Travma 2017 / 1

ISSN 1306 - 696X

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

Volume 23 | Number 1 | January 2017

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): January (Ocak) 2017 • 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 23

Number - Sayı 1 January - Ocak 2017

Contents - İçindekiler Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 1-6 Does protocatechuic acid, a natural antioxidant, reduce renal ischemia reperfusion injury in rats?

Doğal bir antioksidan olan Protocatechuic asit sıçanlarda renal iskemi reperfüzyon hasarını azaltıyor mu?

Yüksel M, Yıldar M, Başbuğ M, Çavdar F, Çıkman Ö, Akşit H, Aslan F, Akşit D 7-14 A biological tube technique for the repair of peripheral nerve defects using ‘stuffed nerves’

Periferik sinir defektlerinin onarımında biyolojik tüp kullanımı ‘sinir dolması’ Çapkın S, Akhisaroğlu M, Ergür BU, Bacakoğlu AA

Original Articles - Orijinal Çalışma 15-22 Complicated colorectal cancer in nonagenarian patients: is it better not to perform anastomosis in emergency?

Doksanlı yaşlardaki hastalarda komplike kolorektal kanser: Acil durumda anastomoz yapmamak daha mı iyi?

De Simone B, Coccolini F, Ansaloni L, Tarasconi A, Baiocchi G, Vettoretto N, Joly P, Ferron M, Pozzo A, Charre L, Di Saverio S, Napoli JA, Agresta F, Sartelli M, Catena F 23-28 An evaluation of factors affecting clinical outcomes in penetrating cardiac injuries: A single center experience

Penetran kardiyak yaralanmalarda klinik sonuçları etkileyen faktörlerin değerlendirilmesi: Tek merkez deneyimi Tezcan O, Karahan O, Yavuz C, Demirtaş S, Çalışkan A, Mavitaş B 29-33 Should Alvarado and Ohmann scores be real indicators for diagnosis of appendicitis and severity of inflammation?

Alvarado ve ohmann skorlamaları apandisit tanısında ve enflamasyonun şiddetinde gerçek yol gösterici olabilir mi?

Yılmaz EM, Kapçı M, Çelik S, Manoğlu B, Avcil M, Karacan E 34-38 Percutaneous cholecystostomy: A curative treatment modality forelderly & high ASA score acute cholecystitis patients

Perkütan kolesistostomi: Yaşlı ve yüksek ASA skorlu akut kolesistitli hastalarda küratif tedavi yöntemi Tolan HK, Semiz Oysu A, Başak F, Atak İ, Özbağrıaçık M, Özpek A, Kaskal M, Ezberci F, Baş G 39-45 Evaluation of risk factors and development of acute kidney injury in aneurysmal subarachnoid hemorrhage, head injury, and severe sepsis/septic shock patients during ICU treatment

Anevrizmal subaraknoid kanama, kafa travması ve sepsis hastalarının yoğun bakım tedavileri sırasında akut böbrek hasarı gelişimi ve etkileyen risk faktörlerinin incelenmesi Kamar C, Ali A, Altun D, Orhun G, Sabancı A, Sencer A, Akıncı İÖ 46-50 What is the clinical yield of capsule endoscopy in the management of obscure bleeding in emergency service?

Nedeni bilinmeyen gastrointestinal sistem (GİS) kanamalarda kapsül endoskopisinin acil servisteki yeri? Üçüncü MZ, Bademler S, İlhan M, Gök AFK, Akyüz F, Güloğlu R 51-55 General characteristics of paint thinner burns: Single center experience

Tiner yanıklarının genel özellikleri: Tek merkezli bir çalışma Haksal MC, Tiryaki C, Yazıcıoğlu MB, Güven M, Çiftci A, Esen O, Turgut HT, Yıldırım A Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

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TURKISH JOURNAL OF TRAUMA & EMERGENCY SURGERY ULUSAL TRAVMA VE ACİL CERRAHİ DERGİSİ Vol. - Cilt 23

Number - Sayı 1 January - Ocak 2017

Contents - İçindekiler

56-60 Physical violence among elderly: analysis of admissions to an emergency department

Yaşlılarda fiziksel şiddet: Acil servise başvuruların analizi Kılıç Öztürk Y, Düzenli E, Karaali C, Öztürk F 61-65 Is surgery necessary to confirm diagnosis of right-sided diverticulitis in spite of relevant clinical and radiological findings?

Radyolojik ve klinik bulgulara rağmen sağ kolon divertiküllerinin tanısında cerrahi gerekli mi?

Yardımcı E, Hasbahçeci M, İdiz UO, Atay M, Akbulut H 66-71 Evaluation of anatomical and functional outcomes in patients undergoing repair of traumatic canalicular laceration

Travmatik kanalikül kesi tamiri yapılan hastalarda anatomik ve fonksiyonel başarının değerlendirilmesi Aytoğan H, Karadeniz Uğurlu Ş

Short Report - Kısa Rapor 72-73 Anticoagulant-induced breast hematoma

Antikoagülan tedaviye bağlı meme hematomu Gündeş E, Değer KC, Taşcı E, Senger AS, Duman M

Case Reports - Olgu Sunumu 74-76 A rare cause of ileus: late jejunal stricture following blunt abdominal trauma

Nadir görülen ileus nedeni; Künt batın travması sonrası geç dönem gelişen jejunal striktür Aday U, Gündeş E, Değer KC, Çiyiltepe H, Kayıpmaz Ş, Duman M 77-80 Case of an intrahepatic sewing needle and review of the literature

Karaciğer içerisinde dikiş iğnesine ait olgu sunumu ve literatür derlemesi Bostancı Ö, İdiz UO, Battal M, Kaya C, Mihmanlı M 81-83 An unusual appearance of complicated hydatid cyst: necrotizing pancreatitis

Komplike kist hidatikte sıradışı bir tablo: Nekrotizan pankreatit Sıkar HE, Kaptanoğlu L, Kement M

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Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

EXPERIMENTAL STUDY

Does protocatechuic acid, a natural antioxidant, reduce renal ischemia reperfusion injury in rats?

Melih Yüksel, M.D.,1 Murat Yıldar, M.D.,2 Murat Başbuğ, M.D.,2 Faruk Çavdar, M.D.,2 Öztekin Çıkman, M.D.,3 Hasan Akşit, M.D.,4 Figen Aslan, M.D.,5 Dilek Akşit, M.D.6 1

Department of Emergency Medicine, Balıkesir University Faculty of Medicine, Balıkesir-Turkey

2

Department of General Surgery, Balıkesir University Faculty of Medicine, Balıkesir-Turkey

3

Department of General Surgery, Çanakkale Onsekiz Mart University Faculty of Medicine, Çanakkale-Turkey

4

Department of Biochemistry, Balıkesir University Faculty of Veterinary, Balıkesir-Turkey

5

Department of Pathology, Balıkesir University Faculty of Medicine, Balıkesir-Turkey

6

Department of Pharmacology and Toxicology, Balıkesir University Faculty of Veterinary, Balıkesir-Turkey

ABSTRACT BACKGROUND: Protocatechuic acid (PCA), which has antioxidant property, is a simple phenolic compound commonly found in many plants, vegetables, and fruits, notably in green tea and almonds. Present study was an investigation of the effects of PCA on rat kidney with ischemia/reperfusion (IR) injury.

METHODS: Sprague-Dawley rats were randomly divided into 4 groups: (1) Sham, (2) Renal IR, (3) Renal IR+Vehicle, and (4) Renal IR+PCA. Renal reperfusion injury was induced by clamping renal pedicle for 45 minutes after right nephrectomy was performed, followed by reperfusion for 3 hours. Dose of 80 mg/kg PCA was intraperitoneally administered to 1 group immediately before renal ischemia; 33% polyethylene glycol was used as vehicle. Total antioxidant status (TAS), malondialdehyde (MDA), superoxide dismutase (SOD), tumor necrosis factor alpha (TNF-α), and interleukin-6 levels were measured in blood and kidney tissue samples taken from sacrificed rats. Kidney tissue samples were examined and scored histopathologically. Terminal deoxynucleotidyltransferase-mediated dUTP digoxigenin nick end labeling assay method was used to detect apoptotic cells.

RESULTS: It was found that PCA significantly reduced serum MDA, TNF-α, and kidney MDA levels, while it increased serum and kidney TAS and SOD levels. Histopathological scores were significantly higher for the group given PCA. CONCLUSION: PCA reduced oxidative stress and can be used as an effective agent in treatment of renal IR injury.

Keywords: Antioxidants; ischemia reperfusion injury; malondialdehyde; protocatechuic acid; reactive oxygen species.

INTRODUCTION One of the primary causes of acute kidney injury is ischemia/ reperfusion (IR) injury.[1] IR can develop in circumstances such as hemorrhagic shock, renal transplantation, and urological surgical procedures that require temporary interruption of blood flow to the kidney, and may lead to loss of the organ.[1–3] Address for correspondence: Melih Yüksel, M.D. Balıkesir Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Çağış Yerleşkesi, Balıkesir, Turkey Tel: +90 266 - 612 10 10 E-mail: melihdr@gmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):1–6 doi: 10.5505/tjtes.2016.20165 Copyright 2017 TJTES

Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Reactive oxygen species (ROS) in the body, which ordinarily have low to moderate concentration, have roles in beneficial physiological functions, including cell signaling and defense against infection.[4] However, in case of post-ischemic reperfusion, for example, protein, lipid, DNA, and mitochondrial damage occur in the cells due to excessive production of intracellular ROS.[1,4] This damage is the beginning of the apoptosis process. As a result of renal tubular cell damage, renal function deteriorates.[2,5] Antioxidant agents are known to decrease IR.[6] Protocatechuic acid (PCA) is a benzoic acid derivative found in vegetables, nuts, brown rice, and fruit, as well as herbal medicines.[7,8] The antioxidant effects of PCA have been demonstrated in previous studies.[9–11] Anti-inflammatory, analgesic, antiplatelet, antiallergenic, antibacterial, antidiabetic, antineoplastic, antiapoptosis, and neuroprotective properties of PCA have been reported.[7,9,12–21] Additionally, it has been stated in various 1

Yüksel et al. Does protocatechuic acid, a natural antioxidant, reduce renal ischemia reperfusion injury in rats?

studies that PCA particularly reduces acute lung injury and cerebral ischemia, as well as IR injury in the liver and spleen.

[22–25] This study was investigation of effects of PCA on renal IR injury, which has not been discussed in previous studies.

MATERIALS AND METHODS Animal Testing and Treatment Procedures Before the study was conducted, the approval of the Çanakkale 18 Mart University animal ethics committee was granted. Unlimited access to food and water was provided to all animals and they were treated humanely, according to the guidelines and the rules of the US National Institutes of Health regarding laboratory animal care and use of animals throughout the protocol.

Total of 24 male Sprague-Dawley rats weighing approximately 250 to 300 g each were randomly divided into 4 groups: (1) Sham (n=8), (2) Renal IR (n=8), (3) Renal IR+Vehicle (n=8), and (4) Renal IR+PCA (n=8). Anesthesia was administered to experimental subjects via intramuscular ketamine/xylazine (Ketalar; Pfizer, Inc., NY, NY, USA/Rompun; Bayer AG, Leverkusen, Germany) 90/10 mg/kg. Renal reperfusion injury was induced through reperfusion performed for 3 hours following right nephrectomy and clamping the left renal pedicle for 45 minutes. Next, 80 mg/kg dose of PCA ethyl ester (Sigma-Aldrich, Corp., St. Louis, MO, USA), which is used therapeutically, was administered intraperitoneally to PCA group immediately before development of renal ischemia. As PCA was solid, saline with 33% polyethylene glycol was used as vehicle. During laparotomy, 50 mL/kg warm 0.9% sodium chloride was added to the abdominal cavity, and 3 hours after laparotomy closure, all rats were sacrificed. Total antioxidant status (TAS), malondialdehyde (MDA), superoxide dismutase (SOD), tumor necrosis factor alpha (TNF-α), and interleukin-6 (IL-6) levels in blood samples and kidneys were analyzed. Kidney tissue samples were used for histopathological scoring. Terminal deoxynucleotidyltransferase-mediated dUTP digoxigenin nick end labeling (TUNEL) assay was used to detect apoptotic cells.

Antioxidant Enzymes, Pro-Inflammatory Cytokines, and MDA Measurement Blood samples taken from rats were incubated for 2 hours at room temperature to allow for clotting. Samples were centrifuged at 2500 g for 15 minutes at 4ºC and then kept at -20°C. Lipid peroxidation was examined via procedure demonstrated by Yoshioka.[26] During the procedure, MDA, which is the final product of peroxidation of fatty acids, reacts with TBA at 532 nm to form a colored compound with maximum absorbance. The method developed by Rel to measure antioxidative influence of the sample against the potent reactive radical reactions started by the reduced hydroxyl radical was utilized to evaluate TAS of the serum. Data were expressed as mmol Trolox equiv/L. In order to assess SOD activity in se2

rum, it was incubated with xantine oxidase solution for 1 hour at 37°C. Absorbance was measured at 490 nm to allow for creation of superoxide anions. Activity of SOD was considered inhibition of chromagen decrease. Superoxide anion concentration decreases in presence of SOD, which leads to less colorimetric signal. SOD activity was expressed as percentage. To assess serum concentration of TNF-α and IL-6, double sandwich enzyme-linked immunosorbent assay kits (Thermo Fisher Scientific, Inc., Waltham, MA, USA) were used. ELISA plates were evaluated using microplate reader at 450 nm.

Histopathological Examination For histopathological examination, tissue samples from 4 groups were identified using 10% formalin and routine procedures were performed. Sections 5-μm thick were taken from paraffin-embedded tissue and stained with hematoxylin eosin.

Light microscope was used to examine hydropic degeneration, tubular dilation, pyknotic nucleus, cell caste in tubulin (debris), and congestion in kidney tissue. Each parameter was scored semi-quantitatively from 0 to 3, i.e., no pathology: 0 points, focal: 1 point, multifocal: 2 points, and diffuse: 3 points.

TUNEL Staining to Detect Apoptotic Cells Apoptotic cells in kidneys were identified by doctor who was blinded to group assignments using TUNEL assay. TUNEL assay kit was used according to the manufacturer’s instructions (ApopTag Peroxidase In Situ Apoptosis Detection Kit, S7101KIT; Merck Millipore, Corp., Billerica, MA, USA).

Statistical Analysis Results were expressed as mean±SD. Data were analyzed using SPSS 20.0 (IBM, Corp., Armonk, NY, USA) software.

Analysis of variance was used to compare all groups. In addition, Tukey’s range test was used as post hoc analysis. P value of 0.05 or less was considered statistically significant.

RESULTS Effects of PCA on TAS, SOD, and MDA Level Serum TAS and SOD values, measured at 2.67±0.23 and 64.51±9.62, respectively, in the Sham group, were significantly lower in the Renal IR group (TAS: 1.78±0.23, SOD: 48.15±4.03; p<0.001, p<0.001). These values were elevated in Renal IR group compared with groups given vehicle before renal IR; however, this change was not statistically significant (TAS: 1.88±0.27, SOD: 49.17±2.11; p=0.856, p=0.989). Values were significantly greater in group given PCA compared with Renal IR group (TAS: 2.36±0.12, SOD: 57.37±3.53; p=0.001, p=0.45). Serum MDA value, with mean score of 10.82±0.75 in the Sham group, was significantly greater in Renal IR group (17.00±2.93; p<0.001). That value was lower in groups given vehicle before renal IR, but decrease was not significant (15.96±1.96; p=0.760). In group given PCA prior to renal IR, it was found that value was significantly lower compared with Renal IR group (11.65±0.68; p<0.001) (Table 1, Figure 1).

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Yüksel et al. Does protocatechuic acid, a natural antioxidant, reduce renal ischemia reperfusion injury in rats?

Table 1. The mean serum TAS, MDA, SOD, TNF-α, and IL-6 level in all experimental groups Groups

TAS (mmol trolox Equiv./L)

MDA (µmol/L)

SOD (% inhibition)

TNF-α (pg/mL)

IL-6 (pg/mL)

Mean±SD

Mean±SD

Mean±SD

Mean±SD Mean±SD

Sham

2.67±0.23

10.82±0.75

64.51±9.62

79.55±7.63 22.92±5.64

Renal IR

1.78±0.23* 17.00±2.93* 48.15±4.03* 104.02±8.98* 34.34±2.47*

Vehicle 1.88±0.27* 15.96±1.96* 49.17±2.11* 101.82±10.69* 35.79±2.68* PCA 2.36±0.12† 11.65±0.68† 57.37±3.53† 85.97±5.02† 30.43±2.71* * Compared with Sham group; p<0.05. †Compared with Renal IR Group; p<0.05.

IL-6: Interleukin-6; IR: Ischemia/reperfusion; MDA: Malondialdehyde; PCA: Protocatechuic acid; SOD: Superoxide dismutase; TAS: Total antioxidant status; TNF-α: Tumor necrosis factor alpha.

Kidney TAS and SOD values, measured at 1.30±0.12, and 58.06±4.70, respectively, in Sham group, were significantly lower in Renal IR group (TAS: 0.86±0.14, SOD: 38.14±4.13; p<0.001, p<0.001). These values were greater in the group given PCA prior to renal IR; however, change was not significant (TAS: 0.91±0.18, SOD: 39.92±4.90; p=0.882, p=0.

878). Values were significantly greater in group given PCA compared with Renal IR group (TAS: 1.10±0.12, SOD: 47.91±2.27; p=0.014, p=0.003). Kidney MDA value, with mean of 13.09±1.11 for Sham group, was significantly greater in Renal IR group (19.24±2.38; p<0.001). There was no significant difference seen in groups given vehicle before renal IR (18.23±2.31; p=0.793). Values were observed to be signifiSerum Kidney

Effects of PCA on TNF-α and IL-6 Levels Serum TNF-α and IL-6 levels, with mean measurement of 79.55±7.63 and 22.92±5.64, respectively, in Sham group, were significantly greater in Renal IR group (TNF-α: 104.02±8.98, IL-6: 34.34±2.47; p<0.001, p<0.001). These values were greater in groups given vehicle prior to renal IR compared with Renal IR group. However, the increase in these markers was not significant (TNF-α: 101.82±10.69, IL-6: 35.79±2.68; p=0.968, p=0.898). In addition, in group given PCA before renal IR, TNF-α levels were found to be significantly lower. IL-6 Serum Kidney

15

20

60

15

40

10

1

20

5

0

Sham

Renal IR + Vehicle Groups

Renal IR

0

Renal IR + PCA

Serum Kidney

80

SOD (% inhibition)

2

MDA (μmol/L)

TAS (mmol trolox Equiv./L)

3

cantly lower in the group given PCA compared with Renal IR group (14.50±1.42; p=0.002) (Table 2, Figure 1).

Sham

Renal IR + Vehicle Groups

Renal IR

Serum Kidney

120

0

Renal IR + PCA

Sham

Renal IR + Vehicle Groups

Renal IR

Renal IR + PCA

Serum Kidney

40

100

IL (pg/ml)

TNF (pg/ml)

30 80 60

20

40 10 20

0

Sham

Renal IR + Vehicle Groups

Renal IR

Renal IR + PCA

0

Sham

Renal IR + Vehicle Groups

Renal IR

Renal IR + PCA

Figure 1. The mean TAS, MDA, SOD, TNF-α, and IL-6 level in all experimental groups. IL-6: Interleukin-6; MDA: Malondialdehyde; SOD: Superoxide dismutase; TAS: Total antioxidant status; TNF-α: Tumor necrosis factor alpha.

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Yüksel et al. Does protocatechuic acid, a natural antioxidant, reduce renal ischemia reperfusion injury in rats?

Table 2. The mean kidney TAS, MDA, SOD, TNF-α and IL-6 level in all experimental groups Groups

TAS (mmol trolox Equiv./L)

MDA (µmol/L)

SOD (% inhibition)

TNF-α (pg/mL)

IL-6 (pg/mL)

Mean±SD

Mean±SD

Mean±SD

Mean±SD Mean±SD

Sham

1.30±0.12

13.09±1.11 58.06±4.70

3.55±0.46 2.10±0.18

Renal IR

0.86±0.14* 19.24±2.38* 38.14±4.13* 4.36±0.43* 2.50±0.14*

Vehicle 0.91±0.18* 18.23±2.31* 39.92±4.90* 4.56±0.38* 2.61±0.16* PCA 1.10±0.12† 14.50±1.42† 47.91±2.27*† 3.78±0.26 2.29±0.31 * Compared with Sham group; p<0.05. †Compared with Renal IR Group; p<0.05.

IL-6: Interleukin-6; MDA: IR: Ischemia/reperfusion; Malondialdehyde; PCA: Protocatechuic acid; SOD: Superoxide dismutase; TAS: Total antioxidant status; TNF-α: Tumor necrosis factor alpha.

levels were also found to be lower, but the decrease was not significant (TNF-α: 85.97±5.02, IL-6: 30.43±2.71; p=0.006, p=0.271) (Table 1, Figure 1).

Kidney TNF-α and IL-6 levels, having mean score of 3.55±0.46 and 2.10±0.18, respectively, in Sham group, were significantly elevated in Renal IR group (TNF-α: 4.36±0.43, IL-6: 2.50±0.14; p=0.010, p=0.011). Values had increased in groups given vehicle prior to renal IR compared with Renal IR group; however, increase in these markers was not significant

(a)

(b)

(TNF-α: 4.56±0.38, IL-6: 2.61±0.16; p=0.794, p=0.750). In group given PCA before renal IR, TNF-α and IL-6 levels were lower, but decrease was not significant (TNF-α: 3.78±0.26, IL-6: 2.29±0.31; p=0.080, p=0.311) (Table, Figure 1).

Effects of PCA on Kidney Tissue During examination with light microscope of tissue sections stained with hematoxylin-eosin, hydropic degeneration in tubule epithelium, tubular dilation, pyknotic nucleus, cell caste

(c)

(d)

Figure 2. Hematoxylin and eosin (H&E) stain of kidney tissue. (a) Sham group sample with normal kidney tissue structure (H&E; x200); (b) Renal ischemia/reperfusion (IR) group sample with apparent tubular hidropic degeneration, intra-tubulin caste (debris) accumulation, pyknotic nuclei, and signs of congestion (H&E; x200); (c) Renal IR+Vehicle group sample with similar histopathological findings to renal IR group (H&E; x200); (d) Significant decline in renal histopathological findings observed in IR+PCA group, and renal IR+Vehicle group. (H&E; x200).

(a)

(b)

Figure 3. Terminal deoxynucleotidyltransferase-mediated dUTP digoxigenin nick end labeling (TUNEL) analysis for apoptotic cells shown (TUNEL; x400). Nuclei of TUNEL-positive cells are stained brown, in contrast to blue-stained TUNEL-negative cells. (a) Renal ischemia/ reperfusion (IR) group; (b) Renal IR+PCA group.

4

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Yüksel et al. Does protocatechuic acid, a natural antioxidant, reduce renal ischemia reperfusion injury in rats?

in tubulin (debris), and tissue damage symptoms, such as congestion, were clearly observed in IR group. Severity of tissue damage did not change in Renal IR+Vehicle group, while in Renal IR+PCA group, tissue damage was found to be less severe than in IR group (Figure 2). Mean score of tissue damage parameters was 1.85±1.22 in Sham group, 10±0.82 in IR group, 10.4±0.89 in Renal IR+Vehicle group, and 6.43±3.21 in Renal IR+PCA group. Mean score of tissue damage parameters was significantly lower in Renal IR+PCA group compared with IR group (p<0.001).

not investigated dose and time dependent effects of PCA. Because effect of PCA on renal IR has not been previously documented, we investigated effects on constant reperfusion time and dose of PCA. We used 45 minute-ischemia and 3-hour reperfusion in this study. Unfortunately, for technical reasons, we could not measure glomerular filtration rate or tubular function, which might have supported our results indicating reduced renal IR damage.

Substantial nuclear changes, including death of apoptotic cells as indicated by TUNEL-positive cells, were observed in the kidneys of IR group. PCA-treatment reduced the number of TUNEL-positive cells (Figure 3).

The results of this study have demonstrated that PCA has a protective effect on renal IR injury by reducing oxidative stress and tissue damage. These effects of treatment with PCA, a natural antioxidant, on renal IR injury have been established for the first time with this study. PCA may be an effective agent to prevent renal IR if our results are supported by other experimental and clinical studies.

DISCUSSION

Ethical Approval

In this study, PCA was demonstrated to have protective influence on renal IR damage. Renal IR damage is known to be associated with cell apoptosis, caused by increased ROS and oxidative stress.[3] Thus, treatment methods reducing ROS may also reduce oxidative stress, apoptosis, and renal IR damage.[3] Antioxidative properties of PCA may be able to target different stages of the pathophysiological events that cause IR damage. As an antioxidant agent, the most likely way is to reduce ROS.[14]

All applicable international, national, and/or institutional guidelines for the care and use of animals were followed. All experimental protocols conducted on the animals were consistent with the National Institutes of Health Guidelines for the Care and Use of Laboratory Animals and approved by the Çanakkale 18 Mart University ethical committee.

Effects of PCA on TUNEL Staining

Excessive production of ROS causes lipid peroxidation. MDA levels increase due to lipid peroxidation.[14,27] It was found in the present study that MDA levels elevated in Renal IR group were lower in group with PCA treatment.

Endogenous antioxidants, such as SOD, protect cells from ROS damage. With increase in ROS production, SOD levels decrease.[4,23] Decrease in SOD lowers antioxidant status.[28] It was observed in this study that antioxidant components SOD and TAS, which decrease following renal IR, increased with PCA therapy.

It has been demonstrated that ROS, produced in tissues after IR, induces release of proinflammatory cytokines by stimulating macrophage.[29] Proinflammatory cytokines, such as TNF-α and IL-6, cause polymorphonuclear leukocyte activation and play an important role in both tissue and distant organ damage.[29,30] In our study, TNF-α and IL-6 levels were found to be lower with PCA treatment.

There are many studies showing that as result of renal IR, apoptosis and damage occur, particularly to the outer tubules of renal medulla.[2] In our study, histopathological scoring performed with samples taken from the outer renal medulla was better in those subjects with PCA treatment, and apoptosis was decreased.

There are some limitations to our study. Primarily, we have Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Conflict of interest: None declared.

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30. Rezende-Neto JB, Moore EE, Melo de Andrade MV, Teixeira MM, Lisboa FA, Arantes RM, et al. Systemic inflammatory response secondary to abdominal compartment syndrome: stage for multiple organ failure. J Trauma 2002;53:1121–8.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Doğal bir antioksidan olan protokateşuik asit sıçanlarda renal iskemi reperfüzyon hasarını azaltıyor mu?

Dr. Melih Yüksel,1 Dr. Murat Yıldar,2 Dr. Murat Başbuğ,2 Dr. Faruk Çavdar,2 Dr. Öztekin Çıkman,3 Dr. Hasan Akşit,4 Dr. Figen Aslan,5 Dr. Dilek Akşit6 Balıkesir Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Balıkesir Balıkesir Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Balıkesir Çanakkale Onsekiz Mart Üniveristesi, Genel Cerrahi Anabilim Dalı, Çanakkale 4 Balıkesir Üniversitesi Veteriner Fakültesi, Biyokimya Anabilim Dalı, Balıkesir 5 Balıkesir Üniversitesi Tıp Fakültesi, Patoloji Anabilim Dalı, Balıkesir 6 Balıkesir Üniversitesi Veteriner Fakültesi, Farmakoloji ve Toksikoloji Anabilim Dalı, Balıkesir 1 2 3

AMAÇ: Protokateşuik asit (PCA) yeşil çay, fındık, badem başta olmak üzere birçok bitki, sebze ve meyvede yaygın olarak bulunan anti-oksidan özelliği olan basit bir fenol bileşiğidir. Bu çalışmada PCA’nın iskemi/reperfüzyon (IR) hasarı oluşturulan böbrekler üzerine olan etkilerini araştırmayı amaçladık.

GEREÇ VE YÖNTEM: Sprague-Dawley cinsi sıçanlar rastgele dört gruba ayrıldı: (1) Sham, (2) Renal IR (3) Renal IR + Vehicle (4) Renal IR + PCA. Renal IR hasarı sağ nefrektomi yapıldıktan sonra 45 dakika boyunca sol renal pedikül klemplenip sonrasında üç saat boyunca reperfüzyon yapılarak indüklendi. Tedavi edici olarak kullanılan PCA renal iskemiden hemen önce 80 mg/kg dozunda intraperitoneal olarak uygulandı. Protokateşuik asiti çözmek için araç olarak %33’lük polietilen glikol kullanıldı. Sıçanlar sakrifiye edildikten sonra alınan kan örmeklerinde ve böbrek dokusunda total antioksidan kapasite (TAS), malondialdehit (MDA), süperoksitdismutaz (SOD), tümör nekroz faktör alfa (TNF-α), interlökin-6 (IL-6) seviyesi ölçüldü.

Böbrek doku örneklerinde histopatolojik incelemeler yapılarak histopatolojik skorlama elde edildi. Apoptotik hücreleri görüntülemek için terminal deoxynucleotidyltransferase-mediated dUTP digoxigenin nick-end-labeling (TUNEL) boyama yapıldı.

BULGULAR: Protokateşuik asitin serum MDA ve TNF-α ile böbrek MDA seviyelerini anlamlı olarak azalttığı, serum ve böbrek TAS ile SOD seviyelerini ise anlamlı olarak artırdığı görüldü. Histopatolojik skorlamanın PCA verilen grupta anlamlı olarak daha iyi idi.

TARTIŞMA: Oksidatif stresi ve renal iskemi reperfüzyon hasarını azalttığını ortaya koyduğumuz PCA, IR hasarına karşı etkili bir ajan olarak kullanılabilir.

Anahtar sözcükler: Antioksidanlar; iskemi reperfüzyon hasarı; malondialdehit; protokateşuik asit; serbest oksijen radikalleri.

Ulus Travma Acil Cerrahi Derg 2017;23(1):1–6

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doi: 10.5505/tjtes.2016.20165

Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

EXPERIMENTAL STUDY

A biological tube technique for the repair of peripheral nerve defects using ‘stuffed nerves’ Sercan Çapkın, M.D.,1 Mustafa Akhisaroğlu, M.D.,2 Bekir Uğur Ergür, M.D.,3 Ali Abdülkadir Bacakoğlu, M.D.4 1

Department of Orthopaedics and Traumatology, Hinis Şehit Yavuz Yürekseven State Hospital, Erzurum-Turkey

2

Department of Physiology, Dokuz Eylül University Faculty of Medicine, İzmir-Turkey

3

Department of Histology and Embryology, Dokuz Eylül University Faculty of Medicine, İzmir-Turkey

4

Department of Orthopaedics and Traumatology, Dokuz Eylül University Faculty of Medicine, İzmir-Turkey

ABSTRACT BACKGROUND: Presently described is research examining the ”stuffed nerve” technique to repair peripheral nerve defects.

METHODS: Twenty-one male Wistar Albino rats were divided into 3 groups of 7, and standard 10-mm defects were created in the sciatic nerve of all subjects. Rats were treated with autogenous nerve graft (Group 1), hollow vein graft (Group 2), or vein graft stuffed with shredded nerves (Group 3). After 12 weeks, electrophysiological and histomorphological analyses were performed to evaluate axonal regeneration.

RESULTS: Rat groups were compared in terms of latency period and peak-to-peak potential. Latency period was significantly shorter and peak-to-peak potential was significantly greater in Group 1 than in Group 2. However, latency period and peak-to-peak potential did not differ significantly between Groups 1 and 3 or between Groups 2 and 3. To evaluate axonal regeneration, number of axons, axon diameter and myelin sheath thickness was compared between groups. Results indicated that axonal regeneration was similar in Groups 1 and 3, and was better than results seen in Group 2.

CONCLUSION: The stuffed nerve technique is an alternative to autogenous nerve grafting and produces similar electrophysiological and histomorphological properties.

Keywords: Biological tube; peripheral nerve defect; stuffed nerve; vein graft.

INTRODUCTION Early primary repair of peripheral nerve injuries can produce ideal reconstruction and provide good long-term functional outcomes.[1] However, associated techniques can only be used to repair small defects without tension, thus limiting their application.[2] In large defects where primary repair is not possible, standard treatment involves repair using autogenous nerves and microsurgical techniques.[2,3] Autogenous nerve grafts can lead to donor site morbidity.[2,4–6] Use of this Address for correspondence: Sercan Çapkın, M.D. Erzurum Hınıs Şehit Yavuz Yürekseven Devlet Hastanesi Başhekimliği, 25600 Erzurum, Turkey Tel: +90 442 - 511 30 15 E-mail: sercancapkn@gmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):7–14 doi: 10.5505/tjtes.2016.89457 Copyright 2017 TJTES

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method is limited by disadvantages such as scar formation, multiple surgical requirements, loss of function, neuroma formation, graft harvesting difficulty, increased risk of secondary deformities due to extent of disease, tissue structure and size differences, as well as development of cold intolerance at distal end of the limb.[7,8] Therefore, various conduits have been used to bridge peripheral nerve defects.[9–11] Autogenous vein grafts are experimentally and clinically validated supportive tunnels for the regeneration and maturation of nerve fibers.[12,13] Depending on capacity to regenerate nerve endings, nerve sprouts with axonal migration provide skeletal structure that contains extracellular matrix components and can be used with various growth factor supplements when necessary. Thus, vein grafts have most of the required qualities for neural tube models.[13] However, the most frequently observed disadvantage of vein grafts is curling, which increases risk of collapse and fibrotic contraction.[14–16] Most successful vein graft repairs are observed in defects less than 3 cm in length.[14] Previous studies have demonstrated utility of filling inside of vein graft with nerve[17] or muscle 7

Çapkın et al. A biological tube technique for the repair of peripheral nerve defects using ‘stuffed nerves’

tissue[18,19] to prevent graft collapse, and this combined technique is effective for defects of less than 3 cm.

In the present study, a biological tube was constructed and filled with nerve particles (stuffed nerve). It demonstrated superior peripheral nerve repair to that seen following routine autogenous nerve graft. The stuffed nerve technique utilizes microenvironment of vein graft and neurotropic factors from stuffed nerve particles.

MATERIALS AND METHODS This study was approved by the animal ethics committee of Dokuz Eylül University. Twenty-one male Wistar Albino rats weighing approximately 300 g each were randomly divided into 3 equal groups. Surgery was performed on the lower extremities of right side in test animals and on left side in control animals. Rats were housed in cages (7 rats per cage) with water and rat chow ad libitum at room temperature with 12-hour light/12-hour dark cycle. Nerve graft, vein graft, and stuffed nerve technique was performed on 7 rats of Groups 1, 2, and 3, respectively.

Surgical Procedures All surgical procedures were performed by the same investigator using microsurgical techniques in sterile conditions with a surgical microscope (Zeiss S3; Carl Zeiss AG, Oberkochen, Germany). Anesthesia of 10 mg/kg xylazine (2% alfazine, 20 mg/mL, Rompun; Bayer AG, Leverkusen, Germany; Bayer) and 100 mg/kg ketamine (Ketalar, 50 mg/mL; Pfizer, Inc., NY, NY, USA) was administered intraperitoneally. Oblique skin incision of approximately 3 cm in length was made from the right gluteal region to the posterior thigh in all test subjects, and sciatic nerve was exposed with blunt dissection of the superficial glu-

teal and biceps femoris muscles and surrounding fascia junction line. From the sciatic foramen to point left of the tibial and common peroneal branches, sciatic nerve was separated and isolated from surrounding tissues (Fig. 1a). Seven mm of sciatic nerve from the proximal sciatic foramen to the point of separation from tibial and common peroneal branches was protected. Ten-mm sections from elsewhere on sciatic nerve were removed with microscissors. All anastomoses were performed using 10/0 ETHILON sutures (Ethicon, Inc., Somerville, NJ, USA). Nerve and vein grafting was performed using epineurial technique with 6 stitches for every 60° angle.

Group 1: In nerve graft group, standard 10-mm nerve defects were created in the subjects and excised 10-mm segment was reversed and reapplied to the same site.

Group 2: Animals of the vein graft group received 10-mm defect in sciatic nerve and vein graft from jugularis externa was used to repair defect.

Group 3: To prepare stuffed nerves, jugular vein graft of 1 cm in length was harvested from left side of the cervical region and rinsed with saline solution (Fig. 1b). Sciatic nerve graft was cut into at least 10 parts of 1 cm each using microscissors (Fig. 1c). Initially, one end of vein graft was attached to proximal end of sciatic nerve using 10/0 ETHILON sutures (Fig. 1d) and minced nerve graft was then equally distributed in the lumen of vein graft (Fig. 1e). Free end of vein graft was joined to distal end of sciatic nerve with 10/0 ETHILON sutures (Fig. 1f ). All muscle and skin incisions were sutured using 4/0 absorbable sutures (Dogsan Tibbi Malzeme San A.S., Trabzon, Turkey). All rats were observed for 12 weeks in standard cages under the conditions described earlier and then underwent further surgery

(a)

(b)

(c)

(d)

(e)

(f)

Figure 1. Preparation of a stuffed nerve. (a) exposure of the sciatic nerve, (b) replacement of 10-mm section from the sciatic nerve with vein graft, (c) rendering of excised nerve section, (d) proximal coaptation of vein graft and stuffing of the nerve particles from the distal end, (e) appearance of the nerve-stuffed vein graft segment, and (f) appearance of the nerve-stuffed vein graft after distal coaptation.

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Çapkın et al. A biological tube technique for the repair of peripheral nerve defects using ‘stuffed nerves’

to visualize the nerves. Electrophysiological function was determined using electroneuromyography (ENMG), and histological analyses were performed using light and electron microscopy after sacrifice.

Electrophysiological Examination To evaluate regeneration of sciatic nerve, impulses were sent from proximal end of the nerve, and electrophysiological response of gastrocnemius muscle was recorded using ENMG. Stimuli were applied directly to the nerve for 0.1 milliseconds to avoid nonselective stimulation. Both control and treated sciatic nerves were dissected from the sciatic notch to the sciatic trifurcation using the previous incision, and impulse electrodes were positioned approximately 5-mm proximal to coaptation area of the exposed sciatic nerve, and recording electrodes were positioned on the insertion and on middle part of the gastrocnemius muscle after passing through the skin. Impulse intensity that provided maximum muscle response was determined for each animal using gradual increase from minimum stimulus amplitude of 0.3 V. Impulses were repeated at least 3 times at optimal intensity, and muscle responses were recorded. Responses of both extremities were graphed and average values were calculated using 3 action potential curves for statistical comparison using 4-channel polygraph system (BIOPAC MP35; BIOPAC Systems, Inc., Goleta, CA, USA) and computer software (BIOPAC BSL Pro, version 3.7; BIOPAC Systems, Inc., Goleta, CA, USA).

ment and morphological characteristics of Schwann cells and connective tissue were analyzed. Histomorphometric analyses were performed using ImageTool version 3.0 (University of Texas Health Science Center at San Antonio, San Antonio, TX, USA) software and images were obtained using an Olympus DP 41 digital camera mounted on an Olympus CX-41 (Olympus, Corp., Tokyo, Japan) light microscope. Biopsy samples were imaged at ×4, ×10, ×20, and ×40 magnification and digital images were acquired in JPEG format with maximum resolution. Three distinct 5000-μm2 areas were examined using ImageTool program at a magnification of ×40. Similarly, axon count was determined at 3 separate 5000-μm2 areas on each animal. Subsequently, 10 myelinated axons were analyzed in 5000-μm2 areas, diameter of myelinated axons and myelin thickness were determined at 3 different locations, and mean and standard error were calculated.

Statistical Analysis All statistical analyses were performed using SPSS version 15.0 (IBM Corp., Armonk, NY, USA) statistical analysis program. Nonparametric differences were identified using Kruskal-Wallis and Mann-Whitney U tests and were considered significant when p<0.05.

RESULTS All rats remained healthy throughout the study and no automutilation or foot ulceration was observed.

Histological Assessment of Regenerated Nerves

Electrophysiological Assessments

After electrophysiological measurements were recorded, 5-mm sciatic nerve biopsy samples were taken from distal coaptation line and middle of the graft from all animals. Rats were then euthanized and nerve tissue samples were incubated in Karnovsky fixative (pH 7.4) at 4°C for 48 hours. After routine electronmicroscopic procedures, tissue samples were embedded in araldite-epon mixture for polymerization, and 1-mm semi-thin sections were taken using ultramicrotome (Leica Ultracut R; Leica Microsystems GmbH, Wetzlar, Germany) and were stained with toluidine blue. Sections were placed on a grid and contrasted using uranyl acetate and lead nitrate. Ultrastructures were evaluated using Zeiss Libra 100 EFTEM (Carl Zeiss AG, Oberkochen, Germany) transmission electron microscope and images were digitally photographed.

Axon diameter, myelin thickness, myelin lamellae arrange-

After ENMG recordings, nerve conduction velocity (latency) values were determined by measuring time between stimuli and response. Peak-to-peak potentials were calculated from amplitude difference between positive and negative peak.

Both extremities of all rats were measured at least 3 times and mean latency and peak-to-peak value of right (test group) and left (control group) sides were compared (Table 1).

Peak-to-peak and average latency values differed between test and control sides (p<0.05) and indicated that present repair procedure produced superior results.

Moreover, ratio of average latency and peak-to-peak value test (right side) and control (left side) groups [(right/left)×100] significantly differed between Groups 1 and 2 (p<0.05; Fig. 2).

