Considering the time frame and single-center nature of our study, we believed that this is one of the biggest surveys trying to describe the epidemiological characteristics and anatomical pattern of GITIs after the Eastern Association for the Surgery of Trauma (EAST) study published in 2003 (14). Therefore, we thought that our study provided detailed and more updated information regarding the exact pattern of GITIs.
Trauma is a leading preventable cause of death and disability worldwide, especially in developing countries (7, 15). The time interval between the patient's arrival and management is of paramount importance and could predict his/her outcome (16). Management of patients sustaining penetrating insults is more straightforward than those with blunt trauma. GITIs were thought to be infrequent following blunt trauma, mainly when associated with other intra-abdominal solid organ injuries, complicating the management and even patients' outcomes (17).
Consistent with our survey, previously conducted studies have shown that the small bowel is the most frequently injured site following blunt trauma (18, 19). GITIs could occur via two distinct mechanisms or, more commonly, a combination of both in the setting of blunt trauma. The first is the compressive forces against a solid, fixed organ such as the lumbar vertebra, and the second is shearing, linear forces after deceleration injuries. These mechanisms explained the higher prevalence of injuries in centrally-located small bowel than in the large colon, which lacked redundancy, avoiding closed-loop formation (20, 21). Duodenal injuries were the third most frequent isolated GITIs following blunt trauma. Duodenal perforation occurred in eight out of ten patients, while SMT/WHs were detected in only two individuals. Duodenum is located retroperitoneally adjacent to the vertebral and is more infrequent among adult populations than children (22).
The small bowel, especially the jejunum, is not enzymatically and microbiologically active; therefore, any small bowel perforation could be easily missed if the clinicians do not consider the injury. Moreover, other types of injury such as SMT/WH and MI might remain undiagnosed until the organ gangrene or bleeding developed. So, surgeons or even radiologists should always consider GITIs for early detection and patients management because delayed intervention could lead to worse outcomes and increase mortality (23). A diagnostic delay of more than 24 hours increases mortality by threefold (24). In our recent study, however, fifty dismissed cases were detected, thirty-eight of which were transferred to the operating room within 24 hours after hospital admission. Therefore, the mortality rate could not be attributed to the delayed intervention. Neurological damage and other associated injuries are thought to be responsible for this mortality rate (25).
The recent study has shown that the most common associated injuries in patients with blunt trauma were liver and splenic injuries, as would be expected (26). GITIs associated with trauma to the solid organs may be complicated by catastrophic bleeding and hypovolemic shock. The presence of such associations might distract physicians from GITIs because the recent trend in the management of solid organ injuries is a conservative treatment leading to more delayed surgical treatment of GITIs (7).
Based on our survey, patients sustaining penetrating injuries were significantly younger and had fewer associated injuries than those following blunt trauma. They were more hemodynamically stable, had shorter HLOS, and better outcomes. We hypothesized that this better outcome could result from more localized injuries after penetrating insults, specifically stabbing as the most common mechanism of injury in penetrating trauma. This led to less frequent associated injuries and, together with the younger age and less comorbid conditions, improved in-hospital outcomes.
The proper management of anorectal injuries is crucial since these injuries might result in morbidity and mortality primarily when associated with concomitant vascular injuries. Steel et al. reported that more than one-third of patients with rectal and vascular injuries died within the first week following the trauma (27). In our study, however, only two cases with anorectal injuries died. They admitted to our center following MVAs and had associated pelvic fractures and vascular injuries. Actually, all MVA-induced anorectal injuries were associated with pelvic fractures. They were died 72 hours after hospital admission.
Diagnosis of GITIs, especially in patients following blunt trauma, is still challenging and is primarily based on clinical and radiological findings (17). Multiple scoring systems have been developed for early detection and prompt management of patients with GITs, although they could not predict the injury in all situations; "Z score" and "Bowel Injury Prediction Score (BIPS)" were not adequately applicable in the presence of intraabdominal free fluid. Raharimanantsoa et al. developed a scoring system based on the mechanism of injury, serum lactate level, presence of long bone fracture, and intraabdominal free fluid on CT images (24). The routine clinical signs and symptoms such as abdominal pain and tenderness may be absent early in hospital arrival; on the other hand, intoxication and decreased level of consciousness due to neurological damages or sedations may mask the symptoms. Moreover, studies have shown that CT images have 88.3% and 99.4 sensitivity and specificity. However, the false-negative results are not uncommon because CT images could not detect the exact source of intraabdominal free fluid when the injury is associated with solid organ injuries (28).
Our study had some limitations; first of all, the retrospective nature of the study is prone to recall bias. However, we thought that this is insignificant due to the high sample size described within the study. Second, the radiological findings were not reported because we wanted to exclusively focused on intra-operative results and characteristics of GITIs. However, the CT findings were indirectly reported in the ISS.