STANDARDIZATION OF TREATMENT AND DIAGNOSTIC APPROACH FOR COMBINED BLUNT BOWEL INJURY Maskin S.S., Aleksandrov V.V., Matyukhin V.V., Derbentseva T.V.
Volgograd State Medical University, Volgograd, Russia
While the abdomen is opened, the surgeons controls it. When closed, it controls you. Moshe Schein, 2010
Small intestine (SI) is injured more often than other hollow organs of abdominal cavity (AC) (16.3-37.8 %). It is determined by SI high length and unprotectedness [7, 22, 30]. Injuries to middle intestine (MI) are rarer due to more favorable anatomic location − 10-17 % of patients with closed injuries to AC and retroperitoneal space (RS) organs [14, 16, 23, 29], and injuries to the rectum − in 1-5 %. Most patients (60-87.9 %) are men of working age [7, 14, 16, 17, 19, 30]. In 70-90 % of cases, it is combined injury (CI) (with closed TBI (35.6 % for MI), rib fractures (35.6 % for MI; 0.9 % for SI), pelvis (36.7% for MI; 3.2 % for SI; 6.6 % for rectum), lower extremities (41.1 % for MI [16]) or multiple (with liver (32.9-35.2 % for MI; 3.2-32 % for SI), spleen (21.6-26.8 % for MI; 12.9-20 % for SI), pancreas (8.3 %), urinary bladder (6 %) [7, 16, 30]) injury. The transverse colon is damaged in 45-65 %, sigmoid colon − in 11.5 %, the descending colon − in 8.7 % of cases, rarer − the cecum and the ascending colon (7.4 %) [14, 16]. Closed injuries occur after a blow with a blunt object (40.6 % [23, 30]; 4.3-7.2 % for rectum), compression between two heavy objects (4.3-5.9 % for rectum) [14] or as result of road traffic accidents (33.8 % [4, 5, 7, 23, 29, 30]; 62.5 % for MI; 24.2–63.1 % for rectum [16]), falling from height (16.6 % [4, 7, 29, 30]; 9.2 % for SI; 5.4-14.1 % for rectum after falling onto the perineum). Closed injures are characterized by formation of mesenteric and intramural hematomas, ruptures, intestine crushing injury and its ruptures from the mesentery [23]. The mesentery is injured in 22 % of patients with closed abdominal injury (CAI), and it is accompanied by intestinal injury in 72 % [7]. Ischemic disorders in the intestinal wall can be associated with both vascular ruptures and development of thrombosis, resulting in its gradual necrosis and peritonitis within several days [29]. Big mesenterial hematomas can extend to RS. Intestinal rupture from the mesentery causes intraabdominal bleeding. Serious intramural bleeding can lead to secondary necrosis and perforation [29]. Complete intraperitoneal ruptures of the rectum (37-44.5 %) are complicated by fecal peritonitis. In case of an extraperitoneal complete laceration (55.5-57.5 %), the contents of the rectum get into surrounding pelvic fat, causing the septic phlegmon of the small pelvis; a combination of extra- and intraperitoneal ruptures happen in 5.5-6 % of cases.
Difficulties of diagnosing of closed intestinal injuries are burdened by shock state of patients who also can be unconscious or in alcoholic intoxication. With this purpose, we developed a medico-diagnostic algorithm. For relatively stable condition, (SAP > 90 mm Hg, HR < 120 per min., RR < 30 per min., no hemorrhagic shock), complex examination is initiated with urgent multi-spiral computer tomography (CT) of the abdomen (for CI and other injured regions) (the level of evidence − A, recommendation strength − 1; A1) [1, 2, 8, 16].
