Travma 2014 1 by KAREPUBLISHING

ISSN 1306 - 696X

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi

Volume 20 | Number 1 | January 2014

www.tjtes.org

TURKISH JOURNAL of TRAUMA & EMERGENCY SURGERY Ulusal Travma ve Acil Cerrahi Dergisi Editor-in-Chief Recep Güloğlu Editors Kaya Sarıbeyoğlu (Managing Editor) Hakan Yanar M. Mahir Özmen Former Editors Ömer Türel, Cemalettin Ertekin, Korhan Taviloğlu Section Editors Anaesthesiology & ICU Güniz Meyancı Köksal, Mert Şentürk Cardiac Surgery Münacettin Ceviz, Murat Güvener Neurosurgery Ahmet Deniz Belen, Mehmet Yaşar Kaynar Ophtalmology Cem Mocan, Halil Ateş Ortopedics and Traumatology Mahmut Nedim Doral, Mehmet Can Ünlü Plastic and Reconstructive Surgery Ufuk Emekli, Figen Özgür Pediatric Surgery Aydın Yagmurlu, Ebru Yeşildağ Thoracic Surgery Alper Toker, Akif Turna Urology Ali Atan, Öner Şanlı Vascular Surgery Cüneyt Köksoy, Mehmet Kurtoğlu

www.tjtes.org

THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ President (Başkan) Vice President (Başkan Yardımcısı) Secretary General (Genel Sekreter) Treasurer (Sayman) Members (Yönetim Kurulu Üyeleri)

Recep Güloğlu Kaya Sarıbeyoğlu M. Mahir Özmen Ali Fuat Kaan Gök Hakan Teoman Yanar Gürhan Çelik Osman Şimşek

CORRESPONDENCE İLETİŞİM Ulusal Travma ve Acil Cerrahi Derneği Şehremini Mah., Köprülü Mehmet Paşa Sok. Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul, Turkey

Tel: +90 212 - 588 62 46 - 588 62 46 Fax (Faks): +90 212 - 586 18 04 e-mail (e-posta): travma@travma.org.tr Web: www.travma.org.tr

ISSUED BY THE TURKISH ASSOCIATION OF TRAUMA AND EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERNEĞİ YAYIN ORGANI Owner (Ulusal Travma ve Acil Cerrahi Derneği adına Sahibi) Editorial Director (Yazı İşleri Müdürü) Managing Editor (Yayın Koordinatörü) Amblem Correspondence address (Yazışma adresi) Tel Fax (Faks)

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

Annual subscription rates: 75.- (USD) Abonelik: 2013 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. p-ISSN 1306-696x • e-ISSN 1307-7945 • Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, and Turkish Medical Index (Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır.) Publisher (Yayımcı): KARE Yayıncılık (KARE Publishing) • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Corinne Can • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): Ocak (January) 2014 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

www.tjtes.org

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.

tion, called “Upload Your Files”.

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.

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.

Submission of a manuscript by electronic means implies: that the work has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis); that it is not under consideration for publication elsewhere; and that its publication in the Turkish Journal of Trauma and Emergency Surgery is approved by all co-authors. The author(s) transfer(s) the copyright to the Turkish Association of Trauma and Emergency Surgery to be effective if and when the manuscript is accepted for publication. The author(s) guarantee(s) that the manuscript will not be published elsewhere in any other language without the consent of the Association. If the manuscript has been presented at a meeting, this should be stated together with the name of the meeting, date, and the place. Manuscripts may be submitted in Turkish or in English. All submissions are initially reviewed by the editor, and then are sent to reviewers. All manuscripts are subject to editing and, if necessary, will be returned to the authors for answered responses to outstanding questions or for addition of any missing information to be added. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication. Final galley proofs are sent to the authors for approval. Unless specifically indicated otherwise at the time of submission, rejected manuscripts will not be returned to the authors, including accompanying materials. TJTES is indexed in Science Citation Index-Expanded (SCI-E), Index Medicus, Medline, EMBASE, Excerpta Medica, and the Turkish Medical Index of TUBITAK-ULAKBIM. Priority of publications is given to original studies; therefore, selection criteria are more refined for reviews and case reports. Open Access Policy: Full text access is free. There is no charge for publication or downloading the full text of printed material. 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” sec-

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.

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. 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. 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. Review articles: Only reviews written by distinguished authors based on the editor’s invitation will be considered and evaluated. Review articles must include the title, summary, text, and references sections. 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.

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. Açık Erişim İlkesi: Tam metinlere erişim ücretsizdir. Yayınlanan basılı materyali tam metni indirmek için herhangi bir ücret alınmaz. 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 190210 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.

TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 20

Number - Sayı 1 January - Ocak 2014

Contents - İçindekiler

Editörden

Experimental Study - Deneysel Çalışma Deneysel Çalışma - Experimental Study 1-6 The protective effect of ClinOleic against post-surgical adhesions Cerrahi sonrası oluşan karıniçi yapışıklıklara karşı ClinOleic’in koruyucu etkinliği Altınel Y, Taşpınar E, Özgüç H, Öztürk E, Akyıldız EÜ, Bağdaş D 7-11 Effects of tissue plasminogen activator in experimentally induced peritonitis Deneysel peritonit modelinde doku plazminojen akivatörlerinin etkisi Erginel B, Öksüz L, Erginel T, Gün F, Yanar F, Gürler N, Salman T, Çelik A

Klinik Çalışma - Original Original Articles - KlinikArticles Çalışma 12-18 How reliable is the Alvarado score in acute appendicitis? Alvarado skoru akut apandisitte ne kadar güvenilir? Yüksel Y, Dinç B, Yüksel D, Enver Dinç S, Mesci A 19-22 Neutrophil-to-lymphocyte ratio as a predictor of acute appendicitis Nötrofil/lenfosit oranının akut apandisit tanısındaki belirleyiciliği Kahramanca Ş, Özgehan G, Şeker D, Gökce Eİ, Şeker G, Tunç G, Küçükpınar T, Kargıcı H 23-27 The role of colorectal stent placement in the management of acute malignant obstruction Akut malign kalın bağırsak tıkanmalarında kolorektal stent uygulamasının rolü Yanar H, Ozcinar B, Yanar F, Sivrikoz E, Dagoglu N, Agcaoglu O, Gunay K, Guloglu R, Ertekin C 28-32 Role of dissemination of microorganisms during laparoscopic appendectomy in abscess formation Laparoskopik apendektomi sırasında apse oluşumunda mikroorganizmaların rolü Akın M, Erginel B, Yıldız A, Bayraktar B, Yanar F, Karadağ CA, Sever N, Dokucu Aİ 33-38 Auto-/homografting can work well even if both autograft and allograft are meshed in 4:1 ratio Hem otogreft hem de allogreft 4:1 oranında meşlendiğinde bile otohomogreftleme başarılı olabilir Şahin İ, Alhan D, Nışancı M, Özer F, Eski M, Işık S 39-44 Yüksek kinetik enerjili silahlarla yaralanmış ardışık 108 olguya ait ISS değerleri ile transfüzyon gereksinimleri arasındaki ilişki ve ileri merkez son mod mortalite analizi The relationship between Injury Severity Scores and transfusion requirements of 108 consecutive cases injured with high kinetic energy weapons: a tertiary center end-mode mortality analysis Eryılmaz M, Tezel O, Taş H, Arzıman İ, Öğünç Gİ, Kaldırım Ü, Durusu M, Kozak O 45-50 Management and treatment of liver injury in children Çocuklarda karaciğer yaralanmasında yönetim ve tedavi Arslan S, Güzel M, Turan C, Doğanay S, Doğan AB, Aslan A

Ulus Travma Acil Cerrahi Derg, January 2014, Vol. 20, No. 1

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 20

Number - Sayı 1 January - Ocak 2014

Contents - İçindekiler 51-55 Intraorbital wooden foreign body: clinical analysis of 32 cases, a 10-year experience İntraorbital tahta cisim yaralanmaları: Otuz iki olgunun klinik analizi, 10 yıllık deneyim Taş S, Top H

CaseSunumu Reports- -Case OlguReports Sunumu Olgu 56-58 Hybrid approach in patients with recurrent brachial artery embolism: adjunctive tissue plasminogen activator infusion following embolectomy Tekrarlayan brakiyal arter embolisinde hibrid yaklaşım: Embolektomi sonrası perkütan doku plazminojen aktivatörü uygulaması Gürsoy M, Bakuy V, Atay M, Gulmaliyev J, Akgül A 59-62 Common carotid artery injury caused by a camel bite: case report and systematic review of the literature Deve ısırığının neden olduğu ana karotis arter yaralanması: Olgu sunumu ve literatürün sistematik biçimde gözden geçirilmesi Abu-Zidan FM, Abdel-Kader S, El Husseini R 63-65 Morel-Lavallee lesion: case report of a rare extensive degloving soft tissue injury Morel-Lavallee lezyonu: Seyrek görülen, yaygın, yumuşak dokunun eldiven soyulması gibi yaralanması Gummalla KM, George M, Dutta R 66-70 Emergency management of traumatic total scalp avulsion with microsurgical replantation Travmatik total kafa derisi avülsiyonunun mikrocerrahi replantasyonla acil tedavisi Jiang Z, Li S, Cao W 71-74 Transverse sacral fractures and concomitant late-diagnosed cauda equina syndrome Transvers sakrum kırıkları ve eşlik eden geç tanı almış kauda ekina sendromu Bekmez Ş, Demirkıran G, Çaglar Ö, Akel İ, Acaroğlu E 75-78 Isolated salpingeal torsion in children: a case series and review of the literature Çocuklarda izole tubal torsiyon: Olgu sunumu ve literatür değerlendirilmesi Erikci VS, Hoşgör M

viii

Ulus Travma Acil Cerrahi Derg, Ocak 2014, Cilt. 20, No. 1

E Dİ T ÖR D EN

Değerli Ulusal Travma ve Acil Cerrahi Dergisi (UTACD) okurları, Yeni bir yıla girdiğimiz bu günlerde dergimizdeki yenilikleri fark ettiğinizi tahmin ediyoruz. Prestijli uluslararası endekslerdeki yerini sağlamlaştıran dergimizin etki faktörü (impact factor), yükseliş trendini 2013 yılında da sürdürdü. Dergimiz yabancı çalışmacıların da tercih ettiği bir yayın organı haline geldi. Her gün dünyanın çeşitli merkezlerinden değerli çalışmalar dergimize değerlendirilmek için gönderiliyor. Artık uluslararası nitelik kazanan UTACD’nin çizgisini yükseltmeyi ve bunu sürdürülebilir bir sistem içinde çözmeyi hedefliyoruz. Bu nedenle geçtiğimiz yılın ikinci yarısı dergimizi; nitelik, içerik ve işleyiş açısından daha ileriye götürmeyi hedefleyen yoğun çalışmalarla geçti. Yayın hayatına başladığı günden bu yana Türk cerrahi dergileri içinde farklı ve öncü olan UTACD, Ocak sayımızla birlikte yeni bir anlayış ve şekil içinde yoluna devam edecek. Son birkaç sayıda dergi mizanpajının değiştiğini görmektesiniz. Son değişikliğimiz dergi kapağımızla olacak ve Ocak sayımızdan itibaren yepyeni bir dergi ile karşınızda olacağız. Bu itibarla, çok nitelikli işlere imza atan yayıncımız “Kare Yayıncılık” Ali Cangül ve ekibine çok teşekkür ediyoruz. Dergimizde uyguladığımız diğer bir önemli değişiklik de işleyiş yapısında oldu. UTACD’nin özel ilgi alanları nedeniyle birçok cerrahi branştan yazı kabul etmekteyiz. Dergimize yollanan yıllık makale sayısının 500’ün üzerinde olduğu dikkate alınırsa değerlendirme yükünün ne kadar fazla olduğu anlaşılacaktır. Bu seneye yepyeni bir sistemle, bölüm editörlerimizle girdik. Yeni çalışma düzenimizin bize hız ve nitelik kazandıracağına hiç şüphemiz yok. Değerlendirme ve baskı süreçlerinde de dünyanın en nitelikli dergilerinin düzeyine ulaşmayi hedefliyoruz. Son birkaç yıldır dünyada yayın etiği alanında yaşanan bazı sorunlar, bilimsel yayıncıları bu açıdan daha titiz çalışmaya sevk etmiştir. UTACD olarak en hassas olduğumuz noktanın bu olduğunu bir kez daha tekrar etmek istiyoruz. “Aşırma” fikir temelinde olabildiği gibi yazıların kopyala-yapıştır yöntemiyle üretilmesiyle de görülebiliyor. Daha “temiz” çalışmaları yayımlamak amacıyla iThenticate programını yayın sürecimizin sabit bir parçası haline getirdik. Dergi yönetimi olarak iThenticate skoru belirli bir eşiğin üzerindeki yazıları basmayacağımızı buradan özellikle duyurmak istiyoruz. Daha kaliteli bir dergi için hepinizin desteğini beklediğimizi ifade ediyor, saygılarımızı sunuyoruz. Editörler kurulu

Ulus Travma Acil Cerrahi Derg, January 2014, Vol. 20, No. 1

EXPERIMENTAL STUDY

The protective effect of ClinOleic against post-surgical adhesions Yüksel Altınel, M.D.,1 Ersoy Taşpınar, M.D.,1 Halil Özgüç, M.D.,1 Ersin Öztürk, M.D.,1 Elif Ülker Akyıldız, M.D.,2 Deniz Bağdaş, M.D.3 1

Department of General Surgery, Uludag University Faculty of Medicine, Bursa;

Department of Pathology, Uludag University Faculty of Medicine, Bursa;

Uludag University Faculty of Medicine, Experimental Animals Breeding and Research Center, Bursa

ABSTRACT BACKGROUND: Although the English-language literature is full of studies about post-surgical adhesions, no definitive method has yet been identified to prevent them. The goal of this study was to investigate the effect of ClinOleic on reducing post-surgical adhesion formation. METHODS: Surgery was performed on 40 adult female Sprague-Dawley rats that were randomly assigned to receive either intraperitoneal ClinOleic, which was used to mimic chyle (ClinOleic group), soybean oil (soybean oil group), olive oil (olive oil group), or 0.9% NaCl suspension (control group). All rats underwent laparotomy, side-wall and cecal abrasion, and primary closure. On the 30th day following surgery, rats were sacrificed and examined using the Majuzi adhesion classification and histopathological grading scales. RESULTS: The adhesion and histopathological scores of the ClinOleic group were significantly lower compared to the control group (0.9% NaCl) (p<0.05). A statistically significant decrease in fibrosis was observed in the soybean and olive oil groups when compared to the control group (p<0.05). However, the adhesion grades of the ClinOleic, soybean and olive oil groups were comparable. We did not observe any post-surgical adhesions in the ClinOleic group. CONCLUSION: The parenteral nutrition solution ClinOleic may be an effective and readily available agent for the prevention of post-surgical adhesions. Key words: Abdominal surgery; adhesion prevention; ClinOleic; intra-abdominal adhesions.

INTRODUCTION Adhesion formation following surgery remains an almost inevitable consequence of most abdominal procedures. After multiple operations, the incidence of intra-abdominal adhesions could be as high as 95%. Advancements in surgical techniques, such as laparoscopy, can help to diminish the probability of post-surgical adhesions.[1] Despite the decrease in the adhesion formation rate from 50% after laparotomy to 12% after laparoscopy, surgery for adhesions may still be required

Address for correspondence: Yuksel Altınel, M.D. Bahçelievler Mahalesi, 276. Sok., Demir Apt., No: 2, D: 7, K: 4, Merkez, 52000 Ordu, Turkey Tel: +90 224 - 295 00 00 E-mail: dryukselaltinel@gmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

after these surgeries.[2,3] Post-surgical adhesions can lead to a broad range of diseases, such as infertility, pelvic pain, bowel obstruction, difficulties during re-operations, and increased morbidity and mortality.[4-6] Many adjuvants that prevent inflammation (steroidal and non-steroidal anti-inflammatory medications), degrade fibrin (recombinant tissue plasminogen activator [t-PA]), or act as barriers (absorbable material/ solution/gel or liquid paraffin) have been evaluated to prevent post-surgical adhesions.[7-9] Nevertheless, no definitive method or agent has been proven to prevent the formation of post-surgical adhesions. Chyle, a milky bodily fluid consisting of lymph and free fatty acids (FFAs), is formed in the small intestine during the digestion of fatty foods and is taken up by lymphatic vessels.[10] In our clinical practice, we have observed that patients who had gastrointestinal surgery with extensive lymphatic dissection did not develop post-surgical adhesions often. This led us to hypothesize that chyle may have acted as a preventive factor against adhesion formation. Therefore, we conducted this study using the parenteral nutrition product ClinOleic (Baxter, UK)[11] to model human chyle in rats. 1

Altınel et al. The protective effect of ClinOleic against post-surgical adhesions

This study examines the effect of ClinOleic and a few other oils on reducing adhesion formation in rats. Our hypothesis was that chyle draining into the peritoneal cavity after gastrointestinal surgery would prevent adhesion formation.

MATERIALS AND METHODS Materials ClinOleic (Baxter, United Kingdom) is a mixture of 80% olive oil and 20% soybean oil. It is used as a parenteral lipid emulsion for supplemental nutrition in patients with intestinal failure (Table 1).[12,13] Soybeans consist of soy protein, isoflavones, fibers, and saponins. Soybean oil is a long-chain triglyceride with two dominant fatty acid residues: 25% oleic acid and 51% linoleic acid (omega-6). It also includes methyl methacrylate, palmitic acid, linolenic acid (omega-3), and stearic acid residues. Many soy ingredients have potential health benefits for patients.[14,15] Olive oil has long been recognized for its unusual fat content. This plant oil is one of the few widely used culinary oils that contain approximately 75% oleic acid (a monounsaturated, omega-9 fatty acid) and 21% linoleic and linolenic acid. Olive oil that has undergone less processing also comprises α-tocopherol (an antioxidant and anti-inflammatory agent), squalene, phytosterols, triterpenes, and phenolic compounds.[16,17] All the fluids used in this study were sterilized prior to the surgical procedures.

Animals The approval for this study was given by the Medical Faculty of Uludağ University, Experimental Animals Production and Research Laboratory Ethical Committee. The protocols were in compliance with the conditions governing the care and use of laboratory animals (Declaration of Helsinki). Forty adult female Sprague-Dawley rats, 3-4 months of age and weighing 350-400 grams, were used. Cages measuring 40x25x25 cm with plastic sides and bottoms covered with stainless woven wire were used. Wood shavings on the floor of the cages were replaced every two days. A maximum of five rats were kept in each cage under standard laboratory conditions, with water in drinking bottles and a pellet food manufactured specially for rats provided. They were housed at a temperature of 20-22 ºC, relative humidity of 50-60% and with 12-hour light-dark cycles. The rats were divided into four groups.

Surgical Procedures All animals were fasted overnight prior to surgery and were anesthetized in jars. Anesthesia was maintained with an injection of a combination of 10 mg/kg intramuscular ketamine (Ketalar®) and 1 ml/kg xylazine (Rompun®). Antibiotics were not administered prior to incision. All surgical procedures were performed under sterile conditions. Following povidone iodine application to the skin, a 4 cm midline abdominal incision was made. The cecum and the terminal ileum were grasped and scraped with sterile dry gauze. After the injured cecum was returned to the intraperitoneal

Table 1. Compounds of 20% ClinOleic (per 100 ml) lipid emulsion Ingredients Amount Purified olive oil (80%) and soybean oil (20%)

20 g

Purified egg phosphatides

1.2 g

Glycerol

2.25 g

Sodium oleate

0.03 g

Sodium hydroxide

As needed for Ph adjustment

Water for injection

Sufficient quantity

Table 2. Adhesion grading according to Majuzi classification

Grade

Description of Grade

No adhesion

Very small, irregular adhesion

Easily separable medium intensity adhesion

Intense, not easily separable regular adhesion

Very intense, not easily separable, homogeneous adhesion

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Alt覺nel et al. The protective effect of ClinOleic against post-surgical adhesions

Table 3. Inflammation grading scale 0 Nil 1

Grant cells, occasional scattered lymphocytes and

plasma cells

Grant cells with increased numbers of admixed

lymphocytes, plasma cells, eosinophils, neutrophils

Many admixed inflammatory cells, micro abscesses

present

Table 4. Fibrosis grading scale

excised en-bloc. A pathologist, who was uninformed regarding the methods and groups, examined the damaged abdominal wall of each rat. Through this examination, the interactions of the oily fluids with the peritoneum and the efficacy of these fluids in preventing adhesions were observed. The tissues were fixed in a 10% buffered formaldehyde solution and embedded in paraffin following dehydration. Tissue sections of 5 繕m thickness were obtained and stained with hematoxylin and eosin. These sections were evaluated using light microscopy at a magnification of 100x. The histopathological grade was measured with a semi-quantitative scoring system (Tables 3, 4). Vascular proliferation was scored as follows: 0, no vascular proliferation; 1, mild vascular proliferation; 2, moderate vascular proliferation; and 3, intense vascular proliferation.[19,20]

0 Nil 1

Statistical Analysis

Minimal, loose

2 Moderate 3

Florid, dense

cavity, a 2x2 cm apposing parietal and visceral peritoneal abrasion was performed using dry gauze. After the procedure, 5 ml 0.9% NaCl suspension was added into the peritoneal cavity of rats in the control group (Group 1), 5 cc of soybean oil was added into the peritoneal cavity of rats in the soybean oil group (Group 2), 5 cc of olive oil was added into the peritoneal cavity of rats in the olive oil group (Group 3), and 5 cc ClinOleic was added into the peritoneal cavity of rats in the ClinOleic group (Group 4). The abdominal fascia was closed using a continuous technique with 000 polypropylene suture. The skin was closed with a surgical stapler.

Evaluation of Adhesion Formation On the 30th postoperative day, the rats were sacrificed by cervical dislocation. Through the initial laparotomy scar, the abdomen was opened using a midline incision from cranial to caudal to view the extent of intra-abdominal adhesion formation. The adhesions were graded according to the Majuzi classification system[18] by an experienced surgeon of the clinic who was blinded to the different treatment groups (Table 2).

Morphologic Evaluation The 2x2 cm area of abrasion in the right lower quadrant was

Adhesion and histopathological scores did not always follow normal distributions. Thus, statistical inferences were made using Mann-Whitney U-tests and the Statistical Package for the Social Sciences (SPSS) 10.0 software (Chicago, IL). A p value <0.05 on a two-tailed test was considered statistically significant. The Kruskal-Wallis test for intergroup comparisons was used to evaluate the data.

RESULTS No rat died during or after surgery in this experiment. There were no signs of clinical inflammation on the incision in any rats. When comparing adhesion grades (Table 5), a significant difference was observed between the control and ClinOleic groups (p<0.05). However, the soybean oil and olive oil groups did not show any significant differences compared to the control group. Additionally, the adhesion grades of the ClinOleic, soybean oil and olive oil groups were comparable. We did not observe any post-surgical adhesions in the ClinOleic group (Fig. 1a). The median histopathological fibrosis, inflammation and vascular proliferation scores of the ClinOleic group were significantly lower than of the control group (p<0.05), but were comparable to the soybean oil group and olive oil group (Fig 1b-d). The histopathological fibrosis score of the control group was significantly higher compared to both the soybean oil group and olive oil group (p<0.05) (Table 6).

Table 5. Postoperative adhesion grades of groups and histopathological features of biopsies from the peritoneum

1-Control

2-Soybean oil

3-Olive oil

4-ClinOleic

Adhesion grade

1.5 (0-3)

0 (0-2)

0 (0-0)

0.023*

Fibrosis Inflammation Vascular proliferation

1 (0-3)

0 (0-1)

0 (0-0)

<0.05**

1.5 (0-3)

0 (0-2)

0 (0-1)

0 (0-0)

1 (0-2)

0 (0-2)

0 (0-1)

0 (0-0)

* Group 4 was significantly lower than the control group (p<0.05). ** Soybean and olive oil groups (p=0.043) and ClinOleic group (p=0.023) were significantly lower than the control group.

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Alt覺nel et al. The protective effect of ClinOleic against post-surgical adhesions (a)

(b)

(c)

(d)

Figure 1. (a) Oil vacuoles of the ClinOleic group (hematoxylin & eosin [H&E]). (b) Peritoneum of the control group (H&E). (c) Oil vacuoles of the soybean oil group (H&E). (d) Oil vacuoles of the olive oil group (H&E).

DISCUSSION In this experimental study modeling intra-abdominal adhesions in rats, adhesions were diminished when ClinOleic was applied into the intraperitoneal cavity. Despite some similar effects when other oil products were used, the greatest improvement was observed when ClinOleic was used. This finding has encouraged us to repeat this study in humans.

In this study, we investigated ClinOleic and its additives. Soybeans are associated with low levels of inflammatory markers and enhanced endothelial function; however, the exact mechanisms of these activities are not known.[15,21,22] Olive oil is the main component of ClinOleic. Hydroxytyrosol and polyphenol are believed to be the main antioxidant compounds in olive oil and contribute significantly to the many health benefits of this oil. Oleic acid and phenolic compounds

Table 6. Statistical comparison of the groups according to the adhesion, fibrosis, inflammation, and vascular proliferation grades Groups p-value

Adhesion

Fibrosis

Inflammation

Vascular proliferation

Group 1 vs. Group 2*

0.12

0.043

0.16

0.39

Group 1 vs. Group 3**

0.08

0.043

0.06

0.10

Group 1 vs. Group 4***

0.023

Group 2 vs. Group 3

0.73

0.63

Group 2 vs. Group 4

0.28

0.73

0.28

Group 3 vs. Group 4

0.48

0.73

0.48

*, ** Soybean and olive oil groups were significantly lower than the control group (p<0.05). *** ClinOleic group was significantly lower than the control group (p<0.05).

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Altınel et al. The protective effect of ClinOleic against post-surgical adhesions

exert anti-inflammatory and anti-thrombotic activities. Hydrocarbons, polyphenols, tocopherols, sterols, triterpenoids, and other components of olive oil usually exert beneficial effects on vascular dysfunction by modulating the mechanisms of endothelial activity. Such mechanisms involve the release of nitric oxide, eicosanoids (prostaglandins and leukotrienes) and adhesion molecules. In most cases, the release of these molecules is promoted by the activation of nuclear factor κB by reactive oxygen species.[23] Several in vitro studies have shown that ClinOleic may interfere less with inflammatory responses, including monocyte, lymphocyte, and neutrophil responses, than soybean oil.[24] However, the preventive effect of ClinOleic may be linked to its barrier effect. Many pharmacologic agents in the form of liquids, gels and solids have been implicated in the prevention of intra-abdominal adhesions. These agents are believed to act as mechanical barriers between peritoneal surfaces, and include agents such as modified chitosan-dextran gel,[25] nitric oxide, a Chinese medicinal compound known as Changtong oral liquid,[7] intravenous melatonin,[2] a combination of t-PA and phosphatidylcholine,[26] and poly(ethylene glycol)-poly(εcaprolactone)-poly(ethylene glycol) (PEG-PCL-PEG, PECE) hydrogel.[6] Previously evaluated adhesion barriers include Seprafilm® II[19] and polyethylene glycol spray (SprayGel).[27] In an experimental study by Schreinemacher et al.,[28] the authors reported that polypropylene mesh with an omega-3 fatty acid barrier coating, C-Qur (Ethicon Inc., Somerville, NJ, USA), reduced adhesion formation to intraperitoneal mesh in the short term, but the effect diminished in the long term. Phagocytosis of absorbable coatings may have contributed to adhesion formation. Ferric hyaluronate gel has also been investigated and was found to lead to a 69% reduction in intra-abdominal adhesion formation. This was due to an increase in viscosity caused by the ferric ions.[29] Conversely, another animal study demonstrated that no significant prevention of adhesions was observed with this compound.[3] Highly viscous liquids may prevent adhesion formation by forming a layer between surfaces, thereby preventing any contact of the de-peritonealized surface with the surrounding tissues. In vitro studies showed that, in a highly viscous medium, the movement of cells or cell groups towards each other is delayed and adhesion either does not occur or is delayed, depending on the viscosity.[30-32] Aysan et al. performed many different studies regarding the prevention of peritoneal adhesions. These included using soybean oil[14] before peritoneal trauma, using honey, which has a dense and complex chemical composition,[33] and using viscous 6% hydroxy ethyl starch (HES) solution.[34] When the viscosity of the fluid inserted into the intraperitoneal cavity was increased, the reduction of intra-abdominal adhesion formation was achieved by an unknown viscosity-dependent process.[34] In summary, the preventive effect of ClinOleic may be due to the anti-inflammatory effects of its olive oil component or to its barrier effect. Because the results of the ClinOleic group were improved relative to its additive groups (olive oil and soybean oil groups), the net effect may not be linked only to Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

the anti-inflammatory effects of olive oil. It is likely that more than one mechanism is responsible for the protective effect of ClinOleic against post-surgical adhesions. Nevertheless, ClinOleic showed a significant anti-adhesive property in our rat model and has encouraged us to perform human studies. According to our encouraging results, ClinOleic may act as an anti-adhesive material, which is a very important clinical gain for patients undergoing abdominal surgery. Among the many materials used in animal adhesion studies, ClinOleic seems to be the option most preferred for use in humans. Additionally, our study may lead to some new trends. For instance, the use of intra-abdominal drains could be questioned. Using energy devices in dissecting the mesentery of hollow viscus could also be reconsidered. Additionally, the effect of early enteral feeding may not only prevent translocation of bacteria from the intestines, but may also cause the formation of more chyle in the intraperitoneal cavity. To the best of our knowledge, this is a novel study that attempts to examine the effect of chyle on preventing intraabdominal adhesions. In this report, we present a useful antiadhesive material for gastrointestinal surgeons that can be applied in everyday practice, and our encouraging results also offer many other findings and ideas in the field.

Acknowledgements This study was not funded by any company or institution. This study was presented in the Congress of the 47th ESSR 2012.

Ethical standards The experiments complied with the current laws of Turkey. Conflict of interest: None declared.

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23. Perona JS, Cabello-Moruno R, Ruiz-Gutierrez V. The role of virgin olive oil components in the modulation of endothelial function. J Nutr Biochem 2006;17(7):429-45. 24. Buenestado A, Cortijo J, Sanz MJ, Naim-Abu-Nabah Y, Martinez-Losa M, Mata M, et al. Olive oil-based lipid emulsion’s neutral effects on neutrophil functions and leukocyte-endothelial cell interactions. JPEN J Parenter Enteral Nutr 2006;30:286-96. 25. Lauder CI, Garcea G, Strickland A, Maddern GJ. Use of a modified chitosan-dextran gel to prevent peritoneal adhesions in a rat model. J Surg Res 2011;171:877-82. 26. Ferland R, Mulani D, Campbell PK. Evaluation of a sprayable polyethylene glycol adhesion barrier in a porcine efficacy model. Hum Reprod 2001;16:2718-23. 27. Hellebrekers BW, Trimbos-Kemper GC, van Blitterswijk CA, Bakkum EA, Trimbos JB. Effects of five different barrier materials on postsurgical adhesion formation in the rat. Hum Reprod 2000;15:1358-63. 28. Schreinemacher MH, Emans PJ, Gijbels MJ, Greve JW, Beets GL, Bouvy ND. Degradation of mesh coatings and intraperitoneal adhesion formation in an experimental model. Br J Surg 2009;96:305-13. 29. Lundorff P, van Geldorp H, Tronstad SE, Lalos O, Larsson B, Johns DB, et al. Reduction of post-surgical adhesions with ferric hyaluronate gel: a European study. Hum Reprod 2001;16:1982-8. 30. Wallwiener M, Brucker S, Hierlemann H, Brochhausen C, Solomayer E, Wallwiener C. Innovative barriers for peritoneal adhesion prevention: liquid or solid? A rat uterine horn model. Fertil Steril 2006;86(4 Suppl):1266-76. 31. diZerega GS, Cortese S, Rodgers KE, Block KM, Falcone SJ, Juarez TG, et al. A modern biomaterial for adhesion prevention. J Biomed Mater Res B Appl Biomater 2007;81:239-50. 32. Folger R, Weiss L, Glaves D, Subjeck JR, Harlos JP. Translational movements of macrophages through media of different viscosities. J Cell Sci 1978;31:245-57. 33. Aysan E, Ayar E, Aren A, Cifter C. The role of intra-peritoneal honey administration in preventing post-operative peritoneal adhesions. Eur J Obstet Gynecol Reprod Biol 2002;104:152-5. 34. Aysan E, Basak F, Kinaci E, Yanar H, Coskun H. Experimental adhesion model: effect of viscosities of fluids put in the peritoneal cavity on preventing peritoneal adhesions. Exp Anim 2007;56:349-54.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Cerrahi sonrası oluşan karıniçi yapışıklıklara karşı ClinOleic’in koruyucu etkinliği Dr. Yüksel Altınel,1 Dr. Ersoy Taşpınar,1 Dr. Halil Özgüç,1 Dr. Ersin Öztürk,1 Dr. Elif Ülker Akyıldız,2 Dr. Deniz Bağdaş3 1 2 3

Uludağ Üniversitesi Tip Fakültesi, Genel Cerrahi Anabilim Dalı, Bursa; Uludağ Üniversitesi Tip Fakültesi, Patoloji Anabilim Dalı, Bursa; Uludağ Üniversitesi Tip Fakültesi, Deney Hayvanları Araştırma Merkezi, Bursa

AMAÇ: Karıniçi yapışıklıklar morbiditenin önemli bir sebebi olmaya ve tedavi maliyetinin artmasına neden olmaktadır. Bu çalışmada, abdominal cerrahi sonrasında yapışıklıkları önlemede bir parenteral beslenme ürünü olan ClinOleic’in intraperitoneal kullanımının yapışıklık oluşumuna etkisi araştırıldı. GEREÇ VE YÖNTEM: Rastgele seçilen 40 yetişkin Sprague-Dawley cinsi sıçana anestezi altında laparatomi yapıldı ve karın yan duvarı ve çekumda abrazyon oluşturuldu. Peritoneal boşluğa grup 1’de (kontrol grubu) %0.9 NaCl çözeltisi, grup 2’de soya yağı, grup 3’de zeytin yağı, grup 4’de ClinOleic uygulandı. Daha sonra karın primer kapatıldı. Deneyin 30. gününde sıçanlar öldürüldü. Gruplarda yapışıklık miktarı kör olarak makroskopik değerlendirme Majuzi skalasına göre, histopatolojik değerlendirme ise semikantitatif skorlama sistemlerine (enflamasyon grade skalası, fibrozis grade skalası ve vasküler proliferasyon grade skalası) göre ölçüldü. BULGULAR: Makroskopik olarak yapışıklık derecesi grup 1 ile karşılaştırıldığında grup 4’de anlamlı olarak düşüktü (p<0.005). Grup 4’de cerrahi sonrası yapışıklık görülmedi. Grup 2, 3 ile grup 4 arasında yapışıklık derecesi açısından istatistiksel fark saptanmadı. Histopatolojik skorlar ise grup1 ile karşılaştırıldığında grup 4’de belirgin olarak düşüktü (p<0.005). Grup 2, 3 ile grup 4 arasında histopatolojik anlamlı fark saptanmadı. TARTIŞMA: Parenteral beslenme ürünü olan ClinOleic’in intraperitoneal kullanımı deneysel şartlarda karıniçi yapışıklıkları önlemede başarılı bulunmuştur. Klinikte de rahatlıkla uygulanabilecek bu yöntemin daha fazla klinik çalısmaya ihtiyacı vardır. Anahtar sözcükler: Abdominal cerrahi; yapışıklık önleyici; ClinOleic; karıniçi yapışıklık. Ulus Travma Acil Cerr Derg 2014;20(1):1-6

doi: 10.5505/tjtes.2014.12244

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EXPERIMENTAL STUDY

Effects of tissue plasminogen activator in experimentally induced peritonitis Başak Erginel, M.D.,1 Lütfiye Öksüz, M.D.,2 Turgay Erginel, M.D.,3 Feryal Gün, M.D.,1 Fatih Yanar, M.D.,4 Nezahat Gürler, M.D.,2 Tansu Salman, M.D.,1 Alaaddin Çelik, M.D.1 1

Department of Pediatric Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul;

Department of Microbiology, Istanbul University Istanbul Faculty of Medicine, Istanbul;

Department of General Surgery, Istanbul Training and Research Hospital, Istanbul;

Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul

ABSTRACT BACKGROUND: We aimed to evaluate the microbiological and immunological effects of tissue plasminogen activator (tPA) in a rat model of peritonitis. METHODS: Twenty-four male Wistar albino rats were divided equally into three groups. Peritonitis and thereafter laparotomy and partial omentectomy were performed in all rats. The control group (C) had no further treatment. The antibiotics group (A) received metronidazole and ceftriaxone. The antibiotic and tPA group (A+T) received the same antibiotics as well as tPA. For microbiological and immunological analysis, blood samples were obtained at the 24th hour, and peritoneal fluid samples were obtained at the 24th and 72nd hours. On the fifth day after surgery, all rats were sacrificed, and the macroscopic findings of the peritoneal cavity were recorded. RESULTS: The mean number of intraperitoneal abscesses was significantly higher in the control group and the lowest in the twotreatment group (A+T). The levels of cytokines were not significantly different between groups. Giving tPA reduced the number and sizes of the abscesses with no significant difference in inflammatory response. CONCLUSION: In this experimental peritonitis model, it can be postulated that tPA decreased abscess formation without exaggerating the inflammatory response. Key words: Cytokine; intraperitoneal abscess; peritonitis; probiotic; tissue plasminogen activator (tPA).

INTRODUCTION Secondary peritonitis is a life-threatening condition. It mostly occurs after disruption of the integrity of the gastrointestinal tract. Since intra-abdominal abscesses are the source of abdominal infection, their prevention is one of the goals in peritonitis therapy. In intra-abdominal infections, the coagulation cascade is

activated and fibrin deposits capture bacteria, preventing bacteremia and sepsis. Since fibrin deposition is an intrinsic element in abscess formation, it is logical to investigate fibrinolytic agents for peritonitis therapy.[1] We aimed to evaluate the microbiological and immunological effects of tissue plasminogen activator (tPA) in a rat model of peritonitis.

MATERIALS AND METHODS Address for correspondence: Başak Erginel, M.D. Şişli Etfal Eğitim ve Araştırma Hastanesi, Çocuk Cerrahisi Kliniği, İstanbul, Turkey Tel: +90 212 - 373 50 00 E-mail: basakerginel@hotmail.com Qucik Response Code

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After obtaining the approval of the Animal Ethics Committee, 24 male Wistar albino rats (Institute of Experimental Medical Research and Application) weighing 300-350 g were divided equally into three groups of eight rats each. They were housed under controlled temperature (21 ºC±2), lighting (12-hour light/dark cycle) and humidity. For the peritonitis, we used the model modified by Buyne et al.,[2] according to which, all rats received intraperitoneal Bacteroides fragilis (104 CFU/ml) and Escherichia coli (105 CFU/ml) through a 7

Erginel et al. Effects of tissue plasminogen activator in experimentally induced peritonitis

fecal suspension processed from sterile stool. After one hour, all rats underwent laparotomies, their peritoneal cavities were debrided, and partial omentectomies were performed. The control group (C) had no further surgery and no further medical treatment. In the antibiotics group (A), the rats received intramuscular metronidazole and ceftriaxone at 15 mg/kg twice daily. The rats in the antibiotics and tPA group (A+T) received the same antibiotics as well as tPA (Actilyse falcon, Boehringer, Ingelheim, Germany) (1.25 mg, in 2.5 mg saline), which was injected percutaneously at 1, 6 and 24 hours after surgery.

Microbiological Analysis Peritonitis was graded by standard parameters. To evaluate peritonitis, microbiological analysis, such as culture and direct staining, was performed. For the evaluation of the immunologic parameters of peritonitis, cytokine levels in blood and peritoneal fluid samples were studied. At the 24th hour after the induction of peritonitis, 500 µl blood, and at the 72nd hour, peritoneal fluid samples were obtained and evaluated with BACTEC Peds Plus medium of BACTEC 9120 (bioMérieux, France) automation system. All samples were positively alarmed within 24 hours. Then, blood cultures were inoculated with 5% sheep-blood agar and chocolate agar (bioMérieux, France). At the end of the incubation period, colony counting was performed. For peritoneal sampling at the 24th and 72nd hour after inoculation, 5 ml saline was injected intraperitoneally and 2 ml of it was removed. The samples were centrifuged at 750 g for 10 minutes and stored at -80 ºC, and immunological analysis of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-10 was performed on these samples.

