TRAUMA 2017 / 3

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ISSN 1306 - 696X

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

Volume 23 | Number 3 | May 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): May (Mayıs) 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 3 May - Mayıs 2017

Contents - İçindekiler Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 173-180 Anti-edematous, anti-inflammatory and neuroprotective effect of etanercept in acute stage in experimental head injury Deneysel kafa travmasında etanercept’in akut dönemdeki anti-ödem, anti-enflamatuvar ve nöroprotektif etkisi Aykanat Ö, Karakoyun DO, Türkoğlu ME, Dinç C 181-187 Beneficial effects of garlic (Allium sativum) oil in experimental corrosive esophageal burns effects of garlic oil in esophageal burns Deneysel korozif özefagus yanıklarında sarımsak yağının (Allium Sativum) yararlı etkileri Şen Tanrıkulu C, Tanrikulu Y, Kılınç F, Bahadır B, Can M, Köktürk F

Original Articles - Orijinal Çalışma 188-192 Diagnostic value of appendicular Doppler ultrasonography in acute appendicitis Akut apandisitte appendiküler dopplerin tanısal değerliliği Uzunosmanoğlu H, Çevik Y, Çorbacıoğlu ŞF, Akıncı E, Buluş H, Ağladıoğlu K 193-198 Macrophage migration inhibitory factor levels correlate with an infection in trauma patients Travma hastalarında makrofaj migrasyonunu inhibe edici faktör düzeyleri enfeksiyonla koreledir Cho YD, Choi SH, Kim JY, Park SJ, Yoon YH, Cho HJ, Yeom JW 199-206 Characteristics of the injuries of Syrian refugees sustained during the civil war Suriyeli mültecilerin süren iç savaş sırasındaki yaralanma özellikleri Kocamer Şimşek B, Dokur M, Uysal E, Çalıker N, Gökçe ON, Deniz İK, Uğur M, Geyik M, Kaya M, Dağlı G 207-211 Efficiency of instant messaging applications in coordination of emergency calls for combat injuries: A pilot study Anlık mesajlaşma uygulamasının harp kaynaklı yaralanmalar için acil iletişim koordinasyonunda kullanım verimliliği: Pilot çalışma Eksert S, Aşık MB, Akay S, Keklikçi K, Aydın FN, Çoban M, Kantemir A, Güngör O, Garip B, Turgut MS, Olcay K 212-216 A rare type of burn injury due to butane gas inhalation Butan gazının inhalasyon yoluyla kötüye kullanımına bağlı nadir görülen yanıklar Seven E, Horoz U, Sarı E, Özakpınar HR, Sandıkcı MM, İnözü E, Tellioğlu AT 217-222 A surgical approach to iatrogenic vascular injuries in pediatric cases İatrojenik pediatrik damar yaralanmalarına cerrahi yaklaşım Beşir Y, Gökalp O, Eygi B, Bahriye Lafcı B, Gökalp G, Yılık L, İner H, Gürbüz A 223-229 Factors affecting mortality among victims of electrical burns Elektrik yanıklarında mortaliteye etki eden faktörler Tiryaki Ç, Haksal MC, Yazıcıoğlu MB, Çiftçi A, Esen O, Turgut HT, Yıldırım A, Güven M

Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

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

Number - Sayı 3 May - Mayıs 2017

Contents - İçindekiler

230-234 Clinicopathological analysis of patients operated for appendiceal mucocele Appendiks mukoseli nedeni ile ameliyat edilen hastaların klinik ve patolojik analizi Abuoğlu H, Yıldız MK, Kaya B, Odabaşı M 235-244 A comparison of the treatment results of open reduction internal fixation and intramedullary nailing in adult forearm diaphyseal fractures Yetişkin önkol diafiz kırıklarında açık redüksiyon internal fiksasyon ve intramedüller çivi tedavi sonuçlarının karşılaştırılması Köse A, Aydın A, Ezirmik N, Yıldırım ÖS 245-250 Predictive factors for early hospital readmission and 1-year mortality in elder patients following surgical treatment of a hip fracture Cerrahi olarak tedavi edilmiş ileri yaş kalça kırığı hastalarında taburculuk sonrası erken dönem hastane başvurusu ve bir yıllık mortalitenin belirleyici faktörleri Sofu H, Üçpunar H, Çamurcu Y, Duman S, Konya MN, Gürsu S, Şahin V 251-257 Retromandibular transparotid approach for subcondylar mandibular fractures: A retrospective study Subkondiler mandibula kırıklarına retromandibular transparotid yaklaşım: Geriye dönük bir çalışma Göçmen G, Varol A, Atalı O, Aktop S, Basa S

Case Reports - Olgu Sunumu 258-262 An unusual etiology in cold injury: Liquefied petroleum gas Donuk hasarında alışılmadık bir etiyoloji: Likit petrol gaz Kapı E, Bozkurt M, Taylan Filinte G, Kuvat SV, Alioğlu C 263-265 Multiple thoracic vertebral fractures as a complication of cardiopulmonary resuscitation: A case report Kardiyopulmoner resüsitasyonun bir komplikasyonu olarak çoklu torasik vertebra kırıkları: Bir olgu raporu Jeong TS, Lee SG 266-268 A rare case of obscure gastrointestinal bleeding: Small bowel varices flowing into the inferior epigastric vein Seyrek görülen okült gastrointestinal kanama: İnferiyor epigastrik vene boşalan ince bağırsak variköz venleri Hoshiai A, Tsurukiri J, Sumi Y 269-271 Rectosigmoidoscopy complicated by bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoderma İki taraflı pnömotoraks, pnömoperitoneum, pnömoretroperitoneum, pnömomediastinum ve pnömoderma ile komplike olmuş rektosigmoidoskopi Hekimoğlu E, Turna A, Kara HV, Demirkaya A, Kaynak K

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EXPERIMENTAL STUDY

Anti-edematous, anti-inflammatory and neuroprotective effect of etanercept in acute stage in experimental head injury Ömer Aykanat, M.D.,1 Durmuş Oğuz Karakoyun, M.D.,1 Mehmet Erhan Türkoğlu, M.D.,2 Cem Dinç, M.D.3 1

Department of Neurosurgery, Dr. Ersin Arslan Training and Research Hospital, Gaziantep-Turkey

2

Department of Neurosurgery, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara-Turkey

3

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

ABSTRACT BACKGROUND: To study the anti-edematous, anti-inflammatory, and neuroprotective effect of etanercept in the model of experimental head injury. METHODS: In this study, 40 male-adult Spraque-Dawley rats, with weight ranging from 250g to 300g, were used. The rats are divided into groups as control; non-penetrating trauma; trauma +NS; post-traumatic normal saline; trauma + D; post-traumatic dexamethasone and trauma + E. All medicines were given into peritoneum. After applying trauma and medicine, rats were decapitated in the 24th hour and the samples were studied histopathologically. RESULTS: In the study, a statistically significant difference was observed between the groups of trauma + NS and trauma dexamethasone according to the variables of edema and inflammation, but no difference was observed according to the variables of neuronal damage, astrocytic damage, and glial apoptosis. Moreover, a significant difference was observed between groups of Trauma + NS and trauma+etanercept and between the groups of trauma + dexamethasone and trauma + etanercept in terms of all variables. CONCLUSION: It was observed that etanercept has anti-edematous, anti-inflammatory, and neuroprotective effect on the rats which experienced traumatic brain injury. Keywords: Brain edema; etanercept; head injury.

INTRODUCTION Head injury is one of the most commonly encountered problems in neurosurgery emergencies. Traumatic Brain Injury (TBI) occurring after head trauma continues to be a primary health problem despite all improvements in modern medicine. After trauma, primary brain injury occurs in central nerve system. Primary brain damage involves intracranial hemorrhage such as subdural hematoma, epidural hematoma, and intracerebral hematoma; skull fractures, scalp injury, brain contusion, and laceration. After head trauma, secondAddress for correspondence: Ömer Aykanat, M.D. Binevler Mah., 52 Nolu Sok., No: 39/5, Şahinbey, Gaziantep, Turkey Tel: +90 342 - 221 07 00 E-mail: yomeycik@hotmail.com Ulus Travma Acil Cerrahi Derg 2017;23(3):173–180 doi: 10.5505/tjtes.2016.43692 Copyright 2017 TJTES

Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

ary damage as well as the primary damage is responsible for the injury occurring in the brain. The secondary damage is a situation depending on various physiopathological events and it could happen after hours or days from the primary brain damage. It has been proven that the secondary damage negatively influences the prognosis for the patients having TBI. Various mechanisms, such as neurotransmitter release, free radical formation, calcium dependent cell damage, gene activation, mitochondrial dysfunction, and inflammation, play role in the secondary damage.[1] Besides, activation of excitatory receptors, hypermetabolism, ischemia, lack of membrane ion pumps, increase in arachidonic acid metabolism, cerebral edema, and acute brain swelling can also mediate secondary damage.[2] The secondary brain injuries spread through neurochemical agents.[3] Excitatory amino acids, such as glutamate and aspartate increase after TBI. They cause swelling in cells, vacuolization, and neuronal death. They not only lead to entry of chlorine and sodium into cells and thus causing acute neuronal swelling but also lead to delayed cell destruction depending on entry of calcium into cells. Increased metabolic activity in traumatized brain and decreased glucose 173


Aykanat et al. Anti-edematous, anti-inflammatory and neuroprotective effect of etanercept in acute stage in experimental head injury

consumption along with inducement of serotonergic system and post-traumatic sympatho-adreno medullary axis further increase the damage. To summarize, various pathophysiological mechanisms are responsible for brain deterioration function, e.g., increased release of neurotransmitters, including acetylcholine, catecholamine, and glutamate occurring immediately after the stroke.[4] These are. Inflammation, which is responsible for the secondary damage, increases exitotoxity and intracranial pressure as a result of brain edema and unless effectively treated, it increases mortality and morbidity. For the treatment, commonly mannitol, hypertonic saline, hypothermia, barbiturate coma, and several anti-inflammatory drugs (TNF-alfa antagonists) are used. Some proinflammatory cytokines released after TBI cause microglial and astrocytic activation and this activation can increase the intensity of the damage. The leading proinflammatory cytokines are TNF-alpha, IL-1, and IL-6 which increase the severity of the damage by causing the secondary neuronal damage, destruction of the blood brain barrier, and cerebral edema.[5,6] Etanercept is a dimer of a protein domain of recombinant TNF-alpha receptor that mediates its effect by binding to IgG1. As it is an antagonist of TNF-Alpha, it shows a strong anti-inflammatory effect. In the previous studies, it that use of etanercept in the patients withTBI has been shown to reduce the dysfunction of blood brain barrier, intracerebral infiltration of neutrophils, and death of neuronal cell. As a result of these, it leads to significant recovery.[7] Our aim in this study was to study the anti-edema, anti inflammatory and neuroprotective effects of etanercept in rats which underwent acute brain trauma.

MATERIALS AND METHODS For this study, 40 male-adult Spraque-Dawley rats, weight ranging from 250g to 300g which have never participated in any test before, were used. The rats were procured from the Laboratory of Animal Studies and Production in Bolu Abant Izzet Baysal University. Until the experimental stage, they were fed with standard rat bait and tap water and kept in a cage for 12 hours night and 12 hours day time. During the whole experiment, standard conditions determined by the National Institute of Health in US were implemented. Induction of trauma and ongoing processes of the experiment were completed in the laboratory of Animal Studies and Production in Bolu Abant Izzet Baysal University. The ethical approval was obtained from the ethics committee of animal studies of Medical Faculty in Bolu Abant Izzet Baysal University on 13.02.2013 with 2012/62 code number.

Groups Experiment animals were randomly divided into 4 groups, each of which has 10 rats. Group 1 (Control group, C): No head trauma was applied 174

to the rats in this group and they were not given any treatment. Group 2 (Trauma+NS group, TP): Head trauma was applied to the rats in this group and then they were given NS. Group 3 (Trauma+Dexamethasone group, TD): First, head trauma was induced in the rats in this group, then dexamethasone was given to them. Group 4 (Trauma+Etanercept group, TE): Head trauma was induced in the rats in this group and etanercept was given to them afterwards.

Anesthesia and Creating Trauma Before Anesthesia, all test subjects were weighed and they were given 50 mg/kg ketamine hydrochloride by intraperitoneal route. After checking anesthetic depth by corneal reflex and tail pinch test, the physiological values such as breathing, pulse, rectal temperature of the animals were recorded at 0th and 24th hour (Table 1, 2). The animals were weltered in the groups in which trauma was to be induced. A skin incision was made along the mid-line in a way in which bregma and lambdoid suture could be seen. Periosteum was separated from the edges so that sutures could be seen totally from the front to the back. A steel disc with diameter of 10 mm and thickness of 3 mm (Figure 3a ve 4a) was placed into the midline between coronal and lambdoid sutures. Subsequently, the rats were placed in prone position on a sponge ground measuring 12x12x43 cm and the trauma tool was positioned as described by Marmarou. A 450g steel bar targeting the animal’s head was dropped from 2 m height through a tube, with 19 mm inside diameter and 25 mm outside diameter. Rats whose respiration was stopped soon after the trauma and whose pupils were dilated and who had seizure (respiratory arrest, 5 rats; seizure, 3 rats) were resuscitated by performing CPR. The resuscitation was continued until the sufficient respiration recovered. The skin incisions were sutured with 2/0 silk suture. The animals whose respiration recovered were taken to their cages. Two rats killed during the trauma were replaced with the new ones, so the equal numbers in the groups were maintained. According to the treatment protocol in respective groups, the test subjects were given dexamethasone or etanercept via intraperitoneal route in various doses soon after the resuscitation. At 24th hour, all animals were decapitated, their brain and brain stem were removed as a whole (Fig. 1) and were fixed by 10% formalin.

Histopathologic Assessment Brain materials, after fixation for 48 hours with 10% buffered formalin, were sliced in coronal plane, sampled as two from front to back and taken in tissue processing. Once they were dehydrated with the formalin, alcohol and xylene successively, paraffin blocks were prepared. After hydration and deparafUlus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Aykanat et al. Anti-edematous, anti-inflammatory and neuroprotective effect of etanercept in acute stage in experimental head injury

Table 1. BBetween-group distribution of physiological parameters measured before trauma (at 0th hour) of test subjects

Control Trauma+NS Trauma+Dexamethasone Trauma+Etanercept (n=10) (n=10) (n=10) (n=10)

Mean±SD Mean±SD

Mean±SD

Mean±SD

Weight

303.8±10.1 307.5±8.1

303.2±10.1

302.4±7.9

Rectal temperature

36.2±0.2

36.2±0.2

36.4±0.2

36.3±0.2

Number of respirations

130.8±0.9

132.5±1.0

134.3±1.1

133.5±1.4

Heart rate

231.2±4.9

233.4±6.1

233.9±3.8

235.4±5.2

NS: Normal Saline; SD: Standard deviation.

Table 2. Between-group distribution of physiological parameters measured after trauma (at 24th hour) of the test subjects.

Control Trauma+NS Trauma+Dexamethasone Trauma+Etanercept (n=10) (n=10) (n=10) (n=10)

Mean±SD Mean±SD

Mean±SD

Mean±SD

Weight

301.3±9.9 306.2±7.3

302.8±5.9

303.1±7.1

Rectal temperature

36.7±0.2

36.1±0.2

36.8±0.3

36.3±0.1

Number of respirations

136.7±0.8

134.3±0.7

138.5±1.1

137.7±1.2

Heart rate

240.4±6.1

239.6±7.3

242.1±4.3

237.5±6.6

NS: Normal Saline; SD: Standard deviation.

finization, hematoxylin eosin stain and immunohisto-chemical stains such as anti caspase-3, anti İBA-1, anti GFAP, and anti NeuN were applied to 5 mm cross-sections taken from paraffin blocks, as the manufacturer states. The preparates studied by Nikon Eclipse 80i light microscope were transferred into the digital platform by Nikon DS-Fi1 camera attachment. In histopathological assessment, existence and severity of edema, and existence and severity of inflammation were used as variables. The existence of edema was assessed according to occurrence of microcystic areas by opening inside of the cells in parenchyma, however, the severity of edema was assessed as 1+ when edema is less than 10% in a magnification of 20x in microscope, 2+ when it is between 10% and 50% and 3+ when it is over %50. The existence of inflammation was conducted by searching the existence of leukocyte with polymorphic nuclei, lymphocyte, plasma cell and eosinophils.

Immunohistochemical Assessment After the most affected sides in terms of cell damage were detected, preparates obtained as immunohistochemically were taken into the digital platform by taking view from the most effected sides three at a time during the large magnification (x200). The number of cytoplasmic cell GFAP, İBA, and Caspase 3 and the number of nuclear positive stained cell of NeuN was counted by means of digital program counter. In immunohistochemical assessment, astrocytes, microglial cells, severity and damage occurring in neurons, and severity and existence of glial apoptosis were taken as variables. The exisUlus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

tence of glial apoptosis was conducted by searching, with anti Caspase 3, the existence of glial cell that shows cytoplasmic positivity. The damage occurring in astrocytes was detected by searching, with anti GFAP (Glial fibrillary acidic protein), the existence of cell that shows cytoplasmic positivity. The damage occurring in microglial cells was detected by searching, with anti Iba-1, existence of cell that shows cytoplasmic positivity while the damage occurring in neurons was detected by searching, with anti NeuN (Neuron-Specific Nuclear Protein), existence of cell that shows nuclear positivity. The severity of the occurring damage in cells was assessed as 1+ when the number of cells that shows nuclear and cytoplasmic positivity was less than 10%, 2+ when it was between 10% and 50%, and 3+ when it was over % 50.

Statistical Methods For the statistical comparison, chi-square tests (q square test) and SPSS 15.0 were used and p value less than 0.05 was regarded as statically significant.

Findings In the traumatic cases, in addition to edema and inflammation; microglial, astrocytic damage, and glial apoptosis were observed, however, in the dexamethasone group edema and inflammation decreased considerably and etanercept group all variables decreased significantly. The assessment of pathologies in different groups is shown in Table 3. 175


Aykanat et al. Anti-edematous, anti-inflammatory and neuroprotective effect of etanercept in acute stage in experimental head injury

While edema, inflammation, microglial cell damage, neuronal damage, astrocytic cell damage, and glial apoptosis was detected in rats in the control group (Fig. 2); edema and inflam-

mation were detected at level 1+ in 10 rats in the normal saline group, 2+ microglial cell damage in 8 animals, 2+ neuronal and astrocytic damage in 7 animals and 2+ glial apoptosis in

Table 3. The table of pathological results Groups

Edema

Inflammation

Microglial damage

C-1 – –

Astrocytic damage

Neuronal damage

Glial apoptosis

C -2

C -3

C -4

C -5

C -6

C -7

C -8

C -9

C -10

T+ NS-1

+

+

++

++

++

T+ NS -2

+

+

++

++

++

T+ NS -3

+

+

++

T+ NS -4

+

+

++

++

++

T+ NS -5

+

+

++

T+ NS -6

+

+

++

++

++

T+ NS -7

+

+

++

++

++

T+ NS -8

+

+

++

++

++

T+ NS -9

+

+

++

T+ NS-10

+

+

++

++

++

++

T+D-1 –

++

T+D-2 +

+

++

++

++

T+D-3 +

+

++

++

++

T+D-4 –

++

++

++

++

T+D-5 –

T+D-6 –

++

++

++

++

T+D-7 +

+

++

++

++

T+D-8 –

T+D-9 +

+

++

++

++

++

T+D-10 +

+

++

++

++

T+E-1 – –

T+E-2 – –

+

+

+

+

T+E-3 – –

T+E-4 + +

+

+

T+E-5 – –

T+E-6 – –

T+E-7 – –

+

+

+

+

T+E-8 – –

T+E-9 – –

T+E-10 –

C: Control; T + NS: Trauma + Normal Saline; T + D: Travma + Dexamethasone; T + E: Travma + Etanercept.

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Aykanat et al. Anti-edematous, anti-inflammatory and neuroprotective effect of etanercept in acute stage in experimental head injury

3 animals (Fig. 3). In the dexamethasone group, edema and inflammation at 1+ level was observed in all rats except 5 animals, 2+ microglial cell damage in 7 rats, 2+ neuronal damage in 8 rats, 2+ astrocytic cell damage in 7 rats, and 2+ glial apoptosis in 4 rats (Fig. 4). In the etanercept group, edema and inflammation at 1+ level was observed in 1 rat while 9 rats didn’t show any edema and inflammation. Other histopathological changes include 1+ microglial cell damage in 3 rats, 1+ neuronal damage in 1 rat, 1+ astrocytic cell damage in 3 rats, and 1+ glial apoptosis in 2 rats (Fig. 5).

primary mechanisms causing the secondary injury include calcium dependent cell damage, neurotransmitter emission, free radical formation, gene activation, mitochondrial dysfunction, and inflammation.[1] Mortality and morbidity could be reduced with treatment by eliminating the factors causing secondary brain injury which significantly negatively affect the TBI prognosis.[8]

(a)

(b)

(c)

(d)

RESULTS In our study, a statistically significant difference between the groups of trauma + dexamethasone and trauma + NS was observed according to the variables of edema and inflammation (p=0.027), but there was no significant difference according to the variables of neuronal damage, astrocytic damage, and glial apoptosis (p>0.05). A significant difference was observed between the groups of trauma + NS and trauma + etanercept in all variables (p=0.003). Lastly, a significant difference was observed between the groups of trauma + dexamethasone and trauma + etanercept in the variables of edema and inflammation (p=0.032), likewise, there was a significant difference in the variables of neuronal damage, astrocytic damage, and glial apoptosis (p=0.004).

DISCUSSION TBI is one of the most commonly encountered traumas which occurs depending on head injury and is a pathological situation that can be fatal or crippling and usually requires a prolonged treatment and care. However, physiopathological mechanism of secondary brain injury appearing within minutes or even days following the primary brain injury due to the trauma is not clearly known. In recent years, studies have focused on some cellular and biochemical factors. The

Figure 1. Tissue sample obtained after removing the brain and brain stem of the test subjects as a whole with decapitation. (from C group, Group-1).

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Figure 2. (a-d) The control group in which edema, inflammation, microglial cell damage, neuronal damage, astrocytic cell damage and glial apoptosis were not found.

(a)

(b)

(c)

(d)

Figure 3. (a-d) Trauma + NS group in which edema, inflammation, microglial cell damage, neuronal damage, astrocytic cell damage and glial apoptosis were found.

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Aykanat et al. Anti-edematous, anti-inflammatory and neuroprotective effect of etanercept in acute stage in experimental head injury

(a)

(c)

(b)

(d)

Figure 4. (a-d) The group given dexamethasone after trauma. It was observed that though edema and inflammation were seen, it was determined that there is no a specific change in microglial cell, neuronal, astrocytic cell damage and glial apoptosis.

(a)

(b)

(c)

(d)

Figure 5. (a-d) The group given etanercept after trauma; it was observed that edema and inflammation were not seen, but microglial cell, neuronal cell, astrocytic cell damage and glial apoptosis decreased specifically.

In order to restrict the secondary biochemical damage and cell death in TBI, the effects of various pharmacological agents have been studied in various animal models. However, when these promising neuroprotective treatment protocols were applied to people, satisfactory success could not be obtained. 178

Some conceptual and methodological reasons increase the difficulties in transferring animal testing into clinics.[9] Among the reasons, first is that there is little similarity between the traumatic brain injury in human and induced brain trauma in animal models, second, insufficient drug distribution and shortage or inappropriate time in animal testing could be attributed. Besides, the fact that these studies target on only one mechanism is perhaps the most important reason.[10] In this study, etanercept treatment which is a TNF-alpha blocker in acute stage was given to the rats in which experimental head trauma was induced for studying the possible protective effects against the trauma-induced brain damage. On grounds of its similarity to diffuse head trauma seen in people and often occurring in motor vehicle crashes, a model of closed head injury in which the skull remains intact was practiced in this study as stated by Marmarou and Ark.[11] Tumor Necrosis Factor Alpha (TNFα) is called as cachectin and it is produced by many normal cells, tumor cells, and traumatic cells. It can also be produced by various stimulus such as viruses, bacteria, parasites, cytokines, and mitogens. In the solution, TNFα is a trimeric molecule which is both transmembrane and soluble. The secreted TNFα forms are biologically active. TNF-alfa is a cytokine the receptors of which have the capability to activate multiple signaling mechanisms due to their presence simultaneously in multiple locations and it has the capability to activate proinflammatory cytokines. In many studies conducted, it has been reported that TNFα plays an important role in TBI and leads to glial, microglial, astrocytic, and neuronal damage.[12–16] TBI is related with microglial and astrocytic cell activation, and the secretion of proinflammatory cytokines like TNFα and IL-1. [17] TNFα which is secreted after trauma and which is one of major proinflammatory cytokines of trauma plays an important role in inducing brain edema and neuronal cell damage, and in breaking down of blood brain barrier. Therefore, it is important to understand basic mechanism of TNFα levels and the consequences which increased after trauma.[6] It has been reported that TNFα causes extensive calcium build-up in cell and this triggers the process resulting in free radical formation and lipid peroxidation and at the same time it leads to calmodulin dependent nitric oxide synthase activity making up toxic hydroxyl radicals and hampering mitochondrial respiration.[16] Rising of intracellular calcium causes the break-down of oxidative phosphorylation, the formation of free radicals, the increasing of cellular enzymes, and death by dissolving of cell metabolism.[18] Etanercept is a recombinant TNFα antagonist which is effective when it binds TNF-alpha receptor proteins on lgG. Due to the antagonistic effect, it displays a strong anti inflammatory effect. It is preferred as a primary cure for many rheumatic diseases. The experimental studies in recent years have shown that etanercept could be beneficial in TBI. Etanercept cannot cross CSF due to its high molecular weight. However, Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Aykanat et al. Anti-edematous, anti-inflammatory and neuroprotective effect of etanercept in acute stage in experimental head injury

since blood brain barrier is broken down in TBI, it crosses CSF and it can display protective effect on glial cells, neurons, and microglial cells, and anti-inflammatory and anti-edema effect on cerebral tissue.[19] In some studies, it was reported that etanercept prevents leukocytes infiltration to protect brain and spinal cord from secondary damage, thereby inhibiting the inflammatory reaction of brain.[20,21] In the research, it has been shown that in traumatic brain edema, vasogenic edema resulting from blood-brain barriers disruption is not the only reason of clinical deterioration, cellular edema associated with ischemia is also involved.[12] Increased secretion of proinflammatory cytokines like TNFalpha causes the imbalance of sodium and calcium, and this leads to ischemic edema.[22–25] In a previous study on focal cerebral ischemia/reperfusion by Yoo-kyung Kim et al., central cerebral artery occlusion was done and after 24 hours reperfusion was enabled. Etanercept 5 mg/kg via intraperitoneal route was given 20 minutes before occlusion. Consequently, it has been proved that etanercept attenuates brain edema and infarct in all groups and it has neuroprotective effect.[16] In their study on neuroprotective effect of etanercept in spinal cord injury in rats, Ke-Bing Chen et al. exhibited with histopathological and biochemical parameters that etanercept has anti-inflammatory and anti-apoptotic effect, besides it has neuroprotective effect on neurons and oligodendroglias. They suggested that etanercept could be used as a neuroprotective agent in spinal cord injury.[17,18] In our study, for edema and inflammatory variables, a statistically significant difference (p=0.027) between the groups of trauma+NS and trauma+dexamethasone was observed, whereas there was no significant difference (p>0.05) in terms of neuronal damage, astrocytic damage, and glial apoptosis variables. In terms of all variables, there was a significant difference (p=0.003) between the groups of trauma+NS and trauma+etanercept. On the other hand, the significant difference (p=0.032) was observed between the groups of trauma+dexamethasone and trauma+etanercept for edema and inflammatory variables and (p=0.004) for neuronal damage, astrocytic damage, and glial apoptosis variables. Edema and inflammation was seen in all 10 rats in trauma+NS group, in 5 rats in trauma+dexamethasone group and in only 1 rat in trauma+etanercept group; neuronal and astrocytic damage was seen in 7 rats in trauma+NS group; in trauma+dexamethasone group, neuronal damage was seen in 8 rats and astrocytic damage in 7 rats; in trauma+etanercept group, neuronal and astrocytic damage were seen in 2 rats. In addition, 2+ glial apoptosis in 3 rats in trauma+NS group, 2+ glial apoptosis in 4 rats in trauma+dexamethasone group and 1+ glial apoptosis in 2 rats in trauma+etanercept group were observed. This shows that both dexamethasone and etanercept have anti-inflammatory and anti-edema effect and anti inflammatory and anti-edema effects with latter showing stronger effects than former. It also shows that etanercept has neuroprotective effect. Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

Conclusion Our study results have shown that etanercept has anti-inflammatory, anti-edema, and neuroprotective effects in acute traumatic brain injury and it can be protective against traumatic brain injury. We are of the opinion that for the treatment of traumatic brain injury, etanercept could be a beneficial option for people. Conflict of interest: None declared.

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Aykanat et al. Anti-edematous, anti-inflammatory and neuroprotective effect of etanercept in acute stage in experimental head injury trogliosis in the neonatal and adult murine brain post-trauma: elevation of inflammatory cytokines and the lack of requirement for endogenous interferon-gamma. J Neurosci 1997;17:3664–74. 18. Feuerstein GZ, Liu T, Barone FC. Cytokines, inflammation, and brain injury: role of tumor necrosis factor-alpha. Cerebrovasc Brain Metab Rev 1994;6:341–60. 19. Francis J, Chu Y, Johnson AK, Weiss RM, Felder RB. Acute myocardial infarction induces hypothalamic cytokine synthesis. Am J Physiol Heart Circ Physiol 2004;286:H2264–71. 20. Campbell SJ, Jiang Y, Davis AE, Farrands R, Holbrook J, Leppert D, et al. Immunomodulatory effects of etanercept in a model of brain injury act through attenuation of the acute-phase response. J Neurochem 2007;103:2245–55. 21. Genovese T, Mazzon E, Crisafulli C, Di Paola R, Muià C, Bramanti P, et

al. Immunomodulatory effects of etanercept in an experimental model of spinal cord injury. J Pharmacol Exp Ther 2006;316:1006–16. 22. Katayama Y, Becker DP, Tamura T, Hovda DA. Massive increases in extracellular potassium and the indiscriminate release of glutamate following concussive brain injury. J Neurosurg 1990;73:889–900. 23. Kontos HA. Oxygen radicals in CNS damage. Chem Biol Interact 1989;72:229–55. 24. Laura D. Errante & Ognen A. C. Petroff. Acute effects of gabapentin and pregabalin on rat forebrain cellular GABA, glutamate, and glutamine concentrations. Seizure 2003;12:300–6. 25. Chen KB, Uchida K, Nakajima H, Yayama T, Hirai T, Watanabe S, et al. Tumor necrosis factor-α antagonist reduces apoptosis of neurons and oligodendroglia in rat spinal cord injury. Spine (Phila Pa 1976) 2011;36:1350–8.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Deneysel kafa travmasında etanercept’in akut dönemdeki anti-ödem, anti-enflamatuvar ve nöroprotektif etkisi Dr. Ömer Aykanat,1 Dr. Durmuş Oğuz Karakoyun,1 Dr. Mehmet Erhan Türkoğlu,2 Dr. Cem Dinç3 1 2 3

Dr. Ersin Arslan Eğitim ve Araştırma Hastanesi, Beyin ve Sinir Cerrahisi Kliniği, Gaziantep Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Beyin ve Sinir Cerrahisi Kliniği, Ankara Düzce Üniversitesi Tıp Fakültesi, Beyin ve Sinir Cerrahisi Anabilim Dalı, Düzce

AMAÇ: Deneysel kafa travması modelinde etanerceptin antiödem, antienflamatuvar ve nöroprotektif etkinliğinin araştırılması amaçlandı. GEREÇ VE YÖNTEM: Bu çalışmada ağırlıkları 250–300 g arasında değişen 40 adet erkek erişkin Spraque-Dawley sıçanı kullanıldı. Sıçanlar kontrol; travma uygulanmayan; travma+SF; travma sonrası serum fizyolojik, travma+D; travma sonrası deksametazon ve tarvma+E: travma sonrası etanercept verilen gruplara ayrıldı. Tüm ilaçlar periton içine verildi. Travma ve ilaç uygulaması sonrası 24. saatte sıçanlar dekapite edildi, örnekler histopatolojik olarak incelendi. BULGULAR: Çalışmamızda ödem ve enflamasyon değişkenlerine göre travma+SF ve travma+deksametazon grupları arasında istatistiksel olarak anlamlı bir farklılık tespit edildi, nöronal hasar, astrositik hasar ve glial apoptoz değişkenlerine göre ise anlamı bir farklılık tespit edilmedi. Travma+SF ile travma+etanercept grupları arasında ve travma+deksametazon ile travma+etanercept grupları arasında tüm değişkenlere göre istatistiksel olarak anlamlı bir farklılık izlendi. TARTIŞMA: Travma sonrası beyin hasarı oluşturulan sıçanlarda etanercept uygulamasının antiödem, antienflamatuvar ve nöroprotektif etkisinin olduğu saptanmıştır. Anahtar sözcükler: Beyin ödemi; etanercept; kafa travması. Ulus Travma Acil Cerrahi Derg 2017;23(3):173–180

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doi: 10.5505/tjtes.2016.43692

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EXPERIMENTAL STUDY

Beneficial effects of garlic (Allium sativum) oil in experimental corrosive esophageal burns effects of garlic oil in esophageal burns Ceren Şen Tanrıkulu, M.D.,1 Yusuf Tanrikulu, M.D.,2 Fahriye Kılınç, M.D.,3 Burak Bahadır, M.D.,4 Murat Can, M.D.,5 Füruzan Köktürk, M.D.6 1

Department of Emergency Medicine, Bülent Ecevit University Faculty of Medicine, Zonguldak-Turkey

2

Department of General Surgery, Zonguldak Atatürk State Hospital, Zonguldak-Turkey

3

Department of Pathology, Konya Numune Hospital, Konya-Turkey

4

Department of Pathology, Bülent Ecevit University Faculty of Medicine, Zonguldak-Turkey

5

Department of Biochemistry, Bülent Ecevit University Faculty of Medicine, Zonguldak-Turkey

6

Department of Biostatistics, Bülent Ecevit University Faculty of Medicine, Zonguldak-Turkey

ABSTRACT BACKGROUND: Corrosive esophageal burns, particularly common in developing countries, lead to different problems in different age groups. The ingestion of corrosive substances can cause such problems as stricture of the esophagus, to acute perforation, and even death. Because stricture formation is related to the severity of the initial injury, the prevention of stricture constitutes a main goal of treatment. The aim of this study was to investigate the protective and anti-inflammatory effects of garlic (Allium sativum) oil in corrosive esophageal burn. METHODS: Twenty-eight rats were randomly divided into 4 equal groups: group 1 (sham), group 2 (control), group 3 (topical treatment), and group 4 (topical and systemic treatment). In groups 2, 3, and 4, corrosive esophageal burns were generated by applying sodium hydroxide to a 1.5-cm segment of the abdominal esophagus. Normal saline was applied to group 2, topical garlic oil to group 3, and topical and systemic garlic oil were used in group 4. RESULTS: The level of hydroxyproline was lower in the topical treatment groups than in the control group (p=0.023). There was difference in tumor necrosis factor alpha level between the systemic treatment groups and the control group (p=0.044). Treatment with garlic oil decreased stenosis index (SI) and histopathological damage score (HDS) in corrosive esophageal burn rats. The SI in the topical treatment group was significantly lower than that of the control group (p=0.016). The HDS was significantly lower in group 4 when compared with the control group (p=0.019). CONCLUSION: Garlic oil is an effective agent in promoting the regression of esophageal stenosis and tissue damage caused by corrosive burns. While the protective effect of garlic oil on tissue damage is more significant when applied topically, the anti-inflammatory effect is more pronounced when applied systemically. Therefore, we believe that the application of garlic oil in patients with corrosive esophageal burns can reduce complication rates. Keywords: Corrosive esophageal burn; garlic oil; hydroxyproline; stenosis index; tumor necrosis factor alpha.

Address for correspondence: Ceren Şen Tanrıkulu, M.D. Konya Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, 42100 Konya, Turkey Tel: +90 505 - 887 13 87 E-mail: cerensen81@hotmail.com Ulus Travma Acil Cerrahi Derg 2017;23(3):181–187 doi: 10.5505/tjtes.2016.64509 Copyright 2017 TJTES

Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

INTRODUCTION Corrosive esophageal burns are quite common leading to different problems in different age groups. Corrosive substances are accidentally ingested by children and purposely by adults. [1] Alkaline substances are easily accessible because they are commonly used for cleaning, soap making, and fruit drying; 90% of the corrosive esophageal burn cases are caused by alkaline substances.[2,3] The severity of gastrointestinal tract damage depends on the 181


Şen Tanrıkulu et al. Beneficial effects of garlic oil in esophageal burns

concentration, amount, and physical form (solid or liquid) of the ingested substance and the duration of contact with the mucosa.[4] The ingestion of corrosive substances can cause issues such as stricture of the esophagus, acute perforation, and even death.[5] The aims of corrosive esophageal burn treatment are to improve wound healing, prevent perforation, and reduce stricture formation. Stricture formation is correlated with the severity of the initial injury and is a significant problem in corrosive esophageal burns. Therefore, preventing stricture formation is the main goal in most of the treatments.[6–8] Additionally, because stricture formation consists of fibrosis and inflammation during the wound healing process, medical treatments should also aim to reduce the inflammation.[9] Although many agents have been used in various studies to prevent the stricture development, antibiotics and steroids have only recently gained clinical approval.[10–13] Garlic oil, a diallyl trisulfide, is the main active constituent of garlic. The beneficial effects of dietary garlic have been known for centuries. To this end, garlic has been used in many different areas of clinical medicine. Furthermore, garlic oil has a wide range of pharmacological properties, such as anticancer, antibacterial, anti-inflammatory, fibrinolytic, wound healing, antioxidant, and antiadhesive activities.[14,15] However, no studies have examined the effects of garlic oil in a corrosive esophageal injury. Herein, we investigate the beneficial effects of garlic oil in corrosive esophageal burns.

MATERIALS AND METHODS Study Design and Animals All experiments were conducted in accordance with the National Guidlines for the Use and Care of Labortaory Animals at the Bülent Ecevit University Laboratory for animal experiments after obtaining an approval from the animal ethics committee of Bülent Ecevit University. Twenty-eight male adult Wistar albino rats, weighing 250±30 g, were individually housed under a constant temperature (21±1°C) in wire cages with 12 h light–dark cycles. The rats were fed a standard diet and water ad libitum. Twelve hours before anesthesia, the animals were deprived of food but had free access to water up to 2 h before anesthesia. No enteral or parenteral antibiotics were administered at any time.

Experimental Groups The animals were randomly divided into four equal groups (seven rats in each group): Group 1 (Sham): A corrosive esophageal burn was not created after the laparotomy. A 0.1 mL dose of saline was intraperitoneally administered to each rat daily for 10 days. Group 2 (Control): A corrosive esophageal burn was cre182

ated after the laparotomy. A 0.1 mL dose of saline was intraperitoneally administered to each rat daily without any treatment for 10 days. Group 3 (Topical treatment group): A corrosive esophageal burn was created after the laparotomy. After washing the esophageal lumen with saline, a 5 ml/kg dose of garlic oil was topically administered to the esophageal lumen. Rats were incubated for 30 min in a reverse Trendelenburg position to provide sufficient mucosal contact with the drug. Then, a 0.1 mL dose of saline was intraperitoneally administered to each rat daily for 10 days. Group 4 (Topical and Systemic treatment group): A corrosive esophageal burn was created after the laparotomy. After washing the esophageal lumen with saline, a 5 ml/kg dose of garlic oil was topically administered to the esophageal lumen. Rats were incubated for 30 min in a reverse Trendelenburg position to provide sufficient mucosal contact with the drug. Then, a 5 ml/kg dose of garlic oil was intraperitoneally administered to each rat daily for 10 days.

Experimental Model The experimental corrosive esophageal burns were formed according to the model described by Gehanno et al. in 1981. [16] Animals were anesthetized by an intramuscular injection of 80 mg/kg ketamine hydrochloride (Ketalar®, Parke-Davis, Istanbul, Turkey) and 20 mg/kg xylazine (Rompun®, Bayer, Istanbul, Turkey). In this study, a 1.5-cm distal esophageal segment was used. Following a median laparotomy, a 5-Fr catheter was passed through the mouth and placed into the distal esophagus. To prevent escape directly into the stomach and respiratory tract by aspiration, the cardioesophageal junction and proximal esophagus were tied with 2/0 silk. Then, 0.1 mL of 37.5% sodium hydroxide (NaOH) solution were administered for 90 s and aspirated. Subsequently, the burned segment was washed with distilled water for 30 s. Catheters were withdrawn by cutting the sutures, and the gastric insertion site was repaired. Following closure of the laparotomy, 10 mL 0.9% saline were intraperitoneally administered, and the rats were fasted for the next 24 h. The treatment of the study groups was started from the first postoperative day. The rats were fed standard food and water ad libitum in standard laboratory conditions during the treatment period.

Histopathological Evaluation HDS and SI were chosen as methods of evaluation. All specimens were evaluated and scored by a single pathologist blinded to the study groups. For the histopathological evaluation, 2-cm distal esophageal sections were taken. The esophageal tissue samples were fixed in 10% neutral formaldehyde. Fixed tissue samples were routinely embedded using the paraffin embedding technique. Then, 5-µm thick tissue samples were taken and stained with hematoxylin-eosin (H&E) and Masson’s trichrome (MT) to evaluate changes in the ligament tisUlus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Şen Tanrıkulu et al. Beneficial effects of garlic oil in esophageal burns

sue. Tissues were scored in three categories for a total score of 0–5 (Table 1).[17] For the SI evaluation, the esophageal wall thickness and luminal diameters were measured using a millimetric ocular microscope (Olympus BX53, Tokyo, Japan). For the SI calculation, the averages of the measurements taken from four different locations by two pathologists were used. SI was calculated as follows: SI = [wall thickness (A1 + A2)/2]/ [lumen diameter (B1 + B2)/2].[18]

Biochemical Analysis Tissue hydroxyproline concentrations were determined using the spectrophotometric method of Bergman and Loxley.[19] The results were expressed as micrograms of hydroxyproline per milligram of tissue (μg/mg). Rat TNF-α levels were detected in the serum by a rat TNF-α ELISA kit (Eastbiopharm, Hangzhou, China). Briefly, samples, standards, and streptavidin-HRP were added into the plate wells of the kit. Antibodies were labeled with enzyme, and the plate was incubated for 60 m at 37ºC. Then, the plate was washed five times and chromogen solutions were added. Subsequently, the plate was further incubated for 10 min at 37ºC before the stop solution was added into the wells. The optical density (OD) of each well was measured at 450 nm with a microplate reader. The corresponding sample OD values were calculated from a linear regression of a set of standards to determine the corresponding sample concentration.

Statistical Analysis Data were analyzed using the SPSS (Statistical Package for Social Science) for Windows 19.0 package program. Data normality was tested using a one-sample Kolmogorov–Smirnov test. Continuous variables were reported as means±standard deviation and were compared using Kruskal–Wallis variance analyses. Dunn’s test was used for post hoc tests after the Kruskal–Wallis test. Noncontinuous variables were reported

as medians (min–max) and were compared using the ChiSquare test. P values of <0.05 were considered statistically significant.

RESULTS The comparison levels of hydroxyproline and TNF-α among the groups are summarized in Table 2. The levels of hydroxyproline were significantly lower in group 3 than in group 2 (p=0.023). Based on the TNF-α levels, there was no difference between group 2 and group 3. The TNF-α level was significantly lower in group 4 than in group 2 (p=0.044). There were no differences among the treatment groups for hydroxyproline and TNF-α levels (p=1.000). The comparisons of esophageal stenosis among the groups are summarized in Table 3. There was no difference among the groups based on the lumen diameters (p=0.920). The wall thicknesses in the treatments groups were lower than that in group 2. According to the wall thickness, there was a significant difference between group 3 and group 2 (p=0.047), whereas there was no significant difference between group 4 and group 2 (p=0.151). According to SI, there was a significant difference between group 3 and group 2 (p=0.016). The comparisons of histopathological evaluations among the groups are summarized Table 3 and Figure 1. HDS was selected as the method of evaluation (Table 1). The sham group generally showed normal histologic state with slight increase in the submucosal collagen. Other groups showed variable number of inflammatory cells in the esophagus wall with characterized reactions. The control group showed an increase in the submucosal connective tissue, collagen in tunica muscularis, and esophagus wall thickness (p=0.043). Increase of submucosal collagen was still active, but the deposition of collagen in muscularis mucosa was way less than the control group. In accordance with these results, the total HDS were

Table 1. Histopathological evaluation criteria Criteria Score Increase in submucosal collagen None

0

Mild (submucosal collagen at least twice the thickness of muscularis mucosa)

1

Severe (submucosal collagen more than twice the thickness of muscularis mucosa)

2

Damage to the muscularis mucosa None

1

Present

2

Damage and collagen deposition in tunica muscularis None

0

Mild (collagen deposition around the smooth muscle fibers)

1

Severe (same as mild with collagen deposition replacing some muscle fibers)

2

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Table 2. Comparisons of hydroxyproline and TNF-α among groups Groups

Hydroxyproline (μg/mg)

TNF-α

Mean±SD Mean±SD

Group 1 (SHAM)

0.73±0.18

24.65±9.24

Group 2 (control)

3.14±0.52

53.92±8.87

Group 3 (topical treatment)

1.37±0.46 44.61±13.18

Group 4 (topical+systemic treatment)

1.77±0.19

a

39.80±15.16b

p=0.023, bp=0.044 vs. group 2.

a

Table 3. Comparisons of histopathological evaluation among groups Groups

Wall thickness (μm)

Stenosis index

Total histopathologic score

Mean±SD Mean±SD

Group 1 (SHAM)

0.72±0.22

0.41±0.11

Group 2 (control)

1.21±0.11

0.73±0.21

3 (1–3)

Group 3 (topical treatment)

0.73±0.17a 0.43±0.05b

2 (1–2)#

Group 4 (topical+systemic treatment)

0.91±0.33

1 (1–2)*

0.51±0.18

0 (0–1)

p=0.047, bp=0.016 vs. group 2; #p=0.026, *p=0.033 vs. group 2.

a

significantly lower in the treatment groups than in group 2 (p=0.026, group 3; p=0.033, group 4).

proliferation. The stricture formation occurs via collagen accumulation.[12,20]

DISCUSSION

The main goal of any medical treatment is to reduce any inflammation because the severity of the acute inflammatory reaction plays the most significant role in stricture formation. [21] The current treatment protocols in corrosive esophagitis remain limited to antibiotics and steroids administration and neutralizations during the acute phase. There are many treatment methods that vary according to the phase and severity of damage.[9] To reduce inflammation and collagen synthesis and to prevent fibroplasia and stricture formation, many clinical and experimental studies have evaluated the medical efficiency of antioxidant and anti-inflammatory agents, such as sucralfate, palifermin, dimethyl sulfoxide, prednisolon, retinoic acid, zinc, trapidil, trimetazidine, and pentoxifylline.[9–13,20,21] Despite decreased stricture formations in these studies, the rate of stricture formation remained at 70%–100% in highgrade corrosive esophagitis.[9]

Despite many experimental and clinical studies, no effective and safe agent other than steroids has been identified for the treatment of corrosive esophageal burns. While garlic oil has been used effectively in many areas of medicine, no studies have investigated its effects in a corrosive esophageal injury. This study revealed the beneficial effect of garlic oil in corrosive esophageal burns. The ingestion of caustic substances is a serious problem because these substances cause corrosive esophagitis in the acute necrotic phase and stricture formation in the long-term. Therefore, the key to coping with these complications is to understand the pathophysiology. The level of damage differs depending on the type of tissue; the amount, type (acid and alkali) and physical structure (solid or liquid) of the caustic substance; and the duration of contact.[4] While ingestion of alkaline substances causes liquefaction necrosis in esophageal mucosa and submucosa, in severe cases, acidic substances cause coagulation necrosis in the muscularis mucosae layer. [20] Acute necrotic phase is seen over the first 1– 4 days and is characterized by decreased tissue perfusion, increased lipid peroxidation, hydrolysis, reactive oxygen radicals, and beginning of inflammation. Following the subacute phase and long-term period, the scar formation begins with fibroblast 184

Garlic oil, a diallyl trisulfide, is the main active constituent of garlic and is one of the oldest medicine. Garlic oil has diverse biological properties, including anticarcinogenic, antibacterial, anti-inflammatory, fibrinolytic, wound healing, antioxidant, and antiadhesive activities.[14,22] Studies have indicated that garlic oil shows an anti-inflammatory effect by reducing the production of IL2, IL12, IL6, Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Şen Tanrıkulu et al. Beneficial effects of garlic oil in esophageal burns (a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

Figure 1. The sham group appears to have normal esophagus histology with a slight increase in the submucosal collagen (a, b). The control group show no apparent increase in the lumen diameter, but has a thicker wall and contains focal inflammatory cells that raise the epithelium in comparison to the sham group (markedly with star) (c). Muscularis mucosa and tunica muscularis are thickened, also the submucosal collagen is slightly increased (d). Topically treatment group (Group 3) has evident differences in the lumen diameter when compared to the sham and control group. The wall thickness is more significant compared to the sham group and less prominent compared to the control group (e). Submucosa and muscularis tunica store minimal amounts of collagen (f). Systemically treatment group (Group 4) does not show an apparent difference in the lumen diameter in comparison to other groups; the increase in wall thickness is more compared to the sham group, less compared to the control group, and close to the topically treatment group (g). Submucosa shows a slight rise in the collagen, muscularis mucosa shows no increase in thickness, and tunica muscularis shows a bit of increase in thickness with no damage or rise in collagen (h). In the Masson Trichrome figures, the star represents the muscularis mucosal layer, the arrow represents the submucosal layer, and the triangle represents the tunica muscularis. For A, C, E, and G; B; and D,F, and H, H&E with x40 magnification, MT with magnification x200, and MT with magnification x100, respectively, were used.

