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Chapter 20

Contents

CHAPTER XX

Wounds of the Colon and Rectum 
(1,222 Casualties)

C. Frank Chunn, M. D., and Richard V. Hauver, M. D.

In the 3,154 casualties with abdominal wounds treated by surgical teams of the 2d Auxiliary Surgical Group between 1 January 1944 and 8 May 1945, there were 1,222 with wounds of the colon, rectum, or both. These injuries are in addition to the 136 similar injuries treated between April and December 1943. The case fatality rate in the 1943 series was 42.6 percent (58 deaths), as compared with 35.4 percent (433 deaths) in the cases managed in 1944 and 1945. The essential data in the 1944-45 cases are set forth in table 55.

TABLE 55. -Essential data in 1,222 wounds of colon and rectum

Type of wound

Cases

Frequency

Deaths

Case fatality rate

In 3,154 abdominal injuries

In 1,222 colon-rectum injuries

Percent

Percent

Colon only

1,067

33.8

87.3

386

36.2

Univisceral

251

7.9

20.5

57

22.7

Multivisceral

816

25.9

66.8

329

40.3

Rectum only

116

3.7

9.5

27

23.3

Univisceral

64

2.0

5.2

9

14.1

Multivisceral

52

1.7

4.3

18

34.6

Colon and rectum

39

1.23

3.2

20

51.3

Univisceral

13

.41

1.1

6

46.2

Multivisceral

26

.82

2.1

14

53.8

Total

1,222

38.7

100.0

433

35.4

Univisceral

328

10.41

26.8

72

21.9

Multivisceral

894

28.32

73.2

361

40.4


As in all other groups in this series, the 1,005 patients with wounds of the colon and rectum for whom these data were available were chiefly (63.0 percent) in the age range 20 to 40 years. The case fatality rate was essentially the same for this age group (33.8 percent) as for the group from infancy to 20 years (32.4 percent), although the latter group includes civilian children who had a rate somewhat above the average. The 22 casualties over 40 years of age, 10 of whom died, were chiefly civilians.


256

NATURE OF THE LESION

Wounds of the colon were caused by the same agents, which were implicated with approximately the same frequency, as all other abdominal wounds (p. 92). The series does not include serous and seromuscular lacerations without perforation into the lumen. There were only a few of these injuries, and they resulted chiefly in minor bruises or subserosal hematomas. The series is made up entirely of perforations, transections, and other severe injuries to the large bowel, including injuries which resulted in interruption of the blood supply. The perforations, as in injuries of other portions of the bowel, ranged from small holes without leakage to injuries which completely destroyed large segments of the bowel and were associated with massive fecal spillage.

Contamination of the retroperitoneal space from a perforation of the extraperitoneal colon was common and always presented a formidable complication, particularly in extensive wounds of the right colon. Fecal matter was spread widely and forcibly through severely damaged muscle and areolar tissue. Adequate debridement often required extensive excision of the lumbar and iliopsoas muscles, and satisfactory surgery was often performed with difficulty because of extensive hematoma formation and the close proximity of important anatomic structures, notably the ureter and the great vessels of the pelvis. Identification of retroperitoneal structures and the control of hemorrhage were frequently time consuming and of great technical difficulty.

Of the 1,358 wounds of the colon treated in the 1943-45 period, 191 were thoracoabdominal (table 56).

TABLE 56.-Case fatality rates in 191 thoracoabdominal injuries involving the colon

 

Site of intestinal injury

Cases

Deaths

Case fatality rate

Ascending colon

13

9

69.2

Hepatic flexure

22

15

68.2

Transverse colon

76

33

43.4

Splenic flexure

57

30

52.6

Descending colon

23

8

34.8

Total

191

95

49.7


1These injuries occurred in the 1,358 wounds of the large bowel treated in 1943-45.

TIMELAG AND THE MULTIPLICITY FACTOR

The average lapsed time from wounding to operation in the 1,222 wounds of the colon and rectum in this series was 10.9 hours, the interval being essentially the same for both fatal and nonfatal cases.1 It is to be compared with

1It will be noted that in this chapter there are apparently no cases in which data concerning timelag are lacking. There are two explanations: (1) The authors of the chapter made a special effort to check all nonrecord cases with the operating surgeons and were often able to secure approximate time intervals from them. (2) When they could not secure these data, as well as in cases in which investigation of the missing data was not possible, they adopted the plan of using for their calculations the average timelag of all cases treated by the teams which handled these cases.