Macroscopic Analysis Two rats in the control group died within the first 24 hours. On the 5th day after surgery, all rats were sacrificed and the macroscopic findings regarding the peritoneal cavity (number, size and localization of the abscesses) were recorded. The abscesses were evaluated according to three main localizations, as subdiaphragmatic and right and left paracolic.

Statistical Analysis Descriptive statistical methods were used for groups. Kolmogorov-Smirnov and Shapiro-Wilk normality tests were used for normality analysis. ANOVA and t-test methods were used to compare the groups to ensure that normal distribution was found. Kruskal-Wallis test was used for the variance analysis and Mann-Whitney U-test was used to compare those groups for which a normal distribution did not exist. Ninety-five percent was accepted as the confidence interval, and a p value ≤0.05 was considered significant for the analysis. 8

RESULTS Macroscopic Findings In all rats, anorexia, piloerection and immobilization occurred after inoculation. Loss of body weight: In all groups, there was a decrease in weights, especially in the first 24 hours after inoculation. The loss of body weight was similar between the groups, at 10%. Mean number of intraperitoneal abscesses: The mean number of intraperitoneal abscesses was significantly higher in group C than group A+T (Table 1). Mean size of the abscesses: The mean size of the abscesses was larger in group C than group A+T (Table 2). Abscess localization: There was no significant difference in localization of the abscesses between groups (Table 3).

Microbiological Analysis Bacterial culture: E. coli was the most isolated microorganism from samples from blood (after 24 hours’ incubation) and peritoneal fluid (after 72 hours’ incubation) in the control group. In the A and A+T groups, in addition to E. coli, bacteria such as Enterococcus, Bacillus and Klebsiella were also produced. Cytokine levels: Cytokine levels of group C in comparison to group A and group A+T at the 24th hour of peritonitis are listed in Table 4. The difference was not significant except for IL-1β: there was a significant decrease in IL-1β in group A+T in comparison to group C (p=0.029). In Table 5, cytokine levels of group C in comparison to group A and group A+T at the 72nd hour of peritonitis are listed. Again, there was a significant decrease in IL-1β between group C and group A+T (p=0.020). Table 1. The mean number of abscesses Groups Control group (C)

4.33

Antibiotics group (A)

1.63

Antibiotics and tPA group (A+T)

1.25

Table 2. The mean size of the abscesses Groups

Sizes (mm)

Control group (C) Antibiotics group (A) Antibiotics and tPA group (A+T)

8.83

3.76

1.19

2.5

1.3

SD: Standart deviation.

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Erginel et al. Effects of tissue plasminogen activator in experimentally induced peritonitis

Table 3. Abscess localizations Groups

Total number of abscess no

Subdiaphragmatic

Right paracolic

Left paracolic

5 11

A+T

C: Control group; A: Antibiotics group; A+T: Antibiotics and tPA group.

In Table 6, TNF-α and IL-1β values obtained 24 hours after inducing peritonitis are significantly different between group A and group A+T (p=0.001, p=0.07). These values are significantly lower in the group in which tPA was given. Table 4. TNF-α, IL-1β, IL-6, and IL-10 levels of the control group (C) in comparison to the other groups at the 24th hour of peritonitis

A+T

TNF-α 21.93 18.14 0.852 5.77 0.228 IL1-β 17.63 12.52 0.573 1.78 0.029 IL-6

13.32 26.49 1.00 – 0.345

IL-10 72.08 33.26 0.95 15.12 0.181 C: Control group; A: Antibiotic group; A+T: Antibiotic and tPA group; TNF: Tumor necrosis factor; IL: Interleukin (p≤0.05: significant).

Table 5. TNF-α, IL-1β, IL-6, and IL-10 levels of the control group (C) in comparison to the other groups at the 72nd hour of peritonitis

A+T

TNF-α 12.48 7.41 0.573 7.41 0.573 IL1-β 11.17 2.72 0.59 2.61 0.020 IL-6

5.36 9.06 0.95 – 0.662

IL-10 23.82 14.86 0.95 12.55 0.755 C: Control group; A: Antibiotic group; A+T: Antibiotic and tPA group; TNF: Tumor necrosis factor; IL: Interleukin (p≤0.05: significant).

Table 6. TNF-α, IL-1β, IL-6, and IL-10 levels of the antibiotic group (A) in comparison to the other groups at the 24th hour of peritonitis

A A+T p

TNF-α 18.14 5.77 0.001 IL1-β 12.52 1.78 0.007 IL-6 26.49 – 0.442 IL-10 33.26 15.12 0.051 C: Control group; A: Antibiotic group; A+T: Antibiotic and tPA group; TNF: Tumor necrosis factor; IL: Interleukin (p≤0.05: significant).

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The cytokine values at the 72nd hour of peritonitis were not significantly different between the groups.

DISCUSSION Peritonitis is still a life-threatening condition related to surgery, despite modern broad- spectrum antibiotics and advanced intensive care units. It is especially fatal in infants and newborns. Therefore, new treatments are being investigated. However, these treatments are still insufficient for cure. Antibiotics alone cannot be the definitive solution. Alternative treatments and surgical techniques are also being investigated, and among these new experimental drugs, tPA shows promising results. There are many experimental peritonitis models. Among these experimental models, we preferred the one that was modified by Buyne et al.[2] because of its effectiveness, low mortality rate, and ease. Until recently, experimental intraabdominal abscess models were provided with endogenous and exogenous contamination of the peritoneum. In endogenous contamination models, such as cecal ligation and puncture, the integrity of the gastrointestinal tract is disturbed, causing the inoculation of the bacteria to the peritoneum. In exogenous contamination, peritonitis is induced by injection of living, exogenous bacteria, liposaccaritis, or adjuvant substances, such as zymosan. The cecal ligation and puncture model is a well-defined method to induce peritonitis. The model is created by ligation of the cecum and puncture of the cecum with a standard needle under anesthesia. After this operation, the abdominal cavity is closed and subcutaneous fluid is given for resuscitation. Peritonitis is caused by cecal ischemia and the leakage of cecal contents into the abdominal cavity.[3,4] However, cecal ischemia also aggravates the inflammatory response. Thus, the cecal ligation and puncture model is more appropriate for evaluating systemic inflammatory response, rather than local immune response.[5] Inoculation of a mixture of presterilized feces with B. fragilis and E. coli is an easily reproducible model to investigate residual abscesses after generalized peritonitis. Decreasing the percentage of feces and mixing it with sterile stool produces a model of septic shock. This model mimics the situation of perforated appendicitis, diverticulitis or secondary peritonitis due to colonic perforation.[6] An experimental model to study the pathophysiology and treatment modalities of intra9

Erginel et al. Effects of tissue plasminogen activator in experimentally induced peritonitis

abdominal abscesses is needed. Our model’s mortality is directly relevant to the amount of E. coli used in the inoculation. The dosage of bacteria providing peritonitis is relevantly small and the abscess formation ratio is high. Since the peritonitis is created without laparotomy and anesthesia, the recovery period is short, and the risk of complications is lower. During the experiment, the weight loss did not increase in the tPA group. Our results showed that rats were affected seriously by peritonitis, but these effects were not so much as to mask the local influence of peritonitis. In the 24th and 72nd hours, peritoneal fluid samples were obtained for culture analysis to demonstrate peritonitis. Although E. coli and B. fragilis were the only inoculated bacteria in all groups, the microbiological culture of the control group produced E. coli. In the tPA group, in addition to E. coli, bacteria such as Enterococcus, Bacillus and Klebsiella were also produced. This situation may be the result of antibiotics and tPA suppressing the normal flora and the overproduction of more resistant bacteria. The most variable microorganisms were produced in the group that received all three treatment modalities, which supports our hypothesis. The number of abscesses was the highest in the control group. In the other groups, the number of abscesses was significantly lower, especially in the rats receiving tPA. Since the lowest number of abscesses was observed in the group that received tPA, it can be concluded that the addition of tPA might have positive effects on the treatment of peritonitis. Most of the abscesses were located in the paracolic area. The drugs did not have any influence on the abscess localizations. Proinflammatory mediators TNF-α, IL-1β, and IL-6 and the anti-inflammatory mediator IL-10 were measured to evaluate the local inflammatory response. TNF-α, IL-1β, and IL-6 are the cytokines that initiate acute inflammation, and their increase is proportional to the degree of peritonitis.[7,8] Since IL-10 decreases the production of proinflammatory cytokines, it is known as an anti-inflammatory cytokine.[7] At the 24th hour after peritonitis induction, a strong local inflammatory reaction occurs, and all cytokines in the peritoneal fluid increase. Bacterial inoculation significantly increases the concentration of various inflammatory cytokines. Buyne et al.[2] found a direct proportion between bacterial load in the abdomen in peritonitis and the number of cytokines in the peritoneal fluid. As mortality increases with bacterial density, mortality and the cytokine levels in the peritoneum are also correlated. We measured the cytokine levels in order to investigate whether the substances we used have any negative effects that could potentially increase mortality. However, the tPA treatment caused a significant increase in these cytokines. Moreover, in comparison to the control group and the group that received antibiotics, the tPA group demonstrated a drop in the IL-1β responses measured from peritoneal fluid at the 10

24th and 72nd hours. In peritonitis therapy, applying tPA in addition to antibiotic can even decrease the IL-1β production, which is an inflammatory cytokine. This result makes us think that even though tPA is an exogenous substance, it does not aggravate the local inflammatory response. In 1994, van Goor et al.[9] claimed that tPA may have positive effects in experimental peritonitis. Later, Buyne et al.[10,11] obtained some remarkable results regarding peritonitis treatment in a series of experimental studies. In the peritonitis model, conducted with rats, they showed that tPA has significantly positive effects on peritonitis, especially on abscess formation. Similarly, we have shown the positive effects of tPA. The previously mentioned investigators, in other research they conducted, also proved the effect of antibiotics to be limited. However, in our study, no major difference between tPA and antibiotics was observed. In the peritonitis model of Buyne et al.,[12] the effect of tPA was investigated, and it was concluded that the level of cytokines is not affected by tPA treatment. Accordingly, in our research, there was no significant difference in the measurements of cytokine levels after either 24 hours or 72 hours. The hypothesis that these exogenous materials would exaggerate the inflammatory response was falsified by our results. In conclusion, tPA may decrease abscess formation, without exaggerating the inflammatory response. Conflict of interest: None declared.

REFERENCES 1. Buyne OR, van Goor H, Verweij PE, Bleichrodt RP, Hendriks T. Timing and dose of tissue plasminogen activator to prevent abscess formation after surgical treatment of secondary peritonitis in the rat. Surg Innov 2009;16:299-305. 2. Buyne OR, Bleichrodt RP, Verweij PE, Groenewoud HM, van Goor H, Hendriks T. A peritonitis model with low mortality and persisting intraabdominal abscesses. Int J Exp Pathol 2006;87:361-8. 3. Hubbard WJ, Choudhry M, Schwacha MG, Kerby JD, Rue LW 3rd, Bland KI, et al. Cecal ligation and puncture. Shock 2005;24 Suppl 1:527. 4. Baker CC, Chaudry IH, Gaines HO, Baue AE. Evaluation of factors affecting mortality rate after sepsis in a murine cecal ligation and puncture model. Surgery 1983;94:331-5. 5. Singleton KD, Wischmeyer PE. Distance of cecum ligated influences mortality, tumor necrosis factor-alpha and interleukin-6 expression following cecal ligation and puncture in the rat. Eur Surg Res 2003;35:48691. 6. Nathens AB. Relevance and utility of peritoneal cultures in patients with peritonitis. Surg Infect (Larchmt) 2001;2:153-62. 7. Haupt W, Riese J, Denzel C, Zowe M, Gusinde J, Siassi M, et al. Culture of human peritoneum--a new method to measure the local cytokine response and the effect of immunomodulators. Infection 1998;26:345-8. 8. Schein M, Wittmann DH, Holzheimer R, Condon RE. Hypothesis: compartmentalization of cytokines in intraabdominal infection. Surgery 1996;119:694-700.

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Erginel et al. Effects of tissue plasminogen activator in experimentally induced peritonitis 9. van Goor H, de Graaf JS, Kooi K, Sluiter WJ, Bom VJ, van der Meer J, et al. Effect of recombinant tissue plasminogen activator on intra-abdominal abscess formation in rats with generalized peritonitis. J Am Coll Surg 1994;179:407-11.

11. van Goor H, de Graaf JS, Kooi K, Bleichrodt RP. Gentamycin reduces bacteremia and mortality rates associated with the treatment of experimental peritonitis with recombinant tissue plasminogen activator. J Am Coll Surg 1995;181:38-42.

10. van Goor H, Bom VJ, van der Meer J, Sluiter WJ, Geerards S, van der Schaaf W, et al. Pharmacokinetics of human recombinant tissue-type plasminogen activator, administered intra-abdominally, in a rat peritonitis model. Eur Surg Res 1996;28:287-94.

12. Buyne OR, Bleichrodt RP, van Goor H, Verweij PE, Hendriks T. Tissuetype plasminogen activator prevents formation of intra-abdominal abscesses after surgical treatment of secondary peritonitis in a rat model. Int J Colorectal Dis 2007;22:819-25.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Deneysel peritonit modelinde doku plazminojen akivatörlerinin etkisi Dr. Başak Erginel,1 Dr. Lütfiye Öksüz,2 Dr. Turgay Erginel,3 Dr. Feryal Gün,1 Dr. Fatih Yanar,4 Dr. Nezahat Gürler,2 Dr. Tansu Salman,1 Dr. Alaaddin Çelik1 İstanbul Üniversitesi İstanbul Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, İstanbul; İstanbul Üniversitesi İstanbul Tıp Fakültesi, Mikrobiyoloji Anabilim Dalı, İstanbul; 3 İstanbul Eğitim ve Araştırna Hastanesi, Genel Cerrahi Kliniği, İstanbul; 4 İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul 1 2

AMAÇ: Peritonit, cerrahi girişimler sonrasında sık görülen iltihabi bir reaksiyondur. Tedavide antibiyotikler ve cerrahi yer alır. Hayatı tehdit eden enfeksiyonların başında gelmesi nedeniyle alternatif tedavi yöntemleri araştırılmaktadır. Bu çalışmada, sıçanlarda oluşturulan deneysel peritonit modelinde, doku plazminojen aktivatörlerinin (tPA) mikrobiyolojik ve immünolojik etkilerinin değerlendirilmesi amaçlandı. GEREÇ VE YÖNTEM: Yirmi dört erkek Wistar albino sıçan sekizerli üç gruba ayrıldı. Fekal örnekler steril edildikten sonra, Bacteroides fragilis (104 CFU/ml) ve Escherichia coli (105 CFU/ml) bakteri süspansiyonu eklenerek intraperitoneal olarak sıçanlara uygulandı. Bir saat sonra tüm sıçanlara laparotomi yapıldı, peritoneal kavite debride edildi ve parsiyel omentektomi uygulandı. Kontrol grubuna (K) tedavi uygulanmadı, antibiyotik grubuna (A), günde iki defa intravenöz metronidazol+seftriakson tedavisi uygulandı. Antibiyotik ile birlikte doku plazminojen aktivatörü (A+T) alan üçüncü gruba, cerrahiden sonraki 1., 6. ve 24. saatlerde antibiyotiğin yanı sıra periton içine tPA enjekte edildi. Mikrobiyolojik ve immünolojik analizler için 24. saatte kan ve periton sıvısı, 72. saatte sadece periton sıvısı örneği alındı. Cerrahinin beşinci günü tüm sıçanlar öldürüldü ve peritoneal kavitedeki makroskopik bulgular (apse oluşumu, boyutu ve yerleşimi) kaydedildi. BULGULAR: Ortalama periton içi apse sayısı kontrol grubunda en yüksek, üçüncü grupta (A+T) en düşük sayıda bulundu. Gruplar arasındaki sitokin seviyelerinde anlamlı farklılık bulunmadı. TARTIŞMA: Bu deneysel peritonit modelinde, doku plazminojen aktivatörü uygulanmasının enflamatuvar cevabı fazla etkilemeden apse oluşumunu bir miktar azalttığı bulunmuştur. Anahtar sözcükler: Antibiyotik; doku plazminojen aktivatörü; peritonit. Ulus Travma Acil Cerr Derg 2014;20(1):7-11

doi: 10.5505/tjtes.2014.70594

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ORIGIN A L A R T IC L E

How reliable is the Alvarado score in acute appendicitis? Yücel Yüksel, M.D.,1 Bülent Dinç, M.D.,2 Deniz Yüksel, M.D.,3 Selcan Enver Dinç, M.D.,4 Ayhan Mesci, M.D.5 1

Department of General Surgery, Tatvan State Hospital, Bitlis;

Department of General Surgery, Atatürk State Hospital, Antalya;

Department of Anaesthesiology, Tatvan State Hospital, Bitlis;

Department of Emergency Medicine, Akdeniz University Faculty of Medicine, Antalya;

Department of General Surgery, Akdeniz University Faculty of Medicine, Antalya

ABSTRACT BACKGROUND: We aimed to investigate the reliability of the Alvarado score (AS) in determining acute appendicitis and the different parameters that affect the AS. METHODS: Three hundred and thirteen patients suspected of acute appendicitis (AA) aged 18-70 years were included in this study. Patient data including AS calculated from emergency services and at discharge, follow-up, and operations were recorded. Patients were divided into three groups according to the AS, as AS <4, AS 5-7 and AS 8-10. AA and appendicitis perforation rates were compared according to the different parameters. RESULTS: The mean age of patients (55% females, 45% males) was 30.8±10.8 years. The AA (appendix perforation) rates of 211 patients who underwent operation were found as: AS ≤4: 56.5% (7.7%), AS 5-7: 75.9% (10%), and AS 8-10: 89% (27.8%). The percentage of negative appendectomy was 19.4%. The scoring was more reliable in males with AS 5-7, and the reliability weakened as body mass index (BMI) increased in all groups. CONCLUSION: Patients with AS ≤4 must be followed up and should be informed at the time of their discharge about the slight possibility of appendicitis. The effect of AS in determining the diagnosis of appendicitis is not influenced by age or symptom duration. Key words: Alvarado score; appendicitis; diagnosis; perforation.

INTRODUCTION Acute appendicitis (AA) is one of the most common emergent surgical conditions. It accounts for 1% of abdominal surgeries.[1-3] Attempts at the diagnosis of AA are made by anamnesis, physical examination, laboratory analyses, and imaging methods.[4,5] Since appendicitis may lead to morbidity and mortality unless treated, surgery is mandatory in cases with a possible diagnosis of appendicitis.[2,6] It is difficult to Address for correspondence: Bülent Dinç, M.D. Antalya Atatürk Devlet Hastanesi, Anafartalar Caddesi, 07040 Antalya, Turkey Tel: +90 242 - 345 45 50 E-mail: bulent1999@yahoo.com Qucik Response Code

make a definite diagnosis of appendicitis despite the current advanced imaging methods. Prevalence of a clinically correct diagnosis of AA is approximately 85%.[5] Lower prevalence rates lead to unnecessary surgeries; therefore, the differential diagnosis should be made precisely.[7] It is known that diagnostic interventions dramatically reduce the number of appendectomies among patients without appendicitis, the prevalence of perforation, and the duration of their hospital stay. Diagnostic methods used for the diagnosis of appendicitis include scoring systems, computer programs, ultrasonography (US), computed tomography (CT), magnetic resonance (MR), and laparoscopy.[2,5,8] Among the scoring systems, the Alvarado score (AS) is a well-tested, extensively experienced, 10-point clinical scoring system. This scoring system consists of anamnesis, physical examination findings and laboratory results.[2,4,5] The AS is a reliable, cheap and reproducible tool for the diagnosis of AA in the emergency room.[9] Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Yüksel et al. How reliable is the Alvarado score in acute appendicitis?

Many prospective studies have reported that while AS alone is an inadequate test, it can be used effectively to specify those patients that require scanning.[2,5]

Table 1. Components of the Alvarado score Alvarado Score

Score

The AS for the diagnosis of AA comprises many components, as shown in Table 1. Many studies have recommended that patients with AS <4 can be discharged, while those with scores of 5-7 should be followed, and those with scores >7 should undergo surgery.[2,4,5]

Migration of pain

This present study investigated to what extent the efficacy of the AS in detecting AA is influenced by age, gender, body mass index (BMI), and symptom duration, as well as the prevalences of AA in patients with low AS, negative appendectomy and perforation.

Elevated temperature (>37.3ºC)

MATERIALS AND METHODS The present study, which was performed after obtaining approval of the local ethical committee, included 313 patients aged 18-70 years, who applied to the Emergency Unit of Akdeniz University Hospital between March 2007 and May 2009. Pregnant women, transplant patients, and patients with known malignancy, median laparotomy, and palpable mass were all excluded from the study. Treatment was planned by the relevant physician independent of the AS. Patients were divided into three groups according to the AS, as: 1-4 (low risk), 5-7 (moderate risk) and 8-10 (high risk). The groups were compared in terms of age (≤40 years [incidence more than]/>40 years [incidence less than]), gender (male/ female), BMI (≤25 kg/m2/>25 kg/m2), and symptom duration (≤24 hours/>24 hours). Treatment of patients, as discharged, monitored or operated, was recorded. Patients who underwent surgery were grouped as AA or non-AA. We investigated whether or not the AS was influenced by age, gender, BMI, or symptom duration as well as its efficacy in detecting AA. The Statistical Package for the Social Sciences (SPSS) for Windows 16.0 program was used for the statistical analyses of the study data. As well as descriptive statistical methods (mean, standard deviation), intergroup comparison of normally distributed parameters of the quantitative data was done by Student’s t-test, whereas the Mann-Whitney U-test was used for the parameters not normally distributed. Relationships between numeric data were analyzed using correlation analysis. Qualitative data was compared by using the chi-square test. Results were evaluated within 95% confidence interval and at a P level less than 0.05.

RESULTS A total of 313 cases were included in the study between March 2007 and May 2009. Of these cases, 141 (45%) were male and 172 (55%) were female. The overall mean age was 30.8±10.8 (18-69) years. The mean age of males was 31.1±10.3 (18-69) years and of females was 30.5±11.1 (18-69) years. Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Anorexia 1 Nausea 1 Tenderness in right lower quadrant

Rebound pain

1 1

Leukocytosis >10.000/mm 2 3

Neutrophilia >75%

Total 10

1-4 Discharge 30% Appendicitis

5-7 Monitoring/Admission 66% Appendicitis

8-10 Surgery 93% Appendicitis

One hundred and fifty-seven (50%) of 313 patients underwent surgery after the first examination in the emergency room. Fifty-four (47.8%) of 113 patients hospitalized for the follow-up underwent surgery after being monitored. AA was detected in 136 (86.6%) of 157 patients and 34 (62.9%) of 54 patients who underwent surgery directly or after being monitored, respectively (Figure 1). Patients who had been discharged from the emergency room were called back for a physical examination after 24 hours. One of these patients had undergone surgery due to AA (without perforation) in an external center, whereas one patient presented with abdominal pain 12 hours after the examination in the emergency room; this patient underwent surgery and AA was detected. 38.3% of patients with AS <4 and 0% of patients with AS 8-10 had been discharged directly from the emergency room (Table 2). Among the 211 patients that underwent surgery, 56.5% of AS ≤4 patients had signs consistent with AA, whereas this ratio was 75.9% for AS 5-7 patients and 89% for AS 8-10 patients. The negative appendectomy rate (19.4%) decreased in conjunction with an increase in the calculated AS (Table 3). Patients with negative appendectomy were identified as having genitourinary diseases (tuboovarian pathology, pelvic inflammatory disease, endometriosis), colonic diseases (Crohn disease, colonic perforation, colonic diverticulosis), psoas hematoma, and normal appendix. Among patients with AS of 5-7, male patients were found more likely to have AA compared with females (Table 4). There was no significant difference between AS and AA diagnosis according to the patient’s age (Table 5). 13

Yüksel et al. How reliable is the Alvarado score in acute appendicitis?

313 patients

43 patients Discharged from the emergency department (15%)

59 patients Discharged after observation (52.2%)

113 patients Observation

157 patients Surgery

(36.1%)

(49.9%)

54 patients Surgery after observation (47.8%)

34 patients Acute appendicitis

20 patients Other

(62.9%)

(37.1%)

136 patients Acute appendicitis

21 patients Other

(86.6%)

(13.4%)

5 patients Perforated appendicitis (14.7%)

28 patients Perforated appendicitis (18.4%)

Figure 1. Distribution of the study patients.

Table 2. Distribution of the patients according to the Alvarado score Alvarado score

Discharged

Discharged after observation

n %

Surgery

Surgery after observation

Total

n %

≤4

23 38.3

14 23.3

16.7

13 21.7

100

5-7

20 14.8

36 21.7

37.8

28 20.7

135

100

8-10

9 7.6

81.4

13 11.0

118

100

Total

43 13.7

59 18.8

157

50.1

54 17.4

313

100

Table 3. Distribution of surgical findings of the patients who underwent surgery according to the Alvarado score Results Appendicitis (-)

Appendicitis (+)

n %

≤4

10 43.5

13 56.5

23 100

5-7

19 24.1

60 75.9

79 100

8-10

12 11.0

97 89.0

109 100

Total

41 19.4

170 80.6

211 100

Alvarado score

Total

=0.001

Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Yüksel et al. How reliable is the Alvarado score in acute appendicitis?

Table 4. Distribution of patients according to gender and the Alvarado score Results Alvarado score

Gender

≤4

5-7

8-10

Appendicitis (-)

Appendicitis (+)

Total

n %

Female

29 85.3

5 14.7

34 100

Male

18 69.2

8 30.8

26 100

Total

47 78.3

13 21.7

60 100

Female

55 73.3

20 26.7

75 100

Male

20 33.3

40 66.7

60 100

Total

75 55.6

60 44.4

135 100

Female

16 25.4

47 74.6

63 100

Male

6 10.9

49 89.1

55 100

Total

22 19.4

96 44.4

118 100

=0.119

<0.001

=0.55

Table 5. Distribution of patients according to age and the Alvarado score Results Alvarado score

Age

≤4

5-7

8-10

Appendicitis (-)

Appendicitis (+)

Total

n %

≤40

42 77.8

12 22.2

54 100

>40

5 83.4

1 16.6

6 100

Total

47 78.3

13 21.7

60 100

≤40

67 58.8

47 41.2

114 100

>40

8 38.1

13 61.9

21 100

Total

75 55.6

60 44.4

135 100

≤40

19 20.5

74 79.5

93 100

>40

3 22.0

22 88.0

25 100

Total

22 18.7

96 81.3

118 100

=0.369

=0.147

=0.233

Table 6. Distribution of patients according to BMI and the Alvarado score Results Alvarado score

BMI

≤4

5-7

8-10

Appendicitis (-)

Appendicitis (+)

Total

n %

≤25

32 77.8

8 22.2

40 100

>25

15 83.4

5 16.6

20 100

Total

47 78.3

13 21.7

60 100

≤25

51 62.2

31 37.8

82 100

>25

24 45.3

29 54.7

53 100

Total

75 62.3

60 37.7

135 100

≤25

19 20.5

74 79.5

93 100

>25

3 22.0

22 88.0

25 100

Total

22 18.7

96 81.3

118 100

=0.448

=0.04

=0.077

BMI: Body mass index.

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Yüksel et al. How reliable is the Alvarado score in acute appendicitis?

Table 7. Distribution of patients according to symptom duration and the Alvarado Score Results Alvarado score ≤4

5-7

8-10

Duration of symptoms

Appendicitis (-)

Appendicitis (+)

Total

n %

≤24

27 77.2

8 22.8

35 100

>24

20 80.0

5 20.0

25 100

Total

47 78.3

13 21.7

60 100

≤24

51 51.0

49 49.0

100 100

>24

24 68.6

11 31.4

35 100

Total

75 62.3

60 37.7

135 100

≤24

14 16.9

69 83.1

83 100

>24

8 22.9

27 77.1

35 100

Total

22 18.7

96 81.3

118 100

=0.525

=0.066

=0.332

Table 8. Comparison between the Alvarado Score and appendix perforation Results Appendicitis (+)

n %

≤4

12 92.3

1 7.7

13 100

5-7

54 90.0

6 10.0

60 100

8-10

70 72.2

27 27.8

97 100

Total

136 80.0

34 20.0

170 100

In the comparison of BMI in the patient group with AS 5-7, 37.8% of patients with BMI ≤25 and 54.7% of patients with BMI >25 had appendicitis, and this difference was significant. An increase in BMI reduced the reliability of AS in all groups (Table 6). There was no difference between groups in the comparison of the diagnosis of appendicitis by the AS according to the variation in symptom duration as more or less than 24 hours (Table 7). In patients with AS ≤4 and AS 5-7, the rates of perforated appendicitis were found as 7.7% and 27.8%, respectively (Table 8). Accordingly, the incidence of perforation was seen to increase as the AS increased.

DISCUSSION Acute appendicitis (AA) is the most common cause of acute abdomen in all age groups. Accurate and prompt diagnosis in those admitted to the emergency room with the preliminary diagnosis of AA remains problematic.[10] Anamnesis and physical examination are the cornerstones of the diagnosis.[11] The aim is to make an early and accurate diagnosis before the de16

Appendicitis (-)

Alvarado score

Total %

=0.013

velopment of complications, thereby reducing the prevalence of negative appendectomy. Studies in the literature have recommended hospital discharge for patients with AS ≤4.[5,12] In the study of Khan et al.,[13] when patients with AS ≤4 were divided into two as those discharged after monitoring (emergency room and surgery clinic) and those who underwent surgery, 17 of 100 patients were in the first group, and were discharged. Three of the patients returned within 48 hours and the new AS was calculated as 7; they underwent surgery and AA was detected (17%). Winn et al.[12] discharged 12 patients (9.8%) and offered no medical follow-up; 4 patients were re-admitted and 2 underwent surgery, but appendicitis was not found. In the present study, 37 patients with AS ≤4 were discharged; 2 of them underwent surgery due to re-admittance, and AA was detected (5.4%). With regard to the patients that underwent surgery with AS ≤4, Yildirim et al.[5] performed surgery in 14 patients, and detected AA in 13 (92.8%). In the present study, 23 patients with AS ≤4 underwent surgery, and AA was detected in 13 (56.5%). The result was higher than that in the literature. We think that patients with AS ≤4 should be monitored; discharged patients should be informed about abdominal pain Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Yüksel et al. How reliable is the Alvarado score in acute appendicitis?

and asked to re-apply to the hospital if their pain increases. If a patient is coming from a remote distance, patients with AS ≤4 should be hospitalized and monitored, and their AS should be calculated regularly. We concluded that some cases may be overlooked if patients with AS ≤4 are discharged without clinical correlation. If surgery is not considered in the patients with AS ≤4, we think that it would be appropriate to repeat the scoring at 3-4-hour intervals. Recurrent examinations may reduce morbidity in suspected patients. With regard to the patients with AS 5-7, our results (75.9%) of AA are comparable with those of Yildirim et al.,[5] who detected AA in 84.2% of their patients. We think that patients with AS 5-7 should be evaluated based on the clinical picture, scanning methods should be considered for young females, and a decision should be made by calculating AS at certain intervals. With regard to the patients with AS 8-10, AA was detected in 91% of patients by Yildirim et al.,[5] in 86.5% by Khan et al.,[13] in 80.7% by Winn et al.,[12] and in 82% in the present study. The results were consistent with the literature. According to our results, reliability of AS is increased in the patients with AS of 8-10. This group of patients should undergo surgery without the need of other scanning methods. It should be kept in mind that morbidity, mortality and cost may increase in such patients if the surgery is delayed. A negative appendectomy rate of 15-30% was found by Douglas et al.,[2] 6.8% by Jo et al.,[14] 32.5% by Menteş et al.,[11] and 19.4% in the present study. The distribution of negative appendectomy rates according to the three groups as AS ≤4, AS 5-7 and AS 8-10 was not examined in the literature. According to Alvarado, a score of ≤6 is significant in 80% of negative appendectomies. It is thought that using their scoring system, particularly in children and the elderly, would reduce the prevalence of negative appendectomy and perforation. In this study, negative appendectomy rates were found as 43.5% for AS ≤4, 24.1% for AS 5-7 and 11% for AS 8-10, respectively. Prevalence of negative appendectomy ranges between 15% and 40% in the literature.[4,15-20] Based on these data, prevalence of negative appendectomy in the AS ≤4 group is beyond acceptable values. In the other groups, prevalence of negative appendectomy is reduced to more acceptable levels. However, as is known, operating on a patient with suspected AA and obtaining a negative appendectomy should not be considered as negativity. No study in the literature has investigated the efficacy of the AS according to age, gender and BMI. The present study evaluated the efficacy of AS (≤4, 5-7, 8-10) according to age, gender and BMI. The present study found no difference between genders in terms of the reliability of the AS in the AS ≤4 group. The AS revealed more correct result in males in the AS 5-7 group. We think that male patients with AS 5-7 Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

should undergo surgery without monitoring or using other auxiliary scanning methods, whereas female patients should be monitored or evaluated by other scanning methods. No difference was found between genders in the AS 8-10 group. In the present study, we observed no difference in terms of the reliability study performed by considering the age threshold as 40 years. Thus, AS can be used for evaluation of AA independent of age. With regard to the BMI reliability of the AS, a statistically significant result was found only for the AS 5-7 group. No statistically significant difference was found for the AS 8-10 group despite such close values as 79.5% and 88% (BMI ≤25, BMI >25, respectively) for those with AA. Considering overall cases, high BMI reduces the reliability of the AS. Delayed treatment of AA prolongs the duration of hospitalization and return to normal life and increases the prevalence of perforation.[19,20] The general perforation rate of AA was 20% according to Menteş et al.[11] In the present study, the prevalence of perforated appendicitis was 7.7% in the AS ≤4 group, 10% in the AS 5-7 group, 27% in the AS 8-10 group, and 20% in all cases. As seen in the Table, the prevalence of perforation increases as the AS increases. Although Douglas et al.[2] defended surgical intervention as being non-essential in patients with AS ≤4, the present study detected perforation in one case (7.7%) in this group. Therefore, we think that perforation may not be determined based on the AS. However, it is a fact that perforation is more likely in patients with a high AS. We believe there is a risk for perforation even when the AS is low, and such patients should undergo repeated AS calculation. In conclusion, in the present study, we investigated the efficacy of the Alvarado score in determining acute appendicitis. The results are summarized below: 1) Acute appendicitis may be detected in patients with AS ≤4, and thus recommendations should be made while patients with AS ≤4 are being discharged. 2) In patients with AS of 5-7, the efficacy of AS in detecting AA is lower in females than males. 3) In patients with AS of 5-7, the efficacy of AS in detecting appendicitis is higher in patients with BMI <25. 4) Evaluating the patient’s age in conjunction with AS has no efficacy in detecting appendicitis. Conflict of interest: None declared.

REFERENCES 1. Özuğur Ş. Klinik olarak şüpheli akut apandisitlerin değerlendirilmesinde Tc-99m HMPAO işaretli lökosit sintigrafisinin yeri. [Uzmanlık Tezi] Akdeniz Üniversitesi Tıp Fakültesi Nükleer Tıp Anabilim Dalı, Antalya 2001. 2. Douglas CD, Macpherson NE, Davidson PM, Gani JS. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ 2000;321:919-22.

Yüksel et al. How reliable is the Alvarado score in acute appendicitis? 3. Poortman P, Oostvogel HJ, Bosma E, Lohle PN, Cuesta MA, de Langede Klerk ES, et al. Improving diagnosis of acute appendicitis: results of a diagnostic pathway with standard use of ultrasonography followed by selective use of CT. J Am Coll Surg 2009;208:434-41. 4. Denizbasi A, Unluer EE. The role of the emergency medicine resident using the Alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident. Eur J Emerg Med 2003;10:296-301. 5. Yildirim E, Karagülle E, Kirbaş I, Türk E, Hasdoğan B, Tekşam M, et al. Alvarado scores and pain onset in relation to multislice CT findings in acute appendicitis. Diagn Interv Radiol 2008;14:14-8. 6. Menteş O, Eryılmaz M, Harlak A, Oztürk E, Tufan T. The value of serum fibrinogen level in the diagnosis of acute appendicitis. Ulus Travma Acil Cerrahi Derg 2012;18:384-8. 7. Schwartz S. Apendiks. In: Rosemay A, Rosly K, Rosly JJ, editors. Geçim İE. Cerrahinin ilkeleri. 7th ed. Ankara: AnTıp; 2004. p. 1403-17. 8. 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;80:253-8. 9. Pouget-Baudry Y, Mucci S, Eyssartier E, Guesdon-Portes A, Lada P, Casa C, et al. The use of the Alvarado score in the management of right lower quadrant abdominal pain in the adult. J Visc Surg 2010;147:40-4. 10. Ohle R, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med 2011;9:139. 11. Menteş Ö, Eryılmaz M, Yiğit T, Taşcı S, Balkan M, Kozak O, et al. Retrospectively analysis of appendectomies which performed elderly cases.

[Article in Turkish] Akademik Acil Tıp Dergisi 2008;7:36-41 12. Winn RD, Laura S, Douglas C, Davidson P, Gani JS. Protocol-based approach to suspected appendicitis, incorporating the Alvarado score and outpatient antibiotics. ANZ J Surg 2004;74:324-9. 13. Khan I, ur Rehman A. Application of alvarado scoring system in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2005;17:41-4. 14. Jo YH, Kim K, Rhee JE, Kim TY, Lee JH, Kang SB, et al. The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis. Am J Emerg Med 2010;28:766-70. 15. Kamran H, Naveed D, Nazir A, Hameed M, Ahmed M, Khan U. Role of total leukocyte count in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2008;20:70-1. 16. Hernandez JA, Swischuk LE, Angel CA, Chung D, Chandler R, Lee S. Imaging of acute appendicitis: US as the primary imaging modality. Pediatr Radiol 2005;35:392-5. 17. Chong CF, Thien A, Mackie AJ, Tin AS, Tripathi S, Ahmad MA, et al. Comparison of RIPASA and Alvarado scores for the diagnosis of acute appendicitis. Singapore Med J 2011;52:340-5. 18. Palabıyık F, Kayhan A, Cimili T, Toksoy N, Bayramoğlu S, Aksoy S. The comparison of plain film and ultrasound findings of appendicitis in children. [Article in Turkish] Marmara Medical Journal 2008;21:203-9. 19. 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. 20. 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.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Alvarado skoru akut apandisitte ne kadar güvenilir? Dr. Yücel Yüksel,1 Dr. Bülent Dinç,2 Dr. Deniz Yüksel,3 Dr. Selcan Enver Dinç,4 Dr. Ayhan Mesci5 Tatvan Devlet Hastanesi, Genel Cerrahi Kliniği, Bitlis; Atatürk Devlet Hastanesi, Genel Cerrahi Kliniği, Antalya; 3 Tatvan Devlet Hastanesi, Anesteziyoloji ve Reanimasyon Bölümü, Bitlis; 4 Akdeniz Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Antalya; 5 Akdeniz Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Antalya 1 2

AMAÇ: Bu çalışmada, Alvarado skorunun (AS) akut apandisiti (AA) saptamadaki güvenilirliği ve farklı parametrelerden ne oranda etkilendiği araştırıldı. GEREÇ VE YÖNTEM: Akut apandisit şüphesi olan 18-70 yaş arası 313 hasta çalışmaya alındı. Acil serviste AS’leri hesaplanan hastaların taburcu, izlem ve ameliyat bilgileri kayıt edildi. Hastalar AS ≤4, AS 5-7 ve AS 8-10 olmak üzere üç gruba ayrıldı. Farklı parametrelerde hastaların AA ve apendiks perforasyon oranlarına bakıldı. BULGULAR: Hastaların (%55 kadın, %45 erkek) yaş ortalaması 30.8±10.8 idi. Ameliyat edilen 211 hastanın sırasıyla akut apendisit (apendiks perforasyon) oranları: AS ≤4; %56.5 (%7.7), AS 5-7; %75.9 (%10), AS 8-10; %89 (%27.8) olarak bulundu. Negatif apendektomi %19.4 saptandı. AS 5-7 arası erkeklerde skorlama daha güvenilir olmakla birlikte tüm gruplarda beden kütle indeksi (BKİ) arttıkça güvenilirlik azaldı. TARTIŞMA: Alvarado skoru ≤4 olan hastalar izlenmeli, taburcu edilen hastalar akut apandisit olabilecekleri hakkında bilgilendirilmelidir. AS’nin apandisiti saptamadaki etkisi, yaş ve semptomların başlama süresinden etkilenmemektedir. Anahtar sözcükler: Alvarado skoru; apandisit; perforasyon; tanı. Ulus Travma Acil Cerr Derg 2014;20(1):12-18

doi: 10.5505/tjtes.2014.60569

Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

ORIGIN A L A R T IC L E

Neutrophil-to-lymphocyte ratio as a predictor of acute appendicitis Şahin Kahramanca, M.D.,1# Gülay Özgehan, M.D.,1 Duray Şeker, M.D.,1 Emre İsmail Gökce, M.D.,1 Gaye Şeker, M.D.,1 Gündüz Tunç, M.D.,2 Tevfik Küçükpınar, M.D.,1 Hülagü Kargıcı, M.D.1 1

Department of General Surgery, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara;

Department of General Surgery, Acibadem Hospital, Ankara

ABSTRACT BACKGROUND: Accurately diagnosing appendicitis can be difficult. This retrospective study aimed to evaluate the ability of the neutrophil-to-lymphocyte ratio (NLR) to predict acute appendicitis pre-operatively and to differentiate between simple and complicated appendicitis. METHODS: A database of 1067 patients who underwent surgery was evaluated. Based on postoperative histopathological examination, the patients were divided into two groups: acute appendicitis (G1) and normal appendix (G2). Patients in the acute appendicitis group were further divided into two subgroups: simple appendicitis (G1a) and complicated (gangrenous and perforated) appendicitis (G1b). RESULTS: G1 included 897 patients and G2 included 170 patients. Among the 897 G1 patients, there were 753 G1a patients and 144 G1b patients. A NLR of 4.68 was associated with acute appendicitis (G1 vs G2, p<0.001). The sensitivity and specificity were 65.3% and 54.7%, respectively. A NLR of 5.74 was associated with complicated appendicitis (G1a vs G1b, p<0.001). The sensitivity and specificity of the two clinical features were 70.8% and 48.5%, respectively. CONCLUSION: We suggest that preoperative NLR is a useful parameter to aid in the diagnosis of acute appendicitis and differentiate between simple and complicated appendicitis, and can be used as an adjunct to the clinical examination. Key words: Appendicitis; complicated appendicitis; lymphocyte; neutrophil.

