Penetrating colonic trauma and damage control surgery: Anastomosis or stoma?

Abstract

Background: The management of colon injuries in damage control surgery (DCS) remains controversial. Methods: A retrospective study investigating outcomes of penetrating colonic trauma in patients who survived beyond the initial repeat laparotomy (IRL) after DCS was performed. Patients over 18 years with penetrating colon injury and who underwent DCS from 2012 to 2020 were included from our electronic trauma registry. Demographic data, admission physiology and Injury Severity Score (ISS) were reviewed. Patients were classified into three groups: primary repair of non-destructive injuries at DCL, delayed anastomosis of destructive injuries at IRL and diversion of destructive injuries at IRL. Outcomes observed included leak rates, length of intensive care unit stay, length of hospital stay, morbidities, mortality and colon-related mortality. Results: Out of 584 patients with penetrating colonic trauma, 89 (15%) underwent DCS. After exclusions, 74 patients were analysed. Mean age was 32.8 years (SD 12.5); 67 (91%) were male. Mechanism of injury was gunshot in 63 (85%) and stab 11 (15%) patients. Seventeen patients underwent primary repair at DCS, of which one leaked. Twenty patients underwent delayed anastomosis at IRL. Of these, five (25%) developed leaks. Mortality was significantly higher for those with an anastomotic leak compared to those without (p < 0.001). Thirty-seven patients were diverted at IRL. Overall mortality (p = 0.622) and colon-related mortality (p = 0.592) were not significantly different across groups. Conclusion: Delayed anastomosis at IRL following DCL was associated with a leak rate of 25% in this study. When anastomotic leak did occur, it was associated with significant mortality. Delayed anastomosis should only be undertaken in highly selected patients.

Gunshot bullet trauma of the colon in combat patients injured in hybrid period of Russian-Ukrainian war during 2014-2020

“…The overall rate of colostomy in our cohort is in contrast to other reports: Steele (33%), Glasgow ( (1,9,14,22,26). However, a similar proportion of colostomies was also reported by Cardi et al, showing it in 13.6% of the patients with colorectal wounds in case of high fecal spread or at damage control surgery (24).…”

“…As judged from the analyses of other series and our experience, there are multiple factors to play a role in surgeons' decision to choose a certain operative approach in each situation, including a colostomy. The observed proportion of colostomies could be attributed to severe colon trauma, which is in line with previously published series (14,15,20). We agree with other researchers suggesting avoiding colostomy and performing primary closure in selected patients with injury by shape-stable bullets (14,15,20).…”

“…Mortality is usually high in patients with gunshot colon wounds, mainly because of multiorgan injury and severe hemorrhagic shock (14). In our study, we showed lethal outcomes in 21.4% of patients which is close to data in studies of Oosthuizen et al who showed overall mortality of 26%, and Vertrees et al 29% of patients with gunshot wounds (10,15).…”

“…Similar to other reports we showed that majority of the patients were evacuated within the "golden hour" to Level II and treated according to with principle of damage control surgery, which is standard protocol for Ukrainian military medicine and in line with other studies of gunshot abdominal trauma (12)(13)(14)(15).…”

Gunshot bullet trauma of the colon in combat patients injured in hybrid period of Russian-Ukrainian war during 2014-2020

“…The observed proportion of colostomies could be attributed to severe colon trauma, which is in line with previously published series (14,15,20). We agree with other researchers suggesting avoiding colostomy and performing primary closure in selected patients with injury by shape-stable bullets (14,15,20). However, colon injury by the hollow-point bullets is associated with more severe trauma as showed by our results, thus decision to perform colostomy was made after evaluation of the abdomen in the context of damage control surgery.…”