Surgical management of 114 patients with colonic injuries related to trauma who were treated over a six-year period is reviewed. Eighty-three (73%) injuries were secondary to gunshot wounds. Twenty-six patients (24%) had isolated colonic injuries. The majority of patients (60%)) were treated with colostomies: exteriorization of the injury, repair with proximal colostomy, or resection with colostomy and mucous fistula. Exteriorization of repaired colon, primary repair, and resection with primary anastomosis were performed in 40% of the patients. Six patients (5.3%) in our series died, and 24% had complications directly related to the colon injury. Based on this study, no standard method for treatment of colonic trauma is advised. Colostomy is recommended for patients with massive multiple intra-abdominal injuries and gross fecal contamination. In selected patients, primary repair may be performed

Horan, D. Paul

Horst, H. Mathilda

Obeid, Farouck N.

Sorensen, Victor

Vij, Deepak

Vincent, Gilford

English

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical Journal Volume 31 Number 1 Article 5 3-1983 Management of Colonic Trauma: Six-Year Experience at Henry Ford Hospital Farouck N. Obeid Victor Sorensen Gilford Vincent Deepak Vij H. Mathilda Horst See next page for additional authors Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Obeid, Farouck N.; Sorensen, Victor; Vincent, Gilford; Vij, Deepak; Horst, H. Mathilda; and Horan, D. Paul (1983) "Management of Colonic Trauma: Six-Year Experience at Henry Ford Hospital," Henry Ford Hospital Medical Journal : Vol. 31 : No. 1 , 17-20. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol31/iss1/5 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Management of Colonic Trauma: Six-Year Experience at Henry Ford Hospital Authors Farouck N. Obeid, Victor Sorensen, Gilford Vincent, Deepak Vij, H. Mathilda Horst, and D. Paul Horan This article is available in Henry Ford Hospital Medical Journal: https://scholarlycommons.henryford.com/hfhmedjournal/vol31/iss1/5 Henry Ford Hosp Med J Vol 31, No 1,1983 Management of Colonic Trauma: Six-Year Experience at Henry Ford Hospital Farouck N. Obeid, MD,* Victor Sorensen, MD,* Gilford Vincent, MD,* Deepak Vij, MD,* H. Mathilda Horst, MD,* and D. Paul Horan, MD*t Surgical management of 114 patients with colonic inju-ries related to trauma who were treated over a six-year period is reviewed. Eighty-three (73%) injuries were sec-ondary to gunshot wounds. Twenty-six patients (24%) had isolated colonic injuries. The majority of patients (60%)) were treated with colostomies: exteriorization of the injury, repair with proximal colostomy, or resection with colostomy and mucous fistula. Exteriorization of repaired colon, primary repair, and resection with pri-mary anastomosis were performed in 40% ofthe patients. Six patients (5.3%o) in our series died, and 24% had com-plications directly related to the colon injury. Based on this study, no standard method for treatment of colonic trauma is advised. Colostomy is recommended for patients with massive multiple intra-abdominal injuries and gross fecal contamination. In selected patients, primary repair may be performed. M ost deaths that occur immediately after trauma are secondary to cardiorespiratory problems or hemorrhage, whi le delayed morbid i ty and mortal i ty are usually secondary to sepsis. Sepsis develops f rom peritoneal soilage with the high bacterial count of 10 " organisms per gram of colonic contents. Many methods are pro-posed to treat penetrating and blunt colonic trauma. We present our experience with colonic trauma f rom January 1975 to December 1980. Henry Ford Hospital is a major trauma center with approximately 70,000 patient visits in the Emergency Room annually. The Division of Trauma Surgery is consulted for 2-3% of these patients. Materials and Methods A retrospective review of patients f rom 1975 through 1980 identif ied 114 patients who were treated for colonic trauma at Henry Ford Hospital within the Division of Trauma Surgery. Of these patients, 102 (89%) were men and 13 (11%) were women. The patients ranged in age f rom 3 to 80 years, and most patients were between 21 and 40 years (Fig. 1). The mechanism of injury included: gunshot wounds in 83 patients (73%), stab wounds in 25 (22%), shotgun wounds in four, and blunt trauma in one patient. All