INTRODUCTION Acute appendicitis (AA) is one of the most common causes of acute abdomen. The lifetime occurrence of this disease is approximately 7%, with perforation rates of 17-20%.[1] The mortality risk is less than 1% in the general population, but this number can rise to 50% among the elderly population. [2,3] This entity has some well-known signs and symptoms, like increased leukocyte count and right lower quadrant pain. However, these predictors are not constant and their accu#Current affiliation: Department of General Surgery, Kars State Hospital, Kars, Turkey Address for correspondence: Şahin Kahramanca, M.D. Kars Devlet Hastanesi, Genel Cerrahi Kliniği, Kars, Turkey Tel: +90 474 - 212 56 68 E-mail: drkahramancasahin@gmail.com Qucik Response Code

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racy is questionable. Many authors have reported that a raised leukocyte count is a sensitive test for AA but is not diagnostic because of its low sensitivity.[4,5] Further, atypical presentations are not infrequent, especially in the elderly. To overcome morbidity and mortality of perforation before surgery, a negative appendectomy is somewhat acceptable traditionally. However, in recent years, many have considered this unacceptable, and have studied means of improving the preoperative diagnosis,[6-8] since the operation itself is a cause of morbidity and mortality. In recent years, some authors reported that the neutrophil-to-lymphocyte ratio (NLR) is a predictor of inflammation and useful in the preoperative diagnosis of AA.[9-11] In this study, we suggest that calculation of the NLR may provide a sensitive parameter in the preoperative prediction of AA and may help preoperatively to differentiate complicated from non-complicated appendicitis. We also suggest that this parameter may prevent negative appendectomies based on its predictive value.

MATERIALS AND METHODS We retrospectively reviewed a database of 1184 patients who 19

Kahramanca et al. Neutrophil-to-lymphocyte ratio as a predictor of acute appendicitis

had undergone open appendectomy for a preoperative diagnosis of AA between 2005 and 2013. The clinical diagnosis of AA was established preoperatively by means of clinical history, physical examination, traditional laboratory tests, and in some patients, by imaging studies like ultrasonography. Laboratory tests were performed on blood samples obtained on admission to the hospital. The leukocyte count and neutrophil percentage were measured by an automated hematology analyzer (Coulter® LH 780 Hematology Analyzer, Beckman Coulter Inc., Brea, CA, USA). The upper limits of the reference interval for leukocyte counts were 4500-10300/µL.

were compared by using Student’s t or Mann-Whitney U-test, where appropriate. Categorical data were analyzed by Pearson’s chi-square test, where appropriate. The cutoff values of parameters for discrimination of the groups were determined using the receiver operating characteristic (ROC) analysis. At each value, the sensitivity and specificity for each outcome under study were plotted, thus generating an ROC curve. A p value less than 0.05 was considered statistically significant.

One hundred and seventeen patients with a normal appendix, but who had another pathological process diagnosed intraoperatively that explained their presentation of acute abdomen, were excluded. Totally, the data of 1067 patients were analyzed. Pathology reports were used to determine whether the appendix was inflamed or normal. According to pathology reports, patients were grouped into two as positive appendectomy (G1) and negative appendectomy (G2) groups. For subgroup analysis, G1 was divided into two as complicated (G1a) and non-complicated (G1b) appendicitis according to the intraoperative findings. Complicated appendicitis was defined as gangrenous and/or perforated appendicitis.

The recommended cutoff value of the NLR for positive and negative appendectomies was decided using ROC curve analyses. The recommended cutoff value of the NLR was based on the most prominent point on the ROC curve for sensitivity (0.653) and specificity (0.547). Because these two parameters indicated a cutoff value of 4.68, the recommended NLR cutoff value was defined as 4.68 (Figure 1). The area under the ROC curve was 0.639 (95% confidence interval [CI] 0.591-0.687; p<0.001). For sub-group analysis, the recommended cutoff value of the NLR was based on the most prominent point on the ROC curve for sensitivity (0.708) and specificity (0.485). Because these two parameters indicated a cutoff value of 5.74, the recommended NLR cutoff value was defined as 5.74 (Figure 2). The area under the ROC curve was 0.609 (95%CI 0.560-0.659; p<0.001).

Statistical Analysis

RESULTS

The data analysis was performed using the Statistical Package for the Social Sciences for Windows, version 17.0 (SPSS Inc, Chicago, IL, USA). Whether the distributions of continuous variables were normal or not was determined by Shapiro-Wilk test. Data were shown as mean±standard deviation or median (min-max), where applicable. The differences between groups

The data of 1067 patients were analyzed. The mean age of the analyzed group was 31.22±11.9 (SD), and 66.5% of the patients were male. There were 170 patients in G2, and 897 patients in G1. In subgroups, there were 753 patients in G1a, and 144 patients in G1b. There was no significant difference in mean age between G1 and G2 (31.0±11.61 vs 32.3±13.28; ROC Curve

1.0

0.8

Sensitivity

ROC Curve

0.6

0.4

0.2

0.0

0.2

0.4

0.6

0.8

1.0

0.0

0.2

0.4

0.6

0.8

1 - Specificity

Diagonal segments are produced by ties

Figure 1. ROC curve for negative and positive appendectomies. The area under ROC curve: 0.639. 95%CI 0.591-0.687; p value <0.001.

0.6

1.0

Figure 2. ROC curve for complicated and non-complicated appendectomies. The area under ROC curve: 0.609. 95%CI 0.560-0.659; p value <0.001.

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Table 1. Distribution of patients according to the NLR cutoff values in the main groups Cutoff value of NLR

Negative appendectomy (G2)

Positive appendectomy (G1)

<4.68 93 311 >4.68 77 586 Total 170 897 NLR: Neutrophil-to-lymphocyte ratio.

Table 2. Distribution of patients according to the NLR cutoff value in subgroups Cutoff value of NLR

Non-Complicated AA

Complicated AA

<5.74

365 42

>5.74

388 102

Total

753 144

AA: Acute appendicitis; NLR: Neutrophil-to-lymphocyte ratio.

p=0.201). The male/female ratio was significantly higher in G1 (69.0% vs 53.6%, p<0.001). The mean NLR values in G1 and G2 were 8.10±7.00 and 5.89±5.22, respectively, and there was a significant difference in NLR values between the groups (p<0.001). Cutoff value of NLR was 4.68, giving a sensitivity of 65.3% and specificity of 54.7%. Negative predictive value (NPV) was 23.0% and positive predictive value (PPV) was 88.4%. The mean ages in G1a and G1b were 36.7±14.65 (SD) and 29.9±10.61 (SD), respectively, and this difference was significant (p<0.001). There was no significant difference in sex ratio between these subgroups (p=0.210). Mean NLR values for G1a and G1b were 9.85±8.68 (SD) and 7.77±6.59 (SD), respectively. Cutoff value for this subgroup was 5.74, with a sensitivity of 70.8% and specificity of 48.5%. PPV was 20.8% and NPV was 89.7%. Distribution of patients among groups according to the presence or absence of AA and type of appendicitis is given in Tables 1 and 2. Intergroup findings are given in Table 3.

DISCUSSION Early diagnosis of AA is not always easy. The decision to observe the patient until the diagnosis becomes obvious or to operate early to prevent unwanted complications like perfora-

tion and peritonitis represents a serious dilemma for surgeons. An early operation may result in the removal of a normal appendix with a small risk of morbidity.[6-8,12] AA is most likely an everyday occurrence in emergency units. Especially in rural areas, surgeons may not have imaging facilities. Further, presence of ultrasonography or computed tomography imaging may not help in achieving an accurate diagnosis. Thus, surgeons are still in need of an accurate and easy test to obtain the diagnosis. Our results show that NLR with a cutoff value of 4.68 can significantly differentiate a normal appendix and inflamed AA. This value is much higher than the numbers given in previous reports,[9,11] but less than the number reported by Ishizuka et al.[13] The sensitivity of this cutoff value is 65.3%, which means that a total of 65% of patients with histologically confirmed AA have an elevated ratio. The specificity of 54.7% is also low (thus a high false-positive rate). These low sensitivity and specificity values may be explained by the fact that only operated patients were included in this study; data about other suspected cases who were not operated or were medically treated are unknown. Another interesting finding is that the female to male ratio is significantly higher in the negative appendectomy group. This may be attributed to gynecological diseases mimicking AA.

Table 3. Intergroup comparison Group

Mean NLR

SD (±)

Cutoff value

Sensitivity

G1 8.1 7.00 4.68 <0.001 65.3%

Specificity

PPV

NPV

54.7% 88.4% 23%

G2 5.89 5.22 G1a 9.85 8.65 5.74 <0.001 70.8%

48.5% 20.8% 89.7%

G1b 7.77 6.58 G1: Positive appendectomy group; G2: Negative appendectomy group; G1a: Complicated appendectomy group; G1b: Non-complicated appendectomy group; NLR: Neutrophil-to-lymphocyte ratio; PPV: Positive predictive value; NPV: Negative predictive value.

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The cutoff value of NLR for complicated appendicitis was 5.74, with a sensitivity of 70.8% and specificity of 48.5%. With regard to sensitivity and specificity values, it seems NLR is more helpful in differentiating complicated cases. Our cutoff value is lower than the value (8.00) recommended for the differentiation of gangrenous appendicitis in the report of Ishizuka et al.[13] In the study of Yazici et al.,[11] it was reported that the sensitivity is maximum when NLR is >3.5, but specificity and PPV increase steadily when NLR increases, and the most prominent values are reached when NLR is >5.0. There are very few studies on this subject, but all reported that NLR appears to have greater diagnostic accuracy than traditional diagnostic laboratory tests (either white blood cell or C-reactive protein alone). It is also reported that NLR on admission to the hospital is an independent predictor of positive appendicitis histology.[10] Further, lymphocyte counts may even fall in appendicitis, with the largest decrease occurring in gangrenous appendicitis.[7,14-17] This phenomenon may explain the higher cutoff value in complicated appendicitis. The significant rise in NLR in cases without complicated appendicitis may be explained by a greater increase in the number of neutrophils in comparison with leukocyte count in the beginning of the acute phase of acute inflammation. In conclusion, according to the results of our study, NLR of 4.68 seems to be a reliable parameter to obtain a more certain diagnosis of acute appendicitis, and NLR of 5.74 may help to differentiate complicated from non-complicated appendicitis. However, a normal value for NLR does not exclude the diagnosis. To find the optimal NLR and to test its accuracy, prospective randomized studies are needed. The clinical evaluation by the surgeon should continue to take precedence. Conflict of interest: None declared.

REFERENCES 1. Storm-Dickerson TL, Horattas MC. What have we learned over the past 20 years about appendicitis in the elderly? Am J Surg 2003;185:198-201.

2. Franz MG, Norman J, Fabri PJ. Increased morbidity of appendicitis with advancing age. Am Surg 1995;61:40-4. 3. Freund HR, Rubinstein E. Appendicitis in the aged. Is it really different? Am Surg 1984;50:573-6. 4. Yang HR, Wang YC, Chung PK, Chen WK, Jeng LB, Chen RJ. Role of leukocyte count, neutrophil percentage, and C-reactive protein in the diagnosis of acute appendicitis in the elderly. Am Surg 2005;71:344-7. 5. Hallan S, Asberg A, Edna TH. Additional value of biochemical tests in suspected acute appendicitis. Eur J Surg 1997;163:533-8. 6. Schellekens DH, Hulsewé KW, van Acker BA, van Bijnen AA, de Jaegere TM, Sastrowijoto SH, et al. Evaluation of the diagnostic accuracy of plasma markers for early diagnosis in patients suspected for acute appendicitis. Acad Emerg Med 2013;20:703-10. 7. Hoffmann J, Rasmussen OO. Aids in the diagnosis of acute appendicitis. Br J Surg 1989;76:774-9. 8. Dunn EL, Moore EE, Elerding SC, Murphy JR. The unnecessary laparotomy for appendicitis-can it be decreased? Am Surg 1982;48:320-3. 9. Goodman DA, Goodman CB, Monk JS. Use of the neutrophil:lymphocyte ratio in the diagnosis of appendicitis. Am Surg 1995;61:257-9. 10. Markar SR, Karthikesalingam A, Falzon A, Kan Y. The diagnostic value of neutrophil: lymphocyte ratio in adults with suspected acute appendicitis. Acta Chir Belg 2010;110:543-7. 11. Yazici M, Ozkisacik S, Oztan MO, Gürsoy H. Neutrophil/lymphocyte ratio in the diagnosis of childhood appendicitis. Turk J Pediatr 2010;52:400-3. 12. Mason RJ, Moazzez A, Sohn H, Katkhouda N. Meta-analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon) appendicitis. Surg Infect (Larchmt) 2012;13:74-84. 13. Ishizuka M, Shimizu T, Kubota K. Neutrophil-to-Lymphocyte Ratio Has a Close Association With Gangrenous Appendicitis in Patients Undergoing Appendectomy. Int Surg 2012;97:299-304. 14. Raftery AT. The value of the leucocyte count in the diagnosis of acute appendicitis. Br J Surg 1976;63:143-4. 15. Doraiswamy NV. Leucocyte counts in the diagnosis and prognosis of acute appendicitis in children. Br J Surg 1979;66:782-4. 16. English DC, Allen W, Coppola ED, Sher A. Excessive dependence on the leukocytosis cue in diagnosing appendicitis. Am Surg 1977;43:399-402. 17. Sasso RD, Hanna EA, Moore DL. Leukocytic and neutrophilic counts in acute appendicitis. Am J Surg 1970;120:563-6.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Nötrofil/lenfosit oranının akut apandisit tanısındaki belirleyiciliği Dr. Şahin Kahramanca,1# Dr. Gülay Özgehan,1 Dr. Duray Şeker,1 Dr. Emre İsmail Gökce,1 Dr. Gaye Şeker,1 Dr. Gündüz Tunç,2 Dr. Tevfik Küçükpınar,1 Dr. Hülagü Kargıcı1 1 2

Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara; Acıbadem Hastanesi, Genel Cerrahi Kliniği, Ankara

AMAÇ: Akut apandisitin tanısı zor olabilmektedir. Bu retrospektif çalışmada, nötrofil/lenfosit oranının (NLR) akut apandisit tanısındaki ve komplike apandisit ile basit apandisit ayrımındaki belirleyiciliği araştırıldı. GEREÇ VE YÖNTEM: Akut apandisit tanısı ile ameliyat edilmiş 1067 hastanın kayıtları retrospektif olarak incelendi. Histopatolojik değerlendirmeye göre hastalar akut apandisit (G1) ve normal appendiks (G2) olarak iki ana gruba ayrıldı. Akut apandisit grubundaki hastalar ise yeniden basit apandisit ve komplike (perfore ve gangrene) olarak alt iki gruba ayrıldı. BULGULAR: G1 grubunda 897, G2 grubunda 170 hasta vardı. G1a’da 753, G1b’de ise 144 hasta vardı. Akut apandisit tanısı konulmasında NLR için cut-off değeri 4.68 (p<0.001) olarak hesaplandı. Sensitivite %65.3, spesifite ise %54.7 idi. Komplike apandisit ayırımı için NLR cut-off değeri 5.74 olarak hesaplandı. Sensitivitesi %70.8, spesifitesi ise %48.5 idi. TARTIŞMA: Akut apandisit tanısının konulmasında ve komplike apandisit ayrımında NLR klinik değerlendirmeye ek olarak faydalı bir parametredir. Anahtar sözcükler: Apandisit; komplike apandisit; lenfosit; nötrofil. #Şimdiki kurumu: Kars Devlet Hastanesi, Genel Cerrahi Kliniği, Kars Ulus Travma Acil Cerr Derg 2014;20(1):19-22

doi: 10.5505/tjtes.2014.20688

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ORIGIN A L A R T IC L E

The role of colorectal stent placement in the management of acute malignant obstruction Hakan Yanar, M.D.,1 Beyza Ozcinar, M.D.,1 Fatih Yanar, M.D.,1 Emre Sivrikoz, M.D.,1 Nergiz Dagoglu, M.D.,2 Orhan Agcaoglu, M.D.,1 Kayihan Gunay, M.D.,1 Recep Guloglu, M.D.,1 Cemalettin Ertekin, M.D.1 1

Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul;

Department of Radiation Oncology, Istanbul University Istanbul Faculty of Medicine, Istanbul

ABSTRACT BACKGROUND: In recent decades, the use of colorectal stents for palliation or as a bridge to surgery in acute malignant colorectal obstruction has increased. We aimed to evaluate the technical and clinical efficacy, safety and clinical outcomes of endoscopic stenting for the relief of acute colorectal obstruction secondary to cancer. METHODS: From March 2006 to December 2012, among 100 patients with acute malignant colorectal obstruction, stenting procedures were performed on 42 patients for relief of obstruction. Uncovered self-expanding metal stents (SEMS) were placed endoscopically under fluoroscopic guidance in all patients. Using the patient database, a review was conducted to determine the effectiveness of the procedure and the short- and long-term complications. RESULTS: Stent placement was technically successful in 39/42 (92.8%) and clinically successful in 38/42 (90.4%) patients. Sixteen patients later underwent an elective surgical resection, and in 26 patients with metastatic disease or comorbidity, stent placement was palliative. Complications occurred in 10 (23.8%) patients, and the most common was tenesmus (n=3). Migration, bleeding, and rectosigmoid perforation occurred in two patients each. Stent obstruction due to fecal impaction was seen in one case. CONCLUSION: Stent placement for colorectal obstruction is an effective and relatively safe procedure, with minor complications. It not only allows subsequent elective resection, but is also definitive for palliative treatment in patients with obstructive colorectal cancer. Key words: Colorectal cancer; obstruction; self-expanding metal stents; stent.

INTRODUCTION Acute mechanical intestinal obstruction secondary to colorectal cancer is one of the most common surgical emergencies, usually affecting the left colon. In patients with this condition, emergency surgery is associated with significantly increased morbidity and mortality, as well as ostomy rates.[1] Since the introduction of colonic stenting, the endoscopic approach has been advocated as an alternative to traditional surgery for relieving acute colorectal obstruction, whether palliative or as a Address for correspondence: Hakan Yanar, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Travma ve Acil Cerrahi Servisi, Genel Cerrahi Anabilim Dalı, Fatih, İstanbul, Turkey Tel: +90 212 - 531 12 46 E-mail: htyanar@yahoo.com Qucik Response Code

bridge to definitive surgery. Advantages of preoperative stent placement also include an elective laparoscopic resection of the tumor as well as the ability to perform a full colonoscopy preoperatively to exclude any synchronous lesions. Utilization of self-expanding metal stents (SEMS) in the colon was first reported in 1991,[2] and one year later, Spinelli and colleagues[3] reported the placement of a modified GianturcoRosch stent to relieve an acute colonic obstruction secondary to cancer. Although endoscopic alleviation of colorectal obstruction has been used increasingly in recent years, it has not yet become a standard treatment option. In the present study, we aimed to evaluate the technical and clinical efficacy, safety and clinical outcomes of SEMS for the relief of acute colorectal obstruction secondary to cancer.

Ulus Travma Acil Cerr Derg 2014;20(1):23-27 doi: 10.5505/tjtes.2014.39596

MATERIALS AND METHODS

From March 2006 to December 2012, 100 patients with a mean age of 66 years (range, 32-88 years) admitted due to acute colorectal obstruction secondary to cancer were treated

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Yanar et al. The role of colorectal stent placement in the management of acute malignant obstruction

in our emergency surgery service. Acute colorectal obstruction was diagnosed as follows: absence of any flatus or bowel movements in the preceding 24 hours, abdominal distention, fecaloid vomiting, and the presence of dilated colonic loops on abdominal radiograph. All patients underwent a routine workup employed for acute mechanical intestinal obstruction (physical exam, blood tests, abdominal X-ray, and computed tomography [CT] scan or magnetic resonance imaging [MRI]). The rectal cancers were grouped into upper (8-15 cm) and lower (0-7 cm) rectum based on the distance from the anal verge. Colonoscopy with biopsy was performed after hemodynamic stabilization of the patient. In all patients, uncovered self-expanding, through-the-scope metal stents were inserted endoscopically under endoscopic and fluoroscopic monitoring within 24 hours of admission. Prior to the stent placement, the colon or rectum was cleansed per enema below the stricture. All stenting procedures were performed in the left lateral decubitus position. All patients were premedicated with 2-4 mg intravenous (IV) midazolam and 25-50 mg pethidine hydrochloride before the procedure. To estimate the length, proximal extension, and diameter of the stricture, a water-soluble contrast agent was injected. Under fluoroscopic guidance, a SEMS (Changzhou Zhiye Medical® China), 6-12 cm in length and 22 mm in diameter, was inserted through the colonoscope. All patients underwent abdominal radiographs to verify the position of the stent as well as to rule out free air. In cases of free peritoneal air, emergency laparotomy was undertaken. After staging, all patients were evaluated with total colonoscopy passing through the stent to rule out any synchronous lesions. Technical success was defined as successful placement and deployment of the SEMS. Clinical success was considered as colonic decompression within 48 hours without additional endoscopic or surgical intervention following a technically successful SEMS insertion. Antibiotic prophylaxis was applied either with cefuroxime axetil plus metronidazole or ampicillinsulbactam, because inflation of the colon with air during the procedure risks promoting perforation and/or bacteremia. After obtaining adequate decompression of the colon (in cases

Figure 1. CT scan of a stent placed across a malignant recto-sigmoid structure.

when staging necessitated a neoadjuvant treatment, following chemoradiotherapy), patients underwent elective open or laparoscopic resection. A retrospective review of the prospectively compiled patient database was conducted to determine the effectiveness of the procedure, as well as short- and long-term complications. The complications and success rates of the two study groups were compared using Pearson’s chi-square or Fisher’s exact test as appropriate for categorical variables. Statistical significance was set as p<0.05. The Statistical Package for the Social Sciences (SPSS) V16.0 was used for the statistical analyses.

RESULTS Stent placement was attempted in 42 of 100 patients. Twenty-six patients underwent SEMS insertion for palliation and 16 patients as a bridging to surgery. The location of obstruction was observed as the left colon in 2 patients, sigmoid colon in 3 patients, recto-sigmoid junction in 9 patients, upper rectum in 16 patients, and lower rectum

Table 1. Complications and success rate according to the indication for stenting

Palliation group Bridging to surgery group (n=26) (n=16)

Technical success

0.858

Clinical success

0.606

Tenesmus 2

1 1.000

Migration

– 0.255

Perforation 1

1 0.722

Bleeding

– 0.255

Re-obstruction –

0.197

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(a)

sigmoid loop colostomy for re-obstruction. Rectal bleeding, observed in 2 of 42 patients (4%), stopped spontaneously, and neither blood transfusion nor any other treatment was required.

(b)

Insertion-related immediate perforation occurred in 2 patients at the recto-sigmoid junction, whereas no delayed perforation was observed. These patients underwent subtotal colectomy with ileorectal anastomosis. Stent obstruction due to fecal impaction was encountered in 1 case.

DISCUSSION

Figure 2. (a, b) Sigmoid colectomy specimen showing an endoluminal metallic stent when resected en bloc with the sigmoid tumor.

in 12 patients. The median follow-up period was 28 months (range, 3-58 months) and the median length of hospital stay was 4 days (range, 2-12 days). Technical success of SEMS placement was achieved in 39/42 (92.8%) and clinical success in 38/42 (90.4%) patients (Fig. 1). There were no significant differences in complications and success rates when the palliation group was compared with the bridging-to-surgery group (p>0.05) (Table 1). Through-the-stent colonoscopy revealed right colon and transverse colon polyps in 2 patients, who subsequently underwent an endoscopic polypectomy. Sixteen patients, for whom bridging to surgery proved successful later, underwent an elective surgical resection (Table 2) (Fig. 2), while for 26 patients who had metastatic disease or comorbidity, stent placement was palliative. Tenesmus was the most common complication, noted in 3 (7%) patients, and resolved within 10 days (8-12 days). Distal stent migration occurred in 2 of 42 (4%) cases in whom a technically successful insertion had been achieved. Both of the migrations occurred within the same day of stent placement (1 patient with extrinsic compression and 1 patient with distal rectal cancer). Stent replacement was unsuccessful, and these 2 patients underwent

Approximately 30% of patients with primary colorectal cancer present with subtotal or complete bowel obstruction, which may lead from nausea and vomiting to bowel rupture and finally to death should the condition remain untreated. [4,5] A number of surgical techniques are available: intraoperative lavage with resection of the involved colonic segment followed by primary anastomosis; subtotal colectomy followed by primary anastomosis; decompressive colostomy followed by resection; and resection of the involved colonic segment followed by end colostomy (Hartmannâ&#x20AC;&#x2122;s operation), ultimately requiring another operation to constitute the gastrointestinal continuity. However, permanent ostomy creation undertaken under emergency conditions is associated with high morbidity rates. The alteration of an acute mechanical colonic obstruction requiring prompt surgical intervention into a semi-elective decompressed state that allows bowel preparation and one-stage definitive oncologic colorectal resection renders this initial endoscopic approach most appealing. Self-expanding metal stents (SEMS) are placed for several indications in patients with obstructive colorectal malignancies. Advantages of preoperative stent placement include laparoscopic resection of the tumor as well as the ability to perform an elective preoperative colonoscopy to exclude synchronous lesions. On the other hand, following relief of the obstruction with SEMS, the patient can be adequately staged and offered neoadjuvant chemoradiotherapy -whenever indicated- and eventually undergo an elective or semi-elective one-stage colorectal resection. Additionally, stents can be used for palliation of inoperable obstructive colorectal malignancies or extrinsic compression.

Table 2. Type of surgical procedure after bridging to surgery Diagnosis

Type of surgical procedure

n 9

Low rectal tumor

Laparoscopic low anterior resection

Low rectal tumor

Low anterior resection* 4

Sigmoid tumor

Laparoscopic sigmoid resection

Sigmoid tumor

Sigmoid resection

* After neoadjuvant chemoradiotherapy.

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Yanar et al. The role of colorectal stent placement in the management of acute malignant obstruction

The feasibility, safety, and efficacy of SEMS were evaluated by various retrospective studies. Technical and clinical success rates of SEMS insertion are reported as 94% and 91%, respectively, with negligible SEMS-related mortality.[6-9] According to these studies, colonic stent placement was found to be a relatively safe technique with a high success rate. In the present study, technical and clinical success rates of SEMS insertion were comparable to those reported in the literature, at 92.8% and 90.4%, respectively. Colorectal perforation is one of the most common and feared complications of SEMS placement. The greatest risk of perforation is in the recto-sigmoid area, especially at the rectosigmoid junction. A higher probability of perforation appears to confront patients who have had balloon pre-dilation; thus, prior stricture dilation is not recommended.[6-9] Bevacizumab has also been reported to put patients at significant risk for perforation. Stenting is best avoided, if possible, in patients who are candidates for bevacizumab therapy.[10] In this study, even though balloon dilation was performed on four patients before stent placement, two perforations occurred. These patients had a sharp angulation at the perforation site. Following these events, we abandoned the practice of performing balloon dilation prior to stent insertion. Stent migrations tend to occur with size-mismatched stents (either too narrow or short in relation to the obstructing lesion) and in the presence of a non-obstructive stricture or of tumor shrinkage following neoadjuvant therapy. In a systematic review evaluating the efficacy and safety of colorectal stents, migration was found to be notably more frequent after laser debulking or chemotherapy, as well as in patients with strictures of benign etiology.[7] In this study, distal stent migration was reported in two (5%) patients, one with extrinsic compression and the other with a lower rectum tumor (0-7 cm), and both occurred within 24 hours. In our experience, stenting should be avoided in patients with a distal rectal tumor up to 2 cm from the anal canal. Extrinsic compression from pelvic malignancies and lymphadenopathy causing obstruction may also be palliated with stents.[11] However, stenting of extracolonic malignancy is clinically less successful (20%) when compared to colorectal malignancy. Complication rates (33.3%) are markedly increased, and surgical diversion is required more frequently. [12] In the present series, SEMS was used in one patient for palliation of gastric cancer metastasis to the pelvis. In this patient, stent migration occurred and stent replacement was unsuccessful. Due to the relatively small sample size of this study, we were unable to clarify the difference in overall complication rates between intrinsic and extrinsic lesions. There are a number of reported absolute contraindications to colorectal stenting: (1) clinical or radiological evidence of perforation, and (2) distal rectal cancer (0-5 cm from anal 26

verge), where stenting is likely to cause intense anal pain and/ or fecal incontinence. Relative contraindications include challenging colorectal anatomy (i.e. long strictures, tortuous colonic segments) and colonic ischemia.[13-15] Laparoscopy is generally contraindicated in the presence of bowel obstruction since a distended bowel precludes a safe access to the abdominal cavity as well as manipulation of the bowel segments. Conversion of an emergent colonic resection into an elective one permits bowel preparation and may potentially avoid an ostomy. Following successful endoscopic stenting of acute colorectal obstruction secondary to cancer, laparoscopic resection may be performed safely with wellknown short-term advantages. An endoluminal stent per se does not necessarily preclude a laparoscopic approach.[16-20] In this study, laparoscopic resection was technically feasible and comparable to elective colorectal operations, and the presence of a colorectal stent did not affect the laparoscopic approach; 11 patients underwent a successful laparoscopic colorectal resection. SEMS may also provide long-term symptom relief for benign colorectal strictures secondary to diverticular disease, radiotherapy, inflammation, or Crohn’s disease, should these patients be deemed medically unfit to undergo a major abdominal operation.[21-23] Benign stricture was not evaluated in the present study. In conclusion, stenting of acute mechanical colonic obstruction is an effective option for patients presenting with obstructive colorectal cancer, in which decompression is required to perform an elective one-stage oncologic surgical resection. This approach may also offer palliation for patients who are not candidates for operative intervention, and it is associated with a lower mortality, shorter hospital stay, and decreased stoma creation. Conflict of interest: None declared.

REFERENCES 1. Ansaloni L, Andersson RE, Bazzoli F, Catena F, Cennamo V, Di Saverio S, et al. Guidelenines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society. World J Emerg Surg 2010;5:29. 2. Dohmoto M. New method endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endoscopia Digestiva 1991;3:1507-12. 3. Spinelli P, Dal Fante M, Mancini A. Self-expanding mesh stent for endoscopic palliation of rectal obstructing tumors: a preliminary report. Surg Endosc 1992;6:72-4. 4. Mauro MA, Koehler RE, Baron TH. Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents. Radiology 2000;215:659-69. 5. Soto S, López-Rosés L, González-Ramírez A, Lancho A, Santos A, Olivencia P. Endoscopic treatment of acute colorectal obstruction with self-expandable metallic stents: experience in a community hospital. Surg Endosc 2006;20:1072-6.

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Yanar et al. The role of colorectal stent placement in the management of acute malignant obstruction 6. Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of selfexpandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010;71:560-72. 7. Khot UP, Lang AW, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002;89:1096-102. 8. Sebastian S, Johnston S, Geoghegan T, Torreggiani W, Buckley M. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 2004;99:2051-7. 9. Dionigi G, Villa F, Rovera F, Boni L, Carrafiello G, Annoni M, et al. Colonic stenting for malignant disease: review of literature. Surg Oncol 2007;16 Suppl 1:153-5. 10. Cennamo V, Fuccio L, Mutri V, Minardi ME, Eusebi LH, Ceroni L, et al. Does stent placement for advanced colon cancer increase the risk of perforation during bevacizumab-based therapy? Clin Gastroenterol Hepatol 2009;7:1174-6. 11. Shin SJ, Kim TI, Kim BC, Lee YC, Song SY, Kim WH. Clinical application of self-expandable metallic stent for treatment of colorectal obstruction caused by extrinsic invasive tumors. Dis Colon Rectum 2008;51:578-83. 12. Keswani RN, Azar RR, Edmundowicz SA, Zhang Q, Ammar T, Banerjee B, et al. Stenting for malignant colonic obstruction: a comparison of efficacy and complications in colonic versus extracolonic malignancy. Gastrointest Endosc 2009;69:675-80. 13. Song HY, Kim JH, Shin JH, Kim HC, Yu CS, Kim JC, et al. A dualdesign expandable colorectal stent for malignant colorectal obstruction: results of a multicenter study. Endoscopy 2007;39:448-54. 14. Harris GJ, Senagore AJ, Lavery IC, Fazio VW. The management of neoplastic colorectal obstruction with colonic endolumenal stenting devices. Am J Surg 2001;181:499-506.

15. Baron TH, Kozarek RA. Endoscopic stenting of colonic tumours. Best Pract Res Clin Gastroenterol 2004;18:209-29. 16. Stipa F, Pigazzi A, Bascone B, Cimitan A, Villotti G, Burza A, et al. Management of obstructive colorectal cancer with endoscopic stenting followed by single-stage surgery: open or laparoscopic resection? Surg Endosc 2008;22:1477-81. 17. Balagué C, Targarona EM, Sainz S, Montero O, Bendahat G, Kobus C, et al. Minimally invasive treatment for obstructive tumors of the left colon: endoluminal self-expanding metal stent and laparoscopic colectomy. Preliminary results. Dig Surg 2004;21:282-6. 18. Morino M, Bertello A, Garbarini A, Rozzio G, Repici A. Malignant colonic obstruction managed by endoscopic stent decompression followed by laparoscopic resections. Surg Endosc 2002;16:1483-7. 19. Dulucq JL, Wintringer P, Beyssac R, Barberis C, Talbi P, Mahajna A. One-stage laparoscopic colorectal resection after placement of self-expanding metallic stents for colorectal obstruction: a prospective study. Dig Dis Sci 2006;51:2365-71. 20. Law WL, Choi HK, Lee YM, Chu KW. Laparoscopic colectomy for obstructing sigmoid cancer with prior insertion of an expandable metallic stent. Surg Laparosc Endosc Percutan Tech 2004;14:29-32. 21. Small AJ, Young-Fadok TM, Baron TH. Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases. Surg Endosc 2008;22:454-62. 22. Baron TH. Colonic stenting: technique, technology, and outcomes for malignant and benign disease. Gastrointest Endosc Clin N Am 2005;15:757-71. 23. Suzuki N, Saunders BP, Thomas-Gibson S, Akle C, Marshall M, Halligan S. Colorectal stenting for malignant and benign disease: outcomes in colorectal stenting. Dis Colon Rectum 2004;47:1201-7.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Akut malign kalın bağırsak tıkanmalarında kolorektal stent uygulamasının rolü Dr. Hakan Yanar,1 Dr. Beyza Özçınar,1 Dr. Fatih Yanar,1 Dr. Emre Sivrikoz,1 Dr. Nergiz Dağoğlu,2 Dr. Orhan Ağcaoğlu,1 Dr. Kayıhan Günay,1 Dr. Recep Güloğlu,1 Dr. Cemalettin Ertekin1 1 2

İstanbul Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul; İstanbul Üniversitesi Tıp Fakültesi, Radyasyon Onkolojisi Anabilim Dalı, İstanbul

AMAÇ: Son yıllarda akut malign kalın bağırsak tıkanmalarında gerek palyasyon gerek cerrahi öncesi dekompresyon amaçlı kolorektal stentlerin kullanımı artış göstermektedir. Bu çalışmada, kansere bağlı akut kolorektal tıkanmalarda endoskopik stent uygulamasının teknik ve klinik açıdan etkinliği, güvenilirliği ve klinik sonuçlarını değerlendirmeyi amaçladık. GEREÇ VE YÖNTEM: Mart 2006-Aralık 2012 tarihleri arasında acil cerrahi kliniğimizde akut malign kalın bağırsak tıkanması tanısıyla tedavi edilen 100 hastanın 42’sine stentleme uygulandı. Tüm hastalara kaplı olmayan genişleyen metal stentler endoskopik yöntemle fluoroskopi eşliğinde yerleştirildi. Hasta veritabanı kullanılarak yöntemin etkinliği ve komplikasyonlar geriye dönük olarak değerlendirildi. BULGULAR: Stentleme işlemi teknik açıdan 39/42 (%92.8), klinik açıdan 38/42 (%90.4) hastada başarıyla uygulandı. Bunlardan 16 hastaya elektif cerrahi rezeksiyon uygulandı, diğer 26 hastada metastatik tümör veya yandaş hastalıklar nedeniyle işlem palyatif olarak kabul edildi. On (%23.8) hastada komplikasyon gelişti, en sık tenesmus (n=3) izlendi. Stent migrasyonu, kanama ve rekto-sigmoid kolon perforasyonu ikişer hastada izlendi. Bir olguda gaita sıkışmasına bağlı stent tıkanması meydana geldi. TARTIŞMA: Malignite kaynaklı akut kolorektal tıkanmalarda stentleme efektif ve göreceli olarak güvenli bir işlem olup, hafif dereceli komplikasyolara neden olur. Obstrüktif kolorektal kanser hastalarında elektif rezeksiyona olanak sağlamakta, ayrıca cerrahi tedaviye uygun olmayan olgularda palyasyon amaçlı kullanılabilmektedir. Anahtar sözcükler: Kolorektal kanser; tıkanıklık; kendiliğinden genişleyen metal stent; stent. Ulus Travma Acil Cerr Derg 2014;20(1):23-27

doi: 10.5505/tjtes.2014.39596

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ORIGIN A L A R T IC L E

Role of dissemination of microorganisms during laparoscopic appendectomy in abscess formation Melih Akın, M.D.,1 Başak Erginel, M.D.,1 Abdullah Yıldız, M.D.,1 Banu Bayraktar, M.D.,2 Fatih Yanar, M.D.,3 Çetin Ali Karadağ, M.D.,1 Nihat Sever, M.D.,1 Ali İhsan Dokucu, M.D.1 1

Department of Pediatric Surgery, Sisli Etfal Training and Research Hospital, Istanbul;

Department of Microbiology, Sisli Etfal Training and Research Hospital, İstanbul;

Department of General Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul

ABSTRACT BACKGROUND: The aim of this study was to investigate the potential contributory role of laparoscopic appendectomy in the occurrence of postoperative intra-abdominal infections. METHODS: A prospective single-center study including 48 patients who underwent laparoscopic appendectomy was conducted between August 2010 and September 2011. Two peritoneal samples were obtained from each patient in the pre- and post-appendectomy period. Aerobic and anaerobic microbiological cultures were obtained from the samples. The data were analyzed with statistical methods. RESULTS: The mean age of the 48 patients (29 male, 19 female) was 10.9 years. Among the pre-appendectomy aerobic cultures, microorganisms were isolated in 18 of the patients (38%), with Escherichia coli being the most common. In post-appendectomy aerobic cultures, various bacteria were isolated in 7 patients (14.6%), with the numbers of bacteria statistically significantly reduced (p<0.05). Anaerobic microorganisms were isolated in 12 patients (25%) and 4 patients (8.3%) in pre- and post-appendectomy cultures, respectively, with Bacteroides fragilis the most common organism; there was a significant reduction in the bacterial count (p<0.05). Each patient was regarded as their own control. CONCLUSION: Our results suggest that laparoscopic appendectomy does not cause an increase in intra-abdominal infections, and particularly not infections associated with anaerobic bacteria. Key words: Aerobic and anaerobic infections; Bacteroides fragilis; Escherichia coli; intra-abdominal abscess; laparoscopic appendectomy.

