Travma 2011-3

www.tjtes.org

Cilt - Volume 17

Sayı - Number 3

Mayıs - May 2011

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY

www.tjtes.org Index Medicus, Medline, EMBASE/Excerpta Medica, Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜB‹TAK-ULAKB‹M Türk Tıp Dizini’nde yer almaktadır.

Indexed in Index Medicus, Medline, EMBASE/Excerpta Medica and Science Citation Index-Expanded (SCI-E), Index Copernicus and the Turkish Medical Index of TÜB‹TAK-ULAKB‹M.

ISSN 1306 - 696x

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA AND EMERGENCY SURGERY Editör (Editor) Recep Güloğlu Yardımcı Editörler (Associate Editors) Kaya Sarıbeyoğlu Hakan Yanar Ahmet Nuray Turhan Redaksiyon (Redaction) Erman Aytaç Geçmiş Dönem Editörleri (Former Editors) Ömer Türel Cemalettin Ertekin Korhan Taviloğlu

ULUSAL BİLİMSEL DANIŞMA KURULU (NATIONAL EDITORIAL BOARD) Fatih Ağalar Yılmaz Akgün Levhi Akın Alper Akınoğlu Mehmet Ali Akkuş Murat Aksoy Şeref Aktaş Ali Akyüz Ömer Alabaz Cem Alhan Nevzat Alkan Edit Altınlı Acar Aren Cumhur Arıcı Oktar Asoğlu Mehmet Aşık Ali Atan Bülent Atilla Levent Avtan Yunus Aydın Erşan Aygün Mois Bahar Akın Eraslan Balcı Emre Balık Umut Barbaros Semih Baskan M Murad Başar Mehmet Bayramiçli Ahmet Bekar Orhan Bilge Mustafa Bozbuğa Başar Cander Nuh Zafer Cantürk Münacettin Ceviz Banu Coşar Figen Coşkun İrfan Coşkun Nahit Çakar Adnan Çalık Fehmi Çelebi Gürhan Çelik Oğuz Çetinkale Sebahattin Çobanoğlu Ahmet Çoker Cemil Dalay Fatih Dikici Yalım Dikmen Osman Nuri Dilek Levent Döşemeci Murat Servan Döşoğlu Kemal Durak Koray Dural Engin Dursun Mehmet Eliçevik İmdat Elmas Ufuk Emekli Haluk Emir

Kırıkkale Çanakkale İstanbul Adana Ankara İstanbul İstanbul İstanbul Adana İstanbul İstanbul İstanbul İstanbul Antalya İstanbul İstanbul Ankara Ankara İstanbul İstanbul İstanbul İstanbul Elazığ İstanbul İstanbul Ankara Kırıkkale İstanbul Bursa İstanbul Edirne Konya Kocaeli Erzurum İstanbul Ankara Edirne İstanbul Trabzon Erzurum İstanbul İstanbul Edirne İzmir Adana İstanbul İstanbul Sakarya Antalya Düzce Bursa Ankara Ankara İstanbul İstanbul İstanbul İstanbul

Yeşim Erbil Şevval Eren Hayri Erkol Metin Ertem Mehmet Eryılmaz Figen Esen Tarık Esen İrfan Esenkaya Ozlem Evren Kemer Nurperi Gazioğlu Fatih Ata Genç Alper Gökçe Niyazi Görmüş Feryal Gün Ömer Günal Nurullah Günay Haldun Gündoğdu Mahir Günşen Emin Gürleyik Hakan Güven Tufan Hiçdönmez Gökhan İçöz İbrahim İkizceli Murat İmer Haluk İnce Fuat İpekçi Ferda Şöhret Kahveci Selin Kapan Murat Kara Özalp Karabay Hasan Eşref Karabulut Ekrem Kaya Mehmet Yaşar Kaynar Mete Nur Kesim Yusuf Alper Kılıç Hakan Kınık Talat Kırış Haluk Kiper Hikmet Koçak M Hakan Korkmaz Güniz Meyancı Köksal Cüneyt Köksoy İsmail Kuran Necmi Kurt Mehmet Kurtoğlu Nezihi Küçükarslan İsmail Mihmanlı Mehmet Mihmanlı Köksal Öner Durkaya Ören Hüseyin Öz Hüseyin Özbey Faruk Özcan Perihan Ergin Özcan Akın Özden Cemal Özçelik Niyazi Özçelik

İstanbul Diyarbakır Bolu İstanbul Ankara İstanbul İstanbul Malatya Ankara İstanbul İstanbul Tekirdağ Konya İstanbul Düzce Kayseri Ankara Adana Bolu İstanbul Edirne İzmir Kayseri İstanbul İstanbul İzmir Bursa İstanbul Ankara İzmir İstanbul Bursa İstanbul Samsun Ankara Ankara İstanbul Eskişehir Erzurum Ankara İstanbul Ankara İstanbul İstanbul İstanbul Ankara İstanbul Sakarya İstanbul Erzurum İstanbul İstanbul İstanbul İstanbul Denizli Diyarbakır Ankara

İlgin Özden Mehmet Özdoğan Şükrü Özer Halil Özgüç Ahmet Özkara Mahir Özmen Vahit Özmen Volkan Öztuna Süleyman Özyalçın Emine Özyuvacı Salih Pekmezci İzzet Rozanes Kazım Sarı Ali Savaş İskender Sayek Tülay Özkan Seyhan Gürsel Soybir Yunus Söylet Erdoğan Sözüer Mustafa Şahin Cüneyt Şar Mert Şentürk Feridun Şirin İbrahim Taçyıldız Gül Köknel Talu Ertan Tatlıcıoğlu Gonca Tekant Cihangir Tetik Bülent Tırnaksız Mustafa Tireli Alper Toker Rıfat Tokyay Salih Topçu Turgut Tufan Fatih Tunca Akif Turna Zafer Nahit Utkan Ali Uzunköy Erol Erden Ünlüer Özgür Yağmur Müslime Yalaz Serhat Yalçın Sümer Yamaner Mustafa Yandı Nihat Yavuz Muharrem Yazıcı Cumhur Yeğen Ebru Yeşildağ Hüseyin Yetik Cuma Yıldırım Bedrettin Yıldızeli Sezai Yılmaz Kaya Yorgancı Coşkun Yorulmaz Tayfun Yücel

İstanbul Ankara Konya Bursa İstanbul Ankara İstanbul Mersin İstanbul İstanbul İstanbul İstanbul İstanbul Ankara Ankara İstanbul İstanbul İstanbul Kayseri İstanbul İstanbul İstanbul İstanbul Diyarbakır İstanbul Ankara İstanbul İstanbul Ankara Manisa İstanbul İstanbul Kocaeli Ankara İstanbul İstanbul Kocaeli Urfa Balıkesir Adana İstanbul İstanbul İstanbul Trabzon İstanbul Ankara İstanbul Tekirdağ İstanbul Gaziantep İstanbul Malatya Ankara İstanbul Sakarya

ULUSLARARASI BİLİMSEL DANIŞMA KURULU INTERNATIONAL EDITORIAL BOARD

Juan Asensio Zsolt Balogh Ken Boffard Fausto Catena Howard Champion Elias Degiannis Demetrios Demetriades Timothy Fabian Rafi Gürünlüoğlu Clem W. Imrie Kenji Inaba Rao Ivatury Yoram Kluger Rifat Latifi Sten Lennquist Ari Leppaniemi Valerie Malka Ingo Marzi Kenneth L. Mattox Carlos Mesquita Ernest E Moore

Miami, USA New Castle, Australia Johannesburg, S. Africa Bologna, Italy Washington DC, USA Johannesburg, S. Africa Los Angeles, USA Memphis, USA Denver, USA Glasgow, Scotland Los Angeles, USA Richmond, USA Haifa, Israel Tucson, USA Malmö, Sweden Helsinki, Finland Sydney, Australia Frankfurt, Germany Houston, USA Coimbra, Portugal Denver, USA

Pradeep Navsaria

Cape Town, S. Africa

Andrew Nicol

Cape Town, S. Africa

Hans J Oestern

Celle, Germany

Andrew Peitzman

Pittsburgh, USA

Basil A Pruitt

Peter Rhee

Pol Rommens

William Schwabb

Michael Stein

Spiros Stergiopoulos

Michael Sugrue

Liverpool, Australia

Otmar Trentz

Zurich, Switzerland

Donald Trunkey

Oregon, USA

Fernando Turegano

Madrid, Spain

Selman Uranues

Vilmos Vecsei

George Velmahos

Boston, USA

Eric J Voiglio

Lyon, France

Mauro Zago

San Antonio, USA Tucson, USA Mainz, Germany Philadelphia, USA Petach-Tikva, Israel Athens, Greece

Graz, Austria Vienna, Austria

Milan, Italy

ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

Başkan (President) Başkan Yardımcısı (Vice President) Genel Sekreter (Secretary General) Sayman (Treasurer) Yönetim Kurulu Üyeleri (Members)

Recep Güloğlu Kaya Sarıbeyoğlu Ahmet Nuray Turhan Hakan Yanar M. Mahir Özmen Ediz Altınlı Gürhan Çelik

İLETİŞİM (CORRESPONDENCE)

Ulusal Travma ve Acil Cerrahi Derneği İstanbul Üniversitesi İstanbul Tıp Fakültesi Genel Cerrahi Anabilim Dalı, Travma ve Acil Cerrahi Servisi, 34390 Çapa, İstanbul

Tel: +90 212 - 588 62 46 - 531 12 46 Faks (Fax): +90 212 - 533 18 82 e-posta (e-mail): travma@travma.org.tr Web: www.travma.org.tr

ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY

Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi (Owner) Yazı İşleri Müdürü (Editorial Director) Yayın Koordinatörü (Managing Editor) Amblem Yazışma adresi (Correspondence address)

Tel Faks (Fax)

Recep Güloğlu Recep Güloğlu M. Mahir Özmen Metin Ertem Ulusal Travma ve Acil Cerrahi Dergisi Sekreterliği Deniz Abdal Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 531 09 39 +90 212 - 533 18 82

Abonelik: 2011 yılı abone bedeli (Ulusal Travma ve Acil Cerrahi Derneği’ne bağış olarak) 75.- YTL’dir. Hesap No: Türkiye İş Bankası, İstanbul Tıp Fakültesi Şubesi 1200 - 3141069 no’lu hesabına yatırılıp makbuz dernek adresine posta veya faks yolu ile iletilmelidir. Annual subscription rates: 75.- (USD) p-ISSN 1306-696x • e-ISSN 1307-7945 • Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır. (Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus and Turkish Medical Index) • Yayıncı (Publisher): KARE Yayıncılık (KARE Publishing) • Tasarım (Design): Ali Cangül • İngilizce Editörü (Linguistic Editor): Corinne Can • İstatistik (Statistician): Empiar • Online Dergi & Web (Online Manuscript & Web Management): LookUs • Baskı (Press): Yıldırım Matbaacılık • Basım tarihi (Press date): Mayıs (May) 2011 • Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur. (This publication is printed on paper that meets the international standard ISO 9706: 1994).

YAZARLARA BİLGİ Ulusal Travma ve Acil Cerrahi Dergisi, Ulusal Travma ve Acil Cerrahi Derneği’nin yayın organıdır. Travma ve acil cerrahi hastalıklar konularında bilimsel birikime katkısı olan klinik ve deneysel çalışmaları, editöryel yazıları, klinik olgu sunumlarını ve bu konulardaki teknik katkılar ile son gelişmeleri yayınlar. Dergi iki ayda bir yayınlanır.

Ulusal Travma ve Acil Cerrahi Dergisi, 2001 yılından itibaren Index Medicus ve Medline’da, 2005 yılından itibaren Excerpta Medica / EMBASE indekslerinde, 2007 yılından itibaren Science Citation Index-Expanded (SCI-E) ile Journal Citation Reports / Science Edition uluslararası indekslerinde ve 2008 yılından itibaren Index Copernicus indeksinde yer almaktadır. 2001-2006 yılları arasındaki 5 yıllık dönemde SCI-E kapsamındaki dergilerdeki İmpakt faktörümüz 0,5 olmuştur. Dergide araştırma yazılarına öncelik verilmekte, bu nedenle derleme veya olgu sunumu türündeki yazılarda seçim ölçütleri daha dar tutulmaktadır. PUBMED’de dergi “Ulus Travma Acil Cerrahi Derg” kısaltması ile yer almaktadır.

Dergiye yazı teslimi, çalışmanın daha önce yayınlanmadığı (özet ya da bir sunu, inceleme, ya da tezin bir parçası şeklinde yayınlanması dışında), başka bir yerde yayınlanmasının düşünülmediği ve Ulusal Travma ve Acil Cerrahi Dergisi’nde yayınlanmasının tüm yazarlar tarafından uygun bulunduğu anlamına gelmektedir. Yazar(lar), çalışmanın yayınlanmasının kabulünden başlayarak, yazıya ait her hakkı Ulusal Travma ve Acil Cerrahi Derneği’ne devretmektedir(ler). Yazar(lar), izin almaksızın çalışmayı başka bir dilde ya da yerde yayınlamayacaklarını kabul eder(ler). Gönderilen yazı daha önce herhangi bir toplantıda sunulmuş ise, toplantı adı, tarihi ve düzenlendiği şehir belirtilmelidir.

Dergide Türkçe ve İngilizce yazılmış makaleler yayınlanabilir. Tüm yazılar önce editör tarafından ön değerlendirmeye alınır; daha sonra incelenmesi için danışma kurulu üyelerine gönderilir.

Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; gerektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamamlanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “manuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getirilerek yazarların kontrolüne ve onayına sunulur. Editörün, kabul edilmeyen yazıların bütününü ya da bir bölümünü (tablo, resim, vs.) iade etme zorunluluğu yoktur.

Yazıların hazırlanması: Tüm yazılı metinler 12 punto büyüklükte “Times New Roman” yazı karakterinde iki satır aralıklı olarak yazılmalıdır. Sayfada her iki tarafta uygun miktarda boşluk bırakılmalı ve ana metindeki sayfalar numaralandırılmalıdır. Journal Agent sisteminde, başvuru mektubu, başlık, yazarlar ve kurumları, iletişim adresi, Türkçe özet ve yazının İngilizce başlığı ve özeti ilgili aşamalarda yüklenecektir. İngilizce yazılan çalışmalara da Türkçe özet eklenmesi gerekmektedir. Yazının ana metnindeyse şu sıra kullanılacaktır: Giriş, Gereç ve Yöntem, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekiller.

Başvuru mektubu: Bu mektupta yazının tüm yazarlar tarafından okunduğu, onaylandığı ve orijinal bir çalışma ürünü olduğu ifade edilmeli ve yazar isimlerinin yanında imzaları bulunmalıdır. Başvuru mektubu ayrı bir dosya olarak, Journal Agent sisteminin “Yeni Makale Gönder” bölümünde, 10. aşamada yer alan dosya yükleme aşamasında yollanmalıdır.

Başlık sayfası: Yazının başlığı, yazarların adı, soyadı ve ünvanları, çalışmanın yapıldığı kurumun adı ve şehri, eğer varsa çalışmayı destekleyen fon ve kuruluşların açık adları bu sayfada yer almalıdır. Bu sayfaya ayrıca “yazışmadan sorumlu” yazarın isim, açık adres, telefon, faks, mobil telefon ve e-posta bilgileri eklenmelidir. Özet: Çalışmanın gereç ve yöntemini ve bulgularını tanıtıcı olmalıdır.

Türkçe özet, Amaç, Gereç ve Yöntem, Bulgular, Sonuç ve Anahtar Sözcükler başlıklarını; İngilizce özet Background, Methods, Results, Conclusion ve Key words başlıklarını içermelidir. İngilizce olarak hazırlanan çalışmalarda da Türkçe özet yer almalıdır. Özetler başlıklar hariç 190-210 sözcük olmalıdır.

Tablo, şekil, grafik ve resimler: Şekillere ait numara ve açıklayıcı bilgiler ana metinde ilgili bölüme yazılmalıdır. Mikroskobik şekillerde resmi açıklayıcı bilgilere ek olarak, büyütme oranı ve kullanılan boyama tekniği de belirtilmelidir. Yazarlara ait olmayan, başka kaynaklarca daha önce yayınlanmış tüm resim, şekil ve tablolar için yayın hakkına sahip kişiler-

den izin alınmalı ve izin belgesi dergi editörlüğüne ayrıca açıklamasıyla birlikte gönderilmelidir. Hastaların görüntülendiği fotoğraflara, hastanın ve/veya velisinin imzaladığı bir izin belgesi eşlik etmeli veya fotoğrafta hastanın yüzü tanınmayacak şekilde kapatılmış olmalıdır. Renkli resim ve şekillerin basımı için karar hakemler ve editöre aittir. Yazarlar renkli baskının hazırlık aşamasındaki tutarını ödemeyi kabul etmelidirler.

Kaynaklar: Metin içindeki kullanım sırasına göre düzenlenmelidir. Makale içinde geçen kaynak numaraları köşeli parantezle ve küçültülmeden belirtilmelidir. Kaynak listesinde yalnızca yayınlanmış ya da yayınlanması kabul edilmiş çalışmalar yer almalıdır. Kaynak bildirme “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” (http:// www.icmje.org) adlı kılavuzun en son güncellenmiş şekline (Şubat 2006) uymalıdır. Dergi adları Index Medicus’a uygun şekilde kısaltılmalıdır. Altı ya da daha az sayıda olduğunda tüm yazar adları verilmeli, daha çok yazar durumunda altıncı yazarın arkasından “et al.” ya da “ve ark.” eklenmelidir. Kaynakların dizilme şekli ve noktalamalar aşağıdaki örneklere uygun olmalıdır: Dergi metni için örnek: Velmahos GC, Kamel E, Chan LS, Hanpeter D, Asensio JA, Murray JA, et al. Complex repair for the management of duodenal injuries. Am Surg 1999;65:972-5.

Kitaptan bölüm için örnek: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62.

Sizlerin çalışmalarınızda kaynak olarak yararlanabilmeniz için www.travma.org.tr adresli web sayfamızda eski yayınlara tam metin olarak ulaşabileceğiniz bir arama motoru vardır.

Derleme yazıları: Bu tür makaleler editörler kurulu tarafından gerek olduğunda, konu hakkında birikimi olan ve bu birikimi literatüre de yansımış kişilerden talep edilecek ve dergi yazım kurallarına uygunluğu saptandıktan sonra değerlendirmeye alınacaktır. Derleme makaleleri; başlık, Türkçe özet, İngilizce başlık ve özet, alt başlıklarla bölümlendirilmiş metin ile kaynakları içermelidir. Tablo, şekil, grafik veya resim varsa yukarıda belirtildiği şekilde gönderilmelidir.

Olgu sunumları: Derginin her sayısında sınırlı sayıda olgu sunumuna yer verilmektedir. Olgu bildirilerinin kabulünde, az görülürlük, eğitici olma, ilginç olma önemli ölçüt değerlerdir. Ayrıca bu tür yazıların olabildiğince kısa hazırlanması gerekir. Olgu sunumları başlık, Türkçe özet, İngilizce başlık ve özet, olgu sunumu, tartışma ve kaynaklar bölümlerinden oluşmalıdır. Bu tür çalışmalarda en fazla 5 yazara yer verilmesine özen gösterilmelidir.

Editöre mektuplar: Editöre mektuplar basılı dergide ve PUBMED’de yer almamakta, ancak derginin web sitesinde yayınlanmaktadır. Bu mektuplar için dergi yönetimi tarafından yayın belgesi verilmemektedir.

Daha önce basılmış yazılarla ilgili görüş, katkı, eleştiriler ya da farklı bir konu üzerindeki deneyim ve düşünceler için editöre mektup yazılabilir.

Bu tür yazılar 500 sözcüğü geçmemeli ve tıbbi etik kurallara uygun olarak kaleme alınmış olmalıdır. Mektup basılmış bir yazı hakkında ise, söz konusu yayına ait yıl, sayı, sayfa numaraları, yazı başlığı ve yazarların adları belirtilmelidir. Mektup bir konuda deneyim, düşünce hakkında ise verilen bilgiler doğrultusunda dergi kurallarına uyumlu olarak kaynaklar da belirtilmelidir.

Bilgilendirerek onay alma - Etik: Deneysel çalışmaların sonuçlarını bildiren yazılarda, çalışmanın yapıldığı gönüllü ya da hastalara uygulanacak prosedür(lerin) özelliği tümüyle anlatıldıktan sonra, onaylarının alındığını gösterir bir cümle bulunmalıdır. Yazarlar, bu tür bir çalışma söz konusu olduğunda, uluslararası alanda kabul edilen kılavuzlara ve T.C. Sağlık Bakanlığı tarafından getirilen yönetmelik ve yazılarda belirtilen hükümlere uyulduğunu belirtmeli ve kurumdan aldıkları Etik Komitesi onayını göndermelidir. Hayvanlar üzerinde yapılan çalışmalarda ağrı, acı ve rahatsızlık verilmemesi için neler yapıldığı açık bir şekilde belirtilmelidir.

Yazı gönderme - Yazıların gönderilmesi: Ulusal Travma ve Acil Cerrahi Dergisi yalnızca www.travma.org.tr adresindeki internet sitesinden on-line olarak gönderilen yazıları kabul etmekte, posta yoluyla yollanan yazıları değerlendirmeye almamaktadır. Tüm yazılar ilgili adresteki “Online Makale Gönderme” ikonuna tıklandığında ulaşılan Journal Agent sisteminden yollanmaktadır. Sistem her aşamada kullanıcıyı bilgilendiren özelliktedir.

INFORMATION FOR THE AUTHORS The Turkish Journal of Trauma and Emergency Surgery (TJTES) is an official publication of the Turkish Association of Trauma and Emergency Surgery. It is a peer-reviewed periodical that considers for publication clinical and experimental studies, case reports, technical contributions, and letters to the editor. Six issues are published annually.

As from 2001, the journal is indexed in Index Medicus and Medline, as from 2005 in Excerpta Medica and EMBASE, as from 2007 in Science Citation Index Expanded (SCI-E) and Journal Citation Reports / Science Edition, and as from 2008 in Index Copernicus. For the five-year term of 2001-2006, our impact factor in SCI-E indexed journals is 0.5.

It is cited as ‘Ulus Travma Acil Cerrahi Derg’ in PUBMED. Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Association of Trauma and Emergency Surgery to be effective if and when the manuscript is accepted for publication. The author(s) guarantee(s) that the manuscript will not be published elsewhere in any other language without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place.

Manuscripts may be submitted in Turkish or in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for addition of any missing information to be added. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval.

Unless specifically indicated otherwise at the time of submission, rejected manuscripts will not be returned to the authors, including accompanying materials.

TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medical Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for reviews and case reports.

Manuscript submission: TJTES accepts only on-line submission via the official web site (please click, www.travma.org.tr/en) and refuses printed manuscript submissions by mail. All submissions are made by the on-line submission system called Journal Agent, by clicking the icon “Online manuscript submission” at the above mentioned web site homepage. The system includes directions at each step but for further information you may visit the web site (http://www.travma.org/en/ journal/).

Manuscript preparation: Manuscripts should have double-line spacing, leaving sufficient margin on both sides. The font size (12 points) and style (Times New Roman) of the main text should be uniformly taken into account. All pages of the main text should be numbered consecutively. Cover letter, manuscript title, author names and institutions and correspondence address, abstract in Turkish (for Turkish authors only), and title and abstract in English are uploaded to the Journal Agent system in the relevant steps. The main text includes Introduction, Materials and Methods, Results, Discussion, Acknowledgments, References, Tables and Figure Legends.

The cover letter must contain a brief statement that the manuscript has been read and approved by all authors, that it has not been submitted to, or is not under consideration for publication in, another journal.

It should contain the names and signatures of all authors. The cover letter is uploaded at the 10th step of the “Submit New Manuscript” section, called “Upload Your Files”.

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Chapter in book: Jurkovich GJ. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62.

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ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 17

SAYI - NUMBER 3

MAYIS - MAY 2011

İçindekiler - Contents Deneysel Çalışma - Experimental Studies 193-198 Diagnostic and prognostic value of procalcitonin and phosphorus in acute mesenteric ischemia Akut mezenter iskemide prokalsitonin ve fosforun tanısal ve prognostik değeri Karabulut K, Gül M, Dündar ZD, Cander B, Kurban S, Toy H 199-204 Hemostatic effect of a chitosan linear polymer (Celox®) in a severe femoral artery bleeding rat model under hypothermia or warfarin therapy Hipotermi ve varfarin uygulanan şiddetli femoral arter kanamalı sıçan modelinde kitosan lineer polimer’in (Celox®) hemostatik etkinliği

Köksal Ö, Özdemir F, Çam Etöz B, İşbil Büyükcoşkun N, Sığırlı D 205-209 The effects of methylene blue on adhesion formation in a rat model of experimental peritonitis Deneysel peritonit modelinde metilen mavisinin adezyon formasyonu üzerine etkileri

Kalaycı MU, Eroğlu HE, Kubilay D, Soylu A, Sancak B, Uğurluoğlu C, Erçin U, Koca YS

Klinik Çalışma - Original Articles 210-214 Spontaneous rectus sheath hematoma in patients on anticoagulation therapy Antikoagülan tedavi altındaki hastalarda spontan rektus kılıfı hematomu

Dağ A, Özcan T, Türkmenoğlu Ö, Çolak T, Karaca K, Canbaz H, Dirlik M, Sarıbay R 215-219 Will computed tomography (CT) miss something? The characteristics and pitfalls of torso CT in evaluating patients with blunt solid organ trauma Bilgisayarlı tomografi (BT) bir şeyleri atlıyor mu? Künt solid organ travmalı hastaların değerlendirilmesinde, gövde BT’sinin özellikleri ve tuzakları

Kuo WY, Lin HJ, Foo NP, Guo HR, Jen CC, Chen KT 220-224 Impact of para-neurologic and para-mental premorbidities on burn injury patients Yanık hastalarında nörolojik ve mental morbiditelerin etkisi

Bozkurt M, Kapı E, Gedik E, Kuvat SV 225-230 Penetrating cardiac injury: factors affecting outcome Penetran kalp yaralanmaları: Sağ kalımı etkileyen faktörler

Kamalı S, Aydın MT, Akan A, Karatepe O, Sarı A, Yüney E 231-237 Analysis of trauma patients in a rural hospital in Turkey Türkiye’nin kırsal bir hastanesindeki travma olgularının analizi

Kahramansoy N, Erkol H, Kurt F, Gürbüz N, Bozgeyik M, Kıyan A 238-242 Splenic trauma - our experience at a level I Trauma Center Dalak travması - I. Basamak Travma Merkezi’ndeki deneyimimiz

Saurabh G, Kumar S, Gupta A, Mishra B, Sagar S, Singhal M, Khan RN, Misra MC 243-247 Pediyatrik yaş grubunda trafik kazası sonucu oluşan yaralanmalar ve özellikleri Characteristics of injuries due to traffic accidents in the pediatric age group Serinken M, Özen M

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ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 17

SAYI - NUMBER 3

MAYIS - MAY 2011

İçindekiler - Contents 248-252 Türk acil tıbbının uluslararası literatüre katkısı: 15 yılın değerlendirilmesi Contribution of Turkish Emergency Medicine to the international literature: evaluation of 15 years

Çınar O, Dokur M, Tezel O, Arzıman İ, Acar YA 253-260 Long-term objective results of proximal phalanx fracture treatment Proksimal falanks kırığı tedavisinin geç dönem objektif sonuçları

Özçelik D, Toplu G, Ünveren T, Kaçağan F, Şenyuva CTG 261-266 Long-term outcome and quality of life of patients with unstable pelvic fractures treated by closed reduction and percutaneous fixation Kapalı redüksiyon ve perkütan vidalama ile tespit edilmiş anstabil pelvis kırıklı hastalarda yaşam kalitesinin ve uzun dönem sonuçların değerlendirilmesi

Ayvaz M, Çağlar Ö, Yılmaz G, Güvendik Gİ, Acaroğlu RE

Olgu Sunumu - Case Reports 267-268 Stump appendicitis after laparoscopic appendectomy: case report Laparoskopik apendektomiden sonra güdük apandisit: Olgu sunumu

Bu-Ali O, Al-Bashir M, Samir HA, Abu-Zidan FM 269-272 Travmatik pulmoner psödokist: İki olgu sunumu Traumatic pulmonary pseudocyst: two case reports

Çaylak H, Kavaklı K, Sapmaz E, Yücel O, Genç O 273-276 Reconstruction of complex groin defects with inferior epigastric artery-based rectus abdominis muscle flaps: report of two cases Kompleks inguinal defektlerin inferior epigastrik arterden kanlanan rektus abdominis kas flepleri ile rekonstrüksiyonu: İki olgu sunumu

Kuvat SV, Yanar H, Biçer A, Tunçer S, Özalp B, Topalan M 277-279 Sciatic hernia clinically mimicking obturator hernia, missed by ultrasonography: case report Ultrasonografi tarafından atlanan ve klinik olarak obturator herniyi taklit eden siyatik herni: Olgu sunumu

Rather SA, Dar TI, Malik AA, Parray FQ, Ahmad M, Asrar S 280-282 Nadir görülen bir hemopnömotoraks nedeni: Aberan sistemik arter A rare cause of hemopneumothorax: an aberrant systemic artery

Tezel Ç, Okur E, Baysungur V, Çardak E, Halezeroğlu S 283-285 Rapid resolution of acute epidural hematoma: case report and review of the literature Hızlı rezolüsyon gösteren akut epidural hematom: Olgu sunumu ve literatürün değerlendirilmesi

Dolgun H, Türkoğlu E, Kertmen H, Yılmaz ER, Ergun BR, Şekerci Z 286-288 An unusual cause of small bowel perforation: apricot pit Nadir bir ince bağırsak delinme nedeni: Kayısı çekirdeği

Atila K, Güler S, Bora S, Gülay H

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Mayıs - May 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):193-198

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2011.70493

Diagnostic and prognostic value of procalcitonin and phosphorus in acute mesenteric ischemia Akut mezenter iskemide prokalsitonin ve fosforun tanısal ve prognostik değeri Keziban KARABULUT,1 Mehmet GÜL,1 Zerrin Defne DÜNDAR,1 Başar CANDER,1 Sevil KURBAN,2 Hatice TOY3

BACKGROUND

AMAÇ

In this study, using an animal model of acute mesenteric ischemia (AMI), we investigated the possible use of procalcitonin and phosphorus in the early diagnosis of AMI.

Akut mezenter iskemi (AMİ) modeli kullanılarak yapılan bu çalışmada, serum prokalsitonin ve fosfor düzeylerinin AMİ erken tanısında kullanılabilirliği araştırıldı.

METHODS

GEREÇ VE YÖNTEM

In this study, 21 New Zealand rabbits were used. Subjects were allocated into three groups as Control, Sham and Ischemia. No intervention was performed in the subjects in the Control group. In the subjects in the Sham and Ischemia groups, laparotomy was performed with midline incision.

In the Ischemia group, the superior mesenteric artery was found and tied after laparotomy. Blood was drawn from the animals in all groups at 0, 1, 3 and 6 hours, and procalcitonin and phosphorus levels were studied in these samples.

Çalışmada 21 adet Yeni Zelanda tavşanı kullanıldı. Denekler Kontrol, Sham ve İskemi grubu olarak adlandırıldı. Kontrol grubundaki deneklere herhangi bir girişim yapılmadı. Sham ve İskemi grubundaki deneklere orta hat insizyonu ile laparotomi yapıldı. İskemi grubundaki deneklere ise laparatomi yapıldıktan sonra süperior mezenterik arter bulunarak bağlandı. Her üç gruptaki hayvanlardan 0., 1., 3. ve 6. saatlerde kan alındı, bu numunelerden prokalsitonin ve fosfor çalışıldı.

RESULTS

BULGULAR

In the Ischemia group, the increase in the levels of serum phosphorus and procalcitonin was found to be statistically significant compared to the Control and Sham groups (p<0.05). The levels of phosphorus and procalcitonin were detected to increase from the 1st hour after ischemia onset, and the increase continued for the following 6 hours (p<0.05).

İskemi grubunda, serum fosfor ve prokalsitonin düzeylerindeki yükselme kontrol ve sham gruplarına göre istatistiksel olarak anlamlı bulundu (p<0,05). Fosfor ve prokalsitonin düzeylerinin, iskemi oluşturulduktan sonra 1. saatten itibaren arttığı ve bu yüksekliğin 6 saat boyunca devam ettiği saptandı (p<0,05).

CONCLUSION

Phosphorus and procalcitonin may be important parameters for use in the early diagnosis and prognosis of AMI.

Fosfor ve prokalsitonin’in AMİ’nin erken tanısında ve prognozunda kullanılabilecek önemli parametreler olabileceğini düşünüyoruz.

Key Words: Acute mesenteric ischemia; phosphorus; procalcitonin.

Anahtar Sözcükler: Akut mezenter iskemi; fosfor; prokalsitonin.

Departments of 1Emergency Medicine, 2Biochemistry, 3Pathology, Selcuk University Meram Faculty of Medicine, Konya, Turkey.

SONUÇ

Selçuk Üniversitesi Meram Tıp Fakültesi, 1Acil Tıp Anabilim Dalı, 2 Biyokimya Anabilim Dalı, 3Patoloji Anabilim Dalı, Konya.

Correspondence (İletişim): Keziban Karabulut, M.D. Selçuk Üniversitesi Meram Tıp Fakültesi Acil Tıp Anabilim Dalı, 42100 Konya, Turkey.

Tel: +90 - 332 - 223 72 03 e-mail (e-posta): dr_kezi@hotmail.com

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Acute mesenteric ischemia (AMI) remains a highly fatal disease (70%) despite the improvements in diagnostic and therapeutic methods.[1] The most important factor affecting the outcome of AMI is the duration of the ischemia. Diagnosis must be made immediately in case of suspicion in these patients. Re-instating the blood supply of the bowel in the first 6 hours (h) of ischemia improves the prognosis, especially in emboli-related ischemia. Bacterial and endotoxin absorption causing an inflammatory response increases as the duration of ischemia prolongs. Ischemia progresses and results in sepsis, acidosis, septic shock, and finally death.[2]

Ketamine (50 mg/kg) and xylazine (15 mg/kg) were administered into the hind legs of the subjects in all 3 groups. Vascular access was established on the dorsal auricular veins of the animals using a 22 G needle after anesthesia was provided with the aim of drawing blood and administering fluid. Without any interventions, 3 ml of blood was drawn into gel Vacutainer tubes in order to study procalcitonin and phosphorus at 0, 1, 3, and 6 h in the subjects in the Control group. 5 ml of 0.9% normal saline was administered using the same vascular access following every blood draw. Tissue samples were not obtained from this group.

In AMI, in which early diagnosis is essential, the common result of studies on biochemical markers carried out in recent years is that there is a lack of a sensitive and specific marker with diagnostic potential, sufficient to increase survival. The optimum biochemical marker for the early diagnosis of AMI must be released from the intestinal mucosa, must avoid the hepatic first-pass effect, and must be detected in the peripheral blood. Novel diagnostic markers studied in recent years based on this opinion are promising.

[3-5] Procalcitonin is a protein with a molecular weight of 13 kDa, consisting of 116 amino acids. Its levels increase in severe bacterial, fungal and parasitic infections, autoimmune diseases, sepsis, and multi-organ deficiency syndrome (MODS). Procalcitonin is a pro-inflammatory cytokine-like mediator. Its expression is regulated by pro-inflammatory cytokines like tumor necrosis factor-alpha (TNF-帢) and interleukin (IL)-6.[6] One of the most promising parameters in the early diagnosis of AMI is the serum phosphorus level, which increases just after the occlusion of the mesenteric artery due to release of intracellular phosphorus into the circulation in ischemic injury.[7]

Blood was similarly drawn at 0 h from the subjects of the Sham and Ischemia groups. The abdominal sites of the subjects in each of the two groups were shaved and cleaned using 10% povidone iodine. Laparotomy was performed through a midline incision. The peritoneum was passed in the Sham group. Thereafter, the abdominal wall and the peritoneum were sutured using 2/0 silk. In the Ischemia group, the superior mesenteric artery (SMA) was found and ligated using 0 silk following laparotomy. Thereafter, the abdominal wall and the peritoneum were closed by suturing. 3 ml of blood was drawn from the subjects of the two groups at 0, 1, 3, and 6 h following these procedures. 5 ml of 0.9% normal saline was administered following every blood draw. Tissue samples were not obtained from the Sham group. Subjects in the Ischemia group were sacrificed by administering 50 ml/kg of ketamine intravenously (IV). After the subjects were sacrificed, 10-cm distal ileum specimens were placed in 10% formaldehyde solution after having been washed with normal saline solution for histopathological examination. Tissue specimens were stained with hematoxylin-eosin as paraffin blocks and examined under light microscopy.

In this experimental study, we investigated the possible roles of two markers (procalcitonin and phosphorus) in the early diagnosis and prognosis of AMI by determining the short-term alterations in their levels after development of ischemia.

MATERIALS AND METHODS Approval was obtained from the Experimental Animals Ethics Committee of the Experimental Medicine Research and Training Center. The study was carried out in Selcuk University Experimental Medicine Research and Training Center.

A total of 21 New Zealand rabbits weighing 30003500 g were used in the study. The animals were fed with the same standard feed until 12 h before the experiment. They were fasted for 12 h before beginning the test. The subjects were randomly divided into 3 groups of 7 animals each as Control, Sham and Ischemia groups.

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Sample Preparation Every 5 ml of blood sample placed into gel Vacutainer tubes was centrifuged at 3000 rpm for 10 minutes (min), and then waited for 30 min for coagulation.

The obtained serum samples were placed in Eppendorf tubes by pipetting. 10 cm distal ileum specimens obtained for histopathological examination were fixed with 10% formaldehyde solution after having been washed with normal saline solution and embedded in paraffin blocks following routine xylol-alcohol series.

Evaluation of Samples Biochemical Evaluation An ELISA kit appropriate for determination of procalcitonin (ELISA kit for procalcitonin E0689 Uscn Life Science Inc., Wuhan) was used. A routine biochemistry kit was used for determination of serum phosphorus levels.

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Diagnostic and prognostic value of procalcitonin and phosphorus in acute mesenteric ischemia

Statistical Analysis The collected data were recorded in previously prepared forms. Statistical analyses were performed using the SPSS 16.0 package program. Inter-group comparisons were made using the variance analysis (ANOVA) post-hoc Tukey test in repeated measurements. The Bonferroni correction paired t test was used to determine the difference between measurements. A p value of <0.05 was considered statistically significant.

RESULTS Serum Procalcitonin Values Serum procalcitonin values at 0, 1, 3, and 6 h were significantly higher in the Ischemia group compared to the Control and Sham groups (p=0.003 for both) (Table 1). No statistically significant difference was found between the Control and Sham groups (p=0.809). In the Ischemia group, serum procalcitonin values were found to be higher at 1, 3 and 6 h compared to 0 h, and these increases were found to be statistically significant (p=0.008 at 1 h, p=0.01 at 3 h, p=0.02 at 6 h) (Fig. 1).

Serum Phosphorus Values Serum phosphorus values at 0, 1, 3, and 6 h were significantly higher in the Ischemia group compared to the Control and Sham groups (p=0.001 for both) (Table 2). A statistically significant difference was

1.2

Procalcitonin (ng/dl)

1 0.8 Control Sham Ischemia

0.6 0.4 0.2 0

0

1

3

6

Time (h)

Fig. 1. Time-dependent changes of serum procalcitonin levels.

16 14 Phosphorus (mg/dl)

Histopathological Evaluation On microscopic evaluation of the subjects, it was found that the pulse in the SMA disappeared immediately after ligation and the bowel turned pale. Tissue samples obtained from the Ischemia group at the end of the 6th hour for histopathological examination were evaluated under light microscopy with 100x magnification after staining with hematoxylin-eosin. Mucosal injury was graded according to the scoring system determined by Chiu et al.[8]

12 10

Control Sham Ischemia

8 6 4 2 0 0

1

3

6

Time (h)

Fig. 2. Time-dependent changes in serum phosphorus levels.

found between the Control and Sham groups (p>0.05).

Increases in serum phosphorus levels at 1, 3 and 6 h were found to be statistically significant compared to 0 h levels (p=0.002 at 1 h, p=0.00 at 3 h, p=0.00 at 6 h) (Fig. 2).

Histopathological Findings On histopathological examination of bowel tissues of 7 rabbits from the Ischemia group, bowel tissues of 5 rabbits (71.4%) were evaluated as Grade 5 (hemorrhage, ulceration and necrosis in the lamina propria)

Table 1. Mean, standard error, %95 interval values of procalcitonin in groups Groups Control

Sham

Ischemia*

Time (h)

Mean (ng/dl)

Std. error

%95 interval

0 1 3 6 0 1 3 6 0 1 3 6

0.03 0.03 0.04 0.04 0.03 0.04 0.04 0.17 0.03 0.11 0.61 0.98

0.001 0.009 0.001 0.001 0.001 0.001 0.002 0.11 0.005 0.01 0.17 0.17

0.03-0.04 0.03-0.04 0.03-0.04 0.03-0.04 0.03-0.04 0.04-0.05 0.04-0.05 0.11-0.45 0.04-0.06 0.06-0.15 0.19-1.03 0.4-1.3

*p values determined for the comparison of time-dependent procalcitonin levels in the ischemia group; p=0.008 for hour 1, p=0.01 for hour 3, p=0.02 for hour 6.

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Table 2. The serum phosphorus levels (mg/dl) Phosphorus Control Sham Ischemia*

0. hour

1. hour

3. hour

6. hour

5.14±0.58 5.42±1.16 3.8±0.67

4.32±0.39 5.94±0.52 6.25±1.67

4.45±0.61 6.25±0.76 8.81±0.70

4.55±0.571 5.81±0.69 14.78±1.77

*p values determined for the comparison of time-dependent procalcitonin levels in the ischemia group; p=0.002 for hour 1, p=0.00 for hour 3, p=0.00 for hour 6.

(Fig. 3); bowel tissues of 2 rabbits (28.6%) were evaluated as Grade 4 (ulceration in villus) (Fig. 4).

DISCUSSION Acute mesenteric ischemia (AMI) is a clinical condition that must be diagnosed immediately due to the high mortality rate. Diagnosis is the most important step in the course of the disease due to the insignificant and non-specific clinical findings and limited diagnostic tests.[9] Systemic inflammatory response syndrome and septic complications are usually responsible for the high mortality in AMI.[10] Studies aimed at finding a specific biochemical, serological parameter in the early diagnosis of AMI have been intensified recently.[11] Many laboratory parameters used in the diagnosis of inflammatory diseases indicating the immune response are available. Procalcitonin is a novel parameter that has been added to the infection markers in recent years. Procalcitonin is encountered as an early increasing marker in sepsis and serious infections compared to the inflammatory response parameters such as body temperature, C-reactive protein (CRP) and white blood cell count.[12] With regard to AMI, many studies are available on ILs, TNF-α and CRP of pro-inflammatory cytokines. The increase in blood cytokine levels in AMI indicates that the systemic response appears in the early stages of ischemia, and rather than making the diagnosis, it is valuable in terms of prognosis of the patients.[13,14] In one study, serum IL-6 levels were found to be higher in patients with the diagnosis of AMI compared to the healthy

Fig. 3. Grade 5 hemorrhage, ulceration and necrosis in the lamina propria (H-E x 100).

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control group.[15] In another study performed by creating SMA occlusion in rats, a significant increase was found in TNF-α, IL-6 and IL-1 levels beginning from the 2nd hour in the ischemia group compared to control and laparotomy groups.[16] The procalcitonin level is below detectable values (<0.1 ng/ml); all values above 0.5 ng/ml are considered pathological. Procalcitonin production can be stimulated by bacterial endotoxins, exotoxins and some cytokines. Procalcitonin has been shown to increase before CRP and after TNF-α and IL-6 in acute inflammatory conditions.[12] In previous studies, injection of a small amount of bacterial endotoxin was found to stimulate procalcitonin production in healthy individuals. Procalcitonin levels reach detectable values after 2-3 hours, increase rapidly in 6-8 hours and reach their peak value in 12 hours. The levels remain the same for approximately 12 hours. Thereafter, the levels decrease to the normal level in two days. Half-life of procalcitonin varies between 20-24 hours.[17] In a study comparing procalcitonin levels with CRP, TNF-α and IL-6 levels, procalcitonin was detected to increase before CRP. When this condition was adapted to clinics, procalcitonin was considered to be a better indicator for detection of early stage infections compared to CRP. On the other hand, cytokines like TNF-α and IL-6 increase in the early stage. However, procalcitonin is superior to these cytokines for determination of infections owing to their significantly shorter half-lives.[18]

Fig. 4. Grade 4 uulceration in villus (H-E x 100).

May - Mayıs 2011

Diagnostic and prognostic value of procalcitonin and phosphorus in acute mesenteric ischemia

In a study performed by creating bowel strangulation in rabbits, procalcitonin levels were analyzed and found to be higher in the group with strangulation compared to the normal group. An increase was detected in procalcitonin levels at the 30th and 60th minutes of the study, and it was found to peak at the 120th minute.[19] In another study, procalcitonin levels were detected to be higher in inflammatory bowel disease - Crohn’s disease compared to normal individuals.[20] Studies and information about the course of procalcitonin in AMI and acute ischemic conditions are limited. There is no experimental study in the literature in which procalcitonin levels were assessed in AMI. A few published studies are available on procalcitonin in acute myocardial infarction and acute stroke. In the study of Kafkas et al.,[21] procalcitonin levels were found to be high in the early stage of acute myocardial infarction. In another study, serum procalcitonin levels were evaluated in patients experiencing acute stroke, and an increase in serum procalcitonin levels was detected beginning from the 1st day, with the peak level reached on the 7th day.[22] In this study, procalcitonin levels were evaluated in AMI, which is an ischemic and acute inflammatory disease of the bowel. Carrying out the study on rabbits enabled repetitive blood to be drawn from the same subject, and thus the effect of ischemia duration on procalcitonin levels could be evaluated more accurately. In the study, a minimal increase was detected in the procalcitonin levels at 1 hour. This increase continued over the following hours and reached more significant levels.

In AMI, it was detected in clinical and experimental studies that phosphorus diffused into the circulation as a result of ischemic injury of intestinal tissue, renal phosphorus excretion decreased following ischemia, and the hepatic clearance of phosphorus decreased related to decreased effective perfusion.[7] While the serum phosphorus levels were reported to be high as early as 1 hour after the onset of mesenteric ischemia in some previous studies,[7] other studies reported that the phosphorus level increased only at 3-4 hours following ischemia. In the experimental study of Lores et al.[23] performed on dogs, they found that an increase in the phosphorus levels could be an indicator of an early diagnosis of ischemia; however, the phosphorus levels significantly increased at the 4th hour of ischemia. In another study performed on 28 rabbits, inorganic phosphorus levels were found to increase 2 hours following ischemia, and this increase continued for 24 hours.[24] In a meta-analysis of 20 studies reviewing 18 different biochemical markers, the specificity and sensitivity of serum phosphorus levels in the diagnosis of AMI were found as 82% and 26%, respectively.[3] Cilt - Vol. 17 Sayı - No. 3

In this study, a significant increase in serum phosphorus levels was detected beginning from the 3rd hour in the Ischemia group, consistent with the literature. A significant increase was detected at 6 hours compared to 0, 1 and 3 hours. When compared to the Control and the Sham groups, serum phosphorus was found to increase significantly in the Ischemia group.

In this study, procalcitonin levels were observed to begin increasing as of the 1st hour in the AMI model, and this increase was found to continue in the following hours. Furthermore, a significant increase was found in the phosphorus levels beginning from the 3rd hour.

In conclusion, procalcitonin and phosphorus, which have a prognostic value in inflammatory conditions, can have a significant value in the early diagnosis and prognosis of AMI. However, we believe that further studies are needed in which the other ischemic and inflammatory abdominal pains along with AMI are compared in terms of procalcitonin and phosphorus levels. Supportive clinical and experimental studies on this issue must be carried out.

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2. Acosta-Mérida MA, Marchena-Gómez J, Cruz-Benavides F, Hernández-Navarro J, Roque-Castellano C, Rodríguez-Méndez A, et al. Predictive factors of massive intestinal necrosis in acute mesenteric ischemia. Cir Esp 2007;81:144-9. [Abstract] 3. Evennett NJ, Petrov MS, Mittal A, Windsor JA. Systematic review and pooled estimates for the diagnostic accuracy of serological markers for intestinal ischemia. World J Surg 2009;33:1374-83.

4. Block T, Nilsson TK, Björck M, Acosta S. Diagnostic accuracy of plasma biomarkers for intestinal ischaemia. Scand J Clin Lab Invest 2008;68:242-8.

5. Glenister KM, Corke CF. Infarcted intestine: a diagnostic void. ANZ J Surg 2004;74:260-5.

6. Carrol ED, Thomson AP, Hart CA. Procalcitonin as a marker of sepsis. Int J Antimicrob Agents 2002;20:1-9.

7. Uncu H, Uncu G. Diagnosis of intestinal ischemia by measurement of serum phosphate and enzyme changes and the effectiveness of vitamin E treatment. Turkish Journal of Gastroenterology 1999;10:272-5.

8. Chiu CJ, McArdle AH, Brown R, Scott HJ, Gurd FN. Intestinal mucosal lesion in low-flow states. I. A morphological, hemodynamic, and metabolic reappraisal. Arch Surg 1970;101:478-83.

9. Marshall JC, Vincent JL, Fink MP, Cook DJ, Rubenfeld G, Foster D, et al. Measures, markers, and mediators: toward a staging system for clinical sepsis. A report of the Fifth Toronto Sepsis Roundtable, Toronto, Ontario, Canada, October 25-26, 2000. Crit Care Med 2003;31:1560-7.

10. Abboud B, Daher R, Boujaoude J. Acute mesenteric ischemia after cardio-pulmonary bypass surgery. World J Gastroenterol 2008;14:5361-70.

11. Gönüllü D, Yankol Y, Işiman F, Akyildiz Iğdem A, Yücel O, 197

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Köksoy FN. pH value and potassium level of diagnostic peritoneal lavage fluid in the early diagnosis of acute mesenteric ischemia secondary to arterial occlusion in rats. Ulus Travma Acil Cerrahi Derg 2007;13:261-7.

12. Meisner M. Pathobiochemistry and clinical use of procalcitonin. Clin Chim Acta 2002;323:17-29.

13. Teke Z, Sacar M, Yenisey C, Atalay AO, Kavak T, Erdem E. Activated protein C attenuates intestinal mucosal injury after mesenteric ischemia/reperfusion. J Surg Res 2008;149:21930.

14. Karatepe O, Gulcicek OB, Ugurlucan M, Adas G, Battal M, Kemik A, et al. Curcumin nutrition for the prevention of mesenteric ischemia-reperfusion injury: an experimental rodent model. Transplant Proc 2009;41:3611-6.

15. Sutherland F, Cunningham H, Pontikes L, Parsons L, Klassen J. Elevated serum interleukin 6 levels in patients with acute intestinal ischemia. Hepatogastroenterology 2003;50:41921.

16. Karaagaç H, Zeybek N, Peker Y, Yagci G, Sengul A, Gunhan O, et al. Diagnostic value of plasma cytokine levels in acute mesenteric ischemia: an experimental study. Gulhane J Med 2007;49:216-21.

17. Becker KL, Nylen ES, Cohen R, Snider RH. Calcitonin:

198

Structure, molecular biology, and actions. Principles of Bone Biology. Academic Press Inc.; 1996. p. 471-4.

18. Brunkhorst FM, Heinz U, Forycki ZF. Kinetics of procalcitonin in iatrogenic sepsis. Intensive Care Med 1998;24:888-9.

