TRAUMA 2015 / 3 by KAREPUBLISHING

ISSN 1306 - 696X

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

Volume 21 | Number 3 | May 2015

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) M. Mahir Özmen Hakan Yanar 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 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

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) • www.kareyayincilik.com • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Merve Şenol • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): April (Nisan) 2015 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

KARE 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 21

Number - Sayı 3 May - Mayıs 2015

Contents - İçindekiler

Deneysel Çalışma - Experimental Study Experimental Study - Deneysel Çalışma 163-169 Sıçanlarda oluşturulan ince bağırsak iskemi reperfüzyon hasarında ligustrazin’in etkisi The effect of ligustrazin in intestinal ischemia reperfusion injury generated on rats Polat H, Türk Ö, Yaşar B, Uysal O

Original Articles - Orijinal Çalışma 170-174 Comparison of early surgical alternatives in the management of open abdomen: a randomized controlled study Open abdomen yönetiminde erken dönem cerrahi alternatiflerin karşılaştırılması: Randomize ileriye yönelik çalışma Rencüzoğulları A, Dalci K, Eray IC, Yalav O, Okoh AK, Akcam T, Ulku A, Sakman G, Parsak CP 175-181 Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey Türkiye’de acil servislerde çalışan hekimler arasında şiddet ve tükenmişlik ilişkisinin değerlendirilmesi Erdur B, Ergın A, Yuksel A, Türkçüer İ, Ayrik C, Boz B 182-186 The analysis of scoring systems predicting mortality in geriatric emergency abdominal surgery Geriatrik abdominal acil cerrahide mortaliteyi öngörmede skorlama sistemlerinin analizi Özban M, Birsen O, Şenel M, Özden A, Kabay B 187-192 Repairing post burn scar contractures with a rare form of Z-plasty Yanık sonrası skar kontraktürlerinin nadir bir Z-plasti yöntemi ile düzeltilmesi Gümüş N 193-196 The frequency of type 2 second-degree and third-degree atrioventricular block induced by blunt chest trauma in the emergency department: a multicenter study Acil serviste künt göğüs travmasına bağlı tip 2 ikinci derece ve üçüncü derece atriyoventriküler blok sıklığı: Çok merkezli çalışma Şahin Yıldız B, Astarcıoğlu MA, Başkurt Aladağ N, Aykan AÇ, Hasdemir H, Şahin A, Yıldız M 197-203 Fixation of distal femoral fractures: Restoration of the knee motion Distal femoral fraktürlerin fiksasyonu: Diz kinematiğinin restorasyonu Massoud EIE 204-208 Evaluation of the medical malpractice cases concluded in the General Assembly of Council of Forensic Medicine Adli Tıp Kurumu Genel Kurulu’nca sonuçlandırılan tıbbi uygulama hatası olgularının değerlendirilmesi Yazıcı YA, Şen H, Aliustaoğlu S, Sezer Y, İnce CH

Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 21

Number - Sayı 3 May - Mayıs 2015

Contents - İçindekiler

209-215 Opere tibia plato Schatzker tip I ve tip II kırıklarda, iyileşme üzerine obezitenin olumsuz etkisi var mı? The impact of obesity on the outcomes of the patients operated on due to Schatzker type I and type II tibial plateau fractures Çeçen GS, Gülabi D, Pehlivanoğlu G, Elmalı N, Teköz A 216-219 Elektrik yaralanmalarında elektrokardiyografi bulgularının klinik gidişte önemi The importance of electrocardiography in the clinical course of electric injuries Vural A, Sarak T, Vural S, Yastı AÇ

Case Reports - Olgu Sunumu 220-222 Unilateral spontaneous adrenal hemorrhage in a young patient Genç hastada spontan tek taraflı adrenal kanama Çelik MF, Akarsu C, Dural AC, Çikot M, Ünsal MG, Alış H 223-227 The repair of complex penile defect with composite anterolateral thigh and vascularized fascia lata flap Kompleks penis defektinin komposit anterolateral uyluk ve vaskülarize fasta lata flebi ile onarımı Yazar S, Eroglu M, Gokkaya A, Semercıoz A 228-230 Künt travmada penetran kardiyak yaralanma: Olgu sunumu Penetrating cardiac injury in blunt trauma: a case report Dereli Y, Öncel M 231-234 Nazal kırığa neden olan neodyum mıknatıs ile yaralanma: Olgu sunumu Neodymium magnet injury causing nasal fracture: a case report Aykan A, Güzey S, Avşar S, Öztürk S

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DE NE Y SEL ÇA LI Ş M A

Sıçanlarda oluşturulan ince bağırsak iskemi reperfüzyon hasarında ligustrazin’in etkisi Dr. Hasan Polat,1 Dr. Özgür Türk,2 Dr. Bekir Yaşar,3 Dr. Onur Uysal4 1

Bingöl Karlıova Devlet Hastanesi, Genel Cerrahi Kliniği, Bingöl

Sivrihisar Devlet Hastanesi, Genel Cerrahi Kliniği, Eskişehir

Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Eskişehir

Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Histoloji Anabilim Dalı, Eskişehir

ÖZET AMAÇ: İnce bağırsak iskemi reperfüzyon (İR) hasarı ciddi ve sık görülen klinik bir durumdur. Birçok etiyolojik etkenin neden olduğu süperiyor mezenterik arter’in (SMA) tıkanmasının sonucudur. İnce bağırsak iskemisini sepsis ve çoklu organ yetersizliği takip edebilir. Bu çalışmada vazodilatatör etkisi olan ligustrazin’in iskemik ince bağırsaklar üzerindeki etkilerini araştırmayı hedefledik. GEREÇ VE YÖNTEM: Kırk adet erkek Wistar cinsi sıçan randomize olarak üç gruba ayrıldı. Grup S’ye (n=7) sham operasyonu; Grup MI’ya (n=7) 45 dk’lık mezenterik iskemi ve takiben 60 dk’lık reperfüzyon; Grup MI+L’ye (n=7) 45 dk’lık mezenterik iskemi, takiben 60 dk’lık reperüzyon ve reperfüzyon başında 80 mg/kg ligustrazin intraperitoneal olarak verildi. Tüm sıçanlardan reperfüzyon sonunda doku malondialdehit (MDA) ve süperoksit dismutaz (SOD) düzeyi, doku nitrik oksit (NO) düzeyi için ince bağırsak doku örneği ve histopatolojik inceleme için jejunum ve ileum spesmeni alındı. BULGULAR: Grup MI-L’de doku MDA ve doku NO düzeylerinin Grup MI’ya göre anlamlı olarak azaldığı saptandı. Doku SOD düzeyi ise Grup S’ye benzer olarak bulundu. Grup MI-L’de Jejunum ve ileumda İR hasarının histopatolojik göstergesi olan jejunum Chiu sınıflaması skorlarının Grup MI’ya göre anlamlı olarak azaldığı tespit edildi. SONUÇ: Sonuç olarak, ligustrazin’in mezenterik İR’de hem biyokimyasal parametrelerde lipit peroksidasyonunu düzeltmekte, hem de histopatolojik skorlamada jejunum ve ileumdaki İR hasarının şiddetini azaltmaktadır. Anahtar sözcükler: İnce bağırsak; iskemi-reperfüzyon; ligustrazin; nitrik oksit.

GİRİŞ İnce bağırsak iskemi reperfüzyon (İR) hasarı ciddi ve sık görülen klinik bir durum olup birçok etiyolojik etkenin neden olduğu süperiyor mezenterik arterin (SMA) tıkanmasının sonucudur. Bu durum şiddetli yerel veya yaygın doku hasarıyla sonuçlanır. Bu hasarı takiben çoklu organ yetersizliği gelişebilir. Mezenterik dolaşım bozukluğu arteriyel tromboz, emboli, Henoch-Schonlein purpurası, dissemine intravasküler koagülasyon gibi damar içi veya volvulus, invaginasyon, boğulmuş kasık fıtığı, tümör, fibrotik bant gibi damarlara dışarıdan bası yapan nedenlerle ince bağırsak iskemisi oluşmaktadır.[1] Chuanxiong sıkça kullanılan bir Çin şifalı bitkisidir ve genel olarak Sorumlu yazar: Dr. Özgür Türk, Sivrihisar Devlet Hastanesi, Genel Cerrahi Kliniği, 26000 Eskişehir Tel: +90 222 - 711 20 01 E-posta: drozgurturk@gmail.com Ulus Travma Acil Cerrahi Derg 2015;21(3):163-167 doi: 10.5505/tjtes.2015.55212 Telif hakkı 2015 TJTES

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

ligusticum ya da cnidium olarak anılır. Chuanxiong’ın içeriğinde birçok aktif bileşenler vardır. Ancak bunlardan en ilginç olanı kimyasal ismi tetramethylpyrazine olan alkaloid ligustrazin’dir. Vazodilatatör etkisi olan ve yapılan çalışmalarda kalsiyum kanal blokeri olabileceği belirtilen ligustrazin’in hipoksik dokularda PGI2 düzeyini artırarak ve TXA2 seviyesini azaltarak vazodilatasyona neden olduğu gösterilmiş.[2,3] İskemi reperfüzyon hasarında ligustrazin’in oksidatif stresi nötrofil infiltrasyonu ve apopitozisi azalttığı gösterilmiştir.[3] Bu çalışmada, ligustrazin’in iskemik ince bağırsaklar üzerindeki etkilerini araştırmayı hedefledik.

GEREÇ VE YÖNTEM Deney Hayvanları Bu çalışma Eskişehir Osmangazi Üniversitesi Tıp Fakültesi Hayvan Deneyleri Yerel Etik Kurulu’nun onayı alınarak, ESOGÜ Tıbbi ve Cerrahi Araştırma Merkezi laboratuvarında yapıldı. Çalışmada ağırlıkları 200-250 gr arasında değişen Sprague-Dawley cinsi erkek ve dişi 21 adet sıçan kullanıldı. Deney hayvanları standart laboratuvar koşullarında, sıçan yemi ve 163

Polat ve ark. Sıçanlarda oluşturulan ince bağırsak iskemi reperfüzyon hasarında ligustrazin’in etkisi

çeşme suyuyla beslendi. Deney hayvanları randomize olarak üç gruba ayrıldı. Sham grubu (n=7), mezenterik iskemi grubu (n=7) mezenterik iskemi ve ligustrazin tedavi grubu (n=7).

Cerrahi Teknik ve Tedavi Uygulanması Tüm sıçanlara sekiz saatlik açlık sonrasında, subkutan olarak 50 mg/kg sodyum pentotal (Pental Sodyum, İ.E. Ulagay, Türkiye) anestezisi verildi. Anestezinin ardından sıçanlar supin pozisyonda yatırılarak %10’luk povidon iyot (İsosol, Merkez Lab, Türkiye) ile bölge temizliği yapılarak geleneksel asepsi ve antisepsi kurallarına uyuldu. Orta hat insizyon ile laparotomi yapıldı. Sham grubundaki (Grup S) sıçanlara mezenterik pedikül diseksiyonu yapılarak sadece %0.9 sodyum klorür intraperitoneal olarak verildi. Mezenterik iskemi grubundaki (Grup MI) sıçanların SMA aortadan çıktığı yerden askıya alınarak, atravmatik mikrovasküler klemp yardımıyla 45 dakika süreyle kapatıldı. Bunu takiben orta laparotomi kesisi 3/0 ipekle devamlı dikişle kapatıldı. İskemi süresini takiben ipek dikiş alınarak laparotomi kesisi tekrar açıldı. Sıçanların SMA’ine yerleştirilen bulldog klemp açılıp çıkarıldı. SMA nabzının alındığı ve ince bağırsak beslenmesinin düzeldiği gözlendi. Bu gruptaki sıçanlar 60 dakika süreyle reperfüzyona maruz bırakılmak üzere laparotomi kesisi tekrar 3/0 ipekle devamlı dikişle kapatıldı. Mezenterik iskemi+Ligustrazin grubundaki (Grup MI+L) sıçanlara laparatomi yapılmadan 30 dk önce 80 mg/kg ligustrazin intraperitoneal olarak verildi. Bu gruptaki sıçanlara da MI grubundaki cerrahi prosüdür uygulandı. Altmış dakikalık reperfüzyon süresi sonunda tüm gruplarda 10 cm’lik bir ileum ansı alınarak sıçanlar dekapite edildi. Alınan spesmenler, %0.9 sodyum klorür solüsyonunda yıkandıktan sonra %10 formal-

dehitte tespit edildi. Doku malondialdehit (MDA), süperoksit dismutaz (SOD) ve nitrik oksit (NO) düzeyleri tayini için alınan örnekler, buzlu %0.9 NaCl solüsyonunda yıkandıktan sonra alüminyum folyoya sarılarak biyokimyasal incelemenin yapılacağı güne kadar -70 ºC’de derin dondurucuda saklandı.

Biyokimyasal İnceleme Biyokimyasal değerlendirme için MDA düzeyi ve SOD enzimi ve NO aktivitesi araştırıldı.

İnce Bağırsak Dokusunun Histolojik İncelenmesi Hazırlanan preparatlar kör olarak Chiu ve ark.nın tarif ettiği mezenterik İR hasarı skorlaması esas alınarak ve aşağıdaki kriterler göz önünde bulundurularak ışık mikroskobunda değerlendirildi (Tablo 1).[4]

İstatistiksel Değerlendirme Verilerin istatistiksel değerlendirmelerinde SPSS 15.0 ve Sigma Stat 3.1 paket programlar kullanıldı. Çalışma verileri değerlendirilirken tanımlayıcı istatistiksel metotların yanı sıra normal dağılımın incelenmesi için Kolmogorov-Smirnov dağılım testi kullanıldı. MDA, SOD ve NO düzeyleri için tek yönlü varyans analizi (Oneway ANOVA) uygulanmış olup, bu testin çoklu karşılaştırmalarında ise Turkey HDS metodundan yararlanıldı. Histopatolojik bulgular için skor değerlerinden oluşan altı parametremizin değerlendirilmesinde niceliksel verilerin karşılaştırılmasında normal dağılım gösteren parametrelerin gruplar arası karşılaştırmalarında Oneway ANOVA testi ve farklılığa neden olan grubun tespitinde Turkey HDS testi kullanıldı. Niceliksel verilerin karşılaştırılmasında ikiden fazla grup durumun-

Tablo 1. Histolojik skorlama Grade 0 Normal mukozal villuslar. Grade 1 Subepitelyal Gruenhagen aralığının oluşması. Genellikle mukozal villus apeksinde oluşur ve sıklıkla kapiller konjesyonla birliktedir. Grade 2 Subepitelyal aralığın artması ve epitelyal tabakanın lamina propriadan ayrılması. Grade 3 Masif epitelyal ayrılma. Villuslar arasında bazı uçlarda çıplaklaşma. Grade 4 Çıplak villuslar. Lamina propria ile birlikte dilate kapillerlerin görülmesi. Bazen lamina propriada artmış hücre yoğunluğu (selülarite) görülür. Grade 5 Lamina proprianin sindirimi ve parçalanması. Beraberinde ülserasyon ve hemoraji de görülür.

Tablo 2. Tüm grupların biyokimyasal ve histolojik skor ortalama değerleri Gruplar

Doku MDA

Doku SOD

Doku nitrik oksit

Ort.±SS Ort.±SS

Ort.±SS

Histolojik skor Ort.±SS

Grup S

32.70±8.26

46.32±0.89

14.48 ±3.18

0±0.08

Grup MI

116.85±23.92

31.72±0.74

45.24 ±9.24

3.57 ±0.53

Grup MI+L

75.03±14.67

43.72±0.37

21.90 ±5.96

2.14 ±1.46

Ort.: Ortalama; SS: Standard sapma; MDA: Malondialdehit; SOD: Süperoksit dismutaz; S: Sham; MI: Mezenter iskemi; MI+L: Mezenter iskemi ve ligustrazin.

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Polat ve ark. Sıçanlarda oluşturulan ince bağırsak iskemi reperfüzyon hasarında ligustrazin’in etkisi

140

Grup S

120

Grup MI

S ile Grup MI+L arasında anlamlı bir fark olmamakla birlikte (p>0.05) Grup MI ile Grup MI+L arasında istatistiksel anlamlı fark tespit edildi (p<0.01, Şekil 1).

Grup MI+L

100

Doku Nitrik Oksit Düzeylerinin Sonuçları

Ortalama doku NO düzeyleri Grup S’de 14.48 µmol/mgr protein, Grup MI’de 45.24 µmol/mgr protein, Grup MI+L’de 21.90 µmol/mgr protein olarak bulundu (Tablo 2). Gruplar kendi içlerinde istatistiksel olarak karşılaştırıldıklarında Grup S ile Grup MI arasında ileri düzeyde önemli istatistiksel fark gözlendi (p<0.001). Grup S ve Grup MI+L arasında anlamlı fark olmadığı görüldü (p>0.05). Grup MI ve Grup MI+L arasında ileri düzeyde anlamlı fark mevcuttu (Şekil 1).

60 40 20 0

Doku MDA

Doku SOD

Doku NO

Şekil 1. Sham grubu, MI grubu ve MI+L grubunda ince bağırsak doku MDA, SOD ve NO düzeyleri ortalamalarının karşılaştırması.

Histolojik Bulgular

da parametrelerin gruplar arası karşılaştırmalarında Kruskal Wallis testi ve farklılığa neden olan grubun tespitinde MannWhitney U-test kullanıldı. Sonuçlar %95 güven aralığında, anlamlılık p<0.05 düzeyinde değerlendirildi. Niteliksel verilerin karşılaştırılmasında ise Ki-Kare testi kullanıldı. Sonuçlar %95 güven aralığında, anlamlılık p<0.05 düzeyinde değerlendirildi.

Histolojik değerlendirme Chiu ve ark.nın tanımlamış oldukları sınıflama sistemi kullanılarak bir histolog tarafından kör olarak incelendi ve her preparata bir skor verildi.[4] Her sıçana ait preparatlardan elde edilen skorlar toplanarak ortalamaları alındı ve bu şekilde her sıçana ait tek bir ortalama ileum skoru elde edildi. Bu değerlerin Kruskal-Wallis tek yönlü varyans analizi ile incelenmesi sonucunda ortalama ileum skorları; Grup S’de 0.00, Grup MI’da 3.45, Grup MI+L’de 2.71 olarak bulunmuş olup, her üç grup arasında anlamlı fark tespit edildi (p<0.001).

BULGULAR Doku Malondialdehit Düzeylerinin Sonuçları Ortalama doku MDA düzeyleri Grup S’de 32.70 nmol/mg protein, Grup MI’de 116.85 nmol/mg protein, Grup MI+L’de 75.02 nmol/mg protein olarak bulundu (Tablo 2).

Sıçanlarda S, MI ve MI+L gruplarında ortalama ileum skorları değerlendirildiğinde; sham grubuna ait dokular normal mukoza görünümüne sahipti. Mezenterik İR uygulanan Grup MI’da ortalama ileum skorunun tüm gruplardan anlamlı derecede daha yüksek olduğu görüldü. Mukozal hasarın genellikle Grade 3 ve 4 arasında olduğu, bu gruptaki mukozal hasarda, villus uçlarında gözlenen çıplaklaşma, yer yer lamina propriaya doğru ilerlemişti. Kapillerlerdeki dilatasyonlar oldukça belirgindi (Şekil 2a). Mezenterik İR uygulanarak ligustrazin verilen Grup MI+L’de ortalama ileum skorunun sham grubundan yüksek olmakla birlikte diğer gruplardan daha düşük olduğu görüldü. Mukozal hasar incelemesinde iyileşmeye ait bulgulara rastlandı. Bu grupta Grade 1 düzeyinde villusların ucunda subepitelial

Gruplar kendi içlerinde birbirleri ile istatistiksel olarak karşılaştırıldıklarında; Grup S ile Grup MI (p<0.001), Grup S ile Grup MI+L (p<0.01), Grup MI ile Grup MI+L arasında anlamlı istatistiksel fark olduğu görüldü (p<0.01, Şekil 1).

Doku Süperoksit Dismutaz Enzim Sonuçları Ortalama doku SOD düzeyleri Grup S’de 6.60 U/mgr protein, Grup MI’da 4.53 U/mgr protein, Grup MI+L’de 6.25 U/ mgr protein olarak bulundu (Tablo 2). Grup S ile Grup MI arasında anlamlı istatistiksel fark tespit edildi (p<0.001). Grup

(a)

(b)

Şekil 2. (a) İR grubundan (Grup MI) alınan ileum spesmeninin mikroskopik görünümü (Grade 4) (H-E x 100) (Çıplak villuslar) (Lamina propriada artmış hücre yoğunluğu ve dilate kapillerler). (b) I-R + Ligustrazin grubundan (Grup MI+L) alınan ileum spesmeninin mikroskopik görünümü (Grade 2) (H-E x 100) (Gruenhagen aralığında artış).

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

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boşlukların gelişmeye başladığı ve yer yer kapiller konjesyon olduğu gözlendi. Bu grupta da Grade 3 ve Grade 4’e ait bulgulara da rastlandı (Şekil 2b). Gruplar kendi içlerinde birbirleri ile Student-Newman-Keuls çoklu karşılaştırma testi ile karşılaştırıldıklarında Grup S ile Grup MI, Grup S ile Grup MI+L arasında anlamlı fark olduğu tespit edildi (p<0.05). Grup MI ve Grup MI+L grupları arasında olarak anlamlı derecede fark olmadığı görüldü (p>0.05). Mezenterik İR uygulanarak ligustrazin verilen Grup MI+L’de ortalama ileum skorunun sham grubundan yüksek olmakla birlikte diğer grupdan daha düşük olduğu görüldü.

TARTIŞMA Bağırsakları besleyen arterlerin emboli, tromboz veya ateroskleroza bağlı tıkanıklıkları ile volvulus, intestinal strangülasyon, invajinasyon gibi mekanik vasküler nedenler veya bağırsağın venöz dönüşünde tıkanıklık gibi çok çeşitli nedenlerle bağırsaklarda iskemik hasar görülür.[5,6] Dokunun yaşaması için iskemiyi takiben reperfüzyon zorunludur. Ancak reperfüzyon hasarının tek başına iskeminin neden olduğu doku hasarından daha fazla hasar yaptığı gösterilmiştir.[7,8] İR sonucunda endotelin hasarlanması ile birlikte NO biyo yararlanımında bir azalma meydana gelmektedir ve böylece NO süperoksit dengesinde süperoksit lehine bir kayma oluşmaktadır. Aynı zamanda oksijen kaynaklı serbest radikallerde de bir artma meydana gelmektedir.[9] İR sonrasında ilk olarak etkilenen yerlerden biri endotel tabakasıdır. İR sonucu görülen vasküler disfonksiyonun mezenter arterin distal kısımlarında proksimale göre daha fazla olduğu gösterilmiştir.[10] Mezenterik iskemilerin mortalite ve morbidite oranlarının günümüz tıbbındaki gelişmelere rağmen hala azaltılamamış olması ve klinik tedavisindeki zorluklar bizi bu konu hakkında araştırma yapmaya yöneltti. Bu amaçla sıçanlarda deneysel bir mezenterik İR modeli oluşturarak ligustrazin’in İR hasarına etkileri incelendi. Araştırmamızın temelini ligustrazin’in yapılan çalışmalarda hipoksik dokularda PGI2 düzeyini artırarak ve TxA2 seviyesini azaltarak vazodilatasyona neden olduğu İR hasarında oksidatif stres, nötrofil infiltrasyonu ve apopitozisi azalttığı ve damar endotelini de içeren birçok dokuda NO sentezini artırıcı etkisinin İR hasarını önleyebileceği hipotezini oluşturdu.[2,3] NO’nun İR hasarına etkileri birçok araştırmada yararlı, bazılarında ise zararlı olarak rapor edilmiştir.[11,12] İskemi süresi belirlenirken bunun belirgin hasar oluşturacak kadar uzun, fakat tam kat ve geri dönüşsüz nekroz oluşturmayacak kadar kısa olmasına özen gösterildi. Çünkü tam kat nekroz gelişen durumlarda cerrahi rezeksiyon dışındaki tedavilerin anlamsız olduğu bilinmektedir. Bu ölçütlere en uygun iskemi süresinin 45 dk olduğu düşünüldü. Aynı süreyle iskemi literatürdeki diğer çalışmalarda da uygulanmıştır.[1,13] Reperfüzyon süresi belirlenirken de uygulanan deneysel maddelerin etkilerinin görüleceği kadar uzun, rejenerasyon çalışmalarında geçen iyileşme sürecinin deneysel maddelerin etkilerini mas166

kelemeyecek kadar kısa olmasına özen gösterildi. Bu ölçütlere en uygun reperfüzyon süresinin 60 dk olduğu düşünüldü. Aynı süreyle reperfüzyon literatürdeki diğer çalışmalarda da uygulanmıştır.[13] Serbest oksijen radikallerinin en zararlı etkisi lipit peroksidasyonudur. Hücre membranları, poliansatüre yağ asitleri ve fosfolipitlerden oluşmaktadır.[14] Serbest oksijen radikalleri (SOR) yapısal ve fonksiyonel hücre hasarı ile sonuçlanan lipit peroksidasyonunu artırarak hücre ölümüne neden olur. Lipit peroksidasyonu, lipit molekülünde iki doymamış bağ arasında bulunan bir metilen grubundan H atomunun uzaklaştırılması ile başlayan kompleks bir süreçtir. Bu olay sonucunda, oksijen varlığında lipit peroksitleri veya hidroksiperoksitleri oluşturan karbon merkezli lipit serbest oksijen radikali meydana gelir. Bu karbon kökenli lipit radikallerin daha da bozulması ile rölatif olarak daha stabil olan son ürün, MDA oluşur. MDA, lipit peroksidasyonu göstergesi olarak kullanılabilir.[15] Birçok çalışmada İR hasarında SOR’nin etkilerini değerlendirmek amacıyla serum veya doku MDA düzeyleri incelenmiştir. Doku MDA düzeyi ölçümleri, serum MDA ölçümlerinden farklı olarak sadece İR hasarından etkilenen dokuyu ilgilendirdiği için literatürde MDA düzeyi sıklıkla doku düzeyinde incelenmiştir. Literatür incelendiğinde intestinal iskemi reperfüzyon çalışmalarında Okhawa ve ark.nın tarif ettiği doku MDA ölçüm yöntemini sıklıkla kullanılmıştır.[16-18] Çalışmamızda ince bağırsak MDA düzeyleri incelenmiştir. Doku MDA düzeyleri Okhawa ve ark.nın tarif ettiği spektrofotometrik yöntemle ölçülerek, nmol/mg protein olarak ifade edilmiştir.[19] Deney sonucunda elde edilen doku MDA düzeyleri incelendiğinde gruplar arasında anlamlı istatistiksel fark tespit edilmiştir (p<0.05). Sham grubunun (Grup S) MDA değerlerinin diğer tüm gruplardan anlamlı olarak daha düşük olması; doku MDA düzeylerinin İR hasarı ile birlikte yükseldiğini ve lipit peroksidasyonu için önemli bir ölçüt olduğunu göstermiştir. Çalışmamızın bu bulguları, literatürde doku MDA düzeylerinin incelendiği diğer çalışmalarla uyumludur.[17-22] Ligustrazinin miyokardiyal iskemi reperfüzyon hasarı üzerinde olumlu etkileri mevcuttur.[23] Ayrıca oksidatif stresin olumsuz etkilerini önleyerek ateroskleroz oluşumunda ve tedavisinde etkili olduğunu gösteren çalışmalar mevcuttur.[24] Bizim çalışmamızda ligustrazin uygulanan sıçanlarda doku MDA düzeylerinin uygulanmayan gruba göre anlamlı olarak azaldığı görüldü. Doku NO düzeylerinin anlamlı olarak azaldığı saptandı. Doku SOD düzeyinin Grup S’deki değere yakın olduğu görüldü. Grup MI-L’de jejunumda İR hasarının histopatolojik göstergesi olan Chiu sınıflaması skorlarının anlamlı olarak azaldığı, jejunum ve ileumda gelişen İR hasarının ligustrazin verildiğinde azaldığı tespit edildi. Sonuç olarak, ligustrazin’in mezenterik İR’de hem biyokimyasal parametrelerde lipit peroksidasyonunu düzeltmekte, hem de histopatolojik skorlamada jejunum ve ileumdaki İR hasarının şiddetini azaltmaktadır. Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

Polat ve ark. Sıçanlarda oluşturulan ince bağırsak iskemi reperfüzyon hasarında ligustrazin’in etkisi

Teşekkür Çalışamanın istatistiksel değerlendirmesindeki katkılarından dolayı Dr. Canan BAYDEMİR’e, biyokimyasal çalışmalardaki yardımlarından dolayı Dr. Mine İNAL ve Eda ÖZÇELİK’e teşekkür ederiz. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. Badak B, Turk O, Caga T, Burukoglu D. The protective effect of milrinone on ischemia/reperfusion injury on superior mesenteric artery ligated rats. Journal of Surgical Arts 2014;7:1-6. 2. Feng J, Liu R, Wu G, Tang S. Effects of tetramethylpyrazine on the release of PGI2 and TXA2 in the hypoxic isolated rat heart. Mol Cell Biochem 1997;167:153-8. 3. Feng L, Ke N, Cheng F, Guo Y, Li S, Li Q, et al. The protective mechanism of ligustrazine against renal ischemia/reperfusion injury. J Surg Res 2011;166:298-305. 4. Chiu CJ, McArdle AH, Brown R, Scott HJ, Gurd FN. Intestinal mucosal lesion in low-flow states. I. A morphological, hemodynamic, and metabolic reappraisal. Arch Surg 1970;101:478-83. 5. Talbot W. Ischaemia and infarction. General pathology. 7th ed., Pearson Professional Limited; 1996. p. 709-22. 6. Brand JL, Boley JS. İschemic and vascular lesions of the bowel. Gastrointestinal Diseas; 1993. p. 1927-31. 7. Grace PA. Ischaemia-reperfusion injury. Br J Surg 1994;81:637-47. 8. Aktan S, Aykut C, Yegen BC, Ozkutlu U, Okar I, Ercan S. Prostaglandin E2 and leukotriene C4 levels following different reperfusion periods in rat brain correlated with morphological changes. Prostaglandins Leukot Essent Fatty Acids 1992;46:287-90. 9. Tsao PS, Aoki N, Lefer DJ, Johnson G 3rd, Lefer AM. Time course of endothelial dysfunction and myocardial injury during myocardial ischemia and reperfusion in the cat. Circulation 1990;82:1402-12. 10. Lefer AM, Ma XL. Endothelial dysfunction in thesplanchnic circulation following ischemia and reperfusion. Journal of Cardiovascular Pharmacology 1991;17:186-90.

11. Oztürk H, Kara IH, Otçu S, Kilinc N, Yagmur Y. Influence of L-NAME and L-Arg on ischaemia-reperfusion induced gastric mucosa damage. Acta Gastroenterol Belg 2002;65:150-4. 12. Wu B, Iwakiri R, Tsunada S, Utsumi H, Kojima M, Fujise T, et al. iNOS enhances rat intestinal apoptosis after ischemia-reperfusion. Free Radic Biol Med 2002;33:649-58. 13. Itoh H, Yagi M, Hasebe K, Fushida S, Tani T, Hashimoto T, et al. Regeneration of small intestinal mucosa after acute ischemia-reperfusion injury. Dig Dis Sci 2002;47:2704-10. 14. Kellogg EW 3rd, Fridovich I. Superoxide, hydrogen peroxide, and singlet oxygen in lipid peroxidation by a xanthine oxidase system. J Biol Chem 1975;250:8812-7. 15. Slater TF. Free-radical mechanisms in tissue injury. Biochem J 1984;222:1-15. 16. Baykal A, Kaynaroğlu V, Demirpençe E, Kilinç K, Sayek I, Sanaç Y. Experimental study of the effect of adrenaline tolerance on intestinal ischaemia-reperfusion. Br J Surg 1998;85:947-50. 17. Oztürk C, Avlan D, Cinel I, Cinel L, Unlü A, Camdeviren H, et al. Selenium pretreatment prevents bacterial translocation in rat intestinal ischemia/reperfusion model. Pharmacol Res 2002;46:171-5. 18. Weiss SJ, LoBuglio AF. Phagocyte-generated oxygen metabolites and cellular injury. Lab Invest 1982;47:5-18. 19. Ohkawa H, Ohishi N, Yagi K. Assay for lipid peroxides in animal tissues by thiobarbituric acid reaction. Anal Biochem 1979;95:351-8. 20. Vaughan WG, Horton JW, Walker PB. Allopurinol prevents intestinal permeability changes after ischemia-reperfusion injury. J Pediatr Surg 1992;27:968-73. 21. Topaloglu U, Güran M, Odabası M, Karadag N, Senel G, Kabasakal L, et al. The effects of prostaglandin E2 on ischemia-reperfusion damage, resulting from mesenter arterial ischemia in small intestines. Ulus Travma Acil Cerrahi Derg 1997;3:258-64. 22. Onal A, Astarcioğlu H, Ormen M, Atila K, Sarioğlu S. The beneficial effect of L-carnitine in rat renal ischemia-reperfusion injury. Ulus Travma Acil Cerrahi Derg 2004;10:160-7. 23. De-yi P, and Ke-mei S. Clinical Analysis of Tanshinone A Sulfonic Acid Sodium, Ligustrazine and Western Medicine Combined Therapy of Myocardial Ischemia Patients. Guide of China Medicine 2013;10:334. 24. Huang GD, Jian M, ZW Ji. Anti-oxidative Effect of Ligustrazine on Treatment and Prevention of Atherosclerosis. Tropical Journal of Pharmaceutical Research 2014;12:949-57.

EXPERIMENTAL STUDY - ABSTRACT OLGU SUNUMU

The effect of ligustrazin in intestinal ischemia reperfusion injury generated on rats Hasan Polat, M.D.,1 Özgür Türk, M.D.,2 Bekir Yaşar, M.D.,3 Onur Uysal, M.D.4 Department of General Surgery, Bingol Karliova State Hospital, Bingol Department of General Surgery, Sivrihisar State Hospital, Eskişehir 3 Department of General Surgery, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir 4 Department of Histology, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir 1 2

BACKGROUND: Intestinal ischemia is a serious and common clinical status. It develops as result of superior mesenteric artery (SMA) obstruction caused by many etiologic factors. Sepsis and multiple organ failure could develop following intestinal ischemia. The present study aimed to investigate the effects of ligustrazin, which has a vasodilator impact on intestinal ischemia. METHODS: Forty male Wistar rats were divided into three groups randomly. Sham operation was performed on Group S (n=7); mesenteric ischemia and then 60 minutes reperfusion of the intestine process was performed on Group MI (n=7); mesenteric ischemia and then 60 minutes reperfusion of the intestine process was performed and 80 mg/kg ligustrazin was administrated intraperitoneally on Group MI+L (n=7). Intestinal tissue samples were taken for tissue MDA, SDO and nitric oxide (NO) levels, and ileum and jejunum samples were taken for histopathologic examination. RESULTS: Tissue MDA levels and tissue NO levels of Group MI-L was determined to have significantly decreased. Tissue SOD levels were found similar to Group S. Chiu classification score of the jejunum and ileum was determined to have decreased in Group MI-L compared to Group MI. DISCUSSION: As a result of this study, Ligustrazin was found to adjust lipid peroxidation in biochemical parameters during mesenteric I-R and decrease the severity of damage of I-R on the histopathological scores of the jejunum and ileum. Key words: Intestine; ischemia reperfusion; ligustrazin; nitric oxide. Ulus Travma Acil Cerrahi Derg 2015;21(3):163-167

doi: 10.5505/tjtes.2015.55212

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ORIGIN A L A RT I C L E

Comparison of early surgical alternatives in the management of open abdomen: a randomized controlled study Ahmet Rencüzoğulları, M.D.,1 Kubilay Dalcı, M.D.,1 İsmail Cem Eray, M.D.,1 Orçun Yalav, M.D.,1 Alexis Kofi Okoh, M.D.,2 Tolga Akcam, M.D.,1 Abdullah Ülkü, M.D.,1 Gürhan Sakman, M.D.,1 Cam P. Parsak, M.D.1 1

Department of General Surgery, Çukurova University Faculty of Medicine, Adana

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

ABSTRACT BACKGROUND: Abdominal compartment syndrome (ACS) is a clinical syndrome characterized by progressive intraabdominal organ dysfunction resulting from an acute increase in intra-abdominal pressure (IAP). In the absence of prompt treatment, ACS can lead to lethal organ failure. Treatment of ACS is achieved by immediate decompression of the abdominal cavity. As to how and when decompression laparotomy should be performed depends on the clinical condition of the patients. There is limited data regarding outcomes of abdominal closure techiques. The present study aimed to investigate two different temporary closure methods, the vacuum assisted closure (VAC) and Bogota bag techniques, in 40 patients who underwent decompressive laparotomy as part of the management of ACS. METHODS: The study included 40 patients who developed ACS during follow-up or following trauma and abdominal surgery. As part of the treatment for ACS, these patients underwent decompressive laparotomy at the Cukurova University Medical Faculty, General Surgery Department and followed up in the Intensive Care Unit of the same hospital. VAC and Bogota bag procedures were performed as temporary closure methods for the treatment of ACS. Patients were randomly assigned to each of the two groups according to the temporary closure method performed. Clinical, laboratory, mortality and morbidity results of the patients in both groups were compared. RESULTS: Demographic features of the patients (age, sex, body mass index, co-morbidities) were similar between the two groups. The most common reason of ACS was gastrointestinal perforation in 12 (30%) patients. Decrease in incision width was significantly faster in the VAC group than in the Bogota group. Primary closure of fascia was considered appropriate in 16.9 days in the VAC group and 20.5 days in the Bogota bag group. The decrease in abdominal pressure was similar between the two groups on days 1, 4 and 7 but appeared to be significantly lower on day 14 in the VAC group. 12 patients (30%) died during the study. Among the deceased patients, 5 (12%) were in the VAC group, whereas, 7 (17.5%) belonged to the Bogota bag group. CONCLUSION: Based on these results, it is suggested that VAC has advantages when compared to the Bogota bag as a temporary closure method in the management of abdominal compartment syndrome. Key words: Abdominal compartment syndrome; Bogota bag; intraabdominal hypertension; vacuum assisted closure.

