Penetrating colon injuries requiring resection: Diversion or primary anastomosis? An AAST prospective multicenter study

Background: The management of colon injuries that require resection is an u nresolved issue because the existing practices are derived mainly from clas s III evidence. Because of the inability of any single trauma center to acc umulate enough cases for meaningful statistical analysis, a multicenter pro spective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications. Methods: This was a prospective study from 19 trauma centers and included p atients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to comp are outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. Results: Two hundred ninety-seven patients fulfilled the criteria for inclu sion and analysis. Overall, 197 patients (66.3%) were managed by primary an astomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary ana stomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Mu ltivariate analysis including all potential risk factors with p values < 0. 2 identified three independent risk factors for abdominal complications: se vere fecal contamination, transfusion of <greater than or equal to> 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxi s. The type of colon management was not found to be a risk factor. Comparis on of primary anastomosis with diversion using multivariate analysis adjust ing for the above three identified risk factors or the risk factors previou sly described in the literature (shock at admission, delay > 6 hours to ope rating room, penetrating abdominal trauma index > 25, severe fecal contamin ation, and transfusion of > 6 units blood) showed no statistically signific ant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no diff erence in outcome. Conclusion: The surgical method of colon management after resection for pen etrating trauma does not affect the incidence of abdominal complications, i rrespective of associated risk factors. Severe fecal contamination, transfu sion of a: 4 units of blood within the first 24 hours, and single-agent ant ibiotic prophylaxis are independent risk factors for abdominal complication s. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should b e considered in all such patients.