19. Ayten R, Dogru O, Camci C, Aygen E, Cetinkaya Z, Akbulut H. Predictive value of procalcitonin for the diagnosis of bowel strangulation. World J Surg 2005;29:187-9.

20. Oruç N, Ozütemiz O, Osmanoğlu N, Ilter T. Diagnostic value of serum procalcitonin in determining the activity of inflammatory bowel disease. Turk J Gastroenterol 2009;20:9-12.

21. Kafkas N, Venetsanou K, Patsilinakos S, Voudris V, Antonatos D, Kelesidis K, et al. Procalcitonin in acute myocardial infarction. Acute Card Care 2008;10:30-6.

22. Miyakis S, Georgakopoulos P, Kiagia M, Papadopoulou O, Pefanis A, Gonis A, et al. Serial serum procalcitonin changes in the prognosis of acute stroke. Clin Chim Acta 2004;350:237-9.

23. Lores ME, Cañizares O, Rosselló PJ. The significance of elevation of serum phosphate levels in experimental intestinal ischemia. Surg Gynecol Obstet 1981;152:593-6.

24. Hatipoglu A, Koyuturc I. Serum levels of inorganic phosphorus and creatının kinase in experimental occlusion of mesenteric artery Turkish Journal of Surgery 1999;15:348-55.

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Ulus Travma Acil Cerrahi Derg 2011;17 (3):199-204

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2011.88155

Hemostatic effect of a chitosan linear polymer (Celox®) in a severe femoral artery bleeding rat model under hypothermia or warfarin therapy Hipotermi ve varfarin uygulanan şiddetli femoral arter kanamalı sıçan modelinde kitosan lineer polimer’in (Celox®) hemostatik etkinliği Özlem KÖKSAL,1 Fatma ÖZDEMİR,1 Betül ÇAM ETÖZ,2 Naciye İŞBİL BÜYÜKCOŞKUN,2 Deniz SIĞIRLI3

BACKGROUND

AMAÇ

In this study, the hemostatic efficacy of Celox® in rats under hypothermia or warfarin treatment was investigated.

Bu çalışmada hipotermi ve varfarin tedavisi altındaki sıçanlarda Celox®’un hemostatik etkinliği araştırıldı.

METHODS

GEREÇ VE YÖNTEM

A total of forty-eight Sprague-Dawley female rats weighing 200-350 g were used in the study. Six experimental study groups were designed, as follows: Group 1: Normothermia + compression; Group 2: normothermia + Celox®; Group 3: hypothermia + compression; Group 4: hypothermia + Celox®; Group 5: normothermia + warfarin + compression; and Group 6: normothermia + warfarin + Celox®.

Çalışmada toplam 48 adet ortalama 200-350 gram ağırlığında Sprague-Dawley cinsi dişi sıçan kullanıldı. Her birinde 8 sıçan olan 6 grup oluşturuldu; 1. grup: normotermi + bası, 2. grup: normotermi + Celox®, 3. grup: hipotermi + bası, 4. grup: hipotermi + Celox®, 5. grup: normotermi + varfarin + bası, 6. grup: normotermi + varfarin + Celox®.

RESULTS

BULGULAR

Celox® provided effective hemorrhage control in all three tested groups. There was a statistically significant difference between compression and Celox® implementation in all groups in terms of hemostasis (p-values for the normothermia, hypothermia and warfarin groups were p<0.05, p<0.01 and p<0.01, respectively). Furthermore, the compression numbers were significantly lower in all of the groups that received Celox® than in those in which compression alone was applied (p-values for the normothermia, hypothermia and warfarin groups were p<0.01, p<0.01 and p<0.001, respectively).

Celox® uygulanan tüm gruplarda etkin kanama kontrolü sağlandı. Bası ve Celox® uygulanan tüm gruplar arasında hemostaz açısından istatistiksel olarak anlamlı farklılık saptandı (p değerleri normotermi, hipotermi ve varfarin grupları için sırasıyla; p<0,05, p<0,01 ve p<0,01). Benzer şekilde bası sayısı, Celox® uygulanan tüm gruplarda sadece bası uygulanan gruplardan anlamlı derecede daha azdı. (p değerleri normotermi, hipotermi ve varfarin grupları için sırasıyla; p<0,01, p<0,01 ve p<0,001).

CONCLUSION

Celox®, sadece normotermide değil aynı zamanda hipotermide ve bir oral antikoagülan ajan olan varfarin kullanımında da etkin kanama kontrolü sağlamaktadır.

Celox® provides effective hemorrhage control under conditions of normothermia, hypothermia and use of the oral anticoagulant agent warfarin.

Key Words: Bleeding control; Celox®; hypothermia; warfarin.

Departments of 1Emergency Medicine, 2Physiology, 3Statistic, Uludag University Faculty of Medicine, Bursa, Turkey.

SONUÇ

Anahtar Sözcükler: Kanama kontrolü; Celox®; hipotermi; varfarin.

Uludağ Üniversitesi Tıp Fakültesi, 1Acil Tıp Anabilim Dalı, Fizyoloji Anabilim Dalı, 3Biyoistatistik Anabilim Dalı, Bursa.

2

Correspondence (İletişim): Özlem Köksal, M.D. Uludağ Üniversitesi Tıp Fakültesi, Acil Tıp Ana Bilim Dalı, Görükle Yerleşkesi, 16049 Bursa, Turkey.

Tel: +90 - 224 - 295 32 22 e-mail (e-posta): koksalozlem@gmail.com

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Uncontrolled hemorrhage after trauma is the leading cause of death among military personnel and the second leading cause of death among civilians worldwide.[1] Uncontrolled hemorrhage also has an important role in morbidity.[2] Better methods for providing hemostasis will improve survival and reduce the long-term effects of hemorrhage, and it is expected that one-third of the deaths can be prevented with these methods.[2] Consequently, numerous hemostatic agents have been produced in recent years, and significant improvements have been achieved in their use for traumatic hemorrhage.[2-7] These agents have become alternatives to classical methods of hemostasis like compression and tourniquet, especially for prehospital control of hemorrhage, because standard gauze field dressings and direct pressure are often inadequate in the control of hemorrhage.[8] However, the comparative evaluation of hemostatic agents in human clinical studies is very difficult, and animal studies are therefore needed.[9] Several studies have compared the effects of hemostatic agents, but the results of these studies are controversial.[2,4-7,9] Most of the studies investigating the effectiveness of hemostatic products have employed normothermic conditions. However, hypothermia is a frequent problem encountered in trauma patients and is related to arduous hemorrhage control and increased mortality.

[10-15] Thus, the effects of hemostatic agents should be evaluated under hypothermic conditions.

Many patients today use anticoagulant drugs for thrombotic diseases, mainly heparin, low-molecularweight heparin, pentasaccharide, and warfarin. The effects of hemostatic agents on trauma patients receiving this kind of therapy have been examined; however, these studies were generally performed with heparin, thus necessitating the evaluation of warfarin.

In the present study, Celox®, a hemostatic agent containing chitosan that is approved by the FDA (Food and Drug Administration) for external use, was evaluated in rats with severe femoral artery bleeding under hypothermia or warfarin therapy.

MATERIALS AND METHODS Forty-eight Sprague-Dawley female rats weighing 200-350 g, obtained from Uludag University Faculty of Medicine Laboratory Animals Growing Application and Research Center, were used in the study. The study was supported by the Uludag University Research Fund and was approved by the Uludag University Animal Experiments Ethics Committee.

The rats were anesthetized with 3% isoflurane after being fasted for 12 hours, and after tracheostomy, they were maintained under anesthesia with 2% isoflurane with 21% oxygen support, permitting spontane200

ous respiration via the anesthesia system during the procedure (SurgiVet, Inc., Veterinary Anesthesia and Monitoring Equipment, Multi-Station Lab Research Anesthesia System).

Rat temperatures were recorded by rectal probe (Biopac Systems, Inc., SSGL Fast Temp. SN6053859), and were maintained at 37±0.5 °C in the normothermia group by heater pads and at 32±0.5 °C in the hypothermia group by the application of alcohol to the skin under an electric fan.

The left femoral artery was cannulated to monitor blood pressure and heart rhythm and to perform blood sampling. The catheter was connected to a volumetric pressure transducer (Biopac Data Acquisition Unit MP30), and blood pressure and heart rate were recorded continuously. The right femoral artery was perforated with a 24-gauge needle, which was then removed to allow free bleeding for 30 seconds (sec). Standard compression or compression + Celox® was then applied according to the respective groups. All bleeding and pressure procedures were performed by the same person. The rats were divided into six groups of eight rats each to evaluate the hemostatic effect of Celox®.

Normothermia + compression group: In this group, the core temperature of the rats was maintained at 37±0.5 °C, and after 30 sec of bleeding from the femoral artery, compression was provided by 100 g of standard weight for 30 sec. Hemostasis was subsequently evaluated, and the test was terminated if the bleeding stopped. If the bleeding continued, compression was applied for an additional 30 sec and bleeding was again assessed for hemostasis. If hemostasis was not achieved after the second compression, a final 30 sec of compression was applied. The test was regarded as a failure if bleeding continued following the third compression.

Normothermia + Celox® group: The core temperature of the rats was maintained at 37±0.5 °C. After 30 sec of bleeding from the femoral artery, Celox® (1 g/ kg) was applied to the bleeding area, and compression was provided by 100 g of standard weight for 30 sec.

Subsequently, hemostasis was evaluated and second and third compressions were applied if necessary. If hemostasis was not achieved after 90 sec of treatment, uncontrolled hemorrhage was concluded.

Hypothermia + compression and hypothermia + Celox® groups: In these groups, the core temperature of the rats was maintained at 32±0.5 °C, and bleeding, compression, Celox® administration, and the test evaluation were performed as described for the normothermia groups.

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Hemostatic effect of a chitosan linear polymer (Celox®)

rin (0.06 mg/kg) was administered to the rats by oral gavage for three days, and the experiments were performed 30 minutes (min) after the final dose. In these groups, the core temperature of the rats was maintained at 37±0.5 °C, and bleeding, compression, Celox® administration, and the test evaluation were performed as described for the other normothermia groups.

As previously indicated, physiological parameters of mean blood pressure, heart rate and rectal temperature were recorded continuously during the tests.

Blood samples were obtained to analyze the hemoglobin levels, platelet counts, red blood cell counts, prothrombin time, and the International Normalized Ratio (INR) values before bleeding (0 sec) and at the end of the test. All animals were euthanized by high-dose isoflurane inhalation at the end of the experiment.

Statistical Analysis Statistical analysis was performed using SPSS version 13.0 for Windows. The Mann-Whitney U test was used to compare two independent groups, the Kruskal-Wallis test to compare more than two independent groups and the Wilcoxon test to compare two dependent groups. Pearson’s and Fisher’s chi-square tests were used to compare the distributions of categorical variables. Data are expressed as the mean ± SD and p-values less than 0.05 were regarded as statistically significant.

RESULTS The mean blood pressure and heart rate of the rats were recorded before (0 sec) and 30, 60 and 90 sec after hemorrhage, and the difference between before and after bleeding represented the percent change. There were no statistically significant differences between the groups with respect to changes in the mean blood pressure and heart rate (Tables 1 and 2).

No statistically significant differences were observed between the compression and Celox® groups with regard to hemoglobin levels, red blood cell counts, platelet counts, prothrombin time, and INR evaluated before and after bleeding. In the warfarin groups, prothrombin time and INR were very high but could not be accurately determined in the laboratory, thus precluding a statistical analysis of these groups.

Hemostasis was achieved in 4 of 8 rats in the normothermia + compression group (50%), whereas it was provided in all rats in the normothermia + Celox® group (100%). In the hypothermia + compression group, hemostasis was observed in 6 of 8 rats, whereas it was 100% successful in the hypothermia + Celox® group. In the groups that received warfarin therapy, hemorrhage control was achieved in only 2 of 8 rats in the compression group; however, it was successful in all rats in the normothermia + warfarin + Celox® group (Fig. 1). There was a statistically significant difference

Table 1. Blood pressure changes (%) in all groups

Normothermia + compression Normothermia + Celox® Hypothermia + compression Hypothermia + Celox® Warfarin + compression Warfarin + Celox®

Blood pressure change (%) 30 sec

60 sec

90 sec

73.9±0.2 62.9±0.1 46.7±0.3 39.4±0.9 49.4±0.1 43.3±0.1

73.7±0.2 61.6±0.1 52.6±0.3 42.5±0.1 50.4±0.1 53.3±0.1

74.2±0.2 52.7±0.1 53.5±0.3 42.5±0.1 53.5±0.3 55.9±0.2

Blood pressure was recorded and allowed to stabilize for 30 min prior to bleeding. Blood pressure changes (%) from baseline levels were determined by comparison of the levels at 30, 60, and 90 sec of bleeding. No significant differences were observed between the groups (p>0.05).

Table 2. Heart rate changes (%) in all groups

Normothermia + compression Normothermia + Celox® Hypothermia + compression Hypothermia + Celox® Warfarin + compression Warfarin + Celox®

Heart rate changes (%) 30 sec

60 sec

90 sec

20.9±0.4 29.2±0.1 26.7±0.2 19.4±0.3 9.0±0.1 16.8±0.2

24.2±0.6 26.8±0.9 29.6±0.2 26.5±0.3 8.9±0.1 12.3±0.1

25.5±0.7 29.3±0.2 36.7±0.2 23.1±0.3 8.9±0.2 9.1±0.9

Heart rate was recorded and allowed to stabilize for 30 min prior to bleeding. Heart rate changes (%) from baseline levels were determined by comparison of the levels at 30, 60, and 90 sec of bleeding. No significant differences were observed between the groups (p>0.05).

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Table 3. Evaluation of the number of compressions needed for hemostasis after severe femoral artery bleeding

in normothermia, hypothermia and warfarin groups with compression and Celox® implementation Groups

Normothermia Hypothermia Warfarin

Compression

Celox®

1st compression 2nd compression 3rd compression

1st compression 2nd compression 3rd compression

– – –

– – –

4 6 2

7 4 6

1 3 2

–* 1* –**

The differences between compression and Celox® were statistically significant for compression time in terms of hemostasis (*p<0.01, **p<0.001).

Assessment of the number of compressions in rats required to achieve hemostasis revealed hemorrhage control with the third compression in 4 rats in the normothermic + compression group, whereas it was achieved after the first compression in 7 of 8 rats and after the second compression in 1 rat in the normothermia + Celox® group. In the hypothermia + compression group, hemostasis was successful in 6 of 8 rats and in all rats after the third compression. However, when hypothermic rats were treated with Celox®, hemostasis was possible in 4 rats after the first, in 3 rats after the second and in 1 rat after the third compression. Hemostasis was achieved in 2 rats in the group that received warfarin therapy + compression after the third compression and in 6 and 2 rats in the normothermia + warfarin therapy + Celox® group after the first and second compression, respectively (Table 3).

The compression numbers were significantly lower in all of the groups that received Celox® (p-values for the normothermia, hypothermia and warfarin groups were p<0.01, p<0.01 and p<0.001, respectively).

DISCUSSION The early recognition and treatment of bleeding is a critical process and currently remains a serious clinical issue. At present, local hemostatic agents are added to conventional methods such as manual compression, ligation and tourniquet application for the control of bleeding.[16,17] It is estimated that hemostatic agents are particularly useful in comparison to conventional methods in cases of hemorrhage in difficult anatomic regions such as the axillary and femoral areas.

In several studies,[18-21] Celox® was found to be 100% effective in rats with severe femoral artery bleeding under normothermic conditions. In a study reported by Ersoy et al.,[1] the time required for hemostasis was found to be significantly shorter with the implementation of TraumaDEX® (microporous polysaccharide hemisphere) in rats with uncontrolled hemorrhage. In the present study, the use of Celox® pro202

vided hemostasis control in 100% of the animals, and compression numbers were significantly lower than in the groups in which compression alone was applied.

In a comparative study, Kozen et al.[19] demonstrated the superiority of Celox® for survival as compared to HemCon®, QuikClot® and standard compression technique in a porcine model of inguinal injury. In the present study, the animals were not resuscitated and were euthanized at the end of the study; therefore, despite the achievement of hemostasis with Celox® in all rats, survival could not be evaluated.

Devlin et al.,[18] using a porcine model study, demonstrated that local hemostatic agents (ChitoFlex®, OuikClot®, Celox®) were not superior to standard gauze. They emphasized that these agents could be effective for venous or mixed hemorrhage but were not suitable for high pressure artery bleeding. In the present study, Celox® was significantly effective for the treatment of severe femoral artery bleeding in a rat model. The only difference between these two studies was the animal model used for the analysis. In addition

Normothermia Hypothermia Warfarin

8

6 Number of rats

between compression and Celox® implementation in all groups in terms of hemostasis (p-values for the normothermia, hypothermia and warfarin groups were p<0.05, p<0.01 and p<0.01, respectively).

4

2

0

Compression

Celox

Fig. 1. Evaluation of hemostasis after severe femoral artery bleeding in the normothermia, hypothermia and warfarin groups with compression and Celox® implementation. *There was a statistically significant difference in successful hemostasis in favor of the Celox® group when compared to the compression group (*p<0.05, **p<0.01).

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to these studies, Kheirabadi et al.[20] showed the positive effect of several new hemostatic agents including Celox® on artery bleeding. In contrast to Devlin’s study, Gustafson et al.[21] reported that local hemostatic agents containing chitosan were found to be 100% effective in a porcine model of femoral artery bleeding, consistent with the present results. Gustafson et al. noted that the use of different techniques and animal models could affect study outcomes, potentially explaining the different results obtained in our study and that reported by Devlin et al.

In a porcine model study of mortal inguinal injury reported by Alam et al.,[22] QuikClot® (mineral zeolite) decreased blood loss and resulted in 100% survival; however, the mortality was found to be 83% in the compression group. Concordantly, Pusateri et al.[23] and Baker et al.[24] reported the superiority of QuikClot® as compared to other homeostatic agents.

Although blood loss was not evaluated in the present study, 100% hemostasis was achieved with Celox®. In contrast, compression provided successful hemostasis in only 50% of the normothermic, 75% of the hypothermic and 25% of the warfarin-treated groups. In considering the results of these studies, it is important to note that QuikClot® causes a local increase of heat via an exothermic reaction and causes minimal tissue damage.[4] Hypothermia due to environmental losses and after surgery is related with uncontrolled hemorrhage and mortality in trauma patients.[10-15,25] Several studies[26-28] have demonstrated increased survival under conditions of hypothermia with controlled hemorrhage; however, another study[29] reported a higher mortality with hypothermia. In the present study, controlled, moderate hypothermia (32±0.5 °C) was assessed in one group of rats. Successful hemostasis was observed in six of eight rats in the hypothermia group and in four of eight rats in the normothermia group, consistent with previous studies. Therefore, we can conclude that Celox® has a favorable effect during hypothermia. In addition, we found that Celox® had similar effects in the hypothermia and normothermia groups.

Several studies have assessed the effects of local hemostatic agents after trauma on patients undergoing anticoagulant therapy, and most of these studies have employed heparin, a parenteral anticoagulant agent.[30,31] Klokkevold et al.[30] demonstrated the efficacy of chitosan in a heparinized rabbit model, and Tuthill et al.[31] showed significantly decreased blood loss through the use of a fibrin sealant hemostatic agent in heparinized rats undergoing heminephrectomy. Schwaitzberg et al.[32] asserted that local hemostatic agents containing poly-N-acetylglucosamine are effective even in congenital or acquired diseases of coagulopathy in a study performed in dogs with heCilt - Vol. 17 Sayı - No. 3

mophilia and in heparinized pigs. In the present study, we investigated the efficacy of Celox® with warfarin treatment. As expected, hemostasis was not achieved with compression in six of eight rats in the warfarin treatment group. In contrast, hemostasis was successfully provided by Celox® in all rats, demonstrating that warfarin therapy did not influence the effect of Celox®. The efficacy of Celox® even under warfarin therapy, a condition presenting a deficit of coagulation factors, is consistent with previous studies[33-35] suggesting that the capacity of Celox® to achieve hemostasis is independent of the effects of coagulation factors and platelets.

As a limitation of the study, animal studies are not universally accepted to reflect the effect of hemostatic agents on wounds in humans. In addition, small animal models likely do not reflect the effect of hemostasis in the context of high-pressure bleeding. Although the present study was performed to evaluate the hemostatic efficiency of Celox®, the effect of Celox® on blood loss and mortality was not determined. In addition, the results of the present study were not blinded, as the implementation of compression and hemostatic agents and the evaluation of hemostasis were performed by the same researcher.

In conclusion, Celox® provides hemostasis not only under normothermic conditions but also under conditions of hypothermia and warfarin therapy. However, further clinical investigations are needed to validate the results of these animal studies.

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24. Baker SE, Sawwel AM, Zheng N, Stucky GD. Controlling bioprocesses with inorganic surfaces: layered clay hemostatic agents. Chemistry of Materials 2007;19:4390-92.

25. Gentilello LM, Jurkovich GJ. Hypotermia. In: Ivatory RR, Cayten CG, editors. The textbook of penetrating trauma. PA Williams&Wilkins; 1996. p. 995-1006.

26. Valeri CR, MacGregor H, Cassidy G, Tinney R, Pompei F. Effects of temperature on bleeding time and clotting time in normal male and female volunteers. Crit Care Med 1995;23:698-704.

27. Takasu A, Sakamoto T, Okada Y. Effect of induction rate for mild hypothermia on survival time during uncontrolled hemorrhagic shock in rats. J Trauma 2006;61:1330-5.

28. Alam HB, Chen Z, Li Y, Velmahos G, DeMoya M, Keller CE, et al. Profound hypothermia is superior to ultraprofound hypothermia in improving survival in a swine model of lethal injuries. Surgery 2006;140:307-14.

29. Gentilello LM, Jurkovich GJ, Stark MS, Hassantash SA, O’Keefe GE. Is hypothermia in the victim of major trauma protective or harmful? A randomized, prospective study. Ann Surg 1997;226:439-49.

30. Klokkevold PR, Fukayama H, Sung EC, Bertolami CN. The effect of chitosan (poly-N-acetyl glucosamine) on lingual hemostasis in heparinized rabbits. J Oral Maxillofac Surg 1999;57:49-52.

31. Tuthill DD, Bayer V, Gallagher AM, Drohan WN, MacPhee MJ. Assessment of topical hemostats in a renal hemorrhage model in heparinized rats. J Surg Res 2001;95:126-32.

32. Schwaitzberg SD, Chan MW, Cole DJ, Read M, Nichols T, Bellinger D, et al. Comparison of poly-N-acetyl glucosamine with commercially available topical hemostats for achieving hemostasis in coagulopathic models of splenic hemorrhage.

J Trauma 2004;57:S29-32.

33. Malette WG, Quigley HJ. Method of achieving hemostasis.

U.S. Pat. 4394373 1983.

34. Klokkevold PR, Lew DS, Ellis DG, Bertolami CN. Effect of chitosan on lingual hemostasis in rabbits. J Oral Maxillofac Surg 1991;49:858-63.

35. Klokkevold PR, Subar P, Fukayama H, Bertolami CN. Effect of chitosan on lingual hemostasis in rabbits with platelet dysfunction induced by epoprostenol. J Oral Maxillofac Surg 1992;50:41-5.

May - Mayıs 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):205-209

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2011.93609

The effects of methylene blue on adhesion formation in a rat model of experimental peritonitis Deneysel peritonit modelinde metilen mavisinin adezyon formasyonu üzerine etkileri Mustafa Uygar KALAYCI,1 Hasan Erol EROĞLU,2 Dilek KUBİLAY,3 Aliye SOYLU,4 Banu SANCAK,5 Ceyhan UĞURLUOĞLU,6 Uğur ERÇİN,5 Yavuz Savaş KOCA2

BACKGROUND

AMAÇ

We investigated the effects of methylene blue (MB) on the early and late phases of adhesion and abscess formation in a standard colonic wall injury and fecal peritonitis model in rats.

Sıçanlarda oluşturulan kolon duvar hasarı ve fekal peritonit modelinde metilen mavisinin (MM) erken ve geç dönemde adezyon ve apse oluşumu üzerine etkileri incelendi.

METHODS

GEREÇ VE YÖNTEM

There were four groups: Group I (only laparotomy, n=10), Group II (peritonitis + MB, n=15), Group III (peritonitis + saline, n=15), and Group IV (colon incision + saline, n=15). Mortality, morbidity, adhesion scores, histopathologic analyses, serum tumor necrosis factor-alpha (TNF-α) levels, and tissue hydroxyproline (5-HP) levels were evaluated in all animals. Descriptive statistical methods were used with Kruskal-Wallis test. When a statistical difference was obtained between groups, Mann-Whitney U test was used to confirm the difference between two groups.

Çalışmada dört grup vardı; Grup I (yalnızca laparotomi, n=10), Grup II (peritonit ve MM, n=15), Grup III (kolon insizyonu ve salin, n=15) ve Grup IV (kolon insizyonu ve salin, n=15). Tüm deneklerde mortalite, morbidite, adezyon skorları, histopatolojik analiz, serum tümör nekroz faktörü-α (TNF-α) ve doku hidroksiprolin (5-HP) düzeyleri değerlendirildi. Tanımlayıcı istatistiksel analiz Kruskal Wallis testi ile, istatistiksel anlamlılık saptandığında ise gruplar arasındaki fark Mann-Whitney U testi ile analiz edildi.

RESULTS

BULGULAR

Adhesion scores of Groups I, III and IV were significantly higher than in Group II. TNF-α levels were significantly higher in Groups I, III and IV. 5-HP levels were significantly lower in Groups I and II compared to Groups III and IV.

Grup I, Grup III ve Grup IV’ün adezyon skorları Grup II’ye göre anlamlı yüksekti. TNF-α düzeyleri ise Grup I, Grup III ve Grup IV’de yüksek bulundu. 5-HP düzeyleri Grup I ve Grup II’de Grup III ve Grup IV’e göre düşüktü.

CONCLUSION

SONUÇ

Based on these results, it appears that MB may prevent peritoneal adhesions in a peritonitis model, but wound healing could be impaired. MB should be further evaluated because of its dual effect.

MM’nin peritonit modelinde peritoneal adezyonları önlediği, ancak yara iyileşmesini olumsuz etkilediği söylenebilir. Bu ikili karşıt etkinin daha fazla araştırılması gerekir.

Key Words: Adhesion; methylene blue; peritonitis.

Anahtar Sözcükler: Adezyon; metilen mavisi; peritonit.

1 Dept. of General Surgery, Okmeydani Training and Research Hospital, Istanbul; 2Dept. of General Surgery, Suleyman Demirel University, Faculty of Medicine, Isparta; 3Dept. of Medical Biochemistry, Dr. Abdurrahman Yurtarslan Training and Research Hospital, Ankara; 4Dept. of Gastroenterology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul; 5Dept. of Medical Biochemistry, Gazi University Faculty of Medicine, Ankara; 6Dept. of Pathology, Dr. Faruk Sukan Children Hospital, Konya, Turkey.

1 Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul; 2Süleyman Demirel Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Isparta; 3Dr. Abdurrahman Yurtaslan Eğitim ve Araştırma Hastanesi, Biyokimya Bölümü, Ankara; 4Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Gastroenteroloji Kliniği, İstanbul; 5 Gazi Üniversitesi Tıp Fakültesi, Klinik Biyokimya Anabilim Dalı, Ankara; 6 Dr. Faruk Sükan Çocuk Hastanesi, Patoloji Bölümü, Konya.

Correspondence (İletişim): Hasan Erol Eroğlu, M.D. Muzaffer Türkeş Mah., Doktorlar-Mühendisler Sitesi No: 15/1, 32200 Isparta, Turkey.

Tel: +90 - 246 - 211 55 87 e-mail (e-posta): heroleroglu@hotmail.com

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Adhesion formation is a major complication in surgery.[1,2] It has been estimated that the annual healthcare costs associated with adhesiolysis procedures amount to more than 1 billion USD in the United States.[3] After colon surgery, the readmission rate due to adhesions is about 5-15%.[4] Adhesion-related mortality reaches up to 15%, and inadvertent enterotomy at a desiotomy occurs in 19% in additional operations.

[5] Indeed, the rate of residual infection after peritonitis can be as high as 50%, necessitating abdominal re-exploration or percutaneous abscess drainage in adhesions.[5,6] Multiple factors have been associated with this problem, such as poor surgical technique, damage to the serosal surface of the intestinal wall, powder of gloves, type of suture material, devitalized tissue, pelvic inflammatory disease, cholecystitis, and appendicitis.[7,8] Although several materials have been used to avoid adhesion formation in elective surgery, there are insufficient data on this issue in the case of peritonitis.

Experimental data show that the use of antiadhesive agents in peritonitis reduces adhesions and abscesses and related mortality.[9,10] To avoid adhesion formation in peritonitis, tenoxicam, aminoguanidine, beta glucan, polysaccharide carboxy methyl cellulose and phlennium saprophyte have been used in different studies.[11-14] Adhesion formation is associated with significant oxidative stress, both from the activation of the mesothelium and underlying endothelial cells and, more importantly, from the infiltration and subsequent activation of neutrophils and macrophages and cytokines.

[15-17] Methylene blue (MB) acts as an antioxidant and may reduce intraabdominal nascent fibrinous adhesions, and is rapidly degraded via intraabdominal proteases such as tissue plasminogen activator (tPA), which is a major component of the peritoneal fibrinolytic system.[16] MB was defined as an effective agent to avoid the permanent fibrous adhesion formation in peritoneal trauma due to antioxidant activity.[18] Based on the literature concerning the antiadhesive properties of MB, the present study was designed to investigate the effects of MB on the early and late phases of adhesion and wound healing in an experimental colonic wall injury and fecal peritonitis model in rats.

MATERIALS AND METHODS Animals Female Wistar-Albino rats (225-280 g) were housed in an air-conditioned room at a constant temperature of 22±2°C with 12:12 h light/dark cycle and fed a standard diet and water ad libitum. The animals were acclimatized for one week before the experiments. Only water was provided in the 12 hours pre206

ceding the experiments. The experimental protocol was approved by the Suleyman Dermirel University Faculty of Medicine Animal Care and Use Committee.

Experimental Groups Rats were divided into four groups including laparotomy (Group I; n=10), peritonitis+MB (Group II; n=15), peritonitis+saline (Group III; n=15), and colon incision+saline (Group IV; n=15) groups. Mortality, morbidity, adhesion scores, bacterial analysis, histopathologic analysis, tissue hydroxyproline (5-HP), and plasma tumor necrosis factor-alpha (TNF-α) level were taken as control parameters.

Surgical Operations The animals were weighed and anesthetized with intramuscular (im) ketamine (50 mg/kg) and xylazine (6 mg/kg). The abdominal skin was disinfected with 70% Betadine solution. Midline laparotomy performed with a 3 cm incision was the sole intervention in the laparotomy group. In the peritonitis+MB group, the colon was explored and incised with a scalpel. The abdomen was contaminated with the cecal content in order to induce fecal peritonitis. The defect was sutured with 4-0 polypropylene. Before closing the abdomen, MB (1%, 2 ml) was applied through the suture line and abdominal viscera. In the peritonitis+saline group, the colon was explored and incised with a scalpel. The abdomen was contaminated with the cecal content in order to induce fecal peritonitis. The defect was sutured with 4-0 polypropylene. Before closing the abdomen, sterile saline solution (2 ml) was applied through the suture line and abdominal viscera. In the colon incision+saline group, the colon was explored and incised with a scalpel. The defect was sutured with 4-0 polypropylene. Before closing the abdomen, sterile saline solution (2 ml) was applied through the suture line and abdominal viscera. The abdomen was closed in two layers with 3-0 silk.

Postoperative Evaluations All animals were given water only on the first postoperative day; standard rat chow and water ad libitum were provided on the second postoperative day. There was no difference in food intake between the groups.

Body weight and water and food intake were monitored daily throughout the postoperative period, for up to 7 days.

On the postoperative 3rd day, 5 animals from Group I and 7 animals from Groups II, III and IV were taken for analyses. On the postoperative 7th day, 5 animals from Group I and 8 animals from Groups II, III and IV were taken for the rest of the examinations.

Mortality, morbidity, adhesion scores, histopathologic analyses, serum TNF-α levels and tissue 5-HP levels were evaluated in all animals.

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The effects of methylene blue on adhesion formation in a rat model of experimental peritonitis

Microbiologic Analysis For aerobic culture, the samples were inoculated onto 5% sheep blood agar and MacConkey agar, and incubated for 24-48 hours (h) at 35°C. Adhesion Study A “U”-shaped laparotomy incision was made for evaluating the adhesion formation. Adhesion scores were given as mentioned before by Bothin et al.[19] Degree, characteristics and localizations of the adhesions were evaluated. Development of intraabdominal adhesions was then assessed in animals for qualitative aspects, which were defined formerly as shown in Table 1. Each observation is given 1 point and the points are added to obtain the total score.

Biochemical Analysis 5-HP levels were measured from the sutured part of the cecum. 0.5 cm of the sutured part of the cecum was cleared of overlying adherent tissue and resected.

The specimen was wrapped in aluminum foil, coded appropriately, frozen in liquid nitrogen, and kept at -30°C for 5-HP content determination. Biochemical studies were made as defined by Jamall et al.[20] Briefly, the frozen tissues were dried with filter paper, weighed and divided into tiny pieces, and hydrolyzed in 6 Nhydrochloric acid. The free 5-HP was then oxidized by chloramines to produce a pyrrole-type compound. The addition of Ehrlich’s reagent resulted in the formation of chromophore with a wave length maximum at 558 nm. These procedures yielded HP levels equivalent to nanomoles. These absolute measures were proportioned to tissue weights and the results were obtained as moles/gram tissue.[20] Cardiac blood samples were drawn in sterile fashion for TNF-α measurement. Samples were kept at -80°C for storage and evaluated immediately for bioTable 1. Cumulative adhesion scoring scale (0) (1) (1) (1) (1)

(1)

(1)

(1)

(1) (1) (1) (1) (1)

No adhesions One adhesive band from the omentum to the target organ One adhesive band from the omentum to the abdominal scar One adhesive band from the omentum to another place One adhesive band from the adnexa/epididymal fat bodies to the target organ One adhesive band from the adnexa/epididymal fat bodies to the abdominal scar One adhesive band from the adnexa/epididymal fat bodies to the another place Any adhesive band other than described above (e.g., liver to scar) Target organ adherent to the abdominal wall Target organ adherent to the abdominal scar Target organ adherent to the bowel Target organ adherent to the liver or the spleen Any other organ adherent

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chemical analyses. TNF-α levels of serum samples were determined using the BioSource International rat TNF-α kit, which is a solid-phase sandwich ELISA (BioSource, USA). The minimum detectable dose of TNF-α is 1.7 pg/ml. This was determined by adding 2 SD to the mean optical density obtained when the zero standard was assayed 20 times. Tissue 5-HP content and serum TNF-α levels were studied at Gazi University Faculty of Medicine, Department of Medical Biochemistry.[21] Histopathological Examination Histopathological examinations were performed by light microscopy at x100, and the resected tissues were fixed in formaldehyde and embedded in paraffin block, and stained with hematoxylin and eosin (H&E).

A pathologist who was blind to the groups graded the extent of fibrosis and inflammation in each specimen using a semiquantitative scoring system.

Statistical Analysis Results of the study were statistically analyzed with NCSS 2007 & PASS 2008 Statistical Software (Utah, USA) program. For evaluating the data, descriptive statistical methods were used with KruskalWallis test in order to analyze numeric values because of the insufficient number of the group population.

When a statistical difference was obtained between groups, Mann-Whitney U test was used to confirm the difference between two groups. A statistically significant difference was accepted at a p value of <0.05.

RESULTS Morbidity and Mortality Following the operations, all rats had symptoms of intraabdominal sepsis. They demonstrated apathetic behavior, and had ocular exudates, piloerection and diarrhea. Weight loss was observed on the 1st day.

After the postoperative 1st day, rats regained weight.

Differences in weight loss or weight gain were not statistically significant between the study groups. No deaths were seen in any group. Abscesses were predominantly located at the suture site. Abdominal wall suture line abscesses were seen in 5 rats in Group III and 2 rats in Group IV, while no abscesses were larger than 1 cm.

Microbiological Findings Culture results of the samples taken revealed polymicrobial intraabdominal infection. Frequently isolated microorganisms were Escherichia coli, Proteus species, Streptococcus, and coagulase-negative Staphylococcus.

Adhesion Scores In all examinations, the most frequently detected adhesion formation was the adhesion of the omentum 207

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to the target organ. In Group II, the number of the adhesions and their characteristics were different compared to Groups III and IV (less and soft). In Group II, adhesion formation especially involved the omentum.

In the 3rd day analyses, adhesion scores of Groups I, III and IV were significantly higher than in Group II (p=0.028, p=0.05, p=0.012). In the 7th day analyses, the adhesion scores of Groups III and IV were significantly higher than in Groups I and II (Table 2).

Biochemical Analysis TNF-α levels were significantly higher in Groups I, III and IV in the 3rd day analyses (p<0.05). However, there was no significant difference between groups in the 7th day analyses (p>0.05; Table 2).

5-HP levels were significantly lower in Groups I and II compared to Groups III and IV (p<0.05). The differences were significant in the 3rd and also 7th day analyses (Table 2).

Histopathologic Findings In the histopathologic examination, mild mesothelial cell proliferation, fibrosis, inflammatory cell infiltration in serosal surfaces, acute cell inflammation, and fibroblastic proliferation were seen generally.

Moderate inflammation and cell infiltration with lymphoid hyperplasia were observed in Group III. Acute inflammatory reactions were dense on serosal surfaces with extensive polymorphonuclear cell infiltration in this group. Submucosal inflammatory cell infiltration and serosal microabscess formation were also seen in this group.

DISCUSSION Complications and relaparotomies due to adhesions have been seen frequently in emergency operations for peritonitis. Colorectal surgery has a high risk of infection in a wide range from colostomies to abdomino-

perineal resection.[22] Relaparotomies due to adhesion can be seen in 19% of cases, and complications due to adhesions appear in 25% of the patients.[23] Peritonitis seems to be the major cause of intraabdominal adhesion formation, but there are not enough experimental and clinical studies on this issue.[24] Generalized infection in the abdominal cavity affects abdominal tissues in relation to operative materials and fluids. While results of some materials tested in the prevention of adhesion formation were reported in a limited number of studies in the literature, an ideal material has yet to be identified.

Adhesion formation is a dynamic and complex process, which can be triggered by any peritoneal injury and even through a controlled injury, such as surgery.

It involves a cascade of cellular, biochemical and immunological factors.[25] Inflammatory cellular activity in mesothelial regeneration and the alteration of the peritoneal fibrinolytic system are considered as the main pathways of adhesion formation.[25] According to our findings, MB application reduces adhesion formation after peritonitis based on alterations determined in adhesion scores, whereas it impairs wound healing as depicted by reduction in serum TNF-α and tissue 5-HP levels.

MB was reported to cause a significant impairment in the early phases of wound healing.[18] In addition, as demonstrated experimentally,[10] MB has been reported to inhibit generation of oxygen radicals, such as superoxide, by competing with the molecular oxygen for the transfer of electrons from xanthine oxidase.

[18] Although the antiadhesive effect of MB has been associated with its antioxidant properties, increased peritoneal fibrinolytic activity was also documented to have a role in subsequent degradation of nascent adhesions.[17]

Table 2. 5-HP and TNF-α levels and adhesion scores in the experimental groups on the postoperative 3rd and 7th days

Group I (Laparotomy)

Group II (MB + Peritonitis)

Group III (Peritonitis + Saline)

Group IV (Colitis + Saline)

5-HP levels Mean±SD Mean±SD Mean±SD Mean±SD Postop. day 3 15.16±1.04 5.62±0.5 9.27±2.73 14.97±0.22 Postop. day 7 16.92±1.05 5.68±0.43 8.36±1.88 18.04±3.98 #p value 0.248 0.697 1.0 0.021 TNF-α levels Postop. day 3 28.49±8.33 1.18±0.04 131.04±28.14 125.4±35.21 Postop. day 7 46.01±18.1 20.18±4.9 72.92±17.0 52.52±16.14 #p value 0.276 0.465 1.0 0.541 Adhesion scores Postop. day 3 0.4±0.14 1.75±0.16 6.5±1.29 4.0±0.81 Postop. day 7 0.6±0.14 1.71±0.35 5.12±1.41 4.36±1.5 #p value 0.375 0.948 0.549 0.504

†p 0.02 0.03 0.009 0.49 0.001 0.001

† Kruskal-Wallis Test; # Mann-Whitney U Test.

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The effects of methylene blue on adhesion formation in a rat model of experimental peritonitis

Subsequent to the acute inflammation of the peritoneum in response to trauma, there is an influx of cells, mainly macrophages, by chemotactic mechanisms. These macrophages, when activated again by plasmin, produce interleukin (IL)-1 and TNF-α, important factors in wound healing.[26] In line with these statements, TNF-α levels were significantly lower in the MB group on the 3rd day examinations, indicating impairment in wound healing. Furthermore, based on the well-known correlation between tensile strength of the wound and its 5-HP content, the significant reduction obtained in tissue HP levels postoperatively seems also to be responsible for the delayed wound healing in our rats.

Whether resulting from its antioxidant or fibrinolytic effect, the antiadhesive properties of MB have been documented to be dose-dependent, with increased efficacy at its lower doses.[27] In conclusion, while MB seems to prevent peritoneal adhesions in a rat peritonitis model, wound healing could be impaired concomitantly. MB should be further evaluated because of its dual effect.

REFERENCES 1. Sahin Y, Saglam A. Synergistic effects of carboxymethylcellulose and low molecular weight heparin in reducing adhesion formation in the rat uterine horn model. Acta Obstet Gynecol Scand 1994;73:70-3.

2. Thompson JN, Whawell SA. Pathogenesis and prevention of adhesion formation. Br J Surg 1995;82:3-5.

3. Mirastschijski U, Johannesson K, Jeppsson B, Agren MS. Effect of a matrix metalloproteinase activity and TNF-alpha converting enzyme inhibitor on intra-abdominal adhesions.

Eur Surg Res 2005;37:68-75.

4. Wilson MS. Practicalities and costs of adhesions. Colorectal Disesase 2005;7:551-8.

5. Van Der Krabben AA, Dijkstra FR, Nieuwenhuijzen M, Reijnen MM, Schaapveld M, Van Goor H. Morbidity and mortality of inadvertent enterotomy during adhesiotomy. Br J Surg 2000;87(4):467-71.

6. Hutchins RR, Gunning MP, Lucas DN, Allen-Mersh TG, Soni NC. Relaparotomy for suspected intraperitoneal sepsis after abdominal surgery. World J Surg 2004;28:137-41.

7. Ellis H. Internal overhealing: the problem of intraperitoneal adhesions. World J Surg 1980;4:303-6.

8. Fabri PJ, Rosemurgy A. Reoperation for small intestinal obstruction. Surg Clin North Am 1991;71:131-46.

9. Bedirli A, Gokahmetoglu S, Sakrak O, Ersoz N, Ayangil D, Esin H. Prevention of intraperitoneal adhesion formation using beta-glucan after ileocolic anastomosis in a rat bacterial peritonitis model. Am J Surg 2003;185:339-43.

10. Galili Y, Ben-Abraham R, Rabau M, Klausner J, Kluger Y. Reduction of surgery-induced peritoneal adhesions by methylene blue. Am J Surg 1998;175:30-2.

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11. Ezberci F, Bulbuloglu E, Ciragil P, Gul M, Kurutas EB, Bozkurt S, et al. Intraperitoneal tenoxicam to prevent abdominal adhesion formation in a rat peritonitis model. Surg Today 2006;36:361-6.

12. Ara C, Karabulut AB, Kirimlioglu H, Yilmaz M, Kirimliglu V, Yilmaz S. Protective effect of aminoguanidine against oxidative stress in an experimental peritoneal adhesion model in rats. Cell Biochem Funct 2006;24:443-8.

13. Sikkink CJ, de Man B, Bleichrodt RP, van Goor H. Autocross-linked hyaluronic acid gel does not reduce intra-abdominal adhesions or abscess formation in a rat model of peritonitis. J Surg Res 2006;136:255-9.

14. Müller SA, Treutner KH, Haase G, Kinzel S, Tietze L, Schumpelick V. Effect of intraperitoneal antiadhesive fluids in a rat peritonitis model. Arch Surg 2003;138:286-90.

15. Steinberg J, Halter J, Schiller HJ, Dasilva M, Landas S, Gatto LA, et al. Metalloproteinase inhibition reduces lung injury and improves survival after cecal ligation and puncture in rats. J Surg Res 2003;111:185-95.

16. Galili Y, Kluger Y, Mianski Z, Iaina A, Wollman Y, Marmur S, et al. Methylene blue--a promising treatment modality in sepsis induced by bowel perforation. Eur Surg Res 1997;29:390-5.

17. Heydrick SJ, Reed KL, Cohen PA, Aarons CB, Gower AC, Becker JM, et al. Intraperitoneal administration of methylene blue attenuates oxidative stress, increases peritoneal fibrinolysis, and inhibits intraabdominal adhesion formation. J Surg Res 2007;143:311-9.

18. Dinc S, Ozaslan C, Kuru B, Karaca S, Ustun H, Alagol H, et al. Methylene blue prevents surgery-induced peritoneal adhesions but impairs the early phase of anastomotic wound healing. Can J Surg 2006;49(5):321-8.

19. Bothin C, Okada M, Midtvedt T, Perbeck L. The intestinal flora influences adhesion formation around surgical anastomoses. Br J Surg 2001;88:143-5.

20. Jamall IS, Finelli VN, Que Hee SS. A simple method to determine nanogram levels of 4-hydroxyproline in biological tissues. Anal Biochem 1981;112:70-5.

21. Engelberts I, Möller A, Schoen GJ, van der Linden CJ, Buurman WA. Evaluation of measurement of human TNF in plasma by ELISA. Lymphokine Cytokine Res 1991;10:69-76.

22. Parker MC, Wilson MS, Menzies D, Sunderland G, Thompson JN, Clark DN, et al. Colorectal surgery: the risk and burden of adhesion-related complications. Colorectal Dis 2004;6:506-11.

23. Stanciu D, Menzies D. The magnitude of adhesion-related problems. Colorectal Dis 2007;9:35-8.

24. Müller SA, Treutner KH, Haase G, Kinzel S, Tietze L, Schumpelick V. Effect of intraperitoneal antiadhesive fluids in a rat peritonitis model. Arch Surg 2003;138:286-90.

25. Duron JJ. Postoperative intraperitoneal adhesion pathophysiology. Colorectal Dis 2007;9:14-24.

26. van der Wal JB, Jeekel J. Biology of the peritoneum in normal homeostasis and after surgical trauma. Colorectal Dis 2007;9:9-13.

27. Raşa K, Erverdi N, Karabulut Z, Renda N, Korkmaz A. The effect of methylene blue on peritoneal adhesion formation.

Turk J Gastroenterol 2002;13:108-11.

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Ulus Travma Acil Cerrahi Derg 2011;17 (3):210-214

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.84669

Spontaneous rectus sheath hematoma in patients on anticoagulation therapy Antikoagülan tedavi altındaki hastalarda spontan rektus kılıfı hematomu Ahmet DAĞ,1 Turkay ÖZCAN,2 Özgür TÜRKMENOĞLU,1 Tahsin ÇOLAK,1 Kerem KARACA,3 Hakan CANBAZ,1 Musa DİRLİK,1 Ramazan SARIBAY1

BACKGROUND

AMAÇ

This clinical study was conducted to present the clinical features, treatment and outcomes of rectus sheath hematoma (RSH), which is a complication of anticoagulation therapy that can present as acute abdomen.

Antikoagülan tedavinin bir komplikasyonu olan ve akut karın kliniği oluşturan rektus kılıfı hematomunun (RKH) klinik özelliklerini, tedavisini ve sonuçlarını sunmayı amaçladık.

METHODS

GEREÇ VE YÖNTEM

Twenty-two spontaneous RSH cases who were on anticoagulation therapy were reviewed. Patient characteristics, anticoagulant therapy form and indications, clinical presentation, radiologic work-up, treatment modalities, recurrence, morbidity, and follow-up data were analyzed.

Antikoagülan tedaviye bağlı gelişen 22 RKH olgusu incelendi. Olguların klinik özellikleri, antikoagülan tedavinin şekli ve endikasyonları, radyolojik bulgular, tedavi yöntemleri, nüksetme, morbidite ve mortalite bilgileri incelendi.

RESULTS

BULGULAR

The majority of the patients were female (64%), and the mean age was 60.6 years. All of the patients (100%) were receiving at least one form of anticoagulation therapy; most (72%) were on warfarin therapy. History of coughing was found in 45% of the cases. The most common presenting signs and symptoms were abdominal pain and mass (77%).

International normalized ratio (INR) was >3.0 in all patients on warfarin therapy. The diagnosis was made by abdominopelvic ultrasonography (US) and computerized tomography (CT). CT showed 100% sensitivity. The majority of patients (87%) were treated conservatively. Three patients (13%) were operated and 2 patients (9%) died as a result of RSH. Two patients experienced recurrence in one year.

Olguların %72’si kadın olup, yaş ortalaması 60.6 idi. Tüm olgular (%100) antikoagülan tedavisinin en az bir türünü, %72’si varfarin tedavisi almaktaydı. Olguların %45’inde öksürük hikayesi bulunmuştu. En sık karşılaşılan bulgu ve semptomlar karın ağrısı ve kitleydi (%77). Varfarin tedavisi gören olgularda INR (International Normalized Ratio) ortalaması 3’ün üstünde bulunmuştu. Tanılar, abdominopelvik ultrasonografi ve bilgisayarlı tomografi (BT) aracılığıyla konuldu, BT %100 duyarlılık gösterdi. Olguların çoğu (%87) konservatif tedavi aldı. Üç olgu (%13) ameliyat edildi. İki olgu (%9) RKH sonucu hayatını kaybetti, 2 olgu da bir yıl içinde hastalık tekrarladı.

CONCLUSION

Akut karın kliniğiyle gelen, yaşlı, öksüren ve antikoagülan tedavi alan hastalarda RKH den şüphelenilmelidir. Tercih edilen tanı şekli BT’dir. Erken tanı, morbiditeyi ve gereksiz cerrahi müdahaleyi önler.

RSH should be suspected in elderly, coughing patients on anticoagulation therapy, who present with clinical manifestations of acute abdomen. Early diagnosis can help to avoid increased morbidity or unnecessary surgical intervention.

Key Words: ��������������������������������������������������� Acute abdomen; anticoagulation; rectus sheath hematoma.

Departments of 1General Surgery, 2Cardiology, 3Cardiovascular Surgery, Mersin University Faculty of Medicine, Mersin, Turkey.

SONUÇ

Anahtar Sözcükler: Akut karın; antikoagulasyon; rektus kılıfı hematomu.

Mersin Üniversitesi Tıp Fakültesi, 1Genel Cerrahi Anabilim Dalı, Kardiyoloji Anabilim Dalı, 3Kalp-Damar Cerrahisi Anabilim Dalı, Mersin.

2

Correspondence (İletişim): Ahmet Dağ, M.D. Zeytinlibahçe Cad. Mersin Üniversitesi Tıp Fakültesi 33079 Mersin, Turkey.

Tel: +90 - 324 - 337 43 00 e-mail (e-posta): ahmetdag@yahoo.com

210

Spontaneous rectus sheath hematoma in patients on anticoagulation therapy

Rectus sheath hematoma (RSH) is a rare complication of anticoagulation, which is often misdiagnosed as acute abdominal disorder and leads to a delay in diagnosis or unnecessary surgical intervention.[1-3] The causes of RSH described in the literature include anticoagulant therapy, hematological disorders, trauma, physical exercise, coughing, sneezing, pregnancy, and hypertension.[3-5] The most common predisposing factor is anticoagulant therapy, and coughing has been implicated as the most important precipitating risk factor.

