A Brief History

Management of colonic injury has fluctuated over the past 100 years. During the first world war, the first papers describing large numbers of colonic injuries were published. The overall mortality from colonic injury was around 60%. At the time most injuries presented over 6 hours old, there were no antibiotics and intravenous fluid infusion was rare. Laparotomy was not universal for these injuries, and mobilisation of the colon was not routinely practiced.

Colon & Rectum

Introduction
Diagnosis
Management - History
Management - Colon
Management - Rectum
Management - Guidelines
References

By the end of the war most series were reporting favourable results with primary suture of simple colonic injuries, and suggesting that colostomy be reserved for more extensive trauma. However, in the early part of the second world war, and despite the previous evidence to the contrary, Ogilvie recommended colostomy for all colonic injuries. This was despite Ogilivie's own paper recording a mortality of 50% for primary repair compared to 59% for colostomy.

"The treatment of colon injuries is based on the known insecurity of suture and the dangers of leakage. Simple closure of a wound of the colon, however small, is unwarranted; men have survived such an operation, but others have died who would still be alive had they fallen into the hands of a surgeon with less optimism and more sense. Injured segments must either be exteriorized, or functionally excluded by a proximal colostomy." - W. H. Ogilvie. 1944

Adding to the call for colostomy was a publication from the Office of the Surgeon General of the United States in 1943 which mandated that all colonic injuries be treated by colostomy. By the end of the second world war, mortality from colon injuries was being reported at 5-20%. This was attributed to the use of colostomy, but again all series reporting both treatment methods had a lower mortality in the primary repair group. The use of colostomy for all colonic injuries continued into the Korean and Vietnam wars.

After the second world war, civilian surgeons started reporting their experience with colonic injuries. Again, primary repair was associated with better outcomes. Woodhall & Oschner reported an 8.3% mortality for primary repair compared with 35% mortality for colostomy. More evidence supporting primary repair emerged over the next decades. In the past 2 decades there are been several prospective studies and randomised control trials supporting primary repair in most cases of penetrating colonic injury.

Management - Colon Injury