IL8, and TNF-α and by increasing the production of IL10.[23,24] Keiss et al.,[25] showed that garlic oil reduced the activation of NFκB and the production of IL1β and TNF-α. Chang et Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

al.,[26] found that garlic oil showed anti-inflammatory effects in suppressing the production of nitric oxide (NO) and prostaglandin E2 in activated macrophages. The antioxidant activity of garlic oil is primarily dependent on sulfur-containing compounds. This activity is higher in aged garlic extracts.[22] Nencini et al.,[27] found that fresh Allium homogenates possess antioxidant properties. Park et al.,[28] further described the antioxidant activities of garlic extracts. Additionally, garlic oil has broad-spectrum antibacterial effects, and its antibacterial mechanism may be related to the growth inhibition of bacteria by sulfur-containing compounds in garlic.[14] In a randomized retrospective study conducted by Gümüldülü et al.,[9] the prevalence of stricture formation was shown to be reducible with sucralfate treatment. Howell et al.,[29] found that the steroidal treatment of corrosive esophagitis decreased the frequency of stricture formation. Aciksari et al.,[13] compared the treatment effects of beta-aminopropionitrile (BAPN) and prednisolone and found that BAPN was better able to decrease the development of stenosis and tissue damage than prednisolone. In another study,[21] dimethyl sulfoxide was observed to reduce acute phase symptoms and to decrease the severity of tissue damage. Apart from inflammation, oxidative stress is believed to play an important role in increasing tissue damage. Günel et al.,[30] found that reactive oxygen radicals increased during the early phase of esophageal burns. In another study, Ocakci et al.,[17] showed that NaOH treatment increased lipid peroxidation. In corrosive esophageal burns, while SI and HDS are the most important indicators of esophageal damage, the hydroxyproline level is an indicator collagen accumulation. These indicators are used to demonstrate esophageal strictures and to evaluate the efficacy of therapeutic agents.[11] In our study, we examined SI and HDS to evaluate esophageal damage, the levels of hydroxyproline to evaluate the collagen accumulation, and the levels of TNF-α to evaluate anti-inflammatory effects. We found that the levels of TNF-α were significantly lower in the systemic treatment groups than in the control group. However, the levels of hydroxyproline were significantly lower in the topical treatment groups than in the control group. Additionally, there was a difference in SI between group 3 and the control group (p=0.016). In terms of histopathological results, the total histopathological damage scores were significantly lower in the treatments groups than in group 2 (p=0.026, group 3; p=0.033, group 4).

Conclusion We found that the topical or systemic administrations of garlic oil were effective in regressing esophageal stenosis and tissue damage caused by corrosive burns. This effect was more pronounced in the systemic treatment. While the effect of garlic oil on tissue damage was more significant when topically applied, the anti-inflammatory effect was more pro185


Şen Tanrıkulu et al. Beneficial effects of garlic oil in esophageal burns

nounced in systemic applications. We believe that the application of garlic oil during the initial treatment of emergency clinic patients with corrosive esophageal burns can reduce the complication rates of stenosis and strictures. However, to further assess the effectiveness of garlic oil applications, comprehensive clinical studies are required.

Ethical Approval None.

Conflict of interest: None declared.

REFERENCES 1. Karaoglu AO, Ozutemiz O, Ilter T, Batur Y, Yonetci N, Tekesin O, et al. Caustic ingestion injuries: evaluation of 108 cases. Turk J Gastroenterol 1998;9:55–60. 2. Bautista A, Varela R, Villanueva A, Estevez E, Tojo R, Cadranel S. E f fects of prednisolone and dexamethasone in children with alkali burns of the oesophagus. Eur J Pediatr Surg 1996;6:198–203. 3. Millar AJW and Cywes S. Caustic strictures of esophagus. In: Pediatric Surgery. O’Neill JJ, Rowe MI, Grosfeld JL, et al (eds). St Louis: Mosby 1998. p. 969–79. 4. Peters JH, De Meester TR. Esophagus and diaphragmatic hernia. Schwartz SI, Shires GT, Spencer FC (Ed). Principles of Surgery. Seventh ed. New York: McGraw-Hill 1999. p. 1158–61. 5. Ekingen G, Ozden M, Sözübir S, Maral H, Müezzinoğlu B, Kahraman H, et al. Effect of the prostacyclin derivate iloprost in experimental caustic esophageal burn. Pediatr Surg Int 2005;21:441-4. 6. Koltuksuz U, Mutuş HM, Kutlu R, Ozyurt H, Cetin S, Karaman A, et al. Effects of caffeic acid phenethyl ester and epidermal growth factor on the development of caustic esophageal stricture in rats. J Pediatr Surg 2001;36:1504–9. 7. Cakmak M, Nayci A, Renda N, Erekul S, Gökçora H, Yücesan S. The effect of corticosteroids and pentoxifylline in caustic esophageal burns. A prospective trial in rats. Int Surg 1997;82:371–5. 8. Demirbilek S, Bernay F, Rizalar R, Bariş S, Gürses N. Effects of estradiol and progesterone on the synthesis of collagen in corrosive esophageal burns in rats. J Pediatr Surg 1994;29:1425–8. 9. Gümürdülü Y, Karakoç E, Kara B, Taşdoğan BE, Parsak CK, Sakman G. The efficiency of sucralfate in corrosive esophagitis: a randomized, prospective study. Turk J Gastroenterol 2010;21:7–11. 10. Corduk N, Koltuksuz U, Calli-Demirkan N, Rota S, Abban G, Sarioglu-Buke A. Effects of retinoic acid and zinc on the treatment of caustic esophageal burns. Pediatr Surg Int 2010;26:619–24. 11. Caliskan C, Bolukbasi H, Firat O, Yeniay L, Ozutemiz O, Korkut MA. Stricture-prevention effects of pentoxifylline and trimetazidine in an experimental corrosive esophagitis model. Akademik Gastroenteroloji Dergisi 2009;8:6–11. 12. Somuncu S, Cakmak M, Erdogan S, Caglayan O, Akman H, Kaya M. Trapidil, an inhibitor for phosphodiesterase and platelet-derived-growth factor, ameliorates corrosive esophageal burn in rats. Tohoku J Exp Med

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2005;207:203–8. 13. Aciksari K, Yanar HT, Hepgul G, Ozucelik DN, Yanar F, Agcaoglu O, et al. The effect of Beta-aminopropionitrile and prednisolone on the prevention of fibrosis in alkali esophageal burns: an experimental study. Gastroenterol Res Pract 2013;2013:574260. 14. Guo Y. Experimental study on the optimization of extraction process of garlic oil and its antibacterial effects. Afr J Tradit Complement Altern Med 2014;11:411–4. 15. Schäfer G, Kaschula CH. The immunomodulation and anti-inflammatory effects of garlic organosulfur compounds in cancer chemoprevention. Anticancer Agents Med Chem 2014;14:233–40. 16. Gehanno P, Guedon C. Inhibition of experimental esophageal lye strictures by penicillamine. Arch Otolaryngol 1981;107:145–7. 17. Ocakci A, Coskun O, Tumkaya L, Kanter M, Gurel A, Hosnuter M, et al. Beneficial effects of Ebselen on corrosive esophageal burns of rats. Int J Pediatr Otorhinolaryngol 2006;70:45–52. 18. Berthet B, di Costanzo J, Arnaud C, Choux R, Assadourian R. Influence of epidermal growth factor and interferon gamma on healing of oesophageal corrosive burns in the rat. Br J Surg 1994;81:395–8. 19. Bergman RL. Two improved and simplified methods for the spectrophotometric determination of OH-proline. Anal Chem 1963;35:1961–5. 20. Numanoğlu KV, Tatli D, Bektaş S, Er E. Efficacy of keratinocyte growth factor (palifermin) for the treatment of caustic esophageal burns. Exp Ther Med 2014;8:1087–91. 21. Kilincaslan H, Ozbey H, Olgac V. The effects of dimethyl sulfoxide on the acute phase of experimental acid and alkali corrosive esophageal burns. Eur Rev Med Pharmacol Sci 2013;17:2571–7. 22. Capasso A. Antioxidant action and therapeutic efficacy of Allium sativum L. Molecules 2013;18:690–700. 23. Hodge G, Hodge S, Han P. Allium sativum (garlic) suppresses leukocyte inflammatory cytokine production in vitro: potential therapeutic use in the treatment of inflammatory bowel disease. Cytometry 2002;48:209– 15. 24. Chang HP, Huang SY, Chen YH. Modulation of cytokine secretion by garlic oil derivatives is associated with suppressed nitric oxide production in stimulated macrophages. J Agric Food Chem 2005;53:2530–4. 25. Keiss HP, Dirsch VM, Hartung T, Haffner T, Trueman L, Auger J, et al. Garlic (Allium sativum L.) modulates cytokine expression in lipopolysaccharide-activated human blood thereby inhibiting NF-kappaB activity. J Nutr 2003;133:2171–5. 26. Chang HP, Chen YH. Differential effects of organosulfur compounds from garlic oil on nitric oxide and prostaglandin E2 in stimulated macrophages. Nutrition 2005;21:530–6. 27. Nencini C, Franchi GG, Cavallo F, Micheli L. Protective effect of Allium neapolitanum Cyr. versus Allium sativum L. on acute ethanol-induced oxidative stress in rat liver. J Med Food 2010;13:329–35. 28. Park JH, Park YK, Park E. Antioxidative and antigenotoxic effects of garlic (Allium sativum L.) prepared by different processing methods. Plant Foods Hum Nutr 2009;64:244–9. 29. Howell JM, Dalsey WC, Hartsell FW, Butzin CA. Steroids for the treatment of corrosive esophageal injury: a statistical analysis of past studies. Am J Emerg Med 1992;10:421–5. 30. Günel E, Cağlayan F, Cağlayan O, Akillioğlu I. Reactive oxygen radical levels in caustic esophageal burns. J Pediatr Surg 1999;34:405–7.

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Şen Tanrıkulu et al. Beneficial effects of garlic oil in esophageal burns

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Deneysel korozif özefagus yanıklarında sarımsak yağının (Allium Sativum) yararlı etkileri Dr. Ceren Şen Tanrıkulu,1 Dr. Yusuf Tanrikulu,2 Dr. Fahriye Kılınç,3 Dr. Burak Bahadır,4 Dr. Murat Can,5 Dr. Füruzan Köktürk6 Bülent Ecevit Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Zonguldak Zonguldak Atatürk Devlet Hastanesi, Genel Cerrahi Kliniği, Zonguldak Konya Numune Hastanesi, Patoloji Kliniği, Konya 4 Bülent Ecevit Üniversitesi Tıp Fakültesi, Patoloji Anabilim Dalı, Zonguldak 5 Bülent Ecevit Üniversitesi Tıp Fakültesi, Biyokimya Anabilim Dalı, Zonguldak 6 Bülent Ecevit Üniversitesi Tıp Fakültesi, Bioistatistik Anabilim Dalı, Zonguldak 1 2 3

AMAÇ: Özellikle gelişmekte olan ülkelerde daha yaygın görülen korozif özefagus yanıkları farklı yaş gruplarında farklı problemlere yol açarlar. Korozif maddelerin yutulması özefagus striktürlerinden perforasyona hatta ölüme kadar birçok problem neden olabilir. Striktür oluşması ilk hasarın şiddeti ile ilişkili olduğundan striktür gelişiminin önlenmesi tedavinin asıl amacıdır. Bu çalışmada, korozif özefagus yanığında sarımsak yağının (Allium Sativum) koruyucu ve antienflamatuvar etkisi araştırıldı. GEREÇ VE YÖNTEM: Yirmi sekiz sıçan rastgele dört eşit gruba ayrıldı; 1. grup (Sham), 2. grup (kontrol), 3. grup (topikal tedavi) ve 4. grup (topikal ve sistemik tedavi). Sham grubu hariç diğer gruplarda abdominal özefagusun 1.5 cm’lik distal kısmına NaOH uygulanarak korozif özefagus yanığı oluşturuldu. İkinci gruba normal salin, 3. gruba topikal sarımsak yağı ve 4. gruba topikal ve sistemik sarımsak yağı verildi. BULGULAR: Hidroksiprolin seviyeleri topikal tedavi grubunda kontrol grubundan daha düşüktü (p=0.023). Sistemik tedavi grubu ile kontrol grubu arasında tümör nekrozis faktör alfa (TNF-α) seviyelerine göre farklılık mevcuttu (p=0.044). Sarımsak yağı ile tedavinin stenoz indeksini (SI) ve histopatolojik hasar skorunu (HDS) azalttığı görüldü. Kontrol grubu ile karşılaştırıldığında topikal tedavi grubunda SI belirgin olarak daha düşüktü (p=0.016). Histopatolojik hasar skoru kontrol grubuna göre sistemik tedavi grubunda anlamlı olarak düşüktü (p=0.019). TARTIŞMA: Sarımsak yağı korozif özefagus yanığına bağlı oluşan doku hasarının ve özefagial stenozun azaltılmasında etkili bir ajandır. Sarımsak yağı topikal uygulandığında doku hasarı üzerine koruyucu etkisi daha belirgin iken, sistemik uygulandığında antienflamatuvar etkilerinin daha ön plandaydı. Bundan dolayı, korozif özefagus yanığı olan hastalarda sarımsak yağı uygulamasının komplikasyon oranlarını azaltacağına inanıyoruz. Anahtar sözcükler: Hidroksiprolin; korozif özefagus yanığı; sarımsak yağı; stenoz indeksi; TNF-α. Ulus Travma Acil Cerrahi Derg 2017;23(3):181–187

doi: 10.5505/tjtes.2016.64509

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ORIG I N A L A R T IC L E

Diagnostic value of appendicular Doppler ultrasonography in acute appendicitis Hüseyin Uzunosmanoğlu, M.D.,1 Yunsur Çevik, M.D.,1 Şeref Kerem Çorbacıoğlu, M.D.,1 Emine Akıncı, M.D.,1 Hakan Buluş, M.D.,2 Kadir Ağladıoğlu, M.D.3 1

Department of Emergency Medicine, Keçiören Training and Research Hospital, Ankara-Turkey

2

Department of General Surgery, Keçiören Training and Research Hospital, Ankara-Turkey

3

Department of Radiology, Pamukkale University Faculty of Medicine, Denizli-Turkey

ABSTRACT BACKGROUND: Acute appendicitis is one of the most common causes of acute abdominal pain prompting emergency department (ED) visits. It is critical for the physicians to promptly and accurately diagnose acute appendicitis. The present study aimed to evaluate the diagnostic efficacy of Doppler ultrasonography (USG) in patients with acute appendicitis and compare this new method with other commonly used radio-diagnostic tools. METHODS: All patients who were diagnosed with acute appendicitis at the Kecioren Training and Research Hospital ED and later underwent appendectomy between October 2012 and April 2013 were included in the study. Approval from the ethics committee was obtained for this prospective study. The patients’ demographic information, physical examination findings, vital signs, Alvarado scores, and laboratory and radiological exam results were recorded. RESULTS: A total of 60 patients were enrolled in the study. In 46 of the 60 patients, diagnosis of acute appendicitis was confirmed by histopathology results, whereas 14 patients, diagnoses was not confirmed by lab tests. Doppler USG could detect 43 of the 46 patients as true positives, and it detected 2 of the 14 patients with negative lab results as false positives. For diagnosis of acute appendicitis, sensitivity of appendicular Doppler USG was 93%, specificity was 85%, accuracy was 91%, positive likelihood ratio was 6.5, and negative likelihood ratio was 0.08. CONCLUSION: Doppler imaging can offer a high level of diagnostic success in patients with acute appendicitis. Appendicular Doppler USG offers a rapid and easy application without the need to expose patients to contrast medium and is superior to both USG and computed tomography. Therefore, we recommend the use of appendicular Doppler imaging as the primary radiological exam in diagnosing acute appendicitis. Keywords: Acute appendicitis; appendicular Doppler ultrasonography; emergency radiology.

INTRODUCTION Acute appendicitis is one of the most common abdominal pathologies requiring surgical intervention.[1] A prompt diagnosis is necessary to avoid complications, such as gangrene and perforation. In addition, delayed surgical intervention increasAddress for correspondence: Hüseyin Uzunosmanoğlu, M.D. Mimar Sinan Mahallesi, Oğuz Han Sokak., No: 33/12, 06415 Ankara, Turkey Tel: +90 312 - 396 15 20 E-mail: huzunosmanoglu@gmail.com Ulus Travma Acil Cerrahi Derg 2017;23(3):188–192 doi: 10.5505/tjtes.2016.10576 Copyright 2017 TJTES

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es the chances of complications and delayed diagnosis may result in life-threatening conditions, such as abscess, peritonitis, or sepsis.[2,3] The time interval between diagnosis and surgical intervention is a determinant in the risk of perforation.[4] The diagnosis of acute appendicitis is initially made with a physical examination; in addition, laboratory and radiological exams are used to support a suspected diagnosis. Currently, plain radiographs, ultrasonography (USG), and computed tomography (CT) are among the commonly used radio-diagnostic methods. However, none can diagnose the condition alone;[1] thus, new diagnostic methods are needed in this field. The present study aimed to evaluate the diagnostic effectiveness of Doppler USG in patients with acute appendicitis and to compare this new method with other commonly used radiodiagnostic tools. Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Uzunosmanoğlu et al. Diagnostic value of appendicular Doppler ultrasonography in acute appendicitis

MATERIALS AND METHODS Ethical committee approval was obtained before this prospective study, which included patients aged 18–65 years who presented to the Emergency Department (ED) of the Kecioren Training and Research Hospital with complaints related to abdominal pain; they were diagnosed with acute appendicitis and underwent appendectomy between October 2012 and April 2013. Owing to the absence of any radiologist who can perform Doppler USGs between 5 pm to 8 am, the study included only those patients who were admitted between 8 am to 5 pm. Therefore, exclusion criteria included being admitted after 5 pm, being under 18 or over 65 years of age, having had an appendectomy, pregnancy, lack of consent, and having presented to the ED more than 24 hours after the onset of abdominal pain. Clinical findings, physical, and radiological exams and laboratory results were recorded for all patients. History, physical exam results, and laboratory findings were used to calculate each patient’s Alvarado score. Patients who scored ≥8 on a scale of 10 were considered as probable cases of acute appendicitis; those who scored 5–7 were considered possible cases; and those who scored 4 or below were considered unlikely to have acute appendicitis. USG, Doppler USG, and contrastenhanced CT were performed on all study patients. USG and Doppler USG were conducted by separate radiologists, each of whom was blinded to the results of the other examiner. A third radiologist read the CT scans. Following these examinations, the patients were referred to general surgeons. After their appendectomies, the histopathology (HPE) results of all patients were recorded. This study recognized pathological confirmation as the gold standard diagnostic method. Based on the results of appendicular Doppler USG, patients were grouped as either edematous or perforated. Blood flow to the appendix and temperature were measured and compared with the pathology results. All Doppler examinations were performed by B-mod using a Toshiba SSA-770A ultrasound machine equipped with a 5 MHz color and pulse Doppler and a 3–9 MHz electronic phased array probe. Appendices were first located by a radiologist. Systolic and diastolic blood flows were measured, and the resistance index (RI) and pulsatility index (PI) values were calculated using peak systolic blood flow velocity and end diastolic flow velocity.

Statistical Analysis Statistical analysis of the data was performed using the Statistical Package for Social Sciences (SPSS) 13.0 software. Chisquare and analysis of variance (ANOVA) tests were used to compare differences between the groups. A p-value of <0.05 was considered statistically significant.

RESULTS

nosed with acute appendicitis. The study excluded 32 patients for reasons like missing data, lack of consent, and technical problems (the linear probe malfunctioned one day). Of the 60 patients who met the inclusion criteria for the study, the mean age was 30.3 years (min-max: 19–61 years), and 33 patients (55%) were male. Table 1 shows patients’ demographic variables, vital signs, laboratory findings, Alvarado scores, and histopathology (HPE) results. In 46 patients, the clinical diagnosis of acute appendicitis was concordant with the pathology, while in 14 patients, the clinical diagnosis could not be confirmed by pathology results. Of these 46 patients, the USG detected 43 as true positives, and of the 14 patients whose diagnosis was not confirmed by HPE, it detected 6 as false positives. Of the 46 patients, the CT detected 39 as true positives, and of the 14 patients who had negative pathology, it detected 5 as false positives. Table 1. Patient’s demographic variables, vital signs, laboratory findings, Alvarado scores, and pathological results

n

%

Sex Female

33 55

Male

27 45

Temperature

Normal (<37°C)

31

52

Sub-febrile (37°C–38.3°C)

21

35

High fever (>38.3°C)

8

13

Heart rate Normal

49 82

Tachycardia

11 18

Systolic blood pressure (SBP)

Normal (90 mmHg<SBP<150 mmHg)

52

87

Hypotension (<90 mmHg)

8

13

Body mass index <20

32 53

20–25

20 33

>25

8

13

Pathology confirmation Confirmation

46 77

14

No confirmation

23

White blood cell >11.000/mm3

39 65

<11.000/mm3

21 35

Alvarado scores

1–4 points

22

37

5–7 points

23

38

8–10 points

15

25

The study originally included 92 patients who had been diagUlus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

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Uzunosmanoğlu et al. Diagnostic value of appendicular Doppler ultrasonography in acute appendicitis

Table 2. Comparison of computed tomography, ultrasonography, and appendicular Doppler ultrasonography findings % (95%CI)

Ultrasonography

Abdominal computed tomography

Doppler ultrasonography

Sensitivity

93 (82–98)

84 (71–93)

93 (82–98)

Specificity

57 (28–82)

64 (35–87)

85 (57–98)

Accuracy

85 (69–92)

80 (65–90)

91 (82–98)

Positive likelihood ratio

2.1 (1.1–4.0)

2.3 (1.1–4.8)

6.5 (1.8–23.6)

Negative likelihood ratio

0.1 (0.03–0.3)

0.2 (0.1–0.5)

0.08 (0.02–0.2)

Positive predictive value

87 (75–95)

88 (75–96)

95 (84–99)

Negative predictive value

72 (39–93)

56 (29–88)

80 (51–95)

Finally, of the 46 patients, the Doppler USG detected 43 as true positives, and of the 14 patients with negative pathology, it detected 2 as false positives. Table 2 shows sensitivity, specificity, accuracy, positive likelihood ratio (PLR), negative likelihood ratio (NLR), positive predictive values (PPV), and negative predictive values (NPV) of the Doppler USGs, USGs, and CTs. Of the 46 patients, 25 with acute appendicitis were at the edematous histopathological stage and 21 were at the perforated stage. In particular, of the 43 patients whose diagnosis was confirmed by Doppler USG, 21 were at the edematous stage and 20 were at the perforated stage. Although two patients were diagnosed to be at the perforated stage by Doppler USG, the results were not confirmed by HPE. The mean RI and PI index were calculated as 0.78 and 1.2, respectively, at the edematous stage, while the mean RI and PI index were 0.81 and 1.0, respectively, at the perforated stage. The sensitivity of the Doppler USG in detecting pathology during the edematous stage was 90%, the PPV was 100%, and the accuracy was 95%.

DISCUSSION We determined the sensitivity of appendicular Doppler USG to be 93%, its specificity to be 85%, its accuracy to be 91%, its PLR to be 6.5, and its NLR to be 0.08. Based on these findings, the Doppler method was more accurate than conventional methods, such as USG and CT. The diagnostic accuracy of the Doppler USG was 86% in cases of perforated appendicitis and 95% in cases of edematous appendicitis. Diagnosing acute appendicitis is not always easy, and the time spent in arriving at diagnosis leads to delayed surgical intervention, which in turn causes related complications.[2] Akyıldız et al. investigated whether acute appendicitis and perforated appendicitis are different clinical entities.[5] They found that the two were not different clinical entities and that perforated appendicitis was a pathology developed after progressive acute appendicitis. They also found that the time required to prepare for surgical intervention was longer in cases of perforated appendicitis. 190

The use of diagnostic imaging modalities in patients with suspected acute appendicitis reduces the time it takes to decide on the method of surgical intervention, decreases the possibility of negative appendectomy, and reduces both the cost and morbidity related to delay in diagnosis and treatment.[6] USG is commonly used to image acute appendicitis and is inexpensive, rapid, and noninvasive and has sensitivity of 78%–96% and specificity of 85%–98%.[7] In a study conducted by Hussain et al., the sensitivity of USG in patients with an appendix root diameter ≥7 mm was 88%, specificity was 92%, PPV was 94%, NPV was 84%, and accuracy was 90%. The study measured the diagnostic success of USG imaging by evaluating the diameter of the appendix. In the present study, the sensitivity of USG was 93%, specificity was 57%, PPV was 87%, NPV was 72%, and accuracy was 85%. This shows that the PPV or sensitivity values of USG in the present study were comparable to those in the literature; however, the specificity value was low compared to those obtained by other studies. One reason for these findings could be that USG is a user-dependent method, which can explain the variations in the results. In addition, the present study did not measure the root diameter of the appendices, and this could be the reason for low accuracy of USG in diagnosing newly developed acute appendicitis.[8] The related literature shows that the sensitivity of CTs ranges from 87%–100% and specificity from 83%–100%.[3] The CT can be considered as having more valuable diagnostic properties than the USG. In the present study, the sensitivity of CT exams was 84%, specificity was 64%, PPV was 88%, NPV was 56% and accuracy was 80%. Except for the sensitivity, all the CT values obtained in the present study were relatively low compared to those in the literature. This could be due to the small number of patients enrolled in the study and the fact that all CT images were evaluated by the same radiologist. In their study Aranda et al., found that CTs had higher sensitivity than USGs, but both had similar PPVs. The authors concluded that both USGs and CTs were useful diagnostic tools in acute appendicitis; however, they recommended other radio-diagnostic tools that provide higher specificity and sensitivity in diagnosing acute appendicitis.[9] Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Uzunosmanoğlu et al. Diagnostic value of appendicular Doppler ultrasonography in acute appendicitis

Doppler evaluation is effective in detecting increased blood flow, hyperemia, and temperature increases during inflammation. The use of Doppler significantly increases the sensitivity and accuracy of USG. Doppler imaging is particularly effective in detecting hyperemia, inflammation, and edema, all of which are present during the first stage of acute appendicitis. On the other hand, the diagnostic accuracy of Doppler is reduced by conditions that impair blood flow, such as necrotic and gangrenous appendicitis. In the present study, no patients had necrotic or gangrenous appendicitis, and the study grouped patients based on the stages of their appendicitis: edematous (inflamed), 21 patients; and perforated, 22 patients. Of those in the edematous stage, the Doppler results had near-complete agreement (95%) with the pathology results, except in the cases of two patients who had perforated appendicitis. While of those patients in the perforated stage, the Doppler USG results agreed with the pathology results in 86% of cases. These results are consistent with those in the literature, which report high rates of diagnostic success with contrast-induced appendicular Doppler imaging used to diagnose acute appendicitis.[10] Some studies have compared abdominal CT and Doppler USG. One such study, by Gaitini et al., compared the diagnostic values of appendicular Doppler USG and CT in patients with acute appendicitis and found that Doppler’s sensitivity was 74.2%, specificity was 97%, PPV and NPV were both 88%, and accuracy was 93%. In contrast, they found that CT offered superior results, with a sensitivity of 100%, specificity of 98.9%, PPV of 97.4%, NPV of 100%, and accuracy of 99%. The authors suggested examining patients suspected of having acute appendicitis with a USG first to reduce costs and prevent unnecessary exposure to radiation. They recommended using CT examination only to confirm diagnoses in cases in which USG was not sufficient.[11] Gutierrez et al. investigated the correlation between USG and Doppler in diagnosing acute appendicitis and found a sensitivity of 90% and a specificity of 94%. They attempted to improve the diagnostic accuracy of USG for acute appendicitis by adding Doppler imaging. The authors suggested using both USG and Doppler imaging to diagnose acute appendicitis.[12] In a similar study, Incesu et al. compared USG, Doppler USG, and contrast-induced appendicular Doppler USG in diagnosing acute appendicitis. They evaluated hyperemia and RI (resistance index) for the appendix by using both appendicular Doppler USG and contrast-induced appendicular Doppler USG and compared the outcomes with the pathology results. Their study revealed that appendicular Doppler USG had 80% accuracy and 74% sensitivity in suppurative and gangrenous appendicitis, while contrast-induced appendicular Doppler USG had 98% accuracy and 100% sensitivity. The

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authors concluded that contrast-induced Doppler USG had near-complete accuracy in both inflamed and gangrenous appendicitis and that it is a strong candidate for being the most valuable diagnostic tool to diagnose acute appendicitis.[10]

Conclusions In conclusion, Doppler imaging provides a high level of diagnostic success in patients with acute appendicitis. Appendicular Doppler USG features rapid, easy application, without the need to expose patients to a contrast medium, and it is more accurate than either USG or CT. Therefore, we recommend the use of appendicular Doppler imaging as the primary radiological examination method to diagnose acute appendicitis. Conflict of interest: None declared.

REFERENCES 1. Pittman-Waller VA, Myers JG, Stewart RM, Dent DL, Page CP, Gray GA, et al. Appendicitis: why so complicated? Analysis of 5755 consecutive appendectomies. Am Surg 2000;66:548–54. 2. Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 2006;244:656–60. 3. Yildirim E, Karagülle E, Kirbaş I, Türk E, Hasdoğan B, Tekşam M, et al. Alvarado scores and pain onset in relation to multislice CT findings in acute appendicitis. Diagn Interv Radiol 2008;14:14–8. 4. Buckley RG, Distefan J, Gubler KD, Slymen D. The risk of appendiceal rupture based on hospital admission source. Acad Emerg Med 1999;6:596–601. 5. Akyıldız H, Akcan A, Sözüer EM, Küçük C, Korkut Ç, Ekici F. Acute appendicitis-perforated appendicitis: are they differently clinical Antities? Akademik Acil Tıp Dergisi 2008;7:13–5. 6. Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998;338:141–6. 7. Fazio VW, Church JM, Delaney CP. Current Therapy in Colon and Rectal Surgery Elsevier Mosby 2006:271–5. 8. Hussain S, Rahman A, Abbasi T, Aziz T. Diagnostic accuracy of ultrasonography in acute appendicitis. J Ayub Med Coll Abbottabad 2014;26:12–7. 9. Aranda-Narváez JM, Montiel-Casado MC, González-Sánchez AJ, Jiménez-Mazure C, Valle-Carbajo M, Sánchez-Pérez B, et al. Radiological support for diagnosis of acute appendicitis: use, effectiveness and clinical repercussions. [Article in Spanish] Cir Esp 2013;91:574–8. [Abstract] 10. Incesu L, Yazicioglu AK, Selcuk MB, Ozen N. Contrast-enhanced power Doppler US in the diagnosis of acute appendicitis. Eur J Radiol 2004;50:201–9. 11. Gaitini D, Beck-Razi N, Mor-Yosef D, Fischer D, Ben Itzhak O, Krausz MM, et al. Diagnosing acute appendicitis in adults: accuracy of color Doppler sonography and MDCT compared with surgery and clinical follow-up. AJR Am J Roentgenol 2008;190:1300–6. 12. Gutierrez CJ, Mariano MC, Faddis DM, Sullivan RR, Wong RS, Lourie DJ, et al. Doppler ultrasound accurately screens patients with appendicitis. Am Surg 1999;65:1015–7.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut apandisitte appendiküler Dopplerin tanısal değerliliği Dr. Hüseyin Uzunosmanoğlu,1 Dr. Yunsur Çevik,1 Dr. Şeref Kerem Çorbacıoğlu,1 Dr. Emine Akıncı,1 Dr. Hakan Buluş,2 Dr. Kadir Ağladıoğlu3 Keçiören Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Ankara Keçiören Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara 3 Pamukkale Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Denizli 1 2

AMAÇ: Akut apandisit ani başlangıçlı karın ağrısı nedeni ile acil servis başvurularında en sık karşılaşılan nedenlerden birisidir. Hekimler için akut apandisit tanısının zamanında ve doğru olarak konulması kritiktir. Bu çalışmanın amacı akut apandisit tanılı hastalarda Doppler ultrasonografinin (USG) tanısal değerliliğini değerlendirmek ve bu yeni tanısal metodu diğer sık kullanılan tanısal metotlarla karşılaştırmaktır. GEREÇ VE YÖNTEM: Ekim 2012 ile Nisan 2013 arasında Keçiören Eğitim ve Araştırma Hastanesi’ne başvuran ve akut apandisit tanısı alan sonrasında ise apendektomiye alınan hastalar çalışmaya dahil edildi. İleriye yönelik olan çalışmaya başlanmadan önce lokal etik kuruldan izin alındı. Hastaların demografik verileri, fizik muayene bulguları, vital bulguları, Alvarado skorları, radyoloji ve laboratuvar sonuçları kayıt edildi. BULGULAR: Toplamda 60 hasta çalışmaya dahil edildi. Kırk altı hasta yapılan cerrahi sonrası patolojik olarak apendisit tanısı doğrulanırken 14 hasta patolojik sonuçlarla doğrulanmadı. Doppler USG 46 hastanın 43’ünü doğru pozitif olarak saptayabilirken iki hastayı yanlış pozitif olarak yorumladı. Doppler USG duyarlılığı 0.93, özgüllüğü 0.85, doğruluk 0.91, pozitif likelihood ratio (PLR) 6.5 ve negatif likelihood ratio 0.08 olarak bulundu. TARTIŞMA: Doppler USG akut apandisit hastalarının tanı sürecinde yüksek seviyede başarılı gibi görünmektedir. Hızlı ve kolay uygulanabilmesi, hastaya kontrast madde verilmemesi nedenleri ile klasik USG ve bilgisayarlı tomografiye üstün gibi görünmektedir. Biz bundan dolayı Doppler USG’nin akut apandisit tanısında öncelikle kullanılması gerektiğini önermekteyiz. Anahtar sözcükler: Acil radyoloji; akut apandisit; apendiküler doppler USG. Ulus Travma Acil Cerrahi Derg 2017;23(3):188–192

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doi: 10.5505/tjtes.2016.10576

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ORIG I N A L A R T IC L E

Macrophage migration inhibitory factor levels correlate with an infection in trauma patients Young-Duck Cho, M.D.,1 Sung-Hyuk Choi, M.D.,1 Jung-Youn Kim, M.D.,1 Sung-Jun Park, M.D.,1 Young-Hoon Yoon, M.D.,1 Han-Jin Cho, M.D.,2 Ji-Won Yeom, M.D.3 1

Department of Emergency Medicine, Korea University Guro Hdspital, Seoul-South Korea

2

Department of Emergency Medicine, Korea University Ansan Hospital, Ansan, Kyunggi-do-South Korea

3

College of Medicine, Korea University, Seoul-South Korea

ABSTRACT BACKGROUND: The role of migration inhibitory factor (MIF) is best understood in septic shock and septic disease; however, the role of MIF in a secondary infection after trauma has not yet been completely studied. This study aimed to evaluate the role of MIF in trauma patients. METHODS: The patients in the study population were divided into two groups according to the results of their MIF levels. The initial MIF levels, trauma mechanism, revised trauma score, survival rate, length of stay (LOS) in the intensive care unit (ICU), level of leukocytes, and level of C-reactive protein (CRP) were compared between the groups. RESULTS: Overall, 116 patients were enrolled from August 1, 2014 to July 31, 2015. LOS in ICU in the elevated MIF group was 5.67±7.54 days compared with 2.09±2.26 days in the normal MIF group. Further, CRP level in the elevated MIF group was higher than that in the normal MIF group. CONCLUSION: In a place such as the department of emergency medicine, it is critical and important for emergency physicians to make a proper judgment and to prepare for the worst scenario. Therefore, the utilization of MIF level in trauma patients has a possibility for assisting emergency physicians. Keywords: Infection; macrophage migration inhibitory factor; trauma.

INTRODUCTION In innate and acquired immune responses, migration inhibitory factor (MIF) plays a critical role as a pleiotropic cytokine and critical mediator.[1] About 50 years ago, it was the first cytokine that was discovered.[2] With the identification of the CXC chemokine receptors 2 (CXCR2) and 4 (CXCR4), it became possible to identify MIF’s function in promoting the directed migration and recruitment of leukocytes into infectious and inflammatory sites such as a chemokine-like cytokine.[3,4] MIF is commonly expressed in both immune and Address for correspondence: Sung-hyuk Choi, M.D. 148, Gurodong-ro, Guro-gu, 08308 Seoul - South Korea Tel: 8210-5059-9090 E-mail: kuedchoi@korea.ac.kr Ulus Travma Acil Cerrahi Derg 2017;23(3):193–198 doi: 10.5505/tjtes.2016.04780 Copyright 2017 TJTES

Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

non-immune cells. Stored in the pituitary gland, in T cells and macrophages, MIF reacts to various stimuli such as infection and stress.[5,6] Most of the critical functions of MIF include macrophage function regulation,[7] lymphocyte immunity,[8] and endocrine function.[9–11] It also counter-regulates the immunosuppressive and anti-inflammatory activities of glucocorticoids.[9,12,13] In the pathogenesis of acute and inflammatory diseases, such as septic shock, rheumatoid disease, inflammatory lung disease, glomerulonephritis, and inflammatory bowel disease, MIF plays a critical role, as shown in studies using MIF-/- mice, recombinant MIF, and neutralizing anti-MIF antibodies.[14–16] MIF is best understood with regard to its role in septic shock and septic disease. Mice with a genetic deletion of the Mif gene were protected from endotoxin shock, gram-negative septic shock, and gram-positive toxic shock.[16–19] Nevertheless, the relationship between trauma patients and MIF levels has not been clearly established. Cellular immune function suppressed by trauma can lead to sepsis, multi-organ failure, and even death. Patients with severe trauma are vulnerable to infection and, in turn, have a high risk of mortality. MIF has important roles in several immune responses such as the modulation of numerous 193


Cho et al. Macrophage migration inhibitory factor levels correlate with an infection in trauma patients

cytokines, and it is considered to play a major part in the pathophysiology of septic shock and chronic inflammation.[20] However, MIF’s role in traumatic conditions has not yet been determined. In this study, we aimed to investigate the specific role of MIF levels in the infection risk in trauma patients. We designed a prospective study of trauma patients in our emergency department (ED). We compared MIF levels in trauma patients with a number of indicators related to an infection, such as fever, c-reactive protein (CRP), length of stay (LOS) in the intensive care unit (ICU), injury severity score (ISS), and revised trauma score (RTS).

MATERIALS AND METHODS Study Design and Setting The study protocol and written informed consent form were reviewed and approved by Korea University Guro Hospital (institutional review board No. 11017). This study had a single center, with a prospective cohort study design. It was performed in a level 1 academic trauma center located in the metropolitan area of Seoul, South Korea from August 1, 2014 to July 31, 2015.

Study Group Overall, 116 patients participated in this prospective study. The inclusion criteria were blunt or penetrating trauma in patients who were >18 years and were transported to our ED by the emergency medical service and required a whole-body CT and trauma team activation. The initial clinical assessment and decision were made by a board-certified attending emergency physician. The physician’s decision was based on the American College of Surgeons Committee on Trauma criteria for trauma triage.

Study Parameters The trauma patients were divided into two groups: 1) normal MIF group and 2) elevated MIF group. The initial MIF levels, trauma mechanism, RTS, ISS, LOS in the ICU, and level of CRP were compared between the two groups. The patients’ temperatures were taken at least four times (at 6:00 am, 12:00 pm, 6:00 pm, 12:00 am) during admission by a nurse using an infrared tympanic thermometer. Fever was defined as having a core body temperature ≥38.0°C (F).

Samples 1) MIF Serum blood samples were collected within 2 h of arrival at ED and sent to the laboratory for MIF level measurement. Supernatants were collected after incubation for 2 or 20 h. MIF concentration in the culture supernatants was measured by sandwich ELISA. Briefly, 2 μg/ml of monoclonal capture antibody (R&D Systems, Minneapolis, MN, USA) was added to a 96-well plate and incubated for one day at room tempera194

ture and washed with a buffer three times. After washing, the plates were incubated in a blocking solution of phosphatebuffered saline (PBS) containing 1% bovine serum albumin and 0.05% Tween-20 for 1 h at room temperature and washed with a buffer three times. Test samples and standard recombinant MIF (R&D Systems) were added to the plates and incubated for 2 h at 4°C. The plates were washed three times with PBS containing Tween-20, 200 ng/ml of biotinylated detection monoclonal goat-antihuman antibodies (R&D Systems) were added, and the plates were incubated for 2 h at room temperature. After washing thrice, streptavidinalkaline-phosphatase (1:2000; Sigma-Aldrich Co.) was added, and the reaction was allowed to proceed for 20 min at room temperature. The plates were washed thrice, and 1 mg/ml of p-nitrophenylphosphate dissolved in diethanolamine (SigmaAldrich Co.) was added to induce a color reaction which was stopped with 50 μl of 1 M NaOH. The optical density at 450 nm was measured on an automated microplate reader (BioRad Laboratories Inc., Hercules, CA, USA). A standard curve was generated by plotting the optical density versus the log of the MIF concentration. The experiments were conducted 10 times. 2) CRP Serum blood samples were collected within 2 h after arrival at ED for a serum CRP analysis. The serum CRP concentrations were determined using a human turbidimetric immunoassay (human CRP turbidimetric immunoassay kit, Beckman Coulter, Inc., USA). Analyses were performed on an automated analyzer (IMMAGE 800, Beckman Coulter, USA) according to the manufacturer’s instructions.

Statistics For the statistical analysis, SPSS statistical software (SPSS, Inc., Chicago, IL, USA) was used. The mean and standard deviation, sensitivity, and specificity were used for data description. The means were measured with 95% confidence interval (CI). Pearson’s chi-squared test for categorical variables and an independent t-test were used for measuring continuous variables. The receiver operating characteristics (ROC) curve was used to assess the cutoff value of MIF levels in the patients with fever. The area under the ROC curve (AUC) of the sensitivity over 1-specificity was determined to provide a numerical summary of the indicator’s performance. P<0.05 was considered significant.

RESULTS Overall, 192 patients were enrolled, of which 76 patients were excluded from the study. Among those excluded, 20 patients had been transferred elsewhere, 36 had a trauma of an unknown origin, and 20 patients had been transferred from other hospitals. Among the 116 patients, 72 (62%) had an elevated MIF level, and 44 (38%) had a normal MIF level. The normal range of MIF levels was not clearly defined in Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Cho et al. Macrophage migration inhibitory factor levels correlate with an infection in trauma patients

Table 1. General demographics Variables

Elevated MIF

Normal MIF

p

n % Mean±SD n % Mean±SD

Total

72 62

44 38

Male

48 67

32 73

Female

24 33

12 27

Age (years)

47

35

Sex 0.732

Mechanism of trauma

Traffic accident

48

67

4

9

0.004

Fall

16 22

32 63

0.026

Assault

8 11

8 18

0.592

Systolic blood pressure (mmHg)

118.06±28.97

122.64±13.63

0.631

Injury severity score

23.0±12.0

25.0±15

0.612

Revised trauma score

7.17±1.17

7.39±0.62

0.572

MIF: Macrophage migration inhibition factor; SD: Standard deviation.

other studies; therefore, it was determined by samples from 20 healthy volunteers. The mean value of MIF from the volunteers was 588±485 pg/mL.

stay in the ICU was longer in the patients with elevated MIF levels (5.67±9.51) than that (2.09±2.26) in the patients with normal MIF levels (p=0.233) (Table 4).

Table 1 compares the baseline demographic background, clinical characteristics (systolic blood pressure, ISS, and RTS), and trauma mechanism between the elevated and normal MIF groups. No difference was observed in the general demographic backgrounds and clinical characteristics. No significant difference was observed in RTS and ISS scores between the elevated and normal MIF groups. Among the trauma mechanisms, traffic accident and a fall showed significant differences (p=0.004 and 0.026, respectively). ROC curve for MIF levels in febrile and afebrile patients are shown in Figure 1. AUC for the correlation between MIF and fever was 0.738 (95% CI, 0.54–0.93, p=0.029). The cutoff value, sensitivity, and specificity of the elevated MIF level were 944 pg/mL, 86.7%, and 64.3%, respectively (Table 2).

DISCUSSION

The mean value of CRP (121.08±104.14) was higher in the patients with an elevated MIF level than that (49.60±47.04) in the patients with a normal MIF level (p=0.04). Although the difference was not significant, the mean number of days of Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

ROC Curve

1.0

1.0

Sensitivity

MIF levels of 72 patients were elevated above the cutoff value and those of 44 patients were below the cutoff value. Of the 72 patients with an elevated MIF level, 56 were febrile, and only 8 out of the 36 patients with a normal MIF level were afebrile. Sensitivity and specificity for fever in the discriminating MIF level were 86.67% (59.51%–97.95%) and 64.29% (35.18%–87.11%) (p=0.005). Sensitivity and specificity for CRP in the discriminating MIF level were 66.67% (43.04%– 85.35%) and 57.14% (18.75%–89.58%) (p=0.076) (Table 3).

To the best of our knowledge, our prospective study is believed to be the first to analyze the relationship between MIF level and infection in trauma patients. MIF levels were

1.0

1.0

1.0

0

0.0

0.2

0.4 0.6 1 - Specificity

0.8

1.0

Figure 1. The receiver operating characteristics (ROC) curve was used to assess the cutoff value of MIF levels in patients with fever. The area under the ROC curve (AUC) for the correlation of MIF and fever was 0.738 (95% CI, 0.54–0.93, p=0.029).