Table 1. Electrophysiological analysis

Group 1

Group 2

Group 3

Left Right Left Right Left Right

Latency (ms)

1.48±0.02 2.15±0.09 1.44±0.05 3.10±0.27 1.47±0.09 2.55±0.09

Peak to peak (mV)

4.25±0.49

2.28±0.24

Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

4.94±0.74

1.21±0.23

4.18±0.85

1.76±0.17

9

Çapkın et al. A biological tube technique for the repair of peripheral nerve defects using ‘stuffed nerves’

Latency

*

200

100

0

G1

Peak to Peak Amplitude

100

Right/Left ratio (%)

Right/Left ratio (%)

300

G2

G3

*

80 60 40 20 0

G2

G1

G3

Figure 2. Average latency, peak-to-peak values, and right/left ratios of rats from Groups 1, 2 and 3.

Histomorphological Assessments Group 1 (nerve graft group): Unmyelinated axons were infrequently observed in sections from grafts and distal parts of grafts. Although nearly normal number and diameter of myelinated axons were observed and were well organized in graft sections, myelinated axons and some degenerated axons were found in distal sections. Similarly, electron microscopy analyses revealed that myelinated axons and myelin sheath of nerve fibers generally maintained normal structure, and Schwann cells were wrapped around myelinated and unmyelinated nerve fibers (Fig. 3a, b).

Group 2 (vein graft group): In sections of mid portions and distal parts of vein grafts, irregular organized myelinated axons and demyelinated axons were observed in some areas, with increased peripheral vascularity. However, small number of myelinated axons was found in sections of distal vein grafts.

Moreover, diameter of myelinated axons and myelin thickness was decreased, and fibrosis and increased vascularity were observed in some areas. In addition, electron microscope analyses indicated that myelin sheaths were invaginated toward the inside of axons in significant proportion of myelinated nerve fibers, and local myelin sheath lamellae separation was evident (Fig. 3c, d).

Group 3 (stuffed nerve group): Examination of sections from proximal and distal parts of grafts revealed multiple regularly organized myelinated axons in sections of the graft.

Moreover, myelin thickness and axon diameter were sufficient in distal sections of grafts and even greater in some

areas. Electron microscope images of Groups 1 and 3 were similar (Fig. 3e, f).

Histomorphometric Analyses Light microscopy images at ×40 magnification were analyzed using ImageTool program, and the number and diameter of axons (µm), and myelin sheath thickness (µm) were measured in cross sections from distal and middle specimens (Table 2).

Axon count was estimated in 3 different 5000-μm2 central and distal coaptation areas of grafts in animals from treatment Groups 1, 2, and 3. Number of axons significantly differed between Groups 1 and 2 and between Groups 2 and 3 (p<0.05; Fig. 4).

In addition, 10 myelinated axons were selected from central areas of graft and distal sections of coaptation areas in all animals using ×40 magnification ImageTool program, selected axon diameter (μm) and myelin thickness (μm) were measured in 3 different areas for each axon and mean axon diameter was calculated for each treatment group. Mean axon diameter differed significantly between Groups 1 and 2 and between Groups 2 and 3 (p<0.05; Fig. 5).

Myelin thickness differed significantly between Groups 1 and 2 and between Groups 2 and 3 (p<0.05; Fig. 6).

DISCUSSION Autogenous nerve grafting is currently ideal method for re-

Table 2. Histomorphometric analysis

Group 1

Group 2

Group 3

Middle Distal Middle Distal Middle Distal

Number of axons

97.4±6.3

101.6±6.6

62.1±4.4

61.6±4.5

91.8±3.6

83.5±5.7

Diameter of axons (µm)

7.20±0.7

7.44±0.4

5.44±0.1

4.40±0.3

7.14±0.2

7.28±0.5

Myelin sheath thickness (µm)

1.36±0.1

1.37±0.1

0.85±0.01

0.80±0.01

1.41±0.2

1.54±0.1

10

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Çapkın et al. A biological tube technique for the repair of peripheral nerve defects using ‘stuffed nerves’

(a)

(b)

(c)

(d)

(e)

(f)

Figure 3. Electron and light microscopy analyses. (a) and (b), Group 1; (c) and (d), Group 2; (e) and (f), Group 3. Sections (a), (c), and (e) were obtained from middle part of the nerve, whereas sections (b), (d), and (f) were obtained from distal part of the nerve. All images are of semi-thin sections stained with toluidine blue (×40 magnification) and small frames represent electron microscopic micrographs stained with lead citrate-uranyl acetate; (a-c) and (d), ×10000; (e) and (f) sections, ×8000. Myelinated nerve axons (a), myelin sheath (Msh) and Schwann cells (Sh) were observed. Changes in myelinated nerve fibers are indicated with a star (★). Myelin sheath lamellae degeneration is visible in (c) and (d).

pairing peripheral nerve defects.[20] However, nerve grafting from donor site requires anesthesia and may lead to paresthesia, neuroma formation, pain, and additional scarring.

Moreover, long surgery duration and mismatches of diameter may occur.[21] Thus, development of simpler and more functional procedures that reduce morbidity are eagerly awaited.

Recent studies have examined various conduits using biological fillings and synthetic tubes to repair nerve defects. In particular, biological and synthetic conduits with similar qualities to autogenous nerve grafts reportedly provide suitable microenvironments for axonal regeneration.[22,23] Vein grafts are the most frequently used biological conduits, and autogUlus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

enous vein grafts have been widely used as biological conduits for the regeneration and maturation of nerve fibers in both experimental and clinical settings.[12,24,25] Vein grafts are nonimmunogenic, easier to obtain than nerve grafts, and last longer than bioabsorbable nerve tubes. Moreover, various alternatives are available to accommodate range of diameters, and autogenous tissue grafts do not need to be removed from the surgical field after nerve repair. Furthermore, all 3 layers of vein graft are rich in laminin and share similarities with the basal lamina that surrounds normal and traumatized nerve fibers. Laminin plays role in the adhesion, multiplication, and differentiation of nerve cells.[26] The most commonly ob11

Çapkın et al. A biological tube technique for the repair of peripheral nerve defects using ‘stuffed nerves’

Middle Segment

150

100

50

0

G1

G2

*

* The number of axon

The number of axon

*

Distal Segment

150

*

100

50

0

G3

G1

G2

G3

Figure 4. Statistical analyses of axon count in central graft areas and distal coaptation sections of grafts.

Middle Segment

*

*

8 6 4 2 0

G1

G2

Distal Segment

10 Diameter of axon (μm)

Diameter of axon (μm)

10

8

*

6 4 2 0

G3

*

G1

G2

G3

Figure 5. Comparison of axon diameter from central area of graft and distal coaptation area between animals of Groups 1, 2, and 3.

Middle Segment

*

Distal Segment

*

2.0 Myelin sheath thickness (μm)

Myelin sheath thickness (μm)

2.0

1.5

1.0

0.5

0

G1

G2

G3

*

* 1.5

1.0

0.5

0

G1

G2

G3

Figure 6. Comparison of mean myelin thickness from central area of graft and distal coaptation area from animals in Groups 1, 2, and 3.

served disadvantage of vein grafts is fibrotic contraction and associated risks of curling and collapse.[4,16,27] Hence, the use of vein graft with other materials that benefit axonal growth will likely produce significant improvements in outcomes.

To reduce complications of vein grafts, Keskin et al. enhanced graft microenvironment by forming biological conduit with nerve graft inside vein graft, and functional, electrophysiological and histomorphometric evaluations revealed no significant differences with nerve grafts.[17] Alternatively, Sahin et al. cre12

ated 1-cm defect on rat’s tibial nerve and repaired it with minced nerve tissue in vein graft[23] and then placed 1 of the 3 equal-sized pieces of nerve graft into vein graft. Although they did not report details of their mincing process, subsequent outcomes were similar to those achieved with autogenous nerve grafts. Similarly, we divided nerve graft into as many small pieces as possible prior to placement in vein graft, which was then tightly stuffed into the defect area (Fig. 1f ). In subsequent analyses, no fibrosis was observed, and axonal regeneration was almost identical to that following autogenous Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Çapkın et al. A biological tube technique for the repair of peripheral nerve defects using ‘stuffed nerves’

nerve grafts. In histomorphometric analyses, Sahin et al. only determined myelinated axon counts, whereas we also determined myelin sheath thickness and axon diameter (Table 2).

However, further gait analyses are required to confirm the efficacy of stuffed nerve grafts.

of the nerve, and degree of myelination has been associated with axon maturity.[33] Because myelination occurs before contact of axons with target organs, it may not be associated with function. However, rate of axon myelination may indicate progress of regeneration.[34,35]

In a previous study, silicon conduits containing minced nerves were placed into 12-mm defects in rat sciatic nerve.[28] However, no significant difference in motor or sensory variables was observed between animals with differing nerve fragments, potentially reflecting use of non-biological synthetic conduit that lacks the selective permeability and flexibility of vein graft. In addition, those investigators did not perform electrophysiological assessments to confirm histological and morphometric observations.

Accordingly, number and diameter of myelinated axons as well as myelin sheath thickness were determined in the present histomorphological analyses, and there were significant differences between Groups 1 and 2 and between Groups 2 and 3 (p<0.05). Number, diameter and myelin thickness of axons in Group 2 were smaller than in the other groups, and similarities between Groups 1 and 3 indicated equivalent regeneration following nerve and stuffed nerve grafts (Figs. 4, 5 and 6).

In another study, Zhang created 4-cm defect in rabbit tibial nerve and repaired it with autologous vein graft containing transplanted Schwann cells or with conventional vein graft.

Subsequent comparisons revealed superior axon regeneration in veins with transplanted Schwann cells.[29] However, Schwann cells are difficult to isolate and are expensive, making the use of minced nerve parts as shown in the present study a practical option.

Although numerous biological and synthetic nerve conduits continue to be investigated, none have clinical advantages over conventional nerve grafts. However, present vein grafts are biological tubes, and suitable microenvironment was produced by stuffing shredded nerves into the graft, providing neurotrophic and neurotropic factors for axon regeneration.

Subsequent ENMG analyses showed shorter latency in nerve graft group (Group 1) than in vein graft group (Group 2), suggesting more rapid transmission of growth signals in the presence of nerve tissue. Peak-to-peak potential was significantly higher in nerve graft group than in vein graft group, reflecting more efficient axonal progress. However, latencies and peak-to-peak potentials did not significantly differ between Groups 1 and 3, indicating similar properties of autogenous and stuffed nerve grafts.

The concept of regeneration unit is that axonal sprouting occurs, involving movement of myelinated axons toward the endoneurial tube. Numerous axons have been observed previously in histological analyses of nerve repair areas, although these axons were not fully functional until they gained access to appropriate receptors.[30] Functional recovery has been observed following the access of sufficient numbers of axons to correct sensory/motor destinations.[31] However, number of axons may be excessive in experimental models, and inappropriate axons that cannot locate appropriate end-organs are removed from fascicles and eliminated by atrophy over some years. In a rat model of nerve repair, distal axon numbers were significantly increased in the first few months and were present in numbers twice normal at 3 months and 2 years.

[32] Axon diameter is dependent on the source and maturity Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

In summary, the effects of autogenous nerve, conventional vein, and stuffed nerve grafts on axonal regeneration were compared using series of electrophysiological and histomorphological analyses. These experiments demonstrated that autogenous nerve and stuffed nerve grafts were more successful than conventional vein grafts.

Conclusion In the present study, repair of sciatic nerve defects using stuffed nerve tissue was superior to conventional vein graft technique. The present technique offers advantages of avoiding collapse often seen in vein grafts to repair defects of >3 cm. Defect size and nerve diameter were limited to rat sciatic nerves in the present study, precluding comparisons with previous studies. Nonetheless, the present data indicate that stuffed nerve grafts offer convenient alternative to nerve grafts, which have disadvantage of donor site morbidity. Additional basic and clinical studies of stuffed nerve graft applications are warranted.

Conflict of interest: None declared.

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12. Chiu DT, Janecka I, Krizek TJ, Wolff M, Lovelace RE. Autogenous vein graft as a conduit for nerve regeneration. Surgery 1982;91:226–33.

13. Brushart TM. Nerve repair and grafting. In: Green DP, Hotchkiss RN, Pederson WC, editor. Green’s operative hand surgery. Vol. 2. Philadelphia: Churchill Livingstone; 1999. p 1381–403.

14. Chiu DT. Autogenous venous nerve conduits. A review. Hand Clin 1999;15:667–71.

15. Foidart-Dessalle M, Dubuisson A, Lejeune A, Severyns A, Manassis Y, Delree P, et al. Sciatic nerve regeneration through venous or nervous grafts in the rat. Exp Neurol 1997;148:236–46.

16. Suematsu N, Atsuta Y, Hirayama T. Vein graft for repair of peripheral nerve gap. J Reconstr Microsurg 1988;4:313–8.

17. Keskin M, Akbaş H, Uysal OA, Canan S, Ayyldz M, Ağar E, et al. Enhancement of nerve regeneration and orientation across a gap with a nerve graft within a vein conduit graft: a functional, stereological, and electrophysiological study. Plast Reconstr Surg 2004;113:1372–9.

18. Battiston B, Tos P, Cushway TR, Geuna S. Nerve repair by means of vein filled with muscle grafts I. Clinical results. Microsurgery 2000;20:32–6.

19. Battiston B, Tos P, Geuna S, Giacobini-Robecchi MG, Guglielmone R. Nerve repair by means of vein filled with muscle grafts. II. Morphological analysis of regeneration. Microsurgery 2000;20:37–41.

20. Ayhan S, Yavuzer R, Latifoğlu O, Atabay K. Use of the turnover epineurial sheath tube for repair of peripheral nerve gaps. J Reconstr Microsurg 2000;16:371–8.

21. Mackinnon SE. Surgical management of the peripheral nerve gap. Clin

Plast Surg 1989;16:587–603.

22. Terzis JK, Kostas I. Vein grafts used as nerve conduits for obstetrical brachial plexus palsy reconstruction. Plast Reconstr Surg 2007;120:1930–41.

23. Sahin C, Karagoz H, Kulahci Y, Sever C, Akakin D, Kolbasi B, et al.

Minced nerve tissue in vein grafts used as conduits in rat tibial nerves.

Ann Plast Surg 2014;73:540–6.

24. Smahel J, Jentsch B. Stimulation of peripheral nerve regeneration by an isolated nerve segment. Ann Plast Surg 1986;16:494–501.

25. Thanos PK, Okajima S, Terzis JK. Ultrastructure and cellular biology of nerve regeneration. J Reconstr Microsurg 1998;14:423–36.

26. Doolabh VB, Hertl MC, Mackinnon SE. The role of conduits in nerve repair: a review. Rev Neurosci 1996;7:47–84.

27. Whitworth IH, Doré C, Hall S, Green CJ, Terenghi G. Different muscle graft denaturing methods and their use for nerve repair. Br J Plast Surg 1995;48:492–9.

28. Lloyd BM, Luginbuhl RD, Brenner MJ, Rocque BG, Tung TH, Myckatyn TM, et al. Use of motor nerve material in peripheral nerve repair with conduits. Microsurgery 2007;27:138–45.

29. Zhang F, Blain B, Beck J, Zhang J, Chen Z, Chen ZW, et al. Autogenous venous graft with one-stage prepared Schwann cells as a conduit for repair of long segmental nerve defects. J Reconstr Microsurg 2002;18:295– 300.

30. Kanaya F, Firrell JC, Breidenbach WC. Sciatic function index, nerve conduction tests, muscle contraction, and axon morphometry as indicators of regeneration. Plast Reconstr Surg 1996;98:1264–74.

31. Saray A, Can B, Akbiyik F, Askar I. Ischaemia-reperfusion injury of the peripheral nerve: An experimental study. Microsurgery 1999;19:374–80.

32. Mackinnon SE, Dellon AL, O’Brien JP. Changes in nerve fiber numbers distal to a nerve repair in the rat sciatic nerve model. Muscle Nerve 1991;14:1116–22.

33. Zenzai K, Shibata M, Okado H, Endo N, Hirano S. Newly-formed axonal branches of rat sciatic neurons sprouting in the spinal cord after peripheral axotomy. Scand J Plast Reconstr Surg Hand Surg 2004;38:129–34.

34. George LT, Myckatyn TM, Jensen JN, Hunter DA, Mackinnon SE. Functional recovery and histomorphometric assessment following tibial nerve injury in the mouse. J Reconstr Microsurg 2003;19:41–8.

35. Keilhoff G, Fansa H. Successful intramuscular neurotization is dependent on the denervation period. A histomorphological study of the gracilis muscle in rats. Muscle Nerve 2005;31:221–8.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Periferik sinir defektlerinin onarımında biyolojik tüp kullanımı ‘sinir dolması’ Dr. Sercan Çapkın,1 Dr. Mustafa Akhisaroğlu,2 Dr. Bekir Uğur Ergür,3 Dr. Ali Abdülkadir Bacakoğlu4 Hınıs Şehi̇ t Yavuz Yürekseven Devlet Hastanesi̇ , Ortopedi ve Travmatoloji Kliniği, Erzurum Dokuz Eylül Üni̇ versi̇ tesi̇ Tıp Fakültesi, Fi̇ zyoloji̇ Anabi̇ li̇ m Dalı, İzmi̇ r Dokuz Eylül Üni̇ versi̇ tesi̇ Tıp Fakültesi, Hi̇ stoloji̇ ve Embri̇ yoloji̇ Anabi̇ li̇ m Dalı, İzmi̇ r 4 Dokuz Eylül Üni̇ versi̇ tesi̇ Tıp Fakültesi, Ortopedi̇ ve Travmatoloji̇ Anabi̇ li̇ m Dalı, İzmi̇ r, Türki̇ ye 1 2 3

AMAÇ: Periferik sinir defektlerinin onarımında ‘sinir dolması’ tekniği araştırıldı.

GEREÇ VE YÖNTEM: Çalışmada 21 adet Wistar Albino cinsi sıçan kullanıldı. Her grupta yedi sıçan olacak şekilde üç grup belirlendi. Tüm sıçanların siyatik sinirinde 10 mm’lik defekt oluşturuldu. Grup 1’de otojen sinir grefti ile, grup 2’de içi boş ven grefti ile, grup 3’de içi parçalanmış sinir ile doldurulmuş ven grefti ile onarım yapıldı. On ikinci haftanın sonunda aksonal rejenerasyonu değerlendirmek için elektrofizyolojik ve histomorfolojik analizler yapıldı.

BULGULAR: Latans süresi ve tepe-tepe potansiyelleri istatistiksel olarak karşılaştırıldığında grup 1 ve grup 3, grup 2 ve grup 3 arasındaki fark anlamsızdı. Grup 1’in latans süresi grup 2’den daha kısa ve tepe-tepe potansiyeli ise daha büyüktü. Aksonal rejenerasyonu değerlendirmek için; akson sayısı, akson çapı ve miyelin kılıf kalınlığı gruplar arasında karşılaştırıldı. Aksonal rejenerasyonun grup 1 ve grup 3’de benzer olduğu ayrıca grup 2’den daha iyi olduğu görüldü.

TARTIŞMA: Sinir dolması tekniğinin otojen sinir grefti ile benzer elektrofizyolojik ve histomorfolojik özellikler göstermesi otojen sinir greftinin bir alternatifi olabileceğini gösterdi.

Anahtar sözcükler: Biyolojik tüp; periferik sinir defekti; sinir dolması; ven grefti.

Ulus Travma Acil Cerrahi Derg 2017;23(1):7–14

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doi: 10.5505/tjtes.2016.89457

Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

ORIG I N A L A R T IC L E

Complicated colorectal cancer in nonagenarian patients: is it better not to perform anastomosis in emergency?

Belinda De Simone, M.D.,1 Federico Coccolini, M.D.,2 Luca Ansaloni, M.D.,2 Antonio Tarasconi, M.D.,3 Gianluca Baiocchi, M.D.,3 Nereo Vettoretto, M.D.,4 Peggy Joly, M.D.,5 Marianne Ferron, M.D.,5 Alessandro Pozzo, M.D.,5 Lionel Charre, M.D.,5 Salomone Di Saverio, M.D.,6 Josephine Andrea Napoli, M.D.,7 Ferdinando Agresta, M.D.,8 Massimo Sartelli, M.D.,9 Fausto Catena, M.D.1 Department of Emergency Surgery, University Hospital of Parma, Parma-Italy Emergency and General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo-Italy 3 Department of General and Emergency Surgery, Ospedali Civili, Brescia-Italy 4 Department of General and Emergency Surgery, Montichiari Hospital, Brescia-Italy 5 Department of General and Emergency Surgery, Renè Dubos Hospital, Pontoise-France 6 Emergency and General Surgery Department, Maggiore Hospital, Bologna-Italy 7 Department of Surgical Sciences, University of Hawaii-United States of America 8 Department of General Surgery, Adria Hospital, Adria-Italy 9 Department of General Surgery, Macerata Hospital, Macerata-Italy 1 2

ABSTRACT BACKGROUND: Colorectal cancer (CRC) is predominantly a disease of elderly people. Cancer in nonagenarian patients presents an ethical dilemma for surgeons and oncologists, and management of this group of patients in emergency for complicated CRC is debated. Presently described is retrospective study reporting experience of 6 departments of emergency surgery with management of nonagenarian patients sent to emergency surgery for CRC complications.

METHODS: Data concerning patients aged over 90 years hospitalized from January 2011 to June 2015 in 6 departments of emergency surgery for complicated CRC were retrospectively analyzed. Data were collected in a dedicated database. Statistical analysis was conducted using IBM software SPSS 22 (IBM Corp., Armonk, NY, USA); statistical significance was set at p=0.05.

RESULTS: In the period of study,19 patients aged over 90 underwent surgery in emergency department for complicated CRC. Of the total, 52.63% were female, with sex ratio F:M of 1.11:1. Mean age was 92.52 years (range: 90-97 years; SD 1.49). Preoperative assessment of surgical risk was made using American Society of Anesthesiologists (ASA) score. There was no statistically significant difference in terms of in-hospital mortality between patients with ASA score ≤ 3 and patients with an ASA score >3. Primary anastomosis was performed in 6 of 19 patients (31.57%), all of whom had right-side colon cancer. Diverting stoma was created for 12 of 19 patients (63.15%). There was a statistically significant difference in incidence of postoperative complications between patients with right-side colon cancer and patients with left-side colon cancer (p=0.0498). Mean length of hospital stay was 12.78 days (range: 2–31 days; SD 6.31). In-hospital mortality rate was 21.05% (n=4). At follow up, overall survival was 47.36% (n=9).

CONCLUSION: Elective surgery is the best way to manage CRC in all patients affected. Emergency surgery for CRC complications in patients over 90 is feasible with careful preoperative selection and evaluation of the patient. One-stage surgery is the best choice, in selected patients. Two- and three-stage surgery is indicated in case of peritonitis, for frail patients, for hemodynamically unstable patients. If there is high risk of anastomotic leakage, decompressive stoma is suggested as bridge to elective surgery, and in advanced neoplastic disease, as palliative procedure. In emergency setting, diverting stoma is a good surgical option in nonagenarian patients to decrease surgical risk, morbidity, and mortality; however, clinical randomized controlled trials are necessary to confirm this.

Keywords: Colorectal cancer; decompressive stoma; emergency surgery; large bowel obstruction; oncogeriatric patient; primary anastomosis.

Address for correspondence: Belinda De Simone, M.D. Via Gramsci 15 43100 Parma, Italy Tel: 00393200771984 E-mail: desimoneb@hotmail.it Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):15–22 doi: 10.5505/tjtes.2016.77178 Copyright 2017 TJTES

Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

INTRODUCTION Colorectal cancer (CRC) is predominantly a disease of elderly people; over 70% of cases occur in patients aged over 65 years, with mean age at diagnosis of 72 years.[1–3] A natural consequence of the improvement of living conditions and achievement of high standards of care is aging world population with growing number of those over 90 years of age.

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Simone et al. Complicated colorectal cancer in nonagenarian patients

In Italy, population aged 85 and older will increase from 2.8% in 2011 to 7.8% in 2050. Average life expectancy is projected to be 85.3 years for males and 90.5 years for females (Italian National Institute of Statistics data).

This highly significant change in age demographics and within society has an important impact on healthcare, and especially cancer care. Treating cancer in people aged over 90 presents an ethical dilemma for surgeons and oncologists.

In clinical practice, management of this group of patients is frequently suboptimal and there is an increasing number of nonagenarian CRC patients requiring emergency surgical treatment due to serious complications of advanced neoplastic colic disease.

Emergency abdominal procedures are generally associated with increased morbidity and mortality rates, particularly for frail elderly patients. Emergency surgeon often has crucial role of selecting patients for surgery, and balancing benefits and high surgical risk. Another important issue to consider is high cost of postoperative care for this group of patients, which frequently requires rehabilitation and longer recovery, even after minor surgery.

In the recent literature there is still a lack of data concerning abdominal surgery in emergency conditions for nonagenarians; no randomized controlled trials look exclusively at elderly patients undergoing emergency surgery for CRC and no evidence-based clinical guidelines are available.

The aim of the present study was to report the experience of 6 departments of emergency surgery in the management of nonagenarian patients sent to emergency surgery for CRC complications and to analyze the outcomes of surgery.

MATERIALS AND METHODS Data concerning patients aged over 90 years who were hospitalized between January 2011 and June 2015 in 6 emergency surgery departments in Italy and France (Parma, Bergamo, Adria, Brescia, and Bologna, Italy and Pontoise, France) and underwent emergency abdominal surgery for complicated CRC, presenting with colic obstruction or perforation at admission were retrospectively analyzed.

Data used for the study were demographic characteristics, preoperative comorbidities, operative and postoperative information. These data were collected in a dedicated database. Perioperative individual surgical risk was assessed using American Anesthesiology Association (ASA) score.

Follow-up to assess overall survival was made by phone call.

Statistical analysis was performed using IBM software SPSS 22 (IBM Corp., Armonk, NY, USA), and statistical significance was set at p=0.05.

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RESULTS Between January 2011 and June 2015, 19 patients over age 90 underwent emergency abdominal surgery for complicated CRC in 6 emergency surgery departments included in the study.

Of the total, 52.63% of these patients were female, with a sex ratio F:M of 1.11:1. Mean age was 92.52 years (range: 90–97 years; SD: 1.49).

For all of these patients, obstruction and peritonitis were primary manifestation of neoplastic disease.

At admission, 14 patients (73.68%) presented with intestinal obstruction, and 5 patients (26.31%) presented with peritonitis and colic perforation.

Majority of patients had co-existing diseases: 16 patients (84.21%) had arterial hypertension ; chronic obstructive pulmonary disease (COPD) was present in 5 patients (26.31%); diabetes, without distinguishing between type 1 or 2, was seen in 4 patients (21%); chronic renal insufficiency, defined by serum creatinine ≥2 mg/dL was observed in 3 patients (15.78%); and chronic cardiovascular disease, chronic heart failure, or arrhythmia was present in 13 patients (84.21%), as summarized in Table 1.

Preoperative assessment of surgical risk was made using ASA score: 57.89% of patients (n=11) had an ASA score of 3, 31.57% of patients (n=6) had ASA score of 4 and 10.52% of patients (n=2) were classified with ASA score of 2.

Considering p<0.05, there was no statistically significant difference in in-hospital mortality between the group of patients with ASA score of ≤3 and patients with ASA score of >3.

Mean length of time between admission and surgical procedure was 53.81 hours (range: 2–264 hours; SD 65.38).

General anesthesia was used for all surgeries. Surgical exploration was performed by laparotomy in 18 patients (94.73%), with a mean surgical time of 94.44 minutes (range: 45–180 minutes; SD 35.10). One exploratory laparoscopy associated with diverting ileostomy was performed for peritoneal carcinomatosis.

Tumor was localized in the right colon in 8 patients (42.10%), the left colon/sigmoid colon in 8 patients (42.10%), and the transverse colon in 2 patients (10.52%); peritoneal carcinomatosis was found in 1 patient during surgery.

Primary and secondary surgical procedures performed are summarized in Table 2.

After colic resection, primary anastomosis was performed in Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

De Simone et al. Complicated colorectal cancer in nonagenarian patients

Table 1. Co-existing diseases at the admission Co-existing diseases

Number of patients

%

Arterial hypertension

16/19

84.21

Chronic cardiovascular diseases

13/19

68.42

Chronic obstructive pulmonary disease

5/19

26.31

Dementia

3/19 15.78

Diabetes

4/19 21.05

Chronic renal insufficency

3/19

15.78

Number of patients

%

Right hemicolectomy with anastomosis

6/19

31.57

Left hemicolectomy with loop ileostomy

1/19

5.26

Sigmoidectomy with loop ileostomy

1/19

5.26

Right hemicolectomy enlarged to the transverse colon with ileocolostomy

1/19

5.26

Subtotal colectomy with double stoma

1/19

5.26

Hartmann’s procedure

2/19

10.52

Decompressive left colostomy

2/19

10.52

Decompressive caecostomy

2/19

10.52

End ileostomy

2/19

10.52

Exploratory laparoscopy with diverting ileostomy

1/19

5.26

Table 2. Surgical procedures performed Surgical procedures

6 patients (31.57%), and temporary or permanent diverting stoma (colostomy, ileostomy, ileocolostomy) was created in 12 patients (63.15%).

Specifically, 6 right hemicolectomies with contemporary anastomosis, 1 left hemicolectomy with temporary diverting ileostomy, 1 sigmoidectomy with temporary loop ileostomy, 1 right hemicolectomy enlarged to the transverse colon with ileocolostomy, 1 subtotal colectomy with double stoma, 2 Hartmann’s procedures, 2 decompressive cecostomies, 2 decompressive left colostomies, 2 end ileostomies, and 1 exploratory laparoscopy were performed (Table 2).

Total of 12 patients (63.15%) had no postoperative complications, while 21.05% of patients (n=4) had complications related to surgery: 3 surgical site infections and 1 anastomotic dehiscence. In addition, 3 patients (15.78%) had medical complications: 1 instance of heart failure, 2 cases of pneumopathy.

Using the Clavien-Dindo classification system of surgical complications, 4 of the 7 patients (57.14%) were classified grade 2, and remaining 3 patients were classified grade 5. One patient died of unknown causes.

Given that p<0.05, incidence of postoperative complications was significantly higher in group of patients with right colon Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

cancer (p=0.0498), compared with patients with left colon cancer.

No statistically significant difference was found in overall survival between patients who underwent colonic resection with primary anastomosis and patients with diverting stoma (p=0.64).

There was no statistically significant difference in in-hospital mortality rate between patients operated on in first 24 hours after admission and patients who underwent surgery more than 24 hours after admission (p=0.60).

Mean length of hospital stay was 12.78 days (range: 2–31 days; SD 6.31).

In-hospital mortality was 21.05% (n=4).

Five patients (33.3%) were discharged to home and remaining 10 patients (66.66%) were transferred to long-term care facilities.

Mean time of follow up was 6.31 months (range: 0–26 months; SD 7.71). At follow-up, overall survival was 47.36% (9 of 19 patients).

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Simone et al. Complicated colorectal cancer in nonagenarian patients

DISCUSSION The growing population of the elderly is leading to increase in number of patients aged over 90 who need surgical treatment in emergency setting for complicated CRC. Clinical features such as bowel obstruction and abdominal pain may be primary manifestations of neoplastic colic disease, or they may represent late complications in patients judged unfit for surgery or who refused surgical and medical treatment.

Frequently, symptoms at admission are aspecific: severe asthenia, anorexia, dyspnea, nausea, vomiting, chronic abdominal pain without defense on the clinical examination, and rarely, fever.

Difficulty in obtaining an accurate history can delay surgical decision-making, thereby increasing mortality.

Abdominal computed tomography (CT) has been demonstrated to be the best radiological diagnostic test for elderly patients with acute abdominal pain. Reginelli et al. retrospectively analyzed data from 126 patients aged 65 years and older who presented at emergency department with acute abdominal pain in order to assess the diagnostic performance of abdominal CT. He reported that in the care of elderly patients, CT is accurate for diagnosing cause of acute abdominal pain, particularly when it is of gastrointestinal surgical origin.[3] Compared with younger patients admitted to acute care surgery service, patients over 80 years of age have higher risk of complications and increased morbidity and mortality rates,[1–4] although improvements in preoperative care, surgical techniques, and advancements in anesthesiology and intensive therapies have made surgery feasible for the majority of elderly patients.

There is still a lack of studies evaluating early and late outcomes of emergency abdominal surgery in the cohort of patients aged over 90 with CRC, and there is no consensus about optimal surgical management for elderly people admitted to the emergency department with diagnosis of complicated CRC. The emergency surgeon has the crucial role of selecting patients who may benefit from surgical treatment in an emergency, weighing high surgical risk due to comorbidities, polypharmacy, advanced age, and surgical outcomes.

In surgical decision-making, they have to evaluate whether to administer the treatment with palliative or curative intent, and finally, to clearly communicate the decision to relatives.

As result of these issues, they require a model or a scoring system to use in preoperative evaluation to predict postoperative mortality in patients older than 90 years.

18

Smothers, in a controlled case study of 184 patients who underwent primary surgery in elective and emergency settings for colon cancer, concluded that emergency surgery has strong negative influence on immediate surgical morbidity and mortality, without distinguishing patients by age.[5] This is most likely related to degree of severity of the patient at admission. Moreover, we have to know that in very elderly patients, there is decline in physiological reserves, which makes the patient vulnerable to any stressful event.[6,7] However chronological age cannot be the only selection factor to consider in surgical decision-making; in fact, a considerable number of elderly patients will continue to live with good function and excellent quality of life after emergency surgery.[6–9] There is great variation in individual health status with increasing age: physiological/biological age is not often chronological age.

Many patients in our study had comorbidities, but none were predictive of postoperative complications or early mortality.

The patient aged over 90 years is generally defined as “frail” to indicate weak or vulnerable status, sustained by co-existing chronic disease and poly-pharmacy; we have to understand that frailty is a physiological status that comes with aging.

In the literature, “frailty phenotype” is defined by presence of 5 criteria: unintentional weight loss, self-reported exhaustion, weakness (grip strength), slow walking speed and low physical activity.[6,7] Many frailty screening tests are available to determine if elderly patients qualify for emergency abdominal surgery.[8,9] Kenig, in a prospective study conducted with 184 patients aged ≥65 years, reported that it is possible to perform safe and efficient screening for frailty in older candidates for emergency surgery, and that Vulnerable Elders Survey-13, which simply asks questions about independent living, was the best screening instrument with highest sensitivity and negative predictive value for both postoperative mortality and morbidity.[10] Gomes et al. reported that Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and morbidity (CR POSSUM) was the best predictor of surgical mortality and morbidity, that POSSUM and Portsmouth POSSUM scoring systems underestimated surgical mortality and morbidity, and that Colorectal Biochemical and Haematological Outcome Model overestimated surgical mortality. However, none of the scores in his retrospective study demonstrated sufficient discriminatory power to have clinical application value. Moreover, Gomes stated that in elderly patients, it is the patient’s health status and not the type of surgery that is mainly responsible for the surgical outcome.[11] Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

De Simone et al. Complicated colorectal cancer in nonagenarian patients

In emergency conditions, it is fundamental to have a predictive test that is easy and quick to administer in order to select patients for surgery, even in cases of altered cognitive status.

In our experience, individual preoperative risk in nonagenarian patients was assessed using ASA classification because it can be determined quickly on admission and it has been shown in the literature to be predictive of complications and mortality. Consistent with results of recent retrospective studies,[7,8,12] in our cohort of patients, high ASA class was associated with high mortality following emergency surgery, but we found no statistically significant difference between patients with ASA score ≤3 and patients with ASA score >3. This may be because very elderly patients with high ASA score, affected by severe disease, needed to be treated first in ICU, where they often die. Consequently, in our study we included patients who were already selected by ASA classification at admission.

In our experience, mean delay in surgery was 53.81 hours.

Some authors have reported that time between admission and surgery does not increase morbidity and mortality rates;[13] others demonstrated that delay in performing emergency surgery in elderly patients leads to higher complication rates.[14] We did not find a statistically significant difference in patients operated on within 24 hours in terms of early mortality rate. We have to consider that several patients needed to be monitored and clinically stabilized in department of internal medicine before surgery, and this may be a factor responsible for delay in surgery.

After making the decision to perform surgery, the primary objectives of the emergency surgeon are maintenance of independence, life expectancy, and quality of life of the elderly patient.

Surgical treatment of large bowel obstruction for cancer depends on location of colic obstruction, intraoperative findings, patient’s general condition, patient’s nutritional status, and the experience of the surgeon.[15–22] Generally right hemicolectomy with primary anastomosis and eventually extended to the transverse colon is indicated for right-sided lesions or transverse colon-obstructing cancers.

In case of left-sided lesions, surgical treatment is still debated and includes: -primary resection and anastomosis associated with on-table irrigation or manual decompression of the colon (one-stage procedure). It prevents the confection of a loop colostomy but presents risk of anastomotic leakage; -Hartmann’s procedure (two-stage surgery), which allows the treatment of both obstruction and cancer and prevents anasUlus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

tomotic leakage, but requires second operation to reverse the colostomy; -three stage procedure (decompressive colostomy-colic resection-colostomy closure); -subtotal or total colectomy with/without primary anastomosis, indicated in case of diastatic colon perforation or synchronous right colonic cancer; and -temporary or definitive loop colostomy/ileostomy, in case of important bowel dilatation proximal to obstruction, advanced neoplastic disease, or peritoneal carcinomatosis due to high risk of anastomotic leakage.[20–23] In the literature, many studies have reported increasing number of surgical procedures involving creation of diverting stoma, and this seems to increase with age,[24] probably with the aim of avoiding anastomotic dehiscence in frail nonagenarian patients. Several authors have reported that if the patient does not exhibit hypoalbuminemia, the surgeon may be able to perform an emergency operation with low risk of surgical mortality.[25] Immediate colic resection with primary anastomosis is optimal in selected patients with low risk, either a typical resection with washout, or subtotal colectomy. Temporary defunctioning colostomy or ileostomy could be proposed for patients with intermediate anesthetic risk, and in high-risk cases with advanced obstruction, simultaneous colonic perforation, metastatic or locally advanced disease, Hartmann’s procedure should be preferred as safer surgical procedure.[26] The World Society of Emergency Surgeons, after a consensus conference on management of obstructing cancer of the left colon, stated that primary resection and anastomosis with manual decompression seems to be procedure of choice; loop colostomy and staged procedure should be adopted in extreme cases when neoadjuvant therapy could be expected.

Hartmann’s procedure should be performed in case of high risk of anastomotic dehiscence, and subtotal and total colectomy should be attempted in presence of cecal perforation or synchronous colonic neoplasms.[27] In our experience, we performed 6 right hemicolectomies with primary anastomosis for right colon cancer. For left colon cancer, we performed 2 Hartmann’s procedures, 1 sigmoidectomy with temporary diverting ileostomy, and 2 decompressive colostomies.

We had 1 dehiscent anastomosis in right hemicolectomy patient.

In our cohort of patients, incidence of postoperative complications was significantly higher in the group of patients with right colon cancer compared with patients with left colon cancer. This is probably a consequence of management 19

Simone et al. Complicated colorectal cancer in nonagenarian patients

of right and left obstructive cancers in emergency settings: surgeons feel safer performing primary anastomosis for right colon cancers than for left colon cancers. This means exposing the “non-selected,” frail, geriatric patient to the risk of postoperative complications, increasing morbidity and mortality.[28,29] In our experience, only anastomotic dehiscence was just after right hemicolectomy with primary anastomosis.

No significant statistical difference was found in mortality rate between patients with stoma and patients without stoma.

After surgery, length of stay is typically longer for patients aged over 90 years. Emergency surgical treatment of CRC is potential promoter of permanent disability in frail and vulnerable patients, and discharge is often to long-term care facilities.[29,30] In the literature, longer hospitalization is often due to high incidence of Post Operative Delirium (POD).[31] Ansaloni et al. affirmed that to minimize POD, associated risk factors of comorbidity, cognitive impairment, psychopathology, and abnormal glycemic control must be identified and treated.[32] Delay in surgery is considered the most important risk factor in postoperative morbidity and mortality rates. In our experience, no statistically significant difference was found between patients who underwent surgery within 24 hours and those who were operated on later than 24 hours after admission.

In agreement with the literature, our population study of oncogeriatric patients revealed in-hospital mortality of 21.05% (4 of 19 patients), and at follow up, overall survival was 47.36% (9 of 19 patients were alive). Mean follow up time was 6.31 months.[33,34] Several studies have found similar disease-specific survival rate for elderly and young colorectal cancer patients,[35,36] but differences in overall survival, indicating that increased mortality in oncogeriatric patients was due to competing cause of death and not to CRC. Therefore, decreased survival in the elderly is mainly due to differences in early mortality.[36,37]

Conclusion Elective surgery is the best way to manage CRC in all patients, but an increasing number of nonagenarians are admitted to emergency departments for complicated CRC. Emergency surgery for complicated CRC in patients over 90 years old is feasible with careful selection and preoperative evaluation of the patient, which will maximize surgical outcomes.

In preoperative evaluation, emergency surgeon has to con20

sider global health status using ASA score, nutritional status defined by albuminemia, and quality of life before hospitalization (degree of independence) of the geriatric patient needing surgery.

In emergency situations, nonagenarian patients with ASA score 1–3, no hypoalbuminemia and high independence in daily activities have the same surgical risk as younger patients.

One-stage surgery is the best choice, when possible, in selected patients. Two- and three-stage surgery is indicated in case of peritonitis, for frail patients, and for those who are hemodynamically unstable. For those with high risk of anastomotic leakage, decompressive ileostomy/colostomy is suggested as bridge to elective surgery, and in advanced neoplastic disease, as palliative procedure.

