The war on terror: High rates of stoma creation after colorectal injury

Over one third of military personnel in Iraq and Afghanistan who sustain colorectal injury undergo fecal diversion, show coalition force data.

Soldiers who underwent diversion had lower mortality rates than those who did not, despite overall greater severity of injury.

"The decision to perform primary repair, resection and anastomosis, or diversion remains one of the most controversial in trauma," say Sean Glasgow (San Antonio Military Medical Center, Fort Sam Houston, Texas) and colleagues.

"When dealing with injuries to the colon and rectum, fecal diversion may seem a 'safer' option than primary repair or anastomosis."

The authors reviewed data from 977 military personnel who sustained colorectal injury in Afghanistan and Iraq over an 8-year period.

Gunshot wounds accounted for the majority of injuries (57.6%), with explosions being responsible for a further 35%. The average Injury Severity Score (ISS) was 22.2, where a score over 16 is considered serious injury. The authors say that colorectal injury could therefore serve as a marker for severe injury.

The overall fecal diversion rate was 36.6%, but was higher, at 56.2%, for rectal injuries. Notably, the mortality rate was 3.7% among those who underwent fecal diversion compared with 10.8% among those who did not. This was despite diverted patients having a significantly higher ISS score at 23.9 than non-diverted patients at 21.2.

Glasgow and colleagues say the reasons for this disparity are unclear but suggest that an in-depth assessment of the causes of death in the non-diverted group could help determine risk factors to guide surgeons' treatment decisions.

Writing in the Journal of Trauma and Acute Care Surgery, they say the findings show that more research is needed to optimize the care of military personnel who sustain colorectal injuries, in particular the impact of stoma on quality of life.

"By building on the lessons learned from such prospectively acquired data, military surgeons of the future will be better equipped to provide surgical care to the troops who inevitably will sustain wartime colorectal trauma."

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