Examination is supplemented with angiocontrasting for identification of a bleeding source in case of suspected mesenterial vascular injuries and/or presence of free fluid (FF) in AC, retroperitoneal hematoma (RH) and absence of free gas (FG) in AC and RS [7, 13]. The signs of intestinal injury and mesentery are FF in AC (68.8 %), wall thickness, FG in AC and RS (50 % for MI [29]), intestinal dilatation, decreased peristalsis, formation of stripes in mesenterial fat tissues, increasing echoicity of mesenterial fat, mesenterial hematoma or a clot on the intestinal wall, output of contrast medium into intestinal lumen (19 % for MI [29] or a vessel [7, 13, 29]). Sensitivity and specificity of three-contrast (oral, rectal and intravenous) CT are 90-97 and 98 % correspondingly [13, 22, 29]. CT with proctography for diagnosis of rectal injuries gives more information than X-ray contrast proctography owing to 3D reconstruction of an image, clear visualization of a level and location of a rupture (entry of contrast medium into surrounding fat and AC), estimation of injuries to adjacent structures and identification of purulence foci [13].
For contrast medium extravasation (CME) into AC, RS and mesentery (unstable hematoma), endovascular embolization (EE) of an injured vessel is performed [2, 7, 11]. Ghelfi J et al., 2016 [11] reported on EE in 6 patients with CAI and bleeding from the superior mesenterial artery. 1 patient had intestinal ischemia that required for resection.
Urgent laparotomy, bleeding arrest and estimation of intestine vitality are carried out for inefficient EE and FF in AC > 500 ml, and increasing retroperitoneal and mesenterial hematoma [2].
Laparoscopy, hemostasis, sanitation and draining of AC are conducted for inefficient EE and FF in AC < 500 ml [16]. Laparoscopy can identify intramural hematomas, partial lacerations of intestinal walls, and mesenterial injuries, which are difficult to diagnose in the early period. There are some advantages for examination of fixed parts of MI as compared to laparotomy [7, 18, 22]. Conversion is performed for unclear source of ongoing bleeding, inefficient hemostasis and identification of intestinal rupture [7].
For inefficient EE and absent hemoperitoneum ("stabilization" of unstable retroperitoneal and mesenterial hematoma), with stable hemodynamics, dynamic follow-up in ICU is performed.
If EE is efficient, and FF > 500 ml (arrested intraabdominal bleeding with stable hemodynamics), AC sanitation and draining is conducted with laparoscopy.
Dynamic follow-up is conducted in case of efficient EE, FF < 500 ml (arrested insignificant intraabdominal bleeding with stable hemodynamics), absent pneumoperitoneum and pneumoretroperitoneum, with normal abdomen (no signs of peritonitis, no intestinal obstruction, no anterior abdominal wall tension). Diagnostic peritoneal lavage (DPL) (A1) and mini-laparotomy (for multiple postsurgical scars) are conducted for unstable abdomen [1, 2, 8, 16]; in presence of corresponding indications (hollow organ rupture without discharge of FG into AC and RS: bile, intestinal contents, food residuals, turbid effusion with fibrin clots, fecal smell, > 500 leukocytes per ml), alkaline phosphatase > 10 IU/l (produced by mucosa of small intestine and colon; specificity for intestinal injury − 99.8 %, sensitivity − 94.7 %) or amylase > 75 IU/l) − laparotomy [2, 7, 16].
Dynamic follow-up is conducted for absent CME in AC, RS and mesentery, FG in AC, RS, hemoperitoneum [7].
Diagnostic peritoneal lavage is conducted in absence of MCE in AC, RS, mesentery and FG in AC, RS, FF ≤ 500 ml for clarification of characteristics (for patients with stable hemodynamics, CT and diagnostic peritoneal lavage are techniques which supplement each other (A1) [8]), and in case of identification of corresponding indications (hollow organ rupture without discharge of FG into AC, RS), laparotomy is conducted [1, 8].
For absence of CME in AC, RS, mesentery, absence of FG in AC, RS, FF > 500 ml, laparoscopy [18] is conducted for identification of possible rupture of a hollow organ (without discharge of FG), as well as sanitation and draining of AC, and conversion (if indicated).