[6] Anticoagulant therapy is indicated for the prophylaxis of cardiac valve prosthesis, left ventricular dysfunction, and atrial fibrillation, and for the treatment of acute coronary syndrome, pulmonary embolism, deep vein thrombosis, and acute ischemic cerebrovascular disease. It has been the basic approach to initiate anticoagulant therapy with heparin followed by warfarin, but both require laboratory monitoring of dose.

The risk of RSH may be increased in elderly patients with both impaired functional status and weakened rectus muscle, when coagulation parameters are uncontrolled. When RSH occurs, early recognition, diagnosis and treatment are necessary to minimize further complications including hemodynamic instability, abdominal compartment syndrome (ACS), multiorgan dysfunction, and death.[2,3,7]

cations, morbidity, mortality, and long-term follow-up results of the RSH patients were analyzed.

The aging population and increased use of anticoagulant therapy without adequate control of coagulation parameters may cause a rise in the incidence of this condition. Because data about this relatively uncommon but life-threatening clinical entity are insufficient at present, we report a series of 22 patients with RSH.

Fifteen patients (68%) had comorbid conditions including diabetes mellitus (n=5), chronic lung disease (n=2), prior myocardial infarction (n=3), hypertension (n=2), congestive heart failure (n=2), Buergerâ&#x20AC;&#x2122;s disease (n=1), and idiopathic dilated cardiomyopathy (n=1). History of coughing was found in 10 patients (45%).

MATERIALS AND METHODS The records of 26 cases who were diagnosed clinically, radiologically or surgically as RSH in the Department of General Surgery of Mersin University Medical Faculty during the period September 2002 - August 2009 were reviewed retrospectively. Twentytwo spontaneous RSH patients who were on anticoagulation therapy without abdominal surgery within a few months were included in the study. Four patients with RSH, including one caused after laparoscopic cholecystectomy, one after inguinal hernia repair and two after a traffic accident, were excluded from the study. Patient characteristics (age and sex), clinical characteristics and comorbidity, indications and form of anticoagulant therapy, number of anticoagulant therapy agents, laboratory tests (blood counts, platelet counts, activated partial thromboplastin time [APTZ] and international normalized ratio [INR]), medications, clinical presentation, radiological work-up (ultrasonography [US] or computerized tomography [CT] of the abdomen and pelvis), treatment modalities (surgery, conservative or blood transfusions), compliCilt - Vol. 17 SayÄą - No. 3

RESULTS Twenty-two patients were treated in our clinic for spontaneous RSH caused by anticoagulation therapy.

The study group consisted of 8 males (36%) and 14 females (64%), with a mean age of 60.6 years (range, 21-81 years). The patient characteristics are shown in Table 1.

All of the patients were receiving at least one form of anticoagulation therapy; 16 patients (72%) were on warfarin, and 6 patients (28%) were on low-molecular-weight heparin therapy.

The indications for anticoagulation therapy were atrial fibrillation or flutter with left ventricular dysfunction in 7 patients (31.8%), cardiac valve replacement in 7 patients (31.8%), acute deep vein thrombosis in 3 patients (13.6%), ischemic cerebrovascular disease in 2 patients (9.5%), documented or suspected pulmonary embolism in 1 patient (4.5%), myocardial infarction in 1 patient (4.5%), and left ventricular mural thrombus in 1 patient (4.5%). Additionally, 14 patients (63%) were receiving both anticoagulation and antiplatelet agents.

Seventeen (77%) patients complained of abdominal mass and abdominal pain. Other presenting signs and symptoms of the patients included a decrease in hemoglobin of 0.4 g/dl or greater (n=10, 45%), nausea or vomiting (n=8, 36%), abdominal wall ecchymosis (n=5, 22%), peritoneal irritation (n=4, 18%), fever (n=4, 18%), and abdominal distension (n=2, 9%).

For all of the patients on warfarin therapy, INR was found to be >3.0 (3.2 - 6.0).

The diagnosis was made by both abdominopelvic US and CT in 11 cases, by only CT in 3 cases, by only US in 6 cases, and by surgical exploration for acute abdomen in 2 cases. In 2 cases diagnosed during surgery, US had failed to show the RSH. Blood transfusion and antibiotherapy were administered in all of the cases. In 11 patients, anticoagulant therapies were discontinued and intravenous vitamin K and fresh frozen plasma were administered. In 3 cases, bleeding was controlled during the operation.

Complications in RSH patients included hematoma infection (n=2), deep vein thrombosis (n=1), acute re211

Ulus Travma Acil Cerrahi Derg

Table 1. Clinical and demographic characteristics of patients No

Age

Sex

Anticoagulation therapy

Antiplatelet agent

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

74 51 65 21 78 45 68 62 56 74 41 81 67 63 56 42 68 76 34 67 74 71

Female Female Male Female Female Male Female Male Female Female Female Female Male Male Female Male Female Female Female Male Female Male

Warfarin Warfarin Warfarin Warfarin LMWH Warfarin Warfarin Warfarin LMWH LMWH Warfarin Warfarin LMWH Warfarin Warfarin Warfarin Warfarin LMWH Warfarin Warfarin Warfarin LMWH

+ – + + – + + – – + + + – – + – + + – + + +

Anticoagulation indication

Comorbidity

Cough INR

CVR Chronic lung disease AF + LVD MI CVR DM AF Idiopathic CMP Pulmonary embolism DM AF+LVD – CVR – AF+LVD – Acute deep vein thrombosis – AF+ ICVD – CVR Hypertension Left ventricular mural thrombosis DM Acute deep vein thrombosis – AF + Mitral stenosis – CVR Chronic lung disease Acute deep vein thrombosis Buerger disease CVR – ICVD – AF+ LVD DM+MI CVR – AF+LVD MI MI DM + Hypertension

+ – – + – – + + + – – + – + – – + + – + – –

4.6 5.3 3.9 4.2 1.2 4.8 6.0 3.2 1 0.9 4.4 3.8 1.1 4.6 4.0 3.8 4.8 1.0 3..8 4.2 3.5 1

INR: International normalized ratio; LMWH: Low-molecular-weight heparin; CVR: Cardiac valve replacement; AF: Atrial fibrillation; LVD: Left ventricular dysfunction; ICVD: Ischemic cerebrovascular disease; CMP: Cardiomyopathy; DM: Diabetes mellitus; MI: Myocardial infarction.

nal failure (n=1), and ileus of the bowel (n=1). Two patients (9%) died (1 treated surgically and 1 managed conservatively). The causes of deaths were acute respiratory distress syndrome and multiple organ failure.

Two patients experienced recurrent RSH in the following year and were managed conservatively again.

Diagnostic and treatment modalities and outcomes of the patients are given in Table 2.

DISCUSSION Hemorrhagic complications are the most important adverse effects of anticoagulant therapy, and RSH is one of these complications that is commonly associated with anticoagulation.[4] Adverse drug effects are more common among the geriatric population.[8] The majority of patients are aged between 60 and 70 years. In our series, similarly, the mean age of patients with RSH caused by anticoagulation was 60.6 years. Elderly patients are more likely to be receiving anticoagulation therapy, and they also have impaired homeostatic reserve and functional status and use multiple medications. In addition, the rectus abdominis muscle becomes weakened with inactivity and aging that results in increased vascularity of the abdominal wall.

RSH occurs more frequently in women than in men, and it demonstrates a male: female ratio of 1: 212

2–3.[4,5,9] Concordant with the previous reports, the male to female ratio was in favor of females in our series. One possible reason for the sex difference is the disparity in the size, shape and tone of the rectus Table 2. Diagnostic and treatment modalities and outcomes No Diagnostic Management

modalitiy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

US, CT US CT US Surgical CT US, CT Surgical US US, CT US, CT CT US, CT US US, CT US US, CT US, CT US, CT US US, CT US, CT

Complication

Recurrence

Conservative

Conservative

Conservative Deep vein thrombosis Conservative

Surgery Death Conservative

Conservative Hematoma infection Surgery

Conservative

Conservative Ileus Conservative

Conservative

Conservative Acute renal failure Conservative

Conservative

Conservative

Conservative Hematoma infection Conservative Death Conservative

Conservative

Surgery

Conservative

– – – – – – – – – – + – – – – – – – + – – –

May - Mayıs 2011

Spontaneous rectus sheath hematoma in patients on anticoagulation therapy

muscle. Men have a larger rectus muscle and this may provide protection against trauma to the muscle.

In the pathophysiology of RSH, there is an accumulation of blood in the sheath of the rectus abdominis muscle, secondary to either epigastric vessel tear or direct rupture of the rectus muscleâ&#x20AC;&#x2122;s fibers. The anatomical feature predisposes to vessel rupture with accumulation of large hematomas.[10] The classical clinical description of RSH includes sudden onset of abdominal pain that is often associated with nausea, fever and vomiting. Patients may present with Fothergillâ&#x20AC;&#x2122;s sign including a painful, palpable mass in the abdominal wall that does not cross the midline.[11] In our series, the most common presenting sign or symptom was abdominal pain and mass, followed by a decrease in hemoglobin of 0.4 g/ dl or greater. Abdominal wall ecchymosis, peritoneal irritation, fever, and abdominal distension were less common presenting signs and symptoms. Laboratory findings may demonstrate a decrease in the hemoglobin level, although this may be misleading early in the course. Leukocytosis, thrombocytosis and prolonged clotting studies in patients on oral anticoagulation may also be present. Patients on warfarin must be under close monitoring of INR. In other studies, patients with INR level >3 showed a 5-times increased risk of hemorrhagic complication. In addition, hypertension and renal or cerebrovascular diseases significantly increase the bleeding risk. In our series, the INR levels of all patients on warfarin therapy were >3.

Both US and CT are the diagnostic modalities of choice. US has sensitivity ranging from 70% to 90% in published reviews, while CT has 100% sensitivity and specificity for RSH in many series.[5,12-14] Both methods are useful for differentiating intra-abdominal pathologies and reducing unnecessary laparotomy. On the other hand, CT is the gold standard diagnostic modality, because most of these patients are elderly cardiac patients, and several acute abdominal conditions including mesenteric ischemia, rupture of an abdominal aneurysm, peptic ulcer disease, and perforation secondary to aspirin must be excluded. CT can also show whether the bleeding is active or not. Although CT successfully showed RSH in 14 of our patients with 100% sensitivity, US failed to show RSH in 2 patients.

Conservative methods should be used primarily in the treatment of RSH. Conservative methods consist of bed rest, analgesia, intravenous fluid resuscitation, ice pack application, compression, blood transfusions, and correction of coagulopathy. In patients with high risk of thromboembolic events, when the bleeding is under control, heparin and warfarin therapy must be started, synchronized with INR follow-up. When INR reaches the desired level, heparin is discontinued.

Cilt - Vol. 17 SayÄą - No. 3

In the study by Cherry et al.,[3] only 4.8% of the patients had a repeat episode of RSH after the anticoagulation therapy was restarted. Reinitiating anticoagulation was shown to be safe in high-risk patients for thromboembolic events. Two out of 22 patients had a repeat episode of RSH in our series after anticoagulation therapy was restarted.

Surgical intervention should be considered when conservative treatment fails and would be indicated when hemodynamic stability cannot be achieved.

When active bleeding is identified, patients can be managed with catheter-based arterial embolization, by radiologically guided drainage or by laparotomy with vessel ligation and evacuation of the hematoma.[2,3,5,15] Although the surgical treatment of patients with larger RSH due to anticoagulation therapy is associated with shorter hospital stay and less need for analgesics, patients may also develop abdominal hypertension that may progress to ACS and an increased risk of significant morbidity or death.[16] With early diagnosis and conservative management, surgical intervention can be avoided even with large hematomas.

RSH can lead to serious complications including infection, acute renal failure, myocardial infarction, hypovolemic shock, myonecrosis, ACS, small bowel infarction, and death.[2,3,14,17] In our series, hematoma infection, deep vein thrombosis, acute renal failure, and ileus were the complications of RSH that were treated conservatively. The overall mortality in patients with RSH has been reported to be 4%. The mortality is higher (25%) in patients undergoing anticoagulation therapy, whereas mortality rates in iatrogenic RSH and pregnant patients are 18% and 13%, respectively.[10] In our series, the causes of the two deaths (9%) were acute respiratory distress syndrome and multiple organ failure.

In conclusion, the diagnosis of RSH should always be considered in elderly, especially female, coughing patients on anticoagulation therapy, who present with clinical manifestations of acute abdomen, a palpable abdominal mass and anemia. CT of the abdomen and pelvis is the diagnostic modality of choice. Early diagnosis is important to avoid increased morbidity or unnecessary surgical intervention. Treatment is mainly conservative with pain management, antibiotherapy and blood transfusions. Surgery may be needed in cases when hemodynamic stability cannot be achieved. In addition, we advise that all patients on anticoagulation therapy should be under laboratory monitoring.

REFERENCES 1. Miyauchi T, Ishikawa M, Miki H. Rectus sheath hematoma in an elderly woman under anti-coagulant therapy. J Med Invest 2001;48:216-20.

2. Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg 1988;54:630-3.

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3. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore) 2006;85:105-10.

4. Denard PJ, Fetter JC, Zacharski LR. Rectus sheath hematoma complicating low-molecular weight heparin therapy. Int J Lab Hematol 2007;29:190-4.

5. Berná JD, Zuazu I, Madrigal M, García-Medina V, Fernández C, Guirado F. Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging 2000;25:230-4.

6. Fukuda T, Sakamoto I, Kohzaki S, Uetani M, Mori M, Fujimoto T, et al. Spontaneous rectus sheath hematomas: clinical and radiological features. Abdom Imaging 1996;21:58-61.

7. Osinbowale O, Bartholomew JR. Rectus sheath hematoma.

Vasc Med 2008;13:275-9.

8. Arai H, Akishita M, Teramoto S, Arai H, Mizukami K, Morimoto S, et al. Incidence of adverse drug reactions in geriatric units of university hospitals. Geriatr Gerontol Int 2005;5:293-7.

9. Luhmann A, Williams EV. Rectus sheath hematoma: a series of unfortunate events. World J Surg 2006;30:2050-5.

10. Hildreth DH. Anticoagulant therapy and rectus sheath hematoma. Am J Surg 1972;124:80-6.

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11. Fothergill WE. Haematoma in the Abdominal Wall Simulating Pelvic New Growth. Br Med J 1926;1:941-2.

12. Moreno Gallego A, Aguayo JL, Flores B, Soria T, Hernández Q, Ortiz S, et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath haematoma. Br J Surg 1997;84:1295-7.

13. Berná JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging 1996;21:62-4.

14. Khan MI, Medhat O, Popescu O, Rastogi A, Thompson T. Rectus sheath haematoma presenting as acute abdomen.

ANZ J Surg 2005;75:502-3.

15. Rimola J, Perendreu J, Falcó J, Fortuño JR, Massuet A, Branera J. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol 2007;188:W497-502.

16. O’Mara MS, Semins H, Hathaway D, Caushaj PF. Abdominal compartment syndrome as a consequence of rectus sheath hematoma. Am Surg 2003;69:975-7.

17. Dineen RA, Lewis NR, Altaf N. Small bowel infarction complicating rectus sheath haematoma in an anticoagulated patient. Med Sci Monit 2005;11:CS57-9.

May - Mayıs 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):215-219

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.12844

Will computed tomography (CT) miss something?

The characteristics and pitfalls of torso CT in evaluating patients with blunt solid organ trauma Bilgisayarlı tomografi (BT) bir şeyleri atlıyor mu? Künt solid organ travmalı hastaların değerlendirilmesinde, gövde BT’sinin özellikleri ve tuzakları Wan-Yin KUO,1 Hung-Jung LIN,1 Ning-Ping FOO,2 How-Ran GUO,3 Cheng-Chih JEN,2 Kuo-Tai CHEN1 BACKGROUND

AMAÇ

Selective nonoperative management has become the standard care for blunt solid organ trauma patients, and torso computed tomography (CT) provides useful therapeutic clues. We conducted this study to determine the frequency and character of missed diagnoses in blunt solid organ trauma patients.

Selektif non-operatif tedavi, künt solid organ travmalı hastalar ile ilgili standart tedavi haline gelmiştir ve bilgisayarlı vücut tomografisi (BT) yararlı terapötik ipuçları sağlamaktadır. Biz, bu çalışmayı künt solid organ travmalı hastalarda atlanan tanıların sıklığını ve karakterini belirlemek üzere yürüttük.

METHODS

GEREÇ VE YÖNTEM

We reviewed the medical records of all blunt trauma patients who underwent torso CT and who were admitted for solid organ injuries (liver, spleen and kidney) at the ChiMei Medical Center from August 2003 to October 2006.

Ağustos 2003 ile Ekim 2006 tarihleri arasında solid organ yaralanmaları (karaciğer, dalak ve böbrek) nedeniyle ChiMei Tıp Merkezine yatırılan ve vücut BT’si çekilen bütün künt travmalı hastaların tıbbi kayıtları gözden geçirildi.

RESULTS

BULGULAR

The patients were divided into the Missed Group (24 patients) and the Unaltered Group (262 patients) according to the presence or absence of a missed diagnosis. The overall missed diagnosis rate was 8.4%. Only one unidentified bowel injury was disclosed by follow-up CT, and all of the missed injuries were revealed by laparotomy. The Missed Group had a higher Injury Severity Score, lower Glasgow Coma Scale, more Intensive Care Unit (ICU) care, and longer duration of hospitalization.

Hastalar, atlanmış bir tanı bulunup bulunmamasına göre atlanan grup (24 hasta) ve değişmeyen grup (262 hasta) şeklinde gruplara ayrıldı. Genel atlanan tanı oranı %8,4 idi. Yalnızca tanımlanmamış bir bağırsak yaralanması takip BT’si ile açığa çıkarıldı, atlanan yaralanmaların hepsi laparotomi ile ortaya çıkarıldı. Atlanan grup, daha yüksek bir Yaralanma Şiddet Skoru, daha düşük Glasgow Koma Skalası, daha fazla Yoğun Bakım Ünitesi (YBÜ) tedavisi ve daha uzun hastanede kalma süresine sahip olmuştur.

CONCLUSION

SONUÇ

Discovery of missed diagnoses is not uncommon in patients who sustain severe trauma. Laparotomy revealed all of the missed diagnoses, and follow-up CT demonstrated a poor ability to detect unidentified injuries. We suggest laparotomy instead of follow-up CT in the nonoperative management of patients with blunt solid organ injuries if clinical deterioration occurs.

Ciddi travması uzun süre devam eden hastalarda, atlanmış tanıların ortaya çıkarılması seyrektir. Laparotomi atlanmış tanıların hepsini ortaya çıkarmış ve takip BT’si tanımlanmamış yaralanmaların saptanmasında düşük bir yeteneğe sahip olduğunu ortaya koymuştur. Klinik kötüleşme oluşması durumunda, künt solid organ travmalı hastaların non-operatif tedavisinde takip BT’si yerine laparotomi yapılmasını öneriyoruz.

Key Words: �������������������������������������������������� Blunt abdominal trauma; computed tomography; laparotomy; missed injury; solid organ injury.

Anahtar Sözcükler: Künt abdominal travma; bilgisayarlı tomografi; laparotomi; atlanan yaralanma; solid organ yaralanması.

Emergency Department, Chi-Mei Medical Center, Tainan; 2Department of Emergency Medicine, Chi-mei Medical Center, Liouying 3 Department of Environmental and Occupational Health and Department of Environmental and Occupational Medicine, Medical College, National Cheng Kung University, Tainan, Taiwan.

Chi-Mei Tıp Merkezi, Acil Servis, Tainan; 2Chi-Mei Tıp Merkezi, Acil Tıp Anabilim Dalı, Liouying; 3 Ulusal Cheng Kung Üniversitesi, Tıp Fakültesi, Çevre ve İş Sağlığı Anabilim Dalı ve Çevre ve İş Hastalıkları Anabilim Dalı, Tainan, Tayvan.

1

1

Correspondence (İletişim): Kuo-Tai Chen, M.D. 901 Chung-Hwa Road, Yung Kang, Tainan 710, Tainan, Taiwan.

Tel: +886 - 6 - 2812811 ext. 57196 e-mail (e-posta): 890502@mail.chimei.org.tw

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Ulus Travma Acil Cerrahi Derg

Selective nonoperative management (NOM) of solid organ injuries (SOIs) has become the standard of care for two decades. The success of NOM relies on the following criteria: accurate diagnosis of SOIs, maintenance of hemodynamic stability by administration of a limited amount of fluid and absence of associated injuries.[1,2] Thus, trauma surgeons need a diagnostic tool to discover SOIs and to exclude associated injuries. In the early 1980s, computed tomography (CT) became available and improved the diagnosis of SOI in blunt trauma patients. Management decisions may therefore be based on the results of CT. Especially those patients who have sustained a blunt SOI and undergo NOM, torso CT performed in the emergency department (ED) provides most therapeutic guides.

Therefore, trauma surgeons need to understand the types of visceral injuries that might be missed by CT, and whether these missed diagnoses might influence the management and the prognosis of the patients. The missed diagnoses could be discovered by a second CT scan or by other diagnostic tools. Accordingly, we conducted a retrospective study to determine the frequency and character of missed diagnoses after CT in blunt solid organ trauma patients.

MATERIALS AND METHODS We reviewed the medical records of all trauma patients admitted to the Chi-Mei Medical Center from August 2003 to October 2006. Patients sustaining penetrating injuries and those did not have a torso helical CT scan (Four Slice: HiSpeed CT, GE) in the ED were excluded. All reports of the CT scans performed in the ED were reviewed, and only patients with SOI (liver, spleen and kidney) were included in the study.

Patients who were diagnosed with SOI based solely on clinical suspicion and patients who sustained internal injuries to organs other than the liver, spleen and kidney were also excluded from the study. The hospital course, follow-up imaging studies and subsequent surgical interventions were studied. Any alteration of the diagnosis resulting from further imaging studies and surgical findings were recorded, and the laparotomy results were considered authoritative if the imaging reports contradicted the surgical findings. An unidentified injury that was not identified in the ED but was identified during the hospital stay was defined as an under-diagnosis, and an initial diagnosis of SOI that was excluded during admission was regarded as an over-diagnosis.

Patients who had at least one missed diagnosis were categorized as the Missed Group, and patients whose diagnoses were unaltered were categorized as the Unaltered Group. Patient age and gender, Glasgow Coma Scale (GCS) in ED, mechanisms of trauma, number of internal organ injuries, requirements of laparotomy or arterial embolization, hospital course, duration of in216

tensive care unit (ICU) and hospital stays, rate of ICU admission and mortality, and the Injury Severity Score (ISS) of all patients were collected for statistical analysis. Fisher’s exact test was used to compare the rates of ICU admission, GCS <13, head Abbreviated Injury Scale (AIS) >2, presence of more than two organ injuries, mortality, laparotomy, and arterial embolization between the Missed Group and the Unaltered Group.

We compared the ISSs, number of days in the ICU and number of days in the hospital of the two groups using the Wilcoxon rank-sum test. All statistical analyses were performed at the two-tailed significance level of 0.05 using the SPSS software package (SPSS 12.0).

RESULTS The cases of 286 patients were reviewed in this study, including 24 patients who had at least one missed diagnosis (Missed Group) and 262 patients whose diagnoses were unaltered (Unaltered Group).

The general characteristics of the study population are presented in Table 1. There were no statistical differences in age and gender between the two groups.

In the Missed Group, 2 patients underwent followup CT scans before laparotomy. One patient had an unidentified bowel injury disclosed by follow-up CT, and the lesion was confirmed further by surgery. For the other patient whose follow-up CT scan did not reveal any additional abnormality, subsequent laparotomy discovered an unidentified liver injury. All 24 patients in the Missed Group required a laparotomy.

In the Unaltered Group, 177 patients received only a CT scan. Twenty-six patients had follow-up CT, and 59 patients underwent laparotomy. The numbers and the results of follow-up CT and the laparotomy in the study cohort are illustrated in Fig. 1.

The overall missed rate of the study population was 8.4%. Eighty-three patients underwent laparotomy, and missed diagnoses were revealed in 24 patients.

Twenty-eight percent of laparotomies discovered unidentified internal organ injuries, whereas only 1 of the Table 1. General characteristics of the patient population

Age Gender Female Male Mechanisms Traffic accident Fall Assault Others

Unaltered group Missed group p (n=262) (n=24) 33.5±16.7

103 (39.3%) 159 (60.7%)

215 (82.1%) 29 (11.1%) 10 (3.8%) 8 (3.1%)

36.8±13.6

12 (50.0%) 12 (50.0%)

21 (87.5%) 2 (8.3%) 1 (4.2%) 0 (0%)

NS NS

NS: Nonsignificant.

May - Mayıs 2011

The characteristics and pitfalls of torso CT in evaluating patients with blunt solid organ trauma

Missed diagnosis (24)

Follow up CT: altered diagnosis.

Laparotomy: altered diagnosis (1) Laparotomy: altered diagnosis (22)

Total (286)

100 80 Percent

Follow up CT: unaltered diagnosis.

Laparotomy: altered diagnosis (1)

59

60

27

262

Unaltered diagnosis

40

Missed diagnosis 24

20

24

1

0

Laparotomy (28.9%)

CT (3.6%)

Total (8.4%)

Fig. 2. Comparison of the ability of laparotomy and followup CT to detect missed diagnoses.

Follow up CT (26)

Unaltered diagnosis (262)

Laparotomy (59)

Liver (6)

Spleen (111)

Kidney (69) Others (6)

One CT only (177)

Spleen (6)

Liver (143)

Kidney (1)

Fig. 1. The numbers and results of follow-up CT and laparotomy in the study population.

28 follow-up CT scans led to an altered diagnosis. The capability of laparotomy and follow-up CT to detect a missed diagnosis is compared in Fig. 2.

Twenty-two under-diagnoses and 6 over-diagnoses were found in the Missed Group. Two patients had 2 under-diagnoses, and 2 patients had both an over- and an under-diagnosis. Hollow viscus injuries were the most common causes of under- diagnoses, including 8 bowel and mesentery injuries, 2 diaphragm perforations, 1 gallbladder hematoma, 1 urinary bladder rupture, and 1 left atrium perforation. The over-diagnoses comprised 3 splenic injuries, 2 hepatic injuries and 1 renal injury. The initial diagnoses and over-diagnoses are presented in Fig. 3. The revised diagnoses and under-diagnoses are shown in Fig. 4.

Comparing the Missed Group and the Unaltered Group, there were no statistically significant differences in the mortality rate, head AIS >2, the requirement for arterial embolization, and the presence of more than two organ injuries. However, patients in the Missed Group had a higher rate of GCS <13 in the ED and requirement for ICU admission (Table 2). Comparing the durations of hospital and ICU stays and the ISSs between the two groups, the Missed Group had longer hospital and ICU stays and higher ISSs (p=0.002, p<0.001, and p<0.001, respectively) (Fig. 5).

DISCUSSION There are opposing views regarding the effectiveness of CT scans in trauma patients. Two studies Cilt - Vol. 17 Sayı - No. 3

Fig. 3. Initial diagnoses based on the CT in the ED of the study cohort. “Others” represents the over-diagnoses.

Bowel and mesentery (6)

Spleen (111)

Kidney (70) Diaphragm (2) Gall bladder (1) Urinary bladder (1) Inferior vena cava (1) Liver (4)

Others (22)

Liver (146)

Kidney (3) Pancreas (1) Atrium (1)

Fig. 4. Revised diagnoses of the study cohort. “Others” represents the under- diagnoses.

Missed group

Unaltered group 33.6

35 30

24.4

22.5

25 20 15 10 5

14.4 6.7 3.2

0 ICU days

Hospital days

ISS

Fig. 5. Comparison of Injury Severity Scores (ISSs) and the duration of intensive care unit (ICU) and hospital stays between the Missed Group and the Unaltered Group.

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Table 2. Rates of mortality, requirement of arterial embolization, presence of more than two organ injuries, head AIS >2, GCS <13, and intensive care unit admission Characteristics

Missed group

Unaltered group

p

Mortality Arterial embolization > Two organ injuries Head AIS > 2 GCS < 13 ICU admission

3/24 (12.5%) 1/24 (4.2%) 6/24 (25.0%) 4/24 (16.7%) 14/24 (58.3%) 22/24 (91.3%)

15/262 (5.7%) 8/262 (3.1%) 36/262 (13.7%) 26/262 (9.9%) 94/262 (35.9%) 187/262 (71.4%)

NS NS NS NS 0.046 0.031

AIS: Abbreviated Injury Scale; GCS: Glasgow Coma Scale; ICU: Intensive Care Unit; NS: Nonsignificant.

have suggested that a blunt trauma patient could be discharged safely after a negative CT examination.[3,4] However, another study compared the results of CT and autopsy in 113 trauma patients and found that CT had a high rate of missed diagnoses of abdominal organ injuries.[5] In addition, CT has proven to be less useful in detecting hollow viscus injuries.[6,7] Even with the introduction of helical CT, the diagnostic accuracy of CT is still debated.[8,9] Many studies have emphasized the importance of physical examinations to offset the shortcomings of CT.[10,11] Nevertheless, the findings upon physical examination are often prejudiced by the presence of torso contusions or bony fractures and by reduced consciousness because of drugs and brain injuries. Thus, it is imperative for trauma surgeons to know the advantages and pitfalls of torso CT in the evaluation of trauma patients.

In this study, a small but significant portion (8.4%) of patients sustaining blunt abdominal SOI had a missed diagnosis. However, we believe that the missed rate might have been underestimated because only 29% of the patients received a laparotomy and most missed diagnoses were revealed by surgery. With the trend of decreased surgical intervention for blunt SOI, there will be more internal organ injuries that are not discovered on CT images. Several studies have proposed that patients with more than two organ injuries have a high rate of NOM failure associated with more hollow viscus injuries.[12,13] However, the differences were not obvious in our study.

The severity of the trauma had an obvious impact on the occurrence of missed diagnoses. The patients with missed diagnoses had higher ISS, lower GCS in the ED, needed more ICU care, and stayed longer in the hospital and ICU. The presence of distracting injuries and reduced consciousness impeded the patientsâ&#x20AC;&#x2122; expression and the reliability of the physical examination.

Follow-up CT had a poor ability to detect unidentified injuries. The impaired performance may contribute to the limited ability of CT to detect hollow viscus injuries, and some of the diagnostic signs were obscured by adjacent organ injuries. In our study, the 218

majority of under-diagnoses were hollow viscus injuries, which are easily overlooked in CT images. Several studies have suggested that CT is a reliable modality to evaluate hollow viscus injuries.[8,9,14] Nevertheless, the ability of doctors to identify hollow viscus injuries based on a CT scan relies on some non-specific CT findings such as free intra-abdominal fluid, visceral wall thickening or increased fat infiltration.[15-17] In patients who had sustained SOI, these indirect signs cannot represent the concomitant presence of hollow viscus injuries.

Routine follow-up CT is no longer suggested for NOM of patients with SOI. It increases medical expenses and usually does not affect patient management.[18,19] Even in patients undergoing NOM who experience clinical deterioration, we suggest conducting a laparotomy instead of a follow-up CT scan. Clinical deterioration may result from failed NOM of SOI or unidentified concurrent internal organ injuries, and follow-up CT does not perform well in detecting missed lesions. Laparotomy can reveal the missed injuries and accomplish therapeutic goals. Thus, follow-up CT has a limited role and should be used only in those patients who are unwilling or unable to undergo surgery who present with new abnormal findings on physical examination or signs of hemodynamic instability.

The limitations of the study come mainly from the retrospective design. First, the criteria for follow-up CT and laparotomy were based on the subjective judgments of each trauma surgeon; therefore, there were no uniform rules to decide who should undergo follow-up CT and laparotomy or when the follow-up procedure should be conducted. Second, the CT findings were based on the radiologistsâ&#x20AC;&#x2122; reports instead of the readings of trauma surgeons. However, the official reports are usually unavailable, and the real-time opinions of the trauma surgeons are crucial for decision-making.

This mismatch might have influenced the results of the study.

Discovery of missed diagnoses is not uncommon in patients who sustain severe trauma. All missed diagnoses could be discovered during laparotomy, and folMay - MayÄąs 2011

The characteristics and pitfalls of torso CT in evaluating patients with blunt solid organ trauma

low-up CT provided little information about the missed injuries. The majority of the missed diagnoses were hollow viscus injuries. We suggest that laparotomy be performed instead of repeat CT if clinical deterioration occurs during NOM of patients with blunt SOI.

REFERENCES 1. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg 2003;138:844-51.

2. Galvan DA, Peitzman AB. Failure of nonoperative management of abdominal solid organ injuries. Curr Opin Crit Care 2006;12:590-4.

3. Livingston DH, Lavery RF, Passannante MR, Skurnick JH, Fabian TC, Fry DE, et al. Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional trial. J Trauma 1998;44:273-82.

4. Awasthi S, Mao A, Wooton-Gorges SL, Wisner DH, Kuppermann N, Holmes JF. Is hospital admission and observation required after a normal abdominal computed tomography scan in children with blunt abdominal trauma? Acad Emerg Med 2008;15:895-9.

5. Molina DK, Nichols JJ, Dimaio VJ. The sensitivity of computed tomography (CT) scans in detecting trauma: are CT scans reliable enough for courtroom testimony? J Trauma 2007;63:625-9.

6. Sherck J, Shatney C, Sensaki K, Selivanov V. The accuracy of computed tomography in the diagnosis of blunt smallbowel perforation. Am J Surg 1994;168:670-5.

7. Liu M, Lee CH, Pâ&#x20AC;&#x2122;eng FK. Prospective comparison of diagnostic peritoneal lavage, computed tomographic scanning, and ultrasonography for the diagnosis of blunt abdominal trauma. J Trauma 1993;35:267-70.

8. Scaglione M, de Lutio di Castelguidone E, Scialpi M, Merola S, Diettrich AI, Lombardo P, et al. Blunt trauma to the gastrointestinal tract and mesentery: is there a role for helical CT in the decision-making process? Eur J Radiol 2004;50:67-73.

9. Atri M, Hanson JM, Grinblat L, Brofman N, Chughtai T,

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Tomlinson G. Surgically important bowel and/or mesenteric injury in blunt trauma: accuracy of multidetector CT for evaluation. Radiology 2008;249:524-33.

10. Fakhry SM, Brownstein M, Watts DD, Baker CC, Oller D. Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma 2000;48:408-15.

11. Miller PR, Croce MA, Bee TK, Malhotra AK, Fabian TC. Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management. J Trauma 2002;53:238-44.

12. Nance ML, Keller MS, Stafford PW. Predicting hollow visceral injury in the pediatric blunt trauma patient with solid visceral injury. J Pediatr Surg 2000;35:1300-3.

13. Yanar H, Ertekin C, Taviloglu K, Kabay B, Bakkaloglu H, Guloglu R. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma 2008;64:943-8.

14. Pal JD, Victorino GP. Defining the role of computed tomography in blunt abdominal trauma: use in the hemodynamically stable patient with a depressed level of consciousness.

Arch Surg 2002;137:1029-33.

15. Tan KK, Liu JZ, Go TS, Vijayan A, Chiu MT. Computed tomography has an important role in hollow viscus and mesenteric injuries after blunt abdominal trauma. Injury 2010;41:475-8.

16. Ruess L, Sivit CJ, Eichelberger MR, Gotschall CS, Taylor GA. Blunt abdominal trauma in children: impact of CT on operative and nonoperative management. AJR Am J Roentgenol 1997;169:1011-4.

17. Brofman N, Atri M, Hanson JM, Grinblat L, Chughtai T, Brenneman F. Evaluation of bowel and mesenteric blunt trauma with multidetector CT. Radiographics 2006;26:111931.

18. Lyass S, Sela T, Lebensart PD, Muggia-Sullam M. Followup imaging studies of blunt splenic injury: do they influence management? Isr Med Assoc J 2001;3:731-3.

19. Thaemert BC, Cogbill TH, Lambert PJ. Nonoperative management of splenic injury: are follow-up computed tomographic scans of any value? J Trauma 1997;43:748-51.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):220-224

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.82160

Impact of para-neurologic and para-mental premorbidities on burn injury patients Yanık hastalarında nörolojik ve mental morbiditelerin etkisi Mehmet BOZKURT,1 Emin KAPI,1 Ercan GEDİK,2 Samet Vasfi KUVAT1

BACKGROUND

AMAÇ

The aim of this article was to determine whether there are differences in the progression, mortality and morbidity of these premorbid patients compared to normal burn injury patients.

Bu yazının amacı, normal yanık travmalı hastalara göre ek morbiditeli hastaların gidişat, mortalite ve morbiditelerinde farkların olup olmadığının saptanmasıdır.

METHODS

GEREÇ VE YÖNTEM

In this study, 26 premorbid cases (8 males, 18 females; mean age: 30.8 years; range: 3-74 years) hospitalized in the Dicle University Burn Center between July 2007 and November 2009 were evaluated.

Bu çalışmada, Temmuz 2007 ve Kasım 2009 tarihleri arasında Dicle Üniversitesi Yanık Merkezi’nde yatırılan ek morbiditeli 26 olgu (8 erkek, 18 kadın; ortalama yaş: 30,8 yaş; dağılım 3-74 yıl) değerlendirildi.

RESULTS

BULGULAR

Appreciation of the pathophysiological basis of the premorbidity in burn patients is important. When the treatment for premorbid burn patients is planned, the associated co- or premorbidity must be kept in mind. To improve the outcome of the treatment, considerable attention must be paid to these patients.

Yanık hastalarında ek morbiditenin patofizyolojik kaynağı önem kazanır. Ek morbiditesi olan yanık hastalarının tedavisi planlanırken eşlik eden morbiditeler akılda bulundurulmalıdır. Tedavinin neticesini sağlamak için, bu hastalara ciddi dikkat harcanmalıdır.

CONCLUSION

SONUÇ

This article gives an overview of the current literature regarding premorbid patients in the Turkish population and draws attention to this specific topic.

Bu yazı Türk toplumunda ek morbiditeli hastalara ait güncel literatürlerin gözden geçirilmesini sağlamakta ve bu özel konuya dikkati çekmektedir.

Key Words: Burn; complication; premorbidity.

Anahtar Sözcükler: Yanık; komplikasyon; morbidite.

Burn injury is a multisystemic trauma characterized by a devastating effect on the human body. Burn injury can be observed with an additional premorbid disease in burn injury patients. The pathophysiologic mechanisms of the burn injury may aggravate and influence the progression of the premorbid disease. Additionally, existing systemic diseases can change the progression of the burn injury.[1,2]

Patients with weak mental and motor functions are at greater risk than those with normal burn injuries.

Victims having sensorimotor deficits are likely to be exposed to more severe burn injuries for a longer period.[3,4]

Departments of 1Plastic Reconstructive and Aesthetic Surgery and Burn Center, 2General Surgery, Dicle University Faculty of Medicine, Diyarbakır, Turkey.

Dicle Üniversitesi Tıp Fakültesi, 1Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı ve Yanık Merkezi, 2Genel Cerrahi Anabilim Dalı, Diyarbakır.

We focus on burn injury cases with pre-exiting para-mental and para-neurological premorbidities.

Correspondence (İletişim): Mehmet Bozkurt, M.D. Dicle Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi ABD, 21280 Diyarbakır, Turkey.

Tel: +90 - 412 - 248 80 01 e-mail (e-posta): drmbozkurt@yahoo.com

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Impact of para-neurologic and para-mental premorbidities on burn injury patients

The aim of this article was to determine whether there are differences in the progression, mortality and morbidity of these premorbid patients compared to normal burn injury patients. We also aimed to ascertain whether there are differences in the treatment principles of burn patients with premorbidities.

The burn etiologies were flame (5 cases), scalding (13 cases), stove contact (2 cases), electrical injury (2 cases), falling into the tandir (clay cooker) (2 cases), and water heater (2 cases). Most of the cases were exposed to burn injury while undertaking routine home activities.

MATERIALS AND METHODS Twenty-six premorbid cases (8 males, 18 females; mean age: 30.8 years; range: 3-74 years) hospitalized in the Burn Center between July 2007 and November 2009 were evaluated. Psychiatric premorbid cases, such as those with personality disorders and psychosis, were not included in the study. The main premorbid etiologies were seizures (11 cases), mental retardation (5 cases), Down syndrome (3 cases), paraplegia (3 cases; caused by pes equinovarus deformity in 1 case and motor neuron disease in 2 cases), Parkinson’s disease (3 cases), and Alzheimer’s disease (1 case) (Table 1). When the medical history and previous records of these patients were examined, nine of the epileptic cases showed tonic-clonic epilepsy and two showed absence epilepsy. Eight cases were under Epdantoin and the other three were under carbamazepine drug therapy. Six were under regular medication and five were under irregular antiepileptic medical therapy.

RESULTS Based on the total body surface area (TBSA), the average burn area was 16.3% (5-30). The burn defects were determined to be second-degree in 16 cases (4 superficial, 12 deep defects) and third-degree in 10 cases. The defects were primarily localized in the upper extremities in 14 cases (Fig. 1). Premorbid cases accounted for 4% of all the patients (22/541) admitted to our facility during the study period.

In the course of the follow-up period, two of the patients had an aggravated petit mal convulsion due to the devastating effect of the burn injury.

Twenty-four patients underwent surgery, and one patient’s defect healed secondarily. One case with Down syndrome had a ventricular septal defect confirmed by echocardiography. The family of this patient rejected surgical treatment.

A perusal of the medical histories of subnormal

Table 1. Demographic features of burn cases with comorbidity No Age Sex Comorbid

etiology

Burn etiology

Burn localization

1 2 3

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

19 20 21 22 23 24 25 26

Hot water Flame Electric

Hot tea Hot food Tandir Electric Hot water Hot water Hot food Hot water Flame Stove Flame Water boiler Stove Water boiler Hot water

Face, trunk Cruris Cruris, foot

Thigh, cruris Face, upper extremity Trunk, thigh Trunk, upper extremity Trunk, thigh Upper extremity Trunk, upper extremity Upper extremity Trunk, thigh, cruris Thigh, cruris Trunk Trunk, upper extremity Upper extremity Upper extremity, foot Cruris, foot

2º 2º 2-3º

2º 2º 2-3º 2º 2º 3º 2-3º 2º 2º 2º 2º 2-3º 2º 3º 2º

15 12 10

30 7 15 18 25 5 15 10 30 20 15 25 18 5 9

Debridement+Grafting Debridement+Grafting Debridement+Grafting

Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting Refused the operation Healed secondarily Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting

None None Pressure Sore + Urethral infection Weight loss None None None None None – – Partial graft loss None None None Partial graft loss None None

32 36 30 34 34 36 30 32 31 36 35 32 33 35 29 36

Tandir Hot food Flame Hot water Hot water Hot water Flame Hot water

Thigh, upper extremity Face, upper extremity Trunk, upper extremity Thigh, cruris Trunk, upper extremity Face, upper extremity Lower extremity Face, upper extremity

2-3º 2º 2º 2-3º 3º 2-3º 3º 2-3º

12 16 10 25 13 25 25 15

Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting Debridement+Grafting

None None None Partial graft loss None None None None

37 35 38 36 34 33 34 32

6 17 65

74 3 43 52 66 6 5 6 13 65 57 57 7 14 6

13 65 12 65 50 17 4 13

F F F

F F M F M F M M M F F M F F M

F M F F F F F F

Down syndrome Epilepsy Paraplegia

Parkinson Down syndrome Epilepsy Epilepsy Parkinson Epilepsy Down syndrome Epilepsy Mental retardation Paraplegia Epilepsy Epilepsy Mental retardation Mental retardation Paraplegia (pes equinovarus) Mental retardation Parkinson Mental retardation Alzheimer Epilepsy Epilepsy Epilepsy Epilepsy

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Depth TBSA Progress of burn (%)

Complication

Hospital stay (day) 27 33

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Fig. 1. Preoperative view of the defect in a case with burns of the upper extremity.

Fig. 2. Postoperative view of a case in whom debridement and grafting were performed.

mental cases revealed that congenital infections or teratogens may be the etiologic cause. Down syndrome was confirmed by the medical reports submitted by the family. Patients with Down syndrome ranged in age between 3 to 6 years; unfortunately, IQ scores were not obtained in these cases. The rest of the mental retardation cases were over 6 years old, with an IQ level of 70-75.

disability. Intellectual disability may also be used to describe dementing conditions such as Alzheimer’s disease.

In 14 of the premorbid cases, early tangential excision and grafting were performed. Full thickness skin grafting was applied to seven cases and split thickness skin grafting to 17 cases (Fig. 2). In two cases with mental retardation, 8% graft loss was observed due to the hyperactivity of the patients and non-compliance (Fig. 3). In one geriatric case, a 10% graft failure was attributed to Staphylococcus aureus infection. The overall graft failure ratio was 11.5%. The average hospital stay of premorbid cases was 33.4 days.

The management of geriatric burn victims is also a major challenge. In this study, we included six senior patients who were ≥65 years old with pre-existing conditions. The pre-burn functional status and premorbid conditions of these geriatric patients are useful tools for developing an interdisciplinary treatment protocol. The premorbid geriatric burn victims have a higher mortality rate than geriatric patients.[6] In deciding burn treatment, we also needed to focus on the associated pathophysiological conditions. Six of our patients were in the geriatric age range; of these, three

DISCUSSION Premorbidity can be simply defined as a condition or ailment that occurs or exists before the occurrence of a physical disease or emotional illness. In psychiatry and neurology, the term “premorbid personality” is used to determine the psychological risk factors for the development of a particular disorder. In this article, we investigated the impact of para-neurologic and para-mental premorbidities. The psychotic cases were excluded from our study.

There is a strong association between premorbid cases and burn injury. The premorbid condition can influence the etiologic reasons and the severity of the burn injury.[2] Geriatric and pediatric cases are both prone to burn injury. When neurological or para-neurological premorbid diseases are present, the morbidity and mortality will increase. It is reported in the literature that the severity of the injury is important and the hospital stay is longer.[5] Intellectual disability is characterized by the limitations from a specific emotional or psychological 222

Fig. 3. View of a case with partial graft loss caused by hyperactivity.

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Impact of para-neurologic and para-mental premorbidities on burn injury patients

had Parkinson’s disease, two had paraplegia and one had Alzheimer’s. Four suffered scalding injury.

The ability of elderly patients to grasp or hold objects decreases because of aging tremors and other weaknesses. In addition, their cognitive functions and reflex response to hazardous events wanes and may contribute to burn injuries. The risk increases when premorbidity is also taken into account. In our community, in the presence of cold temperatures, people frequently stand with their extremities close to a burning stove. This is a hazardous action that may cause contact burns. Burns were localized on the lower extremities in premorbid geriatric cases. The mean burn total area was 21% (range: 10-30%). The depths of these injuries were almost the same as with the pediatric cases, but the total area was wider. The mean hospital stay was 35.1 days (32-36 days).

A sub-average intellectual ability is manifested through learning difficulties and social adaptation problems.[7] In the literature, it is reported that 2-3% of the total population is mentally retarded. An IQ level of <50 is prevalent in 3.6/1000 live births in the United States population. An equivalent IQ level percentage has not been reported for the Turkish population.[8] Oyeckin,[8,9] in a study limited in number, reported that this rate was about 2.5%. There may be different etiological reasons, such as chromosomal abnormalities, genetic metabolic disorders and genetic neurological disorders.[10] Pediatric cases with neurosensorial motor deficits such as mental retardation or seizures are also at risk for burn injuries. These handicaps make the pediatric population more vulnerable to frequent and serious burn injuries. Of 15 pediatric cases aged between 3 and 17 years, seven cases had scalding burn injury from hot liquids. The epidemiology of pediatric burn injuries in the literature suggests that the most common cause of burns in Turkey is scalding, and the ages of these cases ranged from 1 to 6 years.[11] Children, especially toddlers, are naturally curious and attempt to taste and touch things around them. This instinct can be more intense and often unmanageable in premorbid pediatric cases.[12-14] In this respect, these cases had greater exposure to home accidents compared to the normal pediatric population. Most of our pediatric patients were injured by scalding. There may be different etiological causes for these injuries. However, in the Turkish pediatric population, non-bath scalding is related to contact with the traditional tea-making systems.[15,16] Injuries were usually localized on the upper extremities. The mean total burn area was 14.1% - 5-30%. The total hospital stay was 32.8 days (27-38 days).

Of the 15 pediatric cases, nine were admitted from Cilt - Vol. 17 Sayı - No. 3

rural or urban areas with ignorant parents as the primary caregivers. It is known that children who live in the rural areas of Turkey are at a greater risk for serious burns than those in the cities. Our results indicate that premorbid pediatric patients are highly vulnerable to frequent burn injuries.

Epileptic cases are prone to injuries, fractures, lacerations, and burns.[17,18] In the literature, 42% of injuries are associated with cooking, which is also more common among females because of their domestic responsibilities.[19-21] In most of our cases, the injuries occurred during bathing. Use of different types of boilers is common in Turkey. However, the majority of water heaters installed in bathrooms are not controlled effectively; some of these devices work with LPG tubes.[22] As excessive heat and humidity may trigger an epileptic attack, scalding injuries may result from the accidental spilling of hot water.[18,23,24] Some of the patients used electric heaters immersed in water; however, these instruments can be dangerous and may cause scalding injuries.

Burn injury was observed frequently on the upper extremities and on the trunk in epileptic cases. These cases were exposed to burn injury while undertaking domestic activities such as having a bath. The mean total burn area was 16.1% (range: 7-30%). The total hospital stay was 32.7 days (30-34 days).

The longer hospital stay observed among premorbid patients is associated with several factors.[5] The average hospital stay of premorbid cases in our study was 33.4 days. To our knowledge, there is no detailed study about premorbid cases and the length of their hospital stay. Further in-depth research is needed.

Moreover, special care should be taken in the treatment of the burn injury cases with premorbidity.

Prevention measures also need to be integrated with day-to-day activities. For example, the tubs used must have levers to regulate the water temperature. In the event of a seizure attack, the victim can hit the lever arm and avoid exposure to hot water. A scalding injury is more likely when the water is warmer than 43 °C.[21] Safety devices that limit the water temperature are recommended. In the homes of pediatric premorbid patients, water heaters should be set at 37.7 °C (100 °F); in the case of other adults, these devices can be set to 48.8-51.6 °C (120-125 °F).[25] Special care and additional measures should be taken in the treatment of burn injury patients with premorbidity. Psychological, neurological and geriatric causes are factors that may affect recovery from the burn injury or the success of the operation. A detailed evaluation of coexisting disorders and additional care are key points in the treatment of comorbid burn patients. Burn prevention materials targeting the premor223

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bid patient population remain relatively scarce in Turkey. Therefore, health organizations need to focus on providing basic and lifesaving information to patients and their families.

REFERENCES 1. Uygur F, Özyurt M, Evinç R, Hosbul T, Çeliköz B, Haznedaroğlu T. Comparison of octenidine dihydrochloride (Octenisept®), polihexanide (Prontosan®) and povidon iodine (Betadine®) for topical antibacterial effects in Pseudomonas aeruginosa-contaminated, full-skin thickness burn wounds in rats. CEJMed 2008;3:417-21.

2. Germann G, Barthold U, Lefering R, Raff T, Hartmann B. The impact of risk factors and pre-existing conditions on the mortality of burn patients and the precision of predictive admission-scoring systems. Burns 1997;23:195-203.

3. Alden NE, Rabbitts A, Rolls JA, Bessey PQ, Yurt RW. Burn injury in patients with early-onset neurological impairments: 2002 ABA paper. J Burn Care Rehabil 2004;25:107-11.

