Management of colorectal trauma: a review

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Colorectal trauma is a common injury in time of war; thus, there have been specific time periods in which the management of colonic and rectal injuries has undergone significant changes. Until the 19th century, including the American Civil War, soldiers with colon injuries were treated non‐operatively, with the majority of patients dying from sepsis. During World War I, the management of colonic injuries shifted towards laparotomy and primary repair; however, the mortality from injury was still 75%.1 Monumental changes in the management of colorectal trauma came with World War II, when a British surgeon, Sir William Heneage Ogilvie, recognized the importance of creating a stoma for colonic injuries.2 Ogilvie's work was truly remarkable not only for meticulous observation but also for the principles that he described, which made him clearly ahead of his time; these included ‘trimodal’ peaks in trauma mortality, damage control surgery, massive transfusion and abdominal compartment syndrome. His results led to the United States Office of the General Surgeon in 1943 mandating the exteriorization of the injury or repair with proximal diversion for colonic injuries, with an elective closure at a later date.4 This mandate, along with better antibiotics, surgical techniques and instruments, improved triage, and the use of banked blood collections led to a dramatic decrease in colon injury‐related mortality of 22–35% by the end of World War II.5
The next milestone was the Vietnam War, during which improvements in casualty evacuation and antibiotics were observed. From this time, left‐sided colonic injuries were diverted, but more variation was given in the management of right colonic injuries, and some injuries were managed with resection and primary anastomosis rather than exteriorization with stoma.6 Additionally, surgeons recognized that compared with military settings, colonic injuries in civilian populations were different, with civilian wounds being far less destructive and thus more amenable to less aggressive surgical management with resection and primary repair.7 In 1979, a civilian‐based randomized‐controlled trial found that treating colonic injuries with primary repair was superior to a diverting colostomy. The study found higher infection rates, longer hospital stays, higher cost of care and higher overall morbidity in patients who were managed with diverting colostomy.8 Another two features of the Vietnam War era have been the use of presacral drainage and distal rectal washout. Distal rectal washout has been found to significantly reduce mortality from 22% to 0% and morbidity from 72% to 10%.9
The lessons from war times are that (i) the non‐operative management of colorectal trauma is unsatisfactory; (ii) colostomy greatly reduces mortality; (iii) civilian and military injuries are different entities; and (iv) some post‐World War II studies have suggested that compared to primary anastomosis, there is higher morbidity with stoma.
The aim of this review is to provide a clear narrative on colorectal trauma, including (i) its mechanism of injury in the modern era; (ii) its classification; (iii) its clinical presentation/investigations; and (iv) the key dilemma in the management of colorectal trauma, that is whether a diversion or a primary repair should be done in the era of damage control surgery.
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