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Management of perforating injuries to the colon in civilian practice
Management of Perforating Injuries Colon in Civilian Practice
to the
W. R. ROOF, M.D., GEORGE C. MORRIS, JR., M.D. ANDMICHAEL E. DE BAKEY, M.D., Houston, Texas injury in order of frequency was buIIet, knife, shotgun and bIunt trauma. (TabIe I.) MuItipIe injuries to the coIon were encountered in 20 per cent of patients, and the majority were the resuIt of firearms. The transverse coIon was injured most frequentIy, foIlowed in order of diminishing frequency by the descending coIon, ascending coIon and rectosigmoid. Wounds by firearms were aImost equaIIy distributed about the coIon but the majority of knife wounds invoIved the transverse coIon. BulIets ranged in size from .22 through .45 calibres and were usuahy low veIocity missiIes. The high veIocity injuries were usually in patients wounded by peace officers. Shotgun wounds were caused by pehets ranging from No. 12 through oo discharged from shotguns ranging in size from .410 through 12 gauge. AutomobiIe accidents caused four of the bIunt trauma injuries. The remaining bIunt trauma injury resuIted from vigorous jumping of a companion on the abdomen of the victim. Other objects causing trauma incIuded impaIement with fence stakes, pieces of gIass and a sharp iron rod. Ingested foreign bodies causing injuries to the coIon were a chicken bone and a toothpick.
From tbe Cora and Webb Mading Department of Surgery, Baylor University College of Medicine, Houston, Texas.
ORTALITY and morbidity from acute injuries to the coIon have been reduced continuousIy by aggressive surgery during the twentieth century. AIthough improved anesthesia, fluid and brood replacement and the use of antibiotic and chemotherapeutic agents have contributed greatIy to the reduction in mortality, definitive operative repair of the injury has been IargeIy responsibIe for the improved resuIts. The technical procedure of choice, however, has remained controversia1. During WorId War II the routine practice of exteriorization of the damaged coIon as the first phase of a two-stage repair was credited with markedIy increased surviva1 rates [5,6,8]. This form of therapy was carried into civiIian practice in the postwar years and stiI1 has many advocates. Other surgeons have urged that seIected patients be treated with primary repair [10,14]. The present report is an anaIysis of 186 cases of traumatic Iesions of the coIon seen during the past ten years at the Jefferson Davis HospitaI. The majority of these patients were treated by primary repair. IncIuded in the series are the resuIts previousIy reported from this institution in 1956 by Pontius, Creech and De Bakey [IO].
M
TABLE I MECHANISM
MATERIAL From January rg4g to January 1959, 186 patients were operated upon for traumatic Iesions of the colon. Over go per cent of these patients were young aduIts between fifteen and fortyfive years of age. Two-thirds of the patients were Negro and the remainder aImost equaIIy divided between Latin Americans and a11 other white races combined. Males outnumbered females by a ratio of four to one. Mode of 64’
OF
INJURY
Mechanism
No.
BulIet..................................... Knife. Shotgun................................... Blunt trauma.. . . . Varied objects (sticks, rods). Ingested foreign body..
94
Total.................................
186
American Journal
of Surgery.
4,’
3 4
2
Volume gg. May, rg6o
Roof, Morris
and De Bakey pIaced near the area of injury and brought out through the abdominal waII IateraIIy.
