Defining Outcomes after Colon Resection in Blunt Trauma: Is Diversion or Primary Anastomosis More Favorable?

Abstract

Previous literature demonstrates the safety of primary repair in penetrating colon injury requiring resection, without the creation of a diverting ostomy. It is unknown whether a similar approach can be applied to patients with blunt colon injury. The aim of this study was to measure outcomes in patients who underwent colon resection with and without ostomy creation after blunt trauma injury to help direct future management. Using the National Trauma Data Bank for years 2008 to 2012, we identified patients with blunt trauma mechanisms who underwent colectomy. Patients were stratified into two groups: primary anastomosis and diversion with ostomy. Primary outcome was inpatient mortality. Secondary outcomes included length of stay and perioperative complications. All risk-adjusted analyses were performed using logistic regression with consideration of interactions. Five hundred eighty-one observations met our inclusion criteria. Baseline characteristics between the two groups were similar with the exception of age (37.3 vs 42.2 years, P < 0.001) and admission Glasgow coma score (13.2 vs 12.1, P = 0.002). Risk-adjusted mortality for the two groups was not statistically significant (2.3% vs 3.0%, P = 0.63); however, patients with primary anastomosis had a shorter length of stay (18.2 vs 28.1, P < 0.001), fewer days in the intensive care unit (10.9 vs 16.2, P < 0.001), and fewer ventilator days (10.5 vs 14.6, P = 0.01). In patients requiring colon resection after blunt trauma, mortality is not different for those who receive a primary anastomosis versus ostomy. Patients without diversion had shorter hospital stays, intensive care unit days, and ventilator days. These data support that primary anastomosis is safe in this patient population.

Complete transection of the descending colon following blunt abdominal trauma

“…Demetriades et al 13 in their multicentre prospective study of 297 patients found that severe faecal contamination, transfusion ≥4 units with 24 hours or a single-agent antibiotic prophylaxis to carry significant risk for abdominal complications 13. Recently, Lasinski et al 14 in their multicentre retrospective study of 581 patients treated with either primary anastomosis after resection or with diverting colostomy did not have any difference in mortality, hence advocating for primary repair after resection 14…”

Anorectal emergencies: WSES-AAST guidelines

“…However, restoration of bowel continuity after a Hartmann's procedure is associated with significant morbidity and resource utilization and many of these patients do not undergo reversal surgery, remaining with a permanent stoma [274,275]. Given the absence of high-quality evidence in the specific population of AFB, we refer to the trauma literature [276][277][278][279] and to the WSES guidelines for the management of acute colonic diverticulitis [280] and for the management of iatrogenic colonoscopy perforation [281]: we suggest that a resection with primary anastomosis, with or without a diverting stoma, may be performed in otherwise healthy patients, with good tissue quality and without risk factors for anastomotic leakage, in case a primary suture is not feasible. On the other hand, Hartmann's procedure is suggested for the management diffuse peritonitis in critically ill patients and in selected patients with multiple comorbidities and risk factors for anastomotic leakage (i.e., requirement of vasoactive drugs, hemodynamic instability, corticosteroid therapy).…”