Travma 2016 / 6 by KAREPUBLISHING

ISSN 1306 - 696X

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

Volume 22 | Number 6 | November 2016

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 (2. Başkan) Secretary General (Genel Sekreter) Treasurer (Sayman) Members (Yönetim Kurulu Üyeleri)

Kaya Sarıbeyoğlu M. Mahir Özmen Hakan Yanar Ali Fuat Kaan Gök Gürhan Çelik Osman Şimşek Orhan Alimoğlu

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)

Kaya Sarıbeyoğlu Kaya Sarıbeyoğlu 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, EBSCO, and Turkish Medical Index (Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, EBSCO 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): Suzan Atwood • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): November (Kasım) 2016 • This publication is printed on paper that meets the international standard ISO 9706: 1994 (Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur.)

KARE P U B L I S H I N G

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. 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. 2015 yılında SCI-E kapsamında 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 22

Number - Sayı 6 November - Kasım 2016

Contents - İçindekiler Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 509-515 Effects of alpha lipoic acid on ischemia-reperfusion injury in rat hindlimb ischemia model Sıçanlarda arka bacak iskemi modelinde alfa lipoik asitin iskemi/reperfüzyon hasarı üzerine etkisi Aydın A, Yıldırım AM 516-520 Effect of medical treatment on histological findings in rabbits with acute appendicitis Tavşanlarda oluşturulan akut apandisit modelinde tıbbi tedavinin histopatolojik bulgular üzerindeki etkisi Şimşek G, Sevinç B, Ünlü Y, Hasırcı İ, Kurku H, Karahan Ö 521-525 Therapeutic efficacy of tadalafil and eriythropoietin in experimental spinal cord injury Deneysel spinal kord travmasında eritropoetin ve tadalafilin terapötik etkinliği Kökoğlu Ç, Delen E, Arslantaş A, Arslantaş D, Kökoğlu B, Özbek Z, Uslu S, Akıncı AT 526-530 The acute effects of thymoquinone on acute peripheral nerve injury: an experimental study Timokinonun akut periferik sinir hasarı üzerine akut etkisi: Deneysel bir çalışma Gülşen İ, Ak H, Kara M, Gökalp A, Akyol V, Koçak ÖF, Rağbetli MÇ

Original Articles - Orijinal Çalışma 531-535 Endovascular treatment of peripheral and visceral arterial injuries in patients with acute trauma Akut travma hastalarında periferik ve viseral arteriyel yaralanmaların endovasküler tedavisi Erbahçeci Salık A, İslim F, Çil BE 536-540 Comparison of Revised Trauma Score, Injury Severity Score and Trauma and Injury Severity Score for mortality prediction in elderly trauma patients Yaşlı travma hastalarında mortaliteyi öngörmeded gözden geçirilmiş Travma Skoru, Yaralanma Şiddet Skoru ve Travma ve Yaralanma Şiddet Skoru’nun karşılaştırması Yousefzadeh-Chabok S, Hosseinpour M, Kouchakinejad-Eramsadati L, Ranjbar F, Malekpouri R, Razzaghi A, Mohtasham-Amiri Z 541-544 Gender does not affect the prognosis of Fournier’s gangrene: a case-matched study Cinsiyet Fournier gangreni prognozuna etkili bir faktör değildir: Olgu-eşleme çalışması Sarkut P, Işık Ö, Öztürk E, Gülcü B, Ercan İ, Yılmazlar T 545-548 Acute appendicitis during pregnancy: case series of 20 pregnant women Gebelikte akut apandisit: 20 hamile kadın olgu çalışması Arer İM, Alemdaroğlu S, Yeşilağaç H, Yabanoğlu H 549-552 Contribution of MRI to clinically equivocal penile fracture cases Klinik olarak tanı konulamayan penil fraktür olgularına MR görüntülemenin katkısı Türkay R, Yenice MG, Aksoy S, Şeker G, Şahin S, İnci E, Tuğcu V, Taşcı Aİ 553-558 Importance of fixation of posterior malleolus fracture in trimalleolar fractures: A retrospective study Trimalleoler ayak bileği kırıklarında posterior malleol fiksasyonunun önemi: Retrospektif çalışma Karaca S, Enercan M, Özdemir G, Kahraman S, Çobanoğlu M, Küçükkaya M Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 22

Number - Sayı 6 November - Kasım 2016

Contents - İçindekiler

559-565 Investigation of hand function among children diagnosed with autism spectrum disorder with upper extremity trauma history Üst ekstremite travma öyküsü olan otizm spektrum bozukluğu tanılı çocuklarda el fonksiyonlarının değerlendirilmesi Huri M, Şahin S, Kayıhan H

Case Reports - Olgu Sunumu 566-568 ERCP with stenting of traumatic pancreatic duct transection: A case report Travmatik pankreas kanal transeksiyonunda stentlemeyle birlikte ERKP: Olgu sunumu Makhija DP, Desale J, Tiwari C, Shah H 569-571 Hemoptysis caused by pulmonary sequestration in perforated appendicitis: A rare case report Perfore apandisitte pulmoner sekestrasyonun neden olduğu hemoptizi: Seyrek görülen bir olgunun raporu Tartaglia D, Cascione F, Modesti M, Gianardi D, Caputo R, Galatioto C, Chiarugi M 572-574 Laparoscopic resection and intracorporeal anastomosis of perforated small bowel caused by fish bone ingestion Balık kılçığı yutulmasına bağlı gelişen ince bağırsak perforasyonunun laparoskopik rezeksiyon ve anastomozu Dural AC, Çelik MF, Yiğitbaş H, Akarsu C, Doğan M, Alış H 575-577 Obturator hernia should be considered in the differential diagnosis of hip and knee pain Obturator herni kalça ve diz ağrısının ayırıcı tanısında yer almalıdır Belli AK, Memiş G, Dere Ö, Koşan U, Nazlı O

578-584 Turkish Journal of Trauma & Emergency Surgery Index of Vol. 22 Ulusal Travma ve Acil Cerrahi Dergisi 22. Cilt Dizini

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EXPERIMENTAL STUDY

Effects of alpha lipoic acid on ischemia-reperfusion injury in rat hindlimb ischemia model Arif Aydın, M.D.,1 Alpagan Mustafa Yıldırım, M.D.2 1

Department of Plastic Reconstructive and Aesthetic Surgery, Afyonkarahisar State Hospital, Afyonkarahisar-Turkey

Department of Plastic Reconstructive and Aesthetic Surgery, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar-Turkey

ABSTRACT BACKGROUND: This study was performed to evaluate the effect of alpha lipoic acid (ALA) on prevention of ischemia-reperfusion (IR) injury in rat hindlimb ischemia model. METHODS: Forty male Sprague Dawley rats weighing between 250 and 300 g were divided into 4 groups of 10 rats. Hindlimb composite island flaps were raised in all rats. Clamps were applied to femoral vessels of all subjects, but immediately released without causing ischemia in Group 1. In Group 2, after 4 hours of ischemia, 24 hours of reperfusion was performed. Following 4 hours of ischemia, saline was administered to rats in Group 3 and flaps were reperfused for 24 hours. In Group 4, ALA was administered intraperitoneally after 4 hours of ischemia and flaps were reperfused for 24 hours. RESULTS: In Group 4, there was a significant decrease of liver malondialdehyde compared to Group 2 and decrease of muscle tumor necrosis factor-alpha compared to Group 3. There was also increase in levels of glutathione in erythrocytes compared to Group 3 and increase of plasma vitamin C compared to all groups. CONCLUSION: ALA was found to be effective in prevention of ischemia-reperfusion injury. Further studies are needed before clinical application. Keywords: Alpha lipoic acid; ischemia-reperfusion; rat.

INTRODUCTION A flap is a unit of tissue that is transferred from the donor area to another site of the body with its blood supply preserved intact. Flaps are widely used in reconstructive surgery for defects caused by various conditions such as trauma, surgery, tumors, and congenital diseases. One of the major problems after flap transfer is partial or total necrosis. A great deal of research has been conducted on prevention of flap necrosis, and some studies have investigated prevention of ischemiareperfusion (IR) injury. Flap elevation causes ischemia, especially in distal part of the flap where vessels are removed. Flap circulation in first 24 hours determines flap survival. Address for correspondence: Arif Aydın, M.D. Afyon Devlet Hastanesi, Plastik Rekonstrüktif ve Estetik Cerrahi Kliniği, Afyonkarahisar, Turkey Tel: +90 272 - 214 00 30 E-mail: arifaydin4@gmail.com Qucik Response Code

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One of the primary causes of flap necrosis is IR injury arising from vascular endothelial damage.[1] Ischemia damages cells through several mechanisms such as decreasing adenosine triphosphate and calcium, increasing carbon dioxide and lactic acid, and damaging cell membrane. Reperfusion causes cellular injury by creating free radicals, which induce neutrophil respiratory burst, neutrophil diapedesis, proinflammatory cytokines arising from leukocytes, thrombocytes, and endothelial cells.[2] Alpha lipoic acid (ALA) is an endogen molecule that is essential for decarboxylation of pyruvate to acetyl coenzyme A between glycolysis and Krebs cycle. ALA is an important cofactor of many mitochondrial enzyme complexes and a powerful antioxidant. It has been demonstrated that ALA and its reduced form, dihydrolipoic acid, neutralize reactive oxygen and reactive nitrogen species in vitro.[3] In many studies, ALA has been reported to reduce IR injury in the myocardium, kidney, liver, ovaries, testes, peripheral nerves, and brain.[4–9] The fundamental aim of this study was to investigate the effect of ALA on IR injury in rat hindlimb model. 509

Aydın et al. Effects of alpha lipoic acid on ischemia-reperfusion injury in rat hindlimb ischemia model

Group 4: Following 4 hours of ischemia, first venous and then arterial clamps were removed. Intraperitoneal injection of 24 mg/kg (2 cc/kg) of ALA (Thioctacid 600 T, Mylan N.V., Canonsburg, PA, USA/Meda Pharma GmbH & Co., Bad Homburg vor der Höhe, Germany) was administered at start of 24hour period of reperfusion.

MATERIALS AND METHODS This study was conducted with the permission of the ethics committee for animal experimentation of Afyon Kocatepe University. A total of 40 male Sprague Dawley rats with mean weight of 250 to 300 g were used in this study and were separated into 4 equal groups. Before and after the experiment, rats were fed with standard rat chow and water ad libitum, kept in a laboratory environment at 20 to 24°C, and 12/12 hour light/dark cycle was maintained.

Surgical Technique Rats were anesthetized with intramuscular injection of 100 mg/kg ketamine hydrochloride (Ketalar; Pfizer, Inc., NY, NY, USA) and 60 mg/kg xylazine (Rompun; Bayer AG, Leverkusen, Germany) combination. Animals were placed on operating table in supine position with limbs fastened to the table. Surgical site was shaved and wiped with 10% povidone iodine solution. Circular incision was made on right inguinal area, and femoral vessels were dissected and protected under 3x loupe magnification (Fig. 1a, b). Muscles were incised circularly and osteotomy was performed on femur to prepare composite island flap (Fig. 1c). Microvascular clamps were placed on femoral vessels (Fig. 1d). All the rats were anesthetized during 4 hours of ischemia, then awakened and observed for 24 hours before being euthanized (Fig. 1e, f ). Tissue and blood samples were taken after sacrifice for analysis.

After right hindlimb composite island flaps were raised, microvascular clamps (Acland Micro Vessel Clamp, Neuhausen, Switzerland) were applied to femoral artery and veins of all subjects. Group 1: Venous and then arterial clamps were immediately removed without creating ischemia. Group 2: Clamps were left in place and after 4 hours of ischemia, first venous and then arterial clamps were removed and 24 hours of reperfusion was performed. Group 3: After 4 hours of ischemia, venous clamp was removed, followed by arterial clamps. At initiation of 24 hours of reperfusion, 2 cc/kg of 0.09% saline was administered intraperitoneally.

(a)

(b)

(c)

(d)

(e)

(f)

Figure 1. (a) Preoperative marking. (b) Dissection of femoral vessels. (c) Raising the hindlimb composite island flap after femur osteotomy. (d) Applying clamps to femoral artery and vein. (e) Macroscopic view after 4 hours of ischemia. (f) Macroscopic view after 24 hours of reperfusion.

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Biochemical Evaluation Intracardiac blood samples, as well as gastrocnemius muscle and liver tissue samples were taken to analyze local tissue damage. Tissue samples were kept at -20°C degrees. Malondialdehyde (MDA), tumor necrosis factor (TNF)-alpha, nitrite, and nitrate levels in plasma, muscle, and liver samples were tested using enzyme-linked immunosorbent assay (ELISA) technique. ELISA was also used to determine glutathione (GSH) levels in erythrocytes. Vitamin A, vitamin E, and vitamin C levels in plasma were tested using high-performance liquid chromatography.

Statistical Analysis SPSS software version 16.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analyses of data obtained from the study. Shapiro-Wilk test was used to test assumption of normality. Normal values were evaluated with one-way analysis of variance test, and non-normal values were evaluated with Kruskal-Wallis test followed by Tukey’s test. P values of <0.05 were considered significant.

RESULTS Macroscopic Evaluation After 24 hours of follow up, 100% survival of all the composite island flaps was observed.

Biochemical Evaluation Significant increase was found in Group 1 compared to Group

2 and Group 3 in terms of plasma MDA (p<0.05). There was no significant difference between Groups 2, 3, and 4. There was no significant difference between groups in muscle MDA levels (p>0.05), but values were lower in Group 4 compared to Group 2 and Group 3. Liver MDA was significantly decreased in Group 4 compared to Group 2 (p<0.05) (Table 1). Plasma TNF-alpha levels revealed no significant difference between groups (p>0.05). There was significant increase in Group 3 compared to Group 1 (p<0.05) and Group 2 (p<0.05) in terms of muscle TNF-alpha levels. There was significant decrease in Group 4 compared to Group 3 in terms of muscle TNF-alpha levels (p<0.05). Significant decrease was observed in Group 3 and Group 2 compared to Group 1 in liver TNF-alpha levels (p<0.05). There was decrease in liver TNF-alpha levels in Group 4 compared to Group 1, but statistically it was not significant (Table 2). There was significant increase in plasma nitrate levels in Group 3 and Group 4 compared to Group 1 and Group 2 (p<0.05). There was no significant difference between Group 1 and Group 2. Muscle nitrate levels were significantly increased in Group 2,

Table 1. Plasma, muscle, and liver MDA levels Groups

MDA plasma (μM)

MDA muscle (mmol/g protein)

MDA liver (mmol/g protein)

Mean±SD

1 6.00±3.61

2.09±0.58

0.88±0.09

2 1.99±1.25

3.98±2.61

1.14±0.33

3 2.77±2.53

3.69±1.97

0.96±0.27

4 3.74±2.51

2.44±1.53

0.80±0.07

MDA: Malondialdehyde; SD: Standard deviation.

Table 2. Plasma, muscle, and liver tumor necrosis factor-alpha levels Groups

TNF plasma (pg/ml)

TNF muscle (ug/g protein)

TNF liver (ug/g protein)

Mean±SD Mean±SD

Mean±SD

1 3.03±1.53 95.90±56.59

572±118

2 6.13±3.19 92.90±75.22

469±91

3 6.68±5.57 250.30±163.32

463±32

4 5.81±4.37 74.10±34.49

502±60

TNF: Tumor necrosis factor; SD: Standard deviation.

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Aydın et al. Effects of alpha lipoic acid on ischemia-reperfusion injury in rat hindlimb ischemia model

Group 3, and Group 4 compared to Group 1 (p<0.05). There was no significant difference between Groups 2, 3, and 4. There was no significant difference between groups in terms of liver nitrate levels (Table 3). There was no significant difference between groups in plasma nitrite levels. No significant difference in muscle nitrite levels was determined between groups, but lower values were obtained in Group 4 compared to Groups 1, 2, and 3. There was no significant difference found in terms of liver nitrite levels (Table 4). Levels of erythrocyte GSH in Group 4 were significantly in-

creased compared to Group 1 (p<0.05) and Group 3 (p<0.05). There was significant increase in Group 1 compared to Groups 2, 3, and 4 in terms of muscle GSH levels (p<0.05). There was no significant difference between Groups 2, 3, and 4. Significant decrease in liver GSH levels was seen in Group 1 compared to Groups 2, 3, and 4 (p<0.05). There was no significant difference between Groups 2, 3, and 4 (Table 5). Group 4 had significant increase in plasma vitamin C (p<0.05). There was no significant difference between other groups. There was significant increase in Group 1 compared to others groups in plasma vitamin A levels (p<0.05). There was no significant difference found between other groups.

Table 3. Plasma, muscle and liver nitrate levels Groups

Nitrate plasma (uM)

Nitrate muscle (mmol/g protein)

Nitrate liver (mmol/g protein)

Mean±SD

1 11.92±4.44

2.05±1.47

0.55±0.12

2 20.03±11.89

4.12±1.91

0.55±0.12

3 39.64±19.31

3.93±2.71

0.55±0.03

4 40.18±17.63

5.38±3.71

0.63±0.13

SD: Standard deviation.

Table 4. Plasma, muscle and liver nitrite levels Groups

Nitrite plasma (uM)

Nitrite muscle (mmol/g protein)

Nitrite liver (mmol/g protein)

Mean±SD

1 3.38±1.08

0.94±0.14

1.15±0.33

2 2.32±1.04

1.12±0.59

1.01±0.12

3 2.04±1.60

1.47±1.03

0.94±0.08

4 3.16±1.28

0.77±0.08

1.13±0.29

SD: Standard deviation.

Table 5. Erythrocyte, muscle, and liver GSH levels Groups

GSH erytrocyte (umol/g Hgb)

GSH muscle (mmol/g protein)

GSH liver (mmol/g protein)

Mean±SD

Mean±SD Mean±SD

1 0.12±0.06

0.35±0.24

0.27±0.13

2 0.13±0.10

0.12±0.04

1.26±0.30

3 0.10±0.05

0.16±0.10

1.03±0.73

4 0.24±0.15

0.10±0.03

1.20±0.94

GSH: Glutathion; SD: Standard deviation.

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Table 6. Plasma vitamin C, vitamin A, vitamin E levels Groups

Vitamin C (mmol/l)

Vitamin A (mmol/L)

Vitamin E (mmol/L)

Mean±SD Mean±SD Mean±SD 1 0.57±0.35 0.51±0.11 7.25±1.72 2 0.65±0.18 0.30±0.07 11.64±2.29 3 0.65±0.18 0.27±0.05 9.67±1.20 4 2.51±2.80 0.22±0.03 7.22±1.69 SD: Standard deviation.

Plasma vitamin E levels increased significantly in Group 2 compared to Group 1 and Group 4 (p<0.05). There was significant increase in Group 3 compared to Group 1 and Group 4 in terms of plasma vitamin E (p<0.05). No significant difference was observed between Group 2 and Group 3 (Table 6).

DISCUSSION Flap loss is still an important problem in reconstructive surgery. Although flap anatomy and physiology are better known as result of recent research, flap loss of 25% in pedicled skinmuscle flaps has been reported, though most are partial.[10] Development of microsurgery made application of free flaps more common and flap survival rates increased, but new problems also occurred. Flap loss is less common in free flaps compared with pedicled flaps, but flap loss is usually total rather than partial. Independent of partial or total status, flap loss increases morbidity, mortality, hospitalization period, and number of surgeries performed. IR injury is a big problem in major replantations and composite tissue allotransplantations, which is why rat hindlimb transplantation model was selected for the present study. ALA was tested to determine if it would reduce production of free oxygen radicals. Damage occurring during reperfusion from free radicals was demonstrated by measuring TNF-alpha, a cytokine that triggers inflammation, and GSH, which is an antioxidant substance. Lipid peroxidation, which causes cell membrane damage was assessed by measuring MDA. Nitric oxide (NO), which is a highly reactive free radical, is not stable, and when it reacts with oxygen, various nitric oxide products are formed. The most stable derivatives are nitrite and nitrate. Nitrite and nitrate levels were tested in the present study to estimate NO levels. In addition, plasma levels of vitamin A, E, and C were measured to illustrate effect of ALA. Unal et al.[11] reported that gradually increased blood flow decreased IR injury. In our study, after 4 hours of ischemia, we first released venous clamp and then arterial with intent of returning normal blood flow to the extremity gradually. Zaccaria et al.[12] found that vitamin C reduced IR injury. In the current study, plasma vitamin C levels were significantly Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

increased in rats that received intraperitoneal ALA compared with all other groups. We think that ALA contributes antioxidant effect by increasing vitamin C. It was suggested that ALA had protective effect in a model where peroxy radical was used to induce erythrocyte hemolysis.[13] Also, it was found that ALA stabilized erythrocyte membrane and increased myocardial blood flow in an IR model using myocardial cells.[14] Yilmaz et al. reported that ALA, ascorbic acid-6-palmitate, and fish oil improve recycling of glutathione disulfide into reduced GSH in erythrocytes of diabetic rats.[15] In our study, significant increase in erythrocyte GSH levels was found in rats that had ALA administered compared with rats that received saline injection and rats that did not undergo ischemia reperfusion. It is possible that ALA protects erythrocyte membrane by increasing levels of GSH. Yamada et al.[16] reported that in hepatocytes stimulated with proinflammatory cytokines, ALA suppressed iNOS gene expression and prevented excess NO expression. However, in present study no significant decrease in levels of nitrite or nitrate was found in plasma, muscle, or liver in the ALA group compared with other groups. Tunc et al.[17] studied intestinal IR model in which clamp was applied to superior mesenteric artery for 30 minutes followed by 3 days of reperfusion. Superoxide dismutase, MDA, protein carbonyl, and glutathione peroxidase levels were measured in intestine tissue. They reported that MDA levels were significantly lower in rats treated with ALA in comparison with IR group. In addition, glutathione peroxidase levels were significantly higher in rats treated with ALA in comparison with IR group, but lower than control group. In present study, erythrocyte GSH levels were even higher in ALA treatment group than control group; however, we didn’t find any beneficial effect of ALA in terms of muscle and liver GSH. Koga et al.[18] conducted IR study on kidneys and found decreased levels of blood urea nitrogen, creatinine, and MDA in ALA treatment group compared to control group. In our study, we found significantly decreased levels of liver MDA in ALA treatment group compared with IR group. On the other hand, we didn’t find any beneficial effects of ALA in plasma in terms of MDA. 513

Aydın et al. Effects of alpha lipoic acid on ischemia-reperfusion injury in rat hindlimb ischemia model

Huk-Kolega et al.[19] found that ALA significantly decreased TNF-alpha level in rat spleen homogenates. In current study, muscle TNF-alpha levels were significantly decreased in ALA treatment group compared with rats that had saline administered. Safa et al.[20] investigated effects of ALA supplementation on serum levels of interleukin-8 and TNF-alpha in patients with end-stage renal disease undergoing hemodialysis. There was no significant difference between treatment group and placebo group. There was also no significant difference between groups in our study in terms of plasma TNF-alpha levels. Furthermore, we did not find any beneficial effects of ALA with respect to liver TNF-alpha. Werker et al.[21] investigated effects of ALA and desferrioxamine on cold ischemia tolerance in rat epigastric free flap model. After elevating epigastric flaps, they administered 15 mg/kg ALA and applied clamp to pedicle. Flaps were perfused with 0°C hypertonic citrate solution for 4 intervals: 0, 72, 96, and 120 hours. Before releasing clamps, 15 mg/ kg ALA was administered once again. Same procedure was followed with desferrioxamine. In comparison with control group, they found that neither desferrioxamine nor ALA enhanced cold ischemic tolerance of epigastric free flaps in rats. In present study, composite flap model was used, 4 hours warm ischemia was applied, and higher dose of ALA (24 mg/kg) was administered. Freisleben et al.[22] disarticulated both hindlimbs of rats, used right hindlimb as control group (n=7) and left hindlimb as treatment group (n=8). They cannulated femoral artery and vein, and after 4 hours of ischemia at 18°C degrees, reperfusion was carried out for 30 minutes with a controlled reperfusate, followed by 30 minutes modified Krebs-Henseleit solution. In the treatment group, they added 8.33 mM dihydrolipoic acid to the controlled reperfusion solution. They evaluated muscle contraction, flexibility of the hindlimbs, and creatine kinase in the buffer after 15 minutes of reperfusion. In the treatment group, they found muscle contractile function was significantly higher and creatine kinase levels were significantly lower, compared to control group. In our study, reperfusion was established with blood flow, which is more physiological. To evaluate reperfusion damage, we measured parameters that are more specific to IR injury and used separate rats for each group to obtain more objective results. The present study is unique in showing the effects of ALA on IR injury in composite island flaps. Further studies are needed using different types of flap models and more parameters to determine efficacy of ALA. ALA is cheap, easy to apply, and doesn’t require special equipment. It doesn’t have risks of infection, bleeding, or pain. It is our belief that ALA may be applied in clinics in order to prevent IR injury in the future. Conflict of interest: None declared. 514

REFERENCES 1. Leng X, Zhang Q, Zhai X, Chen Z. Local transplant of human umbilical cord matrix stem cells improves skin flap survival in a mouse model. Tohoku J Exp Med 2012;227:191–7. 2. Gute DC, Ishida T, Yarimizu K, Korthuis RJ. Inflammatory responses to ischemia and reperfusion in skeletal muscle. Mol Cell Biochem 1998;179:169–87. 3. Kramer K, Packer L. R-alpha-lipoic acid. In: Kramer K, Hoppe P, Packer L, editors. Nutraceuticals in Health and Disease Prevention. New York: Marcel Dekker, Inc. 2001. p. 129–64. 4. Sehirli O, Sener E, Cetinel S, Yüksel M, Gedik N, Sener G. Alpha-lipoic acid protects against renal ischaemia-reperfusion injury in rats. Clin Exp Pharmacol Physiol 2008;35:249–55. 5. Takaoka M, Ohkita M, Kobayashi Y, Yuba M, Matsumura Y. Protective effect of alpha-lipoic acid against ischaemic acute renal failure in rats. Clin Exp Pharmacol Physiol 2002;29:189–94. 6. Cosar E, Sahin FK, Köken G, Toy H, Basarali K, Büyükbas S. The protective effect of alpha-lipoic acid in experimental ovarian ischaemia-reperfusion injury. Aust N Z J Obstet Gynaecol 2007;47:499–503. 7. Müller C, Dünschede F, Koch E, Vollmar AM, Kiemer AK. Alpha-lipoic acid preconditioning reduces ischemia-reperfusion injury of the rat liver via the PI3-kinase/Akt pathway. Am J Physiol Gastrointest Liver Physiol 2003;285:G769–78. 8. Xie R, Li X, Ling Y, Shen C, Wu X, Xu W, et al. Alpha-lipoic acid preand post-treatments provide protection against in vitro ischemia-reperfusion injury in cerebral endothelial cells via Akt/mTOR signaling. Brain Res 2012;1482:81–90. 9. Wang X, Yu Y, Ji L, Liang X, Zhang T, Hai CX. Alpha-lipoic acid protects against myocardial ischemia/reperfusion injury via multiple target effects. Food Chem Toxicol 2011;49:2750–7. 10. Dunn RM, Mancoll J. Flap models in the rat: a review and reappraisal. Plast Reconstr Surg 1992;90:319–28. 11. Unal S, Ozmen S, DemIr Y, Yavuzer R, LatIfoğlu O, Atabay K, et al. The effect of gradually increased blood flow on ischemia-reperfusion injury. Ann Plast Surg 2001;47:412–6. 12. Zaccaria A, Weinzweig N, Yoshitake M, Matsuda T, Cohen M. Vitamin C reduces ischemia-reperfusion injury in a rat epigastric island skin flap model. Ann Plast Surg 1994;33:620–3. 13. Constantinescu A, Tritschler H, Packer L. alpha-Lipoic acid protects against hemolysis of human erythrocytes induced by peroxyl radicals. Biochem Mol Biol Int 1994;33:669–79. 14. Ghibu S, Lauzier B, Delemasure S, Amoureux S, Sicard P, Vergely C, et al. Antioxidant properties of alpha-lipoic acid: effects on red blood membrane permeability and adaptation of isolated rat heart to reversible ischemia. Mol Cell Biochem 2009;320:141–8. 15. Yilmaz O, Ozkan Y, Yildirim M, Oztürk AI, Erşan Y. Effects of alpha lipoic acid, ascorbic acid-6-palmitate, and fish oil on the glutathione, malonaldehyde, and fatty acids levels in erythrocytes of streptozotocin induced diabetic male rats. J Cell Biochem 2002;86:530–9. 16. Yamada M, Kaibori M, Tanaka H, Habara K, Hijikawa T, Tanaka Y, et al. alpha-lipoic acid prevents the induction of iNOS gene expression through destabilization of its mRNA in proinflammatory cytokine-stimulated hepatocytes. Dig Dis Sci 2012;57(4):943–51. 17. Tunc T, Oter S, Güven A, Topal T, Kul M, Korkmaz A, et al. Protective effect of sulfhydryl-containing antioxidants against ischemia/reperfusion injury of prepubertal rat intestine. J Gastroenterol Hepatol 2009;24(4):681–7. 18. Koga H, Hagiwara S, Kusaka J, Goto K, Uchino T, Shingu C, et al. New α-lipoic acid derivative, DHL-HisZn, ameliorates renal ischemia-reperfusion injury in rats. J Surg Res 2012;174:352–8. 19. Huk-Kolega H, Ciejka E, Skibska B, Kowalczyk A, Goraca A. Influence of lipoic acid on the level of TNF-alpha in spleen homogenates. [Article

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Aydın et al. Effects of alpha lipoic acid on ischemia-reperfusion injury in rat hindlimb ischemia model in Polish] Pol Merkur Lekarski 2014;36:379–81. [Abstract] 20. Safa J, Ardalan MR, Rezazadehsaatlou M, Mesgari M, Mahdavi R, Jadid MP. Effects of alpha lipoic acid supplementation on serum levels of IL-8 and TNF-α in patient with ESRD undergoing hemodialysis. Int Urol Nephrol 2014;46:1633–8.

21. Werker PM, Kon M, Green CJ, Franken RJ, Overgoor ML. Neither desferrioxamine nor lipoic acid enhances the cold ischaemic tolerance of epigastric free flaps in rats. Microsurgery 1993;14:574–8. 22. Freisleben HJ. Lipoic acid reduces ischemia-reperfusion injury in animal models. Toxicology 2000;148:159–71.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Sıçanlarda arka bacak iskemi modelinde alfa lipoik asitin iskemi/ reperfüzyon hasarı üzerine etkisi Dr. Arif Aydın,1 Dr. Alpagan Mustafa Yıldırım2 1 2

Afyonkarahisar Devlet Hastanesi, Plastik Rekonstrüktif ve Estetik Cerrahi Kliniği, Afyonkarahisar Afyon Kocatepe Üniversitesi Tıp Fakültesi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Afyonkarahisar

AMAÇ: Bu çalışma sıçanlarda arka bacak modelinde alfa lipoik asitin iskemi reperfüzyon hasarını önlemedeki etkinliğini araştırmak amacıyla yapıldı. GEREÇ VE YÖNTEM: Çalışmada 250–300 gr ağırlığında 40 adet Sprague Dawley cinsi erkek sıçan kullanıldı. Her grupta 10 hayvan olacak şekilde, randomize dört grup oluşturuldu. Tüm sıçanlarda arka bacak kompozit ada flebi hazırlandı. Grup 1’de arka bacakta femoral damarlara klemp uygulanıp hemen açıldı ve iskemi oluşturulmadı. Grup 2’de dört saat iskemi uygulandı ve sonrasında 24 saat reperfüzyon edildi. Grup 3’te dört saat iskemi sonrası parenteral olarak serum fizyolojik verildi ve 24 saat reperfüzyon yapıldı. Grup 4’te dört saatlik iskemi sonrası parenteral olarak alfa lipoik asit verildi ve 24 saat reperfüzyon yapıldı. Tüm sıçanlar 24 saatlik reperfüzyon sonrası sakrifiye edildi. Biyokimyasal inceleme için kan, karaciğer ve transplante edilen arka bacaktan kas dokusu örneği alındı. Homogenizasyon sonrası kanda ve dokularda nitrit, nitrat, glutatyon, MDA, TNF-alfa, plazmada vitamin A, vitamin E, vitamin C düzeyleri test edildi. BULGULAR: İskemi sonrası alfa lipoik asit eklenen grupta GSH (eritrosit), MDA (karaciğer), vitamin C (plazma),TNF-alfa (kas) değerlerinde yalnız iskemi veya iskemi ve serum fizyolojik uygulanan gruplara göre anlamlı farklar görüldü. TARTIŞMA: Çalışmamızda, alfa lipoik asitin iskemi-reperfüzyon hasarını önlemede olumlu etkilerinin olduğu bulunmuştur. Ancak klinik uygulama için yeni ve geniş çalışmalara ihtiyaç vardır. Anahtar sözcükler: Alfa lipoik asit; iskemi-reperfüzyon; sıçan. Ulus Travma Acil Cerrahi Derg 2016;22(6):509–515

doi: 10.5505/tjtes.2016.00258

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515

EXPERIMENTAL STUDY

Effect of medical treatment on histological findings in rabbits with acute appendicitis Gürcan Şimşek, M.D.,1 Barış Sevinç, M.D.,2 Yaşar Ünlü, M.D.,3 İsmail Hasırcı, M.D.,1 Hüseyin Kurku, M.D.,4 Ömer Karahan, M.D.5 1

Department of General Surgery, Konya Training and Research Hospital, Konya-Turkey

Department of General Surgery, Sarıkaya State Hospital, Yozgat-Turkey

Department of Pathology, Konya Training and Research Hospital, Konya-Turkey

Department of Biochemistry, Konya Training and Research Hospital, Konya-Turkey

Department of General Surgery, Necmettin Erbakan University Meram Faculty of Medicine, Konya-Turkey

ABSTRACT BACKGROUND: Acute appendicitis (AA) is the most common reason for abdominal surgery in the world. The aim of this study was to evaluate the effect of medical treatment on histological findings in rabbits with AA. METHODS: Twenty-one male New Zealand rabbits were divided into 3 groups: appendix ligation and medical treatment, appendix ligation and no treatment, and control group, which underwent only laparotomy. RESULTS: In appendix ligation without treatment group, AA findings were much more severe. CONCLUSION: Medical treatment reduced inflammation of AA. Keywords: Acute appendicitis; antibiotic; medical treatment.

INTRODUCTION Acute appendicitis (AA) is the most common abdominal surgical emergency all around the world. Lifetime risk of AA is about 7% to 8%. It is most commonly seen in second and third decades of life. Preferred treatment for AA is surgery.[1] There are, however, several reports about medical treatment for uncomplicated cases of AA such as acute cholecystitis and acute diverticulitis. In fact, medical treatment for AA is not so new. First successful medical treatment was performed during World War II.[2] In 1959, Coldrey reported 474 cases of medical treatment of AA, as well as treatment failure and surgery in 48 cases.[3]

Address for correspondence: Barış Sevinç, M.D. Sarıkaya Devlet Hastanesi, Genel Cerrahi Kliniği, Sarıkaya, 66650 Yozgat, Turkey Tel: +90 354 - 772 33 66 E-mail: drbarissevinc@gmail.com Qucik Response Code

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In studies conducted regarding medical treatment of AA, patients have been included according to clinical findings and imaging results. Histological proof of AA was not possible. However, AA is a histopathological term, meaning polymorphonuclear leukocyte invasion at the muscular layer of appendix vermiformis.[4] Histological confirmation of AA is only possible in an experimental study. To our knowledge, there is no previous report of animal experiment regarding medical treatment of AA. The aim of this study was to evaluate effect of medical treatment on histopathological findings in rabbits with AA.

MATERIALS AND METHODS The study was conducted at Necmettin Erbakan University Meram Faculty of Medicine Experimental Medicine Application and Research Center after receiving approval of the ethical committee. Twenty-one male New Zealand rabbits (Oryctolagus cuniculus), weighing between 2050 and 2450 g, were divided into 3 groups: Group 1: Appendix ligation and antibiotic treatment (n=7), Group 2: Appendix ligation, no treatment (n=7), and Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Şimşek et al. Effect of medical treatment on histological findings in rabbits with acute appendicitis

Table 1. Histopathological scoring of acute appendicitis

0 1

Inflammation

None

Acute inflammation

Phlegmonous inflammation

Gangrenous inflammation

Necrosis

None

Limited to mucosa

Less than half of the

Whole appendix wall

appendix wall

Residual follicle

None

Minimal

Significant

Inflammation of surrounding fatty tissue

None

Mild

Moderate

Severe

Periappendicular abscess

None

Mild

Moderate

Severe

Organization and remodeling

None

Mild

Moderate

Severe

Fibroblastic activity

and presence of capillaries

Group 3: No appendix ligation, just laparotomy and no treatment (n=7). AA model described by Menteş et al. was used for the study. [5] All subjects were operated on under general anesthesia induced with ketamine hydrochloride (Ketalar; Pfizer, Inc., NY, NY, USA) and xylazine (Rompun; Bayer AG, Leverkusen, Germany). After shaving the abdomen, skin was disinfected with iodine solution. After midline laparotomy, appendix vermiformis was identified. Base of the appendix was dissected with careful preservation of mesentery and blood vessels (Fig. 1). In Group 3, surgery ended at this stage. In Group 1 and Group 2, ligation with polyglactin sutures was performed to obstruct the appendix. Abdominal wall was closed primarily.

scopic findings (perforation, fibrin plaques, abscess formation, etc.) were recorded. Appendicectomy material was collected for histopathological examination. Histopathological examination was performed by a single, blinded pathologist. As there is no classification method for microscopic findings of AA, standard scoring system was used (Table 1). Total AA score was calculated and groups were compared in terms of this score. SPSS software version 20.0 (SPSS, Inc., Chicago, IL, USA) was used for statistical analysis. Independent samples t-test was used for comparison of the groups. Statistical significance level was accepted as 0.05.

Standard daily diet was provided to subjects during follow-up. Daily ceftriaxone 50 mg/kg/d and lincomycin 2 mg/kg/d were administered intramuscularly to subjects in Group 1. Antibiotherapy was continued for 5 days. At the end of the fifth day, all subjects underwent appendicectomy under general anesthesia. Blood samples were collected for complete blood count and measurement of C-reactive protein (CRP) levels. During this second operation, macro-

Figure 1. Normal appendix vermiformis, Clamp shows the area to be ligated.

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Figure 2. Macroscopic view of acute appendicitis. Fibrin plaques and perforation are seen at the proximal part.

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Ĺ&#x17E;imĹ&#x;ek et al. Effect of medical treatment on histological findings in rabbits with acute appendicitis

Table 2. Macroscopic findings of the subjects

Group 1

Group 2

Group 3

Perforation

0 4 0

Abscess

2 3 0

Generalized peritonitis 0 2 0 Fibrin plaques

2 7 1

RESULTS In terms of leukocyte count and CRP levels, the groups were similar (p>0.05). During the experiment, 2 subjects in Group 2 died. Postmortem examination revealed perforated appendicitis and generalized peritonitis in both subjects. No perforation or generalized peritonitis was observed in Group 1. However, in Group 2, there was perforation in 4 subjects and generalized peritonitis in 2 (Fig. 2). Localized abscess formation was detected in 2 subjects in Group 1 and 3 subjects in Group 2. There was no perforation, abscess, or peritonitis found in Group 3 (Table 2).

appendiceal lumen. Most of the time, obstruction is caused by feces or lymphoid hyperplasia. However, parasites, foreign bodies, and occasionally, cecal or appendiceal tumors can also lead to obstruction.[4] In this experiment, AA was induced with ligation of the base of appendix vermiformis. AA was successfully developed in all subjects in Groups 1 and 2. There are several reports about medical treatment of AA. The first randomized clinical trial regarding medical treatment of AA was conducted by Eriksson et al. in 1995.[6] They reported that medical treatment was as effective as surgery; however, recurrence was major problem. In a randomized prospective trial conducted by Turhan et al., success rate of medical treatment was reported as 82.2%.[7] In meta-analysis performed by Liu et al., 1-year recurrence rate of AA treated medically was reported as 14.2%.[8] Current experiment showed medical treatment causes suppressed inflammatory reaction; however, as obstruction continues, total cure seems to be impossible. Medical treatment can lead to partial relief in luminal obstruction and clinical findings. Since re-obstruction of the lumen is main cause of recurrence, medical treatment may be especially useful in cases with lymphoid hyperplasia.