MANAGEMENT
Preoperative management consisted of the usua1 preparations for emergency surgery in acute abdominal trauma. Venesection by Iarge bore needles, and surgica1 cutdowns were performed in the upper extremities for rapid restoration of blood voIume and eIectroIyte equilibrium. Dextran was used as a pIasma expander when rapid repIacement was imperative. When dextran was used, no more than 1,000 ml. was given because of the danger of cIotting disturbances. SaIine soIution was used as the non-coIIoida1 fluid, and an average of 2,200 m1. of bIood was given before and during the various operative procedures. Tetanus antitoxin or toxoid according to the individua1 indication was given in the receiving ward. Antibiotics were started as soon as possibIe. Nasogastric suction was utilized to evacuate stomach contents, often consisting of recently ingested aIcohoIic Auids. An indweIIing urinary catheter was routineIy inserted both to check for the presence of gross hematuria indicating injury to the urinary tract and to foIIow urine voIume as a guide to ffuid and blood repIacement. CarefuI history and compIete physica examination were performed to determine the probabIe site and extent of damage. Proctoscopy was performed in Iower abdomina1 injuries when trauma to the rectosigmoid region was suspected. Roentgenographic examination of the thorax and abdomen was performed to further trace the course and Iocation of the missiIe. However, in some cases bIeeding was so massive that expIoration was performed before such diagnostic procedures couId be obtained. Operative management consisted of the rapid expIoration of the patient through a midIine abdomina1 incision. After significant hemorrhage was controIIed, injuries to the coIon were repaired by two-Iayer cIosure technic turning in generous amounts of Iarge bowe1 waI1. When the coIon was badIy damaged, segmenta resection was performed with end-to-end anastomosis. Exteriorization was used in cases in which Iong segments of bowel had been destroyed making repair diffrcuIt. ProximaI coIostomy was used in Iow recta1 Iesions and in some cases of massive destruction of Iong segments of bowe1. Thorough irrigation with saIine and antibiotic soIutions was performed during the procedure and immediately prior to closure of the abdomina1 waI1. Drains were usuaIIy
RESULTS
Over-al1 mortatity for the 186 patients was 13.9 per cent. Primary repair was empIoyed in 144 patients, with ten deaths, a mortarity rate of 7 per cent. (Table II.) In fifty-three patients with knife injuries repaired primariIy there was onIy one death, a mortaIity rate of 2 per cent. Primary repair was performed in eighty-one firearm injuries with eight deaths, a mortaIity rate of IO per cent. There was one death from bIunt trauma in the ten patients repaired primariIy. Two-stage repairs were performed in thirtynine patients with tweIve deaths, a mortality rate of 30 per cent. CoIostomy was performed in nine patients with Iow rectosigmoid Iesions with no deaths. In the thirty remaining patients, twenty exteriorizations and ten proximal coIostomies were performed for massive destruction of Iarge segments of the colon. Firearms inflicted the damage in twenty-five of these patients and accounted for a11 the deaths in this group. Two Iacerations were treated by repair and diverting colostomy, and two by exteriorization. One case of blunt trauma was treated by repair and diverting coIostomy. Comparison of mortaIity rate between different types of repair is not justified in this series since the type of repair to be empIoyed was determined by the severity and extent of injury to the bowe1. Thus higher mortaIity wouId be expected in the more severeIy injured patient treated with the two-stage procedure. Comparison of the type of repair and resuIts for the first seven years versus the Iast three years of this study shows an increasing proportion of the patients being managed by primary TABLE TYPE
Type
Primary
OF
II
TREATMENT
Repair
. .
Firearms Knife Other .~.
Two-stage
ertenor~zatmn.. Repair and proximal coIostomy .
. ..
Firearms Knife
i Other 642
i
AND
RESULTS
Cases (No.)
Deaths (No.)
Mortality ( 5%)
Perforating
Injuries
to CoIon
PRIMARY REPAIR
MORTALITY
NUMBER CASES
TWO STAGE REPAIR
MORTALITY
NUMBER CASES
FIRST
OVERALL
SEVEN
YEARS
MORTALITY LAST
%
THREE
YEARS
FIG. I. Comparison method of repair and resuks for the first seven versus the Iast three years of study. _
repair. (Fig. I.) Mortality for primary repair has dropped from g per cent to 5 per cent and the over-all mortality has decreased from 15 per cent to g per cent. Average hospita1 stay for primary repair of the colon was fourteen days while an average of thirty-live days was required with the two-stage procedure. FACTORS
INFLUENCING
arteriosclerosis make hemorrhage difficult to control, but it also makes the brain, heart and kidney vulnerable to periods of hypotension. Blood Replacement. Although the average amount of blood administered was 2,200 ml., an average of over 5,000 ml. was required in TABLE III ASSOCIATED INJURIES
RESULTS
Intervalfrom Znjury to Surgery. The average time interval elapsing from injury until admission to the receiving ward was 1.2 hours. Operative treatment was started an average of 2.8 hours after injury. Others have stressed the importance of early operation pointing to superior results in the patients who underwent exploration within six hours of the injury [I?, 141. Seven patients in this series had a delay of more than six hours between injury and operation, yet there was no mortality nor significant morbidity in this group. Associated Injuries. There were 272 major injured in this series exclusive of organs injuries to the colon and averaged 1.5 injuries per patient. (Table III.) In forty-three patients without associated injuries (23 per cent), there was no mortahty and onIy one complication, a singIe fecal listula. Patients who did not survive had an average of five major organs involved. Age. In patients over fifty years of age the mortality rate was 46 per cent indicating that with increasing age, tolerance for major trauma markedly declines [a]. Not only does
No.
