CHAPTER XX
Wounds of the Colon and Rectum
(1,222Casualties)
C. Frank Chunn, M. D., and Richard V. Hauver, M. D.
In the 3,154 casualties with abdominal wounds treated bysurgical teams of the 2d Auxiliary Surgical Group between 1 January 1944 and 8May 1945, there were 1,222 with wounds of the colon, rectum, or both. Theseinjuries are in addition to the 136 similar injuries treated between April andDecember 1943. The case fatality rate in the 1943 series was 42.6 percent (58deaths), as compared with 35.4 percent (433 deaths) in the cases managed in 1944and 1945. The essential data in the 1944-45 cases are set forth in table 55.
TABLE 55. -Essential data in 1,222 woundsof 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 patientswith wounds of the colon and rectum for whom these data were available werechiefly (63.0 percent) in the age range 20 to 40 years. The case fatality ratewas essentially the same for this age group (33.8 percent) as for the group frominfancy to 20 years (32.4 percent), although the latter group includes civilianchildren who had a rate somewhat above the average. The 22 casualties over 40years of age, 10 of whom died, were chiefly civilians.
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NATURE OF THE LESION
Wounds of the colon were caused by the same agents, which were implicatedwith approximately the same frequency, as all other abdominal wounds (p. 92).The series does not include serous and seromuscular lacerations withoutperforation into the lumen. There were only a few of these injuries, and theyresulted chiefly in minor bruises or subserosal hematomas. The series is made upentirely of perforations, transections, and other severe injuries to the largebowel, including injuries which resulted in interruption of the blood supply.The perforations, as in injuries of other portions of the bowel, ranged fromsmall holes without leakage to injuries which completely destroyed largesegments of the bowel and were associated with massive fecal spillage.
Contamination of the retroperitoneal space from a perforationof the extraperitoneal colon was common and always presented a formidablecomplication, particularly in extensive wounds of the right colon. Fecal matterwas spread widely and forcibly through severely damaged muscle and areolartissue. Adequate debridement often required extensive excision of the lumbar andiliopsoas muscles, and satisfactory surgery was often performed with difficultybecause of extensive hematoma formation and the close proximity of importantanatomic structures, notably the ureter and the great vessels of the pelvis.Identification of retroperitoneal structures and the control of hemorrhage werefrequently time consuming and of great technical difficulty.
Of the 1,358 wounds of the colon treated in the 1943-45 period, 191 werethoracoabdominal (table 56).
TABLE 56.-Case fatality rates in 191thoracoabdominal 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 |
| 191 | 95 | 49.7 |
1These injuries occurred in the 1,358 wounds of thelarge bowel treated in 1943-45.
TIMELAG AND THE MULTIPLICITY FACTOR
The average lapsed time from wounding to operation in the1,222 wounds of the colon and rectum in this series was 10.9 hours, the intervalbeing essentially the same for both fatal and nonfatal cases.1It 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.
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the average time interval of 10.5 hours recorded for all3,154 cases in the total series, as well as with the interval of 11.3 hoursreported for all abdominal injuries in 1943. The average time spent inresuscitation in the hospital before operation was undertaken was 3 hours, whichmakes the interval from wounding to hospitalization between 7 and 8 hours. Inmore than a quarter of all cases (27.5 percent), operation was begun within 6hours of injury, and in almost three-quarters of the cases (74.5 percent) it wasbegun within 12 hours.
A tendency toward an increase in the case fatality rate in wounds of thecolon (table 57) was apparent through the 18-hour period. It ceased after thisinterval. In later categories, the figures available for analysis were too smallto permit conclusions.
The case fatality rates in relation to the timelag between wounding andoperation must be interpreted in the light of two considerations:
1. While in general the patient's chances were improved the shorter theinterval between wounding and surgery, account must also be taken of theinfluence 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 factthat this group included the casualties who were critically and often mortallywounded and who often reached the hospital alive only because of rapidity ofevacuation.