Laparotomy is conducted in case of identification of CT signs of a hollow organ injury (FF in AC, RS; extraluminal contrast) and clinical signs of peritonitis [2, 8]. For unclear and negative results of CT and normal abdomen, dynamic follow-up (A1) and recurrent CT after 12-24 hours from an injury (A2) are conducted [2, 8]. Laparotomy is conducted according to indications.
For hemodynamic instability (SAP < 90 mm Hg, HR > 120 per min.), RR > 30/min., clinical signs of hemorrhagic shock, the complex examination in the anti-shock surgery room is initiated with ultrasonic examination of AC and RS (A1) (FAST-protocol) and plain X-ray imaging of AC (with radiography of required regions). Urgent laparotomy (A1) and RS revision are conducted for ongoing intraabdominal bleeding (with FF > 500 ml) or retroperitoneal bleeding (signs of blood flow in RH) [1, 2, 7, 14, 16, 18, 22, 30]. FAST-protocol can identify intramural or RH, pneumoperitoneum with an injury to the retroperitoneal part of MI; for intraabdominal rupture − FF 9A1) and FF in AC [1, 8, 10, 22].
Information capacity of ultrasonic examination for intestinal injury is 67-87.5 % [1, 10, 16, 22, 30]. The method allows identification of FF up to 200 ml with accuracy of 94.3 %, 200-500 ml − 98.5 % [7]. Sonography can identify pneumoperitoneum of 1.5 ml in view of a thin echogenic line below the muscular layer and preperitoneal abdominal wall fat tissue. Liver region scanning allows differentiation of intraperitoneal and intraluminal intestinal gas since it is extraluminal in this region. Pneumoperitoneum is characterized with "displacement phenomenon" from anterior to lateral regions of the liver from the back to the left side [8] in contrast to intraluminal and pulmonary gas. Pneumoretroperitoneum is not accompanied by "displacement phenomenon". Gas is identified around the kidney, which has signs of mist, disguise and the renal ring sign (hyperechogenicity of extrarenal tissue); a view with dissappeared big vessels − between the aorta and the inferior vena cava; around pancreas head and behind the gall bladder. Laparotomy is conducted for identification of FG in AC and RS [2, 8, 10].
With complete rupture of the intestine, plain abdominal X-ray imaging identifies FG in AC [1, 8, 10, 16, 22]. laparotomy is conducted. A retroperitoneal laceration is characterized with retroperitoneal emphysema in view of clarification along the kidney and/or RH with intensifying shadow around the clear contour of the kidney, high position of diaphragmatic cupula, disguised external border of the psoas muscle [13]. The information capacity of plain abdominal X-ray imaging in presence of FG in AC is about 25 % for SI injury, 40-67 % − for colon injury, FF − 31.3 % [8, 10, 16, 22].
For diagnosing of rectal injuries, X-ray contrast proctography with water-soluble contrast medium, rectoromanoscopy and transrectal ultrasonic examination are additionally used, but after stabilization of the patient's condition, usually at the second stage of damage control (DC).
Diagnostic peritoneal lavage (A1) is conducted for hemodynamic instability, presence of abdominal fluid > 500 ml, non-diagnostic ultrasonic examination, absent FF and FG in AC and RS, with clinically non-stable abdomen [1, 7, 10, 16]; laparotomy is conducted according to indications (A1) [7, 8, 10, 16]. Diagnostic peritoneal lavage is obligatory for severe CT with disordered consciousness and unstable hemodynamics. It increases the accuracy of presurgical diagnosis up to 75.5-95 % [10, 16].
Dynamic follow-up is conducted for absence of fluid and gas in AC and RS, with absent signs of blood flow in RH, with stable abdomen [10].
Treatment. For intestinal injury, urgent surgery is conducted. It is the only rational treatment technique (A1) [1, 2, 8, 10, 23]. Most patients are admitted in shock condition (up to 80 % for SI, 97 % − for CI [16]). Anti-shock procedures are conducted simultaneously with diagnostic ones.
