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Surgical management of colon trauma in civilian practice
Surgical
Management Civilian
of Colon Practice*
Trauma
ROBERT S. VANNIX, M.D., RICHARD CARTER, M.D., DAVID B. HINSHAW, EUGENE J. JOERCENSON, M.D., Los Angeles, California From the Loma Linda University School of Medicine, Department of Surgery, tbe Los Angeles County General Hospital and tbe Wbite Memorial Hospital, Los Angeles, California.
ROGRESS in the management of wounds of coIon and rectum has IargeIy resuIted from experiences in miIitary surgery [r-4] and more recentIy from observations made in Iarge civiIian hospitaIs [f-9]. During WorId War II and the Korean conflict, the routine use of exteriorization or proxima1 coIostomy resuIted in a striking reduction in mortaIity, and this method has subsequentIy become popuIar in civilian practice. However, it has become evident that exteriorization or prox$maI coIostomy may not be necessary in the majority of civiIian injuries and may be associated with proIonged convaIescence and additiona complications
P the
MANAGEMENT
In an attempt to further evaIuate this probIem, an analysis was made of 138 patients with coIon and recta1 injuries treated on the TABLE
The preoperative compIete physica
management consisted of evaIuation of the patient, TABLE
I OF
AND
Loma Linda University surgica1 services from 1956 to 1962. There were twenty deaths in this totaI group, a mortaIity rate of 14.5 per cent. One hundred thirty-two patients of the 138 received operative treatment. The average age was 34.6 years, with extremes being a gir1, age three, and a man of ninety-four years. The mechanisms of trauma are outIined in TabIe I. The number of injuries with accompanying mortaIity for each anatomica segment of the coIon and rectum are Iisted in TabIe II. As has been frequently emphasized, recta1 injuries, particuIarIy those that are extraperitonea1, tend to be more serious than injuries elsewhere in the coIon. The transverse colon was the site most frequentIy injured. (Fig. I.) TweIve patients had three or more perforations, of whom three died.
[9ml*
MECHANISM
M.D.
in
INJURY
LOCATION
OF
II INJURY
-
-7
No.
Data
62 34 I7
BulIet .............. Stab. ............... TransanaI trauma .... BIunt trauma ........ Shotgun. ........... Ingested foreign body Operative. ..........
TotaI . .
of
Cases
No. of Deaths
Location
Cecum and ascending coIon. ....... Hepatic flexure ................... Transverse c&n. ................. Spknic flexure. ................... Descending colon. ................ Sigmoid .......................... IntraperitoneaI rectum ............. ExtraperitoneaI rectum ............
: 4
6’
0 0
.
.
2
.
138
Deaths
__
7
.
No.
I
TotaI
20
. .
25
3 40
II 15
19 19 6 138
20
* Presented American
at the annua1 meeting of the Pacific Coast SurgicaI Association, 3-6, 1963.
Journal
OJ Surgery,
Volume
rd.
August
rg63
364
Palm
Springs, California, February
SurgicaI Management
of CoIon Trauma
HEPATIC FL’EXURE
3, ot TRkNS’ COLON 40,s-t
’ 6
_
RECTUM: INTRAPERITONEAL EXTRAPERITONEAL FIG. x. Location
PRIMARY CLOSURE WITHEXTERIORIZATION
of injury.
5
67
1
10 %
0
0
11 23.9 % FIG.
2.
Left to right. Cases, deaths and mortaIity.
365
Vannix, Carter, Hinshaw and Joergenson TABLE METHODS
OF
TABLE
IzI
SURGICAL
Deaths
Data
Primary closure. . Simple closure. Resection and primary anastomosis . . . Primary cIosure with exteriorization . . Primary venting.. Proximal colostomy or cecostomy.......... Exteriorization of injured segment resulting in coIostomy. .
INTERVAL
MANAGEMENT
76 69
I
I7
Cases
TREATMENT
Operated
Death s
1:aIity
2 Hr./ less (Per cent)
Per cent
iPrimary closure. o-6 hr. 6-12 hr., 12-18 hr.. 18-z4hr 5 week.
10.0
II
29
IllterKd
I
IO
46
TO
MOP
4
7
IV
INJURY
6.6
5
I
MortaIity (Per cent)
FROM
23.9
5
24-w
bIood voIume and ffuid replacement, tetanus nasogastric suction, indwelling prophyIaxis, catheters with monitoring of urine output, pIus Iaboratory studies as indicated. Urography, sigmoidoscopy and abdominal paracentesis were utiIized when indicated. Preoperative antibiotics were frequently given. Operative management consisted in contro1 of hemorrhage, closure of perforation sites, repair of other injuries when present, and adequate drainage when indicated. Three genera1 methods were utiIized whichare summarized in TabIe III. (Fig. 2.) The first was primary closure in which the injured site was either debrided and closed or resected with primary anastomosis [g]. Seventy-six patients were in this primary cIosure group with a mortaIity rate of 6.6 per cent. Of these, sixtynine had the injury site debrided and closed, and seven had the site resected with primary anastomosis. Four of the seven primary resections were right coIectomies, one patient died. There were four deaths among the sixty-nine patients treated by debridement with cIosure. Forty-five of the injuries in this group were in the ascending or transverse coIon with three deaths; thirty-one injuries were in the Ieft coIon incIuding the rectum, with two deaths. The second surgical method was primary cIosure with exteriorization which was used in ten patients with one death [a. Six of the injuries occurred in the hepatic ffexure or transverse coIon with one death; four injuries were in the Ieft coIon. The third method was primary venting (coIostomy or cecostomy) utiIizing a staged 366
4 I 0 0
,
_._.
56
__
6.6 10.3
5 39 31 3 I
ex&orization and primary venting. odhr _.._.__._._.. 6-12 hr.. la-18 hr.. 10-24 hr., hr., zday. 3dsy .._ 4day .._ 5day. .,,....._ 10 day
_.
6
76
o
21.4 12.5 38.8 ..
12 24 18 3
75
3.2
3 7 0
z I
o 0
3 , 2 I I
I I o o 0
I
-
60 .
