Table of Contents  

Eltayeb, Yammahi, and Al-Ozaibi: Delayed primary colon repair – does it have a place in surgical practice?

Introduction

Primary repair of colonic injuries was once associated with high morbidity and mortality. Following Ogilvie’s mandate to treat all colonic injuries by colostomy,1 mortality fell from 70% during the First World War to 53% during the Second World War.2,3 Influenced by the impressive military results, civilian practice followed suit, although many surgeons continued to have doubts.46 Thus, credit must be given to the publication by Stone and Fabian in 1979, which restored confidence in the safety of primary colon repair and made it popular once more.7 Since then, many studies have demonstrated the safety of primary colon repair,721 closing down the debate. In recent years, the popularity of damage control surgery utilizing temporary abdominal closure (laparotomies) has increased exponentially.2023 This has led to a surge in delayed primary repair for destructive colon injuries, leading to a revival of the debate on its safety, although this continues to be demonstrated in many emerging studies.11,2429 Rashid Hospital, Dubai, is a major trauma centre treating a large number of polytrauma patients with associated colonic injuries. The hospital’s surgeons come from different educational backgrounds embracing varying scientific convictions. Although the hospital has no protocol regarding the management of traumatic colon injuries, most surgeons are proponents of primary repair provided they consider it safe. With temporary abdominal closure during damage control surgery being performed with increasing frequency, we decided to find out if delayed primary colon repair has a place in our practice and to identify issues related to its safety.

Methods

Patients admitted to Rashid Hospital with polytrauma associated with colonic injuries between January 2010 and August 2015 were identified using International Classification of Diseases coding.30 Records were retrospectively reviewed. Patients who underwent damage control laparotomy and delayed primary colon repair were included.

Results

During the specified period, 804 polytrauma patients were admitted to Rashid Hospital. Fifty-eight patients had associated colonic injuries (Table 1); 49 were men and nine were women. The age of participants ranged between 21 and 56 years. Thirty-eight patients had definitive treatment at the initial laparotomy; the remaining 20 patients had damage control surgery because their condition was unstable (Figure 1).

TABLE 1

Abdominal trauma cases admitted between January 2010 and December 2015

Organ injured Number of cases
Stomach 11
Small bowel 56
Colonic injuries 58
Multiple intra-abdominal injuries 236
Spleen 188
Liver 253
Total 802
FIGURE 1

Management of colonic trauma injuries admitted between January 2010 and December 2015.

HMJ-681-fig1.jpg

Abdominal injuries were managed by control of bleeding points and packing of solid organs. Devitalized, injured colons were resected and their ends stapled, and patients were sent to the surgical intensive care unit (ICU) with a view to performing a repeat laparotomy within 24–72 hours. In 14 patients, repeat laparotomy led to the creation of a stoma; in the remaining six patients the stapled ends were rejoined. Details of the two groups are shown in Table 2. Subsequently, colostomies were reversed in 15 patients: in four patients, reversal failed; in seven patients, the colostomy was made permanent because of extensive perineal wounds; and five patients were lost to follow-up. Eight patients in the colostomy group had a significant wound infection; four of these developed incisional hernias.

TABLE 2

Comparison between characteristics of patients with primary colon repair vs. delayed primary repair

Variable Primary repair (single laparotomy) Delayed primary repair (staged laparotomy)
Total number 20 6
Age range (years) 31–56 21–45
Mechanism of injury
 Road traffic accident 15 4
 Fall from height 4 1
 Fall of heavy object 1 0
 Penetrating wound 1 1
Time from injury to surgery (hours) 2–3 2–3
Perioperative transfusion (units) 4–9 4–14
Time for fascial closure During the same laparotomy During the repeat laparotomy
Number of days in ICU 5–28 5–32
Hospital stay (days) 10–42 10–370
Complications related to colonic repair 2 0

Discussion

Colostomy is no longer accepted as mandatory in the management of colonic injuries since the publication by Stone and Fabian ended the ongoing debate regarding the safety of primary colon anastomosis.7 Subsequently, several other studies have demonstrated the safety of primary repair for colonic injuries7,8,1020 or highlighted drawbacks of colostomy.10,22,23 Damage control surgery, since its introduction by Rotondo et al.,25 has undergone a remarkable evolution.8,9 Recently, debate has been revived in the wake of damage control surgery with the increasing practice of laparotomies. In Rashid Hospital there is no protocol dictating how colon injuries should be managed; therefore, it is left to the discretion of surgeons to decide how to manage colonic injury. The majority of Rashid Hospital surgeons prefer to avoid colostomy whenever possible. This is evident from Figure 1, which shows that damage control laparotomies are preferred to colostomies to increase patients’ chance of successful delayed primary colon repair. In our sample, 20 patients underwent damage control laparotomy with resection and stapling the ends of their devitalized colon. Following optimization in surgical ICU, patients were taken for a repeat laparotomy after 24–72 hours. Delayed primary repair was successfully completed in six patients and abdominal facial closure was performed; traditionally, these six patients would have had a colostomy during the first laparotomy. Colostomy was performed in the remaining nine patients. Table 2 shows that were no noticeable differences between patients in the primary and delayed colon repair groups. Although some authors recommend that delayed colon repair should be reserved for patients whose perioperative blood transfusion does not exceed 4–5 units,12,20,26 in some of our patients transfusion requirements exceeded this (see Table 2). One patient received 14 units of blood in the perioperative period because of multiple injuries to the spleen, pancreas, small bowel and large bowel, as well as the inferior vena cava.