INTRODUCTION Abdominal compartment syndrome (ACS) is a clinical synAddress for correspondence: Ahmet Rencüzoğulları, M.D. Balcalı Hastanesi, Sarıçam, 01330 Adana, Turkey Tel: +90 322 - 338 60 60 E-mail: rncz1980@gmail.com Qucik Response Code

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drome that occurs secondary to an acute increase in intraabdominal pressure (IAP) resulting in malfunctioning of respiratory, renal or cardiovascular organs.[1,2] Major abdominal trauma, disseminated intra-abdominal infections and complicated or prolonged surgeries are among some of the clinical causes of ACS. Laparostomy, often called as open abdomen, and temporary abdominal closure are life saving interventions in ACS, trauma and abdominal sepsis.[3-8] Protein deficiency, hypothermia, massive fluid loss due to abdominal wall deficiency and contamination with exogenous bacteria are known to complicate the medical management of ACS.[8,9] The main objective of open wound treatment is to save the integrity of the Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

Rencüzoğulları et al. Comparison of early surgical alternatives in the management of open abdomen: a randomized controlled study

abdominal wall, banish the exudate, reduce fluid loss to the third spaces, control the infection and to avoid fistula formation.[9,10] The optimum temporary closure technique should, therefore, provide these main goals without traumatizing intestinal organs. Different choices of temporary abdominal closure with considerable advantages and disadvantages currently exist; however, a consensus on which technique should be the treatment of choice hasn’t been reached yet. To the best of our knowledge, a prospective study comparing the advantages and disadvantages of different techniques is lacking in the current literature. In the current prospective randomized study, the results of two different temporary abdominal closure techniques, the vacuum assisted closure (VAC) and Bogota bag were compared.

MATERIALS AND METHODS Between February 2007 and September 2010, forty patients, who developed ACS during follow-up or following trauma and abdominal surgery, underwent decompressive laparotomy as part of the treatment for ACS in the General Surgery Department of the Çukurova University Medical Faculty. Patients with grade III (21-25 mmHg) and IV (>25 mmHg) IAP according to the World Society of Abdominal Compartment Syndrome (WSACS) grading system, patients who were under follow up in the surgical intensive care unit, and those who developed ACS as a result of progressively increasing IAP were included into the study. Patients with American Society of Anesthesologists score 5 exculed from the study.

ments. Intraabdominal pressure was measured by using the bladder pressure measurement technique which was first described by Kron et al. and later confirmed by Obeid et al. With the patient in 180° supine position, a drainage tube connected to the Foley catheter was clamped. 25 ml of saline was instilled into the bladder via the aspiration port using an 18-gauge needle. The needle was attached to a three-way stopcock and water manometer. After saline injection, a wait time of 60 seconds was allowed for decontraction of the detrusor muscle. The zero mark of the manometer was placed at the level of the pubic symphysis, and the pressure was read at the meniscus at the end of expirium. Since mechanical ventilation can act as a predisposing factor for elevated IAP, especially in scenarios where positive end respiratory pressure is applied, ventilation was ceased in patients on mechanical ventilation during IAP measurements to avoid false results. Vecuronium bromide (0.1 mg/kg) in intermittent dosing schedule was used for adequate muscular relaxation for two reasons: to eliminate spontaneous breathing and to decrease oxygen consumption. IAP results, patient characteristics, co-morbidities and mortalities were recorded. VAC system consisted of a polyure-

Forty patients were prospectively randomized either into a VAC and Bogota group in which the open abdomen was managed with vacuum assisted closure or Bogota bag procedures. The study group consisted of twenty-three males and seventeen females. The median age of the patients was 50.9 years. Clinical, laboratory, mortality and morbidity results of the patients in both groups were recorded and prospectively analyzed. Local ethical Committee approval for the study was received from Çukurova University, Medical Faculty. In order to prevent the development or deterioration of ACS, daily monitorization of IAP was carried out in patients with abdominal and pelvic trauma, head trauma with associated increased intracranial pressure, respiratory insufficiency requiring high pressure ventilation, complicated abdominal surgeries and those with major trauma requiring greater volumes of fluid resuscitation. So as to decrease the risk of developing ACS, fluid administration was limited in patients, and colloids were used under certain circumstances. Nasogastric and rectal drainage were employed as intraabdominal pressure reducing measures in patients with bowel distention. All patients were placed in supine position to eliminate the effect of patient positioning on IAP measureUlus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

Figure 1. Vacuum assisted closure in a patient.

Figure 2. Bogota bag application in a patient.

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Rencüzoğulları et al. Comparison of early surgical alternatives in the management of open abdomen: a randomized controlled study

Table 1. Patient demographics

Vacuum assisted closure %

Bogata bag

Mean±SD

Male

11 55.0

12 60.0

Female

9 45.0

8 40.0 0.749

p Median (Min.-Max.)

Age

52.3±15.9

50.1±18.0

49.5 (24.0-81.0)

0.678

Body mass index

27.5±5.3

27.1±5.0

27.4 (18.7-41.0)

0.784

thane sponge that was placed on the abdominal cavity with an 18-French sized vacuum tube. It was covered with a second layer of occlusive sterile coat. The system was settled after the vacuum tube was connected to a portable pump. The sterile coat was changed every 72 hours (Fig. 1). The Bogota Bag technique was performed by fixing a sterile plastic bag onto the skin of abdomen (Fig. 2). The primary end points measured were pre and postoperative IAPs, width of incision, duration of wound healing, time of abdomen closure and discharge, mortalities and complications.

most common etiology in ACS patients was gastrointestinal perforation that occurred in twelve (30%) patients. Other etiological factors are shown in Table 2. The mean time between admission of the patients and laparostomy was 3.9±3.2 h in the VAC group and 5.7±4.9 h in the Bogota bag group (p>0.05). Measurements of skin-to-skin width of incision were made; however, the results did not differ significantly between groups on day 1 (VAC: 13.8±3.2 cm, Bag 15.0±3.8, p=0.289), but the width in the VAC group was reduced significantly on days 4 and 7 (Table 3, Fig. 3).

Statistical Analysis

Mean IAP was 21.1±4.3 mmHg before laparostomy in the VAC group and 21.6±4.1 mmHg in the Bogota bag group (p>0.05). Mean IAP on day 1, 4, 7 and 14 was 7.6±2.9 mm-hg, 6.3±2.7 mm-hg, 5.2±2.9 mmHg, and 3.5±1.6 mmHg in the VAC group,

Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS version 17). Continuous variables were checked for normality by using the Kolmogorov Smirnov, Shapiro-Wilk tests and histograms. Comparisons between groups were made using the Student’s t-test for normally distributed data. The Mann-Whitney U-test was used for data that were not normally distributed. Pre and post operative days were analyzed using the Reorat measure Analysis-Greenhouse-Geisser Test. Statistical significance was accepted for p values less than 0.05.

RESULTS Forty patients with grade III and IV IAP and abdominal compartment syndrome were included into the study. Demographic characteristic of the patients are given in Table 1. The

Table 2. Etiology of abdominal compartment syndrome Primer etiology

Gastrointestinal perforation

30.0

Pancreatitis

9 22.5

Ileus

3 7.5

Major Trauma

Malignancy

9 2.5

Total

40 100.0

16 Intra-abdominal pressure

Incision width (cm)

15 14 13 12

Group

11 10 1. Day

VAC BAG 4. Day

7. Day

Figure 3. The reduction of the incision width by time in groups.

170

17.5

Group VAC

BAG 1. Day

4. Day

7. Day

14. Day

Figure 4. Postoperative intra-abdominal pressure changes in groups.

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Table 3. Skin to skin width of incisions on different days

Vacuum assisted closure

Bogata bag

Mean±SD Median (Min.-Max.) Mean±SD Median (Min.-Max.)

Day 01

13.8±3.2

13.0 (9.0-23.0)

15.0±3.8

15.5 (7.0-25.0)

0.289

Day 04

11.9±2.7

11.5 (8.0-2.0)

14.3±3.8

15.0 (5.0-24.0)

0.029

Day 07

10.5±2.4

10.0 (7.0-18.0)

13.9±3.8

14.5 (5.0-24.0)

0.002

0.0001

Table 4. IAP on different days

Vacuum assisted closure

Bogata bag

Mean±SD Median (Min.-Max.) Mean±SD Median (Min.-Max.)

Day 01

7.6±2.9

7.0 (4.0-16.0)

8.4±3.4

8.0 (3.0-15.0)

0.460

Day 04

6.3±2.7

6.0 (2.0-15.0)

6.3±3.4

6.5 (2.0-13.0)

0.959

Day 07

5.2±2.9

4.0 (2.0-13.0)

5.6±2.9

5.0 (1.0-11.0)

0.705

Day 14

3.5±1.6

3.0 (1.0-8.0)

5.1±2.5

4.5 (0.0-10.0)

0.026

0.160

p: Mann Whitney Test; p*: Repeated Measures Analyses –Greenhouse-Geisser test.

Table 5. Complications seen in both groups Complication

Vacuum assisted closure

Bogata bag

Acute renal failure

22.5

Sepsis

4 6 15.0

Pneumonia

3 6 15.0

Myocardial infarction

–

Fistula

1 3 7.5

Pulmonary emboli

–

1 1

2.5 2.5

Absent 14 35.0 Total 40 100.0

respectively. In the Bogota group, mean IAPs were 8.4±3.4 mmHg, 6.3±3.4 mmHg, 5.6±2.9 mmHg, and 5.1±2.5 mmHg, respectively (Table 4). Mean values were not significantly different on days 1, 4, and 7, but on day 14, the IAP was significantly lower in the VAC group (Table 4, Fig. 4). Mean time for wound closure was 16.9±3.2 days in the VAC group and 20.5±9.9 days in the Bogota bag group (p=0.003). Mean intensive care unit stay was similar in both groups (VAC: 33.9±15.2 days; Bogota bag: 31.3±20.0 days; p=0.640). Mean time for patient discharge was similar in both groups (28.5±21.3 days in the VAC group; 27.4±25.3 days in the Bogota bag group). During clinical follow up, complications were observed in Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

eleven patients (55%) from the VAC group and in fifteen (75%) patients in the Bogota bag group (p>0.05). The most common complication was acute renal failure, which was seen in nine patients. Other developing complications and their distribution among the groups are shown in Table 5. There were no statistically significant relationships between complications seen in both groups. There were no complications in fourteen patients. Five patients died in the VAC group and seven patients died in the Bogota Bag group, but the difference was not statistically significant.

DISCUSSION Temporary abdomen closure in the management of open abdomen is not standardized and depends solely on the discretion and experience of the attending surgeon. However, in 171

RencĂźzoÄ&#x;ullarÄą et al. Comparison of early surgical alternatives in the management of open abdomen: a randomized controlled study

patients who develop ACS with grade III and IV IAP, the need for temporary abdomen closure as part of the management of open abdomen is clear. In the current, prospective, randomized study, the results of two different temporary abdominal closure techniques, VAC and Bogota bag in ACS patients were compared and it was found that the width of incision decreased significantly faster in the VAC group. Moreover, IAP was significantly lower on day 14 in the VAC group with faster wound closure and no increase in complication and mortality. The most common reason for high intra-abdominal pressure is the increase in the intraperitoneal fluid volume. Pancreatitis, blood loss, edema and secondary increase in the retroperitoneal volume can cause ACS.[11-13] Meldrum et al. have reported that ACS occurred in twenty-one of one hundred and fortyfive patients (14%) with serious abdominal trauma[14] and that the most common cause was intra-abdominal bleeding due to liver injury in 57% of the cases. Morris et al. have observed one hundred and seven patients with serious abdominal trauma and declared that ACS occurred in sixteen (15%) patients. In the present study including forty patients, the most common reason for ACS was gastrointestinal perforation in twelve patients. Trauma was the etiology in seven patients.[15] Measurement of bladder pressure which was first described by Kron et al.[16] and confirmed by Obeid et al.[17] has been shown to be the most reliable method of measuring IAP. In their study, they have measured the IAP directly via an intraperitoneal catheter from the bladder, stomach or rectum. They have also compared the changes in position and concluded that the IAP results measured from the bladder are the most reliable and that the other three ways are not reliable when the positions changed. Our study adopted the bladder catheter method as described above for the measurements of IAP. ACS is becoming a more common problem in modern trauma centers.[18,19] Temporary abdominal closure techniques are used in the management of this situation, but some authors have suggested utilization of different techniques. To date, a consensus on which treatment method should be used has not been reached yet,[20-23] and to the best of our knowledge this is the first prospective, randomized study comparing the results of these techniques. The optimum temporary closure technique should prevent intestinal adhesion, protect the skin and allow a close observation of the abdominal cavity.[22-25] The main advantages of the Bogota bag are that it is cheap, easily performed and replaceable. In addition, the volume loss can be reduced to minimum, and muscular necrosis can be avoided, infection can be drained and inspection is easily done.[26,27] Current VAC systems have advantages like reduced escape, easy manipulation and control of the fistula. In most series, VAC allows 172

primary abdominal closure without causing ventral hernia.[28] It is also skin protective. However, the major disadvantage of the VAC technique is its high cost. The most common complications in patients treated with VAC are fistula and abdominal compartment syndrome.[29-31] In our study, none of the patients in both groups had reoccurred ACS; however the most common complication was acute renal failure. Fistula developed in two (5%) patients in the VAC group and in one (2.5%) patient in the bag group. Batacchi et al. have compared abdominal closure time using the VAC and Bogota bag techniques and reported that abdominal closure could be achieved earlier in the VAC group. [32] Similarly, the present study revealed a significantly earlier abdominal closure time in the VAC group. Recently, a study by Long and colleagues has evaluated the utility of concomitant therapies for open abdomen by comparing the VAC used in combination with the abdominal re-approximation abdominal wall anchor closure (ABRA) system for closure of open abdomen. Primary closure rates between the groups were not statistically significant; however, their study reported fewer operating room visits and time use in patients treated with both systems.[33] Despite recent developments in surgery, mortality among patients with ACS still remains high with a reported range between 42% and 71%,[34] which is probably due to co-morbidities. In our study, five patients in the VAC group and seven patients in the bag group died. (12 in total, 30%). Mortality in ACS is still the most important problem in the early period of ACS. Parsak et al. have declared that intra-abdominal hypertension is directly correlated with mortality in ACS, but that it is not the only factor.[35] They have found that mortality is highest during the first three days and suggested that the IAP should be decreased under a cut off level in the first three days. In the present study, the IAP levels were similar in the two groups on days 1, 4, 7 and so were mortality rates. Yet, IAP was significantly lower in the VAC group on day 14, which could be one of the reasons for earlier abdominal closure in this group. This study offers a closer look at the potential benefits VAC may have over the Bogota bag as a temporary closure technique in the management of abdominal compartment syndrome. The need for larger prospective studies comparing current methods for abdominal closure should be addressed especially in this era where multiple options and increasing operative interventions have been developed for the treatment of critically ill patients. Conflict of interest: None declared.

REFERENCES 1. Schein M, Wittmann DH, Aprahamian CC, Condon RE. The abdomi-

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Rencüzoğulları et al. Comparison of early surgical alternatives in the management of open abdomen: a randomized controlled study nal compartment syndrome: the physiological and clinical consequences of elevated intra-abdominal pressure. J Am Coll Surg 1995;180:745-53. 2. Nathens AB, Boulanger BR. The abdominal compartment syndrome. Curr Opin Crit Care 1998;4:116-20. 3. Iberti TJ, Kelly KM, Gentili DR, Hirsch S, Benjamin E. A simple technique to accurately determine intra-abdominal pressure. Crit Care Med. 1987;15:1140-2. 4. Eddy V, Nunn C, Morris JA Jr. Abdominal compartment syndrome. The Nashville experience. Surg Clin North Am 1997;77:801-12. 5. Mayberry JC, Mullins RJ, Crass RA, Trunkey DD. Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure. Arch Surg 1997;132:957-62. 6. Boffard K. Abdominal trauma. In: Patterson- Brown S, editor. Core topics in general and emergency surgery, 2nd edn. Edinburgh: Saunders 2001;305-52. 7. Malbrain ML. Is it wise not to think about intraabdominal hypertension in the ICU? Curr Opin Crit Care 2004;10:132-45. 8. Brooks A, Mahoney P, Schwab CW. Critical care of the trauma patient. In: Brooks A, Girling K, RileyB, RowlandsB, editors. Critical care for postgraduate trainees. London: Hodder Arnold 2005;119-20. 9. Schecter WP, Ivatury RR, Rotondo MF, Hirshberg A. Open abdomen after trauma and abdominal sepsis: a strategy for management. J Am Coll Surg 2006;203:390-6. 10. Deenichin GP. Abdominal compartment syndrome. Surg Today 2008;38:5-19. 11. Schein M, Wittman DH, The abdominal comparment syndrome following peritonitis, abdominal trauma and operations. Complications in Surgery 1996;15:1-10. 12. Hamzaoğlu İ, Erdoğan K, Yiğitbaşı R, Abdominal kompartman sendromu. Aktüel Tıp Dergisi 1999;4:259-62. 13. Saggi BH, Sugerman HJ, Ivatury RR, Bloomfield GL. Abdominal compartment syndrome. J Trauma 1998;45:597-609. 14. Meldrum DR, Moore FA, Moore EE, Franciose RJ, Sauaia A, Burch JM. Prospective characterization and selective management of the abdominal compartment syndrome. Am J Surg 1997;174:667-73. 15. Morris JA Jr, Eddy VA, Blinman TA, Rutherford EJ, Sharp KW. The staged celiotomy for trauma. Issues in unpacking and reconstruction. Ann Surg 1993;217:576-86. 16. Kron IL, Harman PK, Nolan SP. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg 1984;199:28-30. 17. Obeid F, Saba A, Fath J, Guslits B, Chung R, Sorensen V, et al. Increases in intra-abdominal pressure affect pulmonary compliance. Arch Surg 1995;130:544-8. 18. Losanoff JE, Richman BW, Jones JW. Temporary abdominal coverage and reclosure of the open abdomen: frequently asked questions. J Am Coll Surg 2002;195:105-15. 19. Vertrees A, Kellicut D, Ottman S, Peoples G, Shriver C. Early definitive abdominal closure using serial closure technique on injured soldiers

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returning from Afghanistan and Iraq. J Am Coll Surg 2006;202:76272. 20. Navsaria PH, Bunting M, Omoshoro-Jones J, Nicol AJ, Kahn D. Temporary closure of open abdominal wounds by the modified sandwichvacuum pack technique. Br J Surg 2003;90:718-22. 21. Howdieshell TR, Proctor CD, Sternberg E, Cué JI, Mondy JS, Hawkins ML. Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen. Am J Surg 2004;188:301-6. 22. Rutherford EJ, Skeete DA, Brasel KJ. Management of the patient with an open abdomen: techniques in temporary and definitive closure. Curr Probl Surg 2004;41:815-76. 23. Hutchins RR, Gunning MP, Lucas DN, Allen-Mersh TG, Soni NC. Relaparotomy for suspected intraperitoneal sepsis after abdominal surgery. World J Surg 2004;28:137-41. 24. Labler L, Zwingmann J, Mayer D, Stocker R, Trentz O, Keel M. V.A.C.İ abdominal dressing system. Eur J Traum 2005;31:488-94. 25. Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Richart CL, Burns RP. Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients. J Trauma 2000;48:201-7. 26. Townsend C, Beauchamp RD, Evers M. Sabiston textbook of surgery. 17th ed; Philadelphia, PA: Elsevier Saunders 2004. 27. Stonerock CE, Bynoe RP, Yost MJ, Nottingham JM. Use of a vacuumassisted device to facilitate abdominal closure. Am Surg 2003;69:1030-5. 28. Fansler RF, Taheri P, Cullinane C, Sabates B, Flint LM. Polypropylene mesh closure of the complicated abdominal wound. Am J Surg 1995;170:15-8. 29. Benninger E, Labler L, Seifert B, Trentz O, Menger MD, Meier C. In vitro comparison of intra-abdominal hypertension development after different temporary abdominal closure techniques. J Surg Res 2008;144:102-6. 30. Collicott PE, Hughes I. Training in advanced trauma life support. JAMA 1980;243:1156-9 31. Rutherford EJ, Skeete DA, Brasel KJ. Management of the patient with an open abdomen: techniques in temporary and definitive closure. Curr Probl Surg 2004;41:815-76. 32. Batacchi S, Matano S, Nella A, Zagli G, Bonizzoli M, Pasquini A, et al. Vacuum-assisted closure device enhances recovery of critically ill patients following emergency surgical procedures. Crit Care 2009;13:R194. 33. Long KL, Hamilton DA, Davenport DL, Bernard AC, Kearney PA, Chang PK. A prospective, controlled evaluation of the abdominal reapproximation anchor abdominal wall closure system in combination with VAC therapy compared with VAC alone in the management of an open abdomen. Am Surg 2014;80:567-71. 34. Lacey SR, Bruce J, Brooks SP, Griswald J, Ferguson W, Allen JE, et al. The relative merits of various methods of indirect measurement of intraabdominal pressure as a guide to closure of abdominal wall defects. J Pediatr Surg 1987;22:1207-11. 35. Parsak CK, Seydaoglu G, Sakman G, Acarturk TO, Karakoc E, Hanta I, et al. Abdominal compartment syndrome: current problems and new strategies. World J Surg 2008;32:13-9.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Open abdomen yönetiminde erken dönem cerrahi alternatiflerin karşılaştırılması: Randomize ileriye yönelik çalışma Dr. Ahmet Rencüzoğulları,1 Dr. Kubilay Dalcı,1 Dr. İsmail Cem Eray,1 Dr. Orçun Yalav,1 Dr. Alexis Kofi Okoh,2 Dr. Tolga Akçam,1 Dr. Abdullah Ülkü,1 Dr. Gürhan Sakman,1 Dr. Cam P. Parsak1 1 2

Çukurova Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Adana Ankara Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Ankara

AMAÇ: Abdominal kompartman sendromu (AKS), sınırlı bir anatomik alana sahip karında basıncın akut ve patolojik artışı ile karakterize olup, tedavi edilmediği takdirde yüksek oranda mortaliteyle sonuçlananan klinik bir durumdur. Karıniçi basıncın progresif yükselmesi sonucu ortaya çıkan bu sendromun etkileri sistemik olarak ortaya çıkar. Abdominal kompartman sendromunun tedavisi, artmış karıniçi basıncın düşürülmesidir. Dekompresif laparotomi kararını vermede en önemli kriter hastanın klinik tablosudur. Grade 3 ve 4 hastalarda dekompresif laparatomiyi takiben ameliyat sonrası karıniçi basıncın tekrar yükselmesini engellemek için karın kapatılmaz, açık abdomen uygulanır. Bu çalışmada, dekompresif laparotomi uygulanmış evre 3 ve 4 AKS’li hastalara geçici karın kapatılmasında kullanılan Vacuum-assisted closure (VAC) ve Bogota bag yöntemlerinin randomize ileriye yönelik değerlendirilmesi amaçlandı. GEREÇ VE YÖNTEM: Bu çalışmaya Şubat 2007 ile Eylül 2010 tarihleri arasında Çukurova Üniversitesi Tıp Fakültesi Genel Cerrahi Yoğun Bakımı’na travma, geçirilmiş cerrahi sonrası ya da medikal takiplerinin izlemi sırasında AKS gelişmiş ve tedavilerinin bir parçası olarak dekompresif laparotomi uygulanmış 40 hasta alındı. Hastalar ardışık randomizasyon yöntemi ile VAC ve Bogota bag olmak üzere iki gruba ayrıldı. Geçici karın kapama yöntemleri olan bu yöntemlerin sonuçları gruplar arasında randomize ileriye yönelik olarak klinik, laboratuvar, morbidite ve mortalite yönünden karşılaştırılarak değerlendirilldi. BULGULAR: Her iki gruptaki hastaların yaş, cinsiyet, vücut kitle indeksi ve yandaş hastalıkları gibi demografik özellikleri arasında anlamlı fark yoktu. AKS gelişen hastalarda etiyolojik faktörler arasında en sık neden 12 hastada (%30) görülen gastrointestinal sistem perforasyonu idi. İnsizyon boyutu ölçümlerinde VAC grubunda daha anlamlı bir azalma vardı. Hastanın primer fasya kapatılması için uygun hale gelmesi için geçen zaman VAC grubunda 16.9 gün iken, Bogota bag’li grupta 20.5 gün idi. Karıniçi basıncı düşürme değerlendirildiğinde; her iki grupta 1., 4. ve 7. günlerde benzer oranlarda düşme saptanırken, ameliyat sonrası 14. günde VAC grubunda anlamlı olarak daha fazla düşme saptandı. Mortalite gelişen hasta sayısı 12 (%30) iken, beş (%12.5) hasta VAC grubuna, yedi (%17.5) hasta Bogota bag grubuna aitti. TARTIŞMA: Bulgulara dayanarak geçici karın kapama yöntemi olarak VAC uygulamasının daha uygun olduğu kanaatindeyiz. Anahtar sözcükler: Abdominal kompartman sendromu; Bogota bag; karıniçi hipertansiyon; randomize klinik çalışma; Vacuum assisted closure. Ulus Travma Acil Cerrahi Derg 2015;21(3):168-174

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doi: 10.5505/tjtes.2015.09804

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ORIGIN A L A R T IC L E

Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey Bülent Erdur, M.D.,1 Ahmet Ergin, M.D.,2 Aykut Yüksel, M.D.,5 İbrahim Türkçüer, M.D.,1 Cüneyt Ayrık, M.D.,4 Bora Boz, M.D.3 1

Department of Emergency Medicine, Pamukkale University Faculty of Medicine, Denizli

Department of Public Health, Pamukkale University Faculty of Medicine, Denizli

Department of Forensic Medicine, Pamukkale University Faculty of Medicine, Denizli

Department of Emergency Medicine, Mersin University Faculty of Medicine, Denizli

Department of Emergency Service, Göztepe Training and Research Hospital, İstanbul

ABSTRACT BACKGROUND: Violence and burnout are frequently seen among medical doctors; however, the relation is not clear. This study aimed to assess the violence and its possible effects on burnout in physicians working in emergency units. METHODS: This cross-sectional study targeted all physicians working in the emergency units of Pamukkale University Hospital, County and City Hospitals, 112 Emergency Services, and Private Hospitals in Denizli. Data were obtained by means of a self-administered questionnaire that consisted of questions on the demographics of the participants, Turkish version of the Maslach Burnout Inventory, and of the perpetrators of violence. What was also documented on the questionnaire was whether participants had been subjected to or had witnessed any verbal or physical violence during the previous one month of emergency physicians’ certification program. RESULTS: A total of one hundred and seventy-four physicians were included into the study (85% of the targeted group). Many of the participants were between 24 and 59 years of age, with a mean age of 36.8±5.8 years. Married male doctors working in the City Hospital made up the majority. There were significant associations between emotional exhaustion and total violence (p=0.012) and verbal violence (p=0.016); depersonalization and total violence (p=0.021) and verbal violence (p=0.012). CONCLUSION: The results presented here indicated that there was a strong relation between burnout and violence experienced by physicians working in emergency units. Violence in the emergency department has a substantial effect on the physicians’ well-being. Key words: Burnout; emergency department; emergency physician, emergency physician wellness; violence.

INTRODUCTION Burnout in emergency physicians is multi-factorial and has previously been linked to a number of factors related to the working environment. It may result from the progressive loss of the health care workers’ ability to feel emotionally involved in their work. Continuous exposure to critical incidents may Address for correspondence: İbrahim Türkçüer, M.D. Pamukkale Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Denizli, Turkey Tel: +90 258 - 444 07 28 / 6311 E-mail: iturkcuer@pau.edu.tr Qucik Response Code

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be another factor increasing the risk of developing professional burnout. Exposure to violent patients is an aspect of one of the many occupational hazards associated with working in an emergency department (ED), which may induce the development of burnout.[1] Workplace violence is defined as any incident that puts health care workers at risk, which includes verbal abuse, threatening behaviour, or assault by a patient or patient accompanier, and it has currently been an increasing concern in the workplace. [2,3] Violence towards health care workers has been shown to often have short and long-term psychological effects on its victims, including post-traumatic stress disorder even when physical injury is not present.[4,5] Healthcare workers bearing the brunt of violence can evaluate their work with patients in a negative light, which may lead to burnout. Eventually, they may develop cynical attitudes towards the patients, thereby, compromising the quality of care that they provide. 175

Erdur et al. Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey

In the hospital setting, emergency departments are common sites for substantial and significant violence.[6-8] An increased risk of experiencing burnout has previously been linked to a number of factors related to the working environment of the emergency physicians.[1,9-12] Certain environmental factors also appear to affect the risk of violence, and these factors are important variables for burnout.[13-15] The problem of workplace violence and burnout in the EDs has not been well documented, researched, or managed.[16] Additionally, the majority of the studies regarding these issues prior to the current study had been conducted in different populations, including emergency room nurses and other emergency staff. The purpose of this study was to assess the experience of workplace violence and the status of burnout in attending emergency physicians (EP) within the Emergency Medical System in a western Turkish city and detect the relation between these two.

(i) Emotional exhaustion, consisting of nine items measuring reduced energy and job enthusiasm, emotional and cognitive distancing from the job; (ii) Depersonalization, consisting of five items measuring cynicism, lack of engagement and distancing from the patients, treatment of patients as inanimate, unfeeling objects; and (iii) Personal accomplishment, consisting of eight items measuring perception of having an influence on others, working well with others and dealing well with problems.[19]

MATERIALS AND METHODS

Each item consists of a 5-point rating scale ranging from 1 (never) to 5 (every day), and on the basis of the MBI responses, independent subscale scores are calculated for each of the three domains of burnout. High scores on emotional exhaustion or depersonalization subscales indicate burnout as do low scores on the personal accomplishment subscale.

Study Design and Subjects

Data Entry and Analysis

This cross sectional study included all physicians working in the emergency departments in Pamukkale University Hospital, State Hospitals, County Hospitals, Citywide Primary Health Care Centres, 112 Emergency Services, and Private Hospitals in Denizli. One hundred and seventy-four physicians (85% of the targeted group) participated in the study. Denizli is located in the Aegean region of Turkey, which is a relatively developed part of Turkey and the population of the province is close to a million. Most physicians were government employees. The salaries of emergency room doctors in Turkey are low compared to those of the doctors in the Organization for Economic Co-operation and Development countries (OECD).

Data Collection Data were obtained by means of a self-administered questionnaire that consisted of questions on the demographics of the participants, the Turkish version of the Maslach Burnout Inventory (MBI),[17] and the questions about whether participants had been subjected to or had witnessed any verbal or physical violence[18] during the previous month were also included into the questionnaire. Data were collected during an emergency physician certification program. Content validity of the violence questions is supported by the literature. This questionnaire was piloted on a pre-study group of five people, and amendments were made to the document in accordance with this input. MBI is the most widely used standardized measure of burnout, consisting 22 items with each of the three components of burnout (exhaustion, cynicism, professional efficacy) measured on separate likert-type subscales. It has been translated into Turkish and shown to have internal consistency: testretest reliability, convergent validity, and discriminant validity. [17] MBI evaluates three domains of burnout: 176

Data entry and analysis were performed using the SPSS-PC version 17.0 statistical package (SPSS; Cary, NC). Percentages, mean and SD were used as descriptive statistics. Studentâ&#x20AC;&#x2122;s t-test, Chi-square test, and ANOVA were used for bivariate analyses. Linear regression was the method of choice to adjust confounding variables.

RESULTS One hundred and seventy-four doctors were included into the study. Table 1 shows the characteristics of the participants and association of burnout with socio-demographic and work-related factors in the EPs. Many of the participants were between 24 and 59 years of age. Married male doctors working in the State Hospital made up the majority. There were significant differences between the groups in marital status, workplace, hobbies, habits monthly income and work hours in terms of emotional exhaustion (p=0.014, p=0.033, p<0.001, p=0.038, p=0.04 and p=0.006, respectively); in terms of personal accomplishment in the workplace (p<0.001) and in terms of depersonalization in hobbies (p=0.024) (Table 1). There were significant differences between the groups in gender, workplace, hobbies in terms of verbal violence (p=0.008, p=0.05 and p=0.002, respectively) and in terms of total violence (p=0.013, p=0.03 and p=0.002, respectively) (Table 2). There were significant associations between emotional exhaustion and total violence (the sum of verbal and physical violence) (p=0.012) and verbal violence (p=0.016); depersonalization and total violence (the sum of verbal and physical violence) (p=0.021) and verbal violence (p=0.012) experienced by physicians in the last month (Table 3). Table 4 shows the effects of factors on burnout. Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

Erdur et al. Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey

Table 1. Description of the sample and association of burnout with demographic and work-related factors in EPs Emotional exhaustion

n Variables Age (years) <34 35-44 ≥45 Sex Male Female Marital status Married Unmarried Having children Yes No Workplace 112 emergency services State hospital University hospital Other Work type Shift 24-h shift Day or night shift Hobbies Yes No Habits None Cigarette smoke Alcohol Both Working years in Medicine 0-5 6-10 11-15 >16 Years in EM <5 6-10 >11 Predicted future in EM <5 5-10 >10 Monthly income 2-3 3-4 4-5 >5 Work hours (per month) ≤160 >160

Personal accomplishment

Depersonalization

Mean±SD

60 99 15

24.0±5.9 25.0±6.3 23.3±6.1

0.45

30.1±3.4 29.8±3.8 30.6±2.5

0.69

10.6±3.5 11.0±3.5 12.0±2.6

0.4

138 36

24.6±6.0 24.1±6.7

0.69

30.0±3.4 29.9±3.9

0.87

11.0±3.2 10.7±4.1

0.61

139 35

23.9±6.3 26.8±5.1

0.014

30.1±3.7 29.7±2.9

0.53

10.9±3.4 11.0±3.3

0.93

129 45

25.3±5.5 24.2±6.4

0.3

29.9±3.5 30.0±3.6

0.96

10.6±3.3 11.0±3.4

0.51

49 102 15 8

22.6±6.0 25.2±6.1 23.9±6.7 28.2±5.1

0.033

31.3±2.9 29.3±3.6 31.4±3.5 27.7±2.8

0.001

10.7±3.4 11.1± 3.4 9.6±3.2 12.6±3.4

0.19

17 119 38

23.2±5.4 25.0±6.0 23.6±7.0

0.32**

30.1±3.3 29.9±3.1 30.0±4.7

0.99**

10.4±3.6 11.1±3.1 10.7±4.2

0.69**

118 56

23.4±6.2 26.9±5.5

<0.001

30.3±3.4 29.3±3.8

0.085

10.5±3.3 11.8±3.5

0.024

97 46 12 19

23.4±5.6 25.6±6.9 25.0±7.7 27.2±5.1

0.04

30.2±3.4 29.5±3.4 30.3±3.9 29.9±4.6

0.72

10.4±3.2 11.0±3.9 13.0±3.1 12.1±2.8

0.03

20 49 63 42

24.9±5.4 23.5±6.2 25.3±6.8 24.4±5.5

0.51

31.1±3.6 29.4±3.2 30.0±3.7 30.0±3.6

0.38

10.4±2.9 10.4±3.7 11.5±3.7 11.0±2.9

0.37

90 49 35

23.8±6.2 25.5±5.8 25.0±6.6

0.23

30.2±3.4 29.3±3.5 30.4±4.0

0.27

10.5±3.2 11.3±3.3 11.6±4.0

0.19

35 57 82

26.0±5.4 24.8±6.3 23.7±6.3

0.16

30.2±2.8 29.1±4.0 30.4±3.4

0.1

11.4±3.8 11.5±3.2 10.4±3.3

0.11

106 46 13 9

24.5±6.7 25.3±5.3 25.5±4.0 18.8±4.2

0.03

29.9±3.6 29.4±3.5 31.2±2.9 31.8±3.2

0.15

10.7±3.8 11.5±2.8 11.0±2.0 10.5±2.8

0.6

36 138

22.0±6.2 25.2±6.0

0.006

30.4±3.1 29.8±3.6

0.37

11.1±3.0 10.9±3.5

0.8

*p values come from either t-test or Anova. **p values come from Kruskal Wallis. ED: Emergency department.

