ORIGINAL ARTICLE

ANZJSurg.com

Gunshot wounds to the colon: predictive risk factors for the

development of postoperative complications, an experience of
172 cases in 4 years

Osama Elfaedy,*† Khaled Elgazwi,* Jamal Alsharif‡ and Salah Mansor *§

*Department of General Surgery, Al-Jalaa Teaching Hospital, Benghazi University, Benghazi, Libya
†Department of General Surgery, St. Luke’s General Hospital, Kilkenny, Ireland
‡Department of General Surgery, Ajdabiya Teaching Hospital, Ajdabiya University, Ajdabiya, Libya and
§Department of Surgery, Libyan International Medical University, Benghazi, Libya

Key words Abstract

gunshot injury, pentriating injury.
Correspondence
Dr Salah Mansor, Department of General Surgery,
Al-Jalaa Teaching Hospital, Benghazi University,
P.O. Box 22144, Benghazi, Libya.
Email: salah.mansor@uob.edu.ly
O. Elfaedy FACS, FEBS; K. Elgazwi MRCS, MD;
J. Alsharif MBBCh, FRCSC; S. Mansor MBBCh,
MD.
Accepted for publication 13 October 2019.
doi: 10.1111/ans.15575
Background: In our study, we have defined and evaluated risk factors for the development
of post-operative complications in patients with gunshot wounds to the colon. The purpose
of the study is to identify the most influential risk factors.
Methods: A retrospective study of 172 patients admitted with gunshot wounds to the colon
from 17 February 2011 to 31 December 2014. Age, gender, shock upon admission defined
by vital signs and haemoglobin level, blood transfusion, injured site of the colon, the colon
injury score, faecal contamination, surgical procedure, colon diversion, multiple organ inju-
ries, delay time pre-operation and duration of the operation were considered as risk factors.
All patients were observed for any postoperative complications.
Results: One hundred and sixty-six patients (96.5%) were males, and six (3.5%) were
female. The mean age was 28.5 years. On admission 104 (60.5%) patients were in shock,
89 (51.7%) required blood transfusion. Forty-four (25.5%) patients had an injury to the
ascending colon, while 53 (30.8%), 13 (7.6%), 23 (13.4%), 21 (12.2%) and 18 (10.5%)
patients had an injury in transverse, descending, sigmoid, rectum and multiple colon injuries
respectively. A colon diversion was used in 64 patients (37.2%). Post-operative complica-
tions documented in 67 (38.9%) patients, 35 (20.3%) required re-exploratory laparotomy,
while the disability occurred in 18 (10.4%)) cases, and post-operative mortality
was 12 (6.9%).
Conclusion: Surgeons should be aware that shock state upon admission and blood transfu-
sion are risk factors for postoperative complications in a patient with a gunshot penetrating
injury to the colon.

There is clear evidence that, because of the anatomical features

Introduction
The last war in Libya was during the Second World War. Subse-
quently, the state of a peaceful country lasting 60 years resulted in
generations of surgeons who were lacking sufficient experience to
deal with the casualties of war and gunshot injuries. The sudden
change that has occurred during the conflict which started in 2011
led to the widespread availability of weapons in the community,
and an increased incidence of firearm-related violence.1 Many
studies have documented that gunshot injuries are a common sur-
gical condition and have become a significant problem
globally.2,3
of the colon, the colon is one of the most commonly injured organs
in penetrating abdominal gunshot injuries,4,5 and this has a pro-
found clinical significance because of the risk of septic complica-
tions. Colon-related complications result in significant clinical
problems which include wounds infection, anastomotic leakage and
intra-abdominal abscess.6 Still, there’s a debate amongst surgeons
about the right way in dealing with the patient with a colonic gun-
shot injury,7 and continuing investigation has led to progressive
evolution in treatment with experience gained. In the elective surgi-
cal management of colonic diseases, there are well recognized risk
factors for postoperative complications.8–10

© 2019 Royal Australasian College of Surgeons ANZ J Surg (2019)

2 Elfaedy et al.

Our objectives in this study were to analyse the predictive risk

factors which help the military as well as trauma surgeons to deal
with penetrating colon injuries caused by high energy rifles in order
to produce a management plan which leads to the lowest rate of
complications for these patients.

