Improved Outcomes in Colon and Rectal Surgery part 40 pps

The next RCT examining this issue after the work of Stone and Fabian was not published until 1991 by Chappuis and colleagues.14 Although there are several methodological limita-tions, th

and that was reliable in the acute postinjury setting as opposed to

other etiologies for critical illness (i.e sepsis or major operation)

Three hundred sixty patients undergoing laparotomy for

pen-etrating trauma were the basis of this study Each intraabdominal

organ was assigned a weight in terms of potential for developing

complications, and a sub-grading from 1–5 based on severity of

the injury A PATI cutoff of 25 separated a substantial increase in

complication rates (17% vs 50% for stab wounds, and 12% vs

44% for gunshot wounds) Notably, this scale provided a basis

for the development of the Organ Injury Scale of the American

Association for the Surgery of Trauma (AAST)

In 1987, Dr Donald Trunkey, the president of the AAST at that

time, appointed the Organ Injury Scaling Committee to derive

an injury scaling system that unified several previously proposed

scoring systems for the purposes of conducting higher-quality

research, and to provide a common parlance amongst centers and

authors (Trunkey, DD, personal communication) This

commit-tee cites the results of 2 prior studies of penetrating colon injuries

(47, 48), in which scoring systems proved useful to guide

manage-ment, as support for creating this scoring system for all

abdomi-nal organs Their work utilized some of the structure of the PATI

proposed by Moore, as previously discussed The AAST Colon

Injury Scale is shown in Table 35.2.(49)

management of penetrating Colon injury

The argument for primary repair

The management of penetrating colon injury has undergone

sig-nificant changes during the past 50 years Today, primary repair is

considered the treatment of choice for most colon injuries Stone

and Fabian’s seminal paper set the stage for this strategy Earlier

authors recognized that a strategy mandated during wartime,

under combat conditions, and practiced by surgeons with

vary-ing levels of experience may not be applicable to modern civilian

conditions As an example, Pontius, Creech, and DeBakey (50)

reported their experience with 122 civilian colon injuries in 1957

They reviewed military series between WWII and the Korean

con-flict, noting a drop in mortality from 53% to 15%, and civilian

series during the same era, noting a drop in mortality from 62% to

14% These authors primarily repaired 83 colon injuries with 8%

mortality and diverted 36 colon injuries with 25% mortality They

acknowledge that primary repair was only attempted in patients

without extensive fecal contamination, complete destruction of a

segment of bowel or rectal injuries In addition, they note that, of

all survivors in both groups, there was a 20% complication rate,

including only 3 intraabdominal abscesses This complication rate

is similar to rates seen half a century later

The modern era of data supporting primary repair for pen-etrating colon injuries includes several randomized controlled tri-als (RCT) The next RCT examining this issue after the work of Stone and Fabian was not published until 1991 by Chappuis and colleagues.(14) Although there are several methodological limita-tions, this study was important in that it excluded only patients with rectal injuries and attempted to answer the question that Stone and Fabian did not address, which is whether primary repair was equivalent in more severely injured patients with a greater degree

of colon injury Stone and Fabian (9) excluded almost half of the patients with colon injuries due to preoperative shock, multiple organs injured, gross contamination, greater than 8 hours from injury to repair, blood loss >1 L, and destructive injury Chappuis and colleagues randomized 56 patients into either a primary repair

or a diversion group, with 28 patients in each group There were similar grades of colon injury (primarily grade III), PATI (26 and 23.9), transfusion rates (43% and 39%), complication rates (32% and 35%), and numbers of intraabdominal abscess (3 and 4) in the primary repair and diversion groups respectively However, the sample size was small, and the authors reported no statistics Although the PATI was indicative of severe intraabdominal injury, only four patients were admitted in hemorrhagic shock (defined as

a systolic blood pressure less than 80 mm Hg) Additionally, only

13 total patients (5 in the primary repair group and 8 in the diver-sion group) required more than 4 units of packed red blood cells (PRBC) Thus, although this series represented an unselected pop-ulation, the sample size was insufficient to conclude that primary repair is equivalent to diversion in severely injured patients Since these two reports, there have been four other RCT that support primary repair in most situations.(23, 25, 26, 51) Although Gonzalez and colleagues published the results of their first 109 patients in 1996 (24), the authors state that this study was continued in order to assess complication rates associated

Table 35.1 Flint grades of colonic injury.

1 Isolated colon injury, minimal contamination, 4% 0%

no shock, minimal delay

2 Through-and-through perforation, lacerations, 20% 20%

moderate contamination

3 Severe tissue loss, devascularization, heavy 25% 31%

contamination

a n = 137.

Table 35.2 AAST grades of colon and rectal injury.

Organ injury scale: Colon

I Hematoma Contusion/hematoma without 863.40 – 44

devascularization Laceration Partial thickness, no perforation 863.40 – 44

II Laceration Laceration <50% circumference 863.50 – 54 III Laceration Laceration ≥50% circumference 863.50 – 54

IV Laceration Transection of the colon 863.50 – 54

V Laceration Transection with segmental 863.50 –.54

tissue loss Vascular Devascularized segment 863.50 – 54 Organ injury scale: Rectum

I Hematoma Contusion/hematoma without 863.45

devascularization Laceration Partial thickness, no perforation 863.45

II Laceration Laceration <50% circumference 863.55 III Laceration Laceration ≥50% circumference 863.55

IV Laceration Full thickness laceration extending 863.55

into perineum

V Vascular Devascularized segment 863.55

a Advance one grade for multiple injuries to the same organ.

b .41 & 51 = Ascending; 42 & 52 = Transverse; 43 & 53 = Descending; 44 & 54 = Rectum.

with destructive injuries requiring resection and

anastomo-sis.(25) Table 35.3 summarizes the findings from these studies,

excluding the preliminary 1996 data generated by Gonzalez

Falcone et al (51), also had stringent exclusion criteria, and had a

small sample size of 22 patients The other studies excluded only

extraperitoneal rectal injury.(14, 23, 25, 26) Notably, Sasaki and

colleagues (23) noted more patients in shock defined as a systolic

blood pressure (SBP) <80 mm Hg (28% vs 4%), a higher degree

of gross contamination (60% moderate or heavy contamination

vs 25%), and more patients requiring more than 4 units of blood

(16% vs 4%) in the primary repair group as compared to the

diversion group The authors report that all of these comparisons

were statistically significant, although p values were not reported

Despite these differences, and despite similar PATI scores of

25.5 and 23.4 for primary repair and diversion respectively, they

found an increase in the likelihood of complications in the

diver-sion group (odds ratio of 1.99, p = 0.02) Using a multivariate

regression model, they analyzed the exclusion criteria of previous

studies (associated organ injury, shock on admission, fecal

con-tamination, location of colon injury, age, transfusion requirement,

delay of operation, extent of colon injury, abdominal wall loss, and mechanism of injury) as potential risk factors for complica-tions They found that only the PATI score was an independent predictor for complications but this was regardless of the type of repair Gonzalez et al (25) found no difference in complication rate, and noted that this lack of difference persisted when patients with a PATI >25 in each group were compared Kamwendo and colleagues (26) randomized 240 patients to diversion or pri-mary repair, and also further stratified these groups into those that underwent operation before and after 12 hours postinjury They found no differences in overall complication rate, mortality, number of patients in shock or requiring transfusion, or septic complications between the primary repair and diversion groups Further, they found no difference in complication rate between the early and late repair groups

