Treatment of injuries of the large bowel in civilian practice

Treatment

of Injuries in Civilian

NORMAN CHRISTENSEN, M.D., JOSEPH

IGNATIUS, M.D. AKD LRLETON

San Francisco, From tbe Stunford University Surgical Service of the San Francisco City and County Hospital, Department of Public Health, San Fruncisco, CaliJ.

injuries of the Large intestine among the most Iethal of al1 abdominal injuries and present problems distinct from similar injuries to the other viscera. These differences chiefly concern the viruIent nature of the fecal stream, the fixed position of the large intestine throughout much of its course, the wide avenues for retroperitoneal sepsis that may be opened foIlowing injuries to it, and the broad range of intraIumina1 pressures to which it may be subjected, placing undue strain on suture lines. Our present understanding of the management of these serious injuries has come Iargely from experience with battIe casuaIities from the two World Wars. This paper reviews a portion of this experience, particularly that from WorId War II,and discusses twenty-three cases of penetrating injuries of the large intestine encountered during the past twelve years on the Stanford Surgical Service at the San Francisco City and County HospitaI. AIthough the number of cases presented is small compared to the Iarge series reported from WorId War II, it is beIieved that certain factors distinguish these civiIian cases from the military ones. These factors, chieffy, are a shorter time interval between injury and definitive care, the immediate avaiIabiIitv of blood, the use of the broad spectrum antibiotics, the relative infrequency of severe associated injuries, and the continuity of care offered and warrant, in some cases, a departure from the proved Iessons of military surgery and offer a considerably better prognosis. Prognosis is dependent IargeIy on the presence or absence of feca1 contamination, associated injuries and shock. Jarvis4 and others state that gross feca1 contamination is the singIe most IethaI factor. Taylor and ThompERFORATING

P are

of the Large Practice

Bowel

MATHEWSON,

JR., M.D.,

California son8 contrast a mortaIity rate of 65 per cent when fecal contamination was present against one of z$ per cent when it was absent. CoIcock’ has stated that patients dying after the first twenty-four hours do so from sepsis. He cites the possibIe causes of sepsis, other than initial contamination, as: (I) failure to close an unrecognized perforation, (2) secondary perforation with peritonitis from a traumatized area of bowel, (3) faiIure to remove a retroperitoneal foreign body, and (4) the deveIopment of intraperitonea1, lumbar and subphrenic abscesses from retraction of an exteriorized segment of bowel. Associated injuries, of course, adverseIy affect prognosis. CoIcock,’ reviewing the experience from World War II, states that approximately 40 per cent of Iarge bowel injuries had wounds of other intra-abdominal organs and in 30 per cent the small bowe1 was the organ involved. The presence of shock before, during or following surgery indicates a less favorable prognosis. Taylor and Thompson* state that the continuation of shock, once it has been corrected, probabIy indicates continuing disguised hemorrhage, disturbance of the cardiorespiratory mechanism from thoracic injury, massive fecal contamination or earIy, fulminating anaerobic infection with gas-forming organisms. They and others stress that the failure of the patient to respond to adequate shock treatment, or to reIapse after it has been corrected, should not constitute cause for delay in surgical intervention, but on the contrary shoulci point the way to immediate exploration. It is readily apparent that the management of perforating wounds of the colon and rectum has been and is a matter of some controversy. The trend has gone from the wide use of primary suture during WorId War I to the broad apphcation of exteriorization in WorId War II to the present time, when emphasis, at Ieast in civilian cases, is again being pIaced on primary

