title: Epidemiology of modern battlefield colorectal trauma: a review of 977 coalition casualties.
abstract: BACKGROUND
  Traumatic injuries to the lower gastrointestinal tract occur in up to 15% of all injured combatants, with significant morbidity (up to 75%) and mortality. The incidence, etiology, associated injuries, and overall mortality related to modern battlefield colorectal trauma are poorly characterized.
  
  
  METHODS
  Using data from the Joint Theater Trauma Registry and other Department of Defense electronic health records, the ongoing Joint Surgical Transcolonic Injury or Ostomy Multi-theater Assessment project quantifies epidemiologic trends in colon injury, risk factors for prolonged or perhaps unnecessary fecal diversion, and quality of life in US military personnel requiring colostomies. In the current study, all coalition troops with colon or rectal injuries as classified by DRG International Classification of Diseases-9th Rev. diagnosis and Abbreviated Injury Scale (AIS) codes in the Joint Theater Trauma Registry were included.
  
  
  RESULTS
  During 8 years, 977 coalition military personnel with colorectal injury were identified, with a mean (SD) Injury Severity Score (ISS) of 22.2 (13.2). Gunshot wounds remain the primary mechanism of injury (57.6%). Compared with personnel with colon injuries, those with rectal trauma sustained greater injury to face and extremities but fewer severe thoracic and abdominal injuries (p < 0.005). Overall fecal diversion rates were significantly higher in Iraq than in Afghanistan (38.7% vs. 31.6%, respectively; p = 0.03), predominantly owing to greater use of diversion for colon trauma. There was little difference in diversion rates between theaters for rectal injuries (59.6% vs. 50%, p < 0.15). The overall mortality rate was 8.2%. Notably, the mortality rate for patients with no fecal diversion (10.8%) was significantly greater than those with fecal diversion (3.7%, p < 0.0001).
  
  
  CONCLUSIONS
  Military personnel sustaining colon or rectal trauma continue to have elevated mortality rates, even after reaching surgical treatment facilities. Furthermore, associated serious injuries are commonly encountered. Fecal diversion in these patients may lead to reduced mortality, although prospective selection criteria for diversion do not currently exist. Future research into risk factors for colostomy creation, timing of diversion in relation to damage-control laparotomy, and quality of life in veterans with stomas will produce useful insights and help guide therapy.
  
  
  METHODS
  Epidemiologic study, level III.
authors.affiliation: Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA. sean.glasgow@amedd.army.mil
authors.forename: Sean C
authors.initials: SC
authors.lastname: Glasgow
authors.forename: Scott R
authors.initials: SR
authors.lastname: Steele
authors.forename: James E
authors.initials: JE
authors.lastname: Duncan
authors.forename: Todd E
authors.initials: TE
authors.lastname: Rasmussen
mesh_terms: D000007:Abdominal Injuries / Q000453:epidemiology* / Q000209:etiology / Q000601:surgery; D000328:Adult; D000346:Afghanistan; D001753:Blast Injuries / Q000150:complications*; D015331:Cohort Studies; D003106:Colon / Q000293:injuries / Q000601:surgery; D003125:Colostomy / Q000379:methods / Q000706:statistics & numerical data; D013505:Digestive System Surgical Procedures / Q000379:methods / Q000706:statistics & numerical data; D004638:Emergency Treatment / Q000379:methods; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007493:Iraq; D007813:Laparotomy / Q000379:methods / Q000706:statistics & numerical data; D008297:Male; D054527:Mass Casualty Incidents / Q000401:mortality / Q000706:statistics & numerical data*; D008875:Middle Aged; D008889:Military Personnel; D011379:Prognosis; D012007:Rectum / Q000293:injuries / Q000601:surgery; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D014857:Warfare; D055815:Young Adult