Improved Outcomes in Colon and Rectal Surgery part 41 ppsx

 improved outcomes in colon and rectal surgery (96, 108) Given the relative ease of the procedure and subse- quent reversal, a loop colostomy is recommended (100, 102, 103) if solely for the purpose of diversion in rectal injury, while an end colostomy is performed if there are other indications, such as associated colonic injury. Extraperitoneal injuries can be treated without repair, unless they are easily accessible or uncovered in the course of treating other injuries.(96, 102, 103, 108) There is some evidence to support this principle. Gonzalez et al. (111), implemented a protocol for the management of extraperitoneal rectal injury without fecal diversion, presacral drainage, or distal irrigation in patients with nondestructive penetrating injury. Although they had no mortality or infectious complications, the series included only 14 patients, making these results difficult to generalize. Interestingly, in all 14 patients a barium enema was performed and demonstrated complete healing by postinjury day 10, demonstrating the rapid healing capacity of the rectum, likely due to its rich blood supply. Abdominoperineal resection has been described in the setting of traumatic rectal injury (102), but should be regarded as an extraordinary measure under extremely rare circumstances. The steps in the classic, conservative management of rectal injury have been described by Stewart and Rosenthal (20) and are summarized in Table 35.8. A modi- fication to these steps as suggested by modern series is presented in Table 35.9. summary Rectal injury is uncommon and often accompanied by significant associated injury, most commonly genitourinary. Data is scarce, and is mostly limited to retrospective reviews. Diagnosis is challenging, and is most often made by clinical suspicion, digital exam, and proctoscopy or sigmoidoscopy. Intraperitoneal injury can be treated with primary repair in a manner analogous to colon injury. Extensive destructive injury can be diverted with lower expected complication rates than colon injury. Extraperitoneal injury can be treated with diversion alone, although selected cases of partial or nondestructive injury can be treated with nonoperative management. Presacral drainage is sometimes recommended in these cases in order to prevent pelvic sepsis. Presacral drainage and distal rectal washout are more appropriate in high-velocity injuries similar to combat injuries but have less efficacy in civilian settings. Foreign bodies Anorectal foreign bodies are almost always inserted during sexual conduct.(113–117) The most common objects found are sexual implements such as vibrators and dildos (115, 116) (Figure 35.2). Other, less common causes are ingested material, most often bones, or iatrogenic causes such as thermometers and enema tips. (113) A case of a live eel inserted into the anus as a folk remedy for constipation has been reported, in which the eel migrated proximally and was found biting the perforated splenic flexure.(118) The patient presented with peritonitis, which led the clinicians to note “the shadow of an eel on abdominal radiograph”, confirming the diagnosis. There is a predominance of males, ranging from 93–100% in the largest series.(114–116, 119) Goals of initial assessment are to create an atmosphere that allows the patient to give a detailed history, to recognize the potential of rape or assault, and to recognize signs of perforation that require more urgent therapy. Multiple-view plain radio- graphs should be obtained. Plain films will help localize the object, although rubber will not be apparent on radiography. Free air or obvious perforation can be ruled out. Patients with signs and symptoms of obstruction or perforation should have basic labs drawn, intravenous fluids initiated, antibiotics started and proceed to urgent laparotomy with no further attempt at removal of the object.(117) A perforation should be treated as any traumatic rectal injury, with removal of the foreign body, which will be discussed subsequently. Table 35.8 Traditional steps in the management of rectal injury.(20) Perineolithotomy position Management of concomitant injuries Debridement Proximal diversion Remove foreign bodies Presacral drainage Distal rectal washout Repair injury if possible Repair sphincters if possible External wound drainage Broad spectrum antibiotics Skin left open Figure 35.2 Foreign body requiring operative extraction. This patient sustained a full-thickness rectal injury from the foreign body placement. Table 35.9 Modified steps in management of rectal injury. Perineolithotomy position Management of concomitant injuries Debridement Intraperitoneal injury Extraperitoneal injury Primary repair Diversion Diversion if destructive injury (Loop colostomy preferred) Selective presacral drainage Repair if easily accessible Repair sphincters if possible Selective external wound drainage Broad spectrum antibiotics Skin left open  colorectal trauma The majority of rectal foreign bodies can be removed at the bedside, which is successful in 60–75% of cases.(114, 115, 119) An attempt at bedside extraction is reasonable in patients without signs of peritonitis.(113–115, 119) Sedation and local anesthesia can assist with relaxation and extraction, and an awake patient can be asked to perform a valsalva maneuver. If these maneuvers are unsuccessful, a stable patient can be admitted and observed for 12 hours; during this time the object will often descend into the rectum.(114) Foreign bodies removed nonoperatively require a postprocedure sigmoidoscopy to assess the viability of the rectum and rule out perforation.(113–117, 119) Operative removal can be accomplished with local, regional, or general anesthesia. Either the lithotomy or prone position can be used, but one advantage of lithotomy is that pressure can be applied to the abdomen to move the object distally.(117) Retractors can be placed and the anus dilated. Obstetric forceps and balloon-tipped catheters are commonly employed.(113–117, 119) Balloon-tipped catheters are useful in the case of jars or containers that are positioned with the mouth facing proximally, where the suction generated can prevent removal. The passage of a Foley catheter past the object can serve to break the suction and can be used to aid in extraction.(113) Rarely, laparotomy is required (0–6% of cases).