Trauma of the Colon, Rectum, and Anus
The management of colonic trauma has evolved considerably over the past century and a half. The initial futility of abdominal surgery during the American Civil War gave way to mandatory colostomy in World War II. Recent well-done trials have now demonstra
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Key Concepts • Primary repair is the treatment of choice for all nondestructive colonic injuries. • Resection and anastomosis is the treatment of choice for most destructive colonic injuries. • Diversion should be considered in patients undergoing damage-control laparotomy or who have significant pre-injury comorbidities or significant hemodynamic derangement. • Primary repair is appropriate for accessible rectal injuries. • Diversion alone without direct repair is sufficient to treat isolated extraperitoneal rectal injuries. • Presacral drainage and distal washout are no longer recommended for rectal injuries. • Anal injuries are often amenable to delayed reconstruction.
Introduction The management of the injured colon has evolved considerably over the past century and a half. Accumulated wartime experience demonstrates that mortality fell from >90% during the American Civil War to 500 white cells/>100,000 red cells on lavage analysis is highly suggestive of significant intra-abdominal injury and should prompt exploration [5]. Laparoscopy has little role in evaluating the most penetrating anterior abdominal trauma, but may be useful in stable patients with back, flank, or pelvic wounds.
The accumulated experience of military surgeons has been critical to the evolution of current civilian colonic injury management [6]. With only a few exceptions, laparotomy was considered futile in the management of penetrating abdominal injury until the early stages of World War I. Wallace, in defiance of accepted doctrine, insisted that hemorrhage was killing soldiers and advocated for prompt laparotomy [7]. This approach was accepted by June 1915 and was augmented by more expeditious evacuation of the wounded (Figure 43-7); mortality decreased from 87 to 40% by Armistice Day [8]. Ogilvie reported his experience in the North African Campaign in World War II, recommending colostomy, although his data did not clearly support it. Mortality ranged from 44% for simple suture repair to 100% for resection and anastomosis [9]. Multiple authors have failed to find the “colostomy or court-martial” edict, but the US Army Surgeon General Circular clearly mandated colostomy for penetrating injuries [10]. Regardless of the true impact of this specifically, mortality declined further to around 30%. Mortality continued to improve through the Korean War, but primary repair remained rare. During the Vietnam War, there were multiple series showing the feasibility of resection and anastomosis for right-sided injuries; left colon and rectal injuries were still treated with colostomy. Mortality fell to just over 13% [6]. Recent experiences in Iraq and Afghanistan with primary repair or resection and anastomosis showed some success in selected cases. However, intra-abdominal repair failure was >15% in one review, typically in patients with other injuries; such failure complicated subsequent continuity restoration in 75% of patients. This experience reinforces the concern for primary repair in patients who experience significant hemodynamic derangement pre- or
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