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Ostomies in Trauma
Matthew C. Byrnes and Greg J. Beilman
1 3
Introduction
Injuries to the colon represent a challenging and controversial facet of trauma surgery. Colonic trauma can be treated
with primary repair, diversion, resection and anastomosis or
resection and diversion, depending upon the extent of the
injury. These are the standard options for treating all types of
colon pathology; however, traumatic injuries to the colon
represent a fundamentally different form of colon pathology
compared to elective or other emergent colon procedures.
The injured colon often has vascular compromise.
Additionally, there is a likelihood of postoperative shock that
may lead to further malperfusion of the remaining colon segment. Trauma patients tend to be younger and healthier than
other populations requiring colon surgery, so they may be
more resistant to such insults. These divergent components
of colonic injuries have generated much of the controversy
that has surrounded the treatment of these injuries over the
past two decades.
Each avenue of the treatment algorithm has benefi ts and
pitfalls. The ultimate goal in treating colonic injuries is to
restore physiologic stability and avoid postoperative complications. Diversion has been historically considered to be the
safest option [ 1– 5 ] ; however, the abdomen must frequently
be left open after completing a trauma laparotomy due to
concerns for intra-abdominal compartment syndrome. An
ostomy adjacent to an open abdomen may yield increased
infectious complications. Additionally, there are more psychological components to consider when creating ostomies
in trauma patients [
than patients undergoing elective colon resections and are
never prepared for an ostomy prior to their injury. There are
also pitfalls to colonic repair without diversion. Trauma
patients may be multiply injured and have severe organ
M. C. Byrnes (*) • G. J. Beilman
Department of Surgery , University of Minnesota ,
Minneapolis , MN , USA
e-mail: byrne147@umn.edu
3, 4 ] . These patients tend to be younger
derangement. Each insult could be life threatening, so an
anastomotic leak could be a fatal complication.
Herein, we review the indications for colostomies in
trauma patients. We then review the techniques that can be
employed to create a manageable colostomy.
History
The fi rst serious attempts at performing laparotomy for
trauma took place in the late 1800s. Prior to this time, abdominal gunshot wounds were nearly universally fatal. Mortality
rates of abdominal gunshot wounds were well over 50% in
the fi rst half of World War II. Dr. Ogilvie in Great Britain and
the offi ce of the Surgeon General in the United States issued
separate decrees that colon trauma should be treated with
diversion [ 2, 3 ] . The mortality rates of colon injuries
decreased in the second half of WWII. This military dictum
was translated into civilian practice, and diversion became
the primary mode of treatment for several decades. In 1979,
Stone et al. performed a randomized, prospective trial
designed to evaluate diversion versus primary repair in a
highly selected population of injured patients (no fecal spillage, hemodynamically stable, and no delay to operation) [
They found decreased abdominal infections in the group
undergoing primary repair (15% versus 29%). This marked a
transition point favoring primary repair over ostomies in
trauma.
6 ] .
Indications for Colostomy – by Type of Injury
Colonic trauma can be categorized by the amount of damage
to the colon wall [ 3, 7 ] . Nondestructive injuries encompass
less than 50% of the circumference of the colon wall, do not
involve devascularization, and have minimal injury of the
surrounding tissue (Fig. 13.1 ). These lesions are most com-
monly caused by stab wounds or low velocity gunshot
wounds. Destructive injuries to the colon wall encompass
V.W. Fazio et al. (eds.), Atlas of Intestinal Stomas,
DOI 10.1007/978-0-387-78851-7_13, © Springer Science+Business Media, LLC 2012
151
152 M.C. Byrnes and G.J. Beilman
Fig. 13.1 Nondestructive colonic injury. Illustration © CCF Fig. 13.2 Simple destructive injury to right colon. Illustration © CCF
greater than 50% of the colon circumference or involve
devascularization (Figs. 13.2 – 13.4 ). These injuries are typi-
cally caused by blunt trauma or higher velocity gunshot
wounds. There is signifi cant variability in the presentation of
destructive lesions, with the spectrum ranging from simple
transection of the colon to complete obliteration of large segments of bowel in major blast injuries.