(114, 115, 119) Attempts should be made at distally displacing the object without entering the bowel. If this is unsuccessful, an enterotomy can be made through which the object can be removed.(117, 119) Even more uncommonly, a lateral sphincterotomy may be required. Lake and colleagues (119) performed a recent review of 93 retained colorectal foreign bodies in 87 patients to determine predictors of operative intervention. Two patients (2%) presented with signs of peritonitis and were taken to the operating room. Seventy five percent of attempts at bedside extraction were successful. Of 23 cases requiring operative management, 6 required laparotomy and 5 (6%) required creation of a colotomy. Size of object (greater than 10 cm) and time to presentation (greater than 48 hours) were not associated with an increase in operative intervention. Only location in the sigmoid was predictive of failure of nonoperative management (55% versus 24%, p = 0.04), with an associated OR of 2.25. Anal sphincter and perineal injury Anal sphincter injury Anal sphincter function is extremely complex, and a full discussion is outside the scope of this discussion. Anal sphincter trauma is highly unusual due to its protected anatomic location and abundant blood supply (113). The most common cause of anal sphincter injury is obstetric trauma, followed by sequelae of anorectal operations, and uncommonly by etiologies similar to those causing rectal injuries.(113, 120) Stapling procedures such as for hemorrhoidectomy have been shown to cause anal sphincter injuries as well.(113) Life-threatening injuries should be addressed first in trauma patients, particularly massive, complex perineal injury (discussed subsequently). In a comprehensive review, Hellinger (113) out- lines the initial management of anal sphincter injury. As men- tioned, documentation of the extent and nature of the sphincter injury is imperative. Superficial injuries can be debrided and repaired without proximal diversion and minimal injury iso- lated to the internal sphincter can be left unrepaired. Destructive injury requires diversion following the same principles as rectal injury. In most cases primary repair should be undertaken, commonly in an end-to-end or overlapping fashion. Overlapping repair is accomplished by dissecting out the sphincter muscles and wrapping them anteriorly around the anus. Although overlapping repair increases the surface area of muscular apposition, this repair is difficult to achieve without tension in the acute setting, and thus end-to-end repair may be the principal option in the setting of acute trauma.(113, 120) Other techniques for repair include muscle transpositions (e.g. gracilis or gluteal) and artificial sphincters.(113,120) However, these procedures are best undertaken in the delayed setting and should be performed by surgeons with extensive experience. For example, graciloplasty for fecal incontinence has been shown in several large series to have success rates of 60–66% by various measures (121–123), but infectious complications in 34–39% of patients and donor-site morbidity (pain, paresthesias) have been reported in 22–72%.(121, 123) Artificial anal sphincters have been associated with success rates of 75–98% by various measures, but infection rates range from 13–34%, erosions from 8–21%, explants in 19–37%, and revisionary procedures in 26–45%.(124, 125) In the long-term, sphincter repairs tend to degenerate (120), with rates in the elective population ranging between 2.8–10%. (126, 127) It is important to arrange appropriate follow-up for the assessment of anal function in these patients. Physical exam, myography, manometry, and contrast studies are all routinely employed to assess sphincter function.(113) In addition, endo- scopic ultrasound has been shown to be a useful adjunct to visu- alizing the anal sphincters and predicting defects. A sensitivity of 100% and specificity ranging from 83–100% has been reported when compared to intraoperative findings in elective operations for fecal incontinence.(128, 129) Delayed repair has been shown to have good results in approximately 70% of patients with fecal incontinence due to nonobstetric trauma.(130) Complex perineal injury Kudsk and Hanna (131) have published a complete review of complex perineal injuries, describing a 15-year experience in the comprehensive care of these patients. Figures 35.3a–3c illustrate complex perineal injury. The authors demonstrate the synthe- sis of the principles of ATLS, damage control, and distal rectal injury required to manage these potentially devastating injuries. Their review included only those patients with evidence of severe degloving (25 total) and the reported mortality was 24% during the first 2 hours of admission. Two additional patients died for reasons unrelated to their perineal injury, for an overall mortality of 32%. Their review of the literature revealed similar mortality rates. Roughly half of the patients were pedestrians hit by cars, one-third were involved in motor vehicle crashes, and the remainder sustained industrial accidents. The second most common cause of mortality after exsanguinating hemorrhage is pelvic sepsis. The authors’ review of the literature revealed a 21–25% death rate from this cause. For  improved outcomes in colon and rectal surgery authors emphasize that in complex pelvic injuries, lower extremity central access is contraindicated in that it may contribute to further hemorrhage by delivering fluids and blood products directly into the abdominal cavity through lacerated vessels. Access above the diaphragm is recommended. Laparotomy should be performed and intraabdominal injuries addressed. Early pelvic fixation and hemorrhage control should proceed by packing, direct ligation or clamping, and angiography as necessary. The lithotomy position is essential to appropriate exposure. Associated genitourinary injuries should be addressed. Debridement should continue only in the absence of refractory hemorrhage and the patient should be returned to the ICU for further resuscitation before prolonged operative interventions. Following stabilization, fecal diversion should be undertaken early. Aggressive debridement and irrigation should be undertaken with frequent return trips to the operating room. Kudsk and Hanna report an average of 8 trips to the operating room using pulse-lavage before closure or coverage was attempted. These principles are similar to the management of Fournier’s gangrene. Enteral feeding should be initiated as early as