Extensive midline laparotomy (B1) is the most appropriate technique [1, 14, 21, 23]. The volume of surgical intervention is determined only after hemostasis and proper revision of all abdominal organs [29]. Presence of RH in the plane of ascending and descending colons is the indication for examination of their retroperitoneal parts [21, 29]. Difficulties of examination of hepatic and splenic curves should be removed [21]. Mesenterial hematomas near the intestinal wall must be carefully opened and examined [7]. For mobilization of the mesenteric edge, one should not skeletonize the colon wall. It is necessary to spare even small mesenterial vessels and appendix epiploica [7, 21]. Non-adherence to these rules causes a disorder of colon nutrition and inconsistent sutures. However, insufficient mobilization of the intestinal wall can cause adhesion of non-homogenous tissues, and failure of sutures. Other mesenterial hematomas are estimated according to stability during the whole time of surgery. For bleeding from mesenterial vessels, their ends are applied onto clamps, with subsequent ligation or application of figure-of-eight suture. Mesenterial defects are sutured later [7]. For bleeding from the mesenteric root, hemostasis is to be conducted very carefully owing to possible disorders of intestinal perfusion.
DC is used for unfavorable prognosis of concomitant closed shock-producing abdominal injures with abdominal damages, in conditions of extensive purulent or fecal peritonitis in toxic or terminal phase or abdominal sepsis [20], for extremely severe condition, unstable hemodynamics at the background of inotropic and infusion therapy and presence of "lethal triad" (hypothermia, acidosis, coagulopathy (B1) [1, 8, 15, 16, 23].
The stage 1 of DC is primary urgent surgery with shortened volume (≤ 90 min.): hemostasis, removal of hollow organs injuries without intestinal stoma and anastomosis (B2) [1, 2, 8, 15, 16, 23]. After revision and draining, subserous hematomas and incomplete ruptures (I AAST) are covered with serous-muscular interrupted stitches with non-absorbable suture in transverse direction in relation to course of intestine.
Suturing (A1) is conducted for one or several ruptures with significant distance from each other, with size < ½ of intestine diameter (II AAST) [19, 23, 28, 29] in transverse direction with continuous one-row serous-muscular-subserous suture [2, 6, 16, 18, 23, 27] with absorbable suture with atraumatic needle after economic dissection of hemorrhagic borders. It has some advantages as compared to two-row suture. Chemical and enzyme aggression of intestinal contents decreases in distal direction, but bacterial flora virulence increases. Therefore, it is better to start with suturing of distal parts of defects.
For significant injuries (> 2 ruptures on the distance of 10 cm or 2 ruptures over distance ≤ 5 cm from each other, for wall defects > ½ of circumference without crossing (III AAST), penetrating defects, complete crossing of intestine (IV AAST), extensive crushing injury to the wall, a transverse rupture of mesentery (longwise the intestinal axis) over > 5 (SI) and 10 (MI) cm, with ischemia and necrosis of the intestinal wall (V AAST), resection is carried out [2, 12, 16, 19, 26, 28, 29] with closure of ends with the purse suture and lineal stapler [16], with application of clamps, with placement of distal and proximal intestine into AC (B2) [1, 24]. Nasogastrointestinal intubation (NII) with two-lumen probe Miller-Abbot of the proximal part (B2) is conducted [1, 6, 18, 22, 23, 27], as well as bleeding arrest, abdominal sanitation and draining (A1) [1], introduction of the colonic tube (A1) and anus divulsion (for colon injury) [22]. Chamieh J et al., 2018 [4] believe that such interrupted condition of the intestine can be up to 3 days, to the moment of intense edema of the wall. However, the optimal time for anastomosing is 12-48 hours. If patient's condition is not stabilized within the indicated intervals, the preference is given to colostoma at the stage 3 of DC.
