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Identifying the low-risk patient with penetrating colonic injury for selective use of primary repair
S C Schultz1, C M Magnant, M F Richman
1Department of Surgery, Georgetown University Hospital, Washington, District of Columbia.
Insights
This study identified low-risk patients with penetrating colon injuries who can safely undergo primary repair. Minimizing extensive morbidity and mortality is achievable with careful patient selection and management strategies.
Area of Science:
- Trauma Surgery
- Colorectal Surgery
- Surgical Outcomes
Background:
- Mortality for penetrating colonic injuries has decreased, shifting focus to reducing morbidity.
- Identifying patients at low risk for complications after primary repair is crucial.
Purpose of the Study:
- To identify patients at low risk for colon-related extensive morbidity after primary repair of penetrating colonic injury.
Main Methods:
- Retrospective review of 100 patients with penetrating colonic injuries surviving over 24 hours.
- Data collected: injury mechanism, management, location, Trauma Score (TS), Penetrating Abdominal Trauma Index (PATI), Flint Colon Injury Score (FCIS), operative time, blood transfused, preoperative shock.
- Analysis of injury severity and patient outcomes.
Main Results:
- Only 2% extensive morbidity (parastomal hernia, wound dehiscence) in this series.
- No intraperitoneal abscesses occurred.
- Low morbidity attributed to high TS, low PATI, low FCIS, and fewer associated intra-abdominal injuries.
Conclusions:
- Primary repair is safe for selected patients with penetrating colonic injuries.
- Patients with high TS, low PATI/FCIS, and minimal associated injuries have low morbidity risk.
- This approach can minimize morbidity and mortality in penetrating colon trauma.
Abstract:
As the mortality rate for penetrating colonic injuries approaches zero, emphasis has shifted toward reducing associated morbidity. This study was done to identify patients at low risk for colon-related extensive morbidity after primary repair of a penetrating colonic injury. The records of 100 consecutive patients admitted to the District of Columbia General Hospital (DCGH) between 1984 to 1990, surviving more than 24 hours after full-thickness penetrating colonic injuries, were retrospectively reviewed. Data collection included mechanism, management and anatomic location of the colonic injury. Severity of injury was evaluated by the Trauma Score (TS), Penetrating Abdominal Trauma Index (PATI), Flint Colon Injury Score (FCIS), time in the operating room, blood transfused during the first 24 hours and presence of preoperative shock (systolic blood pressure less than 90 millimeters of mercury). Mechanism of injury included 97 gunshot wounds and three stab wounds. Fifty-seven patients had primary repair (17 having resection and anastomosis) and 43 had colostomy. The anatomic location of injury was right colon in 37, transverse colon in 27, left colon in 35 and multiple sites (two) in one patient. In this series, only two patients had colon-related extensive morbidity--a parastomal hernia and wound dehiscence, both requiring operative intervention. There were no instances of intraperitoneal abscess formation. One patient died from overwhelming pneumonia after segmental resection of the colon with primary anastomosis. The literature reports a 12 to 42 percent colon-related morbidity rate in patients sustaining penetrating colonic injuries. This series from DCGH represents the lowest colon-related extensive morbidity and mortality rates reported to date in any substantial series of penetrating abdominal trauma. We attribute the 2 percent extensive morbidity rate to high TS (mean of 15.7), low PATI (mean of 24.2), low FCIS (mean of 1.9) and few associated intra-abdominal injuries (59 percent of patients with less than two). We have identified a group of patients with full-thickness penetrating injuries to the colon, few associated intra-abdominal injuries, high TS, low PATI and low FCIS who can be managed safely and judiciously by primary repair without undue morbidity and mortality.