Methods
A retrospective review of our database was carried out of
172 patients that sustained gunshot injuries to the abdomen with a
penetrating colon injury, admitted to our department in the time
period February 2011 to December 2014.
The age, gender, shock upon admission with systemic tissue
hypoperfusion confirmed by altered vital signs and haemoglobin
level, blood transfusion, injured site of the colon, colon injury
Fig. 1. The locations of the colonic injury with the rate of post-operative
score, faecal contamination, surgical procedure, colon diversion, complication in each segment.
multi-organ injury, delay time before the operation and duration of
the operation were considered as risk factors during the pre- and
intra-operative periods. Blood transfusion was commenced when
the patient had clear vital signs of shock due to blood loss and/or Table 1 Type and number of colonic surgical procedure
haemoglobin less than 8 g/L.
No Type of procedure Operation Cases
To determine the grade of colon injury, the American Associa-
tion for the Surgery of Trauma Colonic Injury Scale has been 1 Conservative No operation 1
2 Primary repair Cecal primary repair 5
adopted (Table S1).3,11 Postoperative complications were docu-
Ascending colon primary 8
mented. Patients who died in the first 24 h due to high-grade injury repair
and massive bleeding were excluded from the study. Transverse colon primary 33
repair
Ethics approval of the publication and statistical analysis are pro-
Descending colon primary 7
vided in Appendix S1. repair
Sigmoid colon primary 14
repair
Rectum primary repair 2
Results 3 Primary repair with Transverse colon primary 2
proximal colon repair with proximal loop
Of the 172 eligible patients included, 166 (96.5%) were males and diversion colostomy
six (3.5%) females, mean age 28.5 years (Fig. S1). Upon admission Descending colon primary 3
repair with proximal loop
to the hospital 104 (60.5%), patients were in shock, 89 (51.7%)
colostomy
needed a blood transfusion of which 38 (22%) required immediate Sigmoid colon primary 3
transfusion on arrival because of massive bleeding, while 35 (20%) repair with proximal loop
colostomy
received transfusion during surgery, and 16 (9%) received blood in
Rectum primary repair with 20
the postoperative period. The mean number of units transfused was proximal loop colostomy
2.4. The rate of complications was significantly raised after transfu- 4 Resection Ileocecal resection 1
Right hemicolectomy 32
sion of 3 units (P = 0.047). Forty-four (25.5%) had an injury in the
Extended right 7
ascending colon, while 53 (30.8%) in the transverse colon, hemicolectomy
13 (7.6%) descending colon, 23 (13.4%) sigmoid, 21 (12.2%) in Transverse colon resection 9
and anastomosis
the rectum and 18 (10.5%) patients had multiple colon injuries.
Left hemicolectomy 1
Figure 1 shows the frequency of the injury in the different anatomi- Sigmoid colon resection 1
cal segments of the colon with the rate of postoperative complica- and anastomosis
5 Resection and Left hemicolectomy with 1
tion in each segment. According to the colon injury scale, in grade
proximal colon proximal loop colostomy
I there were five (2.9%) cases, grade II in 36 (20.9%), grade III in diversion
80 (46.5%), grade IV in 45 (26.3%) and grade V in six (3.5%) 6 Colon diversion Ascending colon loop 1
colostomy
cases. One hundred and forty-three (83.1%) cases had faecal con-
Transverse colon loop 13
tamination, and 130 (75.6%) had a multi-organ injury. Two patients colostomy
required a nephrectomy. The delay time from the injury to the oper- Descending colon loop 2
colostomy
ation was less than 200 minutes in all cases.
Sigmoid colon loop 8
All patients were treated surgically with emergency laparotomy colostomy
according to the type and severity of colon injury. The types of Hartmann’s operation 9
operative procedures are shown in Table 1.