possible. In the delayed setting, coverage can be achieved with skin grafts and muscle flaps as indicated. Using these techniques, the authors were able to discharge 17 of 19 patients (89%) to home. Feeding jejunostomies were placed in 6 patients and enteral nutrition was initiated in all 6 within 48 hours. summary Anal sphincter and complex perineal injuries are uncommon in civilian settings. Life-threatening hemorrhage and pelvic fracture are the first concerns. Documentation of the extent of sphincter injury is imperative. Genitourinary and rectal injuries should be suspected until ruled out by careful investigation. Primary repair of sphincter injury should be undertaken if feasible. Referral is recommended for cases where complex repair is required. Follow-up is important for assessment of long-term function, as Figure 35.3a Complex perineal injury. The patient was run over by heavy road- repair equipment. The patient also sustained urethral injury, sigmoid colon injury, and severe pelvic fracture. Figure 35.3b CT scan of complex perineal injury. Note the large soft-tissue defect. Figure 35.3c Pelvic fracture associated with complex perineal injury. example, Maull et al. (132), reported a 25% mortality due to pelvic sepsis in their series. Kudsk and Hanna report a 21% pelvic sepsis rate but no mortality, which they attribute to their aggressive, multisystem approach as described. Immediate assessment of the ABCs, intravenous access, and limited radiographic imaging are the initial steps. In cases of severe injury resuscitation should occur in the operating room. The most serious and most common associated injury was severe complex pelvic fracture, which occurred 74% of the time (Figure 35.3c). The  colorectal trauma functional deterioration is common after repair. Fecal diversion may be necessary in cases of massive injury. The primary concern initially is hemorrhage control, while infection and nutrition are more important in the next several days. In the longer-term, tissue coverage and functional issues become more important. With aggressive, comprehensive management, the majority of patients have good outcomes. referenCes 1. Yaw PB, Smith RN, Glover JL. Eight years experience with civilian injuries of the colon. Surg Gynecol Obstet 1977; 145: 203–5. 2. Perry WB, Brooks JP, Muskat PC. The history of military colorectal trauma management. Semin Colon Rectal Surg 2002; 15: 70–9. 3. LoCicero J, Tajima T, Drapanas T. A half-century of experience in the management of colon injuries: Changing con- cepts. J Trauma 1975; 16: 575–9. 4. Ogilvie WH. Abdominal wounds in the Western desert. Surg Gynecol Obstet 1944; 78: 225–38. 5. Singer MA, Nelson RL. Primary repair of penetrating colon injuries: A systematic review. Dis Colon Rectum 2002; 45: 1579–87. 6. Burch JM, Brock JC, Gevirtzman L et al. The injured colon. Ann Surg 1986; 203: 701–11. 7. Steichen FM, Ravitch MM. Contemporary stapling instru- ments and basic mechanical suture techniques. Surg Clin N Am 1984; 64: 425–40. 8. Curran TJ, Borzotta AP. Complication of primary repair of colon injury: Literature review of 2964 cases. Am J Surg 1999; 177: 42–7. 9. Stone HH, Fabian TC. Management of perforating colon trauma: Randomization between primary closure and exte- riorization. Ann Surg 1979; 190: 430–5. 10. Eshraghi N, Mullins RJ, Mayberry JC et al. Surveyed opinion of American trauma surgeons in management of colon injuries. J Trauma 1998; 44: 93–7. 11. Pezim ME, Vestrup JA. Canadian attitudes toward use of primary repair in management of colon trauma. Dis Colon Rectum 1996; 39: 40–4. 12. Demetriades D, Velmahos G, Cornwell E et al. Selective nonoperative management of gunshot wounds to the anterior abdomen. Arch Surg 1997; 132: 178–83. 13. Burch JM, Martin RR, Richardson RJ et al. Evolution of the treatment of the injured colon in the 1980s. Arch Surg 1991; 126: 979–84. 14. Chappuis CW, Frey DJ, Dietzen CD et al. Management of penetrating colon injuries: A prospective randomized trial. Ann Surg 1991; 213: 492–7. 15. Adkins RB, Zirkle PK, Waterhouse G. Penetrating colon trauma. J Trauma 1984; 24: 491–9. 16. Flint LM, Vitale GC, Richardson JD, Polk HC. The injured colon. Ann Surg 1981; 193: 619–23. 17. Watts DD, Fahkry SM. Incidence of hollow viscus injury in blunt trauma: An analysis from 2,75,557 trauma admissions form the EAST multi-institutional trial. J Trauma 2003; 54: 289–94. 18. Ricciardi R, Paterson CA, Islam S et al. Independent predictors of morbidity and mortality in blunt colon trauma. Am Surg 2004; 70: 75–9. 19. Ross SE, Cobean RA, Hoyt DB et al. Blunt colonic injury—a multicenter review. J Trauma 1992; 33: 379–84. 20. Stewart RM, Rosenthal D. Colorectal Trauma. In: Corman, M, ed. Colon and Rectal Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2005: 427–49. 21. Nelson R, Singer M. Primary repair for penetrating colon injuries. Cochrane Database of Syst Rev 2003; 3: CD002247 22. Singer MA, Nelson RL. Primary repair of penetrating colon injuries. Dis Colon Rectum 2002; 45: 1579–87. 23. Sasaki LS, Allaben RD, Golwala R, Mittal VK. Primary repair of colon injuries: A prospective, randomized study. J Trauma 1995; 39: 895–901. 24. Gonzalez RP, Merlotti GJ, Holevar MR. Colostomy in penetrating colon injury: Is it necessary? J Trauma 1996; 41: 271–5. 25. Gonzalez RP, Falimirski ME, Holevar MR. Further evaluation of colostomy in penetrating colon injury. Am Surg 2000; 66: 342–7. 26. Kamwendo NY, Modiba MCM, Matlala NS, Becker PJ. Randomized Clinical trial to determine if delay from time of penetrating colon injury precludes primary repair. Br J Surg 2002; 89: 993–8. 27. Demetriades D, Murray JA, Chan L et al. Penetrating colon injuries requiring resection: Diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma 2001; 50: 765–75. 28. Schreiber MA. Damage control surgery. Crit Care Clin 2004; 20: 101–18. 29. Lee JC, Peitzman AB. Damage control laparotomy Curr Opin Crit Care 2006; 12: 346–50. 30. Demetriades D, Salim A. Colon and rectal trauma and rectal foreign bodies. In: Wolff BG, Fleshman JW, Beck DE, et al eds. The ASCRS Textbook of Colon and Rectal Surgery. New York, NY:Springer, 2008: 322–34. 31. Sokolove PE, Kuppermann N, Holmes JF et al. Association between the “Seat Belt Sign” and intraabdominal injury in chil- dren with blunt torso trauma. Acad Emer Med 2005; 12: 808–13. 32. LeGay DA, Petrie DP, Alexander DI et al. Flexion-distraction injuries of the lumbar spine and associated abdominal trauma.J Trauma 1990; 30(4): 436–44. 