Primary Repair Of Colon Injuries Research Articles

Traumatic colonic injuries in Westmead Hospital – A paradigm shift in management over 10 years

Over the years, there has been a shift towards more conservative treatment, with primary repair of colonic injuries being preferred over faecal diversion. We present a cohort study of the management of penetrating colon injury over the past 10 years from a major trauma hospital in western Sydney. We aim to evaluate the trend of operative management of penetrating colonic injuries. Methods Patients were identified via the prospectively collected trauma registry at Westmead Hospital from 2003 to 2013. Fifty-seven patients initially identified with a proven diagnosis of penetrating colonic injury had their medical records reviewed. Excluded in the study are patients who had rectal injuries or serosal tears of the colon. Patient characteristics, mechanisms of injury, treatment course and complications were analysed. Extent of colonic injury was graded of using American Association for the Surgery of Trauma scalings. Results A total of 55 patients were then included in the study. Primary repair of colon injuries was the most common method used (63.6%, n = 35) followed by resection and primary anastomosis (21.8% n = 12), diverting colostomy (14.3%, n = 5) and non-operative management (5.5%, n = 3). There was a higher rate of diversion in the earlier time period (2003–2007) when compared to the later time period (2008–2013), p = 0.03. Over the 10-year period, there was no significant difference with regards to complications among groups, particularly intra-abdominal complications. Conclusion From 2003 to 2013, there is a shift of management of penetrating colonic injuries from diversion to resection and primary anastomosis to that of primary repair. Primary repair of colonic injuries is a safe option and is associated with low morbidity. It should be considered as a valid tool in the armamentarium of today’s surgeon.

Indications for and outcome of primary repair compared with faecal diversion in the management of traumatic colon injury.

Injuries of the colon are a serious sequel of abdominal trauma owing to the associated morbidity and mortality. This study aims to assess postoperative outcome and complications of faecal diversion and primary repair of colon injuries when applied according to established guidelines for the management of colon injuries. This retrospective study was conducted on 110 patients with colon injuries. Guided by estimation of risk factors, patients were managed either by primary repair alone, repair with proximal diversion or diversion alone. There were 102 (92.7%) male patients and 8 (7.3%) female patients of median age 38years. Thirty-seven were managed by primary repair and 73 by faecal diversion. Colon injuries were caused by penetrating abdominal trauma in 65 and blunt trauma in 45 patients. Forty-three patients were in shock on admission, and were all managed by faecal diversion. Forty patients developed 84 complications after surgery. Primary repair had a significantly lower complication rate than faecal diversion (P=0.037). Wound infection was the commonest complication. The overall mortality rate was 3.6%. Primary repair, when employed properly, resulted in a significantly lower complication rate than faecal diversion. Significant predictive factors associated with a higher complication rate were faecal diversion, severe faecal contamination, multiple colon injuries, an interval of more than 12h after colon injury and shock.

Primary repair verses colostomy for colonic injuries

Objective: The objectives of this study are to: evaluate the role of primary repair with or without defunctioning colostomy in the management of colonic injury. identify the factors contributing to the outcome in management of colonic injuries. Study Design: Prospective Observational Setting: Surgical Unit IV, DHQ Hospital PMC Faisalabad. Duration: November 2001 to November 2003. Subjects and Methods: The patients of colonic injury presenting at one emergency day were included in primary repair group (n=20) and patient of colonic injury at next emergency day were included in colostomy group (n=20). All patients were aggressively resuscitated and investigated. Colonic injury was suspected on clinical grounds and managed according to standard protocol (vide infra). Associated injures were managed accordingly. Colostomy was closed after three months and all patients were followed for six months complete record was maintained on preformed proforma. Results: Most patients were males and average age in both groups was 28.5 years. Fire arm injury was the top most cause of colonic injury in both groups. In both groups left colon was injured in majority of cases. Maximum time interval between injury and treatment in both groups was within 24 hours. Majority of patients in both groups had associated injuries and commonest injured viscera was small gut. The average hospital stay in primary repair group was half of that in colostomy group. Two patients (10%) in primary repair group who developed complications had right colonic injuries with moderate fecal contamination. In colostomy group ten patients (50%) developed complications majority having left colonic injury with moderate contamination. In majority of the patients who developed complications in both groups the delay was more than 6 hours. There was no mortality in either of the groups. Conclusion: Primary repair of colonic injuries has less morbidity and is less expensive as compared to colostomy and is ideal method of management for colonic injury in patients aggressively resuscitated with no pre existing medical illness.