33.3 00
-
-
approach. Forty-six patients were treated in this way, eIeven deaths occurred, an operative mortaIity rate of 23.9 per cent. Of the forty-six patients, twenty-nine had a proximal vent, and five died; seventeen had exteriorization of the site of injury with six deaths. Thirteen injuries occurred in the ascending or transverse colon with three deaths, and thirty-three injuries were in the left colon including rectum with eight deaths. There were three deaths in the remaining six patients in whom no surgica1 procedure was performed. It wouId appear in review that the three deaths wouId have been prevented by prompt surgical intervention. Of the three survivors two had posterior extraperitonea recta1 perforations and the other had an intraperitoneal recta1 injury. This intraperitonea1 perforation which was of specia1 interest was caused by an enema tip one month prior to admission. A c&de-sac abscess had deveIoped, which spontaneousIy drained at sigmoidoscopy. The time interva1 from injury to treatment is significant. It has been noted by many authors that resuIts improve when surgica1 treatment is prompt, especiaIIy under six hours. Data reIated to a time interval is summarized in Table IV. TabIe v lists the associated trauma in the 132 operated cases. Forty-four patients had a
SurgicaI
Management
of CoIon Trauma
TABLE v ASSOCIATEDTRAUMA IN I32 OPERATED CASES
-
-
- -
CoIon or rectal injuq 7 only. ............... SmaII bowe1. .......... Stomach .............. Liver ................. Pancreas. ............. CaIIbIadder and/or corn, mon duct. .......... Lung and/or hemo- 01r pneumothorax. ......
_ 13.3 17.9 7.6 9.1 7.6
3 4
IS.9 12.0 10.0 25.0 40.0
5
3.8
I
20.0
IO 6
7.6 4.5 5.3 7.6 3.8 3.0 I.5
3 I 2 2
30.0 16.7 28.6 20.0 20.0 50.0 50.0
7 IO 5 4 2 2
smaI1
associated bowe1
Extremity by
I
5 24 29
;:: 8.3 !2.0
3 2
-
-
In
injured
taiity
seven per
15.9
of patients or
One
treated
primary is
ciated
faiIures
or 9.1 per or
TabIe
Ieaks
recta1
cases.
VI summarizes
cIosure
with
with
of primary
freedom
from
primary
coIostomies
two 5.3
There
uneventfu1
deaths).
were
cent a
I
2 2 IO I 4 2 2 0
I 46 16 9 12 5 I I 2
four
of had
the
seventy-six
an
Of the
uneventfu1 remaining
mortaIity
of
had
recovery forty
6.6 per
cIuded twenty-seven subcutaneous
who
(IO per cent).
cent. wound
abscesses),
(47.3
patients,
per
five
infections
cent).
died,
Compbcations five
Primary cIosure Seventy-one patients Iived. . . . . Five patients died.. . . . Primary cIosure with exteriorizatior and primary venting Twenty coIostomies not closed. Twenty-four coIostomies cIosed TweIve died. . . .. . .
a in-
(six were
intraperitonea1 367
was
DAYS
Minima1 and Maximal Days
Data
cIosure
of
cIosure
There
I
patients
primary
group
IX) one onIy had an
asso-
exteriorization
Ieaks
seventy-six
who had primary (TabIe
renal
compIications.
or anasto-
VIII thirty-six
four
the
-
RESULTS OF MANAGEMENT in TabIe
two
anastomotic
These of
procedures.
As indicated
obstructions
surgery,
misceIIaneous
other assorted
recovery
7
and two were cause
and
per
27 18 rg
TABLE VII LENGTH OF HOSPITALIZATIONIN
vent-
morbidity
and
(with
deaths,
with exteriorization
exteriorization.
cIosure
the
with
Deaths
76
intestina1
subsequent
Of the ten patients
and
cIosure
by primary
smaI1
required
twenty-one
of initia1 hospitaIizawith
two
represented
a mor-
coIon injury
(one subphrenic,
death),
which
foIIowed
coIon
to those treated
advantage
mosis
of
frequency
occurred,
between
VII the Iength
is compared ing
abscesses
cent).
and diaphragm.
with
No.
Primary cIosure.. . CoIon aIone. . . CoIon pIus one other viscus. Colon pIus two other viscera. CoIon pIus three other viscera.. CoIon pIus four other viscera. CoIon pIus five other viscera Colon plus six other viscera. 1 Exteriorization.. CoIon aIone.. CoIon pIus one other viscus Won pIus two other viscera. CoIon plus three other viscera. CoIon pIus four other viscera. CoIon pIus five other viscera. Primaryvent.................... CoIon alone.. CoIon pIus one other viscus CoIon pIus two other viscera. CoIon pIus three other viscera. CoIon pIus four other viscera. CoIon pIus five other viscera. CoIon plus six other viscera.
trauma.
In TabIe tion
cases
deaths
cent.
in
per cent),
pancreas
the interreIationship associated
the
per
37.9
(tweIve
patients
onIy, of
fre-
was
next
forty-four
trauma
most
were
to Iiver
6.9
The
injuries
then stomach,
40.0 12.5
structure or
cases or 18.3
.
-
cases
injuries
cent),
2 I
2 I 0 2
(fifty
(twenty-four
Data
-_
soIitary coIon or recta1 injury. quentIy
Per cent
Deaths
44 50 IO 12 IO
SpIeen................ Kidney ............... Diaphragm. ........... Duodenum. ........... Great vessek. ......... Bladder. .............. Ureter. ............... SpinaIcord ............ Extremities. ........... MisceIIane0u.s. .........
T
Per :ent
1No.
Data
TABLE VI ASSOCIATEDTRAUMA
AverN”,“. of Days
3 to 84 4to 41
15.4 21.8
5 to 60 13 to 92 1 to 37
25.2 36.4 10.0
1
Vannix, Carter, Hinshaw and Joergenson TABLE RESULTS
TABLE IX
VIII
IN SEVENTY-SIX PRIMARY CLOSURES
Data
UneventfuI recovery. Deaths..................... Complications. Wound infection. Intraperitoneal abscess.. Anastomotic Ieaks.. IntestinaI obstruction. Renal faihrre. MiscelIaneous.