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Table 2. Description of the sample and association of violence with demographic and work-related factors in EPs Physical violence Variables Age (years) <34 35-44 â&#x2030;Ľ45 Sex n (%) Male Female Marital Status Married Unmarried Having children Yes No Workplace 112 emergency services State hospital University hospital Other Work type Shift 24-h shift Day or night shift Hobbies Yes No Habits No Cigarette smoking Alcohol Both Working years in Medicine 0-5 6-10 11-15 >16 Years in medicine EM <5 6-10 >11 Predicted future years in EM <5 5-10 >10 Monthly income 2-3 3-4 4-5 >5 Work hours (per month â&#x2030;¤160 >160

178

Verbal violence

Total violence

2 7 0

3.3 7.1 0

0.013

28 41 6

45.9 41.4 40.0

0.8

28 44 6

45.6 44.4 40

0.91

9 0

6.5 0

0.24

52 23

37.7 62.2

0.008

55 23

39.9 62.2

0.013

7 2

5 6.1

0.98

62 12

44.3 36.4

0.69

64 13

45.7 39.4

0.79

2 7

4.3 5.4

0.80

18 57

39.1 44.2

0.55

19 59

41.3 45.7

0.36

3 5 0 1

6.1 4.9 0 12.5

0.86

20 50 2 3

40.8 49.0 12.5 37.5

0.05

21 52 2 3

42.9 51.0 12.5 37.5

0.03

0 8 1

0 6.7 2.6

0.64

3 54 18

17.6 45.0 47.4

0.08

3 56 19

17.6 46.7 50.0

0.059

5 4

4.2 7.0

0.25

41 34

34.7 59.6

0.002

43 35

36.4 61.4

0.002

5 2 2 0

5.6 4.3 16.7 0

0.67

39 17 4 8

43.3 37 33.3 42.1

0.1

40 18 5 8

44.4 39.1 41.7 42.1

0.15

0 4 4 1

0 8 6.3 2.4

0.43

7 21 27 20

35 42 42.9 47.6

0.82

7 22 29 20

35.0 44.0 46.0 47.6

0.81

4 4 1

4.4 8.2 2.9

0.67

36 20 19

39.6 40.8 54.3

0.30

37 22 19

40.7 44.9 54.3

0.38

1 5 3

2.9 8.8 3.6

0.17

17 27 31

48.6 47.4 37.3

0.37

17 30 31

48.6 52.6 37.3

0.17

6 3 0 0

5.6 6.5 0 0

0.64

44 22 4 5

41.1 47.8 30.8 55.6

0.58

62 22 9 4

57.9 47.8 69.2 44.4

0.42

1 8

2.8 5.8

0.67

12 63

33.3 45.3

0.19

12 66

33.3 47.5

0.09

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Erdur et al. Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey

Table 3. Relation of violence with burnout in EPs Variables

Emotional exhaustion

Personal accomplishment

Depersonalization

Mean±SD p Mean±SD p Mean±SD p Total violence Yes

78 25.8±5.9 0.012 29.4±3.8 0.074 11.6±3.5 0.021

96 23.5±6.2 30.4±3.3 10.4±3.3

Physical violence Yes

9 26.8±3.7 0.09 30.5±3.2 0.63 11.3±3.4 0.75

165 24.4±6.3 29.9±3.6 10.9±3.4

Verbal violence Yes

75 25.8±6.0 0.016 29.4±3.9 0.1 11.7±3.5 0.012

99 23.5±6.2 30.3±3.2 10.4±3.3

Table 4. Multivariate analysis of the effects of factors on burnout* Variable

Emotional exhaustion

Personal accomplishment

Depersonalization

Beta

±SE

95% CI

Beta

±SE

95% CI

Beta

±SE

95% CI

2.1

0.96

0.03

0.19-4.0

-0.94

0.6

0.1

-2.08-0.19

1.09

0.5

0.049

0.004-2.2

Total violence

*Models are adjusted for age, gender, work place and hobbies.

DISCUSSION This study showed that violence (especially, verbal violence) and burnout are common among physicians working in emergency departments. There have been few studies in the literature with similar results.[1,9,12,20-24] Our results also indicated that there was a strong association between burnout and violence experienced by physicians working in emergency departments in our community. Violence-burnout relation in the literature has been referred to as anecdotal so far. However, this study is one of the few studies showing direct relation between violence and burnout. All forms of aggression have the potential to impact significantly on the well-being of health professionals, including impaired job performance, moderate to severe and long-term psychological effects, burnout and turnover.[22,24-26] The association between burnout and violence towards health care staff also found by Arnetz and Arnetz[20] is similar to our study. It has also been reported that violence or threats experienced by health care staff, as well as burnout, have negative effects on the quality of health care services offered.[20,21] There seems to be a tight circle between violence and burnout among physicians working in emergency departments. As long as violence is frequent, it is expected that it will have a substantial effect on the staff’s well-being and burnout in our Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

emergency departments. In another study within the EDs, the authors have experienced high levels of burnout primarily among physicians owing to the increased work load caused by access block and overcrowding, which, in turn, may lead to longer waiting times, and consequently, an increase in violence and aggression contributing to the risk of burnout.[23] Violence is always present in the EDs, and the main contributing factors have been indicated as sudden illness or injury of individuals, overcrowding of the EDs because of access block or bed shortages, and longer waiting periods, alcohol or substance use. Misunderstandings about the assignments of medical priorities can easily aggravate patients and their companions, who are naturally in an anxious and worried mood. These findings are supported by other studies.[7,12,18,23] The negative influence of violence on the well-being of the affected person has been demonstrated in some studies. The consequences are emotions like anger or anxiety extending to psychological disorders like burnout.[12,27-31] Gascón et al.[30] have found that there is a statistically significant association between verbal violence and anxiety and symptoms of PostTraumatic Stress Syndrome. In their report, both physical and non-physical violence has had an identical negative impact in terms of burnout, exhaustion and conflicts of values in health care workers, which are similar to our study. In addition, the same study has found that verbal and physical violence against accident and emergency service workers are shown to be simi179

Erdur et al. Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey

lar in the literature. In a recent study with a large participation, Estryn-Behar et al.[31] have compared the rate of burnout and violence and found that both are higher in the ED physicians than in other physicians. Emergency physicians have declared being subjected to monthly violence from patients or their relatives twice as often as the physicians in the representative sample (69.3% vs. 27.5%). They have reported that violence, as one of the working environment risk factors, is highly linked to burnout as was also demonstrated in our study. The aggressions suffered by the workers fall within a wide range of risks that affect the safety and health of health workers, who are already subjected to high stress leading to high levels of burnout. Healthcare workers with burnout suffer from physical and emotional symptoms, lose joy in providing care, distance themselves from others, view their patients as objects, and spend less time with abusive patients. On the other hand, professional exhaustion of emergency doctors, with negative attitudes at work, increases the risk of aggressions against themselves and their colleagues.

Limitations The main limitation of this study is due to its cross-sectional design. The study subjects were not followed-up, and the relation between violence and burnout was determined at the same time. The former one is always a subject to debate. The one-month brief period of the study, which has a potential to limit the sample size and reliability of the conclusion, seems to be another limitation. However, this should also be considered an advantage for this study in terms of reducing the recall bias and seeing the immediate effect of violence on burnout of the participants. However, it is thought that this did not cause a significant negative impact on the study results since it is known that the prevalence of violence is very high in our emergency rooms. It is a well-known fact from our daily practices and also from a previous study.[18]

Conclusion The results presented here indicated that there was a strong association between burnout and violence (verbal or physical violence) experienced by physicians working in the emergency departments. Violence in the emergency department had a substantial effect on the well-being of the physicians. Further studies on the topic are required. These studies should quantify the actual impact of violence and burnout on EP’s well-being-time off, career change, and early retirement, and consider interventions/coping strategies to address the problem. Moreover, further studies could consider how ED activities, workforce numbers and crowded ED influences violence and burnout.

REFERENCES 1. Crabbe JM, Bowley DM, Boffard KD, Alexander DA, Klein S. Are health professionals getting caught in the crossfire? The personal implications of caring for trauma victims. Emerg Med J 2004;21:568-72. 2. Cole LL, Grubb PL, Sauter SL, Swanson NG, Lawless P. Psychosocial correlates of harassment, threats and fear of violence in the workplace. Scand J Work Environ Health 1997;23:450-7. 3. Saines JC. Violence and aggression in A & E: recommendations for action. Accid Emerg Nurs 1999;7:8-12. 4. Caldwell MF. Incidence of PTSD among staff victims of patient violence. Hosp Community Psychiatry 1992;43:838-9. 5. Wykes T, Whittington R. Reactions to assault. In T. Wykes (Ed.), Violence and health care professionals. London: Chapman & Hall 1994. p. 105-26. 6. Corbett SW, Grange JT, Thomas TL. Exposure of prehospital care providers to violence. Prehosp Emerg Care 1998;2:127-31. 7. Grange JT, Corbett SW. Violence against emergency medical services personnel. Prehosp Emerg Care 2002;6:186-90. 8. Mock EF, Wrenn KD, Wright SW, Eustis TC, Slovis CM. Prospective field study of violence in emergency medical services calls. Ann Emerg Med 1998;32:33-6. 9. Goldberg R, Boss RW, Chan L, Goldberg J, Mallon WK, Moradzadeh D, et al. Burnout and its correlates in emergency physicians: four years’ experience with a wellness booth. Acad Emerg Med 1996;3:1156-64. 10. Felton JS. Burnout as a clinical entity--its importance in health care workers. Occup Med (Lond) 1998;48:237-50. 11. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. 12. Gates DM, Ross CS, McQueen L. Violence against emergency department workers. J Emerg Med 2006;31:331-7. 13. Gerberich SG, Church TR, McGovern PM, Hansen HE, Nachreiner NM, Geisser MS, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study. Occup Environ Med 2004;61:495-503. 14. Arnetz JE, Arnetz BB, Pettersson IL. Violence in the nursing profession: occupational and lifestyle risk factors in Swedish nurses. Work Stress 1996;10:119-27. 15. Almberg B, Grafström M, Krichbaum K, Winblad B. The interplay of institution and family caregiving: relations between patient hassles, nursing home hassles and caregivers’ burnout. Int J Geriatr Psychiatry 2000;15:931-9. 16. Blanchard JC, Curtis KM. Violence in the emergency department. Emerg Med Clin North Am 1999;17:717-31. 17. Ergin C. Adaptation and validity of MBI for measuring burnout among Turkish physicians and nurses. VIIth National Psychology Congress 1993; Ankara Turkish Psychologists Association. 18. Boz B, Acar K, Ergin A, Erdur B, Kurtulus A, Turkcuer I, et al. Violence toward health care workers in emergency departments in Denizli, Turkey. Adv Ther 2006;23:364-9. 19. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual, 3rd edition. Palo Alto, CA: Consulting Psychologists Press, 1996. 20. Arnetz JE, Arnetz BB. Violence towards health care staff and possible effects on the quality of patient care. Soc Sci Med 2001;52:417-27.

Funding: No funding received.

21. Gates D, Fitzwater E, Succop P. Reducing assaults against nursing home caregivers. Nurs Res 2005;54:119-27.

Conflict of interest: None declared.

22. Fernandes CM, Bouthillette F, Raboud JM, Bullock L, Moore CF, Christenson JM, et al. Violence in the emergency department: a survey of

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Erdur et al. Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey health care workers. CMAJ 1999;161:1245-8. 23. Potter C. To what extent do nurses and physicians working within the emergency department experience burnout: A review of the literature. Aust Emerg Nurs J 2006;9:57-64. 24. Lau JBC, Magarey J, McCutcheon H. Violence in the emergency department: A literature review. Aust Emerg Nurs J 2004;7:27-37. 25. Pich J, Hazelton M, Sundin D, Kable A. Patient-related violence against emergency department nurses. Nurs Health Sci 2010;12:268-74. 26. McGowan S, Wynaden D, Harding N, Yassine A, Parker J. Staff confidence in dealing with aggressive patients: a benchmarking exercise. Aust N Z J Ment Health Nurs 1999;8:104-8. 27. Voyer P, Verreault R, Azizah GM, Desrosiers J, Champoux N, Bédard A. Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities. BMC Geriatr 2005;5:13.

28. Evers W, Tomic W, Brouwers A. Aggressive behaviour and burnout among staff of homes for the elderly. Int J Ment Health Nurs 2002;11:29. 29. Winstanley S, Whittington R. Violence in a general hospital: comparison of assailant and other assault-related factors on accident and emergency and inpatient wards. Acta Psychiatr Scand Suppl 2002;412:144-7. 30. Gascón S, Martínez-Jarreta B, González-Andrade JF, Santed MA, Casalod Y, Rueda MA. Aggression towards health care workers in Spain: a multi-facility study to evaluate the distribution of growing violence among professionals, health facilities and departments. Int J Occup Environ Health 2009;15:29-35. 31. Estryn-Behar M, Doppia MA, Guetarni K, Fry C, Machet G, Pelloux P, et al. Emergency physicians accumulate more stress factors than other physicians-results from the French SESMAT study. Emerg Med J 2011;28:397-410.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Türkiye’de acil servislerde çalışan hekimler arasında şiddet ve tükenmişlik ilişkisinin değerlendirilmesi Dr. Bülent Erdur,1 Dr. Ahmet Ergin,2 Dr. Aykut Yüksel,5 Dr. İbrahim Türkçüer,1 Dr. Cüneyt Ayrık,4 Dr. Bora Boz3 Pamukkale Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Denizli Pamukkale Üniversitesi Tıp Fakültesi, Halk Sağlığı Anabilim Dalı, Denizli Pamukkale Üniversitesi Tıp Fakültesi, Adli Tıp Anabilim Dalı, Denizli 4 Mersin Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Mersin 5 Göztepe Eğitim ve Araştırma Hastanesi, Acil Servisi, İstanbul 1 2 3

AMAÇ: Şiddet ve tükenmişlik hekimler arasında sık görülmektedir ancak ilişkileri açık değildir. Acil ünitelerinde çalışan hekimlerde şiddeti ve tükenmişlik üzerindeki muhtemel etkilerini değerlendirmeyi amaçladık. GEREÇ VE YÖNTEM: Bu kesitsel çalışmaya Denizli Pamukkale Üniversitesi Hastanesi, il, ilçe hastaneleri, 112 Acil Servis ve özel hastanelerin acil birimlerde çalışan tüm hekimler alındı. Veriler, katılımcıların kendi kendilerine uyguladıkları Maslach Tükenmişlik Ölçeğinin Türkçe versiyonu, şiddetin failleri ve demografik bilgiler hakkındaki sorulardan oluşan bir anket vasıtasıyla elde edildi. Ayrıca katılımcıların acil hekimi sertifika programından önceki bir ay boyunca maruz kaldığı veya tanıklık ettiği herhangi bir sözlü ya da fiziksel şiddet ankette soruldu. BULGULAR: Çalışmaya toplam 174 hekim (hedef grubun %85) alındı. Katılımcıların çoğu 24 ve 59 yaş aralığında, ortalama yaş 36.8±5.8 yıl idi. Şehir merkezindeki hastanede çalışanların çoğunluğunu evli erkek hekimler oluşturmaktaydı. Duygusal tükenme, toplam şiddet (p=0.012) ve sözel şiddet (p=0.016) arasında; duyarsızlaşma, toplam şiddet (p=0.021) ve sözel şiddet (p=0.012) arasında anlamlı bir ilişki vardı. TARTIŞMA: Elde ettiğimiz sonuçlar, acil birimlerinde çalışan hekimlerin yaşadığı tükenmişlik ve şiddet arasında güçlü bir ilişkinin olduğunu göstermektedir. Acil servisteki şiddet, hekimlerin refahı üzerinde önemli bir etkiye sahiptir. Anahtar sözcükler: Acil hekimi; acil hekimi sağlıklı yaşam; acil tıp; şiddet; tükenmişlik. Ulus Travma Acil Cerrahi Derg 2015;21(3):175-181

doi: 10.5505/tjtes.2015.91298

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ORIGIN A L A R T IC L E

The analysis of scoring systems predicting mortality in geriatric emergency abdominal surgery Murat Özban, M.D., Onur Birsen, M.D., Mahmut Şenel, M.D., Akın Özden, M.D., Burhan Kabay, M.D. Department of General Surgery, Pamukkale University Faculty of Medicine, Denizli

ABSTRACT BACKGROUND: Accurate measurement of surgical outcomes, proper evaluation of hospitals and surgeons regardless of case can be performed by mortality prediction models. The aim of this study was to analyze factors affecting mortality, present our clinical experience and patient profile and evaluate different scoring systems in use of these patients. METHODS: A retrospective review of one hundred and twelve geriatric patients who underwent major abdominal emergency surgery between 2004 and 2008 was performed. APACHE II, ODIN, SAPS II expanded, P-POSSUM, Manheim peritonitis and Charlson comorbidity index, Goldman and ASA scores were calculated using patient data. Sensitivity, positive predictive value and Odd’s ratio were calculated to predict the mortality for these scoring systems. RESULTS: The overall mortality rate for our patients was found 33.9%. The factors affecting mortality in this study were found to be the duration of initial complaint, requirement of intensive care unit, requirement of mechanical ventilation and its duration, the presence of coexisting disease and peritonitis. CONCLUSION: According to our study, in this particular group of patients, APACHE II scoring system is more valid and accurate in estimating the mortality risk when compared to other scoring systems. Key words: Emergency surgery; geriatrics; scoring system.

INTRODUCTION The definiton of ‘the aged’ changes very rapidly. Even though most authors agree to limit the age of 65, this number is not under control and may vary with longevity and overall health of community.[1] The elderly has many concomitant diseases limiting functional capacity required for postoperative recovery. In order to ensure the ability and evaluate pathophysiological risks of concomitant diseases and clinical competence, it is essential to provide a safe, beneficial and effective surgical care.[2] Elderly patients have more complications after abdominal surgery. Compared to the general population, it is three times Address for correspondence: Murat Özban, M.D. Pamukkale Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Denizli, Turkey Tel: +90 258 - 444 07 28 E-mail: muratozban@yahoo.com Qucik Response Code

182

more common in appendix perforation. Similarly, complications of acute cholecystitis is more common in the elderly. [1] Morrow has determined that 40% of elderly patients with acute cholecystitis also have gallbladder empyema, gangrenous cholecystitis, subphrenic or hepatic abscess or free perforation.[1] Consequently, in geriatric patients, it is required to select certain indications for reducing the risks of surgery besides an optimal preoperative preparation, the short duration of the operation, the appropriate method of anesthesia and resuscitation and a proper postoperative care. The purpose of this study was to investigate the factors influencing mortality in this group of patients, which is increasing by number and requiring a multidisciplinary approach, introduce our clinical experience and patient profiles, analyze scoring systems envisioning mortality rates, and determine the most appropriate scoring system for our clinic.

MATERIALS AND METHODS One hundred and twelve geriatric patients operated as emergency cases were included into the study between October 2004 and December 2008 at Pamukkale University School of Medicine Training and Research Hospital, Department of General Surgery. Ethics committee approval No.4830 was reUlus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

Özban et al. The analysis of scoring systems predicting mortality in geriatric emergency abdominal surgery

ceived before the study. All patients were selected among the emergency department patients aged 65 and over. Patients were reviewed retrospectively. Age, sex, length of stay, intensive care unit stay, duration of mechanical ventilation, referral status, social security, complaint, duration of complaint, preoperative diagnosis, postoperative diagnosis, APACHE II score, ASA score, the Goldman cardiac risk index, Charlson comorbidity index, Mannheim Peritonitis Index, ODIN score, the expanded SAPS II score, P-POSSUM score, the risk of venous thromboembolism, the causes of morbidity and mortality were recorded as parameters to data forms. Mortality was analyzed in two groups as compatible and incompatible causes with life, as defined by Seymour and Pringle.[3] APACHE II, ODIN, the expanded SAPS II and P-POSSUM scores were calculated automatically from www.sfar.com website. The ability to predict mortality in the validation study was evaluated through observed over expected mortality ratio (O:E ratio) and calibration analysis.

Mortality O:E Ratio ‘O’ was defined as the number of observed patients who died during the study period. ‘E’ was defined as the number of operated patients expected to die, multiplied by the mean risk of mortality, expressed as a percentage. The mean risk of mortality was the mean of estimated risk of mortality given by the ‘R’ in the logistic regression equation of the P-POSSUM score, calculated in each band risk of mortality. O:E ratio methodology can be used as a cross sectional audit, as well as for continuous or sequential monitoring of surgical quality performance between subgroups.[4]

Calibration Calibration (model fit), assesed by the Hosmer-Lemeshow (HL) statistic is a goodness-of-fit test analogous to a Chisquare statistic where the degrees of freedom (df) equal the number of deciles or the number of risk bands minus. The HL statistics, H2 and C2, indicate the degree of agreement between the observed and the expected mortality across risk ranges. When p>0.05, the calibration was considered to be ‘good’; i.e., the observed mortality was well described, whereas when p≤0.05, calibration was considered to be ‘poor’.[5] All data were given as the average ± standard error of mean. The differences between the groups were analyzed with Chisquare and Kruskal Wallis test, the differences between two groups were analyzed with Mann-Witney U-test. Statistical analysis was performed by using SPSS software (SPSS Inc., Chicago, IL). Results with %95 confidence interval, significance of p<0.05 were evaluated. Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

RESULTS Forty-seven (42%) patients were female and 65 (50%) patients were male. The mean age, duration of symptoms and hospital stay of our patients are given in Table 1. Morbidity was detected in 47 patients and morbidity rate was found to be 63.51%. Thirty-one patients were determined to have pneumonia and atelectasis, 18 patients to have wound infection, 10 patients to have acute renal failure, and 8 patients to have acute coronary syndrome. Mortality was detected in 38 patients (33.9%). Mortality was analyzed in two groups as compatible and incompatible causes with life, as defined by Seymour and Pringle.[3] The causes of mortality, incompatible with life, are given in Table 2. Twenty-five (22.3%) patients were detected in the group of compatible with life. Eight (7.1%) of these patients were identified with sepsis, two (1.8%) with anastomosis leakage, two (1.8%) with bleeding, five (4.5%) with pneumonia, seven (6.3%) with myocardial infarction, and one (0.9%) patient with pulmonary embolism were identified. Peritonitis was established in 43 (38.39%) of our cases. Mortality for patients with peritonitis was found to be 41.86% in eighteen patients. Positive predictive values and sensitivity of each scoring systems were given in Table 3. As determined by Wijesingheve et al, the linear analysis for SAPS II expanded, ODIN, APACHE II scores and both linear and geometric analysis for P-POSSUM score were performed. [6] The results are given in Table 4. The presence and severity of peritonitis is a factor affecting mortality in patients. Peritonitis was detected in 38.39% of our patients. Mortality for patients with peritonitis was found to be 41.86%. While 39.53% of patients in the group of Table 1. The mean age, duration of symptoms and hospitalization Age (year)

Duration of symptoms (hour)

Hospitalization (hour)

Mean±SD 74.30±0.5

71.10±5.7

Minimum 65

261.47±21.9 8

Maximum 87

360

1680

Table 2. The causes of mortality which incompatible with life Mortality causes

Terminal stage of malignancy

4.5

Massive bowel infraction

7.1

Total

13 11.6

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Ă&#x2013;zban et al. The analysis of scoring systems predicting mortality in geriatric emergency abdominal surgery

Table 3. The statistical analysis of the scoring systems

Oddsâ&#x20AC;&#x2122; ratio

%95 CI

Sensitivity (%)

Positive predictive value

APACHE II

4.00

2.80-5.19

0.0001

P-POSSUM

4.43

3.06-5.80 0.0001

ODIN

2.96

1.93-4.00 0.0001

SAPS II Expanded

3.2

2.23-4.35

0.0001

Peritonitis MPI

4.06

1.40-5.77

0.0001

Table 4. Prediction of mortality

Estimated mortality (n)

Observed mortality (n)

Observed: Estimated mortality ratio

P-POSSUM 112

0.70

APACHE II

1.08

ODIN 112 32

112

1.18

SAPS II Expanded

1.52

112

peritonitis score 24 and above died, only 2.32% of patients in the group of peritonitis score less than 24 died. Mortality in patients with Mannheim peritonitis score 24 and above was found to be significantly increased.

DISCUSSION Basically, all scoring systems aim to predict the risk of death by calculating the value of certain vital, clinical and laboratory findings. A scoring system to predict surgical outcomes via calculating the risk of mortality and morbidity must be a valid and reliable method. A lot of earlier scoring systems were very complex and frequently failed to reach an accurate result in estimating the risk of mortality. There are two objective measures that have been used to evaluate the performance of the prognostic models: calibration and discrimination. Calibration determines the correlation between the probability of mortality with the observed mortality and can be tested using Hosmer-Lemeshow goodness-of-fit statistical analysis. On the other hand, discrimination shows the usefulness of a scoring system in classifying patients properly as survivors or non-survivors and is measured by AUC. While it would be important for a scoring system to have a good discrimination for a specific patient, stratifying patients for clinical trials or comparison of the results and quality of care between different clinics, calibration is preferable. Consequently, we evaluated the performance of selected scoring systems according to calibration analysis in our study. POSSUM scoring system obtained from a heterogeneous population was successfully used as an audit tool, but in lowrisk groups, it seemed that it overestimated mortality rates. Predictive value of POSSUM to morbidity was affected by the 184

type of surgery and the sample size of studies.[7] Compared with POSSUM, P-POSSUM was more accurate for predicting postoperative mortality.[8] Therefore, P-POSSUM scoring system designed and used successfully for high risk group of patients.[9] However, in a study evaluating gastrointestinal surgery in elderly patients, both the POSSUM and P-POSSUM over-predicted the morbidity and mortality.[10] Similarly, in our study, P-POSSUM scoring system overpredicted the mortality rates when compared with other scoring systems according to both linear analysis and O:E results (Tables 3, 4). APACHE II is a scoring system in which especially vital signs of the patient besides hematologic and biochemical laboratory findings are evaluated. In a recent study, the discriminative ability of APPACHE II has been found to be excellent in surgical intensive care unit patients.[11] Moreover, APACHE II also had a better, more appropriate calibration than APACHE III or SAPS II in the same study. APACHE II scores can prognostically stratify acutely ill patients and assist investigators comparing the success of new or differing forms of therapy. Hospital mortality is predicted using the APACHE II score, the principal diagnostic category with which the patient is admitted to ICU and also depending on whether or not the patient required emergency surgery.[12] In a recent study, APACHE II has also had a better, more appropriate calibration than other widely used scoring systems; so only APACHE II properly predicts mortality risk.[11] The major limitation of this scoring system is the varibility of physiological parameters which are all dynamic and can be influenced by multiple factors, including ongoing resuscitation and treatment, hence, time bias is present. It may explain our findings for APACHE II that although the sensitivity was found to be 96%, positive Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

Özban et al. The analysis of scoring systems predicting mortality in geriatric emergency abdominal surgery

predictive value was found to be lower (86%) than others. In spite of these limitations, with calibration analysis, it was found that APACHE II scoring system more accurately predicted the mortality risk when compared to other scoring systems in our patients (Tables 3, 4).

A better calibration of APACHE II was found besides improving the ability to predict hospital mortality risk in comparison with P-POSSUM, SAPS II expanded or ODIN in geriatric group of patients who underwent emergency abdominal surgery.

ODIN scoring system includes parameters such as oxygen pressure determined in basic organ functions, arterial pressure, serum creatinine, Glascow coma score, serum bilirubin level, hematological parameters. The assessment of the presence of infection is the difference of ODIN scoring system from APACHE II. Therefore, although positive predictive value was found to be high (91%), the sensitivity of this system also was found to be quite low (78%). Basically, all scoring systems obtained parameters by calculating vital and laboratory evaluation of patients. While these systems were being developed and modified, the follow-up process and diseases other than these criterias of patients have been added to the avaluated parameters over time. Although SAPS II has similar features, ‘SAPS II expanded’ has included the duration of hospitalization before intensive care. However, the values of age and gender that it contained were not found as factors affecting mortality in our study. Therefore, the sensitivity (74%) and positive predictive value (89%) were found quite low.

Conflict of interest: None declared.

In this study, we investigated the scoring systems that predicted the factors affecting mortality and morbidity rate in geriatric patients, which is increasing by number and requiring a multidisciplinary approach. The mortality rate was found to be 33.9% and the morbidity rate was 63.51%. The factors affecting mortality in our study were found to be the duration of initial complaint, requirement of intensive care unit, requirement of mechanical ventilation and its duration, the presence of coexisting disease and peritonitis. Conversely, poor calibration (goodness-of-fit), especially in subgroup analysis, and underestimation or overestimation of O:E ratios considerably limits the value of P-POSSUM for prediction of mortality in individuals. Therefore, P-POSSUM should not be used in comparison of different clinics and stratifying the patients for in-clinical trials to predict outcomes.[13] The present study has some limitations. As a single-centre study, there may be bias with regard to case mix, quality clinical care and policy. In addition, our relatively small sample size is a limiting factor for calibration analysis. Furthermore, APACHE II is based on retrospective data that is available within 24 h of ICU admission; consequently, the sampling rate that is used can influence mortality prediction. In our opinion, a multi-centre study would diminish the concerns over case mix and benefit from a larger sample size.

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REFERENCES 1. Hendrickson M, Naparst TR. Abdominal surgical emergencies in the elderly. Emerg Med Clin North Am 2003;21:937-69. 2. Halpern LR, Feldman S. Perioperative risk assessment in the surgical care of geriatric patients. Oral Maxillofac Surg Clin North Am 2006;18:1934. 3. Seymour DG, Pringle R. A new method of auditing surgical mortality rates: application to a group of elderly general surgical patients. Br Med J (Clin Res Ed) 1982;284:1539-42. 4. Tekkis PP, McCulloch P, Poloniecki JD, Prytherch DR, Kessaris N, Steger AC. Risk-adjusted prediction of operative mortality in oesophagogastric surgery with O-POSSUM. Br J Surg 2004;91:288-95. 5. Hosmer DW, Lemeshow S. Applieed logistic regression. Wiley, New York. 6. Wijesinghe LD, Mahmood T, Scott DJ, Berridge DC, Kent PJ, Kester RC. Comparison of POSSUM and the Portsmouth predictor equation for predicting death following vascular surgery. Br J Surg 1998;85:20912. 7. Markus PM, Martell J, Leister I, Horstmann O, Brinker J, Becker H. Predicting postoperative morbidity by clinical assessment. Br J Surg 2005;92:101-6. 8. Chen T, Wang H, Wang H, Song Y, Li X, Wang J. POSSUM and PPOSSUM as predictors of postoperative morbidity and mortality in patients undergoing hepato-biliary-pancreatic surgery: a meta-analysis. Ann Surg Oncol 2013;20:2501-10. 9. Pelavski AD, Lacasta A, de Miguel M, Rochera MI, Roca M. Mortality and surgical risk assessment among the extreme old undergoing emergency surgery. Am J Surg 2013;205:58-63. 10. Wakabayashi H, Sano T, Yachida S, Okano K, Izuishi K, Suzuki Y. Validation of risk assessment scoring systems for an audit of elective surgery for gastrointestinal cancer in elderly patients: an audit. Int J Surg 2007;5:323-7. 11. Gilani MT, Razavi M, Azad AM. A comparison of Simplified Acute Physiology Score II, Acute Physiology and Chronic Health Evaluation II and Acute Physiology and Chronic Health Evaluation III scoring system in predicting mortality and length of stay at surgical intensive care unit. Niger Med J 2014;55:144-7. 12. Rapsang AG, Shyam DC. Scoring systems in the intensive care unit: A compendium. Indian J Crit Care Med 2014;18:220-8. 13. Merad F, Baron G, Pasquet B, Hennet H, Kohlmann G, Warlin F, et al. Prospective evaluation of in-hospital mortality with the P-POSSUM scoring system in patients undergoing major digestive surgery. World J Surg 2012;36:2320-7.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Geriatrik abdominal acil cerrahide mortaliteyi öngörmede skorlama sistemlerinin analizi Dr. Murat Özban, Dr. Onur Birsen, Dr. Mahmut Şenel, Dr. Akın Özden, Dr. Burhan Kabay Pamukkale Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Denizli

AMAÇ: Cerrahi sonuçların doğru ölçümü, hastane ve cerrahın doğru değerlendirilmesi, olgudan bağımsız olarak mortalite tahmin yöntemleri tarafından yapılır. Bu çalışmanın amacı, mortaliteyi etkileyen faktörleri analiz etmek, klinik deneyimimizi ve hasta profilimizi sunmak ve bu hastalarda farklı skorlama sistemlerinin kullanımını araştırmaktır. GEREÇ VE YÖNTEM: 2004-2008 yılları arasında majör abdominal acil cerrahi geçirmiş 112 yaşlı hastanın dosyası geriye dönük olarak incelendi. APACHE II, ODIN, SAPS II genişletilmiş, P-POSSUM, Manheim peritonit skoru, Charlson komorbidite indeksi, Goldman ve ASA skorları hesaplandı. Bu skorlama sistemlerinin mortaliteyi öngörme açısından duyarlılık, pozitif prediktif değer ve odds oranları hesaplandı. BULGULAR: Hastalarımız için tüm mortalite oranı %33.9 oldu. Bu çalışmada mortaliteyi etkileyen faktörler başlangıç şikayeti, yoğun bakım ihtiyacı, mekanik ventilasyon ihtiyacı ve süresi, peritonit varlığı ve eşlik eden hastalık durumu olarak belirlendi. TARTIŞMA: Buna göre, bizim çalışmamızda APACHE II skorlama sisteminin bu grup hastalarda mortalite riskini öngörmede daha gerçekçi sonuçlar verdiği saptanmıştır. Anahtar sözcükler: Acil cerrahi; geriatri; skorlama sistemi. Ulus Travma Acil Cerrahi Derg 2015;21(3):182-186

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ORIGIN A L A R T IC L E

Repairing post burn scar contractures with a rare form of Z-plasty Nazım Gümüş, M.D. Department of Plastic and Reconstructive Surgery, Numune Training and Research Hospital, Adana

ABSTRACT BACKGROUND: Although many precautions have been introduced into early burn management, post burn contractures are still significant problems in burn patients. In this study, a form of Z-plasty in combination with relaxing incision was used for the correction of contractures. METHODS: Preoperatively, a Z-advancement rotation flap combined with a relaxing incision was drawn on the contracture line. Relaxing incision created a skin defect like a rhomboid. Afterwards, both limbs of the Z flap were incised. After preparation of the flaps, advancement and rotation were made in order to cover the rhomboid defect. Besides subcutaneous tissue, skin edges were closely approximated with sutures. RESULTS: This study included sixteen patients treated successfully with this flap. It was used without encountering any major complications such as infection, hematoma, flap loss, suture dehiscence or flap necrosis. All rotated and advanced flaps healed uneventfully. In all but one patient, effective contracture release was achieved by means of using one or two Z-plasty. In one patient suffering severe left upper extremity contracture, a little residual contracture remained due to inadequate release. CONCLUSION: When dealing with this type of Z-plasty for mild contractures, it offers a new option for the correction of post burn contractures, which is safe, simple and effective. Key words: Advancement; contracture; relaxing incision; rotation; Z-plasty.

INTRODUCTION Although many precautions such as splints, pressure therapy, massage and rehabilitation have been introduced into the early burn management to avoid forming scar contracture and soften the hypertrophic scar after skin damage, post burn contractures are still significant problems in burn patients. They usually take place over flexor surfaces of the joints, and either restrict limb, hand, foot, finger or neck motions or deform the skin cover of the affected area, and commonly, surgical correction is necessary to release them completely. Minimal contractures may be released by a simple Z-plasty; Address for correspondence: Nazım Gümüş, M.D. Numune Eğitim ve Araştırma Hastanesi, Plastik Rekonstrüktif ve Estetik Cerrahi Kliniği, Adana, 01720 Adana, Turkey Tel: +90 322 - 233 79 89 E-mail: gumus1970@hotmail.com Qucik Response Code

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however, moderate ones may require various forms of multiple Z-plasties, and more complicated ones like severe contractures may be released effectively with skin grafts and flaps such as local flaps, regional flaps, transposition flaps, rotating flaps, axial flaps, perforator flaps, and free flaps. Many of the methods described to treat them can be used under proper indications to obtain the best results both cosmetically and functionally since they still have some disadvantages such as necrosis, donor site morbidity, long operation time, and difficult surgical dissection.[1-4] Although new clinical researches focus on finding more simple, reliable and versatile alternatives, simple Z-plasty and various forms of multiple Z-plasties are being used most commonly in daily clinical practice. In this study, clinical experience in a rare form of Z-plasty combined with relaxing incision for the release of scar contractures was presented.

MATERIALS AND METHODS This study included sixteen patients who had post burn scar contractures treated successfully with an unusual form of Z-plasty called Z advancement rotation flap (ZAR). Patients were between 3 and 25 years of age with a mean age of 10.3 years. The patients suffered from a contracture for a mini187

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Table 1. Clinical details of patients Case no. Age Sex

Average time from burn Location Complication to operation (months)

Result

Good

Male

Axilla

Male

Poplitea

Good

Male

Elbow

Scar enlargement

Acceptable

Male

Follow-up (months)

Axilla

Good

25 Female

Elbow

Good

Male

Forearm

Good

Male

Upper extremity

Inadequate release

Reoperation

Male

Elbow

Good

Male

thigh

Good

Female

Axilla

Good

Male

Upper extremity

Good

Female

Upper extremity

Female

Male

Good

Elbow

Good

Neck

Good

Upper extremity

Good

Elbow

Good

mum of one year so scar maturation was completed enough to release it. Contractures were in mild severity except in one in which there was a severe contracture of upper extremity. As all joints had more than 50% of normal joint range of motion (ROM), contractures were classified as in mild severity according to the algorithm for the release of burn contractures described by Hudson.[1] The treated sites were the axilla in three patients, the poplitea in one patient, the elbow in five patients, the upper extremity in four patients, the forearm in one patient, the neck in one patient, and the thigh in one patient (Table 1). Preoperatively, a Z advancement rotation flap combined with

a relaxing incision was drawn on the contracture line (Fig. 1). While limbs of the Z were being placed lateral to the contracture, relaxing incision line was drawn just over the contracture area perpendicular to the contracture line (Fig. 2a-d). Length and width of the limbs of the ZAR flap, which had a modified shape of classical Z-plasty suitable for advancement and rotation, were determined according to the need of flap size which would cover the skin defect arising from the released contracture line. After marking was completed, firstly, relaxing incision was made into the skin and scar tissue, and deepened to the superficial fascia, releasing the contracture completely without leaving any contracture band (Fig. 2b). The depth of incision varied according to the characteristics

a a d

a b

b c

Figure 1. Schematic illustration of the procedure. a and b represent flaps of the Z-plasty, and c and d show relaxing incision line and skin defect in rhombus shape, respectively. When relaxing incision is made, a rhomboid defect,‘d’ develops. After flap incisions, a and b flaps are advanced and rotated into the rhombus, and then, they are sutured to each other.