4. Ramirez RJ, Behrends LG, Blakeney P, Herndon DN. Children with sensorimotor deficits: a special risk group. J Burn Care Rehabil 1998;19:124-7.

5. Thombs BD, Singh VA, Halonen J, Diallo A, Milner SM. The effects of preexisting medical comorbidities on mortality and length of hospital stay in acute burn injury: evidence from a national sample of 31,338 adult patients. Ann Surg 2007;245:629-34.

6. Rao K, Ali SN, Moiemen NS. Aetiology and outcome of burns in the elderly. Burns 2006;32:802-5.

7. Patterson DR, Finch CP, Wiechman SA, Bonsack R, Gibran N, Heimbach D. Premorbid mental health status of adult burn patients: comparison with a normative sample. J Burn Care Rehabil 2003;24:347-50.

8. Roeleveld N, Zielhuis GA, Gabreëls F. The prevalence of mental retardation: a critical review of recent literature. Dev Med Child Neurol 1997;39:125-32.

9. Oyekcin DG. Sociodemographic features and psychiatric diagnosis of the patients who referred to an East Anatolian city hospital’s psychiatry policlinic during one year period.

(Bir devlet hastanesi psikiyatri polikliniğine bir yıl içinde başvuran olguların sosyodemografik özellikleri ve psikiyatrik tanı dağılımı) (Article in Turkish). Anadolu Psikiyatri Dergisi 2008;9:39-43.

10. Barret JP, Gomez P, Solano I, Gonzalez-Dorrego M, Crisol FJ. Epidemiology and mortality of adult burns in Catalonia.

224

Burns 1999;25:325-9.

11. Sakallioğlu AE, Başaran O, Tarim A, Türk E, Kut A, Haberal M. Burns in Turkish children and adolescents: nine years of experience. Burns 2007;33:46-51.

12. Kumar P, Chirayil PT, Chittoria R. Ten years epidemiological study of paediatric burns in Manipal, India. Burns 2000;26:261-4.

13. Fukunishi K, Takahashi H, Kitagishi H, Matsushima T, Kanai T, Ohsawa H, Epidemiology of childhood burns in the critical care medical center of Kinki University Hospital in Osaka, Japan. Burns 2000;26:465-9.

14. Lin TM, Wang KH, Lai CS, Lin SD. Epidemiology of pediatric burn in southern Taiwan. Burns 2005;31:182-7.

15. Tarim A, Nursal TZ, Yildirim S, Noyan T, Moray G, Haberal M. Epidemiology of pediatric burn injuries in southern Turkey. J Burn Care Rehabil 2005;26:327-30.

16. Kut A, Basaran O, Noyan T, Arda IS, Akgün HS, Haberal M. Epidemiologic analysis of patients with burns presenting to the burn units of a University Hospital Network in Turkey. J Burn Care Res 2006;27:161-9.

17. Beghi E. Accidents and injuries in patients with epilepsy. Expert Rev Neurother 2009;9:291-8.

18. Josty IC, Narayanan V, Dickson WA. Burns in patients with epilepsy: changes in epidemiology and implications for burn treatment and prevention. Epilepsia 2000;41:453-6.

19. Bekerecioğlu M, Yüksel F, Peker F, Karacaoğlu E, Durak N, Kişlaoğlu E. “Tandir”: an old and well known cause of burn injury in the Middle East. Burns 1998;24:654-7.

20. Akçay MN, Oztürk G, Aydinli B, Ozoğul B. Tandir burns: a severe cause of burns in rural Turkey. Burns 2008;34:268-70.

21. Unglaub F, Woodruff S, Demir E, Pallua N. Patients with epilepsy: a high-risk population prone to severe burns as a consequence of seizures while showering. J Burn Care Rehabil 2005;26:526-8.

22. Shoufani A, Golan J. Shabbes burn, a burn that occurs solely among Jewish orthodox children; due to accidental shower from overhead water heaters. Burns 2003;29:61-4.

23. Spitz MC. Severe burns as a consequence of seizures in patients with epilepsy. Epilepsia 1992;33:103-7.

24. Hampton KK, Peatfield RC, Pullar T, Bodansky HJ, Walton C, Feely M. Burns because of epilepsy. Br Med J (Clin Res Ed) 1988;296:1659-60.

25. Feldman KW, Schaller RT, Feldman JA, McMillon M. Tap water scald burns in children. 1997. Inj Prev 1998;4:238-42.

May - Mayıs 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):225-230

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.71598

Penetrating cardiac injury: factors affecting outcome Penetran kalp yaralanmaları: Sağ kalımı etkileyen faktörler Sedat KAMALI,1 Mehmet Timuçin AYDIN,2 Arzu AKAN,1 Oğuzhan KARATEPE,1 Ayhan SARI,1 Enis YÜNEY1

BACKGROUND

AMAÇ

Penetrating cardiac injuries are rare but represent a high mortality. Early recognition of the injury and rapid intervention are necessary. We analyzed the characteristics of patients with penetrating injury and the factors affecting the outcome, including the experience of the general surgeon.

Penetran kalp yaralanmaları nadirdir ancak yüksek mortalite gösterir. Yaralanmalarda erken tanı ve hızlı müdahale gereklidir. Penetran kalp yaralanması ile görülen hastaların karakteristikleri ve bir eğitim hastanesinde acil hizmeti veren genel cerrahların bireysel tecrübeleri dahil bu hastalarda sağkalımı etkileyen faktörler irdelendi.

METHODS

GEREÇ VE YÖNTEM

Twenty-three patients suffering penetrating cardiac injury were retrospectively evaluated in the Istanbul Okmeydanı Training and Research Hospital, Department of General Surgery between 1995 and 2009. Patients with no sign of life on admission were excluded.

1995-2009 yılları arasında İstanbul Okmeydanı Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği’nde penetran kalp yaralanması nedeni ile tedavi edilen 23 hasta retrospektif kohort olarak analiz edildi. Hastaneye ulaştığında hayat belirtisi olmayan hastalar çalışma dışında tutuldu.

RESULTS

BULGULAR

All patients were male, and the median age was 25 years.

Fifteen patients had left ventricular, 4 had right ventricular and 4 had right atrial injuries; in addition, 2 patients had accompanying intra-abdominal injuries. No coronary vascular injury was reported, and pericardial tamponade did not statistically influence the outcome. Ten of 23 patients suffering of penetrating cardiac injury were lost, and in 6 of the 10 cases, the patient represented the first experience for the operating surgeon.

Hastaların tamamı erkekti. Median yaş 25 yıl olarak saptandı. On beş hastada sol 4 hastada sağ ventriküler yaralanma saptandı, 4 hastada sağ atriyal yaralanma görülürken, 2 hastada karın içi yaralanma da eşlik etmekteydi. Hiçbir hastada koroner vasküler yaralanma saptanmadı. Yirmi üç hasta arasından 10 hasta kaybedildi, bu hastalardan altısının bu tip yaralanmalarda ilk tecrübesini yaşayan cerrahlar tarafından müdahale gördüğü ön plana çıkmıştır. Ayrıca kardiyak tamponad sağ kalımda anlamlı fark oluşturmamıştır.

CONCLUSION

SONUÇ

The characteristics of the penetrating cardiac injuries seen in our institution are consistent with the literature. However, we believe that the surgeon’s experience is another prognostic factor. Dedicated level 1 emergency services and trained trauma surgeons are invaluable.

Kurumumuza görülen penetran kardiyak yaralanma özellikleri literatür ile uyumludur. Bu tip yaralanma oranının nispeten az görüldüğü göz önüne alındığında travma cerrahisi eğitimi almış cerrahların ve kapsamlı travma referans merkezlerinin gerekliliği kaçınılmaz olarak gereklidir.

Key Words: Experience; general surgeon; outcome; penetrating cardiac injury.

Anahtar Sözcükler: Tecrübe; genel cerrah; penetran kalp yaralanması.

1 Department of General Surgery, Okmeydani Training and Research Hospital, Istanbul; 2Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey.

Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul; 2Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul.

1

Correspondence (İletişim): Mehmet Timuçin Aydın, M.D. Karaman Çiftlik Yolu Günyeli Apt., 6A Daire 28, Libadiye 34704 İstanbul, Turkey.

Tel: +90 - 216 - 578 30 00 / 4510 e-mail (e-posta): mtimucina@gmail.com

225

Ulus Travma Acil Cerrahi Derg

Penetrating cardiac trauma is rare compared to other injuries in urban violence.[1,2] They are infrequent but difficult challenges for the surgeon and represent a very high mortality unless diagnosed and treated in a timely manner. Diagnosis can be easily missed, and expertise in the management is difficult to achieve owing to the relative infrequency (0.1% of all trauma admissions).[3] In addition to the stabbing type of violence, the rates of both permitted and unlicensed firearm possession are increasing, and statistics reported almost a two-fold increase in 2007 in Turkey.

Improved transport systems and emergency medical services permit an increased number of patients with penetrating cardiac injury to arrive at the hospitals.

The surgeons need to be familiar with the possibility of a heart injury, should there be any injury localized to the area between the left anterior axillary and the right mid-clavicular line, as well as between the jugular line and the upper epigastrium.

Clinical presentations of the patients vary according to the wounding mechanism, the time interval before arrival and the time elapsed until entering the operating room (OR), the presence of cardiac tamponade, and the number of associated injuries. Death may be imminent due to cardiac tamponade or exsanguination. Some patients may arrive in extremis with no pulse or detectable blood pressure such that preoperative resuscitation may be of little benefit and treatment requires prompt surgical repair, while others may be in a relatively stable hemodynamic condition and suitable to undergo diagnostic testing.

We planned a retrospective cohort study to evaluate the prognostic factors in the treatment of patients with penetrating cardiac injury and to compare the outcome in such rare injuries with respect to the experience of the general surgeon.

MATERIALS AND METHODS Twenty-three patients were operated for penetrating cardiac injury from 1995 to 2009 in Okmeydani Training and Research Hospital, Istanbul. The significance between survival and age, clinical findings at presentation, interval before surgery, type and number of injuries, cardiac massage, and the experience of surgeons in heart injury was investigated via questionnaires to the responsible surgeon and a review of the patientsâ&#x20AC;&#x2122; files retrospectively. Patients with no signs of life on admission were excluded.

The results were analyzed using chi-square and the Pearson correlation tests.

RESULTS Between 1995 and 2009, 23 patients were brought to the emergency department of Okmeydani Training and Research Hospital. All patients were male and 226

aged between 17 to 60 years, with a median age of 25 years. There was no correlation between survival and age (p=0.55). Twenty-two patients had been wounded by stabbing or a similar type of device and one patient suffered a gunshot wound to the pericardial area.

One patient had attempted suicide; the others were victims of homicidal acts. All patients were brought to the hospital with non-emergency vehicles by civilians.

None of the patients arrived in a stable hemodynamic condition, and they were classified on the basis of clinical status at presentation as: (1) hemodynamically unstable with hypotension (systolic blood pressure of â&#x2030;¤80 mmHg) but conscious, and (2) in shock or in extremis with no detectable blood pressure or pulse, and semiconscious to flask. There were 11 patients in the unstable group and 12 patients in the in extremis group. Patients in both groups were assessed primarily in the emergency room (ER) and resuscitation was started. As the hospital facility did not have a cardiologist on call nor echocardiography or ultrasonography devices in the ER, the only possibility for an echocardiographic examination was on the 8th floor in the cardiology ward. The surgeons lacked the experience of performing focused sonography for trauma. As the general condition of the patients dictated, they were transferred directly to the OR, which was within close proximity to the ER (20 m). No ER thoracotomy was performed as the OR equipment was more available for use. The median systolic blood pressure in the unstable patients (Group 1) was 62.7 mmHg (40-80 mmHg, SD 16.1). There were 2 deaths out of 11 patients in the unstable group, and 8 deaths out of 12 patients in the flask group (p=0.01). The clinical presentations of the patients carried significance with respect to survival (Table 1). Localization of the wounds on the thorax wall did not demonstrate any relationship with survival (p=0.28) (Table 2).

All patients underwent left anterolateral thoracotomy initially. Fourteen patients had left ventricular injury, followed by 4 right atrial injuries. Four patients had right ventricular injury. One patient, the gunshot case, had left ventricular and right atrial injuries. The wounds were closed with 2/0 interrupted polypropylene sutures and no bio prosthetic materials were used in cardiorrhaphy. Five patients with left ventricular injury, 3 patients with right atrial injuries and 1 patient with left ventricular injury died. The gunshot patient also died. As the number of the cases is low, we were unable to show any significance regarding the injury site, although 3 out of 4 patients with right atrial injuries died (p=0.26) (Table 3).

No coronary vascular injuries were reported. The surgeons were also questioned about cardiac tamponade. In 5 cases, no cardiac tamponade was reported, May - MayÄąs 2011

Penetrating cardiac injury: factors affecting outcome

Table 1. Survival, surgical experience, cardiac massage, blood pressure cross-tabulation Surgical experience

Survival

No

Yes

No

Yes

Cardiac massage

Cardiac massage

Blood pressure

Blood pressure

No Yes No Yes Not detectable Detectable Not detectable Detectable

No (10)

Yes (13)

Total (23)

0 6 1 3 6 0 2 2

1 0 9 3 0 1 4 8

1 6 10 6 6 1 6 10

Two patients had extrathoracic injuries. One patient had gastric and the other had left colonic injury; both patients had accompanying penetrating diaphragmatic injuries. Extrathoracic injuries did not affect survival (p=0.71) (Table 4).

but no statistical significance was proven (p=1.00) (Table 4).

When the duration of time that elapsed in the ER was compared, 5 patients were resuscitated for 15 minutes or less and 1 was lost in the OR. However, an intervention period of more than 15 minutes before the OR also had no correlation with survival (p=0.33) (Table 4). Patients who required per-operative cardiac massage demonstrated a lower survival rate; 9 of 12 patients died (p=0.003) (Table 1).

DISCUSSION Penetrating cardiac injuries represent a very difficult challenge for the general surgeon working in usual emergency departments. They are rare encounters in the ER and require quick decision-making and timely surgical intervention.

In summary, 10 of 23 patients died due to penetrating cardiac injuries. The results were re-evaluated comparing the experience of the operating surgeons.

Seven cases were operated by surgeons whose sole experience in cardiac injuries was that case only and 6 of them were lost. On the other hand, the surgeons with operative experience in cardiac injury on more than one case operated on 16 patients and 12 of these patients survived (p=0.01). The most experienced among the surgeons had operated on three patients.

In 1983, Feliciano et al.[1] described a one-year experience of cardiac injuries in a single institution consisting of 48 patients. A 30-year experience of cardiac injuries from the same institution consisting of 539 patients (18 cardiac injuries per year) was presented

by Mattox and associates in 1989.[2] A recent review

by Assensio et al.[3] that focused on the National Trauma Data Bank (NTDB) of the American College of

Table 2. Trauma localization, survival, surgical experience cross-tabulation

Cilt - Vol. 17 Say覺 - No. 3

Thorax left 4 intercostal space

Thorax left 5 intercostal space

Thorax left 6 intercostal space

Thorax right 2 intercostal space

Thorax right 3 intercostal space

Thorax right 4 intercostal space

Thorax right 5 intercostal space

Thorax right 6 intercostal space

Total

No Yes No Yes

Thorax left 3 intercostal space

Survival

Survival

Sub xiphoid

No

Yes

Trauma localization Thorax left side (Gunshot)

Surgical experience

0 0 1 0

0 1 0 3

0 0 1 1

2 0 1 1

1 0 0 3

1 0 0 1

0 0 0 1

1 0 1 0

0 0 0 1

1 0 0 0

0 0 0 1

6 1 4 12 227

Ulus Travma Acil Cerrahi Derg

Table 3. Survival, injury site, experience cross-tabulation Surgical experience

No

Yes

Survival

Survival

No Yes No Yes

Cardiac injury site Left ventricle

Right atrium

Right ventricle

Atrium & ventricle

Total

3 1 2 8

2 0 1 1

1 0 0 3

0 0 1 0

6 1 4 12

Surgeons identified 2016 patients sustaining penetrating cardiac injuries, with a nationwide incidence of 0.016% for these injuries. All the data thus far indicate that penetrating cardiac injuries are indeed rare.

The number and etiology of penetrating cardiac injuries reflect the society in which they occur. In the United States, where firearms are easier to obtain by civilians, the majority of penetrating cardiac injuries are due to gunshot wounds (slightly more than 60%).

[3] Although the number of the people with individual firearms is increasing in Turkey, stabbing- type penetrating injuries are more frequent in this country, similar to the early reports from South Africa and China.

[4-8] Owing to the very nature of the injury, it was reported that up to 90% of the victims with penetrating cardiac wounds die before reaching the hospital.

Although there is no trauma data bank in Turkey, we believe that most of the patients with firearm injuries to the heart are lost before their arrival to the ER.[9,10] The surgeon should be familiar with the anatomic properties of the heart. The boundaries of the precordium are defined by the surface anatomy of the heart.

In the normal individual, about one-third of the heart lies to the right of the midline and two-thirds to the left. The right cardiac border extends from the 3rd to the 6th costal cartilage just lateral to the sternum.

The left border lies between the 2ndcostal cartilage 2 cm left of the sternum and the cardiac apex at the 5th

left intercostal space in the mid-clavicular line.[11] The term “cardiac box” can be used as a crude simplification, and refers to the rectangular area between the two mid-clavicular lines laterally and clavicles superiorly to costal margins inferiorly. Most of the anterior surface of the heart is made up by the ventricles. The right ventricle makes up the majority of the anterior sternocostal surface of the heart and it is more prone to injuries than the left atrium, which is smaller and almost an entirely posterior chamber.[11] Because of the high pressure system in the left side of the heart, injuries to the left ventricle are more lethal. The frequency of ventricular injuries in metachronous reports varies from 37% to 67% (43% right ventricle, 34% left ventricle).[3-5,12] Right atrial injuries appear to occur with a greater frequency than the left atrium, ranging from 5% to 20%; the most recessed chamber of the heart is injured in 2%-12% of the cases.[3,12-15] Although the patients in this report possessed a highly suggestive representation of cardiac injury (pericardial stabbing on anterior chest in the “cardiac box”, hypotension, shock), the clinical manifestations of cardiac injuries may vary from a stable hemodynamic condition to a rapid cardiovascular collapse. No blood pressure or pulse, absence of cardiac rhythm, dilated and fixed pupils, and no motion in extremities are poor prognostic factors.[3,13-17] The greatest danger is missing the diagnosis.

Table 4. Survival, surgical experience, time, other trauma, cardiac

tamponade cross-tabulation Surgical experience

228

Survival

No

Yes

No

Yes

No

Yes

Time

Time

Other trauma

Other trauma

Tamponade

Tamponade

>15 minutes <15 minutes >15 minutes <15 minutes No Yes No Yes No Yes No Yes

No (10) Yes (13) 5 1 4 0 6 0 3 1 1 5 1 3

1 0 8 4 1 0 10 2 0 1 3 9

Total (23) 6 1 12 4 7 0 13 3 1 6 4 12 May - Mayıs 2011

Penetrating cardiac injury: factors affecting outcome

Beckâ&#x20AC;&#x2122;s triad - distant heart sounds, jugular venous distension, hypotension - and Kussmaulâ&#x20AC;&#x2122;s sign - jugular venous distension on inspiration - are classical signs of pericardial tamponade, but they are reported in only 10% of the cases.[3,12] Non-specific signs of shock such as hypotension, agitation, tachypnea, diaphoresis, and cool extremities in a patient with anterior thoracal injury should alert the physician to the possibility of cardiac involvement. Chest X-ray may be misleading since the acute cardiac tamponade may not enlarge the cardiac silhouette. Signs of other thoracic injuries should also be checked, such as pneumo- or hemothoraces. Focused assessment by sonography in trauma (FAST) is currently the more frequently used tool.[11] It is a rapid, non-invasive and repeatable tool, but not available in every emergency department, as was the case in this report. A positive FAST scan provides an echo-free area between the echogenic inner (epicardium) and outer leaves of the pericardium with almost 100% sensitivity, specificity and accuracy if performed by experienced staff in selected patients (not morbidly obese, no subcutaneous emphysema, and without a very narrow subcostal area) (Fig. 1).[11,18] Thus, the main caveat is that it is both operator- and patient-dependent but still has largely supplanted the pericardial window in the diagnosis.[11,12,18] As pericardiocentesis has high false-positive and -negative rates in the diagnosis of cardiac tamponade, it is generally not recommended.

with increased coronary oxygen demand to a point where the heart fails to pump.[3,11,12] In a retrospective review of 100 consecutive patients with penetrating cardiac injury, Moreno et al.[15] suggested a protective effect of the cardiac tamponade by reporting 73% (with tamponade) versus 11% (without tamponade) survival. On the other hand, Asensio et al.[14,16] in a prospective study of predictors of the outcome after penetrating cardiac injury could not confirm a beneficial effect of the cardiac tamponade. In our report of 23 patients, we could not show a beneficial effect of tamponade.

Emergency room (ER) thoracotomy is reported as a life-saving procedure in a select group of patients, but it is a matter of controversy in the literature. It is a frequent disclosure that ER thoracotomy is of benefit in penetrating precordial injury victims in whom a traumatic arrest develops after previously witnessed pre-hospital or in-hospital cardiac activity and who suffer from unresponsive hypotension.[11,19] No patient in this report underwent an ER thoracotomy. Departmental policies of the institution suggested that the correct surgical equipment should be preserved in the OR, which is in close proximity.

Initially, there may be a beneficial effect of the pericardial tamponade by limiting the hemorrhage into the thoracic cavity, but a sudden surge of blood increases the pressure within the pericardium above the level of the filling pressure of the right ventricle first. Then, the left ventricular filling becomes compromised, with a final result of decreased stroke volume and cardiac output. This, in turn, increases the cardiac workload

The ventricular injuries can be controlled by finger pressure at first. Then, the wounds are closed by simple interrupted or horizontal mattress sutures using 2/0 monofilament Prolene materials. It is also possible to repair the laceration with running sutures. Care should be given to the coronary vessels; otherwise, acute coronary infarction on the operating table should be anticipated.[3,6,7,13-15] Atrial injuries can be controlled by placing a vascular clamp to control the hemorrhage and they can then be sutured with running 2/0 Prolene.

The surgeon should pay attention to the thinner walls of the atria, which can easily be torn, thereby enlarging the laceration.[3,17,20]

Fig. 1. Arrow indicating a hypoechogenic blood accumulation between two echogenic leaves of the pericardium (cardiac tamponade).

In addition to all the factors that may affect the outcome of the penetrating cardiac injuries that have been identified thus far, we strongly believe that the experience of the general surgeon is a major determinant in the evaluation and treatment of the patient as well as the outcome, especially if the facility lacks a cardiovascular surgery unit. Concerning penetrating cardiac trauma, the number of cases per year and per institution is not frequent. In the United States, the nationwide incidence is 0.016%.[3] Furthermore, a post-mortem study in a city that has a much smaller population than the metropolitan city of Istanbul indicated that only 3.5% of the penetrating cardiac injury cases were admitted to the hospitals.[10] We lost six of seven patients when the surgeon had no previous experience in penetrating cardiac injury. The general surgeon is usually much more experienced in abdominal procedures in contrast to thorax procedures, includ-

Cilt - Vol. 17 SayÄą - No. 3

229

Ulus Travma Acil Cerrahi Derg

ing cardiac surgery. A report from the United States, where trauma surgery is a subspecialty after general surgery training, stated that only 62% of surgeons had performed an emergency cardiac repair. Since the incidence is rare, timing is very critical; mortality is reported as high even in high-volume centers. As some injuries may require cardiopulmonary bypass surgery, the decision-making by the general surgeon becomes even more difficult. Without proper training of the surgeons in trauma surgery, the learning curve will be greatly prolonged. Although the best prohibitive measure is to prevent any injury if possible, dedicated trauma centers with experienced trauma surgeons cannot be underestimated.

REFERENCES 1. Feliciano DV, Bitondo CG, Mattox KL, Burch JM, Jordan GL Jr, Beall AC Jr, et al. Civilian trauma in the 1980s. A 1-year experience with 456 vascular and cardiac injuries.

Ann Surg 1984;199:717-24.

2. Mattox KL, Feliciano DV, Burch J, Beall AC Jr, Jordan GL Jr, De Bakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients. Epidemiologic evolution 1958 to 1987. Ann Surg 1989;209:698-707.

3. Asensio JA, Garcia-Nunez LM, Petrone P, Duran D, et al.

Penetrating cardiac injuries in America- predictors of outcome in 2016 patients from the national trauma data bank; in preparation As quoted by Asensio JA, et al. Cardiac injuries. In: Asensio JA, Trunkey DD, editors. Current therapy of trauma and surgical critical care. Philadephia: Mosby Elsevier; 2008. p. 304-15.

4. Demetriades D, van der Veen BW. Penetrating injuries of the heart: experience over two years in South Africa. J Trauma 1983;23:1034-41.

5. Gao JM, Gao YH, Wei GB, Liu GL, Tian XY, Hu P, et al.

Penetrating cardiac wounds: principles for surgical management. World J Surg 2004;28:1025-9.

6. Günay K, Taviloglu K, Eskioglu E, Ertekin C. The factors affecting mortality in penetrating heart wounds. Ulus Travma Derg 1995;1:47-50.

7. Keçeligil HT, Bahcivan M, Demirağ MK, Celik S, Kol-

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bakir F. Principles for the treatment of cardiac injuries: a twenty-two year experience. Ulus Travma Acil Cerrahi Derg 2009;15:171-5.

8. Türkiye’de Bireysel Silahlanmaya’ya İlişkin istatistikler.

Umut Foundation, 2007.

9. Campbell NC, Thomson SR, Muckart DJ, Meumann CM, Van Middelkoop I, Botha JB. Review of 1198 cases of penetrating cardiac trauma. Br J Surg 1997;84:1737-40.

10. Fedakar R, Türkmen N, Durak D, Gündoğmuş UN. Fatal traumatic heart wounds: review of 160 autopsy cases. Isr Med Assoc J 2005;7:498-501.

11. Kang N, Hsee L, Rizoli S, Alison P. Penetrating cardiac injury: overcoming the limits set by Nature. Injury 2009;40:91927.

12. Asensio J, Garcia-Nunez L, Wood D, Jurkovich G. Trauma to the heart. In: Feliciano D, Mattox KL, Moore E. editors.

Trauma. Mc-Graw Hill; 2008. p 569-8.

13. Wall MJ Jr, Mattox KL, Chen CD, Baldwin JC. Acute management of complex cardiac injuries. J Trauma 1997;42:90512.

14. Asensio JA, Murray J, Demetriades D, Berne J, Cornwell E, Velmahos G, et al. Penetrating cardiac injuries: a prospective study of variables predicting outcomes. J Am Coll Surg 1998;186:24-34.

15. Moreno C, Moore EE, Majure JA, Hopeman AR. Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds. J Trauma 1986;26:821-5.

16. Asensio JA, Berne JD, Demetriades D, Chan L, Murray J, Falabella A, et al. One hundred five penetrating cardiac injuries: a 2-year prospective evaluation. J Trauma 1998;44:1073-82.

17. Asensio JA, Soto SN, Forno W, Roldan G, Petrone P, Salim A, et al. Penetrating cardiac injuries: a complex challenge.

Injury 2001;32:533-43.

18. Rozycki GS, Feliciano DV, Schmidt JA, Cushman JG, Sisley AC, Ingram W, et al. The role of surgeon-performed ultrasound in patients with possible cardiac wounds. Ann Surg 1996;223:737-46.

19. Brohi K. Emergency room thoracotomy. September 2006.

Trauma.org web site. Available from URL: http// www.trauma.org/index.php/main/article/361.

20. Tyburski JG, Astra L, Wilson RF, Dente C, Steffes C. Factors affecting prognosis with penetrating wounds of the heart. J Trauma 2000;48:587-91.

May - Mayıs 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):231-237

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.60938

Analysis of trauma patients in a rural hospital in Turkey Türkiye’nin kırsal bir hastanesindeki travma olgularının analizi Nurettin KAHRAMANSOY,1 Hayri ERKOL,1 Feyzi KURT,2 Necla GÜRBÜZ,3 Murat BOZGEYİK,1 Aysu KIYAN4

BACKGROUND

AMAÇ

There is a grey zone about the epidemiology of trauma in eastern Turkey. The present study was aimed at obtaining data on this subject.

Bu çalışmanın amacı, travma ile ilgili yeterli verinin olmadığı Türkiye’nin doğusundan epidemiyolojik veriler yanında hastaların çıkış durumlarını sunmaktadır.

METHODS

GEREÇ VE YÖNTEM

Trauma patients who applied to the emergency department (ED) between January 2006 and December 2007 were analyzed.

Muş Devlet Hastanesi Acil Birimi’ne Ocak 2006 - Aralık 2007 tarihleri arasında başvuran travma hastalarının kayıtları retrospektif olarak incelendi.

RESULTS

BULGULAR

There were 6183 patients, of whom 87% were male. The mean age was 26.2±13.6 years. Assault was the most common cause (63.2%). Motor vehicle injury (MVI) and fall were encountered at frequencies of 21.2% and 6.5%, respectively. The most frequently injured body regions were head-neck and extremities. The majority of patients were managed and discharged from the ED (89.8%) with no consultation (81.8%). Interestingly, the discharge rate of assault cases was 98.7%. Patients were hospitalized (4.2%) mostly for MVI (32.6%) and fall (19%); however, hospitalization rates for firearm and piercing/cutting injury (36.1% and 16.7%) were significantly high. Among the transported patients (5.3%), the rates of MVI and fall were high (41.5% and 24.3%, respectively). In groups, for burn and firearm injuries, these were 42.1% and 24.1%, respectively. Forty-eight patients (0.8%) died, mostly from MVI by number, but by self-infliction and firearm by rate (8.3% and 6%).

Toplam 6183 hastanın 5377’si (%87) erkek ve ortalama yaş 26,2±13,6 idi. Darp-şiddet 3910 (%63,2) hasta ile en sık travma nedeni idi. Ardından trafik kazası ve düşme sırasıyla %21,2, %6,5 oranlarında idi. En sık baş-boyun ve ekstremite yaralanmaları görülmüştür. Olguların %89,8’inin, darp şiddet olgularının ise %98,7’sinin acil polikliniğinde müdahale sonrası taburcu edildiği gözlendi. Konsültasyona hastaların çoğunda (%81,8) ihtiyaç duyulmadı. Yatışı yapılan 258 (%4,2) hastanın %32,6’sı trafik kazası, %19’u düşme olguları idi. Ancak ateşli silahla ve delici-kesici aletle yaralanan olguların yatış oranları (%16,7, %36,1) yüksekti. Hastaların %5,3’ü sevk edildi. Sevk edilen hastaların %41,5’i trafik kazası, %24,3’ü düşme olguları idi. Bununla birlikte yanık ve ateşli silahla yaralanma olguları arasında sevk daha yüksek oranda (%42,1, %24,1) idi. Yarısı trafik kazasından olmak üzere 48 (%0,8) hasta hayatını kaybetti. Ancak canına kastetmeye ve ateşli silahla yaralanmaya bağlı ölüm oranı (%8,3,%6) daha yüksek bulundu.

CONCLUSION

SONUÇ

Assault cases caused an excessive trauma patient density in the ED, as 98.7% were discharged from the ED. Further studies are needed regarding the high rate of assault cases.

Darp şiddet olguları acil biriminde travma hastası yoğunluğuna neden olmaktadır. Yüksek darp şiddet oranı ile ilgili ileri çalışmalar gerekli gözükmektedir.

Key Words: Epidemiology; rural; trauma; Turkey.

Anahtar Sözcükler: Epidemiyoloji; kırsal; travma; Türkiye.

Departments of 1General Surgery, 3Pediatric Surgery, 4Public Health, Abant Izzet Baysal University, Faculty of Medicine, Bolu; 2 Department of General Surgery, State Hospital, Adiyaman, Turkey.

Abant İzzet Baysal Üniversitesi, Tıp Fakültesi, 1Genel Cerrahi Anabilim Dalı, 3Çocuk Cerrahisi Anabilim Dalı, 4Halk Sağlığı Anabilim Dalı, Bolu; 2 Adıyaman Devlet Hastanesi, Genel Cerrahi Kliniği, Adıyaman.

Correspondence (İletişim): Nurettin Kahramansoy, M.D. Abant İzzet Baysal Üniversitesi Tıp Fakültesi, Genel Cerrahi ABD, 14280 Bolu, Turkey.

Tel: +90 - 374 - 253 46 56 / 3517 e-mail (e-posta): nurkahramansoy@yahoo.com

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Trauma is an important problem worldwide and causes huge economic and social losses. Twelve percent of all the diseases in the world have been reported to be associated with trauma, and five million people were reported dead due to injuries in 2000.[1] The economic cost of trauma is estimated to be around $406 billion in the United States alone.[2] By taking appropriate legal and social preventive steps, the economic and social burdens of trauma, along with mortality rates, are considered reducible at significant levels.[3,4] Trauma system organization and effective trauma centers have been reported to reduce morbidity and mortality rates by 15-39% among patients with trauma.[5,6] Data on trauma epidemiology vary between countries and even among different regions of a country.

[3,4,7-9] This variance brings about differences in solutions and priorities as well. Therefore, different regional management methods are carried out.[10-14] The current study was conducted in the rural Muş province located in the eastern part of Turkey, where there is little information available on trauma, with an aim to analyze the trauma cases, compare our results with previous literature reports, and discuss possible solutions.

MATERIALS AND METHODS The Muş province is a predominantly rural area with an underdeveloped industry and education level and with high unemployment rates. As in other similar rural regions, agriculture is the main employment source. There are few motor vehicles in the province.

Buildings are generally single-storey. The population is not centered in a single area and therefore has a low density. Winters are harsh and extended in duration.

Between winter and summer, roads are usually closed due to the heavy snow and mud.

Muş State Hospital serves a population of 400,000 people, the majority of whom live in rural areas, and has a 360-bed capacity. The hospital, which provides general healthcare services, is classified as a Level II

healthcare center according to the Turkish classification system, which corresponds to a Level III hospital in the literature.[15] There are five community healthcare centers within a 25-100 km radius of Muş State Hospital, each of which has less than a 30-bed capacity. As the closest Level II and III healthcare centers are more than 250 km in each direction, Muş State Hospital is a crucial healthcare provider for the region (although only a Level III healthcare center).

In the current study, all the trauma or suspected trauma cases presented to the emergency department (ED) of Muş State Hospital between January 2006 and December 2007 due to assault, motor vehicle injuries (MVI), falls, stab wounds, firearm injuries, burns, or self-inflicted trauma were evaluated retrospectively based on the data included in the forensic reports.

Evaluation was made in terms of demographic characteristics, trauma mechanism, injury site, consultations, and ED discharge forms. Of the 6720 forensic reports, 537 were excluded from the study. The excluded reports were either incomplete or previously enrolled or pertaining to cases of intoxication with various agents (e.g. alcohol, drug, food, carbon monoxide). Patients of all ages were included in the study. MVI cases included both passengers and pedestrians. Similarly, cases of falls included all kinds of falls. The term ‘normal’ used for injury sites refers to minor abrasions or ecchymosis with a radius of a few centimeters or pain without any lesion. Statistical analysis was performed by using descriptive statistics.

RESULTS The ratio of trauma cases to all the cases presenting to the ED within the study period was 2.0% (6720/337,608). Among the 6183 patients included in the study, 5377 were male, and 806 were female.

The mean age was 26.2±13.6 (1 month-81 years). The discharge status of the cases regarding their trauma mechanisms are outlined in Table 1.

The most common causes of the trauma cases presented to the ED were assault (63.2%), MVI

Table 1. Trauma mechanisms and discharge status of cases

Discharge n [%]

Inpatient n [%]

Transfer n [%]

Exitus n [%]

Total n [%]

Assault (%) MVI (%) Fall (%) P/CI (%) Firearm (%) Burn (%) Self infliction (%) Others (%) Total n (%)

3861 (98,7) [69,5] 1065 (81,2) [19,2] 267 (66,6) [4,8] 197 (74,9) [3,5] 28 (33,7) [0,5] 39 (51,3) [0,7] 18 (75,0) [0,3] 77 (67,0) [1,4] 5552 (89,8) [100]

26 (0.7) [10.1] 84 (6.4) [32.6] 49 (12.2) [19.0] 44 (16.7) [17.1] 30 (36.1) [11.6] 4 (5.3) [1.6] 1 (4.2) [0.4] 20 (17.4) [7.8] 258 (4.2) [100]

22 (0.6) [6.8] 135 (10.3) [41.5] 79 (19.7) [24.3] 18 (6.8) [5.5] 20 (24.1) [6.2] 32 (42.1) [9.8] 3 (12.5) [0.9] 16 (13.9) [4.9] 325 (5.3) [100]

1 – [2.1] 27 (2.1) [56.3] 6 (1.5) [12.5] 4 (1.5) [8.3] 5 (6.0) [10.4] 1 (1.3) [2.1] 2 (8.3) [4.2] 2 (1.7) [4.2] 48 (0.8) [100]

3910 [63.2] 1311 [21.2] 401 [6.5] 263 [4.3] 83 [1.3] 76 [1.2] 24 [0.4] 115 [1.9] 6183 [100]

Percentage in brackets is of outcome rate in total; percentage in parenthesis is of trauma mechanism rate in total.

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Analysis of trauma patients in a rural hospital in Turkey

100

50.4%

90 Percent of patients (%)

2500 26.3% 20% 6.6%

Head-neck

20

Normal rs O th e

rn

ic tio n

lf in fl

Bu

ar

m

0

Se

H

10

Fi re

al ea dne ck Ex tre m iti es A bd om en Th or ac od or su m Lu m bo pe lv is M ul ti or ga ns

1.3%

3.4%

or m N

Extremities

30

ll

2.5%

0

Abdomen

40

P/ CI

500

Thoracodorsum

50

Fa

1000

60

lt

1500

Lumbopelvis

70

au

2000

Multi organs

80

A ss

3000

M V I

3500

Trauma mechanism

Fig. 1. Distribution of injured body regions in all trauma patients.

Fig. 2. Distribution of injured body regions due to each trauma mechanism.

(21.2%) and falls (6.5%). According to the evaluation performed within the groups, the most common trauma types treated on an outpatient basis and discharged were assault (98.7%), MVI (81.2%), selfinflicted traumas (75.0%), and piercing/cutting injury (P/CI) (74.9%). In the firearm injury cases, this rate was found to be 33.7%. The majority of the patients (89.8%) were discharged after treatment in the ED.

Head-neck injuries were most commonly observed in assault (774), MVI (511) and fall (231) cases. However, this order changed with evaluation within each group as follows: falls (57.6%), MVI (39.0%) and assault (19.8%). In 7.0% of the patients with head-neck injuries, facial injuries were present as well.

Hospitalization rates were 32.6%, 19.0% and 17.1%, respectively, for MVI, falls and P/CI cases.

However, hospitalization rates within groups were as follows: firearm injuries (36.1%), P/CI (16.7%), falls (12.2%), and MVI (6.4%). Hospitalization rates of firearm injuries and P/CI were significantly high.

Transfer rates (rate of patients referred to other healthcare institutions) of MVI, fall and burn cases were 41.5%, 24.3% and 9.8%, respectively. However, transfer rates within groups were as follows: burns (42.1%), firearm injuries (24.1%) and falls (19.7%).

The transfer rate for burn injuries was remarkably high.

In total, 48 patients (0.8%) died, of whom 27 were in the MVI group. Furthermore, 11 patients (22.9%) were ascertained to be dead upon arrival at the hospital.

The patients were assessed regarding injury sites, and 3116 of the 6183 patients (50.4%) were found to display minor signs and were deemed normal (Fig. 1).

Head-neck injuries and abdominal injuries accounted for 26.3% and 2.5% of the injured body sites. Approximately 86.5% of the patients who showed minimal physical findings (referred to as normal) were in the assault group (Fig. 2). However, 68.9% of the assault cases were evaluated to be normal. Patients who were hospitalized and transferred or who died were suggested to have major trauma. Herein, 631 cases were assessed as major trauma.

Cilt - Vol. 17 Say覺 - No. 3

Extremity injuries and thoracodorsal injuries were seen at a higher rate in the P/CI and firearm groups.

Abdominal injuries were more commonly encountered in firearm (15.7%) and P/CI (8.0%) cases compared to fall (7.7%) and MVI (4.3%) cases.

The highest number of multiple organ injuries among the groups occurred in the MVI cases (85 patients), whereas within the groups, it was present in firearm, MVI and fall cases at frequencies of 9.6%, 6.5% and 5.2%, respectively. Lumbopelvic injuries were found to be most common in firearm (4.8%), fall (4.2%) and MVI (2.1%) cases.

In the ED, the rate of consultation varied depending on the trauma etiology, and in the majority (81.8%), no consultation was deemed necessary. One of the most interesting findings of the present study was that ED physicians suggested the initial treatment as adequate in 96.0% of the assault cases and did not consult any other specialty (Table 2). On the contrary, a specialist was consulted in most of the firearm cases (81.9%). Consultation was sought in more than half of the burn and fall cases. The three most frequently consulted medical specialties, in decreasing order, were neurosurgery, orthopedics and general surgery (Table 3).

While 37.6% of the patients hospitalized had headneck injuries, 33.7%, 15.5% and 11.6% had extremity, thoracodorsal and abdominal injuries, respectively (Fig. 3). Nonetheless, the evaluation performed with regard to the injury sites revealed a hospitalization rate of 30.2%, 19.6% and 18.8% for patients with extremity, abdominal and lumbopelvic injuries, respectively.

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Table 2. Consultation rates in certain trauma

mechanisms Consultations

None (%)

Yes (%)

Assault MVI Fall Burn P/CI Firearm Self infliction Others Total

96.0 64.9 44.4 57.8 18.1 66.7 52.2 35.1 81.8

4.0 42.1 55.5 57.9 42.2 81.9 33.3 47.8 18.2

Table 3. Rates of consulted specialties Consultations

%

None Neurosurgery Orthopedics General surgery Thoracic surgery Plastic surgery Otolaryngology Others Multiple

81.8 8.3 6.2 5.2 1.6 1.1 1.1 1.4 3.9

Among cases with head-neck injuries, the hospitalization rate was 6.0%.

The rate of head-neck injury cases was significant (43.1%) among the patients transferred to other institutions, followed by patients with extremity injuries (30.2%) and with multiple organ injuries (17.5%).

Regarding the injury site, patients with multiple organ (27.1%), lumbopelvic (22.5%) and abdominal injuries (19.6%) were found to be the most commonly transferred patients. Among major trauma patients (631 patients), the transfer rate rose to 51.5%.

Percentage of injured body region (%)

100 90 80

Multi organs

70

Lumbopelvis

60

Thoracodorsum

50

Abdomen

40

Extremities

30

Head-neck

20

Normal

10 s itu Ex

sf er Tr an

nt tie pa In

D

isc ha

rg e

0

Fig. 3. Outcomes of the cases based on the injured body regions.

234

Approximately 52.1% of the patients who died had head-neck injuries, whereas 37.5% had multiple organ injuries. Furthermore, 8.6% of the patients with multiple organ injuries, and 2.2%, 2.1% and 1.5% of the patients with thoracodorsal, abdominal and head-neck injuries, respectively, died.

DISCUSSION Current epidemiological data differ from historical data because of today’s dynamics and ever-improving societies.[16] Previous studies generally focused on the trauma mechanism in moderate-severe injuries.[7,8,14,16] Therefore, it is not easy to determine the frequency of the overall number of patients with trauma presenting to the ED. Nonetheless, some studies suggest that this rate is 24-30%.[17,18] Dalkılıç et al.[19] from Istanbul reported the number of trauma patients as 43,915, which corresponded to a rate of 49.5% for trauma cases out of all patients presented to the surgical ED of a Level I trauma center over 4 years. A high rate can be expected due to the presentation of selected cases to the ED of surgery. In the current study, the rate of trauma cases presenting to the ED was approximately 2.0%.

This rate, which is not in agreement with literature reports, may be explained by the exploitation of the ED by nontraumatic patients. Patients demand to be examined, diagnosed and treated without delay by the ED staff. Preventing the abuse of ED utilization will increase the percentage of trauma cases among all ED cases relatively. However, the most important benefit will be the prevention of time loss suffered by trauma patients in the ED. While more than half of the patients with a major trauma are hospitalized, most of the trauma patients (95% or above) presented to the ED are discharged after ambulatory treatment.[16,20-22] Nevertheless, the cost of patients receiving treatment on an outpatient basis is estimated to be rather high.

Vyrostek et al.[21] performed a survey study in the United States in 2001 and found 4.6 million unintentional strike cases and 1.4 million intentional strike cases, which accounted for 20.2% of all injury cases.

In a rural health center in Kenya, 43% of patients presented to the ED were reported to be assault cases.[22] Prekker et al.[17] conducted a prevalence study with selected cases in which the authors particularly excluded patients younger than 18 years and people who could not speak the official language, and found the assault rate to be 35%. Among all ED cases, this rate may be higher because adolescent patients excluded from the study constitute the social age group that most frequently resorts to violence.[23] Moreover, people who cannot speak the official language are probably individuals at a low socioeconomic level among whom violence is known to be high. Furthermore, high unemployment rates and low income are known to be factors May - Mayıs 2011

Analysis of trauma patients in a rural hospital in Turkey

Table 4. Distribution of major trauma mechanisms in the literature

MVI (%) Assault (%) Fall (%) P/CI (%) Firearm (%) Burn (%) Self infliction (%) Blunt injury (%) Hanging (%) Others (%) Total

Muş, Turkey Quebec, Can.[16] LA, USA [8] Ohio, USA[14] Auckland, NZ[7] Minneapolis, USA[17] 246 (39.0) 49 (7.7) 134 (21.2) 66 (10.4) 55 (8.7) 37 (5.8) 6 (0.9)

38 (6.0) 631

7727 (27.3)

13927 (49.2) 1790 (6.3) 408 (1.4)

1261 (4.4)

1995 (7.0) 28295

6467 (45.7) 5120 (36.4) 1274 (9.05)

539 (3.8)

665 (4.7) 14065

that increase violence among people.[24] In the current study, the rate of assault cases was 63.2% (Table 1).

The high nature of the assault rate in our study can be explained by the prevalent regional factors. In our region, the unemployment rate is high and the income level is low. Moreover, because of large families and the high number of relatives, a simple dispute between two people easily turns into a large-scale violence in which multiple numbers of families are involved. In big cities, violence is limited to individuals; however, in our region, each assault case has the potential to evolve into mass violence. Although the Van province is socioeconomically similar and close to the Muş province, probably due to the presence of a Level I healthcare center, the assault rate has been reported to be 5%.[25] The reason behind this low rate is probably because assault cases are treated at lower-level hospitals. We believe that another cause of the high assault rate in our study might be the patient’s intention to file a lawsuit, as verified by minor or absent abrasion or ecchymosis in 68.9% of the cases.

Patients who are hospitalized and transferred or who die generally have moderate or major trauma.

[7,8,14,16] In the current study, among patients evaluated to have major trauma, the prevalence of assault was 7.7%. Willette[14] found a similar rate (Table 4). This rate is markedly lower than the one reported in Demetriades’ study,[8] which was 36.4%. In light of the data mentioned above, we understand that assault cases that lead to major trauma do not have as high a frequency as predicted in the literature.

Data available on MVI in the literature vary.

In our study, the MVI rate (21.2%) was slightly higher than that reported in the United States in 2000 and 2001 (10-15.2%, respectively).[2,21] Considering the low number of automobiles relative to the population in our region, the elevated MVI rate may be explained by rural characteristics as well as the failure to comply with the traffic codes and mass MVIs. Geographic conditions, delay in arrival to the hospital and the se[7,8,17]

Cilt - Vol. 17 Sayı - No. 3

2119 (65.3) 257 (7.9) 534 (16.4) 35 (1.0) 85 (2.6)

213 (6.5) 3243

222 (49.5) 48 (10.7) 83 (18.5)

67 (14.9) 28 (6.2) 448

139 (13) 360 (35) 239 (23) 117 (11) 8 (1)

173 (17) 1036

clusion of the trauma location may have a negative effect on both the number of patients and the injury severity.[13,17,26] The most severe trauma arising from fall is observed in cases of high falls. Generally, varying rates are reported for all types of fall (9-55%).[13,16,17] In the current study, falls were the second most common (21.2%) major trauma mechanism (Table 4).

P/CI and firearm injuries have a high morbidity and mortality rate among intentional injuries. While Corso and Vysotek reported a rate of 8% for the United States on a national basis, the same rate was found to be 11% in a rural ED of the same country.[2,17,21] If the patients who were younger than 18 and who did not speak the official language had been included, the rate in Prekker’s study may have been higher.[17] Considering that Corso excluded cases with mild injuries of the musculoskeletal system, the true P/CI prevalence may be considered to be higher.[2] In this study, the rate of P/CI (4.3%) seems low enough.

The prevalence of firearm injuries is reported as 0.2-2.7%.[2,16,21] Firearm injuries are the most lethal among other major trauma factors. Therefore, such patients are generally hospitalized or transferred to other hospitals. In another study, Newgard[15] reported the rate of hospitalized patients with a firearm injury as 8%, whereas the transfer rate was 5.5%. In the present study, we obtained similar results for hospitalization and transfer, as 11.6% and 6.2%, respectively.

The frequency of suicidal acts is reported as 1.114% in Western countries. However, the mortality rate reaches up to 100%.[7,8,21] In the current study, the frequency of suicidal/self- inflicted cases was as low as 0.4%, but mortality in this group was 8.3%. Mortality rates may appear lower than the true values because if mortality occurs at the scene, autopsies are performed there and such cases are not entered into hospital records. The parameters influencing this rate must be investigated further.

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The sites most commonly affected in trauma are the extremities, head-neck, thorax, and abdomen.[16,17,27] While musculoskeletal injuries constitute the majority among ED cases, head and thorax injuries are prevalent in major traumas.[20] Therefore, neurosurgery and orthopedics consultations are observed more frequently. Since Turkey has no medical training program for trauma surgery, general surgery specialists take part in general trauma consultations. Nonetheless, the consultation rate of general surgery is not higher than that of neurosurgery or orthopedics. The consultation rate for all patients is estimated to be approximately 18.2%.

The aforementioned low rate might be associated with the high frequency of patients presenting to EDs with minor trauma, which results in emergency physicians considering consultation unnecessary. Nonetheless, the frequencies of consultation in major trauma cases due to firearm injuries, burns and falls were above 50% (Table 2).

The hospitalization rate parallels that of trauma severity. Vyrostek[21] reported a hospitalization and transfer rate of 4.8% in accidental injuries and of 34.2% in major trauma cases. Moreover, several conditions, such as the characteristics of the hospital and the region and the availability of relevant specialists, all influence the hospitalization rate, which can alter it from <1% to 46.8%.[9,11,17,28] A nationwide study performed in the United States indicated an increase in the hospitalization rate as the population decreased, such as in rural regions.[28] In the current study, the 4.2% hospitalization rate is not very low. Nonetheless, based on the transfer rate mentioned below, the hospitalization rate can be suggested as low. The hospitalization/transfer ratio is predicted to be 3/1â&#x20AC;&#x201C;3/2.[13,15,20] Further studies are required to reveal the causes of this hospitalization rate.

The majority of the transferred patients are known to be blunt and major trauma cases such as fall or MVI. In our study, the distribution was consistent with the available knowledge. The exception was the transfer of half of the burn patients due to the absence of a burn unit or intensive care unit. According to the literature, the transfer rates vary depending on the level of the hospital. About 25-40% of patients presented to a Level I hospital are known to be transferred cases.[11,29,30] In the present study, the transfer rate was 5.3%, and the high rate of assault cases represented a relatively low portion. However, the transfer rate in patients with major trauma was 51.5%. As mentioned by Sampalis,[30] the reason behind this might be the effort to transfer patients to a Level I hospital with minimal time loss.