257

the average time interval of 10.5 hours recorded for all 3,154 cases in the total series, as well as with the interval of 11.3 hours reported for all abdominal injuries in 1943. The average time spent in resuscitation in the hospital before operation was undertaken was 3 hours, which makes the interval from wounding to hospitalization between 7 and 8 hours. In more than a quarter of all cases (27.5 percent), operation was begun within 6 hours of injury, and in almost three-quarters of the cases (74.5 percent) it was begun within 12 hours.

A tendency toward an increase in the case fatality rate in wounds of the colon (table 57) was apparent through the 18-hour period. It ceased after this interval. In later categories, the figures available for analysis were too small to permit conclusions.

The case fatality rates in relation to the timelag between wounding and operation must be interpreted in the light of two considerations:

1. While in general the patient's chances were improved the shorter the interval between wounding and surgery, account must also be taken of the influence of the multiplicity factor (table 58).

2. The case fatality rate in patients operated on within 12 hours of wounding (320 of 911 patients, table 57) was kept to 35.1 percent, in spite of the fact that this group included the casualties who were critically and often mortally wounded and who often reached the hospital alive only because of rapidity of evacuation.

TABLE 57.-Influence of timelag on case fatality rates in 1,222 wounds of colon and rectum

Timelag

All cases

Colon only

Return only

Colon and rectum

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

0 to 6 hours

336

105

31.3

314

96

30.6

15

5

33.3

7

4

57.1

To 12 hours

575

215

37.4

497

192

38.6

57

12

21.1

21

11

52.4

To 18 hours

168

65

38.7

139

55

39.6

23

7

30.4

6

3

50.0

To 24 hours

66

20

30.3

51

18

35.3

11

1

9.1

4

1

25.0

To 48 hours

65

25

38.5

54

22

40.7

10

2

20.0

1

1

100.0

48 hours or more

12

3

25.0

12

3

25.0

---

---

---

---

---

---

Total

1,222

433

35.4

1,067

386

36.2

116

27

23.3

39

20

51.3


Injuries of the colon were accompanied by injuries of 1 or more other viscera (table 58) in approximately 3 out of every 4 cases (74.7 percent). Injuries of the rectum were accompanied by injuries of other viscera in more than half of all cases (58.7 percent). In both portions of the large bowel, wounds of additional viscera caused an increase in the case fatality rate, the increase being directly proportional to the number of viscera affected. Injuries of both solid and hollow viscera caused an increase in the case fatality rate in about the same proportion. In the 552 wounds of the colon in which hollow viscera were also injured, there were 205 deaths (37.1 percent); and in


258

TABLE 58.- Influence of combined timelag and multiplicity factor on case fatality rates in 1,155 injuries of colon and rectum

Injury

0 to 6 hours

To 12 hours

To 18 hours

To 24 hours

Over 24 hours

Total

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rates

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

Colon or rectum only

71

9

12.7

120

26

21.7

38

6

15.8

25

4

16.0

38

12

31.6

292

57

19.5

Colon and 1 viscus

159

45

28.3

242

79

32.6

79

32

40.5

25

6

24.0

28

10

35.7

533

172

32.3

Colon and 2 viscera

67

31

46.3

110

53

48.2

34

17

50.0

14

6

42.9

8

5

62.5

233

112

48.1

Colon and 3 viscera

25

14

56.0

31

12

38.7

7

6

85.7

5

4

80.0

2

1

50.0

70

37

52.9

Colon and 4 viscera

7

6

85.7

13

10

76.9

1

1

100.0

---

---

---

1

1

100.0

22

18

81.8

Colon and 5 viscera

1

1

100.0

4

4

100.0

---

---

---

---

---

---

---

---

---

5

5

100.0

Total

330

106

32.1

520

184

35.4

159

62

39.0

69

20

29.0

77

29

37.7

1,155

401

34.7

Multiplicity index

2.22

2.21

2.08

1.99

1.70



259

the 161 wounds in which solid viscera were also injured, there were 55 deaths (34.2 percent).

In addition to the complicating visceral injuries just discussed, damage to a major blood vessel of the abdomen was a complication in 25 cases, 23 of which terminated fatally. In 8 cases, 6 of which were fatal, the vascular injury was the only complicating wound.

In the 1,155 cases in which adequate data on the multiplicity factor were available for the tabulation (table 58), there was a definite and almost arithmetical increase in the case fatality rate from 19.5 percent in univisceral injuries (22.7 percent in wounds of the colon, 14.1 percent in wounds of the rectum) to 100 percent when 5 additional organs were injured. The outcome in every injury of the colon apparently depended more upon the number of additional organs injured than upon precisely which organs were involved.

