Trauma is the leading cause of death and disability in the first four decades of life and is the third most common cause of death overall. It has been calculated that 1,20,000 people die from trauma each year in the USA. In the UK there are more than 18,000 deaths annually due to trauma, the vast majority being RTA (Road Traffic Accidents) [1]. In last 50 years, surgery advanced progressively in managing the trauma victims and enormous studies were made in trauma management. Abdomen is one of the common site of the body-susceptible to various injuries due to its-wider surface area, lack of protection and easily approachable height. Injuries to the intra-abdominal organ may result from blunt trauma (road traffic accidents, assault, falls from a height, crushing etc.), penetrating and perforating injuries (stab, bullet missile, sharp instruments, spikes of glass, wood or metal etc.) and blast trauma. Blast injury is usually the result of explosions from gas leakage, faulty household appliances and sometimes from bomb blast (cocktail) injuries. However, penetrating injuries predominate in urban areas while blunt injuries are more common in rural areas [2]. In traumatic abdominal injury the small intestine is commonly involved viscera (20-25) %. Because, small intestine is occupied most of the abdominal cavity below the liver and stomach and remains in contact with the anterior abdominal wall and against the vertebral column or sacrum, it can easily compressed between vertebral column and injurious agents [3]. The morbidity and mortality for abdominal injuries were quite high. But today the rate has been reduced significantly as compared to previous one. The factors responsible for this are-a) Modern diagnostic facilities b) Early recognition c) Early operation d) A better understanding of Pathophysiology of hemorrhage, shock, sepsis and provision of facilities for its treatment e) Improved pre-and postoperative care f) Improved surgical techniques in the management of some specific injuries and g) Adequate and selective use of antibiotics. Anesthesiologist, diagnostic radiological facilities, intensive nursing care, ready availability of an adequate supply of blood products and a modern operating room remain the other key elements in successful trauma care.

Traumatic small bowel injury is one of the curable traumatic conditions and early detection and treatment giving excellent results in most of the cases. Delay in their recognition often greatly impairs the chance of recovery and outcome. Initial evaluation serves as a base line but is frequently difficult because of masking of abdominal injury by other associated injuries. Under certain circumstances few patients are often unconscious due to alcohol, drug abuse, shock or associated head injury, chest trauma, orthopaedic problems and retroperitoneal injuries may further complicate the diagnostic process [4]. Outcome measures were mortality rate, rates of anastomotic leakage, intra-abdominal and wound sepsis, fascial dehiscence and pulmonic complications. In this series a study of 100 cases on traumatic small bowel injury was conducted with special reference to type and mechanism of injury, age incidence, sex distribution, presentation, pattern with distribution of small gut injuries, operative findings and outcomes of the management of the patients with abdominal trauma.

AIMS AND OBJECTIVES

Traumatic small bowel injury is an emergency case of abdominal trauma which mainly occur by the penetrating and non-penetrating intra- abdominal injuries. Most of the cases of abdominal trauma which we across in our hospital practice are due to road-traffic accidents, assaults, stab injuries, gunshot injuries and injuries by sharp cutting weapons. Meticulous clinical examination and relevant investigations were helped to come in early diagnosis for most of the cases. All the cases were managed by surgical intervention. The aims and objectives of my study were carried out as follows-

• To evaluate early diagnosis of penetrating and non-penetrating intra-abdominal injuries which were involved in small gut.
• To evaluate surgical intervention which was done for management.
• To evaluate elimination of the complications by using a pattern of treatment.
• To evaluate the ultimate outcome of the treatment for formulation a management protocol of these patient.

This study will enable us to realize the importance of early detection, treatment and thereby reducing the mortality and morbidity of small bowel injuries following abdominal trauma.

