Travma 2017 / 6

ISSN 1306 - 696X

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

Volume 23 | Number 6 | November 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 Osman Şimşek Orhan Alimoğlu Mehmet Eryılmaz

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

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

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

Tel Fax (Faks)

Kaya Sarıbeyoğlu Kaya Sarıbeyoğlu M. Mahir Özmen Metin Ertem Ulusal Travma ve Acil Cerrahi Dergisi Sekreterliği Şehremini Mah., Köprülü Mehmet Paşa Sok., Dadaşoğlu Apt., No: 25/1, 34104 Şehremini, İstanbul +90 212 - 531 12 46 - 588 62 46 +90 212 - 586 18 04

p-ISSN 1306-696x • e-ISSN 1307-7945 • Included in Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, EBSCO, and Turkish Medical Index (Index Medicus, Medline; EMBASE, Excerpta Medica; Science Citation Index-Expanded (SCI-E), Index Copernicus, DOAJ, EBSCO ve TÜBİTAK ULAKBİM Türk Tıp Dizini’nde yer almaktadır.)

Publisher (Yayımcı): KARE Yayıncılık (KARE Publishing) • www.kareyayincilik.com • Design (Tasarım): Ali Cangül • Graphics (Grafikler): Edibe Çomaktekin • Linguistic Editor (İngilizce Editörü): Suzan Atwood • Redaction (Redaksiyon): Erman Aytaç • Online Manuscript & Web Management (Online Dergi & Web): LookUs • Press (Baskı): Yıldırım Matbaacılık • Press date (Basım tarihi): November (Kasım) 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 2014 in EBSCOhost. Our impact factor in SCI-E indexed journals is 0.473 (JCR 2016). 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 must be submitted 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 TÜBİTAK TR Dizinde taranmaktadır, ayrıca uluslararası indekslerde, 2001 yılından itibaren Index Medicus, PubMed’de, 2005 yılından itibaren EMBASE’de, 2007 yılından itibaren Web of Science, Science Citation Index-Expanded’de (SCI-E), 2014 yılından itibaren de EBSCOhost indeksinde dizinlenmektedir. 2016 Journal Citation Report IF puanımız artarak 0.473 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 İngilizce yazılmış makaleler yayınlanır. 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 kişilerden 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 6 November - Kasım 2017

Contents - İçindekiler Deneysel Çalışma - Experimental Experimental Studies - DeneyselStudy Çalışma 445-451 Application of pulsed arterial resuscitation in a rabbit model of hemorrhagic shock

Tavşan hemorajik şok modelinde atımlı arteriyel resüsitasyon uygulaması Sun W, Shao Z, Xu H, Qiu W, Sun J 452-458 Combined and individual use of pancaspase inhibitor Q-VD-OPh and NMDA receptor antagonist riluzole in experimental spinal cord injury

Deneysel omurilik yaralanmasında genel kaspaz inhibitörü Q-VD-OPh ve NMDH reseptör antagonisti riluzole’ün izole ve birlikte kullanımı Can H, Aydoseli A, Gömleksiz C, Göker B, Altunrende ME, Dolgun M, Sencer A 459-465 A new perspective on life-saving procedures in a battlefield setting: Emergency cricothyroidotomy, needle thoracostomy, and chest tube thoracostomy with night vision goggles

Savaş alanında hayat kurtarıcı prosedürlere yeni bir bakış: Gece görüş gözlükleri ile acil krikotroidotomi, iğne torakostomi ve göğüs tüp torakostomi Bilge S, Aydın A, Bilge M, Aydın C, Çevik E, Eryılmaz M

Original Articles - Orijinal Çalışma 466-471 Clinical infection in burn patients and its consequences

Yanık hastalarında klinik enfeksiyonlar ve sonuçları Güldoğan CE, Kendirci M, Tikici D, Gündoğdu E, Yastı AÇ 472-476 Correlation between ischemia-modified albumin and Ranson score in acute pancreatitis

Akut pankreatitte iskemi modifiye albümin ve Ranson skoru arasındaki korelasyon Güldoğan CE, Kılıç MÖ, Balamir İ, Tez M, Turhan T 477-482 Role of inflammatory markers in decreasing negative appendectomy rate: a study based on computed tomography findings

Enflamatuvar belirteçlerin negatif apendektomi oranını azaltmadaki rolü: Bilgisayarlı tomografi bulgularına dayanan bir çalışma Ozan E, Ataç GK, Alişar K, Alhan A 483-488 Spontaneous rectus sheath hematoma in cardiac in patients: a single-center experience

Kardiyak nedenlerle hastanede yatan hastalarda spontan rektus kılıf hematomu: Tek merkez deneyimi Gündeş E, Çetin DA, Aday U, Çiyiltepe H, Değer KC, Uzun O, Senger AS, Polat E, Duman M 489-494 Computed tomography findings of primary epiploic appendagitis as an easily misdiagnosed entity: Case series and review of literature