Based on Svensonâ&#x20AC;&#x2122;s[31] assumption, this high rate might also be due to negligence in transferring patients after maintaining hemodynamic stability and determining cases with minor trauma. Patients could have been 236

more accurately selected for transfer based on the severity of the trauma after stabilization, as noted by Newgard and Svenson, because 28-37% of the transferred patients were those with a minor trauma.[15,31] In Scotland, patients have been reported to be transferred to an ED in 40-50 minutes in urban areas and in 70 minutes in rural areas.[13] However, geographic variables such as traffic congestion may prolong this time. For patients admitted to the ED, a mean time of 40 minutes to 4 hours passes for examination and stabilization.[14,31] Some studies report the transfer length between hospitals as 30-110 minutes.[11,29] In United States-based sources, transfer distances are noted to vary between 5 and 144 miles (231 km).[15,29] Our region is situated 250 km away from Level I and II hospitals in all directions. The geographic and climatic conditions are challenging. Therefore, a transferred patient does not reach an upper-level healthcare center in less than 4 hours. During the study period, since airway transfer had not been established, the only means of transfer was by land. In brief, it takes around 5 hours for a patient to present to the ED and be transferred to an upper-level hospital. It is known that more than half of the mortalities observed in trauma patients appears within the first 4 hours, due to a rush to reduce the total transport time that impedes accurate assessment of the severity of the cases; those with minor trauma and unstable cases may be among the transferred patients from the ED at the rates noted by Newgard and Svenson.[15,31,32] Moreover, Certo[33] mentioned that the death of 22% of transferred patients can be prevented by patient stabilization and resuscitation. In the present study, there are no data on mortality rates occurring during or immediately after the transfer of patients. Further studies on this issue are required.

The rate of mortality associated with trauma is known to be 0.6-10%.[12,15,17,21] Mortality increases in cases with major trauma. It is most commonly seen secondary to traffic accidents and falls.[32] In our study, 56.3% of the deaths were due to MVIs. Previous studies indicate that 46-57% of mortalities occurred due to head injuries.[31,34] In the present study, similar to those studies, we frequently observed deaths associated with head-neck, multiple organ and thoracodorsal injuries.

As of the end of the data collection period (December 2007), the hospital lacked an effective radiology department and intensive care unit. No possibility of radiology consultation was available off-hours. Therefore, craniovertebral tomographic examinations were carried out by neurosurgeons. Under normal circumstances, general surgeons do not make ultrasonographic thoracoabdominal evaluations for medical/legal reasons and lack of proper education in this field. These details have been provided here as we think that they might influence the hospitalization and transfer rates.

May - MayÄąs 2011

Analysis of trauma patients in a rural hospital in Turkey

In conclusion, while assault cases, most of which are associated with minor trauma cases, are encountered frequently in our region, assault is not observed to be a common major trauma cause. Major trauma cases have a high transfer rate. Improving hospital conditions (i.e. establishing an effective radiology department and an intensive care unit) for the management of major trauma cases is believed to increase the hospitalization rate, and the number of deaths occurring during or after prolonged transfers could thus be reduced.

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27. MacKenzie EJ, Fowler CJ. Epidemiology. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. McGrawHill Inc.; 2000. p. 21-40.

28. Coben JH, Tiesman HM, Bossarte RM, Furbee PM. Ruralurban differences in injury hospitalizations in the U.S., 2004.

Am J Prev Med 2009;36:49-55.

29. Rogers FB, Osler TM, Shackford SR, Cohen M, Camp L, Lesage M. Study of the outcome of patients transferred to a level I hospital after stabilization at an outlying hospital in a rural setting. J Trauma 1999;46:328-33.

30. Sampalis JS, Denis R, Fréchette P, Brown R, Fleiszer D, Mulder D. Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma. J Trauma 1997;43:288-96.

31. Svenson J. Trauma systems and timing of patient transfer: are we improving? Am J Emerg Med 2008;26:465-8.

32. Søreide K, Krüger AJ, Vårdal AL, Ellingsen CL, Søreide E, Lossius HM. Epidemiology and contemporary patterns of trauma deaths: changing place, similar pace, older face.

World J Surg 2007;31:2092-103.

33. Certo TF, Rogers FB, Pilcher DB. Review of care of fatally injured patients in a rural state: 5-year followup. J Trauma 1983;23:559-65.

34. Yagmur Y, Kiraz M, Kara IH. Looking at trauma and deaths: Diyarbakir city in Turkey. Injury 1999;30:111-4.

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Ulus Travma Acil Cerrahi Derg 2011;17 (3):238-242

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.72621

Splenic trauma - our experience at a level I Trauma Center Dalak travması - I. Basamak Travma Merkezi’ndeki deneyimimiz Gyan SAURABH, Subodh KUMAR, Amit GUPTA, Biplab MISHRA, Sushma SAGAR, Maneesh SINGHAL, Rehan N KHAN, Mahesh C MISRA

BACKGROUND

AMAÇ

A retrospective study was performed to identify the effect of non -operative management on splenic trauma patients and its implications at our Level I Trauma Centrer between January 2007 and June 2008.

Non-operatif tedavinin dalak travmalı hastalar üzerindeki etkilerini belirlemek üzere, I. Basamak Travma Merkezimizde Ocak 2007 ile Haziran 2008 tarihleri arasında retrospektif bir çalışma yürütüldü.

METHODS

GEREÇ VE YÖNTEM

Data regarding patient demography, mode of splenic injury, computerized tomography (CT) grading, blood transfusion requirement, operative findings, hospital stay, and followup were collected. The results of abdominal sonography and CT scan were utilized as proof of splenic injury and to determine the grade of injury. Subjects were divided into splenectomy and non-operative groups. Results were analyzed using non-parametric Mann-Whitney U tests.

Hasta demografisi, dalak yaralanması biçimi, bilgisayarlı tomografi (BT) evrelemesi, kan transfüzyon gereksinimi, cerrahi bulgular, hastanede kalış ve takip ile ilgili bilgiler toplandı. Splenik yaralanmanın kanıtı olarak ve yaralanmanın evresini belirlemek üzere, karın ultrasonografisi ve BT tarama sonuçları kullanıldı. Hastalar splenektomi ve non-operatif gruplarına ayrıldı. Bulgular non-parametrik Mann-Whitney U testiyle analiz edildi.

RESULTS

BULGULAR

Sixty-seven patients were enrolled in this study. All patients with grade I injury and 12 of 13 patients with grade II injury were managed non-operatively, whereas 9 of 16 patients with grade III injuries, 12 of 14 patients with grade IV injuries and all patients with grade V injuries were managed operatively. Thus, the higher the grade of injury, the greater the likelihood of operative management. The mean Injury Severity Score of the operative group was 20.12, significantly higher (p=0.001) than in the non-operative group, at 11.9. Mean hospital stays in the operative and non-operative groups were 12.8 and 8.3 days, respectively.

Altmış yedi hasta çalışmaya alındı​​. Evre I yaralanması olan bütün hastalarla evre II yaralanması bulunan 13 hastanın 12’si non-operatif olarak tedavi edilirken, evre III 16 hastanın 9’u, evre IV 14 hastanın 12’si ve evre V bütün hastalar cerrahi yöntemle tedavi edildi. Bu nedenle, ne kadar yüksek yaralanma derecesi söz konusu ise o kadar çok operatif tedavi gerçekleşti. Operatif grubun ortalama Yaralanma Şiddet Skoru (20,12), non-operatif grubun Yaralanma Şiddet Skorundan (11,9) anlamlı şekilde daha yüksek bulundu (p=0,001). Operatif ve non-operatif gruplardaki ortalama hastane kalışları, sırasıyla 12,8 ve 8,3 gün idi.

CONCLUSION

SONUÇ

Non-operative management of splenic trauma can be performed with an acceptable outcome.

Dalak travmasının non-operatif tedavisi kabul edilebilir sonuçlarla uygulanabilmektedir.

Key Words: �������������������������������������������������� Splenic trauma; splenectomy; non-operative management.

Anahtar Sözcükler: Splenik travma; splenektomi; non-operatif tedavi.

India Institute of Medical Sciences, New Delhi, India.

Hindistan Sağlık Bilimleri Enstitüsü, Yeni Delhi, Hindistan.

Correspondence (İletişim): Subodh Kumar, M.D. Ansari Nagar New Delhi - India.

Tel: +91 - 9868397705 e-mail (e-posta): subodh6@gmail.com

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Until recently, the accepted treatment for splenic trauma, even for minor injuries, was splenectomy.

This aggressive approach was based on the belief that, in adulthood, the spleen does not contribute to any major function, and non-operative management (NOM) was associated with potential life-threatening hemorrhage. With increasing recognition of the role of the spleen in immunological function and awareness of overwhelming post-splenectomy infection (OPSI), atherogenesis and ischemic diseases, there has been an increasing trend towards NOM and splenic salvage procedure.[1] However, this policy change towards splenic conservation requires careful risk-benefit analysis in the face of potentially life-threatening hemorrhage from delayed splenic rupture and the possibility of transfusion-induced viral infections. Furthermore, the increasing availability of reliable and good quality radiological imaging, including ultrasound and computerized tomography (CT) scanning, has greatly improved the information available with regard to the nature of the splenic injury, and this may well help to identify the suitable patients for NOM,[2] but at the expense of radiation to the patient.

We have reviewed the outcome of splenic injuries from our tertiary trauma center with the main aim of examining the effect of this changed non-operative policy on patients and its implications.

MATERIALS AND METHODS We have undertaken a retrospective study of patients with splenic injury admitted to our tertiary trauma center (located in New Delhi, India) between January 2007 and June 2008. Patients were identified with the help of clinical coding data on a Centralized Patient Record System (CPRS). Coding data were extracted from documentation found in the patient casenote and operation theater register. Data regarding patient demographics, mode of splenic injury, pre-op-

Fig. 1. Abdominal CT - Grade II splenic trauma.

Cilt - Vol. 17 Say覺 - No. 3

erative investigations, operative findings, and followup were collected. For each patient, an Injury Severity Score (ISS)[3] was calculated. All CT scans performed on admission were blindly and retrospectively reviewed by an otherwise uninvolved senior radiologist to grade splenic injury from grade I to V according to the American Association for the Surgery of Trauma (AAST) Splenic Injury Grading Scale. Transfusion requirements, length of hospital stay and the use of imaging in follow-up were also recorded. Follow-up status reports of all patients were obtained from their concerned admitting surgical units. Patients were placed into one of two groups based on the planned intervention, as splenectomy group or non-operative group.

Statistical analysis of the data was performed using non-parametric Mann-Whitney U tests.

RESULTS Sixty-seven patients were enrolled in this study, 5 of whom were children less than 15 years of age who were excluded from the study. The mean age was 25.25 years (16-60 years). These cases included isolated splenic injuries as well as polytrauma. As expected, males were predominantly affected, with a male:female ratio of 5.7:1. Sixty-four (95.5%) patients had blunt abdominal trauma and 3 (4.5%) had penetrating trauma. Among patients with blunt abdominal trauma, motor vehicle crash was the most common cause, in 38 (61.3%), followed by fall from height in 19 (30.6%) and assault in 5 (8%).

Most of the patients who suffered blunt splenic trauma were young males less than 30 years of age (70%). Of the 67 patients who underwent CT scan, 21 had grade I injury, 13 had grade II (Fig. 1), 16 had grade III, 14 had grade IV (Fig. 2), and 3 had grade V (Figs. 3 and 4). All patients with grade I injury and 12 of 13 patients with grade II injury were managed non-

Fig. 2. Abdominal CT - Grade IV splenic trauma.

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Table 1. Demographic and clinical characteristics of patients with splenic trauma

Splenectomy (N=25)

Non-operative (N=42)

p

Mean age Sex (Male : Female) Injury Severity Score Blood transfusion Mean hospital stay Mean ICU stay Lowest hemoglobulin in first 24 hrs (g/L) Admission systolic blood pressure Admission pulse rate Positive initial USG ≥ 3 regions injured

23 5.6:1 20.12 4.04 7-26 (12.8) 7-18 (10.6) 9.3 ± 1.37 89 (60-101) 112 (81-128) 23 12 (48%)

25 5.8:1 11.9 1.4 7-22 (9.9) 7-12 (7.8) 11.4 (9.8-12.8) 112 (100-140) 93 (81.5-109) 35 7 (16.6%)

>0.05 >0.05 <0.001 <0.001 0.005 <0.05 0.002 0.001 0.10 >0.05 0.06

operatively. Nine of 16 patients with grade III injuries, 12 of 14 patients with grade IV injuries and all patients with grade V injuries were managed operatively. That is, the higher the grade of injury, the greater the likelihood of operative management.

splenectomy due to the failure of NOM. Again, the cause of failed NOM was hypotension. Out of 42 patients in the non-operative group, 37 had normal SBP at presentation and 5 had shock due to related injuries, but they were later stabilized after resuscitation.

Of 25 patients who were managed operatively, 2 underwent splenorrhaphy (1 with grade II and 1 with grade III splenic injury). All 3 of the penetrating splenic trauma patients underwent splenectomy. A splenic artery embolization facility was not available in our center during the time this study was performed.

The mean ISS of the operative group was 20.12, significantly higher (p≤0.001) than in the non-operative group, with a mean ISS of 11.9.

Transfusion requirement (Table 1) was 4.04 units in the operative group and 1.4 units in the non-operative group (p≤0.001). Mean hospital stay in the operative group was 12.8 days (range 7-26) and in the nonoperative group was 8.3 days (range 7-16) (p=0.005).

Because systolic blood pressure (SBP) at presentation is a major determinant of the management of blunt splenic injuries (BSIs), the majority of patients in the operative group, 19 (76%), had SBP <90 mmHg at presentation. One patient in the operative group was initially managed non-operatively but later required

Twelve patients in the splenectomy group and 7 patients in the non-operative group had associated injuries. Bilateral hemothorax in 5 and left hemothorax in 14 patients was managed with intercostal tube drainage alone. Four of 5 patients with bilateral hemothorax had associated multiple rib fractures, which required no surgical intervention apart from intercostal tube drainage. Four patients had mild head injury and 2 had moderate head injury managed with non-operative approach alone. Seven patients had associated liver injury (grade I-III) managed non-operatively. Six patients had associated long bone fracture managed with external fixation in 3 left humerus fractures and with internal fixation in 3 left femur fractures.

Fig. 3. Abdominal CT - Grade V splenic trauma.

Fig. 4. Splenic injury involving the hilum.

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Splenic trauma - our experience at a level I Trauma Center

All the patients in the non-operative group with injury grades of III and IV were followed up weekly for six weeks, fortnightly for the next 12 weeks and then monthly thereafter until one year. At every visit, they were followed by clinical examination and ultrasonography. Patients with grade I and II splenic injuries were followed up fortnightly for two months and monthly for the next four months. Grade I and II splenic injury patients were followed up only clinically, but grade III and IV patients were followed up with monthly ultrasonography for three months followed by contrastenhanced CT scan at one year. At the one-year followup, all the patients are doing well with none presenting with features of delayed rupture or OPSI.

DISCUSSION This study suggests that BSIs in adults could be successfully managed non-operatively in at least 63% of the patients; however, all the penetrating splenic injuries underwent splenectomy. The need for surgical intervention is usually decided within 24 hours of admission. Therefore, inpatient monitoring after BSI for 8 days should identify >95% of failed NOM. Although success rates as high as 98% have been previously reported,[4] success of NOM is undoubtedly a consequence of how often it is attempted. If one operates on most BSI patients and reserves NOM only for those with minor injuries, success rates would be anticipated. This is supported by recent results from a large multi-institutional study conducted by Peitzman and colleagues,[5] who showed that when NOM was attempted, 61.5% of the time there was an associated 10.8% failure rate. The length of time that patients should be monitored as inpatients after BSI, at which point NOM should be considered successful and patients safe for discharge, is presently not well defined.

The reported durations of observation after BSI have varied widely in the literature, with most studies reporting mean lengths of stay between 4.1 and 12 days.

[6,7] Mean hospital stay among our patients was 12.8 days in the splenectomy group and 8.3 days in the nonoperative group, which is longer than the international average, and may be attributed to the nature of the associated injuries.

Previous studies have suggested that splenic injury grade, ISS, Glasgow Coma Scale (GCS), initial BP, as well as other variables may be important predictors of failure of NOM for BSI.[8-11] Our study suggests that splenic injury grade has a significant effect on the success of NOM, confirming the finding of Nix and colleagues.[11] This was evident for both patients with isolated BSI and those with BSI and associated injuries. ISS is another factor, being significantly higher in patients with BSI requiring surgery and with higher rates of failed NOM seen with an increase in ISS. In our study, SBP on arrival was another effective facCilt - Vol. 17 Say覺 - No. 3

tor, and was significantly lower in the operative group than in the non-operative group. Taken together, our results suggest that higher grade injuries in more severely injured patients are more likely to cause failed NOM. The major complications that can be avoided by splenic conservation are thrombocytosis and OPSI. [12] None of our patients developed OPSI in the followup. The obvious disadvantage of NOM is the possibility of sudden, severe, delayed hemorrhage leading even to death before surgical intervention can be arranged.[13] In our series, only 1 of 42 patients deteriorated in the non-operative group and required urgent splenectomy. Other problems in NOM highlighted in the literature include the greater requirement of blood transfusions and transfusion-related complications.

[2] In our series, requirement of blood transfusions in the operative group was significantly higher than in the non-operative group. Another consideration for NOM is the possibility of missing other associated intra-abdominal injuries. None of our patients, to date, has presented with late associated injuries. It is stated that hospital stay for NOM patients is shorter than for patients undergoing operative management.[14,15] Similarly, in our study, mean hospital stay for the NOM patients was shorter than for the operated group.

In conclusion, BSIs can be managed non-operatively in the majority of patients with an acceptable outcome even in the developing world well-equipped with the latest medical advancement and expertise.

Selection of patients for operative versus non-operative treatment is difficult. Close in-patient monitoring for 8 days is essential to the successful non-operative management of the majority of patients.

REFERENCES 1. Mikocka-Walus A, Beevor HC, Gabbe B, Gruen RL, Winnett J, Cameron P. Management of spleen injuries: the current profile. Aust NZ J Surg 2010;80:157-61.

2. Aseervatham R, Muller M. Blunt trauma to the spleen. Aust NZ J Surg 2000;70:333-7.

3. Greenspan L, McLellan BA, Greig H. Abbreviated Injury Scale and Injury Severity Score: a scoring chart. J Trauma 1985;25:60-4.

4. Pachter HL, Guth AA, Hofstetter SR, Spencer FC. Changing patterns in the management of splenic trauma: the impact of nonoperative management. Ann Surg 1998;227:708-19.

5. Peitzman AB, Heil B, Rivera L, Federle MB, Harbrecht BG, Clancy KD, et al. Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma. J Trauma 2000;49:177-89.

6. Myers JG, Dent DL, Stewart RM, Gray GA, Smith DS, Rhodes JE, et al. Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages. J Trauma 2000;48:801-6.

7. Harbrecht BG, Peitzman AB, Rivera L, Heil B, Croce M, Morris JA Jr, et al. Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma. J Trauma 2001;51:887-95.

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8. Velmahos GC, Zacharias N, Emhoff TA, Feeney JM, Hurst JM, Crookes BA, et al. Management of the most severely injured spleen: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Arch Surg 2010;145:456-60.

9. Cathey KL, Brady WJ Jr, Butler K, Blow O, Cephas GA, Young JS. Blunt splenic trauma: characteristics of patients requiring urgent laparotomy. Am Surg 1998;64:450-4.

10. Stranes S, Klein P, Magagna L, Pomerantz R. Computed tomographic grading is useful in the selection of patients for non operative management of blunt injury to the spleen. Am Surg 1998;64:743-749.

11. Nix JA, Costanza M, Daley BJ, Powell MA, Enderson BL.

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Outcome of the current management of splenic injuries. J Trauma 2001;50:835-42.

12. Finch R, Banting SW. Modern management of splenic injury. Aust NZ J Surg 2004; 74: 513-4. DOI: 10.1111/j.14452197.2004.03068.x 13. Benjamin CI, Engrav LH, Perry JF Jr. Delayed rupture or delayed diagnosis of rupture of the spleen. Surg Gynecol Obstet 1976;142:171-2.

14. Sanders MN, Civil I. Adult splenic injuries: treatment patterns and predictive indicators. Aust N Z J Surg 1999;69:430-2.

15. Smith JS Jr, Cooney RN, Mucha P Jr. Nonoperative management of the ruptured spleen: a revalidation of criteria. Surgery 1996;120:745-51.

May - May覺s 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):243-247

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.13845

Pediyatrik yaş grubunda trafik kazası sonucu oluşan yaralanmalar ve özellikleri Characteristics of injuries due to traffic accidents in the pediatric age group Mustafa SERİNKEN, Mert ÖZEN

AMAÇ

BACKGROUND

Bu çalışmada, pediyatrik yaş grubunda trafik kazasına maruz kalan olgular araştırıldı ve risk etmenleri ile ilgili veriler elde edilmeye çalışıldı.

In this study, the pediatric age group exposed to road traffic accidents was investigated, and patients with risk factors were studied to obtain relevant data.

GEREÇ VE YÖNTEM

METHODS

Bir üniversite acil servisine beş yıl süre ile başvuran 15 yaş ve altındaki travma olguları retrospektif olarak incelendi.

Yaş, cinsiyet, kazanın oluş zamanı, kazanın oluş şekli, yaralanma bölgesi, yaralanma tipi ve klinik gidiş verileri araştırıldı.

Trauma patients under the age of 15 who were admitted to the emergency department of this university over five years were analyzed retrospectively. Age, gender, accident time and type, personal injury area, type of injury, and clinical outcome were examined.

BULGULAR

RESULTS

Çalışma kriterlerine uyan 812 olgu olduğu belirlendi. Oluş nedenlerine göre, araç içi trafik kazaları en büyük grubu oluşturdu (n=479, %59). Yaz aylarında tüm başvuruların %34’ü (n=236) gerçekleşti. 17:00-17:59 (n=94, %11,6) ve 18:00-18:59 (n=88, %10,8) saatleri başvuruların en yogun olduğu zaman dilimleriydi. Baş-boyun bölgesinin (n=226, %27,8) ve ekstremitelerin (alt ekstremite: n=144, %17,7; üst ekstremite: n=99, %12,2) en sık etkilenen vücut bölgeleri olduğu ve olgularda kontüzyon, abrazyon, hematom ve crush tipi yaralanmaların daha sık görüldüğü belirlendi (n=443, %54,6). Hayatını kaybeden olguların büyük çoğunluğu, yayaya araç çarpması şeklinde gerçekleşen araç dışı trafik kazası olgularıydı (n=19, %59,4).

When the cases were analyzed with respect to the causes that led to the accidents, in-vehicle accidents formed the largest group (n=479, 59%). More than a quarter of all applications (34%) took place in summer months. Most of the applications were between 17:00 and 17:59 (n=94, 11.6%), followed by between 18:00 and 18:59 (n=88, 10.8%). The most commonly affected body parts were the head and neck region (n=226, 27.8%) and extremities (lower extremity: n=144, 17.7%; upper extremity: n=99, 12.2%). The most frequently seen injuries were contusions, abrasions, hematomas, and crush (n=443, 54.6%). The majority of patients who died were pedestrians who were hit by a motor vehicle (n=19, 59.4%).

SONUÇ

CONCLUSION

Bu çalışmada, araç dışı trafik kazalarının pediyatrik yaş grubu için daha ölümcül olduğu ve bu kazaların sıklıkla yaya olarak araç ile çarpışma sonrası gerçekleştiği gözlenmiştir.

In this study, it was observed that in the pediatric age group, traffic accidents involving a pedestrian and vehicle collision have greater fatality.

Anahtar Sözcükler: Acil servis; trafik kazası; pediyatrik travma.

Key Words: Emergency department; traffic accident; pediatric trauma.

Pamukkale Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Denizli.

Department of Emergency Medicine, Pamukkale University, Faculty of Medicine, Denizli, Turkey.

İletişim (Correspondence): Dr. Mustafa Serinken. Pamukkale Üniversitesi Tıp Fakültesi Hastanesi Acil Servisi, 20070 Kınıklı, Denizli, Turkey.

Tel: +90 - 258 - 212 71 94 e-posta (e-mail): mserinken@hotmail.com

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Trafik kazası sonucu oluşan yaralanmalar halk sağlığı açısından çok önemli bir problem oluşturmaktadır. Özellikle çocukluk döneminde, trafik kazaları önlenebilir sağlık sorunlarının başında gelmektedir.[1] Risk etmenleri belirlenebildiğinde, trafik kazaları öngörülebilir ve önlenebilir kazalardır. 2-14 yaş arası gerçekleşen ölümlerin önemli bir bölümü trafik kazalarına bağlı olduğu ve en az yarısının emniyet kemeri ve çocuk araba koltukları gibi basit önlemlerle önlenebileceği bildirilmiştir.[2,3] Ülkemizde 0-14 yaş arası çocukların, trafik kazaları sonucu hayatlarını kaybetme oranı %14,7 olarak bildirilmiştir. Bu oranın Almanya’da %4,09, İngiltere’de %5,86, ABD’de %6,59, Yunanistan’da %2,89 olduğu göz önüne alındığında, ülkemizde çocukların trafik eğitimi ve trafik güvenliği konusunda bir şeylerin yapılamadığı ya da eksik veya yanlış yapıldığı ortadadır.[4] Ülkemizde trafik kazalarının pediyatrik yaş grubu üzerine olan etkilerini araştıran bilimsel çalışmalar sınırlı sayıdadır. İlköğretim çağındaki çocuklarda yapılan bir çalışmada, bu yaş grubundaki travmaların önemli bir bölümünün trafik kazaları (%38,3) sonucu oluştuğu bildirilmiştir.[5] Çocukluk çağında kafa travmasına bağlı ölümleri araştıran bir çalışmada ise, etyolojide trafik kazalarının ilk sırada yer aldığı ve bunlarında önemli bölümünün araç dışı trafik kazalarından kaynaklandığı belirlenmiştir.[6] Bu çalışmada, trafik kazalarının çocuklar üzerindeki fiziksel etkileri ve sonuçları araştırılmış, risk etmenleri ile ilgili veriler elde edilmeye çalışılmış ve önlenmesi için öneriler sunulmuştur.

GEREÇ VE YÖNTEM 1 Nisan 2005 - 1 Nisan 2010 tarihleri arasındaki 5 yıllık zaman diliminde bir üniversite acil servisine trafik kazası nedeniyle başvuran 15 yaş ve altındaki çocuk travma olguları retrospektif olarak incelendi.

Kaza sonrası, herhangi bir yakınması ve travma bulgusu olmayan, adli rapor düzenlenmesi için acil servisimize getirilen olgular çalışma dışı bırakıldı.

Olguların hastane dosyalarından ve arşivlenen adli raporlarından çalışma verilerine ulaşıldı. Yaş, cinsiyet, kazanın oluş zamanı, kazanın oluş şekli, yaralanma bölgesi, yaralanma tipi ve klinik gidiş verileri araştırıldı.

Çalışmadan elde edilen tüm veriler, “Statistical Package for Social Sciences for Windows 11” adlı standart programa kaydedildi ve değerlendirmeleri yapıldı. Sayısal değişkenler ortalama ± SD, kategorik değişkenler sayı ve yüzde olarak özetlendi.

BULGULAR Çalışma süresince acil servise başvuran ve çalışma kriterlerine uyan 812 olgu belirlendi. Olguların 559’u (%68,8) erkek, 253’ü (%31,2) kadındı. Tüm grubun yaş ortalaması 7,6±3,9 (aralık: 1 ve 15) olarak saptandı. Oluş nedenlerine göre araç içi trafik kazaları (AİTK) en büyük grubu oluşturdu (n=479, %59). Bunu sırasıyla araç dışı trafik kazaları (ADTK), bisiklet ve motosiklet kazaları takip etti. ATİK’ya maruz kalan olguların yaş ortalamalarının diğer gruplara oranla daha düşük olduğu belirlendi (6,7±3,8) (Tablo 1).

Olguların acil servise geliş şekli incelendiğinde, sıklıkla özel araç ile getirildiği belirlendi (n=514, %63,3). Olguların 290’ının (%35,7) ambulansla getirildiği saptandı. Başvuruların ay, gün ve saat olarak zamansal özellikleri araştırıldı. Ekim ayında pik yaptığı belirlendi (n=108, %13,3). Yaz aylarında (Haziran, Temmuz, Ağustos) tüm başvuruların %34’ü (n=236) gerçekleşti. Olguların en sık cuma günü acil servise başvuruda bulunduğu saptandı (n=163, %20,1). Saat olarak 17:00-17:59 (n=94, %11,6) ve 18:00-18:59 (n=88, %10,8) başvuruların en yogun olduğu zaman dilimleriydi.

Yaralanma bölgeleri incelendiğinde baş-boyun bölgesinin (n=226, %27,8) ve ekstremitelerin (alt ekstremite: n=144, %17,7, üst ekstremite: n=99, %12,2) kazalarda en sık etkilenen bölgeler olduğu saptandı (Tablo 1). Yaralanma bölgeleri birbirinden bağımsız olarak sınıflandırıldığında ise baş-boyun bölgesi %34,8 (n=405), alt ekstremite %25 (n=291), üst ekstremite %20,1 (n=234), gögüs-sırt %7,2 (n=84), karın %6,9 (n=80), omurga %6 (n=69) şeklinde bir dağılım elde edildi. Olgularda en sık rastlanan yaralanma tipinin, kontüzyon, abrazyon, hematom ve crush tipi yaralanmalar olduğu belirlendi (n=443, %54,6) (Tablo 2).

Tüm olgular içinde 32 olgunun hayatını kaybettiği saptandı. Bunların önemli bir bölümü, yayaya araç çarpması şeklinde gerçekleşen ADTK olgularıy-

Tablo 1. Kazaların oluş nedenleri ve yaş ortalamaları Kazaların oluş nedenleri Araç içi trafik kazası Araç dışı trafik kazası Bisiklet kazası Motosiklet kazası Toplam 244

n

%

Yaş ortalaması

Min.

Maks.

479 162 99 72 812

59 19,9 12,2 8,9 100

6,7±3,8 9,5±3,4 8,6±3,7 9,3±4,6 7,6 ± 3,9

1 3 4 2 1

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Pediyatrik yaş grubunda trafik kazası sonucu oluşan yaralanmalar ve özellikleri

Tablo 2. Yaralanma bölgelerinin dağılımı Yaralanma bölgesi Baş-boyun bölgesi Göğüs-sırt bölgesi Üst ekstremite Alt ekstremite Üst + Alt ekstremite Baş-boyun + Göğüs bölgesi Baş-boyun + Karın bölgesi Baş-boyun + Üst ekstremite Baş-boyun + Alt ekstremite Göğüs + Karın bölgesi Göğüs + Üst ekstremite Göğüs + Alt Ekstremite Karın + Üst ekstremite Karın + Alt ekstremite Omurga yaralanması Genel vücut travması (3 ve fazla bölge) Toplam

n

%

226 9 99 144 20 22 13 48 55 4 26 4 4 18 53 67 812

27,8 1,1 12,2 17,7 2,5 2,7 1,6 5,9 6,8 0,5 3,2 0,5 0,5 2,2 6,5 8,3 100

n

%

443 217 102 49 812

54,6 26,7 12,6 6 100

Tablo 3. Yaralanma tipleri Yaralanma tipi Kontüzyon, abrazyon, hematom, crush Kesici, delici, sıyrık, ampütasyon Dislokasyon, kırık Sprain/strain Toplam

dı (n=19, %59,4), 10 (%31,2) olgunun AİTK sonucu, 3 olgunun ise motosiklet veya bisikletle motorlu araç çarpması ile gerçekleştiği belirlendi. ADTK’da kaybedilen olguların yaş ortalamaları [10,7±3,1 (aralık: 4 ve 15)] AİTK olgularına [7,3±3,3 (aralık: 2 ve 13)] oranla daha yüksekti. Hayatını kaybeden olguların %78,1’i (n=25) erkek cinsiyetteydi. Hayatını kaybeden olguların büyük çoğunluğunda genel vücut travması mevcuttu (n=28, %87,5) ve ölüm nedeni olarak en sık hipovolemik şok rapor edilmişti (n=24, %75). Çalışma grubundaki olguların önemli bir bölümünün acil serviste müdahale edilip, sonrasında taburcu edildiği belirlendi (n=654, %80,5). Olguların 126’sının (%15,5) hastanede çeşitli servislere yatışının yapıldığı saptandı. Yatış yapılan olguların çoğunu, ekstremite yaralanması (özellikle kırıklar) nedeniyle ortopedi ve travmatoloji servisine yatırılan olgular oluşturdu (n=97, %76,9).

TARTIŞMA Bu kesitsel çalışmada, çocukların tıpkı erişkinlerde olduğu gibi trafikte sıklıkla AİTK’ya maruz kaldığı fakat daha çok ADTK nedeniyle hayatını kaybettiği belirlenmiştir. Kaybedilen olguların önemli bir bölümünün yayaya motorlu araç çarpması nedeniyle kaza geCilt - Vol. 17 Sayı - No. 3

çirdiği, AİTK’ya maruz kalan çocukların diğerlerine oranla yaş ortalamalarının daha düşük olduğu önemli diğer bulgular arasındadır.

Pediyatrik grupta travma, sakatlıkların ve ölümlerin en sık nedenidir. Çocuklarda travma nedenleri ve yaralanma mekanizmalarının yaşa göre farklılık gösterdiği bildirilmiştir. Yaşamın erken dönemlerinde ve yürüme çagında ev içindeki düşmeler en sık travma nedeni iken yaş ilerledikçe trafik kazaları daha yaygın görülmeye başlamaktadır. Sözüer ve arkadaşlarının[6] ilkögretim dönemi (6-13 yaş) çocuklarda yaptıkları araştırmada travma nedenleri arasında ilk sırada düşmelerin (%40,3) ikinci sırada ise trafik kazalarının (%38,3) görüldüğünü bildirmiştir.[5] Sever ve arkadaşlarının[1] yaptığı çalışmada ise ilk sırada trafik kazaları (%32,5), ikinci sırada düşmeler (%16,9) yer almıştır. Trafik kazaları çocukluk çağının en sık ölüm nedenidir ve travmaya bağlı yatış nedenleri arasında ilk sırada yer almaktadır.[5,7,8] Çeşitli ülkelerdeki trafik kazaları istatistikleri, yaya ve bisikletli küçük çocukların en çok zarar gören yaş grubunda olduğuna işaret etmektedir.[9] Çalışmamızda da benzer şekilde kaybedilen çocukların çogunlukla yaya olduğu belirlenmiştir.

Fakat yaş olarak büyük çocukların daha fazla araç dışı trafik kazalarına karıştığı ve daha ciddi yaralanmaya maruz kaldığı dikkati çekmiştir. Ülkemizde ADTK’da mortalitenin pediyatrik grupta daha fazla olduğunu bildiren araştırmalar vardır.[6,10-12] AİTK’nın çocuklar için daha az ölümcül olmasının nedeni, ebeveynlerin geçmiş yılllara oranla daha bilinçli olmaları, arabalardaki güvenlik sistemlerinin daha ileri teknolojiye sahip olmaları, trafikdeki cezai uygulamaların daha caydırıcı olması, çocukların arka koltukta ve emniyet kemeri veya araba koltuğu gibi koruyucu önlemlerle yolculuk etmesinin yaygınlaşması ile açıklanabilir. Dünya Sağlık Örgütü’nün raporunda çocuk araba koltuklarının arkaya bakacak şekilde sürücü koltuğunun arkasına yerleştirilmesi ile, tüm yaralanmalarda %76, ciddi yaralanmalarda %92 koruyuculuğa sahip olduğunu bildirmiştir.[13] Literatürde araç içi trafik kazalarına sıklıkla büyük çocukların maruz kaldığını destekleyen yayınlarda vardır. Durkin ve arkadaşları[14] çocukların araç dışı kazalarına 6-10 yaşlarında, bisiklet kazalarına 9-15 yaşlarında ve araç içi trafik kazalarına da 12-16 yaşları arasında daha çok maruz kaldığını bildirmiştir. Aynı çalışmada çocukların yaz aylarında ve öğleden sonra daha fazla trafik kazasına maruz kaldığı bildirilmiştir.[14] Sözüer ve arkadaşlarının[5] çalışmasında da benzer sonuçlar elde edilmiştir. Emniyet Genel Müdürlüğü trafik istatistiklerine göre, ülkemizde çocuk trafik kazalarının sıklıkla yaz ve ikinci olarak ilkbahar aylarında görülmektedir. Aynı zamanda bu istatistiklerde, 1-l5 yaş grubunda görülen ölümlerin sıklıkla okulların dağılma saatlerine karşılık gelen 14:00-18:00 saatle245

Ulus Travma Acil Cerrahi Derg

ri arasında meydana geldiği bildirilmiştir.[9,10] Gündüz çocuklarla ilgili trafik kazalarının en fazla olduğu dönem öğleden sonradır. Tüm dünyada, çocukların okula gitme ve okuldan dönme zamanlarında kaza sayısında artış olduğu görülmüştür.[9] Çalışmamızda çocuk trafik kazalarının zamansal özellikleri ile ilgili elde ettiğimiz veriler yukarıdaki çalışmaları destekler niteliktedir.

Resmi kurumların yayınladıkları istatiksel bilgilerde, trafik kazaları ile ilgili kaza, yaralı ve ölü sayıları gibi genel bilgilere yer verilmekte, yaralanma bölgesi ve tipi ile ilgili bilgilere ulaşılamamaktadır. Ülkemizde trafik kazalarında yaralanma bölgesini araştıran yayınlar sınırlı sayıdadır. Farklı bölgelerde gerçekleştirilen bu araştırmaların çoğunda, en sık yaralanma bölgesi olarak baş-boyun ve daha sonra alt ekstremite saptanmıştır.[1,5,15] Alt ekstremite travmatik yaralanmalarını inceleyen bir çalışmada etyolojide trafik kazaları ilk sırada yer almıştır.[16] Aktaş ve arkadaşları[17] yaşı dikkate alınmaksızın tüm trafik kazalarını incelemiş, vücutta en sık yaralanma bölgesinin baş-boyun bölgesi (%26,6) olduğunu bildirmiştir. Bunu sırasıyla alt ekstremite (%19,2) ve üst ekstremite (%8,3) bölgeleri takip etmiştir. Sadece çocuk olguları incelediğimiz araştırmamızda da, bu oranların benzer şekilde olduğu söylenebilir (baş-boyun %27,8, alt ekstremite %17,7, üst ekstremite %12,2). Fakat farklı olarak omurga yaralanması ve genel vücut travması oranlarımız (omurga yaralanması: %6,5, genel vücut travması: %8,3), Aktaş ve arkadaşlarının bildirdiği oranlardan (omurga yaralanması: %3,7, genel vücut travması: %5,7) daha yüksek bulunmuştur. Bu sonuç çocukların trafik kazalarında erişkinlere göre daha korumasız olduğunu düşündürmektedir. Fakat konu ile ilgili ülkemizde geniş çaplı araştırmalara ihtiyaç vardır. Çalışmamızda olguların büyük kısmının (%68,8) erkek cinsiyette olması diğer çalışma sonuçları ile uyumludur. Ülkemizde yapılan benzer çalışmalarda bu oran %65 ile %77 arasında değişen değerlerdedir.

[15,17,18] Türkiye İstatistik Kurumu’nun (TÜİK) verilerine göre,[19] trafik kazasına maruz kalan tüm yaralıların yaklaşık ¾’ü erkek cinsiyettedir. Ülkemizde pediyatrik yaş grubundaki travmaları inceleyen araştırmalarda da erkeklerin genel olarak daha fazla travmaya maruz kaldığı görülmektedir.[5,6] Erkek çocukların kızlara oranla daha fazla trafik kazasına maruz kalması beklenen bir sonuçtur. Bu durum bazı araştırmacılar tarafından, erkek çocukların trafik kurallarına daha az uyması ve trafikte daha tehlikeli hareketlerde bulunması ile açıklanmıştır.[9] Erkek olma olgusu cesaret kaynakların biri olarak gösterilmektedir. Ayrıca bir çok araştırmacı, pediyatrik yaş grubunda majör travmaya maruz kalan olguların sıklıkla erkek olduğunu bildirmiştir.[15,20-22] Franzen ve arkadaşları[20] 0-16 yaş grubunda yaptıkları çalışmada çoklu travmaya maruz kalan olguların %64’ünün erkek cinsiyette olduğunu sapta246

mıştır. Tomas ve arkadaşlarının[21] yaptığı benzer bir çalışmada ise bu oran %62 olarak belirtilmiştir. Çalışmamızda hayatını kaybeden olguların %78,1’inin erkek cinsiyette olması ve genellikle çoklu travmaya maruz kalmış olmaları yukarıdaki verileri destekler niteliktedir. Pediyatrik yaş gurubundaki erkeklerin, kızlara oranla daha aktif olması da şüphesiz bu sonuçlara etki etmektedir. Çalışmamızda olguların acil servise geliş şekli incelendiğinde erişkinlerde olduğu gibi pediyatik yaş grubununda da, yaralıların sıklıkla özel araç veya taksi ile acil servise getirildiği görülmektedir. Ambulans ile gelen hastaların oranı ise genel olarak yüksek (%35,7) bulunmuştur. Ege Üniversitesi Hastanesi Acil Servisi’nde yapılan benzer bir çalışmada bu oran %28,8 olarak bildirilmiştir.[10] Genel olarak üniversitesi hastanelerinden ve çevre sağlık kuruluşlarından sevk edilen olguların fazla olması nedeniyle, ambulans ile olan başvuruların devlet hastanelerine oranla yüksek olduğu görülmektedir.

TÜİK verilerine göre,[19] son 15 yılda ülkemizde trafik kazalarının sayısı katlanarak artmıştır (1995 yılı: 279663, 2000 yılı: 500664, 2005 yılı: 620789 2008 yılı: 950120). Buna karşın kazalardaki ölüm sayılara giderek azalmıştır (1995 yılı: 6004, 2000 yılı: 5510, 2005 yılı: 4505, 2008 yılı: 4236). Bu azalış pediyatrik grupta (15 yaş altı) çok daha dramatik olmuştur (1995 yılı: 1285, 2000 yılı: 685, 2005 yılı: 287, 2008 yılı: 231). Bu başarıda çocuklara ve ebeveynlere verilen trafik eğitimlerinin önemi büyüktür. Fakat hala 1-15 yaş grubu trafik kazalarından kaynaklanan ölüm oranlarında, ülkemiz diğer avrupa ülkelerinden daha kötü durumdadır.[9] Bu da ülkemizde yapılması gerekenlerin henüz bitmediğini göstermektedir. Bazı avrupa ülkelerinde (Fransa, Norveç, Portekiz) çocuk araba koltuklarının kullanımı 2000 yılından beri zorunludur.[3] Ülkemizde bu yıl kullanımı zorunlu hale getirilmiş ve henüz yaygınlaşmamıştır. Beklentimiz bu uygulama ile önümüzdeki yılllarda AİTK’daki ölüm oranlarının daha da azalacağı yönündedir. Alınabilecek bir diğer önlem çocukların ön koltuğa oturmalarının engellenmesidir. Birçok avrupa ülkesinde 12 yaşından küçük çocukların ön koltukta seyahat etmeleri yasaklanmıştır. Ülkemizde bu yaş sınırı 10 olarak yasalaşmıştır.

Sonuç olarak, AİTK’lar erişkinlerin olduğu gibi çocuklarında en sık maruz kaldığı trafik kazası şeklidir. Bu çalışmada, ADTK’ların pediyatrik yaş grubu için daha ölümcül olduğu ve bu kazaların sıklıkla yaya olarak araç ile çarpışma sonrası gerçekleştiği gözlenmiştir. Bunlar için tüm çocukların, yaş gruplarına uygun trafik eğitimlerini almaları sağlanmalıdır. Alınabilecek bir diğer önlem okul çıkış saatlerinde sürücülerin daha dikkatli olmalarına yönelik olabilir.

May - Mayıs 2011

Pediyatrik yaş grubunda trafik kazası sonucu oluşan yaralanmalar ve özellikleri

KAYNAKLAR 1. Sever M, Saz EU, Koşargelir M. An evaluation of the pediatric medico-legal admissions to a tertiary hospital emergency department. Ulus Travma Acil Cerrahi Derg 2010;16:260-7.

2. Baysal S, Birinci A. Çocukluk çağında kazalar ve yaralanma kontrolü. Türkiye Klinikleri J Pediatr Sci 2006;2:64-78.

3. Boztaş G, Özcebe H. Trafik kaza paralanmalarında ikincil korunma: Çocuk araba koltukları. STED Dergisi 2005;14:68-9.

4. Hatipoğlu, S. Okul öncesi çocuklarda trafik eğitiminin gerekliliği. Ulaşım adresi: http://www.trafik.gov.tr/ YayınlarTrafik Güvenliği Kongre Yayınları. Ulaşım tarihi: 30 Temmuz 2010.

5. Sözüer EM, İkizceli İ, Avşarogullları L, Yürümez Y, Yavuz Y, Yücel M. Acil servise başvuran ilköğretim çağı çocuk travmalarının özellikleri. TRJEM 2004;4:59-63.

6. Berber G, Arslan MM, Karanfil R, Çekin N. Diyarbakır’da Kafa Travmalarına Bağlı Çocuk Ölümleri. Türkiye Klinikleri J Foren Med 2008;5:19-23.

7. Sala D, Fernández E, Morant A, Gascó J, Barrios C. Epidemiologic aspects of pediatric multiple trauma in a Spanish urban population. J Pediatr Surg 2000;35:1478-81.

8. Bulut M, Korkmaz A, Akkose S, Balci V, Ozguc H, Tokyay R. Epidemiologic and clinical features of childhood falls.

Ulus Travma Derg 2002;8:220-3.

9. Tombaklar, ÖH. Çocuklar ve trafik kazaları. Ulaşım adresi: http://www.trafik.gov.tr/ Yayınlar-Trafik Güvenliği Kongre Yayınları. Ulaşım tarihi: 30 Temmuz 2010.

10. Aktaş EÖ, Koçak A, Zeyfeoğlu Y, Solak İ, Aksu, H. Trafik kazası nedeniyle Ege Üniversitesi Tıp Fakültesi Acil Servise başvuran olguların özelikleri, Ulaşım adresi: http://www. trafik.gov.tr/ Yayınlar-Trafik Güvenliği Kongre Yayınları.

Ulaşım tarihi: 30 Temmuz 2010.

11. Tokdemir M, Kafadar H, Düzer S. Elazığ’da 2001-2007 yılları arasında otopsisi yapılan 0-18 yaş arası olgularının değerlendirilmesi. Fırat Tıp Dergisi 2009;14:111-4.

12. Tokdemir M, Kafadar H, Turkoglu A, Deveci SE, Colak C. Comparison of the everity of traumatic brain injuries in pedestrians and occupants of motor vehicles admitted to firat health center: A five-year series in an Eastern Turkish city.

Cilt - Vol. 17 Sayı - No. 3

Med Sci Monit 2009;15:1-4.

13. WHO. World report on road trafic injury prevention. Eds: Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, et al. Geneva, 2004. Ulaşım adresi: http://www.who. int/violence_injury_prevention/publications/road_traffic/ world_report/summary_en_rev.pdf. Ulaşım tarihi: 28 Haziran 2010.

14. Durkin MS, Laraque D, Lubman I. Epidemiology and prevention of traffic injuries to urban children and adolescents.

Pediatrics 1999;103:e74.

15. Varol O, Eren ŞH, Oguztürk H, Korkmaz İ, Beydilli İ. Acil servise trafik kazası sonucu başvuran hastaların incelenmesi.

C.Ü. Tıp Fakültesi Dergisi 2006;28:55-60.

16. Rasouli MR, Moini M, Khaji A, Heidari P, Anvari A. Traumatic vascular injuries of the lower extremity: report of the Iranian National Trauma Project. Ulus Travma Acil Cerrahi Derg 2010;16:308-12.

17. Aktaş EÖ, Koçak A, Zeyfeoglu Y. Ege Üniversitesi Tıp Fakültesi Adli Tıp Anabilim Dalı’na trafik kazası nedeniyle başvuran adli olguların değerlendirilmesi. Ulaşım adresi: http://www.trafik.gov.tr/ Yayınlar-Trafik Güvenliği Kongre Yayınları. Ulaşım tarihi: 30 Temmuz 2010.

18. Katkıcı U, Örsal M, Özkök S. Trafik kazası ile yaralanarak Cumhuriyet Üniversitesi Tıp Fakültesi Hastanesi’ne başvuran adli olgular. CÜ. Tıp Fakültesi Dergisi 1993;15:221-4.

19. Türkiye İstatistik Kurumu (TÜİK) web sitesi, Trafik kaza istatistikleri, yıllara göre ölü ve yaralı sayılarının yaş gruplarına göre dağılımı. Ulaşım adresi: http://www.tuik. gov.tr/VeriBilgi.do?tb_id=52&ust_id=15 Ulaşım tarihi: 31 Temmuz 2010.

20. Franzén L, Ortenwall P, Backteman T. Major trauma with multiple injuries in Swedish children. Eur J Surg Suppl 2003;588:3-7.

21. de Tomás E, Navascués JA, Soleto J, Sánchez R, Romero R, García-Casillas MA, et al. Events related with injury severity in pediatric multiple trauma. [Article in Spanish] Cir Pediatr 2004;17:40-4. [Abstract] 22. Sözüer E M, Yıldırım C, Şenol V, Naçar M, Günay O. Trafik kazalarında risk faktörleri. Ulusal Travma ve Acil Cerrahi Dergisi 2000;6:237-40.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):248-252

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.26879

Türk acil tıbbının uluslararası literatüre katkısı: 15 yılın değerlendirilmesi Contribution of Turkish Emergency Medicine to the international literature: evaluation of 15 years Orhan ÇINAR,1 Mehmet DOKUR,2 Onur TEZEL,1 İbrahim ARZIMAN,1 Yahya Ayhan ACAR1

AMAÇ

BACKGROUND

Türk acil tıbbının kurulduğu günden bugüne uluslararası literatürde yayınlanmış bilimsel çalışmalarının genel karakteristik özelliklerini ortaya koymaktır.

The aim of this study was to present characteristics of internationally published articles originating from Turkish Emergency Medicine (EM) departments over the last 15 years.

GEREÇ VE YÖNTEM

METHODS

PubMed veritabanı, Türkiye’deki acil servislerden gönderilen ve 1995-2010 tarihleri arasında yayınlanan makaleleri tespit etmek amacıyla tarandı.

The PubMed database was searched for all articles published from 1995 to 2010 that originated from Turkish EM departments.

BULGULAR

RESULTS

Çalışmaya dahil edilen 514 makalenin %77’sinin (n=396) son 5 yılda yayınlandığı, artış oranının yılda 6,2 makale olduğu saptandı. Tüm makalelerin %58,7’lik (n=302) bir oranı acil tıp kategorisi dışındaki dergilerde yayınlanmıştır. Bu kategide en popüler dergi 27 makale ile Advances in Therapy olurken, acil tıp kategorisinde ilk sırayı 48 makale ile Ulusal Travma ve Acil Cerrahi Dergisi almıştır. En sık toksikoloji %26 (n=134) ve travma %16 (n=86) konularında makale gönderilmiştir. Tüm makalelerin %7,7’sinin (n=40) hayvan çalışması, %6’sının (n=31) randomize kontrollü çalışma olduğu saptanmıştır.

