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450 The ASCRS Manual of Colon and Rectal Surgery
Table 22.1. Incidence of abdominal septic complications in colon injuries (prospective studies) .
Author Number of patients Abdominal sepsis (%)
George et al. 102 33
Chappuis et al. 56 20
Demetriades et al. 100 16
Ivatury et al. 252 17
Gonzalez et al. 114 24
Demetriades et al. 297 24
Overall 921 22
• In stab wounds, the left colon is the most frequently injured
segment, probably because of the predominance of righthanded assailants.
• Blunt trauma to the colon is uncommon and is diagnosed in
about 0.5% of all major blunt trauma or in 10.6% of patients
undergoing laparotomy. Most of these injuries are partial thickness and only 3% of patients undergoing laparotomy have fullthickness colon perforations.
• Traffi c trauma is the most common cause of blunt colon
injury.
• Seatbelts increase the risk of hollow viscous perforations and
the presence of a seatbelt mark sign is a predictor of hollow
viscous injury.
Diagnosis
• The diagnosis of colon injury is almost always made intraoperatively.
• A rectal examination may show blood in the stool, especially
in cases with distal colon or rectal injuries.
• The colon can reliably be evaluated by soluble enema studies or abdominal computed tomography (CT) scan with
soluble rectal contrast. Retroperitoneal gas or contrast extravasation are diagnostic and an exploratory laparotomy should be
performed.
• The diagnosis may be suspected by the presence of free gas or
thickened colonic wall on the routine abdominal CT scan.
22. Colon and Rectal Trauma and Rectal Foreign Bodies 451
Table 22.2. AAST colon injury scale.
Grade Injury description
I (a) Contusion or hematoma without devascularization
(b) Partial thickness laceration
II Laceration £ 50% of circumference
III Laceration >50% of circumference
IV Transection of the colon
V Transection of the colon with segmental tissue loss
• Intraoperatively, every paracolic hematoma caused by penetrating trauma should be explored and the underlying colon
should be evaluated carefully.
• Paracolic hematomas caused by blunt trauma should not
undergo routine exploration unless there is evidence of colon
perforation.
Colon Injury Scale
• The American Association for the Surgery of Trauma (AAST)
developed a grading system for organ injuries in order to have
objective criteria for the classifi cation of the severity of the
injury and enable reliable comparisons of results.
• The AAST Colon Injury Scale is shown in Table 22.2 .
B. Operative Management
Historical Perspective
• The policy of mandatory colostomy for all colon injuries
remained the unchallenged standard of care until the late 1970s.
Stone and Fabian reported the fi rst major scientifi c challenge
of this policy in 1979. In a prospective, randomized study,
which excluded patients with hypotension, multiple associated
injuries, destructive colon injuries, and delayed operations,
the authors concluded that primary repair was associated with
fewer complications than colostomy. The exclusion criteria
were perceived as risk factors for anastomotic leak and were
absolute indications for diversion.
452 The ASCRS Manual of Colon and Rectal Surgery
• In the 1990s and 2000s, primary repair became the standard of
care in most cases although there is still some skepticism by
many surgeons, especially in the presence of certain risk factors such as destructive colon injuries, severe contamination,
multiple injuries, and delays in treatment.
• The recent reported experience deals mostly with civilian
trauma. Military combat injuries have different mechanisms
of injury, potential delays in evacuation and management, and
challenges in postoperative management. Civilian trauma principles may not be appropriate to military trauma.
Nondestructive Colon Injuries
• There is now enough class I evidence (prospective, randomized
studies) supporting primary repair in all nondestructive colon
injuries (injuries involving <50% of the bowel wall and without devascularization) irrespective of risk factors.
• Overall, collective review of all available prospective, randomized
studies (class I evidence) identifi ed 160 patients with primary
repair and an incidence of 13.1% of abdominal sepsis complications. In the group of 143 patients treated with diversion, the
abdominal sepsis complication rate was 21.7% (Table 22.3 ).
