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Chapter 10

Contents

CHAPTER X

Traumatic Evisceration (312 Casualties)

Samuel B. Childs, M. D.

In the 3,154 instances of abdominal injury observed by the 2d Auxiliary Surgical Group during 1944 and 1945, there were 312 traumatic eviscerations (table 19), 126 of which (40.4 percent) were fatal. Evisceration, for the purposes of this discussion, is defined as the protrusion of an abdominal viscus outside of the peritoneal cavity through a missile track which has interrupted the continuity of all layers of the abdominal wall.

TABLE 19.-Distribution of wounds and deaths in 312 traumatic eviscerations in 3,154 abdominal injuries

Organs injured

Cases


Proportion

Deaths

Case fatality rate

 

 


Percent

 

 

Omentum only

86

27.57

32

37.2

Stomach

9

2.88

3

33.3

Stomach, small bowel, and colon

5

1.60

2

40.0

Stomach and colon

2

.64

2

100.0

Stomach and spleen

1

.32

0

0

Small bowel

123

39.43

43

34.9

Small bowel and colon

24

7.69

14

58.3

Small bowel and liver

1

.32

0

0

Colon

38

12.19

21

55.3

Colon and liver

3

.96

3

100.0

Colon and spleen

1

.32

0

0

Liver

7

2.24

3

42.8

Spleen

3

.96

0

0

Not recorded

9

2.88

3

33.3


Total

312

100.00

126

40.4


In this series, the frequency of evisceration of a particular organ apparently varied in relation to (1) its own mobility and volume and (2) the site and size of the missile track. The omentum alone, the small bowel alone, the colon alone, and the small bowel and colon in combination were involved in 86.9 percent of the total number of eviscerations. In 5 injuries (4 involving the small bowel and 1 the small bowel and colon), the protruding abdominal viscus had not been injured. The organ extruded was not recorded in 9 cases.

Exclusive of 25 cases in which the site of extrusion was not recorded and of 86 in which only the omentum was involved, the evisceration occurred in the upper abdomen 75 times, in the lower abdomen 68 times, in the left flank 28 times, the right flank 13 times, the left chest 10 times, the right chest 3 times, the right side of the back twice, and the left sacral region and the left buttock


174

in 1 case each. If the wound of entry in perforating wounds was sufficiently large, evisceration sometimes occurred through it. More often it occurred through the wound of exit. Sometimes a wide-open track was found between the wounds of entry and exit.

The wounding agent, which was recorded in 299 cases, was a shell fragment in 171 cases, a small-arms bullet in 97, and a mortar, bomb, grenade, or mine fragment in the remaining 31 cases.

CASE FATALITY RATE IN RELATION TO SHOCK AND PERITONITIS

In 86 cases, 32 of which (37.2 percent) were fatal, only the omentum protruded from the abdomen. The 24 deaths which occurred in this group by the end of the second postoperative day were all attributed to shock. Two deaths in this group (6.3 percent of the total number) which occurred on the ninth postoperative day were attributed to peritonitis; perforations of the stomach and the colon were also present in both. Four patients in this group died of other causes, and in two instances (also 6.3 percent of the total number) the cause of death was not recorded. The proportion of the 32 deaths attributed to peritonitis (6.3 percent), corrected for the 2 no-record cases to 6.7 percent, did not exceed the case fatality rate for peritonitis (12.3 percent) in the whole group of 3,154 cases (p. 208). The data suggest that evisceration of the omentum alone introduced no additional factor of contamination and was significant only in relation to the severity of the abdominal wound.

In the 226 cases in which an abdominal organ other than the omentum was extruded, there were 94 deaths (41.6 percent). All but 2 of the 61 deaths which occurred by the end of the second postoperative day were caused by shock (table 20). The 10 deaths caused by peritonitis accounted for 10.6 percent of the 94 fatalities, corrected for no-record cases to 11.6 percent. This rate approximated the case fatality rate for peritonitis (12.3 percent) in the whole group of 3,154 cases.

The single fatality in the 5 cases in which there was no injury to the extruded viscus (in all instances intestine) occurred on the fourth postoperative day and was caused by a massive pulmonary embolism. Whether evisceration occurred in this group of casualties at the time of wounding or subsequently was not known. It seems significant, however, that, whatever the duration might be, none of these 5 patients exhibited signs of clinical shock either when they arrived at the field hospital or during their later postoperative course.