Injury
Vascular injuries Heart .................................. Aorta .................................. Venacava ............................... Other major vesseIs ....................... Total vascuhu injuries.
16
.................
Stomach .................................. Ileum or jejunum ........................... Duodenum ................................ SpIeen .................................... Liver ..................................... Kidney or ureter ........................... CentraI nervous system. .................... Diaphragm ................................ Chest (hemothorax)........................ GaIibIadder ................................ Pancreas .................................. Madder and urethra ........................ Uterus .................................... Extremities. .............................. TotaI ................................
643
29 79 I4 I7 37 22 4 8 4 I2 6 5 3 16
-I
256
Roof, Morris and De Bakey TABLE IV COMPLICATIONS Wound infection. Wound dehiscence.. FecaI fistuIa., Acute renaI faiIure.. IntestinaI obstruction.. Abscess................................... Jaundice.................................. DuodenaI f%tuIa. Urinary fistula. BiIiaryfistuIa............................... Pneumonia................................ PuImonary emboIism. . . OsteomyeIitis of sacrum..
tonitis and one from feca1 urinary fistuIas. Of the six deaths occurring in the Iast three years of the present study, three were caused by irreversibIe shock, two by renaI faiIure and the remaining death by peritonitis.
Iz 7 7 7 5 3 2 2 2 I I
COMMENTS
I I
There is no doubt that routine exteriorization of a11 traumatic injuries to the coIon in the earIy phases of WorId War II resuIted in increased surviva1 rates. However, by Iate 1944, military surgeons in some theaters of operation were performing primary repair of seIected injuries to the coIon with equaIIy good resuIts yet decreased hospitaIization time [I 01. NevertheIess, in the immediate postwar period, exteriorization or primary repair and diverting coIostomy remained the dominant method of treatment of injuries to the coIon. WoodhaII and Ochsner [r4] pointed out that routine use of this form of therapy resuIted in increased hospitaIization time and needIess second operations, and further noted that this treatment was appIied “too whoIeheartedIy for the good of the patient.” Marked differences exist between most civiIian and miIitary injuries to the coIon. ApproximateIy 75 per cent of battIefieId injuries are caused by fragmentation missiIes, resuIting in wounds with massive destruction of tissue. Many of the remaining war injuries resuIt from high velocity missiIes which cause Iarge coIon defects with surrounding zones of devitalized tissue. High veIocity civiIian injuries to the colon are rare and usuaIIy resuIt from missiIes discharged from big game riffes or specia1 pistoIs of Iaw enforcement oficers. Shotgun injuries, especiaIIy when inflicted at cIose range, have a simiIar degree of destruction. These injuries with massive bowe1 destruction in which restoration of continuity is difTicuIt shouId be treated by two-stage repair. The majority of civiIian injuries to the coIon are Iimited in extent and can be managed best by simpIe cIosure or resection with end-to-end anastomosis. Injuries to the extraperitonea1 rectum shouId be treated by repair and diverting coIostomy.