Primary factor in pathophysiology of AA is obstruction of

In surgical series about AA, negative appendicectomy rate ranges between 9% and 27%.[9] Even routine use of imaging studies cannot eliminate negative appendicectomies. In a study with routine use of computed tomography, negative appendicectomy rate was reported as 6%.[10] In studies regarding medical treatment of AA, patients were included according to clinical findings and imaging results. According to data from the literature, about 10% of patients with medically treated AA are misdiagnosed. In a report comparing surgery and medical treatment, it was noted that false positive diagnosis rate can be determined for surgery cases; however, the same cannot be said for medical treatment. This makes

Figure 3. Microscopic view of reactive fibroblastic activity (black arrow) and reactive lymphoid follicle (white arrow). Hematoxylin and eosin stain; x100.

Figure 4. Microscopic view of necrosis zone in an untreated subject. Hematoxylin and eosin stain; x100.

Acute inflammation was seen in all members of Group 1 and Group 2 (Figs. 3 and 4). Histological findings of all subjects are provided in Table 3. In Group 3, histological score was zero; therefore, this group was excluded from statistical analysis. Histological findings in Group 2 were much more severe than those of Group 1 (Table 4).

DISCUSSION

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Şimşek et al. Effect of medical treatment on histological findings in rabbits with acute appendicitis

Table 3. Histopathological evaluation of appendicectomy material Group Subject Inflammation Necrosis

Inflammation Periappendicular of surrounding absces fatty tissue

Organization and remodeling

Total score

Acute appendicitis + Medical treatment

1.1

1.2 2 1

2 7

1.3 2 1

2 6

1.4 2 1

2 6

1.5 2 0

1 4

1.6 2 2

1 8

1.7 1 0

2 4

no treatment

2.1

2.2 3 3

0 12

2.3 3 2

0 11

2.4 3 2

0 9

2.5 2 1

1 6

2.6 2 1

1 7

2.7 2 1

1 7

No intervention

3.1

3.2 0 0

0 0

3.3 0 0

0 0

3.4 0 0

0 0

3.5 0 0

0 0

3.6 0 0

0 0

3.7 0 0

0 0

Acute appendicitis + 2

Table 4. Comparison of histopathological scores between groups

Mean±SD

Total histopathological score

Group 2

8.4286±2.29907

Group 1

5.5714±1.61835

0.02

Independent samples t-test. SD: Standard deviation.

analysis of effectiveness of medical treatment difficult in comparative trials. In the current study, no perforation or generalized peritonitis was found in medically treated subjects. This indicates medical treatment had beneficial effect of decreasing instances of perforation and septic complications of AA. The main limitation of the current study is constant luminal obstruction. An experimental model with AA due to lymUlus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

phoid hyperplasia could provide additional information. However, as the first experimental study regarding medical treatment of AA, the results of this study showing beneficial effect on histological findings are important. Conflict of interest: None declared.

REFERENCES 1. Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Vega Rivera F, et al. Global disease burden of conditions requiring emergency surgery. Br J Surg 2014;101:9–22. 2. Turhan AN, Kapan S. Akut apandisit. In: Ertekin C, Güloğlu R, Taviloğlu K (ed.) Nobel Tıp Kitabevi. Acil Cerrahi 2009. p. 301–16. 3. Coldrey E. Five years of conservative treatment of acute appendicitis. J Int coll Surg 1959;32:225–61. 4. Crawford J. (Çeviren: Çevikbaş U, Güllüoğlu M). Ağız boşluğu ve gastrointestinal sistem. In: Kumar V, Cotran RS, Robbins SL (Ed.) Çeviri Ed: Çevikbaş U. Basic pathology. 6th ed. Nobel Tıp Kitabevleri; 2000. p. 514. 5. Menteş Ö, İde T, Akdağ E, Balkan M, Öngörü Ö, Kozak O ve ark. Akut apandisit: Apendiksin bağlanması (Tavşanlarda deneysel model). Gülhane Tıp Dergisi 2008;50:27–9. 6. Eriksson S, Granström L. Randomized controlled trial of appendi-

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Şimşek et al. Effect of medical treatment on histological findings in rabbits with acute appendicitis cectomy versus antibiotic therapy for acute appendicitis. Br J Surg 1995;82:166–9. 7. Turhan AN, Kapan S, Kütükçü E, Yiğitbaş H, Aygün E. Akut apandisitte nonoperatif takip ve tedavi. Bakırköy Tıp Dergisi 2006;2:134–6. 8. Liu K, Fogg L. Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta-analysis. Surgery 2011;150:673–83.

9. Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015;386:1278–87. 10. SCOAP Collaborative, Cuschieri J, Florence M, Flum DR, Jurkovich GJ, Lin P, Steele SR, et al. Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program. Ann Surg 2008;248:557–63.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Tavşanlarda oluşturulan akut apandisit modelinde medikal tedavinin histopatolojik bulgular üzerindeki etkisi Dr. Gürcan Şimşek,1 Dr. Barış Sevinç,2 Dr. Yaşar Ünlü,3 Dr. İsmail Hasırcı,1 Dr. Hüseyin Kurku,4 Dr. Ömer Karahan5 Konya Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Konya Sarıkaya Devlet Hastanesi, Genel Cerrahi Kliniği, Yozgat Konya Eğitim ve Araştırma Hastanesi, Patoloji Kliniği, Konya 4 Konya Eğitim ve Araştırma Hastanesi, Biyokimya Laboratuvarı, Konya 5 Necmettin Erbakan Üniversitesi Meram Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Konya 1 2 3

AMAÇ: Akut apandisit dünyada genel cerrahların karşılaştığı en sık akut karın nedenidir. Bu çalışmada, akut apandisit oluşturulan tavşanlarda antibiyotik tedavisinin akut apandisitte ortaya çıkan histopatolojik bulgular üzerine etkisinin değerlendirilmesi amaçlandı. GEREÇ VE YÖNTEM: Çalışma için 21 adet Yeni Zelenda cinsi (Oryctogaluscuniculus), erkek ve ağırlıkları 2050–2450 gram arasında değişen tavşan kullanıldı. Denekler üç gruba ayrıldı: Grup 1: Apendiks ligasyonu yapılan ve antibiyotik tedavisi verilen grup (n=7), Grup 2: Apendiks ligasyonu yapılan ama antibiyotik tedavisi verilmeyen grup (n=7), Grup 3: Apendiks ligasyonu yapılmayan ve antibiyotik tedavisi verilmeyen grup (sham grubu) (n=7). BULGULAR: Grup 1 ve Grup 2 arasında yapılan istatistiksel analiz sonucunda Grup 2’de ortaya çıkan histopatolojik değişiklikler Grup 1’den anlamlı olarak daha şiddetliydi. TARTIŞMA: Antibiyotik tedavisi akut apandisitte histolojik olarak enflamasyonun şiddetini azaltmaktadır. Anahtar sözcükler: Antibiyotik tedavisi; apandisit; medikal tedavi. Ulus Travma Acil Cerrahi Derg 2016;22(6):516–520

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doi: 10.5505/tjtes.2016.79825

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EXPERIMENTAL STUDY

Therapeutic efficacy of tadalafil and eriythropoietin in experimental spinal cord injury Çağrı Kökoğlu, M.D.,1 Emre Delen, M.D.,2 Ali Arslantaş, M.D.,3 Didem Arslantaş, M.D.,4 Burcu Kökoğlu, M.D.,5 Zühtü Özbek, M.D.,3 Sema Uslu, M.D.,6 Ahmet Tolgay Akıncı, M.D.7 1

Department of Neurosurgery, Eskişehir Yunus Emre State Hospital, Eskişehir-Turkey

Department of Neurosurgery, Trakya University Faculty of Medicine, Edirne-Turkey

Department of Neurosurgery, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir-Turkey

Department of Public Health, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir-Turkey

Department of Family Medicine, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir-Turkey

Department of Biochemistry, Eskisehir Osmangazi University Faculty of Medicine, Eskişehir-Turkey

Department of Neurosurgery, Tokat State Hospital, Tokat-Turkey

ABSTRACT BACKGROUND: This experimental study was an investigation of the efficacy of erythropoietin and tadalafil in rats with induced spinal cord injury (SCI). METHODS: Thirty-five Sprague Dawley rats were distributed into 5 groups. First group was used for normal biochemical values. Spinal cord injury was induced in 4 remaining groups with clip compression technique after laminectomy process to T10 vertebra. Second group was designated solvent group and received 1 cc physiological serum after injury. Third group was medicated with intraperitoneal 2000 u/kg single dose erythropoietin after injury. Orogastric 2 mg/kg single dose tadalafil was administered to fourth group after injury. Fifth group did not receive any treatment and was used for biochemical values with injury. All subjects were sacrificed 48 hours after application. Malondialdehyde (MDA) and total antioxidant capacity (TAOC) values were evaluated using blood and tissue samples. RESULTS: Lowest serum and tissue MDA values were found in group with erythropoietin intake. While highest serum TAOC values of all groups were seen in tadalafil group, highest tissue TAOC values were observed in group given erythropoietin. CONCLUSION: It was concluded that by decreasing oxidative stress, tadalafil and erythropoietin can inhibit secondary damage in SCI. Keywords: Erythropoietin; neuroprotection; spinal cord injury; tadalafil.

INTRODUCTION Though no longer thought to be hopeless, spinal cord injury (SCI) still cannot be treated efficiently with modern medicine. Therefore, it creates physical, emotional, and economic burdens for both the individual and society.[1] Allen’s 2-step injury model encouraged related studies and additional laboratory studies are ongoing, but efficient treatment for SCI has not Address for correspondence: Çağrı Kökoğlu, M.D. Eskişehir Yunus Emre Devlet Hastanesi, Nöroşirürji Kliniği, 26000 Eskişehir, Turkey Tel: +90 222 - 211 95 95 E-mail: cagrikokoglu@gmail.com Qucik Response Code

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yet been found. In recent years, additional therapeutic effects of erythropoietin (EPO) and tadalafil have been studied aside from its routine clinical use, and promising results have been published. Presently described is research regarding effects of both agents on reducing secondary damage in cases of SCI, and discussion based on data available in the literature.

MATERIALS AND METHODS This experimental study was conducted at the Medical and Surgical Experimental Research Center (MESERC) with the approval of the university ethics committee for animal experimentation. Total of 35 female Sprague Dawley rats weighing between 200 and 250 g were randomly divided into 5 groups. General anesthesia for the subjects was provided with intraperitoneal injection of 60 mg/kg ketamine hydrochloride (Ketalar; Pfizer, Inc., NY, NY, USA) and 12 mg/kg xylazine (Rompun, Bayer AG, Leverkusen, Germany) mixture. T10 laminectomy was performed to expose spinal cord. Clip com521

Kökoğlu et al. Therapeutic efficacy of tadalafil and eriythropoietin in experimental spinal cord injury

pression technique was then used to achieve experimental SCI in all groups except first group, which served as control group. Aneurysm clip providing closing force of 1.43 N (Yasargil FE 740 K; Aesculap AG, Tuttlingen, Germany) was applied to the spinal cord, and macroscopic SCI was observed (Fig. 1). Second group was designated solvent group (injury+solvent) and was given 1 cc physiological serum. Single dose 2000 u/ kg EPO (Eprex 2000; Cilag AG, Schaffhausen, Switzerland) (treatment 1) was administered intraperitoneally to third group after clip application to the spinal cord. Orogastric 2 mg/kg single dose tadalafil (Cialis; Eli Lilly and Co., Indianapolis, IN, USA) (treatment 2) was given to fourth group. Fifth group received no treatment after SCI (injury group). Subjects were sacrificed using intracardiac exsanguination technique 48 hours post surgery. Serum and tissue malondialdehyde (MDA) and total antioxidant capacity (TAOC) values were measured using blood and tissue samples.

Biochemical Measures Blood samples were centrifuged for 10 minutes at 3000 rpm to obtain serum for MDA and TAOC studies. Spinal cord segments 1 cm in length, which included injured cord area, were harvested as samples. Blood and tissue samples were transferred immediately to deep freezer for preservation at -80°C until biochemical testing was conducted. Measurement of lipid peroxide levels was performed using method described by Ohkawa et al., which consists of spectrophotometric measurement of color at 532 nm created by reaction of tiobarbuturic acid with MDA in acid environment. Protein levels were expressed as nmol/mg in tissue and as nmol/mL in plasma. [2] TAOC was measured using Total Antioxidant Status kit (Mega Tıp San. Tic. Ltd. Şti., Gaziantep, Turkey) in automatic biochemical analyzer and results obtained were expressed as nmol Trolox Eq/L.[3]

Statistical Method SPSS (Statistical Package for Social Sciences) software version 15.0 (SPSS, Inc., Chicago, IL, USA) was used to evaluate study findings. Results were presented as mean±standard deviation. One way analysis of variance was applied and least significant difference test was used for group comparisons. Confidence interval of 95% and value of p<0.05 were accepted as significance thresholds.

RESULTS Serum and tissue MDA and TAOC levels were examined in every group. Post-hoc evaluation for in-group comparison revealed serum TAOC levels were highest after tadalafil medication (p<0.0001). Minimum tissue TAOC level was seen in injury group and maximum was demonstrated in EPO group (p<0.0001). Distribution of mean TAOC values can be seen in Figure 2. Serum and tissue TAOC levels are summarized in Table 1. Statistical evaluation indicated maximum serum MDA values were found in injury group, decreased with tadalafil treatment, and were lowest after EPO treatment (p<0.05). Tissue MDA values were highest maximum in injury group, and low2.5

Serum Tissue

1.5

0.5

Control

Solvent

Erythropoietin

Tadalafil

Injury

Tadalafil

Injury

Figure 2. Serum and tissue TAOC levels. 3 2.5

Serum Tissue

2 1.5 1 0.5 0

Figure 1. Clip application to the spinal cord.

522

Control

Solvent

Erythropoietin

Figure 3. Serum and tissue MDA levels.

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Kökoğlu et al. Therapeutic efficacy of tadalafil and eriythropoietin in experimental spinal cord injury

Table 1. TAOC levels by group

TAOC levels of serum

Statistical values

Mean±SD Control

1.85±0.35 F=162.03

Solvent

1.83±0.52 p=0.000

Eriythropoietin 2.14±0.64 Tadalafil 2.17±0.33 Injury 1.64±0.24

TAOC levels of tissue

Mean±SD Control

0.36±0.44 F=130.16

Solvent

0.33±0.02 p=0.000

Eriythropoietin

0.67±0.06

Tadalafil 0.54±0.01 Injury 0.22±0.03 TAOC: Total Anti-Oxidant Capacity; SD: Standard deviation.

Table 2. MDA levels by group

MDA levels of serum

Statistical values

Mean±SD Control 1.87±0.43 F=2.68 Solvent 2.04±1.05 p=0.05 Eriythropoietin 1.32±0.70 Tadalafil 1.50±1.16 Injury 2.68±0.70

MDA levels of tissue

Mean±SD Control 1.49±0.62 F=6.28 Solvent

1.31±0.73 p=0.001

Eriythropoietin

0.55±0.24

Tadalafil 0.58±0.59 Injury 1.83±0.65 MDA: Malondialdehyde; SD: Standard deviation.

est in EPO group (p<0.05). Distribution of serum and tissue MDA mean values is provided in Figure 3. Serum and tissue levels of MDA are summarized in Table 2.

DISCUSSION EPO is a glycoprotein hormone. It was first isolated from urine of anemic patients.[4] Essentially, it participates in proliferation and differentiation of erythroid precursor cells. Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Therefore, routine clinical use includes anemia treatment for primary patients with renal tumors and chronic renal insufficiency. EPO is produced in the kidneys[5] and its secretion increases in response to hypoxia, reaching 50 times normal physiological values in blood.[6] Neuroprotective effects of EPO have been reported in recent years in addition to previously known clinical effects.[7,8] In experimental studies done in field of SCI, EPO has been reported to be extremely effective at enhancing neurological recovery.[9–12] In clinical studies, EPO has been demonstrated to be spinal as well as cranial neuroprotective agent. Ehrenreich et al. associated high dose intravenous EPO treatment with improvement in clinical outcome in study evaluating clinical results in cases of acute stroke at the end of first month. [13] There are also other studies in the literature supporting neuroprotective impact of EPO in acute stroke cases.[14] This neuroprotective quality of EPO on central and peripheral nervous systems has been reported to occur through various mechanisms. EPO has been claimed to promote axonal regeneration to increase neoangiogenesis, to inhibit apoptosis, to have anti-inflammatory effects, to have anti-ischemic effects, to decrease microglial infiltration, to inhibit scar formation, and thereby may contribute to neurological improvement. [15–19] Nevertheless, the exact mechanism of neuroprotection of EPO is still not certain. Even if key determinant to EPO secretion is hypoxia, EPO receptors are more sensitive to pro-inflammatory cytokines such as tumor necrosis factor-1 and interleukin-1 beta than hypoxia.[20,21] Weak stimulation of EPO receptors as result of hypoxia, unlike stimulation of EPO, makes us think that there is a not-yet discovered mechanism for neuroprotective role of EPO. Tadalafil augments cyclic guanosine monophosphate (cGMP) concentration by inhibiting phosphodiesterase 5 enzyme (PED5).[22] CGMP is a strong mediator of nitric oxide pathway. In sum, tadalafil inhibits PED5 enzyme and as a consequence, increasing nitric oxide concentration causes vasodilatation. Tadalafil is used for routine treatment of erectile dysfunction. Clinical studies supporting use for pulmonary hypertension and heart disease have also been published.[23,24] In recent years, alongside routine clinical use, neuroprotective effect has been subject of much study. Neuroprotective effect of tadalafil is reported to be especially efficient in brain ischemia.[25,26] Similar efficiency has been reported in decreasing oxidative stress related to SCI. [27] Neuroprotection mechanism of tadalafil is not yet known; neurogenesis, synaptic plasticity, and physiological modulation of neurotransmitters caused by cGMP have all been proposed.[28–31] Most likely, tadalafil plays role in neuroprotection through effect on cGMP. In the present study, neuroprotective effects of EPO and 523

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tadalafil on SCI were analyzed. MDA and TAOC values, which reflect lipid peroxidation, were measured using blood and tissue samples. Most efficient decrease of serum and tissue MDA values was found in EPO-treated group. Neuroprotective effect of EPO use in SCI by decreasing MDA values is consistent with existing literature. Antioxidant effect of tadalafil in SCI was observed in finding of maximum serum TAOC values in tadalafil-treated group, which is also as previously stated in the literature. In general, all of present study data confirm what is found in the literature; EPO and tadalafil have an effect on reducing secondary damage in SCI cases. However, additional clinical and experimental studies of neuroprotective abilities of these agents are needed. Conflict of interest: None declared.

REFERENCES 1. Collie A. Gains in neurotrauma research activity and output associated with a Victorian state government funding program. Med J Aust. 2010;192:712–4. 2. Ohkawa H, Ohishi N, Yagi K. Assay for lipid peroxides in animal tissues by thiobarbituric acid reaction. Anal Biochem 1979;95:351–8. 3. Erel O. A novel automated method to measure total antioxidant response against potent free radical reactions. Clin Biochem 2004;37:112–9. 4. Powell JS, Berkner KL, Lebo RV, Adamson JW. Human erythropoietin gene: high level expression in stably transfected mammalian cells and chromosome localization. Proc Natl Acad Sci U S A 1986;83:6465–9. 5. Jacobson LO, Goldwasser E, Fried W, Plzak L. Role of the kidney in erythropoiesis. Nature 1957;179:633–4. 6. Carelli S, Marfia G, Di Giulio AM, Ghilardi G, Gorio A. Erythropoietin: recent developments in the treatment of spinal cord injury. Neurol Res Int 2011;2011:453179. 7. Montero M, Poulsen FR, Noraberg J, Kirkeby A, van Beek J, Leist M, et al. Comparison of neuroprotective effects of erythropoietin (EPO) and carbamylerythropoietin (CEPO) against ischemia-like oxygen-glucose deprivation (OGD) and NMDA excitotoxicity in mouse hippocampal slice cultures. Exp Neurol 2007;204(1):106–17. 8. Okutan O, Solaroglu I, Beskonakli E, Taskin Y. Recombinant human erythropoietin decreases myeloperoxidase and caspase-3 activity and improves early functional results after spinal cord injury in rats. J Clin Neurosci 2007;14:364–8. 9. Sekiguchi Y, Kikuchi S, Myers RR, Campana WM. ISSLS prize winner: Erythropoietin inhibits spinal neuronal apoptosis and pain following nerve root crush. Spine (Phila Pa 1976) 2003;28:2577–84. 10. Kaptanoglu E, Solaroglu I, Okutan O, Surucu HS, Akbiyik F, Beskonakli E. Erythropoietin exerts neuroprotection after acute spinal cord injury in rats: effect on lipid peroxidation and early ultrastructural findings. Neurosurg Rev 2004;27:113–20. 11. Celik M, Gökmen N, Erbayraktar S, Akhisaroglu M, Konakc S, Ulukus C, et al. Erythropoietin prevents motor neuron apoptosis and neurologic disability in experimental spinal cord ischemic injury. Proc Natl Acad Sci U S A 2002;99:2258–63. 12. Gorio A, Gokmen N, Erbayraktar S, Yilmaz O, Madaschi L, Cichetti C, et al. Recombinant human erythropoietin counteracts secondary injury and markedly enhances neurological recovery from experimental spinal cord trauma. Proc Natl Acad Sci U S A 2002;99:9450–5. 13. Ehrenreich H, Hasselblatt M, Dembowski C, Cepek L, Lewczuk P, Sti-

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efel M, et al. Erythropoietin therapy for acute stroke is both safe and beneficial. Mol Med 2002;8:495–505. 14. Yip HK, Tsai TH, Lin HS, Chen SF, Sun CK, Leu S, et al. Effect of erythropoietin on level of circulating endothelial progenitor cells and outcome in patients after acute ischemic stroke. Crit Care 2011;15:R40. 15. Matis GK, Birbilis TA. Erythropoietin in spinal cord injury. Eur Spine J 2009;18:314–23. 16. Gorio A, Madaschi L, Di Stefano B, Carelli S, Di Giulio AM, De Biasi S, et al. Methylprednisolone neutralizes the beneficial effects of erythropoietin in experimental spinal cord injury. Proc Natl Acad Sci U S A 2005;102:16379–84. 17. Lombardero M, Kovacs K, Scheithauer BW. Erythropoietin: a hormone with multiple functions. Pathobiology 2011;78:41–53. 18. Sargin D, Friedrichs H, El-Kordi A, Ehrenreich H. Erythropoietin as neuroprotective and neuroregenerative treatment strategy: comprehensive overview of 12 years of preclinical and clinical research. Best Pract Res Clin Anaesthesiol 2010;24:573–94. 19. Kretz A, Happold CJ, Marticke JK, Isenmann S. Erythropoietin promotes regeneration of adult CNS neurons via Jak2/Stat3 and PI3K/ AKT pathway activation. Mol Cell Neurosci 2005;29:569–79. 20. Nagai A, Nakagawa E, Choi HB, Hatori K, Kobayashi S, Kim SU. Erythropoietin and erythropoietin receptors in human CNS neurons, astrocytes, microglia, and oligodendrocytes grown in culture. J Neuropathol Exp Neurol 2001;60:386–92. 21. Beleslin-Cokic BB, Cokic VP, Yu X, Weksler BB, Schechter AN, Noguchi CT. Erythropoietin and hypoxia stimulate erythropoietin receptor and nitric oxide production by endothelial cells. Blood 2004;104:2073–80. 22. Uckert S, Hedlund P, Andersson KE, Truss MC, Jonas U, Stief CG. Update on phosphodiesterase (PDE) isoenzymes as pharmacologic targets in urology: present and future. Eur Urol 2006;50:1194–207. 23. Sebkhi A, Strange JW, Phillips SC, Wharton J, Wilkins MR. Phosphodiesterase type 5 as a target for the treatment of hypoxia-induced pulmonary hypertension. Circulation 2003;107:3230–5. 24. Katz SD, Balidemaj K, Homma S, Wu H, Wang J, Maybaum S. Acute type 5 phosphodiesterase inhibition with sildenafil enhances flow-mediated vasodilation in patients with chronic heart failure. J Am Coll Cardiol 2000;36:845–51. 25. Gulati P, Singh N. Neuroprotective effect of tadalafil, a PDE-5 inhibitor, and its modulation by L-NAME in mouse model of ischemia-reperfusion injury. J Surg Res 2014;186:475–83. 26. Kim KT, Chung KJ, Lee HS, Ko IG, Kim CJ, Na YG, et al. Neuroprotective effects of tadalafil on gerbil dopaminergic neurons following cerebral ischemia. Neural Regen Res 2013;8:693–701. 27. Yazihan N, Uzuner K, Salman B, Vural M, Koken T, Arslantas A. Erythropoietin improves oxidative stress following spinal cord trauma in rats. Injury 2008;39:1408–13. 28. Prickaerts J, Steinbusch HW, Smits JF, de Vente J. Possible role of nitric oxide-cyclic GMP pathway in object recognition memory: effects of 7-nitroindazole and zaprinast. Eur J Pharmacol 1997;337:125–36. 29. Prickaerts J, Sik A, van Staveren WC, Koopmans G, Steinbusch HW, van der Staay FJ, et al. Phosphodiesterase type 5 inhibition improves early memory consolidation of object information. Neurochem Int 2004;45:915–28. 30. Lin CS, Lin G, Xin ZC, Lue TF. Expression, distribution and regulation of phosphodiesterase 5. Curr Pharm Des 2006;12:3439–57. 31. Giorgi M, Melchiorri G, Nuccetelli V, D’Angelo V, Martorana A, Sorge R, et al. PDE10A and PDE10A-dependent cAMP catabolism are dysregulated oppositely in striatum and nucleus accumbens after lesion of midbrain dopamine neurons in rat: a key step in parkinsonism physiopathology. Neurobiol Dis 2011;43:293–303.

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Kökoğlu et al. Therapeutic efficacy of tadalafil and eriythropoietin in experimental spinal cord injury

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Deneysel spinal kord travmasında eritropoetin ve tadalafilin terapötik etkinliği Dr. Çağrı Kökoğlu,1 Dr. Emre Delen,2 Dr. Ali Arslantaş,3 Dr. Didem Arslantaş,4 Dr. Burcu Kökoğlu,5 Dr. Zühtü Özbek,3 Dr. Sema Uslu,6 Dr. Ahmet Tolgay Akıncı7 Eskişehir Yunus Emre Devlet Hastanesi, Nöroşirürji Kliniği, Eskişehir Trakya Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Edirne 3 Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Nöroşirürji Anabilim Dalı, Eskişehir 4 Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Halk Sağlığı Anabilim Dalı, Eskişehir 5 Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Aile Hekimliği Anabilim Dalı, Eskişehir 6 Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Biyokimya Anabilim Dalı, Eskişehir 7 Tokat Devlet Hastanesi, Nöroşirürji Kliniği, Tokat 1 2

AMAÇ: Bu çalışma, spinal kord travması (SCI) oluşturulan sıçanlarda eritropoetin ve tadalafilin etkinliğini araştırmak için yapıldı. GEREÇ VE YÖNTEM: Sprague-Dawley cinsi 35 adet sıçan beş gruba ayrıldı. Spinal kord travması T10 vertebraya laminektomi işleminden sonra klip kompresyon yöntemi uygulanarak gerçekleştirildi. Birinci grupta travma yapılmadı ve normal biyokimyasal değerler için kullanıldı. İkinci grup çözücü grubu idi ve travma sonrası 1 cc serum fizyolojik verildi. Üçüncü grup travma sonrasında tek doz 2000 ü/kg intraperiteneal yol ile eritropoetin verildi. Dördüncü gruba ise travma sonrasında tek doz 2 mg/kg oragastrik yol ile tadalafil verildi. Beşinci gruba herhangi bir tedavi verici işlem yapılmadan sadece travma uygulandı ve travmadaki biyokimyasal değerlerin tespiti için kullanıldı. Tüm denekler cerrahi işlemden 48 saat sonra desakrafiliye edildi. Kan ve doku örneklerinden malondialdehid (MDA) ve toplam antioksidan kapasite (TAOK) değerleri ölçüldü. BULGULAR: Eritropoetin verilen grupta diğer tüm gruplara göre en düşük serum ve doku MDA değerlerine ulaşılmıştır. Tüm gruplara göre serum TAOK değerleri en yüksek tadalafil verilen grupta bulunmuş iken doku TAOK değerleri en yüksek eritropoetin verilen grupta tespit edilmiştir. TARTIŞMA: Tadalafil ve eritropoetinin dokudaki oksidatif stresi azaltarak spinal kord travmasında ikincil hasarlanmayı engelleyebileceği sonucuna varıldı. Anahtar sözcükler: Eritropoetin; nöroproteksiyon; spinal kord hasarı; tadalafil. Ulus Travma Acil Cerrahi Derg 2016;22(6):521–525

doi: 10.5505/tjtes.2016.37571

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EXPERIMENTAL STUDY

The acute effects of thymoquinone on acute peripheral nerve injury: an experimental study İsmail Gülşen, M.D.,1 Hakan Ak, M.D.,2 Mikail Kara, M.D.,3 Abdulsemat Gökalp, M.D.,4 Veysel Akyol, M.D.,3 Ömer Faruk Koçak, M.D.,5 Murat Çetin Rağbetli, M.D.3 1

Department of Neurosurgery, Yüzüncü Yıl University Faculty of Medicine, Van-Turkey

Department of Neurosurgery, Bozok University Faculty of Medicine, Yozgat-Turkey

Department of Histology, Yüzüncü Yıl University Faculty of Medicine, Van-Turkey

Department of Neurosurgery, Tatvan State Hospital, Bitlis-Turkey

Department of Plastic and Reconstructive Surgery, Yüzüncü Yıl University Faculty of Medicine, Van-Turkey

ABSTRACT BACKGROUND: The purpose of this study was to evaluate the acute effects of thymoquinone (TQ) on acute nerve injury. METHODS: A rat model of crush injury of the sciatic nerve was used. Animals were divided into 3 groups: control, trauma, and TQ treatment groups (n=6 per group). Seven days after injury, sciatic nerve specimens were obtained from the site of the injury and analyzed histologically and stereologically. Axon diameter, myelin thickness, and axon density were measured. RESULTS: There were no significant differences in axon diameter, myelin thickness, or axon density among groups. CONCLUSION: TQ has no acute therapeutic effect on acute nerve injury. Keywords: Axon wdensity; myelin thickness; sciatic nerve; thymoquinone.

INTRODUCTION The management of acute peripheral nerve injury is unsatisfactory, particularly in patients who are not good candidates for surgery. Levels of free oxygen radicals increase after peripheral nerve injury due to tissue destruction, which leads to further tissue damage. In order to better treat acute peripheral nerve injury, several chemical agents with antioxidant effects have been evaluated for their ability to inhibit this cascade.[1–3] Thymoquinone (TQ, C10H12O2, 2-isopropyl-5-methylbenzo-1,4-quinone) is a bioactive phytochemical compound found in the seeds of Nigella sativa.[4,5] Several studies have reAddress for correspondence: İsmail Gülşen, M.D. Yüzüncü Yıl Üniversitesi Dursun Odabaş Tıp Merkezi, Beyin ve Sinir Cerrahisi Anabilim Dalı, 65080 Van, Turkey Tel: +90 432 - 216 83 52 E-mail: dr-ismailgulsen@hotmail.com Qucik Response Code

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ported that it exhibits anticarcinogenic, antioxidant, anti-inflammatory, and antiepileptic properties.[6–9] However, studies analyzing the effects of TQ on the peripheral nervous system have focused only on models of neuropathic pain.[10,11] To the best of our knowledge, no studies have assessed therapeutic effects of TQ on peripheral nerves following an acute crush injury. The aim of the present study was to evaluate the acute effects of TQ on the sciatic nerve following an acute crush injury using histological and stereological methods.

MATERIALS AND METHODS This study was performed after receiving approval from the ethics committee on use of laboratory animals of Yüzüncü Yıl University (YÜHADYEK; date: 09/05/2014; approval number: 2014/10). Female adult Wistar albino rats (n=18) weighing 250±20 g were divided into 3 groups of 6 animals. All animals were weighed before the operation and before sacrifice. For anesthesia, 8 mg ketamine (Alfamine 10%; Alfasan International BV, Woerden, Netherlands) and 1 mg xylazine per 100 g body weight (Alfazyne 2%; Alfasan International BV, Woerden, Netherlands) were administered intraperitoneally. Surgery was performed on the left sciatic nerve of all animals. Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Gülşen et al. The acute effects of thymoquinone on acute peripheral nerve injury: an experimental study

Control group (n=6) underwent only sciatic nerve dissection. In the acute crush model group (n=6), the sciatic nerve was dissected and then clamped for 30 seconds using medium pressure aneurysm clip. TQ treatment group (n=6) underwent the same surgical procedure as the acute crush model group and were injected intraperitoneally with 5 mg/kg/day TQ for 7 days. On day 8, all animals were sacrificed, and the sciatic nerve was excised approximately 5 mm proximal and distal from the lesion at the site of injury. TQ, thiobarbituric acid, Ellman’s reagent (DTNB, 5-5′-dithiobis-[2-nitrobenzoic acid]) and bovine serum albumin were purchased from Sigma Chemical Co. (St. Louis, MO, USA).

Histology and Stereology For the stereological analysis, the left sciatic nerve of each animal was exposed, and nerve segment 4 mm in length was carefully removed. Segments were cut into blocks of equal length and then fixed using 2.5% glutaraldehyde in 0.1 M sodium cacodylate buffer (pH 7.4) for 20 hours. After fixation, tissues were rinsed twice in sodium cacodylate buffer, and then postfixed in 1% osmium tetroxide for 1½ hours. Peripheral nerves were dehydrated in an ascending alcohol series, placed in propylene oxide twice, and embedded in epoxy resin. For light microscopy, semi-thin sections of 750 nm were obtained using an Ultracut UCT ultramicrotome (Leica Microsystems GmbH, Wetzler, Germany) and then stained with modified toluidine blue solution (1% toluidine blue and 2% borate in distilled water).[12,13] Researchers blinded to the groups analyzed the peripheral nerves stereologically according to method described by Turgut et al.[12] Only 1 section was obtained from each sciatic nerve. An unbiased counting frame sized 2500 µm2 was used. Area sampling of sciatic nerve section was done with a 1/6 proportion and systematic random sampling steps. Cross-sections of all axon profiles were sampled, regardless of their shape. A light microscope (BX53F; Olympus Corp., Tokyo, Japan) with a CCD color video camera (JVC/ Victor Company of Japan, Ltd, Yokohama, Japan) was used at a magnification of 1000 (×100 oil objective; N.A.: 1.25). Total axon number in each peripheral nerve was estimated by normalizing the number of axons counted in entire area. Unbiased disector/Cavalieri combination stereological method was used, which is advantageous in that it is influenced less by technical artifacts and section thickness (Figure 1).[14] The following formula was used to assess axon numbers: a/p N = Ǭ− × ∑P × k × ——— , a (frame) N=total axon number density, Ǭ−=the mean axon number, ∑P=the total point number, k=the section sequence, a/p=the point area, and a(frame)=the frame area counted.

Figure 1. A section of the sciatic nerve (×10 magnification).

expressed as frequency and percentage, mean±standard deviation, or median and interquartile range. Statistical analyses were performed using SPSS version 15.0 (SPSS Inc., Chicago, IL, USA), and the level of statistical significance was set at p<0.05.

RESULTS Mean axon diameters were 3.60 μm (range: 3.2–3.86 μm), 4.41 μm (range: 4.0–5.15 μm), and 4.40 μm (range: 3.53–5.06 μm) in the control, trauma, and TQ groups, respectively. There was a statistically significant difference between control and trauma groups (p=0.013). A similar significant difference was observed between control and TQ groups (p=0.014). However, there was no statistically significant difference between trauma and TQ groups (p=0.99). Mean myelin thickness was 1.31 µm (range: 1.0–1.7 μm), 1.61 µm (range: 1.45–1.75 μm), and 1.87 µm (range: 1.45–2.27 Table 1. Axon diameter, myelin thickness, and axon density

Group

Mean±SD

Axon diameter

Group 1

3.60±0.24

Group 2

4.41±0.44

Group 3

4.40±0.53

Total

18 4.13±0.55

Myelin thickness

Group 1

1.31±0.22

Group 2

1.61±0.11

Group 3

1.87±0.30

Total

18 1.60±0.31

Axon density

Group 1

563±120

Group 2

801±160

Statistical Analysis

Group 3

805±140

Shapiro-Wilk test and Levene’s test were used to test normality and homogeneity of the data. One-way analysis of variance was used to compare continuous variables. Values were

Total

18 635±116

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SD: Standard deviation.

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Table 2. Results of the statistical analyses performed Axon diameter

Groups 1

p 0.013

3 0.014

0.013

3 0.999

0.014

2 0.999 Myelin thickness

0.087

3 0.002

2 1 0.087

3 0.154

3 1 0.002

2 0.154 Axon density

0.152

ferences between control and trauma groups or control and TQ groups (p=0.15 and 0.98, respectively). Similarly, there was no significant difference between trauma and TQ groups (p=0.11) (Table 1 and 2). Neuronal degeneration rates were 80%, 90%, and 90% in control, trauma, and TQ groups, respectively. There was no statistically significant difference between trauma and TQ groups (Figures 2–4).

DISCUSSION The present study demonstrated that TQ has no therapeutic effect on acute peripheral nerve injury. Previous studies reported that TQ was a promising agent because of its anticarcinogenic, antioxidant, and antiepileptic properties.[6–8] Therapeutic effects of TQ have been evaluated in a wide variety of different systems, including lipid and cholesterol metabolism, glucose metabolism (antidiabetic), and the gastrointestinal, circulatory, and peripheral nervous systems, as well as its antioxidant and anticarcinogenic effects.

3 0.981

2 1 0.152

3 0.111

3 1 0.981

2 0.111

μm) in control, trauma, and TQ groups, respectively. There was no statistically significant difference between control and trauma groups; slight increase observed in trauma group was likely due to an edematous effect (p=0.087). Although there was a statistically significant difference between control and TQ groups (p=0.002), there was no statistically significant difference between trauma and TQ groups (p=0.15). Axon density was 563 (range: 243–887), 801 (range: 497– 956), and 805 (range: 400–960) in control, trauma, and TQ groups, respectively. There were no statistically significant dif-

Figure 3. Micrographs of a cross-section of the sciatic nerve in the sham group; the myelin sheaths were intact. Toluidine blue staining is shown (magnification ×100, oil immersion).

Figure 2. Micrographs of a cross-section of the trauma-inflicted area of the sciatic nerve. Images revealed vacuolization of myelin sheath. Toluidine blue staining is shown (scale bar=10 µm).

Figure 4. Micrographs of a cross-section of the sciatic nerve in the TQ group; the myelin sheath exhibits vacuolization and degeneration (black arrow). Toluidine blue staining is shown (magnification ×100, oil immersion; scale bar=10 µm).

