Traumatic Colon Injuries
April 29, 2022 - read ≈ 15 min
Sarabeth A. Spitzer, MD
Department of Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA
Megan L. Sulciner, MD
Department of Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA
Jennifer S. Davids, MD
Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
Nelya Melnitchouk, MD, MSc
Department of Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA
Colonic injuries may be caused by either penetrating or blunt trauma. Colonic injury from penetrating injury is far more common and often found at the transverse colon, in part due to its anterior position in the abdomen [1,2,3].
In a retrospective study of the primary mechanism of colonic injury in United States military personnel, gunshot wounds were responsible for over 50% of colorectal injury and explosion or blast injuries were responsible for 35% . In civilians, gunshot wounds compromise the majority of colon injury mechanisms, followed by stab wounds .
While less common, blunt trauma resulting in colonic injury is often devastating due to the high force required to result in significant injury to the colon [2,3,6]. The mechanism of injury in civilians is most commonly motor vehicle collision (MVC), though other etiologies include assault, pedestrian collision, and falls .
In the event that blunt trauma results in colonic injury, the scope of injury burden is likely to be extensive with concern for perforation, serosal tears, mesenteric rents with associated devascularization, and ischemia . The most common site of blunt trauma colonic injuries is the right colon due to its thinner walls .
Though the management of colonic injuries has historically been considered controversial regarding the decision to perform a primary anastomosis or colonic diversion, there is now strong evidence to support the safety of primary anastomosis in qualifying trauma patients . The indication for ostomy creation in trauma patients is far more limited than previously considered.
II. Clinical Presentation
Colonic injury in the setting of trauma can have a wide range of clinical presentations. A high suspicion for injury is necessary, as hollow viscus injury may not be immediately evident on primary survey. Circumstances that raise particular concern for colon injuries include penetrating wounds to the chest, flank, abdomen, and back. Any penetrating wound below the fourth intercostal space (nipple line) should be treated with concern for abdominal trauma.
Patients will likely present with generalized abdominal tenderness, abdominal pain, and/or evidence of peritonitis. Blood on digital rectal exam is highly suggestive of a colonic or rectal injury, though the lack of blood does not rule out an injury .
As with all trauma patients, a thorough history and physical exam are critical in the initial evaluation. Special attention should be paid to the perineum, anus, rectal vault, and prostate. A digital rectal exam is crucial to evaluation of a patient with concern for colonic injury [2,3].
For those presenting with either penetrating or blunt abdominal trauma who are hemodynamically unstable, a focused assessment with sonography in trauma (FAST) scan can be considered as an adjunct to the primary survey prior to proceeding to the operating room (OR).
For those with penetrating abdominal trauma who are hemodynamically stable, a computed tomography (CT) scan of the abdomen and pelvis with intravenous (IV) contrast is helpful in determining the extent of injury. Extraluminal air, intraperitoneal fluid, pneumoperitoneum, and colonic wall thickening are suggestive of a colonic injury.
Notably, if the patient remains hemodynamically stable, non-peritoneal on abdominal exam, and there is no evidence of violation of the fascia on CT or physical exam, a local wound exploration may be attempted at bedside prior to determining the need for the OR .
Individuals presenting with blunt abdominal trauma who are hemodynamically stable should also be evaluated with a CT scan. If findings on CT are concerning for perforation or there is high suspicion for colonic injury, the patient should be evaluated in the OR. Missed colonic injuries have a high mortality and morbidity, and thus those managed non-operatively should be followed closely with serial abdominal exams and a high index of suspicion .
The American Association for the Surgery of Trauma (AAST) has a helpful grading system that aids in management of traumatic colonic injuries :
- Grade I: Hematoma or contusion without devascularization (Nondestructive),(Figure 1)
- Grade II: Laceration <50% circumference (Nondestructive),(Figure 2)
- Grade III: Laceration >50% of circumference without transection (selected injuries only considered nondestructive),(Figure 3)
- Grade IV: Transection of the colon (Destructive),(Figure 4)
- Grade V: Transection of the colon wall with segmental tissue loss, devascularized segment (Destructive),(Figure 5)
Initial management includes standard resuscitation with blood products as needed . Preoperative IV antibiotics should be administered to decrease risk of postoperative surgical site infection. Cefazolin (2g IV if <120kg, 3g IV if ≥120kg) plus metronidazole 500mg IV or alternatively a second-generation cephalosporin such as cefoxitin 2g IV or cefotetan 2g IV can be given.
Preoperative antibiotics should be continued at a minimum for 24 hours post-operatively, with continuation for four days total if evidence of significant intra-abdominal spillage is found .
Historically, traumatic colon injuries were managed almost universally with colostomy or injury exteriorization. However, the safety of primary anastomosis for select trauma patients has been shown extensively in multiple randomized controlled trials [11,12,13,14]. We now conservatively recommend following Stewart’s Protocol when deciding definitive management for operative colonic injuries (Figure 6) [3,15].
