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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 51  |  Issue : 1  |  Page : 32-37

Experience in traumatic small bowel perforation management


Department of Surgery, Division of General Surgery, Taoyuan Armed Forces General Hospital, Taoyuan City, Taiwan

Date of Submission05-Jun-2017
Date of Decision08-Aug-2017
Date of Acceptance15-Sep-2017
Date of Web Publication09-Feb-2018

Correspondence Address:
Dr. Hong-Ming Chao
No. 168, Zhongxing Road, Longtan District, Taoyuan City
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_104_17

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  Abstract 


Small bowel perforations due to blunt abdominal injury are rare. In this study, we compiled five cases of traumatic small bowel perforation and then analyzed a number of the prognostic factors. Elapsed time to surgery was identified as the most important prognostic factor, due to the risk of peritonitis. Laparoscopy surgery appears to be a safe, effective procedure in cases where the diagnosis is uncomplicated by other major problems, such as lacerations to the liver or spleen.

Keywords: Blunt abdominal injury, laparoscopy, traumatic small bowel perforation


How to cite this article:
Chen PT, Chao HM. Experience in traumatic small bowel perforation management. Formos J Surg 2018;51:32-7

How to cite this URL:
Chen PT, Chao HM. Experience in traumatic small bowel perforation management. Formos J Surg [serial online] 2018 [cited 2019 Jan 18];51:32-7. Available from: http://www.e-fjs.org/text.asp?2018/51/1/32/225126




  Introduction Top


Small bowel perforations due to blunt abdominal contusion are rare and somewhat difficult to diagnose accurately. Formulating a timely diagnosis is particularly difficult in cases where the perforation occurs in conjunction with other problems. Any delay in diagnosis and/or management leads inevitably to longer hospital stays, higher complication rates, and the need for additional medical interventions. This article presents five cases of traumatic small bowel perforation between 2014 and 2017 from the perspectives of injury severity score, time to surgery, perforation region and size, length of hospital stay, medical costs, and the types of surgical intervention.


  Case Study Top


Case 1

A 40-year-old male was brought to the emergency department following a car accident. The patient presented blood pressure of 108/68 mmHg, pulse rate of 100 beats/min, and body temperature of 36.2°C. Under physical examination, the abdomen presented signs of tenderness. Computed tomography (CT) images of the chest and abdomen revealed an intrapulmonary hemorrhage in the right lung, whereupon the patient was admitted to the Intensive Care Unit (ICU) for observation. However, after the patient went into shock the following day, CT of the abdomen was performed again, revealing extraluminal air + ascites in the abdomen [Figure 1]. Emergent exploratory laparotomy revealed a 1.5-cm perforation over the ileum [Figure 2], which was subsequently sutured. Postsurgery, the patient was admitted to the ICU during which piperacillin-tazobactam was administered. At 5 days' postsurgery, the patient began the oral intake of water before progressing to a full diet. Unfortunately, the patient suffered infection of the periumbilical, necessitating the removal of 3 stiches and the application of wet dressing. The infection eventually healed, and the patient was discharged after being hospitalized for 36 days.
Figure 1: Abdomen contrast computed tomography revealing extraluminal air + ascites

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Figure 2: 1.5-cm perforation hole over ileum

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Case 2

An 18-year-old male was brought to the emergency department following a motor vehicle accident. The patient presented blood pressure of 94/41 mmHg, pulse rate of 121 beats/min, and body temperature of 36.1°C. Under physical examination, signs of severe tenderness were observed over the chest area. Under the impression of hypovolemic shock, CT scans of the chest and abdomen revealed a traumatic rupture of the descending aorta [Figure 3]. The patient immediately underwent surgery to deal with a rupture of the endovascular thoracic aorta. Postsurgery, the patient was admitted to the ICU under deep sedation to prevent high blood pressure-related rupturing of the aorta. At 5 days' postoperative period, muscle guarding over the abdominal region was observed. Emergent CT scans of the abdomen revealed extraluminal air + ascites [Figure 4]. Emergent exploratory laparotomy revealed a 1.0-cm perforation over the ileum [Figure 5], whereupon primary suturing was performed. Postsurgery, the patient was admitted to the ICU during which piperacillin-tazobactam was administered. At 5 days' postsurgery, the patient began the oral intake of water before progressing to a full diet. Unfortunately, the patient suffered infection of the periumbilical, necessitating the removal of all stiches and the application of wet dressing. The infection eventually healed, and the patient was discharged after being hospitalized for 55 days.
Figure 3: Chest contrast computed tomography revealing traumatic descending aorta rupture

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Figure 4: Abdomen contrast computed tomography revealing extraluminal air + ascites