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Cho et al. Macrophage migration inhibitory factor levels correlate with an infection in trauma patients

Table 2. Coordinates of the curve Test result variable(s): Macrophage migration inhibition factor Positive if greater than or equal toa

Sensitivity (%)

Specificity (%)

740

93.3

58.1

833

93.3

58.1

944

86.7

64.3

1042

80.0

64.3

1125

80.0

72.4

The smallest cutoff value is the minimum observed test value minus 1, and the largest cutoff value is the maximum observed test value plus 1. All the other cutoff values are the averages of two consecutive ordered observed test values.

a

Table 3. Sensitivities and specificities of a fever and C-reactive protein

Macrophage migration inhibition factor value

p

0.005

Fever

Sensitivity (95% CI)

86.67% (59.51%–97.95%)

Specificity (95% CI)

64.29% (35.18%–87.11%)

C-reactive protein

Sensitivity (95% CI)

66.67% (43.04%–85.35%)

Specificity (95% CI)

57.14% (18.75%–89.58%)

0.076

Table 4. Mean values of C-reactive protein and length of stay in the intensive care unit C-reactive protein (mg/L) Length of stay in Intensive care unit (days)

Elevated MIF

Normal MIF

p

Mean±SD Mean±SD 121.08±104.14

49.60±47.04

0.043

5.67±9.51

2.09±2.26

0.233

MIF: Macrophage migration inhibition factor; SD: Standard deviation.

measured in a cohort of 116 trauma patients who required a complete body CT and trauma team activation. The purpose of our study was to investigate the utility of MIF for the prediction of a poor prognosis, even as serious as death, because of an infection in the trauma patients. A number of studies showed a principal role of MIF in the pathophysiology of sepsis, and in our study, we demonstrated a correlation between an elevated MIF level and a delayed infection in trauma patients. MIF level had a high sensitivity and specificity in discriminating trauma patients who were more likely to have an infection. It is well known that severe trauma weakens the host immune system, and the patients become vulnerable to infections. This phenomenon can be explained by a two-hit model. There is a close relationship between systemic inflammation and the two-hit model. The priming and subsequent response to neutrophil has been closely investigated and used to explain the two-hit model. If the initial insult primes the 196

inflammatory response, the tissue from the immune system is injured and reaches a state similar to the systemic inflammatory syndrome. At this critical point, if a proper response does not take place, the tissue becomes vulnerable to a second hit and is led to a multiple organ dysfunction syndrome (MODS). We believe that vulnerability caused by severe trauma may work as the first hit followed by the infection as the second hit. MIF plays an important role in regulating immunologic functions.[3,4] The major cause of delayed mortality in trauma patients is MODS, resulting from a dysregulation of homeostasis and an imbalance of the immune inflammatory response. After major trauma, polymorphonuclear neutrophils, monocytes, and macrophages release a number of proinflammatory and anti-inflammatory cytokines. Among the parameters, elevated MIF levels were positively correlated with fever, CRP, and the LOS in the ICU. Initially, Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Cho et al. Macrophage migration inhibitory factor levels correlate with an infection in trauma patients

we set the cutoff value of the elevated MIF levels with the ROC curve for patients with a fever. In this study, the patients with an elevated MIF showed higher CRP levels, and a greater proportion of patients had a fever compared with the group with normal MIF levels. None of the patients were diagnosed with an infectious disease during their hospital stay. The patients with elevated MIF levels tended to be febrile, whereas most of the patients with normal MIF levels were afebrile. We believe that a fever indicates the presence of an inflammation along with an elevated CRP. MIF functions as a chemokine-like cytokine recruiting leukocytes into inflammatory sites.[3] Fever is usually a symptom of an underlying condition, most often an infection. Fever indicates an infection or inflammation. In an infection, fever is caused by cytokines, and such cytokines are called pyrogenic cytokines. A wide spectrum of bacterial and fungal products induces the synthesis and release of pyrogenic cytokines. A measurement of circulating cytokines in patients with fever is rarely used because the level of pyrogenic cytokines in the circulation is often below the detection limit or does not coincide with fever.[21] In patients with low-grade fevers, the most valuable measurements are CRP level and the erythrocyte sedimentation rate.[22] CRP is an acute-phase protein found in the blood, the levels of which rise in response to an inflammation or an infection.[22] The major portion of CRP is produced by hepatocytes following a stimulation by interleukin 6, with an increased expression occurring within four to six hours of an inciting insult.[23] CRP has been studied as a screening device for inflammation, as a marker for disease activity, and as a diagnostic adjunct. The values of CRP may reflect the severity of an inflammation or a tissue injury.[24,25] Patients with an elevated MIF level tend to stay in the ICU longer than patients with a normal MIF level. However, the RTS and ISS had limited correlations with MIF levels. These findings are particularly important. The RTS is the trauma scoring system that represents the severity of trauma. It is a physiologic scoring system based on a patient’s initial set of vital signs and the Glasgow coma score that has been shown to have a strong correlation with the prognosis.[26,27] The ISS has served as a summary measure of anatomic injury since 1974 and has been incorporated in many trauma risk adjustment models to quantify the severity of an injury.[28] The elevation of the MIF levels has a meaningful correlation with a fever and the CRP levels. Nevertheless, the RTS and ISS showed no correlation with an elevated MIF level. These results suggest that the severity of the trauma or the injury does not affect the MIF level. Also RTS and ISS scores were not significantly different in our study groups because all of the patients included in our study required a complete body CT and trauma team activation, and in such cases, all of them were severely injured. According to our results, an elevated MIF level after a certain period of time may predict whether an infection will occur or not in the trauma patients. Among the mechanisms of trauma, the traffic accident patients’ group showed higher MIF levels. Patients after a traffic Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

accident that require a complete body CT and trauma team activation mostly suffer from multiple fractures along with an internal organ injury and/or head injury, in which cases the probability of an inflammation or an infection risk is even higher. On the other hand, both the fall and assaulted patients’ groups tend to have isolated injuries confined to either the head or the trunk. Our results also prove that the combined monitoring of MIF levels, a fever, and CRP may be effective in identifying trauma patients who are likely to suffer from an infection. It has a number of limitations. First, the foci of infection were not clearly identified which leading to defining some fever to an infection may lack definite evidence. Second, an association of an elevated MIF level with a longer length of the stay in ICU can be explained by a number of reasons. The trauma mechanism could be the main reason in which the traffic accidents’ group with more severe injuries with an elevated MIF level probably stayed longer. Since there could be other factors that may influence the length of the stay, it is sufficient to propose that a study would need to sample many later studies using the multi-center study. However, in this study, it is sufficient to study the early suggesting MIF.

Conclusion Our prospective study is believed to be the first to analyze the relationship between the MIF level and an infection in trauma patients, to the best of our knowledge. From this study, the patients with an elevated MIF showed higher CRP levels, and more patients had a fever compared to the normal MIF patients’ group. In a place such as the department of emergency medicine, it is critical and important for emergency physicians to make proper judgments and to prepare for the worst scenario. Therefore, the utilization of the MIF level in trauma patients has a possibility for assisting emergency physicians.

Acknowledgments This study was partially supported by Korea University grant and Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (R1522002). Conflict of interest: None declared.

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17. Calandra T, Echtenacher B, Roy DL, Pugin J, Metz CN, Hültner L, et al. Protection from septic shock by neutralization of macrophage migration inhibitory factor. Nat Med 2000;6:164–70. 18. Calandra T, Spiegel LA, Metz CN, Bucala R. Macrophage migration inhibitory factor is a critical mediator of the activation of immune cells by exotoxins of Gram-positive bacteria. Proc Natl Acad Sci U S A 1998;95:11383–8. 19. Tohyama S, Onodera S, Tohyama H, Yasuda K, Nishihira J, Mizue Y, et al. A novel DNA vaccine-targeting macrophage migration inhibitory factor improves the survival of mice with sepsis. Gene Ther 2008;15:1513– 22. 20. Bernhagen J, Calandra T, Bucala R. Regulation of the immune response by macrophage migration inhibitory factor: biological and structural features. J Mol Med (Berl) 1998;76:151–61. 21. Chen JS, Changchien CR, Tang R. Postoperative fever and survival in patients after open resection for colorectal cancer: a long-term followup study of 2,311 prospectively enrolled patients. Dis Colon Rectum 2008;51:1649–55. 22. Thompson D, Pepys MB, Wood SP. The physiological structure of human C-reactive protein and its complex with phosphocholine. Structure 1999;7:169–77. 23. Mackenzie I, Woodhouse J. C-reactive protein concentrations during bacteraemia: A comparison between patients with and without liver dysfunction. Intensive Care Med 2006;32:1344–51. 24. van der Meer V, Neven AK, van den Broek PJ, Assendelft WJ. Diagnostic value of C reactive protein in infections of the lower respiratory tract: systematic review. BMJ 2005;331:26. 25. Ranzani OT, Zampieri FG, Forte DN, Azevedo LC, Park M. C-reactive protein/albumin ratio predicts 90-day mortality of septic patients. PLoS One 2013;8:59321. 26. Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. Trauma score. Crit Care Med 1981;9:672–6. 27. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma 1988;29:623–9. 28. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187–96.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Travma hastalarında makrofaj migrasyonunu inhibe edici faktör düzeyleri enfeksiyonla koreledir Dr. Young-Duck Cho,1 Dr. Sung-Hyuk Choi,1 Dr. Jung-Youn Kim,1 Dr. Sung-Jun Park,1 Dr. Young-Hoon Yoon,1 Dr. Han-Jin Cho,2 Dr. Ji-Won Yeom3 1 2 3

Kore Üniversitesi Guro Hastanesi, Acil Tıp Bölümü, Seul-Güney Kore Kore Üniversitesi Ansan Hastanesi, Acil Tıp Bölümü, Ansan, Kyunggi-do-Güney Kore Kore Üniversitesi Tıp Koleji, Seul-Güney Kore

AMAÇ: Migrasyon inhibe edici faktörün (MİF) rolü en iyi septik şok ve septik hastalıkta anlaşılır. Ancak travmayla ilişkili enfeksiyonda MİF’nin rolü henüz tam olarak incelenmemiştir. Bu çalışmada, travma hastalarında MİF’nin rolü değerlendirildi. GEREÇ VE YÖNTEM: Çalışma popülasyonu MİF düzeyleri sonuçlarına göre iki gruba ayrıldı. Gruplar arasında başlangıçta MİF düzeyleri, travmanın mekanizması, gözden geçirilmiş travma skoru (RTS), sağkalım oranı, yoğun bakım ünitesinde (YBÜ) kalış süresi, lökosit sayıları ve C-reaktif protein (CRP) düzeyleri karşılaştırıldı. BULGULAR: Çalışmaya 1 Ağustos 2014 ile 31 Temmuz 2015 arasında toplam 116 hasta alındı. Yüksek MİF’li grupta ortalama YBÜ’de kalış süresi 5.67±7.54 gün iken normal MİF düzeyli grupta 2.09±2.26 gün idi. Yine yüksek MİF’li grupta CRP düzeyi normal MİF’li gruptakinden daha yüksekti. TARTIŞMA: Acil tıp departmanı gibi bir bölümde acil hekimlerin en kötü senaryoya göre uygun yargıda bulunması ve hazırlıklı olması kritik değer ve önem taşır. Bu nedenle, travma hastalarında MİF düzeyinin kullanılması acil hekimlerine ipuçları verme olasılığına sahiptir. Anahtar sözcükler: Enfeksiyon; makrofaj migrasyonunu inhibe edici faktör; travma. Ulus Travma Acil Cerrahi Derg 2017;23(3):193–198

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doi: 10.5505/tjtes.2016.04780

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ORIG I N A L A R T IC L E

Characteristics of the injuries of Syrian refugees sustained during the civil war Betül Kocamer Şimşek, M.D.,1 Mehmet Dokur, M.D.,2 Erdal Uysal, M.D.,3 Necdet Çalıker, M.D.,4 Oruç Numan Gökçe, M.D.,5 İbrahim Kürşat Deniz, M.D.,5 Murat Uğur, M.D.,6 Murat Geyik, M.D.,7 Mehmet Kaya, M.D.,8 Güner Dağlı, M.D.1 1

Department of Anesthesiology and Reanimation, Sanko University Faculty of Medicine, Gaziantep-Turkey

2

Department of Medical Education, Dicle University Health Sciences Institue, Diyarbakır-Turkey

3

Department of General Surgery, Sanko University Faculty of Medicine, Gaziantep-Turkey

4

Department of Anesthesiology, Kilis State Hospital, Kilis-Turkey

5

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

6

Department of Neurosurgery, Kilis State Hospital, Kilis-Turkey

7

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

8

Department of Public Health, Turgut Özal University Faculty of Medicine, Ankara-Turkey

ABSTRACT BACKGROUND: During a war, many civilians are severely injured by firearms, bombs, and shrapnel. The triage of war injuries involves difficult and complicated processes requiring surgical procedures and patient monitoring in the Intensive Care Unit (ICU) of hospitals. In this study, we examine the demographic, traumatic, and critical care characteristics of cases injured during the civil war in Syria and requiring emergency surgery. METHODS: Electronic data of the traumatic, surgical, and ICU monitoring features of 707 patients admitted to Kilis Public Hospital between March 2012 and January 2013 were analyzed retrospectively RESULTS: Most of the patients reported having been injured due to firearms (83.75%). Of the 707 cases studied in this work, 93.2% was male. Male patients reported a mean age of 26.1±12.1 years, while pediatric cases reported a mean age of 11.7±3.41 years. The most frequently injured region of the body was the head–neck region (52.7%). The New Injury Severity Score (NISS) of the cases was 42.5±11.2 and their American Society of Anesthesiologists (ASA) score was 3.2±0.7. The number of cases with intraoperative exitus was 7, while the number of cases who had undergone damage control surgery was 204. The number of cases hospitalized in the ICU during the postoperative period was 233, and the average hospitalization duration in the ICU was 4.67±1.32 days. Among survivor patients, the first 24-hour invasive measurements (i.e., pH, hemoglobin, body temperature, and mean arterial blood pressure) and international normalized ratio were found to be high. The number of blood products used for surviving patients was fewer relative to that used for non-surviving patients, and these NISS of these patients was 29.7±10.1. The mortality rate of all patients followed up in the ICU after emergency surgery was 45%, and neurosurgical cases showed the lowest level of survival (24.1%). CONCLUSION: The results of this study indicated that head–neck, chest–abdomen, and multiple body injuries are the most widely seen among civilians brought to Turkey because of gunshot injuries sustained during the Civil War in Syria. The number of emergency operations performed in the study sample was high, and critical care follow-up durations were long. In addition, the NISS and ASA scores of mortal cases were fairly high. Keywords: Injury characteristics; refugees; Syria’s civil war. Address for correspondence: Betül Kocamer Şimşek, M.D. Sanko Üniversitesi Tıp Fakültesi, Anestezi ve Reanimasyon Anabilim Dalı, İncilipınar Mah., No: 36, Şehitkamil, 27090 Gaziantep, Turkey Tel: +90 342 - 211 65 00 E-mail: btlkcmr@gmail.com Ulus Travma Acil Cerrahi Derg 2017;23(3):199–206 doi: 10.5505/tjtes.2016.95525 Copyright 2017 TJTES

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INTRODUCTION Wars date back to the beginning of human history. About 1.6 million lives worldwide are lost annually because of gunshot injuries, and deaths during continuing wars constitute approximately a fifth of these cases.[1] Besides adults, children also suffer from the war (Fig. 1). Because of injuries caused by war weapons, fragmentation, and blast effect, wars require emergency teams and operations working in the field to develop new trauma approaches. The severity of the injuries of soldiers and civilians sustained during the war further require 199


Kocamer Şimşek et al. Characteristics of the injuries of Syrian refugees sustained during the civil war

innovative surgical treatment and intensive care follow-up processes of these cases. Because of the difficulties associated with providing pre- and intra-hospitalization emergency healthcare services under war conditions, triage systems (e.g., SAMPLE) and trauma scoring systems (e.g., New Injury Severity Score (NISS)) featuring improved efficiency have been established. The Damage Control Surgery (DCS) and Damage Control Resuscitation (DCR) practices are among the newer approaches utilized in the war surgery domain.[2,3] In this study, we aimed to contribute to the literature on the treatment of way injuries by evaluating the clinical characteristics of injured cases as well as the characteristics of surgical, critical, and intensive care treatment under war conditions.

MATERIALS AND METHODS After obtaining permission from local authorities, files of Syrian refugee patients admitted to the Emergency Department (ED) of Kilis Public Hospital (Turkey) were examined retrospectively. A total of 8,318 Syrian Refugee Patients were enrolled from March 2012 to January 2013. Within this group, 707 trauma patients required emergency operation. All of the surgical patients were given general anesthesia with 1 mg/ kg, 0.01–0.03 mg/kg midazolam, and 1 mg/ ropivacain kg and then intubated. At least two intravenous (IV) lines with a 16G intracath were started, and urinary bladder and nasogastric catheters were inserted. Arterial and central venous catheters were also placed to monitor blood pressures. Temperature was measured by an oropharyngeal probe, and blood samples were collected to determine blood gases, complete blood count, biochemistry, and crossmatch for blood transfusion. Hydroxyethyl starch, O Rh (-)-type blood infusion, and inotropic agents were started when needed. All patients were heated with air warmer blankets, and all fluids were heated prior to administration. Fluid and blood transfusions were given according to central venous pressure and urinary output.

ferred to the intensive care unit (ICU) of the hospital while intubated and provided midazolam and remifentanil infusion. Patients were evaluted for blood gas, hemoglobin, biochemical parameters, and body temperature, and intra-abdominal pressure was measured indirectly via a urinary catheter intravesicular probe. All patients were extubated when considered stable. The data analyzed include surgery type, blood and fluid transfusion requirements, inotropic use, length of total ICU stay, mechanical ventilation duration, blood gas values, hemoglobin, and four temperature values: pre-operation, post-operation, first hour in the ICU, and 24 hours after admittance to the ICU.

Statistical Analysis Research data were processed and analyzed using the SPSS software package (version 16.0; SPSS Inc., Chicago, IL, USA). Data are presented as numbers and percentages for categorical variables and as mean±standard deviation for quantitative variables. A value of p<0.05 was considered significant in all analyses.

RESULTS Over a span of 10 months (March 2012–January 2013), a total

Addmitted to surgical inpatient clinics 23.96% 53.65%

Addmitted to surgical intensive care unit 4.11%

8.50% 7.90%

Directly addmitted to the emergency operation Referred to another hospital outside the province Death in the emergency department Outpatient treatment in the emergency department

1.88%

The decision to initiate DCS was based on standard DCS inclusion criteria (i.e., injury severity score ≥25, systolic blood pressure <70 mmHg, body temperature <34 °C, and blood pH <7.1).[4] Following surgery, DCS patients were trans-

Figure 2. Fate of injured Syrian refugees admitted to the Emergency Department (n=8.318). 0.75%

15.50% Gunshot injuries Explosive and shrapnel injuries 83.75%

Figure 1. A Syrian child suffering from the effects of civil war (courtesy of Mr. Lokman HAPPANI-war reporter).

200

Others

Figure 3. Causes of injury among Syrians admitted to the Emergency Department (n=8.318).

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Kocamer Şimşek et al. Characteristics of the injuries of Syrian refugees sustained during the civil war

number of 8,318 injured persons were admitted to the ED of Kilis Public Hospital from the southern border of Turkey. More than half of these patients were treated as outpatients (4,463 cases, 53.65%), and approximately a quarter of the cases were treated by hospitalization in surgical clinics (1,993 cases, 23.96%). Approximately 1 of every 25 traumatic cases taken to the ED was directly accepted to the ICU (342 cases, 4.11%), and 1 of every 44 traumatic cases died during admission to this department (156 cases, 1.88%). The numbers of traumatic patients referred out of the city and those requiring emergency surgery were similar and accounted for less than 10% of the traumatic cases admitted to the ED (Fig. 2). Some of the cases were directly accepted from the ED to the ICU (342 cases, 4.11%) and underwent DCS by volunteer surgeons under poor healthcare conditions. Nineteen cases (5.5%) underwent DCS in Syria. The most frequent reason for injury was gunshot (6,966 cases, 83.75%), and the effects of injuries caused by firearms were very significant. Explosives and shrapnel (1,290 cases, 15.5%) were the second most-frequently reported cause of injury. Among explosive-caused injuries, bomb attacks, and landmines were the most prominent (Fig. 3). Other reasons for injury included being trapped in the wreckage of buildings during bombing, falls, and traffic accidents (62 cases, 0.75%). Most the traumatic cases directly taken from the ED to surgery (707 cases, 8.5%) were male (659 cases, 93.2%), and their mean age was 25.8±12.7 years. The mean age of 84 pediatric and adolescent cases was 11.7±3.41 years (range, 1–18 years). A significant difference was found in terms of sex (p=0.006). The most frequently injured region of the body was the head–neck area (373 cases, 52.7%), followed by the thorax, abdomen, and backplane–dorsal area (197 cas-

es, 27.8%). Traumatic cases admitted to emergency surgery showed very high NISS and American Society of Anesthesiologists (ASA) scores (Table 1). In terms of the distribution of emergency operations (707 cases, 754 emergency operations) by surgical department, most of the patients required orthopedic, general surgical, and plastic surgical operations. Among these departments, the intraoperative mortality rate and number of patients requiring monitoring in the ICU after emergency surgery were found to be the highest in general surgical patients (Table 2). The number of semi-elective operations performed on the patients was 3,454, and the number of cases referred to hospitals in other cities was 456 (Fig. 2). Among emergency cases, most of the femoral fracture operations were performed by the Orthopedics and Traumatology departments (94 cases, 37%). Most the plastic and reconstructive surgical (PRS) cases reported burns due to various firearms (91 cases, 75.8%). The top three multidisciplinary departments carrying out emergency operations (93 operations, 12.3%) were the General Surgery and Thoracic Surgery departments (36 operations, 38.7%), the General Surgery and Urology departments (15 operations, 16.1%), and the Orthopedics and Cardiovascular Surgery (CVS) departments (10 operations, 10.7%). Among 233 cases admitted to the ICU after emergency surgery, the hospitalization duration of survivors was significantly shorter than those of intubated and exitus cases (p=0.001). Similarly, the arterial blood pH of survivors was significantly higher than those of intubated and exitus cases (p=0.001), and the blood hemoglobin, body temperature, and mean arterial blood pressure (MABP) values of the former were significantly higher than those of the latter (p=0.001, p=0.001, and p=0.002, respectively). The International Nor-

Table 1. Characteristics of cases directly admitted from the Emergency Department to the operating room (n=707) Parameters

n % Minimum–Maximum Mean±SD

Age (years)

Male

Female All patients

659

93.2

1–67

26.1±12.1

48

6.8

1–65

22.2±17.8

707

100

1–67

25.8±12.7

Injured body parts Head-Neck

373

52.7

Chest-Abdomen-Back

197

27.8

Extremities

39

5.5

Multiple parts (3+)

98

13.8

New Injury Severity Score (0–75)

707

100

11–75

42.5±11.2

American Society of Anesthesiologists Score (0–6)

707

100

1–5

3.2±0.7

SD: Standard deviation.

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Kocamer Şimşek et al. Characteristics of the injuries of Syrian refugees sustained during the civil war

Table 2. Distribution of emergency operations by surgical department and outcome (n=707) Departments

All

Pediatric

Damage control surgery

Exitus

Intensive care unit

Orthopedics

254 26

91

9

General surgery

148

69

3

77

Plastic and reconstructive surgery

120

17

11

Thoracic surgery

95

5

17

1

50

Neurosurgery

76 19

27

2

73

Cardiovascular surgery

35

4

1

6

Ophthalmic surgery

17

10

Pediatric surgery

6

6

6

Others Total

3 1 754 88

malized Ratio (INR) values of survivor cases were significantly higher than those of intubated and exitus cases (p=0.002), and the amounts of erythrocyte suspension (ES) and fresh frozen plasma (FFP) used by the former were significantly less than those required by the latter (p=0.001 and p=0.002 respectively). The NISS values of survivor cases were found to be significantly lower than those of intubated and exitus cases (p=0.003) (Table 3). The top three surgical cases followed up in the ICU by intubation after emergency operation (83 cases) included neurosurgical cases (40 cases, 48.1%), general surgical cases (21 cases, 25.3%), and thoracic surgical cases (15 cases, 18%). The highest survival rate was observed in PRS cases (admitted, 11;

204

7

1 233

survived, 11; survival rate, 100%), while the lowest survival rate was observed in neurosurgical cases (admitted, 73 cases; survived, 18 cases; survival rate, 24.6%) (Table 4). Among patients who underwent DCS (204 cases), the highest mortality rates within the first 24 and 72 hours after surgery were reported in neurosurgical patients (6 cases, 22.2% and 15 cases, 55.5%, respectively). By comparison, the lowest mortality rates within the first 24 and 72 hours after surgery were reported in orthopedics patients (0 cases, 0% and 1 case, 1.09%, respectively) (Table 5). The number of complications that developed in general surgery cases with DCS (69 cases) during the first 72 hours of

Table 3. Clinical characteristics of cases admitted to the ICU after emergency operation (n=233) Parameters Length of stay (day)

All patients

Intubated

Exitus

Survivor

Mean±SD (Min.–Max.)

Mean±SD (Min.–Max.)

Mean±SD (Min.–Max.)

Mean±SD (Min.–Max.)

4.67±1.32 (1–65)

3.27±1.01 (1–27)

5.13±1.76 (1–41)

2.74±1.12 (1–16)

Invasive measurements

(ICU 24th hour)

Arterial blood pH

7.41±0.02

7.34±0.09

7.34±0.21

7.43±0.02

Hemoglobin (g/dL)

10.3±0.71

9.6±1.1

9.9±0.8

10.7±0.5

Body temperature (°C)

35.9±0.51

35.1±0.74

35.4±0.79

36.1±0.42

MAP (mmHg)

74±8.1

71±5.7

67±9.8

84±4.3

Use of blood products

ES (Unit)

2.4±0.80 (1–9)

2.7±1.16 (1–8)

2.4±1.05 (1–9)

2.2±0.45 (1–6)

FFP (Unit)

2.0±0.48 (1–6)

1.9±0.33 (1–4)

2.3±0.63 (1–6)

1.7±0.21 (1–2)

Prothrombin time

INR

New Injury Severity Score

1.2±0.4

0.97±0.2

0.93±0.3

1.46±0.7

44.7±11.2

35.2±7.9

61.4±15.8

29.7±10.1

ICU: Intensive Care Unit; SD: Standard deviation; Min.: Minimum; Max.: Maximum; MAP: Mean arterial pressure; ES: Erythrocyte suspension; FFP: Fresh frozen plasma; INR: International normalized ratio.

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Kocamer Şimşek et al. Characteristics of the injuries of Syrian refugees sustained during the civil war

Table 4. Survival rates of cases admitted to the ICU after emergency operation by surgical department (n=233) Outcomes Admission Intubated Exitus Survivor

Departments

73

Neurosurgery

40 55 18

General surgery

77

21

36

41

Thoracic surgery

50

15

8

42

Orthopedics

9

– 2 7

Plastic and reconstructive surgery

11

1

11

Cardiovascular surgery

6

4

3

3

Pediatric surgery

6

2

1

5

1

Others

233

Total

– – 1 83 105 128

Table 5. Mortality rates of cases who underwent DSC in the ICU (n=204)

Mortality rates

First 24 hours

First 72 hours

Departments DCS n % n % Orthopedics

91

0

0

1

1.09

General surgery

69

4

5.7

9

13

Neurosurgery

27 6 22.2 15 55.5

Thoracic surgery 17 3 17.6 3 17.6 Total

204

13

6.3

28

13.7

ICU: Intensive care unit; DCS: Damage control surgery.

admittance was 26. Specifically, sepsis developed in 12 cases, adult respiratory distress syndrome (ARDS) developed in 9 cases, disseminated intravascular coagulation (DIC) developed in 3 cases, and acute tubular necrosis (ATN) developed in 2 cases. By comparison, the number of complications that developed in thoracic surgery patients with DCS (13 cases) during the first 72 hours of admittance was found 4 (i.e., ARDS in 1 case and sepsis in 3 cases).

DISCUSSION The firearms used in war feature high kinetic energy and unique bullet structures. Thus, the level and variety of damage inflicted by these weapons on the viscera differ from those observed from civilian firearms. Visceral injury-related deaths because of shrapnel injuries, which are not observed in civilian life, and the blast effects of bombs are most frequently observed in wars. Weapons of mass destruction are created to present specific injurious and mostly lethal features.[5–8] Recent studies on Syrian refugees have shown that the numUlus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

ber of injured patients who have been brought to Turkey in the early years of the Syria’s Civil War (between 2011 and 2013) was very high. In a previous study carried out in Hatay, Karakuş et al. found that the total number of cases admitted to Mustafa Kemal University Research and Training Hospital over a14-month period (from June 2011 to July 2012) was 1,355; of this number of cases, 482 (35.6%) were taken to the ED, 94.6% were referred to outpatient treatment, 4.6% died in the ED, and less than 1% were referred to other medical centers.[9] In their study in Kashmir, Mushtaque et al. found that 59% of the injured individuals reporting to the ED were referred to outpatient treatment.[10] Hakimoglu et al., in a study involving patients admitted to MKU Research and Training Hospital’s Reanimation ICU for 6 months (2012), reported that the number of injured Syrian refugees who were hospitalized in the perioperative period was 364.[11] This result is also consistent with the number of cases requiring emergency surgery (perioperative) we observed in our study for the same period. In both studies, most the cases was noticeably male and their mean ages were between 21 and 30 years. 203


Kocamer Şimşek et al. Characteristics of the injuries of Syrian refugees sustained during the civil war

Especially young men and children have been injured during Syria’s civil war. The demographic findings in our study are consistent with those reported in previous studies (Karakus and Hakimoglu). However, in our study, the total number of injured Syrian refugees taken to our ED over a 10-month period (2012–2013) was 8,318. The number of cases referred to outpatient treatment in our study is lower than that reported by Karakuş et al. but close to that determined in Mushtaque et al.’s study, which involved a wider series and similar conditions. During civil wars in the last 50 years, in-hospital mortality rates have been reported between 1.8% and 8.5%.[10] The exitus rate found in our study (1.88%) is within these limits. The higher number (7.9%) of referred cases found in our study in comparison with those reported in previous may be mainly attributed to the transfer of many patients with complicated injuries to hospitals closer to the border and also it may be related to exceeding the hospital capacity in a short time (Fig. 2). Studies by Karakuş et al. and Zeren et al. on injured Syrian refugees revealed that the most frequent reason for injury is gunshot, followed by explosives and shrapnel.[1,9] In their postmortem examination of 186 Syrian refugees who died during the war, Çelikel et al. reported that the most frequent injuries leading to death were those caused by explosives and shrapnel followed by gunshots.[7] The results of our study are consistent with those of Karakuş et al. and Zeren et al. In their study on individuals injured during the civil war in Kashmir, Mushtaque et al. determined that the most frequent injuries sustained by civilians were upper-extremity injuries, followed by thorax–abdomen injuries, head–neck–face injuries, and burns. Cardiovascular, ophthalmologic, and urologic injuries were relatively less reported. The possibility of multiple injuries sustained in a war is fairly high.[1,9,12] In their postmortem examination of Syrian refugees injured in civil war, Çelikel et al. reported that the most frequent injuries observed were head–neck injuries, followed by thorax–abdomen–backplane injuries, multiple injuries, and extremity injuries.[7] Our study results are consistent with those of Çelikel et al. in terms of the distribution of injury locations. Çelikel et al. reported NISS values of 43.0±21.5 among nonsurvivors of civil war. The mean NISS scores of our injured patients were consistent with those recorded in this previous study, and our ASA scores were quire high.[12] This finding may be attributed to high numbers of severely traumatic and exitus cases recorded in our work. The literature reports that the proportion of women injured in civil wars after World War II varies between 9% and 12% while that of children varies between 5% and 10%.[1,9,12,13] The percentages of women taken to emergency surgery (6.8%) and children (10.6%) in the present work were consistent 204

with similar reported studies. The lower proportions of women and children injured in the war in comparison with the proportion of men may be explained by the fact that the two former groups do not actively participate in the war and, instead, live in residential areas. The distribution of pediatric cases requiring emergency surgery by surgical department shows some similarity with that of adult cases. The majority of cases treated by the PRS department suffered from burns, likely due to the frequent use of firearms in war. According to Midwinter, the factors to consider when deciding on the DCS approach include high-energy blunt trauma, multiple body penetration, hemodynamic stability, coagulopathy and/or hypothermia. In complex cases, major abdominal vascular injuries together with multiple visceral injuries, multifocal or multicavity hemorrhage together with visceral injuries, primary multiple regional injuries are also considered. Severe metabolic acidosis (pH <7.30), hypothermia (body temperature <35 °C), duration of resuscitation, and operation longer than 90 minutes are considered critical factors, and coagulopathy and massive transfusion (>10 units of PRBC) are applied as indicators of non-mechanical hemorrhage development.[4] In a previous study, the criteria adopted for making a DCS decision are ISS >25, systolic blood pressure <70 mmHg, core body temperature <34 °C, and pH <7.1.[14] Only a limited number of DCS cases carried out on individuals injured during the Syrian Civil War have been reported. [15] In our study, 204 patients meeting the criteria were subjected to DCS in our hospital. Among these patients, those with the lowest survival rates were neurosurgical, thoracic surgical, and general surgical patients; this fact is consistent with the distribution of injuries from gunshots, explosives, and shrapnel throughout the body and indicates that these types of injuries present vital consequences to patients. In their study on injured Syrian refugees hospitalized in the ICU after civil war, Ozdogan et al. reported the mean hospitalization duration of these cases to be 12 days.[16] The mean hospitalization duration in emergency surgery intensive care in our study was shorter (4.67±1.32 days) than that observed by Ozdogan et al. We were unable to obtain a more extensive study on the follow-up details of similar cases in the literature. In our study, we determined that rate of entubated patients and mortality rate was very high in post-operative period (37.6% and 47.5%, respectively). Moreover, duration of stay in hospital of the patients monitored with mechanical ventilation was shorter (3.27±1.01 days) than the patients who died (5.13±1.76 days); this finding is related to the clinical characteristics of the cases (multiple trauma, hemodynamic status, and ICU follow-up conditions). These results may be the most dramatic follow-up results regarding injured Syrian refugees reported in the literature to date. The fact that head, abdominal, and thoracic injuries were the most prominent among patients who died in the postoperative period in the ICU is important because this finding reveals the body Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Kocamer Şimşek et al. Characteristics of the injuries of Syrian refugees sustained during the civil war

regions affected most extensively by gunshot, explosives, and shrapnel.

DIC, ATN, and sepsis among general surgical and thoracic surgical patients (30 cases, 14.7%).

In a study by Hakimoglu et al. on 364 preoperative injured Syrian refugees, the mean ES amount was found to be 2.6±5.4 units, and the mean FFP amount was found to be 0.8±2.6 units. Moreover, the amount of products used for survivor perioperative cases was less for exitus cases.[11] In a systematic review study on penetrant-traumatic cases, Tapia et al. reported that when beginning of trauma centers mortality rates were high in the traumatic cases are not given optimal levels of liquid and blood products.[17] In our study, the mean ES amount used for emergency-operation cases was consistent with these results, the amount of FFP was higher. These findings are consistent with the results of our study. Among the emergency-operation cases we observed, the departments requiring the highest levels of blood product use included the General Surgery, Thoracic Surgery, CVS, and Orthopedics departments, and this finding may be related to the hemodynamic instability of the cases reporting for treatment in these departments. In our study, the amounts of blood product transfusions were optimal according to the principles of DCR practice.

In conclusion, all wars cause severe trauma in both the physical and emotional aspects. Most injured Syrian refugees suffering from the effects of civil war consisted of young males and children. Since ground attacks were more prominent in the first years of war than in later years, the most-cited reason for injury was firearms. Half of all traumatic cases taken to the ED of Kilis Public Hospital were treated as outpatients, and head–neck, thorax–abdomen–backplane, and multiple body injuries were the most frequently reported injuries among severely traumatic cases requiring emergency surgery. The NISS and ASA scores of these patients were relatively higher. Although the most frequent emergency surgery and DCS requirements were observed in orthopedic surgical cases requiring, the highest mortality rates were observed in neurosurgical cases. The mean hospitalization duration of survivor cases followed-up in the ICU after emergency surgery was shorter than that of non-survivors, and the amounts of blood products required by the former were lower than that of the latter. As well, the invasive measurement parameters (i.e., pH, hemoglobin, body temperature, and MABP) and INR values of survivors were better than those of intubated and exitus cases. According to this study, in severely traumatic cases under difficult war conditions, DCR and DCS should be preferred with appropriate indications.

The pH, hemoglobin, and core temperature values measured from the blood gases of exitus cases who died during and early after operation in the ED and consulted by the General Surgery, Thoracic Surgery, and Neurosurgery Departments were significantly lower than normal limits. The pH, hemoglobin, and core temperature values of exitus cases who died in the preoperative and intraoperative periods were lower than those of cases who died in the postoperative period, which may be related to long periods without any treatment after the trauma, clinical conditions upon admission to the ED, early intervention priority, and limited healthcare opportunities. In neurosurgical cases, the pH, hemoglobin, and core temperature values of cases who died in different periods were higher than those of patients who consulted and/ or followed-up in the General Surgery and Thoracic Surgery departments. This finding indicates that lesions in the central nervous system directly affect vital centers and may lead to exitus without significantly influencing the parameters measured from blood gas. The extent of trauma-induced coagulopathy (TIC), the endogen-based response of the body to any severe trauma, is proportional to the severity of the trauma. In TIC management, early diagnosis, fast transportation, hemorrhage control, and avoidance of crystalloid resuscitation are very important.[18] DCR refers to the plasma-rich and crystalloid-poor liquid resuscitation approach applied for shock developing from massive hemorrhages. The effect of DCR on hypoxia development after massive transfusion is not known.[1] In our study, the mortality of 204 cases followed-up in the ICU after DCS within the first 72 hours of admittance (28 cases, 13.7%) may be related to the high rate of complications such as ARDS, Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

Conflict of interest: None declared.

REFERENCES 1. Zeren C, Arslan MM, Aydoğan A, Özkalıpçı Ö, Karakuş A. Firearm injuries documented among Syrian refugees in Antakya Turkey. British Journal of Arts and Social Sciences 2012;5:1–5. 2. Ma X, Xiao Y, Chen T, Jiang D, Zhou J, Yan J, Liang H. Predictive value of combining of anatomy scoring system and physiological scoring system for the diagnosis of multiple organ dysfunction syndrome in patients with severe trauma. [Article in Chinese] Zhonghua Shao Shang Za Zhi 2016;32:105–8. 3. Giannoudi M, Harwood P. Damage control resuscitation: lessons learned. Eur J Trauma Emerg Surg 2016;42:273–82. 4. Midwinter MJ. Damage control surgery in the era of damage control resuscitation. J R Army Med Corps 2009;155:323–6. 5. Bellamy RF. The medical effects of conventional weapons. World J Surg 1992;16:888–92. 6. Wightman JM, Gladish SL. Explosions and blast injuries. Ann Emerg Med 2001;37:664–78. 7. Çelikel A, Karaarslan B, Demirkıran DS, Zeren C, Arslan MM. A series of civilian fatalities during the war in Syria. Ulus Travma Acil Cerrahi Derg 2014;20:338–42. 8. Aboutanos MB, Baker SP. Wartime civilian injuries: epidemiology and intervention strategies. J Trauma 1997;43:719–26. 9. Karakuş A, Yengil E, Akkücük S, Cevik C, Zeren C, Uruc V. The reflection of the Syrian civil war on the emergency department and assessment of hospital costs. Ulus Travma Acil Cerrahi Derg 2013;19:429–33. 10. Mushtaque M, Mir MF, Bhat M, Parray FQ, Khanday SA, Dar RA,

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Kocamer Şimşek et al. Characteristics of the injuries of Syrian refugees sustained during the civil war Malik AA. Pellet gunfire injuries among agitated mobs in Kashmir. Ulus Travma Acil Cerrahi Derg 2012;18:255–9. 11. Hakimoglu S, Karcıoglu M, Tuzcu K, Davarcı I, Koyuncu O, Dikey İ, et al. Assessment of the perioperative period in civilians injured in the Syrian Civil War. [Article in Portuguese] Rev Bras Anestesiol 2015;65:445– 9. [Abstract] 12. Çelikel A, Karbeyaz K, Kararslan B, Arslan MM, Zeren C. Childhood casualties during civil war: Syrian experience. J Forensic Leg Med 2015;34:1–4. 13. Devakumar D, Birch M, Rubenstein LS, Osrin D, Sondorp E, Wells JC. Child health in Syria: recognising the lasting effects of warfare on health. Confl Health 2015;9:34. 14. Kisat M, Zafar SN, Hashmi ZG, Pardhan A, Mir T, Shah A, et al. Experience of damage control trauma laparotomy in a limited resource healthcare setting: A retrospective Cohort Study. Int J Surg 2016;28:71–6. 15. Hornez E, Boddaert G, Baudoin Y, Daban JL, Ollat D, Ramiara P, et al.

Concomitant Vascular War Trauma Saturating a French Forward Surgical Team Deployed to Support the Victims of the Syrian War (2013). Interest of the Vascular Damage Control. Ann Vasc Surg 2015;29:1656. e7–12. 16. Ozdogan HK, Karateke F, Ozdogan M, Satar S. Syrian refugees in Turkey: effects on intensive care. Lancet 2014;384:1427–8. 17. Tapia NM, Suliburk J, Mattox KL. The initial trauma center fluid management of penetrating injury: a systematic review. Clin Orthop Relat Res 2013;471:3961–73. 18. Simmons JW, Pittet JF, Pierce B. Trauma-Induced Coagulopathy. Curr Anesthesiol Rep 2014;4:189–99. 19. Campion EM, Pritts TA, Dorlac WC, Nguyen AQ, Fraley SM, Hanseman D, et al. Implementation of a military-derived damage-control resuscitation strategy in a civilian trauma center decreases acute hypoxia in massively transfused patients. J Trauma Acute Care Surg 2013;75(2 Suppl 2):221–7.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Suriyeli mültecilerin süren iç savaş sırasındaki yaralanma özellikleri Dr. Betül Kocamer Şimşek,1 Dr. Mehmet Dokur,2 Dr. Erdal Uysal,3 Dr. Necdet Çalıker,4 Dr. Oruç Numan Gökçe,5 Dr. İbrahim Kürşat Deniz,5 Dr. Murat Uğur,6 Dr. Murat Geyik,7 Dr. Mehmet Kaya,8 Dr. Güner Dağlı1 Sanko Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalı, Gaziantep Dicle Üniversitesi Sağlık Bilimleri Enstitüsü, Tıp Eğitimi Anabilim Dalı, Diyarbakır Sanko Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Gaziantep 4 Kilis Devlet Hastanesi, Anestezi Kliniği, Kilis 5 Kilis Devlet Hastanesi, Genel Cerrahi Kliniği, Kilis 6 Kilis Devlet Hastanesi, Nöroşirürji Kliniği, Kilis 7 Gaziantep Üniversitesi Tıp Fakültesi, Nöroşirurji Anabilim Dalı, Gaziantep 8 Turgut Özal Üniversitesi Tıp Fakültesi, Halk Sağlığı Anabilim Dalı, Ankara 1 2 3

AMAÇ: Savaşlar sırasında çok sayıda sivil, sıklıkla yüksek kinetik enerjili ateşli silahlar, bomba ve şarapnel etkisiyle ciddi yaralanmalarla karşı karşıya kalmışlardır. Savaş yaralısı olguların triyajı, cerrahi prosedürleri ve yoğun bakım takipleri oldukça zor ve karmaşık süreçleri içerir. Biz bu çalışmada, Suriye İç Savaşı sırasında yaralanan ve acil operasyon gerektiren olguların demografik ve travmatik özelliklerini inceledik. GEREÇ VE YÖNTEM: Türkiye’nin güneyindeki Suriye sınırından Mart 2012 ve Ocak 2013 arasında Kilis Devlet Hastanesi’ne getirilen 8318 Suriyeli yaralı sığınmacı arasından acil olarak operasyona alınan 707 olgunun travmatik, cerrahi ve yoğun bakım takip özellikleri, elektronik datalar üzerinden geriye dönük olarak incelendi. BULGULAR: Olgulardaki en sık yaralanma nedeni yüksek kinetik enerjili ateşli silahlar (%83.75) idi. Acil servisten direkt olarak operasyon odasına alınan 707 olgunun %93.2’si erkek cinsiyetinde yaş ortalaması 26.1±12.1 ve çocuk olguların yaş ortalaması ise 11.7±3.41 olarak saptandı. En sık yaralanan vücut bölgesi baş-boyun idi (%52.7). New Injury Severity Score (NISS): 42.5±11.2 ve American Society of Anesthesiologists (ASA) Score: 3.2±0.7 olarak bulundu. Ameliyatta hayatını kaybeden olgu sayısı yedi, hasar kontrol cerrahisi uygulanan olgu sayısı 204 ve ameliyat sonrası periyotta yoğun bakıma yatırılan olgu sayısı ise 233 olarak bulundu.Yoğun bakımda yatış süresi 4.67±1.32 idi.Yaşayan hastalarda ilk 24 saatte bakılan invaziv ölçümler (pH, hemoglobin, vücut ısısı, ortalama arteriyal kan basıncı) ve International Normalized Ratio (INR) daha yüksek bulundu. Yaşayabilen hastalar için kullanılan kan ürünü miktarları daha azdı ve bu hastalarda NISS 29.7±10.1 olarak bulundu. Acil operasyon sonrası yoğun bakımda takip edilen tüm hastalardaki mortalite oranı %45 ve en düşük sağ kalım oranı nöroşirürji olgularına aitti (%24.1). TARTIŞMA: Bu çalışmanın verileri, Suriye İç Savaşı sırasında tahrip gücü yüksek olan savaş silahları ile yaralanarak Türkiye’ye getirilen ve acil operasyona alınan Suriyeli sivillerde baş-boyun, göğüs-abdomen ve çoklu vücut yaralanmalarının sık görüldüğüne, acil cerrahi operasyon sayılarının fazla ve yoğun bakım takip sürelerinin uzun olduğuna, mortal olgularda ise NISS ve ASA skorlarının anlamlı bir şekilde yüksek olduğuna işaret etmektedir. Anahtar sözcükler: Yaralanma özellikleri; mülteciler; Suriye iç savaşı. Ulus Travma Acil Cerrahi Derg 2017;23(3):199–206

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ORIG I N A L A R T IC L E

Efficiency of instant messaging applications in coordination of emergency calls for combat injuries: A pilot study Sami Eksert, M.D.,1 Mehmet Burak Aşık, M.D.,2 Sinan Akay, M.D.,3 Kenan Keklikçi, M.D.,4 Fevzi Nuri Aydın, M.D.,5 Mehmet Çoban, M.D.,6 Ali Kantemir, M.D.,4 Onur Güngör, M.D.,7 Beyazıt Garip, M.D.,8 Mustafa Suphi Turgut, M.D.,9 Kenan Olcay, M.D.10 1

Department of Anesthesiology and Reanimation, Şırnak Military Hospital, Şırnak-Turkey

2

Department of Otolaryngology, Head and Neck Surgery, Şırnak Military Hospital, Şırnak-Turkey

3

Department of Radiology, Şırnak Military Hospital, Şırnak-Turkey

4

Department of Orthopedics and Traumatology, Şırnak Military Hospital, Şırnak-Turkey

5

Department of Biochemistry, Şırnak Military Hospital, Şırnak-Turkey

6

Department of Infectious Diseases, Şırnak Military Hospital, Şırnak-Turkey

7

Department of Pediatrics, Şırnak Military Hospital, Şırnak-Turkey

8

Department of Psychiatry, Şırnak Military Hospital, Şırnak-Turkey

9

Department of General Surgery, Şırnak Military Hospital, Şırnak-Turkey

10

Department of Eye Diseases, Şırnak Military Hospital, Şırnak-Turkey

ABSTRACT BACKGROUND: Coordination of an emergency response team is an important determinant of prompt treatment for combat injuries in hospitals. The authors hypothesized that instant messaging applications for smartphones could be appropriate tools for notifying emergency response team members. The objective of this study was to investigate the efficiency of a commercial instant messaging application (WhatsApp, Mountain View, CA) as a communication tool for the emergency team in a level-I trauma center. METHODS: We retrospectively evaluated the messages in the instant messaging application group that was formed to coordinate responses to patients who suffered from combat injuries and who were transported to our hospital via helicopter during an 8-week period. We evaluated the response times, response time periods during or outside of work hours, and the differences in the response times of doctors, nurses, and technicians among the members of the emergency team to the team leader’s initial message about the patients. RESULTS: A total of 510 emergency call messages pertaining to 17 combat injury emergency cases were logged. The median time of emergency response was 4.1 minutes, 6 minutes, and 5.3 minutes for doctors, nurses, and the other team members, respectively. The differences in these response times between the groups were statistically significant (p=0.03), with subgroup analyses revealing significant differences between doctors and nurses (p=0.038). However, no statistically significant differences were observed between the doctors and the technicians (p=0.19) or the nurses and the technicians (p=1.0). From the team leader’s perspective, using this application reduced the workload and the time loss, and also encouraged the team. CONCLUSION: Instant messaging applications for smartphones can be efficient, easy-to-operate, and time-saving communication tools in the transfer of medical information and the coordination of emergency response team members in hospitals. Keywords: Combat-related injuries; medical informatics; trauma. Address for correspondence: Mehmet Burak Aşık, M.D. Şırnak Asker Hastanesi, 73000 Şırnak, Turkey Tel: +90 486 - 218 10 00 E-mail: burock312@yahoo.com Ulus Travma Acil Cerrahi Derg 2017;23(3):207–211 doi: 10.5505/tjtes.2016.37897 Copyright 2017 TJTES

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INTRODUCTION Nowadays, smartphones represent an important part of modern life. As long as a signal is available, these devices ensure that we can communicate from nearly everywhere, access the Internet, check e-mails, and follow social networks. In Turkey alone, 58% of the population uses cell phones and smartphones to access the internet outside their homes and workplaces.[1] In the surgical and emergency fields, members of any division 207


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generally communicate verbally via telephones. Such communication can be rapid if it occurs between two people. However, if more than one member of the team needs to be informed, the telephone may not be the fastest and most appropriate tool for communication. Furthermore, such communication can, at times, lack objectivity and precision.[2] Nowadays, with technological advancements occurring at an unprecedented pace, images taken by a smartphone can be instantly transferred to another smartphone via specific applications,[3–5] and this technique is used as a communication method among physicians during patient evaluations. Founded in 2009 by Brian Acton and Jan Koum, WhatsApp (Mountain View, CA, USA) is an instant messaging application for smartphones. It is a proprietary application and operates under a subscription business model used for sending messages, images/photos, videos, audio media messages, and the user’s location. WhatsApp is the most popular messaging application globally, with the number of its active users reaching 900 million in September 2015.[6] Limited studies[2,7] have investigated the role and efficiency of using social media services in medical practices. The present study hypothesizes that instant messaging applications are effective and fast communication tools for an emergency team (ET) in combat injuries. The study aims to investigate the efficiency of this smartphone application as a communications tool for the ET at a level-I trauma center.