TABLE 57.-Influence of timelag on casefatality 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 | --- | --- | --- | --- | --- | --- |
| 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 ofthe rectum were accompanied by injuries of other viscera in more than half ofall cases (58.7 percent). In both portions of the large bowel, wounds ofadditional viscera caused an increase in the case fatality rate, the increasebeing directly proportional to the number of viscera affected. Injuries of bothsolid and hollow viscera caused an increase in the case fatality rate in aboutthe same proportion. In the 552 wounds of the colon in which hollow viscera werealso injured, there were 205 deaths (37.1 percent); and in
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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 |
| 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 | |||||||||||||
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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 amajor blood vessel of the abdomen was a complication in 25 cases, 23 of whichterminated fatally. In 8 cases, 6 of which were fatal, the vascular injury wasthe only complicating wound.
In the 1,155 cases in which adequate data on the multiplicity factor wereavailable for the tabulation (table 58), there was a definite and almostarithmetical increase in the case fatality rate from 19.5 percent in univisceralinjuries (22.7 percent in wounds of the colon, 14.1 percent in wounds of therectum) to 100 percent when 5 additional organs were injured. The outcome inevery injury of the colon apparently depended more upon the number of additionalorgans injured than upon precisely which organs were involved.
It should be noted that while the case fatality rate rose progressively foreach additional organ injured, there was no consistent increase in the rate forthe various time intervals after injury. The timelag, naturally, is not unimportant. In view of the danger of infection of the peritoneum in wounds of thelarge bowel, timelag was probably more important in such wounds than in anyother type of abdominal wound. When the figures are interpreted in the light ofthese various considerations, they strongly suggest that reduction of thetimelag in patients with wounds of the large bowel enhanced their chances ofsurvival. On the other hand, the bad effects of delay in surgery, the chief ofwhich was the development of peritonitis, were overshadowed by the increasedinfluence of multiple visceral injury, the chief of which was probably shock.
SHOCK
On the basis of clinical appearance, blood pressure, amounts of blood andplasma used in resuscitation, response to measures of resuscitation, and similarcriteria, it was possible to classify 1,140 patients according to the degree ofshock 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 casefatality rate increased proportionately with the increase in the degree ofshock, though when the cases were classified according to the timelag nopronounced differences were observed (table 59) except in the 12- to 18-hourperiod. On the other hand, it seems reasonable to surmise that, as time passedwithout treatment, patients who at first were in minor degrees of shock enteredmore 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 foroperation of patients with wounds of the colon, the greatest reliance was placedupon blood, which was used immediately, liberally, and always in larger amountsthan plasma (table 60). The quantities of plasma, however,
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were probably larger than the tabulated data suggest, because under fieldconditions the full amounts used were not always recorded.
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 |
| 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 1,106casualties.
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 todelay operation until the systolic blood pressure was over 100 mm. Hg. Asexperience increased, this policy was replaced by a regimen in which operationwas performed earlier in the period of resuscitation and active shock therapywas continued throughout the operative procedure. The timelag before operationwas thus shortened in numerous cases in which full resuscitation beforeoperation was notably hard to achieve, particularly in severe injuries of theright colon, evisceration, and active abdominal hemorrhage. Casualties withwounds of the colon associated with extensive fecal soiling showed markedresistance to resuscitation therapy.
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TREATMENT
While on first glance (table 61) it might seem that a verylarge number of procedures were utilized in the 1,222 wounds of the colon andrectum which make up this series, actually there was no wide divergence ofopinion among surgeons in the 2d Auxiliary Surgical Group over how wounds of thelarge bowel should be managed. There were numerous modifications of technique,it is true, but the opinion of the various teams was probably as definite, asconcrete, and as unanimous concerning methods of management as it was in anyintra-abdominal injury. Exteriorization of the injured bowel was a fundamentalprinciple, though several different techniques were employed to accomplish it,and procedures other than exteriorization were resorted to only when for anyreason it was inadvisable or actually impossible to perform this operation.
In general, all surgical procedures for wounds of the colon and rectuminvolved three basic techniques:
1. Exteriorization of the wounded segment of bowel, toprevent intraperitoneal leakage at a suture line. The damaged exteriorizedsegment could be used as the site of colostomy on appropriate indications.