INTRODUCTION Acute appendectomy is one the most common surgical procedures in children and requires urgent and appropriate treatment; otherwise, it may progress to complicated intraabdominal infections.[1,2] Minimally invasive surgery has gained acceptance for application in acute and complicated appendicitis, as it offers reduced scarring of the abdomen, earlier recovery, and a shorter hospital stay.[3,4] Studies have suggested that Address for correspondence: Başak Erginel, M.D. Şişli Etfal Eğitim ve Araştırma Hastanesi, Çocuk Cerrahisi Kliniği, İstanbul, Turkey Tel: +90 212 - 373 50 00 E-mail: basakerginel@hotmail.com Qucik Response Code

an infected appendix can contaminate adjacent tissues during surgery because the intra-abdominal pressure of carbon dioxide (CO2) provides a suitable condition for the spread of infection, particularly by anaerobic microorganisms.[5] In this study, we aimed to investigate the effects of laparoscopic appendectomy on the spread of intra-abdominal infections.

MATERIALS AND METHODS This prospective study included patients aged 2 to 18 years who underwent laparoscopic appendectomy between August 2010 and September 2011 in our Department of Pediatric Surgery. Patients were admitted to the study after parental consent and ethical committee approval were obtained. Demographic variables, clinical presentations, radiological findings, pathological diagnosis, preoperative laboratory parameters (white blood cell count, C-reactive protein [CRP] levels), length of hospital stay, and time since onset of complaints Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Akın et al. Role of dissemination of microorganisms during laparoscopic appendectomy in abscess formation

were recorded on a standard data sheet. Postoperative abscess formation, wound infections, and antibiotic resistance were recorded. Afebrile patients with normal bowel movement were discharged. Patients with open appendectomies, Meckel diverticulitis, and appendectomies that had not been completed laparoscopically were excluded. Suspected appendicitis was evaluated pathologically, and patients with negative pathology were excluded.

Surgical Technique Laparoscopic appendectomy, utilizing the three-trocar technique, was performed as the standard method. A 10 mm trocar was inserted into the abdomen via the open technique through an intraumbilical incision. After creating a pneumoperitoneum with CO2 at a pressure between 8 and 10 mmHg, two 5 mm trocars were introduced at the left lower abdomen and at the midline above the symphysis pubis under direct vision of a 5 mm 30° laparoscope.[6] A grasper was used to identify the appendix and to dissect retroperitoneal adhesions. When the tip of the appendix was freed, the mesoappendix was divided by hook cautery. An intracorporeal appendectomy was performed via two-loop ligation, with a division between the loops. The appendix was removed with a grasper held from the closed side, without a bag, through the (umbilical) trocar. After removal of the appendix, a second peritoneal sample was obtained.

Bacteriological Analyses Peritoneal samples were obtained twice for isolation of microorganisms. The first peritoneal samples were collected at the beginning of the operation, and the second were obtained following the appendectomy. They were transported to the laboratory in Portagerm bottles recommended for the transport of liquid specimens (BioMerieux, France). All the samples were inoculated on sheep-blood agar, chocolate agar, and MacConkey agar and incubated at 35-37°C for 24-48 hours. Significant growth of microorganisms in culture was identified using conventional and semiautomatic methods, namely BBL Crystal Identification Systems (Becton Dickinson, USA).

Definitions Acute appendicitis was defined as inflammation or suppura-

tive inflammation of the appendix without perforation and without gangrenous or abscess formation. Complicated appendicitis was defined as gangrenous or perforated appendicitis with or without an abscess or peritonitis. The diagnosis was confirmed with intraoperative macroscopic findings and/ or pathology.[7]

Antibiotic Therapy All patients received a single dose of amoxicillin clavulanic acid preoperatively in the operating room. If the appendicitis was acute, antibiotic therapy was continued with amoxicillin clavulanic acid. If there were complications, combination therapy with gentamicin and metronidazole was added. The antibiotic therapy was modified according to culture results.[7-9]

Statistical Analyses The Statistical Package for the Social Sciences (version 16.0 software) was used to analyze the results. The results were expressed as mean±standard deviation (SD) for continuous variables and as a percentage for qualitative variables. The distribution of the variables was analyzed with the KruskalWallis test. Differences were assessed using the paired t test or the Mann-Whitney U-test, as appropriate. Nominal variables were assessed by the Pearson chi-square test and by Fisher’s exact chi-square test. Wilcoxon’s signed-rank test was used for related samples. Statistical significance was considered as p<0.05.

RESULTS Forty-eight patients (29 male, 19 female) aged 2-18 years, with a mean age of 10.9 years, were included in the study. Twenty cases had acute appendicitis, 12 had suppurative appendicitis, 9 had local perforated appendicitis, and 7 had perforated appendicitis and generalized peritonitis. The mean length of the hospital stay was 3.2 (range, 1-10) days. The mean CRP level was 54.8 mg/dl (range, 0.1-284), and the mean leukocyte count was 15.130/mm3 (range, 5.100-29.000). With the use of preoperative ultrasound, the mean noncompressible appendix diameter was found to be 8.3 mm (range, 6-13). Intraabdominal fluid without the presence of an abscess was found in 15 (17.4%) of the patients, and an abscess was present in 1 patient (2%) (Table 1).

Table 1. Demographic findings of the patients Age (years) Leukocytes (/mm ) 3

Mean values

Range

10.9

2-18

15000 5100-29000

C-reactive protein (mg/dl)

54.8

0.1-284

Diameter of appendicitis on USG (mm)

8.3

6-13

Length of hospital stay (days)

3.2

1-10

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AkÄąn et al. Role of dissemination of microorganisms during laparoscopic appendectomy in abscess formation

Aerobic microorganisms were isolated in 18 of the 48 patients (38%) in the first cultures. Escherichia coli was the most common microorganism, in 12 of the 18 pre-appendectomy aerobic cultures, with an incidence of 66.6%. In 2 patients, both E. coli and Pseudomonas aeruginosa were present in the first cultures. Klebsiella oxytoca, beta-hemolytic streptococci, and methicillin-resistant Staphylococcus aureus (MRSA) were also isolated from the pre-appendectomy aerobic cultures. Post-appendectomy aerobic cultures were positive in 7 patients. E. coli was again the most common microorganism in the second cultures, being positive in 5 patients. Both E. coli and P. aeruginosa were also identified in 2 patients. E. coli was resistant to ampicillin-sulbactam in 10 patients (83%) and to gentamicin in 3 patients (25%). Ampicillin-sulbactam- and gentamicin-resistant E. coli in these 3 patients was sensitive to ceftriaxone (Table 2). Anaerobic microorganisms were isolated in the pre-appendectomy cultures of 12 (25%) of the 48 patients. Bacteroides fragilis was the most commonly identified microorganism in 10 (83.3%) of the patients. In 4 of these patients, Peptostreptococcus accompanied Bacteroides, which was the second most common (50%) anaerobic microorganism. The second culture results were positive in only 4 patients. In the postappendectomy anaerobic cultures, Bacteroides was also the

most common microorganism. The decrease in the bacterial count in the post-appendectomy anaerobic cultures was also significant (p<0.05). In 2 patients, Peptostreptococcus accompanied Bacteroides. The number of patients in which a positive culture was reported for each bacterium is listed in Table 3. In our study, each patient acted as their own control in lieu of choosing a control group consisting of open appendectomies. Postoperatively, exudative fluid developed in 5 patients, and the mean duration to the diagnosis of abscess formation was 5 days (3-7 days). The diagnosis of an abscess was confirmed by ultrasonography. In large, accessible abscesses more than 3 cm in diameter, percutaneous drainage with ultrasound was performed. E. coli was isolated from abscess cultures in 2 patients, and the remaining 2 only showed leukocytosis. E. coli was the most common microorganism in the pre-appendectomy cultures. All the abscesses developed after perforated appendicitis, except one (Table 4). Wound infection developed in 5 of the patients, but it resolved with conservative treatment.

DISCUSSION Laparoscopic appendectomy is performed for acute and complicated appendicitis in children. Following the removal of the appendix, infections may occur, except in cases of limited intraluminal acute appendicitis. Complicated appendicitis can

Table 2. Susceptibility/resistance of E. coli, the most frequently identified microorganism, to commonly used antibiotics E. coli (n=12)

Susceptible

Susceptible (%)

Ampicillin-sulbactam 2

Resistant

16.6

Resistant (%)

83.3

Gentamicin

9 75 3 25

Ceftriaxone

12 100 â&#x20AC;&#x201C; 0

Table 3. Number of patients in which positive culture was reported is listed for each bacterium Aerobic bacteria

Anaerobic bacteria Preapp Postapp

E. coli

Preapp Postapp

10 5 B. fragilis

4 2

E. coli+ P. aeruginosa

2 2 B. fragilis+Peptostreptococcus 4

Klebsiella oxytoca

2 0 Bacteroides spp.

2 0

Beta-hemolytic streptococci

2 0

Peptostreptococcus

MRSA

2 0

Total

18 7

12 4

Preapp: Pre-appendectomy; Postapp: Post-appendectomy; MRSA: Methicillin-resistant Staphylococcus aureus. For aerobic and anaerobic microorganisms isolated in pre- and post-appendectomy cultures, there were significant decreases in the number of positive cultures for aerobic (p<0.01) and anaerobic (p<0.05) microorganisms between pre- and post-appendectomy cultures.

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Table 4. Ultrasonography (USG) and culture results of patients who developed an abscess Patient appendicitis

Type of USG

Preoperative USG

Postoperative culture results

Preoperative

Perforated + generalized

Appendix not visualized

30x30 mm abscess

K. oxytoca

peritonitis

Minimal fluid

Localized perforated

Appendix 8 mm,

30x30 mm abscess

E. coli

uncompressed

Fluid absent

Perforated + generalized

Appendix 13 mm,

Three abscesses

E. coli

peritonitis

uncompressed

24x15 mm

Peptostreptococcus

Minimal fluid

Acute

31x62x69 mm

E. coli

Appendix 6 mm,

uncompressed,

Minimal fluid

abscess

Localized

Appendix not

Two abscesses

Perforated

visualized,

50x18, 8x6 mm

Minimal fluid

lead to the development of abdominal abscesses and generalized peritonitis.[4,8] During laparoscopic surgery, the anaerobic environment and the manipulation of the appendix may result in infections in the abdomen. In open appendectomies, the abdomen is exposed to normal air containing 20% oxygen, which is toxic to anaerobic microorganisms. Serour et al.[10] reported that intra-abdominal CO2 in the pneumoperitoneum may increase the risk of intraperitoneal infections in laparoscopic appendectomies. Although some studies have shown no difference between open and laparoscopic appendectomies in terms of infection, we hypothesized that CO2 insufflation may facilitate the spread of bacterial colonization. CO2 insufflations at a continuous pressure (10-12 cm H2O), entrance of the ports, movement of the appendix during the preparation of the mesoappendix, and removal of the appendix via intraoperative or transumbilical excision provide a suitable environment for the spread of microorganisms, particularly anaerobes. The intraluminal microorganisms can be flushed out into the intraperitoneal area. Contaminated pieces of fecaliths can also spread throughout the abdomen during aspiration. The contamination can increase complications.[11] Some studies have found that there was no significant bacterial translocation or dissemination of microorganisms in the peritoneum after appendectomy.[12] In our study, we did not observe any increase in the numbers of microorganisms in the post-appendectomy cultures of peritoneal fluid after manipulations associated with appendectomy, aspiration of abscesses, and the removal of the appendix. Bacteroides is the most common Gram-negative anaerobic bacteria encountered in appendicitis, and it can play a significant role in complications in appendicitis. In pre-appendectomy culUlus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

E. coli

tures, we isolated these bacteria in 25% of patients, a number compatible with that reported in the literature. However, B. fragilis was present in only four patients in the second batch of cultures, thereby showing a significant decrease. Low numbers of aerobic bacteria were also found in the second cultures relative to the first (pre-appendectomy) cultures (p<0.05). E. coli has been reported to be the most commonly isolated organism in appendicitis in the literature.[13] Although laparoscopic procedures were associated with decreased numbers of E. coli in the second cultures, complications occurred due to antibiotic resistance. Aided by ultrasonography, abscesses that were larger than 3 cm and easily accessible were drained percutaneously. Laparoscopic drainage is an effective procedure for intraabdominal abscesses when percutaneous drainage is not possible.[11,13] E. coli was the most commonly identified organism isolated from the pre-appendectomy cultures (4/5, 80%) and from the abscesses (2/5, 40%). The bacterium was also resistant to ampicillin-sulbactam (100%) and gentamicin (50%). In the cases that were resistant to ampicillin-sulbactam and gentamicin, the antibiotic therapy was altered to ceftriaxone and tazobactam. The treatment was successful with these drugs. Patients who had abscesses smaller than 3 cm were treated with antibiotics. We think that the abscesses were the result of ampicillin-sulbactam-resistant E. coli. Following the replacement with ceftriaxone and tazobactam, all the abscesses resolved.[8] The numbers of anaerobic organisms were reported to be decreased following laparoscopic appendectomy, but they were 31

Akın et al. Role of dissemination of microorganisms during laparoscopic appendectomy in abscess formation

responsible for complications, such as a longer hospital stay and, particularly, abscess formation.[4,11] Although the numbers of E. coli were decreased in the second cultures following laparoscopic procedures, E. coli was responsible for complications due to antibiotic resistance and virulence. E. coli was isolated from the abscesses that developed postoperatively. The limitations of this study are the relatively small number of cases and the difficulty in the production of anaerobic microorganisms in laboratory cultures. In conclusion, laparoscopy is gaining acceptance in complicated cases of gangrenous or perforated appendicitis in children. [4,6] Suspicions have been raised about a potential increase in the rates of infection, particularly with anaerobic bacteria, due to the anaerobic atmosphere of the pneumoperitoneum, contamination with the contents of the appendix during the preparation of the mesoappendix, and the removal of the appendix via the right paracolic area of the abdomen.[14] Our study showed that laparoscopic appendectomy did not increase intra-abdominal rates of infection, and particularly not with anaerobic bacteria. Intra-abdominal abscesses following laparoscopic appendectomies can develop due to bacterial virulence and the resistance of intraluminal organisms. Conflict of interest: None declared.

REFERENCES 1. David IB, Buck JR, Filler RM. Rational use of antibiotics for perforated appendicitis in childhood. J Pediatr Surg 1982;17:494-500. 2. Henry MC, Walker A, Silverman BL, Gollin G, Islam S, Sylvester K, et al. Risk factors for the development of abdominal abscess following operation for perforated appendicitis in children: a multicenter case-control study. Arch Surg 2007;142:236-41.

3. Li X, Zhang J, Sang L, Zhang W, Chu Z, Li X, Liu Y. Laparoscopic versus conventional appendectomy--a meta-analysis of randomized controlled trials. BMC Gastroenterol 2010;10:129. 4. Mallick MS, Al-Qahtani A, Al-Bassam A. Laparoscopic appendectomy is a favorable alternative for complicated appendicitis in children. Pediatr Surg Int 2007;23:257-9. 5. Evasovich MR, Clark TC, Horattas MC, Holda S, Treen L. Does pneumoperitoneum during laparoscopy increase bacterial translocation? Surg Endosc 1996;10:1176-9. 6. Suttie SA, Seth S, Driver CP, Mahomed AA. Outcome after intra- and extra-corporeal laparoscopic appendectomy techniques. Surg Endosc 2004;18:1123-5. 7. Chan KW, Lee KH, Mou JW, Cheung ST, Sihoe JD, Tam YH. Evidencebased adjustment of antibiotic in pediatric complicated appendicitis in the era of antibiotic resistance. Pediatr Surg Int 2010;26:157-60. 8. Liu K, Fogg L. Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta-analysis. Surgery 2011;150:673-83. 9. Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 2011;377:1573-9. 10. Serour F, Witzling M, Gorenstein A. Is laparoscopic appendectomy in children associated with an uncommon postoperative complication? Surg Endosc 2005;19:919-22. 11. Nataraja RM, Teague WJ, Galea J, Moore L, Haddad MJ, Tsang T, et al. Comparison of intraabdominal abscess formation after laparoscopic and open appendicectomies in children. J Pediatr Surg 2012;47:317-21. 12. Aslan A, Karaveli C, Ogunc D, Elpek O, Karaguzel G, Melikoglu M. Does noncomplicated acute appendicitis cause bacterial translocation? Pediatr Surg Int 2007;23:555-8. 13. Clark JJ, Johnson SM. Laparoscopic drainage of intraabdominal abscess after appendectomy: an alternative to laparotomy in cases not amenable to percutaneous drainage. J Pediatr Surg 2011;46:1385-9. 14. McKinlay R, Neeleman S, Klein R, Stevens K, Greenfeld J, Ghory M, et al. Intraabdominal abscess following open and laparoscopic appendectomy in the pediatric population. Surg Endosc 2003;17:730-3.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Laparoskopik apendektomi sırasında apse oluşumunda mikroorganizmaların rolü Dr. Melih Akın,1 Dr. Başak Erginel,1 Dr. Abdullah Yıldız,1 Dr. Banu Bayraktar,2 Dr. Fatih Yanar,3 Dr. Çetin Ali Karadağ,1 Dr. Nihat Sever,1 Dr. Ali İhsan Dokucu1 Şişli Etfal Eğitim ve Araştırma Hastanesi, Çocuk Cerrahisi Kliniği, İstanbul; Şişli Etfal Eğitim ve Araştırma Hastanesi, Mikrobiyoloji Kliniği, İstanbul; 3 İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul 1 2

AMAÇ: Bu çalışmada, laparoskopik apandektomi operasyonunun karıniçi enfeksiyon oluşumundaki rolü değerlendirildi. GEREÇ VE YÖNTEM: Ağustos 2010-Eylül 2011 arasında laparoskopik apandektomi yapılan 48 çocuk hasta çalışmaya alındı. Çalışmamız tek merkezli ve prospektif olarak yapıldı. Her hastadan ameliyat sırasında apandektomi öncesi ve sonrası, aerob ve anaerob olmak üzere dörder adet kültür örneği alındı. Hastaların demografik bilgileri toplandı. Sonuçlar istatistiksel olarak karşılaştırıldı. BULGULAR: Hastaların ortalama yaşı 10.9±3.3 idi, 29’u erkek, 19’u kızdı. Apendektomi öncesi alınan 48 aerob kültürün 18’inde üreme oldu (%38), E.coli en sık üreyen mikroorganizma idi. Apendektomi sonrası aerob kültürlerin 7’sinde (%15.9) üreme oldu, bakteri sayısı anlamlı olarak azalmıştı (p<0.05). Anaerobik kültürlerde ise 48 hastanın 12’sinde (25%) apandektomi öncesi, 4’ünde (8.3%) ise apendektomi sonrası üreme oldu. B. fragilis ensık izole edilen organizma idi. Azalma istatistiksel olarak anlamlı idi (p<0.05). TARTIŞMA: Bizim sonuçlarımız laparoskopik apendektominin karıniçi enfeksiyon riskini, özelikle de aneorop enfeksiyonların riskini artırmadığı yönünde idi. Anahtar sözcükler: Aerob ve anaerob enfeksiyon; Bacteroides fragilis; Escherichia coli; karıniçi apse; laparoskopik apendektomi. Ulus Travma Acil Cerr Derg 2014;20(1):28-32

doi: 10.5505/tjtes.2014.40359

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ORIGIN A L A R T IC L E

Auto-/homografting can work well even if both autograft and allograft are meshed in 4:1 ratio İsmail Şahin, M.D., Doğan Alhan, M.D., Mustafa Nışancı, M.D., Fırat Özer, M.D., Muhitdin Eski, M.D., Selçuk Işık, M.D. Department of Plastic and Reconstructive Surgery, Gulhane Military Medical Academy, Ankara

ABSTRACT BACKGROUND: Patients suffering major burns of more than 50% total burn surface area lack an adequate skin graft donor site to resurface extensive burn wounds and usually need widely meshed autografting and allografting. Anything over the 3:1 expansion ratio is strongly associated with low graft take, poor or delayed epithelialization, and hypertrophic scarring. METHODS: In this study, both autografts and allografts were expanded at a 4:1 ratio. We aimed to use skin grafts effectively and to decrease the morbidity due to graft harvesting. Nine patients with major burns were treated with this method. Graft gain ratio and percentage of actual expansion to predicted expansion were calculated. RESULTS: Ten auto-allografting procedures were performed on a mean of day 16. Graft take was over 95% successful. Five patients survived, and four patients died. The mean total burn surface area was 58.8% in patients who recovered, and 77.5% in the patients who died. The graft gain ratio was 74.8%. The actual expansion rate was 43.7% of the predicted expansion rate. CONCLUSION: In this study, we demonstrated that the donor site morbidities were reduced and successful epithelialization was completed on the eighth day after using both autograft and allograft meshed with a 4:1 ratio. Key words: Allograft; autograft; graft expansion; major burn.

INTRODUCTION Early excision of deep burn wounds has been one of the most critical advances in modern burn care. Janzekovic[1] emphasized the advantages of early burn wound excision and closure, and it is generally accepted that this technique is a life-saving procedure. Split thickness skin autografting is the gold standard surgical treatment for coverage of deep partial and full-thickness burn wounds. Autografting has very important functions including epidermal function and prevention of infection, protein loss, and hypothermia.[2] However, coverage of the wounds of patients with major burns is commonly limited by the lack of available skin graft donor sites.[2-5]

Address for correspondence: İsmail Şahin, M.D. Gülhane Askeri Tıp Akademisi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Ankara, Turkey Tel: +90 312 - 304 20 00 E-mail: drismailsahin@yahoo.com Qucik Response Code

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Several autogeneic or allogeneic materials (human allografts, xenografts, human amnions, allogeneic cultured dermal substitute, cultured epithelial autograft) or techniques (meshed auto-allografting with various ratios, widely meshed auto-skin with allogeneic cultured dermal substitute, microskin autografting, etc.) are used clinically to overcome this problem.[5-8] Although each technique has its own advantages, they also have many disadvantages, including low graft take, high cost, infectious diseases, and delay or poor epithelialization. Skin graft meshing as described by Lanz[9,10] has many advantages, including increasing the graft area, improving graft take rates by preventing seroma and hematoma, and better graft take over the irregular contoured surfaces. However, the question remains as to the optimal skin graft meshing ratio. Meshed autografts with a 3:1 ratio have been recommended in the literature because 6:1 and greater expanded grafts are often accompanied by significant graft loss and poor epithelialization.[5] Allografts with 1.5:1 or 2:1 meshed ratio over the autografts provide epithelialization between the inter-space of autograft bridges. When skin is meshed, the increase in skin area will not be sufficient to multiply harvested skin with a ratio of expansion. Peeters and Hubens[11] measured the expansion area of the 33

Şahin et al. Auto-/homografting can work well even if both autograft and allograft are meshed in 4:1 ratio

skin grafts with 1.5:1 and 3:1 ratios before and after grafting, and they found skin graft expansions of only 82% and 50% of the expected amount for each ratio, respectively. It is important to know before the operation how much skin area can be gained after meshing, as this will inform physicians how much burned area can be covered in one session, and will decrease the morbidity due to allograft harvest. In this clinical study, we aimed to present the results of nine major burn patients whose burn wounds were treated in our burn center with skin autograft and allograft, both meshed at a 4:1 ratio.

MATERIALS AND METHODS Nine patients treated with auto-allografting due to major burns between 2008 and 2011 were included in the study. The Lund and Browder chart was used to calculate the size of the burn injury. Allograft donors were close relatives, and

(a)

specific preoperative screening tests for human immunodeficiency virus (HIV) and hepatitis were conducted for all allograft donors. All operations were performed under general anesthesia. First, split-thickness skin allografts were harvested from the thigh in all allograft donors with the aid of an electrical dermatome (Padgett®) set at 0.012 inch. Immediately after the harvesting of the allograft, the size of the donor area was measured and recorded as a pre-expanded allograft area (Fig. 1a). Autografts were harvested from any suitable area of the patients (thigh, abdominal area, scalp, leg). The size of the donor area was measured and recorded as a pre-expanded autograft area. Both autografts and allografts were meshed with Padgett® Skin Graft Mesher in a 4:1 ratio (Fig. 1b). After tangential excision of the necrotic and eschar tissue, autografts were placed on the burn wound area. One edge of the graft was sutured using a skin stapler, and the graft was expanded vertically until the angle between graft bridges was 90° (Fig. 2). The meshed

(b)

Figure 1. (a) The graft donor area was measured immediately after the graft harvesting. (b) Allografts meshed with 4:1 ratio.

Figure 2. Preoperative appearance of the patient (left); after tangential excision of the necrotic and eschar tissue (middle), autografts were placed on the burn wound area.

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Ĺ&#x17E;ahin et al. Auto-/homografting can work well even if both autograft and allograft are meshed in 4:1 ratio

Table 1. Five patients survived, and four patients died. Of the nine patients, six were male and three were female, with a mean age of 26.3 years (range, 6-50). The mean age of the exitus and surviving patients was 28 years (range, 21-48) and 25 years (range, 6-50), respectively. The total body surface area (TBSA) of these nine patients ranged between 42% and 87%. The mean TBSA of the exitus and surviving patients was 77.5 (range, 70-85) and 58.8 (range, 42-87), respectively (Fig. 4). We performed 10 auto-allografting procedures (twice in 1 patient) at an average of 16 days (range, 3-35). The mean pre-expanded and expanded autograft area was 81.88 cm2 (range, 48-160 cm2) and 143.77 cm2 (range, 90-280 cm2), respectively. The mean pre-expanded and expanded allograft donor area was 68.55 cm2 (range, 36-91 cm2) and 121.33 cm2 (range, 63-165 cm2), respectively. Skin grafts were expanded to 74.8% of the expected expansion. The actual expansion area at this ratio was 43.7% of the expected expansion. Graft take percentage was over 95%, and epithelialization between graft bridges was achieved on approximately the postoperative 8th day (Fig. 5). No secondary operations were needed. An average of 15.2% of the BSA was grafted in one procedure. We did not observe any clinically significant allograft rejection. Figure 3. Allografts were placed over the autograft in the same manner.

graft area was measured and recorded as an expanded autograft area. Allografts were placed over the autograft in the same manner, and the meshed allograft area was measured and recorded as an expanded allograft area (Fig. 3). Autoallografts were covered with BactigrasÂŽ, and the first dressing change was made on the postoperative 3rd day. After the first dressing change, graft care was performed on a daily basis to monitor autograft take and allograft rejection.

RESULTS Demographic characteristics of the patients are presented in

DISCUSSION In this study, autografts and allograft meshed with a 4:1 ratio were used for closure of major burn wounds. We found that the wounds could be closed successfully with epithelialization on the 8th day. Skin grafts were expanded to 74.8% of expected, and the actual expansion area at this ratio was 43.7% of expected. Richard et al.[12] compared two different skin mesher systems for maximal skin graft expansion, and they found skin graft expansion was 65.7% of expected for a 2:1 meshing ratio and 41.4% of expected for a 4:1 meshing ratio, similar to our re-

Table 1. The demographic characteristics of the patients Patient no Age/Sex TBSA Etiology Donor

Result

31/M 53

Survived

48/F 70 Flame+inhalation Boy

Death

30/M 42

Father

180

Survived

Mother

Survived

8/F

Electric Flame

6/F 50

105

Survived

50/M

Flame+inhalation

Boy, brother

18, 35

150

Survived

21/M

Flame+inhalation

Father

Death

21/M 71 Flame+inhalation Father

Death

22/M

Death

Scald

Father

Length of hospital stay (day)

2 4

Flame

Time of the initial surgery

Flame+inhalation

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Mother

Brother

Ĺ&#x17E;ahin et al. Auto-/homografting can work well even if both autograft and allograft are meshed in 4:1 ratio

Figure 4. Appearance of the patient on the postoperative 8th day. The epithelialization between graft bridges was achieved.

sults. However, we believe that both our results and their results are subjective because of non-standardized stretching of the graft. With a standardized stretching method, more predictable results could be obtained. The data obtained from this study have several clinically important advantages. To the best of our knowledge, this is the first time that allograft over autograft meshed with a 4:1 ratio for closure of burn wounds has been presented in the literature, and we showed that successful epithelialization could be achieved on the wound with this expansion ratio of the grafts. Closure of large burn areas in one session is one of the most important goals in the treatment of major burns because patients with major burns may not survive long enough to undergo an additional skin grafting operation. Therefore, autografts obtained from a limited donor area should be used as effectively as possible. Autografts with a 3:1 expansion ratio and fresh allograft with a 2:1 expansion ratio are still recommended.[5] There are many articles describing skin graft expansion ratios from 1.5:1 to 1:30.[13-15] However, anything over the 3:1 expansion ratio is strongly associated with low graft take, poor or delayed epithelialization, and hypertrophic scarring. To overcome these problems, many autogeneic or allogeneic materials have been tested.

Figure 5. 84% flame+inhalation burn. The patient died on the postburn 34th day with intact auto-allograft (appearance of the autoallografts on the postoperative 10th day).

Kashiwa et al.[5] used concomitant grafting of six-fold extended mesh auto-skin and allogeneic cultured dermal substitute (CDS) for the treatment of full-thickness skin defect. CDS was applied repeatedly at intervals of 3-5 days. The mean Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Ĺ&#x17E;ahin et al. Auto-/homografting can work well even if both autograft and allograft are meshed in 4:1 ratio

number of CDS exchanges was 7, and most of the wound surface between the strips of meshed skin epithelialized within three weeks. Cultured keratinocytes were first used as permanent autografts in burn wounds, but the results remain controversial. Many centers have stopped using the method because of low take and high cost.[16,17] In a recent article, Chen et al.[8] used microskin autografting to cover burn wounds with autografts expanded from a 1:6 to 1:18 ratio. Briefly, autografts were cut into tiny pieces smaller than 1 mm.[3] Micrografts were applied to the wound and covered with a large sheet of allograft. Forty of 63 patients with burn size over 70% survived with this technique. In this excellent study, microskin autografting failed to take in eight patients because the allograft did not take in the first postoperative dressing change. The authors stated that a large sheet of viable allograft skin is necessary and should first be guaranteed to obtain a successful take of the microskin autograft. Therefore, this technique could not be applied theoretically in countries like ours, which do not have a skin bank facility. With the described method, we can determine how much allograft is needed, so that it is possible to prevent donor site morbidities, or we can harvest the allografts more precisely. Richard et al.[12] found that when meshed skin grafts are used for wound closure, 12.9%-58.6% greater than the anticipated area of donor skin should be harvested. Both autografts and allografts were used efficiently and the donor site morbidities were reduced with the 4:1 expansion rate. With this technique, we were able to close 15.2% of TBSA in one procedure. There is no skin bank in our country. In the countries in which there are skin banks and cadaver skin can be used, the amount of allograft needed to close the burn wound can be determined preoperatively. Thus, the use of unnecessary allograft and cost can be prevented. Horner et al.[18] examined the records of patients that were treated with allograft in the burn center. They calculated the amount of allograft and termed it as an allograft index. They thusly calculated the amount of allograft that the skin bank was required to have for fire disaster and ordinary usage. In this study, five patients survived, and the four patients that died all had inhalation injury. Muller et al.[19] evaluated the charts of 4094 patients retrospectively. Multivariate analysis of the individual prognostic factors showed that the determinants of death were increasing age and burn size, inhalation injury, and female sex. Ryan et al.[20] conducted a similar retrospective review of 1665 patients. They found that identifiable risk factors for death were an age greater than 60 years, a burn covering more than 40% TBSA, and inhalation injury. They stated that patient mortality is 0.3% with no risk factors, 3% with one risk factor, 33% with two risk factors, and approximately 90% with all three risk factors. Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

In conclusion, patients with greater than 50% TBSA may have limited skin graft donor area for covering burn wounds. We believe that auto-allografting is the gold standard treatment modality in these patients. It is crucial to find the most effective skin expansion rate and to determine how much skin is required for covering. In our study, we aimed to answer these questions. We used both autograft and allograft with a 4:1 expansion rate and were able to cover extensive burn wound areas successfully in two weeks without requiring a secondary intervention. Conflict of interest: None declared.

REFERENCES 1. Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma 1970;10:1103-8. 2. Coruh A, Yontar Y. Application of split-thickness dermal grafts in deep partial- and full-thickness burns: a new source of auto-skin grafting. J Burn Care Res 2012;33:94-100. 3. Alexander JW, MacMillan BG, Law E, Kittur DS. Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay. J Trauma 1981;21:433-8. 4. Qaryoute S, Mirdad I, Hamail AA. Usage of autograft and allograft skin in treatment of burns in children. Burns 2001;27:599-602. 5. Kashiwa N, Ito O, Ueda T, Kubo K, Matsui H, Kuroyanagi Y. Treatment of full-thickness skin defect with concomitant grafting of 6-fold extended mesh auto-skin and allogeneic cultured dermal substitute. Artif Organs 2004;28:444-50. 6. Ramakrishnan KM, Jayaraman V. Management of partial-thickness burn wounds by amniotic membrane: a cost-effective treatment in developing countries. Burns 1997;23 Suppl 1:33-6. 7. Ersek RA, Denton DR. Silver-impregnated porcine xenografts for treatment of meshed autografts. Ann Plast Surg 1984;13:482-7. 8. Chen XL, Liang X, Sun L, Wang F, Liu S, Wang YJ. Microskin autografting in the treatment of burns over 70% of total body surface area: 14 years of clinical experience. Burns 2011;37:973-80. 9. Haeseker B. Forerunners of mesh grafting machines. From cupping glasses and scarificators to modern mesh graft instruments. Br J Plast Surg 1988;41:209-12. 10. Henderson J, Arya R, Gillespie P. Skin graft meshing, over-meshing and cross-meshing. Int J Surg 2012;10:547-50. 11. Peeters R, Hubens A. The mesh skin graft--true expansion rate. Burns Incl Therm Inj 1988;14:239-40. 12. Richard R, Miller SF, Steinlage R, Finley RK Jr. A comparison of the Tanner and Bioplasty skin mesher systems for maximal skin graft expansion. J Burn Care Rehabil 1993;14:690-5. 13. Dziewulski P, Phipps AR. Modification of the dermacarrier to obtain meshed split skin grafts of different expansion ratios. Br J Plast Surg 1991;44:315-7. 14. Nanchahal J. Stretching skin to the limit: a novel technique for split skin graft expansion. Br J Plast Surg 1989;42:88-91. 15. Blair SD, Nanchahal J, Backhouse CM, Harper R, McCollum CN. Microscopic split-skin grafts: a new technique for 30-fold expansion. Lancet 1987;2:483-4. 16. Grafting of burns with cultured epithelium prepared from autologous epidermal cells. Lancet 1981;1:75-8.

Şahin et al. Auto-/homografting can work well even if both autograft and allograft are meshed in 4:1 ratio 17. Lineen E, Namias N. Biologic dressing in burns. J Craniofac Surg 2008;19:923-8.

19. Muller MJ, Pegg SP, Rule MR. Determinants of death following burn injury. Br J Surg 2001;88:583-7.

18. Horner CW, Atkins J, Simpson L, Philp B, Shelley O, Dziewulski P. Estimating the usage of allograft in the treatment of major burns. Burns 2011;37:590-3.

20. Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL, Cassem EH, Tompkins RG. Objective estimates of the probability of death from burn injuries. N Engl J Med 1998;338:362-6.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Hem otogreft hem de allogreft 4:1 oranında meşlendiğinde bile otohomogreftleme başarılı olabilir Dr. İsmail Şahin, Dr. Doğan Alhan, Dr. Mustafa Nışancı, Dr. Fırat Özer, Dr. Muhitdin Eski, Dr. Selçuk Işık Gülhane Askeri Tıp Akademisi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Ankara

AMAÇ: Vücut yüzey alanının %50’sinden fazlasının yandığı majör yanıklı hastalarda geniş yanık alanlarının tedavisinde deri grefti donör alanları yetersiz kalır ve bu hastalar genellikle genişçe meşlenmiş otogreftleme ve allogreftlemeye ihtiyaç duyarlar. 3:1’in üzerindeki meşleme oranları kuvvetle az greft tutması, kötü veya gecikmiş epitelizasyon ve hipertrofik skar ile beraberlik gösterir. GEREÇ VE YÖNTEM: Bu çalışmada otogreftler ve allogreftler 4:1 oranında meşlendi. Deri greftlerini daha efektif kullanmayı ve greft alınmasına bağlı morbiditeyi azaltmayı amaçladık. Majör yanıklı 9 hasta bu yöntemle tedavi edildi. Greft kazanç oranları ve gerçek greft genişleme oranının beklenen genişleme oranına olan yüzdesi hesaplandı. BULGULAR: Ortalama 16. günde ve toplam 10 oto-allogreftleme ameliyatı gerçekleştirildi. Greft tutma oranı %95 idi. Beş hasta yaşamaya devam ederken 4 hasta çalışma esnasında hayatını kaybetti. Yaşayan hastalarda ortalama toplam vücut yanık alan yüzdesi %58.8 iken ölen hastalarda bu oran %77.5 idi. Greft kazanç oranı %74.8 oldu. Gerçek greft genişleme oranı beklenenin %43.7’si olarak bulundu. TARTIŞMA: Bu çalışmada, otogreftler ve allogreftler 4:1 oranında meşlendiğinde, donör alan morbiditesinin azaltıldığı ve 8. günde başarılı epitelizasyonun sağlandığı gösterilmiştir. Anahtar sözcükler: Allogreft; greft genişlemesi; majör yanık; otogreft. Ulus Travma Acil Cerr Derg 2014;20(1):33-38

doi: 10.5505/tjtes.2014.49204

Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

K Lİ NİK Ç A LI ŞM A

Yüksek kinetik enerjili silahlarla yaralanmış ardışık 108 olguya ait ISS değerleri ile transfüzyon gereksinimleri arasındaki ilişki ve ileri merkez son mod mortalite analizi Dr. Mehmet Eryılmaz,1 Dr. Onur Tezel,1 Dr. Hüseyin Taş,2 Dr. İbrahim Arzıman,1 Dr. Gökhan İbrahim Öğünç,3 Dr. Ümit Kaldırım,1 Dr. Murat Durusu,1 Dr. Orhan Kozak2 1

Gülhane Askeri Tıp Akademisi, Acil Tıp Anabilim Dalı, Ankara;

Gülhane Askeri Tıp Akademisi, Genel Cerrahi Anabilim Dalı, Ankara;

Emniyet Genel Müdürlüğü Kriminal Polis Laboratuvar Daire Başkanlığı, Ankara

ÖZET AMAÇ: Çalışmamızda yüksek kinetik enerjili silahla yaralanmış olgulara ait ISS değerlerinin tıbbi müdahaleleri süresince gereksinim duyulan transfüzyon stratejileri ile ilişkisini ve son mod mortalite analizlerini gerçekleştirmeyi amaçladık. GEREÇ VE YÖNTEM: Olgulara ait tıbbi veriler çalışmaya dahil edildi. Olguların demografik özellikleri, yüksek kinetik enerjili silah türü, yaralanma şiddet skorları (Injury Severity Score, ISS), transfüzyon strateji seçenekleri, transfüzyon gereksinimi olan ve olmayan olguların ISS değerleri açısından anlamlı bir korelasyon olup olmadığı analiz edildi. Hospitalizasyon sürecinde mortalite ile sonuçlanan olgulara ait nedenler ait değerlendirildi. BULGULAR: Yüz sekiz ardışık olgu çalışmaya dahil edildi. Yaş ortalaması 25 olan olguların biri dışında tamamı erkek idi. Olguların %64.8’inin uzun namlulu ateşli silahlar, %35.2’sinin patlayıcılar ile yaralandığı tespit edildi. Ortalama ISS değeri 13.9 saptandı. Transfüzyon uygulanan gruptaki olguların ISS değeri: 16 (median 5-48), uygulanmayan gruptaki olguların ISS değeri ise 9 (median 3-36) olarak saptandı. Hospitalizasyon sürecinde mortalite ile sonuçlanan üç olguya ait nedenler; SIRS, MODS ve sepsis açısından irdelendi. SONUÇ: Yüksek kinetik enerjili silah yaralılarında ISS değeri yükseldikçe olguların transfüzyon gereksinimleri arasında korelasyon bulunduğu, patlayıcılarla yaralananlarda ise bu gereksinimin ISS değerinden bağımsız olduğu tespit edildi. Anahtar sözcükler: Ateşli silah yaralanması; mortalite; transfüzyon; yaralanma hasar skoru.