It should be noted that while the case fatality rate rose progressively for each additional organ injured, there was no consistent increase in the rate for the various time intervals after injury. The timelag, naturally, is not unimportant. In view of the danger of infection of the peritoneum in wounds of the large bowel, timelag was probably more important in such wounds than in any other type of abdominal wound. When the figures are interpreted in the light of these various considerations, they strongly suggest that reduction of the timelag in patients with wounds of the large bowel enhanced their chances of survival. On the other hand, the bad effects of delay in surgery, the chief of which was the development of peritonitis, were overshadowed by the increased influence of multiple visceral injury, the chief of which was probably shock.

SHOCK

On the basis of clinical appearance, blood pressure, amounts of blood and plasma used in resuscitation, response to measures of resuscitation, and similar criteria, it was possible to classify 1,140 patients according to the degree of shock present when they were admitted to the field hospital (table 59). Approximately a third of this number was in each of the three categories; namely, no shock or slight shock, moderate shock, and severe shock. The case fatality rate increased proportionately with the increase in the degree of shock, though when the cases were classified according to the timelag no pronounced differences were observed (table 59) except in the 12- to 18-hour period. On the other hand, it seems reasonable to surmise that, as time passed without treatment, patients who at first were in minor degrees of shock entered more serious states and so fell into different categories. The degree of shock, as would have been expected, was also related to the number of organs injured.

Resuscitation therapy-In the immediate resuscitation and preparation for operation of patients with wounds of the colon, the greatest reliance was placed upon blood, which was used immediately, liberally, and always in larger amounts than plasma (table 60). The quantities of plasma, however,


260

were probably larger than the tabulated data suggest, because under field conditions the full amounts used were not always recorded.

TABLE 59.-Influence of degree of shock and timelag on case fatality rates in 1,140 injuries of colon and rectum1

Timelag

Degree of shock

Total

None to slight

Moderate

Severe

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

0 to 6 hours

217

24

11.1

199

58

29.1

225

153

68.0

641

235

36.7

6 to 12 hours

101

7

7.0

103

24

23.3

125

84

67.2

329

115

35.0

12 to 18 hours

24

1

4.2

32

15

47.0

24

20

83.3

80

36

45.0

18 to 24 hours

20

3

15.0

11

1

9.1

12

9

75.0

43

13

30.2

Over 24 hours

21

3

14.3

14

7

50.0

12

8

66.7

47

18

38.3

Total

383

38

9.9

359

105

29.2

398

274

68.8

1,140

417

36.6


1Data on these points are lacking in 82 cases.

TABLE 60.- Blood and plasma replacement in wounds of colon and rectum 1

Cases

Units2

Average per patient

cc.

Blood:

Total

4,165

1,841

Survivals

2,043

1,415

Deaths

2,122

2,590

Plasma:

Total

3,220

728

Survivals

1,722

610

Deaths

1,498

938


1The figures for blood are based on 1,131 casualties and for plasma on 1,106 casualties. 
2A unit of blood is 500 cc. and a unit of plasma is 250 cc.

It was the policy in the earlier cases in this series to delay operation until the systolic blood pressure was over 100 mm. Hg. As experience increased, this policy was replaced by a regimen in which operation was performed earlier in the period of resuscitation and active shock therapy was continued throughout the operative procedure. The timelag before operation was thus shortened in numerous cases in which full resuscitation before operation was notably hard to achieve, particularly in severe injuries of the right colon, evisceration, and active abdominal hemorrhage. Casualties with wounds of the colon associated with extensive fecal soiling showed marked resistance to resuscitation therapy.


261

TREATMENT

While on first glance (table 61) it might seem that a very large number of procedures were utilized in the 1,222 wounds of the colon and rectum which make up this series, actually there was no wide divergence of opinion among surgeons in the 2d Auxiliary Surgical Group over how wounds of the large bowel should be managed. There were numerous modifications of technique, it is true, but the opinion of the various teams was probably as definite, as concrete, and as unanimous concerning methods of management as it was in any intra-abdominal injury. Exteriorization of the injured bowel was a fundamental principle, though several different techniques were employed to accomplish it, and procedures other than exteriorization were resorted to only when for any reason it was inadvisable or actually impossible to perform this operation.

In general, all surgical procedures for wounds of the colon and rectum involved three basic techniques:

1. Exteriorization of the wounded segment of bowel, to prevent intraperitoneal leakage at a suture line. The damaged exteriorized segment could be used as the site of colostomy on appropriate indications.