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Regarding lipid and cholesterol metabolism, TQ decreases levels of total cholesterol and low-density lipoprotein and increases the level of high-density lipoprotein; therefore, it reduces the risk of cardiovascular disease development.[15,16] Effects of TQ on glucose metabolism have been reported in various studies, but the data are conflicting. For example, Hawsawi et al. reported that TQ reduces blood glucose levels in normal rats,[17] and similar results were reported in normal and alloxan-induced diabetic rabbits, alloxan-induced diabetic rats, and human subjects.[18–21] However, 2 different studies reported that TQ did not change fasting blood glucose levels significantly in normal or streptozotocin-induced diabetic rats.[22,23] Although the reason for these differing effects is unclear, TQ might cause hypoglycemia in 2 ways. First, it increases glucose usage by increasing insulin secretion. Second, TQ might decrease hepatic gluconeogenesis.[24] In another study, Kanter et al. reported that TQ had protective therapeutic effects on diabetes by decreasing oxidative stress and preserving pancreatic β-cell integrity; therefore, the authors concluded that TQ might be useful clinically for protecting β-cells from oxidative stress.[25] TQ exerts gastroprotective and hepatoprotective effects on the gastrointestinal system. A previous study reported that TQ could protect gastric mucosa from acute alcohol-induced mucosal injury, and that this gastroprotective effect might be induced by its radical-scavenging activity.[26] In addition, hepatoprotective effects of TQ against several hepatotoxic agents have been reported, which were attributed to its antioxidant activity.[27–29] It was also reported that TQ could be used to treat ethanol-induced hepatotoxicity because of its antioxidant and anti-inflammatory effects.[30] Several antioxidant effects of TQ have been reported. For example, TQ is a potent scavenger of many reactive oxygen species, including superoxide radicals and hydroxyl radicals. It also inhibits the formation of free radicals by inhibiting the activity of 5-lipoxygenase and 5-hidroxyicosatetraenoic acid.[7,31] In the cardiovascular system, TQ dose-dependently decreased arterial blood pressure and heart rate in a rat model.[32] TQ has also been reported to have anticarcinogenic effects by blocking tumor cell progression via apoptosis of cells in G1 phase of the cell cycle in breast, ovary, colorectal, osteosarcoma, fibrosarcoma, lung, and prostate cancers.[33–37] Effects of TQ on the peripheral nervous system were reported in 3 studies.[10,11] The first of these was performed in an experimental streptozotocin-induced diabetic neuropathy model. The authors reported that TQ improved ultrastructural features of axons remarkably.[10] In the second study, Amin et al. used a rat model of chronic neuropathy and concluded that TQ plays an anti-nociceptive role, possibly by exerting antioxidant effects and inhibiting microglial activity. [11] However, no published studies have assessed the acute efUlus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

fects of TQ in a peripheral nerve model. Current histological and stereological results suggest that TQ has no therapeutic effect on acute nerve injury.

Conclusion TQ has no beneficial acute effects on acute nerve injury, despite its reported antioxidant and anti-inflammatory effects. However, our results should be confirmed by large-scale experimental studies.

Acknowledgements None Conflict of interest: None declared.

REFERENCES 1. Senoglu M, Nacitarhan V, Kurutas EB, Senoglu N, Altun I, Atli Y, et al. Intraperitoneal Alpha-Lipoic Acid to prevent neural damage after crush injury to the rat sciatic nerve. J Brachial Plex Peripher Nerve Inj 2009;4:22. 2. Yılmaz Z, Senoglu M, Kurutas EB, Ciralik H, Ozbağ D. Neuroprotective Effects of Mannitol and Vitamin C on crush injury of sciatic Nerve. An experimental rat study. J Neurol Sci Turk 2011;28:538–51. 3. Yalçın SS, Ak H, Aydın V, Serter M, Göçmen AY. Evaluation of the acute period effects of nicergoline in the management of acute peripheral nerve injury. J Neurol Sci Turk 2013;30:651–9. 4. Pari L, Sankaranarayanan C. Beneficial effects of thymoquinone on hepatic key enzymes in streptozotocin-nicotinamide induced diabetic rats. Life Sci 2009;85:830–4. 5. Abukhader MM. The effect of route of administration in thymoquinone toxicity in male and female rats. Indian J Pharm Sci 2012;74:195–200. 6. Gali-Muhtasib H, Roessner A, Schneider-Stock R. Thymoquinone: a promising anti-cancer drug from natural sources. Int J Biochem Cell Biol 2006;38:1249–53. 7. Badary OA, Taha RA, Gamal el-Din AM, Abdel-Wahab MH. Thymoquinone is a potent superoxide anion scavenger. Drug Chem Toxicol 2003;26:87–98. 8. Akhondian J, Kianifar H, Raoofziaee M, Moayedpour A, Toosi MB, Khajedaluee M. The effect of thymoquinone on intractable pediatric seizures (pilot study). Epilepsy Res 2011;93:39–43. 9. Alsaıf MA. Effect of thymoquinone on ethanol-induced hepatotoxicity in Wistwar rats. J of Med Sci 2007;7:1164–70. 10. Kanter M. Effects of Nigella sativa and its major constituent, thymoquinone on sciatic nerves in experimental diabetic neuropathy. Neurochem Res 2008;33:87–96. 11. Amin B, Taheri MM, Hosseinzadeh H. Effects of intraperitoneal thymoquinone on chronic neuropathic pain in rats. Planta Med 2014;80:1269– 77. 12. Turgut M, Kaplan S, Unal BZ, Bozkurt M, Yürüker S, Yenisey C, et al. Stereological analysis of sciatic nerve in chickens following neonatal pinealectomy: an experimental study. J Brachial Plex Peripher Nerve Inj 2010;5:10. 13. Woods AE, Stirling JW. Electron microscopy. In: Bancroft JD, Gamble M, editors. Theory and pratice of histological techniques. China: Churchill Livingstone Elsevier; 2008. p. 611. 14. Pakkenberg B, Gundersen HJ. Total number of neurons and glial cells in human brain nuclei estimated by the disector and the fractionator. J Microsc 1988;150:1–20. 15. Al-Naqeep G, Ismaıl M, Yazan LS. Effects of thymoquinone rich fraction

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Gülşen et al. The acute effects of thymoquinone on acute peripheral nerve injury: an experimental study and thymoquinone on plasma lipoprotein levels and hepatic low density lipoprotein receptor and 3-hydroxy-3-methylglutaryl coenzyme A reductase genes expression. Journal of Functional Foods 2009;1:298–303. 16. Nofer J. HDL and arteriosclerosis: beyond reverse cholesterol transport. Atherosclerosis 2002;161:1–16. 17. Hawsawi ZA, Ali BA, Bamosa AO. Effect of Nigella sativa (Black Seed) and thymoquinone on blood glucose in albino rats. Ann Saudi Med 2001;21:242–4. 18. Al-Hader A, Aqel M, Hassan Z. Hypoglycemic effects of the volatile oil of Nigella sativa seeds. Int J Pharmacol 1993;31:96–100. 19. Kanter M. Protective effects of thymoquinone on streptozotocin-induced diabetic nephropathy. J Mol Histol 2009;40:107–15. 20. Eskander H, Emad F, Won Jun A, Ibrahim K, Abelal WE. Hypoglycemic effect of a herbal formulation in alloxan-induced diabetic rats. Egypt J Pharm Sci 1995;36:253–70. 21. Bamosa A, Ali BA, Sowayan S. Effect of oral ingestion of Nigella sativa seeds on some blood parameters. Saudi Pharmacol J 1997;5:126–9. 22. Al-Awadi FM, Gumaa KA. Studies on the activity of individual plants of an antidiabetic plant mixture. Acta Diabetol 1987;24:7–41. 23. El-Naggar AM, El-Deib AM. A study of some biological activities of Nigella sativa (black seeds) “Habat El Baraka.” J Egypt Soc Pharmacol Exp Ther 1992;11:781–99. 24. Fararh KM, Shimizu Y, Shiina T, Nikami H, Ghanem MM, Takewaki T. Thymoquinone reduces hepatic glucose production in diabetic hamsters. Res Vet Sci 2005;79:219–23. 25. Kanter M. Protective effects of thymoquinone on β-cell damage in streptozotocin-induced diabetic rats. Tıp Araştırmaları Dergisi 2009;7:64– 70. 26. Kanter M, Demir H, Karakaya C, Ozbek H. Gastroprotective activity of Nigella sativa L oil and its constituent, thymoquinone against acute alcohol-induced gastric mucosal injury in rats. World J Gastroenterol 2005;11:6662–6. 27. Al-Gharably N, Badary O, Nagı MN, Al-Shabanah OA, Al-Sawaf HA, Al-Rıkabı AC, Al-Bekaırı AM. Protective effect of thymoquinone against

carbotetrachloride induced hepatotoxicity in mice. Res Commun Pharmacol Toxicol 1997;2:41–50. 28. Aycan IÖ, Tüfek A, Tokgöz O, Evliyaoğlu O, Fırat U, Kavak GÖ, et al. Thymoquinone treatment against acetaminophen-induced hepatotoxicity in rats. Int J Surg 2014;12:213–8. 29. Suddek GM. Protective role of thymoquinone against liver damage induced by tamoxifen in female rats. Can J Physiol Pharmacol 2014;92:640–4. 30. Alsaıf MA. Effect of thymoquinone on ethanol-induced hepatotoxicity in Wistar rats. J of Med Sci 2007;7:1164–70. 31. El-Dakhakhny M, Madi NJ, Lembert N, Ammon HP. Nigella sativa oil, nigellone and derived thymoquinone inhibit synthesis of 5-lipoxygenase products in polymorphonuclear leukocytes from rats. J Ethnopharmacol 2002;81:161–4. 32. el Tahir KE, Ashour MM, al-Harbi MM. The cardiovascular actions of the volatile oil of the black seed (Nigella sativa) in rats: elucidation of the mechanism of action. Gen Pharmacol 1993;24:1123–31. 33. Shoieb AM, Elgayyar M, Dudrick PS, Bell JL, Tithof PK. In vitro inhibition of growth and induction of apoptosis in cancer cell lines by thymoquinone. Int J Oncol 2003;22:107–13. 34. Gali-Muhtasib H, Diab-Assaf M, Boltze C, Al-Hmaira J, Hartig R, Roessner A, et al. Thymoquinone extracted from black seed triggers apoptotic cell death in human colorectal cancer cells via a p53-dependent mechanism. Int J Oncol 2004;25:857–66. 35. Roepke M, Diestel A, Bajbouj K, Walluscheck D, Schonfeld P, Roessner A, et al. Lack of p53 augments thymoquinone-induced apoptosis and caspase activation in human osteosarcoma cells. Cancer Biol Ther 2007;6:160–9. 36. Kaseb AO, Chinnakannu K, Chen D, Sivanandam A, Tejwani S, Menon M, et al. Androgen receptor and E2F-1 targeted thymoquinone therapy for hormone-refractory prostate cancer. Cancer Res 2007;67:7782–8. 37. Motaghed M, Al-Hassan FM, Hamid SS. Thymoquinone regulates gene expression levels in the estrogen metabolic and interferon pathways in MCF7 breast cancer cells. Int J Mol Med 2014;33:8–16.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Timokinonun akut periferik sinir hasarı üzerine akut etkisi: Deneysel bir çalışma Dr. İsmail Gülşen,1 Dr. Hakan Ak,2 Dr. Mikail Kara,3 Dr. Abdulsemat Gökalp,4 Dr. Veysel Akyol,3 Dr. Ömer Faruk Koçak,5 Dr. Murat Çetin Rağbetli3 Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Beyin ve Sinir Cerrahisi Anabilim Dalı, Van Bozok Üniversitesi Tıp Fakültesi, Beyin ve Sinir Cerrahisi Anabilim Dalı, Yozgat 3 Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Histoloji ve Embriyoloji Anabilim Dalı, Van 4 Bitlis Tatvan Devlet Hastanesi, Beyin ve Sinir Cerrahisi Kliniği, Bitlis 5 Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Plastik ve Rekonstruktif Cerrahi Anabilim Dalı, Van 1 2

AMAÇ: Bu çalışmanın amacı akut sinir hasarında timokinonun akut dönem etkilerini değerlendirmektir. GEREÇ VE YÖNTEM: Çalışma sıçan sinirinde siyatik sinirde ezilme modeli geliştirilerek yapıldı. Sıçanlar kontrol, travma ve timokinon tedavi grubu olmak üzere üç gruba ayrıldı (n=6). Sinir hasarından yedi gün sonra hasar yerinden siyatik sinir doku örnekleri alındı. Bu doku örneklerinde histolojik ve steryolojik çalışma yapıldı. Akson çapı, myelin kalınlığı ve akson yoğunluk ölçümleri yapıldı. BULGULAR: Gruplar arasında akson çapı, miyelin kalınlığı ve akson yoğunluğu bakımından anlamlı bir farklılık görülmedi. TARTIŞMA: Timokinon akut sinir hasarı üzerinde akut dönemde iyileştirici etkiye sahip değildir. Anahtar sözcükler: Akson; akson yoğunluğu; miyelin kalınlığı; siyatik sinir; timokinon. Ulus Travma Acil Cerrahi Derg 2016;22(6):526–530

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Endovascular treatment of peripheral and visceral arterial injuries in patients with acute trauma Aysun Erbahçeci Salık, M.D.,1 Filiz Saçan İslim, M.D.,1 Barbaros Erhan Çil, M.D.2 1 2

Department of Radiology, Bakirköy Dr. Sadi Konuk Training and Research Hospital, İstanbul-Turkey Department of Radiology, Hacettepe University School of Medicine, Ankara-Turkey

ABSTRACT BACKGROUND: The present study is an evaluation of the efficacy of endovascular treatment in emergency setting for patients with acute peripheral and visceral arterial injury secondary to penetrating or blunt trauma. METHODS: Twelve patients (11 men) aged 35.8±11.3 years (range: 18–56 years) with penetrating or blunt trauma who underwent endovascular treatment in our department between March 2010 and June 2014 for peripheral and visceral arterial injury were retrospectively reviewed. Selective coil embolization was performed on 11 patients and particle embolization of the injured vessel was performed on 1 patient. Criteria for endovascular treatment included active extravasation or pseudoaneurysm on contrast-enhanced computed tomography and decrease in hemoglobin level or temporary hemodynamic instability. RESULTS: Arterial injuries were secondary to penetrating injury due to gunshot wound in 4 patients and stab wound in 5, and blunt abdominal injury as result of traffic accident in 3 patients. Traumatic lesions were in the right hepatic artery (n=3), left hepatic (n=2), right hepatic and right renal (n=1), left inferior epigastric (n=2), left facial (n=1), anterior tibial (n=1), and deep femoral (n=1) arteries. Technical success with no procedural complications was seen in all cases. Two patients died due to coexisting injuries on 29th and 43rd days of hospitalization. Median hospitalization period was 6.0 days (range: 1–43 days) and mean intensive care unit hospitalization was 7.7 days (range: 0–43 days). CONCLUSION: In our experience, endovascular treatment was a safe and effective option for acute traumatic peripheral and visceral arterial lesions. Keywords: Arterial injury; embolization; endovascular treatment.

INTRODUCTION Interventional radiologists play an increasingly important role in the initial stabilization and management of acutely injured trauma patients.[1] Successful use of embolization has been described in all areas of the body following vascular injury. [2,3] Percutaneous transcatheter embolization (TCE) of injured arteries has become a valuable treatment option in management of trauma patients.[4] Selective arterial embolization can stop arterial hemorrhage, often avoiding the need for surgery, or it can establish hemodynamic stability in the presence of other injuries requiring open operation.[2] Address for correspondence: Aysun Erbahçeci Salık, M.D. Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, Zuhuratbaba, Bakırköy, İstanbul, Turkey Tel: +90 212 - 414 74 85 E-mail: aysunerbahceci@yahoo.com Qucik Response Code

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Over the last 2 decades, there has been a paradigm shift in management of solid visceral organ injuries toward non-operative management, and transarterial embolization now has a recognized role in the non-operative management of these injuries.[5] Mortality rate in surgery for blunt hepatic trauma has been reported to be 33% or greater.[5,6] Effectiveness of TCE for vascular liver injury has been well established, with success rates ranging from 85% to 100%.[6–10] The present study is an evaluation of the efficacy of endovascular treatment in emergency setting for patients with acute peripheral and visceral arterial injury secondary to penetrating or blunt trauma.

MATERIALS AND METHODS Patient Population This is a retrospective analysis of patients with peripheral and visceral arterial injury due to penetrating or blunt trauma who underwent endovascular treatment at our department between March 2010 and June 2014. During this period, 12 531

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patients (11 men) with mean age of 35.8±11.3 years (range: 18–56 years) were treated. All patients had documented clinical signs of hemorrhage except 1 patient who was victim of knife assault and was treated for facial artery pseudoaneurysm (Fig. 1). Patients were defined as hemodynamically stable if they were euvolemic with normal clinical and laboratory parameters, and hemodynamically unstable if they were hypovolemic (systolic blood pressure <80 mmHg with tachycardia) with worsening clinical and laboratory parameters. Patients who were hemodynamically unstable after initial resuscitation were transported directly to operating room for exploration. Hemodynamically stable patients were treated with TCE. Blood transfusions were required for all patients except the patient with fascial artery pseudoaneurysm.

sheath was placed in the femoral artery, and 4-5 F diagnostic catheters (Cordis Corp., Zug, Switzerland) were placed in the aorta to obtain non-selective diagnostic arteriogram. Diagnostic catheter maneuvers were performed with 0.035inch guidewire. For extremity lesions, contralateral femoral artery approach was used, and 6 F Destination long introducer sheaths (Terumo Medical Corp., Somerset, NJ, USA) were positioned. When needed, microcatheters (Rebar-18; Micro Therapeutics, Inc., Irvine, CA, USA and Progreat 2.7 F; Terumo Medical Corp., Somerset, NJ, USA) were used for superselective catheterization. Injured vessels were embolized as distally as possible and pseudoaneurysms were embolized proximally as well as distally, the so-called “closing the front and back door” technique. All lesions were embolized with metallic coils with exception of 1 patient with liver injury for whom microspheres were used for particle embolization.

Diagnosis was established for all patients with contrastenhanced computed tomography (CT) or CT angiography (CTA). Presence of active arterial extravasation and pseudoaneurysm formation on CT were accepted as indication for digital subtraction angiography (DSA). Arterial extravasation is identified by focus or area of high attenuation that does not conform to normal vascular structure and is isodense to arterial contrast on arterial phase CT image, which may be contained, as in the case of pseudoaneurysm, or uncontained with free spill.

RESULTS

Endovascular Procedures

Arterial injuries were confirmed by CT scan in all cases. CT scan demonstrated pseudoaneurysms in 4 patients at anterior tibial, deep femoral (Fig. 2), left hepatic, or facial arteries. In the remaining 8 patients, active extravasation was detected on CT examination.

All procedures were carried out in fully equipped angio suite with the patient under general anesthesia or deep sedation. Procedures were performed with fluoroscopic control (Allura Xper FD 20/20, Koninklijke Philips N.V., Amsterdam, Netherlands). Arterial access was obtained via right or left common femoral artery using standard Seldinger technique. A 4-6 F introducer

(a)

(b)

Traumatic lesions were located in the right hepatic (n=3), left hepatic (n=2), right hepatic and right renal (n=1), left inferior epigastric (n=2), left facial (n=1), anterior tibial (n=1), and deep femoral (n=1) arteries. Mechanisms of arterial injuries were secondary to penetrating injury due to gunshot wound in 4 (33.3%) patients and stab wound in 5 (41.7%) patients, and blunt abdominal injury due to traffic accident in 3 (25%) patients.

Six patients presented with hemodynamic instability, and 3 patients responded to initial resuscitation. Three patients did not respond to initial resuscitation in the emergency department

(c)

(d)

Figure 1. A 33-year-old male with a stab wound to the neck. (a) CT scan revealed a pseudoaneurysm at fascial artery; (b) Pseudoaneurysm was seen on angiography and (c) the injured branch was superselectively catheterized; (d) Pseudoaneurysm was embolized proximally and distally (arrows) with detachable coils and the pseudoaneurysm was no longer filling.

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and were transported to operating room for exploration and compression. After operative packing of liver in 2 patients, and surgical exploration and compression of pelvis in 1 patient,

(a)

(b)

hemodynamic status of patients were stabilized; however, hemoglobin levels continued to decrease. CTA was performed on these patients and vascular injuries were localized.

(c)

(d)

(e)

Figure 2. A 33-year-old male presented with a pulsatile mass in the right thigh due to a stab wound. (a) Computed tomography angiography image revealed a pseudoaneurysm and arteriovenous fistula at right deep femoral artery; (b, c) Arteriography confirmed the diagnosis and (d) completion angiography after treatment with pushable coils showed full embolization of the pseudoaneurysm; (e) Computed tomography angiography image after embolization confirmed complete embolization of the pseudoaneurysm.

(a)

(b)

(c)

(d)

Figure 3. A 23-year-old male with grade IV liver injury due to a gunshot wound. (a) Contrast-enhanced computed tomography in the arterial phase revealed active arterial bleeding with contrast extravasation; (b) Superselective angiography confirmed active arterial extravasation; (c) Completion angiography after embolization with detachable coils showed successful control of the hemorrhage; (d) Successful control of the extravasation was seen on computed tomography angiography image 7 days after the embolization procedure.

(a)

(b)

(c)

Figure 4. A 42-year-old male with a stab wound. (a) Contrast-enhanced computed tomography in the arterial phase revealed contrast extravasation in the left inferior epigastric artery; (b) Selective angiography confirmed active arterial bleeding; (c) Completion angiography after embolization with detachable coils revealed complete embolization.

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Six hemodynamically stable patients underwent TCE following CT examination and technical success rate was 100% (Figs. 3, 4). Pushable (n=5) and detachable (n=6) coils were used in 11 cases, and spherical particles were used as embolic agent in procedure for patient with high-grade liver injury. Particles were preferred due to presence of widespread multiple arterial injuries in lacerated liver parenchyma. There was no procedure-related mortality, or complications. Two patients died due to coexisting injuries on 29th and 43rd days of hospitalization. Outcomes were assessed by clinical examination, CT, and Doppler ultrasonography. Median hospitalization period was 6.0 days (range: 1–43 days) and mean intensive care unit hospitalization was 7.7 days (range: 0–43).

DISCUSSION In this series, arterial hemorrhage of 12 patients with peripheral and visceral arterial injury due to trauma was treated successfully with TCE. TCE was performed on patients who were hemodynamically stable, or whose hemodynamic status was stabilized with initial resuscitation. Patients who were hemodynamically unstable despite initial resuscitation were directly transported to operating room for exploration. Traditionally, hemodynamically unstable patients have been taken straight to surgery rather than undergo CT or angiography.[2,11] For hemodynamically stable patients, advances in vascular interventional radiology now offer alternative minimally invasive treatment.[11] There is consensus on operative exploration for hemodynamically unstable patients with suspected high-grade liver injury.[12] However, endovascular treatment option is increasingly selected for some unstable patients. Trellopoulos et al. reported 100% technical success rate with no procedural complications in endovascular management of peripheral arterial trauma in patients presenting in hemorrhagic shock.[13] Mohan et al. also reported successful results of prompt endovascular treatment in both pediatric and adult patients with hemodynamically compromised hepatic vascular trauma.[7] While surgical exploration has the advantage of directly visualizing an injured blood vessel, it is associated with blood loss and infection. It is also important to remember that a surgeon can only see the outside of a blood vessel and may miss significant damage to arterial intima. In addition, direct exploration risks disturbing a hematoma, which may bleed substantially and might have been self-limiting if left undisturbed.[2] Hepatic arterial hemorrhage in deep liver parenchyma is difficult to control, even with operative packing. Furthermore, surgical exploration to localize exact bleeding point may sometimes be troublesome. Postoperative CT examination and TCE may be useful for patients with persistent hemoglobin level decrease. All of our patients were treated with TCE as result of indications confirmed by CT. Multislice CT is the best imaging study for evaluation of stable trauma patients.[5] Primary screening of hemorrhagic trauma patients with rapid early-phase CT 534

has been shown to be useful to determine subsequent angiographic intervention.[13] A prospective multicenter trial using contrast-enhanced helical CT to evaluate stable patients found that 18.4% of patients with visceral injuries had arterial extravasation, and patients with arterial extravasation were significantly more likely to undergo TCE or surgery.[14] We preferred to use coils as embolic agent for the procedures in this study. The choice of embolic agent will vary based on the site and nature of the injury, the desire to preserve collateral flow, and operator experience. Gelfoam (Pfizer, Inc., NY, NY, USA), particles, glue, and coils are the most commonly selected embolic agents in trauma.[2,5] In emergency situation, coils are often the fastest agent to deploy and can be delivered with considerable accuracy.[5] Quick diagnosis and prompt TCE can be life-saving for patients with hemorrhagic trauma. Furthermore, endovascular treatment options may avoid need for surgery, which has high mortality and morbidity rates in emergency setting. With technological improvements in the last decades, minimally invasive techniques have become alternative treatment option for acutely injured patients. In conclusion, TCE is technically feasible and effective for trauma patients with acute arterial hemorrhage. Conflict of interest: None declared.

REFERENCES 1. Glorsky SL, Wonderlich DA, Goei AD. Evaluation and management of the trauma patient for the interventional radiologist. Semin Intervent Radiol 2010;27:29–37. 2. Nicholson AA. Vascular radiology in trauma. Cardiovasc Intervent Radiol 2004;27:105–20. 3. Rich NM, Rhee P. An historical tour of vascular injury management: from its inception to the new millennium. Surg Clin North Am 2001;81:1199–215. 4. Müller-Wille R, Heiss P, Herold T, Jung EM, Schreyer AG, Hamer OW, et al. Endovascular treatment of acute arterial hemorrhage in trauma patients using ethylene vinyl alcohol copolymer (Onyx). Cardiovasc Intervent Radiol 2012;35:65–75. 5. Gould JE, Vedantham S. The role of interventional radiology in trauma. Semin Intervent Radiol 2006;23:270–8. 6. Schwartz RA, Teitelbaum GP, Katz MD, Pentecost MJ. Effectiveness of transcatheter embolization in the control of hepatic vascular injuries. J Vasc Interv Radiol 1993;4:359–65. 7. Mohan B, Bhoday HS, Aslam N, Kaur H, Chhabra S, Sood N, et al. Hepatic vascular injury: clinical profile, endovascular management and outcomes. Indian Heart J 2013;65:59–65. 8. Ciraulo DL, Luk S, Palter M, Cowell V, Welch J, Cortes V, et al. Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries. J Trauma 1998;45:353–9. 9. Hagiwara A, Yukioka T, Ohta S, Tokunaga T, Ohta S, Matsuda H, et al. Nonsurgical management of patients with blunt hepatic injury: efficacy of transcatheter arterial embolization. AJR Am J Roentgenol

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Erbahçeci Salık et al. Endovascular treatment of peripheral and visceral arterial injuries in patients with acute trauma 1997;169:1151–6. 10. Mohr AM, Lavery RF, Barone A, Bahramipour P, Magnotti LJ, Osband AJ, et al. Angiographic embolization for liver injuries: low mortality, high morbidity. J Trauma 2003;55:1077–82. 11. Naidoo NM, Corr PD, Robbs JV, Maharaj J, Nair R. Angiographic embolisation in arterial trauma. Eur J Vasc Endovasc Surg 2000;19:77–81. 12. Kong YL, Zhang HY, He XJ, Zhao G, Liu CL, Xiao M, et al. Angiographic embolization in the treatment of intrahepatic arterial bleeding in patients with blunt abdominal trauma. Hepatobiliary Pancreat Dis Int

2014;13:173–8. 13. Okamoto K, Norio H, Kaneko N, Sakamoto T, Kaji T, Okada Y. Use of early-phase dynamic spiral computed tomography for the primary screening of multiple trauma. Am J Emerg Med 2002;20:528–34. 14. Yao DC, Jeffrey RB Jr, Mirvis SE, Weekes A, Federle MP, Kim C, et al. Using contrast-enhanced helical CT to visualize arterial extravasation after blunt abdominal trauma: incidence and organ distribution. AJR Am J Roentgenol 2002;178:17–20.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut travma hastalarında periferik ve viseral arteriyel yaralanmaların endovasküler tedavisi Dr. Aysun Erbahçeci Salık,1 Dr. Filiz Saçan İslim,1 Dr. Barbaros Erhan Çil2 1 2

Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, İstanbul Hacettepe Üniversitesi, Tıp Fakültesi, Radyoloji Kliniği, Ankara

AMAÇ: Bu çalışma, penetran ve künt travmaya bağlı akut periferik ve viseral arteriyel yaralanması olan hastalarda endovasküler tedavinin etkinliğini araştırmayı amaçlamaktadır. GEREÇ VE YÖNTEM: Mart 2010 ve Haziran 2014 tarihleri arasında, penetran ve künt travmaya bağlı periferik ve viseral arteriyel yaralanma nedeniyle bölümümüzde endovasküler yolla tedavi edilen yaşları 35.8±11.3 yıl (dağılım: 18–56 yıl) olan 12 hasta (11 erkek) geriye dönük olarak incelendi. Hastaların 11’inde selektif koil embolizasyonu, birinde partikül embolizasyonu ile yaralanan arterler embolize edildi. Endovasküler tedavi kriterleri; kontrastlı bilgisayarlı tomografide aktif arteriyel ekstravazasyon veya psödoanevrizma ve hemoglobin seviyelerinde düşüş veya geçici hemodinamik instabilite idi. BULGULAR: Arteriyel yaralanma mekanizmaları dört hastada ateşli silah yaralanması, beş hastada delici kesici alet yaralanmasına bağlı penetran travma ve üç hastada trafik kazasına bağlı künt travma idi. Travmatik lezyonlar sağ hepatik arterde (n=3), sol hepatik (n=2), sağ hepatik ve sağ renal (n=1), sol inferior epigastrik (n=2), sol fasiyal (n=1), anteriyor tibial (n=1) ve derin femoral (n=1) arterlerde yer almaktaydı. Tüm olgular işleme bağlı komplikasyon olmaksızın teknik başarı ile tedavi edildi. İki hasta hastane yatışlarının 29. ve 43. günlerinde eşlik eden yaralanmaları nedeniyle kaybedildi. Ortanca hastane yatış süresi altı gün (1–43 gün) ve ortalama yoğun bakım yatış süresi ise 7.7 (0–43 gün) gündü. TARTIŞMA: Bizim deneyimlerimize göre endovasküler tedavi akut periferik ve viseral arteriyel yaralanmaların tedavisinde etkili ve güvenli bir seçenektir. Anahtar sözcükler: Arteriyel yaralanma, embolizasyon; endovasküler tedavi. Ulus Travma Acil Cerrahi Derg 2016;22(6):531–535

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Comparison of Revised Trauma Score, Injury Severity Score and Trauma and Injury Severity Score for mortality prediction in elderly trauma patients Shahrokh Yousefzadeh-Chabok, M.D.,1,2 Marieh Hosseinpour, M.D.,1 Leila Kouchakinejad-Eramsadati, M.D.,1 Fatemeh Ranjbar, M.D.,2 Reza Malekpouri, M.D.,1 Alireza Razzaghi, M.D.,1 Zahra Mohtasham-Amiri, M.D.1,3 1

Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht-Iran

Department of Neurosurgery, Guilan University of Medical Sciences, Rasht-Iran

Department of Social and Preventive Medicine, Guilan University of Medical Sciences, Rasht-Iran

ABSTRACT BACKGROUND: Trauma is the fifth leading cause of death in patients 65 years and older. This study is a comparison of results of Revised Trauma Score (RTS), Injury Severity Score (ISS), and Trauma and Injury Severity Score (TRISS) in prediction of mortality in cases of geriatric trauma. METHODS: This is a cross-sectional study of records of 352 elderly trauma patients who were admitted to Pour-Sina Hospital in Rasht between 2010 and 2011. Injury scoring systems were compared in terms of specificity, sensitivity, and cut-off points using receiver operating characteristic curve of patient prognosis. RESULTS: Mean age of patients was 71.5 years. Most common mechanism of injury was traffic accident (53.7%). Of the total, 13.9% of patients died. Mean ISS was higher for patients who did not survive. Mean of TRISS and RTS scores in elderly survivors was higher than non-survivors and difference in all 3 scores was statistically significant (p<0.001). Best cut-off points for predicting mortality in elderly trauma patients in RTS, ISS, and TRISS systems were ≤6, ≥13.5, and ≤2, with sensitivity of 99%, 84%, and 95% and specificity of 62%, 62%, and 72%, respectively. CONCLUSION: TRISS was the strongest predictor of mortality in elderly trauma patients as result of combination of both anatomical and physiological parameters. Keywords: Geriatric, ROC curve; scoring; trauma.

INTRODUCTION The world population is aging.[1] It is expected that the elderly population will double and triple in developed and developing countries by 2050, respectively.[2] Geriatric trauma is a significant issue for healthcare systems, as the size of elderly population is already growing.[3–5] Secondly, greater activity and mobility in their lifestyle puts them at serious risk,[3,6] Address for correspondence: Zahra Mohtasham-amiri, M.D. Guilan Road Trauma Research Center, Poursina Hospital, Namjoo Street Rasht, Iran Tel: +00981333338373 E-mail: mohtashamaz@yahoo.com Qucik Response Code

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and thirdly, post-trauma outcomes have shown that results of injury are substantially worse for the elderly than for younger patients.[3,7,8] According to previous studies, trauma accounts for about 28% of mortality in geriatric patients, while mortality rate has been estimated at 12% of total trauma population.[9] The phenomenon of population aging has started in Iran, too. Although the population is still relatively young, it is predicted that the elderly population will double in less than 20 years.[10] Trauma is the fifth leading cause of death in people 65 years and older.[7,9,11] Elderly trauma patients are hospitalized for a longer period, pay higher hospital costs, and often require an extended period of rehabilitation. These patients also have higher rates of post-trauma complications that contribute to worse outcomes.[9] However, outcomes of major trauma can be minimized through pre-hospital admission measures.[12,13] To study the outcomes of trauma, accurate and reliable methodological tools are required for appropriate scoring of severity and outcome prediction.[14–18] Statistical scores for predicting outcomes can be divided into Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Yousefzadeh-Chabok et al. Comparison of RTS, ISS and TRISS for mortality prediction in elderly trauma patients

3 categories: anatomical scores, physiological scores, or a combination of the 2.[18] Trauma and Injury Severity Score (TRISS), Revised Trauma Score (RTS), and Injury Severity Score (ISS) are scoring systems used to assist in clinical decision-making and to aid physicians in initial evaluation of trauma. ISS is an anatomical score and independent predictor of death that is mostly used for patients with multiple injuries.[19] RTS is a physiological score for predicting in-hospital mortality and outcome of traumatic patients.[20] TRISS uses a combination of both physiological and anatomical injury severity scores (ISS and RTS) as well as patient age to predict post-trauma survival.[16] Trauma scoring systems are key indicators used to identify adverse outcomes within first hours of admission and predict outcomes of elderly patients.

patients was 72.7 years (±8.24 years) and 70.55 years (±7.79 years), respectively. Most common mechanism of trauma was road traffic accident (53.7%), followed by fall (41.5%). Overall, 96.6% (n=340) and 3.4% (n=12) of total trauma cases were blunt and penetrating, respectively. Most common injured organs were upper and lower extremities (93.5%; n=329), followed by head and neck (37.8%; n=133) (Figure 1).

This study examined outcomes of trauma and relationship to ISS, RTS, and TRISS scores with underlying variables such as morbidity and mortality rates. This study was an effort to identify the best scoring system to apply for prompt and appropriate therapeutic approach with geriatric patients.

Numerical values were used to calculate mean and comparison between survivors and non-survivors. Mean ISS, RTS, and TRISS

Results indicated that all 3 indices followed a normal distribution (p>0.05) in non-survivor group, while distribution of survivors was not normal (p<0.001).

350

329

300 250

MATERIALS AND METHODS

200

. To compare

ISS, RTS, and TRISS in terms of mortality prediction accuracy, Kolmogorov-Smirnov test was used to examine normality distribution. Mann-Whitney test was employed to compare distribution of values for ISS, RTS, and TRISS in survivors and nonsurvivors. Finally, they were compared in terms of specificity, sensitivity, and cut-off points based on receiver operating characteristic curve (ROC) associated with prognosis of patients using SPSS software (version 18; SPSS Inc., Chicago, IL, USA).

RESULTS This study was conducted using records of 352 elderly trauma patients. Of the total, 46.6% were women (n=164) and 53.4% were men (n=188). Mean age of patients was 71.55±8.07 years (range: 60–100 years). Mean age of female and male Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

150

133

100 50 0

87 9 Spinal cord

Abdomen and pelvic

Chest

Face

Head and Extremity neck

Figure 1. Frequency of injuries in different organs of trauma patients ROC Curve

1.0

0.8

Sensitivity

This is a cross-sectional study conducted on 352 elderly trauma patients who were admitted to emergency ward of Pour-Sina Hospital of Rasht (Guilan Province, Iran) between 2010 and 2011. Data collection tool was a checklist, which included demographic information, site, and type of injury, initial assessment of patient (vital signs), and scoring tables for calculation of ISS, RTS, and TRISS. To calculate ISS, 3 most injured organs were evaluated. Square values of 3 highest Abbreviated Injury Scale scores in different areas of body were used. RTS is calculated based on Glasgow Coma Scale, systolic blood pressure, and respiratory rate, according to effect coefficient determined by logistic regression model. TRISS is obtained based on physiological and anatomical status of patient on admission and patient age according to the following formula: βi=β1+β2(RTS)+β3(ISS)+β4(AGE), where βi is regression coefficient. In this score, probability of patient survival (Ps) is calculated using logistic function

Of total 352 patients, 303 patients (86.1%) recovered after treatment in hospital and 49 patients (13.9%) died.

0.6

0.4 Source of the Curve RTS TRISS ISS Reference Line

0.2

0.0

0.2

0.4 0.6 0.8 1-Specificity Diagonal segments are produced by ties

1.0

Figure 2. ROC curve of ISS, RTS, and TRISS in mortality prediction of elderly trauma patients. ISS: Injury Severity Score; ROC: Receiver operating characteristic RTS: Revised Trauma Score; TRISS: Trauma and Injury Severity Score.

537

Yousefzadeh-Chabok et al. Comparison of RTS, ISS and TRISS for mortality prediction in elderly trauma patients

Table 1. Mean ISS, RTS, and TRISS of elderly survivors and non-survivors Index

Survivors Non-survivors (n=49) (n=303)

Mean±SD Mean±SD

Injury Severity Score

15.95±10.46

7.31±6.22

0.000

Revised Trauma Score

5.65±1.82

7.79±0.27

0.000

Trauma and Injury Severity Score

1.04±1.49

3.49±0.60

0.000

SD: Standard deviation.

Table 2. Comparison of area under ROC curve for trauma scoring systems Index

Area under the Curve*

CI: 95%

Injury Severity Score

0.76

0.68–0.85

0.000

Revised Trauma Score

0.87

0.79–0.94

0.000

Trauma and Injury Severity Score

0.94

0.90–0.98

0.000

*: Statistically significant for all three scores.

Table 3. Comparison of sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of optimum cut-off points based on ROC in ISS, RTS and TRISS -LR** +LR*

Specificity (%)

Sensitivity (%)

Cut-off

ISS

0.24

2.04

≤12.5

RTS

0.02

2.60

≥6

TRISS

0.07

3.39

≥2

* +LR: Positive likelihood ratio= sensitivity/1-specificity; **-LR: Negative likelihood ratio= 1-sensitivity/specificity. ISS: Injury Severity Score; ROC: Receiver operating characteristic RTS: Revised Trauma Score; TRISS: Trauma and Injury Severity Score.

of both survivors and non-survivors are presented in Table 1. As can be seen in Table 1, mean ISS was higher for non-surviving elderly patients than survivors. It was determined that means of TRISS and RTS were higher for survivors than nonsurviving patients. Difference in mean was statistically significant in all 3 scores (p<0.001). TRISS (94%) and ISS (76%) had the highest and lowest area under ROC for prediction of mortality. Area under ROC curve for all 3 scores was statistically significant (Table 2 and Figure 2). The best cut-off point for predicting mortality in elderly patients was ≤6 for RTS with sensitivity of 99% and specificity of 62%, while for ISS it was determined to be ≥13.5 with 84% sensitivity and 62% specificity, and for TRISS it was ≤2 with 95% sensitivity and 72% specificity (Table 3).