MATERIALS AND METHODS The present study was conducted at a level-I trauma hospital, which is the primary center for combat injuries in its region. The study protocols were approved by Kecioren Research and Training Hospital institutional review board. In the past, ET members communicated using telephone calls during emergency cases in the hospital. Each ET comprises four distinct task teams: the transportation team, the triage-cardiopulmonary resuscitation team, the operation room and intensive care unit team, and the blood transfusion-laboratory team. An anesthesiologist, the ET leader, communicates the emergency calls to all team members and coordinates their actions. The emergency call process, the teams’ tasks, and their respective actions are shown in a flowchart in Figure 1. An instant messaging application (WhatsApp, Mountain View, CA) message group was created for communicating emergency calls for combat injuries incurred on the tactical field to the team leader, facilitate the patient’s transport to the trauma hospital, and coordinate all team members’ actions. All ET members, already active users of the application, were included in this group. Communication and message rules were determined and texted to all team members via instant messaging application messages. Further messages were not sent to the team members to avoid Pygmalion and Hawthorne biases. These rules are shown in Figure 2. After affirming an emergency case, the team leader texted

EMERGENCY CALL

Transportation Team – Affirmation of emergency case

Emergency Team Leader – Sharing emergency call by Whats App – Coordination of team subgroups

– Initial avaluation and urgent aid – Blood type determination

Operation Romm-Intensive

Triage-Cardiopulmonary

Care Unit Team

Resuscitation Team

– Control of blood stocks

– Specific surgical preparation

– Monitorization and initiation of

– Call fon blood donor

and technical support

CPR if needed

– Identification of blood type

– Surgery and intensive care

– Triage of cases

– Phelebotomy and or oss-matching

Blood Transfusion-Laboratory Team

Figure 1. Emergency call flowchart.

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1. First emergency call was always made by the team leader. 2. It was forbidden to text social sharings. 3. It was forbidden to share patient’s identity and nonethical pictures. 4. Whatsapp application and call signal should be got online 7 days/24 hours. 5. Respond to the emergency call within the shortest time as soon as possible.

Figure 2. Emergency communication rules.

and shared emergency call and patient information (Figure 3). A strict message format specific for each case was not used. However, origin time and the injury pattern, the affected organ or body region, the geographical location of the event, the patient’s blood group (if applicable), transportation type, and the patient’s expected arrival were the main components of the patient’s information message. A helicopter transported all cases from the tactical field. The team comprised 1 team leader, 13 doctors, 8 nurses, and 9 medical technicians, for a total of 31 members.

Statistical Analyses Statistical analyses were performed using the SPSS software version 15 (Chicago, Illinois, USA). To determine whether the variables were normally distributed, they were investigated using visual (histograms, probability plots) and analytical methods (Shapiro–Wilk test). The descriptive analyses presented the means and standard deviations for the normally distributed “Responding Time” variable. To compare these parameters among the team member groups, one-way analysis of variance (ANOVA) was used. Levene’s test was used to assess the homogeneity of the variances. When overall significance was observed, pairwise post-hoc tests were performed using the Bonferroni test. An overall pvalue of less than 0.05 was considered to be a statistically significant result.

RESULTS A total of 510 emergency call messages pertaining to 17 combat injury emergency cases were logged. Of these, 221 were from doctors, 136 from nurses, and 153 from technicians. The messages were grouped according to response time, response time in different time periods, and the type of ET member (i.e., doctor, nurse, or technician). Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

Figure 3. Sample of instant messaging application message.

9.00 8.00 Responce time (Min)

The instant messaging application was used as the official communication platform for two months, and a hard copy of the communications was printed out, stored, and checked by the team leader at regular intervals. We assessed the response time to emergency calls, response time periods inside or outside of working hours (00:00–08:00, 08:00–17:00, 17:00–24:00), and the differences in the response times of doctors, nurses, and technicians.

7.00 6.00 5.00 4.00 3.00 Doctors Nurses Technicians

2.00 1.00 0.00

1

2

3

4

5

6 7 8 9 Team members

10

11

12

13

Figure 4. Individual response time graph.

Response Time of Team Members Doctors responded to emergency calls in a median time of 4.1 minutes, nurses in 6 minutes, and the other team members in 5.3 minutes. Between the groups, the differences in these response times were statistically significant (p=0.03), with subgroup analyses revealing significant differences between the doctors and the nurses (p=0.038). However, no statistically significant differences were observed between the doctors and the technicians (p=0.19) or the nurses and the technicians (p=1.0) (Figure 4).

Response Times in Different Periods ET members responded to emergency calls during normal 209


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working hours, 08:00–17:00, in a median time of 4.5 minutes, between 17:00–24:00, in a median time of 4.5 minutes, and between 00:00–08:00 in a median time of 6.0 minutes. Of the emergency calls, 12 out of 17 occurred during the normal working hours of 08:00–17:00.

DISCUSSION According to the results of and experiences in the present study, we can conclude that an instant messaging application is efficient for ET coordination in combat injuries, although it was not compared with other communication tools. However, a single source relayed the exact information to the emergency team within a short time, and the anecdotal data from the team leader’s perspective shows that the team leader’s energy and time loss were reduced by using the instant messaging application. Used by more than 900 million people worldwide, WhatsApp is a commonly used and popular smartphone application [6]. It enables the sharing of text messages, videos, voice messages, and photographs. It also allows for simultaneous communication with multiple online consumers. Moreover, it is widely used by healthcare professionals for social messaging. The authors of the present study concluded that an instant messaging application is a useful communication tool for the transfer of medical information among healthcare professionals because of its widespread use and fast and efficient features. Few studies in the existing medical literature examine the use of instant messaging applications for smartphones in the medical field. Johnston et al.[7] reported that WhatsApp is a safe and efficient application for communication within emergency surgical teams. Wani et al.[2] demonstrated that WhatsApp is a cheap, fast, and easy-to-operate tool for communication between plastic and reconstructive surgeons. The current study also indicated that it is an efficient and timesaving tool for communicating with the ET. Response times were compared in the present study, similar to the study by Johnston et al.;[7] the response times of the doctors were found to be significantly shorter than those of the other two groups. The reason for this difference may be the more efficient role played by doctors in the ET.

have affected the attainability and timeliness of the responses. Easy access to patient information and verbal communication by the team members within the hospital facilities might have influenced their less frequent use of the text messaging system. Finally, the limited number of emergency events and the lack of a comparative study with another communication tool, such as a pager or a telephone, were the other limitations of the present study.

Conclusion Although WhatsApp is an efficient and commonly used smartphone application, its medical use is limited. Only a few studies in existing medical literature have explored this subject. In the current study, based on the experiences of ET members, the authors concluded that WhatsApp is an efficient, easy-tooperate, and time-saving communication tool for the transfer of medical information and the coordination of ET members. Furthermore, the response times of the doctors were significantly shorter than those of the other ET members.

Key Messages • Coordination among emergency response team members is an important determinant for the prompt treatment of combat injuries. • WhatsApp (Mountain View, CA, USA) is an instant messaging application for smartphones and operates under a subscription business model used for sending messages, images/photos, videos, and audio media messages. • Although instant messaging applications for smartphones are efficient and commonly used, their use in the medical field is limited. • WhatsApp is an efficient, easy-to-operate, and time-saving communication tool for the transfer of medical information and the coordination of ET members, according to their experiences. • The role and efficiency of using social media services in medical practices requires further study.

Sponsor None

Funding Source None

In contrast to the existing literature on this subject, the response times were also assessed in three different time periods (00:00–08:00, 08:00–17:00, and 17:00–24:00) in the current study; no statistically significant differences were observed. Because this is a pilot study, further studies examining more number of cases are essential. This study has some limitations. Differences in the signal coverage of the Global System for Mobile (GSM) operators used by the various team members and occasional internet restrictions in the region where the hospital is located might 210

Ethical Approval This article does not contain any studies with human participants or animals performed by any of the authors. Conflict of interest: None declared.

REFERENCES 1. Turkish Statistics Institute. News Bulletin 2014. 2. Wani SA, Rabah SM, Alfadil S, Dewanjee N, Najmi Y. Efficacy of com-

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Eksert et al. Efficiency of instant messaging applications in coordination of emergency calls for combat injuries munication amongst staff members at plastic and reconstructive surgery section using smartphone and mobile WhatsApp. Indian J Plast Surg 2013;46:502,5. 3. Baldwin AJ, Langton SG. Postoperative monitoring of flaps by digital camera and Internet link. Br J Oral Maxillofac Surg 2001;39:120–1. 4. Varkey P, Tan NC, Girotto R, Tang WR, Liu YT, Chen HC. A picture speaks a thousand words: the use of digital photography and the Internet as a cost-effective tool in monitoring free flaps. Ann Plast Surg 2008;60:45–8.

5. Engel H, Huang JJ, Tsao CK, Lin CY, Chou PY, Brey EM, et al. Remote real-time monitoring of free flaps via smartphone photography and 3G wireless Internet: a prospective study evidencing diagnostic accuracy. Microsurgery 2011;31:589–95. 6. Wikipedia, the free encyclopedia en [Last updated on Sep 5, 2015]. Available from https://en.wikipedia.org/wiki/WhatsApp. 7. Johnston MJ, King D, Arora S, Behar N, Athanasiou T, Sevdalis N, et al. Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. Am J Surg 2015;209:45–51.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Anlık mesajlaşma uygulamasının harp kaynaklı yaralanmalar için acil iletişim koordinasyonunda kullanım verimliliği: Pilot çalışma Dr. Sami Eksert,1 Dr. Mehmet Burak Aşık,2 Dr. Sinan Akay,3 Dr. Kenan Keklikçi,4 Dr. Fevzi Nuri Aydın,5 Dr. Mehmet Çoban,6 Dr. Ali Kantemir,4 Dr. Onur Güngör,7 Dr. Beyazıt Garip,8 Dr. Mustafa Suphi Turgut,9 Dr. Kenan Olcay10 Şırnak Asker Hastanesi, Anestezi ve Reanimasyon Kliniği, Şırnak Şırnak Asker Hastanesi Kulak Burun Boğaz ve Baş-Boyun Cerrahisi Kliniği, Şırnak Şırnak Asker Hastanesi Radyoloji Kliniği, Şırnak 4 Şırnak Asker Hastanesi Ortopedi ve Travmatoloji Kliniği, Şırnak 5Şırnak Asker Hastanesi, Biyokimya Kliniği, Şırnak 6 Şırnak Asker Hastanesi, Enfeksiyon Hastalıkları Kliniği, Şırnak 7 Şırnak Asker Hastanesi, Çocuk Hastalıkları Kliniği, Şırnak 8 Şırnak Asker Hastanesi, Psikiyatri Kliniği, Şırnak 9 Şırnak Asker Hastanesi, Genel Cerrahi Kliniği, Şırnak 10 Şırnak Asker Hastanesi, Göz Hastalıkları Kliniği, Şırnak 1 2 3

AMAÇ: Acil müdahale ekibi koordinasyonu hastanelerde savaşa bağlı ateşli silah yaralanmalarında hızlı ve etkin tedavinin önemli bir belirleyicisidir. Yazarlar akıllı telefonlar için anlık mesajlaşma uygulamalarının, acil müdahale ekip üyelerinin iletişimi için etkin bir araç olarak kullanılabileceğini düşünmektedir. Bu çalışmada, seviye 1 travma merkezinde acil ekibi iletişim aracı olarak ticari bir anlık mesajlaşma uygulamasının (WhatsApp, Mountain View, CA) etkinliği araştıldı. GEREÇ VE YÖNTEM: Sekiz haftalık süre içinde helikopter ile hastanemize sevk edilen savaşa bağlı ateşli silah yaralanmaları ile ilgili anlık mesajlaşma uygulaması mesaj grubu kuruldu ve bu gruba ait mesajlar değerlendirildi. Acil ekip lideri tarafından yaralı ile ilgili gönderilen ilk bilgi mesajına acil ekip üyesi olan doktorlar, hemşireler ve teknisyenler tarafından verilen ortalama yanıt süreleri ve mesai içi veya mesai dışında ortalama yanıt süreleri değerlendirildi. BULGULAR: On yedi çatışmaya bağlı ateşli silah yaralanması olgusuna ile ilgili 510 acil çağrı mesajı bulunmaktadır. Ekip üyesi doktor, hemşire ve teknisyenler tarafından ilk bilgi mesajına verilen ortalama yanıt süreleri sırasıyla 4.1 dakika, 6 dakika ve 5.3 dakika idi. Gruplar arasında yanıt süreleri farkı (p=0.03) istatistiksel olarak anlamlı idi. Alt grup analizinde ise doktorlar ve hemşireler (p=0.038) arasında istatistiksel olarak anlamlı fark mevcuttu. Ancak, doktorlar ve teknisyenler (p=0.19), ya da hemşire ve teknisyenler (p=1.0) arasında istatistiksel olarak anlamlı fark saptanmadı. Acil travma ekip liderleri açısından bakıldığında, bu uygulamanın kullanımı ile iletişim için zaman kaybı ve ekip liderinin iş yükü azaltılabilmiştir. TARTIŞMA: Akıllı telefonlar için anlık mesajlaşma uygulamaları, tıbbi bilgi transferi ve hastanelerde acil müdahale ekibi üyelerinin koordinasyonu için etkin, kullanımı kolay ve zaman tasarrufu sağlayan bir iletişim aracı olabilir. Anahtar sözcükler: Ateşli silah yaralanmaları; medikal iletişim; travma. Ulus Travma Acil Cerrahi Derg 2017;23(3):207–211

doi: 10.5505/tjtes.2016.37897

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A rare type of burn injury due to butane gas inhalation Ergin Seven, M.D.,1 Uğur Horoz, M.D.,1 Elif Sarı, M.D.,2 Hülda Rifat Özakpınar, M.D.,1 Mert Muhittin Sandıkcı, M.D.,1 Emre İnözü, M.D.,1 Ali Teoman Tellioğlu, M.D.3 1

Department of Plastic, Reconstructive and Aesthetic Surgery, Dışkapı Yıldırım Beyazıt Training and Research Hospital; Ankara-Turkey

2

Department of Plastic, Reconstructive and Aesthetic Surgery, Kırıkkale University Faculty of Medicine; Kırıkkale-Turkey

3

Department of Plastic, Reconstructive and Aesthetic Surgery, Yıldırım Beyazıt University Faculty of Medicine; Ankara-Turkey

ABSTRACT BACKGROUND: Abusive inhalation of butane gas is becoming a serious public health problem among teenagers and young adult population; however, there has been little reporting on explosion burns associated with abuse of butane cigarette lighter fluid. METHODS: Retrospective study was conducted of 22 patients who were burned in last 2 years in explosion of butane gas, a flammable, odorless, and colorless aliphatic hydrocarbon. RESULTS: Details of sociodemographic profile of the patients, any underlying psychiatric illness, alcohol abuse, depth of burn injury, any associated injury, duration of hospitalization, and percentage of burned area were recorded and analyzed. CONCLUSION: All of the patients were young men, and most had superficial burn injury. Hospital stay ranged from 0 to 11 days. All of the patients were treated with conservative management. Keywords: Abuse; burn; butane; explosion.

INTRODUCTION Burn is individual and highly variable injury that can occur in all ages and social groups. Types of burn injury include thermal, chemical, or electrical burn.[1] Flash or explosion burns are most often seen in industrial injuries, and typically result from ignition of flammable gas. Explosion injuries caused by terrorist attacks or received in combat have been widely described, but there is little in the literature related to gas explosion burns related to inhalant abuse.[2–4] Explosion injuries, a type of flash injury, can be classified into 4 types. Type 1 is primary blast injury (blast wave), type 2 is secondary blast injury (ballistic trauma), type 3 is tertiary blast injury (caused by a combination of blunt and penetrating traumas), and type 4 is quaternary blast injury (burns and other injuries not in previous categories).[2] Address for correspondence: Uğur Horoz, M.D. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Plastik Rekonstrüktif ve Estetik Cerrahi Kliniği, Ankara, Turkey Tel: +90 312 - 596 21 74 E-mail: ugur_horoz@hotmail.com Ulus Travma Acil Cerrahi Derg 2017;23(3):212–216 doi: 10.5505/tjtes.2016.37999 Copyright 2017 TJTES

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Butane, an aliphatic hydrocarbon derived from petroleum, is highly flammable, odorless, colorless, nonhalogenated gas. Butane gas is used as fuel for cooking and heating, lighter fluid, refrigerant, deodorant propellant, and for industrial purposes, among other applications.[3–10] Boiling point of butane gas is -0.5°C.[4,8,10] As it has many uses in daily life, butane gas is widely available in stores without any legal restriction.[3–11] Inhalant abuse is becoming an important public health problem.[6,7,11] When butane gas inhalant enters pulmonary system it displaces oxygen from red blood cells.[3–19] Butane gas is absorbed by various tissues and has elective tropism for the encephalon, spleen, liver, and kidneys.[6] Reactions begin within 5 minutes and acute period typically lasts between 15 and 45 minutes.[4] Butane gas inhalation may cause euphoria, dizziness, and hallucinations after inhalation.[3–7] Effect depends on the duration of inhalation, quantity of substance inhaled, and its concentration. It causes toxicity to several organ systems, depending on exposure time and concentration of the gas.[3–6] Acute and short-term side effects of butane inhalation, including sudden death, as well effects of chronic exposure are provided in Table 1 and Table 2.[3–7,9–19] Burns reported related to butane gas were usually due to explosion of camping gas, accident during motor vehicle refueling, or abusive inhalation of the gas.[2–4,9–17] The present study Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Seven et al. A rare type of burn injury due to butane gas inhalation

Table 1. Side effects of butane gas inhalation Exposure type

Signs, symptoms and effects

Acute

Irritability, cough, euphoria, excitation, nausea, headache, rhinorrhea, sneezing, vomiting, syncope

Alert symptoms

Abnormal speech, headache, confusion, delusions, decreased reflex.

Shortly after

Anoxia, tachycardia, hallucinations of all senses, ataxia, dissociation, hypoxia, tinnitus, nystagmus, dizziness

Chronic

Neurological, psychiatric, hematological, renal, pulmonary, cardiovascular

Sudden

Fatal arrhythmia, asphyxia, hypoxia, central nervous system depression, cardiac arrest, asystole, ventricular

fibrillation, sudden death

Table 2. Chronic effects of butane gas on multiple organ systems System

Chronic effects

Renal

Hematuria, proteinuria, renal tubular acidosis, acid-base disturbance, renal failure

Cardiovascular

Dysrhythmias, myocardial fibrosis, direct myocardial toxicity, myopericarditis

Neurological

Ataxia, optic atrophy, sensorineural hearing loss, dementia, peripheral neuropathy, tremor, loss of motor control

Psychiatric

Depression, insomnia, memory loss, psychosis

Hematological

Anemia, thrombocytopenia, leukopenia

Pulmonary

Cough, emphysema, chemical pneumonitis

is review of 22 patients with rare type of burn injury resulting from butane gas inhalation abuse and explosion. In an enclosed space, vapor becomes extremely flammable and explosive when ignition source is introduced, whether it be flame or spark.[3,4,16] Emergency staff need to be aware of special circumstances in these scenarios and remove inhaling victim’s clothing (decontamination), as well as follow pulse, oxygen saturation, and cardiac activity closely. These initial management steps should precede approach used for typical burn patient. Records of 22 patients who were admitted our burn unit over 2 years were reviewed. All of the injuries occurred as result of butane gas explosion in enclosed car when cigarette lighter was ignited. Face and upper extremities were most affected areas. All of the injuries were treated conservatively. The aim of this study is to report an unusual burn type due to gas explosion after inhalant misuse, as well as examine incidence and detrimental effects of a different type of substance abuse.

MATERIALS AND METHODS The study was conducted over a period of 2 years (2013– 2014). Records of 22 patients who were treated for effects of explosion that occurred when inhaling butane gas were reviewed. All of the injuries took place inside vehicle. Butane gas was discharged into car by group of young men in order to inhale it, and explosion occurred when cigarette lighter was ignited in presence of flammable gas. All burn injuries Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 2

were localized on upper extremities or face (Figure 1a–e). All patients were male, single, and smokers. All 22 patients had history of alcohol use at varying rates. There had been no previous diagnosis of any psychiatric disorder. Groups of 2 to 4 men were involved in total of 6 explosions. Age of patients in present study ranged between 17 and 24 years (median: 19.1 years). Average extent of injury was 8.5% of total body surface area (range: 3–20%), and were usually second-degree superficial burns.

RESULTS Clinical findings did not note any direct consequence of butane gas inhalation, such as euphoria, impaired coordination, disorientation, behavioral changes, or confusion. There were no electrocardiographic changes observed, or inhalation injuries due to explosion of the gas. Hospital stay ranged from Table 3. Butane gas explosion burn patients (n=22) Male to female ratio

22–0

Age range (average)

17–24 (19.1) years

Extent of injury (total body area)

3–20%

Length of hospital stay

0–11 days

Discharged on same day

4

Number who consume alcohol

22

Number discharged to home

100%

Number with inhalation injury

0

213


Seven et al. A rare type of burn injury due to butane gas inhalation

(a)

(d)

(b)

(c)

(e)

Figure 1. (a) A 19-year-old patient with facial burn treated conservatively. (b) A 21-year-old patient whose facial burn improved under conservative management without hospitalization. (c) A 22-year-old patient whose hand and facial burns improved under conservative management. (d) Left hand of a 22-year-old burn patient. (e) Right hand of a 22-year-old patient.

0 to 11 days, with mean of 3.5 days. All wounds healed with dressing and antibacterial ointment; none required surgical intervention. No complications or repetition of patient injury were observed. The primary aim of this study was to demonstrate different type of substance abuse using combustible butane gas and potential results. Patient details are summarized in Table 3.

DISCUSSION Inhalant misuse has become more popular among adolescents and young adults in the last few decades.[6] Butane is found in many common items, such as cleaning products, paint, shoe polish, gasoline, glue, aerosol propellant, bug bombs, lighter fluid, and sealants.[3–5,11–16] Inhalants can be found in offices and homes, and are easily and inexpensively purchased in stores, as they are not legally controlled substances.[3–16] Three of the methods of inhalant abuse that have been reported are “Sniffing,” direct inhalation from the source; “bagging,” pouring the substance into a bag and breathing from the bag while it is held over the mouth and nose; and “huffing,” inhalation of vapors from piece of cloth that has been soaked with inhalant. [5,6] Sequentially, abusers typically adopt sniffing, huffing, and finally bagging in order to get greater concentration of inhalant and prolong the effects.[6,18] Direct inhalation from source or using plastic bag provides more concentrated exposure in short period of time. Once inhaled, hypotension and tachy214

cardia develop, followed by increase in cardiac output and bradycardia.[6] Butane gas affects multiple organs, such as central nervous system (CNS), myocardium, liver, spleen, and kidneys. Gas leaves the body via exhalation. Butane and isobutane are primary volatile components of cigarette lighter fuel and other products, and they have an anesthetic, sedative, narcotic effect on CNS.[8–10] Chronic butane abuse may lead to selective thalamic damage in the brain. It can also increase dopamine level and prompt fatal arrhythmia Sudden death has been associated with acute inhalation of gas. Butane sensitizes cardiac muscles to effects of catecholamines, predisposing patient to epinephrine-induced cardiac arrhythmia.[8,10] After breathing the gas in an enclosed area, acute effects begin within 5 minutes. Kurtzman et al. pointed out that effects occur and disappear more quickly when compared with other drugs. Abusers can return to daily activities without any significant symptoms.[6] Abusers typically begin to increase the frequency and duration of inhalants when they want to extend the effects. Inhalant misuse is increasing because abusers can find the items easily, they are low-cost, and they are legal. Inhalant abuse has been reported among small groups in young population.[6] It has also been reported that abusers have higher rate of suicide attempt compared with contemporaries.[11,13,19] Freedenthal et al. and Rossi et al. reported between 9% and 20% of adolescents had misUlus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Seven et al. A rare type of burn injury due to butane gas inhalation

used inhalants, and that girls had more psychopathological and behavioral problems in the juvenile population.[19] Wick et al. found 39 deaths related to gasoline and butane inhalation in retrospective study of 18880 autopsies.[7] Inhalants are easily absorbed by lipid-rich tissues and CNS is vulnerable to toxic effects.[6] Toluene is a toxic aromatic hydrocarbon that primarily affects CNS.[6] Spontaneous abortion and premature parity risks increase when inhalants are used during pregnancy.[5,6] It has also been reported that inhalation abusers usually have problems with family, friends, or academics, and may have suicidal thoughts.[6,13,19] Busche et al. reported on 71 patients burned in gas explosions; total of 11 were injured during recreational activities and 4 burn cases were smoking-related (gas lighters). More than half of burn injuries occurred in private households.[2] Explosion burns that occurred during inhalation of butane abuse gas have been reported in the literature.[3,4] In 1992, Scerri et al. described 7 patients who were burned in explosion after gathering as a group in an enclosed car to inhale butane gas. All patients were treated with conservative management.[3] In 1999, Oh et al. reported explosion burns in 48 patients who had inhaled butane gas at home or in motel rooms.[4] In 5-year retrospective study, 5 patients died during hospitalization, 22 patients needed skin graft, 12 patients were followed with conservative management, and 9 were treated and discharged or transferred. Rates of mortality and severe injuries were likely related to limited space of enclosed area and amount of gas. Marc et al.[16] reported fatal case of woman who used air freshener in the kitchen and died in subsequent flash fire. Sugie et al.[10] reported 3 cases of sudden death due to butane or propane gas inhalation. Seyhan et al.[15] and Wright et al.[17] also reported liquefied petroleum gas (butane and isobutene are primary ingredients)-related cold injuries. Inhalant abuse is becoming a serious public health problem which has been underreported and poorly reviewed.[6] Burns related to gas explosions need special attention as result of thermal trauma as well as possible associated psychopathological problems of abusers. Psychological evaluations and required support should be provided in cases of inhalant abuse.

Conclusion Studies targeting abusers and their friends at an early age should be conducted to prevent and discourage misuse of inhalants. Studies should not only try to make teenagers aware of health threats in abuse of inhalants, but must also highlight public health problem. We physicians should be worried about misuse of inhalants by young population, a problem that is growing and still too much of a mystery. To the best of our knowledge this is the second report in the literature regarding explosions in enclosed cars due to butane and the

Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 2

third report of the explosion burns received during inhalation of butane gas. Conflict of interest: None declared.

REFERENCES 1. Thorne CH, Chung KC, Gosain AK. Grabb and Smith’s Plastic Surgery. 7th ed: Philadelphia: Lippincott Williams & Wilkins: 2014. 2. Busche MN, Gohritz A, Seifert S, Herold C, Ipaktchi R, Knobloch K, et al. Trauma mechanisms, patterns of injury, and outcomes in a retrospective study of 71 burns from civil gas explosions. J Trauma 2010;69:928– 33. 3. Scerri GV, Regan PJ, Ratcliffe RJ, Roberts AH. Burns following cigarette lighter fluid abuse. Burns 1992;18:329–31. 4. Oh SJ, Lee SE, Burm JS, Chung CH, Lee JW, Chang YC, et al. Explosive burns during abusive inhalation of butane gas. Burns 1999;25:341–4. 5. Anderson CE, Loomis GA. Recognition and prevention of inhalant abuse. Am Fam Physician 2003;68:869–74. 6. Kurtzman TL, Otsuka KN, Wahl RA. Inhalant abuse by adolescents. J Adolesc Health 2001;28:170–80. 7. Wick R, Gilbert JD, Felgate P, Byard RW. Inhalant deaths in South Australia: a 20-year retrospective autopsy study. Am J Forensic Med Pathol 2007;28:319–22. 8. Fuke C, Miyazaki T, Arao T, Morinaga Y, Takaesu H, Takeda T, et al. A fatal case considered to be due to cardiac arrhythmia associated with butane inhalation. Leg Med (Tokyo) 2002;4:134–8. 9. Bayar N, Baş CY, Erkal Z, Arslan Ş. A case of myopericarditis following butane gas inhalation. [Article in Turkish] Anadolu Kardiyol Derg 2013;13:505–6.. 10. Sugie H, Sasaki C, Hashimoto C, Takeshita H, Nagai T, Nakamura S, et al. Three cases of sudden death due to butane or propane gas inhalation: analysis of tissues for gas components. Forensic Sci Int 2004;143:211–4. 11. Akcan R, Cekin N, Hilal A, Arslan MM. Sudden death due to inhalant abuse in youth:Case Report. Dicle Medical Journal 2010;37:154–6. 12. Khalessi A, Maitz P, Haertsch P, Kennedy P. Adult burn injuries due to domestic barbeques in New South Wales. Burns 2008;34:1002–5. 13. Rossi R, Suadoni F, Pieroni L, De-Giorgio F, Lancia M. Two cases of acute propane/butane poisoning in prison. J Forensic Sci 2012;57:832– 4. 14. Farace F, Gallo A, Lissia M, Di Giulio S, Mele A, Rubino C. Camping gas burns: our experience. J Plast Reconstr Aesthet Surg 2007;60:450–1. 15. Seyhan N, Jasharllari L, Kayapınar M, Savacı N. An unusual cause of cold injury: liquified petroleum gas leakage. Ulus Travma Acil Cerrahi Derg 2011;17:561–2. 16. Marc B, Blanchet P, Boniol L. Domestic aerosol and flash fire: warning from a fatal case. Burns 2001;27:783–4. 17. Wright TC, Kim JB, Currie LJ, Kay AR, Burge TS. Leakage of liquefied petroleum gas during motor vehicle refuelling--a new cause of cold injury. Burns 2006;32:132–3. 18. Desouches C, Salazard B, Romain F, Karra C, Lavie A, Volpe CD, et al. Analysis of burns caused by pre-filled gas canisters used for lamps or portable camping stoves. Burns 2006;32:1028–31. 19. Freedenthal S, Vaughn MG, Jenson JM, Howard MO. Inhalant use and suicidality among incarcerated youth. Drug Alcohol Depend 2007;90:81–8.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Bütan gazının inhalasyon yoluyla kötüye kullanımına bağlı nadir görülen yanıklar Dr. Ergin Seven,1 Dr. Uğur Horoz,1 Dr. Elif Sarı,2 Dr. Hülda Rıfat Özakpınar,1 Dr. Mert Muhittin Sandıkcı,1 Dr. Emre İnözü,1 Dr. Ali Teoman Tellioğlu3 Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Plastik, Rekonstruktif ve Estetik Cerrahi Kliniği, Ankara Kırıkkale Üniversitesi Tıp Fakültesi, Plastik, Rekonstruktif ve Estetik Cerrahi Anabilimdalı, Kırıkkale 3 Yıldırım Beyazıt Üniversitesi Tıp Fakültesi, Plastik, Rekonstruktif ve Estetik Cerrahi Anabilimdalı, Ankara 1 2

AMAÇ: İnhalasyon yoluyla bütan gazı kötüye kullanımı ergen ve genç erişkinlerde giderek artan halk sağlığı problemi halini almaktadır. Çakmak gazı olarak kullanılan bütan gazının suistimali sırasında oluşan patlama yanıkları az sayıda bildirilmiştir. GEREÇ VE YÖNTEM: Son iki yılda, kokusuz ve renksiz bir gaz olan bütan gazının alev alması sonucu oluşan parlamalarla yaralanmış 22 hastayı içeren geriye dönük bir çalışma gerçekleştirildi. BULGULAR: Hastaların sosyo-demografik özellikleri, mevcut psikiyatrik hastalıkları, alkol bağımlılığı, yanığın derinliği, eşlik eden yaralanmalar, hastanede kalış süreleri ve yanık yüzdesi kayıt edildi. TARTIŞMA: Hastaların tamamı erkek ve çoğunun yanıkları yüzeyel olarak görüldü. Hastaların hastanede kalış süreleri 0–11 gün arasında değişmekteydi. Hastaların tamamı konservatif yöntemlerle tedavi edildi. Anahtar sözcükler: Butan; suistimal; patlama; yanık. Ulus Travma Acil Cerrahi Derg 2017;23(3):212–216

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doi: 10.5505/tjtes.2016.37999

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A surgical approach to iatrogenic vascular injuries in pediatric cases Yüksel Beşir, M.D.,1 Orhan Gökalp, M.D.,1 Börteçin Eygi, M.D.,2 Banu Bahriye Lafcı, M.D.,2 Gamze Gökalp, M.D.,3 Levent Yılık, M.D.,1 Hasan İner, M.D.,2 Ali Gürbüz, M.D.1 1

Department of Cardiovascular Surgery, İzmir Katip Çelebi University Faculty of Medicine, İzmir-Turkey

2

Department of Cardiovascular Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir-Turkey

3

Department of Pediatric Emergency, İzmir Tepecik Training and Research Hospital, İzmir-Turkey

ABSTRACT BACKGROUND: Surgical intervention is mandatory in many children who present with vascular trauma or in complicated cases after medical interventions. In this study, surgical interventions applied after vascular injuries in children were analyzed. METHODS: Between January 2002 and December 2012, 17 patients (aged under 18) who were admitted to the emergency room with vascular injuries were retrospectively analyzed. The data was collected through hospital records. Preoperative and postoperative data of the patients were recorded and analyzed. RESULTS: Of the total, 11 patients were female (64.7%) and 6 patients were male (35.3%) with a range of 4–192 months. In total, 14 (82.3%) injuries were due to angiographic interventions, 1 (5.9%) was due to external trauma, 1 (5.9%) was due to preoperative trauma, and 1 (5.9%) was due to a catheterization complication in the intensive care unit. Additionally, 11 (64.7%) injuries were located in the right femoral artery, 3 (17.6%) were located in the left femoral artery, 2 (11.8%) were located in the left brachial artery, and 1 (5.9%) was located in the left external iliac vein. Also, 5 (29.4%) patients were managed under local anesthesia and 12 (70.6%) patients were managed under general anesthesia. With respect to treatment, 15 (88.2%) injuries were repaired with primary sutures, 1 (5.9%) injury was repaired with an end-to-end anastomosis, and 1 (5.9%) injury was repaired with a saphenous vein graft interposition. In addition, 16 (94.1%) patients underwent a thrombectomy prior to the repair. The total hospital stay was calculated as 2.7±1.4 days. The intensive care unit stay was calculated as 1.1±0.4 days. There was no mortality, a loss of an injured extremity, or an infection. No other complication was detected. CONCLUSION: Iatrogenic interventional procedures seem to be responsible for the majority of pediatric vascular injuries. The results of surgical repairs in these injuries are successful and efficient. Keywords: Injury; pediatric; surgical approach; vascular.

INTRODUCTION Vascular traumas are seen in 0.06% of all of the children admitted due to a trauma as recorded in the United States of America.[1] Pediatric vascular trauma cases are rare in occurrence although they may lead to serious morbidity and morAddress for correspondence: Yüksel Beşir, M.D. İzmir Katip Çelebi Üniversitesi Tıp Fakültesi, Kalp Damar Cerrahisi Anabilim Dalı, İzmir, Turkey Tel: +90 232 - 325 05 35 E-mail: yukselbesir@hotmail.com Ulus Travma Acil Cerrahi Derg 2017;23(3):217–222 doi: 10.5505/tjtes.2016.61282 Copyright 2017 TJTES

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tality.[2–4] Iatrogenic interventional procedures seem to be responsible for a majority of pediatric vascular injuries.[5,6] Interventional diagnostic tools are widely used in the diagnoses of congenital heart diseases; thus, approximately one-third of pediatric vascular traumas are due to iatrogenic causes.[5,6] Pediatric vascular injuries are harder to manage compared to vascular injuries in adults due to the anatomical and physiologic differences. Thus, managing these cases can be harder than expected because weak surrounding supportive tissue, the spasmodic tendency of the vessels, and a thinner and more fragile vessel structure may easily complicate the injury even further in these cases.[5] A loss of intravascular volume should also be managed accordingly in pediatric cases. We analyzed the data of previously operated patients due to a vascular trauma in our clinic. 217


Beşir et al. A surgical approach to iatrogenic vascular injuries in pediatric cases

MATERIALS AND METHODS Between January 2002 and December 2012, 17 patients (aged under 18) who were admitted to the emergency room with vascular injuries were retrospectively analyzed. The data was collected through hospital records. The preoperative and postoperative data of the patients were recorded and analyzed. The following data were recorded: preoperative age, gender, the route of the injury, the site of the injury, the perioperative management of the anesthesiology, the surgical procedure, and the hospital and intensive care unit (ICU) stay. An arterial-venous duplex ultrasound and a physical examination were the main tools in the diagnosis. However, some patients were taken into operation theaters immediately be-

cause they were admitted with a pre-established diagnosis of vascular injuries, and some patients did not receive imaging modalities because they were accepted directly from the angiography rooms. In these patients, only the physical examination was performed. All the patients received low molecular weight heparin until they left the hospital. Those patients whose conditions improved after conservative heparin treatments were excluded from the study.

Technique Embolectomy: After local or general anesthesia, the artery that was to be operated on was explored. After the artery was encircled with the vascular tape following heparinization, vas-

Table 1. Preoperative data

n

%

Mean±SD

Gender Female

11

Male

6

64.7 35.3

Age (months)

60.7±54.4

Etiology

After angiographic interventions

14

82.3

After intra-arterial catheterization (for blood pressure)

1

5.9

Peroperative injury

1 5.9

External injury

1

5.9

3

17.6

*

Additional disease

Atrial septal defect

Ventricular septal defect

2

11.8

Ventricular septal defect+pulmonary stenosis

2

11.8

Tetralogy of Fallot

4

23.6

Patent ductus arteriozus

2

11.8

Aortic stenosis

2

11.8

Inguinal hernia

1

5.9

None

1 5.9

Localization of the injury Right femoral artery

11

64.7

Left femoral artery

3

17.6

Left brachial artery

2

11.8

Left external iliac vein

1

5.9

10

58.8

Symptoms on admission

Acute ischemia

Acute ischemia + puncture-induced bleeding

5

29.4

Retroperitoneal hematoma and ecchymosis

1

5.9

Active bleeding

1

5.9

*Left external iliac vein injury during inguinal hernia surgery. SD: Standard deviation.

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cular clamps were applied. An embolectomy was performed using a Fogarty catheter, and the anastomosis was performed by the separated suture technique with 6/0 or 7/0 prolene. An end-to-end anastomosis: The patient had external iliac vein injury. The external iliac vein was repaired with 6/0 prolene by using an end to end anastomosis. A saphenous vein interposition: An interposition of the saphenous vein was applied to a 48-month-old patient with a brachial artery cut. By considering the growth progress of the patient, a saphenous vein interposition was performed with 7/0 prolene by the separated suture technique.

RESULTS From the total, 11 patients were female (64.7%) with the mean age of 60.7±54.4 months, 16 (94.1%) patients had vascular injuries due to interventional procedures, invasive imaging, and perioperative trauma, and 1 (5.9%) had an external trauma. Excluding the patient with an external trauma, 16 (94.1%) patients had additional diseases as follows: 3 (17.6%), atrial septal defects; 2 (11.8%), ventricular septal defects; 2 (11.8%), ventricular septal defects + pulmonary stenosis; 4 (23.6%), Tetralogy of Fallot; 2 (11.8%), patent ductus arteriosus; 2 (11.8%), aortic stenosis; and 1 (5.9%), inguinal hernia. Additionally, 11 (64.7%) injuries were located in the right femoral artery, 3 (17.6%) were located in the left femoral artery, 2 (11.8%) were located in the left brachial artery, and 1 (5.9%) was located in the left external iliac vein. Acute ischemic findings were present in 10 (58.8%) patients, and 5 (29.4%) patients had an additional hemorrhage in the arterial access site. In addition, 1 (5.9%) patient had a retroperitoneal hemorrhage and ecchymosis due to perioperative trauma, and 1 (5.9%) patient with external trauma had an active hemorrhage. The preoperative data of the patients are summarized in Table 1.

Of the total, 7 patients (41%) were under the age of 24 months. Of these, 6 patients were operated on due to a femoral arterial thrombosis following transcatheter interventions, and one patient was operated on for a brachial arterial thrombosis during invasive arterial monitoring in the ICU. All of the 7 patients were observed in follow-up visits for 12 months. There were no complications or any need for additional intervention. Also, 10 patients (58.8%) received surgical treatments for acute limb ischemia. These patients were transferred from various centers after failing to respond to conservative heparin treatments. Local anesthesia was applied to 5 (29.4%) patients, and general anesthesia was applied to 12 (70.6%) patients. In addition, 15 (88.2%) injuries were repaired with primary sutures, 1 (5.9%) injury was repaired with an end-to-end anastomosis, and 1(5.9%) injury was repaired with a saphenous vein graft interposition. Also, 16 (94.1%) patients underwent thrombectomy prior to the repair. The total hospital stay was calculated as 2.7±1.4 days. The ICU stay was calculated as 1.1±0.4 (1–3) days. The patients received 0.4±1.2 (0–4) units of blood transfusions. The perioperative data of the patients are summarized in Table 2. There was no mortality, loss of an injured extremity, or an infection. No other complication was detected. None of the patients needed secondary interventions. Due to the fact that the patients who were operated on had distal pulses positive at palpation, we did not measure the ankle brachial indexes. All the patients were followed-up with a duplex ultrasound instead of an ankle brachial index.

Table 2. Peroperative data

n

%

Mean±SD

Type of anesthesia Local

5

29.4

General

12

70.6

15

88.2

Type of operation

Primary repair

End to end anastomosis

1

5.9

Interposition of the saphenous vein

1

5.9

Thrombectomy (as additional surgery)

16

94.1

Blood utilization (IU)

0.4±1.2

Duration in intensive care unit (days)

1.1±0.4

Duration of hospitalization (days)

2.7±1.4

SD: Standard deviation.

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DISCUSSION In the United States, trauma in children older than 1 year of age is the leading cause for morbidity and mortality. A lack of the appropriate use of diagnostic and interventional techniques in these patients may result in catastrophic mortalities and morbidities, such as a loss of the related limb.[4] Vascular trauma etiologies in pediatric trauma patients vary in different studies. Some studies suggested the vascular penetrating injuries secondary to bone fractures is the most common underlying factor (31.8%).[6–8] In contrast, de Virgilio et al.[2] suggested that the most common etiological factor for vascular injuries is firearm incidences (70.8%). However, Jaipuria et al. suggested in their series that the most common etiological factor is blunt trauma due to crush injuries (56%), followed by traffic accidents and penetrating glass wounds (44%).[9] In the last decade, interventional imaging techniques have become the core imaging modalities in the diagnosis of congenital heart diseases; thus, they play a major role in the etiology of vascular traumas in this group. Recently, it has been suggested that the interventional imaging modalities are responsible for one-third of pediatric vascular traumas.[5] Lin et al. also suggested that arterial catheterization is the leading underlying factor in vascular injuries in children.[10] Interventional pediatric vascular injuries are at the present even being categorized in some studies. Bergqvist et al. divided the injuries in two groups, namely, iatrogenic vascular and non-iatrogenic vascular injuries, in their study.[11] Underlying etiological factors in vascular injuries may vary among various centers. In our clinic, we also found that the iatrogenic vascular trauma is the leading etiologic factor. In this study, we found that the main etiological factor for vascular injures is determined as iatrogenic vascular traumas (94.1%). As per literature, the site of injuries varies, according to the underlying etiology. In interventional procedures, the general choice for a vascular access is the femoral artery; thus, the iatrogenic vascular injuries are naturally located in the femoral region.[10] There is one study excluding iatrogenic injuries that listed the most common sites of injuries as follows: the femoral artery (25%), the brachial artery (22%), the tibial artery (16%), and the radial and ulnar arteries (12%).[5] Jaipuria et al gathered a diverse group together and reported the site of injuries as follows: the brachial artery (26%) and the femoral artery (18%).[9] In our patient pool, we encountered mainly iatrogenic vascular traumas; thus, the most common site of injury was the femoral artery and the femoral region (82.3%). Lin et al had a similar patient population when we compare the condition of the patients at their first admittance to the hospital. They presented with the following conditions: acute ischemia (41%), chronic ischemia (20%), an arteriovenous fistula (15%), and hematoma/hemorrhage (12%).[10] In our clinic, all of the patients were immediately taken to the operating 220

room and operated on; thus, in our group we did not have any patients with chronic ischemic findings and an arteriovenous fistula. In this study, 5.8% of the patients had acute ischemic findings and 29.4% had a hemorrhage and acute ischemic findings in the affected limb. Surgical management of these cases can be more difficult than expected since weak surrounding supportive tissue, a spasmodic tendency of the vessels, and a thinner and more fragile vessel structure may easily complicate the injury even further in these cases.[5] Because the long-term morbidity of a thrombosed limb artery in infants and neonates is uncertain and because there is a great potential for the rapid development of adequate collateral circulation in these age groups, an avoidance of an open repair with conservative treatment consisting of heparin administration has been suggested.[8] The decision for medical or surgical treatment depends on the type of lesion. Arterial lesions that present with bleeding, false aneurysms, and arteriovenous fistulae require an open repair. However, if distal ischemia is the only finding many surgeons prefer to use heparin or thrombolytic agents with an additional careful observation and thus, avoid an open repair unless the limb viability is jeopardized.[12] In our study, we only included the patients who were transferred to our clinic after failing to respond to conservative treatments in various centers. The patients with iatrogenic limb ischemia are often managed with conservative heparin treatments as a first line approach in our clinic. A surgical approach may vary according to the site of injury and the route, but the most common techniques generally include ligation, the primary repair of the vessel, an endto-end anastomosis, and a repair with a graft interposition. [1,3,5,10,11,13] It is also common practice to perform thrombectomy in these cases with an accompanying thrombosis.[8,11–14] The thrombectomy catheter should be carefully chosen, and it is also suggested not to reach a full inflation to prevent a possible endothelial catheter-induced injury.[11,13,14] We also applied a similar therapeutic approach in this study. The mode of anesthesia was mostly general anesthesia as appearing in many of the various reports.[10,11,14,15] In our study, 70.6% of the patients underwent general anesthesia. As seen in recent literature, the length of the hospital stay varies among clinics. It is mostly due to the nature of the traumatic event itself and the complications of the surgical procedures applied. Nazem et al. reported the mean hospital stay in their study of non-iatrogenic vascular injuries as 9.55±7.1 days. Their group included 6 patients who also underwent a fasciotomy.[13] Shah et al. also conducted a study including vascular injuries accompanied by many traumatic bone fractures and reported the mean hospital stay as 5.00±5.08 days and the mean ICU stay as 4.14±4.05 days.[3] In our study, the mean hospital stay was found to be shorter Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Beşir et al. A surgical approach to iatrogenic vascular injuries in pediatric cases

than expected compared to that in these reports. We believe that the shorter hospital stay is related directly to the nature of the injuries and the accompanying complications. The majority of the cases in our study were iatrogenic in nature, and there were no complications. Many reports stated that non-iatrogenic vascular traumas in a pediatric group may have high mortality and morbidity rates. Shah et al. presented 3 pediatric patients with non-iatrogenic vascular traumas who had complications postoperatively.[3] In this study, 2 patients required a fasciotomy, and 1 patient had venous congestion, but there was no mortality. Another report also suggested high mortality and morbidity rates in pediatric patients with lower extremity non-iatrogenic traumas.[8] In this study, 2 (4%) patients with a blunt trauma died, and 73% of the patients with multiple fractures suffered from neurologic deficits. Mommsen et al.[5] reported their mortality rate as 6.8% and postoperative complication rate as 18.2%. Jaipuria et al.[9] reported 2 (2.5%) mortalities and 6 (7.5%) amputations as complications in an 82-patient non-iatrogenic vascular trauma group. In this group, a majority of the cases were crashfallings and traffic accidents. Lin et al. conducted a study with only iatrogenic vascular traumas and reported their postoperative mortality rate as 3% and postoperative morbidity rate as 12%6. There is no postoperative fasciotomy or amputation reported in this study. In our study, there is no mortality and morbidity. These results can be expected because the iatrogenic vascular traumas may have clean-cut traumas with no additional organ injuries. On the other hand, Lin et al.[10] also studied a similar group; however, their mortality and morbidity rates are higher in comparison with our study. We believe there are some limitations to this study, such as a small patient pool, heterogeneity in the patient group, and the lack of a control group including non-iatrogenic vascular trauma patients. Iatrogenic vascular traumas are seen more often than we had anticipated in pediatric patients. However, the general outcome of these patients is favorable when compared with the non-iatrogenic trauma group because injuries are generally confined to one area, and they tend to be clean sharp wounds that can be more easily managed.

