Resection with primary anastomosis was associated with a 14% anastomotic leak rate in this review of 60 patients with destructive colon wounds. The presence of an underlying medical illness or massive blood transfusion was associated with anastomotic complications. In the high-risk subset of patients who had one or both of these risk factors, the anastomotic leak rate was 42%. The incidence of anastomotic leak in previously healthy patients without massive transfusion was 3%. Ileocolostomies were no safer than colocolostomies. We conclude that resection with anastomosis should not be performed on all patients with destructive colon injuries, as the risk of anastomotic leak is prohibitive in those with either massive blood loss or underlying medical illness. We continue to perform primary anastomosis in healthy patients without excessive blood loss.