CASE FATALITY RATE IN RELATION TO MULTIPLICITY FACTOR AND TIMELAG

An analysis of the 298 cases in which sufficient data were available for this purpose (1) indicated that the multiplicity factor played the same significant role in the case fatality rate for traumatic eviscerations as for other groups of injuries (table 21), and (2) further supported the concept that this


175

TABLE 20.-Primary cause of death and time of death in 94 traumatic eviscerations1

Cause

Deaths


Proportion


Postoperative day

2d

3d

4th

5th

6th

7th

8th

9th

After
 9th


Not recorded

 

 

Percent

 

 

 

 

 

 

 

 

 

 

Shock

59

62.8

59

---

---

---

---

---

---

---

---

---

Peritonitis

10

10.6

---

2

---

1

1

1

2

1

2

---

Anuria

5

5.3

---

---

3

1

---

---

1

---

---

---

Pulmonary embolism

4

4.2

---

---

1

1

1

---

1

---

---

---

Pneumonitis

3

4.2

---

1

---

2

---

---

---

---

---

---

Empyema

1

4.2

---

1

---

2

---

1

---

---

---

---

Thrombosis, inferior mesenteric vein

1

1.1

1

---

---

---

---

---

---

---

---

---

Brain injury

1

1.1

1

---

---

---

---

---

---

---

---

---

Intestinal obstruction

1

1.1

---

---

---

---

1

---

---

---

---

---

Jaundice, edema

1

1.1

---

---

---

---

---

---

1

---

---

---

Not recorded

8

8.5

---

2

1

2

---

---

---

---

2

1


Total

94

100.0

61

5

5

7

3

2

5

1

4

1


1The 32 fatal cases in which only the omentum was extruded are excluded from this table.

factor is a satisfactory index of the severity of battle-incurred abdominal injuries.

The influence of the timelag is by no means as clear cut as is the influence of the multiplicity factor (table 22). Variations in the case fatality rate suggest that other factors played a part. Two are immediately apparent:

1. A large proportion of severely wounded men seen after a short timelag had wounds whose lethality was not altered by surgery.

2. Men who were more lightly wounded (relatively or absolutely) died after a longer timelag and in smaller numbers. Probably not all of the casualties with traumatic eviscerations would have died within a 10-day period if they had not been operated on, and certainly surgery could not alter the essentially lethal nature of the wounds sustained by many of the severely injured casualties.

TABLE 21.- Combined influence of evisceration and multiplicity factor on case fatality rates in 3,129 abdominal injuries

Organs injured

Without evisceration


With evisceration

Cases

Deaths

Case fatality rate


Cases

Deaths

Case fatality rate

None

287

21

7.3

5

1

20.0

One

1,253

177

14.1

95

24

25.2

Two

913

247

27.1

101

38

37.7

Three

279

119

42.7

71

43

60.5

Four

81

48

59.3

15

11

73.3

Five

16

16

100.0

7

5

71.4

Six

2

2

100.0

4

4

100.0


Total

2,831

630

22.3

298

126

42.3


176

TABLE 22.-Influence of timelag on case fatality rates in 203 traumatic eviscerations


Timelag

Cases

Deaths

Case fatality rate

0 to 6 hours

77

29

37.7

6 to 12 hours

94

42

44.7

12 to 18 hours

16

5

31.3

18 to 24 hours

6

2

33.3

Over 24 hours

10

4

40.0


Total

203

82

40.4


In 41 of the 123 instances in which evisceration of the small bowel occurred, only the bowel was extruded, and there were no complicating multivisceral injuries. The bowel itself was injured in all 41 cases, but the absence of the compounding effect of injuries to other structures makes it possible to consider in this group the effects of evisceration per se on the case fatality rate for abdominal injury.

There were 8 deaths, 19.5 percent, among these 41 patients. Four died within the first two postoperative days, in shock, with peritoneal contamination by small-bowel contents perhaps playing some part in the fatality. Two died of peritonitis, on the 8th and 22d days, respectively, after operation. Another died of pneumonia on the 5th day, and the remaining patient died on the same day, of an unstated cause. The timelag in all of these cases was short, the average being 52/3 hours, which shows that it was not necessary to keep the patients in the shock ward for a long time before operation. It also implies priority of evacuation and surgery. In spite of these favorable factors, the case fatality rate in these 41 cases (19.5 percent) was higher than the rate of 13.1 percent for the 314 univisceral injuries of the small bowel in which evisceration did not occur.

This discrepancy suggests that traumatic evisceration is, in itself, a serious type of injury. This is well demonstrated by comparison of the case fatality rates in casualties who did and who did not sustain it. In the first five multiplicity categories (0 to 4 organs wounded), the average increase in rates from category to category when evisceration had occurred was approximately 13 percent (table 21). The trend was reversed when five organs were injured, but the figures are not large enough to be of statistical significance. Apparently evisceration affected the prognosis adversely to approximately the same degree as did the involvement of each additional organ in the multiplicity factor scale (table 21).

The occurrence of traumatic evisceration was also, in general, an indication of the severity of the wound. It was observed in only 1.7 percent of patients having no visceral injury but in 4 out of 6 with 6 viscera damaged (table 21).

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