MATERIALS AND METHODS

The study was carried out with patients of abdominal trauma with suspected small bowel injuries admitted in the Casualty Block of Dhaka Medical College Hospital (DMCH), Dhaka. It was retrospective study and a total number of 100 patients were studied between January 2002 to July 2002. Those cases who died preoperatively and the cases although diagnosed provisionally as small bowel injury but later, on laparotomy, no injury was detected in small gut were excluded from this study. Immediately after admission, the patients were subjected to a thorough and detailed history taking and clinical examination. History taking provided particular attention to the type of injury and time of injury. The clinical examination stressed on pulse rate, blood pressure, respiratory rate, state of hydration, level of consciousness, anaemia, degree of abdominal distension, evisceration of gut or omentum, muscle guard, rebound tenderness, presence or absence of bowel sound and extra-abdominal injuries. Relevant investigations as far as practicable were done and recorded. In those patients requiring urgent laparotomy, all routine investigations were not possible because of lack of urgent laboratory diagnostic facilities. The investigations that could be done on urgent basis were plain x-ray abdomen and chest, Hb% and blood grouping and cross-matching. In a few patients, abdominal paracentesis were done. The preoperative management, like parenteral fluids, nasogastric tube, antibiotics and blood transfusion, given to the patients were recorded. Detailed operative findings and procedures were noted. A careful record of the hospital stay, the postoperative complications and their management were done. Information's regarding particulars of the patient, history, clinical examination, relevant investigations, treatment and ultimate outcome of treatment were recorded from the admission and treatment record files in the standardized protocol purposed for this study. Then all these information's were presented in tabular and graphical form.

RESULTS

Table-1: Nature of trauma (penetrating/blunt) (n=100)

Out of 100 patients in this series, 48 (48%) were penetrating and 52 (52%) were blunt injuries.

Table-2: Types of penetrating trauma (n=48)

Out of 48 patients of penetrating trauma in this series, stab injury was 10 (20.83%), gunshot injury 34 (70.83%), bomb blast injury 2 (4.17%) and instrument injury 2 (4.17%).

Table-3: Types of blunt trauma (n-52)

Out of 52 patients of blunt trauma in this series, 42 (80.77%) cases were from road-traffic accidents, 8 (15.38%) from assault and 2 (3.85%) from animal attack.

Table-4:  Age distribution of the patients (n=100)

Age distribution Age of the patients in this series ranged from 8-68 years with the highest incidence (39%) in persons between 21-30 years, followed by age group 31- 40 (29%) years. The mean age was 33.50 years. Two patients were at ten or below ten years of age and four patients over sixty years of age.

Table-5:  Sex distribution of patients (n=100)

 From the above table out of 100 patients we see that 93 (93%) patients were male, whereas only 7 (7%) patients were female. So, the male to female ratio was (M: F=13.3:1).

Table-6: Clinical presentation (n=100)

In the traumatic abdominal injury almost all of the patients were pain in the abdomen (88%). 55 cases were either localized or generalized abdominal distension, while in 71 and 29 cases there were rigidity and absent bowel sound respectively. It was observed that 38 cases were anaemic while 21 cases were dehydrated.

Table-7: Distribution of patients according to their socio- economic conditions (n=100)

Analyzing the socio-economic condition of the patients it is evident from the above table that highest incidence of trauma found among the patients belonging to the poor socio-economic class i.e. 54 cases (54%) and lowest incidence observed among the high class i.e. 5 cases (5%).

Table-8: Distribution of patients according to their personal habits (n=100)

Above table shows, it is observed that majority of the trauma victims 55 cases (55%) did not have the habit of smoking or drug abuse or alcoholism. 45 cases (45%) were smoker. Whereas, 08 cases (08%) were Next alcoholic and only 03 (03%) cases were drug abuser and both group of them group also were smoker.

Table-9: Time interval between the time of trauma and the time presentation in the casualty unit (n=100)

All the patients arrived in the casualty ward between 1/2 to 50 hours. Maximum number of patients (53%) reported between 1-6 hours, followed by 6-12 hours (24%) and 12-24 hours (13%).

