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Sat Oct 27 14:44:07 BST 2007

In a message dated 10/27/2007 5:39:42 A.M. Central Daylight Time,  
hpb.surgery at gmail.com writes:

1.  Pelvic fracture + suspected ongoing retro peritoneal venous bleed,  what
surgical strategy would you employ?
2. If a rectal tear is  suspected, without any perioneal trauma, how would you
de-function, loop  colostomy? Or end colostomy and mucous fistula? Would you
try and establish  the site of perforation - on-table flexible  sigmoidoscopy
etc.?

I agree with Bjorn regarding the excessive fluid administration.  

The patient appears to be hemodynamically stable.    If  unstable, then one 
of several tactics to impede ongoing blood loss is  indicated.   I have never 
been totally satisfied with arterial  embolization for control of venous 
bleeding.    I also have not  been satisfied with external fixation to reduce blood 
loss.   The  orthopedic community is mixed in its support of external  
fixation.    The new extra peritoneal packing as reported from  Europe and from a 
couple of centers in the United States bears  watching.    I might have 
considered such a procedure in this  patient.   It is a temporizing ("damage control") 
tactic.  

With the case as you describe, I would consider going to OR for an  
examination under anesthesia, looking mainly at the rectum.     For this one does not 
need to do a flexible sigmoidoscopy, as it is only the  rectum which is of 
concern.     This can be done with a  straight short scope.     Even a full 
thickness injury might  be missed, but your CT description is suggestive of a rectal 
 injury.     I would strongly consider a LOOP colostomy, but  to be sure that 
the distal stoma is totally defunctionalized, unless the patient  is obese 
and the mesentery is foreshortened and to do a loop would create  vascular 
compromise to the exteriorized segment.       If the patient's pelvis was 
operatively repaired, and he did not become  febrile, I would study the distal rectum 
via the loop colostomy and if NO LEAK,  I would consider closing this colostomy 
at the first  hospitalization.   

k

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