Two meta-analyses have been published on this topic Singer and Nelson (22) published a systematic review of the litera-ture in 2002 They pooled data from five RCTs (9, 14, 23, 25, 51), totaling 467 patients The following year, the Cochrane Collaboration (21) pooled data from six RCTs, including five

Table 35.3 Randomized trials investigating primary repair versus diversion in colon injury.

Complication mortality

Stone (9) 1979 139 1% a 10% a 1.5% 1.4% Preoperative BP < 80/60 PR lower total and

BL > 1000 ml infectious complication

>2 organs injured rate

Gross contamination Excluded group: More Operation >8 hr post-injury infectious complications, Destructive injury higher mortality Loss of abdominal wall

Chappuis (14) 1991 56 32% 35% 0% 0% Extraperitoneal rectal 1 st study with broad

injury inclusion criteria

Low N in shock (3 PR,

1 Div) but PATI scores equivalent (26 & 24) Falcone (51) 1992 22 8/11 b 10/9 b 9% 0% Death < 24 hr post-injury Used intracolonic bypass.

Admit > 8 hr post-injury Operation at another institution Deemed inadmissible Sasaki (23) 1995 71 19% a 36% a NR NR Extraperitoneal rectal PR more shock, gross

injury contamination,

transfusions, left-sided

injury (p < 0.05)

PATI >25 independent risk for complications Div OR 1.99 for complications vs PR Gonzalez (25) 2000 176 18% 21% 2% 1% Extraperitoneal rectal PATI > 25 subgroup no

injury difference PR vs Div Kamwendo (26) 2002 240 37% 26% 0% 1.7% Extraperitoneal rectal Equivalent complication

injury rate PR vs Div:

• Overall

• Early vs late (cutoff 12hr post-injury) Note: PR = Primary repair, Div = Diverted, NR = Not reported, PATI = Penetrating Abdominal Trauma Index.

a Significantly different.

b Total number of complications was reported, p = 0.516.

c Reported as significantly different but no p values reported.

d Number randomized.

of the studies addressed in their prior meta-analysis (9, 14, 23,

25, 26, 51), comparing 361 patients in the primary repair group

with 344 patients in the diversion group They noted that the

PATI was reported in five of the six trials, and although

statisti-cal analysis could not be performed on this data, the primary

repair group had higher mean PATI scores (29 vs 26) Their

analysis revealed a lower overall complication rate in patients

undergoing primary repair The authors conducted a rigorous

analysis in which data that contributed to possible

heterogene-ity were excluded This resulted in a strengthening of the odds

ratio favoring primary repair When considering

intraabdomi-nal infection, there were no significant differences between the

two groups, although when sensitivity analysis was performed,

the remaining data generated an odds ratio (OR) that favored

primary repair (0.59, CI 0.37–0.94) Thus, meta-analysis showed

a decreased risk of complications, and an either equivalent or

lower risk of intraabdominal infection with primary repair Neither

analysis found any differences in mortality between the two groups,

with rates of <3% A summary of these 2 meta-analyses is

pre-sented in Table 35.4

Both meta-analyses were authored by Nelson and Singer, and

both were conducted in the same fashion by the authors The

Cochrane review included the report by Kamwendo (26), and

noted that these were the only data from outside the United States

Although differences in resources, transport time, and patient

population may have implications for including this data in the meta-analysis, similar findings amongst such a potentially differ-ent population support the generalizability of primary repair In general, these analyses do not include the complication rate from subsequent ostomy takedown

Injuries requiring resection and anastomosis

Current evidence clearly supports primary repair in the set-ting of uncomplicated colon injury defined as injuries easily repaired by direct suture, without significant devascularization

or a destructive component The summary of existing prospec-tive, randomized data suggests that this is the method of choice even in the setting of significant hypotension, high transfusion requirement, associated injury, gross contamination, and delay

to operation The issue of performing primary repair in the sub-set of injuries requiring resection and anastomosis is less clear The data still favor primary resection and anastomosis without proximal diversion in the sense that all of the RCTs classified these repairs as primary repair A review of these studies finds only 43 cases of resection and anastomosis without diversion

in 6 randomized studies, which is a potential source of type II error The most well-documented data in a randomized set-ting comes from Sasaki and colleagues (23), who noted patient characteristics, complications, and outcomes in the subset of

12 patient who underwent resection and anastomosis versus

Table 35.4 Meta-analyses investigating primary repair vs diversion in colon injury.

N (patients) 467 705 Patients analyzed in an intention to treat manner

Injury severity by PATI for PR 28.9 28.9 Only 4 trials (REFS) reported PATI

Variance not provided, thus statistical analysis could not be performed

PR included higher PATI patients Injury severity by PATI for Div 25.8 25.8

OR (CI) for mortality 1.7 (0.51 – 5.7) 1.22 (0.4 – 3.74) Mortality low for both groups (1.7-2.9%)

No heterogeneity among trials

OR (CI) for all complications 0.28 (0.18 – 0.42) 0.54 (0.39 – 0.76) P value for heterogeneity < 0.01

OR (CI) for all complications

(excluding heterogeneous study)

0.13 (0.08 – 0.23) 0.13 (0.08 – 0.23) P value for heterogeneity = 0.16

Study by Gonzalez, et al (REF) contributed the heterogeneity to the meta-analysis

OR (CI) for all infectious complications 0.41 (0.27 – 0.63) 0.44 (0.17 – 1.1) Including intra-abdominal abscess, anastomotic

leak, peristomal abscess, sepsis, wound infection, and abdominal wound dehiscence

OR (CI) for abdominal infection (including wound dehiscence) 0.59 (0.38 – 0.94) 0.67 (0.35 – 1.3) Including all of the above except sepsis.