DISCUSSION Most of 352 elderly trauma patients in the present study were men. Some studies have had similar results,[21–23] while 538

other studies reported that more geriatric trauma patients were women.[24,25] Mean age of our patients was 71.5 years with age range of 60 to 100 years. This is consistent with other studies.[4,26,27] The present study indicated that the most common mechanisms leading to trauma in the elderly were motor vehicle accidents, followed by falls. A study by Akköse Aydin et al. also revealed that most common mechanism leading to trauma was motor vehicle accident,[22] while in a study conducted by Richmond et al. it was found that 61.7% of injuries in the elderly occurred due to fall.[26] Moreover, study by Bradburn et al. indicated that the most frequent mechanism was fall followed by road traffic accidents. [24] Present study was conducted at Pour-Sina Hospital, in northern Iran, which has the highest accident referral rate in this region of country and this may have influenced finding about incidence of accidents. Most frequently injured organ was extremity, followed by head and neck. In their research, Akköse Aydin et al. reported that the most common injury sites were head and extremities.[22] In this study, 13.9% of Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Yousefzadeh-Chabok et al. Comparison of RTS, ISS and TRISS for mortality prediction in elderly trauma patients

elderly trauma patients died. Parreira et al. found that 5% of the patients in 70–79 age group and 5.3% of patients aged over 80 years died.[4] Kim’s study reported mortality rate of 18.1%.[27] In the present study, mean plus standard deviation of ISS for non-survivors was 15.95±10.46 and 7.31±6.22 for survivors; mean plus standard deviation of RTS for former was 5.65±1.82, and 7.79±0.27 for latter group. Mean plus standard deviation of TRISS for non-survivors was 1.04±1.49 and was 3.49±0.6 for survivors. In research conducted by Akköse Aydin et al., mean of RTS was 11.6 and 8.3 in survivors and non-survivors, while mean of ISS was 8 in survivors and 20 in non-survivors.[22] Cevik et al. study that involved 395 elderly trauma patients who were injured in motor vehicle accidents found that median of ISS was 30.5 (range: 17–41) and 3 (range: 1–9) in non-survivors and survivors, respectively. Mean of RTS was 6.9 (range: 3.98–7.84) and 7.84 (range: 7.84–7.84) in former and latter, respectively. [21] Results indicated that ISS value for survivors is significantly lower than for non-survivors (p<0.0001). Also, RTS (p<0.0001) and TRISS (p<0.0001) for survivors were higher than non-survivors. This difference was statistically significant. Akkose’s study revealed significant difference between RTS and ISS in both groups. According to their results, mean ISS was lower for survivors, while mean RTS of survivors was higher than that of non-survivors.[22] Area under ROC curve using ISS, RTS, and TRISS for predicting death was 0.76, 0.87, and 0.94, respectively; all of these scores were statistically significant in terms of mortality prediction. Murlidhar et al. reported that patient mortality rate predicted using TRISS was 10.89%, while rates for RTS and ISS were 61.6% and 16.6%, respectively, but actual mortality rate was 21.26%. Greater age of patients compared with other studies accounted for this remarkable difference.[28] According to logistic regression model used in our study, TRISS was the strongest predictor of mortality in elderly trauma patients. In a study conducted by Mitchell et al. in Canada published in 2007, it was reported that scoring systems including TRISS had a good ability to predict the prognosis of patients with trauma.[29] In a study conducted in India, Hariharan et al. concluded that using TRISS system to predict morbidity and mortality after fall in the elderly can play an important role in treatment planning. Another study found that TRISS was not very accurate in predicting the prognosis of trauma patients in developing country setting; however, they maintained that TRISS was the most reliable scoring method.[30]

Conclusion Mortality rate due to trauma in elderly patients is high, and based on our results, TRISS is the most powerful predictor of mortality in these patients, which may be due to consideration of physiological and anatomical parameters. Thus, using TRISS is recommended for proper scoring of trauma severity and predicting mortality in order to implement timely preventive measures and treatments as well as appropriate management of trauma in this age group. Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Acknowledgements We thank the Clinical Research Development Unit staff of Pour-Sina Hospital and Guilan University of Medical Sciences for their cooperation, and Ms. Fatemeh Javadi for translating the manuscript.

Funding/Support None. Conflict of interest: None declared.

REFERENCES 1. Adib-Hajbaghery M, Aghahoseini S. The evaluation of disability and its related factors among the elderly population in Kashan, Iran. BMC Public Health 2007;7:261. 2. Tavakoli H, Ahmadi-Amoli H, Yaghoobi Notash A, Adelyazdankhah Konari A, Gholkhani F, Khashayar P. Trauma-related Mortality and Morbidity due to Trauma in the Elderly. Iranian Journal of Aging 2009;4:30–6. 3. Jacobs DG. Special considerations in geriatric injury. Curr Opin Crit Care 2003;9:535–9. 4. Parreira JG, Farrath S, Soldá SC, Perlingeiro JA, Assef JC. Comparative analysis of trauma characteristics between elderly and superelderly. Rev Col Bras Cir 2013;40:269–74. 5. Chu I, Vaca F, Stratton S, Chakravarthy B, Hoonpongsimanont W, Lotfipour S. Geriatric trauma care: challenges facing emergency medical services. Cal J Emerg Med 2007;8:51–5. 6. Callaway DW, Wolfe R. Geriatric trauma. Emerg Med Clin North Am 2007;25:837–60. 7. Heffernan DS, Thakkar RK, Monaghan SF, Ravindran R, Adams CA Jr, Kozloff MS, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma 2010;69:813–20. 8. Victorino GP, Chong TJ, Pal JD. Trauma in the elderly patient. Arch Surg 2003;138:1093–8. 9. Aschkenasy MT, Rothenhaus TC. Trauma and falls in the elderly. Emerg Med Clin North Am 2006;24:413–32. 10. Tajvar M, Arab M, Montazeri A. Determinants of health-related quality of life in elderly in Tehran, Iran. BMC Public Health 2008;8:323:1–8. 11. Mangram AJ, Mitchell CD, Shifflette VK, Lorenzo M, Truitt MS, Goel A, et al. Geriatric trauma service: a one-year experience. J Trauma Acute Care Surg 2012;72:119–22. 12. Sasser S, Varghese M, Kellermann A, Lormand JD. Prehospital trauma care system. World Health OrganizationGeneva.2005.on May 2015, In: http://www.who.int/violence_injury_prevention/media/ news/04_07_2005/en/, Access on 2015.05.01. 13. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366–78. 14. Sharma BR. Triage in trauma-care system: a forensic view. J Clin Forensic Med 2005;12:64–73. 15. Moradi Lakeh M, Tehrani-Banihashemi S.A., Varasteh-Kia G.R, Roohipour M.R. Comparison of Trauma Scoring Systems for Prediction of Patients’ Prognosis. RJMS 2002;9:128–9. 16. Chawda MN, Hildebrand F, Pape HC, Giannoudis PV. Predicting outcome after multiple trauma: which scoring system? Injury 2004;35:347– 58. 17. Champion HR. Trauma scoring. Scand J Surg 2002;91:12–22. 18. Guzzo JL, Bochicchio GV, Napolitano LM, Malone DL, Meyer W, Scalea TM. Prediction of outcomes in trauma: anatomic or physiologic pa-

539

Yousefzadeh-Chabok et al. Comparison of RTS, ISS and TRISS for mortality prediction in elderly trauma patients rameters? J Am Coll Surg 2005;201:891–7. 19. Grinkeviciūte DE, Kevalas R, Saferis V, Matukevicius A, Ragaisis V, Tamasauskas A. Predictive value of scoring system in severe pediatric head injury. Medicina (Kaunas) 2007;43:861–9. 20. Norouzi V, Feizi I, Vatankhah S, Pourshaikhian M. Calculation of the probability of survival for trauma patients based on trauma score and the injury severity score model in fatemi hospital in ardabil. Arch Trauma Res 2013;2:30–5. 21. Cevik Y, Doğan NÖ, Daş M, Karakayali O, Delice O, Kavalci C. Evaluation of geriatric patients with trauma scores after motor vehicle trauma. Am J Emerg Med 2013;31:1453–6. 22. Akköse Aydin S, Bulut M, Fedakar R, Ozgürer A, Ozdemir F. Trauma in the elderly patients in Bursa. Ulus Travma Acil Cerrahi Derg 2006;12:230–4. 23. Joseph B, Pandit V, Rhee P, Aziz H, Sadoun M, Wynne J, et al. Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer? J Trauma Acute Care Surg 2014;76:196–200. 24. Bradburn E, Rogers FB, Krasne M, Rogers A, Horst MA, Beelen MJ,

25. 26.

27. 28.

29.

30.

et al. High-risk geriatric protocol: improving mortality in the elderly. J Trauma Acute Care Surg 2012;73:435–40. Ferrera PC, Bartfield JM, D’Andrea CC. Outcomes of admitted geriatric trauma victims. Am J Emerg Med 2000;18:575–80. Richmond TS, Kauder D, Strumpf N, Meredith T. Characteristics and outcomes of serious traumatic injury in older adults. J Am Geriatr Soc 2002;50:215–22. Kim JK, Choe MS, Lee JH, Park JB, Seo KS, Yun YK. Factors Influencing Mortality in Geriatric Trauma. J Korean Soc Emerg Med 1999;10:421–30. Murlidhar V, Roy N. Measuring trauma outcomes in India: an analysis based on TRISS methodology in a Mumbai university hospital. Injury 2004;35:386–90. Mitchell AD, Tallon JM, Sealy B. Air versus ground transport of major trauma patients to a tertiary trauma centre: a province-wide comparison using TRISS analysis. Can J Surg 2007;50:129–33. Hariharan S, Chen D, Parker K, Figari A, Lessey G, Absolom D, et al. Evaluation of trauma care applying TRISS methodology in a Caribbean developing country. J Emerg Med 2009;37:85–90.

ORİJİNAL ÇALIŞMA - ÖZET

Yaşlı travma hastalarında mortaliteyi öngörmeded gözden geçirilmiş Travma Skoru, Yaralanma Şiddet Skoru ve Travma ve Yaralanma Şiddet Skoru’nun karşılaştırması Dr. Shahrokh Yousefzadeh-Chabok,1,2 Dr. Marieh Hosseinpour,1 Dr. Leila Kouchakinejad-Eramsadati,1 Dr. Fatemeh Ranjbar,2 Dr. Reza Malekpouri,1 Dr. Alireza Razzaghi,1 Dr. Zahra Mohtasham-Amiri1,3 1 2 3

Guilan Road Travma Araştırma Merkezi, Guilan Tıp Bilimleri Üniversitesi, Rasht-İran Guilan Tıp Bilimleri Üniversitesi, Nöroşirürji Anabilim Dalı, Rasht-İran Sosyal ve Önleyici Tıp Bölümü, Guilan Tıp Bilimleri Üniversitesi, Rasht-İran

AMAÇ: Altmış beş yaş ve üstü kişilerde travma önde gelen beşinci ölüm nedenidir. Bu çalışma geriyatrik travma olgularında mortaliteyi öngörmede Gözden Geçirilmiş Travma Skoru (RTS), Yaralanma Şiddet Derecesi Skoru (ISS) ve Travma ve Yaralanma Şiddet Skorunu (TRISS) karşılaştırmayı amaçlamıştır. GEREÇ VE YÖNTEM: 2010 ila 2011 yılları arasında Rasht, Poursina Hastanesi’ne kabul edilmiş 352 yaşlı travma hastasının kayıtlarında yapılmış enine kesit çalışmasıdır. Hastanın prognozuna ilişkin ROC analizini kullanarak yaralanmayı skorlama sistemleri özgüllük, duyarlılık ve kesim değerleri açısından karşılaştırıldı. BULGULAR: Hastalar ortalama 71.5 yaşındaydı. En sık görülen yaralanma mekanizması trafik kazası olup hastaların %13.9’u kaybedilmişti. Sağ kalan yaşlılara göre ölenlerin ISS’si daha yüksek idi. Ölenlere göre yaşlı sağ kalanlarda TRISS ve RTS skorları daha yüksek olup farklılıklar istatistiksel açıdan anlamlı idi (p<0.001). Yaşlı travma hastalarında mortaliteyi öngörmede RTS, ISS ve TRISS skorlama sistemlerinin en iyi kesim değerleri sırasıyla ≤6, ≥13,5 ve ≤2, duyarlılıkları sırasıyla %99, 84 ve 95, özgüllükleri ise %62, 62 ve 72 idi. TARTIŞMA: Hem anatomik hem de fizyolojik parametrelerin kombinasyonu olduğu için mortalitenin en güçlü öngördürücü parametresi TRISS idi. Anahtar sözcükler: Geriyatrik, ROC eğrisi; skorlama; travma. Ulus Travma Acil Cerrahi Derg 2016;22(6):536–540

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doi: 10.5505/tjtes.2016.93288

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ORIG I N A L A R T IC L E

Gender does not affect the prognosis of Fournier’s gangrene: a case-matched study Pınar Sarkut, M.D.,1 Özgen Işık, M.D.,1 Ersin Öztürk, M.D.,1 Barış Gülcü, M.D.,1 İlker Ercan, M.D.,2 Tuncay Yılmazlar, M.D.1 1

Department of General Surgery, Uludağ University Faculty of Medicine, Bursa-Turkey

Department of Biostatistics, Uludağ University Faculty of Medicine, Bursa-Turkey

ABSTRACT BACKGROUND: Female gender is accepted as a poor prognostic factor for Fournier’s gangrene (FG). However, there is a paucity of data in the literature regarding this matter. This case-matched study was designed to investigate the impact of gender on outcomes of FG. METHODS: Study patient data were retrieved from 120-patient, prospectively maintained database. Thirty-two female patients with FG were case-matched to 32 male patients based on symptom duration (days), FG severity index score, patient age, etiology, and presence of diabetes mellitus (DM) terms. Outcomes of FG were compared between the 2 groups. RESULTS: Median age was 57 years (range: 22-80 years), and 35 (54.7%) patients had DM. Patients underwent average of 3 debridement procedures (range: 1–9 debridements), and 15 (23.4%) received diverting stoma. Overall mortality rate was 28.1% (18 of 64 patients). Female gender was associated with widespread disease (p=0.009), increased need for consecutive debridements (p=0.005), prolonged length of intensive care unit stay (p=0.035), and increased requirement for split-thickness skin graft reconstruction (p=0.040). However, mortality rates were comparable between genders (p=0.264). CONCLUSION: FG is often more extensive in females and seems to be associated with anatomical features of female pelvis. However, female gender is not a factor affecting prognosis of patients with FG. Keywords: Fournier’s gangrene; gender; mortality.

INTRODUCTION Fournier’s gangrene (FG) was first described in males. It is now known to be a potentially fatal soft tissue infection that affects males, females, and even children.[1] Although the disease is more common among males, it has been reported that mortality due to FG is higher for females.[2–4] This discrepancy may be associated with anatomical differences between genders. FG may not be common among females because the perineal region can drain easily via the vagina. This anatomical feature Address for correspondence: Ersin Öztürk, M.D. Uludağ Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Görükle, 16150 Bursa, Turkey Tel: +90 224 - 295 00 00 E-mail: drozturk@uludag.edu.tr Qucik Response Code

Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

appears to be an advantage, but there is a direct connection between the female genitalia and the intra-abdominal space through the fallopian tubes. Anatomy of the female pelvis may also lead to rapid progression of FG and is considered to be linked to fatal peritonitis, which is associated with increased mortality.[2] Previously published studies have reported that female gender is a poor prognostic factor for FG and suggested that gender does not affect prognosis.[4–7] However, there are no published data available focusing directly on impact of gender on outcomes of FG. In this study, we aimed to investigate whether female gender affects prognosis of FG by analyzing case-matched data derived from large, single-center database.

MATERIALS AND METHODS After obtaining institutional review board approval, data for this study were extracted from prospectively maintained departmental FG database of 120 patients who were treated in our department between 1996 and 2012. Female patients were matched to male counterparts based on the following 541

Sarkut et al. Impact of gender on the prognosis of Fournier’s gangrene

criteria that are well-known factors associated with outcomes of FG: symptom duration (days), FG severity index score, patient age, etiology, and presence of diabetes (DM). In total, 32 female patients matched to 32 males were included in the study. The 2 groups were compared based on grade of disease-spread, number of debridement procedures, number of stomas required, and mortality rate. All patients underwent at least 1 radical debridement of the affected devitalized tissue within 12 hours of admission. Intravenous third-generation cephalosporin and metronidazole antibiotherapy was initiated in the emergency room and continued. Empiric antibiotherapy was changed as required according to microbiological analysis results of removed tissue samples in first debridement. During wound exploration at the time of wound dressing change, patients underwent additional debridement procedures as necessary. Additional debridements were performed until all necrotic tissue was removed and healthy granulation tissue was established in the wound. Patients with severe sepsis and patients requiring vasopressors or mechanical ventilation support were treated in the intensive care unit (ICU). Skin defects that were not appropriate for staged tertiary closure were reconstructed with split-thickness skin graft (STSG). A previously published[5] 3-grade scoring system was used to assess degree of spread.[5] Grade I was identified as FG involving the perineum, scrotum and penis, vulva, or perianal region. In addition to meeting the criteria for grade I, grade II spread of FG was localized in the pubic region or femoralpelvic region, while in grade III it extended beyond the pelvic region. Categorical variables were reported as frequency (%) and quantitative variables were reported as the mean±standard deviation, except when noted otherwise. Categorical variables were compared using Fisher exact or chi-square test, and quantitative and ordinal variables were compared using Mann-Whitney U or Wilcoxon rank sum test. P value of <0.05 was considered statistically significant. All statistical

analyses were performed using JMP software, version 10.0 (SAS Institute Inc., Cary, NC, USA).

RESULTS There were 64 patients in the study with median age of 57 years (range: 22–80 years). Etiology of FG was anorectal in 51.5% of the patients, while other cases of FG originated urogenitally. There were 35 patients with DM, and median duration of symptoms was 7 days (range: 3–35 days). Patients underwent an average of 3 debridement procedures (range: 1–9 debridements). Median length of ICU stay and hospital stay were 0 days (range: 0–40 days) and 7 days (range: 3–65 days), respectively. Diverting stoma was necessary for 23.43% of the patients. STSG was required for 40.62% of wound closures. Overall mortality rate was 28.12%. Results of comparison of the 2 groups based on matching criteria are provided in Table 1. Majority of male patients (62.50%) had grade I disease-spread, while FG was limited to the perineum, vulva, or perianal region in only 25.0% of females. Time from onset of symptoms to first debridement was comparable between genders; however, grade II and grade III FG was significantly more common in females. Frequency of grade III disease in females was more than double that in males: 31.25% of all patients had Grade III spread, and 70% of those were female (p=0.009). Distribution of patients based on grade of disease-spread can be seen in Table 2. Female gender was associated with increased debridement count, prolonged length of ICU stay, and increased need for wound reconstruction with STSG. However, need for mechanical ventilation support, length of hospital stay, need for diverting stoma, and mortality rates (34.38% vs 21.88%; p=0.266) were comparable in the 2 groups (Table 3).

DISCUSSION Although FG affects both genders regardless of age, it occurs less frequently among women compared with men. Female/ male ratio varies between 1/10 and 1/50.[8,9] In spite of emerg-

Table 1. Comparison of the 2 groups based on matching criteria¶

Female (n=32)

Male (n=32)

Age

56 (22–65)

57 (32–80)

0.48

Etiology 0.21 Anorectal

43.8%

59.4%

Urogenital

56.2%

40.6%

Diabetes mellitus

65.6%

43.8%

0.07

Symptom duration (days)

8 (3–30)

7 (3–35)

0.82

FGSI score

6 (5–8)

6 (5–7)

0.89

¶ Categorical variables were reported as frequency (%) and quantitative variables were reported as median (range). FGSI: Fournier’s Gangrene Severity Index.

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Sarkut et al. Impact of gender on the prognosis of Fournier’s gangrene

ated with extensive FG. Moreover, length of hospital stay was comparable between groups.

Table 2. Distribution of the patients based on disease-spread grade

Female (%)

Male (%)

Grade I

62.5

0.009*

Grade II

31.3

18.8

Grade III

43.8

18.8

*: Chi-square test.

ing technologies and advances in medical knowledge, it is still a fatal disease. Thus, mortality is still the major outcome parameter for FG. After analysis of case-matched data, our results revealed that FG is more aggressive in females; however, patient gender did not seem to influence mortality. The infection that triggers the mechanism of necrotizing soft tissue infection arises from the perianal or urogenital region and rapidly spreads to the fascial planes. The most important fascia associated with the extension of the disease is Colles’ fascia, which continues superiorly as Scarpa’s fascia.[10] Colles’ fascia is inferiorly attached to the ischiopubic rami and posteriorly attached to the urogenital diaphragm in females. However, it is not anteriorly attached, which may cause early extension of infection to the anterior abdominal wall in females.[11] In the present study, female patients had more extensive disease compared to males, and they underwent debridements more frequently than males. Although symptom duration was comparable between the 2 groups, majority of the males had grade I disease (62.50% vs 25.0%), while grade III disease was more frequent among females (43.75% vs 18.75%). Greater number of debridements in female patients may be associated with need for recurrent removal of devitalized tissue in order to control widespread necrotizing fasciitis. Prolonged ICU length of stay for females may be explained by need for excessive care to treat sepsis associ-

Creation of diverting stoma is preferred by some authors in order to facilitate wound care in FG patients,[9,12,13] while other authors claim that stomas provide no benefits.[9,14] Additionally, it has been reported that stoma creation is associated with high risk of mortality in FG patients.[15,16] However, creating stoma is sometimes unavoidable in order to control fecal contamination of open wound. Interestingly, frequency of diverting stoma was comparable between genders in our study, despite the finding that the disease was more widespread in females. Staged wound closure by tertiary intent can be performed for skin defects occurring after debridements for FG. However, reconstructive procedures may be necessary in some patients.[17–19] Our data showed that need for reconstruction was higher among female patients. Higher chance of staged tertiary closure for male patients may be associated with healthy scrotal skin that may facilitate wound closure by providing extra skin, especially in patients without urogenital etiology. FG is a fatal disease with mortality rate ranging from 3% to 40%.[1] There are several studies reporting an increased mortality rate for female gender,[2–5] and female gender has even been reported as a risk factor for mortality in FG patients.[2] In a previously published study, we reported a mortality rate of 30.8% for female patients, while it was 16% for males in our recently published study; however, we failed to show gender as a risk factor of mortality (p=0.454).[4] Similarly, analysis of case-matched data did not show statistically significant difference in mortality rates by gender, though mortality rate for females was higher than for males (34.38% vs 21.88%; p=0.266). This finding suggests that female gender may be an advantage to survival despite the involvement of larger areas of soft tissue.

Table 3. Comparison of outcomes of Fournier’s gangrene by gender¶

Female (n=32)

Male (n=32)

Debridement count

3.5±1.8

2.±2.1

0.005*

Length of intensive care unit stay (days)

6.2±9.3

2.8±5.4

0.035*

Mechanical ventilation support (days) Length of hospital stay (days) Diverting stoma

3.3±6.4

1.2±2.8

0.14

18.5±12.8

14.7±13.1

0.07

15.6%

31.3%

Wound closure

0.14 0.04#

Tertiary

46.9% 71.9%

Split thickness skin graft

53.1%

28.1%

Mortality

34.4%

21.9% 0.26

Categorical variables were reported as frequency (percentage) and quantitative variables were reported as mean±standard deviation.. Wilcoxon rank sum test. #Chi-square test.

¶ *

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Sarkut et al. Impact of gender on the prognosis of Fournier’s gangrene

Main limitation of this study is its retrospective nature. Although we have one of the largest single-center databases for FG, limited number of patients may also limit strength of this research. Further, studying case-matched data based on strict matching criteria gives this paper clinical value. To the best of our knowledge, this is the first case-matched study comparing outcomes of FG by gender. In conclusion, FG is more widespread in females when compared with males, and female patients require additional debridements to manage the disease, possibly proportional to the amount of affected body surface area. Performing frequent debridements and occurrence of severe sepsis due to extensive disease may account for the prolonged length of ICU stay in females. Another result of widespread disease that may be unavoidable is greater need for STSG in closing female patients’ wounds. However, gender does not seem to be a prognostic factor affecting mortality rate of patients with FG. Conflict of interest: None declared.

REFERENCES 1. Eke N. Fournier’s gangrene: a review of 1726 cases. Br J Surg 2000;87(6):718–28. 2. Czymek R, Frank P, Limmer S, Schmidt A, Jungbluth T, Roblick U, et al. Fournier’s gangrene: is the female gender a risk factor? Langenbecks Arch Surg 2010;395:173–80. 3. Taviloglu K, Cabioglu N, Cagatay A, Yanar H, Ertekin C, Baspinar I, et al. Idiopathic necrotizing fasciitis: risk factors and strategies for management. Am Surg 2005;71:315–20. 4. Yılmazlar T, Işık Ö, Öztürk E, Özer A, Gülcü B, Ercan İ. Fournier’s gangrene: review of 120 patients and predictors of mortality. Ulus Travma Acil Cerrahi Derg 2014;20:333–7. 5. Yilmazlar T, Ozturk E, Ozguc H, Ercan I, Vuruskan H, Oktay B. Fournier’s gangrene: an analysis of 80 patients and a novel scoring system. Tech

Coloproctol 2010;14:217–23. 6. Yanar H, Taviloglu K, Ertekin C, Guloglu R, Zorba U, Cabioglu N, et al. Fournier’s gangrene: risk factors and strategies for management. World J Surg 2006;30:1750–4. 7. Ersoz F, Sari S, Arikan S, Altiok M, Bektas H, Adas G, et al. Factors affecting mortality in Fournier’s gangrene: experience with fifty-two patients. Singapore Med J 2012;53(8):537–40. 8. Hasdemir AO, Büyükaşik O, Cöl C. The clinical characteristics of female patients with Fournier’s gangrene. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:1439–43. 9. Liang SG, Chen HH, Lin SF, Chang CL, Lu CC, Hu WH. Fournier’s Gangrene in Female Patients. J Soc Colon Rectal Surgeon (Taiwan) 2008;19:57–62. 10. Morpurgo E, Galandiuk S. Fournier’s gangrene. Surg Clin North Am 2002;82:1213–24. 11. Yavagal S, de Farias TF, Medina CA, Takacs P. Normal vulvovaginal, perineal, and pelvic anatomy with reconstructive considerations. Semin Plast Surg 2011;25:121–9. 12. Bronder CS, Cowey A, Hill J. Delayed stoma formation in Fournier’s gangrene. Colorectal Dis 2004;6:518–20. 13. Ayan F, Sunamak O, Paksoy SM, Polat SS, As A, Sakoglu N, et al. Fournier’s gangrene: a retrospective clinical study on forty-one patients. ANZ J Surg 2005;75:1055–8. 14. Ozturk E, Sonmez Y, Yilmazlar T. What are the indications for a stoma in Fournier’s gangrene? Colorectal Dis 2011;13:1044–7. 15. Yaghan RJ, Al-Jaberi TM, Bani-Hani I. Fournier’s gangrene: changing face of the disease. Dis Colon Rectum 2000;43:1300–8. 16. Benizri E, Fabiani P, Migliori G, Chevallier D, Peyrottes A, Raucoules M, et al. Gangrene of the perineum. Urology 1996;47:935–9. 17. Korkut M, Içöz G, Dayangaç M, Akgün E, Yeniay L, Erdoğan O, et al. Outcome analysis in patients with Fournier’s gangrene: report of 45 cases. Dis Colon Rectum 2003;46(5):649–52. 18. Chen SY, Fu JP, Wang CH, Lee TP, Chen SG. Fournier gangrene: a review of 41 patients and strategies for reconstruction. Ann Plast Surg 2010;64:765–9. 19. Chen SY, Fu JP, Chen TM, Chen SG. Reconstruction of scrotal and perineal defects in Fournier’s gangrene. J Plast Reconstr Aesthet Surg 2011;64:528–34.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Cinsiyet Fournier gangreni prognozuna etkili bir faktör değildir: Olgu-eşleme çalışması Dr. Pınar Sarkut,1 Dr. Özgen Işık,1 Dr. Ersin Öztürk,1 Dr. Barış Gülcü,1 Dr. İlker Ercan,2 Dr. Tuncay Yılmazlar1 1 2

Uludağ Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Bursa Uludağ Üniversitesi Tıp Fakültesi, Biyoistatistik Anabilim Dalı, Bursa

AMAÇ: Kadın cinsiyet Fournier gangreni (FG) için olumsuz bir prognostik faktör olarak görülmektedir. Ancak literatürde bu konuya özgün yeterli veri yoktur. Bu olgu-eşleme çalışması kadın cinsiyetin FG prognozuna etkisini incelemek için yapıldı. GEREÇ VE YÖNTEM: Çalışmaya alınan hastalar kliniğimizin 120 hastalık ileriye yönelik olarak tutulan veritabanından çekildi. Otuz iki kadın hasta aşağıdaki kriterler baz alınarak 32 erkek hastayla eşleştirildi: Semptom süresi, FG severity indeks (FGSI) skoru, hasta yaşı, etiyoloji ve eşlik eden diyabetes mellitus (DM) varlığı. Daha sonra iki grup hasta klinik sonuçlar açsından karşılaştırıldı. BULGULAR: Medyan yaş 57 (22–80) idi ve 35 (%54.7) hastada DM vardı. Hastalara ortalama 3 (1–9) debridman yapıldı ve 15 hastaya (%23.4) saptırıcı stoma açıldı. Mortalite oranı %28.1 (64’te 18 hasta) idi. Kadınlarda FG daha yaygındı (p=0.009), daha fazla debridmana ihtiyaç duyulmuştu (p=0.005), kadınlar yoğun bakım ünitesinde daha fazla oranda kalmıştı (p=0.035) ve kadınlarda split thickness skin graft (STSG) ile rekonstrüksiyon daha fazla oranda yapılmıştı (p=0.040), ancak mortalite oranları iki grup arasında benzerdi (p=0.264). TARTIŞMA: Fournier gangreni kadınlarda erkeklere oranla daha yaygın seyreder. Bu muhtemelen kadınların anatomik yapısı ile ilgilidir. Ancak kadın cinsiyet FG mortalitesini artıran bir faktör değildir. Anahtar sözcükler: Cinsiyet; Fournier gangreni; mortalite. Ulus Travma Acil Cerrahi Derg 2016;22(6):541–544

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ORIG I N A L A R T IC L E

Acute appendicitis during pregnancy: case series of 20 pregnant women İlker Murat Arer, M.D.,1 Songül Alemdaroğlu, M.D.,2 Hasan Yeşilağaç, M.D.,3 Hakan Yabanoğlu, M.D.1 1

Department of General Surgery, Başkent University Adana Teaching and Research Center, Adana-Turkey

Department of Obstetrics and Gynecology, Başkent University Adana Teaching and Research Center, Adana-Turkey

Department of Emergency Medicine, Başkent University Adana Teaching and Research Center, Adana-Turkey

ABSTRACT BACKGROUND: Acute appendicitis (AA) is the most common cause of acute abdomen during pregnancy. Most of the signs of appendicitis are also found during normal pregnancy period, however, and diagnosis of appendicitis during pregnancy remains challenging. The aim of the current study was to report our clinical experience of AA during pregnancy and investigate optimal management of this difficult situation. METHODS: Records of 20 pregnant women with diagnosis of AA who underwent appendectomy between 2005 and 2015 were included in this study. Data were collected retrospectively. Patients were evaluated according to age, signs and symptoms, gestational age, physical findings, serum white blood cell count, ultrasound (US) findings, pathology reports, surgical technique, operation time, and complications. RESULTS: Of 20 patients, 16 (80%) underwent open appendectomy and 4 (20%) underwent laparoscopic appendectomy. Mean age of patients was 29.6±5.6 years. Most common symptom was abdominal pain (95%). Six (30%) patients were in first trimester, 9 (45%) patients were in second trimester and 5 (25%) patients in were in third trimester. US findings consistent with AA were found in 12 (60%) patients. Negative appendectomy rate was 30%. Maternal complication was seen in only 1 (5%) patient. No fetal complication was observed. CONCLUSION: Accurate diagnosis and prompt surgical treatment of AA in pregnant women should be performed due to high rates of maternal and fetal complications. Keywords: Acute appendicitis; appendectomy; pregnancy.

INTRODUCTION Acute appendicitis (AA) is the most common cause of acute abdomen during pregnancy and accounts for 25% of non-obstetric surgery during pregnancy with an incidence of 1/500 to 1/2000 of all pregnancies.[1,2] Diagnosis of appendicitis during pregnancy remains challenging. Physiological mild leukocytosis seen in pregnant women, change in location of appendix and low sensitivity rates of ultrasound (US) imaging cause

Address for correspondence: İlker Murat Arer, M.D. Dadaloğlu Mah., Başkent Üniversitesi Adana Uygulama ve Araştırma Merkezi, Genel Cerrahi Anabilim Dalı, Yüreğir, Adana, Turkey Tel: +90 322 - 327 27 27 E-mail: igy1981@yahoo.com Qucik Response Code

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delay in diagnosis of appendicitis.[3–5] Therefore, complications occur more frequently during pregnancy than in non-pregnant women.[6] Although US is the most commonly and easily performed diagnostic tool for AA in pregnancy, recently magnetic resonance imaging (MRI) has been reported to be superior, with sensitivity and specificity rates of 96.8% and 99.2% respectively.[7,8] Since most of the signs of appendicitis are also found during normal pregnancy period, decisions about surgery become more difficult with these patients. Surgery is unavoidable, but there are stıll questions about which technique to be used for appendectomy, laparoscopic or open surgery. Laparoscopic surgery for pregnant women has been found to be safe and accurate.[9] However, while laparoscopic appendectomy during pregnancy is associated with low rate of intraoperative complications in all trimesters, it is associated with significantly higher rate of fetal loss compared to open appendectomy.[10] The aim of the current study was to report our clinical experience with AA during pregnancy and investigate optimal management of this difficult situation. 545

Arer et al. Acute appendicitis during pregnancy: case series of 20 pregnant women

MATERIALS AND METHODS Our study consisted of records of 20 pregnant women with AA diagnosis who underwent appendectomy between September 2005 and September 2015 at Başkent University Adana Teaching and Research Center. Data were collected retrospectively from software database and patient files. Patients were evaluated according to age, signs and symptoms, gestational age, physical findings, serum white blood cell (WBC) count, US findings, pathology reports, surgical technique, operation time, and complications.

Statistical Analysis SPSS software was used for statistical analysis (Version 17.0; SPSS Inc., Chicago, IL, USA). If continuous variables were normal, they were described as mean±standard deviation (p>0.05, Kolmogorov-Smirnov test; n<30, Shapiro-Wilk test), and if the continuous variables were not normal, they were described as median.

RESULTS Twenty pregnant women underwent appendectomy during 10-year period of study. Of those, 16 (80%) underwent open appendectomy and 4 (20%) underwent laparoscopic appendectomy. Mean age of the patients was 29.6±5.6 years. Most Table 1. Demographic characteristics of patients (n=20)

n % Mean±SD

Age (Years)

29.6±5.6

Symptoms

Abdominal pain

Nausea

1 5

Physical finding RLQP

7 35

RLQP+rebound

11 55

RLQP+rebound+defense

2 10

Surgical technique Laparoscopic

16 80

Open

4 20

Gestational age 1st trimester

2 trimester

3rd trimester

White blood cell count (x103/µL) 14.2±5.9 Operation time (minutes) Negative appendectomy

Complication (SSI)

45.45±21.03

SD: Standard deviation; RLQP: Right lower quadrant pain, SSI: surgical site infection.

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common symptom, abdominal pain, was seen in 19 (95%) patients, and nausea was reported in 1 (5%) patient. In physical examination right lower quadrant pain (RLQP) was present in 7 (35%), both RLQP and rebound were present in 11 (55%), and RLQP with rebound and defense was present in 2 (10%) patients. At time of diagnosis, 6 (30%) patients were in first trimester, 9 (45%) patients in second trimester and 5 (25%) patients in third trimester. US findings consistent with AA were found in 12 (60%) patients. Average WBC count of patients was 14.2±5.9 x103/µL (range: 3–30 x103/µL). Mean operation time was 45.45±21.03 minutes. Permanent pathology report of AA was found in 6 (30%) cases. Surgical site infection as postoperative complication was observed in only 1 patient (5%) with perforated appendicitis. No fetal complication was observed (Table 1).

DISCUSSION Non-obstetric surgical intervention is performed on nearly 2% of all pregnant women annually worldwide.[11,12] The most commonly performed non-obstetric operation (44%) on pregnant women is appendectomy.[13] Diagnosis of commonly encountered signs of appendicitis is challenging due to physiological changes that occur during pregnancy. Mild leukocytosis and abdominal tenderness are common findings in pregnant women. Thus, delay in diagnosis can lead to perforation of the appendix. Perforation rate has also been found to be associated with advanced gestational age and delayed admission to the hospital.[14] Therefore, prompt diagnosis and appropriate therapy are crucial for pregnant patients with acute abdomen in order to prevent fetal and maternal mortality and morbidity.[15] In a study of 52 pregnant women who underwent appendectomy, perforation of the appendix was found to be the only predictive factor for maternal morbidity, and if interval between onset of symptoms and operation exceeds 20 hours, perforation is almost inevitable.[16] Although diagnosis of appendicitis is clinical, fetal growth makes it difficult by changing the location of the appendix. RLQ tenderness elevates superiorly in the second and third trimesters.[17] Imaging studies are recommended in order to reduce delays in surgery due to diagnostic uncertainty and to reduce rate of negative appendectomies.[18] US is typically the first radiological modality used to aid in diagnosis of appendicitis is US. However, US imaging has limitations even in nonpregnant population, and it is difficult to visualize appendix or secondary findings of appendicitis during pregnancy. US is reported to be valuable in evaluation of appendicitis in pregnant women, especially in the first trimester, but non-visualization rate of US is high, particularly in advanced pregnancy.[19] In the present study, though most of the patients (70%) were in second and third trimesters, contrary to literature findings, US indicated AA with 40% accuracy in these patients. We believe that in experienced hands, US is a very useful diagnostic tool for AA in pregnancy, regardless of trimester. Another radiological modality, MRI, is also used for diagnosis Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Arer et al. Acute appendicitis during pregnancy: case series of 20 pregnant women

of appendicitis in pregnant women due to high rate of appendix non-visualization in US scanning. MRI has been reported to have sensitivity and specificity rates as high as 91.7% and 95.3%, respectively,[20] and can be used when surgical exploration is considered.

REFERENCES

Negative appendectomy rates during pregnancy have been reported as between 3% and 23%.[21,22] Terzi et al. found rate of 13%[14] and Miloudi et al. reported negative appendectomy rate of 3.4%.[23] Present study finding of 30% rate is higher than literature findings, but may be explained by inability to perform MRI or presence of physical findings that indicated urgent exploration.

3. Abbasi N, Patenaude V, Abenhaim HA. Evaluation of obstetrical and fetal outcomes in pregnancies complicated by acute appendicitis. Arch Gynecol Obstet 2014;290:661–7.

Although treatment for appendicitis is surgery, technique to be used for the procedure continues to be a subject of investigation. Should we perform open or laparoscopic appendicitis? Which one is feasible? Some authors encourage laparoscopic approach,[24] whereas some have found open appendectomy to be safer.[10] In a hospital-based retrospective review of 65 pregnant women with suspected appendicitis, laparoscopic appendectomy was found to be a safe, feasible, and efficacious approach.[25] Laparoscopy offers shorter hospital stay and reduced risk of thromboembolic events.[26] Some authors state that even in perforated cases, laparoscopy appears safe in pregnant patients.[27] There are also some limitations to use of laparoscopic appendectomy such as instance of diffuse peritonitis, advanced pregnancy with markedly enlarged uterus, or lack of experience of the surgeon or operating team. [13] In the present study, laparoscopic appendectomy was performed in 20% of all patients without any complication; thus, we also believe that it is a safe and feasible approach for pregnant women with appendicitis. Since perforated appendicitis is known to be associated with high rate of maternal and fetal morbidity and mortality, rapid and accurate diagnosis of appendicitis is particularly critical in pregnant patients. Risk of premature onset of labor has been reported to be between 8% and 33%.[28,29] Fetal loss has been reported as between 0% and 12.1%.[10,30] There was no case of fetal demise in this current study. This can be explained by the low rate of perforation (5%) in our study, found only in 1 patient.