Kolaylıkla atlanabilen bir antite olan epiploik apandisitin bilgisayarlı tomografi bulguları: Olgu serisi ve literatürün gözden geçirilmesi Ergelen R, Asadov R, Özdemir B, Tureli D, Demirbaş BT, Tuney D 495-500 Early laparoscopic cholecystectomy following acute biliary pancreatitis expedites recovery

Akut biliyer pankreatiti izleyen erken laparoskopik kolesistektomi iyileşme sürecini kısaltır Eğin S, Yeşiltaş M, Gökçek B, Tezer H, Karahan SR

Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

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

Number - Sayı 6 November - Kasım 2017

Contents - İçindekiler

501-506 Bridge treatment for early cholecystectomy in geriatric patients with acute cholecystitis: Percutaneous cholecystostomy

Akut kolesistitli yaşlı hastalarda erken kolesistektomi için köprü tedavisi: Perkütan kolesistostomi Zeren S, Bayhan Z, Koçak C, Kesici U, Korkmaz M, Ekici MF, Algın MC, Yaylak F

Case Series - Olgu Serisi 507-514 Management of capitellar fractures with open reduction and internal fixation using Herbert screws

Açık redüksiyon ve Herbert vidalarıyla internal fiksasyon yöntemiyle kapitellar kırıkların tedavisi Sultan A, Khursheed O, Bhat MR, Kotwal HA, Manzoor QW

Case Report - Olgu Sunumu 515-520 Delayed bipedicled flap: An alternative and new method for reconstruction of distal leg defect after gunshot trauma: A case report and review of the literature

Gecikmeli bipediküllü flep: Ateşli silah yaralanması sonrası bacak distalindeki defektlerin rekonstrüksiyonu için alternatif ve yeni metod: Olgu sunumu ve literatürün taranması Yıldırım AR, İğde M, Öztürk MO, Ergani HM, Ünlü RE 521-524 Endoscopic drainage and cystoduodedonstomy in a child with pancreatic pseudocyst

Pankreatik psödokistli bir çocukta endoskopik drenaj ve kistoduodenostomi Ateş U, Küçük G, Çınar K, Bahadır B, Bektaş M, Göllü G, Bingöl Koloğlu M 525-527 Wrapping degloved fingers with a distal-based radial forearm perforator flap: A repair method for multiple digital degloving injury

Çoklu parmak degloving yaralanmasında bir tamir yöntemi: Yaralı parmakların distal bazlı radiyal önkol perforator flebi ile sarılması Çoban YK, Öcük Ö, Bekircan K

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EXPERIMENTAL STUDY

Application of pulsed arterial resuscitation in a rabbit model of hemorrhagic shock Wendong Sun, M.D.,1 Zhihui Shao, M.D.,2 Haisong Xu, M.D.,2 Wusi Qiu, M.D.,2 Jiahua Sun, M.D.2 1

Department of Orthopedics, Shaoxing People’s Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing-PRC

2

Department of Neurosurgery, Hangzhou Second Hospital, College of Medicine, Hangzhou Normal University, Hangzhou-PRC

ABSTRACT BACKGROUND: Hemorrhagic shock is characterized by tissue hypoperfusion caused by a sharp reduction in the effective circulating volume of blood. The key to successful resuscitation lies in eliminating the shock as soon as possible while simultaneously restoring blood perfusion to vital organs. We present the applicability of pulsed arterial blood reinfusion for resuscitation of hemorrhagic shock.

METHODS: Sixty rabbits were randomly assigned to resuscitation and control groups. A rabbit hemorrhagic shock model was developed by bloodletting from the carotid artery. The dynamic changes in blood pressure, urine output, blood lactate, and other indicators were measured.

RESULTS: Compared with the control group, the mean arterial pressure (MAP), pulse pressure, and urine output were significantly higher in the resuscitation group at 60 min (MAP: 83.67±3.90 vs. 38.19±3.50 mmHg, p<0.001; pulse difference: 16.46±2.21 vs.

10.27±2.99 mmHg, p<0.001; urine output: 3.68±0.74 vs. 0.10±0.05 mL·kg−1·min−1, p<0.001), whereas the serum lactate level was significantly lower (3.82±0.50 vs. 6.49±0.61 mmol/L, p<0.001). In addition, the resuscitation group had a significantly higher lactate clearance rate (30 min: 0.26%±0.11% vs. 0.25%±0.14%, p<0.001; 60 min: 0.30%±0.09% vs. 0.67%±0.26%, p<0.001) than the control group.

CONCLUSION: Pulsed arterial resuscitation might be useful for emergency treatment of hemorrhagic shock.

Keywords: Artery; hemorrhagic shock; pulse; resuscitation.