33. Hoff WS, Holevar M, Nagy KK et al. Practice Management Guidelines for the evaluation of blunt abdominal trauma, EAST Practice Management Guidelines Work Group. J Trauma 2002; 53: 602–15. 34. Otomo Y, Henmi H, Mashiko K et al. New diagnostic peritoneal lavage criteria for diagnosis of intestinal injury. J Trauma 1998; 44: 991–9. 35. Liu M, Lee CH, P’eng FK. Prospective comparison of diagnostic peritoneal lavage, computed tomographic scanning, and ultrasonography for the diagnosis of blunt abdominal trauma. J Trauma 1993; 35: 267–70. 36. Boulanger BR, Brenneman FD, McLellan BA et al. A prospective study of emergent abdominal sonography after blunt trauma. J Trauma 1995; 39: 325–30.  improved outcomes in colon and rectal surgery 37. Smith SR, Kern SJ, Fry WR et al. Institutional learning curve of surgeon-performed trauma ultrasound. Arch Surg 1998; 133: 530–6. 38. McKenney MG, Martin L, Lentz K et al. 1000 consecutive ultrasounds for blunt abdominal trauma. J Trauma 1996; 40: 607–12. 39. Kern SJ, Smith RS, Fry WR et al. Sonographic examination of abdominal trauma by senior surgical residents. Am Surg 1997; 63: 669–74. 40. Rozycki GS, Ochsner MG, Schmidt JA et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma 1995; 39: 492–500. 41. Malhotra AK, Fabian TC, Katsis SB et al. Blunt bowel and mesenteric injuries: the role of screening computer tomog- raphy. J Trauma 2000; 48: 991–1000. 42. Gutela ST, Federle MP, Huang LF et al. Performance of CT in detection of bowel injury. Am J Radiol 2001; 176: 129–35. 43. Rizzo MJ, Federle MP, Griffiths BG et al. Bowel and mesenteric injury following blunt abdominal trauma: evaluation with CT. Radiology 1989; 173: 143–8. 44. Ahmed N, Whelan J, Brownlee J et al. The Contribution of Laparoscopy in Evaluation of Penetrating Abdominal Wounds. J Am Coll Surg 2005; 201: 213–6. 45. Mitsuhide K, Junichi S, Atsushi N et al. Computed Tomographic Scanning and Selective Laparoscopy in the Diagnosis of Blunt Bowel Injury: A Prospective Study. J Trauma 2005; 58: 696–703. 46. Moore EE, Dunn EL, Moore JB, Thompson JS. Penetrating abdominal trauma index. J Trauma 1981; 21: 439–45. 47. Nallathambi MN, Ivatury RR, Shah PM et al. Aggressive definitive management of penetrating colon injuries—136 cases with 3.7 percent mortality. J Trauma 1984; 24: 500–5. 48. Nelken N, Lewis F. The influence of injury severity on complication rates after primary closure or colostomy for penetrating colon trauma. Ann Surg 1989; 209: 439–47. 49. Moore, EE, Cogbill TH, Malangoni MA et al. Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 1990; 30: 1427–9. 50. Pontius RG, Creech O, DeBakey ME. Management of large bowel injuries in civilian practice. Ann Surg 1957; 146: 291–5. 51. Falcone RE, Wanamaker SR, Santanello SA, Carey LC. Colorectal trauma: Primary repair or anastomosis with intracolonic bypass vs. ostomy. Dis Colon Rectum 1992; 35: 957–63. 52. Stewart RM, Fabian TC, Croce MA et al. Is resection with primary anastomosis following destructive colon wounds always safe? Am J Surg 1994; 168: 316–9. 53. George SM, Fabian TC, Voeller GR et al. Primary repair of colon wounds. Ann Surg 1989; 209: 728–34. 54. Miller PR, Chang MC, Hoth JJ, Homes JH, Meredith JW. Colonic resection in the setting of damage control laparotomy: Is delayed anastomosis safe? Am Surg 2007; 76: 606–10. 55. Chavarria-Aguilar M, Cockerham WT, Barker DE et al. Management of destructive bowel injury in the open abdomen. J Trauma 2004; 56: 560–4. 56. Johnson JW, Gracias VH, Schwab CW et al. Evolution in damage control surgery for exsanguinating penetrating abdominal injury. J Trauma 2001; 51: 261–71. 57. Miller PR, Fabian TC, Croce MA et al. Improving outcomes following penetrating colon wounds: Application of a clinical pathway. Ann Surg 2002; 235: 775–81. 58. Fahkry SM, Watts DD, Luchette FA et al. Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial. J Trauma 2003; 54: 295–306. 59. Fahkry SM, Brownstein M, Oller D et al. Relatively short diagnostic delays (<8 hrs) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma 2000; 48: 408–15. 60. Williams MD, Watts D, Fakhry S et al. Colon Injury after Blunt Abdominal Trauma: Results of the EAST Multi- institutional Hollow Viscus Injury Study.J trauma 2003; 55: 906–12. 61. Dauterive AH, Flancbaum L, Cox EF. Blunt intestinal trauma: A modern-day review. Ann Surg 1985; 201: 198–203. 62. Ross SE, Cobean RA, Hoyt DB et al. Blunt Colonic Injury – A Multicenter Review. J Trauma 1992; 33: 379–84. 63. Nance ML, Peden GW, Schwab CW et al. Solid viscus injury predicts major hollow viscus injury in blunt abdominal trauma. J Trauma 1997; 43: 618–23. 64. Yegiyants S, Abou-Lahoud G, Taylor E. The management of blunt abdominal trauma patients with computed tomogra- phy scan findings of free peritoneal fluid and no evidence of solid organ injury. Am Surg 2006; 72: 943–6. 65. Hughes TMD, Elton C. The pathophysiology and management of bowel and mesenteric injuries due to blunt trauma. Injury 2002; 33: 295–302. 66. Parks SE, Hastings PR. Complications of colostomy closure. Am J Surg 1985; 149: 672–5. 67. Bulger EM, McMahon K, Jurkovich GJ. The morbidity of penetrating colon injury. Injury 2003; 34: 41–6. 68. Berne JD, Velmahos GC, Chan LS, Asensio JA, Demetriades D. The high morbidity of colostomy closure after trauma: Further support for the primary repair of colon injuries. Surgery 1998; 123: 157–64. 69. PokornyH, Herkner H, Jakesz R, Herbst F. Mortality and complications after stoma closure. Arch Surg 2005; 140: 956–60. 70. Dente CJ, Tyburski J, Wilson RF et al. Ostomy as a risk factor for posttraumatic infection in penetrating colonic injuries: Univariate and multivariate analyses. J Trauma 2000; 49: 628–37. 71. Fabian TC. Infection in penetrating abdominal trauma: risk factors and preventive antibiotics. Am Surg 2002; 68: 29–35. 72. Hudolin T, Hudolin I. The role of primary repair for colonic injuries in wartime. Br J Surg 2005; 92: 643–7. 73. Steele SR, Wolcott KE, Mullenix PS et al. Colon and rectal injuries during Operation Iraqi Freedom: Are there any changing trends in management or outcome? Dis Colon Rectum 2006; 50: 870–7.  colorectal trauma 74. Welling DR, Hutton JE, Minken SL, Place RJ, Burris DG. Diversion defended—military colon trauma. J Trauma 2008; 64: 1119–22. 75. Duncan JE, Corwin CH, Sweeney WB et al. Management of colorectal injuries during Operation Iraqi Freedom: Patterns of stoma usage. J Trauma 2008; 64: 1043–7. 