Meta-analysis on surgical management of colonic injuries in trauma: to divert or to anastomose?

BACKGROUND: Primary repair or resection with anastomosis (PR/A) has been gaining increasing recognition for traumatic colonic injuries, with the need for faecal diversion (FD) especially those of penetrating etiology being questioned. However, the role of PR/A in critically ill patients is still controversial with concerns pertaining to safety and anastomotic leak. AIMS AND METHODS: We performed a systemic review of studies comparing outcomes of FD versus PR/A in traumatic colonic injuries. A systematic review was performed as per PRISMA guidelines utilizing three electronic databases: Pubmed, EMBASE, and Cochrane Library resources. Mortality and anastomotic leak rates are identified as the primary and secondary outcomes, respectively. Data extracted include mortality rates, type of surgical intervention, surgical complications, and need for DC (damage control) surgery. RESULTS: Fourteen studies were identified comprising 11 retrospective, 2 prospective cohort and 1 randomized trial with a total of 2071 patients. Six studies included patients that underwent DC surgery. The overall mortality rate was 3.77% and was higher in the FD group compared to PR/A group (5.38% vs 2.49%, p = 0.07). 71.3% of patients underwent PR/A with an overall leak rate of 4.63%. There was no difference in intra-abdominal collections between the PR/A and FD groups. In the subgroup analysis, anastomotic leak rate was significantly higher in the DC group compared to non-DC group (16.7% vs 3.2%, p = 0.003). CONCLUSIONS: This meta-analysis supports PR/A in stable patients with traumatic colonic injuries. FD should be considered in critically ill patients who require DC surgery as leak rates are significantly higher.

Endoscopic Findings in Patients Under the Age of 40 Years with Hematochezia in Singapore.

BACKGROUND/AIMS: Sigmoidoscopy is performed in most medical centers to evaluate the distal colons of young adults presenting with hematochezia who are at risk of developing proximal lesions. Colonoscopies offer more complete evaluations but are associated with a higher incidence of complications and possible low yield. METHODS: An analysis was conducted on colonoscopies performed in our center on patients 40 years of age or younger. The study population was sub-divided into 2 age groups for analysis: <30 years of age and 30-39 years of age. RESULTS: We recruited 453 patients for the study. Patients were 115 and 338 individuals that were <30 and 30-39 years of age, respectively. Hemorrhoids was identified as the cause of bleeding in the majority of cases. The overall incidence of polyps was 6.5%; this was significantly higher in the 30-39 age group (7.4% vs. 1.7%, p=0.026). There were two cases of advanced/malignant polyps. While the majority of the polyps were in the distal colon, 28% of the polyps in the older age group were found in the proximal colon. There was one case of colonic perforation. CONCLUSION: Colonic polyps are more prevalent in patients aged 30-39. Colonoscopies should be considered for patients over the age of 30 with rectal bleeding.

Colonic stenting for malignant large bowel obstruction is safe and effective: a single-surgeon experience.

INTRODUCTION: Self-expanding metal stents (SEMS) can be used as a bridge to surgery (BTS) or for palliation in the treatment of malignant large bowel obstruction. This case series evaluates the short-term outcomes of SEMS and success rates over time. METHODS: A total of 75 consecutive patients who underwent colonic stenting for malignant colonic obstruction over a period of six years were included. This time period was subdivided into two equal parts for analysis. The procedure was carried out by a single surgeon from a tertiary institution in Singapore. RESULTS: Technical success was reported in 93.3% of cases and clinical success in 81.3% of cases, with better success rates in the second half of the study (89.2% vs. 73.7%; p < 0.05). There were seven cases of inadequate decompression and two cases of colonic perforation. The median duration from stent insertion to surgery was ten days, and the median postoperative length of stay was six days. CONCLUSION: SEMS are a safe and effective way of relieving malignant large bowel obstruction, including those that are proximal. The improvement in success over time reflects the importance of having an experienced endoscopist carry out the procedure to ensure optimum success rates.

An Unusual Case of Ovarian Carcinomatosis with Microscopic Tumor Embolism Leading to Rectal Ischemia and Perforation.

We present an unusual case of advanced ovarian carcinoma with postoperative complications of ischemia and perforation of the rectum as a result of tumor embolism. The interval progression from ischemia to infarction of the rectum was captured in repeated sigmoidoscopies. A brief discussion on tumor embolism and management of this case is also included.