Destructive Colon Injuries
• The available prospective, randomized studies, which include
only a small number of cases, recommend resection with anastomosis irrespective of risk factors.
• In view of the lack of large prospective studies in the literature,
the AAST sponsored a prospective multicenter study to evaluate the safety of primary anastomosis or diversion and identify independent risk factors for colon-related complications in
patients with destructive colon injuries requiring resection.
• Multivariate analysis identifi ed three independent risk factors
for abdominal complications: severe fecal contamination, >4
units of blood transfusions within the fi rst 24 h, and singleagent antibiotic prophylaxis. If all three risk factors were
present, the incidence of abdominal complications was about
60%, if any two factors were present the complications rate
was 34%, if only one factor was present this fi gure was about
20%, and with no risk factors it was 13%.
22. Colon and Rectal Trauma and Rectal Foreign Bodies 453
Table 22.3. Primary repair versus diversion: prospective, randomized studies
with no exclusion criteria.
Primary Repair Diversion
Study
Chappuis et al. 28 4 (14.3) 28 5 (17.9)
Sasaki et al. 43 1 (2.3) 28 8 (28.6)
Gonzalez et al. 89 16 (18) 87 18 (21)
Total 160 21 (13.1) 143 31 (21.7)
Table 22.4. AAST colon resection study: comparison of abdominal complications between primary anastomosis and diversion in high- and low-risk patients.
Patient
population
All patients 22 27 0.81 (0.55–1.41) .69
Low-risk
patients
High-risk
patients
a
High-risk patients were those with PATI >25 or severe fecal contamination or 6 h
from injury to operation or transfusion of >6 units of blood pre-/intraoperatively
systolic blood pressure £ 90 mm Hg. Low-risk patients were those without any of
the above risk factors.
Number
of patients
Primary anastomosis: abdominal
complications (%)
13 8 1.26 (0.21–8.39) .82
28 30 0.90 (0.53–1.40) .67
Abdominal
septic complications (%)
Diversion:
abdominal
complications
(%)
Number of
patients
Adjusted
relative risk
(95% CI) P value
Abdominal
complications
(%)
• Multivariate analysis showed that the adjusted relative risk of
abdominal complication in patients with primary anastomosis
or diversion was similar, in both the low-risk and high-risk
patients (Table 22.4 ). The study concluded that “In view of
these fi ndings and the fact that colon diversion is associated
with worse quality of life and requires an additional operation
for closure, colon injuries requiring resection should be managed by primary repair, irrespective of risk factors.”
• The only conditions for which there is agreement for colostomy are the presence of severe colon edema or a questionable
blood supply of the colon. In these situations, at least theoretically, a diversion procedure might be a safe option.
454 The ASCRS Manual of Colon and Rectal Surgery
Risk Factors for Abdominal Complications
• The abdominal complication rate in colon injuries is very high,
with a sepsis rate of about 20% (Table 22.1 ).
Left Versus Right Colon Injuries
• No clinical or experimental study has ever demonstrated any
healing differences between the two sides of the colon or
any evidence that the two anatomic sides should be treated
differently.
Associated Abdominal Injuries
• Class I and II studies have shown that although multiple associated intraabdominal injuries are signifi cant risk factors for
intraabdominal sepsis, the method of colon management does
not affect the incidence of abdominal sepsis.
• The current class I and II literature supports primary repair or
resection and anastomosis in patients with severe or multiple
associated abdominal injuries.
Shock
• There is now suffi cient class I and II evidence that preoperative
or intraoperative shock is neither an independent risk factor for
abdominal sepsis nor a contradiction for primary colon repair
or anastomosis.
Blood Transfusions
• In a large prospective AAST study of 297 patients with penetrating destructive colon injuries requiring resection, blood transfusion was the most critical independent factor for abdominal
sepsis [adjusted relative risk (RR), 2.0; 95% confi dence interval (CI), 1.31–2.83; P = 0.001]. However, the method of colon
management did not infl uence the complication rate in this
group of patients and primary anastomosis was recommended.
