穿透性结肠损伤后部位对结局的影响。

Impact of location on outcome after penetrating colon injuries.

机构信息

Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.

出版信息

J Trauma Acute Care Surg. 2012 Dec;73(6):1428-32; discussion 1433. doi: 10.1097/TA.0b013e31825bff06.

DOI:10.1097/TA.0b013e31825bff06

PMID:22914082

Abstract

BACKGROUND

Most studies examining suture line failure after penetrating colon injuries have focused on right- versus left-sided injuries. In our institution, operative decisions (resection plus anastomosis vs. diversion) are based on a defined management algorithm regardless of injury location. The purpose of this study was to evaluate the effect of injury location on outcomes after penetrating colon injuries.

METHODS

Consecutive patients with full thickness penetrating colon injuries for 13 years were stratified by age, injury location and mechanism, and severity of shock. According to the algorithm, patients with nondestructive injuries underwent primary repair. Destructive wounds underwent resection plus anastomosis in the absence of comorbidities or large preoperative or intraoperative transfusion requirements (>6 U of packed red blood cells); otherwise, they were diverted. Injury location was defined as ascending, transverse, descending (including splenic flexure), and sigmoid. Multivariable logistic regression was performed to determine whether injury location was an independent predictor of either morbidity or mortality.

RESULTS

Four hundred sixty-nine patients were identified: 314 (67%) underwent primary repair and 155 (33%) underwent resection. Most injuries involved the transverse colon (39%), followed by the ascending colon (26%), the descending colon (21%), and the sigmoid colon (14%). Overall, there were 13 suture line failures (3%) and 72 abscesses (15%). Most suture line failures involved injuries to the descending colon (p = 0.06), whereas most abscesses followed injuries to the ascending colon (p = 0.37). Multivariable logistic regression failed to identify injury location as an independent predictor of either morbidity or mortality after adjusting for 24-hour transfusions, base excess, shock index, injury mechanism, and operative management.

CONCLUSION

Injury location did not affect morbidity or mortality after penetrating colon injuries. Nondestructive injuries should be primarily repaired. For destructive injuries, operative decisions based on a defined algorithm rather than injury location achieves an acceptably low morbidity and mortality rate and simplifies management.

LEVEL OF EVIDENCE

Prognostic study, level III.

摘要

背景

大多数研究关注的是穿透性结肠损伤后缝线失败的问题，主要集中在右侧和左侧损伤的比较上。在我们的机构中，手术决策（切除加吻合术与转流术）是根据既定的管理算法做出的，而不考虑损伤的位置。本研究的目的是评估损伤位置对穿透性结肠损伤后结果的影响。

方法

对 13 年来连续的全层穿透性结肠损伤患者按年龄、损伤位置和机制以及休克严重程度分层。根据算法，非破坏性损伤患者行一期修复。无合并症或术前或术中大量输血需求（>6 单位浓缩红细胞）的破坏性伤口行切除加吻合术；否则，行转流术。损伤位置定义为升结肠、横结肠、降结肠（包括脾曲）和乙状结肠。采用多变量逻辑回归分析确定损伤位置是否是发病率或死亡率的独立预测因素。

结果

共确定 469 例患者：314 例（67%）行一期修复，155 例（33%）行切除。大多数损伤涉及横结肠（39%），其次是升结肠（26%）、降结肠（21%）和乙状结肠（14%）。总体上有 13 例缝线失败（3%）和 72 例脓肿（15%）。大多数缝线失败发生在降结肠损伤（p = 0.06），而大多数脓肿发生在升结肠损伤（p = 0.37）。多变量逻辑回归未能确定损伤位置在调整 24 小时输血、碱剩余、休克指数、损伤机制和手术管理后，是发病率或死亡率的独立预测因素。