Primary repair vs colostomy in colonic injuries - a two year experience at Lahore General Hospital and Mayo Hospital, Lahore

The object of the study was to compare the results of primary repair in colonic injury with colostomy. 200 patients were selected, 100 being allocated to each group .All patients underwent laprotomy mostly indicated by peritoneal irritation. Most of the injuries were of the transverse colon. 22 patients underwent into exteriorization of the repaired part. Right hemicolectomy and ileocolic anastomosis was done in 30 patients. A significant morbidity occurred from wound sepsis, abdominal abscess formation and postoperative pulmonary complications. 22 patients suffered from burst abdomen and 10 developed faecal fistulas. 4 patients died. Prolonged mean hospital stay and more incidences of postoperative complications occurred in colostomy group. This shows that primary repair of colonic injuries should be done in selected cases instead of colostomy in each case.

Loop versus end colostomy reversal: has anything changed?

Though primary repair of colon injuries is preferred, certain injury patterns require colostomy creation. Colostomy reversal is associated with significant morbidity and healthcare cost. Complication rates may be influenced by technique of diversion (loop vs. end colostomy), though this remains ill-defined. We hypothesized that reversal of loop colostomies is associated with fewer complications than end colostomies. This is a retrospective, multi-institutional study (four, level-1 trauma centers) of patients undergoing colostomy takedown for trauma during the time period 1/2006-12/2012. Data were collected from index trauma admission and subsequent admission for reversal and included demographics and complications of reversal. Student's t test was used to compare continuous variables against loop versus end colostomy. Discrete variables were compared against both groups using Chi-squared tests. Over the 6-year study period, 218 patients underwent colostomy takedown after trauma with a mean age of 30; 190 (87%) were male, 162 (74%) had penetrating injury as their indication for colostomy, and 98 (45%) experienced at least one complication. Patients in the end colostomy group (n = 160) were more likely to require midline laparotomy (145 vs. 18, p < 0.001), had greater intra-operative blood loss (260.7 vs. 99.4 mL, p < 0.001), had greater hospital length of stay (8.4 vs. 5.5 days, p < 0.001), and had more overall complications (81 vs. 17, p = 0.005) than patients managed with loop colostomy (n = 58). Local takedown of a loop colostomy is safe and leads to shorter hospital stays, less intra-operative blood loss, and fewer complications when compared to end colostomy.

6 Year Prospective Clinical Trial of Primary Repair Versus Diversion Colostomy in Colonic Injury Cases

Management pathway of colonic injury has been evolving over last three decades. There has been general agreement that surgical methods dealing with colonic injury did not affect the outcome but there are certain independent risk factors for complications. These risk factors are still not clear and studies are going on to specify these risk factors. The primary objective of this study was to demonstrate that primary closure of colonic injury without colostomy in selective patient is safe. This was a prospective study of 6year duration. All the colonic injuries operated and divided into two groups: primary repair and colostomy. The criteria for exclusion of primary repair taken were; injury time >8hour, patient need >4 unit of blood transfusion till surgery, devascularization injury of colon, any pre existing disease of bowel, any severe co morbid disease like uncontrolled diabetes mellitus, tuberculosis, malignancy etc. Both groups are analyzed by assessing complications with special emphasis on leak rate. Patients died within 72hours of admission were excluded from study. Total 55 colonic injury cases operated and primary repair was done in 35 cases and colostomy in 20 cases. There was 1 mortality in colostomy group and no major morbidity in both groups. The complications in primary repair group were; 1 leak (treated conservatively), 5 wound infections 1 incisional hernia and 1 intra abdominal abscess. In colostomy group 8 cases of wound infections, 2 incisional hernias and 2 intra abdominal abscesses occurred. Primary repair of colon injuries can be safely done in selected patient.

COLONIC INJURIES

Objectives: To determine the effectiveness of primary repair of colonic injuries and its comparison with the traditionalcolostomy or exteriorization. Methods: The study was performed in Mayo hospital Lahore. Of the initial 114 patients 63 patients with colonicinjuries were selected and divided into 2 groups. After resuscitation these patients were operated. Both methods of treatment of colonic injurieswere employed in different patients. Results were tabulated and a comparison of primary repair vs colostomy was done. Results: Recoveryof patients undergoing primary repair was comparable with those having colostomy done. Only one major complication of leak occurred in theprimary repair group. Abdominal dehiscence occurred in the colostomy group. Average hospital stay of 9 days in the primary repair group wassignificant and far less, than 22 days in colostomy group. Conclusion: Under controlled circumstances primary repair of colonic injuries appearsto be a good mode of treatment.