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Conflict of interest: None declared.

REFERENCES 1. Corneille MG, Gallup TM, Villa C, Richa JM, Wolf SE, Myers JG, et al. Pediatric vascular injuries: acute management and early outcomes. J Trauma 2011;70:823–8. 2. de Virgilio C, Mercado PD, Arnell T, Donayre C, Bongard F, White R. Noniatrogenic pediatric vascular trauma: a ten-year experience at a level I trauma center. Am Surg 1997;63:781–4. 3. Shah SR, Wearden PD, Gaines BA. Pediatric peripheral vascular injuries: a review of our experience. J Surg Res 2009;153:162–6. 4. Klinkner DB, Arca MJ, Lewis BD, Oldham KT, Sato TT. Pediatric vascular injuries: patterns of injury, morbidity, and mortality. J Pediatr Surg 2007;42:178–83. 5. Mommsen P, Zeckey C, Hildebrand F, Frink M, Khaladj N, Lange N, et al. Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score. J Orthop Surg Res 2010;5:25. 6. Mills RP, Robbs JV. Paediatric arterial injury: management options at the time of injury. J R Coll Surg Edinb 1991;36:13–7. 7. O’Neill JA. Traumatic vascular lesions in infants and children. In Vascular disorders of childhood Edited by: O’Neill JA. Philadelphia: Lea and Febiger 1983:181–93. 8. Lazarides MK, Georgiadis GS, Papas TT, Gardikis S, Maltezos C. Operative and nonoperative management of children aged 13 years or younger with arterial trauma of the extremities. J VascSurg2006;43:72–6. 9. Jaipuria J, Sagar S, Singhal M, Bagdia A, Gupta A, Kumar S, et al. Paediatric extremity vascular injuries - experience from a large urban trauma centre in India. Injury 2014;45:176–82. 10. Lin PH, Dodson TF, Bush RL, Weiss VJ, Conklin BS, Chen C, et al. Surgical intervention for complications caused by femoral artery catheterization in pediatric patients. J Vasc Surg 2001;34:1071–8. 11. Bergqvist D, Karacagil S, Westman B. Paediatric arterial trauma. Eur J Surg 1998;164:723–31. 12. Gamba P, Tchaprassian Z, Verlato F, Verlato G, Orzali A, Zanon GF. Iatrogenic vascular lesions in extremely low birth weight and low birth weight neonates. J Vasc Surg 1997;26:643–6. 13. Nazem M, Beigi AA, Sadeghi AM, Masoudpour H. Non iatrogenic paediatric vascular trauma of the extremities and neck. Afr J Paediatr Surg 2009;6:35–9. 14. Rowland SP, Dharmarajah B, Moore HM, Dharmarajah K, Davies AH. Venous injuries in pediatric trauma: Systematic review of injuries and management. J Trauma Acute Care Surg 2014;77:356–63. 15. Sciarretta JD, Macedo FI, Chung EL, Otero CA, Pizano LR, Namias N. Management of lower extremity vascular injuries in pediatric trauma patients: a single Level I trauma center experience. J Trauma Acute Care Surg 2014;76:1386–9.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

İyatrojenik pediatrik damar yaralanmalarına cerrahi yaklaşım Dr. Yüksel Beşir,1 Dr. Orhan Gökalp,1 Dr. Börteçin Eygi,2 Dr. Banu Bahriye Lafcı,2 Dr. Gamze Gökalp,3 Dr. Levent Yılık,1 Dr. Hasan İner,2 Dr. Ali Gürbüz1 İzmir Katip Çelebi Üniversitesi Tıp Fakültesi, Kalp Damar Cerrahisi Anabilim Dalı, İzmir İzmir Katip Çelebi Üniversitesi Atatürk Eğitim ve Araştırma Hastanesi, Kalp Damar Cerrahisi Kliniği, İzmir 3 İzmir Tepecik Eğitim ve Araştırma Hastanesi, Çocuk Acil Kliniği, İzmir 1 2

AMAÇ: Çocuklarda travma ya da girişimsel işlemlere bağlı olarak meydana gelen vasküler yaralanmaların birçoğu cerrahi müdahale gerektirir. Bu çalışmada herhangi bir nedenle vasküler yaralanmaya maruz kalınan çocuklarda uygulanan cerrahi işlemler incelendi. GEREÇ VE YÖNTEM: Ocak 2002–Aralık 2012 yılları arasında vasküler yaralanma nedeniyle acil operasyona alınan 18 yaş altı 17 hasta geriye dönük olarak incelendi. Çalışma verilerine hastane kayıtlarından ulaşıldı. Çalışmaya alınan hastaların ameliyat öncesi ve ameliyat sırasındaki verileri kaydedildi. BULGULAR: Hastaların 11’i kız (%64.7) ve yaş ortalaması 60.7±54.4 ay idi. Vasküler yaralanmaların 14’ü (%82.3) anjiyografik işlemlere bağlı, biri (%5.9) eksternal travmaya, biri (%5.9) ameliyat sırasında travmaya, biri (%5.9) ise yoğun bakım takibi sırasındaki invaziv arter takibine bağlı olarak meydana gelmiştir. Bu yaralanmaların 11’i (%64.7) sağ femoral arterde, üçü ise (%17.6) sol femoral arterde, ikisi (%11.8) sol barakiyal arterde ve biri (%5.9) sol eksternal iliak vende gerçekleşmiştir. Anestezi yöntemi olarak beş (%29.4) hastada lokal, 12 (%70.6) hastada ise genel anestezi kullanıldı. Yaralanmaların 15’i (%88.2) primer olarak tamir edilirken, birinde (%5.9) uç-uca anastomoz, birinde (%5.9) safen ven interpozisyonu gerekmiştir. Ayrıca 16 (%94.1) olguda ilave olarak trombektomide uygulanmıştır. Hastanede yatış süresi ortalama 2.7±1.4 gün, yoğun bakım kalış süresi ise 1.1±0.4 gün olarak tespit edilmiştir. Hiçbir hastada mortalite görülmemiş olup ekstremite kaybı, yara yeri enfeksiyonu gibi herhangi bir komplikasyon da gelişmemiştir. TARTIŞMA: Pediatrik vasküler yaralanmaların etiyolojisinde sıklıkla girişimsel işlemlere bağlı iyatrojenik nedenler görülmektedir. Bu tip yaralanmalarda acil olarak uygulanan cerrahi işlemlerin sonuçları oldukça iyidir. Anahtar sözcükler: Cerrahi; damar; pediyatrik; yaralanma. Ulus Travma Acil Cerrahi Derg 2017;23(3):217–222

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doi: 10.5505/tjtes.2016.61282

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ORIG I N A L A R T IC L E

Factors affecting mortality among victims of electrical burns Çağrı Tiryaki, M.D.,1 Mustafa Celalettin Haksal, M.D.,2 Murat Burç Yazıcıoğlu, M.D.,1 Ali Çiftçi, M.D.,1 Osman Esen, M.D.,3 Hamdi Taner Turgut, M.D.,1 Abdullah Yıldırım, M.D.,4 Murat Güven, M.D.5 1

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

2

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

3

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

4

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

5

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

ABSTRACT BACKGROUND: The aim of this study was to determine the factors affecting mortality rate among patients with an electrical burn. METHODS: A total of 115 patients admitted to the emergency department and hospitalized in the Burn Treatment Center or Intensive Care Unit (ICU) due to the electrical burn, were included in the study. RESULTS: A total of 115 patients (4 female and 111 male) with a mean age of 32.88±12.87 years were included in the study. The mean hospitalization period was 25.03±20.50 days, and the mean total body surface area burned (% TBSA) was 22.83±15.54%. Among those patients, 9 (8.5%) expired, and the remaining 106 were discharged after treatment. In a logistic regression analysis, TBSA >20% (p=0.02, OR: 11.7, CI: 1.38–99.16); ICU requirement (p=0.005, OR: 1.28, CI: 1.08–1.58); erythrocyte transfusion requirement (p=0.02, OR: 12.48, CI: 1.44–107.83); fresh frozen plasma (FFP) requirement (p=0.03, OR: 10.23, CI: 1.18–88.17); albumin requirement (p=0.02, OR: 12.60, CI: 1.44–109.85); admission serum albumin level <3.5 mg/dl (p=0.04, OR: 7.25, CI: 0.82–63.64); and admission hemoglobin level <12 mg/dl (p=0.01, OR: 8.29, CI: 1.57–43.61) were determined as risk factors for mortality in patients with electrical burns. CONCLUSION: In clinical practice, defining a mortality risk analyzer using these factors may be helpful in the management of patients with electrical burns. Additional, more comprehensive studies are required to define the risk factors for mortality and long-term morbidities in patients with electrical burns. Keywords: Albumin; burn extent; calcium; electrical burns; hemoglobin; mortality.

INTRODUCTION Electrical burns are one of the causes of important health burdens throughout the world with incidences varying between 4–18% of all burns.[1–3] In the pathogenesis, with the passage of electric through the human body, the biochemical compositions of the body are altered together with many electro-traumas. Necrosis on the skin and deeper tissues may cause the dysfunction of the affected limbs and life-threatening organ complications including renal failure or sepsis.[4] Address for correspondence: Murat Burç Yazıcıoğlu, M.D. Derince Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Kocaeli, Turkey Tel: +90 262 - 319 50 79 E-mail: mbyazicioglu@gmail.com Ulus Travma Acil Cerrahi Derg 2017;23(3):223–229 doi: 10.5505/tjtes.2016.29166 Copyright 2017 TJTES

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Electrical burns are most commonly reported among young men causing long-term hospitalization and high cost rates. [5] They are still important causes of work-power loss with high rates of morbidity and mortality especially in developing countries.[6] As high as 21.7% of the mortality rate has also been reported in electrical burn patients.[7] Recently Ghavami et al. investigated 682 electrical burn patients and reported the mortality rate as 2.5%, while those requiring amputation was 23.7%.[8] The aim of this study was to determine the factors affecting mortality rates among the victims of an electrical burn. In this way, we aimed to draw attention to these points for the prompt and improved management of patients.

MATERIALS AND METHODS This retrospective study was conducted in the Derince Training and Research Hospital, between January 2012 and December 2015. The study was approved by the local ethics committee. A total of 115 patients, admitted to the emer223


Tiryaki et al. Factors affecting mortality among victims of electrical burns

gency department and hospitalized in the General Surgery Department or Intensive Care Unit (ICU) due to the electrical burns, was included in the study.

expired, and the remaining 106 were discharged after treatment. The general characteristics of the expired and discharged patients are summarized in Table 1.

The total body surface area was calculated by the rule of nines, and the maximally affected burn area was also recorded. Burns are graded as: Grade 1: the superficial thickness of the skin is involved; Grade 2: the full thickness of skin is destroyed; Grade 3: the skin, subcutaneous tissues, fat, and muscles are destroyed; Grade 4: the skin, subcutaneous tissues, and bones are destroyed.

The mean age of the expired group was older (42.89±19.00 vs 32.42±12.28 years, p=0.03); the mean total body surface area burned (% TBSA) was larger (40.75±18.79 vs 20.46±14.62, p=0.001); the ICU requirement was more common (100% vs 65.1%, p=0.05), and the mean of the required erythrocyte suspensions (4.14±5.52 vs 1.19±2.53, p=0.01), the fresh frozen plasma (6.00±10.03 vs 2.47±5.38, p=0.04) and the albumin (1.62±1.84 vs 0.52 vs 0.76, p=0.003) were also significantly higher in the expired group.

After an initial assessment, intravenous fluid resuscitation was started with the monitoring of the urine output. Erythrocyte or fresh frozen plasma (FFP) was transfused when necessary. Surgical interventions including debridement, escharatomies, fasciotomies, or a flap coverage were also managed where required. Demographic data, the hospitalization period, the surgical interventions, and the laboratory data including a complete blood count, renal, and liver function tests, Creactive protein, blood coagulation parameters, and serum electrolyte levels were recorded. The corrected calcium level was calculated based on the formula Corrected calcium = serum calcium + 0.8 * (4 - serum albumin). Patients with incomplete records were not included in the study.

The Statistical Analysis Statistical analyses of the results were performed using the SPSS software (version 21, IBM SPSS Statistics). The results were presented as a mean±SD for continuous variables and as a number and proportions (%) for categorical variables. The student’s t-test or the chi square test was used for the analyses. The risk level was assessed by a logistic regression analysis. A p value of less than 0.05 was considered statistically significant.

RESULTS A total of 115 patients (4 female and 111 male) with a mean age of 32.88±12.87 (16–82) years were included in the study. The accident took place at the home in 19 cases and at work in 81 cases, as well as a traffic accident in 1 case. In the remaining 14 cases, the accident happened in other places. The patients were admitted to the hospital by ambulance (n=98), by their own cars (n=14) or by air ambulance (n=3). Among those patients, 65 were directly hospitalized in the intensive care unit. A tracheotomy was required in one patient. An inhalation injury accompanying an electric burn was present in one patient. The mean hospitalization period was 25.03±20.50 (1–163) days, and the mean burn extent was 22.83±15.54% (1.0–66.0%). Among those patients, 9 (8.5%) 224

The laboratory data of the study participants at admission are summarized in Table 2. The mean of serum creatinine (1.14±0.59 vs 0.81±0.21, p=0.03), phosphorus (4.85±3.10 vs 3.22±1.11, p=0.005) and aspartate amino transferase (AST) (466.71±549.61 vs 213.55±254.55, p=0.03) levels were significantly higher; while serum calcium (6.90±1.37 vs 8.32±1.05 p=0.01), albumin (2.68±0.85 vs 3.46±0.73, p=0.01), corrected calcium (8.74±0.88 vs, p=0.04) and hemoglobin (9.89±4.90 vs 13.05±2.43, p=0.002) levels were significantly lower in the expired group. A logistic regression analysis was performed for these parameters, with their laboratory limits defined as normal, to determine the risk factors in mortality (Table 3). In the logistic regression analysis, TBSA >20% (p=0.02, OR: 11.7, CI: 1.38– 99.16); ICU requirement (p=0.005, OR: 1.28, CI: 1.08–1.58); erythrocyte transfusion requirement (p=0.02, OR: 12.48, CI: 1.44–107.83); FFP requirement (p=0.03, OR: 10.23, CI: 1.18– 88.17); albumin requirement (p=0.02, OR: 12.60, CI: 1.44– 109.85); admission serum albumin level <3.5 mg/dl (p=0.04, OR: 7.25, CI: 0.82–63.64); admission hemoglobin level <12 mg/dl (p=0.01, OR: 8.29, CI: 1.57–43.61) were determined as risk factors for mortality in patients with electrical burns.

DISCUSSION Electrical burns are devastating conditions. In this study we have evaluated the risk factors for mortality in victims of electrical burns and TBSA >20%; ICU requirement, erythrocyte FFP or albumin transfusion requirements, admission albumin level <3.5 mg/dl and admission hemoglobin level <12 mg/dl were determined as the risk factors for mortality. In patients with electrical burns, since morbidity, and mortality rates are high, defining risk factors is important for the prompt and precise management and especially to reveal preventive measures in high-risk patients. To the best of our knowledge, this is one of the studies evaluating the largest demographic and laboratory features in the prediction of mortality in patients with electrical burns. Epidemiological data obtained in our study was concomitant with the literature. In a study of Iqbal et al.,[9] among 13,295 Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Tiryaki et al. Factors affecting mortality among victims of electrical burns

Table 1. The general characteristics of the study participants

Discharged (n=106)

Expired (n=9)

p

n % n %

Age (Mean±SD) 32.42±12.28 42.89±19.00 0.03 Gender (Male/Female) 102/4 9/0 1.0 Total body surface area burned 0.009 Lower than 10% 32 30.2 0 0 10–19% 31 29.3 0 0 20–29% 26 24.5 4 44.4 ≥30% 17 16.0 5 55.6 Burn degree 0.72 2nd degree 70 66.0 5 55.6 3rd degree 36 33.9 4 44.4 Burn area (maximally affected) 0.15 Hairy skin 4 3.7 0 0 Extremity 69 65.1 5 55.6 Body 19 17.9 3 33.3 Head and neck 8 7.5 1 11.1 Genital-gluteal region 6 5.7 0 0 Operation requirement 74 69.8 8 88.9 0.58 Debridement number 0.53 Lower than 5 56 52.8 6 66.6 6–10 20 18.9 1 11.1 11–20 16 15.1 1 11.1 >20 14 13.2 1 11.1 Hospitalization time (days) 0.19 1-10 18 16.9 4 44.4 11-20 25 23.6 3 33.3 21-30 27 25.5 0 0 31-40 21 19.8 0 0 41-50 10 9.4 1 11.1 ≥51 5 4.7 1 11.1 Intensive care unit requirement 69 65.1 9 100 0.005 Multi-trauma presence 9 8.5 2 22.2 0.38 0.55 Intensive care unit hospitalization time 1–10 days 19 17.9 3 33.3 11–20 days 25 23.6 3 33.3 21–30 days 16 15.1 1 11.1 ≥31 days 9 8.5 2 22.2 Erythrocyte transfusion requirement 0.009 No 84 79.2 0 0 1 unit 13 12.3 3 33.3 2 units 4 3.8 2 22.2 3 units 1 0.9 2 22.2 ≥4 units 4 3.8 2 22.2 Fresh frozen plasma requirement 0.04 No 81 76.4 0 0 1 unit 18 16.9 4 44.4 2 units 3 2.8 1 11.1 3 units 1 0.9 1 11.1 ≥4 units 12 11.3 3 33.3 Albumin requirement 0.006 No 87 82.1 1 11.1 1 unit 10 9.4 6 66.6 2 units 9 8.5 2 22.2 Dialysis requirement 5 4.7 1 11.1 0.12

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Tiryaki et al. Factors affecting mortality among victims of electrical burns

Table 2. Laboratory data of the study participants at their admission to the hospital Creatinine (mg/dL)

Discharged (n=106)

Expired (n=9)

p

Mean±SD Mean±SD 0.81±0.21

1.14±0.59

0.03

Urea (mg/dL)

29.29±11.89

34.55±23.96

0.28

Glucose (mg/dL)

132.25±56.29

167.85±47.31

0.11

Calcium (mg/dL)

8.32±1.05

6.90±1.37

0.01

Corrected calcium (mg/dL)

8.74±0.88

7.95±1.30

0.04

104.82±6.27

104.85±4.14

0.99

Total protein (mg/dL)

6.01±1.09

4.81±1.55

0.01

Albumin (mg/dL)

3.46±0.73

2.68±0.85

0.01

Phosphorus (mg/dL)

3.22±1.11

4.85±3.10

0.005

Uric acid (mg/dL)

4.49±1.82

3.69±1.70

0.11

Aspartate amino transferase (IU/l)

213.55±254.55

466.71±549.61

0.03

Alanine aminotransferase (IU/l)

103.50±174.10

136.71±119.37

0.62

Total bilirubin (mg/dL)

0.83±0.49

0.90±0.54

0.71

Potassium (mEq/L)

3.83±0.68

4.04±0.87

0.44

Sodium (mEq/L)

136.88±4.98

136.57±5.13

0.87

C-reactive protein

75.88±62.40

72.10±70.73

0.86

Hemoglobin (g/dL)

13.05±2.43

9.89±4.90

0.002

Lymphocyte count

15.18±7.93

9.72±6.54

0.09

Chloride (mEq/L)

Mean platelet volume

8.44±1.90

8.40±0.75

0.92

Neutrophil (%)

74.73±9.75

66.85±32.41

0.12

Red cell distribution width

14.39±1.88

14.76±2.24

0.61

228.43±82.68

259.50±136.63

0.35

White blood cell count count

16.96±6.73

18.15±6.98

0.64

International normalized ratio

1.11±0.32

1.22±0.14

0.34

29.95±21.08

29.98±5.24

0.99

Platelet count

Activated partial thromboplastin time (sec) SD: Standard deviation.

patients admitted with burns, about 10% were with electrical burns. The patients with electrical burns were mainly (98.6%) males as in our study. The mortality rate was 14% in all of the hospitalized burn patients while in the electrical burn sub-group, the mortality rate was reported to be lower than 1%. Kym et al.[10] retrospectively analyzed the clinical records of 625 patients with a mean age of 33.4±18.2 years admitted with an electrical injury. They determined the male/ female ratio as 13.5 and the burn extent as 14.0%±13.8%. Mohammadi et al.[11] reported the mean age as 30.5 years and the mean burn extent as 27.5% with a 95.3% male predominance among electrical burn patients and defined that 59.3% of them occurred at the work site. Similarly Ghavami et al.[7] assessed 682 electrical burn patients (~10.8% of all burn patients); with a mean age of 29.4 years and 97.8% of a male predominance. They also defined that most of the electrical burns took place at work. The young age and high percentage of the male gender may be explained by the work 226

conditions that result in the higher exposure to electrical devices. The mortality rate has been defined as varying between 0–21.7% in electrical burns in previous studies.[11–13] We have reported an 8.5% mortality rate which may be regarded as not low. We believe that since our hospital is a tertiary center, more complicated cases are being admitted, and in this study, we only have investigated the hospitalized patients which are considered as the main reasons of this not low rate. The risk factors of mortality in patients with electrical burns have been studied in several previous studies. Agbenorku et al.[14] investigated 13 electrical burn patients (11 male, 2 female; with a mean age of 37.8 years) and reported an older age and TBSA >20% as risk factors for mortality. The overall mortality rate reported was 23.1% in that study. Saracoglu et al.[15] investigated the factors affecting the mortality rate of Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Tiryaki et al. Factors affecting mortality among victims of electrical burns

Table 3. The logistic regression analysis

p

Odd’s ratio (95% confidence interval)

Age >33 years of age

0.18

2.74

Total body surface area burned >20%

0.02

11.7 (1.38–99.16)

Intensive care unit requirement

0.005

1.28 (1.08–1.58)

Erythrocyte transfusion requirement

0.02

12.48 (1.44–107.83)

Fresh frozen plasma requirement

0.03

10.23 (1.18–88.17)

Albumin requirement

0.02

12.60 (1.44–109.85)

Admission creatinine >1.1

0.10

4.72

Admission albumin <3.5 mg/dL

0.04

7.25 (0.82–63.64)

Admission phosphorus> 4.5 mg/dL

0.20

3.25

Admission calcium <8.5 mg/dL

0.07

7.24

Admission aspartate amino transferase >40

0.60

1.57

Admission hemoglobin <12 mg/dL

0.01

8.29 (1.57–43.61)

patients presenting with electrical burn wounds in a retrospective study and reported the mortality rate as high as 26% in 101 patients. Similar with our study, they also reported that 72% of the burns took place at work. In this study, all of the expired patients were men, and the mean age, creatine kinase, and creatine kinase-MB levels, TBSA, the hospitalization period in the intensive care unit, and the intubation rate were significantly higher in the expired group. The mortality associated risk factors have been studied more extensively in all types of burn patients. Quite recently, Huang et al.[16] developed a mathematical model of predicting mortality based on the admission characteristics including gender, age, the total burn area, the full thickness burn area, the inhalation injury, shock, and the period before admission in 6220 burn cases. Ceniceros et al.[17] investigated the factors associated with mortality in burn patients and reported that age, the burn extent, and the SOFA score at the onset of bacteremia and recurrent bacteremia were significantly associated with the mortality. We did not investigate the bacteremia status of the participants. In our study, although the mean age was statistically significantly different between the expired and discharged patients, we did not determine age as a risk factor for mortality, but the TBSA >20% in the logistic regression analysis. Nevertheless, the association of laboratory data at admission with mortality has only been studied in a limited number of previous studies. Aguayo-Becerra et al.[18] reported that burn patients with albumin levels <2 g/dL at admission had a mortality risk of >80%, with 84% sensitivity and 83% specificity. Maldonado et al.[19] investigated the role of some biochemical variables including albumin and calcium levels in the prediction of mortality in 143 patients with major burns hospitalized in the ICU but reported that in a multi-variate analysis, only age, the total body surface area burned, the pH value, Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

and the magnesium levels were independently associated with mortality. Hamilton et al. reported that there was not any significant difference regarding 30-day mortality rates between patients with a hemoglobin level of higher or lower than 10 mg/dl among critically ill burn patients.[20] We have defined the admission albumin level <3.5 mg/dl and admission hemoglobin level <12 mg/dl as the risk factors for mortality in electrical burns. There are some mechanisms of the hypo-albuminemia development in burn patients. All types of burns result in hyper-catabolic responses that decrease serum albumin levels, and also with an increase in TBSA%, an extracellular fluid loss induces vascular permeability and a plasma albumin loss from the wound exudations. When developed, hypoalbuminemia is associated with edema, disturbances in wound healing, and an increased susceptibility to sepsis that may play a role in mortality.[21] On the other hand, anemia directly reduces the oxygen delivery and worsens the multi-organ failure, especially an acute kidney injury if present which may be associated with the increased mortality.[22] The effects of transfusion requirements in defining mortality risk factors in burns also were not studied considerably previously. In concomitant with our results, Caleman et al.[23] defined the albumin transfusion requirement as a risk factor for mortality in burn patients. Lu et al.[24] did not define the erythrocyte or plasma transfusion as a predictor of mortality in patients with a burn injury. Nevertheless, we have determined that erythrocyte, FFP, or albumin transfusion requirements were all associated with the increased risk of mortality in electrical burn patients. Similar to our results, Palmieri et al.[25] also defined an association of increased mortality with a blood product use in severe burns in childhood. There are some limitations of this study that should be mentioned. High voltage burns have been defined as a risk factor for mortality in previous studies, but we did not classify 227


Tiryaki et al. Factors affecting mortality among victims of electrical burns

the burns at a high or low voltage. Secondly, the long-term complications could not be defined since the follow-up records were not examined. Lastly, the bacteremia status of the participants was not investigated which may also have some effects on mortality.

Conclusion In this study, we have evaluated the risk factors for mortality in victims of electrical burns and reported that TBSA >20%; ICU requirement, erythrocyte, FFP or albumin transfusion requirements, admission albumin level <3.5 mg/dl and admission hemoglobin level <12 mg/dl are the risk factors for mortality. In clinical practice, defining a mortality risk analyzer using these factors may be helpful in the management of these patients. Additional, larger studies are required to define the risk factors for mortality and long-term morbidities in patients with electrical burns. Conflict of interest: None declared.

REFERENCES 1. Burn Incidence and Treatment in the United States: 2015. Available from: http://www.ameriburn.org/resources_factsheet.php. 2. Aldemir M, Kara IH, Girgin S, Güloglu C. Factors affecting mortality and epidemiological data in patients hospitalised with burns in Diyarbakir, Turkey. S Afr J Surg 2005;43:159–62. 3. Sun CF, Lv XX, Li YJ, Li WZ, Jiang L, Li J, Feng J, et al. Epidemiological studies of electrical injuries in Shaanxi province of China: a retrospective report of 383 cases. Burns 2012;38:568–72. 4. Buja Z, Arifi H, Hoxha E. Electrical Burn Injuries. An Eight-year Review. Ann Burns Fire Disasters 2010;23:4–7. 5. Patil SB, Khare NA, Jaiswal S, Jain A, Chitranshi A, Math M. Changing patterns in electrical burn injuries in a developing country: should prevention programs focus on the rural population? J Burn Care Res 2010;31:931–4. 6. Sahin I, Ozturk S, Alhan D, Açikel C, Isik S. Cost analysis of acute burn patients treated in a burn centre: the Gulhane experience. Ann Burns Fire Disasters 2011;24:9–13. 7. Ghavami Y, Mobayen MR, Vaghardoost R. Electrical burn injury: a fiveyear survey of 682 patients. Trauma Mon 2014;19:18748. 8. Acosta AS, Azarcon-Lim J, Ramirez AT. Survey of electrical burns in Philippine General Hospital. Ann N Y Acad Sci 1999;888:12–8. 9. Iqbal T, Saaiq M, Ali Z. Epidemiology and outcome of burns: early experience at the country’s first national burns centre. Burns 2013;39:358–62. 10. Kym D, Seo DK, Hur GY, Lee JW. Epidemiology of electrical injury:

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Differences between low- and high-voltage electrical injuries during a 7-year study period in South Korea. Scand J Surg 2015;104:108–14. 11. Mohammadi AA, Amini M, Mehrabani D, Kiani Z, Seddigh A. A survey on 30 months electrical burns in Shiraz University of Medical Sciences Burn Hospital. Burns 2008;34:111–3. 12. Rai J, Jeschke MG, Barrow RE, Herndon DN. Electrical injuries: a 30year review. J Trauma 1999;46:933–6. 13. Luz DP, Millan LS, Alessi MS, Uguetto WF, Paggiaro A, Gomez DS, et al. Electrical burns: a retrospective analysis across a 5-year period. Burns 2009;35:1015–9. 14. Agbenorku P, Agbenorku E, Akpaloo J, Obeng G, Agbley D. Electrical burns: The trend and risk factors in the Ghanaian population. Ann Burns Fire Disasters 2014;27:176–83. 15. 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. 16. Huang Y, Zhang L, Lian G, Zhan R, Xu R, Huang Y, et al. A novel mathematical model to predict prognosis of burnt patients based on logistic regression and support vector machine. Burns 2016;42:291–9. 17. Ceniceros A, Pértega S, Galeiras R, Mourelo M, López E, Broullón J, et al. Predicting mortality in burn patients with bacteraemia. Infection 2016;44:215–22. 18. 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. 19. Maldonado AA, Sillero A, Küntscher M. Prediction of mortality in patients with major burns: clinical and biochemical factors. Ann Plast Surg 2011;67:226–31. 20. Hamilton JA, Mora AG, Chung KK, Bebarta VS. Impact of Anemia in Critically Ill Burned Casualties Evacuated From Combat Theater via US Military Critical Care Air Transport Teams. Shock 2015;44 Suppl 1:50–4. 21. Lehnhardt M, Jafari HJ, Druecke D, Steinstraesser L, Steinau HU, Klatte W, et al. A qualitative and quantitative analysis of protein loss in human burn wounds. Burns 2005;31:159–67. 22. Han SS, Baek SH, Ahn SY, Chin HJ, Na KY, Chae DW, et al. Anemia Is a Risk Factor for Acute Kidney Injury and Long-Term Mortality in Critically Ill Patients. Tohoku J Exp Med 2015;237:287–95. 23. Caleman G, Morais JF, Puga ME, Riera R, Atallah AN. Use of albumin as a risk factor for hospital mortality among burn patients in Brazil: nonconcurrent cohort study. Sao Paulo Med J 2010;128:289–95. 24. Lu RP, Lin FC, Ortiz-Pujols SM, Adams SD, Whinna HC, Cairns BA, et al. Blood utilization in patients with burn injury and association with clinical outcomes (CME). Transfusion 2013;53:2212–21. 25. Palmieri TL, Sen S, Falwell K, Greenhalgh DG. Blood product transfusion: does location make a difference? J Burn Care Res 2011;32:61–5.

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Tiryaki et al. Factors affecting mortality among victims of electrical burns

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Elektrik yanıklarında mortaliteye etki eden faktörler Dr. Çağrı Tiryaki,1 Dr. Mustafa Celalettin Haksal,2 Dr. Murat Burç Yazıcıoğlu,1 Dr. Ali Çiftçi,1 Dr. Osman Esen,3 Dr. Hamdi Taner Turgut,1 Dr. Abdullah Yıldırım,4 Dr. Murat Güven5 Kocaeli Derince Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Kocaeli Medipol Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul 3 Kocaeli Derince Eğitim ve Araştırma Hastanesi, Anestezi ve Reanimasyon Kliniği, Kocaeli 4 Kocaeli Derince Eğitim ve Araştırma Hastanesi, Yanık Tedavi Merkezi, Kocaeli 5 Kocaeli Derince Eğitim ve Araştırma Hastanesi, Plastik ve Rekonstrüktif Cerrahi Kliniği, Kocaeli 1 2

AMAÇ: Bu çalışmanın amacı elektrik yanığı olan hastalarda mortalite oranlarına etki eden faktörleri belirlemektir. GEREÇ VE YÖNTEM: Elektrik yanığı nedeniyle Derince Eğitim ve Araştırma Hastanesi Acil Servisi’ne kabul edilip yanık tedavi merkezi veya yoğun bakıma (YB) yatırılan 115 hasta çalışmaya dahil edildi. BULGULAR: Ortalama yaşı 32.88±12.87 yıl olan toplam 115 hastanın (4 kadın, 111 erkek) çalışmaya alındı. Ortalama hastanede yatış süresi 25.03±20.50 gün ve yanan ortalama toplam vücut yüzey alanı (%TVYA) ise %22.83±15.54 idi. Bu hastaların 106’sı tedavi sonrası taburcu edilirken, dokuzu (%8.5) hayatını kaybetti. Lojistik regresyon analizinde, TVYA >%20 (p=0.02, odds ratio (OR): 11.7, confidence interval (CI): 1.38–99.16), YB gerekenler (p=0.005, OR: 1.28, CI: 1.08–1.58); eritrosit transferi gerekenler (p=0.02, OR: 12.48, CI: 1.44–107.83); Taze donmuş plazma (TDP) gereksinimi olanlar (p=0.03, OR 10.23, CI: 1.18–88.17); albümin gereksinimi olanlar (p=0.02, OR: 12.60, CI: 1.44–109.85); kabulde serum albümin seviyesi <3.5 mg/dL (p=0.04, OR: 7.25, CI: 0.82–63.64); kabul hemoglobin seviyesi <12 mg/dL (p=0.01, OR: 8.29, CI: 1.57–43.61) hastalarda mortaliteyi belirleyen risk faktörleri olarak belirledik. TARTIŞMA: Klinik uygulamada, elektrik yanığı olan hastalarda bu faktörlerin analiz edilmesi mortalite oranını belirlemede yararlı olabilir. Elektrik yanığı olan hastalarda mortalite risk faktörlerini ve uzun dönem morbiditeleri belirlemek için daha geniş çalışmalara gereksinimi vardır. Anahtar sözcükler: Albümin; elektrik yanığı; hemoglobin; kalsiyum; mortalite; yanık derecesi. Ulus Travma Acil Cerrahi Derg 2017;23(3):223–229

doi: 10.5505/tjtes.2016.29166

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ORIG I N A L A R T IC L E

Clinicopathological analysis of patients operated for appendiceal mucocele Hasan Abuoğlu, M.D.,1 Mehmet Kamil Yıldız, M.D.,1 Bülent Kaya, M.D.,2 Mehmet Odabaşı, M.D.1 1

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

2

Department of General Surgery, Fatih Sultan Mehmet Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: The term mucocele refers to the dilatation of the appendix due to mucus, and it is an uncommon disorder with an estimated incidence of 0.2%–0.3% of all appendectomies performed and 8%–10% of all appendiceal tumors. It is often asymptomatic, but may manifest appendicitis-like symptoms. METHODS: Twenty-six patients (14 females and 12 males) were operated on due to mucocele of the appendix. Sixteen patients exhibiting the characteristics of clinically acute appendicitis required an emergency operation. Appendectomy was performed on 14 patients, and right hemicolectomy was carried out on 2 patients. Of the remaining 10 patients who received surgery under elective conditions, 4 underwent a right hemicolectomy and 6 underwent an appendectomy. RESULTS: The patients’ age ranged from 27 to 81 years. Sixteen open and 4 laparoscopic appendectomies were performed. An incidental appendiceal mucocele was identified in 2 patients who had undergone colonoscopy. According to the histopathological examination, the incidence rate of mucosal hyperplasia, mucinous cystadenoma, and mucinous cystadenocarcinoma was found to be 23.1%, 61.4%, and 15.5%, respectively. CONCLUSION: In patients with long-term pain in the right lower quadrant of the abdomen, appendiceal mucocele should be considered, and the results of radiological imaging tests should be carefully analyzed before surgery. Keywords: Appendectomy; appendiceal neoplasms; mucocele.

INTRODUCTION Appendiceal mucocele is an obstructive dilatation of the appendix caused by the intraluminal accumulation of mucoid material.[1] Appendiceal mucocele is a disease with an incidence estimated at 0.2%–0.3% of all appendectomies performed and 8%–10% of all appendiceal tumors.[2] It was first described by Rokitansky in 1842.[3] Mucocele of the appendix can be categorized in four histological types, including retention cyst, mucosal hyperplasia, mucinous cystadenoma, and mucinous cystadenocarcinoma.[4,5] The affected patients are usually above the age of 50 years.[6] Clinical signs include abAddress for correspondence: Bülent Kaya, M.D. Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey Tel: +90 216 - 578 30 00 E-mail: drbkaya@yahoo.com Ulus Travma Acil Cerrahi Derg 2017;23(3):230–234 doi: 10.5505/tjtes.2016.30276 Copyright 2017 TJTES

230

dominal pain in the right lower quadrant, a palpable mass, colicky pain in case of obstruction or intussusception, gastrointestinal bleeding and anemia, genitourinary symptoms or acute abdomen, and sepsis in case of spontaneous rupture of the cyst. However, since these symptoms are nonspecific or absent, the disease is usually detected incidentally by radiological, sonographic, or endoscopic intervention.[7–9] The worse complication is pseudomyxoma peritonei characterized by peritoneal dissemination caused by the iatrogenic or spontaneous rupture of the mucocele.[10,11] The recommended treatment for appendiceal mucocele is surgery, and the surgical procedure must be performed according to the examination of the tumor (size, presence of local or diffuse mucus collection throughout the peritoneum, or ruptured appendix or safety margins) and its histology. A simple appendectomy is postulated in benign processes, and cecal resection or right ileal colectomy is suggested when there is involvement of adjacent intestinal segments, regional lymphadenopathy, peritoneal pseudomyxoma, or malignancy. [12] Despite the higher risk of the rupture involved, laparoscopic surgery can be safely performed.[13,14] Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Abuoğlu et al. Clinicopathological analysis of patients operated for appendiceal mucocele

MATERIALS AND METHODS This study is a retrospective evaluation of 26 patients who were diagnosed with appendiceal mucocele and underwent surgery in the General Surgery Clinic of Haydarpaşa Numune Education and Research Hospital between 2006 and 2014. Based on the literature, a histopathological analysis was performed to determine the treatment options by taking into consideration the patients’ gender, age, clinical findings, and results of the biochemical and diagnostic tests.

RESULTS Mucocele was identified in 26 (0.31%) of the 8,347 appendectomy cases. The age of the patients ranged from 27 to 81 years (mean: 55.35±12.96 years), and 14 (53.8%) were females. Sixteen patients (61.5%) reported pain in the right lower quadrant of the abdomen that had started less than 72 h earlier and they exhibited the clinical symptoms of acute appendicitis. These patients were admitted for emergency surgery. The symptoms of the remaining 10 patients (38.5%) included a mass lesion in the right lower quadrant, chronic pain, anemia, and weight loss. An abdominal ultrasonography (USG) was performed in 23 patients (88%), while a computed tomography (CT) was required for 12 patients (69.2%–46%). USG showed a dilated tubular structure in the right iliac fossa, and CT revealed a long tubular structure distended with hypodense material with or without calcification in the wall of the appendix, together with mass effect in six cases. Two of the colonoscopy patients (13%) were referred for CT upon the appearance of the cecum around the appendiceal orifice (also known as volcano sign). Mucocele was identified in two patients. In one of these two patients, a histopathological diagnosis of sigmoid cancer was made, and therefore, a left hemicolectomy and appendectomy were simultaneously performed on this patient. This patient was identified as having mucosal hyperplasia. In the other patient, mucinous cystadenoma was identified following a right hemicolectomy. Appendectomies were performed on 20 patients (76.8%) (14 emergency and 6 elective), which included 16 (75%) open and 4 (25%) laparoscopic surgeries. The histological results were benign in all 20 patients with appendectomy. Six patients (23.2%) underwent a right ileocolectomy, of which two

surgeries were emergency and four were elective. Mucinous cystadenocarcinoma was identified in four patients and mucinous adenoma in two patients. Table 1 shows the type of operations and the results of the histopathological evaluation. In two patients who underwent a right hemicolectomy, acellular mucin extravasation was observed in the mesoappendix. The histopathological examination revealed very few histiocytes and macrophages without signs of dysplasia. These patients were included in the follow-up program; however, they did not require further surgery. The analysis of tumor markers in the preoperative period showed that three patients (11.5%) had high levels of carcinoembryonic antigen (CEA). During surgery, cystadenocarcinoma was detected in two of these patients. After the surgery, 22 patients were followed up for an average of 21.82±12.50 months, and no mortality was observed.

DISCUSSION Patients with mucocele of the appendix can exhibit confusing symptoms and may even be asymptomatic. The literature reports a very low prevalence of mucocele in appendectomy patients, and the majority of studies have been based on case reports. One of the most comprehensive series of cases was that of Stocchi et al.[15] who investigated 135 patients over a 24-year period. Another study was conducted by Lozano et al.[2] with 31 cases. The incidence of mucocele predominates in the age range of 50–69 years, although it can be diagnosed at any age.[16] In a series of 31 appendiceal mucocele cases, García Lozano et al.[2] reported the mean age of the patients to be 62.1 years. In our study, the mean age of 25 of the 26 patients was found to be within the range reported in the literature. However, a female patient aged 27 years who was suspected to have appendicitis was included in the study, and after surgery, she was diagnosed with mucinous hyperplasia. Regarding gender distribution, discrepancies have been reported in the literature.[10] Some studies describe a female predominance,[17] whereas others report a similar incidence in males and females.[2,16] In our study, the female-to-male ratio was 14:12. Acute or chronic pain in the right iliac fossa is the most fre-

Table 1. Type of operations and the results of the histopathological evaluation

Type of operation

Pathology

Appendectomy Right Mucosal Mucinous Mucinous Hemicolectomy Hyperplasia Adenocarcinoma Cystadenocarcinoma Emergency 4

2

5

10

1

Elective 16

4

1

6

3

Total

20 (76.8%)

6 (23.2%)

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6 (23.1%)

16 (61.5%)

4 (15.4%)

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quent symptom, appearing sometimes as a mass in the physical examination.[8,9,18] The symptoms of malignant mucocele cases were linked to weight loss, deterioration of general health, and the presence of intra-abdominal masses, whereas benign mucoceles were more related to acute pain in the right iliac fossa.[2] In our study, 61.5% of patients (n=16) exhibited the characteristics of acute appendicitis. Mucinous cystadenocarcinoma was identified in one patient who underwent a right hemicolectomy. Of the 10 patients (38.5%) who exhibited symptoms of a mass lesion in the right lower quadrant of the abdomen, anemia, and weight loss and underwent elective surgery, 3 (30%) were found to have malignant mucoceles. The advancements in diagnostic methods primarily related to ultrasound and abdominal CT have led to an increase in the possible preoperative diagnosis of the mucocele.[2] Depending on the composition of the mucus, the ultrasound can reveal cysts with variable echogenicity. Multiple echogenicity foci can reveal multiple echogenic layers in a dilated appendix giving the appearance of onion skin concentric layers that may be pathognomonic for the mucocele.[19] In a USG examination, an appendix with a diameter of ≥15 mm is determined as the threshold for mucocele diagnosis with a sensitivity of 83% and a specificity of 92%.[20] In a CT scan, the appearance of cystic masses well circumscribed with low attenuation is indicative of mucocele; furthermore, curvilinear mural calcifications can be observed about 50% of the time that are highly suggestive of mucocele.[21,22] The appearance of enhancing nodules in the mucocele wall suggests a diagnosis of cystadenocarcinoma.[23] To rule out the association of colorectal neoplasm, a colonoscopy is recommended in all patients in whom there is a suspicion of an appendiceal mucocele.[9] Colonoscopic findings include the “volcano sign” in which the appendiceal orifice is observed in the center of a firm mound covered by normal mucosa or a yellowish, lipoma-like submucosal mass[24] Mucosal biopsies are often normal;[9] however, in our study, the mucocele was an incidental finding during the colonoscopy of two patients. Blood tests also contribute to the diagnosis of the mucocele, wherein elevated levels of CEA can be seen in malign cystadenocarcinomas.[15] In the current study, cystadenocarcinoma was observed in two of the three patients with elevated preoperative CEA levels. Elevated CEA levels with cystadenoma rarity may be explained by the fact that routine CEA tests are not usually requested for patients with cystadenoma, although this antigen is often produced by neoplasms of the colon.[25] The remaining one patient with elevated CEA levels was diagnosed with sigmoid cancer and appendiceal mucocele hyperplasia. Shimizu and Oshimo reported elevated preoperative CEA levels in patients with mucinous cystadenoma of the appendix. [26,27] It should be remembered that 11%–20% of patients with colonic cancer are accompanied by an appendiceal mucocele, 232

and in malignant cases, tumors in solid organs such as the kidneys and lungs should be investigated. Postoperative followup should be carefully performed,[28] and furthermore, tumor markers such as alpha-fetoprotein (AFP), CEA, and CA19-9 should be determined during the preoperative evaluation. The mucinous neoplasms of the appendix are classified into the following four pathological entities according to the characteristics of the epithelium: retention cyst, mucosal hyperplasia, mucinous cystadenoma, and mucinous cystadenocarcinoma.[3] A simple retention cyst determined by the intraluminal accumulation of mucoid material is rarely greater than 2 cm. Mucosal hyperplasia, a mild dilatation, constitutes 5%–25% of mucoceles. In the current study, this percentage was found to be 23.1. Mucinous cystadenoma is characterized by a dilatation of the lumen by up to 6 cm with low-grade dysplasia. Mucinous cystadenomas are the most common form, accounting for 63%–84% of cases. In our study, mucinous cystadenoma was identified in 61.4% of the patients.[4,29] Mucinous cystadenoma is at the benign end of the spectrum with no risk of recurrence. Mucinous cystadenocarcinoma with stromal invasion and intraperitoneal spread is similar to that of ovarian mucinous cystadenocarcinoma. Malign mucinous cystadenocarcinoma represents 11%–20% of all cases of mucosal cases. In our study, 15.4% of the patients presented with malign mucinous cystadenocarcinoma. Pseudomyxoma peritonei is the formation of peritoneal implants containing mucin due to the perforation of a lesion and the subsequent entry of the contents into the peritoneal cavity. Pseudomyxoma peritonei can occur during appendectomy due to the perforation of the mucocele of the appendix or other conditions such as mucinous cystadenoma and mucinous cystadenocarcinoma. The most common symptom is acute or chronic pain in the right lower quadrant of the abdomen.[30] The ruptured primary mass and the mucinous cells spreading along the peritoneal surfaces can be benign or malign. However, in both cases, the disease is progressive. Pseudomyxoma peritonei usually develops as a complication of ovarian and appendiceal masses. Current treatment strategies range from careful continuous observation to extensive cytoreductive surgery alone or with hyperthermic intraoperative peritoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC).[31] In our study, none of the patients developed diffuse pseudomyxoma peritonei. Mucin extravasation in the periappendiceal mesoappendix was detected in two patients who had undergone a right hemicolectomy; however, the histopathological examination did not reveal dysplasia and no problems were reported during the follow-up. Mucoceles are treated surgically, and the preoperative diagnosis aids in the planning of careful mobilization and resection to prevent peritoneal contamination. There is a consensus that appendectomy is sufficient to treat benign mucoceles of the appendix that have not ruptured.[32,33] Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Abuoğlu et al. Clinicopathological analysis of patients operated for appendiceal mucocele

A right hemicolectomy is frequently performed if a malignant cause is suspected based on imaging or the analysis of an intraoperative frozen section.[34] In the current study, the diagnosis of mucinous cystadenocarcinoma was confirmed in the frozen sections of four of six patients who underwent a right hemicolectomy, and the remaining two patients exhibited a large malignant mucocele forming adhesion on the intestinal segments. The histopathological examination confirmed the diagnosis of mucinous cystadenoma. The choice of open or laparoscopic surgery is controversial in patients with mucocele of the appendix.[31,35] If the mucocele is large and resection will be difficult, open laparotomy is the best option. In laparoscopic surgery, it is important to prevent rupture and peritoneal mucus contamination, and the appendix should be removed using an endobag. Among the six appendectomies performed laparoscopically, we did not observe any intra-abdominal mucus contamination. In conclusion, mucocele is a rare tumor of the appendix, which can be characterized as benign or malign. In addition to presenting with clinically acute appendicitis, this tumor can cause several nonspecific symptoms. Ultrasound and CT can be useful in preoperative diagnosis. Mucoceles can also be incidentally detected during a colonoscopy. They can be accompanied by solid organ tumors, in particular, colon cancer. The surgical treatment of mucoceles is an open or laparoscopic appendectomy. Other viable treatment options include cecal resection and right hemicolectomy. The most dreadful complication is pseudomyxoma peritonei, and therefore, surgeons should be careful to prevent the rupture of the appendix and avoid peritoneal mucus contamination. Conflict of interest: None declared.