Conclusion Although diagnosis remains challenging, urgent surgical treatment of AA in pregnant women should be performed due to high rates of maternal and fetal complications. Radiological modalities such as US or MRI should be performed in cases of unclear diagnosis.

Acknowledgments

1. Andersen B, Nielsen TF. Appendicitis in pregnancy: diagnosis, management and complications. Acta Obstet Gynecol Scand 1999;78:758–62. 2. Long SS, Long C, Lai H, Macura KJ. Imaging strategies for right lower quadrant pain in pregnancy. AJR Am J Roentgenol 2011;196:4–12.

4. Spalluto LB, Woodfield CA, DeBenedectis CM, Lazarus E. MR imaging evaluation of abdominal pain during pregnancy: appendicitis and other nonobstetric causes. Radiographics 2012;32:317–34. 5. Pitkin RM, Witte DL. Platelet and leukocyte counts in pregnancy. JAMA 1979;242:2696–8. 6. Dietrich CS 3rd, Hill CC, Hueman M. Surgical diseases presenting in pregnancy. Surg Clin North Am 2008;88:403–19. 7. Greenhalgh R, Punwani S, Taylor SA. Is MRI routinely indicated in pregnant patients with suspected appendicitis after equivocal ultrasound examination? Abdom Imaging 2008;33:21–5. 8. Burke LM, Bashir MR, Miller FH, Siegelman ES, Brown M, Alobaidy M, et al. Magnetic resonance imaging of acute appendicitis in pregnancy: a 5-year multi-institutional study. Am J Obstet Gynecol 2015. 9. Rizzo AG. Laparoscopic surgery in pregnancy: long-term follow-up. J Laparoendosc Adv Surg Tech A 2003;13:11–5. 10. Walsh CA, Tang T, Walsh SR. Laparoscopic versus open appendicectomy in pregnancy: a systematic review. Int J Surg 2008;6:339–44. 11. Cheek TG, Baird E. Anesthesia for nonobstetric surgery: maternal and fetal considerations. Clin Obstet Gynecol 2009;52:535–45. 12. Gilo NB, Amini D, Landy HJ. Appendicitis and cholecystitis in pregnancy. Clin Obstet Gynecol 2009;52:586–96. 13. Juhasz-Böss I, Solomayer E, Strik M, Raspé C. Abdominal surgery in pregnancy--an interdisciplinary challenge. Dtsch Arztebl Int 2014;111:465–72. 14. Terzi A, Yildiz F, Vural M, Coban S, Cece H, Kaya M. A case series of 46 appendectomies during pregnancy. Wien Klin Wochenschr 2010;122:686–90. 15. Unal A, Sayharman SE, Ozel L, Unal E, Aka N, Titiz I, et al. Acute abdomen in pregnancy requiring surgical management: a 20-case series. Eur J Obstet Gynecol Reprod Biol 2011;159:87–90. 16. Yilmaz HG, Akgun Y, Bac B, Celik Y. Acute appendicitis in pregnancy-risk factors associated with principal outcomes: a case control study. Int J Surg 2007;5:192–7. 17. Pates JA, Avendanio TC, Zaretsky MV, McIntire DD, Twickler DM. The appendix in pregnancy: confirming historical observations with a contemporary modality. Obstet Gynecol 2009;114:805–8. 18. de Franca Neto AH, do Amorim MM, Nóbrega BM. Acute appendicitis in pregnancy: literature review. Rev Assoc Med Bras 2015;61:170–7. 19. Drake FT, Kotagal M, Simmons LE, Parr Z, Dighe MK, Flum DR. Single institution and statewide performance of ultrasound in diagnosing appendicitis in pregnancy. J Matern Fetal Neonatal Med 2015;28:727–33. 20. Theilen LH, Mellnick VM, Longman RE, Tuuli MG, Odibo AO, Macones GA, et al. Utility of magnetic resonance imaging for suspected appendicitis in pregnant women. Am J Obstet Gynecol 2015;212:345. e1–6.

This study did not receive any specific funding or grants.

21. McGee TM. Acute appendicitis in pregnancy. Aust N Z J Obstet Gynaecol 1989;29:378–85.

Conflict of interest: None declared.

22. McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM. Negative appendectomy in pregnant women is associated with a substan-

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Arer et al. Acute appendicitis during pregnancy: case series of 20 pregnant women tial risk of fetal loss. J Am Coll Surg 2007;205:534–40. 23. Miloudi N, Brahem M, Ben Abid S, Mzoughi Z, Arfa N, Tahar Khalfallah M. Acute appendicitis in pregnancy: specific features of diagnosis and treatment. J Visc Surg 2012;149:275–9. 24. Barnes SL, Shane MD, Schoemann MB, Bernard AC, Boulanger BR. Laparoscopic appendectomy after 30 weeks pregnancy: report of two cases and description of technique. Am Surg 2004;70:733–6. 25. Sadot E, Telem DA, Arora M, Butala P, Nguyen SQ, Divino CM. Laparoscopy: a safe approach to appendicitis during pregnancy. Surg Endosc 2010;24:383–9. 26. Pearl J, Price R, Richardson W, Fanelli R; Society of American Gastrointestinal Endoscopic Surgeons. Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc

2011;25:3479–92. 27. Cox TC, Huntington CR, Blair LJ, Prasad T, Lincourt AE, Augenstein VA, et al. Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients. Surg Endosc 2016;30:593–602. 28. Kazim SF, Pal KM. Appendicitis in pregnancy: experience of thirty-eight patients diagnosed and managed at a tertiary care hospital in Karachi. Int J Surg 2009;7:365–7. 29. Aggenbach L, Zeeman GG, Cantineau AE, Gordijn SJ, Hofker HS. Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment. Int J Surg 2015;15:84–9. 30. Kapan S, Bozkurt MA, Turhan AN, Gönenç M, Alış H. Management of acute appendicitis in pregnancy. Ulus Travma Acil Cerrahi Derg 2013;19:20–4.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Gebelikte akut apandisit: 20 hamile kadın olgu çalışması Dr. İlker Murat Arer,1 Dr. Songül Alemdaroğlu,2 Dr. Hasan Yeşilağaç,3 Dr. Hakan Yabanoğlu1 Başkent Üniversitesi Adana Uygulama ve Araştırma Merkezi, Genel Cerrahi Anabilim Dalı, Adana Başkent Üniversitesi Adana Uygulama ve Araştırma Merkezi, Kadın Hastalıkları ve Doğum Anabilim Dalı, Adana 3 Başkent Üniversitesi Adana Uygulama ve Araştırma Merkezi, Acil Tıp Anabilim Dalı, Adana 1 2

AMAÇ: Hamilelikteki en sık akut karın nedeni akut apandisittir. Apandisit bulgularının çoğu normal hamlilelik sürecinde olabileceğinden, gebelerde akut apandisit tanısı zordur. Çalışmamızın amacı, hamilelik döneminde karşılaştığımız akut apandisit olgularını aktarmak ve bu zor durumda uygun tedaviyi araştırmak. GEREÇ VE YÖNTEM: 2005–2015 yılları arasında akut apandisit nedeniyle ameliyat edilen 20 hamile kadın hasta çalışmaya dahil edildi. Veriler geriye dönük olarak toplandı. Hastalar, yaş, bulgu ve semptomlar, gestasyon yaşı, fiziksel inceleme bulguları, ameliyat süresi ve komplikasyon açısından incelendi. BULGULAR: On altı (%80) hastaya açık, dört (%20) hastaya laparoskopik apendektomi yapıldı. Ortalama yaş 29.6±5.6 yıldı. En sık semptom karın ağrısıydı (%95). Altı (%30) hasta 1. üç ayda, dokuz (%45) hasta 2. üç ayda ve beş (%25) hasta son üç ayda idi. On iki (%60) hastada ultrasonografide akut apandisit bulgusu saptandı. Negatif apendektomi oranı %30’du. Sadece bir (%5) hastada maternal komplikasyon saptandı. Hiç fetal komplikasyon saptanmadı. TARTIŞMA: Yüksek maternal ve fetal komplikasyon oranlarından dolayı, gebelerde akut apandisitin doğru tanısı ve hızlı cerrahi tedavisi yapılmalıdır. Anahtar sözcükler: Akut apandisit; apendektomi; gebelik. Ulus Travma Acil Cerrahi Derg 2016;22(6):545–548

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Contribution of MRI to clinically equivocal penile fracture cases Rüştü Türkay, M.D.,1 Mustafa Gürkan Yenice, M.D.,2 Sema Aksoy, M.D.,1 Gökhan Şeker, M.D.,2 Selçuk Şahin, M.D.,2 Ercan İnci, M.D.,1 Volkan Tuğcu, M.D.,2 Ali İhsan Taşcı, M.D.2 1

Department of Radiology, İstanbul Dr. Sadi Konuk Training and Research Hospital, İstanbul-Turkey

Department of Urology, İstanbul Dr. Sadi Konuk Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Penile fracture is a surgical emergency defined as rupture of the tunica albuginea. Although most cases can be diagnosed with clinical evaluation, it has been stated in the literature that diagnosis in as many as 15% of cases can be challenging. In uncertain cases, imaging can help determine diagnosis. METHODS: Present study included 20 cases where diagnosis could not be made with certainty and magnetic resonance imaging (MRI) was performed. MR images were examined for tunical rupture and accompanying pathologies. When rupture was observed, localization and length of rupture were noted. All patients underwent degloving surgery. All imaging findings were compared to surgical findings. RESULTS: MRI revealed 19 tunical ruptures. In 1 case, hematoma was seen with no sign of penile fracture. No urethral injuries were found. All MRI findings were confirmed during surgery. CONCLUSION: Performing MRI in clinically equivocal cases can provide crucial data to make precise diagnosis and improve patient management. Keywords: Magnetic resonance imaging; penile fracture; radiology.

INTRODUCTION Penile fracture is a rare, traumatic rupture of the tunica albuginea that most often occurs during sexual intercourse, but sometimes occurs during masturbation or in fall on the erect penis.[1] Generally, diagnosis of fracture is based on history and physical examination. Classic presentation may include cracking sensation, severe penile pain associated with shaft deviation, ecchymosis, and palpable defect in the tunica albuginea.[2] Nevertheless, this description is not pathognomonic for rupture of corporeal bodies. Atypical cases may occur, and in 1 study, history and physical examination were inaccurate in 15% of patients with suspected penile fracture.[3] DifAddress for correspondence: Rüştü Türkay, M.D. İstanbul Sadi Konuk Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, İstanbul, Turkey Tel: +90 212 - 414 71 71 E-mail: rustuturkay@hotmail.com Qucik Response Code

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ferential diagnosis of penile fracture includes injury to dorsal penile vessels and extra-albugineal hematoma.[4] Differentiating these diagnoses from penile fracture is important clinically because fractures require surgical intervention, whereas other conditions can generally be managed conservatively. Penile fracture is a surgical emergency. If not treated immediately, complications such as chronic pain, penile curvature, Peyronie’s plaque formation, arteriovenous fistula, or erectile dysfunction have been seen in 10% to 53% of patients.[5] In the management of clinically uncertain penile fracture cases, imaging studies can be helpful to clarify the diagnosis. The present study is an evaluation of the contribution of magnetic resonance imaging (MRI) to clinically equivocal penile fracture cases.

MATERIALS AND METHODS The institutional review board of Dr. Sadi Konuk Training and Research Hospital approved this study. The Declaration of Helsinki protocols were followed. Written informed consent was obtained from each participant. There were 20 patients (aged 19-60 years with mean age of 39.5 years) in the study whose diagnosis could not be made based only 549

TĂźrkay et al. Contribution of MRI to clinically equivocal penile fracture cases

on clinical findings. MRI was performed to assess diagnosis of penile fracture. Blunt penile trauma occurred during erection in all patients. History revealed that etiology was sexual intercourse activity in 12 patients. For the remaining 8 patients, causes were rolling over in bed (n=3) and masturbation (n=5). Delay between injury and management ranged from 4 to 46 hours (mean: 25 hours). Acute penile pain was present in all cases. Cracking sound was reported by 8 patients. Urethral injury was not detected in any of the patients. In all cases there was sudden detumescence after injury. Physical examination revealed grossly ecchymotic penis with normal glans and no palpable tunical defect. Ecchymosis involved the scrotum in 2 patients and the pubic area in 1 other. Penile shaft deviation was found in 8 cases. MR imaging was used to evaluate need for immediate surgery in all patients. All cases underwent degloving surgery. In 1 case, careful dissection revealed avulsion of superficial dorsal vein was source of bleeding and no tunical defect was observed. No significant intraoperative or immediate postoperative complications were noted. Patients were discharged 1 or 2 days postoperatively.

(a)

(b)

Figure 1. (a) T2-weighted sagittal magnetic resonance image. Arrow shows the disruption of low signal line of tunica albuginea (b) Same patient with T1-weighted axial magnetic resonance image. Arrow indicates fracture of tunica.

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MR Imaging MR sequences: All MR imaging was performed with 3T Magnetom Verio (Siemens, AG, Berlin, Germany). High resolution, thin slice (3 mm) images of the penis were taken in the anatomical position. T2-weighted spin echo sequences in 3 orthogonal planes and T1 in axial plane were used. Contrast material was not used.

Findings In 19 of 20 patients, MRI depicted disruption of low-signalintensity tunica albuginea, which is generally well seen on both T2- and T1-weighted images (Figs. 1a, b). Location of tears was noted according to distance from corona. We observed 11 right and 8 left corpus cavernosum tears. Extent of tunical tears was measured (range: 6.5â&#x20AC;&#x201C;14 mm; mean 9 mm). In 1 patient, no tunical laceration was visible on MRI, only large hematoma in shaft of the penis (Figs. 2a, b). Underlying cause was not evident. No signs of urethral injury were observed in any MR images.

RESULTS Total of 19 of 20 clinically equivocal patients were diagnosed

(a)

(b)

Figure 2. (a) Sagittal T2-weighted magnetic resonance images of intact tunica albuginea (arrows). (b) Axial T1-weighted magnetic resonance image of intact tunica albuginea (arrows).

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as having penile fracture based on MRI findings. MRI depicted intact tunica albuginea in 1 patient and thereby did not support clinical prediagnosis of penile fracture. Strong clinical suspicion prompted surgery; however, which revealed dorsal vein rupture. There were no findings of urethral injury in the study. All MRI findings were confirmed during surgery.

DISCUSSION Penile fracture is rupture of 1 or both of the tunica albuginea, the fibrous covering that envelops the corpora cavernosa in the erect penis. When erect, thick tunica albuginea become thin and fracturable. Penile fracture usually occurs during sexual intercourse or masturbation. Rarely, cause may be blunt force to erect penis such as in fall from bed or during a fight. Penile rupture can usually be diagnosed based solely on history and physical examination findings; however, in equivocal cases, radiological examinations should be performed to confirm diagnosis as well as to determine precise localization and extent of tunical rupture.[6] Cracking sound has been reported in 43% of cases, palpable defect seen in 55% of cases, and penile deviation has been observed in 83% of cases. On basis of history and physical examination alone, rate of misdiagnosis can be as high as 15%.[3,6] Differential diagnosis of penile fracture includes superficial dorsal vein rupture, deep dorsal vein rupture, dorsal penile artery avulsion, and nonspecific dartos bleeding.[4,7] Differentiating these diagnoses from penile fracture is important clinically because fractures require surgical intervention, whereas dorsal penile vessel injuries and extra-albugineal hematomas can generally be managed conservatively. All entities may cause penile pain and swelling. Extraalbugineal hematoma, for example, is more common with trauma to flaccid penis, whereas fractures usually occur when the penis is erect.[6] Rupture of dorsal penile vessels tends to occur with trauma to erect penis, but detumescence tends to be delayed, unlike instance of fracture. Fractures also tend to present with palpable defects of cavernosa that are usually painful on palpation, a finding usually not present with more superficial injury. When diagnosis of penile fracture based on history and physical examination alone is not possible, imaging studies may be useful to clarify diagnosis. Imaging modalities such as cavernosography, ultrasonography (US), and MRI can be used to positively identify penile fracture. Cavernosography is invasive and painful imaging modality that has significant false-negative results.[8] US can help detect defects in the tunica albuginea in the majority of patients (although false-negative results do occur),[9] and can also depict hematoma and injuries of the corpus spongiosum and urethra. In difficult cases, handicap of US is lack of tissue contrast, especially in detumescent pendulous part of the penis. MRI is superior to US in soft tissue imaging. Fedel et al. compared US and MR imaging and found that US was not helpful, whereas MR imaging was much more informative in penile fracture cases.[10] Furthermore, US is user-dependent modality, and experience in penile sonography is not common among radiologists. MRI can also depict urethral injury, whereas US is not quite capable of showing Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

injury to urethra.[11] For these reasons, we prefer MR imaging in evaluation of this type of clinically challenging case. The key finding in penile fracture is disruption of low-signalintensity tunica albuginea, which can be easily seen on both T2- and T1-weighted images (Figs. 1a, b). Although contrast resolution is better with T2-weighted sequences, T1-weighted sequences may help detect more subtle fractures. One study reported that defect in the tunica albuginea was clearly seen with T1-weighted sequences in 3 of 4 patients.[11] A possible explanation is that acute hematoma may have low signal intensity on T2-weighted images and thereby mimic intact tunica albuginea.[11] In present series, all tunical tears were visible in T2-weighted images. One possible explanation for this may be that Uder et al. used 1T MRI in that study, while we used 3T MRI scan, which has higher resolution and thereby provides greater detail than 1T MRI. In another study, MR imaging helped identify 3 cases of painful post-traumatic hematoma (either intracavernosal or outside the tunica albuginea) without disruption of the tunica albuginea, thereby avoiding surgical exploration.[12] Rupture of the dorsal vein of the penis is a rare condition that mimics acute fracture and should be distinguished from rupture with MR imaging.[12] In the present series, we had 1 case of dorsal vein rupture, which was confirmed surgically. MR images revealed subcutaneous hematoma with intact tunica albuginea. Although MRI did not illustrate dorsal vein rupture, it allowed us to correctly rule out diagnosis of penile rupture, which is a surgical emergency entity. In the literature, several groups have found that accurate delineation of the site of fracture can enable surgeon to use a small focal incision,[11,12] rather than the extensive subcoronal degloving approach used in the past and which probably has a higher prevalence of complications.[13] In the present series of clinically equivocal penile fracture cases, MRI indicated precise location and extent of defect in the tunical albuginea. Although MRI is expensive and needs additional apparatus, it is an informative tool for evaluating and documenting penile fracture and it also improves the management plan. In equivocal cases, MR imaging may provide additional data to make confident diagnosis. Furthermore, in small number of patients, diagnosis of rupture may confidently be excluded, avoiding unnecessary surgical exploration. With knowledge of exact location of tunical rupture, MRI may also help surgeons keep incision small and thereby contribute to decreasing possible complications of surgery. Conflict of interest: None declared.

REFERENCES 1. Kirkham AP, Illing RO, Minhas S, Minhas S, Allen C. MR imaging of nonmalignant penile lesions. Radiographics 2008;28(3):837–53. 2. Nomura JT, Sierzenski PR. Ultrasound diagnosis of penile fracture. J Emerg Med 2010;38:362–5.

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Türkay et al. Contribution of MRI to clinically equivocal penile fracture cases 3. Beysel M, Tekin A, Gürdal M, Yücebaş E, Sengör F. Evaluation and treatment of penile fractures: accuracy of clinical diagnosis and the value of corpus cavernosography. Urology 2002;60:492–6. 4. Feki W, Derouiche A, Belhaj K, Ouni A, Ben Mouelhi S, Ben Slama MR, et al. False penile fracture: report of 16 cases. Int J Impot Res 2007;19:471–3. 5. Gedik A, Kayan D, Yamiş S, Yılmaz Y, Bircan K. The diagnosis and treatment of penile fracture: our 19-year experience. Ulus Travma Acil Cerrahi Derg 2011;17:57–60. 6. Karadeniz T, Topsakal M, Ariman A, Erton H, Basak D. Penile fracture: differential diagnosis, management and outcome. Br J Urol 1996;77:279– 81. 7. De Rose AF, Giglio M, Carmignani G. Traumatic rupture of the corpora cavernosa: new physiopathologic acquisitions. Urology 2001;57:319–22. 8. Grosman H, Gray RR, St Louis EL, Casey R, Keresteci AG, Elliott DS.

The role of corpus cavernosography in acute “fracture” of the penis. Radiology 1982;144:787–8. 9. Dierks PR, Hawkins H. Sonography and penile trauma. J Ultrasound Med 1983;2:417–9. 10. Fedel M, Venz S, Andreessen R, Sudhoff F, Loening SA. The value of magnetic resonance imaging in the diagnosis of suspected penile fracture with atypical clinical findings. J Urol 1996;155:1924–7. 11. Uder M, Gohl D, Takahashi M, Derouet H, Defreyne L, Kramann B, et al. MRI of penile fracture: diagnosis and therapeutic follow-up. Eur Radiol 2002;12:113–20. 12. Abolyosr A, Moneim AE, Abdelatif AM, Abdalla MA, Imam HM. The management of penile fracture based on clinical and magnetic resonance imaging findings. BJU Int 2005;96:373–7. 13. Morris SB, Miller MA, Anson K. Management of penile fracture. J R Soc Med 1998;91:427–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Klinik olarak tanı konulamayan penil fraktür olgularına MR görüntülemenin katkısı Dr. Rüştü Türkay,1 Dr. Mustafa Gürkan Yenice,2 Dr. Sema Aksoy,1 Dr. Gökhan Şeker,2 Dr. Selçuk Şahin,2 Dr. Ercan İnci,1 Dr. Volkan Tuğcu,2 Dr. Ali İhsan Taşcı2 1 2

İstanbul Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, İstanbul İstanbul Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Üroloji Kliniği, İstanbul

AMAÇ: Penil fraktür tunika albugineada oluşan rüptür olup acil cerrahi müdahale gerektirir. Olguların çoğunluğu klinik değerlendirme ile tanı alabilirse de literatürde belirtildiği gibi %15 gibi bir oranda sadece klinik ile tanı konulmasında zorlanılabilir. Bu durumda görüntüleme tanı konmasında yardımcı olabilir. GEREÇ VE YÖNTEM: Bizim çalışmamızda tanısı klinik olarak konulamamış 20 hastaya manyetik rezonans (MR) görüntüleme yapıldı. Manyetik rezonans görüntülerinde tunikal bütünlük kaybı ve eşlik edebilecek diğer patolojiler araştırıldı. Rüptür izlenen olgularda bu rüptürün lokalizasyonu ve uzunluğu kaydedildi. Hastaların tamamı ameliyat edildi. Görüntüleme bulguları operasyon bulguları ile karşılaştırıldı. BULGULAR: Manyetik rezonans görüntülemede 19 tunikal rüptür tanımlandı. Bir olguda sadece hematom görüntülenebilmiş olup tunikal rüptür lehine bir bulgu saptanmadı. Hiçbir olguda üretral yaralanma gözlenmedi. Görüntüleme bulgularının tamamı operasyon bulguları ile doğrulandı. TARTIŞMA: Klinik olarak tanısında zorlanılan penil fraktür olgularında MR görüntüleme tanının doğrulukla ve güvenle konmasında kritik bilgiler sağlayabilir. Anahtar sözcükler: Manyetik rezonans görüntüleme; penil fraktür; radyoloji. Ulus Travma Acil Cerrahi Derg 2016;22(6):549–552

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doi: 10.5505/tjtes.2016.50955

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Importance of fixation of posterior malleolus fracture in trimalleolar fractures: A retrospective study Sinan Karaca, M.D.,1 Meriç Enercan, M.D.,2 Güzelali Özdemir, M.D.,1 Sinan Kahraman, M.D.,3 Mutlu Çobanoğlu, M.D.,4 Metin Küçükkaya, M.D.3 1

Department of Orthopedics and Traumatology, Fatih Sultan Mehmet Training and Research Hospital, İstanbul-Turkey

Department of Orthopedics and Traumatology, İstanbul Florence Nightingale Hospital, İstanbul-Turkey

Department of Orthopedics and Traumatology, Adnan Menderes University Faculty of Medicine, İstanbul-Turkey

Department of Orthopedics and Traumatology, İstanbul Bilim University Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: The aim of this retrospective study was to evaluate treatment effect and importance of posterior malleolus (PM) fixation in surgically treated trimalleolar fractures. METHODS: A total of 57 cases of ankle joint fracture involving PM and treated with open reduction and internal fixation technique between 2004 and 2011 were evaluated. PM fixation was performed with cannulated screws in 46 cases, and in 11 cases, PM plate was used. All patients were assessed using American Orthopaedic Foot and Ankle Society (AOFAS) score, American Academy of Orthopedic Surgeons (AAOS) foot and ankle questionnaire, and Visual Analog Score (VAS) pain scale. Ankle joint mobility was also compared with unaffected side. RESULTS: Mean follow-up period was 44.6 months (range: 24–108 months). There were 36 female patients and 21 male patients between 23 and 85 years of age (mean: 55.9 years). Average time to surgery was 1.1 day (range: 1–3 days). According to AOFAS assessment, result was excellent in 21 patients and good in 26 patients. AAOS score was 92.4 (range: 32–100). Mean VAS score when resting was 1.1, and mean score was 1.3 when walking (range: 0–10). When compared with uninjured side, there was no significant difference in plantar flexion of ankle (p=0.325) but there was significant difference in dorsiflexion of ankle joint (p<0.001). CONCLUSION: Anatomical reduction and rigid internal fixation of PM provide satisfactory clinical and functional outcomes even in elderly patients where bone quality may make adequate fixation difficult. Fixation of even small PM fragments can facilitate rehabilitation by creating more stable construction. Keywords: Ankle fracture; posterior malleolus; syndesmosis injury.

INTRODUCTION Ankle fractures are relatively common, with an incidence of roughly 187 fractures per 100,000 people each year.[1] Posterior malleolus fracture (PMF) occurs in 7% to 44% of all ankle fractures, most in the setting of rotational ankle fractures,[2,3] and are rarely seen alone.[4] Address for correspondence: Meriç Enercan, M.D. İstanbul Florence Nightingale Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul, Turkey Tel: +90 212 - 375 65 65 E-mail: mdsnn@hotmail.com Qucik Response Code

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PM fracture may occur as part of any rotational mechanism, and fragment size varies. Large fragments are often associated with posterior fracture dislocation of the ankle and can be difficult to keep in reduced position. PM is significant stabilizer preventing posterior subluxation of the ankle; however, primary restraint to posterior forces is the anterior tibial fibular ligament and the fibula. In general, most PMF tend to be small, laterally based fragments, still connected to the posterior tibiofibular ligament.[5] Optimal treatment of ankle fractures, including PMF, has not been fully established.[6] While surgical treatment of displaced fractures of the medial and lateral malleolus is common,[7] when PM is also fractured, the trimalleolar pattern, necessity for fixation of that fragment is less clear. Several biomechanical studies have demonstrated that PM has an important role in transferring load between the distal 553

Karaca et al. Importance of fixation of posterior malleolus fracture in trimalleolar fractures

tibia and the talar dome, as well as in posterior stability, especially when lateral restraints are injured.[8,9] Furthermore, several authors have suggested that arthritis is triggered by change in stress distribution on the articular surface, which is caused by change in the articular surface area at the distal end of the tibia and talar dome after PMF.[2,6,10]

Table 1. Demographic details of the patient population Demographic n 57 Male/Female 21/36 Age (y)

Based on biomechanical, cadaveric, and small population studies, fragment size is frequently cited as one of the main indications for fixation with thresholds for surgery ranging from 25% to 33% of the anteroposterior (AP) dimension of the articular surface.[2,10–13] However, thus far there has not been any strong clinical evidence and no consensus. Aim of this retrospective, clinical cohort study was to evaluate radiographic osteoarthritis (OA), function, and pain in patients who had operative treatment for trimalleolar ankle fracture.

MATERIALS AND METHODS Patients and Inclusion Criteria In all, 65 cases of ankle joint fracture involving PM that were treated with open reduction and internal fixation regardless of the size of fracture between January 2006 and December 2012 at our institution with a minimum follow-up of 2 years were reviewed retrospectively. Inclusion criteria were (1) definitive diagnosis of unilateral ankle joint fracture based on clinical and imaging technologies, (2) open reduction internal fixation surgery performed by the same senior author, (3) involvement of PM, and (4) presence of complete clinical follow-up data.

55.9

Diabetes 3 Smoking 6 AO 44B AO 44C Body mass index (Mean±SD)

38 19 29.1±4.7

AO: Müller AO Classification; SD: Standard deviation.

of motion (ROM) exercise was initiated with referral to a physiotherapist. As general protocol, all patients did not bear weight on the injured extremity for 6 weeks and then advanced to weight bearing as tolerated.

Measurement and Evaluation Indices Size of PM fragment was calculated as percentage of total distal tibial articular surface as measured in a straight line from anterior to posterior margins of articular surface on computed tomography (CT) scan (Fig. 1). All patients had been evaluated preoperatively with AP, lateral, and mortise X-rays, as well as 3-dimensional CT. To describe fractures, Müller AO Classification of fractures system was used (Table 1). Fracture union was defined as loss of fracture lines in PM.

Total of 57 of the 65 patients who met criteria for the study agreed to participate and were seen at outpatient clinic. Physical examination was performed, X-rays (mortise, AP, and lateral radiographs) were taken, questionnaires were discussed, and medical history and general patient characteristics were evaluated. Mean follow-up period was 44.6 months (range: 24 to 108 months). Right ankle fractures accounted for 36 of those studied and 21 were left ankle. At time of hospital admission, each patient’s demographic information, medical history (including any diagnosis of diabetes mellitus), and smoking history were recorded (Table 1). Operative details (including tourniquet time) were recorded in database at time of surgery. Each patient’s postoperative course, including incidence of postoperative complications (e.g., medical, surgical, thromboembolic, or genitourinary complications) and length of hospital stay, was also recorded. Postoperatively, all ankles were splinted and kept immobilized for 3 weeks. At that time, active-assisted ankle range 554

Figure 1. Distance between c and d divided by distance between a and b seen in lateral computed tomography scan is equal to percentage of fragment.

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Post-traumatic arthritis imaging score on X-ray of ankle joint during follow-up was recorded and classified using the following scores: 0 indicated normal joint, 1 indicated osteophytes but no joint space narrowing, 2 indicated joint space narrowing with or without osteophytes, and 3 indicated disappearance or deformation of joint space.[14] Ankle-Hindfoot Scale of American Orthopaedic Foot and Ankle Society (AOFAS)[15] and American Academy of Orthopedic Surgeons (AAOS) foot and ankle questionnaire[16] were used to asses functional outcome. Both scores range from 0 to 100 points, where 0 is the worst result possible. AOFAS consists of questionnaire examining pain (40 points), function in daily living (28 points), ROM (22 points), and ankle alignment (10 points). AAOS questionnaire is comprised of 25 questions regarding experience of ankle disability in the past week. Visual Analog Scale (VAS) was used to quantify pain at time of survey when resting and walking (score 0–10 where 0 represents no pain and 10 indicates unbearable pain). Finally, general physical examination of the ankle was performed and ROM of the affected ankle was evaluated. Restriction in dorsiflexion was compared with contralateral, uninjured side; difference was noted as dorsiflexion restriction. Greater dorsiflexion restriction reflects worse outcome. Statistical analysis included mean value of ROM of ankle joint on affected and unaffected side. Paired samples t-test was

(a)

(b)

(c)

used to compare ROM value between ankles. P value of <0.05 represented statistical significance.

RESULTS Fifty-seven patients were evaluated. There were 36 females and 21 males, from 23 to 85 years of age (mean: 55.9 years). None of the patients had pre-existing ankle arthritis. Etiology was motor vehicle accident for 16 (28.1%) patients, fall from height for 18 (31.5%), and ground-level fall for 23 (40.3%). In 46 cases, after anatomical reduction of lateral and medial malleolus, PM fixation was performed with 1 or 2 3.5 mm cannulated screws, from anterior to posterior in 35 cases (Figure 2), and from posterior to anterior in 11 cases (Figure 3). In remaining 11 cases, PM plate was used for fixation (Figure 4). Average time to surgery was 1.1 day (range: 1–3 days). Mean tourniquet time was 96 minutes (range: 78–109 minutes). Mean fragment size was 21.06±6.24% (range: 13–36%). In 38 cases, fragment size was <25%, while in 19 cases, fragment size was ≥25%. Mean fragment size and percentage of involved distal tibial articular surface was 18.65±3.83% (range: 13–25%) in PMF fixed with cannulated screws and 31.22±3.56% (range: 25–36%) when plate was used. Average length of hospital stay was 6.3 days (range: 3–21 days). There was 1 superficial wound infection, which resolved with use of oral antibiotics after index surgery. No

(d)

(e)

(f)

(g)

Figure 2. Posterior malleolar fracture treated with anteroposterior screw fixation (a) preoperative anteroposterior X-ray, (b) preoperative lateral X-ray, (c) preoperative sagittal section, (d) intraoperative anteroposterior X-ray, (e) intraoperative lateral X-ray, (f) postoperative 2-year X-ray, (g) postoperative 2-year lateral X-ray.

(a)

(b)

(c)

(d)

(e)

(f)

(g)

Figure 3. Posterior malleolar fracture treated with posteroanterior screw fixation (a) preoperative anteroposterior X-ray, (b) preoperative lateral X-ray, (c) preoperative sagittal section, (d) intraoperative anteroposterior X-ray, (e) intraoperative lateral X-ray, (f) postoperative 2-year X-ray, (g) postoperative 2-year lateral X-ray.

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Karaca et al. Importance of fixation of posterior malleolus fracture in trimalleolar fractures

(a)

(b)

(c)

(d)

(e)

(f)

(g)

Figure 4. Posterior malleolar fracture treated with plate fixation (a) preoperative anteroposterior X-ray, (b) preoperative lateral X-ray, (c) preoperative sagittal section, (d) postoperative 6-month X-ray, (e) postoperative 6-month lateral X-ray, (f) postoperative 2-year X-ray, (g) postoperative 2-year lateral X-ray.

loss of reduction occurred on radiographic follow-up, and no hardware irritation or failure was seen. Clinical union of fracture was achieved in 3 months in all patients. At final follow-up, arthritis score was 0 or 1 (mean: 0.63) for all patients. AOFAS score indicated results were excellent in 21 patients and good in 26 patients. Mean AAOS score was 92.4 (range: 32–100). Mean VAS score was 1.1 when resting and 1.3 when walking (range: 0–10). Average dorsiflexion was 14.8°±2.7° (range: 11–23°) on affected side and 22.3°±2.5° (range: 17–27°) on unaffected site. Loss of dorsiflexion of ankle joint in affected side was mean 7°. There was significant difference in dorsiflexion of ankle joint between sides (p<0.001). Average plantar flexion was 38.6°±3.5° (range: 33–44°) in affected side and 47°±3.1° (range: 41–54°) in uninjured side. But there was no significant difference (p=0.325) in plantar flexion of ankle joint between sides (Table 2).

DISCUSSION In recent years, there has been increased interest in fixing PMF fragments.[5,7,13] It is thought that it might reduce development of OA, which would ultimately result in better function. As of yet, however, there is no good scientific evidence of this. Table 2. Comparison of range of motion between affected and unafffected side

Dorsiflexion Plantarflexion

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

Affected side

14.8°±2.7°

38.6°±3.5°

(11 to 23)

(33 to 44)

Unaffected side

22.3°±2.5°

47°±3.1°

(17 to 27)

(41 to 54)

<0.001

0.325

P value

SD: Standard deviation; Min.: Minimum; Max.: Maximum.

556

Treatment of ankle fractures involving PM has been source of intense debate over the last several decades. Both nonoperative and surgical treatments have been proposed by many authors. Factors such as fragment size, joint congruity, and talocrural and syndesmotic stability have to be taken into account for optimal treatment of PMF. While some authors have found no differences in clinical outcomes and ankle stability in PMF treatment based on posterior fixation, others have found that reduction and fixation performed on large fragments yields better results.[2,11,17,18] Furthermore, nonanatomical reduction of PMF leads to worse outcomes than non-operative treatment.[19] In this study, all PMF were fixed and there was normal reduction. Good clinical results were obtained compared to unaffected ankle, AOFAS assessment was excellent/good for all patients, at rate of 21/26, and mean AAOS score was 92, which is comparable to other studies of outcomes after ankle fracture.[20,21] Mean VAS pain score was 1.1 when resting and 1.3 when walking (range: 0–10), which is also comparable to the literature.[20] PM is an important structure of the distal tibiofibular joint, as it provides osseous restraint for the distal fibula as well as stability of the syndesmosis through the posterior inferior tibiofibular ligament (PITFL) and inferior transverse ligament. The other important effect of stabilizing PM is to restore attached PITFL to anatomic position with appropriate tension and integrity. This may be important even for smaller fractures when joint stress transfer is not significantly altered. Gardner et al. reported that increased syndesmotic stability was obtained in simulated cadaveric pronation external rotation stage 4 fractures after fixation of posterior fragment compared with conventional syndesmotic screw fixation.[5] Another study suggested that CT scans might help to accurately determine size and anatomy of PM preoperatively.[22] In present study, all fractures were evaluated by CT scan preoperatively and size of fragment was measured on sagittal scan. Restriction of dorsiflexion has been found to be significantly decreased compared with uninjured side.[23] In this study, we Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Karaca et al. Importance of fixation of posterior malleolus fracture in trimalleolar fractures

also found significant difference between injured and uninjured side when comparing dorsiflexion.

6. van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma 2009;66:279–84.

There is no consensus in the literature regarding fragment size of PMF that should be fixed. Minimum size of fragments fixed in the present study was 10%. Lindsjö et al. found significantly higher incidence of post-traumatic OA among patients with posterior fragments involving the tibial plafond (34%) than in fractures with small posterior fragments (17%) or no posterior involvement (4%).[11] Jaskulka et al. reported that even small PM fragments (tibial rim fractures) may increase risk of arthritis.[2] In our study, correlation between fragment size and arthritis was not evaluated. But score of arthritis was 0 or 1 on follow-up.

7. Özkan Y, Öztürk A, Özdemir R, Atıcı T, Özbölük S. The results of surgical management of ankle fractures. Ulus Travma Acil Cerrahi Derg 2005;11:329–35.

Limitations of this study include that there was no non-operative control group, and due to relatively small cohort, there was no comparison made between fragment size and results or between plate fixation and screw fixation. Retrospective nature of this study contributes to a certain amount of bias. Strengths of the study include that CT scan was used to measure size of fragments and results of minimum 2-year followup were evaluated.

Conclusion In conclusion, unstable ankle fractures with PM involvement require surgical fixation. Fixation of even small PM fragments can facilitate rehabilitation by creating a more stable construction. This might stabilize the syndesmosis, and make early range of motion easier. Procedure offers benefit even in elderly patients where bone quality may make adequate fixation difficult. Conflict of interest: None declared.

REFERENCES 1. Daly PJ, Fitzgerald RH Jr, Melton LJ, Ilstrup DM. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthop Scand 1987;58:539–44. 2. Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma 1989;29:1565–70. 3. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem? Acta Orthop Scand 1998;69:43–7. 4. Neumaier Probst E, Maas R, Meenen NM. Isolated fracture of the posterolateral tibial lip (Volkmann’s triangle). Acta Radiol 1997;38:359–62. 5. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006;447:165–71.