Kamwendo study contributed heterogeneity OR values same as Singer review favoring PR when this trial excluded

OR (CI) for abdominal infection (excluding wound dehiscence) 0.52 (0.31 – 0.86) 0.69 (0.32 – 1.39)

OR (CI) for wound complications

(including wound dehiscence)

0.55 (0.34 – 0.89) 0.55 (0.34 – 0.9) Including peristomal abscess, wound infection, and

abdominal wound dehiscence

No heterogeneity among trials

OR (CI) for wound complications

(excluding wound dehiscence)

0.43 (0.25 – 0.76) 0.43 (0.24 – 0.77)

* When the heterogeneous study was excluded, the OR (CI) became 0.24 (0.14 – 0.40), favoring primary repair.

PATI= Penetrating abdominal trauma index, PR= Primary repair, Div= Diversion, OR= Odds Ratio, CI= 95% confidence interval.

31 patients who did not require resection, all within their

primary repair group When these data were independently

extracted and analyzed by chi squared analysis and Fisher’s

exact test, there were no differences between number of organs

injured (p = 1.0), proportion of patients in shock (p = 0.46),

presence of either moderate or heavy gross contamination (p =

0.31), proportion of patients needing more than 4 units of PRBC

(p = 0.38), left-sided injury (p = 0.75), proportion with PATI > 25

(p = 0.17), or number of complications (p = 0.67) As would be

expected, the mean PATI was greater in the resection subgroup,

although this was not statistically significant (29 vs 24) Also as

expected, the number of patients with Flint grade 3 injury was

higher in the resection subgroup versus the direct repair group

(92% vs 23%, p < 0.001) In their study, the primary repair group

as a whole was more ill than the diversion group Despite this, the

diversion group was twice as likely to develop complications as

compared to the primary repair group Within the primary repair

group, there were no differences between the resection and

non-resection groups Thus, the analysis above supports non-resection and

anastomosis without diversion Two caveats to this statement are

that the numbers of patients are small, and the study was not

powered to make this conclusion definitively

Demetriades et al (27), conducted a nonrandomized,

multi-center prospective review of 297 patients who sustained colon

injury that required resection One-hundred ninety-seven patients

underwent primary anastomosis exclusively and 100 patients

underwent diversion at 19 trauma centers The method of repair

was left to the discretion of the operating surgeon The authors

identified severe gross contamination, transfusion >4 units of

PRBC in the first 24 hours, and single agent antibiotic

prophy-laxis as independent risk factors for abdominal complications in

a multivariate regression analysis The presence of all 3 factors

was associated with a complication rate of 68%, 2 factors with a

rate of 17–38%, one factor with a rate of 17–21%, and none of

these factors with a rate of 13% Subsequently, two sets of analyses

were then conducted comparing primary repair with diversion,

the first controlling for these 3 independent risk factors, and the

second adjusting for ‘traditional’ risk factors commonly found in

the literature: hypotension (SBP < 90), transfusion >6 units of

PRBC, severe contamination, PATI >25, and delay of operation

>6 hours The authors found similar rates of abdominal

compli-cations between the 2 groups, no difference in complication rate

by location of repair (e.g ileocolostomy, colocolostomy,

ileos-tomy, colostomy), and no difference in hospital or ICU stay They

noted 24% and 22% overall rates of abdominal and

extraabdomi-nal complications respectively

One major limitation of this study was that the diversion

group had a higher incidence of delayed operation, shock at

admission, left colon injuries, PATI >25, small bowel and liver

injuries, transfusion requirement, and severe fecal

contamina-tion Further, the diversion group received antibiotics longer

than the primary repair group, although the median duration is

not reported However, the authors performed a separate

analy-sis controlling for these factors and again found no difference in

abdominal complications, hospital stay, or ICU stay They did

note an increased colon-related mortality with the diversion

group (4.5% vs 0%, p = 0.03), which translated to 4 deaths in

this group Thirteen patients in the primary repair group had an anastomotic leak, compared to one leak from a Hartmann pouch

No risk factors could be identified for leak within the primary repair group, and no patient died as a result of leak The authors concluded that method of colon management does not influence the development of colon-related abdominal complications, and primary repair should therefore be practiced for all injuries They also concluded that transfusion, severe contamination, and single agent antibiotic prophylaxis are independent risk factors associ-ated with complications

On the other side of this argument, several retrospective series have been published that present a caution to the concept of uni-form primary repair of all colon injuries As an example, Stewart

et al (52), published a follow-up study based on their previous experience with 95 direct repairs with no suture line complica-tions and an 11% incidence of abscess.(53) The authors changed their management strategy and repaired all injuries primarily, including destructive wounds requiring resection and anasto-mosis Forty-three patients undergoing resection and anastomo-sis and 17 undergoing colostomy were analyzed They noted no statistically significant difference in complication rate However, when comparing the 6 anastomotic leaks to 37 primary repairs that did not leak, they noted a 12-fold risk of leak in patients that had an underlying illness (e.g diabetes mellitus, cirrhosis, HIV infection) The need for transfusion was not significantly associ-ated with increased risk, but the combination of transfusion >6 units of PRBC and medical illness resulted in a 14-fold increased risk of leak The sample size was small, but the authors concluded that a 14% leak rate is excessively high Other limitations include

a shift in practice toward primary repair during the study period and inherent problems with determining underlying illness in the trauma population in general Although these reports are ret-rospective reviews of a relatively small number of patients, high transfusion requirement (commonly 4 or 6 units) consistently appears as a risk factor for complications.(27, 53) Results of the randomized trials previously discussed did not identify this as a risk factor for complications

Damage Control

Data concerning repair of colon injuries in the setting of damage control surgery (DCS) are scarce There are no randomized data, and literature that specifically describes the management of colon injury in the context of damage control surgery is limited to three reports analyzing 34 patients.(54–56)