I I
SUMMARY
I I
.
those patients that died. No patient receiving more than 10,000 ml. of blood survived. Four deaths in this series resuIted from hemorrhage and two patients died because of disturbances in the clotting mechanism. There were eight cases of acute renaI faiIure. No doubt some of these compIications resuIted from massive bIood transfusions necessary to sustain Iife. COMPLICATIONS
Wound infection and dehiscence were the most common compIications. (TabIe IV.) FecaI fistuIa occurred in seven patients with six fistuIas cIosing spontaneousIy, and in the seventh patient death resulted from muItipIe compIications. Intra-abdomina1 abscess was surgicaIIy drained in three instances. CAUSE
OF DEATH
Hemorrhage, irreversibIe shock (with death occurring within forty-eight hours of the injury), renaI failure and peritonitis caused twenty of twenty-five deaths. (TabIe v.) Seven deaths were reIated to the injury to the coIon directly, six patients dying from periTABLE v CAUSE OF DEATH Hemorrhage. Shock.. . . .. Peritonitis.. RenaI faiIure.. ..... . . FecaI and urinary fistuIa. DuodenaI fistuIa.. . Pneumonia................................ Pulmonary emboIism. . No demonstrabIe cause.. TotaI.................................
4 6 6
. .
4
I
The present study is an anaIysis of the surgica1 treatment of 186 traumatic Iesions of the coIon. Primary repair without coIostomy
25
644
Perforating
Injuries
was empIoyed as the definitive operation in 144 patients with a mortality of 7 per cent. Twostage procedures were used in thirty-nine patients with a mortahty rate of 30 per cent. Overall mortality in this series was 13.9 per cent. HospitaIization stay averaged onIy fourteen days in patients with primary repair and thirty-five days when the two-stage procedure was used. Significant factors in mortality were advanced age, muItipIe organ injuries and massive transfusion. Primary repair without coIostomy is the treatment of choice in civiIian injuries to the coton. Exteriorization or diverting coIostomy is reserved for Iesions with massive destruction of the coIon and in Iesions of the extraperitonea1 rectum.
5.
6.
7. 8. g.
IO.
II.
REFERENCES I. BEEBE, G. W. and DE BAKEY, M. E. BattIe Casualties. SpringheId, III., 1952. Charles C Thomas. 2. CHASSIN, J. L. and MULHOLLAND, J. H. Complications of surgery of the colon. S. Clin. North America, 35: 1337, I95j. 3. CROCE, E. J., JOHNSON,V. S. and WIPER, T. B. The management of war injuries of the extraperitona1 rectum. Ann. Surg., 122: 408, 1945. 4. HAMILTON, J. E. Penetrating gunshot and stab
12.
13.
14.
645
to CoIon wounds of the abdomen: review of 336 cases. Surgery, 13: 107, 1943. HORSLEY, G. W. and MICHAUX, R. A. Surgery of the coIon as seen in an overseas general hospita1. Surgery, rg: 845, 1946. HURT, L. E. The surgical management of coIon and recta1 injuries in the forward area. Ann. Surg., 122: 398, 1945. LICHTENSTEIN, M. E. CoIostomy. S. Clin. North America, 35: 1347, 1955. OGLILVIE, W. H. AbdominaI wounds in the western desert. Surg., Gynec. CY Obst., 78: 225, 1944. POER, D. H. The management of penetrating abdominal injuries, comparison of military and civiIian experiences. Ann. Surg., 127: 1092, 1948. PONTIUS, R. G., CREECH, O., JR. and DE BAKEP, M. E. Management of Iarge bowel injuries. Ann. Surg., 146: 291, 1957. ROWE, R. J. and WILLIFORD, C. E. Factors inAuencing the morbidity and mortality of major surgery of the colon and rectum. Soutb M. J., 48: 1069, 1955. SAKO, Y., ARTZ, C. P., HOWARD, J. M., BROMWELL, A. W. and INUI, F. F. A survey of evacuation, resuscitation and mortaIity in a forward surgical hospita1. Surgery, 37: 602, 1955. TUCKER, J. W. and FEY, W. P. The management of perforating injuries of the coIon and rectum in civiIian practice. Surgery, 35: 213, 1954. WOODHALL, J. P. and OCHSNER, A. The management of perforating injuries of the colon and rectum in civiIian practice. Surgery, 29: 305, 195 I.