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8. Raasch WG, Larkin JJ, Draganich LF. Assessment of the posterior malleolus as a restraint to posterior subluxation of the ankle. J Bone Joint Surg Am 1992;74:1201–6. 9. Scheidt KB, Stiehl JB, Skrade DA, Barnhardt T. Posterior malleolar ankle fractures: an in vitro biomechanical analysis of stability in the loaded and unloaded states. J Orthop Trauma 1992;6:96–101. 10. Macko VW, Matthews LS, Zwirkoski P, Goldstein SA. The joint-contact area of the ankle. The contribution of the posterior malleolus. J Bone Joint Surg Am 1991;73:347–51. 11. Lindsjö U. Operative treatment of ankle fracture-dislocations. A follow-up study of 306/321 consecutive cases. Clin Orthop Relat Res 1985;199:28–38. 12. de Souza LJ, Gustilo RB, Meyer TJ. Results of operative treatment of displaced external rotation-abduction fractures of the ankle. J Bone Joint Surg Am 1985;67:1066–74. 13. Erdem MN, Erken HY, Burc H, Saka G, Korkmaz MF, Aydogan M. Comparison of lag screw versus buttress plate fixation of posterior malleolar fractures. Foot Ankle Int 2014;35:1022–30. 14. Domsic RT, Saltzman CL. Ankle osteoarthritis scale. Foot Ankle Int 1998;19:466–71. 15. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15(7):349–53. 16. Johanson NA, Liang MH, Daltroy L, Rudicel S, Richmond J. American Academy of Orthopaedic Surgeons lower limb outcomes assessment instruments. Reliability, validity, and sensitivity to change. J Bone Joint Surg Am 2004;86:902–9. 17. Harper MC. Talar shift. The stabilizing role of the medial, lateral, and posterior ankle structures. Clin Orthop Relat Res 1990;257:177–83. 18. Hartford JM, Gorczyca JT, McNamara JL, Mayor MB. Tibiotalar contact area. Contribution of posterior malleolus and deltoid ligament. Clin Orthop Relat Res 1995;320:182–7. 19. McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res 1977;122:37–45. 20. Mingo-Robinet J, López-Durán L, Galeote JE, Martinez-Cervell C. Ankle fractures with posterior malleolar fragment: management and results. J Foot Ankle Surg 2011;50:141–5. 21. Yu G, Zhao H, Yang Y, Zhou J, Yuan F, Li H. Effectiveness of open reduction and internal fixation in treatment of posterior malleolus fractures. [Article in Chinese] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2011;25:774–7. [Abstract] 22. Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am 2006;88:1085–92. 23. Xu HL, Li X, Zhang DY, Fu ZG, Wang TB, Zhang PX, et al. A retrospective study of posterior malleolus fractures. Int Orthop 2012;36:1929–36.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Trimalleoler ayak bileği kırıklarında posterior malleol fiksasyonunun önemi: Retrospektif çalışma Dr. Sinan Karaca,1 Dr. Meriç Enercan,2 Dr. Güzelali Özdemir,1 Dr. Sinan Kahraman,3 Dr. Mutlu Çobanoğlu,4 Dr. Metin Küçükkaya3 Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul İstanbul Florence Nightingale Hastanesi, Ortopedi ve Travmatoloji Kliniği, İstanbul Adnan Menderes Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, İstanbul 4 İstanbul Bilim Universitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Bölümü, İstanbul 1 2 3

AMAÇ: Bu çalışmanın amacı cerrahi olarak tedavi edilen trimalleoler kırıklarda posterior malleol (PM) fiksasyonunun etkinliği ve önemini değerlendirmektir. GEREÇ VE YÖNTEM: 2004 ile 2011 yılları arasında PM içeren ayak bileği eklemi kırıklı toplam 57 olgu açık redüksiyon ve internal fiksasyonla tedavi edildi. Posterior malleol fiksasyonu 46 olguda kanüllü vida ile, 11 olguda plak ise plak ile gerçekleştirildi. Tüm olgular Amerikan Ortopedik Ayak ve Ayak Bileği birliği Skoru (AOFAS), Amerikan Ortopedik Cerrahlar Akademisi Ayak ve Ayak Bileği Anketi (AOOS), Görsel Analog Skala (VAS) ve sağlam tarafla karşılaştırılan ayak bileği eklemi hareketliliği ile değerlendirildi. BULGULAR: Yaşları 23 ile 85 arasında (ortalama 55.9) olan, 36’sı kadın ve 21’i erkek olan olguların ortalama takip süresi 44.6 (24–108) aydı. Cerrahiye kadar geçen süre 1.1 (1–3) gündü. AOFAS’a göre 21 olgu mükemmel ve 26 olgu iyi olarak değerlendirildi. AOOS skoru ortalama 92.4 (32–100) idi. Ortalama VAS istirahatta 1.1 ve yürümede 1.3 idi. Sağlam tarafla karşılaştırıldığında, ayak bileği eklemi plantar fleksiyonunda anlamlı farklılık görülmedi (p=0.325) ancak ayak bileği eklemi dorsifleksiyonunda anlamlı farklılık görüldü (p<0.001). TARTIŞMA: Posterior malleolün anatomik redüksiyon ve rijit internal fiksasyonu, yeterli fiksasyon için zayıf kemik kalitesi problem olan yaşlı hastalarda bile tatminkar klinik ve fonksiyonel sonuçlar sağlar. Küçük PM fragmanlarının bile fiksasyonu rehabilitasyona daha stabil bir yapı oluşturabilir. Anahtar sözcükler: Ayak bileği kırığı; posterior malleol; sindezmoz yaralanması. Ulus Travma Acil Cerrahi Derg 2016;22(6):553–558

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doi: 10.5505/tjtes.2016.44844

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ORIG I N A L A R T IC L E

Investigation of hand function among children diagnosed with autism spectrum disorder with upper extremity trauma history Meral Huri, M.D., Sedef Şahin, M.D., Hülya Kayıhan, M.D. Department of Occupational Therapy, Hacettepe University Faculty of Health Sciences, Ankara-Turkey

ABSTRACT BACKGROUND: The present study was designed to compare hand function in autistic children with history of upper extremity trauma with that of autistic children those who do not have history of trauma. METHODS: The study group included total of 65 children diagnosed with autism spectrum disorder (ASD) and was divided into 2 groups: children with trauma history (Group I) and control group (Group II) (Group I: n=28; Group II: n=37). Hand function was evaluated with 9-Hole Peg Test and Jebsen Hand Function Test. Somatosensory function was evaluated using somatosensory subtests of Sensory Integration and Praxis Test. Results were analyzed with Student’s t-test and Mann-Whitney U test using SPSS version 20 software. RESULTS: Hand function and somatosensory perception test scores were statistically significantly better in children without upper extremity trauma history (p<0.05). When association between hand function tests and upper extremity somatosensory perception tests was taken into account, statistically significant correlations were found between all parameters of hand function tests and Manual Form Perception and Localization of Tactile Stimuli Test results (p<0.05). CONCLUSION: Autistic children with upper extremity trauma history had poor somatosensory perception and hand function. It is important to raise awareness among emergency service staff and inform them about strong relationship between somatosensory perception, hand function, and upper extremity trauma in children with ASD in order to develop appropriate rehabilitation process and prevent further trauma. Keywords: Autism; hand; tactile perception.

INTRODUCTION Hand and upper extremity traumas are one of the most important health problems for children after the age of 1 year old, and it is one of the most common reasons for visits to emergency services.[1,2] According to results of 2 retrospective studies, the percentage of patients applying to pediatric emergency services for hand injuries in children were 1.7% and 2%, respectively; 65% of them were bone injuries, while 33% of them were soft tissue injuries.[3] The incidence of having a bone injury before 2 years of age was 34/100,000, Address for correspondence: Meral Huri, M.D. Hacettepe Üniversitesi Sağlık Bilimleri Fakütesi, Ergoterapi Bölümü, Sıhhiye, 06460 Ankara, Turkey Tel: +90 532 - 655 55 90 E-mail: meralhuri@yahoo.com Qucik Response Code

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663/100,000 for 10-year-old children and 418/100,000 overall.[3,4] Additionally, according to results of a meta-analysis, having a disability makes a child more vulnerable to trauma. It was reported that 33% of disabled children faced an upper extremity trauma that led them to seek care at pediatric emergency services during their lifetime.[5] Approximately 32% of these disabled children treated at emergency services were diagnosed with physical disability, while 24% were diagnosed with neurodevelopmental disorder.[4] Autism spectrum disorder (ASD) is defined as neurodevelopmental disorder characterized by impaired social interaction and communication, both verbal and non-verbal, as well as restricted and repetitive behavior with sensory difficulties.[6] Number of children with ASD is increasing; medical and emergency service staff need to be more aware of commonly seen sensory, motor, and perceptual differences in these children, as they can include self-injury behaviors or lead to trauma while participating in activities of daily living (ADL).[7] For example, 2 studies reported that children with autism 559

Huri et al. Investigation of hand function among children diagnosed with autism spectrum disorder with upper extremity trauma history

have self-injury behavior rate ranging from 5% to 66%, and that childhood trauma occurred during daily activities at rate ranging from 12% to 53%.[7,8] Iannuzzi et al. suggested that trauma among children with ASD may be related to somatosensory (tactile and proprioceptive) perception and praxis problems (limitations in ideation, problem solving, and motor planning), which can cause stereotypical hand behaviors and clumsiness in daily life.[7] Somatosensory perception of children with ASD has been found to be lower than typically developing peers in various studies.[9,10] There is also strong research supporting idea that hand function in children with ASD is lower than typically developing peers.[11] But researchers are still trying to understand the complex relationship between advanced skills and hand/upper extremity function in children diagnosed with ASD.[10–12] To our knowledge, this is the first study reporting the sensory and functional differences between autistic children with and without upper extremity trauma history. The primary purpose of the study was to compare levels of somatosensory perception and hand function between autistic children with and without upper extremity trauma history.

MATERIALS AND METHODS Department of Occupational Therapy at Hacettepe University Faculty of Health Sciences is a referral center for pediatric rehabilitation with interdisciplinary team of occupational therapists and physical therapists. Pediatric Rehabilitation Unit of the department accepts pediatric patients with various diagnoses such as autism spectrum disorders, cerebral palsy, neuromuscular disorders, and learning disorders. The present study is a single-centered retrospective analysis of children who participated in occupational therapy at the Pediatric Rehabilitation Unit between September 2, 2014 and January 1, 2016. All data used in this study were collected from database of Pediatric Rehabilitation Unit. Relevant information from patient medical files was recorded on standardized data collection form and subsequently entered into a database. All information in the database was double-checked against data collection forms. Random sample of 10% of medical files was rechecked and compared with data collection form for any errors. If error rate greater than 5% was found, study protocol required rechecking another random sample of 40% of patient files. Any discrepancies found were corrected. Data were de-identified to maintain patient privacy. Individual patient consent was not obtained. The Hacettepe University ethics committee approved the study. Total of 323 files were evaluated. Children aged between 3 years and 8 years, 11 months and who had been diagnosed with ASD according to criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, with intelligence quotient (IQ) score of at least 60 were included. Children with mixed developmental disorders or medical disorders such as additional mental retardation, congenital anomalies/ 560

malformations (81 children), unexpected brain anomalies (7 children), disorders with auditory or visual cortex problems (19 children), systemic disease such as diabetes or metabolic syndrome (3 children), epilepsy (21 children), and chromosome abnormalities such as Fragile X Syndrome (3 children) were excluded. Files with missing data were eliminated (33 children). In total, 65 children met the inclusion criteria and were included in the study. Study participants were separated into 2 groups: children with trauma history were placed in Group I (n=28; male: 22; mean age: 6.42±2.1 years) and children without history of trauma made up Group II (n=37; male: 32; mean age: 7.13±1.5 years). Demographic information form developed by the authors and used regularly during initial evaluation of children who apply for occupational therapy was used. Form includes details of age, gender, IQ level (obtained from medical records and parental interview), parental information, severity of autism, trauma history, and physical and social development milestones. Somatosensory subtests of Sensory Integration and Praxis Test (SIPT) were used to evaluate tactile, muscle, and joint perception of the hand and upper extremity, while 9-Hole Peg Test (9-HPT) and Jebsen Hand Function Test were used to assess hand function. These are the gold standard tests for children and they are used worldwide by occupational therapists. SIPT is a valid and reliable test for assessing sensory integration and praxis skills of children aged between 4 years and 8 years, 11 months. Certified occupational therapist administers Manual Form Perception, Kinesthesia, Graphesthesia, Finger Identification, and Localization of Tactile Stimuli subtests of SIPT to evaluate somatosensory perception. Manual Form Perception and Localization of Tactile Stimuli subtests specifically test somatosensory perception, while the other tests include assessment of praxis.[13–17] The 9-Hole Peg Test is a brief, standardized, quantitative test of upper extremity function. Both dominant and non-dominant hands are tested twice. Child is seated at a table with a small, shallow container holding 9 pegs and a wooden or plastic block with 9 empty holes. Start command is given, stopwatch is started, and patient picks up the 9 pegs 1 at a time as quickly as possible using just the hand being tested, puts them in the holes, and, once 9 holes are filled, removes the pegs one at a time, replacing them in the shallow container as quickly as possible. Time required to complete the task is recorded. Two consecutive trials with dominant hand are immediately followed by 2 consecutive trials with nondominant hand.[18,19] Jebsen Hand Function Test evaluates unilateral hand skills and provides an objective assessment of hand function involved in ADL. Test includes a series of 7 subtests performed with Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

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each hand that represent a wide range of tasks involving upper extremities. Subtests consist of the following: (1) printing a 24-letter, third-grade reading difficulty sentence; (2) turning over 7.6x12.7 cm (3x5 in) cards (simulated page turning); (3) picking up small, common objects (such as coins, paper clips, bottle caps) and placing them in a container; (4) stacking checkers (test of eye-hand coordination); (5) simulated feeding; (6) moving large, empty cans; and (7) moving large, weighted (0.45 kg) cans. Subtest scores are the number of seconds required to complete each task.[20,21] All statistical analysis was performed using SPSS software, version 20 (SPSS, Inc., Chicago, IL, USA).[22] Descriptive statistics, including proportions, means, medians, standard deviations, and confidence intervals were calculated for demographic characteristics, clinical features, and test results. Student’s t-test and Mann-Whitney U test, were used to analyze the data, as appropriate. Statistical significance was defined as p<0.05.

RESULTS Total of 65 children with ASD were included in the study. Group I comprised 28 children with mean age of 6.42±2.1 years; 22 were male and 6 were female. There were 37 children in Group II with mean age of 7.13±1.5 years; 32 were male and 5 were female. Severity of ASD according to DSM-

5 in Group I was 25% (n=7) severe, 35.7% (n=10) moderate, and 39.2% (n=11) mild; in Group II, 27.2% (n=10) were classified as severe, 32.4% (n=12) moderate, and 40% (n=15) mild. When trauma history was evaluated for Group I, 53.5% (n=15) were orthopedic injuries caused by fall (bone injuries resulting from fall on stairs, from window or high place, wrist injuries), 35.7% (n=10) were soft tissue injuries to upper extremity or hand (self-injury, knife cut, burn, bite), and 10.7% (n=3) were upper extremity injuries caused by total body complex trauma (struck by car as result of pedestrian error, home or school accidents). Mean age of mother at childbirth in Group I was 25.43±5.34 years and 67.8% (n=19) had graduated from university. Mean age of mother was 33.62±6.19 years and 64.8% (n=24) had graduated from university in Group II. The 2 groups were statistically different according to mother’s age and education level (p<0.05). Table 1 illustrates comparison of average scores of Group I and Group II on Manual Form Perception, Kinesthesia, Finger Identification, Graphesthesia, and Localization of Tactile Stimuli subtests. Results indicated that autistic children with trauma history had significantly lower scores on all somatosensory perception subtests than autistic children without trauma history (p<0.05).

Table 1. Somatosensoriel perception tests scores for Group I and Group II

Group I (n=28)

Group II (n=37)

<0.001

Manual Form Perception

-2.76

-.1.82

-2.13

Kinesthesia

-3.00

-2.75

-1.63 <0.001

Graphesthesia

-2.80

-2.13

-3.54 <0.001

Finger Identification

-2.86

-1.91

-3.41

<0.001

Localization of Tactile Stimuli

-2.02

-1.85

-2.43

<0.001

Table 2. Scores of 9-Hole Peg Test for Group I and Group II

Group I (n=28)

Group II (n=37)

Mean±SD

9-Hole Peg Test (right-hand, s) Insert

74±37.43

57.34±21.32

-8.34

<0.001

Extract

41.34±11.2

29.43±11.23

-6.31

<0.001

Insert

88.43±43.45

61.43±32.61

-7.45

<0.001

Extract

53.21±6.62

18.45±8.5

-7.12

<0.001

9-Hole Peg Test (left-hand, s)

SD: Standard deviation.

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Table 2 demonstrates comparison of average speed of Group I and Group II on 9-Hole Peg Test. According to the results, slower speed of autistic children with trauma history was statistically significant (p<0.05). Comparison of average speed in each performance of Group I and Group II for Jebsen Hand Function Test can be seen in Table 3. Performance of autistic children with trauma history was statistically significantly slower than that of the autistic children without trauma history (p<0.05). Relationships between somatosensory perception subtests and hand function tests are provided in Table 4. Negative correlations between scores on Manual Form Perception, Localization of Tactile Stimuli subtests, all subtests of 9-Hole Peg Test, and Jebsen Hand Function Test were found (p<0.05).

DISCUSSION There are variety of upper extremity traumas that children can face during childhood. Although their recovery is better than that of adults, trauma during childhood can cause longterm severe injuries.[1–4] If they do not reach motor, sensory, or cognitive developmental milestones, children with disabilities can have difficulty adapting to their environment, and this makes them more vulnerable to trauma.[5]

Especially for children with ASD, developmental delays in sensory and motor performance can lead to childhood trauma such as upper extremity self-injury behavior or clumsiness due to dyspraxia (motor planning problems).[7] The aim of the present study was to compare levels of somatosensory perception and hand function in autistic children with and without history of upper extremity trauma. Studies have reported that trauma in childhood is seen more often in boys than girls in the 10- to 12-year-old age group, and that incidence of trauma is higher among 13- to 14- yearolds with physical disabilities while it is high in 6- to 8-year-old children with neurodevelopmental disorders such as ASD.[1–5] Trauma history data of children in the present study reflected similar age and gender characteristics.[1–5] It is thought that the incidence of ASD is 4 times higher in boys than in girls, but when seen in girls, the severity of autism is often greater. [6–8] As a result, girls are often less independent in performing daily living activities, and therefore they may be more protected from trauma due to greater role of caregiver. Boys may be more vulnerable to trauma and represent the majority of cases despite less severe diagnosis. Some studies have also reported that children of younger mothers with lower education level suffer greater incidence

Table 3. Scores of Jebsen Hand Function Test for Group I and Group II

Group I (n=28)

Group II (n=37)

Mean±SD

Printing

264.64±231.94 125.43±42.54 -3.16 <0.001

Turning over (s) Right

11.55±3.23

9.76±3.21

-3.85

<0.001

Left

11.43±2.54

9.12±2.32

-6.73

<0.001

Right

8.77±3.45

6.81±3.13

-5.14

<0.001

Left

9.12±2.78

8.43±2.65

-5.32

<0.001

Right

12.34±4.32

5.62±3.19

-4.73

<0.001

Left

12.42±4.51

7.52±1.94

-3.76

<0.001

Right

9.54±1.23

7.73±1.62

-4.82

<0.001

Left

9.39±2.74

7.63±2.71

-4.12

<0.001

Right

13.54±3.26

7.41±2.64

-4.23

<0.001

Left

12.35±4.31

9.52±1.43

-4.63

<0.001

Right

14.32±3.26

8.63±2.84

-5.49

<0.001

Left

16.53±4.37

9.41±2.23

-5.71

<0.001

Picking up objects (s)

Stacking checkers (s)

Simulated feeding (s)

Moving large empty can (s)

Moving large weighted can (s)

SD: Standard deviation.

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Table 4. Relationships between Finger Identification and Localization of Tactile Stimuli tests and hand function tests (9-Hole Peg Test and Jebsen Hand Function Test) scores for Group I and Group II

Manual Form Perception

Localization of Tactile Stimuli

Group I r (p)

Group II r (p)

Group I r (p)

Group II r (p)

9-Hole Peg Test (total s left and right hand)

Insert

-0.812 (<0.001)

-0.623 (<0.001)

-0.872 (<0.001)

-0.673 (<0.001)

Extract

-0.853 (<0.001)

-0.639 (<0.001)

-0.874 (<0.001)

-0.629 (<0.001)

Jebsen Hand Function Test

Printing

-0.711 (<0.001)

-0.583 (<0.001)

-0.784 (<0.001)

-0.591 (<0.001)

Turning over

-0.817 (<0.001)

-0.694 (<0.001)

-0.749 (<0.001)

-0.632 (<0.001)

Picking up objects

-0.883 (<0.001)

0.616 (<0.001)

-0.829 (<0.001)

-0.548 (<0.001)

Stacking checkers

-0.780 (<0.001)

-0.621 (<0.001)

-0.772 (<0.001)

-0.631 (<0.001)

Simulated feeding

-0.832 (<0.001)

-0.711 (<0.001)

-0.799 (<0.001)

-0.597 (<0.001)

Moving large empty can

-0.769 (<0.001)

-0.597 (<0.001)

-0.758 (<0.001)

-0.511 (<0.001)

Moving large weighted can

-0.849 (<0.001)

-0.623 (<0.001)

-0.793 (<0.001)

-0.526 (<0.001)

r=Spearman correlation coefficient.

of trauma than children with older, more educated mothers. [1–5] In the present study, consistent with the literature, mother’s age and education level were lower in cases of children with trauma history than the children without trauma history. It is thought that age and education level of the mother are important to prevention of trauma in children with ASD. There is good evidence that hand function of typically developing children is better than that of children with disabilities. [11] Children with ASD may have different levels of fine motor skills.[11,12] About 10% of the children with ASD have a similar level of fine motor skills to each other, but there is a big gap between level of hand function in typically developing children with and without trauma history, and furthermore an even greater gap exists in hand function among autistic children with trauma history.[9,11] The literature supports theory that children with ASD may have somatosensory perception problems.[14,23–26] Consistent with the literature, results of the present study indicated that children with ASD have poor somatosensory scores compared with norms of their typically developing peers.[23–26] However, the literature is still limited regarding somatosensory perception of children with history of trauma.[7,8] As this study is the first study in this area, it provides some evidence that autistic children without trauma history had higher scores on all somatosensory subtests of SIPT, suggesting that children with ASD and trauma history have weaker somatosensory perception. Physical and social environment have a great impact on sensory and motor development of children.[23,24] Differences in motor and sensory development of children with ASD may Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

affect ability to reach developmental milestones.[23–26] This developmental delay may lead to difficulties carrying out daily living activities.[17,18] Therefore, Jebsen Hand Function Test was used to assess hand function while performing daily living activities, as well as 9-Hole Peg Test, which assesses speed of hand function. According to the literature, endurance and speed in use of upper extremity and hand affect quality life of children with ASD.[20,21] Studies have shown that sensory and motor development differences may cause motor planning difficulty during daily living activities, affecting quality of life of children with ASD from early stage of life.[14–18,23–26] The present study indicated that autistic children without history of trauma had better scores in 9-Hole Peg Test and Jebsen Hand Function Test. It has been determined that autistic children with trauma history had greater limitation in fine motor skills. [11,20] It is thought that somatosensory perception problems may increase rate of trauma experience during childhood, and that this may be related to decreased scores for hand function and speed tests. There are study results demonstrating lower scores on 9-Hole Peg Test and Jebsen Hand Functions Test for children with ASD compared with typically developing peers, but there is not yet sufficient evidence on hand function among children with trauma history.[11,20] Our study revealed that hand function of autistic children with trauma history was slower and poor in comparison with those who did not have trauma history. Briefly, our study results indicated that somatosensory perception and hand function of autistic children without trauma history was better than those of autistic children with trauma history. Autistic children with history of trauma may 563

Huri et al. Investigation of hand function among children diagnosed with autism spectrum disorder with upper extremity trauma history

have somatosensory perception problem that complicates or obstructs achieving greater proficiency level in performance of daily living activities, which may also expose these children to greater risk of further trauma. The present study demonstrated relationship between somatosensory perception tests and subtests of hand function. Results of Manual Form Perception Test and Localization of Tactile Stimuli Tests correlated with those of the subtests of hand functions in the present study, which is consistent with the literature.[9,10] This result indicates that those tests can not only be used to identify problems and successes in hand manipulation skills of children with ASD, but may provide valuable insight with regard to possible upper extremity trauma. In summary, our study results are initial evidence that children with ASD who have difficulty with Manual Form Perception Test and Localization of Tactile Stimuli Test are more likely to have experienced upper extremity trauma. All of the tests used in the present study are standardized and can be used to assess children with ASD. It is generally thought that 9-Hole Peg Test is easy and suitable for younger children with ASD. Writing and page-turning subtests of Jebsen Hand Function Test offer advantages for assessment of hand function of school-age children with autism. Eating subtest of Jebsen Hand Faction Test can give indication about hand function while performing daily living activities. Somatosensory perception and hand function of autistic children with trauma were very poor, which increases risk of trauma occurring in daily life. Early occupational therapy interventions to increase somatosensory perception and hand function may help to prevent trauma in autistic children.

Conclusion It is crucial to understand upper extremity function in children with ASD as it may affect the child’s ability to perform daily living activities. It may be explained by the complex relationships between hand perception and function. Male children with ASD with lower mother education level experienced upper extremity trauma more often than female children with ASD with higher mother education level in the present study. Improving mother’s level of awareness about limitations of upper extremity function, perception, and the kinds of traumas that children with ASD can face is very important. Caregivers of children with mild and moderate autistic severity must observe the child while participating in daily living activities to prevent possible upper extremity trauma. Lack of upper extremity perception and function can lead to upper extremity trauma, but can also inform with regard to rehabilitation needs of the children. It is also important to inform and raise awareness of emergency service staff about complex relationships between upper extremity perception, function, and trauma history among children with ASD. This study will provide basic knowledge for future interdisci564

plinary teamwork with rehabilitation therapists and emergency service staff for children diagnosed with ASD and may help the children in this population to be evaluated and treated for somatosensory perception problems earlier and prevent further trauma. Conflict of interest: None declared.

REFERENCES 1. Jiménez-Escobar I, Weingerz-Mehl S, Castillo-Macedo E, JiménezGutiérrez C, Gutiérrez-Castrellón P. Characterization of adolescents and reason for the visit when attending the pediatric emergency department of the General Hospital Dr. Manuel Gea González. [Article in Spanish] Gac Med Mex 2016;152:30–5. [Abstract] 2. Gornitzky AL, Milby AH, Gunderson MA, Chang B, Carrigan RB. Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center. Orthopedics 2016;39:333–9. 3. Valencia J, Leyva F, Gomez-Bajo GJ. Pediatric hand trauma. Clin Orthop Relat Res 2005;(432):77–86. 4. Duman A, Kapçı M, Bacakoğlu G, Akpınar O, Türkdoğan KA, Karabacak M. Evaluation of trauma patients in emergency department. Medical Journal of Suleyman Demirel University 2014;21:2. 5. Hoxter S. The significance of trauma in the difficulties encountered by physically disabled children. Journal of Child Psychotherapy 1986;12:87–102. 6. Lauritsen MB. Autism spectrum disorders. Eur Child Adolesc Psychiatry 2013;22:7–42. 7. Iannuzzi DA, Cheng ER, Broder-Fingert S, Bauman ML. Brief report: Emergency department utilization by individuals with autism. J Autism Dev Disord 2015;45:1096–102. 8. Kalb LG, Stuart EA, Freedman B, Zablotsky B, Vasa R. Psychiatric-related emergency department visits among children with an autism spectrum disorder. Pediatr Emerg Care 2012;28:1269–76. 9. Huri M, Mehr BK, Altuntaş O, Kayihan H. Yaygın gelişimsel bozukluğu olan ve normal gelişim gösteren çocukların taktil tercihlerinin karşılaştırılması. Ergoterapi ve Rehabilitasyon Dergisi 2014;2:21–8. 10. Azouz HG, Khalil M, El Ghani HMA, Hamed HM. Somatosensory evoked potentials in children with autism. Alexandria Med J 2014;50:99– 105. 11. Provost B, Heimerl S, Lopez BR. Levels of gross and fine motor development in young children with autism spectrum disorder. Phys Occup Ther Pediatr 2007;27:21–36. 12. Lloyd M, MacDonald M, Lord C. Motor skills of toddlers with autism spectrum disorders. Autism 2013;17:133–46. 13. Lai JS, Fisher AG, Magalhães LC, Bundy AC. Construct validity of the sensory integration and praxis tests. OTJR 1996;16:75–97. 14. Roley SS, Mailloux Z, Parham LD, Schaaf RC, Lane CJ, Cermak S. Sensory integration and praxis patterns in children with autism. Am J Occup Ther 2015;69:6901220010. 15. Bodison SC. Developmental Dyspraxia and the Play Skills of Children With Autism. Am J Occup Ther 2015;69:6905185060. 16. Oswald D. Sensory differences in autism. Research Reports 2013. 17. Stackhouse TM, Kuhaneck HM, Watling R. Motor differences in the autism spectrum disorders. Autism: A comprehensive occupational therapy approach 2010:163–200. 18. Wang YC, Magasi SR, Bohannon RW, Reuben DB, McCreath HE, Bubela DJ, et al. Assessing dexterity function: a comparison of two alter-

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Huri et al. Investigation of hand function among children diagnosed with autism spectrum disorder with upper extremity trauma history natives for the NIH Toolbox. J Hand Ther 2011;24:313–21. 19. Wang YC, Bohannon RW, Kapellusch J, Garg A, Gershon RC. Dexterity as measured with the 9-Hole Peg Test (9-HPT) across the age span. J Hand Ther 2015;28:53–9; quiz 60. 20. Carr K, McKeen P, Daabous J, Azar N, Horton S, Sutherland C. Reliability of four subtests of the jebsen test of hand function among adults with autism and an intellectual disability. Journal of Developmental Disabilities 2015;21:1. 21. Harte D, Curran D, Hamill P, Porter-Armstrong A, Wilson L. Using a template to improve the accuracy and efficiency of the Jebsen–Taylor Hand Function Test: A comparative study. Hand Ther 2014;19:11–6. 22. Pallant, J. SPSS survival manual. McGraw-Hill Education (UK) 2013.

23. Case-Smith J, Bryan T. The effects of occupational therapy with sensory integration emphasis on preschool-age children with autism. Am J Occup Ther 1999;53:489–97. 24. Pfeiffer BA, Koenig K, Kinnealey M, Sheppard M, Henderson L. Effectiveness of sensory integration interventions in children with autism spectrum disorders: a pilot study. Am J Occup Ther 2011;65:76–85. 25. Schaaf RC, Benevides TW, Kelly D, Mailloux-Maggio Z. Occupational therapy and sensory integration for children with autism: a feasibility, safety, acceptability and fidelity study. Autism 2012;16:321–7. 26. Schaaf RC, Lane AE. Toward a Best-Practice Protocol for Assessment of Sensory Features in ASD. J Autism Dev Disord 2015;45:1380–95.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Üst ekstremite travma öyküsü olan otizm spektrum bozukluğu tanılı çocuklarda el fonksiyonlarının değerlendirilmesi Dr. Meral Huri, Dr. Sedef Şahin, Dr. Hülya Kayıhan Hacettepe Üniversitesi, Sağlık Bilimleri Fakültesi, Ergoterapi Bölümü, Ankara

AMAÇ: Çalışmamız üst ekstremite travma öyküsü olan ve olmayan otizmli çocukların el fonksiyonlarını karşılaştırmak amacı ile planlandı. GEREÇ VE YÖNTEM: Çalışmaya otizm spektrum bozukluğu tanısı ile takip edilen toplam 65 (Grup I, n=28; Group II, n=37) çocuk dahil edildi. Çocukların el fonksiyonları 9-Delikli Peg Testi ve Jebsen El Fonksiyon Testi ile değerlendirildi. Üst ekstremite ve elin somatoduyusal algısı Duyusal İşlemleme ve Praksis Testi’nin somatoduyusal algı alt testleri ile değerlendirildi. Sonuçlar Student t-testi and Mann-Whitney U-Testi ile SPSS 20 bilgisayar programı ile karşılaştırıldı. BULGULAR: Her iki el fonksiyon testine ait sonuçlar travma geçmişi olmayan çocuklar lehine farklı bulundu (p<0.05). Üst ekstremite somatosensoriyel algı ile el fonksiyon testleri arasındaki ilişki incelendiğinde, çocukların 9-Delikli Peg Testi ve Jebson El Fonsiyonları Test puanları ile Manuel Obje Algısı ve Taktil Uyaranın Lokalizasyonu test puanları arasında istatistiksel olarak anlamlı ilişkiler bulundu (p<0.05). TARTIŞMA: Travma öyküsü olan otizm spektrum bozukluğu tanılı çocuklar zayıf somatoduyusal algı ve el fonksiyonlarına sahiptirler. Acil servislerde çalışan profesyonellerin somatoduyusal algı, el fonsiyonları ve üst ektremite travma öyküsü arasındaki kuvvetli ilişki konusunda bilgilendirilip, farkındalıklarının arttırılmasınının; bu popülasyondaki çocukların rehabilitasyon süreçleri için önemli olduğu düşünülmektedir. Anahtar sözcükler: Dokunma duyusu; el; otizm. Ulus Travma Acil Cerrahi Derg 2016;22(6):559–565

doi: 10.5505/tjtes.2016.58712

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CA S E REP OR T

ERCP with stenting of traumatic pancreatic duct transection: A case report Deepa Prashant Makhija, M.Ch., Jayesh Desale, M.Ch., Charu Tiwari, M.Ch., Hemanshi Shah, M.Ch. Department of Paediatric Surgery, T.N.M.C, Mumbai-India

ABSTRACT Pancreatic injuries, though rare, are associated with high morbidity because of location of pancreas adjacent to the various hollow and solid organs. Difficulty in early diagnosis adds to morbidity. Condition of the pancreatic duct is an important factor in grading the injury and deciding upon course of management. Conservative management is the line of treatment in lower grade injuries. Higher grades of pancreatic injuries are usually managed surgically. Endoscopic retrograde cholangiopancreaticography (ERCP) has recently emerged as an effective diagnostic as well as therapeutic modality for hepatobiliary and pancreatic pathologies. Presently described is case of a 12-year-old boy who presented with post-traumatic complete transection of pancreatic duct, which was successfully managed by ERCP-guided stenting of the duct. Therapeutic advantages of ERCP in trauma setting and difficulties involved are highlighted. Keywords: Blunt abdominal trauma; ERCP; pancreatic transection; stenting.

INTRODUCTION Blunt abdominal trauma is principal cause of abdominal injury in children. In absence of hemodynamic instability, unresponsiveness to resuscitation, or associated hollow visceral injuries, non-operative management of blunt abdominal trauma is well documented and widely accepted. However, the same cannot be said for blunt injuries involving the pancreas, as there is still much debate about optimal management. Pancreatic injury is uncommon and occurs in 3% to 12% of blunt abdominal trauma.[1] However, in addition to pancreatic parenchymal injury, due to close proximity of adjacent solid and hollow organs and vascular structures, pancreatic injury is associated with high morbidity rate of up to 60% and high mortality rate of up to 30%.[2]

injury is of utmost importance. However, pancreatic injury lacks early clinical signs due to retroperitoneal location of the pancreas. Also, since biochemical tests such as serum amylase levels can be unreliable, it is often very difficult to diagnose pancreatic injury at an early stage. Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for ductal evaluation.[3] ERCP has also shown promising results as minimally invasive therapeutic alternative. Condition of the pancreatic duct is not only an important factor for evaluation of severity of pancreatic injury, but also an important basis for choice of therapy. Although early and precise evaluation of the pancreatic duct is crucial, ERCP has been underutilized because of perceived difficulty in performing the procedure and a lack of available expertise.[2]

In order to reduce the serious consequences caused by pancreatic injury, an accurate and early diagnosis of pancreatic

Presently described is a case of traumatic pancreatic duct transection managed with endoscopic stent placement.

Address for correspondence: Hemanshi Shah, M.D. A L Nair Road, Mumbai Central, Mumbai, 40008 Maharashtra, India. Tel: +022-23027671 E-mail: hemanshisshah@gmail.com Qucik Response Code

566

CASE REPORT A 12-year-old boy was referred from peripheral hospital with suspected pancreatic injury on computed tomography (CT) scan. There was history of fall from ladder 1 day earlier with blunt abdominal trauma. On examination, patient had tachycardia and was normotensive. There was tenderness and guarding in the upper abdomen. On investigation, there was moderately elevated serum amylase (336 IU/L). CT of abdomen was suggestive of suspected breach in the pancreatic Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Makhija et al. ERCP with stenting of Traumatic Pancreatic duct transection

neck and hypodense non-enhancing peripancreatic collection with moderate free fluid (Fig. 1a). There was no evidence of any other solid organ injury. Magnetic resonance cholangiopancreaticography (MRCP) showed near complete transection at the junction of head and neck of the pancreas, 9x5x6

(a)

cm collection in the lesser sac, and distal main pancreatic duct was normal (Fig. 1b). Ultrasonography-guided external drainage of peripancreatic collection was performed. ERCP was done on day 7 of trauma, which revealed leak at the genu (Fig. 1c). Stenting of the pancreatic duct was completed using 5 F stent. Patientâ&#x20AC;&#x2122;s serum amylase showed decreasing trend. Oral diet was initiated. External drain output progressively decreased. After confirming absence of collection on ultrasound, drain was removed. ERCP with stent removal was performed at 6 weeks. Patient was doing well on follow-up.

DISCUSSION

(b)

(c)

As retroperitoneal location offers relative protection, injury to the pancreas is unusual in blunt abdominal trauma; occurrence of high-grade or ductal injury is rare, with an estimated frequency of 0.12%.[4] Most common etiology is bicycle handle bar injury.[5] Diagnosis involves high index of suspicion, as symptoms are often insidious in onset and serum enzyme markers (amylase and lipase) usually do not correlate with severity of injury and may be normal in proportion of injuries. [6] Early diagnosis is crucial in pancreatic injury, and while CT and MRCP are good, non-invasive imaging modalities, ERCP has been proven to be the most specific and sensitive diagnostic tool.[6] Management of pancreatic injury is based on 2 factors: integrity of the main pancreatic duct and location of the pancreatic injury, both of which constitute the American Association for the Surgery of Trauma grading system.[6] Evolution in management of blunt pancreatic injuries over the last 20 years has trended toward non-operative management of lower grade injuries, with surgical intervention reserved for high grade injuries.[6] Decision to pursue conservative treatment rather than operative intervention depends on hemodynamic stability of the patient, whether injury is isolated, and suitability of injury for endoscopic treatment.[6] Current literature is divided on the benefits of operative intervention, with outcome measures focused on length of hospital stay, failure of non-operative management, need for repeat intervention, and rates of surgical complications.[6] There are no consensus guidelines, but non-operative management is usually advocated in the first instance. Simple external drainage is frequently proposed as standard surgical procedure for treating contusions or small lacerations. Cited rationale is removal of activated proteolytic enzymes that can lead to formation of fistulae, abscesses, and pseudocysts.[4]

Figure 1. (a) Computed tomography of abdomen suggesting suspected breach in the pancreatic neck and hypodense nonenhancing peripancreatic collection. (b) Magnetic resonance cholangiopancreaticography showing near complete transection at the head-neck junction of the pancreas and normal distal main pancreatic duct. (c) Endoscopic retrograde cholangiopancreatography revealing leak at the genu.

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Potential advantages of ERCP as an adjunct to non-operative management may include reduced rates of pseudocyst formation, shorter hospital stay, and quicker return to oral intake. Common potential risks of non-operative management are pancreatic duct strictures, atrophy of the distal duct despite intervention, post-ERCP pancreatitis, and need for future intervention. ERCP and the expertise needed to perform this 567

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procedure in pediatric population may not be readily available and can limit utilization of ERCP at smaller centers.[7]

promptly be referred to a specialist center for appropriate and timely management.

Most of previously reported studies are from small case series with retrospective data, and literature for the pediatric population is even more sparse. However, ERCP has been recommended for consideration in all children with blunt abdominal trauma since as early as 1986. ERCP for diagnosis, definitive therapy, or as an adjuvant to avoid laparotomy may be beneficial in some cases and should be considered for evaluation of higher grade pancreatic injuries.

Conflict of interest: None declared.