Miller et al (54) retrospectively analyzed 17 patients who underwent DCS and subsequent delayed definitive repair of colon injury All patients had destructive colon injury, under-went abbreviated laparotomy at their initial operation, and were returned to the operating room after correction of acido-sis, coagulopathy, and hypothermia in the ICU Eleven patients underwent resection and primary anastomosis and 6 under-went diversion The authors compared the 11 anastomosis after DCS patients to 21 controls, who were patients with traumatic colon injuries undergoing anastomosis at initial operation There were no leaks in the DCS group and one in the initial

anasto-mosis group (p = 0.66) The abscess and colon-related mortality

were also similar As would be expected, the ISS and overall

mortality were higher in the damage control group The authors

then compared the 11 anastomosis after DCS patients to the other

6 patients, who underwent colostomy after damage control They

found no differences in ISS, abscess rate, colon-related mortality,

or overall survival

Chavarria-Aguilar et al (55) reviewed the management of

destructive bowel injury in the setting of the open abdomen The

data are heterogeneous, as patients with small bowel injuries are

included in the analysis Of 104 patients with destructive bowel

injury requiring resection and anastomosis, 29 underwent

tem-porary vacuum closure and the rest primary fascial closure Eight

patients with colon injuries underwent resection and delayed

anastomosis after initial packing Two leaks occurred, both from

small bowel anastomoses There were no differences in rate of

abdominal abscess between the anastomosis and stoma groups

in either the vacuum-closure group or the initial fascial closure

group, with rates of 7–21% These findings led the authors to

conclude that resection and anastomosis is safe in the face of

destructive injury and an open abdomen and should be

consid-ered in most patients The retrospective nature of the study did

not allow causality to be established, and the small sample size

did not allow for the identification of risk factors or appropriate

candidates for anastomosis versus ostomy

Finally, Johnson and colleagues (56) describe general changes

in DCS over an 8-year period and comment on 7 colonic

anasto-moses and 2 primary repairs They report one leak and 3 abscesses,

but do not specify if this was within the colon resection group or

the 13 small bowel resections performed

The authors of this chapter recently reviewed data collected

on soldiers undergoing damage control laparotomy in Operation

Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)

during 2005–2006 (unpublished data) We found a 51% rate of

concomitant colon injury, or 77 of 152 patients This is more than

twice the number of patients studied than in the existing

civil-ian literature The early colon-related complication rate (7 days

postinjury) was 14% These included 5 leaks, 3 abscesses, and

6 cases of ischemia on further evaluation requiring reoperation

Complications were essentially equally distributed among the

ostomy and anastomosis groups (p = 0.54) Results are

summa-rized in Table 35.5 Further, there were no differences in

compli-cations by location of injury (p = 0.58) There were no differences

in ISS between colostomy and no colostomy (all primary repairs)

and colostomy, direct repair, and resection and anastomosis

groups The colostomy group was more likely to have a massive

transfusion, but there were no differences in the complication

rate in any comparison Although follow-up is currently limited

to a mean of 7 days postinjury, data collection is ongoing These

results support the conclusion of Chavarria-Auguilar and

col-leagues (55), that even in combat settings with massive injury and

tissue loss, primary repair is feasible However, as discussed later

in this chapter, war injuries in combat situations may require

dif-ferent management than civilian injuries

Practice patterns

In an attempt to synthesize the diverse conclusions found in the

literature, Miller and colleagues (57) developed a clinical

path-way for destructive colon injuries in 1995 and compared patients

treated during this period with their experience before its imple-mentation Primary repair was undertaken in all colon injuries except patients with destructive injuries requiring >6 units of PRBC pre- or intraoperatively, or patients with significant under-lying medical illness These high-risk patients underwent diver-sion Two hundred nine patients in the clinical pathway group were compared to 60 prepathway patients The authors found no difference in abscess, anastomotic leak, or colon related mortality rates between the two time periods They also found no differ-ence in leak rates between anastomosis and direct repair groups after implementation of the clinical pathway, whereas there was

a higher leak rate in the resection group in the prior era Finally, they found that there was a reduction in the number of patients undergoing diversion from 31% to 9% This translates to a rela-tive risk reduction of 71%, an absolute risk reduction of 22%, and

a number needed to treat of 4.5 That is, for every five patients treated according to the pathway, one colostomy and subsequent takedown was avoided Further, there were no differences in com-plications with gross contamination, associated injury, or location

of colon injury These results suggest that the authors improved their patient selection for colostomy, and that destructive injury alone is not a contraindication to primary repair The notable corollary to this conclusion is that there was a role for colostomy

in their experience

summary

The treatment of penetrating colon injury has changed markedly

in the past 50 years Level I evidence supports primary repair (with-out diversion) of nondestructive injuries as the method of choice

in nearly all circumstances Specifically these circumstances include hypotension, gross contamination, high transfusion requirement, associated injury, and delay from injury to operative treatment Level I data also exists supporting primary repair for destructive injuries requiring resection and anastomosis but is more limited Transfusion requirement, gross contamination, and high penetrat-ing abdominal trauma index have been independently associated with infectious complications by a number of authors, but this has been regardless of the type of management (diversion or primary repair) Data regarding primary repair in the setting of damage

Table 35.5 Colon injuries in the setting of damage control surgery

during Operation Iraqi Freedom 2005–2006

Colostomy no colostomy (n = 44) (n = 30) p value

ISS a 24.7 ± 2.2 24.8 ± 3.2 0.98 Massive 25/44 8/30 0.02

transfusion (56.8%) (26.7%) Complications 9/44 4/31 0.54

(20.5%) (12.9%)

Colostomy direct repair anastomosis

(n = 44) (n = 10) (n = 20) p value

ISS a 24.7 ± 2.2 24.4 ± 3.8 24.9 ± 6.0 1.00 Massive 25/44 3/10 5/20 0.04

transfusion (56.8%) (30%) (25%) Complications 9/44 1/10 3/20 0.69

(20.5%) (10.0%) (15%)

a mean ± standard error of the mean.

control is even more limited, and no level I data exists However,

small series, including a recent large review of military injuries

sug-gests that primary repair is feasible in the damage control setting

No convincing data exist supporting diversion as superior to

pri-mary repair In severely injured patients, a reasonable strategy is to

initiate damage control techniques, including leaving the bowel in

discontinuity, and subsequently performing an anastomosis once

normal physiology is restored

A low threshold of suspicion is the key to diagnosis in most

cases Most injuries are found intraoperatively, and most are

uncomplicated Thus, primary repair is appropriate for the

major-ity of colon injuries As always, sound judgment, skilled

resuscita-tion, and attentive postoperative care are keys to good outcomes

The complication rate is high regardless of method of

manage-ment, and providers should be aware of this fact “… it cannot

be emphasized too strongly that the dangers of the abdominal

patient are not over when the last stitch has been put in Recovery

depends almost as much on the skill and the duration of the

after-care as on the operation itself.” (Ogilvie, 1944) (4)