The indications for SI intubation [1, 8, 18]: multiple intestinal and mesenteric injuries; small intestine dilatation > 4-5 cm; peristalsis only as response to stimuli; high amount of sequester fluid, extensive intramural hematomas in the small intestine; extensive fecal or purulent peritonitis with fibrin and multiple abscesses; infected hemoperitoneum, extensive RH; decompression of a region of applied anastomosis in paresis and extensive peritonitis; extensive adhesive process in AC.
The contraindications for NII (B2) [1, 8]: anatomical features, narrowing of curvature of nasal passages, organic disease of upper part of the gastrointestinal tract, varicose esophageal veins, esophageal stricture, deformation of pyloroduodenal zone in region of Treitz ligament; extensive adhesion in the upper AC; intestinal wall infiltration; intense respiratory and cardiac failure.
If NII is impossible, the intestinal probe is guided through the gastrostoma (according to Yu.M. Dederer), cecostoma (according to G. Scheide) or suspended ileostoma (retrograde draining 40 cm from the ileocecal angle according to I.D. Zhitnyuk) [1].
NII is used for decompression, intestinal paresis or suture failure prevention, detoxication therapy (intestinal dialysis, enterosorption), transprobe correction of intraintestinal medium, pharmaceutical influence on the mucosa, enteral nutrition, creation of "frame" for SI, prevention of adhesive obstruction, recovery of motional function of the intestine.
Anastomosis is not applied after resection (delayed anastomosis strategy (B2) [1, 2, 23, 26].
If indications for DC are absent, application of primary anastomosis after resection of SI is allowable in absence of widespread purulent peritonitis (within the first 6 hours) and intraabdominal hypertension, as well as after high-level resection of the jejunum, when the probability of high small intestine fistula is higher than the risk of failure of anastomosis sutures (C1) [23].
In the absence of the following conditions including contraindications for DC, fecal and purulent peritonitis (up to 2 hours after trauma), intraabdominal abscesses, dense fecal masses in intestinal lumen, extensive retroperitoneal and mesenterial hematomas [28], endotoxicosis, respiratory distress syndrome, DIC, requirement for transfusion of more than 6 doses of packed red blood cells [24, 29], intense concurrent pathology, intraabdominal hypertension [20], extensive injury to the right side of MI, the right-sided hemicolectomy and ileotransverse anastomosis are performed [16]; for transverse MI − resection with transverse anastomosis; for the sigmoid − left-sided hemicolectomy and obstructive resection with anastomosis. To consolidate the suture lines one can use plastic materials (Tachocomb, biological glue agents). In the presence of the above-mentioned risk factors, the anastomosis is not applied (the risk of anastomosis failure in presence of evident concurrent pathology and transfusion of 6 doses of packed red blood cells is 42 % vs. 3-4 % in absence of these factors), stomas are made (C1) [8, 23, 24, 28, 29].
Rectal injury: bleeding arrest, small pelvis tamponade, suturing of intraabdominal ruptures of the continuous one-row suture in transverse direction, transanal draining (A1) [1, 23, 25]. Incomplete extraabdominal ruptures of the rectum without contamination of paraproctium are treated with conservative methods: stool retention up to 5 days, low-residue diet, microclisma with antiseptics, antibacterial therapy. For inefficient therapy and development of purulent process in paraproctium, the surgery is conducted at the third stage. Hemostasis is performed in case of sphincter damage.
Then the laparotomy wound is temporarily closed (VAC-laparostomy) (B1) [1, 23].
The stage 2 − Damage Control Resuscitation − stabilization of vital functions, identification of injuries [15].
The stage 3 − recurrent planned reconstructive surgical intervention after 24-96 hours, with detailed revision of all injuries [15, 25]; programmed sanitation relaparotomy [1, 8, 20, 23].
Resection is made for significant narrowing of intestine lumen after its suturing at the stage 1, necrosis after ligation of mesenterial vessels [19, 23]. After intestine resection with use of delayed anastomosis strategy, the anastomosis with the continuous one-row suture with the suturing device is made. According to AAST, there are not differences in the rate of failure for manual and instrumental anastomosis, including for conditions with various severity of intestinal injury [3, 12, 19, 23, 26].
