Primary repair of civilian colon injuries is safe in the damage control scenario.
BACKGROUND
Although the safety of primary repair/anastomosis for civilian colon injuries after standard laparotomy (SL) has been established, recent civilian and military reports have questioned the advisability of this technique in the patient requiring damage control laparotomy (DL). We hypothesized that, even in the high-risk DL group, primary repair could be safely used after patient stabilization and that the open abdomen would facilitate the safety of this procedure.


METHODS
All patients admitted to our level 1 trauma center with a colon injury over a 7-year period were reviewed from a prospectively collected database. Patients were categorized as having undergone either SL or DL at initial operation. Primary variables of interest were as follows: injury patterns; method of primary repair (suture repair, resection and primary anastomosis, resection and delayed anastomosis); diversion techniques (planned diversion or diversion for anastomotic dehiscence); and colon-related morbidity and mortality. High-risk status in the DL group was identified by the following physiologic variables: mean injury severity score (ISS), red blood cell (RBC) transfusions, ventilator days, and intensive care unit (ICU) duration of stay.


RESULTS
During the study period, 309 patients had colonic wounds identified at laparotomy. Of these 309 patients, 280 (91%) underwent SL, of which 277 (98.9%) had primary colonic repair/anastomosis. In the SL group, 1 (0.3%) patient required diversion for subsequent leak and 2 (0.6%) patients had planned diversion The remaining 29 hemodynamically unstable patients required DL. Mean +/- standard deviation indices of injury severity in this group included: ISS = 36.2 +/- 15.8, RBC = 28.7 +/- 25.4 units, ventilator days = 20.1 +/- 16.3, ICU duration of stay = 29.5 +/- 21.6 days. Of the 29 patients in the DL group, 21 (72%) had bowel continuity successfully reestablished in 2.6 +/- 2 days after initial attempts at primary suture repair or resection/anastomosis. A total of 4 (16.6%) patients in this group developed colon-related complications, 3 of whom were treated with subsequent diversion before definitive abdominal closure. One patient developed a late leak. (day 43). Another 4 (13.8%) patients had planned diversion for injuries that were considered to be high risk for leak at subsequent reexploration. There were no colon-related deaths in either group.


CONCLUSIONS
Primary repair of colon injuries appears safe in the majority of patients after DL. Although it is associated with a higher leak rate than SL, the open abdomen affords careful inspection of abdominal contents at reexploration to identify patients who require subsequent diversion.
Kashuk
Jeffry L
JL
Department of Surgery, Denver Health Medical Center, University of Colorado Denver and Health Sciences Center, Denver, CO 80204, USA. jeffry.kashuk@dhha.org
Cothren
C Clay
CC
Moore
Ernest E
EE
Johnson
Jeffrey L
JL
Biffl
Walter L
WL
Barnett
Carlton C
CC
D000328:Adult; D003106:Colon / Q000293:injuries* / Q000601:surgery; D005260:Female; D006801:Humans; D007813:Laparotomy / Q000379:methods*; D008297:Male; D008875:Middle Aged