Injuries

of Large BoweI

suture in seIected cases IargeIy because of the advent of the broad spectrum antibiotics. Essentially four methods of operative management may be empIoyed: (I) primary suture, (2) exteriorization, (3) proximal diversion of the feca1 stream and (4) resection. Primary suture, though non-shocking, involving a considerabIy shortened convaIescence without the necessity of secondary procedures, and performed with ease and speed, has as its major potential disadvantage the danger of breakdown of the suture Iine with resultant feca1 contamination. However, it is of interest, as noted by TayIor and Thompson,* that almost no cases were recorded in WorId War II in which the sutured wound in the coIon broke down, and that the mortality rate was the lowest of any method-22 per cent as averaged from several miIitary series. In generaI, however, primary suture was reserved for wounds of Iesser magnitude. WoodhaII and 0schner12 in 1951 and Tucker and Fey9 in 1954 have shown that primary suture in seIected cases is a sound procedure. Most surgeons with experience in WorId War II have beIieved that exteriorization is the method of choice in combat casualties and was the single most important technica factor contributing to the improvement in mortaIity rate from 60 per cent during WorId War I to 35 per cent in WorId War II.* Exteriorization eIiminates continued feca1 contamination, Ieaves no suture Iine within the abdomen and aIIows for decompression of the boweI through the exteriorized segment. Its chief disadvantage is that the mobiIization required to permit exteriorization of the fixed portions of the coIon can be a shocking procedure in the poor risk patient. There are the additional hazards of severe ceIIuIitis in the broad retroperitoneal planes opened foIIowing mobiiization of the fixed portions of the coIon and of retraction of the exteriorized segment with resuItant fecal contamination of the abdomina1 waI1 or cavity. CoIcockr has categoricaIIy stated that “any perforating wound of the coIon should be exteriorized on the surface of the abdomen or, if this is not feasible, the wound shouId be cIosed and a proxima1 coIostomy performed.” Woodha11 and Ochsner12 advanced the thesis that the writings of the American surgeons with broad miIitary experience inffuenced to a great degree the management in civilian cases with overemphasis on the use of exteriorization.

They made a plea for the more frequent use of primary suture in seIected cases in civiIian practice. ProximaI diversion of the fecaI stream is accompIished by iIeostomy, cecostomy or coIostomy. These stomas, by minimizing or aboIishing the fecaI stream distaIIy and reducing intraIumina1 pressure, protect the wounds and suture lines. IIeostomy is unsatisfactory because of the possibIe severe eIectroIyte and ffuid 10s~. Cecostomy, while decompressing the bowe1, diverts the feca1 stream onIy partiaIIy. Loop coIostomy, though superior to cecostomy in this respect, stiI1 does not defunctionalize the bowe1 completeIy. This may be accomphshed by dividing the bowel and performing doubIe-barrelled spur coIostomy or actuaIIy separating the bowe1 ends several centimeters apart. Diversion of the feca1 stream generahy is used in conjunction with suture of the wound or with IocaI drainage. AI1 authorities agree that resection is best avoided because of its prohibitive mortaIity. It finds appIication chiefly in extensive injuries of the right coIon. The reasons for this are two: first, diversion of the feca1 stream, mandatory in extensive wounds, can be estabIished onIy by iIeostomy, which is objectionabIe because of the danger of severe Auid and eIectroIyte Ioss and the digestive action of ileal drainage on the abdomina1 waI1. Thus, recourse is had to resection and anastomosis. Second, as pointed out by 0giIvie,5 “anastomosis between smaI1 and Iarge bowe1 has few of the risks of coIon-to-coIon anastomosis since the materia1 passing the suture line is fluid, not very infective and flows at an even rate and at Iow pressure.” Taylor and Thompson8 favor ileotransverse colostomy foIIowing resection and recommend that the proxima1 end of the transverse coIon be brought out through a separate stab wound as a safety vaIve. CoIcockr is opposed to anastomosis foIIowing resection of the right colon because it adds considerabIy to the operating time and Ieaves a potentiaIIy dangerous suture Iine within the abdomen. He favors doubIe-barreIed spur iIeotransverse coIostomy and states he has begun destruction of the spur as earIy as the seventh day with subsequent cIosure of the stoma by an extraperitonea1 procedure. It is obvious that a11 these procedures and combinations thereof wiI1 have a distinct place in the management of these wounds. The 754