Blunt colon injury

Colonic injury is uncommon after blunt abdominal trauma,

accounting for only 1–5% of blunt traumatic injury.(58) It is

notoriously difficult to diagnose, but a delay in diagnosis is

associated with significant morbidity including fatal peritonitis,

sepsis, and life-threatening hemorrhage.(59, 60) There are three

primary proposed mechanisms in the pathogenesis of blunt

colonic injury.(61) The first is crush injury between an object

such as a steering wheel, seat belt, or vertebral column Second,

shear injury occurs at points of fixation, particularly the sigmoid

mesentery Third, burst injury can occur when a closed loop is

formed at impact The resultant injury pattern is characteristic

and can include mural and mesenteric hematomas, partial

thick-ness tears, full thickthick-ness perforations, and transection at fixation

or contact points

Blunt colonic injury (BCI) is usually partial thickness, with

rare exceptions (3%) being full-thickness colonic perforations

(62) The most common cause is motor vehicle crashes, both

restrained and unrestrained.(62) The left colon is the most

fre-quently injured, followed by the right and transverse colon.(62)

The diagnosis of blunt colon injury is a diagnostic dilemma,

and requires a high index of suspicion In a retrospective

multi-center 5 year review of patients with BCI, the diagnosis was made

preoperatively only 5% of the time.(62) These injuries are often

diagnosed upon laparotomy for other indications, and although

rare, colon injury ranks 4th among injuries found at laparotomy

in blunt trauma patients.(60) Physical exam findings are

incon-sistent or manifest late after injury and the patient may be

diffi-cult to evaluate secondary to traumatic head injury, intoxication,

or distracting extraabdominal traumatic injury The presence of

a ‘seat-belt’ sign or a Chance fracture, as described previously, are

predictors of hollow viscus injuries Figure 35.1c demonstrates a

blunt colonic injury Nance et al (63) studied solid organ injury

as a predictor of hollow viscus injury in blunt trauma patients

They found that as the number of solid organ injuries increased,

the likelihood that a hollow viscus injury coexisted increased, up

to 34.4% in patients with three solid organ injuries

CT scan is currently the most utilized modality for the diagno-sis of blunt colonic injury.(33, 42) Findings suggestive of BCI on

CT include evidence of extraluminal air, extraluminal contrast material, bowel wall thickening, streaking of the mesentery, and free fluid in the absence of solid organ injury (Figure 35.1b) Williams et al (60) studied trauma patients with blunt colonic injury They evaluated the ability of physical exam, plain radiogra-phy, CT scan, FAST, and DPL to accurately detect BCI They found that no individual or combination of diagnostic tests was able to accurately detect BCI For example, the sensitivity of CT findings including free air, contrast extravasation, and free fluid had sensi-tivities ranging from 6–49% and positive predictive values between 50–72% Ultrasound examination had a sensitivity of 58%, speci-ficity of 44%, a positive predictive value of 61%, and a negative predictive value of 41% Physical examination findings such as the seat-belt sign, peritoneal signs, and abdominal pain performed similarly, with sensitivity between 21 and 59% and positive predic-tive values between 57 and 63% Diagnostic peritoneal lavage had

a sensitivity of 97% but a specificity of 13%, a positive predictive value of 55% and a negative predictive value of 80%

Malhotra et al (41) evaluated the accuracy of CT scan in the diagnosis of blunt bowel injury They found the sensitivity and specificity of CT for these injuries was 88.3% and 99.4%, respec-tively, with an accuracy of 99.9% The positive and negative predictive values were 53.0% and 99.9%, respectively The most common finding they reported associated with BCI was unex-plained free fluid Yegiyants and colleagues (64) found 14 cases

of blunt injury with free fluid on CT scan but no evidence of solid organ injury (0.5% of admissions in their review) Eleven

of these patients (74%) required laparotomy, with hypotension (3 patients) and peritoneal signs (6 patients) being the two most common triggers In their series, physical exam was predictive

in 43% and FAST exam was positive in 50% It is possible that the addition of laparoscopy may aid in the management of blunt colonic injuries As previously noted, Ahmed (44) and Mitsuhide (45) report the avoidance of between 21–75% of laparotomies in blunt abdominal trauma

Figure 35.1c Intraoperative findings in a patient with a “seat-belt sign” The

patient sustained a hematoma in the cecal mesentery and a serosal tear in the sigmoid colon which was primarily repaired.

summary

The management of blunt small bowel injury is relatively

straightforward, requiring mainly primary repair or resection

and anastomosis.(65) Blunt colonic injury is more complex In a

comprehensive review of the pathophysiology and management

of blunt bowel and mesenteric injuries, Hughes and Elton (65)

suggest that most blunt colonic injuries should be categorized

as high grade (AAST grade V or Flint grade 3, Tables 35.1 and

35.2) and treated accordingly A high index of suspicion,

experi-ence, and appropriate follow-up are the cornerstone to the

diag-nosis of this uncommon injury Currently, physical exam, and

CT scanning appear to be the most used methods of diagnosis

Laparoscopy may be a useful adjunct to diagnosis Devascularized

mesentery presents a challenging problem The viability of the

bowel should be assessed if in question and resected if indicated

In cases of severe injury a second look may be considered to

assess for progressive ischemia Once diagnosed, the treatment of

blunt colonic injury should follow the guidelines for penetrating

colonic injury

Outcomes of colostomy closure

Only one RCT included subsequent colostomy takedown in the

primary analysis Chappuis et al (14), reported 22 closures out of

28 patients in the diversion arm of their RCT with one

complica-tion (4.5%), an enterocutanous fistula after ileostomy reversal The

absence of good follow-up limits the conclusions that can be made

from this study It is thus debatable whether this is an appropriate

analytical strategy, in that initial management is a separate issue

from colostomy closure However, the risk of subsequent colostomy

reversal should be considered when the decision to proceed with

diversion is made This topic is well represented in the literature,

with a wide array of heterogeneous conclusions made Differences

in conclusions are due to varied definitions of complications and

infections, the inclusion or exclusion of rectal injury, varied

indica-tions for original diversion (trauma, cancer, etc), and the

retrospec-tive nature of published data.(66–70) Mortality as a consequence

of colostomy reversal is sufficiently low (0–3%)(69) that most

authors report infectious complications as their primary endpoint

Further, infectious complications remain the major source of

mor-bidity after wounding of the abdominal cavity.(71)

Two series reviewing stoma closures after diversion for any

indication found complication rates of 20–36%.(66,69) These

rates are similar despite the reports being separated by 20 years

Factors associated with increased complications range from

reversal performed in less than 90 days (66), diverting versus loop

colostomy (66), age >55 (69), and use of a silicone drain.(69)

