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Chapter 17

Contents

CHAPTER XVII

Wounds of the Stomach (416 Casualties)

Luther H. Wolff, M. D.

An analysis of the 416 wounds of the stomach (table 38) which occurred in the 3,154 abdominal injuries treated by the 2d Auxiliary Surgical Group during 1944 and 1945 makes three points clear:

1. Wounds of this organ were considerably more frequent than they had heretofore appeared to be.

2. They were complicated by injuries to other viscera in 9 out of every 10 cases.

3. The case fatality rate in gastric injuries (40.6 percent) was significantly higher than it was in injuries of the colon, small intestine, liver, spleen, or genitourinary tract (q. v.).

TABLE 38.-Essential data in 416 wounds of stomach

Type of wound

Cases


Frequency

Deaths

Case fatality rate


In 3,154 abdominal injuries

In 416 gastric injuries

 

 


Percent

Percent

 

 

Univisceral

42

1.3

10.1

12

28.6

Multivisceral

374

11.9

89.9

157

42.0


Total

416

13.2

100.0

169

40.6


One hundred and ninety-six of these gastric injuries (47.1 percent) were produced by missiles which traversed the diaphragm. There were 85 deaths in these thoracoabdominal injuries (43.4 percent). In the remaining 220 cases, the projectiles entered or traversed only the abdominal cavity. There were 84 deaths in this group (38.2 percent).

In addition to the unexpectedly high frequency of injuries of the stomach in relation to total injuries in this series, the ratio of univisceral to multivisceral wounds is at marked variance with data reported in other series of abdominal wounds (table 39). The frequency was nearly twice as great as that previously reported. Actually, this is what might be expected. As has been pointed out (p. 92), the incidence of wounding of any organ is almost directly proportional to the space which it occupies. It follows, therefore, since the stomach 


224

is a relatively large organ, that it would be injured fairly frequently. Furthermore, the frequency of wounding was probably even higher than is indicated by these figures, which take no account of casualties who died before reaching a field hospital.

TABLE 39.- Comparative distribution of wounds of stomach in various recorded series of abdominal injuries1

Source

Total series


Wounds of stomach

Multivisceral wounds of stomach

Cases


Frequency (total series)

Cases

Frequency (wounds of stomach)

 

 

 

Percent

 


Percent

World War I: 

 

 

 

 

 

    

American

(2)

144

7.0

48

33.3

    

British

965

82

8.5

26

31.7

Spanish Civil War

238

20

8.4

(2)

(2)

World War II:

 

 

 

 

 

    

British3

628

29

4.6

15

51.7

    

2d Auxiliary Surgical Group

3,154

416

13.2

374

89.9


1The American World War I figures are from the Medical Department of the United States Army in the World War (Washington: U. S. Government Printing Office, 1927, vol. XI, pt. 1, pp. 65, 457, 458). The British World War I figures were reported by Cuthbert Wallace in War Surgery of the Abdomen (London: J. & A. Churchill, 1918). The Spanish Civil War series was reported by Douglas W. Jolly in Field Surgery in Total War (New York: Paul B. Hoeber, Inc., 1941). The British World War II figures were reported by W. H. Ogilvie in Abdominal Wounds in the Western Desert (Surg., Gynec. & Obst., March 1944).
2Not stated.
3Western Desert combined series.

The marked predominance of multivisceral over univisceral wounds is also what might be expected. Univisceral wounds are naturally infrequent in an organ almost completely invested by the liver, spleen, colon, and kidneys. It is believed that the figures for this series more nearly approach both the true frequency of wounds of the stomach and the true ratio of univisceral and multivisceral gastric injuries than any statistics previously reported, if only because in World War II more casualties survived to undergo surgery than in any previous war.

DIAGNOSTIC CONSIDERATIONS

Experience showed that only two signs could be regarded as conclusive in the preoperative diagnosis of a wound of the stomach. One was the emission of undigested food from an abdominal wound. The other was the actual observation of a perforation or laceration in an eviscerated stomach. In the absence of these two signs, the diagnosis was only presumptive.

