Colostomy in penetrating colon injury: is it necessary?

Bowel Preparation Before Nonelective Sigmoidectomy for Sigmoid Volvulus: Highly Beneficial but Vastly Underused

BACKGROUND

Although strong evidence exists for combined mechanical and oral antibiotic bowel preparation before elective colorectal resection, the utility of preoperative bowel preparation for patients undergoing sigmoid resection after endoscopic decompression of sigmoid volvulus has not been previously examined. The goal of this study was to evaluate the association between bowel preparation and postoperative outcomes for patients undergoing semielective, same-admission sigmoid resection for acute volvulus.

STUDY DESIGN

Patients from the 2012 to 2019 Colectomy-Targeted American College of Surgeons NSQIP dataset who underwent sigmoid resection with primary anastomosis after admission for sigmoid volvulus were included. Multivariable logistic regression was used to compare the risk-adjusted 30-day postoperative outcomes of patients who received combined preoperative bowel preparation with those of patients who received either partial (mechanical or oral antibiotic alone) or incomplete bowel preparation. Effort was made to exclude patients whose urgency of clinical condition at hospital admission precluded an attempt at preoperative decompression and subsequent bowel preparation.

RESULTS

Included were 2,429 patients, 322 (13.3%) of whom underwent complete bowel preparation and 2,107 (86.7%) of whom underwent partial or incomplete bowel preparation. Complete bowel preparation was protective against several postoperative complications (including anastomotic leak), mortality, and prolonged postoperative hospitalization.

CONCLUSIONS

This study demonstrates a significant benefit for complete bowel preparation before semielective, same-admission sigmoid resection in patients with acute sigmoid volvulus. However, only a small percentage of patients in this national sample underwent complete preoperative bowel preparation. Broader adoption of bowel preparation may reduce overall rates of complication in patients who require sigmoid colectomy due to volvulus.

Outcomes of Primary Repair and Anastomosis for Traumatic Colonic Injuries in a Tertiary Trauma Center

Background: Surgical management for traumatic colonic injuries has undergone major changes in the past decades. Despite the increasing confidence in primary repair for both penetrating colonic injury (PCI) and blunt colonic injury (BCI), there are authors still advocating for a colostomy particularly for BCI. This study aims to describe the surgical management of colonic injuries in a level 1 metropolitan trauma center and compare patient outcomes between PCI and BCI. Methods: Twenty-one patients who underwent trauma laparotomy for traumatic colonic injuries between January 2011 and December 2018 were retrospectively reviewed. Results: BCI accounted for 67% and PCI for 33% of traumatic colonic injuries. The transverse colon was the most commonly injured part of the colon (43%), followed by the sigmoid colon (33%). Primary repair (52%) followed by resection-anastomosis (38%) remain the most common procedures performed regardless of the injury mechanism. Only two (10%) patients required a colostomy. There was no significant difference comparing patients who underwent primary repair, resection-anastomosis and colostomy formation in terms of complication rates (55% vs. 50% vs. 50%, p = 0.979) and length of hospital stay (21 vs. 21 vs. 19 days, p = 0.991). Conclusions: Regardless of the injury mechanism, either primary repair or resection and anastomosis is a safe method in the management of the majority of traumatic colonic injuries.

Article Commentary: Evolving Colon Injury Management: A Review

The colon is the second most commonly injured intra-abdominal organ in penetrating trauma. Management of traumatic colon injuries has evolved significantly over the past 200 years. Traumatic colon injuries can have a wide spectrum of severity, presentation, and management options. There is strong evidence that most non-destructive colon injuries can be successfully managed with primary repair or primary anastomosis. The management of destructive colon injuries remains controversial with most favoring resection with primary anastomosis and others favor colonic diversion in specific circumstances. The historical management of traumatic colon injuries, common mechanisms of injury, demographics, presentation, assessment, diagnosis, management, and complications of traumatic colon injuries both in civilian and military practice are reviewed. The damage control revolution has added another layer of complexity to management with continued controversy.

Gunshot wounds to the colon: predictive risk factors for the development of postoperative complications, an experience of 172 cases in 4 years

BACKGROUND

In our study, we have defined and evaluated risk factors for the development of post-operative complications in patients with gunshot wounds to the colon. The purpose of the study is to identify the most influential risk factors.

METHODS

A retrospective study of 172 patients admitted with gunshot wounds to the colon from 17 February 2011 to 31 December 2014. Age, gender, shock upon admission defined by vital signs and haemoglobin level, blood transfusion, injured site of the colon, the colon injury score, faecal contamination, surgical procedure, colon diversion, multiple organ injuries, delay time pre-operation and duration of the operation were considered as risk factors. All patients were observed for any postoperative complications.

RESULTS

One hundred and sixty-six patients (96.5%) were males, and six (3.5%) were female. The mean age was 28.5 years. On admission 104 (60.5%) patients were in shock, 89 (51.7%) required blood transfusion. Forty-four (25.5%) patients had an injury to the ascending colon, while 53 (30.8%), 13 (7.6%), 23 (13.4%), 21 (12.2%) and 18 (10.5%) patients had an injury in transverse, descending, sigmoid, rectum and multiple colon injuries respectively. A colon diversion was used in 64 patients (37.2%). Post-operative complications documented in 67 (38.9%) patients, 35 (20.3%) required re-exploratory laparotomy, while the disability occurred in 18 (10.4%)) cases, and post-operative mortality was 12 (6.9%).

CONCLUSION

Surgeons should be aware that shock state upon admission and blood transfusion are risk factors for postoperative complications in a patient with a gunshot penetrating injury to the colon.

Contemporary Trends and Outcomes of Blunt Traumatic Colon Injuries Requiring Resection

BACKGROUND

After traumatic injury, primary anastomosis after colon resection has overtaken ostomy diversion. Improved technology facilitating primary anastomosis speed and integrity may have driven this change. Trends in ostomy versus anastomosis have yet to be quantified, and recent literature comparing outcomes is incomplete.