TABLE 61.- Influence of location of injury and type of operation on case fatality rates in 1,222 wounds of colon and rectum


262

2. Diversion of the fecal stream away from wounds of the distal or lower colon and rectum, which was accomplished by any one of several techniques of colostomy. Colostomy was always performed for perforation of the rectum, but adequate posterior drainage through the fascia propria was also mandatory. 

3. Incomplete diversion of the fecal stream, which was a temporary measure, designed for purposes of decompression as well as to bring the bowel to the surface, so that a diversional colostomy could be performed. Either a tube or a tangential enterostomy was utilized in the cecum, though this type of opening could not be converted into a diversional colostomy.

Special procedures carried out in these wounds of the colon and rectum were as follows:

1. Loop colostomy, which was a simple exteriorization of a segment of colon through an abdominal incision. The exteriorized segment was maintained by a tube laid across the incision and under the segment of colon (fig. 28A). 

2. Spur colostomy, which was exteriorization of a segment of colon or of the proximal and distal ends of a segment of colon, through an abdominal incision. Both limbs of the colostomy were sutured together along the antimesenteric surface for a distance of 3 to 4 inches to form the spur (fig. 28B). The colon was rotated so that the mesentery lay medially.

3. Tube cecostomy, which was an enterostomy with a rubber tube sutured into the lumen of the colon and brought out through a small abdominal incision (fig. 28C).

4. Intraperitoneal closure with proximal colostomy, which consisted of repair of the perforated colon which was left in the peritoneal cavity while a loop or spur colostomy was done at a convenient distance proximal to the repair.

5. Diversional colostomy, which was a spur or loop colostomy placed proximal to a perforation of the colon or rectum to divert the fecal stream.

6. Resection with ileocolic anastomosis and colostomy. This was a procedure (fig. 29A) which included (1) resection of the terminal ileum and ascending colon; (2) closure of the terminal end of the ileum; (3) side-to-side anastomosis of the ileum and transverse colon, the anastomosis being left in the peritoneal cavity; and (4) exteriorization of the proximal end of the transverse colon as a mucous fistula through a separate incision in the abdominal wall. This procedure was sometimes varied by performing end-to-side ileocolostomy with exteriorization of the proximal end of the colon (fig. 29B). Another variation of the basic technique was the performance of a side-to-side anastomosis between the ileum and transverse colon, with exteriorization of the distal end of the ileum and the proximal end of the transverse colon through separate incisions in the abdominal wall, to create mucous fistulas (fig. 29C).

7. Resection with double-barreled ileocolostomy, which was essentially the same as resection with spur colostomy, the only difference being that one of the exteriorized limbs was ileum and one was colon (fig. 30A).


263

FIGURE 28.-Types of colostomy. A. Loop colostomy. B. Spur colostomy. C. Tube cecostomy.


264 

FIGURE 29.-Types of colostomy. A. Resection of wounded segment, with side-to-side ileocolic anastomosis and creation of single mucous fistula. B. Same, with end-to-side anastomosis. C. Same with side-to-side anastomosis and creation of double mucous fistulas.

8. Posterior drainage (drainage of the fascia propria) and proximal colostomy, which was indicated in wounds of the rectum or of the rectum and the sigmoid. It included (1) a coccygectomy or an incision just lateral to the coccyx; (2) freeing of the rectum from the fascia propria for drainage of the perforated rectum, which was not repaired; and (3) creation of a proximal loop or spur colostomy through an abdominal incision. One variation of this technique was to repair the perforated rectum and drain the perirectal space.

9. Resection, with separate exteriorization of the limbs, which required resection of a segment of the colon with exteriorization of the proximal and distal limbs through individual abdominal incisions rather than as a double-barreled colostomy.

10. Tangential colostomy, which was exteriorization of a small area of the antimesenteric wall of the colon through a separate abdominal incision (fig. 30B), with maintenance of the continuity of the bowel.

Whenever the retroperitoneal space had been penetrated or perforated, it was drained through an independent incision. The peritoneal cavity itself was drained in not more than 10 percent of the remaining cases.

REGIONAL INJURIES

The transverse colon alone was involved in the largest number of cases in this series (417 cases, 34.2 percent), followed in the descending order of frequency by the ascending colon (282 cases, 23.1 percent), sigmoid (157 cases, 12.8 percent), descending colon (120 cases, 9.8 percent), extraperitoneal rectum (116 cases, 9.5 percent), transverse and descending colon (49 cases, 4.0 percent), colon and rectum (39 cases, 3.2 percent), ascending and transverse


266

colon (33 cases, 2.7 percent), and ascending and descending colon (9 cases, 0.7 percent).

