The morbidity of penetrating colon injury

Abstract

The purpose of this study is to define the current morbidity and mortality associated with penetrating colon injury and to determine the impact of management strategy on outcome. Methods: A retrospective review was performed of all penetrating colon injuries managed at a level I trauma center (1990–2000), n=186. Stepwise logistic regression was used to determine the independent predictors for colostomy and morbidity following colon injury. Results: Fifty-three percent of the patients were managed with primary repair or anastomosis while 47% received a colostomy. Independent predictors of colostomy included gunshot wound (GSW), degree of peritoneal contamination, and location of injury. The complication rate for patients requiring a colostomy was 57% versus 42% for the primary repair group, P=0.01. When adjusted for injury severity and hypotension, the presence of a colostomy was not associated with a significant increase in the complication rate (OR 1.7, 95% CI: 0.9–3.25). Independent predictors for the development of intra-abdominal abscess were hypotension on admission (OR 2.4, 95% CI: 1.1–5.8) and penetrating abdominal trauma index (PATI) score >25 (OR 4.2, 95% CI: 2.0–8.9). The complication rate for colostomy takedown was 17%. Conclusion: Penetrating colon injury carries a high rate of infectious morbidity. The development of infectious complications is related to the injury severity and haemodynamic status of the patient, not the type of operation performed.

Introduction

Historically, faecal diversion with colostomy was performed for all penetrating colon injuries, to establish an alternate pathway for the faecal stream and prevent the development of intra-abdominal infection resulting from soiling of the peritoneal cavity. During World War II, the Surgeon General of US insisted on a colostomy for all penetrating colon injuries regardless of how trivial the injury appeared [23]. Over the past 20 years, however, several studies have demonstrated the safety of primary repair for many penetrating colon injuries and as a result clinical practice patterns have changed, resulting in fewer colostomies in this setting [5], [15], [16], [17], [19], [20], [25], [31]. There remain, however, patients who continue to receive a colostomy either due to haemodynamic instability, associated injuries, or severity of colon injury. Thus, patients who currently receive a colostomy are likely to be more severely injured than those in previous reviews. This may lead to higher complication rates, not necessarily associated with the procedure, but rather due to the initiating factors for the procedure. In this report, we explore this hypothesis by reviewing the 10-year experience of a single urban level I trauma center. In addition, patients who receive a colostomy require a second operation to restore bowel continuity and the morbidity associated with this procedure has not been recently reviewed.

The objectives of this study were: (i) to determine the independent predictors of the need for colostomy, (ii) to define the current morbidity and mortality associated with penetrating colon trauma and factors contributing to this morbidity, and (iii) to determine the morbidity associated with a colostomy and subsequent colostomy takedown.