GİRİŞ Yüksek kinetik enerjili (YKE) silahla gerçekleşen yaralanmalar, travmaya bağlı ölümlerin önemli nedenidir.[1] Trunkey’e göre bu ölümler trimodal dağılım gösterir.[2] Son yıllarda YKE silah teknolojisindeki gelişim, bireysel ve kitlesel travma olaylarına bağlı ölümcüllüğün artmasına neden olmuştur.[1] Diğer yandan da “hasar kontrol resüsitasyonu” ilkelerini sahada uygulayan gelişmiş ülkeler mortalite ve morbidite oranları üzerine savaş Sorumlu yazar: Dr. Mehmet Eryılmaz, Gülhane Askeri Tıp Akademisi, Acil Tıp Anabilim Dalı, Ankara Tel: +90 312 - 304 30 76 E-posta: mehmeteryilmaz@hotmail.com Ulus Travma Acil Cerr Derg 2014;20(1):39-44 doi: 10.5505/tjtes.2014.90490 Telif hakkı 2014 TJTES

Ulus Travma Acil Cerr Derg, Ocak 2014, Cilt. 20, Sayı. 1

tarihinin en iyi sonuçlarını bildirmişlerdir.[3] Oranlardaki iyileşme trimodal dağılımın daha çok ikinci modundaki kazanımlardan sağlanmıştır. Sırasıyla ilk ve son mod mortalite oranları olan %50 ve %20’lik rakamlarda bir değişiklik bildirilmemiştir. Bu nedenle son zamanlarda trimodal dağılım yerine bimodal dağılım ilkelerinden bahsedilmektedir.[4] İster trimodal ister bimodal dağılım olsun, erken döneminde kaybedilen olguların hemen hemen hepsi, yaralanma şiddet skorları (Injury Severity Score-ISS) yüksek olan olgulardır.[4] Son mod’a ait olgular ise ileri inceleme ve tedavi olanaklarından yararlanabilmelerine rağmen hastanede sistemik enflamatuvar yanıt sendromu (SIRS), sepsis veya çoklu organ yetersizliği sendromu (MODS) nedeniyle kaybedilen olgulardır. Hasar kontrol resüsitasyonu[5] ilkelerinden birisi de uygun transfüzyon ilkesidir. Özellikle masif transfüzyon ilkelerindeki gelişmeler sayesinde ağır yaralı olguların mortalite ve morbidite oranlarında anlamlı iyileşme bildirilmiştir.[6] Fakat anatomik 39

Eryılmaz ve ark. Yüksek kinetik enerjili silahlarla yaralanma ve transfüzyon gereksinimleri ile son mod mortalite analizi

GEREÇ VE YÖNTEM Hasar kontrol resüsitasyonu ilkeleri kapsamında ilk iki basamakta resüsite ve stabilize edildikten sonra ileri inceleme ve tedavi amacıyla üçüncü basamak sağlık teşkili olan merkezimize 01 Ocak 2012 ile 31 Aralık 2012 tarihleri arasında müracaat eden veya sevkle getirilen YKE silahla yaralanmış ardışık olgulara ait tıbbi veriler derlendi ve çalışma kapsamına alındı. Kesitsel araştırma olarak planlanan çalışmada olguların; demografik özellikleri, yaralanmaya neden olan silahın türü, hastaneye kabul edildiği andaki ISS değerleri, tedavi süreçlerinde transfüze edilen kan kompanenti ve miktarları kaydedildi. Transfüzyonlar literatürde tarif edildiği şekilde majör, minör ve moderate olarak seviyelendirildi.[7] Genel olarak transfüzyon uygulanan grup ile uygulanmayan grup arasında ISS değerleri açısından, özel olarak da ayrı ayrı silah türüne göre transfüzyon uygulanan grup ile uygulanmayan grup arasında ISS değerleri açısından istatistiki bir anlam var mı? sorularına yanıt arandı. Bunların yanı sıra ISS değerleri ile ES transfüzyonları açısından, ISS değerleri ile TDP transfüzyonları açısından ve ES ile TDP transfüzyonları arasındaki ilişki açısından ilişki bulunup bulunmadığı araştırıldı. Hospitalizasyon sürecinde mortalite ile sonuçlanan üç olguya ait son mod tıbbi analizi gerçekleştirildi ve mortalite nedenleri nedenleri olan SIRS, MODS ve sepsis açısından irdelendi. Hastalardan elde edilen ölçümlerin bazılarının normal dağılıma uymamaları nedenle tanımlayıcı istatistiklerde ortanca (min-maks) değerleri verildi. ISS skorlarının belirlenen gruplar arasındaki farklılığı araştırmak için Kruskal-Wallis analizlerine başvuruldu. Farklılığın kaynağını araştırmak için Bonferroni düzeltmeli Mann-Whitney U-testi uygulandı. Değişkenler arasındaki ilişkinin belirlenmesinde Spearman Korelasyon Analizi kullanıldı. Tüm istatistiksel hesaplama ve analizler için “SPSS for Windows Ver. 15.00” (SPSS Inc., Chicago, IL., USA) paket programı kullanıldı. İstatistiksel kararlarda p<0.05 seviyesi anlamlı farklılığın göstergesi olarak kabul edildi.

BULGULAR Son bir yıllık süre zarfında yüksek kinetik enerjili silahla yaralanmış 108 ardışık olgu çalışmaya dahil edildi. Yaş ortalaması 25 (17-47) (ortanca [min-maks]) olan olguların biri dışında tamamı erkek idi (Erkek/Kadın=107/1). Olguların %64.8’inin 40

Olguların hastanemize kabul edildikleri andaki yaralanma şiddet skorları (ISS) Şekil 2’de gösterilmiştir. Transfüzyonların seviyelendirilmesi Tablo 1’de gösterilmiştir. Buna göre transfüzyon uygulanan tüm olguların transfüzyon seviyeleri açısından minör seviyede olduğu anlaşılmıştır. Olguları transfüzyon uygulanıp uygulanmadıklarına göre tasnif ettiğimizde genel olarak transfüzyon uygulanan grubun hastanemize kabul edildikleri andaki ISS değer ortanca’larının uygulanmayan gruba gore istatistiksel olarak anlamlı farklılık gösterdiği saptandı (Tablo 2). Silah türüne göre gruplar arasında ISS değerleri açısından istatistik olarak anlamlı bir farklılık bulunmadı (Tablo 3). Patlayıcı ile yaralanan olguların transfüzyon uygulanmış ve uygulanmamış grupları arasında istatistiksel olarak anlamlı fark tespit edilmedi (p=0.351) (Tablo 4). Uzun namlulu silahla yaralanmış olguların transfüzyon uygulanmış ve uygulanmamış grupları arasında istatistiksel olarak anlamlı fark saptandı (p<0.001) (Tablo 5).

Sayı

Bu nedenle çalışmamızda YKE silahlarla yaralanma sonrası, hasar kontrol resüsitasyonu konsepti dahilinde merkezimize sevk edilmiş ve hemodinamik olarak stabil olan olgulara ait ISS değerlerinin; yine hastanemizde gerçekleştirilen tıbbi müdahaleleri ve izlemleri süresince ihtiyaç duydukları transfüzyon kompanentleri ile korelasyonunu ve süreç sonunda kaybedilen olguların son mod mortalite analizlerini gerçekleştirmeyi amaçladık.

(n=70) uzun namlulu, %35.2’sinin (n=38) ise patlayıcı silahlarla yaralandığı tespit edildi (Şekil 1).

Uzun namlulu silah Patlayıcı silah Silah çeşidi

Şekil 1. Silah türleri. 60 30 Olgu sayısı

yaralanma skorları yüksek olgulara transfüzyon protokollarının hangi kriterler dahilinde kullanılması gerektiğine yönelik literatürde bir uzlaşı saptanamamıştır.

25 20 15 10 5 0

3 4 5 6 8 9 10 11 12131416 171819 20 212529 343536 4148 ISS Skorları

Şekil 2. Olguların kabul edildikleri andaki yaralanma şiddet skorları (ISS).

Ulus Travma Acil Cerr Derg, Ocak 2014, Cilt. 20, Sayı. 1

Eryılmaz ve ark. Yüksek kinetik enerjili silahlarla yaralanma ve transfüzyon gereksinimleri ile son mod mortalite analizi

pozitif yönde orta güçte anlamlı bir ilişki bulundu (p=0.005, r=0.565) (Şekil 4).

Tablo 1. Transfüzyonların seviyelendirilmesi Majör –

Moderate

Minör

–

Tablo 2. Genel olarak transfüzyon uygulanan grup ile uygulanmayan grup arasında olguların kabul edildikleri andaki ISS değerleri ISS ortanca (min-maks)

Transfüzyon Transfüzyon p uygulanan uygulanmayan (n=23) (n=85) 16 (5-48)

9 (3-36)

<0.001

“Uygulanan ES ile TDP transfüzyonları arasındaki ilişki açısından ilişki var mı?” diye incelendiğinde; ES yüksekliği ile TDP arasında pozitif yönde orta güçte istatistiksel olarak anlamlı ilişki saptandı (p=0.012, r=0.512) (Şekil 5). Hospitalizasyon sürecinde mortalite ile sonuçlanan 3 (%2.77) olgunun yapılan mortalite analizinde birinci olguda renal hasarın baskın olduğu akciğer (AC) hasarı ile birlikte sepsisin mortalite üzerine esas zemin oluşturduğu değerlendirildi. İkinci olguda santral sinir sistemi (SSS) hasarı baskın patolojiyi işaret ediyordu. Yine renal hasarın mortaliteye neden olan ana organ yetersizliğinin sebebi olarak dikkate değer bulundu.

Tablo 3. Genel olarak yaralanmaya sebep olan silah türüne göre gruplandırıldığında olguların kabul edildikleri andaki ISS değerleri

ISS ortanca (min-maks)

Uzun namlulu Patlayıcı p (n=70) (n=38) 10 (3-48)

10 (4-41)

=0.896

40.00

ISS

50.00

30.00

20.00

Tablo 4. Patlayıcı ile yaralanan olgular açısından, transfüzyon uygulanmış ve uygulanmamış olgular arasındaki ISS değerleri ISS ortanca (min-maks)

10.00 R Sq Cubic =0.157

Transfüzyon Transfüzyon p uygulanan uygulanmayan (n=15) (n=23) 11 (4-41)

9 (6-36)

=0.351

0.00 0.00

7 (3-36)

<0.001

“ISS değerleri ile uygulanan eritrosit süspansiyonu (ES) açısından ilişki var mı?” diye incelendiğinde; ISS değerleri ile ES transfüzyonları arasında pozitif yönde zayıf güçte istatistiksel olarak anlamlı bir ilişki saptandı (p<0.001, r=0.157) (Şekil 3). Injury Severity Score değerleri ile uygulanan taze donmuş plazma (TDP) transfüzyonları açısından ilişki var mı? diye incelendiğinde; ISS değerleri ile TDP transfüzyonları arasında Ulus Travma Acil Cerr Derg, Ocak 2014, Cilt. 20, Sayı. 1

8.00

10.00

12.00

40.00

Transfüzyon Transfüzyon p uygulanan uygulanmayan (n=8) (n=62) 10 (3-48)

6.00 ES

50.00

30.00 ISS

ISS ortanca (min-maks)

4.00

Şekil 3. ISS değerleri ile uygulanan ES ilişkisi.

Tablo 5. Uzun namlulu silahla yaralanmış olgular açısından, transfüzyon uygulanmış ve uygulanmamış olgular arasındaki ISS değerleri

2.00

20.00

10.00 R Sq Cubic =0.299

0.00 0.00

5.00

10.00

15.00

20.00

25.00

TDP

Şekil 4. ISS değerleri ile uygulanan TDP transfüzyonları arasındaki ilişki.

Eryılmaz ve ark. Yüksek kinetik enerjili silahlarla yaralanma ve transfüzyon gereksinimleri ile son mod mortalite analizi

12.00 10.00

8.00 6.00 4.00 2.00 R Sq Cubic =0.694

0.00 0.00

5.00

10.00

15.00

20.00

25.00

TDP

Şekil 5. Uygulanan ES ile TDP transfüzyonları arasındaki ilişki.

Son olguda ise renal hasarın baskın neden olduğu ve tabloya eklenen sepsis nedeniyle olgunun kaybedildiği anlaşıldı. Mortal olguların her üçünde de renal yetmezliğin mortaliteye neden olan baskın patoloji olduğu değerlendirildi. Mortal olguların transfüzyon gereksinimleri arasında anlamlı bir farklılık saptanmadı.

TARTIŞMA 2010 yılında dünyada 32 savaş veya ciddi çatışma yaşandığı ve yine 2003 yılından bu yana dünyada her yıl yaklaşık 80110.000 kişinin savaş koşullarına bağlı YKE silah yaralanmasına bağlı öldüğü bildirilmektedir.[8] YKE silah yaralanmaları, travmaya bağlı mortalite ve morbiditenin en önemli nedenidir. [9] Silah teknolojisindeki gelişimlerin, ateşli silah yaralanmasına bağlı ölümcüllüğü artırmış olmasına rağmen[10] hasar kontrol resüsitasyonu ilkelerindeki eş zamanlı geliştirilen strateji ve uygulamalar söz konusu ölümcüllüğü kabul edilebilir sınırlarda tutmayı başarmıştır.[3,11,12] O’Kelly ve ark.nın sekiz yıllık çalışmalarında 59 YKE silahla yaralanma olgusu bildirilmiştir.[13] Olgularının yaş ortalaması 26.64 olup bizim çalışmamıza benzer olgulardır. Erkek olguların %93.22 oranında olduğu izlenmektedir. Simmons ve ark. nın[14] çalışmasındaki olguların yaş ortalaması 25 olarak bildirilmiştir. Köksal ve ark.nın[15] Uludağ Üniversitesi’nde yaptıkları araştırmaya göre beş yıllık YKE silah yaralanmalı olgu sayıları 135’tir. Sunduğumuz çalışmada ise bir yıllık sürede 108 olgu kapsama alınmıştır. İleri merkez asker hastanesi olmamız nedeniyle olgu sayımızın literatürdeki çalışmalara göre daha yeterli olduğu kanısındayız. Eastridge ve ark.nın[16] 2001-2011 yılları arasında savaş sahasında gerçekleşen ölümlere dair yaptıkları çalışmada on yıl içinde 4596 ölümcül yaralanma bildirmişlerdir. Bunların %73.7’si patlayıcılarla, %22.1’i ise tabanca ve tüfek yaralanması olarak bildirilmiştir. Tabanca-tüfek/patlayıcı oranı kabaca 1/3’tür. Bizim çalışmamızda ise uzun namlulu silahlarla yaralanmalar patlayıcılarla yaralanmaların kabaca iki katıdır. 42

Simmons ve ark.nın[14] çalışmalarında transfüzyon uygulaması gerçekleştirdikleri olguların ISS değerlerinin ortalaması olarak 24 ve 25 değerlerini bildirmişlerdir. Eastridge ve ark.[16] çalışmalarında olguların hastane öncesi alandaki %28.6’sının ISS değerlerinin 25 ve altında; %61.2’sinin 25-50, %10.2’sinin ise 50’nin üzerinde ISS değerlerine sahip olduğunu bildirmişlerdir. ISS değerinin 25’in üzerinde olmasının mortalite oranını %20 -30 artırırken; ISS değeri 25-75 arasında ise mortalite riskinin %75’e kadar yükselttiğini ifade etmişlerdir. Köksal ve ark.[15] YKE silah yaralanmalı olgu çalışmalarında ISS değerlerinin ortalaması olarak 17.04 olarak belirtmişlerdir. Bizde çalışmamızda olguların hastanemize kabul edildikleri andaki yaralanma şiddet skorlarını (ISS) Baker ve ark.nın literatürde belirttiği şekilde belirledik.[17,18] Olgularımıza ait ortalama ISS değerleri literatürle uyumlu olarak değerlendirildi. Ancak çalışmamızda transfüzyon uygulanan olguların ISS değerlerinin transfüzyon uygulanmayan olgulara gore istatistiksel olarak anlamlı derecede yüksek olduğu tespit edildi. Son yıllarda savaşlara bağlı mortalite oranlarındaki düşüşlerin bir nedenide travmalı olgulara güncel yaklaşım ilkelerindeki gelişmelerdir. Bunlardan birisi de hasar kontrol resüsitasyonu ilkesidir. Bu ilkeye göre yüksek TDP/ES oranında gerçekleştirilen transfüzyonların mortalite oranlarında düşüşe neden olduğu bildirilmiştir.[19] Önerilen hedef 1:1 oranıdır.[20] Simmons ve ark.[14] çalışmalarında ilk 24 saat içindeki transfüzyon ihtiyaçlarını belirlemişlerdir. Bizim çalışmamızdaki transfüzyon uygulamaları ise olguların hastaneye kabul edildikleri ve tedavileri süresince yattıkları süre içinde gerçekleştirilen transfüzyonlardır. Clarke ve ark.[21] Afganistan’da konuşlu III. Basamak Bastion Seyyar Hastanesi’ne müracaat eden olgulara uygulanan kan ve kan ürünleri transfüzyonlarını bildirdikleri çalışmalarında bir ay içinde transfüzyon uygulanan 2602 olgunun 74’üne ve yine bir diğer ay içinde transfüzyon gerçekleştirdikleri 1415 olgunun ise 33’üne majör transfüzyon uyguladıklarını bildirmişlerdir. Bu olguların müracaat etmeden önceki sağlık birimlerinde uygulanan tedaviye dair bir bilgi bulunmadığını belirtmişlerdir. Çalışmamızda sunulan olguların tümü de sunulan sınıflamaya göre[19] minör gruba ait transfüzyonlar idi. Silah türüne göre ISS değerleri açısından istatistiki bir anlam var mıdır? Amerikan kaynakları eski savaşlarda uzun namlulu silah yaralanmalarının çokluğuna rağmen son savaşlarda patlayıcılarla yaralanmaların daha fazla olduğunu bildirmektedirler.[12] Navarro Suay ve ark.[10] uzun namlulu silahlar ile patlayıcılar arasında oluşan yaralanmalarda şiddet skorlarını karşılaştırmıştır. Patlayıcılarla oluşan yaralanmaların daha yüksek şiddet skoruna sahip olduklarını ifade etmişlerdir. Bizim çalışmamızda uzun namlulu ve patlayıcılar benzer ISS skorlarına sahipti. Bu farkın o çalışmada olgu sayısının fazla olmasından kaynaklandığı düşünülmektedir. Bizim çalışmamızda silah türlerine göre olgular ayrı ayrı tasnif edildiklerinde gruplar arasında ISS değerleri açısından anlamlı bir farklılık saptanmamıştır. Bu nedenle gruplar tek tek Ulus Travma Acil Cerr Derg, Ocak 2014, Cilt. 20, Sayı. 1

Eryılmaz ve ark. Yüksek kinetik enerjili silahlarla yaralanma ve transfüzyon gereksinimleri ile son mod mortalite analizi

ele alınarak her bir silah türü için transfüzyon uygulanan ve uygulanmayan gruplar arasında ISS değerleri karşılaştırılmıştır. Bu durumda patlayıcı ile yaralanan olguların transfüzyon uygulanmış ve uygulanmamış grupları arasında istatistiksel olarak anlamlı fark yokken, uzun namlulu silahla yaralanmış olguların transfüzyon uygulanmış ve uygulanmamış grupları arasında istatistiksel olarak anlamlı fark bulunmuştur. Literatürde bu sonuçları destekleyen başka bir çalışmaya ulaşılamadı. Ancak elde ettiğimiz verilere göre özellikle patlayıcılarla yaralanmış olgularda ISS değeri her ne düzeyde olursa olsun transfüzyon ihtiyacının göz önünde tutulması gerekliliğine dikkat çekmek istedik. Yine çalışmamızda ISS değerleri ile ES transfüzyonları arasında pozitif yönde zayıf güçte; ISS değerleri ile TDP transfüzyonları arasında pozitif yönde orta güçte ve ES ile TDP uyguılamaları arasında pozitif yönde orta güçte istatistiki ilişki saptandı. Literatürde ISS değeri ile transfüzyon kompanentleri arasında karşılaştırma yapan bir yayına ulaşılamadı. Ancak Clarke ve ark.nın[21] ES ile TDP transfüzyonları açısından değerlendirme yaptıkları bir çalışmada transfüzyon miktarları ortalama değerlerinde anlamlı bir farklılık gözlenmediği anlaşılmaktadır. Bizim bulgularımızda ise ES ile TDP arasında orta güçte olmakla birlikte pozitif yönde bir ilişki saptadık. Hospitalizasyon sürecinde mortalite ile sonuçlanan olgulara ait son mod tıbbi analizi gerçekleştirildi ve mortalite nedenleri yorumlandı. Savaş ortamlarında görülen ölümlerin aslında %90’ı hastane öncesi alanda gerçekleşen ölümlerdir.[22,23] Hastane öncesi alanda görülen ölümleri etkileyen birçok neden vardır. Hastanede ise genellikle bu neden enfeksiyon, sepsis, şok ve çoklu organ yetersizliğidir. Eastridge ve ark.[16] çalışmalarında on yıllık sürede mortal seyreden 580 olgunun son mod seyyar hastaneye ulaştıktan sonra gerçekleştiğini ve bunun mortal seyreden olguların %12.7’sine karşılık geldiğini bildirmişlerdir. Beekley ve ark.nın[24] hospitalizasyon sürecinde mortalite ile sonuçlanan olguları değerlendirdikleri çalışmalarında mortalite nedeni olarak SSS hasarı ve hemoraji önemli iki neden olarak ifade edilmektedir. Bizim mortal olgularımızda ise SIRS ve SSS hasarı ön plandadır. Bu farkın bizim üçüncü basamak hastane olmamız ve kanama/şok açısından stabilize edilmiş olguları kabul etmiş olmamızdan kaynaklandığı düşünülmektedir. Bizim çalışmamızda sunduğumuz üç olgunun genel mortalite nedeni renal yetmezlik idi. Sepsis, AC yetmezliği ve SSS hasarı diğer mortalite nedenleri olarak gözlendi. Çalışmamızda yapılan mortalite analizinde birinci olguda renal hasarın baskın olduğu AC hasarı ile birlikte sepsisin mortalite üzerine esas zemin oluşturduğu değerlendirildi. Papadopoulos ve ark.[25] ateşli silah yaralanmasına bağlı ölüm gerçekleşmiş 370 olguya ait otopsi çalışmalarında, olguların ISS değerlerini 43 (975) olarak bildirmişlerdir. Bunların 150’sinin ISS değeri 75; 220’sinin ise 74 ve altındadır. ISS’si 75 olan olguların hastaneye getirildiklerinde sağ olmadıkları bildirilmiştir. ÇalışmalarınUlus Travma Acil Cerr Derg, Ocak 2014, Cilt. 20, Sayı. 1

da mortal seyreden sadece 18 (%4.9) olgunun ISS değerinin 16’nın altında olduğunu belirtmişlerdir. Bizim mortal seyreden olgularımızın ISS değerileri ise ardışık olarak 36, 25 ve 25 idi. Kotwal ve ark.nın[26] çalışmalarına göre Amerikan 75. Ranger Birliğinin Afganistan ve Irak Savaşları’ndaki yaklaşık on yıllık verilerine göre son mod mortalite oranları sırasıyla 2/167 olgu ve 2/224 olgu olarak izlenmektedir. Yine tüm amerikan birlikleri açısından bu oran 141/5266 ve 764/29952 olgu olarak bildirilmiştir. Bizim çalışmamızda bu oran bir yıllık sürede 3/108 olarak tespit edilmiştir. Bulgularımız Amerikan Özel Birliği verileri ile uyumludur.

Kısıtlılıklar Çalışmada doğal olarak randomizasyon uygulanamamıştır. Olguların demografik özellikleri gözönüne alındığında yaş ortalamasının 25 olması genç ve rezervi olan bir bünyeye ait travmayı tanımlamaktadır. İleri yaş travmalarda aynı sonuçlara varılabilmesi tartışılmalıdır. Yine olguların biri dışında tümü erkekdir. Bulgular erkek fizyolojisi açısından değerlendirilmelidir. Çalışma kapsamındaki olgular ileri merkezde kabul ve müdahale edilmiş olgulardır. Bir önceki basamak sağlık kurumunda hemodinamik olarak stabilize edilmiş olgulardır. Çalışmanın sonuçları bu açıdan değerlendirilmelidir. Bu nedenle olguların tümünde ihtiyaç duyulan transfüzyon uygulaması minör kategoride tasniflenmiştir. Ancak çalışada uygulanan transfüzyon stratejilerine ait bir standardizasyon olmaması zayıflık olarak değerlendirilmektedir. Olguların farklı disiplinlere ait klinik takiplerde olması ise yine standardizasyonda güçlüklere neden olmuştur. Ayrıca çalışmanın tek merkez yerine çok merkezli planlanıp yapılması halinde daha anlamlı sonuçlara ulaşılacağı açıktır.

Sonuç Yüksek kinetik enerjili silah yaralılarında hasar kontrol resüsitasyonu ilkeleri kapsamında ilk iki basamakta resüsite ve stabilize edildikten sonra ileri inceleme ve tedavi için sevk edildikleri üçüncü basamak-ileri merkezde devam eden tedavi sürecinde; uzun namlulu silahlarla yaralanan olguların ISS değeri yükseldikçe transfüzyon gereksinimlerinin artacağı, patlayıcılarla gerçekleşen yaralanmalarda ise transfüzyon gereksinimlerinin ISS değerinden bağımsız olduğu kanısına vardık. İleri klinik çalışmalarla, özellikle ilk müdahale esnasında ISS değerleri için elde edilecek cut-off değerlerinin hastane kabulleri sonrası için oluşturulacak transfüzyon protokollarının hazırlanmasında yarar sağlayacağı düşüncesindeyiz. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. Walker JJ, Kelly JF, McCriskin BJ, Bader JO, Schoenfeld AJ. Combat-related gunshot wounds in the United States military: 2000-2009 (cohort study). Int J Surg 2012;10:140-3. 2. Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery

Eryılmaz ve ark. Yüksek kinetik enerjili silahlarla yaralanma ve transfüzyon gereksinimleri ile son mod mortalite analizi and further research. Sci Am 1983;249:28-35. 3. Geiling J, Rosen JM, Edwards RD. Medical costs of war in 2035: longterm care challenges for veterans of Iraq and Afghanistan. Mil Med 2012;177:1235-44. 4. Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc (Bayl Univ Med Cent) 2010;23:349-54. 5. Duchesne JC, Holcomb JB. Damage control resuscitation: addressing trauma-induced coagulopathy. Br J Hosp Med (Lond) 2009;70:22-5. 6. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg 2008;248:447-58. 7. Dunne JR, Hawksworth JS, Stojadinovic A, Gage F, Tadaki DK, Perdue PW, et al. Perioperative blood transfusion in combat casualties: a pilot study. J Trauma 2009;66(4 Suppl):150-6. 8. Willy C, Hauer T, Huschitt N, Palm HG. “Einsatzchirurgie”--experiences of German military surgeons in Afghanistan. Langenbecks Arch Surg 2011;396:507-22. 9. Camm CF, Agha RA, Edison E. Commentary on: Combat-related gunshot wounds in the United States military: 2000-2009. Int J Surg 2012;10:322-3. 10. Navarro Suay R, Abadía de Barbará AH, Gutierrez Ortega C, Bartolomé Cela E, Lam DM, Gilsanz Rodríguez F. Gunshot and improvised explosive casualties: a report from the Spanish Role 2 medical facility in Herat, Afghanistan. Mil Med 2012;177:326-32. 11. Belmont PJ Jr, Goodman GP, Zacchilli M, Posner M, Evans C, Owens BD. Incidence and epidemiology of combat injuries sustained during “the surge” portion of operation Iraqi Freedom by a U.S. Army brigade combat team. J Trauma 2010;68:204-10. 12. Belmont PJ, Schoenfeld AJ, Goodman G. Epidemiology of combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom: orthopaedic burden of disease. J Surg Orthop Adv 2010;19:2-7. 13. O’Kelly F, Gallagher TK, Lim KT, Smyth PJ, Keeling PN. Gun shot-101: an 8-year review of gunshot injuries in an Irish teaching hospital from a general surgical perspective. Ir J Med Sci 2010;179:239-43. 14. Simmons JW, White CE, Eastridge BJ, Mace JE, Wade CE, Blackbourne LH. Impact of policy change on US Army combat transfusion practices. J

Trauma 2010;69 Suppl 1:S75-80. 15. Köksal O, Ozdemir F, Bulut M, Aydin S, Almacioğlu ML, Ozgüç H. Comparison of trauma scoring systems for predicting mortality in firearm injuries. Ulus Travma Acil Cerrahi Derg 2009;15:559-64. 16. Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg 2012;73(6 Suppl 5):431-7. 17. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187-96. 18. Baker SP, O’Neill B. The injury severity score: an update. J Trauma 1976;16:882-5. 19. Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007;63:805-13. 20. USAISR. Damage control resuscitation at level IIb/III treatment facilities. Available at: http://www.usaisr.amedd.army.mil/cpgs/DmgCntrlResus0903.pdf.2009. 21. Clarke JE, Davis PR. Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010-April 2011. Mil Med 2012;177:1261-6. 22. Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med 1984;149:55-62. 23. Champion HR, Bellamy RF, Roberts CP, Leppaniemi A. A profile of combat injury. J Trauma 2003;54(5 Suppl):13-9. 24. Beekley AC, Martin MJ, Spinella PC, Telian SP, Holcomb JB. Predicting resource needs for multiple and mass casualty events in combat: lessons learned from combat support hospital experience in Operation Iraqi Freedom. J Trauma 2009;66(4 Suppl):129-37. 25. Papadopoulos IN, Kanakaris NK, Danias N, Sabanis D, Konstantudakis G, Christodoulou S, et al. A structured autopsy-based audit of 370 firearm fatalities: Contribution to inform policy decisions and the probability of the injured arriving alive at a hospital and receiving definitive care. Accid Anal Prev 2013;50:667-77. 26. Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK Jr, Mabry RL, et al. Eliminating preventable death on the battlefield. Arch Surg 2011;146:1350-8.

ORIGINAL ARTICLE - ABSTRACT OLGU SUNUMU

The relationship between Injury Severity Scores and transfusion requirements of 108 consecutive cases injured with high kinetic energy weapons: a tertiary center end-mode mortality analysis Mehmet Eryilmaz, M.D.,1 Onur Tezel, M.D.,1 Hüseyin Taş, M.D.,2 İbrahim Arzıman, M.D.,1 Gökhan İbrahim Öğünç, M.D.,3 Ümit Kaldırım, M.D.,1 Murat Durusu, M.D.,1 Orhan Kozak, M.D.2 Department of Emergency Medicine, Gulhane Military Medicine Faculty, Ankara; Department of General Surgery, Gulhane Military Medicine Faculty, Ankara; 3 Turkish National Police Directorate, Criminal Police Laboratory, Ankara 1 2

BACKGROUND: We aimed in this study to investigate the relationship between Injury Severity Score (ISS) and transfusion strategies required during medical intervention in patients wounded by high kinetic energy (HKE) gunshot, and to analyze end-mode mortality. METHODS: The medical data of patients were included in the study. We evaluated whether there was any significant correlation in terms of demographic characteristics, HKE weapon type, ISSs, and transfusion strategy options and transfusion requirements. RESULTS: Causes of mortality in cases resulting in mortality during hospitalization were evaluated. One hundred and eight consecutive patients were included in the study. All patients except one were male, with an average age of 25 years. 64.8% of them were injured by long-barreled firearms, whereas 35.2% were injured by explosives. Average ISS was 13.9. ISS values for the patients with and without transfusion were 16 (5-48) and 9 (3-36), respectively. Causes of mortality were evaluated in terms of systemic inflammatory response syndrome (SIRS), sepsis, and multiorgan dysfunction syndrome (MODS). DISCUSSION: It was determined that there was a significant correlation between increase in ISS values in cases with HKE weapon wounds and their transfusion requirements, whereas this requirement was independent of the ISS value in cases with explosive wounds. Key words: Gunshot wounds; Injury Severity Score (ISS); mortality; transfusion. Ulus Travma Acil Cerr Derg 2014;20(1):39-44

doi: 10.5505/tjtes.2014.90490

Ulus Travma Acil Cerr Derg, Ocak 2014, Cilt. 20, Sayı. 1

ORIGIN A L A R T IC L E

Management and treatment of liver injury in children Serkan Arslan, M.D.,1 Mahmut Güzel, M.D.,2 Cüneyt Turan, M.D.,2 Selim Doğanay, M.D.,3 Ahmet Burak Doğan, M.D.,2 Ali Aslan, M.D.2 1

Department of Pediatric Surgery, Dr. Münif İslamoğlu Kastamonu State Hospital, Kastamonu;

Department of Pediatric Surgery, Erciyes University Faculty of Medicine, Kayseri;

Department of Radiology, Erciyes University Faculty of Medicine, Kayseri

ABSTRACT BACKGROUND: We aimed to assess the causes of trauma that result in liver injury and additional solid organ injuries, management types and results of management in children referred to our clinic for liver injuries. METHODS: The records of 52 patients who were managed for liver injuries due to blunt abdominal trauma between January 20052010 were reviewed retrospectively. RESULTS: The patients were 1-17 (8.3±5.4) years old; 32 (62%) were male and 20 (38%) were female. Causes of injuries included pedestrian traffic accidents (19, 37%), falls from height (15, 29%), passenger traffic accidents (8, 15%), bicycle accidents (8, 15%), and objects falling on the body (2, 4%). Isolated liver injury was present in 32 patients (62%), while 20 patients (38%) had other organ injuries. Liver injuries were grade I in 6 patients (12%), grade II in 14 (28%), grade III in 22 (43%), grade IV in 9 (17%), and grade V in 1 (2%). Forty-five patients (87%) were managed conservatively in this series of liver injury, whereas seven patients (13%) who had unstable vital signs underwent surgery. The mortality rate, duration of stay in intensive care and hospital, and number of blood transfusions were higher in surgically managed patients, while hemoglobin level and blood pressure were significantly lower in surgically managed patients. CONCLUSION: As a result, conservative management should be preferred in patients with liver injuries who are hemodynamically stable. Conservative management has some advantages, including shorter duration of stay in hospital, less need for blood transfusion and lower morbidity and mortality rates. Key words: Children; hepatic; injury; liver; management; trauma.

INTRODUCTION Liver injuries in children occur as a result of compression to the abdomen and thorax due to high-energy traumas like traffic accidents and falls from height. The liver is the second most commonly injured organ after blunt abdominal traumas.[1-3] The most common cause of liver injury is trauma to the upper right abdomen or right hemithorax. Injuries occur mostly in the right liver lobe because of its localization and size.[4] Address for correspondence: Serkan Arslan, M.D. İnönü Mah., Rauf Denktaş Cad., Günışığı Evleri, A Blok, Kat: 4, No: 14, 37000 Kastamonu, Turkey Tel: +90 366 - 214 72 35 E-mail: drserkanarslan@hotmail.com Qucik Response Code

Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Ultrasonography (US), computed tomography (CT) and liver function tests (LFTs) are tools used for the diagnosis. Physical examination findings may not be sufficient for diagnosis even in serious injury.[5] The liver takes blood from the systemic and portal circulation, so injury to the liver can cause serious blood loss.[1,3] In hemodynamically stable patients, liver injuries are managed conservatively, but if there is hemodynamic instability, patients are managed surgically.[6] Surgery is required if patients need blood transfusions of over 40 ml/kg/day or if there are findings indicating peritoneal irritation or hollow organ perforation.[1] Segmental resections or repairs can be performed in surgery according to the type of injury.[4] Complications like atelectasis, pneumonia, sepsis, intraabdominal abscess, and hemobilia and those due to blood transfusions have been observed after liver injuries.[1] The aim of this study was to assess the types of trauma, management types in liver injuries and additional organ injuries, 45

Arslan et al. Management and treatment of liver injury in children

Table 1. Other system and organ injuries

Affected systems Head Thorax

Extremity

Multiple

Other intraabdominal injuries Liver only

Kidney

Spleen

Gastrointestinal tract

Pancreas

and the success of management types in children referred to our clinic for liver injuries.

MATERIALS AND METHODS The records of 52 patients who were managed for liver injuries due to blunt abdominal trauma between January 2005 and January 2010 were reviewed. Patients were grouped according to liver injury grades. Blood pressure, hemoglobin level, need for blood transfusion, and duration of stay in intensive care were compared between the groups (Table 1). No records were excluded from the study. General information, age, sex, duration of stay in hospital, causes of traumas, additional organ injuries, and treatment methods were evaluated. Hemodynamic status was determined with blood pressure at referral, hemoglobin levels, and need for blood transfusion. All patients in the records were admitted to the intensive care unit, and heart rate, respiratory rate, blood pressure,

and density and amount of urine were measured hourly, and hemoglobin level was monitored at the 6th and 24th hours. Routine biochemical laboratory parameters were checked in all patients. Diagnoses of liver and additional organ injuries were made by anamnesis, physical examination, US, and/or CT examination. Liver injuries were graded using the classification of the American Association for the Surgery of Trauma (AAST) (Table 2). All US and CT images were interpreted by radiologists. All hemodynamically stable liver injuries were managed conservatively. In the presence of suspected perforation on the physical examination and hemodynamic instability in spite of blood transfusions, an emergency laparotomy was performed. Analyses were performed with the Statistical Package for the Social Sciences (SPSS) 19.0 statistical program. We used the Shapiro-Wilk test to determine the normality distribution of the variables. Independent comparisons among the groups were analyzed using a Kruskal-Wallis test. Median (minimummaximum) values were used to determine the numerical variables. Comparisons of categorical data were carried out using a Pearsonâ&#x20AC;&#x2122;s chi-square test. A p-value of less than 0.05 was considered statistically significant.

RESULTS The patients were aged between 1-17 (8.3Âą5.4) years; 32 (62%) were male and 20 (38%) were female. Causes of injuries were pedestrian traffic accidents (19, 37%), falls from height (15, 29%), passenger traffic accidents (8, 15%), bicycle accidents (8, 15%), and objects falling on the body (2, 4%) (Figure 1). Isolated liver injuries were observed in 32 (62%) and additional injuries in 20 (38%) patients. Among these, cranial injuries were commonly seen. The spleen and kidneys were the most affected intraabdominal organs. Additional injuries are summarized in Table 1.

Table 2. Classification of the American Association for the Surgery of Trauma (AAST)[19]

Grade

The size of liver laceration

Small subcapsular haematoma or superficial laceration

Subcapsular haematoma covering 10-50% of surface area or a 1-3 cm

laceration less than 10 cm in length

Large (>50%) ruptured subcapsular haematoma, an intraparenchymal

haematoma >2 cm, or a laceration >3 cm in depth

Ruptured intraparenchymal haematoma or lobar parenchymal

disruption involving 25-50% of the lobe

Lobar parenchymal disruption >50% or juxta-hepatic venous injury

Hepatic avulsion

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Arslan et al. Management and treatment of liver injury in children

Mechanism of trauma 20 18 16 14 12 10 8 6 4 2 0

19 Patients 15 Patients

37%

8 Patients

15%

2 Patients

Passenger traffic accidents

Bicycle accidents

Object falling on the body

29%

Pedestrian traffic accidents

Falls from height

Figure 1. Causes of trauma.

On US examination, liver injuries were present in 42 (81%) and free fluid in the abdomen in 28 (54%) patients. Liver injuries on US examination were graded by CT according to AAST classification. These injuries were classified as grade I in 6 (12%), grade II in 14 (28%), grade III in 22 (43%), grade IV in 9 (17%), and grade V in 1 (2%) patient(s). There were no cases of grade VI liver injury in the present study. Grade I and II injuries were managed conservatively, while 1 patient (5%) with grade III, 5 patients (50%) with grade IV and 1 patient (100%) with grade V were managed surgically (Table 3). Duration of stay in intensive care and hospital, hemoglobin levels, number of blood transfusions, and treatment methods according to injury grades on CT are summarized in Table 3. Increased number of blood transfusions, decreased rate of conservative management, increased rate of surgical management, and increased duration of stay in intensive care and hospital as the grade of injury increased were statistically significant (p<0.05). However, decreased blood pressure and hemoglobin levels as grade of injury increased were not significant (p>0.05).