Table-10: Frequency of associated extra-abdominal injuries (n=100)

Isolated trauma to the abdomen (55%) was the commonest findings. Long bones fracture (20%) were the commonest associated extra abdominal injury, followed by thoracic injury (17%) and soft tissue injury (13%).

Table -11:  Results of investigations (n=100)

From the above table we see that out of 100 patients, 72 patients underwent plain X-ray abdomen. Of them, 44 patients (61.11%) showed free gas under the diaphragm but 22 cases (30.56%) no free gas revealed. Four-quadrant peritoneal tap were performed in 15 cases and found positive in 10 cases (66.67%). There were suspected chest injuries in 17 cases found rib fracture, pneumothorax in 12 cases (70.59%) and suspected pelvic injuries in 52 cases, found pelvic fracture only in 7 cases (13.46%) in chest and pelvic X- ray respectively. Unfortunately, IVU, ultrasonography, CT scan etc. could not be conducted due to various difficulties in doubtful, complex situations in any case in this study.

Table-: 12 Subsequent management of the patients (n=66)

Blood transfusion required in 66 patients, preoperative in 42 patients (63.64%), preoperative in 40 patients (60.61%) and postoperative in 40 patients (60.61%).

Table-13:  Associated other intra-abdominal visceral injuries (n=100)

Above table shows no other intra-abdominal injury was encountered in 54 cases (54%) in which 20 cases were penetrating and 34 cases were blunt trauma. Various part of large gut injuries were most common 24 cases (24%), following by mesenteric injury (20%) and liver (12%) and stomach (10%). Solid organs like spleen, kidney, pancreas etc. were less likely involved other than soft hollow viscera in our study.

Table-14:  Laparotomy findings of small gut injury after penetrating abdominal trauma and mortality (n=48)

Above table shows the laparotomy findings out of 48 patients of small gut injury after penetrating abdominal trauma was most common involved organ in jejunal injury with or without other organs in 20 cases (41.67%), followed by ileal injury in 16 cases (33.33%) with or without other organs involvement and 10 cases (20.83%) were occurred in both jejunum and ileum. Out of 48 cases of penetrating abdominal trauma in small gut injury recovered with 8 cases (16.67%) mortality were high incidence in jejunum, ileum with other organs injury in 2 cases (33.33%).

Table-15:  Laparotomy findings of small gut injury after blunt abdominal trauma and mortality (n=52)

Above table shows the laparotomy findings out of 52 patients of small gut injury after blunt abdominal trauma was most common involved organ in jejunal injury with or without other organs in 24 cases (46.15%), followed by ileal injury in 22 cases (42.31%) with or without other organs involvement and 4 cases (7.69%) were occurred in both jejunum and ileum. Out of 52 cases of blunt abdominal trauma in small gut injury recovered with 10 cases (19.23%) mortality were high incidence in jejunum, ileum with other organs injury in 1 case (50%).

Table-16:  Relationship between the time of injury and the time of laparotomy and mortality (n=100)

Above table shows the relationship between the treatment of patients and their mortality rate with time interval. In 30 cases laparotomy was done within 6 hours only 2 patients were died, where the time interval was 6-12 hours 27 cases were cured while 5 cases expired, in 22 cases within 12-24 hours 17 patients were cured and 5 patients died, those patients in whom the time interval was 24-48 hours 9 patients were cured and 5 patients expired and after 48 hours one patient was cured and one patient died. The total mortality out of the 100 cases were 18 (18%).

Table-17:  Operative procedures carried out in this series (n=100)

Out of total 100 cases, 34 patients (34%) required simple repair. Resection and anastomosis were undertaken in 76 cases (76%), repair of mesenteric tear and haemostasis done in 20 cases (20%) while repair liver, spleen and kidney injury in 24 cases (24%), repair of colonic injury and proximal temporary colostomy done in 16 cases (16%).