Risk of leakage or dehiscence of intestinal anastomosis is high both for right and left colic resection after emergency surgery in elderly patients.

We think that temporary colostomy or ileostomy is a good surgical option in nonagenarian patients, to decrease surgical risk, length of hospitalization, morbidity, and mortality, but clinical randomized controlled trials are necessary to confirm this.

In conclusion, a multidisciplinary approach to oncogeriatric patient and evidence-based clinical guidelines for management in emergency setting are essential in order to offer optimal, disability-free treatment and to not decrease life expectancy and overall survival.

Conflict of interest: None declared.

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22. Gainant A. Emergency management of acute colonic cancer obstruction.

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Simone et al. Complicated colorectal cancer in nonagenarian patients

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Doksanlı yaşlardaki hastalarda komplike kolorektal kanser: Acil durumda anastomoz yapmamak daha mı iyi?

Dr. Belinda De Simone,1 Dr. Federico Coccolini,2 Dr. Luca Ansaloni,2 Dr. Antonio Tarasconi,3 Dr. Gianluca Baiocchi,3 Dr. Nereo Vettoretto,4 Dr. Peggy Joly,5 Dr. Marianne Ferron,5 Dr. Alessandro Pozzo,5 Dr. Lionel Charre,5 Dr. Salomone Di Saverio,6 Dr. Josephine Andrea Napoli,7 Dr. Ferdinando Agresta,8 Dr. Massimo Sartelli,9 Dr. Fausto Catena1 Parma Üniversitesi Hastanesi, Acil Cerrahi Bölümü, Parma-İtalya XXIII. Papa Giovanni Hastanesi, Acil Tıp ve Genel Cerrahi Bölümü, Bergamo-İtalya Ospedali Civili, Genel ve Acil Cerrahi Bölümü, Brescia-İtalya 4 Montichiari Hastanesi, Genel Cerrahi ve Acil Cerrahi Bölümü, Brescia-İtalya 5 Renè Dubos Hastanesi, Genel ve Acil Cerrahi Bölümü, Pontoise-Fransa 6 Maggiore Hastanesi, Acil ve Genel Cerrahi Bölümü, Bologna-İtalya 7 Hawaii Universitesi, Cerrahi Bilimler Bölümü, Amerika Birleşik Devletleri 8 Adria Hastanesi, Genel Cerrahi Bölümü, Adria-İtalya 9 Macerata Hastanesi, Genel Cerrahi Bölümü, Macerata-İtalya 1 2 3

AMAÇ: Kolorektal kanser (KRK) başlıca yaşlı kişilerin hastalığıdır. Doksanlı yaşlardaki hastalarda kanser cerrahlar ve onkologlar için etik bir ikilemi temsil eder. Bu hasta grubunda, komplike KRK’nin acil durumda tedavisi tartışılmaktadır. Kolorektal kanser komplikasyonları için acilen cerrahiye başvuran doksanlık hastalarda altı acil cerrahi bölümünün tedavideki deneyimlerini sunmak amacıyla bu geriye dönük çalışma yapıldı.

GEREÇ VE YÖNTEM: Ocak 2011 ile Haziran 2015 arasında komplike KRK için altı acil cerrahi kliniğinde yatırılan 90 yaş üstü hastalara ilişkin veriler geriye dönük olarak analiz edildi. Veriler bu amaca ilişkin veri tabanında toplandı. IBM SPSS 22 yazılımı kullanılarak istatistiksel analiz yapıldı ve istatistiksel anlamlılık düzeyi olarak p=0.05 belirlendi.

BULGULAR: Çalışma döneminde 90 yaş üstü 15 hasta komplike KRK için acilen cerrahi geçirdi. Olguların %52.63’ü kadın olup kadın/erkek oranı 1.11: 1 ve yaş ortalaması 92.52±1.49 yıl (dağılım: 90–97) idi. Ameliyat öncesinde ASA skoruyla cerrahi risk değerlendirildi. ASA skorları ≤3 ve >3 olan hastalar arasında hastane içi mortalitede istatistiksel açıdan hiçbir farklılık yoktu. Hastaların %31.57’sinde (6/19) primer anastomoz uygulandı.

Bu hastaların tümü sağ kolon kanserinden etkilenmişti. Hastaların %63.15’ine (12/19) diversiyon stroması gerçekleştirildi. Sağ veya sol kolon kanser hastalar arasında ameliyat sonrası komplikasyonların insidansı arasında istatistiksel açıdan farklılık vardı (p=0.0498). Hastanede ortalama kalış süresi 12.87±6.31 (dağılım: 2–31). Hastanede mortalite oranı %21.05 (4/19 hasta) idi. İzlem sırasında genel sağkalım oranı %47.36 (9/19 hasta) idi.

TARTIŞMA: Etkilenmiş hastaların tümünde KRK’yi tedavi etmenin en iyi yöntemi elektif cerrahidir. Hastaların ameliyat öncesinde dikkatli seçimi ve değerlendirmesiyle 90 yaş üstü hastalarda KRK komplikasyonları için acil cerrahi mümkündür. Seçilmiş hastalarda tek evrelik cerrahi en iyi seçimdir.

Peritonitli, güçsüz hastalarda, hemodinamik açıdan kararsız, anastomoz yeri kaçağı açısından yüksek risk taşıyan hastalarda iki–üç evreli cerrahi endikedir. Elektif cerrahiye geçiş olarak ve ilerlemiş neoplastik hastalıkta palyatif işlem olarak dekompresif stoma gerçekleştirilir. Acil durumlarda doksanlık hastalarda cerrahi riski, morbidite ve mortaliteyi azaltma açısından diversiyon stoması iyi bir cerrahi seçimdir. Bunu doğrulama için klinik randomize kontrollü çalışmalara gerek vardır.

Anahtar sözcükler: Acil cerrahi; dekompresif stoma; doksanlık hasta; kalın bağırsak tıkanıklığı; kolorektal kanser; primer anastomoz.

Ulus Travma Acil Cerrahi Derg 2017;23(1):15–22

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doi: 10.5505/tjtes.2016.77178

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ORIG I N A L A R T IC L E

An evaluation of factors affecting clinical outcomes in penetrating cardiac injuries: A single center experience Orhan Tezcan, M.D., Oğuz Karahan, M.D., Celal Yavuz, M.D., Sinan Demirtaş, M.D., Ahmet Çalışkan, M.D., Binali Mavitaş, M.D. Department of Cardiovascular Surgery, Dicle University Faculty of Medicine, Diyarbakır-Turkey

ABSTRACT BACKGROUND: Penetrating cardiac injury (PCI) has highly mortal outcome. Therefore, management of this emergency situation is extremely important. The present study is an investigation of main factors that can affect mortality and morbidity in PCI. METHODS: Records of 112 patients who were admitted to emergency department with PCI in the last decade were evaluated retrospectively. Demographic data, initial approach, transfer duration and conditions, vital status and findings, type of injury, localization, characteristics, and type of surgical application were recorded.

RESULTS: Demographic findings (age, sex, cause of injury) were not found to be significant factors affecting mortality. Early mortality (1-week observation period) occurred in 14 (12.5%) patients. Method of transfer to hospital (under medical team supervision by ambulance, or without supervision), transfer duration, initial vital findings upon arrival (blood pressure, rhythm, breathing, consciousness), operation timing (elective or emergency), and injuries to additional organs were determined to be important predictors of survival.

CONCLUSION: Cardiac injury is highly mortal emergency situation. Expert medical management is important for survival. However, basic first aid measures and immediate hospital transfer are as important as expert clinical management.

Keywords: Mortality; penetrating cardiac injuries; predictors of survival.

INTRODUCTION Penetrating cardiac injury (PCI) is highly mortal acute clinical emergency. Timely diagnosis and immediate treatment is important for survival. Despite the fact that cardiac structures are affected by only 10% of all thorax traumas, cardiac injuries are responsible for 40% of overall mortality due to thorax trauma.[1] Some regions have high risk for injuries due to war, individual armament, and other reasons. In such regions, specialized intervention centers, trauma clinics, or expert first aid teams can decrease mortality and morbidity rates with appropriate collaboration, rapid transfer, and immediate intervention by experienced hands.[2] Although there have been advances in opportunities and techniques for prehospital reAddress for correspondence: Oğuz Karahan, M.D. Dicle Üniversitesi Tıp Fakültesi, Kalp Damar Cerrahisi Anabilim Dalı, Diyarbakır, Turkey Tel: +90 412 - 248 80 01 / 1108 E-mail: oguzk2002@gmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):23–28 doi: 10.5505/tjtes.2016.95994 Copyright 2017 TJTES

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ferral and clinical management in recent years, only 6% of patients with these injuries reach the hospital alive, and only 50% of them can be saved.[1] PCI can be accompanied by hypotension following hypovolemic shock, or cardiac tamponade findings and breathing problems due to concomitant pulmonary injuries, such as contusions, lacerations, and pneumothoraces.[1,3] In previous reports, injured cardiac site of PCI was listed as right ventricle (35%), left ventricle (25%), right atrium (33%), left atrium (14%), and aorta (14%).[3] When possible with vitally stable patients, diagnostic methods can facilitate approach of clinician.[1,3] Chest radiogram can provide evidence of concomitant lung injury, but it is inadequate to evaluate injuries involving the heart and the pericardium. Echocardiography, which is non-invasive and easily available, can provide knowledge about valvular function, wall motion, and left ventricular ejection fraction, which are helpful for detecting pericardial effusion and tamponade.[3] However, device wires, tubes, wound dressings, or chest bleeding, and even electrocardiogram cables and lead wires, often limit visualization of echocardiogram.[1,3] Multidetector computed tomography (CT) is highly sensitive for evaluation of lung and cardiac structures. It can help identify wound track of penetrating trauma and guide clinicians.[3,4] 23

Tezcan et al. An evaluation of factors affecting clinical outcomes in penetrating cardiac injuries: A single center experience

In the current study, clinical outcomes and associated risk factors for mortality, such as injury type, length of time before hospital referral, vital signs, concomitant organ injuries, and surgical procedures, were evaluated in PCIs.

MATERIALS AND METHODS Files of 112 patients with PCI from last decade were evaluated retrospectively. Demographic findings (age, sex, cause of injury), injury type, time for transfer to hospital, transfer type, concomitant organ injury, initial vital signs, diagnostic methods, cardiac findings (rhythm, hypovolemia, tamponade, coronary injury, incision or injury length, involved site), and operational procedures were recorded. Approval for the study was obtained from the ethics committee of Dicle University Faculty of Medicine.

Injuries that involved principal areas (anterior axillary line on left side, vertical line that crosses the right breast areola at right side, jugular area on upper side and upper part of the epigastrium at lower side) were considered suspected cardiac injuries1. Patients with severely disrupted vital findings were operated on without additional diagnostic examination, according to injuries involved. Blood transfusion and volume replacement were utilized for patients with cardiogenic shock.

[1,5] Hemodynamically stable patients were evaluated with additional diagnostic methods (chest radiogram, echocardiography, CT). Pericardiocentesis and subxiphoid drainage were not performed for diagnosis or treatment.

Central venous catheterization was used for all patients, and standard median sternotomy, or anterior, anteromedial, or anterolateral thoracotomy via fourth or fifth intercostal area was performed under general anesthesia to reach intrathoracic structures. Pericardia were incised vertically from 1 to 2 cm of proximal side of the phrenic nerve. Bleeding was controlled with finger compression until repair. Cardiac injury was repaired with Teflon pledget, and the pericardium was secured with 3.0 monofilament polypropylene suture.

Statistical Analysis SPSS 13.0 statistical software (IBM, Corp., Armonk, NY,

USA) was used for statistical analysis. Variables were expressed as mean±standard deviation. Categorical variables were expressed as frequency percentages. Differences were evaluated with chi-squared distribution for categorical variables and Student’s t-test for continuous variables. P<0.05 was considered significant.

RESULTS There were 99 (88%) males and 13 (12%) females with mean age of 29.3±14.1 years in the study. Age and gender distribution were statistically similar according to mortality rate. However, important relationship was detected between mortality and length of time until hospital arrival (Table 1). Mean arrival time for all patients was 39.4±22.6 minutes (min-max: 14–108 minutes). Mean arrival time was determined to be 53.2±17.8 minutes for expired group and 30.8±15.4 minutes for survival group. Difference between time until hospital arrival and mortality or survival was found to be significant (p=0.001).

Distribution of injuries according to etiological factors was as follows: 79 (71%) patients had stab wound, 26 (23%) patients had gunshot wound, and 7 (6%) patients had iatrogenic injury.

Mortality was not observed in iatrogenic injuries; however, mortality was observed in 10 (13%) patients in stab wound injury group and 4 (15%) patients in gunshot injury group.

Difference in mortality between gunshot and stab wound groups was statistically insignificant (p>0.05).

Eighty-five (76%) patients arrived at hospital by their own means, and 27 (24%) patients were transferred by authorized ambulance. Mean length of transfer time was 47.6±32.3 minutes for transfer by ambulance and 35.1±11.3 minutes for self-transfer. Mortality rate with ambulance transfer (n=10) rose with longer transfer time (p<0.001).

Twenty-two (20%) patients were taken directly for resuscitative thoracotomy. Cardiac injury was thought to be critical in 24 (21%) patients, and they were immediately taken to surgery. Further radiological diagnosis was performed for 66 (59%) patients, and operation procedures were determined according to radiological findings. Highest mortality rate

Table 1. Relationship between mortality and initial data

Mortality n

%

Survival

Mean±SD

n

%

p

Mean±SD

Age (years) 28.7±9.2 27.1±11.3 >0.05 Sex

Male

13 13 86 87 >0.05

Female

1

8

Transfer time to hospital (min)

12

92

53.2±17.8

30.8±15.4

>0.05 0.001

SD: Standard deviation.

24

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Tezcan et al. An evaluation of factors affecting clinical outcomes in penetrating cardiac injuries: A single center experience

was detected in resuscitative thoracotomy (RT) group, with 8 (50%) patients expiring (p=0.005). Mortality rate in clinical diagnosis and radiological diagnosis groups was 4 (43%) patients and 2 (7%) patients, respectively. Mortality rate in radiological diagnosis group was markedly lowest (p<0.001).

One of these patients had multiple stab wounds, and injuries to the lung, the liver, and the heart were detected with CT and echocardiograms. Right ventricular repair, hepatic repair, and left tube thoracostomy were performed; however, the patient died on third day due to sepsis. The other patient also had multiple wounds (the right ventricle, the liver, the lung, and the trachea) detected in CT scans that were result of shotgun wound. Simultaneous right ventricular and hepatic repairs were made, and left lower lobectomy was performed due to uncontrolled bleeding. This patient died on fifth day due to multiple organ failure.

Initial vital findings were found to be important predictors of mortality. Mortality rate was 6 (43%) patients in group of those classified as in agony on arrival (n=9), 6 (43%) patients among those in shock (n=46), 1 (7%) from group of those who were hypotensive (n=20), and 1 (7%) from normotensive group (n=37) (p<0.001). Tamponade was detected in 30 (27%) patients, 1 of whom (3%) died. Thirteen (16%) patients died in group without tamponade (n=82). Mortality rate was insignificantly lower in tamponade group compared with patients without tamponade (p=0.108). Although statistically insignificant, higher mortality rate of 23% was observed in patients with hemothorax (n=44; p>0.05). In contrast, lower mortality rate of 5% was seen in patients with pericardial hematoma (n=75; p=0.005).

Highest mortality rate (33%) was found in left ventricular injuries (n=30). Mortality rate was 5% in right ventricular injuries (n=72). Mortality was not observed in injuries to other sites [right atrium (n=6), left atrium (n=2) and 2-site (n=2)].

Two-site injury was detected in 2 patients: right and left atria were injured in 1 patient, and right atrium and ventricle were injured in other patient. Isolated cardiac injury was detected in 63 (56%) patients, and concomitant organ injury was seen in 49 (44%) patients. Most common concomitant organ injury was lung injury. Other organs injured were the diaphragm, the liver, the spleen, the abdominal aorta, the stomach, the left internal mammarian artery, the right internal mammarian artery, and the pulmonary artery. Mortality rate was markedly higher in patients with concomitant organ injury, as expected (p=0.014). Concomitant organ injuries and mortality rates are presented in Table 2.

Lower mortality rate (n=8) was observed in patients with sinus rhythm (n=100). Mortality (n=6; 50%) was significantly higher (p=0.001) in patients with asystole or ventricular fibrillation (n=12). Coronary injury was detected in 5 (4%) patients. The left anterior descending artery was injured in 1 patient, and direct ligation was applied due to inappropriate location of injured vessel for bypass (patient died on second Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Table 2. Concomitant organ injury and mortality rates Involved organ

n

Mortality

n % Lung*

33 7 21

Diaphragm

5 3 60

Liver*

7 5 71

*

Spleen

4 3 75

Pancreas*

2 2 100

*

Abdominal aorta

1

Gastrointestinal tract*

5 0 0

0

0

Left internal mammarian artery

3

1

33

Right internal mammarian artery

1

0

0

Pulmonary artery

1

1

100

*

Multiple organ injury.

day due to left ventricular failure). Acute margin of right coronary artery was injured in 3 patients, and distal side of the left anterior descending artery was injured in 1 patient; direct ligation was applied in all of these cases.

Mortality rate was found to be closely associated with incision or injury length in PCI. Higher mortality rate (42%) was detected in patients (n=26) with incision length of >2 cm (p<0.001). Standard median sternotomy was performed for 19 patients. Left thoracotomy was performed for 88, and right thoracotomy was performed for 5 patients. Relationship between surgical approach and mortality rate was found to be statistically insignificant (p>0.05).

Total mortality rate was 13% for all PCI. Causes were determined to be prolonged shock for 6 (43%) patients, multiple organ failure due to multiple organ injury and ventricular failure for 4 (29%) patients, brain death for 3 (21%) patients, and sepsis for 1 (7%) patient.

Clinical features and mortality rates are comprehensively summarized in Table 3.

DISCUSSION Despite recent advances in trauma and emergency medical care, PCI remains the most challenging of all injuries seen in the field of trauma surgery.[6,7] Therefore, prehospital management, initial assessment and findings, and appropriate procedures are important to increase likelihood of survival.[8] In this study, etiology, manner and duration of hospital transfer, and concomitant organ injuries were detected as most significant risk factors affecting survival. Age and gender were insignificant factors for mortality.

Yavuz et al. reported that length of time elapsed before arrival to hospital was important risk factor that determined mor25

Tezcan et al. An evaluation of factors affecting clinical outcomes in penetrating cardiac injuries: A single center experience

Table 3. Clinical features and mortality rates

Mechanism of injury

Stab wound

Gun shot

Iatrogenic Surgical decision

Resuscitative thoracotomy

Clinical diagnosis Radiological diagnosis Transfer type

Ambulance

Self Arrival status

Agony

Shock Hypotensive Normotensive Tamponade +

– Coronary injury

+ – Concomitant organ injury

+

– Arrival rhythm

Sinus

Asystole/ventricular fibrillation Incision length

>2 cm

≤2 cm Hemothorax

+

– Pericardial hematoma

+

– Injury site

Right ventricle

Left ventricle Other (right atrium, left atrium, multiple sites) Surgical incision

Medial sternotomy

Right thoracotomy

Left thoracotomy Total

Injury

Mortality p*

n % n %

79 71 10 71 0.599 26 23 4 29 7 6 0 0 22 20 8 50 <0.001 24 21 4 43 66 59 2 7 27 24 10 71 <0.001 85 76 4 29 9 8 6 43 <0.001 46 41 6 43 20 18 1 7 37 33 1 7 30 27 1 7 0.108 82 73 13 93 5 4 1 7 0.657 107 96 13 93 49 44 11 79 0.014 63 56 3 21 100 89 8 57 0.001 12 11 6 43 26 23 11 79 <0.001 86 77 3 21 44 39 10 71 0.022 68 61 4 29 75 67 4 29 0.005 37 33 10 71 72 64 4 29 0.003 30 27 10 71 10 9 0 0 19 17 3 21 0.814 88 79 10 72 5 4 1 7 112 100 14 100

p<0.05 was considered significant. Each p value represents comparison of event with entire group.

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Tezcan et al. An evaluation of factors affecting clinical outcomes in penetrating cardiac injuries: A single center experience

tality.[1] In another study, it was reported that only 4% of PCI patients reached hospital alive via ambulance transfer.[9] Rhee et al. indicated that prehospital time is important in order to maintain signs of life until arrival.[10] Patients with prehospital mortality were excluded from our study. We found elapsed time until transfer to be significant risk factor for mortality, as in previous reports. Moreover, means of transfer (self-effort or ambulance) was also determined to be factor for mortality.

Eighty-five (76%) of patients transported themselves, and 27 (24%) patients were transferred with authorized ambulances.

Prolonged transfer duration was observed with ambulance transfer. Self-transfer seems to reduce transfer duration, as there can be wait for an ambulance.

Most of the previous reports indicated that gunshot wounds have higher mortality rates than stab wounds. Tyburski et al. found that gunshot wounds have poorer survival rate (23%) than stab wounds (58%).[9] According to Tang et al.â&#x20AC;&#x2122;s report, stab wound has 5-fold higher survival rate when compared with gunshot wound.[11] Conversely, mortality rate for these injuries was similar in current study. According to our data, most stab wound patients had multiple stab wounds. Similarity in mortality between gunshot wounds and stab wounds may have been due to this feature of stab wound patients.

Lowest mortality rate was in group with iatrogenic injuries, which may have been associated with timely diagnosis and early intervention due to hospital conditions.

Initial findings (cardiac rhythm, blood pressure), presence of cardiac tamponade, presence of hemothorax, and location of injury were reported as other mortality predictors in recent population-based studies.[12] Higher mortality rate was identified in PCI patients with preoperative arrhythmia.[13] Yavuz et al. reported lower mortality rate in patients with sinus rhythm compared with patients with asystole or ventricular fibrillation.[1] Presence of tamponade in PCI patients can prevent exsanguination; it also causes subendocardial ischemia, which may lead to sudden cardiac failure.[9] Presence of tamponade was associated with higher survival rate in previous reports.

[9] It has been reported that 18% of deaths could potentially be saved due to compression of bleeding site in isolated cardiac wounds with tamponade.[14] Furthermore, hemorrhagic shock due to hemothorax is an important determinant for clinical outcomes in PCI.[15] Presence of hemothorax was associated with high mortality rate.[1] In the current study, sinus rhythm, normal blood pressure, presence of cardiac tamponade, and hematoma were detected as positive indicators for survival. In contrast, high mortality rate was found in patients with hemothorax.

RT and efficient open cardiac massage play essential role in recovery for patients who have loss of vital signs.[16,17] Approximately 35% success rate was reported with RT in PCI patients.[16] Nevertheless, higher mortality rate was reported in RT when compared with other operations performed with clinical or radiological diagnosis.[1] Algorithms for RT Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

were designed according to loss of vitality and signs of life.

Poor outcome after RT was associated with poor vital signs. Injury localization is another important parameter for mortality in PCI. Main injury sites were reported as follows: right and left ventricle with range of 40%, right atrial injury with range of 24%, left atrial injury with range of 3%, and complex (more than 1 site or additive coronary artery, papillary muscle injury, etc.) injuries with range of approximately 5%.[8] Better survival rate was reported for right ventricle injuries.[19] Also, poor outcome was reported with concomitant coronary artery injury.[19] Yavuz et al. reported approximately 33% mortality rate in patients with concomitant coronary artery injury.[1] The other major predictor has been reported to be concomitant organ injury, which can contribute to loss of vital signs.[20] Thus, these types of multiple injuries have been labeled situation of â&#x20AC;&#x153;double jeopardyâ&#x20AC;? in previous studies.[21] Most common concomitant organ injury reported was lung injury.[1,21] Increased mortality rate has been reported in patients in patients with longer injury length due to larger incision size, as expected. Yavuz et al. reported 45% mortality rate in patients with more than 2-cm incision.[1] According to our series, high mortality rate was detected in patients who underwent initial RT. Most common anatomical localization was right ventricle (64%), with rate of 5% mortality.

Left ventricle injury (27%) was determined to be most fatal (71%) anatomical localization in this study, and 20% mortality rate was observed with concomitant coronary injury. Difference in mortality rate between patients with coronary injury and patients without coronary injury was not statistically significant. However, in our series, group with coronary injury was small (4% of the patients), which could explain statistical insignificance. Most frequently injured concomitant organ was the lung, but most fatal concomitant organ injuries were determined to be those to the pancreas, the spleen, the liver, and the diaphragm. Higher mortality might be associated with features such as high vascularization, important regulatory functions, etc. Mortality rate was found to be 42% greater with longer injury incision length (>2 cm). Additionally, some reports have mentioned benefits of cardiopulmonary bypass (CPB) for cardiac injury. Although it is rarely required, CPB can provide bloodless and stable operating area to optimize conditions for more effective repair.[13] Most often, CBP is required for complex injuries with concomitant coronary or valvular injury, or uncontrollable, excessive bleeding.[13,20] Coronary artery injuries can be controlled with ligation, or bypass can be performed if proximal site is affected.[13,20] In our series, there were no valvular injuries. We used ligation to control coronary injuries without using CBP. [18]

In conclusion, cardiac injury is still challenging emergency situation. As described in the literature, many factors may be associated with mortality. However, hospital transfer duration seems to be the primary modifiable risk factor that is important determinant for survival. We suggest that advanced hospital transfer strategies and collaborative management are important for avoiding time lag and enhancing survival rate.

27

Tezcan et al. An evaluation of factors affecting clinical outcomes in penetrating cardiac injuries: A single center experience

Funding There authors certify that no financial support was provided for this study.

Conflict of interest: None declared.

REFERENCES 1. Yavuz C, Çil H, Başyiğit I, Demirtas S, İslamoglu Y, Tekbaş G, et al.

Factors affecting mortality in penetrating cardiac injuries: our 10-year results. Turk Gogus Kalp Dama 2011;19:337–43.

2. Yazıcı S, Karahan O, Güçlü O, Yavuz C, Demirtaş S, Çalışkan A, et al.

Analysis of peripheral vascular injuries: A social catastrophe. Dicle Medical Journal 2014;41:441–5.

3. Co SJ, Yong-Hing CJ, Galea-Soler S, Ruzsics B, Schoepf UJ, Ajlan A, et al. Role of imaging in penetrating and blunt traumatic injury to the heart.

Radiographics 2011;31:101–15.

4. Shanmuganathan K, Matsumoto J. Imaging of penetrating chest trauma.

Radiol Clin North Am 2006;44:225–38.

5. Gao JM, Gao YH, Wei GB, Liu GL, Tian XY, Hu P, et al. Penetrating cardiac wounds: principles for surgical management. World J Surg 2004;28:1025–9.

6. Yanar H, Aksoy M, Taviloglu K, Unal ES, Kurtoglu M, Nisli K. Trans-sternal cardiac injury caused by a hooked needle. Emerg Med J 2005;22:751–3.

7. Rashid MA, Lund JT. Trauma to the heart and thoracic aorta: the Copenhagen experience. Interact Cardiovasc Thorac Surg 2003;2:53–7.

8. Ivatury RR. The injured heart. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000.

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

10. Rhee PM, Acosta J, Bridgeman A, Wang D, Jordan M, Rich N. Survival after emergency department thoracotomy: review of published data from

the past 25 years. J Am Coll Surg 2000;190:288–98.

11. Tang AL, Inaba K, Branco BC, Oliver M, Bukur M, Salim A, et al.

Postdischarge complications after penetrating cardiac injury: a survivable injury with a high postdischarge complication rate. Arch Surg 2011;146:1061–6.

12. Lustenberger T, Talving P, Lam L, Inaba K, Mohseni S, Smith JA, et al.

Penetrating cardiac trauma in adolescents: a rare injury with excessive mortality. J Pediatr Surg 2013;48:745–9.

13. Kang N, Hsee L, Rizoli S, Alison P. Penetrating cardiac injury: overcoming the limits set by Nature. Injury 2009;40:919–27.

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

15. Rozycki GS, Feliciano DV, Ochsner MG, Knudson MM, Hoyt DB, Davis F, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma 1999;46:543–52.

16. Al Hassani A, Abdul Rahman Y, Kanbar A, El-Menyar A, Al-Aieb A, Asim M, et al. Left internal mammary artery injury requiring resuscitative thoracotomy: a case presentation and review of the literature. Case Rep Surg 2012;2012:459841.

17. Kalina M, Teeple E, Fulda G. Are there still selected applications for resuscitative thoracotomy in the emergency department after blunt trauma?

Del Med J 2009;81:195–8.

18. Burlew CC, Moore EE, Moore FA, Coimbra R, McIntyre RC Jr, Davis JW, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg 2012;73:1359–63.

19. Asensio JA, Petrone P, Karsidag T, Ramos-Kelly JR, Demiray S, Roldan G, et al. Penatrating cardiac injuries. Complex injuries and difficult challenges. Ulus Travma Acil Cerrahi Derg 2003;9:1–16.

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

21. Berg RJ, Karamanos E, Inaba K, Okoye O, Teixeira PG, Demetriades D. The persistent diagnostic challenge of thoracoabdominal stab wounds. J Trauma Acute Care Surg 2014;76:418–23.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Penetran kardiyak yaralanmalarda klinik sonuçları etkileyen faktörlerin değerlendirilmesi: Tek merkez deneyimi Dr. Orhan Tezcan, Dr. Oğuz Karahan, Dr. Celal Yavuz, Dr. Sinan Demirtaş, Dr. Ahmet Çalışkan, Dr. Binali Mavitaş Dicle Üniversitesi Tıp Fakültesi, Kalp ve Damar Cerrahisi Anabilim Dalı, Diyarbakır

AMAÇ: Penetran kalp yaralanmaları (PKY) yüksek ölümcül sonuçlara sahiptir. Bu nedenle, bu acil durumların yönetimi özellikle önemlidir. Bu çalışmada, PKY’de ölümü ve sakat kalmayı etkileyebilen ana faktörler araştırıldı.

GEREÇ VE YÖNTEM: Geriye dönük olarak son on yıl içerisinde PKY ile acil servise başvuran 112 hasta değerlendirildi. Demografik veriler, ilk müdahaleler, transfer süreleri ve durumları, hayati durum ve bulgular, yaralanma şekli, bölgesi, karakteristikleri ve uygulanan cerrahinin şekli kayıt edildi.

BULGULAR: Demografik veriler (yaş, cinsiyet, yaralanma sebebi) ölüm için anlamlı etken olarak bulunmadı. Erken mortalite (1 haftalık izlem süresi içerisinde) 14 (%12.5) hasta da gözlendi. Ayrıca, hastaneye transfer şekli (sağlık ekibi gözetiminde ambulansla veya gözetimsiz), transfer süresi, ilk gelişteki hayati bulgular (kan basıncı, ritim, solunum, bilinç), operasyon zamanlaması (elektif veya acil) ve ek organ yaralanması sağ kalım için önemli belirleyiciler olarak saptandı.

TARTIŞMA: Kalp yaralanmaları son derece ölümcül acil durumlardır. Sağ kalım için tecrübeli tıbbi yönetim önemlidir. Nitekim, temel ilk yardım yaklaşımları ve acil hastane transferi tecrübeli klinik yaklaşım kadar önemlidir.

Anahtar sözcükler: Mortalite; penetran kalp yaralanmaları; sağ kalım belirteçleri.

Ulus Travma Acil Cerrahi Derg 2017;23(1):23–28

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doi: 10.5505/tjtes.2016.95994

Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

ORIG I N A L A R T IC L E

Should Alvarado and Ohmann scores be real indicators for diagnosis of appendicitis and severity of inflammation?

Eyüp Murat Yılmaz, M.D.,1 Mücahit Kapçı, M.D.,2 Sebahattin Çelik, M.D.,3 Berke Manoğlu, M.D.,4 Mücahit Avcil, M.D.,2 Erkan Karacan, M.D.1 1

Department of General Surgery, Adnan Menderes University Faculty of Medicine, Aydın-Turkey

2

Department of Emergency Medicine, Adnan Menderes University Faculty of Medicine, Aydın-Turkey

3

Department of General Surgery, Van Yüzüncu Yıl University Faculty of Medicine, Van-Turkey

4

Department of General Surgery, Aydın State Hospital, Aydın-Turkey

ABSTRACT BACKGROUND: Acute appendicitis is one of the most common causes of abdominal pain seen in surgical clinics. Although it can be easily diagnosed, the picture may be confusing, particularly in premenopausal women and the elderly. The present study is an evaluation of 2 of the current scoring systems with respect to accurate diagnosis of the disease and indication of inflammation severity.

METHODS: A total of 105 patients diagnosed with acute appendicitis were included in the study. Subsequent to Alvarado and Ohmann scoring, ultrasonography image was obtained and appendectomy was performed. A unique intraoperative severity scoring system was used to measure severity of inflammation and to compare Alvarado and Ohmann scoring system results to assess accuracy of predictive value for acute appendicitis.

RESULTS: Moderate positive correlation was found between Alvarado score and Ohmann score (r=0.508; p<0.001). Rate of Alvarado score successfully predicting diagnosis of acute appendicitis based on histopathological results was statistically significant (p=0.027), while rate of Ohmann score was not statistically significant (p=0.807). Correlation between both scores and grading of inflammation performed during the operation was weak, but statistical significance was observed between Alvarado scoring system and intraoperative severity scoring (r=0.30; p=0.002). No statistical difference was observed between Ohmann scoring and intraoperative severity scoring (r=0.09; p=0.384).

CONCLUSION: Alvarado score is better able to predict acute appendicitis and provide an idea of severity of inflammation. Ohmann score is more useful to provide guidance and eliminate acute appendicitis from consideration when conditions are more uncertain and obscured.

Keywords: Alvarado; appendicitis; inflammation; Ohmann.

INTRODUCTION Acute appendicitis is the most common clinical diagnosis in general surgery clinics for patients who require urgent operation due to abdominal pain.[1] Diagnosis is generally made based on history, symptoms, physical examination, and laboAddress for correspondence: Eyüp Murat Yılmaz, M.D. Adnan Menderes Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, 09100 Aydın, Turkey Tel: +90 256 - 212 18 50 E-mail: drmyilmaz80@gmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):29–33 doi: 10.5505/tjtes.2016.89894 Copyright 2017 TJTES

Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

ratory findings. Ultrasonography (USG) and computed tomography (CT) images should be considered in evaluation of acute appendicitis, and in some cases, advanced imaging may also be needed.[2] Gynecological emergencies, particularly in premenopausal women, such as pelvic inflammatory disease, ovarian cyst rupture, and tubal pregnancy mimic acute appendicitis and may be mistaken for acute appendicitis at a rate of 40%.[2,3] In addition, diseases that do not require surgery, such as urological disease, colonic diverticulitis, and epiploic appendicitis, may be confused with acute appendicitis. Since diagnostic markers for acute appendicitis are limited, advanced imaging methods should be used for these patients. Negative appendectomy rate has been reported as 12%, and undiagnosed perforated acute appendicitis rate has been reported as 3.4% in the literature.[4] Patients are exposed to unnecessary surgical stress in cases of negative appendectomy while other diagnoses may be ignored. When diagnosis is clinically 29

Yılmaz et al. Should Alvarado and Ohmann scores be real indicators for diagnosis of appendicitis and severity of inflammation?

or radiologically suspected acute appendicitis, or if it is omitted altogether, more complex clinical picture may develop.

In order to minimize these cases, various diagnostic scoring systems, such as Alvarado, Ohmann, Eskelinen and Lintula scores, have been developed for use in daily practice.[5,6]

Table 1. Alvarado scoring Feature

Score when present

Migration of pain

1

Anorexia 1

Alvarado score, which is based on symptoms, physical examination, and laboratory findings, has been in use since 1986.

It is a simple and inexpensive test that can be applied for patients with right lower quadrant pain.[5] Ohmann score is another easily applied scoring system to explore possibility that patient with abdominal pain has appendicitis.[7] The present study examined efficacy of both systems for diagnosis of appendicitis and assessment of severity of inflammation.

Nausea 1 Tenderness in right lower quadrant

2

Rebound pain

1

Elevated temperature

1

Leukocytosisa 2 Shift of white blood cell count to lefta

1

Total (maximum)

10

MATERIALS AND METHODS This prospective study was conducted between November 1, 2014 and July 31, 2015 with the permission of the ethics committee of Adnan Menderes University Faculty of Medicine. Total of 105 patients who came to Adnan Menderes University emergency service and were prediagnosed with acute appendicitis were included. Alvarado score (Table 1) and Ohmann score (Table 2) were calculated. Abdominopelvic examinations and laboratory findings were evaluated, and all patients underwent abdominal USG. All patients who underwent surgery at Adnan Menderes University Faculty of Medicine General Surgery Clinic provided written informed consent. Intraoperative severity scoring system was used during operation to determine severity of inflammation (Table 3). Definitive diagnosis was made histopathologically after surgery. Patients who declined surgery, who did not want to participate in the study, who were not operated on due to doubt in the diagnosis of appendicitis, or who were discharged after follow-up and had regression of symptoms were excluded from the study.

The study was explained to all patients who underwent surgery and their relatives, and written, informed consent was provided for the findings to be used for scientific purposes.

Alvarado scoring system consists of 8 parameters, and rate of accuracy varies between 78% and 82%.[8,9] Surgery is recommended for patients who receive score of 7 or more, and follow-up is suggested for those whose score is less than 7.[10] Ohmann scoring system also consists of total of 8 parameters. Patients whose score is less than 6.5 are evaluated as “low probability of appendicitis,” while score of between 6.5 and 12 is interpreted as “may have appendicitis” and followup is recommended. Score of 12 or more is seen as “most likely has appendicitis.”[11] Although Mannheim Peritonitis Index is a scoring system used to measure severity of peritonitis, there is no system specific to appendicitis that has generally proven to be valid for assessment of severity of intraoperative inflammation.[12] For 30

Table 2. Ohman scoring Parameter

Result

Tenderness in right lower quadrant

4.5 points

Rebound tenderness, contralateral

2.5 points

Dysuria

2.0 points

Constant pain

2.0 points

White blood cell >10000/mL

1.5 points

Patient aged >50 years

1.5 points

Local guarding

1.0 points

Shifting pain

1.0 points

Total <6.5

Acute appendicitis

unlikely Total 6.5–12

Finding unclear

(observation) Total >12

Acute appendicitis very likely (operation)

Table 3. Intraoperative severity scoring Major finding

Points

Negative appendectomy

0

Increased vascularity

1

Perforated appendix

2

Perforated appendix + phlegmonous appendicitis

3

the present study, simple grading system based on intraoperative macroscopic findings was used to evaluate inflammation.

Intraoperative severity scoring system awarded 0 points to patients with negative appendicitis, 1 point to patients with increase in vascularity only, 2 points to patients with perforated appendix, and 3 points to those with perforation and phlegmonous appendicitis.

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YÄąlmaz et al. Should Alvarado and Ohmann scores be real indicators for diagnosis of appendicitis and severity of inflammation?

Continuous and categorical data were analyzed using SPSS software (version 20.0; IBM Corp., Armonk, NY, USA). Descriptive statistics were expressed as numbers and percentages for categorical data, while average standard deviation and median with minimum-maximum were used to express continuous data, depending on normal distribution. As it was determined that Alvarado and Ohmann scores were not normally distributed (Kolmogorov-Smirnov test), these variables and ordinal variable of intraoperative severity score were compared using Kruskal-Wallis test. The possible factors determined in the previous analyses were used in multivariate analysis, and logistic regression analysis was performed to analyze independent estimators in prediction of appendicitis as determined by pathology results. Agreement between pathology results and results of USG was investigated using Kappa statistic correlation test. Cases in which type I errors were below 5% were accepted as statistically significant.

RESULTS Patients and Treatments A total of 105 patients were included in the study; 50.48% (n=53) were female and 49.52% (n=52) were male. Open appendectomy was performed in 41 cases (39.10%) and laparoscopic technique was used in 64 cases (60.90%). Median age was 31 years (min=16, max=76 years). Median age of female patients was 28 years, while that of males was 34 years.

Relationship between Alvarado and Ohmann scoring systems Moderate positive correlation was found between Alvarado score and Ohmann score (r=0.508; p<0.001). According to histopathological results, rate of accurate prediction of acute appendicitis diagnosis according to Alvarado scoring system was statistically significant (p=0.027), while rate of prediction using Ohmann score was not statistically significant (p=0.807).

When patient white blood cell (WBC) count was evaluated against scoring system results, difference for Alvarado score was statistically significant, but only weak positive correlation was observed (r=0.279; p=0.004). No statistical significance was observed for Ohmann scoring system based on WBC. (r=-0.021; p=0.834) (Figs. 1, 2).

Intraoperative Severity Score Link between 2 scores and the intraoperative severity score was determined to be weak; however, statistical significance Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

20000 White blood cell

Statistical Analysis

Scatterplot diagram of correlation between Alvarado score and white blood cell

15000 10000 5000 3

4

5

6 Alvarado

7

8

9

Figure 1. Relationship between Alvarado score and white blood cell count.

Scatterplot diagram of correlation between Ohmann score and white blood cell

20000 White blood cell

This study is an investigation of correlation between Alvarado and Ohmann scores and inflammation severity, conducted with the intent to contribute to the available statistics by identifying the contributions of these scoring systems to accurate diagnosis of acute appendicitis in terms of predictive sensitivity and evaluation of inflammation severity.