No. of Patients
RESULTS
IN
TEN
PRIMARY
CLOSURES
EXTERIORIZATION
T I?er cent
WITH
No. of 1Per cent Patient! s
Data
-36 5 40 27 5 4 2 2 21
“~:~ 5.3
one death (IO per cent). The probIem of handling the exteriorized coIon is dificult [IO]. Of the ten cases exteriorized six had dehiscence of the closure with the formation of a coIostomy, thus converting them to a vent at the site of the injury. OnIy four were repIaced without having to open the coIon, one of which cIosure sites reperforated after it was repIaced and required another exteriorization with the patient eventuaIIy dying. Seventeen compIications occurred in the nine remaining patients. There were four intraperitonea1 Ieaks either at the site of cIosure of the injury or after a subsequent coIostomy cIosure (an incidence of 40 per cent Ieaks). One patient had a subphrenic and cuI-de-sac abscess which required drainage. EarIy smaI1 bowe1 obstruction occurred in two patients, which required operative decompression. Another patient had coIon obstruction due to tension of exteriorized coIon over the supporting rod. Nine miscelIaneous complications occurred. In the forty-six cases in which a primary vent was utiIized (TabIe x), eight patients (17.4 per cent) had an uneventfu1 recovery. EIeven deaths occurred (23.9 per cent mortaIity rate). Wound infection occurred in twenty-one cases. CoIostomy probIems deveIoped in ten patients (21.7 per cent) incIuding skin autodigestion, pericolostomy abscess and proIapse; three coIostomy cIosure Ieaks, smaI1 bowe1 obstruction, gangrene of coIostomy, and three coIostomy closure strictures. Other compIications incIuded four smaI1 bowe1 obstructions which required Iaparotomy, three patients with intraperitonea1 sepsis (subphrenic abscesses), and twenty-four misceIIaneous complications.
Uneventful recovery. . Deaths........................ Exteriorized cIosure replaced as foIIows: RepIaced without having colostomy....................... Required colostomy through exteriorized segment. CoIon reperforated after repIacemerit........................ CompIications. . Subphrenic and cuI-de-sac abscess........................ Small bowel obstruction requiringsurgery.................. CoIon obstruction at exteriorization site.. Anastomotic Ieaks.
I
10.0
I
10.0
4
.
.
6
. . .
.
.
40.0
MisceIIaneous -
ANALYSIS
OF PRIMARY
CLOSURE
DEHISCENCE
AND DEATHS
There were four anastomotic Ieaks with two survivorsamongtheseventy-sixpatients treated by primary cIosure. One was a thirty-seven year oId man who had a stab wound of the transverse colon and a feca1 impaction. It subsequentIy disrupted, requiring reoperation with exteriorization and eventua1 recovery. Another instance was a twenty-seven year oId man TABLE RESULTS
IN
FORTY-SIX
X PRIMARY
VENTS
ResuIts
Uneventfuf recovery. . Deaths......................... Comphcations. CoIostomy problems (proIapse, frstuIization, abscess, gangrene)...................... Wound infection. . Small bowe1 obstruction.. IntraperitoneaI sepsis. Anastomotic Ieaks.. MisceIIaneous..
8 II 36
17.4 23.9
10 21 4 3 4 24
21.7
.
8.7 I
368
SurgicaI TABLE
Management
XI
CAUSE OF DEATH IN PRIMARY CLOSURES
-
-
Mechanism
Cause of death
IlljUry
-_ Gunshot wound
Transverse colon and four other viscera ErtraperitoneaI rec. turn during pelvic exenteration Rectosigmoid perforation Cecum. ileum, and [ spinal cord
Operative Foreign body Gunshot wound Gunshot wound
Transverse colon and five other viscera
-
Acute renal faiture
Acute pyelonephritis Generalized peritonitis Suture line dehiscence with fecal peritonitis and sepsis Exsanguination due to acute hemorrhagic pancreatitis and liver necrosis with disruption of colon closure
-
with a gunshot wound of the extraperitonea1 ascending colon in whom a fistuIa deveIoped, which required a right coIectomy before fina recovery. The two deaths with anastomotic disruption are Iisted in TabIe XI. AI1 five deaths are, aIso, analyzed in TabIe XI. DEATHS
IN
PRIMARY
EXTERIORIZATION VENTING
CLOSURE AND
WITH
PRIMARY
PROCEDURES
The one death in the primary cIosure with exteriorization group was due to dehiscence of the suture Iine when the coIon was repIaced. Of the eIeven deaths with primary venting procedures, nine were caused by massive injury or generaIized peritonitis and were not reIated to operative error. A fifty-three year oId man with a rectosigmoid foreign body perforation had a wound evisceration and died from cardiac arrest at surgery. A fifty-seven year old man had blunt trauma injury with Iaceration of the extraperitonea1 rectum treated by coIostomy and died of an unreIated aspiration probIem.
of CoIon Trauma jority of battIefieId coIon wounds requires an exteriorization approach, whereas a Iarge percentage of civilian coIon injuries may be accompanied by less IocaI tissue destruction and are adaptabIe to primary cIosure. It is of interest to note that there were four patients (5.3 per cent) who had a dehiscence of the primary suture Iine. Two of these died, but the other two were successfuIIy managed, one by a coIostomy and the other by right coIectomy. Wound infection proved to be a common compIication in primary cIosure. Of ten patients who had primary cIosures of their coIon perforation associated with exthere were four instances of teriorization, suture-Iine dehiscence. There were frequent complications associated with the coJostomy in the primary vent and exteriorization groups. SUMMARY
AND
CONCLUSIONS
This study is an anaIysis of the management of 138 cases of coIon and recta1 trauma. Primary cIosure was used in seventy-six instances with a mortaIity of 6.6 per cent; it is considered to be the treatment of choice when circumstances permit [7-91. When coIon wounds are accompanied by extensive IocaI tissue injury or massive feca1 peritonitis, primary venting procedures are recommended. AIthough selected wounds of the extraperitonea1 rectum may be treated by primary repair, the majority require proxima1 coIostomy and perinea1 drainage [IO-141. Extensive muItipIe organ trauma and associated diseases are serious factors in prognosis. REFERENCES
BOWERS, W. F. Surgical treatment in abdominaI trauma: a comparison of resuIts in war and peace. Military Med., I 18: g, 1956. 2. COLCOCK, B. P. Battle wounds of the colon and rectum. Mil. Surgeon, 109: 688, 1951. 3. HURT, L. E. The surgica1 management of coIon and recta1 injuries in the forward areas. Ann. Surg., 122: 398, 1945. of penetrating 4. POER, D. H. The management abdominal injuries. Ann. Surg., 127: Iogz. 1~8. 5. ISAACSON, J. E., BUCK, R. L. and KAHLE, H. R. Changing concepts of treatment of traumatic injuries of the coIon. Dis. Colon @ Rectum, I.
COMMENTS
The effective routine use of exteriorization procedures during WorId War II and the Korean conff ict had a widespread inff uence in civilian practice. However, as the differences between military and civilian injuries have been evaIuated, it has become evident that a different approach shouId be considered in nonmiIitary hospitak. The massive tissue injury a.nd devitalization which characterizes the ma-
4:. 168,
1961.
