Pell M, Flynn W J, Seibel R W
Department of Surgery, State University of New York at Buffalo, USA.
J Trauma. 1998 Aug;45(2):371-3. doi: 10.1097/00005373-199808000-00029.
Wound management in open pelvic fractures has used fecal diversion, debridement, and closure by secondary intention to prevent pelvic sepsis. Colostomy care and takedown adds to the morbidity and resource utilization of this approach. We reviewed our experience to determine if a selective approach to fecal diversion based on wound location was possible.
Retrospective analysis of patients admitted to a Level I trauma center during an 8-year period. Fractures were classified as open if the fracture was in continuity with the wound. Wounds were classified as perineal if they involved the rectum, ischiorectal fossa, or genitalia, and as nonperineal if they involved the pubis anteriorly, iliac crest, or anterior thigh. Pelvic sepsis was defined as cellulitis, fasciitis, or infection of a pelvic hematoma. Diversion consisted of loop or end colostomy.
Eighteen patients with open fractures were identified. Four died from closed head injury and blood loss. The remaining 14 were treated as follows. Five patients with perineal wounds had diversion of their fecal stream. Their Injury Severity Score was 34 +/- 8.3 and their Revised Trauma Score was 7.69 +/- 0.15. No patient developed pelvic sepsis. Nine patients with nonperineal wounds did not undergo diversion. Their Injury Severity Score was 28.6 +/- 5.3 and their Revised Trauma Score was 7.36 +/- 0.45. No patients developed pelvic sepsis in the nondiverted group.
No patients with anterior wounds and an intact fecal stream developed pelvic sepsis. Colostomy may not be necessary in all patients with open pelvic fracture. Protocols using fecal diversion based on wound location appear to be safe and may decrease resource utilization and subsequent morbidity related to colostomy closure.
开放性骨盆骨折的伤口处理采用粪便转流、清创以及二期愈合缝合，以预防骨盆感染。结肠造口护理及回纳增加了该方法的发病率及资源利用。我们回顾了我们的经验，以确定是否有可能基于伤口位置采取选择性粪便转流方法。
对一家一级创伤中心8年期间收治的患者进行回顾性分析。若骨折与伤口相通，则骨折被分类为开放性骨折。若伤口累及直肠、坐骨直肠窝或生殖器，则分类为会阴伤口；若伤口累及耻骨前部、髂嵴或大腿前部，则分类为非会阴伤口。骨盆感染定义为蜂窝织炎、筋膜炎或骨盆血肿感染。转流包括袢式或端式结肠造口术。
确定了18例开放性骨折患者。4例死于闭合性颅脑损伤和失血。其余14例患者的治疗如下。5例会阴伤口患者进行了粪便转流。他们的损伤严重度评分是34±8.3，改良创伤评分是7.69±0.15。没有患者发生骨盆感染。9例非会阴伤口患者未进行转流。他们的损伤严重度评分是28.6±5.3，改良创伤评分是7.36±0.45。未转流组没有患者发生骨盆感染。
粪便排出正常且前部有伤口的患者均未发生骨盆感染。并非所有开放性骨盆骨折患者都需要进行结肠造口术。基于伤口位置采用粪便转流的方案似乎是安全的，并且可能减少资源利用以及与结肠造口回纳相关的后续发病率。