METHODS

The National Trauma Databank (2007-2014) was queried for all blunt colon injuries requiring resection. Patients were dichotomized into study groups based on whether they underwent ostomy creation. Ostomy creation frequency was compared over time. After subgrouping patients by colon injury location, multivariate regression adjusted for baseline characteristics and evaluated the impact of ostomy on clinical outcomes.

RESULTS

A total of 13,949 colon injuries requiring colectomy were identified. Ostomy frequency did not vary by study year (P = 0.536). Univariate analysis showed that patients undergoing ostomy were older (median, 40 versus 32; P < 0.001) and more often had comorbidities (65% versus 56%; P < 0.001). Multivariate analysis showed that ostomy creation was significantly associated with lower mortality after sigmoid colon injury (odds ratio, 0.512; P = 0.011) and higher rates of unplanned reoperation after transverse colon injury (odds ratio, 3.135; P = 0.048). Across all colon injuries, ostomies were significantly associated with longer hospital length of stay, intensive care unit length of stay, and ventilator days.

CONCLUSIONS

Ostomy creation for colonic injury has reached an equilibrium trough. The impact of ostomy creation varies by not only clinical outcome but also injury location. Further study is needed to define the optimal surgical management for blunt colon injuries requiring resection.

Rectal foreign body causing perforation: Case report and literature review

Background

Clinicians must maintain an index of suspicion to diagnose an anorectal foreign body (FB). The patient may not be forthcoming with information secondary to embarrassment or possibly psychiatric issues. Providers must express empathy and compassion while maintaining nonjudgmental composure. Despite accounts of anal FB insertion, this pathology is lacking level one evidence-based surgical algorithms.

Case presentation

A 46-year-old male psychiatric patient presented in septic shock, complaining of lower abdominal/pelvic pain starting 1 week prior. His past medical history was significant for schizophrenia, bipolar disorder, and noncompliance with medications. CT of the abdomen/pelvis revealed a rectal perforation with free air and a FB which appeared to be a screwdriver. Fluid resuscitation and broad-spectrum antibiotics were administered. In the operating room, after unsuccessful transrectal removal, an exploratory laparotomy was performed. The metallic end of the screwdriver had perforated the rectosigmoid. Resection of the perforated rectum with removal of the screwdriver, incision and drainage of a large right buttock abscess and colostomy was performed. The patient recovered and was discharged to behavioral health. At 2 weeks follow-up the patient was doing well with a functioning colostomy and reversal was planned for later this year.

Conclusion

This case highlights the importance of maintaining a high index of suspicion when encountering psychiatric patients with nonspecific lower abdominal or anorectal pain with inconsistent presentations. Controversy exists regarding the type of surgical treatment in case of anorectal perforation. More research is needed to provide surgeons with evidence-based standardized methods for dealing with these rare pathologies.

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Maintaining a high index of suspicion when encountering patients with nonspecific lower abdominal and/or rectal pain.

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Despite the numerous reports of anal FB trauma there are no cases documenting a unique incident with a screwdriver being inserted through the anus.

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Controversy exists regarding the type of surgical treatment.

Current U.S. Pre-Operative Bowel Preparation Trends: A 2018 Survey of the American Society of Colon and Rectal Surgeons Members

Background: The effect of an oral antibiotic preparation prior to colorectal surgery was first examined and exalted in the 1973 paper by Nichols et al. Since this commencement, enthusiasm for the oral antibiotic regimen has waxed and waned reflecting the literature focused on this topic over the past 40 years. Polling colorectal surgeons of define current practices has been performed at intervals throughout the years and has demonstrated a trend to decline in the practice. The most recent publication surveying U.S. practices was in 2010, which reported a minority, 36%, use of oral antibiotics prior to elective colorectal surgery; a marked downtrend from the 88% use described in 1990. Since this last survey, the colorectal surgery community has performed considerable research examining the benefit of oral antibiotic and mechanical bowel preparation. This manuscript evaluates the current use of oral antibiotics in colorectal surgery in the U.S. and how practice trends have developed in response to current recommendations in the literature. Methods: An electronic survey was created and distributed to U.S. colorectal surgeons to evaluate current opinions and practice trends. A total of 359 American Society of Colon and Rectal Surgeons members responded. A review of the recent literature pertaining to pre-operative bowel practices and outcomes was performed to compare with current practices. Results: A significant majority (83.2%) of respondents use pre-operative oral antibiotics routinely, and 98.6% routinely use mechanical bowel preparation. The use of a combination of parenteral antibiotics, oral antibiotics, and mechanical bowel preparation is reported by 79.3%. The most commonly employed oral antibiotic regimen is neomycin and metronidazole. The most common mechanical bowel preparation is polyethylene glycol (PEG). The most common parenteral antibiotics are cefazolin and metronidazole. There was no statistically significant difference in this practice by geographic region, Board-certified status, or practice setting. Conclusion: The majority of colorectal surgeons employ a combination of oral antibiotics, mechanical bowel preparation, and parenteral antibiotics prior to colorectal surgery. This is consistent across geographic regions, despite Board certification status or practice setting, and is reflective of the recommendations based on recent literature.

Management of penetrating intraperitoneal colon injuries: A meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

The management of penetrating colon injuries in civilians has evolved over the last four decades. The objectives of this meta-analysis are to evaluate the current treatment regimens available for penetrating colon injuries and assess the role of anastomosis in damage control surgery to develop a practice management guideline for surgeons.

METHODS

Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines section of EAST conducted a systematic review using MEDLINE and EMBASE articles from 1980 through 2017. We developed three relevant problem, intervention, comparison, and outcome (PICO) questions regarding penetrating colon injuries. Outcomes of interest included mortality and infectious abdominal complications.

RESULTS

Thirty-seven studies were identified for analysis, of which 16 met criteria for quantitative meta-analysis and included 705 patients considered low-risk in six prospective randomized studies. Seven hundred thirty-eight patients in 10 studies undergoing damage control laparotomy and repair or resection and anastomosis (R&A) were included in a separate meta-analysis. Meta-analysis of high-risk patients undergoing repair or R&A was not feasible due to inadequate data.

