Management of

Traumatic Colon
injury
Gan Dunnington M.D.
Trauma Conference
Stanford University
7/24/06

Case Report

HPI: 16 yo boy involved in MVC as restrained

back seat passenger
Trauma 97 Report ambulatory at scene, c/o
abd pain

Airway intact
Breathsounds equal
HR 76, BP 140/76, equal pulses
GCS 15, MAE, AxOx3
Impressive seatbelt sign, Large left flank
eccymosis/fullness
FAST negative
CT no solid organ injury, small amt free fluid

Case Report

Case Report

Case Report

Hopital course

Admitted to trauma for observation,

pain control, spine consult for
question of compression fx
HD#4 develops tachycardia,
tachypnea, abd pain

Hopital course

Hospital Course

OR
Exploratory laparotomy midline
Suprafascial hematoma superiorly
Devascularized portion of small bowel
8cm
Devascularized, necrotic, perforated
sigmoid colon

Minimal fecal contamination

Large left flank hernia with hematoma

Hopital course

Hospital Course

Returned to ICU with open abdomen for

planned 2nd look at fascia
2nd look POD#2, fascia viable, bowel
healthy and fascia closed, skin left open
Intermittent fevers post-op, but
currently doing well, tolerating diet,
stoma functioning, dispo planning
Plan colostomy reversal in approx 3
months, then will plan later lumbar
hernia repair

Traumatic Colon Injury

Incidence:
2nd most frequent injury in GSW
3rd most frequent in stab wounds
Relatively infrequent after blunt trauma
(2-5%)

Morbidity 20-35%
Mortality 3-15%

Traumatic Colon Injury

Assessment:

Physical exam

Peritoneal signs
Rectal exam blood
is fairly sensitive
DPL

X-ray, CT
GSW mandates
operation

History

Historically colon repair a failure until WWI

1943 - Due to failure rate Major General W.H.
Ogilvie mandated colostomy
1950s improvements in trauma care, and
surgeons began to challenge diversion dogma
1979 Stone and Fabian prospective study
confirmed safety and efficacy of primary repair in
selected patients
Exteriorization in 1960s-70s abandoned
1980s present greater move to primary
repair

Risk factors for primary

repair

Delayed treatment (>12hrs)

Prolonged shock
Gross fecal contamination
>4-6 units PRBCs transfused
Need for mesh to close abdominal
wall

Trauma grading scores

Flint grading
I isolated colon, no shock, minimal
contamination, minimal delay
II Through and through perforation,
laceration, moderate contamination
III severe tissue loss, devascularization,
heavy contamination

Advantage simplicity
Disadvantage does not factor in
other injury

Trauma grading scores

Penetrating
Abdominal Trauma
Index combined
severity of injury to
individual abd
organs assessed
operatively

Disadvantage does
not take into
account rest of body

Lewis et al. Ann Surg. 1989

Trauma grading scores

Lewis et al. Ann Surg. 1989

Therapeutic options

Two stage
Repair and protective-ostomy
Resection and stoma formation proximally

Distal Hartmanns or mucous fistula

Exteriorization of repaired bowel

uncommon now

One stage
Simple suture repair
Resection and primary anastamosis

Anastamosis

Stapled vs. Hand-Sewn

Brundage et al. J trauma.

1999
Multicenter retrospective
cohort design

anastamotic leaks and

intra-abdominal
abscesses appear to be
more likely with stapled
bowel repairs compared
with sutured anastamoses
in the injured patient.
Caution should be
exercised in deciding to
staple a bowel
anastomosis in the
trauma patient.

Anastamosis

Burch et al. Ann Surg. 1999

Burch et al. Ann of Surg.

1999.
Prospective randomized
trial of single-layer
continuous vs. two layer
interrupted intestinal
anastamosis
NB: Important to invert, 46mm seromuscular bites,
5mm advances, larger
bites at mesenteric border
Single layer similar leak
rate (approx 2%), cheaper,
faster

Studies

Review: Tzovaras et al. New Trends in

Management of colon trauma. Injury. 2005
Fabian and Stone study criticized for excluding
48% before randomization
3 prospective studies consecutive patients
without exclusion criteria

Studies

3 prospective randomized trials comparing

diversion to primary repair without exclusion
criteria

Tzovaras et al. New Trends in

Management of colon trauma. Injury.
2005

Authors all conclude primary repair should be first

treatment in civilian penetrating colon trauma

Studies

Demetriades et al. 92 prospective study of 100 GSW to

colon

Stewart et al. 94 reviewed series of 60 pts who required

resections

Routine colostomy on all resections (16 pts)

37.5% abdominal septic complication rate

43 primary anastamosis, 17 with diversion

Abdominal sepsis in 37% anastamosis, 29% diversion
Leak in 14% total, 33% if >6U PRBCs

Murray et al 99 retrospective series of 140pts requiring

resection

80% anastamosis, 20% diversion

Equal abdominal sepsis rates

4% leak ileocolic, 13% leak in colocolostomy

Studies

Cornwell et al. 98 prospective study of 27 pts

requiring resection

All had delay>6hrs, >6U prbcs, or PATI>25

25pts had primary anastamosis, 2 with colostomy
Abd septic complications in 20% anastamosis group,
2 leaks and both fatal

Demetriades et al. 01 propective, multicenter

on penetrating colon injuries requiring
resection

22% complication with primary repair, 27%

diversion
3 risk factors severe fecal contam., >4U prbc,
single agent abx
Type of management did not affect complications

Studies

Hudolin et al. Br. J Surg. 2005 Role of

primary repair of colon injuries in wartime

5370 casualties 259 (4.8%) with colon injuires

122 had primary repair, 137 had colostomy

58% explosive, 42% gsw, 1pt had stab wound
Associated injury in 96%

Complications in 27% primary repair, 30%

colostomy
Mortality 8% and 7% respectively
Conclusion primary repair safe and effective
treatment for colon injuries during war

Studies

Adedoyin et al. 60 pts over 10 yrs

No difference in outcome of primary
repair vs. colostomy
Colostomy closure related morbidity
21%, mortality 5%

Studies

Multiple studies show no difference in

complication rates between right and left
colon injuries repaired primarily
Eshraghi N et al. J Trauma. 1998

Survey of trauma surgeons AAST members

30% never diverted, 1% always diverted
High velocity GSW only indication where majority
diverted
Negative correlation between surgeon age and
preference for anastamosis
Lower volume surgeons preferred diversion

EAST Guidelines

Published in 1998
Level I

Sufficient class I and class II data to

support primary repair for
nondestructive colon wounds(<50%
bowel wall without devascularization),
in the absence of peritonitis

EAST Guidelines

Level II

Patients with penetrating

intraperitoneal colon wounds which are
destructive can undergo resection and
primary anastomosis if they are:
Hemodynamically stable without shock
Have no significant underlying disease
Have minimal associated injuries
Have no peritonitis

EAST Guidelines

Level II

Patients with shock, underlying disease,

significant associated injuries, or peritonitis
should have destructive colon wounds managed
by resection and colostomy
Colostomies after trauma can be closed within 2
weeks if contrast enema is performed in distal
colon if no unresolved sepsis, instability, nor nonhealing bowel injury
BE not necessary to r/o cancer or polyps prior to
colostomy closure for trauma patients who
otherwise have no risk factors.

Summary

Colon trauma carries significant

morbidity and mortality
Choice of diversion vs. primary repair
should be individualized to situation
Move towards more primary repairs and
resections with anastamosis without
colostomy
Right colon = Left colon for management
Suture>Stapled for trauma?