INTRODUCTION In recent decades, great progress has been made in the resuscitation of hemorrhagic shock, enabling most patients to receive timely medical treatment.[1–7] However, while early mortality has been significantly reduced, long-term mortality rate remains high. The main causes of death secondary to hemorrhagic shock are tissue hypoperfusion, major bleeding, and reperfusion injury, which can lead to multiple organ dysfunction syndrome.[8–12] Hemorrhagic shock is characterized by tissue hypoperfusion caused by a sharp reduction in the effective circulating volume of blood. Therefore, the key to successful resuscitation lies in eliminating the shock as soon as possible while simultaneously restoring blood perfusion to Address for correspondence: Wusi Qiu, M.D. 126 Wenzhou Road,Gongshu District 310015 Hangzhou - China Tel: +8613858019591 E-mail: shihai954@163.com Qucik Response Code

Ulus Travma Acil Cerrahi Derg 2017;23(6):445–451 doi: 10.5505/tjtes.2017.99567 Copyright 2017 TJTES

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vital organs, terminating ischemia and hypoxia in the cells, and rebuilding balance of the body’s oxygen supply and demand.

Irrespective of whether the traditional liberal fluid resuscitation or the newly proposed restricted fluid resuscitation method is used, a large amount of resuscitation fluids such as crystalloids, hypertonic saline and synthetic colloids need to be infused in a short time.[2,4,13–15] However, because of the high risk of peripheral venous collapse in these patients, the implementation of both these methods is difficult. In addition, the liquid is infused into a vein and thus cannot directly increase the perfusion to the heart, brain, kidney, and other organs; furthermore, the sudden rise in intravascular hydrostatic pressure and continuing decrease in plasma colloid osmotic pressure can lead to tissue edemas, such as pulmonary edema and cerebral edema, associated with increased intracranial pressure.[2,4,14,16] Rectifying tissue edema caused by fluid overload is currently a popular topic in fluid resuscitation research.[1,15] In recent years, the available arterial puncture procedures have gradually become more sophisticated. The carotid artery is located relatively superficially, is close to the heart, and has many receptors involved in regulating blood circulation on its vessel walls. In addition, as the blood supply of the brain depends on 445

Sun et al. Application of pulsed arterial resuscitation in a rabbit model of hemorrhagic shock

the bilateral common carotid arteries, if the liquid is infused through one side of the common carotid artery, the infusion will not cause reduction in blood flow to the brain because of the compensation from the other side. Thus, arterial resuscitation may represent an effective option for critically ill patients in whom conventional intravenous resuscitation is not suitable. In this study, we aimed to explore the applicability of pulsed arterial blood reinfusion for the resuscitation of hemorrhagic shock using a rabbit model of hemorrhagic shock. Furthermore, we hypothesized that pulsed arterial reinfusion would be more effective than the traditional liberal fluid resuscitation.

MATERIALS AND METHODS Animal Grouping and Preparation Sixty male or female (non-pregnant) rabbits, with a body weight of 1.5–2.5 kg, were provided by the Animal Center of the Southeast University School of Medicine (Animal Certificate of Conformity: SCXK [Su] 2012-0003). The rabbits were 1:1 randomly assigned using a random number table to the resuscitation or control group, with 30 rabbits in each group.

After they were weighed, the rabbits were anesthetized by injecting 20% urethane solution (5 mL/kg) through the ear vein and were fixed on the bench. Subsequently, the rabbits were subjected to a midline neck incision. The common carotid arteries were isolated and catheterized to collect blood samples with heparinization. The end of the catheter was connected to a biological signal acquisition system through a sterilized three-way connector (i.e., sterilized T-branch threeway pipe) to trace the arterial blood pressure, electrocardiography parameters, and other vital indicators.[5] The bladder was exposed and catheterized to collect urine specimens.

The end of the catheter was connected to a biological signal acquisition system to monitor urine output.

The research protocol was approved by the Institutional Review Board and the ethical committees of the Clinical Medical College of Hangzhou Normal University.

Preparation of the Hemorrhagic Shock Model The model was established using the described method with slight modifications.[4,17] After catheterization was completed and stabilized for 10 min, the blood pressure and heart rate were recorded, and blood samples were obtained as the baseline parameters. Next, blood was withdrawn at 2 mL/min from the common carotid artery through a 50-mL syringe.

The blood received an immediate anti-coagulant treatment with pH control and was stored for the subsequent blood reinfusion. Within 30 min after bloodletting, the mean arterial pressure (MAP) had decreased to 50% of the baseline value, which was maintained for 30 min.

30 min. Within 5 s, rabbits in the resuscitation group were reinfused with 5 mL of blood from the carotid artery, followed by 5 mL of saline (using the same lavage tube). This procedure was repeated every 5 min. Rabbits in the control group were reinfused into the venous system with 5 mL of blood from the ear vein at a constant speed, followed by 5 mL of saline (using the same lavage tube). This procedure was repeated every 5 min. The volume of the reinfused blood was 40% of the total blood volume removed.

Monitoring of indicators Animal systolic blood pressure, diastolic blood pressure, MAP, pulse pressure changes, and urine output were monitored throughout the experiment, and the changes in lip color were continuously observed. At 0, 30, 60 (start of resuscitation), and 90 min after the hemorrhagic shock model was established, blood was withdrawn to measure the lactate level (kit provided by Nanjing Jiancheng Bioengineering Research Institute, Jiangsu, China).

