Colon Trauma

Richard E. Karulf, MD
Associate Clinical Professor of Surgery
Department of Surgery
Division of Colon and Rectal Surgery
University of Minnesota

Greg Fitzharris, MD
Colon and Rectal Surgery Fellow
Department of Surgery
Division of Colon and Rectal Surgery
University of Minnesota

Colon trauma has been recorded from early times. In the third chapter of the book of Judges it is written "Ephud put forth his left hand, and took the sword from his right thigh and thrust it into his belly. And the hilt also went in after the blade; and the fat closed upon the blade, for he drew not the sword out of his belly; and the dirt came out". (Verses 21-22) This early reference suggests a colon injury but does not describe the treatment or outcome. Matthaeus Gottfried Purman, a surgeon of the Brandenburg Army, was noted for his skill and courage performing surgery in the field. He is credited with being the first to suture intestinal wounds in 1675 (Garrison FW 1929). His treatment of abdominal wounds was unusual for his time and only a few surgeons considered repairing even eviscerated loops of bowel that were damaged. Through the time of the Civil War, the conventional approach for abdominal trauma was expectant management because of the high morbidity and mortality with surgical intervention. At the time of the Civil War, the mortality rate for penetrating colon trauma was greater than 90%. In 1881, James Marion Sims wrote a journal article entitled "The careful aseptic invasion of the peritoneal cavity for the arrest of hemorrhage, the suture of intestinal wounds and the cleansing of the peritoneal cavity"(Sims JM 1881). This article, which promotes exploration of the abdominal cavity in some cases of trauma, foreshadows a debate that will linger for the next century.

By World War I, many surgeons were convinced of the dismal results of non-operative management of penetrating colon trauma and a few surgeons were converting to prompt intervention. These surgeons remained in the minority and the mortality rate for penetrating colon trauma in WWI remained as high as 60%. In the early stages of WWII, a British surgeon in the North African campaign reported promising results with the use of diverting colostomies for penetrating colon trauma (Ogilvie 1944). In part due to this article, the Surgeon General of the United States Army ordered that all penetrating colon injuries sustained in battle would be treated with diverting colostomy (Army 1943). This change in philosophy, along with improvements in medical care and early evacuation from the field, produced a drop in the mortality rate for penetrating colon trauma to 30%.

The mortality rate for penetrating colon trauma continued to decline after WWII. In the Korean War, the mortality rate for colon trauma was 15% and a decade later, during the war in Vietnam, the rate had dropped to 13%. A number of factors, other than the use of diverting colostomy, were also involved in the improved survival after penetrating colon trauma including availability of antibiotics and blood products, more aggressive fluid resuscitation, improvements in anesthesia and rapid evacuation from the from line (Haygood FD 1976). The decrease in evacuation time (time from injury until medical care) may have been one of the most important factors in decreasing mortality from penetrating colon trauma (figure 1). The improved overall health of the soldiers prior to their trauma, although difficult to measure, may have contributed to the improved survival as well.

As surgeons returned from the battlefield to their civilian practice, they brought home their philosophy for treatment of trauma patients along with their other memories of the military. Following WWII, the standard of care for penetrating colon trauma became mandatory use of diverting colostomy in the civilian sector. Many authors point out that there are substantial differences between civilian and military trauma. Factors such as availability of resources, number of concurrent casualties, continuity of care and evacuation time all favor patients with civilian trauma (figure 2). However, the single factor that distinguishes civilian from military trauma, in its classic sense, is the mechanism of injury. In traditional warfare, penetrating colon injuries are often a result of high velocity weapons and shrapnel while civilian trauma is more commonly a result of handguns, stab wounds and blunt trauma. The greater kinetic energy associated with high velocity weapons imparts much more damage to surrounding tissues than low velocity weapons. As urban violence escalates and assault rifles and other high velocity weapons are used, and as military deployments are used to treat rogue elements with less sophisticated weaponry, the distinction between civilian and military trauma becomes blurred.

In 1951, Ochsner suggested primary repair of penetrating colon trauma for civilian trauma (Woodhall JP 1951). Although he suggested this was a safe approach, the medical community did not accept it. The first widely accepted article to challenge the doctrine of mandatory colostomy for penetrating colon trauma did not emerge until 1979 (Stone HH 1979). In this prospective, randomized, non-blinded study of 268 patients over 44 months, primary closure was compared with diverting colostomy for penetrating colon wounds. Strict exclusion criteria were utilized to separate out patients that were felt to need mandatory colostomies and who could not participate in the study (Table 1). As a result, only 139 of the 268 patients were eligible for randomization. Of the 139 patients, 67 patients had primary closure of the colon wounds and 72 patients had colostomies. The results of the study revealed that the patients with primary closure had a lower infection rate than the patients with colostomies and that the immediate mortality rates were identical between the two groups. As an added benefit, there was a shorter length of stay (when ostomy closure is included) and lower costs associated with primary closure of colonic wounds, in this study.