76. American College of Surgeons Committee on Trauma, eds. Advanced Trauma Life Support Course, 7th ed. Chicago, Ill: American College of Surgeons; 2004. 77. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996; 9: 1209–15. 78. Van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001; 345: 1359–67. 79. Dunne JR, Riddle MS, Danko J, Hayden R, Petersen K. Blood transfusion is associated with infection and increased resource utilization in combat casualties. Am Surg. 2006; 72: 619–25. 80. Taylor RW, Manganaro L, O’Brien J et al. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med 2002; 30: 2249–54. 81. Taylor RW, O’Brien J, Trottier SJ et al. Red blood cell trans- fusions and nosocomial infections in critically ill patients. Crit Care Med 2006; 34: 2302–8. 82. Kudsk KA, Croce MA, Fabian TC et al. Enteral versus par- enteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg 1992; 215: 503–13. 83. Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major abdominal trauma- -reduced septic morbidity. J Trauma 1989; 29: 916–23. 84. Moore FA, Moore EE, Kudsk KA et al. Clinical benefits of an immune-enhancing diet for early postinjury enteral feeding. J Trauma 1994; 37: 607–15. 85. Polk HC, Lopez-Mayor JF. Postoperative wound infection: A prospective study of determinant factors and prevention. Surgery 1969; 66: 97–103. 86. Stone HH, Hooper CA, Kolb LD, Geheber CE, Dawkins EJ. Antibiotic prophylaxis in gastric, biliary and colonic surgery. Ann Surg 1976; 184: 443–52. 87. Mazuski JE, Sawyer RG, Nathens AB et al. The Surgical infection society guidelines on antimicrobial therapy for intra-abdominal infections: An executive summary. Surg Infect 2002; 3: 161–73. 88. Bozorgzadeh A, Pizzi WF, Barie PS et al. The duration of antibiotic administration in penetrating abdominal trauma. Am J Surg 1999; 177: 125–31. 89. Cornwell EE, Dougherty WR, Berne TV et al. Duration of antibiotic prophylaxis in high-risk patients with penetrating abdominal trauma: a prospective randomized trial. J Gastrointest Surg 1999; 3: 648–53. 90. Kirton OC, O’Neill PA, Kestner M, Tortella BJ. Perioperative antibiotic use in high-risk penetrating hollow viscus injury: a prospective randomized, double-blind, placebo-control trial of 24 hours versus 5 days. J Trauma 2000; 49: 822–32. 91. Poret HA, Timothy TC, Croce MA, Bynoe RP, Kudsk KA. Analysis of septic morbidity following gunshot wounds to the colon: The missile is an adjuvant for abscess. J Trauma 1991; 31: 1088–95. 92. Demetriades D, Charalambides D. Gunshot wounds of the colon: Role of retained bullets in sepsis. Br J Surg 1993; 80: 772–3. 93. Sarmiento JM, Yugueros P, Garcia AF, Wolff BG. Bullets and their role in sepsis after colon wounds. World J Surg 1997; 21: 648–52. 94. Edwards DP, Brown D, Watkins PE. Should colon-penetrating small missiles be removed? An experimental study of retrocolic wound tracks. J Invest Surg 1999; 12: 25–9. 95. Flint LM, Voyles CR, Richardson JD, Fry DE. Missile tract infections after transcolonic gunshot wounds. Arch Surg 1978; 113: 727–8. 96. Merlino JI, Reynolds HL. Management of rectal injuries. Semin Colon Rectal Surg 2004; 15: 95–104. 97. Lüning TH, Keemers-Gels ME, Barendregt WB, Tan AC, Rosman C. Colonoscopic perforations: a review of 30,366 patients. Surg Endosc 2007; 21: 1975–7. 98. Gedebou TM, Wong RA, Rappaport WD et al. Clinical presentation and management of iatrogenic colon perforations. Am J Surg 1996; 172: 454–8. 99. Morken JJ, Kraatz JJ, Balcos EG et al. Civilian rectal trauma: A changing perspective. Surgery 1999; 126: 693–700. 100. evy RD, Strauss P, Aladgem D et al. Extraperitoneal rectal gunshot injuries. J Trauma 1995; 38: 273–7. 101. McGrath V, Fabian TC, Croce MA, Minard G, Pritchard FE. Rectal trauma: Management based on anatomic distinc- tions. Am Surg 1998; 64: 1136–41. 102. Burch JM, Feliciano DV, Mattox KL. Colostomy and drainage for civilian rectal injuries: Is that all? Ann Surg 1989; 209: 600–11. 103. Navsaria PH, Edu S, Nicol AJ. Civilian extraperitoneal rectal gunshot wounds: Surgical management made simpler. World J Surg 2007; 31: 1345–51. 104. Velmahos GC, Gomez H, Falabella A, Demetriades D. Operative management of civilian rectal gunshot wounds: Simpler is better. World J Surg 2000; 24: 114–8. 105. Rubesin SE, Levine MS. Radiologic diagnosis of gastrointestinal perforation. Rad Clin N Am 2003; 41: 1095–115. 106. Navsaria PH, Shaw JM, Zellweger R et al. Diagnostic laparoscopy and diverting sigmoid loop colostomy in the management of civilian extraperitoneal rectal gunshot injuries. Br J Surg 2004; 91: 460–4. 107. Navsaria PH, Graham R, Nicol A. A new approach to extraperitoneal rectal injuries: Laparoscopy and diverting sigmoid colostomy. J Trauma 2001; 51: 532–5. 108. Weinberg JA, Fabian TC, Magnotti LJ et al. Penetrating rectal trauma: Management by anatomic distinction improves outcome. J Trauma 2006; 60: 508–14. 109. Marti MC, Morel P, Rohner A. Traumatic lesions of the rectum. Int J Colorectal Dis 1986; 1: 152–4. 110. Gonzalez RP, Falimirski ME, Holevar MR. The role of presacral drainage in the management of penetrating rectal injuries. J Trauma 1998; 45: 656–61.  improved outcomes in colon and rectal surgery 111. Gonzalez RP, Phelan H, Hassan M, Ellis N, Rodning CB. Is fecal diversion necessary for nondestructive penetrating extraperitoneal rectal injuries? J Trauma 2006; 61: 815–9. 112. Steinig JP, Boyd CR. Presacral drainage in penetrating extraperitoneal rectal injuries: is it necessary? Am Surg 1996; 62: 765. 113. Hellinger MD. Anal trauma and foreign bodies. Surg Clin N Am 2002; 82: 1253–60. 114. Barone JE, Sohn N, Nealon TF. Perforations and foreign bodies of the rectum: Report of 28 cases. Ann Surg 1976; 184: 601–4. 115. Barone JE, Yee J, Nealon TF. Management of foreign bodies and trauma of the rectum. Surg Gynecol Obstet 1983; 156: 453–7. 116. Busch DB, Starling JR. Rectal foreign bodies: case reports and a comprehensive review of the world’s literature. Surgery 1986; 110: 512–9. 117. Kann BR, Hicks TC. Anorectal foreign bodies: Evaluation and treatment. Semin colon rectal surg 2004; 15: 119–24. 118. Lo SF, Wong SH, Leung LS, Law IC, Yip AWC. Traumatic rectal perforation by an eel. Surgery 2004; 135: 110–1. 119. Lake JP, Essani R, Petrone Pet al. Management of retained colorectal foreign bodies: Predictors of operative intervention. Dis Colon Rectum 2004; 47: 1694–8. 120. Brill SA, Margolin DA. Anal sphincter trauma. Semin Colon Rectal Surg 2004; 15: 90–4. 