A total of 514 articles were included. Of all articles, 77% (n=396) were published in the last five years. Publications were detected to increase at a rate of 6.2 articles per year.

58.7% (n=302) of the articles were published in non-EM journals. Advances in Therapy in the non-EM group, with 27 articles, and the Turkish Journal of Trauma & Emergency Surgery in the EM group, with 48 articles, were the preferred journals. The most popular subjects were toxicology, at 26% (n=134), followed by trauma, at 16% (n=86). 7.7% (n=40) of all articles were animal studies and 6% (n=31) were randomized controlled trials.

SONUÇ

CONCLUSION

Türk acil tıbbındaki gelişmelere paralel olarak uluslararası bilimsel yayın üretimi de her geçen yıl katlanarak artmaktadır. Acil tıp kategorisi dışındaki dergilerin daha çok tercih edilmesi, toksikoloji konulu yayınların çokluğu, üniversite hastanelerinin katkısı dikkat çekicidir. Çok merkezli, randomize kontrollü ve etki faktörü yüksek dergilerde yayınlanan çalışmaların azlığı yayın sayısı kadar yayın kalitesi konusuna da önem verilmesi gerektiğini düşündürmektedir.

Significant publication growth was detected related with the development of EM in Turkey. The preference for nonEM journals, toxicology as the most popular subject and the effect of university hospitals were the interesting results of this study. The low number of multicenter, randomized controlled trials and of published articles in high impact factor journals have led us to consider the importance of publication quality, which requires additional effort.

Anahtar Sözcükler: Acil tıp; bilimsel yayın; Türkiye; uluslararası.

Key Words: Emergency medicine; scientific publication; Turkey; international.

Gülhane Askeri Tıp Akademisi, Acil Tıp Anabilim Dalı, Ankara; 2 Kilis Devlet Hastanesi, Kilis.

1

Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara; 2Kilis State Hospital, Kilis, Turkey.

1

İletişim (Correspondence): Dr. Orhan Çınar. GATA Acil Tıp Anabilim Dalı, Etlik 06018 Ankara, Turkey.

Tel: +90 - 312 - 304 30 20 e-posta (e-mail): orhancinar@yahoo.com

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Cilt - Vol. 17 Sayı - No. 3

Makalelerin yıllara göre dağılımı göz önüne alındığında yayın sayılarının düzenli logaritmik bir artış gösterdiği, özellikle son 5 yıl içinde önemli bir artış olduğu ve tüm yayınların %77’sinin (n=396) son 5 yılda yapıldığı saptanmıştır. Yayınların artış oranı yılda 6,2 makale olarak saptanmıştır (Şekil 1).

Makalelerin yayınlanması amacıyla acil tıp kategorisi dışındaki dergilerin %58,7’lik bir oranla daha sık tercih edildiği görülmüştür (302/212). Acil tıp dışı kategoride en sık tercih edilen dergi 27 makale ile Advances in Therapy olurken, bunu 16 makale ile Human & Experimental Toxicology, 12 makale ile Clinical Toxicology ve 11 makale ile Veterinary and Human Toxicology takip etmiştir (Tablo 1). Acil tıp kategorisinde ise en sık tercih edilen dergi 48 makale ile Ulusal Travma ve Acil Cerrahi Dergisi olurken, bunu 45 makale ile American Journal of Emergency Medicine, 38 makale ile European Journal of Emergency Medicine, 34 makale ile Emergency Medicine Journal ve 30 makale ile Journal of Emergency Medicine takip etmiştir (Tablo 2).

Makaleler konu olarak toksikoloji (%26, n=134), travma (%16, n=86), kardiyoloji (%7, n=41), genel cerrahi (%6, n=31), nöroloji (%4, n=21) şeklinde dağılım göstermiştir (Tablo 3). Araştırma tipine bakıldığında makalelerin %61’inin (n=317) orijinal araştır90 59

68

72

76

10

09

20

08

20

07

20

06

20

20

05

03

20

31

20

02

20

01

04

19

20

00

20

99

23 10 10

20

98

96

8

19

2

2

19

3

97

41

19

90 80 70 60 50 40 30 20 10 0

95

Makalelerin yayınlandığı yıllara göre dağılımı incelenmiş, yıllık artış oranları hesaplanmıştır. Dergiler; acil tıp dergileri ve acil tıp dışı dergiler olmak üzere iki gruba ayrılmıştır. Ayrım işleminde derginin Thompson Scientific Journal Citation Reports’ta acil tıp kategorisinde yer alıp almaması olması esas alınmıştır.[4] Makalelerin sıklıkla yayınlandığı acil tıp dergileri (Tablo 1) ve acil tıp dışı dergiler (Tablo 2), bu dergilerin 2009 yılı etki faktörleri ve toplam yayın sayıları belirlenmiştir. Makaleler konu olarak toksikoloji, travma, genel cerrahi, nöroloji gibi acil tıbbın ana başlıkları altında sınıflandırılmıştır. Araştırma metodolojisi olarak orijinal araştırma makalesi, derleme, olgu sunumu, editöre mektup olarak 4 ana başlık altında toplanmıştır. Bunun dışında araştırmalar içinde hayvan çalışmalarının, randomize kontrollü çalışmaların miktarları belirlenmiştir. Araştırmaya katılan merkez sayısı, ilk isim yazarın uzmanlık dalı, ortak çalışılan kli-

BULGULAR PubMed veritabanı taraması sonucunda “affiliation” kısmında Turkey ve Emergency ifadesi yer alan 585 makale bulunmuştur. Bunlardan konu itibariyle acil tıbbın ilgi alanına girmeyen 71 tanesi çalışma dışına çıkarılmıştır. Geriye kalan 514 makale çalışmaya dahil edilmiştir.

19

GEREÇ VE YÖNTEM Çalışmamız retrospektif gözlemsel bir çalışma olarak tasarlanmıştır. Uluslararası literatürde yayınlanmış Türkiye’deki acil servislerden gönderilmiş çalışmaların saptanabilmesi için PubMed veritabanındaki arama limitleri 01 Ocak 1995-30 Haziran 2010 tarihleri arasında 15 yıllık süreyi kapsayacak şekilde ayarlanmış, yazarın kurum ve adres bilgilerini içeren ‘affiliation’ kısmında Türkiye (Turkey) ve Acil (Emergency) bulunan makaleler değerlendirmeye alınmıştır. PubMed veritabanı tüm dünyada yaygın olarak kullanılması, 39 dilde 5400 seçilmiş medikal dergiden oluşan geniş kapsamı nedeniyle tercih edilmiştir.[3] Elde edilen veriler XML formatında dışa aktarılmış, MySQL veritabanına aktarılarak yeniden oluşturulmuştur. Bütün makalelerin tam metinlerine ulaşılmış, PubMed’ten elde edilen veriler arasında bulunmayan bilgiler buradan tamamlanmıştır. Elde edilen verilerin değerlendirmesini 2 araştırmacı bağımsız olarak yapmış verilerin gruplandırılmasında anlaşmazlık oluştuğu durumlarda 3. araştırmacının hakemliği ile karara bağlanmıştır.

Verilerin istatistiksel analizinde “SPSS for Windows 15.0” programı kullanılmıştır. Çalışma tüm popülasyonu kapsadığından tanımlayıcı istatistikler kullanılmıştır. Veriler ortalama, standart sapma ve yüzde olarak ifade edilmiştir.

19

Amacımız Türk acil tıbbının kurulduğu günden bugüne uluslararası literatürde yayınlanmış bilimsel çalışmalarının genel karakteristik özelliklerini ortaya koymak ve yapılacak araştırmalara yol göstermektir.

nik branşlar açısından da makaleler sınıflandırılmıştır. Araştırmanın yapıldığı kurum üniversite hastanesi, devlet hastanesi, eğitim araştırma hastanesi ve özel hastane olmak üzere 4 grup altında toplanmıştır.

Makale sayısı

Türkiye’de acil tıp henüz 17 yıllık bir geçmişe sahip olmasına rağmen çok hızlı bir gelişim göstermiştir.

Ayrı bir uzmanlık dalı olarak kabul edildiği 1993 yılından bu yana 46 üniversite hastanesi, 29 eğitim araştırma hastanesinde acil tıp uzmanlık eğitim programı oluşturulmuştur. Mevcut durumda 250’nin üzerinde acil tıp uzmanı yetişmiş, 300’ün üzerinde uzmanlık öğrencisi de eğitimlerine devam etmektedir.[1] Bu gelişim ile birlikte acil tıp alanında Türkiye’de yapılan bilimsel araştırmaların da arttığı bilinmesine rağmen bunların sayısı ve niteliği ile ilgili veriler sınırlıdır.[2]

Yıllar

Şekil 1. Makalelerin yayınlanma yıllarına göre dağılımı.

249

Ulus Travma Acil Cerrahi Derg

Tablo 1. Acil tıp dergi kategorisi dışındaki dergiler No Dergi adı 1. Advances in Therapy 2, Human & Experimental Toxicology 3. Clinical Toxicology (Philadelphia, PA) 4. Veterinary and Human Toxicology 5. Saudi Medical Journal 6. The Mount Sinai Journal of Medicine (New York) 7. International Journal of Clinical Practice 8. American Journal of Therapeutics 9. Bratislavske Lekarske Listy

Diğer Toplam

Makale sayısı

Etki Faktörü* 2009

27 16 12 11 11 11 10 6 5 204 302

0,936 1,307 1,460 0,66 0,51 1,295 2,245 – 0,317

* 2009 Journal Citiation Report.

Tablo 2. Acil tıp dergi kategorisinde listelenen dergiler (Thompson Scientific 2009) No Dergi adı 1. Ulusal Travma ve Acil Cerrahi Dergisi 2. American Journal of Emergency Medicine 3. European Journal of Emergency Medicine 4. Emergency Medicine Journal SCI 5. Journal of Emergency Medicine 6. Academic Emergency Medicine SCI 7. Annals of Emergency Medicine SCI 8. Injury-International Journal of the Care of the Injured 9. Pediatric Emergency Care 10. Journal of Emergency Nursing 11. Resuscitation SCI 12. Unfallchirurg Toplam

Makale sayısı

Etki Faktörü* 2009

48 45 38 34 30 4 3 3 3 2 1 1 212

0,274 1,542 0,733 1,477 0,778 2,478 4,232 2,383 0,916 0,359 2,712 0,592

* 2009 Journal Citiation Report.

ma makalesi, %35 (n=181) kadarının ise olgu sunumu, 11’inin derleme ve 5’inin editöre mektup olduğu saptanmıştır. Çalışmaların %7,7’sinin (n=40) hayvanlar üzerinde yapıldığı tespit edilmiştir. Çalışmaların %6’sının (n=31) randomize kontrollü, %14’ünün (n=75) ise retrospektif olduğu belirlenmiştir. Çok merkezli çalışmaların tüm çalışmaların %17’sini (n=92) oluşturduğu saptanmıştır.

ji 14 bu bölümleri takip etmişlerdir. Makalelerin 14’ü S.B. Eğitim ve Araştırma Hastaneleri, 10’u özel hastaneler ve 13’ü devlet hastaneleri acil servisinde çalışan hekimler tarafından gönderilmiştir. Kalan 477 (%92) makalenin tamamı ise üniversite hastanesinde görev yapan hekimlerce gönderilmiştir. Makalelerdeki yazar sayısı 1 ile 13 arasında değişmekle birlikte ortalama 5,09 olarak tespit edilmiştir.

En fazla birlikte çalışılan bölümler arasında genel cerrahi 28 ve kardiyoloji 26 çalışma ile ilk sırada yer almış, halk sağlığı 20, biyokimya 17, radyolo-

TARTIŞMA Türkiye’de acil tıbbın kuruluşundan bugüne kadar ki süre göz önüne alındığında uluslararası dergilerde yayınlanan bilimsel çalışmaların yıllar içinde düzenli logaritmik bir artış gösterdiği dikkati çekmektedir. Özellikle tüm yayınların %77’sinin (n=396) son 5 yıllık süreçte yapılmış olması, acil tıbbın gelişimin olgunlaşmaya başladığını düşündürmektedir. Acil tıp uzman ve asistan sayısındaki artışın yanında, pek çok acil servislerin kuruluş aşamalarını tamamlamış olmaları, bilimsel çalışmalar için ayrılan zamanında artmasına neden olarak bu sonuca katkı sağlamış olması muhtemeldir. Yanturalı ve arkadaşları[2] 1994-2004

Tablo 3. Makalelerin konulara göre dağılımı Konu başlığı

Miktar n (%)

Toksikoloji Travma Kardiyoloji Genel cerrahi Nöroloji

134 (%26) 86 (%16) 41 (%7) 31 (%6) 21 (%4)

250

May - Mayıs 2011

Türk acil tıbbının uluslararası literatüre katkısı

yılları ararında Türkiyedeki anabilim dallarından yapılan uluslararası yayınları değerlendirdikleri 84 makaleyi içeren çalışmalarında yıllar içindeki artışa ve son yıllardaki ivmelenmeye dikkati çekmişler ve önümüzdeki yıllarda yayın sayısında ciddi bir artışın olabileceği öngörüsünde bulunmuşlardır. Çalışmamız bu öngörünün gerçekleştiğini teyit etmektedir. Bunun yanında aynı ivmelenmenin devam ettiği ve önümüzdeki yakın gelecekte de bu artış trendinin bozulmayacağı söylenebilir.

Türkiye’de acil tıbbın bilimsel yayınlar konusundaki bu başarısının uluslararası platformdaki etkilerinden de bahsedilebilir. Wilson ve arkadaşları 19962005 yılları arasında dünyada yayınlanmış acil tıp makalelerinin karakteristiklerini araştırdıkları çalışmaları incelendiğinde Türkiye’nin yayın sayısında 9. sırada yer aldığı, yayınların yıllık artışında ise 7,2’lik oranla 5. sırada yer aldığı dikkati çekmektedir.[5] Türkiye’de son 5 yılda yayınlardaki ciddi artış dikkate alındığında, bu yılları içeren değerlendirmelerde daha üst sıralarda yer alınacağı öngörülebilir. Bu durum Türkiye acil tıbbının gelişiminin somut bir göstergesi olması açısından önemlidir.

Dergi seçiminde genel toplamda acil tıp dışı dergilerin %58,7 (n=302) gibi bir oranla daha fazla tercih edildiği dikkati çekmektedir. Bu durumun dünyada da %58,2 (n=212) gibi bir oranla benzer olduğu görülmektedir.[5] Bunun sebeplerini net bir şekilde ortaya koyabilmek eldeki verilerle mümkün değildir ancak acil tıbbın multidisipliner doğası gereği böyle bir dengenin oluşmasının olağan olduğu söylenebilir. Acil tıpta yapılan birçok çalışmanın başka bir disipline ait dergilerinde ilgi alanına girdiği dolayısıyla dergi seçiminde acil tıpçıların daha fazla seçim şansları olduğu bir gerçektir.

Dergi seçimiyle ilgili dikkat çekici bir diğer konu ise acil tıp dışı dergilerde yayınların pek çok dergiyi içeren dağınık bir dağılım göstermesi ve toksikoloji dergilerinin bu grupta ağırlıkta olmasıdır. Acil tıp dergilerinde ise yayınların 5 acil tıp dergisinde toplanmış olduğu dikkati çekmektedir. Ulusal Travma ve Acil Cerrahi Dergisi’nin bu grupta ilk sırada yer alması ulusal bir dergi olması, yayın dilinin Türkçeyi de içermesi ve SCI-E kapsamında yer alma başarısını göstermiş olması ile açıklanabilir. Acil tıp kategorisinde SCI-E kapsamında olan ve PubMed veritabanında dizinlenen ülkemizden bir derginin de bulunuyor olması sevindiricidir. Acil tıbbın gelişimi ve mevcut acil tıp dergilerinin ciddi duruşu dikkate alındığında yakın gelecekte bu kategoride ülkemizden daha fazla derginin yer alacağını öngörmekteyiz. Diğer taraftan SCI kapsamında bulunan, etki faktörü yüksek önemli acil tıp dergilerinden olan Annals of Emergency Medicine, Academic Emergency Medicine, Resuscitation ve Injury dergilerindeki yayın sayısının azlığı düşündüCilt - Vol. 17 Sayı - No. 3

rücüdür. Bu dergilerde makale yayınlatmanın zorluğu bir sebep olmakla birlikte, madalyonun diğer tarafında iyi dizayn edilmiş, yüksek kalitede bilimsel araştırmaların azlığı bulunuyor olabilir. Etki faktörü her ne kadar tartışmalara neden olsa da yayınlanan makalelerin metodolojik gücü ve atıf alma oranı ile güçlü korelasyonu bulunan önemli bir faktördür.[6,7] Bu nedenle etki faktörü yüksek dergilerle yayın kalitesi arasında ilişki kurmanın uygun olacağı düşünülmüştür.

TÜBİTAK-ULAKBİM tarafından 2009 yılında yayınlanan “1981-2007 Türkiye Bilimsel Yayın Göstergelerine” göre Türkiye 45 ülke arasında 26. sırada yer almıştır. Türkiye özellikle son yıllarda yayın sayısında aşama göstererek 45 ülke arasında toplam yıllık bilimsel yayın sayısı açısından 2007 yılında 19. 2008 yılında 18. sırada yer almıştır. Ancak yayın başına düşen atıf sayısı (etki değeri) açısından bir inceleme yapıldığında Türkiye’nin bu 27 yıllık süreçte 4,55 etki değeri ile 45 ülke arasında 42. sırada yer alabilmesi çok çarpıcı bir veridir. Aynı raporda acil tıp alanında 193 yayın yapıldığı bunlara atıf sayısının 329 olduğu, etki değerinin ise 1,70 olarak hesaplandığı görülmektedir.

Buna göre Türkiye acil tıp alanında yayın sayısı olarak 16. sırada yer alırken, etki değeri olarak 45 ülke arasında 42. sırada yer alabilmiştir.[8] Bu raporda ortaya konan yayın kalitesi sorununun sadece acil tıp ile ilişkili değil Türkiye’deki tüm bilim dallarının ortak sorunu olduğu, nedenlerinin ise başta bilimsel araştırmalara ayrılan kaynak sıkıntısı olmak üzere birçok faktörün içinde yer aldığı çok boyutlu bir problem olduğu değerlendirilmektedir.

Araştırma konusu olarak toksikoloji (%26), travma (%16) ve kardiyolojinin (%7) ilk 3 sırayı aldığı görülmektedir. Yanturalı ve arkadaşlarının[2] çalışmasında da bu üçlünün değişmediği fakat travmanın ilk sırada yer aldığı görülmektedir. Ülkemizden acil tıp ile ilgili yapılan her 4 bilimsel yayından birinin toksikoloji ile ilgili olması dikkat çekicidir. Bu vakaların ilk müracaat yerlerinin acil olması önemli bir etken olmasının yanında, ülkemizde sık karşılaşılması ve bazı acil tıpçıların bu konuyla özellikle ilgilenmesi bu konudaki yayınların sıklığını etkiliyor gibi görünmektedir.

Makalelerde olgu sunumlarının (%35) önemli bir yer tutması, havyan çalışmalarının (%7), randomize kontrollü çalışmaların (%6) ve çok merkezli çalışmaların (%14) miktarlarının düşük olması yayın sayısındaki artışın yanında yayın kalitesinde de önemli gelişmelere ihtiyaç olduğunu düşündürmektedir.

Makalelerin %92’sinin üniversite hastanelerinden gönderilmiş olması akademik kadroda yer alan acil tıp uzmanlarının kariyerleri için yayın konusunda çaba sarfetmeleri ve üniversitelerde araştırma olanaklarının daha fazla olması ile açıklanabilir. Akademik ünvanlar özellikle de doçentlik için sayısal olarak bir asgari ya251

Ulus Travma Acil Cerrahi Derg

yın zorunluluğunun bulunması yayın sayısını etkileyen önemli bir motivasyondur.

Araştırmamızın en önemli kısıtlılığı PubMed veritabanıyla sınırlandırılmış olması bu veritabanında yer almayan dergilerde yayınlanan araştırmaları kapsamamasıdır. Geniş bir veri tabanı olmasına rağmen bazı uluslararası dergilerin dolayısıyla buralarda yayınlanmış makalelerin çalışmanın kapsamı dışında kalmış olması önemli bir kısıtlılıktır. Yine acil tıp alanında yapılmış birçok ulusal dergilerde yayınlanmış önemli çalışma kapsam dışında kalmıştır. Buna rağmen Türkiye acil tıbbının dünya literatürüne katkısını ve bilimsel yayınların genel özelliklerini ortaya koymayı amaçladığımız bu çalışmada PubMed veri tabanından elde edilen sonuçların evrenin tamamını olmasa da önemli bir kısmını içerdiği dolayısıyla evrenin tamamı hakkında fikir edinmeye engel teşkil etmeyeceği düşünülmüştür.

Sonuç olarak, Türkiyede acil tıpdaki gelişmelere paralel olarak uluslararası bilimsel yayın üretimi de her geçen yıl katlanarak artmaktadır. Acil tıp kategorisi dışındaki dergilerin daha çok tercih edilmesi, toksikoloji konulu yayınların çokluğu, üniversite hastanelerinin katkısı dikkat çekicidir. Çok merkezli, randomize kontrollü ve etki faktörü yüksek dergilerde ya-

252

yınlanan çalışmaların azlığı yayın sayısı kadar yayın kalitesi konusuna da önem verilmesi gerektiğini düşündürmektedir.

KAYNAKLAR 1. Aksay E, Sahin H, Kiyan S, Ersel M. Current status of emergency residency training programs in Turkey: after 14 years of experience. Eur J Emerg Med 2009;16:4-10.

2. Yanturali S , Aksay E, Cevik AA. International Publications from Turkish Emergency Medicine Departments: analysis of first ten years. Turkish J Emerg Med 2004;4:170-3.

3. National Library of Medicine. Available at: http://www.nlm. nih.gov/pubs/factsheets/factsubj.html. [Accessed: Aug 18, 2010].

4. Thompson Scientific. Journal Citation Reports. Availableat: http://scientific.thomson.com/products/jcr/ [Accessed: Aug 18, 2010].

5. Wilson MP, Itagaki MW. Characteristics and trends of published emergency medicine research. Acad Emerg Med 2007;14:635-40.

6. Callaham M, Wears RL, Weber E. Journal prestige, publication bias, and other characteristics associated with citation of published studies in peer-reviewed journals. JAMA 2002;287:2847-50.

7. Patsopoulos NA, Analatos AA, Ioannidis JP. Relative citation impact of various study designs in the health sciences.

JAMA 2005;293:2362-6.

8. Tubitak-Ulakbim http://www.ulakbim.gov.tr/cabim/yayin/ tbyg_1981_2007/ektablo2.pdf. [Accessed: Aug 18, 2010].

May - Mayıs 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):253-260

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.54280

Long-term objective results of proximal phalanx fracture treatment Proksimal falanks kırığı tedavisinin geç dönem objektif sonuçları Derya ÖZÇELİK, Gaye TOPLU, Toygar ÜNVEREN, Fatma KAÇAĞAN, Cemal Tahsin Gökhür ŞENYUVA

BACKGROUND

AMAÇ

Proximal phalanx fractures are common. In this study, our preferred methods regarding the treatment of proximal phalanx fractures and their long-term objective results are presented.

Proksimal falanks kırıkları sık görülmektedir. Bu çalışmada proksimal falanks kırıklarının tedavisinde tercih ettiğimiz yöntemler ve geç dönem objektif sonuçları sunuldu.

METHODS

Ekim 2001 ve Mart 2010 tarihleri arasında Düzce Tıp Fakültesi Plastik Rekonstrüktif ve Estetik Cerrahi Bölümü’nde, 23 hastanın 32 proksimal falanks kırığı tedavi edildi. Stabil kırıklar (n=5) atel ile takip edilirken stabil olmayan kırıklar (n=27) açık redüksiyon sonrası 1,0 mm çaplı perkütan intramedüller Kirschner telleri ile tespit edildi.

Between October 2001 and March 2010, in the Plastic Reconstructive and Aesthetic Surgery Department of Düzce Medical Faculty, we treated 23 patients with 32 proximal phalanx fractures. Stable fractures (n=5) were treated with splints, while unstable fractures (n=27) were stabilized with 1.0 mm percutaneous intramedullary Kirschner wires following open reduction.

RESULTS

GEREÇ VE YÖNTEM

BULGULAR

At follow-ups, ranging from 3 months to 9 years, patients were evaluated with radiologic efficiency, range of motion (ROM), total active movements (TAM), and grip power of the digit. TAM scores of 20 fingers were perfect (≥220° for D2-5, ≥150° for D1), for 7 fingers were good (180220° for D2-5, 120-150° for D1), and for 5 fingers were either moderate or poor. No difference was observed between grip strength of broken fingers and that of healthy fingers. As a major complication, non-union occurred in one finger.

Üç ay ile 9 yıl arasında değişen takiplerde, hastalar redüksiyonun radyolojik yeterliliği, parmağın eklem hareket aralığı (EHA), parmağın total aktif hareketi (TAH) ve parmağın kavrama gücü açısından değerlendirildi. Hastaların 20’sinde redüksiyonun iyi sağlandığı gözlendi. TAH skoru, 20 parmakta mükemmel (D2-5 için ≥220°, D1 için ≥150°), 7 parmakta iyi (D2-5 için 180-220°, D1 için 120-150°) ve 5 parmakta orta veya kötüydü. Kırık parmakların kavrama gücü sağlam parmaklarla karşılaştırıldığında fark olmadığı gözlendi. Majör komplikasyon olarak 1 proksimal falanksta non-union gözlendi.

CONCLUSION

SONUÇ

We concluded that Kirschner wire fixation is a reliable and simple method of treating unstable proximal phalangeal fractures, and excellent long-term results can be obtained in suitable cases. In stable proximal phalanx fractures, splints provide sufficient treatment.

Sonuç olarak, Kirschner teli ile tespit yöntemi anstabil kırıkların tedavisinde güvenilir ve teknik açıdan basit bir yöntemdir. Uygun olgularda çok iyi geç dönem sonuçları elde edilmektedir. Stabil proksimal falanks kırıklarında ise alçı atel ile tespit yeterli tedaviyi sağlamaktadır.

Key Words: Fracture; hand; Kirschner wire; proximal phalanx.

Anahtar Sözcükler: Kırık; el; Kirschner teli; proksimal falanks.

Department of Plastic, Reconstructive and Aesthetic Surgery, Düzce University Faculty of Medicine, Düzce, Turkey.

Düzce Üniversitesi Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Düzce.

Correspondence (İletişim): Derya Özçelik, M.D. Düzce Üniversitesi Tıp Fakültesi Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Konuralp, Düzce, Turkey.

Tel: +90 - 380 - 541 41 07 e-mail (e-posta): deryaozcelik68@yahoo.com

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The most common fractures in the skeleton occur in the small tubular bones of the hands and feet.[1] Of these, fractures of the phalanges are seen most frequently.[1] Distal phalanx fractures are the most common among phalangeal fractures, followed by proximal phalanx (PP) fractures.[1,2] Fractures of the PP are twice as common as fractures of the middle phalanx.[1] Between October 2001- March 2010, 69 patients with 88 hand fractures (distal phalanx, middle phalanx, PP and metacarpal fractures) were treated in our clinic. The distribution of the fractures was as follows: 21 distal phalanx, 21 middle phalanx, 32 PP, and 14 metacarpal fractures. Although metacarpal and phalanx fractures are common, the literature on this subject is lacking. We designed this prospective study to evaluate the treatments and long-term results of PP fractures, which is the most common hand fracture seen in our clinic.

To diagnose PP fractures effectively, the mechanism and the force of the trauma should be queried in the initial examination. In the examination, after careful inspection, identification of the most painful area should be done by palpation. Additionally, active and passive ranges of motion (ROM) of the joints, existence of a possible capsule and ligament instability and associated tendon, neurovascular and soft tissue injuries should be searched. The stability of the joint can be assessed with the stress test performed while the finger is in flexion and extension. In X-ray examination, three views are essential: anteroposterior, lateral and 45° oblique. Articular fractures are often not seen without the oblique views.[1,3,4] Anatomically, PP fractures can be divided into four categories, including condyle, neck, shaft, and base.

Other parameters important for PP fractures are: 1. Displacement of the fracture 2. Stability of the fracture 3. Involvement of the joints 4. Type of the fracture, such as oblique, spiral, transverse or comminuted 5. Associated soft tissue injury (tendon, nerve, artery, skin…)

Stable and nondisplaced PP fractures can be effectively managed by protective splinting and early controlled mobilization. Although three weeks of immobilization is accepted as safe,[3] each patient and fracture type has its own characteristics. Each fracture, therefore, should be assessed individually.

Unstable and nondisplaced PP fractures should be managed with fixation. PP fractures may angulate volarly or dorsally due to localization of the fracture and interactions with the tendons and interosseous and lumbrical muscles. Angulated fractures are considered as unstable and require open reduction and fixation.

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Nondisplaced intraarticular PP fractures are highly unstable and susceptible to displacement. Those fractures are occasionally misdiagnosed as sprain, and early mobilization may cause their displacement.

Bicondylar fractures are almost always multiple fractures and require open reduction as with unicondylar fracture treatment. Multiple fractures in proximal interphalangeal (PIP) joints are known as pilon fractures.[3] If open reduction and fixation is not possible in such multiple fracture cases, traction-closed reduction or dynamic external fixation devices can be options.

Restoration of movement is usually unpredictable in such cases. Primary arthrodesis or osteosynthesis applications may cause unexpected results, such as excessive shortening of the finger. Since arthrodesis is already possible as a secondary procedure, restoration of the primary structure should be preferential. Dynamic external fixation devices are hinged and span the PIP joint to allow early protected ROM while maintaining reduction of the joint.[3] There is a consensus about treating displaced PP fractures with open reduction and internal fixation.

Present lacerations secondary to injury can be used for access to the fracture line. Dorsal incision is usually preferred when the fracture is not adequately exposed.

The fracture line is exposed without damaging the connections of the central slip of the extensor tendon.

Ligamentous and soft tissue attachments of the fracture fragments should be preserved, if possible. Fracture lines are fixated with one or multiple Kirschner wires (K-wire) or screws. Generally, 1 mm or 1.2 mm K-wires will serve. Sometimes K-wires and screws can be used together. When placing the splint, the PIP joints are held in nearly full extension to prevent the collateral ligament and volar plate contracture that occurs in flexion. Other soft tissue injuries are repaired after fixation of the fracture. The K-wire is removed 3-6 weeks postoperatively and the mobilization starts under the observation of a physiotherapist.

In this article, we present our choice of treatments and the long-term objective results of our patients with PP fractures.

MATERIALS AND METHODS Between October 2001 and March 2010, in the Plastic Reconstructive and Aesthetic Surgery Department of Düzce Medical Faculty, we treated 23 consecutive patients with 32 PP fractures. Here, the treatment choices and results are presented.

Seventeen male and 6 female patients were included. The ages of the patients ranged from 5 to 78 years (mean: 41). Two patients were under the age of 16 (5 and 8 years old); the other 21 patients were over 16 years.

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Long-term objective results of proximal phalanx fracture treatment A

B

(a)

C

Fig. 1. (a) Unstable, displaced proximal phalanx shaft fracture extending to the IP joint with dislocation of the IP joint in the left hand 1st finger. Fracture was treated with a transverse K-wire. Extensor pollicis longus tendon injury was also repaired. A-B: Preoperative anteroposterior and lateral X-ray views. C-D-E-F: Postoperative anteroposterior, lateral and oblique X-ray views.

(b)

(b) Functional results of the patient with unstable, displaced proximal phalanx shaft fracture extending to the IP joint with dislocation of the IP joint in the left hand 1st finger. A-B: No flexion or extension deficit was observed in the postoperative 2nd year. C: Dorsal view.

Regarding the etiology, work-related accidents (56%) were the most common cause, followed by home accidents (21%). Six patients (26%) suffered from right hand injury and 17 patients (74%) from left hand injury.

The first and second fingers were the most commonly injured. Of 32 fractures, seven were observed at the first finger and seven at the second finger; the rest of the fractures were distributed among the other fingers.

Ten (31%) of the 32 fractures were intraarticular and 22 (69%) were extraarticular. One patient had a fracture line extending between the PIP and metacarpophalangeal (MCP) joints.

Eleven patients had associated metacarpal or middle or distal phalangeal fractures. The most common fracture associated with PP fractures was distal phalanx fracture (4 distal phalanx fractures accompanied 32 PP fractures) (13%). Metacarpal fracture was the second most common fracture associated with PP fractures (3 metacarpal fractures accompanied 32 PP fractures).

The most common soft tissue injury associated with PP fractures was extensor tendon injury (15 extensor tendon injuries in 32 PP fractures) (34%) (Fig. 1a-b).

Other soft tissue injuries associated with PP fractures were flexor tendon, digital artery and digital nerve inCilt - Vol. 17 Say覺 - No. 3

juries, and skin defects, which require reconstruction with a flap or a graft. The extent of comminution of PP fractures did not preclude the use of K-wires in any of the patients in this study.

Eight patients were operated under general anesthesia and 15 under digital or axillary block. Twentyseven of 32 fractures were unstable and treated with open reduction, K-wire fixation and splinting. Five of the 32 fractures were treated with closed reduction and splint application.

Fixations were achieved with 1 mm percutaneous intramedullary K-wires. Two K-wires were used for fixation when one K-wire did not provide enough stability (Fig. 2a-b). When possible, the proximal and distal interphalangeal (DIP) joints were held in nearly full extension during the fixation to prevent the collateral ligament and volar plate contracture. A splint was used for all patients and elevation was recommended.

Postoperatively, follow-up radiographs were taken immediately to verify adequate reduction. If there was a suspicion of inadequate reduction during the operation, intraoperative scopy was used. Usually, empiric oral sulbactam-ampicillin treatment was administered postoperatively.

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(b) Fig. 2 (a) Unstable, displaced oblique proximal phalanx shaft fracture extending to the MCP joint in the right hand 3rd finger was treated with 2 oblique K-wires. Excellent bone healing was observed in the postoperative 8th year. A: Preoperative X-ray views. B: Early postoperative X-ray views. C-D: Late postoperative X-ray views. (b) Functional results of the patient with unstable, displaced proximal phalanx shaft fracture extending to the MCP joint in the right hand 3rd finger in the postoperative 8th year. A-B: ROM of the fractured finger showed no difference from healthy fingers. C: The grip strength of the broken finger was compared with that of healthy fingers and no difference was observed. D: No extension deficit was observed in the postoperative 8th year.

(a)

Since joint stiffness occurs after a three-week immobilization period, K-wires are removed at the end of the 3rd week.[3] Radiographs are also used for evaluation of bone healing in the postoperative 3rd week.

The removal of the K-wire is delayed if adequate bone healing is not observed in the follow-up radiographs.

In our series, K-wires were removed between 4-6 weeks. Then, Coban® bandage was applied to the fingers to control edema. Physiotherapy was started just after the removal of the K-wires.

In the long-term evaluations, the following parameters were considered: 1. Total active movement (TAM); 2. PIP or IP joint and MCP joint ROM; 3. The function of the hand and the injured finger (grip strength).

Table 1. Grading for range of motion results

Perfect Good Moderate Poor Total 256

MCP

PIP

IP

60-85° 90-110° 60-90° 40-60° 60-90° 40-60° 20-40° 30-60° 20-40° 0-20° 0-30° 0-20°

MCP PIP IP 29 1 0 2 32

15 5 1 4 25

7 0 0 0 7

1. Total active movement: TAM can be calculated by sum of the angles formed by MCP, PIP and DIP joints in maximum active flexion, minus total extension deficit at the MCP, PIP and DIP joints during active finger extension. In a normal finger flexion, the MCP joint can flex up to 85°, PIP joint can flex up to 110° and the DIP joint can flex up to 65°. If the finger is capable of full extension, the loss of extension is calculated as 0°. As a result, TAM is measured as 260° (260°-0°: 260°).

In a normal first finger, the MCP joint can flex up to 85° and the IP joint can flex up to 90°, and as a result, TAM is measured as 175°.

2. In all 32 fingers, for two adjacent joints including MCP and/or PIP-IP, ROM values were measured. We designed a grading system for ROM of the PIP joint as: 0-30° poor, 30-60° moderate, 60-90° good, and 90110° perfect. The grading system for the ROM of the IP joint of the first finger was: 0-20° poor, 20-40° moderate, 40-60° good, and 60-90° perfect (Table 1).

3. In the grading system for ROM of the MCP joint of all fingers, we considered 0-20° as poor, 20-40° as moderate, 40-60° as good, and 60-85° as perfect (Table 1).

4. In the long-term follow-ups, the grip strength of the broken fingers was compared with that of healthy fingers.

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Table 2. Mean total active movement values in all proximal phalanx fractures (n: 32)

TAM

Normal value

D1 (n=7) D2-3-4-5 (n=25)

156° 205.5°

175° 260°

Table 3. Grading of total active movement results

Perfect Good Moderate Poor Total

D1 grading D2-3-4-5 grading Phalanx values values number 150-175° 120-150° 90-120° 0-90°

220-260° 180-220° 150-180° 0-150°

20 7 1 4 32

MCP

PIP

IP

74° 71° 72° 85°

– 87° – 110°

82.5° – – 90°

D1 (n=7) D2-3-4-5 (n=25) D1-2-3-4-5 (n=32) Normal

Table 5. Mean range of motion values for intraarticular proximal phalanx fractures (n: 10)

D1 (n=5) D2-3-4-5 (n=5) D1-2-3-4-5 (n=10) Normal

MCP

PIP

IP

62.5° (n=2) – 75° (n=3) 77° (n=3) 70° (n=3*) – 71° (n=5) 70° (n=3*) 75° (n=3) 85° 110° 90°

* One patient had a fracture line extending between the proximal interphalangeal and metacarpophalangeal joints, which was counted twice.

Table 6. Mean range of motion values for extraarticular proximal phalanx fractures (n: 22)

D1 D2-3-4-5 D1-2-3-4-5 Normal

MCP

PIP

IP

77.5° (n=5) – 87.5° (n=4) 70.5° (n=22) 90° (n=22) – 71° (n=27) – – 85° 110° 90°

RESULTS Follow-up periods of patients ranged from 3 months to 9 years. In the follow-ups, we evaluated radiological efficiency of reduction, TAM of the finger, ROM of the joints, and the grip strength of the finger.

Immediately after the surgery, radiological efficiency of reduction was determined. When inadequate or poor reduction was present, reduction and fixation were repeated.

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Except for one patient with associated radius-ulna fractures, all patients were discharged from the hospital on the same day of the operation. After bone healing was completed, K-wires were removed in an outpatient setting and controlled mobilization started immediately. No infection was observed in any of the cases.

1- Total active movement (TAM) measurements: a) The mean TAM score of 25 PP fractures in the 2nd, 3rd, 4th, and 5th fingers was 205.5° (Normal: 260°) (Table 2). b) The mean TAM score of 7 PP fractures in the 1st finger was 156° (Normal: 175°) (Table 2).

Table 4. Mean range of motion values for all proximal phalanx fractures (n: 32)

The mean time for radiological bone healing was 6 weeks (4 - 8 weeks). The mean time for complete bone union in fracture lines was approximately 4 months.

The TAM scores of 32 PP fractures were calculated, and it was observed that 20 fingers (63%) had perfect, 7 fingers (22%) good, 1 finger (3%) moderate and 4 fingers (12%) poor results (Table 3).

2- ROM value of PIP (or IP) and MCP joints: a) ROM of MCP joint (Normal: 85° for all fingers) (n=32) Mean ROM for MCP joints in 32 fingers was 72° (Mean ROM for MCP joints with PP fractures of 1st finger was 74%, mean ROM for MCP joints with PP fractures of other fingers was 71%) (Table 4).

Intraarticular PP fractures extending into the MCP joint was observed in 5 out of 32 fingers (Table 5).

Two of these 5 fractures were in the 1st finger and 3 of them were in other fingers. Mean ROM for 2 MCP joint intraarticular PP fractures of the 1st finger was 62.5°. Mean ROM for 3 MCP joint intraarticular PP fractures of other fingers was 77°. Mean ROM of these 5 fingers was 71° (Table 5).

Mean ROM of 27 MCP joint extraarticular PP fractures of all fingers was also 71°. b) ROM of PIP joint (Normal: 110° for 2nd, 3rd, 4th and 5th fingers) (n=25) Mean ROM for PIP joints in 25 fingers was 87° (Table 4).

Three intraarticular PP fractures extending into the PIP joint was observed in 25 fingers. Mean ROM for PIP joints in these 3 fractures was 70° (Table 5).

Mean ROM for PIP joints in extraarticular fractures (n=22) was 90° (Table 6). c) ROM for IP joint (Normal: 90°- for 1st finger) (n=7) Mean ROM for IP joints in 7 fingers was 82.5° (Table 4).

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Mean ROM for 3 intraarticular PP fractures extending into the IP joint was 75° (Table 5). Mean ROM for IP joints in 4 extraarticular fractures was 87.5° (Table 6).

ROMs of 29 fingers (91%) for MCP joint, 15 fingers (47%) for PIP joint and 7 fingers (100%) for IP joint were calculated as perfect (Table 1).

3. Function of the hand and the injured finger (grip strength): In long-term follow-ups, the grip strength of the broken fingers was compared with that of healthy fingers and no difference was observed.

In our study, nonunion occurred in 1 patient. Bone ends were debrided again, and fixation was re-achieved with K-wire. Complete bone healing was achieved in the follow-up. Angulations occurred in 2 patients but did not interfere with the normal function of the finger.

There was no pain on fracture lines. Arthrodesis was applied in 2 patients having intraarticular PP fractures extending into the PIP joint. Cases with arthrodesis were excluded from the average ROM calculation.

All patients were satisfied with the results.

DISCUSSION In our cases, we observed that PP fractures are the commonest among the phalanx and metacarpal fractures. This can be explained by the type of injury, which was mostly open unstable fracture complicated with soft tissue injury such as tendon, nerve or artery injury or skin loss. This is likely why patients were referred to our University Hospital. The simpler cases

are probably treated in local centers successfully.

Treatment of PP fractures is based on the presentation of the fracture, degree of displacement and difficulty in maintaining fracture reduction. A wide array of treatment options exists for the variation in fracture patterns observed. Inherently stable fractures do not require surgical treatment; all other fractures should be considered for additional stabilization. In general, many combinations of internal fixation are possible; K-wires and screw-and-plate fixation predominate.

Plate fixation is used in comminuted PP and lag screws in spiral long oblique phalanx shaft fractures.[5] Although successful results were reported regarding screw-and-plate fixation in different studies,[6] we use screw-and-plate fixation in metacarpal fractures in a limited number. We observed that the plate and screw present some disadvantages such as the requirement of extensive dissection over the phalanx or metacarpal, formation of a large bulk under the tendon and the possibility of inadequate stabilization using microplates. Additionally, in some cases, we observed extrusion of the screws (Fig. 3). Kurzen et al.[6] assessed the complications after plate fixation of 64 phalangeal fractures in 54 consecutive patients and their outcome.

Among the complications, stiffness (TAM <180°) contributed the highest number (22 patients, 24 fractures).

In spite of early mobilization, stiffness is the most frequent complication after open reduction and plate fixation of phalangeal fractures. The authors thought that the undue amount of scarring and adhesion may arise from the implant itself or the difficulty in finding the perfect mixture between the minimal surgical

Fig. 3. Traumatic absence of the first metacarpal bone was reconstructed with the radial osteocutaneous pedicled flap and fixation was provided with the plate-screw. Postoperatively, extrusion of the screws was observed.

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invasiveness and a sufficient restoration of skeletal stability. Otherwise, they found that plate fixation of unstable and complex phalangeal fractures provided efficient and reliable results.

Al-Qattan et al.[7] reported 78 male workers with displaced unstable transverse fractures of the PP shaft.

They divided the patients into two groups according to the treatment applied. Group 1 (n=40) was treated with closed reduction and percutaneous K-wires, and Group 2 (n=38) was treated with open reduction and interosseous loop wire fixation. At the final follow-up, Group 2 had significantly better overall TAM scores than Group 1 (p=0.03). The complication rate was higher in Group 1 than Group 2 (28% versus 11%), but the difference did not reach statistical significance (p=0.084).

Sorene et al.[8] reported a retrospective study of the non-operative treatment of displaced avulsion fractures of the ulnar base of the PP of the thumb. The study included 28 thumbs that were stable to lateral stress testing at the time of the initial investigation. The patients were treated by immobilization of the thumb in a spica cast. The mean follow-up interval was 2.5 years. Twenty-six patients (93%) reported no pain on movement of the thumb. Grip and pinch strengths did not differ significantly on the injured and non-injured

(a)

sides. No thumbs showed instability on stress testing.

Non-operative treatment is recommended in cases of displaced or rotated avulsion fractures provided that there is no lateral instability of the MCP joint. They stressed that patients with unstable thumbs should always be treated surgically.

Horton et al.[9] randomly divided patients with an isolated spiral or long oblique fracture of the PP into two groups. One group was treated by closed reduction and K-wire fixation and the second by open reduction and lag screw fixation. An independent observer assessed function, pain, movement, grip strength, and intrinsic muscle function. Thirty-two patients were entered into the study, and 15 in the K-wire and 13 in the lag screw group were reviewed at a mean follow-up of 40 months. There was no significant difference in the functional recovery rates or in the pain scores for the two groups. X-rays showed similar rates of malunion, and there were no statistically significant differences in ROM or grip strength.

Elmaraghy et al.[10] presented a retrospective review of 35 digits in 24 patients with unstable fractures of the PP treated using the technique of percutaneous transmetacarpal intramedullary K-wire fixation.

Outcome measures, including radiological adequacy

(b)

Fig. 4. (a) A comminuted T-fracture of the base and the shaft of the proximal phalanx extending to the MCP joint in the left hand 4th finger; unstable displaced extraarticular proximal phalanx shaft fracture in the 5th finger; and unstable displaced middle phalanx shaft fracture extending to the DIP joint in the 3rd finger. Fractures were treated with K-wires. A second K-wire could be used for further reduction and fixation of the T-fracture of the 4th finger, but its comminuted nature was found to be unsuitable for additional K-wire placement. Good bone healing was observed in the postoperative 2nd year.

A-B: Preoperative anteroposterior and oblique X-ray views. C: Early postoperative anteroposterior X-ray view. D: Late postoperative anteroposterior and oblique X-ray views.

(b) Functional results of the patient with unstable displaced proximal phalanx shaft and base fractures extending to the MCP joint in the left hand 4th finger; unstable displaced extraarticular proximal phalanx shaft fracture in the 5th finger; and unstable displaced middle phalanx shaft fracture extending to the DIP joint in the 3rd finger in the postoperative 2nd year. A: Minimal angulation at the 5th finger was observed in the dorsal view with no functional impairment. B: No extension deficit was observed. C-D: ROM and TAM evaluations were excellent (TAMs of 4th and 5th fingers were 260簞).

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of reduction, total active ROM, development of joint contracture, grip strength, and digital grip strength, were assessed. Good or excellent results were obtained in 76% of fractures (19 of 25). They concluded that transmetacarpal K-wire fixation is a technically simple method of treating unstable PP fractures, and good or excellent results can be obtained in the majority of appropriately selected patients. Similar successful results were reported in different studies as well.[11-13] The data (Tables 1-6) in our study also verified successful usage of K-wire in PP fracture management.

In our cases, we used splint only when the fracture line was stable. In case of unstable fractures, we definitely used K-wire. By following this basic principle, we did not notice any displacement following mobilization in 32 PP fractures. Of 32 fingers, late-term TAM scores were evaluated, and 20 fingers were graded as perfect and 7 fingers as good (Table 3). In long-term follow-ups, the grip strength of the broken finger was compared with that of healthy fingers, and no difference was observed. Results were accepted as successful.

Stanton et al.[2] analyzed 423 hand fractures (metacarpal and phalanx) using X-rays, and demonstrated that 363 of them were extraarticular and 70 were intraarticular fractures. This distribution is similar to that of our cases, which included 22 (69%) extraarticular and 10 (31%) intraarticular fractures (Table 5).

In our series, mean ROM values of the PIP joint (90°) and IP joint (87.5°) extraarticular fractures were found higher than that of PIP joint (70°) and IP joint (75°) intraarticular fractures, as expected. Mean ROM value of the MCP joint (71°) in extraarticular fractures, however, was the same as that of MCP joint (71°) intraarticular fractures.

ROMs of 29 fingers (91%) for MCP joint, 15 fingers (47%) for PIP joint and 7 fingers (100%) for IP joint were calculated as perfect (Table 1). In other words, the poorest outcome was observed in the PIP joint.

There is a common consensus among many authors that radiographic healing is not correlated well with clinical healing.[1] The average time for clinical union was 5-7 weeks for the middle portion of the PP and up to 10-14 weeks for transverse fractures of the exceedingly hard cortical portion of the middle phalanx.[14] Complete bone healing generally takes about 5 months. Clinical healing, however, occurs in onefourth of this period. In our series, clinical healing occurred between 4-6 weeks.

Among the complications such as malunion, nonunion, loss of movement (tendon adhesion, capsule contraction, crush injury), infection, or tendon rupture, we observed 1 non-union in 32 PP cases. No infection or other complications were observed.

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In late-term follow-ups, we did not observe significant angulation or rotation interfering with the function of the finger (Fig. 4a-b). The low complication rate was thought to be related with the sufficient debridement intraoperatively, good reduction of the fragments, stable fixation, close follow-up, and early mobilization of the finger.

We concluded that Kirschner wire fixation is a reliable and technically simple method for treating unstable PP fractures, and results in long-term good or excellent results in appropriately selected patients.

In stable PP fractures, it was observed that cast splint provides adequate treatment.

REFERENCES

1. Dick HM, Carlson EC. Fractures of the fingers and thumb. In: Smith JW, Aston SJ, editors. Grabb and Smith’s plastic surgery. Boston: Little, Brown and Company; 1991. p. 909-16.

2. Stanton JS, Dias JJ, Burke FD. Fractures of the tubular bones of the hand. J Hand Surg Eur Vol 2007;32:626-36.

3. Stern PJ. Fractures of the metacarpals and phalanges. In: Green DP, Hotchkiss RN, Pederson WC, editors. Green’s operative hand surgery. New York: Churchill Livingstone; 1993. p. 711-71.

4. Koman LA, Coonrad R, Poehling GG. Sprains and dislocations of the fingers and thumb. In: Smith JW, Aston SJ, editors. Grabb and Smith’s Plastic Surgery. Boston: Little, Brown and Company; 1991. p. 889-907.

5. Henry MH. Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization. J Am Acad Orthop Surg 2008;16:586-95.

6. Kurzen P, Fusetti C, Bonaccio M, Nagy L. Complications after plate fixation of phalangeal fractures. J Trauma 2006;60:841-3.

7. Al-Qattan MM. Closed reduction and percutaneous K-wires versus open reduction and interosseous loop wires for displaced unstable transverse fractures of the shaft of the proximal phalanx of the fingers in industrial workers. J Hand Surg Eur Vol 2008;33:552-6.

8. Sorene ED, Goodwin DR. Non-operative treatment of displaced avulsion fractures of the ulnar base of the proximal phalanx of the thumb. Scand J Plast Reconstr Surg Hand Surg 2003;37:225-7.

9. Horton TC, Hatton M, Davis TR. A prospective randomized controlled study of fixation of long oblique and spiral shaft fractures of the proximal phalanx: closed reduction and percutaneous Kirschner wiring versus open reduction and lag screw fixation. J Hand Surg Br 2003;28:5-9.

10. Elmaraghy MW, Elmaraghy AW, Richards RS, Chinchalkar SJ, Turner R, Roth JH. Transmetacarpal intramedullary Kwire fixation of proximal phalangeal fractures. Ann Plast Surg 1998;41:125-30.

