Primary repair for penetrating colon injuries
Editorial Group: Cochrane Injuries Group
Published Online: 21 JUL 2003
Assessed as up-to-date: 25 SEP 2008
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Nelson RL, Singer M. Primary repair for penetrating colon injuries. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD002247. DOI: 10.1002/14651858.CD002247.
- Publication Status: Edited (no change to conclusions)
- Published Online: 21 JUL 2003
Primary repair of penetrating colon injuries is an appealing management option. However, uncertainty about its safety persists.
The objective of this review was to compare morbidity and mortality rates after primary repair to the rates after fecal diversion, in the management of penetrating colon injuries, using a meta-analysis of randomized controlled trials.
We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE 1950 to Sept 2008, EMBASE 1980 to Sept 2008, ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) 1970 to Sept 2008, Conference Proceedings Citation Index-Science (CPCI-S) 1990 to Sept 2008, and PubMed (searched 26 Sept 2008). The most recent searches were carried out in September 2008.
Studies were included if they were randomized controlled trials comparing the outcomes of primary repair versus fecal diversion in the management of penetrating colon injuries.
Data collection and analysis
Two authors independently extracted the data. Outcomes evaluated from each trial included mortality, total complications, infectious complications, intra-abdominal infections, wound complications and penetrating abdominal trauma index (PATI). We calculated Peto odds ratios (ORs) for combined effect with a 95% confidence interval (95% CI) for each outcome. Heterogeneity was assessed for each outcome, using a chi-squared test.
Six trials involving 705 patients were included. Mortality was not significantly different between groups, which was low in both the primary repair (1.94%) and the diverted groups (1.74%). The Peto OR for mortality was 1.22 (95% CI 0.40 to 3.74). However, the primary repair group experienced a significantly lower rate of complications (Peto OR 0.54; 95% CI 0.39 to 0.76), total infectious complications (Peto OR 0.44; 95% CI 0.17 to 1.1), abdominal infections including dehiscence (Peto OR 0.67; 95% CI 0.35 to 1.3), abdominal infections excluding dehiscence (Peto OR 0.69; 95% CI 0.34 to 1.39), wound complications including dehiscence (Peto OR 0.73; 95% CI 0.38 to 1.39), and wound complications excluding dehiscence (Peto OR 0.67; 95% CI 0.32 to 1.39). Statistical significance favoring primary repair over fecal diversion was achieved for all outcomes related to abdominal infections and wound complications when one study was excluded for both clinical and statistical heterogeneity in the sensitivity analysis.
Meta-analysis of currently published randomized controlled trials favors primary repair over fecal diversion for penetrating colon injuries.
Plain language summary
Direct (primary) repair for penetrating colon injuries
A common treatment for wounds that penetrate the colon (part of the large intestine) is to attach the colon, from at or above the injury, to a bag outside the body via the abdominal wall (this is called a colostomy or fecal diversion). This diverts feces from the injury, to prevent infection and death. With improved critical care techniques and antibiotic therapy many trauma centers now manage their patients with direct repair of the colon to close the injury. The potential advantages are avoidance of complications of having an opening of the colon in the abdomen wall (stoma) to a bag, the need for another procedure for stoma closure, and the psychological and financial burden of stoma care.
The review authors searched the medical literature and found six controlled studies in which patients were randomized to primary repair or fecal diversion. Results were reported for a total of 705 patients. The two groups sustained significant injuries with the primary repair patients at least as ill as the diverted patients. The studies were reported from 1979 to 2002 and involved increasingly 'high risk' patients. Five were conducted in the United States and one in South Africa. Primary closure was at least as safe as fecal diversion. The number of deaths was similar in both the primary repair (1.94%) and the diverted groups (1.74%). Total complications, total infectious complications, abdominal infections and wound complications all favored primary repair. The studies did not adequately report colostomy closure for trauma-related colostomies, which can itself result in complications and significant illness.
我們搜尋了Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS，並使用colon, penetrating, injury, colostomy, prospective, and randomized等為關鍵字。最後一次搜尋的更新在2005年12月。
我們分別擷取資料。每個試驗的結果分析包括死亡率，所有的併發症，感染的併發症，腹部內的感染，傷口的併發症，penetrating abdominal trauma index (PATI)以及住院天數。由於combined effect，我們計算每個結果的Peto odds ratios (ORs) 及其95%信賴區間(95% CI)。每個結果的異質性採用chisquared test來評估。
6個試驗共705名病人被納入本研究。研究間納入的病人其PATI scores並無顯著差異。群體間的死亡率無顯著差異，初次修補術(1.94%)與糞便分流術(1.74%)兩組的死亡率都不高。死亡率的Peto OR值是1.22(95% CI 0.40, 3.74)。然而，初次修補組其併發症(Peto OR 0.54；95% CI 0.39, 0.76)、所有感染的併發症(Peto OR 0.44；95% 0.17, 1.1)、腹部感染包括破裂(Peto OR 0.67；95% CI 0.35, 1.3)、腹部感染排除破裂(Peto OR 0.69；95% CI 0.34, 1.39)、傷口併發症包括破裂(Peto OR 0.73；95% CI 0.38, 1.39)以及傷口併發症排除破裂等(Peto OR 0.67；95% CI 0.32, 1.39)，都有顯著較低的比率。採用敏感度分析有關腹部感染和傷口併發症的所有結果，在排除一篇臨床和統計具異質性的研究後發現，統計顯著性較偏向於初次修補術勝於糞便分流術。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。