to the
W. R. ROOF, M.D., GEORGE C. MORRIS, JR., M.D. ANDMICHAEL E. DE BAKEY, M.D., Houston, Texas injury in order of frequency was buIIet, knife, shotgun and bIunt trauma. (TabIe I.) MuItipIe injuries to the coIon were encountered in 20 per cent of patients, and the majority were the resuIt of firearms. The transverse coIon was injured most frequentIy, foIlowed in order of diminishing frequency by the descending coIon, ascending coIon and rectosigmoid. Wounds by firearms were aImost equaIIy distributed about the coIon but the majority of knife wounds invoIved the transverse coIon. BulIets ranged in size from .22 through .45 calibres and were usuahy low veIocity missiIes. The high veIocity injuries were usually in patients wounded by peace officers. Shotgun wounds were caused by pehets ranging from No. 12 through oo discharged from shotguns ranging in size from .410 through 12 gauge. AutomobiIe accidents caused four of the bIunt trauma injuries. The remaining bIunt trauma injury resuIted from vigorous jumping of a companion on the abdomen of the victim. Other objects causing trauma incIuded impaIement with fence stakes, pieces of gIass and a sharp iron rod. Ingested foreign bodies causing injuries to the coIon were a chicken bone and a toothpick.
From tbe Cora and Webb Mading Department of Surgery, Baylor University College of Medicine, Houston, Texas.
ORTALITY and morbidity from acute injuries to the coIon have been reduced continuousIy by aggressive surgery during the twentieth century. AIthough improved anesthesia, fluid and brood replacement and the use of antibiotic and chemotherapeutic agents have contributed greatIy to the reduction in mortality, definitive operative repair of the injury has been IargeIy responsibIe for the improved resuIts. The technical procedure of choice, however, has remained controversia1. During WorId War II the routine practice of exteriorization of the damaged coIon as the first phase of a two-stage repair was credited with markedIy increased surviva1 rates [5,6,8]. This form of therapy was carried into civiIian practice in the postwar years and stiI1 has many advocates. Other surgeons have urged that seIected patients be treated with primary repair [10,14]. The present report is an anaIysis of 186 cases of traumatic Iesions of the coIon seen during the past ten years at the Jefferson Davis HospitaI. The majority of these patients were treated by primary repair. IncIuded in the series are the resuIts previousIy reported from this institution in 1956 by Pontius, Creech and De Bakey [IO].
M
TABLE I MECHANISM
MATERIAL From January rg4g to January 1959, 186 patients were operated upon for traumatic Iesions of the colon. Over go per cent of these patients were young aduIts between fifteen and fortyfive years of age. Two-thirds of the patients were Negro and the remainder aImost equaIIy divided between Latin Americans and a11 other white races combined. Males outnumbered females by a ratio of four to one. Mode of 64’
OF
INJURY
Mechanism
No.
BulIet..................................... Knife. Shotgun................................... Blunt trauma.. . . . Varied objects (sticks, rods). Ingested foreign body..
94
Total.................................
186
American Journal
of Surgery.
4,’
3 4
2
Volume gg. May, rg6o
Roof, Morris
and De Bakey pIaced near the area of injury and brought out through the abdominal waII IateraIIy.
