of stay (29 versus 23 d; P=0.89), and in-patient mortality (11% versus 12%; P=1.0) were similar between groups. There were a total of 11 anastomotic leaks, five of which were related to non-colonic enteric repairs. Colonic anastomosis leak rates were 16% overall (six of the 38 patients), 14% in group 1 (four of the 28 patients), and 20% in group 2 (two of the 10 patients). Compared with patients who did not leak, patients who leaked had a higher median age (37 versus 25 y; P=0.05), greater likelihood of not achieving facial closure before post-injury day 5 (18% versus 2%; P=0.003), and a longer hospital length of stay (46 versus 25 d; P=0.003).
Outcomes after colonic injury in the setting of DCL were similar regardless of the surgical management strategy. Based on these findings, a strategy of diversion over anastomosis cannot be strongly recommended.
对于需要损伤控制剖腹术（DCL）的结肠损伤患者，其最佳处理方式仍存在争议。本研究旨在评估在需要 DCL 的创伤患者中，结肠切除吻合术与肠造口术相比的安全性。
通过数据库和病历回顾，确定了 2000 年至 2010 年间接受 DCL 的创伤性结肠损伤患者。排除了 48 小时内死亡的患者。将患者分为两组：接受一次或多次结肠吻合术，加或不加远端结肠造口术（组 1）和仅行结肠造口术或一次或多次结肠吻合术，加近端保护性造口术（组 2）。使用 Wilcoxon 秩和检验、卡方检验或 Fisher 确切概率法比较变量。
共纳入 61 例患者（组 1，28 例；组 2，33 例）。筋膜闭合率（组 1，50%比组 2，61%；P=0.45）、住院时间（29 天比 23 天；P=0.89）和住院病死率（11%比 12%；P=1.0）在两组间无差异。共有 11 例吻合口漏，其中 5 例与非结肠肠吻合修复有关。总的吻合口漏发生率为 16%（38 例中的 6 例），组 1 为 14%（28 例中的 4 例），组 2 为 20%（10 例中的 2 例）。与未发生吻合口漏的患者相比，发生吻合口漏的患者年龄较大（37 岁比 25 岁；P=0.05），更有可能在损伤后第 5 天前未实现筋膜闭合（18%比 2%；P=0.003），住院时间更长（46 天比 25 天；P=0.003）。
DCL 情况下结肠损伤的治疗结果无差异，无论选择哪种手术处理策略。基于这些发现，不能强烈推荐将肠造口术作为首选的手术策略。