REFERENCES 1. Demetrashvili Z, Chkhaidze M, Khutsishvili K, Topchishvili G, Javakhishvili T, Pipia I, et al. Mucocele of the appendix: case report and review of literature. Int Surg 2012;97:266–9. 2. García Lozano A, Vázquez Tarrago A, Castro García C, Richart Aznar J, Gómez Abril S, Martínez Abad M. Mucocele of the appendix: Presentation of 31 cases. Cir Esp 2010;87:108–12. 3. Spyropoulos C, Rentis A, Alexaki E, Triantafillidis JK, Vagianos C. Appendiceal mucocele and pseudomyxoma peritonei; the clinical boundaries of a subtle disease. Am J Case Rep 2014;15:355–60. 4. Paladino E, Bellantone M, Conway F, Sesti F, Piccione E, Pietropolli A. Large mucocele of the appendix at laparoscopy presenting as an adnexal mass in a postmenopausal woman: a case report. Case Rep Obstet Gynecol 2014;2014:486078. 5. Sridhar M, Chetty YVN, Saheb B. Peculiar case of mucocele of appendiceal tip. J Clin Diagn Res 2013;7:2017–8. 6. Dixit A, Robertson JH, Mudan SS, Akle C. Appendiceal mucocoeles and pseudomyxoma peritonei. World J Gastroenterol 2007;13:2381–4. 7. Kim-Fuchs C, Kuruvilla YC, Angst E, Weimann R, Gloor B, Candinas D. Appendiceal mucocele in an elderly patient: how much surgery? Case Rep Gastroenterol 2011;5:516–22. 8. Ruiz-Tovar J, Teruel DG, Castiñeiras VM, Dehesa AS, Quindós PL,

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Molina EM. Mucocele of the appendix. World J Surg 2007;31:542–8. 9. Zanati SA, Martin JA, Baker JP, Streutker CJ, Marcon NE. Colonoscopic diagnosis of mucocele of the appendix. Gastrointest Endosc 2005;62:452–6. 10. Rojnoveanu G, Ghidirim G, Mishin I, Vozian M, Mishina A. Preoperatively diagnosed mucocele of the appendix. Chirurgia (Bucur) 2014;109:416–20. 11. Karakaya K, Barut F, Emre AU, Ucan HB, Cakmak GK, Irkorucu O, et al. Appendiceal mucocele: case reports and review of current literature. World J Gastroenterol 2008;14:2280–3. 12. Rappoport J, Steiner M, Moyano L, Amat J, Bezama J, Garrido R, et al. Mucocele appendicular. Rev Chilena Cir 2002;54:339–44. 13. Ertuğrul G, Toydemir T, Ertuğrul F. A rare cause of chronic abdominal pain: A case of appendiceal mucocele. J Ist Faculty Med 2013;76:1. 14. Laalim SA, Toughai I, Benjelloun el B, Majdoub KH, Mazaz K. Appendiceal intussusception to the cecum caused by mucocele of the appendix: Laparoscopic approach. Int J Surg Case Rep 2012;3:445–7. 15. Stocchi L, Wolff BG, Larson DR, Harrington JR. Surgical treatment of appendiceal mucocele. Arch Surg 2003;138:585–90. 16. Serrano Sánchez PA, Pérez-Bedmar JA, Larrañaga Barrera E. Appendicular mucocele. Review of the literature and presentation of 8 cases. [Article in Spanish] Rev Esp Enferm Apar Dig 1989;76:35–41. [Abstract] 17. Isaacs KL, Warshauer DM. Mucocele of the appendix: computed tomographic, endoscopic, and pathologic correlation. Am J Gastroenterol 1992;87:787–9. 18. Mishin I, Ghidirim G, Vozian M. Appendiceal mucinous cystadenocarcinoma with implantation metastasis to the incision scar and cutaneous fistula. J Gastrointest Cancer 2012;43:349–53. 19. Caspi B, Cassif E, Auslender R, Herman A, Hagay Z, Appelman Z. The onion skin sign: a specific sonographic marker of appendiceal mucocele. J Ultrasound Med 2004;23:117–23. 20. Lien WC, Huang SP, Chi CL, Liu KL, Lin MT, Lai TI, et al. Appendiceal outer diameter as an indicator for differentiating appendiceal mucocele from appendicitis. Am J Emerg Med 2006;24:801–5. 21. Zissin R, Gayer G, Kots E, Apter S, Peri M, Shapiro-Feinberg M. Imaging of mucocoele of the appendix with emphasis on the CT findings: a report of 10 cases. Clin Radiol 1999;54:826–32. 22. Madwed D, Mindelzun R, Jeffrey RB Jr. Mucocele of the appendix: imaging findings. AJR Am J Roentgenol 1992;159:69–72. 23. Chiou YY, Pitman MB, Hahn PF, Kim YH, Rhea JT, Mueller PR. Rare benign and malignant appendiceal lesions: spectrum of computed tomography findings with pathologic correlation. J Comput Assist Tomogr 2003;27:297–306. 24. Hamilton DL, Stormont JM. The volcano sign of appendiceal mucocele. Gastrointest Endosc 1989;35:453–6. 25. McFarlane ME, Plummer JM, Bonadie K. Mucinous cystadenoma of the appendix presenting with an elevated carcinoembryonic antigen (CEA): Report of two cases and review of the literature. Int J Surg Case Rep 2013;4:886–8. 26. Shimizu T, Shimizu M, Kawaguchi K, Yomura W, Ihara Y, Matsumoto T. Mucinous cystadenoma of the appendix with raised serum carcinoembryonic antigen concentration: clinical and pathological features. J Clin Pathol 1997;50:613–4. 27. Oshimo Y, Otsu N, Ota M, Imamura M, Kim S, Masanga T, et al. A case of appendiceal mucocele with elevated CEA level in the cystic fluid detected by colonoscopic examination. Gastroenterological Endoscopy 2000;42:41–5. 28. Stevens KJ, Dunn WK, Balfour T. Pseudomyxoma extraperitonei: a lethal complication of mucinous adenocarcinoma of the appendix. Am J

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Gastroenterol 1997;92:1920–2. 29. Demetrashvili Z, Chkhaidze M, Khutsishvili K, Topchishvili G, Javakhishvili T, Pipia I, et al. Mucocele of the appendix: case report and review of literature. Int Surg 2012;97:266–9. 30. Hasbahçeli M, Başak F, Kılıç A, Atak İ, Canbak T, Alimoğlu O. Is removal of mucocele of the appendix by laparoscopic appendectomy contraindicated? Report of a case. Journal of Disease of the Colon and Rectum 2012;22:34–7.

dix treated by different approaches. Ulus Cerrahi Derg 2014;30:97–9. 33. Rampone B, Roviello F, Marrelli D, Pinto E. Giant appendiceal mucocele: report of a case and brief review. World J Gastroenterol 2005;11:4761–3. 34. Singh MK, Kumar MK, Singh R. Laparoscopic appendectomy for mucocele of the appendix. J Nat Sci Biol Med 2014;5:204-6. 35. González Moreno S, Shmookler BM, Sugarbaker PH. Appendiceal mu-

31. Dhage-Ivatury S, Sugarbaker PH. Update on the surgical approach to mucocele of the appendix. J Am Coll Surg 2006;202:680–4.

cocele. Contraindication to laparoscopic appendectomy. Surg Endosc 1998;12:1177–9.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Appendiks mukoseli nedeni ile ameliyat edilen hastaların klinik ve patolojik analizi Dr. Hasan Abuoğlu,1 Dr. Mehmet Kamil Yıldız,1 Dr. Bülent Kaya,2 Dr. Mehmet Odabaşı1 1 2

Haydarpaşa Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

AMAÇ: Mukosel apendiksin mukus tarafından tıkanması sonrası genişlemesini tanımlar. Nadir bir bozukluktur. Çoğu zaman semptomsuz olmakla beraber apandisit kliniğine sebep olabilir. Tüm apendektomilerin %0.2–0.3 ve apandiks tümörlerinin %8–10’unda görülür. GEREÇ VE YÖNTEM: Yirmi altı hasta (14 kadın–12 erkek) apandiks mukoseli nedeni ile ameliyat edildi. On altı hasta klasik apandisit bulguları ile acil şartlarda ameliyat edildi. Acil ameliyat edilenlerin 14’üne apendektomi, ikisine sağ hemikolektomi uygulandı. Elektif hastaların altısına apendektomi dördüne sağ hemikolektomi uygulandı. BULGULAR: Hastaların yaşı 27–81 arasında idi. On altı hastaya açık, dört hastaya laparoskopik apendektomi uygulandı. Histopatolojik sonuçlara göre mukozal hiperplazi %23.1, müsinöz kistadenom %61.4 ve müsinöz kistadenokarsinom %15.5 oranında tespit edildi. TARTIŞMA: Uzun süre sağ alt kadran ağrısı ile görülen hastalarda apandiks mukoseli ayırıcı tanıda düşünülmelidir. Ameliyat öncesi radyolojik değerlendirme doğru cerrahi tedavi için gereklidir. Anahtar sözcükler: Apandiks tümörleri; apendektomi; mukosel. Ulus Travma Acil Cerrahi Derg 2017;23(3):230–234

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ORIG I N A L A R T IC L E

A comparison of the treatment results of open reduction internal fixation and intramedullary nailing in adult forearm diaphyseal fractures Ahmet Köse, M.D.,1 Ali Aydın, M.D.,2 Naci Ezirmik, M.D.,2 Ömer Selim Yıldırım, M.D.2 1

Department of Orthopedics, Erzurum Regional Training and Research Hospital, Erzurum-Turkey

2

Department of Orthopedics and Traumatology, Atatürk University Faculty of Medicine, Erzurum-Turkey

ABSTRACT BACKGROUND: We compared the union and functional results of intramedullary nailing and open reduction internal fixation treatment applied to adults with a forearm diaphysis fracture (fracture of the radius and/or ulna). METHODS: We retrospectively examined 90 patients with completed skeletal maturation who were surgically treated for a forearm diaphyseal fracture. Patients with a Monteggia Galeazzi and ipsilateral upper extremity fracture and those with an open epiphyseal line, Type 3 open fracture, pathological fracture, or brain trauma were excluded from the study. Open reduction and internal fixation (ORIF) was applied to 42 patients (plate group), and intramedullary nailing was performed in 48 patients (intramedullary nailing group). Both treatment groups were compared with respect to time to union, joint range of motion, operating time, grip strength, Grace-Eversman criteria, and complications. RESULTS: The mean operating time was 63.29 (range, 40–100) min in the plate group and 46.02 (range, 17–85) min in the intramedullary nailing group. The mean time to union was 13.19 (range, 10–20) and 10.85 (range, 8–20) weeks, respectively. While a statistically significant difference was determined between groups with respect to operating time and time to union, no difference was determined in the Grace-Eversman evaluation criteria, forearm supination, pronation degrees, and grip strength. CONCLUSION: The results of this study showed a significant difference in the intramedullary nailing treatment with respect to time to union, operating time, and amount of bleeding compared with the ORIF treatment. However, no difference was determined in the functional evaluation criteria. Thus, both treatment methods are acceptable in the treatment of forearm diaphyseal fractures in adults with skeletal maturation. Keywords: Forearm; internal fixation; intramedullary nail; open reduction.

INTRODUCTION Forearm supination and pronation movements are initiated from the proximal and distal radioulnar joints. Therefore, the radius and ulna have an important role in the movement of not only the forearm but also the whole upper extremity. Treatment of forearm fractures with insufficient or inapproAddress for correspondence: Ahmet Köse, M.D. Yukarı Köşk Mahallesi, Malazgirt Sok., Doğuş Apt:, A Blok, Kat: 5, Daire: 10, 25100 Erzurum, Turkey Tel: +90 442 - 232 59 98 E-mail: kose.ahmet.46@hotmail.com Ulus Travma Acil Cerrahi Derg 2017;23(3):235–244 doi: 10.5505/tjtes.2016.66267 Copyright 2017 TJTES

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priate implants restricts forearm rotation. Simultaneously, wrist and elbow joint movements are affected negatively. Due to functional and anatomic features, forearm diaphyseal fractures are different from diaphyseal fractures of other long bones and must be evaluated as intraarticular fractures, with treatment planned accordingly.[1,2] Conservative methods are not recommended for these fractures, which are relatively rare in adults.[3] The deforming effect of muscle strength, continuity of the radial incline, and intraosseous membrane damage are significant factors that affect the stabilization and maintenance of a reduction.[4] It is almost impossible to achieve sustainable and stable fixation with conservative treatment. The basic aim of treatment is to provide axial alignment and rotational stability. Open reduction and internal fixation (ORIF) is a widely used and accepted treatment method that is associated with high rates of union and satisfactory functional results. However, open application of the method has attracted some criticism. Problems such 235


Köse et al. Treatment of adult forearm diaphyseal fractures with intramedüller nail or plate

as cosmetic issues, drainage of the fracture hematoma, the risk of soft tissue and periosteal damage, and skin irritation of implants, particularly in ulnar fractures, have been reported. The criticized aspects of ORIF have made it controversial as a standard treatment method. Along with traditional treatments for forearm diaphyseal fractures, an ongoing search for an alternative treatment method is being conducted. Generally, nonspecific intramedullary (IM) implants have been used as an alternative treatment method. Because they do not have locking and compression features, these materials cause high rates of nonunion; therefore, their use has been abandoned. Current IM forearm nails have emerged with locking and compression features. The use of this method in treatment is increasing with union rates similar to those of ORIF and very good functional results.[5–8] In this study, we conducted a retrospective examination of adults who underwent ORIF and IM nailing for forearm di-

aphyseal fractures. We compared the two treatment methods with respect to union status, functional and radiological results, and patient satisfaction.

MATERIALS AND METHODS We conducted a retrospective evaluation of adults with complete skeletal maturation who underwent ORIF or IM nailing because of an isolated fracture of the ulna and/or radius. Approval for the study was granted by the Institutional Review Board. Written informed consent was obtained from all patients. A total of 130 patients treated between 2008 and 2014, with at least 1 year of follow-up, were contacted by telephone and invited to attend the hospital. Of 110 patients who accepted the invitation, 90 met the criteria for inclusion in the study, which was conducted at a single center. Two surgeons performed ORIF and two performed IM nailing.

Table 1. Patients’ medical information and demographic distribution Number of patients

Plate group

Intramedullary nail group

42

48

AO/OTA fracture type, n (%)

A1

6 (14.3)

8 (16.7)

A2

5 (11.9)

6 (12.5)

A3

4 (9.5)

4 (8.3)

B1

7 (16.7)

8 (16.7)

B2

5 (11.9)

4 (8.3)

B3

3 (7.1)

3 (6.25)

C1

6 (14.3)

9 (18.75)

C2

4 (9.5)

4 (8.3)

C3

2 (4.8)

2 (4.2)

Fractured forearm, n (%)

Right

19 (45.2)

28 (58.3)

Left

23 (54.8)

20 (41.7)

Closed fracture, n (%)

34 (81)

36 (75)

Type 1-2 open fracture, n (%)

8 (19)

12 (25)

Gender distribution, n (%)

Female

28 (66.7)

14 (33.3)

Male

37 (77.1)

11 (22.9)

Trauma etiology, n (%)

Traffic accident

15 (35.7)

26 (54.16)

Fall

10 (23.8)

9 (18.75)

Work injury

5 (11.9)

4 (8.33)

Sports injury

9 (21.4)

6 (12.50)

Assault

3 (7.1)

3 (6.25)

Average age Follow-up period, avg. (week)

38.02 (18–65)

36.6 (18–63)

70 (65–150)

55.49 (52–170)

AO/OTA: Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association Classification.

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Köse et al. Treatment of adult forearm diaphyseal fractures with intramedüller nail or plate

Patients with a Monteggia Galeazzi, an open epiphyseal line, Type 3 open fracture, pathological fracture, an insufficient follow-up period, or brain trauma were excluded from the study. Patients with a Type 1–2 open fracture were admitted for emergency surgery after sufficient irrigation had been applied. ORIF was performed in 42 patients (plate group) and IM nailing in 48 (IM nailing group). Fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen/ Orthopaedic Trauma Association Classification (AO/OTA)[9] system. In the plate group, 15 (35.7%) fractures were Type A, 15 (35.7%) were Type B, and 12 (28.6%) were Type C, as compared with 18 (37.5%), 15 (31.25%), and 15 (31.25%), respectively, in the IM nailing group (Table 1). The limited contact dynamic compression plate (LC-DCP) was used in plate osteosynthesis, and newly designed radius and ulnar screws were used in IM fixation. Union was evaluated radiologically as bridge callus formation or the absence of a fracture line and clinically as lack of pain on the fracture line. Nonunion was considered when no bridge callus formation was observed after 6 months of follow-up. Functional results and union evaluation were made according to the Grace-Eversman[10] criteria. Patient satisfaction was evaluated with the Disabilities of the Arm, Shoulder, and Hand (DASH)[11] questionnaire on the basis of physical activity in the previous week and satisfaction level. In patients with fracture of the radius and fractures of both bones, the maximum radial incline (MRI) and maximum radial incline localization (MRIL) were measured[3] (Fig. 1). Joint range of movement was evaluated goniometrically. With the elbow in 90° flexion, the forearm pronation and supination angles were measured. Grip strength was measured with a hydraulic hand dynamometer (SAEHAN Hydraulic Hand Dynamometer [SH5001], Gyeongnam, South Korea). With the patient in a sitting position, the shoulder neutral in abduction, the forearm and wrist neutral, and the elbow in 90° flexion, separate measurements were taken of the treated and healthy forearms. Patients’ preoperative demographic information and postoperative follow-up data were obtained from the hospital database. Data related to operating time, amount of blood loss, fluoroscopy time, and complications were obtained from the surgical records. Radiological data were evaluated using the radiographs taken at the 6-month follow-up examination. Union was evaluated on AP, lateral, and oblique radiographs. Callus formation in four cortices was evaluated as union. The Grace-Eversman criteria, joint range of motion (ROM) measurements, and grip strength measurements were obtained for all patients from the postoperative 6-month data. The DASH questionnaire was applied and scored at the final follow-up examination. Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

Surgical Technique All patients were treated within 1–5 days of presentation; mean 1.67 (range, 1–5) days in the plate group and 17.42 (range, 6–48) h in the IM nailing group. All patients received 1 g cefazolin intravenously at 30 min preoperatively. For the application of IM nailing, the patients were positioned in a supine position on a radiolucent operating table. A tourniquet was applied in the ORIF operations but not in the IM method. Operations on patients with a forearm double fracture were started from the ulna. Closed reduction was attempted under fluoroscopy on all fractures before starting the application of IM nailing. With the forearm in a neutral position, a 2-cm longitudinal skin incision was made from the most prominent point of the olecranon while the elbow was in 90° flexion. A 2-mm-thick K-wire was advanced IM from a point 6.5 mm proximal and 3 mm lateral to the most prominent point of the olecranon.[12] After drilling IM for 5 cm proximally with a cannulated drill over the K-wire, the prepared nail was advanced as far as the fracture line with partial rotation. In patients where fixation was obtained with closed reduction, the nail was advanced as far as the most distal point. In patients where closed reduction could not be achieved, fixation was obtained with partial open reduction from the fracture line. The forearm was positioned neutrally with distal and proximal locking. In fractures requiring static locking, double cortex distal locking was applied with a sufficient number of 3-mm cortical screws. Depending on the fracture stability status from the proximal, single cortex locking was performed, or compression was applied (Fig. 2a). For radial fractures, a 1–1.5-cm longitudinal skin incision was made at least 1 cm proximal to the distal joint space from the

Figure 1. Measurement of radial inclination and maximum radial inclination localization in subjects with radial fractures. (A) Radial inclination (mm), x/y × 100 = Maximum radial inclination localization (%). (a)

(b)

Figure 2. View of the ulna intramedullary nail compression applications up to 7 mm at the proximal of the ulna (a), view of the LC-DCP compression applications (b).

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Köse et al. Treatment of adult forearm diaphyseal fractures with intramedüller nail or plate

lateral aspect of the distal metaphysis (Lister tubercle lateral). The extensor carpi radialis longus and brevis (ECRB) tendons were located. The ECRB tendon sheath was opened longitudinally with a blunt dissection. The first entry into the second extensor compartment was made with an awl perpendicular to the radial metaphysis. The first entry area was widened by targeting the medullar cavity with a curved awl. A nail of specified appropriate length and diameter was advanced with a nail holder with partial rotational forces. When the tip of the nail reached the fracture line, we checked whether the

nail had been advanced intramedullarly using fluoroscopy. It was advanced until a final push achieved full contact of the nail with the distal radial metaphyseal cortex. Static distal locking was applied. Newly designed radius and locking ulna screws were used as IM fixation material (TST Rakor Tıbbi Aletler San. ve Tic. Ltd. Sti., Istanbul, Turkey). For the plate application, the volar Henry incision was used in distal and mid third radius fractures, and the Thompson approach was used for proximal third fractures. For ulnar

Table 2. Comparison of post treatment and surgery data of patients in the plate and IM nail groups Fluoroscopy period (minute), avg. (range)

Plate group 0

SD

p

IM nail group

SD

1.2 (0.2–5)

0.55

p

Surgery period (minute), avg. (range)

63.29 (40–100)

14.3

0.001

46.02 (17–85)

23.8

0.001

Union period (week), avg. (range)

13.19 (10–20)

2.65

0.01

10.85 (8–20)

2.66

0.01

AO/OTA Tip A1

13.00 (12–20)

8.00

0.17

10.16 (8–12)

2.00

0.05

AO/OTA Tip A2

14.2 (12–20)

10.00

0.21

9.3 (8–12)

4.00

0.10

AO/OTA Tip A3

14.25 (10–20)

6.00

0.13

11.25 (11–12)

3.00

0.07

AO/OTA Tip B1

13.14 (12–16)

8.00

0.17

11.75(8–20)

4.00

0.10

AO/OTA Tip B2

12.2 (10–14)

4.00

0.08

10 (8–12)

3.00

0.07

AO/OTA Tip B3

12.33 (11–16)

7.00

0.15

10.33 (8–11)

3.00

0.07

AO/OTA Tip C1

12.5 (11–14)

2.00

0.04

11.44 (8–20)

9.00

0.21

AO/OTA Tip C2

14.00 (10–20)

1.00

0.02

13.75 (10–20)

8.00

0.19

AO/OTA Tip C3

12.00 (11.13)

2.00

0.04

14.00 (12–16)

6.00

0.14

Post Follow up ROM (degree) (avg.) (range)

Supination

74.64 (65–80)

4.07

0.631

75.06 (65–80)

3.75

0.631

Pronation

84.55 (64–90)

4.27

0.645

84.92 (74–90)

4.15

0.645

9.81 (3.3–30)

6.72

0.63

12.87 (3.3–38.8)

8.65

0.63

DASH score, avg. (range) Grace-Eversman ratio (n,%)

Perfect

36 (85.7%)

40 (83.3%)

Good

4 (9.5%)

8 (16.7%)

Acceptable

1 (2.4%)

Not acceptable

1 (2.4%)

Grip strength (kgw), avg. (range)

60.02 (30–115)

22.5

0.731

55.21 (30-110)

17.2

0.731

Bleeding during surgery (ml), avg. (range)

84.04 (40–250)

59.3

0.000

37.91 (10–100)

30.2

0.000

Complication ratio

3 (7.1%)

2 (4.16%)

Elbow joint ROM (degree) (avg.) (range)

Flexion

Extension

142.36 (133–145)

3.6

0.519

142.63 (132–145)

3.5

0.519

0.67 (0-5)

1.5

0.683

0.75 (0–5)

1.55

0.683

Wrist joint ROM (degree) (avg.) (range)

Dorsiflexion

78.57 (75–80)

1.79

0.009

78.31 (74–80)

1.9

0.009

Volar flexion

75.07 (73–80)

0.83

0.514

74.46 (71–80)

1.8

0.514

Radiological Evaluation, avg. (range)

MRI

13.74 (12.5–16.67)

0.9

0.231

13.36 (10–14.9)

0.93

0.231

MRIL

57.29 (53–61.5)

2.38

0.138

58.04 (49–65.5)

3.61

0.138

IM: Intramedullary; SD: Standard deviation; AO/OTA: Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association Classification; ROM: Range of motion; DASH: Disabilities of the Arm, Shoulder and Hand; MRI: Maximum radial incline; MRIL: Maximum radial incline localization.

238

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Köse et al. Treatment of adult forearm diaphyseal fractures with intramedüller nail or plate (a)

(b)

(c)

(d)

(e)

(f)

Figure 3. AP and lateral radiographs (a, b) Type 22C1 fracture on the right radius and ulna diaphysis belonging to a 32-year-old male patient after in vehicle traffic accident. The patient’s second month (c, d) and 12th month (e, f) direct radiographs.

fractures, a transcutaneous incision was made.[1] The fracture line was reached with controlled surgical dissection and control of bleeding. Care was taken not to strip the periosteum excessively. The plate used as fixation material was a 3.5-mm LC-DCP. A plate of appropriate size was selected according to the fracture type and degree of fragmentation. We applied compression AO principles based on the fracture line (Fig. 2b). Fixation was made with a minimum of three screws holding at least six cortices distal and proximal to the fracture line. Following fixation and bleeding control, an aspirative drain was placed in the surgical area. The drain was removed on postoperative day 2. No graft was used in the primary surgery of any patient in either the plate or IM group. In patients who underwent IM nailing, early-stage ROM exercises were started without immobilization. In the plate group, ROM exercises were started following 2 weeks of splint immobilization.

Statistical Methods

There were 16 (38.1%) patients with a fracture of both bones, 14 (33.3%) with a radial fracture, and 12 (28.6%) with an ulnar fracture in the plate group, compared with 18 (37.5%), 15 (31.25%), and 15 (31.25%), respectively, in the IM nailing group. According to the Gustilo-Anderson[13] open fracture classification, 8 (19%) patients in the plate group and 12 (25%) patients in the IM group had Type 1–2 open fractures. The mean time to union was 13.19 (range, 10–20) weeks in the plate group and 10.85 (range, 8–20) weeks in the IM nailing group (Table 2). A statistically significant difference was determined between the two groups (p<0.05). Bone union was achieved at 100% in the IM nailing group and at 97.6% in the plate group (Fig. 3, 4). Mean operating time was 63.29 (range, 40–100) min in the plate group and 46.02 (range, (a)

(b)

In the data analyses, SPSS v.20 computer software was used. Data were stated as number, percentage, mean, and standard deviation. Conformity of the data to the normal distribution for the variables included in the analysis was analyzed with the Kolmogorov-Smirnov test. Spearman’s correlation analysis was used to evaluate the correlation between parameters. Nonparametric data on the plate and IM nailing groups were compared by means of the Mann-Whitney U-test. Parametric data were analyzed with the Student’s t-test. A value of p<0.05 was accepted as statistically significant.

RESULTS Fractures were in the right extremity in 19 (45.2%) patients and in the left in 23 (54.8%) in the plate group, compared with 28 (58.3%) and 20 (41.7%), respectively, in the IM nailing group. The etiology of the fractures was a traffic accident in 15 (35.7%) cases, a fall in 10 (23.8%), a sporting injury in 9 (21.4%), an industrial accident in 5 (11.9%), and impact in 3 (6.25%; Table 1). Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

Figure 4. AP and lateral radiographs (a) Type 22B3 fracture on the right radius and ulna diaphysis belonging to a 40-year-old male patient after a motor vehicle accident. The patient’s 12th month (b) direct radiographs.

239


240

2 (12.5) 2 (10) 3 (8.57) 3 (7.1) ROM: Range of motion; DASH: Disabilities of the Arm, Shoulder and Hand.

3 (13.6) Complication ratio (%)

1 (3.12)

1 (3.2)

13.9±2.9 13.74 (12.5–16.67)

57.29 (53–61.5) Not reported Not reported 61.1±7.6 Maximum radial inclination localization (%)

Not reported Not reported 14.8±2.5 Radial inclination (mm)

Radiological evaluations, avg. (range)

17–85) min in the IM nailing group. A statistically significant difference was determined between the groups (p<0.05). The mean DASH score was 9.81 (range, 3.3–38) in the plate group and 12.87 (range, 3.3–38.8) in the IM nailing group. According to the GraceEversman criteria, results were excellent in 36 (85.7%) patients, good in 4 (9.5%), and acceptable in 1 (2.4%) in the plate group and excellent in 40 (83.3%) and good in 8 (16.7%) patients in the IM nailing group (Tables 2, 3).

2 (4.16)

Not reported Not reported

58.04 (49–65.5)

Not reported Not reported

13.36 (10–14.9)

37.91 (10–100) Not reported

67.5±6.4

55.21 (30–110) Not reported

2

0 Not reported 84.04 (40–250) 60 Not reported Bleeding during surgery (ml), avg. (range)

Not reported

Not reported Not reported 60.02 (30–115) Not reported Not reported Not reported Grip strength (kgw), avg. (range)

2 1 (4)

1 (2.4)

1 (2.4) 1 4 (18.2)

Not Acceptable

1 (4.5) Acceptable

1

9 2 (10%)

8 (16.7%)

3 18 (90)

3 (12) 4 (9.5) 14 4 (18.2)

15 14 (63.6)

2 (9) Good

19 (86.3) Perfect

15 (4–30) Grace-Eversman ratio (%)

DASH score, avg. (range)

15±3

7.1 (0–19.2)

36 (85.7)

9.81 (3.3–30)

18±3

21 (84)

15.1 (0–29.6) 13 (3–25)

40 (83.3%)

12.87 (3.3–38.8)

73 (60–90)

84.92 (74–90)

75.06 (65–80) 76 (50–90)

Nearly full 157±6 84.55 (64–90)

74.64 (65–80)

Nearly full

79 (50–90)

Nearly full

159±5 Pronation

159±5 Supination

14 (10–20) 10±3 Post follow-up ROM (degree) (avg.) (range)

Union period (week), avg. (range)

85 (70–90)

11.1 (6–41)

13.19 (10–20)

14±5

157±6

Nearly full

10.85 (8–20) 13.1 (5–41) 10 (9–12)

1.2 (0.2–5) Not reported Not reported

46.02 (17–85) Not reported 61 (35–90)

7.0±3.0 0

63.29 (40–100)

Not reported 2.0±0.7 Fluoroscopy period (minute), avg. (range)

Not reported 65 (40–97) 74±8 Surgery period (minute), avg. (range)

Not reported

52±10

Kim et al. Özkaya et al Kim et al. Özkaya et al. Lee et al.

Plate osteosynthesis

Table 3. Comparison of plate and nail studies in the literature with our study

Our study

Lee et al.

Intramedullary nail

Our study

Köse et al. Treatment of adult forearm diaphyseal fractures with intramedüller nail or plate

No statistically significant difference was determined between groups with respect to DASH score and GraceEversman evaluation criteria (p>0.05). No difference was observed between groups with respect to the measurement of degree of supination and pronation and grip strength (p>0.05; Table 2). The mean MRI was 13.74 (range, 12.5–16.67) in the plate group and 13.36 (range, 10–14.49) in the IM nailing group, and the mean MRIL was 57.29 (range, 53–61.5) and 58.04 (range, 49–65.5), respectively. No statistically significant difference was determined between groups with respect to MRI and MRIL measurements (p>0.05). The mean amount of bleeding was 84.04 (range, 40–250) and 37.91 (range, 10– 100) ml, respectively. The difference between groups was statistically significant (p<0.05; Table 2). The two groups were not significantly different in terms of fracture type, open fracture, wrist ROM, duration of hospitalization, and time spent until the time of surgery. Fluoroscopy guidance was not used during plate application. The mean duration of fluoroscopy use during IM nailing application was 1.2 (range, 1.2–5) min. Changes were observed in operating time and fluoroscopy time together with the learning curve (Fig. 5). No iatrogenic bone, tendon, vascular, or nerve damage developed in any patient in either group during the operation. Postoperative superficial infection developed in two patients in the plate group, which recovered with antibiotic therapy. In one patient, nonunion was

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Köse et al. Treatment of adult forearm diaphyseal fractures with intramedüller nail or plate

40 35

Second

30 25 20 Fluoroscopy Time

15 10 5 0

1 4 7 10 13 16 19 22 25 2831 34 37 40 Patients

Figure 5. The learning curve and fluoroscopy time distribution based on patients.

observed in the postoperative month 8, so autogenous bone graft taken from the iliac wing was applied with plate osteosynthesis. In the IM nailing group, in one patient, superficial infection was treated successfully with antibiotic therapy. In one patient at 4 months postoperatively, rupture of the extensor pollicis longus (EPL) tendon developed as a result of wear from the nail tip. Tendon repair was applied using an autograft from the ipsilateral palmaris longus. At the final follow-up examination, the patient had no subjective complaints. No mechanical irritation, implant failure, synostosis, or compartment syndrome developed in any patient in either group. In four patients in each group, the implant was removed on patient request at mean 23 (range, 20–28) months. No refracture was observed in the follow-up period.

DISCUSSION The current treatment for adult forearm diaphyseal fractures is surgery. The traditional surgical method is ORIF.[14] Aspects of the method have been criticized, and there are complications. Therefore, it is not a standard treatment method.[8] The search for alternative methods to ORIF has been ongoing in the historical treatment process. Although IM implants have been attempted from time to time as an alternative treatment, due to poor results, this has not been used sufficiently. Intramedullary treatment was reported first in 1913[14] using nonspecific materials (first generation) such as the K-wire, rush pin, and Steinmann nail. Sufficient rotational stability could not be achieved with these materials. Intramedullary treatment used as a support caused high rates of nonunion. The first nail design to take the forearm anatomy into account (second generation) was by Sage in 1959.[15] The nail was designed with anatomic features than enabled it to maintain rotational stability. However, there were no locking or compression features. As fracture stability could not be achieved, additional fixation materials were required, and high rates of nonunion were seen; thus, IM implants did not find a place of sufficient use in treatment. Just as it is today, ORIF has always been an acceptable treatment method. However, Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

this has not prevented researchers from developing new IM implants, which have been designed with anatomic and biomechanical analyses of the forearm bones as references (third generation), and very good clinical and radiological results have been obtained. The possibility of stronger rotational stability is provided with the anatomic design of third generation nails and the locking and compression effects.[16–19] The basic aim of surgical treatment of forearm diaphyseal fractures is to provide stable axial and rotational fixation. To achieve excellent rotational results, the acceptable axial angulation must be <10°.[3] Even if radial bowing and the interosseous gap are fully restored, it has been reported that rotational functional results could be limited.[20] Anatomic reduction is obtained with open reduction, which results in optimal repair of axial alignment, radial incline, and the interosseous gap. Forearm IM treatment differs from nail application in other long bones, as there are no anatomical landmarks providing guidance for rotational alignment. In fluoroscopic imaging of rotational reduction, the continuity of the cortical distance in the distal and proximal areas of the fracture can be evaluated. There is little subcutaneous tissue support of the ulna. In IM treatment, axial and rotational alignment can be checked with palpation. However, in ORIF, it may be necessary to remove the implant because of mechanical irritation of the plate and screws. Greater soft tissue support in the radius makes correction of reduction and radial bowing more difficult.[21] There are two curvatures in the coronal and sagittal planes of the radius.[22] It is necessary to take these curvatures into account when preoperatively shaping the nails to appropriate IM anatomy. In the current study, the radius nails were parabola shaped. With a titanium elastic structure and the 3-point principle with parabolic shape, rotational stability was achieved. In addition, by conforming to the radial bowing, the optimal interosseous space was formed. Few studies have compared ORIF and IM nailing treatment results in forearm diaphyseal fractures. These studies have compared, in particular, union status, time to union, and functional evaluation criteria. Anatomic or close to anatomic reduction is obtained with ORIF. Axial and rotational rigid, stable fixation is obtained. However, drainage of the fracture hematoma has negative effects on union, and it has been reported that excessive soft tissue and periosteal stripping could cause union problems. It is known that, as a result of the super periosteal pressure of conventional plates, osseous feeding is impaired, which has a negative effect on union. However, this risk is reduced with the LC-DCP plate. The risk of refracture is increased due to cortical atrophy, which develops in the screw application areas. It is necessary to apply immobilization, regardless of the stability of the fixation. Cosmetic problems may also develop associated with the surgical approach. [5–8] Surgical intervention causes more bleeding. For the provision of open reduction, there is no fluoroscopy guidance 241


Köse et al. Treatment of adult forearm diaphyseal fractures with intramedüller nail or plate

and therefore no exposure to radiation. Despite the stated advantages and disadvantages of the method, union rates of 87%–98% are reported.[3,4,7,10,23–25,27] Time to union has been reported as between 7.4 and 33 weeks.[23–27] Functional evaluation results generally are at a satisfactory level. In the plate group of the current study, union was achieved at a rate of 97.6% at a mean of 13.19 (range, 10–20) weeks. Bleeding in the plate group was measured as mean 84.04 (range, 40–250) ml. The mean operating time was 63.29 (range, 40–100) min. In one patient with nonunion, grafting from the iliac wing and plate osteosynthesis was applied. Union was achieved 6 months after the second operation. Intramedullary nailing causes less soft tissue damage in the surgical application and provides cosmetic superiority. The amount of bleeding during surgery is lower. Intramedullary implants generally have the property of stress distribution, and stronger callus tissue is formed. An important cosmetic advantage is that the implant can be removed from the same incision. Length is protected in segment forearm fractures. However, exposure to radiation is a significant disadvantage in IM nailing applications, and the immobilization period is shorter. Nailing treatment is contraindicated in patients with an open epiphysis line when there is active infection and in those with IM diameter <3 mm. In IM applications, union rates of 94%–100% and time to union of 10 weeks to 4.4 months have been reported. [12,16,17,28] Good functional results have been reported similar to those of plate osteosynthesis. In the IM group of the current study, 100% union was obtained at a mean of 10.85 (range, 8–20) weeks. The amount of bleeding in the IM group was 37.91 (range, 10–100) ml. The mean operating time was 46.02 (range, 17–85) min. A statistically significant difference was determined between groups with respect to time to union, amount of bleeding, and operating time. No statistically significant difference was determined with respect to radiological and functional results (Grace-Eversman criteria, DASH score, grip strength, MRI and MRIL values, and functional joint range of movement; Table 3). The shorter time to union of the IM method compared with that of ORIF could have been due to not draining the fracture hematoma and early mobilization. As the IM method is less invasive, the amount of bleeding is reduced. The stage of controlled exposure in ORIF was thought to have prolonged the operating time. The areas of application of both treatment methods carry potential risks. In proximal radius diaphyseal fractures, the posterior interosseous nerve is at risk.[29] There is a risk of damage in open reduction during surgical exposure and in IM treatment during locking. Careful surgical exposure in open reduction can reduce the risk to a minimum. In radius nails with proximal locking, the risk can be reduced to a minimum with locking made in a neutral position with the screw 3 cm distal to the radius head.[17] Iatrogenic fracture may be caused by the use of a nail with a larger than normal diameter and rotational instability by the use of a small nail. In the 242

area of nail application in the radius, the EPL and superficial branch of the radial nerve are at risk.[30,31] In the current study, EPL tendon rupture developed in one patient at 4 months postoperatively as a result of friction from the nail tip. Tendon repair was made with palmaris longus autograft and at the final follow-up examination, the patient had no subjective complaints. The removal after union of the internal fixation material used is controversial. In open or fragmented fractures or those that have resulted from high-energy trauma, when there is insufficient compression or reduction in fragmented fractures and when there is another fracture in the same extremity, the rate of refracture has been reported to increase.[32,33] It has been reported that removal of the fixation material at 8 months postoperatively reduces the rate of refracture,[33] and refracture could be observed at 2–24 months after implant removal.[32] In the current study, implants were removed on patient request in 4 (9.5%) of the plate group and 4 (8.3%) of the IM group. No cases of refracture were observed during the follow-up period. There were some limitations to this study, the most important of which are that the number of patients was low, and the study was retrospective. A non-standardized follow-up period is a general deficiency of retrospective studies. Furthermore, it is difficult to obtain simultaneous data. With the exception of the DASH score, all data are the findings of the 6-month follow-up examination. We aimed to standardize the radiological data by using data obtained from the evaluations at the same time point for all patients. The distribution of heterogeneous fracture bone type (isolated fractures and both bone fractures were included) is a significant limitation. The selections of treatment method and evaluation methodology cause conflict in retrospective evaluations. The treatment choice is explained by the routine treatment protocols of the surgeons. The patient evaluation forms created were routine data, independent of personal interpretation. Future prospective studies conducted on a greater number of patients in multiple centers, comparing homogenous fracture types would be able to make a greater contribution to the literature.

Conclusion The current treatment method for adult forearm diaphyseal fractures is plate osteosynthesis. The results of the current study showed IM nailing treatment to be superior to ORIF with respect to operating time and time to union. However, no difference was determined between the two methods according to the functional evaluation criteria. Radiologically, plate osteosynthesis is superior in restoration of MRI and MRIL. However, a statistically significant relationship was not detected between supination and pronation with MRI and MRIL. Due to the shorter time to union, shorter operating time, and cosmetic advantages, IM nailing treatment can be Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Köse et al. Treatment of adult forearm diaphyseal fractures with intramedüller nail or plate

considered a good alternative method to ORIF in the treatment of adult forearm diaphyseal fractures. Conflict of interest: None declared.

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medullary canal of the radius and a report of fifty fractures of the radius treated with a prebent triangular nail. J Bone Joint Surg Am 1959;41A:1489–516. 16. Lee YH, Lee SK, Chung MS, Baek GH, Gong HS, Kim KH. Interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of the forearm in adults. J Bone Joint Surg Am 2008;90:1891–8. 17. Köse A, Aydın A, Ezirmik N, Topal M, Can CE, Yılar S. Intramedullary nailing of adult isolated diaphyseal radius fractures. Ulus Travma Acil Cerrahi Derg 2016;22:184–91. 18. Weckbach A, Blattert TR, Weisser Ch. Interlocking nailing of forearm fractures. Arch Orthop Trauma Surg 2006;126:309–15. 19. Köse A, Aydin A, Ezirmik N, Yildirim ÖS. Treatment of Ipsilateral Distal Humerus and Diaphyseal Ulna Fractures by Using an Olecranon Osteotomy and Intramedullary Nail. J Orthop Trauma 2016;30:251–5. 20. Tarr RR, Garfinkel AI, Sarmiento A. The effects of angular and rotational deformities of both bones of the forearm. An in vitro study. J Bone Joint Surg Am 1984;66:65–70. 21. Bot AG, Doornberg JN, Lindenhovius AL, Ring D, Goslings JC, van Dijk CN. Long-term outcomes of fractures of both bones of the forearm. J Bone Joint Surg Am 2011;93:527–32. 22. Bartoníček J, Naňka O, Tuček M. Internal fixation of radial shaft fractures: Anatomical and biomechanical principles. [Article in Czech] Rozhl Chir 2015;94:425–36. [Abstract] 23. Stevens CT, ten Duis HJ. Plate osteosynthesis of simple forearm fractures: LCP versus DC plates. Acta Orthop Belg 2008;74:180–3. 24. Stern PJ, Drury WJ. Complications of plate fixation of forearm fractures. Clin Orthop Relat Res 1983;175:25–9. 25. Leung F, Chow SP. A prospective, randomized trial comparing the limited contact dynamic compression plate with the point contact fixator for forearm fractures. J Bone Joint Surg Am 2003;85-A:2343–8. 26. Jones DB Jr, Kakar S. Adult diaphyseal forearm fractures: intramedullary nail versus plate fixation. J Hand Surg Am 2011;36:1216–9. 27. Droll KP, Perna P, Potter J, Harniman E, Schemitsch EH, McKee MD. Outcomes following plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am 2007;89:2619–24. 28. Köse A, Aydin A, Ezirmik N, Topal M, Can CE. Treatment of isolated ulnar fractures in adults with a new intramedullary nail. Minerva Ortopedica e Traumatologica 2015;66:123–31. 29. Tabor OB Jr, Bosse MJ, Sims SH, Kellam JF. Iatrogenic posterior interosseous nerve injury: is transosseous static locked nailing of the radius feasible? J Orthop Trauma 1995;9:427–9. 30. Fanuele J, Blazar P. Extensor pollicis longus tendon rupture in an adult after intramedullary nailing of a radius fracture: case report. J Hand Surg Am 2009;34:627–9. 31. Köse A, Aydın A, Köse M, Tipi T. Late rupture of extensor pollicis longus as a complication of treatment of forearm both bone fracture with the new intramedullary nail. Eur Orthop Traumatol 2015;6:273–6. 32. Deluca PA, Lindsey RW, Ruwe PA. Refracture of bones of the forearm after the removal of compression plates. J Bone Joint Surg Am 1988;70:1372–6. 33. Labosky DA, Cermak MB, Waggy CA. Forearm fracture plates: to remove or not to remove. J Hand Surg Am 1990;15:294–301.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yetişkin önkol diafiz kırıklarında açık redüksiyon internal fiksasyon ve intramedüller çivi tedavi sonuçlarının karşılaştırılması Dr. Ahmet Köse,1 Dr. Ali Aydın,2 Dr. Naci Ezirmik,2 Dr. Ömer Selim Yıldırım2 1 2

Erzurum Bölge Eğitim ve Araştırma Hastanesi, Ortopedi Kliniği, Erzurum Atatürk Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Erzurum

AMAÇ: Yetişkin önkol diafiz kırığı (radius, ulna veya her iki kemik kırığı) olan hastalarda uyguladığımız intramedüller çivi tedavisi ile açık redüksiyon internal fiksasyon tedavi yöntemlerini kaynama ve fonksiyonel sonuçlar açısından karşılaştırmayı amaçladık. GEREÇ VE YÖNTEM: Önkol diafiz kırığı nedeniyle cerrahi tedavi uyguladığımız, iskelet sistemi matürasyonu tamamlanmış 90 hastayı geriye dönük olarak inceledik. Monteggia, Galeazzi, ipsilateral üst ekstremite fraktürü olan hastalar, epifiz hattı açık hastalar, Tip 3 açık kırığı olan hastalar, patolojik kırığı olan hastalar ve beyin travması olan hastalar çalışmaya dahil edilmedi. Hastaların 42’sine açık redüksiyon internal fiksasyon (plak grubu), 48’ine intramedüller çivi tedavisi (İM çivi grubu) uygulandı. İki tedavi grubu; kaynama zamanı, eklem hareket açıklığı, ameliyat süresi, kavrama gücü, GraceEversman kriterleri ve komplikasyon sonuçlarına göre karşılaştırıldı. BULGULAR: Ameliyat süresi plak grubunda 63.29 (40–100) dakika, intramedüller çivi grubunda 46.02 (17–85) dakika idi. Plak grubunda ortalama kaynama süresi 13.19 (10–20) hafta, İM çivi grubunda ortalama 10.85 (8–20) hafta değerlendirildi. İstatistiksel olarak kaynama süresi ve ameliyat süreleri açısından her iki grup arasında anlamlı fark saptanırken Grace-Eversman değerlendirme kriterleri, önkol supinasyon, pronasyon dereceleri ve kavrama gücü açısından iki grup arasında fark saptanmadı. TARTIŞMA: İntramedüller çivi tedavisinde kaynama süresi, ameliyat süresi ve kanama miktarı açısından açık redüksiyon internal fiksasyon tedavisine göre anlamlı fark saptandı. Ancak fonksiyonel değerlendirme kriterlerine göre fark saptanmamıştır. Bu nedenle iskelet sistemi matürasyonu tamamlanmış önkol diafiz kırığı olan erişkin hastalarda her iki tedavi metodu kabul edilebilir yöntemlerdir. Anahtar sözcükler: Açık redüksiyon; internal fiksasyon; intramedüller çivi; önkol. Ulus Travma Acil Cerrahi Derg 2017;23(3):235–244

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doi: 10.5505/tjtes.2016.66267

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ORIG I N A L A R T IC L E

Predictive factors for early hospital readmission and 1-year mortality in elder patients following surgical treatment of a hip fracture Hakan Sofu, M.D.,1 Hanifi Üçpunar, M.D.,2 Yalkın Çamurcu, M.D.,3 Serda Duman, M.D.,4 Mehmet Nuri Konya, M.D.,5 Sarper Gürsu, M.D.,2 Vedat Şahin, M.D.1 1

Department of Orthopedics and Traumatology, Erzincan University Faculty of Medicine, Erzincan-Turkey

2

Department of Orthopedics and Traumatology, Baltalimani Bone and Joint Diseases Training and Research Hospital, İstanbul-Turkey

3

Department of Orthopedics and Traumatology, Devrek State Hospital, Zonguldak-Turkey

4

Department of Orthopedics and Traumatology, Diyarbakır Selahaddin Eyyübi State Hospital, Diyarbakır-Turkey

5

Department of Orthopedics and Traumatology, Afyon Kocatepe University Faculty of Medicine, Afyon-Turkey

ABSTRACT BACKGROUND: Early hospital readmission after surgically treated hip fracture is a common entity, often involving an adverse event and causing strains on an already overburdened healthcare system. The main purposes of the present study were to determine the 30-day readmission rate, analyze the predictive factors for early hospital readmissions, and assess 1-year mortality following surgical treatment of hip fracture in elderly patients. Retrospective case-control study. METHODS: In total, 517 patients with a mean age of 74 years were evaluated. The rate of early readmission, age, gender, body mass index, fracture type, pre-fracture mobility status, preoperative time to surgery, American Society of Anesthesiologists score, implant type, postoperative intensive care unit stay, total length of postoperative hospital stay, comorbidities, and the main reasons for readmission were the criteria for data collection. Multivariate analysis was performed to determine the main predictors of early hospital readmission. Mortality within the first year after surgery was also assessed. RESULTS: A higher prevalence of chronic obstructive pulmonary disease, cardiac arrhythmia or ischemic heart disease, diabetes, and dementia or Parkinson’s disease was detected in readmitted patients. Advanced age, American Society of Anesthesiologists (ASA) grade ≥3, postoperative intensive care unit (ICU) stay, and pre-existing cardiac arrhythmia or ischemic heart disease were identified as the main predictors. The 1-year mortality rate for the readmitted group was 53.9%, whereas it was 24% for those patients who were not readmitted. CONCLUSION: The readmission rate following surgical treatment of hip fracture in elder patients was 12%, and its main predictive factors were advanced age, ASA grade ≥3, postoperative ICU stay, and pre-existing cardiac arrhythmia or ischemic heart disease. Hospital readmission within the first 30-day period following initial discharge was significantly correlated with an increased 1-year mortality rate. Keywords: Elderly; hip fracture; mortality; readmission.