Table-18: Postoperative complications (n=42)

Above table shows the postoperative complications following operative procedures carried out in this series. Out of the 100 patients, developed postoperative complications in 42 cases (42%) in which, wound infection occurred in 6 cases (14.29%), chest complications in 8 patients (19.05%), residual abscess in 8 cases (19.05%), anastomotic leakage in 10 cases (23.81%), wound dehiscence in 10 cases (23.81%), cardiac complications in 10 cases (23.81%) and septicaemia occurred in 6 cases (14.29%). 18 patients were occurred more than 1 complications.

Table- 19: Rate of incidence of post operative complications of traumatic small gut injury and mortality (n=100)

Above table shows that out of 48 patients, 20 cases (41.67%) were postoperative complications due to penetrating/perforating injury and their mortality were 8 cases (16.67%). Out of the 52 patients, 22 cases (42.31%) were post-operative complications due to blunt trauma and their mortality were 10 cases (19.23%).

Table 20:  Relationship between duration of trauma with admission and postoperative complications (n=100)

Above table shows that as the duration of symptoms increase, number of patients having postoperative complications also increased.

Table-21: Incidence of postoperative complications in relation with perioperative antibiotics (n=100)

Above table shows incidence of postoperative complications were more when no perioperative antibiotics was used.

Table -22:  Eliminate the postoperative complications by using Complications Diarrhoea Wound a pattern of treatment and mortality (n=42)

Above table shows out of the 100 patients of traumatic small bowel injury developed postoperative complications in 42 cases (42%) in which 18 patients were occurred more than one complication. After treated of these 42 complicated patients cured in 24 cases (57.14%) and died in 18 cases (42.87%) were most common septicaemia in 5 cases (83.33%), followed by pulmonary complications in 5 cases (62.5%) and cardiac complications in 6 cases (60%).

Table 23: Mortality chart (n=18)

100 patients having small gut injury following abdominal trauma were selected on the basis of laparotomy findings in this study. Deaths occurred in preoperative resuscitation period were excluded from this calculation. Per operative death: Only 2 patients out of 100 cases, died on operation table in spite of all available measures and technique applied. Post operative death: 15 patients died post operatively; ICU facility being ensured properly. 6 patients having multiple long bones fracture were transferred to orthopedic hospital after laparotomy where one patient succumbed to death due to respiratory failure.

Table-24: Mortality factors (n=18)

In this series, 18 patients expired, 4 cases (22.22%) died due to irreversible shock and multi-organ failure, 5 cases (27.78%) died due to respiratory failure, another 5 cases (27.78%) died from septic shock, 2 patients (11.11%) died from renal failure, only 2 patients (11.11%) died on operation table due to cardiac arrest and uncontrolled haemorrhage.

Table-25:  Outcome of treatment (n=100)

Above table shows the outcome of treatment, majority (71%) of the patients recovered with mortality (18%). Out of 6 patients who were transferred to other hospital after laparotomy where one patient succumbed to death.

Table -26:  Duration of hospital stay (n=81)

Out of 100 cases, 18 patients expired and one patient absconded. So, their hospital stay was not considered. From the above chart it is clear that out of remaining 81 patients, majority 64 (79.02%) of the patients were discharged within 15 days and only 8 patients (9.88%) stayed in the hospital for more than 21 days.

