A critical review of management of right colon injuries

[The role of enterostomy in the management of colonic injuries]

The circumstances, evaluation and results of the management of 67 colonic and rectal injuries during the period 1992-2003 in Clinical Centre of Podgorica are presented. In 32 war and 37 civilian injuries to colon, several systems of the severity trauma determination, as well as systems of grading and classification of injuries of colon were evaluated, and the surgical access according to achieved results was investigated in order to determine the use of enetrostomy in the management of these inuries. From the presented and statistically evaluated results, it can be concluded that Flintzs 3 grade classification can be used as the most reliable indicative and prognostic system. For the succes of One stage surgical procedure, the most critical fact is differentiation between Flintzs Grade I and II (Chi Square 4.514; P) as well between Grade II and III. That means that by using One stage procedure, unfavourable results may be expected not only in Grade II, but as well in border cases between II and III. Also, according to the presented results, there were not differences observed in the success of management between Grade II and III (Chi Square 0.678; P0.05). That means that using Two stage procedure, unfavourable results can be prevented not only in the borderline cases between Grades II and III, but also in the Grade III. Two stage surgical approach in the repair of injuried colon remains valuable and usefull surgical procedure, even in spite of success of surgical technology and operative technique, in cases with severe and multiple abdminal injuries, and in borderline decision making. These procedures are also inevitable in the management of any complication of primary repair of the colonic wound. Using rational evaluation and good surgical techniqe, primary repair of can be used in almost 50% of civilian and war injuries injuries of colon.

Surveyed opinion of American trauma surgeons in management of colon injuries

BACKGROUND

Primary repair or resection and anastomosis of colon wounds have been advocated in many recent studies, but the proportion of trauma surgeons accepting these recommendations is unknown.

OBJECTIVE

To determine the current preferences of American trauma surgeons for colon injury management.

METHODS

Four hundred forty-nine members of the American Association for the Surgery of Trauma were surveyed regarding their preferred management of eight types of colon wounds among three options: diverting colostomy (DC), primary repair (PR), or resection and anastomosis (RA). The influence of selected patient factors and surgeons' characteristics on the choice of management was also surveyed.

RESULTS

Seventy-three percent of surgeons completed the survey. Ninety-eight percent chose PR for at least one type of injury. Thirty percent never selected DC. High-velocity gunshot wound was the only injury for which the majority (54%) would perform DC. More than 55% of the surgeons favored RA when the isolated colon injury was a contusion with possible devascularization, laceration greater than 50% of the diameter, or transection. Surgeons who managed five or fewer colon wounds per year chose DC more frequently (p < 0.001) and PR less frequently (p < 0.001) than surgeons who managed six or more colon wounds per year.

CONCLUSION

The prevailing opinion of trauma surgeons favors primary repair or resection of colon injuries, including anastomosis of unprepared bowel. Surgeons who manage fewer colon wounds prefer colostomy more frequently.

Stab wounds of the anterior abdomen. Analysis of a management plan using local wound exploration and quantitative peritoneal lavage

A management plan for stab wounds to the anterior abdomen incorporating local wound exploration and quantitative peritoneal lavage was applied to 572 patients. One hundred eighty-five of these patients presented with shock, peritonitis, or evisceration and underwent immediate exploratory laparotomy with the finding of an intraperitoneal organ injury in 183 (99%). The remaining 387 patients with a negative physical examination underwent exploration of the stab wound to determine fascial penetration. Wound exploration was negative in 151 of these patients and they were discharged from the emergency room. Two hundred thirty-six additional patients had penetration of the fascia and underwent peritoneal lavage. Ninety-two per cent of patients with lavage counts greater than 50,000 had an intraperitoneal organ injury. No patients with lavage counts less than 1,000 red cells had an organ injury. Forty-three per cent of patients in the intermediate group (1,000-50,000 RBCs/mm3) had an organ injury and 59% included penetration of a hollow viscus. An approach incorporating local wound exploration and quantitative peritoneal lavage followed by exploratory laparotomy for red blood cell counts greater than 1,000 should result in less than 10% negative laparotomies and no missed injuries.

Comparison of penetrating injuries of the right and left colon

Controversy still exists whether penetrating injuries of the right colon have more favorably than those to the left. The importance of the issue rests in the operative management. This is a review of 50 cases of penetrating injuries of the right colon and 55 of the left treated at our institution from 1975 to 1980. The two patient groups were similar with respect to mechanism of injury, presence of shock at admission, degree of fecal contamination, severity of injury, and the percentage of cases with associated intra-abdominal injuries. The number of patients managed by primary repair or resection (52 vs. 45%), repair or resection with exteriorization (20 vs. 22%), and colostomy (28 vs. 33%) were also comparable in right versus left injuries. The treatment of right colon injuries resulted in 32% morbidity rate and 2% mortality rate, and that of left sided injuries 33% morbidity and rate of 4% mortality rate. These findings indicate that, despite known anatomic and physiologic differences, penetrating trauma to the right and left colon should be managed similarly.

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%), followed by the ascending colon (27%), rectosigmoid (19%), and descending colon (10%). 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% of the patients, with a resultant 19% rate of wound infection and 14% 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%) and serious complications (36%) as compared with end-colostomy and mucous fistula, which resulted in a 24% rate of wound infection and 24% rate of serious complication. The rate of wound infection between these groups is significant (p = 0.05). Results end-colostomy and mucous fistula were better than with attempted primary anastomosis.