© 2019 Royal Australasian College of Surgeons

Gunshot wounds to the colon 3

Table 2 Indication and type of procedure in re-laparotomy cases chronic diseases, helping to smooth recovery and reduce complica-
Indication of re-laparotomy Type of procedure n
tion rates.13,14
Due to the fact that the active participants in the armed conflict
2nd laparotomy were males, all six female patients had stray bullet injuries that
Colon anastomosis leak Hartmann’s operation 6
Extended right 2 occurred during attacks inside the city. Some studies have shown
hemicolectomy that males have a higher risk of complications after colon-related
Missed gauze with colon Extended right 1 injuries, but we were not able to assess this in our study.8,15
anastomosis leak and hemicolectomy
abscess Hartmann’s operation 1 Shock due to bleeding leads to a decrease in colonic blood supply,
Damage Control Surgery Remove of abdominal 10 causing a state of insufficient colonic mucosal blood flow with cellu-
backing lar ischemia and hypoxia, which, with the addition of the effect of
Intra-abdominal abscess Collection washing and 4
drainage bacterial colonization at the site of injury, may cause failure of
Colostomy abscess Incision and drainage 2 healing after colon repair.16 Colonic anastomosis performed in an
Post-operative bleeding Re-laparotomy with 2 ischemic bowel and contaminated abdomen increases the risk of
haemostasis
Missed colon injury Hartmann’s operation 2 anastomotic leakage.17 The local blood flow at the site of colon
Colostomy necrosis New colostomy 1 injury is the most critical factor in healing, and anastomotic leak rate
Burst abdomen Abdominal wall closure 1 in an ischemic colon is about 35%, which is higher than rates seen in
Urine leak Re-laparotomy with repair 1
Missed stomach injury Re-laparotomy with repair 1 elective surgery.18 Patients who had shock and blood transfusions
Small bowel fistula Re-laparotomy with 1 had higher rates of complications than those who were not shocked
excision or did not require blood transfusions (P = 0.017, P = 0.048 respec-
3rd laparotomy
Upper and lower GIT bleeding Aorto-enteric fistula 2 tively). Many studies have concluded that the shock status is associ-
excision ated with increased morbidity and mortality,19 and recent studies
Colonic fistula Resection and 1 found the 30-day morbidity and mortality rates increased in associa-
anastomosis
Burst abdomen Abdominal wall closure 1 tion with a significant fall in haematocrit levels.20,21
Colostomy necrosis Hartmann’s operation 1 We have also investigated the relationship between the injured
part of the colon and postoperative complications. In our study, the
transverse colon was the most commonly injured part, probably
due to greater length and mobility.22,23 The rate of postoperative
Post-operative complications occurred in 67 (38.9%) patients, complications was more frequent with transverse colon injuries
the most common complications being wound infection in (53% of cases; Fig. 1). We found, however, that the site of the
24 (14%), intra-abdominal abscess in 12 (6.9%), septicaemia in
injured colon was not a significant risk factor for postoperative
10 (5.8%) and colon anastomosic leak in 10 (5.8%) patients. One complications (P = 0.062), as with other previous reports24 as well
patient had a myocardial infarction. Re-laparotomy was needed in as after penetrating non-destructive colon injuries.25 Some authors
35 (20.3%) patients; Table 2 shows indications and type of proce-
have concluded that wounds to the splenic flexure should be treated
dures in second and third re-laparotomy. with particular caution26 and that injury to the rectum or transverse
Seven patients had pelvic nerve injury, four of whom developed colon is an independent predictor of mortality.27
foot drop, two have retrograde ejaculation and one patient has erec-
The colon injury score (Table S1)12 was used to help determine
tile dysfunction. Four patients developed paraplegia due to spinal the optimal method for surgical repair. In our study, there was no
cord injury. Two developed a urethral stricture. Two have anal significant statistical difference between colon injury scale and
incontinence. Eighteen patients developed an incisional hernia
complications (P = 0.448). Some previous studies concluded that
(Table S2). the colon injury scale does not support diversion over primary
repair.28,29
Faecal contamination of the peritoneal cavity is considered an
important influencing factor in the healing of the repaired colon in
Discussion
emergency surgical interventions and was previously considered an
Trauma is still considered the most frequent aetiology of morbidity indication for diversion to avoid septic complications.30 However,
and mortality in the first four decades of life. The abdomen is one contamination is related to two other factors, the colon injury score
of the areas that is commonly exposed to trauma. Gunshot wound and the exposure time, where the amount of faecal contamination is
to the abdomen represents a high energy penetrating injury, and directly proportional to both. In our cases, the exposure time was
continues to be a significant cause of trauma admission in the relatively short because of the short delay between the injury and
United States, with a high mortality rate.12 The small and large the operation with early washing and irrigation. There was no sig-
bowel occupy a large part the abdominal cavity, and thus are likely nificant statistical difference between faecal contamination of the
to be injured by penetrating abdominal injuries.4,5 Penetrating inju- peritoneal cavity and postoperative complications (P = 0.588). Mul-
ries of the colon have a very significant clinical value with high tiple previous studies showed that the degree of faecal contamina-
rates of morbidity and mortality.3 tion did not affect the outcome of patients treated by diversion
The vast majority of patients were young, with mean age versus primary repair,29 and supported primary repair even in cases
28.5 years (Fig. S1). Young patients had a very low prevalence of of massive faecal contamination,7 and massive faecal contamination

