Proximal protective diverting ostomy following colon anastomosis for penetrating trauma may not be protective: A matched cohort study

INTRODUCTION

Despite the shift toward liberal primary anastomosis in penetrating colon injuries, some surgeons recommend a protective diverting ostomy (DO) proximal to the anastomosis. This study evaluates the effect of DO on outcomes in patients undergoing colon resection and anastomosis following penetrating trauma.

METHODS

The TQIP database (2013-2018) was queried for penetrating colon injuries undergoing colectomy and anastomosis. Patients receiving DO were propensity matched to patients without diverting ostomy (woDO) (1:3). Outcomes were compared between groups.

RESULTS

After matching, 89 DO patients were analyzed. The DO group had more surgical site infections (32 ​% vs. 21 ​%; p ​< ​0.05) and longer hospital stay (20 [13-27] vs. 15 [9-25]; p ​< ​0.05) compared to the woDO group. Mortality and unplanned operations were similar between groups.

CONCLUSIONS

Diverting ostomy after colon resection and anastomosis is associated with increased infectious complications without decreasing unplanned operations or mortality. Its routine role in penetrating colon trauma needs reassessment.

Complete transection of the descending colon following blunt abdominal trauma

We present the case of a man in his 30s who was crushed between two vehicles sustaining blunt trauma to his lower limbs and torso. The patient was in shock on arrival to the emergency department, and immediate resuscitation was given with massive transfusion protocol activation. Once the patient's haemodynamic status was stabilised, a CT scan revealed a complete colon transection. The patient was taken to the operating theatre where a midline laparotomy was performed, and the transected descending colon was managed with a segmental resection and handsewn anastomosis. The patient followed an unremarkable postoperative course, with bowels opening on day 8 postoperatively. Colon injuries are rare following blunt abdominal trauma, and a delay in diagnosis may lead to increased morbidity and mortality. As such, a low threshold for surgical intervention is recommended.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Contemporary Trends and Outcomes of Blunt Traumatic Colon Injuries Requiring Resection

BACKGROUND

After traumatic injury, primary anastomosis after colon resection has overtaken ostomy diversion. Improved technology facilitating primary anastomosis speed and integrity may have driven this change. Trends in ostomy versus anastomosis have yet to be quantified, and recent literature comparing outcomes is incomplete.

METHODS

The National Trauma Databank (2007-2014) was queried for all blunt colon injuries requiring resection. Patients were dichotomized into study groups based on whether they underwent ostomy creation. Ostomy creation frequency was compared over time. After subgrouping patients by colon injury location, multivariate regression adjusted for baseline characteristics and evaluated the impact of ostomy on clinical outcomes.

RESULTS

A total of 13,949 colon injuries requiring colectomy were identified. Ostomy frequency did not vary by study year (P = 0.536). Univariate analysis showed that patients undergoing ostomy were older (median, 40 versus 32; P < 0.001) and more often had comorbidities (65% versus 56%; P < 0.001). Multivariate analysis showed that ostomy creation was significantly associated with lower mortality after sigmoid colon injury (odds ratio, 0.512; P = 0.011) and higher rates of unplanned reoperation after transverse colon injury (odds ratio, 3.135; P = 0.048). Across all colon injuries, ostomies were significantly associated with longer hospital length of stay, intensive care unit length of stay, and ventilator days.

CONCLUSIONS

Ostomy creation for colonic injury has reached an equilibrium trough. The impact of ostomy creation varies by not only clinical outcome but also injury location. Further study is needed to define the optimal surgical management for blunt colon injuries requiring resection.