While the data is heterogeneous, conclusions that can be made

are that colostomy reversal is associated with a high complication

rate of approximately 20–30%, and that some retrospective data

seem to suggest an increase in complications with diversion (68,

70) which supports at least consideration of primary repair in

almost all cases and a more selective use of diversion than what

has been taught in previous years

Military perspective

The recent military conflicts in Iraq and Afghanistan have raised

questions about the applicability of the civilian experience to

combat settings and war injuries In light of this conflict a brief overview of the impact that active wartime has had on trauma surgery—and colon injury specifically—is worthwhile

There is a long history of the lessons of war having a deep and lasting impact on civilian surgical management One of the clas-sic papers in the trauma literature is Ogilvie’s account of mili-tary surgery during World War II.(4) Although this is the paper most often cited as the impetus behind mandatory colostomy, it describes many classic precepts that were not widely recognized until much later decades Ogilvie’s paper is remarkable both for his foresight but also the number of principles he describes These include: the ‘trimodal’ peaks in trauma mortality, damage control, massive transfusion, ARDS, abdominal compartment syndrome, and many of the logistical issues later incorporated into both military and civilian trauma programs

Ogilvie reports a 60% mortality rate from colon inju-ries Direct suture repair resulted in a 44% mortality rate as opposed to 45–65% for colostomy with and without resection However, 2 of 2 patients who underwent resection and anas-tomosis died He attributes the lower mortality with suture repair to less severe injury but nevertheless makes no recom-mendation about selective repair in these cases Further, he acknowledges the beneficial effects that antibiotics, improved logistics, and liberal use of blood products had on outcomes Despite these other factors, he strongly advocates for colos-tomy in all cases and states that it is “perhaps the greatest sin-gle factor in the improved results we are able to record” It is likely that a mandate and automatic action were preferred in the face of the challenges involving resources, evacuation, and ever-changing groups of surgeons of vastly different levels of training and experience This can be seen in his assertion that

“the forward surgeon must have good hands, a stout heart, and not too much philosophy He is called upon for decision rather than discussion, for action rather than a knowledge of what the best writers think should be done”

Perry and colleagues (2), in a comprehensive review of the military management of colon injury, describe its evolution throughout modern history Before World War I, laparotomy was discouraged and observation afforded the wounded soldier the best chance of survival Laparotomy and rapid evacuation dur-ing WWI saw a dramatic decrease in mortality from abdominal injuries from almost 90% to 40% The changes wrought during WWII have been detailed previously During the Korean War, air superiority led to improvements in evacuation Further, the practice of exteriorization, in which the repaired colon was mobi-lized and brought out above the skin for observation, was largely abandoned Finally, some leeway in the primary repair and anas-tomosis of right colon injuries was allowed These factors led to

a further decline in colon-related mortality from 35% to 16% Aside from well-documented advances in resuscitation and criti-cal care, the Vietnam War saw improvements in evacuation and antibiotics, as well as more location-specific trends in colon man-agement Left-sided wounds were diverted, while recommenda-tions for right-sided wounds included resection and primary anastomosis, exteriorization, and resection, ileostomy and mucus fistula During this time mortality dropped to around 10% Perry and colleagues stress that the best results with primary repair

are obtained by surgeons experienced in this strategy and when

patients remain under the care of the same surgeon

Hudolin and Hudolin (72) reviewed their experience during

the Bosnia-Herzegovina conflict in 1992–1995 Two-hundred

fifty-nine patients with colonic injury were treated at a single

receiving facility with no radiologic capability and a single field

generator Rapid evacuation made long-term follow-up

impos-sible Roughly equal numbers of patients were treated with

pri-mary repair and colostomy (47% and 53% respectively) Overall

mortality was 7.7% in both treatment groups There were no

dif-ferences in associated injuries, or mechanism of injury

(explo-sive or gunshot) between groups Overall complication rate was

similar between groups (27% for primary repair and 30% for

colostomy) The authors did not perform statistical analysis on

individual complications, citing low numbers, but there were

more leaks in the primary repair group (8 vs 2) and fewer wound

complications (7 vs 15) These authors also cite surgeon

experi-ence as an important factor in management with primary repair,

but conclude that it is safe even with subsequent rapid evacuation

if treatment is undertaken soon after injury and with

administra-tion of perioperative antibiotics

Steele and colleagues (73) reviewed the treatment of 175

patients during the 2003–04 period of OIF Primary repair was

undertaken in 53%, the leak rate was 10%, and overall mortality

was 17.7% Only 37% of patients were United States or coalition

forces and the rest were local nationals Mean ISS and AIS were

similar among different regions of the colon Stomas were more

frequently performed for rectal or anal sphincter injuries than

colonic injuries, and for left-sided versus right-sided or

trans-verse injuries Leaks after primary repair were equally distributed

throughout the colon Although the leak rate was higher in the

primary repair group, there was no difference in rate of sepsis

or mortality between groups on multivariate analysis Only ISS

>15 was associated with an increase in sepsis, while only rectal or

transverse injuries were associated with an increase in mortality

Follow-up is not reported likely due to rapid evacuation and the

high proportion of local nationals included in the study

We conducted a review of colon injuries sustained during

OIF during 2005–2006 (unpublished data) One hundred

thirty-three patients with colon injuries were admitted from Iraq and

Afghanistan to Landstuhl Regional Medical Center (LRMC) in

Landstuhl, Germany, the tertiary referral center for combat

casu-alties in this theater The average time spent in the three echelons

of combat care facilities (battalion aid station, forward surgical

team, and combat hospital) was 2 days and the average time spent

at LRMC was 4.7 days, translating to about 7 days from injury

to echelon V (tertiary US military hospital) care in the United

States Anatomic distribution of injury is depicted in Table

35.6 Primary repair or resection and anastomosis was the

ini-tial method of treatment in 34%, colostomy in 45%, and

dam-age control consisting of bowel left in discontinuity in 21% The

complication rate was 12% overall and was not related to type

of management (p = 0.172) Complications were linked to open

abdomen (p = 0.031), increased ICU days (p = 0.015), gunshot

wound (p = 0.021), and number of procedures before admission

at LRMC (p = 0.008), but not LOS, ISS, mechanism, location of

injury, or massive transfusion These results are limited by the lack

of long-term follow-up Data collection from US sites is ongoing, however, and will be the subject of future publications

summary

These examples demonstrate that the use of primary repair in military series is lower than reported in the civilian literature (27, 57) Contributing factors include varied training and per-sonal philosophy of treating surgeons, higher number of dam-age control procedures performed, and higher incidence of rectal injury, which in turn results from the contribution of blast and high-energy mechanisms of injury These differences in combat trauma contribute to the active debate on the method of choice,

as is evidenced by recent publications by authors deployed to OIF calling for an expanded role for diversion.(74, 75) To date, how-ever, the experience has been limited to small series and expert opinion Larger series previously described currently lack long term follow-up The bulk of the data seems to support primary repair

