Penetrating colonic trauma and damage control surgery: Anastomosis or stoma?

BACKGROUND: The management of colon injuries in damage control surgery (DCS) remains controversial. METHODS: A retrospective study investigating outcomes of penetrating colonic trauma in patients who survived beyond the initial repeat laparotomy (IRL) after DCS was performed. Patients over 18 years with penetrating colon injury and who underwent DCS from 2012 to 2020 were included from our electronic trauma registry. Demographic data, admission physiology and Injury Severity Score (ISS) were reviewed. Patients were classified into three groups: primary repair of non-destructive injuries at DCL, delayed anastomosis of destructive injuries at IRL and diversion of destructive injuries at IRL. Outcomes observed included leak rates, length of intensive care unit stay, length of hospital stay, morbidities, mortality and colon-related mortality. RESULTS: Out of 584 patients with penetrating colonic trauma, 89 (15%) underwent DCS. After exclusions, 74 patients were analysed. Mean age was 32.8 years (SD 12.5); 67 (91%) were male. Mechanism of injury was gunshot in 63 (85%) and stab 11 (15%) patients. Seventeen patients underwent primary repair at DCS, of which one leaked. Twenty patients underwent delayed anastomosis at IRL. Of these, five (25%) developed leaks. Mortality was significantly higher for those with an anastomotic leak compared to those without (p < 0.001). Thirty-seven patients were diverted at IRL. Overall mortality (p = 0.622) and colon-related mortality (p = 0.592) were not significantly different across groups. CONCLUSION: Delayed anastomosis at IRL following DCL was associated with a leak rate of 25% in this study. When anastomotic leak did occur, it was associated with significant mortality. Delayed anastomosis should only be undertaken in highly selected patients.

Prospective review of cytotoxic snakebite envenomation in a paediatric population.

Cytotoxic snakebite envenomation is prevalent in Kwazulu-Natal and may be associated with significant physical disability. The aim of this study was to provide an overview of the effects of cytotoxic envenomation in children. The patient population were all patients attending the Emergency Department at Ngwelezana Tertiary Hospital with snakebite from December 2014 to March 2015. All children 13 years or younger presenting with painful progressive swelling (PPS) following snakebite were included in this study. They were further classified according to severity: mild, moderate and severe. Patient demographic and clinical data was collected prospectively. Fifty-one children were included in this study. Nine were classified as mild, 24 as moderate and 18 as severe. The median time of presentation after bite was 6 h in the mild group, 7 h in the moderate group and 12 h in the severe group. There was a positive correlation between increasing severity and INR (p=< .00001) and no correlation between WCC (p = .175) or renal function and severity (p = .963). A total of 11 children (22%) developed an acute kidney injury (AKI). A total of 23/51 patients received antivenom; 25% of patients with moderate cytotoxicity and 94% of patients with severe cytotoxicity. Thirteen percent developed allergic reactions (3/23) and 57% (13/23) anaphylaxis. A total of 15 patients underwent one or more procedures on their affected limbs. There was one recorded mortality during this period, related to severe anaphylaxis following antivenom administration. Access to healthcare for antivenom administration is often delayed and ongoing education within affected areas is advised. Whilst majority of snakebite victims can be adequately managed with basic supportive measures, early identification of severe envenomation is crucial to enable timeous antivenom administration and prevention of further complications such as compartment syndrome and loss of limb. Hypersensitivity reactions are alarmingly common following antivenom administration in children and strict protocols should be followed when administering antivenom.