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Figure 5: 1.0-cm perforation hole over ileum

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Case 3

A 21-year-old male was brought to the emergency department following a motor vehicle accident. The patient presented blood pressure of 112/72 mmHg, pulse rate of 116 beats/min, and body temperature of 36.3°C. Under physical examination, signs of tenderness were observed in the abdominal region. Under the impression of internal bleeding, CT scans of the abdomen revealed a Grade IV rupture to the spleen [Figure 6]. Emergent exploratory laparotomy prior to a splenectomy revealed a 0.5-cm perforation over the ileum [Figure 7], whereupon primary suturing was performed. Postsurgery, the patient was admitted to the ICU, during which piperacillin-tazobactam was administered. At 5 days' postsurgery, the patient began the oral intake of water before progressing to a full diet. No infection developed and the patient was discharged after being hospitalized for 10 days.
Figure 6: Abdomen contrast computed tomography revealing spleen laceration

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Figure 7: 0.5-cm perforation hole over ileum

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Case 4

A 48-year-old female was brought to the emergency department following a motor vehicle accident. The patient presented blood pressure of 125/60 mmHg, pulse rate of 72 beats/min, and body temperature of 36.5°C. Under physical examination, the abdomen appeared soft with signs of tenderness.

Abdominal muscle guarding was observed while the patient was under observation in the emergency department. CT scans of the abdomen revealed extraluminal air [Figure 8]. Emergent laparoscope revealed a 2.0-cm perforation over the jejunum [Figure 9], whereupon primary suturing was performed. Postsurgery, the patient was admitted to the ICU, during which piperacillin-tazobactam was administered. At 5 days' postsurgery, the patient began the oral intake of water before progressing to a full diet. No infection developed and the patient was discharged after being hospitalized for 13 days.
Figure 8: Abdomen contrast computed tomography revealing extraluminal air

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Figure 9: 2.0-cm perforation hole over jejunum

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Case 5

A 36-year-old male was brought to the emergency department following a car accident. The patient presented blood pressure of 122/78 mmHg, pulse rate of 78 beats/min, and body temperature of 36.2°C. Under physical examination, the abdomen presented signs of tenderness. CT scans of the abdomen revealed extraluminal air [Figure 10]. Emergent laparoscope revealed a 2.0-cm perforation over the jejunum [Figure 11], whereupon primary suture was performed. Postsurgery, the patient was admitted to the ICU, during which piperacillin-tazobactam was administered. At 5 days' postsurgery, the patient began the oral intake of water before progressing to a full diet. No infection developed and the patient was discharged after being hospitalized for 7 days.
Figure 10: Abdomen contrast computed tomography revealing extraluminal air

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Figure 11: 2.0-cm perforation hole over jejunum

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  Discussion Top


The four male patients and one female patient in this study presented physical status classification I (American Society of Anesthesiologists [ASA] I). Three of the cases were traffic accidents involving motor vehicles and the other two cases were car accidents. The injury severity scores ranged from 9 to 43. Three of the cases involved perforation of the ileum whereas the other two cases were to the jejunum. The perforations were 1.5 cm, 1.0 cm, 0.5 cm, 2.0 cm, and 2.0 cm in the five cases, respectively. Two of the patients underwent laparoscopic surgery and the other three patients underwent exploratory laparotomy surgery. Two of the patients who underwent exploratory laparotomy surgery suffered infections of the wound.

Blunt abdominal injuries make up 80% of the abdominal injuries in emergency departments, and most of these are related to motor vehicle accidents. Approximately 13% of the patients with blunt abdominal injuries suffer from intra-abdominal injuries.[1] After injuries to the spleen and liver, traumatic injury to the small bowel is the most common.[2] As shown in [Table 1], three of the patients in this study suffered perforation to the ileum whereas the other two suffered perforation to the jejunum.
Table 1: Characteristics of these five patients

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The prognosis for patients with a perforated small bowel depends on their physiological state (ASA score), the extent of peritoneal soiling, the size of the traumatic lesion, and the elapsed time to surgery. Only the elapsed time to surgery is modifiable and therefore related to the quality of medical care. Excessive elapsed time to surgery can lead to significant morbidity and/or mortality.[3] After confirming a diagnosis of traumatic small bowel perforation, definitive repair or resection must be performed as soon as possible within 24 h.[4] In this study, the times from injury to diagnosis were 18, 121, 1, 1.5, and 7 h, respectively, in the five cases, and the time spent in surgery was approximately 2.5 h. In case 2, the elapsed time to surgery was 121 h, due to traumatic descending aorta rupture status postsurgery of endovascular thoracic aorta stent, deep sedation after surgery made it difficult to detect peritonitis and abdominal muscle guarding. Postsurgery, wound infection resulted in a hospital stay of 55 days due to the severity of peritoneal soiling.