The appendix was either perforated or transected in 12 instances (1.0 percent of the total number of wounds of the large bowel). All of these patients had other and more important intra-abdominal wounds. All were treated by appendectomy.

Ascending colon-Wounds of the ascending colon (table 62) presented particularly difficult problems when it was necessary to resect the entire right colon and terminal ileum. Early in the war, the most favored procedure under these circumstances was resection and double-barreled ileocolostomy, but it carried a case fatality rate of almost 65 percent and was unsatisfactory for other reasons. It combined the most undesirable feature of small-bowel fistula, that is, an irritant and digestive discharge, with the contaminating discharge of a colostomy. The resulting fecal contamination of irritated and digested wound surfaces produced conditions which at times it was impossible to control. Later, resection and ileocolic anastomosis and colostomy, with the creation of a single or double mucous fistula, accomplished some improvement in the case fatality rate, which still, however, remained high (51.7 percent). Two patients who required resection of a portion of the ascending colon were treated by separate exteriorization of the proximal and distal ends; both died.

There were no deaths in the 27 patients treated by tangential colostomy (included under loop colostomy, table 62). This method was employed only when the perforation was small and was located on the antimesenteric border of the bowel. Two techniques were used: The bowel was repaired and no fecal fistula was established at operation, or it was not repaired and the perforation was permitted to serve as the fistula.

FIGURE 30.-Types of colostomy. A. Double-barreled ileocolostomy. B. Tangential colostomy.


266

TABLE 62.-Influence of technique on case fatality rates in 273 wounds of ascending colon1

Operation

Cases

Deaths

Case fatality rate

Colostomy:

Loop

145

32

22.1

Spur

27

10

37.0

Tube

39

10

25.6

Closure, proximal colostomy

1

0

0

Resection, ileocolic anastomosis and colostomy

29

15

51.7

Resection, double-barreled ileocolostomy

17

11

64.7

Closure only

13

1

7.7

Resection, separate exteriorization of limbs

2

2

100.0

Total

273

81

30.0


1Nine additional cases are omitted because no intestinal operation was performed in them: Six patients died on the operating table, and in 3 cases, 2 of which were fatal, the lesion was missed.

Thirteen patients with injuries of the right side of the colon were subjected to primary repair, without colostomy, with only one death. The results are not statistically significant, nor are they of particular significance clinically. These patients were among the least seriously wounded and are in no wise comparable to the casualties who required resection of the right side of the colon. They are not even comparable to casualties with large single wounds of the colon.

Transverse colon-The 417 wounds of the transverse colon included 6 comparatively minor injuries in which primary repair of the perforation was successfully carried out without colostomy (table 63). All these six patients made smooth recoveries. No special comment is necessary on any of the other cases in this group.

TABLE 63.-Influence of technique on case fatality rates in 414 wounds of transverse colon1

Operation

Cases

Deaths

Case fatality rate

Colostomy:

Loop

252

80

31.7

Spur

146

72

49.3

Tube

4

2

50.0

Closure, proximal colostomy

1

0

0

Resection, double-barreled ileocolostomy

2

1

50.0

Closure only

6

0

0

Resection, separate exteriorization of limbs

3

3

100.0

Total

414

158

38.2


1Three additional cases are omitted because no intestinal operation was performed in them. Two patients died on the operating table, and in 1 case, also fatal, the lesion was missed.


267

Descending colon-Wounds of the descending colon (table 64) presented no special problems as compared with wounds of the ascending colon or the lower sigmoid. All were dealt with by some form of colostomy except for the single case managed by repair of the perforation with return of the bowel to the peritoneal cavity.

Sigmoid colon-Wounds of the sigmoid colon (table 65) presented two problems not encountered in wounds of the colon proximal to the sigmoid:

1. When a perforation of the lower sigmoid was present, it was often impossible to exteriorize the wounded segment because the distal bowel was not long enough. In this type of case, the perforation was repaired and a proximal diversional colostomy of either the loop or the spur type was created.

TABLE 64.-Influence of technique on case fatality rates in 119 wounds of descending colon1

Operation

Cases

Deaths

Case fatality rate

Colostomy:

Loop

67

19

28.4

Spur

48

21

43.8

Closure, proximal colosomy

3

1

33.3

Closure only

1

0

0

Total

119

41

34.5


1An additional (fatal) case is omitted because the lesion was missed at operation.