15000 10000 5000 5.0

7.5

10.0 12.5 Ohmann

15.0

17.5

Figure 2. Relationship between Ohmann score and white blood cell count.

was observed between Alvarado score and intraoperative severity score (r=0.30; p=0.002) Increase in Alvarado score was reflected in increase in intraoperative severity, but this link was weak. No statistical significance was found between Ohmann scoring system and intraoperative severity scoring (r=0.09; p=0.384). When patients were divided into 4 groups according to intraoperative severity scoring (0â&#x20AC;&#x201C;3), significant difference was observed based on Alvarado score (p=0.016).

Patients who had intraoperative severity score of 0, 1, or 2 had median Alvarado score of 7, and patients with intraoperative severity score of 3 had median Alvarado score of 8. No significant difference was observed between these 4 groups according to Ohmann score (p=0.457).

Accuracy of USG Sensitivity of USG based on histopathology results was 80.22% and specificity was 92.86%. USG consistency with final histopathology determination was 48.3%.

DISCUSSION Acute appendicitis is the most common cause of abdominal pain cases seen in emergency services and surgery clinics, but it can be difficult to make definitive diagnosis, particularly in premenopausal women and elderly patients.[13] Genitourinary diseases and gynecological disorders can have similar symp31

YÄąlmaz et al. Should Alvarado and Ohmann scores be real indicators for diagnosis of appendicitis and severity of inflammation?

toms and may be easily confused with appendicitis.[2,14] Delayed diagnosis and intervention in case of acute appendicitis can lead to clinical picture of perforation, sepsis, and increase in morbidity and mortality. On the other hand, cases of appendectomy performed with diagnosis of appendicitis and negative appendicitis result determined intraoperatively and histopathologically are reported to be at rate of 12% to 40% in the literature.[4,15] Many authors have reported that this rate is acceptable in order to decrease rate of perforation to minimal.[16] Though there are now advanced imaging methods, such as USG and CT, many diagnostic scoring systems have been developed to help decrease rate of negative appendectomies. The present study compared predictive diagnosis of acute appendicitis according to Alvarado and Ohmann scoring systems and correlation to severity of inflammation.

Alvarado score is simple test that is accepted as having high sensitivity and specificity.[9,17] Many studies have been performed affirming general validity for predicting acute appendicitis. Dumlu et al.[18] stated in a study they performed that as Alvarado score increased, inflammation also increased. In a study performed by Kariman et al.,[19] patients who presented with acute abdominal pain and had result greater than 7 on Alvarado scoring system were 93% more likely to be diagnosed with acute appendicitis, while patients with score below 7 had 26% chance of being diagnosed with acute appendicitis. Therefore, one may have great confidence in guidance of tool in instance of Alvarado score of 7 or more, but patients with lower score should be approached cautiously.

The Alvarado score rate of accurate prediction of diagnosis of acute appendicitis was determined to be statistically significant in our study (p=0.027). Moreover, statistical difference, though weak positive correlation, was observed between Alvarado scoring system and WBC (r=0.279; p=0.004). Significance of Alvarado scoring in prediction of acute appendicitis is consistent in the literature. We wanted to investigate correlation to degree of clinical severity of inflammation. We did not use Mannheim Peritonitis Index, a scoring system used for years in order to determine severity of peritonitis, as it is not specific to appendicitis.[12] In order to determine severity of intraoperative macroscopic clinical inflammation, we used a basic but useful intraoperative severity scoring system in this study. Other authors have created and published studies with similar, unique macroscopic severity scores in the literature. Sousa-Rodrigues et al.[6] used 4 inflammation groupings in their study. A scoring system was established to measure minimal changes: necrosis without perforation, perforation, perforation with limited peritonitis, and generalized peritonitis. No strong correlation was observed in their findings despite statistical significance. Dumlu et al.[18] classified patient groups in terms of severity of inflammation as having acute appendicitis, perforated appendix, perforation + phlegmonous appendicitis, or perforated appendix and negative appendectomy. Correlation was observed between severity of inflammation and Alvarado scoring system. In our study, 0 points were given to patients with negative appendicitis, 1 32

point to patients with increase in vascularity only, 2 points to patients with perforated appendix, and 3 points to those with perforated appendix and phlegmonous appendicitis. In our study, link between Alvarado score and intraoperative severity scoring was found to be weak, though there was statistical significance between them (r=0.30; p=0.002). In addition, when Alvarado score increased, intraoperative severity score was observed to increase. For this reason, according to the results of our study, we believe that Alvarado score may be a means to both predict appendicitis and estimate severity of inflammation.

Ohmann scoring system was developed by Ohmann et al.[20] and it is a useful and easy test employed in diagnosis of acute appendicitis. KÄąyak et al.[7] reported in their study that Ohmann scoring system may be more successful at excluding diagnosis of acute appendicitis. Zielke et al.[20] stated in a multicenter study that Ohmann score may be beneficial in predicting diagnosis of acute appendicitis. In our study, moderately positive correlation was found between Alvarado score and Ohmann score (r=0.50; p<0.001). However, diagnosis of appendicitis by Ohmann scoring system was not found to be statistically significant according to histopathological results (p=0.807). Another study also reported that Ohmann score was better at excluding acute appendicitis, rather than predicting it.[21] No statistical significance was observed in relationship to WBC. (r=-0.021; p=0.834). Weak link was found between WBC and intraoperative severity score, but no statistical significance was observed (r=0.09; p=0.384). We believe that the reason for this is higher specificity of Ohmann scoring system. Exclusion of diagnosis of acute appendicitis can be made for patients with low Ohmann score; however, higher score merits further examination. We believe that there is no correlation between Ohmann score and severity of inflammation.

Doubt regarding diagnosis of appendicitis remains, despite availability of several scoring systems. The easiest and most widely known of these, the Alvarado scoring system, provides a path to diagnosis of acute appendicitis. It can also provide clinician with idea about severity of inflammation. Ohmann scoring system is generally used for exclusion of acute appendicitis rather than prediction and it does not seem sufficiently sensitive. Nor does it give much idea about severity of inflammation. Further studies with wider context and more patients are needed.

No financial funding was provided for this study.

Conflict of interest: None declared.

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3. McKay R, Shepherd J. The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED. Am J Emerg Med 2007;25:489–93.

4. Toorenvliet BR, Wiersma F, Bakker RF, Merkus JW, Breslau PJ, Hamming JF. Routine ultrasound and limited computed tomography for the diagnosis of acute appendicitis. World J Surg 2010;34:2278–85.

5. Konan A, Hayran M, Kılıç YA, Karakoç D, Kaynaroğlu V. Scoring systems in the diagnosis of acute appendicitis in the elderly. Ulus Travma Acil Cerrahi Derg 2011;17:396–400.

6. Sousa-Rodrigues CF, Rocha AC, Rodrigues AK, Barbosa FT, Ramos FW, Valões SH. Correlation between the Alvarado Scale and the macroscopic aspect of the appendix in patients with appendicitis. Rev Col Bras Cir 2014;41:336–9.

7. Kıyak G, Korukluoğlu B, Özgün Y, Devay AÖ, Kuşdemir A. Evaluation of Ohmann and Eskelinen scores, leukocyte count and ultrasonography findings for diagnosis of appendicitis. Ulus Travma Acil Cerrahi Derg 2009;15:77–81.

8. Alvarado A. A practical score for the early diagnosis of acute appendicitis.

Ann Emerg Med 1986;15:557–64.

9. Nirajlal B, Gabriel R, Anand R, Sohil AK. Evaluation of Alvarado score in acute appendicitis: A prospective study. The Internet Journal of Surgery 2007;9.

10. İnan M, Tulay SH, Besim H, Karakaya J. The value of ultrasonography and its’ comparison with Alvarado scoring system in acute appendicitis.

Ulusal Cerrahi Dergisi 2011;27:149–53.

11. Ohmann C, Franke C, Yang Q, Margulies M, Chan M, van Elk PJ, et al. Diagnostic score for acute appendicitis. [Article in German] Chirurg 1995;66:135–41. [Abstract]

12. Bosscha K, Reijnders K, Hulstaert PF, Algra A, van der Werken C. Prognostic scoring systems to predict outcome in peritonitis and intra-abdominal sepsis. Br J Surg 1997;84:1532–4.

13. Stephens PL, Mazzucco JJ. Comparison of ultrasound and the Alvarado score for the diagnosis of acute appendicitis. Conn Med 1999;63:137– 40.

14. N N, Mohammed A, Shanbhag V, Ashfaque K, S A P. A Comparative Study of RIPASA Score and ALVARADO Score in the Diagnosis of Acute Appendicitis. J Clin Diagn Res 2014;8:NC03–5.

15. Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study.

Ann R Coll Surg Engl 1994;76:418–9.

16. Antevil JL, Rivera L, Langenberg BJ, Hahm G, Favata MA, Brown CV. Computed tomography-based clinical diagnostic pathway for acute appendicitis: prospective validation. J Am Coll Surg 2006;203:849–56.

17. Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation of the Alvarado score in acute appendicitis. J R Soc Med 1992;85:87–8.

18. Dumlu EG, Tokaç M, Bozkurt B, Yildirim MB, Ergin M, Yalçin A, et al.

Correlation between the serum and tissue levels of oxidative stress markers and the extent of inflammation in acute appendicitis. Clinics (Sao Paulo) 2014;69:677–82.

19. Kariman H, Shojaee M, Sabzghabaei A, Khatamian R, Derakhshanfar H, Hatamabadi H. Evaluation of the Alvarado score in acute abdominal pain. Ulus Travma Acil Cerrahi Derg 2014;20:86–90.

20. Zielke A, Sitter H, Rampp TA, Schäfer E, Hasse C, Lorenz W, et al.

Validation of a diagnostic scoring system (Ohmann score) in acute appendicitis. [Article in German] Chirurg 1999;70:777–84. [Abstract] 21. Zielke A, Sitter H, Rampp T, Bohrer T, Rothmund M. Clinical decisionmaking, ultrasonography, and scores for evaluation of suspected acute appendicitis. World J Surg 2001;25:578–84.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Alvarado ve Ohmann skorlamaları apandisit tanısında ve enflamasyonun şiddetinde gerçek yol gösterici olabilir mi?

Dr. Eyüp Murat Yılmaz,1 Dr. Mücahit Kapçı,2 Dr. Sebahattin Çelik,3 Dr. Berke Manoğlu,4 Dr. Mücahit Avcil,2 Dr. Erkan Karacan1 Adnan Menderes Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Aydın Adnan Menderes Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Aydın Van Yüzüncü Yıl Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Van 4 Aydın Devlet Hastanesi, Genel Cerrahi Kliniği, Aydın 1 2 3

AMAÇ: Akut apandisit cerrahi kliniklerinde görülen en yaygın karın ağrısı sebeplerinden birisidir. Tanı kolay konulabilse de özellikle premenopozal kadınlar ve yaşlılarda karıştırılabilmektedir. Bu sebeple mevcut bazı skorlama sistemlerinin hastalığın kolay tanı konabilmesine ve hastalığın enflamasyon şiddetine yol göstermesine katkısını araştırmak istedik.

GEREÇ VE YÖNTEM: Akut apandisit tanısı konan toplam 105 hasta çalışmaya dahil edildi. Alvarado ve Ohmann skorlamaları yapılan hastalara ultrasonografi yapılıp apendektomi uygulandı. Ameliyatta “intraoperatif şiddet skorlaması” uygulandı ve bu skorlamaların birbiriyle korelasyonu, Alvarado ve Ohmann skorlarının akut apandisiti ön görmede önemi araştırıldı.

BULGULAR: Alvarado skoru ile, Ohmann skoru arasında pozitif yönde orta derecede korelasyon bulundu (r=0.508, p<0.001). Histopatolojik sonuçlara göre Alvarado skorunun akut apandisit tanısını ön görme oranı istatistiksel olarak anlamlı iken (p=0.027) Ohmann skorlamasının ön görme oranı istatistiksel olarak anlamlı bulunmadı (p=0.807). Ameliyatta şiddet skoruna bakıldığında ise, her iki skorun da ameliyat sırasında yapılan skorlama ile bağıntısı zayıf bulunurken Alvarado skorlaması ile intraoperatif şiddet skorlaması arasında anlamlılık saptandı (r=0.30, p=0.002). Ohmann skorlaması ile intraoperatif şiddet skorlaması arasında anlamlılık saptanmadı (r=0.09, p=0.384).

TARTIŞMA: Alvarado skorlaması akut apandisiti ön görme ve enflamasyon şiddeti hakkında fikir verebilirken, Ohmann skorlaması daha çok akut apandisiti dışlama konusunda fikir vermektedir.

Anahtar sözcükler: Alvarado; apandisit; enflamasyon; Ohmann.

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ORIG I N A L A R T IC L E

Percutaneous cholecystostomy: A curative treatment modality forelderly & high ASA score acute cholecystitis patients Hüseyin Kerem Tolan, M.D.,1 Aslıhan Semiz Oysu, M.D.,2 Fatih Başak, M.D.,1 İbrahim Atak, M.D.,1 Mustafa Özbağrıaçık, M.D.,1 Adnan Özpek, M.D.,1 Mert Kaskal, M.D.,1 Fikret Ezberci, M.D.,1 Gürhan Baş, M.D.1 1

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

2

Department of Radiology, Ümraniye Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: Acute cholecystitis (AC) is a common emergency seen by general surgeons. Optimal treatment is laparoscopic cholecystectomy (LC); however, in cases where surgery cannot be performed due to high risk of morbidity and mortality, such as in elderly patients with comorbid diseases, other treatment modalities may be used. Percutaneous cholecystostomy (PC) is one alternative method to treat AC. PC can be used to provide drainage of the gall bladder and control infection. Subsequently, interval cholecystectomy can be performed when there are better conditions. Presently described is experience and results with PC in high risk, elderly patients with AC. METHODS: Medical records of all consecutive patients who underwent PC between January 2011 and January 2014 were identified.

Tokyo Guidelines were used for definitive diagnosis and severity assessment of AC. Senior surgeon elected to perform PC based on higher risk-benefit ratio due to comorbidity, age, or duration of symptoms. All PC procedures were performed by the same interventional radiologist under local anesthesia with ultrasonographic guidance.

RESULTS: Total of 40 PC procedures were performed during the study period. Of those, 22 (55%) were male and 18 were (45%) were female, with median age of 70.5 years (range: 52–87 years). All of the patients had American Society of Anesthesiologists classification of either 3 or 4. Success rate of PC was 100% with complication rate of 2.5% (n=1). One patient was operated on shortly after PC procedure due to bile peritonitis complication. PC drains were kept in place for 6 weeks. Total of 16 patients (40%) had surgery following removal of PC drain. In 3 (18.8%) cases, conversion from LC was required. Remaining 23 (57.5%) patients did not have subsequent operation after drain removal. No disease recurrence was observed in follow-up.

CONCLUSION: When elderly patients present in emergency setting with AC and LC cannot be performed due to comorbid disease or poor general condition, PC can be performed safely. After removal of PC drain, LC may be performed with acceptable conversion rate of 18.8%.

Keywords: Acute cholecystitis; ASA score; cholecystostomy; elderly.

INTRODUCTION Acute cholecystitis (AC) is a disease seen frequently in genAddress for correspondence: Hüseyin Kerem Tolan, M.D. Ümraniye Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey Tel: +90 216 - 565 15 66 E-mail: mdkeremtolan@gmail.com Qucik Response Code

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eral surgery practice. It is a surgical disease treated by cholecystectomy whenever possible. In young and healthy patients, laparoscopic cholecystectomy (LC) has become optimal treatment procedure.[1] Cholecystectomy procedure has 10% operative mortality even in low operative risk patients. This rate increases 3-fold with high operative risk, elderly (65 years and older) patients.[2,3] LC is preferred surgical technique for AC, but rate of conversion from LC to open cholecystectomy is high (11% to 28%)[4] compared with elective LC (5%)[5] in general population.

Percutaneous cholecystostomy (PC) has been described as Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Tolan et al. Percutaneous cholecystostomy

safe alternative treatment option for AC in elderly or critically ill patients. A Cochrane Review published with a small, retrospective patient population analyzed the safety and efficacy of PC in elderly and critically ill patients. PC seemed promising according to results of this review, with success rate of 91% and procedure-related mortality of 0.4%. Overall mortality was found to be around 12.7% and overall complication rate was approximately 6.2%.[6] Presently described is a retrospective review and follow-up of prospectively collected data for patients who underwent PC for acute calculous cholecystitis in our hospital between January 2011 and January 2014.

MATERIALS AND METHODS Medical records of all consecutive patients who underwent PC between January 2011 and January 2014 were identified.

Study was reviewed and approved by institutional review board at Umraniye Training and Research Hospital. Tokyo Guidelines were criteria used for definitive diagnosis and severity assessment of AC. On the basis of these criteria, definitive diagnosis of AC requires at least 1 local sign of inflammation in the right upper quadrant combined with at least 1 systemic sign of inflammation. If these clinical signs are present and AC is suspected, predefined set of radiological (ultrasonographic, computed tomographic scan, or hepatobiliary scan) findings suffices to establish diagnosis of AC.[7] All patients were hospitalized, nothing was given per oral, and antibiotic (third-generation cephalosporin) was administered. After sufficient resuscitation, anesthesiology and other consultations related to comorbid diseases were held. The American Society of Anaesthesiology (ASA) score of the patients was calculated and reported on anesthesiology preoperative evaluation forms.[8]

PC was performed due to either comorbidity, age, or duration of symptoms. Decision to perform PC procedure was made by a senior surgeon based on risk-benefit ratio. All PC procedures were performed by the same interventional radiologist under local anesthesia with ultrasonographic guidance using 8-F pigtail catheter and Seldinger technique for transhepatic cholecystostomy.

Records of study participants were subsequently reviewed for baseline patient characteristics, baseline procedural factors, and procedural outcomes. Baseline patient characteristics were those recorded at time of presentation for AC, before initiation of antibiotics, and included age and ASA class. Procedural factors included type of treatment for AC (PC alone, PC with interval LC, or LC alone), and severity of AC (Grade I: mild, Grade II: moderate, and Grade III: severe) as per Tokyo criteria for assessment of AC. Interval LC was defined as LC performed 6 weeks after PC drainage. Drain was checked by the radiologist via ultrasound and then removed if AC had healed. Patients were informed about LC procedure and possible risks of disease recurrence after drain removal. All patients were advised to have interval LC because it is known as the gold standard of treatment for AC at present. Some patients who had PC agreed to have interval LC operation, but some declined, acknowledging awareness of all risk factors with written consent form.

All records were updated and patients were followed-up.

RESULTS Total of 40 PC procedures were performed at Umraniye Training and Research Hospital during the study period. Of those, 22 (55%) were male and 18 were (45%) were female, with median age of 70.5 years (range: 52â&#x20AC;&#x201C;87 years). All of the patients who had PC performed had ASA classification of 3 or 4.

Table 1. Tokyo Guidelines for assessment Tokyo guidelines diagnostic criteria of AC Clinical manifestations Local symptoms & signs

Murphyâ&#x20AC;&#x2122;s

Right upper quadrant (RUQ) tenderness and/or pain

RUQ palpable mass

Systemic signs

Fever

Leucocytosis

High C-reactive protein level

Imaging findings

Confirmation with ultrasound (US) and/or sintigraphy

Diagnosis Presence of; one local sign or symptom, one systemic sign and confirmation by imaging findings

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Tolan et al. Percutaneous cholecystostomy

Table 2. American Society of Anaesthesiology risk index American Society of Anaesthesiology (ASA) Risk Index Classification Classification

Physical condition of the patient

ASA 1

Normal, healthy

ASA 2

Mild systemic disease with out functional limitation

ASA 3

Severe systemic disease with functional limitation

ASA 4

Life-threatining severe systemic disease

ASA 5

Not expected to survive operation

ASA 6

Brain death

ASA E

Emergency surgery

(www.asahq.org)

Success rate of PC was 100%, and complication rate was 2.5 % (n=1). One of 40 patients (2.5%) was operated on shortly after PC due to bile peritonitis that developed as complication of percutaneous intervention. There was no procedurerelated mortality.

PC drains were kept in place for 6 weeks. After 6 weeks, drains were checked and then removed by the radiologist if AC had healed. All patients were followed-up.

Total of 16 (40%) of 40 patients underwent subsequent surgery after removal of PC drain. LC was performed in 13 (81.2%) cases. Three (18.8%) patients had conversion to open surgery during LC due to perioperative technical difficulties (difficulty in exposing Calot’s Triangle, intra-abdominal adhesions due to inflammation caused by drain, etc.).

Twenty-three (57.5%) of the 40 patients whose drain was removed after 6 weeks did not have operation. After receiving detailed information, these 23 patients either did not want to undertake risk of LC procedure or risks related to general anesthesia. They were taken under follow-up for median of 17.4 months. None of these 23 (57.5%) patients were admitted to any hospital for recurrent biliary disease or symptoms, and no recurrence of AC was seen during follow-up period.

DISCUSSION In the literature, mortality rate for elderly patients who have LC is higher than mortality rate seen in the younger patients.

[2,3] Conversion to open cholecystectomy rate is also higher[4,5] in these patients. In this group of patients, PC can be used as treatment of choice and may be an alternative to surgery in some selected cases.

In the present study, we followed patients who presented at our clinic with AC and were treated with PC. Our success rate in performing PC was 100%. There was 1 complication (2.5%) after PC in which the patient had bile peritonitis diagnosed in the ward during follow-up period. General medical 36

condition of our PC patients reflects comorbidities seen in elderly population. Patients had comparable mean age (70.5 years) to those reported in the literature (68.1 years).[6] Sixteen (40%) of 40 patients underwent LC operation 6 weeks after removal of PC drain. In our PC group, rate of conversion from laparoscopic to open surgery during interval LC procedure was 18.8% (3 of 16), which is similar to what has been reported in the literature.[9,10] Median follow-up period for the 23 patients not operated on was 17.4 months.

A Cochrane Review of small number of patients in retrospective patient population analyzed the safety and efficacy of PC in elderly and critically ill patients. PC seemed promising, with success rate of 91% and procedure-related mortality rate of 0.4%.[6] There are other, similar randomized controlled studies in the literature. One conducted by radiologists analyzing PC as treatment modality for AC reported that only 1 (5.2%) of 19 patients had recurrent biliary symptoms. Another study was performed at Seoul National University Hospital in South Korea between 2000 and 2011 with 183 patients, 60 of whom were reviewed retrospectively. Recurrent AC was observed in 7 high-risk patients (11.7%). The remaining patients (88.3%) were managed successfully with PC alone.[11] Wang et al. reported 1-year recurrence rate of 9.2% in 184 cases in which PC was performed. It was observed that in cases with complicated AC or with elevated white blood cell count (≥18 000/μL), recurrence was much more common.

[12] In another study, performed by Popowicz et al., which compared 71 cases from 2 different time periods (2003 and 2008), recurrence rate of AC was reported to be 28%.[13] Also, Yeo et al. reported readmission rate of 6.8% in their study consisting of 103 cases. LC was performed in 81% and conversion rate was 15% in that study.[14] In a retrospective study comprising 53 PC patients from between 2000 and 2010 with median age of 74 years and ASA Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

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score of 3 or 4, 18 patients underwent cholecystectomy after PC. Six (33%) of those 18 patients underwent LC and remaining 12 (67%) patients required conversion to open cholecystectomy.[15] Conversion to open surgery in our study was necessary in 3 (18.8%) of 16 LC patients due to perioperative technical difficulties. Majority of the patients, 13 of 16 (81.2%), were successfully operated on laparoscopically.

In reports that have favored PC as definitive treatment modality, such as study of Bala et al. conducted with 257 PC patients with age ≥75 from 10-year period, high alkaline phosphatase level and history of coronary artery disease were found to be predictors of PC as definitive treatment modality in those high-risk AC cases.[16] Furthermore, PC was reported to have lower complication rate, and 96% of cases had symptomatic relief after the procedure in a retrospective study conducted with 104 patients. PC alone was the only definitive treatment for 70% of the cases.[17] These results are similar to those of our study. Twenty-three (57.5%) patients who did not have further surgery did not have any recurrent disease or symptoms during follow-up period.

As a result, it was determined that PC can be used as lifesaving procedure for severely ill, high ASA score patients with comorbidities when early cholecystectomy cannot be performed, which is consistent with the literature. After removal of PC drain, patients may safely be followed and may not experience further symptoms, recurrence of AC, or have need for interval LC surgery.[17,18]

Conclusion In emergency settings when elderly patients present with AC, surgery may not be possible immediately due to accompanying comorbid diseases or poor general condition. PC can be easily and safely performed in all patient groups under local anesthesia with low complication rate and can be treatment of choice. In our series, conversion rate of 18.8% in LC procedure following removal of PC drain was determined to be reasonable rate and was similar to that in the current literature. The 57.5% of patients who were followed nonoperatively did not have recurrent disease or symptoms. PC alone can be curative treatment for AC without further need for additional surgery in future. Longer follow-up period study and prospective randomized trials would contribute to further analysis of end results of PC procedure in high risk elderly AC patients.

Conflict of interest: None declared.

REFERENCES 1. Keus F, Gooszen HG, van Laarhoven CJ. Open, small-incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis.

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An overview of Cochrane Hepato-Biliary Group reviews. Cochrane Database Syst Rev 2010;1:CD008318.

2. Glenn F. Cholecystectomy in the high-risk patient with biliary tract disease. Ann Surg 1977;185:185–91.

3. Edlund G, Ljungdahl M. Acute cholecystitis in the elderly. Am J Surg 1990;159:414–6.

4. Lai PB, Kwong KH, Leung KL, Kwok SP, Chan AC, Chung SC, et al.

Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 1998;85:764–7.

5. Alponat A, Kum CK, Koh BC, Rajnakova A, Goh PM. Predictive factors for conversion of laparoscopic cholecystectomy. World J Surg 1997;21:629–33.

6. Winbladh A, Gullstrand P, Svanvik J, Sandström P. Systematic review of cholecystostomy as a treatment option in acute cholecystitis. HPB (Oxford) 2009;11:183–93.

7. Hirota M, Takada T, Kawarada Y, Nimura Y, Miura F, Hirata K, et al.

Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:78–82.

8. Owens WD, Felts JA, Spitznagel EL Jr. ASA physical status classifications: a study of consistency of ratings. Anesthesiology 1978;49:239–43.

9. Berber E, Engle KL, String A, Garland AM, Chang G, Macho J, et al.

Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis. Arch Surg 2000;135:341–6.

10. Patterson EJ, McLoughlin RF, Mathieson JR, Cooperberg PL, MacFarlane JK. An alternative approach to acute cholecystitis. Percutaneous cholecystostomy and interval laparoscopic cholecystectomy. Surg Endosc 1996;10:1185–8.

11. Chang YR, Ahn YJ, Jang JY, Kang MJ, Kwon W, Jung WH, et al. Percutaneous cholecystostomy for acute cholecystitis in patients with high comorbidity and re-evaluation of treatment efficacy. Surgery 2014;155:615–22.

12. Wang CH, Wu CY, Yang JC, Lien WC, Wang HP, Liu KL, et al. Long-Term Outcomes of Patients with Acute Cholecystitis after Successful Percutaneous Cholecystostomy Treatment and the Risk Factors for Recurrence: A Decade Experience at a Single Center. PLoS One 2016;11:e0148017.

13. Popowicz A, Lundell L, Gerber P, Gustafsson U, Pieniowski E, Sinabulya H, et al. Cholecystostomy as Bridge to Surgery and as Definitive Treatment or Acute Cholecystectomy in Patients with Acute Cholecystitis.

Gastroenterol Res Pract 2016;2016:3672416.

14. Yeo CS, Tay VW, Low JK, Woon WW, Punamiya SJ, Shelat VG. Outcomes of percutaneous cholecystostomy and predictors of eventual cholecystectomy. J Hepatobiliary Pancreat Sci 2016;23:65–73.

15. Sanjay P, Mittapalli D, Marioud A, White RD, Ram R, Alijani A. Clinical outcomes of a percutaneous cholecystostomy for acute cholecystitis: a multicentre analysis. HPB (Oxford) 2013;15:511–6.

16. Bala M, Mizrahi I, Mazeh H, Yuval J, Eid A, Almogy G. Percutaneous cholecystostomy is safe and effective option for acute calculous cholecystitis in select group of high-risk patients. Eur J Trauma Emerg Surg 2015.

17. Viste A, Jensen D, Angelsen J, Hoem D. Percutaneous cholecystostomy in acute cholecystitis; a retrospective analysis of a large series of 104 patients. BMC Surg 2015;15:17.

18. Chok KS, Chu FS, Cheung TT, Lam VW, Yuen WK, Ng KK, et al. Results of percutaneous transhepatic cholecystostomy for high surgical risk patients with acute cholecystitis. ANZ J Surg 2010;80:280–3.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Perkütan kolesistostomi: Yaşlı ve yüksek ASA skorlu akut kolesistitli hastalarda küratif tedavi yöntemi Dr. Hüseyin Kerem Tolan,1 Dr. Aslıhan Semiz Oysu,2 Dr. Fatih Başak,1 Dr. İbrahim Atak,1 Dr. Mustafa Özbağrıaçık,1 Dr. Adnan Özpek,1 Dr. Mert Kaskal,1 Dr. Fikret Ezberci,1 Dr. Gürhan Baş1 1 2

Ümraniye Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul Ümraniye Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği, İstanbul

AMAÇ: Akut kolesistit (AC) genel cerrahların sık karşılaştığı acillerdendir. En uygun tedavi laparoskopik kolesistektomidir (LK); ancak yüksek morbidite ve mortalite riski nedeniyle cerrahi uygulanamayan hastalarda diğer tedavi yöntemleri uygulanabilir. Perkütan kolesistostomi (PK) bu alternatif yöntemlerden biridir. Yaşlı ve komorbid hastalıkları olan hastalarda acil cerrahi yapılamadığı durumlarda bu yöntem kullanılabilinir. Safra kesesinin drenajı ile enfeksiyon kontrol altına alınmaktadır. Perkütan kolesistostomi sonrasında, kolesistektomi daha uygun ve elektif koşullarda yapılabilir. Bu çalışmada yüksek riskli, yaşlı akut kolesistiti olan hastalardaki perkütan kolesistostomi deneyimlerimiz sunuldu.

GEREÇ VE YÖNTEM: Ocak 2011 ve ocak 2014 arasında hastanemizde PK uygulanmış tüm hastaların tıbbi kayıtları incelendi. Çalışmamıza hastanemiz kurulu tarafından onay verildi. Akut kolesistit tanısı ve derecelendirmesi için Tokyo ölçütleri kullanıldı. Perkütan kolesistostomi uygulama nedenleri; komorbiditeler, yaş veya semptomların süresi idi. Hastalara PK uygulama kararı kıdemli cerrah tarafından kar-zarar oranına bakılarak verildi. Tüm PK uygulamaları aynı girişimsel radyolog tarafından lokal anestezi ile ultrasonografi eşliğinde yapıldı.

BULGULAR: Toplam 40 PK işlemi belirtilen çalışma süresinde hastanemizde yapıldı. Hastaların 22’si (55%) erkek ve 18’i (45%) kadın; ortalama yaş 70.5 (dağılım, 52–87 yıl) idi. Perkütan kolesistostomi uygulanan hastaların tümünün ASA değeri 3 veya 4 olarak değerlendirildi. Perkütan kolesistostomi uygulamasının başarı oranı %100 ve komplikasyon oranı da 2.5% (n=1) idi. Drenler altı hafta yerinde tutuldu. Toplam 40 hastanın 16’sı (40%) takiplerinde dren çekildikten sonra ameliyat edildi. Ameliyatlardan sadece üçünde (18.8%) laparoskopiden açığa dönüldü. Kalan 23 (%57.5) hasta ise drenlerin çekilmesinden sonara ameliyat edilmeden takip edildi ve takiplerinde herhangi bir hastalık nüksü olmadı.

TARTIŞMA: Acil koşullarda AC ile gelen yaşlı, eşlik eden hastalıkları olan ve kötü genel durumu olan hastalarda LK yapılamadığında PK güvenli bir şekilde uygulanabilir. Drenin çekilmesi sonrasında uygun olan hastalarda LK kabul edilebilir %18.8 açığa dönme oranları ile elektif koşullarda yapılabilir.

Anahtar sözcükler: Akut kolesistit, ASA skoru; kolesistostomi; yaşlı.

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doi: 10.5505/tjtes.2016.26053

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ORIG I N A L A R T IC L E

Evaluation of risk factors and development of acute kidney injury in aneurysmal subarachnoid hemorrhage, head injury, and severe sepsis/septic shock patients during ICU treatment Ceren Kamar, M.D.,1 Achmet Ali, M.D.,1 Demet Altun, M.D.,1 Günseli Orhun, M.D.,1 Akın Sabancı, M.D.,2 Altay Sencer, M.D.,1 İbrahim Özkan Akıncı, M.D.1 1

Department of Anesthesiology, İstanbul University İstanbul Faculty of Medicine, İstanbul-Turkey

2

Department of Neurosurgery, İstanbul University İstanbul Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: There are few studies examining development of acute kidney injury (AKI) in the various types of patients in intensive care units (ICUs). Presently described is evaluation of risk factors and development of AKI in different groups of ICU patients.

METHODS: Present study was performed in 3 different ICUs. Development of AKI was measured using Acute Kidney Injury Network (AKIN) classification system. Total of 300 patients who were treated in trauma, neurosurgery, or general ICU departments (due to head injury, aneurysmal subarachnoid hemorrhage [aSAH], or severe sepsis/septic shock, respectively) were assessed for incidence, risk factors, and development of AKI. RESULTS: AKI did not develop in aSAH patients when evaluated based on serum creatinine level; however, it was observed in 5% of aSAH patients according to volume adjusted creatinine (VACr) level. AKI developed in 76% of sepsis group, and in 20% of head injury group, based on AKIN classification, according to both serum and VACr levels. Incidence of AKI was significantly higher in sepsis group (p<0.001). Only use of vasopressor was significantly related to AKI development in sepsis and head injury groups. Mortality rate was 8%, 22%, and 42% in aSAH, head injury, and sepsis groups, respectively. AKI development and vasopressor use were significantly related to mortality in sepsis group.

CONCLUSION: Despite similar characteristics and risk factors, there were fewer instances of AKI in aSAH group. Hypertension or hydration therapy used to treat vasospasm and polyuria due to cerebral salt-wasting syndrome may prevent aSAH patients from developing AKI. Keywords: Head trauma; renal insufficiency; sepsis; subarachnoid hemorrhage.

INTRODUCTION Acute kidney injury (AKI) is common in intensive care units (ICUs) and adversely affects patient morbidity and mortality.[1] Despite this fact, there is no consensus on definition of AKI; the condition includes broad clinical spectrum from Address for correspondence: İbrahim Özkan Akıncı, M.D. İstanbul Üniversitesi İstanbul Tıp Fakültesi, Anesteziyoloji Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 414 12 00 / 32553 E-mail: iozkana@gmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):39–45 doi: 10.5505/tjtes.2016.83451 Copyright 2017 TJTES

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modest changes in creatinine (Cr) level to decreasing glomerular filtration rate, decreased urine output, and eventually, anuria. Currently, 2 common tools defining AKI are the most routinely used assessment systems: risk, damage, failure, loss, and end-stage (RIFLE) classification and the Acute Kidney Injury Network (AKIN) classification.[1,2] Incidence of AKI in ICU patients is approximately 67% and this condition directly affects their mortality.[3] Risk factors for AKI are sepsis, high disease severity scores (Acute Physiology and Chronic Health Evaluation [APACHE] II and Sequential Organ Failure Assessment [SOFA]), vasopressor use, pulmonary disease, and malignancy. Despite large multicenter studies performed on the general population in ICUs, only limited number of studies have evaluated specific clinical situations.[1,4,5] 39

Kamar et al. Kidney injury in neurosurgery

Sepsis is one of the most common medical problems in ICUs and is the most important risk factor for developing AKI. Therefore, many studies have assessed development of AKI. Incidence of various degrees of renal injury in these studies was as follows: 19% in patients with mild sepsis, 23% in severe sepsis patients, and 51% in patients with septic shock (serious enough to require dialysis for 15% to 20% of the patients with sepsis).[6,7] Development of AKI and risk factors for AKI can vary in different clinical situations, such as head injury or subarachnoid hemorrhage, due to differences in treatment approach. Limited data are available regarding development of AKI in ICU patients with aneurysmal subarachnoid hemorrhage (aSAH). Search revealed only 1 study on this subject, which identified development of AKI in 0.8% to 7% of aSAH patients. However, evaluation criteria for diagnosing AKI were different at each center in this multicenter study.[8] There are also few studies on non-neurological complications after traumatic brain injury; incidence of AKI was reported to be 23%.[9] Although many studies have examined development of AKI in all ICU patients, very few investigations have targeted specific ICU patient groups, such as those with subarachnoid hemorrhage, head injury, severe sepsis, and septic shock. Therefore, present study was conducted to compare 3 different patient groups (head injury, aSAH, and severe sepsis/septic shock) at 3 different ICUs for risk factors and development of AKI.

MATERIALS AND METHODS This study was performed in neurosurgery ICU, emergency surgery and traumatology ICU, and adult general ICU after approval was obtained from the Istanbul Medical Faculty ethics committee. Patients were enrolled in the study after providing written, informed consent. This study began on January 1, 2010. First 100 patients who had the following diagnoses from each ICU were evaluated: aSAH in neurosurgery ICU, head injury in emergency surgery and traumatology ICU, and sepsis in adult general ICU. Selection criteria for patients were as follows: ICU stay of more than 48 hours, age over 18 years, absence of chronic renal failure, and lack of pre-existing renal transplantation. Severe sepsis and septic shock were diagnosed based on the American College of Chest Physicians/ Society of Critical Care Medicine consensus criteria.[10] Patients were monitored daily for development of renal failure based on AKIN classification criteria.[2] Follow-up period was limited to 30 days.

Groups were as follows: aSAH patients in neurosurgery ICU (aSAH group), severe sepsis and septic shock patients in adult general ICU (sepsis group), and head injury patients in emergency surgery and traumatology ICU (head injury group).

Age, gender, and additional diseases that could contribute to development of acute or chronic renal failure were recorded for each patient enrolled in the study. All patients were also evaluated on admission to ICU with APACHE II score using 40

worst values of first day to evaluate disease severity. Common parameters of presence of infection, requirement for mechanical ventilation support, use of antibiotic therapy, use of vasopressor support, use of steroids or insulin, or presence of hyponatremia or hypernatremia were recorded. Degree of renal failure was determined based on AKIN classification.[2] Patients were evaluated every day, and total urine output (in 24 hours) and/or daily Cr value was recorded. Data of each patient, including use of renal replacement therapy, length of ICU stay, and survival information, were recorded at end of ICU stay. Volume adjusted creatinine (VACr) level for all patient groups was calculated using the following formula described by Lui et al.: VACr = SCr x (1 + cumulative net fluid balance / total body water), in which SCr is measured serum creatinine and total body water is 0.6 x patient weight on ICU admission. SCr, VACr level, and urine output were used to determine AKI level in all patients.[11] Hydration and hypertension (2H) therapy were used to treat vasospasm in aSAH group, in contrast to other groups. Criteria for initiating 2H therapy included at least 2 minor signs of vasospasm (e.g., headache, agitation, rising white blood cell count without infection, development of new motor loss, decrease of more than 2 points on Glasgow Coma Scale [GCS]).

For 2H therapy, at least 3500 mL/day intravenous fluid was used for hydration, and norepinephrine was used to induce hypertension (systolic blood pressure >160 mmHg). Clinical vasospasm was diagnosed with existence of 3 symptoms, such as headache, development of new neurological deficit, or decrease of more than 2 points on GCS. All the data were evaluated using SPSS 16.0 statistical program for Windows (IBM Corp., Armonk, NY, USA). Data were expressed as mean valueÂąstandard deviation, and categorical variables were expressed as percentage of number of cases. P value <0.05 was considered significant. Chi-square test, Mann-Whitney U test and multivariate logistic regression analysis (to determine risk factors for AKI development and mortality) were used to determine clinically and statistically significant variables that were predeterminants of acute renal failure and mortality.

RESULTS Total of 300 patients were evaluated in this study. Demographic data of the groups and morbidity and mortality rates are displayed in Table 1. Sepsis group exhibited highest mortality; aSAH group mortality rate was lower than that of head injury group (Table 1).

Development of AKI VACr level was calculated for all groups, but result only differed from SCr level in aSAH group. Although there was no AKI in aSAH group according to SCr level, there were 5 (5%) patients with AKI based on VACr level. AKI developed Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

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Table 1. Demographic data and clinical characteristics of the 3 groups

aSAH group Sepsis group Head injury group (n=100) (n=100) (n=100)

Female/Male

64/36 50/50

Age (years)

p

28/72 <0.001

51.0±11.3

58.2±17.0

35.7±14.8

0.006

Hypertension (%)

64

54

14

<0.0001

Diabetes mellitus (%)

26

36

8

0.004

Ischemic heart disease (%)

18

28

4

0.001

Mortality

8

42

24

<0.001

aSAH: Aneurismal subarachnoid hemorrhage.

Table 2. Classification of acute kidney injury based on AKIN classification

Acute Kidney Injury Network

No.

aSAH group

Sepsis group

Head injury group

n % n % n % 100 100 95 95* 24 24 80 80

Stage 1

–

–

5

5* 14 14 12 12

Stage 2

–

–

–

–

30

30

4

4

Stage 3

–

–

–

–

32

32

4

4

Total – – 5 5* 76 76 20 20 aSAH: Aneurismal subarachnoid hemorrhage. *: According to volume adjusted creatinine level.

in 76 patients (76%) in sepsis group, and also developed in 20 patients (20%) in head injury group, based on AKIN classification. AKI incidence in aSAH, head injury, and sepsis groups is provided in Table 2; difference between groups was statistically significant (p<0.01). Cr value at admission and discharge from ICU were compared between groups; Cr value was similar for all groups at admission (p=0.68).