The technique of the manual anastomosis includes application of the one-row serous-muscular-submucosal (70 % of mechanic load attributes to the submucosal layer) continuous (if the interrupted suture is applied, the weight of the fiber in tissues is 4 times higher; the tissue response is also 4 times higher) suture with non-absorbable monofilament (incidence of strictures after anastomosis with monofilament suture < 0.7 %, with polyfilament one − 9.5 %) [12, 16] or two-row anastomosis (with continuous internal suture with absorbable sutures and external suture according to Lamber with non-absorbable suture).
For the two-row intestinal anastomosis, the incidence of stenosing is 8-10 times higher, the rate of food bolus transit is 6 times lower, and the incidence of failure is the same as for the one-row suture [3].
Dibirov M.D. et al. (2018) [9] analyzed the results of applications of 76 compression anastomosis with use of titanium nickelide rings with shape memory at the background of widespread peritonitis, including DC strategy. The anastomosis failure was 2.6 %. The authors note their reliability, hermetic state, technical simplicity of application, exclusion of bleeding in this site, of severe anastomositis and strictures in the long term period [9].
After iliac resection, if the terminal part ≤ 10 cm, the ileotransverse anastomosis in the end-to-side manner is performed, since probability of failure of ileotransverse anastomosis is high due to poor perfusion (critical vascular point by Griffith). The abducent end of the ileum is sutured hermetically.
After suturing of the antimesenteric edge of intraperitoneal regions of MI, in presence of doubts about reliability of suturing, it is possible to perform extraperitonization of the intestinal region with a sutured defect [23].
After resection of MI, recurrent assessment of vitality of resected parts is made, and the intestinal anastomosis is applied or a colostoma is made (C1) [2, 4, 17, 24, 27, 29].
After right-sided hemicolectomy, the ileotransverse anastomosis + NII, end ileostoma ± transverse colostoma are made [14, 16, 22]. In doubtful cases, the cecum gut rupture results in cecostoma.
The proximal loop transverse colostoma is made for an injury to transverse MI and thereat of failure in the site of suturing; after resection − anastomosis / proximal ± distal one-stem colostomas [4].
The loop transverse colostoma is made for an injury to descending MI and sigma, and for thereat of failure in the site of suturing (presence of preventive stoma does not decrease the incidence of failure, but reduces severity of clinical manifestations and increases the success of conservative treatment of failure) [16, 25]; after left-sided hemicolectomy / obstructive resection− anastomosis / end two-stem colostoma (surgery by type of Mikilich) / proximal single-stem colostoma and suturing of distal part (Hartman surgery) [16, 22].
Application of the delayed anastomosis does not increase the incidence of colostomas, complications or mortality [1, 6, 23, 27]. Sharpe JP et al. (2017) [24] reviewed the results of delayed application of MI anastomosis after trauma (III VAAST) and concluded that the risk of failure decreased to 4 % in absence of evident concurrent pathology and of requirement for transfusion of more than 6 doses of packed red blood cells. The end-to-end anastomosis is more reliable from the perspective of blood perfusion and more physiological. Its application takes less time. For mismatch between diameters of adducting and abducting loops, the preference is given to the end-to-end anastomosis [4, 19]. Ligation of feeding vessels is realized between the gut and the nearest arcade. For application of the anastomosis to the colon, decompression with anus divulsion according to Recamier − Subbotin is performed, and the colon probe is introduced through the rectum behind the suture lines (A1) [1, 16].
Colostomy is more preferable for severe peritonitis with intraabdominal abscesses, evident intestinal wall edema, metabolic acidosis, persistent coagulopathy and hypothermia, increasing intraabdominal pressure > 25 mm Hg [1, 2, 4, 24, 28]. Cheng V. et al. (2020) [5] analyzed the results of MI resection after CAI in 13,949 patients. They concluded that stoma exteriorization was reliably associated with lower mortality after sigmoid injury and higher amount of recurrent non-planned relaparotomy after transverse MI damage. For closed MI injuries, colostoma exteriorization is associated with longer ALV, ICU and hospital stay [4, 5, 17]. Lasinski AM et al. (2018) [17] showed that mortality did not differ after application of the delayed anastomosis as compared to stoma exteriorization.
