Canadian Association of General Surgeons evidence based reviews in surgery. 12. Primary repair for penetrating colon injuries

• Published in: Canadian Journal of Surgery Vol. 48; no. 1; pp. 63 - 65
• Main Authors: Taylor, Mark, Logsetty, Sarvesh
• Format: Journal Article
• Language: English
• Published: Canada CMA Impact Inc 01.02.2005; CMA Impact, Inc; Canadian Medical Association
• Subjects: Colon (Anatomy); Evidence-Based Surgery; Injuries; Surgery; Canada
• ISSN: 0008-428X; 1488-2310

Objective: To determine if the treatment of penetrating colonic injury must include fecal diversion at or proximal to the injury, to avoid sepsis and mortality. Data source: Studies were identified by searching MEDLINE 1966-2001, the Cochrane Controlled Trials Registry and EMBASE. Study selection: Studies were included if they were randomized controlled trials comparing outcomes of primary repair versus fecal diversion in the management of penetrating colon injuries; 5 studies were identified. Outcome measures: Operative mortality, total complications, total infectious complications, intraabdominal infections, abdominal infections excluding dehiscence, and wound complications including and excluding dehiscence. Penetrating abdominal trauma index (PATI) and length of stay were included when available. Results: PATI did not significantly differ between groups; neither did mortality (odds ratio [OR] 1.7, 95% confidence interval [CI] 0.51-5.66). However, total complications (OR 0.28, CI 0.18-0.42), total infectious complications (OR 0.41, CI 0.27-0.63), intra-abdominal infections (OR 0.59, CI 0.38-0.94), abdominal infections excluding dehiscence (OR 0.52, CI 0.31-0.86) and wound complications including (OR 0.55, CI 0.34-0.89) and excluding dehisccnce (OR 0.43, CI 0.25-0.76) all significantly favoured primary repair. Conclusions: Primary repair of penetrating colon injuries is as safe as fecal diversion and has a lower complication rate. [Nelson R] and Singer, the authors of this Cochrane review,1 sought to determine whether appropriate treatment of penetrating colonic injuries must include fecal diversion with an intestinal stoma at or near the site of injury. Extensive searches were made of 3 major medical databases for prospective randomized controlled trials of patients with penetrating colon injuries that compared primary repair sans stoma against fecal diversion with a stoma at or proximal to the point of injury. Patients with rectal injuries were excluded. All study patients must have had laparotomies that confirmed penetrating injury of the colon. Type of repair had to have been decided by randomization after confirmation of the colon injury. Patients in one comparison group must have undergone repair of the injury with primary closure or resection with anastamosis; those in the other group, one of: exteriorization of the injury as a stoma, resection of the injured segment with an end stoma, or repair of the injury with proximal fecal diversion. Outcomes under consideration were as stated in the Abstract. For the 5 studies included in the meta-analysis, the χ^sup 2^ test for heterogeneity for the outcome "overall mortality" was non-significant (p = 0.77). For the outcomes "intraabdominal infection" and "wound complication," there was likewise no significant heterogeneity. But for the outcomes "total complications" and "infectious complications," test results for heterogeneity were significant. In both cases, 1 trial accounted for the heterogeneity; when it was excluded, test results for both outcomes became non-significant. In summary, the results of the 5 studies can be combined with some assurance that differences are due to chance alone for the outcomes "overall mortality," "intra-abdominal infection" and "wound complication."