TRAVMA 2013-1

Cilt - Volume 19

Say› - Number 1

www.tjtes.org

Ocak - January 2013

Cilt - Volume 19

Sayı - Number 1

Ocak - January 2013

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 ACİL CERRAHİ DERGİSİ TURKISH JOURNAL OF TRAUMA AND EMERGENCY SURGERY Editör (Editor) Recep Güloğlu Yardımcı Editörler (Associate Editors) Kaya Sarıbeyoğlu Hakan Yanar Ahmet Nuray Turhan 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 Murat Aksoy Şeref Aktaş Ali Akyüz Ömer Alabaz Orhan Alimoğlu Nevzat Alkan Edit Altınlı Acar Aren Gamze Aren Cumhur Arıcı Oktar Asoğlu Ali Atan Bülent Atilla Levent Avtan Yunus Aydın Önder Aydıngöz Erşan Aygün Mois Bahar Akın Eraslan Balcı Emre Balık Umut Barbaros Semih Baskan M Murad Başar Mehmet Bayramiçli Ahmet Bekar Orhan Bilge Mustafa Bozbuğa Mehmet Can Başar Cander Nuh Zafer Cantürk Münacettin Ceviz Banu Coşar Figen Coşkun İrfan Coşkun Nahit Çakar Adnan Çalık Fehmi Çelebi Gürhan Çelik Oğuz Çetinkale M. Ercan Çetinus Sebahattin Çobanoğlu Ahmet Çoker Cemil Dalay Fatih Dikici Yalım Dikmen Osman Nuri Dilek Kemal Dolay Levent Döşemeci Murat Servan Döşoğlu Kemal Durak Engin Dursun

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

Atilla Elhan Mehmet Eliçevik İmdat Elmas Ufuk Emekli Haluk Emir 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 İbrahim İkizceli Haluk İnce Fuat İpekçi Ferda Şöhret Kahveci Selin Kapan Murat Kara Hasan Eşref Karabulut Ekrem Kaya Mehmet Yaşar Kaynar Mete Nur Kesim Yusuf Alper Kılıç 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 Cemal Özçelik İlgin Özden Mehmet Özdoğan

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

Şükrü Özer Halil Özgüç Ahmet Özkara Mahir Özmen Vahit Özmen Niyazi Özüçelik Süleyman Özyalçın Emine Özyuvacı Salih Pekmezci İzzet Rozanes Kazım Sarı Esra Can Say Ali Savaş İskender Sayek Tülay Özkan Seyhan Gürsel Remzi Soybir Yunus Söylet Erdoğan Sözüer Mustafa Şahin Cüneyt Şar Mert Şentürk Feridun Şirin İbrahim Taçyıldız Gül Köknel Talu Ertan Tatlıcıoğlu Gonca Tekant Cihangir Tetik 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 Cumhur Yeğen Ebru Yeşildağ Hüseyin Yetik Cuma Yıldırım Bedrettin Yıldızeli Sezai Yılmaz Kaya Yorgancı Coşkun Yorulmaz Tayfun Yücel

Konya Bursa İstanbul Ankara İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul İstanbul Ankara Ankara İstanbul Tekirdağ İstanbul Kayseri Tokat İstanbul İstanbul İstanbul Diyarbakır İstanbul Ankara İstanbul İstanbul Manisa İstanbul İstanbul Kocaeli Ankara İstanbul İstanbul Kocaeli Urfa İzmir Adana İstanbul İstanbul İstanbul Trabzon İstanbul İstanbul Tekirdağ İstanbul Gaziantep İstanbul Malatya Ankara İstanbul İstanbul

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

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

Ernest E Moore Pradeep Navsaria Andrew Nicol Hans J Oestern Andrew Peitzman Basil A Pruitt Peter Rhee Pol Rommens William Schwabb Michael Stein Spiros Stergiopoulos Michael Sugrue Otmar Trentz Donald Trunkey Fernando Turegano Selman Uranues Vilmos Vecsei George Velmahos Eric J Voiglio Mauro Zago

Denver, USA Cape Town, S. Africa Cape Town, S. Africa Celle, Germany Pittsburgh, USA San Antonio, USA Tucson, USA Mainz, Germany Philadelphia, USA Petach-Tikva, Israel Athens, Greece Liverpool, Australia Zurich, Switzerland Oregon, USA Madrid, Spain Graz, Austria Vienna, Austria Boston, USA Lyon, France Milan, Italy

REDAKSİYON (REDACTION) Erman Aytaç

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 Şehremini Mah., Köprülü Mehmet Paşa Sok. Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul

Tel: +90 212 - 588 62 46 - 588 62 46 Faks (Fax): +90 212 - 586 18 04 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 Şehremini Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 588 62 46 +90 212 - 586 18 04

Abonelik: 2012 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 (karepublishing) • 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): Ocak (January) 2013 • 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.

Abstract: The abstract should be structured and serve as an informative guide for the methods and results sections of the study. It must be prepared with the following subtitles: Background, Methods, Results and Conclusions. Abstracts should not exceed 200 words.

Figures, illustrations and tables: All figures and tables should be numbered in the order of appearance in the text. The desired position of figures and tables should be indicated in the text. Legends should be included in the relevant part of the main text and those for photomicrographs and slide preparations should indicate the magnification and the stain used. Color pictures and figures will be published if they are definitely required and with the understanding that the authors are prepared to bear the costs. Line drawings should be professionally prepared. For recognizable photographs, signed releases of the patient or of his/her legal representatives should be enclosed; otherwise, patient names or eyes must be blocked out to prevent identification.

References: All references should be numbered in the order of mention in the text. All reference figures in the text should be given in brackets without changing the font size. References should only include articles that have been published or accepted for publication. Reference format should conform to the “Uniform requirements for manuscripts submitted to biomedical journals” (http://www.icmje.org) and its updated versions (February 2006). Journal titles should be abbreviated according to Index Medicus. Journal references should provide inclusive page numbers. All authors, if six or fewer, should be listed; otherwise the first six should be listed, followed by “et al.” should be written. The style and punctuation of the references should follow the formats below: Journal article: 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.

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

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.

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.

Our journal has succeeded in being included in several indexes, in this context, we have included a search engine in our web site (www. travma.org.tr) so that you can access full-text articles of the previous issues and cite the published articles in your studies.

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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Any accompanying tables, graphics, and figures should be prepared as mentioned above.

Case reports: A limited number of case reports are published in each issue of the journal. The presented case(s) should be educative and of interest to the readers, and should reflect an exclusive rarity. Case reports should contain the title, summary, and the case, discussion, and references sections. These reports may consist of maximum five authors.

Letters to the Editor: “Letters to the Editor” are only published electronically and they do not appear in the printed version of TJTES and PUBMED. The editors do not issue an acceptance document as an original article for the ‘’letters to the editor. The letters should not exceed 500 words. The letter must clearly list the title, authors, publication date, issue number, and inclusive page numbers of the publication for which opinions are released.

Informed consent - Ethics: Manuscripts reporting the results of experimental studies on human subjects must include a statement that informed consent was obtained after the nature of the procedure(s) had been fully explained. Manuscripts describing investigations in animals must clearly indicate the steps taken to eliminate pain and suffering. Authors are advised to comply with internationally accepted guidelines, stating such compliance in their manuscripts and to include the approval by the local institutional human research committee.

ULUSAL TRAVMA VE AC‹L CERRAH‹ DERG‹S‹ TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY C‹LT - VOL. 19

SAYI - NUMBER 1 OCAK - JANUARY 2013

İçindekiler - Contents

Deneysel Çalışma - Experimental Study 1-7 Medicinal plant extract (Ankaferd Blood Stopper) application in deep tissue injuries in rats: histopathological investigation of the effect on regional and systemic tissues

Bitkisel özlü Ankaferd Blood Stopper’in sıçanlarda derin dokulara uygulamada bölgesel ve sistemik dokulara etkilerinin histopatolojik olarak incelenmesi

Okumuş M, Yüksel KZ, Özbağ D, Çıralık H, Yılmaz Z, Gümüşalan Y, Bakan V, Kalender AM 8-12 Glucosamine-sulfate on fracture healing

Glukozamin sülfatın kırık iyileşmesine etkisi

Uğraş A, Güzel E, Korkusuz P, Kaya İ, Dikici F, Demirbaş E, Çetinus E

Klinik Çalışma - Original Articles 13-19 Appendicitis scores may be useful in reducing the costs of treatment for right lower quadrant pain

Apandisit skorları, sağ alt kadran ağrısı için tedavi maliyetlerini düşürmede faydalı olabilir

Kırkıl C, Karabulut K, Aygen E, İlhan YS, Yur M, Binnetoğlu K, Bülbüller N 20-24 Management of acute appendicitis in pregnancy

Gebelikte akut apandisit tedavisi

Kapan S, Bozkurt MA, Turhan AN, Gönenç M, Alış H 25-28 Overlooked extremity fractures in the emergency department

Acil serviste gözden kaçan ekstremite kırıkları

Er E, Kara PH, Oyar O, Ünlüer EE 29-32 Prophylactic injection therapy is necessary for Forrest type 2b duodenal ulcers

Forrest tip 2b duodenal ülserlerde profilaktik enjeksiyon tedavisi gereklidir

Öner OZ, Gönenç M, Kalaycı MU, Bozkurt MA, Kapan S, Alış H 33-40 Gastrointestinal kanal perforasyonlarında perforasyon bulgularının ve yerinin saptanmasında karın bilgisayarlı tomografisinin rolü

The role of abdominal computed tomography in determining perforation findings and site in patients with gastrointestinal tract perforation

Ilgar M, Elmalı M, Nural MS 41-44 Inferior glenohumeral dislocation (luxatio erecta humeri): report of six cases and review of the literature

İnferior omuz çıkığı (luksasyo erekta): Altı olgu sunumu ve literatürün gözden geçirilmesi

İmerci A, Gölcük Y, Uğur SG, Ursavaş HT, Savran A, Sürer L 45-48 Does a penetrating diaphragm injury have an effect on morbidity and mortality?

Penetran diyafram yaralanması morbidite ve mortaliteyi etkiler mi?

Özoğul B, Kısaoğlu A, Öztürk G, Atamanalp SS, Aydın Y, Aydınlı B, Yıldırgan Mİ

Cilt - Vol. 19 Sayı - No. 1

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SAYI - NUMBER 1 OCAK - JANUARY 2013

İçindekiler - Contents 49-52 Local differences in the epidemiology of traumatic spinal injuries

Spinal yaralanma epidemiyolojisinde yerel farklılıklar

Erdoğan MÖ, Anlaş Demir S, Koşargelir M, Çolak Ş, Öztürk E 53-57 The management of penetrating abdominal trauma by diagnostic laparoscopy: a prospective non-randomized study

Penetran karın travmalarının tanısal lapararoskopi ile yönetimi: Prospektif randomize olmayan çalışma

Karateke F, Özdoğan M, Özyazıcı S, Daş K, Menekşe E, Gülnerman YC, Bali İ, Önel S, Gökler C 58-64 Foreign body penetrations of hand and wrist: a retrospective study

El ve el bileğinin yabancı cisim penetrasyon yaralanmaları: Retrospektif çalışma

Hocaoğlu E, Kuvat SV, Özalp B, Akhmedov A, Doğan Y, Kozanoğlu E, Mete FS, Erer M

Olgu Sunumu - Case Reports 65-68 Unexpected colonic perforation in a renal recipient: a case report

Böbrek nakli sonrası gelişen beklenmedik kolon perforasyonu: Olgu sunumu

Serin KR, Keskin M, Bakkaloğlu H, Tunca F, Aydın AE, Eldegez CU 69-72 Post-traumatic sagittal sinus thrombosis: case report

Posttravmatik sagittal sinüs trombozu: Olgu sunumu

Khursheed N, Altaf R, Furqan N, Wani A, Jain A, Ali Y 73-76 Diffuse idiopathic skeletal hyperostosis and central cord syndrome after minor trauma: a case report

Diffüz idiyopatik iskeletsel hiperosteozis ve minör travma sonrası santral kord sendromu: Olgu sunumu

Eser O, Karavelioğlu E, Boyacı MG, Ayçiçek A 77-79 Rotational head trauma with callosal contusion and C6 fracture: a high-speed motorcycle accident

Kallozal kontüzyonla birlikte rotasyonel kafa travması ve C6 kırığı: Yüksek hızlı motosiklet kazası

Vyshka G, Troshani B, Bozaxhiu D, Mitrushi A 80-82 Unusual manifestation of acute retrocecal appendicitis: pericholecystic fluid

Akut retroçekal apandisitin sıra dışı bulgusu: Perikolesistik sıvı

Algın O, Özmen E, Özcan AŞ, Erkekel Ş, Karaoğlanoğlu M 83-85 Double acute appendicitis in appendical duplication

Apendiks duplikasyonunda çift akut apandisit

Tutcu Şahin S, Erhan Y, Aydede H 86-88 Barolith as a rare cause of acute appendicitis: a case report

Akut apandisitin nadir bir nedeni; baryum taşı: Olgu sunumu

İnce V, Işık B, Koç C, Başkıran A, Onur A

viii

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):1-7

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2013.65642

Medicinal plant extract (Ankaferd Blood Stopper) application in deep tissue injuries in rats: histopathological investigation of the effect on regional and systemic tissues Bitkisel özlü Ankaferd Blood Stopper’in sıçanlarda derin dokulara uygulamada bölgesel ve sistemik dokulara etkilerinin histopatolojik olarak incelenmesi Mehmet OKUMUŞ,1 Kasım Zafer YÜKSEL,2 Davut ÖZBAĞ,3 Harun ÇIRALIK,4 Zeki YILMAZ,2 Yakup GÜMÜŞALAN,3 Vedat BAKAN,5 Ali Murat KALENDER6

BACKGROUND

AMAÇ

This study was planned to evaluate both the histopathological changes under light microscope as well as the systemic organ effects following application of Ankaferd Blood Stopper® (ABS) (a mixture of five plant extracts) in an animal model of deep tissue hemorrhage.

Bu çalışmada, Ankaferd Blood Stopper® (ABS) (beş bitki özü karışımı), bir hayvan modelinde derin doku kanamalarına uygulandığında, histopatolojik değişikliklerin ve sistemik organ etkilerinin ışık mikroskobu altında değerlendirilmesi planlandı.

METHODS

GEREÇ VE YÖNTEM

A total of 50 Wistar Albino rats were divided into five groups of 10 rats each. The rats underwent femoral vein puncture and were treated with ABS tampon, ABS spray, or Surgicel, and one group was left untreated. After two weeks, each group underwent partial tissue excision from the same femoral region as well as from the brain, heart, kidney, and liver.

Toplamda 50 adet Wistar Albino sıçanlar her birinde 10’ar adet olmak üzere 5 gruba ayrıldı. Sıçanlarda femoral ven delinerek ABS tampon, ABS sprey, Surgicel ile tedavi edildi, bir grup hiç tedavi almadı. İki hafta sonra her gruptan aynı femoral bölgeden ve aynı zamanda beyin, kalp, böbrek ve karaciğerden kısmi doku alındı.

RESULTS

BULGULAR

The specimens from all groups were obtained from the femoral region after two weeks and evaluated under light microscope. The light microscope revealed no histopathological changes in neurovascular structures or in deep connective tissues in any of the groups.

İki hafta sonra tüm gruplarda femoral bölgeden elde edilen örnekler ışık mikroskobu ile değerlendirildi. Tüm gruplarda nörovasküler yapılarda veya derin bağ dokularında ışık mikroskobu incelemesinde herhangi bir histopatolojik değişiklik ortaya çıkmadı.

CONCLUSION

SONUÇ

ABS provided hemostasis and was observed to stop bleeding. There were no histopathological changes at the tissue level and no pathological effects in other organs tissues under light microscope, and the remote organ tissue remained clear.

Ankafer Blood Stopper’in hemostazı sağladığı ve kanamayı durdurduğu gözlemlendi. Işık mikroskobunda doku düzeyinde histopatolojik değişiklikler ve diğer organlarda patolojik etkiler yoktu, uzak organ dokuları temizdi.

Key Words: Ankaferd blood stopper; deep tissue injury; hemostasis.

Anahtar Sözcükler: Ankaferd kan durdurucu; derin doku yaralanması; hemostaz.

Departments of 1Emergency Medicine, 2Neurosurgery, 3Anatomy, 4 Pathology, 5Pediatric Surgery, 6Orthopedics and Traumatology, Sutcu Imam University Faculty of Medicine, Kahramanmaras, Turkey.

Sütçü İmam Üniversitesi Tıp Fakültesi, 1Acil Tıp Anabilim Dalı, Beyin ve Sinir Cerrahisi Anabilim Dalı, 3Anatomi Anabilim Dalı, 4 Patoloji Anabilim Dalı, 5Çocuk Hastalıkları Anabilim Dalı, 6 Ortopedi ve Travmatoloji Anabilim Dalı, Kahramanmaraş.

2

Correspondence (İletişim): Mehmet Okumuş, M.D. Sütçü İmam Üniversitesi Tıp Fakültesi Acil Tıp Anabilim Dalı, 46050 Kahramanmaraş, Turkey.

Tel: +90 - 344 - 215 19 42 e-mail (e-posta): okumus@hotmail.com

1

Ulus Travma Acil Cerrahi Derg

Approximately one-half of the deaths in trauma are associated with hemorrhagic shock.[1] The first step in managing trauma patients is to establish a secure airway, immobilize the cervical column, and obtain adequate breathing and circulation; control of hemorrhage is the second crucial step.[2] Many methods and pharmacological agents are being used to stop or control the hemorrhage that could end mortally. The accustomed hemostasis comprises vasoconstriction and clot formation, which leads to cessation of bleeding. Hemostasis is achieved through the activation of platelets and the coagulation cascade.[3] In cases of trauma including major arteries and veins or internal organs, it is essential to control the hemorrhage in a timely manner. The vascular endothelium plays a pivotal role in the regulation of hemostasis. After the occurrence of vascular injury, endothelial cells limit clot formation to the areas where hemostasis is needed to restore vascular integrity.[4] Ankaferd Blood Stopper® (ABS) is a unique folkloric medicinal plant extract. ABS has been approved in the management of external hemorrhage and dental surgery by the Ministry of Health in Turkey.

Exposure to ABS results in a very rapid formation of network within the plasma and serum. The basic mechanism of action of ABS is through the formation of an encapsulated protein network.[5] The ABS-induced protein network formation involves blood cells, especially erythrocytes, without affecting the physiological individual coagulation systems.[5] ABS is a standardized extract from the following plants: Glycyrrhiza glabra, Vitis vinifera, Alpinia officinarum, Urtica dioica, and Thymus vulgaris, in a weight ratio of 9:8:7:6:5, respectively.[5,6] Alpinia officinarum inhibits nitric oxide production by lipopolysaccharide-activated mouse peritoneal macrophages.[7] Urtica dioica causes vasodilatation via inducing nitric oxide production by the endothelium.[8] Glycyrrhiza glabra has anti-inflammatory, anti-thrombin, anti-platelet, anti-oxidant, anti-atherosclerotic, and anti-tumor activities. It inhibits angiogenesis and decreases vascular endothelial growth factor production and cytokine-induced neovascularization.[9] Thymus vulgaris has anti-oxidative actions, such as prevention of lipid peroxidation.[10] Vitis vinifera exerts anti-tumor and anti-atherosclerotic effects.[11,12] Thus, the mechanisms underlying the hemostatic control by ABS have been investigated thoroughly in many studies.

ABS induced very rapid (<1 second) formation of a cellular protein network especially through vital erythroid aggregates within the plasma and serum samples.[13] ABS has no toxic reactions when applied to mucosal surfaces like the mouth and through the gastrointestinal tract.[13-17] However, the effects of longterm and deep tissue exposure to ABS remain unclear in these studies.

2

Since the histopathological effect of ABS at the deep tissue level and the result of the dark clot created are not adequately known at present, this study aimed to investigate the basic histopathological changes under light microscope in deep tissue injuries as well as remote organs when ABS is applied deeply in the tissues and to determine if the dark clot is reabsorbed after two weeks. In this study, we compared two forms of ABS (spray and tampon) with Surgicel.

MATERIALS AND METHODS This is an open-label trial of ABS in a rat model of femoral vein puncture. A total of 50 Wistar Albino adult (280-320 g) female rats were used in this study.

The animals were kept in a room at a constant temperature of 22±1°C and fed with standard pellet chow, and the room was maintained on a 12-hour light/dark cycle. Food and water were available ad libitum. All experiments were performed in conformity with the European Community Council Directive. This experimental study was carried out in the animal research laboratory of a university hospital and was approved by the Kahramanmaras Sutcu Imam University Medical Faculty Animal Ethics Committee.

The rats were divided into five groups of 10 rats each. The animals were anesthetized intraperitoneally with combinations of ketamine (60 mg/kg) and xylazine (10 mg/kg). Each group except Group 5 underwent femoral vein puncture with a needle 0.6 mm in diameter in the middle part of the femoral vein after skin incision and tissue dissection (Fig. 1a).

The tampon group treated with ABS tampon underwent the conventional technique with hemostatic agent application (approximately 0.5 cm2 ABS tampon [containing ~0.9 ml] was placed on the punctured vein region for 30 seconds with mild pressure) (Fig. 1b).

The spray group was treated with ABS spray (containing 0.1 ml per pump). The Surgicel group was treated with Surgicel (approximately 0.5 cm2) (Fig. 1c), and the animals in the control group were left without any treatment for bleeding after puncturing the vein; a spontaneously formed clot limited the bleeding. The sham group underwent only skin and tissue dissection.

After treatment, all rats underwent simple closure with 3/0 silk suture. All rats survived through 14 days and were fed and kept in the same conditions as before the experimental study. The rats were sacrificed by overdose anesthesia on the 14th day. Then, each group underwent partial tissue excision in the same femoral region (including femoral artery, vein and nerve) that had been treated with ABS and Surgicel two weeks before. In addition, samples were also obtained from the brain, heart, kidney, and liver to investigate the remote organ effects of ABS. All specimens were kept in 10% neutral formaldehyde solution. Tissue specimens were prepared after routine procedures and then embedOcak - January 2013

Medicinal plant extract (Ankaferd Blood Stopper) application in deep tissue injuries in rats

(a)

(b)

(c)

(d)

Fig. 1. (a) The view of the femoral vein. (b) Bleeding control with ABS tampon. (c) Treatment with Surgicel. (d) The view of the punctured vein after hemostasis. (e) The dark clot formation after ABS spray. (e)

ded in paraffin. Sections (5 μm) were prepared from all specimens and stained with hematoxylin and eosin (H&E). All specimens were evaluated under light microscope histopathologically and photographs were taken (H&Ex40, H&Ex100, H&Ex200) by a pathologist blinded to the study groups. Light microscopic findings were graded semi-quantitatively from 0 (no histopathological change) to +3 (severe histopathological change). This histopathological grading was performed for perivascular connective tissue as acute inflammation, chronic inflammation, hemosiderinloaded macrophages, fibrosis, and necrosis by using the four-point scale of Bautista et al.[18] Statistical analysis Statistical analyses were carried out using the Statistical Package for the Social Sciences (SPSS) softCilt - Vol. 19 Sayı - No. 1

(Color figures can be viewed in the online issue, which is available at www.tjtes.org).

ware (v. 16.0 for Windows, SPSS Inc.; Chicago, IL).

All values were expressed as means ± SD. p values less than 0.05 were assumed to be statistically significant. Group comparisons were made by Kruskal-Wallis analysis, followed, in cases of significance, by the Mann-Whitney U-test.

RESULTS In this study, cessation of bleeding was achieved successfully after ABS tampon application to the punctured vein in the tampon group (Group 1). The ABS tampon took the excess clot after removal, and the hemorrhage area remained clear; the defective vein was closed with a wall-like clot formation without any sign of leakage (Fig. 1d). In the spray group (Group 2), after application of ABS spray to the fresh blood pool, a dark clot mass was formed very rapidly, 3

Ulus Travma Acil Cerrahi Derg

which closed the view of the punctured vein, but it also achieved the presumed purpose in a very short time after the spray application (Fig. 1e). In Group 3, Surgicel also stopped the bleeding. Group 4 was left (a)

(b)

(c)

Fig. 2. (a) The microscopic view of the tampon group after two weeks. (b) The microscopic view of the spray group after two weeks. (c) The microscopic view of the Surgicel group after two weeks.

4

(Color figures can be viewed in the online issue, which is available at www.tjtes.org).

untreated after the puncture, and bleeding stopped spontaneously following a huge clot mass (Fig. 1c).

After two weeks, no animals were lost. The animals were examined twice a day for local-systemic infection or regional hematoma, and none occurred in either the treated groups or the controls. All rats survived without any complication. The rats underwent incision in the same area two weeks after sacrificed with overdose anesthetics. In the tampon group, the macroscopic view was clear without any remarkable fibrosis or adhesion. In the spray group, there was a petechia-like appearance in the ABS spray-applied area. In the Surgicel group, Surgicel was absorbed and there were no signs of adhesion or fibrosis in the macroscopic view. In the control group, a hematoma formation-like appearance was seen in the macroscopic observation, while in the baseline group (sham), the macroscopic tissue appearance was normal.

After collecting the specimens from the brain, heart, kidney, and liver of each group, they were examined under light microscope to determine any histopathological changes. The neurovascular structures from the femoral region in all groups and remote organs remained normal. The specimens from the femoral region, especially the connective tissues, were also examined in all groups under light microscope, and the results are respectively mentioned. Light microscopic findings in the perivascular connective tissue of the rats on the 14th day are shown in Table 1. In the tampon group, the specimen included mild chronic inflammatory and hemosiderin-loaded cells and mild fibrosis in perivascular connective tissue, without any finding of cell degeneration or necrosis (Fig. 2a). In the spray group, the specimen included mild acute inflammatory and moderate chronic inflammatory cells, and moderate hemosiderin-loaded macrophages and moderate fibrosis were observed in the perivascular connective tissue; however, neurovascular structures remained normal (Fig. 2b). There were significant differences in acute inflammatory cells, hemosiderinloaded macrophages and fibrosis between the tampon and spray groups (p<0.05). There were mild chronic inflammatory cells and hemosiderin-loaded macrophages in the perivascular connective tissue in the Surgicel group (Fig. 2c). While there was no statistical difference in any of the findings between the Surgicel and tampon group (p>0.005), in contrast, there were significant differences between the Surgicel and spray groups in acute inflammation and hemosiderin-loaded macrophages (p<0.05). In the control group, the specimens included apparent congestion in vessels, and mild acute inflammatory cells and mild fibrosis were observed in the perivascular connective tissue.

A comparison of the control group with the tampon, spray and Surgicel groups revealed that there were significant differences in all findings (p<0.05) except Ocak - January 2013

Medicinal plant extract (Ankaferd Blood Stopper) application in deep tissue injuries in rats

Table 1. The mean values of inflammation

Groups

Histopathological changes

Tampon Mean±SD

Spray Mean±SD

Surgicel Mean±SD

Control Mean±SD

Sham Mean±SD

Necrosis Acute inflammation Chronic inflammation Hemosiderin - loaded macrophage Fibrosis

None 0.3±0.95 1.3±0.48 0.8±0.63 1.1±0.74

None 0.7±0.48 1.6±0.52 2.4±0.52 2.0±0.47

None 0.0±0.00 1.2±0.42 1.3±1.06 1.7±1.25

None 1.2±0.42 0.2±0.42 0.2±0.42 0.5±0.53

None 0.2±0.42 0.8±0.42 0.2±0.42 0.5±0.53

0=None; 1=Mild; 2=Moderate; 3=Severe.

fibrosis in the tampon group, and there were significant differences in all findings between the spray and Surgicel groups. In the baseline group (sham), there were mild chronic inflammatory cells and mild fibrosis in the perivascular connective tissue. There were significant differences in acute and chronic inflammatory cells (p<0.05), but no difference in hemosiderinloaded macrophages and fibrosis (p>0.05), between the sham and control groups. There were significant differences in chronic inflammatory cells and hemosiderin-loaded macrophages and no difference in acute inflammatory cells and fibrosis between the sham and tampon groups. There were significant differences in all findings between the sham and spray groups. There were significant differences in hemosiderin-loaded macrophages and fibrosis and no difference in acute and chronic inflammatory cells between the sham and Surgicel groups. Comparisons of the histopathological changes in groups are shown in Table 2.

DISCUSSION Ankaferd Blood Stopper® (ABS) has been used to stop hemorrhage on skin surfaces, during dental

procedures and on internal surfaces in many cases, without any toxic reaction, but there has been no investigation regarding the histopathological long-term effects in tissues. The clinical observations and macroscopic appearance of the applied area are enough to prove the safety of ABS.[14-17,19-21] The recent data, especially in animal-based studies, have shown the efficacy and non-toxicity of ABS in the management of hemorrhage.[4,5,22-24] In vitro data on the anti-infective characteristic of ABS and preliminary successful applications in the gastrointestinal tract and dental bleedings have represented incoming clues regarding ABS activity.[19,20,22,25] In this study, we planned an animal model of femoral venipuncture in which different methods of ABS application were compared with Surgicel, and we also investigated the histopathological changes with respect to the long-term effects of the plant extracts (mixed in a prescribed ratio) on regional and systemic tissues in rats. After puncturing the vein, application of ABS rapidly stopped the bleeding in both forms of tampon and spray (in 1 second), and the excess forma-

Table 2. The p values of results of comparisons between the groups according to acute and chronic inflammatory cells, macrophages and fibrosis

Groups

Histopathological changes Acute Inflammation

Chronic Inflammation

Hemosiderin - loaded macrophage

Fibrosis

Necrosis

0.020 0.317 0.001 0.626 0.001 0.028 0.028 0.000 0.146 0.000

0.189 0.615 0.000 0.028 0.075 0.000 0.003 0.000 0.051 0.009

0.000 0.247 0.025 0.025 0.014 0.000 0.000 0.012 0.012 1.000

0.006 0.181 0.062 0.062 0.897 0.000 0.000 0.029 0.029 1.000

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Tampon - Spray Tampon - Surgicel Tampon - Control Tampon - Sham Spray - Surgicel Spray - Control Spray - Sham Surgicel - Control Surgicel - Sham Control - Sham N/A: Not applicable.

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Ulus Travma Acil Cerrahi Derg

tion of the formed black clot was remarkable in the spray group. Examination of the specimens that underwent ABS application in both forms of tampon and spray under light microscope revealed no histopathological toxicity, cell degeneration or necrosis even after two weeks.

Inflammation is a protective response intended to eliminate the initial cause of cell injury as well as the necrotic cells and tissues resulting from the original insult. Acute inflammation is rapid in onset and of short duration, lasting from a few minutes to as long as a few days, and is characterized by fluid and plasma protein exudation and a predominantly neutrophilic leukocyte accumulation. If the injurious agent cannot be eliminated quickly, the result may be chronic inflammation. Chronic inflammation may be more insidious, is of longer duration (days to years), and is typified by an influx of lymphocytes and macrophages with associated vascular proliferation and fibrosis (scarring).[26] In our study, as we compared the groups, there was mild inflammation in all groups except the spray group. Only the spray group differed from the other groups, and the difference in severity of inflammation was statistically significant (p<0.05); while the inflammation severity was moderate in the spray group, there was only mild inflammation in the other groups. The reason for this difference may be the excessive use of ABS spray. When using the ABS tampon to stop bleeding, the tampon contacts the hemorrhagic surface and leaves minimal residue of the ABS extract (the approximately 0.5 cm2 of ABS tampon contained 0.09 ml extract). However, in ABS spray form, approximately 0.1 ml of ABS extract was sprayed onto the hemorrhagic area. The amount of blood clot seems to be irrelevant because there was a significant difference between the spray and control group (p<0.001) in all findings except acute inflammatory cells. This may result from the amount of ABS extract used.

Acute inflammation may progress to chronic inflammation when the acute response cannot be resolved.[26] Because of the greater amount of ABS used in spray form than tampon, the inflammation might have progressed to chronic inflammation, and hemosiderinloaded macrophages were the dominant cells that were clearing the injured area from clot and plant extract.

In a recent study, OdabaĹ&#x; et al.[27] found that ABS was cytotoxic to human pulp fibroblasts. The sensitivity of cytotoxicity depended on the concentration of the material tested. The greater dilutions exhibited less cytotoxicity compared to the more concentrated forms of ABS extract. This new study supports our findings that higher concentrations of ABS may result in more severe inflammatory reaction in the perivascular connective tissue. However, there were no signs of ne6

crosis or cell degeneration in any of the groups in our study that demonstrated cytotoxicity. This result needs to be investigated further.

In one study, ABS was used in the damaged bladder wall in rats. Similar to our study, the authors found that there were no toxic reactions or fibrosis after two weeks.[23] In another study, no acute mucosal toxicity, hematotoxicity, hepatotoxicity, nephrotoxicity, or biochemical toxicity was observed during the short-term follow-up of the animals when ABS was applied to internal topical surfaces.[28] Neither local nor systemic adverse effects or toxicity were observed in association with experimental and anecdotal topical application of ABS. ABS may offer a valuable option due to its ease of application and speed of action; it does not require precise localization to the bleeding site. Simple topical application and easy use over the hemorrhagic area was able to stop the bleeding.[17] A double-blinded, randomized, placebo-controlled, crossover phase I clinical study with a five-day washout period between the crossover periods demonstrated the safety of topical ABS administration in healthy human volunteers. Following these findings, it was concluded that topical application of ABS is safe.[29] Further investigations in control of the bleeding with application of ABS could shed light regarding safer use in clinical conditions.

The effects of ABS on vascular endothelium, blood cells, angiogenesis, cellular proliferation, vascular dynamics, and cellular mediators are being investigated currently to determine its potential role in many pathological states and tissue repair.[30,31] These results are promising regarding the non-toxicity of ABS in the use of traumatic hemorrhage in deep tissues.

In conclusion, based on its hemostatic actions, ABS, a traditional folkloric medicinal plant extract, could be a candidate for use in clinical medicine in pre-hospital settings after trauma pending its ability to reduce blood loss and increase survival and in the management of patients with coagulopathy disorders or using anticoagulant-antiaggregant drugs. ABS successfully stopped hemorrhage in deep tissue traumas locally. No pathological changes were determined under light microscopic examination two weeks later.

We conclude that ABS can be used safely since it does not lead to any degeneration of regional and systemic tissues, but there is a need for further investigations in human models.

Acknowledgement This experimental study was supported by Kahramanmaras University Council of Experts (decision 2009/4-8 m).

Ocak - January 2013

Medicinal plant extract (Ankaferd Blood Stopper) application in deep tissue injuries in rats

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al. Epidemiology of trauma deaths: a reassessment. J Trauma 1995;38:185-93.

2. Edward E. Cornwell III. Initial approach to trauma. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, editors. Emergency medicine: a comprehensive study guide.

New York, NY: McGraw-Hill; 6th ed. 2004. p. 1537-42.

3. Teller P, White TK. The physiology of wound healing: injury through maturation. Surg Clin North Am 2009;89:599-610.

4. Cipil HS, Kosar A, Kaya A, Uz B, Haznedaroglu IC, Goker H, et al. In vivo hemostatic effect of the medicinal plant extract Ankaferd Blood Stopper in rats pretreated with warfarin. Clin Appl Thromb Hemost 2009;15:270-6.

5. Goker H, Haznedaroglu IC, Ercetin S, Kirazli S, Akman U, Ozturk Y, et al. Haemostatic actions of the folkloric medicinal plant extract Ankaferd Blood Stopper. J Int Med Res 2008;36:163-70.

6. Ankaferd web site. Available at: http://www.ankaferd.com/ eng/abs-formul.php Accessed March 20, 2010.

7. Matsuda H, Ando S, Kato T, Morikawa T, Yoshikawa M. Inhibitors from the rhizomes of Alpinia officinarum on production of nitric oxide in lipopolysaccharide-activated macrophages and the structural requirements of diarylheptanoids for the activity. Bioorg Med Chem 2006;14:138-42.

8. Testai L, Chericoni S, Calderone V, Nencioni G, Nieri P, Morelli I, et al. Cardiovascular effects of Urtica dioica L. (Urticaceae) roots extracts: in vitro and in vivo pharmacological studies. J Ethnopharmacol 2002;81:105-9.

9. Sheela ML, Ramakrishna MK, Salimath BP. Angiogenic and proliferative effects of the cytokine VEGF in Ehrlich ascites tumor cells is inhibited by Glycyrrhiza glabra. Int Immunopharmacol 2006;6:494-8.

10. Lee SJ, Umano K, Shibamoto T, Lee KG. Identification of volatile components in basil (Ocimum basilicum L.) and thyme leaves (Thymusvulgaris L.) and thei antioxidant properties. Food Chem 2005;91:131-7.

11. Zhao J, Wang J, Chen Y, Agarwal R. Anti-tumor-promoting activity of a polyphenolic fraction isolated from grape seeds in the mouse skin two-stage initiation-promotion protocol and identification of procyanidin B5-3’-gallate as the most effective antioxidant constituent. Carcinogenesis 1999;20:1737-45.

12. Yamakoshi J, Kataoka S, Koga T, Ariga T. Proanthocyanidinrich extract from grape seeds attenuates the development of aortic atherosclerosis in cholesterol-fed rabbits. Atherosclerosis 1999;142:139-49.

13. Haznedaroglu BZ, Haznedaroglu IC, Walker SL, Bilgili H, Goker H, Kosar A, et al. Ultrastructural and morphological analyses of the in vitro and in vivo hemostatic effects of Ankaferd Blood Stopper. Clin Appl Thromb Hemost 2010;16:446-53.

14. Kurt M, Oztas E, Kuran S, Onal IK, Kekilli M, Haznedaroglu IC. Tandem oral, rectal, and nasal administrations of Ankaferd Blood Stopper to control profuse bleeding leading to hemodynamic instability. Am J Emerg Med 2009;27:631. e1-2.

15. Teker AM, Korkut AY, Gedikli O, Kahya V. Prospective,

Cilt - Vol. 19 Sayı - No. 1

controlled clinical trial of Ankaferd Blood Stopper in children undergoing tonsillectomy. Int J Pediatr Otorhinolaryngol 2009;73:1742-5.

16. Kurt M, Kacar S, Onal IK, Akdogan M, Haznedaroglu IC. Ankaferd Blood Stopper as an effective adjunctive hemostatic agent for the management of life-threatening arterial bleeding of the digestive tract. Endoscopy 2008;40:E262.

17. Kurt M, Akdogan M, Onal IK, Kekilli M, Arhan M, Shorbagi A, et al. Endoscopic topical application of Ankaferd Blood Stopper for neoplastic gastrointestinal bleeding: A retrospective analysis. Dig Liver Dis 2010;42:196-9.

18. Bautista A, Tojo R, Varela R, Estevez E, Villanueva A, Cadranel S. Effects of prednisolone and dexamethasone on alkali burns of the esophagus in rabbit. J Pediatr Gastroenterol Nutr 1996;22:275-83.

19. Kurt M, Disibeyaz S, Akdogan M, Sasmaz N, Aksu S, Haznedaroglu IC. Endoscopic application of ankaferd blood stopper as a novel experimental treatment modality for upper gastrointestinal bleeding: a case report. Am J Gastroenterol 2008;103:2156-8.

20. Dogan OF, Ozyurda U, Uymaz OK, Ercetin S, Haznedaroglu IC. New anticoagulant agent for CABG surgery. Eur J Clin Invest 2008;38:341.

21. Ibis M, Kurt M, Onal IK, Haznedaroglu IC. Successful management of bleeding due to solitary rectal ulcer via topical application of Ankaferd blood stopper. J Altern Complement Med 2008;14:1073-4.

22. Bilgili H, Kosar A, Kurt M, Onal IK, Goker H, Captug O, et al. Hemostatic efficacy of Ankaferd Blood Stopper in a swine bleeding model. Med Princ Pract 2009;18:165-9.

23. Kilic O, Gonen M, Acar K, Yurdakul T, Avunduk MC, Esen HH, et al. Haemostatic role and histopathological effects of a new haemostatic agent in a rat bladder haemorrhage model: an experimental trial. BJU Int 2010;105:1722-5.

24. Kosar A, Cipil HS, Kaya A, Uz B, Haznedaroglu IC, Goker H, et al. The efficacy of Ankaferd Blood Stopper in antithrombotic drug-induced primary and secondary hemostatic abnormalities of a rat-bleeding model. Blood Coagul Fibrinolysis 2009;20:185-90.

25. Akkoc N, Akcelik M, Haznedaroglu I, Goker H, Aksu S, Kirazli S, et al. In vitro antibacterial activities of Ankaferd Blood Stopper. Int J Lab Hematol 2008;30:95.

26. Kumar V, Abbas AK, Fausto N, Mitchell R (editors). Robbins basic pathology. Saunders, Elsevier; 8th ed. 2007.

27. Odabaş ME, Ertürk M, Çınar Ç, Tüzüner T, Tulunoğlu Ö.

Cytotoxicity of a new hemostatic agent on human pulp fibroblasts in vitro. Med Oral Patol Oral Cir Bucal 2011;16:e5847.

28. Bilgili H, Captug O, Kosar A, Kurt M, Kekilli M, Shorbagi A, et al. Oral systemic administration of Ankaferd blood stopper has no short-term toxicity in an in vivo rabbit experimental model. Clin Appl Thromb Hemost 2010;16:533-6.

29. Adouble-blinded, randomized, placebo-controlled, crossover phase I clinical study of Ankaferd Blood Stopper. ANKAFERD Blood Stopper Investigational Drug Research Activities Report. 2008. p. 66-74.

30. Huri E, Akgül T, Ayyildiz A, Ustün H, Germiyanoğlu C. Hemostatic role of a folkloric medicinal plant extract in a rat partial nephrectomy model: controlled experimental trial. J Urol 2009;181:2349-54.

31. Haznedaroglu IC. Molecular basis of the pleiotropic effects of Ankaferd Blood Stopper. IUBMB Life 2009;61:290.

7

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):8-12

Experimental Study

Deneysel Çalışma doi: 10.5505/tjtes.2013.03256

Glucosamine-sulfate on fracture healing Glukozamin sülfatın kırık iyileşmesine etkisi Akın UĞRAŞ,1† Elif GÜZEL,2 Petek KORKUSUZ,3 İbrahim KAYA,1 Fatih DİKİCİ,4 Emrah DEMİRBAŞ,1 Ercan ÇETİNUS1

BACKGROUND

AMAÇ

The aim of this study is to determine whether glucosaminesulfate has any effects on bone-healing.

Bu çalışmanın amacı kıkırdak glukozaminin kırık iyileşmesi üzerinde etkisi olup olmadığının araştırılmasıdır.

METHODS

GEREÇ VE YÖNTEM

A unilateral fracture was created in the tibia of sixty-one female rats. Rats were given no drug or 230 mg/kg glucosamine-sulfate daily. Fractures were analyzed during the first, second and fourth weeks after creation of fracture. Quantitative measurement for new bone formation and osteoblast lining were determined histologically. Semiquantitative score for fracture healing was used for histomorphometric analyses. Bridging bone formation was assessed radiographically.

Altmış bir dişi şıçan tibiasında tek taraflı kırık oluşturuldu.

Sıçanlara ya 230 mg/kg glukozamin sülfat verildi ya da ilaç verilmedi. Kırıklar, kırık oluşumundan sonra birinci, ikinci ve dördüncü haftalarda incelendi. Yeni kemik oluşum miktarı ve osteoblast sayısı histolojik olarak ölçüldü. Histomorfometrik analiz için kırık iyileşmesi semikantitatif olarak skorlandı. Radyografik olarak kemik köprü oluşumu değerlendirildi.