Numerous studies, review articles, and meta-analyses
have indicated that most nondestructive injuries can safely be
repaired primarily without diversion. There is a large volume
of retrospective data that indicate that primary repair is preferable to diversion [ 8– 13 ] . Maxwell et al. summarized these
studies and found an increased risk of complications among
patients who were diverted compared with patients who were
treated with repair without diversion (31% versus 14%) [ 1 ] .
However, mortality rates in these studies were less than 1%,
which suggests that they represented a low-risk patient population. Initial prospective studies were criticized because
they either excluded high-risk patients or were nonrandom-
6, 14, 15 ] . As such, it was generally agreed that low-
ized [
risk patients (no hypotension, no fecal spillage, no delay to
operation) could be treated without diversion, but there was
signifi cant debate about treating patients with a risk factor
for anastomotic failure. There are now several randomized
prospective studies that evaluated a mixture of nondestructive and destructive injuries among all patients regardless of
risk factors [
16– 19 ] . Complication rates ranged between
20% and 30% and were similar between the groups. Sasaki
et al. reported an additional 7% complication rate among
patients undergoing colostomy reversal [ 18 ] . The complica-
tion rate of colostomy reversal has been reported by other
authors and has been cited as an additional reason to perform
repair without diversion [ 20– 22 ] . A recent Cochrane meta-
analysis evaluated six randomized prospective trials comparing primary repair to diversion [ 23 ] . Mortality was similar
between the groups, but overall complications were higher
among the patients undergoing diversion (OR = 0.54).
The aforementioned studies included a mixture of nondestructive injuries amenable to primary repair and destructive
injuries requiring resection; however, few studies focused
specifi cally on destructive wounds. Accordingly, it is diffi cult to extrapolate these results to patients with higher grade,
destructive injuries. The largest prospective study to date
was published by Demetriades et al. in 2001 [ 24 ] . Nineteen
trauma centers participated in the study. All patients in the
study had a destructive injury that required resection. The
15313 Osto mies in Trauma
Fig. 13.3 Devascularization. Illustration © CCF
decision to divert the patient was left to the discretion of the
trauma surgeon. Mortality related to colon pathology was
1% in the diverted group and 0% in the nondiverted group.
There was a 6.6% anastomotic leak rate. Patients were categorized as high risk or low risk. High-risk patients were
defi ned as patients with hypotension, severe fecal spillage, a
penetrating abdominal trauma index of ³ 25, or the require-
ment of six or more units of packed red blood cells. This
group of patients had historically been considered to have the
highest risk of anastomotic complications. Complications
were similar between the high-risk patients who underwent
diversion or repair without diversion. The mortality rate
among high-risk diverted patients was higher than high-risk
patients who underwent repair without diversion (4.5% versus 0%). This led the authors to conclude that all patients
should be treated with anastomosis without diversion regardless of risk factors.
Historically, delayed time to operation has been considered an absolute indication for diversion. Kamwendo et al.
randomized patients with colonic injury to receive either primary repair or diversion [ 25 ] . Patients who underwent lapa-
rotomy within 12 h were compared to patients with delayed
treatment. There was not an increased risk of complications
Fig. 13.4 Major blast injury. Illustration © CCF
among the patients who underwent primary repair after an
operative delay. The authors concluded that operative delay
is not an indication for colostomy.
Although the preponderance of the literature supports
repair of colonic injuries without diversion, there are certain
high-risk populations that have been poorly studied. These
groups include patients who have multiple risk factors
(hypotension, fecal spillage, and delayed operation), patients
with severe edema of the bowel wall, or patients with high
velocity (military type) gunshot wounds or severe blast injuries with a signifi cant amount of devitalized tissue. Previous
studies have indicated that repair without diversion is appropriate in patients with a single high-risk factor; however, no
studies have evaluated the select group of patients with multiple high-risk factors for anastomotic failure. Accordingly,
we recommend proceeding with diversion in these groups of
patients. Severe edema of the bowel wall increases the likelihood of anastomotic failure, as the tissue is not as amenable
to healing. Groups of patients suffering high-velocity gunshot wounds or severe blast injuries have never been evaluated prospectively. Nonetheless, the general wisdom among
surgeons is that diversion is safer in this population. We also
recommend proceeding with colostomy in patients on highdose vasopressor medications, as perfusion to the anastomotic segment may be compromised.