TABLE 65.-Influence of technique on case fatality rates in 154 wounds of sigmoid colon1

Operation

Cases

Deaths

Case fatality rate

Colostomy:

Loop

82

21

25. 6

Spur

32

14

43. 8

Closure, proximal colostomy

34

11

32.4

Posterior drainage, closure, proximal colostomy

4

1

25.0

Resection, separate exteriorization of limbs 

2

2

100.0

Total

154

49

31.8


1Three additional cases are omitted because the patients died on the operating table before the intestinal operation could be performed.

2. The second problem, which was encountered in only four cases, concerned perforations at the rectosigmoid junction, just at the reflection of the peritoneum on the pelvic floor. In these cases, the procedure just described


268

was followed, with the addition of fascia propria (posterior) drainage of the rectum.

Rectum.-The majority of patients with injuries of the extraperitoneal rectum (table 66) were treated by proximal colostomy and posterior drainage. The perforation was closed in 25 of the 107 cases in which this technique was used.

Multiple intestinal injuries-The case fatality rate, as might have been expected, increased sharply when more than one segment of the large bowel had been wounded (tables 67 to 70, inclusive). Of the 1,222 patients in this series, 130 had injuries of two different segments of the colon or injuries of the colon and rectum. There were 64 deaths in this group (49.2 percent). There were 17 deaths (39.5 percent) in the 43 cases in which colostomies were created at two different sites.

TABLE 66.-Influence of technique on case fatality rates in 116 wounds of extraperitoneal rectum

Operation

Cases

Deaths

Case
 fatality 
rate

Diversional colostomy

8

5

62. 5

Posterior drainage, proximal colostomy

82

15

18.3

Posterior drainage, closure, proximal colostomy

25

6

24.0

Closure only 

1

1

100.0

Total

116

27

23. 3


TABLE 67.-Influence of technique on case fatality rates in 32 wounds of ascending and transverse colon1

Operation

Cases

Deaths

Case 
fatality 
rate

Colostomy:

Loop

3

0

0

Spur

9

6

66.7

Closure distal perforation, loop exteriorization proximal perforation

6

3

50.0

Resection, ileocolic anastomosis and colostomy

6

4

66.7

Resection, double-barreled ileocolostomy

6

4

66.7

Closure only

2

1

50.0

Total

32

18

56.3


1An additional case is omitted because the patient died on the operating table before the intestinal operation could be completed


269

TABLE 68.-Influence of technique on case fatality rates in 9 wounds of ascending and descending colon

Operation

Cases

Deaths

Case 
fatality 
rate

Colostomy:

Double loop

1

1

100.0

Spur and loop

1

1

100.0

Tube and loop

1

0

0

Closure distal perforation, loop exteriorization proximal perforation

6

4

66.7

Total

9

6

66.7


TABLE 69.-Influence of technique on case fatality rates in 48 wounds of transverse and descending colon1

Operation

Cases

Deaths

Case 
fatality 
rate

Colostomy:

Double loop

9

3

33.3

Spur and loop

29

11

38.0

Proximal tube, distal loop

1

0

0

Closure distal perforation, exteriorization proximal perforation

9

4

44.4

Total

48

18

37.5


1An additional case is omitted because the patient died on the operating table before the intestinal operation could be completed.

TABLE 70.-Influence of technique on case fatality rates in 39 combined wounds of colon and rectum

Operation

Cases

Deaths

Case
 fatality 
rate

Diversional colostomy

2

1

50.0

Resection, double-barreled ileocolostomy, loop sigmoidostomy

1

1

100.0

Posterior drainage, proximal colostomy

19

9

47.4

Posterior drainage, closure, proximal colostomy

17

9

52.9

Total

39

20

51.3


270 

Up to May 1944, when penicillin first became available, sulfadiazine was given by vein after operation in all injuries of the colon and rectum. Thereafter, penicillin was given at 3-hour intervals from the time the patient reached the hospital until 5 days, or more, after operation. A few surgeons continued to use sulfadiazine intravenously in conjunction with it.

Some surgeons who used no antibacterial agent in the abdomen in mildly contaminated cases are known to have employed this method when contamination of the peritoneal cavity was serious or massive. The case fatality rate in wounds of the colon and rectum does not seem to have been materially affected by the introduction of either chemotherapeutic or antibiotic agents into the peritoneal cavity.

