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Chapter 19

Contents

CHAPTER XIX

Wounds of the Jejunum and Ileum (1,168 Casualties)

W. Philip Giddings, M. D., and John R. McDaniel, M. D.

Between 1 January 1944 and 8 May 1945, the surgeons of the 2d Auxiliary Surgical Group treated 1,168 casualties with injuries of the jejunum and ileum, of whom 345 (29.5 percent) died (table 50). These 1,168 injuries represent 37.0 percent of the 3,154 abdominal injuries observed over the period of time stated.

TABLE 50.- Essential data in 1,168 wounds of jejunum and ileum

Type of wound

Cases

Frequency

Deaths

Case fatality rate

In 3,154 abdominal injuries

In 1,168 jejuno-ileal injuries

 

 

Percent

Percent

 

 

Univisceral

353

11.2

30.2

49

13.9

Multivisceral

815

25.8

69.8

296

36.3

Total

1,168

37.0

100.0

345

29.5


NATURE OF INJURY

Included in these injuries of the jejunum and ileum are six in which the abdominal wall was not penetrated. All were incurred in vehicular accidents and all resulted in rupture of the small bowel. Another patient, who sustained a severe transfixing thoracoabdominal wound, was injured when he was impaled on the stump of a small tree by the blast of an exploding shell. With these seven exceptions, all the wounds in the series were caused by high-explosive fragments or missiles from small arms. There were no bayonet or stab wounds. 

The lesions varied from pinpoint perforations and small contusions to extreme maceration and destruction of the greater portion of both ileum and jejunum. For convenience of discussion, the injuries have been classified under four headings: (1) Injury to the intestinal wall, (2) injury to the mesentery, (3) perforating injury, and (4) transections (table 51). Wide extremes of severity were noted in each group, and as a rule 2 or even 3 lesions were seen in combination.


242

TABLE 51.- Frequency of various types of injury in 1,168 wounds of jejuno-ileum

Injury

Cases

Injuries

Average frequency per case

Injury to intestinal wall

27

31

1

Injury to mesentery1

30

30

1

Perforation2

1,083

4,589

4

Transection

213

361

2


1Severe enough to require resection.
2The arbitrary figure of 5 was used when perforations were recorded as "multiple," without statement of the precise number. Whenever the precise number was recorded, it was used.

Injury to the intestinal wall-Trauma to the intestinal wall included contusions and lacerations of the serosal or seromuscular coats which did not perforate the mucosa. This type of injury was not frequent (table 51). Contusions, which were seldom more than 2 cm. in diameter, varied from areas of slight ecchymosis to circumscribed areas of gangrene. A contusion of the bowel wall implied, by its very nature, that the missile which had caused it had reached the end of its flight and was traveling at such low velocity that its impact against the intestine was sufficient to stop it. In this type of injury, the missile either was embedded in the wall of the bowel or lay free in the peritoneal cavity. 

Lacerations of the intestinal wall were caused by tangential impact, and no inferences are, therefore, permissible concerning the velocity of the causative missile. They usually occurred in association with perforations of the lumen in other portions of the bowel. Theoretically, a laceration might be of any length. Practically, in the absence of a perforation, it was seldom more than 2 cm. long. Some lacerations were merely breaks in the serosa. Usually there were evidences of contusion about the margins of a laceration, and the laceration-contusion type of injury was considered a potential site for future perforation.

Injury to the mesentery-Injuries of the mesentery occurred both at the mesenteric attachment and at a considerable distance from the bowel. They varied from small hematomas or peritoneal lacerations to rents which extended across the mesentery to its root. Some damage to the adjacent mesentery nearly always occurred in transections of the bowel and in perforations involving the mesenteric border. Bleeding had usually ceased when the casualty was first seen, but in some instances bleeding was still active.

Perforations of the mesentery other than those adjacent to injuries of the bowel were frequent. They were usually simple through-and-through holes. Hematomas were sometimes present also, but in the majority of cases there was no indication that a vessel of major consequence was involved. The incidence of mesenteric damage sufficiently extensive to necessitate intestinal resection was remarkably low; in all 1,168 injuries of the jejunum and ileum there were only 30 cases in which resection was required because of vascular impairment


243

from mesenteric injury. The circumstances of this type of injury, including the effects of energy transmitted to the tissues and the natural tendency to clot formation in a lacerated blood vessel, would be expected to produce thrombosis. Thrombi were commonly found protruding from the ends of severed vessels in the mesentery, even when the vessels were of considerable size, but the thrombotic process was invariably restricted to the immediate area of damage. There was no instance in the series of extensive mesenteric thrombosis (in the usual clinical sense of the term) in which the pathologic process could be regarded as caused primarily by trauma to the mesentery.