CONCLUSIONS

In adult civilian patients sustaining penetrating colon injury without signs of shock, significant hemorrhage, severe contamination, or delay to surgical intervention we recommend that colon repair or R&A be performed rather than routine colostomy. In adult high-risk civilian trauma patients sustaining penetrating colon injury, we conditionally recommend that colon repair or R&A be performed rather than routine colostomy. In adult civilian trauma patients sustaining penetrating colon injury who had damage control laparotomy, we conditionally recommend that routine colostomy not be performed; instead, definitive repair or delayed R&A or anastomosis at initial operation should be performed rather than routine colostomy.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level III.

Gastrointestinal injuries during gynaecologic operations at a university teaching hospital in Thailand: a 10-year review

The objective of this study was to investigate the incidence of gastrointestinal injuries during gynaecologic operations, the management of such injuries and associated risk factors. This case-control study (1:4) examined patients who received gynaecologic operations from 2007 to 2016 in Ramathibodi Hospital. The study cases comprised patients who had gastrointestinal injuries, while the control cases comprised patients who had gynaecologic surgeries in the same period with matching the types of procedures. The 10-year incidence was 0.38% (104 cases of gastrointestinal injuries among a total of 27,520 cases). The most common injury site was the small bowel (43.3%). There were 102 cases (98%) of gastrointestinal injuries which were diagnosed intraoperatively and which were immediately repaired with successful outcomes. Logistic regression indicated that a pelvic adhesion, previous pelvic surgery and previous abdominal surgery were predictive risk factors associated with the injuries (odds ratios: 9.45, 3.20 and 11.84, respectively). An immediate consultation with a surgeon and surgical repair of the injury resulted in excellent outcomes. Impact statement What is already known about this subject? Gastrointestinal injury is a rare, but fatal complication of gynaecologic operations. The previous small study identified some risk factors such as surgical approach and pelvic surgery associated with the injury. What do the results of this study contribute? Our study identified the associated risk factors for gastrointestinal injury, including previous abdominal injury, pelvic adhesion and previous pelvic surgery. A previous abdominal surgery was the most associated risk factor. Patients with the history of abdominal surgery had an almost 4-fold higher odds ratio than the ones with previous pelvic surgery. Other factors, including endometriosis, ovarian cancer and subsequent oncological procedures, and surgical staging were less related to the gastrointestinal injury. What are the implications of these findings for clinical practice and/or further research? The knowledge is useful for pre-operative evaluation and preparation. Bowel preparation and consultation with surgeon are necessary for patients with these risk factors prior to their surgeries. Moreover, an immediate intra-operative surgical correction of the injury results in excellent outcomes.

The incidence of stoma related morbidity - a systematic review of randomised controlled trials

Introduction Several stoma related complications can occur following ileostomy or colostomy formation. The reported incidence of these conditions varies widely in the literature. A systematic review of randomised controlled trials reporting the incidence of stoma related complications in adults was performed to provide the most comprehensive summary of existing data. Methods PubMed, CINAHL® (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library were searched for trials assessing the incidence of complications in adults undergoing conventional stoma formation. Data were extracted by two independent reviewers and entered into SPSS® for statistical analysis. The Cochrane Collaboration tool for assessing risk of bias was used to critically appraise each study. Cochran's Q statistic and the I2 statistic were used to measure the level of heterogeneity between studies. Results Overall, 18 trials were included, involving 1,009 patients. The incidence of stoma related complications ranged from 2.9% to 81.1%. Peristomal skin complications and parastomal hernia were the most common complications. End colostomy had the highest incidence of morbidity, followed by loop colostomy and loop ileostomy. There were no trials involving patients with end ileostomy. There was a high level of detection bias and heterogeneity between studies. Conclusions This systematic review has summarised the best available evidence concerning the incidence of stoma related morbidity. The high level of heterogeneity between studies has limited the accuracy with which the true incidence of each stoma related complication can be reported. Large, multicentre trials investigating homogenous participant populations are therefore required.

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

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.

Assessing Risk and Related Complications after Reversal of Combat-Associated Ostomies

BACKGROUND

During the past decade of conflict, numerous patients with combat-associated injuries required the formation of an ostomy. However, outcomes in those patients undergoing ostomy reversal have yet to be analyzed. We review the experience and identify risk factors for complications after ostomy reversal in a series of patients with combat injuries at our military treatment facility.

STUDY DESIGN

A retrospective review of patients with combat-associated injuries managed with a diverting ostomy who underwent ostomy reversal at our military treatment facility during a 13-year period. Demographic and clinical data were collected for all patients and postoperative complications were identified. Multivariate analysis was performed to identify independent risk factors for complications after reversal. Complication rates were calculated for 90-day periods of time after ostomy creation and best-fit curve analysis was conducted.

RESULTS

Ninety-nine patients were identified who underwent ostomy reversal. Forty patients (40.4%) suffered a post-reversal complication. On multivariate analysis, older age (odds ratio 1.11/y; p = 0.038), severe perineal injury indication for diversion (odds ratio 4.37; p = 0.028), and increased time interval between ostomy creation and reversal (odds ratio 1.005/d; p = 0.037), were independently associated with postoperative complications. A cubic regression best fit quarterly complication rate data (R² 0.526; p < 0.001) and calculates a minimum complication rate for reversal 90 to 180 days after ostomy creation.

CONCLUSIONS

Ostomy reversal in patients wounded in combat is a major undertaking with a high complication rate. The finding of a shorter interval from ostomy creation to reversal independently associated with a reduction in complications provides a modifiable risk factor to guide future practice and potentially reduce complications. Our modeling suggests reversal in the 3- to 6-month time frame can have the lowest rate of complications. Future research to reduce complications is indicated, especially in older patients with perineal wounds.

Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery

Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections (SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.

Colon Trauma: Evidence-Based Practices

Colon injury is not uncommon and occurs in about a half of patients with penetrating hollow viscus injuries. Despite major advances in the operative management of penetrating colon wounds, there remains discussion regarding the appropriate treatment of destructive colon injuries, with a significant amount of scientific evidence supporting segmental resection with primary anastomosis in most patients without comorbidities or large transfusion requirement. Although literature is sparse concerning the management of blunt colon injuries, some studies have shown operative decision based on an algorithm originally defined for penetrating wounds should be considered in blunt colon injuries. The optimal management of colonic injuries in patients requiring damage control surgery (DCS) also remains controversial. Studies have recently reported that there is no increased risk compared with patients treated without DCS if fascial closure is completed on the first reoperation, or that a management algorithm for penetrating colon wounds is probably efficacious for colon injuries in the setting of DCS as well.