154 M.C. Byrnes and G.J. Beilman
Delayed repair (24–48 h) is another option in the treatment of colonic injuries. Unstable trauma patients should
have a truncated operation that is completed with an open
abdomen. In this “damage control” procedure, hemorrhagic
solid organs are packed, vascular injuries are rapidly controlled, and enterotomies are repaired or resected without
anastomosis or diversion. The defi nitive operation can then
be accomplished in 24–48 h when the patient is stable and
coagulopathies and hypothermia have been corrected. In this
setting, there is generally a signifi cant amount of fl uid resuscitation that occurs during the interval between operations, so
the bowel may be too edematous to support an anastomosis.
Indications for Colostomy – by Site of Injury
Historically, left-sided anastomoses have been considered to
be at higher risk of failure. There is also a higher theoretical
risk of sepsis with left-sided anastomotic leaks, as the bacterial load is higher in this section of the colon. The largest retrospective study reported an increased risk of complications
of colocolostomy compared with ileocolostomy [
largest prospective trial to date reported a 4.2% complication
rate with ileocolostomy versus 8.9% with colocolostomy
[ 24 ] . Considering all of the aforementioned data, diversion
should be seriously considered for patients with a left-sided
colonic injury and a high risk factor for anastomotic failure.
Rectal injuries differ from colonic injuries in terms of
blood supply and diffi culty of operation. Rectal injuries can
be diffi cult to expose and repair, especially in patients with a
narrow pelvis. Intraperitoneal rectal injuries that can easily
be visualized can be repaired without diversion in the lowestrisk patients [ 27, 28 ] . However, if the injury is diffi cult to
visualize, requires a resection, or there is a high-risk factor
(extensive spillage, hypotension, or delayed time to operation), the patient should be diverted [ 29 ] .
26 ] . The
Special Situations
One of the most vexing problems faced by trauma surgeons
is the presence of an ostomy and an open abdomen. This
group of patients is at a very high risk of subsequent intraabdominal infection. There is no class I or class II data to
direct the care of these patients. As such, experience should
dictate the treatment of individual patients. We recommend
placing the ostomy more laterally in this situation (through
the most lateral portion of the rectus muscle) in order to
divert the fecal stream further away from the open wound.
We recommend placing a suction-assisted dressing in the
midline wound to prevent stool from leaking into the wound
(Fig. 13.5a–d ). This will control the peritoneal drainage and
will protect the wound from fecal contamination. There are
also multiple commercial products available that accomplish
the same goals (KCI Wound Vac, San Antonio, TX or Blue
Sky, Carlsbad, CA).
Injured patients may have signifi cant perineal wounds
with signifi cant tissue loss. This can be the result of a gunshot wound or, more commonly, blunt trauma to the perineum.
If there is enough tissue loss that the wound will have to heal
by secondary intent or be repaired with a tissue fl ap, consideration should be given to temporarily diverting the fecal
stream. An end colostomy with mucus fi stula should be performed (Fig.
Open pelvic fractures represent a unique indication for
diversion, in that there may be no colonic injury present.
A laceration overlying a pelvic fracture can be contaminated
with a fecal stream. Such contamination can lead to lifethreatening osteomyelitis and pelvic sepsis. Because of these
concerns, fecal diversion has generally been the procedure of
choice for open pelvic fractures. Recently, reports have suggested that there is little research supporting such a treatment
algorithm [ 30 ] . We recommend proceeding with diversion in
patients with a pelvic fracture overlying large lacerations
near the fecal stream. Patients with small lacerations that can
be easily closed or anteriorly located open fractures do not
require diversion.
13.6 ).
Techniques of Colostomy Formation in Trauma Patients
A destructive lesion that requires diversion should fi rst be
evaluated for the extent of injury. The colon should be resected
to healthy tissue with good vascularity. A standard end colostomy should be brought up and matured (Fig. 13.7 ).
There are anatomic considerations that must be taken into
account when choosing the type of diversion technique. The
ascending colon is attached to the retroperitoneum laterally.
Even with complete mobilization of the right colon, there is
usually not enough length to bring up an end colostomy.