TABLE 61.- Influence of location of injury and type ofoperation on case fatality rates in 1,222 wounds of colon andrectum
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2. Diversion of the fecal stream away from wounds of the distal or lowercolon and rectum, which was accomplished by any one of several techniques ofcolostomy. Colostomy was always performed for perforation of the rectum, butadequate 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 thesurface, so that a diversional colostomy could be performed. Either a tube or atangential enterostomy was utilized in the cecum, though this type of openingcould not be converted into a diversional colostomy.
Special procedures carried out in these wounds of the colon and rectum wereas follows:
1. Loop colostomy, which was a simple exteriorization of a segment of colonthrough an abdominal incision. The exteriorized segment was maintained by a tubelaid across the incision and under the segment of colon (fig. 28A).
2. Spur colostomy, which was exteriorization of a segment of colon or of theproximal and distal ends of a segment of colon, through an abdominal incision.Both limbs of the colostomy were sutured together along the antimesentericsurface for a distance of 3 to 4 inches to form the spur (fig. 28B). The colonwas rotated so that the mesentery lay medially.
3. Tube cecostomy, which was an enterostomy with a rubber tube sutured intothe lumen of the colon and brought out through a small abdominal incision (fig.28C).
4. Intraperitoneal closure with proximal colostomy, which consisted of repairof the perforated colon which was left in the peritoneal cavity while a loop orspur colostomy was done at a convenient distance proximal to the repair.
5. Diversional colostomy, which was a spur or loop colostomy placed proximalto 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 ascendingcolon; (2) closure of the terminal end of the ileum; (3) side-to-sideanastomosis of the ileum and transverse colon, the anastomosis being left in theperitoneal cavity; and (4) exteriorization of the proximal end of the transversecolon as a mucous fistula through a separate incision in the abdominal wall.This procedure was sometimes varied by performing end-to-side ileocolostomy withexteriorization of the proximal end of the colon (fig. 29B). Another variationof the basic technique was the performance of a side-to-side anastomosis betweenthe ileum and transverse colon, with exteriorization of the distal end of theileum and the proximal end of the transverse colon through separate incisions inthe abdominal wall, to create mucous fistulas (fig. 29C).
7. Resection with double-barreled ileocolostomy, which wasessentially the same as resection with spur colostomy, the only difference beingthat one of the exteriorized limbs was ileum and one was colon (fig. 30A).
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FIGURE 28.-Types of colostomy. A. Loopcolostomy. B. Spur colostomy. C. Tube cecostomy.
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8. Posterior drainage (drainage of the fascia propria) andproximal colostomy, which was indicated in wounds of the rectum or of the rectumand the sigmoid. It included (1) a coccygectomy or an incision just lateral tothe coccyx; (2) freeing of the rectum from the fascia propria for drainage ofthe perforated rectum, which was not repaired; and (3) creation of a proximalloop or spur colostomy through an abdominal incision. One variation of thistechnique was to repair the perforated rectum and drain the perirectal space.
9. Resection, with separate exteriorization of the limbs, which requiredresection of a segment of the colon with exteriorization of the proximal anddistal limbs through individual abdominal incisions rather than as adouble-barreled colostomy.
10. Tangential colostomy, which was exteriorization of a small area of theantimesenteric 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 orperforated, it was drained through an independent incision. The peritonealcavity itself was drained in not more than 10 percent of the remaining cases.
REGIONAL INJURIES
The transverse colon alone was involved in the largest numberof cases in this series (417 cases, 34.2 percent), followed in the descendingorder 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 andtransverse
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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 percentof the total number of wounds of the large bowel). All of these patients hadother and more important intra-abdominal wounds. All were treated byappendectomy.
Ascending colon-Wounds of the ascending colon (table 62)presented particularly difficult problems when it was necessary to resect theentire right colon and terminal ileum. Early in the war, the most favoredprocedure under these circumstances was resection and double-barreledileocolostomy, but it carried a case fatality rate of almost 65 percent and wasunsatisfactory for other reasons. It combined the most undesirable feature ofsmall-bowel fistula, that is, an irritant and digestive discharge, with thecontaminating discharge of a colostomy. The resulting fecal contamination ofirritated and digested wound surfaces produced conditions which at times it wasimpossible to control. Later, resection and ileocolic anastomosis and colostomy,with the creation of a single or double mucous fistula, accomplished someimprovement in the case fatality rate, which still, however, remained high (51.7percent). Two patients who required resection of a portion of the ascendingcolon were treated by separate exteriorization of the proximal and distal ends;both died.