Because of the small size of the United Arab Emirates and an efficient, fast ambulance service, most patients underwent surgery within 2–4 hours of the time of injury. Although no injury severity score was calculated here, it was clear that all patients had polytrauma with multiple organ involvement requiring multiple transfusions and ICU care (see Table 2). The availability of an efficient ICU service greatly helped in optimizing patients for repeat laparotomy, contributing to success in achieving delayed primary closure. In all patients who underwent delayed primary colon repair, abdominal fascial closure was completed during the repeat laparotomy. As a result, we did not observe complications of late fascial closure, as reported in some literature.28 Apart from the development of high-output small bowel fistulae in one case, none of the patients experienced any complications related to the delayed primary colon repair (see Table 2). Similar results were obtained in small series study by Millar et al.29 Looking at the number of stomas performed during a single laparotomy in this series, we believe that colostomy might have been avoided in some patients if staged damage control laparotomy had been performed. Although many studies of the safety of delayed primary colon repair have been small and retrospective, the results obtained from a meta-analysis by Nelson and Singer,10 a prospective non-selective study by George et al.11 and a multicentre trial by Tatebe et al.31 are encouraging and reassuring. However, caution should be exercised in selecting patients for delayed primary colon repair during damage control laparotomy, especially in hospitals lacking an efficient ICU service.32

Conclusion

Our review shows the awareness of our surgeons of the advantages of delayed primary colon repair in saving patients from unnecessary complications of unwarranted colostomy. The relatively high number of stomas performed during a single laparotomy in this series might warrant consideration of staged laparotomy to reduce the current number of stomas. Although it might not be possible to draw conclusions from the small number of patients in this retrospective study, results from various studies support the safety of the procedure. Therefore, the procedure is worthy of careful consideration in selected patients, as it might avoid an unnecessary colostomy.

Acknowledgements

The authors are indebted to Dr Lola Obad Al Mubarak and Dr Tania Hoses Tabassum Biut for their hard work searching the medical records to retrieve the information. Special thanks go to Miss Marilyn Barcilinia Ramirez for typing the manuscript.

References

1. 

Ogilvie WH. Surgical lessons of war applied to civil practice. Br Med J 1945; 1:619–23. https://doi.org/10.1136/bmj.1.4400.619

2. 

Fraser J, Drummond H. A clinical and experimental study of three hundred perforating wounds of the abdomen. Br Med J 1917; 1:321–30. https://doi.org/10.1136/bmj.1.2932.321

3. 

Causey MW, Rivadeneira DE, Steele SR. Historical and current trends in colon trauma. Clin Colon Rectal Surg 2012; 25:189–99. https://doi.org/10.1055/s-0032-1329389

4. 

LoCicero J, Tajima T, Drapanas T. A half-century of experience in the management of colon injuries: changing concepts. J Trauma 1975; 15:575–9. https://doi.org/10.1097/00005373-197507000-00003

5. 

Yaw PB, Smith RN, Glover JL. Eight years experience with civilian injuries of the colon. Surg Gynecol Obstet 1977; 145:203–5.

6. 

Robbs JV. The alternative to colostomy for the injured colon. S Afr Med J 1978; 53:95–7.

7. 

Stone HH, Fabian TC. Management of perforating colon trauma: randomization between primary closure and exteriorization. Ann Surg 1979; 190:430–6. https://doi.org/10.1097/00000658-197910000-00002

8. 

Muffoletto JP, Tate JS. Colon trauma: primary repair evolving as the standard of care. J Natl Med Assoc 1996; 88:574–8.

9. 

Johnson JW, Gracias VH, Schwab CW, et al. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma 2001; 51:261–9. https://doi.org/10.1097/00005373-200108000-00007

10. 

Nelson RL, Singer M. Primary Repair for Penetrating Colon Injuries. Cochrane Database Syst Rev 2003; 3:CD002247. https://doi.org/10.1002/14651858.cd002247

11. 

George SM, Fabian TC, Voeller GR, Kudsk KA, Mangiante EC, Britt LG. Primary repair of colon wounds. A prospective trial in nonselected patients. Ann Surg 1989; 209:728–33. https://doi.org/10.1097/00000658-198906000-00010

12. 

Demetriades D, Murray JA, Chan L, et al. Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma Acute Care Surg 2001; 50:765–75. https://doi.org/10.1097/00005373-200105000-00001

13. 

