European Journal of Trauma and Emergency Surgery

https://doi.org/10.1007/s00068-020-01555-2

REVIEW ARTICLE

Meta‑analysis on surgical management of colonic injuries in trauma:

to divert or to anastomose?
Man Hon Tang1   · Joel Shi Hao Wong1 · Clement Luck Khng Chia1 · Daniel Jin Keat Lee1

Received: 12 August 2020 / Accepted: 10 November 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Background  Primary repair or resection with anastomosis (PR/A) has been gaining increasing recognition for traumatic
colonic injuries, with the need for faecal diversion (FD) especially those of penetrating etiology being questioned. However,
the role of PR/A in critically ill patients is still controversial with concerns pertaining to safety and anastomotic leak.
Aims and methods  We performed a systemic review of studies comparing outcomes of FD versus PR/A in traumatic colonic
injuries. A systematic review was performed as per PRISMA guidelines utilizing three electronic databases: Pubmed,
EMBASE, and Cochrane Library resources. Mortality and anastomotic leak rates are identified as the primary and second-
ary outcomes, respectively. Data extracted include mortality rates, type of surgical intervention, surgical complications, and
need for DC (damage control) surgery.
Results  Fourteen studies were identified comprising 11 retrospective, 2 prospective cohort and 1 randomized trial with a
total of 2071 patients. Six studies included patients that underwent DC surgery. The overall mortality rate was 3.77% and
was higher in the FD group compared to PR/A group (5.38% vs 2.49%, p = 0.07). 71.3% of patients underwent PR/A with
an overall leak rate of 4.63%. There was no difference in intra-abdominal collections between the PR/A and FD groups. In
the subgroup analysis, anastomotic leak rate was significantly higher in the DC group compared to non-DC group (16.7%
vs 3.2%, p = 0.003).
Conclusions  This meta-analysis supports PR/A in stable patients with traumatic colonic injuries. FD should be considered
in critically ill patients who require DC surgery as leak rates are significantly higher.

Keywords  Trauma · Colon injury · Stoma · Anastomotic leak

Background safety of performing primary repair for traumatic colonic

The management algorithm for colonic trauma has evolved
significantly over the past decade. During World War II, it
was mandatory for military surgeons to perform diverting
stomas for all colonic injuries due to high surgical site infec-
tion and mortality rates if a primary repair and anastomosis
(PR/A) was performed [1]. It was a court martial offence
if a stoma was not fashioned. This dogma was eventually
challenged after the war by civilian surgeons, when Stone
and Fabian reported similar outcomes in selected patients
managed with either primary repair or diversion [2]. Many
other studies have since been published demonstrating the
* Man Hon Tang
manhon.tang@mohh.com.sg
1
Department of General Surgery, Khoo Teck Puat Hospital,
90 Yishun Central, Singapore 768828, Singapore
injuries [3−5]. The landmark multicenter study by Demetri-
ades et al showed that PR/A should be considered in all pen-
etrating colonic injuries [3]. A Cochrane review by Nelson
and Singer compared morbidity and mortality rates between
primary repair and fecal diversion (FD) in penetrating colon
injuries and concluded that PR/A is favorable over FD [4].
The majority of the studies on colonic trauma originate
from the US where penetrating injuries are more prevalent.
Penetrating trauma usually present with obvious sites of
injuries that are promptly identified and addressed by the
trauma surgeon. Conversely, blunt colonic injuries can have
a delayed presentation with injuries continuing to evolve
even after the initial assessment and surgery with resultant
delayed perforation and severe intra-abdominal contamina-
tion rendering these patients critically ill. In the last two
decades, the emergence of damage control (DC) surgery
for unstable patients has further added to the diversity of