Statistical analysis All data were analyzed using SPSS 19.0 software (SPSS Inc., Chicago, IL). Quantitative data are presented as mean±standard deviation (x±s) and were analyzed using non-paired t-tests.

Qualitative data were analyzed using chi-squared tests. For all analyses, the level of significance was set at p<0.05.

RESULTS General Condition At 10 min after bloodletting, the animals began to show cyanosis of the lips, which gradually intensified during the shock process. At the beginning of the resuscitation, there were no significant changes in the lip color. However, when the reinfused blood volume amounted to approximately 30% of the total blood loss, the cyanosis on the lips of the rabbits in the resuscitation group began to subside. At the late stage of the resuscitation, the cyanosis had almost disappeared. In the control group, there were no significant changes in the cyanosis, with the rabbit lips exhibiting a dark purple color at the late stage of the resuscitation.

Mortality Rates No experimental animals died during the surgical preparation stage or the 30-min shock period. At 60 min, there were no deaths in the resuscitation group, whereas there were 9 deaths in the control group; however, there was no statistically significant difference in the mortality rate between the two groups at this time (p>0.05). At 90 min, there were still no deaths in the resuscitation group, whereas there were 18 deaths in the control group (p<0.01; Table 1).

Pulsed Arterial Blood Reinfusion Resuscitation

Comparison of Blood Pressure

The resuscitation began after the shock had been stable for

There were no significant changes in the blood pressure at

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Sun et al. Application of pulsed arterial resuscitation in a rabbit model of hemorrhagic shock

Table 1. Comparison of the mortality rates between the two groups treated with different reinfusion methods at different time points after establishing the rabbit model of hemorrhagic shock Group

No. of animals

Mortality rate (% [no. of animals])

0 min

30 min

60 min

90 min

Resuscitation group

30

0 (0)

0 (0)

0 (0)

0 (0)

Control group

30

0 (0)

0 (0)

30 (9)

60 (18)

χ2 value

3.529

8.571

P value

0.060

0.003

The resuscitation group received pulsed carotid artery reinfusion, and the control group received pulsed intravenous reinfusion. The resuscitation began at 60 min. Non-applicable values are left as blanks in this table.

0 and 30 min after the hemorrhagic shock model was established (p>0.05 for both). MAP and pulse pressure of the rabbits in the resuscitation group were significantly increased at 60 min than at 30 min (p<0.05 for both), whereas in the control group, the blood pressure was constantly decreasing.

From the beginning of the resuscitation, MAP and pulse pressure of rabbits in the resuscitation group were significantly higher than those of rabbits in the control group at all time points (p<0.01 for all; Table 2).

shock model was established (p>0.05 for both). At 60 and 90 min, the urine output of the rabbits in the resuscitation group was significantly increased when compared to that at 30 min, although it was lower than that at 0 min (p<0.05 for all).

Conversely, in the control group, the urine output decreased constantly. From the beginning of the resuscitation, the urine output of the rabbits in the resuscitation group was significantly higher than that of the rabbits in the control group at all time points (p<0.01 for all; Table 3).

Comparison of Urine Output

Comparison of Blood Lactate Levels

In both groups, there were no significant differences in the urine output between 0 and 30 min after the hemorrhagic

In both groups, there were no significant differences in the blood lactate levels between 0 and 30 min after the hemor-

Table 2. Comparison of the dynamic changes in blood pressure between the two groups treated with different reinfusion methods at different time points after establishing the rabbit model of hemorrhagic shock (Mean±SD) Group

Mean arterial pressure (mmHg [no. of animals])

0 min

30 min

60 min

90 min

Pulse pressure (mmHg [no. of animals]) 0 min

30 min

60 min

90 min

Resuscitation group 103.15±1.54 (30) 50.41±1.89 (30) 83.67±3.90 (30)a 78.61±4.76 (30)a 23.61±2.74 (30) 11.39±1.28 (30) 16.46±2.21 (30)a 16.24±2.07 (30)a Control group

102.65±1.87 (30) 49.47±3.71 (30) 38.19±3.50 (31)

22.36±4.49 (12) 22.99±2.38 (30) 11.38±1.14 (30) 10.27±2.99 (21)

7.37±1.05 (12)

t value

0.206 0.715 24.672 0.206 0.540 0.020 4.873 8.042

P value

0.839 0.484 0.000 0.000 0.596 0.984 0.000 0.000

The resuscitation group received pulsed carotid artery reinfusion, and the control group received pulsed intravenous reinfusion. Resuscitation began at 60 min. The value at 60 min was compared with that at 30 min within each group (p<0.05 for all). The number of animals is recorded within parentheses. a1 mmHg = 0.133 kPa.