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of the scar being treated. In some cases, the incision involved only skin and superficial layer of fat, whereas, in others, a deep incision through the fascia was necessary. This incision created a skin defect in shape of a rhomboid on the contracture line (Fig. 2b). Then, both limbs of the Z flap were incised on the lateral sides of the rhomboid defect (Fig. 2c). Tips and margins of the limbs were freed a few millimeters from the fascia with sharp dissection, which would facilitate advancement and rotation of the flaps into the defect over subcutaneous pedicle without developing any deformation of the skin surface like wrinkles. After preparation of the flaps, advancement and rotation were made easily in order to cover the rhomboid defect. With subcutaneous stitches, angles of the wound were closely approximated to the tips of the rotated and advanced flaps, and then, besides subcutaneous tissue, skin edges were sutured in the usual manner (Fig. 2d).

RESULTS This Z-plasty procedure was used in the treatment of seventeen scar contractures of sixteen patients, whose ages ranged from 3 to 25 years, with twelve male and four female

patients. Mean age was 10.3 years. None of the patients had undergone any operation for the release of contracture before. All rotated and advanced flaps healed uneventfully without encountering any major complications such as infection, hematoma, flap loss, suture dehiscence or flap necrosis (Figs. 2-4). All contractures were released completely without the need of any skin grafts or additional Z-plasties and local flaps. In the operation, movement of the limbs of the Z flap was quite simple and easy, providing maximum release of the contracture line. During the suturation of the wound edges together, some skin wrinkles developed at the suture line due to the approximation of the incision lines, and continued in the early postoperative period, and then resolved spontaneously. In all but one patient, contractures released effectively by means of using one or two Z-plasty, and normal joint range of motion was achieved completely. In one patient suffering severe left upper extremity contracture, little residual contracture remained after the intervention due to the inadequate release in the operation. In the follow-up period of 13 months, it didn’t resolve and necessitated releasing with a reoperation, suggesting that contracture release by using only one Z-plasty as done in this case was insufficient to release

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(k)

(l)

(m)

(n)

(o)

(p)

Figure 2. (a) Preoperative view of Patient 8 who had significant elbow contracture. A ZAR flap and relaxing incision line were marked on the elbow. (b) Relaxing incision emerged a skin defect like a rhomboid shape. (c) Flaps were sutured. (d) Seventeen months postoperatively. (e) Patient 4 who had anterior axillary contracture. (f) The ZAR flap and relaxing incision line were marked. (g) Appearance of the contracture line just after the procedure was completed. (h) Thirteen months postoperatively. (i) A mild forearm contracture of the patient 6. (j) Preoperative marking of the ZAR flap and relaxing incision. (k) View of the flaps after the suturation. (l) Sixteen months postoperatively. (m) Severe upper extremity contracture of Patient 7. (n) Preoperative marking of the ZAR flap and relaxing incision. (o) Just after the release of the contracture with a large ZAR flap. (p) Late postoperative results showing inadequate release. Note that it needs releasing again.

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(a)

(b)

Figure 3. (a) Preoperative appearance of a popliteal contracture. (b) Early postoperative results indicate complete releasing of it.

severe contractures completely and they were in need of placing at least two Z-plasties for adequate correction (Fig. 2m-p). Follow-up time ranged from 4 to 21 months with a mean of 13.2 months. No recurrence of the contracture was observed in this period.

DISCUSSION Burn contracture seems to be preventable in the early post burn period with regular therapy sessions by means of rehabilitation, splinting, pressure therapy and massage; however, many patients suffer from the disability arising from the contractures, particularly after insufficient primary care or deep burns. Contractures, especially when involving the joints, lead to challenging problems which may cause severe functional impairments related to the activities of daily life. The first step to treat a contracture is making an adequate contracture release, for which releasing incision is the most preferred and effective way. The second component of treatment consists closing the wounds, for which a number of different methods are available including skin grafting, Z-plasty, local/regional flap, island flap, perforator flap, and free flap. In clinical practice, combined methods which offer both the release and resurfacing of the contracture in the same session are usually preferred in many cases because they are simple, easy and fast. Various types of Z-plasties provide both the release and closure of the contractures successfully, especially in mild contractures.[1] Up to now, many forms of Z-plasties

have been described and used successfully in the treatment of scar contractures, whose shapes, number of limbs, degree of angles, size of triangular flaps and transposition procedures differ from each other in designing and using them. In addition to simple Z-plasty, there are multiple serial, four-flap, fiveflap, six-flap, seven flap, v-y, running v-y, double-opposing and single limb Z-plasties, and other variations.[3,5-9] X-plasty is a form of Z-plasty described for partial coverage of joints after the release of contractures of the fingers. This method consists of two opposing triangular flaps which partially advance the opposing ‘Vs’. The rest of the defect areas arising from contracture release are covered by skin grafts. [10] In the ZAR technique, flaps which are nearly in quadrangular shape, are significantly larger than triangular flaps and when totally advanced to the corner of the rhomboid defect, all surface of the contracture is covered completely without necessitating skin grafting. Burow’s triangles at the base of the flaps are advanced into the defect area by incising the flap base in oblique fashion to use the excess tissue next to the contracture band efficiently. V-N plasty is a variation of X plasty used effectively for the release of the contractures of the web spaces. All available tissues in the web space can be utilized as a local flap in this approach.[11] It has a similar design to X plasty, involving an X incision and two triangular flaps. The two opposing Vs of the X is obliquely advanced to lie side by side, giving an N shape to the contracture band. However, the technique is in need of adding multiple Z-plasty procedures to the rest of the contracture band like a five-flap plasty; otherwise, it is not enough to release a contracture band and cover a contracture defect. It doesn’t use the Burow’s triangles effectively. In our presented method, there was no need for additional Z-plasty procedures and skin grafting because of the larger flap design and the use of Burow’s triangles which make the local tissues near the contracture band more convenient and useful for the coverage of contracture defect.

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

Figure 4. (a) Minimal contractures of arm and forearm. (b) Preoperative marking of flaps. (c) Appearance of the flaps after contracture release and flap dissection were completed. (d) Intraoperative view of the contracture areas after flaps were sutured. (e) Linear contracture band located at the cubital area. (f) Preoperative marking of a large flap. (g) Contracture was released entirely by using relaxing incision and flap incisions. (h) Appearance of the flaps in the early postoperative period.

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Double reverse V-Y-plasty, namely diamond shape incision, is a different way to release a contracture.[6] Apart from ZAR flap, a relaxing incision is not utilized in this approach, but a diamond shape incision is localized along the maximum tension site of the contracture band. Moreover, lateral relaxation incisions are used transversely to provide additional release. Closure of the wound is performed in the way of suturing the wound edges in the V-Y and Y-V manner so V-shaped incision is transformed into a Y-shaped wound closure, and Y-shaped incision into V-shaped wound closure.[6] With this closure, a long linear scar is left over the contracture line, possibly resulting in a linear scar contracture. In this procedure, scar bands or tissues are not transposed from their directions to another way, and therefore, there is a strong possibility for recurrences to occur due to wound contraction in the healing period. In our approach, no linear scar was left over the contracture band, and contracture line was broken by the flaps, reducing the recurrence risk. Rhomboid incision is another way to release scar contractures effectively. In this approach, contractures are released by using rhomboid skin incision, and then, lateral relaxation incisions are made to reduce the tension of the contracture sufficiently. Wound is closed in V-Y and Y-V fashion, without making any undermining, elevation, rotation or advancement of the rhomboid skin island.[5] This method is similar to double reverse V-Y-plasty technique and has the same disadvantages over the ZAR flap approach. Furthermore, it has been described primarily for hand contractures, and there is no information on its effectivity in the correction of other contractures. An effective incision shape, namely circumferential incision, has been reported for the release of wide scar contractures. A spindle-shaped incision line is designed around the scar, whose major axis places along the direction of the contracture line. When sufficient release of the contracture is not achieved by a simple incision, the surrounding skin is slightly undermined, and then, skin defect is closed either by simply suturing, or by suturing the wound margins to each other in combination with Z-plasties.[8] Different from the ZAR flap, in the way of this closure, a linear scar is left on the contracture band, being capable of leading to a linear scar contracture. Also, scar bands or tissues are not transposed from their positions to another way so there is a strong possibility for recurrences to develop owing to the wound contraction in the healing period. Moreover, circumferential incision approach needs considerably more incisions and surgical dissection than the ZAR flap. The seven-flap plasty and multiple Y-V plasty are other excellent techniques in the release of burn contractures. Their designs are suitable for the release of burn contractures located on the neck, axilla, cubital fossa, hand, perineum, and poplitea.[7,9,12,13] Successful outcomes and some modifications Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

have been reported after clinical experiences; however, these techniques need many incisions and significantly more surgical dissections when compared to the ZAR flap. The ZAR flap was firstly described by J.W. Pate in the fifth international symposium of plastic and reconstructive surgery of the head and neck in order to cover rhomboid facial skin defects ranging 1 to 3.2 cm in diameters.[14] Thereafter, it was successfully utilized for hand contractures by making some modifications in the original description of the flap.[15] In this study, these modifications were used for the release of scar contractures which were mentioned previously. As ZAR flap was mainly described for the coverage of rhomboid shape defects, contracture wound arising from relaxing incision was accepted as a rhombus shape placed on the contracture line having corners and angles of a rhombus, and then, flaps were planned next to the defect area in a specific shape similar to a quadrangular shape. Flaps were not designed as a triangle and incisions ended at the base in an oblique way to facilitate the movement of Burow’s triangles into the contracture defect. One Z-plasty is enough to release only mild contractures while two or more Z-plasties are necessary for severe ones. As flaps are in need of only advancement and rotation over subcutaneous tissue without requiring any undermining or elevation, viability of flaps is protected against tip necrosis that usually appear in well-known classical Z-plasty flaps. There is no need for extensive dissection, a large number of skin incisions, skin undermining, lateral relaxing incisions, skin grafting and additional Z-plasty procedures to cover the contracture defect. It transposes and elongates contracture bands sufficiently without leaving a linear scar over the contracture line, reducing the recurrence risk. This procedure has also the advantages of simplicity and effectivity of a relaxing incision, and flap closure together without necessitating any additional procedures. This type of Z-plasty provides a useful option for the release of mild contractures, which is safe, simple and effective. It seems to be a potential alternative to the other well-known methods. Conflict of interest: There are no conflict of interest statements. Neither of the authors have any financial interests, commercial associations, or other affiliations which may pose a conflict of interest to disclose. Furthermore, this paper was not supported by any external funding, nor were any special products, devices, or drugs used in the work presented.

REFERENCES 1. Hudson DA, Renshaw A. An algorithm for the release of burn contractures of the extremities. Burns 2006;32:663-8. 2. Ulkür E, Uygur F, Karagöz H, Celiköz B. Flap choices to treat complex severe postburn hand contracture. Ann Plast Surg 2007;58:479-83. 3. Hudson DA. Some thoughts on choosing a Z-plasty: the Z made simple. Plast Reconstr Surg 2000;106:665-71.

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Gümüş. Repairing post burn scar contractures with a rare form of Z-plasty 4. Schwarz RJ. Management of postburn contractures of the upper extremity. J Burn Care Res 2007;28:212-9. 5. Uzunismail A, Kahveci R, Ozdemir A, Bozdogan N, Yuksel F. The rhomboid release: a new approach to the management of digital burn contractures. Ann Mediterran Burns Club 1995;8:94-7. 6. Askar I. Double reverse V-Y-plasty in postburn scar contractures: a new modification of V-Y-plasty. Burns 2003;29:721-5. 7. Karacaoğlan N, Uysal A. The seven flap-plasty. Br J Plast Surg 1994;47:372-4. 8. Ezoe K, Yotsuyanagi T, Saito T, Ikeda K, Yamauchi M, Arai K, et al. A circumferential incision technique to release wide scar contracture. J Plast Reconstr Aesthet Surg 2008;61:1059-64. 9. Pegahmehr M, Hafezi F, Naghibzadeh B, Nouhi A. Multiple V-Y advancement flaps: a new method for axillary burn contracture release. Plast

Reconstr Surg 2008;122:44-5. 10. Vartak A, Keswani MH. X-plasty for repair of burn contractures. Burns 1992;18:326-8. 11. El Kollali R, Ghoneim I, Azemi MA. V-N plasty for the release of severe postburn contractures. J Plast Reconstr Aesthet Surg 2006;59:1424-8. 12. Shaw DT, Li CS. Multiple Y-V plasty. Ann Plast Surg 1979;2:436-40. 13. Lin TM, Lee SS, Lai CS, Lin SD. Treatment of axillary burn scar contracture using opposite running Y-V-plasty. Burns 2005;31:894-900. 14. Pate JW, Wilkinson JC. Z-advancement rotation flap reconstruction of full-thickness cutaneous defects of the nose. In: Stucker JF, Decker BC, editors. Plastic and reconstructive surgery of the head and neck, proceeding of the fifth international symposium. Philadelphia: 1991; p. 549-55. 15. Gümüş N, Yılmaz S. Management of scar contractures of the hand using Z advancement rotation flap. Burns 2013;39:978-83.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yanık sonrası skar kontraktürlerinin nadir bir Z-plasti yöntemi ile düzeltilmesi Dr. Nazım Gümüş Numune Eğitim ve Araştırma Hastanesi, Plastik ve Rekonstrüktif Cerrahi Kliniği, Adana

AMAÇ: Erken yanık tedavisinde birçok önlemler alınmasına rağmen, yanık sonrası kontraktürler yanık hastalarında hala ciddi bir problem olmaya devam etmektedir. Bu çalışmada, gevşetme kesisi ile birleştirilmiş bir Z-plasti şekli skar kontraktürlerinin düzeltilmesinde kullanıldı. GEREÇ VE YÖNTEM: Ameliyattan önce kontraktür çizgisi üzerine gevşetme kesisi ile birleştirilmiş bir Z ilerletme çevirme flebi çizildi. Gevşetme kesisi kontraktür çizgisi üzerinde romboid şekilli bir deri kaybı oluşturdu. Ardından, Z-plastinin her iki bacağı kesildi. Fleplerin hazırlanması sonrasında, romboid deri kaybını kapatmak için fleplerin ilerletme ve çevirmesi yapıldı. Cilt altı dokunun yanısıra, deri kenarları dikişlerle yaklaştırıldı. BULGULAR: Bu çalışma Z ilerletme çevirme flebi ile başarılı olarak tedavi edilmiş yanık sonrası skar kontraktürüne sahip 16 hastayı kapsadı. Yöntem, flep nekrozu, dikiş açılması, flep kaybı, enfeksiyon ve hematom gibi herhangi bir büyük komplikasyonla karşılaşılmadan kullanıldı. Tüm ilerletilip çevrilen flepler sorunsuz iyileşti. Biri dışında tüm hastalarda, etkili kontraktür gevşemesi bir veya iki Z-plasti kullanarak elde edildi. Ciddi üst ekstremite kontraktürü olan bir hastada, yetersiz gevşemeye bağlı az bir miktar artık kontraktür kaldı. TARTIŞMA: Hafif kontraktürler için bu Z-plasti işlemi değerlendirildiğinde, yöntem güvenli, basit ve etkili olup, yanık sonrası kontraktürlerin düzeltilmesinde yeni bir seçenek sunmaktadır. Anahtar sözcükler: Çevirme; gevşeme kesisi; ilerletme; kontraktür; Z-plasti. Ulus Travma Acil Cerrahi Derg 2015;21(3):187-192

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ORIGIN A L A R T IC L E

The frequency of type 2 second-degree and third-degree atrioventricular block induced by blunt chest trauma in the emergency department: A multicenter study Banu Şahin Yıldız, M.D.,1 Mehmet Ali Astarcıoğlu, M.D.,2 Nazire Başkurt Aladağ, M.D.,1 Ahmet Çağrı Aykan, M.D.,3 Hakan Hasdemir, M.D.,4 Alparslan Şahin, M.D.,5 Mustafa Yıldız, M.D.3 1

Department of Internal Medicine, Dr. Lütfi Kırdar Kartal Training and Research Hospital, İstanbul

Department of Cardiology, Dumlupınar University Evliya Çelebi Training and Research Hospital, Kütahya

Department of Cardiology, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul

Department of Cardiology, Dr. Siyami Ersek Cardiovascular and Thoracic Surgery Training and Research Hospital, İstanbul

Department of Cardiology, Dr. Sadi Konuk Training and Research Hospital, İstanbul

ABSTRACT BACKGROUND: Conduction disturbances including type 2 second-degree atrioventricular block (Mobitz II) and third-degree atrioventricular block following blunt chest trauma are probably rare. Moreover, the pathophysiological mechanisms responsible for this rare dysrhythmia following trauma are not well understood yet. In this study, it was aimed to identify the frequency of this dysrhythmia associated with trauma. METHODS: Two hundred and fifty-three consecutive Mobitz II block and third-degree atrioventricular block patients admitted to the Emergency Department of Internal Medicine between January 2012 and March 2013 were evaluated. Only four patients with Mobitz II block and third-degree atrioventricular block associated with trauma were enrolled into the present study. The level of atrioventricular block was defined according to electrocardiographic characteristics. RESULTS: Only four (mean age: 40.2±19.7 years, two male) of 253 patients were associated with trauma. All patients had normal coronary arteries in coronary angiography or multislice computed tomography. Permanent pacemaker was performed in two patients with third-degree atrioventricular block. None of the patients had coronary artery disease or hypertension. CONCLUSION: Rare clinical cases in the literature confirm that blunt chest trauma can cause conduction defects, which are usually transient. However, patients with blunt chest trauma must need an electrocardiographic evaluation for atrioventricular block upon admission and in the follow-up period. Key words: Blunt chest trauma; electrocardiography; third-degree atrioventricular block; Type 2 second-degree atrioventricular block (Mobitz II).

INTRODUCTION Blunt chest trauma is a significant cause of morbidity and mortality in life. It can affect chest wall and thoracic cav-

Address for correspondence: Banu Şahin Yıldız, M.D. Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, Kardiyoloji Anabilim Dalı, İstanbul, Turkey Tel: +90 274 - 230 66 60 E-mail: maliastarcioglu@gmail.com Qucik Response Code

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ity including the clavicles, ribs, esophagus, lungs, and heart. [1] It may cause cardiac lesions in coronary arteries, valves and pericardium. Depending on the extent of trauma, such injuries can cause varying amounts of mechanical or electrical dysfunction including high degree atrioventricular block and ventricular fibrillation.[2] There are still limited data regarding the incidence, prevalence and clinical characteristics of important dysrhythmia including type 2 second-degree atrioventricular block (Mobitz II) and third-degree atrioventricular block following trauma.[2-4] Moreover, the pathophysiological mechanisms responsible for this rare dysrhythmia following trauma are not well understood yet. The aim of this present study was to identify the frequency of the Mobitz II block and third-degree atrioventricular block 193

Şahin Yıldız et al. Type 2 second-degree and third-degree atrioventricular block

associated with trauma in the Emergency Department of Internal Medicine. The dysrhythmia was also assessed for the necessity of permanent pacemaker.

MATERIALS AND METHODS Two hundred and fifty-three consecutive Mobitz II block and third-degree atrioventricular block patients admitted to the Emergency Department of Internal Medicine between January 2012 and March 2013 were evaluated. Only four patients with Mobitz II block (two patients) and third-degree atrioventricular block (two patients) were associated with trauma, and those four patients were enrolled into the present study. The study was approved by the local committee. All subjects gave their consent for inclusion into the study. The investigation conformed to the principles outlined in the Declaration of Helsinki. Patients with electrolyte abnormalities, digitalis toxicity, vasovagal syncope, myocardial infarction history, and patients using drugs, which might affect atrioventricular node, were excluded from the study. The level of atrioventricular block was defined according to the following electrocardiographic characteristics: Type 2 second-degree atrioventricular block (Mobitz II): Mobitz II heart block is characterized on a surface electrocardiography by intermittently non-conducted P waves not preceded by PR prolongation and not followed by PR shortening. The block may progress rapidly to third-degree atrioventricular block.

Figure 1. The patient with Mobitz II block after blowing the soccer ball.

Third-degree atrioventricular block or complete heart block: This is a medical condition in which the impulse generated in the sinoatrial node in the atrium does not propagate to the ventricles. The PR interval will be variable as the hallmark of complete heart block is no apparent relationship between P waves and QRS complexes.

RESULTS Only four patients (mean age: 40.2±19.7 years, two male) with Mobitz II block (two female patients) (Fig. 1) and thirddegree atrioventricular block (two male patients) were associated with trauma. All patients had normal coronary arteries in coronary angiography or multislice computed tomography. Permanent pacemaker was performed in two patients with

Table 1. Baseline clinical and electrocardiographic characteristics and treatment of patients with atrioventricular block Patient

3 4

Age (years)

Sex

Male

Female

Female Male

Event

Blunt chest and head

Automobile accident

Blow with

trauma after a robbery

soccer ball

Symptoms and starting

Dizziness and syncope;

Dizziness;

Chest pain, dyspnea,

Blow with soccer ball Pre-syncope; immediately

time after trauma

2 days

dizziness; immediately

immediately

Risk factors for dysrhythmia

–

Using drugs

–

Electrocardiogram

Complete AV block

Mobitz II block progressed

Mobitz

Complete AV block

II block

to complete AV block

on day 3

RBBB on the

–

Hemo-pericardium –

–

– –

Heart valve injury

–

Tricuspide valve

–

Treatment

Dual-chamber rate-adaptive

Medical

Dual-chamber rate-adaptive

(DDDR) pacemaker

–

electrocardiography

(DDDR) pacemaker

AV: Atrioventricular; RBBB: Right bundle branch block.

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Şahin Yıldız et al. Type 2 second-degree and third-degree atrioventricular block

third-degree atrioventricular block. None of the patients had history of any disease like coronary artery disease and hypertension. Baseline clinical and electrocardiographic characteristics and treatment of patients with atrioventricular block are shown in Table 1.

DISCUSSION In this study, it was found that only four of 253 consecutive Mobitz II block and third-degree atrioventricular block patients, admitted to the Emergency Department of Internal Medicine, were associated with blunt chest trauma. The occurrence of myocardial contusion after blunt chest trauma varies between 8 and 76% according to the clinical criteria used for diagnosis. Traffic accidents are the most common cause, although it has also been described in sport accidents, kicks from animals, falls and cardiac resuscitation maneuvers. [1] These injuries may result from lacerations to valve rupture, myocardial rupture with tamponade, acute myocardial infarction following coronary arteries thrombosis and/or dissection, arrhythmia like ventricular fibrillation and myocardial contusion which may result in dysrhythmias and blocks generally bifascicular or right bundle branch; however, constituting complete AV block is a rare complication.[2-7] Although the occurrence of complete AV block is common in traumatic experimental models, it is an exceptional observation in clinical practice. Although the exact cause of these disorders is unknown, various mechanisms have been proposed, such as the appearance focal hemorrhages in the region of the atrioventricular node, localized hypoxia specific conduction tissue, increased vagal tone or release of depressants of the conduction system. Pathologic changes associated with blunt trauma induced by conduction disturbances are variable.[8,9] Generally, no pathologic changes were found, despite findings of repolarization changes, conduction defects and dysrhythmias. Conduction disturbances might be associated with inflammation. Several inflammatory mediators such as interleukin-6, tumor necrosis factor, and prostanoids are released following blunt chest trauma.[10-12] Moreover, scar tissue formation during the healing process may cause late complications like atrioventricular block in myocardial blunt trauma.[13] Case 1 had normal sinus rhythm in electrocardiography before the event and demonstrated symptomatic complete atrioventricular block with right bundle branch morphology after blunt chest trauma. His echocardiography was normal in terms of trauma. Atrioventricular block may be associated with fibrosis affecting the conduction system as part of the healing process after myocardial injury. While complete atrioventricular block reoccurred after four months and became permanent, the dual-chamber rate-adaptive (DDDR) -mode pacemaker was implanted and the patient had an uneventful recovery. In Case 2, electrocardiography was consistent with Mobitz II block on admission, which subsequently progressed to complete atrioventricular block on day 3. Furthermore, severe tricuspid regurgitation with chordae tendineae rupture was seen in the Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

transthoracic echocardiography. During follow-up with close hemodynamic monitoring, her symptoms disappeared and sequential echocardiographic evaluations revealed a regression in the severity of tricuspid regurgitation. Finally, she was discharged with medical therapy about one week later. During her follow-ups, electrocardiography revealed normal sinus rhythm. In Case 3 (a female footballer), admission electrocardiography was consistent with Mobitz II block alternating sinus rhythm after receiving a blow with the soccer ball. Holter rhythm monitoring, echocardiography and electrophysiological study revealed in normal range. After 12 months of follow-up, as she was athletic, she had no specific cardiovascular symptoms. In addition, she had normal electrocardiography. Case 4 was also admitted with complete atrioventricular block after receiving a blow with the soccer ball. His echocardiography was normal in terms of trauma. While complete atrioventricular block reoccurred after two weeks and became permanent, the DDDR mode pacemaker was implanted and the patient had an uneventful recovery. Baseline clinical and electrocardiographic characteristics and treatment of the patients with atrioventricular block were shown in Table 1. Rare clinical cases in the literature confirm that blunt chest trauma can cause conduction defects and that these defects are usually transient, as they were in our study. However, patients with blunt chest trauma must need an electrocardiographic evaluation for atrioventricular block upon admission and in the follow-up period. Conflict of interest: None declared.

REFERENCES 1. Calhoon JH, Grover FL, Trinkle JK. Chest trauma. Approach and management. Clin Chest Med 1992;13:55-67. 2. Brennan JA, Field JM, Liedtke AJ. Reversible heart block following nonpenetrating chest trauma. J Trauma 1979;19:784-8. 3. Hasdemir H, Arslan Y, Alper A, Osmonov D, Güvenç TS, Poyraz E, et al. Severe tricuspid regurgitation and atrioventicular block caused by blunt thoracic trauma in an elderly woman. J Emerg Med 2012;43:445-7. 4. Aykan AC, Oguz AE, Yildiz M, Özkan M. Complete atrioventricular block associated with non-penetrating cardiac trauma in a 40-year-old man. J Emerg Med 2013;44:41-3. 5. Kumagai H, Hamanaka Y, Hirai S, Mitsui N, Kobayashi T. Mitral valve plasty for mitral regurgitation after blunt chest trauma. Ann Thorac Cardiovasc Surg 2001;7:175-9. 6. Sakka SG, Hüttemann E, Reinhart K. Left ventricular aneurysm after myocardial contusion caused by blunt chest trauma. [Article in German] Anasthesiol Intensivmed Notfallmed Schmerzther 2000;35:412-6. [Abstract] 7. Ildstad ST, Tollerud DJ, Weiss RG, Cox JA, Martin LW. Cardiac contusion in pediatric patients with blunt thoracic trauma. J Pediatr Surg 1990;25:287-9. 8. Carr KW, Johnson AD, Gregoratos G. Transient bifascicular block following blunt chest trauma. West J Med 1982;137:245-9. 9. Cobanoglu U. Göğüs travmalı 70 olguda kardiyolojik değişikliklerin incelenmesi. Toraks Dergisi 2007;8:59-68.

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Şahin Yıldız et al. Type 2 second-degree and third-degree atrioventricular block 10. Knöferl MW, Liener UC, Seitz DH, Perl M, Brückner UB, Kinzl L, et al. Cardiopulmonary, histological, and inflammatory alterations after lung contusion in a novel mouse model of blunt chest trauma. Shock 2003;19:519-25. 11. Perl M, Kieninger M, Huber-Lang MS, Gross HJ, Bachem MG, Braumüller S, et al. Divergent effects of activated neutrophils on inflammation, Kupffer cell/splenocyte activation, and lung injury following blunt

chest trauma. Shock 2012;37:210-8. 12. Majetschak M, Obertacke U, Schade FU, Bardenheuer M, Voggenreiter G, Bloemeke B, et al. Tumor necrosis factor gene polymorphisms, leukocyte function, and sepsis susceptibility in blunt trauma patients. Clin Diagn Lab Immunol 2002;9:1205-11. 13. Liedtke AJ, DeMuth WE Jr. Nonpenetrating cardiac injuries: a collective review. Am Heart J 1973;86:687-97.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Acil serviste künt göğüs travmasına bağlı tip 2 ikinci derece ve üçüncü derece atriyoventriküler blok sıklığı: Çok merkezli çalışma Dr. Banu Şahin Yıldız,1 Dr. Mehmet Ali Astarcıoğlu,2 Dr. Nazire Başkurt Aladağ,1 Dr. Ahmet Çağrı Aykan,3 Dr. Hakan Hasdemir,4 Dr. Alparslan Şahin,5 Dr. Mustafa Yıldız3 Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İstanbul; Dumlupınar Üniversitesi Evliya Çelebi Eğitim ve Araştırma Hastanesi, Kardiyoloji Anabilim Dalı, Kütahya; Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İstanbul; 4 Dr. Siyami Ersek Kardiyovasküler ve Torasik Cerrahi Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İstanbul; 5 Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Kardiyoloji Kliniği, İstanbul 1 2 3

AMAÇ: Künt göğüs travmasını takiben tip 2 ikinci derece atriyoventriküler blok (Mobitz II) ve üçüncü derece atriyoventriküler blok iletim bozuklukları oldukça nadirdir. Dahası, travmayı takiben oluşan bu disritmilerden sorumlu patofizyolojik mekanizmalar henüz tam olarak anlaşılamamıştır. Biz travma ile ilişkili bu disritmilerin sıklığını tespit etmeyi amaçladık. GEREÇ VE YÖNTEM: Acil servise başvuran ardışık Mobitz II ve üçüncü derece atriyoventriküler bloklu 253 hasta, Ocak 2012 ile Mart 2013 tarihleri arasında değerlendirildi. Mobitz II ve üçüncü derece atriyoventriküler blok ve travma ile ilişkili sadece dört hasta mevcut çalışmaya alındı. A triyoventriküler blok düzeyi elektrokardiyografik özelliklere göre tanımlandı. BULGULAR: 253 hastanın sadece dördü (ortalama yaş: 40.2±19.7 yıl, iki erkek) travma ile ilişkili bulundu. Tüm hastaların koroner anjiyografi veya çok kesitli bilgisayarlı tomografi ile koroner arterleri normal saptandı. Kalıcı kalp pili üçüncü derece atriyoventriküler bloğu olan iki hastaya takıldı. Hastaların hiçbirinde koroner arter hastalığı ve hipertansiyon yoktu. TARTIŞMA: Literatürde künt göğüs travmasına bağlı iletim kusurları nadir görülen klinik olgulardır ve genellikle geçici olmaktadır. Bu nedenle künt göğüs travması olan hastaların başvuru sırasında ve takiplerde atriyoventriküler blok açısından elektrokardiyografik değerlendirilmesi gerekir. Anahtar sözcükler: Elektrokardiyografi; künt göğüs travması; üçüncü derece atriyoventriküler blok; tip 2 ikinci derece atriyoventriküler blok (Mobitz II). Ulus Travma Acil Cerrahi Derg 2015;21(3):193-196

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doi: 10.5505/tjtes.2015.04763

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ORIGIN A L A RT I C L E

Fixation of distal femoral fractures: Restoration of the knee motion Elsayed Ibraheem Elsayed Massoud, M.D. Department of Orthopaedic, Sohag Teaching Hospital, General Organization for Teaching Hospitals and Institutes, Sohag, Egypt

ABSTRACT BACKGROUND: Most of healed lower femoral fractures resulted in various degree of loss of the knee motion. Flexion deficit is a serious problem for the Eastern persons that are where squatting and sitting on the ground are necessary for daily activities. The aims of this study were to compare outcomes of using condylar buttress plate and dynamic condylar screw (DCS) in treatment of distal femoral fractures. Secondly, we present our clinical experience for optimizing the technical application of the studied implants. METHODS: Two groups (plate and DCS) of 57 patients were treated for 59 lower femoral fractures with condylar buttress plate or DCS and followed prospectively for 24 months. RESULTS: Plate group reported adequate reduction in 67% and varus angulation in 13.3% of the fractures. DCS group reported adequate reduction in 72.4% and posterior angulations in 17% of the fractures. Other reasons for inadequacy of reduction were reported in both groups. Full knee motion range was achieved in 50% of plate group and in 55% of DCS group. 75% and 90 % satisfactory functional outcomes were reported in the plate and DCS groups respectively. CONCLUSION: Both implants nearly achieved equal results concerning restoration of knee motion range. The condylar buttress plate and DCS are liable for technical optimization. Key words: Condylar buttress plate; dynamic condylar screw; fracture; knee motion; lower femur.

INTRODUCTION Most healed lower femoral fractures result in various degree of loss in knee motion. Fractures treated conservatively complicate with extension lag, flexion deficit or locked knee. Deformity and loss of knee motion have led to widespread attempts at internal fixation.[1] However, surgical treatment has preserved knee extension but failed in restoration of the knee flexion. Fixation using retrograde nails obligates healing with posterior angulation particularly if the distal interlocking screws are fixed while the knee is extended. Posterior attachment of the gastrocnemius muscle encouraged healing with posterior angulation.[2,3] On the other hand, dynamic condylar screw (DCS) and condylar buttress plate give liberty for surgeon to adjust flexion and extension of the distal fragment Address for correspondence: Elsayed Ibraheem Elsayed Massoud, M.D. Nile St Sohag 00 Sohag, Egypt Tel: +2 0934790632 E-mail: elsayedmassoud@hotmail.com Qucik Response Code

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at the main fracture line.[4] Flexion deficit is a serious problem for Eastern people who need to squat and sit on the ground for daily activities, which renders a search for a technique that restores knee motion range mandatory. The aim of this study was to compare the outcomes of using condylar buttress plate and DCS in the treatment of distal femoral fractures. Our clinical experience for optimizing technical application of the studied implants was also presented.

MATERIALS AND METHODS Fifty-seven patients, who agreed to participate in this prospective study between October 2006 and October 2011, were included and managed for 59 lower femoral fractures. Local Ethics Committee approved the study. The fracture patterns were determined radiographically according to AO classification. Preoperative details of the included patients are listed in Table 1. The mean age of the patients at the time of operation was 48 years (range, 24-82 years). The patients were divided into two groups, consisting the plate group and DCS group. The plate group included twenty-eight patients with 30 fractures, of which two were type B3 that was not encountered lone in this study. Coronal fractures (type B3) were fixed using 6.5 mm cancellous screws. The DCS group 197

Massoud. Fixation of distal femoral fractures: restoration of the knee motion

included twenty-nine patients with 29 fractures. A thigh tourniquet was used when the fracture did not extend too far proximally. Primary bone grafting was not done for any of our patients. Postoperative management was individualized based on the quality of reduction obtained. Active and passive knee motions were started on the second postoperative day. Patients were allowed to walk using crutches and toe touch until absence of pain and a good callus had been observed on radiographs. Afterwards, progressive weight bearing was started. However, if the reduction was considered inadequate, partial weight bearing was allowed only when the callus bridged the fracture gap. Follow-up reviews were undertaken at every other week for 16 weeks, and then monthly. After the first year, patients were re-evaluated twice per year. The outcomes were assessed 24 months postoperatively.

Radiological Assessment Reduction was categorized adequate if there was no angulation (extension/flexion, varus/valgus), displacement or rotation at the main fracture line. Angulation >10°, displacement between the main proximal and distal segments >2 mm or rotation was deemed inadequate. Displacements between the fragments within the articular block would be considered a technical failure of fixation. Angulations (varus/valgus and extension/flexion) were assessed by measuring the anatomic lateral distal femoral angle and anatomic posterior distal femoral angle, respectively. The anatomic lateral distal femoral angle describes the intersection between the anatomic axis and the horizontal line tangential to the subchondral surface of the femoral condyles, its normal mean value is 81° (range: 79-83°). The anatomic posterior distal femoral angle describes the intersection between the anatomic axis and the sagittal distal femoral joint orientation line, its normal mean value is 83° (range: 79-87°).[5,6] Proper rotation of the distal segment was judged radiographically using one of the techniques described by Krettek et al.[7] These techniques include: 1) cortical thickness 2) cortical diameters and 3) profile of the lesser trochanter. Choosing any of these technique depends on fracture pattern, site and comminution at the fracture line. Technical failures were defined as screw penetration of ar-

ticular surface of the distal articular block, displacement >2 mm between the femoral condyles or condylar fragments (type B3 fracture), implant breakage or loosening, or nonunion. Penetration of the medial cortex was not considered a technical failure. The fracture was defined healed if there were visible trabeculae across the fracture line. Time to union was calculated from the surgery date to the healing date. Non-union was defined as the absence of bridging bone at the fracture line by follow-up at 12 months, including progressive displacements.

Clinical Assessment Knee joint motion was measured using a goniometer and compared to the healthy side. Leg length was assessed by measuring the distance between the anterior superior iliac spine and the tip of medial malleolus. Lengths of the lower extremities were compared. Functional outcome was classified according to Schatzker and Lambert criteria.[8] The results were then classified satisfactory (excellent and good) and unsatisfactory (fair and poor).

Statistical Analysis The results were expressed as maximum and minimum values, mean and standard deviation (SD). Z test was used for unpaired groups and nominal (categorical) data was used in the comparison between the plate group and the DCS group variables. Wilcoxon Rank Sum Test (Mann-Whitney U test) for unpaired data was used in the comparison between the plate group and the DCS group. Significance was set at p<0.05. Microsoft Excel 2010 was used, and the web site was http://www.socscistatistics.com/tests/ztest/Default2.aspx

RESULTS The baseline data of the patients included into the study are listed in Table 1. Reduction was categorized in the plate group as adequate in 20 fractures (67%) and inadequate in 10 fractures (33%). In the DCS group, reduction was categorized as adequate in 21 fractures (72.4%) and inadequate in 8 fractures (27.6%) (Table 2). Difference between the two groups using Z test, was statistically insignificant (p=0.63122). Reasons for inadequate reduction in the plate group were varus angulation in 4 fractures (13.3%), displacement between the main proxi-

Table 1. Preoperative baseline data for two groups of patients with lower femoral fractures Groups

Patients No.