Perforating trauma of the intestine-By far the commonest type of injury to the small intestine was perforation into the lumen. This occurred in 1,083 of the 1,168 injuries, and multiplicity was the rule, the average number of perforations per case being four (table 51).

Small perforations occasionally seemed to have been caused by indriven fragments of bone, especially when the missile had entered the abdomen through the ilium. Generally speaking, the size and shape of the rent in the bowel were determined by the corresponding characteristics of the missile, as well as by its velocity and the direction of its flight. Through-and-through perforations and complete transections were both frequent.

Under some conditions of injury, isolated perforations might be found at a considerable distance from the major trauma, though as a rule multiple injuries were in close proximity to each other, and damage was ordinarily confined to a segment 1 or 2 feet in length, or even less. These phenomena were explained by the fact that in the usual case, intestinal damage was caused by a single missile, the effect of which was confined to its line of flight. Scattered perforations were caused by missiles which traversed major diameters of the abdomen; by separate missiles with different wounds of entry; or by multiple fragments which, though they entered through a common wound, pursued divergent courses within the abdomen.

Individual lesions varied from tiny holes to gashes 6 inches or more in length. When the perforations were of any size, the findings were similar. The tissues about the edges were contused and ecchymotic. The margins were jagged. Mucosa usually pouted from the wound. Bleeding from the intestinal wall was sometimes free, and considerable amounts of blood were seen in the peritoneal cavity when the bowel wall was the only apparent source of hemorrhage. Small perforations were sometimes almost completely sealed off by pouting mucosa, so that there was a minimum of soiling of the cavity. In such cases, there was a bluish discoloration of the bowel, from intraluminal bleeding. Less commonly, blood and intestinal contents were extensively spilled from small perforations, as in the following case:

Case 1.1-A 29-year-old infantryman was wounded by a machinegun bullet which entered the left lower abdomen. The ilium was fractured at the wound of entrance and the greater trochanter of the left femur was fractured at the wound of exit. When the patient was

1This case appears in table 54 as case 18.


244

admitted to a field hospital 20 hours later, he was in severe shock and was anoxic and disoriented.

Operation was performed 23.5 hours after wounding, after the administration of 1 unit of plasma and 5 pints of blood. Although the injury was limited to a single small perforation of the jejunum, which was readily repaired by suture, a generalized, fulminating peritonitis was already present, and the surgeon noted on the operating sheet that the spillage of intestinal contents was the most extensive he had ever seen.

After operation, the patient remained extremely toxic. Oliguria developed and progressed to anuria. Death occurred on the eighth postoperative day. Post mortem examination revealed an acute, fibrinopurulent generalized peritonitis, with a right-sided subphrenic abscess.

Transection.-Transections of the intestine, which were fairly common (table 51), represented the extreme form of perforations of the jejunum and ileum. The most characteristic feature of these injuries was that they were nearly always accompanied by extensive spillage.

State of the peritoneum-The small bowel is well vascularized, and the frequency of hemoperitoneum in injuries of the jejunum and ileum was consistent with that fact. In some instances, 2,000 cc. of blood, or more, were in the peritoneal cavity, usually as the result of massive bleeding from the mesentery. At the other extreme, bleeding was occasionally minimal.

The peritoneal cavity was usually contaminated to some degree with contents of the small bowel, though in an occasional case no gross soiling was apparent. The degree of contamination was usually compatible with the size and number of the perforations. The peritoneal reaction was fairly constant in relation to the time at which surgery was undertaken. When operation was performed within 6 hours of injury, there was usually no visible reaction. Violent exudative peritonitis was the rule only in patients seen after a relatively long timelag (12 hours or more). In casualties who survived longer than 24 hours without operation, early walling off of the perforation with loops of adherent bowel was likely to have occurred. These findings, of course, were not invariable. Severe generalized peritonitis was sometimes seen in patients treated early, and localization was also occasionally seen in early cases. Definitive peritonitis was recorded at operation in only 50 of the 353 univisceral wounds of the jejuno-ileum, a figure which is undoubtedly too low.

