Feasibility of primary repair in extensive gunshot-induced colon injuries with severe fecal contamination: a case series of six patients and review of literature.

Abstract

Background: The optimal management of penetrating colon injuries, particularly in the presence of high-risk features such as severe fecal contamination, hemodynamic instability, and extensive tissue damage, remains controversial. Although primary repair has gained increasing acceptance, fecal diversion is still frequently performed in complex cases due to concerns regarding anastomotic failure and septic complications. Evidence specifically addressing the feasibility of primary repair in patients with extensive destructive injuries is limited.

Case presentation: We report a case series of six patients with shotgun-induced colon injuries characterized by multiple perforations and varying degrees of fecal contamination. All patients met at least one traditionally accepted indication for fecal diversion, including hemodynamic instability, delayed presentation, or extensive injury. Despite these high-risk features, all patients underwent primary repair or resection with primary anastomosis. Postoperative morbidity was limited, with one surgical site infection and one anastomotic leak requiring reoperation. No mortality was observed.

Discussion: Our findings are consistent with an evolving body of literature supporting primary repair in penetrating colon trauma. While prior studies have demonstrated favorable outcomes in selected patients, many have excluded those with extensive destructive injuries or severe contamination. In contrast, this series focuses on a high-risk subgroup, suggesting that traditional contraindications may not independently predict adverse outcomes when contemporary trauma care principles and careful patient selection are applied. These findings support a more individualized, physiology-based approach rather than strict adherence to protocol-driven decision-making.

Conclusion: Primary repair or resection with primary anastomosis may be a feasible and safe option in carefully selected patients with complex, shotgun-induced colon injuries, even in the presence of traditional high-risk features. Further multicenter studies are warranted to better define selection criteria and validate these findings.