MANAGEMENT
Preoperative management consisted of the usua1 preparations for emergency surgery in acute abdominal trauma. Venesection by Iarge bore needles, and surgica1 cutdowns were performed in the upper extremities for rapid restoration of blood voIume and eIectroIyte equilibrium. Dextran was used as a pIasma expander when rapid repIacement was imperative. When dextran was used, no more than 1,000 ml. was given because of the danger of cIotting disturbances. SaIine soIution was used as the non-coIIoida1 fluid, and an average of 2,200 m1. of bIood was given before and during the various operative procedures. Tetanus antitoxin or toxoid according to the individua1 indication was given in the receiving ward. Antibiotics were started as soon as possibIe. Nasogastric suction was utilized to evacuate stomach contents, often consisting of recently ingested aIcohoIic Auids. An indweIIing urinary catheter was routineIy inserted both to check for the presence of gross hematuria indicating injury to the urinary tract and to foIIow urine voIume as a guide to ffuid and blood repIacement. CarefuI history and compIete physica examination were performed to determine the probabIe site and extent of damage. Proctoscopy was performed in Iower abdomina1 injuries when trauma to the rectosigmoid region was suspected. Roentgenographic examination of the thorax and abdomen was performed to further trace the course and Iocation of the missiIe. However, in some cases bIeeding was so massive that expIoration was performed before such diagnostic procedures couId be obtained. Operative management consisted of the rapid expIoration of the patient through a midIine abdomina1 incision. After significant hemorrhage was controIIed, injuries to the coIon were repaired by two-Iayer cIosure technic turning in generous amounts of Iarge bowe1 waI1. When the coIon was badIy damaged, segmenta resection was performed with end-to-end anastomosis. Exteriorization was used in cases in which Iong segments of bowel had been destroyed making repair diffrcuIt. ProximaI coIostomy was used in Iow recta1 Iesions and in some cases of massive destruction of Iong segments of bowe1. Thorough irrigation with saIine and antibiotic soIutions was performed during the procedure and immediately prior to closure of the abdomina1 waI1. Drains were usuaIIy
RESULTS
Over-al1 mortatity for the 186 patients was 13.9 per cent. Primary repair was empIoyed in 144 patients, with ten deaths, a mortarity rate of 7 per cent. (Table II.) In fifty-three patients with knife injuries repaired primariIy there was onIy one death, a mortaIity rate of 2 per cent. Primary repair was performed in eighty-one firearm injuries with eight deaths, a mortaIity rate of IO per cent. There was one death from bIunt trauma in the ten patients repaired primariIy. Two-stage repairs were performed in thirtynine patients with tweIve deaths, a mortality rate of 30 per cent. CoIostomy was performed in nine patients with Iow rectosigmoid Iesions with no deaths. In the thirty remaining patients, twenty exteriorizations and ten proximal coIostomies were performed for massive destruction of Iarge segments of the colon. Firearms inflicted the damage in twenty-five of these patients and accounted for a11 the deaths in this group. Two Iacerations were treated by repair and diverting colostomy, and two by exteriorization. One case of blunt trauma was treated by repair and diverting coIostomy. Comparison of mortaIity rate between different types of repair is not justified in this series since the type of repair to be empIoyed was determined by the severity and extent of injury to the bowe1. Thus higher mortaIity wouId be expected in the more severeIy injured patient treated with the two-stage procedure. Comparison of the type of repair and resuIts for the first seven years versus the Iast three years of this study shows an increasing proportion of the patients being managed by primary TABLE TYPE
Type
Primary
OF
II
TREATMENT
Repair
. .
Firearms Knife Other .~.
Two-stage
ertenor~zatmn.. Repair and proximal coIostomy .
. ..
Firearms Knife
i Other 642
i
AND
RESULTS
Cases (No.)
Deaths (No.)
Mortality ( 5%)
Perforating
Injuries
to CoIon
PRIMARY REPAIR
MORTALITY
NUMBER CASES
TWO STAGE REPAIR
MORTALITY
NUMBER CASES
FIRST
OVERALL
SEVEN
YEARS
MORTALITY LAST
%
THREE
YEARS
FIG. I. Comparison method of repair and resuks for the first seven versus the Iast three years of study. _
repair. (Fig. I.) Mortality for primary repair has dropped from g per cent to 5 per cent and the over-all mortality has decreased from 15 per cent to g per cent. Average hospita1 stay for primary repair of the colon was fourteen days while an average of thirty-live days was required with the two-stage procedure. FACTORS
INFLUENCING
arteriosclerosis make hemorrhage difficult to control, but it also makes the brain, heart and kidney vulnerable to periods of hypotension. Blood Replacement. Although the average amount of blood administered was 2,200 ml., an average of over 5,000 ml. was required in TABLE III ASSOCIATED INJURIES
RESULTS
Intervalfrom Znjury to Surgery. The average time interval elapsing from injury until admission to the receiving ward was 1.2 hours. Operative treatment was started an average of 2.8 hours after injury. Others have stressed the importance of early operation pointing to superior results in the patients who underwent exploration within six hours of the injury [I?, 141. Seven patients in this series had a delay of more than six hours between injury and operation, yet there was no mortality nor significant morbidity in this group. Associated Injuries. There were 272 major injured in this series exclusive of organs injuries to the colon and averaged 1.5 injuries per patient. (Table III.) In forty-three patients without associated injuries (23 per cent), there was no mortahty and onIy one complication, a singIe fecal listula. Patients who did not survive had an average of five major organs involved. Age. In patients over fifty years of age the mortality rate was 46 per cent indicating that with increasing age, tolerance for major trauma markedly declines [a]. Not only does
No.