POSTOPERATIVE COMPLICATIONS

According to the records, important postoperative complications included peritonitis, pneumonia, anuria, wound infection, atelectasis, evisceration, intestinal obstruction, anaerobic infection, fecal fistula, empyema, secondary hemorrhage, subphrenic abscess and pelvic abscess, pulmonary edema, cerebral embolism, and fat embolism. The list is necessarily presented without comment, since the records were entirely inadequate. Unquestionably, there were more instances of nonfatal atelectasis and patchy bronchopneumonia than the records indicate, just as there were unquestionably many more wound infections, minor hemorrhages, and temporary partial obstructions from edema in the area of intestinal anastomoses. As for minor complications, the majority were simply not entered on the charts.

CASE FATALITY RATES

There were 433 deaths in forward hospitals among the 1,222 patients with perforations of, or other severe damage to, the colon, rectum, or both, a case fatality rate of 35.4 percent (table 55, p. 255). Actually, for reasons pointed out elsewhere (p. 85), there is little doubt that the rate was somewhat higher than these figures indicate.

The case fatality rates for injuries of the large bowel improved progressively as the war progressed. In 1943, there were 58 deaths in 136 casualties (42.6 percent); in 1944, 334 deaths in 917 casualties (36.4 percent); and in 1945, 99 deaths in 305 casualties (32.5 percent).

Case fatality rates varied according to the location of the injury (table 71) and according to whether the wound was limited to the large bowel or was multivisceral. In univisceral injuries of the colon, the rate was 22.7 percent (table 55, p. 255). In univisceral injuries of the extraperitoneal rectum, it was 14.1 percent. In multivisceral injuries, these rates were, respectively, 40.3 and 34.6 percent. When the wounds involved both the colon and the rectum, the rate for univisceral injuries was 46.2 percent and for multivisceral injuries 53.8 percent.


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When only univisceral injuries of the large bowel were considered (table 71), the case fatality rate was found to vary according to the site of the wound and the number of wounds. Casualties who had sustained injuries of the extraperitoneal rectum had the best chance of survival, the rate for these wounds being 14.1 percent. Those with combined injuries of the colon and rectum had the least chance, the rate for these wounds being 46.2 percent. Univisceral wounds of the colon carried a higher case fatality rate (22.7 percent) than similar wounds of any other organ except the stomach (table 36, p. 218).

TABLE 71.-Influence of site of injury on case fatality rates in 328 univisceral wounds of colon and rectum

Site of injury

Cases

Deaths

Case
 fatality
 rate

Right colon

107

20

18. 7

Transverse colon

60

14

23. 3

Left colon 

65

17

26. 2

Multiple injuries of colon

19

6

31. 6

Rectum

64

9

14. 1

Colon and rectum

13

6

46.2

Total

328

72

22.0


CAUSES OF DEATH

It is not possible to state the causes of death with complete accuracy in the 433 patients who died with injuries of the colon and rectum (table 72). In many instances, injuries of other viscera, as well as associated injuries of the head, extremities, and chest, were probably responsible, wholly or in part, for the fatality. In 36 cases, the cause of death was not stated at all on the records, and it was not possible to determine it from the data available. Most of the remaining 397 patients were subjected to partial or complete necropsy, or the records were sufficiently detailed and specific to permit a primary cause of death to be determined.

Shock.-Shock, which occurred in 185 cases, 46.6 percent of the fatalities in which the cause of death could be determined, was the largest single primary cause of death. The patients in this group were all gravely wounded. On admission to the field hospital, they were almost invariably in severe shock, which usually did not respond fully, if at all, to adequate preoperative resuscitative therapy. All were operated on, but they usually did not respond to heroic measures employed during and after operation. Sometimes they did not react at all after surgery. Thirteen died on the operating table. A few lived as long as 36 hours, but in most of the fatal cases those who survived the operation died within 24 hours. In numerous instances, it was not possible to determine


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TABLE 72.-Distribution of primary causes of death in 397 injuries of colon and rectum1

Cause

Cases

Proportion


Percent

Shock

185

46.6

Intra-abdominal:

Peritonitis, generalized

87

21.8

Hemorrhage

6

1.5

Cellulitis (retroperitoneal)

5

1.3

Abscess

5

1.3

Anaerobic infection

5

1.3

Intestinal obstruction

4

1.0

Total

112

28.2

Anuria

235

8.8

Intrathoracic:

Pneumonia

13

3.3

Pulmonary embolus

11

2.8

Pulmonary edema

7

1.7

Severe chest injury

6

1.5

Atelectasis

4

1.0

Blast injury

4

1.0

Total

45

11.3

Cranial:

