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Analysis of over 2 decades of colon injuries identifies optimal method of diversion

Does an end justify the means?

Manley, Nathan R., MD, MPH; Sharpe, John P., MD, MS; Lewis, Richard H., MD; Iltis, Mark S., DO; Chaudhuri, Rishi, MD; Fabian, Timothy C., MD; Croce, Martin A., MD; Magnotti, Louis J., MD

Journal of Trauma and Acute Care Surgery: February 2019 - Volume 86 - Issue 2 - p 214–219
doi: 10.1097/TA.0000000000002135

INTRODUCTION Conflicting evidence exists regarding the definitive management of destructive colon injuries. Although diversion with an end ostomy can theoretically decrease initial complications, it mandates a more extensive reversal procedure. Conversely, anastomosis with proximal loop ostomy diversion, while simplifying the reversal, increases the number of suture lines and potential initial morbidity. Thus, the purpose of this study was to evaluate the impact of diversion technique on morbidity and mortality in patients with destructive colon injuries.

METHODS Consecutive patients with destructive colon injuries managed with diversion from 1996 to 2016 were stratified by demographics, severity of shock and injury, operative management, and timing of reversal. Outcomes, including ostomy complications (obstruction, ischemia, readmission) and reversal complications (obstruction, abscess, suture line failure, fascial dehiscence), were compared between patients managed with a loop versus end colostomy. Patients with rectal injuries and who died within 24 hours were excluded.

RESULTS A total of 115 patients were identified: 80 with end colostomy and 35 with loop ostomy. Ostomy complications occurred in 22 patients (19%), and 11 patients (10%) suffered reversal complications. There was no difference in ostomy-related (2.9% vs. 3.8%, p = 0.99) mortality. For patients without a planned ventral hernia (PVH), there was no difference in ostomy complications between patients managed with a loop versus end colostomy (12% vs. 18%, p = 0.72). However, patients managed with a loop ostomy had a shorter reversal operative time (95 vs. 245 minutes, p = 0.002) and reversal length of stay (6 vs. 10, p = 0.03) with fewer reversal complications (0% vs. 36%, p = 0.02). For patients with a PVH, there was no difference in outcomes between patients managed with a loop versus end colostomy.

CONCLUSION For patients without PVH, anastomosis with proximal loop ostomy reduced reversal-related complications, operative time, LOS, and hospital charges without compromising initial morbidity. Therefore, loop ostomy should be the preferred method of diversion, if required, following destructive colon injury.

LEVEL OF EVIDENCE Therapeutic, level IV.

From the University of Tennessee Health Science Center, Department of Surgery, Division of Surgical Critical Care (N.R.M., J.P.S., R.H.L., M.S.I., R.C., T.C.F., M.A.C., L.J.M.).

Submitted: July 31, 2018, Revised: October 23, 2018, Accepted: October 30, 2018, Published online: November 16, 2018.

This study was presented at the 77th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery, September 26–29, 2018, in San Diego, California.

Address for reprints: Nathan R. Manley, MD, MPH, Department of Surgery University of Tennessee Health Science Center, 910 Madison Ave, 2nd Floor, Memphis, Tennessee 38163; email:

© 2019 Lippincott Williams & Wilkins, Inc.