Evolution of the operative management of colon trauma

For any trauma surgeon, colon wounds remain a relatively common, yet sometimes challenging, clinical problem. Evolution in operative technique and improvements in antimicrobial therapy during the past two centuries have brought remarkable improvements in both morbidity and mortality after injury to the colon. Much of the early progress in management and patient survival after colon trauma evolved from wartime experience. Multiple evidence-based studies during the last several decades have allowed for more aggressive management, with most wounds undergoing primary repair or resection and anastomosis with an acceptably low suture line failure rate. Despite the abundance of quality evidence regarding management of colon trauma obtained from both military and civilian experience, there remains some debate among institutions regarding management of specific injuries. This is especially true with respect to destructive wounds, injuries to the left colon, blunt colon trauma and those wounds requiring colonic discontinuity during an abbreviated laparotomy. Some programs have developed data-driven protocols that have simplified management of destructive colon wounds, clearly identifying those high-risk patients who should undergo diversion, regardless of mechanism or anatomic location. This update will describe the progression in the approach to colon injuries through history while providing a current review of the literature regarding management of the more controversial wounds.

Preoperative Bowel Preparation before Elective Bowel Resection or Ostomy Closure in the Pediatric Patient Population Has No Impact on Outcomes: A Prospective Randomized Study

The role of preoperative bowel prep in the pediatric surgical population is uncertain. We performed a randomized prospective study to evaluate noninferiority between the presence or absence of a preoperative bowel prep in elective pediatric bowel surgery on postoperative outcomes. Patients aged three months to 18 years were recruited and randomized to the bowel prep group or the no bowel prep group. Patients were evaluated in-hospital and at postoperative clinic visits. Thirty-two patients were recruited; 18 in the bowel prep group and 14 in the no bowel prep group. There was no statistical difference ( P > 0.05) in complications between the groups. Complications were observed in five patients in each group (27.8% and 35.7%, respectively). In the bowel prep group, two (11.1%) had wound infection (vs three, 21.4%), 0 had an intra-abdominal abscess (vs one, 7.1%), one (5.6%) had sepsis (vs one, 7.1%), one (5.6%) had an anastomotic leak (vs 0), and three (16.7%) had a bowel obstruction (vs one, 7.1%). There were no extra-abdominal complications. There were no significant differences in complications between the two groups. Further research is warranted, but may require a multi-institutional trial to recruit sufficient numbers to make conclusions about the significance of the need for bowel prep.

Damage control surgery: use of diagnostic CT after life-saving laparotomy

Damage control surgery (DCS) is a limited exploratory laparotomy that is performed in unstable trauma patients who, without immediate intervention, would acutely decompensate. Patients usually present with shock physiology and metabolic derangements including acidosis, hypothermia, and coagulopathy. Delayed medical correction of these metabolic derangements leads to an irreversible state of coagulopathic hemorrhagic shock and inevitable patient demise. Therefore, once a patient meets DCS criteria, a limited exploratory laparotomy is performed to stabilize life-threatening injury and expedite initiation of medical resuscitation in the intensive care unit (ICU). The surgeon plans to return to the operating room for definitive surgical treatment once the patient is hemodynamically stabilized and the metabolic derangements have been corrected. DCS patients are frequently sent to the ICU with an open abdomen and purposefully retained surgical equipment. The lack of response to resuscitation efforts, persistent hypotension, tachycardia, and/or the development of sepsis are common indications for this patient population to undergo CT imaging. The indications and findings of multi-detector CT (MDCT) in patients post-DCS have not been thoroughly evaluated in the radiology literature. A radiologist's knowledge of the DCS protocol and pre-imaging surgical interventions helps optimize the MDCT protocol. This enhances the radiologist's ability to evaluate for failure of surgical interventions performed prior to imaging and to search for injuries in areas that were not explored or that were missed during the initial surgical exploration.

Performance of primary repair on colon injuries sustained from low-versus high-energy projectiles

Among various reasons, colon injuries may be caused by low- or high-energy firearm bullets, with the latter producing a temporary cavitation phenomenon. The available treatment options include primary repair and two-stage management, but recent studies have shown that primary repair can be widely used with a high success rate. This paper investigates the differences in performance of primary repair on these two types of colon injuries. Two groups of patients who sustained colon injuries due to single gunshot wounds, were retrospectively categorized based on the type of bullet. Primary colon repair was performed in all patients selected based on the inclusion and exclusion criteria (Stone and Fabian's criteria). An almost absolute homogeneity was attained among the groups in terms of age, latent time before surgery, and four trauma indexes. Only one patient from the low-energy firearm projectile group (4%) developed a postsurgical complication versus nine patients (25.8%) from the high-energy group, showing statistically significant difference (p = 0.03). These nine patients experienced the following postsurgical complications: pneumonia, abscess, fistula, suture leakage, and one multiorgan failure with sepsis. Previous studies concluded that one-stage primary repair is the best treatment option for colon injuries. However, terminal ballistics testing determined the projectile's path through the body and revealed that low-energy projectiles caused considerably lesser damage than their high-energy counterparts. Primary colon repair must be performed definitely for low-energy short firearm injuries but very carefully for high-energy injuries. Given these findings, we suggest that the treatment option should be determined based not only on the bullet type alone but also on other clinical findings.

The safety of primary repair or anastomosis in high-risk trauma patients

PURPOSE

There is currently not enough data regarding the management of bowel injury and the results of primary repair or resection and anastomosis in high-risk trauma patients. We aimed to determine whether there were any short-term (30 days) postoperative complications relevant to the primary reconstruction of such bowel injuries.

METHOD

In a retrospective study, all trauma patients who underwent a definite laparotomy after penetrating or blunt injury in our institution during the last decade were identified. The study group consisted of those who underwent primary repair or resection and anastomosis of the small or large bowel or both. Patients who died within 72 h of admission, who had only serosal injuries or who received resection and diversion, were excluded.

