Intervention Review

Primary repair for penetrating colon injuries

  1. Richard L Nelson1,*,
  2. Marc Singer2

Editorial Group: Cochrane Injuries Group

Published Online: 21 JUL 2003

Assessed as up-to-date: 25 SEP 2008

DOI: 10.1002/14651858.CD002247

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.

Author Information

  1. 1

    Northern General Hospital, Department of General Surgery, Sheffield, Yorkshire, UK

  2. 2

    University of Illinois at Chicago, Department of Surgery, Chicago, Illinois, USA

*Richard L Nelson, Department of General Surgery, Northern General Hospital, Herries Road, Sheffield, Yorkshire, S5 7AU, UK. altohorn@btinternet.com. Rick.Nelson@sth.nhs.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 21 JUL 2003

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Primary repair of penetrating colon injuries is an appealing management option. However, uncertainty about its safety persists.

Objectives

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.

Search methods

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.

Selection criteria

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.

Main results

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.

Authors' conclusions

Meta-analysis of currently published randomized controlled trials favors primary repair over fecal diversion for penetrating colon injuries.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

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.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

穿刺性結腸損傷之初次修補術

穿刺性結腸損傷的初次修補術是一種吸引人的處理方式。然而,有關它的安全性仍有其不確定性存在。

目標

此篇回顧的目的是比較穿刺性結腸損傷處理的初次修補手術與糞便分流手術後其發病率與死亡率,採用隨機對照試驗的統合分析。

搜尋策略

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。

選擇標準

若該研究為比較穿刺性結腸損傷之初次修補手術對照糞便分流手術的隨機對照試驗,則被納入本研究。

資料收集與分析

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chisquared test來評估。

主要結論

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。

作者結論

現今發表的隨機對照試驗其統合分析較偏向穿刺性結腸損傷的初次修補術勝於糞便分流術。

翻譯人

本摘要由高雄榮民總醫院徐圭璋翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

穿刺性結腸損傷的直接(初次)修補術是一種常見的傷口治療方式。另一種常見處理結腸(大腸的一部份)穿刺傷的方法是把是把該穿刺部位或更高位的結腸經由腹壁連接到外面的袋子上。(結腸造口術或糞便分流)。這種從傷口分流糞便是要避免感染和死亡。隨著基礎照護技術和抗生素治療的進步,現在許多創傷治療中心處理病人採用結腸的直接修補來閉合傷口。可能的好處就是避免併發症,腹壁上的開放性結腸(穿孔)形成血腫,為了閉合穿孔施以其他處置的需要,以及穿孔照護的心理和財務負擔。 回顧的作者搜尋醫學文獻並找到六篇對照研究,其病人是隨機分配到初次修補術和糞便分流術兩組。總共報告了705名病人的結果。這兩組病人都受了結腸穿刺傷,並且初次修復組病人的病情至少不亞於糞便分流組病人的病情。研究是從1979年至2002年被報告並包括增加’高風險’的病人。其中五篇是在美國完成,一篇是在南美。初次關合術至少如同糞便分流術一樣安全。初次修補(1.94%)和糞便分流(1.74%)兩組的死亡數相似。所有的併發症,所有感染的併發症,腹部感染以及傷口併發症皆較偏向初次修補。初次修復病人的住院天數平均值為12.7天,糞便分流病人(不包括結腸造口術閉合)住院天數為16.1天。研究中並未充分地指出創傷相關的結腸造口術閉合,它本身會導致併發症,顯明的病況以及長時間的住院。