Multistage surgical treatment of a victim with a gunshot wound of the extraperitoneal part of the rectum complicated by Fournier’s gangrene

AIM: to present a clinical case of extraperitoneal rectal wound complicated by Fournier’s gangrene, within the framework of multi-stage surgical treatment.

PATIENTS AND METHODS: patient H., sustained a shrapnel wound to the perineum with non-destructive extraperitoneal damage to the middle rectum. At the 2nd level of medical care, surgical treatment included end sigmostomy, suturing of the rectal wound, bilateral pararectal drainage. Three days after, a surgical intervention was performed at the 4th level of medical care for the developed complication — Fournier’s gangrene. On the 14th day, the patient was discharged for outpatient treatment.

RESULTS: this clinical case showed that the end colostomy in case of non-destructive extraperitoneal rectal injury became the reason for refusing to perform an important element of the 4D concept — antegrade distal washout. Thus, the unsanitized disconnected section of the rectum most likely became the source of a formidable complication — Fournier’s gangrene. In addition, suturing the defect of the rectal wall in this clinical case was not a priority element of the 4D concept, and routine pararectal drainage did not have a significant impact on the prevention of infectious complications.

CONCLUSION: extraperitoneal rectal wounds are associated with a high risk of developing life-threatening complications. Surgical treatment of this category of victims at various stages of medical evacuation should be based on a personalized approach, depending on the nature of the injury, the patient’s condition, the experience of the medical staff, and the medical tactical situation. Despite the difficulties in continuity between the stages of medical evacuation in the system of multi-stage surgical treatment, timely diagnostiсs and treatment of complications can minimize the consequences of combat surgical trauma.

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