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were over 150 IU/L in 42 patients (81%), 40-150 IU/L in 8 patients (15%) and lower than 40 IU/L in 2 patients (4%). ALT levels were 240 IU/L, 492 IU/L, 485 IU/L, 437 IU/L, and 420 IU/L in Grades I, II, III, IV, and V, respectively; AST levels were 336 IU/L, 627 IU/L, 600 IU/L, 501 IU/L, and 400 IU/L in Grades I, II, III, IV, and V, respectively. Normal enzyme levels were observed in 2 patients with grade I injury. The relationship between enzyme levels and injury grade was not significant (p>0.05). Forty-five patients (87%) were managed conservatively in this series. All of these patients survived. Seven patients (13%) with unstable vital signs underwent surgery for liver injury. One of these patients had grade III injury, 5 had grade IV and 1 had grade V injury. Segmentectomy was performed in 2 patients with grade IV injuries, and hepatic repair was carried out in 3 patients with grade IV injuries and in 1 patient with grade III injury. Liver resection was performed in the patient with grade V injury; this patient died perioperatively. Other patients managed surgically were discharged well. There were no long-term complications in the surgically managed patients. In grade IV, the number of blood transfusions and duration of stay in intensive care and hospital were significantly lower in conservatively managed patients than in surgically managed patients, while hemoglobin level and blood pressure were significantly higher in conservatively managed patients than in surgically managed patients (Table 4). In the conservatively managed group, 3 patients (7%) had resorption fever, 1 (2%) had a reaction to blood transfusion, 1 (2%) developed atelectasis, 1 (2%) had an intraabdominal abscess, and 1 (2%) developed a lung infection postoperatively.

Table 3. The data according to the grades of liver injury Grade I (n=6)

Grade II (n=14)

Grade III (n=22)

Grade IV (n=9)

Grade V (n=1)

Systolic BP*

100 mmHg

110 mmHg

70 mmHg

0.923

(97.5-120) (100-120) (100-120) (90-112)

Diastolic BP*

60 mmHg

40 mmHg

0.910

7 g/dL

0.442

70 mmHg

(60-80) (60-80) (60-70) (60-72)

Hb level*

11.5 g/dL

(9-12.5) (10.7-13) (10.7-12) (9-12)

12 g/dL

11.5 g/dL

No. of transfusions

2 (33%)

6 (43%)

16 (73%)

8 (89%)

0.007

Duration of stayin intensive care unit*

1 day (1-1)

1 day (1-2)

2 day (1.7-3)

–

0.007

Duration of stayin hospital

4.5 days (3-6)

5 days (3-6)

5 days (4-6)

8 days (5.5-11)

–

0.030

6 (100%)

14 (100%)

21 (95.4%)

4 (44%)

–

<0.001

+ (perop ex)

<0.001

No. of conservatively

No. of surgically 0 0 1 (4.5%) 5 (56%) managed patients * Median (Min-Max).

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Arslan et al. Management and treatment of liver injury in children

Table 4. The comparison of conservatively and surgically managed patients in grade IV Grade IV Systolic BP* Diastolic BP *

Conservatively managed patients (n=4)

Surgically managed patients (n=5)

100 mmHg (100-130)

90 mmHg (85-95)

0.008

70 mmHg

60 mmHg

0.016

(70-80) (60-65)

Hb level*

11 g/dL (10-14)

9 g/dL (7-9)

0.008

No. of transfusions

2 (75%) patients

5 (100%) patients

0.444

Duration of stayin intensive care unit*

1 days (1-1)

1 days (2-3)

0.008

Duration of stayin hospital*

5.5 days (4-6)

11 days (8-25)

0.030

*: Median (Min-Max).

DISCUSSION The liver is the second most commonly injured intraabdominal organ after abdominal traumas. The rate of liver injury after blunt abdominal traumas is 2-3%. Most liver injuries occur due to motor vehicle accidents and falls from heights. Penetrative injuries are rare in children. Surgical treatment is not necessary in 70-90% of patients. The aim of non-operative management of liver injuries in children is to reduce operative morbidity and mortality.[4] The right diagnosis and treatment of liver injuries are very important in children because liver injury after blunt abdominal traumas is the most important cause of mortality.[7,8] Leone et al.[9] reported the cases of 27 patients with liver injury due to pedestrian traffic accidents (14 patients, 51%), passenger traffic accidents (7 patients, 26%), bicycle accidents (4 patients, 15%), falls from height (1 patient, 4%), and assault (1 patient, 4%). In the present study, the rate of liver injuries due to pedestrian traffic accidents (19, 37%) was lower than that reported by Leone et al., whereas liver injuries due to falls from height (15, 29%) and bicycle accidents (8, 15%) were higher than in that study. Sociocultural differences could be the reason for this variation. In the study by Leone et al., 13 patients (49%) had grade I injury, 9 (33%) had grade II injury, 3 (11%) had grade III injury, and 2 (7%) had grade IV injury. In the present study, more patients were classed in the higher grades compared to that study. It can be said that the patients admitted to our clinic had more severe traumas. Landau et al.[10] studied 311 patients, and reported that 136 patients (44%) had isolated liver injury, while 175 patients (56%) had additional injuries. These additional injuries were to the head in 147 patients (47%), extremity fractures in 131 patients (42%), and to the thorax in 66 patients (21%). Other intraabdominal organ injuries in addition to liver injury were in the spleen (45 patients, 14%), kidney (4 patients, 1%) and pancreas (4 patients, 1%). In our study, 32 patients (62%) had 48

isolated liver injury and 20 patients (38%) had other organ injuries in addition to liver injury. Other injuries included head (6 patients, 12%), thorax (4 patients, 8%), extremity (4 patients, 8%), and multiple organ injuries (3 patients, 6%). Liver injuries may occur frequently with the right kidney due to trauma to the right abdomen because of its dimensions and localization. Similarly, the spleen is the most injured organ with the left kidney due to trauma to the left abdomen. Injuries to the pancreas are uncommon because of its localization.[1] Holmes et al.[11,12] reported that the sensitivity of US for patients with abdominal trauma is 80%. US determined liver lacerations in 42 patients (81%) and free fluid in the abdomen in 28 patients (54%) in the present study. These rates are similar to those in the literature. Simplicity, ease of use and no radiation are the main advantages of US. Its disadvantages are subjectiveness and low sensitivity with inexperienced users. In several studies, AST and ALT levels over 150 IU/L indicated liver parenchymal damage in 43-61% of patients, but were unable to show the degree of parenchymal damage.[1,13] However, in the present study, all patients had parenchymal damage, and 10 (19%) of them had enzyme levels lower than 150 IU/L. As in the literature, there was no relation between enzyme levels and injury grade in the present study. On the other hand, it has been reported that one can rule out liver parenchymal damage if enzyme levels are normal.[1,13] As in the literature, in the present study, except for two patients with grade I injuries, increased AST and ALT levels were observed and all patients had liver parenchymal damage. Hemoglobin level can decrease and there can be minimal leukocytosis in liver traumas. Karkiner et al.[14] reported the cases of 75 patients whose blood transfusion rates were 13% for grade I, 20% for grade II, 30% for grade III, 50% for grade IV, and 100% for grade V injuries. Ninety-seven percent of patients received conservative treatment and 3% of patients were managed surgically. In the present study, the transfuUlus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Arslan et al. Management and treatment of liver injury in children

sion rates were 33%, 43%, 73%, and 100% for grades I, II, III, and grades IV-V, respectively. There were more blood transfusions in the present study than in other studies in the literature. Patients who received blood transfusion in the present study had hemoglobin levels of 10 g/dl or lower at diagnosis or during the follow-up period. However, some clinics carry out blood transfusion when hemoglobin levels fall below 9 or 8 g/dl. This can explain the different figures in the literature regarding blood transfusion rates. Stabilization of patients hemodynamically is more difficult as the grade of injury increases. We found a statistically significant relation between the grade of injury and blood transfusion (p=0.00). There was also a significant relation between the grade of injury and rate of surgery in the present study (p=0.00). On the other hand, the relation between higher grade injury and lower hemoglobin level was not statistically significant (p<0.05). In the present study, durations of stay were 1, 1, 1, and 2 days in intensive care and 4, 5, 5, 5, and 8 days in hospital for grades I, II, III, and IV, respectively. There was a statistically significant relationship between grade of injuries and duration of stay in intensive care and in hospital (p<0.05). Nellensteijn et al.[15] reported that durations of stay were 0, 0, 0, and 1 days in intensive care and 2, 3, 4, and 5 days in hospital for grades I, II, III and IV, respectively. In that study, there was also a significant relation between the grade of injury and duration of stay in intensive care and in hospital. However, durations of stay in intensive care and in hospital were longer in the present study than in that of Nellenstein et al. This may have been because more severe traumas, and as a result, more severe injuries were observed in the present study. Conservative management is successful in 90% of liver injuries. After discharge, absolute bed rest for 7-10 days and limited physical activity for 4-6 weeks are recommended.[16,17] Forty-five of 52 patients (87%) were managed conservatively in the present study. Of these patients, 20 (100%) with grade I and II injuries, 21 (95%) with grade III injuries and four (40%) with grade IV injuries were managed conservatively. There was transfusion reaction in three patients (7%) in the followup period. Surgical management of liver injury has a higher mortality rate than conservative management because liver resection increases the risk of perioperative and postoperative mortality.[18] Kepertis et al.[19] managed 9 of 34 patients (26%) surgically. Two of these patients had grade IV injuries, one had grade V and one had grade VI; two of the other five patients underwent surgery for splenic laceration, two for head injury, one for diaphragmatic rupture, and one for extremity fracture. There was 1 (11%) mortality in the surgically managed patients and no incidence of mortality in the conservatively managed patients in the study of Kepertis et al.[19] Similarly, in the present study, the mortality rate was high in the surgically managed patients, as one out of seven patients (14%) died. In the Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

present study, duration of stay in intensive care and in hospital and number of blood transfusions were higher in surgically managed patients, while hemoglobin level and blood pressure were significantly lower in surgically managed patients. In 25% of all liver traumas, complications such as atelectasis and pneumonia can be seen. In the present study, of the 45 patients who were managed conservatively, three patients (6.6%) had atelectasis and one patient (2.2%) developed pneumonia. Our complication rate was lower than that in the literature due to the conservative approach adopted in this study. On the other hand, there were no complications in the six surviving patients managed surgically. However, the lower complication rate observed in surgically managed patients in the present study was probably due to the low patient numbers. The incidence of intrahepatic or subhepatic abscess is 0.5-3%.[1] As in the literature, one patient who was managed conservatively (2.2%) had subhepatic abscess in the present study. In conclusion, conservative management has some advantages, including shorter duration of stay in hospital, less need for blood transfusion and lower morbidity and mortality rates. Therefore, conservative management should be preferred in liver injuries in patients who are hemodynamically stable. Conflict of interest: None declared.

REFERENCES 1. Basaklar AC, Türkyılmaz Z. Abdominal and thoracic trauma. In: Başaklar AC, editor. Bebek ve çocukların cerrahi ve ürolojik hastalıkları. Ankara: Palme Yayincilik; 2006. p. 1015-50. 2. Bluett MK, Woltering E, Adkins RB. Management of penetrating hepatic injury. A review of 102 consecutive patients. Am Surg 1984;50:132-42. 3. Bond SJ, Eichelberger MR, Gotschall CS, Sivit CJ, Randolph JG. Nonoperative management of blunt hepatic and splenic injury in children. Ann Surg 1996;223:286-9. 4. Gross M, Lynch F, Canty T Sr, Peterson B, Spear R. Management of pediatric liver injuries: a 13-year experience at a pediatric trauma center. J Pediatr Surg 1999;34:811-7. 5. Feigin E, Aharonson-Daniel L, Savitsky B, Steinberg R, Kravarusic D, Stein M, et al. Conservative approach to the treatment of injured liver and spleen in children: association with reduced mortality. Pediatr Surg Int 2009;25:583-6. 6. Coburn MC, Pfeifer J, DeLuca FG. Nonoperative management of splenic and hepatic trauma in the multiply injured pediatric and adolescent patient. Arch Surg 1995;130:332-8. 7. Keller MS. Blunt injury to solid abdominal organs. Semin Pediatr Surg 2004;13(2):106-11. 8. Eppich WJ, Zonfrillo MR. Emergency department evaluation and management of blunt abdominal trauma in children. Curr Opin Pediatr 2007;19:265-9. 9. Leone RJ Jr, Hammond JS. Nonoperative management of pediatric blunt hepatic trauma. Am Surg 2001;67:138-42. 10. Landau A, van As AB, Numanoglu A, Millar AJ, Rode H. Liver injuries in children: the role of selective non-operative management. Injury 2006;37:66-71.

Arslan et al. Management and treatment of liver injury in children 11. Sivit CJ. Imaging children with abdominal trauma. AJR Am J Roentgenol 2009;192:1179-89.

diatric blunt liver trauma in a Dutch level 1 trauma center. Eur J Pediatr Surg 2009;19:358-61.

12. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 2007;42:1588-94.

16. Oldham KT, Guice KS, Ryckman F, Kaufman RA, Martin LW, Noseworthy J. Blunt liver injury in childhood: evolution of therapy and current perspective. Surgery 1986;100:542-9.

13. Taylor GA, Sivit CJ. Posttraumatic peritoneal fluid: is it a reliable indicator of intraabdominal injury in children? J Pediatr Surg 1995;30:1644-8.

17. Celebi F, Balik AA, Polat KY, Yildirgan MI, Böyük A, Oren D. Hepatic injuries. Surgical treatment experience. Ulus Travma Derg 2001;7:185-8.

14. Karkiner A, Temir G, Utku M, Uçan B, Hoşgör M, Karaca I. The efficacy of non-operative management in childhood blunt hepatic trauma. Ulus Travma Acil Cerrahi Derg 2005;11:128-33.

18. Pachter HL, Hofstetter SR. The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg 1995;169:442-54.

15. Nellensteijn D, Porte RJ, van Zuuren W, ten Duis HJ, Hulscher JB. Pae-

19. Kepertis C, Zavitsanakis A, Filippopoulos A, Kallergis K. Liver trauma in children: Our experience. J Indian Assoc Pediatr Surg 2008;13:61-3.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

Çocuklarda karaciğer yaralanmasında yönetim ve tedavi Dr. Serkan Arslan,1 Dr. Mahmut Güzel,2 Dr. Cüneyt Turan,2 Dr. Selim Doğanay,3 Dr. Ahmet Burak Doğan,2 Dr. Ali Aslan2 Dr. Münif İslamoğlu Kastamonu Devlet Hastanesi, Çocuk Cerrahisi Kliniği, Kastamonu; Erciyes Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Kayseri; 3 Erciyes Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Kayseri 1 2

AMAÇ: Karaciğer travması nedeniyle son 7 yılda kliniğimize başvuran çocuklarda travma tiplerini, eşlik eden solid organ yaralanmalarını, tedavilerini ve tedavi sonuçlarını değerlendirmektir. GEREÇ VE YÖNTEM: Kliniğimizde Ocak 2005-Ocak 2012 arasında künt karın travmalarına bağlı karaciğer yaralanması nedeniyle tedavi edilen 52 hasta retrospektif olarak değerlendirildi. BULGULAR: Hastaların yaşları 1-17 (ortalama 8.3±5.4) yaş arasında olup 32’si (%61.6) erkek, 20’si (%38.4) kızdı. Hastalar en sık araç dışı trafik kazası (19, %37), yüksekten düşme (15, %29), araç içi trafik kazası (8, %15), bisiklet kazaları (8, %15) ve üzerine cisim düşme (2, %4) nedeniyle başvurdu. Hastaların 32’sinde (%61.5) izole karaciğer, 20’sinde (%38.5) eşlik eden diğer organ yaralanmaları vardı. Hastaların 6’sında kafa (%11.5), 4’ünde (%7.6) toraks, 4’ünde (% 7.6) ekstremite, 3’ünde (%5.7) çoklu yaralanma vardı. Karıniçi organlardan 8’inde böbrek (%15), 8’inde (%15) dalak, 2’sinde (%4) GİS, 2’sinde (%4) pankreas yaralanması vardı. Altı hasta (%11.5) Evre I, 14 hasta (%27) Evre II, 22 hasta (%42.5) Evre III, 9 hasta (%17) Evre IV, 1 hasta (%2) Evre V idi. Evre I ve II olan tüm hastalar konservatif tedavi yapılırken, cerrahi tedavi yapılan 1 hasta (%4.5) evre III, 5 hasta (%50) evre IV, 1 hasta (%100) ise Evre V idi. Bu çalışmada 52 hastanın 45’i (% 86.5) konservatif takip edilirken, vital bulguları stabil olmayan 6 hasta ameliyat edildi. Bir hasta ameliyat sırasında hayatını kaybetti (%1.9). TARTIŞMA: Sonuç olarak, karaciğer travmalarında hemodinamik olarak stabil seyreden hastalarda konservatif tedavi tercih edilmelidir. Çocuklarda karaciğer travmalarının çoğu konservatif tedavi edilebilmektedir. Konservatif tedavi daha kısa hastanede kalış süresi, daha az transfüzyon ihtiyacı, morbiditenin ve mortalitenin daha düşük olması gibi avantajlara sahiptir. Anahtar sözcükler: Çocuk, hepatik; karaciğer; tedavi yönetimi; travma; yaralanma. Ulus Travma Acil Cerr Derg 2014;20(1):45-50

doi: 10.5505/tjtes.2014.58295

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ORIGIN A L A R T IC L E

Intraorbital wooden foreign body: clinical analysis of 32 cases, a 10-year experience Süleyman Taş, M.D., Hüsamettin Top, M.D. Department of Plastic Reconstructive and Aesthetic Surgery, Trakya University Faculty of Medicine, Edirne

ABSTRACT BACKGROUND: We aimed to describe herein the clinical features, diagnosis and treatment of intraorbital wooden foreign body injuries. METHODS: A case series review of orbital injuries managed at Trakya University Faculty of Medicine between 2002 and 2012 was performed retrospectively. The clinical analysis of 32 intraorbital wooden foreign body injuries was reviewed. RESULTS: Among the 32 cases, injuries in 16 were caused by a tree branch, in 10 by a pencil, in 5 by a stick, and in 1 by a bush. With respect to preoperative vision, postoperative vision was improved in 69% of patients. Time lapse from injury to presentation was correlated with the size of the foreign body. The subjects were comparable in etiological factor, and distribution of injury according to orbit was as follows: superior 28%, medial 25%, lateral 22%, inferior 16%, and posterior 9%. Computerized tomography (CT) for foreign body was definitive in 72% (n=23) and suggestive in 28% (n=9). CONCLUSION: The diagnosis of orbital wooden foreign body is difficult because it may be missed clinically and from the imaging perspective. If a foreign body is suspected, optimal patient management should be done. Prior to the surgery, imaging modalities should be maximally utilized. A careful preoperative evaluation, imaging studies, which are event-specific, a high index of suspicion, and rigorous surgery and postoperative care are the keys in the management of orbital wooden foreign body injuries. Key words: Foreign body; orbit; trauma; wooden.

INTRODUCTION Intraorbital foreign bodies (IOFBs) are a global injury and occur with a frequency of one in six orbital injuries.[1] However, a wood FB is uncommon.[2] Intraorbital wooden foreign bodies (IOWFBs) carry the risk of damaging the orbital contents, intracranial extension due to the conical shape of the orbit, and infection.[3] For various reasons, the diagnosis and management of IOWFBs are difficult. The history and external signs of injury are often scant or absent (e.g. conjunctiva entry), and the FB

Address for correspondence: Süleyman Taş, M.D. Trakya Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Edirne, Turkey Tel: +90 284 - 236 09 09 E-mail: drsuleymantas@live.com Qucik Response Code

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may be missed by imaging modalities.[4] Most entry points of IOWFBs are the eyelids and conjunctiva, and these occasionally may be quite small and hard to determine even with lamp examination.[4] In many studies, there is a long delay between injury and presentation. Moreover, the first injury may have been forgotten and received different diagnoses.[4,5] Most of what is known about IOWFB has been gleaned from case reports. As the present study is the largest series in the literature, we aimed to present our clinical experience with respect to the clinical features, diagnosis, treatment, and results in IOWFBs, in an effort to facilitate an algorithm for their treatment.

MATERIALS AND METHODS This study was performed under an institutional ethics review board-approved protocol. We conducted a retrospective chart review of 32 patients who admitted to Trakya University Faculty of Medicine and were diagnosed with IOWFB from 2002 through 2012. Medical records of all patients included patient history, clinical examination and evaluation, mechanism and location of injury, and nature of the FB. For each case, we determined the preoperative findings (age, 51

TaĹ&#x; et al. Intraorbital wooden foreign body

sex, characteristic of trauma, preoperative vision acuity, time lapse from injury to presentation) and postoperative findings (results of wound cultures, response to antibiotic therapy, type of imaging modality, postoperative vision acuity, complications). We compared the complications, results and longterm follow-up. Written informed consents were obtained from the patients. This study adhered to the principles of the Declaration of Helsinki.

RESULTS The results are summarized in Table 1. There were 32 cases, and the majority were male (75%, n=24). The mean age was 21 years (range, 4-52 years). The distribution of FB was as follows: tree branch (50%, n=16), pencil (31%, n=10), stick (16%, n=5), and bush (3%, n=1).

Preoperative vision ranged between 20/50 and 20/400 in 31% (n=10) of the patients (with injured globe) and remained the same postoperatively. In 13% (n=4) of the patients (with injured globe), preoperative vision ranged between counting fingers (CF) to light perception (LP) and improved to 20/400 postoperatively. In 56% (n=18) of the patients (with intact globe), vision ranged between 20/20 and 20/40 and increased postoperatively. None of the patients demonstrated worsened visual acuity after surgery. The time lapse from injury to presentation (range, 3 hours-22 months; mean, 54 days) was correlated with the size of the FB (first 72 hours for >2 cm, after 72 hours <2 cm). However, 69% (n=22) of patients presented within 72 hours of the injury. The initial visual acuity was associated with presentation lag.

Table 1. Summary of preoperative status and postoperative outcomes Etiology

Type of foreign body

Site of injury

Preop vision acuity

Postop vision acuity

Size of foreign body

Presentation time after injury

Woodsman

Tree branch (50%)

n=3 medial, 19%

20/20 to 20/40 n=10

Improved

Range: 1-5 cm

5 hours to 2 years

>2 cm, n=11

first 72 hours, n=9

20/50 to 20/400 n=5

No change

<2 cm, n=5

11 days to 22 months, n=7

CF to LP n=1 20/20 to 20/40

Worsened 0 Improved 7

Range: 4-6 cm

3 hours to 1 year

No change

>2 cm, n=10

<2 cm, n=1

CF to LP n=1 20/20 to 20/40 n=2

Worsened 0 Improved

3 hours to 14 days, n=9 30 days to 1 year, n=2

Range: 3-5 cm

>2 cm, n=5

20/50 to 20/400 n=1 CF to LP n=2 20/20 to 20/40, 56% 20/50 to 20/400, 31% CF to LP, 13%

No change

<2 cm, n=0

1 Worsened 0 69% improved

81% >2 cm

69% first 72 hours

31% No change

19% <2 cm

31% after 72 hours

n=4 superior, 25% n=2 posterior, 12% n=3 lateral, 19% n=4 inferior, 25% 10

Pencil (31%)

n=5 medial, 46%

Bush (3%)

n=6 n=4 superior, 36% n=1 posterior, 9% 20/50 to 20/400 n=4 n=1 inferior, 9%

Fall

Physical assault

Total

Stick (16%)

n=5 lateral, 100%

25% medial 28% superior 9% posterior

4 hours to 26 hours 4 hours to 26 hours, n=5 After 26 hours, n=0

0% Worsened

22% lateral 16% inferior CF: Counting fingers; LP: Light perception.

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(a)

(b)

wound closure, and final antibiotic agent based on wound culture results. The upper lid injuries postoperatively included ptosis in 9% (n=3) of subjects, and these cases had a tissue defect of the upper lids (Figure 2a, b). Strabismus surgery was necessary postoperatively in one patient (3%).

DISCUSSION

Figure 1. (a) Preoperative image in normal setting and soft tissue window: the IOWFB is not recognizable. (b) In bone window, with the setting of 4000 HU width, 400 HU level, the IOWFB (red arrows) can be demonstrated easily.

The location of periocular trauma was distributed according to the etiological factor and presented in superior (28%), medial (25%), lateral (22%), inferior (16%), and posterior (9%) orbits. In all cases, computerized tomography (CT) studies were performed. The radiologist recognized IOWFB in 72% of subjects and noted possible FB in 28% of subjects. In these patients, the radiologist requested magnetic resonance imaging (MRI) for two cases and encouraged investigation of the possibility of IOWFB (Figure 1a, b). In 66% of subjects (n=21), wound cultures were taken during the operation, and many species were isolated, including Staphylococcus epidermidis, Staphylococcus aureus, Enterobacter agglomerans, and Clostridium perfringens. There was no particular predominant species. No mycobacterium or fungus was isolated, even when specific cultures were done. The majority of subjects (62%, n=20) were treated with intravenous antibiotics on admission. The treatment approach in all cases was empiric antibiotic therapy (ampicillin-sulbactam), immediate removal of the FB, acquisition of wound culture, adequate debridement, primary

(a)

As our region is in close proximity to the forest and many people are woodsmen by profession, accidents occurring while cutting trees are encountered frequently, including IOWFBs, due to the habit of not wearing protective masks. This explains the high number of cases of IOWFB seen in our institution, although such cases are rare in the literature. The diagnosis of IOWFB can be difficult due to the sometimes negligible external signs of injury and the late presentation after the injury. Some authors have argued that management of such cases should be conservative and that surgical exploration should be done only in the case of complication.[6] However, we recommend surgical removal of the FB because organic materials carry a high risk of infection.[2-4] In clinical practice, we encountered late presentation cases with a complication (e.g., abscess formation, fistula, granuloma). To our knowledge, there has been no study demonstrating the complications rate when conservative treatment is chosen. Infection risk increases with organic FBs, regardless of the anatomic site.[4] Because of the possibility of rapid progression of infection in the orbital area, empiric antibiotic therapy is advised.[4] If there is a suspicion of intracranial penetration, the empiric antibiotic therapy should include a third-generation cephalosporin and vancomycin.[4,7] Though we did not encounter any intracranial penetration, as a rule, FB removal should not be attempted until sufficient imaging has been performed. Consistent with our study, the previous studies have shown no predominant organism. However, cocci, rods, and anaerobes were predominant (S. epidermidis, S. aureus, E. ag-

(b)

Figure 2. (a) Intraoperative IOWFB was explored. (b) A 4 cm wooden piece was removed.

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Taş et al. Intraorbital wooden foreign body

glomerans, C. perfringens).[2,8,9] Fungal organisms do not play a significant role in IOWFB.[2] Imaging of IOWFB is complex with respect to modality (plain X-ray, ultrasonography [USG], CT, MRI), hydration of the wood (dry vs. fresh), type of wood (soft vs. hard), size of wood, and wood treatments (preservatives, paint). In the prior studies, these subjects have been investigated extensively, and the outcomes and suggestions are substantial for reviewing. Plain X-ray does not work for viewing IOWFB because it is hard to visualize wood with this modality.[10,11] USG has a very limited role as it requires expertise and is not reliable for imaging the orbital apex.[10,12] Moreover, it can image the proximity of the orbital cavity in the absence of orbital imaging. CT and MRI are the available modalities for the diagnosis of IOWFB. However, these modalities have limitations and require fine-tuning to maximize their diagnostic potential. In the literature, it is reported that standard CT image is not an appropriate method for showing acute IOWFB due to the possibility of its mimicking air images.[13] However, bone window with parameters of 4000 HU width/400 HU level and simultaneous axial and coronal imaging is certainly more effective for detecting IOWFB (Fig. 3).[13,14] Thus, CT is currently the gold standard for detecting IOWFB with its additional advances over the other imaging modalities (i.e., cheaper, more available, fast result, suitable in children). However, it is important that radiologists be informed regarding the width and level settings when there is a suspicion of IOWFB.[2] Magnetic resonance imaging (MRI) in certain settings may be helpful as an adjunct to CT. In T-1-weighted images, the signal from an IOWFB is uniform and more diagnostic than T-2- weighted or proton density images.[15] In T-2 images, the signal from an IOWFB is indiscernible from the surrounding soft tissue, independent of its hydration. Further, since T-2 images are obtained over a longer period than T-1 images, the possibility of motion artifact may increase. On T-1 images, the IOWFB is hypointense from surrounding soft tissue, independent of its hydration, although this is not a uniform finding and ring enhancement with gadolinium may be seen initially in some cases.[15,16] In our series, in line with these rec-

ommendations, we needed MRI images for only two patients at the beginning of the study. As the radiologist’s experience increased, CT images were adequate. Organic FBs are well-known causes of infection, regardless of the anatomical site. In the presence of an intracranial penetration, the management of the infection will be more complicated, and antibiotics, which have good blood-brain barrier penetration, are recommended.[17-20] In the current study, we did not experience any such case of an infectious complication, which we attribute to the sufficient debridement and our close consultation with the Infectious Diseases Department and compliance with their recommendations. Our culture results were similar to those in the literature, and no particular dominant organism was identified. In the literature, no IOWFB with eyelid defect was reported. In our series, we observed three such cases. We repaired the lacerated levator muscle and reconstructed the skin defect with advancement flaps after accurate debridement and irrigation with antibiotic solutions. In these cases, as a fundamental principle, if there is a suspicion of inadequate debridement, a secondary closing should be planned. In these cases, there is risk of ptosis or lagophthalmus due to injury to the levator and Muller’s muscles. Thus, in defects of the upper eyelids, care should be given in repairing the levator muscle. Because the majority of the cases were woodsmen, we stress the importance of wearing protective masks in such occupations to avoid these types of injuries. We observed that young men had the highest risk for IOWFB, as in prior studies (75% had a mean age of 21 years).[2] The most common site of IOWFB is not clear in prior case series. In our report, we observed that the site of IOWFB depended on the etiology of the injury. In the woodsmen group, we could not determine the most frequent site because the site changed with changes in the positioning of the electrical saw. In the group suffering a fall, superior and medial orbit were frequent, which can be explained by neck hyperextension as a reflex to prevent the injury.[17] In the group that suffered physical assault with a stick, the lateral orbit was frequent (the rarest site in the literature), and again, this could be attributed to turning one’s head as a reflex mechanism. In a prior study, the presentation time after injury was variable (range, 1 day to over 1 year).[2] However, we reported that it was compatible with the size of the WFB. The presentation time was <2 days for WFB >2 cm and >2 days for WFB <2 cm. This information is extremely important to anticipate the size of the FB.

Figure 3. Postoperative early result: a mild ptosis was observed.

In conclusion, satisfactory results can be achieved in IOWFBs in the presence of a careful history and physical examination, CT imaging (with the radiologist well-informed of the optimal settings), a timely exploratory surgery, removal of the Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Taş et al. Intraorbital wooden foreign body

foreign body with a heightened level of attention, postoperative antibiotic prophylaxis, and close consultation with the Infectious Diseases Department. However, this report is the largest series in the literature, and thus more definitive for the clinical features of IOWFBs. We believe it will shed light on the management of IOWFBs. Conflict of interest: None declared.

REFERENCES 1. Boncoeur-Martel MP, Adenis JP, Rulfi JY, Robert PY, Dupuy JP, Maubon A. CT appearances of chronically retained wooden intraorbital foreign bodies. Neuroradiology 2001;43:165-8. 2. Shelsta HN, Bilyk JR, Rubin PA, Penne RB, Carrasco JR. Wooden intraorbital foreign body injuries: clinical characteristics and outcomes of 23 patients. Ophthal Plast Reconstr Surg 2010;26:238-44. 3. Dunn IF, Kim DH, Rubin PA, Blinder R, Gates J, Golby AJ. Orbitocranial wooden foreign body: a pre-, intra-, and postoperative chronicle: case report. Neurosurgery 2009;65:383-4. 4. Miller CF, Brodkey JS, Colombi BJ. The danger of intracranial wood. Surg Neurol 1977;7:95-103. 5. Herman TE, Shackelford GD, Tychsen L. Unrecognized retention of intraorbital graphite pencil fragments: the role of computerized tomography. Pediatr Radiol 1995;25:535-7. 6. Agarwal PK, Kumar H, Srivastava PK. Unusual orbital foreign bodies. Indian J Ophthalmol 1993;41:125-7. 7. Roos KL. Principles of neurologic infectious diseases. New York, NY: McGraw-Hill; 2005. 8. Jabaly-Habib HY, Muallm MS, Garzozi HJ. An intraorbital injury from an occult wooden foreign body. J Pediatr Ophthalmol Strabismus

2002;39:300-2. 9. Sullivan TJ, Patel BC, Aylward GW, Wright JE. Anaerobic orbital abscess secondary to intraorbital wood. Aust N Z J Ophthalmol 1993;21:49-52. 10. Ho VT, McGuckin JF Jr, Smergel EM. Intraorbital wooden foreign body: CT and MR appearance. AJNR Am J Neuroradiol 1996;17:134-6. 11. Lagalla R, Manfrè L, Caronia A, Bencivinni F, Duranti C, Ponte F. Plain film, CT and MRI sensibility in the evaluation of intraorbital foreign bodies in an in vitro model of the orbit and in pig eyes. Eur Radiol 2000;10:1338-41. 12. Mutlukan E, Fleck BW, Cullen JF, Whittle IR. Case of penetrating orbitocranial injury caused by wood. Br J Ophthalmol 1991;75:374-6. 13. Dalley RW. Intraorbital wood foreign bodies on CT: use of wide bone window settings to distinguish wood from air. AJR Am J Roentgenol 1995;164:434-5. 14. Yamashita K, Noguchi T, Mihara F, Yoshiura T, Togao O, Yoshikawa H, et al. An intraorbital wooden foreign body: description of a case and a variety of CT appearances. Emerg Radiol 2007;14:41-3. 15. Glatt HJ, Custer PL, Barrett L, Sartor K. Magnetic resonance imaging and computed tomography in a model of wooden foreign bodies in the orbit. Ophthal Plast Reconstr Surg 1990;6:108-14. 16. Smely C, Orszagh M. Intracranial transorbital injury by a wooden foreign body: re-evaluation of CT and MRI findings. Br J Neurosurg 1999;13:206-11. 17. Miller CF, Brodkey JS, Colombi BJ. The danger of intracranial wood. Surg Neurol 1977;7:95-103. 18. Mandell GL, Bennett JE, Dolin R, (editors). Principles and practice of infectious disease. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2005. 19. Nasr AM, Haik BG, Fleming JC, Al-Hussain HM, Karcioglu ZA. Penetrating orbital injury with organic foreign bodies. Ophthalmology 1999;106:523-32. 20. Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002;109:494-500.

KLİNİK ÇALIŞMA - ÖZET OLGU SUNUMU

İntraorbital tahta cisim yaralanmaları: Otuz iki olgunun klinik analizi, 10 yıllık deneyim Dr. Süleyman Taş, Dr. Hüsamettin Top Trakya Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Edirne

AMAÇ: Bu yazıda, intraorbital tahta cisim yaralanmalarının klinik özellikleri, tanı ve tedavi rejimlerini tanımlamak amaçlandı. GEREÇ VE YÖNTEM: 2002 ile 2012 yılları arasında Trakya Üniversitesi Tıp Fakültesine başvuran orbital yaralanmalar geriye dönük olarak incelendi. Tespit edilen 32 intraorbital tahta cisim yaralanması değerlendirildi. BULGULAR: Otuz iki yaralanmanın, 16’sı ağaç kabuğu, 10 tanesi kalem, 5 tanesi çubuk, 1 tanesi ise çalıdan kaynaklanmaktaydı. Ameliyat öncesi görme keskinliği ameliyat sonrası genelikle arttı (%69). Yaralanma zamanı ile başvuru zamanlaması arasındaki süre, yabancı cisimin boyut ile kolere bulundu. Yaralanma lokalizasyonu, yaralanmanın etiyolojisi ile ilişkili olup, %28’i superior, %25’i medial, %22’si lateral, %16’sı inferior, %9’u ise posterior orbita yerleşimliydi. Bilgisayarlı tomografi olguların %72’sinde tanıda tek başına yeterli iken, kalan %28’inde muhtemel yabancı cisim kanısı verdi. TARTIŞMA: İntraorbital tahta cisim yaralanmalarının tanısı, klinik ve radyolojik olarak fark edilmesi güç olduğundan zordur. Alınan anamnezde eğer bir şüphe varsa, optimal hasta yönetimi gerçekleştirilmelidir. Cerrahi öncesi, görüntüleme yöntemlerinden maksimum faydalanmalıdır. Dikkatli bir ameliyat öncesi değerlendirme ve görüntüleme, yüksek klinik şüphe, titiz cerrahi ve ameliyat sonrası bakım intraorbital tahta cisim yaralanmalarının anahtar noktalarıdır. Anahtar sözcükler: Orbita; tahta; travma; yabancı cisim. Ulus Travma Acil Cerr Derg 2014;20(1):51-55

doi: 10.5505/tjtes.2014.93876

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C A S E REP OR T

Hybrid approach in patients with recurrent brachial artery embolism: adjunctive tissue plasminogen activator infusion following embolectomy Mete Gürsoy, M.D., Veday Bakuy, M.D., Mehmet Atay, M.D., Jabir Gulmaliyev, M.D., Ahmet Akgül, M.D. Department of Cardiovascular Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul

ABSTRACT Acute ischemia of an upper extremity occurs less frequently than vascular events of the leg and accounts for 15%-32% of all cases. Embolectomy provides prompt and effective treatment in the majority of cases. Recurrence of embolism and failed reperfusion can result in poor outcomes, even extremity loss. Adjunctive managements become important in this patient group. In this report, we present percutaneous intraarterial drip tissue plasminogen activator infusion to rescue the extremity in a patient with small cell lung cancer who experienced thromboembolism an additional six times following embolectomy. Key words: Embolectomy; recurrent brachial artery embolism; tissue plasminogen activator.

INTRODUCTION Acute ischemia of an upper extremity occurs less frequently than vascular events of the leg and accounts for 15%-32% of all cases. Embolism, usually cardiac, is the most common etiologic factor, with an incidence range of 58-93%.[1,2] The brachial artery is a frequently occluded vessel. Atrial fibrillation is responsible in the majority of patients with cardiac embolism. Malignant tumor-related acute extremity ischemia is a rare but well-analyzed entity.[3] Malignancy may trigger predisposition to hypercoagulability. On the other hand, cardiac myxoma and non-cardiac tumors invading the left atrium or pulmonary veins may cause fragmented mass embolism directly. Conventional embolectomy promptly restores blood flow in the majority of cases. Alternative approaches are necessitated rarely in cases in which embolectomy is unable to provide reperfusion.[4]

Address for correspondence: Mete Gürsoy, M.D. Tevfik Sağlam Caddesi, No: 11, Zuhuratbaba, 34147 İstanbul, Turkey Tel: +90 212 - 414 71 80 E-mail: metegursoy35@gmail.com Qucik Response Code

In this report, we present intraarterial drip infusion of tissue plasminogen activator following surgery in a patient with small cell lung cancer.

CASE REPORT A 46-year-old man with a diagnosis of small cell lung cancer was admitted to our institution with pain and coldness at the distal right upper extremity. On the physical examination, the extremity was found cold and cyanotic, and radial and ulnar pulses were not palpable. Doppler ultrasonography showed triphasic flow in the brachial artery and hyperechogenic thrombus material in the proximity of the radial and ulnar arteries. The patient underwent brachial and selective radial and ulnar embolectomy under local anesthesia. Fresh arterial thrombus was removed. Distal blood flow recovered promptly. Routine heparin, prostacyclin analogue and antiplatelet therapy were started. One day later, we observed weak radial and ulnar pulses and the patient complained of pain again. Brachial embolectomy was performed an additional six times. Subclavian artery stenosis was excluded with computerized tomography (CT) angiography (Fig. 1a). Although coagulation parameters were found to be normal, dual antiplatelet and warfarin were initiated, but could not prevent recurrence of thromboembolism. The treatment strategy was re-considered and intraarterial drip infusion of tissue plasminogen activator was planned. In the last operation, the brachial artery was repaired with saphenous vein patch plasty technique following embolectomy. Intraarterial Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

G端rsoy et al. Hybrid approach in patients with recurrent brachial artery embolism

(a)

(b)

Kingdom.[5] Alternative treatment options are not well documented. To the best of our knowledge, there is no large study analyzing the risk factors for embolism recurrence and failed embolectomy. Conventional thromboembolectomy depends on mechanical clot removal with balloon catheter. This procedure is able to restore blood flow by recanalizing the arterial lumen, but catheter insertion may cause embolism of thrombus fragments into the distal vascular bed. In addition, distal, small arteries are not accessible by Fogarty catheter. In this context, antithrombotic and anticoagulant therapies become important following thromboembolectomy. Distal obstructed small arteries increase capillary pressure and decrease run-off quality. High resistance and impaired vascular endothelium trigger clot formation and recurrence of ischemia, particularly in patients with hypercoagulability. Aggressive antiplatelet and anticoagulant therapy, peripheral vasodilators, and prostacyclin analogues may be helpful in preventing recurrence in some cases. In the literature, various treatment alternatives have been reported in extreme patients in whom conventional embolectomy and routine medical treatment were unsatisfactory in restoring blood flow.