Abdominal trauma is a surgical emergency case occurring both penetrating (e.g. stab, bullet injury) and non-penetrating trauma (e.g. road traffic accident RTA, assault). An injury to the abdomen and its contents accounts for approximately 10% of traumatic deaths that occur annually in the United States [3]. The experience gained during the last three major wars, vast changes in the understanding of the mechanisms of injury, pathophysiology of trauma, improvement in the transport system and technology, methods of anesthesia, knowledge of fluid electrolyte balances and wound management have all improved greatly which are responsible for the advance management of the injured patients and mortality has been reduced markedly. In 1988, Royal College of Surgeon of England report the management of the multiple injured highlighted that at least one in five, and possibly as many as one in three, trauma deaths in the hospital were avoidable which introduced the Advanced Trauma Life Support Course (ATLS), followed by the Advanced Trauma Nursing Course (ATNC) and subsequently the Pre- Hospital Trauma Life Support Course (PHTLS) [1]. These training course have radically altered the management and outcome of injured patients. This study comprises 100 patients of abdominal trauma having small gut injuries admitted in the department of Casualty Surgery, Dhaka Medical College Hospital, Dhaka, from January 2002 to July 2002 in a period of 7 months’ time. So, this study is not a complete one and should not be considered as standard finding in Bangladesh because very few cases are studied against millions of abdominal trauma cases, again because of the source of sample and a very short period of study. From this study it was found that majority 52% was due to blunt trauma and 48% was due to penetrating injury (table-1). In a study by Roy [5], the incidence of gut injury following penetrating versus blunt trauma was 1.5:1. Out of the cases of penetrating trauma, 70.83% comprised by gunshot injury, 20.83% by stab injury, 4.17% by bomb blast injury and 4.17% by sharp instrument injury (Table-2). This figure varies from time to time depending on the law-and-order situation of the country. According to Hoyt and Moossa [3], intra-abdominal injury occurs about 80% of gunshot wounds, 20-30% of stab wounds. The findings as well as our study findings are quite compatible. Out of the cases of blunt trauma, RTA accounted for 80.77%, assault (blow) for 15.38% and animal attack for 3.85% (Table-3I). In a study by Robbs et al [6]. of king Edward Table 3 Hospital, Durban, South Africa, the causes of blunt trauma were as follows: RTA (23.2%), industrial accident (8.9%), physical assault (67.9%). Another study by Perry [7], reported that RTA were responsible for blunt abdominal trauma for 75% of cases. In all these studies and also in our study RTA remained the major cause of blunt abdominal trauma. The mean age incidence in this series was 33.50 years with the highest incidence was in the age group 21-30 years (39%), followed by 31-40 years (29%) (table-4). The above figure indicate that the affected people are younger who are most mobile and active in their daily life and incidence was decreasing with advancing age. This is quite similar with the findings of a study in South Africa by Thomson et al [8] (1996), Richardson et al [9] (1995) showed that 36% patients were in the age group 20-29 years in his study which is almost same as our study (39%). Another study in USA by Dautrive et al. where the peak incidence was in the 4th decade of life [10]. In this series, the incidence was much higher in males (93%) than in females (7%), male to female ratio was 13.3:1 (Table-5). The male predominance in this series may be due to various reasons like male dominant society of the country as well as males are mainly involved in outdoor works, more hospital beds are available for male patients and more awareness of the male patients. Detailed clinical presentation and findings of the cases were studied (Table-6). The commonest modes of presentation were pain (88%) and abdominal distension (55%). Major clinical signs were signs of peritonitis (tenderness-81%), rigidity (71%), hypotension (29%), anaemia (38%), dehydration (21%) and absent bowel sound (29%), indicating peritonitis and paralytic ileus. Hall and Angles [11], have also shown 100% of their cases presented with abdominal pain and 89.3% cases with tenderness with voluntary guarding. Obliteration of upper border of liver dullness was found in (28%) cases and in all such cases, on laparotomy, it was found to have intraperitoneal gut injury. There were also a good number of cases of gut injury without liver dullness obliteration. In this series, the most frequent victims were poor (55%) and middle (41%) socio-economic class (table-7), smokers (45%) (table-8). This figure reflects that violence in the society and ignorance of road traffic rules by the lower socio-economic class, who are mostly illiterate. The well-off socio-economic class were affected due to their continuous traveling nature of works and also by some terrorist in their field of works. In this series, 53% cases arrived at the hospital within 1-6 hours, followed by 24% reached within 6-12 hours (Table-9). This duration of time interval has an important basis regarding the prognosis of the patient. Less the interval of time, better is the chance of survival of the patient with trauma [12]. Among the associated extra-abdominal injuries, long bones fracture (20%) were most common, followed by thoracic injury (17%) and pelvic fracture (7%). Most of the pelvic fractures belonged causing injury to urinary bladder and urethra. Patients (55%) in our series commonly were presented with isolated injury to abdomen and (45%) cases had additional extra-abdominal injuries (table-10). This is again contradictory to published reports of Western series. The answer could lie in the fact that traffic moves at a slower pace in our country and accident involving isolated vehicle is almost always the rule. Whereas multiple vehicles are usually involved in high-speed congested traffic lane in Western country [13,14] Various investigations were done with limited resources. Plain X-ray abdomen in upright position was done in 72% cases, of which 44 cases (61.11%) showed subdiaphragmatic free gas but with no gas in 22 cases (30.56%). Later all patients were found to have hollow viscus injury (small intestine rupture) in this series. So, X-ray examination is not very useful in the diagnosis of traumatic small gut injury as in the