According to the literature, vomiting is a cardinal sign of a wound of the stomach. An analysis of these 416 gastric wounds does not support this observation. Vomiting was no more frequent in wounds of the stomach than


225

in wounds of other abdominal viscera. It was actually recorded only 7 times in the 416 cases, and inquiry of resuscitation officers and of surgeons in the group revealed that none of them considered it an outstanding or a reliable sign of gastric injury.

Blood in the vomitus or in the aspirated gastric contents was, however, regarded as both suggestive and reliable. It was noted altogether in 41 wounds of the stomach (4 times in vomitus), and constituted a valuable clue to the nature of the injury when blood swallowed in wounds of the head, neck, or lungs could be ruled out. The absence of blood was not recorded consistently, being mentioned only eight times. The negative observation, even when it was recorded, was obviously of no diagnostic value.

The preoperative passage of a Levin tube, in the opinion of the surgeons of the group, not only did no harm in suspected wounds of the stomach but was, on the contrary, a useful diagnostic and therapeutic measure. The risk of introducing possible contamination to the injured site was far outweighed by the relief of the accumulations of gas and fluid which were common in gastric and other abdominal injuries and whose persistence led to increased leakage of gastric contents and more serious peritoneal contamination.

Leakage of gas from the damaged stomach was sometimes a valuable diagnostic sign, though it could also produce a variety of confusing but interesting clinical pictures. Thus subcutaneous emphysema of varying degrees was at times observed in the abdominal and chest walls, and in some instances gas actually bubbled from the abdominal wound. If the gastric wound were thoracoabdominal, gas from the stomach might escape into the pleural cavity through the lacerated diaphragm and produce pneumothorax.

Pneumoperitoneum was a matter of record in only six of the roentgenograms taken in wounds of the stomach. This is a deceptively low figure, since 90 percent of all casualties with abdominal wounds had preoperative roentgenographic examinations. The circumstances, however, were not conducive to precise roentgenography. All the examinations were made with portable apparatus. Practically always, as a concession to pain and shock, the patients were not moved from the supine position. Lateral views were impractical and were seldom attempted. Finally, conditions for both development and interpretation of the films were difficult. Under the circumstances, there is no doubt that a gas bubble lying free in the peritoneal cavity was sometimes overlooked.

In some cases, as soon as the peritoneum was opened, the surgeon was greeted by a rather disconcerting gush of air. It was often difficult to determine whether it originated in the stomach or from the chest, through a perforation of the diaphragm, and careful exploration was necessary to determine its origin. The presence of gas in the abdomen also introduced still another diagnostic problem-the possibility of an anaerobic infection. Crepitus and discoloration of tissues might be the result of gas and leakage of acid secretions from a perforation of the stomach, but it might also be explained by an early infection of this kind.


226

The preoperative diagnosis of a wound of the stomach depended chiefly on visualization of the course of the missile and the application of accurate anatomic knowledge concerning the location of the organ. In the great majority of these wounds, the location of the wounds of entry and exit-if the injury was perforating-and the location of the wound of entrance, combined with localization of the missile by two-plane roentgenography-if the injury was penetrating-permitted an accurate preoperative diagnosis.

Variations in the shape of the stomach and the position of the soldier at the time of wounding (p. 100) naturally complicated the diagnosis, as the following case history indicates:

Case 1.-A prisoner of war was seen in a field hospital with a wound of entrance in the left hip just above the head of the femur and a wound of exit in the right hip through the wing of the ilium. A low midline exploratory incision disclosed multiple perforations of the small bowel and sigmoid colon. It also, rather unexpectedly, disclosed a severe laceration of the stomach some 4 inches above the upper end of the midline incision. Reconstruction of the injury suggested that the stomach was in the lower abdomen at the time of wounding, the man undoubtedly being crouched over in the position a combat soldier automatically assumes when he is under fire.

