A half-century of experience in the management of colon injuries: changing concepts

A total of 773 patients who sustained colon injuries during the period 1927-1974 at Charity Hospital of Louisiana in New Orleans was reviewed. For purposes of comparison the patients were grouped into three 15-year periods. The first period (1927-1942) represented patients treated in the pre-antibiotic era exclusively with exteriorization. The second period (1943-1958) included patients in whom a program of selective surgical treatment of colon injuries was instituted, and included the advent of antibiotics and improved resuscitation. The final period (1959-1974) represented the increased use of primary repair of colon injuries. In comparing the three consecutive periods there was a marked increase (106%) in the frequency of colon injuries, primarily due to gunshot wounds in young males. The average age of our patients during this last 15-year period was 27 years. The transverse colon was the most frequent site of the injury (37%) followed by the left colon (31%) and the right colon (20%). From 60 to 75% of the patients also had associated intra-abdominal or other injuries. The mortality from colon injuries has declined steadily from 67.5% in the initial period to a low of 9.2% during the past 15 years. This drop in mortality occurred despite the fact that a larger number of patients sustained associated injuries. When comparing the three methods of therapy, primary repair, repair with proximal colostomy, and exteriorization was used less frequently during the past 15 years. It was the exclusive form of therapy in all patients treated before 1942. With the advent of selective management and antibiotics we have seen a transition from exteriorization to primary repair without colostomy. During the past 15 years primary repair was used in 44% of the patients; repair with a proximal decompressive procedure was utilized in 22%; exteriorization was carried out in 33% of the patients. The selective use of primary repair has been associated with lower mortality, fewer complications, and a shorter hospital stay, despite the increasing incidence of multiple associated injuries in this latter group of patients. Based on these studies, a plea is made for the selective use of primary repair of colon injuries of patients in good general condition when the local injury to the colon appears to warrant such an approach=