However, upon last measurement before discharge, average Cr value was significantly higher in sepsis group than in the other 2 groups according to both SCr and VACr levels (p<0.001). Furthermore, average Cr value on discharge was significantly higher in head injury group than in aSAH group (p=0.006). Blood urea nitrogen (BUN) value at admission to ICU was statistically higher in sepsis group than in the other groups (p<0.001). Mean BUN value was lowest in aSAH group at discharge from ICU, and it was highest in sepsis group (p<0.001) (Table 3). Cr value decreased from admission to discharge only in aSAH group; in this group, 64% of the patients received 2H therapy for vasospasm. Moreover, in aSAH group, 38% of patients developed sodium imbalance, 32% of the patients exhibited cerebral salt-wasting syndrome or syndrome of inappropriate antidiuretic hormone secretion-induced hyponatremia (<130 mEq/L), and 6% of the patients had hypernatremia with diabetes insipidus (>155 mEq/L).

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Evaluation of risk factors associated with development of AKI Illness Severity Score: Sepsis group average APACHE II score was significantly higher than that of the other 2 groups (p<0.001), and head injury group average APACHE II score was higher than that of aSAH group (p<0.001) (Table 4).

Age: Age of sepsis and aSAH groups was significantly higher than age of head injury group (p<0.0001), but there was no significant difference between age of sepsis and aSAH groups (p=0.41) (Table 1).

ICU length of stay: Length of stay in ICU was significantly higher in sepsis group than in head injury group (p<0.001); there was no significant difference between sepsis and aSAH groups (Table 4).

Vasopressor use: Use of vasopressor was significantly higher in sepsis group than other groups (p<0.001), and it was similar between head injury and aSAH groups (p=0.503) (Table 4).

ICU infections: As expected, number of infections in sepsis group was significantly higher than in head injury and aSAH groups (p<0.001); there was no significant difference in in41

Kamar et al. Kidney injury in neurosurgery

Table 3. Creatinine and blood urea nitrogen levels of the groups at admission and discharge

aSAH group

Sepsis group

Head injury group

p

Creatinine (mg/dL) at admission

0.98±0.23

1.20±0.36

0.96±0.25

0.68

BUN at admission

14.64±3.61

29.48±17.64

17.38±9.69

<0.001

Creatinine (mg/dL) at discharge

0.47±0.16/0.52±0.17* 1.26±0.46

Blood urea nitrogen at discharge

0.69±0.35 <0.001

10.28±2.99

30.64±10.05

16.98±7.49

<0.001

Renal support (%)

0

38

6

<0.001

Sodium imbalance (%)

38

0

8

–

aSAH: Aneurismal subarachnoid hemorrhage, *: Volume adjusted creatinine level.

Table 4. Evaluation of factors that could be related to survival and renal failure in the groups

aSAH group

Sepsis group

Head injury group

p

APACHE II (Mean±SD)

6.7±2.3

19.1±5.5

12.3±3.5

<0.001

ICU length of stay (days), (Mean±SD)

14.2±6.8

15.7±5.2

10.5±5.9

<0.001

Vasopressor use, n (%)

9 (18)

31(62)

18 (36)

<0.001

Infection, n (%)

13 (26)

50 (100)

18 (36)

<0.001

Duration of antibiotic use (day), (Mean±SD)

2.8±5.2

13.9±4.2

3.6±5.3

<0.001

Insulin use (%)

38

58

34

0.035

Steroid use (%)

100

44

40

<0.001

Mechanical ventilation (%)

60

80

86

0.004

APACHE II: Acute physiology and chronic health evaluation score, ICU: Intensive care unit, aSAH: Aneurismal subarachnoid hemorrhage.

cidence of infection between head injury and aSAH groups (p=0.387) (Table 4).

Antibiotic use: Average duration of antibiotic use was significantly higher in sepsis group than in other groups (p<0.001), but was similar between aSAH and head injury group (p=0.738) (Table 4).

Insulin use: There was greater use of insulin in sepsis group; however, there was no statistically significant difference between groups (p=0.035) (Table 4).

Steroid use: Steroids were used to treat all the patients in aSAH group, and usage was statistically significant compared with other 2 groups (p<0.001). However, use of steroids was similar between sepsis and head injury groups (p=0.875) (Table 4).

Mechanical ventilation: Requirement for mechanical ventilation in sepsis and head injury groups was similar (p=0.454), and it was significantly higher in these groups compared with aSAH group (p=0.004) (Table 4).

Evaluation of Mortality According To AKI Within sepsis group, mortality rate was significantly higher in 42

AKI patients than in those patients who had no AKI (p=0.018).

However, there was no difference in mortality between AKI and non-AKI patients in head injury group (p=0.823). While aSAH group mortality rate was 8%, there was no mortality in AKI group. Sepsis group mortality rate based on AKIN classification was 42.9% (n=6) in Stage 1, 26.7% (n=8) in Stage 2, and 75% (n=24) in Stage 3. Mortality rate was higher in sepsis group than in other 2 groups. Mortality rate in head injury group was 24% based on AKIN classification system. Mortality rate was 33.3% (n=4) in Stage 1, 50% (n=2) in Stage 2, and 50% (n=2) in Stage 3.

Multivariate logistic regression analysis was conducted to evaluate possible factors that could have affected mortality rate. No factor affecting patient mortality was found for aSAH group. In sepsis group, development of AKI (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 0.86–2.92; p=0.022) and vasopressor use (OR: 1.21, 95% CI: 1.04–1.38; p=0.009) were determined to have effect on mortality. In head trauma group, neither of these factors affected mortality. However, when all 300 patients were collectively evaluated, vasopressor use (OR: 2.21, 95% CI: 0.45–4.01; p=0.012) and requirement for mechanical ventilation (OR: 1.53, 95% CI: 0.90–2.15; p=0.013) increased mortality.

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Detecting Risk Factors For Development of AKI Multivariate logistic analysis for risk factors that might cause AKI was performed for all groups. There was no significant risk factor for aSAH group. For sepsis group, vasopressor use was the only significant risk factor for developing AKI (OR: 0.04, 95% CI: 0.01–0.06; p=0.038), as was also the case for head injury group (OR: 4.89, 95% CI: 3.04–6.74; p=0.044).

When data from all groups were collectively analyzed, APACHE II scores (OR: 1.21, 95% CI: 1.09–1.31; p<0.001), steroid use (OR: 7.31, 95% CI: 5.04–9.58; p=0.003), and antibiotic use (OR: 1.21, 95% CI: 1.00–1.40; p=0.043) were determined to be significant risk factors for developing AKI.

DISCUSSION Although AKI did not develop in any patient in aSAH group based on SCr level, by contrast, AKI was present in 5 (5%) patients in the group according to VACr level during the 30day ICU follow-up period. Condition developed in 76 (76%) patients in severe sepsis/septic shock group, and in 20 (20%) patients in head injury group, based on AKIN classification.

Vasopressor use was only significant risk factor for development of AKI in sepsis and head injury groups; however, high APACHE II score, as well as steroid and antibiotic use, were determined to be risk factors for AKI when all groups were analyzed collectively. We calculated VACr level according to fluid balance in aSAH group. Although there was no AKI in aSAH group according to SCr level, after fluid adjustment and corrected calculation of Cr, 5 patients received Stage 1 AKI diagnosis. Intense fluid management could influence SCr and Cr-based diagnosis of AKI.[11,12] Cr level could be low due to fluid overload as result of dilution.[12] For this reason, we used VACr level in addition to SCr. But we did not observe any problem related to AKI, such as longer hospital stay or inhospital mortality, in this group of patients.

Solenski et al. performed multicenter study of 457 aSAH patients in ICU in which they evaluated non-neurological problems, and they determined that AKI incidence in that group of patients was between 0.8% and 7%.[8] However, AKI was diagnosed only by rise in Cr and/or urea value. To our knowledge, the present study is the only one to utilize current AKI evaluation criteria for aSAH patients. Two main reasons may explain difference between our findings and Solenski’s results on development of AKI. First, our patients exhibited normal renal function. Almost one-fifth of all ICU patients have different degrees of renal impairment,[5] but this status was not indicated in Solenski’s study; thus, mild renal impairment in those patients on admission to ICU might explain rate of AKI in that study. Second, there could have been a type II error in our study due to small number of patients. Another research group that evaluated effect of AKI on survival of aSAH patients (using RIFLE classification) determined that AKI patients exhibited 3-fold increase in mortality rate compared with non-AKI patients; this risk factor for poor prognosis Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

confirmed patient statistics in our study.[5] However, there are no data indicating that AKI either developed in ICU or was acquired on admission to this study. AKI patients with sepsis are older and have higher mortality rates and APACHE II scores compared with septic patients who do not develop AKI.[13] Although our single-center study had limited number of patients, these findings confirmed our results. Several investigations have revealed that AKI develops in approximately 11% to 42.1% of all sepsis cases depending on severity of the illness.[14,15] In a German multicenter study, AKI developed in approximately 41.4% of severe sepsis and septic shock cases.

[16] In our study, AKI developed in 76% of patients in sepsis group. This rate is higher than that reported in other studies and might be explained by fact that 62% of the patients in sepsis group were in septic shock; however, this rate was not indicated in German study. Risk for development of AKI in sepsis group was increased by use of antibiotics and vasopressors. In another study, in which 415 severe sepsis and septic shock patients were examined for development of AKI, mortality rate was 39.5% in non-AKI patients but was 64.6% in AKI patients (p<0.001). However, in this study, only development of AKI was determined to be significant risk factor for mortality.[17] In our study, mortality rate for sepsis patients without AKI was 14.3% (2/14), but was 52.8% (19/36) for sepsis patients with AKI; this difference was significant (p=0.013). Li et al. reported that AKI developed in 23% of 136 traumatic brain injury patients (based on AKIN classification) and that average age of patient group who developed AKI was higher. They also found that mortality rate was greater in AKI group.[18] In another study, based on RIFLE classification system, incidence of AKI was 9.2%, and these patients were significantly older and had higher APACHE II scores compared with non-AKI patients.[19] Furthermore, mortality rate was 42.1% in the patients who developed AKI and 18.1% in non-AKI patients.[19] In our study, AKI developed in 20% of head injury patients, based on AKIN classification. Majority of the patients were male. Multivariate analysis revealed that vasopressor use (p=0.044) was the only risk factor for developing AKI. We found no factor related to mortality. Mortality rate in this group was 19% (8/42) for non-AKI patients and 37.5% for AKI patients, but difference was not statistically significant.

When all of the patients were assessed collectively, use of vasopressors (OR: 2.21, 95% CI: 0.45–4.01; p=0.012) and need for mechanical ventilation (OR: 1.53, 95% CI: 0.90–2.15; p=0.013) were determined to be risk factors for mortality.

However, development of AKI alone had no effect on mortality, in contrast with sepsis group. We suppose that this significant difference is due to younger patient profile in head injury group, which had smaller comorbid disease ratio and lower mortality rate among AKI patients compared with sepsis group. Whereas similar age, ICU length of stay, comorbid diseases, and Cr and BUN values were observed on admis43

Kamar et al. Kidney injury in neurosurgery

sion in aSAH group compared with sepsis group, similar infection rate and similar use of antibiotics and vasopressors were observed in head injury group. Moreover, steroids were used by all of the patients in aSAH group. Although aSAH group had similar risk factors for developing AKI compared with the 2 other groups, Stage 1 AKI based on VACr value developed in only 5 patients. Most of the patients with even minor signs of vasospasm underwent 2H therapy in aSAH group; we believe that this therapy could protect renal function. In addition, we also believe that electrolyte imbalance that commonly occurs in this patient group (due to cerebral salt-wasting syndrome, inappropriate secretion of antidiuretic hormone or central diabetes insipidus) and causes polyuria could also protect against renal injury. Risk factors for development of AKI were higher age, higher disease-severity scores (APACHE II and SOFA), vasopressor therapy, sepsis, pre-existing renal insufficiency, malignancy, and pulmonary disease.1 When all of the patients in our study were evaluated using multivariate regression analysis, APACHE II score (OR: 1.21, 95% CI: 1.09–1.31; p<0.001) and use of steroids (OR: 7.32, 95% CI: 5.04–9.58; p=0.003) or antibiotics (OR: 1.21, 95% CI: 1.00–1.40; p=0.043) were determined to be risk factors for development of AKI. In conclusion, AKI developed in only 5% of aSAH patients, but occurred in 70% of the patients in sepsis group, and 20% of the patients in head injury group. Conditions and risk factors were similar in all groups, but 2H therapy was applied to 64% of aSAH patients. In addition, centrally originating electrolyte imbalances that cause polyuria may explain low incidence of AKI among aSAH patients. Results of our investigation might not accurately reflect general population as it was single-center study that included limited number of patients who were also renally intact. Therefore, multicenter studies with larger and more homogeneous patient populations are necessary to obtain more representative results.

Conflict of interest: None declared.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Anevrizmal subaraknoid kanama, kafa travması ve sepsis hastalarının yoğun bakım tedavileri sırasında akut böbrek hasarı gelişimi ve etkileyen risk faktörlerinin incelenmesi Dr. Ceren Kamar,1 Dr. Achmet Ali,1 Dr. Demet Altun,1 Dr. Günseli Orhun,1 Dr. Akın Sabancı,2 Dr. Altay Sencer,1 Dr. İbrahim Özkan Akıncı1 1 2

İstanbul Üniversitesi İstanbul Tıp Fakültesi, Anesteziyoloji Anabilim Dalı, İstanbul İstanbul Üniversitesi İstanbul Tıp Fakültesi, Beyin Cerrahisi Anabilim Dalı, İstanbul

AMAÇ: Yoğun bakım ünitelerinde (YBÜ) takip edilen farklı hasta gruplarında akut böbrek hasarı (ABH) gelişimini inceleyen az çalışma bulunmaktadır. Çalışmamızda farklı yoğun bakım hasta gruplarında ABH gelişmesini ve bunda etkili risk faktörlerini incelemeyi amaçladık.

GEREÇ VE YÖNTEM: Bu çalışma üç farklı YBÜ’de gerçekleştirildi ve AKI network (AKIN) sınıflandırmasına göre ABH oluşumu karşılaştırıldı. Travma, beyin cerrahi ve genel YBÜ’lerde yatan sırası ile kafa travması, anevrizmal subaraknoid kanama (aSAK) ve septik şok nedeniyle takip edilen 300 hasta ABH insidansı ve risk faktörleri açısından incelendi.

BULGULAR: Anevrizmal subaraknoid kanama grubunda serum kreatin değerine göre ABH gelişen hasta saptanmadı fakat volüm düzeltilmiş kreatinin değerine göre (VACr) hastaların %5’inde ABH geliştiği görüldü. AKI network sınıflandırması baz alındığında sepsis grubunda %76, kafa travması grubunda hastaların %20’sinde hem serum kreatin hemde VACr değerine göre ABH geliştiği görüldü ve sepsis grubunda ABH insidansı anlamlı oranda yüksek bulundu (p<0.001). Sadece vazopresör kullanımı sepsis ve kafa travması grubunda ABH gelişimi için risk faktörü olarak saptandı.

Hastaların mortalite oranları aSAK, kafa travması ve sepsis grubu için sırası ile %8, %22 ve %42 saptandı. Vazopressör kullanımı ve ABH gelişmesi sepsis grubunda mortalite için risk faktörü olarak saptandı.

TARTIŞMA: Benzer özellikler ve risk faktörlerine rağmen aSAK hastalarında ABH daha nadir görülmektedir. Vazospazm tedavisi için uygulanan hipertansiyon, hipervolemi ve tuz kaybettirici sendrom sonucu oluşan poliüri aSAK hastalarında ABH gelişimden koruyan faktörler olabilir.

Anahtar sözcükler: Böbrek yetmezliği; kafa travması; sepsis; subaraknoid kanama.

Ulus Travma Acil Cerrahi Derg 2017;23(1):39–45

doi: 10.5505/tjtes.2016.83451

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ORIG I N A L A R T IC L E

What is the clinical yield of capsule endoscopy in the management of obscure bleeding in emergency service?

Muhammed Zübeyr Üçüncü, M.D.,1* Süleyman Bademler, M.D.,2 Mehmet İlhan, M.D.,2 Ali Fuat Kaan Gök, M.D.,2 Filiz Akyüz, M.D.,3 Recep Güloğlu, M.D.2 1

Department of General Surgery, Arnavutköy State Hospital, İstanbul-Turkey

2

Department of General Surgery, İstanbul Universty İstanbul Faculty of Medicine, İstanbul-Turkey

3

Department of Gastroenterology, İstanbul Universty İstanbul Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: The aim of this study was to investigate the efficacy of capsule endoscopy (CE) performed on patients who presented to emergency room with clinically evident gastrointestinal (GI) bleeding from unknown source and were hospitalized for follow-up.

METHODS: Total of 38 patients who underwent CE and were followed-up for evaluation of clinically perceptible GI bleeding with no obvious etiology in Istanbul Medical Faculty emergency surgery department were included in the study. Patient data, which were collected between January 1, 2007 and June 1, 2015, were reviewed retrospectively.

RESULTS: Of the 38 patients included in this study, 12 (32%) patients were women and 26 (68%) were men. Average age was 55.57 years (range: 20–88 years). Nine patients were using anticoagulants. Ten patients were followed-up in intensive care, and 7 patients underwent angiography. Angioembolization was performed for 1 patient who was diagnosed as having active bleed with CE. Average erythrocyte suspension replacement was 20.7 units. Total of 13 patients underwent surgery for bleeding found with CE. Eleven (34%) patients underwent double-balloon endoscopy, during which 5 patients were treated with cauterization and sclerotherapy was performed on 2. Four (18%) patients died during the study period: 2 died as result of bleeding from unknown source, 1 died of cholangiocarcinoma recurrence, and 1 died of anastomotic leakage. One patient was readmitted to hospital due to recurrence of bleeding.

Nineteen (50%) patients were treated successfully based on CE findings. Diagnostic yield of CE was determined to be 78.9%. Average length of hospital stay was 32.68 days (range: 3–153 days).

CONCLUSION: CE is an effective tool to detect source of GI bleeding. CE should be first choice of evaluation method for patients admitted to emergency room with obscure overt GI bleeding once radiological imaging determines absence of obstruction.

Keywords: Capsule endoscopy; emergency service; obscure bleeding.

INTRODUCTION Gastrointestinal (GI) tract bleeding that persists or recurs with no obvious etiology represents approximately 5% of all cases of GI system bleeding.[1] These patients can be defined Current affiliation: İstanbul Gelişim University, Health Sciences Institute.

*

Address for correspondence: Muhammed Zübeyr Üçüncü, M.D. Arnavutköy Devlet Hastanesi, Genel Cerrahi Kliniği, Arnavutköy, İstanbul, Turkey Tel: +90 212 - 453 12 12 E-mail: muhammeducuncu@gmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):46–50 doi: 10.5505/tjtes.2016.79360 Copyright 2017 TJTES

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as those who have undergone at least 1 colonoscopy and gastroscopy, but source of continuous bleeding could not be detected.[2] Angiodysplasia has been detected as most frequent source of these GI bleeds.[3] GI bleeding without obvious etiology may be either occult or overt. Overt bleeding is defined as visible GI bleeding that generally presents as melena, or hematochezia. In contrast, occult bleeding is not visible to the patient or the physician. These bleeds may be associated with iron deficiency anemia and may manifest as positive fecal blood test.[4] Debate continues on treatment of GI bleeding with no obvious etiology as result of difficulties in determining source.

Capsule endoscopy (CE) is favored technique to evaluate these bleeds.[5–7] Several studies have shown high specificity and sensitivity of CE in setting of overt GI bleeding (OGIB) and reported that it has better diagnostic yield than other Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Üçüncü et al. What is the clinical yield of capsule endoscopy in the management of obscure bleeding in emergency service?

endoscopic or radiological techniques. The aim of this study was to present our experience in evaluation of patients with OGIB using CE in emergency service.

MATERIALS AND METHODS Patients who were admitted to the Istanbul University Istanbul Faculty of Medicine emergency unit with symptoms of melena or hematochezia were included in the study if there was no evidence of obvious decline in hemoglobin or hematocrit in gastroscopic and colonoscopic examination, and if CE was performed. Patients were hemodynamically stable and had at least 2 units of erythrocyte replacement. Study cohort included patients who presented between January 1, 2007 and June 1, 2015. Informed written and oral consent were obtained from all patients included in the study. CE was performed after abdominal tomography with contrast agent in order to prevent capsule retention.

CE Procedure CE procedure was performed in outpatient clinic without hospitalization using Pillcam SB2 (Medtronic, Inc., Minneapolis, MN, USA). Bowel preparation was performed with 4 L polyethylene glycol solution 1 day before procedure. Patients swallowed Pillcam capsule in outpatient clinic and were not permitted to drink for 2 hours or eat for 4 hours. Patients were asked to verify ejection of capsule in stool and to alert endoscopy unit if it was not ejected.

was performed in 11 patients. Of these, sclerotherapy was performed on 2 patients and cauterization was used in 5 cases. According to CE findings, 19 patients were therapeutically treated (Figure 1). Four patients died: 2 patients died in hospital during conservative follow-up. One patient who was undergoing therapeutic treatment died of anastomotic leakage after bowel resection and anastomosis. One patient died as result of cholangiocarcinoma recurrence (Table 1).

Source of bleeding was detected in 35 patients based on CE Table 1. Comparison of the therapeutically treated patients with the conservatively followed ones

Conservative Therapeutic treatment treatment

Sex (Male/Female)

19 (15/4)

19 (11/8)

Average age

56.94

54.2

RBC replacement

11.7

29.6

Additional illness

10

11

17.1

48.2

Avarage hospitalisation Mortality

2 2

Anticoagulant users

5

3

Patients stayed in ICU

1

9

RBC: Red blood cell; ICU: Intensive care unit.

Capsule retention was defined as presence of capsule in the GI tract 2 weeks after ingestion. One gastroenterologist (FA) with extensive experience in small bowel endoscopy evaluated recorded CE images.

Therapeutic treatment

9

3

RESULTS Thirty-eight patients who were under follow-up to identify source of GI bleeding of unknown origin in the Istanbul University Istanbul Faculty of Medicine emergency surgery department and who were screened using CE were included in this study. Twelve patients (32%) were women and 26 (68%) were men. Average age was 55.57 years (range: 20–88 years). Nine patients were using anticoagulants. Ten were followed-up in intensive care, and 7 underwent angiography.

Angioembolization was performed on 1 patient who was diagnosed with CE as having active bleed. Average erythrocyte suspension replacement was 20.7 units. Thirteen patients underwent surgery for bleeding found with CE. Tumor was detected in 8 of these patients. Double-balloon endoscopy Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

2

2

1

1

1

do ub le

Descriptive statistics were used to summarize patient demographic and clinical characteristics, endoscopic findings, and therapeutic procedures. Categorical variables were presented as percentages and numeric variables as means and ranges.

Pa rti al re inte sm -b Ca sec stin all al ut lo e tion e on riz C en atio a do n sm ut e sc wi al riz op th li a nt tio y es n tin w e ith re p se ar ct tia io l n Sd er ot w he ith r D apy An BE gi oe m bo liz at io Tr n an s on fic du tion ed s on titc um h To ta lc ol e ile cto os m to y + m y

Statistical Analysis

Figure 1. Therapeutically treated patients. DBE: Double-balloon endoscopy.

20 18 16 14 12 10 8 6 4 2 0

19

12 6 1 Vascular lesion

Active bleeding

Mass

Normal

Figure 2. Capsule endoscopy results

47

Üçüncü et al. What is the clinical yield of capsule endoscopy in the management of obscure bleeding in emergency service? (a)

(b)

(c)

(d)

Figure 3. (a) Capsul endoscopy image. (b) Double baloon image. (c) 36 age man patient photos. (d) Pathologically image.

DISCUSSION According to the American Gastroenterology journal guidelines issued in 2015, bleeding from small intestine was categorized into 2 main groups. If no specific source of bleeding could be identified after thorough examination, bleeding was referred to as obscure. However, overt and occult GI bleeding refers to known source, even if etiology is not initially obvious. Performance of CE has had great impact on correct categorization of suspected cases of GI bleeding. In study conducted by Pennazio et al., diagnostic value of CE in patients with occult bleeding was 92.3%, and it was 44% for overt bleeding.[8] According to some published literature, this rate may decrease to 45.7%. This may be due to length of time between bleeding occurrence and CE. Bresci et al. revealed inverse relationship between timing of CE and bleeding. The authors found higher diagnostic value in patients who underwent earlier CE.[9] It has been proposed in international consensus meetings that earliest CE performance should be within the first 2 weeks of symptom observation.

Figure 4. (a) Active bleeding. (b) Vascular lesion.

results. Source of GI bleeding was not determined based on CE evaluation in 2 patients, and CE evaluation was normal in remaining patient. Diagnostic yield was 78.9% in the present study. Capsule retention occurred in 3 patients due to small bowel adenocarcinoma and in 1 patient due to lipoma. One patient was readmitted to hospital due to multiple angiodysplasia of the small intestine. Average length of hospital stay was 32.68 days (range: 3–153 days) CE results were grouped in 4 categories: 1) active bleeding, 2) vascular lesions (angiodysplasia, erosion, ulcers, vascular ectasia), 3) mass (bulk), and 4) normal findings (Figure 2–4).

Age is a factor that improves diagnostic efficiency in determining etiological source of GI bleeding. Scaglione et al. reported that diagnostic value under the age of 65 years was 45% while ratio goes up to 75% for patients aged over 65 years.[10]

Seventeen patients from conservatively managed group were not readmitted to hospital for any GI bleeding symptoms.

Suspected Small Bowel Bleeding Treat origin

+

Repeat endoscopy

–

Check for small bowel obstruction

+ Spesific management • Doble baloon endoscopy

CT/MRI

–

+

Capsule endoscopy

–

• Intraoperative enteroscopy • Red cell scan

Further evaluation is needed?

• Angiography YES

NO

Spesific management

Follow

Figure 5. Our algorthym.

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Üçüncü et al. What is the clinical yield of capsule endoscopy in the management of obscure bleeding in emergency service?

Different methods have been used to identify source of bleeding, such as double-balloon endoscopy, angiography, and radionuclide imaging. In addition to drawbacks of these methods, including invasiveness, sedation requirement, and radiation involvement, diagnostic value has been found to be lower when compared with CE. Angiography can detect source of bleeding with intra-arterial contrast agent, but only when intensity of bleeding is at least 0.5 mL/min.[11] Advantage of angiography is that intervention can be performed in the same session if bleeding is detected. However, it does not give us any information about nature of the lesion. Although radionuclide scanning is superior to angiography in terms of being non-invasive method and providing information about active bleeding (0.1–0.4 mL/min), no bleeding intervention can be performed with this method.

Double-balloon endoscopy requires significant experience, sedation of the patient, and has lower diagnostic yield compared with CE. Kameda et al. examined diagnostic yield of double-balloon endoscopy (65%) and CE (71%). Although Lin et al. supported Kamada, diagnostic yield of double-balloon endoscopy was found to be higher than that of CE in a study conducted by Arakawa et al.[12,13] In conclusion, CE is superior method because it is non-invasive, does not require sedation or radiation, and provides better diagnostic value.

Although CE offers advantages over other methods, it also has drawbacks, such as inability to perform biopsy or therapeutic intervention, and there is risk for capsule retention.

Although tomography performed prior to CE would seem to be solution in terms of preventing capsule retention, it should be noted that it is also possible that battery life may expire before capsule reaches the cecum in patients with no evidence of obstruction. Furthermore, experienced physician is needed to recognize lesions seen with CE. In our study, retention was detected in 4 patients due to presence of mass.

Intraoperative enteroscopy has been proposed as alternative method and should be preferred for evaluation in unstable situation.[14] Guidelines have begun to emerge with widespread use of CE in patients with GI bleeds and no obvious etiology. Guidelines developed by Gerson et al. are presented here as an example.[8–18] Our algorithm is shown in Figure 5.

In the present study, after gastroscopy and colonoscopy, tomography was performed on patients with GI bleeding to determine presence of any obstruction before CE. Appropriate treatment for each patient was based on CE results.

Diagnostic yield was found to be 78.9%, which is consistent with the literature.[19] Main limitations of this study include its retrospective nature and the inability to perform CE in large population due to cost to patients. Thus, patient standardization and comparison could not be made.

Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Conclusion CE should be selected as first-line diagnostic evaluation method for patients without evidence of obstruction in tomography results who have clinically perceptible GI bleeding that recurs or persists after negative upper and lower GI tract endoscopic examination.

Conflict of interest: None declared.

REFERENCES 1. Katz LB. The role of surgery in occult gastrointestinal bleeding. Semin Gastrointest Dis 1999;10:78–81.

2. American Gastroenterological Association medical position statement: evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology 2000;118:197–201.

3. Foutch PG. Angiodysplasia of the gastrointestinal tract. Am J Gastroenterol 1993;88:807–18.

4. American society for gastrointestinal endoscopy. Gastrointestınal endoscopy 2003;58:5.

5. Scapa E, Jacob H, Lewkowicz S, Migdal M, Gat D, Gluckhovski A, et al. Initial experience of wireless-capsule endoscopy for evaluating occult gastrointestinal bleeding and suspected small bowel pathology. Am J Gastroenterol 2002;97:2776–9.

6. Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy.

Nature 2000;25:405–417.

7. Swain P, Fritscher-Ravens A. Role of video endoscopy in managing small bowel disease. Gut 2004;53:1866–75.

8. Pennazio M, Santucci R, Rondonotti E, Abbiati C, Beccari G, Rossini FP, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology 2004;126:643–53.

9. Bresci G, Parisi G, Bertoni M, Tumino E, Capria A. The role of video capsule endoscopy for evaluating obscure gastrointestinal bleeding: usefulness of early use. J Gastroenterol 2005;40:256–9.

10. Scaglione G, Russo F, Franco MR, Sarracco P, Pietrini L, Sorrentini I. Age and video capsule endoscopy in obscure gastrointestinal bleeding: a prospective study on hospitalized patients. Dig Dis Sci 2011;56:1188–93.

11. Singh V, Alexander JA. The evaluation and management of obscure and occult gastrointestinal bleeding. Abdom Imaging 2009;34:311–9.

12. Lin TN, Su MY, Hsu CM, Lin WP, Chiu CT, Chen PC. Combined use of capsule endoscopy and double-balloon enteroscopy in patients with obscure gastrointestinal bleeding. Chang Gung Med J 2008;31:450–6.

13. Arakawa D, Ohmiya N, Nakamura M, Honda W, Shirai O, Itoh A, et al.

Outcome after enteroscopy for patients with obscure GI bleeding: diagnostic comparison between double-balloon endoscopy and videocapsule endoscopy. Gastrointest Endosc 2009;69:866–74.

14. Gerson LB, Fidler JL, Cave DR, Leigthon JA. ACG Clinical guidelines: Diagnosis and management of small bowell bleeding. The American journal of Gastroenterology 2015.

15. Gupta R, Reddy DN. Capsule endoscopy: current status in obscure gastrointestinal bleeding. World J Gastroenterol 2007;13:4551–3.

16. Kameda N, Higuchi K, Shiba M, Machida H, Okazaki H, Yamagami H, et al. A prospective, single-blind trial comparing wireless capsule endoscopy and double-balloon enteroscopy in patients with obscure gastrointestinal bleeding. J Gastroenterol 2008;43:434–40.

17. Lecleire S, Iwanicki-Caron I, Di-Fiore A, Elie C, Alhameedi R, Ramirez

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S, et al. Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding. Endoscopy 2012;44:337–42.

18. Heo HM, Park CH, Lim JS, Lee JH, Kim BK, Cheon JH, et al. The role of capsule endoscopy after negative CT enterography in patients with ob-

scure gastrointestinal bleeding. Eur Radiol 2012;22:1159–66.

19. Calabrese C, Liguori G, Gionchetti P, Rizzello F, Laureti S, Di Simone MP, et al. Obscure gastrointestinal bleeding: single centre experience of capsule endoscopy. Intern Emerg Med 2013;8:681–7.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Nedeni bilinmeyen gastrointestinal sistem kanamalarda kapsül endoskopisinin acil servisteki yeri?

Dr. Muhammed Zübeyr Üçüncü,1 Dr. Süleyman Bademler,2 Dr. Mehmet İlhan,2 Dr. Ali Fuat Kaan Gök,2 Dr. Filiz Akyüz,3 Dr. Recep Güloğlu2 Arnavutköy Devlet Hastanesi, Genel Cerrahi Kliniği, İstanbul İstanbul Üniversitesi İstanbul Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul 3 İstanbul Üniversitesi İstanbul Tıp Fakültesi, Gastroenteroloji Bilim Dalı, İstanbul 1 2

AMAÇ: Bu çalışmanın amacı acilde nedeni bilinmeyen gastrointestinal (GİS) kanama tanısı ile yatırılarak takip edilen hastalarda kapsül endoskopisinin yerini irdelemek.

GEREÇ VE YÖNTEM: İstanbul Üniversitesi İstanbul Tıp Fakültesi Acil Cerrahi biriminde 1 Ocak 2007 ile 1 Haziran 2015 tarihleri arasında nedeni bilinmeyen aşikar GİS kanama tanısı ile takip edilen ve kapsül endoskopisi yaptığımız 38 hastanın verileri geriye dönük olarak incelendi.

BULGULAR: İstanbul Üniversitesi İstanbul Tıp Fakültesi Acil Cerrahi’de nedeni bilinmeyen GİS kanama tanısıyla takip edilen ve kapsül endoskopisi yapılabilen 38 hasta çalışmaya dahil edildi. On iki hasta kadın (%32) 26 hasta erkekti (%68). Ortalama yaş: 55.57 (20–88) idi. Dokuz hasta kan sulandırıcı ilaç kullanıyordu. 10 hasta yoğun bakımda takip edildi. Yedi hastaya anjiyo yapıldı aktif kanama saptanmadı. Kapsül endoskopisinde aktif kanama saptanan bir hastaya anjiyoembolizasyon yapıldı. Ortalama eritrosit süspansiyon replasmanı 20.7 ünite idi. On üç hasta kapsül endoskopisinde bulunan kanama odakları nedeniyle ameliyat edildi (%34). On bir hastaya çift balon endoskopisi yapıldı. Bunlardan beşine koterizasyon ikisine skleroterapi yapılarak müdahale edildi (%18). Dört hasta hayatını kaybetti. İki olgu kanama odağı saptanamadığı için bir olgu kolanjiyokarsinom nüksü nedeniyle bir olguda anastomoz kaçağı nedeniyle hayatını kaybetti. Bir olgu tekrar kanama nedeniyle hastaneye başvurdu. On dokuz hastaya kapsül endoskopisi bulgularına dayanılarak başarılı şekilde müdahale edildi (%50). Tanısal değer %78.9 olarak saptandı. Hastanede ortalama kalış süresi 32.68 (dağılım, 3–153 gün) idi.

TARTIŞMA: Kapsül endoskopisi kanama etiyolojisini saptamada etkindir. Acile başvuran hastalarda nedeni bilinmeyen kanamalarda radyolojik olarak obstrüksiyon bulunmayan olgularda ilk tercih edilecek yöntem kapsül endoskopi olmalıdır.

Anahtar sözcükler: Acil servis; gizli kanama; kapsül endoskopi.

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doi: 10.5505/tjtes.2016.79360

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ORIG I N A L A R T IC L E

General characteristics of paint thinner burns: Single center experience Mustafa Celalettin Haksal, M.D.,1 Cağrı Tiryaki, M.D.,2 Murat Burç Yazıcıoğlu, M.D.,2 Murat Güven, M.D.,3 Ali Çiftci, M.D.,2 Osman Esen, M.D.,4 Hamdi Taner Turgut, M.D.,2 Abdullah Yıldırım, M.D.5 1

Department of Surgery, Medipol University Faculty of Medicine, İstanbul-Turkey

2

Department of General Surgery, Kocaeli Derince Training and Research Hospital, Kocaeli-Turkey

3

Burn Treatment Center, Kocaeli Derince Training and Research Hospital, Kocaeli-Turkey

4

Department of Anesthesiology and Reanimation, Kocaeli Derince Training and Research Hospital, Kocaeli-Turkey

5

Department of Plastic Reconstructive Surgery, Kocaeli Derince Training and Research Hospital, Kocaeli-Turkey

ABSTRACT BACKGROUND: The aim of the present study was to present characteristic features and risk factors of paint thinner burns in order to raise awareness and help prevent these injuries.

METHODS: Records of patients admitted to the burn unit due to paint thinner burns were retrospectively reviewed, and patients with comprehensive data available were included in the study. Total of 48 patients (3 female and 45 male) with mean age of 27.79±11.49 years (range: 4–58 years) were included in the study.

RESULTS: Mean total hospitalization period was 30.25±27.11 days (range: 3–110 days), and mean total burn surface area was 32.53±24.06% (range: 3.0–90.0%). In 31 cases (64.6%), intensive care unit admission was required. Among all 48 patients, 9 (18.8%) died in hospital and remaining 38 were discharged after treatment. Primary cause of death was septicemia (n=7) or respiratory failure (n=6). Inhalation injury was present in 12 of the patients, 6 of whom died (50%). Statistically significant differences were found between expired and discharged patients when compared for presence of inhalation injury (p=0.01) and septicemia (p=0.031).

CONCLUSION: Ignition of paint thinner is an important cause of burn injuries that may result in very severe clinical picture. Patients require prompt and careful treatment. Clinicians should be aware that inhalation injury and sepsis are the 2 main factors affecting mortality rate in this group of patients. With increased awareness, preventive measures may be defined. Further studies are warranted to decrease mortality rate in this subgroup of burn patients.

Keywords: Inhalation injury; mortality; paint thinner burn.

INTRODUCTION Unfortunately, especially in developing countries, paint thinner is an easily accessible, common household product, and for that reason, paint thinner-associated accidents, including burns, are not rare.[1] Paint thinner is highly inflammable liquid that should be handled carefully.[2] It is also toxic for almost Address for correspondence: Murat Burç Yazıcıoğlu, M.D. Derince Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Kocaeli, Turkey Tel: +90 262 - 317 80 00 E-mail: mbyazicioglu@gmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):51–55 doi: 10.5505/tjtes.2016.66178 Copyright 2017 TJTES

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all systems of the body, including the central nervous system, the lungs, the heart, the liver and the kidneys.[3] Although data in the literature about paint thinner burns are limited, it has been associated with high total burn surface area percentage (%TBSA), and with resulting high mortality and morbidity rates. Furthermore, concomitant inhalation injury may also worsen clinical picture of the victims.[4] The aim of the present study was to present the characteristic features and risk factors related to paint thinner burns in order to help prevent them.

MATERIALS AND METHODS After receiving approval from the Kocaeli University School of Medicine ethics committee, this study was conducted at Kocaeli Derince Training and Research Hospital between January 2012 and December 2015. Patient records of those 51

Haksal et al. General characteristics of paint thinner burns

admitted to burn unit due to paint thinner burns were retrospectively reviewed and patients with comprehensive data were included in the study. During this period, total of 630 major burn patients were admitted and hospitalized in burn center, and among those, 48 (7.6%) were paint thinner burns.

After initial assessment, intravenous fluid resuscitation was initiated in all cases with monitoring of urine output. Surgical interventions, including debridement, escharatomy, fasciotomy, and flap coverage, were performed as needed. Erythrocyte or fresh frozen plasma was transfused when required.

Demographic details; routine laboratory data, including complete blood count, renal and liver function tests, and Creactive protein (CRP) and serum electrolyte levels; intensive care unit (ICU) requirements; total hospitalization period; and presence of blood culture positivity were recorded.

Rule of Nines was used to calculate %TBSA. Most affected region and depth of burn were also recorded for each patient using burn grading scale: Grade 1, superficial thickness of skin is involved; Grade 2, full thickness of skin is destroyed; Grade 3, skin, subcutaneous tissue, fat, and muscle

are destroyed; Grade 4, skin, subcutaneous tissue, and bone are destroyed.

Statistical Analysis Statistical analysis of the results was conducted using SPSS software (version 21; IBM Corp., Armonk, NY, USA). Results were presented as mean±SD for continuous variables and as number and proportion (percentage) for categorical variables. Descriptive statistics were used for analyses. P value of less than 0.05 was considered statistically significant.

RESULTS Total of 48 patients (3 female and 45 male) with mean age of 27.79±11.49 years (range: 16–58 years) were included in the study. Burn took place at home in 14 cases, at work in 25 cases, and in another location in 9 cases. The patients arrived at the hospital by ambulance (n=36), with their own vehicle (n=7), or by air ambulance (n=5). For 25 patients (1 female, 24 male), paint thinner burn was due to work-related accident, and in remaining 23 cases (2 female, 21 male) it was

Table 1. The general characteristics of the study participants

Paint thinner burns (n=48)

n

%

Age (years)

Mean±SD 27.79±11.49

Gender Male

45

Female

3

Total body surface area burned (%)

32.53±24.06

Burn degree 2nd degree

37

77.1

3 degree

11

22.9

rd

Burn area (most affected)

3

6.3

Extremity

Hairy skin

18

37.5

Body

14

29.2

Head and neck

11

22.9

Genital-gluteal region

Operation requirement

2

4.2

38

79.2

Mean number of debridement procedures

6.04±8.12

Hospitalization time (days)

30.25±27.11

Intensive care unit requirement

31

64.6

Intensive care unit hospitalization time (days)

25.48±27.77

Mean erythrocyte transfusion requirement

2.05±3.49

Mean fresh frozen plasma requirement

4.47±8.45

Mean albumin requirement

1.00±2.43

Dialysis requirement

5

10.4

SD: Standard deviation.

