Primary repair of the colon: when is it a safe alternative?

Management of civilian colon injuries has clearly departed from the military directive advocating mandatory colostomy. The treatment of 228 colon injuries at the Denver General Hospital was reviewed to elucidate risk factors for colon-related complications and quantify the morbidity of available surgical treatment options. In our population, 68% of patients sustained gunshot wounds with a high percentage of severe colon injuries and associated abdominal organ damage. Primary repair was accomplished in 49% with 17% septic morbidity and 1% septic mortality rates. Colostomy was required in 36% with a cumulative septic morbidity of 48% and 2% septic mortality. The most common complications were abdominal abscess (12%), wound infection (7%), and fecal fistula (4%). Analysis of risk factors for colon-related morbidity showed that the Abdominal Trauma Index (ATI), colon injury severity, preoperative shock, and peritoneal contamination were most important. Synthesis of the treatment outcome and risk factor data yields a proposed management scheme for colon injuries that is based on the patient's hemodynamic status, colon injury severity, and ATI scores. Primary repair by either debridement and simple closure or resection with primary anastomosis is advocated for colon injuries in patients who are hemodynamically stable with an ATI score less than 25.