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Surgical Considerations in the Treatment of War Wounds of the Rectum and Rectosigmoid Colon

Medical Science Publication No. 4, Volume 1

FRIDAY MORNING SESSION
23 April 1954

MODERATOR
LIEUTENANT COLONEL CARL W. HUGHES, MC


SURGICAL CONSIDERATIONS IN THE TREATMENT OF WAR WOUNDS OF THE RECTUM AND RECTOSIGMOID COLON*

LIEUTENANT COLONEL H. HASKELL ZIPERMAN, MC

Introduction

Wars tend to increase in lethality through the discovery of new weapons of destruction and the application of old concepts of warfare in a newer and more deadly fashion. Always parallel with and tending to act as a limiting factor in this destructiveness is the introduction of new medical and surgical principles which save life and decrease morbidity. That this applies is shown by the decreasing mortality among casualties reaching medical attention in World War II as compared with the Korean war-4.5 percent in the former as compared with 2 percent in the latter.

In the Korean war, principles of the management of battle casualties learned in preceding wars were applied. Changes were made as experience and new technics necessitated. Since the war-free interval from the end of World War II to the beginning of the Korean conflict was short, much of what was learned in the former was applied in the latter with little change. This was especially true in the handling of casualties with penetrating wounds of the abdomen and perforations of bowel. That some changes were made will be evident by comparing this paper with the discussion of rectal and rectosigmoid injuries in TB Med 147.

Diagnosis

Perhaps the first clue found in a casualty who had suffered a penetration of the rectum or rectosigmoid was the site of the wound of entrance, and in some cases the location of the wound of exit. It was possible by projection in cases with wounds of exit and entrance to mentally visualize the missile tract and coupled with physical findings to determine the organs damaged. All penetrating perineal, buttocks, and low abdominal and back wounds were considered as potential sources of wounds of the rectum and rectosigmoid until proven otherwise.


*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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When first seen, the patient with a penetrating wound of the peritoneal cavity with massive fecal contamination of the peritoneum presented a picture of shock which was difficult to differentiate from that due to severe blood loss. In fact, in cases with wounds of the peritoneal cavity the attempt to make this clinical differentiation was purely academic since exploration was essential to determine the true extent of involvement and to institute proper treatment. It was generally agreed by all surgeons in the Korean Theater that the most profound and unresponsive shock picture seen among battle casualties was that among wounded with severe and continuing hemorrhage and those with massive fecal contamination of the peritoneal cavity.

The shock picture in the patient with an extraperitoneal perforation of the rectum was totally different. Here the casualty was rarely in shock unless there were associated injuries of sufficient severity to cause a marked drop in blood pressure. As can be surmised, it was impossible to determine bowel perforation on the basis of shock alone.

In the emergency surgical hospitals in the combat zone in Korea as soon as the possibility of peritoneal penetration was entertained, a Levin tube was introduced into the stomach both to ascertain whether bleeding was present and to empty the stomach; a catheter was introduced into the urinary bladder to rule out damage to the genitourinary tract; and inspection, palpation, percussion and auscultation of the abdomen were carried out. Typically the casualty with intraperitoneal perforation of the gastrointestinal tract showed mild to moderate abdominal distention associated with tympany, abdominal rigidity and absent bowel sounds. Clinically it was difficult to determine whether the abdominal distention was due to paralytic ileus with accumulation of gas, intraperitoneal hemorrhage, or both. Some of these casualties were in such a severe state of shock that all muscular tonus was decreased and consequently no abdominal splinting was present.

In wounds of the extraperitoneal portion of the rectum there was rarely any abdominal distention unless there was an associated perforation of the bladder or great vessels so that low abdominal distention was produced by extravasation of blood or urine or both into the pelvic tissues and peritoneal cavity. This extravasation was rare and easily differentiated from true abdominal distention.

As frequently as not a digital rectal examination added considerable information with regard to lower colon and rectal perforation and associated injuries of pelvic structures. The presence of blood in the cul-de-sac could be determined by bulging into the rectum. A low rectal perforation could actually be palpated in this manner. In any instance where blood was found on the palpating finger when withdrawn, it had to be assumed that either a rectosigmoid or rectal


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perforation existed since rarely did perforations higher in the descending colon produce blood in the rectum in the short time elapsed between wounding and admission to the surgical hospital in the Korean experience.