PATTON. R. T. and LYONS. C. The treatment of traumatic injuries of the coIon. Trauma, I : 298, 1961. 7. PONTIUS, R. G., CREECH, 0. and DEBAKEY, M. E. Management of Iarge bowe1 injuries in civilian practice. Ann. Surg., 146: 291, 1937.
6.
369
Vannix,
Carter,
Hinshaw
8. ROOF, W. R., MORRIS, G. C. and DEBAKEY, M. E.
Management of perforating injuries to the coIon in civiIian practice. Am. J. Surg., gg: 641, 1960. 9. WOODHALL, J. P. and OCHSNER,A. The management of perforating injuries of the coIon and rectum in civiIian practice. Surgery, 29: 305, 1951. IO. PILCHER,L. S. Wounds of the colon and rectuma critica anaIysis of current methods of surgica1 treatment with emphasis on detaiIs of surgica1 technique. Mil. Surgeon, 104: 188, 1949. I I. LAUFMAN,H. The initial surgical treatment of penetrating wounds of the rectum. Surg. Gynec c Obst., 82: 219, 1946. 12. NEVIN, I. N., SENIEK, I. E. and JOHNSON,A. G. Foreign-body penetration of the rectum. New England J. Med., 264: 1127, 1961. 13. TURELL, R., KRAKAUER, J. S. and MAYNARD, A. CoIonic and anorecta1 function and disease. Surg. Gynec. FY Obst., 96: 313, 1953. 14. WECKESSER, E. C. and PUTNAM, T. C. Perforating injuries of the rectum and sigmoid coIon. J. Trauma, 2: 474, 1962.
DISCUSSION JACK FARRIS (Los AngeIes, CaIif.): I am certain that we are al1 grateful to Dr. Vannix and his associates for this presentation which caIIs our attention to the feasibiIity of definitiveIy treating coIon injuries by primary suture. Those who have done this type of cIinica1 investigation are aware, I am certain, of the enormous amount of effort that goes into the analysis of these data. As you wiI1 recaI1, there were 132 operations performed in 138 patients with twenty deaths, a mortaIity rate in the over-a11 group of about fourteen or 14.5 per cent. Of interest to us today is the group of seventysix patients who were treated by primary cIosure with a mortaIity rate of 6.6 per cent. I am certain that Dr. Vannix did not impIy the Iower mortaIity rate in the primary cIosure group was a direct resuIt of the method of treatment, but rather that this group of patients, nameIy, those without massive tissue injury, without sepsis, and those who have had a short time interva1 between injury and operation, are usuaIIy chosen for this particular modaIity. I have been interested recentIy in reviewing some of the pertinent literature on colon injuries since being given this assignment by Dr. Vannix and his coIIeagues; I was surprised to find numerous references in the Iiterature to the use of primary cIosure in the treatment of coIon injuries. As a matter of fact, OgiIvie in 1944 suggested primary suture particuIarIy for ceca1 wounds and wounds of the ascending colon. Those of us in the European theater during the war treated a11 coIon injuries by coIostomy di370
and Joergenson
version, aIthough we had a tacit agreement that most Iesions of the cecum and the ascending coIon, if at a11 suitabIe, shouId be treated by primary suture or by right coIectomy and iIeotransverse coIostomy rather than by iIeostomy. AIso, I was interested to see that Doctors Christianson, Ignatius and Mathewson had reported a number of patients who had been treated in civilian Iife by primary cIosure with no Ieaks and no deaths. Innes, in 1947, reported twenty-five injuries of the coIon in civiIian practice which were cIosed primarily with no Ieakage and IOO per cent recovery. About forty-seven years ago, a Captain Fraser, who was in the RoyaI Canadian MedicaI Corps, pubIished in Tbe British Medical Journal an extensive experience with 300 abdominaI injuries during WorId War I; he says, in summarizing his experience, that at first he folIowed a practice of a proximal coIostomy in combination with the operation of suture. “There are the obvious advantages that it increases the safety of the suture whiIe it obviates the passage of feca1 matter through the damaged gut. At this time we were suspicious regarding the viabiIity of the Iine of coIon suture, and we felt that coIotomy had a greater security. Later we recognized that the performance of proxima1 coIostomy was rareIy necessary, and we have, therefore, aImost abandoned its use. We now reinforce the suture line by an omenta1 graft. We beIieve that our results have improved since we have aItered our procedure.” This was about fifty years ago. So, I would compIiment the authors on a most carefu1 study of a reaIIy significant number of cases, and I am certain that I can summarize their beIiefs and emphasize that this particuIar maneuver shouId be used onIy in the ideal case, in a case in which there is minima1 tissue injury, when a short time has eIapsed, and where, perhaps, there is a skiIIfu1 surgeon. I wiI1 summarize by saying that, in short, there is a pIace for both methods of treatment, and that the two stage procedures in my opinion aIways wiI1 occupy an important pIace in the armamentarium of the general surgeon. I wouId Iike to close by CompIimenting Dr. Vannix on his beautiful presentation, his exceIIent sIides, and I think he Iends credence to the axiom that a good presentation for its background has lots of preparation. CARLETON MATHEWSON, JR. (San Francisco, Calif.): I hope you wiII forgive me for speaking again, but I, too, wouId like to extend my compliments to the authors and wouId Iike to emphasize the important difference between treating patients with injuries of this type in civiIian Iife and those in wartime. CertainIy, we who see these patients early and are abIe to keep them under constant observation are justified in doing primary cIosures
SurgicaI Management of the coIon. In wartime, however, the transportation probIems and rapid evacuation make it dangerous and, therefore, unjustified. My main reason, however, for speaking is to object to the faith that a great many people have in proxima1 colostomy. A proximal coIostomy does act as a vent and gets rid of gas and pressure, but rareIy gets rid of contamination. One, in treating a sigmoid perforation from a diverticuIitis, frequentIy wiI1 do a transverse coIostomy; often doing the transverse coIostomy on the right side of the colon in order to faciIitate subsequent Ieft coIectomy and re-establishment of continuity. In so doing, one Ieaves a tremendous reservoir of retained feca1 materia1 which continues to con-
of CoIon Trauma taminate the area of perforation. If one does choose to do a proxima1 coIostomy, it should be done in as cIose approximation to the injury as possibIe. DAVID B. HINSHAW (closing): We wouId Iike to thank Dr. Farris and Dr. Mathewson for their kind and thoughtfu1 comments. We wouId agree, strongIy so, that a surgeon shouId be famiIiar with a11 methods of dealing with this type of injury. It is cIear that each case must be individuaIized, and that no “ruIe of thumb” can be Iaid down for the treatment of coIon and recta1 injuries. We appreciate the opportunity to present this paper to the Association.
