Chapter 33: Colon and Rectal Trauma

Demetrios Demetriades; Elizabeth Benjamin; Kenji Inaba

COLON INJURIES

Introduction

The approach to patients who have sustained colon trauma has changed dramatically over the last several decades. This has been associated with a significant improvement in colon-related mortality from approximately 60% during World War I to 40% during World War II, 10% during the Vietnam War and even lower in the current era. Colon-related morbidity, however, still remains high and in most prospective studies the abdominal sepsis rate is approximately 20% (Table 33-1).^{1,2,3,4,5,6,7} In patients with destructive colon injuries, high Penetrating Abdominal Trauma Index (PATI), or multiple blood transfusions the incidence of intra-abdominal sepsis has been reported to be as high as 27%.^8,9

TABLE 33-1Incidence of Abdominal Septic Complications in Colon Injuries (Prospective Studies)

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TABLE 33-1 Incidence of Abdominal Septic Complications in Colon Injuries (Prospective Studies)

Author

Number of patients

Abdominal sepsis (%)

George et al¹

102

Chappuis et al²

Demetriades et al³

100

Ivatury et al⁴

252

Gonzalez et al⁵

114

Demetriades et al⁶

297

Overall

921

Epidemiology

In the United States, the overall incidence of blunt and penetrating trauma remains similar⁷; however, this will vary depending on the center's incoming demographic. In general, blunt trauma patients can be expected to be older, have a higher total burden of injury and endure longer hospital stays with a higher mortality and complication rate.⁷ In abdominal gunshot wounds the colon is the second most commonly injured organ after the small bowel and is involved in approximately 27% of cases undergoing laparotomy.^10,11 In anterior abdominal stab wounds the colon is the third most commonly injured organ after the liver and small bowel and is found in approximately 18% of patients undergoing laparotomy. In posterior stab wounds the colon is the most commonly injured organ and is seen in about 20% of patients undergoing laparotomy.¹² The right colon is most frequently injured after blunt force trauma⁷ whereas the transverse colon is the most commonly injured segment after gunshot wounds and the left colon the most commonly injured segment after stab wounds.

Stab wounds or low-velocity civilian gunshot wounds usually cause limited damage and most are amenable to debridement and primary repair (Fig. 33-1). High-velocity penetrating injuries, such as in war-related trauma, cause major tissue damage and almost always require colon resection (Fig. 33-2).