RESULTS

Seventeen of the trauma patients who were treated at our institution during the study period had bowel injuries. Thirteen fit our criteria. All of them had at least one risk factor, and 61.5% of them had at least three risk factors for anastomotic or suture line disruption. Overall, 35 repairs and anastomoses took place. Only one patient developed clinical anastomotic leakage, resulting in a fistula, which did not require re-operation.

CONCLUSION

Our study contributes to the controversial issue of post-traumatic bowel reconstruction in high-risk trauma patients, and suggests that primary reconstruction is feasible and can provide a good outcome.

Care of the patient with anorectal trauma

Blunt and penetrating injuries to the anus and rectum are uncommon. Considerable debate remains regarding the optimal treatment of rectal injuries. Although intraperitoneal rectal injuries can be treated similarly to colonic injuries, treatment options for extraperitoneal injuries include fecal diversion with a colostomy, presacral drainage, repair of the rectal defect, and distal rectal washout. Perineal injuries resulting in anal sphincter disruption often occur with severe associated injuries. Small defects can be repaired primarily, but extensive injuries often require diversion and sphincter reconstruction.

Historical and current trends in colon trauma

The authors discuss the evolution of the evaluation and management of colonic trauma, as well as the debate regarding primary repair versus fecal diversion. Their evidence-based review covers diagnosis, management, surgical approaches, and perioperative care of patients with colon-related trauma. The management of traumatic colon injuries has evolved significantly over the past 50 years; here the authors describe a practical approach to the treatment and management of traumatic injuries to the colon based on the most current research. However, management of traumatic colon injuries remains a challenge and continues to be associated with significant morbidity. Familiarity with the different methods to the approach and management of colonic injuries will allow surgeons to minimize unnecessary complications and mortality.

Iatrogenic gastrointestinal injuries during obstetrical and gynecological operation

Background

Gastrointestinal Injuries (GI) during gynecological operation are uncommon but proper management of these injuries is very important.

Objectives

The aim of this study was to review the causes and management of gastrointestinal injuries during gynecological and obstetrical operations.

Patients and Methods

In this descriptive retrospective study, 25 patients with gastrointestinal injuries during gynecological and obstetrical operation at Shabihkhani Maternity Hospital in Kashan city were reviewed. Demographic data such as age, gravid, parity, type of surgery or procedure, history of laparotomy, the surgical operation, injury site, time of diagnosis and method of treatment were extracted from medical records.

Results

The mean age of women was 33.2 ± 7.57 years. Fourty-four percent of the patients had a history of abdominal scar. Thirty-two percent of all GI injuries occurred during total abdominal hysterectomy (TAH). The small bowel was injured in 36% of cases. Fifty-two percent of injuries were diagnosed during the operation and the mean time of injury diagnosis was 2.8 ± 0.9 days.

Conclusions

All of the gynecologic surgeons must be aware of gastrointestinal injuries and should anticipate injury to these organs especially in high-risk patients for decreasing patient morbidity.

Examining the safety of colon anastomosis on a rat model of ischemia-reperfusion injury

Introduction

Intestinal ischemia and reperfusion can impair anastomotic strength.

The purpose of this study was to evaluate the safety of delayed colon anastomosis following remote ischemia-reperfusion (IR) injury.

Methods

Rats divided into two groups underwent bilateral groin incisions, however only the study group had femoral artery clamping to inflict IR injury. Twenty-four hours following this insult, the animals underwent laparotomy, incision of the transverse colon and reanastomosis. End points included anastomotic leakage, strength and histopathological features.

Results

Anastomotic leak among IR animals (22.2%) was not statistically different in comparison to the controls [10.5% (p = 0.40)]. Anastomotic mean burst pressures showed no statistically significant difference [150.6 ± 15.57 mmHg in the control group vs. 159.9 ± 9.88 mmHg in the IR group (p = 0.64)]. The acute inflammatory process in the IR group was similar to controls (p = 0.26), as was the chronic repair process (p = 0.88). There was no significant difference between the inflammation:repair ratios amongst the two groups (p = 0.67).

Conclusion

Primary colon repair is safe when performed 24 hours following systemic IR injury.

Prognostic factors for traumatic bowel injuries: killing time

BACKGROUND

Intestinal rupture/perforation after abdominal trauma is a rare complication, but it is related to significant morbidity and mortality. Our objective is to identify determinants of prognosis in patients surgically treated for a bowel injury (small bowel and colon) after abdominal trauma.

METHODS

The present study is a retrospective analysis of 102 patients seen at our hospital during a 10-year period in whom laparotomy for traumatic bowel injury was performed. Predictors for morbidity and mortality were assessed in univariate and multivariate analysis models.

RESULTS

Mean age at diagnosis was 40 years, and most patients were male. There was a slight preponderance of blunt abdominal trauma, and the most frequent mechanism of injury was motor vehicle accident. In 75% of patients there was a small bowel lesion, and the colon was affected in 47%. There was no statistical relation between stoma construction and mortality, but an increase in morbidity was ultimately dependent on the severity of the underlying trauma. The univariate determinants of mortality were the new injury severity score (NISS) and American Society of Anesthesiologists (ASA) scores, the presence of blunt trauma and multiple intestinal or extra-abdominal lesions, and the elapsed time to surgery. The occurrence of postoperative complications was related to all these factors, as well as to tachycardia, hypotension, and bleeding. In multivariate analysis ASA score (p = 0.015), NISS (p = 0.002), time to surgery (p = 0.007), and presence of colonic lesions (p = 0.02) were identified as independent prognostic factors for postoperative morbidity.

CONCLUSIONS

The only modifiable determinant of morbidity seems to be the time to surgery. Only an expeditious evaluation and diagnosis and prompt surgical intervention can improve the prognosis of these patients.

Colonic injuries and the damage control abdomen: does management strategy matter?

BACKGROUND

The optimal management of colon injury patients requiring damage control laparotomy (DCL) is controversial. The objective of this study was to assess the safety of colonic resection and anastomosis versus fecal diversion in trauma patients requiring DCL.