RESULTS

BULGULAR

New bone formation and osteoblast lining were significantly higher in glucosamine-treated group at week 1. Surrounding connective tissue was more cellular and vascular, and the newly formed bone trabecules were present in greater amounts in glucosamine-treated group, compared to control group at week 1 and 4. But radiologically, the control group had better scores than that of the glucosamine-treated group at week 4.

Glukozamin verilen grupta yeni kemik oluşumu ve osteoblast sayısı 1. haftada anlamlı derecede yüksekti. 1. ve 4. haftalarda kontrol grubuna göre, glukozamin verilen grupta çevre bağ dokusu hücre sayısı bakımından zengin, daha vasküler ve yeni oluşan kemik trabekülleri daha fazla sayıdaydı.

Fakat radyolojik olarak 4. haftada kontrol grubu, glukozamin verilen gruptan daha iyi skorlar aldı.

CONCLUSION

Bu veriler günlük glukozamin verilmesinin sıçan tibiasında kırık iyileşmesinin erken fazını, artmış yeni kemik oluşumu ve osteoblast sayısı ile histolojik olarak hızlandırdığı, fakat radyolojik olarak aynı etkinin görülmediğini göstermektedir.

These data demonstrate that daily glucosamine-sulfate administration accelerates early phase of fracture repair in the rat tibia, with increased new bone formation and osteoblast lining histologically, but radiologic bone union is not favored on radiographs.

SONUÇ

Key Words: Bone; fracture healing; glucosamine; osteoblast.

Anahtar Sözcükler: Kemik; kırık iyileşmesi; glukozamin; osteoblast.

1 Department of Orthopedics and Traumatology, Haseki Training and Research Hospital, Istanbul; 2Department of Histology and Embryology, Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul; 3 Department of Histology and Embryology, Hacettepe University, Faculty of Medicine, Ankara; 4Department of Orthopedics and Traumatology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey. †Current affiliation: Department of Orthopedics and Traumatology, Istanbul Medipol University, Faculty of Medicine, Istanbul.

Haseki Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul; 2İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Histoloji ve Embriyoloji Anabilim Dalı, İstanbul; 3Hacettepe Üniversitesi Tıp Fakültesi, Histoloji ve Embriyoloji Anabilim Dalı, Ankara; 4 İstanbul Üniversitesi İstanbul Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul. †Şimdiki Kurumu: İstanbul Medipol Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul.

1

Correspondence (İletişim): Akın Uğraş, M.D. İstanbul Medipol Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, TEM Avrupa Otoyolu Göztepe Çıkışı No: 1, Bağcılar 34214 İstanbul, Turkey.

Tel: +90 - 212 - 529 44 00 e-mail (e-posta): akinugras@gmail.com

8

Glucosamine-sulfate on fracture healing

Glucosamine has been shown to have a number of favorable effects on cartilage metabolism in vitro, including a reduction in articular cartilage breakdown and stimulation of synthesis of matrix components by condrocytes.[1] Administration of glucosamine normalizes cartilage metabolism, by inhibiting degradation and stimulating the synthesis of proteoglycans, and restoring the articular functions.[2] However, the effect of glucosamine on bone metabolism has not been investigated before. We hypothesized that glucosamine could be a therapeutic agent for the treatment of intraarticular fractures. The aim of this study is to determine whether glucosamine-sulfate has any effects on bone-healing. Glucosamine exists in several forms, usually as glucosamine-sulfate and glucosamine hydrochloride. Sulfate form has been used in most experimental studies.[3] We investigate the role of glucosamine-sulfate on fracture healing.

MATERIALS AND METHODS The study was conducted in accordance with principles and procedures approved by Istanbul University, the Local Ethics Committee on animal experimentation. Sixty-one female Wistar rats were used for this study. Only the sixth group had 11 rats (Glucosaminetreated group). Two or three rats were housed in each cage with a 12h-12h light-dark cycle and controlled temperature of 24±3 ºC with humidity of 55±15%.

They were fed with water and standard rat chow ad libitum. Rats were 6 weeks old and weighing 200-250 g. Three groups of rats received 230 mg/kg glucosamine-sulfate (Abdi Ibrahim, Dona, Turkey) intraperitoneally (IP), daily. The other three groups of rats served as a control group. Dose selection was based on preliminary studies.[1,4] Rats were anesthetized with ketamine (0.25 mg/100 g) and xylazine (10 mg/100 g) IP. Once the animal was sedated, the skin overlying knee was shaved. A prophylactic dose of 60.000 IU of procain penicillin was administered intramuscularly. The skin overlying left knee was incised. Anterior tibial cortex was cut with sagittal saw and posterior tibial cortex was broken. A 0.25 mm metal pin was inserted in to the medullary canal of the tibia. The incision was closed.[5-7] The rats were allowed to recover and were permitted to eat and walk ad libitum. Subsets of animals from each glucosamine-treated and control group were sacrificed at first, second, and fourth weeks postoperatively by administering a lethal dose of sodium pentobarbital IP. Radiographs were made of all tibia to determine whether administration of glucosamine-sulfate resulted in radiographic evidence of delayed healing. Bone formation was scored on a 6-point scale as follows: 0, no formation of bone; 1, formation of less than 25% Cilt - Vol. 19 Sayı - No. 1

of bone; 2, formation of more than 25% of bone; 3, formation of more than 50% of bone; 4, formation of more than 75% of bone; and 5, formation of 100% of bone.[8] The radiographs were blindly scored by three orthopedic surgeons for the presence of calcified fracture callus and evidence of bone union. The final score was the mean of all three scores.

Bones were fixed in 10% neutral buffered formalin at room temperature. All specimens were decalcified in De Castro solution (chloral hydrate, nitric acid, distilled water) and embedded in paraffin. Three to five micrometer thick sections were stained with haematoxylin & eosin (HE), and Masson’s trichrome (MT).

Quantitative measurement for new bone formation and osteoblast lining at fracture site MT produces high contrast images with red (bone), green (osteoid-cartilage), and purple (cell cytoplasm).

Photomictographs of each fracture area were generated by a light microscope (Leica DMR) with attached computerized digital camera (Model DFC 480, Leica Westlar Germany). The entire fracture area was visible at the lowest magnification. Bright-field images were captured and analyzed quantitatively by image processing program (Qwin Plus, Leica Inc. Westlar Germany). The number of pixels corresponding to new trabecular bone area in each image was quantified, divided by the total number of pixels corresponding to total fracture area, and converted to μm2 in each specimen. Osteoblasts were quantified based on their morphology on HE stained sections for length of their linear apposition along osteoid-new bone surfaces relative to total new bone-osteoid surface length for three randomly selected high power fields (200x) and are reported as a fraction (%) average for each sample.[9] Semiquantitative scoring for fracture healing A total fracture healing score was given to each specimen regarding the callus formation, bone union, marrow changes, and cortex remodeling.[10] Regarding callus formation, (3) was given for presence of full callus formation across the defect, (2) for presence of moderate callus formation, (1) for presence of mild callus formation, and (0) for no callus formation. Bone union was scored as (3) for full bone bridge (union), (2) for moderate bridge (>50%), (1) for mild bridge (<50%), and (0) for the lack of new bone in the fracture line (nonunion). Regarding marrow changes, (4) was given for the presence of adult type fatty marrow, (3) for 2/3 of marrow replaced by new tissue, (2) for 1/3 of marrow replaced by new tissue, (1) for the presence of fibrous tissue, and (0) for the red tissue.

Regarding cortex remodeling, (2) was given for the presence of full remodeling cortex, (1) for intramedullary canal, and (0) for the lack of cortical remodeling.

9

Ulus Travma Acil Cerrahi Derg

(a)

(b)

(c)

Fig. 1. Radiographs of isolated tibia at (a) one, (b) two, and (c) six weeks after the fracture. Left: Glucosamine-treated group, Right: Control group.

Fracture healing score is the sum of callus formation score, bone union score, marrow changes score, and cortex remodeling score.

[10]

Statistical analysis Independent variables were the division of groups based upon glucosamine-sulfate administration, and the dependent variables were the histology and radiology parameters. The normality of distribution and the homogeneity of variances of the sample were established using the Shapiro-Wilk test. All week 1 parameters, osteoblast lining parameter of week 2, and osteoblast lining and bone healing parameters of week 4 were analyzed by parametric test one way ANOVA. All other parameters were analyzed by nonparametric tests. Kruskal-Wallis was used for multiple comparison and Mann-Whitney U as post-hoc test with

Bonferroni correction. Correlation between the histologic and radiologic measurements were assessed using Spearman test. Radiologic scoring was performed by blind independent investigators (n=3). The intraclass (reliability) correlation coefficient was calculated (r=0.80). Then the mean of calculated radiologic scores was included in parametric and nonparametric analyses. Descriptive statistical values were expressed as median, minimum, and maximum. The difference was considered significant if p<0.05.

RESULTS The radiographic appearance of films suggested normal fracture healing. There was neither ectopic calcification nor unusual (e.g., over-abundant) callus formation. Complete bone healing was observed in both groups. Radiologic scores did not show any significant

Table 1. The data of variables belonging to different groups are given as mean, standart deviation and p values Sacrification time

Groups

Radiologic score

New bone per fracture line ratio (μm2)

Osteoblast lining (%)

First week Glc 2.85±0.89 0.22±0.07 30.36±8.92

Control 3.08±0.69 0.09±0.03 19.5±6.84

p 0.405 0.000* 0.007*

Second week Glc 3.8±1.12 0.29±0.07 35.29±11.25

Control 3.2±0.61 0.23±0.08 35.6±12.38

p 0.057 0.226 0.820

Fourth week Glc 4.25±0.59 0.92±0.07 55.5±17.85

Control 4.85±0.36 0.93±0.06 59.56±17.02

p 0.036* 0.809 0.654

Fracture healing score 3.9±1.28 3±0.94 0.101 6.6±1.26 6.5±1.35 0.846 10.36±1.12 10±1.41 0.705

Glc: Glucosamine-treated group; * p<0.005.

10

Ocak - January 2013

Glucosamine-sulfate on fracture healing

difference between groups at week 1 and week 2. Radiologically, the control group received significantly better scores than the glucosamine-treated group at week 4 (p=0.036) (Fig. 1, Table 1).

New bone per fracture line ratio was significantly higher in glucosamine-treated group comparing to that of control group at week 1 (p=0.000). New bone trabecules lined by active bone-forming cells (osteoblasts) were higher in the glucosamine-treated group in comparison to control on day 7 (p=0.007) (Fig. 2, Table 1).

Histologic scores did not show any significant difference between groups at week 2.

DISCUSSION According to this data, glucosamine sulphate increased new bone formation, osteoblastic cell lining, bone trabecules, and cellularity and vascularity of the cartilage matrix. New bone formation was accelerated in the glucosamine-treated group at week 1, whereas radiographic bone healing was diminished at week 4.

Histomorphologically, a highly vascular and cellular connective tissue callus initiated intramembranous and/or endochondral bone formation at the fracture area in both groups. Surrounding connective tissue was more cellular and vascular and the newly formed bone trabecules were more numerous in the glucosamine-treated group, comparing to control at week 1 and 4 (Fig. 2, Table 1).

Fracture repair is a complex process that involves mesenchymal and/or surface osteoblasts and signaling molecules including proinflammatory cytokines, transforming growth factor-beta (TGF-β) superfamily members and angiogenic factors.[11,12] The repair is initiated by an immediate inflammatory response that leads to the recruitment of mesenchymal stem cells and subsequent differentiation into mesenchymal osteoblasts that produce cartilage matrix.[12] According to this data, glucosamine-sulfate affects the first stages of bone repair and increases osteoblastic cell lining, bone trabecules, and cellularity and vascularity of the cartilage matrix.

The radiologic and histologic bone healing parameters generally increased over time (1 to 2, 2 to 4, and 1 to 4 weeks) in control and glucosamine-treated groups (p≤0.05). This data demonstrates that a healthy healing process occurred in both groups.

Kim and collaborators[13] demonstrated that glucosamine sulfate can increase Alchalen phospatase activity, collagen synthesis, osteocalcin secretion, and mineralization in osteoblastic cells in vitro. Glucosamine sulfate exerts a stimulatory effect on differentiation in

Fig. 2. Fracture line consists of a fibrous, cartilaginous (Ca) and bony callus (NBT: New bone trabecules in green) at 1 week; in both glucosamine and the control groups. Note the high amount of new bone trabecules in B with glucosamine when compared to control (D). Cartilage islands are obvious in D. CB: Cortical bone; HE: Haematoxylin eosin, MT: Masson’s trichrome.

Cilt - Vol. 19 Sayı - No. 1

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Ulus Travma Acil Cerrahi Derg

osteoblast-like MG-63 cells in vitro.[13] We think that the probable mechanism of glucosamine sulphate’s effect on bone healing is through the stimulation of osteoblastic cells.

We did not observe the same effect at the end of the healing process. In comparison to the glucosaminetreated group, radiologic bone union was not as evident as in the control group. However, the histologic parameters of bone union did not differ between the two groups at the fourth week. We did not perform mechanical testing to accurately interpret the results.

However, bone strength is mainly characterized by architectural structure, the mineral content of bone, extracellular matrix properties, and cellular biomechanics and these are accurately assessed by histological analysis.[14] The major limitation of this study is the absence of a dose-response study of glucosamine-sulfate. However, this is the first study, to our knowledge, evaluating the effects of glucosamine-sulfate on fracture healing. Additional studies are necessary to determine the effects of glucosamine on fracture-healing.

Given the central role of glucosamine in cartilage metabolism, it is likely to have a profound influence on bone metabolism. In summary, daily glucosamine sulfate administration following fracture increased bone formation in the rat tibia, with increased new bone formation and osteoblast lining histologically. However, the presence of radiologic bone union was not demonstrated by radiographs in the treatment group.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Maganhin CC, Correa O, Regina Ct G, Simões R, Baracat EC, Soares-Jr JM. Effects of glucosamine on the tibial epiphyseal disk of ovariectomized rats: morphologic and morphometric analysis. Clinics (Sao Paulo) 2007;62:607-12.

2. Hua J, Suguro S, Hirano S, Sakamoto K, Nagaoka I. Preventive actions of a high dose of glucosamine on adjuvant arthritis in rats. Inflamm Res 2005;54:127-32.

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3. Mobasheri A, Vannucci SJ, Bondy CA, Carter SD, Innes JF, Arteaga MF, et al. Glucose transport and metabolism in chondrocytes: a key to understanding chondrogenesis, skeletal development and cartilage degradation in osteoarthritis.

Histol Histopathol 2002;17:1239-67.

4. Rezende MU, Gurgel HM, Vilaça Junior PR, Kuroba RK, Lopes AS, Phillipi RZ, et al. Diacerhein versus glucosamine in a rat model of osteoarthritis. Clinics (Sao Paulo) 2006;61:461-6.

5. Hollinger JO, Onikepe AO, MacKrell J, Einhorn T, Bradica G, Lynch S, et al. Accelerated fracture healing in the geriatric, osteoporotic rat with recombinant human platelet-derived growth factor-BB and an injectable beta-tricalcium hosphate/ collagen matrix. J Orthop Res 2008;26:83-90.

6. Miles JD, Weinhold P, Brimmo O, Dahners L. Rat tibial osteotomy model providing a range of normal to impaired healing. J Orthop Res 2011;29:109-15.

7. Gardner MJ, van der Meulen MC, Carson J, Zelken J, Ricciardi BF, Wright TM, et al. Role of parathyroid hormone in the mechanosensitivity of fracture healing. J Orthop Res 2007;25:1474-80.

8. Yasko AW, Lane JM, Fellinger EJ, Rosen V, Wozney JM, Wang EA. The healing of segmental bone efects, induced by combinant human bone morphogenetic protein (rhBMP-2).

A radiographic, histological, and biomechanical study in rats.

J Bone Joint Surg [Am] 1992;74:659-70.

9. Lu M., Rabie ABM. Quantitative assessment of early healing of intramembranous and endochondral autogenous bone grafts using micro-computed tomography and Qwin image analyzer. Int J Oral Maxillofac Surg 2004;33:369-37.

10. An Y H, Friedman RJ. Animal models in orthopedic research.

CRC Press USA: 1999. p. 209.

11. Tat SK, Pelletier JP, Vergés J, Lajeunesse D, Montell E, Fahmi H, et al. Chondroitin and glucosamine sulfate in combination decrease the pro-resorptive properties of human osteoarthritis subchondral bone osteoblasts: a basic science study.

Arthritis Res Ther 2007;9:R117.

12. Wang SX, Laverty S, Dumitriu M, Plaas A, Grynpas MD. The effects of glucosamine hydrochloride on subchondral bone changes in an animal model of osteoarthritis. Arthritis Rheum 2007;56:1537-48.

13. Kim MM, Mendis E, Rajapakse N, Kim SK. Glucosamine sulfate promotes osteoblastic differentiation of MG-63 cells via anti-inflammatory effect. Bioorg Med Chem Lett 2007;17:1938-42.

14. Kreider JM, Goldstein SA. Trabecular bone mechanical properties in patients with fragility fractures. Clin Orthop Relat Res 2009;467:1955-63.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):13-19

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.88714

Appendicitis scores may be useful in reducing the costs of treatment for right lower quadrant pain Apandisit skorları, sağ alt kadran ağrısı için tedavi maliyetlerini düşürmede faydalı olabilir Cüneyt KIRKIL,1 Koray KARABULUT,1 Erhan AYGEN,1 Yavuz Selim İLHAN,1 Mesut YUR,1 Kenan BİNNETOĞLU,1 Nurullah BÜLBÜLLER2

BACKGROUND

AMAÇ

Unnecessary hospital admissions and negative appendectomies increase healthcare costs of patients with right lower quadrant (RLQ) pain. This study aimed to evaluate the impact on the cost of treatment of appendicitis scoring systems.

Sağ alt kadran (SAK) ağrısı olan hastaların gereksiz hastane yatışları ve negatif apendektomiler tedavi giderlerini artırır. Bu çalışmada, apandisit skorlama sistemlerinin tedavi maliyetine etkisi değerlendirildi.

METHODS

GEREÇ VE YÖNTEM

Charts were reviewed of patients admitted to the general surgery ward of our hospital with RLQ pain within a year.

Alvarado and Lintula scores were calculated, and a simulation was performed to determine the treatment charges that would have been generated had the scoring recommendations been used for admission and surgical decision-making.

Bir yıl içinde SAK ile hastanemiz genel cerrahi kliniğine kabul edilen hastaların kayıtları incelendi. Alvarado ve Lintula skorları hesaplandı. Hastaneye yatış ve cerrahi tedavi kararında skorlama önerileri kullanılmış olsaydı, tedavi giderlerinin ne olacağını saptamak için bir benzetim çalışması düzenlendi.

RESULTS

BULGULAR

Of the 114 admitted patients, 64 (56%) underwent appendectomy. The rate of negative appendectomy was 17.2%. The overall accuracy rates of the Alvarado and Lintula scores for both ‘admit’ and ‘operate’ decision-making were 82.7% and 91.9%, respectively (p=0.102). Total charges for the 114 patients were $39,655. If the Alvarado or Lintula score had been used, the total treatment charges would have been $34,087 and $25,772 (p=0.015 and p=0.000), with negative appendectomy rates of 18.5% and 3.6%, respectively.

Yüz on dört hastanın 64’üne (%56) apendektomi yapıldı.

Negatif apendektomi oranı %17,2 idi. Alvarado ve Lintula skorlarının yatış ve tedavi kararı vermedeki genel doğruluk oranları sırasıyla %82,7 ve %91,9 idi (p=0,102).

Hastaların tümü için toplam tedavi maliyeti 39,655 $ idi.

Alvarado ve Lintula skorları kullanılmış olsaydı toplam tedavi giderleri sırasıyla 34,087 $ ve 25,772 $ (p=0,015 ve p=0,000); negatif apendektomi oranları %18,5 ve %3,6 olacaktı.

CONCLUSION

SONUÇ

The implementation of Alvarado and Lintula scores for the decision of hospital admission and appendectomy would have reduced overall treatment charges for acute RLQ pain.

Key Words: Acute appendicitis; Alvarado scores; cost; Lintula scores; score.

Department of General Surgery, Firat University, Faculty of Medicine, Elazığ; 2 Department of General Surgery, Antalya Training and Research Hospital, Antalya, Turkey.

1

Alvarado ve Lintula skorlarının hastaneye kabul ve apendektomi kararı için kullanılması akut SAK ağrısı için tedavi giderlerini düşürecektir.

Anahtar Sözcükler: Akut apandisit; Alvarado skoru; maliyet; Lintula skoru; skor.

Fırat Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Elazığ; 2 Antalya Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Antalya.

1

Correspondence (İletişim): Cüneyt Kırkıl, M.D. Fırat Üniversitesi Hastanesi, Genel Cerrahi Kliniği, 23169 Elazığ, Turkey.

Tel: +90 - 424 - 233 35 55 / 2222 e-mail (e-posta): ckirkil@yahoo.com

13

Ulus Travma Acil Cerrahi Derg

Abdominal pain is a common presenting complaint of emergency department (ED) patients who are admitted to general surgery wards. Making an early diagnosis of appendicitis, one of the causes of an acute abdomen, can be difficult. Typical symptoms, signs, and supportive laboratory data are not present in 2033% of acute abdominal pain patients in whom acute appendicitis is the primary working diagnosis.[1,2] Delay in diagnosis may lead to perforation, periappendicular abscess, wound infection, and intraabdominal adhesions. In the past, it was believed that the most effective way to avoid these complications was to broaden surgical indications at the expense of an increased rate (up to 40%) of negative appendectomy.

[3-5] The downsides of this approach are increased hospital bed utilization, higher treatment costs, and loss of productivity.

The Alvarado (Table 1) and Lintula (Table 2) scoring tools were developed in an attempt to assist clinicians in distinguishing acute appendicitis from other causes of abdominal pain, with the aim of reducing the negative appendectomy rate.[6-12] Acute abdominal pain patients with a total score of ≤3 on the Alvarado and ≤15 on the Lintula scales have a lower probability of acute appendicitis and thus do not require hospitalization. Patients with scores of ≥7 and ≥21, respectively, have a higher probability of acute appendicitis requiring emergency appendectomy. Patients with Alvarado scores between 4 and 6 and Lintula scores between 16 and 20 are suspected cases for acute appendicitis; close inpatient follow-up is recommended for this group.[13,14] We performed a retrospective simulation to determine how charges would have changed if the Alvarado and Lintula appendicitis scoring systems had been used in patients admitted to our department due to right lower quadrant (RLQ) pain. A secondary objective of the study was to determine the diagnostic accuracy of the Alvarado and Lintula scoring systems.

MATERIALS AND METHODS Charts of patients presenting with RLQ pain to the ED of our hospital between November 2009 and November 2010 and admitted to the general surgery inpatient ward were analyzed. Exclusion criteria included prior appendectomy, concurrent antibiotic therapy, chronic RLQ pain, abdominal trauma, and inguinal hernia. All patients underwent ultrasound (US) examination by a radiology resident in the ED. If the US findings were not consistent with clinical findings, an oral and intravenous (IV) contrast-enhanced multislice computed tomography (CT) was performed.

“Clinical decision” was defined as the treatment decision that was reached after the evaluation of medical history, physical examination, laboratory tests, and 14

Table 1. Alvarado score

Symptoms Migratory right iliac fossa pain Anorexia Nausea/vomiting Signs Right lower quadrant tenderness Right iliac fossa rebound Elevation of temperature Laboratory findings Leukocytosis Left shift (neutrophils) Total score

Score 1 1 1 2 1 1 2 1 10

imaging studies. Patients without a diagnosis of acute appendicitis were admitted for close clinical followup; they were kept nil per os (NPO), received maintenance IV fluids, and IV H2-receptor blockers as stress ulcer prophylaxis.

The Alvarado and Lintula scores of the patients were calculated by a staff surgeon, and in case appenTable 2. Lintula score

Gender Male Female Intensity of pain Severe Mild or moderate Migration of pain Present Absent Right lower quadrant pain Present Absent Vomiting Present Absent Body temperature ≥37.5° C <37.5° C Guarding Present Absent Bowel sounds Absent, tinkling or high-pitched Normal Rebound tenderness Present Absent Total score

Score 2 0 2 0 4 0 4 0 2 0 3 0 4 0 4 0 7 0 32 Ocak - January 2013

Appendicitis scores may be useful in reducing the costs of treatment for right lower quadrant pain

dectomy had been performed, the pathology report was used as the final diagnosis. Patients whose abdominal pain resolved spontaneously within the first 24 hours of observation, without undergoing appendectomy, were considered not to have acute appendicitis. The hospital charges incurred after evaluation in the ED were calculated from the sum of invoices issued by the government insurance agency to the patient.

Simulation study design Low-score group (≤3 for Alvarado, ≤15 for Lintula): These patients were considered to probably not have acute appendicitis, and thus discharge home from the ED would be appropriate. As this group would not have been hospitalized, their post-ED charges were taken to be $0. The charges for patients who had low scores but who underwent appendectomy, and in whom the pathology was positive for appendicitis, were used as they were, without adjustment.

Mid-score group (4-6 for Alvarado, 16-20 for Lintula): The treatment costs of those who underwent appendectomy, and in whom the pathology was positive for appendicitis, and of those who were followed closely on the ward without surgery and who had no progression to appendicitis were used as they were, without adjustment. In cases of negative appendectomy, surgery and anesthesia-related charges were subtracted from the patient’s total treatment-related bill.

High-score group (≥7 for Alvarado, ≥21 for Lintula): The treatment costs of those who underwent positive or negative appendectomy were used as they were. If the scoring systems had been used for decision-making, the patients whose symptoms spontaneously resolved in this group would have undergone a negative appendectomy. Their treatment costs were assumed to be $454, the average invoice amount of appendectomized patients in this study.

Outcome measures The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy rates of the scoring systems and

charges for treatment were calculated.

Statistics Differences between the actual and calculated treatment charges had the Alvarado and Lintula scores been used were analyzed with paired t-testing and 95% confidence intervals. The differences between the sensitivity, specificity, PPV, NPV, and diagnostic accuracy rates of the scoring systems and the actual clinical decision were tested using chi-square testing and 95% confidence intervals. Pearson correlation coefficients were calculated in order to determine the relationship between the Alvarado score, Lintula score, and pathology result.

RESULTS During the study period, 127 patients with a primary complaint of RLQ pain were evaluated in the ED and referred to the general surgery clinic. Of these, data from the charts of 13 patients were excluded for the following reasons: 1 for having had a prior appendectomy, 6 for concurrent use of antibiotics, 4 for a history of chronic abdominal pain, 1 for a history of abdominal trauma, and 1 for presence of a right inguinal hernia.

In the remaining 114 patients, Alvarado and Lintula scores were calculated. In these patients, US was consistent with acute appendicitis in 56 (49.1%). Only 4 of 22 patients who underwent oral and IV contrastenhanced CT had a radiologic diagnosis of probable acute appendicitis. Appendectomy was performed in 64 of the 114 patients (56.1%; 33 laparoscopic appendectomies, 31 open appendectomies). Histopathological examination was negative for acute appendicitis in 11 of these 64 patients (17%; 1 of 33 laparoscopic appendectomies, 10 of 31 open appendectomies).

The total bill for the services provided in the general surgery department was $39,655: mean of $454 per patient who underwent appendectomy ($345 in the open appendectomy group and $563 in the laparoscopic appendectomy group) and $208 per patient

Table 3. Sonographic and histopathologic results in 22 patients with right lower quadrant pain who underwent CT in addition to ultrasound scanning Computed tomography

Ultrasound

Management

Normal

Appendicitis

Normal

Appendicitis

Normal

Appendicitis

Observation Appendectomy Observation Appendectomy Observation Appendectomy Observation Appendectomy

Cilt - Vol. 19 Sayı - No. 1

No. of patients 14 3 0 1 1 2 0 1

Histopathology Appendicitis in all 3 Normal appendix Appendicitis in both Appendicitis 15

Ulus Travma Acil Cerrahi Derg

Table 4. Patient management and histopathological results according to the Alvarado and Lintula scores in 114 patients admitted with right lower quadrant pain

Alvarado score ≤3 4-6 ≥7 Lintula score ≤15 16-20 ≥21

Observation

Normal appendix

Appendicitis

22 19 9

3 5 3

2 9 42

46 4 0

7 2 2

5 22 26

who was observed on the ward without appendectomy.

Of the 56 patients who had US findings compatible with acute appendicitis, 10 recovered spontaneously during inpatient observation, and 46 underwent appendectomy (6 negative, 40 positive). Of the 58 patients who did not have US findings compatible with acute appendicitis, 40 recovered spontaneously during inpatient observation, and 18 underwent appendectomy (5 negative, 13 positive). The US and histopathology results of 22 patients who were also investigated

by CT are summarized in Table 3.

Table 4 lists the distribution of Alvarado and Lintula scores of the patients. Had the Alvarado score been implemented for decision-making, 22 patients with a score of ≤3 would not have been hospitalized, and $7,319 would not have been charged. Eight patients with a score of <7 would not have undergone a negative appendectomy, and $4,017 would not have been charged. Had an Alvarado score of ≥7 been used to operate and perform an appendectomy, nine additional patients would have undergone a negative appendectomy (a negative appendectomy rate of 18.5%), resulting in $4,085 in charges. The actual total charges for these patients, who were in fact observed, was $1,649.

Two patients with initial Alvarado scores of ≤3 turned out to have acute appendicitis on their pathology reports, a false-negative rate of 4.5% if the Alvarado score had been used for decision-making. We assumed that the charges of these two patients, who would have presented eventually and undergone emergent appendectomy, would not have changed from their actual charges. Thus, total charges would have been $34,087 instead of 39,655, a 14% difference (p=0.015).

Had the Lintula score been used for decision-making, 58 patients with a score of ≤15 would not have been unnecessarily hospitalized. The treatment cost of these patients was $15,519. Nine patients with scores <21 would not have undergone a negative appendec16

Appendectomy

tomy, and $4,516 in charges would have been avoided. All 28 patients with a score of ≥21 were operated, and all but two had a pathology diagnosis of appendicitis. Had the Lintula score been implemented, the negative appendectomy rate would have been 3.6%.

Five of 58 patients with a Lintula score <15 turned out to have acute appendicitis, a false-negative rate of 16.1%. We assumed that the charges of these five patients, who would have presented eventually and undergone emergent appendectomy, would not have changed from their actual charges. Charges of patients whose treatment decisions would not have been different if the Lintula score had been used were used as is.

Thus, if the Lintula score has been used, total charges would have been $25,772. This figure is significantly lower than actual charges incurred in our patient group (p=0.000).

The sensitivity, specificity, PPV, NPV, and diagnostic accuracy rates of the Alvarado score, Lintula score, and clinical decisions are depicted in Table 5. Sensitivity of the Lintula score was significantly lower than of clinical decision-making (p=0.006), but the difference between the sensitivity of the Alvarado and Lintula scores was not statistically significant (p=0.118). On the other hand, the specificity of the Lintula score was significantly greater than both the Alvarado score and clinical decision-making (p=0.000 and p=0.018, respectively). The difference in specificity between the Alvarado score and clinical decision-making was insignificant (p=0.140). The Alvarado and Lintula scores correlated highly with the histopathological results (Pearson correlation testing, p=0.001 and p=0.000, respectively).

DISCUSSION The lifelong incidence of acute appendicitis ranges between 5-25%, and appendectomy is the most frequently performed emergency abdominal surgery in the world; in the United States alone, 250,000 appenOcak - January 2013

Appendicitis scores may be useful in reducing the costs of treatment for right lower quadrant pain

dectomies are performed annually, using one million hospital days and costing 3 billion dollars per year.

[15-20] To minimize expenditures while providing the highest quality of service, unnecessary appendectomies should be avoided. Our study demonstrated that common scoring systems used to reduce negative appendectomy rates also significantly reduced treatment charges.

The preoperative diagnosis of acute appendicitis is usually based on clinical findings, but these are only 60-80% accurate due to atypical presentations and the presence of other diseases that cause RLQ pain.[21,22] While US is the most frequently used imaging method to confirm the diagnosis, diagnostic accuracy rates (71% and 97%) are limited by practitioner experience, localization of the appendix, the patient’s body mass index, and density of bowel gases.[23-25] CT is a more reliable imaging method for diagnosing acute appendicitis, having a diagnostic accuracy rate of 93-98%.

[26] The training and experience of the radiologist significantly affects the accuracy of CT imaging.[27] On the other hand, CT has disadvantages such as contrastrelated complications, exposure to ionizing radiation, and high costs. Therefore, US is the preferred imaging modality in pregnant and breastfeeding women, as well as in children.[28] For these reasons, US and CT should be considered complementary techniques, rather than rivals. In SCOAP (Surgical Care and Outcomes Assessment Program), the prevalence of negative appendectomy was found to be higher in patients with conflicting US/CT findings.[29] In our series, the diagnostic accuracy of CT (74.6%) was lower than is commonly reported in the literature, probably due to the fact that radiology residents were reading the emergency CT scans. In addition, CT scanning was performed in only a small proportion of our patients, making meaningful statistical comparisons of the CT results with other parameters impossible.

In our patients, a diagnostic accuracy rate of 90.4% was achieved by clinical examination aided by laboratory and imaging findings. In 1986, when Alvarado proposed a scoring system for the early diagnosis of acute appendicitis, CT and US imaging were not com-

monly used.[6] In subsequent years, others developed scoring systems based on symptoms as well as associated clinical and laboratory findings.[7-12] The sensitivity, specificity, and diagnostic accuracy of the Alvarado score were reported to be between 84.2-92%, 66.791.2%, and 87-92%, respectively.[30-33] The sensitivity, specificity, and diagnostic accuracy of the Lintula score in adults are reported to be 87%, 98%, and 91%, respectively.[14] All three articles found through a PubMed-based literature research on the Lintula scoring system are written by Lintula et al.[7,14,34] According to the results of the present study, the diagnostic accuracy of the Alvarado and Lintula scoring systems in our patients was consistent with the existing literature. We found the specificity of the Lintula score to be very high; thus, had the Lintula score been used for decision-making, our negative appendectomy rates would have been significantly lower.

The Alvarado score has been found to be most accurate in men and children.[35] Having used a modified Alvarado score, Kanumba et al.[36] found sensitivity, specificity, and diagnostic accuracy rates to be different for men and women (95.8%, 92.9%, and 91.5% versus 88.3%, 89.7% and 87.6%, respectively). In the Lintula scoring system, however, the sex of the patient is considered a separate parameter. In our patients, only two women had a Lintula score of ≥21; thus, subgroup analyses by sexes were not performed.

We found high NPVs for the Alvarado and Lintula scoring systems (91.4% and 92.6%, respectively), which means a low false-negativity rate in patients with a low score. Therefore, imaging of patients with a low appendicitis score is not recommended. Supporting this, McKay and Shepherd[13] reported that CT imaging in 52 out of the 55 patients with an Alvarado score of ≤3 was negative (94.5%), and the incidence of delayed presentation of acute appendicitis was only 3.6%. They even argued that because the incidence of acute appendicitis in patients with an Alvarado score of ≥7 was 77.7%, these patients should be referred directly to surgery without CT imaging in the ED. Although acute appendicitis is considered to result from progressive inflammation, spontaneous resolu-

Table 5. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy rates of the Alvarado and Lintula scores and clinical decision in patients with right lower quadrant pain

Sensitivity (%) Specificity (%) Positive predictive value (%) Negative predictive value (%) Diagnostic accuracy (%) Cilt - Vol. 19 Sayı - No. 1

Alvarado

Lintula

Clinical decision

p

95.5 67.6 77.8 92.6 82.7

83.9 96.4 92.9 91.4 91.9

100 82.0 82.8 100 90.4

0.007 0.001 0.228 0.111 0.133 17

Ulus Travma Acil Cerrahi Derg

tion has also been reported.[37-40] Our assumption that spontaneously resolving cases were not true acute appendicitis may be criticized. However, the incidence of spontaneously healing acute appendicitis is not known. Scoring of patients with RLQ pain can be repeated during active observation while patients are worsening or improving clinically; symptoms and signs resolve completely in some patients.[41] In this retrospective study, both the Alvarado and Lintula scoring systems had high diagnostic accuracy rates for acute appendicitis. Treatment charges would have been significantly lower had these scores been utilized for decision-making in patients with acute RLQ pain.

Conflict-of-interest issues regarding the authorship or article: None declared.

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A critical review of diagnosis and treatment in 1,000 cases.

Arch Surg 1975;110:677-84.

2. Berry J Jr, Malt RA. Appendicitis near its centenary. Ann Surg 1984;200:567-75.

3. Velanovich V, Satava R. Balancing the normal appendectomy rate with the perforated appendicitis rate: implications for quality assurance. Am Surg 1992;58:264-9.

4. Simpson J, Speake W. Appendicitis. Clin Evid 2005;14:52935.

5. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004;91:28-37.

6. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-64.

7. Lintula H, Kokki H, Kettunen R, Eskelinen M. Appendicitis score for children with suspected appendicitis. A randomized clinical trial. Langenbecks Arch Surg 2009;394:999-1004.

8. Christian F, Christian GP. A simple scoring system to reduce the negative appendicectomy rate. Ann R Coll Surg Engl 1992;74:281-5.

9. Dado G, Anania G, Baccarani U, Marcotti E, Donini A, Risaliti A, et al. Application of a clinical score for the diagnosis of acute appendicitis in childhood: a retrospective analysis of 197 patients. J Pediatr Surg 2000;35:1320-2.

10. Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002;37:877-81.

11. Eskelinen M, Ikonen J, Lipponen P. A computer-based diagnostic score to aid in diagnosis of acute appendicitis. Theor Surg 1992;7:86-90.

12. Fenyö G, Lindberg G, Blind P, Enochsson L, Oberg A. Diagnostic decision support in suspected acute appendicitis: validation of a simplified scoring system. Eur J Surg 1997;163:831-8.

13. McKay R, Shepherd J. The use of the clinical scoring system

by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med 2007;25:489-93.

14. Lintula H, Kokki H, Pulkkinen J, Kettunen R, Gröhn O, Eskelinen M. Diagnostic score in acute appendicitis. Validation of a diagnostic score (Lintula score) for adults with suspected appendicitis. Langenbecks Arch Surg 2010;395:495-500.

15. Flum DR, Koepsell T. The clinical and economic correlates 18

of misdiagnosed appendicitis: nationwide analysis. Arch Surg 2002;137:799-804.

16. Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? A populationbased analysis. JAMA 2001;286:1748-53.

17. Guller U, Jain N, Curtis LH, Oertli D, Heberer M, Pietrobon R. Insurance status and race represent independent predictors of undergoing laparoscopic surgery for appendicitis: secondary data analysis of 145,546 patients. J Am Coll Surg 2004;199:567-77.

18. Margenthaler JA, Longo WE, Virgo KS, Johnson FE, Oprian CA, Henderson WG, et al. Risk factors for adverse outcomes after the surgical treatment of appendicitis in adults. Ann Surg 2003;238:59-66.

19. Sugimoto T, Edwards D. Incidence and costs of incidental appendectomy as a preventive measure. Am J Public Health 1987;77:471-5.

20. Davies GM, Dasbach EJ, Teutsch S. The burden of appendicitis-related hospitalizations in the United States in 1997.

Surg Infect (Larchmt) 2004;5:160-5.

21. Bendeck SE, Nino-Murcia M, Berry GJ, Jeffrey RB Jr. Imaging for suspected appendicitis: negative appendectomy and perforation rates. Radiology 2002;225:131-6.

22. Ashraf K, Ashraf O, Bari V, Rafique MZ, Usman MU, Chisti I. Role of focused appendiceal computed tomography in clinically equivocal acute appendicitis. J Pak Med Assoc 2006;56:200-3.

23. Gamanagatti S, Vashisht S, Kapoor A, Chumber S, Bal S. Comparison of graded compression ultrasonography and unenhanced spiral computed tomography in the diagnosis of acute appendicitis. Singapore Med J 2007;48:80-7.

24. Wilson EB, Cole JC, Nipper ML, Cooney DR, Smith RW. Computed tomography and ultrasonography in the diagnosis of appendicitis: when are they indicated? Arch Surg 2001;136:670-5.

25. Rao PM, Boland GW. Imaging of acute right lower abdominal quadrant pain. Clin Radiol 1998;53:639-49.

26. Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998;338:141-6.

27. in’t Hof KH, Krestin GP, Steijerberg EW, Bonjer HJ, Lange JF, Becking WB, et al Interobserver variability in CT scan interpretation for suspected acute appendicitis. Emerg Med J 2009;26:92-4.

28. Old JL, Dusing RW, Yap W, Dirks J. Imaging for suspected appendicitis. Am Fam Physician 2005;71:71-8.

29. SCOAP Collaborative, Cuschieri J, Florence M, Flum DR, Jurkovich GJ, Lin P, et al. Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program. Ann Surg 2008;248:557-63.

30. Inci E, Hocaoglu E, Aydin S, Palabiyik F, Cimilli T, Turhan AN, et al. Efficiency of unenhanced MRI in the diagnosis of acute appendicitis: comparison with Alvarado scoring system and histopathological results. Eur J Radiol 2011;80:2538.

31. Rezak A, Abbas HM, Ajemian MS, Dudrick SJ, Kwasnik EM. Decreased use of computed tomography with a modified clinical scoring system in diagnosis of pediatric acute appendicitis. Arch Surg 2011;146:64-7.

32. Escribá A, Gamell AM, Fernández Y, Quintillá JM, Cubells CL. Prospective validation of two systems of classification for the diagnosis of acute appendicitis. Pediatr Emerg Care 2011;27:165-9.

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Appendicitis scores may be useful in reducing the costs of treatment for right lower quadrant pain

33. Kostić A, Slavković A, Marjanović Z, Madić J, Krstić M, Zivanović D, et al. Evaluation of using Alvarado score and C-reactive protein in diagnosing acute appendicitis in children. [Article in Serbian] Vojnosanit Pregl 2010;67:644-8.

[Abstract] 34. Lintula H, Pesonen E, Kokki H, Vanamo K, Eskelinen M. A diagnostic score for children with suspected appendicitis.

Langenbecks Arch Surg 2005;390:164-70.

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36. Kanumba ES, Mabula JB, Rambau P, Chalya PL. Modified Alvarado Scoring System as a diagnostic tool for acute appendicitis at Bugando Medical Centre, Mwanza, Tanzania.

BMC Surg 2011;11:4.

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37. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Ann Surg 1995;221:278-81.

38. Hansson LE, Laurell H, Gunnarsson U. Impact of time in the development of acute appendicitis. Dig Surg 2008;25:394-9.

39. Migraine S, Atri M, Bret PM, Lough JO, Hinchey JE. Spontaneously resolving acute appendicitis: clinical and sonographic documentation. Radiology 1997;205:55-8.

40. Cobben LP, de Van Otterloo AM, Puylaert JB. Spontaneously resolving appendicitis: frequency and natural history in 60 patients. Radiology 2000;215:349-52.

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19

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):20-24

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.81889

Management of acute appendicitis in pregnancy Gebelikte akut apandisit tedavisi Selin KAPAN, Mehmet Abdussamet BOZKURT, Ahmet Nuray TURHAN, Murat GÖNENÇ, Halil ALIŞ

BACKGROUND

AMAÇ

Acute appendicitis is the most common surgical non-obstetric pathology during pregnancy. In this report, pregnant patients operated with a diagnosis of acute appendicitis in the last three years are evaluated retrospectively.