Antibiotic therapy

As previously mentioned, infectious complications are the major source of morbidity after abdominal trauma.(71) Infection is a major contributor to the third peak in the ‘trimodal’ distribution

of trauma mortality, which was recognized by Ogilvie in 1944 (4) and described by Trunkey in 1982.(76) Causes can be sepa-rated into two broad categories, those related to the patient or the disease process and those related to treatment The latter are the modifiable factors

A number of disease-related factors have been reported to contribute to infectious complications In a recent, comprehen-sive review of the literature addressing infections in penetrating abdominal trauma, Fabian (71) describes colon injury, rate of transfusion, shock (generally SBP < 90 mm Hg), and PATI >25

as well-investigated independent risk factors Treatment related factors include careful attention to measures that contribute to improved outcomes in the trauma and critically ill population in general; aggressive efforts to achieve normothermia (77), correc-tion of coagulopathy and acidosis, euglycemia (78), minimiza-tion of transfusions (79–81), and careful attenminimiza-tion to nutriminimiza-tion (82–85)

Choice, timing, and duration of antibiotic therapy have been well studied and deserve a brief comment The efficacy of prein-tervention versus posttreatment (postoperative) therapy is well established.(85, 86) In addition, the choice of antibiotic does not seem to matter as much as the adequacy of anaerobic and gram-negative coverage The only study that appeared to have generated

Table 35.6 Anatomic distribution of colon injuries during

Operation Iraqi Freedom 2005–2006

a Totals exceed 100% due to multiple injuries in some patients.

data favoring multiple agent therapy was the prospective

nonran-domized study of colon injury requiring resection and

anastomo-sis conducted by Demetriades and colleagues that was discussed

previously.(27) In this report, single agent antibiotic therapy was

an independent risk factor for abdominal complications, with an

RR of 1.89 (p = 0.004) and an RR of 1.12 when adjusted for

trans-fusion of 4 or more units of PRBC, severe fecal contamination, or

method of colon injury management However, the most recent

guidelines published by the Surgical Infection Society in 2002

rec-ommend 24 hours of organism-specific coverage in instances of

peritoneal contamination due to traumatic bowel injury repaired

within 12 hours.(87) There is sufficient class I evidence to

recom-mend 24 hours of an appropriate antibiotic for the minimization

of infectious morbidity in colon trauma.(88–90)

Bozorgzadeh et al (88) randomized 300 patients to either

24 hours or 5 days of therapy with cefoxitin after penetrating

abdominal injury There were no exclusion criteria and patients

with colon injury (32%), shock on admission (31%), and multiple

abdominal organ injuries (19%) were included The overall

infec-tion rate was 25%, while deep surgical site infecinfec-tions occurred in

6% There were no differences in complications or length of stay

between groups In addition, multivariate analysis found only

colon injury to be independently associated with infection and

increased length of stay One limitation of this study was that the

5 day group had a higher incidence of intraoperative shock,

mul-tiple organ injury, and intraoperative blood loss

Cornwell and co-workers (89) randomized patients with

full-thickness, penetrating colon injury and one risk factor consisting

of PATI>25, transfusion of 6 or more units of PRBC, or greater

than 4 hours from injury Sixty three patients were randomized

to either 24 hours or 5 days of cefoxitin therapy There were no

differences in severity of injury or other baseline characteristics,

infectious complications, length of stay, or mortality Overall

abdominal infection rate was 29% and overall mortality was

9.5% Although the sample size was adequate by power analysis,

there were a small number of patients in each group

Kirton and colleagues (90) performed a multicenter, double

blinded, placebo-controlled RCT in which 317 patients with

pen-etrating hollow viscus injury were randomized to receive either

24 hours of ampicillin/sulbactam followed by 4 days of saline

placebo, or 5 days of antibiotic therapy The proportion of colon

injuries (50%), AAST grade of colon injury, distributions of solid

organ injury, ISS, PATI, and infection rates were similar in each

group The overall infection rate was 19%, with 9% surgical site

infections Mortality was 1.6% overall On multivariate

analy-sis only total number of PRBC transfused and PATI >25 were

independent contributors to infectious complications Both the

Cornwell and Kirton studies identified gram-negative bacilli as

the most common isolates

Although this topic has been well studied, the demonstrated

risk of infection with colon injury may predispose some

prac-titioners to inappropriately prolong the duration of antibiotic

therapy The rising incidence of resistant bacterial strains makes

this a critical issue Adherence to evidence-based guidelines and

support on an individual, practice, hospital, and national level is

essential in minimizing the incidence of multiply resistant

noso-comial infections

Retained fragments

The traditional teaching regarding retained fragments is that they should be left in place unless they traverse the colon, in which case they should be removed and the tract debrided Data regard-ing this subject is scarce For example, four reports specifically addressing infectious complications after missile injury to the colon have been published since 1990.(91–96) Sarmiento and colleagues, who report the largest experience on this subject, reference six other publications on this topic since 1892.(93) Flint et al (95) reported a series of seven patients with gun-shot wounds through the colon who developed abscesses, two of whom died (28%) They noted that abscess culture revealed E Coli, Klebsiella, Bacteroides, and pseudomonal species in every case, leading to the conclusion that contaminated material was inoculating the wound tract, and that retained fragments should

be removed Based on a small series, Flint refuted the belief held

at that time that bullets and missile tracts were sterile due to the heat and friction generated by the projectile.(91) Poret (91) reviewed 151 patients with gunshot wounds traversing the colon and found a 26% rate of septic complications when the bullet or fragment was retained and a 16% rate when there was no retained

fragment (p = 0.15) Although not statistically significant the

authors note clinical significance, and conclude that the retained missile is a nidus for infection

In contrast, Demetriades and Charalambides (92) reviewed their experience with 84 patients with gunshot wounds to the abdomen traversing the colon Bullets were removed only if they were pal-pable In 48% of patients the bullet was retained, while in 52% it was either removed or had exited the body The two groups were matched in severity of injury, site of injury, number of colonic per-forations, and method of repair (primary versus colostomy) The overall abdominal complication rate was 14% and the incidence of missile tract infection was 4% with no differences between groups Antibiotics were given for 48 hours The authors concluded that missiles should only be removed if they are easily palpable Edwards

et al (93) studied the effects of low-velocity, small-fragment injury

in a porcine model designed to simulate injury from antipersonnel devices in combat They fired steel fragments through the unpre-pared colons of swine into a gelatin medium, then cultured several points along the missile tract, as well as the fragment itself No cul-ture reached 1 × 105 organisms and average tract size was 5 cm long

by <1 mm in diameter The authors concluded that small-fragment removal and debridement of wound tracts would not present an increased risk of infection if antibiotics were administered soon after injury