diagnosis of fractures (table-11). Abdominal paracentesis was done in 15 cases, of which 10 cases (66.67%) gave positive results. In a study by Robbs et al. [6] abdominal paracentesis yielded 85% positive results. In addition to small gut injuries, 46% cases had associated other intra- abdominal visceral injury [15] in this series, were most common in large gut (24%) cases, followed by mesenteric injury (20%) and liver (12%) and stomach (10%) (table-13). In a study by Hurt in Kentucky in 1980, 73% cases had associated other intra-abdominal injury. In this series incidence of associated injury is less probably because early deaths of patients with multiple solid organs injury before reaching the hospital even death at the spot, poor mode of transportation etc. which were not included in this study which may not be the fact in Western world. On the laparotomy, out of the 48 cases (48%) of small gut injury after penetrating abdominal trauma was most common involved organ in jejunum with or without other organs in (41.67%) cases, followed by ileal injury in (33.33%) cases with or without other organs involvement and (20.83%) cases in both jejunum and ileum. This series shows, out of the 48 patients of penetrating abdominal trauma in small gut injury recovered with 8 cases (16.67%) mortality (table-14). On laparotomy, out of the 52 patients (52%) of small gut injury after blunt abdominal trauma was most common involved organ in jejunum with or without other organs in (46.15%) cases, followed by ileal injury in (42.31%) cases with or without other organs involvement and (7.69%) cases in both jejunum and ileum. This series shows, out of the 52 patients of blunt abdominal trauma in small gut injury recovered with 10 cases (19.23%) mortality (table-15). In the penetrating injuries, highest number of injury were in the jejunum, followed by ileum as because this part of small gut is freely mobile. In blunt trauma, maximum injury also was in the jejunum than ileum. This peritoneal fixed point probably affects injury indirectly by placing this segment of the intestine over the spine. In a study by Martin et al., jenunal injury was commonest in blunt abdominal trauma [16]. In this respect, our study is consistent with them. In this series, 30% cases had surgery within 6 hours of injury where mortality was (6.67%), 32% cases within 6-12 hours of injury where mortality was (15.62%), 22% cases within 12-24 hours of injury where mortality was (22.73%), 14% cases within 24-48 hours of injury where mortality was (35.71%) and 2% cases after 48 hours of injury where mortality was (50.00%) (table-16). This study shows that grater was delayed, more was the mortality. Robbs et al. [6] (1980) shown that mortality was 47.2% in patients who were operated after 24 hours. The results are almost similar to our study. All 100 patients were underwent operative treatment. Resection followed by end-to-end anastomosis required in 76 cases, simple repair and peritoneal toileting in 34 cases, mesenteric repair and haemostasis in 20 cases and large gut repair and proximal temporary colostomy in 16 cases. Other associated injuries like bladder, kidney, liver and splenic injuries were managed accordingly (table-17). Out of the 100 patients 42 cases (42%) developed various post- operative complications where penetrating injurie were in 20 cases (41.67%) and blunt trauma in 22 cases (42.31%) (table-18 & 19). Wound dehiscence, anastomotic leakage and cardiac complications (23.81% each) were the most common complications. Respiratory tract infections and residual abscess were occurred in (19.05% each) cases. Wound infection, urinary tract infection, septicaemia and diarrhoea also occurred in (14.29% each) cases. In was found in this series that postoperative complications rate was greatly increased in patients (85.71%) who were presented after 24 hours of injury (table-20). In our series from the result, it was seen that postoperative complications can be reduced from 55.56% to 34.38% by the use of perioperative antibiotics (table-21). Ridley [17] in his series showed that postoperative complications were found in 48% of cases with perioperative use of antibiotics. 45 18 patients (18%) died out of the 100 patients in my series (table- 22) of these, two patients died during operation on OT table due to and uncontrolled haemorrhage. 15 patients died cardiac arrest postoperatively - 5 cases died due to septic shock, 4 cases due to irreversible shock and multi-organ failure, another 4 cases from respiratory failure and 2 patients from renal failure (table-24). 6 patients had been transferred to orthopedic hospital after laparotomy where one patient succumbed to death due to respiratory failure. Richardson et al [9]. (1995) in his study showed the mortality to be 5.9%. The higher rate of mortality in our country is mostly due to delay in the start of treatment after sustaining injury as most of the patients are transported to the hospital either by tempo or babytaxi and rickshaw van and a few got ambulance. Patients also came from the periphery, during which time they lose most of their blood volume and come in state of irreversible shock. A lack of aseptic environment around the casualty block in our hospital and due to cross-infection among the patients they become infected. These together with their poor socio-economic condition leading to inability to buy proper antibiotics and essential operative materials which contribute to septic shock. Outcome of the treatment, majority (71%) of the patients were discharged on complete recovery and mortality was (18%) (table-25). Transferred to other discipline (3%) for further management and 6 patients who were transferred to other hospital after laparotomy where one patient succumbed to death. A number of patients (2%) left the hospital on risk bond. It may be related to their wrong self-assessment that they have been cured. One patient (1%) mostly police case suspected of criminal offence left hospital unnoticed. Hospital stay of the patients showed that out of 100 cases, 18 patients expired and one patient absconded. So, their hospital stay was not considered. Out of remaining 81 patient’s majority of the patients (51.86%) were discharged within 10 days, (27.16%) patients went home within 11-15 days, (11.11%) within 16-20 days and only (9.88%) patients after more than 21 days, in whom secondary surgery needed either in the form of secondary suture, drainage of residual abscess or relaparotomy was done (table-26). Long-term follow-up of the patients were beyond the scope of this study.