patients were resuscitated with crystalloids and, if necessary, transfused with cross-matched or type-specific b lood. A t the t ime of initial evaluation, 27 of 114 patients (24%) had evidence of shock (blood pressure of less than 100 mm Hg systolic). Most patients received intravenous antibiotics before operation. Sixty-six percent of patients were operated on within three hours after they arrived in the Emergency Room, and the remaining 34% were operated on f rom three to six hours after arrival. Laparotomy in this group of 114 patients identif ied iso-lated colonic trauma in only 26 patients (24%). In 17 patients the injury was secondary to gunshot wounds, and in nine patients secondary to stab wounds. Most patients had mult iple intra-abdominal injuries. There were 147 associated intra-abdominal injuries in 88 patients (Table I). The most commonly injured segment of colon was the right colon in 47 patients (37%), fol lowed closely by the rectosigmoid in 37 patients (26%). The transverse colon was the site of injury for 30 patients (21%), and the left colon for 27 patients (19%). After intraperitoneal bleeding was controlled, the colonic injury was treated. During the review period, no single standard operation was performed to treat colonic This paper was presented at the Henry Ford Hospital 1982 A lumn i Reunion on October 21-23, 1982. Submit ted for pub l icat ion: October 22,1982 Accepted for publ icat ion: March 16,1983 *Depar tment of Surgery, Division of Trauma Surgery, Henry Ford Hospital Address repr int requests to Dr. O b e i d , Department of Surgery, Henry Ford Hospital , 2799 W Grand Blvd, Detroi t , M l 48202 tD r . Horan died unexpectedly in 1982. 17 Obeid, Sorenson, Vincent, Vij, Horst and Horan TABLE I Associated Injuries in 88 Patients wi th Colonic Trauma Small Bowel 61 14 Liver Retroperitoneal Hematoma Diaphragm Genitourinary Tract Stomach Spleen Gallbladder Pancreas Major Abdominal Wall Defect Total Injuries* •Some patients had more than one site of injury. 14 13 13 12 10 4 3 3 147 trauma. The surgeon chose the technique of treatment according to the severity and anatomic location of the injury (Table II). Results In 114 patients with colonic trauma, 27 patients had complications related directly to the colon injury. One th i rd of these complications occurred in those who underwent resection with colostomy and mucous fis-tula. Wound infection or dehiscence, anastomotic leak, or intraperitoneal abscesses occurred in eight of 25 patients (32%) in this group. These 25 patients also had the highest mortality rate: five patients died (20%). In 46 patients who underwent exteriorization of the colonic injury or repair with proximal colostomy (Table II), six patients (13%) had similar complications, but none o f the 46 patients died. Primary repair of colonic injury with exteriorization was performed in 26 patients. A suture line leak devel-oped in nine (35%), and one patient died. The complica-tions in this group accounted for one third of the total complications. Primary repair of the colon without proximal colostomy was performed on 12 patients, and two patients devel-oped complications. One patient developed a retro-per i toneal abscess at the site of repair , and the other patient developed a wound infection and subse-quent dehiscence. Resection and primary anastomosis was performed wi th-out complications or mortality in four patients, all of whom had right-sided colonic injuries. In our series of 114 patients, six patients died, for a 5.3% mortality rate. Causes of death included hemorrhagic shock, complications of sepsis, and renal failure. Deaths f rom isolated colon injury occurred in 3.7% of patients. whi le the mortality rate rose to 29% when four or more organs were involved. Discussion During the First Wor ld War, the colonic injuries of those wounded in battle were routinely treated by primary repair, and the mortality rate was prohibit ively high at 58%. During the Second Wor ld War, the policy of the U.S. Army mandated colostomy or exteriorization o f the colonic injury for those injured in battle, and the mortal-ity rate dropped to 37% (1). The rate was further reduced dur ing the Korean and Vietnam conflicts to 13% and 11%, respectively, by the use of aggressive preoperative volume replacement, antibiotics, and rapid evacuation of the wounded from the battlefield