Injuries to the ascending colon can be treated in three different ways. The right colon can be resected and an ileocolostomy can be performed. Alternatively, the right colon can be
repaired primarily. Both of these repairs can be protected
with a loop ileostomy. This allows preservation of the ileocecal valve. If the injury is near the cecum, we perform a cecal
resection and an end ileostomy (Fig. 13.8 ).
The remainder of the colonic injuries can be treated with
resection and colonic diversion. There is almost always
enough length in the transverse colon to bring up an end
colostomy with a long Hartmann’s pouch. Injuries to the
descending colon should be treated with resection to the
transverse colon with formation of an end transverse colostomy. Injuries to the sigmoid colon should be treated with a
standard Hartmann’s pouch and end colostomy.
ab
d
15513 Ostomies in Trauma
c
Fig. 13.5 ( a ) Open abdomen with extreme lateral ostomy. ( b ) Open abdomen covered with vacuum-assisted dressing. ( c ) Abdominal wound
packed with gauze and drain. ( d ) Complete wound cover with Ioban™. Illustrations © CCF
156 M.C. Byrnes and G.J. Beilman
Fig. 13.6 Large perineal wound.
Illustration © CCF
Fig. 13.7 Blast injury with left hemicolectomy. Illustration © CCF
15713 O stomies in Trauma
Fig. 13.8 Blast injury with right hemicolectomy. Illustration © CCF
A previously used technique was exteriorization of repair.
The injured colonic segment was repaired primarily and was
brought up into the wound or through another skin incision.
This was fraught with complications of bowel desiccation
and necrosis, so it has fallen out of favor and is not suggested
by the authors.
Indications for Small Bowel Diversion
The bulk of this chapter focuses on colon injuries. Nearly all
of the literature on bowel diversion distal to the ligament of
Treitz focuses on colon injuries. Nearly all small bowel injuries should be treated with primary repair or resection and
anastomosis. Small bowel diversion for a small bowel injury
should only be undertaken in certain disastrous injuries such
as a destructive small bowel injury coupled with an injury to
the portal vein. In this situation, a standard end ileostomy or
jejunostomy can be created. The primary use of ileostomy in
the trauma setting is to divert enteric contents away from a
colonic injury. Either a loop ileostomy or an end ileostomy
will suffi ce as described elsewhere in this chapter.
Conclusion
The treatment of colonic injuries is complex and requires
consideration of the patient’s physiologic condition, their
premorbid status, the extent of the injury, and the vascular
supply. Although there has been a signifi cant trend toward
repair without diversion in recent years, there still is a role
for colostomy in high-risk patients. Surgeons should be
familiar with the techniques for performance of colostomy in
the injured colon.
158 M.C. Byrnes and G.J. Beilman
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CCF Color Photo Gallery
1 4
Victor W. Fazio, Paula Erwin-Toth,
James M. Church, and James S. Wu
Fig. 14.1 ( a , b ) Stoma site-tattoo with India ink
V. W. Fazio (*)
Department of Colorectal Surgery , Digestive Diseases Institute,
Cleveland Clinic Lerner College of Medicine of Case Western Reserve
University, Cleveland Clinic Foundation , Cleveland , OH , USA
e-mail: faziov@ccf.org
P. Erwin-Toth
The Rupert B. Turnbull School of WOC/ET,
Cleveland Clinic/ET , Cleveland , OH , USA
J. M. Church • J. S. Wu
Department of Colorectal Surgery , Digestive Diseases Institute,
Cleveland Clinic Foundation , Cleveland , OH , USA
Fig. 14.2 End ileostomy, conventional Brooke construction
V.W. Fazio et al. (eds.), Atlas of Intestinal Stomas,
DOI 10.1007/978-0-387-78851-7_14, © Springer Science+Business Media, LLC 2012
159
160 V.W. Fazio et al.
Fig. 14.3 Loop Ileostomy. The diminutive inactive lumen is identifi ed
with the instrument
Fig. 14.6 Transverse loop colostomy through incision (not usually
recommended)
Fig. 14.4 End descending colostomy
Fig. 14.5 Transverse loop colostomy
Fig. 14.7 Divided sigmoid colostomy and mucous fi stula
Fig. 14.8 Loop colostomy, incomplete stoma maturation