Primary repair of colon injuries in a developing country

Because there are several specific disadvantages to a colostomy in a developing country, primary repair for colon injury was electively performed. Sixty-one consecutive patients with colon injury were seen between 1978 and 1989 and 57 of these (93 per cent) underwent primary repair. In four a colostomy was constructed. Emergency repair was carried out regardless of site or mode of injury, presence of hypotension or peritoneal contamination. There was one death unrelated to anastomotic complications and one anastomotic leakage. The faecal fistula closed spontaneously in 4 weeks. The wound infection rate was 10 per cent. These data support the emerging view that primary repair of colon injury is the management of choice.

Treatment of casualties in a forward hospital of Indian Army: Nine year experience

Background: To analyze the outcome of the management of casualties in a level II trauma centre of a forward hospital of Armed Forces over a nine year period. Retrospective analysis of all casualties received in a single forward hospital of Indian Army was carried out. Method: During 9 years (1990–1998), a total of 5737 casualties were received in a single level II zonal hospital of the Army in a forward area. Majority of the injuries were caused by bullets, or by fragments of improvised explosive devices. A policy of aggressive resuscitation and early primary repair of injuries was followed. General surgeons routinely performed craniotomies, thoracotomies, laparotomies, stabilization of fractures by fixators and repair of vascular injuries. Result: 38% of patients had injuries to several body parts (polytrauma), resulting in a total of 8578 injuries. Region-wise distribution of injuries was as follows: 14.2% head and neck injuries, 13.3% chest wounds, 13.5% abdominal injury and 59% extremity wounds. The overall mortality rate was 3.6%. The complication rate was about 7% with infection as the major complication. The results of primary repair of colonic injuries were similar to those of staged repairs. The results after primary closure of war wounds were better than those treated with delayed primary closure in selected cases. Conclusion: Prompt evacuation, speedy resuscitation and early definitive repair of war injuries results in low mortality and morbidity. A motivated and dedicated team and adequate availability of blood and ancillary services adds to the excellent outcome. The policy of primary repair of colonic and selected soft tissue injuries appears justified in selected cases.

Colon injuries in children

Background/Purpose: Colonic injuries are rare in childhood, but when they do occur, they are mostly associated with penetrating abdominal injuries. The primary repair of colon injuries without stoma is still controversial within surgical experience, and the potential risk factors affecting morbidity and mortality is not sufficiently known. Methods: Between 1985 and 1997, 34 children presenting with traumatic colonic perforations were reevaluated by analyzing the relationship between the overall morbidity and mortality and the potential risk factors. Results: Of the 34 children in the case study, 27 boys and 7 girls, there were 7 (21%) isolated colonic injuries. The remaining 27 (79%) patients showed colonic injuries most frequently associated with the small bowel, the liver, and the bladder. Localization of injury was distributed thus: 21% in the right colon, 29% in the transverse colon, and 50% in the left colon. Primary repair, with or without intestinal resection, was performed in 27 (79%) of the patients. In total, postoperative complications occurred in 10 (29%) of the patients. Risk factors such as age, abdominal contamination, and associated abdominal organ injuries were found significant in these complications, however, the mechanism of injury, shock, blood transfusion, and localization of injury were not correlated significantly to postoperative complications. “`Flint's Colon Grading System” was used to ascertain the sensitivity of trauma scoring systems for postoperative complications. Conclusion: Colonic wounds can be repaired primarily without the need of colostomy in the majority of cases in children when the required selections are established. J Pediatr Surg 35:1799-1804. Copyright © 2000 by W.B. Saunders Company.

Complications of primary repair of colon injury: literature review of 2,964 cases

Objective: To evaluate the safety and efficacy of primary repair of colon injuries. Materials and methods: A literature review was made of 35 publications containing 5,400 colon injuries in retrospective and prospective studies. Results: There were 62 (2.4%) failures in 2,627 primary repairs based on surgeon discretion or absence of risk factors. In prospective series of 337 patients repaired without exclusionary criteria, there were 4 (1.2%) suture line failures ( P = not significant). In prospective randomized trials without exclusionary criteria, 127 primary repairs had less morbidity compared with 109 diverted patients ( P <0.02). The leak rate after resection and anastomosis (5.5%) is greater than after simple suture of perforation (1.4%; P <0.001). The 66 colon repair leaks were treated by conversion to colostomy or led to fistulae that usually healed spontaneously. A preponderance of failed repairs occurred in the setting of multiple injuries or comorbid conditions. Conclusions: Penetrating and blunt colon injuries in civilian practice are safely managed by primary repair, but colostomy may still be advised in selected cases.

