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Management of penetrating intraperitoneal colon injuries

A meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma

Cullinane, Daniel C. MD; Jawa, Randeep S. MD; Como, John J. MD, MPH; Moore, Ashlee E. MD; Morris, David S. MD; Cheriyan, Jerry MD; Guillamondegui, Oscar D. MD; Goldberg, Stephanie R. MD; Petrey, Laura MD; Schaefer, Gregory P. DO; Khwaja, Kosar A. MD; Rowell, Susan E. MD; Barbosa, Ronald R. MD; Bass, Gary A. MD, MSc; Kasotakis, George MD, MPH; Robinson, Bryce R.H. MD, MS

Journal of Trauma and Acute Care Surgery: March 2019 - Volume 86 - Issue 3 - p 505–515
doi: 10.1097/TA.0000000000002146
SYSTEMATIC REVIEWS
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BACKGROUND The management of penetrating colon injuries in civilians has evolved over the last four decades. The objectives of this meta-analysis are to evaluate the current treatment regimens available for penetrating colon injuries and assess the role of anastomosis in damage control surgery to develop a practice management guideline for surgeons.

METHODS Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines section of EAST conducted a systematic review using MEDLINE and EMBASE articles from 1980 through 2017. We developed three relevant problem, intervention, comparison, and outcome (PICO) questions regarding penetrating colon injuries. Outcomes of interest included mortality and infectious abdominal complications.

RESULTS Thirty-seven studies were identified for analysis, of which 16 met criteria for quantitative meta-analysis and included 705 patients considered low-risk in six prospective randomized studies. Seven hundred thirty-eight patients in 10 studies undergoing damage control laparotomy and repair or resection and anastomosis (R&A) were included in a separate meta-analysis. Meta-analysis of high-risk patients undergoing repair or R&A was not feasible due to inadequate data.

CONCLUSIONS In adult civilian patients sustaining penetrating colon injury without signs of shock, significant hemorrhage, severe contamination, or delay to surgical intervention we recommend that colon repair or R&A be performed rather than routine colostomy. In adult high-risk civilian trauma patients sustaining penetrating colon injury, we conditionally recommend that colon repair or R&A be performed rather than routine colostomy. In adult civilian trauma patients sustaining penetrating colon injury who had damage control laparotomy, we conditionally recommend that routine colostomy not be performed; instead, definitive repair or delayed R&A or anastomosis at initial operation should be performed rather than routine colostomy.

LEVEL OF EVIDENCE Systematic review/meta-analysis, level III.

From the Department of Surgery, Marshfield Clinic, Marshfield, Wisconsin (D.C.C.); Division of Trauma, Stony Brook University School of Medicine, Stony Brook, New York (R.S.J.); Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio (J.J.C.); Department of Surgery, Holmes Medical Center, Melbourne, Florida (A.M.); Department of Surgery, Intermountain Health Care, Murray, Utah (D.S.M.); Department of Surgery, Kern Medical Center, Bakersfield, California (J.C.); Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee (O.D.G.); Department of Surgery, Virginia Commonwealth University, Richmond, Virginia (S.R.G.); Department of Surgery, Baylor University Medical Center, Dallas, Texas (L.P.); Department of Surgery, West Virginia University Medical Center, Morgantown, West Virginia (G.S.); Department of Surgery, Montreal General Hospital, Montreal, Quebec, Canada (K.A.K.); Department of Surgery, Oregon Health & Science University, Portland, Oregon (S.E.R.); Department of Surgery, Legacy Emmanuel Medical Center, Portland, Oregon (R.R.B.); Department of Surgery, St. Vincent's Hospital, Dublin, Ireland (G.A.B.); Department of Surgery, Boston Medical Center, Boston, Massachusetts (G.K.); and Department of Surgery, University of Washington, Seattle, Washington (B.R.H.R.).

Submitted: June 20, 2018, Revised: July 11, 2018, Accepted: November 11, 2018, Published online: November 21, 2018.

Address for reprints: Daniel C. Cullinane, MD, Marshfield Clinic, 1000 N Oak Avenue, Marshfield, WI 54449; email: cullinane.daniel@marshfieldclinic.org.

This manuscript was not presented at any meeting or conference.

© 2019 Lippincott Williams & Wilkins, Inc.