In the past century, the frequency of fecal diversion in penetrating colorectal injuries has progressively declined. The shortening of the interval between trauma and definitive treatment, more effective early management, improvements in intensive care conditions, the increased feasibility of damage-control surgery, and advances in surgical technology and experience have substantially transformed the management of colon injuries. As a result of these developments, treatment strategies have increasingly shifted away from colostomy and brought non-diversional surgical approaches to the forefront. In addition, the comprehensive evaluation of concomitant organ injuries and the development of various injury-severity and scoring systems (such as APACHE, CISS, and PATI) have contributed to standardizing surgical treatment approaches in colorectal trauma.
Colon injuries are more common in young male patients and most frequently result from stab wounds, gunshot injuries, traffic accidents, and iatrogenic causes, in that order. It has also been reported that gunshot wounds tend to cause more severe injuries 5,6. Most of the patients with colorectal injuries in our study were young males. The most common etiology of colorectal injury was penetrating stab injury (PSI) with 12 (48%) cases, followed by gunshot injury (GSI) in 8 (32%), vehicle traffic accident (VTA) in 4 (16%), and blunt abdominal trauma (BAT) in 1 (4%) case. In the study by Carap et al. 16, all patients were reported to be male, and, unlike our series, the injuries predominantly resulted from blunt trauma. Thus, the predominance of male patients emerges as a common feature shared by both studies.
The presence of shock and the need for blood transfusion are important indicators of injury severity and significant determinants of prognosis. Prolonged hypotension and impaired tissue perfusion may lead to bacterial translocation and immune dysfunction, facilitating the development of sepsis 2,4. Preoperatively or intraoperatively, an average of 3.25 units of blood (range, 2–6 units) was transfused to 4 patients (16%). Kahya et al. 12 and Hughes et al. 13 reported that the mean time from injury to surgery was approximately 11 hours in their respective studies. In our series, the mean interval between injury and initiation of treatment was 3.6 hours (range, 1–24). Colon injuries caused by gunshot wounds had the shortest preoperative interval (1 hour), whereas the longest interval (24 hours) was observed in a patient with a stab injury (PSI). Although the initial imaging findings of this patient were normal, laparotomy was performed 24 hours later due to the development of acute abdomen.
The presence of concomitant intra-abdominal or extra-abdominal organ injury in patients with colon injury is a marker of trauma severity and a major factor influencing the choice of surgical procedure. The Penetrating Abdominal Trauma Index (PATI) defined by Moore et al. 14 and revised in 2016 is one of the preferred systems for evaluating the severity of abdominal trauma 11. In our study, additional organ injuries were present in 14 (56%) patients. In the study by Kahya et al. 12, the rate of associated organ injury was 65%. Similarly, Köksal et al. 15 reported that small bowel injury was the most frequent concomitant injury in colorectal trauma, with a rate of 54.2%.
In the study by Carâp et al. 16, the most common injury sites were the sigmoid and transverse colon (63%). Similarly, Cheng et al. 17 reported that the sigmoid colon (35%) was the most commonly affected region. In our study, injuries were most frequently localized in the transverse colon, followed by the rectum.
Although primary repair and resection–anastomosis are the most commonly preferred surgical techniques, fecal diversion may be required in certain situations to protect the anastomosis or the primary repair site. The high bacterial load of the large intestine often prompts surgeons to consider such protective measures. However, since some patients still benefit from fecal diversion, the complete elimination of stoma formation following colon injury is unlikely. Prospective clinical studies conducted by Demetriades, Gonzalez, Sasaki, and the meta-analysis by Singer et al. reported that primary repair or resection with anastomosis can be safely performed in all colon injuries, regardless of risk factors. 2-4,18 In our study, primary repair or resection with anastomosis was performed in 18 (72%) cases, whereas fecal diversion was performed in 7 (28%) cases.
Complications were more frequent in patients with CISS grades I–III than in those with grades IV–V; however, these were predominantly minor wound infections. A major complication occurred in one patient with a CISS grade V injury. It has been reported that a PATI score above the mean value increases morbidity and mortality. (14) However, in our study, higher PATI scores were not associated with increased complication rates. Our findings are consistent with those of Kahya et al. 12, who evaluated outcomes according to CISS grading. In many studies, the reported rates of anastomotic leakage and fistula formation vary between 1.2% and 12.7% 19-21. In our study, intra-abdominal abscess developed in only one patient, who was successfully treated with percutaneous drainage catheter insertion. In colorectal injuries, additional complications may arise due to concomitant multi-organ trauma. Indeed, in our study, complications unrelated to colonic injury were observed in two patients, and one patient died on the first postoperative day as a result of multiple organ trauma. Interestingly, in our study, the complication rate was higher in patients with lower CISS scores (I–III); this finding may be explained by the frequent use of primary repair in low-CISS cases, whereas protective fecal diversion was preferred in patients with high CISS scores (IV–V). Therefore, the lower complication rates observed in the high-CISS group may be attributed to the protective effect of the surgical approach, suggesting that the CISS score alone may be insufficient to predict complication risk. In our study, although higher PATI scores appeared to increase the likelihood of complications, this association was not found to be statistically significant (p=0.45); this may indicate that the limited sample size reduced the statistical power to demonstrate a meaningful relationship between PATI and postoperative complications.
The limitations of this study include its retrospective design and relatively small sample size. Nevertheless, well-designed, prospective, and controlled studies with larger patient populations are needed to further elucidate optimal management strategies for colon injuries.
In conclusion, primary repair and resection–anastomosis can be safely performed in penetrating colorectal injuries with low morbidity and mortality rates. However, because not all patients share the same clinical risk profile, fecal diversion may still provide additional protection in certain cases; therefore, the need for a stoma cannot be completely eliminated. In this context, surgical management of colorectal injuries should be individualized by carefully assessing the severity of the injury, the presence of associated organ damage, and patient-specific risk factors.
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