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Haksal et al. General characteristics of paint thinner burns

related to inhalant addiction. In 4 cases, burn was result of suicide attempt.

indicated that respiratory failure increased mortality ratio 9 times (2.44–33.24).

Of all the patients, 27 were directly hospitalized in ICU; in another 4 cases, during follow-up at hospital, ICU hospitalization was required. General characteristics of patients are summarized in Table 1. Mean hospitalization period in ICU was 25.48±27.77 days (range: 7–110 days). Mean total hospitalization period was 30.25±27.11 days (range: 3–110 days), and mean %TBSA was 32.53±24.06% (range: 3.0–90.0%). Total of 20 patients had %TBSA of greater than 30% and 29 patients had %TBSA of greater than 20%. In 5 cases (10.4%), hemodialysis was required due to acute renal failure. Of those 5 cases, 3 patients died and 2 were discharged. In comparison of patients who expired and those who were discharged, hemodialysis requirement did not yield statistically significant difference (p=0.10).

Inhalation injury was present in 12 of the patients, and 6 of those died (50%). In 6 of the patients with inhalation injury, burn was due to work-related accident, while in remaining 6 cases, burn was related to inhalant addiction. Among 36 patients without inhalation injury, 3 patients died (8.3%). In comparison of expired and discharged patients regarding presence of inhalation injury, it was statistically significantly more common in expired group (p=0.01). Presence of inhalation injury increased the mortality ratio 3.22 times (1.38–7.53).

In all, 9 (18.8%) patients in the group expired and remaining 38 were discharged after treatment. Principal cause of death was septicemia (n=7) or respiratory failure (n=6). Septicemia was statistically significantly more common in expired group (p=0.031). When odds ratio (OR) was calculated, presence of septicemia increased mortality ratio 2.19 times (1.21–3.95).

In comparison of expired and discharged patients regarding presence of respiratory failure requiring mechanic ventilation, respiratory failure was also statistically significantly more common in expired group (p=0.001). OR calculation Table 2. Laboratory data of study participants at admission to the hospital

Paint thinner burns (n=48)

Mean±SD Creatinine (mg/dL)

0.83±0.30

Urea (mg/dL)

27.68±9.84

Glucose (mg/dL)

138.36±90.88

Total protein (mg/dL)

5.32±1.62

Albumin (mg/dL)

3.07±0.98

Uric acid (mg/dL)

4.46±1.37

Aspartate amino transferase (IU/l)

53.57±96.67

Alanine aminotransferase (IU/l)

36.85±86.07

Potassium (mEq/L)

4.33±0.76

Sodium (mEq/L)

136.45±2.87

C-reactive protein

80.08±101.85

Hemoglobin (g/dL)

11.75±4.28

Mean platelet volume (fL)

8.45±1.24

Neutrophil (%)

70.12±19.04

Platelet count

266.76±143.82

WBC (103/µL) 21.78±11.19 SD: Standard deviation; WBC: White blood cell count count.

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Study participant laboratory data at admission are summarized in Table 2. Interestingly, at admission, 41 (85.4%) patients had CRP level higher than normal value, and 44 (91.7%) had the white blood cell and neutrophil count above normal values. In 39 (81.3%) of the patients, antibiotherapy was required, and blood cultures were positive in 34 (70.8%) cases.

In 7 of the 9 expired patients, blood cultures were positive and all those who died were receiving antibiotherapy.

DISCUSSION The present study is retrospective assessment of patients with paint thinner burns conducted to determine general characteristics and outcomes. To the best of our knowledge, this is the largest study in the current literature evaluating paint thinner burns. We determined that the victims of paint thinner burns were generally young males, %TBSA was high (32.53±24.06%), along with requirement for operation (79.2%) and ICU (64.6%) care. Total mortality ratio determined in this group was 18.8%, and main cause of death was septicemia or respiratory failure.

Even though paint thinner burns are not rare, data about such burns in the current literature is limited. Queiroz et al.[5] investigated 293 patients admitted to ICU of burn center between 2010 and 2012 and reported that 3.4% (n=10) of cases were due to paint thinner burn. We have reported prevalence of paint thinner burn of 7.6% in this study. Kulahci et al.[6] investigated demographic features of 9 male patients who were the victims of paint thinner burn and reported that mean %TBSA was as high as 67.7% with mortality rate of 33.3%. Benbrahim et al.[7] examined demographic features of 17 patients admitted with paint thinner flame burns. Mean age of the patients was 32 years and nearly all of them (16/17) were male. Mean %TBSA was 23% in that study. Haberal et al.[8] retrospectively evaluated epidemiology of 28 paint thinner burn injuries (25 male, 3 female) from period of 8 years and reported that mean age of the patients was 27.88±14.74 years and mean %TBSA was 48.82±27.39%. They stated that %TBSA was significantly larger in cases of paint thinner burn when compared with other sources of flame burn, and as in our study, the most commonly affected site was the extremities. In that study, overall mortality rate was reported as 53

Haksal et al. General characteristics of paint thinner burns

39.3% and main cause of death was sepsis. Ozgenel et al.[9] reported demographic data of 32 patients (30 males, 2 females) with paint thinner burns and indicated that mean age of patients was 25.9±11 years and mean %TBSA was 33.6±24%.

Mortality ratio was 15.6% in that study. In the present study, mean age of patients (27.79±11.49 years) and male predominance were similar to other results. Also consistent with these studies, mean %TBSA was greater than 30% and mortality rate was greater than 15%.

In this study, main cause of death was septicemia or respiratory failure. Inhalation injury was determined to be statistically significantly more common in the expired group and presence of inhalation injury was associated with more than 3 times greater mortality. Recently, inhalation injury was determined to be independently associated with mortality in adults with %TBSA of 20% or greater.[10] Similarly, Chen et al.[11] also reported that inhalation injuries significantly reduced survival rate in patients with mild or moderate burns (burn index<50%). Aguayo-Becerra et al.[12] reported that mortality was higher for burns caused by inhalation injury and burns associated with infection. However, de Campos et al.[13] and Moore et al.[14] did not determine significant association between inhalation injury and hospital mortality in severe adult burn patients admitted to burn ICU. In our study, we determined that respiratory failure requiring mechanical ventilation increased mortality rate about 9 times. Similarly, Rosanova et al. also determined that mechanical ventilation was an independent variable related to mortality in children with burns.[15] Queiroz et al. also reported that mechanical ventilation requirement was associated with significantly increased mortality rate in burn victims.[5] These results were also compatible with our findings. In the present study, septicemia was one of the most common causes of mortality, and increased mortality by more than double.

In parallel with our results, Krishnan et al.[16] reported that multi-organ failure was primary cause of death, with sepsis being primary trigger in acute burn patients. Elkafssaoui et al.[17] also reported association of sepsis with increased mortality. Multi-organ failure triggered by sepsis-associated inflammatory cytokines may play a role in this association.[18] In a recent review, Stewart et al.[19] did not recommend systemic antibiotic prophylaxis for burns in low- and middle-income countries; however, further studies about prophylactic antibiotic treatment, especially for patients with large paint thinner burns accompanied by inhalation injury, are warranted.

In a retrospective study, Coban et al. investigated 411 burn patients and reported mortality rate of 5.6% (n=23). Among that study group, only 6 patients (1.4%) with acute renal failure responded to hemofiltration. They also determined most common cause of mortality to be septicemia or effects of inhalation injury.[20] Saracoglu et al. recently reported that main cause of death was multiple organ failure or infection in patients with electrical burns. However, they reported that 54

renal injury requiring hemofiltration was associated with an almost 12-fold increased risk for mortality.[21] In our study, we did not determine a significant difference between expired or discharged groups regarding presence of hemodialysis requirement.

There are some limitations to this study that should be mentioned. Although this is one of the largest studies in the literature about paint thinner burns, the number of patients is still low. Secondly, blood culture results and microorganisms found were not recorded in this study, which may be the topic of another study to define an appropriate prophylaxis protocol.

Conclusion Paint thinner ignition is an important cause of burn injuries that may cause very severe clinical picture in patients that requires prompt and careful treatment. Clinicians should be aware that presence of inhalation injury or sepsis were the 2 main factors affecting mortality rate in this group of patients.

With increased awareness, preventive measures can be defined. Further studies are warranted in order to decrease mortality rate in this subgroup of burn patients.

Conflict of interest: None declared.

REFERENCES 1. Anderson CE, Loomis GA. Recognition and prevention of inhalant abuse. Am Fam Physician 2003;68:869–74.

2. Saito J, Ikeda M. Solvent constituents in paint, glue and thinner for plastic miniature hobby. Tohoku J Exp Med 1988;155:275–83.

3. Carabez A, Sandoval F, Palma L. Ultrastructural changes of tissues produced by inhalation of thinner in rats. Microsc Res Tech 1998;40:56–62.

4. Yabanoglu H, Aytac HO, Turk E, Karagulle E, Belli S, Sakallioglu AE, et al. Evaluation of Demographic and Clinical Characteristics of Patients who Attempted Suicide by Self-Inflicted Burn Using Catalyzer. Int Surg 2015;100:304–8.

5. Queiroz LF, Anami EH, Zampar EF, Tanita MT, Cardoso LT, Grion CM. Epidemiology and outcome analysis of burn patients admitted to an Intensive Care Unit in a University Hospital. Burns 2016;42:655–62.

6. Kulahci Y, Sever C, Noyan N, Uygur F, Ates A, Evinc R, et al. Burn assault with paint thinner ignition: an unexpected burn injury caused by street children addicted to paint thinner. J Burn Care Res 2011;32:399– 404.

7. Benbrahim A, Jerrah H, Diouri M, Bahechar N, Boukind EH. Burns caused by paint thinner. [Article in French] Ann Burns Fire Disasters 2009;22:185–8. [Abstract] 8. Haberal M, Kut A, Basaran O, Tarim A, Türk E, Sakallioglu E, et al. Preventable thermal burns associated with the ignition of paint thinner: experience of a burn care network in Turkey. Minerva Med 2007;98:653–9.

9. Ozgenel GY, Akin S, Ozbek S, Kahveci R, Ozcan M. Thermal injuries due to paint thinner. Burns 2004;30:154–5.

10. Sood RF, Gibran NS, Arnoldo BD, Gamelli RL, Herndon DN, Tompkins RG; Inflammation the Host Response to Injury Investigators.

Early leukocyte gene expression associated with age, burn size, and inhalation injury in severely burned adults. J Trauma Acute Care Surg

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11. Chen MC, Chen MH, Wen BS, Lee MH, Ma H. The impact of inhalation injury in patients with small and moderate burns. Burns 2014;40:1481–6.

12. Aguayo-Becerra OA, Torres-Garibay C, Macías-Amezcua MD, FuentesOrozco C, Chávez-Tostado Mde G, Andalón-Dueñas E, et al. Serum albumin level as a risk factor for mortality in burn patients. Clinics (Sao Paulo) 2013;68:940–5.

13. de Campos EV, Park M, Gomez DS, Ferreira MC, Azevedo LC. Characterization of critically ill adult burn patients admitted to a Brazilian intensive care unit. Burns 2014;40:1770–9.

14. Moore EC, Pilcher DV, Bailey MJ, Stephens H, Cleland H. The Burns Evaluation and Mortality Study (BEAMS): predicting deaths in Australian and New Zealand burn patients admitted to intensive care with burns. J Trauma Acute Care Surg 2013;75:298–303.

15. Rosanova MT, Stamboulian D, Lede R. Risk factors for mortality in burn children. Braz J Infect Dis 2014;18:144–9.

16. Krishnan P, Frew Q, Green A, Martin R, Dziewulski P. Cause of

death and correlation with autopsy findings in burns patients. Burns 2013;39:583–8.

17. Elkafssaoui S, Hami H, Mrabet M, Bouaiti E, Tourabi K, Quyou A, et al.

Predictive factors of mortality of the burnt persons: study on 221 adults hospitalized between 2004 and 2009. [Article in French] Ann Chir Plast Esthet 2014;59:189–94. [Abstract] 18. Kraft R, Herndon DN, Finnerty CC, Cox RA, Song J, Jeschke MG. Predictive Value of IL-8 for Sepsis and Severe Infections After Burn Injury: A Clinical Study. Shock 2015;43:222–7.

19. Stewart BT, Gyedu A, Agbenorku P, Amankwa R, Kushner AL, Gibran N. Routine systemic antibiotic prophylaxis for burn injuries in developing countries: A best evidence topic (BET). Int J Surg 2015;21:168–72.

20. Coban YK, Erkiliç A, Analay H. Our 18-month experience at a new burn center in Gaziantep, Turkey. Ulus Travma Acil Cerrahi Derg 2010;16:353–6.

21. Saracoglu A, Kuzucuoglu T, Yakupoglu S, Kilavuz O, Tuncay E, Ersoy B, et al. Prognostic factors in electrical burns: a review of 101 patients. Burns 2014;40:702–7.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Tiner yanıklarının genel özellikleri: Tek merkezli bir çalışma Dr. Mustafa Celalettin Haksal,1 Dr. Cağrı Tiryaki,2 Dr. Murat Burç Yazıcıoğlu,2 Dr. Murat Güven,3 Dr. Ali Çiftci,2 Dr. Osman Esen,4 Dr. Hamdi Taner Turgut,2 Dr. Abdullah Yıldırım5 Medipol Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul Kocaeli Derince Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Kocaeli Kocaeli Derince Eğitim ve Araştırma Hastanesi, Yanık Tedavi Merkezi, Kocaeli 4 Kocaeli Derince Eğitim ve Araştırma Hastanesi, Anestezi ve Reanimasyon Kliniği, Kocaeli 5 Kocaeli Derince Eğitim ve Araştırma Hastanesi, Plastik ve Rekonstrüktif Cerrahi Kliniği, Kocaeli 1 2 3

AMAÇ: Bu çalışmanın amacı tinere bağlı yanıkları önlemek için bu yanıkların karakteristik özelliklerini incelemek ve risk faktörlerine olan farkındalığı artırmaktır.

GEREÇ VE YÖNTEM: Tiner yanığı nedeniyle yanık ünitesine kabul edilen hastalar geriye dönük olarak tarandı, hastaların klinik kayıtları kapsamlı bir şekilde incelendi. Ortalama yaşları 27.79±11.49 (dağılım, 16–58 yaş) olan toplam 48 hasta (3 kadın, 45 erkek) çalışmaya alındı.

BULGULAR: Ortalama hastanede kalış süresi 30.25±27.11 (dağılım, 3–110) gündü, ortalama toplam yanık yüzey alanı %32.53±24.06 (dağılım, %3.0–90.0). Toplam 31 hastada yoğun bakım ünitesi ihtiyacı oldu. Tiner yanığı olan hastaların dokuzu kaybedildi (%18.8), geriye kalan 38 hasta tedavileri sonrasında taburcu edildi. Ana ölüm nedeni septisemi (n=7) ve respiratuvar yetersizlikti (n=6). Hastaların 12’sinde inhalasyon yanığı eşlik ediyordu, bunlardan altısı kaybedilmişti (%50). Septisemi (p=0.031) ve inhalasyon hasarı (p=0.01) varlığı açısından karşılaştırıldığında, kaybedilen veya taburcu edilen hastalar arasındaki farklar anlamlı idi.

TARTIŞMA: Tinerle temas, hızlı ve dikkatli tedaviler gerektiren çok ciddi klinik tablolara neden olabilen önemli bir yanık nedenidir. Klinisyenlerin bunun bilincinde olmalı, bu hasta grubunda inhalasyon yanığı ve sepsisin mortalitenin iki önemli nedeni olduğunu bilmelidir. Artan bilinçle önleyici tedbirler tanımlanabilir. Bu hasta grubunda mortalitenin azaltılması için daha fazla çalışma yapılmasına ihtiyaç vardır.

Anahtar sözcükler: İnhalasyon hasarı; mortalite; tiner yanıkları.

Ulus Travma Acil Cerrahi Derg 2017;23(1):51–55

doi: 10.5505/tjtes.2016.66178

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55

ORIG I N A L A R T IC L E

Physical violence among elderly: analysis of admissions to an emergency department Yasemin Kılıç Öztürk, M.D.,1 Erhan Düzenli, M.D.,2 Cem Karaali, M.D.,3 Faruk Öztürk, M.D.4 1

Department of Family Medicine, Tepecik Training and Research Hospital, İzmir-Turkey

2

Department of Emergency Medicine, Medicana Konya Hospital, Konya-Turkey

3

Department of General Surgery, Tepecik Training and Research Hospital, İzmir-Turkey

4

Department of Emergency, Menemen State Hospital, İzmir-Turkey

ABSTRACT BACKGROUND: Physical violence is defined as deliberate use of physical force likely to result in trauma, bodily injury, pain, or impairment. Present study is pioneering effort to evaluate mechanisms and sociodemographic features of physical violence targeting the elderly in Turkey and to investigate preventive measures.

METHODS: Database records and forensic reports were analyzed in this retrospective study of 54 elderly patients with trauma as result of physical violence who were admitted to emergency department of Şanlıurfa Training and Research Hospital between January 2012 and July 2013.

RESULTS: Of the 54 patients evaluated, 50 (92.4%) were male. History of experiencing previous violence was described by 55.6% (n=30) of the patients. Instances of repeat violence and firearm injuries most often occurred in the home (p=0.006, p=0.007). Need for surgical treatment was also greater among cases that occurred in the home (p=0.016).

CONCLUSION: Firearm injury, recurrent violence, and surgical treatment rates were higher among cases that occurred in the home. Urgent preventive measures are especially needed for the elderly who have already been victims of physical violence.

Keywords: Geriatric; injury; neglect; preventive health care; trauma.

INTRODUCTION Elder exploitation is a worldwide problem of human rights and public health. According to data of World Health Organisation, European population aged 65 years and over may reach 25% by 2050. Currently at least 2.7% of older adults worldwide experience physical violence, and that percentage is expected to increase annually.[1] In our country, elder population is estimated to reach 12 million by 2050.[2] It has also been reported that 1 in 10 individuals over 60 years old faces some form of abuse based on statistics from different countries.[3,4] Address for correspondence: Yasemin Kılıç Öztürk, M.D. İzmir Tepecik Eğitim ve Araştırma Hastanesi, Güney Mahallesi, 1140/1 Sokak, No: 1, Yenişehir, İzmir, Turkey Tel: +90 232 - 469 69 69 E-mail: dryko38@gmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):56–60 doi: 10.5505/tjtes.2016.90457 Copyright 2017 TJTES

56

According to the literature, abuse lowers life expectation for elderly victim. Abuse concept includes 5 types: physical, psychological, and sexual abuse, neglect, and financial exploitation.[5,6] Physical violence may result in bodily injury, pain, and function loss in the victim.[7] What makes the problem more profound is that those inflicting physical violence are most often relatives of the victim.[8–10] In such cases, the victim often keeps the violence a secret and refuses to talk about it, which makes resolving the problem more difficult, and may eventually lead to the death of the victim.

In order to avoid elder abuse and exploitation, it is stressed that an older person be removed from an abusive situation during conflict, that care and support be provided, and furthermore, that medical professionals often have the obligation to report instances of abuse.[11] Literature review revealed that 19% of admissions to emergency department are for diseases related to old age.[12] Another study indicated that 3.8% of geriatric patient admissions to emergency department were due to trauma.[13] Unfortunately, we have limited epidemiological data about unknown and unidentified trauma, and thoroughly investiUlus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Kılıç Öztürk et al. Physical violence among elderly

gated data collected from detailed studies occupies a limited place in the literature.

Table 1. Main features of the cases

In the present study, which is a first in our country, the aim was to investigate precautions to prevent elder abuse by evaluating the physical assault mechanisms and sociodemographic features of geriatric patients admitted to emergency department due to physical violence/assault.

n

%

Thorax

18

33.3

Injured body part 12

22.2

Face

9

16.7

Abdomen

8

14.8

Upper extremities

6

11.1

In this retrospective, sectional study, hospital database and juridical reports of patients 65 years of age and older who were admitted between January 1, 2012 and July 1, 2013 to emergency department of Sanlıurfa Mehmet Akif Inan Training and Research Hospital with complaint of physical assault or abuse were reviewed.

Lower extremities

1

1.9

Ethical approval was granted by the ethics committee of Tepecik Training and Research Hospital and permission for the study was given by the management of Şanlıurfa Mehmet Akif İnan Training and Research Hospital. Data including sociodemographic features (age/sex) of the individuals, means of admission (private vehicle/ambulance), trauma mechanism, injured body area, perpetrator identified by the patient, diagnosis, past history of violence, severity of trauma, treatment result, and place where injury took place, were collected and entered into spreadsheet. Injuries to the abdomen or thoracic organs caused by blunt or sharp objects were identified as internal organ injury. The following result criteria were applied to separate patients into 2 groups: patients discharged from emergency after simple treatment (intervention) and patients who had to be hospitalized due to serious injuries.

Descriptive statistics, chi-square and Fisher’s exact test were used for the statistical analysis of the data. P<0.05 was considered statistically significant.

MATERIALS AND METHODS

RESULTS Of 54 elder patients evaluated due to physical violence, 50 (92.4%) were male, and 4 (7%) were female. Total of 48.2% (n=26) patients were between 65 and 69 years of age, 37% (n=20) were between 70 and 74 years of age, and 14.8% (n=8) were between 75 and 79 years of age. Most, 88.8% (n=48), were admitted to emergency department in the afternoon or evening, between 12:00 pm and 8:00 pm. Elders brought to emergency department by private vehicle represented 70.4% (n=38) of study group. Most frequent sites of injury were face/head neck (38.9%; n=21), thoracic region (33.8%; n=18), and abdominal area (14.8%; n=8). When 8 cases of intra-abdominal injuries were studied, isolated organ injury of liver (n=2), intestine (n=2), and splenic injury (n=1) were found, and 3 cases were multi-organ injury.

In 26 cases (48.1%), there was internal organ injury, and in 11 cases (20.4%) there were skin lacerations. According to paUlus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Head or neck

Diagnosis

Internal organ injuries

26

48.1

Skin laceration

11

20.4

Soft tissue injury

6

11.1

Upper extremity fracture

6

11.1

Isolated head trauma

3

5.6

Maxillofacial injury

1

1.9

Lower extremity fracture

1

1.9

Treatment applied

Major surgery

29

53.7

Primary suture

11

20.4

Pharmaceutical treatment

8

14.8

Plaster splint

6

11.1

26

48.1

Firearm

25

46.3

3

5.6

Wounding implement

Stick or similiar object Any limb (hand. foot)

tient’s statement, 63% (n=34) of the injuries happened outside the home, while 37% (n=20) happened in the home. Member of immediate family was identified by patients as perpetrator of physical assault in 14 (25.9%) cases, other relative in 33 (61.1%) cases, and a stranger in 7 (13%) cases. Past history of experiencing violence was described by 55.6% (n=30) of cases (Table1). There was no statistically significant relationship between history of violence and age, gender, hospitalization requirement, or type of perpetrator described by the victim.

History of repeated violence was observed more often when violence took place at home (p=0.006). Number of injuries due to firearm was significantly higher in cases where violent incident took place at home compared with those that took place outside the home (p=0.007) (Table2). Rate of need for surgical treatment was also higher in cases where violence occurred at home (p=0.016) (Table3). No early mortality occurred during the investigation, treatment, and observation of cases in emergency department.

DISCUSSION In all age groups, trauma is still a leading cause of death.[14,15] 57

Kılıç Öztürk et al. Physical violence among elderly

Table 2. Reationship between location of crime, mechanism, and result of violence

Home

Outside

Total p

n % n % n

Mechanism

Stick/Hand/Foot

6

30

23

67.6

29

Firearm

14 70 11 32.4 25

Surgical treatment

No

5

Yes

Total

25

20

58.8

25

0.007 0.016

15 75 14 41.2 29 20 100 34 100 54

Table 3. Factors related to recurrence of violence

Recurrent

First instance

Total

n % n % n

Perpetrator

Immediate family member

10

71.4

4

28.6

14

Other relative

15

45.5

18

54.4

33

Stranger

5

71.4

2

28.6

7

Crime scene

Home

16

80

4

20

20

Outside

14

41.2

20

58.8

34

Result

Discharge

7

41.2

10

58.8

17

Hospitalization

23

62.2

14

37.8

37

According to 2015 report using data obtained from National Trauma Data Bank in the USA, 29.7% of trauma cases were observed in patients aged 65 years and over.[16] From medicosocial point of view, among geriatric age groups, which are considered to be highly vulnerable, trauma as result of physical violence (physical assault) is second to traffic accidents.[17,18] Tanrıkulu et al. reported on importance of falls among cases of geriatric trauma, and it was noted that cases of geriatric violence were 1% of total in their study.[19] This low percentage may be related to regional and cultural differences in 54 cases from 1½ year period included in present study, or may also be related to fact that all of cases of geriatric violence may not have been identified as such. Articles available in the literature indicate that 1 in 10 elders faces abuse but only 1 in 5 or fewer reports the mistreatment.[20] Even minor injuries may increase mortality risk among elderly patients.[21] In unreported cases of violence, patients may recover with simple treatments performed at home or may be too disabled to go to hospital or police by themselves. In the literature, while evaluating data concerning frequency of geriatric assault, it must be kept in mind that the matter is still almost taboo.[19,22,23] Social mores surrounding family and privacy contribute to low rate of reported assault cases. Furthermore, doctors may not suspect assault in case of fall or other injury seen in elder patient.

58

p

0.173 0.006 0.149

Santos et al. reported negative correlation between abuse and aging, with exception of financial abuse. However, though prevalence declined with age, high incidence of injury to head and neck was observed.[8] Martins et al. noted primacy of financial abuse before 75 years of age, and physical or emotional abuse and neglect after 75.[22] Though no significance was found between physical violence and age or gender in this study, larger series are needed to investigate these relationships.

In the literature, most common form of geriatric trauma is traffic accident, most injured areas are head/neck and extremities, and most frequent diagnosis is soft tissue trauma.

[17,19] In our study of geriatric trauma, primarily face, head, and neck injuries were seen, followed by thoracic and abdominal areas. Use of wooden sticks, sharp or penetrating tools, and firearms often cause such injuries in assault cases, and may be related to large number of patients who required surgical treatment after internal organ injuries.

Need for hospitalization of the patients in this group was determined to be 68.5%. This is higher rate than reported

by Kandiş et al., 17%, and higher than that of Tanrıkulu et al., at 12.4%.[17,19] This difference may be due to regional and cultural reasons or severity of trauma and necessity for surgical treatment.

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Kılıç Öztürk et al. Physical violence among elderly

Another important issue is means of arrival to emergency department. In the study of Kaldırım et al., it was reported that 37.45% of patients reached emergency department via ambulance, and 16.1% of these were trauma cases.[12] Another study determined that 70.5% of geriatric patients arrived at emergency department by private car.[17] Present study results indicated 70.4% of elderly emergency department admissions arrived by private vehicle.

In this study, 92.4% of the geriatric violence cases were male.

This data is similar to results of Tanrıkulu et al., but differs from other studies in the literature.[8,17,19] Studies conducted in Turkey indicate high rate of male trauma. Larger social role of male population may be good partial explanation.

Another observation was time of admission to hospital: most were between hours 12:00 pm and 8:00 pm, coinciding with likely hours many family members or caregivers return home from work. No other study was found in the literature with data about admission time, making this valuable preliminary information. Many other factors may also influence time of admission, including climate and environmental conditions, efforts to earn money and get by, and various other elements of daily life; additional studies that examine timing of admission to hospitals are needed.

Literature indicates in majority of geriatric assault cases, perpetrator is child of the victim.[8,9] In our study, in addition to children, spouse or sexual partner was commonly seen.

Undoubtedly, in such a complicated and multifaceted matter, more studies are needed. However, we believe that our study is a pioneer and highlights gap in research of this field.

This study made clear that 55.6% of cases of physical violence had gone to hospital previously as result of violence.

This data is important result indicating recurring nature of physical assault. When compared with data in the literature, rate of recurring cases in our study is remarkably higher and evidences necessity to increase social awareness.[23,24] Keeping this truth hidden from view by burying our head in the sand will lead to destructive results. Study conducted by Fisher et al. also draws similar attention to internal family (domestic) violence.[25] Social ignorance and perpetrators often not being appropriately punished in such cases make the problem worse. Our results in this study indicated that geriatric violence at home even includes injuries from firearms, and sending elders back to such an environment without resolution of causes is worrisome.

Conclusion It is noteworthy that true number of cases of physical violence against the elderly is almost certainly much greater than the number of reported cases. In cases of abuse and physical violence, the perpetrator is usually a member of the immediate family member or other relative, and majority of recurring casUlus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

es occurred at home, including firearm injuries. Factors influencing reporting include fears of facing violence again, harming relations with family members, and anxiety about being sent to protective government institution and legal procedures.

New, broad investigations taking these factors into consideration will contribute to increased social awareness.

Emergency service doctors are of key importance in geriatric violence cases, and they, as well as general practitioners who are familiar their patients and relatives, should keep this problem in mind. Sensitive questioning of the patients could be the first step toward resolution. General Practitioners often get to know their patients well and can evaluate many aspects of a case. Family doctors are well positioned to shed light on violence cases.

In order to keep elders from violent circumstances and to avoid recurrence, shelters for the elderly, similar to those for women, could be established. Furthermore, education of nursing staff and having the means to initiate legal proceedings in such shelters would reduce the number of offenses and contribute to individual safety.

Conflict of interest: None declared.

REFERENCES 1. Sethi D, Wood S, Mitis F, Bellis M, Penhale B, Marmolejo II, et. al.

European report on preventing elder maltreatment. Rome: World Health Organization 2011 Møller & Kompagni 2011. p. 1–10. Available at: 01.01.2015. http://www.euro.who.int/__data/assets/pdf_ file/0010/144676/e95110.pdf 2. Bilir N. Yaşlılık ve halk sağlığı. İçinde: Gökçe Kutsal Y, Joseph Troisi (Ed): Yaşlılık gerçeği. Ankara: Hacettepe Üniversitesi Hastaneleri Basımevi; 2004. s. 11–29.

3. Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health 2010;100:292–7.

4. Dong X, Simon M, Mendes de Leon C, Fulmer T, Beck T, Hebert L, et al.

Elder self-neglect and abuse and mortality risk in a community-dwelling population. JAMA 2009;302:517–26.

5. Perdue PW, Watts DD, Kaufmann CR, Trask AL. Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death. J Trauma 1998;45:805–10.

6. National Research Council (US) Panel to Review Risk and Prevalence of Elder Abuse and Neglect; Bonnie RJ, Wallace RB, editors. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington (DC): National Academies Press (US); 2003. 2, Concepts, Definitions, and Guidelines for Measurement. Available at:30.12.2015 http:// www.ncbi.nlm.nih.gov/books/NBK98792/.

7. Phillips LR, Guo G, Kim H. Elder mistreatment in U.S. residential care facilities: the scope of the problem. J Elder Abuse Negl 2013;25:19–39.

8. Santos CM, De Marchi RJ, Martins AB, Hugo FN, Padilha DM, Hilgert JB. The prevalence of elder abuse in the Porto Alegre metropolitan area.

Braz Oral Res 2013;27:197–202.

9. Naughton C, Drennan J, Lyons I, Lafferty A, Treacy M, Phelan A, et al.

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Kılıç Öztürk et al. Physical violence among elderly Elder abuse and neglect in Ireland: results from a national prevalence survey. Age Ageing 2012;41:98–103.

10. Caykoylu A, Ibiloglu AO, Taner Y, Potas N, Taner E. The correlation of childhood physical abuse history and later abuse in a group of Turkish population. J Interpers Violence 2011;26:3455–75.

11. Kaldırım Ü, Tuncer SK, Ardıç S, Tezel O, Eyi YE, Arzıman I, et. al.

Analysis of Elderly Patients Presenting to the Emergency Department via Ambulance. Tr J Emerg Med 2013;13:161–5.

12. 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.

13. Periodic health examination, 1994 update: 4. Secondary prevention of elder abuse and mistreatment. Canadian Task Force on the Periodic Health Examination. CMAJ 1994;151:1413–20.

14. TUİK Ölüm İstatistikleri 2014. Available at: 31.12.2015. http://www. tuik.gov.tr/PreHaberBultenleri.do?id=18623.

15. Arias E, Kochanek KD, Anderson RN. How Does Cause of Death Contribute to the Hispanic Mortality Advantage in the United States?

NCHS Data Brief 2015;221:1–8.

16. Committee on Trauma. American College of Surgeons. NTDB Annual Report Chicago: IL 2015. p. 26.

17. Kandiş H, Karakuş A, Katırcı Y, Karapolat S, Kara İH. Geriatric popula-

tion and forensic traumas. Turk J Geriatrics 2011;14:193–19.

18. Kara H, Bayir A, Ak A, Akinci M, Tufekci N, Degirmenci S, et al. Trauma in elderly patients evaluated in a hospital emergency department in Konya, Turkey: a retrospective study. Clin Interv Aging 2014;9:17–21.

19. Tanrıkulu CS, Tanrıkulu Y. Geriatrik popülasyonda travma analizi: Kesitsel Çalışma. Yeni Tıp Dergisi 2013;30:100–4.

20. Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States: prevalence estimates from a nationally representative study. J Gerontol B Psychol Sci Soc Sci 2008;63:248–54.

21. Goodmanson NW, Rosengart MR, Barnato AE, Sperry JL, Peitzman AB, Marshall GT. Defining geriatric trauma: when does age make a difference? Surgery 2012;152:668–75.

22. Martins R, Neto MJ, Andrade A, Albuquerque C. Abuse and maltreatment in the elderly. Aten Primaria 2014;46 Suppl 5:206–9.

23. Fraga S, Costa D, Dias S, Barros H. Does interview setting influence disclosure of violence? A study in elderly. Age Ageing 2012;41:70–5.

24. Ozsaker E, Demir Korkmaz F, Dolek M. Analyzing individual characteristics and admission causes of elderly patients to emergency departments.

Turk J Geriatrics 2011;14:128–34.

25. Fisher BS, Regan SL. The extent and frequency of abuse in the lives of older women and their relationship with health outcomes. Gerontologist 2006;46:200–9.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yaşlılarda fiziksel şiddet: Acil servise başvuruların analizi Dr. Yasemin Kılıç Öztürk,1 Dr. Erhan Düzenli,2 Dr. Cem Karaali,3 Dr. Faruk Öztürk4 Tepecik Eğitim ve Araştırma Hastanesi, Aile Hekimliği Kliniği, İzmir Medicana Konya Hospital, Acil Tıp Kliniği, Konya, Türkiye Tepecik Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İzmir 4 Menemen Devlet Hastanesi, Acil Servis, İzmir 1 2 3

AMAÇ: Fiziksel şiddet kurbanda travma, yaralanma, ağrı ve işlev kaybına yol açmaya yönelik güç uygulama sonucu oluşan ve en sık görülen şiddet türüdür. Türkiye için bu alanda öncü nitelikteki çalışmada fiziksel şiddete uğrayan yaşlıların sosyodemografik özelliklerin ve şiddet mekanizmasının incelenerek Türk toplumunda yaşlıya yönelik şiddetle savaş için alınabilecek önlemler araştırıldı.

GEREÇ VE YÖNTEM: Geriye dönük çalışmada Ocak 2012 ve Temmuz 2013 tarihleri arasında Şanlıurfa Eğitim ve Araştırma Hastanesi Acil Servisi’ne darp nedeniyle başvuran 54 hastanın veri tabanı ve adli rapor kayıtları değerlendirildi.

BULGULAR: Darp tanılı 54 yaşlı hastanın 50’si (%92.4) erkekti. Olguların %55.6’sında (n=30) mükerrer darp tanımlandı. Mükerrer darp ve ateşli silah yaralanma sıklığı evde gerçekleştiği belirtilen olgularda anlamlı yüksek bulundu (p=0.006, p=0.007). Cerrahi gerektiren yaralanma sıklığı evde gerçekleşen darp olgularında daha sık görüldü (p=0.016).

TARTIŞMA: Ateşli silah yaralanması gibi ciddi yaralanmalar ve mükerrer darp olgularının hane içinde gerçekleşmesi darp nedeniyle başvuran yaşlıların koruma altına alınması gerektiğini göstermektedir.

Anahtar sözcükler: Geriatri; istismar; koruyucu sağlık hizmeti; travma; yaralanma.

Ulus Travma Acil Cerrahi Derg 2017;23(1):56–60

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doi: 10.5505/tjtes.2016.90457

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ORIG I N A L A R T IC L E

Is surgery necessary to confirm diagnosis of right-sided diverticulitis in spite of relevant clinical and radiological findings?

Erkan Yardımcı, M.D.,1 Mustafa Hasbahçeci, M.D.,1 Ufuk Oğuz İdiz, M.D.,1 Musa Atay, M.D.,2 Hüseyin Akbulut, M.D.1 1

Department of General Surgery, Bezmialem Vakıf University Faculty of Medicine, İstanbul-Turkey

2

Department of Radiology, Bezmialem Vakıf University Faculty of Medicine, İstanbul-Turkey

ABSTRACT BACKGROUND: Diverticulosis of the right colon is an uncommon entity. Aim of the present study was to report outcome in patients with right-sided diverticulitis diagnosed using computed tomography (CT) and treated conservatively.

METHODS: Twelve patients with clinical and radiological diagnosis of cecal or right-sided diverticulitis who were treated conservatively between February 2013 and December 2014 were included. Demographic and clinical data were retrospectively analyzed.

RESULTS: Female to male ratio was 1:1 with mean age of 45.08±14.4 years. Mean length of symptom history before admission was 2.08±1.3 days. Most common presenting symptom was right lower abdominal pain, seen in 72.7% of the patients. Abdominal ultrasound alone was performed for 10 patients, and 2 also had abdominal CT. Mean duration of hospitalization was 2.8±1.5 days. All patients were successfully treated with medical therapy. There was no recurrence during mean follow-up period of 8.2±5.6 months.

CONCLUSION: If uncomplicated diverticulitis of the right colon is correctly diagnosed with radiological evaluation, antibiotic therapy and bowel rest should be considered as treatment modality, as there was no recurrence observed in short-term follow-up period and this option presents advantage of avoiding surgical intervention.

Keywords: Antibiotic; cecum; computed tomography; diverticulitis; right colon.

INTRODUCTION Right-sided colonic diverticulitis (RCD), is an uncommon entity in Western countries, constituting between 1% and 3.6% of all colonic diverticular diseases; however, diverticular disease of the colon is diagnosed in almost one-quarter of the patients who presented at emergency departments with acute abdominal symptoms.[1,2] Differential diagnosis is important to decrease rate of negative laparotomy in patients with acute symptoms caused by diverticular disease of the colon.

RCD is usually accompanied by lower right quadrant or ilAddress for correspondence: Ufuk Oğuz İdiz, M.D. Şişli Etfal Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey Tel: +90 212 - 373 50 00 E-mail: oguzidiz@yahoo.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):61–65 doi: 10.5505/tjtes.2016.51460 Copyright 2017 TJTES

Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

iac fossa pain, vomiting, nausea, fever, and anorexia.[3] Due to similar presentation to acute appendicitis, misdiagnosis is common. In the past, it was very difficult to distinguish patients with RCD; therefore, intraoperative diagnosis was common and extensive surgical operations were performed.

[4,5] Currently, accurate diagnosis of RCD is usually feasible using radiological techniques, such as ultrasound (US) and/or computed tomography (CT).[6] Treatment of RCD has varied from conservative management to extensive surgery, such as right hemicolectomy.[7] Initial reports have indicated that RCD may be treated conservatively as successfully as left-sided diverticulitis.[6] Conservative management of RCD may be an effective treatment modality in cases diagnosed with imaging techniques. Surgical treatment may be necessary for diverticular bleeding unresponsive to conservative management, or recurrent and/or complicated diverticulitis in cases with perforation, abscess formation, intestinal obstruction, or fistula.[2,8] Therefore, treatment of RCD remains a controversial issue.

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Yardımcı et al. Is surgery necessary to confirm diagnosis of right-sided diverticulitis in spite of relevant clinical and radiological findings?

The aim of this study was to evaluate RCD patients with regard to clinical presentation, laboratory and imaging findings, and outcomes of conservative management.

MATERIALS AND METHODS The Bezmialem Vakif University hospital institutional review board granted approval for retrospective review of patients who were identified using radiology information system (RIS) and hospital information system (HIS) by entering the words “colonic diverticulitis” and “cecal diverticulitis” in keyword search. In addition, reports of imaging methods used (US and CT) in these cases during the study period (from February 2013 to December 2014) were retrieved. Among cases with colonic diverticulitis, diagnoses of right-sided diverticulitis with acute presentation were then identified using HIS. Patients who had left-sided diverticulitis mimicking right colonic diverticulitis or who were diagnosed with colon tumor were excluded from the study. Pregnant patients and patients without complete data were also excluded.

Patient age, sex, history, comorbidities, presenting symptoms, laboratory results, and radiological findings were analyzed retrospectively. All patients admitted with right lower quadrant pain mimicking acute appendicitis underwent blood testing to determine white blood cell (WBC) count (upper limit of normal = 10 x 103/μL) and C-reactive protein (CRP) level (upper limit of normal = 0.5 mg/dL). All patients also underwent US diagnostic imaging, and depending on the discretion of the surgeon, additional CT. If US examination was not diagnostic for pathology of right lower abdominal pain due to characteristics such as obesity, excessive bowel gas, or edematous and incompressible terminal ileum or cecum, the patients underwent CT scanning. Criteria of CT scanning for diagnosis of right-sided diverticulitis included colonic wall thickening and edema, pericolonic fat infiltration, pericolonic abscess, and extraluminal air around the cecum or ascending colon in the presence of diverticula (Figure 1). Inflamed diverticulum or phlegmon determined by

(a)

US and⁄or CT images determined status of uncomplicated diverticulitis.

