Comparing diverting and primary repair/anastomotic techniques for managing colorectal trauma: A systematic review and meta-analysis

Purpose Colorectal trauma management has evolved significantly, with ongoing debate regarding optimal surgical approach between fecal diversion and primary repair/anastomotic techniques. This systematic review and meta-analysis compared diverting and non-diverting operative management strategies for colorectal trauma. Methods A systematic review was conducted following PRISMA guidelines, searching for four databases through October 2024. Studies comparing fecal diversion to primary repair/anastomosis in colorectal trauma were included. Meta-analysis was performed using R software. Results Forty-nine studies comprising 7201 patients were included (7 randomized trials, 40 observational studies, 2 case series). Of these, 4007 (55.6%) patients underwent non-diverting procedures, while 3090 (42.9%) received fecal diversion. Penetrating injury was the most common mechanism. Patients in the diverting group had higher injury severity scores, greater fecal contamination, and more associated injuries. Meta-analysis of 5397 patients demonstrated significantly lower mortality for non-diverting procedures compared to fecal diversion (OR 0.46, CI 0.29-0.75, p < 0.0001). Infectious complications were also significantly lower in the non-diverting group (OR 0.49, CI 0.3-0.8, p < 0.0001) among 4078 patients analyzed. Conclusions Non-diverting operative procedures are a feasible choice for the management of civilian penetrating and blunt colon trauma. Previously established criteria for mandatory fecal diversion do not independently predict poor outcomes and should not be the sole guide in clinical decision-making. On the other hand, diverting ostomy should be conducted in the setting of rectal trauma.