11. Liew KH, Chan BK, Low CO. Metacarpal and proximal phalangeal fractures-fixation with multiple intramedullary Kirschner wires. Hand Surg 2000;5:125-30.

12. Newington DP, Davis TR, Barton NJ. The treatment of dorsal fracture-dislocation of the proximal interphalangeal joint by closed reduction and Kirschner wire fixation: a 16-year follow up. J Hand Surg Br 2001;26:537-40.

13. Hornbach EE, Cohen MS. Closed reduction and percutaneous pinning of fractures of the proximal phalanx. J Hand Surg Br 2001;26:45-9.

14. Moberg E. The use of traction treatment for fractures of phalanges and metacarpals. Acta Chir Scand 1949;99:341-52.

May - Mayıs 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):261-266

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2011.19052

Long-term outcome and quality of life of patients with unstable pelvic fractures treated by closed reduction and percutaneous fixation Kapalı redüksiyon ve perkütan vidalama ile tespit edilmiş anstabil pelvis kırıklı hastalarda yaşam kalitesinin ve uzun dönem sonuçların değerlendirilmesi Mehmet AYVAZ,1Ömür ÇAĞLAR,1 Güney YILMAZ,1 Gizem İrem GÜVENDİK,2 Rıfat Emre ACAROĞLU1 BACKGROUND

AMAÇ

Treatment of unstable pelvic fractures has evolved recently, and percutaneous treatment has become the choice of treatment in most cases. The aim of this study was to evaluate the outcome of percutaneous treatment in patients with unstable pelvic fractures.

Kapalı redüksiyon ve perkütan vidalama ile tespiti son zamanlarda pelvis kırıklı hastaların çoğunda tedavi seçeneği olmuştur. Bu çalışmanın amacı, anstabil pelvis kırıklı hastalarda uygulanan perkütan tedavinin uzun dönem sonuçlarının ve hastaların yaşam kalitesinin değerlendirilmesidir.

METHODS

Twenty patients (11 females, 9 males; mean age, 32 years, range, 11-66 years) who had unstable pelvic fractures and were treated percutaneously were enrolled in the study.

Short Form-36 (SF-36) scores, Majeed scores, Iowa Pelvic Scores, and Pelvic Outcome Scores were determined for the outcome assessment.

GEREÇ VE YÖNTEM

RESULTS

BULGULAR

The minimum duration of follow-up was 2 years, (range, 24-48 months). The mean Injury Severity Score (ISS) was 31 (range, 16-50). The average SF-36 scores were comparable with the general population in terms of bodily pain, general health and social function. The mean Majeed functional pelvic score was 93.3 (range, 72-100; 19 excellent and 1 good clinical grades) and the mean Iowa Pelvic Score was 86 (range, 82-90). The mean Pelvic Outcome Score was 33 (range, 24-37; maximum score, 40).

En kısa takip süresi 2 yıl (dağılım 2-4 yıl) idi. Ortalama yaralanma şiddet skoru 31 (dağılım 16-50) olarak bulundu. Ortalama KF-36 skorları vücut ağrısı, genel sağlık ve sosyal fonksiyonlarda normal toplum değerleri ile benzer bulundu. Ortalama Majeed skoru 93.3 (dağılım 72-100; 19 mükemmel ve 1 iyi klinik sonuç) ve ortalama Iowa pelvik skoru 86 (dağılım 82-90) olarak bulundu. Ortalama pelvik sonuç değerlendirme skoru ise 33 (dağılım 24-37; en yüksek olası skor, 40) idi.

CONCLUSION

SONUÇ

We have demonstrated better outcomes in patients with pelvic fractures treated with percutaneous fixation. The technique may be advantageous as it avoids the use of extensive approaches, bleeding, wound complications, and prolonged surgeries.

Pelvis kırıklarında perkütan tedavi yöntemi ile iyi sonuçlar elde etmek mümkündür. Geniş cerrahi yaklaşımların önlenmesi, kanamanın, yara problemlerinin az olması ve uzun süreli cerrahilerden kaçınılması tekniğin avantajlarıdır.

Key Words: Pelvic fracture; percutaneous treatment; outcome.

Anahtar Sözcükler: Pelvis kırıkları; perkütan tedavi; sonuç.

Department of Orthopedics and Traumatology, Hacettepe University Faculty of Medicine, Ankara; 2 Hacettepe University, School of Physiotheraphy, Ankara, Turkey.

1

Ortalama yaşı 32 (dağılım 11-66 yaş) olan 20 hasta (11 kadın, 9 erkek) çalışmaya dahil edildi. Sonuçların ve yaşam kalitesinin değerlendirilmesi macıyla Kısa Form-36 (KF36) anketi, Majeed skorlaması, Iowa pelvik skorlaması ve pelvik sonuç değerlendirme skorlaması kullanıldı.

1 Hacettepe Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara; 2 Hacettepe Üniversitesi Fizyoterapi Okulu, Ankara.

Correspondence (İletişim): Mehmet Ayvaz, M.D. Hacettepe Hastaneleri Z Katı Ortopedi Anabilim Dalı, Sıhhiye, 06100 Ankara, Turkey.

Tel: +90 - 312 - 305 12 09 e-mail (e-posta): mehmetayvaz@gmail.com

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Despite the fact that unstable pelvic fractures are the most serious orthopedic injury, controversy exists regarding the recommended treatment and outcome.

[1-12] The outcome of these fractures is dependent on anatomic reduction and stabilization. Early anatomic reduction and stable fixation of the unstable pelvis have been shown to diminish pain, allow early mobilization and improve patient outcome.[1-5] Open reduction and internal fixation of pelvic ring disruptions were routinely delayed to avoid entering the pelvic hematoma and thereby causing additional hemorrhage. The techniques of closed reduction and percutaneous pelvic fixation can be used for early stabilization of unstable anterior and posterior pelvic fractures and provide stable internal fixation, while avoiding large surgical exposure, derangement of hematomas and potential complications associated with these major surgeries.[8-12] Percutaneous fixation is thought to improve the outcome of unstable pelvic injuries; however, to our knowledge, no studies have yet demonstrated the long-term functional outcome and quality of life of patients with these injuries.

The aim of the present study was to evaluate the long-term functional outcome and quality of life of patients with unstable pelvic fractures who were treated with closed reduction and percutaneous fixation.

MATERIALS AND METHODS In the present study, 32 patients with pelvic fractures treated in our institution between August 2004 and August 2006 by one surgeon (EA) were evaluated retrospectively. Patients with unstable pelvic fractures who were treated with closed reduction and percutaneous fixation with at least 2 years of followup were included in the study. The patients treated with conservative or open methods and those with <2 years of follow-up were excluded. A total of 20 patients (11 females, 9 males) who fulfilled the inclusion criteria were enrolled in the study. Two patients were excluded (1 patient died in the postoperative 2nd week due to multiorgan failure and nosocomial sepsis, and 1 patient died in the postoperative 11th

month following a myocardial infarction). Hospital charts, pre- and postoperative posteroanterior, inlet and outlet pelvic X-rays and computed tomography scans were evaluated.

There were 9 male and 11 female patients, with an average age of 32 years (range, 11-66 years) at the time of injury. All of the injuries were related to motor vehicle accidents or pedestrian-vehicular collisions.

Fractures were classified according to Young and Burgess[13] (Table 1), and the Injury Severity Scores (ISSs) were calculated.

All of the operations were performed under general anesthesia in the supine position. A radiolucent operating table and conventional fluoroscopy were used. The initial step was closed reduction of the fracture with the aid of traction or an external fixator. For the placement of iliosacral screws, a guidewire was passed from the lateral edge of the ilium, perpendicular to the sacroiliac joint, towards the body of the first sacral vertebra. The pelvic inlet and outlet views and lateral views of the sacrum were obtained to confirm the correct positioning of the guidewire within the safe zone. A 7.3 mm (Kanghui medical) or 6.5 mm (Smith and Nephew) cannulated screw was then placed perpendicular to the sacroiliac joint. Longer screws were used for fixation of sacral fractures. Following placement of the first screw, a second screw was used when needed. For retrograde placement of the superior pubic ramus screw, an incision, 1 cm in length, was performed inferior and lateral to the ipsilateral pubic tubercle. A guidewire was passed at a 45° angle from medial-to-lateral through the superior pubic ramus across the fracture and above and anterior to the hip.

Obturator-outlet and iliac-inlet views were used to check the correct position of the screw. Then, a 7.3 mm or 6.5 mm cannulated screw was used for fixation.

A general health survey (Short Form-36 [SF-36]), commonly used to assess the overall outcome in orthopedic injuries, was used. Orthopedic outcome tools (Majeed score,[14] Iowa Pelvic Score [IPS], and Pelvic Outcome Score) were also used to determine patient

Table 1. Young and Burgess classification Mechanism and Type

Characteristics

Displacement

Stability

AP compression, type I AP compression, type II AP compression, type III Lateral compression, type I

Lateral compression, type II

Vertical shear

Pubic diastasis <2.5 cm Pubic diastasis >2.5 cm, anterior SI joint disruption Type II plus posterior SI joint disruption Ipsilateral sacral buckle fractures, ipsilateral horizontal pubic rami fractures (or disruption of symphysis with overlapping pubic bones) Type I plus ipsilateral iliac wing fracture or posterior SI joint disruption Vertical pubic rami fractures, SI joint disruption ± adjacent fractures

External rotation External rotation External rotation

Stable Rotationally unstable, vertically stable Rotationally unstable, vertically unstable

Internal rotation

Stable

Internal rotation

Rotationally unstable, vertically stable

Vertical

Rotationally unstable, vertically unstable

AP: Anteroposterior; SI: Sacroiliac.

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Patients with unstable pelvic fractures treated by closed reduction and percutaneous fixation

outcome. All of the surveys and tools were applied by an independent observer via personal interviews, except for the Pelvic Outcome Score, which evaluates the radiographs for residual displacement. The SF-36 is a general health assessment tool constructed to provide a broad measurement of health and has been vali-

dated and shown to be reliable for the Turkish population.[15] The survey was administered by means of a personal interview or telephone conversation. Each scale is evaluated with a range score of 0 to 100, and can be compared with an age- and gender-matched set of normal values.

(a) (a)

(b)

(b)

(c)

(c)

Fig. 1. (a) Anteroposterior pelvic X-ray of a 21-year-old man with unstable pelvic fracture. (b) Computed tomography section showing posterior injury. (c) Anteroposterior pelvic X-ray three years after percutaneous treatment of the fracture. The Majeed radiographic score was excellent. The Iowa Pelvic Score was 87 points (excellent). The physical function score of SF-36 was 94.4.

Cilt - Vol. 17 Say覺 - No. 3

Fig. 2. (a) Anteroposterior pelvic X-ray of a 39-year-old woman with unstable pelvic fracture. (b) Computed tomography section showing posterior injury. (c) Anteroposterior pelvic X-ray two years after percutaneous treatment of the fracture. The Majeed radiographic score was excellent. The Iowa Pelvic Score was 90 points (excellent). The physical function score of SF-36 was 100.

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The Majeed score is a pelvic injury-specific functional assessment divided into the following seven items: pain, work, sitting, sexual intercourse, standing, unaided gait, and walking distance.[14] The IPS is also a pelvic injury-specific assessment divided into the following 6 items: daily living activities (20 points), work history (20 points), pain (25 points), limping (20 points), visual pain line (10 points), and cosmesis (5 points).[16] Each of the total Majeed scores and IPSs range from 0-100; higher scores represent decrease in disability.

A 40-point Pelvic Outcome Score is used to assess the following items: pain, ambulation, work and activity status, clinical examination, and radiographs.

[6] Postoperative anteroposterior and inlet and outlet views of the pelvis were used to determine a radiographic score based on the presence of healing, reactive changes or fusion at the sacroiliac joint and the degree of anterior or posterior displacement.

RESULTS The minimum follow-up was 2 years, with a mean duration of follow-up of 33.3 months (range, 24-52 months). The mean ISS was 31 (range, 16-50). Five patients had anteroposterior compression type III (APC-III), 3 patients had APC-II, 3 patients had lateral compression type II (LC-II), 4 patients had LCIII, 4 patients had vertical shear (VS) injuries, and 2 patients had combined mechanism (CM) injuries. The mean delay of surgery was 3 days (range, 0-7 days).

Iliosacral screws were used in all patients for posterior fixation, and for anterior fixation, retrograde pubic ramus screws were used in 11 patients and external fixators in 6 patients. Screws were applied in the supine position and under fluoroscopic guidance. One pubic ramus screw was removed because of an intraarticular placement and another screw was removed due to a superficial infection. One iliosacral screw was changed for treatment of pseudoarthrosis. There were no fixation failures or neurovascular complications.

The radiographs of two patients are shown in Figures 1 and 2.

The associated injuries were as follows: chest injuries (pneumothorax, hemothorax, rib fractures, lung contusions) in 5 patients; cervical spine injuries in 2 patients; thoracic spine injury in 1 patient; lumbar spine injuries in 2 patients; lower extremity fractures in 9 patients; upper extremity fractures in 2 patients; head injuries (skull fractures, subdural and subarachnoid hematomas); hepatic injuries in 2 patients; splenic injury in 1 patient; sigmoid rupture in 1 patient; and urethral injuries in 2 patients. Two patients with sacral fractures had cauda equina lesions pre-operatively that resolved within 6 months after stabilization.

The average Majeed score was 93.3 (range, 72264

100; 19 excellent and 1 good clinical grades). The average IPS was 86 (range, 82-90). There were 11 patients with an excellent IPS, and 9 patients with a good IPS according to Nepola et al.[16] The average Pelvic Outcome Score was 33 (24-37).

The average SF-36 scores were comparable with the general population in terms of bodily pain, general health and social function scores, which were 3.3, 4.4, and 7.9, respectively. Similar to the general population, the average physical component score of the SF36 was 81.3 (range, 22.5-100), and the average mental component score of the SF-36 was 80.8 (range, 33.3100).

Fourteen patients who were working before the injury had returned to their current full-time jobs at the time of the final follow-up evaluation; of those, only 1 patient working as a salesman had to change his job.

DISCUSSION In the present study, we have reported the longterm outcome of patients with unstable pelvic fractures treated with closed reduction and percutaneous fixation. The average Majeed score, IPS and Pelvic Outcome Score of the patients were 93.3, 86, and 33, respectively. The average scores of all components of the SF-36 were comparable with the normal population, and 92% of the working patients returned to their full-time jobs after treatment.

The ideal treatment for unstable pelvic fractures remains a matter of debate. The main purpose of the treatment for these serious injuries is to save the patientâ&#x20AC;&#x2122;s life and then to achieve an excellent functional outcome.

Several operative and non-operative treatment options have been suggested for acute management of severe pelvic disruption. External fixation has been previously recommended for the early emergent stabilization of unstable pelvic ring disruptions to aid in hemodynamic resuscitation;[17] however, the use of external fixation as a definitive means of stabilization in patients with posterior injuries is still questioned because of its mechanical inability to maintain reduction. Current treatment approaches emphasize the need for early anatomic restoration and internal fixation to maintain reduction and to improve the functional outcome of these patients.

Open reduction and internal fixation of pelvic ring disruptions are routinely delayed to avoid entering the pelvic hematoma, thereby causing additional hemorrhage with an increased risk of mortality. Delayed operative intervention allows maturation of the hematoma, but diminishes the success of closed manipulative reduction. However, open reduction and internal fixation of posterior pelvic injuries, in particular, are May - MayÄąs 2011

Patients with unstable pelvic fractures treated by closed reduction and percutaneous fixation

associated with a high rate of wound complications.[18]

REFERENCES

Closed reduction and percutaneous fixation can be urgently performed, even during the initial resuscitation of the patient, thereby diminishing pelvic bleeding. Percutaneous pelvic ring fixation using fluoroscopic guidance provides stability. Stable percutaneous pelvic fixation also decreases operative blood loss and time, is associated with a very low wound complication rate, and allows comfortable mobilization of the patient. Accurate closed reduction of pelvic ring disruption is necessary before percutaneous fixation, and is best accomplished before maturation of the pelvic hematoma and deformity. Percutaneous pelvic fixation does not decompress the pelvic hematoma; thus, early surgical stabilization would be possible without the risk of additional hemorrhage, thereby allowing improved patient comfort, mobility and healing. Although these advantages of closed reduction and percutaneous fixation are well known, to our knowledge there is no published data on the quality of life and functional outcome of patients treated in this manner.

1. Goldstein A, Phillips T, Sclafani SJ, Scalea T, Duncan A, Goldstein J, et al. Early open reduction and internal fixation of the disrupted pelvic ring. J Trauma 1986;26:325-33.

2. Matta JM, Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop Relat Res 1989;242:83-97.

3. Riemer BL, Butterfield SL, Diamond DL, Young JC, Raves JJ, Cottington E, et al. Acute mortality associated with injuries to the pelvic ring: the role of early patient mobilization and external fixation. J Trauma 1993;35:671-7.

4. Dujardin FH, Hossenbaccus M, Duparc F, Biga N, Thomine JM. Long-term functional prognosis of posterior injuries in high-energy pelvic disruption. J Orthop Trauma 1998;12:145-51.

5. Latenser BA, Gentilello LM, Tarver AA, Thalgott JS, Batdorf JW. Improved outcome with early fixation of skeletally unstable pelvic fractures. J Trauma 1991;31:28-31.

6. Cole JD, Blum DA, Ansel LJ. Outcome after fixation of unstable posterior pelvic ring injuries. Clin Orthop Relat Res 1996;329:160-79.

7. Kellam JF, McMurtry RY, Paley D, Tile M. The unstable pelvic fracture. Operative treatment. Orthop Clin North Am 1987;18:25-41.

8. Routt ML Jr, Kregor PJ, Simonian PT, Mayo KA. Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma 1995;9:207-14.

9. Routt M. Supine positioning for the placement of percutaneous sacral screws in complex posterior pelvic ring trauma.

Orthop Trans 1992;16:220.

10. Giannoudis PV, Tzioupis CC, Pape HC, Roberts CS. Percutaneous fixation of the pelvic ring: an update. J Bone Joint Surg [Br] 2007;89:145-54.

11. Shuler TE, Boone DC, Gruen GS, Peitzman AB. Percutaneous iliosacral screw fixation: early treatment for unstable posterior pelvic ring disruptions. J Trauma 1995;38:453-8.

12. Ebraheim NA, Rusin JJ, Coombs RJ, Jackson WT, Holiday B. Percutaneous computed-tomography-stabilization of pelvic fractures: preliminary report. J Orthop Trauma 1987;1:197-204.

13. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986;160:445-51.

14. Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg [Br] 1989;71B:304-306.

15. Demiral Y, Ergor G, Unal B, Semin S, Akvardar Y, Kivircik B, et al. Normative data and discriminative properties of short form 36 (SF-36) in Turkish urban population. BMC Public Health 2006;6:247.

16. Nepola JV, Trenhaile SW, Miranda MA, Butterfield SL, Fredericks DC, Riemer BL. Vertical shear injuries: is there a relationship between residual displacement and functional outcome? J Trauma 1999;46:1024-30.

17. Kellam JF. The role of external fixation in pelvic disruptions.

Clin Orthop Relat Res 1989;241:66-82.

18. Kellam JF, McMurtry RY, Paley D, Tile M. The unstable pelvic fracture. Operative treatment. Orthop Clin North Am 1987;18:25-41.

19. Kabak S, Halici M, Tuncel M, Avsarogullari L, Baktir A, Basturk M. Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): a report of 40 cases. J Orthop Trauma 2003;17:55562.

20. Suzuki T, Shindo M, Soma K, Minehara H, Nakamura K,

The outcome of operatively-treated pelvic fractures has been examined, and many authors have reported that average SF-36 scores were impaired in ≤55% of the patients, and ≤35% of the patients could not return to their current jobs.[6,19-25] The associated injuries alter the long-term outcome of patients with unstable pelvic injuries.[6,19,20] Neurologic injuries have been reported to have a detrimental effect on outcomes.[20] The lack of long-term follow-up, uniformity in initial treatment and experience of the surgeon in this field are other problems when evaluating the long-term functional outcomes.[6] The better findings of the present study regarding the functional outcome of patients may be attributed to the lower percentages of neurologic injuries (10%) compared to studies reported previously (≤38%).[20] Another reason for the discrepancy in findings may be the relatively longer patient follow-up. It has been reported previously that patients with longer than 1 year of follow-up had better outcomes.[6] In addition to the longer follow-up duration, uniformity of the treatment protocol and application of the procedures by the same surgeon may be regarded as the strengths of the present study. On the other hand, the retrospective design, lack of a control group, small sample size, and presence of heterogeneous injuries were the limitations of the study.

Percutaneous treatment is suggested in the treatment of unstable pelvic fractures as it avoids the use of extensive approaches, bleeding, wound complications, and prolonged surgeries. Better outcomes can be achieved in the long-term follow-up. Further studies with larger sample sizes are needed.

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Uchino M, et al. Long-term functional outcome after unstable pelvic ring fracture. J Trauma 2007;63:884-8.

21. Oliver CW, Twaddle B, Agel J, Routt ML Jr. Outcome after pelvic ring fractures: evaluation using the medical outcomes short form SF-36. Injury 1996;27:635-41.

22. Van den Bosch EW, Van der Kleyn R, Hogervorst M, Van Vugt AB. Functional outcome of internal fixation for pelvic ring fractures. J Trauma 1999;47:365-71.

23. Tornetta P 3rd, Matta JM. Outcome of operatively treated

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unstable posterior pelvic ring disruptions. Clin Orthop Relat Res 1996;329:186-93.

24. Pohlemann T, G瓣nsslen A, Schellwald O, Culemann U, Tscherne H. Outcome after pelvic ring injuries. Injury 1996;27:B31-8.

25. Gruen GS, Leit ME, Gruen RJ, Garrison HG, Auble TE, Peitzman AB. Functional outcome of patients with unstable pelvic ring fractures stabilized with open reduction and internal fixation. J Trauma 1995;39:838-45.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):267-268

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.47123

Stump appendicitis after laparoscopic appendectomy: case report Laparoskopik apendektomiden sonra güdük apandisit: Olgu sunumu Omaima BU-ALI,1 Mohamed AL-BASHIR,1 Hashim A SAMIR,2 Fikri M. ABU-ZIDAN1 Stump appendicitis is a rare delayed complication of appendectomy. The delay in diagnosis is usually because of a prior history of appendectomy. We report a case of stump appendicitis diagnosed pre-operatively with a computerized tomography (CT) scan after laparoscopic appendectomy.

An 18-year-old male presented with a one-week history of lower abdominal pain, nausea and vomiting. He had a history of laparoscopic appendectomy for acute appendicitis.

Physical examination revealed tenderness and guarding in the lower abdomen. CT scan showed free pelvic fluid with a tubular structure of about 2.5 cm in length and 0.78 cm in diameter located posterior to the ileo-cecal junction. Laparoscopic exploration confirmed the findings. A residual appendiceal stump was found and dissected from the adhesion and removed. Histopathology showed a residual appendix with transmural neutrophilic infiltration associated with multifocal hemorrhagic necrosis. The postoperative period was uneventful. The diagnosis of stump appendicitis can be challenging. CT scan has proven to be a useful tool for the diagnosis of this rare condition.

Güdük apandisiti, nadir bir geç apendektomi komplikasyonudur. Tanıda gecikme olması, genellikle daha önceden bir apendektomi öyküsü bulunması yüzündendir. Biz, laparoskopik apendektomiden sonra bilgisayarlı tomografi (BT) ile ameliyat öncesi tanı konulan bir güdük apandisiti olgusu sunuyoruz. On sekiz yaşında bir erkek, bir haftalık bir alt karın ağrısı, bulantı ve kusma öyküsü ile başvurdu. Hastanın akut apandisit nedeniyle geçirilmiş bir laparoskopik apendektomi öyküsü vardı. Fiziksel incelemede alt karın bölgesinde hassasiyet, defans ve ağrı belirlendi. BT ile, ileoçekal bileşkenin arkasına yerleşimli yaklaşık 2,5 cm uzunluğunda ve 0,78 cm çapında tübüler bir yapıya sahip serbest pelvik sıvı bulunduğu saptandı. Laparoskopik inceleme, bulguları doğruladı. Rezidüel bir apandiks güdüğü bulundu, yapşıklıklardan ayrıldı ve rezeke edildi. Histopatoloji, multifokal hemorajik nekroz ile birlikte olan transmural nötrofilik infiltrasyona sahip rezidüel bir apendiks bulunduğunu gösterdi. Ameliyat sonrası sorun çıkmadı. Güdük apandisit tanısı zor olabilir. BT taraması, bu nadir durumun tanısına yönelik yararlı bir araç olduğunu kanıtlamıştır.

Key Words: Appendicitis; CT scan; laparoscopy; stump.

Anahtar Sözcükler: Apandisit; BT tarama; laparoskopi; güdük.

Incomplete appendectomy may predispose to the development of stump appendicitis. Stump appendicitis, the interval re-inflammation of the residual appendiceal tissue, is a rare complication of appendectomy.

The diagnosis of stump appendicitis in a patient postappendectomy is challenging since it is rarely considered prospectively.

CASE REPORT An 18-year-old male presented with a one-week history of lower abdominal pain, nausea and vomiting followed by fever for one day. He had undergone laparoscopic appendectomy for acute appendicitis three months earlier with an uneventful postoperative course. Physical examination revealed tenderness and guarding in the lower abdomen. His white blood cell count was 9.8 x 109/L.

We report a case of stump appendicitis following laparoscopic appendectomy that was diagnosed pre-operatively with a computerized tomography (CT) scan.

Departments of 1Surgery, 2Clinical Imaging, Tawam Hospital in affiliation with Johns Hopkins Medicine, Al-Ain, United Arab Emirates.

The CT scan showed free pelvic fluid with a tubu-

Tawam Hastanesi ve Johns Hopkins Tıp işbirliğiyle, 1Cerrahi Kliniği, 2 Klinik Görüntüleme Bölümü, Al-Ain, Birleşik Arap Emirlikleri.

Correspondence (İletişim): Fikri M. Abu-Zidan, M.D. PO Box 17666, Al-Ain, United Arab Emirates.

Tel: +00971 50 8335390 e-mail (e-posta): fabuzidan@uaeu.ac.ae

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The diagnosis of stump appendicitis in a patient with previous appendectomy presents a diagnostic dilemma likely leading to delayed diagnosis and high perforation rate.[1] It requires a high index of suspicion to be determined early. Ultrasonography and CT scan may be helpful in establishing the diagnosis prospectively.[2] Interestingly, CT scan showed the presence of gas in the proximal part of the lumen of the appendix in our patient. About 15% of acute appendicitis cases will have gas in their lumen.[3] There are a variety of possible explanations: the obstruction may have been limited to the distal part; the diagnosis may have been reached before the gas was absorbed; the gas may have been produced by bacteria distal to the obstruction; or the inflammation may have occurred without obstruction.[3]

Fig. 1. Axial CT (A) shows the thickened and enhanced appendix stump (arrow) with peripheral mesenteric fat stranding. Curved multi-planar reconstruction (B) along the long axis of the appendix stump (arrow), measuring 2.5 cm in length, shows enhanced and inflamed distal segment. A small fluid collection is seen nearby. Note the presence of gas in the proximal part of the lumen of the appendix.

lar structure measuring 2.5 cm in length and 0.78 cm in diameter located posterior to the ileo-cecal junction (Fig. 1). Laparoscopic exploration revealed purulent fluid in the pelvis with multiple adhesions in the right iliac fossa. A residual appendiceal stump was found and dissected from the adhesion and removed. Histopathology showed a residual appendix with transmural neutrophilic infiltration associated with multifocal hemorrhagic necrosis. The postoperative period was uneventful. The patient was followed for nine months without any complaints.

DISCUSSION The cause of stump appendicitis is incomplete removal of the appendix during the initial surgery. The re-inflammation of the residual appendiceal tissue is reported to occur as early as two months and as late as 50 years after the initial surgery.[1] 268

The reports of stump appendicitis are rare and no relationship to a particular surgical technique can be made. It has been reported in patients following open appendectomy with stump ligation,[4] open appendectomy with stump inversion[5] and laparoscopic appendectomy.[1,2] In laparoscopic appendectomy, the appendiceal stump is closed with an Endoloop or by stapling. In our case, the stump was closed with an Endoloop in the initial surgery and with staples in the second operation. There is no reported difference between the two surgical techniques except for the lower risk of postoperative intra-abdominal surgical site infection and need for readmission to hospital when staples are used.[6] Regardless of the surgical technique used, identification of the appendiceal base by tracing the taenia coli down to the appendix is crucial in preventing such a complication. Stump appendicitis should be considered in the differential diagnosis of any patient with a previous history of appendectomy who presents with signs and symptoms of appendicitis. CT scan has proven to be a useful tool for the diagnosis of this rare condition.

REFERENCES 1. Liang MK, Lo HG, Marks JL. Stump appendicitis: a comprehensive review of literature. Am Surg 2006;72:162-6.

2. Shin LK, Halpern D, Weston SR, Meiner EM, Katz DS. Prospective CT diagnosis of stump appendicitis. AJR Am J Roentgenol 2005;184:62-4.

3. Rettenbacher T, Hollerweger A, Macheiner P, Rettenbacher L, Frass R, Schneider B, et al. Presence or absence of gas in the appendix: additional criteria to rule out or confirm acute appendicitis--evaluation with US. Radiology 2000;214:183-7.

4. Thomas SE, Denning DA, Cummings MH. Delayed pathology of the appendiceal stump: a case report of stump appendicitis and review. Am Surg 1994;60:842-4.

5. Mangi AA, Berger DL. Stump appendicitis. Am Surg 2000;66:739-41.

6. Beldi G, Vorburger SA, Bruegger LE, Kocher T, Inderbitzin D, Candinas D. Analysis of stapling versus endoloops in appendiceal stump closure. Br J Surg 2006;93:1390-3.

May覺s - May 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):269-272

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.68888

Travmatik pulmoner psödokist: İki olgu sunumu Traumatic pulmonary pseudocyst: two case reports Hasan ÇAYLAK, Kuthan KAVAKLI, Ersin SAPMAZ, Orhan YÜCEL, Onur GENÇ

Travmatik pulmoner psödokistler (TPP) künt toraks travmasının nadir görülen sekelleridir. Çoğunlukla çocuklar ve genç erişkinlerde görülürler. Bu yazıda, TPP gelişen iki genç olgu sunuldu. Tanı için akciğer grafisi genellikle yeterli olmayıp tercih edilen görüntüleme yöntemi bilgisayarlı tomografidir (BT). TPP’ler genellikle spesifik tedaviye gerek göstermeksizin kendini sınırlayan iyi huylu lezyonlardır. Cerrahi tedavi endikasyonu nadir olup yalnızca komplikasyonlar geliştiğinde uygulanmalıdır.

Traumatic pulmonary pseudocysts (TPPs) are rare sequelae of blunt chest trauma. Young adults and adolescents are predominantly affected. In this study, two cases of TPPs in young patients are presented. Chest radiographs are usually insufficient for the diagnosis, and the imaging modality of choice is computed tomography (CT). TPPs are self-limiting, benign lesions that usually require no specific therapy.

Surgical treatment is indicated in rare instances and only when complications occur.

Anahtar Sözcükler: Künt toraks travması; travmatik pulmoner psödokist.

Key Words: Blunt chest trauma; traumatic pulmonary pseudocyst.

Künt toraks travması sonrası meydana gelen akciğer parankim yaralanmaları basit kontüzyondan laserasyonlara kadar değişir. Bu tür travmalardan sonra kendini akciğer parankiminde kaviter lezyon şeklinde gösteren yaralanmalara literatürde yaygın kabul gören ismiyle travmatik pulmoner psödokist (TPP) adı verilmektedir. TPP’ler oldukça nadir görülen lezyonlardır. Literatürde 10 veya daha fazla sayıda olgudan oluşan seriler az olup çoğunlukla olgu sunumu şeklindedir. Künt toraks travması sonrası meydana gelen parankimal yaralanmaların sadece %2,6-3’ünü TPP’ler oluşturur. Genellikle çocuk ve genç erişkinlerde görülürler. Benign karekterli lezyonlar olup büyük bir kısmı herhangi bir spesifik tedaviye gerek kalmaksızın iz bırakmadan iyileşirler.[1-3] Bu yazıda, künt toraks travması sonrası TPP gelişen iki olgu sunuldu.

OLGU SUNUMU Olgu 1- Yirmi dokuz yaşında erkek hasta, motosiklet kazası sonrası acil servise kabul edildi. Göğüs ağrısı ve nefes almada güçlük şikayeti bulunan hastanın yapılan fiziksel incelemede; bilinç açık, kooperasyonu tam, Glaskow koma skalası 15 ve inspeksiyonda her iki üst ekstremitede sızıntı tarzında kanamalı cilt laserasyonları dışında patoloji saptanmadı.

Hayati bulguları (Ateş: 36,7, Nabız: 87, Kan basıncı: 130/90 mmHg, oda havasında SpO2: %96) stabildi. Solunum sistemi muayenesinde her iki hemitoraksın solunuma iştiraki eşit ve göğüs duvarının sol tarafında palpasyonda yaygın hassasiyet mevcuttu. Solunum sesleri normal olarak değerlendirildi. Diğer sistem incelemeleri ve kan biyokimyasal analizleri normaldi. Akciğer grafisinde hemotoraks veya pnömotoraksı düşündüren bulgu olmaksızın sol 6., 7., 8., 9. ve

Gülhane Askeri Tıp Akademisi, Göğüs Cerrahisi Anabilim Dalı, Ankara.

Department of Thoracic Surgery, Gülhane Military Medical Academy, Ankara, Turkey.

İletişim (Correspondence): Dr. Hasan Çaylak. GATA Göğüs Cerrahisi Anabilim Dalı, Etlik 06018 Ankara, Turkey.

Tel: +90 - 312 - 304 51 87 e-posta (e-mail): hcaylak04@hotmail.com

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10. kotlarda kırık saptandı. Çoklu kot kırığı nedeniyle gelişebilecek komplikasyonlar açısından hasta kliniğe yatırıldı. Analjezik ve mukolitik tedaviye başlanan olgu günlük akciğer grafileri ile takibe alındı. Yatışının ikinci gününde çekilen akciğer grafisinde sol hemitoraksta kaviter lezyon saptanan hastaya toraks bilgisayarlı tomografi (BT) incelemesi yapıldı. BT incelemesinde sol akciğer alt lob posterobazal segmentte yaklaşık 5x5 cm boyutunda ince duvarlı hava sıvı seviyesi göstermeyen kistik lezyon tespit edildi (Şekil 1a, 1b).

Travmatik pulmoner psödokist teşhis edilen olgu herhangi bir komplikasyon gelişmemesi üzerine yatışının 6. gününde semptomatik tedavi verilerek kontrole gelmek üzere taburcu edildi. Olgunun iki ay sonra çekilen kontrol BT incelemesinde sol akciğerdeki kaviter lezyonun tamamen gerilediği ve ortadan kaybolduğu belirlendi (Şekil 1c, 1d).

Olgu 2- Yirmi yaşında erkek hasta, trafik kazası sonrasında başında kanama, göğüs ve bel ağrısı şikayetleri ile bölge devlet hastanesi acil servise nakledilmiş. Hastanın yapılan fiziksel incelemesinde, frontal bölgede 4 cm uzunluğunda kanamalı lezyon ve göğüs duvarının her iki tarafında palpasyonda hassasiyet dışında diğer sistem incelemeleri, biyokimyasal kan/ idrar analizleri, ultrasonografik ve radyolojik görüntüleme incelemelerinde patoloji saptanmamış. Damar yolu açılarak bir gün gözlem altında tutulan hasta antibiyotik ve analjezik tedavi düzenlenerek taburcu edil-

miş. Hasta, düzenli ağrı kesici tedavisine rağmen devam eden göğüs ağrısı şikayetiyle travma sonrası 3. günde kliniğimize başvurdu. Göğsünün sol tarafında daha belirgin olmak üzere her iki tarafta palpasyonda hassasiyet mevcut olan hastanın diğer solunum sistem incelemeleri normal olarak değerlendirildi. Akciğer grafisinde sol akciğer orta kısımda daha önceki grafilerinde olmayan nispeten düzgün sınırlı kaviter lezyon tespit edildi. Bunun üzerine hasta yatırıldı. İleri değerlendirme amacıyla çekilen BT incelemesinde üst lob anterior segment ile süperior lingular segment arasında 3x5 cm boyutunda kalın duvarlı, hava sıvı seviyesi göstermeyen kaviter lezyon saptandı (Şekil 2a).

TPP tanısı konulan olguya herhangi bir cerrahi girişim uygulanmadı. Hasta yatışının 4. günü analjezik tedavi düzenlenerek kontrole gelmek üzere taburcu edildi.

Bir ay sonra yapılan ilk kontrol muayenesinde herhangi bir şikayeti bulunmayan hastanın akciğer grafisinde kaviter lezyonun gerilediği saptandı. BT incelemesinde lezyonun öncesine göre ¾ oranında gerilediği rapor edildi (Şekil 2b). Hastanın üç ay sonraki BT kontrolünde ise lezyonun tamamen ortadan kaybolduğu gözlendi. Bu zaman zarfında hastada herhangi bir şikayet veya komplikasyon gelişmedi (Şekil 2c).

TARTIŞMA TPP toraks travmaları sonrası ortaya çıkabilen kaviter bir lezyondur. Literatürde raporlanan olguların

Şekil 1. Olgunun travma sonrası ikinci günde çekilen (a) akciğer grafisi ve (b) BT kesiti ile travmadan 2 ay sonra çekilen (c) akciğer grafisi ve (d) BT kesiti.

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Şekil 2. Olgunun travmadan (a) 4 gün, (b) bir ay ve (c) üç ay sonraki BT kesitleri.

hemen tamamına yakınında künt toraks travması söz konusu iken çok nadir olarak bu lezyonların penetran toraks travmalarına bağlı olarak da gelişebileceği bildirilmektedir. Pulmoner kontüzyon veya pulmoner hematom gibi çok sık karşılaşılan diğer pulmoner parankimal yaralanmalarla karşılaştırıldığında oldukça ender görülürler. Künt toraks travması sonrası gelişebilen tüm pulmoner parankimal yaralanmaların yaklaşık %2,6-3’ünü oluştururlar.[1-6] Travma kaynaklı enerjinin büyük bir kısmının akciğer parankimine aktarılmasına olanak sağlayan elastik yapıda göğüs duvarına sahip olmaları nedeniyle genellikle çocuklar ve genç erişkinlerde görülürler. TPP gelişen hastaların %7585’inin 30 yaş altında olduğu bildirilmektedir. Ortalama yaş 20 yıl olup erkeklerde daha sık görülür.[1,7,8] Çalışmamızdaki her iki olgu da erkekti ve 30 yaşın altındaydı.

TPP’lerin nasıl oluştukları konusunda çeşitli mekanizmalar ileri sürülmektedir. Bunlardan birisi, travmanın oluşturduğu ani basınç etkisiyle periferik hava yollarının bir bölümünde patlama tarzında ani bir basınç artışı olması ve bu nedenle sıkışan havanın alveol duvarını yırtarak genişlemesidir. Diğer bir mekanizma ise akciğer parankimi boyunca yayılan sarsıcı dalgaların parankimde yırtıklara neden olduğudur.[7] TPP’nin tanısı göğüs travması öyküsü bulunan hastada karakteristik akciğer grafi ve/veya BT bulguları ile konulur. Radyolojik olarak oval veya yuvarlak yapıda tek veya birden fazla kaviter lezyon şeklinde görülürler.[1,7] Hava sıvı seviyesi olabilir veya tamamen hava ile dolu olabilirler. Akciğerlerin her bölgesinde yerleşim gösterebilmekle birlikte çoğunlukla alt kısımlarda yerleşirler. Büyüklükleri değişkendir. Literatürde çapları 1-14 santimetre arasında değişen lezyonlar bulunmaktadır. Künt travma sonrasında ilk birkaç saat gibi erken dönemde veya günler sonra tespit edilebilirler. Erken dönemde doğrudan çekilen akciğer grafilerinde eşlik edebilen pulmoner kontüzyonun lezyonu maskelemesi nedeniyle fark edilemeyebilirler. Travma günü çekilen direk akciğer grafilerinde TPP’leri sadece %50’sinin görüntülenebildiği bildirilmektedir.[1,7,8] Her iki olgumuzda travma günü çekilen direk akciğer grafilerinde lezyon saptanamamıştır.

Cilt - Vol. 17 Sayı - No. 3

TPP’lerin erken tespitinde BT daha duyarlı olup, direk akciğer grafisinden üstündür. BT, lezyonun yerleşimi, büyüklüğü ve eşlik eden diğer parankimal yaralanmalar ile kaviter lezyonla seyreden diğer hastalıklardan ayıracı tanıda önemli bilgiler verir. TPP’ler radyolojik olarak genellikle 2-3 ay içerisinde gerileyerek tamamen iyileşirler.[1,3,4] Olgularımız için travma sonrası 2. ve 4. günlerde çekilen BT incelemelerinde hava sıvı seviyesi göstermeyen ince duvarlı kistik yapılar saptanmıştır. İki ay sonra BT kontrolü yapılan olguda lezyonun tamamen gerilediği gözlenirken bir ay sonra BT kontrolü yapılan diğer olguda ise lezyonun büyük oranda gerilediği ancak sebat ettiği görüldü. Bu durumda olgularımızda saptanan TPP’lerin gerileyerek tamamen iyileşmeleri için en az iki aylık bir sürenin gerektiği söylenebilir.

Ayırıcı tanıda kaviter lezyonla seyreden diğer patolojiler akılda bulundurulmalıdır. Yetişkinlerde bül, bleb, akciğer apsesisi, bronşiyal karsinom, bronkojenik kist, pulmoner enfarktüs ve özellikle endemik bölgelerde tüberküloz, kist hidatik ve koksidoidomikozis ile çocuklarda doğuştan pulmoner kist ve pulmoner sekestrasyon TPP’ye benzer şekilde karşımıza çıkabilmektedir. Ancak, TPP tanısı koymada genellikle zorluk yaşanmaz. Hastada travma öyküsünün olması ve radyolojik olarak lezyonun zamanla gerilemesi TPP’yi düşündürür. Gerilemeyen lezyonlarda ise diğer patolojilere yönelik araştırmalar yapılmalıdır.[5-7] TPP’ler klinik olarak asemptomatik olabilirler. En sık karşılaşılan semptomlar ise hemoptizi, göğüs ağrısı ve öksürüktür. Bu semptomlar sadece TPP’nin kendisine bağlı olmayıp başta pulmoner kontüzyon gibi psödokiste eşlik eden diğer parankimal yaralanmalara bağlıdır. Klinik gidiş olarak benign lezyonlardır. Çoğunlukla spesifik tedavi gerektirmezler.[1-3] Tedavi tipik olarak bulgulara yöneliktir. Enfeksiyon, bronşiyal kanama veya plevral boşluğa rüptür gibi komplikasyonlar gelişmedikçe cerrahi tedavi düşünülmemelidir.

[4] Hemoptizi çoğunlukla hayatı tehdit etmez ve cerrahi tedavi gerektirmez. Ancak, bronşiyal kanamayı kontrol etmek amacıyla lobektomi gerektiren olgular bildirilmektedir.[7] Psödokistlerin enfeksiyon ile komplike olmaları enderdir. Ancak, Carol ve arkadaşları enfekte TPP’lerin uygun antibiyotik tedavisine tipik ak271

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ciğer apsesi gibi yanıt vermeyebileceklerini ve bu nedenle hayatı tehdit edebileceklerini vurgulamışlardır.

Uzun süre ateşi devam eden ve akciğer patolojisi kötüleşen olgularda torakotomi ile debridman ve uygun drenaj hayat koruyucu olabilmektedir.[9] Her iki olgumuzda da herhangi bir komplikasyon ve bu nedenle cerrahi müdahale gereksinimi olmadı.

Sonuç olarak künt toraks travması sonrası nadiren gelişen TPP’ler klinik açıdan benign seyir gösterirler. TPP saptanan olgularda komplikasyon gelişmedikçe cerrahi tedaviye gerek olmadığı ve bu tür olgularda semptomlara yönelik medikal tedavi ile radyolojik takibin yeterli olacağı kanaatindeyiz.

KAYNAKLAR 1. Melloni G, Cremona G, Ciriaco P, Pansera M, Carretta A, Negri G, et al. Diagnosis and treatment of traumatic pulmonary pseudocysts. J Trauma 2003;54:737-43.

2. Chon SH, Lee CB, Kim H, Chung WS, Kim YH. Diagnosis and prognosis of traumatic pulmonary psuedocysts: a review of 12 cases. Eur J Cardiothorac Surg 2006;29:819-23.

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3. Athanassiadi K, Gerazounis M, Kalantzi N, Kazakidis P, Fakou A, Kourousis D. Primary traumatic pulmonary pseudocysts: a rare entity. Eur J Cardiothorac Surg 2003;23:43-5.

4. Kato R, Horinouchi H, Maenaka Y. Traumatic pulmonary pseudocyst. Report of twelve cases. J Thorac Cardiovasc Surg 1989;97:309-12.

5. Stathopoulos G, Chrysikopoulou E, Kalogeromitros A, Papakonstantinou K, Poulakis N, Polyzogopoulos D, et al.

Bilateral traumatic pulmonary pseudocysts: case report and literature review. J Trauma 2002;53:993-6.

6. Kocer B, Gulbahar G, Gunal N, Dural K, Sakinci U. Traumatic pulmonary pseuodocysts: two case reports. J Med Case Reports 2007;1:112.

7. De A, Peden CJ, Nolan J. Traumatic pulmonary pseudocysts.

Anaesthesia 2007;62:409-11.

8. Celik B, Basoglu A. Posttraumatic pulmonary pseudocyst: a rare complication of blunt chest trauma. Thorac Cardiovasc Surg 2006;54:433-5.

9. Carroll K, Cheeseman SH, Fink MP, Umali CB, Cohen IT. Secondary infection of post-traumatic pulmonary cavitary lesions in adolescents and young adults: role of computed tomography and operative debridement and drainage. J Trauma 1989;29:109-12.

Mayıs - May 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):273-276

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.32848

Reconstruction of complex groin defects with inferior epigastric artery-based rectus abdominis muscle flaps: report of two cases Kompleks inguinal defektlerin inferior epigastrik arterden kanlanan rektus abdominis kas flepleri ile rekonstrüksiyonu: İki olgu sunumu Samet Vasfi KUVAT,1,3 Hakan YANAR,2 Ahmet BİÇER,3 Serdar TUNÇER,4 Burhan ÖZALP,3 Murat TOPALAN3 Because the extremities are dependent on a single vascular supply, namely the brachial and femoral arteries, injuries around the girdles are challenging, and may contribute to high morbidity rates such as extremity loss, or even mortality due to bleeding, sepsis or vascular compromise. The reconstruction or aided closure of these regions may present additional technical difficulties in the presence of a vascular injury that complicates the use of a microvascular-free transfer, which sometimes may be needed to cover the exposed vessels, bones, tendons, and cartilages whenever the neighboring skin and subcutaneous tissue are inadequate or demised. In these circumstances, pedicled regional flaps of muscular or musculocutaneous consistency (especially if a bulk or rich vascular tissue is needed) would be an alternative. In this report, we present two cases that underwent femoral artery repair via saphenous vein grafting in the vascular surgery clinic followed by our inferiorly based pedicled rectus abdominis muscle flap coverage procedure.

Brakiyal ve femoral arterler gibi tek vasküler kaynağı olan ekstremitelerin damar ve çevresi yaralanmalarında, ekstremite kaybı gibi morbidite ya da kanama, sepsis ve vasküler uyuşmazlığa bağlı mortalite riski yüksektir. Ekspoze damar, kemik, tendon ve kıkırdakları kapatacak komşu deri ve subkütan doku yetersizliği durumunda, bu bölgelerin rekonstrüksiyonunda ihtiyaç duyulabilen serbest mikrovasküler doku transferi, vasküler yaralanma sebebi ile beraberinde ek teknik zorlukları da ortaya çıkarabilir. Bu koşullarda, pediküllü kas ve kas-deri flebi gibi rejyonel flepler (özellikle dolaşımı iyi hacimli dokuya ihtiyaç varsa) alternatif olabilir. Bu yazıda, vasküler cerrahi kliniğince safen ven grefti ile femoral arter onarımı sonrası inferiora baze pediküllü rektus abdominis kası ile rekonstrüksiyon uyguladığımız iki olgu sunuldu.

Key Words: Groin defect; rectus abdominis muscle flap; vascular injury.

Anahtar Sözcükler: İnguinal defekt; rektus abdominis kas flebi; vasküler yaralanma.

The last decades have witnessed a gain in popularity of the concept “limb salvage surgery”, especially concerning trauma or oncologic surgery. Providing reliable soft tissue coverage to the girdle regions can be considered to be a limb salvage reconstructive surgery.[1] Wound healing in the groin region is somehow defective owing to a thin and relatively avascular soft tissue coverage.[2] Moreover, complications like wound infection and wound dehiscence are often encountered following

primary closure of defects in this region.[1,3] When all these factors are taken into account, reconstruction confined to these regions may need pedicled or free muscle flaps, which provide adequate blood supply.[1]

1 Department of Plastic and Reconstructive Surgery, Istanbul Training and Research Hospital, Istanbul; Departments of 2Surgery, 3Plastic and Reconstructive Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul; 4Department of Plastic and Reconstructive Surgery, Bilim University Faculty of Medicine, Istanbul, Turkey.

Inferiorly based rectus abdominis muscle/muscleskin (RAMs) flaps are among the valid emerging alternatives in reconstruction of inguinal region soft tissue defects. Adequate soft tissue volume, wide arc İstanbul Eğitim ve Araştırma Hastanesi, Plastik, Rekonstrüktif ve Cerrahi Kliniği, İstanbul; 2İÜ İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 3 Plastik, Rekonstrüktif ve Cerrahi Anabilim Dalı, İstanbul; 4 Bilim Üniversitesi, Tıp Fakültesi, Plastik, Rekonstrüktif ve Cerrahi Anabilim Dalı, İstanbul.

1

Correspondence (İletişim): Samet Vasfi Kuvat, M.D. Seyitömer Mah., Emrullah Efendi Sok., No: 60/6 Fındıkzade 34098 Fatih, İstanbul, Turkey.

Tel: +90 - 212 - 588 44 60 e-mail (e-posta): sametkuvat@yahoo.com

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rotation, no repositioning required during surgery, and relatively rapid and straightforward flap harvesting render these flaps advantageous.[1-3] Two cases that underwent vascular repair in the femoral region followed by our inferiorly based pedicled RAM flap coverage procedure are presented herein.

days, after which it had been confirmed that the local infection was under control; a split thickness skin graft was used to ensure skin protection. Total healing of the skin was observed following a three-week period of local wound care postoperatively, after which the patient was discharged (Fig. 1).

CASE REPORTS Surgical anatomy: The RAM is nourished by the inferior epigastric artery, which is a branch of the external iliac artery, and the superior epigastric artery, which is the continuity of internal thoracic artery. The RAM/musculocutaneous flap based on its superior pedicle is commonly used to close defects of the superior and anterior thoracic wall, whereas defects of the inferior abdominal wall and the inguinal region are covered by the same muscle based on its inferior pedicle.[2,4] Case 1- A 45-year-old male presented to our emergency department following an occupational injury.

Physical examination revealed a complex crush injury in the suprapubic and both inguinal regions with bilateral femoral artery and vein disruption. The right femoral artery was repaired with a reversed great saphenous vein graft interposition, whereas the left was repaired using the ipsilateral superficial femoral vein as a graft. The demised, degloved skin was primarily closed. On the 3rd postoperative day, the infected and necrotized skin due to the type of injury and subsequent contamination was debrided. The radical debridement resulted in exposition of both vascular repairs. This necessitated extensive closure of the defects. A pedicled tensor fascia lata (TFL) musculofasciocutaneous flap for the fairly smaller right-side defect and an inferiorly pedicled RAM flap for the generously larger left-side defect were planned.