NATURE OF THE INJURY

Wounds of the stomach varied widely in type (table 40). In 16 cases, the wound was a simple tangential laceration of the stomach wall, without penetration into the lumen. At the other extreme were 5 cases in which the violence of the trauma resulted in complete transection of the organ. In the remaining cases, the wound varied from a trivial perforation to a laceration 20 cm. long. 

A fair proportion of the wounds were caused by small missiles, which perforated one or both walls of the stomach in a nearly perpendicular plane. Perforations of this kind often caused little or no peritoneal contamination from gastric leakage, since the redundant gastric mucosa tended to act as a valve and seal off the injury. Shock was not usually severe. A fairly large number of such injuries accounted for the relatively low case fatality rate in perforating wounds of the stomach (table 40). In contrast, missiles which entered the wall of the stomach at an acute angle were likely, regardless of their size, to produce

TABLE 40.- Case fatality rates in relation to type of injury in 416 wounds of stomach

Type of injury

Cases

Deaths

Case fatality rate

Perforating

258

91

35. 3

Laceratingl

117

71

60. 7

Not stated

41

7

17. 1


Total

416

169

40. 6

1Includes 5 complete transections.


227

extensive lacerations. Leakage was profuse, peritoneal contamination was severe, and the case fatality rate was correspondingly higher (table 40). Larger missiles tended to produce lacerating wounds, which were potentially more lethal, and part of the difference in the case fatality rates of perforating and lacerating wounds can be explained on this basis.

TIMELAG AND THE MULTIPLICITY FACTOR

As has already been mentioned (p. 217), the timelag was of the utmost importance in individual wounds of the viscera. In the whole series of 416 injuries, however, it did not seem of serious significance unless the analysis also took into account such other considerations as the multiplicity of visceral injuries, the number and character of associated injuries. and the degree of peritoneal contamination.

Univisceral wounds of the stomach (table 41) were so few (42, 10.1 percent) that their analysis from the standpoint of the timelag would be of no statistical importance. This is, also as already noted, a considerably lower frequency than is reported in any other comparable series. The case fatality rate, 28.6 percent, was surprisingly high. Although the multiplicity factor (p. 111) was found to be a more reliable prognostic index in abdominal injuries than any other factor, the general rule that the greater the number of organs injured, the higher the case fatality rate (fig. 21, p. 108) did not hold in wounds of the stomach in the first two multiplicity categories (table 41). It is true that in a category of only 42 univisceral wounds, statistical error is likely. On the other hand, an analysis of the 12 deaths in these 42 injuries seems to provide a clue to the lethality of a type of wound which in other structures was attended with a proportionately lower case fatality rate. This analysis showed that 7 of the 12 deaths in univisceral gastric injuries occurred either on the day of operation or within the first 2 days after operation, and that the cause was recorded in every instance as shock or shock and peritonitis. In two other cases, death occurred from peritonitis, one on the fourth and one on the eighth postoperative day. Another death was caused by peritonitis and a gastric fistula on the 15th postoperative

TABLE 41.-Influence of multiplicity factor on case fatality rates in 416 wounds of stomach

Organs injured

Cases


Deaths

Case fatality rate

Stomach only

42

12

28.6

Stomach and 1 viscus

174

47

27.0

Stomach and 2 viscera

112

44

39.3

Stomach and 3 viscera

50

29

58.0

Stomach and 4 viscera

23

23

100.0

Stomach, other viscera, and great vessels

15

14

93.3


Total

416

169

40.6


228

day. One of the two remaining deaths was caused by secondary hemorrhage from the stomach, on the 14th postoperative day. In the other case, no cause of death was stated. These are small figures and of no statistical significance, but a clinician cannot fail to be impressed by the causes and time of death and by the number attributed to shock.