Injury
Vascular injuries Heart .................................. Aorta .................................. Venacava ............................... Other major vesseIs ....................... Total vascuhu injuries.
16
.................
Stomach .................................. Ileum or jejunum ........................... Duodenum ................................ SpIeen .................................... Liver ..................................... Kidney or ureter ........................... CentraI nervous system. .................... Diaphragm ................................ Chest (hemothorax)........................ GaIibIadder ................................ Pancreas .................................. Madder and urethra ........................ Uterus .................................... Extremities. .............................. TotaI ................................
643
29 79 I4 I7 37 22 4 8 4 I2 6 5 3 16
-I
256
Roof, Morris and De Bakey TABLE IV COMPLICATIONS Wound infection. Wound dehiscence.. FecaI fistuIa., Acute renaI faiIure.. IntestinaI obstruction.. Abscess................................... Jaundice.................................. DuodenaI f%tuIa. Urinary fistula. BiIiaryfistuIa............................... Pneumonia................................ PuImonary emboIism. . . OsteomyeIitis of sacrum..
tonitis and one from feca1 urinary fistuIas. Of the six deaths occurring in the Iast three years of the present study, three were caused by irreversibIe shock, two by renaI faiIure and the remaining death by peritonitis.
Iz 7 7 7 5 3 2 2 2 I I
COMMENTS
I I
There is no doubt that routine exteriorization of a11 traumatic injuries to the coIon in the earIy phases of WorId War II resuIted in increased surviva1 rates. However, by Iate 1944, military surgeons in some theaters of operation were performing primary repair of seIected injuries to the coIon with equaIIy good resuIts yet decreased hospitaIization time [I 01. NevertheIess, in the immediate postwar period, exteriorization or primary repair and diverting coIostomy remained the dominant method of treatment of injuries to the coIon. WoodhaII and Ochsner [r4] pointed out that routine use of this form of therapy resuIted in increased hospitaIization time and needIess second operations, and further noted that this treatment was appIied “too whoIeheartedIy for the good of the patient.” Marked differences exist between most civiIian and miIitary injuries to the coIon. ApproximateIy 75 per cent of battIefieId injuries are caused by fragmentation missiIes, resuIting in wounds with massive destruction of tissue. Many of the remaining war injuries resuIt from high velocity missiIes which cause Iarge coIon defects with surrounding zones of devitalized tissue. High veIocity civiIian injuries to the colon are rare and usuaIIy resuIt from missiIes discharged from big game riffes or specia1 pistoIs of Iaw enforcement oficers. Shotgun injuries, especiaIIy when inflicted at cIose range, have a simiIar degree of destruction. These injuries with massive bowe1 destruction in which restoration of continuity is difTicuIt shouId be treated by two-stage repair. The majority of civiIian injuries to the coIon are Iimited in extent and can be managed best by simpIe cIosure or resection with end-to-end anastomosis. Injuries to the extraperitonea1 rectum shouId be treated by repair and diverting coIostomy.
