Aggressive definitive management of penetrating colon injuries: 136 cases with 3.7 per cent mortality

One hundred thirty six patients with penetrating colon injuries (gunshot wounds, 95; stab wounds, 41) were retrospectively analyzed. A scoring system, the Penetrating Abdominal Trauma Index (P.A.T.I.), was employed to quantitatively assess the severity of injuries in each patient. Of 67 patients with right colon injuries, 48 (72%) were treated definitively by primary repair (32) and by resection and ileocolic anastomosis (16), with minimal morbidity. In 69 patients with left colon injuries, 47 (68%) were treated by colostomy (28) and by exteriorized repair (19). Overall, exteriorized repair was successful in 74% of patients. All five mortalities (3.7%) were related to associated injuries. It is concluded that the majority of the right colon injuries can be treated definitively. Exteriorized repair should be the preferred method whenever colostomy is considered, except in severe left colon injuries requiring resection.     

PRIMARY REPAIR FOR COLONIC GUNSHOT WOUNDS

Background: Penetrating injuries of the colon have been managed traditionally by diverting colostomy. Recently, a trend towards primary repair has been observed, particularly for knife injuries. The purpose of this study is to evaluate the safety of primary repair for colonic gunshot wounds in the presence of certain clinical risk factors. Methods: A retrospective analysis of 223 patients with colonic bullet injuries in a period of 3 years (1990–93) was performed. Results: Of 223 patients with colonic trauma, 168 were primarily repaired (group A) and 55 underwent a colostomy (group B). Intra-abdominal septic complications occurred in 5.9% of group A patients and 10.9% of group B patients (P > 0.05, NS). These patients were, furthermore, stratified according to well-known risk factors for the development of complications, namely, site of injury, presence of shock on admission, degree of faecal contamination and number of associated injuries. We were unable to find any statistically significant differences in intra-abdominal septic complication rates between patients treated with primary repair and patients treated with colostomy. Conclusions: Primary repair seems to be a safe therapeutic option for gunshot wounds of the colon. Even in the presence of the abovementioned risk factors, colostomy may be avoided in most cases as primary repair does not appear to be associated with higher complication rates.     

Gunshot wounds of the colon: A review of 100 consecutive patients,with emphasis on complications and their causes

The cases of one hundred civilian patients with gunshot wounds of the colon treated at the Louisville General Hospital have been reviewed. Most injuries were in the transverse colon (44 per cent), followed by the ascending colon (27 per cent), rectosigmoid (19 per cent), and descending colon (10 per cent). Associated injuries occurred in 81 per cent of the patients; the small bowel was the most common structure injured.Primary closure was used in 52 per cent of the patients, with a resultant 19 per cent rate of wound infection and 14 per cent rate of serious complication. When the extent of contamination or tissue destruction required resection, an attempted primary anastomosis was followed by a high rate of wound infection (57 per cent) and serious complications (36 per cent) as compared with end-colostomy and mucous fistula, which resulted in a 24 per cent rate of wound infection and 24 per cent rate of serious complication. The rate of wound infection between these groups is significant (p = 0.05). Results with end-colostomy and mucous fistula were better than with attempted primary anastomosis.Primary closure of missile injuries of the colon is feasible but should not be attempted in the presence of gross fecal peritonitis or massive tissue destruction. If resection is undertaken, end-colostomy (or ileostomy) and distal mucous fistula should be performed in the presence of intra-abdominal contamination to reduce the incidence of postoperative wound infection and serious complications. Delayed primary closure should also reduce the rate of wound infection in these patients.     

Penetrating colon injuries: exteriorized repair vs. loop colostomy

Eighty-five patients with penetrating colon injuries, treated either by exteriorized repair (39) or loop colostomy (46), were analyzed. Missile wounds accounted for 75.3% of the injuries. The Penetrating Abdominal Trauma Index (PATI) was the scoring method employed to assess quantitatively the severity of injuries in each patient. Of 21 patients with right colon injuries, eight were treated by exteriorized repair and the remainder by loop colostomy. PATI and other variables were comparable in both groups. Suture line leaks occurred in two patients (25%) with exteriorized repair. The morbidity was similar in both groups. In left colon trauma, exteriorized repair was employed in 31 patients and 33 underwent loop colostomy. The injury severity indices, clinical status, and time lapse to laparotomy were similar in both groups. Colostomy was avoided in 67.7% (21 of 31) patients with exteriorized repair. The incidence of abscesses was significantly higher in the colostomy group compared to the group treated by exteriorized repair (24.2% and 6.4%, respectively; p less than 0.05). The length of hospital stay was shorter after exteriorized repair (17.2 days vs. 23.2 days; p less than 0.05). All three mortalities (3.5%) were related to associated injuries. We conclude that exteriorized repair is a safe and superior alternative to loop colostomy in penetrating colon trauma.     