13
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surgical armamentarium in traumatic colonic injuries. The
new paradigm shift for DC surgery is to control bleeding
and soilage in an abbreviated procedure, before performing
definitive surgery as a staged procedure after the patient’s
physiology has been restored [6, 7]. However the definitive
repair of colonic injuries in patients requiring DC surgery
remains controversial as primary repair, delayed anastomosis
and stoma creation have all been reported with conflicting
results [6–11].
Therefore, the aim of our meta-analysis is to compare the
outcomes of PR/A versus FD in traumatic colonic injury,
including both penetrating and blunt mechanisms. The pri-
mary outcome will be overall mortality rate. The secondary
outcomes will be anastomotic leak rate and intra-abdomi-
nal infection. We also aim to perform a subgroup analysis
to compare outcomes of DC versus non-DC patients with
colonic injuries.
Methods
Search strategy
A systematic review was performed according to the guide-
lines and recommendations from the preferred reporting
items for systematic reviews and meta-analyses checklist
(PRISMA). Institutional review board approval was not
required. The first (MHT) and last (DJKL) authors con-
ducted an electronic systematic search using of the Pubmed,
EMBASE, and Cochrane Library resources from 01 Jan
1990 to 31 Dec 2017. The following search terms were used:
‘bowel injury*’, ‘bowel trauma’, ‘intestin* injur*’,’intestin*
trauma’, ‘gastrointestin* injur*’, ‘gastrointestin* trauma’,
‘hollow viscus injur*’, ‘ hollow viscus trauma’, ‘colon*
injur*’, ‘colon* trauma’, ‘mesenter* tear’, ‘mesenter*
injur*’, ‘blunt abdom* trauma’, ‘penetrati* abdom* trauma’,
‘blunt abdom* injur*’, ‘penetrati* abdom* injur*’, ‘damage
control surger*’, ‘damage control laparotomy*’. The data-
base search was also supplemented by a manual search of
the reference lists of the included studies for relevant articles
for inclusion.
Inclusion
We included studies that compared outcomes between PR/A
versus FD in patients with traumatic colonic injury. Colonic
injuries that underwent either primary repair, or resection
with anastomosis without any stomas were grouped as PR/A.
These two approaches were grouped together as we do not
have information on usage of an objective process that guide
surgical decision and our main objective is to determine if a
stoma is necessary. FD was defined as patients having resec-
tion and anastomosis with proximal defunctioning stoma and
13
M. H. Tang et al.
those that underwent colonic resection and primary stoma
creation. Studies must report mortality as one of the out-
comes. We included studies in both civilian and military
settings. Only studies published in English were considered.
Exclusion
Case reports and experimental studies were excluded. Stud-
ies that did not have a comparative arm were also excluded.
Studies that included non-traumatic colonic injuries, small
bowel injuries, or had duplicate patient data were excluded.
Studies that did not include our primary outcome (mortality
rate) were excluded.
Selection criteria
Study selection was performed independently by two authors
(MHT, DJKL) using predefined inclusion and exclusion
criteria. The studies were first screened by their titles and
abstract before the full text was assessed for selection. Any
disagreements between the two authors were resolved by
consensus with another author (CLKC).
Outcomes
The primary outcome in this systemic review is overall in-
hospital mortality rate and secondary outcomes are anasto-
motic leak and intra-abdominal infection.
Data extraction
Using a standardized Pro-Forma, two authors (MHT, DJKL)
independently extracted details of study population, inter-
ventions and outcome measures. Differences in data extrac-
tion were resolved by mutual consensus in consultation with
CLKC. The following data were extracted: General informa-
tion (title; authors; year of publication); study characteristics
(design, study population, mean age, gender, DC cohort if
present); interventions (PR/A, FD), outcomes (mortality,
anastomotic leaks, intra-abdominal collections). Data from
articles that also included DC surgery as part of traumatic
colonic injuries were extracted for sub-group analysis in this
systemic review.
Data analysis
The Methodological Index for Non-Randomised Stud-
ies (MINORS) [12] was used to evaluate the risk of bias
and the methodological quality of the selected studies
and listed in Table 1. Data analysis was performed using
Review Manager version 5 (The Cochrane Collaboration,
The Nordic Cochrane Centre, Copenhagen, Demark) using
random effects model. Data were pooled and risk ratios were
 Table 1  List of included studies with baseline characteristics
S/N References Study design Country of origin DCL Population type Study PR/A (%) FD (%) Mechanism of injury MINORS score
popula-
tion
Penetrating (%) Blunt (%)

