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Injury (1990) 21,294-295

Printedin Great Britain

Traumatic perforation of the bowel J. Alexander-Williams The General Hospital, Birmingham,

UK

In fiction, particularly in cinema fiction, we often see the victims of stabbing or gunshot wounds to the abdomen dying rapidly and often dramatically at the site of combat. All surgeons who have been involved in the treatment of traumatic perforations of the bowel know that this is far from the truth. Death is not the inevitable consequence of traumatic bowel perforation; it now occurs rarely and, if it does so, then only after days, weeks, or even months of a battle against infection. We also know that traumatic perforation of the bowel, even in elderly Presidents and Popes, eventually responds satisfactorily to surgical intervention. There will probably be few of us who have the worrying privilege of being on duty when Heads of State or Church are admitted with such a mishap, but in case we ever are we should be aware of current thinking lest the eyes of the world turn on us and find us unprepared. The management of such perforations has been subjected to pendulum swings of fashion almost as great as those of skirt length. Most of the major advances in the management of this once frequently fatal mishap have been the experience of war, which has provided thinking surgeons with an enormously concentrated experience. Sadly, in modem so-called ‘peacetime’ there are some parts of the world with such endemic violence from what is sometimes described as the local Knife and Gun Clubs that some hospitals have such a wealth of clinical material that even prospective randomized trials become possible. In 1979, following the presentation to the Annual Meeting of the American Surgical Association of one of the few prospective randomized studies performed on this subject (Stone and Fabian, 1979) the discussant was Dr Owen Wangensteen of Minneapolis (Wangensteen, 1979), already emeritus and steeped in surgical history. It was he who informed the audience that it was a Russian surgeon and affluent Princess, Vera Gedroitz, who was the first to operate successfully on a series of abdominal gunshot injuries in the Russo-Japanese war of 1904. Apparently her wealth enabled her to engage ambulances to send to the fighting front and evacuate the casualties rapidly to hospital. It is amazing that in those days any such patients survived. That they did was a tribute to the Princess’s surgical ability and clairvoyance in arranging early ambulance evacuation. Before the Second World War and the ready availability of antibiotics, the surgical textbooks apparently advocated primary closure more in hope than expectation. In Britain it has been customary to cite the writings of Major General (later Sir) Heneage Ogilvie who, observing a 53 per cent mortality in battle wounds associated with a perforated 0 1990 Butterworth-Heinemann OOZO-1383/90/050294-2

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colon, advocated exteriorization (Ogilvie, 1944). Whether it was this change of practice or the synchronous advent of antibiotics and an understanding of fluid and electrolyte balance and blood replacement but the mortality was soon halved. As was usual after Ogilvie’s dicta the rule of post hoc ergo pmpber hoc was applied. Therefore exteriorization became fashionable even though it led to protracted hospitalization and further operative intervention. Since then the pendulum has continued to swing until in the late 1980s most of the reports were of the success with primary closure. My own introduction to bowel trauma was as a highly inexperienced army surgical specialist recalled from the reserves with only an appendicectomy or two to my credit. I was entrusted with the management of battle wounds incurred during the ill-fated Suez invasion at the end of 1956. Instead of being confronted by a wounded churchman or politician I remember vividly being entrusted with the care of a portly, middle-aged Egyptian police sergeant who had a bullet through the middle of his lower abdomen that left his body at the back taking a large central portion of his sacrum with it. I operated on an improvised table on the lower flight deck of a superannuated aircraft carrier, steaming its sickening way westwards from the battle area to Malta. Hanging on to retractors for support I found no other visceral injury but the entrance and exit from the rectum with little contamination. Playing Pope-safe, I performed a sigmoid colostomy over a large glass rod and sutured the anterior rectum. Friends told me later that he survived! Since then, working in Birmingham, England, a gentle part of the world and mostly at peace, my continued experience of colonic perforation has been almost exclusively that of iatrogenic injuries. Spurred on by my reading of those with a large experience of civilian injuries, I have been persuaded to adopt a more and more aggressive approach of primary suture without decompression or exteriorization. Such seems to be the hallmark of contemporary civilian practice. The story of the swings of the pendulum, although it makes interesting history, contributes little to current practice. Let me summarize my understanding of recent events and present perceived wisdom. The wartime dictum of Gordon-Taylor (1939), Ogilvie (1944), Imes (1945) and others that primary suture was dangerous, was questioned soon after the war by Woodhall and Ochsner (X951), and shortly after by Pontius et al. (1957). From civilian centres where urban violence was common, it was soon realized that it was no longer necessary to exteriorize most wounds; there was early admission to hospital, laparotomy before

Alexander-Williams:

Traumatic perforation of the bowel

infection had caused widespread peritonitis and the appropriate use of resuscitation and antimicrobial prophylaxis. Clean wounds without gross contamination could be sutured primarily. The only debate then was what were the factors that made it unsafe to adopt this primary suture policy. Moore et al. (1981) helped to make it easy for the relatively inexperienced surgeon to prognosticate by developing a penetrating abdominal trauma index (PATI). This was calculated by assigning risk factors I to 5 to each organ injured and multiplying it by the severity of the injury estimate, also from I to 5. The sum of the individual organ scores was then used to make the final penetrating abdominal trauma index. They found that gunshot wounds resulted in a PAT1 greater than 25 in one-third of their patients and was associated with a 46 per cent complication rate. When the PATI was less than 25 there was only a 7 per cent complication rate. Not surprisingly they also found that only 6 per cent of patients with stab wounds had scores above 25. The complication rate was related directly to the PAT1 rather than to whether the injury was by knife or gun. In theory, such an index is of great importance but, as Walt (1981) pointed out in the discussion of this paper, assessment of severity requires more than gross observation of the sum of the seventy of the damage to each organ. He pointed out that we need to take into account the degree of physiological erosion associated with age, smoking, liquor and obesity. Also the degree of physiological disruption caused by the length and depth of shock and the variety of micro-organism invasion associated with any intestinal damage. Also, how much faeces had poured out of the colon and for how long it had been in contact with other tissues. He felt, what others have come to emphasize since, that prognosis was more related to the institution where the treatment was carried out than to the severity of the injury. The best way to achieve a good result in a patient with penetrating visceral trauma is to send them to the right place. In the last decade it has become clear that severe injuries treated in major accident centres achieve incomparably better results, with lower morbidity and mortality, than those treated by general surgeons in smaller institutions. In centres with extensive experience of civilian trauma such as Chicago, Houston, and many other large cities in North, Central and Southern America, they concentrate resources into major trauma centres where skills they have, working together, those of all surgical, anaesthetic and resuscitative disciplines with enough experience in this sad but nonetheless rewarding business of patching together the injured belly. In Britain the experience of such injuries is sporadic, although some would say that in Belfast it is minor endemic. How then should we deal with the problem? For us

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to achieve good results as satisfactorily and efficiently as they do in the Americas we would have to concentrate on staffing relatively few major trauma centres throughout the country. Their experience could become sufficiently concentrated to bring us up into the world league. This would necessitate a degree of organization and, probably, helicopter evacuation that we have not achieved at the moment. Perhaps with the initiative shown by the Royal College of Surgeons of England we will achieve such centres in the future. In the meantime for those of us on duty in district general, or even most teaching hospitals, faced with penetrating abdominal trauma with colonic injury it would probably be best to play safe, consider Walt’s modification of PAT1 and perform primary closure only when it seems perfectly safe to do so. If we continue to follow our wartime heroes and perform the occasional colostomy or exteriorization we will often be wasting the country’s resources and usually much of the patient’s time. Perhaps this is a price we pay for not being under the influence of the local Knife and Gun Club; which is also one of the reasons why many of us prefer practising surgery in Britain.

References Gordon-Taylor G. (1939) War wounds and air raid casualties: the abdominal injuries of warfare - II. Br. Med. J i 235. Imes P. R. (1945) War surgery of the abdomen. Surg. Gynecol. Obstet. 81, 608. Ogilvie W. H. (1944) Abdominal wounds in the Western Desert. Surg. Gynecol. Obstet. 78, 225. Moore E. E., Dunn E. L., Moore J. B. et al. (1981) Penetrating abdominal trauma index. J Trauma 21,439. Pontius R. G., Creech 0. and Debakey M. E. (1957) Management of large bowel injuries in civilian practice. Ann. Surg. 146,291. Stone H. H. and Fabian T. C. (1979) Randomization between primary closure and exteriorization. Ann Surg. 190,430. Walt A. (1981) Discussion of paper on Penetrating Abdominal Trauma Index. J. Trauma 21, 444. Wangensteen 0. H. (1979) Discussion of paper on Management of Perforating Colon Trauma. Ann. Swg. 190, 436. Woodhall J. P. and Oschsner A. (1951) The management of perforating injuries of the colon and rectum in civilian practice. Surgery 29, 305.

Correspondence shouti be addressed to: Prof J. Alexander-Williams, Professor of Gastrointestinal Surgery, The General Hospital, Birmingham B4 6NH, UK.

Traumatic perforation of the bowel.

294 Injury (1990) 21,294-295 Printedin Great Britain Traumatic perforation of the bowel J. Alexander-Williams The General Hospital, Birmingham, UK...
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