Author, year
Number of patients
Abdominal sepsis (%)
George, 1989
102
33
Chappuis, 1991
56
20
Demetriades, 1992
100
16
Ivatury, 1993
252
17
Gonzalez, 1996
114
24
Demetriades, 2001
297
24
Overall
921
22
Epidemiology
In American urban centers, firearms are by far the most common cause of injury.
The colon is the second most commonly injured organ after the small bowel, and it is involved in about 27 % of cases undergoing laparotomy.
In stab wounds, the left colon is the most commonly injured segment.
In anterior abdominal stab wounds, the colon is the third most commonly injured organ after the liver and small bowel and is found in about 18 % of patients.
In posterior stab wounds, the colon is the most commonly injured organ and is injured in about 25 % of patients undergoing laparotomy.
In abdominal gunshot wounds, the transverse colon is the most commonly affected segment.
Blunt trauma to the colon is uncommon and is diagnosed in about 0.5 % of all major blunt trauma or in 10.6 % of patients undergoing laparotomy.
Only 3 % of blunt trauma patients undergoing laparotomy have full-thickness colon perforations.
Seat belts increase the risk of hollow viscous perforations, and the presence of a seat-belt mark sign is a predictor of hollow viscous injury.
Diagnosis
A rectal examination may show blood in the stool, especially in cases with distal colon or rectal injuries.
A preoperative upright chest film may show free air under the diaphragm.
The colon can reliably be evaluated by water-soluble contrast enema studies or abdominal CT scan with soluble rectal contrast. Retroperitoneal gas or contrast extravasation is diagnostic, and an exploratory laparotomy should be performed.
Ultrasound or diagnostic peritoneal lavage is unreliable in the evaluation of suspected colon injuries due to its retroperitoneal location.
The preoperative diagnosis of colon injury following blunt trauma can be a major challenge, especially if the patient is unevaluable due to associated head injuries.
Intraoperatively, every paracolic hematoma due to penetrating trauma should be explored.
Paracolic hematomas due to blunt trauma should not undergo routine exploration unless there is evidence of colon perforation (Table 26.2 ).
Table 26.2
American Association for the Surgery of Trauma (AAST) colon injury scale
Grade
Injury description
I
(a) Contusion of hematoma without devascularization
(b) Partial-thickness laceration
II
Laceration ≤50 % of circumference
III
Laceration >50 % of circumference
IV
Transection of the colon
V
(a) Transection of the colon with segmental tissue loss
(b) Devascularized segment
Operative Management
Historical Perspective
The first guidelines were published by the United States Surgeon General in 1943 and mandated proximal diversion or exteriorization of all colon wounds.
The policy of mandatory colostomy for all colon injuries remained the unchallenged standard of care until the late 1970s.
Stone reported the first major scientific challenge of this policy in 1979. It was concluded that primary repair was associated with fewer complications than colostomy.
In the 1990s and 2000s, primary repair became the standard of care except in the presence of certain risk factors such as destructive colon injuries, severe contamination, multiple injuries, and delays in treatment.
Nondestructive Colon Injuries
There is now enough class I evidence (prospective randomized studies) supporting primary repair in all nondestructive colon injuries (injuries involving <50 % of the bowel wall and without devascularization, i.e., AAST Grade I or II, irrespective of risk factors).
Primary repair is the method of choice of treatment of all penetrating colon injuries in the civilian population despite any associated risk factors for adverse outcome.
Numerous prospective observational studies (class II evidence) demonstrated the superiority of primary repair over diversion in nondestructive injuries.
In conclusion, there is sufficient class I and II data to support routine primary repair of all nondestructive colon injuries, irrespective of risk factors for abdominal complications.
No study has ever shown that colostomy is associated with better results than primary repair.
Destructive Colon Injuries
Until 2000, the available prospective randomized studies, which include only a small number of cases, recommend resection with anastomosis irrespective of risk factors.
Two large retrospective studies advocate diversion in the subgroups of patients with certain risk factors such as PATI ≥25, multiple blood transfusions, or associated medical illness.
Subsequently, the guidelines of the Eastern Association for the Surgery of Trauma (EAST) published in 1998 supported resection and primary anastomosis in the subgroups of patients with destructive colon injuries if they (a) are hemodynamically stable intraoperatively, (b) have minimal associated injuries (PATI <25, ISS <25), (c) have no peritonitis, and (d) have no underlying medical illness.
The guidelines suggest that patients with shock, significant associated injuries, peritonitis, or underlying disease should be managed with resection and colostomy.
In view of the lack of large prospective studies in the literature, the AAST sponsored a prospective multicenter study This study, published in 2001, included 297 patients with penetrating injuries requiring colon resection (rectal injuries were excluded) that survived at least 72 h.
The overall colon-related mortality was 1.3 % (four deaths) and all deaths occurred in the diversion groups (P = 0.01).
The overall incidence of abdominal complications was 24 %, and the most common complication was an intra-abdominal abscess.Related posts:
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