1 Stewart et al. [13] Retrospective, single centre, cohort USA No Civilian 60 43 (71.7) 17 (28.3) 56 (93.3) 4 (6.7) 12
2 Gonzalez et al. [14] Prospective, single centre, randomised USA No Civilian 181 92 (50.8) 89 (49.2) 181 (100) 0 (0) 16
3 Demetriades et al. [3] Prospective, multi centre, cohort USA No Civilian 297 197 (66.3) 100 (33.7) 297 (100) 0 (0) 16
4 Kamwendo et al. [15] Prospective, single centre, randomised South Africa No Civilian 240 120 (50) 120 (50) 240 (100) 0 (0) 16
5 Fealk et al. [16] Retrospective, single centre, cohort USA No Civilian 74 60 (81.1) 14 (18.9) 61 (82.4) 13 (17.6) 12
6 Weinberg et al. [17] Retrospective, single centre, cohort USA Yes Civilian 157 143 (91.1) 14 (8.9) 125 (79.6) 32 (20.4) 13
7 Kashuk et al. [8] Retrospective, single centre, cohort USA Yes Civilian 309 303 (98.1) 6 (1.9) 222 (71.8) 87 (28.2) 9
8 Vertrees et al. [9] Retrospective, single centre, cohort USA Yes Militant 65 38 (58.5) 27 (41.5) 63 (96.9) 2 (3.1) 13
9 Ordonez et al. [7] Retrospective, single centre, cohort Columbia Yes Civilian 60 53 (88.3) 7 (11.7) 60 (59.2) 0 (0) 13
10 Ott et al. [10] Retrospective, single centre, cohort USA Yes Civilian 174 116 (66.7) 58 (33.3) 103 (59.2) 71 (40.8) 11
Meta‑analysis on surgical management of colonic injuries in trauma: to divert or to anastomose?

11 Georgoff et al. [11] Retrospective, single centre, cohort USA Yes Civilian 61 28 (45.9) 33 (54.1) 56 (91.8) 5 (8.2) 14
12 Torba et al. [18] Prospective, single centre, cohort Albania No Civilian 157 107 (68.2) 50 (31.8) 116 (73.9) 41 (26.1) 13
13 Fouda et al. [19] Retrospective, single centre, cohort Egypt No Civilian 110 37 (33.6) 73 (66.4) 65 (59.1) 45 (40.9) 12
14 Shazi et al. [20] Retrospective, single centre, cohort South Africa Yes Civilian 126 102 (81.0) 24 (19.0) 125 (97.7) 3 (2.3) 8

USA United States of America, DCL damage control laparotomy, PR/A primary repair/anastomosis, FD fecal diversion

13
 M. H. Tang et al.

calculated with their 95 per cent confidence intervals. Het-
erogeneity was tested and reported using the I2 value.
Results
Our systemic search revealed a total of 3721 publications
for possible inclusion. Duplicate publications were excluded
leaving 3694 publications for review. After screening based
on title and abstract, a further 3639 were excluded leaving 55
publications being assessed in their entirety. 41 publications
were further excluded due to (1) insufficient data presented
(n = 8), (2) repeat data set (n = 2), (3) primary outcomes not
assessed (n = 27), (4) review articles (n = 4). The remain-
ing 14 studies were selected for this systemic review with
data extraction performed (Table 1) [3, 7–11, 13–20]. The
PRISMA flowchart is shown in Fig. 1. The earliest study
was published in 1994 [13] and the latest one in 2017 [20],
with the majority of studies from United States of America
(USA). Of the 14 studies, 11 were retrospective, 2 were
prospective cohort and 1 was a randomized study. Seven
studies [7–11, 17, 20] included a subgroup that underwent
DC surgery, however there was insufficient extractable data
(mortality and anastomotic leak rates of DC subgroup not
clearly stated) in 1 study [20] and was excluded from sub-
group analysis. There were no standardized criteria for DC
surgery as most were left to the trauma surgeon’s discretion,
but most studies cited severe physiological derangement
and shock as the main criteria that necessitated temporary
abdominal closure and subsequent definitive surgery.
A total of 2071 patients were included for analysis with
a mean age of 31.6 years old with a predominant male
proportion of 80.4%. The majority of the study popula-
tion (85.5%) had penetrating injuries; 3 of the studies
[2–4] included only penetrating injuries while the remain-
ing studies included both penetrating and blunt injuries.
71.3% and 28.7% of the overall cohort population under-
went a PR/A and FD respectively. Majority of the studies
excluded mortality within the first 24–48 h from injury
from their study population. The overall mortality rate was
3.77% after surgical intervention for colonic trauma. Over-
all mortality rate favored PR/A over FD although it did not
reach statistical significance (2.49% vs 5.38%, risk ratio
0.65, p = 0.07) (Fig. 2). 12 of the 14 studies included data