Injuries of Large BoweI severity and nature of the wound usuaIIy wiI1 dictate which surgica1 principIe is to be used rather than the preference of the surgeon. An extensive, jagged wound of the colon cannot be sutured safely, but ordinariIy must be exteriorized; whereas a small, clean laceration can be sutured primarily with confidence as to the ultimate outcome. Thus the probIem resolves itself into one of surgica1 judgment and case individualization, rather than strict adherence to a particular dictum. The appeal that primary suture has in civilian practice is understandable since considerable priority must be placed on minimizing hospital expense and time lost from work. It is in %t-ounds of the rectum, however, that more rigid operative management is justified. The intraperitoneal rectum cannot be exteriorized and must be handled by suture combined with proximal colostomy. Sometimes it may not be possible to suture the perforation and the suggestion of WaIIace’O may be used. This consists of converting the wound to an cstraperitoneal one by elevating the rectovcsical pouch. The management of this type ol‘ wound \\ ill fje discussed. Simple loop sigmoid colostomy is adequate for all but the most extensive w,ounds in this area, in which event complete diversion of the fecal stream must he established. As cited by Taylor and Thompson,8 the mortality rate in wounds of the extraperitoneal rectum is the lowest for any portion of the Iarge intestine, approximateIy 6 per cent in WorId War II in contrast to World War I when virtually all \vere fatal. The major factor causing death has been fulminating pelvic ceIIuIitis. Treatment embodies two principles: (I) proximal colostomy and (2) drainage of the retrorectal space. Colostomy should provide for complete diversion of the fecal stream. Taylor and ThompsonX favor the Ieft inguinal region as the site for the sigmoid coIostomy. However, if further surgery is contemplated in the future in the left lower quadrant, transverse coIostomy should be performed. Drainage of the retrorectal area is accomplished by an incision Iateral to or below the tip of the coccyx. Coccygectomy is not necessary for adequate drainage and when performed, has been compIicated by osteomyelitis of the sacrum. Whether or not the rectal Lvounds shouJd be sutured apparentIy is not of importancr if the two cardinal principles of adequate local drainage and fecal stream diver-

sion are performed. If the perforation can be cIosed without too much diffIcuIty, it shouId be sutured. Prior to Woodhall and Oschner’s report in mortality rates consistently 195’1” civilian exceeded those of World War II. They reported

No. of Cases

Authors

lllortality (‘; ’

Civilian:

Rippy’.

‘941

EIkin and W,rhz: : I : : Wilkinson. tiiIl and Wright”. M’oodhalI and 0chsner12 Tucker and Feyg. Present series. ‘Ililitnry : 0gilvie5. TayIor and Thompson”. Porritt”

62

: : ‘943

32 ‘7

1946 ‘951 ‘953 ‘954

37 $5 42 23

1944 1948 1946

160

53

70 440

27.

j

i3

I

4i

fifty-five cases with a mortality rate of 20 per cent and advised the use of primary suture in selected instances. In 1954 Tucker and FexY also recommended simple suture in certarn cases, citing reduced mortality and morbidit> figures to back up their advice. (Table I.) Our experience substantiates the tendency in recent years to treat large bowel injuries encountered in civilian practice more radicalI> than those seen in military practice. Between 1942 and 1954, twenty-three consecutive cases of injury of the coIon or rectum were cared for on the Stanford University Service at the County Hospital tvithout a S an Francisco fatality. We believe that a more radical procedure is possible in civilian practice since civilian injuries differ from combat wounds in the following ways: (I) the wounds, as a rule, are less extensive, (2) the time Iag between injury and surgery is shorter, (3) the treatment of shock can be started sooner and carried on more vigorously,

(4) the patient

is under continuous

care by the same physician. The avaiIability of wide spectrum antibiotics assures the success of more radical treatment. Site of I@u_v. Th e sites of injury of the large bowel are shown in Table II. The most common site \Y:LS the transverse colon (ten

Injuries

of Large Bowel Preoperative Preparation, Surgical Treatment and Complications. Shock, which was present in six patients on entry, was corrected prior to surgery. BIood was not given routineIy, but only when indicated by evident hemorrhage or shock. Seventeen patients were given bIood

cases), foIIowed by the sigmoid (five cases) and the rectum (three cases), the spIenic fIexure (two cases) and the cecum, descending coIon and rectosigmoid (each one case). Associated Injuries. In seventeen of the twenty-three cases associated injuries of other TABLE II SITE OF INJURY

Cecum. Ascending

colon.

Hepatic Aexure. Transverse coIon.. SpIenic Aexure, Descending colon. Sigmoid.. Rectosigmoid...................... Extraperitoneal rectum..