Akut apandisit gebelikte en sık rastlanan obstetrik dışı cerrahi patolojidir. Bu yazıda son 3 yılda ameliyat edilen gebelikteki akut apandisit olguları geriye dönük olarak değerlendirildi.

METHODS

GEREÇ VE YÖNTEM

Between January 2009 and January 2011, 20 pregnant patients were operated for acute appendicitis. Patients were evaluated regarding age, gestational age, clinical and laboratory examinations, imaging studies, operative findings, mean hospital stay, mean operative time, and outcome.

RESULTS

In 17 of 20 patients, acute appendicitis was confirmed and appendectomy was performed. Ten of the patients were operated with laparoscopic technique and the remaining 10 had open appendectomy. There was no fetal or maternal morbidity or mortality in any patient. All 20 patients delivered healthy babies during the postoperative course.

CONCLUSION

Ocak 2009 ve Ocak 2011 arasında 20 gebe hasta akut apandisit nedeniyle ameliyat edildi. Hastalar yaş, gebelik yaşı, klinik ve laboratuvar bulguları, görüntüleme sonuçları, ameliyat bulguları, ortalama hastanede yatış süresi, ortalama ameliyat süresi ve sonuçlar açısından değerlendirildi.

BULGULAR

Çalışmaya alınan 20 hastanın 17’sinde apandisit doğrulandı ve apendektomi uygulandı. Hastaların 10’u laparoskopik, diğer 10 hasta ise açık ameliyata alındı. Hastaların hiçbirinde fetal morbidite ve mortalite görülmedi. Hastaların tümü ameliyat sonrası gebelik sonunda sağlıklı bebekler doğurdular.

SONUÇ

Acute appendicitis is a challenging diagnosis in the pregnant patient; however, early surgical intervention should be performed with any suspicion. The type of surgery depends on the surgeon’s preference and experience.

Akut apandisit gebe hastada zor bir tanı olmasına rağmen şüphe anında erken cerrahi girişim yapılmalıdır. Cerrahinin tipi cerrahın seçimine ve tecrübesine bağlıdır.

Key Words: Acute appendicitis; appendectomy; laparoscopy; pregnancy.

Anahtar Sözcükler: Akut apandisit; apendektomi; laparoskopi; gebelik.

Acute appendicitis is the most common surgical condition requiring non-obstetric abdominal surgery during pregnancy, and its incidence is reported to be between 1:1250 and 1:1500 pregnancies, with 50% of cases occurring in the second trimester.[1-3] The high

prevalence of nausea, vomiting and abdominal pain in the normal obstetric patient population leads to the delayed surgical intervention.[4,5] In addition, there is a general reluctance to operate unnecessarily on a gravid patient. In any pregnant patient, right-sided abdominal

Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey.

Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul.

Correspondence (İletişim): Selin Kapan, M.D. Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Tevfik Sağlam Cad. No: 11., Zuhuratbaba, Bakirkoy 34147 İstanbul, Turkey.

Tel: +90 - 212 - 414 71 59 e-mail (e-posta): selinkapan@gmail.com

20

Management of acute appendicitis in pregnancy

pain, associated with guarding and rebound and accompanied by fever should always be considered appendicitis unless proven otherwise. Assessment of the white blood cell count may not be particularly helpful because pregnant patients often have a physiological leukocytosis. Careful physical examination is key to making the diagnosis.[6] Ultrasonography should be used to assess for the presence of an obstetrical pathology such as an ovarian cyst or torsion of an adnexal mass. In the general population, there are several scoring systems available to aid the accuracy of diagnosis of appendicitis, including the Alvarado scoring system. No such system is available for the obstetric population.[3-5]

pendix, acute appendicitis was confirmed in 10 during the operation. The median time between consultation and operation was 6 hours (3-10). The mean operation time was 54.1 minutes (12-135 min). The mean operation time in open and laparoscopic approach was 51.7 min (12-120) and 56.5 min (30-135), respectively. The mean hospital stay was 1.1 days (1-2 days). In 8 of the 10 laparoscopic procedures, the first trocar was inserted with open technique; in the remaining, Veress insufflation was performed.

In this study, we present our cases of acute appendicitis during pregnancy in light of the related literature.

In the remaining 10 patients, open appendectomy was performed, and all 10 had acute appendicitis.

There was no maternal or fetal mortality, morbidity, or uterine injury in any of the patients. No case of fetal mortality was encountered. Twenty patients delivered 20 healthy infants. Demographic data of the patients are given in Table 1.

MATERIALS AND METHODS Twenty pregnant women who were consulted to the Emergency Surgery Clinic for acute abdominal pain from January 2009 to January 2011 were included in this study. Clinical data collected retrospectively included physical examination findings, age of the patients, week of pregnancy, presenting symptoms, ultrasonographic confirmation, leukocyte count, and postoperative complications. All patients were assessed by a gynecologist and a general surgeon before and after surgery. The diagnosis of acute appendicitis was based on clinical examination, ultrasound (US) and leukocyte count, and pregnancy was confirmed by US. Each patient was evaluated by the Alvarado scoring system. The period between surgical consultation and surgery was evaluated.

Appendectomies were performed by laparoscopic or open approach. General inhalational anesthesia was employed routinely during the operation. Urinary catheters were used routinely.

RESULTS The mean age of the patients was 26 (19-35) years.

The mean gestational age at the time of LA was 17.6 weeks (4-33 weeks). Ten patients were in the second trimester, 6 were in the first trimester and 4 were in the third trimester of pregnancy. The mean Alvarado score was 7.7 (7-9). The mean leukocyte count was 13920 (7200-22300), and mean neutrophil % was 81.65% (91.4%-67.3%). All 20 patients were admitted with complaints of abdominal pain. Thirteen patients had additional nausea and vomiting. Abdominal ultrasonography was performed in all patients after gynecological examination. Ultrasonography revealed acute appendicitis in seven patients. All these seven patients were acute appendicitis. In the remaining 13 patients, in whom ultrasonography could not visualize the apCilt - Vol. 19 SayÄą - No. 1

In 10 patients, diagnostic laparoscopy was performed and seven of these patients had acute appendicitis. One patient had paraovarian cyst, whereas the other two patients had no pathology.

DISCUSSION Certain anatomic and physiologic changes specific to pregnancy may make the cause of the abdominal pain difficult to ascertain in pregnant patients.[3,4] The uterus becomes an abdominal organ at around 12 weeksâ&#x20AC;&#x2122; gestation and compresses the underlying abdominal viscera. This enlargement may make it difficult to localize the pain and may also mask or delay peritoneal signs. The laxity of the anterior abdominal wall may also mask or delay peritoneal signs. The ureters became dilated as early as the first trimester and remain dilated into the postpartum period. This distension may lead to urinary stasis, increasing not only the risk of urolithiasis, but also infection. Increasing progesterone increases respiratory drive. Functional residual capacity decreases. Hemostatic changes also add to the challenge of evaluating and caring for pregnant women. Pregnancy produces a thrombogenic state, with two-to-three-fold increase in fibrinogen levels. In pregnancy, physiologic leukocytosis occurs, and in our study, all patients had leukocytosis.[4] Anatomical changes related to the gravid uterus, gestational symptoms, the physiological inflammatory response, and a wider differential diagnosis in pregnant women result in poor diagnostic accuracy, reported to range from 36% to 86%.[2] Acute appendicitis has a peak incidence in the second and third decades coinciding with the childbearing years, and the incidence in pregnancy appears broadly the same as in the nonpregnant, whereas the rate of perforation and subsequent complications are greater.[2,7] Fetal mortality is given as 5% after appendicitis, whereas this rate increases to approximately 20% in a 21

Ulus Travma Acil Cerrahi Derg

Table 1. Demographic data of 20 patients Age

21 28 27 27 24 31 35 19 24 25 27 21 31 26 23 19 32 26 24 31

Gestational age

Alvarado score

Leukocyte count

Neutrophil (%)

US

MPT

Type of operation

MOT

HT

20 11 30 16 19 20 27 18 20 18 23 6 22 18 6 9 7 4 26 33

8 7 8 8 7 8 9 7 8 7 8 8 7 7 7 8 8 8 8 9

18000 20100 11200 22300 7200 13300 8000 13900 5900 15100 19500 15700 10800 8800 15500 11600 16800 17000 11400 16300

90 91.4 89.6 91.3 75 93.1 71.6 83.2 81 68.9 89.8 81.1 75.8 67.3 91.1 67.4 78 84.4 68.9 93.2

App Neg Neg App Neg App Neg App Neg Neg Neg App Neg Neg App App Neg Neg Neg Neg

8 3 4 8 7 6 9 3 9 8 4 5 4 6 10 9 3 4 4 6

LA OA OA LA OA OA LA OA DL DL OA OA LA DL OA OA LA LA LA OA

30 50 40 50 70 40 135 50 30 60 40 50 60 65 20 12 60 45 60 120

1 1 1 1 2 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1

DL: Diagnostic laparoscopy; HT: Hospitalization time (days); LA: Laparoscopic approach; MOT: Mean operation time (minute); MPT: Time period between consultation and operation (hours); Neg: Negative; OA: Open approach.

perforated appendicitis. Similarly, maternal mortality also increases in perforated cases.[3] Given the lack of sensitivity of the preoperative evaluation, it is not surprising that the pathologic diagnosis of appendicitis is confirmed in 36-50% of cases.[5] In our study with laparoscopy, three patients were determined to have no acute appendicitis. Seventeen of 20 patients were diagnosed as appendicitis, and pathologic investigation of the 17 specimens confirmed our diagnosis.

The accuracy of the diagnosis is greater in the first trimester, but more than 40% of patients who undergo appendectomy in the second and third trimester have a normal appendix. The negative laparotomy rate for suspected appendicitis in obstetric cases is 25-50%, compared with 15-35% in general surgical cases in non-obstetric patients.[2] In our study, 10 of 20 patients were second trimester, and three of them went to negative laparoscopy.

It has been nearly 100 years since Balber stated that â&#x20AC;&#x2DC;the mortality of appendicitis complicating pregnancy is the mortality of delayâ&#x20AC;&#x2122;. The wisdom of this statement has been repeatedly demonstrated. Delay in the diagnosis of appendicitis is associated with significant complications.[2] Delay to surgery is equally risky, with rates of fetal loss reported to be 1.5-4% in uncomplicated appendicitis compared with 21-35% 22

in the presence of ruptured appendicitis.[2] A fetal loss rate of 3-5% is observed with an unruptured appendix; this rate increases up to 20% if the appendix is ruptured. The risk of preterm labor is greatest during the first week after surgery, but preterm delivery is rare.

[4,8] Furthermore, increasing gestational age reduces diagnostic accuracy and is associated with increased rates of appendiceal perforation and hence complications.[2,9] We operated the patients in our series within 12 hours. Contrary to the literature, in our study, there was no fetal loss or appendiceal perforation. The reason for this difference was the short time period between consultation and operation in our study.

The authors suggest that none of the clinical parameters investigated is useful in predicting appendicitis in pregnancy. US and magnetic resonance imaging (MRI) are not associated with ionizing radiation, have not been shown to have any deleterious effects on pregnancy, and should be used when feasible.[4,9-11] Retrospective studies have suggested that MRI of the appendix is useful in delineating the presence of appendicitis in pregnant women, but the small number of patients in these studies limits the inference that can be drawn.[12] There are also studies using computed tomography (CT) for the diagnosis of acute appendicitis in pregnancy; however, due to the deleterious effects of ionizing radiation on the fetus, it is suggested to be used only in severe trauma patients with pregnancy.

Ocak - January 2013

Management of acute appendicitis in pregnancy

Wallace et al.[10] reported an overall negative appendectomy rate of 37% for pregnant patients with presumed acute appendicitis. They also reported no difference in the negative appendectomy rate with the addition of CT scan after US. We did not use MRI, only physical examination with US. However, we operated 13 patients with normal ultrasonographic findings, and only three patients in this group went to negative laparoscopy (15%).

[4,13-15]

Currently, accumulating data support the use of laparoscopy regarding safety and efficacy in all trimesters of pregnancy for acute abdomen.[1,16-18] Laparoscopy is associated with decreased hospital stay, quicker return of bowel function, less postoperative pain, and smaller chance of wound infection and hernia.[3,19] Hasson trocar and Veress needle can be used for insufflation; however, we preferred open technique for first trocar insertion in eight patients. Many studies have demonstrated no increased fetal risk with laparoscopic procedures.[20-24] Critics of laparoscopy in pregnant patients raise concerns over the possible effects of laparoscopic intervention on the developing fetus and emphasize that the limited literature regarding laparoscopic appendectomy is concerning.[25-28] The laparoscopic approach has several advantages over open technique. The position of the incision over the displaced appendix is no longer an issue with a minimally invasive approach. In our opinion, the success of the laparoscopy depends on the surgeon’s experience and skills. Another benefit of diagnostic laparoscopy is that it decreases the number of false-positive appendectomies performed.[1] In our study, the overall negative appendectomy rate was 15%, and all of them were diagnosed by laparoscopy. The higher rate of negative appendectomy in the laparoscopic group might reflect a surgical trend during pregnancy in which early diagnostic laparoscopy is considered minimally invasive and safer than observation and re-evaluation. The latter approach can reduce the negative appendectomy rate but might raise the perforation rate. That is why we did not hesitate to perform surgery in our clinic. It should be considered that it is not the laparoscopic approach itself, but the type of infection and delay in diagnosis that are the principal causes of adverse effects attributed to laparoscopy during pregnancy. In our series, no adverse effects on the fetus or the pregnancy were observed after surgery.

Several studies have revealed that the performance of early diagnostic laparoscopy is beneficial when appendicitis is suspected.[29-31] We operated 10 patients within 12 hours with laparoscopic approach. We used open technique for the first trocar insertion. We discharged patients within 24 hours postoperatively.

The symptom/sign complex does not sufficiently diverge from other causes of abdominal pain during Cilt - Vol. 19 Sayı - No. 1

pregnancy. There is no current possibility of developing a sufficiently accurate scoring system as in the non-pregnant patients. There is also increasing competence in the use of laparoscopy in pregnancy.[2] In view of the facts of rare occurrence but increased incidence of perforation in the third trimester and increased fetal mortality in perforated cases, early surgery should be considered in any pregnant patient suspected as having acute appendicitis. The type of surgery, whether open or laparoscopic approach, depends on the experience and preference of the surgeon.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Upadhyay A, Stanten S, Kazantsev G, Horoupian R, Stanten A. Laparoscopic management of a nonobstetric emergency in the third trimester of pregnancy. Surg Endosc 2007;21:13448.

2. Brown JJ, Wilson C, Coleman S, Joypaul BV. Appendicitis in pregnancy: an ongoing diagnostic dilemma. Colorectal Dis 2009;11:116-22.

3. Turhan AN, Kapan S. Akut apandisit. In: Ertekin C, Güloğlu R, Taviloğlu K, editors. Acil cerrahi. İstanbul: Nobel Tıp Kitabevleri; 2009. p. 301-16.

4. Kilpatrick CC, Monga M. Approach to the acute abdomen in pregnancy. Obstet Gynecol Clin North Am 2007;34:389-402, x.

5. Stone K. Acute abdominal emergencies associated with pregnancy. Clin Obstet Gynecol 2002;45:553-61.

6. Butala P, Greenstein AJ, Sur MD, Mehta N, Sadot E, Divino CM. Surgical management of acute right lower-quadrant pain in pregnancy: a prospective cohort study. J Am Coll Surg 2010;211:490-4.

7. Coleman MT, Trianfo VA, Rund DA. Nonobstetric emergencies in pregnancy: trauma and surgical conditions. Am J Obstet Gynecol 1997;177:497-502.

8. Mourad J, Elliott JP, Erickson L, Lisboa L. Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. Am J Obstet Gynecol 2000;182:1027-9.

9. Terzi A, Yildiz F, Vural M, Coban S, Cece H, Kaya M. A case series of 46 appendectomies during pregnancy. Wien Klin Wochenschr 2010;122:686-90.

10. Wallace CA, Petrov MS, Soybel DI, Ferzoco SJ, Ashley SW, Tavakkolizadeh A. Influence of imaging on the negative appendectomy rate in pregnancy. J Gastrointest Surg 2008;12:46-50.

11. Kilpatrick CC, Orejuela FJ. Management of the acute abdomen in pregnancy: a review. Curr Opin Obstet Gynecol.

2008;20:534-9.

12. Blumenfeld YJ, Wong AE, Jafari A, Barth RA, El-Sayed YY. MR imaging in cases of antenatal suspected appendicitis-a meta-analysis. J Matern Fetal Neonatal Med 2011;24:485-8.

13. Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics 2007;27:1705-22.

14. Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics 2007;27:1705-22.

23

Ulus Travma Acil Cerrahi Derg

15. Ames Castro M, Shipp TD, Castro EE, Ouzounian J, Rao P. The use of helical computed tomography in pregnancy for the diagnosis of acute appendicitis. Am J Obstet Gynecol 2001;184:954-7.

16. Jeong JS, Ryu DH, Yun HY, Jeong EH, Choi JW, Jang LC. Laparoscopic appendectomy is a safe and beneficial procedure in pregnant women. Surg Laparosc Endosc Percutan Tech 2011;21:24-7. doi: 10.1097/SLE.0b013e3182051e44.

17. Corneille MG, Gallup TM, Bening T, Wolf SE, Brougher C, Myers JG, et al. The use of laparoscopic surgery in pregnancy: evaluation of safety and efficacy. Am J Surg 2010;200:363-7.

18. de Bakker JK, Dijksman LM, Donkervoort SC. Safety and outcome of general surgical open and laparoscopic procedures during pregnancy. Surg Endosc 2011;25:1574-8.

19. Kapan S, Kapan M. Gebelik ve akut karın. Türkiye Klinikleri Cerrahi Tıp Bilimleri Dergisi 2005;4:84-9.

20. Cohen-Kerem R, Railton C, Oren D, Lishner M, Koren G. Pregnancy outcome following non-obstetric surgical intervention. Am J Surg 2005;190:467-73.

21. Ortega AE, Hunter JG, Peters JH, Swanstrom LL, Schirmer B. A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy. Laparoscopic Appendectomy Study Group. Am J Surg 1995;169:208-13.

22. Pedersen AG, Petersen OB, Wara P, Rønning H, Qvist N, Laurberg S. Randomized clinical trial of laparoscopic versus open appendicectomy. Br J Surg 2001;88:200-5.

23. Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Data-

24

base Syst Rev 2004;4:CD001546.

24. Oelsner G, Stockheim D, Soriano D, Goldenberg M, Seidman DS, Cohen SB, et al. Pregnancy outcome after laparoscopy or laparotomy in pregnancy. J Am Assoc Gynecol Laparosc 2003;10:200-4.

25. Costantino GN, Vincent GJ, Mukalian GG, Kliefoth WL Jr. Laparoscopic cholecystectomy in pregnancy. J Laparoendosc Surg 1994;4:161-4.

26. Motew M, Ivankovich AD, Bieniarz J, Albrecht RF, Zahed B, Scommegna A. Cardiovascular effects and acid-base and blood gas changes during laparoscopy. Am J Obstet Gynecol 1973;115:1002-12.

27. Ivankovich AD, Miletich DJ, Albrecht RF, Heyman HJ, Bonnet RF. Cardiovascular effects of intraperitoneal insufflation with carbon dioxide and nitrous oxide in the dog. Anesthesiology 1975;42:281-7.

28. Thomas SJ, Brisson P. Laparoscopic appendectomy and cholecystectomy during pregnancy: six case reports. JSLS 1998;2:41-6.

29. Jackson H, Granger S, Price R, Rollins M, Earle D, Richardson W, et al. Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review.

Surg Endosc 2008;22:1917-27.

30. Lemieux P, Rheaume P, Levesque I, Bujold E, Brochu G. Laparoscopic appendectomy in pregnant patients: a review of 45 cases. Surg Endosc 2009;23:1701-5.

31. Turhan AN, Kapan S, Kütükçü E, Yiğitbaş H, Hatipoğlu S, Aygün E. Comparison of operative and non operative management of acute appendicitis. Ulus Travma Acil Cerrahi Derg 2009;15:459-62.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):25-28

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.08555

Overlooked extremity fractures in the emergency department Acil serviste gözden kaçan ekstremite kırıkları Erhan ER,1 Pınar H. KARA,1 Orhan OYAR,2 Erden E. ÜNLÜER1

BACKGROUND

AMAÇ

The purpose of the study was to analyze the accuracy of interpretation of extremity traumas by emergency physicians (EP) to determine the most difficult areas for interpretation in comparison to official radiology reports of direct X-ray.

Bu çalışmanın amacı izole ekstremite travmalarında, acil servis doktorlarının yorumlarının resmi radyoloji raporlarıyla karşılaştırılmasıyla en zor yorumlama alanını belirlemek ve acil doktorlarının yorumlarının doğruluğunu analiz etmektir.

METHODS

GEREÇ VE YÖNTEM

Radiologist reports and EP reports of direct X-rays from isolated extremity trauma patients were retrospectively compared from 01.05.2011 to 31.05.2011. A total of 181 fractures in 608 cases were confirmed.

Radyolog raporları ve acil servis doktorlarının yorumları izole ekstremite travmalı hastalarda geriye dönük olarak 01.05.2011’den 31.05.2011 tarihine kadar karşılaştırıldı.

Toplam 608 olguda 181 kırık saptandı.

RESULTS

BULGULAR

The locations of the misinterpreted fractures were ankle and foot (51.4%), wrist and hand (32.4%), elbow and forearm (5.4%), shoulder and upper arm (5.4%), hip and thigh (2.7%), and knee and leg (2.7%). The diagnostic accuracy of the EPs and radiologists were not significantly different (kappa=0.856, p=0.001).

Yanlış yorumlanan kırıkların yerleri sırasıyla ayak bileği ve ayak (%51.4), el bileği ve el (%32.4), dirsek ve önkol (%5.4), omuz ve üst kol (%5.4), kalça ve uyluk (%2.7), diz ve bacak (%2.7) olarak belirlendi. Acil servis doktorlarının ve radyologların tanısal doğrulukları arasında anlamlı bir fark saptanmadı (kapa=0.856, p=0.001).

CONCLUSION

SONUÇ

Knowledge about the types of fractures that are most commonly missed facilitates a specifically directed educational effort.

En sık atlanan kırık tiplerinin bilinmesi, bu konuda eğitimin yoğunlaştırılmasıyla acil servislerde kaçırılan olguların en aza indirilmesini sağlayabilir.

Key Words: Emergency department; extremities; overlooked fractures; radiography.

Anahtar Sözcükler: Acil servis; ekstremite; kaçırılan kırıklar; radyografi.

Direct radiographic examinations frequently contribute important information to the medical decisionmaking processes in trauma units (TU) of emergency departments (ED). Radiographs are often initially interpreted by an emergency physician (EP), and decisions are made based on this initial interpretation.

Studies analyzing errors in fracture diagnoses have focused on the nature of the fractures and the interpretation of X-rays.[1-4] Misdiagnosis of a fracture is a very common occurrence in EDs and can have serious consequences because of delays in treatment and resulting long-term disability.[1] It is also one of the most

Departments of 1Emergency Medicine, 2Radiology, Izmir Katip Celebi University Ataturk Research and Training Hospital, Izmir, Turkey.

İzmir Katip Çelebi Üniversitesi Atatürk Eğitim ve Araştırma Hastanesi, 1 Acil Tıp Kliniği, 2Radyoloji Kliniği, İzmir.

Correspondence (İletişim): Erden E. Ünlüer, M.D. İzmir Katip Çelebi Üniversitesi, Atatürk Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği 35000 İzmir, Turkey.

Tel: +90 - 232 - 244 44 44 / 2696 e-mail (e-posta): erdenun@yahoo.com

25

Ulus Travma Acil Cerrahi Derg

common causes of medical legal claims in the United States.[5,6] Analysis of the circumstances in which errors in medical practice occur may suggest ways to prevent them. Several strategies are available to reduce the misdiagnosis rate: radiograph interpretation by a radiologist who provides full-time, on-site coverage of the ED; coverage of the ED with teleradiology; coverage of the ED by radiology house staff during off-hours; elimination of over-interpretation of ED radiographs by radiologists; and reduction in radiology department workload.[7] In exploring the implications of radiologists workload reduction, it is necessary to determine the potential areas of misdiagnosis by EPs in TUs and to develop a relevant educational program.

Therefore, we conducted a study to analyze the accuracy interpretation of extremity traumas by EPs in comparison to interpretations in official radiology reports following X-ray analysis (gold standard).

MATERIALS AND METHODS We conducted a retrospective cross-sectional study from 01.05.2011 to 31.05.2011 at an academic, adult tertiary care center ED of a university hospital in Turkey. This ED serves more than 240,000 adult patients annually, and 19% of these involve isolated extremity trauma. The study protocol was approved by our local ethics committee. All ED patients who were undergoing evaluation in the TU and had an isolated extremity trauma with direct X-rays were recruited for this study. Patients were ineligible if they were medically unstable, had multiple traumas, were <18 years old, or were pregnant. In addition, cases lacking a written radiography interpretation by EPs were excluded.

We have also reviewed the radiology reports of the direct X-ray images. During the data collection phase in the ED, fractures were categorized as upper or lower extremity, long or short bone, articular or extra articular, and shaft or distal fracture by an EP who was blinded to the study protocol. The independent sample t-test was used for descriptive analyses between groups, and kappa statistics were calculated for comparing EP and GS results.

A receiver operator characteristic curve (ROC) analysis was conducted to identify the threshold that maximized the sensitivity and specificity of the EPs interpretation. The sensitivity, specificity, the positive likelihood ratio (+LR), and the negative likelihood (-LR) were calculated. In this study, the maximum type I error was 0.05 and the level of significance was accepted as p<0.05. In this study, MedCalc Software version 11.5 and SPSS version 15 were used for statistical analyses. Confidence intervals for the sensitivity, specificity, positive, and negative likelihood ratios were calculated.

26

RESULTS During the study period, 608 patients, including 302 (49.7%) men and 306 (50.3%) women, with isolated extremity trauma were evaluated using the GS. The mean age of the patients was 41.89Âą17.49. The characteristics of the fractures are listed in Table 1.

Of these, 181 (29.8%) were corroborated by GS reports and 427 (70.2%) were negative. In 405 (94.8%) cases, the EP was negative for fractures (true negatives), whereas 22 (5.2%) were diagnosed as fracture by the EP (false positives). In 166 (91.7%) cases, the EP was positive for fractures (true positives), whereas 15 (8.3%) were diagnosed negative for fractures by Xray (false negatives) (Table 2). In addition, 47 patients were excluded from the data analyses because no reports were found in the ED files. The results for the EP and GS are listed in Table 2 and 3. The diagnostic accuracy of the EP and the GS were not significantly different (kappa=0.856, p=0.001).

DISCUSSION It is critical to regularly evaluate our methods of caring for patients admitted to ED in order to better serve the needs of patients and to reduce costs. In other national systems, the diagnostic error rate has been evaluated systematically, with revisions made accordingly. In the literature, the observed rate of disagreement between EPs and radiologists in the interpretation of radiographs ranges from 8-11%[2,8-12] and a change in treatment was required for 1-3% of these patients. These errors in interpreting radiographs Table 1. The distribution of false positive and false negative cases according to anatomical location, extremity, bone size and shaft-joint rates

Region Shoulder-upper arm Elbow-forearm Wrist-hand Hip-thigh Knee-leg Ankle-foot Extremity Lower extremity Upper extremity Large-small bone Small bone Large bone Shaft-joint Joint Shaft

False positive

False negative

n

n

%

%

Total n

% 5.4 5.4 32.4 2.7 2.7 51.4

1 4.5 2 9.1 11 50.0 0 0.0 0 0.0 8 36.4

1 6.7 0 0.0 1 6.7 1 6.7 1 6.7 11 73.3

2 2 12 1 1 19

8 36.4 14 63.6

13 86.7 2 13.3

21 56.8 16 43.2

17 77.3 5 22.7

8 7

53.3 46.7

25 67.6 12 32.4

14 63.6 8 36.4

7 8

46.7 53.3

21 56.8 16 43.2

Ocak - January 2013

Overlooked extremity fractures in the emergency department

Table 2. The distribution of the diagnoses according to emergency physician and radiologist evaluation

Radiologist

Emergency physician

Positive Negative Total

Positive

Negative

n

%

n

166 15 181

91.7 8.3 29.8

Table 3. The statistical calculations to compare the sensitivities of the emergency physician and radiologist interpretation

Sensitivity Specificity Positive predictive value (+PV) Negative Predictive value (-PV) Positive likelihood ratio (+LR) Negative likelihood Ratio (-LR) ROC area under the curve (AUC)

95% CI

91.7 86.7-95.3 94.6 92.3-96.7 88.3 82.8-92.5 96.4 94.2-98.0 17.8 16.9-18.7 0.09 0.05-0.20 0.933 0.910-0.951

in the ED can also have significant clinical and legal consequences.[13] These studies covered not only isolated extremity scans but also all direct X-rays in ED. Between 1974 and 1985 the liability program of the American Collage of Emergency Physicians identified the most frequent cause of malpractice actions as the failure to diagnose fractures among these direct images. In our country, because of developing medical legal issues in practice, it not possible to obtain reliable data regarding these missed fractures and their medical-legal results. Perhaps in the future, clearer data will be available regarding this issue.

In this study, lower extremity fractures (ankle and foot) were overlooked most frequently (n=19, 51.4%).

The fractures were located at the proximal region around the joint. This result was consistent with those of previous studies.[2,5,14] The wrist and hand (n=12, 32.4%) was the second most common location of missed fracture diagnoses. There were no missed midshaft fractures of any bone. The elbow and forearm (n=2, 5.4%) and the shoulder and upper arm (n=2, 5.4%) were the third most common site of missed fracture diagnosis. These results were correlated with those in the literature.[2,14] None of the fractures were considered to be clinically important after follow up. There are several limitations of our retrospective analysis. It was not possible to determine the impact of the level of training among individual physicians on the pattern of overlooked fractures. We did not analyze fractures at specific anatomical locations, and we were unable to determine the specific distribution of tibial Cilt - Vol. 19 SayÄą - No. 1

%

22 5.2 405 94.8 427 70.2

Total n

%

188 30.9 420 69.1 608 100.0

plateau fractures and tibial spine fractures because these were grouped together.

Studies have shown that there is a problem regarding the speed of X-ray reporting in EDs. Time is a major factor and 48.9% of reports are not available within 48 h. We would therefore recommend a rapid reporting system to decrease the rate of overlooked fractures.[15] In the short-term, teaching methods should be improved and guidelines on the use of ED radiology have been published.[16] However, this cannot be expected to eliminate all errors and it is important to develop fail-safe mechanisms to detect errors when they occur. Radiology departments should give priority to reporting ED films and the best solution is to have an immediate reporting system. Marking of abnormal radiographs by radiographers can assist in reducing diagnostic errors[17] but the value of this may be limited by a high rate of false positives.[18] Few EDs have a full-time radiologist on duty 24 hours a day. When clinicians in an ED read X-ray films that are later reviewed by radiologists, overlooked fractures will inevitably appear. The fractures that were missed most often were elbow and leg fractures. Knowledge about the types of fractures that are most commonly missed facilitates a specifically directed educational effort.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Hallas P, Ellingsen T. Errors in fracture diagnoses in the emergency department-characteristics of patients and diurnal variation. BMC Emerg Med 2006;6:4.

2. Guly HR. Diagnostic errors in an accident and emergency department. Emerg Med J 2001;18:263-9.

3. Juhl M, Moller-Madsen B, Jensen J. Missed injuries in an orthopaedic department. Injury 1990;21:110-2.

4. Espinosa AJ, Nolan WT. Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study.

BMJ 2000;320:737-40.

5. Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou HJ, Chang CY. Systematic analysis of missed extremity fractures in emergency radiology. Acta Radiol 2006;47:710-7.

6. Berlin L. Defending the â&#x20AC;&#x153;missedâ&#x20AC;? radiographic diagnosis.

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Ulus Travma Acil Cerrahi Derg

AJR Am J Roentgenol 2001;176:317-22.

7. Eng J, Mysko WK, Weller GE, Renard R, Gitlin JN, Bluemke DA, et al. Interpretation of Emergency Department radiographs: a comparison of emergency medicine physicians with radiologists, residents with faculty, and film with digital display. AJR Am J Roentgenol 2000;175:1233-8.

8. Robinson PJ, Wilson D, Coral A, Murphy A, Verow P. Variation between experienced observers in the interpretation of accident and emergency radiographs. Br J Radiol 1999;72(856):323-30.

9. Lufkin KC, Smith SW, Matticks CA, Brunette DD. Radiologistsâ&#x20AC;&#x2122; review of radiographs interpreted confidently by emergency physicians infrequently leads to changes in patient management. Ann Emerg Med 1998;31:202-7.

10. Scott WW Jr, Bluemke DA, Mysko WK, Weller GE, Kelen GD, Reichle RL, et al. Interpretation of emergency department radiographs by radiologists and emergency medicine physicians: teleradiology workstation versus radiograph readings. Radiology 1995;195:223-9.

11. Fleisher G, Ludwig S, McSorley M. Interpretation of pediatric x-ray films by emergency department pediatricians. Ann Emerg Med 1983;12:153-8.

28

12. Rhea JT, Potsaid MS, DeLuca SA. Errors of interpretation as elicited by a quality audit of an emergency radiology facility.

Radiology 1979;132:277-80.

13. Guly HR. Missed tendon injuries. Arch Emerg Med 1991;8:87-91.

14. Freed HA, Shields NN. Most frequently overlooked radiographically apparent fractures in a teaching hospital emergency department. Ann Emerg Med 1984;13:900-4.

15. James MR, Bracegirdle A, Yates DW. X-ray reporting in accident and emergency departments-an area for improvements in efficiency. Arch Emerg Med 1991;8:266-70.

16. Touquet R, Driscoll P, Nicholson D. Teaching in accident and emergency medicine: 10 commandments of accident and emergency radiology. BMJ 1995;310(6980):642-5.

17. Berman L, de Lacey G, Twomey E, Twomey B, Welch T, Eban R. Reducing errors in the accident department: a simle method using radiographers. Br Med J 1985;290(6466):4212.

18. Renwick IG, Butt WP, Steele B. How well can radiographers triage x-ray films in accident and emergency departments?.

BMJ 1991;302(6776):568-9.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):29-32

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.88220

Prophylactic injection therapy is necessary for Forrest type 2b duodenal ulcers Forrest tip 2b duodenal ülserlerde profilaktik enjeksiyon tedavisi gereklidir Osman Zekai ÖNER,1 Murat GÖNENÇ,2 Mustafa Uygar KALAYCI,2 Mehmet Abdussamet BOZKURT,2 Selin KAPAN,3 Halil ALIŞ2

BACKGROUND

AMAÇ

We aimed to assess the effect of prophylactic injection therapy during the index gastroscopy on upper gastrointestinal bleeding due to Forrest type 2b duodenal ulcer.

Bu çalışmada Forrest tip 2b duodenal ülserlerde ilk endoskopi işlemi esnasında yapılan profilaktik enjeksiyon tedavisinin ülserin tekrar kanama oranı üzerine etkisinin belirlenmesi amaçlandı.

METHODS

The patients who were admitted with upper gastrointestinal bleeding and who underwent emergency gastroscopy between January 2004 and January 2011 were recruited to the study retrospectively. Among those, the patients with Forrest type 2b duodenal ulcer were selected and divided into two groups. The patients in Group 1 had only diagnostic gastroscopy, whereas those in Group 2 had prophylactic injection therapy during the index gastroscopy.

RESULTS

GEREÇ VE YÖNTEM

Çalışmaya hastanemizde 2004-2011 yılları arasında üst gastrointestinal sistem kanaması nedeniyle yapılan acil endoskopilerinde Forrest tip 2b duodenal ülser belirlenmiş hastalar alındı. Olgular rastgele olmayan iki gruba ayrıldı.

Birinci gruba yalnızca tanısal endoskopi yapılan hastalar ve ikinci gruba tanısal endoskopiye ek olarak profilaktik enjeksiyon tedavisi yapılan hastalar alındı. Çalışmadaki birincil sonuç ölçütleri yeniden kanama ve ölüm oranı idi.

Eighty-seven patients were included in the study. There were 41 patients in Group 1 and 46 patients in Group 2.

There was a significant difference in the incidence of rebleeding (26.8% versus 6.5%, p=0.017). The mortality rate was similar in the two groups (9.7% versus 2.1%, p=0.184).

Çalışmaya 87 hasta alındı. Bunlardan 41’i birinci, 46’sı ikinci grupta idi. Tekrar kanama oranı açısından her iki grup arasında anlamlı fark saptanırken (%26,8 ve %6,5, p=0,017), ölüm oranı açısından iki grup arasında istatistiksel anlam taşıyan bir farklılık gözlenmedi (%9,5 ve %2,1, p>0,05).

CONCLUSION

SONUÇ

BULGULAR

We recommend prophylactic injection therapy in patients with upper gastrointestinal bleeding who have Forrest type 2b duodenal ulcer.

Yeniden kanama riskini anlamlı düzeyde azalttığı için, Forrest tip 2b duodenal ülserlerde profilaktik enjeksiyon tedavisi uygulanmalıdır.

Key Words: Gastrointestinal bleeding; Forrest classification; rebleeding; mortality; injection therapy.

Anahtar Sözcükler: Sindirim sistemi kanaması; sınıflaması; yeniden kanama; ölüm; enjeksiyon tedavisi.

1 Antalya Training and Research Hospital, Antalya; Dr. Sadi Konuk Training and Research Hospital, Istanbul; 3 Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey.

2

Forrest

1 Antalya Eğitim ve Araştırma Hastanesi, Antalya; Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, İstanbul; 3 Kanuni Sultan Süleyman Eğitim ve Araştırma Hastanesi, İstanbul.

2

Correspondence (İletişim): Murat Gonenc, M.D. Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Tevfik Sağlam Cad. No: 11.

E-Blok. 2. Kat. Zuhuratbaba, Bakirkoy 34147 İstanbul, Turkey.

Tel: +90 - 212 - 414 71 59 e-mail (e-posta): gonencmd@hotmail.com

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Ulus Travma Acil Cerrahi Derg

In spite of widely available effective therapeutic agents such as proton pump inhibitors and increasing rates of Helicobacter pylori eradication, complications of peptic ulcer disease are still among the most common problems that clinicians face in the emergency setting.[1] If the patients with esophageal varices are excluded, duodenal ulcer is the leading cause of upper gastrointestinal bleeding (UGIB), which is associated with significant morbidity and mortality.[2] Gastroscopy not only establishes the diagnosis in most patients with UGIB but also leads the clinician to assess the proper treatment option on an individual basis.[3] In addition, endoscopic findings form the major component of various scoring systems used for stratification of the patients with UGIB.[4] Forrest classification, one of the most popular scoring systems, depends solely on endoscopic findings and divides the patients with UGIB into three categories (Table 1).[3] Forrest classification serves as a useful tool to estimate the rebleeding rate, which is considered to be the major determinant for prognosis in patients with bleeding duodenal ulcer.[3,4] Whereas therapeutic endoscopy for Forrest type 1 lesions and prophylactic endoscopic treatment for Forrest type 2a lesions are widely accepted as the standard care in patients with UGIB, the necessity of prophylactic endoscopic treatment for Forrest type 2b lesions remains controversial.[5,6] In this respect, we conducted a retrospective study to assess the efficacy of prophylactic endoscopic treatment with injection therapy in patients with Forrest type 2b bleeding duodenal ulcer.

The study showed that prophylactic injection therapy during the index gastroscopy for such lesions results in a significant reduction in the rebleeding rate.

MATERIALS AND METHODS The study was designed as a retrospective analysis, and was started after receiving approval of the local review board. Medical records of the patients who admitted for UGIB to the emergency department and who underwent an immediate gastroscopy between January 2004 and January 2011 were reviewed. Inclusion criterion was the presence of Forrest type 2b duodenal ulcer located at the posterior wall of the bulbus on endoscopic examination.

Group 1 was the control group, and included patients who underwent only diagnostic gastroscopy, whereas Group 2 was the prophylactic treatment group, and included those who received endoscopic injection therapy in the same session. All of the endoscopic procedures were performed by attending endoscopists experienced in both diagnostic and therapeutic endoscopy, and the standard equipment used for gastroscopy was Fujinon EVE 2200. A 1/10000 epinephrine solution was used for prophylactic injection 30

Table 1. Forrest classification for upper gastrointestinal bleeding Forrest classification Type 1

Type 2

Type 3

Rebleeding

Active bleeding 1a Spurting hemorrhage 1b Oozing hemorrhage Signs of recent bleeding 2a Non-bleeding visible vessel 2b Adherent clot on lesion 2c Hematin-covered lesion Lesion without bleeding (flat spot, clean base)

90-100% 80-85% 40-50% 20-30% 5% â&#x2030;¤3%

therapy. Two millimeters of the solution was injected to each quadrant around the duodenal ulcer by an endoscopic needle.

All of the patients were observed with hemodynamic monitoring, and were started routinely on intravenous fluids and parenteral form of proton pump inhibitors (pantoprazole, 80 mg/day). Blood transfusion was considered for patients with a hemoglobin level <7 g/dl and for those with systemic comorbidities and a hemoglobin level less than 10 g/dl. In the event of the development of the following findings during the follow-up period, an immediate re-gastroscopy was carried out: 1. Deterioration in hemodynamic parameters (hypotension, tachycardia, oligoanuria); 2. Progressive decrease in hemoglobin levels; and 3.

Hematemesis and bright red bleeding per rectum. The patients with rebleeding were managed preferentially by therapeutic gastroscopy. Immediate re-gastroscopy was avoided in patients without clinical signs of rebleeding. The patients were discharged at the end of a 24-hour period without hemodynamic alteration or a decrease of >2 g/dl in hemoglobin levels.

All of the patients were asked to return for followup gastroscopy after a six-week period with medical treatment by proton pump inhibitor (esomeprazole, 40 mg/day, peroral). Since the CLO test is not reliable in patients with UGIB, the test was not carried out, and a combined antibiotherapy with clarithromycin (1000 mg/day, peroral) and amoxicillin (2000 mg/day, peroral) for H. pylori eradication was prescribed on a routine basis as well.[4] Exclusion criteria were: 1. Hemodynamic instability on admission; 2. Serious systemic comorbidities; 3. Use of anticoagulant or antithrombotic agents; 4.

Lesions categorized as other than Forrest 2b; 5. Concomitant gastric lesions or multiple duodenal ulcers on endoscopy; 6. Failure to complete the endoscopic examination due to patient intolerability or technical problems; 7. No return for follow-up endoscopy after Ocak - January 2013

Prophylactic injection therapy is necessary for Forrest type 2b duodenal ulcers

Table 2. The results and comparison of outcome measures Outcome measure

Rebleeding The length of hospital (h) Mortality

Group 1 (n=41)

Group 2 (n=46)

p

26.8% (11/41) 100.9±54.8 (36-264) 9.7% (4/41)

6.5% (3/46) 65.2±35.6 (36-192) 2.1% (1/46)

0.017 0.004 0.184

the six-week period.

The primary outcome measure was the rate of rebleeding. Secondary outcome measures were the length of hospital stay and mortality rate.

The Statistical Package for the Social Sciences (SPSS) 10.1 for Windows was used for statistical analysis. The comparison between the groups was made by Mann-Whitney U and Fisher’s exact test. Descriptive statistics were expressed as mean value and standard deviation. A p value less than 0.05 was considered to be statistically significant.