Table 3. Comparison of the dynamic changes in urine output between the two groups treated with different reinfusion methods at different time points after establishing the rabbit model of hemorrhagic shock (Mean±SD) Group

Urine output (mL•kg-1•min-1, Mean±SD [no. of animals]) 0 min

30 min

60 min

90 min

Resuscitation group

23.674±2.891 (30)

0.282±0.157(30)

3.683±0.740 (30)a,b

2.262±0.496 (30)a,b

Control group

24.786±2.604 (30)

0.298±0.205 (30)

0.100±0.054 (21)

0.010±0.008 (12)

t value

-0.904

-0.196

12.653

8.866

p value

0.378 0.847 0.000 0.000

The resuscitation group received pulsed carotid artery reinfusion, and the control group received pulsed intravenous reinfusion. Resuscitation began at 60 min. The value at 60 min was compared with that at 0 min (ap<0.05) and at 30 min within each group (bp<0.05). The number of animals is recorded within parentheses.

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Sun et al. Application of pulsed arterial resuscitation in a rabbit model of hemorrhagic shock

Table 4. Comparison of the dynamic changes in blood lactate levels and lactate clearance rates between the two groups treated with different reinfusion methods at different time points after establishing the rabbit model of hemorrhagic shock (Mean±SD) Group

Blood Lactate Levels (mmol/L [no. of animals]) 0 min

30 min

60 min

Lactate clearance rate (% [no. of animals])

90 min

30 min

60 min

Resuscitation group

2.85±0.15 (30) 5.16±0.42 (30) 3.82±0.50 (30)a 3.60±0.47 (30)a

0.26±0.11 (30) 16.46±2.21 (30)

Control group

2.96±0.47 (30) 5.13±0.51 (30) 6.49±0.61 (21) 8.70±0.51 (12)

0.25±0.14 (21) 10.27±2.99 (21)

t value

-0.661

p value

0.517 0.678 0.000 0.000

-0.421

-9.916

-17.924

-8.442

-10.822

0.000 0.000

The resuscitation group received pulsed carotid artery reinfusion, and the control group received pulsed intravenous reinfusion. Resuscitation began at 60 min. The value at 60 min was compared with that at 0 min (ap<0.05). The number of animals is recorded within parentheses.

rhagic shock model was established (p>0.05 for both). From the beginning of the resuscitation, the blood lactate level of the rabbits in the resuscitation group significantly decreased, whereas in the control group, the blood lactate level continued to increase. At the beginning of the resuscitation, the blood lactate level of the rabbits in the resuscitation group was significantly decreased when compared with that of the control group, and the trend lasted until 90 min (p<0.01 for all). Moreover, at 30 and 60 min after the model was established, the lactate clearance rate of rabbits in the resuscitation group was significantly higher than that of the rabbits in the control group (p<0.01 for both; Table 4).

DISCUSSION Traditionally, a large influx of liquid is allowed into the systemic circulation within a short period of time, and this increase in circulating blood volume is beneficial for the maintenance of arterial blood pressure.[18,19] However, a sudden influx of liquid into the blood vessels will cause the infused blood to be retained in the venous system as the blood is in a state of stasis in the capillaries, which will cause a constant increase in the intravascular hydrostatic pressure.[13,20–22] In turn, this results in more intravascular liquid penetrating into the extravascular space through the blood vessel walls, which already show increased permeability due to the ischemic and hypoxic injury. Consequently, this process can cause edema of the internal organs, especially pulmonary edema.[2,15,23] which further aggravates the hypoxemia. In addition, this massive infusion of liquid may also lead to heart failure, thus creating a vicious cycle.[4,23–26] Further, after acute major bleeding, the peripheral veins will collapse, and phlebotomy or deep vein puncture will take a long time to complete. Hence, in some cases, the intravenous infusion rate cannot meet the needs of resuscitation.[11] Under these circumstances, other procedures, besides intravenous infusion, are needed for rapid infusion, and arterial resuscitation provides a feasible option for emergency resuscitation.

There have been some reports on arterial blood transfusion.

However, because of its complex nature and risk of adverse reactions such as vasospasm and limb ischemia, it is currently 448

only used as a backup plan in cases of severe shock, acute blood loss, near-death state, and clinical death.[6,17,27] In this study, during the process of preparing the hemorrhagic shock model, the average blood loss of the experimental animals was 25 mL/kg, and MAP decreased to 50% of the baseline value and stabilized at approximately 50 mmHg. MAP, pulse pressure, urine output, and blood lactate levels showed significant changes, indicating that the model met the requirements and was accurate. After the blood was partially reinfused by pulsed arterial reinfusion, MAP increased significantly, and in some rabbits, MAP could even be restored to the level before the shock. In addition, the pulse pressure also significantly increased and could be maintained for a long period of time.

It is generally considered that pulse pressure has a close relationship with tissue perfusion.[12] In this study, the urine output in the resuscitation group was found to significantly increase as well, indicating that the renal perfusion of the experimental rabbits was partially restored. Furthermore, the blood lactate level of the experimental animals decreased, suggesting that hypoxemia, which appeared from the onset of the shock and was aggravated throughout the experiment, was restored to a certain degree.