Two-stem sigmostoma (according to Maydl) and transanal draining (A1) are performed for rectal injury after suturing at the stage 1 and for thereat of failure [1, 23, 25]. Multiple intraabdominal ruptures of the rectum and rectosigmoid part, ruptures of > ½ circumference, a crushing injury with necrosis, and a complete intestinal detachment are treated with resection of a part and exteriorization of the adducting end in view of a single-stem unnatural anal orifice (B2). The abducting end is sealed (by the type of Hartman surgery) [1, 19, 23]. For extraabdominal ruptures, along with two-stem sigmostoma, draining of paraproctium is conducted through the perineum with dissection of necrotic tissues, and an intestinal wall defect is sutured from the side of the lumen with use of one-row interrupted stitches through all layers [19, 23]. The sphincter injury is treated with formation of colostoma with subsequent delayed recovery.
The most common complications of intestinal injuries are suture inconsistency, acute intestinal obstruction, anastomosis narrowing with disordered passage, intraabdominal and retroperitoneal abscesses and phlegmonas, peritonitis [4, 5, 19, 25].
The causes of anastomosis failure [1, 3, 4, 5, 12]: errors in technique of application − bleeding in the site of anastomosis with formation of hematoma, excessive tissue tension, additional punctures of the intestinal wall, disproportion of sutured parts, major step of stitches, incorrect selection of a resection level and surface of anastomosing, inadequate selection of suturing material; arterial hypotension during surgery [1] with decreasing pressure more than by 40 mm Hg within ≥ 7 minutes, use of vasopressors, hypoproteinemia [1] (total protein < 55 g/l), immune deficiency (HIV, hepatitis, immune suppressive therapy), blood loss (decreasing hemoglobin < 95 g/l, transfusion of more than 6 doses of packed red blood cells), mesenterial ischemia, severe peritonitis; disorders in stapler operation; postsurgical intestinal paresis. Mahmood I et al, (2020) [19] analyzed the postsurgical complications in 160 patients with closed intestinal injury. They concluded that the independent predictor of their development (anastomosis failure, wound complications, intraabdominal abscesses) was high lactate level regardless of a type of anastomosis and a way of its application (manual or instrumental).
Surgical intervention outcomes. For intestinal combined injury without use of DC, the postsurgical complications show high incidence: 20.4-67.1 % for the colon, including intraabdominal complications − 50-72 % for MI, 3.6-27.7 % for the rectum, mainly by means of suture inconsistency (up to 69 % for the colon, 12.5 % for SI) [3, 12, 16, 30]. Abdominal sepsis is noted in 4-6.35 %, postsurgical wound purulence − in 6-33 % [16]. Without use of DC, the mortality for SI combined injury is 20 % after surgery within 6 h from injury, 40 % for surgery after 6-8 hours after injury, 52 % − after 12 h [30]; for colon CIs − 39.5-59 % [16]. The main cause of death is peritonitis owing to late admission, anastomosis inconsistency and CI.
For DC, the mortality for intestinal CI decreases to 4.9-16.9 % [4, 5, 26, 27], mainly by means of decreasing invasiveness of a primary intervention and percentage of inconsistency of delayed anastomosis.
CONCLUSION
Standardization of medico-diagnostic approach to combined closed intestinal injury on the basis of severity of patient's condition, hemodynamic stability, location and size of injuries and a degree of abdominal contamination can improve the results of diagnosing and treatment of such patients. Application of the delayed anastomosis and stoma exteriorization with adherence to strict indications at the 3rd stage of DC for severe combined injury decrease or preclude the rate of suture inconsistency and promote the mortality reduction.