TABLE TIME

I o o IO

Time 1-5 hours.. 5-15 hours.. Over 15 hours.

I 5

abdomina1 organs occurred. The smaI1 bowe1 was injured most frequentIy, being invoIved eIeven times. (TabIe III.) Mechanism of Injury. Gunshot wounds (thirteen cases) were the most common mode of injury, foIIowed by stab wounds (eight cases). Two wounds of the rectum were caused by assault. (TabIe xv.) Although by its nature a gunshot wound is apt to be more traumatic than a stab wound, we found no appreciable difference in the compIications or period of convaIescence between the two. TABLE III ASSOCIATED INJURIES OF OTHER ORGANS Small bowe1. II Stomach.......................... I Spleen.. I E;idney........................... 2 Ureter.. 1 Urinary bladder. I

Gunshot

Stabwounds...................... Others.

v INJURY

AND

SURGERY

of Patients 16 3

4

either before or during surgery. We beIieve, as do others, that when shock persists in the face of adequate treatment, it may indicate intraperitoneal hemorrhage or massive feca1 contamination and is an indication for surgery. Preoperative x-rays were taken in fifteen cases. In stab wounds of the abdomen eariy expIoratory Iaparotomy is indicated and IittIe is gained by x-ray examination. The same may be said for gunshot wounds when a wound of exit is present. When onIy the wound of entry is visibIe, Iocalization of the missiIe by x-ray examination may be heIpfu1 in plotting its course. When bIadder wounds are suspected and Iaparotomy is indicated, cystograms are unnecessary since the bIadder can be expIored through the surgical incision. Eight of our patients were treated by suture aIone; these a11 heaIed uneventfuIly. Three were treated by suture with proxima1 cecostomy, four by suture with proximal colostomy, four by exteriorization, one by coIostomy alone, one by resection and proxima1 cecostomy, one by colostomy and drainage of the retrorectaI and retroperitoneal spaces, and one (an injury of the rectum just above the mucocutaneous Iine) by dkbridement of the wound, but no surgery on the bowe1. (TabIe VI.) In three instances there was gross feca1 contamination of the peritonea1 cavity. Two of these healed uneventfuIIy; in the third a peIvic abscess devetoped and was drained. Retention sutures were used in eIeven of the twenty-two cases operated upon. One wound dehiscence occurred in a patient without retaining sutures. Postoperative wound infections deveIoped in six patients, an incidence of ~5 per cent. In three cases evidence of peIvic inffammation occurred. In two of these the mass subsided spontaneousIy and in the third case, which was

I 3

23

TABLE Iv MECHANISM OF INJURY wounds.

BETWEEN

No.

2

-

INTERVAL

13 8

z

Age and Sex of Patients. The ages of the patients varied from seventeen to fifty-four years, with an average of thirty; a11 but four patients were men. Interval between Injury and Surgery. The great majority of patients (sixteen cases) were taken to surgery within five hours of injury. AI1 but four were operated upon within ten hours. These four were treated surgicaIIy sixteen, forty-three, forty-eight and fifty hours after injury. (TabIe v.) 756

Injuries of Large BoweI mentioned previousIy, it was necessary to drain the abscess. One patient sufl’ered with a pulmonary emboIus eight days after surgery, from which he recovered. One other patient had a prolonged convalescence because of atelectasis, a 1‘ABLEVI METHOD

OF

TKEATMENT

8

Primary suture.. Suture and proximal cecostomy. Suture and proximal colostomy.. Exteriorization. Resection with proximal cccostomy Colostomy and drainage of retrorectal space (rectal injury). Local dkbridement (recta1 injury). Colostomy aIone (rectal injury)

3 4

4 I

I I I

poorly functioning coIostomy and a proIonged paralytic ileus. He also recovered. (TabIe VII.) In oniy one instance was the type of complication dependent upon the method of Iocal treatment of the bowel. In this instance the patient sustained severe Iacerations of the rectum during an assauIt. Although she was pIaced on antibiotics, the recta1 injuries were not treated surgicaIIy until twenty-four hours after entry. By this time infection had ascended TABLE VII CO~lPLICATIOiXS Wound infection Pelvic inflammatory mass. Abscess, retroperitoneal PuImonary embolus.. Dehiscence. Poorly functioning colostomy, sis..