Only after the oxygen debt is repaid, tissue acidosis can be corrected; for shock resuscitation to be considered complete, the aerobic metabolism needs to be recovered in addition to the hemodynamic parameters. Our results suggested that pulsed arterial blood reinfusion could increase pulse pressure, elevate tissue perfusion, and alleviate hypoxemia in a rabbit model of shock. Hypoxemia has always been considered the root cause of complications in shock and the major cause of mortality in these rabbits.[13,15,17] Therefore, it is reasonable to believe that the application of pulsed arterial blood reinfusion may reduce early mortality in patients with hemorrhagic shock, while also having positive effects on the incidence of complications due to shock and late mortality.[13,28,29] In addition to rapidly increasing the effective circulating blood volume, arterial blood transfusion can pump the Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

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blood directly into the aorta, from where most of the blood is directly transported to various organs in need, particularly including the heart, brain, and kidneys; this process can rapidly improve the ischemic and hypoxic status of the body.

[15,24] The direct supply of blood to the brain through the carotid tissues is beneficial to the recovery of vital medullary life functions, consequently improving the functioning of the central nervous system, especially that of the cortex and subcortical regions and thereby restoring the regulatory functions that were initially interfered with.[27,30] As the blood is infused under added arterial pressure, which does not rely on the function of the heart that is already fragile, the burden placed on the heart is relieved. Furthermore, because the infused arterial blood can directly flow into the coronary arteries, this also alleviates the myocardial ischemia and facilitates the recovery of cardiac function.[27,30] The blood that flows through the aorta quickly enters the kidneys, gastrointestinal tract, and other organs, thus increasing the blood perfusion, protecting the function of the internal organs, and slowing down the systemic inflammatory response syndrome, as well as reducing the risks of intestinal bacterial translocation and intestinal endotoxemia. Because the transfused blood in the artery flows retrogradely, it forms turbulences in the large vessels (similar to ventricle turbulence), which helps to mix the blood thoroughly. Therefore, the oxygen content of the blood transported to the various organs will not increase too abruptly, thus creating a buffer allowing for a gradual increase of oxygen content in the body. This helps reduce ischemia and reperfusion injury and can hence help reduce the risks of visceral and pulmonary edemas.[13,27,30] Moreover, the pressurized transfusion of arterial blood constantly stimulates the vessel walls, including the chemical receptors and baroreceptors of the aortic arch and carotid sinus. The reflex protection system of the body and the vagal reflex from the direct stimulation of blood on the arterial wall can result in a significant elevation of arterial pressure[29,31] and lead to high blood pressure at the arterial end of the capillaries, which helps reduce capillary congestion. The decrease in heart rate induced by this reflex may increase the pulse pressure, improve the cardiac ejection capability, and eventually augment the tissue perfusion pressure; visceral vasodilation induced by this reflex also helps improve the visceral blood perfusion. A small proportion of the retrograde blood flows into the heart ventricle, thereby prolonging ventricular isovolumic relaxation and promoting rapid closure of the semilunar valves. As a result, the ventricular pressure will decrease sharply, thus forming a large suction force as the main driving force of rapid ventricular filling. This force will cause increased blood flow from the left atrium into the left ventricle, which helps alleviate venous congestion, and will also increase the left ventricular end-diastolic volume. Myocardial contractility is strengthened through self-regulation, and the diastolic extension is also conducive to coronary blood supply, thus forming a virtuous circle.

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As a result of pulsed arterial blood transfusion, the negative effect of stimulating the blood vessel wall is reduced and the occurrence of vasospasm is decreased. Mild protective vasospasm helps increase peripheral resistance to increase blood pressure and will not affect the ability of blood vessels to transport blood. Moreover, pulsed arterial blood transfusion may also help reduce endothelial injury, maintain endothelial secretion and barrier functions, reduce blood vessel wall inflammation, and reduce the risk of thrombosis.[32] The pulsed procedure stimulates the aortic arch and chemical receptors to preserve them in a sensitive state, and therefore, resetting will not occur. Meanwhile, the pulsed procedure does not result in constant stimulation of the vagus nerve to cause hyperexcitability and will hence not cause a reduction in the cardiac ejection blood volume to aggravate low blood pressure. This reduces the blood pressure fluctuations as well as the interference on the hemodynamics and on the body’s own regulation during the buffering period.[22,32] Lastly, blood (especially autologous blood, including uncontaminated body cavity blood and frozen plasma extracted and prepared in advance from high-risk groups such as soldiers) [25–27] has always been considered the best and most effective resuscitation solution. Apart from momentarily increasing blood volume and reducing apoptosis, the blood can moreover supplement coagulation factors, which help control bleeding.

Conclusion With the recent advancements in arterial puncture technology, arterial resuscitation can enable direct transportation of blood to the heart, brain, kidneys, and other organs, thereby greatly reducing the reliance on cardiac function. Therefore, pulsed arterial resuscitation might be useful for the emergency treatment of hemorrhagic shock. However, further studies and discussions are still needed on whether pulsed arterial resuscitation can improve the clinical cure rate and reduce mortality.