METHODS

Patients with traumatic colon injuries undergoing DCL between 2000 and 2010 were identified by the database and chart review. Those who died within 48 h were excluded. Patients were divided into two groups: those undergoing one or more colonic anastomoses with or without distal colostomy (group 1) and those undergoing colostomy only or one or more colonic anastomoses with a protecting proximal ostomy (group 2). Variables were compared using Wilcoxon rank sum, χ2, or Fisher exact tests as appropriate.

RESULTS

Sixty-one patients were included (group 1, n=28 and group 2, n=33). Fascial closure rates (group 1, 50% versus group 2, 61%; P=0.45), hospital length of stay (29 versus 23 d; P=0.89), and in-patient mortality (11% versus 12%; P=1.0) were similar between groups. There were a total of 11 anastomotic leaks, five of which were related to non-colonic enteric repairs. Colonic anastomosis leak rates were 16% overall (six of the 38 patients), 14% in group 1 (four of the 28 patients), and 20% in group 2 (two of the 10 patients). Compared with patients who did not leak, patients who leaked had a higher median age (37 versus 25 y; P=0.05), greater likelihood of not achieving facial closure before post-injury day 5 (18% versus 2%; P=0.003), and a longer hospital length of stay (46 versus 25 d; P=0.003).

CONCLUSIONS

Outcomes after colonic injury in the setting of DCL were similar regardless of the surgical management strategy. Based on these findings, a strategy of diversion over anastomosis cannot be strongly recommended.

Management and Outcomes of Traumatic Colon Injury in Civilian and Military Patients

Divergent injury patterns may indicate the need for differing strategies in combat and civilian trauma patients. This study aims to compare outcomes of colon injury management in these two populations. Parallel retrospective reviews were conducted comparing warfighters (n = 59) injured downrange and subsequently transferred to the United States with civilians (n = 30) treated at a United States Level I trauma center. Patient characteristics, mechanisms of injury, treatment course, and complications were compared. The civilian (CP) and military (MP) populations did not differ in Injury Severity Score (MP 20 vs CP 26; P = 0.41). The MP experienced primarily blast injuries (51%) as opposed to blunt trauma (70%; P < 0.01) in the CP. The site of colon injury did not differ between groups ( P = 0.15). Initial management was via primary repair (53%) and resection and anastomosis (27%) in the CP versus colostomy creation (47%) and stapled ends (32%) in the MP ( P < 0.001). Ultimately, the CP and MP experienced equivalent continuity rates (90%). Overall complications (MP 68% vs CP 53%; P = 0.18) and mortality (MP 3% vs CP 3%; P = 0.99) did not differ between the two groups. The CP and MP experience different mechanisms and initial management of colon injury. Ultimately, continuity is restored in the majority of both populations.

Traumatic injury of the colon and rectum: the evidence vs dogma

BACKGROUND

The treatment of traumatic injuries to the colon and rectum is often driven by dogma, despite the presence of evidence suggesting alternative methods of care.

OBJECTIVE

This is an evidence-based review, in the format of a review article, to determine the ideal treatment of noniatrogenic traumatic injuries to the colon and rectum to improve the care provided to this group of patients. Recommendations and treatment algorithms were based on consensus conclusions of the data.

DATA SOURCES

A search of MEDLINE, PubMed, and the Cochrane Database of Collected Reviews was performed from 1965 through December 2010.

STUDY SELECTION

Authors independently reviewed selected abstracts to determine their scientific merit and relevance based on key-word combinations regarding colorectal trauma. A directed search of the embedded references from the primary articles was also performed in select circumstances. We then performed a complete evaluation of 108 articles and 3 additional abstracts.

MAIN OUTCOME MEASURES

The main outcomes were morbidity, mortality, and colostomy rates.

RESULTS

Evidence-based recommendations and algorithms are presented for the management of traumatic colorectal injuries.

LIMITATIONS

Level I and II evidence was limited.

CONCLUSIONS

Colorectal injuries remain a challenging clinical entity associated with significant morbidity. Familiarity with the different methods to approach and manage these injuries, including "damage control" tactics when necessary, will allow surgeons to minimize unnecessary complications and mortality.

Colon anastomosis after damage control laparotomy: recommendations from 174 trauma colectomies

BACKGROUND

Primary colonic anastomosis in trauma patients has been demonstrated to be safe. However, few studies have investigated this in the setting of damage control laparotomy. We hypothesized that colonic anastomosis for trauma patients requiring an open abdomen (OA) would have a higher anastomotic leak (AL) rate when compared with patients having an immediate abdominal closure following trauma laparotomy.

METHODS

We performed a cohort comparison study of all trauma patients who underwent colectomy, between the years 2004 and 2009. Exclusion criteria were mortality within 24 hours of admission or colectomy for indications unrelated to injury. Data collected included age, gender, injury severity score, mechanism, length of stay, and mortality. Multivariable logistic regression was performed to assess the relationship of OA to our primary outcome measure, AL.

RESULTS

Totally, 174 patients met study criteria. Fecal diversion was performed in 58 patients, and colonic anastomosis was performed in the remaining 116 patients. Patients with OA had a clinically significant increase in AL rate compared with immediate abdominal closure (6% vs. 27%, p=0.002). Logistic regression demonstrated that OA was independently associated with AL, with OA patients having more than a sixfold increase in odds of AL compared with those who were closed (odds ratio=6.37, p=0.002, area under the receiver operator curve=0.72). Transfusion requirement and left-sided anastomosis were risk factors for leak.

CONCLUSIONS

Patients with a colonic anastomosis and an OA have an unacceptably high leak rate compared with those who undergo reconstruction with immediate closure. Given the significant risk of AL, colonic anastomosis should not be routinely performed in patients with OA.

Crystalloids after primary colon resection and anastomosis at initial trauma laparotomy: excessive volumes are associated with anastomotic leakage

BACKGROUND

Recognition of preventable risk factors for suture line failure after colon anastomosis is important for optimizing anastomotic healing. The purpose of this study was to investigate the impact of crystalloids on the occurrence of anastomotic leakage after traumatic colonic injuries.