Surgical technique: The rectus sheath was opened on its lateral border using a paramedian anterior abdominal incision. The deep inferior epigastric artery was identified while the rectus muscle was being dissected from its sheath beneath the arcuate line. After dividing the superior epigastric artery and separation of the superior portion from its insertions, the muscle was transposed upon the wound inferiorly.

The divided anterior rectus sheath was repaired with nonabsorbable sutures in the donor site in an effort to minimize any resultant weakness around the anterior abdomen consequently. The portion of the defect outstretching the right inguinal region where the defect was comparably smaller was repaired with a 15x8 cm TFL musculocutaneous flap. The rectus muscle was left bare on the wound to exclude any possible skin graft failure due to the past skin infection. The open wound was treated with local wound care for seven 274

(a)

(b)

(c) Fig. 1. (a) Complex inguinal and suprapubic defect in a patient with bilateral femoral vascular repair. (b) Design of RAM and TFL flaps. (c) Long-term results of leftsided RAM and right-sided TFL musculocutaneous flap coverage.

May覺s - May 2011

Reconstruction of complex groin defects with inferior epigastric artery-based rectus abdominis muscle flaps

Case 2- A 26-year-old male patient was admitted to our general surgery clinic with a palpable soft tissue mass in his left thigh region. The biopsy was reported as soft tissue sarcoma, after which a wide resection of the tumor was performed subsequently after a neoadjuvant treatment protocol. In the clinical and radio-

(a)

(b)

logical follow-ups, a relapse with an invasion of the femoral artery and vein was seen. A surgical therapy was planned, which included a wide resection, followed by resection of the femoral artery and vein 15 cm along its course down the inguinal ligament, and revascularization with a 20 cm graft obtained from the great saphenous vein. In order to address the vast dead space occurring after the oncologic resection and to cover the exposed femoral vascular repair with an abundant soft tissue mass, an inferiorly based RAM flap was planned.

Surgical technique: A left paramedian abdominal incision was made to expose the rectus muscle and its sheath. After visualization of its inferior pedicle, the muscle was harvested with sharp and blunt dissections along its borders. The inguinal ligament was divided and a subcutaneous tunnel was formed through which the muscle was propelled. The exposed vascular graft was conveniently covered with this flap. The paramedian incisions and the inguinal region were closed primarily, while the skin coverage of the muscle was done by a split thickness skin graft harvested from the contralateral anterolateral thigh (Fig. 2).

DISCUSSION Surgical infections following vascular surgery around the inguinal region, particularly if some sort of prosthetic graft is used, may result in arterial occlusion or emboli leading to drastic consequences such as extremity loss.[3,5,6] Therefore, complex inguinal defects with an underlying vascular surgery should be addressed promptly and radically by flaps with adequate vascularity and volume.[3] In order to obtain vascularity and volume, a pedicled or a free muscle flap can be chosen. With regards to complications, these options were found to be comparable.[1,7] However, because of the scarcity of recipient vessels, free flaps are generally not preferred for this region.[3] Other viable alternative flaps for the inguinal region include TFL,[3,8] gracilis,[3,5] sartorius,[3,9] rectus femoris,[3,10] gluteus medius, and vastus lateralis[2] regional muscle flaps.[3] However, adequate tissue volume needed for a viable reconstruction in this region may not be obtained with these options.[3] Another shortcoming of these flaps is their relatively short arc of rotation.

[2] One of the most viable alternatives for the region is, therefore, a RAM flap with its abundant vascularity, more than adequate volume, and an arc of rotation long enough to ensure a tension-free closure.[1]

(c) Fig. 2. (a) Recurrent sarcoma in the left inguinal region. (b) Inferiorly based RAM flap, being prepared to address the dead space. (c) The definitive repair is made with a split thickness skin graft overlying the muscle flap transposed to the defect, perioperative view.

Cilt - Vol. 17 Say覺 - No. 3

A RAM flap harvested in an inferiorly based fashion, which depends on the inferior epigastric artery, may be used to address defects in the chest wall and lower abdominal, femoral,[11] vaginal,[12,13] penile,[11] ischial-trochanteric,[4] pelvic,[1,14] and sacral[15] regions.

An inferiorly based RAM flap can either be harvested 275

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as a muscular unit only or with a skin paddle that may be planned as extended, oblique or vertical at the anterior abdomen.[1,16] In our first case, the skin defect was too large to be covered with a skin island. Additionally, the defect was horizontal so as to extend to the suprapubic region. Our primary goal was to address the dead space in our second case so a skin component was not regarded necessary.

The relative contraindications for choosing a RAM flap include previous injury to the abdomen with obscure history of depth, inferior epigastric artery ligation, obesity (fat necrosis), or presence of a median or paramedian extensive scar in the abdomen.[11,15] Potential donor site morbidities include anterior abdominal wall weakness (bulge) or herniations. Herniation can be possibly eliminated by tight closure of the rectus sheath either with a mesh or nonabsorbable sutures.[15] The motive behind using a TFL graft for the opposite side in Case 1 was to prevent further abdominal weakness by using the rectus muscle bilaterally. On the other hand, the right-sided defect was small enough to let us conveniently use the TFL flap in spite of its weak arc of rotation.

Defects in the inguinal region are to be assessed promptly, preferably immediately with generation of the defect, as Parrett et al.[1] reported marked differences with regards to complications using delayed versus immediate reconstructions (47% and 9.4%, respectively). In our first case, the delayed reconstruction was planned in order to observe the ultimate extent of soft tissue loss caused by the crush injury. It is often difficult to assess the total damage following a crush injury before it manifests later with a necrosis demarcation line. In any case, it is imperative to intervene immediately since, as a general rule, signs of necrosis and infection are settled following these types of injuries.

In conclusion, complex inguinal region defects with subsequent vascular surgery can be reliably and effectively addressed with an inferiorly based rectus abdominal muscle/musculocutaneous flap.

REFERENCES 1. Parrett BM, Winograd JM, Garfein ES, Lee WP, Hornicek FJ, Austen WG Jr. The vertical and extended rectus abdominis myocutaneous flap for irradiated thigh and groin defects.

Plast Reconstr Surg 2008;122:171-7.

2. Ikeda K, Matsuda M, Yamauchi D, Tomita K. Infection of the

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inguinal region treated by musculocutaneous flaps. J Orthop Surg (Hong Kong) 2001;9:51-56.

3. Qi F, Zhang Y, Gu J. Repairs of complex groin wounds with contralateral rectus abdominis myocutaneous flaps. Microsurgery 2009;29:199-204.

4. Kierney PC, Cardenas DD, Engrav LH, Grant JH, Rand RP. Limb-salvage in reconstruction of recalcitrant pressure sores using the inferiorly based rectus abdominis myocutaneous flap. Plast Reconstr Surg 1998;102:111-6.

5. Morasch MD, Sam AD 2nd, Kibbe MR, Hijjawi J, Dumanian GA. Early results with use of gracilis muscle flap coverage of infected groin wounds after vascular surgery. J Vasc Surg 2004;39:1277-83.

6. Chao A, Lai CH, Chen HC, Hsieh HC, Yeow KM. Limb preservation by Gore-Tex vascular graft for groin recurrence after postoperative adjuvant radiation in vulvar cancer. Gynecol Oncol 2001;82:559-62.

7. Hoy E, Granick M, Benevenia J, Patterson F, Datiashvili R, Bille B. Reconstruction of musculoskeletal defects following oncologic resection in 76 patients. Ann Plast Surg 2006;57(2):190-4.

8. Illig KA, Alkon JE, Smith A, Rhodes JM, Keefer A, Doyle A, et al. Rotational muscle flap closure for acute groin wound infections following vascular surgery. Ann Vasc Surg 2004;18:661-8.

9. Perez-Burkhardt JL, Gonzalez-Fajardo JA, Carpintero LA, Mateo AM. Sartorius myoplasty for the treatment of infected groins with vascular grafts. J Cardiovasc Surg (Torino) 1995;36:581-5.

10. Alkon JD, Smith A, Losee JE, Illig KA, Green RM, Serletti JM. Management of complex groin wounds: preferred use of the rectus femoris muscle flap. Plast Reconstr Surg 2005;115:776-85.

11. Kayes OJ, Durrant CA, Ralph D, Floyd D, Withey S, Minhas S. Vertical rectus abdominis flap reconstruction in patients with advanced penile squamous cell carcinoma. BJU Int 2007;99:37-40.

12. Sevin BU, Abendstein B, Oldenburg WA, Oâ&#x20AC;&#x2122;Connor M, Waldorf J, Klingler JP, et al. Limb sparing surgery for vulvar groin recurrence: a case report and review of the literature.

Int J Gynecol Cancer 2001;11:32-8.

13. Weiwei L, Zhifei L, Ang Z, Lin Z, Dan L, Qun Q. Vaginal reconstruction with the muscle-sparing vertical rectus abdominis myocutaneous flap. J Plast Reconstr Aesthet Surg 2009;62:335-40.

14. Tobin GR, Day TG. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg 1988;81:62-73.

15. Cheong YW, Sulaiman WA, Halim AS. Reconstruction of large sacral defects following tumour resection: a report of two cases. J Orthop Surg (Hong Kong) 2008;16:351-4.

16. Taylor GI, Corlett R, Boyd JB. The extended deep inferior epigastric flap: a clinical technique. Plast Reconstr Surg 1983;72:751-65.

MayÄąs - May 2011

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):277-279

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.62347

Sciatic hernia clinically mimicking obturator hernia, missed by ultrasonography: case report Ultrasonografi tarafından atlanan ve klinik olarak obturator herniyi taklit eden siyatik herni: Olgu sunumu Shiraz Ahmad RATHER, Tanveer Iqbal DAR, Aijaz Ahmad MALIK, Fazal Q PARRAY, Mukhtar AHMAD, Syed ASRAR

Sciatic hernia is a rare pelvic floor hernia that occurs through the greater or lesser sciatic foramen. Sciatic hernias often present as pelvic pain, particularly in women, and diagnosis can be difficult. Sciatic hernia is one of the rarest forms of internal hernia, which can present as signs and symptoms of small bowel obstruction, swelling in the respective gluteal region or pelvic pain. Transabdominal and transgluteal operative approaches, including laparoscopic repair, have been reported. We present a case of left-sided sciatic hernia with incarcerated small bowel as its contents.

The hernia was missed by ultrasonography and plain abdominal radiography, but the clinical features were suggestive of an obturator hernia.

Siyatik herni, büyük veya küçük siyatik foramen içinden geçerek oluşan nadir bir pelvis tabanı hernisidir. Siyatik herniler, özellikle kadınlarda sıklıkla pelvik ağrı şeklinde belirti verir ve tanısı güç olabilir. Siyatik herni, ince bağırsak tıkanıklığının belirti ve semptomları olan ilgili taraftaki gluteal bölgede şişlik veya pelvik ağrı şeklinde belirti verebilen en nadir internal herni formlarından birisidir. Laparoskopik onarımı da içeren transabdominal ve transgluteal operatif yaklaşımlar rapor edilmiştir. Biz, içeriği şeklinde de hapsolmuş ince bağırsakla birlikte olan bir sol taraflı siyatik herni olgusunu sunuyoruz. Herni, ultrasonografi ve düz abdominal grafi tarafından atlanmış ve obturator herniyi düşündürmüştür.

Key Words: Sciatic hernia; obturator hernia; intestinal obstruction.

Anahtar Sözcükler: Siyatik herni; obturator herni; bağırsak tıkanıklığı.

An incarcerated sciatic hernia requires immediate surgery, as the incidence of strangulation and bowel gangrene is high, even if symptom duration prior to patient presentation is short,[1-4] unlike other causes of small bowel obstruction (SBO) such as adhesions, in which conservative treatment and expectant observation may be appropriate.[5] Sciatic hernias are of three types. Type 1 (supra piriform muscle) is the most common (60%), followed by sub-piriform, type 2 (30%), while type 3 (subspinous, through the lesser sciatic foramen) is the least common.[6] Various imaging mo-

dalities have been applied in diagnosing this disorder.

[5] A careful physical examination of the buttocks may reveal a tender or non-tender gluteal mass.[5] Only 53 cases of sciatic hernia have been reported to date.

Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India.

Sher-i Kashmir Tıp Bilimleri Enstitüsü, Genel Cerrahi Kliniği, Srinagar, Hindistan.

The aim of reporting this rare case is to highlight the clinical and ultrasonographic inability to diagnose sciatic hernia, and to stress that exact diagnosis is dependent on laparotomy in most such cases presenting to the emergency department, especially when the role of other investigations like computerized tomography (CT) scan is ruled out due to patient instability.

Correspondence (İletişim): Tanveer Iqbal Dar, M.D. S-23, Unmarried Boys Hostel, Skims, Soura, Srinagar, J&K, India 190011 Srinagar, India.

Tel: +01942432709 e-mail (e-posta): drtanveerdar@gmail.com

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CASE REPORT An 80-year-old thin, multiparous female presented to the accident and emergency department of our tertiary care institute with complaints of lower abdominal pain, constipation, recurrent vomiting, and abdominal distention for the last two days. Her history revealed recurrent abdominal colic episodes associated with vomiting, which were managed conservatively at the periphery. There was no history of abdominal surgery of any type. On examination, she was febrile and dehydrated with a pulse rate of 108 beats per minute. Her blood pressure (BP) was 100/60 mmHg. Her abdomen was distended with visible peristalsis from right to left and exaggerated bowel sounds on auscultation.

Laboratory investigations revealed hemoglobin (Hb) of 9 g/dl and total leukocyte count of 14,500 with 90% neutrophils. Conray study revealed small intestinal obstruction with dilated gut proximally. Ultrasonography (USG) and plain X-ray of the abdomen revealed the same findings without localization of the site of obstruction. The patient was explored immediately in view of the dynamic obstruction with suspicion of obturator hernia because she was an elderly, lean, multiparous female, with history of recurrent bowel obstruction, and current diagnosis of SBO, all favoring obturator hernia. On laparotomy, a loop of small bowel was seen passing over the piriform muscle (type 1) through the greater sciatic foramen (Figs. 1 and 2).

The bowel was reduced and viability ensured (Fig. 3).

The sciatic foramen was covered by a patch of endopelvic fascia, and the patient was discharged on the 7th postoperative day without no new complaint. She has been under follow-up in our outpatient department for the last seven months and is doing well.

DISCUSSION Small bowel obstruction (SBO) is a commonly encountered problem in an emergency department.

In a Mayo clinic series, of 289 patients and 314 op-

erations for SBO, adhesions (49%) and neoplasms (16.2%) were the most common causes. Hernias were the third most commonly encountered etiology, contributing to 15% of cases, but less than one-third of these were internal hernias related to entrapment of the small intestine in mesenteric defects.[1] Only 53 cases of sciatic hernia have been documented,[5] and due to a great variety of clinical presentations that depend on hernial content, this uncommon disease is difficult to diagnose.[2-4] Hernia of the ureter or bladder into the sciatic foramen will manifest as urinary tract symptoms. Other contents like colon, omentum, fallopian tubes, ovary, and Meckel diverticulum have also been described. On rare occasions, sciatic hernias may mimic sciatica, with back pain or leg pain owing to compression of the sciatic nerve.[5] It can present as a painless, reducible swelling in the gluteal region.[3] Transabdominal approach is recommended in patients who present with SBO, especially when incarceration or strangulation is suspected. On the other hand, a less invasive transgluteal approach may be used when the herniated segments appear viable and reducible.[2-4] Color Doppler demonstration of blood flow in bowel obstruction due to intussusception has been reported as a promising predictor of bowel viability and hydrostatic reducibility, and the absence of blood flow on Doppler scanning is highly suggestive of irreducibility and bowel ischemia.[5] Plain abdominal radiography is diagnostic in about 50-60% of cases of SBO, equivocal in about 20-30% of cases and normal or misleading in 10-20% of cases, regardless of etiology.[5] Nevertheless, identification of sciatic hernia on plain radiography is not easy.[2-4] Barium studies of SBO are timeconsuming and the barium column may be diluted by intraluminal fluid obscuring the detail of obstruction.

[5] Sciatic hernia diagnosed by herniography has been reported but this method is invasive.[3] Abdominal CT scan has been found useful in patients with features of SBO due to sciatic hernia,[2-4] but a rational guideline

Fig. 1. Patent greater sciatic foramen on the left side is shown with the help of forceps, after an exploratory laparotomy was done.

Fig. 2. Patent greater sciatic foramen on the left side is visible with blood oozing from it, after the incarcerated small bowel was reduced.

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Sciatic hernia clinically mimicking obturator hernia, missed by ultrasonography

peritoneal repair with plug and patch was performed

by Bernard et al.[9] in a case of sciatic hernia diagnosed before the laparoscopic procedure. The patient was an 80-year-old female with a one-year history of chronic right lower limb pain not responding to the conventional analgesics.

In conclusion, SBO due to sciatic hernia is a rare entity without any medical treatment. With a high index of suspicion, an early laparotomy can save the patient from resection anastomosis and its complications.

REFERENCES Fig. 3. Reduced small bowel with dilated proximal end with impending gangrene and narrowed distal end.

for its use in SBO has not been fully developed. Moreover, CT may not be a practical screening tool for all patients with non-specific abdominal pain or vomiting.[7,8] USG is a versatile tool that can be performed at the bedside in the emergency department. Although abundant gas may prevent satisfactory examination of the abdomen, using fluid filled bowel loops as an acoustic window or performing a meticulous examination through the flank may show the presence, level and cause of SBO. However, less than 20% of underlying etiologies of SBO can definitively be recognized with this method.[5] In our case, we could not do CT scan of the abdomen, and color Doppler was not considered because the patient was in full blown dynamic intestinal obstruction with features of impending small bowel gangrene, and was taken for emergency laparotomy. USG, however, was not helpful in delineating the cause of SBO. Laparoscopic transabdominal extra-

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1. Mucha P Jr. Small intestinal obstruction. Surg Clin North Am 1987;67:597-620.

2. Ghahremani GG, Michael AS. Sciatic hernia with incarcerated ileum: CT and radiographic diagnosis. Gastrointest Radiol 1991;16:120-2.

3. Hayashi N, Suwa T, Kimura F, Okuno A, Ishizuka M, Kakizaki S, et al. Radiographic diagnosis and surgical repair of a sciatic hernia: report of a case. Surg Today 1995;25:1066-8.

4. Servant CT. An unusual cause of sciatica. A case report.

Spine (Phila Pa 1976) 1998;23:2134-6.

5. Yu PC, Ko SF, Lee TY, Ng SH, Huang CC, Wan YL. Small bowel obstruction due to incarcerated sciatic hernia: ultrasound diagnosis. Br J Radiol 2002;75:381-3.

6. Javid PJ, Brooks DC. Hernias. In: Zinner MJ, Ashley SW, editors. Maingotâ&#x20AC;&#x2122;s abdominal operations. 11th ed, McGraw Hill; 2007. p. 103-39.

7. Balthazar EJ. George W. Holmes Lecture. CT of small-bowel obstruction. AJR Am J Roentgenol 1994;162:255-61.

8. Tiao MM, Wan YL, Ng SH, Ko SF, Lee TY, Chen MC, et al. Sonographic features of small-bowel intussusception in pediatric patients. Acad Emerg Med 2001;8:368-73.

9. Bernard AC, Lee C, Hoskins J, Lee J, Patel S, Ginn G, et al.

Sciatic hernia: laparoscopic transabdominal extraperitoneal repair with plug and patch. Hernia 2009; 1265-4906 (Print) 1248-9204.

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Ulus Travma Acil Cerrahi Derg 2011;17 (3):280-282

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.36633

Nadir görülen bir hemopnömotoraks nedeni: Aberan sistemik arter A rare cause of hemopneumothorax: an aberrant systemic artery Çağatay TEZEL, Erdal OKUR, Volkan BAYSUNGUR, Ersin ÇARDAK, Semih HALEZEROĞLU

Spontan hemopnömotoraks nadir görülen bir durumdur, genç hastalarda oluşabilecek hemodinamik dengesizliğe bağlı hipovolemik şok nedeniyle yaşamı tehdit edebilir.

Hemopnömotoraksın nadir nedenlerinden biri apikal bölgede var olan aberran sistemik arterin akciğerin sönmesi sonucu gerilerek yırtılmasıdır. Literatürlerde bu durum nadir rastlanılan bir üçüncü neden olarak gösterilmektedir.

Bu yazıda, spontan hemopnömotoraks nedeni olarak belirlenen aberran sistemik arter literatür eşliğinde tartışıldı.

Spontaneous hemopneumothorax is a rare situation that can be life-threatening in young patients presenting hemodynamic instability due to hypovolemic shock. One of the extraordinary causes of hemopneumothorax is rupture of an apically located aberrant artery after pneumothorax, which is noticed as a third etiological factor in the literature. This case is presented in order to highlight this uncommon etiological factor together with the literature.

Anahtar Sözcükler: Hemopnömotoraks; pnömotoraks; vasküler anomali.

Key Words: anomaly.

Spontan hemopnömotoraks (SHP), travma veya açık bir neden olmadan plevral boşluk içine kan ve hava birikmesi olarak ilk kez otopside Laennec tarafından 1828 de tarif edilmiş olup, Whittaker tarafından 1876 yılında tekrarlayan aspirasyonlarla tedavi edilmiştir.[1] SHP genç erişkinlerde nadir görülen ancak hayatı tehdit edebilen klinik bir durumdur. Tüm spontan pnömotoraksların %1-12’sinde görülebildiği bildirilmiştir.[2]

yer değiştirmiş olduğu izlendi (Şekil 1). Laboratuvar bulgularında lökosit 10,1 10^3/µl, hemoglobin 7,4 gr/ dl, hematokrit %21,9, trombosit 327 10^3/µl olup, koagülometresi normal sınırlardaydı.

OLGU SUNUMU Yirmi dokuz yaşında erkek hasta 5 gündür var olan nefes darlığı ve halsizlik şikayetiyle acil servisimize başvurdu. Fiziksel incelemesinde hastanın soluk ve dispneik olduğu görüldü. Nabız 130/dak, tansiyon arteriyel 130/80 mmHg idi. Oda havasında arteriyel kan gazında O2 sat: %94,8, PO2: 64,7 mmHg, PCO2: 33,8 mmHg idi. Akciğer grafisinde sol hemitoraksta yerleşimli hidropnömotoraks ve mediastenin sağa doğru

Süreyyapaşa Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi, İstanbul

Hemopneumothorax;

pneumothorax;

Bu bulgularla hastamıza 32 F polietilen dren ile tüp torokostomi uygulandı. 2500 ml hemorajik mayi boşaltıldı. Hemorajik drenajın hemotokrit düzeyi %18 idi. Hemogram değeri düşük olan hastaya 2 ünite eritrosit süspansiyon transfüzyonu yapıldı. 12 saatlik takibinde drenaj 800 ml olarak gerçekleşti. Kontrol akciğer grafisi ekspanse olan ve drenajı kesilen hastanın stabil olmasıyla toraks bilgisayarlı tomografisi (BT) çekildi. BT bulgularında, hemotom ve plevral kalınlaşma ile uyumlu görünüm görülmesi üzerine cerrahi girişime karar verildi (Şekil 2).

Hastaya videotoraksokopik yöntemle hematom boşaltılması amaçlandı. Ancak yoğun plöroparankimal yapışıklıklardan dolayı lateral kas koruyucu torako-

Sureyyapasa Chest Diseases and Thoracic Surgery Training Hospital, Istanbul, Turkey.

İletişim (Correspondence): Dr. Çağatay Tezel. Yazmacı Tahir Sok., No: 51/9, Bostancı, İstanbul, Turkey.

Tel: +90 - 216 - 421 42 00 e-posta (e-mail): mdcagatay@hotmail.com

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Nadir görülen bir hemopnömotoraks nedeni: Aberan sistemik arter

Şekil 1. Akciğer grafisinde sol hidropnömotoraks ve buna bağlı sağa mediastinal şift.

Şekil 2. Toraks BT’sinde sol plevral kalınlaşma ve hemotom ile uyumlu görünüm. Eşlik eden sol cilt altı amfizemi izlenmekte.

tomi ile hematom boşaltıldı. Akciğerin üzerindeki kalınlaşmaya neden olan debrisler temizlendi. Akciğerin serbestleştirilmesi sırasında subklavian arter ile üst lob apikal segment arasında anormal vasküler yapı görüldü (Şekil 3). Vasküler yapı klipslenip kesildi. Ameliyat sonrası dönemi sorunsuz geçen hastanın ikinci gün dreni çekildi, üçüncü gün taburcu edildi.

nın 24 saatten az devamı halinde önerilmekteyse de[7] özellikle kontrol akciğer grafilerinde akciğerin ekspansiyon kusurunun devam ettiği durumlarda parankimin bası etkisi ortadan kalkacağı ve var olan intraplevral negatif basınç nedeniyle kanamaların miktar ve süresi fazla olacaktır. Bununla birlikte olgumuzdaki gibi aberan damar kanamalarında damar yapılarının muscularis kas kitlesi zayıflığından pnömotoraksa sekonder kopma veya yaralanma sonucu yeterli konstrikte olamaması da kanamanın kendiliğinden durmasını güçleştiren bir diğer sebeptir.[2]

TARTIŞMA SHP plevral kavite içerisine 400 ml’den fazla kanın biriktiği spontan pnömotorkasın eşlik ettiği durum olarak tanımlanmaktadır.[3] Her ne kadar spontan pnömotoraks insidansı yüksek olsa da SHP nadir görülmektedir. Üç olası kanama mekanizması öngörülmüş olup, ilki akciğerin çökmesi sonrası, parietal ve visseral plevralar arasında oluşmuş küçük ve nonkontrakte damarların yırtılmasıdır,[4] diğeri ise vaskülerize bir bülün rüptürüdür.[3,4] Daha nadir görülen ve olgumuzda da SHP nedeni olan üçüncü sebep ise akciğer parankimine dal veren doğuştan aberan damarların pnömotoraks ile akciğerin çökmesi sonucu gerilip yırtılmasına bağlıdır.[5,6] Olgumuzda gözlemlenmiş olan bu aberan arter, sol subklavian arterden dallanıp akciğerin apeksini beslemektedir.

Olgu sunumlarında, konservatif tedavi kanama-

SHP insindansının spontan pnömotorakslı hastalarının %2 ile %7,3 arasında olduğu gösterilmiştir.[4] Kakaris ve arkadaşlarının 30 yıllık 3489 spontan pnömotoraks serisinin %2’sini SHP oluşturmaktadır.[8] Bu seride SHP olan hastaların %22,5’inde konservatif tedavi başarılı olmuş olup, kalan 55 hastanın %40’ı hemorajik şoka bağlı acil şartlarda ameliyata alınmıştır. Diğerleri elektif şartlarda pıhtılı hemitoraksın irrigasyonu veya bül rezeksiyonu nedeniyle ameliyat edilmiştir.

Bu grup hastalardaki torakotomi endikasyonları hipovolemik şok, hemorajik drenaj (100 ml/saat), hava kaçağının devamı, nükseden pnömotoraks olarak özetlenebilir; 448 olguluk bir diğer spontan pnömotoraks serisinde 27 (%5,5) SHP saptanmıştır, bu seride SHP’li

Şekil 3. Sol torakotomi ile sol subklaviyan arterden akciğer apikaline uzanan aberan arter.

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olguların ortalama drenajları 1,020 ml olarak hesaplanmış, 9 olguda hemorajik şok bulguları saptanmıştır.

Tüm olgulara videotorakoskopik cerrahi uygulanmış ve şok tablosu olan 9 olgunun 7’sinde hemotoraks sebebi aberan damar olarak tespit edilmiştir. Aberan damar kanamalı olgularda hemostaz hemoklips ile sağlanmıştır.[4] Olgumuzun hikayesinin 5 günlük olması, ilk drenajı miktarının fazla olmasına rağmen takibinde drenaj olmaması, yeterli transfüzyonun ardında stabil hale gelmesi olguda konservatif yaklaşımımıza neden olmuştur.

Cerrahi yöntemlerden olan videotorakoskopik cerrahi, erken ve geç dönem tanı ve tedavide kullanılan, ameliyat sonrası ağrıyı ve hastanede kalış süresini azaltan en iyi yöntemdir. Erken cerrahi girişimle pıhtılı hemotoraksın videotoraksokopik yöntemle boşaltılması, hastaları ileriki dönemlerde olası bir dekortikasyon ameliyatından kurtarabilmektedir.[2,4] Bu nedenle erken cerrahi girişim (torakotomi/video yardımlı cerrahi) tanı ve tedaviyi aynı anda başardığından, hastane kalış süresini kısalttığından nadir görülen klinik bir durum olan SHP’li hastalarda düşünülmelidir. Olgumuzda da cerrahi girişim erken dekortikasyonun başarı ile sağlanması amacıyla ilk hafta içerisinde gerçekleştirilmiştir. Düşük anestezi riski bulunan genç hastalarda, videotoraksokopik yöntemin torasik kaviteyi değerlendirme, olası hava kaçağı sebeplerinin tedavisi ve iyi drenaj gibi üstünlüğü vardır.[9] Sonuç olarak, bazı SHP olguları yoğun kanama nedeniyle hayatı tehdit eden hipovolemik şoka neden

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olabilir. SHP nedeni olarak, akciğere giden sistemik bir aberan arterin olabileceği akılda tutulmalı ve cerrahi girişim sırasında böyle bir arter varlığı araştırılmalıdır.

KAYNAKLAR 1. Whitaker JT. Case of hemopneumothorax, relieved by aspiration. Clin Cincinnati 1876;10:793-8.

2. Tatebe S, Kanazawa H, Yamazaki Y, Aoki E, Sakurai Y. Spontaneous hemopneumothorax. Ann Thorac Surg 1996;62:1011-5.

3. Ohmori K, Ohata M, Narata M. Twenty-eight cases of spontaneous hemopneumothorax. J Jpn Assoc Surg1988;36:105964.

4. Hsu NY, Shih CS, Hsu CP, Chen PR. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature. Ann Thorac Surg 2005;80:1859-63.

5. Muraguchi T, Tsukioka K, Hirata S, Fukuda S, Mizugami K, Kishi A, et al. Spontaneous hemopneumothorax with aberrant vessels found to be the source of bleeding: report of two cases. Surg Today 1993;23:1119-23.

6. Kurimoto Y, Hatamoto K, Hase M, Narimatsu E, Asai Y, Abe T. Aberrant artery as a source of bleeding in spontaneous hemopneumothorax. Am J Emerg Med 2001;19:326-7.

7. de Perrot M, Deléaval J, Robert J, Spiliopoulos A. Spontaneous hemopneumothorax--results of conservative treatment.

Swiss Surg 2000;6:62-4.

8. Kakaris S, Athanassiadi K, Vassilikos K, Skottis I. Spontaneous hemopneumothorax: a rare but life-threatening entity.

Eur J Cardiothorac Surg 2004;25:856-8.

9. Hwong TM, Ng CS, Lee TW, Wan S, Sihoe AD, Wan IY, et al. Video-assisted thoracic surgery for primary spontaneous hemopneumothorax. Eur J Cardiothorac Surg 2004;26:8936.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2011;17 (3):283-285

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.46704

Rapid resolution of acute epidural hematoma: case report and review of the literature Hızlı rezolüsyon gösteren akut epidural hematom: Olgu sunumu ve literatürün değerlendirilmesi Habibullah DOLGUN,1 Erhan TÜRKOĞLU,1 Hayri KERTMEN,1 Erdal Reşit YILMAZ,1 Behzat Ruchan ERGUN,2 Zeki ŞEKERCİ1 Acute epidural hematomas present a serious and urgent condition. Standard management is early diagnosis and immediate surgical evacuation. Otherwise, there is a high risk of quick deterioration and death. Only patients with small asymptomatic epidural hematomas can be managed conservatively with close observation. We present a case of traumatic right temporal epidural hematoma. This is one of the rare cases of rapid spontaneous resolution of epidural hematomas within hours. Various possible mechanisms to explain the rapid resolution are discussed together with a review of the literature regarding the conservative treatment of epidural hematoma.

Akut epidural hematomlar ciddi ve ağır klinik tablolardır.

Erken tanı ve cerrahi boşaltma standart tedavi yaklaşımıdır. Aksi takdirde klinik tabloda hızla bozulma ve ölüm riski taşır. Asemptomatik küçük bir hasta grubu, yakın nörolojik ve radyolojik takip ile konservatif olarak tedavi edilebilir. Bu yazıda, 3 saat gibi kısa bir süre içerisinde rezolüsyon gösteren travmatik sağ temporal akut epidural hematom olgusu sunuldu. Bu olgu saatler içerisinde hızlı rezolüsyon görülen nadir olgulardan biridir. Çeşitli rezolüsyon mekanizmaları literatür verileri ışığında tartışılmıştır.

Key Words: Early resolution; cranial epidural hematoma; skull fracture.

Anahtar Sözcükler: Erken rezolüsyon; kraniyal epidural hematom; kafatası kırığı.

Epidural hematoma (EDH) constitutes one of the most critical emergencies after traumatic head injury.

Early diagnosis and fast evacuation are the standard management of this pathology. Advances in imaging techniques have enabled early and accurate diagnosis of EDH and can guide the operative treatment.

Recently, non-operative treatment has been adopted in patients with subacute (3-14 days) and chronic (2 weeks and more) EDH.[1-3] In a small group of patients, EDHs have rapidly disappeared in less than 24 hours.

[4-6] Many mechanisms of resolution have been reported, but exactly how the hematoma disappears remains unclear.[5,7-10]

CASE REPORT A 27-year-old male fell from a height of approximately four meters. He was transported directly to our hospital emergency department by ambulance immediately after injury. On admission, his general condition was poor. He was agitated and had no cooperation or orientation. His pupils were equal and the reaction to light was bilaterally positive. He showed abnormal extremity flexion to pain. Systemic examination revealed right otorrhea and an evident subgaleal swelling on his right temporal region. He had stove-in chest, subcutaneous emphysema of the chest and neck, and open leg fractures bilaterally. Radiological evaluation revealed hemopneumothorax on the right side and tibia fractures bilaterally. His blood hemoglobin level was

We report a case of EDH that disappeared rapidly without surgical evacuation.

1st Department of Neurosurgery, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara; 2Department of Neurosurgery, Abant Izzet Baysal University Faculty of Medicine, Bolu, Turkey.

1

Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, 1. Nöroşirürji Kliniği, Ankara; 2Abant İzzet Baysal Üniversitesi Tıp Fakültesi Beyin Cerrahi Anabilim Dalı, Bolu.

1

Correspondence (İletişim): Erhan Türkoğlu, M.D. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastenesi, 1. Beyin ve Sinir Cerrahisi Kliniği, Dışkapı 06110 Ankara, Turkey.

Tel: +90 - 312 - 360 65 80 e-mail (e-posta): drmet122@yahoo.com

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ternal auditory canal. The patient was intubated and admitted to our intensive care unit and sedated. He was placed on intracranial pressure (ICP) monitoring, and ICP values were normal. There was a steady increase in otorrhea from the right ear. A third CT scan taken 3 hours after admission showed near total resolution of the hematoma (Fig. 2a, b). The patient’s postinjury course did not improve and he died at the 24th hour of the injury as a result of accompanying pathologies such as hemopneumothorax and pulmonary contusion.

Fig. 1. Axial CT scan without contrast obtained on admission shows convex hematoma in the right epidural space.

7.0 g/dl and four units of erythrocyte suspension were transfused. His Glasgow Coma Scale (GCS) score was 7/15 because of serious injury and moderate head trauma. Chest tube thoracostomy was done to drain blood and air. The patient underwent urgent computerized tomography (CT). He was very agitated and active on the positioning table. The head of the patient was not turned while CT images were taken, but slight rotations to the left or right side went unnoticed by the emergency team. Consequently, we could not obtain standard CT images. The brain CT scan revealed a linear skull fracture on his right temporal bone, and an EDH of 1.2 cm thickness in the right temporal region (Fig. 1). The temporal linear fracture crossed the ex-

(a)

DISCUSSION Epidural hematoma is generally managed with surgical treatment but non-operative treatment of EDHs has been argued.[4-10] Weaver et al.[3] first reported two EDH cases who showed spontaneous resolution. Nonoperative management of small hematomas has been proposed. The resolution biomechanism could be comparable to that of chronic subdural hematomas.

The formation of a fibrovascular neomembrane lining the dural side acts as an absorbing structure for the blood clot. The angioblasts form sinusoids that gradually connect with the marginal dural vessels, so blood and blood products can return to the systemic circulation via the permeable membrane of these sinusoids.

[1,5,6,11-13] However, such hematoma resolution is reported as longer than three weeks.[6-8] Medical treatment, repeated CT scan and close neurological follow-up are essential in the conservative management.[2-6,9-11,13] In the present case, the EDH was not large enough to warrant absolute surgical intervention. Surprisingly, a very rapid spontaneous resolution of the hematoma was observed and this can be considered an extremely rare situation.

(b)

Fig. 2. (a) Same level axial CT scan as seen in Fig. 1 does not demonstrate epidural hematoma localization because the patient’s head was not in the same position as in the first CT scan. The head was turned to nearly the opposite side, and the slice shows right mastoid cells and right orbita clearly. (b) Axial CT scan without contrast obtained 3 hours after injury shows almost total disappearance of the hematoma. This cross-section is not at the same level as seen in Fig. 1 because the patient’s head position was altered on each CT slice. In fact, this slice shows the true epidural hematoma area, which had resolved almost totally in 3 hours.

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Rapid resolution of acute epidural hematoma

Table 1. Overview of several reports of acute resolution of epidural hematoma and

possible mechanism of resolution Authors

Year

Age/Sex

Aoki

Servadei Kuroiwa Malek

Ugarriza Wagner Celikoglu Kang

1988

1989 1993 1997

1999 2002 2002 2005

8/M 17/M 65/M 17/M 17/M

43/M 48/M 8/M 34/M

Resolution/mechanism Pressure gradient Pressure gradient Pressure induced redistribution Pressure gradient Elevated interstitial pressure in the subgaleal compartment EDH communicated with EAC Pressure gradient Pressure gradient Pressure gradient

Time to resolution 10h 2h 4h 12h 18h 6h 1h 1h 21h

EAC: External auditory canal; EDH: Epidural hematoma; H: Hour; M: Male.

In the literature, various mechanisms related with early spontaneous resolution of EDH have been reported (Table 1). Some authors emphasized the potential communication between the intra and epicranial spaces through a fracture.[4,14] Increasing ICP creates a pressure gradient between the EDH and epicranial soft tissues, such that the EDH is forced out of the epidural space through the fracture.[2-6] On follow-up CT scans, the changing density in pericranial soft tissues also supported this hypothesis.[5] Another possible mechanism of the spontaneous resolution is the pressureinduced redistribution secondary to brain swelling, but dissipation of the hematoma seems harder because of tenacious adhesion between the dura mater and the skull.[5,8,9] Malek et al.[8] reported another mechanism that might be caused by an elevated epicranial subgaleal interstitial pressure after injury, in which extracranial blood collection or serous fluid could leak to the epidural space through a fracture because of the pressure gradient. When interstitial subgaleal pressure relaxed, the fluid leaked back. This process was completed in 18 hours. On the other hand, hyperacute resolution of EDH is a very rare phenomenon.[4,6,10] Communication between the EDH and external auditory canal made ultra-early resolution possible without symptomatic intracranial hypertension.[11] In the present case, CT scan revealed minimally displaced fracture of the temporal bone that crossed the auditory canal. In addition, there were no clear elevated ICP findings in the CT scan. We thought that the dura might have been torn and the hematoma liquified with the leak of cerebrospinal fluid through this small dural tear. In such a case, early drainage of the EDH might have been possible from the epidural space through the external auditory canal even without ICP elevation. This is the third case in the literature with a rapid resolution time of 3 hours (Table 1).

In conclusion, most EDH cases are treated surgically. Only patients with small asymptomatic EDHs can be managed conservatively with close observaCilt - Vol. 17 Sayı - No. 3

tion, and repeated CT scans are advised to facilitate surgical evacuation in case of deterioration.

REFERENCES 1. Pang D, Horton JA, Herron JM, Wilberger JE Jr, Vries JK. Nonsurgical management of extradural hematomas in children. J Neurosurg 1983;59:958-71.

2. Pozzati E, Tognetti F. Spontaneous healing of extradural hematomas: report of four cases. Neurosurgery 1984;14:724-7.

3. Weaver D, Pobereskin L, Jane JA. Spontaneous resolution of epidural hematomas. Report of two cases. J Neurosurg 1981;54:248-51.

4. Aoki N. Rapid resolution of acute epidural hematoma. Report of two cases. J Neurosurg 1988;68:149-51.

5. Kang SH, Chung YG, Lee HK. Rapid disappearance of acute posterior fossa epidural hematoma. Neurol Med Chir (Tokyo) 2005;45:462-3.

6. Kuroiwa T, Tanabe H, Takatsuka H, Arai M, Sakai N, Nagasawa S, et al. Rapid spontaneous resolution of acute extradural and subdural hematomas. Case report. J Neurosurg 1993;78:126-8.

7. Akagami R, Cochrane DD. Does it leak in or does it leak out.

Concerning the article by Malek et al., Pediatr Neurosurg 1997;26:160-165. Pediatr Neurosurg 1999;30:109-10.

8. Malek AM, Barnett FH, Schwartz MS, Scott RM. Spontaneous rapid resolution of an epidural hematoma associated with an overlying skull fracture and subgaleal hematoma in a 17-month-old child. Pediatr Neurosurg 1997;26:160-5.

9. Servadei F, Staffa G, Pozzati E, Piazza G. Rapid spontaneous disappearance of an acute extradural hematoma: case report.

J Trauma 1989;29:880-2.

10. Celikoğlu E, Süsülü H, Delatioğlu M, Ceçen A, Hakan T, Bozbuğa M. Rapid spontaneous resolution of an acute epidural hematoma. Ulus Travma Derg 2002;8:126-8.

11. Ugarriza LF, Cabezudo JM, Fernandez-Portales I. Rapid spontaneous resolution of an acute extradural haematoma: case report. Br J Neurosurg 1999;13:604-5.

12. Sato S, Suzuki J. Ultrastructural observations of the capsule of chronic subdural hematoma in various clinical stages. J Neurosurg 1975;43:569-78.

13. Wagner A, Freudenstein D, Friese S, Duffner F. Possible mechanisms for rapid spontaneous resolution of acute epidural hematomas. Klin Neuroradiol 2002;12:45-50.

14. Chan KH, Mann KS, Yue CP, Fan YW, Cheung M. The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study. J Neurosurg 1990;72:189-94.

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Ulus Travma Acil Cerrahi Derg 2011;17 (3):286-288

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2011.71676

An unusual cause of small bowel perforation: apricot pit Nadir bir ince bağırsak delinme nedeni: Kayısı çekirdeği Koray ATİLA, Sanem GÜLER, Seymen BORA, Hüseyin GÜLAY

Ingestion of foreign bodies can be a common problem, especially among children, alcoholics, and psychiatric and senile patients. Foreign bodies with smooth edges usually do not pose significant problems, but a sharp foreign object that is not retrieved immediately may penetrate the wall and cause complications. Ingested foreign bodies usually pass the intestinal tract uneventfully, and perforation occurs in less than 1%. In this study, we report a case of small bowel obstruction with perforation in a 73-year-old female due to the accidental swallowing of an apricot pit.

Yabancı cisimlerin yutulması, özellikle çocuklar, alkolikler, psikiyatrik hastalar ve yaşlılar arasında yaygın bir sorundur.

Yuvarlak uçlu yabancı cisimler sıklıkla bir soruna neden olmazken sivri uçlu yabancı cisimler erken dönemde çıkarılmadıkları takdirde intestinal duvara penetre olup komplikasyona neden olabilirler. Yutulan yabancı cisimlerin çoğunluğu sorunsuz intestinal kanaldan geçerken sadece %1’den daha azı perforasyona neden olur. Bu yazıda, 73 yaşında kadın hastada yanlışlıkla yutulan kayısı çekirdeğine bağlı ince bağırsak tıkanıklığı ve delinmesi olgusunu sunduk.

Key Words: Apricot pit; foreign body; small bowel perforation.

Anahtar Sözcükler: Kayısı çekirdeği; yabancı cisim; ince bağırsak delinmesi.

Ingestion of foreign bodies can be a common problem, especially among children, alcoholics, and psychiatric and senile patients. Approximately 80% to 90% of small foreign bodies reaching the stomach will spontaneously pass through the alimentary canal.

[1] It is currently thought that less than 1% of ingested foreign bodies will perforate the bowel; large, sharp or pointed objects carry the greatest risk.[2] Adhesions due to previous abdominal surgery are the most common cause of small bowel obstruction in adults. Food bolus impaction is one of the rare causes of such an obstruction.[3] Food bolus impaction is common with meat and fish bones, but very few cases due to fruits have been reported.[4]

CASE REPORT A 73-year-old female was admitted to the emergency department of our hospital with a three-day history of diffuse abdominal pain, nausea and vomiting. She had vomited her digested daily meal several times and had not passed any gas for two days. She was well before this attack, except for chronic constipation. She had a history of prior abdominal hysterectomy-bilateral salpingo-oophorectomy operation.

In this study, we report a case of small bowel obstruction with perforation in a 73-year-old female due to the accidental swallowing of an apricot pit.

Although she had decreased skin turgor and dry mucosal surfaces, there was no sign or symptom of neurologic deficit or psychiatric illness. On physical examination, abdominal distension and accompanying hyperactive bowel sounds on each upper abdominal quadrant were present. She had a low-midline abdominal incision scar, and no inguinal or incisional hernia was seen. There was generalized tenderness on palpa-

Department of General Surgery, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey.

Dokuz Eylül Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İzmir.

Correspondence (İletişim): Koray Atila, M.D. Dokuz Eylül Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Balçova 35330 İzmir, Turkey.

Tel: +90 - 232 - 412 29 17 Fax (Faks): +90 - 232 - 412 23 88 e-mail (e-posta): katila@deu.edu.tr

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An unusual cause of small bowel perforation: apricot pit

ing situation; however, in most patients, the diagnosis is not confirmed until the surgical intervention.

Fig. 1. Appearance of the apricot pit perforating the distal ileum.

tion. No electrolyte imbalance was observed. A plain X-ray of the abdomen revealed multiple air-fluid levels of the small bowel and no free air in subdiaphragmatic areas. Abdominal ultrasonography revealed only dilated loops of intestinal segments, which confirmed the presumptive diagnosis of ileus. On the 24th hour of admission, she developed an “acute abdomen”. She underwent an exploratory laparotomy, which revealed a peritoneal soiling due to distal ileum perforation caused by an apricot pit. It was loosely sealed off by an omentum patch (Fig. 1). The peritoneal cavity was irrigated with warm normal saline. Segmental resection of the terminal ileum and end to end anastomosis was performed. A closed wound suction drainage tube was placed in the pelvis. Histologic examination revealed focal mucosal necrosis and foreign body type granular reaction on mucosal, submucosal and muscular layers. Necrotic areas were seen extending to the serosal layer.

On the postoperative 10th day, an enterocutaneous fistula developed. It was treated initially with a combination of total parenteral nutrition and somatostatin, then daily output was followed. Since it was considered a low-output fistula, somatostatin treatment was discontinued within 72 hours. The fistula resolved spontaneously and she was discharged from the hospital on postoperative 24th day.

DISCUSSION Accidental ingestion of a foreign body occurs rarely and perforation occurs in less than 1% of ingested bodies.[5] The most common sites of intestinal perforation by a foreign body are the ileocecal and rectosigmoid regions.[6] Clinical presentations vary, depending on the site of perforation and the extent and duration of peritonitis.[7] As these patients usually do not remember the foreign body ingestion, the final diagnosis is frequently delayed. Computed tomography scans and ultrasonography may help clinicians in this challengCilt - Vol. 17 Sayı - No. 3

The risk factors for foreign body ingestion are mental retardation, dental prothesis, alcohol abuse, and rapid eating.[5] In our case, the patient had dental plates and rapid eating habit. On questioning, she explained that she had a fruit garden and reported eating a lot of apricots rapidly during the week. Although an apricot pit is not sharp and pointed, it was impacted to the distal ileum region, causing necrosis with perforation.[8] A myriad of swallowed foreign bodies have been reported.[5-7] Those most commonly associated with complications are toothpicks, fish and chicken bones and needles.[6,8-12] Although most of the sharppointed objects entering the stomach will pass through the remaining gastrointestinal tract without incident, the risk of complication caused by a sharp-pointed object is as high as 35%.[13] Sharp, pointed foreign bodies often cause perforations in the gastrointestinal tract; endoscopic removal is advisable if they are within the reach of available endoscopes.[14] With advances in endoscopic techniques, foreign bodies can be extracted safely in these patients. The majority of foreign body ingestions occur in the pediatric population, and children most often ingest toys, coins, safety pins, and ballpoint pen caps,[15] whereas adults prevalently tend to have problems with meat and bones.[13] Normal physical examination findings and absence of symptoms in children do not eliminate the possibility of foreign body ingestion especially in the presence of positive history.[15] After 14 days, the fistula of the patient resolved with administration of gastrointestinal decompression, total parenteral nutrition and intravenous somatostatin infusion.

In conclusion, although intestinal obstruction and perforation occur rarely after foreign body ingestion,[5] this situation should always be considered in the differential diagnosis, and early therapeutic precautions should be taken especially in selected patients.

REFERENCES 1. Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002;55:802-6.

2. Selivanov V, Sheldon GF, Cello JP, Crass RA. Management of foreign body ingestion. Ann Surg 1984;199:187-91.

3. Lohn JWG, Austin RCT, Winslet MC. Unusual causes of small bowel obstruction. J R Soc Med 2000;93:365-68.

4. Ihara N, Yashiro N, Kinoshita T, Yoshigi J, Kasai T. Small bowel obstruction due to pickled Japanese apricot: CT findings. J Comput Assist Tomogr 2002;26:132-3.

5. Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingested foreign bodies of the gastrointestinal tract: retrospective analysis of 542 cases. World J Surg 1996;20:1001-5.

6. Pinero Madrona A, Fernández Hernández JA, Carrasco Prats M, Riquelme Riquelme J, Parrila Paricio P. Intestinal perfo287

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ration by foreign bodies. Eur J Surg 2000;166:307-9.

7. Losanoff JE, Kjossev KT. Ingested foreign bodies of the gastrointestinal tract. J Emerg Med 1999;17:525-6.

8. Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, et al. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg 2006;30:372-7.

9. Steenvoorde P, Moues CM, Viersma JH. Gastric perforation due to the ingestion of a hollow toothpick: report of a case.

Surg Today 2002;32:731-3.

10. Hsu SD, Chan DC, Liu YC. Small-bowel perforation caused by fish bone. World J Gastroenterol 2005;11:1884-5.

11. Nagaraj HS, Sunil I. Multiple foreign body ingestion and il-

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eal perforation. Pediatr Surg Int 2005;21:718-20.

12. Bhatia R, Deane AJ, Landham P, Schulte KM. An unusual case of bowel perforation due to fish fin ingestion. Int J Clin Pract 2006;60:229-31.

13. Stack LB, Munter DW. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am 1996;14:493-521.

14. Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc 1995;41:39-51.

15. Yalçin S, Karnak I, Ciftci AO, Senocak ME, Tanyel FC, Büyükpamukçu N. Foreign body ingestion in children: an analysis of pediatric surgical practice. Pediatr Surg Int 2007;23:755-61.

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