Colorectal injury: where do we stand with repair?

BACKGROUND

The chief danger of colonic injury is sepsis resulting from faecal spill. Primary repair is now well established in the USA, particularly injuries, in up to 81% of patients. However, in Australia, highly destructive blunt trauma forms a larger proportion of injuries, and the purpose of this study was to determine if there are any contrasts in the management of these patients.

METHOD

A retrospective survey was undertaken over the past 20 years of all of the patients with full-thickness colorectal injuries presenting at the three major hospitals which receive multi-trauma patients in Brisbane.

RESULTS

Of 112 patients 114 sustained full-thickness colorectal injuries. Forty patients had penetrating injuries, 41 had blunt injuries and 33 had iatrogenic injuries. Primary repair or resection and anastomosis was performed in 39% of patients with colonic injuries and the leak rate was 8%. Exteriorized repairs had a 67% leak rate. A colostomy was used in 58% of patients. The mortality for penetrating injuries was zero. The mortality for blunt colonic injuries was 17% and for iatrogenic injuries was 7%, but for blunt rectal injuries was 50%. The overall mortality was 10%. Colostomy closure had a 20% morbidity but no mortality.

CONCLUSIONS

In the absence of shock, associated injuries, or gross faecal soiling primary repair or resection with anastomosis may be considered. For blunt injury, colostomy is still usually indicated, often with resection. For iatrogenic injury, when seen early, primary repair can be performed. We do not recommend exteriorized repair. Extraperitoneal rectal injuries require proximal colostomy and distal washout, with drainage where appropriate. Blunt devitalizing injury is relatively more common in Australia than in the USA, and therefore there is less indication here for primary repair. Colostomy remains an important consideration in operative management.