Diagnostics and Treatment of Colon Injuries in Isolated and Combined Trauma (Clinical and Experimental-Anatomical Studies)

The dissertation is devoted to the diagnostics and surgical treatment of colon injuries in isolated, multiple, and combined trauma. The work is based on clinico-anatomical, experimental, and clinical studies. It addresses relevant questions of traumatology, including morphological changes and reparative regeneration of the colon wall, topographic-anatomical features of injuries, and microcirculatory disorders in combined trauma. The author developed differentiated algorithms of diagnostic-therapeutic tactics and surgical treatment, and justified index assessment of injury severity. The results have been implemented in clinical practice and used in the educational process.

Relevance of the problem

The problem of trauma has been and remains one of the leading causes of mortality and disability in the population. In recent years, severe multiple and combined injuries have taken on dominant significance due to the increase in road traffic, occupational, and domestic trauma, and show a tendency to increase.

Thus, over the past 5 years, mortality from road traffic accidents in Russia has increased by 65%, and the number of deaths, according to the GIBDD, reaches 33,000-35,000 per year (Ermolov A.S., 2003).

Patients with polytrauma account for up to 28% of the total number of trauma patients (Agadzhanyan V.V., 2003). Among them, persons of working age predominate.

According to Sokolov V.A. et al. (2006), among persons under 40 years of age, trauma ranks first among the causes of mortality, and among men it prevails 4.4 times compared with mortality rates in women.

According to the literature, 62.7% of victims sustained extremely severe trauma that caused death at the scene, another 5.4% died during transportation, and only 37.3% of patients received treatment. Trauma as a result of road traffic accidents was the cause of death in 38.7%, catastrophe in 26.8%, railway accidents in 11.2%, stab wounds in 17.6%, and gunshot wounds in 2.4%. Alcohol was detected in the blood of 39.3% of victims. Multiple injuries occurred in 69% of victims, combined injuries in 31.0% (Pugachev A.D. et al., 1990; Khestanov A.K., 2004).

According to the materials of the Military Medical Academy of St. Petersburg (Singaevsky A.B. et al., 2002), one immediate cause of death was identified in 73.5% of victims, two causes in 21.6%, and three causes in 4.9%. Acute massive blood loss led to a fatal outcome in 43.9%, of which it was the sole cause of death in 37.6%, severe traumatic brain injury in 25.1%, pneumonia (including aspiration) in 27.6%. Sepsis was the immediate cause of death in 69.0% of cases.

According to V.V. Agadzhanyan (2003), mortality in the acute period reaches 57.0%, in the early period 18.0%, and in late manifestations 25.0%. Unfortunately, these are young and middle-aged individuals. Taking into account the labor potential and social significance of these patients, the mortality figures are alarming and show a tendency to increase.

According to Sokolov V.A. (2006), persistent loss of working capacity in polytrauma is 15.0-20.0%, and according to Agadzhanyan V.V. (2003), it reaches 45.0%.

Despite close attention to the problem of causes of mortality and disability resulting from polytrauma, these indicators remain sufficiently high. This places polytrauma in the category of not only medical but also socially significant problems.

From a practical standpoint, combined abdominal trauma is of greatest interest to general surgeons. The leading injuries are those of the parenchymal abdominal organs, primarily the liver and spleen, and mesenteric vessels, accompanied by hemorrhage into the abdominal cavity, followed by injuries to hollow organs and the urinary bladder with the escape of their contents into the peritoneal cavity and the development of peritonitis (Khastanov A.K., 2004).

In the first case, victims exhibit a classical picture of hypovolemic (hemorrhagic) shock, while in the second, peritoneal symptoms of varying severity, depending on the localization and extent of the injury.

Of all the listed problems, the most severe is the treatment of colon injuries. The frequency of gunshot wounds of the colon reaches 60.0% of the total number of all abdominal injuries, and among the deceased — 80.0% (Shaposhnikov Yu.G., 1986; Zubarev P.N., Bisenkov I.I., 1993; Totikov V.Z., Khastanov A.K. et al., 2001, 2002; Khastanov A.K., 2004). In peacetime, colon injuries occupy a special place due to frequent complications in the postoperative period and high mortality. This is primarily due to the severity of the intestinal injury itself, and secondly, to multiple and combined injuries of other organs and organ systems, in which the prognostic factor of colon trauma is rightly considered the most unfavorable.

In isolated colon injuries, the case fatality rate exceeds 2-14% (Sheyanov S.D., 2000; Totikov V.Z., Khastanov A.K. et al., 2001, 2002; Khastanov A.K., 2004; Conrad, 2000), in colon injuries against the background of combined trauma up to 39.5-51.8% (Tsybulyak G.N., 1992; Khastanov A.K., 2004; Messmer, 1996; Buchert, 1997), and in multiple injuries it amounts to 25.3-41.2% (Bryusov P.G., 2001; Carlin A.M., 2002).

