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Increasing Preoperative Imaging Studies for Colostomy Reversals in Trauma Patients Delays Surgery without Improving Outcomes

Traumatic injuries to the colon or rectum that are not amenable to primary repair are often managed with a diverting colostomy.1 Before colostomy reversal, many surgeons advocate for obtaining radiographic imaging in the form of computed tomography (CT) or barium enema (BE) to provide an anatomical road map of the colon and to demonstrate the absence of a stricture or leak.2 Traditionally, a BE has been used to study the colon before reversal, yet data suggest it may be unnecessary in the trauma population.3 Given the lack of consistent data on prereversal imaging in trauma patients with diverting colostomies, we sought to investigate our institutional experience with colostomy closures in trauma patients and the impact of preoperative imaging on the timing of reversal. We hypothesized that increasing the number of preoperative imaging studies would increase the overall time until closure without decreasing postoperative complication rates. A retrospective chart review of adult trauma patients who received both their initial colostomy and underwent a colostomy closure at our urban Level 1 trauma center between 2009 and 2016 was performed. Patients who had previously undergone end or loop colostomy creation at our institution because of traumatic intraperitoneal and extraperitoneal injuries to the distal colon or rectumwere identified through our trauma registry. Only those patients subsequently undergoing a colostomy closure were included. This study was approved by our Institutional Review Board. Demographic data collected included patient age, gender, race, and medical comorbidities, as well as the type and frequency of imaging studies obtained before colostomy closure. Imagingmodalities included BE, CT, endoscopic visualization, or antegrade contrast fluoroscopy. The primary outcome was time until colostomy closure and secondary outcomes included postoperative complications such as acute respiratory distress syndrome (ARDS), anastomotic leak, cardiac arrest, deep venous thrombosis (DVT), fistulae, obstruction, sepsis, surgical site infection (SSI), and urinary tract infection (UTI). Study subjects were divided into groups based on preoperative imaging modalities. Wilcoxon ranksums tests and chi-square tests with Poisson rates were used to compare groups. Univariate logistic regression was used to assess the relationship between time to colostomy closure and specific complications. Results were significant if the P value was <0.05. Data analyses were performed with JMP Pro software, version 13 of the SAS System for Windows (Copyright 2016 SAS Institute Inc., Cary, NC). The study cohort included 135 patients. The majority were healthy males (85%, 115/135), and the median age at reversal was 30 years (IQR 23–38 years). Of these patients, 64.4 per cent (87/135) had an end colostomy (Table 1). Most patients (55.5%, 75/135) had only one prereversal study, 37 per cent (50/135) had two, and 4.4 per cent (6/135) had three or more. Only four patients received no preoperative imaging study (3%). Of the 131 patients who received imaging, the most common initial modality was a BE (88.5%, 116/131). If a second imaging modality was obtained, CT was the most commonly used at 58.2 per cent (32/55), followed by BE at 29.1 per cent (16/55), endoscopy at 9.1 per cent (5/55), and antegrade contrast fluoroscopy at 3.6 per cent (2/55). The median time to colostomy closure for the cohort was nine months (IQR 6–13 months). Bivariate analysis revealed a positive linear relationship between the number of prereversal imaging studies and the time to colostomy closure (P 4 0.01, R 4 97.9%). Of note, there was no difference in time until colostomy closure when receiving an initial BE or a CT (median: 9 vs Presented at the Southeastern Surgical Congress 2019 Annual Scientific Meeting, February 23–26, 2019, Charlotte, NC. Address correspondence and reprint requests to Brett M. Tracy, M.D., Department of Surgery, Emory University School of Medicine, 69 Jesse Hill Jr Drive SE, Glenn Memorial Building 3rd Floor, Atlanta, GA 30303. E-mail: Brett.m.tracy@emory.edu.