Injury Severity Score
• The ISS is not an independent risk factor for abdominal sepsis
and high ISS (>15) is not a contraindication for primary repair
or anastomosis.
22. Colon and Rectal Trauma and Rectal Foreign Bodies 455
Fecal Contamination
• All prospective, randomized studies and recent large prospective
observational studies have shown that the method of colon management in this group of patients does not infl uence the septic complication rate and recommended primary repair or anastomosis.
Specifi c Associated Abdominal Injuries
• There is class III evidence that the combination of colon injuries with pancreatic or ureteric injuries is associated with an
increased incidence of septic complications. However, there is
no evidence that the presence of any of these injuries is a contraindication for primary repair or anastomosis.
Time from Injury to Operation
• The length of delay of surgical repair over which the septic
complication rate increases is not well defi ned. Some studies
suggest >6 h whereas others >12 h as the critical delays associated with an increased risk of infections.
• The degree of contamination is much more important than the
delay in surgical management and the time delay in itself should
not be used as a criterion for primary repair or diversion.
Retained Missiles
• Missiles, which passed through the colon and remained lodged
in the tissues, are not associated with increased risk of local
sepsis and they should be removed only if it is technically easy
and does not prolong the operation.
Anatomic Location of Colon Injury
• There is a plethora of classes I, II, and III evidence that the incidence of complications is similar in right and left colon injuries.
Temporary Abdominal Wall Closure
• Damage control laparotomy and temporary abdominal wall
closure with prosthetic material seem to be associated with
increased incidence of abdominal septic complications.
• There is no literature addressing the optimal management of
colon injuries in this group of patients.
• Some authors prefer primary repair or resection and anastomosis, to avoid a colostomy near an open abdomen.
456 The ASCRS Manual of Colon and Rectal Surgery
Anastomotic Leaks
• Colon leaks remain the most serious complication in repaired
or anastomosed colons.
• The overall incidence of suture line failures is fairly low.
• In a collective review of 35 prospective or retrospective studies
with 2,964 primary repairs, Curran reported 66 (2.2%) leaks.
• The leak rate after resection and anastomosis is signifi cantly
higher than in simple repairs.
• The risk factors for anastomotic leak are not well defi ned. It
seems that colocolostomies are associated with a higher incidence of anastomotic leaks than ileocolostomies.
• A multicenter prospective AAST study reported a leak rate
of 4.2% for ileocolostomies and 8.9% in colocolostomies.
The leaks occurred in patients with or without multiple
blood transfusions, severe contamination, and multiple associated injuries. No signifi cant independent risk factors could
be identifi ed.
• The prognosis of anastomotic leaks is usually good and most
of the patients can safely be managed nonoperatively with lowresidue diet.
• In most cases, the leak results in a fecal fi stula, which heals
spontaneously within a few days. In other cases, the leak results
in a local abscess, which can be drained percutaneously.
• In some patients, the colonic leak causes severe intraabdominal
sepsis and a proximal diversion procedure may be required.
• Reexploration of the abdomen and creation of fecal diversion with or without resection of the leaking colon should be
reserved only for patients with generalized peritonitis or failed
percutaneous drainage.
C. Technique of Colon Repair
• In nondestructive injuries, repair of the injured colon should be
performed after debridement of the perforation.
• The method of anastomosis, hand-sewn or stapled, does not
infl uence the incidence of abdominal complications or leak
rate and it should be surgeon’s preference.
• Further protection of the anastomosis with adjacent omentum
is recommended whenever possible.
22. Colon and Rectal Trauma and Rectal Foreign Bodies 457
D. Rectal Injuries
• Because of the paucity of class I and class II data, no consensus
has been achieved with respect to the optimal management of
rectal trauma.
Anatomy
• The anatomy of the rectum makes it diffi cult to apply the principles of colon trauma management.
• The rectum is easily accessible from the anus, with the anterior
peritoneal refl ection only approximately 6 cm from the anal
verge. This results in a not uncommon fi nding of intraperitoneal injury from rectal foreign bodies.