Complicated courses of colon injuries are recorded in the range of 20.0 to 65.0% of cases (Aliev S.A., 2000; Revsky A.K. et al., 2001; Totikov V.Z., Khastanov A.K. et al., 2001, 2002; Khastanov A.K., 2004). The main cause of death in the postoperative period is severe intra-abdominal complications, which may occur in half of the operated patients.

Recognition of closed injuries of the abdominal organs, especially the colon, is one of the difficult tasks due to the heterogeneous nature of the injuring forces and their points of application, sometimes significantly remote from the projection of the injured organ, the diversity of anatomical structures of the abdominal organs, and the varying severity of injuries. The variability of the clinical picture and the absence of absolute clinical signs sometimes make this task difficult to resolve (Nikiforov B.I. et al., 1982; Romanenko A.E., 1986; Khastanov A.K., 2004).

At present, there is no unified strategy for the choice of treatment for colon injuries, especially against the background of combined and multiple trauma, depending on the nature and severity of the injury to the intestinal wall and its mesentery, the time elapsed since the trauma, the degree of contamination of the abdominal cavity, blood loss in multiple injury of parenchymal organs, and the severity of traumatic shock. The literature contains various, often contradictory, data regarding the advisability of radical or palliative operations in this pathology (Biryukov Yu.V., 2000; Aliev S.A., 2000; Revsky A.K. et al., 2001; Lantberg L., 2000; Khastanov A.K., 2004; Barden V.E., 2000).

The development of precise surgical techniques and new modifications of sutures and colonic anastomoses is not a decisive condition for the success of colon operations, although it reduces the number of complications (Aliev S.A., 2005).

The complexity of solving this problem is due to the fact that despite the numerous proposed clinical criteria, laboratory tests, and instrumental methods for assessing the viability of the colon, the question of the state of reparative regeneration of the zone of its injury at various times from the moment of trauma has not yet been resolved (Khastanov A.K., 2004; Mori et al., 1989; Dabareiner et al., 1993; Levine et al., 1995; Mutter et al., 1996; Kruschewski et al., 1997).

Thus, colon injuries, especially against the background of multiple and combined trauma, and their surgical treatment represent an urgent problem that is currently acquiring particular acuity and requires further research in this direction.

Furthermore, the insufficient substantiation of microcirculatory disorders, the imperfection of quantitative assessment of regional microcirculation disorders in combined trauma, and the unresolved nature of many aspects of their pathogenetically grounded, targeted correction in the postoperative period make further research in this direction advisable and promising.

The goal of the work is to improve the results of treatment of patients with colon injuries against the background of combined and multiple trauma through the development and substantiation of a diagnostic-therapeutic and surgical approach.

The set goal determined the following research tasks:

1. To study the clinical anatomy of the colon in relation to the topography and etiology of injury.

2. To study morpho-functional changes and features of wound healing of the colon in experiments on the background of combined and multiple trauma.

3. To substantiate and develop algorithms of diagnostic-therapeutic measures in patients with isolated, combined, and multiple colon injuries.

4. To substantiate and develop index assessment of the severity of colon injuries, allowing determination of treatment tactics and prognosis in patients with isolated, combined, and multiple injuries.

5. To develop a differentiated algorithm of surgical treatment of colon injuries in isolated, multiple, and combined trauma depending on the index assessment of severity.

6. To develop principles for the organization of specialized care at the hospital stage for victims of combined and multiple trauma.

7. Based on the obtained data, to present practical recommendations on the tactics of a differentiated individual approach to the treatment of patients with colon injuries against the background of combined and multiple trauma.

Scientific novelty of the work:

The dissertation work represents a clinico-anatomical and experimental study based on patentable scientific developments.

For the first time, applied clinical anatomy of the colon has been studied in relation to closed and open injuries.

For the first time, in experimental research, morpho-functional changes and features of wound healing of the colon in combined and multiple trauma have been studied, and the dependence of healing times of colon wounds on the duration of the posthemorrhagic period has been established.

The advisability of using videolaparoscopy in the diagnosis of abdominal organ injuries in closed abdominal trauma with colon injury has been substantiated.

A differentiated algorithm of surgical treatment of colon injuries in isolated, multiple, and combined trauma depending on the index assessment of severity has been developed.

A novel method of treatment of injuries of the extraperitoneal part of the rectum (Patent of the Russian Federation for invention No. 2268072 dated January 20, 2006).

A positive decision No. 2005130121 dated September 27, 2005 was obtained on the issuance of a Russian Federation patent for invention "Method for diagnosing injury of an abdominal organ."

A Russian Federation patent for invention No. 2269930 dated February 20, 2006 was obtained for "Method for diagnosing injury of the extraperitoneal segment of the colon."