Fig. 1  PRISMA flow diagram

Records idenfied through Addional records idenfied
database searching (n = 3721) through other sources (n=5 )

Records aer duplicates removed

( n = 3694 )

Records excluded aer

Records screened reading the tle and/or
( n = 3694 ) abstract ( n = 3649 )

Full-text arcles
Full-text arcles assessed excluded with reasons
for eligibility ( n = 41)
( n = 55) Insufficient data 8
Primary outcomes not
assessed 27
Duplicated data 2
Review 4
Studies included in meta-
analysis
( n = 14)

13
Meta‑analysis on surgical management of colonic injuries in trauma: to divert or to anastomose?

Fig. 2  Comparison of overall mortality in primary repair/anastomosis versus faecal diversion

on anastomotic leak rates. Of the 1310 patients that under-
went PR/A in these 12 studies, the overall leak rate was
4.63%. Other complications after traumatic colon injuries
include intra-abdominal infections. Intra-abdominal infec-
tion rates were reported in 11 of the studies. Overall intra-
abdominal infection rate was 15.7%, with no difference
between the PR/A and FD group (11.1% vs 14.9%, risk
ratio 1.00, p = 0.98) (Fig. 3).
Six of the studies that included patients that underwent
DC surgery were included in the subgroup analysis. Thirty
four percent (279/826) of patients underwent DC surgery.
Details pertaining to etiology of trauma were not available
in this subset of patients. The mortality rate in the DC group
was significantly higher compared to the non-DC group
(8.24% vs 0.73%, p < 0.01). However, within the DC group,
there was no significant difference in mortality rate between
the PR/A and the FD group (7.2% vs 10.1%, risk ratio 0.54,
p = 0.23) (Fig. 4).
A lower proportion of the patients had PR/A in the DC
compared to the non-DC cases (64.5% vs 91.6%). In these
cases of PR/A, there was also a significant increase in anas-
tomotic leak rates in DC compared to those in non-DC cases
(16.7% vs 3.2%, risk ratio 4.12, p = 0.003) (Fig. 5) as well
as mortality rate (7.2% vs 0.6%, risk ratio 4.78, p = 0.007)
(chart not shown).
Discussion
Mortality rates for traumatic colonic injuries has fallen dra-
matically since World War II [21]. This can be attributed to
the development of broad-spectrum antibiotics as well as

Fig. 3  Comparison of intra-abdominal infection in primary repair/anastomosis versus faecal diversion