Evisceration.-Evisceration of the jejunum and ileum occurred in 153 instances in the whole series of 3,154 abdominal injuries. Trauma to the involved bowel or its mesentery required repair in 126 cases. In the remaining cases, evisceration was incidental and required no treatment other than reduction. In only one instance was resection necessary because of strangulation of the eviscerated loop.

Associated injuries-Two hundred and fifty-two of the 1,168 casualties with injuries of the jejunum and ileum had major associated peripheral wounds, and 202 had minor associated wounds. Another 143 casualties had penetrating or perforating wounds of the thorax, of which 94 (8.0 percent of all injuries of the jejuno-ileum) were thoracoabdominal. About half (597) of all the casual-


245

ties with injuries of this portion of the small bowel thus had associated wounds, about two-thirds of which (395) were of a major character.

DIAGNOSIS

The preoperative diagnosis of wounds of the jejunum and ileum was made chiefly on probabilities. There were no criteria by which their existence could be established or excluded before operation. Indriven fragments of bone and the concussive effect of missiles passing extraperitoneally were known to cause perforation or rupture, and whenever these circumstances were present it was not regarded as safe to assume that the bowel had not been injured. Diagnosis, therefore, was usually established or, occasionally, disproved by exploration of every case in which the circumstances of wounding and the clinical signs and symptoms indicated possible intra-abdominal injury.

PREOPERATIVE ROUTINE

The preoperative management of wounds of the small intestine differed in no respect from the preoperative management of other abdominal injuries. An essential part of the routine was the introduction of a Levin tube into the stomach, followed by aspiration of the gastric contents.

TREATMENT

Certain general principles were universally followed in the management of wounds of the jejunum and ileum. These included nontraumatic handling of all tissues, maximum protection of the bowel from exposure, the use of fine suture material, and as rapid operation as was consistent with thorough exploration and necessary repair procedures. In many instances, the control of hemorrhage and operations on other viscera took precedence over the repair of the small-bowel lesions. Time was always saved by a preliminary evaluation of the total damage. About a third of the surgeons in the group thought it expedient, in the investigation of possible damage to the small bowel, to bring it out through the surgical incision and examine it outside of the abdomen. Complete examination of the jejuno-ileum and its mesentery was facilitated by this technique, and those who practiced it felt that, if it were carried out gently and expeditiously, it was not shocking to the patient. Its use was limited to cases in which the damage was obviously extensive and the lesions were obscured by some degree of spillage.

Contusions and lacerations of the intestinal wall were repaired and reenforced by a peritonealizing linear or purse-string suture, of whatever material the individual surgeon might prefer. With this exception, the type of repair was related to the type of injury.

Simple through-and-through perforations of the mesentery were sutured, to reperitonealize the raw surfaces, but dissection was carried out in the presence of large hematomas or continuing bleeding. After the hematoma had been


246

evacuated and hemorrhage controlled, the mesentery was closed by suture. As already mentioned, intestinal resection because of mesenteric vascular damage was required in only 30 cases in the series. In these patients, the usual criteria of viability of the bowel were observed, and resection was performed in accordance with recognized surgical principles.

A wide variety of techniques was used in the repair of perforating lesions of the bowel. The basic principle of management was to select the most conservative procedure compatible with secure repair and preservation of an adequate lumen. Very small perforations were usually closed by purse-string suture. Larger perforations were sutured transversely. Debridement of the traumatized edges was frequently omitted. If it was regarded as necessary, it was as conservative as possible. It was sometimes found convenient to convert two perforations into a single lesion, particularly if they were located close together in the same vertical plane. The single defect which resulted could be sutured in less time than was required to suture two separate perforations, and in the end there was less kinking of the bowel.

Resection and anastomosis-The indications for resection (tables 52 and 53) were usually clear cut. It was clearly mandatory when segments of the bowel were hopelessly macerated. It was also required when the bowel had been avulsed from its mesentery. Multiple adjacent perforations separated by areas of intact bowel always presented problems. Under these circumstances, some surgeons repaired each perforation separately. Others, if the involved segment was not too long, resected it in toto, fearing that multiple suture lines so close together might compromise the lumen and lead to intestinal obstruction from kinking.

