The fate of colonic suture lines in high-risk trauma patients: a prospective analysis

Background: Some authors have stated that virtually all patients with penetrating colon injuries can be safely managed with primary repair. The purpose of this study is to test the applicability of this statement to all trauma patients by evaluating a protocol of liberal primary repair applied to a group of patients at high risk of septic complications. Study Design: We performed a prospective analysis of a liberal policy of primary repair applied to patients at high risk of developing postoperative septic complications admitted to a Level I urban trauma center. Inclusion criteria were full-thickness colon injury and at least one of three additional risk factors: 1) Penetrating Abdominal Trauma Index (PATI) of 25 or more; 2) 6 U or more of blood transfused; and 3) 6 hours or longer elapsed between injury and surgery. Results: Of 56 patients studied (55 male, 1 female, average age 28.8 years, mean PATI 35.3), the vast majority had gunshot wounds as the mechanism of injury (89%), PATI 25 or more (95%), multiple blood transfusions (77%), an Injury Severity Score greater than 15 (66%), and a need for postoperative ventilatory support in the surgical intensive care unit (61%). Of 56 patients, 49 (88%) had at least one colonic suture line, and 25 patients (45%) had destructive colon injuries requiring resection. Intraabdominal infections occurred in 15 (27%) of 56 patients and colon suture line disruption occurred in 3 (6%) of 49. Two of these patients developed multisystem organ failure, and death was directly related to breakdown of their colonic anastomosis. Conclusions: On the basis of these data and the relative infrequency of patients in prospective randomized trials with destructive colon injuries, we believe there is still room for consideration of fecal diversion in patients in high-risk categories with destructive colon injuries requiring resection.