X-ray examination was considered to be the best adjunctive method for determining which organs and viscera had been damaged. For good localization, both AP and lateral examinations were essential. Knowing the site of the wound of entrance, it was possible, on the basis of the position of the retained metallic foreign bodies in relation to the known position of organs and viscera, to determine at least moderately well which structures had been damaged. Where there was both a wound of entrance and exit, the position of retained metallic foreign bodies allowed for a reasonably accurate estimation of the structures damaged. Where multiple wounds were present, as so frequently happened, it was difficult to determine which retained missile was responsible for the particular wound but here its localization in the vicinity of a specific structure was helpful in determining the particular structure injured.

In those casualties in whom all other methods of determining whether a vital structure was injured had failed, it was found that débridement of the wound tract proved to be particularly useful. This maneuver consisted in débriding the successive layers of the wound until the missile was found and removed, or until it was determined that penetration of the peritoneal cavity existed or that a vital structure was injured. This procedure was an adjunct to definitive laparotomy and was performed prior to that surgery and after the casualty had been prepared as if for definitive surgery. This maneuver was reserved only for casualties in whom there was a question of penetration of the peritoneal cavity or of injury to a vital structure in the pelvis and saved time and morbidity since an unnecessary laparotomy was thus avoided.

Sigmoidoscopic examination as a means of making the diagnosis of rectal injuries was used as an adjunct to all of the other modalities of diagnosis. All casualties with wounds of the pelvis and buttocks and those in whom blood was found on the examining finger on digital rectal examination were subjected to sigmoidoscopy. These patients were prepared for laparotomy but sigmoidoscopy was done prior to definitive surgery by placing them in the Sims' position on the operating table. This procedure was found to be especially useful in those individuals with an extraperitoneal perforation of the rectum since extensive dissection and mobilization of the rectum could usually be avoided when the exact site of perforation was known in advance. In the presence of blood on the examining glove after digital rectal examination, a negative sigmoidoscopic examination was never taken


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as evidence that rectal injury did not exist, since the blood could either have been from a point which could not be reached by the scope or a perforation might have been overlooked during the examination.

In the ultimate analysis the only absolute method of determining rectal or rectosigmoid injury in a battle casualty whose symptoms and signs were questionable was by performing a laparotomy. While it is true that occasional unnecessary laparotomies were thus performed, these were held to an absolute minimum by first utilizing all of the other diagnostic modalities in each case.

Treatment

It was found expedient in performing a laparotomy on casualties to adopt a relatively standard routine for exploration. Knowing the wound of entrance and having received information from x-ray examination as to the position of fragments within the peritoneal cavity, it was easy to decide where the first focus of attention should be placed on opening the peritoneum. In every instance where a large amount of free blood was found in the peritoneal cavity, it was felt to be expedient to search first for the bleeding source so that it could be controlled by hemostat or pack depending on the amount of blood being lost and the source of the bleeding. Having controlled the bleeding point, attention was then paid to the intra-abdominal organs. A start was made at the point where known injury existed. As soon as the extent of injury at the wounding site had been determined, the entire small bowel was quickly run from the ligament of Treitz to the ileocecal valve, or vice versa, with each perforation being marked. Where indicated by the known path of the missile and its tract, both ascending and descending colon were then reflected towards the midline so that retroperitoneal as well as peritoneal surfaces of the bowel could be examined. In all instances in which injury to the rectum or rectosigmoid was expected but not found, it was deemed advisable to open the pelvic peritoneum and to mobilize and explore the rectum in the hollow of the sacrum. Where carried out, this procedure was performed in such a manner as to allow adequate visualization of all surfaces of the rectum down to the point of attachment of the levator ani muscles.

In all instances where a perforation of the rectum or rectosigmoid was found, all other pelvic viscera, including the urinary bladder, ureters, accessory genital organs and great vessels were visually inspected because of the frequent association of injuries of these structures with wounds of the colon in this region. It was axiomatic that where a single perforation of a hollow viscus was found a second perforation likewise would be found unless the surgeon could prove to his satisfaction either that the injury was due to concussion, that


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only penetration had occurred and the fragment was retained within the hollow viscus, or that a glancing wound with single penetration had occurred.