Delayed diagnosis of traumatic small bowel perforation can result in significant morbidity or mortality; however, obtaining an early diagnosis can be very difficult. In cases where the patient presents signs indicating abdominal surgery or unexplained shock, CT scans of the abdomen must be obtained immediately to rule out the possibility of traumatic gastrointestinal perforation.

The Organ Injury scales proposed by the American Association for the Surgery of Trauma are the most widely used injury classifications for traumatic injury to the small intestine.[5]

Small intestine injury gradings are as follows:

  • Grade I – contusion or hematoma without devascularization; partial-thickness laceration
  • Grade II – full-thickness laceration <50% of circumference
  • Grade III – full-thickness laceration >50% of circumference
  • Grade IV – transection
  • Grade V – transection with tissue loss; devascularized segment


In cases where traumatic bowel injury is identified, definitive surgery must be arranged as soon as possible. Low-grade injuries (Grades I, II, or III) of the small bowel can be repaired primarily, whereas high-grade injuries (Grades IV and V) generally require resection and anastomosis. Intestinal repairs or anastomosis can be repaired using one- or two-layer hand-sewn or stapled technique.

Single-layer hand-sewn anastomosis involves the application of a running 3-O permanent suture, whereas two-layer hand-sewn anastomosis involves a running absorbable suture for the inner layer and an interrupted, permanent suture for the outer layer. There is no difference between one- and two-layer hand-sewn anastomosis with regard to complication rate or hospital stay.[6] The small intestine injuries in the five cases in this study were all full-thickness lacerations <50% of circumference (Grade II). In cases 1, 2, and 3, we performed exploratory laparotomy with two-layer hand-sewn anastomosis, whereas in cases 4 and 5, we performed laparoscopy with one-layer hand-sewn anastomosis. No intestinal anastomosis leakage occurred in any of the cases in this study.

Seat belts have definitely been shown to reduce the severity of trauma due to car accidents. Unfortunately, these devices also tend to increase the possibility of small bowel injury (seat belt syndrome).[7] Three of the cases in this study were motor vehicle accidents and two were car accidents.

Laparoscopic surgery is now widely accepted as a suitable technique for gastrointestinal difficulties. Laparoscopic surgery enables rapid recovery and reduced pain, primarily due to a smaller wound. Wound infection is the major reason for morbidity in cases of traumatic small bowel injury. In some cases, this can even lead to bursting of the abdomen. A smaller wound can reduce the stress response and increase cell-mediated immune response such that laparoscopic surgery results in a better immune response than does exploratory laparotomy.[8] Cases 4 and 5 in this study underwent laparoscopic small bowel repair. Laparoscopic surgery may be an option in cases of small bowel injury; however, it is important to consider whether the patient is suffering from any other problems, such as laceration to the liver or spleen.


  Conclusion Top


Since it is hard to collect the difficulty cases of traumatic small bowel perforation, we had five cases in these years. However, the valuable experiences will be available as a reference for future treatment of the same patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nishijima DK, Simel DL, Wisner DH, Holmes JF. Does this adult patient have a blunt intra-abdominal injury? JAMA 2012;307:1517-27.  Back to cited text no. 1
    
2.
Isenhour JL, Marx J. Advances in abdominal trauma. Emerg Med Clin North Am 2007;25:713-33, ix.  Back to cited text no. 2
    
3.
Faria GR, Almeida AB, Moreira H, Barbosa E, Correia-da-Silva P, Costa-Maia J, et al. Prognostic factors for traumatic bowel injuries: Killing time. World J Surg 2012;36:807-12.  Back to cited text no. 3
    
4.
Schreiber MA. Damage control surgery. Crit Care Clin 2004;20:101-18.  Back to cited text no. 4
    
5.
Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA, et al. Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 1990;30:1427-9.  Back to cited text no. 5
    
6.
Burch JM, Franciose RJ, Moore EE, Biffl WL, Offner PJ. Single-layer continuous versus two-layer interrupted intestinal anastomosis: A prospective randomized trial. Ann Surg 2000;231:832-7.  Back to cited text no. 6
    
7.
Melissa B, Ilardi AA, Leoni R, Roggi A, Meucci D, Messina M, et al. Traumatic gut perforation (seat-belt syndrome): A case report. Pediatr Med Chir 2003;25:277-80.  Back to cited text no. 7
    
8.
Sinha R, Sharma N, Joshi M. Laparoscopic repair of small bowel perforation. JSLS 2005;9:399-402.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
 
 
    Tables

  [Table 1]



 

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