The management of colon injuries.

Surgical management of colon injuries was assessed in 97 patients. Injuries comprised stab wounds (88 cases), blunt trauma (5 cases), and gunshot wounds (4 cases). Injury involved the right colon in 52,6% and the left colon in 47,4% of patients. Fifty-eight per cent had associated major visceral injury. Patients were divided into two categories; those in whom proximal colostomy or exteriorisation of the perforation was performed constituted the one group, and those who had primary closure, the other. Analysis of results were made with regard to the incidence of wound infection, intra-abdominal abscess formation, peritonitis, and other postoperative complications. Seventeen patients had exteriorisation of the colon performed. Colostomy and colostomy closure had a significant morbidity rate, with a mean total period of hospitalisation of 58,5 days. Eighty patients were treated by primary closure. Septic complications occurred in 36,7% of cases. An analysis of the factors influencing mortality and morbidity was made, with reference to the side of the colon involved, the time interval between injury and surgery, faecal contamination of the peritoneal cavity, associated visceral injury and the presence of more than one colonic perforation. Increased morbidity was noted when the operative delay exceeded 6 hours and when faecal contamination of the peritoneal cavity was marked. Primary closure of a lacerated colon is safe provided that careful consideration is given to the above factors.     

Improving outcomes following penetrating colon wounds: application of a clinical pathway

INTRODUCTION: During World War II, failure to treat penetrating colon injuries with diversion could result in court martial. Based on this wartime experience, colostomy for civilian colon wounds became the standard of care for the next 4 decades. Previous work from our institution demonstrated that primary repair was the optimal management for nondestructive colon wounds. Optimal management of destructive wounds requiring resection remains controversial. To address this issue, we performed a study that demonstrated risk factors (pre or intraoperative transfusion requirement of more than 6 units of packed red blood cells, significant comorbid diseases) that were associated with a suture line failure rate of 14%, and of whom 33% died. Based on these outcomes, a clinical pathway for management of destructive colon wounds was developed. The results of the implementation of this pathway are the focus of this report. METHODS: Patients with penetrating colon injury were identified from the registry of a level I trauma center over a 5-year period. Records were reviewed for demographics, injury characteristics, and outcome. Patients with nondestructive injuries underwent primary repair. Patients with destructive wounds but no comorbidities or large transfusion requirement underwent resection and anastomosis, while patients with destructive wounds and significant medical illness or transfusion requirements of more than 6 units/blood received end colostomy. The current patients (CP) were compared to the previous study (PS) to determine the impact of the clinical pathway. Outcomes examined included colon related mortality and morbidity (suture line leak and abscess). RESULTS: Over a 5.5-year period, 231 patients had penetrating colon wounds. 209 survived more 24 hours and comprise the study population. Primary repair was performed on 153 (73%) patients, and 56 patients had destructive injuries (27%). Of these, 40 (71%) had resection and anastomosis and 16 (29%) had diversion. More destructive injuries were managed in the CP group (27% vs. 19%). Abscess rate was lower in the CP group (27% vs. 37%), as was suture line leak rate (7% vs. 14%). Colon related mortality in the CP group was 5% as compared with 12% in the PS group. CONCLUSIONS: The clinical pathway for destructive colon wound management has improved outcomes as measured by anastomotic leak rates and colon related mortality. The data demonstrated the need for colostomy in the face of shock and comorbidities. Institution of this pathway results in colostomy for only 7% of all colon wounds.     

Primary repair of the colon: when is it a safe alternative?