In multivisceral injuries (table 42), the liver, as might be expected, was most frequently involved, with the colon and the spleen next in order. Concomitant injury to the colon produced the highest case fatality rate except for concomitant injuries to the great vessels. The latter were almost universally fatal (table 41).

One extremely significant fact in the analysis of these multivisceral wounds was the discovery that treatment had been successful in certain combinations of wounds which up to this time had been uniformly fatal. Bailey,1 for instance, stated in 1942 that in the past no combination of wounds involving the stomach, small intestine, and colon had ever been successfully treated. In the 24 injuries of this kind in this series, in 11 of which the liver was also injured, there were 15 survivals.

TABLE 42.-Case fatality rates in wounds of stomach complicated by wounds of other viscera1

Organs injured

Cases


Deaths

Case fatality rate

Stomach only

42

12

28.6

Stomach and liver

67

20

29.9

Stomach and spleen

42

8

19.0

Stomach and colon

24

11

45.8

Stomach, colon, and liver

18

9

50.0

Stomach, liver, and spleen

17

5

29.4

Stomach and jejunum

16

4

25.0

Stomach, jejunum, and colon

13

4

30.8

Stomach, jejunum, colon, and liver

11

5

45.5

Stomach and kidney

10

3

30.0

Stomach, jejunum, and liver

9

3

33.3

Stomach and ileum

7

0

0

Stomach, colon, and spleen

6

2

33.3

Stomach, jejunum, and kidney

6

2

33.3

Stomach, spleen, and kidney

6

2

33.3

Stomach and pancreas

6

1

16.7

Stomach, colon, and kidney

5

5

100.0

Stomach, colon, liver and spleen

5

2

40.0

Stomach, liver, and pancreas

5

1

20.0


1This table does not include combinations of visceral wounds which occurred less than 5 times each. It also does not include 2 injuries of the stomach and duodenum in which both patients survived and 2 injuries of the stomach and great vessels in which both patients died.

1Bailey, Hamilton: Surgery of Modern Warfare. Edinburgh: E. & S. Livingstone, 1941-42.


229

ASSOCIATED INJURIES

About a quarter of the 416 casualties with wounds of the stomach also had severe extra-abdominal injuries. Forty-three presented major fractures, forty-one major soft-tissue injuries, nine major amputations, nine injuries of the spinal cord, four injuries of the brain, and four injuries of the heart. The chest injuries present in thoracoabdominal wounds were, strictly speaking, separate associated lesions, and their presence apparently produced a 5-percent increase in the case fatality rate in this group. An evaluation of the effect of the associated injury and its influence on morbidity and case fatality rates would require a case-by-case analysis. Generally speaking, the rate among patients with associated injuries did not differ significantly from that of patients without them, though the fallacy of the application of such a generalization to the individual case is obvious.

TECHNICAL CONSIDERATIONS

The transdiaphragmatic approach to wounds of the fundus and body of the stomach (table 43) greatly facilitated the repair of injuries in these areas, both the anterior and posterior surfaces of the fundus being accessible through the incision without opening of the peritoneal folds. It is, therefore, not surprising that this incision was used in 119 (60 percent) of the 196 thoracoabdominal injuries. Eventually, it became the incision of choice in selected cases, though it was used in only one instance in which there was not a perforation of the diaphragm. In that type of injury, a vertical incision in the upper abdomen was preferred.

The gastrocolic omentum was incised routinely at operation, to permit examination of the posterior gastric wall. Whether operation was done from above or from below the diaphragm, this was a most important step of the procedure in patients known or suspected to have sustained gastric injuries.

TABLE 43.-Distribution of surgical approaches in 412 wounds of stomach1


Approach

Cases

Percentage

Laparotomy

293

71.1

Transdiaphragmatic:

 

 

    

Thoracotomy

95

23.1

    

Combined laparotomy and thoracotomy

18

4.4

    

Thoracolaparotomy2

6

1.4


Total

119

28.9


Grand total

412

100.0


1Information is lacking on this point in four cases.
2By this technique, the thoracic incision is extended across the costal arch onto the abdominal wall.


