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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Colon injuries

and .

Author Information

“Expert opinion is the basis for most of what we do.”

Robert Goldman Trauma Surgeon

Standard management protocols in the surgery of trauma have evolved from experience gained in wartime, where large volumes of casualties had to be managed in a concentrated time frame. Injuries to the large intestine are a classic example, as even the majority of civilian colon injuries are the result of penetrating mechanisms whereas blunt trauma accounts for only approximately 5–15%.

Diagnosis

There is no reliable method for identification of colon injuries other than exploratory laparotomy which generally is done for associated intra abdominal trauma. Nonsurgical diagnosis' are rare and unreliable (Grade C). Symptoms of colon injury present late and are due to the septic sequelae of fecal spillage. Indications for exploratory laparotomy are a high index of suspicion in blunt trauma and in patients with penetrating mechanisms, wounds, or radiologic evidence of bullets below the fifth intercostal space. Untreated colon injuries have a high mortality rate (Grade C). The treatment is surgical. Only early recognition and treatment avoid consequences of fecal spillage such as peritonitis, abscess, multi system organ failure and death from sepsis (Grade C).

Management

As an isolated colon injury is the exception rather than the rule, aggressive resuscitation should be started as quickly as possible prior to exploration. Furthermore, preoperative parenteral antibiotics with coverage against enteric flora, (predominantly grain-negative and anaerobic), are recommended to achieve adequate blood levels at the time of incision in all cases of penetrating abdominal trauma and in cases of suspected blunt colon injury.

Technique of exploration

As the extent of damage is usually unclear prior to a laparotomy, a generous standard midline incision is recommended. To limit fecal contamination, all obvious injuries of the bowel should be controlled initially by non crushing clamps or running sutures that will also achieve hemostasis if necessary.

If no associated injuries demand immediate attention, all gross fecal material should then be removed, followed by careful inspection of the entire colon. This includes exploration of the retroperitoneal portions of the ascending and descending colon by division of their lateral peritoneal attachments. Close attention should be paid to hematomas, fecal staining and/or retroperitoneal air. Opening the peritoneum of the pelvic floor to explore the rectum from above is not recommended (Grade C).

Direct wound management options

Penetrating injuries

Recommendations for current colon wound management need to be understood and explained with the historical evolution from expert opinion, based on uncontrolled retrospective case analysis of the World War II battlefield to recent prospective randomized cohorts from the civilian combat zones (Grade C → Grade B). Shorter transport times, change in weaponry, aggressive resuscitation, better antibiotics, and improved monitoring and diagnostic capabilities have also over time, had a positive impact on patient outcome regardless of operative management strategies. Lastly, the growing sophistication of studies from retrospective case reports to randomized prospective trials with injury scoring and proper patient selection have resulted in data of much greater validity. However, as prospective randomized controlled studies with sufficient patient numbers are exceedingly difficult to perform in emergency surgery, Level I, Class A evidence is still virtually nonexistent. These are all essential considerations to bear in mind when analyzing the still ongoing rather emphatic controversy between the two presently accepted strategies which are:

Primary repair or anastomosis

vs.

Fecal diversion/diverting colostomy

The issues are as follows:

1.

The gold standard is the complication rate/suture-anastomotic leak rate in elective surgery reported from 0% to 30% (Grade A, B, and C).

2.

Primary repair AND resection and primary anastomosis can be safely performed in an unprepped injured colon. This will achieve elective leakage rates as shown in retrospective reports and also in prospective randomized case studies with less and less stringent inclusion criteria (Grade C → B).

3.

The goal is to prevent post-operative septic complications.

4.

The central question is how frequently are intra-abdominal complications synonymous with, caused by, or a cause of suture line disruption as septic complication rates exceed the reported suture line leak rate in almost all series (Grade B + C).

5.

This leads to the final question of whether a diverting colostomy, as it avoids suture lines all together, has a salutary role, and if so, how much of it is negated by the cumulative morbidity of construction and closure (Grade B + C).

The conclusion is not farfetched that there are separate risk factors for leaks and risk factors for post-traumatic/post-operative septic complications. The “elective colon literature” identifies risk factors predisposing to anastomotic leaks (see table I). Of those, peritonitis is probably the most relevant to the colon trauma patient. Of importance is the radiographically reported leak rate is about twice that of clinically manifest rates, which tempts speculation that the identified risk factors do not produce the leaks, but allow them to become clinically symptomatic. The same literature also shows that anastomotic leaks are independent predictors of mortality AND that a proximal diverting colostomy has a minimal effect on leak rates. However, infectious complications of the leak are reduced (Grade B).

Table I

Table I

Blood transfusions > 2u perioperatively Peritonitis

The risk factors for infectious complications and leaks are not inevitably linked. Infections can occur without leaks, and leaks may remain without clinical consequences. Colostomies avoid suture-lines, but not infectious complications. Furthermore, prospective randomized studies without exclusion criteria (the sickest patients with the most severe injuries were included, regardless of risk factors) during the last decade have shown that primary repair/anastomosis does at least equally well, if not better, than diverting colostomy (Grade B). One may be tempted to conclude that the mere presence of a colostomy has a negative impact on outcome (Grade B, C). If one adds the reported colostomy takedown complication rate (5% to as high as 36%) the role of “the diverting colostomy” is further in question. Only expert recommendations exists to guide us. Although the majority of colon injuries do not require a resection, it has been shown that the majority (~ 70%), are in most cases better served with primary repair rather than a diverting colostomy (Grade B, C). The number of reported resection and primary anastomosis cases is small, especially in prospective randomized series. This questions predictive statistical power and cautions about generalization of recommendations.