This article broke new ground in changing the philosophy of treatment for penetrating colon trauma from obligatory colostomy to primary repair. Other authors built upon this foundation as the philosophy evolved. George et al looked at 102 consecutive patients with colon injuries (George SM 1989). In this study, an attempt was made to perform primary closure on all patients. They found that there were only four risk factors that placed the patient at increased risk for septic complications. These risk factors were transfusion of more than four units of blood, two or more associated injuries, significant fecal contamination and a high colon injury severity scale. They pointed out that other traditional risk factors, such as method of treatment of the colon injury, location of the injury in the colon, mechanism of injury and the presence of hypotension prior to surgery did not influence the risk of sepsis. Nelken and Lewis also examined selective management of penetrating colon trauma in a retrospective review of 76 patients (ref). In this study, the two groups, with similar demographic profiles, were patients with primary repair and patients with diverting colostomy after colon trauma. They compared three different scoring systems to try to determine which system could accurately predict success in treatment of colon trauma. The systems included the injury severity score (ISS), the penetrating abdominal trauma index (PATI), and the Flint colon injury score. They concluded that the PATI was the most reliable system for predicting complications and patients that would have success with primary repair. They concluded that in selected patients, primary closure of colon injuries provided outcomes equal to or better than diverting colostomy. This opinion was echoed years later in a large series from Ben Taub Hospital when only 0.9% of patients with primary repair of penetrating colon trauma were found to have an anastamotic leak (Burch JM 1989).

In a more recent study, Chappuis attempted to answer many of the questions related to penetrating colon trauma in one paper (Chappuis CW 1991). This was a prospective, randomized trial of patients with penetrating colon trauma. The type of management was not dependent on associated injuries, transfusions, shock or fecal contamination. The 56 patients were assigned to the colostomy or primary repair groups by a table of random numbers prior to surgery. The two groups were similar in terms of severity and type of injuries. This was reflected by the similar PATI for the two groups. The length of stay was longer in the diversion group but the results were otherwise similar. The authors noted that when victims of colon trauma die in the early post-operative period, death is due to associated injuries rather than the trauma to the colon itself. The results also failed to show a higher infection or complication rate for the primary repair group. The conclusions were that since the purported advantage of diversion over primary repair with colon trauma is the avoidance of suture line leak as a source of sepsis, and since there was no difference in infection rates in the two groups, primary repair should be considered an acceptable option.

Authors have studied subsets of penetrating colon trauma. Equal outcomes are obtained for primary repair of right and left colon injuries (Thompson JS 1981). Similarly, there appears to be equal results for both penetrating and blunt colon trauma (Bugis SP 1992). There appears to be good results with resection as well as repair (Conrad JK 2000). In fact, in a recent article reviewing several prospective studies concluded "Diversion of the fecal stream has no role in the routine management of colon injuries"(Nance ML 1995).

The issue of antibiotic therapy often comes up when dealing with penetrating abdominal trauma. Fullen et al revealed that antibiotic therapy is much more beneficial if it is started before surgery (Fullen 1972). There is a higher infection rate in patients with penetrating abdominal trauma if the antibiotics are not start until during or after the procedure. Fabian looked at the issue of duration of antibiotic therapy in patients with penetrating abdominal trauma (Fabian 1992). This prospective double-blinded study compared one day with five days of antibiotic therapy. The two groups had a similar PATI and both groups received a second-generation cephalosporin prior to surgery. The results showed a similar infection rate in the two groups. The authors concluded that the duration of treatment had no impact on the infection and mortality rate and that a short course of antibiotics is as effective as a more prolonged course of antibiotics regardless of the degree of injury, the presence of shock or the number of associated injuries.

It is interesting to note that even the topic of penetrating colon trauma has not escaped the scrutiny of cost analysis. In a surgical outcomes research project, primary repair and resection with anastamosis both were found to be superior to colostomy both in terms of cost and quality of life analysis (Brasel KJ 1999). Additional support for primary repair of colon injuries is provided when the high morbidity of colostomy closure for trauma is considered (Berne JD 1998).

In summary, recommendations for treatment of patients with colon trauma must be based on patient factors and the experience of the surgeon. In all patients, the mechanism of injury, extent of injury, patient status and associated injuries should be noted at the time of presentation and considered when making decisions. All patients should receive antibiotics prior to surgery. If there is a full thickness colon injury, the wound should be left open to heal by secondary intent. If the surgeon is comfortable in treating patients with primary closure of colon trauma, it is a reasonable option for patients with stab wounds and low velocity gunshot wounds. Debate continues about if a colostomy or ileostomy should be considered when patients have significant associated injuries or when the colon has been devascularized. Greater consideration should be given for high velocity, shrapnel or shotgun injuries or for patients where the injury required insertion of prosthetic material to the area. With these few exceptions in mind, the majority of patients with penetrating colon trauma should be treated with primary repair or resection.

Figure 1. Mortality Rate compared with Evacuation Time for Military Colon Trauma

Figure 2. Comparison of factors associated with Civilian and Military Trauma

Table 1. Historic factors for mandatory colostomy with penetrating trauma (Stone 1979)

Bibliography

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