Figure 1. (a) Preoperative CT angiography shows brachial artery occlusion (black arrow indicates occluded brachial artery). (b) Postoperative CT angiography shows patent upper extremity arteries (white arrow indicates repaired brachial artery segment).

tissue plasminogen activator infusion was started and continued for 24 hours via percutaneous 20 G intraarterial catheter, which was introduced approximately 2 cm proximal to the lesion. Warfarin and dual antiplatelet therapy were also continued. The follow-up examination revealed palpable radial and ulnar pulses on subsequent days. The patient was discharged well. CT angiography showed patent brachial, radial and ulnar arteries at the 6th week follow-up (Fig. 1b).

DISCUSSION Acute arterial embolism can be treated with conventional thromboembolectomy in the majority of cases. Recurrence of thromboembolic events has a poor prognosis, even limb loss. Acute embolism was found to be responsible in approximately 1% of upper limb amputations in the United Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Intraarterial thrombolytic infusion has been used for a long time in patients with acute ischemic disorders.[6] However, to date, neither indications nor administration technique of thrombolysis is adequately established in acute peripheral ischemia. In theory, thrombolytic agents dissolve thrombocyte-fibrin aggregates in clot formation. Although some authors reported similar results with thrombolysis in comparison to surgery in acute peripheral occlusion, major bleeding risk limits initial administration. In 2009, the Thrombosis Interest Group of Canada emphasized that thrombolysis should be utilized if there is additional distal clot embolization that is difficult to reach surgically and only if there is risk of tissue loss related to systemic adverse effects of tissue plasminogen activators, such as major bleeding.[7] In the same year, Gilani and colleagues[8] reported alternative thrombolytic management avoiding systemic adverse effects. They performed isolated limb perfusion technique with tissue plasminogen activator in a patient suffering acute hand ischemia. In our case, small cell lung cancer appeared to be the triggering factor for recurrence, which has not been well documented previously.[3] Additionally, increased thrombogenic tendency was certain due to the six surgical interventions, which can cause serious endothelial damage. Association of these factors made this case more complex than the general arterial embolism patients. Tissue plasminogen activator might be helpful in the prevention of clot formation on the damaged arterial endothelium in patients with thrombogenic tendency due to malignancy. Furthermore, tissue plasminogen activator may increase run-off quality by dissolving an embolus pushed surgically into the distal small arteries. Therefore, we preferred intraarterial drip thrombolytic infusion via percutaneous catheter for 24 hours to prevent acute thrombosis, and 57

Gürsoy et al. Hybrid approach in patients with recurrent brachial artery embolism

we were able to rescue the extremity without any adverse events. In conclusion, conventional embolectomy remains the gold standard in patients with acute arterial ischemia, but it may not be sufficient in patients with distal embolism. Percutaneous catheter-directed intraarterial thrombolytic therapy may be helpful in selected patient groups. Conflict of interest: None declared.

REFERENCES 1. Vohra R, Lieberman DP. Arterial emboli to the arm. J R Coll Surg Edinb 1991;36:83-5.

2. Eyers P, Earnshaw JJ. Acute non-traumatic arm ischaemia. Br J Surg 1998;85:1340-6. 3. Zürcher M, Gerber H, Gebbers JO. Tumor embolism with fatal cerebral infarct in pneumonectomy. Case report and review of the literature. [Article in German] Chirurg 1996;67:959-62. [Abstract] 4. Emrecan B, Ozcan AV, Onem G, Baltalarlı A. Subclavian-carotid transposition for subclavian artery stenosis causing recurrent brachial artery embolism: case report. Ulus Travma Acil Cerrahi Derg 2010;16:483-5. 5. Information Services Division NHSScotland on behalf of National Amputee Statistical Database (NASDAB) Edinburgh. Amputee Statistical Database for the United Kingdom; 2006/07 Report. 6. Ouriel K. Thrombolytic therapy for acute arterial occlusion. Curr Opin Gen Surg 1994:257-64. 7. Roussin A, Carter C, Oliva V. Thrombolytic therapy in peripheral arterial disease. The Thrombosis Interest Group of Canada; 2009. 8. Gilani R, Greenberg RK, Johnston DR. Isolated limb perfusion with tissue plasminogen activator for acute hand ischemia. J Vasc Surg 2009;50:659-62.

OLGU SUNUMU - ÖZET

Tekrarlayan brakiyal arter embolisinde hibrid yaklaşım: Embolektomi sonrası perkütan doku plazminojen aktivatörü uygulaması Dr. Mete Gürsoy, Dr. Veday Bakuy, Dr. Mehmet Atay, Dr. Jabir Gulmaliyev, Dr. Ahmet Akgül Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Kalp ve Damar Cerrahisi Kliniği, İstanbul

Akut üst ekstremite iskemisi alt ekstremitenin vasküler hastalıklarına göre daha nadir olup tüm olguların %15-32’sini oluşturur. Embolektomi olguların büyük kısmında hızlı ve etkili tedavi sağlar. Tekrarlayan ve embolektomi ile reperfüzyon sağlanamayan olgularda prognoz kötü olup amputasyonla sonuçlanan olgular bildirilmiştir. Bu hasta grubunda embolektomi ile birlikte ya da sonrasında destekleyici tedaviler önem kazanmaktadır. Bu yazıda küçük hücreli akciğer kanseri hastasında embolektomi sonrası altı kez tekrarlayan brakiyal arter embolisine bağlı kritik üst ekstremite iskemisinde kurtarıcı teknik olarak yavaş perkütan intraarterial doku plazminojen aktivatörü uygulamamızı sunuyoruz. Anahtar sözcükler: Doku plazminojen aktivatörü; embolektomi; tekrarlayan brakial arter embolisi. Ulus Travma Acil Cerr Derg 2014;20(1):56-58

doi: 10.5505/tjtes.2014.73930

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CA S E R EP O RT

Common carotid artery injury caused by a camel bite: case report and systematic review of the literature Fikri M Abu-Zidan, M.D.,1 Saleh Abdel-Kader, M.D.,2 Radwan El Husseini, M.D.2 1

Trauma Group, Faculty of Medicine and Health Sciences, UAE University, Al-ain, UAE

Department of Surgery, Vascular Surgery Unit, Al-ain Hospital, Al-ain, UAE

ABSTRACT A 25-year-old man was bitten in the neck by an aggressive camel, causing three small puncture wounds. The left carotid pulse of the patient was weakly palpated. Angiography showed irregular dissection of the distal part of the left common carotid artery. Neck exploration confirmed the findings. An interposition autogenous saphenous vein graft was performed successfully. The patient was discharged home in good condition. We have systematically reviewed the literature on this topic, and only four other similar cases were reported previously. Although camel bite wounds are small, they may penetrate deeply, causing serious injuries to the neck structures including the major vessels. Care should be taken when approaching male camels during the rutting season. Key words: Camel; carotid artery; injury; neck bite; trauma.

INTRODUCTION Animal bites are an underestimated public health problem worldwide. In Australia, nearly 2% of the population is bitten by animals every year; more than 80% by dogs.[1] Biting of the neck, which is crowded with vital structures, may lead to major vascular and neurological injuries. We have previously reported the devastating injuries caused by camel bites to the neck.[2] Major vascular injuries of the neck caused by camel bites are extremely rare. Herein, we report a patient who sustained a common carotid artery (CCA) injury caused by a camel bite, and we systematically review the literature on this topic.

CASE REPORT A 23-year-old Pakistani camel caregiver presented to the Emergency Department of Al-Ain Hospital two hours after being bitten in the neck by an aggressive camel. On examination, the patient was fully conscious and talking. His blood Address for correspondence: Fikri M Abu-Zidan, M.D. PO Box 17666 Al-ain, United Arab Emirates Tel: 009713 7137579 E-mail: fabuzidan@uaeu.ac.ae Qucik Response Code

Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

pressure was 140/80 mmHg, pulse rate 78 bpm, and body temperature 37.8 째C. Three small puncture wounds to the left side of the neck were seen. Surgical emphysema of the neck and upper chest were felt on palpation. The left carotid artery pulse was weak. Carotid bruit could not be heard. The patient could not abduct his left arm. He received tetanus toxoid intramuscularly and was admitted to the hospital. Computerized tomography (CT) scan of the neck with intravenous and oral contrast showed non-visualization of the left CCA and surgical emphysema of the neck. There was no leakage of the oral contrast. CT angiography showed that the left CCA was non-contrasted from its origin up to the bifurcation (Figure 1a). Contrast magnetic resonance (MR) angiogram showed intimal tear of the left CCA 2-3 cm below the bifurcation (Figure 1b). Carotid angiogram confirmed the findings. The left CCA was partially patent. Fibro-optic laryngoscopy was normal. Exploration of the neck showed a thrombus and dissection in the distal part of the left CCA 2 cm below the bifurcation. The stump pressure of the left internal carotid artery was 70/40 mmHg. The artery was opened at the site of the hematoma, and a circumferential intimal tear and overlying thrombus were found (Figure 1c). The section of the left CCA containing the intimal tear was excised, and an interposition autogenous saphenous vein graft was performed. A suction drain was inserted, and the wound was primarily closed in layers. The patient was given intravenous ceftriaxone sodium (1 g 12- hourly) and metronidazole (500 mg 8-hourly) for one week. 59

Abu-Zidan et al. Common carotid artery injury caused by a camel bite

(a)

(b)

(c)

Figure 1. (a) CT angiography showing that the left CCA was non-contrasted from its origin up to the carotid bifurcation (arrow heads) and a good back flow in the circle of Willis. (b) MR angiogram with contrast showing intimal tear in the left CCA 2-3 cm below the bifurcation (arrow head). (c) Arteriotomy showing dissection of the distal part of the left CCA, about 2 cm below the bifurcation.

Follow-up Doppler ultrasound study showed good flow in the left common, internal, and external carotid arteries. Nerve conduction velocity and electromyography showed neurapraxia of the left brachial plexus including the left axillary, musculocutaneous and supra-scapular nerves. The patient received physiotherapy for the brachial plexus injury. The patient had a smooth postoperative recovery, and was scheduled to be discharged on the 10th postoperative day. Nevertheless, he was kept in the hospital for social reasons and was discharged home on day 20 on aspirin tablets, 100 mg daily. A follow-up at one month showed improvement in the left arm abduction. 60

DISCUSSION Although the principles of surgical management of carotid artery injuries are well-known, camel bites as a cause of these injuries are extremely rare and unique. A search of Medline revealed only five cases of major vascular injuries of the neck caused by camel bites, including the present case (Table 1).[2-5] Three of these were reported from our hospital. This indicates that these injuries are under-reported because the majority occur in developing countries with a lack of training in research and medical writing. The estimated incidence of camel bite injuries requiring hospitalization in our city is 1.5 per 100,000 inhabitants per year.[6] Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Abu-Zidan et al. Common carotid artery injury caused by a camel bite

Table 1. Summary of reported cases in the literature of major vascular injuries of the neck caused by camel bites Author

Age (yrs)

Sex

Mechanism of injury

Clinical presentation

Wound

Injuries

Management

Outcome

Janjua KJ[3] (1993)

Male Bitten by a camel, Swollen left shoulder, absent lifted up and left radial pulse thrown aside

Bite mark on the left shoulder without penetration

Left subclavian artery occlusion, fractured clavicle, fractured ribs (1-3) left side

Gortex graft bridging a 5 cm loss of the subclavian artery

Complete recovery

Nawaz et al.[4] (2005)

Male Camel bite

Neck wound

Four puncture wounds on left side of the neck, ear and cheek

Intimal tear of the left internal carotid artery without occlusion, fractured mandible

Interposition venous graft bridging a 2 cm defect ORIF of mandible

Complete recovery

Shehu et al.[5] (2007)

Male Camel bite

Four Loss of puncture consciousness, right hemiparesis wounds on the left side of the neck

Left carotid artery occlusion, left brain infarction

Conservative

Right hemiparesis

Abu-Zidan et al.[2] (2007)

Male Bitten by a camel, Unconscious, dyspnea, shock, lifted up and right hemiparesis thrown to the ground

Present case

Male Camel bite

Lacerated wounds of <2 cm on the left side of the neck

Puncture Neck wound, inability to abduct wounds on left side of the left arm the neck

Conservative Left carotid artery injury without occlusion, massive left brain infarction, fractured cervical spine, massive left hemothorax, fractured clavicle and ribs (1-2) on left side Intimal tear of the left common carotid artery, left brachial plexus injury

Interposition venous graft bridging a 3 cm defect

Exitus

Mild paresis of left brachial plexus

ORIF: Open reduction/internal fixation.

The mechanism of camel bite injury is complex, including penetrating and crushing injuries by the camel teeth, and blunt injuries when patients are lifted and thrown to the ground.[2] More than 20% of the patients who had camel bites were lifted by the camel’s teeth and thrown aside.[6] Two of the five patients in Table 1 were lifted and thrown to the ground after being bitten. The increased complexity of the mechanism of injury will increase its severity.[7] All patients in Table 1 were males, with a median age (range) of 30 (11-54) years. Similarly, in a prospective study of 212 camel-related injuries from the United Arab Emirates, all the patients were male.[8] The presented patient was injured in January. More than 70% of camel bites occur during the rutting season, which is between November and March, during which the male camels become irritable and difficult to handle.[6,9] An air-filled pink Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

diverticulum called the “dulla”, reaching up to 25 cm in length, protrudes from the mouth of a sexually active camel.[6] The camel bites thin areas of the body, including the upper limbs and neck. About 8% of camel bites involve the neck.[8] Despite the small size of the puncture wounds of these bites, they penetrate deeply, causing serious injuries to deeper structures, as shown in Table 1. Of these five patients, one patient died, one had right-sided hemiparesis, and another had left brachial plexus paresis. Three patients underwent successful interposition grafting of major vascular injuries of the neck. Interestingly, all wounds were on the left side of the neck, which may be related to the behavior of the camel when it attacks the neck of humans. Selective surgery for penetrating injury of the neck is accepted in civilian trauma centers with proper diagnostic facilities.[10,11] Hard signs serving as reliable indicators for carotid 61

Abu-Zidan et al. Common carotid artery injury caused by a camel bite

artery injury include an expanding or pulsatile hematoma, absence of pulse, presence of bruit, and an active external bleeding. Patients who are hemodynamically stable can be observed clinically and evaluated using radiological investigations.[11] The carotid pulse in our patient was weak and not completely absent. Since he was hemodynamically stable, we decided to do a workup before surgery. The best option for surgical repair of the carotid artery injury, if there is any possibility of tension, is an autogenous saphenous vein graft.[11] We treated our patient with tetanus toxoid and antibiotics, similar to Saxena et al.,[12] who reported the management of the largest series of camel bites in the literature and did not report any case of rabies in their study. Nevertheless, we think that anti-rabies prophylaxis for camel bites should be given in the future because of the risk of rabies.[13] In conclusion, although camel bite wounds are small, they may penetrate deeply, causing serious injuries to neck structures, including the major vessels. Care should be taken when approaching male camels during the rutting season. Rutting camels are recognized by the pink “dulla” protruding from their mouths. Conflict of interest: None declared.

REFERENCES 1. MacBean CE, Taylor DM, Ashby K. Animal and human bite injuries in

Victoria, 1998-2004. Med J Aust 2007;186:38-40. 2. Abu-Zidan FM, Ramdan K, Czechowski J. A camel bite breaking the neck and causing brain infarction. J Trauma 2007;63:1423. 3. Janjua KJ. Camel bite injury: an unusual report of left shoulder mutilation with major vascular and bony injuries. Injury 1993;24:686-8. 4. Nawaz A, Matta H, Hamchou M, Jacobsz A, Al Salem AH. Camel-related injuries in the pediatric age group. J Pediatr Surg 2005;40:1248-51. 5. Shehu BB, Nasiru JI, Mahmud MR, Laseini A, Saidu SA. Carotid occlusion and cerebral infarction from camel bite: case report. East Afr Med J 2007;84:550-2. 6. Abu-Zidan FM, Eid HO, Hefny AF, Bashir MO, Branicki F. Camel bite injuries in United Arab Emirates: a 6 year prospective study. Injury 2012;43:1617-20. 7. Abu-Zidan FM, Rao S. Factors affecting the severity of horse-related injuries. Injury 2003;34:897-900. 8. Abu-Zidan FM, Hefny AF, Eid HO, Bashir MO, Branicki FJ. Camel-related injuries: prospective study of 212 patients. World J Surg 2012;36:2384-9. 9. Food and agriculture organization of the United Nations. A manual for the primary animal health care worker: chapter 7: camels, llamas and alpacas. http://www.fao.org/docrep/T0690E/t0690e09.htm#chapter 7. Accessed 1st August 2012. 10. Ordog GJ, Albin D, Wasserberger J, Schlater TL, Balasubramaniam S. 110 bullet wounds to the neck. J Trauma 1985;25:238-46. 11. Asensio JA, Vu T, Mazzini FN, Herrerias F, Pust GD, Sciarretta J, et al. Penetrating carotid artery: uncommon complex and lethal injuries. Eur J Trauma Emerg Surg 2011;37:429-37. 12. Saxena PS, Sharma SM, Singh M, Saxena M. Camel bite injuries. J Indian Med Assoc 1982;79:65-8. 13. Bloch N, Diallo I. A probable outbreak of rabies in a group of camels in Niger. Vet Microbiol 1995;46:281-3.

OLGU SUNUMU - ÖZET

Deve ısırığının neden olduğu ana karotis arter yaralanması: Olgu sunumu ve literatürün sistematik biçimde gözden geçirilmesi Dr. Fikri M Abu-Zidan,1 Dr. Saleh Abdel-Kader,2 Dr. Radwan El Husseini2 1 2

Birleşik Arap Emirlikleri Üniversitesi, Tıp ve Sağlık Bilimleri Fakültesi, Travma Grubu, Al-ain, BAE Al-ain Hastanesi, Cerrahi Bölümü, Vasküler Cerrahi Ünitesi, Al-ain, BAE

Yirmi beş yaşında bir erkek saldırgan bir deve tarafından boynundan ısırılmış ve boynunda üç küçük delici yara oluşmuştur. Sol karotis nabzı zayıf hissediliyordu. Anjiyografi sol ana karotis arterin distal segmentinde düzensiz kesiler olduğunu gösterdi. Boynun eksplorasyonu bu bulguları doğruladı. Otojen safen ven greft interpozisyonu başarıyla uygulandı. Hasta evine iyi durumda gönderildi. Bu konuya ilişkin literatürü sistematik biçimde gözden geçirdik ve yalnızca dört adet benzer olgu raporuna rastladık. Deve ısırığı yaraları küçük boyutlarda olmalarına rağmen derine penetre olabilerek ana damarlar dahil boyun oluşumlarında ciddi yaralanmalara neden olabilirler. Azgınlık dönemlerinde erkek develere yaklaşırken dikkatli olunmalıdır. Anahtar sözcükler: Boyun ısırığı; deve; karotis arter; travma; yaralanma. Ulus Travma Acil Cerr Derg 2014;20(1):59-62

doi: 10.5505/tjtes.2014.69822

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CA S E R EP O RT

Morel-Lavallee lesion: case report of a rare extensive degloving soft tissue injury Krishna Mohan Gummalla, FRCR, Mathew George, M.D., Rupak Dutta, M.D. Department of Diagnostic and Interventional Radiology, Tan Tock Seng Hospital, Jalan Tan Tock, Singapore

ABSTRACT Morel-Lavallee syndrome (MLS) is a significant post-traumatic soft tissue injury in which the subcutaneous tissue is torn away from the underlying fascia (closed degloving), creating a cavity filled with hematoma and liquefied fat. It commonly occurs over the greater trochanter, but may also occur in the flank, buttocks and lumbodorsal regions. MLS is a rarely reported entity. The trauma surgeon and radiologist must be aware of this condition, as early diagnosis can lead to conservative management, while a delay can lead to surgical exploration.We report a case of extensive Morel-Lavallee lesion involving the left flank and thigh in a young adult.We discuss the magnetic resonance imaging findings and also describe the differential diagnoses and management options for MLS. Key words: Closed degloving injury; Morel-Lavallee lesion; post-traumatic extravasation.

INTRODUCTION Morel-Lavallee syndrome (MLS) is a significant post-traumatic soft tissue injury in which the subcutaneous tissue is torn away from the underlying fascia, creating a cavity filled with hematoma and liquefied fat. We report a case of extensive Morel-Lavallee lesion involving the left flank and thigh in a young adult. We discuss the magnetic resonance imaging findings and also describe the differential diagnoses and management options for MLS.

CASE REPORT We present a case of extensive degloving injury to the left flank and thigh in a young man together with the computed tomography (CT) and magnetic resonance imaging (MRI) findings. A 19-year-old male was admitted to the hospital for progressive soft swelling over the left flank and thigh regions. He had a history of a previous admission in the same hospital for road traffic accident two weeks before, with left wrist Address for correspondence: Krishna Mohan Gummalla, FRCR Associate consultant in Vascular and Interventional Radiology, 11, Jalan Tan Tock 308433 Singapore - Singapore Tel: 006581263432 E-mail: krishna777@gmail.com Qucik Response Code

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fracture and abrasion over the left thigh and left flank. On examination, there was tenderness over the left flank and a fluctuant swelling on the lateral side of the left thigh, and a superficial abrasion was seen on the hip (Figure 1). Blood investigations were unremarkable with no evidence of infection. Pelvic and left femur radiographs revealed no underlying fractures. With a clinical suspicion of Morel-Lavallee lesion (MLL), MRI study of the left flank and upper thigh was requested by the clinician. The CT taken during the first admission two weeks before was also reviewed retrospectively. The CT images showed an irregular soft tissue density lesion in the subcutaneous plane extending from the left flank to the upper thigh on the lateral aspect (Figure 2a). No contrast extravasation was seen. There was no mass effect with indentation of the underlying muscles. No underlying bone fracture was seen. The MRI showed a large subcutaneous collection that was slightly hyperintense on T1-weighted (W) and hyperintense on T2W sequences (Figure 2b), and which was seen to extend from the left flank to the upper thigh on the lateral aspect. Non-enhancing fat lobules and debris were seen within the collection (Figure 2c). There was no post-contrast enhancement in the periphery of the collection, and fat globules were seen as non-enhancing areas within the collection (Figure 2d). The collection had increased in size when compared to the CT done two weeks before, and was seen to indent the lateral thigh muscle. These findings were compatible with MLL. 63

Gummalla et al. Morel-Lavallee lesion

DISCUSSION Morel-Lavallee syndrome or lesion was first described by a French surgeon, Victor Morel LavallĂŠe, in 1863.[1] It is also known as Morel-Lavallee seroma, post-traumatic soft tissue cyst, post-traumatic extravasation, or Morel-Lavallee effusion.[2]

Figure 1. Patient presenting with extensive swelling over the left flank and thigh regions (Photo courtesy of Dr. Kwek Ernest, Department of Orthopaedics, TTSH).

In view of the progressive increasing collection and absence of capsule formation, percutaneous drainage was done. Two liters of darkish brown fluid was drained from the subcutaneous fat plane above the muscle fascia. Areas of necrotic fat were also seen. The underlying soft tissue was not infected. No bacterial organism or growth was cultured from the fluid. Compression dressing was applied, and the patient was discharged without any complication after a few days. (a)

(c)

(b)

The MLL is a closed degloving injury of an extremity after a crush injury, resulting in the skin and subcutaneous fatty tissue abruptly separating from the underlying fascia, creating a cavity filled with bloody serous fluid. The initial injury represents a shearing of subcutaneous tissues away from the underlying fascia. The disrupted capillaries may continuously drain into the perifascial plane, filling up the virtual cavity with blood, lymph, and debris. Subsequent inflammatory reaction may lead to a peripheral capsule formation, which may account for the self-perpetuation and occasional slow growth of the process.[2] The collection may then spontaneously resolve, or become persistent with encapsulation. Morel-Lavallee lesions usually present within a few hours to days post-trauma. However, some of the patients may present months or years post initial trauma. They are frequently associated with underlying fractures, but can be isolated without fractures. These lesions are most often unilateral. Patients usually present with complaints of pain, swelling, and stiffness. On clinical examination, patients often have a soft fluctuant area of contour deformity, with or without skin discoloration. Skin sensation is frequently decreased. Skin necrosis may occur acutely or in a delayed fashion. Closed degloving injuries are most commonly found adjacent to osseous protuberances, with the classical location being over the greater trochanter of the femur. They are also described along the flank, buttocks, lumbar spine, scapula, knee, and calf,[3] and along the abdominal wall post-liposuction.[1,4]

(d)

Figure 2. (a) Coronal CT image showing an irregular soft tissue density lesion in the subcutaneous plane extending from the left flank to the upper thigh on the lateral aspect. (b) Coronal T2 fat-saturated MRI showing subcutaneous collection that was hyperintense on T2-weighted sequences. (c) Coronal T1-weighted MRI showing small fat lobule within the subcutaneous collection. (d) Post-contrast axial MRI showing no enhancement in the periphery of the collection and non-enhancing fat lobules within the collection.

The size of these lesions is variable, ranging from small thin slivers of fluid to thickly encapsulated lesions several centimeters in diameter. When chronic, they are typically oval or fusiform in shape adherent to the underlying fascia. Plain radiography may reveal a noncalcified

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soft tissue mass and associated fractures.[4] On ultrasound, these lesions are anechoic or hypoechoic; however, internal debris, including fat globules, can give rise to echogenic foci or even fluid-fluid levels. A capsule of variable thickness may be seen.[5] CT can show fluid-fluid levels related to sedimentation of the hemolymphatic fluid and varying amounts of internal debris including internal fat lobules, and may show a peripheral capsule. Magnetic resonance imaging (MRI) is the diagnostic imaging modality of choice and is able to clearly determine the relationship of the collection with the underlying fascia. MLLs are well-defined oval, fusiform, or crescentic lesions, and may have tapering margins that fuse with adjacent fascial planes. The fluid is of variable signal intensity depending on its makeup, and may even show a fluid-fluid level.[1-3,6] Initially the space between the subcutaneous fat and the underlying deep fascia is filled with blood or lymph. Later, the blood is largely resorbed and replaced by a serosanguineous fluid and becomes lined by a fibrous capsule. The fluid then shows homogeneous hyperintensity on both T1W and T2W sequences, with the appearance of a hypointense peripheral ring on T1, in keeping with sub-acute hematoma. Chronic MLL may also show variable signal intensity on T1W, heterogeneous hyperintensity on T2W sequences, and a hypointense peripheral ring. Patchy internal enhancement and peripheral enhancement may also be present. The heterogeneous hyperintensity on T2W is characteristic of chronic organizing hematoma. Water-like MRI features may be seen in long-standing lesions, homogeneously hypointense on T1W and hyperintense on T2W images, with a peripheral hypointense ring on all sequences. The differential diagnosis for MLL includes subcutaneous hematoma, hemangioma, fat necrosis, and soft tissue sarcoma. The history of trauma, characteristic location, and MRI features may contribute to a correct diagnosis.

The treatment depends on the duration, size, and presence of a capsule in the lesion. Small acute lesions that have not developed a capsule can be treated conservatively by application of compression bandage. However, those that persist and have capsule formation may require more aggressive treatment. These lesions can be managed with early percutaneous drainage, debridement, irrigation, and suction drainage.[7] These lesions can be complicated by infection, necessitating the use of antibiotics. In rollover trauma with pelvic fractures, urgent surgery with debridement is necessary. In conclusion, though the MLL lesion in our case was quite extensive, extending from the left flank to the upper thigh, there was no capsule formation, and it could be treated by simple percutaneous drainage and compression bandage. The trauma surgeon and radiologist must be aware of the clinical and radiological features of MLL and the implications for its treatment. MRI is the diagnostic imaging modality of choice for MLL, with size, location and signal characteristics determining the appropriate therapy. Conflict of interest: None declared.

REFERENCES 1. Mellado JM, Bencardino JT. Morel-Lavallée lesion: review with emphasis on MR imaging. Magn Reson Imaging Clin N Am 2005;13:775-82. 2. Mellado JM, Pérez del Palomar L, Díaz L, Ramos A, Saurí A. Longstanding Morel-Lavallée lesions of the trochanteric region and proximal thigh: MRI features in five patients. AJR Am J Roentgenol 2004;182:1289-94. 3. Moriarty JM, Borrero CG, Kavanagh EC. A rare cause of calf swelling: the Morel-Lavallee lesion. Ir J Med Sci 2011;180:265-8. 4. Zecha PJ, Missotten FE. Pseudocyst formation after abdominoplasty-extravasations of Morel-Lavallée. Br J Plast Surg 1999;52:500-2. 5. Parra JA, Fernandez MA, Encinas B, Rico M. Morel-Lavallée effusions in the thigh. Skeletal Radiol 1997;26:239-41. 6. Mukherjee K, Perrin SM, Hughes PM. Morel-Lavallee lesion in an adolescent with ultrasound and MRI correlation. Skeletal Radiol 2007;36 Suppl 1:43-5. 7. Tseng S, Tornetta P 3rd. Percutaneous management of Morel-Lavallee lesions. J Bone Joint Surg Am 2006;88:92-6.

OLGU SUNUMU - ÖZET

Morel-Lavallee lezyonu: Seyrek görülen, yaygın, yumuşak dokunun eldiven soyulması gibi yaralanması Krishna Mohan Gummalla (FRCR), Dr. Mathew George, Dr. Rupak Dutta Tan Tock Seng Hastanesi, Tanısal ve Girişimsel Radyoloji Bölümü, Jalan Tan Tock, Singapur

Morel-Lavallee sendromu (MLS) deri altı dokunun alttaki fasyadan yırtılarak eldiven parmağı gibi (kapalı tip) soyulduğu, ardında hematom ve sıvılaşmış yağla dolu bir kavitenin kaldığı önemli bir posttravmatik yumuşak doku yaralanmasıdır. Genellikle büyük trokanter üzerinde meydana gelmesine rağmen, böğürde, kaba etlerde ve lumbodorsal bölgede de oluşabilmektedir. MLS, nadiren rapor edilen bir olgudur. Erken tanı konservatif tedaviye yol açabildiği ve gecikince cerrahi eksplorasyon gerektiği için travma cerrahları ve radyologlar bu olgunun farkında olmalıdır. Bu yazıda, genç bir erişkinde sol hipokondriyum ve uyluğu ilgilendiren yaygın bir Morel-Lavelle lezyonunu sunuldu, MRG bulguları tartışıldı ve yine MLS’nin ayırıcı tanıları ve tedavi seçeneklerini tanımlandı. Anahtar sözcükler: Eldiven parmağı gibi soyulma (kapalı tip); Morel-Lavallee lezyonu; posttravmatik ekstravazasyon. Ulus Travma Acil Cerr Derg 2014;20(1):63-65

doi: 10.5505/tjtes.2014.88403

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CAS E REP OR T

Emergency management of traumatic total scalp avulsion with microsurgical replantation Zhaohua Jiang, M.D., Shengli Li, M.D., Weigang Cao, M.D. Department of Plastic and Reconstructive Surgery, Shanghai Ninth Peopleâ&#x20AC;&#x2122;s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, PRC

ABSTRACT Total scalp avulsion is a rare but serious injury often resulting in defects of the hair-bearing skin, and it may even be life-threatening. Microsurgical hair-bearing scalp replantation is the first choice for the treatment of scalp avulsion. In this article, we describe the microsurgical replantation of two cases with total scalp avulsion.The avulsed scalp involved the hairy scalp, forehead, eyelids, ears, and part of the face. Initial management in the emergency department (ED) included correction of hemorrhagic shock with early blood transfusion, intravenous rehydration, and wound compression after rapid physical examination. A full trauma and preoperative workup prior to attempts at replantation needs to be performed to exclude any associated life-threatening injuries. Good form and function of the completely avulsed tissues and organs were achieved in both cases. Successful replantations can achieve the best esthetic and functional results when compared with other procedures. In addition to the microsurgical technique, preoperative evaluation and preparation in the ED are considered to be an important part of the successful salvage of the avulsed scalp. Key words: Emergency department; microsurgery; replantation; scalp avulsion.

INTRODUCTION Total scalp avulsion is a rare but serious injury often resulting in defects of the hair-bearing skin, and it may even be lifethreatening. With recent advances in microsurgery and emergency management, most cases of traumatic amputations are managed with replantation by establishing revascularization. After the first successful scalp replantation reported by Miller et al. in 1976,[1] some articles, mostly case reports, were published.[2-6] Since that time, microsurgical replantation has been considered the first choice in the treatment of scalp avulsion. Our department has accumulated experience in successful replantation of a completely avulsed scalp.[7] In addition to the microsurgical technique, the successful salvage of the avulsed scalp is closely related to careful preoperative evaluation and preparation in the emergency department (ED). Scalp avul-

Address for correspondence: Weigang Cao, M.D. 639 Zhizaoju Road Shanghai, China Tel: 086-021-23271699-5120 E-mail: drwgcao@163.com Qucik Response Code

sion is potentially accompanied by hemorrhagic shock, which should be addressed first.[8] Early blood transfusion, intravenous rehydration, and wound compression after rapid physical examination are important. A full trauma and preoperative workup prior to attempts at replantation needs to be performed to exclude any associated life-threatening injuries, such as pneumothorax, cervical dislocation and intracranial injuries. This article aimed to present our emergency treatment experience with microsurgical replantation in two recent cases of scalp amputation, and it provides a literature-based update of the evaluation and management of avulsed scalp.

CASE REPORT Case 1â&#x20AC;&#x201C; A 26-year-old woman with no pertinent medical history was brought to our ED via ambulance approximately four hours after a traumatic injury. Her hair was caught in a factory machine, resulting in avulsion of the entire hairy scalp, nasal area, forehead, left ear, and bilateral eyelids and eyebrows (Figure 1a). There was no loss of consciousness. The examination ruled out associated life-threatening cervical dislocation and intracranial injuries. After fluid resuscitation and 1000 ml blood transfusion, the patient was brought to the operating room for immediate replantation under general anesthesia. Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Jiang et al. Emergency management of traumatic total scalp avulsion with microsurgical replantation

According to replantation procedures established in our department, debriding the avulsed scalp, preparing the recipient site of the patient’s head, and harvesting venous grafts from the lower extremity were carried out simultaneously.[8] The avulsed scalp was placed on the underside of an overturned circular basin, carefully shaved and debrided. It was also thoroughly irrigated to remove dirt and oil. Additional lacerations were found in the corona capitis (Figure 1b). The only vessels available for microanastomoses were the bilateral superficial temporal artery and veins. Vein grafts were anastomosed to the arteries on the patient’s head and

veins on the avulsed scalp at the same time. All pre-replant preparation was completed (Figure 1c). Immediately after replantation and anastomosis of the completely avulsed scalp, excellent blood supply was established for all of the avulsed tissue (Figure 1d). Total ischemia time was 10 hours. The dressing was changed initially four days after surgery; the scalp survived well and closed drains were removed at this time. Twenty days after the surgery, the scalp was seen to have survived well, and hair developed gradually. Pressure ulcers developed in a small part of the occipital region. Two and a half years after the accident, anterior and posterior

(a)

(b)

(c)

(d)

(e)

(f)

Figure 1. (a) The intact scalp was carefully removed from the machine. The total scalp was avulsed, including the ear, eyelids, eyebrows, forehead, and part of the nose. (b) Shaving of the long hair. (c) Vein grafts were anastomosed to the arteries on the patient’s head and veins on the avulsed scalp. All pre-transplant preparation was completed. (d) Excellent blood supply was established for all of the avulsed scalp after vascularized replantation. (e) and (f) 2.5 years after microsurgery, good form and function of almost all the hair-bearing scalp, ear, eyelids, eyebrows, forehead, and part of the nose were achieved.

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views revealed that the entire hair-bearing scalp survived well (Figure 1e, f ). Case 2â&#x20AC;&#x201C; A 42-year-old woman had her hair caught in a roller machine while at work, and the entire hair-bearing scalp, nasal area, frontal area, right ear, and bilateral eyelids and eyebrows were avulsed, with a connection only in the left nuchal area (Figure 2a). Associated injuries included left elbow dislocation with a left-sided olecranon fracture and ulnar nerve injury. She was conscious upon presentation to the ED. Blood loss was estimated to be approximately 1800 ml (Figure 2b). Ini-

tially, 1000 ml of blood and Ringerâ&#x20AC;&#x2122;s solution were transfused to correct the massive blood loss, and replantation was performed shortly after her condition was stabilized and other associated injuries were ruled out. The superficial temporal arteries and veins on both sides of the head were identified for anastomosis, and vein grafts from the dorsum of the foot were used to replace the crushed vessels. Total ischemia time was 13 hours. At the end of the surgery, the whole scalp appeared well perfused as reflected in the pink skin color (Figure 2c). Four days after surgery, the scalp appeared to have survived well when the dressing was changed for the first

(a)

(b)

(c)

(d)

(e)

(f)

Figure 2. (a) The avulsed scalp involved the entire hairy scalp, nasal and frontal area, right ear, and bilateral eyelids and eyebrows, with a connection only in the left nuchal area. (b) Image of the blood loss soaking the sheets in the immediate vicinity of the patient. (c) At the conclusion of surgery, the whole scalp showed good blood supply as demonstrated by the pink skin color. (d) Twelve days after the accident, almost all of the scalp was seen to have survived well, and hair developed gradually when the stitches were removed. (e) and (f) 2 months after replantation, good form and function of the complete avulsed tissues and organs were achieved.

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time. Fifteen days after the accident, almost all of the scalp remained viable, and hair developed gradually (Figure 2d). Her associated elbow injuries were addressed by the orthopedic surgery team at the time of her initial scalp replantation. At the one-year follow-up, protective sensibility returned in the replanted scalp, and normal function of the amputated frontalis muscle was restored. The patient was satisfied with the eventual outcome of the reconstruction (Figure 2e, f).

DISCUSSION Total scalp avulsion is a fairly rare and serious injury, usually the result of high-speed rotating machinery coming in contact with the patient’s hair. Successful scalp replantation has been carried out in our department since 1991,[7,9,10] and many cases, including pediatric total scalp avulsion, have been published by our department with improvements in the microsurgical technique.[7,11] In addition to the microsurgical technique, preoperative evaluation and preparation in the ED are considered to be an important part of successful salvage of the avulsed scalp. Scalp avulsion, although rare, represents a true emergency upon presentation to the ED. The scalp-related injuries can be addressed only after establishing a definitive airway, stabilizing hemodynamics, and assessing for other injuries. Scalp avulsion is accompanied by the potential for hemorrhagic shock, which should be corrected first. Hemorrhage from head and facial trauma alone resulting in systemic shock occurs rarely, except in cases of extensive scalp avulsion injuries. Bleeding from the superficial temporal artery, supraorbital artery, occipital artery, facial artery, or a combination of these is most commonly encountered and can usually be controlled, at least temporarily, by applying a pressure dressing to the wound. Accurate evaluation of the blood loss is difficult. Our estimation of bleeding volume is up to 1600 ml. Early blood transfusion and intravenous administration of Ringer’s solution are mandatory, and every effort should be made to decrease the operative time to prevent substantial intraoperative blood loss. Due to the extensive blood supply to the scalp, hemorrhaging of the scalp often appears profuse and always heightens suspicion of intracranial and cervical damage. To avoid missing any scalp-related injuries due to an inadequate examination, patients should be examined thoroughly during the secondary survey. Total scalp avulsion injuries are potentially devastating and may often include eyebrow, eyelid, nasofrontal, and ear avulsion. Assessment of the level and scope of scalp avulsion is helpful to choose the blood vessels available for anastomosis. Every attempt should be made to replant or revascularize as much of the avulsed scalp as possible. Traction force and impact injury often result in cervical spine and brain injuries. Cervical spine and brain computed tomography should be taken in all patients to exclude surgical contraindications. This workup for scalp replantation Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

should be mandatorily performed to exclude any associated life-threatening injuries that would take precedence over the scalp replantation. Contraindications to replantation include severe shearing force causing extensive vessel loss or damage within the avulsed scalp and inability to identify an artery or vein, lengthy warm ischemia time (more than 30 hours) of the scalp, and unfavorable preservation of the avulsed scalp. According to our replantation procedures, debriding the avulsed scalp, preparing the recipient site and harvesting venous grafts from the lower extremity are carried out at the same time. Performing these steps simultaneously facilitates a shortened ischemic time of the avulsed scalp and aids in the reduction of further blood loss intraoperatively. Shaving of the hair is necessary to avoid missing additional lacerations and to remove foreign body fragments lodged in the long hair. Exposed blood vessels are often accompanied by intimal wall damage and are often unsuitable for anastomosis or grafting. We often harvest vein grafts to replace them. In order, the selection of blood vessels is as follows: superficial temporal artery, supraorbital artery, and occipital artery, depending of course on the condition of the vessels available. Based on our experience, bilateral blood supply and venous drainage are necessary for survival of the total scalp after replantation. In addition, intraoperative hypotension (80/50 mmHg) may be necessary to reduce blood loss. Blood transfusion was carried out before and after surgery but was rarely required intraoperatively. As such, blood draws were frequently performed to assess for associated electrolyte abnormalities. Postoperative care is also important. Dressing changes in our experience are best performed four days after replantation in order to prevent movement of the scalp and damage to the vascular anastomosis. Halo application and early changes in head position are necessary to avoid the formation of occipital pressure ulcers. Conflict of interest: None declared.

