Analysis of over 2 decades of colon injuries identifies optimal method of diversion

Does an end justify the means?

Nathan R. Manley, John P. Sharpe, Richard H. Lewis, Mark S. Iltis, Rishi Chaudhuri, Timothy C. Fabian, Martin Croce, Louis J. Magnotti

Research output: Contribution to journalArticle

Abstract

INTRODUCTION Conflicting evidence exists regarding the definitive management of destructive colon injuries. Although diversion with an end ostomy can theoretically decrease initial complications, it mandates a more extensive reversal procedure. Conversely, anastomosis with proximal loop ostomy diversion, while simplifying the reversal, increases the number of suture lines and potential initial morbidity. Thus, the purpose of this study was to evaluate the impact of diversion technique on morbidity and mortality in patients with destructive colon injuries. METHODS Consecutive patients with destructive colon injuries managed with diversion from 1996 to 2016 were stratified by demographics, severity of shock and injury, operative management, and timing of reversal. Outcomes, including ostomy complications (obstruction, ischemia, readmission) and reversal complications (obstruction, abscess, suture line failure, fascial dehiscence), were compared between patients managed with a loop versus end colostomy. Patients with rectal injuries and who died within 24 hours were excluded. RESULTS A total of 115 patients were identified: 80 with end colostomy and 35 with loop ostomy. Ostomy complications occurred in 22 patients (19%), and 11 patients (10%) suffered reversal complications. There was no difference in ostomy-related (2.9% vs. 3.8%, p = 0.99) mortality. For patients without a planned ventral hernia (PVH), there was no difference in ostomy complications between patients managed with a loop versus end colostomy (12% vs. 18%, p = 0.72). However, patients managed with a loop ostomy had a shorter reversal operative time (95 vs. 245 minutes, p = 0.002) and reversal length of stay (6 vs. 10, p = 0.03) with fewer reversal complications (0% vs. 36%, p = 0.02). For patients with a PVH, there was no difference in outcomes between patients managed with a loop versus end colostomy. CONCLUSION For patients without PVH, anastomosis with proximal loop ostomy reduced reversal-related complications, operative time, LOS, and hospital charges without compromising initial morbidity. Therefore, loop ostomy should be the preferred method of diversion, if required, following destructive colon injury. LEVEL OF EVIDENCE Therapeutic, level IV.

Original languageEnglish (US)
Pages (from-to)214-219
Number of pages6
JournalJournal of Trauma and Acute Care Surgery
Volume86
Issue number2
DOIs
StatePublished - Feb 1 2019

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Ostomy
Colon
Wounds and Injuries
Colostomy
Ventral Hernia
Operative Time
Morbidity
Sutures
Hospital Charges
Mortality
Abscess
Shock
Length of Stay
Ischemia
Demography

All Science Journal Classification (ASJC) codes

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Manley, N. R., Sharpe, J. P., Lewis, R. H., Iltis, M. S., Chaudhuri, R., Fabian, T. C., ... Magnotti, L. J. (2019). Analysis of over 2 decades of colon injuries identifies optimal method of diversion: Does an end justify the means? Journal of Trauma and Acute Care Surgery, 86(2), 214-219. https://doi.org/10.1097/TA.0000000000002135

Analysis of over 2 decades of colon injuries identifies optimal method of diversion : Does an end justify the means? / Manley, Nathan R.; Sharpe, John P.; Lewis, Richard H.; Iltis, Mark S.; Chaudhuri, Rishi; Fabian, Timothy C.; Croce, Martin; Magnotti, Louis J.

In: Journal of Trauma and Acute Care Surgery, Vol. 86, No. 2, 01.02.2019, p. 214-219.

Research output: Contribution to journalArticle

Manley, Nathan R. ; Sharpe, John P. ; Lewis, Richard H. ; Iltis, Mark S. ; Chaudhuri, Rishi ; Fabian, Timothy C. ; Croce, Martin ; Magnotti, Louis J. / Analysis of over 2 decades of colon injuries identifies optimal method of diversion : Does an end justify the means?. In: Journal of Trauma and Acute Care Surgery. 2019 ; Vol. 86, No. 2. pp. 214-219.
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abstract = "INTRODUCTION Conflicting evidence exists regarding the definitive management of destructive colon injuries. Although diversion with an end ostomy can theoretically decrease initial complications, it mandates a more extensive reversal procedure. Conversely, anastomosis with proximal loop ostomy diversion, while simplifying the reversal, increases the number of suture lines and potential initial morbidity. Thus, the purpose of this study was to evaluate the impact of diversion technique on morbidity and mortality in patients with destructive colon injuries. METHODS Consecutive patients with destructive colon injuries managed with diversion from 1996 to 2016 were stratified by demographics, severity of shock and injury, operative management, and timing of reversal. Outcomes, including ostomy complications (obstruction, ischemia, readmission) and reversal complications (obstruction, abscess, suture line failure, fascial dehiscence), were compared between patients managed with a loop versus end colostomy. Patients with rectal injuries and who died within 24 hours were excluded. RESULTS A total of 115 patients were identified: 80 with end colostomy and 35 with loop ostomy. Ostomy complications occurred in 22 patients (19{\%}), and 11 patients (10{\%}) suffered reversal complications. There was no difference in ostomy-related (2.9{\%} vs. 3.8{\%}, p = 0.99) mortality. For patients without a planned ventral hernia (PVH), there was no difference in ostomy complications between patients managed with a loop versus end colostomy (12{\%} vs. 18{\%}, p = 0.72). However, patients managed with a loop ostomy had a shorter reversal operative time (95 vs. 245 minutes, p = 0.002) and reversal length of stay (6 vs. 10, p = 0.03) with fewer reversal complications (0{\%} vs. 36{\%}, p = 0.02). For patients with a PVH, there was no difference in outcomes between patients managed with a loop versus end colostomy. CONCLUSION For patients without PVH, anastomosis with proximal loop ostomy reduced reversal-related complications, operative time, LOS, and hospital charges without compromising initial morbidity. Therefore, loop ostomy should be the preferred method of diversion, if required, following destructive colon injury. LEVEL OF EVIDENCE Therapeutic, level IV.",
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T1 - Analysis of over 2 decades of colon injuries identifies optimal method of diversion

