Stomas and Trauma

ABSTRACT

The use of stomas for the surgical treatment of abdominal trauma has generated controversy for the last two decades as surgeons have questioned the propriety of applying military standards of care to civilian injuries. While diversion has been advocated in the treatment of colon injuries to obviate the potential morbidity associated with anastomotic leak, multiple retrospective and prospective trials have consistently demonstrated improved outcomes with primary repair or resection and anastomosis. Initially, primary repair was proposed only in selected patients without shock, high CIS or ATI scores, or extensive fecal contamination. However, these negative variables contribute to an adverse outcome independent of the type of bowel repair. Colon injury itself logically predisposes patients to increased infectious complications but colostomy may actually increase morbidity, particularly if the risk of subsequent surgery to restore bowel continuity is factored in. High-velocity gunshot wounds are still best treated with diversion.

KEYWORDS

ATI (abdominal trauma index) - CIS (colon injury score) - colon injury - colostomy - anastomosis - prospective randomized trial - gunshot wounds

REFERENCES

• 1 Ogilvie W H. Abdominal wounds in the Western Desert.  Surg Gynecol Obstet . 1944;  78 225-238
• 2 Stone H H, Fabian T C. Management of perforating colon trauma: randomization between primary closure and exteriorization.  Ann Surg . 1979;  190 430-435
• 3 Chappuis C W, Frey D J, Dietzen C D. Management of penetrating colon injuries.  Ann Surg . 1991;  213 492-498
• 4 Sasaki L S, Allaben R D, Golwala R, Mittal V K. Primary repair of colon injuries: a prospective randomized study.  J Trauma . 1995;  39 895-901
• 5 Gonzalez R P, Merlotti G J, Holevar M R. Colostomy in penetrating colon injury: is it necessary?.  J Trauma . 1996;  41 271-275
• 6 Demetriades D, Murray J A, Chan L S. Penetrating colon injuries requiring resection: diversion or primary anastomosis?.  J Trauma . 2001;  50 765-775
• 7 Guarino J, Hassett J M, Luchette F A. Small bowel injuries: mechanisms, patterns and outcome.  J Trauma . 1995;  39 1076-1086
• 8 Wisner D H, Yong C, Blaisdell F W. Blunt intestinal injury: keys to diagnosis and management.  Arch Surg . 1990;  125 1319-1323
• 9 Feliciano D V, Moore E E, Mattox K L. Trauma.  3rd ed. Stamford, CT: Appleton and Lange 1996: 717-732
• 10 Malhotra A K, Fabian T C, Katsis S B. Blunt bowel and mesenteric injuries: The role of screening computed tomography.  J Trauma . 2000;  48 991-1000
• 11 McAnena O J, Marx J A, Moore E E. Peritoneal lavage enzyme determinations following blunt and penetrating abdominal trauma.  J Trauma . 1991;  31 1161-1164
• 12 Fang J F, Chen R J, Lin B C. Cell count ratio: new criterion of diagnostic peritoneal lavage for detection of hollow organ perforation.  J Trauma . 1998;  45 540-544
• 13 Hackam D J, Ali J, Jastaniah S S. Effects of other intraabdominal injuries on the diagnosis, management, and outcome of small bowel trauma.  J Trauma . 2000;  49 606-610
• 14 Fang J F, Chen R J, Lin BC et al. Small bowel perforation: is urgent surgery necessary?.  J Trauma . 1999;  47 515-520
• 15 Wisner D H. Injury to the stomach and small bowel. In: Feliciano DV, Moore EE, Mattox KL, eds. Trauma 3rd ed. Stamford, CT: Appleton and Lange 1996: 551-557.
• 16 Burch J M, Martin R M, Richardson R J. Evolution of the treatment of the injured colon in the 1980s.  Arch Surg . 1991;  126 979-984
• 17 Ivatury R R, Gaudino J, Nallathambi M N. Definitive treatment of colon injuries.  Am Surg . 1993;  59 43-49
• 18 Bartizal J F, Boyd D R, Folk F A. A critical review of the management of 392 colonic and rectal injuries.  Dis Colon & Rectum . 1974;  17 313-318
• 19 Eshraghi N, Mullins R J, Mayberry J C. Surveyed opinion of American trauma surgeons in management of colon injuries.  J Trauma . 1998;  44 93-97
• 20 Taheri P A, Ferrarra J J, Johnson C E. A convincing case for primary repair of penetrating colon injuries.  Am J Surg . 1992;  166 39-44
• 21 Sasaki L S, Mittal V, Allaben R D. Primary repair of colon injuries: A retrospective analysis.  Am Surg . 1994;  60 522-527
• 22 Stewart R M, Fabian T C, Croce M A. Is resection with primary anastomosis following destructive colon wounds always safe?.  Am J Surg . 1994;  168 316-319
• 23 Murray J A, Demetriades D, Colson M. Colonic resection in trauma: colostomy versus anastomosis.  J Trauma . 1999;  46 250-254
• 24 George S M, Fabian T C, Voeller G R. Primary repair of colon wounds.  Ann Surg . 1989;  209 728-734
• 25 Moore E E, Cogbill T H, Malangoni M A. Organ injury scaling, II: Pancreas, duodenum, small bowel, colon and rectum.  J Trauma . 1990;  30 1427-1429
• 26 Dente C J, Tyburski J, Wilson R F. Ostomy as a risk factor for posttraumatic infection in penetrating colonic injuries.  J Trauma . 2000;  49 628-635
• 27 Brundage S I, Jurkovich G I, Hoyt D B. Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial.  J Trauma . 2001;  51 1054-1061
• 28 Berne J D, Velmahos G C, Chan L S. The high morbidity of colostomy closure after trauma: further support for the primary repair of colon injuries.  Surgery . 1998;  123 157-163
• 29 Bellamy R F, Zajtchuk R. The physics and biophysics of wound ballistics. In: Zajtchuk R, Jenkins DP, Bellamy RF, Quick CM, eds. Textbook of Military Medicine: Conventional Warfare Washington DC: Office of the Surgeon General 1989: 107-162
• 30 Fabian T C. What's new in trauma and critical care?.  J Am Coll Surg . 2001;  192 276-286