13

Fig. 4  Comparison of overall mortality in primary repair/anastomosis versus faecal diversion in damage control sub-group
Fig. 5  Comparison of anastomotic leak in primary repair/anastomosis in damage control versus non-damage control sub-group
better peri-operative care such as faster evacuation, safer
anesthesia, improved operative techniques and more robust
intensive care. Similarly, the stoma creation rates have also
fallen significantly to about 9% based on data from United
States National Trauma Data Bank [5] consistent with sev-
eral retrospective studies demonstrating good outcomes for
PR/A in traumatic colon trauma [3–5]. Results from the
Cochrane review by Nelson and Singer favored PR/A over
FD overall, with lower rates of overall complications and no
significant increase in mortality in the PR/A group [4]. How-
ever, the meta-analysis only included penetrating injuries,
leaving the optimal management of blunt traumatic colon
injuries unanswered. Colonic resection is usually required
in destructive colonic injuries whereby more than 50% cir-
cumference of the colon is involved or in devascularization
[22]. Primary repair is an option when less than 50% cir-
cumference of the colon is affected. However, a study by
Sasaki et al. showed that colon injury scale (CIS) was unable
to predict for post-operative complications and it does not
support diversion over primary repair [23].
The introduction of DC surgery in the last decade has
been shown to reduce mortality and improve outcomes in
13
M. H. Tang et al.
severely injured patients with physiological derangement
[24–26]. This has created another area in which the manage-
ment of traumatic colon injuries is not clear. In this study, we
hence included both penetrating and blunt colonic injuries in
our analysis, with a subgroup analyzing those that underwent
DC surgery.
Our study reviewed patients with colon injuries in which
either PR/A or FD was performed.
The overall mortality rate in our meta-analysis was low
as most studies were from level I trauma centers, based on
civilian populations and largely involved patients who had
penetrating injuries. The stoma creation rate of 28.7%, while
still significant, demonstrates the shift in perspective that
traumatic colonic injury is no longer an absolute contrain-
dication for colon anastomosis.
Our results favor the role of PR/A in colonic injuries from
trauma, with low rates of anastomotic leak comparable to
that of elective surgery. Moreover, there were no significant
differences in mortality rates and intra-abdominal infec-
tion rates when comparing the PR/A group with FD. This
is likely due to good perioperative care, antibiotics and the
experience of the surgeons in these studies. Importantly our
Meta‑analysis on surgical management of colonic injuries in trauma: to divert or to anastomose?
meta-analysis also identified three studies that analyzed risk
factors associated with anastomotic leak. Stewart et al. iden-
tified massive transfusion requirements > 6 units as well as
pre-existing medical illness as significant risk factors for
leak [13]. Ott et al. also found transfusion requirements as
well as left sided colon injuries to be risk factors [10]. Geor-
goff et al. found age to be a significant risk factor for leak
[11]. Three other studies found risk factors that increased the
risk of intra-abdominal complications, such as severe fecal
contamination, single agent antibiotic prophylaxis, multiple
colon injuries and shock [3, 18–19]. While these data are
heterogenous and not sufficiently powered for any conclusive
guidelines, caution should be exercised when considering
PR/A for patients exhibiting these characteristics.
Most of the studies in this study originated from USA
which accounted for the vast majority of penetrating inju-
ries in this analysis. This is in contrast to blunt abdominal
trauma from road traffic accidents which are more common
in Europe and Asia. Despite the shift towards PR/A for pen-
etrating injuries, there is no clear consensus regarding blunt
colonic injuries as patients often have multi-organ injuries
and are associated with more diffused and delayed injuries.
The full extent of injuries might not be determined at initial
surgery and require staged relook laparotomy. This study
was unfortunately unable to analyze the subgroup of blunt
colonic injuries separately as many of the studies did not
provide required data for analysis. However, three studies
found that the mechanism of colonic injury (penetrating or
blunt) was not a significant risk factor for anastomotic leak
[10, 11, 19]. Similarly, a study by Ricciardi et al. suggested
that stoma formation and management strategy did not inde-
pendently predict increased intra-abdominal complications,
morbidity, or mortality in blunt traumatic injuries of the
colon [27].
DC surgery with temporary abdominal closure and subse-
quent staged procedures allow quick correction of the under-
lying shock state and reversal of the lethal triad of acidosis,
hypothermia and coagulopathy. Delaying definitive repair