Management of civilian colon injuries has clearly departed from the military directive advocating mandatory colostomy. The treatment of 228 colon injuries at the Denver General Hospital was reviewed to elucidate risk factors for colon-related complications and quantify the morbidity of available surgical treatment options. In our population, 68% of patients sustained gunshot wounds with a high percentage of severe colon injuries and associated abdominal organ damage. Primary repair was accomplished in 49% with 17% septic morbidity and 1% septic mortality rates. Colostomy was required in 36% with a cumulative septic morbidity of 48% and 2% septic mortality. The most common complications were abdominal abscess (12%), wound infection (7%), and fecal fistula (4%). Analysis of risk factors for colon-related morbidity showed that the Abdominal Trauma Index (ATI), colon injury severity, preoperative shock, and peritoneal contamination were most important. Synthesis of the treatment outcome and risk factor data yields a proposed management scheme for colon injuries that is based on the patient's hemodynamic status, colon injury severity, and ATI scores. Primary repair by either debridement and simple closure or resection with primary anastomosis is advocated for colon injuries in patients who are hemodynamically stable with an ATI score less than 25.     

Evaluation of three methods for managing penetrating colon injuries.

Although primary intraperitoneal repair of selected penetrating colon injuries is a feasible method of treatment, injudicious use of this method, especially in wounds of the right colon, led to increased morbidity, in the group of 90 patients studied. Colostomy may be avoided in selected patients by using primary repair with exteriorization of the injured segment. The technique described is a reliable compromise which protects the patient from the danger of intraperitoneal suture line disruption and possibly avoids the inconvenience and morbidity of formal colostomy. Since exteriorized primary repair has been a safe, effective method of managing gunshot wounds of the colon in selected patients, we advocate its increased use.     

Successful repair of a penetrating wound of the thoracic aorta.

Penetrating wounds of the aorta are not necessarily fatal. A successfully managed patient with a stab wound of the ascending aorta is reported, and some problems of management associated with such injuries are discussed.     

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.     

Immediate results of the treatment of gunshot wounds of the large intestine

Under analysis were the strategy and results of treatment of 1264 patients with gunshot wounds of the colon. Isolated injuries of the colon were noted in 32.3% of the patients, 67.7% of the patients had combined wounds. The overall lethality was 12.1%. The methods of surgery were chosen depending on the character of the wounds.     

The role of primary repair for colonic injuries in wartime

BACKGROUND: The study reviewed an experience of selective primary repair for penetrating colonic injuries incorporating a number of procedures during the 1992-1995 Bosnia-Herzegovina conflict. METHODS: Of 5370 casualties, 259 (4.8 per cent) had injuries to the colon. The patients were divided into two groups: those who had primary repair and those who needed a colostomy. The patients' records were reviewed to determine the cause of injury (explosive weapons or bullets), the position and type of colon injury, associated injuries, the surgical procedure(s) done, complications related to the colonic wound or its management, and mortality. RESULTS: Some 122 (47.1 per cent) patients had primary colonic repair and 137 (52.9 per cent) had a colostomy. One hundred and fifty (57.9 per cent) were injured by explosive weapons, 108 (41.7 per cent) had bullet wounds and one (0.4 per cent) a stab injury. Associated injuries were seen in 249 (96.1 per cent) patients. Complications related to the colonic wound or its management developed in 27 per cent of patients after primary repair and 30 per cent after colostomy. Mortality rates were 8.2 per cent and 7.2 per cent, respectively. CONCLUSION: Primary repair was a safe and effective treatment for penetrating colonic injuries during war.     

Analysis of 178 Penetrating Stomach and Small Bowel Injuries

Surgical site infections (SSIs), such as wound infection, fascial dehiscence, and intraabdominal abscess, commonly occur following penetrating abdominal trauma. However, most of the literature involves penetrating colon injuries. There are few reports describing complications following penetrating stomach and small bowel injuries. Based on the hypothesis that SSIs are commonly found following penetrating stomach and small bowel trauma, a prospective observational study was performed at an academic Level I trauma center from March 1, 2004 until August 31, 2006. The subjects were patients who had sustained a penetrating injury to the stomach or small bowel. Patients were followed for the development of an SSI, defined as wound infection, fascial dehiscence, or intraabdominal abscess. A total of 178 patients were admitted with penetrating stomach or small bowel injuries over the 29-month period. There were 121 (68%) gunshot injuries and 57 (32%) stab wounds. Associated intraabdominal injuries occurred in 74% of patients. Overall, SSIs occurred in 20% of cases. Risk factors for SSI included associated duodenal or colon injury, whereas time to operating room, blood loss, and type and duration of antibiotic use were not. When associated colon injuries were excluded, SSIs occurred in 16% of patients with gastric injuries and 13% of those with small bowel injuries. SSIs commonly follow penetrating stomach and small bowel trauma. Risk factors for SSI include associated duodenal or colon injury. Delay to operating room, blood loss, and type and length of antibiotic prophylaxis were not associated with an increased risk of SSI.     

