Two trauma patients both with colon injuries - one with nondestructive colonic injuries managed with primary repair and one with a destructive colonic injury managed with resection and primary anastomosis. One patient does fine and is discharged from the hospital without complications, the other patient develops an intra-abdominal abscess and requires operative drainage. What’s the difference and should these patients be diverted??
Although difficult to determine the exact incidence, one paper cites the incidence of colorectal-injured patients as 5 to 10% in wartime series and 1-3% of civilian series. The colon is the second most frequently injured organ in penetrating trauma. The management of colonic injuries in trauma patients, either military or civilian, has undergone a change in the last century. During World War I, practice changed from watchful waiting to exploration and diversion, as this was felt to protect against septic complications from possible anastomotic leaks. This remained the practice until a paper in 1979 by Stone and Fabian suggested equivalent rates of infection and mortality in a cohort of patients randomly assigned to undergo primary repair or colostomy. Since then the idea of NOT diverting all colon injuries has slowly emerged. A Cochrane review of penetrating colonic injuries found 5 prospective randomized trials comparing primary repair to diversion and found no difference in mortality and a decrease in total complications in primary repair groups.
Many risk factors have been examined to determine if some patients are better suited for diversion versus primary repair. Hypotension or hemodynamic instability has been the only consistent risk factor associated with an increase in infectious complications. A review of almost 3000 colon injuries found a 2.4% leak rate after primary repair. In addition, the literature surrounding management of colon injuries in patients undergoing damage control surgery also suggests a similar complication rate in patients undergoing immediate primary repair versus delayed primary anastomosis.
Overall, conclusions by meta-analysis and Cochrane review of this data suggests that primary repair is at least as safe as diversion and destructive colon injuries are likely amenable to resection and anastomosis with at least a similar rate of complications between repair and diversion. That being said, these reviews also conclude that diversion should be considered if the patient has significant comorbidities, has prolonged hemodynamic instability or multiple associated injuries.
The Eastern Association for the Surgery of Trauma guideline suggest:
1. Nondestructive (<50% circumference of the colon wall without devascularization) colon wounds can be managed with primary repair
2. Destructive (>50% bowel wall and/or devascularization) can be managed with resection and anastomosis if
a. No shock
b. No significant underlying disease
c. Minimal associated injuries
d. No peritonitis
3. Patients with the above factors should be managed with resection and colostomy.
References
1. Steele, SR, et al. Traumatic injury of the Colon and Rectum: The Evidence vs Dogma. Dis Colon Rectum 2011; 54: 1184-1201
2. Sharpe, JP, et al. Adherence to a Simplified Management Algorithm Reduces Morbidity and Mortality after Penetrating colon injuries: A 15-Year Experience. J Am Coll Surg 2012;213: 591-597
3. Singer, MA and Nelson RL. Primary Repair of Penetrating Colon Injuries. Dis Colon Rectum. 2002; 45: 1579-1587
4. Greer LT, et al. Evolving Colon Injury Management: A Review. The American Surgeon. 2013; 79: 119-127
5. Eastern Association for the Surgery of Trauma guidelines http://www.east.org/resources/treatment-guidelines
from Dr. Elizabeth Gwinn
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