Isidore Cohn

Management of Penetrating Colon Injuries a Prospective Randomized Trial

Fifty-six patients with penetrating colon injuries were entered into a randomized prospective study. Management of the colon injury was not dependent on the number of associated injuries, amount of fecal contamination, shock, or blood requirements. Twenty-eight patients were treated with primary repair or resection and anastomosis and 28 patients were treated by diversion (24 colostomy, 3 ileostomy, 1 jejunostomy). The average Penetrating Abdominal Trauma Index score was 23.9 for the diversion group and 26 for the primary repair group. There were five (17.9%) septic-related complications in the diversion group. This included four intra-abdominal abscesses and one subcutaneous wound infection. There were six (21.4%) septic-related complications in the primary repair group. This included one wound infection, two positive blood cultures, and three intra-abdominal abscesses. There were no episodes of suture line failure in the primary repair/anastomosis group. The authors conclude that, independent of associated risk factors, primary repair or resection and anastomosis should be considered for treatment of all patients in the civilian population with penetrating colon wounds.

Villous tumors of the duodenum.

Five cases of villous tumors of the duodenum are reported, all of which involve the ampulla of Vater. Three of the five lesions contained either infiltrating carcinoma or carcinoma in situ. Although preoperative endoscopic biopsy was performed on all tumors no malignancy was identified. Frozen sections done at the time of operation on the three patients with carcinoma also failed to identify malignancy. One patient underwent pancreaticoduodenectomy and four patients had local excision of the tumor. Three of the patients treated with local excision developed recurrence and two subsequently had pancreaticoduodenectomy. Because of the difficulty in making an accurate diagnosis and the chance of recurrence when local excision is employed, strong consideration should be given to pancreaticoduodenectomy as the initial form of treatment of these lesions.

Acute Colonic Diverticulitis

Colonic diverticulosis is truly a disease of the 20th century. A direct correlation is thought to exist between the incidence of diverticular disease and the amount of dietary fiber. Acute colonic diverticulitis occurs in approximately 25 per cent of the patients with diverticula, and 20 per cent of the patients with diverticulitis will ultimately require surgical intervention. Because of the often virulent nature of the disease in younger patients and the prevalence in the geriatric population, an aggressive approach is advocated. Primary resection of the involved segment of colon is advocated in all cases requiring operation. A primary anastomosis can be constructed in stage I and some cases of stage II disease. This results in lower morbidity and mortality rates as well as fewer days of hospitalization and disability. Newer techniques such as diagnostic CT scanning, percutaneous drainage of diverticular abscess, and greater application of surgical stapling devices have done much to improve the ultimate outcome of colonic diverticulitis.