Fractures No

Side Right

Left

Sex Male

Fracture types

Female

Type A

Type B

Type C

A1 A2 A3 B1 B2 B3 C1 C2 C3

Plate

15 13 17

11 5 3 6 0 1 2 3 3 7

DCS

18 11 20

198

5 5 5 0 1 0 3 3 7

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Massoud. Fixation of distal femoral fractures: restoration of the knee motion

Table 2. The results for two groups of patients treated for lower femoral fractures with condylar buttress plate and DCS Type/no

Plate group

Sum

DCS group

Sum

A1 A2 A3 B2 B3 C1 C2 C3

5 3 6 1 2 3 3 7

5 5 5 1 0 3 3 7

Reduction Adequate

5 3 2 1 1 2 3 3 20 (67%)

3 3 5 1 0 2 2 5 21 (72.4%)

Inadequate

0 0 4 0 1 1 0 4 10 (33%)

2 2 0 0 0 1 1 2

8 (27.6%)

Shortening

0 0 3 0 0 0 0 4 7 (25%)

1 2 0 0 0 1 1 2

7 (24%)

Flexion deficit

1 1 3 1 2 1 0 5 14 (50%)

1 2 3 1 0 1 1 4

13 (45%)

Pain

0 0 0 0 0 0 0 2

0 0 1 0 0 0 0 0

0 0 0 0 1 0 0 2

0 1 0 0 0 1 0 2

Complications Tf Infection

0 0 0 0 0 0 0 2

0 1 1 0 0 0 0 0

Nonunion

0 0 0 0 0 0 0 0

0 0 1 0 0 0 0 0

4 3 2 0 0 1 2 4

16 (55%)

Grading Excellent

4 2 3 0 – 2 3 2 16 (57%)

Good

1 1 1 1 – 0 0 1 5 (18%)

1 1 2 1 0 2 1 2 10 (34.5%)

Fair

0 0 2 0 – 1 0 2 5 (18%)

0 1 0 0 0 0 1 0

2 (7%)

Poor

0 0 0 0 – 0 0 2 2 (7%)

0 0 1 0 0 0 0 0

1 (3.5%)

Tf: Technical failure.

mal and distal segments in 8 fractures (26.7%) and rotation in one fracture (3.3%). Reasons for inadequacy of reduction in the DCS group were posterior angulation in 5 fractures (17%), displacement between main proximal and distal segments in 7 fractures (24%) and rotation in 2 fractures (6.9%). In both groups, there was more than one reason for inadequacy of reduction per one fracture. It was remarkable that

(a)

(b)

the posterior angulation was detected in the DCS group (Fig. 1); however, it was not observed in the plate group. The fractures united within an average period of 15.5 weeks (8-28 weeks) in the plate group and 12.8 weeks (8-24 weeks) in the DCS group. Non-union was reported in one patient in the DCS group.

(c)

(d)

Figure 1. (a) Preoperative anteroposterior (AP) radiograph for right knee of a 45-year-old female shows AO type A1 lower femoral fracture; (b, c) the AP and lateral radiographs made immediately postoperative shows the fracture was fixed with DCS. The AP view shows medial cortical defect and the lateral view shows posterior angulation; (d) shows healed fracture with no varus collapse.

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Full knee motion range compared to contralateral side was achieved in fourteen patients (50%) of plate group and in sixteen patients (55%) in the DCS group (Table 2). The difference between the two groups using Z test, was statistically insignificant (p=0.69654). Extension lag was not reported in any of the groups even in those with posterior angulation. Flexion deficit in the plate group averaged 10.5째 (SD=11.7, range 0-30째) and in the DCS group averaged 10.3째 (SD=12.7, range 0-40째). The difference between the two groups using U test, was statistically insignificant (p=0.90448). Leg length inequality was reported in seven patients (25%) in the plate group and in seven patients (24%) in the DCS group (Table 2). The difference between the two groups using Z test was statistically insignificant (p=0.93624). Leg shortening in the plate group averaged 0.5 cm (SD=0.88, range 0-2 cm) and in the DCS group averaged 0.3 cm (SD=0.51, range 0-1.5 cm). The difference between the two groups using U test was statistically insignificant (p=0.67448). Persistent pain was reported in two patients of the plate group and in one patient of the DCS group (Table 2). Functional outcomes (Table 2) in the plate group were reported as satisfactory (excellent and good) in twenty-one patients (75%) and unsatisfactory (fair and poor) in seven (25%). In the DCS group, satisfactory results were reported in twenty-six patients (90%) and unsatisfactory in three (10%). The difference between the two groups using Z test was statistically insignificant (p=0.14706).

(a)

(b)

Complications Technical failure and deep infections were reported in five patients (17.9%) of the plate group and in six patients (20.7%) of the DCS group (Table 2). The difference between the two groups using Z test was statistically insignificant (p=0.64514). Technical failure due to displacement between fragments of the articular block was reported in 3 fractures (10%) of the plate group and in 3 fractures (10.3%) of the DCS group. Screw penetration of the distal articular block exclusively reported in one patient of the DCS group. The lag screw was reinserted soundly once discovered. Deep infection was reported in two fractures in each group, three fractures healed after surgical intervention and parenteral antibiotics. The fourth was in the DCS group, an obese diabetic female with type A3 fracture. Deep infection was not controlled and the fracture was not united at the end of the follow-up period despite extensive surgical debridement, parenteral antibiotics and two attempts for bone grafting. Superficial wound infection was reported in three and five patients of the plate and DCS groups, respectively. In one patient of the DCS group with type A1 fracture, lag screw penetration of the medial cortex was observed. Upon bone healing, the lag screw was removed through small medial and lateral incisions, and rest of the DCS components were left (Fig. 2).

DISCUSSION Condylar buttress plate has comparable advantages as DCS

(c)

Figure 2. (a) Preoperative AP radiograph for left knee of a 57-year-old male shows AO type A1 lower femoral fracture; (b) AP radiograph made one month postoperatively shows lag screw penetration of the medial cortex; (c) AP radiograph made 6 months postoperatively shows healed fracture and lag screw was removed, rest of DCS composite was left.

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such as familiarity and liberty for surgeons to reduce anatomically the distal fragment(s). However, it is required to know whether full knee motion range will be restored by using any of them.

realised, the second inserted screw was inserted to distal segment. When the distal segment was excessively short, a plate holding forceps was used to resist the rotation. In this way, posterior angulation was not observed again.

Angle blade plates have been reported to give good results,[9] but the need to hammer the implant into position risks separating the femoral condyles.[10] DCS, which has a design analogous to that of the angled plate, is technically easier to apply and allows more freedom in the coronal and sagittal planes since the plate and screw are separate pieces.[11] Thereby, it makes accurate reduction, particularly when the fractures are intra-articular and the lag screw held well, even in osteoporotic bone.[10] Moreover, DCS did not fail with fatigue testing.[12] On the other hand, the condylar buttress plate was designed to allow multiple lag screw fixations of complex condylar fractures. However, this plate is not a fixed-angle device, and therefore, does not maintain correct alignment of the joint axis.[13]

Posterior angulation was not reported in the plate group, which in our standpoint, was attributed to the fact that the plate was initially held with plate holder forceps, and distal end of the plate allowed multiple lag screw insertion. However, the plate group reported varus angulation in four fractures. The collapse of the distal fragment into varus has previously been attributed to the fact that individual lag screws are not fixed to the plate, and therefore it can easily shift their angulation relative to it.[13] A biomechanical study related varus angulation to decreased rigidity and strength of this device.[14] For maintenance of fixation, some authors have adopted double plating, placement of angulated screw in the lateral condylar buttress plate (Fig. 3) or locked plating.[13-15]

Alignment of the distal articular block of the femur is the main treatment concern. Although the DCS design has the described stability, posterior angulation was reported in five fractures in the DCS group. In the earlier cases of the study, we had used one plate holding forceps prior to insertion of the cortical screws to the proximal bone segment, as we usually do with proximal femoral fractures, which allowed rotation of the distal segment around the lag screw, and consequently, posterior angulation (Fig. 1). Once the error was

(a)

(b)

Flexion deficit has serious effects on the daily activities of Eastern peoples. Moreover, it may accelerate hip joint damage or loosening of hip endoprostheses.[16] The relevant authors have concluded the etiology of flexion loss in intra and extra articular possibilities such as mal reduction of the articular surface, arthrofibrosis, hardware penetration, capsular contractures or muscular scarring.[17,18] In the current study, flexion deficit was reported with intra articular fractures as well as with intact articular block, which theoretically, meant that the cause of deficit probably related to extra articular

(c)

Figure 3. (a) Preoperative AP radiograph for left knee of a 30-year-old male shows AO type C2 lower femoral fracture; (b) AP radiograph made one month postoperatively shows the fracture was fixed with condylar buttress plate, and there is a medial cortical defect. A screw was placed diagonally across the fracture site (arrow) (c) AP radiograph made 6 months postoperatively shows healed fracture with no varus angulation. Screw angulation in the plate strengthened the overall construct to resist the tendency toward varus deformity.[14]

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causes. Anterior adhesions was observed by authors practicing arthroscopic release in post-traumatic stiff knees. Anterior adhesions involve quadriceps expansion in the lateral and medial recesses, the suprapatellar bursa, muscle adhesions to the femur, or even shortening of the rectus femoris.[17] Excursion of the quadriceps, when the knee is flexed from zero to 90 degrees, has been shown to be six to eight centimetres. Therefore, any condition that injures the quadriceps, like a supracondylar femoral fracture, will result in limitation of the muscle elongation with loss of knee flexion.[19] Extension lag, even with posterior angulation, was not reported in the study. Brown et al. have reported that a lag in extension was present in every patient for some weeks following the operation; however, in no case did it persist.[20] Flexion deficit was observed when the lag screw of the DCS was misplaced. In a case with type A1 supracondylar fracture, after assembly of the DCS components, passive flexion deficit was noticed. Mal-positioning of the distal femoral articular block was suspected. Mal-positioning affects patellofemoral kinematics, and abnormal tensioning of the soft tissues may also occur.[21,22] Using a triple reamer, the lag screw hole is re-reamed to a distance shorter than the screw length, which allows the distal articular block to move around the plate nozzle and relaxes the soft tissues. Thus, again tested passive flexion range increased.

Conclusion No implant is superior to the other for restoration of knee motion when used for treatment of distal femoral fracture. Applications of the condylar buttress plate and DCS are liable for technical optimization.

4. Wähnert D, Hoffmeier KL, von Oldenburg G, Fröber R, Hofmann GO, Mückley T. Internal fixation of type-C distal femoral fractures in osteoporotic bone. J Bone Joint Surg Am 2010;92:1442-52. 5. Charles A. In Rockwood and Green’s fractures in adults, 7th ed., vol. 1, Lippincott, Philadelphia 2010. p. 666-73. 6. Keats TE, Teeslink R, Diamond AE, Williams JH. Normal axial relationships of the major joints. Radiology 1966;87:904-7. 7. Krettek C, Miclau T, Grün O, Schandelmaier P, Tscherne H. Intraoperative control of axes, rotation and length in femoral and tibial fractures. Technical note. Injury 1998;29 Suppl 3:29-39. 8. Schatzker J, Lambert DC. Supracondylar fractures of the femur. Clin Orthop Relat Res 1979;138:77-83. 9. Yang RS, Liu HC, Liu TK. Supracondylar fractures of the femur. J Trauma. 1990;30:315-9. 10. Shewring DJ, Meggitt BF. Fractures of the distal femur treated with the AO dynamic condylar screw. J Bone Joint Surg Br 1992;74:122-5. 11. Petsatodis G, Chatzisymeon A, Antonarakos P, Givissis P, Papadopoulos P, Christodoulou A. Condylar buttress plate versus fixed angle condylar blade plate versus dynamic condylar screw for supracondylar intra-articular distal femoral fractures. J Orthop Surg (Hong Kong) 2010;18:35-8. 12. Heiney JP, Barnett MD, Vrabec GA, Schoenfeld AJ, Baji A, Njus GO. Distal femoral fixation: a biomechanical comparison of trigen retrograde intramedullary (i.m.) nail, dynamic condylar screw (DCS), and locking compression plate (LCP) condylar plate. J Trauma 2009;66:443-9. 13. Sanders R, Swiontkowski M, Rosen H, Helfet D. Double-plating of comminuted, unstable fractures of the distal part of the femur. J Bone Joint Surg Am 1991;73:341-6. 14. Simonian PT, Thompson GJ, Emley W, Harrington RM, Benirschke SK, Swiontkowski MF. Angulated screw placement in the lateral condylar buttress plate for supracondylar femoral fractures. Injury 1998;29:101-4. 15. Hoffmann MF, Jones CB, Sietsema DL, Tornetta P 3rd, Koenig SJ. Clinical outcomes of locked plating of distal femoral fractures in a retrospective cohort. J Orthop Surg Res 2013;8:43.

Acknowledgement

16. Fleckenstein SJ, Kirby RL, MacLeod DA. Effect of limited knee-flexion range on peak hip moments of force while transferring from sitting to standing. J Biomech 1988;21:915-8.

I am most grateful to pharmacist Abdulsamad Mahran-Sohag Teaching Hospital-for making of the statistics of the present study.

17. Dhillon MS, Panday AK, Aggarwal S, Nagi ON. Extra articular arthroscopic release in post-traumatic stiff knees: a prospective study of endoscopic quadriceps and patellar release. Acta Orthop Belg 2005;71:197-203.

Conflict of interest: None declared.

18. Link BC, Babst R. Current concepts in fractures of the distal femur. Acta Chir Orthop Traumatol Cech 2012;79:11-20.

REFERENCES 1. Neer CS 2nd, Grantham SA, Shelton ML. Supracondylar fracture of the adult femur. A study of one hundred and ten cases. J Bone Joint Surg Am 1967;49:591-613. 2. El-Kawy S, Ansara S, Moftah A, Shalaby H, Varughese V. Retrograde femoral nailing in elderly patients with supracondylar fracture femur; is it the answer for a clinical problem? Int Orthop 2007;31:83-6. 3. Saw A, Lau CP. Supracondylar nailing for difficult distal femur fractures. J Orthop Surg (Hong Kong) 2003;11:141-7.

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19. Wendt PP, Johnson RP. A study of quadriceps excursion, torque, and the effect of patellectomy on cadaver knees. J Bone Joint Surg Am 1985;67:726-32. 20. Brown A, D’Arcy JC. Internal fixation for supracondylar fractures of the femur in the elderly patient. J Bone Joint Surg Br 1971;53:420-4. 21. Akagi M, Matsusue Y, Mata T, Asada Y, Horiguchi M, Iida H, et al. Effect of rotational alignment on patellar tracking in total knee arthroplasty. Clin Orthop Relat Res 1999;366:155-63. 22. Ghosh KM, Merican AM, Iranpour F, Deehan DJ, Amis AA. The effect of femoral component rotation on the extensor retinaculum of the knee. J Orthop Res 2010;28:1136-41.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Distal femoral fraktürlerin fiksasyonu: Diz kinematiğinin restorasyonu Dr. Elsayed Ibraheem Elsayed Massoud Sohag Eğitim Hastanesi, Ortopedi Kliniği, Eğitim Hastaneleri ve Enstitüleri Genel Organizasyonu, Sohag, Mısır

AMAÇ: İyileşmiş distal femur kırıkları diz hareketlerinde çeşitli derecelerde kayıplara neden olmaktadır. Günlük aktiviteler için yere çömelme ve oturma gereği duyan Doğu toplumları için ciddi bir sorundur. Bu çalışmanın amacı, distal femur kırıklarında kondil destek plağı ve dinamik kondil vidası (DKV) kullanımının sonuçlarını karşılaştırmaktı. İncelenen implantların teknik uygulamasının optimizasyonunda klinik deneyimlerimizi sunduk. GEREÇ VE YÖNTEM: İki gruba ayrılmış (plak ve DCS) 57 hastanın 59 distal femur kırıkları kondil destek plağı veya DKV ile tedavi edilmiş ve ileriye yönelik olarak 24 ay izlenmiştir. BULGULAR: Plak grubu için kırıkların %67’sinde yeterli redüksiyon ve %13.3’ünde varus angülasyonu bildirilmiştir. DKS grubunda kırıkların %72.4’ünde yeterli redüksiyon ve %17’sinde posteriyor angülasyon bildirilmiştir. Her iki grupta redüksiyon yetersizliğinin diğer nedenleri de rapor edilmiştir. Plak grubundakilerin %50 ve DKS grubundakilerin %55’inde tam olarak diz hareket erimi gerçekleşmiştir. Plak ve DKS grubunda sırasıyla %75 ve %90 oranında tatmin edici fonksiyonel sonuçlar bildirilmiştir. TARTIŞMA: Diz kinematiğinin restorasyonu açısından her iki implant ile hemen hemen benzer sonuçlar elde edilmiştir. Kondil destek plağı ve DKS teknik açıdan optimal düzeye getirilebilir. Anahtar sözcükler: Dinamik kondil vidası; distal femur; diz motilitesi; fraktür; kondil destek plağı. Ulus Travma Acil Cerrahi Derg 2015;21(3):197-203

doi: 10.5505/tjtes.2015.00490

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ORIGIN A L A R T IC L E

Evaluation of the medical malpractice cases concluded in the General Assembly of Council of Forensic Medicine Yüksel Aydın Yazıcı, M.D.,1 Humman Şen, M.D.,1 Suheyla Aliustaoğlu, M.D.,1 Yiğit Sezer, M.D.,1 Cengiz Haluk İnce, M.D.2 1

Ministry of Justice Council of Forensic Medicine, İstanbul

Department of Forensic Medicine, İstanbul University İstanbul Faculty of Medicine, İstanbul

ABSTRACT BACKGROUND: Malpractice is an occasion that occurs due to defective treatment in the course of providing health services. Neither all of the errors within the medical practices are medical malpractices, nor all of the medical malpractices result in harm and judicial process. Injuries occurring at the time of treatment process may result from a complication or medical malpractice. This study aims to evaluate the reports of the controversial cases brought to trial with the claim of medical malpractice, compiled by The Council of Forensic Medicine. METHODS: Our study includes all of the cases brought to the Ministry of Justice, Council of Forensic Medicine General Assembly with the claim of medical malpractice within a period of 11 years between 2000 and 2011(n=330). RESULTS: In our study, we saw that 33.3% of the 330 cases were detected as “medical malpractice” by the General assembly. Within this 33.3% segment cases, 14.2% of them resulted from treatment errors such as wrong or incomplete treatment and surgery, use of wrong medication, running late for a true diagnosis after necessary examination, inappropriate medical processes as well as applied treatment having causality with an emergent injury to the patient. 9.7% of them emerged from diagnosis errors like failure to diagnose, wrong diagnosis, lack of consultation request, lack of transfer to a top centre, lack of intervention resulting from not recognizing the postoperative complication on time. 8.8% of them occurred because of careless intervention such as lack of necessary care and attention, lack of post operation follow-ups, lack of essential informing, absenteeism when called for a patient, intervention under suboptimal conditions. Whereas 0.3% of them developed from errors due to inexperience, 0.3% of them were detected to have occurred because of the administrative mistakes following malfunction of healthcare system. CONCLUSION: It is very important to analyze the errors properly in order to get the medical malpractice under control. Going through the errors, on which process of health service they occur and their owners; keeping the record of all examinations and treatments in the course of health service regularly and properly will be a cornerstone for both occupational and forensic medicine practices to be standardized. Key words: Complication; forensic medicine; malpractice; standardization.

INTRODUCTION Malpractice cases are events resulting from faulty actions while providing healthcare services. According to the World

Address for correspondence: Cengiz Haluk İnce, M.D. İstanbul Universitesi İstanbul Tıp Fakültesi, Adli Tıp Anabilim Dalı, 34093 İstanbul, Turkey Tel: +90 212 - 414 20 00 / 31577 E-mail: halukince@gmail.com Qucik Response Code

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Medical Organization’s statement adopted at the 44th World Medical Assembly in 1992, medical malpractice is defined as “physician’s failure to conform to the standard of care for treatment of the patient’s condition, or a lack of skill, or negligence in providing care to the patient, which is the direct cause of an injury to the patient”; and a distinction between medical malpractice and an untoward result occurring in the course of medical care and treatment that is not the fault of the physician (complication) is emphasized.[1,2] Among medical practices, neither all failures are considered as medical malpractice nor do all medical malpractice cases result in harm. Harm occurring during treatment may either develop due to a complication or medical malpractice. When the patient develops an adverse event, it is the experts’ duty to identify whether or not this event was the result Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

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of medical care and treatment and whether or not this care and treatment was faulty.[3] The Council of Forensic Medicine, Ministry of Justice, is an official expert organization in Turkey assigned to deliver expert opinions. Within this structure, the Forensic Medicine General Assembly is a supreme board of experts evaluating expert reports referred by courts and prosecution office due to being considered as unsatisfactory, untrustworthy, inconclusive, or contradictional.

University Hospital (%6) Other Healthcare Institutions (%9.1)

Clinics (%5.5)

State Hospital (%40.3)

This study aimed to evaluate controversial reports prepared by the Forensic Medicine General Assembly for cases referred to courts with medical malpractice claims.

Private Hospital (%39.1)

MATERIALS AND METHODS All cases of medical malpractice claims referred to the Council of Forensic Medicine General Assembly, Ministry of Justice, within a period of 11 years between 2000 and 2011 were reviewed retrospectively and included into our study (n=330). The cases were assessed according to age, gender, courts’ queries, reason for admission to the healthcare institutions, complaints upon admission, healthcare institutions providing the treatment, injuries or harm claimed to result from faulty care and treatment, defendants of the allegations, their field of medical specialization, and the conclusions of the Forensic Medicine General Assembly. Data was identified by SPSS 13.0 computer software using frequency, % percentage.

RESULTS Of the three hundred and thirty cases with medical malpractice claims within a period of 11 years between 2000 and 2011, one hundred and sixty-five cases were female, one hundred and sixty-four were male, and one case was hermaphrodite. Mean age of the cases was 28 (0-86), and 12.7% of the cases were 1 year of age or younger. In 40.3% of the cases, individuals were referred to a state hospital for healthcare services, in 39.1% to a private hospital, 9.1% to other healthcare institutions, 6% to university hospitals, and 5.5% to clinics for out-patients (Figure 1). When queries most frequently referred by courts were investigated, 83.0% of the queries were asking ‘whether or not there was a failure’, 11.5% were asking ‘whether or not the present harm or injury was a result of care and treatment, surgery, drugs, and drug dosage’, and 7.0% were asking ‘whether or not there was a causal link between the present harm or injury and the provided care and treatment’, 6.4% were asking ‘cause of death’, 5.5% were asking ‘failure in service’, 2.1% were asking ‘contradictions between expert reports’. In sixty-two of the cases, courts were asking more than one question (Figure 2). Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

Figure 1. Distribution of expert opinion by the health centers and the state of liability.

When the cases were evaluated according to the reason for admission to the healthcare institutions, 81.5% consisted of individual referral for diagnosis and treatment due to several complaints, and 15.2% consisted of admissions following an accident. The most frequent complaints upon admission were gynecological and obstetrical complaints (n=83), traumatic injuries (n=57), and gastrointestinal complaints (n=45), respectively. In 40.3% of the cases, individuals were referred to a state hospital for healthcare services, in 39.1% to a private hospital, 9.1% to other healthcare institutions, 6% to university hospitals, and 5.5% to clinics for out-patients. The leading harm and injuries in cases with claimed medical malpractice were deaths allegedly due to lack of treatment, lack of care (39.7%), followed by nervous system injuries (12.1%),

Malpractice Result of treatment A causal link between the treatment Cause of death Failure in service Contradictions between expert reports

80 70 60 50 40 30 20 10

11.5

6.4

5.5

2.1

Figure 2. Distribution of malpractice claims according to laws by judgment.

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organ perforations and organ loss (10.9%), incomplete recovery (7.9%), and skeletal system injuries (7%) (Figure 3). In 85.1% of the claims, the defendant was the physician (n=284). When the files were investigated, there were medical malpractice claims against 454 physicians; including 52 medical practitioners, 402 residents, specialists, and academicians, in some files more than one physician, auxiliary healthcare professional and healthcare institution was accused. Considering their medical specialties, Gynecology and Obstetrics (94) was the leading specialty, followed by General Surgery (60), Orthopedics (41), Ear Nose and Throat Diseases (22) and Anesthesiology (21) (Figure 4). Considering the cases evaluated and concluded in the General Assembly (n=330), 33.3% were concluded as ‘medical malpractice’ in 49.5% no failures of health system and healthcare professionals were detected and in 17.3% of the cases medical malpractice was linked with some of the healthcare professionals involved, some were not considered as medical malpractice and some were considered as inconclusive.

Group 1: wrong or incomplete treatment and surgery, wrong drug use during treatment, delay in necessary and accurate diagnosis and treatment, procedures non-compliant with medical principles and medical failures with a causal link between action and injury that the patient has developed (14.2%), Group 2: failure in diagnosis, wrong diagnosis, no request for consultation, no referral to a higher institution, failure in intervention to a complication which developed in the postoperational period and was not identified in time (9.7%), Group 3: failure in providing the necessary standard of care and attention, failure in post-operational monitoring and follow-up, failure in providing the necessary information, no show of physician upon being called in for the patient, intervention under inappropriate conditions (8.8%), Group 4: failures due to professional inexperience (0.3%), Group 5: administrative failures due to defects within the health system (0.3%).

When all General Assembly conclusions were evaluated in more detail, the following were observed:

Justifications for the conclusion in cases concluded as not a medical malpractice (49.5%) were as follows:

In cases concluded to be medical malpractice (33.3%), the reasons of failure were evaluated as;

Group 1: it was stated that symptomatic treatment was provided, that necessary tests and treatments were applied and since no harm or injuries developed following treatment, there was no need for determining the failure (27.6%),

140

131

Death Nervous system injuries Organ perforati ons&lose Incomplete recovery Skelatal system injuries

120 100 80 60 40

Group 2: complication (19.4%), Group 3: no causal link between injury that the patient has developed and medical applications (2.1%), Group 4: necessary care and attention was provided (0.3%). There is an increase in the number of cases over the years, which is seen more clearly in Figure 5. The number of medical

Figure 3. Outcomes of medical/surgical interventions.

60 54 50

206

0 20

Figure 4. Proportion of physicians facing a malpractice claim according to specialty.

13 10

23 20

Orthopedics Surgery Ear Nose and Thorat Surgery Anesthesiology

Gynecology and obsterics General Surgery

Frequency

100

Figure 5. Distribution of cases according to years.

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malpractice cases was seven in 2000 and 55 in 2010. This rate is an increase of 300%.

DISCUSSION The rate of medical malpractice claims against healthcare professionals and healthcare institutions is constantly increasing in recent years. The reasons for this increase include continuous innovations in medical field due to progress in technology, rapid distribution of these innovations, and raise in education and awareness levels of the public and media coverage.[4] The most frequent referral by courts were with the query ‘was there a failure or not’ with 83.0%, followed by ‘was the present harm or injury a result of care and treatment, surgery, drugs, and drug dosage’ and ‘was there a causal link between the present harm or injury and the provided care and treatment’. In a study conducted in Germany, the majority of medical malpractice allegations have been categorized as negligence, complications during surgery, failures in treatment and failures in care.[5] Considering healthcare institutions in medical malpractice claims, state hospitals were the leading healthcare institutions with 40.3%. In a study conducted in our country, state hospitals have been the leading healthcare institutions with 62%.[4] A study conducted in Italy has shown that claims have been against public institutions in 88% and against private sector in 12% of the cases.[6] A study conducted in our country has demonstrated that the most frequent medical malpractice claims have been against Gynecology and Obstetrics (16.8%), followed by General Surgery and Neurology.[7] Maeda et al. have indicated internal diseases as the most frequently alleged medical specialty.[8] In another study regarding clinical departments involved in medical malpractice claims, 52% were surgical departments, 41% internal sciences and 7% were anesthesiology; investigation in more detail revealed that 16% were in Gynecology and Obstetrics, 14% in General Surgery, 10% in Emergency Department, 9% in Internal Diseases, 8% in Orthopedics, 7% in Anesthesiology, 5% in Brain Surgery, 4% in Cardiology, 3% in Pediatrics, 2% in Ear Nose and Throat Diseases, 22% in other departments.[6] The doctoral thesis of Yorulmaz in 2006 evaluated medical malpractice rates, experts and took into account the number of attempts. Gynecology and obstetrics experts led the medical malpractice rate of 1%.[9] In our study, conforming with the literature, considering accused physicians, the leading specialty was Gynecology and Obstetrics (n=94), followed by General Surgery (n=60) and Orthopedics (n=41). The leading harms and injuries in medical malpractice cases in our study were deaths due to alleged failure in treatment and failure in care (39.7%), followed by nervous system injuries (12.1%) organ perforations and organ loss (10.9%). AccordUlus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

ing to a study by Di Nunno N at al. in 2004, between 1991 and 2000 medical malpractice was determined in 364 out of a total of 2123 autopsy cases. In 30% of these cases, a causal link was established between medical malpractice and death, in 55% no failure was determined, and in 15% death was not linked directly with medical malpractice.[6] In a study by Pakiş et al. in 2008 involving only medical malpractice cases that resulted in death, in 60% of the cases, no medical malpractice was observed; whereas, in 32% of the cases, medical malpractice was determined.[4] In a study by Dettmeyer et al., 285 medical malpractice cases were evaluated; in 72 of the cases wrong application within treatment, in 53 cases wrongful diagnosis and in 45 cases failure in recognizing complications following treatment were reported.[10] Our study indicated ‘medical malpractice’ in 33.3% of 330 cases evaluated by the General Assembly. 14.2% of these cases consisted of medical malpractice cases including wrong or incomplete treatment and surgery, wrong drug use during treatment, delay in necessary and accurate diagnosis and treatment, procedures non-compliant with medical principles and medical failures with a causal link between action and injury that the patient has developed, 9.7% consisted of medical malpractice cases including failure in diagnosis, wrong diagnosis, no request for consultation, no referral to a higher institution, failure in intervention to a complication which developed in the post-operational period and was not identified in time, 8.8% consisted of medical malpractice cases including failure in providing the necessary standard of care and attention, failure in post-operational monitoring and follow-up, failure in providing the necessary information, no show of physician upon being called in for the patient, intervention under inappropriate conditions, 0.3% consisted of medical malpractice cases including failures due to professional inexperience, 0.3% consisted of medical malpractice cases including administrative failures due to defects within the health system. Wanzel et al. have reported failure in treatment in 72% and failure in diagnosis in 28% of the investigated medical malpractice cases.[11,12] In 49.5% of the cases evaluated and concluded in the General Assembly (n=330), no failures were attributed to health system and healthcare professionals. In 17.3% of the cases, medical malpractice was linked with some of the healthcare professionals involved, some were not considered as medical malpractice and some could not be evaluated due to incomplete documentation. Proper analysis of medical malpractice cases is very important in the management of medical malpractice. It must be investigated on which level of healthcare services and by whom these failures were caused, and all tests and treatments as well as follow-ups must be archived regularly and accurately in order to provide a significant reference for the standardization of professional as well as medico-legal procedures. Conflict of interest: None declared. 207

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8. Maeda H, Fujita MQ, Zhu BL, Quan L, Taniguchi M. Medical practicerelated fatalities in forensic autopsy during the past 6 years in the southern half of Osaka city and surrounding areas. Leg Med (Tokyo) 2003;5 Suppl 1:S322-4. 9. Yorulmaz AC. İstanbul tabip odası’na yansıyan hekim hatası. İddiası bulunan olguların adli tıp açısından değerlendirilmesi. [Doktora Tezi] İstanbul: İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi; 2005. 10. Dettmeyer R, Egl M, Madea B. Medical malpractice charges in Germany-role of the forensic pathologist in the preliminary criminal proceeding. J Forensic Sci 2005;50:423-7. 11. Wanzel KR, Jamieson CG, Bohnen JM. Complications on a general surgery service: incidence and reporting. Can J Surg 2000;43:113-7. 12. Emircan S, Ozgüç H, Akköse Aydın S, Ozdemir F, Köksal O, Bulut M. Factors affecting mortality in patients with thorax trauma. Ulus Travma Acil Cerrahi Derg 2011;17:329-33.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Adli Tıp Kurumu Genel Kurulu’nca sonuçlandırılan tıbbi uygulama hatası olgularının değerlendirilmesi Dr. Yüksel Aydın Yazıcı,1 Dr. Humman Şen,1 Dr. Suheyla Aliustaoğlu,1 Dr. Yiğit Sezer,1 Dr. Cengiz Haluk İnce2 1 2

Adalet Bakanlığı, Adli Tıp Kurumu, İstanbul İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Adli Tıp Anabilim Dalı, İstanbul

AMAÇ: Malpraktis sağlık hizmetlerinin sunulması sırasında kusurlu hareket edilmesi sonucu ortaya çıkan olaylardır. Tıp uygulamaları içerisinde, yapılan hataların tümü tıbbi uygulama hatası olmadığı gibi tıbbi uygulama hatalarının tümü de zararla ve dolayısıyla hukuki bir süreçle sonuçlanmamaktadır. Tedavi sürecinde gelişen zarar hem komplikasyon, hem de tıbbi uygulama hatası sonucunda ortaya çıkabilir. Bu çalışma ile Türkiye’de tıbbi uygulama hatası iddiası ile mahkemelere yansımış tartışmalı olguların Adli Tıp Genel Kurulu tarafından düzenlenmiş raporlarının değerlendirilmesi amaçlandı. GEREÇ VE YÖNTEM: Çalışmamız, Adalet Bakanlığı Adli Tıp Kurumu Genel Kurulu’na 2000 ile 2011 yılları arasındaki 11 yılı kapsayan bir dönemde, tıbbi malpraktis iddiası ile gelen tüm olguları (n=330) kapsamaktadır. BULGULAR: Çalışmamızda Genel Kurulca değerlendirilen 330 olgunun %33.3’ünde “tıbbi uygulama hatası” olduğu tespit edildiği saptanmıştır. Bunlar kendi içinde değerlendirildiğinde %14.2’sini yanlış ya da eksik tedavi ve ameliyatın yapılması, tedavide yanlış ilaç kullanılması, gerekli inceleme yapılarak doğru tanı konulmasında geç kalınması, yapılan işlemlerin tıp kurallarına uygun olmadığı ve yapılan eylem ile kişide gelişen zarar arasında illiyetin olduğu tedavi hataları oluştururken, %9.7’sini tanı konulamaması, hatalı tanı, konsültasyon istenmemesi, bir üst merkeze sevk edilmemesi, ameliyat sonrası gelişen komplikasyonu zamanında tanımayarak müdahale edilmemesi gibi tanı hataları, %8.8’ini gereken özen ve dikkatin gösterilmediği, ameliyat sonrası gerekli takibin yapılmadığı, gerekli bilgilendirmenin yapılmadığı, hasta için çağrıldığı halde göreve gelmediği, uygun olmayan şartlarda müdahale edildiği özen eksiklikleri, %0.3’ünü meslekte acemiliğin neden olduğu hatalar, %0.3’ünü sağlık sistemindeki aksaklıklar nedeniyle idarenin hatasının olduğu görüldü. TARTIŞMA: Tıbbi uygulama hatalarının kontrol altına alınabilmesi için bu hataların iyi analiz edilmesi çok değerlidir. Hataların sağlık hizmetinin hangi aşamasında, hangi basamakta kimler tarafından yapıldığının araştırılması, sağlık hizmeti esnasında yapılan tüm inceleme ve tedavilerin, takiplerin düzenli ve doğru tutulması hem mesleki hem de adli tıbbi uygulamaların standardize edilmesi için önemli bir referans oluşturacaktır. Anahtar sözcükler: Adli Tıp; komplikasyon; malpraktis; standardizasyon. Ulus Travma Acil Cerrahi Derg 2015;21(3):204-208

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doi: 10.5505/tjtes.2015.24295

Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

ORİJİ N A L Ç A LI Ş M A

Opere tibia plato Schatzker tip I ve tip II kırıklarda, iyileşme üzerine obezitenin olumsuz etkisi var mı? Dr. Gültekin Sıtkı Çeçen, Dr. Deniz Gülabi, Dr. Gökhan Pehlivanoğlu, Dr. Nurzat Elmalı, Dr. Akif Teköz Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul

ÖZET AMAÇ: Schatzker tip I ve tip II tibia plato kırıklarında tedavi sonuçlarının klinik ve radyolojik olarak değerlendirilmesi ve bu sonuçlara vücut kitle indeksinin (VKİ) etkisinin araştırılması. GEREÇ VE YÖNTEM: Çalışma, Schatzker tip I ve tip II tibia plato kırığı nedeniyle ameliyat edilen 64 olgu (44 erkek [%68.8], 20 kadın [%31.3]; ortalama yaş 21-80; dağılım 45.05±13.47) ile yapıldı. Klinik ve radyolojik sonuçlar Rasmussen skorlarına göre değerlendirildi. Değerlendirme sırasında VKİ saptandı. Obezitenin klinik ve radyolojik sonuçlar üzerindeki etkisi araştırıldı. BULGULAR: Schatzker tip II olgularda Rasmussen klinik skorları ile yaş arasında ters yönde %48.4 düzeyinde istatistiksel olarak anlamlı ilişki bulunduğu saptandı (p<0.01). SONUÇ: Tip II kırıklarda obez hastaların klinik ve radyolojik sonuçları normal kilosu olan hastalara göre kötü olarak bulundu. Obezite kısa sürede çözümlenebilecek bir sorun olmadığı için bu gurup hastalarda tedavi başarısını artırmanın, ancak yakın takip ve rehabilitasyonun yeterince yapılması ile mümkün olabileceğini düşünmekteyiz. Anahtar sözcükler: Rasmussen skalası; tibia plato kırıkları; VKİ.