121. Thornton MJ, Kennedy ML, Lubowski DZ, King DW. Long- term follow-up of dynamic graciloplasty for faecal incontinence. Colorectal Dis 2004; 6: 470–6. 122. Wexner SD, Baeten C, Bailey R et al. Long-term efficacy of dynamic graciloplasty for fecal incontinence. Dis Colon Rectum 2002; 45: 809–18. 123. Madoff RD, Rosen HR, Baeten CG et al. Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective, multicenter trial. Gastroenterology. 1999; 116: 549–56. 124. Wong WD, Congliosi SM, Spencer MP et al. The safety and efficacy of the artificial bowel sphincter for fecal incontinence. Dis Colo Rectum 2002; 45: 1139–53. 125. Devesa JM, Rey A, Hervas PL et al. Artificial anal sphincter: Complications and functional results of a large personal series. Dis Colon Rectum 2002; 45: 1154–63. 126. Rotholtz NA, Bun M, Mauri MV et al. Long-term assessment of fecal incontinence after lateral internal sphincterotomy. Tech Coloproctol 2005; 9: 115–8. 127. Casillas S, Hull TL, Zutchi M et al. Incontinence after a lateral internal sphincterotomy: Are we underestimating it? Dis Colon Rectum 2005; 48: 1193–9. 128. Deen KI, Kumar D, Williams JG, Olliff J, Keighley MRB. Anal sphincter defects: Correlation between endoanal ultrasound and surgery. Ann Surg 1993; 218: 201–5. 129. Meyenberger C, Bertschinger P, Zala GF, Buchmann P. Anal sphincter defects in fecal incontinence: Correlation between endosonography and surgery. Endoscopy 1996; 28: 217–24. 130. Engel AF, Kamm MA, Hawley PR. Civilian war injuries of the perineum and anal sphincters. Br J Surg 1994; 81: 1069–73. 131. Kudsk KA, Hanna MK. Management of complex perineal injuries. World J Surg 2003; 27: 895–900. 132. Maull KI, Sachatello GR, Ernst CB. The deep perineal laceration—an injury frequently associated with open pelvic fractures: A need for aggressive surgical management. J Trauma 1977; 17: 685–96.  6 Urologic complications of colorectal surgery Scott Delacroix Jr and J Christian Winters CHALLENGING CASE A laparoscopic left hemicolectomy was performed for an asymptomatic 2.0 cm sigmoid adenocarcinoma found on screening colon- oscopy. Due to her previous three cesarean sections and abdominal hysterectomy with bilateral oopherectomy, she required extensive lysis of adhesions in order to mobilize the left colon. The procedure was uneventful and the patient was discharged home on postoperative day number three. On follow-up at 10 days, patient was doing well except for a new complaint of left “side pain” rated as a 3 out of 10. Management was expectant and patient was scheduled for a follow-up visit. She presented to the emergency room one week later with significant left flank pain and a fever of 102.1. Her WBC count was 21,000 and serum creatinine was 1.2 (preop 0.9). A CT scan of the abdomen and pelvis with and without intravenous contrast was ordered and left hydroureteronephrosis was seen down to the level of the mid-ureter. CASE MANAGEMENT The patient was admitted and placed on intravenous antibiotics. Urology was consulted and the patient was taken to the cystoscopy suite where a cystoscopy and retrograde stent placement was attempted but unsuccessful. No contrast was seen beyond the level of the mid-ureter. The patient was taken to the interventional radiology suite where a percutaneous nephrostomy tube was placed. Patient improved clinically over the next 48 hours with IV antibiotics. An anterograde nephrostogram was performed and a 2.0 cm stenotic segment of ureter was visualized in the middle-third of the left ureter. Iatrogenic injury was presumed and treatment options were discussed with the patient. After a full treatment course of antibiotics for her pyelonephritis, the patient underwent a robotic ureteral reim- plant with Psoas hitch and ureteral stent placement. Her percutaneous nephrostomy tube was removed 1 week later (as outpatient). The ureteral stent was removed at 4 weeks postoperatively and patient remained asymptomatic thereafter. At 4 months postreimplantation, her serum creatinine was 0.9 and renal ultrasound showed a normal left kidney without evidence of obstruction. URETHRAL INJURIES The most common urologic injury in surgery is the traumatic foley catheter placement. It is essential to adequately lubricate the entire foley and insert the catheter past the point at which urine is returned into catheter tubing. Inserting the catheter in a male to the inflation port can help prevent urethral injury. The usual preoperative catheter is either a 16 french or 18 french catheter. It is not necessary to inflate the balloon before placement as this will increase the size and decrease the rigidity of the distal aspect of the catheter. If catheter placement is unsuccessful, a trial of passage with an 18 French coude’ tipped foley catheter is appropriate. Patient dehydration secondary to bowel preparation can make it difficult to determine proper placement if one only looks for urine return. Placement of the entire foley catheter (to port)before inflation will aid in proper placement. If still unsure, usage of a 60 cc catheter tipped syringe to irrigate the bladder can confirm placement before inflation of the balloon. Intraoperative urologic consultation for cystoscopy and foley catheter placement should be performed if the above measures fail. If cystoscopy cannot accurately deline- ate urethral anatomy, a suprapubic catheter can be placed either through a percutaneous or an open technique. Artificial urinary sphincters (AUS) must be deactivated before insertion of a foley catheter. Deactivation is a different mecha- nism than the normal operating “on” and “off ” cycling. It is the author’s experience that most patients do not know how to deactivation their AUS beyond the normal cycling mode. This deactivation must be performed before placement of a foley catheter. Either a device representative or urologist can deactivate the sphincter preoperatively as an outpatient or on the day of surgery. A 12 French foley catheter can then be placed with lubrication and care to ensure placement in the bladder before inflation of balloon. Failure to deactivate the AUS can result in erosion of the urinary sphincter by means of pressure necrosis between the foley catheter and sphincter device. Removal of the catheter should be done in standard fashion postoperatively. If unable to obtain urologic consultation before or intraoperatively, a suprapubic catheter can be placed either by open or percutaneous methods. Care must be taken to avoid intraabdominal prosthetic components, which