METHODS

Retrospective review from January 2005 to August 2009 of severely injured patients who underwent primary colocolonic anastomosis and intensive care unit (ICU) admission for ≥72 hours. Demographics on hospital and ICU admission, amount of crystalloids, and blood component transfusions within the first 72 hours were assessed by multivariate analysis to explore independent associations with anastomotic leakage.

RESULTS

Of a total of 123 patients with primary colocolonic anastomosis, 7 died within 72 hour and 24 were discharged before 72 hour from the ICU. The remaining 92 patients required ICU admission for ≥72 hour. Their mean Injury Severity Score was 20.8 ± 10.7, and they were 29.9 years ± 13.0 years old. Twelve patients (13.0%) developed an anastomotic leak. Demographics on hospital and ICU admission, intraoperative blood loss, and the volume of intraoperative fluids given did not differ statistically between patients with or without anastomotic leakage. However, the cumulative amount of crystalloids given over the first 72 hours significantly predicted anastomotic leakage (area under the receiver operating characteristic curve: 0.758 [95% confidence interval 0.592-0.924], p=0.009). By multivariate analysis, ≥10.5 L of crystalloids given over the first 72 hours was independently associated with anastomotic breakdown (odds ratio [95% confidence interval]: 5.26 [1.14-24.39], p=0.033). In addition, increasing age, hemorrhagic shock on admission, and a concomitant stomach injury were independent risk factors for an anastomotic leak (R=0.396).

CONCLUSION

Increased use of crystalloids after primary colocolonic anastomosis at initial trauma laparotomy is associated with anastomotic leakage. A threshold of 10.5 L of crystalloid fluid infused over the first 72 hours is associated with a 5-fold increased risk for colocolonic suture line failure. The impact of crystalloid restriction on anastomotic failure in trauma patients warrants prospective investigation.

Primary repair of colon injuries: clinical study of nonselective approach

BACKGROUND

This study was designed to determine the role of primary repair and to investigate the possibility of expanding indications for primary repair of colon injuries using nonselective approach.

METHODS

Two groups of patients were analyzed. Retrospective (RS) group included 30 patients managed by primary repair or two stage surgical procedure according to criteria published by Stone (S/F) and Flint (Fl). In this group 18 patients were managed by primary repair. Prospective (PR) group included 33 patients with primary repair as a first choice procedure. In this group, primary repair was performed in 30 cases.

RESULTS

Groups were comparable regarding age, sex, and indexes of trauma severity. Time between injury and surgery was shorter in PR group, (1.3 vs. 3.1 hours). Stab wounds were more frequent in PR group (9:2), and iatrogenic lesions in RS group (6:2). Associated injuries were similar, as well as segmental distribution of colon injuries. S/F criteria and Flint grading were similar.In RS group 15 primary repairs were successful, while in two cases relaparotomy and colostomy was performed due to anastomotic leakage. One patient died. In PR group, 25 primary repairs were successful, with 2 immediate and 3 postoperative (7-10 days) deaths, with no evidence of anastomotic leakage.

CONCLUSIONS

Results of this study justify more liberal use of primary repair in early management of colon injuries.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN94682396.

Management of colonic injuries in the combat theater

PURPOSE

Combat injuries are more often associated with blast, penetrating, and high-energy mechanisms than civilian trauma, generating controversy about the management of combat colonic injury. Despite implementation of mandatory colostomy in World War II, recent civilian data suggest that primary repair without diversion is safe and feasible. This study describes the modern management of battle-related colonic injuries and seeks to determine whether management strategy affects early complications.

METHODS

Records from the combat theater (downrange) and tertiary referral center in Germany were retrospectively reviewed from 2005 to 2006. Patient characteristics, management strategy, treatment course, and early complications were recorded. Comparison groups by management strategy were as follows: primary repair, diversion, and damage control.

RESULTS

A total of 133 (97% male) patients sustained colonic injuries from penetrating (71%), blunt (5%), and blast (23%) mechanisms. Average injury severity score was 21 and length of stay in the referral center was 7.1 days. Injury distribution was 21% ascending, 21% descending, 15% transverse, 27% sigmoid, and 25% rectum. Downrange complications for primary repair, initial ostomy, and damage control groups were 14%, 15%, and 30%, respectively. On discharge from the center, 62% of patients had undergone a diversion. The complication rate was 18% overall and was unrelated to management strategy (P = .16). Multivariate analysis did not identify independent predictors of complications.

CONCLUSION

Early complications were similar by mechanism, anatomic location, severity of injury, and management strategy. More diversions were performed for rectosigmoid injury. Good surgical judgment allows for low morbidity and supports primary repair in selected cases. Damage control surgery is effective in a multinational theater of operations.

Colon and rectal surgery for cancer without mechanical bowel preparation: one-center randomized prospective trial

Background

Mechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. The aim of the study was to assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation.

Methods

Patients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications.

Results

Two hundred forty four patients were included in the study, 120 in group A and 124 in group B. Demographic characteristics, type of surgical procedure and type of anastomosis did not significantly differ between the two groups. There was no difference in the rate of surgical infectious complications between the two groups but the overall infectious complications rate was 20.0% in group A and 11.3% in group B (p .05). Wound infection (p = 0.18), anastomotic leak (p = 0.52), and intra-abdominal abscess (p = 0.36) occurred in 9.2%, 5.8%, and 5.0% versus 4.8%, 4.0%, and 2.4%, respectively. No mechanical bowel preparation seems to be safe also in rectal surgery.

Conclusions

These results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.

Morbidity predicting factors of penetrating colon injuries

THE AIM of this study was to analyze patients suffering from penetrating colon injuries management, clinical outcomes and factors, which predict higher morbidity and complications rate. METHODS: this was a retrospective analysis of prospectively collected data from patients with injured colon from 1995 to 2008. Age, time till operation, systolic blood pressure, part of injured colon, fecal contamination, PATI were registered. Monovariate and multivariate logistic regression was performed to determine higher morbidity predictive factors. RESULTS: 61 patients had penetrating colon injuries. Major fecal contamination of the peritoneal cavity and systolic blood pressure lower than 90 mmHg are independent factors determining the fecal diversion operation. Primary repair group analysis establish that major fecal contamination and systolic blood pressure lower than 90 mmHg OR=4,2 and 0,96 were significant risk factors, which have contributed to the development of postoperative complications. And systolic blood pressure lower than 90 mmHg and PATI 20 predict OR=0,05 and 2,61 higher morbidity. CONCLUSIONS: Fecal contamination of the peritoneal cavity and hypotension were determined to be crucial in choice of performing fecal diversion or primary repair. But the same criteria and PATI predict higher rate of postoperative complications and higher morbidity.