230

Simple suture, which was used in 409 of the 416 injuries of the stomach, was regarded as the procedure of choice, even in extensive lacerations. Resection was required in the five cases in which transection of the stomach was complete. The Polya or Hofmeister technique was used in three cases, all of which were fatal, and end-to-end anastomosis in the other two, one of which was fatal. 

Perforations of the stomach were overlooked at operation in the two remaining cases in the series. One of the patients died of a gastropleural fistula; the other died of embolism. At autopsy, the overlooked perforations were discovered; they had closed spontaneously, without apparent leakage, and had not contributed to the fatal outcome.

The type of suture closure, as well as the kind of suture material, varied with the preference of the individual surgeon. Except that purse-string suture proved unsatisfactory, as will be pointed out shortly, variations in technique seemed to make no difference in the outcome of the case.

In six cases, all simple perforations, severe postoperative hemorrhage occurred from the stomach. This was the largest number of postoperative hemorrhages encountered in the entire series of 3,154 abdominal injuries. Three patients died. Two survived under conservative management, and the other recovered uneventfully after a secondary operation to control bleeding. 

It is significant that in all six instances of postoperative bleeding, closure had been by reenforced purse-string suture. This method can produce circumstances ideal for the development of hemorrhage. Since the suture seldom, if ever, includes the gastric mucosa, the mucosal edges retract. As a result, the blood vessels which traverse the submucosa are exposed, and the resulting pathologic picture simulates that of acute peptic ulceration. Erosion of the previously sealed underlying vessels, and subsequent hemorrhage, are therefore possibilities whenever this method is used. The following case history illustrates this fact:

Case 2.-A soldier with multiple wounds from shell fragments, including a left thoracoabdominal wound, was admitted to a field hospital in excellent general condition. Transdiaphragmatic repair of a single perforation of the upper portion of the stomach was carried out by means of a purse-string suture through a left thoracotomy incision. The operation was performed without complications, and convalescence was smooth until the fifth postoperative day, when evidences of internal bleeding were observed. When laparotomy was resorted to, after 7 hours of conservative therapy, the stomach was found to be completely occupied by a clot estimated to contain 1,500 cc. of blood. After the clot had been removed, the site of perforation and suture was inspected from the mucosal side. The surgeon's notes adequately explained the hemorrhage: "A white indurated area is seen from which the mucosa is retracted. From the edges, in two places, are seen continuous but small streams of blood, one venous and the other arterial. This ulcer-like area, then, is the cause of all bleeding." Excision of the affected area and closure of the wound were followed by an uneventful recovery.

This report and others like it led to certain technical changes:

1. Every effort was made to approximate the gastric mucosa by suture in all wounds of the stomach.


231

2. Small perforations were enlarged transversely so that the mucosal layer could be exposed and accurately sutured.

3. Purse-string suture was no longer employed in wounds of the stomach.

POSTOPERATIVE COMPLICATIONS

As already noted, practically every patient who died within the first 48 hours after operation as the result of a wound of the stomach presented the clinical picture designated under the generic term "shock." All had sustained extensive tissue damage, massive blood loss, disturbed pulmonary physiology, peritoneal contamination of varying degrees, or combinations of these conditions. Persistent shock resulting from these conditions is, strictly speaking, a postoperative complication, but it is not classified as such in this discussion because of the time of its occurrence. Actually, it was part of the original pathologic process.

Of the complications which occurred later than 48 hours after operation, by far the commonest were pulmonary. In fact, pneumonia (12 cases), empyema (11 cases), and atelectasis (6 cases) accounted for approximately 40 percent of the serious complications seen after this time. Peritonitis was observed in 6 cases, 5 of which were fatal. In all instances, it was of the usual clinical (bacterial) type.