Demetriades D, Rabinowitz B, Sofianos C, Prümm E. The management of colon injuries by primary repair or colostomy. Br J Surg 1985; 72:881–3. https://doi.org/10.1002/bjs.1800721110

14. 

Demetriades D, Charalambides D, Pantanowitz D. Gunshot wounds of the colon: role of primary repair. Ann R Coll Surg Engl 1992; 74:381–4.

15. 

Ivatury RR, Gaudino J, Nallathambi MN, Simon RJ, Kazigo ZJ, Stahl WM. Definitive treatment of colon injuries: a prospective study. Am Surg 1993; 59:43–9.

16. 

Cornwell EE, Velmahos GC, Berne TV, et al. The fate of colonic suture lines in high-risk trauma patients: a prospective analysis. J Am Coll Surg 1998; 187:58–63. https://doi.org/10.1016/S1072-7515(98)00111-2

17. 

Sasaki LS, Allaben RD, Golwala R, Mittal VK. Primary repair of colon injuries: a prospective randomized study. J Trauma 1995; 39:895–901. https://doi.org/10.1097/00005373-199511000-00013

18. 

Chappuis CW, Frey DJ, Dietzen CD, Panetta TP, Buechter KJ, Cohn I. Management of penetrating colon injuries. A prospective randomized trial. Ann Surg 1991; 213:492–7. https://doi.org/10.1097/00000658-199105000-00015

19. 

Gonzalez RP, Merlotti GJ, Holevar MR. Colostomy in penetrating colon injury: is it necessary? J Trauma 1996; 41:271–5. https://doi.org/10.1097/00005373-199608000-00012

20. 

Musa O, Ghildiyal JP, Pandey MC. 6 year prospective clinical trial of primary repair versus diversion colostomy in colonic injury cases. Indian J Surg 2010; 72:308–11. https://doi.org/10.1007/s12262-010-0191-4

21. 

Raines A, Garwe T, Albrecht R, et al. Immediate versus delayed repair of destructive bowel injuries in patients with an open abdomen. Am Surg 2015; 81:458–62.

22. 

Nadeem M, Bashir MM, Iqbal J, Rasheed A. Primary repair verses colostomy for colonic injuries. Ann King Edward Med Uni 2016; 10:462–5.

23. 

Berne JD, Velmahos GC, Chan LS, Asensio JA, Demetriades D. The high morbidity of colostomy closure after trauma: further support for the primary repair of colon injuries. Surgery 1998; 123:157–64. https://doi.org/10.1016/S0039-6060(98)70253-3

24. 

Riesener KP, Lehnen W, Höfer M, Kasperk R, Braun JC, Schumpelick V. Morbidity of ileostomy and colostomy closure: impact of surgical technique and perioperative treatment. World J Surg 1997; 21:103–8. https://doi.org/10.1007/s002689900201

25. 

Rotondo MF, Schwab CW, McGonigal MD, et al. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma Acute Care Surg 1993; 35:375–83. https://doi.org/10.1097/00005373-199309000-00008

26. 

Stewart RM, Fabian TC, Croce MA, Pritchard FE, Minard G, Kudsk KA. Is resection with primary anastomosis following destructive colon wounds always safe? Am J Surg 1994; 168:316–19. https://doi.org/10.1016/S0002-9610(05)80156-4

27. 

Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg 1983; 197:532–5. https://doi.org/10.1097/00000658-198305000-00005

28. 

Burlew CC, Moore EE, Cuschieri J, et al. Sew it up! A Western Trauma Association multi-institutional study of enteric injury management in the post injury open abdomen. J Trauma 2011; 70:273–7. https://doi.org/10.1097/TA.0b013e3182050eb7

29. 

Miller PR, Chang MC, Hoth JJ, Holmes JH, Meredith JW. Colonic resection in the setting of damage control laparotomy: is delayed anastomosis safe? Am Surg 2007; 73:606–9.

30. 

World Health Organization. International Classification of Diseases 10th Revision. Geneva: World Health Organization; 2010.

31. 

Tatebe L, Jennings A, Tatebe K, et al. Traumatic colon injury in damage control laparotomy – a multicenter trial: is it safe to do a delayed anastomosis [published online ahead of print December 23 2016]. J Trauma Acute Care Surg 2016. https://doi.org/10.1097/TA.0000000000001349

32. 

Weinberg JA, Griffin RL, Vandromme MJ, et al. Management of colon wounds in the setting of damage control laparotomy: a cautionary tale. J Trauma 2009; 67:929–35. https://doi.org/10.1097/TA.0b013e3181991ab0


Comments on this article



View all comments  |  Add comment 





Home  Editorial Board  Search  Current Issue  Archive Issues  Announcements  Aims & Scope  About the Journal  How to Submit  Contact Us
Find out how to become a part of the HMJ  |   CLICK HERE >>
© Copyright 2012 - 2013 HMJ - HAMDAN Medical Journal. All Rights Reserved         Website Developed By Cedar Solutions INDIA