GİRİŞ Obezite, görülme sıklığı giderek artan önemli bir toplumsal sağlık sorunu olmaya başlamıştır.[1,2] Vücut kitle indeksi (VKİ) tüm vücut ağırılığının (kilogram), kişinin boy uzunluğunun (metre) karesine bölünmesi sonucu (kg/m2) olarak ölçülür. 30 kg/m2 üstü kişiler obez olarak kabul edilir. Obezitenin, kişilerin genel sağlık durumları üzerine olumsuz etkileri daha önce birçok yazar tarafından bildirilmiştir.[3] Ortopedik cerrahide de spinal, diz ve kalça operasyonları sonrası obezitenin olumsuz etkileri gösterilmiştir. Obezitenin, perioperatif ve ameliyat sonrası yara problemleri ve DVT riskini artırdığı görülmüştür. Weinlein JC ve ark. yapmış oldukları geriye dönük olgu-kontrol çalışmasında femoral şaft kırığı nedeniyle intramedüller çivileme yapılan hastalarda obezitenin, ameliyat Sorumlu yazar: Dr. Gültekin Sıtkı Çeçen, Sarraf Ali Sok., Sebat Ap., No: 29/2, Moda, Kadıköy, 81300 İstanbul Tel: +90 216 - 414 51 79 E-posta: gcecen2002@yahoo.com Ulus Travma Acil Cerrahi Derg 2015;21(3):209-215 doi: 10.5505/tjtes.2015.39197 Telif hakkı 2015 TJTES

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

sonrası morbidite üzerinde etkisi olduğunu göstermişlerdir.[4] Ancak yapmış olduğumuz İngilizce literatür taramasında VKİ ile plato tibia kırıkları arasındaki korelasyonu gösteren makale saptanmamıştır. Tibia lateral platosunu etkileyen Schatzker tip I ve tip II kırıklar, eklem içi kırıklar olup, eklem içi yaralanmalar da, kırığa eşlik edebilir.[5-9] Tedavide amaç, stabil, ağrısız ve fonksiyonları tam diz elde edilmesidir. Düşük enerjiyle oluşan tibia plato kırıklarında, konservatif tedavi yöntemleri yeterli olabilirken, yüksek enerjili travmalar sonrası oluşan plato kırıklarında eksternal fiksatör, açık redüksiyon ve internal tespit tek başına yapılabildiği gibi bunların bir arada kulanımları da mümkündür. Schatzker tip I ve tip II tibia kırıkları, birçok olguda vidalarla veya destek plakları kullanılarak başarılı şekilde tespit edilebilmektedir.[10,11] Özellikle obez bireylerde osteoartrit gelişim riskini unutmamak ve eklem içi kırıklarda iyi redüksiyonu sağlamak önemlidir.[12] Bu çalışmadaki amacımız son yıllarda sanayi, yüksekten düşme ve trafik kazaları sonucu sık rastlamış olduğumuz lateral tibia plato Schatzker tip I ve tip II kırıkların cerrahi (açık redüksiyon ve plak vida ile osteosentezi yapılmış) sonuçları üzerine VKİ etkisini araştırmaktı. Hipotezimiz ise VKİ≥ 30 kg/m2 olan has209

Çeçen ve ark. Opere tibia plato Schatzker tip I ve tip II kırıklarda, iyileşme üzerine obezitenin olumsuz etkisi var mı?

taların Rasmussen klinik (RKS) ve Rasmussen radyolojik (RRS) sonuçlarının obez olmayan bireylere göre daha kötü olacağıdır.

GEREÇ VE YÖNTEM Çalışmamıza alınmak üzere, 2008 ile 2012 tarihleri arasında hastanemize başvuran 117 tibia plato kırıklı hastadan, plak osteosentezi ile tedavi edilmiş ve çalışma kriterlerimize uyan, Schatzker tip I ve tip II kırıklı 71 hastanın kayıtlarına ulaşıldı. Çalışmaya, ek kemik patolojisi olmayan, ilave fiziksel ve psikolojik sorunları (diyabet, psikolojik olarak tedaviye uyumsuzluk) bulunmayan hastalar katıldı. Açık kırık nedeniyle tedavi edilen hastalar çalışma dışında bırakıldı. Yedi hasta da, operasyon tarihleri ile çalışmanın yapıldığı tarih arasında VKİ’de yüksek ölçekli değişiklikler olması ve non obez iken obez guruba dahil olmaları nedeniyle çalışma dışı bırakıldı, çalışma 64 hasta 64 hasta (44 erkek [%68.8], 20 kadın [%31.3]; ortalama yaş 21-80; dağılım 45.05±13.47) ile yürütüldü. Yaralanma, hastaların 34’ünde yüksek enerji, 30’unda düşük enerjili travma sonucu olmuştu, 28 hastada Schatzker tip II, 36 hastada tip I kırık saptandı (Tablo 1). Hastaların tamamında pnömotik turnike altında açık redüksiyon sonrası, anterolateral insizyonla, plak vida tespiti yapıldı, hemovak dren tespiti sonrası Paris plaster uygulandı. Schatzker tip II kırık olan yedi (%19.4) hastada, Schatzker tip I kırık olan üç (%10.7) hastada yüzeyel yara enfeksiyonu gelişti. Ek cerrahi tedaviye gerek kalmadan

(a)

(b)

yara bakımı ile, tedavisi tamamlanan bu olgularının tamamının VKİ’leri 30 kg/m2’nin üzerinde olup, obezdi. İki farklı hastanın ameliyat öncesi, ameliyat sonrası ve altıncı ay takip radyografileri, hastalarımızın izin ve onamlarının alınması sonrası Şekil 1a-c ve 2a-c’de sunulmuştur. Kırık iyileşmesi tamamlanmış olan hastalar düz muayene masasına yatırılarak, kontraktür ve hareket açıklığı yönünden değerlendirildi. Rasmussen klinik fonksiyonel skorlama sistemi sonuçları değerlendirmede kullanıldı. Bu fonksiyonel skorlama sisteminde diz ekleminin subjektif şikayetleri ve klinik bulgular toplamı 30 puan olarak değerlendirmeye alındı. Diğer beş kategoride ağrı, yürüme kapasitesi, eklem hareket açıklığı ve stabilite skorlandı. Her kategori maksimum 6 puandır. 30 ile 27 puan arası, mükemmel olarak değerlendirilirken, 26 ile 20 puan arası iyi sonuç, 19 ile 10 arası ortalama sonuç, 10 puan altı kötü sonuç olarak değerlendirilmiştir.[8,13] İyileşmesi tamamlanmış, desteksiz mobilize olan hastaların anteroposteriyor ve lateral radyografileri değerlendirildi. Grafilerinde açısal bozukluklar ölçüldü, artrozik değişiklikler ve eklem içi basamaklar değerlendirildi. Rasmussen radyolojik kriterlerine göre hastalar değerlendirildi.[8] VKİ hesaplamaları sonrasında hastalar normal 20-24.9 kg/m2, hafif şişman 25-29.9 kg/m2, obez 30 kg/m2 ve üzeri olmak üzere üç guruba ayrıldı. Klinik ve radyolojik olarak iyileşmesini tamamlamış hastaların verileri, VKİ sonuçları ile karşılaştırıldı.

(c)

Şekil 1. Trafik kazası geçiren 44 yaşında erkek olgunun (a) ameliyat öncesi AP LAT radyografi Schatzker Tip II, (b) ameliyat sonrası AP LAT radyografi Schatzker Tip II, (c) ameliyat sonrası altıncı ay AP LAT radyografi Schatzker Tip II görüntüleri.

(a)

(b)

(c)

Şekil 2. Düşme sonrası 34 yaşındaki erkek olgunun (a) ameliyat öncesi AP LAT radyografi Schatzker Tip I, (b) ameliyat sonrası AP LAT radyografi Schatzker Tip I, (c) ameliyat sonrası altıncı ay AP LAT radyografi Schatzker Tip I görüntüleri.

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Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

Çeçen ve ark. Opere tibia plato Schatzker tip I ve tip II kırıklarda, iyileşme üzerine obezitenin olumsuz etkisi var mı?

Tablo 1. Genel özelliklerin dağılımı

Min-Maks.

Yaş (yıl)

21-80

Ort.±SS 45.05±13.47

Vücut kitle indeksi (kg/m2) 22.56-39.39 28.65±4.58 Takip süresi (ay)

13-55

29.33±10.98

Rasmussen klinik

8-30

24.42±4.85

Rasmussen radyolojik

4-17

13.36±3.93

Sağ

81.3

Sol

18.8

Kadın

20 31.3

Erkek

44 68.8

Tip 1

43.8

Tip 2

56.3

Yüksek enerjili

53.1

Düşük enerjili

46.9

Rasmussen klinik Kötü

3.1

Orta

10.9

İyi

42.2

43.8

Mükemmel

Ramussen radyolojik Kötü

7.8

Orta

29.7

İyi

62.5

BULGULAR Hastalar ortalama 13-55 (29.33±10.98) ay süreyle takip edildi. Rasmussen klinik skorları (RKS) 8-30 (24.42±4.85), Rasmussen radyolojik skorları (RRS) 4-17 (13.36±3.93). VKİ’leri 22.56-39.39 kg/m2 (28.65±4.58) idi (Tablo 1). Hastaların tamamında değerlendirme yapıldığında RKS ile yaş arasında ters yönde %43.8 düzeyinde istatistiksel olarak anlamlı ilişki bulundu (p<0.01). RKS ile VKİ arasında ters yön-

de %58.7 düzeyinde istatistiksel olarak anlamlı ilişki bulundu (p<0.01). RRS ile VKİ arasında ters yönde %68.9 düzeyinde istatistiksel olarak anlamlı ilişki bulundu (p<0.01). Travma enerjisine göre VKİ ölçümleri arasında istatistiksel olarak anlamlı farklılık bulunmadı (p>0.05) (Tablo 1 ve Tablo 2). Tüm hastalarda gözlenen bu farklılığın, guruplara göre yapılan çalışmada, gerçekte Schatzker tip II kırıklarda olduğu, Schatzker tip I kırıklarda istatistiksel olarak anlamlı bir fark bulunmadığı görüldü (Tablo 2 ve Tablo 3). Schatzker tip II kırıklarda; RKS gruplarına göre yaşlar arasında farklılığın hangi gruptan kaynaklandığını tespit etmek amacıyla yapılan Post-Hoc Tukey HSD testi sonucunda; klinik skoru orta+kötü olan grubun yaş ortalaması klinik skoru mükemmel olan grubun (p=0.001, p<0.01) yaş ortalamasından anlamlı şekilde yüksekti. RKS’ye göre VKİ ölçümleri arasında farklılığın hangi gruptan kaynaklandığını tespit etmek amacıyla yapılan Post-Hoc Tukey HSD testi sonucunda; klinik skoru orta+kötü olan grup (p=0.001, p<0.01) ile klinik skoru iyi olan grubun (p=0.040, p<0.05) VKİ ortalamaları, klinik skoru mükemmel olan grubun VKİ ortalamasından anlamlı şekilde yüksekti. RRS’si kötü+orta olan grubun VKİ ortalaması radyolojik skoru iyi olan grubun VKİ ortalamasından anlamlı şekilde yüksekti (p=0.001, p<0.01). Bu farklılığı Schatzker tip I kırıklarda görmedik. RRS’ye göre yaşlar arasında istatistiksel olarak anlamlı farklılık bulunmadı (p>0.05). Travma enerjisine göre yaşlar arasında istatistiksel olarak anlamlı farklılık bulunmadı (p>0.05). Travma enerjisine göre VKİ ölçümleri arasında istatistiksel olarak anlamlı farklılık bulunmadı (p>0.05). Travma enerjisine göre VKİ ölçümleri arasında istatistiksel olarak anlamlı farklılık bulunmadı (p>0.05) (Tablo 3). Radyolojik ve klinik skorların ikisinin bir arada değerlendirildiği gruplara göre VKİ ortalamaları arasında farklılığın hangi gruptan kaynaklandığını tespit etmek amacıyla yapılan PostHoc Tukey HSD testi sonucunda; her iki skorunda kötü+orta olduğu durumdaki VKİ ortalaması (p=0.001, p<0.01), her iki skorun da iyi+mükemmel olduğu durumdaki VKİ ortalamasından anlamlı şekilde yüksekti (Tablo 4). Klinik skor ile radyolojik skorlar arasında istatistiksel olarak anlamlı farklılık saptandı (p<0.01) (Tablo 5).

Tablo 2. Rasmussen klinik ve radyolojik skorlarının yaş ve VKİ ile ilişkisi

Yaş-Rasmussen klinik

Yaş-Rasmussen radyolojik

VKİ-Rasmussen klinik

VKİ-Rasmussen radyolojik

r R r R Tüm olgular

-0.438** -0.153 -0.587** -0.689**

Tip 1 olgular

-0.195

Tip 2 olgular

-0.484** -0.111 -0.587** -0.673**

-0.034

-0.240

-0.346

VKİ: Vücut kitle indeksi; r: Pearson korelasyon katsayısı; **p<0.01.

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

211

Çeçen ve ark. Opere tibia plato Schatzker tip I ve tip II kırıklarda, iyileşme üzerine obezitenin olumsuz etkisi var mı?

Tablo 3. Yaş ve VKİ’ye ilişkin değerlendirmeler Tüm olgular

R. klinik

Yaş p VKİ p Ort.±SS Ort.±SS 0.001** 33.65±4.84 10.001**

Kötü+Orta

59.67±12.01

İyi

46.19±12.99 29.29±4.11

Mükemmel 39.25±10.52

Kötü+Orta

47.17±14.26

İyi

43.78±12.99 26.18±2.81

Yüksek

42.50±11.43

R. radyolojik Travma enerjisi

26.41±3.44

0.333 32.37±4.37 20.001** 0.108 28.09±4.54 20.632

Düşük 47.93±15.14 28.35±4.69

Tip 1 olgular

Kötü+Orta

R. klinik

–

0.396 – 20.208

İyi

Mükemmel 39.93±11.62

Kötü+Orta

45.25±10.53

İyi

41.79±11.61 25.41±1.75

Yüksek

4077±11.30

R. radyolojik Travma enerjisi

44.33±11.03 24.18±1.75 2

25.18±1.83

0.582 26.94±1.98 20.125 0.521 25.84±1.62 20.581

Düşük 43.60±11.61 25.44±2.04

Tip 2 olgular

Kötü+Orta

60.50±12.56

İyi

47.67±14.58 31.68±3.89

Mükemmel 38.46±9.49 27.83±4.32

Kötü+Orta

47.55±15.09

İyi

46.75±14.70 27.33±3.67

Yüksek

43.57±11.60

R. klinik

R. radyolojik Travma enerjisi

0.002** 34.83±3.52 10.001**

0.874 33.82±3.61 20.001** 0.104 30.83±4.75 20.782

Düşük 52.27±17.31 31.26±4.82

VKİ: Vücut kitle indeksi; Ort.: Ortalama; SS: Standart sapma; 1Oneway ANOVA test; 2Student t-test; **p<0.01.

İstatistiksel İncelemeler Çalışmada elde edilen bulgular değerlendirilirken, istatistiksel analizler için SPSS (Statistical Package for Social Sciences) for Windows 15.0 programı kullanıldı. Çalışma verileri değerlendirilirken tanımlayıcı istatistiksel metodların (Ortalama, Standart sapma) yanı sıra niceliksel verilerin karşılaştırılmasında normal dağılım gösteren parametrelerin gruplar arası karşılaştırmalarında Oneway Anova testi ve farklılığa neden çıkan grubun tespitinde Tukey HSD testi kullanıldı. Normal dağılım Tablo 4. Rasmussen klinik ve radyolojik skorların VKİ ile ilişkisi Rasmussen

VKİ p Ort.±SS

Klinik ve radyolojik

Her ikisi de iyi+mükemmel

26.08±2.79

Diğer durumlar

31.92±3.32

Her ikisi de kötü+orta

34.14±4.93

0.001**

VKİ: Vücut kitle indeksi; Ort.: Ortalama; SS: Standart sapma; Oneway Anova test; **p<0.01.

212

gösteren parametrelerin iki grup arası karşılaştırmalarında ise Student t-test kullanıldı. Normal dağılıma uygunluk gösteren parametreler arasındaki ilişkilerin incelenmesinde Pearson korelasyon analizi kullanıldı. Anlamlılık p<0.05 düzeyinde değerlendirildi.

TARTIŞMA Tibia Plato Schatzker tip I ve tip II kırık nedeniyle cerrahi olarak tedavi ettiğimiz 64 hasta üzerinde yaptığımız geriye dönük kıyaslamalı çalışmamızda, VKİ’ye göre obez ve nonobez guruplar oluşturulup ve klinik ve radyolojik sonuçlar karşılaştırıldı. Hastaların kırık paternine bakmadan yaptığımız analizde, VKİ yüksek olanlarda RRS ve RKS sonuçlarını daha kötü olduğu saptandı. Schatzker tip I ve tip II oluşuna göre ayırdığımızda, Schatzker tip II kırıklarda, VKİ yüksek olan hastalarda RRS ve RKS sonuçlarını istatistiksel olarak anlamlı kötü sonuçlara ulaşırken, tip I kırıklarda aynı etkileşimle karşılaşmadık. Bu durumun kırık paterninden kaynaklanmış olabileceğini düşünmekteyiz. Tibia plato kırıklarının cerrahi tedavisinde iyi klinik ve radyolojik sonuçlara ulaşmak için öncelikle kırık redüksiyonunun Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

Çeçen ve ark. Opere tibia plato Schatzker tip I ve tip II kırıklarda, iyileşme üzerine obezitenin olumsuz etkisi var mı?

Tablo 5. Klinik skor ile radyolojik skor değerlendirmesi Radyolojik skor

Klinik skor Kötü Orta

Toplam

İyi Mükemmel

n % n % n % n % n %

Kötü 2 3.1 0 0 3 4.7 0 0 5 7.8 0.001** Orta 0 0 6 9.4 10 15.6 3 4.7 19 29.7 İyi

0 0 1 1.6 14 21.9 25 39.1 40 62.5

Total 2 3.1 7 10.9 27 42.2 28 43.8 64 100 Wilcoxon Signed Ranks test.

ve eklem restorasyonunun uygun olması gerekir.[14-16] Lateral tibial plato split-depresyon kırıkları tibia plato kırıkları içinde en sıklıkla görülen kırık tipidir.[17] Schatzker tip I ve tip II kırık formları anteroposteriyor pozisyonda olup. Sıklıkla lateral butres plakla tespit edilir.[18,19] Bize başvuran tibia plato kırkları da literatürle uyumlu olarak yüksek oranda Schatzker tip I ve tip II kırıklardan oluştu.[18] Tibia plato Schatzker tip I ve tip II kırıklarda posterolateral fragmanın önemli olduğunu ve cerrahi tedavide ihmal edilmemesi gerektiğini unutmamak gerekir. Uygun eklem restorasyonu ancak ameliyat öncesi iyi planlama ile mümkün olacağından hastalarda cerrahi öncesi bilgisayarlı tomografi (BT) ile değerlendirilmelidir.[18] Biz olgularımızın tamamında plan radyografilerle beraber BT görüntülemelerini de rutin olarak yaptık ve literatürde tanımlanan algoritma ile cerrahi tedavilerimizi gerçekleştirdik.[20,21] Brennan ve ark.’na göre hiç travmaya maruz kalmamış bile olsa VKİ’deki artış, bireylerin yük taşıyan büyük eklemlerinde osteoartrite neden olmaktadır.[20] Maheshwari ve ark. yapmış oldukları geriye dönük analizde, femur veya tibia kırığı nedeniyle ameliyat olan obez hastaların SF-36 sonuçlarının obez olmayanlara göre daha kötü olduğunu göstermişlerdir. [3] Compston ve ark. obez hastaların kırık sonrası SF-35 ve EuroQol EQ-5D skorlarının obez olmayanlara göre daha kötü olduğunu bildirmişlerdir.[22] Schmier JK ve ark. obez hastaların iş yeri verimliliklerinin düşük olduğunu bildirmişlerdir.[23] Total diz protez ve omuz protez ameliyatları sonrası obez hastaların fonksiyonel sonuçları obez olmayan hastalara göre daha kötü olduğu bildirilmiştir.[24,25] Obez bireylerde plato kırıklarında tedavi sırasında uyulması gereken adımlar vardır. Bunlar, insizyon, kemik uçlarının hazırlanması, geçici tespit, kalıcı tespit, dokuyu uygun şekilde kapatma olarak sıralanabilir.[21] Schatzker tip II kırık olan hastalarda klinik ve radyolojik sonuçların olumsuz olmasında ana etkenin obezite olduğu göze çarpmaktadır.[18] Bu da obez hastalarda travma sonucu oluşan kırık paterninin nonobez hastalara göre daha kötü olduğunu göstermektedir. Bulgularımız da Maheshwari ve ark.[3] sonuçlarıyla ve Brown ve ark.[26] bulgularıyla paralellik göstermektedir. Maheshwari ve ark. obez hastalarda distal femur eklem içi OTA/AO Tip 3 B ve C kırık Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

sayısı nonobezlere göre anlamlı şekilde fazlaydı.[3] Brown ve ark. obez hastaların kırık paternlerinin daha ağır ve yumuşak doku hasarının daha fazla olduğunu bildirmişlerdir.[26] Gilbert ve ark. yapmış oldukları geriye dönük çocuk kırık analizinde obez çocuklarda fizisi içeren kırık oranının nonobez olanlara göre daha fazla olduğunu bildirmişlerdir.[27] Dischinger ve ark. nın bildirdiği gibi eklem içi kırıklarda klinik sonuçlar ve fonksiyon bozuklukları sık gözlenir.[28] Obez hastalarda sadece cerrahi yaklaşım ve enstrümantasyon da değil aynı zamanda iyileşme döneminde rehabilitasyonda da sorunlar ortaya çıkmaktadır.[21,29] Bizim uygulamalarımızda, genç ve zayıf hastalarda klinik olarak iyileşme daha iyi olarak görülmektedir. Obez hastalarda radyolojik sonuçlar kötü olarak gözlenmektedir. Bu gözlem Schatzker tip II kırıklar için geçerli iken, Schatzker tip I kırıklardaki analizler anlamlı fark göstermemiştir. Tip II kırıklardaki bu farklılığın kırık paterninden kaynaklandığını düşünmekteyiz.[18,30] Schatzker tip I kırık minimal deplase kama şeklinde kırık olup sıklıkla genç hasta gurubundadır. Schatzker tip II kırık ise valgus zorlanmasıyla depresyonun eşlik ettiği, beraberinde de ligament ve menisküs yaralanmalarının eşlik ettiği ileri yaş osteoporozlu hastalarda görülen bir kırık tipidir.[31,32] Olgularımızda travma enerjisine göre yaşlar ve VKİ istatistiksel olarak anlamlı farklılık saptamadık. Genç zayıf bireylerde de, ileri yaş gurubunda olduğu gibi düşük enerjili travmayla plato kırıkları gelişebilmekte olduğunu gözlemledik. Çalışmamızda gözlemlediğimiz klinik ve radyolojik veriler arasında ilişkinin olmaması ilgi çekmektedir. Zira radyolojik olarak mükemmel sonuç alınan hastalarda klinik başarıdaki yetersizliğin rehabilitasyon yetersizliğinden kaynaklandığını düşündürmekte. Dizin medial kompartmanından yükü uzaklaştıracak ve muhtemelen kıkırdak hasarına bağlı ağrı oluşumunu sınırlayacak egzersizlerin en popüleri ‘yürüme’ ile gerçekleştirilebilir. Çalışmamızın zayıf tarafı olarak; öncelikli olarak kırk tedavisi planlandığından ameliyat öncesi manyetik rezonans görüntüleme (MRG) incelemesi yapılmamıştır. Travmanın yaratmış olabileceği eklem içi patolojiler saptanmadığı için klinik ve radyolojik skorların eklem içi patolojilerle ilişkisini karşılaştırmak 213

Çeçen ve ark. Opere tibia plato Schatzker tip I ve tip II kırıklarda, iyileşme üzerine obezitenin olumsuz etkisi var mı?

mümkün olmamıştır. Hastaların, 15 yıllık mesleki deneyimi olan aynı cerrah tarafından ameliyat edilmiş olması, klinik ve radyolojik değerlendirmelerin beş yıllık mesleki deneyimi olan aynı hekim tarafından yapılmış olması çalışmamızın kuvvetli tarafını oluşturmaktadır.

Sonuç Tibia plato kırıklarının tedavisi yapılırken amaç; stabil, ağrısız ve fonksiyonları tam olan bir diz elde edilmesidir. Schatzker tip II kırıklarda radyolojik ve klinik sonuçların kötü olduğu hasta gurubunu obez hastalardan oluştuğu göze çarpmaktadır. Bu anlamlı etkileşim tip I kırıklarda görülmemektedir. Özellikle obez ve yaşlı Schatzker tip II kırıklı hastalarda, tedavinin olumlu seyri için daha dikkatli tedavi planlaması ve takibin gerekli olduğunu düşünmekteyiz. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. Gonnelli S, Caffarelli C, Nuti R. Obesity and fracture risk. Clin Cases Miner Bone Metab 2014;11:9-14. 2. Sabharwal S, Root MZ. Impact of obesity on orthopaedics. J Bone Joint Surg Am 2012;94:1045-52. 3. Maheshwari R, Mack CD, Kaufman RP, Francis DO, Bulger EM, Nork SE, et al. Severity of injury and outcomes among obese trauma patients with fractures of the femur and tibia: a crash injury research and engineering network study. J Orthop Trauma 2009;23:634-9. 4. Weinlein JC, Deaderick S, Murphy RF. Morbid Obesity Increases the Risk of Systemic Complications in Patients with Femoral Shaft Fractures. J Orthop Trauma 2014 Jun 26. [Epub ahead of print] 5. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968-1975. Clin Orthop Relat Res 1979;138:94-104. 6. Gausewitz S, Hohl M. The significance of early motion in the treatment of tibial plateau fractures. Clin Orthop Relat Res 1986;202:135-8. 7. Hohl M. Articular fractures of the proximal tibial. In: Evarts CM, editor. Surgery of the musculoskeletal system. New York: Churchill-Livingstone; 1993. p. 3471-97. 8. Gardner MJ, Yacoubian S, Geller D, Suk M, Mintz D, Potter H, et al. The incidence of soft tissue injury in operative tibial plateau fractures: a magnetic resonance imaging analysis of 103 patients. J Orthop Trauma 2005;19:79-84. 9. Bennett WF, Browner B. Tibial plateau fractures: a study of associated soft tissue injuries. J Orthop Trauma 1994;8:183-8. 10. Rinonapoli E, Aglietti P. Comparison of treatment by open and closed reduction of comparable cases of articular fractures of the proximal tibia. Ital J Orthop Traumatol Suppl 1977;3:99-116. 11. van Glabbeek F, van Riet R, Jansen N, D’Anvers J, Nuyts R. Arthroscopically assisted reduction and internal fixation of tibial plateau fractures: report of twenty cases. Acta Orthop Belg 2002;68:258-64. 12. Russell EM, Miller RH, Umberger BR, Hamill J. Lateral wedges alter mediolateral load distributions at the knee joint in obese individuals. J Orthop Res 2013;31:665-71. 13. Rasmussen PS. Tibial condylar fractures. Impairment of knee joint

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stability as an indication for surgical treatment. J Bone Joint Surg Am 1973;55:1331-50. 14. Koval KJ, Helfet DL. Tibial plateau fractures: evaluation and treatment. J Am Acad Orthop Surg 1995;3:86-94. 15. Honkonen SE. Degenerative arthritis after tibial plateau fractures. J Orthop Trauma 1995;9:273-7. 16. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968-1975. Clin Orthop Relat Res 1979;138:94-104. 17. Zhu Y, Yang G, Luo CF, Smith WR, Hu CF, Gao H, et al. Computed tomography-based Three-Column Classification in tibial plateau fractures: introduction of its utility and assessment of its reproducibility. J Trauma Acute Care Surg 2012;73:731-7. 18. Zhai Q, Luo C, Zhu Y, Yao L, Hu C, Zeng B, Zhang C. Morphological characteristics of split-depression fractures of the lateral tibial plateau (Schatzker type II): a computer-tomography-based study. Int Orthop 2013;37:911-7. 19. Egol KA. Split depression posterolateral tibial plateau fracture: direct open reduction and internal fixation. Techniques in Knee Surgery 2005;4:257-63. 20. Brennan SL, Cicuttini FM, Pasco JA, Henry MJ, Wang Y, Kotowicz MA, et al. Does an increase in body mass index over 10 years affect knee structure in a population-based cohort study of adult women? Arthritis Res Ther 2010;12:139. 21. Graves ML. Periarticular tibial fracture treatment in the obese population. Orthop Clin North Am 2011;42:37-44. 22. Compston JE, Flahive J, Hooven FH, Anderson FA Jr, Adachi JD, Boonen S, et al. Obesity, health-care utilization, and health-related quality of life after fracture in postmenopausal women: Global Longitudinal Study of Osteoporosis in Women (GLOW). Calcif Tissue Int 2014;94:223-31. 23. Schmier JK, Jones ML, Halpern MT. Cost of obesity in the workplace. Scand J Work Environ Health 2006;32:5-11. 24. Amin AK, Clayton RA, Patton JT, Gaston M, Cook RE, Brenkel IJ. Total knee replacement in morbidly obese patients. Results of a prospective, matched study. J Bone Joint Surg Br 2006;88:1321-6. 25. Linberg CJ, Sperling JW, Schleck CD, Cofield RH. Shoulder arthroplasty in morbidly obese patients. J Shoulder Elbow Surg 2009;18:903-6. 26. Brown CV, Neville AL, Rhee P, Salim A, Velmahos GC, Demetriades D. The impact of obesity on the outcomes of 1,153 critically injured blunt trauma patients. J Trauma 2005;59:1048-51. 27. Gilbert SR, MacLennan PA, Backstrom I, Creek A, Sawyer J. Altered lower extremity fracture characteristics in obese pediatric trauma patients. J Orthop Trauma 2015;29:12-7. 28. Dischinger PC, Kerns TJ, Kufera JA. Lower extremity fractures in motor vehicle collisions: the role of driver gender and height. Accid Anal Prev 1995;27:601-6. 29. Conde J, Scotece M, López V, Gómez R, Lago F, Pino J, et al. Adipokines: novel players in rheumatic diseases. Discov Med 2013;15:73-83. 30. Durakbasa MO, Kose O, Ermis MN, Demirtas A, Gunday S, Islam C. Measurement of lateral plateau depression and lateral plateau widening in a Schatzker type II fracture can predict a lateral meniscal injury. Knee Surg Sports Traumatol Arthrosc 2013;21:2141-6. 31. Biyani A, Reddy NS, Chaudhury J, Simison AJ, Klenerman L. The results of surgical management of displaced tibial plateau fractures in the elderly. Injury 1995;26:291-7. 32. Watson J, Schatzker J. Skeletal trauma. 2nd ed. Philadelphia: W.B. Saunders Company; 1998.

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

Çeçen ve ark. Opere tibia plato Schatzker tip I ve tip II kırıklarda, iyileşme üzerine obezitenin olumsuz etkisi var mı?

ORIGINAL ARTICLE - ABSTRACT OLGU SUNUMU

The impact of obesity on the outcomes of the patients operated on due to Schatzker type I and type II tibial plateau fractures Gültekin Sıtkı Çeçen, M.D., Deniz Gülabi, M.D., Gökhan Pehlivanoğlu, M.D., Nurzat Elmalı, M.D., Akif Teköz, M.D. Department of Orthopedics and Traumatology, Dr. Lütfi Kırdar Kartal Training and Research Hospital, İstanbul

BACKGROUND: This study aimed to conduct a clinical and radiological analysis of treatment results in Schatzker type I and type II tibial plateau fractures and investigate the effect of Body Mass Index on these results. METHODS: A total of 64 patients (44 male [68.8%], 20 female [31.3%]; mean age 21-80; range 45.05±13.47 years) undergoing surgery for Schatzker type I and type II tibial plateau fractures were included into the study. Clinical and radiological results were evaluated according to Rasmussen scores. During evaluation, BMI of the patients was reported. The effects of obesity on these clinical and radiological results were further evaluated. RESULTS: In Schatzker type II cases, there was an indirect 48.4% statistically significant relation (p<0.01) between Rasmussen Clinical scores and age. DISCUSSION: In Type II fractures, the results of obese patients were found to be worse when compared to patients with normal weight. While obesity is not a problem which can be overcome in a short time interval, close follow-up and careful rehabilitation are essential to achieve good results in this group of patients. Key words: BMI; rasmussen assessment; tibia plateau fracture. Ulus Travma Acil Cerrahi Derg 2015;21(3):209-215

doi: 10.5505/tjtes.2015.39197

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

215

ORİJİ N A L Ç A LI Ş M A

Elektrik yaralanmalarında elektrokardiyografi bulgularının klinik gidişte önemi Dr. Aslı Vural,1* Dr. Taner Sarak,2 Dr. Selahattin Vural,3 Dr. Ahmet Çınar Yastı3,4 1

Kırıkkale Yüksek İhtisas Hastanesi, Kardiyoloji Bölümü, Kırıkkale

Hitit Üniversitesi Tıp Fakültesi, Kardiyoloji Anabilim Dalı, Çorum

Ankara Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara

Hitit Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Çorum

ÖZET AMAÇ: Bu çalışmada, elektrik yaralanması nedeniyle başvuran hastaların demografik ve klinik özellikleri, elektrik akımı türleri ve hastaların elektrokardiyografi bulgularının klinik gidişte öneminin incelenmesi amaçlandı. GEREÇ VE YÖNTEM: Hastanemiz yanık tedavi merkezinde 2011-2012 yılları arasında elektrik yaralanması nedeniyle yatarak tedavi edilen 53 hasta (50 erkek [%94.3], 3 kadın [%5.7]; ortalama yaş 34.5±9.6; dağılım 19-61 yaş) geriye dönük olarak incelendi. Hastaların demografik ve klinik özellikleri, elektrokardiografi (EKG) bulguları ve klinik sonuçları değerlendirildi. BULGULAR: Hastaların beşi yüksek gerilimli akımla, 48’i düşük gerilimli akımla yaralanmıştı. Geliş elektrokardiyografilerinde 27’si normal iken 12’sinde sinüs taşikardisi, üçünde atriyal fibrilasyon, yedisinde sağ dal bloğu, dördünde ventriküler erken atım saptandı. Geliş EKG’si normal sinüs ritmi, sağ dal bloğu ve ventriküler erken atımı olan hastalarda ölüm görülmedi. Sinüs taşikardisi olan dört hasta, atriyal fibrilasyonu olan bir hasta hayatını kaybetti (p=0.007). Elektrik akımı türünün elektrokardiyografiye etkisine bakıldığında, yüksek gerilime maruz kalan iki hastada normal sinüs ritmi, iki hastada sinüs taşikardisi, bir hastada atriyal fibrilasyon izlendi. SONUÇ: Elektrik yaralanmalarında, hastaların geliş elektrokardiyografisinde sinüs taşikardisi ve atriyal fibrilasyonu olan hastalarda ölüm oranlarının fazla olduğu saptandı. Yüksek gerilimle olan elektrik yaralanmalarında bu elektrokardiyografi bulguları daha sık görüldü. Bu nedenle, elektrokardiyografi bulguları ve gerilim tipi hastaların klinik gidişinde prognostik değer taşıyabilir. Anahtar sözcükler: Elektrik yaralanmaları; elektrokardiyografi.

GİRİŞ Elektrik akımına maruz kalınması yanık yaralanması, kas iskelet sistemi yaralanmasına ikincil ortopedik hasarlanma ve kardiyak problemlerin dahil olduğu çeşitli klinik durumlar oluşturabilen ve tüm yaş grubunun risk altında olduğu bir travma türüdür. Amerika Birleşik Devletleri’nde elektrik yaralanmasına bağlı bildirilen ilk ölüm 1881 yılında meydana gelmiştir. Yine aynı ülkede, günümüzde her yıl elektrik yaralanmalarına bağlı

*Şimdiki kurumu: Giresun Üniversitesi Tıp Fakültesi, Kardiyoloji Anabilim Dalı, Giresun

Sorumlu yazar: Dr. Aslı Vural, Özata Sokak, No: 35/2, Gazi Mahallesi, 06200 Ankara Tel: +90 454 - 214 03 69 E-posta: drtalu@gmail.com Ulus Travma Acil Cerrahi Derg 2015;21(3):216-219 doi: 10.5505/tjtes.2015.22623 Telif hakkı 2015 TJTES

216

yaklaşık 3000 yanık olgusu ve 1000 ölüm bildirilmektedir. Bu elektrik yaralanmalarının %20’sini çocuklar ve %50’sini de iş kazaları oluşturmaktadır.[1] Elektrik yanıkları akım gücüne bağlı düşük voltaj (<1000 volt) ve yüksek voltaj (>1000 volt), oluşan enerji sıçramaları ile ark yanıkları ve akım tipine bağlı alternatif akım veya doğru akım olarak sınıflandırılır. Yaralanmanın şiddeti elektrik akımının şiddetine, vücut direncine, vücuttan geçiş yoluna ve akım kaynağı ile temas süresine göre değişmektedir.[2] Elektrik çarpmalarında önemli bir ölüm nedeninin de miyokardın, nodların, elektriksel ileti yollarının ve koroner arterlerin nekrozuna ikincil gelişen kardiyak aritmi ve disritmiler olduğu belirtilmektedir. Kardiyak aritmilerin patogenezi tam olarak anlaşılabilmiş değildir ve genellikle multifaktöryeldir. Miyokart nekrozuna bağlı aritmojenik odak oluşması, Na+K+-adenosintrifosfataz konsantrasyonu ve miyosit membranındaki permeabilite değişiklikleri üzerinde tartışılan olası mekanizmalardandır.[3] Ayrıca kardiyak hasar ve ritim bozukluklarının respiratuvar arreste bağlı anoksik hasar sonucu geUlus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

Vural ve ark. Elektrik yaralanmalarında elektrokardiyografi bulgularının klinik gidişte önemi

Tablo 1. Elektrik yaralanmasının olduğu yer ile gerilim tipi ilişkisi

Elektrik yaralanmasının olduğu yer

İş yeri

Açık alan

Toplam

Düşük gerilim

Yüksek gerilim

Toplam

14 23

Tablo 2. Geliş elektrokardiyografi bulgusu ile gerilim tipi ve mortalite ilişkisi Geliş elektrokardiyografi bulgusu

Toplam

Yüksek voltaj

Düşük voltaj

Ölüm

Normal

27 2

25 0

Anormal

26 3

23 5

Sinüs taşikardisi

Atriyal fibirlasyon

Sağ dal bloğu

Ventriküler erken atım

53 5

Toplam

lişebileceği de bildirilmiştir.[4] Biz bu çalışmada elektrik yaralanması nedeniyle başvuran hastaların demografik ve klinik özellikleri ile elektrik akımın türleri ve hastaların elektrokardiyografi (EKG) bulgularının klinik gidişteki önemini incelenmeyi amaçladık.

