Colon wound management and prograde colonic lavage in large bowel trauma

Abstract

Between 1983 and 1987 prograde colonic lavage was prospectively evaluated in 389 patients with colon trauma. Predefined high risk patients had exteriorization of the primarily sutured colon. Intraperitoneal primary closure was otherwise used. Patients received prograde colonic lavage by random allocation. The healing exteriorized colon was interiorized 5-10 days after the initial surgery. The median age was 29 years and only 28 patients were women. Injuries were due to stab (316), gunshot (54), shotgun (10) or blunt trauma (9). Exteriorization of the primarily sutured colon was carried out in 217 patients of whom 101 had prograde colonic lavage. Twenty (9 per cent) died. Of the survivors, 150 (76 per cent) had their colon successfully interiorized and this rate was unaffected by prograde colonic lavage. Intraperitoneal primary closure was performed in 172 patients of whom 91 had prograde colonic lavage. Seven (4 per cent) died. Mortality was directly related to the number of associated injuries. Prograde colonic lavage, irrespective of the type of colonic wound management used, did not reduce the mortality rate, which was 7.2 per cent for those who had such lavage and 6.6 per cent for the rest. Prograde colonic lavage cannot therefore be recommended in colon trauma.

Contemporary management of penetrating colon trauma

“…They concluded that ontable lavage is not necessary for the treatment of colon injuries. 25 We agree that this technique does not seem to improve operative results.…”

The management of colonic trauma in the damage control era

“…Of concern is the association with technical failure and/or poor patient selection and anastomotic breakdown in our series. 5,6,8 Inexperienced staff managing complex injuries will result in poor outcomes. This reflects systems failure and attention must be paid to ensuring that the appropriate levels of staff are involved in the management of these injuries.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12] Following the experience of military surgeons during the Second World War, mandatory diversion of all colonic injuries became the standard of care in civilian practice. 1,2 This dogma has been challenged since the last quarter of the 20th century as authors began to publish their experience with either exteriorised repair or selective primary repair (PR) of civilian colonic injuries.…”

“…1,2 This dogma has been challenged since the last quarter of the 20th century as authors began to publish their experience with either exteriorised repair or selective primary repair (PR) of civilian colonic injuries. [3][4][5][6][7][8][9][10]12 The pendulum of surgical opinion swung increasingly away from mandatory diversion towards a policy of almost universal PR. [13][14][15] The debate changed from which cases should be managed with PR of a colonic injury to which subgroups of patients still required a diversion.…”

“…[13][14][15][16][17] Several authors, however, have reported fairly large series of civilian colonic GSWs that were managed successfully by PR. [3][4][5][6][7][8][9][10]12 Management of destructive colonic injuries still appears to be highly individualised. The emergence of damage control (DC) surgery towards the end of the 20th century once again changed the debate about primary colonic repair.…”