RESULTS Totally, 1148 patients were recruited for the study.

Eighty-seven patients with Forrest 2b duodenal ulcer found at gastroscopy were included in the study. There were 41 patients in Group 1 and 46 patients in Group 2. The mean age and female-to-male ratio in Groups 1 and 2 were 43.7±28.2 (19-83) and 39.6±18.4 (21-73) and 0.5 (14/27) and 0.9 (21/25), respectively.

The success rate at re-gastroscopy in Group 1 and 2 was 70% (7/10) and 66% (2/3), respectively. One patient in Group 1 underwent immediate surgical treatment without an attempt for a re-gastroscopy because of subconsciousness. The patients in whom re-gastroscopy failed underwent emergency surgery.

The results and comparison of outcome measures are shown in Table 2. The sole cause of mortality in both groups was rebleeding.

DISCUSSION Rebleeding in patients with UGIB has several clinical consequences. It strongly correlates with mortality, and is usually the major cause of death.[3] Rebleeding also has a significant impact on morbidity. It apparently diminishes the physiological compensation mechanism that has already been insulted, which may be of paramount importance in patients with limited physiological reserve due to systemic comorbidities.[7] Moreover, it also increases the need for blood transfusion as well as the amount of blood transfusion.[8] Finally, rebleeding results in a prolonged length of hospital stay, and thus causes a significant increase in costs.[9] The rebleeding rate after diagnostic gastroscopy in patients with Forrest type 2b duodenal ulcer in the Cilt - Vol. 19 Sayı - No. 1

present study is consistent with the estimated rate in the literature [26.5% and 20-30%].[10,11] Nevertheless, many endoscopists advocate using only the diagnostic feature of endoscopy or the “wait-and-see” strategy in this setting in order to avoid manipulation of the lesion that has already stopped bleeding and has been covered by an adherent clot.[11] In addition, they rely on the availability of highly effective acid-reducing agents and the fact that most such lesions that rebleed can readily be treated by a second endoscopic intervention.[11] On the other hand, the present study showed that the incidence of rebleeding (26.8% vs. 6.5%, p=0.017) significantly reduced in patients with UGIB due to Forrest type 2b duodenal ulcer who received prophylactic injection therapy during the index gastroscopy when compared to those who underwent only diagnostic gastroscopy. Moreover, this could be readily done using a safe, relatively simple, and cost-effective method like injection therapy, which has a complication rate of less than 0.1%.[5] The reduction in the incidence of rebleeding also minimizes the need for re-gastroscopy, which leads to additional anxiety and fear of death for the patient. In addition, in the case of re-gastroscopy, the endoscopist has to deal with an upper grade lesion, and thus, there is a decrease in success rate and increase in complication rate. Likewise, the success rate at re-gastroscopy was found to be 6670% in Group 2 in the present study, whereas it was 100% in the index gastroscopy. Finally, there was also a significant difference in the length of hospital stay between the groups, which means it is possible to gain cost-effectivity using a method with a negligible increase in costs. A recent meta-analysis also reported similar results.[12] We failed to show a statistical difference between the mortality rates of the groups (9.7% vs. 2.1%, p=0.184) in spite of the significant difference between the rebleeding rates. Whereas this disparity is somewhat surprising, it also supports the fact that the mortality rate in patients with UGIB remains unchanged regardless of emerging treatment modalities.[2] The major limitation of the present study is its retrospective, non-randomized nature. Furthermore, the decision to carry out prophylactic injection therapy in patients with Forrest type 2b duodenal ulcer used to 31

Ulus Travma Acil Cerrahi Derg

be made arbitrarily because strong evidence for such a procedure was lacking until recently. However, after analysis of our own experience in 2011, we were encouraged by the increasing data and began performing prophylactic injection therapy in patients with Forrest type 2b duodenal ulcer on a routine basis.

In conclusion, we recommend prophylactic injection therapy in patients with UGIB who have Forrest type 2b duodenal ulcer, as it significantly reduces the incidence of rebleeding and associated morbidity. In other words, it seems rational to adopt the “nip it in the bud” policy rather than the “wait-and-see” policy.

Acknowledgements All of the authors declare that they have no conflicts of interest or financial ties to disclose.

REFERENCES 1. Courtney AE, Mitchell RM, Rocke L, Johnston BT. Proposed risk stratification in upper gastrointestinal haemorrhage: is hospitalisation essential? Emerg Med J 2004;21:39-40.

2. Schemmer P, Decker F, Dei-Anane G, Henschel V, Buhl K, Herfarth C, et al. The vital threat of an upper gastrointestinal bleeding: Risk factor analysis of 121 consecutive patients.

World J Gastroenterol 2006;12:3597-601.

3. Kim BJ, Park MK, Kim SJ, Kim ER, Min BH, Son HJ, et al. Comparison of scoring systems for the prediction of outcomes in patients with nonvariceal upper gastrointestinal bleeding: a prospective study. Dig Dis Sci 2009;54:2523-9.

4. Chen IC, Hung MS, Chiu TF, Chen JC, Hsiao CT. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding.

32

Am J Emerg Med 2007;25:774-9.

5. Cannistrà F. Emergency endoscopic treatment of digestive hemorrhages of the gastroduodenal tract (Forrest 1a, 1b). [Article in Italian] Minerva Gastroenterol Dietol 1996;42:121-6.

[Abstract] 6. Schröders CP, Glutig H, Frieling T, Imhof M, Röher HD. Ulcer hemorrhage: is aggressive surgical therapy still defensible?. [Article in German] Langenbecks Arch Chir Suppl Kongressbd 1997;114:1191-3. [Abstract] 7. Charatcharoenwitthaya P, Pausawasdi N, Laosanguaneak N, Bubthamala J, Tanwandee T, Leelakusolvong S. Characteristics and outcomes of acute upper gastrointestinal bleeding after therapeutic endoscopy in the elderly. World J Gastroenterol 2011;17:3724-32.

8. Barkun A, Bardou M, Marshall JK; Nonvariceal Upper GI Bleeding Consensus Conference Group. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2003;139:843-57.

9. Saltzman JR, Tabak YP, Hyett BH, Sun X, Travis AC, Johannes RS. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 2011;74:1215-24.

10. Buffoli F, Graffeo M, Nicosia F, Gentile C, Cesari P, Rolfi F, et al. Peptic ulcer bleeding: comparison of two hemostatic procedures. Am J Gastroenterol 2001;96:89-94.

11. Parente F, Anderloni A, Bargiggia S, Imbesi V, Trabucchi E, Baratti C, et al. Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: a two-year survey. World J Gastroenterol 2005;11:7122-30.

12. Kahi CJ, Jensen DM, Sung JJ, Bleau BL, Jung HK, Eckert G, et al. Endoscopic therapy versus medical therapy for bleeding peptic ulcer with adherent clot: a meta-analysis. Gastroenterology 2005;129:855-62.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):33-40

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.44538

Gastrointestinal kanal perforasyonlarında perforasyon bulgularının ve yerinin saptanmasında karın bilgisayarlı tomografisinin rolü The role of abdominal computed tomography in determining perforation findings and site in patients with gastrointestinal tract perforation Mehtap ILGAR, Muzaffer ELMALI, Mehmet Selim NURAL AMAÇ

Bu çalışmada gastrointestinal kanal perforasyonlu hastalarda karın bilgisayarlı tomografisinin (BT) perforasyon bulguları ve perforasyon yerini belirlemedeki rolü araştırıldı.

GEREÇ VE YÖNTEM

BACKGROUND

In this study, we investigated the role of abdominal computed tomography (CT) in determining perforation findings and site in patients with gastrointestinal tract perforation.

METHODS

Temmuz 2007 ve Temmuz 2010 tarihleri arasında, gastrointestinal kanal perforasyonu olduğu cerrahi olarak kanıtlanmış 47 hastanın ameliyat öncesi karın BT görüntüleri geriye dönük olarak değerlendirildi. Her bir hasta için BT’de serbest hava, kontrast madde kaçağı, duvar kalınlaşması, duvar devamsızlığı, apse, flegmon ve serbest sıvı varlığı araştırıldı. Belirlenen bu bulgular ışığında perforasyon yeri tahmin edildi ve cerrahi sonuçlar ile karşılaştırıldı.

Preoperative abdominal CT scans of 47 patients who had surgically proven gastrointestinal tract perforation between July 2007 and July 2010 were reviewed retrospectively.

The presence of free air, leakage of contrast material, wall thickness, wall discontinuity, abscess, free fluid, and phlegmon were investigated for each patient. The site of perforation was estimated in light of these findings and compared with the surgical outcomes.

BULGULAR

RESULTS

Karın BT bulgularına göre gastroduodenal perforasyonu olan hastaların %85,7’sinde, ince bağırsak perforasyonu olanların %85,7’sinde, kalın bağırsak perforasyonu olanların %69,2’sinde, rektum perforasyonu olanların %100’ünde, apendiks perforasyonu olanların %90,9’unda, tüm hastaların ise %82,9’unda perforasyon yeri doğru olarak belirlendi. Gastrointestinal kanal perforasyonunda BT’de en sık rastlanan bulgu %89,4 oranı ile karında serbest sıvı idi. Diğer bulguların rastlanma oranları ise sırasıyla şöyleydi; serbest hava %76.6, segmental duvar kalınlaşması %48.9, duvar devamsızlığı %25.5, apse %12.8, flegmon %10,6. Oral kontrast kullanılan 30 hastanın 7’sinde (%23,3) ekstraluminal kontrast kaçağı saptandı.

Perforation sites were determined correctly in 85.7% of patients with gastroduodenal perforation, 85.7% of patients with small bowel perforation, 69.2% of patients with large bowel perforation, 100% of patients with rectum perforation, 90.9% of patients with appendix perforation, and 82.9% of all patients according to the abdominal CT findings. The most common CT finding in gastrointestinal tract perforation was free fluid, with a rate of 89.4%. The rates of other findings were as follows: free air 76.6%, segmental wall thickening 48.9%, wall discontinuity 25.5%, abscess 12.8%, and phlegmon 10.6%. Of 30 patients who received oral contrast, 7 (23.3%) had extraluminal contrast leakage.

SONUÇ

CONCLUSION

BT gastrointestinal kanal perforasyon bulgularını ve perforasyon yerini belirlemede oldukça etkilidir.

CT is very effective in determining gastrointestinal tract perforation findings and the site of perforation.

Anahtar Sözcükler: Bilgisayarlı tomografi; intestinal perforasyon; spiral bilgisayarlı tomografi.

Key Words: Computed tomography; intestinal perforation; spiral computed tomography.

Ondokuz Mayıs Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Samsun.

Department of Radiology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey.

İletişim (Correspondence): Dr. Muzaffer Elmalı. Ondokuz Mayıs Üniversitesi Tıp Fakültesi Radyoloji Anabilim Dalı, Kurupelit 55139 Samsun, Turkey.

Tel: +90 - 362 - 312 19 19 e-posta (e-mail): muzafel@yahoo.com.tr

33

Ulus Travma Acil Cerrahi Derg

Gastrointestinal kanal perforasyonu peptik ülser hastalığı, travma, iyatrojenik, yabancı cisim, apandisit, enflamasyon, tümör gibi nedenlerle ortaya çıkar ve erken tanı ve zamanında cerrahi müdahale gerektirir.

[1] Gastrointestinal kanal perforasyonu için ana tedavi yöntemi cerrahidir. Artık günümüzde konvansiyonel laparotomi yerine endoskopik ve laparoskopik yardımcı yöntemler tedavi aşamasında artan oranlarda kullanılmaktadır.[2,3] Tedavi seçeneklerinin çeşitli olması ve acil karar verme zorunluluğu nedeniyle görüntülemede yanıtlanması gereken temel soru perforasyonun yeri ve nedeninin ortaya konmasıdır.

Doğru tedavinin planlanması için perforasyonun varlığı, yeri ve nedeni belirlenmelidir. Perforasyon yerinin klinik tanısı zordur, çünkü semptomlar spesifik olmayabilir. Rutin konvansiyonel radyografide serbest intra-peritoneal hava görülmesi genellikle perforasyona işaret eder, ancak başka nedenlerle de görülebilir.

Ayrıca radyografi ile perforasyonun yeri ve nedeni tesbit edilemez.[4,5] Akut karın ağrısı ile gelen ve perforasyondan şüphelenilen hastalarda bilgisayarlı tomografi (BT) yeterli bilgiyi sağladığı için ilk adım görüntüleme yöntemi kabul edilmektedir. Gastrointestinal kanal perforasyonun yerini tanımlamada BT’nin doğruluğu %82-90 arasındadır.[1,3,6,7] Perforasyon yerine göre BT bulguları değişir ve bu bulgular perforasyonun yerini belirlemede faydalıdır.[8] Perforasyon yerinin duvar devamsızlığı şeklinde doğrudan gösterilmesi çoğu olguda mümkün değildir. Bu nedenle duvar devamsızlığının yanında perforasyonda görülen diğer bulgular ve bu bulguların görüldüğü yerler kullanılarak perforasyon yerinin belirlenmesi tedavi seçeneğine karar vermede yardımcıdır.[8-10] Bu çalışmada, künt travmaya veya travma dışı nedenlere bağlı gastrointestinal kanal perforasyonu olan hastalarda BT ile perforasyon bulgularını ve bu bulgular yardımı ile perforasyon yerinin belirlenmesinde BT’nin tanısal değerini araştırdık.

GEREÇ VE YÖNTEM Temmuz 2007 ve Temmuz 2010 tarihleri arasında akut karın ağrısı ile acil servis polikliniğine müracaat etmiş ve karın BT’si çekilmiş olan tüm hastaların tıbbi dosya bilgileri gözden geçirildi. Bu hastalardan operasyonla gastrointestinal kanal perforasyonu tanısı alan 47 hastanın karın BT görüntüleri geriye dönük olarak yeniden değerlendirildi. Özefagus perforasyonları ayrı bir grup olarak düşünülüp çalışma dışı bırakıldı. Çalışmaya başlamadan önce Yerel Etik Kurul onayı alındı.

Karın BT görüntüleri spiral BT (Xpres/GX, TSX002a, Toshiba, Japonya) ile elde edildi. Tüm hastalar sırtüstü pozisyonda alt torakal seviyeden simfizis pu34

bis düzeyine kadar tarandı. Erişkinde 150 mAs ve 120 kV, çocuklarda 70 mAs ve 120 kV kullanılarak 7 mm kesit kalınlığında aksiyel BT görüntüleri elde edildi. İyotlu kontrast madde kullanımı açısından kontrendikasyon olmayan ve böbrek fonksiyonları normal olan hastaların hepsinde intravenöz noniyonik iyotlu kontrast madde (Ultravist 370, Bayer Schering Pharma, Almanya veya Iomeron 400, Bracco ve Patheon S.p.A, İtalya) kullanıldı. Erişkinlerde 100-120 ml noniyonik iyotlu kontrast madde 2,5 ml/sn hızla çocuklarda 2 ml/ kg intravenöz noniyonik kontrast madde 1 ml/sn hızla verildi. Görüntüler 60-70 saniye gecikme zamanı verilerek sadece venöz fazda elde edildi. Genel durumu uygun olan 14’ü erkek, 16’sı kadın toplam 30 hastaya inceleme öncesi 45-60 dakika içinde 1000 ml %3 oranında sulandırılmış iyonik oral kontrast madde (Urografin %76, Bayer Schering Pharma, Almanya) verildi.

Kırk yedi hastanın operasyon öncesinde çekilmiş BT görüntüleri birbirinden habersiz iki radyolog tarafından değerlendirildi. Radyologlardan birisi acil ve abdominal radyoloji konusunda 6 yıl deneyimli iken, diğer radyolog genel radyolojide 10 yıllık deneyime sahipti. Radyologlara sadece hastaların operasyon sonuçlarının gastrointestinal kanal perforasyonu olduğu bilgisi verildi. Değerlendiriciler her bir hasta için ayrı ayrı serbest hava, kontrast madde kaçağı, duvar kalınlaşması, duvar devamsızlığı, apse, flegmon, serbest sıvı varlığını araştırıp, perforasyon yeri için tahminde bulundular. Daha sonra iki radyolog arasında görüş farklılığı olan hastalar birlikte tekrar değerlendirildi ve nihai sonuca uzlaşma varıldı. Perforasyon bölgeleri; mide-duodenum 1. kesimi, duodenum ikinci kesimi başlangıcından itibaren ince bağırsak, kalın bağırsak, rektum ve apendiks olmak üzere 5 grupta toplandı.

Bulgular analiz edilerek BT’nin perforasyon yerini saptamadaki tanısal duyarlılığı araştırıldı.

Ayrıca hastalar “Treitz ligamenti” referans alınarak üst ve alt gastrointestinal kanal perforasyonu şeklinde iki gruba ayrılarak üst ve alt gastrointestinal kanal perforasyonu olan hastaların BT bulguları arasındaki farklılık araştırıldı. Bu gruplama yapılırken apendiks perforasyonunun kendine özel bazı bulgularının olması ve apendiks perforasyonu olan hastalarda serbest hava görülme oranının azlığı nedeniyle apendiks perforasyonu olan hastalar değerlendirme dışı bırakıldı.

Araştırmada elde edilen verilerin istatistiksel analizleri “SPSS for Windows 13.0” programı ile yapıldı. İstatistiksel değerlendirmede ki-kare testi kullanıldı. İstatistiksel anlamlılık düzeyi p<0,05 olarak belirlendi.

BULGULAR Çalışmaya alınan 47 hastadan 27’si erkek (%57,4), 20’si kadındı (%42,6). Yaş ortalaması 56 olup, hastalar 2 ile 94 yaşları arasındaydı. Hastalara BT çekimi ile Ocak - January 2013

Gastrointestinal kanal perforasyonları ve bilgisayarlı tomografi

Tablo 1. Perforasyon yerine göre BT’de serbest hava görülen yerler Perforasyon yeri

Mide-duodenum (n=14) İnce bağırsak (n=7) Kalın bağırsak (n=13) Rektum (n=2) Apendiks (n=11) Toplam (n=47)

KÇ

MÇ

Mezenter

Pelvis

RP

n (%)

n (%)

n (%)

n (%)

n (%)

12 (85,7) 2 (28,6) 6 (46,2) 0 (0,0) 0 (0,0) 20 (38,3)

11 (78,6) 1 (14,3) 2 (15,4) 0 (0,0) 0 (0,0) 14 (29,8)

4 (28,6) 5 (71,4) 6 (46,2) 0 (0,0) 1 (9,1) 16 (34,0)

0 (0,0) 0 (0,0) 6 (46,2) 1 (50,0) 3 (27,3) 10 (21,3)

0 (0,0) 0 (0,0) 2 (15,4) 2 (100,0) 0 (0,0) 4 (8,5)

KÇ: Karaciğer çevresi; MÇ: Mide çevresi; RP: Retroperiton.

cerrahi girişim arasında geçen zaman 1 saat ile 2 gün arasında değişmekteydi. Hastaların hiçbirinde kontrast maddeye karşı ciddi alerjik reaksiyon oluşmamıştı.

Operasyon sonuçlarına göre 14 hastada mide-duodenum 1. kesim (%29,8), 13 hastada kalın bağırsak (%27,7), 11 hastada apendiks (%23,4), 7 hastada ince bağırsak (%14,9), 2 hastada rektum (%4,4) perforasyonu mevcuttu. Bu 47 hastada perforasyon nedenleri ise şöyleydi: apandisit 11, peptik ülser 10, tümör 10, künt karın travması 8, divertikül 4, diğer nedenler 4.

Kırk yedi hastanın 36’sında (%76,6) BT’de serbest hava görülürken, 11 hastada (%23,4) serbest hava görülmedi. Serbest hava görülmeyen hastaların 8’inde apendiks, 2’sinde kalın bağırsak, 1’inde ince bağırsak perforasyonu vardı (Tablo 1).

Otuz hastada (%63,8) oral kontrast madde kullanılmış, 17 hastada (%36,2) kullanılmamıştı. Oral kontrast kullanılan hastalardan sadece biri 6 yaşında, diğerler ise 21 yaşın üzerindeydi. Oral kontrast verilen hastalardan 7’sinde kontrast madde kaçağı saptandı ve bu hastaların hepsinde mide-duodenum 1. kesim per-

Şekil 1. Pilor kanal ülserine bağlı perforasyonu olan 21 yaşında kadın hastanın karın BT aksiyel kesitinde; mide önünde, karaciğer sol lob ve transvers kolon komşuluğunda yaygın kontrast madde kaçağı izleniyor (oklar).

Cilt - Vol. 19 Sayı - No. 1

forasyonu mevcuttu (Şekil 1).

Kırk yedi hastanın 12’sinde (%25,5) duvar devamsızlığı görüldü. Duvar devamsızlığı saptanan hastaların 6’sında mide-duodenum 1. kesim, 2’sinde kalın bağırsak, 1’inde rektum, 3’ünde apendiks perforasyonu vardı. Başka bir deyişle mide-duodenum 1. kesim perforasyonu olan hastaların %42,9’unda, apendiks perforasyonu olan hastaların %27,3’ünde, kalın bağırsak perforasyonu olan hastaların %15,4’ünde perforasyon yeri duvar devamsızlığı şeklinde direkt görüldü (Şekil 2).

Apendiks perforasyonu olan hastalarda apendiks çapı 8-13 mm arasında ölçüldü. Apendiks perforasyonu olan 11 hastadan; 4’ünde komşu bağırsak segmentlerinde duvar kalınlaşması, 3’ünde apendikolit, 2’sinde periapendiküler apse, 4’ünde flegmon saptandı.

Segmental duvar kalınlığında artış 23 hastada (%48,9) görüldü. Serbest sıvı en sık görülen bulgu olup 42 hastada (%89,4) tespit edildi (Tablo 2). Serbest sıvı görülmeyen hastaların 3’ünde kalın bağırsak, 2’sinde apendiks perforasyonu vardı. Altı hastada apse

Şekil 2. Çekum tümörüne bağlı perforasyon gelişen 67 yaşında kadın hastanın karın BT aksiyel kesitinde; çekumda ileri derecede distansiyon ve gaita retansiyonu var. Çekum sağ lateralden perforasyona bağlı duvarda devamsızlık (oklar) ve periçekal alanda sıvı birikimi izleniyor.

35

Ulus Travma Acil Cerrahi Derg

Tablo 2. Perforasyon yerine göre diğer bulguların görülme sıklığı Perforasyon yeri

Mide-duedenum (n=14) İnce bağırsak (n=7) Kalın bağırsak (n=13) Rektum (n=2) Apendiks (n=11) Toplam (n=47)

DD

DK

Flegmon

Apse

SS

n (%)

n (%)

n (%)

n (%)

n (%)

6 (42,9) 0 (0,0) 2 (14,4) 1 (50) 3 (27,3) 12 (25,5)

4 (28,6) 4 (57,1) 9 (69,2) 2 (100,0) 4 (36,4) 23 (48,9)

0 (0,0) 1 (14,3) 0 (0,0) 0 (0,0) 4 (36,4) 5 (10,6)

0 (0,0) 0 (0,0) 4 (30,8) 0 (0,0) 2 (18,2) 6 (12,8)

14 (100,0) 7 (100,0) 10 (76,9) 2 (100,0) 9 (81,8) 42 (89,4)

DD: Duvar devamsızlığı; DK: Duvar kalınlaşması; SS: Serbest sıvı.

(%12,8), 5 hastada flegmon (%10,6) izlendi. Apsesi olan hastalardan 4’ünde kalın bağırsak, 2’sinde apendiks perforasyonu saptandı. Flegmonu olan hastalardan 4’ünde apendiks, 1’inde ince bağırsak perforasyonu vardı.

Genel radyoloji konusunda deneyimli radyolog 47 hastadan 8’inde perforasyonun yeri hakkında yorum yapmadı. Diğer 39 hastanın 35’inde perforasyon yerini doğru olarak tahmin etti. Operasyonda saptanan perforasyon yeri ile bu radyoloğun BT’de tahmin ettiği perforasyon yeri arasındaki uyum katsayısı 0,83 bulundu. Perforasyon yerini saptayabilme yüzdesi ise %74,5 olarak hesaplandı. Acil ve karın radyolojisi konusunda deneyimli radyolog 6 hastada perforasyonun yeri konusunda yorum yapmadı. Kalan 41 hastanın 39’unda perforasyon yerini doğru olarak tahmin etti.

Operasyonda saptanan perforasyon yeri ile bu radyoloğun BT’de tahmin ettiği perforasyon yeri arasındaki uyum katsayısı 0,93 bulundu. Perforasyon yerini saptayabilme yüzdesi ise %82,9 olarak hesaplandı.

Radyologlar aralarında görüş farklılığı olan hastalar birlikte tekrar değerlendirildiğinde 2 hastada perforasyon yeri tekrar hatalı tespit edildi. Bu 2 hastada kalın bağırsak perforasyonu mevcut iken ileumda duvar kalınlaşması saptanması nedeniyle ince bağırsak perforasyonu şeklinde yorumlanmıştı. Uzlaşma ile varılan nihai sonuca göre; toplamda 6 hastada perforasyon yeri konusunda yorum yapılmadı. Bu 6 hastadan 2’sinde kalın bağırsak, 2’sinde mide-duedenum,

1’inde ince bağırsak ve 1’inde de apendiks perforasyonu mevcuttu. Kalan 41 hastanın 39’unda perforasyon yeri BT ile doğru olarak tahmin edildi. Operasyonda tespit edilen perforasyon yeri ile BT’de tahmin edilen perforasyon yeri arasındaki uyum katsayısı 0,93 bulundu. BT’nin perforasyon yerini saptayabilme yüzdesi ise %82,9 olarak hesaplandı (Tablo 3).

Araştırmaya alınan hastalar ayrıca üst ve alt gastrointestinal kanal perforasyonu şeklinde iki gruba ayrıldı. Bu gruplama yapılırken “Treitz ligamenti” referans alındı. Apendiks perforasyonu olan hastalar (11 hasta) değerlendirme dışı bırakıldı. Ameliyat sonucuna göre geriye kalan 36 hastadan 14’ünde üst, 22’sinde alt gastrointestinal kanal perforasyonu vardı. Hastalar bu şekilde gruplandığında üst ve alt gastrointestinal kanal perforasyonunda serbest hava görülme sıklığı, serbest havanın görüldüğü yer, duvar devamsızlığı açısından farklılık olup olmadığını değerlendirmek için ki-kare testi yapıldı. Üst gastrointestinal perforasyonlu 14 hastanın hepsinde (%100), alt gastrointestinal perforasyonu olan 22 hastanın 19’unda (%86,4) serbest hava saptandı. Üst ve alt gastrointestinal perforasyonlu hastalar arasında BT’de serbest hava görülmesi açısından anlamlı bir fark bulunmadı (p=0,149). Üst gastrointestinal perforasyonlu hastaların 12’sinde (%85,7), alt gastrointestinal perforasyonu olan hastaların 8’inde (%36,4) karaciğer çevresinde serbest hava saptandı (Şekil 3). Üst ve alt gastrointestinal kanal perforasyonlu hastalar

Tablo 3. Perforasyon yerine göre BT doğruluk oranları Perforasyon yeri

Mide-duodenum (n=14) İnce bağırsak (n=7) Kalın bağırsak (n=13) Rektum (n=2) Apendiks (n=11) Toplam (n=47)

Gerçek (+)

Yanlış (+)

Belirtilmeyen

n (%)

n (%)

n (%)

12 (85,7) 6 (85,7) 9 (69,2) 2 (100,0) 10 (90,9) 39 (82,9)

– – 2 (15,4) – – 2 (4,3)

2 (14,3) 1 (14,3) 2 (15,4) – 1 (9,1) 6 (12,7)

Belirtilmeyen: Perforasyon yeri konusunda yorum yapılmayan hastalar.

36

Ocak - January 2013

Gastrointestinal kanal perforasyonları ve bilgisayarlı tomografi

Tablo 4. Üst ve alt gastrointestinal kanal perforasyonunda serbest hava ve duvar devamsızlığı görülme durumu Bulgu

Serbest hava (SH) Karaciğer çevresinde SH Mide çevresinde SH Mezenterde SH Pelviste SH Duvar devamsızlığı

Üst Gİ kanal

Alt Gİ kanal

p

n (%)

n (%)

n (%)

14 (%100) 12 (%85,7) 11 (%78,6) 4 (28,6) 0 (%0,0) 6 (%42,9)

19 (%86,4) 8 (%36,4) 3 (%13,6) 11 (%50) 7 (%31,8) 3 (%13,6)

0,149 0,004 0,001 0,204 0,019 0,048

Gİ: Gastrointestinal.

arasında karaciğer çevresinde serbest hava görülmesi açısından anlamlı fark bulundu (p=0,004). Üst gastrointestinal perforasyonlu 11 hastanın (%78,6), alt gastrointestinal perforasyonlu 3 hastanın (%13,6) mide çevresinde serbest hava saptandı. Üst ve alt gastrointestinal kanal perforasyonlu hastalar arasında mide çevresinde serbest hava görülmesi açısından anlamlı fark tespit edildi (p=0,001). Üst gastrointestinal perforasyonlu hastaların 4’ünde (%28,6), alt gastrointestinal perforasyonu olan hastaların 11’inde (%50) mezenterde serbest hava görüldü. Üst ve alt gastrointestinal kanal perforasyonlu hastalar arasında mezenterde serbest hava görülmesi açısından anlamlı bir fark saptanmadı (p=0,204). Üst gastrointestinal perforasyonlu hastaların hiçbirinde pelvisde serbest hava tespit edilmedi. Alt gastrointestinal perforasyonu olan hastaların 7’sinde (%31,8) pelvisde serbest hava saptandı. Üst ve alt gastrointestinal perforasyonlu hastalar arasında pelviste serbest hava görülmesi açısından anlamlı fark bulundu (p=0,019).

Şekil 3. Mide antrum ülserine bağlı perforasyonu olan 71 yaşında kadın hastanın karın BT aksiyel kesitinde; antrum perforasyonuna ait anteriyorda defektif görünüm (ince ok) ve karaciğer etrafında yaygın serbest hava izleniyor (kalın oklar).

Cilt - Vol. 19 Sayı - No. 1

Üst gastrointestinal perforasyonlu hastaların 6’sında (%42,9), alt gastrointestinal perforasyonu olan hastaların 3’ünde (%13,6) duvar devamsızlığı saptandı (Tablo 4). Üst ve alt gastrointestinal perforasyonlu hastalar arasında duvar devamsızlığı varlığı açısından anlamlı fark saptandı (p=0,048).

TARTIŞMA Gastrointestinal kanal perforasyonu tanısında direkt grafi, ultrasonografi (USG) ve BT kullanılmaktadır, ancak BT ile kıyaslandığında doğrudan grafi ve USG’nin tanı değeri düşüktür. Deneysel çalışmalarda 1 ml serbest havanın optimal çekilen ayakta akciğer grafisinde sağ diafragma altında görülebileceği belirtilmektedir.[11] Perforasyon tanısında ilk adım direkt radyografi olmakla birlikte duyarlılığı %50-70 arasındadır. Perforasyon tanısında kullanılan bir diğer yöntem USG’dir. USG’nin BT’ye avantajı radyasyon içermemesidir. Bu nedenle çocuklarda ve gebelerde kullanılabilir. Pnömoperiton USG ile de saptanabilir.

Ayrıca USG ek tanısal bilgiler de sağlar. USG’nin pnömoperitonu saptamada radyografi kadar etkin olduğunu söyleyen çalışmalar olduğu gibi karın gazı nedeniyle perforasyonun ortaya konmasında yetersiz olduğunu söyleyen çalışmalar da vardır.[12,13] Sonuç olarak USG’de direkt radyografide olduğu gibi BT ile kıyaslandığında düşük tanısal duyarlılığa sahiptir.

Gastrointestinal perforasyonun varlığı, yeri, nedeni ve komplikasyonlarını belirlemede BT en iyi görüntüleme yöntemi olarak kabul görmüştür.[1,8,14,15] Araştırmamızda BT bulgularından yola çıkarak gastroduodenal perforasyonu olan hastaların %85,7’sinde, ince bağırsak perforasyonu olan hastaların %85,7’sinde, kalın bağırsak perforasyonu olan hastaların %69,2’sinde, rektum perforasyonu olan hastaların %100’ünde, apendiks perforasyonu olan hastaların %90,9’unda ve tüm hastalar birlikte değerlendirildiğinde hastaların %82,9’unda perforasyon yeri doğru tespit edilmiştir.

Imuta ve arkadaşları[10] 8-slice multi-dedektör BT (MDBT) ile 155 hastada geriye dönük bir çalışma yapmıştır. Bu çalışmada kesit kalınlığı 2,5 mm olarak 37

Ulus Travma Acil Cerrahi Derg

kullanılmıştır. Hiçbir hastaya oral kontrast madde verilmemiş, 44 hastaya intravenöz kontrast verilmiştir.

Imuta ve arkadaşlarının bu çalışmasında yalnızca aksiyel imajlar değerlendirildiğinde hastaların %32’sinde, aksiyel imajlara ilaveten çok düzlemde görüntüleme imajları (multiplanar reformatting, MPR) kullanıldığında %52’sinde perforasyon yeri duvar devamsızlığı şeklinde direkt görüntülenmiştir. Yine bu çalışmada direkt ve indirekt bulgular birlikte kullanıldığında hastaların %90’ında perforasyon yeri doğru tanımlanmıştır. Imuta ve arkadaşlarının[10] bu çalışmasında kontrast madde kullanımı oldukca düşük olmasına rağmen doğruluk oranları bizim çalışmamızdan daha yüksektir. Bu durum MDBT kullanımının avantajları ile açıklanabilir.

Hainaux ve arkadaşları[3] 4-slice MDBT ile 85 hasta ile ileriye dönük bir çalışma yapmıştır. Oral kontrast madde hiçbir hastada kullanılmamış, 46 hastaya intravenöz kontrast madde verilmiştir. Hastaların aksiyel ve çok düzlemde görüntüleme imajları değerlendirilmiş ve operasyon sonuçları ile karşılaştırılmıştır.

Bu çalışmada hastaların %86’sında perforasyon yeri doğru belirlenmiştir. Bu değer bizim çalışmamızda elde edilen değerden yüksektir ancak bu çalışmada da MDBT kullanılmıştır.

Oguro ve arkadaşlarının[16] 64-slice MDBT ile 41 hastada yaptıkları çalışmada 36 hastaya intravenöz kontrast madde verilmiş, hastaların hiçbirine oral kontrast verilmemiştir. Belirtilen bu çalışmada imajlar iki şekilde oluşturulmuştur. İlk olarak 7 mm kalınlığında aksiyel imajlar, 1 hafta sonra da yalnız 2 mm kalınlıkta aksiyel imajlar ve 2 mm aksiyel, 1 mm çok düzlemli imajlar değerlendirilmiştir. Bu çalışmada duvar devamsızlığının gösterilmesi direkt bulgu, diğer bulgular indirekt bulgular olarak sınıflanmış ve MDBT’nin direkt bulguyu göstermedeki avantajı tartışılmıştır. Oguro ve arkadaşlarının[16] bu çalışmasında 7 mm’lik aksiyel imajlar değerlendirildiğinde duvar devamsızlığı hiçbir hastada gösterilememiştir. Yalnız 2 mm kalınlıkta aksiyel imajlar değerlendirildiğinde %48,8 (41 hastadan 20’sinde), 2 mm aksiyel imajlarla birlikte 1 mm çok düzlemli imajlar kullanıldığında %80,5 (41 hastanın 33’ünde) duvar devamsızlığı direkt görülmüştür (p=0,0009). Bu değer bizim çalışmamızda direkt ve indirekt bulgular kullanılarak elde edilen değere yakındır.

Ghekiere ve arkadaşları[17] 8 ve 16-slice MDBT ile yaptıkları çalışmada 40 hastanın BT görüntülerini geriye dönük olarak değerlendirmişlerdir. Hiçbir hastaya oral kontrast verilmemiş, 35 hastaya intravenöz kontrast madde verilmiştir. Bu çalışmada perforasyon yerinin duvar devamsızlığı şeklinde direkt gösterilmesine odaklanılmış, perforasyon yerleri direkt belirtildiği gibi anteriyor, posteriyor, lateral, mediyal duvar gibi ayrıntılı lokalizasyonlar da belirtilmiştir. Bu çalışmada 38

en yüksek tanısal doğruluk aksiyel, sajital ve koronal görüntüler birlikte kullanıldığında elde edilmiştir. Bizim çalışmamız ve yukarıda söz edilen diğer çalışmalar gastrointestinal kanal perforasyon yerinin BT ile yüksek doğruluk oranları ile tahmin edilebileceğini göstermektedir.

Serbest intraperitoneal hava akut karın ağrısı ile birlikte gastrointestinal kanal perforasyonu tanısının majör bulgusudur. Çok sayıda yazar BT’nin intraperitoneal serbest havanın tespitinde çok değerli bir görüntüleme yöntemi olduğunu göstermiştir.[18,19] BT’de serbest hava değerlendirilirken akciğer penceresinde bakmak faydalıdır. Akciğer penceresinde değerlendirme yapıldığında serbest havanın BT’de görülme olasılığı artar.[15] Bizim araştırmamızda 47 hastanın 36’sında (%76,6) serbest hava görüldü. Serbest hava en sık mide duodenum 1. kesim perforasyonu olan hastalarda (%100), en az apendiks perforasyonu olan hastalarda (%27,3) saptandı.

Gastroduodenal perforasyonda karaciğer ve mide çevresinde bol miktarda serbest hava saptanabilir.[14] Serbest hava ya da hava-sıvı seviyesi orta hattı geçip falsiform ligamenti belirgin hale getirebilir (falsiform ligament işareti). Serbest hava lasser sac da bulunuyorsa perforasyon yeri muhtemelen duodenum ya da midenin posteriyor duvarındadır.[20] Sağ anteriyor pararenal alandaki ekstraluminal serbest hava bulber segment dışındaki duodenal perforasyon tanısında güvenilir bir BT bulgusudur.[21] Literatür ile uyumlu olarak bizim çalışmamızda da gastroduodenal perforasyonu olan hastanın hepsinde serbest hava görüldü.

Bu hastalarda serbest havanın en sık görüldüğü yerler karaciğer ve mide çevresiydi.

Apendiks perforasyonunda serbest hava görülme oranı düşüktür. Bunun başlıca nedeni lümenin enflamatuvar duvar kalınlaşması nedeniyle tıkanmasıdır.

Bizim çalışmamızda da literatür ile uyumlu olarak serbest hava en az apendiks perforasyonunda görüldü.

Ekstraluminal oral kontrast madde görülmesi perforasyonun en spesifik bulgusudur. Ayrıca oral kontrast kullanıldığında perforasyon yerinin hipodens görünümü daha belirginleşir. Bu avantajlarına rağmen oral kontrast kullanımı konusu tartışmalıdır. Nastanski ve arkadaşları[22] BT görüntüleme öncesi verilen oral kontrast maddenin aspirasyon riskini artırmadığını ve bağırsak perforasyonunun tespitine yardım ettiğini raporlamıştır. Fakat bazı yazarlar paralitik ileusu olan hastalarda kontrast maddenin yavaş ilerlemesi nedeni ile oral kontrast kullanımını tercih etmezler.[23,24] Oral kontrast peritoneal sıvının miktarını artırarak sepsis riskini artırabilir diyen görüşler de vardır.[25] Ekstraluminal kontrast madde varlığı tanı değeri yüksek bir bulgu olmakla birlikte görülme sıklığı %19-42 gibi düşük değerlerdedir.[26] Shanmuganathan Ocak - January 2013

Gastrointestinal kanal perforasyonları ve bilgisayarlı tomografi

ve arkadaşları[27] penetran travmalı hastalarda oral ve rektal kontrast madde kullanarak yaptıkları çalışmada hastaların yalnızca %15’inde kaçak görmüşlerdir.

Fultz ve arkadaşlarının[28] çalışmasında ise perfore peptik ülserli 11 hastanın tümü oral kontrast madde almış ve yalnızca 3 hastada kontrast madde kaçağı saptanmıştır. Oral kontrast madde alırken hastanın sırtüstü pozisyonda yatıyor olması ve BT çekilirken bu pozisyonda kalması anteriyor duvar perforasyonlarında kontrast madde kaçağını azaltabilir.

Bizim araştırmamızda 30 hastaya (%63,8) oral kontrast madde verilmişti. Oral kontrast verilen hastalardan 7’sinde (%23,3) kontrast madde kaçağı saptandı. Bu hastaların hepsinde mide-duedenum 1. kesim perforasyonu vardı. Araştırmamızda oral kontrast madde kaçağının düşük olmasının başlıca nedeni hastaların acil koşullarda değerlendirilmesi nedeni ile çoğu hastada verilen oral kontrast perforasyon yerine ulaşmadan çekimin yapılmış olması olabilir.

Duvar devamsızlığı perforasyonun primer bulgusudur. Devamsızlık duvarda hipodens kontrastlanma defekti şeklinde görülebilir. Bizim olgularımızın %25,5’inde (47 hastanın 12’sinde) duvar devamsızlığı görüldü. Duvar devamsızlığının dağılımına baktığımızda 6’sı mide-duodenum 1. kesim, 2’si kalın bağırsak, 3’ü apendiks, 1’i rektum perforasyonunda görüldü.

Kim ve arkadaşlarının[29] çalışmasında duvar devamsızlığı %14 oranında görülmüştür. Miki ve arkadaşları[30] kolon rüptürü olan 6 hastada yaptıkları çalışmada 6 hastadan 4’ünde duvar devamsızlığını göstermiştir. Imuta ve arkadaşlarının[10] çalışmasında 155 hastadan 44’ünde intravenöz kontrast madde kullanılmış ve bu 44 hastadan 14’ünde (%32) aksiyel imajlarda duvar devamsızlığı gösterilmiştir. Aksiyel imajlarla birlikte çok düzlemli görüntüler kullanıldığında bu oran %52’ye yükselmiştir. İntravenöz kontrast madde kullanılmayan hastalarda ise %6 gibi düşük bir oran saptanmıştır. Ghekiere ve arkadaşlarının[17] çalışmasında üst gastrointestinal kanal perforasyonu olan hastalarda %72, alt gastrointestinal kanal perforasyonu olan hastalarda %36 oranında duvar devamsızlığı saptanmıştır. Bizim çalışmamızda üst gastrointestinal perforasyonlu hastaların %42,9’unda, alt gastrointestinal perforasyonu olan hastaların %13,6’sında duvar devamsızlığı saptandı. Üst ve alt gastrointestinal perforasyonlu hastalar arasında duvar devamsızlığı görülmesi açısından anlamlı bir fark vardı (p=0,048).

Görüldüğü gibi duvar devamsızlığı perforasyonun yerini direkt gösteren önemli bir bulgu olmakla birlikte görülme oranları çeşitli çalışmalarda belirgin farklılık göstermektedir. İntravenöz kontrast madde kullanımı duvar devamsızlığının tespitini kolaylaştırmakta, intravenöz kontrast kullanılmadığında görülme oranı belirgin azalmaktadır. MDBT ile yapılan çalışmalarda Cilt - Vol. 19 Sayı - No. 1

duvar devamsızlığının saptanma oranı daha yüksektir. Çalışmalar ince kesit ve çok düzlemede oluşturulmuş görüntülerin kullanılmasının perforasyon yerinin saptanmasını kolaylaştırdığını göstermektedir. Bizim çalışmamızda görüntüler tek dedektörlü spiral BT ile elde edilmiş ve hastaların değerlendirilmesi sadece aksiyel planda 7 mm kesit kalınlığı üzerinde yapılmıştır. Geriye dönük olan çalışmamızda ince kesit ve çok düzlemde oluşturulmuş görüntülerin mevcut olmaması çalışmamızın en önemli kısıtlılığıdır. Bununla birlikte sonuçlar tatmin edici özelliktedir.