Epidemiology
• For the various anatomic reasons, injuries to the rectum occur
infrequently, and are usually the result of penetrating trauma.
• In most series, gunshot and shotgun wounds account for
80–85% of injuries, and stab wounds for 3–5%.
• Other causes include iatrogenic injuries from urologic and
endoscopic procedures, sexual misadventure, and anorectal
foreign bodies.
• Rectal injuries have been reported in nearly 2% of all pelvic
fractures.
Diagnosis
• The diagnosis of intraperitoneal rectal injury, similar to colonic
injuries, is almost always made intraoperatively.
• Extraperitoneal rectal injuries may not always be as obvious.
• The cornerstone for diagnosing an extraperitoneal injury is the
combination of a digital rectal examination and rigid proctoscopy. In most series, the diagnostic accuracy of the digital rectal examination and rigid proctoscopy ranges from 80 to 95%.
• In hemodynamically stable patients with a mechanism suspicious for a rectal injury (gluteal, perineal, and transpelvic
gunshot wounds, pelvic fractures, and foreign body insertion),
a digital rectal examination and a rigid proctoscopy must be
458 The ASCRS Manual of Colon and Rectal Surgery
performed and in the appropriate cases further evaluation by
means of a contrast study should be considered.
Rectal Organ Injury Scale
• The grading system developed by the AAST for rectal injuries
(Table 22.5 ) is similar to that of colonic injuries (Table 22.2 ).
E. Operative Management
Historical Perspective
• Presently there is no acceptable gold standard for the treatment
of rectal injuries, because most studies have been unable to
demonstrate any advantage of the various treatment options.
Intraperitoneal Injuries
• Several studies indicate that injuries to the intraperitoneal rectum can be managed similar to left colon injuries with primary
repair without the need for colostomy.
Extraperitoneal Injuries
Fecal Diversion with Colostomy
• Since World War II, the mainstay of management of extraperitoneal injuries has been proximal colostomy. The only controversial aspect has been whether to perform a loop colostomy
versus an end colostomy.
Table 22.5. AAST rectal organ injury scale.
Grade Injury description
I (a) Contusion or hematoma without devascularization
II Laceration £ 50% of circumference
III Laceration >50% of circumference
IV Full-thickness laceration with extension into the perineum
V Devascularized segment
(b) Partial-thickness laceration
22. Colon and Rectal Trauma and Rectal Foreign Bodies 459
• Rombeau et al. demonstrated that a properly constructed loop
colostomy, supported by a solid rod above the level of the skin,
achieves complete fecal diversion.
• The authors believe that the type of colostomy should be dictated
by the operative fi ndings. Extensive destruction of the rectum
that requires a resection may best be served with a Hartmann’s
procedure, whereas injuries that are not repaired or require limited dissection may be addressed by a loop colostomy.
Presacral Drainage
• In a series of 48 patients, 23 randomized to presacral drainage
and 25 randomized to no drainage, no difference in pelvic sepsis was encountered. This represents the fi rst and only class I
study involving rectal injuries.
Distal Rectal Washout
• The authors do not recommend distal bowel irrigation. There
is no proven benefi t, and it may be associated with a high risk
of infection because of spillage of intraluminal contents out of
unrepaired rectal injuries.
Rectal Repair
• Even when repair is performed, no outcome advantage has
been proven.
Miscellaneous Options
• Although extremely rare, abdominoperineal resection has been
described for patients with severe bleeding, massive tissue
loss, or devascularizing injuries.
• In a prospective study of 20 patients with extraperitoneal rectal
injuries, laparoscopy (to rule out an intraperitoneal injury), followed by a diverting loop sigmoid colostomy without laparotomy yielded excellent results.
Associated Injuries
• Associated injuries are often seen with rectal injuries and have
been reported to occur in as many as 77% of cases.
• Genitourinary, and in particular bladder injuries, are the most frequently seen associated injuries, occurring in 30–64% of cases.
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