Penetrating pancreatic injuries. Analysis of 103 consecutive cases

The optimal management of penetrating pancreatic injuries continues to be a matter of debate and controversy. The present study analyzes 103 consecutive patients with these wounds treated at a level I Trauma Center in a 14-year period (1975-1988). Twenty-seven patients died within 48 hours from extensive associated trauma (Abdominal Trauma Index [ATI] 46.7). The majority of the remaining 76 patients were treated by debridement and drainage. Nineteen patients with grade III injuries had distal pancreatectomy. Six patients with extensive combined pancreatoduodenal injuries had pancreatoduodenectomy. Pancreatoenteric anastomoses or duodenal diversion procedures rarely were used. Pancreatic complications included major fistulas in four patients (5%) and pancreatic abscess in nine patients (11%). Only one of the fistulas required subsequent fistulojejunostomy. Intra-abdominal abscesses occurred in 18 patients (23.6%), mostly in patients with associated colon injury (P less than 0.001). It is concluded that a conservative approach to penetrating pancreatic injuries yields optimal results and that associated colon injury is an important predeterminant for abscess formation.     

Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center

Introduction: We present our experience in the management of penetrating pancreatic injuries, focusing on factors related to complications and death.

Methods: Retrospective trauma registry-based analysis of 62 consecutive patients with penetrating pancreatic injuries during an 11-year period. Overall injury severity was assessed by the injury severity score (ISS) and the penetrating abdominal trauma index (PATI). Pancreatic injuries were graded according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scaling (OIS). Complications were characterised using standardised definitions. Mortality was recorded as early (within 48 h after admission) and late (after 48 h).

Results: Thirty patients suffered gunshot wounds and 24 had grade I pancreatic injuries. Shotgun and gunshot wounds were more destructive than stab wounds (higher PATI, number of intraabdominal injuries and mortality). Seventeen patients died. Most deaths occurred within 1 h after admission due to massive bleeding and severe associated injuries. Only one death was potentially related to the pancreatic injury. Mortality rate also correlated with pancreatic injury grading. Sixty-one patients had associated intraabdominal injuries. Combined pancreaticoduodenal injuries were present in 13 patients, and five died. Simple drainage was the most common procedure performed. Pancreas-related complications were found in 12 out of 47 patients who survived more than 48 h; intraabdominal abscess (n=7) that was associated with colon injuries, and pancreatic fistula (n=5).

Conclusion: An approach based on injury grade and location is advised. Routine drainage is recommended; distal resection is indicated in the presence of main duct injury, and the management of severe injuries will be tailored according to the overall physiologic status, presence of associated injuries, and duodenal viability. Morbidity and mortality is mainly due to associated injuries.     