so that they could be treated quickly. Since the late 1950s, two distinct schools of thought about management of colonictrauma have evolved. The first approach employs mandatory exteriorization of colonic injury or colostomy with mucous fistula rather than primary repair (2). According to proponents of this view, the magnitude of fecal contamination is diff icult to determine because mixing of blood and l iquid feces cannot be separated volumetrically (2). Abcarian, et al also suggest that the exact t ime of injury cannot be accurately determined because o f the patient's sensorial impairment and because most patients are not operated on wi th in six hours of injury (2). These authors feel that their low rate of morbidity and mortality of 3.2% argues effectively for their policy, which involves either exte-riorization of injury or resection with colostomy and mucous fistula (2). Advocates of the second approach believe there is a role for primary repair of some colonic injuries. Because civilian gunshot wounds are usually due to low velocity missiles which do not cause extensive tissue destruction, these colonic injuries can be safely repaired primarily (3,4). If gross fecal contamination, extensive devasculari-zation, or extensive destruction of the colon is present, resection with colostomy and mucous fistula is required (3). Recent prospective studies by Stone and Flint del in-eate the exact circumstances under which primary repair of colonic injuries is performed (5,6): blood loss of less than 20% of estimated normal volumes, minimal fecal contamination, two or fewer associated injuries, absence of shock (blood pressure below 80/50), no sig-nificant delay between injury and operat ion, or colonic injury not significant enough to require resection (5,6). If patients do not meet these criteria, exteriorization of injury or colostomy and mucous fistula are performed. Patients who had primary repair for their colon injury 18 Colonic Trauma at Henry Ford Hospital had the lowest complication rate, mortality rate, and the shortest hospital stay (3,5,6). Exteriorization of a repaired colon or resection with primary anastomosis are other approaches to colonic trauma. These techniques have the advantages of avoid-ing a colostomy and the associated significant morbidity of colostomy closure (7,10). The util ization of these two operations depends on criteria similar to those required for primary repair of colonic injuries. Primary repair with exteriorization is a safe alternative, as any leak fol lowing repair can easily be transformed into a colostomy. Kirk-patrick feels that primary repair wi th exteriorization is a safe adjunct for treating colonic injuries above 18 cms (from the anal verge). In his series, the need for colos-tomy was reduced 50% by this alternative (7). Resection with primary anastomosis, which is used most commonly for right colon injuries, causes a significant complication rate (8-10), many of which are due to ana-stomotic leaks into the abdominal cavity. Forthis reason most authors feel that resection and primary anastomo-sis should be used only for those patients who have simple stab wounds or low velocity gunshot wounds of the right colon with minimal spillage and no significant associated injuries (10). In general, surgeons have been reluctant to perform resection and primary anastomosis for injuries to the left colon, which are usually managed by colostomy and mucous fistula or exteriorization (12). Hawley and Hunt's study (13) showed increased collage-nase activity in the left colon and rectum reinforcing the opin ion that left-sided colonic injuries should be exteri-orized or resected with colostomy and mucous fistula. However, some authors take exception to this practice and have repaired injuries to the left colon by primary means in recent years (14,15). When proximal colostomy is indicated, a completely divided colostomy with either a mucous fistula or a Hartman's procedure should be done as close to the site of injury as possible. A loop colostomy does not divert the fecal stream from the area of injury (11). Without complete fecal diversion, a higher complication rate related to the repair can be expected. In our series, more than 60% o f the operative procedures involved some form of colostomy: exteriorization of injury and proximal colostomy with repair or resection of