Sonuç olarak BT, gastrointestinal kanal perforasyonlarında görülebilecek serbest hava, serbest sıvı, kontrast madde kaçağı, duvar devamsızlığı, duvar kalınlaşması, flegmon ve apseyi göstermede oldukça etkilidir ve bu bulgular yardımı ile perforasyon yeri yüksek duyarlılıkla belirlenebilir.

Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması yoktur.

KAYNAKLAR 1. Yeung KW, Chang MS, Hsiao CP, Huang JF. CT evaluation of gastrointestinal tract perforation. Clin Imaging 2004;28:32933.

2. Siu WT, Chau CH, Law BK, Tang CN, Ha PY, Li MK. Routine use of laparoscopic repair for perforated peptic ulcer. Br J Surg 2004;91:481-4.

3. Hainaux B, Agneessens E, Bertinotti R, De Maertelaer V, Rubesova E, Capelluto E, et al. Accuracy of MDCT in predicting site of gastrointestinal tract perforation. AJR Am J Roentgenol 2006;187:1179-83.

4. Cho KC, Baker SR. Extraluminal air. Diagnosis and significance. Radiol Clin North Am 1994;32:829-44.

5. Rice RP, Thompson WM, Gedgaudas RK. The diagnosis and significance of extraluminal gas in the abdomen. Radiol Clin North Am 1982;20:819-37.

6. Mindelzun RE, Jeffrey RB. The acute abdomen: current CT imaging techniques. Semin Ultrasound CT MR 1999;20:637.

7. Rosen MP, Siewert B, Sands DZ, Bromberg R, Edlow J, Raptopoulos V. Value of abdominal CT in the emergency department for patients with abdominal pain. Eur Radiol 2003;13:418-24.

8. Kim SH, Shin SS, Jeong YY, Heo SH, Kim JW, Kang HK. Gastrointestinal tract perforation: MDCT findings according to the perforation sites. Korean J Radiol 2009;10:63-70.

9. Singh JP, Steward MJ, Booth TC, Mukhtar H, Murray D. Evolution of imaging for abdominal perforation. Ann R Coll Surg Engl 2010;92:182-8.

10. Imuta M, Awai K, Nakayama Y, Murata Y, Asao C, Matsukawa T, et al. Multidetector CT findings suggesting a perforation site in the gastrointestinal tract: analysis in surgically confirmed 155 patients. Radiat Med 2007;25:113-8.

11. Miller RE, Nelson SW. The roentgenologic demonstration of tiny amounts of free intraperitoneal gas: experimental and clinical studies. Am J Roentgenol Radium Ther Nucl Med 1971;112:574-85.

12. Muradali D, Wilson S, Burns PN, Shapiro H, Hope-Simpson D. A specific sign of pneumoperitoneum on sonography: en39

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hancement of the peritoneal stripe. AJR Am J Roentgenol 1999;173:1257-62.

13. Ghekiere O, Lesnik A, Hoa D, Laffargue G, Uriot C, Taourel P. Value of computed tomography in the diagnosis of the cause of nontraumatic gastrointestinal tract perforation. J Comput Assist Tomogr 2007;31:169-76.

14. Furukawa A, Sakoda M, Yamasaki M, Kono N, Tanaka T, Nitta N, et al. Gastrointestinal tract perforation: CT diagnosis of presence, site, and cause. Abdom Imaging 2005;30:52434.

15. Leschka S, Alkadhi H, Wildermuth S, Marincek B. Multi-detector computed tomography of acute abdomen. Eur Radiol 2005;15:2435-47.

16. Oguro S, Funabiki T, Hosoda K, Inoue Y, Yamane T, Sato M, et al. 64-Slice multidetector computed tomography evaluation of gastrointestinal tract perforation site: detectability of direct findings in upper and lower GI tract. Eur Radiol 2010;20:1396-403.

17. Ghekiere O, Lesnik A, Millet I, Hoa D, Guillon F, Taourel P. Direct visualization of perforation sites in patients with a non-traumatic free pneumoperitoneum: added diagnostic value of thin transverse slices and coronal and sagittal reformations for multi-detector CT. Eur Radiol 2007;17:23029.

18. Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992;16:713-6.

19. Earls JP, Dachman AH, Colon E, Garrett MG, Molloy M. Prevalence and duration of postoperative pneumoperitoneum: sensitivity of CT vs left lateral decubitus radiography.

AJR Am J Roentgenol 1993;161:781-5.

20. Maniatis V, Chryssikopoulos H, Roussakis A, Kalamara C, Kavadias S, Papadopoulos A, et al. Perforation of the alimentary tract: evaluation with computed tomography. Abdom Imaging 2000;25:373-9.

21. Kunin JR, Korobkin M, Ellis JH, Francis IR, Kane NM, Siegel SE. Duodenal injuries caused by blunt abdominal trauma:

40

value of CT in differentiating perforation from hematoma.

AJR Am J Roentgenol 1993;160:1221-3.

22. Nastanski F, Cohen A, Lush SP, DiStante A, Theuer CP. The role of oral contrast administration immediately prior to the computed tomographic evaluation of the blunt trauma victim. Injury 2001;32:545-9.

23. Grassi R, Pinto A, Rossi G, Rotondo A. Conventional plainfilm radiology, ultrasonography and CT in jejuno-ileal perforation. Acta Radiol 1998;39:52-6.

24. Bulas DI, Taylor GA, Eichelberger MR. The value of CT in detecting bowel perforation in children after blunt abdominal trauma. AJR Am J Roentgenol 1989;153:561-4.

25. Ongolo-Zogo P, Borson O, Garcia P, Gruner L, Valette PJ. Acute gastroduodenal peptic ulcer perforation: contrastenhanced and thin-section spiral CT findings in 10 patients.

Abdom Imaging 1999;24:329-32.

26. Becker CD, Mentha G, Schmidlin F, Terrier F. Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Part 2: Gastrointestinal tract and retroperitoneal organs. Eur Radiol 1998;8:772-80.

27. Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Scalea TM. Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy. AJR Am J Roentgenol 2001;177:1247-56.

28. Fultz PJ, Skucas J, Weiss SL. CT in upper gastrointestinal tract perforations secondary to peptic ulcer disease. Gastrointest Radiol 1992;17:5-8.

29. Kim HC, Shin HC, Park SJ, Park SI, Kim HH, Bae WK, et al.

Traumatic bowel perforation: analysis of CT findings according to the perforation site and the elapsed time since accident.

Clin Imaging 2004;28:334-9.

30. Miki T, Ogata S, Uto M, Nakazono T, Urata M, Ishibe R, et al. Multidetector-row CT findings of colonic perforation: direct visualization of ruptured colonic wall. Abdom Imaging 2004;29:658-62.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):41-44

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.35305

Inferior glenohumeral dislocation (luxatio erecta humeri): report of six cases and review of the literature İnferior omuz çıkığı (luksasyo erekta): Altı olgu sunumu ve literatürün gözden geçirilmesi Ahmet İMERCİ,1 Yalçın GÖLCÜK,2 Sabri Gökhan UĞUR,3 Hüseyin Tamer URSAVAŞ,4 Ahmet SAVRAN,4 Levent SÜRER5

BACKGROUND

AMAÇ

Inferior shoulder dislocation, also referred to as luxatio erecta, is a rare type of shoulder dislocation. Its incidence is about 1 in 200 (0.5%) among all shoulder dislocations. The objective of this study was to review six cases of inferior shoulder dislocation, including their clinical and radiological presentation, management, and final outcome.

İnferior omuz çıkığı, ayrıca luksasyo erekta olarak adlandırıp omuz çıkığının nadir görülen bir tipidir. Görülme sıklığı tüm omuz çıkık arasındaki yaklaşık 200’de 1’dir (%0,5).

Bu çalışmanın amacı, inferior omuz çıkığının klinik ve radyolojik olarak sunumu, tedavisi ve nihai sonucun 6 olgu ile gözden geçirilmesidir.

METHODS

GEREÇ VE YÖNTEM

Four males and two females, a total of six patients, with the diagnosis of inferior shoulder dislocation were treated between 2007 and 2010. Our purpose is to present our experience in the treatment of these patients together with the parallel research available in the literature.

Dört erkek ve iki kadın, toplam 6 hasta aşağı omuz çıkığı tanısı ile 2007 ve 2010 yılları arasında tedavi edildi. Tedavi ettiğimiz bu hastalar nedeniyle, bizim amacımız kaynaklar paralelinde deneyimimizi paylaşmaktır.

RESULTS

Constant score was used to evaluate shoulder function.

Pain, position, daily activities, range of motion, and strength scores were noted. All patients had good to excellent results with full functional recovery within two years after closed reduction and shoulder rehabilitation.

Hastaların omuz fonksiyonlarını değerlendirmek için Constant omuz skorlaması kullanılarak ağrı, pozisyon, günlük yaşam aktiviteleri, eklem hareket açıklıkları ve güçü kaydedildi. Hastaların tamamında kapalı redüksiyon ve rehabilitasyon ile tedavi sonrası 2 yıl içinde tam fonksiyonel iyileşme sağlanarak mükemmel ya da iyi sonuç alındı.

CONCLUSION

SONUÇ

BULGULAR

Doctors should be familiar with the occurrence of this infrequent condition and should prevent possible complications that might result from early reductions by using correct maneuvers in lieu of ordinary reduction techniques.

Doktorlar bu nadir durumun oluşumuna alışık olmalı ve doğru redüksiyon teknikleri dışında yapılan erken redüksiyonlar neticesinde oluşabilecek olası komplikasyonları önlemeleri gerekir.

Key Words: Closed reduction; emergency; inferior dislocation; luxatio erecta; shoulder; trauma.

Anahtar Sözcükler: Kapalı redüksiyon; acil; inferior çıkık; luksasyo erekta; omuz; travma.

Department of Orthopaedics and Traumatology, Erzurum Palandoken State Hospital, Erzurum; 2Department of Emergency, Bitlis State Hospital, Bitlis; 3 Department of Orthopaedics and Traumatology, Karaman State Hospital, Karaman; 4Department of Orthopaedics and Traumatology, Izmir Tepecik Training and Research Hospital, Izmir; 5Department of Orthopaedics and Traumatology, Acibadem Bodrum Hospital, Mugla, Turkey.

1

Erzurum Palandöken Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Erzurum; 2Bitlis Devlet Hastanesi, Acil Servis, Bitlis; Karaman Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Karaman; 4 İzmir Tepecik Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İzmir; 5Acıbadem Bodrum Hastanesi, Ortopedi ve Travmatoloji Kliniği, Muğla.

1

3

Correspondence (İletişim): Ahmet İmerci, M.D. Erzurum Palandöken Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, 25000 Erzurum, Turkey.

Tel: +90 - 442 - 235 50 80 e-mail (e-posta): ahmet_dr81@hotmail.com

41

Ulus Travma Acil Cerrahi Derg

The shoulder joint is the joint where dislocations occur most frequently.[1] Multi-directional mobility of the shoulder joint, its anatomic structure and frequent exposition to traumas result in the more frequent occurrence of dislocations.[2] Forward and backward dislocations are observed at rates of 95% and 4-5%, respectively, in patients with shoulder dislocations.

[1,3] Downward dislocation (luxatio erecta - LE), with an occurrence rate of 0.5% among all shoulder dislocations, on the other hand, is a traumatic case that is observed quite rarely, which generally occurs during hyperabduction type trauma of the arm. In such cases, it is usually observed that the inferior capsule of the joint is torn.[4,5] For the formation of the LE, a great amount of force is required; thus, many other injuries can be seen together.[6]

RESULTS The mean follow-up duration of the patients was 32 months and the mean age was 45 (range, 22-75). Constant shoulder scoring system was used for the clinical examination as pain, position, daily activities, range of motion, and strength were noted. The mean shoulder score was 94 points (range, 86-100 points). In one of the patients, glenoid anterior wall fracture was diagnosed by computed tomography (Fig. 3). Presence of neurologic and vascular injury was followed after reduction. In one of the patients, it was observed during the six-month follow-up that complete recovery of the brachial plexus lesion was achieved with the rehabilitation program. During the follow-up examination

The current study presents six cases of downward dislocation of the glenohumeral joint that were treated with closed reduction.

MATERIALS AND METHODS Four males and two females, a total of six patients, with the diagnosis of inferior shoulder dislocation were treated between 2007 and 2010 (Table 1). Causes of the trauma included fall from a height (n=2), fall down stairs (n=2), motorcycle accident (n=1), and in-vehicle traffic accident (n=1). All six cases were admitted to the emergency service. Three of these patients had right shoulder trauma and the other three had left shoulder trauma; all stated that they had pain and could not bring their arm from abduction to neutral position. In their the clinical examination, it was observed that the shoulders of the patients were painful and were locked in the abduction position. In one of the patients, brachial plexus paralysis was diagnosed. Peripheral pulses were open in all patients. Radiologic examination revealed that the humerus head had been dislocated downwards in all patients (Fig. 1), and in one patient, tuberculum majus fracture accompanied the dislocation (Fig. 2 a, b). Closed reduction was applied to all six patients under anesthesia.

Fig. 1. Anteroposterior view of the right shoulder joint in an adult patient. The right humeral head is dislocated inferiorly (Case 1).

Table 1. Details of the patients No

Age/ Gender

Cause of injury

Anesthesia/ management

Associated injuries/ complications

Follow-up (months)

Constant score

Outcome

1 2 3 4 5 6

38/M 22/M 75/F 50/M 34/M 51/F

Traffic accident Fall Fall from height Traffic accident Fall from height Fall

GA/CR SA/CR GA/CR SA/CR SA/CR GA/CR

â&#x20AC;&#x201C; Fracture of GT Glenoid fracture/RTC Ax nerve lesion â&#x20AC;&#x201C; BP lesion

41 55 29 27 20 25

100 96 86 96 100 88

Excellent Excellent Good Excellent Excellent Good

Ax: Axillary; BP: Brachial plexus; CR: Closed reduction; GA: General anesthesia; RTC: Rotator cuff tear; SA: Sedoanalgesia.

42

Ocak - January 2013

Inferior glenohumeral dislocation (luxatio erecta humeri)

(a)

(b)

Fig. 2. (a) Patient with right luxatio erecta humeri and (b) radiograph displaying inferior shoulder dislocation with fractured greater tuberosity (Case 2).

of all patients, it was observed that anatomic relation of the joint was achieved and the fracture had been reduced.

DISCUSSION Luxatio erecta is the inferior dislocation of the glenohumeral joint, which was defined by Middeldorpf and Scharm.[7] The classical view, which is also characteristic, is the hyper-adduction of the affected arm, flexion of the elbow, and the hand positioned over or behind the head.[5,7,8] The unaffected hand supports the arm in order to stabilize the affected arm and alleviate the pain. On physical examination, the glenoid cavity is empty and the head of the dislocated humerus can

Fig. 3. Anterior wall fracture of the glenoid in a patient (arrow) (Case 3).

Cilt - Vol. 19 Say覺 - No. 1

be palpated in the axilla or over the chest wall. Before the reduction procedure, conventional scapular X-ray films should be obtained in all patients in order to confirm the diagnosis and demonstrate any concomitant fractures. Transscapular Y-graphy, computed tomography and magnetic resonance imaging would be helpful in the diagnosis and treatment.[1,2,9] The early diagnosis of LE is of critical importance. Inferior dislocation occurs mostly due to indirect injury. In the indirect mechanism, inferior dislocation of the shoulder develops due to the lever arm effect of the proximal humerus when a strong hyper-abduction force is applied to the arm. Because of the pulling effect of the pectoralis major, the arm stays in the erected position.

[7,10] There may be severe soft-tissue injury due to the avulsion of the supraspinatus, infraspinatus and teres minor muscles. There are some complications of LE. Tsuchida et al.[10] found axillary nerve palsy in 60%, fracture of the humerus in 37% and rotator-cuff tear in 12% of the patients. Adhesive capsulitis and recurrent subluxation or dislocation can be seen as late complications.[9,11,12] In our series, we found rotator-cuff tear in one patient and hypoesthesia of the axillary sensory area of the lateral shoulder in another.

Early reduction should be done to prevent complications.[3,6] Adequate sedation and analgesia is fundamental to the procedure, and most of the LE cases can be treated successfully in the emergency room with closed reduction. Opposite-traction technique is the most effective closed reduction method. In this technique, traction and mild abduction are applied to the affected arm in the same direction of the humerus, 43

Ulus Travma Acil Cerrahi Derg

while opposite-directional traction is performed with a rounded sheet.[1,2,12,13] Neurovascular examination and follow-up radiographs are important to exclude iatrogenic fractures after reduction. Successfully reduced cases should be immobilized by using arm-body bandage. If the reduction is unsuccessful, it should be repeated under anesthesia. The standard closed reduction of LE is contraindicated in neck and shaft fractures of the humerus and in the case of any suspicion of major vascular injury. In these cases, open reduction with surgery is indicated.[2,9,14] Since LE occurs after highenergy trauma, a complete systemic examination must be done in order not to miss any other organ or system injuries. The prognosis is excellent in most of the noncomplicated LE cases.[2,4,7,9,15] Although closed reduction is usually successful without difficulty, failures do occur, usually secondary to entrapment of the humeral head in the torn inferior joint capsule. If this occurs, operative treatment with open reduction is the treatment of choice.[1,7,10] Additionally, if displacement of the tuberculum majus is more than 5 mm after reduction, surgery would be indicated. If the fracture involves more than 25% of the glenoid cavity, then surgery would also be indicated as instability may occur.[1] In a study of 16 consecutive patients with 18 shoulder dislocations, initial treatment of closed reduction failed in four patients, and they were surgically treated; recurrent instability of the injured shoulder developed in six patients, who were treated with a capsular reconstruction. The mean follow-up was nine years.

Eighty-three percent of the patients had good to excellent treatment outcomes, and none of the associated neurovascular injuries affected final outcomes.[9] In their meta-analysis of 80 cases, Mallon et al.[4] found that 80% of patients sustained a fracture of the greater tuberosity or a rotator cuff tear, and 60% had some degree of neurologic compromise. Typically, however, these injuries resolved within one year. Our study results support those of Groh et al.[9] and Mallon et al.[4] Almost all patients achieved good strength and motion with non¬operative management, and associated neurologic and associated injury did not affect the final outcomes. There was no direct association between age and comorbidities sustained during the injuries.

None of our patients needed surgical intervention, and 100% of the patients had excellent or good outcome.

Post-traumatic frozen shoulder is common and leads to a poor functional result.[16] Post-traumatic frozen shoulder did not develop in any of our patients.

In conclusion, in this series, all dislocations were reduced with close reduction technique, and none of the patients developed recurrent instability. LE is a rare form of shoulder dislocation due to its specific

44

occurrence mechanism and clinical presentation. Doctors should be familiar with the occurrence of this infrequent condition and should prevent possible complications that might result from early reductions by using correct maneuvers in lieu of ordinary reduction techniques.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Rockwood CA, Wirth MA. Subluxations and dislocations about the glenohumeral joint. In: Rockwood CA, Green DP, Bucholz RW, editors. Fractures in adults. Philadelphia: Lippincott-Raven; 1996. p. 1193-39.

2. Yamamoto T, Yoshiya S, Kurosaka M, Nagira K, Nabeshima Y. Luxatio erecta (inferior dislocation of the shoulder): a report of 5 cases and a review of the literature. Am J Orthop (Belle Mead NJ) 2003;32:601-3.

3. Sahin N, Oztürk A, Ozkan Y, Atıcı T, Ozkaya G. A comparison of the scapular manipulation and Kocher’s technique for acute anterior dislocation of the shoulder. Eklem Hastalik Cerrahisi 2011;22:28-32.

4. Mallon WJ, Bassett FH 3rd, Goldner RD. Luxatio erecta: the inferior glenohumeral dislocation. J Orthop Trauma 1990;4:19-24.

5. Yanturali S, Aksay E, Holliman CJ, Duman O, Ozen YK. Luxatio erecta: clinical presentation and management in the emergency department. J Emerg Med 2005;29:85-9.

6. Matsumato K, Ohara A. Yamamoto K,Takigami I, Naganawa T. Luxatio erecta (inferior dislocation of the shoulder): A report of two cases and a review of the literature. Injury Extra 2005;36:450-3.

7. Karaoglu S, Guney A, Ozturk M, Kekec Z. Bilateral luxatio erecta humeri. Arch Orthop Trauma Surg 2003;123:308-10.

8. Mesa M, Carpintero P, Carpintero J. Bilateral luxatio erecta humeri. Acta Orthop Belg 1996;62:116-9.

9. Groh GI, Wirth MA, Rockwood CA Jr. Results of treatment of luxatio erecta (inferior shoulder dislocation). J Shoulder Elbow Surg 2010;19:423-6.

10. Tsuchida T, Yang K, Kimura Y, Taniwaki M, Ishigaki S, Itoi E. Luxatio erecta of bilateral shoulders. J Shoulder Elbow Surg 2001;10:595-7.

11. Musmeci E, Gaspari D, Sandri A, Regis D, Bartolozzi P. Bilateral luxatio erecta humeri associated with a unilateral brachial plexus and bilateral rotator cuff injuries: a case report. J Orthop Trauma 2008;22:498-500.

12. Wang KC, Hsu KY, Shih CH. Brachial plexus injury with erect dislocation of the shoulder. Orthop Rev 1992;21:13457.

13. Camarda L, Martorana U, D’Arienzo M. A case of bilateral luxatio erecta. J Orthop Traumatol 2009;10:97-9.

14. Durukan P, Yıldız M, Barik A, Kaya N, Yılmaz E. Inferior glenohumeral dislokasyon (Luxatio Erecta): İki olgu sunumu. Türkiye Acil Tıp Dergisi 2005;5:142-4.

15. Ebrahimzadeh MH, Fattahi A. Inferior glenohumeral dislocation (luxatio erecta humeri), report of two cases. Eur J Orthop Surg Traumatol 2006;16:30-2.

16. Féry A, Sommelet J. Erect dislocation of the shoulder (luxatio erecta humeri). General review apropos of 10 cases. [Article in French] Int Orthop 1987;11:95-103. [Abstract]

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):45-48

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.14194

Does a penetrating diaphragm injury have an effect on morbidity and mortality?

Penetran diyafram yaralanması morbidite ve mortaliteyi etkiler mi?

Bünyami ÖZOĞUL,1 Abdullah KISAOĞLU,1 Gürkan ÖZTÜRK,1 Sabri Selçuk ATAMANALP,1 Yener AYDIN,2 Bülent AYDINLI,1 Mehmet İlhan YILDIRGAN1

BACKGROUND

AMAÇ

In this study, we investigated the diaphragmatic ruptures that accompanied penetrating abdominal injury.

Bu çalışmada penetran karın hasar ile birlikte olan diyafram yaralanmaları incelendi.

METHODS

GEREÇ VE YÖNTEM

Records of 237 patients with penetrating abdominal trauma seen in the General Surgery Clinic between January 1996 and December 2010 were investigated retrospectively.

Patients without diaphragmatic rupture were allocated to Group I and those with were allocated to Group II.

Bu çalışmaya Ocak 1996- Aralık 2010 tarihleri arasında genel cerrahi kliniğinde penetran karın travmalı 237 hastanın kayıtları geriye dönük olarak incelendi. Diyafram yırtığı olmayan hastalar Grup I, diyafram yırtığı olan hastalar Grup II olarak ayrıldı.

RESULTS

BULGULAR

Diaphragmatic injury was not present in 177 patients and present in 60 patients. Diaphragmatic injury was on the right side in 12, left side in 41, and bilateral in 7. Eleven had thoracic herniation, and the most common hernia contents were the colon, stomach, greater omentum, small bowel, and spleen. The postoperative complication rate was 50% in Group I (n=89) and 47% in Group II (n=28), and there was no significant difference between the two groups (p˃0.05). The length of hospital stay was slightly increased in Group II, but not significant (p˃0.05). Seventeen patients (9.6%) in Group I and four patients (6.6%) in Group II died. The difference in mortality rates between the two groups was not significant (p˃0.05).

Hastaların 177’sinde diyafram hasarı yoktu ve 60 hastada ise diyafram hasarı vardı. Diyafram hasarı hastaların 12’sinde sağda, 7’sinde iki taraflı ve 41’inde sol tarafta idi. 11 olguda toraksa fıtıklaşma vardı ve en fazla kolon, mide, omentum, ince bağırsaklar ve dalak torakal kaviteye fıtıklaşıyordu. Ameliyat sonrası komplikasyon oranı Grup I’de %50 (n=89) ve Grup II’de %47 (n=28) idi. Her iki grup arasında istatistiksel olarak anlamlı bir fark yoktu (p˃0,05). Hastanede kalış süresi Grup II’de az miktarda fazla olmasına rağmen anlamlı bir fark yoktu (p˃0,05).

Grup I’de 17 hasta (%9,6) ve Grup II’de 4 hasta (%6,6) hayatını kaybetti. Mortalite hızları iki grup arasında anlamlı değil idi (p˃0,05).

CONCLUSION

SONUÇ

Diaphragmatic rupture is not common among patients with penetrating abdominal trauma. There was no difference between patients with penetrating injuries and with versus without diaphragmatic injuries in terms of mortality and morbidity.

Penetran karın travmalı hastalarda diyafram yırtılması yaygın değildir. Penetran yaralanmalarda diyafram yaralanması olan hastalarla olmayan hastalar arasında fark bulunamamıştır.

Key Words: Diaphragmatic injury; morbidity; mortality.

Anahtar Sözcükler: Diyafram yaralanması; morbidite; mortalite.

Departments of 1General Surgery, 2Thoracic Surgery, Ataturk University, Faculty of Medicine, Erzurum, Turkey.

Atatürk Üniversitesi Tıp Fakültesi, 1Genel Cerrahi Anabilim Dalı, 2 Göğüs Cerrahisi Anabilim Dalı, Erzurum.

Correspondence (İletişim): Bünyami Özoğul, M.D. Atatürk Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Yenişehir 25070 Erzurum, Turkey.

Tel: +90 - 442 - 316 63 33 / 2216 e-mail (e-posta): bozogul57@hotmail.com

45

Ulus Travma Acil Cerrahi Derg

Diaphragmatic rupture (DR) is a commonly discussed problem in abdominal trauma. Injuries of the diaphragm associated with blunt abdominal trauma can complicate the course of the patient because of difficulty in the diagnosis and delayed intervention.

Several publications report that diaphragmatic injuries in blunt abdominal trauma can have significant morbidity and mortality rates.[1] In penetrating abdominal injuries, however, the contribution of diaphragmatic injuries to the mortality and morbidity is not clarified.

We report herein our diaphragmatic injury cases associated with penetrating abdominal injury.

MATERIALS AND METHODS The records of 398 cases admitted to our clinic, Ataturk University Medical School, Department of General Surgery, with the diagnosis of penetrating abdominal trauma between January 1996 and December 2010 were evaluated retrospectively. The charts of 83 patients were excluded because of inadequate information. Penetrating abdominal trauma index (PATI) score was defined according the description from Moore et al.[2] Patients who had a PATI score lower than 15 or higher than 50 were also excluded. Patients were divided in two groups. Group I consisted of patients without DR, while Group II consisted of patients with DR. The age, sex, mechanism of trauma (gunshot wound (GSW) or stab wound), injured organs, PATI score, presence, site and length of diaphragmatic injury, presence of hemo-pneumothorax, postoperative complications, length of hospital stay (LOS), and morbidity were recorded. Postoperative complications, LOS and morbidity were compared between the two groups. In Group II, the patients were further divided in two subgroups according to the length of the rupture. Patients with a rupture of <5 cm were grouped as Group IIa and those with a rupture of >5 cm were grouped as Group IIb. Postoperative complications, LOS and morbidity were compared between these two subgroups.

Statistical analysis Results are presented as means Âą SD, medians, or percentages. Analysis of variance and post hoc tests were used to compare continuous variables, and exact tests were used to compare proportions. A correlation coefficient was calculated using Spearmanâ&#x20AC;&#x2122;s rho. The Statistical Package for the Social Sciences (SPSS) version 12.0 (SPSS Inc, Chicago, IL) was used for analysis. A p value of 0.05 was considered statistically significant. All tests were two-tailed.

RESULTS The records of 315 patients who were operated for penetrating abdominal trauma at Ataturk University Medical School, Department of General Surgery, 46

with the diagnosis of penetrating abdominal trauma between January 1996 and December 2007 were reviewed. From these patients, 237 had a PATI score higher than 15. Diaphragmatic injury was not present in 177 of these patients (Group I) and present in the remaining 60 (Group II). Table 1 shows the age, sex, mechanism of trauma (GSW or stab wound), injured organs, PATI score, postoperative complications, LOS, and morbidity of the two groups. Table 2 shows the comparison of postoperative complications, LOS and morbidity between the two subgroups of patients with diaphragmatic injuries, consisting of patients with DRs <5 cm (Group IIa) and >5 cm (Group IIb).

In Group II (patients with diaphragmatic injury), diaphragmatic injuries were located on the right side in 12 cases, both sides (right and left) in 7 cases and on the left side in 41 cases. The size of the diaphragmatic defect varied between 1 cm and 12 cm (mean 4.6 cm). There were 29 DRs >5 cm long (Group IIb). In 11 cases, there was partial or total herniation of some intraabdominal organs, including the colon, stomach, greater omentum, small intestines, and spleen, into the thoracic cavity. All herniations were uncomplicated and there was no gangrene or circulatory problems in the herniated organs. All herniations occurred in Group IIb. No further resections or surgical treatments were necessary for the herniated organs. All DRs were primarily repaired. In 31 cases, a chest tube was placed to treat hemo-pneumothorax accompanying the diaphragmatic injury. The daily amount of chest tube drainage was between 50 cc and 420 cc (mean 260 cc). Chest tubes were removed in a median of 4 days. There were no problems with the pulmonary parenchyma or the mediastinal organs. There were also no open thoracostomies or re-operations because of hemo-pneumothorax.

The statistical analysis revealed that there was no statistical difference in age, gender, mechanism of injury, or mean PATI score between Groups I and II. There was also no difference in the involved organs (p>0.05 for all).

The overall complication rates were 50% (89 patients) and 47% (28 patients) in Group I and Group II, respectively. The most common complications were infectious complications (wound infection, pulmonary infection, sepsis, intraabdominal abscess); others included wound dehiscence, pulmonary embolism and anastomotic leakage. When compared statistically, there were no differences in postoperative complications between the two groups (p>0.05). The comparison of complication rates of the two subgroups (Groups IIa and IIb) also revealed no significant difference.

The length of hospitalization (LOS) in the two groups was similar, with a slight increase in Group II, but the difference was not statistically significant Ocak - January 2013

Does a penetrating diaphragm injury have an effect on morbidity and mortality?

Table 1. Age, sex, mechanism of trauma, injured organs, PATI score, postoperative complications, LOS, and morbidity according to groups Group I (n=177)

Group II (n=60)

Age (Mean / Years) Gender (Female / Male) Gunshot wound Stab wound PATI score (Mean)

44.6 30 / 147 105 (59.3%) 72 (40.7%) 24.5

44.1 9 / 51 43 (71.6%) 17 (28.4%) 23.3

Injured organs Liver Small intestine Colon Spleen Stomach Pancreas Kidney and urinary Major vascular Other

69 (38.9%) 101 (57%) 79 (44.6%) 41 (23.1%) 35 (19.7%) 17 (9.6%) 29 (16.4%) 24 (13.5%) 45 (25.4%)

32 (53.3%) 21 (35%) 13 (21.6%) 13 (21.6%) 15 (25%) 5 (8.3%) 9 (15%) 5 (8.3%) 21 (35%)

89 (50%)

28 (47%)

69 (38.9%) 43 (24.2%) 10 (5.6%) 8 (4.5%) 8 (4.5%) 16 (9%) 3 (1.6%) 1 (0.5%)

23 (38.3%) 14 (23.3%) 5 (8.3%) 2 (3.3%) 2 (3.3%) 4 (6.6%) 1 (1.6%) –

17 (9.6%) 13.4±5.1

4 (6.6%) 14.2±6.3

Postoperative complications (overall rate) Infectious Wound infection Pulmonary infections Sepsis Intraabdominal abscess Wound dehiscence Anastomotic leakage Pulmonary embolism Mortality LOS (Days)

PATI : Penetrating abdominal trauma index; LOS: Length of hospital stay.

(p>0.05). There was also no statistically significant difference in the LOS between the two subgroups (Group IIa, Group IIb) of Group II. A total of 17 patients (9.6%) in Group I and 4 patients (6.6%) in Group II died. Mortalities were not statistically different (p>0.05). The mortality rate was also not different between the two subgroups (Group IIa, Group IIb) of Group II.

DISCUSSION Diaphragmatic injury is not common among abdominal trauma patients, with an incidence varying between 4-12%.[3,4] The incidence of penetrating DR is reported to be 10-15%.[5] The importance of diaphragmatic injuries has been mentioned several times by different publications.[3,6] The most common reported adverse outcome in this injury is the herniation of intraabdominal organs into the thoracic cavity.[6] Therefore, the most commonly discussed aspects of this Cilt - Vol. 19 Sayı - No. 1

Table 2. Length of hospital stay and morbidity between the two subgroups of patients with diaphragmatic injuries

Postoperative complications (overall rate) Infectious Wound infection Pulmonary infections Sepsis Intraabdominal abscess Wound dehiscence Anastomotic leakage Pulmonary embolism LOS (days)

Group IIa (n=31)

Group IIb (n=29)

15 (48.3%)

13 (44.8%)

13 (41.9%) 8 (25.8%) 3 (9.6%) 1 (3.2%) 1 (3.2%) 3 (9.6%) 1 (3.2%) –

10 (34.4%) 6 (20.6%) 2 (6.8%) 1 (3.4%) 1 (3.4%) 1 (3.4%) – –

14.9±6.5

13.2±6

LOS: Length of hospital stay.

injury are the difficulties in diagnosis and subsequent problems secondary to misdiagnosis and the early diagnosis of diaphragmatic injuries, especially in blunt trauma victims who will not be operated.[3,4,6] We performed this study to determine the importance of a diaphragmatic injury that is detected during an emergent operation for penetrating abdominal injury. To make the groups comparable, we used PATI scoring and excluded patients with low and high PATI scores. Furthermore, to determine if the length of diaphragmatic injury is important, we divided the patients in two groups according the length of the injury (<5 cm or >5 cm). We actually performed this study to show that diaphragmatic injury is harmless when it is detected during the operation and repaired properly.

About 50% of all diaphragmatic injuries cannot be detected during a routine investigation of trauma patients. They are mostly detected during an exploration for immediate operation of the trauma patient.

[4,7] Clinical findings of DR are not specific. Thoracic and abdominal symptoms may be minimal or even absent, and patients may not present with symptoms for months to years after the trauma.[8] It is reported that penetrating diaphragmatic injuries are accompanied by at least two or three associated injuries, and patients are operated for these injuries.

[9] Therefore, during a routine exploration of the abdominal cavity in a patient with penetrating abdominal trauma, especially when the injury is located in the upper abdomen, the diaphragm must be observed and even explored.[4,5,7] The most important adverse outcome of DR is the herniation of intraabdominal organs into the thoracic cavity. The incidence of herniation of intraabdominal 47

Ulus Travma Acil Cerrahi Derg

organs into the pleural cavity is 58% in left-sided and 19% in right-sided DRs.[10-12] In our series, the herniation rate was 18.3%. We also observed that all herniations occurred in patients who had a DR length >5 cm. Herniations can have an acute onset by causing symptoms arising from both the herniated intraabdominal organs as well as the thoracic organs that are compressed by the herniated organ. This subsequently results in symptoms related with circulatory problems or obstruction of the herniated organs, or dyspnea, cyanosis or cardiac compromise due to compression of the hernia.[13] Furthermore, herniations may not become symptomatic until months or years after the trauma.[14,15] Once detected, treatment is not complex. The operative treatment of diaphragmatic injury can be done by either primary suture repair or replacement with prosthetic materials if needed. It is a simple treatment and can be done with open surgical approach or laparoscopically.[16] Most of the complications are associated with the adverse outcomes of DR. However, there is little information about the DR that is uncomplicated and treated during the exploration. Is this injury important, and could the presence of diaphragmatic injury complicate the postoperative course of a trauma patient?

Theoretically it could. The impairment of diaphragmatic movements during respiration could impair normal breathing and cause atelectasia and associated pulmonary infections.[17] The comparison of the two groups showed that there was no difference in the postoperative complications, LOS or mortality. We tried to create a homogeneous group, and therefore used the PATI score. This shows that diaphragmatic injuries that were diagnosed and repaired during the operation did not increase the complications, LOS or mortality. The complications in both groups were the same, and infectious complications were seen most commonly. In patients with diaphragmatic injuries, the incidence of pulmonary complications was not different from that in patients without diaphragmatic injuries.

Although 31 patients in Group II had tube thoracostomy, this did not influence the postoperative complication rate or LOS. Chest drains were applied to only 31 radiologically detected hemopneumothorax cases. In other cases, diaphragms were closed totally intraoperatively while the lungs were held at inspiration by the anesthetist. Postoperative chest drain was not needed in these cases. None of the patients had pleural contamination, and empyema did not occur in any case.

In conclusion, DR is not common in patients with penetrating abdominal trauma, but can be life-threat48

ening when overlooked. It is important to keep in mind that diaphragmatic injury can associate with penetrating injury of intraabdominal organs, and thus routine observation of the diaphragm is necessary. When detected, the penetrating diaphragmatic injury does not influence the outcome.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Turhan K, Makay O, Cakan A, Samancilar O, Firat O, Icoz G, et al. Traumatic diaphragmatic rupture: look to see. Eur J Cardiothorac Surg 2008;33:1082-5.

2. Moore EE, Dunn EL, Moore JB, Thompson JS. Penetrating abdominal trauma index. J Trauma 1981;21:439-45.

3. Steinau G, Bosman D, Dreuw B, Schumpelick V. Diaphragmatic injuries--classification, diagnosis and therapy. [Article in German] Chirurg 1997;68:509-12. [Abstract] 4. Wirbel RJ, Mutschler WE. Right-sided diaphragmatic rupture with intrathoracic displacement of the entire right lobe of the liver. [Article in German] Unfallchirurg 1997;100:24952. [Abstract] 5. Mihos P, Potaris K, Gakidis J, Paraskevopoulos J, Varvatsoulis P, Gougoutas B, et al. Traumatic rupture of the diaphragm: experience with 65 patients. Injury 2003;34:169-72.

6. Balkan ME, Kara M, Oktar GL, Unlü E. Transdiaphragmatic intercostal hernia following a penetrating thoracoabdominal injury: report of a case. Surg Today 2001;31:708-11.

7. Sadeghi N, Nicaise N, DeBacker D, Struyven J, Van Gansbeke D. Right diaphragmatic rupture and hepatic hernia: an indirect sign on computed tomography. Eur Radiol 1999;9:972-4.

8. Eren S, Kantarci M, Okur A. Imaging of diaphragmatic rupture after trauma. Clin Radiol 2006;61:467-77.

9. Arak T, Solheim K, Pillgram-Larsen J. Diaphragmatic injuries. Injury 1997;28:113-7.

10. Wirbel RJ, Mutschler W. Blunt rupture of the right hemi-diaphragm with complete dislocation of the right hepatic lobe: report of a case. Surg Today 1998;28:850-2.

11. Boulanger BR, Milzman DP, Rosati C, Rodriguez A. A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma 1993;35:255-60.

12. Tribble JB, Julian S, Myers RT. Rupture of the liver and right hemidiaphragm presenting as right hemothorax. J Trauma 1989;29:116-8.

13. Reina A, Vidaña E, Soriano P, Orte A, Ferrer M, Herrera E, et al. Traumatic intrapericardial diaphragmatic hernia: case report and literature review. Injury 2001;32:153-6.

14. Kozak O, Mentes O, Harlak A, Yigit T, Kilbas Z, Aslan I, et al. Late presentation of blunt right diaphragmatic rupture (hepatic hernia). Am J Emerg Med 2008;26:638.e3-5.

15. Mihos P, Potaris K, Gakidis J, Paraskevopoulos J, Varvatsoulis P, Gougoutas B, et al. Traumatic rupture of the diaphragm: experience with 65 patients. Injury 2003;34:169-72.

16. Adesanya AA, da Rocha-Afodu JT, Ekanem EE, Afolabi IR. Factors affecting mortality and morbidity in patients with abdominal gunshot wounds. Injury 2000;31:397-404.

17. Schneider C, Tamme C, Scheidbach H, Delker-Wegener S, Köckerling F. Laparoscopic management of traumatic ruptures of the diaphragm. Langenbecks Arch Surg 2000;385:118-23.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):49-52

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.74501

Local differences in the epidemiology of traumatic spinal injuries Spinal yaralanma epidemiyolojisinde yerel farklılıklar Mehmet Özgür ERDOĞAN,1 Sibel ANLAŞ DEMİR,1 Mehmet KOŞARGELİR,2 Şahin ÇOLAK,1 Engin ÖZTÜRK1

BACKGROUND

AMAÇ

Spinal cord injury (SCI) has a serious lifetime impact as well as obvious social and economic effects for both patients and society. The aim of this study was to collect recent information and analyze changes in the epidemiology of traumatic spinal injuries.

Spinal kord yaralanması ömür boyu süren etkiye sahiptir.

Hastalar ve toplum için ağır sosyal ve ekonomik etkileri vardır. Bu çalışmanın amacı şehir yaşamının travmatik spinal kord yaralanmaları (TSKY) üzerinde yarattığı epidemiyolojik farklılıkları tanımlamaktır.

METHODS

GEREÇ VE YÖNTEM

Data included traumatic SCI (TSCI) patients admitted to the emergency department of Haydarpaşa Numune Training and Research Hospital between January 2007 and December 2011. 409 TSCI patients were included in the study.

Categorical variables were analyzed with Fisher’s exact test and parametric variables with independent samples t test.

RESULTS

Haydarpaşa Numune Eğitim ve Araştırma Hastanesi acil servisine Ocak 2007-Aralık 2011 arasında başvuran 409 TSKY hastası değerlendirildi. Kategorik değişkenler için Fischer kesin testi, parametrik veriler için bağımsız örneklem t-testi kullanıldı.

BULGULAR

The most common injury mechanism was high falls. 85 (20.8%) patients were injured in low falls, which was the second most common injury mechanism. The most common injury was lumbar spine injury (196 [48%] patients suffered isolated lumbar spine injury), followed by thoracal spine injuries. Lumbar spinal injuries (p=0.00011) were observed at a higher rate in high falls. Low fall was a significant mechanism for thoracal spine injuries (p=0.003).

Automobile accidents had a significant relation with cervical (p=0.00001) and lumbar (p=0.004) spinal injuries.

En sık yaralanma şekli yüksekten düşmelerdi, 85 (%20,8) hasta basit düşme sonucu yaralanmıştı. En sık ikinci yaralanma şekli basit düşmelerdi. Hastaların 196’sı (%48) lomber spinal yaralanma geçirmişti. En sık lomber spinal yaralanmalar gözlenmişti. Torakal bölge en sık ikinci yaralanan bölgeydi. Lomber spinal yaralanmalar yüksekten düşmelerde daha sıktı (p=0,00011). Basit düşmelerde torakal bölge yaralanmaları daha sıktı (p=0,003). Otomobil kazalarında belirgin şekilde servikal (p=0,00001) ve lomber (p=0,004) yaralanmalar daha sıktı.