INTRODUCTION The elderly population is growing worldwide in parallel with Address for correspondence: Hakan Sofu, M.D. Erzincan Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Erzincan, Turkey Tel: +90 446 - 226 18 18 E-mail: hakansofu@yahoo.com Ulus Travma Acil Cerrahi Derg 2017;23(3):245–250 doi: 10.5505/tjtes.2016.84404 Copyright 2017 TJTES

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the rising life expectancy in recent decades. Hip fractures in this age group are among the most common acute pathologies in the clinical practice of orthopedic traumatology.[1] Approximately 90% of cases occur due to a simple fall from a standing position.[2] It has been estimated that the incidence of hip fracture will rise to more than 6 million by the year 2050.[3,4] The main purpose of surgical interventions in elderly patients with hip fracture is to return them to a preinjury level of daily living activities and social functioning.[5] However, an increased risk of developing perioperative and/or postoperative infective, cardiac, respiratory, genitourinary, and gastrointestinal complications causing significant rates of mortality and morbidity has been reported for such patients. [6] In-hospital mortality rates may rise to 10%.[7,8] Further245


Sofu et al. Predictive factors for early hospital readmission and 1-year mortality in elder patients following surgical treatment of a hip fracture

more, several studies have demonstrated that up to one third of these patients die within the first year postoperatively.[9,10] Active clinical problems at the time of discharge from hospital following surgical treatment of a hip fracture are also common.[11] The impact of comorbidities on the risk of readmission and death after hip fracture surgery has not been sufficiently discussed and is still controversial in the literature.[12] Readmission to hospital following a hip fracture often involves an adverse event. The main purposes of the present study were to determine the 30-day readmission rate, analyze the predictors of early hospital readmissions, and assess the 1-year mortality rate in relation to early postoperative readmission following surgical treatment of a hip fracture in elderly patients.

MATERIALS AND METHODS The present study retrospectively evaluated clinical data on 517 patients who underwent surgical treatment for a hip fracture between January 2010 and January 2014. Polytrauma patients, fractures associated with a primary or secondary tumor of the bone, patients who were already wheelchair bound or permanently bedridden before the fracture, those with incorrect or incomplete medical records in their hospital files, those who died preoperatively or without discharge postoperatively, and those who were lost to follow-up were excluded. The study group consisted of 354 females and 163 males with a mean age of 74 (range, 65–96) years at the time of surgery. The preoperative diagnosis was intracapsular femoral neck fracture in 290 (56%) and intertrochanteric or subtrochanteric fracture in 227 (44%) patients. Osteosynthesis was performed in 239 (46.2%) hips using either percutaneous cannulated screws (23 hips) or a proximal femoral nail (PFN) (216 hips). Hemiarthroplasty was performed in 201 hips, whereas total hip replacement (THR) was performed in 77. Routine clinical follow-up visits were conducted at 2 weeks, 1 month, 3 months, and 1 year postoperatively and annually thereafter. The rate of early readmission within 30 days after discharge, age, gender, body mass index (BMI), fracture type, pre-fracture mobility status, preoperative time to surgery, American Society of Anesthesiologists (ASA) score, implant type applied during surgery, postoperative intensive care unit (ICU) stay, total length of postoperative hospital stay, comorbidities, and the main reasons for readmission were the criteria for data collection. Mortality within the first year after discharge from hospital was also assessed. Pre-fracture mobility status was categorized as independent walker, walker with a single crutch or stick, and walker with two sticks or a frame. The number and reasons for early hospital readmission were identified. Comparative analyses between readmitted and non-readmitted patient groups were completed to establish the most common factors for early hospital readmission. 246

The procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation and with the Helsinki Declaration of 1975, revised in 2000. The current study was approved by the Ethical Research Institutional Review Board (Document number: 44495147-050.01.04-E.22337).

Statistical Analysis Categorical data are presented as frequencies with percentages and continuous data as means with standard deviations. Relation status between categorical variables was assessed using the chi-square test. The two-sample t-test and the Mann–Whitney U test were implemented to compare independent variables. Multivariate analysis was performed to determine the main predictors of early hospital readmission. The level of significance was set at α=0.05.

RESULTS In total, 63 patients (12.2 %) were readmitted to hospital within 30 days of discharge. The mean time to readmission was 11.7±6.7 (range, 1–25) days from initial discharge. The mean age of readmitted patients was significantly higher; however, there was no difference in the distribution by gender, BMI, or fracture type (Table 1). Over 50% of the readmitted patients could not walk unassisted prior to their hip fracture, whereas most of the non-readmitted patients could walk independently (p<0.05). The mean preoperative time from the first admission to surgery was 2.7±1.8 days. No significant effect of time from injury to surgery on readmission rate was observed. The American Society of Anesthesiologists (ASA) grade was ≥3 in 47 of the 63 readmitted patients, whereas it was ≥3 in 211 of the 454 patients from the non-readmitted group (p<0.05). The rate of early hospital readmission did not differ significantly between patients treated with ostesynthesis and hip replacement surgery using either a hemiarthroplasty or total hip arthroplasty design. Two-hundred nine patients (40.4%) required an ICU stay for a mean of 6.4±4.7 (range, 1–17) days. The proportion of patients who needed an ICU stay was higher in the readmitted group (p<0.05). However, the total length of hospital stay did not differ significantly between patient groups (p>0.05). The primary causes of readmission were surgical in nature for 20 patients (31.7%), and 43 (68.3%) were readmitted for medical or other reasons (Table 2). Patients were more than twice as likely to be readmitted because of medical versus surgical complications. Nine of the 63 readmitted patients (14.3%) died following readmission. A higher prevalence of chronic obstructive pulmonary disease (COPD), cardiac arrhythmia or ischemic heart disease, diabetes, and dementia or Parkinson’s disease were detected in readmitted patients (p<0.05) (Table 3). On the other hand, no significant difference was detected in the prevalence of hypertension, anemia, thyroid disease, or chronic renal failure between the two groups of patients. Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Sofu et al. Predictive factors for early hospital readmission and 1-year mortality in elder patients following surgical treatment of a hip fracture

Table 1. Comparison of demographic and clinical data of the readmitted and non-readmitted patient groups Variable

Readmitted group (n=63)

Non-readmitted group (n=454)

p

81.2±9.6

73±8.2

<0.001

Mean age (years), (Mean±SD) Gender, n (%)

Male

22 (34.9)

141 (31)

Female

41 (65.1)

313 (69)

Mean body mass index (kg/m2)

24.6 25.5

Fracture type, n (%)

Femoral neck

31 (49.2)

259 (57)

Intertrochanteric

24 (38.1)

141 (31)

Subtrochanteric

8 (12.7)

54 (11.9)

Pre-fracture mobility, n (%)

Independent

27 (42.8)

294 (64.7)

Single stick

21 (33.3)

136 (30)

Two sticks or frame

15 (23.8)

24 (5.3)

2.6±1.5

2.7±1.9

Mean time to surgery (days), (Mean±SD)

American Society of Anesthesiologists grade, n (%)

I

1 (1.6)

3 (0.6)

II

15 (23.8)

240 (52.8)

III

27 (42.8)

157 (34.6)

IV

20 (31.7)

54 (11.9)

<0.001

<0.001

Implant type

Cannulated screws

3 (4.8)

20 (4.4)

Proximal femoral nail

32 (50.8)

184 (40.5)

Hemiarthroplasty

23 (36.5)

178 (39.2)

Total hip replacement

5 (7.9)

72 (15.8)

38 (60.3)

171 (37.6)

7.8±4.5

5.7±4.4

15.5±5.4

14±5.3

Postoperative intensive care unit stay

Number of patients, n (%)

Mean duration (days), (Mean±SD)

Postoperative hospital stay (days), (Mean±SD)

<0.001

SD: Standard deviation.

Age, pre-fracture mobility status, ASA grade ≥3, ICU stay, COPD, cardiac arrhythmia or ischemic heart disease, diabetes, and dementia or Parkinson’s disease were identified as potential risk factors according to univariate analysis for early hospital readmission following surgical treatment of a hip fracture. These factors were included in multivariate analysis. Age, ASA grade ≥3, postoperative ICU stay, and pre-existing cardiac arrhythmia or ischemic heart disease were identified as the main predictors (Table 4). The overall 1-year mortality rate was 27.6% (143 patients) for the whole cohort of the present study. The 1-year mortality rate for patients who were readmitted within 30 days of initial discharge from the hospital was 53.9% (34 patients), whereas it was 24% (109 patients) for those who were not readmitted (p<0.001). There was a significant correlation beUlus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

tween early hospital readmission following surgery for a hip fracture and the risk of 1-year mortality (OR: 3.7; 95% CI: 2.1–6.3; p<0.001). The mortality rate was higher in patients with femoral neck fracture than in those with intertrochanteric or subtrochanteric fracture (p<0.05).

DISCUSSION Hip fracture has been reported among the most common causes of hospitalization in the geriatric age group.[13] Parallel to the increase in the elderly population, it has been estimated that the incidence of hip fracture will rise to more than 6 million by the year 2050.[3,4] Because these patients generally have multiple pre-existing medical problems, which may complicate their general health status as well as recovery after a surgical treatment, hospital readmissions can also be expected to rise. Identifying the major risk factors related 247


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to early readmission and establishing a patient-oriented clinical approach for postoperative management can help reduce unexpected hospitalizations, which in turn decrease the fi-

nancial burden on the national healthcare system. Several studies demonstrated that the rate of readmissions within the first month after discharge from the hospital varied from 4% to 34%.[14–16] The 30-day hospital readmission rate for our patients in the present study was 12.2%. This rate was conTable 2. Complications leading to readmission sistent with the literature.[17] However, because patients who Complication n % might have been admitted to different healthcare facilities were not included in the current analysis, the true readmisSurgical sion rate may have been underestimated. 6

9.5

Pain

4

6.3

4

6.3

Surgical site infection

Many different patient-, fracture-, or surgery-related factors have been associated with undesirable early hospital admissions following hip fracture surgery. According to different Hematoma 3 4.8 studies, age, time to surgery, male gender, BMI, functional Hardware failure 3 4.8 dependence status, ASA grade, ICU stay, and length of iniMedical tial hospitalization have been discussed in direct relation to Pneumonia 10 15.9 readmission rates by several authors.[5,17,18] Eschbach et al. Cardiovascular event 8 12.6 reported that patients of advanced age with hip-related frac Acute respiratory distress 7 11.1 tures showed neither a prolonged in-hospital nor ICU stay, and there was no significant relation between advanced age Urinary tract infection 7 11.1 and the number and type of complications.[19] In the current Irregular glucose levels 4 6.3 study, univariate analysis of these factors revealed that age, Constipation 3 4.8 pre-fracture mobility dependence, ASA grade ≥3, and ICU Cerebrovascular accident 2 3.2 stay were significant patient-related risk factors. However, Delirium 2 3.2 there was no significant difference in the distribution by gender, BMI, fracture type, time from injury to surgery, implant Dislocation of the hip prosthesis

Table 3. Comparison of comorbidities between readmitted and non-readmitted patients Comorbidity

Readmitted group Non-readmitted group (n=63) (n=454)

n % n %

p

Chronic obstructive pulmonary disease

17

27

72

15.9

0.028

Cardiac arrhythmia or ischemic heart disease

31

49.2

140

30.8

0.003

Hypertension

33 53.4 251 55.3 0.664

Diabetes

24 38 101 22.2 0.005

Chronic renal failure

5

7.9

40

8.8

0.817

Dementia or Parkinson’s disease

12

19

33

7.3

0.001

Pre-existing anemia

15 23.8 126 27.8 0.509

Thyroid disease

6 9.5 36 7.9 0.187

Table 4. Main predictors of early readmission according to multivariate analysis of the risk factors Variable

Multivariate analysis (logistic regression) Univariate p-value

Odds ratio (95% Confidence interval)

p

Age

<0.001

1.11 (1.07 to 1.14)

<0.001

American Society of Anesthesiologists grade III-IV

<0.001

2.85 (1.47 to 5.52)

0.001

Postoperative intensive care unit stay

<0.001

2.09 (1.12 to 3.88)

0.019

Pre-existing cardiac arrhythmia or ischemic heart disease

0.003

1.84 (1.00 to 3.40)

0.049

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type, or total length of the initial hospital stay according to our data. It has been reported that surgical causes accounted for a limited number of readmissions.[6] In their study, which aimed to identify causes and associated risk factors for admission, Buecking et al. also reported that the most frequent reasons were non-surgical, such as respiratory failure, cardiovascular diseases, and acute renal failure.[17] Surgery-related factors accounted for 31.7% of our patients who were readmitted within the first 30 days of hospital discharge. Surgical site infection was the most common etiology among the surgeryrelated factors; however, no deep infection requiring implant removal was detected. Although surgery-related causes seemed to be higher than in some other studies in the literature, none of the patients in our study group had a lifethreatening surgical complication or required an additional operation. According to Pollock et al., the most common complication precipitating readmission was non-surgical site infection.[5] Respiratory tract infections, particularly pneumonia, have been emphasized by different authors as the leading cause in the literature.[5,15,16,20] Pneumonia was also the most common reason in the current study, accounting for 15.9% of complications leading to readmission, followed by cardiovascular events, respiratory distress, and urinary tract infection. No significant correlation between a pre-existing history of chronic pulmonary disease and subsequent readmission due to pneumonia was detected. Clinical status and management of patients with hip fracture may be affected by many factors.[5] The burden of comorbidities has been demonstrated as significantly associated with a higher risk of readmission.[18] Active clinical problems at the time of discharge may also play a leading role as the potential source of complications and readmission.[11] Härstedt et al. mentioned that hypertension, cognitive disorders, and ischemic heart disease were the most common comorbidities in patients who underwent acute surgery for hip fracture.[12] Khan et al. reported a higher prevalence of each comorbidity in readmitted patients than in the non-readmitted group.[6] On the other hand, Golinvaux mentioned that diabetes confers little to no increased risk of postoperative complications after hip fracture surgery in geriatric patients.[21] Therefore, no consensus exists regarding which comorbidities can be considered as precipitating factors of postoperative adverse events nor to what degree each one contributes to early readmission. Pre-existing hypertension, cardiac arrhythmia or ischemic heart disease, anemia, and diabetes were the most common comorbidities in our study group. Multivariate analysis of the individual clinical features of our study group, which were found to have a significantly higher prevalence among readmitted patients, revealed that age, ASA grade ≥3, postoperative ICU stay, and pre-existing cardiac arrhythmia or ischemic heart disease were the main predictors of early hospital readmission following initial discharge from the hospital. Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

Overall 1-year mortality following surgical treatment for hip fracture in elder patients has been reported as high as 33%. [22] According to French et al., the 1-year mortality rate increased by up to 48.5% in patients treated surgically for a fracture of the hip and with a medical history of early hospital readmission within the first 30 days following initial discharge from the hospital.[15] Khan et al. also concluded that a more than two-fold increase in 1-year mortality was observed in patients readmitted within 28 days compared with those who were not.[6] In the current study, although the overall 1-year mortality rate was 27.6% for our patients, it was 53.9% for those who were readmitted, indicating a significant correlation between early hospital readmission and increased risk of 1-year mortality (OR: 3.7; 95% CI: 2.1–6.3; p<0.001). This finding was consistent with the previous literature. The major limitation of the current study was the retrospective evaluation of a prospectively followed patient group. On the other hand, our cohort was a large series. We did not apply a priori calculation of the sample size. However, post hoc analysis was performed, and the statistical power of our study in the aspect of making a comparison between the two groups according to early hospital readmission was 0.99 with an alpha value of 0.05. Moreover, we performed univariate and multivariate analyses of many different parameters to achieve a better understanding of the main predictive factors. In conclusion, according to our data acquired during the present study, the readmission rate following surgical treatment of hip fracture in elder patients was 12%, and its main predictors were advanced age, ASA grade ≥3, postoperative ICU stay, and pre-existing cardiac arrhythmia or ischemic heart disease. Hospital readmission within the first 30-day period following initial discharge was significantly correlated with an increased 1-year mortality rate. Conflict of interest: None declared.

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hospitalization after hip fracture: predictors and prognosis from a national veterans study. J Am Geriatr Soc 2008;56:705–10. 16. Boockvar KS, Halm EA, Litke A, Silberzweig SB, McLaughlin M, Penrod JD, et al. Hospital readmissions after hospital discharge for hip fracture: surgical and nonsurgical causes and effect on outcomes. J Am Geriatr Soc 2003;51:399–403. 17. Buecking B, Eschbach D, Koutras C, Kratz T, Balzer-Geldsetzer M, Dodel R, et al. Re-admission to Level 2 unit after hip-fracture surgery Risk factors, reasons and outcome. Injury 2013;44:1919–25. 18. Riggs RV, Roberts PS, Aronow H, Younan T. Joint replacement and hip fracture readmission rates: impact of discharge destination. PM R 2010;2:806–10. 19. Eschbach DA, Oberkircher L, Bliemel C, Mohr J, Ruchholtz S, Buecking B. Increased age is not associated with higher incidence of complications, longer stay in acute care hospital and in hospital mortality in geriatric hip fracture patients. Maturitas 2013;74:185–9. 20. Hahnel J, Burdekin H, Anand S. Re-admissions following hip fracture surgery. Ann R Coll Surg Engl 2009;91:591–5. 21. Golinvaux NS, Bohl DD, Basques BA, Baumgaertner MR, Grauer JN. Diabetes confers little to no increased risk of postoperative complications after hip fracture surgery in geriatric patients. Clin Orthop Relat Res 2015;473:1043–51. 22. Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005;331:1374.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Cerrahi olarak tedavi edilmiş ileri yaş kalça kırığı hastalarında taburculuk sonrası erken dönem hastane başvurusu ve bir yıllık mortalitenin belirleyici faktörleri Dr. Hakan Sofu,1 Dr. Hanifi Üçpunar,2 Dr. Yalkın Çamurcu,3 Dr. Serda Duman,4 Dr. Mehmet Nuri Konya,5 Dr. Sarper Gürsu,2 Dr. Vedat Şahin1 Erzincan Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Erzincan Baltalimanı Kemik Hastalıkları Eğitim ve Araştırma Hastanesi, Ortopedi ve Travmatoloji Kliniği, Istanbul Devrek Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Zonguldak 4 Diyarbakır Selahaddin Eyyübi Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Diyarbakır 5 Afyon Kocatepe Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, Afyon 1 2 3

AMAÇ: Cerrahi olarak tedavi edilmiş kalça kırığını takiben taburculuk sonrası erken dönem hastane başvuruları genellikle altta yatan önemli bir etiyolojik faktöre bağlıdır ve sağlık sisteminin yükünü artırır. Bu geriye dönük çalışmanın amaçları cerrahi olarak tedavi edilmiş kalça kırığı hastalarında taburculuk sonrası erken dönem hastane başvuru oranlarını, bu duruma yol açan sebepleri ve hastaların ameliyat sonrası birinci yıl sonunda mortalite oranlarının belirlenmesidir. GEREÇ VE YÖNTEM: Ortalama yaşı 74 olan toplam 517 hasta çalışmaya dahil edildi. Taburculuk sonrası erken hastane başvurusu, yaş, cinsiyet, vücut kitle endeksi, kırık tipi, kırık öncesi mobilizasyon seviyesi, ameliyata kadar geçen süre, American Society of Anesthesiologists (ASA) skoru, implant tipi, ameliyat sonrası yoğun bakımda kalış, toplam hastanede yatış süresi, komorbid hastalıklar ve hastane başvuru sebepleri veri toplama kriterleri olarak belirlendi. Çok değişkenli analiz ile majör belirleyici faktörler değerlendirildi. BULGULAR: Taburculuk sonrası erken dönem hastane başvurusu olan hastalarda kronik obstrüktif akciğer hastalığı, kardiyak aritmi veya iskemik kalp hastalığı, diyabet, demans veya Alzheimer hastalığı prevalansı daha yüksek bulundu. Çok değişkenli analize göre hastane başvurularının ana belirleyicileri ileri yaş, 3 veya üzeri ASA skoru, ameliyat sonrası yoğun bakımda kalma, kardiyak aritmi veya iskemik kalp hastalığı olarak belirlendi. Ameliyat sonunda ilk yıl içinde ölüm oranı taburculuk sonrası hastane başvurusu olan hasta grubunda anlamlı olarak yüksek bulundu. TARTIŞMA: Cerrahi olarak tedavi edilmiş kalça kırığı hastalarında taburculuk sonrası erken dönem hastane başvurusu oranı %12 olarak tespit edilmiştir. Bu durumun ana belirleyicileri ileri yaş, yüksek ASA skoru, ameliyat sonrası yoğun bakım yatışı ve kardiyak aritmi ya da iskemik kalp hastalığı varlığıdır. Anahtar sözcükler: Hastane başvurusu; kalça kırığı, mortalite; yaşlı hasta. Ulus Travma Acil Cerrahi Derg 2017;23(3):245–250

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doi: 10.5505/tjtes.2016.84404

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ORIG I N A L A R T IC L E

Retromandibular transparotid approach for subcondylar mandibular fractures: A retrospective study Gökhan Göçmen, DDS, PhD, Altan Varol, DDS, PhD, Onur Atalı, DDS, PhD, Sertaç Aktop, DDS, PhD, Selçuk Basa, DDS, PhD Department of Oral and Maxillofacial Surgery, Marmara University Faculty of Dentistry, İstanbul-Turkey

ABSTRACT BACKGROUND: The aim was to evaluate the effectiveness and complications of retromandibular transparotid approach performed for the reduction of dislocated subcondylar fractures. METHODS: Fourteen patients with subcondylar mandibular fractures were evaluated (8 male, 6 female, age range 19–43 years). The primary predictor variable in the present study was time (preoperative vs postoperative). The primary outcome variables were inflammatory complication, facial nerve deficit (House and Brackmann classification), and presence of parotid fistula. The secondary outcome variables were occlusal disturbances, maximal interincisal opening (MIO), and temporomandibular joint (TMJ) pain (VAS). RESULTS: Excellent occlusion and function was observed postoperatively. One salivary fistula occurred after surgery but was healed after 3 weeks. No inflammatory complication was observed. Three patients had grade III and one patient had grade II facial nerve deficit, all recovered in 6 weeks. All patients were free of pain and no malocclusion was observed. MIO was ranging from 34 to 58 mm (mean 44.4 mm) after 6 months. CONCLUSION: The retromandibular transparotid approach is feasible and safe. It facilitates reduction and fixation of subcondylar fractures with functional outcomes and rare complications. Keywords: Internal fixation; open reduction; retromandibular; subcondylar; transparotid.

INTRODUCTION Management of subcondylar fractures is a controversial topic in maxillofacial traumatology as similar functional results have been reported with non-surgical (conservative) and open reduction and internal fixation (ORIF).[1] However, follow-up studies have confirmed better functional outcomes with proper occlusion, temporomandibular joint function/ mobility, and faster return to preoperative status when ORIF was used.[2] Preauricular, submandibular, face-lift, bicoronal, retromandibular, and endoscopic assisted intraoral approaches can be used alone or with combination to expose the subcondylar Address for correspondence: Gökhan Göçmen, M.D. Marmara Üniversitesi Diş Hekimliği Fakültesi, Ağız Diş ve Çene Cerrahisi Anabilim Dalı, İstanbul, Turkey Tel: +90 216 - 421 16 21 E-mail: gocmengokhan@hotmail.com Ulus Travma Acil Cerrahi Derg 2017;23(3):251–257 doi: 10.5505/tjtes.2016.43669 Copyright 2017 TJTES

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region.[1,3–5] However, each approach has its own limits to expose directly the region of a subcondylar fracture. The only approach that allows direct access and ease of manipulation of bony stumps in such fracture pattern is the retromandibular or transparotid approach. The aim of this study was to perform retrospective evaluation of subcondylar fractures treated between 2012–2015 years using transparotid approach.

MATERIALS AND METHODS Study Design and Sample This retrospective cohort study enrolled 14 patients (8 male, 6 female). Ethics committee approval was obtained from the appropriate institution (Approval No: 154/6122011). The study sample was derived from the population of patients who received ORIF for mandibular subcondylar fractures between 2012 and 2015. The mean patient age was 26 (range 19–43) years. Inclusion criteria was severely dislocated or displaced collum fractures requiring surgical reduction. Exclusion criteria were Type VI or I fractures according to Spiessl and Schroll Classification,[6] and using additional surgical access other than the transparotid approach. 251


Göçmen et al. Retromandibular transparotid approach for subcondylar mandibular fractures

Study Variables The primary predictor variable in the present study was time (preoperative vs postoperative). The primary outcome variables were inflammatory complication, facial nerve deficit (I- VI House-Brackmann classification),[7] presence of parotid fistula. The secondary outcome variables were occlusal disturbances, maximal interincisal opening (MIO), and TMJ pain (Visual Analog Scale (VAS) from no pain =0 to worst pain imaginable =10).

Patient Selection and Treatment The etiology was fall, traffic accidents, interpersonal violence, and gunshot injury. Twelve patients had unilateral subcondylar fractures, two patients had bilateral subcondylar fractures and five patients had medially dislocated fracture pattern, and 5 patients had lateral overriding dislocated subcondylar fractures (Table 1). Five patients had accompanying parasymphisial/ symphisial mandibular fractures. The unilateral fracture pattern had pathognomic skeletal deformity characterized by malocclusion with significant chin deviation to fractured site and non-occlusion on contralateral site. The bilateral subcondylar fracture presented with anterior open-bite, malocclusion and absence of mandibular protrusion. Additionally, clockwise rotation of the distal segment and shortening of the posterior facial height occurred in bilateral cases. All patients were operated using the transparotid retromandibular approach under general anesthesia. Arch bars or intermaxillary fixation (IMF) screws were placed. IMF was achieved using orthodontic elastics with 5/16 size during pro-

cedure and removed following rigid fixation. The parasymphisial fractures were reduced first using 2 straight adaptation miniplates (2.0 mm profile system, Trimed, Elektron Medikal, Turkey) or KLS Martin (2.0 mm CMF Trauma Module) cranio maxillofacial fracture (CMF) system. Local hemostasis during dissection was achieved by subcutaneous injection of 2 ml epinephrine diluted in 1000 cc saline. Local anesthetic was avoided to facilitate facial nerve monitoring during transparotid dissection. A skin incision starting from 5 mm under the ear lobe was extended down to the retro-angular skin (Fig. 1) until the parotid capsule was reached. The capsule was incised and blunt dissection was continued with a hemostatic clamp until the posterior border of ramus was reached. Nerve stimulator was used to identify any branches of the facial nerve running in the dissection field. None of the patients required ligation of the retromandibular vein. The Senn-Miller retractors were used to pull the skin flap from both caudal and cranial flap poles and the pterygomasseteric sling was incised sharply with no: 15 blade. The periosteum was reflected and fractures site was exposed. The ramus was retracted inferiorly to create a room for reduction of dislocated fragment with the help of a bone reduction forceps. In few cases, this traction was done using a stainless steel wire introduced with a Reverdin’s needle from the submandibular region. The wire was anchored to a head of 2.0 mm profile titanium screw (mostly 12 mm in length) that was placed perpendicularly to the ramus through the retromandibular approach and caudal distraction of the distal segment was done until reduction of the fractures was completed. Two 2.0 mm profile adaptation miniplates were placed at the

Table 1. Description of the mandibular condylar neck fractures in 14 patients Patient Gender Age Spiessl Etiology Dislocation pattern classification

Accompanying fractures

Pre-op MIO

F.A.

Female

19

Cl2

Fall

Right, lateral over-ride

No

23

H.S

Male

23

Cl2

Personal violence

Left, lateral, over-ride

No

23

A.A.

Male

38

Cl4

Fall

Right, anteromedial

No

25

A.K.

Female

19

Cl4

Fall

Left, medial

No

22

S.S.

Male

19

Cl2

Personal violence

Right, lateral over-ride

Unilateral parasymphis

20

S.K.

Male

23

Cl2

Traffic accident

Left, lateral override

No

28

E.T.

Female

43

Cl2

Personal violence

Left, lateral, over-ride

Contralateral parasymphis

20

E.Ç

Male

18

Cl4

Traffic accident

Bilateral, medial

Left parasymphis

25

S.K.V

Female

38

Cl4

Traffic accident

Right, lateral

No

28

E.M.C.

Male

23

Cl2

Traffic accident

Left, medial

No

30

E.L.

Male

15

CL2

Gun shot

Nondislocated

Maxillary fracture

24

G.K.

Female

34

Cl4

Fall

Bilateral medial

Symphisial

18

M.K.

Female

25

cl 4

Personal violence

Medial

No

29

Lateral

No

21

K.I.

252

Male 27

Cl3

Fall

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Göçmen et al. Retromandibular transparotid approach for subcondylar mandibular fractures

(a)

(b)

(d)

(c)

(e)

(g)

(f)

(h)

(i)

(j)

(k)

Figure 1. (a) Pre-op 3D CT view. (b) Note medially dislocated bilateral subcondylar fragment and left parasymphis fracture. (c) Shortening of the ramus height can be observed in panaromic X-Ray. (d) Extraoral view of anterior open bite. (e, f) Right and left intraoral view of open bite due to posterior premature dental contact. (g, h) Post-op coronal CT showing miniplates in position. (i) Post-op 6 months panaromic X-Ray. (j, k) Mouth opening and complete inter-occlusal relationship 1 month after surgery.

anterior plate was placed parallel to mandibular notch and the posterior plate was placed parallel to border of the subcondylar region (Fig. 1). In lateral over-riding fracture patterns (Fig. 2), one miniplate was placed and an additional plate was

posterior and anterior region of the subcondylar fracture. The plates were placed divergent caudally to resist and overcome the pull of lateral pterygoid muscle in medially dislocated fractures owing to unfavorable fracture pattern. The

(a)

(b)

(c)

(d)

Figure 2. (a) Pre-op 3D CT view of lateral over-riding fracture of left condylar head. (b) Intra-op view of one miniplate placed parallel to border of the subcondylar region. (c) Post-op 3D CT showing miniplate in position. (d) Post-op 6 months’ skull PA X-review.

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Göçmen et al. Retromandibular transparotid approach for subcondylar mandibular fractures

(a)

(b)

(d)

(e)

(c)

Figure 3. (a, b) Pre-op 3D CT showing right over-riding subcondylar fragment and left parasymphis fracture. (c) Intra-op view of fixation with two 2.0 miniplates, were placed at the posterior and anterior region of the subcondylar fracture. Secondary plate was used to provide minimal mobility of condylar stump. (d) 2 straight adaptation miniplates were placed for anatomic reduction of parasymphis fracture. (e) post-op 6 months panaromic X-Ray.

used to provide rigid ORIF when minimal mobility of condylar stump was observed (Fig. 3, 4). Condylar function and centric occlusion were double checked to ensure anatomic reduction after removing IMF before wound closure.

age ranging between 19–43 years. The fractures were assessed as low-neck type (n=13) (92.86%) and high neck type (n=1) (7.14%) of the condyle/subcondylar unit. There was no patient drop out.

The wound was closed in layers after copious saline irrigation. We confirmed that watertight closure of the parotid capsule was achieved to avoid any salivary fistula. The skin was closed with 6-0 nylon sutures. Regime type I diet was recommended for postoperative period of 3 weeks. None of the patients were maintained under IMF following procedure. Antibiotic and non-steroidal anti-inflammatory drugs were prescribed for 5 days. The patients were encouraged to undergo physical therapy after a week.

Six patients (42.85%) had fracture dislocations with the condylar head out of the glenoid fossa (Spiessl & Schroll Class IV) and 8 patients (57.15%) had displaced fractures (Spiessl & Schroll Class II). Isolated fractures of the mandibular condyle were seen in 9 patients; the other 5 had additional fractures of the mandible symphisial, and 1 had maxillary fracture. The mechanisms of injury were fall in 5 patients, personal violence in 4 patients, traffic accidents in 4 patients, and 1 gunshot injury (Table 1).

Surgical field was checked for signs of infection (increased pain, swelling, redness, drainage of pus from the area, and fever). Occlusal disturbance was controlled observing maxillomandibular relationship in centric relation of TMJ. The pain at TMJ was evaluated using VAS and MIO for 6 months after surgery.

Salivary fistula occurred in one patient immediately after surgery which was closed spontaneously after applying pressure with dressing for 4 weeks. Three patients had Grade III facial nerve paralyzes according to House & Brackman classification. The facial nerve paralyses resolved completely within 3 weeks in 2 patients and the other one after 6 weeks, 1 patient had nerve weakness in Grade II that recovered in 4 weeks.

RESULTS There were 8 male (57.2%), 6 female (42.8%) patients with 254

In all patients, pre-injury occlusion and mouth opening was Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Göçmen et al. Retromandibular transparotid approach for subcondylar mandibular fractures

(a)

(b)

(c)

Figure 4. (a) Pre-op 3D CT view of lateral over-riding fracture of left condylar fragment and right parasymphis fracture. (b) Intra-op view of two miniplates placed after the ramus was distracted inferiorly with a stainless steel wire. (c) Post-op 6 months panaromic X-Ray.

achieved. This was assessed by clinical examination of the interdental relationship during TMJ in centric relation as well as subjectively by the patients. MIO was 34–58 mm (mean 44.4 mm). All operated 16 joints were pain free after 6 months. There were 4 cases (29%) with facial nerve injury, affecting the buccal or marginal mandibular branches or both (Grade II or III / House & Brackmann classification). Facial nerve injuries in those cases resolved spontaneously and completely after 3–6 weeks. No plate fractures were observed in our cases serial. Postoperative salivary fistulae developed in 1 patient (7%), and lasted for 4 weeks. No incident of greater auricular nerve anesthesia/ paresthesia, postoperative hematoma and wound infection was observed (Table 2).

DISCUSSION The treatment approach to the mandibular condyle fractures is one of the most widely debated subject in maxillofacial traumatology.[8] Conservative treatment may lead to malocclusion, anterior open-bite, facial asymmetry, internal derangement, chronic joint pain, and reduced mobility.[9] The miniplate osteosynthesis of the subcondylar process using Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

an extraoral approach is currently the most popular method followed by the miniplate osteosynthesis using a transoral approach.[10] The purpose of this study was to conduct retrospective evaluation of subcondylar fractures treated using retromandibular transparotid approach. Although ORIF provides better function and anatomical reduction, possible risk of injuring to the facial nerve is the major complication that discourages many surgeons to perform ORIF with any transcutaneous open approach.[3] The traditional retromandibular approach may lead to facial nerve injury in 30% cases.[11,12] Preauricular and submandibular approaches are other options that might be used for open reduction, as they facilitate better exposure of the operating field from caudal and cranial side, and simplify fracture repositioning compared to the cosmetically more favorable transoral approach or its endoscopically assisted modifications.[2,4] However, a more forceful retraction of the soft tissues might be necessary because of the longer working distance, implying a higher risk of facial nerve disturbances.[13] Additionally, temporal, and zygomatic branches of the facial nerve might be 255


Göçmen et al. Retromandibular transparotid approach for subcondylar mandibular fractures

Table 2. Postoperative assessment of outcome variables Patient

House–Brackman Grading System

Parotid fistula

Surgical site Malocclusion infection

Maximal interincisal opening

Temporomandibular joint pain

F.A.

I

No No

No

44

0

H.S

I

No No

No

48

0

A.A.

I

No No

No

50

1

A.K.

I

No No

No

34

1

S.S.

I

Yes No

No

47

0

S.K.

I

No No

No

41

0

E.T.

I

No No

No

38

1

E.Ç

III

No

No

No

44

0

S.K.V

III

No

No

No

40

0

E.M.C.

I

No No

No

58

1

E.L.

II

No No

No

42

0

G.K.

I

No No

No

46

1

M.K.

III

No

No

52

0

K.I.

I

No No

No

38

0

No

vulnerable with rhytidectomy and preauricular approaches.[14] In our study, the occurrence of nerve involvement was low, which might be related to the use of nerve stimulator, short distance of soft tissue dissection, and careful blunt transparotid dissection. Localization and fracture pattern, age, visualization and the ability to reduce fracture stumps, and postoperative complications (occlusal disturbances, fixation failures, infection, or parotid fistula etc.) are mostly discussed topics to determine the most appropriate approach to the condylar fracture. The position of a preauricular approach is too high for subcondylar fractures. Extra difficulty may be encountered in case of low-level subcondylar fracture with this approach, which may necessitate the use of a transbuccal trocar to insert caudal screws.[15] The submandibular approach is mostly preferred for mandibular body and mandibular angle fractures.[16] Intraoral approach prevents cutaneous scars and there is relatively no risk of injuring the facial nerve; but the intraoral endoscopic approach is generally preferred for lateral overriding fractures since reduction of medially dislocated subcondylar fractures is hardly accomplished with the endoscopic technique.[5] Compared with the above-mentioned approaches, the retromandibular approach is advantageous since it provides the shortest distance from the skin to the fracture and allows wide access to the posterior border of the mandible and sigmoid notch. Furthermore, it provides easier manipulation of muscle traction forces, reduction of medially dislocated fracture segments, and correct placement both of the mini256

plates.[2,17] Therefore, this approach might facilitate successful and more stable miniplate osteosynthesis and thereby clinical and functional outcomes of the surgery. For this reason, we evaluated MIO and occlusal disturbances by the means of functional rehabilitation of the temporomandibular joint as the secondary outcomes variables. This approach was first described by Hinds and Girotti and modified by Koberg and Momma.[18,19] Modifications like transparotid,[1] transmasseteric anteroparotid,[20] and high cervical transmasseteric anteroparotid[21] were also described. Earlier low popularity of the transparotid approach may be related to the possible injury of facial nerve occurring mostly during paranchymal parotid dissection and anticipated establishment of salivary fistula.[22] Ellis[11] and Vesnaver[23] reported parotid salivary fistula in 2.3% and 14% of cases, respectively, which was not reported by Bindra.[24] In our study, although we performed a watertight closure of the parotid gland capsule, one patient developed a salivary fistula after removal of drain. The possible reason for this could be the problem with the suturing of the parotid capsule. Therefore, the meticulous and exact closure of the capsule may be considered as the most important measure in the prevention of salivary fistulas.[13] In conclusion, transparotid approach presents shortest and direct access for reduction of subcondylar mandibular fractures. The incidence of facial nerve injuries with this approach is relatively low which should not prevent surgeons to perform anatomical reduction with transparotid retromandibular access. Conflict of interest: None declared. Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Göçmen et al. Retromandibular transparotid approach for subcondylar mandibular fractures

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Subkondiler mandibula kırıklarına retromandibular transparotid yaklaşım: Geriye dönük bir çalışma Dr. Gökhan Göçmen, Dr. Altan Varol, Dr. Onur Atalı, Dr. Sertaç Aktop, Dr. Selçuk Basa Marmara Üniversitesi Diş Hekimliği Fakültesi, Ağız Diş ve Çene Cerrahisi Anabilim Dalı, İstanbul

AMAÇ: Bu çalışmanın amacı dislokasyon olmuş subkondiler kırıkların redüksiyonunda uygulanan retromandibular transparotid yaklaşımın etkinliğinin ve komplikasyonlarının değerlendirilmesidir. GEREÇ VE YÖNTEM: Subkondiler mandibular kırık görülen 14 hasta değerlendirildi (8 erkek, 6 kadın, yaş aralığı: 21–56). Bu çalışmada ameliyat öncesi ve sonrasında elde edilen sonuçlar karşılaştırıldı. Birincil olarak değerlendirilen sonuçlar iltihabi komplikasyon gelişimi, fasiyal sinir hasarı (House ve Brackmann sınıflandırmasına göre) ve parotis fistül oluşumu idi. İkincil olarak değerlendirilen sonuçlar oklüzyon bozuklukları, maksimum ağız açıklığı ve temporomandibular eklemde görülen ağrıydı. (Görsel Analog Skalası’na göre). BULGULAR: Ameliyat sonrası dönemde hatasız bir oklüzyon ve fonksiyon gözlemlendi. Bir hastada parotis fistül oluştu fakat üç hafta içerisinde kapandı. Hiçbir hastada iltihabi komplikasyon gelişmedi. Üç hastada 3. seviye, bir hastada 2. seviye fasiyal sinir hasarı gelişti, fakat bütün fasiyal sinir hasarlarının altı hafta içerisinde iyileşti. Hiçbir hasta da ağrı veya oklüzyon bozukluğu olmadı. Altı ay sonraki maksimum ağız açıklığı 34–58 mm (ortalama 44.4 mm) olarak ölçüldü. TARTIŞMA: Retromandibular transparotid yaklaşım kullanışlı ve güvenli bir yaklaşımdır. Subkondiler kırıkların redüksiyonunu ve fiksasyonunu kolaylaşlaştıran bu yaklaşımda komplikasyon oranı az olup fonksiyonel sonuçlar elde edilir. Anahtar sözcükler: Açık redüksiyon; internal fiksasyon; retromandibular; subkondiler; transparotid. Ulus Travma Acil Cerrahi Derg 2017;23(3):251–257

doi: 10.5505/tjtes.2016.43669

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CA S E SER I ES

An unusual etiology in cold injury: Liquefied petroleum gas Emin Kapı, M.D.,1 Mehmet Bozkurt, M.D.,2 Gaye Taylan Filinte, M.D.,2 Samet Vasfi Kuvat, M.D.,3 Celal Alioğlu, M.D.2 1

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

2

Department of Plastic, Reconstructive and Aesthetic Surgery, Kartal Dr. Lütfi Kırdar Training and Research Hospital, İstanbul-Turkey

3

Department of Plastic, Reconstructive and Aesthetic Surgery, İstanbul University İstanbul Medical Faculty, İstanbul-Turkey

ABSTRACT Cold injury is a condition that causes reversible and irreversible damage when tissues are exposed to cold. This injury occurs due to various etiologies, and the most commonly observed ones include contact with liquefied petroleum gas (LPG) used in households, vehicles, and industry. LPG is a type of gas stored in liquid state under high pressure within cylinders. LPG contains a mixture of propane and butane gases. Direct contact of these gases with the tissues has the potential to cause metabolic, toxic, and respiratory damage. In this study, we present the cases of four patients with cold injury in the face and upper extremity caused by a pressurized jet stream of liquid gas that escaped out of the valves of the LPG cylinders.The patients had bullous lesions in the upper extremities and the face and second- and third-degree cold injuries with fibrotic and necrotic areas.The superficial defects secondarily healed with minimal scarring, while the necrotic finger had to be amputated. Cold injury on the skin caused by high-pressure jet streams of liquid gas as in our study is a rare occurrence. Our patients are important cases due to the rare etiology of cold injury. Keywords: Amputation; cold injury; LPG.

INTRODUCTION Liquefied petroleum gas (LPG) is a substance obtained by condensing flammable liquid petroleum gas at high pressure, and every gas cylinder contains a mixture of cold liquid and gaseous forms.[1] Although the pressurized substance is in a liquid state, it transforms into a gaseous form under normal atmospheric pressure.[2] The gas is extensively used in the household and industry.[1,3] While it has been used for domestic heating purposes for a long time, it is also widely used as a vehicle fuel and a commercial fuel.[1,2,4,5] The number of vehicles equipped with LPG cylinders is estimated to be more than 8 million worldwide. Due to its lower cost and environmentally friendlier nature in comparison to other peAddress for correspondence: Emin Kapı, M.D. Adana Devlet Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, Adana, Turkey Tel: +90 322 - 321 57 52 E-mail: eminkapi@gmail.com Ulus Travma Acil Cerrahi Derg 2017;23(3):258–262 doi: 10.5505/tjtes.2016.66378 Copyright 2017 TJTES

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troleum products, LPG has been becoming more popular in recent years.[6,7] LPG contains 60% butane and 40% propane. [2] These gases are colorless, odorless, and heavier than air. Although the boiling point of propane and butane varies according to the hydrocarbon content, it is between −42°C and 6°C.[2,8] The tissue-damaging potential of volatile liquid propane gas is well known.[9] When LPG stored at a low boiling point and high pressure within the cylinder comes in direct contact with the skin at room temperature, a type of frostbite injury known as cold injury occurs.[1,10] This type of trauma is rarely observed.[2,9] Contact with the eyes can also lead to irritations.[1] Contact with LPG usually occurs due to leakages from the LPG cylinder or from the gas that squirts when the cover is opened during refueling of the vehicle.[8,11] The morbidity of the tissue damage depends on the severity of the damage and the extent of the affected tissue.[8,12–15] In this study, we present the clinical progression of four patients with tissue damage on the face and upper extremities due to direct contact with LPG and the measures to be taken to prevent such damage.