injury with colostomy and mucous fistula. These techniques were chosen because most of the patients (76%) had associated intra-abdominal injuries, and many 45 40 0 26 23 4 25 22 20 12 10 0 4 40 0 1 1.0 0 TABLE II Operat ive Techniques for Treatment of Colonic Trauma Number Percent Mortal i ty % Exteriorization or Repair wi th Proximal Colostomy* Primary Repair w i th Exteriorization Resection wi th Colostomy and Mucous Fistula Primary Repair Resection wi th Primary Anastomosis No Surgery** *The medical records d id not distinguish between these two methods. •*Rectal injury below the peritoneal ref lection (GSW) patients had several sites of colonic injury as well . In addi t ion, 45% of the injuries were in the left colon or rectosigmoid. Al though the highest morbidity and mor-tality rates were found in this group of patients, the added, potentially disastrous consequences of intra-abdominal leaks were avoided. Different types of pr i-mary repair were performed on the remaining 40% of patients. These procedures had the advantage of not requir ing a second hospitalization for colostomy clo-sure. Few colonic injuries met the literature criteria for primary anastomosis: only four of 47 patients with right colon injuries underwent resection and primary ana-stomosis. Complications occurred with primary repair, particularly leak of the repair. Exteriorization of the repair allows suture line leaks to be identif ied and con-version to a colostomy to be performed. This occurred in nine of 26 patients in our series. Based on our retrospective review, we cannot recom-mend one standard method of treatment for colonic injury. However, based on our experience and a review of the literature, we can recommend colostomy and mucous fistula or exteriorization o f the injury in patients who have suffered extensive colonic trauma, mult iple intra-abdominal injuries, massive fecal contamination, and shock. In these patients, the potential hazard of intra-abdominal suture line leaks must be avoided. In the absence of peritoneal contamination, we recom-mend primary repair for simple lacerations and exterior-ization of colonic repair in properly selected patients. 19 Obeid, Sorenson, Vincent, Vij, Horst and Horan References 1. Chum CF, Hauver RV. Wounds of the colon and rectum (1222 casualties). In : M DeBakey, ed. Surgery in Wor ld War I I . Washing-ton , DC: Of f ice of the Surgeon General, Department of the Army, 1955:255-79. 2. Abcarian H, Lowe R. Colon and rectal trauma. Surg Cl in North Am 1978;58:519. 3. Lo Cicero J, Ja jima J, DrapanasJ. A half century of experience in the management of colon injuries: Changing concepts. J Trauma 1975:15:575. 4. Woodhal l JP, Ochsner A. The management of perforat ing injuries of the colon and rectum in civilian practice. Surgery 1951;29:305-20. 5. Stone H, Fabian j . Management of perforat ing colon trauma: Randomization between primary closu re and exteriorizat ion. Ann Surg 1979:190:430. 6. Flint L, Vitale G, Richardson JD, Polk HC. The in jured co lon : Relationships of management to complicat ions. Ann Surg 1981; 193:619. 7. Kirkpatrick J, Rajpal S. The injured co lon: Therapeutic considera-tions. Am J Surg 1975;129:187. 8. Mu lhe r in J, Sawyers J. Evaluation of three methods for managing penetrat ing colon injuries. J Trauma 1975:15:580. 9. Haygood JD, Polk HC. Gunshot wounds of the co lon: A review of 100 consecutive patients, w i th emphasis on complicat ions and their causes. A m J Surg 1976;131:213. 10. Steele M , Blaisdell JW. Treatment of colon injuries. J Trauma 1977;17:557. 11. Mi l ler RE, Sullivan FJ. Rectal wounds incurred in Vietnam. Mi l i t M e d 1976 (Nov); 764-8. 12. Schrock J, Christensen N. Management of perforat ing injuries of the colon. SG&O 1972;135:65. 13. Hawley P, Hunt J, Dumphy JE. Etiology of colonic anastomotic leaks. Proceedings of the Royal Society of Medic ine 1970;63:28. 14. Mato lo N, Wol f man E. Primary repai rof colonic injuries: A clinical evaluation, j Trauma 1977;17:554. 15. Lou M , Johnson A, Atik M , et al. Exteriorized repair in the man-agement of colon injuries. Arch Surg 1981;116:926. 20 

Management of Colonic Trauma: Six-Year Experience at Henry Ford Hospital

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Management of Colonic Trauma: Six-Year Experience at Henry Ford Hospital

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