are normally placed below the rectus muscle suprapubi- cally. An inflatable penile prosthesis (IPP) should not pose any additional difficulty in placing a urethral catheter if lubrication and the aforementioned guidelines are adhered. Urethral injuries are associated with extensive rectal neoplasm or any inflammatory processes that alter surgical planes including pelvic radiation. Urethral injuries are usually identified at the time of surgery secondary to identification of the indwelling foley catheter. Repair of a small urethral laceration can be performed with absorbable 3–0 or 4–0 synthetic absorbable suture (SAS) on a tapered needle. If the patient has had prior radiation or there is poor tissue composition, placement of either an omental flap or local tissue flap to support coverage of the repair is recommended. Injuries not identified at surgery can present postoperatively as urine drainage per rectum, pneumaturia, or fecaluria if fistula is present. It can also present as a delayed urethral stricture with difficult void- ing and bladder outlet obstruction. A retrograde urethrogram will confirm the presence of a urethral stricture but must be done in the bilateral oblique as well as anterior-posterior views. A retrograde urethrogram (RUG) can be performed by affixing a 14-gauge angi- ocatheter to a 60 cc syringe filled with standard water-soluble contrast. A RUG should be performed around an indwelling catheter if already in place. If a radiographic enema is performed, water- soluble contrast is preferred as it does not form concretions in the bladder. Spontaneous closure of a urinary fistula is rare but a trial 6 improved outcomes in colon and rectal surgery of conservative urinary diversion (foley catheter) for low-grade fistulas is recommended for 4–6 weeks. Urinary fistulas are staged according to location, size, and patient’s history.(1) Stage 1—low (<4 cm from the anal verge and non-irradiated) • Stage 2—high (>4 cm for the anal verge and non-irradiated) • Stage 3—small (<2 cm irradiated fistula) • Stage 4—large (>2 cm irradiated fistula) • Stage 5—large (ischial decubitus fistula) • Enteric diversion by means of a diverting colostomy or ileos- tomy is recommended for Stages 3–5. The choices for repair are diverse and depend on local tissue integrity and staging. It is recommended to place a suprapubic catheter at the time of repair in addition to a foley catheter for maximal drainage.(2) Transanal rectal flap advancement can be used for Stage 1 fistulas or in com- bination with other techniques for higher stage fistulas.(3) Other techniques described include: transanal-transphincteric approach (dorsal lithotomy anterior • sphincterotomy).(4) York Mason/transphincteric with rectal advancement flap (2, 5, • 6) (jack-knife posterior sphincterotomy) Perineal approach (Jack knife or dorsal lithotomy).(7, 8) • Gracillus and Rectus Abdominus Flaps.(9, 10) • Surgical selection is based on fistula stage and the experience of the reconstructive surgeon. Higher stage fistulas and recurrences normally require regional flaps and possibly even urinary diversion.(11) Outcomes for surgically corrected rectourethral fistulas are overall favorable with recurrences mostly dependent on stage and appropriate choice in initial surgical treatment. Success rates vary from >90% for low-grade fistulas to 70% for higher-grade fistulas.(1–11) A retrograde urethrogram around foley catheter at 4–6 weeks postoperatively should be performed before urethral catheter removal. BLADDER INJURIES The location of the bladder within the pelvis and its, close prox- imity to the sigmoid colon and rectum predisposes the bladder to injury during surgery of the colon and rectum. Iatrogenic injuries to the bladder can be staged as:(12, 13) Grade 1 : contusion, intramural hematoma, or partial thickness • laceration Grade 2: extraperitoneal bladder wall laceration <2 cm • Grade 3: extraperitoneal >2 cm or intraperitoneal <2 cm blad- • der laceration Grade 4: intraperitoneal bladder wall laceration >2 cm • Grade 5: intra or extra peritoneal bladder wall laceration extend- • ing into the bladder neck or trigone (near ureteral orifice) Risk factors for bladder injury include any process that distorts tissue planes and reduces surgical exposure.(14) This includes adhesions or scarring from prior surgery, radiation, malignant infiltra- tion, chronic inflammation, or infection. Injuries can be apparent intraoperatively or present in a delayed fashion. Intra operative identification of the injury allows for immediate cystorraphy usually in a two layer fashion. In open surgery, the mucosa is closed in a running fashion using a 3–0 SAS suture followed by a seromuscular running suture of 2–0 SAS. The bladder can then be irrigated to ensure a watertight closure. In the laparoscopic setting, a running one layer closure is performed using a 2–0 SAS to close all three layers of the bladder. Care must be taken to ensure closure of the mucosal layer in the laparoscopic one layer technique. Again, the bladder should be irrigated to ensure a watertight closure. Repair can also differ depending on the location of the injury. Anterior and dome injuries can be repaired primarily as above. Posterior injuries involving the trigone or near the ureteral orifices (possible Grade 5) dictate a more thorough inspection of the bladder and an assurance of ureteral integrity before closure. This is done through an anterior cystotomy in the sagittal plane extending down toward the pubic symphisis. This will allow placement of a Balfour or Bookwalter self-retaining retractor and placement of bilateral ureteral open-ended catheters. Giving the patient indigo carmine with Lasix can aid in identification of the ureteral orifices. Closure of the posterior bladder injury can then be done from the bladder lumen—closing the muscular layer first using 2–0 SAS followed by closure of the mucosal layer using 3–0 SAS. The anterior cystotomy is then closed as described above. In cases where neoadjuvant radiotherapy has been used, an interposition of omentum or perivesical fascia is prudent to decrease the risk of fistula formation. A delayed bladder injury will usually manifest in the early postoperative period, especially after removal of foley catheter. The injury can present as drainage from surgical incision; increased output from surgical drain; vaginal leakage; ileus; apparent oliguria; urinary ascites with increasing BUN and serum creatinine secondary to reabsorption of urine through parietal peritoneum—in the case of an unrecognized intraperitoneal injury; pneumaturia or fecaluria in the cases of an enterovesical or colovesical fistula. Delayed urine leaks can be diagnosed radiographically by fluoroscopic cystogram or the CT cystogram.