TABLE 52.-Comparative results of anastomotic and suture repair in 1,117 wounds of jejuno-ileum1

Type of injury

Total series

Anastomosis2

Suture

Cases

Deaths

Case fatality rate

Cases

Frequency

Deaths

Case fatality rate

Cases

Frequency

Deaths

Case fatality rate

 

 

 

 

 

Percent

 

 

 

Percent

 

 

Univisceral

348

47

13.5

135

38.8

25

18.5

213

61.2

22

10.3

Multivisceral

769

281

36.5

347

45.1

155

44.7

422

54.9

126

29.9


Total

1,117

328

29.4

482

43.2

180

37.3

635

56.8

148

23.3


1Omitted from this table are nonperforating injuries and all injuries in which ileocolostomy was the only treatment. 
2In 54 cases, anastomosis was performed without resection.

Various techniques of anastomosis were employed (table 53). The majority of surgeons preferred an open, two-layer, end-to-end method whenever it was practical. Closed methods were used when soiling was minimal. A few surgeons routinely employed the closed silk technique. Side-to-side anastomosis was usually reserved for injuries of the lower ileum or for cases in which, after extensive resection, there was marked discrepancy in the size of the lumens to be


 247

TABLE 53.-Comparative case fatality rates of resection with various techniques of anastomosis in 428 injuries of the jejuno-ileum

Technique of anastomosis

Cases

Frequency

Deaths

Case fatality rate

 

 

Percent

 

 

End-to-end

377

88.1

120

31.8

Side-to-side

34

7.9

16

47.1

Not recorded

17

4.0

9

52.9


Total

428

100.0

145

33.9


anastomosed. Two surgeons reported successful results with a single-layer type of anastomosis. Two others preferred triple layers. Running or interrupted sutures of catgut and interrupted sutures of fine silk or cotton were widely used. As a general rule, the same type of suture and the same suture material employed for anastomosis were also used for the repair of perforations.

Four hundred and twenty-eight patients were subjected to 466 resections, which included 35 double resections with 13 deaths (37.1 percent) and 3 triple resections with 2 deaths. The case fatality rate of 47.1 percent (table 53) for the 34 side-to-side anastomoses is a reflection of the severity of the trauma in the cases in which it was used, rather than an index of the risk of this technique. It was unusually employed only in massive resections.

In the 394 cases in which data on this point were available, the length of the resected segments ranged from 2 inches to 12 feet. In 272 cases, the length was between 2 and 12 inches. In the other 122 cases, it averaged 34 inches. In 4 cases, segments more than 8 feet in length were resected. The case fatality rate in the 122 cases in which the resected segments measured 12 inches and more in length was 35.2 percent (43 deaths), which is in close agreement with the case fatality rate of 33.9 percent for all resections (table 53).

The case fatality rate of resection in injuries of the jejuno-ileum (33.9 percent) was higher than the rate of repair by suture (23.3 percent). The rate for anastomosis without resection (54 cases, 35 deaths, 64.8 percent) was very considerably higher. The ratio of the case fatality rate of repair by anastomosis to repair by suture was 1.79 in univisceral cases (18.5 and 10.3 percent respectively) and 1.50 in multivisceral cases (44.7 and 29.9 percent, respectively). In other words, anastomotic repair carried a higher case fatality rate than suture repair in both groups of cases, and of approximately the same order in each. The multiplicity factor furnishes no explanation of these figures, since the case fatality rate of anastomosis was higher in univisceral cases.

The results in this series therefore confirm the general impression that anastomotic repair of the small bowel is more hazardous than repair by suture, regardless of the circumstances under which it is employed. On the other hand, the principal indication for intestinal resection in this series was always extensive


248

trauma. The procedure was usually undertaken only when the bowel was in shreds and beyond hope of conservative repair. The higher case fatality rate for this procedure is therefore probably as much a reflection of the severity of the injury as of the relative risks of suture repair and intestinal resection.

The following case histories are presented as typical:

Case 2-A medical corpsman was brought into a field hospital about 2 hours after he had sustained a severe penetrating gunshot wound of the left abdomen, with an extensive evisceration of small intestine through a large defect in the abdominal wall. He was in severe shock, and neither blood pressure nor pulse could be obtained. After 2,500 cc. of blood had been administered as rapidly as possible, the blood pressure rose to 52/40 mm. Hg and the pulse became perceptible, though it still could not be counted.

