Clinical practicePerformance of primary repair on colon injuries sustained from low-versus high-energy projectiles
Introduction
The colon is the second most commonly injured intra-abdominal organ in cases of penetrating trauma.1 Although colon trauma is highly prevalent, it can be difficult to identify as different factors influence its origin.2 Fatal penetrating colon injuries are typically caused by firearm bullets, as well as by stabbing with sharp weapons. The mortality rate from gunshot injuries of the colon ranges from 3% to 16%.3 Early death due to penetrating colon trauma is linked to severe bleeding and exsanguination, whereas delayed death is linked to sepsis and multiorganic insufficiency.4 In the late postoperative period, other factors may lead to death, such as abscesses, fistulas, and/or leakage of the anastomosis or even the abdominal wall.5
Due to its complexity, the management of penetrating colon trauma has been extensively studied. The available treatment options include primary repair and various types of two-stage management (e.g., fecal diversion). However, the specific procedures to be used in different cases are still debatable.6, 7, 8, 9 Relevant studies describe several factors that influence prognosis: site of injury, degree of tissue destruction, presence of multiple and/or multisegmentational injuries, number of simultaneous injuries of other organs, time elapsed from injury to surgery, development of shock, fecal contamination, and bowel devitalization. The treatment option should be chosen based on these factors.1, 10, 11, 12, 13
A few methods are available to determine the severity of colon injuries. Apart from universal methods, such as the Revised Trauma Score (RTS) and Injury Severity Score (ISS), other more specific methods are used to assess abdominal trauma: the Penetrating Abdominal Trauma Index (PATI), the Flint scale, and Stone and Fabian's criteria (S/F) for primary repair of colon injury.
The nature of gunshot wounds varies considerably based on the type of firearm causing the injury. Firearms can be broadly categorized as follows: those with long barrels, including shotguns and rifles (the smooth-bore weapon, and single-shot, bolt-loaded, and self-loading rifles), and those with short barrels, commonly known as handguns including pistols and revolvers.14 Shotguns and handguns fire low-velocity projectiles, whereas many rifles fire high-velocity projectiles. The higher the velocity the greater the kinetic energy transfer to the human body. This significant transfer of energy causes temporary cavitation, wherein the tissue stretches radially due to a shock-wave effect. This can cause remote injuries beyond the permanent wound cavity. A missile's ability to produce a temporary cavity is considered an important aspect of wound severity and the degree of damage caused.15, 16 When a missile enters the body, kinetic energy is imparted to the surrounding tissues, which forces the molecules of the tissues adjacent to the track to move centrifugally outwards even after the missile has traveled forward.14 The temporary cavity may be considerably larger than the diameter of the bullet, lasting for a few milliseconds before collapsing into the permanent cavity or wound – bullet track. Ragsdale and Josselson argued that short-barreled firearms also produce some degree of cavitation, but not as much as rifle guns.17 In addition to energy, momentum, mass, and bullet shape also affect wound severity.
This paper investigates the differences in the performance of primary repair of colon injuries based on two different types of projectiles: low energy and high energy. The energy of the missiles will affect the projectile path through the body and the extent of temporary cavitation.
Section snippets
Material and methods
During the last 25 years (1990–2015), 250 patients were admitted to the Clinical Center of Montenegro with penetrating abdominal injury. Of these patients, only those who sustained a single gunshot wound injuring the colon and no more than two other injured abdominal organs were selected for primary colon repair. Sixty patients were identified, all of whom were male. They were divided into two groups based on the type of projectile: low energy (group 1) and high energy (group 2). As both the
Results
Patients with colon injury as well as injuries to no more than two organs were included in this study. These extracolonic organs were (low-vs. high-energy group) as follows: small intestine or stomach (nine vs. 10), spleen (four vs. five), kidney (three vs. four), urinary bladder and/or ureter (three vs. four), liver (two vs. three), pancreas (one vs. two), and caval or iliac vein (zero vs. one).
After selection based on the inclusion and exclusion criteria, all patients underwent one-stage
Discussion
Previous studies have concluded that one-stage primary repair is the best treatment option for a colon injury, if S/F criteria and Flint grading are followed correctly.1, 6, 7, 8, 9, 10, 11, 12, 13 Other studies have shown primary repair with better results such as fewer complications and deaths, and better outcome compared with other treatment options for colon injuries of similar trauma intensity and similar intraoperative findings.25, 26 The most suitable treatment option for destructive
Acknowledgments
During this study, Dr Radojevic was a fellow of the Fogarty International Center of the National Institutes of Health's “Research Ethics Education in the Balkans and Black Sea Countries” (Award Number R25TW008171), provided by Icahn School of Medicine at Mount Sinai, New York, USA, and School of Medicine University of Belgrade, Serbia. As such, the ethical principles followed for this study were influenced by the education acquired. The content is solely the responsibility of the authors, and
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Cited by (1)
FACTORS AFFECTING THE MANAGEMENT OF TRAUMATIC COLONIC INJURY
2019, Journal of University Medical and Dental College