(15) It is important when ordering a CT cystogram that passive filling of the bladder from the upper tracts is not the sole method of bladder opacification. A foley catheter should be placed and the bladder filled in a retrograde fashion with 300–400 cc’s of water-soluble contrast before the scan. The development of a colovesical or enterovesical fistula is a delayed complication of cystotomy.(16–17) Abdominal-pelvic CT scan with oral and/or rectal water-soluble contrast has a greater sensitivity than cystoscopy in diagnosing an enterovesical fistula (Figure 36.1). The most sensitive test to diagnose an enterovesical or colovesical fistula is the poppy seed test.(17) A 1.25-ounce container of poppy seed is mixed into a 12-ounce beverage o r a 6-ounce serving of yogurt and orally ingested by each patient. Urine was visually inspected during 48 hours, during which identification of poppy seed in the urine was a positive confirmatory test for gastrointestinal fistula to the urinary tract. The sensitivity and specificity was 100%.(17) This test does not provide anatomical information as in the case of the abdominal- pelvic CT scan but it is a much more cost effective screening test in patients with equivocal symptoms (5 dollars vs. over 600 dollars). (17) When using Barium contrast, it is the authors recommendation to empty the bladder after a fistulae is diagnosed as there have been reports of Barium concretions within the bladder.  urologic complications of colorectal surgery URETERAL INJURIES Injury to the ureter is one of the most common intraoperative urologic injuries in colorectal surgery. The incidence of iatrogenic injury to the ureter is reportedly from 1 to 10%.(18–22) Iatrogenic ureteral injuries are of 4 types: laceration, ligation, devascularization, and thermal or energy related. Optimal treatment is early recognition and repair of any ureteral injury. Anatomy Iatrogenic ureteral injuries in colorectal surgery usually occur in three distinct locations: at the takeoff of the inferior mesenteric artery, where the infundibulopelvic ligament/uterine vessels crosses the pelvic brim, and between the lateral rectal ligaments (Figure 36.2).(23) The course of the ureter begins posterior to the renal artery and continues along the anterior edge of the psoas muscle. The gonadal vessels cross the ureter from lateral to medial in this region. The ureter next passes over the iliac vessels, generally marking the bifurcation of the common iliac into internal and external iliac arteries.(24) Of greatest importance to the surgeon is that arterial branches to the abdominal ureter approach from the medial direction whereas arterial branches to the pelvic ureter approach from the lateral direction.(24) For the abdominal ureter, these branches originate from the renal artery, gonadal artery, abdominal aorta, and common iliac artery. After entering the pelvis, additional small arterial branches may arise from the internal iliac artery or its branches, and also from the middle rectal and vaginal arteries.(24) The ureter will tend to adhere to the peritoneum during its reflection rather than staying adherent to the Psoas muscle and underlying tissue. The ureter can be identified by visualization and by its peristaltic activity. Gentle pressure applied to the ureter will frequently cause peristalsis—termed the Kelly sign. The right ureter is adjacent to the cecum, terminal ileum, and the appendix. The left ureter is related to the descending and sigmoid colon and their mesenteries. Prevention Ureteral catheterization is used to aid in identification of the ureters and to help identify ureteral injury, but catheters do not prevent ureteral injury. The clinical value of prophylactic ureteral catheter placement before 162 laparoscopic segmental left and right colectomies was assessed by Nam et al. There were no complications from placement of ureteral catheters.(18) Postoperative urinary tract infection was not increased. Total operative time was increased by 11.3 minutes. The ureteral catheter group included more difficult cases including patients with Crohn’s disease and diverticulitis. There were no ureteral injuries in any of the one hundred sixty two patients.(18) An earlier study deemed ureteral catheterization necessary in 27.5% of patients when assessed in a stand- ardized retrospective fashion.(22) There were 4 complications presumably due to ureteral catheterization which included renal colic, oliguria, and one case of anuria attributed to ureteral edema after removal of the ureteral catheters.(20, 25) Chahin et al. stud- ied lighted ureteral stents/catheters placed before laparoscopic colectomy in 66 patients.(20) The most common complication was self-limiting hematuria in 98.4% of patients with an average duration of 2.5 days for unilateral stenting and 3.3 days with bilateral stenting. It is the authors’ opinion that the choice for ureteral stenting is a surgeon preference and depends on multiple variables including complexity of case, anatomy, and experience—especially with the laparoscopic approach in a hostile abdomen. With greater experience, iatrogenic injury decreases. In a study by Larach et al., the incidence of conversions due to iatrogenic injuries showed a decline from 7.3% in the early group to 1.4% in the latter experience group.(26) Once again ureteral catheters have not been shown to decrease ureteral injuries but aid in identification of the ureters and any iatrogenic ureteral injury. Ureteral catheters Figure 36.1 Enterovesical fistula (arrow). Figure 36.2 Anatomy of the ureter. . drainage in the management of penetrating rectal injuries. J Trauma 1998; 45: 656–61.  improved outcomes in colon and rectal surgery 111. Gonzalez RP, Phelan H, Hassan M, Ellis N, Rodning. home. Feeding jejunostomies were placed in 6 patients and enteral nutrition was initiated in all 6 within 48 hours. summary Anal sphincter and complex perineal injuries are uncommon in civilian. Colorectal Trauma. In: Corman, M, ed. Colon and Rectal Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2005: 427–49. 21. Nelson R, Singer M. Primary repair for penetrating colon

Định dạng
Số trang	10
Dung lượng	291,43 KB