CASE FATALITY RATE

The data analyzed in this section bear out the initial statement that wounds of the stomach, whether univisceral or multivisceral, are among the most serious injuries encountered in warfare (table 44). Some perforations were comparatively trivial, but the leakage of acid gastric contents into the general peritoneal cavity was always serious and was likely to be associated with a high degree of shock. In general, patients with wounds of the stomach exhibited a much more severe degree of shock than those with other abdominal wounds. In 22 cases (13 percent of the fatalities) death occurred on the operating table; death occurred in the course of operation in only 11 percent of all other fatalities in the total series of abdominal injuries. The 115 fatalities (68 percent of the total deaths from wounds of the stomach) which occurred by the end of the second postoperative day were chiefly attributable to shock alone or in association with peritonitis and, to a lesser degree, other complications, or to overwhelming peritoneal contamination.

In 12 of the 416 casualties with wounds of the stomach, the records contributed nothing concerning the presence or absence of shock. In 66 other cases, the patients were either in no shock at all or in incipient shock. One hundred and three of the remaining patients were in mild shock, one hundred and six in moderate shock, and one hundred and twenty-nine in severe shock. The unusually high proportion of casualties in moderate and severe shock can be explained, at least in part, by the spillage of acid gastric contents into the


232

general peritoneal cavity. There seems no doubt that whenever spillage of such contents occurred, an immediate chemical peritonitis ensued, which quickly produced either shock or a shocklike state and which was entirely different from the bacterial peritonitis observed in later stages of the injury in patients who survived.

TABLE 44.- Primary cause of death in relation to time of death in 169 wounds of stomach

Time and cause of death


Cases

On operating table:

 

    

Shock

13

    

Shock and hemorrhage

5

    

Shock and atelactasis

1

    

Shock and gas gangrene

1

    

Shock and peritonitis (contamination)

1

    

Cardiac

1


Total

22

Through second postoperative day:

 

    

Shock

43

    

Shock and peritonitis (contamination)

28

    

Shock and hemorrhage

4

    

Shock and atelactasis

3

    

Shock and anaerobic infection

2

    

Peritonitis (massive contamination)

9

    

Peritonitis (massive contamination) and pneumonia

2

    

Peritonitis (massive contamination) and intestinal fistula

1

    

Pulmonary embolism

1


Total

93

After second postoperative day:

 

    

Peritonitis (bacterial)

5

    

Peritonitis (bacterial) and shock (all third day)

8

    

Peritonitis (bacterial) and pneumonia, empyema, or pleurisy 

12

    

Anuria

10

    

Pneumonia

6

    

Hemorrhage, secondary

3

    

Pneumothorax and pleurisy

3

    

Intestinal or gastric fistula

2

    

Brain injury

1

    

Not stated

4


Total

54

Another possible explanation of shock in wounds of the stomach originates in anatomic considerations, that the stomach overlies a highly vascularized area in which are located the celiac axis, the aorta, the inferior vena cava, and


233

the portal vein, and that massive hemorrhage is therefore frequently associated. Although this is theoretically sound reasoning, hemorrhage in gastric wounds did not appear to be more severe than in numerous other visceral wounds in this series. The part which it played in the production of shock was often difficult to evaluate, it is true, but in the usual wound of the stomach it seemed to be secondary in importance to peritoneal contamination.

After the second postoperative day, peritonitis and pulmonary complications were the most important causes of death (table 44). The case fatality rate among casualties with lacerating wounds was almost double that among those with perforating wounds (table 40), the explanation probably being that all patients with lacerating wounds suffered massive peritoneal flooding with acid stomach contents, which presumably happened in a much smaller proportion of those with perforating wounds. The high case fatality rate among patients with univisceral wounds of the stomach (table 41) is further proof of this hypothesis. Although the relative vascularity of the stomach and the adjacent structures theoretically should play a part in the lethality of gastric wounds, the collective clinical observations of the 2d Auxiliary Surgical Group did not support this point of view.

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