There were no deaths in the 27 patients treated by tangentialcolostomy (included under loop colostomy, table 62). This method was employedonly when the perforation was small and was located on the antimesenteric borderof the bowel. Two techniques were used: The bowel was repaired and no fecalfistula was established at operation, or it was not repaired and the perforationwas permitted to serve as the fistula.
FIGURE 30.-Types of colostomy. A. Double-barreled ileocolostomy. B. Tangential colostomy.
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TABLE 62.-Influence of technique on case fatality rates in273 wounds ofascending 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 |
| 273 | 81 | 30.0 |
1Nine additional cases are omitted because no intestinal operation wasperformed in them: Six patients died on the operating table, and in 3 cases, 2of which were fatal, the lesion was missed.
Thirteen patients with injuries of the right side of thecolon were subjected to primary repair, without colostomy, with only one death.The results are not statistically significant, nor are they of particularsignificance clinically. These patients were among the least seriously woundedand are in no wise comparable to the casualties who required resection of theright side of the colon. They are not even comparable to casualties with largesingle wounds of the colon.
Transverse colon-The 417 wounds of the transverse colon included 6comparatively minor injuries in which primary repair of the perforation wassuccessfully carried out without colostomy (table 63). All these six patients made smooth recoveries. Nospecial comment is necessary on any of the other cases in this group.
TABLE 63.-Influence of technique on case fatality rates in 414 wounds oftransverse 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 |
| 414 | 158 | 38.2 |
1Three additional cases are omitted because no intestinal operation wasperformed in them. Two patients died on the operating table, and in 1 case, alsofatal, the lesion was missed.
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Descending colon-Wounds of the descending colon (table 64) presented nospecial problems as compared with wounds of the ascending colon or the lowersigmoid. All were dealt with by some form of colostomy except for the singlecase managed by repair of the perforation with return of the bowel to theperitoneal cavity.
Sigmoid colon-Wounds of the sigmoid colon (table 65) presented twoproblems not encountered in wounds of the colon proximal to the sigmoid:
1. When a perforation of the lower sigmoid was present, itwas often impossible to exteriorize the wounded segment because the distal bowelwas not long enough. In this type of case, the perforation was repaired and aproximal diversional colostomy of either the loop or the spur type was created.
TABLE 64.-Influence of technique on case fatality rates in 119 wounds ofdescending 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 |
| 119 | 41 | 34.5 |
1An additional (fatal) case is omitted because the lesion was missed atoperation.
TABLE 65.-Influence of technique on case fatality rates in 154 wounds ofsigmoid 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 |
| 154 | 49 | 31.8 |
1Three additional cases are omitted because the patients died on theoperating table before the intestinal operation could be performed.
2. The second problem, which was encountered in only fourcases, concerned perforations at the rectosigmoid junction, just at thereflection of the peritoneum on the pelvic floor. In these cases, the procedurejust described
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was followed, with the addition of fascia propria (posterior) drainage of therectum.
Rectum.-The majority of patients with injuries of theextraperitoneal rectum (table 66) were treated by proximal colostomy andposterior drainage. The perforation was closed in 25 of the 107 cases in whichthis technique was used.
Multiple intestinal injuries-The case fatality rate, asmight have been expected, increased sharply when more than one segment of thelarge bowel had been wounded (tables 67 to 70, inclusive). Of the 1,222 patientsin this series, 130 had injuries of two different segments of the colon orinjuries of the colon and rectum. There were 64 deaths in this group (49.2percent). There were 17 deaths (39.5 percent) in the 43 cases in whichcolostomies were created at two different sites.
TABLE 66.-Influence of technique on case fatality rates in 116 wounds ofextraperitoneal rectum
| Operation | Cases | Deaths | Case |
| 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 |
| 116 | 27 | 23. 3 |
| Operation | Cases | Deaths | Case |
| 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 |
| 32 | 18 | 56.3 |
1An additional case is omitted because the patient died on the operatingtable before the intestinal operation could be completed
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TABLE 68.-Influence of technique on case fatality rates in9 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 |
| 9 | 6 | 66.7 |
| 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 |
| 48 | 18 | 37.5 |
1An additional case is omitted because the patient died on the operatingtable before the intestinal operation could be completed.