CONCLUSION

SONUÇ

Although cervical injuries were higher in automobile accidents, the ratio of automobile accident-related TSCI was less than reported in other studies. Cervical injury ratio of the population decreased due to the decrease in the number of automobile accident-related TSCIs.

Servikal yaralanmalar otomobil kazalarında daha sık olmaktadır. Şehir merkezinde otomobil kazasına bağlı TSKY oranı diğer çalışmalara göre daha azdı. Servikal yaralanma oranıda otomobil kazası ilişkili TSKY oranının azalması ile azalmıştır.

Key Words: City; epidemiology; spinal trauma.

Anahtar Sözcükler: Şehir; epidemiyoloji; spinal travma.

1 Department of Emergency Medicine, Haydarpasa Numune Training and Research Hospital, Istanbul; 2Ministry of Health, Department of Emergency Medical Services, Ankara, Turkey.

1 Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, İstanbul; 2Sağlık Bakanlığı Acil Sağlık Hizmetleri Daire Başkanlığı, Ankara.

Correspondence (İletişim): Mehmet Özgür Erdoğan, M.D. Haydarpaşa Numune Hastanesi, Tıbbiye Caddesi, Kadıköy 34710 İstanbul, Turkey.

Tel: +90 - 216 - 542 32 32 e-mail (e-posta): ozgurtheerdogan@mynet.com

49

Ulus Travma Acil Cerrahi Derg

Spinal cord injury (SCI) has a serious lifetime impact as well as obvious social and economic effects for both patients and society. No curative treatment is available for the disease. It is thus imperative to be well aware of the etiology in order to develop precautions for the prevention of spinal trauma.[1-3]

80 70

Patients (n)

60

The aim of this study was to collect recent information and analyze city differences in the epidemiology of traumatic spinal injuries. Improvement in prevention strategies must be the main concern for the management of spinal trauma.

Two hundred and seven (50.6%) patients suffered a high fall, which was the most common injury mechanism. Eighty-five (20.8%) patients were injured in low falls, which was the second most common injury mechanism (Table 1).

The most common injury was lumbar spine injury; 196 (48%) patients suffered isolated lumbar spine

30 20 10 0

Fig. 1. Age distribution of patients.

injury. Thoracal spine injuries were the second most common injuries (Table 2). Spinal fractures were observed in 375 (91.7%) patients; 27 (6.6%) had spinal dislocations and 7 (1.7%) had combined fractures and dislocations. Lumbar spinal injuries (p=0.00011) were Table 1. Injury mechanisms

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) ver. 17.0. Categorical variables were analyzed with Fisher’s exact test and parametric variables with independent samples t test.

The level of significance was set at 0.05.

RESULTS There were 253 (61.9%) males and 156 (38.1%) females. The male to female ratio was 1.6/1. The average age was 46.82±19.05 years (43.75±17.85 for males and 51.80±19.90 for females) (Fig. 1).

40

09 10 -1 9 20 -2 9 30 -3 9 40 -4 9 50 -5 9 60 -6 9 70 -7 9 80 -8 9 90 -9 9

MATERIALS AND METHODS Road traffic accidents (RTAs) were grouped as car, motorcycle or pedestrian accidents. Falls were divided as high falls (>1 m) and low falls (<1 m). All sportsrelated injuries were grouped as sport injuries. All patients were defined according to American Spinal Injury Association Impairment Scale (ASIA) at discharge from the hospital. Data included all traumatic SCI (TSCI) patients admitted to the emergency department (ED) of Haydarpaşa Numune Training and Research Hospital between January 2007 and December 2011.

Four hundred and nine TSCI patients were included in the study.

50

High fall Low fall Pedestrian accidents Automobile accidents Motorcycle accidents Sport injuries Total

n

%

207 85 35 57 11 14 409

50.6 20.8 8.6 13.9 2.7 3.4 100

n

%

79 120 196 6 1 7 409

19.3 29.3 48.0 1.5 0.2 1.7 100

Table 2. Injury level

Cervical Thoracal Lumbar Cervical and thoracal Cervical and lumbar Thoracal and lumbar Total

Table 3. Injury type and injury level relation

Cervical

Thoracal

Lumbar

High fall Low fall Pedestrian Automobile Motorcycle Sports

28 9 13 26 3 7

67 41 9 17 5 0

123 39 14 18 3 7

50

p=0.99 p=0.993 p=0.027 p=0.00001 p=0.706 p=0.014

p=0.531 p=0.003 p=0.352 p=0.548 p=0.52

p=0.00011 p=0.465 p=0.289 p=0.004 p=0.22 p=0.997

Ocak - January 2013

Local differences in the epidemiology of traumatic spinal injuries

140 120

120

Lombar

100 Patients (n)

100 80 60 40

80 60 40

20

20 n um ut A

er Su

m

m

g rin Sp

r

0 te

ts or Sp

cl

M

ot

or

cy

ob om ut

A

str de

e

ile

n ia

ll fa

Pe

w Lo

H

ig

h

fa

ll

0

W in

Patients (n)

140

Cervical Thoracal

Fig. 2. Trauma mechanism and TSCI level relation.

Fig. 3. Seasonal distribution of injuries.

observed at a higher rate in high falls, while low fall was a significant mechanism for thoracal spine injuries (p=0.003). Automobile accidents had a significant relation with cervical (p=0.00001) and lumbar (p=0.004) spinal injuries. Sports-related injuries (p=0.014) had a significant relation with cervical spinal injuries (Table 3, Fig. 2).

patterns in different populations can affect the spinal cord injury etiology.[8] Karacan et al.[4] found that the most common levels of injury were T12 and L1. In our study, the most common injury was lumbar spine injury. Levels of injury also had differing features due to differences in the most common trauma mechanisms.

Although cervical injuries were higher in automobile accidents (p=0.00001), the ratio of automobile accident-related TSCI was less than reported in other studies. The cervical injury ratio of the population has decreased due to a decrease in the number of automobile accident-related TSCIs. This is an innovation in the prevention of TSCI. The former major cause of TSCI has moved to the background due to lower speeds, better car technology and seatbelt use.

The most common season for TSCI was summer (Fig. 3). Three hundred and forty-four patients were classified as ASIA E and 65 patients were classified as ASIA A to D. Three hundred and twenty-nine (80.4%) patients underwent surgical intervention. Eighty (19.6%) patients were treated conservatively.

DISCUSSION Kadıköy is one of the most culturally and economically developed parts of Turkey, and as such, it has unique features in spinal trauma etiology. In our study, the average age for TSCI was 46.82±19.05 years (Fig. 1) and the male to female ratio was 1.6. Prior studies have shown a lower mean age and a male to female ratio of 2.5 to 4.4.[4,5] It was considerably lower in our study. The active participation of women in the social environment makes them more vulnerable to TSCI.

Lumbar spinal injuries (p=0.00011) were higher in high falls. High falls were the most common cause of TSCI. High fall has emerged as the leading cause as the incidence of automobile-related TSCIs has decreased. As the reasons for the falls were not recorded in patient files, our retrospective study design could not reveal the causes of the high falls.

Low fall was a significant mechanism for thoracal spine injuries (p=0.003), and was the second most common mechanism of TSCI. The average age of patients suffering low fall was 68.13±13.34 years. When compared to the whole population, this population was older (p<0.05). As the elderly population grows, TSCI incidence will proportionally increase in this more challenging age group.

Studies usually show automobile accidents as the major cause of TSCI.[5,6] While others have reported falls as the primary cause of TSCI.[7] In our study, the most common cause of injury was high falls, while automobile accidents had a lesser role in the etiology (Table 1). Use of automobiles is very common.

Numerous traffic accidents occur in Kadıköy daily, but high-speed traffic accidents are rare due to the heavy traffic. Furthermore, the population usually uses technologically advanced cars, and because of strict controls, vehicle occupants are forced to use seatbelts.

In conclusion, the effects of the city environment cause changes in the epidemiology of spinal trauma.

In view of the aging population, an increase in the prevalence and modification in epidemiological features of spinal trauma can be expected.

Recent studies show cervical spinal injury as the most common injury level.[1,4,8] Different behavior

Conflict-of-interest issues regarding the authorship or article: None declared.

Cilt - Vol. 19 Sayı - No. 1

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Ulus Travma Acil Cerrahi Derg

REFERENCES 1. Knútsdóttir S, Thórisdóttir H, Sigvaldason K, Jónsson H Jr, Björnsson A, Ingvarsson P. Epidemiology of traumatic spinal cord injuries in Iceland from 1975 to 2009. Spinal Cord 2012;50:123-6.

2. Ackery A, Tator C, Krassioukov A. A global perspective on spinal cord injury epidemiology. J Neurotrauma 2004;21:1355-70.

3. Schoenfeld AJ, Sielski B, Rivera KP, Bader JO, Harris MB. Epidemiology of cervical spine fractures in the US military.

Spine J 2012;12:777-83.

4. Karacan I, Koyuncu H, Pekel O, Sümbüloglu G, Kirnap M, Dursun H, et al. Traumatic spinal cord injuries in Turkey: a nation-wide epidemiological study. Spinal Cord 2000;38:697-701.

52

5. Lenehan B, Street J, Kwon BK, Noonan V, Zhang H, Fisher CG, et al. The epidemiology of traumatic spinal cord injury in British Columbia, Canada. Spine (Phila Pa 1976) 2012;37:321-9.

6. Draulans N, Kiekens C, Roels E, Peers K. Etiology of spinal cord injuries in Sub-Saharan Africa. Spinal Cord 2011;49:1148-54.

7. Couris CM, Guilcher SJ, Munce SE, Fung K, Craven BC, Verrier M, et al. Characteristics of adults with incident traumatic spinal cord injury in Ontario, Canada. Spinal Cord 2010;48:39-44.

8. Tuğcu I, Tok F, Yılmaz B, Göktepe AS, Alaca R, Yazıcıoğlu K, et al. Epidemiologic data of the patients with spinal cord injury: seven years’ experience of a single center. Ulus Travma Acil Cerrahi Derg 2011;17:533-8.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):53-57

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.40799

The management of penetrating abdominal trauma by diagnostic laparoscopy: a prospective non-randomized study Penetran karın travmalarının tanısal lapararoskopi ile yönetimi: Prospektif randomize olmayan çalışma Faruk KARATEKE, Mehmet ÖZDOĞAN, Sefa ÖZYAZICI, Koray DAŞ, Ebru MENEKŞE, Yusuf Can GÜLNERMAN, İlhan BALİ, Safa ÖNEL, Cihan GÖKLER

BACKGROUND

AMAÇ

Penetrating abdominal trauma (PAT) has been traditionally treated by exploratory laparotomy (EL). The aim of our study was to examine the use of diagnostic laparoscopy (DL) in the management of hemodynamically stable patients with PAT.

Penetran karın travmaları (PKT) geleneksel olarak tanısal laparotomi (TL) ile tedavi edilmiştir. Bu çalışmanın amacı hemodinamisi stabil olan PKT’li hastaların yönetiminde diyagnostik laparoskopi (DL) kullanımını incelemektir.

METHODS

GEREÇ VE YÖNTEM

A prospective study was performed to compare the outcomes of hemodynamically stable patients with suspected intra-abdominal injuries due to abdominal stab wounds who underwent either EL or DL. Data extracted for analysis included demographic information, operative findings, rates of non-therapeutic laparotomy, operation time, length of hospital stay, mortality, and postoperative complications.

Hemodinamisi stabil olan delici-kesici alete bağlı karın içi yaralanma şüphesi nedeniyle TL veya DL yapılan hastaların sonuçları prospektif olarak kayıt edildi. Hastaların demografik özellikleri, ameliyat bulguları, hastanede kalış süresi, mortalite ve ameliyat sonrası komplikasyonları irdelendi.

RESULTS

BULGULAR

Fifty-two hemodynamically stable patients were admitted to the trauma service. There were 45 male (86.5%) and 7 female (13.5%) patients. The average age was 34.5 years-old (1860). 26 (50%) patients underwent EL, and 26 (50%) patients underwent DL. Re-exploration by laparotomy was required in 9 of the 26 cases (34.6%). Patients who underwent DL had significantly shorter hospital stays (1.82±0.63 days vs.

5.4±2.1 days, p<0.05) and shorter operation time (17.9±6.38 vs. 68.4±33.2 min, p<0.05) than patients who underwent EL.

Hemodinamisi stabil olan 52 PKT’li hasta travma servisine alındı. Hastaların 45’i (%86,5) erkek, 7’si kadın (%13,5) ve yaş ortalaması 34,5 idi (dağılım 18-60 yaş). Yirmi altı (%50) hastaya TL, 26 (%50) hastaya ise DL yapıldı. DL yapılan hastaların dokuzuna (%34,6) laparotomi gereksinimi oldu. DL yapılan hastaların hastanede kalış süresi ve ameliyat süresi TL yapılan hastalara göre daha kısa idi (DL 1,82±0,63, TL 5,4±2,1 gün, p<0,05), (DL 17,9±6,38, TL 68,4±33,2 dk., p<0,05).

CONCLUSION

SONUÇ

Selective use of DL in the hemodinamically stable penetrating trauma patients effectively decreased the rate of negative laparotomies, minimized morbidity, and decreased hospital stay.

Hemodinamisi stabil olan PKT’li hastalarda DL kullanımının negative laparotomi oranlarını, morbiditeyi ve hastanede kalış süresini azalttığı saptandı.

Key Words: Exploratory laparotomy; diagnostic laparoscopy, penetrating abdominal trauma.

Anahtar Sözcükler: Tanısal laparotomi; diyagnostik laparoskopi; penetran karın travması.

Department of General Surgery, Adana Numune Training and Research Hospital, Adana, Turkey.

Adana Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Adana.

Correspondence (İletişim): Faruk Karateke, M.D. Adana Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Adana, Turkey.

Tel: +90 - 322 - 355 00 00 e-mail (e-posta): karatekefaruk@hotmail.com

53

Ulus Travma Acil Cerrahi Derg

Penetrating abdominal trauma has been traditionally treated with EL. The high non-therapeutic/negative laparotomy rate and associated morbidity after EL for abdominal stab wounds led to the current selective non-operative management strategy.[1-2] In spite of the various diagnostic methods available, diagnostic peritoneal lavage (DPL), focused abdominal sonography for trauma (FAST), and computed tomography (CT), it is difficult to determine the presence and severity of intra-abdominal injuries caused by abdominal stab wounds. EL is the most popular procedure for definitive evaluation of patients sustaining penetrating abdominal trauma (PAT), which carries a 0-5% mortality rate, a 20% morbidity rate, and a 3% long term risk of bowel obstruction.[3] However, more recent reports have shown that 30-50% of all stab wounds do not penetrate the peritoneum and another 20-40% with peritoneal penetration do not involve significant injuries, resulting in non-therapeutic laparotomy rates as high as 70%.[1,4] Laparoscopy has recently been safely used for PAT patients for diagnostic and therapeutic purposes, avoiding unnecessary laparotomies, shortening the length of hospital stay, and reducing medical costs.[5,6] The aim of our study was to examine the use of diagnostic laparoscopy (DL) in the management of hemodynamically stable trauma patients with penetrating anterior abdominal injuries.

MATERIALS AND METHODS We performed a prospective study to compare the outcomes of hemodynamically stable patients with suspected intra-abdominal injuries from abdominal stab wounds who underwent either EL or DL. Fiftytwo hemodynamically stable patients with abdominal stab wounds, admitted to Adana Numune Training and Research Hospital over the 1-year period between June, 1 2010 and July, 1 2011 were included in the study. Our center serves as a level 1 trauma center for a district of 3 million residents. Critically injured patients are either transported directly to our center by the emergency medical service or are transferred from local community hospitals after initial management.

The Ethical Committee of our center approved the study protocol.

Patients with stab wounds located at the flank or back, patients with no penetration of the peritoneum at local wound exploration, and patients who were operated on immediately due to peritonitis, shock, or evisceration of organs on admission were excluded from this study. Our clinical algorithm for abdominal stab wounds is shown on Fig. 1.

All procedures were performed in the operating room under general anesthesia and all patients consented to possible conversion to laparotomy. After 54

induction of general anesthesia, Foley catheter and orogastric or nasogastric tubes were placed in each patient. Tube thoracostomy was performed before laparoscopy when chest radiography showed hemo/ pneumothorax. An umbilical trocar was placed by the Hasson technique and the abdomen was insufflated with CO2 to a pressure of 15 mmHg. A 30째 10-mm laparoscope was used initially in all patients. Additional 5-mm ports were placed under direct vision as necessary for manipulation of the bowel. All quadrants were carefully inspected and the small bowel and colon were examined. Lavage samples were sent for Gram staining in order to detect possible bowel injuries. All EL were performed using a standard midline incision under general anesthesia. The operative procedure was performed by one of seven surgeons who were experienced in emergency laparoscopy and laparotomy.

Definitions Relative to penetrating injuries, several definitions are required for findings of both laparoscopy and laparotomy procedures. Negative laparoscopy was defined as the presence of peritoneal penetration but no intra-abdominal injury. Non-therapeutic laparoscopy is the presence of organ injury that did not require intervention. Therapeutic laparoscopy is a procedure in which the organ injury was managed laparoscopically.

Re-exploration by laparotomy defines a laparoscopic exploration followed by laparotomy. Negative laparotomy was the absence of intra-abdominal injury. Non-

Abdominal stab wounds

Hemodynamically stable

Hemodynamically instable (or peritonitis evisceration)

Local wound exploration

Laparotomy

Equivocal violation of anterior fascia

No violation of anterior fascia

Laparoscopy

Discharge

Fig. 1. Our algorithm for the evaluation of abdominal stab wounds.

Ocak - January 2013

The management of penetrating abdominal trauma by diagnostic laparoscopy

Table 1. Demographic characteristics, hemodynamic parameters in emergency room, and laboratory findings of hemodynamically stable patients with suspected abdominal injuries

Gender (Male / Female) Age Initial SBP (mmHg) Initial HR (beats/min) Hematocrit Multiple stab wounds (%)

Exploratory laparotomy (n=35) Mean±SD

Diagnostic laparoscopy (n=17) Mean±SD

30 / 5 35.2±10.6 107.0±12.3 94.8±12.2 38±6.6 20 (7 / 35)

15 / 2 33.2±9,2 112.3±11.8 91.7±12.0 42.9±2.0 11.7 (2 / 17)

p

0.512 0.142 0.390 <0.0001 0.342

Data are presented a mean ± standard deviation (SD) or number and percentage. SBP: Systolic blood pressure; HR: Heart rate.

therapeutic laparotomy found organ injury that did not require intervention. Therapeutic laparotomy required surgical treatment of organ injury.

Data collection and statistical analysis Data extracted for analysis included demographic information, hemodynamics in the emergency room, operative findings, operative techniques, rates of significant injuries, rates of non-therapeutic laparotomy, operation time, length of hospital stay, hospital mortality, and postoperative complications. Statistical significance (p<0.05) was determined by the chi-square test (or Fisher’s exact test when n<5) for categorical data, and the Mann-Whitney U-test for continuous variables.

RESULTS There were 45 male (86.5%) and 7 female (13.5%) patients. The average age was 34.5 years-old (18-60).

Locations of the stab wounds were: anterior abdomen in 36 (69%) patients and the thoracoabdominal region in 16 (31%). Focused abdominal sonography for trauma (FAST) was positive in 11 patients and computerized tomography (CT) was positive in 1 patient. Table 1 shows the demographic characteristics and hemodynamic and laboratory parameters of the patients. The peritoneal violation rate was 100%.

Of the total 52 patients included in the study, 26 (50%) patients underwent EL, and 26 (50%) patients underwent DL. Re-exploration by laparotomy was required in 9 of the 26 cases (34.6%), which resulted in therapeutic operation for 8 patients, with a non-therapeutic laparotomy for 1 of the 9 cases. That special case was converted to laparotomy because of false positive lavage performed during DL, which revealed Gr. (-) bacteria. Re-exploration by laparotomy was performed for one patient due to intrabdominal abscess detected 3 days after DL. In that case, the abscess was considered to have occurred due to the contamination of washing saline during DL. Re-exploration by laparotomy was performed in 3 patients for small bowel injury, 2 patients for splenic injury and in 2 patients for Cilt - Vol. 19 Sayı - No. 1

Table 2. The operative procedures of the patients admitted with penetrating abdominal trauma Procedure Exploratory laparotomy (n=26, 50%) Negative/nontherapeutic Therapeutic Diagnostic laparoscopy (n=17, 32.7%) Negative/nontherapeutic Therapeutic Re-exploration by laparotomy (n=9, 17.3%) (Laparoscopy / Laparotomy) Negative/nontherapeutic Therapeutic

n

%

13 13

25 25

13 4

25 7.7

1 8

1.9 15.3

gastric injury. Therapeutic laparoscopy was performed in 4 patients. In one patient diaphragmatic injury was repaired and hemostasis of mesenteric and omental bleeding sources were achieved in another 3 patients.

The surgical procedures performed for PAT patients are shown in Table 2.

Seventeen (32.7%) patients were evaluated by laparoscopy (group 1) and a total of 35 (67.3%) patients underwent laparotomy eventually (group 2). There were no significant differences between the demographic characteristics, hemodynamic parameters and laboratory findings in the emergency room between patients in the two groups. Patients in group 1 had a significantly shorter hospital stay (1.82±0.63 days vs.

5.4 ±2.1 days, p<0.05) (Fig. 2a) and shorter operation time (17.9±6.38 vs. 68.4±33.2 minutes, p<0.05) (Fig. 2b) than patients in group 2. The rate of unnecessary laparotomies in group 2 was 40%.

Negative/non-therapeutic laparotomy was performed on 13 patients and negative/nontherapeutic laparoscopy was performed on 13 patients. Patients who underwent negative /non-therapeutic laparoscopy had a significantly shorter operation time and shorter hospital stay than patients who underwent negative/ non-therapeutic laparotomy. There was no significant difference in ICU stay between groups. There was one 55

Ulus Travma Acil Cerrahi Derg

12

200 44

Operation time (min)

Hospital stay (days)

10 8 6 4

100

50

2 0

18

150

15

0 1

(a)

Groups

2

(b)

1

Groups

2

Fig. 2. (a) Comparison of hospital stay between the groups. (b) Comparison of operation time between the goups.

complication among negative /non-therapeutic laparoscopy patients, although 5 patients had complications after negative/non-therapeutic laparotomy. Complications included wound infection in 4 patients and pneumonia in 1 patient (Table 3).

Overall sensitivity for intra-abdominal injuries using DL was 92.3%, and specificity was 100% for penetrating abdominal trauma in hemodinamically stable patients. Similarly, positive predictive and negative predictive values for intra-abdominal injuries were 100% and 92.9%, respectively. Sensitivity of DL for any therapeutic intervention was calculated as 88.9%.

DISCUSSION The aim of our study was to assess the overall benefits of DL in the evaluation of stable patients with abdominal stab wounds. Emergency department evaluation of the injured patient has evolved greatly over the years, mainly due to the advances in imaging technology. Trauma surgeons have a variety of diag-

nostics tools to assist with the management of their patients, including observation with serial physical examination, DPL, FAST, and CT. Each of these modalities has strengths and weaknesses that must be considered and none are 100% reliable. For this reason, EL is often performed in the case of stab wounds, but EL in trauma patients is associated with a high negative laparotomy rate, and procedure-related morbidity can reach up to 40%.[2] The increased availability of laparoscopy now offers even more flexibility during the workup of injured patients. Diagnostic laparoscopy has been proposed for trauma patients to prevent unnecessary exploratory laparotomies with associated higher morbidity and cost.[6] In a review by Villavicencio and Aucar, DL for penetrating trauma reported had sensitivity of 80100%, specificity of 38-86%, and accuracy of 5489%.[7] In another study conducted by Ertekin et al.[8] the specificity and sensitivity of DL were 100% in

Table 3. Comparison of negative/nontherapeutic laparoscopy and negative/nontherapeutic laparotomy patients Negative/nontherapeutic laparotomy

Negative/nontherapeutic laparoscopy

p

Operating time (min) ICU stay Hospital stay (days)

55.77±18.46 1.00±0.00 3.69±0.85

18.08±6.6 1.00±0.00 1.77±0.59

<0.0001 >0.005 <0.0001

Complication Insignificant injuries

Liver

Omentum

Spleen No organ injury

5 (38.4%)

1 (7.6%)

0.047

4 3 4 2

3 5 1 4

Data are presented a mean ± standard deviation (SD) or number and percentage.

56

Ocak - January 2013

The management of penetrating abdominal trauma by diagnostic laparoscopy

lower thoracic penetrating trauma. The positive diagnostic value and negative predictive value for peritoneal penetration were found to be 100%. Laparoscopy can prevent laparotomy in 63% of patients with a variety of injuries.[7] The laparoscopic approach avoids negative laparotomy in 23-54% of patients with stab wounds and blunt abdominal trauma. Laparoscopy is more cost-effective than negative laparotomy.[7] DeMaria et al.[9] compared mandatory celiotomy to laparoscopy in hemodynamically stable patients with thoracoabdominal stab wounds. Non-therapeutic laparotomy was significantly less common in the group initially evaluated by laparoscopy (19% vs. 57%). The sensitivity, specificity and accuracy of laparoscopic evaluation were also superior when compared to DPL in predicting the need for therapeutic intervention at open abdominal exploration. We performed DPL during DL procedure in some of our patients in order to rule out possible hollow viscus injuries.

In our study, patients who underwent DL had shorter hospital stays and shorter operation time than patients who underwent EL. The rate of unnecessary laparotomies was 40%. In our study group, DL could potentially decrease the rate of unnecessary laparotomy as a figure of 59.6% if applied to all patients.

Sensitivity of DL was 92.3%, and specificity was 100% in our study. Similarly, positive predictive and negative predictive values for intra-abdominal injuries were 100% and 92.9%, respectively. Sensitivity of DL for any therapeutic intervention was 88.9%.

Similarly, patients who underwent negative/nontherapeutic laparoscopy had a significantly shorter operation time and shorter hospital stay than patients who underwent negative/non-therapeutic laparotomy.

There was no significant difference in ICU stay between groups. There was one complication among negative/non-therapeutic laparoscopy patients, and 5 patients had complications after negative/nontherapeutic laparotomy.

The opinion in the early 1990s, supported by published data, that there was a higher incidence of complications with laparoscopy is now outdated due to increasing experience and technical improvements.

Procedure-related complications occur in up to 11% of patients and are usually minor (level I-III).[10] A 1999 review of 37 studies, which included more than 1,900 patients, demonstrated a procedure-related complication rate of 1%.[7] Recent studies have reported a median of 0% (range 0-10%) procedure-related morbidity and 0% mortality (level I-III). Intraoperative complications can occur during creation of the pneumoperitoneum, trocar insertion, or during the diagnostic examination.[10] Similar to the literature, procedure-related complication rate due to DL was 7.6% in our study.

Cilt - Vol. 19 Sayı - No. 1

Although we currently use the laparoscope as a screening tool for peritoneal penetration, the next logical progression is to conduct a more effective laparoscopic treatment of specific organs in the trauma setting. This could potentially decrease or eliminate the number of non-therapeutic conversion from laparoscopy to laparotomy. The threshold for conversion would vary among surgeons based on laparoscopic expertise and confidence in the laparoscopic examination. The next step is to increase therapeutic intervention as we gain more experience.

Selective use of DL in penetrating trauma patients effectively decreases the rate of negative laparotomies and minimizes patient morbidity and hospital stay, with its high sensitivity, specificity, positive and negative predictive values. To optimize results, this procedure should be incorporated in institutional diagnostic and treatment algorithms for trauma patients.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Selman U, Katrin D. Laparoscopy in abdominal trauma. Eur J Trauma Emerg Surg 2010;36:19-24.

2. Leppaniemi A, Salo J, Haapiainen R. Complications of negative laparotomy for truncal stab wounds. J Trauma 1995;38:54-8.

3. Shih HC, Wen YS, Ko TJ, Wu JK, Su CH, Lee Ch. Noninvasive evaluation of blunt abdominal trauma: Prospective study using diagnostic algorithms to minimize nontherapeutic laparotomy. World J Surg 1999;23:265-70.

4. Fabian TC, Croce MA, Stewart RM, Pritchard FE, Minard G, Kudsk KA. A prospective analysis of diagnostic laparoscopy in trauma. Ann Surg 1993;217:557-65.

5. Zantut LF, Ivatury RR, Smith RS, Kawahara NT, Porter JM, Fry WR et al. Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience. J Trauma 1997;42:825-31.

6. Taner AS, Topgul K, Kucukel F, Demir A, Sari S. Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital costs in trauma patients. J Laparoendosc Adv Surg Tech 2001;11:207-11.

7. Villavicencio RT, Aucar JA. Analysis of laparoscopy in trauma. J Am Coll Surg 1999;189:11-20.

8. Ertekin C, Onaran Y, Güloğlu R, Günay K, Taviloğlu K. The use of laparoscopy as a primary diagnostic and therapeutic method in penetrating wounds of lower thoracal region. Surg Laparosc Endosc 1998;8:26-9.

9. DeMaria EJ, Dalton JM, Gore DC, Kellum JM, Sugerman HJ. Complimentary role of laparoscopic abdominal exploration and diagnostic peritoneal lavage for evaluating abdominal stab wounds: a prospective study. J Laparoendoscopic Adv Surg Techniques 2000;10:131-6.

10. Hori Y; SAGES Guidelines Committee. Diagnostic laparoscopy guidelines : This guideline was prepared by the SAGES Guidelines Committee and reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), November 2007.

Surg Endosc 2008;22:1353-83.

57

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):58-64

Original Article

Klinik Çalışma doi: 10.5505/tjtes.2013.04453

Foreign body penetrations of hand and wrist: a retrospective study El ve el bileğinin yabancı cisim penetrasyon yaralanmaları: Retrospektif çalışma Emre HOCAOĞLU,1 Samet Vasfi KUVAT,1 Burhan ÖZALP,2 Anvar AKHMEDOV,1 Yunus DOĞAN,1 Erol KOZANOĞLU,1 Fethi Sarper METE,1 Metin ERER1

BACKGROUND

AMAÇ

Despite significant practical knowledge and experience on foreign body penetration injuries to the hand and/or wrist, deficient management and complications can still be encountered, and ignorance of its causative and eventual social aspects unfortunately is a substantial fact. This study aims to cover the clinical and social properties and the management of these kinds of injuries.

Konuyla ilgili ileri seviyedeki pratik bilgi birikimimize rağmen, el ve elbileğinin yabancı cisim penetrasyon yaralanmaları, halen eksik tedaviler ve komplikasyonlarla gündeme gelebilmektedir. Konunun sosyal, etyolojik ve hukuki boyutu günlük yoğun pratik içinde atlanabilmektedir. Bu çalışmada, konunun sosyal, klinik ve terapötik özellikleri ele alındı.

METHODS

A retrospective analysis of 86 patients requiring evaluation and treatment in a Hand Surgery Division of a university hospital was performed.

GEREÇ VE YÖNTEM

Bir el cerrahisi kliniğince tedavisi yapılmış 86 hastanın retrospektif analizi yapıldı.

RESULTS

BULGULAR

The median age was 32 (min: 4, max: 63). Industrial workers constituted the largest occupational group (n=22, 25.6%). Twenty-three (26.7%) of the cases were elective admissions. Thirteen (15.1%) patients had various comorbidities, and five (5.8%) had psychiatric diagnoses at the time of the injury. The index finger was the most frequent site of injury (n=29, 33.7%). General anesthesia was not necessary for the management of 94.2% of the cases. In 26 (30%) of the patients, neural, tendinous or osseous damage was observed. Twenty-four (30%) patients were included in a postoperative hand physiotherapy program.

Ortalama yaşı 32 olan popülasyonun %25,6’sı endüstriyel işçilerden (en kalabalık mesleki grup) oluşmaktaydı. Başvuruların %26,7’si elektif idi. Yaralanma döneminde ek hastalığı olanlar popülasyonun %15,1’ini, psikiyatrik tanısı olanlar %5,8’ini oluşturuyordu. İşaret parmağı en sık yaralanan bölge (%33,7) idi. Ameliyatların %94,2’si lokal anestezi altında yapıldı. %30 hastada nöral, tendinöz ve/veya kemiksel hasar mevcuttu. Hastaların %30’u ameliyat sonrası el fizyoterapi programına dahil edildiler.

CONCLUSION

El ve elbileğinin yabancı cisim penetrasyon yaralanmaları genel yönleri ve pratikte gözden kaçabilen özellikleri ile ele alındı.

The practically well-known general features of the issue and those aspects that may still be overlooked currently are reevaluated herein, in light of our observational data.

Key Words: Foreign body; hand; penetration injury; wrist.

Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul; 2 Department of Plastic Reconstructive and Aesthetic Surgery, Dicle University Faculty of Medicine, Diyarbakır, Turkey.

1

SONUÇ

Anahtar Sözcükler: Yabancı cisim; el; penetrasyon yaralanması; el bileği.

1 İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul; 2 Dicle Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Diyarbakır.

Correspondence (İletişim): Emre Hocaoğlu, M.D. İ.Ü. İstanbul Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul, Turkey.

Tel: +90 - 212 - 414 20 00 e-mail (e-posta): emrehocaoglu@gmail.com

58

Foreign body penetrations of hand and wrist

Foreign body (FB) penetrations of the hand and wrist constitute an important type of injury that is frequently encountered in primary health care units, emergency rooms and hand surgery departments. These usually appear as emergency cases, but the number of patients met under elective conditions cannot be underestimated. A FB, stuck into an extremity, may lead to consequences such as tissue damage, inflammation, infection, delayed wound healing, toxic or allergic reactions, and late injury as a result of migration.[1] When the anatomic properties are taken into consideration, even a tiny object, penetrated through a small skin laceration, may damage significant structures of the hand and wrist where many structures are tightly arranged.

There has been an increasing number of case reports in the literature presenting striking injuries of various body parts associated with FB penetrations.

However, the number of observational studies about hand and wrist penetrations is limited when compared to the high prevalence of subjects. In spite of the substantial experience of clinicians on this issue, there are a significant number of articles denoting defective management strategies, such as inadequate tetanus prophylaxis, and uncertainty in basic principles such as selecting the right solution for wound irrigation.

[2,3] Moreover, wounds with neglected FBs form one of the high-risk emergency medicine categories responsible for malpractice events.[4] Indeed, failure to diagnose or treat retained FBs has been reported to be the fifth leading claim against emergency physicians.

[5] This study thus aims to reveal the basic features of the affected patients, the properties of the penetrated objects, the events causing this specific type of injury, the management of these injuries, and the outcomes of the patients. It is based on an analysis of a group of patients who had FB injuries in a more specific anatomic location, i.e. the hand and wrist.

presence of any legal component of the event were noted for each case. Almost all of these data were obtained from the medical record cards. All the patients were also telephoned to obtain informed consent for the study, gather any data that were unavailable on the cards and query the patients regarding any complaints related to the site of injury.

MATERIALS AND METHODS This study was approved by the Institutional Ethics Committee and is based on a retrospective analysis of patients who had hand and/or wrist injuries caused

by FB penetration. Eighty-six patients, who had been treated by the staff of the Department of Plastic Reconstructive and Aesthetic Surgery (PRAS) between 01/12/2004 and 01/12/2011, were included in the study. Patients had been referred to the Hand Surgery Division (HSD) of the Department of PRAS either from the Emergency Department (ED) of the same hospital or from EDs of other hospitals and primary health care units.

The presented results are objectified by adding remarkable case examples of different types of etiologic bases.

Age, sex, occupation and social status, presence of any accompanying diseases or psychiatric disorders, specific anatomic localization of the FB penetration, injured structure(s), type of anesthesia used, nature of each FB, type of event that resulted in the injury, and Cilt - Vol. 19 Say覺 - No. 1

Occupational features and social status of patients were incorporated in eight separate titles as: unemployed, housewives, retirees, students, industrial workers, service sector workers, civil servants, and others.

For each case, the specific anatomic site of entrance of the FB was allocated into one of eleven groups as: first web space, thumb, index finger, middle finger, ring finger, small finger, hypothenar area, thenar area, hand dorsum, wrist, and carpal tunnel. In terms of injured structures, patients were categorized into one of eight groups as: skin laceration only, digital pulp laceration, nail bed injury, extensor tendon injury, flexor tendon injury, nerve injury, phalangeal fracture, and multiple structural injuries. The types of anesthesia used for the surgery were analyzed. Patients were also categorized as fully recovered or having at least one complaint related to the specific injured site. Data obtained in terms of the structural properties of penetrated FBs could be distributed in 11 groups as: metal splinters, wooden splinters, glass pieces, dyestuff, sewing needles, fish hooks, bullets, nails, pencils, crochet hooks, and other metal objects. Events that resulted in FB penetrations to the hand and wrist were classified in 6 groups as: occupational accidents, accidents occurring during the conduct of daily chores, traffic accidents, deliberate behaviors aimed at secondary gains, pathological behaviors as part of psychiatric disorders, and injuries occurring due to criminal acts. Finally, whether the patient presented as an emergency case or the referral was elective was also noted for each case.

RESULTS The median age of the 86 patients was 32 (min: 4, max: 63). The demographic data including the distribution of patients to the age groups are demonstrated in Table 1. Sixteen (18.6%) patients were being treated or followed up because of one or more additional health problems, including psychiatric disorders, at the time of their injury. The results of analysis of the data that pertains to the anatomical sites of entrance of the FBs, injured structures, affected side of the body, and frequency of postoperative complaints about the injured site are also listed in Table 1.

As summarized in Table 2, the underlying events and the etiologic bases of these injuries were com59

Ulus Travma Acil Cerrahi Derg

Table 1. Demographic and clinical features of the patients Variables

n

Age <1 0 1-4 2 5-14 10 15-24 19 25-34 20 35-44 21 45-54 7 55-64 7 65-74 0 Gender Male 60 Female 26 Extra disease None 70 Extra medical problems 13 Psychiatric disorder 5 Occupation Industrial worker 22 Student 17 Service sector worker 13 Civil servant 8 Unemployed 7 Housewife 6 Retired 6 Others 5 Foreign body entrance site Index finger 29 Middle finger 10 Wrist 10 Thenar area 9 Thumb 7 Hypothenar area 5 Carpal tunnel 4 First web 4 Small finger 4 Hand dorsum 2 Ring finger 2 Injury Skin laceration 44 Digital pulp laceration 11 Nerve 8 Multiple tissue injury 8 Nail bed 5 Extensor tendon 4 Flexor tendon 4 Phalanx fracture 2 Side Left 45 Right 41 Postoperative complaint None 71 60

% 0.0 2.3 11.6 22.1 23.3 24.4 8.1 8.1 0.0 69.8 30.2 81.4 15.1 5.8 25.6 19.8 15.1 9.3 8.1 7.0 7.0 5.8 33.7 11.6 11.6 10.5 8.1 5.8 4.7 4.7 4.7 2.3 2.3 51.2 12.8 9.3 9.3 5.8 4.7 4.7 2.3 52.3 47.7 82.6

posed of 44 (51.2%) accidents that occurred during the conduct of daily chores and hobbies (Figs. 1a, b), 30 (34.9%) occupational accidents (Figs. 1c, d), 4 (4.7%) traffic accidents, 4 (4.7%) pathological behaviors as consequences of psychiatric disorders, 3 (3.5%) criminal activities (Fig. 1e), and 1 (1.2%) deliberate behavior for a secondary gain (Fig. 1f). After the operations, the follow-up of 40 (46.5%) patients was done in the HSD outpatient clinic, and 24 (60%) of these 40 patients were included in a hand physiotherapy program.

The analysis of admission patterns, the diagnostic and therapeutic workups of the patients and the features of the FBs are also demonstrated in Table 2.

Among 23 elective admissions, 7 patients stated that they had not sought any professional healthcare for their injuries; thus, they had not received any tetanus prophylaxis within the acute phase of the injury although they had had received no vaccination during the previous 10 years. The remaining 63 patients who applied as emergency cases were given tetanus prophylaxis on the day of injury, according to the Advisory Committee on Immunization Practices recommendations.[6,7]

DISCUSSION Compatible with our findings, FB penetrations of the hand and/or wrist usually present as emergency cases, but elective applications of patients with embedded objects are not uncommon. Embedded FBs can also be removed from patients who are unaware or uncertain of FB entry.[8] Accidents that happen during the conduct of daily chores, hobbies and occupational activities are the most frequent causes of FB penetrations. In fact, 86.1% of the cases analyzed in our study were due to such accidents, almost all of which resulted in isolated local injuries to the trauma site. On the other hand, they may also occur as minor or major components of multiple trauma cases, as in traffic accidents. Conscious behaviors performed for self-mutilation or secondary gain are other forms of etiologic bases for FB penetrations.

When an embedded FB is suspected due to the medical history and examination, plain radiography, ultrasonography or computed tomography may be used as imaging techniques. It is usually possible to find the embedded FBs through using two-view plain radiographs. We utilized two-view X-rays in 74.4% of our patients. For some cases, sticking radiopaque materials to the skin or wound surface and/or inserting metal grids such as syringe needles to the soft tissue just before taking the radiographs was beneficial. In some centers, fluoroscopy is also being utilized as a routine component of the surgery.[9] Previously, it has been stated that the two-view X-rays have been shown to be equivalent to the three-view X-rays in detecting glass FBs.[10] In another study, when only plain films Ocak - January 2013

Foreign body penetrations of hand and wrist

(a)

(c)

(d)

(e)

(f)

(Color figures can be viewed in the online issue, which is available at www.tjtes.org).

(b)

Fig. 1. (a) A 21-year-old university student was found hanging by his hand, through which a metallic extension of the garden wall had penetrated.

This had occurred while attempting to jump over the wall. He presented with a large piece of the metal railing, which had penetrated through almost the entire length of his left hand. Under general anesthesia, the palmar skin surrounding the FB was opened using Bruner zigzag incisions, and the palmar fascia was passed. The FB was observed to extend between the branches of the median nerve and the digital neurovascular bundles, dissecting but not damaging them. The FB and the involved tissues were lubricated with sterile liquid petroleum jelly. The huge FB was extracted carefully from between the surrounding dissected nerves and vessels. (b) After an accident that had occurred during the conduct of household chores, a 14-year-old girl presented with a crochet-hook stuck in the ulnar side of her wrist. The depth and localization of the hooked tip was estimated through two-view plain radiographs. Even though there were no symptoms or clinical findings regarding a neurovascular or tendon injury, exploration of the site was carried out due to the possibility of damage to the ulnar artery or ulnar nerve. Under loupe magnification, it was seen that the FB had penetrated through the fascicles of the ulnar nerve without causing any ruptures. (c) A 27-year-old male industrial worker was brought to us with a metal mesh penetrating his wrist as a result of an occupational accident. He stated that during a sudden period of drowsiness, he had tried to hold the metal mesh to stop a fall, but the free edge of the object had penetrated his wrist. While radiographs were being taken, the FB was extracted spontaneously despite our routine effort to keep the object still in the wound. Exploration of the site revealed a partially damaged ulnar nerve. (d) A 37-year-old industrial worker with a metal object stuck in his finger was referred to us after an occupational accident. Under local anesthesia, the wound was extended with incisions made proximally and distally on the mid-lateral line. Next, the palmar neurovascular structures, the flexor and extensor tendons, were explored, and the FB was extracted. Finally, the radial collateral ligament and articular surfaces of the middle and distal phalanges were examined.