Acknowledgments The present study was supported by the Health and Familly Plannning Comission of Zhejiang Province, China (No.2014RCA023) and Science and Technology Department of Hangzhou, China (No.20120533Q22, 20150733Q18).

Conflict of interest: None declared.

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27. Elbers P, Gatz R. Crystalloid resuscitation in hemorrhagic shock. Resuscitation 2012;83:e172.

28. Gao J, Zhou L, Ge Y, Lin S, Du J. Effects of different resuscitation fluids on pulmonary expression of aquaporin1 and aquaporin5 in a rat model of uncontrolled hemorrhagic shock and infection. PLoS One 2013;8:e64390.

29. Sloan EP, Koenigsberg MD, Philbin NB, Gao W. Diaspirin cross-linked hemoglobin infusion did not influence base deficit and lactic acid levels in two clinical trials of traumatic hemorrhagic shock patient resuscitation. J Trauma 2010;68:1158–71.

30. Kendigelen P, Kamalak Z, Abat D.Should warm fresh whole blood be the first choice in acute massive hemorrhage in emergency conditions?Ulus Travma Acil Cerrahi Derg 2016;22:195–8.

31. Balbino M, Capone Neto A, Prist R, Ferreira AT, Poli-de-Figueiredo LF. Fluid resuscitation with isotonic or hypertonic saline solution avoids intraneural calcium influx after traumatic brain injury associated with hemorrhagic shock. J Trauma 2010;68:859–64.

32. DU Z, Jia H, Liu J, Zhao X, Wang Y, Sun X. Protective effects of hydrogen-rich saline in uncontrolled hemorrhagic shock. Exp Ther Med 2014;7:1253–8.

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Sun et al. Application of pulsed arterial resuscitation in a rabbit model of hemorrhagic shock

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Tavşan hemorajik şok modelinde atımlı arteriyel resüsitasyon uygulaması Dr. Wendong Sun,1 Dr. Zhihui Shao,2 Dr. Haisong Xu,2 Dr. Wusi Qiu,2 Dr. Jiahua Sun2 1 2

Shaoxing Halk Hastanesi, Zhejiang Üniversitesi Shaoxing Hastanesi, Ortopedi Bölümü, Shaoxing-Çin Halk Cumhuriyeti Hangzhou İkinci Hastanesi, Hangzhou Normal Üniversitesi Tıp Fakültesi, Nöroşirürji Bölümü, Hangzhou-Çin Halk Cumhuriyeti

AMAÇ: Hemorajik şok dolaşımdaki etkin kan volümünde aniden azalmanın neden olduğu doku hipoperfüzyonuyla karakterizedir. Resüsitasyonun anahtarı mümkün olduğu kadar kısa sürede şokun ortadan kaldırılmasıyla birlikte aynı anda yaşamsal organlara kan perfüzyonunu sağlamadaki başarıdır. Biz burada hemorajik şok resüsitasyonunda atımlı arteriyel kan reperfüzyonunun uygulanabilirlik durumunu sunmaktayız.

GEREÇ VE YÖNTEM: Altmış tavşan randomize yöntemle resüsitasyon ve kontrol gruplarına ayrıldı. Karotis arterden kan akıtılarak hemorajik şok modeli geliştirilmişti. Kan basıncı, idrar çıkarımı, kan laktat ve diğer belirteçlerdeki dinamik değişiklikler ölçüldü.

BULGULAR: Kontrol grubuyla karşılaştırıldığında, 60. dakikada resüsitasyon grubunda OAB, nabız basıncı ve idrar çıkarımı anlamlı derecede daha yüksek (OAB: 83.67±3.90’a karşın, 38.19±3.50 mmHg, p<0.001; nabız sayısındaki farklılık: 16.46±2.21’e karşın, 10.27±2.99 mmHg, p<0.001; idrar miktarı: 3.68±0.74’e karşın, 0.10±0.05 mL·kg-1·dk-1, p<0.001), serum laktat düzeyi ise anlamlı derecede daha düşüktü (3.82±0.50’e karşın 6.49±0.61 mmol/L, p<0.001). Ayrıca resüsitasyon grubunda laktat klirens oranı anlamlı derecede daha yüksekti (30 dk: %0.26±0.11’e karşın %0.25±0.14, p<0.001; 60 dk: %0.30±0.09’a karşın %0.67±0.26, p<0.001).

TARTIŞMA: Hemorajik şokun acilen tedavisinde atımlı arteriyel resüsitasyon kullanılabilir.

Anahtar sözcükler: Arter; hemorajik şok; nabız; resüsitasyon.