Within first 24 hours after admission, attending surgeon decided on appropriateness of conservative management based on clinical and laboratory findings and imaging results. Conservative management included pain control, nothing per mouth except fluids, and intravenous broad-spectrum antibiotics. At discharge, oral antibiotics were given. Patients were re-evaluated at 1week and again at 1 month after discharge.

Statistical Analysis Normally distributed continuous variables were expressed as mean±standard deviation. Categorical variables were expressed as frequency and percentage of appropriate denominator.

RESULTS There were 12 patients included in the study, with mean age of 45.08±14.4 years. Female to male ratio was 1:1. Mean length of symptom history before hospital admission was 2.08±1.3 days. Details of presenting symptoms are provided in Table 1. Localized right lower abdominal pain and pain lasting more than 2 days were most common symptoms, seen in 8 (72.7%) and 7 (58.3%) patients, respectively. Of the patients, 66.6% had elevated WBC count (>10x103/μL), with mean of 11.9x103/μL and 91.6% of the patients had high CRP level (>0.5 mg/dL), with mean of 7.3 mg/dL. US was performed on all patients; 2 also underwent abdominal CT. CT findings are provided in Table 2.

Mean duration of hospitalization was 2.8±1.5 days. All patients were successfully treated with conservative management; there were no complications. Patients had appointment for follow-up in the outpatient clinic 1 week and 1 month after discharge. Patients were interviewed over the phone to identify any recurring symptoms or surgical interventions at mean follow-up of 8.2±5.6 months, and no recurrence was found.

(b)

Figure 1. Cecal diverticulitis. Intravenous contrast-enhanced computed tomography examination revealed multiple diverticula at the level of the cecum ([a], small arrows) and thick-walled cecum ([a], long arrow). Segmental colonic wall thickening ([b], long arrow) and pericolic stranding ([b], small arrow) can also be seen.

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Yardımcı et al. Is surgery necessary to confirm diagnosis of right-sided diverticulitis in spite of relevant clinical and radiological findings?

Table 1. Presenting signs and symptoms Features

n

%

Right lower quadrant pain

8

72.7

Leukocytosis

8 66.6

Pain for >2 days

7

58.3

Fever

4

33.3

Generalized abdominal pain

4

33.3

Nausea/vomiting

2 16.6

Diarrhea

1

8.3

Table 2. Computed tomography findings Criteria

n %

Colonic wall thickening and edema

11

91.6

Pericolonic fat infiltration

9

75

Pericolonic abscess

_

_

1

8.3

Extraluminal air around the cecum or the ascending colon

DISCUSSION RCD is more common than left colonic diverticulitis in Asian populations; however, it is not commonly seen in Western countries.[9] Number of cases identified as RCD with use of imaging techniques has been increasing in recent years. Studies have revealed that in the past, more than 70% of patients with cecal diverticulitis underwent surgery with preoperative diagnosis of acute appendicitis.[10] Therefore, differentiation of RCD from acute appendicitis given similar physical examination findings prior to surgery should be regarded as most important point to prevent unnecessary diagnostic and therapeutic interventions.

Radiological evaluation should be performed for correct diagnosis and appropriate treatment of indeterminate right lower abdominal pain. US evaluation can be used as first modality in selected patients to evaluate right lower abdominal pain.

[11,12] RCD should be considered if US findings show local wall thickening of the colon (>4 mm), regional pericolic fat thickening, oval-shaped or rounded hypoechoic or nearly anechoic structure protruding from segmentally thickened cecal or ascending colonic walls.[12] Sensitivity of US for RCD has been reported in range of 78% to 96%.[13] In study conducted

by Chou et al., abdominal US was shown to diagnose acute uncomplicated right colonic diverticulitis in 23 cases among 934 patients with indeterminate acute right lower abdominal pain. They demonstrated high sensitivity (91.3%) and specificity (99.8%) of US for diagnosis of RCD.[12] Although US is one of the most cost-effective diagnostic modalities, it has Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

some disadvantages, including variability, operator dependency, and difficulty in use with obese patients.[14,15] Previous studies have reported several pitfalls and limitations that lowered diagnostic accuracy of US examinations, such as obesity and excessive bowel gas. It may be logical for very obese patients suspected of having RCD in differential diagnosis of right lower quadrant pain to be sent directly to CT because of difficulty in penetrating tissue with US.[14,15] However, US examinations should be primary imaging technique employed in young adults with normal body mass index and pregnant patients.

Diverticulitis is diagnosed more confidently with CT than abdominal US.[15] CT scan has high sensitivity (93–97%) and specificity (approximately 100%) for diagnosis of diverticulitis.

[16] CT scan may also be helpful to reveal other diseases responsible for lower right abdominal pain, such as acute appendicitis, ileitis, epiploic appendagitis, and inflammatory bowel disease.[17] CT findings supportive of RCD include diverticula, regional colonic wall thickening, local pericolic inflammation, thickening of fascial planes, extraluminal air, extraluminal mass involving the cecum and/or ascending colon.[18–20] Disadvantages of CT scanning are high cost, exposure to ionizing radiation and contrast.[14] Our results indicated that majority of patients who were diagnosed with RCD using CT scan had pericolonic fat infiltration (75%), or colonic wall thickening and edema (99.1%). Although these imaging findings are common findings in several pathologies, such as inflammatory bowel disease or locally advanced colon cancer, presence of diverticula can be considered main pathognomonic criterion for RCD. Therefore, CT should be regarded as effective diagnostic modality for RCD due to presence of characteristic findings.

Treatment of RCD has typically been conservative according to studies published in recent years, contrary to studies in which surgical treatment, including diverticulectomy, wedge resection of the diverticulum, right hemicolectomy, and ileocecal resection were recommended or performed in most patients.[10,15,21] According to Puylaert’s study, RCD has been shown to be common pathology seen for every 15 cases of sigmoid diverticulitis and 30 cases of appendicitis. It was also reported that 40% of RCD patients undergo right hemicolectomy due to presence of mass mimicking colonic tumor when operated on for diverticulitis.[15] Fang et al. reviewed 67 patients who underwent laparotomy for cecal diverticulitis. Right hemicolectomy was performed in 34 (50.7%) of 67 cases and diverticulectomy in 9 (13.4%) cases. In that study, there were 2 deaths and 5 postoperative complications in right hemicolectomy group. Despite mortality and morbidity in the study group, they recommended aggressive surgical resection for patients with cecal diverticulitis.[22] Some retrospective reports have shown low mortality rate (1.4%) of right hemicolectomy for cecal diverticulitis.[23] Therefore, it is logical to perform surgical treatment only if complications of diverticulitis occur or malignancy is strongly suspected based on clinical findings.[8,24,25] 63

Yardımcı et al. Is surgery necessary to confirm diagnosis of right-sided diverticulitis in spite of relevant clinical and radiological findings?

Recurrence after conservative treatment of RCD has been reported in previous studies. In Komuta’s study, failure of conservative management was 20.5% (16 of 80 patients with acute uncomplicated RCD). Interestingly, secondary and tertiary recurrences were seen in 81.25% (13 of 16) and 15.4% (2 of 13), respectively. Consequently, they concluded that conservative management rather than elective surgery should be considered for treatment for acute uncomplicated and recurrent RCD, despite these high recurrence rates.[14] Park et al. published a study of 276 patients with RCD who were treated conservatively over mean follow-up period of 38 months and only 2 patients (1%) developed recurrence.

They concluded that if RCD tended to have benign progress, it should be managed conservatively.[6] Yang et al. retrospectively reviewed cases of 87 patients with right colonic diverticulitis regarding response to conservative treatment (medical treatment alone or appendectomy with postoperative antibiotics) and reported recurrence rate of 12.5% over mean follow-up period of 37.5 months. They found that medical therapy can be safe and effective for both uncomplicated RCD and recurrent patients. Our study also demonstrated that recurrence was not found over short follow-up period (8.2±5.6 months) and conservative treatment alone may be sufficient for uncomplicated RCD.

Conclusion The present study has demonstrated that RCD is a self-limiting disease. If uncomplicated diverticulitis of the right colon is correctly diagnosed with radiological evaluation, conservative treatment with antibiotics and bowel rest should be considered for treatment. Colonic wall thickening, edema, and pericolonic fat infiltration have been observed in majority of patients diagnosed with RCD using CT. In-hospital observation was sufficient and there was no need for surgical intervention during hospital stay. In short-term follow-up, no recurrence was observed and conservative therapy offers advantage of avoiding surgery.

Conflict of interest: None declared.

REFERENCES 1. Sardi A, Gokli A, Singer JA. Diverticular disease of the cecum and ascending colon. A review of 881 cases. Am Surg 1987;53:41–5.

2. Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med 2007;357:2057–66.

3. Paramythiotis D, Papadopoulos VN, Michalopoulos A, Panagiotou D, Panidis S, Digkas E, et al. Inflammation of solitary caecal diverticula:a rare aetiology of acute abdominal pain [corrected]. Tech Coloproctol 2011;15 Suppl 1:43–5.

4. Mörschel M, Becker H. Diagnosis and therapy of cecal diverticulitis. [Article in German] Zentralbl Chir 1993;118:81–3. [Abstract]

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5. Lehnert T, Kleikamp G. Diagnosis and therapy of inflammatory cecal diverticula. [Article in German] Zentralbl Chir 1989;114:1337–40. [Abstract] 6. Park HC, Chang MY, Lee BH. Nonoperative management of right colonic diverticulitis using radiologic evaluation. Colorectal Dis 2010;12:105– 8.

7. Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg 1996;171:244–6 8. Hildebrand P, Kropp M, Stellmacher F, Roblick UJ, Bruch HP, Schwandner O. Surgery for right-sided colonic diverticulitis: results of a 10-yearobservation period. Langenbecks Arch Surg 2007;392:143–7.

9. Issa N, Paran H, Yasin M, Neufeld D. Conservative treatment of rightsided colonic diverticulitis. Eur J Gastroenterol Hepatol 2012;24:1254– 8.

10. Papapolychroniadis C, Kaimakis D, Fotiadis P, Karamanlis E, Stefopoulou M, Kouskouras K, et al. Perforated diverticulum of the caecum. A difficult preoperative diagnosis. Report of 2 cases and review of the literature. Tech Coloproctol 2004;8 Suppl 1:116–8.

11. Kang WM, Lee CH, Chou YH, Lin HJ, Lo HC, Hu SC, et al. A clinical evaluation of ultrasonography in the diagnosis of acute appendicitis.

Surgery 1989;105:154–9.

12. Chou YH, Chiou HJ, Tiu CM, Chen JD, Hsu CC, Lee CH, et al. Sonography of acute right side colonic diverticulitis. Am J Surg 2001;181:122–7.

13. Hsu CC, Chou YH, Lai BH. Sonographic appearances of right-sided colonic diverticulitis. Journal of Medical Ultrasound 1996;4:180–3.

14. Komuta K, Yamanaka S, Okada K, Kamohara Y, Ueda T, Makimoto N, et al. Toward therapeutic guidelines for patients with acute right colonic diverticulitis. Am J Surg 2004;187:233–7.

15. Puylaert JB. Ultrasound of colon diverticulitis. Dig Dis 2012;30:56–9.

16. Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med 2007;357:2057–66.

17. Rao PM. CT of diverticulitis and alternative conditions. Semin Ultrasound CT MR 1999;20:86–93.

18. Scatarige JC, Fishman EK, Crist DW, Cameron JL, Siegelman SS. Diverticulitis of the right colon: CT observations. AJR Am J Roentgenol 1987;148:737–9.

19. Crist DW, Fishman EK, Scatarige JC, Cameron JL. Acute diverticulitis of the cecum and ascending colon diagnosed by computed tomography. Surg Gynecol Obstet 1988;166:99–102.

20. Oudenhoven LF, Koumans RK, Puylaert JB. Right colonic diverticulitis: US and CT findings--new insights about frequency and natural history.

Radiology 1998;208:611–8.

21. Lane JS, Sarkar R, Schmit PJ, Chandler CF, Thompson JE Jr. Surgical approach to cecal diverticulitis. J Am Coll Surg 1999;188:629–35.

22. Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF. Aggressive resection is indicated for cecal diverticulitis. Am J Surg 2003;185:135–40.

23. Vajrabukka T, Saksornchai K, Jimakorn P. Diverticular disease of the colon in a far-eastern community. Dis Colon Rectum 1980;23:151–4.

24. Yang HR, Huang HH, Wang YC, Hsieh CH, Chung PK, Jeng LB, et al.

Management of right colon diverticulitis: a 10-year experience. World J Surg 2006;30:1929–34.

25. Papaziogas B, Makris J, Koutelidakis I, Paraskevas G, Oikonomou B, Papadopoulos E, et al. Surgical management of cecal diverticulitis: is diverticulectomy enough? Int J Colorectal Dis 2005;20:24–7.

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Yardımcı et al. Is surgery necessary to confirm diagnosis of right-sided diverticulitis in spite of relevant clinical and radiological findings?

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Radyolojik ve klinik bulgulara rağmen sağ kolon divertiküllerinin tanısında cerrahi gerekli mi?

Dr. Erkan Yardımcı,1 Dr. Mustafa Hasbahçeci,1 Dr. Ufuk Oğuz İdiz,1 Dr. Musa Atay,2 Dr. Hüseyin Akbulut1 1 2

Bezmialem Vakıf Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul Bezmialem Vakıf Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, İstanbul

AMAÇ: Batı toplumlarında sağ kolon divertikülleri nadir görülmektedir. Bu çalışmanın amacı bilgisayarlı tomografi ile tanısı konan sağ kolon divertiküllerinin konservatif tedavi ile sonuçlarını değerlendirmektir.

GEREÇ VE YÖNTEM: Şubat 2013 ile Aralık 2013 tarihleri arasında klinik ve radyolojik olarak sağ kolon ve çekal divertikülleri olan ve konservatif olarak tedavi edilen 12 hasta çalışmaya alındı. Demografik ve klinik veriler geriye dönük olarak değerlendirildi.

BULGULAR: Çalışmaya katılan kadın ve erkeklerin sayısı birbirine eşitti. Ortalama yaş 45.08±14.4 yıl idi. Hastaların hastaneye başvurmadan önce geçen süre 2.08±1.3 gün olup, en sık görülen semptom sağ alt kadran ağrısıydı (%72.7). On hastaya sadece abdominal tomografi çekilirken, iki hastaya hem abdominal tomografi hem de abdominal ultrasonografi çekilmişti. Ortalama hastanede yatış süresi 2.8±1.5 gün olup hastaların hepsi konservatif olarak tedavi edildi. Ortalama 8.2±5.6 aylık takipte hiçbir hastada nüks gözlenmedi.

TARTIŞMA: Komplike olmayan sağ kolon divertikülleri radyolojik olarak tanımlanabilir, bağırsakların istirahati ile birlikte antibiyotik tedavisi düşük nüks olanları ile tedavi seçeneği olarak kullanılabileceği gibi sonraki dönemlerde cerrahi gerekebileceği akılda tutulmalıdır.

Anahtar sözcükler: Antibiyotik; bilgisayarlı tomografi; çekum, divertikülit; sağ kolon.

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doi: 10.5505/tjtes.2016.51460

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ORIG I N A L A R T IC L E

Evaluation of anatomical and functional outcomes in patients undergoing repair of traumatic canalicular laceration Hasan Aytoğan, M.D.,1 Şeyda Karadeniz Uğurlu, M.D.2 1

Department of Eye Disease, Tepecik Training and Research Hospital, İzmir-Turkey

2

Department of Eye Disease, Katip Çelebi University Faculty of Medicine, İzmir-Turkey

ABSTRACT BACKGROUND: The present study was designed to evaluate functional and anatomical success of traumatic canalicular laceration repair.

METHODS: Consecutive patients who presented at Atatürk Training and Research Hospital Eye Clinic, İzmir Katip Çelebi University Faculty of Medicine and had canalicular laceration repair performed by the same surgeon between January 2009 and December 2014 were included in the study. Demographic data, length of time between injury and surgery, and cause of the trauma, surgical method employed, and duration of follow-up were recorded. Postoperative epiphora was evaluated using Munk score. Patency of lacrimal system was assessed with canalicular irrigation.

RESULTS: Thirty-five male and 6 female patients were included in the study. Mean age of 41 participants was 31.85±18.9 years (range: 1–79 years). Avulsive injury was observed in 66% (n=27), and direct (penetrating) injury in 34% (n=14). Distribution of injured canaliculi was as follows: left inferior canaliculus 63.4% (n=26), right inferior canaliculus 19.5% (n=8), right superior canaliculus 9.8% (n=4), and left superior canaliculus 7.3% (n=3). Thirty-four patients had monocanalicular tube implantation (mini-Monoka) and 10 patients had bicanalicular annular intubation using pigtail probe. Average follow-up time was 6±5.7 months. Munk score was Grade 0 in all patients. Canalicular irrigation indicated all canaliculi were patent.

CONCLUSION: Recent microsurgical techniques result in successful repair of canalicular laceration.

Keywords: Epiphora; tear meniscus; traumatic canalicular injury.

INTRODUCTION Canaliculi are structures that play a role in drainage of tears from the eye and are significant part of the active pump system defined by Jones.[1–3] Risk of canalicular laceration is greater in injuries to medial eyelid and canthal region. Canalicular injury can result in epiphora and cosmetic problems.[4] This condition is particularly seen in children and adolescents, and is often caused by incidents of trauma, such as sports-related accidents, fist fights, falling from bicycles, or traffic accidents.

Address for correspondence: Hasan Aytoğan, M.D. Kazım Dirik Mah., 214 Sok., No: 12, Daire 4, 35100 Bornova, İzmir, Turkey Tel: +90 232 - 444 35 60 E-mail: hasan_aytogan@hotmail.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(1):66-71 doi: 10.5505/tjtes.2016.65021 Copyright 2017 TJTES

66

Lacerations resulting from canalicular trauma are repaired with micro-surgical intervention. Treatment consists of maintaining patent passageway and protecting remainder of the lacrimal drainage system, in addition to repair of canalicular trauma.

The present study was an analysis of the demographic characteristics of patients treated for traumatic canalicular damage, features of the injuries causing the damage, and results of surgical treatment.

MATERIALS AND METHODS Patients who presented at the Atatürk Training and Research Hospital Eye Clinic, İzmir Katip Çelebi University Faculty of Medicine between January 2009 and December 2014 with canalicular injury and who underwent canalicular laceration repair by a single surgeon were included in the study. Approval was obtained from the ethics committee of İzmir Katip Çelebi University Faculty of Medicine. The following data were recorded: demographic details of the patients, cause of Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Aytoğan et al. Evaluation of anatomical and functional outcomes in patients undergoing repair of traumatic canalicular laceration

injury, eye findings associated with the damaged canaliculus, length of time between injury and operation, date of removal of tube, and length of follow-up period. Trauma causing canalicular laceration was classified as direct (penetrating injury usually with a sharp object) or avulsive (secondary to forces leading to traction on the eyelid).

Table 1. Survey 1

Do you experience tearing of the operated eye?

2

Is there any difference compared with the other eye

in terms of tearing?

3

If there is tearing, does it occur indoors, outdoors, or

Surgical intervention was performed using operating room microscope. When proximal and distal ends of canalicular laceration could be identified, monocanalicular silicone tube implantation was performed with mini-Monoka. In cases where distal end was not visible, pigtail probe was used and bicanalicular annular silicone tube intubation was performed. In all patients, canalicular edges were approximated using 8–0 vicryl sutures. Next, any accompanying lid laceration or canthal dislocation was addressed to ensure tissue integrity.

both?

During the postoperative period, eye drops containing tobramycin and dexamethasone were applied 4 times a day, 1 drop each, for 2 weeks. Postoperative follow-up was done at 1 week, 1 month, 3 months and 6 months after the operation. Tube was scheduled to be removed at 3 months post-

Grade 4 Epiphora requiring dabbing more than 10 times per day

20

Etiology

15 10

ac

ci Tra de ffi n c Fa dt llin g fro tre m e An n at im ta al c op Sc k er rat at ch ed in dc g r

of llin

g

ry Fa

le ut C

Po

un

di

ng

5 0

Figure 1. The etiology of canalicular trauma.

Table 2. Munk score Grade 0

No epiphora

Grade 1 Occasional epiphora, requiring dabbing less than

twice a day

Grade 2 Epiphora requiring dabbing 2-4 times per day Grade 3 Epiphora requiring dabbing 5-10 times per day

procedure. Anatomical and functional success was assessed at follow-up after tube removal. Anatomical success was defined as patency of canaliculus to irrigation with saline. Functional success was evaluated with a brief questionnaire (Table 1) and appraisal of patient experience of epiphora using Munk score (Table 2).

RESULTS Mean age of 35 (85%) male and 6 (15%) female patients who underwent unilateral canalicular laceration repair was 31.85±18.9 years (range: 1–79 years).

Figure 2. Monocanalicular tube intubation.

Figure 3. Detection of distal end via pigtail probe.

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cated mild tearing in operated eye, though with no difference in the other eye. Munk score was grade 0 in all patients.

DISCUSSION Due to their anatomical location, canaliculi can easily be affected by orbital trauma. When canalicular trauma is suspected, first of all, detailed examination should be performed under a microscope. If this is insufficient, lavage cannula should be employed to examine the canaliculus.

Figure 4. The patient with Monoka tube attached for 2 years.

Avulsive traumas made up 66% (n=27) of injuries in study group, while 34% (n=14) were direct (penetrating) injuries.

Classification made based on etiology of trauma revealed that among 41 patients, 16 suffered canalicular damage as result of blow/punch, 10 patients were wounded with sharp object, 5 patients fell from height, 4 patients were injured in traffic accident, 3 fell from tree, 2 suffered animal attack, and 1 patient “was scratching his eyelid after dacryocystorhinostomy” (Figure 1).

Distribution of trauma according to location of laceration was as follows: 63.4% (n=26) occurred in left inferior canaliculus, 19.5% (n=8) were seen in right inferior canaliculus, 9.8% (n=4) in right superior canaliculus, and 7.3% (n=3) in left superior canaliculus. Left inferior canaliculus was most frequent site of injury.

There was additional injury in 28 (68.3%) patients of the 41 patients included in the study: eyelid injury in 26 (92.9%), corneal perforation in 1 patient (3.6%), and nasal fracture in the other (3.6%).

Microsurgery was performed, on average, within 39±27.8 hours of time of injury; 3 hours was soonest and 14 days was latest. General anesthesia was used for 78% (n=32) of the patients, while local anesthesia was used for 14.6% (n=6), and sedation anesthesia for remaining 7.4% (n=3).

Monocanalicular intubation was performed in 31 cases and bicanalicular annular intubation with pigtail probe (Figure 2, 3) in 10.

Mean follow-up period was 6±5.7 months (range: 1–19 months). Tubes were removed at average of 5.1±4 months (range: 1–24 months). One patient did not return for removal procedure and Monoka tube remained attached at inferior punctum for 2 years (Figure 4). Tube was displaced in the first week in 1 case due to patient rubbing eyelid.

Lavage revealed patency in all patients. Anatomical success was evaluated as 100%. On questionnaire, 2 patients indi68

Canalicular damage may be classified as result of direct or avulsive injury; however, precise boundaries to distinguish groups are very difficult to implement. While sharp, cutting objects produce clean, straight laceration, effects of many types of blunt trauma can lead to avulsion of the canalicular structures. Incidents that exert tearing force on the lid, such as blunt trauma, traffic accidents, blow with club or similar tool, or a fall can induce lacerations, particularly in weak canalicular portion of the eyelid. Jordan et al. reported that direct injury was responsible for laceration in more than half (54%) of cases.[5] In 25-case review conducted by Wulc et al., they reported 84% avulsive injury and 16% direct injury.

[6] In the present study, too, avulsive injury was observed in majority of the patients; however, it seems that this classification is not used in many series regarding canalicular laceration.[7–9] Canalicular laceration is especially seen in children and young adults. In 222-case series of Kennedy et al., mean age was 20 years.[10] Naik et al. reported in a 24-case series that age range of patients was 10 months to 52 years, with mean age of 16 years.[11] In study conducted by Argın et al.[12] in our country, mean age was 21 and age ranged between 1.5 and 64 years. Mean age was 31 years in study reported by Demir et al.[13] Similarly, in this study, there was broad age range in patient group composed primarily of young adults (mean age: 31 years).

Gender distribution in this study is similar to that seen in the literature, and there is an obvious male predominance.

In study conducted by Kennedy et al.,[10] 166 (75%) of 222 patients were male. Argın et al.[12] reported all 10 cases were male, and 15 (75%) of 20 cases were male in the study of Demir et al.[13] As for the present study, 85% of the 41 patients were male and 15% were female. Given that the most common cause of trauma was blow/punch, male predominance is not surprising.

Kennedy et al.[10] reported 66% inferior canaliculus, 28% superior canaliculus, and 6% both canaliculi affected. Jordan et al.[5] found inferior laceration in 50%, superior laceration in 23%, and bicanalicular laceration in 4% of cases. In the present study, percentage of inferior canalicular injury cases was 83% (n=34), whereas superior canaliculus was site of trauma in 17% (n=7). There were no cases of injury to both canaliculi.

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Table 3. The number of canalicular repair cases and success rates seen in the literature Author

Number of cases

Treatment method

Functional success (%)

Jordan D.R.

222

Bicanalicular annular

97

Liu Z.

47

Bicanalicular annular

96

Lee H.

36

Monocanalicular

92

Wu S.Y.

98

Bicanalicular annular

84

Kersten R.C.

67

Bicanalicular annular

97

Saunders D.H.

51

Bicanalicular annular

73

Canavan Y.M.

57

Varied

38

Hing S.J.

42

Bicanalicular annular

42

Walter W.L.

18

Bicanalicular annular

100

Garber P.F.

17

Monocanalicular

100

Hawes M.J.

24

Bican.nasal

95

Argın A.

10

Varied

100

Yaman A.

3

Varied

100

Oltulu R.

17

Monocanalicular

100

Kuru Ö.

15

Monocanalicular

93

Yener H.

20

Bicanalicular annular

100

Şendul S.Y.

44

Monocanalicular

93

Demir T.

20

Bicanalicular annular

100

Canalicular injury can be accompanied by other injuries to the eye. It has been reported that the most frequently seen accompanying injuries are eyelid laceration, hyphema, corneal abrasion, and globe perforation.[14] In this study, 28 (68%) of 41 patients had additional eye injuries. Most common was laceration of other parts of the eyelid.

Ideal length of period between canalicular trauma and surgery for repair is questionable. Edema and wound healing response at ends of the canalicular and pericanalicular tissue can make it difficult to determine localization of distal edge of laceration.

[10] For this reason, it is recommended that repair should be performed within first 24 to 48 hours after trauma. However, authors such as Hawes et al. have reported successful surgical correction can be performed within first 5 days.[15] Kennedy et al. did not establish any correlation between period post trauma and surgery and postoperative epiphora.[10] In the present study, surgery was performed at average of 39 hours, with 3 hours after injury the soonest, and 14 days the latest, and anatomical and functional success was achieved in all patients.

High success rate achieved in this study suggests that treatment provided by experienced team in appropriate conditions is more important than length of time before operation.

The first step in canalicular repair is to find distal part of the canaliculus. Viscoelastic substances, air, water, methylene blue, or fluorescein may be injected into the lacrimal sac through non-traumatic canaliculus to aid visualization.[7,8] In addition, pigtail probe may be used to detect distal end of cut.[5] AlUlus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

though high surgical success rates have been reported with pigtail probe and annular intubation, this technique has disadvantages of creating false passage and causing damage to the unaffected canaliculus.[16] Surgeon using this method must be experienced and avoid iatrogenic damage to robust nasolacrimal tissues. Another preferred type of intubation is bicanalicular nasal intubation, which, in addition to the risks of annular intubation, also carries risk of damage due to passing through nasal passage.[17] In this study, canalicular laceration repair and mini-Monoka tube implantation was performed in 31 patients, and pigtail probe and annular intubation were used in 10 cases. Excellent results were obtained with both methods, and no difference was observed in terms of anatomical or functional success.

There is no consensus on period of time silicone tube is to remain in place in case of canalicular trauma; recommended period varies from 3 months to 1 year.[18,19] Conlon et al., in an animal model, determined higher canalicular patency when removed at 12 weeks compared to 4 or 8 weeks, and reported that 12 weeks was optimal duration before extraction.

[20] In this study, although intended duration was 3 months, removal occurred later (mean: 5.1 months) due to the fact that follow-up did not take place as scheduled. No complaints of irritation as result of delay were recorded.

Most important complication related to monocanalicular intubation is early tube dislocation. Anastas et al. reported 69

Aytoğan et al. Evaluation of anatomical and functional outcomes in patients undergoing repair of traumatic canalicular laceration

29% occurrence.[21] However, in 19-patient series of Leibovitch et al., early tube dislocation was not observed in any patient.[22] Risk of early tube dislocation can increase, especially in children, due to rubbing and scratching. This complication was only seen in 1 case in this study, when 7-year-old child rubbed his eyelid.

Canalicular repair generally has high success rate.[5,12,13,16,23–33] Bicanalicular intubation has rate ranging from 30% to 100%.

[5,13,15,26,31] Jordan et al.[5] reported success rate of 94% in large series, which included 222 bicanalicular intubations. Success rate in binasal intubation series of 24 cases reported

by Hawes et al. was 95%.[15] Success rate of monocanalicular intubation method has been reported in the range of 60% to 100%.[21–23,30,32,33] High rate of success has also been described in some studies conducted in our country. Argın et al.,[12] Yaman et al.,[29] and Oltulu et al. reported success rate of 100%.[30] In 20 cases of bicanalicular annular intubation performed by Yener et al., anatomical success rate and functional success rate were reported as 100% and 95%, respectively.[31] Early tube dislocation was seen in 1 of 15 cases of monocanalicular intubation reported by Kuru et al., and anatomical and functional success rate were each reported as 93% in that study.[32] Demir et al. reported 100% anatomical success and 95% functional success in 20-patient series.[13] Şendul et al. reported 97% anatomical success and 93% functional success in 44-case series.[33] (Table 3) In present study, anatomical and functional success rate was determined to be 100%.

It is widely thought that inferior canalicular laceration repair is more important and requires mandatory treatment because of the belief that it has more significant role in drainage.

Therefore, repair of superior canalicular laceration may be ignored. Contrary to that general belief, however, Daubert et al. found that inferior and superior canaliculi were equally involved in tear drainage in a scintigraphic study.[34] Moore and Linberg, in an experimental study in which they obstructed single canalicular, determined that subjective findings occur in 56% of upper canalicular obstruction events, and in 63% of lower canalicular obstructions, and concluded that both canaliculi have equal role.[35] The present study had limited number of upper canalicular lacerations, and anatomical and functional success was obtained in all of the superior and inferior canalicular lacerations.

Surgical repair of canalicular trauma yields extremely successful results. Use of modern microsurgical techniques by an experienced team with proper stent use during the healing process ensures good outcome. Though injury may be to only 1 canaliculus, patients need not live with single canaliculus. There is possibility of future additional trauma. Canalicular repair should definitely be performed; however it is important that the surgery be performed under appropriate conditions and by an experienced team.

70

Conflict of interest: None declared.

REFERENCES 1. McCord CD. The lacrimal drainage system. In: Duane TD, Jaeger EA, eds. Clinical Ophthalmology. Philadelphia: Harper&Row Pub, 1985:1.

2. Royer J, Adenis JP, Bernard JA. L’appareil Lacrimal. Paris: Masson 1982;17:25–75.

3. Menteş J. Lakrimal sistem; anatomi, fizyoloji, fizyopatoloji. In: Hasanreisoğlu B, editör. XI. Ulusal Oftalmoloji Kursu Bülteni. Ankara: Yıldırım Ofset Basımevi; 1991. s. 18–28.

4. Günenç Ü, Maden A. Kapak yaralanmalarında silikon tüp ile kanalikül rekonstrüksiyonu. Türkiye Klinikleri Oftalmoloji 1995;4:1–4.

5. Jordan DR, Ziai S, Gilberg SM, Mawn LA. Pathogenesis of canalicular lacerations. Ophthal Plast Reconstr Surg 2008;24:394–8.

6. Wulc AE, Arterberry JF. The pathogenesis of canalicular laceration. Ophthalmology 1991;98:1243–9.

7. Morrison FD. An aid to repair of lacerated tear ducts. Arch Ophthalmol 1964;72:341–2.

8. Lerner HA, Boynton JR. Sodium hyaluronate (Healon) as an adjunct to lacrimal surgery. Am J Ophthalmol 1985;99:365.

9. Yang X, Jin T, Pang X. Repair of a canalicular laceration in a neonate. J Pediatr Ophthalmol Strabismus 2005;42:306–7.

10. Kennedy RH, May J, Dailey J, Flanagan JC. Canalicular laceration. An 11-year epidemiologic and clinical study. Ophthal Plast Reconstr Surg 1990;6:46–53.

11. Naik MN, Kelapure A, Rath S, Honavar SG. Management of canalicular lacerations: epidemiological aspects and experience with Mini-Monoka monocanalicular stent. Am J Ophthalmol 2008;145:375–380.

12. Argın A, Demir MN, Duman S. Kanalikül kesilerinde onarım teknikleri.

Türk Oftalmoloji Gazetesi 2001;31:327–32.

13. Demir T, Gül FC. Results of Canalicular Laceration Reperation by Pigtail Probe and Silicon Tube Entubation. İnönü Üniversitesi Tıp Fakültesi Dergisi 2011;18:87–90.

14. Tazartès M, Bénarafa H. Orbital, eyelid and lacrimal trauma. [Article in French] Rev Prat 1995;45:437–41. [Abstract] 15. Hawes MJ, Segrest DR. Effectiveness of bicanalicular silicone intubation in the repair of canalicular lacerations. Ophthal Plast Reconstr Surg 1985;1:185–90.

16. Walter WL. The use of the pigtail probe for silicone intubation of the injured canaliculus. Ophthalmic Surg 1982;13:488–92.

17. Garber PF. Management of injuries to the lacrimal system, in bosniak.

SL (ed). Advences in opthalmic plastic and recosntructive surgery. The lacrimal system Vol 3 New york Pergamon press 1984;175–95.

18. Kersten RC, Kulwin DR. “One-stitch” canalicular repair. A simplified approach for repair of canalicular laceration. Ophthalmology 1996;103:785–9.

19. Liang T, Zhao KX, Zhang LY. A clinical application of laser direction in anastomosis for inferior canalicular laceration. Chin J Traumatol 2006;9:34–7.

20. Conlon MR, Smith KD, Cadera W, Shum D, Allen LH. An animal model studying reconstruction techniques and histopathological changes in repair of canalicular lacerations. Can J Ophthalmol 1994;29:3–8.

21. Anastas CN, Potts MJ, Raiter J. Mini Monoka silicone monocanalicular lacrimal stents: Subjective and objective outcomes. Orbit 2001;20:189– 200.

22. Leibovitch I, Kakizaki H, Prabhakaran V, Selva D. Canalicular lacerations: repair with the Mini-Monoka® monocanalicular intubation stent.

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23. Lee H, Chi M, Park M, Baek S. Effectiveness of canalicular laceration repair using monocanalicular intubation with Monoka tubes. Acta Ophthalmol 2009;87:793–6.

24. Wu SY, Ma L, Chen RJ, Tsai YJ, Chu YC. Analysis of bicanalicular nasal intubation in the repair of canalicular lacerations. Jpn J Ophthalmol 2010;54:24–31.

25. Liu Z, Sha X, Liang X, Wang Z. Use of silicone tubes to repair canalicular lacerations via a novel method. Eye Sci 2013;28:195–200.

26. Saunders DH, Shannon GM, Flanagan JC. The effectiveness of the pigtail probe method of repairing canalicular lacerations. Ophthalmic Surg 1978;9:33–40.

27. Canavan YM, Archer DB. Long term rewİev of injuries to the lacrimal drainage apparatus. Trans optahlmol Soc UK 1979;99:201–4.

30. Oltulu R. Lakrimal kanalikül Travmalı olguların değerlendirilmesi. Turk J Ophthalmol 2014;44:219–22.

31. Yener Hİ, Gül A, Kılıç A, Çinal A, Yaşar T, Demirok A. Annular Silicon Tube Intubation With Pigtail Probe In Canalicular Injuries. Dicle Tıp dergisi 2008;35:245–8.

32. Kuru Ö, Yuttaşer Ocak S, Yıldırım MA, Erden B, Aslankurt M, Elçioğlu MN. Clinical Features of Patients with Post-Traumatic Canalicular Laceration and the Effectiveness of Surgical Repair with Monoka Tube Intubation. Turk J Ophthalmol 2015;45:14–7.

33. Şendul SY, Çağatay HH, Dirim B, Demir M, Çınar S, Üçgül C, et al.

Reconstructions of Traumatic Lacrimal Canalicular Lacerations: A 5 Years Experience. The Open Access Journal of Science and Technology 2015;3:6.

28. Hing SJ. A retrospective study of lacrimal canaliculus injuries in Auckland. Trans Ophthalmol Soc N Z 1984;36:72–3.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Travmatik kanalikül kesi tamiri yapılan hastalarda anatomik ve fonksiyonel başarının değerlendirilmesi Dr. Hasan Aytoğan,1 Dr. Şeyda Karadeniz Uğurlu2 1 2

Tepecik Eğitim ve Araştırma Hastanesi, Göz Hastalıkları Kliniği, İzmir Katip Çelebi Üniversitesi Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı, İzmir

AMAÇ: Tek taraflı kanaliküler kesi tamiri uygulanan hastalarda anatomik ve fonksiyonel başarıyı değerlendirmek.

GEREÇ VE YÖNTEM: 1 Ocak 2009 ile 31 Aralık 2014 tarihleri arasında tek cerrah tarafından kanalikül kesi tamiri yapılan hastalar çalışmaya dahil edildi. Hastaların demografik verileri, travmanın zamanı ve etkeni, uygulanan cerrahi yöntem ve izlem süreleri kaydedildi. Hastaların sulanma yakınmaları cerrahi sonrası entübasyon tüpünün çıkarılmasını takiben en son kontrol muayenede Munk skorlamasına göre değerlendirildi. Gözyaşı yolunun açıklığı kanaliküler irigasyon ile incelendi.

BULGULAR: Tek taraflı kanaliküler kesi tamiri yapılan 41 hastanın (35 erkek, 6 kadın) ortalama yaşı 31.85±18.9 (sınırlar, 1–79) idi. Travma dağılımı indirekt-avülsif yaralanma %66 (n=27), direkt-penetran yaralanma %34 (n=14) şeklindeydi. Kesi yeri sol alt kanalikül %63.4 (n=26), sağ alt kanalikül %19.5 (n=8) sağ üst kanalikül %9.8 (n=4) ve sol üst kanalikül %7.3 (n=3)olarak saptandı. Kırk bir hastadan 10’una pigtai lprob ile bikanaliküler anüler entübasyon uygulanırken, 31 hastaya monokanaliküler entübasyon uygulandı. İzlem süresi ortalama 6±5.7 ay idi. Hastaların tümünde lavaj açık bulundu. Munk skoru hastaların tamamında grade 0 olarak belirlendi.

TARTIŞMA: Günümüzde mikrocerrahi yöntemlerle yapılan kanalikül kesi tamiri ile çok başarılı sonuçlar elde edilmektedir.

Anahtar sözcükler: Epifora; göz yaşı menisküsü; travmatik kanlikül kesisi.

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S HO RT REP OR T

Anticoagulant-induced breast hematoma Ebubekir Gündeş, M.D.,1 Kamuran Cumhur Değer, M.D.,1 Erdal Taşcı, M.D.,2 Aziz Serkan Senger, M.D.,1 Mustafa Duman, M.D.1 1

Department of Gastroenterology Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul-Turkey

2

Department of Thoracic Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul-Turkey

ABSTRACT Warfarin is the most commonly used oral anticoagulant and is widely prescribed to prevent thromboembolic events. Warfarin-dependent spontaneous breast hematoma is a very rare complication. Presently described is rare case of warfarin-induced breast hematoma.

Keywords: Anticoagulant; hematoma; warfarin.

Warfarin inhibits the vitamin K-dependent clotting factors in the liver; the most important complication of warfarin use is excessive bleeding.[1] Warfarin-induced spontaneous breast hematoma is a very rare complication.

A 58-year-old female patient was hospitalized in cardiology clinic of the hospital with diagnosis of heart failure. Consultation was requested because of left breast swelling, redness, and pain. There was no history of trauma. Mitral and aortic valve replacement had been performed 17 years earlier. For the last year, she had been in follow-up due to right heart failure. She was taking warfarin 5 mg/day on a regular basis.

Physical examination was notable for hypotension and tachycardia. Left breast volume was considerably larger than the other breast, and markedly ecchymosed and tender (Figure 1). Laboratory investigations revealed high international normalized ratio (3.8 sec), and prolonged prothrombin time (25 sec) and activated partial thromboplastin time (40 sec). Red blood cell levels were fairly low: hemoglobin: 6.9 gr/dL and hematocrit: 19%. White blood cell and platelet counts were within normal ranges.