The high morbidity of colostomy closure after trauma: Further support for the primary repair of colon injuries

Background: We examined the recent experience of a large urban trauma center to identify overall morbidity and factors predictive of outcome in patients undergoing colostomy closure after trauma. Methods: We did a retrospective analysis of 40 patients who underwent colostomy closure after trauma at our institution between January 1992 and August 1996. Results: The mechanism of injury was a gunshot wound in 30 patients (75%), a motor vehicle accident in 6 (15%), a stab wound in 3 (75%), and a rectal foreign body in 1 (2.5%). Loop colostomies were performed in 28 patients (70%) and end colostomies were peformed in 12 patients (30%). Mean time until colostomy closure was 8 months (range, 0.5 to 28 months). Five patients underwent same admission colostomy closure (SACC). Contrast enemas were performed in 36 patients and found to be abnormal in 2 (6%) patients who were found during planning for SACC to have leaks from rectal trauma at 12 and 19 days after injury. Sixteen complications occurred in 12 patients (30%). Intraoperative complications occurred in two patients (5%) who sustained small and large bowel enterotomies. There were 4 major complications (1 fecal fistula, 1 anastomotic stricture, and 2 small bowel obstructions) in 3 patients (7.5%) and 10 minor complications (25%), 7 prolonged ileus and 3 superficial wound infections. Morbidity was significantly higher for patients whose initial injury involved the colon (11 of 20; 55%) as compared with those whose injury involved the rectum (2 of 16; 12.5%). The demographic, injury, and operative characteristics in the 12 patients with complications and the 28 patients without complications were compared to identify predictors of morbidity. The presence of a colon injury (RR = 7.70; p = 0.009) was a statistically significant predictor of morbidity after colostomy closure. The presence of an initial rectal injury, in contrast, was a predictor of low morbidity after closure (RR = 0.22; p = 0.024). No statistically significant differences were found with respect to age, gender, mode of injury, colostomy type, type of repair, need for laparotomy, or right- versus left-sided colostomy. Clinical trends were noted in five groups in whom the relative risk was greater than 2.0: age older than 30 versus less than 30 years (RR = 2.71; p = 0.079), end versus loop colostomy (RR = 2.33; p = 0.130), operative time greater than 2 versus less than 2 hours RR = 2.80; p = 0.141), estimated blood loss greater than 150 versus less than150 cc (RR = 2.77; p = 0.079), and right- versus left-sided colostomy (RR = 2.00; p = 0.211 ). Patients with complications had significantly longer mean operative times (3.84 versus 2.46 hours; p = 0.02), higher mean blood loss (468 versus 142 cc; p = 0.006), and longer mean time until closure (11.3 versus 6.33 months; p = 0.02). Conclusions: Colostomy closure after trauma remains associated with significant morbidity. The patients in whom a colon injury was the indication for initial colostomy experienced high morbidity (55%) after subsequent closure. Patients who had a colostomy for rectal injury had a low morbidity after closure (6.25%). Intraoperative difficulties (longer operative times, higher blood loss) and long delays until colostomy closure increase complication rates. Timely closure may improve outcome after operation for bowel continuity restoration. Morbidity associated with colostomy closure should be considered additional evidence for performing primary repair of colonic injuries. Because the morbidity of colostomy closure after rectal injuries is low, proximal colostomy for extraperitoneal rectal injuries should remain the treatment of choice. (Surgery 1998;123:157-64.)

The high morbidity of colostomy closure after trauma: Further support for the primary repair of colon injuries

The high morbidity of colostomy closure after trauma: Further support for the primary repair of colon injuries

Fecal diversion for penetrating colon injuries—Still the established treatment

An analysis of the existing literature on primary repair of colon injuries was undertaken to determine if there is sufficient evidence that this approach is superior to fecal diversion. After a thorough literature search, three prospectively randomized studies comparing primary repair with fecal diversion in the management of colon injuries were identified. A variety of factors were examined, including the number of patients in each study arm, morbidity rates, as well as exclusion criteria. An analysis was performed to determine the number of patients required to establish statistical superiority of one procedure over the other. Pooling of the data contained in the aforementioned reports does not provide sufficient statistical power to support the superiority of primary repair of colon injuries. To demonstrate a 5 percent difference between the two approaches, a prospective, randomized study consisting of 200 patients in each arm is necessary. The present literature does not support a statistically valid advantage of primary repair over fecal diversion in the management of traumatic colon injuries.

Are the risks after colostomy closure exaggerated?