Laparotomy was performed 3 hours after wounding. The root of the mesentery was found avulsed, this injury being the source of massive, persistent bleeding. The missile had perforated the left mesocolon and lay in the lumbar musculature. There were multiple lacerations and transections of the ileum and jejunum, and because of vascular impairment it was necessary to resect 10 feet of small intestine. Several perforations of the jejunum were also sutured. The patient's condition began to improve as soon as hemorrhage had been controlled, and by the end of the operation the blood pressure was 104/60 mm. Hg. A transfusion of 500 cc. of whole blood was given on the operating table.

Recovery was uneventful. The Levin tube was removed on the sixth day, and on the same day the patient has a spontaneous bowel movement. He was evacuated in good condition on the 13th postoperative day. A month later, it was learned that his improvement had continued and that he was about to be evacuated to the Zone of Interior.

Case 32-An 18-year-old German prisoner of war was admitted to a field hospital about 20 hours after he had sustained a penetrating wound of the abdomen from a shell fragment. He was in severe shock that did not respond to vigorous resuscitation therapy. Operation was undertaken about 24 hours after wounding. The peritoneal cavity was extensively contaminated with small-bowel content and was the site of a plastic peritonitis. The color of the bowel was unhealthy, and it was seriously mangled in three separate areas. A total of 3 feet was resected in three segmental procedures, and several other perforations were repaired by suture. End-to-end anastomoses were performed, the highest about 4 inches below the ligament of Treitz.

The man's condition became progressively worse during operation, in spite of continuous transfusions of whole blood, and death occurred about 5 minutes after the abdomen had been closed.

Case 4-A 42-year-old artilleryman, wounded by a shell fragment which penetrated the abdomen through the left lower quadrant, arrived at a field hospital in good condition. He was immediately given 500 cc. of blood. Roentgenologic examination disclosed a metallic foreign body in the right lower quadrant of the abdomen. Operation, performed 8 hours after wounding, revealed "multiple perforations of very large size" in the small bowel. Resection of three separate intestinal loops, with end-to-end anastomosis, was performed in the jejunum and in the upper and the lower ileum. The large shell fragment visualized in the roentgenogram was removed from the wall of the ileum.

The postoperative course was entirely uneventful. The patient was in good condition and was taking liquids by mouth when he was evacuated on the eighth postoperative day.

Enterostomy.-Enterostomy was employed only twice in the initial management of these 1,168 injuries of the jejunum and ileum. In the first instance, a small perforation at the ileocecal junction was managed by tube ileocecostomy, the procedure being selected because of the peculiar anatomic site of the injury. The history of the second patient follows:

2This case appears in table 54 as case 9.


249

Case 5-A German prisoner of war was admitted to a field hospital 3 days after he had been wounded by a shell fragment which had penetrated the right lower quadrant of the abdomen. His condition, except for dehydration, appeared good. There was tenderness in the right lower quadrant of the abdomen, and a thin, watery discharge exuded from the wound in this area.

At operation, the wound was converted, by lengthening it, into a modified gridiron incision. A large abscess cavity anterior to the cecum contained a perforated loop of ileum, and tube ileostomy was performed through the perforation. Convalescence was fairly smooth, but undigested food particles were observed in the discharge from the ileostomy. A note was made that the perforation was probably higher in the intestine than it had seemed to be at operation and that an attempt at closure might have been preferable to enterostomy. The patient was evacuated on the 10th postoperative day. This case represents 1 of the 9 instances of fistula formation in the series (p. 251).

Management of the contaminated peritoneal cavity-Two surgeons in the group routinely placed drains to the peritoneal space in the presence of contamination, whether from the small bowel or from other sources. The remainder were opposed to drainage of the cavity. A very few surgeons believed that lavage of a severely contaminated peritoneal cavity prior to closure of the abdomen aided in the removal of gross material which could not be evacuated by other means, but this method was used too infrequently to permit an evaluation of either its efficacy or its possible risks.

According to the records, sulfanilamide crystals or penicillin sodium were used intraperitoneally, alone or in combination, in 59 percent of the injuries of the jejunum and ileum. The actual figure is thought to be higher. Whether or not they were used in this manner rested with the individual surgeon. No opinion was arrived at concerning the efficacy of intraperitoneal chemotherapy and antibiotic therapy in injuries of the small intestine.

POSTOPERATIVE COMPLICATIONS

The recorded complications of injuries of the jejunum and ileum during the time the patients were under observation in forward hospitals were extraordinarily few. It is unlikely that serious complications were not recorded. On the other hand, the figures are perhaps not really representative, since complications undoubtedly developed in many cases after evacuation.