A Russian Federation patent for invention No. 2271740 dated March 20, 2006 was obtained for "Method for studying fasciae and fat spaces."

For the first time, based on the results of experimental and clinical studies, a differentiated treatment algorithm for patients with colon injuries against the background of combined and multiple trauma has been substantiated and implemented in clinical practice, which made it possible to improve the treatment outcomes for this category of patients.

Scientific and practical significance of the work:

The obtained experimental data on pathomorphological changes occurring in the colon wall in combined and multiple trauma made it possible to determine the relationship between the dynamics of hemomicrocirculation changes in the intestinal wall and the stage of development of traumatic shock.

Principles of treatment of patients based on rational criteria for the severity of the pathological process have been developed, and the necessity of their staged treatment has been substantiated.

The principle of a comprehensive approach to the treatment of patients with colon injuries in combined and multiple trauma with a clear and sequential algorithm of examination and treatment has been determined and substantiated.

Based on the analysis of the results of clinical studies of victims with colon injuries in isolated, multiple, and combined abdominal trauma in three groups of clinical observations, the following provisions have been developed and implemented:

• An original videolaparoscopy technique in patients with combined abdominal trauma in shock of varying severity, along with diagnostic and therapeutic algorithms for isolated and combined abdominal trauma, made it possible to reduce the number of exploratory laparotomies.

• An original method for diagnosing injuries of the extraperitoneal segment of the colon, allowing reliable determination of the penetrating nature of the wound channel of the lumbar region during videolaparoscopy.

• Development of an algorithm of surgical assistance for isolated and multiple colon injuries depending on the nature of the wound, time to treatment, degree of contamination of the abdominal cavity, blood loss, and severity of shock improved treatment outcomes by reducing mortality and the number of postoperative complications.

The economic efficiency of the implemented diagnostic-therapeutic algorithms is explained by the lower traumatism of operations, early activation of patients in the postoperative period, a reduction in the number of required medications, a decrease in postoperative complications and mortality, and a shortening of hospital stays.

The main principled provisions related to the therapeutic strategy for colon injuries in combined and multiple trauma formed the basis of published methodological recommendations and were used in lecture courses and practical classes for students and trainee physicians of the FPK and LPU of RostGMU, as well as implemented in the practice of surgical and traumatological departments and centers of the relevant profile.

Main provisions to be defended:

The scientific and practical decision on the goal of the dissertation research — improving the results of diagnosis and treatment of victims with closed and open colon injuries in isolated, combined, and multiple trauma — is being defended.

Under experimental conditions, the features of clinical anatomy, as well as morpho-functional changes and features of wound healing of the colon in relation to the topography and etiology of injury, have been studied.

Principles for the organization of specialized care at the hospital stage for victims of combined and multiple trauma have been developed, and the necessity of their staged treatment has been substantiated.

An algorithm of diagnostic actions for closed colon injuries resulting from isolated, multiple, and combined trauma has been developed.

An algorithm of surgical treatment of victims with colon injuries in isolated, multiple, and combined trauma depending on the nature of the wound, time to treatment, degree of contamination of the abdominal cavity, blood loss, and severity of shock has been developed.

Modern approaches to the diagnosis and treatment of stab and cut wounds of the abdomen with colon injury have been substantiated.

Proposed "Method for treatment of injuries of the extraperitoneal part of the rectum" (Patent of the Russian Federation for invention No. 2268072 dated January 20, 2006).

Developed "Method for diagnosing injury of an abdominal organ" (positive decision No. 2005130121 dated September 27, 2005 on the issuance of a Russian Federation patent for invention).

Proposed "Method for studying fasciae and fat spaces" (Patent of the Russian Federation for invention No. 2271740 dated March 20, 2006).

Proposed "Method for diagnosing injury of the extraperitoneal segment of the colon" (Patent of the Russian Federation for invention No. 2269930 dated February 20, 2006).

Practical application of the results

The main results of the work have been implemented in the clinical practice of the departments of surgical diseases No. 1, 2, 4 of Rostov State Medical University, surgical departments of MLPU Gor BSMp No. 1 and BSMp No. 2 (Rostov-on-Don), surgical departments of OKB No. 1, 2 (Rostov-on-Don), and approved by the city health administration as standards for diagnosis and treatment of abdominal injuries in combined trauma.

The main provisions of the dissertation, published in print and methodological recommendations, are used in lectures and practical classes for students and trainee physicians of the FPK and LPU courses of Rostov State Medical University.

Volume and structure of the dissertation

The dissertation is presented in 248 pages of typescript and was prepared on an IBM PENTIUM 200 MMX, consisting of an introduction, an analytical literature review, results of original research, conclusions, practical recommendations, a reference list (119 sources, including 62 domestic and 57 foreign authors). The work is illustrated with 84 figures and 24 tables, as well as appendices on 3 sheets.