T2 - Does an end justify the means?

AU - Manley, Nathan R.

AU - Sharpe, John P.

AU - Lewis, Richard H.

AU - Iltis, Mark S.

AU - Chaudhuri, Rishi

AU - Fabian, Timothy C.

AU - Croce, Martin

AU - Magnotti, Louis J.

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N2 - INTRODUCTION Conflicting evidence exists regarding the definitive management of destructive colon injuries. Although diversion with an end ostomy can theoretically decrease initial complications, it mandates a more extensive reversal procedure. Conversely, anastomosis with proximal loop ostomy diversion, while simplifying the reversal, increases the number of suture lines and potential initial morbidity. Thus, the purpose of this study was to evaluate the impact of diversion technique on morbidity and mortality in patients with destructive colon injuries. METHODS Consecutive patients with destructive colon injuries managed with diversion from 1996 to 2016 were stratified by demographics, severity of shock and injury, operative management, and timing of reversal. Outcomes, including ostomy complications (obstruction, ischemia, readmission) and reversal complications (obstruction, abscess, suture line failure, fascial dehiscence), were compared between patients managed with a loop versus end colostomy. Patients with rectal injuries and who died within 24 hours were excluded. RESULTS A total of 115 patients were identified: 80 with end colostomy and 35 with loop ostomy. Ostomy complications occurred in 22 patients (19%), and 11 patients (10%) suffered reversal complications. There was no difference in ostomy-related (2.9% vs. 3.8%, p = 0.99) mortality. For patients without a planned ventral hernia (PVH), there was no difference in ostomy complications between patients managed with a loop versus end colostomy (12% vs. 18%, p = 0.72). However, patients managed with a loop ostomy had a shorter reversal operative time (95 vs. 245 minutes, p = 0.002) and reversal length of stay (6 vs. 10, p = 0.03) with fewer reversal complications (0% vs. 36%, p = 0.02). For patients with a PVH, there was no difference in outcomes between patients managed with a loop versus end colostomy. CONCLUSION For patients without PVH, anastomosis with proximal loop ostomy reduced reversal-related complications, operative time, LOS, and hospital charges without compromising initial morbidity. Therefore, loop ostomy should be the preferred method of diversion, if required, following destructive colon injury. LEVEL OF EVIDENCE Therapeutic, level IV.

AB - INTRODUCTION Conflicting evidence exists regarding the definitive management of destructive colon injuries. Although diversion with an end ostomy can theoretically decrease initial complications, it mandates a more extensive reversal procedure. Conversely, anastomosis with proximal loop ostomy diversion, while simplifying the reversal, increases the number of suture lines and potential initial morbidity. Thus, the purpose of this study was to evaluate the impact of diversion technique on morbidity and mortality in patients with destructive colon injuries. METHODS Consecutive patients with destructive colon injuries managed with diversion from 1996 to 2016 were stratified by demographics, severity of shock and injury, operative management, and timing of reversal. Outcomes, including ostomy complications (obstruction, ischemia, readmission) and reversal complications (obstruction, abscess, suture line failure, fascial dehiscence), were compared between patients managed with a loop versus end colostomy. Patients with rectal injuries and who died within 24 hours were excluded. RESULTS A total of 115 patients were identified: 80 with end colostomy and 35 with loop ostomy. Ostomy complications occurred in 22 patients (19%), and 11 patients (10%) suffered reversal complications. There was no difference in ostomy-related (2.9% vs. 3.8%, p = 0.99) mortality. For patients without a planned ventral hernia (PVH), there was no difference in ostomy complications between patients managed with a loop versus end colostomy (12% vs. 18%, p = 0.72). However, patients managed with a loop ostomy had a shorter reversal operative time (95 vs. 245 minutes, p = 0.002) and reversal length of stay (6 vs. 10, p = 0.03) with fewer reversal complications (0% vs. 36%, p = 0.02). For patients with a PVH, there was no difference in outcomes between patients managed with a loop versus end colostomy. CONCLUSION For patients without PVH, anastomosis with proximal loop ostomy reduced reversal-related complications, operative time, LOS, and hospital charges without compromising initial morbidity. Therefore, loop ostomy should be the preferred method of diversion, if required, following destructive colon injury. LEVEL OF EVIDENCE Therapeutic, level IV.

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