6 3

I I I atelccta.I

along the perirectal space into the retroperitonea area and ceIIuIitis of the retroperitonea1 space was visibIe at exploration. In spite of the establishment of coIostomy and drainage of the retroperitoneal and retrorectal spaces, a retroperitoneal abscess deveIoped which Iater had to be drained. The proper treatment in this case wouIc1 have been immediate surgery with construction of coIostomy and drainage of the retrorectal space. During the preparation of the patient for surgery a thorough search for the wound of exit or a foreign body under the skin shouId be undertaken in order to avoid needIess x-ray examinations and harmfuI movement of the patient. An inlying catheter shouId be inserted if there is the sIight.est suspicion of a bIadder injury. Whenever a recta1 injury is suspected, both digital and proctoscopic examination shouId be undertaken.

COMMENTS

Eight of our twenty-three cases were treated by suture aIone. These a11 heaIed uneventfuIIy. In Iight of this experience a review of the treatment employed in each of our early cases made it evident that simpIe cIosure might we11 have been empIoyed in seven additional patients without undue risk. SimpIe suture can be performed easily and quickly-. Its success is made possibIe by the use of wide spectrum antibiotics. When used in properly seIected cases, it cuts operative time, reduces the number and extent of operations and decreases the length of hospital stay for the patient. SUMMARY

I. Most smaI1, grossly clean wounds of the large bowel may be sutured and returned to the abdomen without the estabIishment of proximal colostomy. 2. Large, grossIy contaminated wounds are best treated by exteriorization when feasible. 3. Resection of the unprepared large bowel should be avoided whenever possible. 4. RetroperitoneaIcontaminatedareasshouId be drained through the flank; however, drainage of the peritoneal cavity per se should be avoided. 5. All wounds of the extraperitoneal rectum should be drained posteriorly by opening the retrorectal space in the hoIIow of the sacrum through the rectococcygeal ligament. 6. Exploratory wounds of the abdomen in the face of gross feca1 contamination should be closed with retention sutures and the skin left open for secondary closure. REFERENCES B. P. Battle wounds of colon and rectum. 1!4il. Surgeon, 109: 688-693, 195 I. 2. ELKIN, D. C. and WARD, W. C. Gunshot wounds of the abdomen. Ann. Surg., I 18: 780-787, 1943. 3. IVES, P. K. U’ar surgery of the abdomen. Surg., G~nec. (:* Ok., 81: 608-616, 1945. 4. J.~RVIS, F. J., BYERS, W. L. and PLATT, E. V. Experience in the management of the abdominal wounds of warfare. Surg., Gynec. ti* Obst., 82: I.

COLCOCK,

5.

OCILVIE,

174-193.

1946.

II.: AbdominaI wounds in the western desert. Surg., G~inec. @ Obst., 78:‘229-238, 1944. 6. PORRITT. A. E. Survev of abdokina1 wounds in 21 Army group. Brit. 3. Surg., 33: 267-274, 1946. 7. KIPPEY, E. L. The management of perforating gunshot wounds of the abdomen. South. Surgeon. 10: 441-m450, 1941.

757

W.

Injuries of Large BoweI 8. TAYLOR, E. R. and THOMPSON, J. E. The eady treatment, and results thereof, of injuries of the colon and rectum, with 70 additiona cases. Surg., Gynec. w Obst., 87: 105-122; 209-228,

I I.

1948. g. TUCKER, J. W. and FEY, W. P. The management of perforating injuries of the coIon and rectum in civihan practice. Surgery, 35: 213-220, ‘954. IO. WALLACE, C. A study of 1,200 cases of gunshot

wounds of the abdomen. Brit. J. Surg., 4: 679, 1917. WILKINSON, R. S., HILL, L. M. and WRIGHT, L. T. Gunshot wounds of the abdomen. Surgery, rg:

415-429, 1946. 12. WOODHALL, J. P. and OCHSNER, A. The management of perforating injuries of the coIon and rectum in civilian practice. Surgery, 29: 305-320, ‘95’.

758