© 2019 Royal Australasian College of Surgeons

4 Elfaedy et al.
is no longer considered an absolute contraindication to primary
repair.
It is well known that the treatment of penetrating colon injuries
has changed during the last century because of exposure to a large
volume of cases due to surgeons’ increased wartime experience. At
the end of World War II, surgeons recommended the use of diver-
sion as standard for the treatment of gunshot wounds,31 and then
the treatment option changed to include colostomy proximal to or
at the site of colon injury.32 Primary repair gained popularity as sur-
geons began to understand the differences between military and
civilian injuries.31 In our cases, the treatment options were arranged
as follows: the first group with diversion of the injured segment of
the colon if it has a meso-colon; injury repair with proximal loop
colostomy and Hartmann’s procedure. The second group was
treated with primary suture of injury or resection and anastomosis
of the injured segment. In our study, there was no significant statis-
tical difference between the types of operations and postoperative
complications, although we recognize that the two groups were
highly selected, based on the nature of the injuries. We found that
primary repair of penetrating colon injuries was safe in appropri-
ately selected patients, and agree with others that it is a superior
option to diversion in these cases.5 Although the matter is still con-
troversial and debated, most researches prefer primary anastomosis
and diversion is only used in a limited clinical situation.32–34
Multi-organ injuries are common in victims of gunshot injury
to the abdomen, and in our study occurred in 130 (75.6%) patients.
The most common injured organ with colon was the small bowel.
The significant clinical effect of multi-organ injuries is an increase
in the risk of significant bleeding. Several reports suggest that more
than two organ injuries increases the risk of complications after pene-
trating colon injury,33 although Torba et al.35 observed a weak corre-
lation between the number of injured organs and complication rate.
In our study there was no significant statistical correlation between
multi-organ injury and postoperative complications (P = 0.896).
Penetrating colon injuries have an increased risk of sepsis if there
is a delay in surgical intervention of more than 6 h.36 Baker et al.37
has reported that the increase delay time between injury and opera-
tion is an important factor affecting morbidity and mortality. In our
study, there was no delay time of more than 200 min due to rapid
transport to hospital, and early starting of resuscitation and support-
ive treatment, and therefore we did not observe any significant
effect of the delay time on postoperative outcomes.
There are multiple factors which have a direct effect on the dura-
tion of the operation, including type and site of injury, significant
bleeding, intra-abdominal adhesions, surgeon experience as well as
the cooperation of the surgical teams, and a prolonged operating
time has an odds ratio of 2.8 for developing an anastomotic leak.15
In conclusion, surgeons should be aware that, shock state upon
admission, blood transfusion are risk factors for postoperative com-
plications in a patient with a gunshot penetrating injury.
Acknowledgements
The authors acknowledge Radiology Department, Al-Jalaa Teach-
ing Hospital; Biostatistics Department, Al-Jalaa Teaching Hospital
and Moaz Alowami, English Language Editing Service.
Conflicts of interest
None declared.
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Supporting information
Additional Supporting Information may be found in the online ver-
sion of this article at the publisher’s web-site:
Appendix S1. Ethics approval of the publication and statistical
analysis.
Figure S1. Age distribution of injured patient.
Table S1. Colon injury scale. The American Association for the
Surgery of Trauma.
Table S2. Types and percentages of postoperative complication.