Sarmiento et al (93) retrospectively reviewed 185 patients who sustained gunshot wounds in which the bullet had traversed the colon and extraperitoneal soft tissue only The decision to extract the bullet was according to the discretion of the operating sur-geon at the time of initial laparotomy There was a fivefold lower incidence of infection in those in whom the bullet was extracted

compared to retained (5% vs 25%, p = 0.06) They also found no

difference in risk of infection for injuries that traversed the right and transverse colon compared to the left colon and rectum

In summary, the evidence is sparse on this topic, but seems to sup-port extraction of bullets, debridement of wound tracts and early antibiotic administration with retained fragments that traverse the

colon and embed in soft tissue This is consistent with the basic

gen-eral surgical principle of not leaving foreign material in the presence

of the open gastrointestinal tract Small-fragment injury poses an

additional problem, in that debridement of multiple small-diameter

tracks may be a significantly morbid procedure.(94)

Rectal injury

The classic components of managing rectal injury include the

three (or sometimes four) D’s: diversion, presacral drainage,

dis-tal recdis-tal washout, and sometimes direct repair.(30, 96) These

maneuvers were established during WWII and the Vietnam war

(2), and were credited with decreasing mortality from 67%

dur-ing WWI to essentially zero durdur-ing the Vietnam war, and

decreas-ing morbidity from approximately 70% to 10% durdecreas-ing the same

period.(1, 30, 96) Mortality in recent series is low In a review

of 39 civilian studies, Merlino and Reynolds (96) identified 42

deaths in 1105 patients with rectal injury, 10 of which (0.9%)

were attributed to the rectal injury itself They also report a range

of 1.3 to 4.5 associated injuries per patient, making associated

injury the rule rather than the exception Genitourinary injury is

the most commonly associated injury given the anatomic

prox-imity of these organs

The rectum is protected by the bony pelvis and soft tissue,

which makes injury less frequent, but exposure more difficult It

is mostly accessible from the anus but is only covered by

peri-toneum along its proximal one-third and anteriorly along the

middle one-third, facilitating both repair and intraperitoneal

contamination Penetrating injury accounts for 85% of reported

injuries, with the majority of these being gunshot wounds.(96)

A rare source of rectal injury is iatrogenic perforation, which

reportedly occur in approximately 0.1–0.2% of cases.(97, 98)

Diagnosis

Rectal injuries present a diagnostic challenge Injuries to the

bony pelvis should be rapidly diagnosed, and an unstable

pel-vis should be addressed first Careful perineal and digital rectal

examination is the next step and should be accompanied by a

high clinical suspicion with risk factors outlined in Table 35.7

Sphincter tone and injuries to the sphincter complex should be

carefully noted at this point as well Digital rectal exam has a

reported accuracy of 64–96%.(99–102) Sigmoidoscopy (blood

or lesion visualized) for the diagnosis of rectal perforation

has an accuracy of 89–100%.(99–101, 103, 104) Blood on

digital exam is an indication to further assess the rectum either

by proctoscopy or sigmoidoscopy.(103, 104) Intraluminal hem-orrhage identified by endoscopy should lead to the presump-tive diagnosis of rectal injury and management should follow accordingly.(102–104) Contrast-enhanced CT scan and contrast studies are useful adjuncts in equivocal cases.(105) Diagnostic laparoscopy has been described for hemodynamically stable patients with evidence of extraperitoneal rectal injury (blood

on rectal exam and proctoscopy), no peritonitis, and no intra-peritoneal injury.(103, 106, 107)

Management

Traditionally, the cornerstone of rectal injury management is fecal diversion.(96) In distinction to colon injury, diversion is more often indicated for rectal injury This is partly due to a lack of class I data confirming the safety and feasibility of primary repair alone with rectal injuries, combined with increased difficulty in dissection and exposure, as well as lack of a serosa for much of its extent.(104) Overall mortality rates are low, between 0–9% (99–104, 108–111), including six modern series published since 1996 with a <2% death rate The infrequency of this injury makes it unlikely that an RCT with sufficient power will be performed The safety of colostomy in rectal injuries has been documented In a review of complications related to colostomy, Berne and colleagues (68) reported a 55% inci-dence of complications when colostomy was performed for colon injury versus a 13% incidence when performed for rectal injury

A number of reports have challenged the routine practice of distal irrigation and presacral drainage (101, 103, 108, 110–112), the majority of which cite the differences between civilian and military penetrating trauma as the primary indication for devia-tion from the classic teaching

Only one RCT exists on this topic, conducted by Gonzalez and colleagues.(110) Forty-eight patients were randomized to diver-sion and either presacral drainage or no drainage Distal irriga-tion was not performed on any patient There was no mortality attributable to rectal injury, and complications occurred in two patients in the drainage group and one in the nondrainage group

(p > 0.05) The authors acknowledge that their study was

under-powered to detect a difference in complication rates Others have argued that with unrepaired extraperitoneal injury the risk of overwhelming pelvic sepsis developing within a closed space is high, and in this case presacral drainage is indicated.(96, 108) In the absence of convincing data, this argument represents a rea-sonable approach

Distal washout has largely been abandoned, as many authors have consistently failed to demonstrate any advantage to its use Most authors cite the difference between high-energy, military rectal wounds, and lower-energy civilian injuries as the pri-mary difference in results between the original reports from the Vietnam war and contemporary experience (96, 101–104, 108, 110) There may be a role for distal irrigation in wartime and with injuries resembling combat injuries

One useful convention is to approach rectal injury along ana-tomic lines Intraperitoneal injury can be safely treated in a simi-lar fashion to colon injury, as several authors have demonstrated the feasibility of primary repair without proximal diversion.(96,

101, 108) The exception is in the case of extensive contamination and tissue loss, for which most authors divert the fecal stream

Table 35.7 High-risk factors for rectal injury.

Gunshot wound to pelvis, buttocks, lower back or abdomen

Wound in which injury tract is directed caudad

Penetrating gluteal injury

Blast injury to perineal area

Complex perineal laceration

Pelvic fracture

Lower genitourinary tract injury

Sexual assault

Erotic anal penetration

Gross blood per rectum

High-energy blunt injury to lower abdomen