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.
Wallace C. 'Gunshot wounds
of the abdomen; a study of 1200 cases of gunshot wounds of the
abdomen' Br J Surg 1917;4:679
A publication from the Office of the Surgeon
General of the United States in 1943 mandated that all colonic
injuries be treated by colostomy. This was based on an earlier
paper from W.H. Ogilvie in the UK, recommending colostomy despite
his own paper failing to show any benefit over primary closure.
"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. 'Forward Surgery in Modern
War', 1944
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. Gordon-Taylor in the UK is the only
authority recommending primary repair.
Office of the Surgeon General of
the United States: Circular Letter no. 178, October 23, 1943
Ogilvie WH. 'Abdominal Wounds in the Western Desert.' Surg Gynae
Obstet 1944;78:225
Gordon-Taylor G, 'Second thoughts on the abdominal surgery of
"total war" - a review of over 1300 cases.' Br J Surg
1942;32:247
Woodhall & Oschner report 8.3% mortality
for primary repair compared with 35% mortality for colostomy.
Woodhall JP, Oschner A. 'The management
of perforating injuries of the colon and rectum in civilian practice.'
Surgery 1951;29:305
Chappuis reports on the first randomised controlled trial in colorectal
injuries which shows improved morbidity & mortality with primary
repair.
Chappuis CW, Frey DJ, Dietzen CD
et al. 'Management of penetrating colon injuries: A randomised
controlled trial.' Surg 1991;213:492