of non-life-threatening injuries until normal physiology has
been restored has led to reduced mortality and morbidity
in trauma patients [28]. Before the widespread use of DC
surgery, guidelines from the Eastern Association for the Sur-
gery of Trauma still recommended colostomy for destructive
colonic injuries in the setting of other significant injuries,
shock or peritonitis [29]. However, with the advent of DC
surgery, these injuries that previously would have mandated
a colostomy could in theory be treated with PR/A, albeit in a
delayed fashion after normal physiology has been restored.
In the DC group of patients, the mortality rates were
naturally much higher, likely due to concomitant inju-
ries and derangements in physiology not directly related
to the colonic injury. Of note, the higher stoma creation
rates likely reflect the surgeons’ more careful selection
of patients for PR/A, anticipating higher risks of anas-
tomotic leaks and septic complications. Despite this, the
anastomotic leak rate in the DC group was significantly
higher compared to patients who did not require DC sur-
gery (16.7% vs 3.2%). Ott et al. found that patients with
a colonic anastomosis and have an open abdomen were
at significant risk of anastomotic leak [10]. This was also
evident in the studies by Burlew et al. and Georgoff et al.
whereby patients with fascial closure beyond day 5 had a
four times higher likelihood of developing leak [11, 30].
Again, age was found to be a significant risk factor in pre-
dicting leak in the study by Georgoff et al. in DC patients.
Other contributing factors such as septicemia, poor nutri-
tion, and widespread edema also increased their risk for
leak [11]. Moreover, there are likely non-modifiable risk
factors such as age, co-morbidities that predispose these
patients to both physiologic derangements warranting DC
surgery and anastomotic leak. Consequences of an anasto-
motic leak can be devastating especially in major trauma
patients. It is associated with repeat abdominal surgeries,
reduced likelihood of abdominal closure, prolonged hos-
pital and intensive care stay and significant morbidities
[10, 11].
Therefore, in patients with physiological derangements
requiring DC surgery, we will recommend FD. This is
especially so in patients with risk factors such as high
transfusion requirements, left sided injuries, elderly age
and multiple other injuries. The decision to perform FD
should not be taken lightly with stoma having its asso-
ciated problems. Firstly, a proximal defunctioning stoma
does not prevent anastomotic leaks as almost half of the
anastomotic leaks in the study by Georgoff et al. occurred
despite a proximal diversion [11]. Also, in the setting of
DC, the presence of bowel and abdominal wall oedema,
as well as poorly mobilized bowel mesentery may com-
promise the integrity of a stoma. A loop colostomy might
not be feasible in devastating colonic injuries and most
of these patients may have an end colostomy. Long-term
complications of an end colostomy can occur such as para-
stomal hernias and impact on quality of life especially in
younger patients. Stoma reversal in a hostile scarred abdo-
men can be technically challenging and is also associated
with significant morbidity ranging from hernia, superficial
wound infection, and anastomotic stricture [31, 32].
The nature of traumatic injuries meant that there will be
a large heterogeneity in terms of patients’ clinical status
as well as the extent of colonic injuries. The majority of
the included studies are retrospective in nature, and most
studies had no clear protocols or guidelines on selection
of patients for PR/A, FD and DC and were left to the dis-
cretion of the attending surgeons. Overall, the evidence
available for blunt colonic injuries is still inadequate.
13

Conclusion
This study supports the role PR/A for traumatic colonic
injuries in stable trauma patients. However there is still
insufficient evidence specifically for blunt colonic injuries.
On the contrary, patients who are critically ill requiring DC
surgery have a higher anastomotic leak rate and should have
FD. With DC surgery gaining popularity globally, we would
expect more robust evidence addressing this area in the near
future.
Acknowledgements  The authors would like to thank our institution
Biostatistician Dr. Wang Jiexun for her invaluable statistical assistance
and input with regards to this manuscript.
Author contributions  The MHT and JSHW authors are responsible
for the writing of the manuscript. The MHT, CLKC and DJKL are
responsible for the design of the work, data acquisition and analysis.
All authors reviewed and approved the manuscript.
Compliance with ethical standards  19. Fouda E, Emile S, Elfeki H, et al. Indications and outcome of
Conflict of interest  All authors declare that there is no conflict of inter-
est in the manuscript, including financial, consultant, institutional, and
other relationships that might lead to bias or a conflict of interest. No
additional sources of funding were received for this manuscript.
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