371
Management Civilian
of Colon Practice*
Trauma
ROBERT S. VANNIX, M.D., RICHARD CARTER, M.D., DAVID B. HINSHAW, EUGENE J. JOERCENSON, M.D., Los Angeles, California From the Loma Linda University School of Medicine, Department of Surgery, tbe Los Angeles County General Hospital and tbe Wbite Memorial Hospital, Los Angeles, California.
ROGRESS in the management of wounds of coIon and rectum has IargeIy resuIted from experiences in miIitary surgery [r-4] and more recentIy from observations made in Iarge civiIian hospitaIs [f-9]. During WorId War II and the Korean conflict, the routine use of exteriorization or proxima1 coIostomy resuIted in a striking reduction in mortaIity, and this method has subsequentIy become popuIar in civilian practice. However, it has become evident that exteriorization or prox$maI coIostomy may not be necessary in the majority of civiIian injuries and may be associated with proIonged convaIescence and additiona complications
P the
MANAGEMENT
In an attempt to further evaIuate this probIem, an analysis was made of 138 patients with coIon and recta1 injuries treated on the TABLE
The preoperative compIete physica
management consisted of evaIuation of the patient, TABLE
I OF
AND
Loma Linda University surgica1 services from 1956 to 1962. There were twenty deaths in this totaI group, a mortaIity rate of 14.5 per cent. One hundred thirty-two patients of the 138 received operative treatment. The average age was 34.6 years, with extremes being a gir1, age three, and a man of ninety-four years. The mechanisms of trauma are outIined in TabIe I. The number of injuries with accompanying mortaIity for each anatomica segment of the coIon and rectum are Iisted in TabIe II. As has been frequently emphasized, recta1 injuries, particuIarIy those that are extraperitonea1, tend to be more serious than injuries elsewhere in the coIon. The transverse colon was the site most frequentIy injured. (Fig. I.) TweIve patients had three or more perforations, of whom three died.
[9ml*
MECHANISM
M.D.
in
INJURY
LOCATION
OF
II INJURY
-
-7
No.
Data
62 34 I7
BulIet .............. Stab. ............... TransanaI trauma .... BIunt trauma ........ Shotgun. ........... Ingested foreign body Operative. ..........
TotaI . .
of
Cases
No. of Deaths
Location
Cecum and ascending coIon. ....... Hepatic flexure ................... Transverse c&n. ................. Spknic flexure. ................... Descending colon. ................ Sigmoid .......................... IntraperitoneaI rectum ............. ExtraperitoneaI rectum ............
: 4
6’
0 0
.
.
2
.
138
Deaths
__
7
.
No.
I
TotaI
20
. .
25
3 40
II 15
19 19 6 138
20
* Presented American
at the annua1 meeting of the Pacific Coast SurgicaI Association, 3-6, 1963.
Journal
OJ Surgery,
Volume
rd.
August
rg63
364
Palm
Springs, California, February
SurgicaI Management
of CoIon Trauma
HEPATIC FL’EXURE
3, ot TRkNS’ COLON 40,s-t
’ 6
_
RECTUM: INTRAPERITONEAL EXTRAPERITONEAL FIG. x. Location
PRIMARY CLOSURE WITHEXTERIORIZATION
of injury.
5
67
1
10 %
0
0
11 23.9 % FIG.
2.
Left to right. Cases, deaths and mortaIity.
365
Vannix, Carter, Hinshaw and Joergenson TABLE METHODS
OF
TABLE
IzI
SURGICAL
Deaths
Data
Primary closure. . Simple closure. Resection and primary anastomosis . . . Primary cIosure with exteriorization . . Primary venting.. Proximal colostomy or cecostomy.......... Exteriorization of injured segment resulting in coIostomy. .
INTERVAL
MANAGEMENT
76 69
I
I7
Cases
TREATMENT
Operated
Death s
1:aIity
2 Hr./ less (Per cent)
Per cent
iPrimary closure. o-6 hr. 6-12 hr., 12-18 hr.. 18-z4hr 5 week.
10.0
II
29
IllterKd
I
IO
46
TO
MOP
4
7
IV
INJURY
6.6
5
I
MortaIity (Per cent)
FROM
23.9
5
24-w
bIood voIume and ffuid replacement, tetanus nasogastric suction, indwelling prophyIaxis, catheters with monitoring of urine output, pIus Iaboratory studies as indicated. Urography, sigmoidoscopy and abdominal paracentesis were utiIized when indicated. Preoperative antibiotics were frequently given. Operative management consisted in contro1 of hemorrhage, closure of perforation sites, repair of other injuries when present, and adequate drainage when indicated. Three genera1 methods were utiIized whichare summarized in TabIe III. (Fig. 2.) The first was primary closure in which the injured site was either debrided and closed or resected with primary anastomosis [g]. Seventy-six patients were in this primary cIosure group with a mortaIity rate of 6.6 per cent. Of these, sixtynine had the injury site debrided and closed, and seven had the site resected with primary anastomosis. Four of the seven primary resections were right coIectomies, one patient died. There were four deaths among the sixty-nine patients treated by debridement with cIosure. Forty-five of the injuries in this group were in the ascending or transverse coIon with three deaths; thirty-one injuries were in the Ieft coIon incIuding the rectum, with two deaths. The second surgical method was primary cIosure with exteriorization which was used in ten patients with one death [a. Six of the injuries occurred in the hepatic ffexure or transverse coIon with one death; four injuries were in the Ieft coIon. The third method was primary venting (coIostomy or cecostomy) utiIizing a staged 366
4 I 0 0
,
_._.
56
__
6.6 10.3
5 39 31 3 I
ex&orization and primary venting. odhr _.._.__._._.. 6-12 hr.. la-18 hr.. 10-24 hr., hr., zday. 3dsy .._ 4day .._ 5day. .,,....._ 10 day
_.
6
76
o
21.4 12.5 38.8 ..
12 24 18 3
75
3.2
3 7 0
z I
o 0
3 , 2 I I
I I o o 0
I
-
60 .
