Ilio-sigmoid anastomosis prior to abdominal closure in multitraumapatient

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Tim

GCS 3 on arrival, now progressed to 4, >60units of blood product in a 67
yo after 1 week, has a poor prognosis.  I would leave the ileostomy in
place and use it as "fecal toilet" given the likely bed bound status
this patient will have.  If the abdomen remains open or if there is any
further need to re-explore, I would place a super-pubic for "urinary
toilet", and a feeding gastrostomy/jejunostomy. 

Good luck.

Matthew T. Wilson, MD, FACS
Assistant Director of Trauma Services
Cedars-Sinai Medical Center
Department of Surgery
8700 Beverly Blvd, Suite 8215NT
Los Angeles, Ca  90048
Ph/Fax: (310) 423-6444 / (310) 423-0139
Email: Matthew.Wilson at cshs.org

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of tim cooper
Sent: Tuesday, August 19, 2008 2:48 PM
To: trauma-list at trauma.org
Subject: Ilio-sigmoid anastomosis prior to abdominal closure in
multitraumapatient


Ilio-sigmoid anastomosis prior to abdominal closure in multitrauma
patient
A recent case at our trauma centre has raised the question of the timing
and relative risks/benefits of bowel anastomosis in the multitrauma
patient.

67 year old female, pedestrian hit by car, GCS 3 on scene, major head
and abdominal trauma, unstable T1 fracture, multiple pelvic fractures
with blush (embolized) 
Day 0: Damage control laparotomy with splenectomy, mesenteric bleed
found, ~10cm small bowel resection, abdomen left open 
Day 1: Re-laparotomy with subtotal colectomy (colon found to be
necrotic, sigmoid spared), iliostomy, TAC. Concurrent craniotomy for
expanding extradural, and ICP monitor placement - post op continuous
oozing through vac, additional re-laparotomy that afternoon for packing,
VAC reapplied 
Day 4: tracheostomy and 2nd relook laparotomy for washout and primary
closure 
~60 units of packed cells, 20 of FFP and 20 of cryoprecipitate
transfused during these first 72 hours 
Currently GCS 4 (on day 7) 
Plan to anastomose ileum and sigmoid at later date 
Suggestion was made that anastomosis of ileum and sigmoid could have
occurred during the last laparotomy prior to definitive closure,
avoiding the risks of an additional laparotomy etc. Has anyone had
experience with this approach? What are people's thoughts? Thanks! Tim
(Sydney, Australia)
 
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