Penetrating Injuries to the Colon and Rectum

Authors: Marc D Trust Carlos V R Brown

Publish Date: 2015/04/11

Volume: 1, Issue: 2, Pages: 113-118

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Abstract

The management of colon and rectal injuries has evolved greatly over the last several decades Once known to have significant mortality the implementation of mandatory diversion in the 1940s drastically improved outcomes Since then treatment strategies have now shifted towards primary repair as a safe option for the majority of injuries When wounds are more destructive resection and primary anastomosis are usually appropriate in most situations Management of penetrating colon injuries is more complex in the setting of damage control surgery and may require difficult decisions regarding timing of anastomosis Rectal injuries were also historically known to have significant morbidity until diversion was implemented Extraperitoneal injuries are still treated in a similar fashion while intraperitoneal injuries are managed using the same principles as colon injuries This article will review the management of penetrating colon and rectal injuries with focus on literature that has been published over the last 3 yearsThe trauma surgeon does not commonly encounter colorectal injuries Civilian data report a 1–3  incidence while it is more common in military settings at about 5–10  1 The colon is the second after small bowel most commonly injured organ after gunshot wounds and the third after liver and small bowel most common after anterior abdominal stab wound Historically these injuries resulted in extremely high mortality approximately 60  during World War I 2• A major advance in the treatment of colon trauma came with the advent of proximal diversion by Ogilvie Use of this technique during World War II saw much lower morbidity and mortality rates compared to previous strategies 3• 4 Treatment subsequently evolved to include exteriorization of the injured segment of colon after primary repair a technique that has since been abandoned This practice involved closure of a wound and exteriorizing that segment of colon for several days An intact repair at that time was returned to the abdomen while failure then required diversion 2• The 1970s saw the next major paradigm shift when Stone and Fabian conducted the first randomized prospective study comparing proximal diversion to primary repair Their findings showed that primary repair was not only safe but also associated with better outcomes when used in certain situations 4 5 6 Over the last three decades a great deal of literature has not only validated these findings but also expanded on this principle so much that diversion is now applied in only a few specific situationsColon injuries can generally be categorized into destructive versus nondestructive types Most authors describe nondestructive lesions as those involving less than 50  of colon wall circumference and lack of devascularization A great deal of literature published over the last 30 years supports primary repair of these injuries with lower complication rates compared to diversion Destructive injuries on the other hand are described as involvement of greater than 50  of bowel wall circumference devascularized segments complete transection or significant loss of tissue 2• 7• Management of destructive colon injuries with diversion versus resection with primary anastomosis has received a great deal of attention in the literature Several small studies have suggested that resection with anastomosis is a safe option in patients without significant risk factors for anastomotic leak such as high transfusion requirement hypotension associated medical illness or penetrating abdominal trauma index greater than 25 8 9 A 2001 multicenter prospective AASTsponsored study comparing diversion versus resection and anastomosis for destructive penetrating colon injuries failed to show any difference in complication rates between these management options but did note a higher mortality in patients who received diversion 0 vs 4  They concluded that resection with anastomosis was the better management option given the worse quality of life associated with diversion 10 Morbidity associated with a second operation for reversal must also be considered when choosing between these options 3•There is a longheld belief and surgical dogma that leftsided colon injuries have a higher risk of complications after anastomosis than rightsided injuries but no study has ever demonstrated a difference in outcomes 2• A study by Hatch et al published in 2013 using data from the National Trauma Data Bank evaluated outcomes stratified by mechanism segment of colon injured and management strategy Although they included patients with a blunt mechanism which is outside of the scope of this article the study is worth discussing as it evaluated over 6000 patients Trauma caused by a penetrating mechanism was found to have lower mortality 102 vs 135  overall morbidity 190 vs 220  and shorter ventilator and ICU days 77 vs 91 and 86 vs 99 days respectively When evaluating outcomes based on segment of colon injured they did not appreciate any major differences in overall morbidity or mortality between locations of the colon They did note however that a high percentage 36  of injuries was reported as “nonspecified” thus a strong inference cannot be made from this data There was an overall 9  proximal diversion rate more commonly in older and more severely injured patients In addition sigmoid injuries were more likely to be treated with proximal diversion There was no distinction between destructive or nondestructive injuries and during multivariate analyses diversion was not found to be independently associated with worse outcomes 5

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