Conclusion Pancreatic injury in blunt abdominal trauma in adolescent patients is infrequent and often difficult to diagnose. This case emphasizes need for clinical suspicion based on mechanism of injury, even in a relatively innocuous fall from a ladder. When pancreatic injury is identified, method of management is determined by condition of the patient, severity of injury, and anatomical location. Adequate external drainage is an important principle in management of pancreatic injuries. There is still controversy regarding optimal management of pancreatic injury involving ducts. No absolute algorithm can be used to treat these patients. Suspected ductal injuries can be effectively managed endoscopically and such injuries should

REFERENCES 1. Potoka DA, Gaines BA, Leppäniemi A, Peitzman AB. Management of blunt pancreatic trauma: what’s new? Eur J Trauma Emerg Surg 2015;41:239–50. 2. Yalin K, Xiaojun H, Chengli L, Gang Z, Mei X, Yuying Z, et al. Gradingtherapeutic strategy for pancreatic injury after blunt abdominal trauma: therapy based on the condition of pancreatic duct and report of 95 cases. Hepatogastroenterology 2013;60:1497–503. 3. Ito Y, Kenmochi T, Irino T, Egawa T, Hayashi S, Nagashima A, et al. Endoscopic management of pancreatic duct injury by endoscopic stent placement: a case report and literature review. World J Emerg Surg 2012;7:21. 4. Maeda K, Ono S, Baba K, Kawahara I. Management of blunt pancreatic trauma in children. Pediatr Surg Int 2013;29:1019–22. 5. Lam JP, Eunson GJ, Munro FD, Orr JD. Delayed presentation of handlebar injuries in children. BMJ 2001;322:1288–9. 6. Zala A, Gaszynski R, Punch G. Blunt trauma pancreatic duct injury managed by non-operative technique, a case study and literature review. Trauma Case Reports 1 2015;13–6. 7. Garvey EM, Haakinson DJ, McOmber M, Notrica DM. Role of ERCP in pediatric blunt abdominal trauma: a case series at a level one pediatric trauma center. J Pediatr Surg 2015;50:335–8.

OLGU SUNUMU - ÖZET

Travmatik pankreas kanal transeksiyonunda stentlemeyle birlikte ERKP: Olgu sunumu Dr. Deepa Prashant Makhija, Dr. Jayesh Desale, Dr. Charu Tiwari, Dr. Hemanshi Shah Pediyatrik Cerrahi Anabilim Dalı, T.N.M.C, Mumbai-Hindistan

Seyrek görülmekle birlikte pankreas yaralanmaları çeşitli içi boş ve solid organlara yakınlıkları nedeniyle yüksek bir morbiditeyle ilişkilidir. Erken tanı koyma zorluğu morbiditeye katkıda bulunmaktadır. Pankreas kanalının durumu yaralanmayı derecelendirmede ve tedavi kararında önemli bir etkendir. Düşük dereceli yaralanmalarda konservatif tedavi uygulanır. Daha yüksek dereceli pankreas yaralanmaları genellikle cerrahi yolla tedavi edilir. Son zamanlarda kolanjiyobiliyer ve pankreatik patolojilerin etkili tanısal ve terapötik bir yöntemi olarak endoskopik retrograd kolanjiyopankreatikografi (ERKP) kullanılmaya başlanmıştır. Bu yazıda, endoskopik retrograd kolanjiyopankreatikografi kılavuzluğunda pankreas kanalı stentlenerek başarılı bir şekilde tedavi edilen posttravmatik komplet pankreas kanal transeksiyonu olan 12 yaşındaki bir erkek çocuğu sunuldu. Travma ortamında ERKP’nin terapötik avantajları ve ilişkin zorluklar vurgulanmaktadır. Anahtar sözcükler: ERKP; künt karın travması; pankreas transeksiyonu; stentleme. Ulus Travma Acil Cerrahi Derg 2016;22(6):566–568

568

doi: 10.5505/tjtes.2016.09334

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CAS E R EP O RT

Hemoptysis caused by pulmonary sequestration in perforated appendicitis: A rare case report Dario Tartaglia, M.D., Francesca Cascione, M.D., Matteo Modesti, M.D., Desiree Gianardi, M.D., Rosilde Caputo, M.D., Christian Galatioto, M.D., Massimo Chiarugi, M.D. Department of Emergency, University of Pisa, Pisa, Italy

ABSTRACT Pulmonary sequestration is a rare and usually asymptomatic congenital anomaly. Optimal management of this condition is still a subject of debate, including superiority of surgical resection or angiographic embolization of the aberrant arterial vessel. Presently described is rare case of a 51-year-old male who presented with hemoptysis related to pulmonary sequestration associated with acute right lower quadrant abdominal pain caused by perforated appendicitis. Keywords: Perforated appendicitis; pulmonary sequestration; therapeutic strategy.

The most common treatment is surgical removal of the pulmonary sequestration.

INTRODUCTION Pulmonary sequestration, first described by Rokitansky in 1861, is a rare congenital cystic malformation caused by lung tissue that is non-functioning and does not have normal communication with tracheobronchial vascular system, receiving blood flow instead directly from systemic vessels, such as the descending aorta. The abnormal tissue may be micro-cystic, containing many small cysts, or macro-cystic, containing several large cysts. There are 2 types of pulmonary sequestration: intralobar and extralobar. The first is confined to the lung, while the second involves accessory lung tissue completely enclosed in its own pleural sheath, usually situated between the lower lobe and the diaphragm. This malformation is not a life-threatening condition, but it may present in different clinical ways, such as cardiovascular disease, long-term infection, bronchial cancer, and in very rare situations, hemoptysis caused by rupture of a blood vessel in the abnormal lung. Address for correspondence: Dario Tartaglia, M.D. Via Paradisa, 2 Pisa, Italy Tel: +393334491229 E-mail: dario261184@gmail.com Qucik Response Code

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Presently described is a case in which hemoptysis related to pulmonary sequestration presented simultaneously with acute abdomen caused by perforated appendicitis.

CASE REPORT A 51-year-old male was admitted to the Emergency Department after onset of profuse hemoptysis associated with acute right lower quadrant abdominal pain and fever. Patient was hemodynamically stable. Laboratory exams revealed severe leukocytosis (white blood cell count: 18.490/mm3; neutrophil elastase: 89.1%) and moderate increase in fibrinogen (944 mg/dL). Contrast-enhanced computed tomography (CT) revealed pulmonary sequestration of the left inferior pulmonary lobe fed by an anomalous arterial vessel originating from the celiac trunk. Furthermore, large area of inflammation in the right abdomen with air bubbles was observed, compatible with complicated severe acute appendicitis (Figs. 1, 2). Management plan was to achieve control of hemoptysis first, followed by surgical management of the abdominal condition. Accordingly, the patient underwent selective artery angiography, which confirmed presence of abnormal vessel originating from the celiac trunk and feeding the sequestered pulmonary lobe. Superselective angioembolization of the feeding vessel with 7 mm vascular plug was performed. The procedure was completed without complications (Fig. 3). 569

Tartaglia et al. Hemoptysis caused by pulmonary sequestration in perforated appendicitis

Figure 1. Contrast computed tomography scan. Pulmonary sequestration at the base of left inferior lobe of the lung is perfused by large arterial vessel originating from the celiac trunk (arrow).

Figure 3. Selective angiography of the aberrant arterial vessel tributary to the sequestrated lobe before embolization.

Figure 2. Computed tomography scan of the abdomen showing fluid collection and minute gas bubbles around the cecum (arrow).

Figure 4. Perforated gangrenous appendicitis as seen at laparoscopy.

Following percutaneous procedure, the patient underwent laparoscopy. Exploration of the abdominal cavity showed adhesions among the cecum, the ileum and the anterior abdominal wall, which were cautiously lysed. Voluminous appendicular abscess was drained and samples were sent for cultures. Perforated gangrenous appendicitis was identified (Fig. 4). Appendectomy was then performed.

DISCUSSION

Postoperatively, the patient received broad-spectrum antibiotic therapy with ciprofloxacin and metronidazole. Bacterial culture results were positive for Enterococcus avium and Escherichia coli. Episodes of mild fever occurred during first days of the course, but gradually resolved; follow-up CT scan of the chest did not show any infective complication of the embolization procedure. The patient was discharged in good condition on postoperative day 12. 570

Pulmonary sequestration is a rare congenital malformation with an incidence of 0.15% to 1.8% of all pulmonary malformations.[1,2] According to Pryce et al.,[3] this abnormality is classified in 2 types: type 1 is characterized by an isolated systemic arterial supply to normal lung, while type 2 has dual supply from systemic and pulmonary vascularization. Surgical resection of pulmonary sequestration, usually performed through postero-lateral thoracotomy, has been considered the safest and most effective method of treatment for a long time. Recently, Tamura et al. reported on efficiency and safety of video-assisted thoracoscopy surgery for treatment of extra-lobar sequestration and found less postoperative pain and a faster recovery in comparison with conventional surgery.[4] Angiographic embolization has been proposed as a successful alternative to surgery.[5] Thus far, however, investigations comparing the results of embolization with those of surgical resection are lacking.[6â&#x20AC;&#x201C;8] AngioUlus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Tartaglia et al. Hemoptysis caused by pulmonary sequestration in perforated appendicitis

graphic embolization has the advantage of providing means for effective and immediate control of bleeding in massive hemoptysis. It is also believed to have a role in preventing recurrent episodes of hemoptysis and reducing risk of bleeding during surgery in patients with severe heart failure. When employed as definitive means of treatment, angioembolization was associated with lower risk of morbidities than thoracotomy.[9–11] On the other hand, Diks et al. reported that angiographic embolization could not achieve complete control of main complications of pulmonary sequestration: pleural pain, ischemic infarction, and abscess formation. For this reason, they maintained that surgical resection is still the most effective and definitive therapeutic strategy for this kind of lung malformation.[12] Presently described is a case of symptomatic pulmonary sequestration and gangrenous acute appendicitis. To our knowledge, this is the first case in the literature with simultaneous presentation of these 2 diseases. Therapeutic management was undertaken with multidisciplinary consensus of chest surgeons, general surgeons, and radiologists. Initial therapeutic strategy consisted of performing angiographic embolization of the aberrant arterial vessel from the celiac trunk, followed by laparoscopic appendectomy. Both of these procedures were performed without significant complications, despite some concern about risk of superinfection of the embolized pulmonary tissue from bacteria responsible for the abdominal infection in the bloodstream. At the time of writing, no thoracotomy procedure is planned to resect the sequestration; however, the patient has been provided with radiological follow-up of chest. The present case provides a therapeutic strategy that might be selected in case of contemporaneous presence of symptomatic pulmonary sequestration and perforated appendicitis.

Consent Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review from the editor-in-chief of this journal. Conflict of interest: None declared.

REFERENCES 1. Corbett HJ, Humphrey GM. Pulmonary sequestration. Paediatr Respir Rev 2004;5:59–68. 2. Kabnick EM, Adler L, Susin M, Helfgott A, Alexander LL, Tafreshi M. Pulmonary sequestration. J Natl Med Assoc 1984;76:907–8, 911–2. 3. Pryce DM. Lower accessory pulmonary artery with intralobar sequestration of lung; a report of seven cases. J Pathol Bacteriol 1946;58:457–67. 4. Tamura M, Shimizu Y, Hashizume Y. Single-incision video-assisted thoracic resection for extrapulmonary sequestration: a case report. J Cardiothorac Surg 2014;9:22. 5. Kim JH, Kim SS, Ha KS, Bae J, Park Y. Anomalous arterial supply to normal Basal segment of the right lower lobe: endovascular treatment with the amplatzer vascular plug. Tuberc Respir Dis (Seoul) 2014;76:295–8. 6. Seok JP, Kim YJ, Cho HM, Ryu HY. A rare case of bilateral pulmonary sequestration managed with embolization and surgical resection in a patient. Korean J Thorac Cardiovasc Surg 2013;46:475–7. 7. Gümüştaş S, Akça A, Ciftçi E, Topçu S, Akgül AG. A minimal invasive surgical alternative to aberrant systemic arterial supply: Coil embolization. Interv Med Appl Sci 2013;5:34–8. 8. Bhalla AS, Gupta P, Mukund A, Kumar A, Gupta M. Anomalous systemic artery to a normal lung: a rare cause of hemoptysis in adults. Oman Med J 2012;27:319–22. 9. Marine LM, Valdes FE, Mertens RM, Bergoeing MR, Kramer A. Endovascular treatment of symptomatic pulmonary sequestration. Ann Vasc Surg 2011;25:696.e11–5. 10. Geyik S, Yavuz K, Keller FS. Unusual systemic artery to pulmonary artery malformation without evidence of systemic disease, trauma or surgery. Cardiovasc Intervent Radiol 2006;29:897–901. 11. Saida T, Ninomiya H, Hojo F, Nakayama M, Yamauchi T, Saida Y. Systemic arterial supply to the normal basal segments of the left lower lobe treated by coil embolization, with long-term follow-up. Radiat Med 2006;24:365–8. 12. Diks J, Schütte PR, Cheung D, Schnater JM. Treatment of pulmonary sequestrations by means of endovascular embolization: future or fashion? Case Rep Med 2011;2011:173918.

OLGU SUNUMU - ÖZET

Perfore apandisitte pulmoner sekestrasyonun neden olduğu hemoptizi: Seyrek görülen bir olgunun raporu Dr. Dario Tartaglia, Dr. Francesca Cascione, Dr. Matteo Modesti, Dr. Desiree Gianardi, Dr. Rosilde Caputo, Dr. Christian Galatioto, Dr. Massimo Chiarugi Pisa Üniversitesi, Acil Tıp Anabilim Dalı, Pisa-İtalya

Pulmoner sekestrasyon seyrek görülen ve genellikle semptomsuz bir doğuştan anomalidir. Bu rahatsızlığın optimal tedavisi hâlâ tartışmalı olup cerrahi rezeksiyonları veya aberan arterin anjiyografik embolizasyonunu içerir. Perfore apandisitin neden olduğu akut sağ alt kadran karın ağrısının eşlik ettiği pulmoner sekestrasyonla ilişkili hemoptiziyle gelen 51 yaşında nadir görülen bir erkek olguyu sunuyoruz. Anahtar sözcükler: Perfore apandisit tedavi stratejisi; pulmoner sekestrasyon. Ulus Travma Acil Cerrahi Derg 2016;22(6):569–571

doi: 10.5505/tjtes.2016.99542

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CA S E REP OR T

Laparoscopic resection and intracorporeal anastomosis of perforated small bowel caused by fish bone ingestion Ahmet Cem Dural, M.D.,1 Muhammet Ferhat Çelik, M.D.,2 Hakan Yiğitbaş, M.D.,3 Cevher Akarsu, M.D.,1 Mahmut Doğan, M.D.,1 Halil Alış, M.D.1 1

Department of General Surgery, Bakirköy Dr. Sadi Konuk Training and Research Hospital, İstanbul-Turkey

Department of General Surgery, Yedikule Surp Pırgic Armenian Hospital Foundation, İstanbul-Turkey

Department of General Surgery, Bağcılar Training and Research Hospital, İstanbul-Turkey

ABSTRACT Presently described is case of a 52-year-old man who was admitted to the emergency department with 3-day history of epigastric pain. Abdominal examination revealed diffuse tenderness and muscle guarding. Plain abdominal X-ray showed free subdiaphragmatic air. The patient underwent diagnostic laparoscopy with presumptive diagnosis of peptic ulcer perforation. Laparoscopy showed several inflamed, edematous jejunal loops with proximal obstruction and perforation by an impacted fish bone. Completely intracorporeal resection and anastomosis using laparoscopic linear stapler was performed and segment of resected bowel was removed through trocar site. Postoperative period was uneventful, and the patient was discharged on fourth day. Keywords: Fish bone; foreign body ingestion; perforation; small bowel.

INTRODUCTION The majority of ingested foreign bodies (FB) are seamlessly excreted from the gastrointestinal tract by defecation. Perforation of the small bowel by FB is rare clinical finding, occurring in less than 1% of patients.[1] Fish bones are the most commonly ingested organic objects and most common cause of FB perforation of the gastrointestinal tract.[1,2] Preoperative diagnosis is usually challenging, since ingestion is mostly accidental. Intentional ingestion of FB is more commonly seen in psychiatric patients.[3] Computed tomography is preferred screening method in the preoperative period for ingested bodies and related complications.[4] Present report is description of a patient with acute abdomiAddress for correspondence: Ahmet Cem Dural, M.D. Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Bakırköy, 34147 İstanbul, Turkey Tel: +90 212 - 414 54 10 E-mail: cemdural@hotmail.com Qucik Response Code

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nal pain secondary to small bowel perforation caused by fish bone penetration of the jejunal wall mimicking perforated peptic ulcer.

CASE REPORT A 52-year-old man was admitted to the emergency department with acute abdominal pain in the epigastric region that had been present for preceding 3 days. There was no nausea, vomiting, or diarrhea. Abdominal examination showed generalized tenderness and rigidity. Previous medical and surgical history was unremarkable except for diabetes mellitus and appendectomy. Laboratory tests indicated elevated white cell count of 11700/mm3 with 78% neutrophils, C-reactive protein level of 23.4 mg/dL, and normal amylase level. Plain X-ray of the abdomen showed free air under the right diaphragm. Presumptive diagnosis was perforated peptic ulcer and emergency operation was scheduled. Diagnostic laparoscopy was performed. After trocar and camera insertion via umbilical site, the abdomen was explored under 12 mmHg carbon dioxide insufflation. Several inflamed, edematous small bowel loops and seropurulent fluid in the Douglas pouch were found. Two additional working ports were inserted into left upper and lower quadrants. Examination of the bowel loops revealed through-and-through perforation caused by fish bone on anUlus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Dural et al. Laparoscopic treatment for small bowel perforation by a fish bone

timesenteric side of the bowel loop, approximately 130 cm from the ileocaecal valve (Fig. 1). In addition to obstruction, localized inflammation around edge of perforation was noted. No other pathology was identified. Intracorporeal resection was performed approximately 5 cm proximal and distal to perforation and stricture site with laparoscopic linear stapler. After preparing 2 small enterotomies, 2 arms of 80 mm 3.8 linear endostapler (3.8 mm staple)

Figure 3. Resected bowel segment.

were inserted and fired (Fig. 2a). Second 80 mm linear stapler was placed perpendicularly in T-shape to 2 stapled bowel segments and full intracorporeal, functional, end-to-end anastomosis was performed (Fig. 2b).

Figure 1. Through and through perforation site due to fish bone.

(a)

Resected bowel was removed through 15 mm trocar site (Fig. 3). The patient underwent uneventful recovery and was discharged 4 days after procedure.

DISCUSSION Accidentally ingestion of a FB is common in childhood, but may occur in any age group. The most common causes of intestinal perforation depending on FB are fish bones, chicken bones and sharp objects such as toothpicks in adults.[1,3] However perforation by FB ingestion is a rare clinical condition. Perforation most often occurs at the ileocecal and rectosigmoid level following the stomach and duodenum at areas of angulation.[5] Goh et al reported an FB perforation rate of 39% in the terminal ileum.[4] Perforation of jejunum like this current case has a reported incidence of approximately 14.3%.[6] Other possible regions of FB penetration are the hernia sac, Meckelâ&#x20AC;&#x2122;s diverticulum, or the appendix.

(b)

Figure 2. (a, b) Laparoscopic jejunal resection and intracorporeal anastomosis.

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Fishbone or non-radiopaque objects such as toothpicks can be diagnosed by ultrasonography. The role of CT in the evaluation of patients with FB ingestion has been previously described.[7] A typical CT finding of fish bone perforation is a hyperdense linear lesion surrounded by inflammation. CT imaging of the abdomen was not performed in this case. Initial laboratory and X-ray findings were consistent with a presumptive diagnosis of hollow viscous organ perforation and diagnostic laparoscopy was therefore performed. The complications due to clinically unsuspected foreign body ingestion may not be diagnosed by routine physical examination and standard diagnostic methods. Patients often present with localized or generalized peritonitis, abdominal mass or abscess.[3] The most common radiographic finding is ileus followed by intra-abdominal free air.[3] 573

Dural et al. Laparoscopic treatment for small bowel perforation by a fish bone

Endoscopic therapy, interventional radiological procedures, laparoscopy or laparotomy are used in the treatment of ingested foreign bodies.[4] There are few cases of clinically unsuspected small bowel perforation due to foreign body ingestion diagnosed and treated by laparoscopy reported in the literature.[3] In reported cases although resection is done laparoscopically, anastomosis is completed extracorporealy by the conventional method.[3,8,9] To the best of our knowledge, this is the first case treated with total intracorporeal laparoscopic resection and anastomosis.

Results In the differential diagnosis of acute abdominal pain, bowel perforation due to foreign body ingestion should be considered. A good questionnaire history with appropriate imaging will bring us to a correct diagnosis high probability.

Acknowledgements The authors thank Dr. Burak Kankaya and Dr. Mustafa Gökhan Ünsal for their contributions, and Alexis Kofi Okoh for English language editing assistance. Conflict of interest: None declared.

REFERENCES 1. Mutlu A, Uysal E, Ulusoy L, Duran C, Selamoğlu D. A fish bone causing ileal perforation in the terminal ileum. Ulus Travma Acil Cerrahi Derg 2012;18:89–91. 2. Lin CY, Wu FZ. Fish bone perforation of small intestine. QJM 2012;105:479–80. 3. Lunsford KE, Sudan R. Small bowel perforation by a clinically unsuspected fish bone: laparoscopic treatment and review of literature. J Gastrointest Surg 2012;16:218–22. 4. Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, et al. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg 2006;30:372–7. 5. Gül M, Aliosmanoğlu İ, Hakseven M, Çetinçakmak MG. Migration of two swallowed foreign bodies to different locations in the same case. Ulus Cerrahi Derg 2013;30:228–30. 6. Drakonaki E, Chatzioannou M, Spiridakis K, Panagiotakis G. Acute abdomen caused by a small bowel perforation due to a clinically unsuspected fish bone. Diagn Interv Radiol 2011;17:160–2. 7. Coulier B, Tancredi MH, Ramboux A. Spiral CT and multidetector-row CT diagnosis of perforation of the small intestine caused by ingested foreign bodies. Eur Radiol 2004;14:1918–25. 8. Law WL, Lo CY. Fishbone perforation of the small bowel: laparoscopic diagnosis and laparoscopically assisted management. Surg Laparosc Endosc Percutan Tech 2003;13:392–3. 9. Watanabe Y, Yamada D, Kobayashi K, Ryu S, Akashi Y, Miyoshi A. Single-incision laparoscopic surgery for small bowel perforation by a fish bone. Am Surg 2012;78:513–4.

OLGU SUNUMU - ÖZET

Balık kılçığı yutulmasına bağlı gelişen ince bağırsak perforasyonunun laparoskopik rezeksiyon ve anastomozu Dr. Ahmet Cem Dural,1 Dr. Muhammet Ferhat Çelik,2 Dr. Hakan Yiğitbaş,3 Dr. Cevher Akarsu,1 Dr. Mahmut Doğan,1 Dr. Halil Alış1 1 2 3

Bakırköy Dr. Sadi Konuk Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul Yedikule Surp Pırgiç Ermeni Hastanesi Vakfı, Genel Cerrahi Kliniği, İstanbul Bağcılar Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

Bu yazıda, balık kılçığına bağlı jejunal perforasyon sonrası üç gündür olan epigastrik ağrı şikayeti ile acil servise başvuran 52 yaşında erkek hasta sunuldu. Yapılan karın incelemesinde yaygın hassasiyet ve rebound mevcuttu. Ayakta direkt karın grafisinde diafragma altı serbest hava tespit edildi. Hastaya peptik ülser perforasyonu ön tanısıyla tanısal laparoskopi uygulandı. Yapılan eksplorasyonda jejunal anslarda şiddetli enflamasyon, ödem, proksimal ince bağırsak anslarında obstrüksiyona bağlı dilatasyon ve balık kılçığına bağlı perforasyon odağı görüldü. Perfore ince bağırsak ansı laparoskopik stapler ile rezeke edilip karıniçi anastomoze edildi ve perfore segment trokar yerinden karın dışına alındı. Hastanın ameliyat sonrası takiplerinde sorunu olmadı ve dördüncü günde taburcu edildi. Bu örnekte balık kılçığına bağlı ince bağırsak perforasyonu ve obstrüksiyon gelişen hastada laparoskopik rezeksiyon ve anastomoz tanımlanmıştır. Anahtar sözcükler: Balık kılçığı; ince bağırsak; perforasyon; yabancı cisim yutulması. Ulus Travma Acil Cerrahi Derg 2016;22(6):572–574

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CAS E R EP O RT

Obturator hernia should be considered in the differential diagnosis of hip and knee pain Ahmet Korkut Belli, M.D.,1 Gündüz Memiş, M.D.,1 Özcan Dere, M.D.,1 Ulaş Koşan, M.D.,2 Okay Nazlı, M.D.1 1

Department of General Surgery, Muğla Sıtkı Koçman Faculty of Medicine, Muğla-Turkey

Department of Radiology, Muğla Sıtkı Koçman Faculty of Medicine, Muğla-Turkey

ABSTRACT Obturator hernia is a rare disease usually occurring in debilitated elderly women. Pain radiating down the medial thigh and knee (Howship-Romberg sign) is a specific sign of the disease. Presently described is a case of obturator hernia in a 73-year-old female patient who presented with severe left hip pain radiating down the medial thigh and knee, nausea, and loss of appetite. Initially, vertebral disc herniation was thought to be cause, but abdomino-pelvic computed tomography scan revealed left strangulated obturator hernia. Diagnosis of obturator hernia can be challenging. Physicians should consider obturator hernia in the differential diagnosis of knee and hip pain, and investigate for Howship-Romberg sign. Early diagnosis of the disease not only decreases morbidity and mortality, but also presents opportunity to treat with minimally invasive methods. Keywords: Acute abdomen; hernia; hip pain; knee pain; obturator hernia.

INTRODUCTION Obturator hernia is a rare disease accounting for only 0.05% to 1.4% of all hernias.[1] It is seen most often in thin and weak elderly women. Pain radiating down the medial thigh and knee (Howship-Romberg sign) is a specific sign of the disease. Therefore, obturator hernia can manifest as hip or knee pain. A case of obturator hernia is described and diagnostic challenges of the disease are discussed.

CASE REPORT A thin and debilitated 73-year-old female presented at the emergency department with severe left hip pain radiating down the medial thigh and knee, nausea, and loss of appetite. There was no abdominal pain or vomiting in the history of Address for correspondence: Ahmet Korkut Belli, M.D. Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Menteşe, 48000 Muğla, Turkey Tel: +90 252 - 214 13 26 E-mail: ahmetbelli@gmail.com Qucik Response Code

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present illness. Limitation of left hip movement was found in her physical exam, as well as minimal abdominal tenderness without rebound tenderness or defense. Herniated vertebral disc lesion was initially considered in the differential diagnosis. Patient had consultation with both a neurosurgeon and a general surgeon. Dorso-vertebral magnetic resonance imaging was performed and no abnormalities were found. Abdomino-pelvic computed tomography (CT) scan revealed left strangulated obturator hernia (Fig. 1). Laparotomy was performed with midline incision and strangulated small intestinal segment was reduced from the hernia sac. Ileal segment of 15 cm was resected and reconstructed with end-to-end anastomosis due to non-viability (Fig. 2). Neck of obturator hernia was repaired with prolene sutures. Postoperative recovery period was uncomplicated and Howship-Romberg sign was resolved.

DISCUSSION Obturator hernia accounts for only 0.05–1.4% of all hernias.[1] Females are at 6 to 9 times higher risk than males due to wider pelvis. Advanced age, weight loss, conditions that increase abdominal pressure such as constipation, chronic pulmonary disease, or ascites are other risk factors. Most common presenting signs are bowel obstruction and Howship-Romberg sign. Hannington-Kiff sign, the loss of adductor reflex of the 575

Belli et al. Obturator hernia should be considered in the differential diagnosis of hip and knee pain

reducing it from the hernia sac. Perforating the intestinal segment may increase risk of complications such as intraabdominal abscess. Moreover, delay in diagnosis may cause electrolyte imbalance or renal insufficiency, which may impair the healing process of any necessary intestinal anastomosis.[4] Regarding treatment of obturator hernia, abdominal, retropubic, obturator, and inguinal surgical approaches have been used in non-emergent settings. However, abdominal approach must be preferred in an emergency situation to explore for complications such as strangulation or perforation. Hernia sac must be inverted and ligated after sac is reduced. Stump should be repaired with mesh, Teflon, fascial flap, or primary sutures. It can also be covered with a segment of the omentum. Laparoscopic approaches for obturator hernia have also been defined during the past 2 decades.[5,6] Furthermore, Togawa et al.[7] demonstrated the feasibility of minimal incision trans-inguinal repair. Figure 1. Computed tomography image with arrow indicating left obturator hernia.

In conclusion, obturator hernia is a rare disease and diagnosis is usually challenging. Physicians should consider obturator hernia in differential diagnosis of knee and hip pain, and probe for Howship-Romberg sign. Early diagnosis of the disease not only decreases morbidity and mortality, but allows for use of minimally invasive treatment methods. Financial Interest: None Conflict of interest: None declared.

REFERENCES

Figure 2. Strangulated intestinal segment as seen during surgery.

thigh with a normal patellar tendon reflex, is a more specific finding of the disease.[2] Diagnosis of obturator hernia is usually difficult. Physical examination, ultrasonography, CT scan, laparoscopy, and laparotomy are useful. According to Kulkarni et al., CT scan has superior sensitivity and accuracy compared with other noninvasive diagnostic tools.[3] Early diagnosis of obturator hernia prevents complications such as strangulation and perforation, and thereby reduces mortality and morbidity. As result of diagnostic difficulty, frequently intestinal segment has been ischemic for a long time and can easily be perforated when

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1. Chang SS, Shan YS, Lin YJ, Tai YS, Lin PW. A review of obturator hernia and a proposed algorithm for its diagnosis and treatment. World J Surg 2005;29:450–4. 2. Lee Y, Monson J. Lumbar and Pelvic Hernias. In: Peters JH, McFadden DW, editors. Shackelford’s Surgery of the Alimentary Tract Volume 1. 7th ed. Philadelphia: Elsevier Saunders; 2013. p. 613–27. 3. Kulkarni SR, Punamiya AR, Naniwadekar RG, Janugade HB, Chotai TD, Vimal Singh T, et al. Obturator hernia: A diagnostic challenge. Int J Surg Case Rep 2013;4:606–8. 4. Nazli O, Akaoglu C, Basargan A, Deniz S. Obturator Herni. Cerrahi Tip Bulteni 1993;2:164–7. 5. Bryant TL, Umstot RK Jr. Laparoscopic repair of an incarcerated obturator hernia. Surg Endosc 1996;10:437–8. 6. Yokoyama T, Kobayashi A, Kikuchi T, Hayashi K, Miyagawa S. Transabdominal preperitoneal repair for obturator hernia. World J Surg 2011;35:2323–7. 7. Togawa Y, Muronoi T, Kawaguchi H, Chiku T, Sano W, Hashiba T, et al. Minimal incision transinguinal repair for incarcerated obturator hernia. Hernia 2014;18:407–11.

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Belli et al. Obturator hernia should be considered in the differential diagnosis of hip and knee pain

OLGU SUNUMU - ÖZET

Obturator herni kalça ve diz ağrısının ayırıcı tanısında yer almalıdır Dr. Ahmet Korkut Belli,1 Dr. Gündüz Memiş,1 Dr. Özcan Dere,1 Dr. Ulaş Koşan,2 Dr. Okay Nazlı1 1 2

Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Muğla Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Muğla

Obturator herni tüm hernilerin yaklaşık olarak %0.05–1.4’ünü oluşturan nadir bir hastalıktır. Genellikle zayıf, yaşlı ve düşkün kadınlarda görülmektedir. Uyluk iç kısmından dize yayılan ağrı (Howship Romberg bulgusu) hastalığa özgüdür. Bu yazıda, obturator fıtık tanısı alan bir hasta ve obturator fıtığın tanısal güçlükleri sunuldu. Yetmiş üç yaşında düşkün bir hasta, bulantı, iştahsızlık ve sol kalçasından uyluk iç kısmına ve dize yayılan şiddetli ağrı şikayeti ile acil servise başvurdu. Öncelikli vertebral disk hernisi düşünülen hastanın çekilen abdomino-pelvik bilgisayarlı tomografisinde sol obturator fıtık saptandı. Obturator fıtık tanısı güç olan nadir bir hastalıktır. Hekimler kalça ve diz ağrısının ayırıcı tanısında obturator fıtığı dahil etmelidirler ve lüzüm halinde Howship Romberg bulgusunu sorgulamalıdırlar. Erken tanı konulması hem mortalite ve morbiditeyi azaltmaktadır hem de daha az invaziv yöntemlerle tedavi olanağı sunmaktadır. Anahtar sözcükler: Akut batın; diz ağrısı; fıtıklar; kalça ağrısı; obturator fıtık. Ulus Travma Acil Cerrahi Derg 2016;22(6):575–577

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Turkish Journal of Trauma & Emergency Surgery, Index of 2016

INDE X - D İZİN

Turkish Journal of Trauma & Emergency Surgery Subject Index of 2016 Abdominal pain see 2016;22(2):175–183 Abdominal wall lipoma see 2016;22(5):502–504 Accident see 2016;22(2):145–149 Acetaminophen see 2016;22(4):305–314 Acute abdomen see 2016;22(1):103–105 see 2016;22(1):106–108 see 2016;22(3):290–292 see 2016;22(4):391–394 see 2016;22(6):575–577 Acute abdominal pain see 2016;22(5):502–504 Acute appendicitis see 2016;22(1):17–22 see 2016;22(4):338–343 see 2016;22(6):516–520 see 2016;22(6):545–548 Acute kidney injury see 2016;22(2):121–126 Acute mesenteric ischemia see 2016;22(2):115–120 see 2016;22(4):344–349 Adalimumab see 2016;22(2):134–138 Adipose tissue see 2016;22(1):7–11 Advanced trauma life support see 2016;22(3):242–246 Agomelatine see 2016;22(2):121–126 Air gun pellet see 2016;22(3):301–303 ALP intestine-isomerase see 2016;22(2):115–120 Alpha lipoic acid see 2016;22(6):509–515 Ambulance see 2016;22(2):145–149 Analgesics see 2016;22(2):175–183 Anastomosis see 2016;22(4):315–321 see 2016;22(5):495–497 Aneurysm see 2016;22(1):106–108 Ankle fracture see 2016;22(6):553–558 Anorectal surgery see 2016;22(5):505–508 Antibiotic see 2016;22(6):516–520 Antioxidant see 2016;22(5):423–431 Aortic transection see 2016;22(5):449–456 APACHE IV see 2016;22(1):29–33 Appendectomy see 2016;22(6):545–548 Appendicitis see 2016;22(1):76–83 see 2016;22(2):155–162 see 2016;22(2):163–168 see 2016;22(5):471–476 Arterial injury see 2016;22(6):531–535 Aseptic see 2016;22(3):283–289 Autism see 2016;22(6):559–565

578

Autograft see 2016;22(3):283–289 Autopsy see 2016;22(1):66–75 see 2016;22(4):365–373 Axon axon density see 2016;22(6):526–530

Bacterial translocation see 2016;22(2):127–133 Base deficit see 2016;22(1):29–33 Benign intussusception see 2016;22(2):139–144 Betaine see 2016;22(5):417–422 Bilirubin see 2016;22(2):155–162 Biological factors see 2016;22(3):253–258 Bitemporal hemianopsia see 2016;22(1):97–99 Blast injury see 2016;22(5):405–411 Blunt abdominal trauma see 2016;22(6):566–568 Body mass index see 2016;22(5):457–465 Burn center see 2016;22(1):34–39 Burn injury see 2016;22(5):489–494 Burn see 2016;22(3):224–232 see 2016;22(5):412–416 Burns percentage see 2016;22(1):23–28 Burns see 2016;22(1):12–16 see 2016;22(3):247–252

C-reactive protein see 2016;22(1):76–83 Caecum see 2016;22(3):290–292 Carotid cavernous fistula see 2016;22(2):199–201 Causality relationship see 2016;22(1):66–75 Cause of death see 2016;22(1):66–75 Cecal ligation puncture see 2016;22(2):121–126 Cervical vertebrae see 2016;22(1):100–102 Child see 2016;22(1):109–113 see 2016;22(3):265–268 Children see 2016;22(1):12–16 see 2016;22(3):247–252 see 2016;22(4):328–332 see 2016;22(4):374–378 Chitosan linear polymer see 2016;22(3):215–223 Colon see 2016;22(4):315–321 Colorectal injuries see 2016;22(2):169–174 Comminuted fractures see 2016;22(4):379–385 Common hepatic duct see 2016;22(1):103–105 Complications see 2016;22(4):333–337 Computed tomography see 2016;22(1):100–102

see 2016;22(3):297–300 Condyle see 2016;22(1):40–45 Conservative treatment see 2016;22(3):239–241 Contusion see 2016;22(4):322–327 Corpse examination see 2016;22(1):66–75 Crush injury see 2016;22(4):305–314 Cut-off see 2016;22(1):76–83 Cytokines see 2016;22(5):417–422

-dimer see 2016;22(2):115–120 Damage control surgery see 2016;22(3):273–277 Decleration of the forensic case see 2016;22(1):66–75 Delayed epidural hematoma see 2016;22(4):355–360 Diagnosis see 2016;22(4):344–349 Diaphyseal fracture see 2016;22(2):184–191 Distal humerus see 2016;22(1):58–65 fractures see 2016;22(4):386–390 Distal radius fracture see 2016;22(3):239–241 Distal tibia see 2016;22(1):52–57 see 2016;22(1):90–96 Distally-based sural flap see 2016;22(1):46–51 Distraction see 2016;22(1):100–102 Diverticulum perforation see 2016;22(3):290–292 Duodenal perforation see 2016;22(1):109–113 see 2016;22(4):399–401

arthquake see 2016;22(4):305–314 Elderly see 2016;22(3):293–296 Electrical burns see 2016;22(3):278–282 Electron microscope study see 2016;22(2):134–138 Embolization see 2016;22(6):531–535 Emergency physicians see 2016;22(2):175–183 Endoscopic retrograde cholangiopancreatography see 2016;22(5):441–448 Endoscopic treatment see 2016;22(5):441–448 Endovascular intervention see 2016;22(2):199–201 treatment see 2016;22(2):199–201 treatment see 2016;22(6):531–535 ERCP see 2016;22(6):566–568 Erythropoietin see 2016;22(4):322–327 see 2016;22(6):521–525 Experimental spinal cord injury see 2016;22(5):423–431 Experimental work see 2016;22(4):305–314

Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Turkish Journal of Trauma and Emergency Surgery, Index of 2016 Expression see 2016;22(3):224–232 External bleeding see 2016;22(3):215–223

atal outcome see 2016;22(3):242–246 Fecal occult blood see 2016;22(5):471–476 Fish bone see 2016;22(6):572–574 Forearm see 2016;22(3):283–289 Foreign body see 2016;22(3):269–272 see 2016;22(4):402–404 ingestion see 2016;22(6):572–574 Forensic medicine see 2016;22(4):365–373 Fournier’s gangrene see 2016;22(5):505–508 see 2016;22(6):541–544 Fracture see 2016;22(1):52–57 see 2016;22(4):350–354 see 2016;22(1):90–96 Free flap see 2016;22(1):46–51

astric pull-up see 2016;22(3):293–296 Gastrocnemius see 2016;22(3):205–214 Gender see 2016;22(6):541–544 General practitioners see 2016;22(4):361–364 General surgery see 2016;22(4):365–373 Genetic polymorphism see 2016;22(4):338–343 Geriatric see 2016;22(6):536–540 Glasgow Coma Scale see 2016;22(4):328–332 Greater omentum see 2016;22(4):391–394 Gunshot injury see 2016;22(2):199–201 see 2016;22(4):395–398

Intra-articular fracture see 2016;22(1):58–65 Intramedullary nail see 2016;22(1):90–96 see 2016;22(2):184–191 Intraorbital foreign body see 2016;22(5):432–436 Intussusception see 2016;22(2):139–144 see 2016;22(3):259–264 Invasive aspergillosis see 2016;22(5):498–501 Ischemia-reperfusion see 2016;22(6):509–515