TABLE 70.-Influence of technique on case fatality rates in39 combined wounds of colon and rectum
| Operation | Cases | Deaths | Case |
| 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 |
| 39 | 20 | 51.3 |
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Up to May 1944, when penicillin first became available, sulfadiazine wasgiven by vein after operation in all injuries of the colon and rectum.Thereafter, penicillin was given at 3-hour intervals from the time the patientreached the hospital until 5 days, or more, after operation. A few surgeonscontinued to use sulfadiazine intravenously in conjunction with it.
Some surgeons who used no antibacterial agent in the abdomenin mildly contaminated cases are known to have employed this method whencontamination of the peritoneal cavity was serious or massive. The case fatalityrate in wounds of the colon and rectum does not seem to have been materiallyaffected by the introduction of either chemotherapeutic or antibiotic agentsinto the peritoneal cavity.
POSTOPERATIVE COMPLICATIONS
According to the records, important postoperativecomplications included peritonitis, pneumonia, anuria, wound infection,atelectasis, evisceration, intestinal obstruction, anaerobic infection, fecalfistula, empyema, secondary hemorrhage, subphrenic abscess and pelvic abscess,pulmonary edema, cerebral embolism, and fat embolism. The list is necessarilypresented without comment, since the records were entirely inadequate.Unquestionably, there were more instances of nonfatal atelectasis and patchybronchopneumonia than the records indicate, just as there were unquestionablymany more wound infections, minor hemorrhages, and temporary partialobstructions from edema in the area of intestinal anastomoses. As for minorcomplications, the majority were simply not entered on the charts.
CASE FATALITY RATES
There were 433 deaths in forward hospitals among the 1,222 patients withperforations of, or other severe damage to, the colon, rectum, or both, a casefatality rate of 35.4 percent (table 55, p. 255). Actually, for reasons pointedout elsewhere (p. 85), there is little doubt that the rate was somewhat higher thanthese figures indicate.
The case fatality rates for injuries of the large bowelimproved progressively as the war progressed. In 1943, there were 58 deaths in136 casualties (42.6 percent); in 1944, 334 deaths in 917 casualties (36.4percent); 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 wasmultivisceral. In univisceral injuries of the colon, the rate was 22.7 percent(table 55, p. 255). In univisceral injuries of the extraperitoneal rectum, itwas 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 multivisceralinjuries 53.8 percent.
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When only univisceral injuries of the large bowel wereconsidered (table 71), the case fatality rate was found to vary according to thesite of the wound and the number of wounds. Casualties who had sustainedinjuries of the extraperitoneal rectum had the best chance of survival, therate for these wounds being 14.1 percent. Those with combined injuries of thecolon and rectum had the least chance, the rate for these wounds being 46.2percent. Univisceral wounds of the colon carried a higher case fatality rate(22.7 percent) than similar wounds of any other organ except the stomach (table36, p. 218).
| Site of injury | Cases | Deaths | Case |
| 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 |
| 328 | 72 | 22.0 |
CAUSES OF DEATH
It is not possible to state the causes of death with complete accuracy in the433 patients who died with injuries of the colon and rectum (table 72). In manyinstances, injuries of other viscera, as well as associated injuries of thehead, extremities, and chest, were probably responsible, wholly or in part, forthe fatality. In 36 cases, the cause of death was not stated at all on therecords, and it was not possible to determine it from the data available. Mostof the remaining 397 patients were subjected to partial or complete necropsy, orthe records were sufficiently detailed and specific to permit a primary cause ofdeath to be determined.