33.3 00
-
-
approach. Forty-six patients were treated in this way, eIeven deaths occurred, an operative mortaIity rate of 23.9 per cent. Of the forty-six patients, twenty-nine had a proximal vent, and five died; seventeen had exteriorization of the site of injury with six deaths. Thirteen injuries occurred in the ascending or transverse colon with three deaths, and thirty-three injuries were in the left colon including rectum with eight deaths. There were three deaths in the remaining six patients in whom no surgica1 procedure was performed. It wouId appear in review that the three deaths wouId have been prevented by prompt surgical intervention. Of the three survivors two had posterior extraperitonea recta1 perforations and the other had an intraperitoneal recta1 injury. This intraperitonea1 perforation which was of specia1 interest was caused by an enema tip one month prior to admission. A c&de-sac abscess had deveIoped, which spontaneousIy drained at sigmoidoscopy. The time interva1 from injury to treatment is significant. It has been noted by many authors that resuIts improve when surgica1 treatment is prompt, especiaIIy under six hours. Data reIated to a time interval is summarized in Table IV. TabIe v lists the associated trauma in the 132 operated cases. Forty-four patients had a
SurgicaI
Management
of CoIon Trauma
TABLE v ASSOCIATEDTRAUMA IN I32 OPERATED CASES
-
-
- -
CoIon or rectal injuq 7 only. ............... SmaII bowe1. .......... Stomach .............. Liver ................. Pancreas. ............. CaIIbIadder and/or corn, mon duct. .......... Lung and/or hemo- 01r pneumothorax. ......
_ 13.3 17.9 7.6 9.1 7.6
3 4
IS.9 12.0 10.0 25.0 40.0
5
3.8
I
20.0
IO 6
7.6 4.5 5.3 7.6 3.8 3.0 I.5
3 I 2 2
30.0 16.7 28.6 20.0 20.0 50.0 50.0
7 IO 5 4 2 2
smaI1
associated bowe1
Extremity by
I
5 24 29
;:: 8.3 !2.0
3 2
-
-
In
injured
taiity
seven per
15.9
of patients or
One
treated
primary is
ciated
faiIures
or 9.1 per or
TabIe
Ieaks
recta1
cases.
VI summarizes
cIosure
with
with
of primary
freedom
from
primary
coIostomies
two 5.3
There
uneventfu1
deaths).
were
cent a
I
2 2 IO I 4 2 2 0
I 46 16 9 12 5 I I 2
four
of had
the
seventy-six
an
Of the
uneventfu1 remaining
mortaIity
of
had
recovery forty
6.6 per
cIuded twenty-seven subcutaneous
who
(IO per cent).
cent. wound
abscesses),
(47.3
patients,
per
five
infections
cent).
died,
Compbcations five
Primary cIosure Seventy-one patients Iived. . . . . Five patients died.. . . . Primary cIosure with exteriorizatior and primary venting Twenty coIostomies not closed. Twenty-four coIostomies cIosed TweIve died. . . .. . .
a in-
(six were
intraperitonea1 367
was
DAYS
Minima1 and Maximal Days
Data
cIosure
of
cIosure
There
I
patients
primary
group
IX) one onIy had an
asso-
exteriorization
Ieaks
seventy-six
who had primary (TabIe
renal
compIications.
or anasto-
VIII thirty-six
four
the
-
RESULTS OF MANAGEMENT in TabIe
two
anastomotic
These of
procedures.
As indicated
obstructions
surgery,
misceIIaneous
other assorted
recovery
7
and two were cause
and
per
27 18 rg
TABLE VII LENGTH OF HOSPITALIZATIONIN
vent-
morbidity
and
(with
deaths,
with exteriorization
exteriorization.
cIosure
the
with
Deaths
76
intestina1
subsequent
Of the ten patients
and
cIosure
by primary
smaI1
required
twenty-one
of initia1 hospitaIizawith
two
represented
a mor-
coIon injury
(one subphrenic,
death),
which
foIIowed
coIon
to those treated
advantage
mosis
of
frequency
occurred,
between
VII the Iength
is compared ing
abscesses
cent).
and diaphragm.
with
No.
Primary cIosure.. . CoIon aIone. . . CoIon pIus one other viscus. Colon pIus two other viscera. CoIon pIus three other viscera.. CoIon pIus four other viscera. CoIon pIus five other viscera Colon plus six other viscera. 1 Exteriorization.. CoIon aIone.. CoIon pIus one other viscus Won pIus two other viscera. CoIon plus three other viscera. CoIon pIus four other viscera. CoIon pIus five other viscera. Primaryvent.................... CoIon alone.. CoIon pIus one other viscus CoIon pIus two other viscera. CoIon pIus three other viscera. CoIon pIus four other viscera. CoIon pIus five other viscera. CoIon plus six other viscera.
trauma.
In TabIe tion
cases
deaths
cent.
in
per cent),
pancreas
the interreIationship associated
the
per
37.9
(tweIve
patients
onIy, of
fre-
was
next
forty-four
trauma
most
were
to Iiver
6.9
The
injuries
then stomach,
40.0 12.5
structure or
cases or 18.3
.
-
cases
injuries
cent),
2 I
2 I 0 2
(fifty
(twenty-four
Data
-_
soIitary coIon or recta1 injury. quentIy
Per cent
Deaths
44 50 IO 12 IO
SpIeen................ Kidney ............... Diaphragm. ........... Duodenum. ........... Great vessek. ......... Bladder. .............. Ureter. ............... SpinaIcord ............ Extremities. ........... MisceIIane0u.s. .........
T
Per :ent
1No.
Data
TABLE VI ASSOCIATEDTRAUMA
AverN”,“. of Days
3 to 84 4to 41
15.4 21.8
5 to 60 13 to 92 1 to 37
25.2 36.4 10.0
1
Vannix, Carter, Hinshaw and Joergenson TABLE RESULTS
TABLE IX
VIII
IN SEVENTY-SIX PRIMARY CLOSURES
Data
UneventfuI recovery. Deaths..................... Complications. Wound infection. Intraperitoneal abscess.. Anastomotic Ieaks.. IntestinaI obstruction. Renal faihrre. MiscelIaneous.
