Civilian colon trauma - Factors that predict success by primary repair

BACKGROUND: Primary repair has become the most common method of treatment for civilian injuries of the colon. However, colostomy may still be required in selected patients. AIMS: This study was undertaken to identify factors for the performance of colostomy in patients with colon injuries. METHODS: During a 60-month period, all penetrating injuries to the colon treated at Saint Louis University Hospital were evaluated. All patients underwent an operation within six hours of injury. Rectal injuries were excluded. RESULTS: One hundred thirty consecutive patients with injuries to the colon were identified. Primary repair was performed in 81 patients (62 percent). Fecal diversion was used in 49 patients (38 percent). No deaths occurred related to colon injury. Complications related to colon injury included wound infections in 22 patients (17 percent) and intra-abdominal complications in 16 patients (abscess, 14; fecal fistula, 1). Wound complications were most closely related to whether the skin was closed primarily or left open (22 vs. 8 percent). Intra-abdominal complications occurred in 7 percent of patients in whom the colon injury was closed primarily and in 20 percent of patients in whom a stoma was created (P > 0.05). Patients chosen for colostomy had significantly greater blood loss, more associated injuries, and higher scores on the Abdominal Trauma Index (ATI) and Colon Injury Scale (CIS) and were more likely to have gross contamination (P < 0.05). Stepwise regression analysis of 13 factors revealed that only gross contamination and ATI predicted the occurrence of intra-abdominal complications and that CIS most closely predicted either wound or intra-abdominal complications. Stratification of patients based on an ATI of greater than or equal to 30 and a CIS of greater than or equal to 4 revealed no difference in outcome between primary repair and colostomy in either the low-risk or high-risk groups. However, severity of injury was greater in patients treated with colostomy. CONCLUSIONS: Primary repair can be accomplished with low morbidity in the majority of civilians with penetrating injuries to the colon. Colostomy may be required in high-risk patients as defined by an ATI of greater than or equal to 30 in association with a CIS of greater than or equal to 4.