Ileus, distention, and vomiting apparently were almost universal among patients with abdominal injuries in World War I. In World War II, the routine use of nasogastric decompression practically eliminated these dangerous postoperative complications. Patients with injuries of the jejunum and ileum were intubated with the Levin tube prior to surgery, and three-bottle siphonage suction was instituted as soon as they reached the postoperative ward. The tube was left in place for from 3 to 8 days after operation. Considerable differences of opinion existed as to how long decompression was required after operation, but most surgeons favored a period of 3 to 6 days. Removal of the tube was determined by the standard clinical criterion; namely, return of intestinal function as manifested by audible peristalsis, the passage of flatus


250

and similar phenomena. After the tube had been removed, oral nutrition was cautiously increased in accordance with the patient's ability to tolerate food. 

The Miller-Abbott tube, although it was always readily available, was only occasionally used in the management of jejuno-ileal injuries. It was the consensus of the surgeons of the group that there were few indications for intubation of the intestine since in most instances adequate decompression could be obtained by the Levin tube. This was fortunate, for in the few cases in which the Miller-Abbott tube was used it was difficult, under field conditions, to get it past the pylorus.

Routine postoperative care prevented the development of most other complications. Careful attention was given to the maintenance of the fluid and electrolyte balance, to the hematocrit level, and to nutrition. Patients were usually kept in Fowler's position until peritonitis had definitely subsided. 

Intestinal obstruction.-Of the 1,168 patients with injuries of the jejunum and ileum, 20 (1.7 percent) presented symptoms of mechanical intestinal obstruction while they were still in forward hospitals. Ten had sustained severe multivisceral wounds; peritonitis had been present at operation in two cases; and gross contamination of the cavity had been recorded in six others. Five of the twenty patients had undergone suture repair, four anastomosis without resection, and eleven resection and anastomosis. One patient had had a double resection, and two others had had resections as well as simple anastomoses of transections. In 10 of the 15 cases in which anastomosis was performed, suture repair was also necessary for other injuries.

Obstructive symptoms, in the 17 cases in which these data were recorded, appeared between the 3d and the 32d day after operation. If the 2 cases are omitted in which symptoms became apparent on the 32d day, the average time of appearance of symptoms is lowered to between the 6th and 7th days. 

Seven of the twenty patients died (35.0 percent). In the six instances in which necropsy was carried out, the cause of the obstruction was found to be adhesions in three cases, and kinking of the anastomosis, edema at the anastomosis, and leakage from the anastomosis with subsequent peritonitis in one case each. In the single fatality in which autopsy was not performed, death followed development of a small intestinal fistula which was attributed to leakage at an anastomosis.

The method of management of the obstruction was mentioned in only 1 of the 7 fatal cases. In this instance, although the Miller-Abbott tube did not pass the pylorus, decompression of the obstructed bowel was successful, and death was caused by severe atypical pneumonia and hepatitis of unknown etiology. It seems safe to assume that conservative measures were also employed in the other fatal cases; had operation been performed, it would certainly have been recorded.

Ten of the thirteen patients who survived were treated conservatively, reinstitution of nasogastric decompression being the principal therapeutic measure. Data are not available concerning the length of time it was required.


251

The other (three) patients were operated on when conservative therapy proved unsuccessful. In one case, obstruction was the result of adhesions, in one of adhesions complicated by multiple abscesses, and in one of adhesions complicated by volvulus of the ileum.

Intestinal leakage and fistula formation-Leakage from the small bowel occurred in 12 cases after operation and was followed in 9 instances by fistula formation. In 6 of the 12 cases, there were severe wounds of other hollow viscera. In the 8 cases in which these data were recorded, the complication developed between the 6th and the 26th postoperative days, the average time being 13 days.3

As always, leakage from the small bowel proved a serious matter. It was fatal in all 3 cases in which fistula formation did not occur, and in 2 other cases in which fistulas developed. In 4 of the 5 fatalities, death was attributed to peritonitis; the cause was not stated in the fifth case. In each of the three autopsied cases, leakage was found to have occurred at a suture line, and it seems reasonable to assume that the same accident happened in the two other fatal cases. In 1 of the 3 autopsied cases, 2 perforations of the terminal ileum resulted from erosion of the intestine by the through-and-through wire sutures used to repair a wound disruption on the 9th postoperative day; the patient died of peritonitis on the 22d day. Data are not available concerning the origin of the leakage in the two other autopsied cases.