In this series a study of 100 cases of small bowel injury caused by abdominal trauma was an important approach, towards realization of the importance of early diagnosis and proper management. In this dissertation, an attempt had been made to evaluate clinical pattern and distribution of small intestinal injuries following penetrating and non-penetrating trauma. This study also reveals the importance of repeated clinical assessment and simple investigations should go simultaneously for subsequent definite management. Sophisticated investigations are not always essential rather might delay the management of the patients, resulting in increased morbidity and mortality. This study also shows that in doubtful cases, it is better to explore than to wait. Morbidity and mortality was much lower in patients in whom adequate preoperative resuscitation was done and in patients who were operated early (within 12 hours of trauma). Finally our inference is that a trauma unit should be well-equipped and well-staffed comprising general surgeon, orthopaedic surgeon, neuro- surgeon, urologist, chest surgeon and anaesthesiologist under the guidance of a trauma surgeon. Management of trauma patient is essentially a teamwork. Provision of modern diagnostic aids, intensive care facility and trauma team approach both in the pre-hospital and hospital phase by those specially trained in trauma management (ATLS course) may reduce a significant number of avoidable death as well as suffering of the patient. Lastly, I want to mention that we can not prevent all deaths of the patients but at least we can try with our limited resources to reduce the suffering, complications and deaths of the patients based on our knowledge and keen observations, honest intentions and sincere efforts.

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