I I
SUMMARY
I I
.
those patients that died. No patient receiving more than 10,000 ml. of blood survived. Four deaths in this series resuIted from hemorrhage and two patients died because of disturbances in the clotting mechanism. There were eight cases of acute renaI faiIure. No doubt some of these compIications resuIted from massive bIood transfusions necessary to sustain Iife. COMPLICATIONS
Wound infection and dehiscence were the most common compIications. (TabIe IV.) FecaI fistuIa occurred in seven patients with six fistuIas cIosing spontaneousIy, and in the seventh patient death resulted from muItipIe compIications. Intra-abdomina1 abscess was surgicaIIy drained in three instances. CAUSE
OF DEATH
Hemorrhage, irreversibIe shock (with death occurring within forty-eight hours of the injury), renaI failure and peritonitis caused twenty of twenty-five deaths. (TabIe v.) Seven deaths were reIated to the injury to the coIon directly, six patients dying from periTABLE v CAUSE OF DEATH Hemorrhage. Shock.. . . .. Peritonitis.. RenaI faiIure.. ..... . . FecaI and urinary fistuIa. DuodenaI fistuIa.. . Pneumonia................................ Pulmonary emboIism. . No demonstrabIe cause.. TotaI.................................
4 6 6
. .
4
I
The present study is an anaIysis of the surgica1 treatment of 186 traumatic Iesions of the coIon. Primary repair without coIostomy
25
644
Perforating
Injuries
was empIoyed as the definitive operation in 144 patients with a mortality of 7 per cent. Twostage procedures were used in thirty-nine patients with a mortahty rate of 30 per cent. Overall mortality in this series was 13.9 per cent. HospitaIization stay averaged onIy fourteen days in patients with primary repair and thirty-five days when the two-stage procedure was used. Significant factors in mortality were advanced age, muItipIe organ injuries and massive transfusion. Primary repair without coIostomy is the treatment of choice in civiIian injuries to the coton. Exteriorization or diverting coIostomy is reserved for Iesions with massive destruction of the coIon and in Iesions of the extraperitonea1 rectum.
5.
6.
7. 8. g.
IO.
II.
REFERENCES I. BEEBE, G. W. and DE BAKEY, M. E. BattIe Casualties. SpringheId, III., 1952. Charles C Thomas. 2. CHASSIN, J. L. and MULHOLLAND, J. H. Complications of surgery of the colon. S. Clin. North America, 35: 1337, I95j. 3. CROCE, E. J., JOHNSON,V. S. and WIPER, T. B. The management of war injuries of the extraperitona1 rectum. Ann. Surg., 122: 408, 1945. 4. HAMILTON, J. E. Penetrating gunshot and stab
12.
13.
14.
645
to CoIon wounds of the abdomen: review of 336 cases. Surgery, 13: 107, 1943. HORSLEY, G. W. and MICHAUX, R. A. Surgery of the coIon as seen in an overseas general hospita1. Surgery, rg: 845, 1946. HURT, L. E. The surgical management of coIon and recta1 injuries in the forward area. Ann. Surg., 122: 398, 1945. LICHTENSTEIN, M. E. CoIostomy. S. Clin. North America, 35: 1347, 1955. OGLILVIE, W. H. AbdominaI wounds in the western desert. Surg., Gynec. CY Obst., 78: 225, 1944. POER, D. H. The management of penetrating abdominal injuries, comparison of military and civiIian experiences. Ann. Surg., 127: 1092, 1948. PONTIUS, R. G., CREECH, O., JR. and DE BAKEP, M. E. Management of Iarge bowel injuries. Ann. Surg., 146: 291, 1957. ROWE, R. J. and WILLIFORD, C. E. Factors inAuencing the morbidity and mortality of major surgery of the colon and rectum. Soutb M. J., 48: 1069, 1955. SAKO, Y., ARTZ, C. P., HOWARD, J. M., BROMWELL, A. W. and INUI, F. F. A survey of evacuation, resuscitation and mortaIity in a forward surgical hospita1. Surgery, 37: 602, 1955. TUCKER, J. W. and FEY, W. P. The management of perforating injuries of the coIon and rectum in civiIian practice. Surgery, 35: 213, 1954. WOODHALL, J. P. and OCHSNER, A. The management of perforating injuries of the colon and rectum in civiIian practice. Surgery, 29: 305, 195 I.