Secondary surgery for closure of fistulas was not performed in forward hospitals. The patients were evacuated as promptly as possible to general hospitals, where facilities for prolonged special care were available.

UNIVISCERAL WOUNDS

The 353 univisceral injuries in this series (table 50) include, as already mentioned (p. 241), 2 nonbattle injuries. The other 351 casualties were all wounded by high-explosive fragments or by bullets. The ileum was injured more frequently (180 cases) than the jejunum (128 cases), the ratio being roughly 3:2. Both portions of the bowel were injured simultaneously 45 times, which is only about a quarter as frequently as the ileum was wounded alone.

The case fatality rate for the 353 univisceral injuries (table 50) was 13.9 percent. The rate for wounds of the jejunum alone (13 deaths) and of the ileum alone (23 deaths) was approximately the same, 10.2 and 12.8 percent, respectively. The case fatality rate rose sharply to 28.9 percent (13 deaths) when both portions of the bowel were involved. The increase is readily explained by the fact that many of the injuries represented extensive trauma to a large segment of the midbowel and required massive resection.

The average timelag from. injury to operation in the recorded fatal cases of univisceral injury of the jejuno-ileum was twice that in the recorded nonfatal

3Attention is called elsewhere (p. 249) to the additional case of fistula formation observed in a German prisoner of war, who had an established fistula of the small bowel and an intraperitoneal abscess when he was admitted to a field hospital 3 days after wounding.


252 

cases, being 9.5 hours in 293 nonfatal cases and 19.1 hours in 46 fatal cases. If 2 cases in which the timelag was unusually prolonged (72 hours and 90 hours, respectively) are omitted, the figure for the fatal cases is reduced to 16.3 hours. The timelag for all 339 (recorded) univisceral injuries was 10.9 hours, which is essentially the same as the lag (10.6 hours) for the 1,057 cases in the whole series of jejuno-ileal injuries in which these data are available. If all patients with this type of injury could have been operated on within 8 hours of wounding, their chances of recovery would probably have been greatly enhanced.

A disproportionately large number of severe associated injuries apparently contributed to the case fatality rate of univisceral wounds of the jejunum and ileum. Associated injuries were more than twice as frequent among the fatal as among the nonfatal cases. They were recorded in 72 (23.7 percent) of the 304 patients with univisceral injuries who survived and in 27 (55.1 percent) of the 49 patients who died. They included serious compound fractures of the long bones, traumatic amputations of extremities, penetrating wounds of the thorax other than thoracoabdominal wounds, severe cranial injuries, severe maxillofacial injuries, and soft-tissue wounds which either were extensive or were associated with severe hemorrhage.

At least 3 of the 49 fatalities in univisceral wounds of the jejunum and ileum can be justifiably attributed to these associated injuries. One man with a wound of the heart died on the operating table from cardiac tamponade. Another, who had also sustained a blast injury of the lungs, died 5 hours after operation. The third died from hemolytic streptococcic bacteriemia and pyemia following infection of a massive wound of the thigh. In all three cases, the diagnosis was established at autopsy.

In 15 other cases, death apparently was the result of the combined effects of intestinal and associated wounds, both of which were severe, as the following representative case history indicates:

Case 6-An infantry man was brought into a field hospital in severe shock 20 hours after he had sustained an extensive shell-fragment wound of the right buttock. Operation was performed 4 hours later, after he had received 3,000 cc. of blood. Two small perforations of the ileum were sutured at laparotomy, which revealed an extensive early fibrinous peritonitis.

It proved impossible to control the extensive phagedenic infection which developed in the wound of the buttock and which ultimately involved the entire gluteal muscle group and the lumbar and posterior thigh muscles also. The patient became oliguric and uremic and died on the fifth day after operation, his course having been continuously downhill. At autopsy, the peritoneal cavity was found clean and free of infection, and infection and necrosis in the thigh and buttock were reported to be the chief causes of death.