REFERENCES 1. Miller GD, Anstee EJ, Snell JA. Successful replantation of an avulsed scalp by microvascular anastomoses. Plast Reconstr Surg 1976;58:133-6. 2. Buncke HJ, Rose EH, Brownstein MJ, Chater NL. Successful replantation of two avulsed scalps by microvascular anastomoses. Plast Reconstr Surg 1978;61:666-72. 3. Biemer E, Stock W, Wolfensberger C, Ingianni G, Götz WD. Successful replantation of a totally avulsed scalp. Br J Plast Surg 1979;32:19-21. 4. Tantri DP, Cervino AL, Tabbal N. Replantation of the totally avulsed scalp. J Trauma 1980;20:350-2. 5. Hentz VR, Palma CR, Elliott E, Wisnicki J. Successful replantation of a totally avulsed scalp following prolonged ischemia. Ann Plast Surg 1981;7:145-9.

Jiang et al. Emergency management of traumatic total scalp avulsion with microsurgical replantation 6. Yaffe B, Shvoron A. Successful replantation of a totally avulsed scalp. J Reconstr Microsurg 1986;2:171-3. 7. Cheng K, Zhou S, Jiang K, Wang S, Dong J, Huang W, et al. Microsurgical replantation of the avulsed scalp: report of 20 cases. Plast Reconstr Surg 1996;97:1099-108. 8. Sykes LN Jr, Cowgill F. Management of hemorrhage from severe scalp lacerations with Raney clips. Ann Emerg Med 1989;18:995-6.

9. Wang SL. Microvascular anastomosis in replantation of 6 avulsed scalps. [Article in Chinese] Zhonghua Wai Ke Za Zhi 1992;30:625-7, 37. 10. Zhou S, Chang TS, Guan WX, Chen KX, Wang SL, Cao YL, et al. Microsurgical replantation of the avulsed scalp: report of six cases. J Reconstr Microsurg 1993;9:121-9. 11. Liu T, Dong J, Wang J, Yang J. Microsurgical replantation for child total scalp avulsion. J Craniofac Surg 2009;20:81-4.

OLGU SUNUMU - ÖZET

Travmatik total kafa derisi avülsiyonunun mikrocerrahi replantasyonla acil tedavisi Dr. Zhaohua Jiang, Dr. Shengli Li, Dr. Weigang Cao Shanghai Jiao Tong Üniversitesi Tıp Fakültesi, Shanghai Dokuzuncu Halk Hastanesi, Plastik ve Rekonstrüktif Cerrahi Bölümü, Shanghai, Çin Halk Cumhuriyeti

Total kafa derisi avulsiyonu seyrek görülen, sıklıkla saçlı deride defektlere yol açan, hatta yaşamı tehdit edici olabilen ciddi bir yaralanmadır. Kafa derisi avulsiyonunda mikrocerrahiyle saçlı derinin replantasyonu ilk tedavi seçeneğidir. Bu yazıda, total kafa derisi avulsiyonu olan iki olguda mikrocerrahi replantasyon tekniğini anlattık. Avulsiyona uğramış kafa derisi saçlı kafa derisi, alın, göz kapağı, kulak ve yüzün bir bölümünü içermekteydi. Acil serviste ilk tedavi hızlı bir fiziksel inceleme sonrası erkenden hemorajik şoku düzeltmek için kan transfüzyonu, intravenöz rehidrasyon ile yaranın tamponla bastırılmasından ibarettir. Replantasyondan önce ameliyat öncesi dönemde, eşlik eden yaşamı tehdit edici yaralanmaları ekarte etmek için tam bir travma araştırması yapılmalıdır. İki olguda tam olarak avülsiyona uğramış dokular ve organlar morfoloji ve fonksiyonlarına kavuşmuştur. Başarılı replantasyonlar diğer prosedürlere göre en iyi estetik ve fonksiyonel sonuçları sağlayabilmektedir. Avulsiyone kafa derisinin başarılı onarımında mikrocerrahi tekniğe ilaveten acil serviste ameliyat öncesi değerlendirme ve hazırlığın önemli olduğu düşünülür. Anahtar sözcükler: Acil servis; avulsiyon; kafa derisi; mikrocerrahi; replantasyon. Ulus Travma Acil Cerr Derg 2014;20(1):66-70

doi: 10.5505/tjtes.2014.68253

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CA S E R EP O RT

Transverse sacral fractures and concomitant late-diagnosed cauda equina syndrome Şenol Bekmez, M.D.,1 Gökhan Demirkıran, M.D.,2 Ömür Çaglar, M.D.,2 İbrahim Akel, M.D.,3 Emre Acaroğlu, M.D.4 Department of Orthopedics and Traumatology, Dr. Sami Ulus Maternity, Child Health and Disease Training and Research Hospital, Ankara;

Department of Orthopedics and Traumatology, Hacettepe University Faculty of Medicine, Ankara;

Department of Orthopedics and Traumatology, İzmir Kent Hospital, İzmir;

Department of Orthopedics and Traumatology, Ankara Spine Center, Ankara

ABSTRACT Transverse sacral fractures in young patients occur with high-energy mechanisms. Because of the drawbacks in radiographic and neurologic evaluations of the sacral area in polytrauma patients, misdiagnosis is quite common. In this study, we aimed to report our clinical results in three patients with displaced transverse sacral fractures compromising the sacral canal and concomitant late-diagnosed (at least 48 hours) cauda equina syndrome. Bilateral lumbopelvic fixation, followed by sacral laminectomy and decompression, was performed in all patients. Despite the late- diagnosed cauda equina syndrome, we observed that surgical decompression and lumbopelvic fixation had positive effects on neurologic recovery, pain relief and early unsupported mobilization. Key words: Cauda; equina; misdiagnosed; sacral; transverse.

INTRODUCTION Because of the difficulties in radiographic imaging and subtle clinical signs, sacral fractures are challenging injuries in traumatology. Vertically oriented sacral fractures are the mostly encountered injury pattern. Denis et al.[1] classified sacral fractures according to the proximity of the fracture line to the sacral foramina. Zone 1 fractures pass through the alar area, zone 2 fractures through the foramina, and zone 3 fractures through the central canal. Denis zone 3 fractures display the highest risk of neurologic deficit.[2-5] Transversely oriented sacral fractures are also subclassified in zone 3 fractures. Further studies introduced transverse sacral fractures displaying extension through various planes. It was concluded that transverse sacral fractures could not be accommodated into the Denis classification.[6,7] Address for correspondence: Şenol Bekmez, M.D. Dr. Sami Ulus Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, 06100 Ulus, Ankara, Turkey Tel: +90 312 - 317 07 07 E-mail: drbekmez@hotmail.com Qucik Response Code

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Cauda equina syndrome (CES), described as bladder/bowel dysfunction and S1 motor deficit, can accompany displaced transverse sacral fractures via mechanical compression of the sacral nerve roots. Due to imaging difficulties in the sacral area and failure to determine the concomitant neurologic deficit, misdiagnosis is quite common. Limited data, consisting of case series, do not permit assessing any approvable treatment algorithms.[8] In this study, we aimed to report three cases with transverse sacral fractures whose neurological deficits were overlooked initially.

CASE REPORT Case 1– In October 2011, a 15-year-old male admitted to the emergency department of another hospital after a motor vehicle accident. After the evaluation, bed rest had been recommended with a diagnosis of soft tissue trauma. On the fourth day of the accident, weakness, pain, muscular spasm on lower extremities, and urine retention developed. He admitted to our emergency service with the complaints of pain spreading through the groin, weakness of both legs and urine retention. Decrease in anal tonus and L5 motor weakness on the left side were determined on the physical examination. Radiographic and computed tomography evaluations indicated the displaced high transverse sacral fracture. 71

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Case 2– In February 2012, a 20-year-old male admitted to our emergency department after a motor vehicle accident. He was mentally confused. It was learned from the patient’s relatives that he was a drug addict. Because of his mental disorientation, the neurological examination could not be performed. Displaced high transverse sacral fracture and pubic ramus fracture were detected in the computed tomography scan. Because of patient’s lack of cooperation, the neurological examination could not be performed for 48 hours. After 48 hours, the patient became oriented, and perianal saddle type anesthesia and bilateral S1 motor weakness were detected.

and bilateral S1 motor weakness were detected. Displaced high transverse sacral fracture and left bimalleolar fracture were detected in the radiographic and tomographic evaluations (Figure 1).

Case 3– In April 2010, a 21-year-old male admitted to another hospital after a motor vehicle accident. Sacral fracture and bimalleolar fracture on the left side had been detected. Bed rest had been recommended for his sacral fracture. He admitted to our emergency department with the complaints of increase in pain and weakness on his legs 72 hours after the accident. In the physical examination, perianal saddletype anesthesia, decrease in anal tonus, urinary retention,

Emergent surgical intervention was performed for the diagnosis of CES. Subsequent to the exploration of the posterior elements between levels L5 and S3, bilateral L5 pedicle screws and iliac screws were placed, preserving the L5 and S1 facets. Lumbopelvic fixation was completed with the placement of rods. Schildhauer et al.[9] first described this technique. It is the most stable fixation construct for the posterior pelvic ring according to the biomechanical analyses.[10] Later, S1-S2-

(a)

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(g)

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Between 2010-2012, three patients, with a mean age of 19 (15-20-21) years, were admitted and determined to have a displaced high transverse sacral fracture and concomitant CES detected at least 48 hours after the trauma. The mean follow-up of these three patients was 14.6 months (10-1420).

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(i)

(j)

Figure 1. A 21-year-old male with a transverse sacral fracture after a motor vehicle accident. (a) The fracture can be easily overlooked on plain antero-posterior X-ray. (b, c) Axial and sagittal computed tomography scans revealing the displaced fracture fragments encroaching the sacral canal. (d, e) Axial and sagittal MRG scans revealing the caudal compression. (f) Intraoperative view after sacral laminectomy demonstrating the intact sacral nerve roots. (g, h) Postoperative anteroposterior and lateral X-rays. (i, j) Postoperative x-rays taken after implant removal at sixth month.

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S3 laminectomy and decompression of the sacral nerve roots were performed. Nerve roots were edematous and ecchymotic. Bone fragments that encroached on the sacral canal were excised. In the first 24 hours following the surgery, urinary dysfunction and motor deficits fully recovered immediately in Cases 1 and 3. Case 1 reported a decrement in the pain radiating to the adductor area. Oral gabapentin treatment was started for his pain. He was mobilized with full-weight bearing on postoperative day 1. Pain complaints completely recovered and implants were removed in the sixth month. In Case 3, open reduction and internal fixation were done for the bimalleolar fracture in the same session. He was mobilized with weight bearing on the opposite side on postoperative day 1. The malleolar fracture was united without complication. Implants were removed in the sixth month. The patient was symptom-free at the latest follow-up, except for left deviation of his penis in the course of erection. In Case 2, partial improvement in motor strength was detected in the early postoperative period. Oral gabapentin treatment was started for his complaints of pain in the perianal region. Perianal anesthesia recovered two months after surgery. At the six-month follow-up, his pain had fully recovered and urinary/bladder dysfunction had partially recovered. Full neurologic recovery was detected at the 10-month follow-up.

DISCUSSION We aimed to report herein three cases representing our experience with the surgical treatment of displaced transverse sacral fracture with concomitant late-diagnosed CES. Roy-Camille et al.[11] described transverse sacral fractures as a subtype of Denis zone 3 fractures. Initially, three types were defined, and later, the fourth fracture pattern was included in the classification.[12] There are different characteristics of high and low transverse sacral fracture patterns. High transverse sacral fractures have an S1-S2 fracture dislocation pattern with a three-dimensional configuration (H, U, T patterns).[13] On the other hand, as low transverse sacral fracture pattern passes caudally through the sacroiliac joint, it is accounted as stable.[14] In our series, all three patients had an unstable fracture pattern, and thus internal fixation was performed. Transverse sacral fractures can be easily overlooked in the conventional radiographic evaluation. Despite the fact that the fracture can be detected by plain X-rays, coronal and sagittal computed tomography scanning with 1-2 mm sections is the best means for a detailed evaluation of the posterior pelvic ring.[15] Accompanying neurologic deficit is a clue for the diagnosis of transverse sacral fracture. Denis et al.[1] reported less events of misdiagnosis in the cases with neurologic deficits. Further, Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

Robles[16] reported a delay in the diagnosis in 37% of cases. Of the three cases included in this study, delay in diagnosis occurred only in Case 1. Low sacral nerve roots must be examined in a patient with a suspected sacral fracture. Decrease in anal tonus is a valuable examination finding for sacral nerve root damage.[13] Denis et al.[1] reported neurologic deficit in 21% of cases in their series. The rate increased up to 60% in the case of a zone 3 pattern. They concluded that transverse fractures present a greater risk of neurologic damage than the vertically oriented fractures. CES, characterized by urinary retention and L5 and/ or S1 motor deficit, is the most common neurologic deficit pattern in patients with transverse sacral fractures.[6,16] The neurologic deficit occurring with the mechanisms of angulation and direct compression resolves completely when the mechanical compression disappears. However, neurologic recovery should not be expected with the injury mechanisms of root avulsion or transection.[17] In autopsy series, complete sacral nerve root transection was reported in 35% of cases. [18] In our series, in all three cases, CES had been overlooked and was diagnosed a minimum of 48 hours after the traumatic event. The intraoperative examination did not reveal any interruptions to the nerve roots. There is no consensus about the treatment of transverse sacral fractures. Nevertheless, with the increase in understanding about the fracture pattern and the evolution of spinal stabilization systems, surgical treatment has taken over. However, especially in cases occurring due to lowerenergy mechanisms and cases without neurologic deficits, good results have been reported with conservative treatment methods.[19,20] High transverse sacral fractures occurring due to higher-energy mechanisms require internal fixation because of the mechanical instability.[12] Additionally, as a basic rule for spinal surgery, surgical decompression is definitely indicated in cases with neurological deficits and canal encroachment. While neurological recovery is not expected in cases with a complete spinal cord injury after decompression, complete recovery has been reported in the literature in cases of CES. Surgical timing in the case of CES is controversial. The common concept is to consider the first 48 hours as the critical interval.[21-25] However, there are other studies concluding that decompression before or after 48 hours does not influence the neurologic outcome. [26] In a series of 50 patients with CES diagnosed after an average of 12 days, neurologic recovery was evident in all patients who were surgically decompressed. However, the most obvious recovery was reported in the case of emergent surgical decompression.[27] They concluded that loss of anocutaneous reflex is a predictive parameter for bladder/ bowel dysfunction sequelae.[27] According to our own clinical experience, especially in the case of canal encroachment, despite a delay in diagnosis, eliminating the mechanical pressure on the sacral nerve roots immediately results in neurologic recovery. 73

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Several stabilization methods have been described in addition to surgical decompression. Schildhauer et al.[9] reported the largest series for lumbopelvic fixation. Lumbopelvic fixation is the most reliable stabilization method for the posterior pelvis as determined by biomechanical analyses. Furthermore, this type of fixation permits early full-weight mobilization.[10] In conclusion, despite a delay in diagnosis, we suggest that immediate surgical decompression and stable lumbopelvic fixation have positive effects on the neurologic outcome, early full-weight mobilization and pain control. Conflict of interest: None declared.

REFERENCES 1. Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988;227:6781. 2. Gibbons KJ, Soloniuk DS, Razack N. Neurological injury and patterns of sacral fractures. J Neurosurg 1990;72:889-93. 3. Santiago P, Fessler RG. Trauma surgery: fractures of the lumbar and sacral spine. In: Benzel EC, editor. Spine surgery: techniques, complication avoidance, and management. 2nd ed. Philadelphia: Elsevier; 2004. p. 563-72. 4. Wood KB, Denis F. Fractures of the sacrum and coccyx. In: Vaccaro AR, editor. Fractures of cervical thoracic and lumbar spine. New York: Marcel Dekker; 2003. p. 473-88. 5. Wood KB, Denis F. Sacral fractures. In: Vaccaro AR, Betz RR, Zeidman SM, editors. Principles and practice of spine surgery. St. Louis: Mosby Inc.; 2003. p. 487-94. 6. Bonin JG. Sacral fractures and injuries to the cauda equina. J Bone Joint Surg 1945;27:113-27. 7. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br 1949;31B:376-94. 8. Sapkas GS, Mavrogenis AF, Papagelopoulos PJ. Transverse sacral fractures with anterior displacement. Eur Spine J 2008;17:342-7. 9. Schildhauer TA, Bellabarba C, Nork SE, Barei DP, Routt ML Jr, Chapman JR. Decompression and lumbopelvic fixation for sacral fracture-dislocations with spino-pelvic dissociation. J Orthop Trauma 2006;20:447-57. 10. Schildhauer TA, Josten Ch, Muhr G. Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing. J Orthop Trauma 2006;20(1 Suppl):44-51.

11. Roy-Camille R, Saillant G, Gagna G, Mazel C. Transverse fracture of the upper sacrum. Suicidal jumper’s fracture. Spine (Phila Pa 1976) 1985;10:838-45. 12. Strange-Vognsen HH, Lebech A. An unusual type of fracture in the upper sacrum. J Orthop Trauma 1991;5:200-3. 13. Watkins RG, Dillin WH. Sacral fractures. In: Cooper PR, editor. Management of posttraumatic spinal instability. Park Ridge, IL: AANS Publications Committee; 1990. p. 163-71. 14. Weaver EN Jr, England GD, Richardson DE. Sacral fracture: case presentation and review. Neurosurgery 1981;9:725-8. 15. Templeman D, Goulet J, Duwelius PJ, Olson S, Davidson M. Internal fixation of displaced fractures of the sacrum. Clin Orthop Relat Res 1996;329:180-5. 16. Robles LA. Transverse sacral fractures. Spine J 2009;9:60-9. 17. Vaccaro AR, Kim DH, Brodke DS, Harris M, Chapman JR, Schildhauer T, et al. Diagnosis and management of sacral spine fractures. Instr Course Lect 2004;53:375-85. 18. Huittinen VM. Lumbosacral nerve injury in fracture of the pelvis. A postmortem radiographic and patho-anatomical study. Acta Chir Scand Suppl 1972;429:3-43. 19. Dussa CU, Soni BM. Influence of type of management of transverse sacral fractures on neurological outcome. A case series and review of literature. Spinal Cord 2008;46:590-4. 20. Urzúa A, Marré B, Martínez C, Ballesteros V, Ilabaca F, Fleiderman J, et al. Isolated transverse sacral fractures. Spine J 2011;11:1117-20. 21. Kostuik JP, Harrington I, Alexander D, Rand W, Evans D. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am 1986;68:38691. 22. Kennedy JG, Soffe KE, McGrath A, Stephens MM, Walsh MG, McManus F. Predictors of outcome in cauda equina syndrome. Eur Spine J 1999;8:317-22. 23. Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP. Cauda equina syndrome secondary to lumbar disc herniation: a metaanalysis of surgical outcomes. Spine (Phila Pa 1976) 2000;25:1515-22. 24. McCarthy MJ, Aylott CE, Grevitt MP, Hegarty J. Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome. Spine (Phila Pa 1976) 2007;32:207-16. 25. Shapiro S. Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine (Phila Pa 1976) 2000;25:348-52. 26. Qureshi A, Sell P. Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome. Eur Spine J 2007;16:2143-51. 27. Dhatt S, Tahasildar N, Tripathy SK, Bahadur R, Dhillon M. Outcome of spinal decompression in Cauda Equina syndrome presenting late in developing countries: case series of 50 cases. Eur Spine J 2011;20:2235-9.

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Transvers sakrum kırıkları ve eşlik eden geç tanı almış kauda ekina sendromu Dr. Şenol Bekmez,1 Dr. Gökhan Demirkıran,2 Dr. Ömür Cağlar,2 Dr. İbrahim Akel,3 Dr. Emre Acaroğlu4 Dr. Sami Ulus Kadın Doğum, Çocuk Sağlığı ve Hastalıkları, Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Ankara; Hacettepe Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Ankara; 3 İzmir Kent Hastanesi, Ortopedi ve Travmatoloji Kliniği, İzmir; 4 Ankara Spine Center, Ortopedi ve Travmatoloji Kliniği, Ankara 1 2

Yüksek transvers sakrum kırıkları genç hastalarda yüksek enerjili travma sonrası meydana gelmektedir. Sakrumun radyografik değerlendirmesinde ve sakral düzeydeki nörolojik defisitlerin politravmalı hastalarda değerlendirmesindeki zorluklar nedeniyle bu yaralanmalar gözden kaçabilmektedir. Bu yazıda, üç olgudan oluşan, kauda ekina sendromu tanısı çeşitli nedenlerle geç konulan (en az 48 saat), yüksek enerjili ve kanala bası yapan transvers sakrum kırıklarında cerrahi tedavi sonuçları değerlendirildi. Hastalara sakral laminektomi ve dekompresyon uygulanarak iki taraflı lumbopelvik fiksasyon uygulandı. Her ne kadar kauda ekina sendromu tanısı geç konulsa da, cerrahi dekompresyon ve lumbopelvik fiksasyonun nörolojik fonksiyonlar ve ağrıda düzelme, erken desteksiz mobilizasyon üzerindeki olumlu etkilerini gözlemledik. Anahtar sözcükler: Atlanmış; ekina; kauda; sakrum; transvers. Ulus Travma Acil Cerr Derg 2014;20(1):71-74

doi: 10.5505/tjtes.2014.21208

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CAS E R EP O RT

Isolated salpingeal torsion in children: a case series and review of the literature Volkan Sarper Erikci, M.D., Münevver Hoşgör, M.D. Department of Pediatric Surgery, Dr Behçet Uz Children Hospital, İzmir

ABSTRACT This study was carried out to evaluate and determine the history, clinical presentation, and physical examination and laboratory findings in a pediatric (n=1) and adolescent (n=2) population with isolated tubal torsion (ITT) and to examine its surgical management. A retrospective review of all the cases of ITT treated in our hospital between January 2000 and December 2012 was performed. The diagnosis of ITT was performed by physical examination and radiological studies including ultrasonography (US), color Doppler US, and computed tomography (CT) and confirmed by surgical intervention. There were 3 children with ITT in the study period. Two of the patients were adolescents and one was diagnosed in the neonatal period. Two patients had left-sided ITT. The neonatal patient was diagnosed with abdominopelvic mass antenatally. ITT in the other two children occurred three days after the onset of symptoms. All the patients in this study were treated with salpingectomy. ITT is rarely diagnosed preoperatively, and is treated mostly by salpingectomy. A better recognition of this entity may help to improve the treatment of this rare condition. As advocated for ovarian salvage in adnexal torsions, earlier diagnosis and preservation of the tube, if possible, with prompt surgical intervention may increase the future reproductive potential of these patients. Key words: Children; isolated tubal torsion; salpingectomy.

INTRODUCTION Torsion of the fallopian tube is an uncommon cause of abdominal pain in girls. When it is not associated with torsion of the ovary, the term isolated tubal torsion (ITT) is used. It is defined as the twisting by at least one complete turn of the fallopian tube around a center-line consisting of the infundibulopelvic ligament and tubo-ovarian ligament.[1] ITT is observed in women of reproductive age, with an annual prevalence of 1 in 1.5 million.[2] Ischemia is the direct consequence of a twist in the fallopian tube. The interruption in the arterial blood supply may be the initial consequence of the TT, or develop secondarily to a pause in the venous flow due to the presence of edema. In the absence of treatment, it results in necrosis of the fallopian

Address for correspondence: Volkan Sarper Erikci, M.D. Süvari Caddesi, Babadan Apt., No.34, D.6, Bornova, 35040 İzmir, Turkey Tel: +90 232 - 411 60 36 E-mail: verikci@yahoo.com Qucik Response Code

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tube, which will be followed by loss of the organ and may adversely affect future fertility.[3-6] More rarely, due to the release of cytokines, it may be the origin of potential fatal complications such as pelvic thrombophlebitis or peritonitis.[7] In this article, we present three cases of ITT in order to determine the history, clinical presentation, and physical examination and laboratory findings in a pediatric (n=1) and adolescent (n=2) population and to examine its surgical management.

CASE REPORT A retrospective review of all cases of ITT treated in the Department of Pediatric Surgery, Dr. Behçet Uz Children’s Hospital, between January 2000 and December 2012 was performed. All cases of ITT sparing the ipsilateral ovary were included in this study. Exclusion criteria were fallopian tube torsion combined with ipsilateral ovarian torsion, medical history of pelvic surgery, pelvic inflammatory disease (PID), and tubal/ovarian malignancies, or pregnancy. Our case series consisted of three patients treated in our clinic. Case 1– A 14-year-old girl was admitted to the emergency room with pain in her lower right quadrant of three-days’ duration and bilious vomiting for one day. She had her first menstrual period with the onset of the pain. Her physical examination revealed tenderness in the right lower quadrant 75

Erikci et al. Isolated salpingeal torsion in children

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Figure 1. (a) Pelvic color Doppler US showing bilateral normal perfused ovaries with a cystic mass (Arrow: cystic mass). (b) Computed tomography showing the cystic mass (Arrow: cystic mass).

with mild guarding; the laboratory tests were unremarkable. Radiological evaluation with ultrasonography (US) and a color Doppler showed bilateral normal perfused ovaries with a cystic mass of 6 cm (Figure 1a). Computed tomography (CT) confirmed that the mass was cystic, with a dimension of 5x6 cm (Figure 1b). As TT with hydrosalpinx was diagnosed, the patient underwent an emergent exploration. The left ovary and fallopian tube were normal. The right ovary appeared increased in size, to double that of the left ovary, with multiple follicular cysts inside. The right fallopian tube with hydrosalpinx and a closed tip of the ampulla was found to be torsed 360Â° clockwise, and it was untwisted to its neutral position (Figure 2a). As no change in color was observed in time, salpingectomy was performed. Histopathological evaluation of the specimen revealed hematosalpinx with hemorrhagic necrosis in all sections. She was discharged three days after the surgical intervention. Serial US assessments showed no signs of tubal or ovarian pathologies with both ovaries of equal dimensions during the follow-up of five years.

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Case 2â&#x20AC;&#x201C; A five-day-old female baby with an antenatal diagnosis of abdominal mass was admitted to our clinic. Her physical examination was unremarkable except for a mobile mass in the lower abdominal region. The laboratory tests were normal except for an increase in the ferritin levels (376 ng/ml, N: 25200 ng/ml), lactate dehydrogenase (LDH) (900 u/L, N: 220-480 u/L) and alpha-fetoprotein (36506 IU/ml, N: 0-1400 IU/ml). US revealed a 4x5 cm mobile cystic mass with air-fluid level. CT confirmed the septated mass to be located under the liver with the majority of the mass being cystic in nature (Figure 2b). At laparotomy, the left fallopian tube and ovary were normal. There was no right ovary, and the right tube was 0.5 cm in length with obliterated tip. A mass of 6x5 cm in diameter connected to the tip of the appendix was found in the pelvis and resected with the appendix. Histopathological examination revealed a cystic mass with hemorrhagic infarction and dystrophic calcification in its wall and an inflamed appendix. It was considered as an in-utero TT with autoamputation. The postoperative course was uneventful, and she was discharged

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Figure 2. (a) Intraoperative image showing the detorsed right fallopian tube with hydrosalpinx (RFT: Right fallopian tube; RO: Right ovary; U: Uterus; LO: Left ovary; LFT: Left fallopian tube). (b) Computed tomography showing the septated cystic mass under the liver.

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Erikci et al. Isolated salpingeal torsion in children

from the hospital on the 4th postoperative day. One month after the surgical intervention, she was internalized with the diagnosis of brid ileus and treated conservatively. There has been no recurrence to date after a 12-year follow-up. Case 3â&#x20AC;&#x201C; A 13-year-old girl was admitted to our clinic with pain in her lower left quadrant of three-daysâ&#x20AC;&#x2122; duration. Her menstruation had begun one year before, with regular cycles of 28-32 days. Her laboratory tests were unremarkable. On the physical examination, she had moderate tenderness on deep palpation of her left lower quadrant. A vaginal examination was not performed, and a digital rectal examination revealed a mass in the anterior region of the rectum. Apart from normal-appearing ovaries, US confirmed the presence of a mass containing no vascular flow on color Doppler. CT revealed a 9 cm septated mass separate from the uterus. Diagnostic laparoscopy revealed a 10 cm necrotic blue mass in the left pelvis. For a better exposure and easier removal of necrotic tissue, a laparotomy was performed, and a totally necrotic torsed left fallopian tube was resected with incidental appendectomy. The pathology report revealed extensive hemorrhagic infarction in the left fallopian tube. The postoperative course was uneventful, and she was discharged from the hospital on the 3rd postoperative day with no recurrence to date after a 12-year follow-up.

DISCUSSION Since the initial description of pediatric adnexal torsion by Sutton,[8] a number of adnexal torsion cases in childhood have been reported.[9] ITT in childhood has been a rarely encountered pathology. There are several predisposing factors in this clinical entity, including abnormal tubal peristalsis, hydrosalpinx, tubal ligation or neoplasms, paraovarian/paratubal masses, uterine enlargement, adhesions following surgical interventions, or infections.[10] In the pediatric age group, the possible factors are preexisting congenital malformations such as excessive tortuosity and elongation of the tube.[11,12] In the absence of predisposing tubal pathologies, torsion of the fallopian tube is generally due to abnormal motility observed during early puberty due to the elevated follicle-stimulating hormone (FSH) level that triggers the tubal motility. [12,13] Two of three patients in this study were adolescents, with similar ratios according to those reported. The right side is most frequently affected in cases of adnexal torsion for two reasons.[14,15] Due to the cushioning effect of the sigmoid colon, there is a preventive effect of anatomic positioning on the left side. The second reason is that rightsided pathology is evaluated more often in the context of the differential diagnosis of acute appendicitis. Despite these observations and the fact that the right utero-ovarian ligament is physiologically longer than the left, left-sided TTs reported in the literature outnumber those on the right.[12] Two of three patients in our study had left-sided ITT, and this finding shows a similarity with those reported previously. As a result, Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1

further researches with larger series of patients are needed to shed a new light on the issue of dominant side in ITT. Patients with ITT usually experience the sudden onset of intense pain.[7,16] Pain lasting more than 10 hours before surgery is associated with an increased rate of tubal necrosis.[17] Harmon et al.[10] presented a mean of 1.67 days (range, 0-5 days) from initial imaging (not onset of pain) till surgery in patients with ITT, and all the cases required salpingectomy. With the exception of the neonatal case with an antenatal diagnosis of abdominal mass, late admissions were relevant in our study, as two of our patients presented intense abdominal pain of three-daysâ&#x20AC;&#x2122; duration, and this clinical scenario resulted in tissue necrosis confirmed by the pathological examination. Clinical examination may reveal latero-uterine mass in 4170% of cases.[3,18] However, in this study, only the neonatal case with intrauterine TT presented with a palpable mobile mass in the lower abdominal region. There is no additional biological investigation specific to adnexal torsion. US examination may reveal a pathological adnexal image in most cases,[15,19-21] but these are not pathognomonic for ITT. Due to the dual vascular supply of the tubes, a normal Doppler cannot exclude the diagnosis of TT.[1] CT or magnetic resonance imaging (MRI) can reveal the tubal mass but not signs of ischemia, unlike Doppler US. In one study, US, CT and MRI showed a sensitivity of 22%, 14% and 40% in diagnosing ITT, respectively.[22] As a diagnostic tool, US was the first imaging modality in this study, but revealed nonspecific findings. A color Doppler US combined with pelvic CT was also used in the diagnostic work-up of these patients. However, the definitive diagnosis of TT with hydrosalpinx was possible in only one patient (Case 3) preoperatively. The only certain way to diagnose ITT is surgery, by laparoscopy or laparotomy. There are 45 cases of ITT in the pediatric literature review, with a mean age of 13.2 years at presentation.[22] Although similar to the literature with regard to the ages in this study (Case 1: 13 years; Case 3: 14 years), this study is unique for its presentation of a neonatal baby with ITT. Because no normallooking right tube was observed during laparotomy, it was speculated that it presumably had torsed in utero, resulting in autoamputation. To our knowledge, there is no pediatric case of neonatal age with ITT in the English-language literature. All the patients in this study were treated with salpingectomy. A literature review revealed that of the children with ITT, 88% were treated by salpingectomy, while 12% were treated by tubal detorsion; the long-term outcomes of detorsion were not reported.[22] Salpingoneostomy was also reported as a therapeutic approach, and one case was treated with this modality with an uneventful follow-up of 26 months.[12] ITT in children is still frequently misdiagnosed and is too often managed in a nonconservative manner, which compromises the fertility potential of pediatric patients before the beginning of their reproductive life. As detorsion and ovarian salvage is 77

Erikci et al. Isolated salpingeal torsion in children

a safe choice no matter how necrotic the ovary appears, the same philosophical system may be applied to tubal salvage. [23,24] After detorsion, a second-look surgical intervention may preserve potentially functional tubes. Isolate tubal torsion in girls is rarely diagnosed preoperatively, and is treated mostly by salpingectomy. A better recognition of this entity with an interdisciplinary approach including pediatric surgeons and gynecologists may help to improve the treatment of this rare condition and open a new era in its management. As is commonly advocated for ovarian salvage in adnexal torsions, earlier diagnosis and preservation of the tube, if possible, with prompt surgical intervention may increase the future reproductive potential of these patients in general. Conflict of interest: None declared.

REFERENCES 1. Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol 2010;150:8-12. 2. Lima M, Libri M, Aquino A, Gobbi D. Bilateral hydrosalpinx with asynchronous tubal torsion: an exceptional finding in a premenarcheal girl. J Pediatr Surg 2011;46:27-9. 3. Bayer AI, Wiskind AK. Adnexal torsion: can the adnexa be saved? Am J Obstet Gynecol 1994;171:1506-11. 4. Haskins T, Shull BL. Adnexal torsion: a mind-twisting diagnosis. South Med J 1986;79:576-7. 5. Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985;152:456-61. 6. Ozcan C, Celik A, Ozok G, Erdener A, Balik E. Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion. J Pediatr Surg 2002;37:1617-20. 7. Nichols DH, Julian PJ. Torsion of the adnexa. Clin Obstet Gynecol 1985;28:375-80. 8. Sutton JB. Salpingitis and some of its effects. Lancet 1890;2:1146-8. 9. Sozen I, Nobel PA, Nobel J. Partial tubal salvage through neosalpingostomy in a 12-year-old girl with combined ovarian and fallopian tube torsion. J Pediatr Surg 2006;41:17-9.

10. Harmon JC, Binkovitz LA, Binkovitz LE. Isolated fallopian tube torsion: sonographic and CT features. Pediatr Radiol 2008;38:175-9. 11. James DF, Barber HR, Graber EA. Torsion of normal uterine adnexa in children. Report of three cases. Obstet Gynecol 1970;35:226-30. 12. Boukaidi SA, Delotte J, Steyaert H, Valla JS, Sattonet C, Bouaziz J, et al. Thirteen cases of isolated tubal torsions associated with hydrosalpinx in children and adolescents, proposal for conservative management: retrospective review and literature survey. J Pediatr Surg 2011;46:1425-31. 13. Merlini L, Anooshiravani M, Vunda A, Borzani I, Napolitano M, Hanquinet S. Noninflammatory fallopian tube pathology in children. Pediatr Radiol 2008;38:1330-7. 14. Peña JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertil Steril 2000;73:1047-50. 15. Warner MA, Fleischer AC, Edell SL, Thieme GA, Bundy AL, Kurtz AB, et al. Uterine adnexal torsion: sonographic findings. Radiology 1985;154:773-5. 16. Goldstein DP. Acute and chronic pelvic pain. Pediatr Clin North Am 1989;36:573-80. 17. Mazouni C, Bretelle F, Ménard JP, Blanc B, Gamerre M. Diagnosis of adnexal torsion and predictive factors of adnexal necrosis. [Article in French] Gynecol Obstet Fertil 2005;33:102-6. 18. Chiou SY, Lev-Toaff AS, Masuda E, Feld RI, Bergin D. Adnexal torsion: new clinical and imaging observations by sonography, computed tomography, and magnetic resonance imaging. J Ultrasound Med 2007;26:1289301. 19. Bider D, Mashiach S, Dulitzky M, Kokia E, Lipitz S, Ben-Rafael Z. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet 1991;173:363-6. 20. Chapron C, Capella-Allouc S, Dubuisson JB. Treatment of adnexal torsion using operative laparoscopy. Hum Reprod 1996;11:998-1003. 21. Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics 2008;28:1355-68. 22. Gaied F, Emil S, Lo A, Baird R, Laberge JM. Laparoscopic treatment of isolated salpingeal torsion in children: case series and a 20-year review of the literature. J Laparoendosc Adv Surg Tech A 2012;22:941-7. 23. Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion--a 15-year review. J Pediatr Surg 2009;44:1212-7. 24. Meynol F, Steyaert H, Valla JS. Adnexal torsion in children: plea for early laparoscopic diagnosis and treatment. [Article in French] Arch Pediatr 1997;4:416-9.

OLGU SUNUMU - ÖZET OLGU SUNUMU

Çocuklarda izole tubal torsiyon: Olgu sunumu ve literatür değerlendirilmesi Dr. Volkan Sarper Erikci, Dr. Münevver Hoşgör Dr. Behçet Uz Çocuk Hastalıkları ve Cerrahisi Eğitim ve Araştırma Hastanesi, Çocuk Cerrahisi Kliniği, İzmir

İzole tubal torsiyonlu (İTT) pediatrik ve adölesan popülasyondaki hikaye, klinik yansıma, fiziksel inceleme, laboratuvar bulgularının değerlendirilmesi ve belirlenmesi ile bu olguların cerrahi yönetiminin gözden geçirilmesi için çalışma gerçekleştirildi. Hastanemizde Ocak 2000 ile Aralık 2012 tarihleri arasında İTT tanısı ile tedavi edilen tüm olgular geriye dönük olarak incelendi. İTT tanısı fiziksel inceleme, ultrasonografi (USG), renkli Doppler USG ve bilgisayarlı tomografiyi (BT) de içeren radyolojik çalışmalara dayanılarak konuldu ve cerrahi girişim ile doğrulandı. Çalışma döneminde İTT’li üç olgu bulunmaktadır. Olguların ikisi adölesan biri ise yenidoğan dönemindeydi. İki olguda sol taraflı İTT vardı. Yenidoğan olguda prenatal abdominopelvik kitle tanısı vardı. İTT’li diğer iki olgu semptomların başlamasından üç gün sonra başvurdu. Bu çalışmadaki tüm olgular salpenjektomi ile tedavi edildi. İzole tubal torsiyon ameliyat öncesi olarak nadiren tanınır ve en sıklıkla salpenjektomi ile tedavi edilir. Bu nadir durumun daha iyi tanınması tedavide ilerlemelere yardımcı olabilir. Adneksiyal torsiyonlardaki over koruyucu yaklaşım gibi, daha erken tanı ve mümkünse tubanın korunmasını da içeren çabuk cerrah girişim ile bu olguların ileriki dönem üreme potansiyelleri artırabilir. Anahtar sözcükler: Çocuklar; izole tubal torsiyon; salpenjektomi. Ulus Travma Acil Cerr Derg 2014;20(1):75-78

doi: 10.5505/tjtes.2014.26918

Ulus Travma Acil Cerr Derg, January 2014, Vol. 20, No. 1