Management of colorectal trauma: a review
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.