One hundred twenty-one patients underwent colostomy closure for trauma. There was no mortality and a 4.9 percent incidence of major morbidity. Although there was no apparent relationship between the interval between colostomy creation and closure, three of the six major complications occurred in patients whose colostomies were closed soon after complicated initial injuries. It is recommended that if the primary operation is complicated by intraabdominal sepsis or major wound problems, 6 months should ensue before attempting closure. Long term follow-up of these patients (mean 39 months) disclosed a low incidence of late complications secondary to colostomy closure. Although the trend toward the increased use of primary repair of colon injuries in selected patients is supported, our study indicates that the risk of colostomy closure has been exaggerated and should not be a factor in the decision to create a colostomy after colon trauma.

Colostomy closure after colon injury: a low-morbidity procedure.

One justification for expanding the indications for primary repair of colonic injuries is the high morbidity classically associated with colostomy closure. Our impression that this morbidity is overstated prompted us to review our experience with closure of colostomies constructed for treatment of colon trauma for the 5-year period 1979-1984. During this period 75 colostomies created for treatment of colorectal injuries were closed. Complications were frequent after colostomy creation, but few could be attributed to the colostomy. Following colostomy closure, however, complications were infrequent (5%) and generally minor. If morbidity of colostomy closure is cited as a factor justifying expanded indications for primary repair of colon injuries, current morbidity rates should be borne in mind.

Letter: Primary repair of colonic injuries.

To the Editor.—I am writing concerning the article by Matolo et al, "Experimental Evaluation of Primary Repair of Colonic Injuries" (<i>Arch Surg</i>111:78-80, 1976). I think the authors offer an important contribution in showing that clean, incised wounds of the colon will heal in the presence of infection. However, in a clinical setting, this finding applies only to low-velocity penetrating injuries, such as stab wounds. It does not apply to the high-energy penetrating wounds produced by high-velocity gunshot or a close-range shotgun wound, nor does it apply to perforations induced by blunt trauma. Both blunt injuries and high-velocity penetrating injuries are surrounded by a margin of contusion injury that extends beyond the obvious open edges. Since this area develops subsequent to the "blast" effect of these injuries, it needs time to appear. It does become manifest at the time of an early laparotomy. Therefore, due to the inability to

Primary Repair of Colonic Injuries-Reply

To the Editor.—The article Experimental Evaluation of Primary Repair of Colonic Injuries by Matolo et al ( Arch Surg 111:78-80, 1976) is a valuable—and yet worrisome—contribution. The article reconfirms current knowledge that appropriate preoperative, postinjury antibiotic loading reduces morbidity and mortality. The contribution is worrisome in that the authors render generic conclusions regarding posttraumatic colonic closure from an experimental model that may not be duplicative of human injury. The authors do not state the manner in which their experimental lacerations were created. We suspect these to have been cleanly incised lesions, since that would be the simplest way to control length. Such injury is duplicative only of such penetrating abdominal trauma as a stab wound. Certainly there is no element of crush, temporary cavity effect, or ischemia in the model. Furthermore, it is not at all clear that injury of the midtransverse colon is analogous to injuries elsewhere in the colon.

Experimental evaluation of primary repair of colonic injuries.

To evaluate the management of colonic injuries, experimental models simulating acute injuries of the colon were studied utilizing New Zealand white rabbits. Seventy-nine rabbits underwent primary repair of colonic injuries in the presence of massive contamination and none showed any evidence of anastomotic leakage or breakdown. The fact that primary colonic repairs do heal even in the presence of infection suggests that breakdown of colonic anastomosis results from factors other than infection. Despite the absence of anastomotic leaks in this series, morbidity and mortality were high in those animals not given antibiotics. The high morbidity and mortality were due to peritonitis, intra-abdominal abscess, and wound infection, and were directly proportional to the length of time from colonic injury to repair. On the basis of this study, it is concluded that most isolated injuries of the colon can be closed primarily, if antibiotic therapy is begun immediately after injury and continued throughout the operative and postoperative periods.

Exteriorized primary repair of colon injuries

Two classic approaches have been applied to the surgical management of colon injuries. One has been exteriorization of the injured segment. The other has been primary repair of the injury in selected cases. A compromise approach can be utilized when the risk of leakage is high in a primarily repaired segment of colon: exteriorization of the primarily repaired injury without colostomy. This technic has prevented the need for formal colostomy in 49 per cent of a group of thirty-seven patients who otherwise would have required colostomy. This approach appears to be a useful addition to the various procedures used for the treatment of penetrating injuries of the colon in civilian practice.