Current management of large bowel injuries and factors influencing outcome

BACKGROUND

Colonic and intra-peritoneal rectal injuries may be managed by primary repair and extra-peritoneal rectal injuries by diverting colostomy. This study was undertaken to document our experience with this approach and to identify factors which might impact on outcome.

PATIENTS AND METHODS

Prospective study of all patients treated for colon and rectal injuries in one surgical ward at King Edward VIII hospital, Durban, over a 7-year period (1998-2004). Demographic data, clinical presentation, findings at laparotomy and outcome were documented.

RESULTS

Of 488 patients undergoing laparotomy, 177 (36%) had injuries to the colon and rectum with age 29.8+/-10.9 years. Injury mechanisms were firearms (118) stabs (54) and blunt trauma (5). Delay before laparotomy was 10+/-9.3 h. Complication and mortality rates were 36% and 17%, respectively. 68 patients (38%) required ICU management. Shock on admission and increased transfusion requirements were associated with a significantly increased mortality. Patients with delay < or = 12 h before laparotomy had a higher mortality rate than those with delay >12 h. The mortality rate increased with the number of associated injuries and it was higher the higher the Injury Severity Score (ISS); it was similar for stabs, firearms and blunt trauma. Hospital stay was 9.5+/-9.2 days.

CONCLUSION

We reaffirm that primary repair is appropriate for colonic and intra-peritoneal rectal injuries and that extra-peritoneal rectal injuries require diverting colostomy. Shock on admission, increased blood transfusion requirements, associated organ injury and severity of the injury were associated with high mortality.

Independent Predictors of Treatment Modality for Penetrating Colon Injury

BACKGROUND AND AIMS

We aimed to evaluate the independent factors of the treatment of penetrating colon injuries in a teaching and research hospital in light of some of the most commonly cited considerations affecting the decision as to whether to perform primary repair or divert.

METHODS

Hospital records of patients between January 2004 and January 2007 were reviewed retrospectively. Fifty-seven patients were included and divided into two groups. Group A consisted of patients (n = 43) who had primary repair or resection and anastomosis, and Group B consisted of patients (n = 14) who had diverting colostomy. The degree of fecal contamination was assessed by reviewing the detailed operative dictation. The type of colon injury, as determined from the colon injury scale (CIS) of the American Association for the Surgery of Trauma (AAST), and the penetrating abdominal trauma index (PATI) were recorded.

RESULTS

Age, sex, presence of shock on admission, location of the injury, and colon-related or non-colonrelated complications between the two groups were not significant. Stab or gunshot injury, operation time, degree of fecal contamination (grade 1/2/3), transfusion, PATI score, hospital stay, and associated organ injury were significantly different in the two groups (p < 0.05).

CONCLUSION

Despite the fact that CIS, fecal contamination, transfusion, PATI and delayed operation affect the decision about the procedure, primary repair can be performed safely on patients with penetrating colon injuries.

Impact of Hollow Viscus Injuries on Outcome of Abdominal Gunshot Wounds

Abdominal gunshot wounds (GSW) are a source of morbidity and mortality. Limited data are available on the effect of hollow viscus injuries (HVI) secondary to gunshot wounds. GSW sustained in the Louisville area from 2004 to 2007 were reviewed. Attention was given to the impact of HVI from abdominal GSW. Statistical significance was determined. One-hundred ten patients sustained GSW with peritoneal violation. Eighty-six had HVI. Eighteen died after laparotomy with 15 having an HVI. Patients undergoing damage control (DC) have a significant increase in mortality compared with those not requiring DC. Exsanguination was the major cause of mortality (67%). Mortality directly related to HVI was found in 11 per cent. Twenty patients underwent DC with 11 deaths. Isolated HVI did not show a significantly increased mortality compared with other injury patterns involving solid organ or major vascular structures. Various methods of repair showed no significant survival advantage. Recognition and repair of HVI in abdominal GSW is crucial to patient salvage. Definitive repair of HVI at the initial operation should be considered. Primary repair of HVI is preferred although no survival disadvantage is seen in other forms of repair in marginally stable patients. Definitive repair at the initial operation decreases complications.

Penetrating abdominal injuries: management controversies

Penetrating abdominal injuries have been traditionally managed by routine laparotomy. New understanding of trajectories, potential for organ injury, and correlation with advanced radiographic imaging has allowed a shift towards non-operative management of appropriate cases. Although a selective approach has been established for stab wounds, the management of abdominal gunshot wounds remains a matter of controversy. In this chapter we describe the rationale and methodology of selecting patients for non-operative management. We also discuss additional controversial issues, as related to antibiotic prophylaxis, management of asymptomatic thoracoabdominal injuries, and the use of colostomy vs. primary repair for colon injuries.

Colonic perforation after short-term use of nonsteroidal antiinflammatory drugs: report of two cases

Nonsteroidal antiinflammatory drugs are widely used for acute and chronic pain, but they may have serious side effects such as impairment of renal function, asthma, erosions of the mucosa in the gastrointestinal tract, colonic and intestinal strictures, and gastrointestinal tract bleeding. Although the upper gastrointestinal tract disturbances caused by nonsteroidal antiinflammatory drugs are well known, their side effects in the lower gastrointestinal tract are not clearly defined. There are a limited number of articles and case reports about the latter in the literature. We report two cases of colonic perforation due to short-term use of nonsteroidal antiinflammatory drugs in this study. Colonic perforation should be considered as one of the possible diagnoses in patients with acute abdominal pain and nonsteroidal antiinflammatory drug use should be considered as a possible cause of colonic perforation if other possibilities are excluded.