If the 18 cases in which death was attributable wholly or in part to associated wounds are excluded from this discussion and if only the 31 fatalities in which the intestinal injury played the major role (table 54) are considered, a more accurate impression can be obtained of the causes of death in cases in which injury of the jejunum and ileum was the primarily fatal factor. Shock or peritonitis was listed as the chief cause in 15 patients who survived operation


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for periods of time varying from 5 minutes to 48 hours. These cases fell into the well-defined group of casualties, seen in forward hospitals, who were admitted to the field hospitals in the severe shock which seemed, in part at least, to be secondary to massive peritoneal contamination (p. 127). The timelag was usually long, associated hemorrhage was frequent, and death occurred promptly.

Peritonitis was listed as the primary cause of death in 8 patients who survived operation for periods varying from 3 to 22 days. Peritoneal infection could not be controlled in these cases, but the element of persisting shock, which was present in the patients who died promptly after operation, was no part of the picture.

TABLE 54.-Causes of death in 31 primarily fatal injuries of jejuno-ileum

Case

Timelag

Site of injury

Postoperative survival

Cause of death

 

Hours

 

 

 

11

8.0

Jejuno-ileum

36 hours

Peritonitis; shock.

12

19.0

Ileum

2 days

Generalized peritonitis, severe; pulmonary edema, severe. 

13

17.0

Jejunum

2 hours

Shock; peritonitis.

4

12.0

Jejuno-ileum

24 hours

Shock.

5

20.0

...do...

2 days

Do.

6

38.0

Jejunum

36 hours

Shock; severe mesenteric hemorrhage.

17

27.0

Ileum

9 hours

Generalized fibrinopurulent peritonitis (present at operation).

8

36.0

...do...

5 hours

Shock; peritonitis.

9

22.0

Jejuno-ileum

5 minutes

Do.

10

---

...do...

5 hours

Shock.

11

13.0

Jejunum

24 hours

Shock; peritonitis.

12

48.0

Ileum

6.5 hours

Do.

113

11.5

Jejuno-ileum

24 hours

Generalized peritonitis.

14

37.0

...do...

14 hours

Shock; peritonitis.

115

10.0

...do...

24 hours

Generalized peritonitis; shock.

16

90.0

Jejunum

4 days

Generalized peritonitis.

117

14.5

Ileum

5 days

Suppurative, generalized peritonitis, severe; mesenteric thrombosis lower third ileum.

118

23.5

Jejunum

8 days

Acute fibrinopurulent peritonitis, severe; anuria; uremia.

119

14.0

Jejuno-ileum

22 days

Generalized and localized peritonitis; 2 perforations ileum caused by wire sutures.

20

6.0

Ileum

3 days

Peritonitis.

21

15.0

...do...

11 days

Do.

122

7.0

Jejuno-ileum

12 days

Generalized peritonitis; bronchopneumonia.

123

4.0

Ileum

8 days

Generalized and localized purulent peritonitis; leakage at anastomosis.

124

10.0

...do...

5 days

Intestinal obstruction; kinked anastomosis.

125

7.0

...do...

10 days

Massive pulmonary embolism.

126

16.0

Jejuno-ileum

5 days

Oliguria; anuria; uremia.

127

6.5

Jejunum

3 days

Diffuse purulent tracheobronchitis.

128

6.5

...do...

13 days

Hepatitis; atypical pneumonia; intestinal obstruction.

129

5.5

Ileum

10 minutes

Aspiration of vomitus.

130

4.0 

...do...

1 day

Cardiorespiratory death, unexplained clinically or at autopsy.

31

---

Jejuno-ileum

5 days

Not recorded.


1Autopsy.


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The incidence of peritonitis recorded at operation is not considered reliable because many of the operative notes were incomplete. It is of interest, however, that it was specifically mentioned as being present in 41 percent of the patients who died, as contrasted with only 10 percent of those who survived. 

One death was attributed to intestinal obstruction. In one case, no cause of death was stated. In the six remaining cases, the fatalities were attributed to causes not inherently related to wounds of the small intestine, such as pulmonary embolism and anuria.

In the fatal univisceral wounds, therefore, about half of the patients died in the immediate postoperative period of shock and overwhelming peritoneal contamination. About a quarter died later of peritonitis. The remainder, except for the patient who died of intestinal obstruction, died of unpredictable and unrelated complications. The outstanding causes of death in patients who died primarily of univisceral injuries to the jejunum and ileum were shock, severe peritoneal contamination, prolonged timelag, and peritonitis. Interaction among these factors was often observed clinically. Apparently they were mutually complementary, and they cannot be completely divorced from each other for the purpose of statistical analysis.

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