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Epidemiology of modern battlefield colorectal trauma: A review of 977 coalition casualties

Glasgow, Sean C. MD; Steele, Scott R. MD; Duncan, James E. MD; Rasmussen, Todd E. MD

Journal of Trauma and Acute Care Surgery: December 2012 - Volume 73 - Issue 6 - p S503–S508
doi: 10.1097/TA.0b013e3182754759
Original Articles

BACKGROUND Traumatic injuries to the lower gastrointestinal tract occur in up to 15% of all injured combatants, with significant morbidity (up to 75%) and mortality. The incidence, etiology, associated injuries, and overall mortality related to modern battlefield colorectal trauma are poorly characterized.

METHODS Using data from the Joint Theater Trauma Registry and other Department of Defense electronic health records, the ongoing Joint Surgical Transcolonic Injury or Ostomy Multi-theater Assessment project quantifies epidemiologic trends in colon injury, risk factors for prolonged or perhaps unnecessary fecal diversion, and quality of life in US military personnel requiring colostomies. In the current study, all coalition troops with colon or rectal injuries as classified by DRG International Classification of Diseases—9th Rev. diagnosis and Abbreviated Injury Scale (AIS) codes in the Joint Theater Trauma Registry were included.

RESULTS During 8 years, 977 coalition military personnel with colorectal injury were identified, with a mean (SD) Injury Severity Score (ISS) of 22.2 (13.2). Gunshot wounds remain the primary mechanism of injury (57.6%). Compared with personnel with colon injuries, those with rectal trauma sustained greater injury to face and extremities but fewer severe thoracic and abdominal injuries (p < 0.005). Overall fecal diversion rates were significantly higher in Iraq than in Afghanistan (38.7% vs. 31.6%, respectively; p = 0.03), predominantly owing to greater use of diversion for colon trauma. There was little difference in diversion rates between theaters for rectal injuries (59.6% vs. 50%, p < 0.15). The overall mortality rate was 8.2%. Notably, the mortality rate for patients with no fecal diversion (10.8%) was significantly greater than those with fecal diversion (3.7%, p < 0.0001).

CONCLUSION Military personnel sustaining colon or rectal trauma continue to have elevated mortality rates, even after reaching surgical treatment facilities. Furthermore, associated serious injuries are commonly encountered. Fecal diversion in these patients may lead to reduced mortality, although prospective selection criteria for diversion do not currently exist. Future research into risk factors for colostomy creation, timing of diversion in relation to damage-control laparotomy, and quality of life in veterans with stomas will produce useful insights and help guide therapy.

LEVEL OF EVIDENCE Epidemiologic study, level III.

Supplemental digital content is available in the article.

From the Department of Surgery (S.C.G.), San Antonio Military Medical Center; and US Army Institute of Surgical Research (T.E.R.), Fort Sam Houston, Texas; Department of Surgery (S.R.S.), Madigan Army Medical Center, Fort Lewis, Washington; and Walter Reed National Military Medical Center (J.E.D.), Department of Surgery, Bethesda, Maryland.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journals Web site (

Address for reprints: Sean C. Glasgow, MD, Department of Surgery, San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234-6200; email:

© 2012 Lippincott Williams & Wilkins, Inc.