No. of Patients
RESULTS
IN
TEN
PRIMARY
CLOSURES
EXTERIORIZATION
T I?er cent
WITH
No. of 1Per cent Patient! s
Data
-36 5 40 27 5 4 2 2 21
“~:~ 5.3
one death (IO per cent). The probIem of handling the exteriorized coIon is dificult [IO]. Of the ten cases exteriorized six had dehiscence of the closure with the formation of a coIostomy, thus converting them to a vent at the site of the injury. OnIy four were repIaced without having to open the coIon, one of which cIosure sites reperforated after it was repIaced and required another exteriorization with the patient eventuaIIy dying. Seventeen compIications occurred in the nine remaining patients. There were four intraperitonea1 Ieaks either at the site of cIosure of the injury or after a subsequent coIostomy cIosure (an incidence of 40 per cent Ieaks). One patient had a subphrenic and cuI-de-sac abscess which required drainage. EarIy smaI1 bowe1 obstruction occurred in two patients, which required operative decompression. Another patient had coIon obstruction due to tension of exteriorized coIon over the supporting rod. Nine miscelIaneous complications occurred. In the forty-six cases in which a primary vent was utiIized (TabIe x), eight patients (17.4 per cent) had an uneventfu1 recovery. EIeven deaths occurred (23.9 per cent mortaIity rate). Wound infection occurred in twenty-one cases. CoIostomy probIems deveIoped in ten patients (21.7 per cent) incIuding skin autodigestion, pericolostomy abscess and proIapse; three coIostomy cIosure Ieaks, smaI1 bowe1 obstruction, gangrene of coIostomy, and three coIostomy closure strictures. Other compIications incIuded four smaI1 bowe1 obstructions which required Iaparotomy, three patients with intraperitonea1 sepsis (subphrenic abscesses), and twenty-four misceIIaneous complications.
Uneventful recovery. . Deaths........................ Exteriorized cIosure replaced as foIIows: RepIaced without having colostomy....................... Required colostomy through exteriorized segment. CoIon reperforated after repIacemerit........................ CompIications. . Subphrenic and cuI-de-sac abscess........................ Small bowel obstruction requiringsurgery.................. CoIon obstruction at exteriorization site.. Anastomotic Ieaks.
I
10.0
I
10.0
4
.
.
6
. . .
.
.
40.0
MisceIIaneous -
ANALYSIS
OF PRIMARY
CLOSURE
DEHISCENCE
AND DEATHS
There were four anastomotic Ieaks with two survivorsamongtheseventy-sixpatients treated by primary cIosure. One was a thirty-seven year oId man who had a stab wound of the transverse colon and a feca1 impaction. It subsequentIy disrupted, requiring reoperation with exteriorization and eventua1 recovery. Another instance was a twenty-seven year oId man TABLE RESULTS
IN
FORTY-SIX
X PRIMARY
VENTS
ResuIts
Uneventfuf recovery. . Deaths......................... Comphcations. CoIostomy problems (proIapse, frstuIization, abscess, gangrene)...................... Wound infection. . Small bowe1 obstruction.. IntraperitoneaI sepsis. Anastomotic Ieaks.. MisceIIaneous..
8 II 36
17.4 23.9
10 21 4 3 4 24
21.7
.
8.7 I
368
SurgicaI TABLE
Management
XI
CAUSE OF DEATH IN PRIMARY CLOSURES
-
-
Mechanism
Cause of death
IlljUry
-_ Gunshot wound
Transverse colon and four other viscera ErtraperitoneaI rec. turn during pelvic exenteration Rectosigmoid perforation Cecum. ileum, and [ spinal cord
Operative Foreign body Gunshot wound Gunshot wound
Transverse colon and five other viscera
-
Acute renal faiture
Acute pyelonephritis Generalized peritonitis Suture line dehiscence with fecal peritonitis and sepsis Exsanguination due to acute hemorrhagic pancreatitis and liver necrosis with disruption of colon closure
-
with a gunshot wound of the extraperitonea1 ascending colon in whom a fistuIa deveIoped, which required a right coIectomy before fina recovery. The two deaths with anastomotic disruption are Iisted in TabIe XI. AI1 five deaths are, aIso, analyzed in TabIe XI. DEATHS
IN
PRIMARY
EXTERIORIZATION VENTING
CLOSURE AND
WITH
PRIMARY
PROCEDURES
The one death in the primary cIosure with exteriorization group was due to dehiscence of the suture Iine when the coIon was repIaced. Of the eIeven deaths with primary venting procedures, nine were caused by massive injury or generaIized peritonitis and were not reIated to operative error. A fifty-three year oId man with a rectosigmoid foreign body perforation had a wound evisceration and died from cardiac arrest at surgery. A fifty-seven year old man had blunt trauma injury with Iaceration of the extraperitonea1 rectum treated by coIostomy and died of an unreIated aspiration probIem.
of CoIon Trauma jority of battIefieId coIon wounds requires an exteriorization approach, whereas a Iarge percentage of civilian coIon injuries may be accompanied by less IocaI tissue destruction and are adaptabIe to primary cIosure. It is of interest to note that there were four patients (5.3 per cent) who had a dehiscence of the primary suture Iine. Two of these died, but the other two were successfuIIy managed, one by a coIostomy and the other by right coIectomy. Wound infection proved to be a common compIication in primary cIosure. Of ten patients who had primary cIosures of their coIon perforation associated with exthere were four instances of teriorization, suture-Iine dehiscence. There were frequent complications associated with the coJostomy in the primary vent and exteriorization groups. SUMMARY
AND
CONCLUSIONS
This study is an anaIysis of the management of 138 cases of coIon and recta1 trauma. Primary cIosure was used in seventy-six instances with a mortaIity of 6.6 per cent; it is considered to be the treatment of choice when circumstances permit [7-91. When coIon wounds are accompanied by extensive IocaI tissue injury or massive feca1 peritonitis, primary venting procedures are recommended. AIthough selected wounds of the extraperitonea1 rectum may be treated by primary repair, the majority require proxima1 coIostomy and perinea1 drainage [IO-141. Extensive muItipIe organ trauma and associated diseases are serious factors in prognosis. REFERENCES
BOWERS, W. F. Surgical treatment in abdominaI trauma: a comparison of resuIts in war and peace. Military Med., I 18: g, 1956. 2. COLCOCK, B. P. Battle wounds of the colon and rectum. Mil. Surgeon, 109: 688, 1951. 3. HURT, L. E. The surgica1 management of coIon and recta1 injuries in the forward areas. Ann. Surg., 122: 398, 1945. of penetrating 4. POER, D. H. The management abdominal injuries. Ann. Surg., 127: Iogz. 1~8. 5. ISAACSON, J. E., BUCK, R. L. and KAHLE, H. R. Changing concepts of treatment of traumatic injuries of the coIon. Dis. Colon @ Rectum, I.
COMMENTS
The effective routine use of exteriorization procedures during WorId War II and the Korean conff ict had a widespread inff uence in civilian practice. However, as the differences between military and civilian injuries have been evaIuated, it has become evident that a different approach shouId be considered in nonmiIitary hospitak. The massive tissue injury a.nd devitalization which characterizes the ma-
4:. 168,
1961.
PATTON. R. T. and LYONS. C. The treatment of traumatic injuries of the coIon. Trauma, I : 298, 1961. 7. PONTIUS, R. G., CREECH, 0. and DEBAKEY, M. E. Management of Iarge bowe1 injuries in civilian practice. Ann. Surg., 146: 291, 1937.