The long list of quoted risk factors for post-operative septic complications (see table II) have been gradually refuted over the past two decades with some important exceptions: blood transfusion requirements, PATI > 25, preoperative hypotension, underlying co-morbidity, precluding rapid reestablishment of adequate gut perfusion (Class B), which describe the most seriously multiple injured. For them, rapid control of injuries, also known as “damage control”, is now the accepted standard. This includes ligation or cross stapling of colon injuries with abdominal packing and staging of procedures to allow for rapid resuscitation and restoration of normal metabolic and circulatory parameters. Accurate suture placement or fashioning an anastomosis is time-consuming and technically difficult in the massive enteric edema of protracted shock. The associated low flow state also renders viable resection margins questionable. Currently, no data is available regarding the outcome of an anastomosis in this patient population who are now managed with the techniques of the open abdomen, employed for abdominal compartment syndrome. It appears these very sick patients are best served by pulling out the proximal end of the bowel during the second or third stage of the abdominal management at a time when restoration of circulatory stability allows this. As abdominal hypertension and bowel edema persist beyond even this stage, some experts have recommended delaying the maturing of the ostomy until that has resolved as well.

Table II

Table II

Blood transfusion requirements PATI > 25, and number/type of associated organ injuries

Blunt injuries

This is an uncommon entity and the scarce existing literature are case series reports. Just as penetrating colon injuries, they are rarely diagnosed preoperatively. There is no mandate for routine surgical exploration in blunt abdominal trauma mechanisms and therefore, delayed recognition is more common. Unlike small bowel injuries, colon trauma is associated with very subtle findings and, as a rule, manifests itself by its septic sequelae, in blunt and penetrating mechanisms alike. The same is true for the lack of reliability of diagnostic modalities other than exploration. The available Grade C evidence shows that primary repair does not carry a higher morbidity or mortality rate than in penetrating mechanisms. There is also agreement that gross fecal contamination, associated major extra abdominal injuries, and protracted shock should discourage the surgeon from any type of primary reconstruction.

For both blunt and penetrating mechanisms, exteriorized primary repair was proposed as a “safe” compromise instead of a diverting colostomy. Although this concept sounds plausible, to date there is no equal for the salutary effect of the closed peritoneal environment and added problems with in and out flow obstruction of the exteriorized limb have essentially resulted in the failure of this approach.

Finally, there is sound Grade A, B, and C evidence available to recommend delayed primary or secondary closure of the skin and subcutaneous tissue.

Conclusion

The following management is recommended based on the available literature:

1.

Exploratory laparotomy is the only reliable diagnostic tool.

2.

Primary repair for the majority of penetrating (70–75%) and blunt (60%) mechanisms.

3.

Primary anastomosis is preferred as well when a resection is necessary.

4.

Diverting colostomy in itself appears to have a negative impact on outcome.

5.

In patients with delayed diagnosis and evidence of peritonitis and in patients with prolonged shock, PATI > 25, major associated extra-abdominal injuries, comorbid cardiovascular problems, and gross fecal contamination in blunt trauma, a diverting colostomy is still the management modality of choice.

6.

Skin closure should be delayed.

References

1.
Cornwell E E III, Velmahos G C, Berne T V. et al. The Fate of colonic suture lines in high-risk trauma patients: A prospective analysis. J Am Coll Surg. (1998);187(1):58–63. [PubMed: 9660026]
2.
Gonzalez R P, Merlotti G J, Holevar M R. Colostomy in penetrating colon injury: Is it necessary? J Trauma. (1996);41(2):271–275. [PubMed: 8760535]
3.
Sasaki L S, Allaben R D, Golwala R. et al. Primary repair of colon injuries: A prospective randomized study. J Trauma. (1995);39(5):895–901. [PubMed: 7474005]
4.
Chappuis C W, Frey D J, Diezen C. et al. Management of penetrating colon injuries. A prospective randomized trial. Am Surg. (1991);213(5):492–498. [PMC free article: PMC1358480] [PubMed: 2025069]
5.
Falcome R F, Wanamaker S R, Santanello S A. Colorectal trauma: primary repair or anastomosis with intracolonic bypass vs. ostomy. Dis Colon Rectum. (1992);35(10):957–963. [PubMed: 1395983]
6.
Burch J M, Martin R, Richardson R J. et al. Evolution of the treatment of the injured colon in the 1980's. Arch Surg. (1991);126:976–984. [PubMed: 1863216]
7.
Curran T J, Botzotta A P. Complications of primary repair of colon injury: Literature review of 2964 cases. Am J Surg. (1999);177:42– 47. [PubMed: 10037307]
8.
Murray J A, Demetriades D, Colson M. et al. Colon resection in trauma: colostomy versus anastomosis. J Trauma. (1999);46(2):250–254. [PubMed: 10029029]
9.
Stewart R M, Fabian T C, Croce M A. et al. Is resection with primary anastomosis following destructive colon wounds always safe? Am J Surg. (1994);168:316–319. [PubMed: 7943586]
10.
Ryan M R, Dutta S, Masri L. et al. Fecal diversion for penetrating colon injuries-still the established treatment. Dis Colon Rectum. (1995);38(3):264–267. [PubMed: 7882789]
11.
Carillo E H, Somberg L B, Ceballos C E. et al. Blunt traumatic injuries to the colon and rectum. J Am Coll Surg. (1996);183:548–552. [PubMed: 8957455]
12.
Ross S E, Cobean R A, Hoyt D B. et al. Blunt colon injury-a multicenter review. J Trauma. (1992);33(3):379–384. [PubMed: 1404506]
Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6983

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