Keratoplasty see 2016;22(5):437–440 Knee pain see 2016;22(6):575–577

Lactate see 2016;22(1):29–33 Laparoscopic appendectomy see 2016;22(5):466–470 cholecystectomy see 2016;22(5):498–501 Laparoscopy see 2016;22(3):269–272 see 2016;22(4):391–394 Laparotomy see 2016;22(3):269–272 LDH see 2016;22(2):115–120 Leucocyte see 2016;22(1):76–83 Lipid peroxidation see 2016;22(2):134–138 LncRNAs see 2016;22(3):224–232 Locality of surgery see 2016;22(3):273–277 Lung injury see 2016;22(4):322–327 see 2016;22(5):417–422 Lymphocyte see 2016;22(2):163–168

Malunion see 2016;22(1):52–57

Mannitol see 2016;22(4):305–314 Massive Head trauma hemorrhage see 2016;22(2):195–198 see 2016;22(1):97–99 transfusion see 2016;22(2):195–198 see 2016;22(4):355–360 Mean platelet volume Heart see 2016;22(2):155–162 see 2016;22(3):301–303 see 2016;22(2):163–168 see 2016;22(4):395–398 Mechanical ventilation see 2016;22(2):127–133 Hernia see 2016;22(6):575–577 Medical High velocity missile see 2016;22(2):169–174 malpractice see 2016;22(4):365–373 High-voltage electrical injury see 2016;22(1):46–51 treatment see 2016;22(6):516–520 Hip pain see 2016;22(6):575–577 Melatonin see 2016;22(4):315–321 Humerus see 2016;22(4):350–354 Meta-analysis see 2016;22(3):239–241 Hypothermic see 2016;22(1):1–6 Microarray see 2016;22(3):224–232 Military see 2016;22(2):169–174 maging see 2016;22(5):449–456 Minimally invasive surgery see 2016;22(5):502–504 Incense ashes see 2016;22(1):12–16 MIPO see 2016;22(1):52–57 Infant see 2016;22(5):505–508 Mortality Infrared heater see 2016;22(5):412–416 see 2016;22(1):34–39 Ingested see 2016;22(3):269–272 see 2016;22(3):273–277 Injury see 2016;22(5):495–497 see 2016;22(3):297–300 Injury Severity Score see 2016;22(4):328–332 see 2016;22(6):541–544 Interleukin (IL)-6 see 2016;22(5):466–470 MRI see 2016;22(6):549–552 Internal fixation Muscle see 2016;22(1):58–65 see 2016;22(3):205–214 see 2016;22(3):239–241 wasting see 2016;22(3):224–232 Intestinal parasites see 2016;22(5):471–476 Myelin thickness see 2016;22(6):526–530

Hand see 2016;22(6):559–565

Ulus Travma Acil Cerrahi Derg, Kasım 2016, Vol. 22, No. 6

erve defect see 2016;22(1):7–11 Neuroprotection see 2016;22(2):134–138 see 2016;22(6):521–525 Neutrophil see 2016;22(1):76–83 see 2016;22(2):163–168 Neutrophil-to-lymphocyte ratio see 2016;22(2):155–162 Neutrophil/lymphocyte ratio see 2016;22(1):17–22 Nitric-oxide-synthases see 2016;22(4):338–343 NLR see 2016;22(4):344–349 Nonunion see 2016;22(3):283–289 Normothermic see 2016;22(1):1–6 Nursing care see 2016;22(5):489–494

besity see 2016;22(5):457–465 Obturator hernia see 2016;22(3):297–300 see 2016;22(6):575–577 Ocular trauma see 2016;22(5):437–440 Olecranon osteotomy see 2016;22(1):58–65 see 2016;22(4):386–390 Omental infarction see 2016;22(4):391–394 Open appendectomy see 2016;22(5):466–470 Open reduction with double plating see 2016;22(4):386–390 Optic chiasmal injury see 2016;22(1):97–99 Orbitotomy see 2016;22(5):432–436 Oropharynx see 2016;22(4):402–404 Osteomyelitis see 2016;22(3):205–214 Ostomy see 2016;22(2):169–174 Ottawa ankle rules see 2016;22(4):361–364 Outcome assessment see 2016;22(4):379–385 Oxidative stress see 2016;22(4):322–327 see 2016;22(5):417–422

Pancreas see 2016;22(2):150–154 Pancreatic transection see 2016;22(6):566–568 Paramedic see 2016;22(2):145–149 Pediatric see 2016;22(4):350–354 burns see 2016;22(1):34–39 Trauma Score see 2016;22(4):328–332 Pellet embolization see 2016;22(4):395–398 Penetrating injury see 2016;22(4):402–404 trauma see 2016;22(3):301–303 Penile fracture see 2016;22(6):549–552 Peptic ulcer see 2016;22(2):192–194 Percutaneus locking plate see 2016;22(1):90–96 Perforated appendicitis see 2016;22(6):569–571 Perforation see 2016;22(2):192–194 see 2016;22(5):441–448 see 2016;22(6):572–574 Peripheral nerve injury see 2016;22(2):134–138 Peritoneal

579

Turkish Journal of Trauma & Emergency Surgery, Index of 2016 adhesion see 2016;22(1):1–6 lavage see 2016;22(1):1–6 Permeability see 2016;22(5):405–411 Pin tract infection see 2016;22(5):477–482 Plasminogen activator inhibitor 1 see 2016;22(1):1–6 Plate see 2016;22(3):283–289 Platelet count see 2016;22(2):155–162 Pneumatic reduction see 2016;22(3):259–264 Polytrauma see 2016;22(1):29–33 Posterior approach see 2016;22(5):483–488 cranial fossa see 2016;22(4):355–360 malleolus see 2016;22(6):553–558 Postoperative bile leakage see 2016;22(5):498–501 Predictive factors see 2016;22(2):163–168 Pregnancy see 2016;22(6):545–548 Prevention see 2016;22(3):247–252 Prognosis see 2016;22(2):150–154 Proximal humerus see 2016;22(4):379–385 Pseudocyst see 2016;22(2):150–154 Pulmonary dysfunction see 2016;22(5):405–411 sequestration see 2016;22(6):569–571 Pulselessness see 2016;22(1):84–89

Scoring see 2016;22(6):536–540 system see 2016;22(2):150–154 Self-immolation see 2016;22(1):23–28 Semi-sterile technique see 2016;22(5):477–482 Sepsis see 2016;22(2):121–126 see 2016;22(4):315–321 Serum markers see 2016;22(4):344–349 Shock see 2016;22(5):495–497 SIGH see 2016;22(2):127–133 Sleep quality see 2016;22(5):489–494 Small bowel intussusceptions see 2016;22(2):139–144 Small bowel see 2016;22(6):572–574 obstruction see 2016;22(3):297–300 Snakebite see 2016;22(4):333–337 Spinal cord injury see 2016;22(6):521–525 Spinal gunshot injury see 2016;22(3):253–258 Splenic artery see 2016;22(1):106–108 Spontaneous perforation see 2016;22(1):103–105 reduction see 2016;22(2):139–144 resolution see 2016;22(2):150–154 Stenting see 2016;22(6):566–568 Stool analysis see 2016;22(5):471–476 uercetin see 2016;22(5):423–431 Stromal vascular fraction see 2016;22(1):7–11 Supracondylar adial artery see 2016;22(2):202–204 fracture see 2016;22(4):350–354 Radiography see 2016;22(1):100–102 humerus fracture in child see 2016;22(1):84–89 Radiology see 2016;22(6):549–552 Radius see 2016;22(2):184–191 Supracondylar humerus fracture Rat see 2016;22(5):477–482 see 2016;22(2):134–138 see 2016;22(5):483–488 see 2016;22(6):509–515 Surgery model see 2016;22(5):412–416 see 2016;22(1):103–105 Reconstruction see 2016;22(5):495–497 see 2016;22(1):109–113 Recruitment maneuver see 2016;22(2):127–133 see 2016;22(4):379–385 Recurrent intussusception see 2016;22(3):259–264 Surgical Reliability see 2016;22(5):449–456 intervention see 2016;22(3):269–272 Renal management see 2016;22(5):432–436 colic see 2016;22(1):17–22 Survey see 2016;22(2):175–183 damage see 2016;22(4):305–314 Survival trauma see 2016;22(4):374–378 see 2016;22(3):253–258 Resveratrol see 2016;22(5):423–431 rate see 2016;22(1):23–28 Retromandibular see 2016;22(1):40–45 Swallowed foreign body see 2016;22(4):399–401 Retrospective analysis see 2016;22(3):278–282 Syndesmosis injury see 2016;22(6):553–558 ROC curve see 2016;22(6):536–540 Rupture see 2016;22(1):106–108 actile perception see 2016;22(6):559–565 Tadalafil see 2016;22(6):521–525 Therapeutic strategy see 2016;22(6):569–571 aline solution see 2016;22(1):1–6 Therapy see 2016;22(3):247–252 Sciatic nerve see 2016;22(6):526–530

Q R

580

Thermal trauma see 2016;22(5):417–422 Thymoquinone see 2016;22(6):526–530 Tissue plasminogen activator see 2016;22(1):1–6 TNF-α see 2016;22(2):134–138 Toppling see 2016;22(3):265–268 Torsion see 2016;22(4):391–394 Traffic accident see 2016;22(1):66–75 Transfection see 2016;22(3):205–214 Transient intussusception see 2016;22(2):139–144 Transparotid see 2016;22(1):40–45 TRAP see 2016;22(1):58–65 Trauma see 2016;22(1):100–102 see 2016;22(3):215–223 see 2016;22(3):293–296 see 2016;22(4):328–332 see 2016;22(5):449–456 see 2016;22(6):536–540 centers see 2016;22(3):242–246 severity indices see 2016;22(5):457–465 system see 2016;22(3):242–246 team see 2016;22(3):242–246 Traumatic chiasmal syndrome see 2016;22(1):97–99 Treatment see 2016;22(1):109–113 see 2016;22(4):333–337 Triceps see 2016;22(5):483–488 TRISS see 2016;22(1):29–33 TV see 2016;22(3):265–268

Ulnar artery see 2016;22(2):202–204 nerve see 2016;22(4):350–354 Ultrasonography see 2016;22(5):495–497 Uncontrolled hemorrhage see 2016;22(3):215–223 Urinoma see 2016;22(4):374–378

Vascular injury see 2016;22(1):84–89 see 2016;22(2):202–204 Vascular leakage see 2016;22(5):405–411 VEGF gene see 2016;22(3):205–214 Vein graft See 2016;22(1):7–11 Venous glucose see 2016;22(1):29–33 Ventilator-induced lung injury see 2016;22(2):127–133

Warm fresh whole blood see 2016;22(2):195–198 Work-related see 2016;22(2):145–149 Wound dehiscence see 2016;22(5):437–440

Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Turkish Journal of Trauma & Emergency Surgery, Index of 2016

INDE X - D İZİN

Turkish Journal of Trauma & Emergency Surgery Author Index of 2016 Abat D see 2016;22(2):195–198 Abbasi N see 2016;22(1):23–28 Abdurrahman İ see 2016;22(3):290–292 Abuşka DÖ see 2016;22(4):305–314 Acar E see 2016;22(1):17–22 Acar MA see 2016;22(5):483–488 Acer T see 2016;22(2):139–144 Açıksarı K see 2016;22(4):305–314 Adaletli İ see 2016;22(3):259–264 Ağar F see 2016;22(3):269–272 Ağca B see 2016;22(1):106–108 Ağuş H see 2016;22(5):477–482 Ak H see 2016;22(6):526–530 Akarca FK see 2016;22(5):449–456 Akarsu C see 2016;22(6):572–574 Akça A see 2016;22(4):365–373 Akgül Ö see 2016;22(2):150–154 Akıllı MS see 2016;22(2):139–144 Akıncı AT see 2016;22(6):521–525 Akıncı Öİ see 2016;22(2):127–133 Akira H see 2016;22(5):495–497 Akkaya H see 2016;22(1):66–75 Akküçük S see 2016;22(3):273–277 Akman YE see 2016;22(3):283–289 Akpınar G see 2016;22(2):145–149 Aksoy S see 2016;22(6):549–552 Aktaş RS see 2016;22(4):338–343 Akyol V see 2016;22(6):526–530 Alagöz F see 2016;22(2):134–138 Alagöz F see 2016;22(2):199–201 Alagöz F see 2016;22(3):253–258 Alataş ÖD see 2016;22(1):17–22 Alemdar Ç see 2016;22(1):84–89 Alemdaroğlu S see 2016;22(6):545–548 Alış H see 2016;22(6):572–574 Alimoğlu O see 2016;22(5):502–504 Aliyev M see 2016;22(3):205–214 Allegri A see 2016;22(3):242–246 Alper E see 2016;22(5):441–448 Altay T see 2016;22(4):386–390 Amini S see 2016;22(1):23–28 Ancar C see 2016;22(1):58–65 Ansaloni L see 2016;22(3):242–246 Aras A see 2016;22(3):269–272 Aren A see 2016;22(2):155–162 Arer İM see 2016;22(6):545–548 Arıkan Y see 2016;22(3):283–289 Arslan EE see 2016;22(2):139–144 Arslan H see 2016;22(1):58–65

Arslan H see 2016;22(1):84–89 Arslan N see 2016;22(3):205–214 Arslantaş A see 2016;22(6):521–525 Arslantaş D see 2016;22(6):521–525 Asbitt M see 2016;22(3):293–296 Aslan C see 2016;22(1):40–45 Aslan O see 2016;22(3):278–282 Aslaner EE see 2016;22(1):46–51 Ataee M see 2016;22(1):23–28 Atahan K see 2016;22(5):441–448 Ateş U see 2016;22(2):121–126 Atilla Şenaylı A see 2016;22(1):34–39 Attaallah W see 2016;22(2):163–168 Avkan MC see 2016;22(4):350–354 Aydın A see 2016;22(2):184–191 Aydın A see 2016;22(6):509–515 Aydın E see 2016;22(1):109–113 Aydın MT see 2016;22(1):106–108 Aydınoğlu A see 2016;22(3):215–223 Aydoğan A see 2016;22(3):273–277 Aydoğan İ see 2016;22(2):150–154 Aykaç A see 2016;22(5):417–422 Aykan A see 2016;22(3):205–214 Ayrık C see 2016;22(1):76–83 Ayvacı BM see 2016;22(4):305–314 Azboy İ see 2016;22(1):58–65 Azboy İ see 2016;22(1):84–89

Baca E see 2016;22(4):350–354 Bacaksız T see 2016;22(5):477–482 Bakan S see 2016;22(4):395–398 Bakan V see 2016;22(4):322–327 Balkan M see 2016;22(2):115–120 Baneshi M see 2016;22(1):23–28 Barman HA see 2016;22(4):395–398 Bartın MK see 2016;22(5):466–470 Barut İ see 2016;22(4):399–401 Baş A see 2016;22(4):395–398 Baş S see 2016;22(1):40–45 Başaran SH see 2016;22(4):350–354 Başbuğ HS see 2016;22(2):202–204 Başol N see 2016;22(2):121–126 Batur A see 2016;22(3):269–272 Bayam ME see 2016;22(3):297–300 Baydemir C see 2016;22(5):423–431 Baylan S see 2016;22(2):127–133 Bayrak A see 2016;22(4):350–354 Bayrak S see 2016;22(2):155–162 Bayraktar B see 2016;22(5):502–504

Ulus Travma Acil Cerrahi Derg, Kasım 2016, Vol. 22, No. 6

Bekl Hİ see 2016;22(4):379–385 Bekler Hİ see 2016;22(1):52–57 Belen D see 2016;22(2):134–138 Belli AK see 2016;22(1):17–22 Belli AK see 2016;22(6):575–577 Belotti E see 2016;22(3):242–246 Benzin MF see 2016;22(1):103–105 Bertolucci A see 2016;22(4):391–394 Beydilli H see 2016;22(1):17–22 Bilge AD see 2016;22(5):432–436 Bilgiç Ç see 2016;22(5):502–504 Bilgili F see 2016;22(1):90–96 Bilgili MG see 2016;22(4):350–354 Bitargil M see 2016;22(2):202–204 Bol O see 2016;22(3):265–268 Bol O see 2016;22(4):338–343 Boran ÖF see 2016;22(5):498–501 Bostancı MT see 2016;22(5):466–470 Bozkurt S see 2016;22(1):76–83 Bulut G see 2016;22(4):379–385 Bulut M see 2016;22(1):58–65 Büken B see 2016;22(1):66–75 Bülbül E see 2016;22(4):338–343 Bülbüloğlu E see 2016;22(5):498–501

Cağatay AA see 2016;22(2):127–133 Can CE see 2016;22(2):184–191 Can H see 2016;22(4):355–360 Can İhsan Öztorun Cİ see 2016;22(1):34–39 Cansever T see 2016;22(4):355–360 Caputo R see 2016;22(6):569–571 Cascione F see 2016;22(6):569–571 Castelli CC see 2016;22(3):242–246 Cebiçci H see 2016;22(3):265–268 Celayir S see 2016;22(1):109–113 Celayir S see 2016;22(3):259–264 Cengiz E see 2016;22(5):498–501 Ceresoli M see 2016;22(3):242–246 Ceylan BG see 2016;22(1):1–6 Chai Jiake C see 2016;22(3):224–232 Chen XL see 2016;22(1):12–16 Chiarugi M see 2016;22(4):391–394 Chiarugi M see 2016;22(6):569–571 Cin N see 2016;22(5):441–448 Coccolini F see 2016;22(3):242–246 Coşan DT see 2016;22(5):423–431 Coşkun AK see 2016;22(2):169–174 Coşkun M see 2016;22(2):163–168 Cremonini C see 2016;22(4):391–394

581

Turkish Journal of Trauma & Emergency Surgery, Index of 2016

Çağlı S see 2016;22(4):402–404 Çakal ED see 2016;22(5):449–456 Çakar E see 2016;22(2):155–162 Çakar N see 2016;22(2):127–133 Çakır EA see 2016;22(4):315–321 Çaparlar MA see 2016;22(5):466–470 Çapkınoğlu E see 2016;22(5):441–448 Çavuşoğlu T see 2016;22(2):121–126 Çeçen GS see 2016;22(1):52–57 Çeçen GS see 2016;22(4):379–385 Çelik A see 2016;22(4):315–321 Çelik A see 2016;22(4):322–327 Çelik C see 2016;22(4):379–385 Çelik MF see 2016;22(6):572–574 Çelik T see 2016;22(5):471–476 Çelik V see 2016;22(1):84–89 Çelikmen DM see 2016;22(4):305–314 Çelikmen MF see 2016;22(4):305–314 Çepni KS see 2016;22(1):90–96 Çetin R see 2016;22(1):103–105 Çetinel Ş see 2016;22(5):417–422 Çetinkaya E see 2016;22(3):283–289 Çevik Y see 2016;22(4):361–364 Çınar C see 2016;22(5):449–456 Çınar K see 2016;22(3):253–258 Çıralık H see 2016;22(4):322–327 Çıtak C see 2016;22(4):386–390 Çiftci F see 2016;22(3):290–292 Çiftçi U see 2016;22(5):423–431 Çobanoğlu M see 2016;22(6):553–558 Çoşkun F see 2016;22(2):150–154

ağ A see 2016;22(1):76–83 Dağlıoğl E see 2016;22(2):134–138 Dal AD see 2016;22(5):412–416 Dalgıç A see 2016;22(2):134–138 Dalgıç A see 2016;22(3):253–258 Damnjanovic Z see 2016;22(2):192–194 Daş M see 2016;22(4):361–364 Daylan A see 2016;22(3):301–303 Delen E see 2016;22(5):423–431 Delen E see 2016;22(6):521–525 Deliktaş H see 2016;22(1):17–22 Demir B see 2016;22(3):283–289 Demir F see 2016;22(1):76–83 Demir R see 2016;22(3):247–252 Demir S see 2016;22(3):247–252 Demirtaş A see 2016;22(1):58–65 Dere Ö see 2016;22(6):575–577 Dervişoğlu S see 2016;22(3):259–264 Desale J see 2016;22(6):566–568 Dike MS see 2016;22(2):134–138 Dikme Ö see 2016;22(3):215–223 Dilektaşlı E see 2016;22(3):297–300 Doğan A see 2016;22(3):215–223 Doğan H see 2016;22(4):305–314 Doğan M see 2016;22(6):572–574 Doğaner F see 2016;22(5):423–431 Doğangün M see 2016;22(3):297–300

582

Duman U see 2016;22(3):297–300 Durak E see 2016;22(5):441–448 Dural AC see 2016;22(6):572–574 Durgun HM see 2016;22(5):457–465 Durgun M see 2016;22(1):40–45 Dursun R see 2016;22(5):457–465

dipoğlu İ see 2016;22(2):127–133 Eğrilmez S see 2016;22(5):437–440 Ekinci Ö see 2016;22(5):502–504 El-kamash S see 2016;22(1):29–33 Ellabban G see 2016;22(1):29–33 Elmacı İ see 2016;22(4):355–360 Elmalı N see 2016;22(1):52–57 Emlik GD see 2016;22(1):100–102 Emrah Şenel E see 2016;22(1):34–39 Emre A see 2016;22(5):498–501 Emre Ş see 2016;22(1):109–113 Emre Ş see 2016;22(3):259–264 Enercan M see 2016;22(6):553–558 Engin Ç see 2016;22(3):301–303 Erbaş O see 2016;22(2):121–126 Ercan U see 2016;22(6):541–544 Erçin E see 2016;22(4):350–354 Erdoğan E see 2016;22(1):109–113 Eren A see 2016;22(3):290–292 Eren T see 2016;22(5):502–504 Ergür B see 2016;22(1):7–11 Erhan Çil BE see 2016;22(6):531–535 Erkol Z see 2016;22(1):66–75 Ersel M see 2016;22(5):449–456 Ersoy G see 2016;22(3):215–223 Ersoy ÖF see 2016;22(4):315–321 Ersöz N see 2016;22(2):169–174 Eryiğit U see 2016;22(4):333–337 Eryuva V see 2016;22(4):386–390 Esen F see 2016;22(2):127–133 Eser C see 2016;22(1):46–51 Eski M see 2016;22(3):205–214 Evciler H see 2016;22(4):374–378 Ezirmik N see 2016;22(2):184–191

akıoğlu E see 2016;22(2):139–144 Fersahoğlu MM see 2016;22(1):106–108

alatioto C see 2016;22(4):391–394 Galatioto C see 2016;22(6):569–571 Gem M see 2016;22(1):58–65 Gem M see 2016;22(1):84–89 Gencel E see 2016;22(1):46–51 Gianardi D see 2016;22(6):569–571 Gökalp A see 2016;22(6):526–530 Gökçe EC see 2016;22(3):253–258 Gökmen N see 2016;22(3):215–223 Gökova M see 2016;22(5):441–448 Gül M see 2016;22(4):322–327 Gülabi D see 2016;22(1):52–57 Gülaçtı U see 2016;22(5):471–476 Gülcü B see 2016;22(6):541–544 Gülen B see 2016;22(2):145–149

Güloğlu C see 2016;22(5):457–465 Gülşen İ see 2016;22(6):526–530 Gümüş M see 2016;22(3):278–282 Gümüştaş SA see 2016;22(4):379–385 Gün F see 2016;22(5):505–508 Günal A see 2016;22(2):115–120 Günay N see 2016;22(3):265–268 Günay N see 2016;22(4):338–343 Günay NE see 2016;22(4):338–343 Gündoğdu SB see 2016;22(2):150–154 Güneren E see 2016;22(3):278–282 Güneş MS see 2016;22(4):402–404 Güney LH see 2016;22(2):139–144 Gür Ö see 2016;22(5):441–448 Gür V see 2016;22(3):283–289 Güzey S see 2016;22(5):412–416

an G-F see 2016;22(5):405–411 Harlak A see 2016;22(2):169–174 Hasırcı İ see 2016;22(6):516–520 Hatipoğlu C see 2016;22(2):145–149 Hatipoğlu S see 2016;22(5):471–476 Hekimoğlu Y see 2016;22(1):66–75 Hiçsönmez A see 2016;22(2):139–144 Hosseinpour M see 2016;22(4):328–332 Hosseinpour M see 2016;22(6):536–540 Hoşnuter M see 2016;22(1):40–45 Huri M see 2016;22(6):559–565 Hüseynov M see 2016;22(3):259–264

şık D see 2016;22(1):40–45 Işık O see 2016;22(3):301–303 Işık Ö see 2016;22(6):541–544

nal A see 2016;22(3):297–300 İnci E see 2016;22(6):549–552 İrkoren S see 2016;22(1):7–11 İslim F see 2016;22(6):531–535 İyigün E see 2016;22(5):489–494

Jiang X-X see 2016;22(3):239–241 Kabukçuoğlu YS see 2016;22(1):90–96 Kahraman S see 2016;22(6):553–558 Kalenderer Ö see 2016;22(5):477–482 Kalkan H see 2016;22(1):100–102 Kamalak Z see 2016;22(2):195–198 Kamer E see 2016;22(5):441–448 Kanat BH see 2016;22(5):498–501 Kandemir A see 2016;22(4):305–314 Kaneko N see 2016;22(5):495–497 Kang J-Y see 2016;22(5):405–411 Kar H see 2016;22(5):441–448 Kara İ see 2016;22(4):402–404 Kara M see 2016;22(6):526–530 Karaaslan U see 2016;22(1):76–83 Karaca S see 2016;22(6):553–558 Karadeniz H see 2016;22(1):58–65 Karahan Ö see 2016;22(6):516–520 Karakılıç ME see 2016;22(2):199–201

Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6

Turkish Journal of Trauma & Emergency Surgery, Index of 2016 Karaköse O see 2016;22(1):103–105 Karakuş A see 2016;22(4):333–337 Karataş Silistreli Ö see 2016;22(1):7–11 Karkıner A see 2016;22(4):374–378 Kaya G see 2016;22(2):145–149 Kaya S see 2016;22(1):1–6 Kayalı C see 2016;22(4):386–390 Kayaoğlu HA see 2016;22(4):315–321 Kayıhan H see 2016;22(6):559–565 Kaymak Ş see 2016;22(2):169–174 Kazemnejad-Leili E see 2016;22(4):328–332 Kazımoğlu C see 2016;22(5):477–482 Kelahmetoğlu O see 2016;22(3):278–282 Kement Z see 2016;22(4):386–390 Kemik Ö see 2016;22(5):466–470 Kendigelen P see 2016;22(2):195–198 Kesik K see 2016;22(5):483–488 Kesiktaş E see 2016;22(1):46–51 Kılıç A see 2016;22(1):90–96 Kılıç E see 2016;22(3):273–277 Kınacı E see 2016;22(2):155–162 Kırcelli A see 2016;22(4):355–360 Kırlı İ see 2016;22(1):17–22 Kıyan S see 2016;22(2):175–183 Kızıltan R see 2016;22(3):269–272 Kivanc SA see 2016;22(1):97–99 Koca YS see 2016;22(1):1–6 Koca YS see 2016;22(3):273–277 Koca YS see 2016;22(4):399–401 Koçak EF see 2016;22(6):526–530 Korkmaz T see 2016;22(5):449–456 Korkmazer B see 2016;22(4):395–398 Korucu İH see 2016;22(5):483–488 Koşan U see 2016;22(6):575–577 Kotan Ç see 2016;22(3):269–272 Kouchakinejad-Eramsadati L see 2016;22(4):328–332 Kouchakinejad-Eramsadati L see 2016;22(6):536–540 Koyuncu S see 2016;22(3):265–268 Kozak O see 2016;22(2):115–120 Kozak O see 2016;22(2):169–174 Kökoğlu B see 2016;22(6):521–525 Kökoğlu Ç see 2016;22(6):521–525 Kökoğlu K see 2016;22(4):402–404 Köktürk F see 2016;22(4):344–349 Köse A see 2016;22(2):184–191 Kural C see 2016;22(4):350–354 Kurku H see 2016;22(6):516–520 Kurt A see 2016;22(3):278–282 Kurt B see 2016;22(3):205–214 Kurutaş EB see 2016;22(4):322–327 Kuvandık G see 2016;22(4):333–337 Küçükkaya M see 2016;22(6):553–558

Lapcin O see 2016;22(3):283–289 Lapsekili E see 2016;22(2):115–120 Lapsekili E see 2016;22(2):169–174 Le L-S see 2016;22(3):239–241 Lin Y-B see 2016;22(3):239–241 Lortlar N see 2016;22(4):315–321 Lök U see 2016;22(5):471–476

Magnone S see 2016;22(3):242–246 Makhija DP see 2016;22(6):566–568 Malekpouri R see 2016;22(4):328–332 Malekpouri R see 2016;22(6):536–540 Manfredi R see 2016;22(3):242–246 Melez DO see 2016;22(4):365–373 Melez İE see 2016;22(4):365–373 Memiş G see 2016;22(6):575–577 Memişoğlu K see 2016;22(1):106–108 Menekşe G see 2016;22(2):134–138 Menonna F see 2016;22(4):391–394 Menteş Ö see 2016;22(2):115–120 Meral A see 2016;22(2):121–126 Merli C see 2016;22(3):242–246 Mihajlovic S see 2016;22(2):192–194 Modesti M see 2016;22(6):569–571 Moghazy A see 2016;22(1):29–33 Mohamed N see 2016;22(1):29–33 Mohtasham-Amiri Z see 2016;22(4):328–332 Mohtasham-Amiri Z see 2016;22(6):536–540 Moradinazar M see 2016;22(1):23–28 Müjdem Nur Azılı M see 2016;22(1):34–39

Najafi F see 2016;22(1):23–28 Naqadan F see 2016;22(5):432–436 Nazlı O see 2016;22(6):575–577 Nişancı M see 2016;22(5):412–416 Nur Azılı MN see 2016;22(3):247–252

kuducu M see 2016;22(1):106–108 Olgun DC see 2016;22(4):395–398 Orak M see 2016;22(5):457–465 Orhon O see 2016;22(3):215–223 Orhun K see 2016;22(5):502–504 Oruç C see 2016;22(3):273–277

lmez Ş see 2016;22(3):269–272 Öner MÖ see 2016;22(5):466–470 Önvural B see 2016;22(5):477–482 Ötgün İ see 2016;22(2):139–144 Özakay A see 2016;22(2):155–162 Özaşır D see 2016;22(2):145–149 Özbek Z see 2016;22(6):521–525 Özcan O see 2016;22(4):333–337 Özcan Ö see 2016;22(1):17–22 Özcan PE see 2016;22(2):127–133 Özcan R see 2016;22(1):109–113 Özcan R see 2016;22(3):259–264 Özdemir E see 2016;22(4):365–373 Özdemir G see 2016;22(6):553–558 Özdöl Ç see 2016;22(2):134–138 Özel Ö see 2016;22(4):355–360 Özemir İA see 2016;22(5):502–504 Özen Ö see 2016;22(2):175–183 Özhasenekler A see 2016;22(5):457–465 Özışık K see 2016;22(2):202–204 Özkan HS see 2016;22(1):7–11 Özkan N see 2016;22(4):315–321 Özkul E see 2016;22(1):58–65

Ulus Travma Acil Cerrahi Derg, Kasım 2016, Vol. 22, No. 6

Özkul E see 2016;22(1):84–89 Özsoy Z see 2016;22(4):315–321 Özşay O see 2016;22(5):441–448 Öztürk E see 2016;22(6):541–544 Öztürk F see 2016;22(3):247–252 Özuğurlu AF see 2016;22(4):315–321 Özüçelik DN see 2016;22(4):305–314

Palamar M see 2016;22(5):437–440 Palamara F see 2016;22(3):242–246 Parmaksızoğlu AS see 2016;22(1):90–96 Pazar B see 2016;22(5):489–494 Peker Y see 2016;22(2):115–120 Piazzalunga D see 2016;22(3):242–246 Polat E see 2016;22(2):134–138 Pülat H see 2016;22(1):103–105

Radojkovic M see 2016;22(2):192–194 Rağbetli MÇ see 2016;22(6):526–530 Ranjbar F see 2016;22(4):328–332 Ranjbar F see 2016;22(6):536–540 Razzaghi A see 2016;22(6):536–540 Rodoplu Ü see 2016;22(3):215–223

Saad S see 2016;22(1):29–33 Sabri Demir S see 2016;22(1):34–39 Sabuncuoğlu MZ see 2016;22(1):103–105 Sabuncuoğlu MZ see 2016;22(4):344–349 Sadıllıoğlu S see 2016;22(4):305–314 Sağlam F see 2016;22(1):52–57 Salık AE see 2016;22(6):531–535 Salman N see 2016;22(5):505–508 Sano H see 2016;22(5):495–497 Sarı R see 2016;22(4):355–360 Sarı S see 2016;22(2):155–162 Sarıkaya S see 2016;22(4):305–314 Sarkut P see 2016;22(6):541–544 Satılmış B see 2016;22(5):417–422 Sayar H see 2016;22(5):498–501 Seçer M see 2016;22(3):253–258 Selver ÖB see 2016;22(5):437–440 Serinken M see 2016;22(2):145–149 Sever MŞ see 2016;22(4):305–314 Sevinç B see 2016;22(6):516–520 Sevinç MM see 2016;22(2):155–162 Shah H see 2016;22(6):566–568 Sivri M see 2016;22(1):100–102 Snow D see 2016;22(3):293–296 Somer A see 2016;22(5):505–508 Sökücü S see 2016;22(1):90–96 Sönmez BM see 2016;22(2):199–201 Sönmez E see 2016;22(2):145–149 Srinivasrao H see 2016;22(3):293–296 Stanojevic G see 2016;22(2):192–194 Stojanovic M see 2016;22(2):192–194 Sütçü M see 2016;22(5):505–508

ahan M see 2016;22(4):333–337 Şahin C see 2016;22(1):17–22 Şahin İ see 2016;22(5):412–416

583

Turkish Journal of Trauma & Emergency Surgery, Index of 2016 Şahin İ see 2016;22(5):489–494 Şahin S see 2016;22(6):549–552 Şahin S see 2016;22(6):559–565 Şahutoğlu C see 2016;22(3):301–303 Şarlı B see 2016;22(3):265–268 Şehirli AÖ see 2016;22(5):417–422 Şeker G see 2016;22(6):549–552 Şenaylı A see 2016;22(3):247–252 Şencan A see 2016;22(4):374–378 Şenel E see 2016;22(3):247–252 Şener EF see 2016;22(4):338–343 Şener G see 2016;22(5):417–422 Şengezer M see 2016;22(3):205–214 Şenocak R see 2016;22(2):169–174 Şenol K see 2016;22(2):150–154 Şenol K see 2016;22(3):297–300 Şentürk E see 2016;22(2):127–133 Şenyüz OF see 2016;22(1):109–113 Şık GD see 2016;22(5):505–508 Şimşek G see 2016;22(6):516–520 Şimşek O see 2016;22(4):395–398 Şirin G see 2016;22(1):66–75

Tan O see 2016;22(1):40–45 Tanrıkulu CŞ see 2016;22(4):344–349 Tanrıkulu Y see 2016;22(4):344–349 Tao RQT see 2016;22(1):12–16 Tarhan ÖR see 2016;22(1):1–6 Tartaglia D see 2016;22(4):391–394 Tartaglia D see 2016;22(6):569–571 Taşcı Aİ see 2016;22(6):549–552 Taşdemir Z see 2016;22(1):52–57 Taşın V see 2016;22(4):333–337 Taşlıdere B see 2016;22(4):338–343 Taşlıdere E see 2016;22(4):338–343 Tavusbay C see 2016;22(5):441–448 Tekant G see 2016;22(3):259–264 Tekant GT see 2016;22(1):109–113 Telci L see 2016;22(2):127–133 Temir ZG see 2016;22(4):374–378 Temiz A see 2016;22(4):344–349 Temiz A see 2016;22(4):361–364 Temiz M see 2016;22(3):273–277 Tetik S see 2016;22(5):417–422 Tez M see 2016;22(2):150–154

584

Tezer S see 2016;22(1):106–108 Tihan DN see 2016;22(2):150–154 Tihan DN see 2016;22(3):297–300 Tiwari C see 2016;22(6):566–568 Toker İ see 2016;22(1):76–83 Toker S see 2016;22(5):483–488 Toktaş O see 2016;22(3):269–272 Topal M see 2016;22(2):184–191 Tsurukiri J see 2016;22(5):495–497 Tuğcu V see 2016;22(6):549–552 Turgut A see 2016;22(5):477–482 Türk CÇ see 2016;22(2):134–138 Türkay R see 2016;22(6):549–552 Türkmen F see 2016;22(5):483–488 Türköz KH see 2016;22(2):127–133 Tütüncü Ç see 2016;22(3):259–264

Valle J see 2016;22(3):293–296 Vehid HE see 2016;22(3):259–264 Vural M see 2016;22(5):423–431

Yalçın B see 2016;22(4):344–349 Yaman H see 2016;22(2):115–120 Yardımcı S see 2016;22(2):163–168 Yavan İ see 2016;22(5):412–416 Yavuz M see 2016;22(1):46–51 Yavuz U see 2016;22(3):283–289 Yazar FM see 2016;22(5):498–501 Yazıcı B see 2016;22(5):432–436 Yazıcıoğlu M see 2016;22(4):305–314 Yazici B see 2016;22(1):97–99 Yeğen B see 2016;22(5):417–422 Yeğen ŞC see 2016;22(2):163–168 Yel C see 2016;22(3):253–258 Yenice MG see 2016;22(6):549–552 Yenidoğan E see 2016;22(4):315–321 Yeşilağaç H see 2016;22(6):545–548 Yetim İ see 2016;22(3):273–277 Yılar S see 2016;22(2):184–191 Yıldırım AE see 2016;22(2):134–138 Yıldırım AE see 2016;22(2):199–201 Yıldırım AM see 2016;22(6):509–515 Yıldırım B see 2016;22(1):17–22 Yıldırım K see 2016;22(3):278–282 Yıldız İ see 2016;22(4):399–401 Yılmaz F see 2016;22(2):199–201 Yılmaz H see 2016;22(5):432–436 Yılmaz O see 2016;22(3):215–223 Yılmaz Ö see 2016;22(3):269–272 Yılmaz R see 2016;22(1):66–75 Yılmazlar T see 2016;22(6):541–544 Yiğitbaş H see 2016;22(6):572–574 Yousefzadeh-Chabok S see 2016;22(4):328–332 Yousefzadeh-Chabok S see 2016;22(6):536–540 Yu G-S see 2016;22(3):239–241 Yu Yonghui Y see 2016;22(3):224–232

Wang A-M see 2016;22(5):405–411

Zemheri E see 2016;22(5):502–504

Uçan AB see 2016;22(4):374–378 Uçkun ÖM see 2016;22(3):253–258 Uğur M see 2016;22(3):273–277 Uğurlu MÜ see 2016;22(2):163–168 Ulutabanca H see 2016;22(4):402–404 Ulutaş M see 2016;22(3):253–258 Urfalıoğlu AU see 2016;22(5):498–501 Uslu S see 2016;22(6):521–525 Uysal O see 2016;22(5):423–431

Ünlü A see 2016;22(2):169–174 Ünlü Y see 2016;22(6):516–520 Üstündağ M see 2016;22(5):457–465 Üzün İ see 2016;22(4):365–373

Valetti TM see 2016;22(3):242–246

Wang J see 2016;22(1):12–16 Wang J-M see 2016;22(5):405–411 Wu S-Y see 2016;22(5):405–411

abanoğlu H see 2016;22(6):545–548 Yağcı A see 2016;22(5):437–440 Yağmur Ç see 2016;22(3):278–282

Zengin Y see 2016;22(5):457–465 Zeybek N see 2016;22(2):169–174 Zhan M-F see 2016;22(3):239–241 Zhang Haijun Z see 2016;22(3):224–232 Zhang L-C see 2016;22(5):405–411 Zhou B see 2016;22(1):12–16 Ziya Livanelioğlu Z see 2016;22(1):34–39

Ulus Travma Acil Cerrahi Derg, November 2016, Vol. 22, No. 6