Shock.-Shock, which occurred in 185 cases, 46.6 percent of the fatalities inwhich the cause of death could be determined, was the largest single primarycause of death. The patients in this group were all gravely wounded. Onadmission to the field hospital, they were almost invariably in severe shock,which usually did not respond fully, if at all, to adequate preoperativeresuscitative therapy. All were operated on, but they usually did not respond toheroic measures employed during and after operation. Sometimes they did notreact at all after surgery. Thirteen died on the operating table. A few lived aslong as 36 hours, but in most of the fatal cases those who survived theoperation died within 24 hours. In numerous instances, it was not possible todetermine
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TABLE 72.-Distribution of primary causes of death in397 injuries of colonand 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 |
| 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 |
| 45 | 11.3 |
Cranial: | ||
| Head injury | 6 | 1.5 |
| Fat embolism | 1 | .25 |
| 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 |
| 13 | 3.3 |
| 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 playedthe dominant role.
whether death was caused by shock alone or by a combinationof shock and the effects of an overwhelming peritoneal contamination. There isno doubt that it occurred before a fatal type of infectious peritonitis wasestablished, but there is also no doubt that in most of these early fatal casesthere was enough irritative peritoneal contamination, from the spill of feces,small-bowel contents, and bile,
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blood, and urine, to cause a shock reaction. The actual lossof blood, in combination with other factors, was of enormous importance in thesepatients in the causation of the severe and fatal type of shock which theypresented.
Death from shock was particularly likely to occur after operation forextensive wounds involving the right side of the colon, the cecum, and the lowerileum, the reason being that in these portions of the bowel the contents areliquid and possess notably irritating properties. The high case fatality ratesin these injuries were disturbing, and there were frequent changes in the planof management, with, however, no great improvement in results.
Intra-abdominal causes of death-Intra-abdominal causes of death wereresponsible 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 infectionexcept for six in which hemorrhage was the primary cause. Postoperativehemorrhage 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 peritonitispresent was sufficiently extensive to assign to it the primary role in thefatality. Fatal peritonitis was most frequent in lesions of the right side ofthe colon, in which it accounted for 24 percent of the fatalities, and leastfrequent 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 isdifficult to see how the number of deaths from this cause could have beenfurther reduced. There was no evidence that the intraperitoneal use ofchemotheraeutic and antibiotic agents greatly influenced the case fatalityrates,though there is no doubt that the systemic use of sulfonamide drugs, replaced orsupplemented by penicillin after the latter became generally available in May1944, had an important role in the control and treatment of peritonealinfections.
A number of patients probably died of peritonitis who might have survived theinfection if it had not been present in association with another serious lesion.Others who died from peritonitis during periods of great tactical activity wouldperhaps have been saved if they could have had the individualized treatmentwhich this condition demands but which was practical only when fighting was lessintense.
Two of the five deaths from retroperitoneal cellulitis occurredin patients with wounds of the extraperitoneal portion of the rectum. Inthe three other cases in this group, the original lesions were distributed overthe colon, from the ascending portion to the sigmoid. Of the 5 deaths fromintraperitoneal abscess, 1 followed a wound of the ascending colon and 4followed wounds of the transverse colon. Figures relative to abscess formationmust not be accepted absolutely, since this complication was a delayeddevelopment and deaths caused by it usually occurred in second or third echelonhospitals.
All five deaths from intraperitoneal anaerobic infections occurred prior toFebruary 1944. Whether the availability of penicillin soon after this dateplayed any part in the improvement, it is not possible to say.
All four patients who died of intestinal obstruction also had injuries of thesmall bowel, which in every instance was the site of the obstruction. In two
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known instances, the obstruction followed the breakdown of anintestinal anastomosis. The number of deaths from intestinal obstruction must beevaluated in the light of the fact that this complication, like abscessformation, was often a late development, and fatalities caused by it were aslikely to occur in rear as in forward hospital installations.
Intrathoracic causes of death-The 45 deaths from intrathoracic causesaccounted for 11.3 percent of the total number. The majority need no particularcomment. The fact that pneumonia was responsible for only 13 deaths can probablybe attributed to two circumstances: (1) The routine use of chemotherapeutic andantibiotic agents, and (2) the skill of the anesthetists who worked with thesurgeons on these cases. Endotracheal anesthesia and tracheobronchial aspirationduring and after operation must be assigned an important role in the preventionand control of postoperative atelectasis and, in turn, in the prevention of thepneumonic process which so frequently follows this complication.
Other causes of death-The remainder of the deaths following wounds ofthe colon and rectum (table 72) were attributable to a variety of causes and forthe 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 othercases was considered autogenous; it was apparently the result of directcontamination of the wounds of the buttocks and flank from the wound of thelarge bowel.