After massive irrigation of the site, the partially damaged flexor tendon and the radial collateral ligament were repaired, and the skin was closed primarily. (e) An 11-year-old student was admitted to our clinic because one of his school friends had intentionally stuck a sharp-pointed piece of wood into his right thenar area. Just after the physical examination, a median and radial nerve block was performed at the wrist level. The two-view radiography showed the embedded tip of the object with no extra splinters of wood around it. Under general anesthesia, after extending the wound with incisions, the FB was extracted through the thenar muscles. Exploration revealed no neurovascular or tendinous damage. (f) A 42-year-old prison inmate presented with a nail stuck in his finger stump, which had been operated previously because of another accident. It was reported as an odd accident or was claimed to be an accident involving nail gun usage during voluntary repair work at the prison. The FB had penetrated the entire width of the finger by passing through the middle phalanx. The entrance and exit points of the nail were just on the mid-lateral lines. The nail was removed by traction under local anesthesia without extra incision, and the wounds were left for secondary healing.

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were utilized, wood and glass FBs were missed in 93% and 25% of the cases, respectively, so ultrasound was suggested to be the more sensitive and preferred technique for imaging of wooden FBs.[11] We used no imaging in 25.6% of the cases in which significant parts of the FBs were visible externally. Whatever the chosen imaging technique, it is very important to keep still the injured extremity and the FB during the clinical evaluations and radiological investigations in order to prevent injury to surrounding structures.

In 55.7% of our cases, the FBs were metallic, while they were glass and wood in 23.3% and 11.6% of the cases, respectively. The chemical and physical properties of the embedded FB influence the clinical evaluation and intervention processes. The risk of the damage that emerges as a consequence of leaving the FB in place and the risk of surgical intervention for exploration and removal of the object should be compared, and the action should be taken accordingly. Case reports of embedded organic FBs such as splinters of plants, wood and fish fin fragments demonstrate the typical clinical picture of inflammatory reaction that develops in days or weeks.[12] In this sense, metal objects are less risky than the organic ones.[13] For this reason, if the exploration and extraction attempts have the risk of injury to the neighboring structures, it is better to leave an embedded inert metal object in its place unless it causes any symptoms or infection. However, it should not be forgotten that soft-tissue FBs that are missed on the initial evaluation may migrate to cause significant morbidity, or even mortality, months or years after the traumatic event.[1,8] In case of penetrations with remarkable-sized objects, estimation of the location and the course of the FB in the tissue are usually easier, but removal of the object without damaging the surrounding tissues is obviously the most challenging part of the management. Even if there are no symptoms or findings of a structural injury, removing the FB blindly just by extraction is indisputably an error. This action will most likely be detrimental to the regional structures. With respect to our findings, 36% of the cases had an injury of either a neurovascular or a tendinous structure, or combinations thereof. In general, it is crucial to extend the wound with incisions that will allow exploration of the FB, or the penetrated part of it, and the structures in close proximity.

The type of anesthesia is determined by considering the location of the FB, the depth of penetration, the most likely injured structure(s), the age and psychological status of the patient, and the predicted duration of the operation. Our study demonstrates the great importance of local and regional anesthesia in cases of FB penetrations of the hand and wrist, as 94.2% of our cases were operated under local infiltrations, digital blocks, and blocks at the wrist, elbow and axilla.

62

Table 2. Characteristics of the injuries, events and details about the management Variables

n

Status Emergency 63 Elective 23 Etiology Daily chores accident 44 Occupational accident 30 Psychiatric disorder 4 Traffic accident 4 Criminal 3 Secondary gains 1 Substance Glass 20 Sewing needle 13 Wooden splinter 12 Metal splinter 10 Crochet hook 5 Dyestuff 3 Nail 3 Pencil 3 Bullet 2 Fishhook 2 Other metal objects 13 Radiology Two-view radiograph 64 None 22 Anesthesia Local infiltration and/or digital block 75 Regional block 6 General anesthesia 5 Postoperative follow-up By us 40 By family physician 30 None 16 Rehabilitation None 62 Hand physiotherapy 24

% 73.3 26.7 51.2 34.9 4.7 4.7 3.5 1 23.3 15.1 14.0 11.6 5.8 3.5 3.5 3.5 2.3 2.3 15.1 74.4 25.6 87.2 7.0 5.8 46.5 34.9 18.6 72.1 27.9

The best means of preventing infection is debridement and massive irrigation of the site just after removal of the object. In general, decontamination is far more important than antibiotics.[14] We carry out the massive irrigation process -to which we add scrubbing for some wounds- first by diluted povidone-iodine (PVP-I) solution (1% PVP-I), followed by sterile normal saline solution. Some authors suggest avoiding usage of anti-septic solutions such as PVP-I, chlorhexidine, and hydrogen peroxide for irrigation due to the fact that they have toxic effects on the tissues and slow down the healing process.[13] On the contrary, in a review study, articles with superior level of evidence were analyzed, and it was seen that 71% of the literaOcak - January 2013

Foreign body penetrations of hand and wrist

ture supports the use of PVP-I, and refutes the hypothesis that there is a negative impact on tissue regeneration.[3] Another effective and more practical alternative for wound irrigation might be tap water, especially in pediatric cases.[15] The damaged tissues can be repaired and/or primary closure can be carried out provided the irrigation procedure is adequately accomplished. Our decision to use antimicrobials and to continue antibiotic prophylaxis in the postoperative period is individualized for each patient, and this modality parallels the recommendations in the literature.[16] When any of the structures are repaired, a splint should be applied that provides stabilization in the appropriate position. We recommend hospitalization when there is a need for close follow-up in terms of hematoma and infection and occasionally when there is reason to suspect possible discontinuation of antibiotic therapy at home. Another important issue to be considered is the tetanus prophylaxis, which has been shown to be overlooked in a significant number of cases. In one study, of the 377 patients who initially asserted having had a tetanus vaccine in the last five years, 98 (26.0%) were confirmed to not have received a tetanus vaccine.[17] Similar to a group of cases demonstrated in the study of Tuncer et al.,[9] seven of our 23 elective patients had ignored being examined for their wounds at the time of injury, and thus had not received the appropriate prophylaxis although it was needed. This analysis set forth the importance of the booster dose of tetanus toxoid-containing vaccine every 10 years.

Some comorbidities may have an impact on accident development or sometimes constitute the main etiologic basis for the event causing the injury. Thus, investigating additional medical problems should not be overlooked, as 18.6% of our patients had comorbidities including psychiatric disorders at the time of the injury.

In conclusion, despite the commonness of the subject, some aspects may remain overlooked. Compared to the FB penetrations of the skin or soft tissues of the other body sites, modalities slightly differ when the injured site is the hand or wrist, where there is a higher probability of neurovascular, tendinous, capsular, ligamentous, and bony injury. Overlooked partial injuries of these structures may result in sequelae. All penetrant FBs do not require removal; however, exploration of the wound and removal of FBs in the hand and wrist can be regarded as more important because the detection and repair of underlying structural damage is necessary. Emergency physicians, trauma surgeons and hand surgeons should be watchful about the limitations of direct films for imaging wooden FBs, additional health problems of the injured patients, and probable forensic aspects of the events causing this Cilt - Vol. 19 Say覺 - No. 1

type of injury. Malpractice lawsuits against physicians, concerning retained FBs, represent another considerable issue. A significant number of people fail to present to a healthcare unit after this kind of injury.

It is thus important to check the continuity of routine tetanus boosters for people less than 44 years of age, especially industrial workers and those with hobbies that predispose to this kind of injury. Irrigation of the penetrated tissues with diluted povidone iodine solutions is still a preferred procedure. The retrospective nature of this study limits the power of these conclusions. Prospective, controlled, blinded studies will certainly improve our opinions.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Han KJ, Lee YS, Kim JH. Progressive median neuropathy caused by the proximal migration of a retained foreign body (a glass splinter). J Hand Surg Eur Vol 2011;36:608-9.

2. Talan DA, Abrahamian FM, Moran GJ, Mower WR, Alagappan K, Tiffany BR, et al. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med 2004;43:305-14.

3. Banwell H. What is the evidence for tissue regeneration impairment when using a formulation of PVP-I antiseptic on open wounds? Dermatology 2006;212:66-76.

4. Vukmir RB. Medical malpractice: managing the risk. Med Law 2004;23:495-513.

5. Kaiser CW, Slowick T, Spurling KP, Friedman S. Retained foreign bodies. J Trauma 1997;43:107-11.

6. Centers for Disease Control. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures. Recommendations of the Immunization Practices Advisory committee (ACIP). MMWR Recomm Rep 1991;40;1-28.

7. Kretsinger K, Broder KR, Cortese MM, Joyce MP, OrtegaSanchez I, Lee GM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel.

MMWR Recomm Rep 2006;55:1-37.

8. Ozsarac M, Demircan A, Sener S. Glass foreign body in soft tissue: possibility of high morbidity due to delayed migration. J Emerg Med 2011;41:e125-8.

9. Tuncer S, Ozcelik IB, Mersa B, Kabakas F, Ozkan T. Evaluation of patients undergoing removal of glass fragments from injured hands: a retrospective study. Ann Plast Surg 2011;67:114-8.

10. Steele MT, Tran LV, Watson WA, Muelleman RL. Retained glass foreign bodies in wounds: predictive value of wound characteristics, patient perception, and wound exploration.

Am J Emerg Med 1998;16:627-30.

11. Levine MR, Gorman SM, Young CF, Courtney DM. Clinical characteristics and management of wound foreign bodies in the ED. Am J Emerg Med 2008;26:918-22.

12. Hamnett NT, Tehrani H, McArthur P. Perch fin foreign body in a paediatric hand. J Plast Reconstr Aesthet Surg 63

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2010;63:2198-9.

13. Halaas GW. Management of foreign bodies in the skin. Am Fam Physician 2007;76:683-8.

14. Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999;34:356-67.

15. Valente JH, Forti RJ, Freundlich LF, Zandieh SO, Crain EF. Wound irrigation in children: saline solution or tap water?

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Ann Emerg Med 2003;41:609-16.

16. American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with penetrating extremity trauma. Ann Emerg Med 1999;33:612-36.

17. Gindi M, Oravitz P, Sexton R, Shpak M, Eisenhart A. Unreliability of reported tetanus vaccination histories. Am J Emerg Med 2005;23:120-2.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery Case Report

Ulus Travma Acil Cerrahi Derg 2013;19 (1):65-68 Olgu Sunumu doi: 10.5505/tjtes.2013.53496

Unexpected colonic perforation in a renal recipient: a case report Böbrek nakli sonrası gelişen beklenmedik kolon perforasyonu: Olgu sunumu Kürşat Rahmi SERİN, Metin KESKİN, Hüseyin BAKKALOĞLU, Fatih TUNCA, Ali Emin AYDIN, Cumhur Uluğ ELDEGEZ

Gastrointestinal complications such as gastrointestinal bleeding and perforation due to immunosuppressant use are seen more frequently after solid organ transplantation.

A 52-year-old male was admitted on the 7th day of a living donor renal transplantation with serous drainage at the incision site. He had no abdominal complaints. He was on triple immunosuppressant therapy. Abdominal plain X-ray and ultrasonography were normal, but diffuse extraluminal air was detected on the computed tomography scan. There were no pathological laboratory findings regarding the function of the renal allograft. We began the operation laparoscopically and then converted to laparotomy. Sigmoid colonic perforation was detected on the antimesenteric side. Neither diverticulitis nor ischemia was observed, and no evidence of iatrogenic injury was seen. There was no transrectal instrumentation history. Omentoplasty and sigmoid loop colostomy were performed. He was discharged on the 9th day following the operation. His colostomy was closed one year after the operation. Gastrointestinal complications can be fatal, but do not seem to influence the long-term survival or renal allograft function. Most of them are seen after using high doses of immunosuppressants to manage the early postoperative period or episodes of acute rejection. Early diagnosis and aggressive treatment play an important role in survival.

İmmünite baskılayıcı ilaçlara bağlı olarak gelişen gastrointestinal kanama ve perforasyon gibi komplikasyonlar sıklıkla solid organ nakli sonrası görülmektedir. Elli iki yaşında erkek hasta canlı vericiden böbrek naklinin 7. gününde yara yerinden akıntı şikayeti ile başvurdu. Herhangi bir karın ağrısı yoktu. Üçlü immünsupresan kullanmakta idi.

Karın grafisi ve ultrasonografisi normal saptandı ancak bilgisayarlı tomografide karın içerisinde yaygın serbest hava görüldü. Transplante böbrek fonksiyonları da dahil olmak üzere laboratuvar incelemesinde herhangi bir patolojik bulgu saptanmadı. Tanısal laparoskopi sonrası açığa dönüldü.

Antimezenterik yüzde sigmoid kolon perforasyonu vardı.

Divertikülit ve iskemi bulgusu yoktu, travmaya ait bulgu da görülmedi. Transrektal enstrümentasyon anamnezi de yoktu. Omentoplasti ve sigmoid loop kolostomi yapıldı. Ameliyatının dokuzuncu günüde hasta taburcu edildi.

Ameliyatının birinci yılında da kolostomisi kapatıldı. Gastrointestinal komplikasyonlar ölümcül olabilir ancak uzun dönem sağkalımı ve gref fonksiyonunu etkilemedikleri bilinmektedir. Pekçoğu ameliyat sonrası erken dönem veya rejeksiyon atakları gibi yüksek doz immünite baskılayıcı ilaç kullanılan dönemde görülmektedir. Sağkalımda erken tanı ve tedavide agresif davranmak önemli rol oynar.

Key Words: Colonic perforation; colostomy; immunosuppression.

Anahtar Sözcükler: Kolon perforasyonu; kolostomi; immünsupresyon.

Following the development of solid organ transplantation, complications of transplantation surgery and postoperative medications have appeared. The most common early surgical complications of kidney transplantation are wound complications, bleeding and hematoma, acute vascular thrombosis, urine leak,

ureteral stenosis, and lymphocele. Late-onset lymphocele, renal arterial stenosis and ureteral stenosis are common.[1] Gastrointestinal (GI) complications such as bleeding or perforations are the most common lifethreatening surgical complications, ranging from 1020%.[2-5]

Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey.

İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul.

Correspondence (İletişim): Kürşat Rahmi Serin, M.D. Neslişah Mah., Sofalı Çeşme Sok. Körfez Apt. No: 100/18, 34091 Fatih, İstanbul, Turkey.

Tel: +090 - 212 - 621 12 00 e-mail (e-posta): dr_krserin@yahoo.com

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Ulus Travma Acil Cerrahi Derg

CASE REPORT A 52-year-old male was admitted to our transplantation clinic on the 7th day of living donor-related renal allograft transplantation (right-sided, retroperitoneal approach surgery), after being discharged from a hospital in Egypt. He had end-stage renal failure because of diabetes and was on maintenance therapy by hemodialysis. On his physical examination, there was no finding implicating acute abdomen syndrome or infection. Only serous drainage at the incision was present, but there was no suspicion of intraabdominal infection or peritoneal dehiscence. Laboratory tests and radiological examination were planned for the next day and the patient went home. The same night, he was admitted to the emergency department because of mild abdominal pain. He had pain throughout the abdomen and nausea, and tenderness and rebound were detected. He had dyspnea due to pulmonary edema, but no fever was detected. He was taking methylprednisolone (60 mg/day), mycophenolate mofetil (1 g/day) and tacrolimus (8 mg/day). White blood cell count, abdominal X-ray, abdominal ultrasonography (US), and abdominal computed tomography (CT) were obtained. Leukocyte count was 20000/mm3 (normal range: 4000-10000), abdominal plain X-ray was normal, and there were no pathological findings on abdominal US. Diffuse extraluminal air in the abdomen was detected on CT (Fig. 1), but there was no fluid or collection. No abnormalities were found in his laboratory results to influence the function of the renal allograft. Under these findings (leukocytosis, rebound and CT findings), he was diagnosed with acute abdominal syndrome, and the reason was luminal organ perforation. We began the surgery laparoscopically, at the 24th hour of the onset of symptoms. There was purulent inflammatory fluid of about 20 cc near the cecum and appendix. The rest of the abdominal cavity was clear, and no signs of inflammation were detected. Laparotomy was performed, and a sigmoid colon perforation, 3 mm in diameter, was seen on the an-

timesenteric side, near the cecum and appendix (Fig. 2). Neither diverticulitis nor ischemia was observed.

There was no evidence of iatrogenic-traumatic injury, the whole peritoneum layer was intact, and there was no transrectal instrumentation history. The first surgery was performed with retroperitoneal approach from the right side. The perforated area was explored, and fluid was sampled for culture. The abdominal cavity was irrigated and drained. Exteriorization of the perforated site was not possible because of the edema.

Omentoplasty was done, and sigmoid loop colostomy was performed proximal to the perforation area to decrease fecal contamination and divert the fecal passage. On the first day of the operation, leukocyte count was decreased to 13000/mm3, he had gas passage, and no complication was revealed concerning the renal allograft. Diuresis was forced because of the pulmonary edema. On the 2nd day of the operation, he had defecation and began to take oral nutrition, and parenteral nutrition was stopped. Pseudomonas aeruginosa was identified on his intraabdominal fluid culture, and treated well with antibiotics. On the 8th day of the operation, the drains were removed, no surgical complication or renal allograft dysfunction was detected, the leukocyte count had regressed to 7800/ mm3, the C-reactive protein level was 4.2 mg/L, and cytomegalovirus (CMV) antigens were negative. He was discharged from the hospital on the 9th day of the operation. His colostomy was closed one year after the operation (due to the patientâ&#x20AC;&#x2122;s own hesitation). On his 40th-month follow-up, there was no problem related to the emergency GI surgery or renal allograft.

Fig. 1. Extraluminal air in the abdomen on CT.

Fig. 2. Sigmoid colon perforation on the antimesenteric side.

66

DISCUSSION Colon perforation, especially iatrogenic, is a serious complication in the postoperative course of kidney transplantation. In the past three decades, the incidence has decreased from 1.4% to 0.67%, and the mortality rate has improved from 70% to 32%.[3] Approximately 300 renal transplantations were performed in

Ocak - January 2013

Unexpected colonic perforation in a renal recipient

our clinic, and this patient was the first spontaneous colon perforation case due to high-dose immunosuppression. The most common cause of colon perforation is diverticulitis, and the most common site is the sigmoid colon.[3] We did not find any causes such as diverticulitis or ischemic colitis. He had no transrectal instrumentation history, and there was no evidence of iatrogenic injury. We thus decided that our patient had spontaneous colonic perforation because of immunosuppressant use.

Spontaneous perforation of the GI tract after transplantation surgery is seen especially in the 3rd to 6th months of the transplantation because of the highdose immunosuppressant use, uremia and fecal impaction. In immunosuppressed patients, diagnosis of colonic perforation is a challenge. Abdominal pain, fever, tenderness, and leukocytosis are frequent in colonic perforation, but the clinical presentation in immunosuppressed patients may be atypical with vague abdominal symptoms. The symptoms are sparse and can be masked by the immunosuppressant, and the diagnosis is usually delayed.[6] Nghiem et al.[1] reported the average time of symptoms to surgery as 5.8 days.

ReMine et al.[7] reported the delay as less than 8.3 days in patients receiving greater than 20 mg of prednisone daily. Successful management of the problem often depends upon early diagnosis and prompt therapy. Our patient was in the early period of transplantation. We have no information about the dosage of the induction therapy, although he had been taking high-dose triple therapy, as methylprednisolone (60 mg/day), mycophenolate mofetil (1 g/day) and tacrolimus (8 mg/day). He had typical symptoms such as abdominal pain, tenderness, and rebound, as well as leukocytosis.

The radiologic evaluation usually starts with plain X-rays. Because of the challenge of the diagnosis in immunosuppressed patients based on physical examination and plain X-ray findings, this can be followed by contrast administration orally and rectally under fluoroscopy or CT.[8] The CT diagnosis of perforation was based on direct and indirect findings.[8] Extraluminal air under the diaphragm on plain X-ray can be identified in only 50-70% of these patients. CT is more sensitive in detecting extraluminal air and contrast. CT can also evaluate the bowel wall and extraintestinal structures. The most specific finding for GI perforation is the presence of extraluminal air, barium or radiocontrast fluid.[8] In our patient, there were no pathological findings on plain X-ray or abdominal US. We performed abdominal CT, and found extraluminal air in the entire abdomen. No fluid or abscess was detected. All findings directed us to GI tract perforation, but there was no sign regarding the perforation site.

Cilt - Vol. 19 SayÄą - No. 1

Diverticulitis, colorectal cancer, and idiopathic are the most common causes of colon perforation (>60% of cases).[4,9] Colonic ischemia, iatrogenic (especially during colonoscopy), infections (especially CMV), foreign body, trauma, and gynecological pathologies are other reasons.[10] Spontaneous perforation of the colon, especially of the sigmoid colon, which was revealed as being related to immunosuppression, has been reported previously.[1,4,5,9] Spontaneous perforation of the GI tract usually occurs in the early period after transplantation. The mean duration time is 3 to 6 months after transplantation.[5] The differences in patient characteristics, such as medical problems, general condition, peritonitis grade, or cause of perforation, influence both the surgical decision and outcome.

A cumulative effect of sepsis and medical conditions may be responsible for the high postoperative mortality, which ranges between 30-55%.[2,11] Early diagnosis and surgical repair of perforations are the mainstays of treatment. To evaluate the current diagnosis and the level of the perforation, laparoscopy is a safe and minimally invasive diagnostic tool. Laparoscopy can also be therapeutic.[12] In our patient, we used laparoscopy as a diagnostic tool to explore the abdominal cavity and to confirm and define the level of the perforation.

The optimal surgical approach to complicated colonic disease remains controversial. Without bowel preparation, intraluminal and intraperitoneal fecal contamination at the anastomotic site is the major problem when deciding the surgical technique. Hartmannâ&#x20AC;&#x2122;s procedure has gained in popularity as an alternative to others, and currently, is the most commonly used technique for emergency colon surgery, especially in severely infected peritonitis.[13] However, Hartmannâ&#x20AC;&#x2122;s procedure has frequent complications, and the morbidity rate after restoration is high.

[14] A randomized prospective study by Ravo et al.[15,16] concluded that if feces could be excluded from intraluminal contact with the anastomotic site, an anastomosis can be performed safely even in the presence of peritonitis. Richter et al.[17] reported a perforated sigmoid diverticulosis series with treatment by onestage sigmoid colon resection after peritoneal irrigation with saline in non-immunosuppressed patients.

Nevertheless, many others have concluded that immunosuppression, septic shock, fecal peritonitis, or high cardiac risk patients at admission were correlated with higher morbidity and mortality rates, and that usage of a two-stage procedure with or without primary anastomosis would be safer than one-stage surgery.[1,5,16,18] There is no comment about the timing of the second stage of the operation, but most of the authors favor delaying the second stage, usually preferring to perform it 6 months after the first stage.[14,18] In conclusion, colon perforation due to immuno67

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suppressant use in renal allograft recipients is a rare but serious complication, with high mortality and morbidity rates. It must be diagnosed early and treated aggressively. With the improvements of antibiotics and immunosuppressants, the mortality and morbidity rates have been decreased in recent decades, but it can still be fatal.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Nghiem DD, Corry RJ. Colorectal perforation in renal transplant recipients. Am Surg 1983;49:554-7.

2. Ponticelli C, Passerini P. Gastrointestinal complications in renal transplant recipients. Transpl Int 2005;18:643-50.

3. Konishi T, Watanabe T, Kitayama J, Shibahara J, Hiramatsu T, Hara K, et al. Successfully treated idiopathic rectosigmoid perforation 7 years after renal transplantation. J Gastroenterol 2004;39:484-9.

4. Biondo S, Parés D, Martí Ragué J, De Oca J, Toral D, Borobia FG, et al. Emergency operations for nondiverticular perforation of the left colon. Am J Surg 2002;183:256-60.

5. Meyers WC, Harris N, Stein S, Brooks M, Jones RS, Thompson WM, et al. Alimentary tract complications after renal transplantation. Ann Surg 1979;190:535-42.

6. Lederman ED, Conti DJ, Lempert N, Singh TP, Lee EC. Complicated diverticulitis following renal transplantation.

Dis Colon Rectum 1998;41:613-8.

7. ReMine SG, McIlrath DC. Bowel perforation in steroidtreated patients. Ann Surg 1980;192:581-6.

8. Maniatis V, Chryssikopoulos H, Roussakis A, Kalamara C,

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Kavadias S, Papadopoulos A, et al. Perforation of the alimentary tract: evaluation with computed tomography. Abdom Imaging 2000;25:373-9.

9. Carson SD, Krom RA, Uchida K, Yokota K, West JC, Weil R 3rd. Colon perforation after kidney transplantation. Ann Surg 1978;188:109-13.

10. Iqbal CW, Chun YS, Farley DR. Colonoscopic perforations: a retrospective review. J Gastrointest Surg 2005;9:1229-36.

11. Kriwanek S, Armbruster C, Dittrich K, Beckerhinn P. Perforated colorectal cancer. Dis Colon Rectum 1996;39:1409-14.

12. Geis WP, Kim HC. Use of laparoscopy in the diagnosis and treatment of patients with surgical abdominal sepsis. Surg Endosc 1995;9:178-82.

13. Finlay IG, Carter DC. A comparison of emergency resection and staged management in perforated diverticular disease.

Dis Colon Rectum 1987;30:929-33.

14. Dalla Valle R, Capocasale E, Mazzoni MP, Busi N, Benozzi L, Sivelli R, et al. Acute diverticulitis with colon perforation in renal transplantation. Transplant Proc 2005;37:2507-10.

15. Ravo B, Metwally N, Castera P, Polansky PJ, Ger R. The importance of intraluminal anastomotic fecal contact and peritonitis in colonic anastomotic leakages. An experimental study. Dis Colon Rectum 1988;31:868-71.

16. Biondo S, Jaurrieta E, Martí Ragué J, Ramos E, Deiros M, Moreno P, et al. Role of resection and primary anastomosis of the left colon in the presence of peritonitis. Br J Surg 2000;87:1580-4.

17. Richter S, Lindemann W, Kollmar O, Pistorius GA, Maurer CA, Schilling MK. One-stage sigmoid colon resection for perforated sigmoid diverticulitis (Hinchey stages III and IV).

World J Surg 2006;30:1027-32.

18. Seah DW, Ibrahim S, Tay KH. Hartmann procedure: is it still relevant today? ANZ J Surg 2005;75:436-40.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):69-72

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.79745

Post-traumatic sagittal sinus thrombosis: case report Posttravmatik sagittal sinüs trombozu: Olgu sunumu Nayil KHURSHEED, Ramzan ALTAF, Nizami FURQAN, Abrar WANI, Ashish JAIN, Yawar ALI

Post-traumatic superior sagittal sinus thrombosis is rare.

The usual presentation is raised intracranial pressure symptoms. We report a case of post-traumatic superior sagittal sinus thrombosis in which the computed tomography (CT) scan revealed depressed fracture of the vertex with parasagittal contusions. Despite surgical elevation of the fracture and repair of the superior sagittal sinus, the patient developed thrombosis of the anterior half of the superior sagittal sinus with bilateral hemorrhagic infarcts in the motor strip. This case is reported for its rarity and to highlight the importance of careful postoperative observation of such patients. In such settings, timely diagnosis and anticoagulant therapy are rewarding.

Posttravmatik süperior sagittal sinüs trombozu nadiren görülmektedir. Olağan belirtileri kafa içi basınç semptomlarının ortaya çıkmasıdır. Bu yazıda, bilgisayarlı tomografi taramasının parasagittal kontüzyonlarla birlikte vertekste çökme kırığını gösterdiği bir posttravmatik superior sagittal tromboz olgusu sunuldu. Çökme kırığının cerrahi yolla elevasyonu ve superior sagittal sinüsün onarımına rağmen hastada motor segmentte çift taraflı hemorajik infarktlarla birlikte superior sagittal sinüsün ön yarısında tromboz gelişti. Bu olgu seyrek görülmesi ve bu hastalarda dikkatli ameliyat sonrası gözlemin önemini vurgulamak için sunuldu. Bu ortamlarda zamanında tanı ve antikoagülan tedavi yüzgüldürücüdür.

Key Words: Head injury; sagittal sinus thrombosis; magnetic resonance venogram.

Anahtar Sözcükler: Kafa travması; sagittal sinüs trombozu; manyetik rezonans venogram.

Post-traumatic superior sagittal sinus thrombosis is rare. A depressed skull fracture overlying a major venous sinus in the brain may result in sinus injury and consequent venous thrombosis.[1] Various mechanisms have been postulated.[2] The diagnosis can be overlooked, especially in the setting of concomitant parasagittal contusions, which can lead to a delay in the diagnosis.

normal and in the lower limbs was 2/5.

CASE REPORT A 20-year-old male reported to our hospital within 2 hours of head injury with a history of weakness of both lower limbs. On examination, there was a lacerated wound at the vertex with underlying depressed fracture. His Glasgow Coma Scale (GCS) score at admission was 13/15. The power in the upper limbs was

Plain computed tomography (CT) of the head showed a comminuted depressed fracture of the vertex with bilateral mid-parasagittal hyperdensities, which were thought to be hemorrhagic contusions (Fig. 1a, b). Intraoperatively, a 7 cm x 5 cm comminuted depressed fragment of bone at the vertex and a partial tear in the sagittal sinus were seen. The depressed fragments were elevated and the tear was sealed with gelatin foam. The patient was maintained on decongestants, anticonvulsants and antibiotics. The GCS was 13/15, and he continued to have paraparesis, but on the 5th postoperative day, his GCS score dropped to 10/15. Plain CT scan of the head showed an increase in the size of the mid-parasagittal hemorrhagic lesions with perilesional edema (Fig. 2a). We reviewed our diagnosis, and the possibility of superior sagittal sinus thrombosis was considered. Brain magnetic resonance imaging (MRI) revealed non-visualization of the an-

Department of Neurology, Skims, Kashmir, India.

Skims, Nöroloji Bölümü, Keşmir, Hindistan.

We report a case of vertex fracture with parasagittal contusions superimposed by superior sagittal sinus thrombosis.

Correspondence (İletişim): Nayil Khursheed, M.D. Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Neurology Department, Kashmir, India.

Tel: +09419999465 e-mail (e-posta): nkhursh@rediffmail.com

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(a)

ray lateral view of the skull may reveal a double density of the fractured region.[6] Non-contrast CT scan may reveal hyperdensity of the sinus.[7] This was not seen in our patient as the CT scan was done within 2 hours of injury, which is too early, and the sagittal sinus thrombosis might have supervened later. MR venogram is the gold standard for diagnosis. It shows non-visualization of the sinus.[8] Multi-detector CT venography is another useful modality in the detection of sinus thrombus.[9] Sinus thrombosis may cause increased levels of fibrinogen degradation products in the serum.[10]

(b)

Fig. 1. (a) Plain CT scan showing bilateral parasagittal posterior frontal hemorrhagic contusions and (b) comminuted depressed fracture of the vertex.

terior half of the superior sagittal sinus with features of hemorrhagic infarcts in bilateral medial motor areas (Fig. 2b, c). Systemic anticoagulation was started with heparin on the 5th postoperative day. Complete blood counts revealed mild leukocytosis. The erythrocyte sedimentation rate (ESR) was raised (15 mm 1st hour). Blood cultures were negative. The patient was monitored with serial coagulograms. By the 3rd postoperative week, the GCS of the patient had improved to 15/15, with no improvement in power. He was discharged on anticoagulants and anti-epileptics. At the 8th-month follow-up, power in the lower limbs had improved to 3-4/5. The brain MRI showed recanalization of the superior sagittal sinus (Fig. 3).

DISCUSSION The first case of traumatic sagittal sinus thrombosis was reported by Ecker.[3] The incidence of posttraumatic sinus thrombosis is 4% in penetrating head injury.[4] The pathogenesis is: (a) abnormal clotting mechanism, (b) disturbance of blood flow, and (c) endothelial injury.[2] The most common symptoms are altered sensorium, headache and seizures.[5] Plain X-

(a)

(b)

Untreated depressed fractures of the vertex have been mentioned for their delayed presentation of severe raised intracranial pressure features.[11] Interestingly, even a delayed effort of surgical debridement and subsequent release of the compression on the sagittal sinus has been rewarding. However, this entire scenario has been reported thus far in fractures of the vertex causing direct mechanical obstruction of the sinus without inducing sagittal sinus thrombosis.[1,12-14]

Fig. 3. MRV on follow-up showing restoration of the patency of the sinus.

(c)

Fig. 2. (a) Repeat CT scan and (b) MRI show increase in the size of the hemorrhagic contusions, with (c) MR venogram showing obliteration of the anterior half of the sagittal sinus.

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Post-traumatic sagittal sinus thrombosis

Once thrombosis has occurred, the recovery may not be dramatically fast.[15,16] Our case deviated slightly from the historical examples. Our patient was hit on the vertex by a stone, and the CT scan done within 2 hours of injury revealed bilateral mid-parasagittal contusions in addition to vertex fracture. Most such fractures, which have been managed conservatively in the past for fear of exsanguination during surgery, ultimately had to be treated surgically to alleviate the symptoms of raised intracranial pressure;[12,13,17] thus, we decided to surgically address the fracture without resorting to the conservative management. Surgery was done within 4 hours of injury. The wound was relatively clean and all the bone fragments were removed. However, even then, the patient developed sinus thrombosis possibly because of the endothelial injury to the sinus walls. Various methods to deal with the tear in the sagittal sinus have been mentioned, namely: temporalis muscle and fascia graft, direct repair, saphenous vein graft, and silicone tube interposition.[18-20] In view of the small tear in the sinus of our patient, we could manage it successfully using a gelatin sponge as a sealant. Post-infectious superior sagittal sinus thrombosis can also occur; however, in our case, the wound was relatively clean. Different modalities of treatment have been outlined for the treatment of sinus thrombosis, namely: stents, catheter delivery of thrombolytic agents, and systemic heparin.

Urokinase has been infused into the sinus via a jugular catheter combined with mechanical thrombus disruption or removal with a balloon catheter in patients with superior sagittal sinus thrombosis.[21,22] Stent angioplasty for the thrombotic stenosed sagittal sinus has also been tried.[23] In our case, we started heparin on the 5th postoperative day when the patient deteriorated, and the imaging performed revealed sagittal sinus thrombosis. In the past, the role of heparin in post-traumatic sagittal sinus thrombosis was thought to be hazardous, in view of concomitant hemorrhagic lesions, which may worsen after heparin therapy; however, recent literature supports its use as it inhibits the extension of the thrombosis into adjoining sinuses and cortical veins,[8,24] and a MR venogram, especially in the late phase, usually shows restoration of the patency of the sinus in the follow-up.

In conclusion, even after prompt surgical elevation of depressed fractures of the vertex, possibility of a delayed superior sagittal sinus thrombosis should always be considered.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. du Plessis JJ. Depressed skull fracture involving the superior sagittal sinus as a cause of persistent raised intracranial pressure: a case report. J Trauma 1993;34:290-2.

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2. Carrie AW, Jaffe FA. Thrombosis of superior sagittal sinus caused by trauma without penetrating injury. J Neurosurg 1954;11:173-82.

3. Becker G, Bogdahn U, Gehlberg C, Fröhlich T, Hofmann E, Schlief MD. Transcranial color-coded real-time sonography of intracranial veins. Normal values of blood flow velocities and findings in superior sagittal sinus thrombosis. J Neuroimaging 1995;5:87-94.

4. Ochagavia AR, Boque MC, Torre C, Alonso S, Sirvent JJ. Dural venous sinus thrombosis due to cranial trauma. Lancet 1996;347:1564.

5. Hesselbrock R, Sawaya R, Tomsick T, Wadhwa S. Superior sagittal sinus thrombosis after closed head injury. Neurosurgery 1985;16:825-8.

6. Reilly HP Jr, Erbengi A, Sachs E Jr, Dyke JR. Penetration of the sagittal sinus by a depressed skull fracture. Roentgenographic diagnosis in an asymptomatic boy. JAMA 1967;202:841-2.

7. Rao KC, Knipp HC, Wagner EJ. Computed tomographic findings in cerebral sinus and venous thrombosis. Radiology 1981;140:391-8.

8. Bousser MG, Chiras J, Bories J, Castaigne P. Cerebral venous thrombosis-a review of 38 cases. Stroke 1985;16:199213.

9. Delgado Almandoz JE, Kelly HR, Schaefer PW, Lev MH, Gonzalez RG, Romero JM. Prevalence of traumatic dural venous sinus thrombosis in high-risk acute blunt head trauma patients evaluated with multidetector CT venography. Radiology 2010;255:570-7.

10. Misra UK, Kalita J, Bansal V. D-dimer is useful in the diagnosis of cortical venous sinus thrombosis. Neurol India 2009;57:50-4.

11. Yokata H, Kurowa A , Otsuka T. Significance of MRI in acute head injury. J Trauma 1991;1:351-7.

12. Meltzer H, LoSasso B, Sobo EJ. Depressed occipital skull fracture with associated sagittal sinus occlusion. J Trauma 2000;49:981.

13. Uzan M, Ciplak N, Dashti SG, Bozkus H, Erdinçler P, Akman C. Depressed skull fracture overlying the superior sagittal sinus as a cause of benign intracranial hypertension. Case report. J Neurosurg 1998;88:598-600.

14. van den Brink WA, Pieterman H, Avezaat CJ. Sagittal sinus occlusion, caused by an overlying depressed cranial fracture, presenting with late signs and symptoms of intracranial hypertension: case report. Neurosurgery 1996;38:1044-6.

15. de Bruijn SF, de Haan RJ, Stam J. Clinical features and prognostic factors of cerebral venous sinus thrombosis in a prospective series of 59 patients. For The Cerebral Venous Sinus Thrombosis Study Group. J Neurol Neurosurg Psychiatry 2001;70:105-8.

16. Stiefel D, Eich G, Sacher P. Posttraumatic dural sinus thrombosis in children. Eur J Pediatr Surg 2000;10:41-4.

17. Satoh H, Uozumi T, Kiya K, Arita K, Kurisu K, Sumida M, Ikawa F. Venous thrombosis after closed head injury: a report of two cases presenting as intracranial hypertension. [Article in Japanese] No Shinkei Geka 1993;21:953-7. [Abstract] 18. Ma J, Song T, Hu W, Muhumuza ME, Zhao W, Yang S, et al. Reconstruction of the superior sagittal sinus with silicone tubing. Neurosurg Focus 2002;12:15.

19. Sani S, Jobe KW, Byrne RW. Successful repair of an intracranial nail-gun injury involving the parietal region and the superior sagittal sinus. Case report. J Neurosurg 2005;103:56771

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9.

20. Sindou M, Auque J, Jouanneau E. Neurosurgery and the intracranial venous system. Acta Neurochir Suppl 2005;94:16775.

21. Stam J, Majoie CB, van Delden OM, van Lienden KP, Reekers JA. Endovascular thrombectomy and thrombolysis for severe cerebral sinus thrombosis: a prospective study. Stroke 2008;39:1487-90.

22. Yamashita S, Matsumoto Y, Tamiya T, Kawanishi M, Shindo

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A, Nakamura T, et al. Mechanical thrombolysis for treatment of acute sinus thrombosis-case report. Neurol Med Chir (Tokyo) 2005;45:635-9.

23. Li B, Guo M, Li S, Wang M. Endovascular thrombolysis and stent angioplasty for obliteration in cerebral venous sinuses.

[Article in Chinese] Zhonghua Wai Ke Za Zhi 2002;40:8902. [Abstract] 24. Ferrera PC, Pauze DR, Chan L. Sagittal sinus thrombosis after closed head injury. Am J Emerg Med 1998;16:382-5.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery Case Report

Ulus Travma Acil Cerrahi Derg 2013;19 (1):73-76 Olgu Sunumu doi: 10.5505/tjtes.2013.81593

Diffuse idiopathic skeletal hyperostosis and central cord syndrome after minor trauma: a case report Diffüz idiyopatik iskeletsel hiperosteozis ve minör travma sonrası santral kord sendromu: Olgu sunumu Olcay ESER,1 * Ergün KARAVELİOĞLU,2 † Mehmet Gazi BOYACI,1 # Abdullah AYÇİÇEK3 ¶ Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by anterior and lateral ossification of the vertebral body. We present a case report of central cord syndrome in a patient with DISH after minor trauma. The patient was treated surgically. We also discuss symptomatology and the common mechanism of cord injury in DISH.

Diffüz idiyopatik iskeletsel hiperosteozis (DİİH) vertebra korpusunun ön ve lateralinin kemikleşmesiyle kendini gösteren bir durumdur. Bu yazıda, DİİH’li bir olguda minör travma sonrası santral kord sendromunu sunduk. Hasta cerrahi olarak tedavi edildi. Ayrıca DİİH’nin semptomlarını ve kord yaralanmasının ortak mekanizmalarını tartıştık.

Key Words: Central cord syndrome; diffuse idiopathic skeletal hyperostosis; dysphagia; Forestier’s disease; trauma.

Anahtar Sözcükler: Santral kord sendromu; diffüz idiopatik skeletal hiperosteozis; disfaji; Forestier hastalığı; travma.

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by anterior and lateral ossification of the vertebral body.[1,2] This rare entity is also known as Forestier’s disease, occurs mostly in males and in the fifth decade of life, and is rarely associated with systemic diseases such as diabetes mellitus and obesity.[3] The osteophytes are generally located in the thoracic, lumbar and cervical vertebrae (97%, 90%, 78%, respectively). The entire vertebral column is affected in 70% of all cases.[4]

CASE REPORT A 67-year-old male applied to our emergency department with dysphagia, numbness and tetraparesis.

His complaints started after a minor trauma one month before and worsened progressively. On his neurological examination, he had tetraparesis (+2/5 motor strength), hypoesthesia on his four extremities and upper neuron findings such as hyperreflexia and Babinski sign. There was no sensation or sphincter reflex but he had normal anal reflex.

Although most of cases are asymptomatic, dysphagia is the most common symptom due to esophageal compression by anterior osteophytes at the C4-5 level.

Other symptoms and signs are cervical subaxial pain, stiffness and decreasing range of motion of the cervical spine.

X-rays and cervical computed tomography (CT) revealed bony ankylosis from C2 to C6 without any fractures or dislocation (Fig. 1a, b). Cervical spine magnetic resonance imaging (MRI) demonstrated spinal stenosis at the C3-4 level with both anterior and posterior compression, myelomalacia and slight cord

Departments of 1Neurosurgery, 3ENT, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar; 2 Bolvadin Dr. HI Ozsoy State Hospital, Afyonkarahisar, Turkey.

Afyon Kocatepe Üniversitesi Tıp Fakültesi, 1Nöroşirürji Anabilim Dalı, 3 KBB Anabilim Dalı, Afyonkarahisar; 2 Bolvadin Dr. H.İ. Özsoy Devlet Hastanesi, Afyonkarahisar.

Current affiliation: *Department of Neurosurgery, Balikesir University Faculty of Medicine, Balikesir; †Department of Neurosurgery, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar; #Diyarbakir Silvan State Hospital, Diyarbakir; ¶Department of ENT, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar, Turkey.

Şimdiki kurumu: *Balıkesir Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Balıkesir; †Afyon Kocatepe Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Afyonkarahisar; #Diyarbakır Silvan Devlet Hastanesi, Diyarbakır; ¶Afyon Kocatepe Üniversitesi Tıp Fakültesi, KBB Hastalıkları Anabilim Dalı, Afyonkarahisar.