Whenever a wound of the rectum or rectosigmoid was found, it was felt advisable to close the perforation in two layers if at all possible. Where a large segment of rectosigmoid was destroyed it was occasionally necessary to effect closure by a sleeve type of resection, reestablishing continuity by mobilizing the proximal bowel so that suturing could be done without tension.

Since most of these wounded had fecal material in the colon at the time of wounding, it was usual to find fecal contamination of the peritoneal cavity in casualties with wounds of the rectum and rectosigmoid. It was deemed advisable where contamination of the peritoneum had occurred, to wipe the area free of gross material but not to drain the area after suture of the bowel. Where the wound was extraperitoneal, the peritoneum was closed after exploration and suture of the bowel, and the pre-sacral space was drained, bringing the drain out at a point just anterior to the coccyx. It was necessary at times to remove the coccyx to secure adequate drainage. Where it was felt advisable to do so, a tract for the drain was established in the pre-sacral space from above and the drain inserted by incising the skin from below at the conclusion of the laparotomy.

The use of colostomy as an adjunct for treatment of wounds of the colon became well established during World War II and was carried over into the Korean war. Wounds of that portion of the colon which could be treated by exteriorization of the perforated colon over a glass rod were routinely handled in this way. Wounds of the rectum or rectosigmoid where exteriorization could not be accomplished were treated by a proximal diverting colostomy with the proximal loop being placed caudad to the distal one. It became routine during the Korean war to bring out the sigmoid colon as a diverting colostomy through a left McBurney muscle-splitting incision. The loop was actually divided, the clamps being left in place to keep the ends of the bowel closed, and the ends were separated by closing at least peritoneum and skin between them. It was felt that this served to prevent any spill of feces from the proximal to the distal bowel. No attempt was made to produce a spur for later crushing. Although some surgeons brought the two ends of bowel out through individual stab wounds separated by at least 2 to 3 inches of intact skin, it was felt that this maneuver served to make ultimate closure of the colostomy more difficult unless the two stab wounds were carefully placed with respect to the direction of the line of fibers of the fascial layers. Sutures were never used between the bowel and the abdominal wall for fear of placing the sutures too deep and causing a fecal fistula.


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Instead, dry gauze was placed around the exteriorized bowel near its termination to prevent it from retracting into the peritoneal cavity. The clamp was left across the proximal bowel end for at least 24 hours to assure an adequate seal between the parietal peritoneum and the bowel serosa. The colostomy wound was separated from the laparotomy wound by means of water-tight dressings, and in those instances where an associated bladder injury was present necessitating a drainage of the space of Retzius, care was taken to bring this out through a stab wound completely separated from all other incisions.

The vogue, so popular in World War II, of dusting sulfa powder and/or antibiotics liberally into the peritoneal cavity was completely discontinued during the Korean war without deleterious effect. Because of the availability of antibiotics at all echelons of medical care in Korea, all casualties received penicillin at the same time they received their tetanus toxoid at battalion aid stations. Most of these casualties received 600,000 units of procaine penicillin as an initial dose but in the closing months of the war some question arose as to whether or not an effective blood concentration could be produced by this dosage and it was finally decided to increase this initial dose to 1 million units of crystalline penicillin.

When casualties with penetrating abdominal wounds and intra-peritoneal trauma were received and operated upon at surgical hospitals in Korea, a routine part of their postoperative care consisted in the administration of antibiotics. Almost without exception the parenteral use of penicillin was continued, potentiated either by streptomycin or intravenous aureomycin or terramycin, depending on the specific preference of the surgeon. While earlier in the war the combination of penicillin and streptomycin was used almost to the exclusion of other antibiotics, during the last year of the war more and more surgeons were shifting to the combination of penicillin and either aureomycin or terramycin. Without the availability of statistical data, it is impossible to state whether this produced any significant change in morbidity or mortality figures. Again some question arose as to the efficacy of the antibiotics used in the dosages administered. A research team in the area in the closing months of the war recommended larger dosage in order to obtain more effective blood concentrations of the various antibiotics.