6.
369
Vannix,
Carter,
Hinshaw
8. ROOF, W. R., MORRIS, G. C. and DEBAKEY, M. E.
Management of perforating injuries to the coIon in civiIian practice. Am. J. Surg., gg: 641, 1960. 9. WOODHALL, J. P. and OCHSNER,A. The management of perforating injuries of the coIon and rectum in civiIian practice. Surgery, 29: 305, 1951. IO. PILCHER,L. S. Wounds of the colon and rectuma critica anaIysis of current methods of surgica1 treatment with emphasis on detaiIs of surgica1 technique. Mil. Surgeon, 104: 188, 1949. I I. LAUFMAN,H. The initial surgical treatment of penetrating wounds of the rectum. Surg. Gynec c Obst., 82: 219, 1946. 12. NEVIN, I. N., SENIEK, I. E. and JOHNSON,A. G. Foreign-body penetration of the rectum. New England J. Med., 264: 1127, 1961. 13. TURELL, R., KRAKAUER, J. S. and MAYNARD, A. CoIonic and anorecta1 function and disease. Surg. Gynec. FY Obst., 96: 313, 1953. 14. WECKESSER, E. C. and PUTNAM, T. C. Perforating injuries of the rectum and sigmoid coIon. J. Trauma, 2: 474, 1962.
DISCUSSION JACK FARRIS (Los AngeIes, CaIif.): I am certain that we are al1 grateful to Dr. Vannix and his associates for this presentation which caIIs our attention to the feasibiIity of definitiveIy treating coIon injuries by primary suture. Those who have done this type of cIinica1 investigation are aware, I am certain, of the enormous amount of effort that goes into the analysis of these data. As you wiI1 recaI1, there were 132 operations performed in 138 patients with twenty deaths, a mortaIity rate in the over-a11 group of about fourteen or 14.5 per cent. Of interest to us today is the group of seventysix patients who were treated by primary cIosure with a mortaIity rate of 6.6 per cent. I am certain that Dr. Vannix did not impIy the Iower mortaIity rate in the primary cIosure group was a direct resuIt of the method of treatment, but rather that this group of patients, nameIy, those without massive tissue injury, without sepsis, and those who have had a short time interva1 between injury and operation, are usuaIIy chosen for this particular modaIity. I have been interested recentIy in reviewing some of the pertinent literature on colon injuries since being given this assignment by Dr. Vannix and his coIIeagues; I was surprised to find numerous references in the Iiterature to the use of primary cIosure in the treatment of coIon injuries. As a matter of fact, OgiIvie in 1944 suggested primary suture particuIarIy for ceca1 wounds and wounds of the ascending colon. Those of us in the European theater during the war treated a11 coIon injuries by coIostomy di370
and Joergenson
version, aIthough we had a tacit agreement that most Iesions of the cecum and the ascending coIon, if at a11 suitabIe, shouId be treated by primary suture or by right coIectomy and iIeotransverse coIostomy rather than by iIeostomy. AIso, I was interested to see that Doctors Christianson, Ignatius and Mathewson had reported a number of patients who had been treated in civilian Iife by primary cIosure with no Ieaks and no deaths. Innes, in 1947, reported twenty-five injuries of the coIon in civiIian practice which were cIosed primarily with no Ieakage and IOO per cent recovery. About forty-seven years ago, a Captain Fraser, who was in the RoyaI Canadian MedicaI Corps, pubIished in Tbe British Medical Journal an extensive experience with 300 abdominaI injuries during WorId War I; he says, in summarizing his experience, that at first he folIowed a practice of a proximal coIostomy in combination with the operation of suture. “There are the obvious advantages that it increases the safety of the suture whiIe it obviates the passage of feca1 matter through the damaged gut. At this time we were suspicious regarding the viabiIity of the Iine of coIon suture, and we felt that coIotomy had a greater security. Later we recognized that the performance of proxima1 coIostomy was rareIy necessary, and we have, therefore, aImost abandoned its use. We now reinforce the suture line by an omenta1 graft. We beIieve that our results have improved since we have aItered our procedure.” This was about fifty years ago. So, I would compIiment the authors on a most carefu1 study of a reaIIy significant number of cases, and I am certain that I can summarize their beIiefs and emphasize that this particuIar maneuver shouId be used onIy in the ideal case, in a case in which there is minima1 tissue injury, when a short time has eIapsed, and where, perhaps, there is a skiIIfu1 surgeon. I wiI1 summarize by saying that, in short, there is a pIace for both methods of treatment, and that the two stage procedures in my opinion aIways wiI1 occupy an important pIace in the armamentarium of the general surgeon. I wouId Iike to close by CompIimenting Dr. Vannix on his beautiful presentation, his exceIIent sIides, and I think he Iends credence to the axiom that a good presentation for its background has lots of preparation. CARLETON MATHEWSON, JR. (San Francisco, Calif.): I hope you wiII forgive me for speaking again, but I, too, wouId like to extend my compliments to the authors and wouId Iike to emphasize the important difference between treating patients with injuries of this type in civiIian Iife and those in wartime. CertainIy, we who see these patients early and are abIe to keep them under constant observation are justified in doing primary cIosures
SurgicaI Management of the coIon. In wartime, however, the transportation probIems and rapid evacuation make it dangerous and, therefore, unjustified. My main reason, however, for speaking is to object to the faith that a great many people have in proxima1 colostomy. A proximal coIostomy does act as a vent and gets rid of gas and pressure, but rareIy gets rid of contamination. One, in treating a sigmoid perforation from a diverticuIitis, frequentIy wiI1 do a transverse coIostomy; often doing the transverse coIostomy on the right side of the colon in order to faciIitate subsequent Ieft coIectomy and re-establishment of continuity. In so doing, one Ieaves a tremendous reservoir of retained feca1 materia1 which continues to con-
of CoIon Trauma taminate the area of perforation. If one does choose to do a proxima1 coIostomy, it should be done in as cIose approximation to the injury as possibIe. DAVID B. HINSHAW (closing): We wouId Iike to thank Dr. Farris and Dr. Mathewson for their kind and thoughtfu1 comments. We wouId agree, strongIy so, that a surgeon shouId be famiIiar with a11 methods of dealing with this type of injury. It is cIear that each case must be individuaIized, and that no “ruIe of thumb” can be Iaid down for the treatment of coIon and recta1 injuries. We appreciate the opportunity to present this paper to the Association.
371