GEREÇ VE YÖNTEM Ankara Numune Eğitim ve Araştırma Hastanesi Yanık Tedavi Merkezi’nde 2011-2012 yılları arasında elektrik yaralanması nedeniyle yatarak tedavi edilen 53 hasta çalışmaya alındı. Hastaların demografik ve klinik özellikleri, elektrokardiografi bulguları, yanık genişliği, hastanede kalma süreleri, uygulanan cerrahi işlemler ve klinik sonuçlar yatış dosyaları ve bilgisayar kayıtları kullanılarak geriye dönük değerlendirildi. Kategorik değişkenler sayı ve yüzde olarak ifade edildi. Gruplar ile kategorik değişkenler arasındaki ilişkiyi belirlemede ki-

48 5

kare testi kullanıldı. Hesaplamalarda istatistiki anlamlılık düzeyi, p<0.05 olması halinde anlamlı kabul edildi.

BULGULAR Çalışmaya 53 hasta (50 erkek [%94.3], 3 kadın [%5.7]; ortalama yaş 34.5±9.6; dağılım 19-61 yaş) alındı. Yaralanma yerleri değerlendirildiğinde hastaların 14’ü (%26.4) evde, 23’ü (%43.4) iş yerinde, 16’sı (%30.2) açık alanda elektrik akımına maruz kalmıştı. Hastaların beşi (%9.4) yüksek gerilimli akımla, 48’i (%90.4) düşük gerilimli akımla yaralanmıştı. Yüksek gerilimle olan beş elektrik yaralanmasının biri evinde balkonda boya yapmak için demir çubuk kullanan hane halkında, biri işyerinde, üçü açık alanda meydana gelmişti (Tablo 1). Elektrik çarpmasından sonra hastaların ikisi ilk dört saat içinde, 19’u ilk 12 saatte, 21’i ilk 24 saatte, altısı ilk 48 saatte, beşi 48 saatten sonra kliniğimize yatırılmıştı. Hastanede yatış süresi ortalama 33.6±21.3 gün olarak bulundu. Toplam vücut yanık yüzey alanı %23.3±18.1 olarak tespit edildi. Düşük gerilimli elektrikle yaralanan 48 hastanın ortalama yanık yüzdesi %22.5, yüksek

Tablo 3. Elektriğin gerilim tipi ile mortalite ilişkisi

Yaşayanlar

Ölenler

Yüksek gerilim

Düşük gerilim

Toplam

48 5

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Vural ve ark. Elektrik yaralanmalarında elektrokardiyografi bulgularının klinik gidişte önemi

gerilimli elektrikle yaralanan beş hastanın ortalama yanık yüzdesi %31’di ve iki grup arasında anlamlı fark yoktu (p=0.324). Hayatını kaybeden beş hastanın ortalama yanık yüzdesi %48.6 iken, yaşayan 48 hastanın ortalama yanık yüzdesi %20.6 olarak bulundu (p=0.029). Hastanede yatış süresi ölenlerde ortalama 15±19.0 gün (5.-6.-7.-8. ve 49. günlerde ölüm olmuş), yaşayanlarda ortalama yatış süresi 35.58±20.76 gün olarak tespit edildi. Yatış süresince uygulanan cerrahi işlemlere bakıldığında 15 (%28.3) hastaya eskarotomi, 12 (%22.6) hastaya fasiyotomi, düşük gerilime maruz kalan bir hastaya ön kol ampütasyonu, yüksek gerilime maruz kalan bir hastaya da ayak parmak ampütasyonu yapıldı. Hastaların geliş EKG’lerinde 27’sinde (%50.9) normal sinüs ritmi, 12’sinde (%22.6) sinüs taşikardisi, üçünde (%5.7) atriyal fibrilasyon, yedisinde (%13.2) sağ dal bloğu, dördünde (%7.5) ventriküler erken atım saptandı (Tablo 2). Hastaların yedisine (%13.2) yatış süresince kardiyak monitorizasyon yapıldı. Geliş EKG’si normal sinüs ritmi olan 27 hasta, sağ dal bloğu olan yedi hasta ve ventriküler erken atımı olan dört hastada ölüm görülmedi. Sinüs taşikardisi olan 12 hastanın dördü, atriyal fibrilasyonu olan üç hastanın biri hayatını kaybetti (p=0.007). Geliş EKG’si sinüs taşikardisi olan ve hayatını kaybeden dört hasta incelendiğinde: ikisi yaralanmadan sonraki 1-4 saat içinde, birisi 4-12 saat içinde, birisi de 48 saatten sonra hastanemize kabul edilmişti. 1-4 saat içinde başvuran hastaların yanık yüzdeleri %49 ve %60 bulunurken ikisi de düşük gerilimli elektrikle yaralanmıştı. Yaralanmadan sonraki 4-12 saat içinde kabul edilen hasta yüksek gerilime maruz kalmıştı ve yanık yüzdesi %70 olarak bulunmuştu. Travmadan sonraki 1-4 saat ve 4-12 saatler arasında başvuran hastalarda, yanıklı yüzey alanı genişti ve majör yanık mevcuttu. Hastalar majör cilt yanığı, hipovolemi, yetersiz sıvı resüsitasyonu ve sonrasında gelişen çoklu organ yetersizliğine bağlı kaybedilmişti. Kliniğe, başka bir merkezde 48 saat takibinden sonra yatırılan dördüncü hasta ise yüksek gerilime maruz kalmıştı ve yanıklı yüzey alanı %19 idi. Bu son hasta, sepsis gelişmesi üzerine hastanemize sevk edilmişti ve hasta yine dirençli sepsis nedeniyle kaybedilmişti. Elektrik akımı türünün EKG’ye etkisine bakıldığında yüksek gerilime maruz kalan iki hastada normal sinüs ritmi, iki hastada sinüs taşikardisi, bir hastada atriyal fibrilasyon izlendi. Yüksek gerilimle olan elektrik yaralanmalarında düşük gerilimle olan elektrik yaralanmalarıyla kıyaslandığında mortalite daha yüksekti (p=0.002) (Tablo 3).

TARTIŞMA Bu çalışmamızda elektrik yaralanmalarının kardiyak ritim üzerindeki etkilerini araştırdık. Daha önce yapılan çalışmalara göre asistoli ve ventriküler fibrilasyon elektrik yaralanmalarına bağlı gelişen ölümcül kardiyak problemler olup bunlardan başka sinüs taşikardisi, nonspesifik ST-T değişiklikleri, kalp blokları, QT uzaması, supraventriküler-ventriküler aritmiler ve atriyal fibrilasyon gibi EKG değişiklikleri görülebilmektedir.[5,6] Arrowsmith ve ark.[7] çalışmalarında, olguların %3’ünde EKG 218

anormalliği olduğunu bildirmişlerdir. Bizim çalışmamızda hastaneye başvuru sırasında çekilen EKG’lerin %50.9’u normaldi. Geriye kalan hastalardaki EKG değişikliklerine bakıldığında sinüs taşikardisi, atriyal fibrilasyon, ventriküler erken atım ve sağ dal bloğu saptandı. Ventriküler fibrilasyon ya da asistoli gibi ciddi aritmiler genellikle olay yerinde ölümle sonuçlandığı için hastaneye başvuran hastalarda saptamadık. Ülkemizde yapılan bir çalışmada, elektrik yaralanması nedeniyle acil servise getirilen 102 hastanın yedisinde asistoli ve birinde ventriküler fibrilasyon bildirilmiştir. Yazarlar, yaralanma esnasında farklı bir kardiyak ritmin olabileceğini, asistoli veya ventriküler fibrilasyonun transport edilirken gelişmiş olabileceğinin düşünüldüğünü bildirmişlerdir.[3] Voltaj ne kadar yüksek ise miyokart hasarının o derece fazla olduğu bildirilmiştir.[5] Literatürde, EKG değişikliklerinin ise daha düşük akımlarda ortaya çıktığı belirtilmektedir.[4] Rai ve ark.[8] çalışmalarında, 58 yüksek voltaj elektrik yaralanmalı hastanın yedisinde kardiyojenik şok veya aritmiye sekonder kardiyak arrest geliştiğini rapor etmişlerdir. Ülkemizde yapılan bir çalışmada, elektrik akımıyla yaralanan 102 hastadan, ölen dokuz hastanın altısının yüksek voltaja, üçünün düşük voltaja maruz kaldığı bildirilmiş.[3] Bizim çalışmamızda da yüksek voltajlı elektrik yaralanmalarında mortalite artmış bulundu. Yüksek voltajlı elektrik yaralanması olan bir hastada atriyal fibrilasyon, iki hastada sinüs taşikardisi saptadık. Yalnızca EKG bulgularına bakılarak miyokart hasarının ciddiyetini belirlemek ya da bu bulgularının mortalite nedeni olup olmadığını söylemek mümkün değildir. Sinüs taşikardisi ve atriyal fibrilasyon ölümcül ritim bozuklukları olmamasına rağmen; hipovolemi, hipoksi, sepsis ve anemi gibi doku oksijenlenmesini azaltan nedenlere sekonder olarak gelişebilir ve hastalığın ciddiyetinin bir göstergesi olabilir. Geliş EKG’leri normal veya sağ dal bloğu ya da ventriküler ekstrasistol bulguları olan hastaların hiç birinde ölüm görülmemesi sonucunda, bu hastalarda kardiyak komplikasyonlar açısından artmış risk olmadığını söyleyebiliriz. Elektrik yaralanmalarında kardiyak komplikasyonlar hastaların az bir kısmında görülür, fakat ciddi ve ölümcül olabilir. Elektrik yanıkları sonrasında gelişen kardiyak hasar atipik şekillerde belirti verebilir, geç ortaya çıkabilir ya da diğer travmalar nedeniyle zor tanı konulabilir.[4] Bu sebeplerle her hasta dikkatli bir şekilde değerlendirilmeli, EKG ve kardiyak enzim, gerekirse kardiyak monitorizasyonla takip edilmelidir. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. National Burn Repository. 2011 Report Dataset. Version 7.0. American Burn Association, Chicago, IL USA 2011. [www.ameriburn.org.] 2. Smith MA, Muehlberger T, Dellon AL. Peripheral nerve compression associated with low-voltage electrical injury without associated significant cutaneous burn. Plast Reconstr Surg 2002;109:137-44. 3. Akkaş M, Hocagil H, Ay D, Erbil B, Kunt MM, Ozmen MM. Cardiac monitoring in patients with electrocution injury. Ulus Travma Acil Cer-

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

Vural ve ark. Elektrik yaralanmalarında elektrokardiyografi bulgularının klinik gidişte önemi rahi Derg 2012;18:301-5. 4. Koumbourlis AC. Electrical injuries. Crit Care Med 2002;30(11 Suppl):424-30. 5. Carleton SC. Cardiac problems associated with electrical injury. Cardiol Clin 1995;13:263-6. 6. Varol E, Ozaydin M, Altinbas A, Dogan A. Low-tension electrical in-

jury as a cause of atrial fibrillation: a case report. Tex Heart Inst J 2004;31:186-7. 7. Arrowsmith J, Usgaocar RP, Dickson WA. Electrical injury and the frequency of cardiac complications. Burns 1997;23:576-8. 8. Rai J, Jeschke MG, Barrow RE, Herndon DN. Electrical injuries: a 30year review. J Trauma 1999;46:933-6.

ORIGINAL ARTICLE - ABSTRACT OLGU SUNUMU

The importance of electrocardiography in the clinical course of electric injuries Aslı Vural, M.D.,1* Taner Sarak, M.D.,2 Selahattin Vural, M.D.,3 Ahmet Çınar Yastı, M.D.3,4 Department of Cardiology, Kırıkkale Yüksek İhtisas Hospital, Kırıkkale Department of Cardiology, Hitit University Faculty of Medicine, Çorum Department of General Surgery, Ankara Numune Training and Research Hospital, Ankara 4 Department of General Surgery, Hitit University Faculty of Medicine, Çorum 1 2 3

BACKGROUND: The aim of the present study was to investigate the demographic and clinical characteristics of electrical injuries, type of electrical current and the importance of electrocardiography in clinical course. METHODS: Fifty-three patients (50 males [94.3%], 3 females [5.7%]; mean age 34.5±9.6; range 19 to 61 years) with electrical injuries treated in the burn center between 2011 and 2012 were retrospectively analyzed. The patients were evaluated for demographic and clinical characteristics, electrocardiographic findings and clinical outcomes. RESULTS: The electrocardiography findings of the patients were as follows: twenty-seven normal, twelve sinus tachycardia, three atrial fibrillation, seven right bundle brunch block, and four ventricular extra-systole. There was no mortality among patients with electrocardiographic findings of normal, right bundle brunch block, and ventricular extra-systole. Four patients with sinus tachycardia and one patient with atrial fibrillation died. Electrocardiographic findings of the patients wounded by high-voltage electricity were: two normal, two sinus tachycardia, and one atrial fibrillation. DISCUSSION: Mortality was higher in patients with sinus tachycardia and atrial fibrillation in the electrocardiography at the time of admission. These ECG findings were more often in patients wounded by high-voltage electricity. Therefore, electrocardiographic findings and type of the electrical current may provide prognostic value in the clinical course of patients. Key words: Electrocardiography; electric injuries. *Current affiliation: Department of Cardiology, Giresun University Faculty of Medicine, Giresun, Turkey. Ulus Travma Acil Cerrahi Derg 2015;21(3):216-219

doi: 10.5505/tjtes.2015.22623

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CA S E R EP O RT

Unilateral spontaneous adrenal hemorrhage in a young patient Muhammet Ferhat Çelik, M.D., Cevher Akarsu, M.D., Ahmet Cem Dural, M.D., Murat Çikot, M.D., Mustafa Gökhan Ünsal, M.D., Halil Alış, M.D. Department of General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, İstanbul

ABSTRACT The objective of this study was to report an unusual case of unilateral adrenal hematoma in; a 19-year-old young man who did not have a history of any specific systemic disease. The patient was admitted to hospital with chest pain that lasted for one day. Preoperative contrast-enhanced computerized tomography evaluated an adrenal mass (sized, 10.5x12.7 cm) adjacent to the anterior of the left kidney, and findings were indicative of adrenal hematoma. The final pathological diagnosis was adrenal adenoma. Key words: Adrenal gland; adrenal hematoma; adrenal hemorrhage.

INTRODUCTION

CASE REPORT

Adrenal hemorrhage (AH) can result from a variety of reasons. The large majority of patients with unilateral adrenal hemorrhage do not have clinically obvious signs of adrenal insufficiency, and diagnosis is usually made incidentally by the imaging performed for another reason. When unilateral, it is often clinically silent.[1]

A 19-year-old man was admitted to hospital for acute chest pain and generalized weakness that continued for one day. There was no history of abdominal trauma, fever, hematuria, urinary symptoms or any specific systemic disease. On examination, the patient had tachycardia (120 beats per minute), but his blood pressure was normal. The patient had normal abdominal examination except for mild abdominal distension. Hematological investigation revealed severe anemia (hemoglobin 6.8 g/dL) with decreased hematocrit (23.2%) and neutrophilic leukocytosis (19800/mm3). Routine urine examination revealed 2 red blood cells and 10 pus cells/high power field (HPF). The coagulation profile as well as the serum amylase and lipase levels were normal. Abdominal ultrasound revealed diffuse free liquid into the peritoneal cavity. A computerized tomography (CT) scan of the abdomen was performed, which showed a left-sided perirenal solid mass and hematoma suggestive of renal origin in size of 10.5x12.7 cm (Fig. 1). The endocrinological examinations of the patient revealed Aldosterone 23.1 g/dL and Cortisol 34.6 µg/dL.

Adrenal hemorrhage is associated with not only meningococcal septicemia but also disseminated intravascular coagulation (Waterhouse-Friderichsen syndrome); however, trauma, complications of pregnancy, tumors, surgical stress or anticoagulation therapy may also cause AH.[2] Primary adrenal cortical neoplasm rarely presents with spontaneous retroperitoneal hemorrhage. Nonetheless, spontaneous or idiopathic, AH is extremely rare in adults.[2] This article reported the case of a young patient with spontaneous unilateral adrenal hemorrhage. Address for correspondence: Muhammet Ferhat Çelik, M.D. Tevfik Sağlam Cad., No: 11, Zuhuratbaba Mahallesi, Bakırköy, İstanbul, Turkey Tel: +90 212 - 414 71 71 E-mail: mferhatcmd@yahoo.com Qucik Response Code

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Preoperatively, six bags of erythrocyte suspension and four bags of fresh frozen plasma was transfused to the patient. An emergency operation was performed due to the worsening of the patient’s general condition on day three. A laparotomic left adrenalectomy and drainage of the hematoma was performed. The excised specimen contained an adenoma of the adrenal gland (Fig. 2). Postoperative recuperation was uneventful. Therefore, the final pathological diagnosis was adrenal adenoma. This study reported a case of spontaneous AH in a young man. Ulus Travma Acil Cerrahi Derg, May 2015, Vol. 21, No. 3

Ă&#x2021;elik et al. Unilateral spontaneous adrenal hemorrhage in a young patient

(a)

DISCUSSION Common etiologies of spontaneous retroperitoneal hemorrhage in adults include trauma, coagulopathy or anticoagulation therapy, ruptured aneurysm of the aorta, splenic or renal artery and an arteriovenous malformation.[3] Spontaneous or idiopathic adrenal hemorrhage is extremely rare in adults. The incidence of spontaneous AH has been reported between 0.14% and 1.1%, usually involving the right gland.[4] Spontaneous hemorrhage can also occur in the retroperitoneum. Adrenal hematomas have numerous and highly dissimilar radiographic appearances in CT. Magnetic resonance imaging is an alternative imaging modality for characterization of adrenal masses including adrenal hemorrhage.[5]

(b)

Since the 1990s, open adrenalectomy has been replaced with laparoscopic adrenalectomy (LA), and the implementation of minimally invasive surgery in adrenal gland surgery has gained significant momentum. Currently, LA has become a standard surgical method in many centers.[6] AH rarely results from ruptured adrenal neoplasm. AH from a malignant primary adrenal neoplasm is also rare.[3] Adrenocortical carcinoma is a rare malignancy with an annual incidence of 1-2/million.[7] It is common in the fifth decade of life and in children under the age of 5.[8] Baksi et al.[3] have presented a similar case with spontaneous retroperitoneal hemorrhage in a 21-year-old woman. Histological examination of the resected specimen has revealed an adrenocortical neoplasm.

Figure 1. (a, b) Computerized tomography scan of the abdomen.

Patients with hemorrhage usually do not present with hemorrhagic shock. Initially, they can be managed conservatively and investigated prior to surgery. Our patient had no fever, neck stiffness, findings of meningitis and meningococcal septicemia; and therefore, these diseases were excluded.

Figure 2. Macroscopic imaging of the excised specimen.

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Endocrinological examinations could not be fully carried out as an emergency surgery had to be performed in the preoperative preparation stage. In addition, it was initially thought as having renal origin. Possible differential diagnoses included a ruptured splenic or renal vascular aneurysm, an arteriovenous malformation or an adrenal vascular lesion. In this regard, angio-embolization of the bleeding adrenal vessels was reported.[9] Interventional radiology concluded that embolization was not suitable for the patient as the bleeding came from the mass. In a retrospective study of one hundred and forty-one patients of spontaneous AH admitted in the Mayo Clinic, College of Medicine from 1972 to 1997, sixteen patients presented with sudden abdominal pain and unilateral AH, and only seven required surgery in order to control the 221

Çelik et al. Unilateral spontaneous adrenal hemorrhage in a young patient

retroperitoneal hemorrhage associated with the hemorrhagic adrenal gland, just like in our patient.[2] The possibility of AH should be kept in mind for acute abdominal pain, especially in patients with a diagnosis of a perirenal hematoma upon imaging. It can be concluded that in clinically stable patients, preoperative investigation and diagnosis can be performed in detail with a conservative approach. Conflict of interest: None declared.

REFERENCES 1. Imachi H, Murao K, Yoshimoto T, Sugimoto M, Kakehi Y, Hayashi T, et al. Idiopathic unilateral adrenal hemorrhage in an elderly patient. Endocrine 2010;37:249-52. 2. Vella A, Nippoldt TB, Morris JC 3rd. Adrenal hemorrhage: a 25-year experience at the Mayo Clinic. Mayo Clin Proc 2001;76:161-8. 3. Baksi A, Gupta S, Ray U, Ghosh S. Spontaneous retroperitoneal haem-

orrhage in a young adult. BMJ Case Rep 2014;2014. 4. Gavrilova-Jordan L, Edmister WB, Farrell MA, Watson WJ. Spontaneous adrenal hemorrhage during pregnancy: a review of the literature and a case report of successful conservative management. Obstet Gynecol Surv 2005;60:191-5. 5. Sacerdote MG, Johnson PT, Fishman EK. CT of the adrenal gland: the many faces of adrenal hemorrhage. Emerg Radiol 2012;19:53-60. 6. Akarsu C, Dural AC, Kankaya B, Çelik MF, Köneş O, Mert M, et al. Robotik adrenalektomide başlangıç deneyim ve ilk sonuçlarımız. Ulusal Cer Derg 2014;30:28-33. 7. Schteingart DE, Doherty GM, Gauger PG, Giordano TJ, Hammer GD, Korobkin M, et al. Management of patients with adrenal cancer: recommendations of an international consensus conference. Endocr Relat Cancer 2005;12:667-80. 8. Yeh MW, Duh QY. The adrenal glands. In: Townsend CM Jr, ed. Sabiston text book of surgery: the biological basis of modern surgical practice, 19th ed. Philadelphia: Saunders, Elsevier; 2012. p. 979-80. 9. Nakajo M, Onohara S, Shinmura K, Fujiyoshi F, Nakajo M. Embolization for spontaneous retroperitoneal hemorrhage from adrenal myelolipoma. Radiat Med 2003;21:214-9.

OLGU SUNUMU - ÖZET

Genç hastada spontan tek taraflı adrenal kanama Dr. Muhammet Ferhat Çelik, Dr. Cevher Akarsu, Dr. Ahmet Cem Dural, Dr. Murat Çikot, Dr. Mustafa Gökhan Ünsal, Dr. Halil Alış Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

Bu yazıda, herhangi bir spesifik sistemik hastalık öyküsü olmayan 19 yaşında genç bir hastada, nadir görülen tek taraflı adrenal hematomu sunuldu. Hasta bir gündür olan göğüs ağrısı şikayeti ile acil servise başvurdu. Ameliyat öncesi dönemde yapılan değerlendirmede çekilen kontrastlı bilgisayarlı tomografi sonucunda sol böbrek komşuluğunda 10.5x12.7 cm adrenal kitle ve hematom saptandı. Ameliyat sonrası kitlenin patolojik incelemesinde adrenal adenom saptandı. Anahtar sözcükler: Adrenal bez; adrenal hemoraji; adrenal hematom. Ulus Travma Acil Cerrahi Derg 2015;21(3):220-222

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CA S E R EP O RT

The repair of complex penile defect with composite anterolateral thigh and vascularized fascia lata flap Şükrü Yazar, M.D.,1 Muzaffer Eroğlu, M.D.,2 Ali Gökkaya, M.D.,3 Atilla Semerciöz, M.D.2 1

Department of Plastic and Reconstructive Surgery, Acıbadem University Faculty of Medicine, İstanbul

Department of Urology, Abant İzzet Baysal University Faculty of Medicine, Bolu

Department of Plastic and Reconstructive Surgery, Abant İzzet Baysal University Faculty of Medicine, Bolu

ABSTRACT One-stage reconstruction of complex penile defects with functional and cosmetic results is a challenging procedure. The selection of proper technique and materials for reconstruction depends on the type of the deficient tissue components, the size of the wound surface, and the donor site.This article presented a case of a partial penile and urethral defect due to an infection in the previous surgical site. The patient was treated with a perforator based pedicled composite anterolateral thigh flap combined with vascularized fascia lata. The urethral defect was reconstructed with the vascularized fascia lata. The remaining part of the flap was used for the resurfacing of the right cavernous body and penile skin defect. There was no fistula and the urinary caliber was accepted as good. The pedicled composite anterolateral thigh flap contains various tissue components suitable for a functional and cosmetic reconstruction of complex penile defects using the one-stage technique. Key words: Complex penile defect; perforator based pedicled anterolateral thigh flap; vascularized fascia lata.

INTRODUCTION Complex penile defects involving the urethra, cavernous bodies, and penile or scrotal skin may result from congenital hypospadias, trauma, burn, infection, and cancer surgery. Although several different repair techniques have been described, reconstruction of complex penile defects is quite challenging. As well as the ability to urinate, a reconstructed penis and urethra should ensure erectile function, tactile sensibility, sexual satisfaction, and aesthetic integrity. Many methods of restoring urethral continuity and/or resurfacing of penile skin defects have been described. Various graft materials such as genital or extra genital skin or mucosa

Address for correspondence: Şükrü Yazar, M.D. Acıbadem Üniversitesi Tıp Fakültesi Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı, 34457 Maslak, Turkey Tel: +90 212 - 304 44 44 E-mail: sukruyazar@hotmail.com Qucik Response Code

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have been used for establishing a normal urethral lumen,[1-5] or split-thickness skin grafts used for coverage of a denuded penile shaft.[6] Local pedicled penile or scrotal flaps and pedicled regional flaps have allowed reliable long-term results to create a solution to long urethral defects and resurfacing of large penile skin defects.[7-13] Unfortunately, previous surgery or trauma may preclude using local pedicled penile and regional flaps. Recently, microsurgical transfers of different tissues have been used for reconstruction of the more complex urethral and penile defects.[12,14-17] This study aimed to report a case of a partial penile and urethral defect due to an infection in the previous surgical site of a penile fracture. The complex penile defect was reconstructed with a perforator based pedicled anterolateral thigh flap combined with the vascularized fascia lata. The urethral defect was reconstructed with the vascularized fascia lata. The remaining part of the flap was used for the resurfacing of the right cavernous body and penile skin defects.

CASE REPORT A 42-year-old male patient was admitted to our hospital with pain and dark-brown discoloration of his penis. The patient was healthy and did not have any diseases like DM. The patient had been operated on for a penile fracture ten days pri223

Yazar et al. The repair of complex penile defect with composite anterolateral thigh and vascularized fascia lata flap

or in another hospital and discharged from the hospital eight days after surgery. Local examination revealed infection and necrosis of the penile skin without any clear line of demarcation (Fig. 1a). The patient was hospitalized and a sistofix was inserted into his bladder. The wound was managed with repeated debridements of necrotic tissues, culture specific antibiotics, and meticulous local wound care for the eradication of the infection. Unfortunately, after serial debridements of necrotic tissues a right cavernous body, a 5 - 6 cm urethral, and a partial penile skin defect occurred (Figs. 1b, c).

of the perforators through the muscle down to their origin on the main pedicle was performed under surgical loupe magnification. The muscle around the perforator was divided piece-by-piece following their course, and all tiny muscular branches were carefully ligated with hemoclips or cauterized with bipolar cautery. Later, the main pedicle, descending branch of the lateral circumflex femoral artery, was dissected and isolated to preserve the motor nerve to the vastus lateralis muscle and rectus femoris muscle. The entire length of the perforator flap pedicle was 16 cm.

Surgical Technique

At the upper portion of the flap, the lateral cutaneous femoral nerve was identified in subcutaneous tissue and dissected at the suprafascial level toward the anterior superior iliac spine for sensation of the skin island (Fig. 1d).

A 7 x 16 cm dimensional anterolateral thigh flap was designed on the right side. The location of the main cutaneous perforators was detected and marked with an ultrasound Doppler preoperatively. A medial incision above the rectus femoris muscle was made and deepened down to the subfascial plane. The pedicle was identified in the intermuscular septum between the rectus femoris and vastus lateralis muscle. The dissection continued underneath the deep fascia of the vastus lateralis muscle to determine the relation of the perforators between the muscle and deep fascia.[18,19] Two musculocutaneous perforators were observed. Intramuscular dissection

(a)

(c)

The dissection was extended laterally to the vastus lateralis muscle to include the adjoining fascia lata. Together with an adequate fascia lata strip, the flap was elevated as a composite flap. A tunnel was created under the adjacent muscles and skin in order to reach the defect on the penis. Under magnification, a part of the fascia lata was dissected and separated from the skin island in a thin layer at the dis-

(b)

(d)

(e)

Figure 1. (a) Necrotic tissue of the penis after first debridement. (b) Right cavernous body defect. (c) Urethral and skin defects. (d) The sensate perforator based pedicled composite anterolateral thigh flap combined with vascularized fascia lata. (e) Urination with good caliber 14 months after operation.

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tal part of the flap. The lateral and ventral semicircular wall defect of the urethra was reconstructed with the dissected vascularized fascia lata and the overlying skin was used to cover the reconstructed urethra. The remaining skin and vascularized fascia lata of the composite flap was used for the resurfacing of the right cavernous body and penile skin defect. The donor site of the flap was closed primarily. No complications were observed during the postoperative period. The urinary diversion was clamped and the urethral catheter was taken out three weeks post reconstruction. Even from the early post-operative period, the patient urinated easily. External urethral meatus stenosis occurred two times in the first month and it was dilated with the passage of metal rods. No urination problems were observed during the 24-month long postoperative follow up. There was no fistula and the urinary caliber was accepted as good (Fig. 1e). Normal protective sensation and tactile sensibility were recorded with two-point discrimination test. The patient reported penile erectile function and ability to perform intercourse despite a right side penile curvature, 10 months after the operation. He had a baby 2 years after surgery.

DISCUSSION One-stage reconstruction of the urethra, cavernous bodies, and penile or scrotal skin defects with functional and cosmetic results presents reconstructive challenges to the surgeon. The selection of proper techniques and tissue for reconstruction of such complex penile defects usually depends on the type of the deficient tissue components, the size of the defects, the status of the wound, the condition of local tissues, and the donor site and its morbidity. Genital or extra genital skin or mucosal grafts require close contact with a well-vascularized recipient bed. Any loss of the graft could result in recurrent stricture and increase scar

(a)

tissues.[4,7,8,16,17] The advantage of using a flap for urethral reconstruction is that viability does not depend on the quality of the recipient bed.[7-9,12,16,17] In addition, the superiority of skin flaps to skin graft is obvious for the resurfacing of a large or a denuded penile shaft.[10-13] Therefore, many local and regional flap options have been reported.[7-13] However, these flaps usually require a two-stage procedure, they have limited dimensions, and previous surgery or trauma may preclude using these local penile or regional flaps. When grafts and pedicle flaps are inadequate or unavailable, microsurgical transfers of fasciocutaneous flaps, the appendix, and intestinal segments are possible tissues for the reconstruction of more complex urethral and penile defects.[12,14-17] Although the safety and versatility of microvascular free tissue transfer for reconstruction of complex penile defects is impressive, it is time consuming and it necessitates microsurgical experience. The free radial forearm flap has been widely used for both penis reconstruction and penile resurfacing. Its disadvantages are donor-site morbidity, limited dimensions, the complexity of the free tissue transfer procedure, significant atrophy of the flap, and relatively poor reinnervation. [12,13,15] Intestinal and appendix free flaps should be considered in situations when the other urethral reconstruction methods cannot be safely used. Patients must undergo a laparotomy to harvest these flaps. This surgery requires a full day and patients must be able to safely withstand lengthy anesthesia. Furthermore, sacculation of the neourethra may develop when intestine is used, which could lead to post-voit dribbling, infection and even stone formation.[16,17] However, none of these techniques, excluding tubed skin grafts and flaps, are popular for urethral reconstruction. Urethral reconstruction using tube-shaped skin grafts or flaps are not always successful because of postoperative complications such as infection, hair growth, fistula, stone formation, diverticula, and strictures.[4,12,15-17]

(b)

Figure 2. (a, b) The reconstructed penis.

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In this patient, the urethral defect was reconstructed with the vascularized fascia lata and the right cavernous body and penile skin defects were resurfaced with the remaining part of the flap in one-stage. In previous reports, the fascia lata had been used for urethral reconstruction as a non-vascularized graft.[5,18] In this patient, the fascia lata was transferred and combined to the anterolateral thigh flap as a vascularized graft. The fascia lata received sufficient blood supply via the prefascial and subfacial vascular plexus when attached to the anterolateral thigh flap.[19,20] The fascia lata has a pliable and stretchable structure. These characteristics may help create a tube-shaped neo-urethra. Furthermore, the fascia lata has no hair; therefore, postoperative complications such as, infection, stone formation, fistula and strictures may occur less. The other advantage of using a vascularized fascia lata graft for urethral reconstruction is that the viability does not depend on the quality of the recipient bed. Penile erectile function and the subsequent ability to perform intercourse can be preserved by the use of gliding tissue for penile coverage. The anterolateral thigh flap combined with vascularized fascia lata has been successfully used for the resurfacing of penile skin defects.[13] The vascularized fascia lata is a suitable tissue for providing an appropriate gliding effect to the overlying skin for penis resurfacing.[13] On the other hand, an anterolateral thigh flap combined with a vascularized fascia lata may be too bulky for resurfacing a penis, but it can be safely thinned in a second stage procedure. In this patient the bulky appearance of the flap was thinned by a defatting and liposuction technique in the plane between the fascia lata and skin (Figs. 2a, b). Therefore, composite anterolateral thigh flap combined with a vascularized fascia lata may tolerate the subsequent secondary surgical procedures because of the rich subcutaneous vascular plexus, which permits a reliable surgical dissection. Furthermore, this flap may provide skin component continuity with the surrounding skin, which may present better venous and lymphatic drainage and a better cosmetic appearance.[21] The advantages of the anterolateral thigh flap were reported previously. The flap has a large cutaneous area.[22] In chimeric flap principle, the flap can be combined with adjacent tissues such as the rectus femoris muscle, the tensor fasciae latae muscle, and the fascia lata.[22,23] The long vascular pedicle provides a long rotation arch when transferred as a pedicled flap. It is a potentially sensate flap when the lateral cutaneous nerve is included in the flap. The donor site morbidity is minimal, and the scar is easily concealed.[22,23] The perforator based pedicled anterolateral thigh flap combined with vascularized fascia lata can easily reach and cover the entire surface of the penis. The main advantage of this composite flap is that it may provide a large amount of sensate skin for a penile shaft and a large amount of well-vascularized and hairless fascia lata for urethral conduit recon226

struction, without the need for microsurgery. This technique can be used for one-stage reconstruction of complex penile defect or total penile reconstruction. Harvesting of the pedicled anterolateral thigh flap combined with vascularized fascia lata is safe and fast. The flap can contain various tissue components for functional and cosmetic reconstruction of complex penile defects in one-stage without the need for microsurgical procedures. Therefore, this flap may be a good alternative for urethral conduit and penile shaft reconstruction. Conflict of interest: None declared.