Notably, the Eastern Association for the Surgery of Trauma (EAST) conditionally recommends consideration of resection and anastomosis in all patients- including considered higher risk by Stewart’s protocol with ostomy formation only in select patients . Though these guidelines are based on civilian trauma, it is therefore reasonable to consider resection and anstomosis for all patients with destructive injuries.
The first determination that should be made when choosing appropriate operative management is whether the patient has a non-destructive or destructive injury . Non-destructive injuries include Grade I, Grade II and select Grade III injuries. There is now overwhelming evidence to suggest that non-destructive colonic injures can be managed with debridement or resection with primary repair, regardless of whether fecal contamination is present [12,13,14].
There is no evidence to suggest that fecal contamination increases risk of leak, though there is an increased risk of intra-abdominal abscess . These guidelines should be followed regardless of the presence of additional intra-abdominal injuries .
Destructive injuries are defined to be select Grade III, all Grade IV and all grade V injuries. If a destructive injury is present, debridement or resection with primary anastomosis is recommended in individuals who both do not have additional comorbidities and who have received fewer than 6 units of pack red blood cell (pRBC) transfusions [15,17,18,19,20,21].
For individuals who have significant comorbidities or who have received 6 or more units pRBC, fecal diversion or exteriorization of injury is recommended, though resection and anastomosis may be appropriate in select patients pending clinical appearance per EAST guidelines . Notably, fecal contamination is not a determining factor in definitive surgical management. 
During damage-control laparotomies, in which the patient is too unstable for definitive management of the colonic injury, the colon is often left in discontinuity to allow for expedited arrival in an intensive care unit [11,12].
Definitive surgical management of these patients during second-look laparotomy poses a significant challenge, as multiple studies have shown a high leak rate in delayed anastomoses [22,23,24,25].
However, a reduced leak rate has been associated with anastomoses performed in individuals who fit Stewart’s criteria for primary anastomosis under initial management [26,27,28], i.e., when performed in patients with a non-destructive injury, few comorbidities and who received fewer than 6 units pRBC. We therefore recommend following these same guidelines when determining management of colon injuries on second-look.
Some technical tips that surgeons may find helpful:
- Dissect fat off colon wall to fully visualize wound
- Debride non-viable tissue
- Primary repair should be performed, reapproximating the bowel wall so as to avoid narrowing of the colonic lumen. The mucosa should be fully imbricated.
- Two layer closure: inner full thickness with absorbable 3-0 suture, outer seromuscular closure with interrupted silk 3-0 Lembert
- Single layer closure: full thickness running or interrupted 2-0 or 3-0 PDS, or interrupted 4-0 silk full thickness are acceptable options
Conventionally, primary skin closure has been associated with significantly increased risk of wound infection and fascial dehiscence . Nevertheless, if there is minimal feculent contamination, and the patient does not have strong risk factors for infection (such as diabetes or immunosuppression), reapproximating the skin loosely with staples (+/- wicks), or an incisional wound vac is a safe option. More data are needed for definitive recommendation of incisional wound-management post-operatively  given increased infection rates with primary closure.
V. Postoperative Management
Patients should be monitored closely post-operatively for anastomotic leak, development of intra-abdominal abscess, bowel obstruction, or ileus . Prophylactic antibiotics should be continued 24 hours post-operatively, or for a total of four days depending on the extent of intra-abdominal fecal contamination .
Patients with colonic injuries have a high incidence of post-operative complications; approximately 20% of individuals with colonic injury will go on to experience abdominal sepsis .
Other commonly seen complications include suture line and intra-abdominal abscess. While these were historically thought to occur more frequently with left sided anastomoses, most recent data did not find any association with location of colon injury to risk of intra-abdominal abscess or dehiscence .
In addition, while there was increased risk of intra-abdominal abscess with fecal contamination, there was no increased risk of suture line dehiscence .
Depending on hospital capabilities, intra-abdominal abscess management can range from antibiotics alone to antibiotics with percutaneous drainage, recommended generally for abscesses over 3 cm, to surgical management with failed prior therapy .
Management of suture line dehiscence or anastomotic leak often requires operative intervention (laparotomy, washout, wide drainage, conversion to an end colostomy or creation of a diverting loop ileostomy).
- Penetrating colonic injuries are more common, though blunt are often associated with devastating injuries
- Primary operative management of colon injuries should be managed using Stewart’s algorithm
- Non-devastating injury can be managed with debridement or resection with primary repair
- Devastating injury:
- No comorbidities AND fewer than 6u pRBC can be managed with debridement or resection with primary repair
- Comorbidities OR 6u or greater pRBC can be managed with fecal diversion or exteriorization
- Damage-control laparotomy for patients who require massive ongoing resuscitation; colon may be stapled off and left in discontinuity, with either ostomy or anastomosis at second-look laparotomy
- The presence of fecal spillage does not mandate ostomy creation
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