Mistakes and Complications

Perhaps the commonest mistake seen in the handling of casualties with wounds of the rectum and rectosigmoid colon in the Korean Theater was lack of recognition that this type of wound was present. This oversight was encountered most frequently in those casualties who had suffered retroperitoneal trauma so that the site of injury


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could not be seen unless the bowel was mobilized. Commonly this resulted in a pelvic or pararectal abscess, as frequently as not associated with a fecal fistula along the missile tract. In at least one instance known to the author this resulted in a peritonitis with adhesions and repeated obstructions of the small intestine.

Less frequent were those instances in which the pre-sacral drain was not placed deep enough in the pelvis or where by some oversight the pre-sacral space was not drained at all. These errors commonly led to deep retroperitoneal or pararectal suppuration so that adequate drainage had to be instituted. In a few instances, after débridement of the missile tract, drains had been placed down to the rectum or rectosigmoid along these tracts. This type of drainage especially in those casualties in whom the wound of the colon was not sutured led to a particularly intractable sinus tract infection with prolonged morbidity and convalescence.

Occasionally an inexperienced surgeon would bring at least the distal colostomy loop out through some part of the laparotomy wound. Almost inevitably this led to wound infection and breakdown. It was therefore felt to be absolutely mandatory to insist not only that the colostomy be brought out through a separate incision but that it also be separated from the laparotomy wound by some type of waterproof dressing.

The problem of adequate diversion of the fecal flow in wounds of the rectum and rectosigmoid was not solved until midway through the Korean war. It was found that the term "diverting colostomy" meant different things to different surgeons. After several casualties with rectal wounds were found to have simple loop colostomies with no diversion of the fecal stream from the suture line in the bowel, it was felt necessary to insist that diverting colostomies be so constructed that the two bowel ends were separated by 2 or more inches. General acceptance of this procedure decreased markedly the incidence of fecal fistula resulting from spillage of fecal material from the proximal into the distal bowel.

In the last three wars in which the United States has engaged, there has been a progressive decline in the mortality rate among battle casualties reaching medical attention. The exact reason for this decline is hard to pinpoint but most observers are in agreement that two of the more important factors are availability and utilization of various antibiotics, and speedy, nontraumatic evacuation of seriously wounded casualties to surgical hospitals. (The time lag between wounding and surgery of 58 casualties in World War II was 15.2 hours as compared with 9.95 hours for 62 casualties in the Korean war.) Although statistics for this latest war have not yet been analyzed, it is probably logical to assume that along with the overall


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decrease in mortality there was probably also a decrease in the mortality associated with wounds of the rectum and rectosigmoid colon. Due credit for the methods of handling this type of casualty must be given to the surgeons of World War II who evolved so much of this routine of management by trial and error based on experience.

References

Bradford, B., Jr., Battle, L. H., Jr., and Pasachoff, S. S.: Abdominal Surgery in an Evacuation Hospital. Ann. Surg. 123: 32, 1946.

DeBakey, M. E., and Simeone, F. A.: Battle Injuries of the Arteries in World War II, Ann. Surg. 123: 534, 1946.

Department of the Army Technical Bulletin, TB Med. 147: 12, 1951.

Haffner, H., and Lynn, R. B.: The Closure of Colostomies. Ann Surg. 127: 243, 1948.

Holder, H. G., and Lewison, E. F.: Management of Colostomies Performed for War Injuries. Ann. Surg. 126: 253, 1947.

Pearson, R. W., Tuhy, J. E., and Welch, C. S.: Abdominal Surgery in the Evacuation Hospital. Surgery 21: 1, 1947.

Poer, D. H.: The Management of Penetrating Abdominal Injuries. Ann. Surg. 127: 1092, 1948.

Sperling, L., Bosher, L. H., and Zimmerman, H.: Surgery of War Wounds of the Abdomen. Surgery 21: 258, 1947.

Ziperman, H. H.: Acute Arterial Injuries in the Korean War. Ann. Surg. 139: 1, 1954.