Head injury

6

1.5

Fat embolism

1

.25

Total

7

1.8

Other:

Anaerobic infection

4

1.0

Injury of extremity

1

.25

Not recorded, but primary cause clearly not intra-abdominal

8

2.0

Total

13

3.3

Total deaths from known causes

397

100.0


1Exclusive of 36 cases in which the primary cause of death was not stated.
2In some of these cases hemorrhage, shock, and peritonitis perhaps played the dominant role.

whether death was caused by shock alone or by a combination of shock and the effects of an overwhelming peritoneal contamination. There is no doubt that it occurred before a fatal type of infectious peritonitis was established, but there is also no doubt that in most of these early fatal cases there was enough irritative peritoneal contamination, from the spill of feces, small-bowel contents, and bile,


273

blood, and urine, to cause a shock reaction. The actual loss of blood, in combination with other factors, was of enormous importance in these patients in the causation of the severe and fatal type of shock which they presented.

Death from shock was particularly likely to occur after operation for extensive wounds involving the right side of the colon, the cecum, and the lower ileum, the reason being that in these portions of the bowel the contents are liquid and possess notably irritating properties. The high case fatality rates in these injuries were disturbing, and there were frequent changes in the plan of management, with, however, no great improvement in results.

Intra-abdominal causes of death-Intra-abdominal causes of death were responsible for the fatalities in 112 cases, 28.2 percent of the total number (table 72). All these deaths were the direct or indirect result of infection except for six in which hemorrhage was the primary cause. Postoperative hemorrhage was, however, unimportant in this series as a primary cause of death.

In 87 cases (21.8 percent of the total number of deaths), the peritonitis present was sufficiently extensive to assign to it the primary role in the fatality. Fatal peritonitis was most frequent in lesions of the right side of the colon, in which it accounted for 24 percent of the fatalities, and least frequent in sigmoid lesions, in which it was responsible for 15 percent. Peritonitis was less to be feared in World War II than in former wars, and it is difficult to see how the number of deaths from this cause could have been further reduced. There was no evidence that the intraperitoneal use of chemotheraeutic and antibiotic agents greatly influenced the case fatality rates, though there is no doubt that the systemic use of sulfonamide drugs, replaced or supplemented by penicillin after the latter became generally available in May 1944, had an important role in the control and treatment of peritoneal infections.

A number of patients probably died of peritonitis who might have survived the infection if it had not been present in association with another serious lesion. Others who died from peritonitis during periods of great tactical activity would perhaps have been saved if they could have had the individualized treatment which this condition demands but which was practical only when fighting was less intense.

Two of the five deaths from retroperitoneal cellulitis occurred in patients with wounds of the extraperitoneal portion of the rectum. In the three other cases in this group, the original lesions were distributed over the colon, from the ascending portion to the sigmoid. Of the 5 deaths from intraperitoneal abscess, 1 followed a wound of the ascending colon and 4 followed wounds of the transverse colon. Figures relative to abscess formation must not be accepted absolutely, since this complication was a delayed development and deaths caused by it usually occurred in second or third echelon hospitals.

All five deaths from intraperitoneal anaerobic infections occurred prior to February 1944. Whether the availability of penicillin soon after this date played any part in the improvement, it is not possible to say.

All four patients who died of intestinal obstruction also had injuries of the small bowel, which in every instance was the site of the obstruction. In two


274

known instances, the obstruction followed the breakdown of an intestinal anastomosis. The number of deaths from intestinal obstruction must be evaluated in the light of the fact that this complication, like abscess formation, was often a late development, and fatalities caused by it were as likely to occur in rear as in forward hospital installations.

Intrathoracic causes of death-The 45 deaths from intrathoracic causes accounted for 11.3 percent of the total number. The majority need no particular comment. The fact that pneumonia was responsible for only 13 deaths can probably be attributed to two circumstances: (1) The routine use of chemotherapeutic and antibiotic agents, and (2) the skill of the anesthetists who worked with the surgeons on these cases. Endotracheal anesthesia and tracheobronchial aspiration during and after operation must be assigned an important role in the prevention and control of postoperative atelectasis and, in turn, in the prevention of the pneumonic process which so frequently follows this complication.

Other causes of death-The remainder of the deaths following wounds of the colon and rectum (table 72) were attributable to a variety of causes and for the most part need no special comment. In 2 of the 4 fatal anaerobic infections, the infection was in a wound of the extremity. The infection in the two other cases was considered autogenous; it was apparently the result of direct contamination of the wounds of the buttocks and flank from the wound of the large bowel.

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