REFERENCES 1. Latifoğlu O, Yavuzer R, Unal S, Cavuşoğlu T, Atabay K. Surgical treatment of urethral fistulas following hypospadias repair. Ann Plast Surg 2000;44:381-6. 2. El-Sherbiny MT, Abol-Enein H, Dawaba MS, Ghoneim MA. Treatment of urethral defects: skin, buccal or bladder mucosa, tube or patch? An experimental study in dogs. J Urol 2002;167:2225-8. 3. Ransley PG, Duffy PG, Oesch IL, Van Oyen P, Hoover D. The use of bladder mucosa and combined bladder mucosa/preputial skin grafts for urethral reconstruction. J Urol 1987;138(4 Pt 2):1096-8. 4. Kahveci R, Kahveci Z, Sirmali S, Ozcan M. Urethral reconstruction with autologous vein graft: an experimental study. Br J Plast Surg 1995;48:500-3. 5. Kargi E, Yeşilli C, Akduman B, Babucçu O, Hoşnuter M, Mungan A. Fascia lata grafts for closure of secondary urethral fistulas. Urology 2003;62:928-31. 6. Georgiou P, Liakopoulos P, Gamatsi E, Komninakis E. Degloving injury of the penis from pig bite. Plast Reconstr Surg 2001;108:805-6. 7. Wessells H, McAninch JW. Current controversies in anterior urethral stricture repair: free-graft versus pedicled skin-flap reconstruction. World J Urol 1998;16:175-80. 8. Jordan GH. Penile reconstruction, phallic construction, and urethral reconstruction. Urol Clin North Am 1999;26:1-13. 9. Secrest CL, Jordan GH, Winslow BH, Horton CE, McCraw JB, Gilbert DA, et al. Repair of the complications of hypospadias surgery. J Urol 1993;150(5 Pt 1):1415-8. 10. Jeong JH, Shin HJ, Woo SH, Seul JH. A new repair technique for penile paraffinoma: bilateral scrotal flaps. Ann Plast Surg 1996;37:386-93. 11. Borovikov A, Scheplev P. Axial flaps for treatment of penis lesions due to granulomas. Ann Plast Surg 1990;25:116-8. 12. Cheng KX, Hwang WY, Eid AE, Wang SL, Chang TS, Fu KD. Analysis of 136 cases of reconstructed penis using various methods. Plast Reconstr Surg 1995;95:1070-84. 13. Gravvanis AI, Tsoutsos DA, Iconomou TG, Papadopoulos SG. Penile resurfacing with vascularized fascia lata. Microsurgery 2005;25:462-8. 14. Young VL, Khouri RK, Lee GW, Nemecek JA. Advances in total phalloplasty and urethroplasty with microvascular free flaps. Clin Plast Surg 1992;19:927-38. 15. Gottlieb LJ, Levine LA. A new design for the radial forearm free-flap phallic construction. Plast Reconstr Surg 1993;92:276-84. 16. Koshima I, Inagawa K, Okuyama N, Moriguchi T. Free vascularized appendix transfer for reconstruction of penile urethras with severe fibrosis. Plast Reconstr Surg 1999;103:964-9. 17. Bales GT, Kuznetsov DD, Kim HL, Gottlieb LJ. Urethral substitution using an intestinal free flap: a novel approach. J Urol 2002;168:182-4. 18. Atalan G, Cihan M, Sozmen M, Ozaydin I. Repair of urethral defects

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Soyisimi et al. The repair of complex penile defect with composite anterolateral thigh and vascularized fascia lata flap using fascia lata autografts in dogs. Vet Surg 2005;34:514-8. 19. Cormack GC, Lamberty BG. The blood supply of thigh skin. Plast Reconstr Surg 1985;75:342-54. 20. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987;40:113-41. 21. Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg

2006;117:2468-77. 22. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:2219-30 23. Kuo YR, Kuo MH, Chou WC, Liu YT, Lutz BS, Jeng SF. One-stage reconstruction of soft tissue and Achilles tendon defects using a composite free anterolateral thigh flap with vascularized fascia lata: clinical experience and functional assessment. Ann Plast Surg 2003;50:149-55.

OLGU SUNUMU - ÖZET

Kompleks penis defektinin kompozit anterolateral uyluk ve vaskülarize fasta lata flebi ile onarımı Dr. Şükrü Yazar,1 Dr. Muzaffer Eroğlu,2 Dr. Ali Gökkaya,3 Dr. Atilla Semerciöz2 1 2 3

Acıbadem Üniversitesi Tıp Fakültesi, Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı, İstanbul Abant İzzet Baysal Üniversitesi Tıp Fakültesi, Üroloji Anabilim Dalı, Bolu Abant İzzet Baysal Üniversitesi Tıp Fakültesi, Plastik ve Rekonstrüktif Cerrahi Anabilim Dalı, Bolu

Kompleks penis defektlerinin estetik ve fonksiyonel sonuçlarla tek aşamalı onarımı oldukça zorlayıcı cerrahi prosedürlerdir. Rekonstrüksiyon için uygun teknik ve materyal seçimi, eksik dokuların tipi, yara yüzeyinin genişliği ve donör saha göz önünde bulundurularak yapılır. Bu yazıda, geçirilmiş cerrahi bölgesinde gelişen enfeksiyona bağlı olarak parsiyel penis ve üretral defekt oluşan bir olgu sunuldu. Hasta perforator bazlı pediküllü kompozit anterolateral uyluk flebi ve vaskülarize fasya lata ile tedavi edildi. Üretral defekt vaskülarize fasya lata ile rekonstrükte edildi. Flebin geri kalan kısmı sağ kavernöz cisim ve penisteki deri defektinin kapatılmasında kullanıldı. Rekonstrüksiyon sonrasında fistül gelişmedi ve üretra çapı iyi olarak nitelendirildi. Pediküllü kompozit anterolateral uyluk flebi, kompleks penis defektlerinin fonksiyonel ve estetik tek aşamalı rekonstrüksiyonuna uygun farklı doku komponentleri sunmaktadır. Anahtar sözcükler: Kompleks penis defekti; perforator bazlı pediküllü anterolateral uyluk flebi; vaskülarize fasya lata. Ulus Travma Acil Cerrahi Derg 2015;21(3):223-227

doi: 10.5505/tjtes.2015.47629

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Künt travmada penetran kardiyak yaralanma: Olgu sunumu Dr. Yüksel Dereli,1 Dr. Murat Öncel2 1

Necmetti̇ n Erbakan Üni̇ versi̇ tesi̇ Meram Tıp Fakültesi̇ , Kalp ve Damar Cerrahi̇ si̇ Anabilim Dalı, Konya

Selçuk Üni̇ versi̇ tesi̇ Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, Konya

ÖZET Künt toraks travmasına bağlı olarak nadiren kardiyak yaralanmalar görülebilmektedir. Kardiyak yaralanma genellikle hayatı tehdit eden durum yaratır, acil cerrahi müdahele geretirir ve bu hastaların perioperetif dönemde dikkatli takip edilmesi gerekir. Klinik tablo, yaralanma şekli, hastaneye ulaşana dek geçen süre, kanama miktarı, kardiyak tamponad varlığı veya ilave yaralanmalar gibi değişik faktörlere bağlıdır. Bu yazıda, künt toraks travmasına bağlı olarak penetran kardiyak yaralanma tespit edilen bir olgu sunuldu. Acil serviste araç içi trafik kazası nedeniyle değerlendirilen 61 yaşındaki erkek olgunun akciğer grafisinde pulmoner kontüzyon, kot kırığı ve kardiyak tamponad saptandı. Acilen ameliyata alınan hastada sağ atriyum yaralanması gözlendi. Kardiyak yaralanma primer dikiş tekniği ile onarıldı. Sonuç olarak, künt toraks travmalı hastalarda kardiyak yaralanma ihtimali yüksektir. Bu hastalarda dikkatli fiziksel inceleme, erken tanı ve tedavi gereklidir. Anahtar sözcükler: Künt travma; penetran kardiyak yaralanma; toraks travması.

GİRİŞ

OLGU SUNUMU

Travmaya bağlı ölümlerin önemli bir kısmı toraks travmaları sonucu meydana gelmektedir. Künt toraks travmalarında tespit edilen kardiyak yaralanma sıklıkla miyokardiyal kontüzyon şeklinde olup, genellikle benign seyir gösterir. Ancak blust etkiye veya kot kırıklarına bağlı olarak nadiren penetran kardiyak yaralanmalar da meydana gelebilir ve bu durumda mortalite oranları daha yüksek olmaktadır.[1] Künt toraks travmalarının en önemli nedenleri arasında motorlu taşıt kazaları, iş kazaları, yüksekten düşme ve spor yaralanmaları yer almaktadır.[2]

Araç içi trafik kazası geçiren 61 yaşındaki erkek hasta ambulans ile hastanemiz acil servisine getirildi. Hastanın genel durumu orta, şuuru kofüze, sistemik kan basıncı 80/40 mmHg, nabzı 110/dk ve solunumu hiperpneik idi. Hastaya öncelikle gerekli ilk yardım işlemleri ve destekleyici tedavi uygulandı. Hasta hemodinamik olarak kararlı hale getirildikten sonra ayrıntılı sistemik inceleme yapıldı, rutin ve ayırıcı tanıya yönelik incelemeler istendi. Hastada sol orbital yaralanma, sağ hemotoraks, sağ femur ve tibia kırığı ve akut karın benzeri tablo mevcut idi. Hastanın hemoglobini 7 gr/dl ve hematokriti 20 olup, diğer rutin incelemeleri normal sınırlarda idi. Hasta ilgili tüm klinikler tarafından konsülte edildi. Akciğer grafisinde sağ tarafta çoklu kot kırığı, pulmoner kontüzyon, hemotoraks ve kardiyak tamponad bulguları tespit edildi (Şekil 1a). Hematoraks ve perikardiyal hematom bulguları, bilgisayarlı toraks tomografisi ve transtorasik ekokardiyografi incelemeleri ile de doğrulandı (Şekil 1b). Hasta acilen ameliyata alındı. Sağ torakotomi ile girilerek akciğer ve perikarda ulaşıldı. Akciğerde yaralanma tespit edilmedi, ancak perikardın mayi ile dolu ve gergin olduğu görüldü. Perikart açıldı ve hemorajik vasıftaki tamponad mayisi boşaltıldı. Sağ atriyum apendajında yırtık tespit edildi (Şekil 1c). Atriyal yaralanma 4/0 poliprolen dikişle primer olarak tamir edildi. Kanama kontrolü sonrası toraksa dren yerleştirildi ve kesiler usulüne uygun olarak kapatıldı. Hasta diğer yaralanmalar için göz ve ortopedi ekiplerine devredildi ve gerekli bütün müdahaleler yapıldıktan sonra yoğun bakım ünitesine alındı. Hasta ameliyat sonrası birinci gün mekanik ventilatörden ayrıldı ve yapılan kontrol transtorasik

Bu yazıda, araç içi trafik kazası sonucu sağ atriyal apendaj yaralanması gelişen bir olgu ve literatür eşliğinde künt toraks travması sonucunda gelişen penetran kardiyak yaralanmalar değerlendirildi.

İletişim adresi: Dr. Yüksel Dereli, Necmettin Erbakan Üniversitesi Meram Tıp Fakültesi, Kalp ve Damar Cerrahisi Anabilim Dalı, 42080 Konya Tel: +90 332 - 223 62 58 E-mail: yuxel.dereli@mynet.com Qucik Response Code

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Dereli ve ark. Künt travmada penetran kardiyak yaralanma

(a)

(b)

(c)

Şekil 1. (a) Olgunun akciğer grafisi. (b) Olgunun bilgisayarlı tomografi görüntüsü. (c) İntraoperatif görüntü.

ekokardiyografide kardiyovasküler yapılar normal olarak değerlendirildi. Ameliyat sonrası ikinci gün toraks dreni çekilen hasta servise alındı. Hasta nöroloji, göz ve ortopedi klinikleri ile tekrar konsülte edilerek önerileri alındı. Takibinde ilave problem görülmeyen hasta ameliyat sonrası yedinci gün medikal tedavisi düzenlenerek önerilerle taburcu edildi.

TARTIŞMA Künt toraks travmasının en sık nedenleri motorlu taşıt kazaları, yüksekten düşme, iş kazaları ve spor yaralanmalarıdır. Yine künt toraks travmalı hastaların çoğunda eşlik eden kafa, batın veya ekstremite travması bulunmaktadır.[2] Motorlu taşıt kazalarında, travma riskini en aza indirmek için emniyet kemeri kullanımı gereklidir. Karataş ve ark., trafik kazası nedeniyle acil servise getirilen dört kişilik bir aileden, ön koltukta oturan ve emniyet kemeri takılı olan anne ve babanın kazayı ufak tefek sıyrıklarla atlattığını, arka koltukta oturan ve emniyet kemerleri bağlanmayan iki çocuktan birini öldüğünü, diğerinde ise posttravmatik ventriküler septal defekt geliştiğini bildirmişlerdir.[3] Künt toraks travmasında kardiyak yaralanmanın mekanizması tam olarak anlaşılamamış olmakla birlikte, kalbin vertebral kolon ve sternum arasında sıkışması ile veya artmış toraks içi basıncın kalp boşluklarına aktarılması sonucu kardiyak hasar geliştiği düşünülmektedir.[4] Daha nadir olarak ise sternum veya kot kırıklarının yol açtığı penetran kardiyak yaralanmalar ortaya çıkabilir. Bizim olgumuzda da sebep araç içi trafik kazası idi, eşlik eden kafa travması ile sağ alt ekstremitesinde femur ve tibia kırıkları bulunuyordu ve sağ atriyum yaralanmasının muhtemelen sebebi aynı taraftaki çoklu kot kırığı idi. Künt toraks travmalarında meydana gelen kardiyak lezyon basit miyokart kontüzyonundan, büyük damar yapılarının yaralanması, kapak lezyonları, koroner arter yaralanması, septum veya kalp boşluklarından birinin rüptürüne kadar değişen geniş bir yelpaze oluşturmaktadır.[5] Miyokardiyal kontüzyon, farklı çalışmalarda %7-71 oranı ile en sık görülen ve prognozu en iyi seyirli olan kardiyak yaralanma şeklidir.[2] Künt travmaya bağlı kapak hasarı en sık aort kapakta görülürken, bunu mitral ve triküspit kapaklar izler. Mitral kapak hasarının en sık sebebi papiller adele ve korda tendinea rüptürüdür.[6] Koroner arter trombozu veya kesisine bağlı olarak miyokart enfarkUlus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

tüsü gelişebilir. Kaplan ve ark.,[7] 63 olguluk toraks travması çalışmalarında, sol ön inen (LAD) koroner arter laserasyonu olan üç olguda ise LAD-LİMA (sol internal mamaryan arter) anastomozu ile koroner baypas operasyonu uyguladıklarını bildirmişlerdir. Kardiyak rüptür künt toraks travmasının nadir görülen, ancak yüksek mortalite ile ilişkili bir komplikasyondur ve hastaların çoğu acil servise bile ulaşamadan kaybedilir.[8] Otopsi çalışmalarında künt travma sonrası meyadana gelen ölümlerin %36-65’inde kardiyak rüptür tespit edilmiştir.[9] Kardiyak rüptür kalbin sağ tarfında sol tarafa göre daha sık görülür. Sağ atriyal apendaj, muhtemelen ince duvar yapısı nedeniyle kardiyak rüptürün en sık görüldüğü bölgedir.[8] Kardiyak rüptürlü 42 hastanın sunulduğu bir çalışmada kardiyak odacıkların tutulum oranının şu şekilde dağılım gösterdiği bildirilmiştir; sağ atriyum: 21 (%50) hasta, sağ ventrikül: yedi (%17) hasta, sol atrium: 10 (%24) hasta ve sol ventrikül: dört (%9) hasta.[10] Literatürde künt toraks travmasına bağlı olarak izole atriyal yaralanma tespit edilen birkaç olgu bildirilmiştir. Fang ve ark. [11] motorlu taşıt kazasına bağlı künt toraks travması sonrasında izole sağ atrial yaralanma nedeniyle primer tamir uyguladıkları üç olgu bildirmişlerdir. Yine, Souteyrand ve ark. [12] motorlu taşıt kazası sonrası kardiyak yaralanma nedeniyle ameliyat ettikleri bir hastada inferiyor vena kava yakınında izole sağ atriyum yaralanması tespit etmişler ve primer dikiş tekniği ile tedavi uyguladıklarını bildirmişlerdir. Tanoue ve ark. [13] ise yüksekten düşme nedeniyle başvuran bir hastada sol atriyal apendaj rüptürü nedeniyle başarılı şekilde ameliyat ettikleri bir olgu bildirmişlerdir. Bizim olgumuzda da sebep motorlu taşıt kazası ve rüptür sağ atriyal apendajda idi. Künt kardiyak travmalı hastalar başvuru anında tamamen semptomsuz olabilir veya kardiyojenik şok tablosu ile karşımıza gelebilir. Kardiyak yaralanmayı akla getirecek olan patolojik üfürümler muayenede atlanabilir veya geç dönemde ortaya çıkabilir.[5] Rutin kan incelemeleri ve kardiyak enzim seviyeleri normal, elektrokardiyografi bulguları nonspesifik olabilir. Hipotansiyon, taşikardi ve yüksek santral venöz basınç gibi kardiyak tamponad bulgularının varlığı, takipte ani gelişen hipotansiyon veya yeni duyulmaya başlanan üfürüm kardiyak pa229

Dereli ve ark. Künt travmada penetran kardiyak yaralanma: Olgu sunumu

tolojiyi akla getirmelidir. Akciğer grafisinde hemotoraks veya kardiyak tamponad tespit edilebilir. Kesin tanı için ekokardiyografi ve manyetik rezonans görüntüleme veya bilgisayarlı tomografi gibi radyolojik yöntemleri kullanılabilir. Ekokardiyografi transözofajiyal yolla intraopratif olarak da kullanılabilir. Biz de olgumuzda kesin tanı için ekokardiyografi ve bilgisayarlı toraks tomografisi yöntemlerini kullandık. Sağ atriyal rüptür için ilk başarılı tamirin 1955 yılında yayımlandığı bildirilmektedir.[8] Hemodinamisi kararlı olmayan kardiyak travmalı hastalar acil olarak ameliyata alınmalıdır. Hasta hemodinamik olarak kararlı ise tanıyı netleştirmek ve eşlik eden yaralanmaları tespit edebilmek için gerekli incelemeler yapılmalıdır. Çoğu olguda ameliyat için torakotomi yeterlidir, ancak kalp ve büyük damarları daha detaylı olarak ortaya koyabilmek için median sternotomi tercih edilebilir. Bu tür yaralanmalar genellikle ekstrakorporal dolaşıma ihtiyaç duyulmadan ve basit sütür tekniği kullanılarak tamir edilebilir.[8] Biz de hastamıza sağ torakotomi uyguladık ve atriyal yaralanmayı primer dikiş tekniği ile tamir ettik. Başka bir çalışmada ise, kardiyak travma ile başvuran hastalarda prognozu etkileyen faktörlerin; hastanın başvuru anındaki fizyolojik durumu, kardiyak rüptürün paterni, hızlı tanı ve tadavi olduğu bildirilmişltir.[10] Kalbin sol tarafına ait rüptürlerin sağ taraf rüptürlerine göre daha kötü prognoza sahip olduğu bildirilmektedir.[1] Sonuç olarak, künt toraks travması ile başvuran hastalarda kardiyak yaralanma olasılığı akılda tutulmalıdır. Kot kırıkları bu hastaları penetran kardiyak yaralanmaya da açık hale getirir. Künt travmaların en sık sebebi trafik kazaları olup, prognozu olumlu yönde etkileyen en etkili ve kolay önlem emniyet kemeri kullanma bilincinin yerleştirilmesidir. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

KAYNAKLAR 1. Salooja MS, Singla M, Srivastava A, Mukherjee KC. Isolated tear in left atrial appendage due to blunt trauma chest: A rare case report. J Saudi Heart Assoc 2013;25:95-7. 2. Taşdemir HK, Ceyran H, Kahraman C. Künt göğüs travması nedeniyle oluşan nadir bir yaralanma: Sağ süperiyor pulmoner ven yaralanması. Türk Göğüs Kalp Damar Cer Derg 2011;19:255-7. 3. Karataş Z, Sap F, Altin H, Alp H, Baysal T, Karaaslan S. Ventricular septal defect developed due to coronary artery injury after blunt chest trauma in childhood. Ulus Travma Acil Cerrahi Derg 2012;18:185-8. 4. Tanoue K, Sata N, Moriyama Y, Miyahara K. Rupture of the left atrial ‘basal’ appendage due to blunt trauma in an elderly patient. Eur J Cardiothorac Surg 2008;34:1118-9. 5. Bitigen A, Mutlu B, Basri Erdoğan HB, Başaran Y. A case of papillary muscle rupture due to blunt chest trauma. [Article in Turkish] Turk Kardiyol Dern Ars 2005;33:473-5. 6. Gökçen B, Şanlı A, Önen A, Karaçam V, Okan T, Açıkel Ü. Künt toraks travması sonrası gelişen akut mitral yetmezliği. DEÜ Tıp Fakültesi Dergisi 2005;19:111-3. 7. Kaplan M, Demirtaş M, Alhan C, Aka SA, Dağsalı S, Eren E ve ark. Kalp yaralanmaları: 63 vakalık deneyim. GKDCD 1999;7:287-90. 8. Telich-Tarriba JE, Anaya-Ayala JE, Reardon MJ. Surgical repair of right atrial wall rupture after blunt chest trauma. Tex Heart Inst J 2012;39:57981. 9. Hirai S, Hamanaka Y, Mitsui N, Isaka M, Kobayashi T. Successful emergency repair of blunt right atrial rupture after a traffic accident. Ann Thorac Cardiovasc Surg 2002;8:228-30. 10. Ryu DW, Lee SY, Lee MK. Rupture of the left atrial roof due to blunt trauma. Interact Cardiovasc Thorac Surg 2013;17:912-3. 11. Fang BR, Kuo LT, Li CT, Chang JP. Isolated right atrial tear following blunt chest trauma: report of three cases. Jpn Heart J 2000;41:535-40. 12. Souteyrand G, Combes S, Dauphin C, Geoffroy E, Motreff P, Joly H, et al. Right atrial tear associated with a tumour in the right atrium after blunt chest trauma. Eur J Echocardiogr 2008;9:116-8. 13. Tanoue K, Sata N, Moriyama Y, Miyahara K. Rupture of the left atrial ‘basal’ appendage due to blunt trauma in an elderly patient. Eur J Cardiothorac Surg 2008;34:1118-9.

CASE REPORT - ABSTRACT

Penetrating cardiac injury in blunt trauma: a case report Yüksel Dereli, M.D.,1 Murat Öncel, M.D.2 1 2

Department of Cardiovascular Surgery, Necmettin Erbakan University Meram Faculty of Medicine, Konya Department of Thoracic Surgery, Selçuk University Faculty of Medicine, Konya

Cardiac injuries may rarely be observed due to blunt thoracic traumas. Cardiac injury often creates a life-threatening condition requiring urgent surgical intervention, and follow-up of these patients should be carefully carried out in the perioperative period. These injuries depend on various factors including clinical presentation, type of injury, the time that passes until the patient reaches the hospital, bleeding, cardiac tamponade, or additional injuries. This article aimed to report a case who suffered penetrating cardiac injury in blunt thoracic trauma. Evaluated in the emergency department due to a motor vehicle accident, the 61-year-old male patient’s chest x-ray revealed pulmonary contusion, rib fractures and cardiac tamponade. The patient was operated emergently. Right atrial injury was observed in the operation. The cardiac injury was repaired with primary suture technique. Cardiac injury in patients with blunt thoracic trauma is likely to be observed. In these patients, careful physical examination, early diagnosis, and treatment are very important. Key words: Blunt trauma; penetrating cardiac injury; thoracic trauma. Ulus Travma Acil Cerrahi Derg 2015;21(3):228-230

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doi: 10.5505/tjtes.2015.88393

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

OLGU SUNUMU

Nazal kırığa neden olan neodyum mıknatıs ile yaralanma: Olgu sunumu Dr. Andaç Aykan,1 Dr. Serbülent Güzey,2 Dr. Sedat Avşar,1 Dr. Serdar Öztürk1 1

Gülhane Askeri Tıp Akademisi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Ankara

Kasımpaşa Asker Hastanesi, Plastik Rekonstrüktif ve Estetik Cerrahi Kliniği, İstanbul

ÖZET Teknolojik gelişmelere paralel olarak, küçük boyutlu ancak güçlü mıknatıslar günümüz cihazlarında sıkça kullanılmaktadır. Yabancı cisim yaralanmaları arasında oldukça ender olarak görülen mıknatıs yaralanmaları kendilerine has özellikleri nedeniyle tedavilerinde bazı zorluklar içerirler. Mıknatısın oluşturduğu manyetik alanın cerrahi enstrümanları etkilemesi ve müdahaleyi güçleştirmesi bu zorlukların en önemlilerinden bir tanesidir. Bu olgu sunumunda ender olarak karşılaşılan neodyum mıknatıs yaralanması sonucunda nazal bölgesinde hasar oluşan bir hasta ile mıknatısın çıkarılması esnasında karşılaşılan güçlük ve bunun aşılmasında kullanılan alternatif yaklaşımımız sunulmaktadır. Anahtar sözcükler: Mıknatıs; nazal kırık; nazal travma; neodyum mıknatıs; yabancı cisim; yüz travması.

GİRİŞ Burun, nazal kemiğin çıkıntılı ve kolay kırılabilen yapısı sebebiyle yüz travmalarında en fazla hasar gören bölgedir.[1-3] Bu bölge kırıkları, maksillofasiyal travmalarının yaklaşık %40’ına eşlik ederken kırığın tipini travmanın şiddeti ve yönü belirlemektedir.[1,4,5] Hafif travmalarda sıklıkla darbenin geldiği taraftaki nazal kemik kaviteye doğru yer değiştirirken şiddetli travmalarda karşı taraf nazal kemiğe kadar uzanabilen ciddi hasarlanmalar ortaya çıkabilmektedir.[6,7] Bu tipteki yaralanmalar estetik sorunların dışında fonksiyonel kayıplara da yol açarak hastanın yaşam kalitesini olumsuz yönde etkileyen sonuçların doğmasına yol açabilmektedir. Bilinen en güçlü mıknatıs olan “Neodyum mıknatıslar” metalik görünümlü olup, günümüzde tıp, eğitim, hobi araçları, oyuncak ve takı gibi birçok farklı endüstriyel alanda kullanılmaktadır.[8] Bu mıknatıslar neodyum, demir ve bor (Nd2Fe14B) elementİletişim adresi: Dr. Andaç Aykan, Gülhane Askeri Tıp Akademisi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Etlik, Ankara Tel: +90 312 - 304 20 00 E-mail: andac_aykan@yahoo.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2015;21(3):231-234 doi: 10.5505/tjtes.2015.46588 Telif hakkı 2015 TJTES

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

lerinden oluşurken yapısal olarak kırılgan, tetragonal kristal bir form sergilerler.[9] Bu kırılgan yapının daha dayanıklı hale getirilebilmesi içinse neodyum mıknatıslar nikel, çinko ve krom tozları ile kaplanırlar.[10] Bu işlem hem sürtünmeye bağlı yüzey aşınmasını önlerken hem de karşılaşılan yüksek ısı veya çarpışmalardan doğabilecek hasarların önüne geçilmesine imkan tanır. Tüm bu önlemlere rağmen, literatürde bugüne kadar bildirilmemekle birlikte neodyum mıknatıs içeren cihazlarla çalışan kişilerde mıknatısın hasarlanması sonrasında kopan ve fırlayan parçalar ile farklı şiddetlerde yaralanmalar oluşabilir. Özellikle tecrübesiz kişilerce neodyum mıknatıs gibi yüksek çekim gücüne sahip olan mıknatıslara metal enstrümanlarla müdahalede bulunulma çabası ise ek travmaların ortaya çıkmasına neden olabilir. Bu yazıda, ender olarak karşılaşılan, neodyum mıknatısın parçalanması sonrasında nazal bölgesinde yaralanma oluşan bir olguda müdahale esnasında yaşadığımız güçlük ve geliştirdiğimiz alternatif yaklaşım sunuldu.

OLGU SUNUMU Elli iki yaşında erkek hasta nazal bölgesinde oluşan yaralanma nedeniyle acil servise başvurdu. Hastanın alınan anamnezinde neodyum mıknatıs içeren bir düzenek ile deneysel amaçlı elektrik üretmeye çalışırken, parçalanan mıknatısların çevreye saçılarak yüzüne isabet ettiği öğrenildi. 231

Aykan ve ark. Nazal kırığa neden olan neodyum mıknatıs ile yaralanma

Hastanın fiziksel incelemesinde burnun yaygın ödemli olduğu, burun sağ tarafı ve dorsumunda cilt bütünlüğünün bozulduğu saptandı. Laserasyon oluşan bu alan içerisinde mıknatıs parçası kısmen görünür bir haldeydi (Şekil 1). Elle muayenede burunda yaygın ağrı, nazal kemikte ise krepitasyon ve hareketlilik mevcuttu. İntranazal muayenede ise mıknatısın nazal pasajı deldiği ve sağ nazal pasaj posteriyorunda derinde yerleşim gösterdiği saptandı. Bunlara ek olarak sol tarafta daha belirgin olmak üzere her iki periorbital alanda yaygın ödem ve ekimoz mevcut olup elle muayenede orbital rimlerde kırık düşündürecek basamaklaşma veya krepitasyon bulgusuna rastlanmadı. Hastanın maksillofasiyal bölgeye yönelik direkt grafi incelemesinde sağ nazal pasaj içerisine yerleşen, yuvarlak, radyo-opak yabancı cisim tespit edildi (Şekil 1). Her iki nazal kemikte kırık saptanırken septumun intakt olduğu görüldü. Direkt grafiye ek olarak hastanın maksillofasiyal bölge bilgisayarlı tomografi incelemesi yapılırken mıknatısa bağlı yaygın artefakt oluşumu sebebiyle bu yöntemle yeterli değerlendirme yapılamadı. Hastaya lokal anestezi altında yabancı cisim çıkarılması ve nazal çatı redüksiyonu kararı verildi ve %2’lik lidokain ile lokal anestezi sağlandıktan sonra, burun cildine yapışık olan mıknatıs parçası ciltten ayrıldı ve sahadan uzaklaştırıldı. Daha sonra paslanmaz çelikten yapılan pens ve portegü ile derin dokuda yerleşimli olan mıknatıs çıkarılmaya çalışıldı. Fakat mıknatısın

Şekil 2. Cerrahi ekipmanların uç kısımları katmanlar halinde steril flaster ile sarılarak mıknatısın etkisi azaltılmaya çalışıldı (üst). Çıkarılan neodyum mıknatıslar (alt).

çok güçlü olması sebebiyle kontrollü yaklaşım ve yeterli müdahale sağlanamadı. Daha fazla kontrolsüz müdahalede bulunma riski düşünülerek oluşturmamak için mıknatıs tarafından etki altına alınmayacak farklı bir cerrahi alet arayışına girildi. Fakat elimizde kullanabilecek titanyum veya alternatif bir tıbbi alet bulunmaması sebebiyle mevcut aletlerin modifiye edilerek kullanılmasına karar verildi. Bu amaçla cerrahi ekipmanların uç kısımları steril flaster ile sarılarak mıknatısın etkisi azaltılmaya çalışıldı ve bu sayede mıknatıs parçaları kontrollü olarak çıkarılabildi (Şekil 2). Hastanın geç dönem takibinde burun bölgesi cildinde kalan skar dokusu haricinde belirgin bir şekil bozukluğu tespit edilmedi (Şekil 3).

Şekil 1. Hastanın yaralanma sonrasındaki görünümü (üst). Hastanın direk grafilerinde nazal bölgede yerleşim gösteren radyo-opak mıknatıslar (alt) görülmekte.

232

Şekil 3. Hastanın yaralanma ve onarım sonrası üçüncü aydaki görünümü.

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

Aykan ve ark. Nazal kırığa neden olan neodyum mıknatıs ile yaralanma

TARTIŞMA Mıknatıs; oyuncak, ev ürünleri, takı, endüstriyel ürünler, inşaat malzemeleri, tıp ve sağlık ürünleri gibi günlük hayatta sık olarak kullanılan birçok farklı malzemenin içerisinde yer almaktadır. Gün geçtikçe teknolojideki gelişime paralel olarak kullanımı artan ve farklı tipleri tanımlanan mıknatıslara bağlı yaralanmalar ise kullanım miktarıyla doğru orantılı olarak son yıllar içerisinde artış göstermektedir. İçerisinde Amerikan Tüketici Güvenliği Komisyonu’nun da bulunduğu birçok çalışma mıknatıs kullanımının yaygınlığının artmasına bağlı oluşan yaralanmaları giderek artan bir sağlık sorunu olarak kabul etmektedir.[11-13] Mıknatıs ile yaralanmalar çocukluk döneminde daha sık görülmekte ve çoğunlukla mıknatısın yutulmasına bağlı oluşmaktadır. Bu da solunum yollarının tıkanması, sindirim sisteminde pasajın daralması ile birlikte ince ve kalın bağırsak patolojilerine yol açabilmektedir. Özellikle bu dönemde yutulan birden fazla mıknatıs yaralanma açısından daha yüksek risk oluştururken manyetik alan etkisiyle birbirine yapışan mıknatısların arasına giren dokuların ezilmesine bağlı ciddi mukozal hasarlanmalar ortaya çıkabilmekte ve laparotomi gerektirecek cerrahi müdahalelere sebep olmaktadır. Genç erişkinlerde ise yaralanmalar daha sıklıkla çekici görünüm elde etmek amacıyla mıknatısların burun, dil, dudak, yanak bölgelerinde “piercing” olarak kullanılması sonucunda ortaya çıkarken, erişkin yaş grubunda daha çok mıknatısın kırılması, parçalanması veya direkt teması sonucunda oluşmaktadır.[14] Neodyum mıknatıslar şiddetli manyetik alan gerektiren cihazlarda kullanılır. Bu mıknatısların çekim gücü hacimlerine oranla çok yüksek olup kendi boyutunun 1300 katı bir ağırlığı taşıyabilecek kapasitededirler.[8] Boyut ve güç arasındaki bu oran farklı sektörlerde yoğun olarak kullanılmalarının en önemli nedenini oluşturmaktadır. Bu derece güçlü mıknatıslarla oluşan yaralanmalar ise mıknatısın etkisine paralel olarak şiddetli olabilmektedir. Sunulan olguda tamir için müdahele edilen bir cihaz içerisinde parçalanan neodyum mıknatıs hastanın nazal bölgesinde hasara neden olmuştur. Mıknatısın gücünden kaynaklanan yüksek hızlı parçalar, cilt ve yumuşak doku hasarının yanında kemik dokuda da kırık oluşumuna neden olarak derin doku içerisine saplanmıştır. Doku içerisindeki mıknatıs parçaları, yüksek çekim gücü sebebiyle paslanmaz çelikten imal edilen cerrahi aletlere kuvvetle yapışarak müdahaleyi imkânsız hale getirmiştir. Cerrahi aletlerin manyetik alandan daha az etkilenmesi için farklı yollar denendi. Öncelikle cerrahi aletler steril eldiven içerisine yerleştirilerek mıknatısın çıkarılmasına çalışıldı. Fakat eldivenin ince olması sebebiyle manyetik alanı önleyecek yeterli bariyer oluşturulamadı. Daha sonra aletlerin uç kısımları steril flasterler ile katmanlar halinde sarılarak mıknatıs parçalarının manyetik etkisinden büyük oranda kurtulmaları sağlandı. Geliştirilen bu yöntem, mıknatıs parçalarının çevre dokulara hasar vermeden uzaklaştırılabilmesine imkân tanıdı. Bizim uyguladığımız Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3

pratik yaklaşımın dışında, uygulanabilecek diğer alternatif yaklaşımların ise manyetik alandan etkilenmeyen malzemelerden imal edilen cerrahi aletlerin kullanılması olabilir. Titanyum; dayanıklılığı, hafifliği ve paslanmaz özelliği ile özellikle cerrahinin hassas malzemeleri; mikro pensetler, pensler, portegüler, dissektörler ve ekartörler için tercih edilen bir materyal olup manyetik alan tarafından etki altına alınamamaktadır.[15] Bu yönüyle mıknatıs gibi materyallerin uzaklaştırılmasında titanyum malzemelerin kullanımı uygun bir seçenek gibi görünse de şu an için titanyumdan üretilmiş cerrahi aletlerin fiyatlarının fazlalığı ve birçok merkezde bulunmaması sebebiyle günlük uygulamada çok makul bir seçenek oluşturmamaktadır. Manyetik alandan etkilenmeyen bir başka madde olan plastikten yapılan cerrahi aletlerde bu amaçla kullanılabilecek diğer seçeneği oluşturmaktadır. Özellikle yakın dönemde farklı üreticiler tarafından tanıtılan (Spectrum surgical instruments corp. OH, USA) steril edilebilen sert plastikten yapılan cerrahi ürünler bu amaçla tercih edilebilirken çok fazla kullanım alanı olmaması ve nadir ihtiyaç duyulması sebebiyle bir çok merkezde bulunmamaktadır. Manyetik alandan etkilenmeyen bu tipteki malzemelerin ulaşılmasındaki güçlük karşılaştığımız olguda bizi alternatif yaklaşım arayışlarına yöneltirken uyguladığımız yaklaşım sayesinde sorunsuz bir şekilde mıknatıs parçası çıkarılabilmiştir. Her ne kadar bu işlem esnasında steril flaster kullanmış olsa da steril flasterin bulunmadığı durumlarda nazogastrik veya üriner sondalar gibi tüp şeklindeki plastik malzemelerin de cerrahi aletlerin kaplanması amacıyla etkin şekilde kullanılabileceğini düşünmekteyiz.

Sonuç

Mıknatısların kullanım alanlarının geniş olması farklı tipteki yaralanmalarda artışı beraberinde getirmektedir. Bu nedenle çalışanların koruyucu önlemlere özen göstermesi sağlık kuruluşlarının ise paslanmaz çelikten imal edilen malzemelerle kontrolsüz müdahalelerde bulunulmaması, mümkünse manyetik alandan etkilenmeyen malzemelerden yapılan cerrahi aletleri bulundurulması veya alternatif yaklaşımları bilinmesinin gerekli olduğunu düşünmekteyiz. Çıkar örtüşmesi: Çıkar örtüşmesi bulunmadığı belirtilmiştir.

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CASE REPORT - ABSTRACT

Neodymium magnet injury causing nasal fracture: a case report Andaç Aykan, M.D.,1 Serbülent Güzey, M.D.,2 Sedat Avşar, M.D.,1 Serdar Öztürk, M.D.1 1 2

Department of Plastic Reconstructive and Aesthetic Surgery, Gülhane Military Medical Academy, Ankara Department of Plastic Reconstructive and Aesthetic Surgery, Kasımpasa Military Hospital, İstanbul

In parallel with technological developments, small size but strong magnets are commonly used in modern devices. In terms of foreign body injuries, magnet injuries are quite rare. However, due to their unique characteristics, there are some difficulties in their management. The magnetic field generated by the magnet affects the surgical instruments and make treatment difficult. In this case report, a nasal injury due to neodymium magnet and our alternative approach for its management was reported. Key words: Facial trauma; foreign body; magnet; nasal fracture; nasal trauma; neodymium magnet. Ulus Travma Acil Cerrahi Derg 2015;21(3):231-234

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doi: 10.5505/tjtes.2015.46588

Ulus Travma Acil Cerrahi Derg, Mayıs 2015, Cilt. 21, Sayı. 3