Occult diaphragmatic injuries caused by stab wounds

BACKGROUND: Missed diaphragmatic perforation caused by penetrating trauma can lead to subsequent strangulation of a hollow viscus, which has prompted the use of invasive diagnostic procedures to exclude occult diaphragmatic injuries in asymptomatic, high-risk patients. The objective of this study was to determine the incidence of occult diaphragmatic injuries caused by stab wounds of the lower chest and upper abdomen, and to examine the natural history and consequences of missed diaphragmatic injuries. METHODS: On the basis of patient data from two previous randomized studies from our institution, a retrospective analysis was performed on 97 patients treated for anterior stab wounds located between the nipple line, the umbilical level, and the posterior axillary lines not having indications for immediate surgical exploration. The patients were divided into two groups on the basis of their initial randomized management (open or laparoscopic exploration vs. expectant observation). RESULTS: In the exploration group (n = 47), four diaphragmatic injuries (9%) were detected (three left-sided and one right-sided). Excluding patients with associated injuries requiring surgical repair, the incidence of occult diaphragmatic injuries was 3 of 43 (7%). In the observation group (n = 50), there were two patients (4%) with delayed presentation of missed left-sided diaphragmatic injury 2 and 23 months later, respectively. Both injuries resulted from stab wounds of the left flank and presented with herniation of the stomach or small bowel and colon. The overall incidence of occult diaphragmatic injuries in left-sided thoracoabdominal stab wounds was 4 of 24 (17%), and was much lower after stab wounds of left epigastrium (0%), right lower chest (0%), and right epigastrium (4%). CONCLUSION: In asymptomatic patients with anterior or flank stab wounds of the lower chest or upper abdominal area, the risk of an occult diaphragmatic injury is approximately 7% which, if undetected, is associated with a high risk of subsequent hollow viscus herniation. Exclusion of an occult diaphragmatic injury with invasive diagnostic methods, such as laparoscopy or thoracoscopy, should be considered at least in left-sided stab wounds of the lower chest.     

Primary repair of colon wounds. A prospective trial in nonselected patients.

102 patients with penetrating intraperitoneal colon injuries were entered into a prospective study. Colon wound management was undertaken without regard to associated injuries or amount of fecal contamination. Primary repair was performed in 83 patients, segmental resection with anastomosis in 12, and resection with end colostomy in 7. There were no suture line failures in the primary repair group, and one suture line failure in the anastomosis group. The one failure was in a patient who underwent repeated explorations for bleeding before the leak occurred. The septic complication rate was 33% of the entire series and was unrelated to primary repair. Logistic regression analysis to identify risk factors for sepsis included transfusion greater than or equal to 4 units (p less than 0.02), more than two associated injuries (p less than 0.04), significant contamination (p less than 0.05), and increasing colon injury severity scores (p less than 0.02). The method of colon wound management, location and mode of injury, presence of hypotension (BP less than 90), and age did not significantly contribute to sepsis. We conclude that nearly all penetrating colon wounds can be repaired primarily or with resection and anastomosis, regardless of risk factors.     

The alternative to colostomy for the injured colon

In 34 patients with penetrating colon wounds which were considered to be liable to dehiscence, the sutured wounds were exteriorized. There were several 'high-risk' factors, i.e. operative delay of more than 6 hours after injury, faecal contamination of the peritoneal cavity, marked contusion of the bowel wall, and severe associated visceral haematoma which is deemed liable to infection. Additional considerations were thoraco-abdominal penetration and combined colonic and renal injuries. The operative technique is described in detail, and the morbidity of the procedure, which is low, is analysed. Comparison is made with a similar group of patients in whom colostomy was performed with subsequent closure. Exteriorization and closure of the penetrating colon wound appear significantly superior to colostomy in terms of mortality, septic complications and period of hospitalization.     

Shotgun arterial injuries of the extremities.

Even though shotgun injuries are often grouped with gunshot wounds, the former are ballistically and clinically far different from gunshot wounds. Two groups of patients with shotgun and gunshot wounds of the extremities, respectively, were compared with regard to clinical features. Although the vascular wound was the most dramatic aspect in both groups of patients, associated injuries, especially to the nerves and bones, played a significant role in the ultimate rehabilitation of the patients with shotgun wounds. Shotgun injuries more frequently required the use of saphenous vein grafts than did gunshot wounds. The infection and amputation rates were much higher in patients with shotgun wounds than in those with gunshot wounds. Patients with shotgun injuries of the extremities often required secondary reconstructive procedures such as tendon transfer or bone and joint fusion. Despite these measures the outlook for the ultimate rehabilitation of the extremity after shotgun injury was dismal, whereas after gunshot wounds complete rehabilitation was the rule.     

Analysis of fractures treated in the Royal Victoria Hospital, Belfast, in 1972, with special reference to gunshot wounds and bomb blast injuries

The total number of patients admitted to the Fracture Unit in the Royal Victoria Hospital in 1972 is recorded and classified according to cause.

Fractures resulting from gunshot wounds and bomb injuries are examined more closely together with associated injuries and complications. These groups are compared briefly with the open fractures resulting from road traffic accidents.

Treatment of fractures in gunshot wounds and bomb injuries is discussed.

Reference is made to the mechanisms of injury by gunshot and explosions.