Address for correspondence: Ebubekir Gündeş, M.D. Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Gastroenteroloji Cerrahisi Kliniği, İstanbul, Turkey Tel: +90 216 - 500 15 00 E-mail: ebubekir82@hotmail.com Qucik Response Code

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Breast ultrasonography revealed collection area beginning from level of anterior axillary line that encompassed the left breast and spread to the anterior thoracic wall. Computerized tomography also revealed widespread hematoma in the left breast and left pectoral region (Figure 2).

The patient underwent surgery and 1000 mL of defibrinated blood was drained from hematoma via supramammary incision. Transfusion of 3 units of red blood cells and 3 units of fresh frozen plasma was administered. Packing was applied to fill the pouch due to continuous oozing-type bleeding from the wound bed. Depacking was performed after 24 hours, and no bleeding was observed in the hematoma bed. A tight bandage was applied, and the patient was transferred to the cardiology department on second postoperative day. Tight bandage was removed on postoperative day 7. Written informed consent was obtained from the patient for the publication of this case report and accompanying images.

Warfarin can lead to severe, life-threatening bleeding in some patients as result of the narrow therapeutic range of the drug, despite its antithrombotic benefits. Hemorrhagic complications are seen in approximately 10% of those under anticoagulant therapy. Bleeding is usually encountered in the skin, or genitourinary, gastrointestinal, spinal, or intracranial regions. Hematomas due to anticoagulant therapy occurring in extremely rare locations have been reported in the literature, such as retropharyngeal hematoma,[2] rectus sheath hematoma,[3] esophageal hematoma[4] and breast hematoma.[5] Breast hematoma is extremely rare in patients without history of trauma. Thrombocytopenia, coagulation disorders, or history of anticoagulant therapy should be investigated in such cases. Bleeding creates palpable breast mass, density Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Gündeş et al. Anticoagulant-induced breast hematoma

Figure 2. Computerized tomography showing widespread hematoma in left breast and pectoral region.

enough to require blood transfusion, we believe that surgery must be considered without delay.

Conflict of interest: None declared.

REFERENCES Figure 1. Markedly enlarged, ecchymosed, and tender breast due to hematoma.

increase, and color change. Bleeding can also spread to the chest wall. Red blood cell transfusion and surgery may be needed in such cases.[5] In conclusion, medical treatment may be adequate for selflimited small breast hematoma; however, in cases with risk of necrosis in the skin of the breast or if hematoma is extensive

1. Landefeld CS, Beyth RJ. Anticoagulant-related bleeding: clinical epidemiology, prediction, and prevention. Am J Med 1993;95:315–28.

2. Toker I, Duman Atilla O, Yesilaras M, Ursavas B. Retropharyngeal Hematoma due to Oral Warfarin Usage. Turk J Emerg Med 2016;14:182–4.

3. Yunokizaki H, Tamura K, Li ZL, Abe T. Large spontaneous rectus sheath hematoma associated with severe anemia. Internal medicine 2015;54:349.

4. Guzman R, Ding L, Watson TJ, Hobbs SK, Litle VR. Spontaneous esophageal hematoma in a patient with atrial fibrillation. Ann Thorac Surg 2013;95(3):1089–91.

5. Özdemir B, Bayram AS, Bolca N, Kumbay E. Warfarin-Induced Chest Wall and Breast Hematoma in an Elderly Female Patient with Atrial Fibrillation: Original Image. Turkiye Klinikleri J Med Sci 2008;6:28.

KISA RAPOR - ÖZET

Antikoagülan tedaviye bağlı meme hematomu Dr. Ebubekir Gündeş,1 Dr. Kamuran Cumhur Değer,1 Dr. Erdal Taşcı,2 Dr. Aziz Serkan Senger,1 Dr. Mustafa Duman1 1 2

Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Gastroenteroloji Cerrahisi Kliniği, İstanbul Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Göğüs Cerrahisi Kliniği, İstanbul

Tromboembolik olayların önlenmesinde yaygın olarak kullanılan varfarin en sık kullanılan oral antikoagülandır. Varfarine bağlı spontan meme hematomu oldukça nadiren görülen bir komplikasyondur. Varfarine bağlı memede hematom gelişmesi nadir bir durumdur.

Anahtar sözcükler: Antikoagülan; hematom; varfarin.

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CA S E REP OR T

A rare cause of ileus: late jejunal stricture following blunt abdominal trauma Ulaş Aday, M.D.,1 Ebubekir Gündeş, M.D.,1 Kamuran Cumhur Değer, M.D.,1 Hüseyin Çiyiltepe, M.D.,1 Şükran Kayıpmaz, M.D.,2 Mustafa Duman, M.D.1 1

Department of Gastrointestinal Surgery, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital, İstanbul-Turkey

2

Department of Patology, Kartal Dr. Lütfi Kırdar Training and Research Hospital, İstanbul-Turkey

ABSTRACT Small intestinal stricture forming in the late phase following nonpenetrating abdominal trauma is rare cause of ileus. It has often been suggested that it is result of localized feeding deficiency on the intestinal wall related to minor trauma in the mesentery. Laparoscopy has been increasingly used for diagnosis and treatment. Diagnosis should be supported by pathological analyses in case of intestinal stenosis related to blunt abdominal traumas.

Keywords: Intestinal stenosis; laparoscopy; trauma.

INTRODUCTION Small intestinal obstruction forming in the late phase following blunt abdominal trauma is quite rare; studies have reported rate as 1%.[1,2] It is often caused by fibrotic scar formation and blockage of passage entry during healing process of ischemic areas, which develop as result of localized damage to the intestinal wall or the mesentery.[1–4] A 37-year-old male patient, who had occupational accident 2 years prior, was surgically treated at our clinic after presenting with occasional abdominal pain and swelling that had been going on for a year.

Presently described is rarely seen case of patient diagnosed with post-traumatic jejunal stricture.

CASE REPORT A 37-year-old male patient presented at the clinic with complaints of occasional abdominal pain and distension that had been going on for a year. The patient’s history revealed that Address for correspondence: Ulaş Aday, M.D. Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi, 34000 İstanbul, Turkey Tel: +90 216 - 459 44 40 E-mail: ulasaday@gmail.com Qucik Response Code

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he had previously been treated at another clinic for left iliac wing fracture following a fall from a tractor and that he had been discharged without surgical procedure. His physical examination revealed distended abdomen, increase in intestinal sounds and tympanism in the left upper quadrant, and mild sensitivity. He had linear scar tissue 10 cm in length on the left iliac wing as result of the traumatic skin laceration. The patient had no known chronic disease or earlier history of surgery.

Standing abdominal computed tomography indicated dilated loops of small bowel segments. The patient’s hemoglobin level was 9.6 g/dL (normal range: 11.1–17.1 g/dL), hematocrit volume was 29.9% (normal range: 33–54%), albumin level was 3.2 g/dL (normal range: 3.5–5.2 g/dL), and C-reactive protein level was 4.74 mg /dL (normal range 0–0.34 mg/dL). His other laboratory parameters were within normal limits. Oral and intravenous contrasted abdominopelvic tomography revealed dilated jejunal loops and obstructed area with partial passage at the end point of dilatation. There was also thickening and irregularity in the mesentery of the same segment (Figure 1).

Nasogastric tube was inserted and medical observation was initiated; however, upon seeing no development in his clinical condition, laparoscopic exploration was performed. Fibrotic thickening was seen in the mesentery of the jejunal segment about 80 cm from the ligament of Treitz, and circular fibrotic area of 1 cm diameter was observed on the intestinal wall. It was also seen that the proximal segment was quite dilated.

Laparoscopic segmental resection and side–to-side jejunojejunal anastomosis were performed. Macroscopic evaluation of the resected portion revealed circular cicatricial area causing narrowness, fibrotic thickening in the mesentery, and dilaUlus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Aday et al. A rare cause of ileus

Figure 2. Image of the resected portion.

Figure 1. Abdominal tomography section with oral and intravenous contrast.

tation and edema in the proximal loop. It was also observed that distal crossing diameter was quite narrowed (Figure 2).

The patient was discharged on post-operative day 8 without any problems. Pathological analysis demonstrated focal ulcerated area and active chronic nonspecific inflammation of the site (Figure 3).

DISCUSSION Ileus related to post-traumatic intestinal stenosis is rare; studies have reported that rate is about 1%.[1,2] Jejunal stricture related to blunt abdominal trauma often form as result of minor trauma to the mesentery or the intestinal wall. There may be no symptoms that can be seen in the clinical condition of the patient in the early phase.[1,3] Small laceration, hematoma in the mesentery, or contusion and mural hematoma on the intestinal wall give way to localized ischemia. Inadequate mucosal feeding causes bacterial translocation, and ulcer formation and inflammation during tissue healing result in fibrosis and scarring. Authors agree that feeding deficiency related to damaged mesentery is primary reason for stricture formation.[4–6] In the present case, macroscopic evaluation showed fibrotic thickening in the mesentery of the strictured segment. It was suggested that the damage to the mesentery was the principal reason for the patient’s condition as pathological analysis revealed focal ulcerated area and active chronic nonspecific inflammation in the area.

Although post-traumatic symptoms are frequently seen 5 weeks after the trauma, there are also reports presentUlus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

Figure 3. Low-power view of the ulcer illustrates the depth of the lesion and intense mixed-type inflammation (hematoxylin and eosin, x40).

ing cases that remained asymptomatic for a long time.[2–4] In our case, the patient’s complaints started a year after the traumatic incident. Symptoms related to partial small bowel obstruction, such as intermittent abdominal pain, distension, nausea, and vomiting are seen.[4,6] Rate of proximal jejunal stricture reported in the literature varies; however, Konobu et al. provided rate of 17.9% in their study.[4,7] Diagnostic criteria for the condition are as follows: a) previous history of blunt abdominal trauma, b) absence of described pathology before trauma, c) start of symptoms after trauma, d) radiological detection of intestinal stenosis, e) malignity or signs of specific inflammatory diseases seen in pathological evaluation of the resected portion.[1,2,7] Pathological confirmation is significant for cases in which no differential diagnosis 75

Aday et al. A rare cause of ileus

can be reached through radiological evaluation, and for differentiating cases of Crohn’s disease, intestinal tuberculosis, radiation enteritis, or cancer.[1,2,7,8] There has been increase in laparoscopic surgery as result of technological developments and accumulated experience with laparoscopic procedures. Small intestinal obstruction related to adhesion occurs far less often in intra-abdominal laparoscopic procedure in comparison with open surgery. Studies with large scope have demonstrated that laparoscopic treatment has low morbidity and mortality rates for adhesions, which are the most common reason for small bowel obstruction.[8,9] Adhesions requiring re-operation formed within 30 years in 29% of cases of laparoscopic adhesiolysis.[9,10] In our case, trauma-related stenosis was not initially thought of in the preoperative period. Macroscopic results cast doubt on the diagnostic laparoscopy and the patient was diagnosed based on pathological evaluation. Less invasive laparoscopy to complete the surgical procedure decreased risk of adhesions forming later.

Intestinal stenosis in the late phase related to blunt abdominal trauma is a rare cause of ileus in surgical practice. Resection of the segment causing stricture not only achieves treatment, but also enables histopathological confirmation. Increased surgical experience with laparoscopic procedures has facilitated safe resection of pathological segment and thereby decreased rate of post-operative adhesion formation.

Conflict of interest: None declared.

REFERENCES 1. Kang GH, Jeon TJ, Seo DD, Oh TH, Kim SH, Cho HS, et al. Ileal stenosis occurred 3 months after blunt abdominal trauma. Korean J Gastroenterol 2011;57:370–3.

2. Kaban G, Somani RA, Carter J. Delayed presentation of small bowel injury after blunt abdominal trauma: case report. J Trauma 2004;56:1144– 5.

3. De Backer AI, De Schepper AM, Vaneerdeweg W, Pelckmans P. Intestinal stenosis from mesenteric injury after blunt abdominal trauma. Eur Radiol 1999;9:1429–31.

4. Jones VS, Soundappan SV, Cohen RC, Pitkin J, La Hei ER, Martin HC, et al. Posttraumatic small bowel obstruction in children. J Pediatr Surg 2007;42:1386–8.

5. Loberant N, Szvalb S, Herskovits M, Cohen I, Salamon V. Posttraumatic intestinal stenosis: radiographic and sonographic appearance. Eur Radiol 1997;7:524–6.

6. Maharaj D, Perry A, Ramdass M, Naraynsingh V. Late small bowel obstruction after blunt abdominal trauma. Postgrad Med J 2003;79:57–8.

7. Konobu T, Murao Y, Miyamoto S, Nakamura T, Imanishi M, Ueda S, et al. Posttraumatic intestinal stenosis presenting as a perforation: report of a case. Surg Today 1999;29:564–7.

8. O’Connor DB, Winter DC. The role of laparoscopy in the management of acute small-bowel obstruction: a review of over 2,000 cases. Surg Endosc 2012;26:12–7.

9. Ghosheh B, Salameh JR. Laparoscopic approach to acute small bowel obstruction: review of 1061 cases. Surg Endosc 2007;21:1945–9.

10. Gutt CN, Oniu T, Schemmer P, Mehrabi A, Büchler MW. Fewer adhesions induced by laparoscopic surgery? Surg Endosc 2004;18:898–906.

OLGU SUNUMU - ÖZET

Nadir görülen ileus nedeni: Künt karın travması sonrası geç dönem gelişen jejunal striktür Dr. Ulaş Aday,1 Dr. Ebubekir Gündeş,1 Dr. Kamuran Cumhur Değer,1 Dr. Hüseyin Çiyiltepe,1 Dr. Şükran Kayıpmaz,2 Dr. Mustafa Duman1 1 2

Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Gastroenteroloji Cerrahisi Kliniği, İstanbul Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Patoloji Bölümü, İstanbul

Penetran olmayan karın travmalarına bağlı geç dönemde oluşan ince bağırsak striktürü nadir ileus nedenidir. Sıklıkla mezenterde oluşan minör travmaya bağlı bağırsak duvarındaki lokalize beslenme bozukluğunun sonucu olduğu düşünülmektedir. Laparoskopi tanı ve tedavi uygulamalarında artan oranlarda uygulanmaktadır. Künt karın travmasına bağlı intestinal stenozlarda tanının patolojik değerlendirme ile desteklenmesi gerekir.

Anahtar sözcükler: İntestinal stenoz; laparoskopi; travma.

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CAS E R EP O RT

Case of an intrahepatic sewing needle and review of the literature Özgür Bostancı, M.D., Ufuk Oğuz İdiz, M.D., Muharrem Battal, M.D., Cemal Kaya, M.D., Mehmet Mihmanlı, M.D. Department of General Surgery, Şişli Etfal Training and Research Hospital, İstanbul-Turkey

ABSTRACT An intrahepatic foreign body (FB) is rarely observed. In most cases, object passes from the gastrointestinal tract to the liver via migration. Uncomplicated intrahepatic FB can be followed without surgical intervention; however, complicated intrahepatic FB requires laparoscopy or laparotomy. Presently described is laparoscopic operation on 22-year-old female patient who had incidental sewing needle in the right liver lobe. As there were initially no complications, follow-up monitoring was recommended. However, the patient subsequently complained of stomach pain and developed fever. Laparoscopic exploration located sewing needle in the right liver lobe lateral to the gall bladder with end of needle protruding from the liver. Needle was removed with laparoscopic grasper. Review of the literature regarding 23 other intrahepatic sewing needle cases is also presented.

Keywords: Foreign body; liver; sewing needle.

INTRODUCTION Although swallowing of foreign body (FB) is a problem particularly observed in the pediatric population, it is also seen in adults. Gastrointestinal perforation occurs in less than 1% of patients. Intrahepatic FB is more rarely observed. Intrahepatic FB may enter the liver via direct penetration from the abdominal wall, via the bloodstream, or, most often, via migration from the gastrointestinal tract.[1] Uncomplicated hepatic may be followed-up without requiring surgery.[2] Endoscopy, ultrasonography, and abdominal tomography may help to arrive at diagnosis and plan treatment.[3]

CASE REPORT A 22-year-old female patient with no previous abdominal surgery presented at polyclinic complaining of intermittent pain Address for correspondence: Ufuk Oğuz İdiz, M.D. Şişli Etfal Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey Tel: +90 212 - 373 50 00 E-mail: oguzidiz@yahoo.com Qucik Response Code

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in the abdominal right upper quadrant (RUQ) for 6 months.

On examining the patient, abdominal RUQ was painful on palpation, defense and rebound were negative, and lung sounds were normal. Temperature was also normal at 37°C. Blood examination revealed white blood cell (WBC) count of 9000/ mm3 (normal range: 4000–11000/mm3), C-reactive protein (CRP) was 3 mg/L (normal range: 0–6 mg/L), aspartate aminotransferase (AST) was 60 U/L (Normal range: 4–37 U/L), and alanine aminotransferase (ALT) was 53 U/L (normal range: 0–42 U/L). Ultrasonography revealed radiolucency in the right liver lobe adjacent to the gall bladder, which dictated need for computed tomography (CT). CT image suggested that object similar to radiopaque sewing needle was present in the right liver lobe adjacent to the gall bladder and protruded outside the liver (Fig. 1a). Due to absence of significant complication, initially, the patient was merely monitored closely. In first month, WBC and CRP values remained normal, AST was 65, and ALT was 58. In second follow-up month, because the patient had abdominal RUQ pain and WBC count of 13000/ mm3, CRP of 23 mg/L, AST of 130 U/L, ALT of 120 U/L and temperature was 38°C, abdominal exploration was planned.

Laparoscopic exploration located sewing needle in the right liver lobe lateral to the gall bladder with one end outside the liver (Fig. 1b). There were no abscesses or organ perforations in the abdomen. The end of the sewing needle was freed from the liver and needle was removed with laparoscopic grasper (Fig. 1c). The patient was discharged from the hospital with no complications on second postoperative day. No problem occurred during follow-up every week for 1 month.

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BostancÄą et al. Case of an intrahepatic sewing needle

(a)

(b)

(c)

Figure 1. (a) Computer tomography of the liver before operation. (b) Sewing needle in the liver. (c) Appearance of the liver after removing the sewing needle.

DISCUSSION Considering that FB in the liver is rarely seen, occurrence of sewing needle in the liver is even more rare. Review of the literature disclosed 23 cases to date[2,4â&#x20AC;&#x201C;25] (Table 1). When blunt bodies are swallowed, conservative follow-up is generally sufficient. With respect to radiopaque FBs, patients are monitored with weekly radiograph and regular stool examination.[26] Despite the fact that most FBs are excreted from the body within 4 to 6 days, this period may extend to 4 weeks. When object is not excreted via stool within 3 to 4 weeks or if symptoms such as stomach pain, fever, etc., de-

velop within this period, surgical or endoscopic intervention may be required.[27] Uncomplicated intrahepatic FB can be monitored without surgical intervention; however, complicated intrahepatic FB requires laparoscopy or laparotomy. During surgical intervention, in addition to removing FB, abscess drainage or hepatic segmentectomy may be required in some cases.[11] Gastrointestinal perforation due to swallowing FB is observed in less than 1% of patients. Other manifestations include peritonitis, localized abscess or inflammatory mass, bleeding, or

Table 1. Summary of data from 23 cases of hepatic sewing needle

Deveci, 2014 Xu, 2013 Incedayi, 2012 Bakal, 2012

Sex

Age

Diagnosis

Location Intervention

Female

15 years

Acute abdomen

Right lobe

Laparotomy

Male

5 months

Incidental

Right lobe

Laparotomy

Female

52 years

Incidental

Left lobe

Laparotomy

Male

14 years

Acute abdomen

Right lobe

Laparotomy

Bulakci, 2011

Female

22 years

Incidental

Right lobe

Laparoscopy

Jutte, 2010

Female

45 years

Hepatic abcess

Undisclosed

Laparoscopy

Bolonaki, 2010

Male

21 years

Acute abdomen

Left lobe

Laparotomy

Senol, 2010

Male

27 years

Incidental

Undisclosed

No intervantion

Dominguez, 2009

Male

3 years

Incidental

Left lobe

Laparoscopy

Feng, 2009

Female

76 years

Incidental

Left lobe

No intervantion

Avcu, 2009

Female

16 years

Acute abdomen

Right lobe

Laparotomy

Saitua, 2009

Undisclosed

3 months

Incidental

Undisclosed

Laparotomy

Lanitis, 2007

Female

35 years

Swallowing history

Left lobe

Endoscopy

Azili, 2007

Female

14 years

Swallowing history

Right lobe

Laparotomy

Le Mandat-Schultz, 2003

Male

11 months

Swallowing history

Right lobe

Laparoscopy

Chintamani, 2003

Male

26 years

Hepatic abcess

Right lobe

Laparotomy

Nishimoto, 2003

Male

1 year

Transcutaneous

Left lobe

Laparotomy

Roca, 2003

Female

85 years

Swallowing history

Left lobe

No intervantion

Rahalkar, 2003

Female

23 years

Swallowing history

Left lobe

No intervention

Saviano, 2000

Female

65 years

Transcutaneous

Left lobe

Laparoscopy

Male

2 years

Incidental

Right lobe

No intervention

Female

20 years

Swallowing history

Left lobe

Laparotomy

Male

11 months

Incidental

Left lobe

Laparotomy

Crankson, 1997 Ward, 1978 Abel, 1971

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fistula.[2,28] CT, colonoscopy, and surgical exploration are all useful to examine FB in the gastrointestinal tract.[29] According to the literature, presence of sewing needle in the right liver lobe has been documented in 9 cases and in the left liver lobe in 11 cases. In another 3 cases, localization was not specified. Twelve patients were female and 10 were men; 11 were under the age of 18 years and 12 were over 18 years of age. From a diagnostic perspective, 6 patients went to the hospital after swallowing needle without acute abdomen, 2 patients were diagnosed with liver abscess,[8,19] and needle in the livers of 9 patients were diagnosed as incidental. Four patients were examined for acute abdomen, and FB in the liver was observed.[4,7,9,14] In 1 patient who had acute abdomen, the abdomen was explored with right paramedian incision.

Intraoperatively, needle could not be seen or palpated from outside. Therefore, needle was located with the help of fluoroscopy, which indicated that needle was embedded nearly 1 cm into the right hepatic lobe. It was exposed by opening the overlying liver parenchyma with electrocautery.[7] Two patients evidently inserted the sewing needle transcutaneously into the liver.[20,24] Treatment for sewing needle in the liver is based upon its location, displacement, and presence of symptoms or complications. No intervention was planned for any of the 5 asymtomatic cases which were diagnosed incidentally or had swallowing history. There were no complications on follow-up.

[2,10,13,21,22] In case of a 76-year-old woman who was hospitalized due to complaint of fatigue, X-ray incidentally revealed metal needle in superior abdominal area. Ultrasound examination revealed 3.5 cm-long, metal, needle-like object in the left lobe of the liver. Acupuncture had been performed on the abdomen more than 20 years previously. She had no abdominal pain and no operation was performed. The patient was followed-up for 2 years and the needle remained stable in the liver without any abdominal symptoms.[13] Laparoscopic intervention was performed on 5 patients to remove FB, while laparotomy was preferred for 11 patients.

Bulakçı et al. reported case of a patient who had accidental ingestion of sewing needle in which gastroscopy and colonoscopy were performed 2 weeks after ingestion, but failed to locate the needle. CT scan was performed and they noticed that the needle had migrated from the duodenum to the liver.

Because of moderate abdominal RUQ pain, laparoscopy was performed. Needle was then easily removed due to extracapsular migration.[11] In 1 patient who swallowed 2 needles, 1 in the liver was removed with gastroscopy and the other with laparoscopy.[16] In another case, patient had 2 surgeries. The swallowed needle was not found in the first operation, and the patient used antibiotherapy for inflammation.

After 2 months, the patient had abdominal pain and underwent second operation. Sewing needle was easily found due to migration close to the gallbladder.[14] Of the patients who required surgical intervention, 10 of 16 underwent surgery Ulus Travma Acil Cerrahi Derg, January 2017, Vol. 23, No. 1

due to possible complications. In our case, the patient arrived at the hospital with no initial complications, but ultimately required laparoscopy 2 months later because of stomach pain and fever.

Conclusion Although FB in the liver is rarely seen, when it does occur, it may progress with various complications. Thus, patients with uncomplicated, stable, sewing needle should be followed up with regard to possible complications.

Conflict of interest: None declared.

The authors further declare that they received no financial or editorial assistance.

REFERENCES 1. Lotfi M. Foreign body in the liver. Int Surg 1976;61:228.

2. Crankson SJ. Hepatic foreign body in a child. Pediatr Surg Int 1997;12:426–7.

3. Santos SA, Alberto SC, Cruz E, Pires E, Figueira T, Coimbra E, et al. Hepatic abscess induced by foreign body: case report and literature review.

World J Gastroenterol 2007;13:1466–70.

4. Deveci U, Bakal Ü, Doğan Y. Foreign body in liver: sewing needle. Turk J Gastroenterol 2014;25:737-8.

5. Xu BJ, Lü CJ, Liu WG, Shu Q, Zhang YB. A sewing needle within the right hepatic lobe of an infant. Pediatr Emerg Care 2013;29:1013–5.

6. Incedayi M, Sonmez G, Gulec B, Yigitler C, Basekim C. A migrated sewing needle to the liver. JBR-BTR 2012;95:337.

7. Bakal U, Tartar T, Kazez A. A rare mode of entry for needles observed in the abdomen of children: Penetration. J Indian Assoc Pediatr Surg 2012;17:130–1.

8. Jutte E, Cense H. Liver abscess due to sewing needle perforation. ScientificWorldJournal 2010;10:1532–4.

9. Bolanaki H, Kirmanidis MA, Courcoutsakis N, Tsalkidou EG, Simopoulos C, Karayiannakis AJ. Gastric penetration by an ingested sewing needle with migration to the liver. J Gastrointestin Liver Dis 2010;19:223–4.

10. Senol A, Isler M, Minkar T, Oyar O. A sewing needle in the liver: 6 years later. Am J Med Sci 2010;339:390–1.

11. Bulakçı M, Agayev A, Yanar F, Sharifov R, Taviloğlu K, Uçar A. Final destination of an ingested needle: the liver. Diagn Interv Radiol 2011;17:64– 6.

12. Dominguez S, Wildhaber BE, Spadola L, Mehrak AD, Chardot C. Laparoscopic extraction of an intrahepatic foreign body after transduodenal migration in a child. J Pediatr Surg 2009;44:17–20.

13. Feng QZ, Wang J, Sun H. A sewing needle in liver: a case report and review of the literature. Cases J 2009;2:6520.

14. Avcu S, Unal O, Ozen O, Bora A, Dülger AC. A swallowed sewing needle migrating to the liver. N Am J Med Sci 2009;1:193–5.

15. Saitua F, Acosta S, Soto G, Herrera P, Tapia D. To remove or not remove...asymptomatic sewing needle within hepatic right lobe in an infant.

Pediatr Emerg Care 2009;25:463–4.

16. Lanitis S, Filippakis G, Christophides T, Papaconstandinou T, Karaliotas C. Combined laparoscopic and endoscopic approach for the management of two ingested sewing needles: one migrated into the liver and one stuck in the duodenum. J Laparoendosc Adv Surg Tech A 2007;17:311–4.

17. Azili MN, Karaman A, Karaman I, Erdoğan D, Cavuşoğlu YH, Aslan MK, et al. A sewing needle migrating into the liver in a child: case report and review of the literature. Pediatr Surg Int 2007;23:1135–7.

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Bostancı et al. Case of an intrahepatic sewing needle 18. Le Mandat-Schultz A, Bonnard A, Belarbi N, Aigrain Y, De Lagausie P. Intrahepatic foreign body laparoscopic extraction. Surg Endosc 2003;17:1849.

19. Chintamani, Singhal V, Lubhana P, Durkhere R, Bhandari S. Liver abscess secondary to a broken needle migration-a case report. BMC Surg 2003;3:8.

20. Nishimoto Y, Suita S, Taguchi T, Noguchi S, Ieiri S. Hepatic foreign body - a sewing needle - in a child. Asian J Surg 2003;26:231–3.

21. Roca B. A sewing needle in the liver. South Med J 2003;96:616–7.

22. Rahalkar MD, Pai B, Kukade G, Al Busaidi SS. Sewing needles as foreign bodies in the liver and pancreas. Clin Radiol 2003;58:84–6.

23. Abel RM, Fischer JE, Hendren WH. Penetration of the alimentary tract by a foreign body with migration to the liver. Arch Surg 1971;102:227–8.

24. Saviano M, Melita V, Tazzioli G, Farinetti A, Drei B. Videolaparoscopic removal of a foreign body from the liver. Eur J Surg 2000;166:744–6.

25. Ward A, Ribchester J. Migration into the liver by ingested foreign body.

Br J Clin Pract 1978;32:263.

26. Spina P, Minniti S, Bragheri R. Usefulness of ultrasonography in gastric foreign body retention. Pediatr Radiol 2000;30:840–1.

27. Jecković M, Anupindi SA, Barbir SB, Lovrenski J. Is ultrasound useful in detection and follow-up of gastric foreign bodies in children? Clin Imaging 2013;37:1043–7.

28. Ngan JH, Fok PJ, Lai EC, Branicki FJ, Wong J. A prospective study on fish bone ingestion. Experience of 358 patients. Ann Surg 1990;211:459–62.

29. Lee KF, Chu W, Wong SW, Lai PB. Hepatic abscess secondary to foreign body perforation of the stomach. Asian J Surg 2005;28:297–300.

OLGU SUNUMU - ÖZET

Karaciğer içerisinde dikiş iğnesine ait olgu sunumu ve literatür derlemesi Dr. Özgür Bostancı, Dr. Ufuk Oğuz İdiz, Dr. Muharrem Battal, Dr. Cemal Kaya, Dr. Mehmet Mihmanlı Şişli Etfal Eğitim ve Aratırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

İntrahepatik yabanci cisimler nadir olarak gözlenir. Birçok olguda gastrointestinal kanaldan migrasyon ile karaciğere geçiş olmaktadır. Komplike olmayan intrahepatik yabanci cisimler cerrahi müdahaleye ihtiyaç duyulmadan takip edilebilirler. Komplike olmuş intrahepatik yabanci cisimlerde ise laparotomi veya laparoskopi ile cerrahi müdahaleye gerek duyulabilmektedir. Bu olgu sunumunda karaciğerde insidental olarak dikiş iğnesi saptanmış 22 yaşındaki kadın olgu komplikasyonu olmadığı için takibe alındı. Takipleri sırasında karın ağrısı ve aralıklı ateş şikayetleri gelişti. Laparoskopik olarak eksplore edilen hastada karaciğer sağ lob lateralinde hemen safra kesesi komşuluğunda bir ucu karaciğerden dışarıda olduğu gözlenen dikiş iğnesi laparoskopik grasper ile çıkarıldı. Bu olgu sunumu ile birlikte literatürde bulunan 23 benzer olgu da irdelendi.

Anahtar sözcükler: Dikiş iğnesi; karaciğer; yabancı cisim.

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CAS E R EP O RT

An unusual appearance of complicated hydatid cyst: necrotizing pancreatitis Hasan Ediz Sıkar, M.D., Levent Kaptanoğlu, M.D., Metin Kement, M.D. Department of General Surgery, Kartal Dr. Lütfi Kirdar Training and Research Hospital, İstanbul-Turkey

ABSTRACT Hydatid acute pancreatitis is a rare condition and always presents as consequence of acute edematous pancreatitis. Intrabiliary rupture of hepatic hydatid cysts and obstruction of papillary orifice with hydatid membrane is possible mechanism. A 49-year-old man was admitted with epigastric and right upper quadrant pain, nausea, and vomiting. Computed tomography scan showed 5 x 5 cm cyst in left hepatic lobe, which had ruptured into the biliary tract and caused necrotizing pancreatitis. Endoscopic retrograde cholangiopancreatography trial failed. Surgical choice was drainage of cyst, insertion of T-Tube, exploration of common bile duct and omentoplasty. No additional necessary surgical intervention was necessary for necrotizing pancreatitis. Clinical and laboratory findings resolved rapidly and there was no recurrent pancreatitis episode during 1 year of follow-up. Hydatid edematous and necrotizing pancreatitis have similar progress. Recovery is quick and uneventful after elimination of mechanical obstruction of papillary orifice.

Keywords: Biliary fistula; echinococcosis; pancreatitis.

INTRODUCTION Echinococcosis, also called hydatid disease, hydatidosis or echinococcal disease, is a parasitic illness of tapeworms of the genus Echinococcus. Cysts are most common form of disease appearance, typically in the liver.[1,2] In many cases, lack of symptoms is major obstacle to early diagnosis. Localization and size of cyst play major role in late symptoms, which often include abdominal pain, weight loss, and icterus.

Simple cysts may be easily treated with surgery, punctureaspiration-injection-reaspiration procedure, or albendazole.

Successful therapy for complicated hydatid liver disease, however, continues to be a challenge. Intrabiliary rupture of cyst is one of the life threatening complications of hydatid disease.

Hydatid abscess, cholangitis, obstructive jaundice, and acute pancreatitis are possible clinical presentations. Rupture and obstruction of papillary orifice with hydatid membrane is a Address for correspondence: Hasan Ediz Sıkar, M.D. Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Şemsi Denizer Cad., Cevizli, Kartal, İstanbul, Turkey Tel: +90 216 - 458 30 00 E-mail: hasan.sikar@me.com Qucik Response Code

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potential mechanism for acute pancreatitis. Existing literature reports that hydatid acute pancreatitis presents as edematous pancreatitis.[3,4] Presently described is case of hydatid necrotizing pancreatitis.

CASE REPORT A 49-year-old male patient was admitted to clinic with complaints of epigastric and right upper quadrant pain, nausea, and vomiting continuing for 3 days. Fever (39°C) and jaundice were observed on clinical examination. Laboratory data were: white blood cell count of 17 000/mm3, amylase level of 2192 U/L, total bilirubin level of 8.2 mg/dL, direct bilirubin level of 6.9 mg/dL, aspartate aminotransferase level of 312 U/L, alanine aminotransferase level of 409 U/L, gamma glutamyl transferase level of 318 IU/L, and C-reactive protein level of 93 mg/L. Abdominal computed tomography (CT) scan revealed 5x5 cm cyst in the left hepatic lobe, which had ruptured into the biliary tract. Dilated main biliary ducts and signs of necrotizing pancreatitis were detected (Fig. 1a, 2a).

Endoscopic retrograde cholangiopancreatography trial failed due to difficult cannulation. Patient underwent urgent surgery 24 hours after admission as result of cholangitis. Surgical choice was drainage of the cyst, cholecystectomy, exploration of common bile duct (CBD), and extraction of scolices and hydatid debris from CBD. Isotonic saline solution used to eliminate hydatid debris in biliary tree, and omentoplasty and T-tube drainage of CBD were performed to control bile leakage. In the present case, fine needle aspiration was also 81

Sıkar et al. Necrotizing pancreatitis

(a)

(b)

(c)

Figure 1. Complicated hydatid cyst in the liver. Intrabiliary rupture of cyst in left lobe (a). Drained cyst on seventh postoperative day (b).

Drained cyst 6 months after surgery (c).

(a)

(b)

(c)

Figure 2. Necrotizing pancreatitis. Necrosis on tail of pancreas (a). Peripancreatic fluid collection around necrosis on seventh postoperative day (b). Pancreas 6 months after surgery (c).

performed to assess infected pancreatic necrosis; however, no additional surgical intervention was required for necrotizing pancreatitis.

Clinical and laboratory findings resolved rapidly. Only serum amylase level remained elevated for 2 weeks. CT scan showed peripancreatic fluid collection around necrosis on seventh postoperative day (Fig. 2b). T-tube was removed after 12 days, following evaluation with T-tube cholangiography.

Patient was discharged uneventfully 2 weeks after surgery.

Daily 15 mg/kg albendazole treatment was administered for 6-month period (cycle of 3 weeks with medication followed by 1 week without). There was no recurrent episode of pancreatitis during 1 year of follow-up.

DISCUSSION Hydatid disease usually presents as liver cysts, and frequently produces no symptoms for many years until cyst exerts pressure on surrounding liver tissue.[1,2] In 1% to 25% of cases, hydatid cyst ruptures into the biliary tree, causing biliary colic, obstructive jaundice, and cholangitis.[5] Reports in the literature reveal that hydatid acute pancreatitis presents as edematous pancreatitis.[3,4] Mechanical obstruction of papillary orifice by daughter cysts resulting in reflux of bile with hydatid material and increase in intrapancreatic pressure may be mechanism for pancreatitis.[2,6–10] Our case supports this clinical entity.

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Endoscopic sphincterotomy is safe and well-defined method to treat hydatid cysts with intrabiliary rupture and pancreatitis.[2,6–10] Surgery following initial episode is common choice for most cases. Drainage of cyst, appropriate cavity management, and T-tube drainage of common bile duct to control bile leakage are principles of operation.[2] In our case, difficult cannulation prevented endoscopic sphincterotomy. An emergency operation was performed to eliminate possible cause of necrotizing pancreatitis: mechanical obstruction of papillary orifice.

Conservative management is basis of treatment and results in success in most cases of acute pancreatitis. There is recognized increase in morbidity and mortality in infected versus sterile pancreatic necrosis.[11] Infected pancreatic necrosis is primary indication for surgical intervention, and the goal of successful therapy is to identify patients who progress to infected necrosis.[11,12] Intraoperative fine needle aspiration confirmed sterile necrosis in present patient. CT scan showed peripancreatic fluid collection around necrosis on seventh postoperative day, without expansion of necrosis and no additional surgery was performed for necrotizing pancreatitis.

Hydatid necrotizing and edematous pancreatitis have similar progress. Recovery is quick and uneventful after elimination of mechanical obstruction on papillary orifice.

Conflict of interest: None declared.

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REFERENCES 1. Avgerinos ED, Pavlakis E, Stathoulopoulos A, Manoukas E, Skarpas G, Tsatsoulis P. Clinical presentations and surgical management of liver hydatidosis: our 20 year experience. HPB (Oxford) 2006;8:189–93.

2. Menteş A. Hydatid liver disease: a perspective in treatment. Dig Dis 1994;12:150–60.

3. Zeytunlu M, Coker A, Yüzer Y, Ersöz G, Aydin A, Tekeşin O, et al. Hydatid acute pancreatitis. Turk J Gastroenterol 2004;15:229–32.

4. Mestiri S, Salah HH, Achour H, Jerbi A, Belaid S. Acute pancreatitis, complication of hydatid cysts of the liver opening into the biliary tract.

[Article in French] Chirurgie 1975;101:639–41. [Abstract] 5. Erzurumlu K, Dervisoglu A, Polat C, Senyurek G, Yetim I, Hokelek M. Intrabiliary rupture: an algorithm in the treatment of controversial complication of hepatic hydatidosis. World J Gastroenterol 2005;11:2472–6.

6. Cakır OO, Ataseven H, Demir A. Hydatid acute pancreatitis. Turkiye

Parazitol Derg 2012;36:251–3.

7. Katsinelos P, Chatzimavroudis G, Fasoulas K, Kamperis E, Katsinelos T, Terzoudis S, et al. Acute pancreatitis caused by impaction of hydatid membranes in the papilla of Vater: a case report. Cases J 2009;2:7374.

8. Aydin A, Ersöz G, Tekesin O, Mentes A. Hydatid acute pancreatitis: a rare complication of hydatid liver disease. Report of two cases. Eur J Gastroenterol Hepatol 1997;9:211–4.

9. Ozaslan E, Bayraktar Y. Endoscopic therapy in the management of hepatobiliary hydatid disease. J Clin Gastroenterol 2002;35:160–74.

10. Dumas R, Le Gall P, Hastier P, Buckley MJ, Conio M, Delmont JP. The role of endoscopic retrograde cholangiopancreatography in the management of hepatic hydatid disease. Endoscopy 1999;31:242–7.

11. Fink D, Alverdy JC. Acute pancreatitis. In: Cameron JL, Cameron A, editors. Current surgical therapy. 10th ed. Philadelphia: Elsevier Saunders; 2011. pp. 383–8.

12. Martin RF, Hein AR. Operative management of acute pancreatitis. Surg Clin North Am 2013;93:595–610.

OLGU SUNUMU - ÖZET

Komplike kist hidatikte sıradışı bir tablo: Nekrotizan pankreatit Dr. Hasan Ediz Sıkar, Dr. Levent Kaptanoğlu, Dr. Metin Kement Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

Hidatik akut pankreatit nadir görülen ve her zaman akut ödematöz pankreatit olarak seyreden bir tablodur. Karaciğer kist hidatiğinin safra yollarına açılması ve papiller açıklığın hidatik membranlarla tıkanması olası mekanizmalardan biridir. Epigastrik ve sağ üst kadran ağrısı, bulantı, kusma şikayetiyle başvuran 49 yaşında erkek hastanın bilgisayarlı tomografi incelemesinde karaciğer sol lobunda 5x5 cm ebatlarında kistin safra yollarına açılarak nekrotizan pankreatite yol açtığı görüldü. Endoskopik retrograd kolanjiyopankreatikografi denemesinin başarısız olması nedeniyle hastada kistotomi, koledok eksplorasyonu, T-Tüp drenaj ve omentoplasti operasyonu tercih edildi. Nekrotizan pankreatit için ilave girişim yapılmadı. Klinik ve laboratuvar bulguları hızla düzelen hastada bir yıllık takip süresinde tekrar pankreatit gelişimi saptanmadı. Hidatik ödematöz ve nekrotizan pankreatit benzer kliniğe sahiptir, papillada bulunan tıkanıklığın ortadan kaldırılmasıyla iyileşme süreci hızlı ve sorunsuz olmaktadır.

Anahtar sözcükler: Ekinokokkoz; pankreatit; safra fistülü.

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