Australia: A recent study published in the World Journal of Emergency Surgery reports World Society of Emergency Surgery (WSES) guideline on diagnosis, investigations, and treatment of blunt and penetrating bowel injury.
Traumatic hollow viscus and mesenteric injury are relatively uncommon, with the prevalence of approximately 1% in blunt trauma and 17% in penetrating trauma. Following blunt and penetrating trauma, and especially in the context of multiple other injuries, hollow viscus and mesenteric injuries pose a clinical challenge mainly due to their relative infrequency, diagnostic uncertainties, and deleterious consequences when not promptly treated.
Cino Bendinelli, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia, and collegaues in their study, aimed to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh), where knowledge gaps were identified.
Blunt abdominal trauma: observation and nonoperative management
Recommendations
Management of the awake and oriented blunt abdominal trauma patient starts with the primary survey, E-FAST, physical examination and the secondary survey, blood chemistry, vital signs followed by contrast-enhanced abdominal CT.
The presence of a seatbelt sign should prompt a CT scan and a high index of suspicion for bowel injury.
Patients with high-risk mechanisms (i.e., handlebar, seatbelt sign) and non-specific CT findings should be admitted for observation including serial clinical examination.
In selected cases a repeat CT might be considered. Patients with equivocal signs on initial CT scan should be re-imaged after 6 hours. Patients that demonstrate evolving clinical signs suspicious for bowel injury, re-imaging should be considered.
Although highly sensitive, serum procalcitonin and CRP are not necessarily specific and as supportive biomarkers will help to exclude bowel injuries; but if too heavily relied upon, may lead to nontherapeutic laparotomy, or missed bowel injury.
Blunt abdominal trauma: role and pitfalls of CT in the diagnosis of bowel injury
Recommendations
The presence of highly specific CT findings such as extraluminal air, extraluminal oral contrast, or bowel-wall defects warrants prompt surgical exploration.
The presence of highly sensitive CT findings such as free fluid in the absence of solid organ injury, abnormal enhancement of bowel wall, and mesenteric stranding can be used as an adjunct to the clinical picture but should not solely determine management.
Scoring systems that include radiologic, biochemical, and clinical signs can guide management in difficult scenarios.
A repeat CT scan can be considered in patients with high-risk mechanisms without peritoneal signs and subtle signs on initial CT of bowel injury who do not show clinical improvement or are not clinically evaluable.
Role of peritoneal lavage, diagnostic laparoscopy, and therapeutic laparoscopy
Recommendations
Diagnostic peritoneal lavage has a limited role. It can be used as an adjunct to a negative laparoscopy to definitively exclude bowel injury, particularly in conjunction with the use of biomarkers.
Diagnostic laparoscopy can be used in haemodynamically compensated patients with highly sensitive findings of bowel injury on CT.
In penetrating trauma, local wound exploration is used to confirm peritoneal breaching. When positive, serial clinical examinations should follow, where there is clinical suspicion for bowel injury a diagnostic/therapeutic laparoscopy or laparotomy is warranted. Conversion to laparotomy is always possible and highly recommended if any doubts or difficulties arise.
Based on the surgeon experience and logistics of the trauma centre, bowel injuries identified during diagnostic laparoscopy can be treated laparoscopically.
Surgical options for bowel trauma
Recommendations
Primary repair of small bowel injuries is preferred when possible.
Primary anastomosis of colon injuries is safe in a subgroup of patients selected based on physiology, concomitant injuries, and resilience to a possible anastomotic leak.
Diverting stomas remain a safe option and are recommended in high-risk patients with high-risk colon anastomoses.
The risk of anastomotic leak following DCS increases with: a) time from initial surgery; b) ongoing transfusion requirements, ongoing inotropic support, tissue oedema and intraabdominal sepsis; c) time to abdominal fascia closure.
Hand sawn versus staple anastomosis in bowel injuries
Recommendations
There is a lack of evidence to demonstrate the superiority of anastomotic techniques following a bowel resection in trauma patients.
The decision to perform either a handsewn or stapled bowel anastomosis in the setting of emergency trauma laparotomy should be individualised to the patient's condition and the surgeon's technical abilities.
Missed bowel injury: management and outcome
Recommendations
In the context of blunt abdominal trauma with or without solid organ injury, bowel injuries are often missed. A high index of suspicion is required.
Delay in the diagnosis of bowel injury is linked to increased morbidity and mortality.
Long-term follow-up of patients with blunt abdominal trauma is required to identify the sequelae of mesenteric injuries.
"Several knowledge gaps in the literature have been identified and highlighted by this collaborative attempt to guide clinicians with evidence-based recommendations," wrote the authors. "With the gaps identified in the literature, we envision a collaborative effort to assess anastomosis techniques with a multicentre RCT, validate the CT findings of bowel injury in trauma in prospective multicentre studies, and refine nonoperative management requirements for penetrating abdominal trauma."
"Future research should focus on minimizing missed bowel injuries, combining clinician awareness and improved understanding of the utility of biomarkers in a trauma setting," they concluded.
Reference:
Smyth, L., Bendinelli, C., Lee, N. et al. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. World J Emerg Surg 17, 13 (2022). https://doi.org/10.1186/s13017-022-00418-y
KEYWORDS: bowel injury, World Journal of Emergency Surgery, World Society of Emergency Surgery, penetrating trauma, blunt trauma, bowel trauma, diagnosis, surgical management, bowel injury management, CT diagnosis bowel injury, abdominal trauma