Correspondence (İletişim): Ergün Karavelioğlu, M.D. Afyon Kocatepe Üniversitesi Tıp Fakültesi Nöroşirurji Anabilim Dalı, Afyonkarahisar, Turkey.

Tel: +090 - 272 - 246 33 01 e-mail (e-posta): ergunkara@hotmail.com

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(a)

(b)

Fig. 1. (a, b) Bony ankylosis from C2 to C6 without any fractures or dislocation.

edema (Fig. 2). At surgery, C3-4 total laminectomy, C2-C5 lateral mass screws and C3-4 anterior microdiscectomy and fusion with cage and plate were performed (Fig. 3). He had minimal dysphagia at the sixmonth follow-up after surgery.

DISCUSSION Diffuse idiopathic skeletal hyperostosis is characterized by calcification and ossification of the ligaments, tendons and fascia. It has an estimated prevalence rate of up to 10%.[5] The spine is mostly involved followed by the pelvis, patella, calcaneus, and olecranon.[4]

range of motion.[4] Dysphagia can be explained by four different hypotheses: 1) anterior bony fragments projecting between the C4-C6 level, causing rigid and fixed pharynx and esophagus, which cannot move easily while swallowing; 2) the presence of large anterior osteophytes and direct compression of the esophagus;

The suggested pathogenesis of DISH indicates that ossification and new bone formation are the result of abnormal osteoblast cell growth/activity in the bony ligamentous region.[6] In the literature, studies have reported that patients with DISH have high insulin and growth hormone levels.[7] As is well known, insulin-like growth factor 1 (IGF-1) stimulates alkaline phosphatase activity and type II collagen production in osteoblasts, and growth hormone can induce the local development of IGF-1 and IGF binding proteins in chondrocytes and osteoblasts, which explains the osteoblast cell growth and proliferation.[8] Diffuse idiopathic skeletal hyperostosis incidence increases with age and is very rare in the first four decades of life. Obesity and type 2 diabetes mellitus are major risk factors. Other risk factors include hypervitaminosis A, high body mass index and hyperuricemia.[4,9,10] This rare disease is usually asymptomatic and diagnosed incidentally. The most common symptoms of DISH are pain and stiffness, dysphagia and decreased 74

Fig. 2. Spinal stenosis at the C3-4 level with both AP compression, myelomalacia and slight cord edema.

Ocak - January 2013

Diffuse idiopathic skeletal hyperostosis and central cord syndrome after minor trauma

Fig. 3. At surgery, C3-4 total laminectomy, C2-C5 lateral mass screws and C3-4 anterior microdiscectomy and fusion with cage and plate were performed.

3) inflammation around the esophagus, causing swelling of surrounding tissues, and 4) reflex spasm in the cricopharyngeal segment provoked by pressure of solid bolus on osteophytes.

Involvement of the cervical spine is the primary cause of the neurological findings. This is due to the reduced flexibility of the spine, spinal canal narrowing secondary to ossification of anterior and posterior longitudinal ligaments and atlantoaxial subluxation of the cervical spine.[4] The diagnosis of DISH is based mainly on data obtained from the radiological evaluation: 1) Presence of flowing new bone formation on at least four contiguous vertebral bodies; 2) Absence of degenerative disc disease and relative preservation of intervertebral disc height; and 3) Absence of inflammatory changes in facet or sacroiliac joints.[4,11,12] The management of patients with DISH is mostly conservative including nonsteroidal antiinflammatory drugs (NSAID) and steroid therapy. Surgery including anterolateral, posterolateral and transoral approaches could be an appropriate choice in patients with severe and progressive symptoms.[13,14] The anterolateral approach in particular provides better exposure of large osteophytes and the large cervical vessels and vagus Cilt - Vol. 19 SayÄą - No. 1

nerve, but more attention should be given regarding recurrent laryngeal nerve palsy.[9] While several articles have reported DISH presenting with compressive symptoms, the authors report herein DISH causing cervical cord compression and central cord syndrome. There are few reported cases of DISH coexisting with ossified posterior longitudinal ligament giving rise to neurological sequelae as a result of minor trauma to the neck.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Carlson MJ, Stauffer RN, Payne WS. Ankylosing vertebral hyperostosis causing dysphagia. Arch Surg 1974;109:56770.

2. Ladenheim SE, Marlowe FI. Dysphagia secondary to cervical osteophytes. Am J Otolaryngol 1999;20:184-9.

3. Resnick D, Shaul SR, Robins JM. Diffuse idiopathic skeletal hyperostosis (DISH): Forestierâ&#x20AC;&#x2122;s disease with extraspinal manifestations. Radiology 1975;115:513-24.

4. Cammisa M, De Serio, Guglielmi G. Diffuse idiopatic skeletal hyperostosis. Eur J Radiol 1997;27:7-11.

5. Bessetle L, Katz JN, Liang MH. Differential diagnosis and conservative treatment of rheumatic disorders. In: Frymoyer JW, Ducker TM, Weinstein JN, editors. The adult spine: Principles and practice. 2nd ed., Philadelphia: Lippincott-Raven

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Publishers; 1997. p. 821.

6. el Miedany YM, Wassif G, el Baddini M. Diffuse idiopathic skeletal hyperostosis (DISH): is it of vascular aetiology? Clin Exp Rheumatol 2000;18:193-200.

7. Atzeni F, Sarzi-Puttini P, Bevilacqua M. Calcium deposition and associated chronic diseases (atherosclerosis, diffuse idiopathic skeletal hyperostosis, and others). Rheum Dis Clin North Am 2006;32:413-26, viii.

8. Vetter U, Zapf J, Heit W, Helbing G, Heinze E, Froesch ER, et al. Human fetal and adult chondrocytes. Effect of insulinlike growth factors I and II, insulin, and growth hormone on clonal growth. J Clin Invest 1986;77:1903-8.

9. Akhtar S, Oâ&#x20AC;&#x2122;Flynn PE, Kelly A, Valentine PM. The management of dysphasia in skeletal hyperostosis. J Laryngol Otol 2000;114:154-7.

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10. Smythe H, Littlejhon G. Diffuse idiopathic skeletal hyperostosis. In: Klippel JH, Dieppe PA, editors. Rheumatology. 2nd ed., London: Mosby; 1997. 8 10.1-10.6.

11. Resnick D, Niwayama G. Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology 1976;119:559-68.

12. Resnick D. Degenerative diseases of the vertebral column.

Radiology 1985;156:3-14.

13. Oga M, Mashima T, Iwakuma T, Sugioka Y. Dysphagia complications in ankylosing spinal hyperostosis and ossification of the posterior longitudinal ligament. Roentgenographic findings of the developmental process of cervical osteophytes causing dysphagia. Spine (Phila Pa 1976) 1993;18:391-4.

14. Meeks LW, Renshaw TS. Vertebral osteophytes and dysphagia. Ann Otol Rhinol Laryngol 1970;79:1091-7.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):77-79

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.40374

Rotational head trauma with callosal contusion and C6 fracture: a high-speed motorcycle accident Kallozal kontüzyonla birlikte rotasyonel kafa travması ve C6 kırığı: Yüksek hızlı motosiklet kazası Gentian VYSHKA,1 Blerti TROSHANI,2 Dorjan BOZAXHIU,3 Arben MITRUSHI4

We present the case of a 34-year-old Albanian male who was riding a motorcycle when he collided at high-speed with a four-wheel vehicle. After a triple pivotal rotation in the air at the moment of impact, he fell from the motorcycle to the ground. The clinical picture thereafter was one of deep coma, treated in the intensive care unit for nine days, until he regained consciousness and long-term rehabilitation procedures were put in place. The magnetic resonance and computed tomography images were very illustrative of a rotational head trauma mechanism, since in addition to multiple callosal hemorrhages and the lack of cranial fractures, a linear complex fracture of the C6 vertebra was seen, justifying orthopedic treatment through immobilization of the cervical spine. Rotational angular acceleration seems to be an important causative factor toward provoking diffuse brain and/or axonal injury; the etiological importance on the direct skull impact is controversial, but in any case not negligible.

Bu yazıda, yüksek hızla motosiklet sürerken dört tekerli bir araca çarpmış 34 yaşındaki bir Arnavut erkeği olgusu sunuldu. Çarpma anında havada ekseni etrafında üç kez döndükten sonra motosikletinden yere düşen olgu, daha sonra derin koma klinik tablosuyla yoğun bakım ünitesinde, bilincine yeniden kavuşana kadar dokuz gün tedavi edilmiş ve uzun dönemli rehabilitasyon prosedürleri uygulanmış.

Manyetik rezonans ve bilgisayarlı tomografi görüntüleri rotasyonel kafa travması açısından çok aydınlatıcıydı. Gerçekten kafatası kırıkları olmaksızın birden fazla kallozal kanama odağına ilaveten C6 vertebrasında lineer kompleks kırık hattı izlenmekteydi. Bu olgu boyun omurgasını hareketsiz durumda tespit edip ortopedik tedavi uygulanmaya uygundu. Rotasyonel açısal akselerasyonun diffüz beyin ve/veya aksonal hasarına neden olan önemli bir nedensel faktör olduğu görünmektedir. Doğrudan kafatasına gelen darbenin etyolojik önemi tartışma konusuysa da asla gözardı edilmemelidir.

Key Words: Axonal injury; brain trauma; rotational angular acceleration; traffic accident.

Anahtar Sözcükler: Aksonal travma; beyin travması; rotasyonel açısal akselerasyon; trafik kazası.

CASE REPORT A 34-year-old male (height 176 cm, weight 85 kg) was riding his motorcycle on a secondary rural road in central Albania when the motorcycle collided at high speed with a four-wheel drive vehicle. According to witnesses, the injured person was wearing a helmet and was driving approximately 50 km/hr. At the site of the accident, tracks on the ground indicating a triple pivotal rotation of the motorcycle were evident. The injured lost consciousness immediately at the site of

the collision; the driver of the car causing the crash and other witnesses accompanied the patient to the nearest hospital.

Departments of 1Neurology, 4Radiologic Anatomy, Tirana University Faculty of Medicine, Tirana; Departments of 2Radiology, 3Surgery, Hygeia Hospital, Tirana, Albania.

Upon arrival, he was in a deep coma (Glasgow Coma Scale score: 5 points) with flexion provoked only by painful stimuli; an anisocoria with left but reactive mydriasis was present. The patient was otherwise stable from the hemodynamic point of view.

He was admitted in the Intensive Care Unit (ICU) and intubated; appropriate therapy followed, and a comTiran Üniversitesi Tıp Fakültesi, 1Nöroloji Anabilim Dalı, Radyolojik Anatomi Anabilim Dalı, Tiran; Hygeia Hastanesi, 2 Radyoloji Bölümü, 3Cerrahi Kliniği, Tiran, Arnavutluk.

4

Correspondence (İletişim): Gentian Vyshka, M.D. Tirana University Faculty of Medicine, Department of Neurology, Tirana, Albania.

Tel: +035542375808 e-mail (e-posta): gvyshka@yahoo.com

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plete diagnostic workup was performed within the day of admittance.

Magnetic resonance imaging (MRI) performed upon admission showed multiple contusions, almost all of which were remarkably concentrated in the midline structures: callosal gyrus and upper brain stem; no skull fractures were seen (Figs. 1a, b). A discrete subdural temporal-occipital hematoma requiring no neurosurgical intervention resolved under conserva-

tive treatment. On the computed tomography (CT) scan of the cervical spine, a linear complex fracture of the posterior arch of C6 was also evident and treated through immobilization (Fig. 1c, d).

The patient left the ICU nine days after admittance and was discharged from the hospital three weeks after being released from the ICU; amnesia regarding the traumatic event and anosmia were the only sequelae. He was referred to a neuropsychological facility

(a)

(b)

(c)

(d)

Fig. 1. (a) Callosal contusion and hemorrhagic upper brain stem foci (MRI image T2-weighted, FLAIR). (b) Contusive hemorrhagic foci concentrated on the midline and on the central structures, suggesting the existence of a shear momentum, probably related to the fact that the outer [cortical] structures [inset schema, above right] had a higher tangential speed during acceleration-deceleration when compared to the inner and medially positioned areas (MRI image T2-weighted, FLAIR). (c) A linear complex fracture at the left posterior arch of the 6th cervical vertebra was treated through immobilization (CT image). (d) A follow-up cranial CT was performed five days after the MRI; callosal hemorrhagic foci and diffuse white matter edema are visible, with a slight midline shift.

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Ocak - January 2013

Rotational head trauma with callosal contusion and C6 fracture

abroad for long-term cognitive rehabilitation, and no pharmacological therapy was advised upon discharge; no eventual clinical and imaging follow-up took place.

DISCUSSION Angular and rotational acceleration has been mentioned as an important factor causing head injury of different gravity, since 1943.[1] Generally, all studies point to brain deformation, strain and shear forces created during the high-speed motion, be it linear or angular, and direct impact with hard structures. When angular acceleration was proposed as a cause of gliding contusion, creating strain and eventually lacerating deep small vessels, it was suggested that the maximum shear zone deepened with an increasing angular acceleration speed.[2] On the other hand, intracranial motion seems to be slower and following that of the skull; inertia of central midline structures might play a role in rapid accelerative rotation, even more during the deceleration phase prior to the final impact with the hard structures (for example, during fall to the ground). The severity of diffuse brain injury (DBI) and diffuse axonal injury (DAI) has been correlated with the amplitude of the angular acceleration.[3] Different models have been proposed and experimented, aiming for a better comprehension of the head trauma mechanism in humans. Among others, rabbits, rats and even sheep have been selected and experimented, although the authors themselves sometimes acknowledge the structural and morphologic differences in comparison to the human brain, thus making the laboratory results hard to extrapolate to everyday settings.[4,5] It is accepted that the brain is heterogeneous and anisotropic. Furthermore, when studying soft tissue properties, elastoplastic responses and viscoelastic mechanisms, authors suggest different mechanical intrinsic properties of three cranial structures: gray matter (GM), white matter (WM), and brain stem with corpus callosum (BSCC).[6] Thus, data offered for the long-term shear modulus (elastoplastic response) are 6.80 kPa for GM, 8.20 kPa for WM and 11.60 kPa for BSCC.[6] The same source also offers different figures for the initial shear modulus for all three of

Cilt - Vol. 19 Say覺 - No. 1

these rather schematic divisions of the central nervous system, which might correspond, in an approximate form, to the cortex (GM), to the corona radiata, with the subcortical and periventricular areas (WM), and to the central-midline structures (BSCC). Thus, albeit authors generally agree that the brain and spinal cord move as a unit when exposed to a sagittal rotational acceleration of the head and neck,[7] our case suggests that a different momentum might exist, mainly during the deceleration that follows the abrupt cessation of an angular head motion, creating an important shear factor between the cortical-external structures and the BSCC on the other side. The angular speed is by far a very important aggravating factor for the overall clinical picture and prognosis.[8] In our case, the presence of a vertebral fracture warranted even more the suspicion of a high-speed rotational head trauma, causing multiple callosal and brain stem contusions.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Holbourn AHS. Mechanics of head injuries. Lancet 1943; ii: 438-441.

2. L繹wenhielm P. Mathematical simulation of gliding contusions. J Biomech 1975;8:351-6.

3. Margulies SS, Thibault LE. A proposed tolerance criterion for diffuse axonal injury in man. J Biomech 1992;25:917-23.

4. Krave U, Al-Olama M, Hansson HA. Rotational acceleration closed head flexion trauma generates more extensive diffuse brain injury than extension trauma. J Neurotrauma 2011;28:57-70.

5. Davidsson J, Risling M. A new model to produce sagittal plane rotational induced diffuse axonal injuries. Front Neurol 2011;2:41.

6. El Sayed T, Mota A, Fraternali F, Ortiz M. A variational constitutive model for soft biological tissues. J Biomech 2008;41:1458-66.

7. Bayly PV, Black EE, Pedersen RC, Leister EP, Genin GM. In vivo imaging of rapid deformation and strain in an animal model of traumatic brain injury. J Biomech 2006;39:108695.

8. King AI, Yang KH, Zhang L, Hardy W, Viano DC. Is head injury caused by linear or angular acceleration? Proceedings of the IRCOBI Conference, Lisbon Portugal: September 2003. p. 1-12.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):80-82

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.74508

Unusual manifestation of acute retrocecal appendicitis: pericholecystic fluid Akut retroçekal apandisitin sıra dışı bulgusu: Perikolesistik sıvı Oktay ALGIN, Evrim ÖZMEN, Ayşenur Şirin ÖZCAN, Şehnaz ERKEKEL, Mustafa KARAOĞLANOĞLU

Subhepatic-retrocecal appendicitis is a rare entity in which the diagnosis is challenging. In patients presenting with right abdominal pain with atypical clinical, laboratory and ultrasound (US) findings, acute appendicitis should be eliminated with computed tomography (CT). Multi-detector CT (MDCT) can be used effectively for the diagnosis of retrocecal appendicitis without additional preparation or focused examination. Here, we present a patient with acute subhepatic-retrocecal appendicitis in whom the clinical and US findings mimicked acute cholecystitis. To the best of our knowledge, there is no previous report related to acute appendicitis presented only with pericholecystic fluid that could be diagnosed with MDCT. Retrocecal-subhepatic appendicitis is a rare condition that might present with atypical clinical, laboratory and radiological signs. US is usually insufficient for the definitive diagnosis. In this situation, MDCT could be a rapid and efficient tool for localizing the appendix and for the differential diagnosis.

Subhepatik alana uzanan retroçekal yerleşimli apandisit, nadir bir durumdur ve tanısı oldukça zordur. Karın ağrısı ile başvuran ve atipik klinik, laboratuvar ve ultrasonografi (USG) bulguları olan hastalarda akut apandisit bilgisayarlı tomografi (BT) ile ekarte edilmelidir. Çok detektörlü BT (ÇDBT) ile retroçekal apandisit tanısı, ek bir hazırlığa gerek kalmaksızın konulabilir. Bu yazıda, klinik ve USG bulguları akut kolesistiti taklit eden ve ÇDBT ile tanı konulan subhepatik-retroçekal yerleşimli akut apandisit olgusu sunuldu. Bizim bilgimize göre literatürde yalnızca perikolesistik sıvı izlenmesi ile şüphelenilen ve ÇDBT ile tanı konulan, akut retroçekal yerleşimli apandisit olgusu bulunmamaktadır. Subhepatik-retroçekal apandisit oldukça nadir bir durumdur ve atipik klinik, labaratuvar ve radyolojik bulgularla karşımıza çıkabilir. Ultrasonografi tanı konulmasında sıklıkla yetersizdir. Bu durumda ÇDBT, hızlı ve etkin bir tanı aracı olarak kullanılabilir.

Key Words: Computed tomography; retrocecal appendicitis; ultrasonography; upper abdominal pain.

Anahtar Sözcükler: Bilgisayarlı tomografi; retroçekal apandisit; ultrasonografi; üst kadran ağrısı.

Acute appendicitis is the most common surgical and radiological abdominal emergency in the western world, occurring in 7-12% of the general population.

[1] The location and extent of the inflammatory processes of acute appendicitis may vary depending on the location of the appendix.[2] When the appendix is in the retrocecal position, the signs and symptoms of acute appendicitis might be atypical and could mimic right flank and hypochondriac pathologies including acute cholecystitis, diverticulitis, acute gastroenteritis, ureteral colic, acute pyelonephritis, intestinal neopla-

sia, and irritable bowel syndrome.[3] Rapid and precise diagnosis could reduce the morbidity and mortality of acute appendicitis.[1] Here, we present a case of acute subhepatic-retrocecal appendicitis, in whom clinical and sonographic findings mimicked acute cholecystitis. In the ultrasound (US) examination, the only pathologic finding was pericholecystic fluid. In the multi-detector computed tomography (MDCT) examination, we noticed a retrocecal inflamed appendix, which extended to the

Department of Radiology, Ataturk Training and Research Hospital, Bilkent, Ankara, Turkey.

Atatürk Eğitim ve Araştırma Hastanesi, Radyoloji Bölümü, Bilkent, Ankara.

Correspondence (İletişim): Evrim Özmen, M.D. Atatürk Eğitim ve Araştırma Hastanesi, Radyoloji Bölümü, Bilkent, Ankara, Turkey.

Tel: +090 - 312 - 291 25 25 / 3240 e-mail (e-posta): evrimkilicdr@gmail.com

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Unusual manifestation of acute retrocecal appendicitis

pericholecystic-subhepatic area. To our knowledge, there has been no reported acute appendicitis case who presented only with pericholecystic fluid and was later definitively diagnosed with MDCT. We think that this case report could be useful for the rapid and precise diagnosis of similar cases.

CASE REPORT A 38-year-old male presented with right hypochondriac pain lasting for 6 hours. There was no significant finding in his medical history or on chest and abdominal roentgenograms. In his physical and laboratory examination, Murphyâ&#x20AC;&#x2122;s sign was positive and leukocytosis was detected. Therefore, abdominal US examination was performed with a pre-diagnosis of acute cholecystitis; there was no abnormal finding except pericholecystic fluid. For the differential diagnosis, MDCT was performed under emergent conditions without preparation. In intravenous contrast-material enhanced MDCT, the appendix was situated in the retrocecal region with an increased diameter of 2 cm. Appendicular wall thickening was observed as well. In multiplanar reformatted images, retrocolic-pericecal inflammation along with an inflamed appendix extending to the subhepatic region was detected (Fig. 1).

Moreover, in MDCT, pericholecystic fluid and appendicolith with a diameter of 8 mm in the proximal portion of the appendix were detected (Fig. 2). No other pathologic finding was observed in MDCT. The patient was diagnosed as acute retrocecal appendicitis and operated based on these findings. Acute appendicitis was confirmed with surgery, and the patient healed without complication. The histologic examination was reported as perforated acute appendicitis.

DISCUSSION Acute appendicitis is one of the most common surgical abdominal emergencies.[4] Early diagnosis and treatment could reduce the mortality and morbidity of acute appendicitis significantly.[5] The most common position of the appendix is intraperitoneal, and the second is in the retrocecal region.[3,6] More than 50% of the patients with retrocecal appendicitis can present with atypical findings.[2] This condition could even mimic acute cholecystitis or gallbladder perforation.[3,7] Although US should be the first-line choice in the diagnosis of acute appendicitis, it might be inadequate in retrocecal appendicitis.[4] Moreover, as US is a rapid technique and it is significantly operator-dependent,[4] MDCT could be useful in such patients. An increased appendiceal diameter (>6 mm), pericecal-retrocolic inflammation, and the presence of an appendicolith are diagnostic for acute retrocecal appendicitis.[5,8] As in our patient, MDCT was helpful in the evaluation of Cilt - Vol. 19 SayÄą - No. 1

Fig. 1. Coronal reformatted MDCT images of the patient.

Morphology of the appendix (white arrow, right image), pericholecystic fluid (black arrow, left image) and periappendiceal inflammation are clearly seen in the reformatted images.

the periappendiceal-pericecal region and could demonstrate the appendix in high resolution. On the other hand, US examination is not optimal in patients with obesity and excessive bowel gases. CT is a diagnostic method for such patients.[9] Technical details of the CT examination, in patients pre-diagnosed with acute appendicitis, are controversial. Various CT techniques have been described for diagnosing acute appendicitis, including intravenous contrast-material enhanced CT with or without orally and/or rectally administered colon contrast material, and they have a high diagnostic accuracy.[8] Some authors suggest that a non-contrast examination would be sufficient.[1,9] In such cases in our department, we perform MDCT examination after administration of oral and intravenous contrast material. However, in the presented patient, we could not give oral contrast

Fig. 2. Sequential sagittal reformatted MDCT images. Morphology of the appendix (long white arrow), pericholecystic fluid (black arrow), periappendiceal inflammation, and appendicolith (short white arrow) are clearly seen in the reformatted images.

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since the patient had nausea and vomiting. According to the findings detected in the MDCT examination, we understand that MDCT without oral and rectal contrast media is a valuable and accurate method in the diagnosis of appendicitis and can be an effective diagnostic tool when the sonographic results are inadequate.[1] In conclusion, acute appendicitis may present with various atypical clinical signs. Patients with retrocecal appendicitis may present only with minimal pericholecystic fluid as well. In such cases, when the appendix cannot be seen clearly or seems in an unusual localization, MDCT can be a useful method for establishing the correct diagnosis. Furthermore, the radiologist’s diagnostic confidence appears greater with MDCT.

3.

4.

5.

6.

7.

Conflict-of-interest issues regarding the authorship or article: None declared.

8.

REFERENCES

9.

1. Chalazonitis AN, Tzovara I, Sammouti E, Ptohis N, Sotiropoulou E, Protoppapa E, et al. CT in appendicitis. Diagn Interv Radiol 2008;14:19-25.

2. Kim S, Lim HK, Lee JY, Lee J, Kim MJ, Lee AS. Ascending

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retrocecal appendicitis: clinical and computed tomographic findings. J Comput Assist Tomogr 2006;30:772-6.

Ong EM, Venkatesh SK. Ascending retrocecal appendicitis presenting with right upper abdominal pain: utility of computed tomography. World J Gastroenterol 2009;15:3576-9.

Buluş H, Coşkun A. Subhepatik appendisit. Kolon Rektum Hast Derg 2010;20:29-32. van Randen A, Laméris W, van Es HW, ten Hove W, Bouma WH, van Leeuwen MS, et al. Profiles of US and CT imaging features with a high probability of appendicitis. Eur Radiol 2010;20:1657-66.

Peletti AB, Baldisserotto M. Optimizing US examination to detect the normal and abnormal appendix in children. Pediatr Radiol 2006;36:1171-6.

Algin O, Ozlem N, Kilic E, Karaoglanoglu M, Arslan H. Gd-BOPTA-enhanced MR cholangiography findings in gall bladder perforation. Emerg Radiol 2010;17:487-91.

Yeung KW, Chang MS, Hsiao CP. Evaluation of perforated and nonperforated appendicitis with CT. Clin Imaging 2004;28:422-7.

Cağlayan K, Günerhan Y, Koç A, Uzun MA, Altınlı E, Köksal N. The role of computerized tomography in the diagnosis of acute appendicitis in patients with negative ultrasonography findings and a low Alvarado score. Ulus Travma Acil Cerrahi Derg 2010;16:445-8.

Ocak - January 2013

Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):83-85

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.80557

Double acute appendicitis in appendical duplication Apendiks duplikasyonunda çift akut apandisit Semra TUTCU ŞAHİN,1 Yamaç ERHAN,2 Hasan AYDEDE2

Duplication of the vermiform appendix is a rare congenital abnormality and usually found incidentally during laparotomy. The Modified Cave-Wallbridge classification is used to describe the location of the appendixes in relation to each other and to the cecum as well as the extent of the duplication. We report a 45-year-old patient who underwent laparotomy for acute abdominal pain. The operative finding was double acute appendicitis in appendical duplication.

The appendixes were removed separately, as it was type B duplication. Since appendectomy is the most common abdominal operation, all surgeons should keep this rare clinical entity in mind.

Appendiks vemiformis duplikasyonu nadir bir doğumsal anomalidir ve genellikle laparotomi esnasında tesadüfen saptanır. Apendikslerin birinin diğerine ve çekuma göre lokalizasyonunu tanımlamada ve aynı zamanda duplikasyonun boyutunu göstermede modifiye Cave ve Wallbridge sınıflaması kullanılır. Bu yazıda akut karın ağrısı nedeniyle laparotomi uygulanan 45 yaşında bir hasta sunuldu. Operasyon bulguları, apendiks duplikasyonu ile birlikte çift akut apandisit şeklinde idi. Tip B duplikasyon olması nedeniyle apendiksler ayrı ayrı alındı. Apendektomi en sık uygulanan abdominal cerrahi olması nedeniyle tüm cerrahlar bu nadir klinik antiteyi akılda tutmalıdırlar.

Key Words: Appendicitis; duplication; vermiform appendix.

Anahtar Sözcükler: Apandisit; duplikasyon; appendiks vemiformis.

Appendical duplication is a rare abnormality, with an estimated incidence of 0.004% among patients undergoing appendectomy.[1,2]

McBurney incision was extended with the help of several retractors for optimal display of the surgical region, as shown in Figure 1. During exploration through the McBurney incision, a small amount of inflammatory fluid was noted. After cecal mobilization, two appendixes were seen: one on the corner where the taenia coli converge, and the other just next to it, with two separate bases. They shared the same mesoappendix, and both were erectile, hyperemic and inflamed; however, one was gangrenous and showed serosal necrosis (Figs. 1, 2). Routine appendectomy was performed for each. The postoperative period was uneventful, and the patient was discharged on the 3rd postoperative day.

We report a case of appendical duplication presented with double acute appendicitis.

CASE REPORT A 45-year-old male presented with right lower quadrant pain, anorexia, nausea, and vomiting. The pain started in the epigastric region three days ago, and then intensified in severity with migration to the right lower quadrant. On physical examination, rigidity and rebound tenderness were noted in the right lower quadrant. The patient was febrile and tachycardic. White blood cell count was 21900/mm3. Other laboratory values were normal. Plain abdomen and chest X-rays appeared normal. Pelvic ultrasound in the emergency suite showed minimal periappendicular fluid and a non-peristaltic, non-compressible tubular structure with a diameter of 10 mm.

1 Avukat Cengiz Gökçek State Hospital, Gaziantep; Department of General Surgery, Celal Bayar University Faculty of Medicine, Manisa, Turkey.

2

On pathological examination, the appendixes measured 5x0.7 cm and 8x0.8 cm. The lumen of the first was obstructed completely with fecalith resulting in serosal necrosis, whereas the other still had a 2 mm luminal passage despite the fecalith. Both appendix1 Avukat Cengiz Gökçek Devlet Hastanesi, Gaziantep; Celal Bayar Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Manisa.

2

Correspondence (İletişim): Semra Tutcu Şahin, M.D. Avukat Cengiz Gökçek Devlet Hastanesi, 65300 Gaziantep, Turkey.

Tel: +090 - 342 - 221 07 00 e-mail (e-posta): semratutcu@gmail.com

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Fig. 1. Two appendixes share the same mesoappendix with different openings to the cecum.

(Color figure can be viewed in the online issue, which is available at www.tjtes.org).

es had lymphoid tissues infiltrated predominantly by neutrophils.

DISCUSSION Duplicated appendix vermiformis is a quite uncommon entity, believed to be seen in 1 in 25000 appendectomies.[1,2] Cave and Wallbridge classified appendical duplication by their anatomical localization into three groups. Type A refers to incomplete duplication, where both appendixes arise from a common base from the cecum. Type B is the complete duplication, where one appendix is found in the usual location, where the taenia coli converge, while the localization of the other varies. Duplication of the cecum is classified as type C, where each cecum has its own appendix.[3-5] Mesko et al.[4] described one appendix connected to the cecum with two openings, horseshoe appendix, which can be classified as type D. In our case, two appendixes sharing the same mesoappendix were found next to each other, and thus were classified as type B duplication.

The majority of duplicated appendixes are believed to be silent and only discovered when one of them becomes inflamed.[3-5] Our patient was 45 years old and had never experienced any symptoms regarding appendical duplication. Both appendixes appeared inflamed at the time of the operation.

It has been mentioned in the literature in a few reports that although barium enema may be helpful in the radiological diagnosis, the exact diagnosis can only be made during the operation and postoperative 84

pathological examination. All these anomalies are of great practical importance, and a surgeon must bear them in mind during an operation. They also carry legal importance in cases where repeated exploratory laparotomy reveals a â&#x20AC;&#x153;previously removedâ&#x20AC;? vermiform appendix.[6] During the first operation, insufficient exploration may result in overlooking the second appendix. In the case of appendicitis at a later time, the presence of an appendectomy history may cause a delay in the diagnosis and the differential diagnosis for appendicitis, which can cause some complications and medicolegal problems.

Fig. 2. Gangrenous appendix (left) and fecaliths obstructing the lumen (right). Note each appendix has its own lumen.

(Color figure can be viewed in the online issue, which is available at www.tjtes.org).

Ocak - January 2013

Double acute appendicitis in appendical duplication

Although seen rarely, duplication of the appendix should be kept in mind since appendectomy is the most common abdominal operation. During routine appendectomy, the cecum should be well mobilized to visualize any kind of possible duplication.

Conflict-of-interest issues regarding the authorship or article: None declared.

3.

4.

5.

REFERENCES 1. Travis JR, Weppner JL, Paugh JC 2nd. Duplex vermiform appendix: case report of a ruptured second appendix. J Pediatr Surg 2008;43:1726-8.

2. Chew DK, Borromeo JR, Gabriel YA, Holgersen LO.

Cilt - Vol. 19 Say覺 - No. 1

6.

Duplication of the vermiform appendix. J Pediatr Surg 2000;35:617-8.

Cave AJ. Appendix Vermiformis Duplex. J Anat 1936;70:28392.

Mesko TW, Lugo R, Breitholtz T. Horseshoe anomaly of the appendix: a previously undescribed entity. Surgery 1989;106:563-6.

Kabay S, Yucel M, Yaylak F, Hacioglu A, Algin MC, Olgun EG, et al. Combined duplication of the colon and vermiform appendix in an adult patient. World J Gastroenterol 2008;14:641-3.

Yanar H, Ertekin C, Unal ES, Taviloglu K, Guloglu R, Mete O. The case of acute appendicitis and appendiceal duplication. Acta Chir Belg 2004;104:736-8.

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Turkish Journal of Trauma & Emergency Surgery

Ulus Travma Acil Cerrahi Derg 2013;19 (1):86-88

Case Report

Olgu Sunumu doi: 10.5505/tjtes.2013.39327

Barolith as a rare cause of acute appendicitis: a case report Akut apandisitin nadir bir nedeni; baryum taşı: Olgu sunumu Volkan İNCE, Burak IŞIK, Cemalettin KOÇ, Adil BAŞKIRAN, Asım ONUR

A barolith consists of inspissated barium associated with feces and is seen, rarely, after barium studies for imaging the gastrointestinal system. The barium used in such studies can enter the appendiceal lumen and, rarely, cause appendicitis by obliterating or narrowing the lumen of the appendix. The appendix fills with barium and the entire appendix is visualized in 80-90% of barium swallow or enema studies, and this is accepted as a reliable sign of a non-diseased appendix Post-examination retention of barium in the appendix is very common (90~95%), and 10% of the patients retain barium in the appendix beyond 72 hours. If the barium is retained for more than two months, complicated appendicitis can result.

We present a 46-year-old male who was diagnosed with acute appendicitis due to a barolith and required an appendectomy three months after a double-contrast barium enema study.

After barium studies, patients should be informed regarding retention of barium in the appendix and the possibility that it can cause acute appendicitis. Thus, if abdominal pain develops, the patient can be referred quickly to a medical center for the appropriate treatment and the complications of acute appendicitis can be prevented with early intervention.

Baryum taşı, yoğunlaşmış baryum ile feçesten oluşur ve gastrointestinal sistem (GİS) görüntüleme çalışmalarından sonra nadiren görülür. Bu tür görüntüleme yöntemlerinde kullanılan baryum apendiks lümenine girebilir ve lümeni daraltarak ya da tıkayarak nadiren akut apandisite sebep olabilir. Baryum yutularak ya da lavmanla yapılan bu görüntüleme tetkiklerinde, baryum %80-90 apendiks lümenini doldurur ve apendiks görüntülenir ve bu sağlıklı apendiks bulgusu olarak kabul edilir. İnceleme sonrası %90-95 oranında baryum apendikste kalır ve bu kalma süresi hastaların %10’unda 72 saatten uzundur. Baryumun apendikste kalışı 2 aydan uzun sürerse komplike apendisitle sonuçlanabilir. Bu yazıda, baryumlu çift kontrast kolon grafisinden 3 ay sonra, baryum taşına bağlı akut apandisit tanısı alan ve apendektomi yapılan 46 yaşında erkek hasta sunuldu.

Baryumlu görüntülemelerden sonra baryumun apendikste kalarak akut apandisite sebep olabileceği yönünden hastalar bilgilendirilmeli ki eğer karın ağrısı gelişirse, hızlı bir şekilde uygun tedavi için bir sağlık merkezine yönlendirilebilir ve erken girişimle akut apandisitin komplikasyonları önlenebilir.

Key Words: Appendicitis; barium; barolith; fecalith.

Anahtar Sözcükler: Apandisit; baryum; baryum taşı; fekalit.

A barolith consists of inspissated barium associated with feces, and is seen, rarely, after barium studies for imaging the gastrointestinal system. It may cause different clinical conditions, depending on its location in the gastrointestinal system, including volvulus, intussusception, colonic obstruction, ulceration or perforation, and appendicitis.[1] We present a patient who developed appendicitis due to a barolith three months after a barium swallow for an upper intestinal series and a double-contrast barium enema.

CASE REPORT A 46-year-old male was admitted to our clinic complaining of abdominal pain in the right lower quadrant for one week. He had undergone an upper intestinal series and double-contrast barium enema to investigate the etiology of his chronic diarrhea three months previously, and these had been reported as normal.

An opacity was seen in the right lower quadrant, at the location of the appendix, on an abdominal X-ray (Fig. 1a). We reviewed the double-contrast barium enema performed three months earlier and saw that the

Department of General Surgery, Inonu University Faculty of Medicine, Malatya.

İnönü Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Malatya.

Correspondence (İletişim): Volkan İnce, M.D. İnönü Üniversitesi Tıp Fakültesi Turgut Özal Tıp Merkezi, Genel Cerrahi ABD, 44280 Malatya, Turkey.

Tel: +090 - 422 341 06 60 / 3725 e-mail (e-posta): volkanince@hotmail.com

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Barolith as a rare cause of acute appendicitis

(a)

(b)

(c)

(d)

Fig. 1. (a) Appearance of the appendix on the abdominal X-ray. (b) The appendix is filled with barium during the doublecontrast barium enema. (c) The appendix is hyperemic and erectile, with a barolith in the distal part. (d) The appearance of the barolith and fecalith in the cut appendix.

appendix had been filled with barium (Fig. 1b). The patient was admitted with a diagnosis of acute appendicitis. On physical examination, the patientâ&#x20AC;&#x2122;s vital signs were stable, but he had tenderness, rigidity, and rebound in the right lower quadrant of the abdomen.

There were no abnormalities on laboratory testing, so a laparotomy was performed. The appendix was hyperemic and erectile, and a barolith was palpable in the distal section (Fig. 1c). An appendectomy was performed. When the specimen was cut, a barolith was seen in the distal part and a fecalith proximally (Fig. 1d). The postoperative follow-up was uneventful, and the patient was discharged on postoperative day 1.

DISCUSSION The appendix fills with barium and the entire appendix is visualized in 80-90% of barium swallow or enema studies, and this is accepted as a reliable sign of a non-diseased appendix.[2] Post-examination retention of barium in the appendix is very common (9095%), and 10% of the patients retain barium in the appendix beyond 72 hours.[3] The interval between a barium study and the presentation of barium appendiCilt - Vol. 19 SayÄą - No. 1

citis ranges from four days to four years.[4] If the barium is retained for more than two months, complicated appendicitis can result.[5,6] The spontaneous evacuation of barium from the appendix in children may take longer than in adults.[6] Patients on a low-residue diet suffering from dehydration have altered colonic motility and are at potential risk of barolith obstruction.[6] In our case, despite increased colonic motility, the barium was retained in the appendix and acute appendicitis developed three months after the examination.

An appendectomy is often performed in patients who present with symptoms of acute appendicitis, regardless of a history of barium imaging. The literature discusses this topic, including the etiology of bariuminduced appendicitis and when we should perform an appendectomy.

The pathogenesis of appendicitis due to barium is still unclear, but the consensus holds that inspissated barium triggers inflammation by narrowing or obliterating the appendix lumen, like an appendicolith, and 87

Ulus Travma Acil Cerrahi Derg

causes appendicitis or appendix perforation.[1-5] Barium is inert and has little physiological effect on the gastrointestinal tract, so inflammation triggered via chemical irritation is not a more likely possibility.

An appendectomy is not recommended for every patient who has prolonged retention of barium in the appendix; they may be followed unless they become symptomatic.[2,5,6] These patients should be followed closely because the risk of developing complications increases with the duration of barium retention. In our case, the laboratory parameters were normal, while the physical examination was suggestive of acute appendicitis. Consequently, an appendectomy was performed.

In conclusion, after barium studies, patients should be informed regarding possible retention of barium in the appendix, which can cause acute appendicitis.

Thus, if abdominal pain develops, the patient can be referred quickly to a medical center for the appropriate

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treatment, and the complications of acute appendicitis can be prevented with early intervention.

Conflict-of-interest issues regarding the authorship or article: None declared.

REFERENCES 1. Champman AH, el-Hasani S. Colon ischaemia secondary to barolith obstruction. Br J Radiol 1998;71:983-4.

2. Palder SB, Dalessandri KM. Barium appendicitis. West J Med 1988;148:462-4.

3. Maglinte DD, Bush ML, Aruta EV, Bullington GE. Retained barium n the appendix: diagnostic and clinical significance.

AJR Am J Roentgenol 1981;137:529-33.

4. Novotny NM, Lillemoe KD, Falimirski ME. Barium appendicitis after upper gastrointestinal imaging. J Emerg Med 2010;38:148-9.

5. Fang YJ, Wang HP, Ho CM, Liu KL. Barium appendicitis.

Surgery 2009;146:957-8.

6. Nagata H, Ohga S, Hattori S, Masumoto K, Taguchi T, Matsumoto T, et al. Barium-associated appendicitis in a childhood case with Crohnâ&#x20AC;&#x2122;s disease. Acta Paediatr 2006;95:889-90.

Ocak - January 2013

Değerli Meslektaşlarım, Sizleri 19-23 Nisan 2013 tarihleri arasında Antalya’da gerçekleşecek olan 9. Ulusal Travma ve Acil Cerrahi Kongresi’ne davet etmekten mutluluk duyuyoruz.

Bu kongrede, Travma ve Acil Cerrahi konusunda en üst düzeyde bilgi birikimi ve yoğun deneyimle elde edilebilecek, tanı, tedavi, organizasyon ve hasta bakımı alanındaki tüm gelişmeler bilgilerinize sunulacaktır.

Kongre programı kongre öncesi kursları, uzman oturumları, video sunumları, interaktif paneller, tartışma oturumları, uzlaşma toplantıları, konferanslar ve uzmanlık alanındaki yenilikleri içermektedir. Hedefimiz değerli görüşlerinizle bilimsel programımızı zenginleştirip, herkesin birbirinden bir şeyler öğrenebileceği bilimsel bir platform gerçekleştirmektir.

Antalya tarih boyunca kültürün, sanatın, mimarinin ve mitolojinin merkezi olmuştur. Muhteşem doğası, açık maviden laciverte uzanan denizi, şelaleleri, Toros dağları ve palmiye ağaçları ile bu gölgenin büyüsüne kapılacaksınız. Bu özellikleri ile de Antalya, Travma ve Acil Cerrahideki son gelişmeleri tartışabileceğimiz en uygun yer.

Sizi Antalya’da ağırlamaktan büyük memnuniyet duyacağız.

Saygılarımızla, Recep Güloğlu Salih Pekmezci Ulusal Travma ve Acil Cerrahi Derneği Başkanı Kongre Başkanı

DÜZENLEME KURULU Kongre Başkanı Salih PEKMEZCİ Kongre Eş Başkanı Tayfun YÜCEL Genel Sekreter M. Mahir ÖZMEN Bilimsel Sekreterya Kaya SARIBEYOĞLU Hakan YANAR Üyeler Ediz ALTINLI Acar AREN Gürhan ÇELİK Cemalettin ERTEKIN Recep GÜLOĞLU Ahmet Nuray TURHAN