MATERIALS AND METHODS Four male patients presented to our clinic with cold injury on the face and upper extremities due to direct contact with Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


KapÄą et al. An unusual etiology in cold injury: Liquefied petroleum gas

LPG. The mean age of the patients was 32.4 years (range: 26–44 years). Two of them were injured when they were replacing the LPG cylinder at home; one patient was exposed to gas when he was trying to close the cover of the LPG tank in the vehicle, and the other patient was injured when he came in direct contact with the gas leaking through the valve of the LPG tank during refueling at the gas station. These patients reportedly attempted to apply pressure on the valve of the LPG cylinder with their hands to stop the leakage but could not prevent the contact of the jet stream of the gas with the upper extremities and the face, which led to the tissue damage. They stated that they felt pain and coldness in the affected area immediately after the injury, which subsided after a few hours. Two patients did not even seek medical help after the injury. The first patient presented to the emergency room due to increasing pain in the volar and dorsal surfaces of the first to third fingers of the right hand and the loss of sensation and formation of bullae and vesicles in these fingers on the 2nd day following the injury that was caused when he was replacing the LPG cylinder at home. In the emergency room, incisions were made on the bullae and blisters. He presented to our clinic on the 3rd day. His physical examination revealed a circular edema at the metacarpal level, bullae, and vesicles in the right hand, and widespread epidermolysis and macerations in all the fingers (Figure 1). Examination of blood circulation demonstrated that the distal circulation in the second and third phalanges was disturbed up to the level of the proximal

phalanges, while the circulation was weakened especially in the dorsal region. The second patient reported that the cold injury in his right forearm and hand had occurred due to exposure to a spray of liquid gas for about 20 s when he was trying to tighten the cover of the LPG tank in his vehicle to prevent the gas leakage. He had a skin defect with vesicular–-bullous lesions at the level of the elbow progressing distally primarily at the distal side of the right upper extremity (Figure 2). There was a mild sensory loss in the fingers due to the edema. The other patients also had superficial erythematous, bullous, and fibrous defects and blisters on the upper extremities and the face (Figure 3). These defects were painful accompanied by leakage of fluid. When the patients were questioned about LPG and its effects, it was understood that they did not have any knowledge on the possibility of developing a cold injury due to contact with LPG. The defects received thermal damage treatment. Under local anesthesia, the defects were debrided and the bullae and vesicles were excised. All the patients were started on a regimen of nonsteroidal anti-inflammatory drugs and wide-spectrum antibiotics, while the patient with circulation disturbances in the fingers was also prescribed low-molecular dextran and acetylsalicylic acid. The extremities with defects were elevated. The wounds were dressed daily with paraffin and moisturizing dressing materials.

Figure 2. View of the patient with skin macerations due to contact with LPG in the right forearm and hand.

Figure 1. View of the patient with vesicles and macerations due to cold injury in the right hand.

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Figure 3. View of the erythematous and epidermolytic areas due to contact with liquid gas in the facial area.

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Kapı et al. An unusual etiology in cold injury: Liquefied petroleum gas

RESULTS The first patient did not seek medical help because of not feeling the pain on the 1st day of exposure to the trauma; however, on the 2nd day, due to the obvious pain and edema, he visited the emergency department. On the 2nd day, as he was sent home from the emergency department after opening the blisters, it caused a delay in adequate and appropriate intervention. The epidermolytic areas on the first to fourth metacarpals and the volar thenar regions of the volar and dorsal surfaces of the hand healed secondarily. The superficial defects in the fifth phalanx and the bullous lesions on the anterior surface of the first phalanx also healed secondarily. On the 7th day after his visit, the demarcation lines in the second to fourth phalanges started becoming visible (Figure 4a). The necrotic areas in a circular manner in the second and third phalanges and the proximal dorsal region of the fourth phalanx became apparent. Under general anesthesia, amputations were performed at the level of the proximal phalanx in the second and third phalanges and at the level of the medial phalanx in the fourth phalanx, and the defects were repaired. The necrotic tissues in the other phalanges were debrided. The patient was discharged on the 2nd postoperative day. No wound healing problems were observed in the early phase after the surgery, and all the defects healed completely in the 2nd postoperative month (Figure 4b). The second patient did not seek medical help assuming that his wounds were mild. In the other patients, the defects healed completely within approximately 3 weeks after the injury leaving sporadic areas

(a)

(b)

(c)

Figure 4. (a) The patient with full-thickness necrosis in the phalanges. (b) The patient at the 2nd postoperative month following the phalangeal amputation. (c) The patient with secondary healing in the upper extremity defect 3 weeks after the injury.

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of hyperpigmentation. The functions of the extremities were normal (Figure 4c). These patients were started on a hand physiotherapy program.

DISCUSSION LPG is a commonly used fuel worldwide. In recent years, it has become increasingly more commonly used in households, offices, camping places, vehicles, and industry.[9] This fuel is extremely flammable and may therefore cause serious flame burns.[12] On the other hand, due to its chemical characteristics, LPG may also cause cold injuries when it comes into direct contact with the skin. Although burn injuries due to LPG are commonly reported worldwide, the literature reports on cold injuries due to direct contact are limited in number.[9] In this context, the patients described in our study are very interesting. No studies investigating the correlation between gender and LPG-related cold injury have been found in the literature. However, a predominance of male gender among patients has been observed. Similarly, all the patients in our study were males, which is related to the fact that occupations on LPG tanks are frequently done by men. Therefore, males can be considered to be at an increased risk compared with females. Cold injuries may present with several clinical findings according to the degree of the cold and the length of exposure.[11] The injury may involve a partial- or full-thickness cutaneous damage of unknown depth.[16–18] Nevertheless, deep injuries are more frequently observed.[16] The damage on the skin is usually in the form of epidermolysis, bullae, and vesicles as in flame burns. Tissue necroses may also occur depending on the damage in the deeper tissues.[17–19] The clinical spectrum ranging from superficial defects to necrosis and amputations indicates that the findings are highly variable. The exposure time of the liquid gas is quite a determining factor in the variety of clinical findings. Hicks et al. have demonstrated in their animal studies that direct exposure of the skin to propane for 12 s leads to epidermal necrosis, whereas an exposure for 30 s causes dermal necrosis at the end of 24 h and damage in the superficial muscles after 5 days.[17] In our study also, the exposure time in patients with necrosis was about 15–20 s. Short-term liquid gas exposure in our patients was similar to experimental results. The intense damage despite the short exposure time of LPG is related to the skin contact of the cold liquid gas, which is compressed under high pressure in the tank and leaks out with a high acceleration from the tank lid. This damage occurs due to the loss of heat from the skin and the underlying tissues within a few seconds as the LPG is transformed from the liquid form into the volatile gas form without combustion. [1,9,17] This rapid transformation shows its effect quickly and causes tissue damage in a short period of time extending into the deep tissue. Therefore, a cold injury could be more severe than other injuries caused due to flame burns. However, Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Kapı et al. An unusual etiology in cold injury: Liquefied petroleum gas

comparative clinical trials should be done on this issue. Although the cold injury appears to be superficial during the first few days after the exposure, it may cause greater damage than initially expected.[20,21] Therefore, an evaluation of the tissues based on the appearance of the uppermost layers may not be reliable in the early period.[22] Indeed, in one of the patients in our study, the apparently mild skin damage immediately after the exposure to LPG led the healthcare providers to assess the damage as superficial. After the discharge, the patient did not seek further treatment as his pain diminished. When his clinical status deteriorated in the subsequent period, he returned to the emergency room to continue his treatment, but this misdiagnosis delayed healing. Therefore, in cold injuries caused due to LPG, degenerative tissue necroses that may develop in later phases should not be overlooked. It should also be considered that the findings may become clearer in later phases, and the patients should be kept under close monitoring from the first day onward. In case of a cold injury, the recommended first aid methods are washing the skin area that came into contact with the liquid gas with soap and water and warming up the skin in water close to the body temperature.[2,23–25] Wrapping the injured area immediately with a warm compress may help to warm up the area gradually. After the warm-up, the area with bullae, vesicles, and epidermolysis should be debrided. In patients at risk of compartment syndrome, an escharotomy and fasciotomy should be performed on the injured extremity, followed by sterile application of topical antibacterial agents chosen according to the nature of the defect.[2,26] Prophylactic treatment against infection and thrombosis, systemic antibiotherapy, anti-inflammatory agents, elevation of the extremity, hyperbaric oxygen therapy (HBO), and treatment with circulation-enhancing agents (dextran 40–500 ml/24 h, lowmolecular-weight heparin 6.000 IU/0.6 ml, acetylsalicylic acid 80–100 mg/24 h, vasodilatatory agent, and pentoxifylline) are among the methods for preventing deterioration of the tissue damage. Distal circulation should be monitored by pulse oximetry.[27] The most effective strategy for avoiding cold injury due to LPG exposure is prevention. Individuals should be warned against the danger of direct contact. Care must be taken during replacement of the LPG cylinders in households or offices, and professional assistance should be sought when necessary. The valves of the tanks should be regularly checked. Especially the tank nozzles and pumps in gas stations should be regularly checked and closely monitored. Vehicle users and gas station employees should be aware of the risks of liquid gas exposure during refueling. We believe that this issue should be emphasized during the in-service training of the fuel station staff. Although the necessary measures against the risk of explosion of LPG tanks and cylinders are well known among the general Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3

population, there is only inadequate awareness regarding the risk of cold injuries due to direct contact with LPG among both the general population and healthcare professionals in emergency rooms.[19] Therefore, the first aid measures to be taken in case of such injuries are usually neglected, although they are simple and easy to apply. Although rare, since this type of injury has the potential to cause functional losses in the extremities and permanent malformations on the face, it may have an impact on the social life of the patient. It has been observed that the subject does not draw adequate attention in the mass media, and not enough public education is given.[9] Since none of our patients had information regarding cold injury, it is clear that this issue needs adequate attention. Furthermore, we believe that healthcare workers should be trained especially on first aid attempts, and regarding the society, the work of the public spotlight should be expanded.

Conclusion Direct contact with the gases present in LPG may cause varying degrees of cold injuries and tissue necroses, especially in the extremities. The greatest problem associated with this type of trauma is the limited clinical experience of healthcare professionals on the diagnosis and treatment, the tissue damage that manifests itself in later phases after the injury, and the delayed medical care due to the late referral of the patient to the healthcare facility. Therefore, to reduce morbidity in cold injuries caused due to LPG or similar etiologies, it is important that the patients refer a medical facility at an early stage and the healthcare providers be aware of the grading of cold injuries. Conflict of interest: None declared.

REFERENCES 1. Bonamonte D, Profeta G, Conserva A, Mazzoccoli S, Foti C, Angelini G. Cold burn from contact with a propane and butane gas blend inside a spray canister used as a hooter. Contact Dermatitis 2008;59:61–2. 2. Wright TC, Kim JB, Currie LJ, Kay AR, Burge TS. Leakage of liquefied petroleum gas during motor vehicle refuelling--a new cause of cold injury. Burns 2006;32:132–3. 3. Stawczyk J. Experimental evaluation of LPG tank explosion hazards. J Hazard Mater 2003;96:189–200. 4. Murugkar PM, Jones NW, Shokrollahi K, Potokar TS, Drew PJ, Dickson WA. Hand burns sustained whilst refuelling car with LPG (liquefied petroleum gas). Burns 2006;32:515–6. 5. Paliwal G, Agrawal K, Srivastava RK, Sharma S. Domestic liquefied petroleum gas: are we using a kitchen bomb? Burns 2014;40:1219–24. 6. Kumar P. Fire disaster following LPG tanker explosion at Chala in Kannur (Kerala, India): August 27, 2012. Burns 2013;39:1479–87. 7. Zengin Y, Dursun R, İçer M, Gündüz E, Durgun HM, Erbatur S, et al. Fire disaster caused by LPG tanker explosion at Lice in Diyarbakır (Turkey): July 21, 2014. Burns 2015;41:1347–52. 8. Scarr B, Mitra B, Maini A, Cleland H. Liquefied petroleum gas cold burn sustained while refueling a car. Emerg Med Australas 2010;22:82–4. 9. James NK, Moss AL. Cold injury from liquid propane. BMJ 1989;299:950–1. 10. Tarim MA. Evaluation of burn injuries related to liquefied petroleum gas.

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Kapı et al. An unusual etiology in cold injury: Liquefied petroleum gas J Burn Care Res 2014;35:159–63. 11. Woo EK, Lee JW, Hur GY, Koh JH, Seo DK, Choi JK, et al. Proposed treatment protocol for frostbite: a retrospective analysis of 17 cases based on a 3-year single-institution experience. Arch Plast Surg 2013;40:510– 6. 12. Bozkurt M, Kulahci Y, Zor F, Kapi E. Burn injuries related to liquefied petroleum gas-powered cars. J Burn Care Res 2008;29:897–901. 13. Nowakowski A, Kaczmarek M, Renkielska A, Grudzinski J, Stojek W. Reaction of normal and burned tissue to cold excitation. Conf Proc IEEE Eng Med Biol Soc 2007;2007:239–42. 14. Carpenter HM, Hurley LA, Hardenbergh E, Williams RB. Vascular injury due to cold. Affects of rapid rewarming. Arch Pathol 1971;92:153– 61. 15. Geng Z, Tong X, Jia H. Reactive oxygen species (ROS) mediates nonfreezing cold injury of rat sciatic nerve. Int J Clin Exp Med 2015;8:15700– 7. 16. Corn CC, Wachtel TL, Malone JM, Wood M. Liquid-propane freeze injury: a case history. J Burn Care Rehabil 1991;12:136–9. 17. Hicks LM, Hunt JL, Baxter CR. Liquid propane cold injury: a clinicopathologic and experimental study. J Trauma 1979;19:701–3. 18. Li AK, Ehrlich HP, Trelstad RL, Koroly MJ, Schattenkerk ME, Malt RA. Differences in healing of skin wounds caused by burn and freeze injuries. Ann Surg 1980;191:244–8. 19. Seyhan N, Jasharllari L, Kayapınar M, Savacı N. An unusual cause of cold

injury: liquified petroleum gas leakage. Ulus Travma Acil Cerrahi Derg 2011;17:561–2. 20. Mäkinen TM, Jokelainen J, Näyhä S, Laatikainen T, Jousilahti P, Hassi J. Occurrence of frostbite in the general population--work-related and individual factors. Scand J Work Environ Health 2009;35:384,93. 21. Mehrkens HH. Cold injuries and thermal lesions. [Article in German] ZFA (Stuttgart) 1981;57:209–21. [Abstract] 22. Fudge JR, Bennett BL, Simanis JP, Roberts WO. Medical Evaluation for Exposure Extremes: Cold. Clin J Sport Med 2015;25:432–6. 23. Uygur F, Sever C, Noyan N. Frostbite burns caused by liquid oxygen. J Burn Care Res 2009;30:358–61. 24. Sachs C, Lehnhardt M, Daigeler A, Goertz O. The Triaging and Treatment of Cold-Induced Injuries. Dtsch Arztebl Int 2015;112:741–7. 25. Nygaard RM, Whitley AB, Fey RM, Wagner AL. The Hennepin Score: Quantification of Frostbite Management Efficacy. J Burn Care Res 2016;37:317–22. 26. O’Brien C, Castellani JW, Muza SR. Acute Hypobaric Hypoxia Effects on Finger Temperature During and After Local Cold Exposure. High Alt Med Biol 2015;16:244–50. 27. Keramidas ME, Kounalakis SN, Eiken O, Mekjavic IB. Effects of Two Short-Term, Intermittent Hypoxic Training Protocols on the Finger Temperature Response to Local Cold Stress. High Alt Med Biol 2015;16:251–60.

OLGU SERİSİ - ÖZET

Donuk hasarında alışılmadık bir etiyoloji: Likit petrol gaz Dr. Emin Kapı,1 Dr. Mehmet Bozkurt,2 Dr. Gaye Taylan Filinte,2 Dr. Samet Vasfi Kuvat,3 Dr. Celal Alioğlu2 1 2 3

Adana Devlet Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, Adana Kartal Dr. Lütfi Kırdar Eğitim ve Araştırma Hastanesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Kliniği, İstanbul İstanbul Üniversitsi İstanbul Tıp Fakültesi, Plastik, Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, İstanbul

Donuk hasarı, soğuğa doğrudan ya da dolaylı yoldan maruz kalınması sonucunda etkilenen dokuda geri dönüşümlü ya da dönüşümsüz harabiyete neden olan bir durumdur. Donuk hasarı oluşumuna yol açan farklı etiyolojik nedenler bulunmaktadır. Bunlar arasında en sık karşılaşılan nedenler; ev, araç ya da endüstriyel alanlarda kullanılan LPG (liquefied-petroleum gases) temasına bağlı hasarlardır. LPG, yüksek basınç altında tanklar içerisinde sıvı halde depolanan bir yakıt türüdür. İçeriğinde propan ve bütan gazları karışım halinde bulunur. Bu gazların, dokularla direkt temas halinde metabolik, toksik ve solunumsal hasar oluşturma potansiyeli bulunmaktadır. Bu çalışmada, LPG tankının kapakçıklarından likid formdaki gazın yüksek basınçla fışkırması sonucunda oluşan jet akıma bağlı olarak üst ekstremite ve yüzde donuk hasarı oluşmasına neden olan dört olgu değerlendirildi. Olgularda üst ekstremite ve yüzde büllöz lezyonlar, fibrotik ve nekrotik alanlar içeren ikinci ve üçüncü derece donuk hasarları mevcuttu. Yüzeyel defektler sekonder olarak yer yer minimal skar alanları bırakarak iyileşti, parmaklarda nekroz gelişen olguya amputasyon uygulandı. Çalışmamızdaki olgularda olduğu gibi, likit nitrojen içeriğinin yüksek basınçla fışkırması ve deride donuk hasarı oluşturması sık rastlanan bir durum değildir. Olgularımız farklı bir donuk etiyolojisine sahip olması nedeniyle oldukça ilgi çekicidir. Anahtar sözcükler: Amputasyon; LPG; soğuk hasarı. Ulus Travma Acil Cerrahi Derg 2017;23(3):258–262

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CAS E R EP O RT

Multiple thoracic vertebral fractures as a complication of cardiopulmonary resuscitation: A case report Tae Seok Jeong, M.D., Sang Gu Lee, M.D. Department of Neurosurgery, Gil Medical Center, Gachon University, Incheon-Korea

ABSTRACT A 50-year-old man experienced cardiac arrest. The patient underwent standard cardiopulmonary resuscitative measures for approximately 20 minutes before spontaneous circulation returned. He was diagnosed with variant angina, and subsequent imaging for evaluation of upper back pain revealed fractures of the fifth through eighth thoracic vertebrae. Multiple thoracic vertebral fractures are extremely rare. Here we report a case of multiple thoracic vertebral fractures as a complication of cardiopulmonary resuscitation. Keywords: Cardiopulmonary resuscitation; electric countershock; osteoporosis; spinal fractures; thoracic vertebrae.

INTRODUCTION Cardiopulmonary resuscitation (CPR) currently includes external chest compressions and ventilation as well as definitive emergency maneuvers and is a desperate but potentially life-saving measure for recovery of spontaneous circulation. However, several complications resulting from CPR have been reported.[1,2] The most common injuries sustained from CPR include rib fractures, with the literature suggesting an incidence of 13%–97%, and sternal fractures, with an incidence of 1%–43%.[3] Vertebral body fractures can also occur; however, they are seldom observed, and multiple fractures rarely occur.[4] Here, we report a case of multiple thoracic vertebral body fractures sustained in a 50-year-old man during CPR.

CASE REPORT A 50-year-old man with no medical history developed sudden chest pain and lost consciousness while sitting in a bathtub. An emergency team arrived 10 minutes after being notified, and the patient became alert upon their arrival. He lost consciousness again 15 minutes after departing for the hospital Address for correspondence: Sang Gu Lee, M.D. Gil Medical Center, 1198 Block, Guweol-Dong, Namdong-Gu Incheon - South Korea Tel: 82324603304 E-mail: samddal@gilhospital.com Ulus Travma Acil Cerrahi Derg 2017;23(3):263–265 doi: 10.5505/tjtes.2016.04401 Copyright 2017 TJTES

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and received chest compressions from an emergency medical technician in the ambulance because of cardiac arrest caused by ventricular fibrillation. The patient arrived at the emergency room after undergoing 5 minutes of chest compressions. The cardiac arrest persisted, and he was defibrillated twice with 200 joules (J) for ventricular tachycardia. The emergency room physician performed additional chest compressions for periods of 8, 10, and 10 minutes. Spontaneous circulation resumed, and the patient’s vital signs stabilized after CPR. Cardiac angiography was performed to evaluate the cause of the cardiac arrest, and it revealed minimal stenosis at the proximal portion of the left anterior descending artery. The patient was treated with nitroglycerin, aspirin, and clopidogrel. A provocation test utilizing ergonovine was performed, and near-total spastic obstructions of the left anterior descending artery and the left circumflex coronary artery following injection of ergonovine 20 mcg were observed. A change to a Mobitz type II atrioventricular block was observed on echocardiography. A temporary pacemaker was inserted for variant angina. Since then, no arrhythmia was observed on Holter monitoring. Because the patient had persistent severe upper back pain, particularly during movement, thoracic spine radiographs were obtained, and radiography and computed tomography of the thoracic spine revealed fifth, sixth, seventh, and eighth thoracic vertebral compression fractures and a sternal fracture. Magnetic resonance imaging showed additional tears in the sixth and seventh interspinous ligaments but no damage to the spinal cord (Fig. 1). The Cobb angle (or thoracic kyphotic angle) as measured from T1 to T12 was 30°, well within the normal range (25–40°). Osteopenia was diag263


Jeong et al. Multiple thoracic vertebral fractures as a complication of cardiopulmonary resuscitation

(a)

(b)

(c)

Figure 1. Computed tomography (a and b) and magnetic resonance imaging with fat suppression (c) of the thoracic spine, showing fifth, sixth, seventh, and eighth thoracic vertebral compression fractures (arrow); sixth and seventh interspinous ligament tears (star); and a sternal fracture (arrowhead).

nosed following a bone mineral density test T-score of −2.4. A thoracolumbosacral orthosis (TLSO) was applied, and he was treated with pain medication without surgery since there was no instability from the thoracic vertebral fractures or any neurologic deficits. The total hospitalization period was 45 days (12 days in the Cardiology Department and 33 days in the Spine Department). At discharge, it was recommended that he wear the TLSO whenever performing activity and to rest whenever possible to prevent aggravation of compression fractures. He was treated with teriparatide, a recombinant form of parathyroid hormone, and calcium additive for the osteopenia. Follow-up imaging obtained 6 months after discharge revealed no interval changes.

DISCUSSION Complications following CPR have been described in several publications. Skeletal injuries, particularly fractures of the ribs and sternum, are the most common complications of CPR. In addition, upper airway complications, including tracheal and esophageal rupture, and injuries of the gastrointestinal system, including liver laceration, gastric rupture, and pneumoperitoneum, have been reported.[1,2] However, vertebral body fracture following CPR has only been reported by four groups. Azuma et al.[4] reported two cases: a 90-year-old man with rhabdomyolysis who received chest compressions for 60 minutes and whose autopsy revealed an eleventh thoracic vertebral compression fraction and a 71-year-old man who had cardiopulmonary arrest due to sepsis caused by a urinary tract infection. Our patient received compressions for 30- and 15-minute periods, and his autopsy revealed a first lumbar compression fracture. Goldberg et al.[5] reported the case of a 76-year-old woman who had cardiopulmonary arrest due to acute myocardial infarction and received chest compressions lasting 30 and 15 minutes and whose autopsy showed a tenth thoracic vertebral compression fracture. Jeong et al.[6] reported the case of a 264

54-year-old woman in whom spontaneous circulation returned after external cardiac massage and cardiac shock (400 J) were delivered twice and whose thoracic spine radiograph showed sixth, seventh, and eighth thoracic vertebral compression fractures. Four causes of vertebral body fractures may be considered. First, it is possible to fracture the vertebral bodies by using excessive force during chest compressions. Although chest compressions were performed by an emergency medical technician who had completed special CPR training, excessive force could have been delivered while chest compressions were being performed during transit to the hospital. Second, severe kyphosis of the thoracic spine with a sagittal imbalance may increase lumbar lordosis, exposing the spine to greater shearing forces during chest compression[4,7] and resulting in a fragile thoracic spine. Third, osteopenia decreases the bearable force of the vertebral body to external impact.[8,9] Chest compressions during CPR provide adequate trauma to induce fractures of the vertebral bodies in a patient with severe kyphosis and osteopenia. Fourth, defibrillation causes instantaneous muscle contractions and could lead to such fractures. The most common fracture location is at the mid-thoracic level, because compressive forces during muscle contraction are concentrated along the anterior and middle columns of the mid-thoracic kyphotic curve.[3,5] Takahashi et al.[10] reported that a 34-year-old man with persistent severe back pain after a seizure was diagnosed with sixth and seventh thoracic spine compression fractures. Such forceful muscle contractions during a convulsive seizure could result in a vertebral compression fracture. In the current case, our patient with osteopenia underwent defibrillation three times, as well as lengthy chest compressions. We hypothesize that a patient with a bone-weakening condition would not be able to withstand forceful muscle contraction and external trauma and would therefore develop multiple vertebral fractures. Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Jeong et al. Multiple thoracic vertebral fractures as a complication of cardiopulmonary resuscitation

Conclusion CPR is an essential lifesaving procedure but has several possible complications. Repetitive education is necessary to prevent such complications. However, complications can occur unintentionally, even with proper technique. Vertebral fractures are rare and easily missed. Therefore, while performing CPR, one must recognize that it is possible to fracture the vertebral body by sudden muscle contraction and external trauma, particularly in patients with osteopenia or osteoporosis. If the patient complains of persistent back pain after CPR, a spinal evaluation should be performed.

3. 4. 5.

6. 7.

Conflict of interest: None declared.

8.

REFERENCES

9.

1. Krischer JP, Fine EG, Davis JH, Nagel EL. Complications of cardiac resuscitation. Chest 1987;92:287–91. 2. Patterson RH, Burns WA, Jannotta FS. Complications of external car-

10.

diac resuscitation: a retrospective review and survey of the literature. Med Ann Dist Columbia 1974;43:389–94. Hoke RS, Chamberlain D. Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation 2004;63:327–38. Azuma SS, Mashiyama ET, Goldsmith CI, Abbasi AS. Chest compression-induced vertebral fractures. Chest 1986;89:154–5. Goldberg RM, Rowan L, Anderson RE. Thoracic vertebral fracture as a complication of cardiopulmonary resuscitation. J Emerg Med 1988;6:177–8. Jeong YG, Caccamo LP. Letter: Cardiac resuscitation and vertebral fracture. JAMA 1975;234:1223. Kim DH, Choi DH, Park JH, Lee JH, Choi YS. What is the effect of spino-pelvic sagittal parameters and back muscles on osteoporotic vertebral fracture? Asian Spine J 2015;9:162–9. Davey DA. Osteoporosis, osteopenia and fracture risk: widening the therapeutic horizons. S Afr Med J 2012;102:285–8. Torpy JM, Lynm C, Glass RM. JAMA patient page. Osteopenia and preventing fractures. JAMA 2006;296:2644. Takahashi T, Tominaga T, Shamoto H, Shimizu H, Yoshimoto T. Seizure-induced thoracic spine compression fracture: case report. Surg Neurol 2002;58:214–7.

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Kardiyopulmoner resüsitasyonun bir komplikasyonu olarak çoklu torasik vertebra kırıkları: Bir olgu raporu Dr. Tae Seok Jeong, Dr. Sang Gu Lee Gachon Üniversitesi, Gil Tıp Merkezi, Nöroşirürji Anabilim Dalı, Incheon-Kore

Elli yaşındaki bir adam kardiyak arest geçirdi. Hasta spontane dolaşım geri dönmeden önce yaklaşık 20 dakika standart kardiyopulmoner resüsitasyon uygulandı. Hastaya variyant anjina tanısı kondu. Ardından üst sırt ağrısını değerlendirmek için yapılan görüntüleme beşinci ila sekizinci torasik vertebra arasında kırıklar olduğunu ortaya çıkardı. Çoklu torasik vertebra kırıkları son derece seyrek görülmektedir. Burada kardiyopulmoner resüsitasyonun bir komplikasyonu olarak çoklu torasik vertebra kırıklı bir hasta sunuldu. Anahtar sözcükler: Elektrik kontrşok; kardiyopulmoner resüsitasyon; osteoporoz; spina kırıkları; torasik vertebralar. Ulus Travma Acil Cerrahi Derg 2017;23(3):263–265

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CA S E REP OR T

A rare case of obscure gastrointestinal bleeding: Small bowel varices flowing into the inferior epigastric vein Akira Hoshiai, M.D.,1 Junya Tsurukiri, M.D.,1 Yasuhiro Sumi, M.D.2 1

Department of Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Tokyo-Japan

2

Department of General Surgery, Shizuoka Medical Center, Shizuoka-Japan

ABSTRACT Ectopic varices include all varices except esophageal or gastric varices and comprise large portosystemic venous collaterals that occur anywhere in the abdomen. Ectopic varices are relatively rare; however, approximately 5% are related to gastrointestinal bleeding. Ectopic varices usually occur in the rectum, duodenum, or colon, and portal hypertension is the most common cause. Hemodynamic profiles of ectopic varices remain unknown, and extensive bleeding from these structures occurs because diagnosis and treatment are difficult. Here we report a case of obscure gastrointestinal bleeding (GIB) due to ectopic varices in the small intestine that flowed into the inferior epigastric vein. Our observations suggest that when obscure GIB is detected in patients with either cirrhosis or post-surgical history including incisional hernia, it is essential to acquire multilanar reconstruction images and volume-rendered 3-dimensional reconstruction of computed tomography scans to investigate the complex venous supply and optimize decisions for therapy. Keywords: Cirrhosis; ectopic varices; incisional hernia; portal hypertension; submucosal varices.

INTRODUCTION

CASE REPORT

Ectopic varices are defined as all varices excluding those of esophageal or gastric origin and refer to large portosystemic venous collaterals occurring anywhere in the abdomen.[1] Although ectopic varices are relatively rare, approximately 5% of these anomalies are associated with gastrointestinal bleeding (GIB).[2] The hemodynamic profiles of ectopic varices remain unknown, especially in the small intestine, and GIB from these varices tends to be extensive because of the difficulty of diagnosis and treatment.[2] Most bleeding ectopic varices associated with poor outcomes warrant emergency intervention. Here we report a rare case of obscure GIB caused by ectopic varices in the small intestine flowing into the inferior epigastric vein.

A 69-year-old woman was transferred to our surgery department with severe anemia requiring blood transfusion caused by obscure GIB, because the bleeding site had not been detected by upper nor lower endoscopy at another hospital. She had suffered from obscure GIB 6 months earlier. Her past medical history included cirrhosis caused by non-alcoholic steatohepatitis, and she had an abdominal incisional hernia following the surgical removal of a cervical cancer ≥15 years earlier. Physical examination revealed normal vital signs. Hemoglobin, hematocrit, and serum blood urea nitrogen levels were 6.8 g/dL (reference range, 12.0–16.0 g/dL), 21% (reference range, 35%–48%), and 8 mg/dL (reference range, 8–20 mg/dL), respectively. Platelet count was 12.7×104/µL (reference range, 15–35×104/µL), and prothrombin time and hepaplastin test were 58.5% (reference range, 80%–100%) and 60% (reference range, 70%–130%), respectively. Initially, the patient complained of abdominal pain.

Address for correspondence: Junya Tsurukiri, M.D. 1163 Tatemachi Hachioji Tokyo - Japan Tel: +81-4256655611 E-mail: junya99@tokyo-med.ac.jp Ulus Travma Acil Cerrahi Derg 2017;23(3):266–268 doi: 10.5505/tjtes.2016.01394 Copyright 2017 TJTES

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Because repeated upper and lower endoscopies were negative in obscure upper gastrointestinal bleeding (UGIB), we performed contrast-enhanced computed tomography (CT) of the trunk, which revealed varices in the small intestine at the site of the abdominal incisional hernia, which drained into the inferior epigastric vein (Fig. 1a). Volume-rendered Ulus Travma Acil Cerrahi Derg, May 2017, Vol. 23, No. 3


Hoshiai et al. A rare case of obscure gastrointestinal bleeding: Small bowel varices flowing into the inferior epigastric vein

(a)

(b)

Figure 1. (a) Contrast-enhanced computed tomography. (b) A volume-rendered three-dimensional reconstruction of contrast-enhanced computed tomography. A superior mesenteric vein (the afferent vessel; arrow), varices (arrow head), and inferior epigastric vein (the efferent vessel; small arrow).

three-dimensional (3D) reconstruction also detected that the afferent vessel was a superior mesenteric vein (Fig. 1b). Thereafter, the patient underwent open surgery because endovascular treatment required advanced technical procedures for successful obliteration due to the complex anatomic features of the ectopic varices. Partial removal of the small intestine, including the varices following the ligation of the afferent and efferent vessels was achieved. The subsequent

Figure 2. Photograph showing an operative view. The efferent vessel (arrow), and varices (circle). Pathology revealed submucosal varices in the small intestine.

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pathology report revealed submucosal varices in the small intestine (Fig. 2). After surgery, no further bleeding was encountered, and the patient was discharged from our hospital in good condition.

DISCUSSION Varices form in any abdominal viscera in patients with portal hypertension, which results in an increase in the resistance of blood flow from the venous system of the gastrointestinal organs or other abdominal viscera. Liver cirrhosis is the most common cause of ectopic varices.[3,4] Previous studies have reported that ectopic varices commonly occur in the rectum, duodenum, and colon. Approximately 6%–17% of ectopic varices are discovered in the small intestine.[3] However, the diagnosis of varices in this region may be challenging because varices often develop in the submucosa of the small intestine, making them more difficult to detect by endoscopy than esophageal or gastric varices. Recently, double balloon endoscopy and capsule endoscopies have made it possible to observe such varices in the small intestine.[5,6] Although it is not clear whether the inferior mesenteric vein has any communication with the portal system, ectopic varices in the small intestine are usually associated with adhesions between the small intestine and the abdominal wall. Furthermore, small bowel varices can develop as a consequence of previous operations or abdominal injury. Sato et al. 267


Hoshiai et al. A rare case of obscure gastrointestinal bleeding: Small bowel varices flowing into the inferior epigastric vein

reported that a triad of portal hypertension, hematochezia without hematemesis, and previous abdominal surgery characterizes bleeding from small intestinal varices.[7] Moreover, they mentioned that the development of collateral circulation via postoperative adhesions is a risk factor for small bowel varices. In the present case, we determined the development of collateral circulation in the incisional hernia cavity. Therefore, when obscure GIB is detected in patients with either cirrhosis or post-surgical history, including incisional hernia, ectopic varices in the small intestine and varices with unusual collaterals should be suspected. Furthermore, it is essential to acquire multiplanar reconstruction images and volumerendered 3D reconstructions of CT scans to investigate the complex venous supply and optimize therapeutic decisions. Recently, endovascular treatment, including transjugular intrahepatic portosystemic shunts or balloon-occlusion retrograde transvenous obliteration (BRTO) may have a role in the treatment of gastric or duodenal varices. Although BRTO can obliterate not only varices but also the afferent and efferent veins in gastric or duodenal varices, this approach may be a technical challenge in other ectopic varices because of the complex anatomic features of the varices.[4,8] Therefore, surgical removal of submucosal varices is the preferred treatment to stop the enlargement of small bowel varices with high success. In the future, endovascular treatment may have a role in the treatment of patients in whom open surgery is prohibitively risky.

Conclusion Small intestinal varices are rare causes of GIB. When obscure

GIB is detected in patients with either cirrhosis or post-surgical history including incisional hernia, multiplanar reconstruction of CT images is an effective means of investigating the complex venous supply and optimizing therapeutic decisions. Conflict of interest: None declared.

REFERENCES 1. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007;46:922–38. 2. Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998;28:1154–8. 3. Watanabe N, Toyonaga A, Kojima S, Takashimizu S, Oho K, Kokubu S, et al. Current status of ectopic varices in Japan: Results of a survey by the Japan Society for Portal Hypertension. Hepatol Res 2010;40:763–76. 4. Sato T, Akaike J, Toyota J, Karino Y, Ohmura T. Clinicopathological features and treatment of ectopic varices with portal hypertension. Int J Hepatol 2011;2011:960720. 5. Teshima CW, Kuipers EJ, van Zanten SV, Mensink PB. Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis. J Gastroenterol Hepatol 2011;26:796–801. 6. Garcia MC, Ahlenstiel G, Mahajan H, van der Poorten D. Small bowel varices secondary to chronic superior mesenteric vein thrombosis in a patient with heterozygous Factor V Leiden mutation: a case report. J Med Case Rep 2015;9:210. 7. Pennick MO, Artioukh DY. Management of parastomal varices: who re-bleeds and who does not? A systematic review of the literature. Tech Coloproctol 2013;17:163–70. 8. Okahara M, Kiyosue H, Ueda S, Kashiwagi J, Tanoue S, Hongo N, et al. Anatomic features and retrograde transvenous obliteration of duodenal varices associated with mesocaval collateral pathway. J Vasc Interv Radiol 2012;23:1339–46.

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Seyrek görülen okült gastrointestinal kanama: İnferiyor epigastrik vene boşalan ince bağırsak variköz venleri Dr. Akira Hoshiai,1 Dr. Junya Tsurukiri,1 Dr. Yasuhiro Sumi2 1 2

Tokyo Tıp Üniversitesi Hachioji Tıp Merkezi, Acil ve Kritik Bakım Bölömü, Tokyo-Japonya Shizuoka Tıp Merkezi, Genel Cerrahi Bölümü, Shizuoka-Japonya

Ektopik varisler özofagus veya gastrik varisler dışında tüm varisleri içerir ve karın bölgesinin herhangi bir yerinde oluşan geniş portosistemik venöz kollateralleri belirtir. Ektopik varisler göreceli olarak seyrek görülür ve bu varislerin ortalama %5’i gastrointestinal kanamaya neden olur. Ektopik varisler genellikle rektum, duodenum ve kolonda oluştuğu gibi en sık görülen nedeni portal hipertansiyondur. Ektopik varislerin hemodinamik profilleri halen bilinmemekte olup tanı ve tedavisi güç olduğundan bu oluşumlardan yaygın kanamalar meydana gelir. Burada, inferiyor epigastrik vene boşalan ince bağırsaktaki ektopik varislere bağlı bir okült gastrointestinal kanama (GİK) olgusunu bildirmekteyiz. Gözlemlerimiz siroz hastalarında veya insizyonal herni cerrahisi geçirmişlerde nedeni belli olmayan GİK saptandığında çok düzlemli bilgisayarlı tomografi (BT) rekonstrüksiyon görüntüleri ve 3-boyutlu BT rekonstrüksiyon taramaları elde edilerek kompleks venöz dolaşımı araştırmak ve tedavi kararlarını optimize etmek gerekir. Anahtar sözcükler: Ektopik varisler, insizyonal herni; portal hipertansiyon; siroz; submukozal varisler. Ulus Travma Acil Cerrahi Derg 2017;23(3):266–268

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CAS E R EP O RT

Rectosigmoidoscopy complicated by bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoderma Elvin Hekimoğlu, M.D., Akif Turna, M.D., H. Volkan Kara, M.D., Ahmet Demirkaya, M.D., Kamil Kaynak, M.D. Department of Thoracic Surgery, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul-Turkey

ABSTRACT Rectosigmoidoscopy is a common procedure for diagnosis and follow-up of diseases of the lower gastrointestinal system. Although the procedure is proven to be safe in experienced hands, there is always risk of complications. We report a case of bilateral pneumothoraces, pneumoperitonium, pneumoretroperitoneum, pneumomediastinum, and pneumoderma due to perforation during a rectosigmoidoscopy. Co-occurrence of all these in 1 patient is a very rare clinical condition. This report underlines the possibility of even the rarest and unexpected complications related to rectosigmoidoscopy. Endoscopist should be careful to avoid perforation, be aware of the potential complications, and be able to manage them. Keywords: Pneumoderma; pneumomediastinum; pneumoperitoneum; pneumoretroperitoneum; rectosigmoidoscopy.

INTRODUCTION Rectosigmoidoscopy is a common procedure for the diagnosis and follow-up for benign and malignant diseases of the lower intestinal system. Although it is known to be a safe procedure, complications such as hemorrhage, perforation, and infection may occur with low rates. Perforation is an even rarer complication but may cause serious problems. The rate of perforation reported in large patient series is less than 0.3%.[1] We present a case of rec-tosigmoidoscopy complicated with bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoderma.

CASE REPORT A 46-year-old female with a 6-year history of ulcerative colitis Address for correspondence: Akif Turna, M.D. İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 414 30 00 E-mail: akifturna@yahoo.com Ulus Travma Acil Cerrahi Derg 2017;23(3):269–271 doi: 10.5505/tjtes.2016.48566 Copyright 2017 TJTES

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was admitted to our hospital with abdominal pain. An urgent diagnostic rectosigmoidoscopy was performed, which revealed deep ulcerations in the sigmoid colon and rectum. During the procedure, the physician clearly recognized the perforated area in the sigmoid colon after mucosal biopsies were taken. The patient was admitted to the hospital for close follow up. During follow-up in the ward, she started suffering from dyspnea. The peripheral blood oxygen saturation meas-ured decreased to 94% in room air. Her arterial blood pressure was 130/75 mm Hg, her heart rate was 94 beats/ min, and her respiratory rate was 19 breaths/min. Arterial blood gas analysis in room air revealed pH=7.36, PaCO2=38 mmHg, PaO2 =83 mmHg, and oxygen satura-tion = 89%. Respiratory sounds were decreased in both hemithoraces, and she developed ab-dominal distension and tenderness. Meanwhile, she started developing progressive subcuta-neous emphysema, predominantly located in the pectoral area, which also extended to her face and neck. Biochemical measurements, including blood count and C reactive protein (CRP), were in the normal ranges, and she did not have any fever. A computed tomography (CT) of the thorax and abdomen revealed bilateral pneumothoraces; subcutaneous air in the pectoral and neck areas; pneumomediastinum (Figure 1a); massive free air in the peritoneum; and free air images around bilateral perirenal areas, the right pelvic area, the caecum and the ascending colon (Figure 1b). Because she was symptomatic, bilateral chest tubes were placed. As the clinical symptoms 269


HekimoÄ&#x;lu et al. Rectosigmoidoscopy complicated by air behind multiple fascial planes

worsened during follow-up and the endoscopist was certain of visu-alizing the perforation, an urgent laparotomy was performed. In the exploration, the exact site of perforation could not be defined. The operative team decided to create an ileostomy near the ileocecal valve because a perforation near the ileocecal valve was also suspected. The postoperative course was uneventful. Periperitoneal and retroperitoneal air (pneumoperitoneum, pneumoretroperitoneum) and pneumoderma were resolved by the second day. Both lungs were re-expanded, and the chest tubes were removed on the fourth postoperative day. The patient was discharged on the sixth postoperative day. Pathological evaluation of colonic biopsy revealed chronic active colitis. The ileostomy was closed 2 months later. She has been doing well and symptom-free for 18 months.

DISCUSSION Perforation of the colon during the rectosigmoidoscopy procedure allows passage of free air into the intraperitoneal cavity and/or retroperitoneal tissue planes. Retroperitoneal air results from either direct retroperitoneal colonic perforation or from dissection of air through the colonic wall (pneumatosis coli) and subsequent air entry along the mesentery to the retro-peritoneum. Retroperitoneal air may pass along the fascial planes to enter the mediastinum. Subsequent rupture of the mediastinal pleura allows air to enter the bilateral pleural cavities and cause pneumothoraces. Different mechanisms have been postulated whereby extraluminal air may reach and dissect different body compartments.[2] Undue instrument manipulation, air insufflations during endoscopy, or improper use of diathermy may cause colonic perforation.[3] Alternatively, forcible herniation of the colonic mucosa may occur, such that the mucosa becomes permeable to air without an actual perforation developing.[4] Air may move through the retroperitoneal area and esophageal and aortic hiatus into the mediastinum, extending to the neck.[5] It has been shown that air may also move into the thoracic cavities and, very

(a)

rarely, may cause bilateral pneumothoraces.[6] Only three of five pneumothorax cases that have been reported secondary to colonoscopy were bilateral.[5] The treatment plan for perforations following colonoscopy varies from nonsurgical (medical treatment) to surgical (urgent laparotomy or laparoscopy) approaches.[7,8] The decision depends on the clinical presentation, primary tumor described by colonoscopy, site of perforation, and degree of colon wall damage. Urgent surgery with laparotomy or laparoscopy might be curative and life saving for exploration and repair of the defect.[2,7,8] However, it may not be possible to find and exact location of perforation. It is plausible to speculate that perforation can be occult due to the rapid healing of a small defect. Yet, an ileostomy should be created for stabilization, decompression, and to aid in healing. However, nonsurgical management was also advocated.[3,8] Marwan and colleagues indicated that nonsurgical management may be appropriate in a patient with a properly prepared bowel.[4] Nevertheless, air entry should be found and repaired in such patients. In our case, perforation is thought to be located at the ileum. However, the endoscopist did not recall any maneuver resulting in perforation. The decision about surgical or nonsurgical management and the procedures should be made on a case-by-case basis. In our case, an ileostomy provided certain and immediate relief of pneumoperitoneum, pneumoderma, and pneumoretroperitoneum. Bilateral pneumothoraces were treated by bilateral chest tube insertion. Pneumothorax accompanied by pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and pneumoderma is a very rare complication of rectosigmoidoscopy. If the patient develops dyspnea and pneumoderma during or after this procedure, a chest radiogram or thoracoabdominal CT should be taken for diagnostic purposes. Urgent treatment, starting with chest tube insertion(s) and laparotomy would be lifesaving.

(b)

Figure 1. (a) Chest computed tomography (CT) showing bilateral pneumothoraces (black arrow), pneumoderma (white arrow), and pneumomediastinum (asterisk). (b) CT of the abdomen showing pneumoperitotenum (black arrow) and pneumoretro-peritoneum (gray arrow).

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Conflict of interest: None declared.

REFERENCES

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1. Ko CW, Dominitz JA. Complications of colonoscopy: magnitude and management. Gastrointest Endosc Clin N Am 2010;20:659–71. 2. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984;144:1447–53. 3. Marwan K, Farmer KC, Varley C, Chapple KS. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema following diagnostic colonoscopy. Ann R Coll Surg Engl 2007;89:W20–1. 4. Ho HC, Burchell S, Morris P, Yu M. Colon perforation, bilateral pneu-

6.

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mothoraces, pneumopericardium, pneumomediastinum, and subcutaneous emphysema complicating endoscopic polypectomy: anatomic and management considerations. Am Surg 1996;62:770–4. Webb T. Pneumothorax and pneumomediastinum during colonoscopy. Anaesth Intensive Care 1998;26:302–4. Ignjatović M, Jović J. Tension pneumothorax, pneumoretroperitoneum, and subcutaneous emphysema after colonoscopic polypectomy: a case report and review of the literature. Langenbecks Arch Surg 2009;394:185–9. Hall C, Dorricott NJ, Donovan IA, Neoptolemos JP. Colon perforation during colonoscopy: surgical versus conservative management. Br J Surg 1991;78:542–4. Ker TS, Wasserberg N, Beart RW Jr. Colonoscopic perforation and bleeding of the colon can be treated safely without surgery. Am Surg 2004;70:922–4.

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İki taraflı pnömotoraks, pnömoperitoneum, pnömoretroperitoneum, pnömomediastinum ve pnömoderma ile komplike olmuş rektosigmoidoskopi Dr. Elvin Hekimoğlu, Dr. Akif Turna, Dr. H. Volkan Kara, Dr. Ahmet Demirkaya, Dr. Kamil Kaynak İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi, Göğüs Cerrahisi Anabilim Dalı, İstanbul

Rektosigmoidoskopi alt gastrointestinal sistemin hastalıklarının teşhis ve takibinde sık kullanılan bir işlemdir. İşlemin tecrübeli ellerde güvenilirliği ispatlanmıştır, ancak komplikasyon ortaya çıkma ihtimali vardır. Rektosigmoidoskopi esnasında perforasyona bağlı tümü aynı anda ortaya çıkan iki taraflı pnömotoraks, pnömoperitoneum, pnömoretroperitoneum, pnömomediastinum ve pnömoderma olgusunu çok nadir görülmesi nedeniyle sunuyoruz. Bu olgu ile rektosigmoidoskopide nadir komplikasyonların mümkün olduğunun altı çizilmektedir. Endoskopistin işlem sırasında perforasyon oluşmaması için azami özen ve gayret göstermesi, sıklığından bağımsız tüm olası komplikasyonlar hakkında bilgi sahibi olması ve gerektiğinde süreçlerini yönetebilmesi gerekmektedir. Anahtar sözcükler: Pnömoderma; pnömoperitoneum; pnömoretroperitoneum; pnömotoraks; rektosigmoidoskopi. Ulus Travma Acil Cerrahi Derg 2017;23(3):269–271

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