Ulus Travma Acil Cerrahi Derg 2017;23(6):445–451

doi: 10.5505/tjtes.2017.99567

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EXPERIMENTAL STUDY

Combined and individual use of pancaspase inhibitor Q-VD-OPh and NMDA receptor antagonist riluzole in experimental spinal cord injury Halil Can, M.D.,1 Aydın Aydoseli, M.D.,2 Cengiz Gömleksiz, M.D.,1 Burcu Göker, M.D.,3 Muhittin Emre Altunrende, M.D.,4 Müge Dolgun, M.D.,2 Altay Sencer, M.D.2 1

Department of Neurosurgery, Medicine Hospital, Istanbul-Turkey

2

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

3

Department of Neurosurgery, Liv Hospital, İstanbul-Turkey

4

Department of Neurosurgery, Gaziosmanpaşa Taksim Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: We investigated the effects of an N-methyl-D-aspartate receptor antagonist, riluzole, and a pancaspase inhibitor and basic apoptosis mediator, Q-VD-OPh, in combination or alone in posttraumatic spinal cord injury.

METHODS: In our study, 45 healthy male Sprague Dawley rats were used. Spinal trauma was induced by the clip compression technique via thoracal 7, 8, 9 laminectomies. After inducing the trauma, the drug was continuously administered intraperitoneally for 5 days. After inducing the trauma, the subjects were assessed using Tarlov’s motor grading scale and inclined plane test. Five days after the trauma, the spinal cord specimens were harvested, and a histopathological examination was performed.

RESULTS: Compared with the other groups, a statistically significant difference with regard to better results for necrosis, inflammation, and apoptosis was observed in the riluzole only and combination groups. Statistically better motor function scores were observed in the Q-VD-OPh only group than in the other groups.

CONCLUSION: With regard to limiting secondary damage after trauma, statistically significant results were observed in the Q-VDOPh only and Q-VD-OPh–riluzole combination groups. More extensive laboratory studies are required to limit and control the effects of secondary damage after spinal cord trauma.

Keywords: Apoptosis; caspases; necrosis; neuroprotection; NMDA receptor antagonist; pancaspase inhibitor; Q-VD-OPh; riluzole; spinal cord injury.

INTRODUCTION Spinal cord injury (SCI) results in an irreversible primary traumatic damage, which is followed by a secondary damage that is mediated by different mechanisms. Researches mainly focused on preventing secondary damage mechanisms in SCI, which start at the exact moment of trauma and may conAddress for correspondence: Burcu Göker, M.D. Ahmet Adnan Saygun Caddesi, Canan Sokak, No: 5, Ulus, Beşiktaş, İstanbul, Turkey Tel: +90 212 - 999 84 19 E-mail: burcugoker79@yahoo.com Submitted: 22.12.2016 Accepted: 03.03.2017

Ulus Travma Acil Cerrahi Derg 2017;23(6):452–458 doi: 10.5505/tjtes.2017.09694 Copyright 2017 TJTES

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tinue for several weeks. Major cell death mechanisms, namely necrosis and apoptosis, are involved in secondary damage.

Therefore, many experimental studies have been conducted to inhibit necrosis or apoptosis to prevent secondary damage.

Until recent years, necrosis has been accepted as the only mechanism that plays a role in secondary damage, and excitotoxicity has been indicated as the main factor in the necrosis pathway that leads to posttraumatic neural degeneration.

[1,2] Glutamate is the key excitatory neurotransmitter in the central nervous system. In case of ischemia or hypoxia, the cellular energy levels decrease, causing glutamate to induce neurotoxicity by activating N-methyl-D-aspartate (NMDA) receptors.[3] At the same time, trauma-induced activation of voltage-sensitive sodium channels causes intracellular ion influx, particularly increased sodium and calcium levels; this leads to cytotoxic edema.[4] NMDA receptor antagonists in Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Can et al. Combined and individual use of Q-VD-OPh and riluzole in experimental spinal cord injury

experimental SCI models have been well studied to reverse excitotoxicity.[5,6] Although many NMDA receptor antagonists usually have limited clinical use because of their adverse effects, memantine, a non-competitive NMDA receptor antagonist, is clinically used for a series of cerebral disorder with minimal adverse effects. Memantine also has neuroprotective effects, which have been demonstrated in several experimental SCI models.[7–9] Besides Memantine, a sodium channel-blocking benzothiazole anticonvulsant and an NMDA receptor antagonist, riluzole, plays a neuroprotective role in preclinical SCI models.[10] Riluzole inhibits glutamate excretion at the presynaptic level and modulates glutamate transfer from synapses. Furthermore, by blocking voltage-dependent sodium channels, riluzole inhibits the G protein signaling guanylyl cyclase cascade and protects the cell from the excitotoxic effects of glutamic acid that is secreted after cell death.

[11] Recent researches indicate that riluzole has a neuroprotective effect against the neurodegenerative disorder called amyotrophic lateral sclerosis (ALS). Riluzole has only minor adverse effects such as affecting serum alanine transaminase levels and has made a significant delay in the timing of tracheostomy, therefore it has been approved by FDA in the treatment of amniotrophic lateral sclerosis (ALS).[12] Current studies have underlined the role and importance of apoptosis in secondary damage after SCI.[13–17] As defined “programmed cell death,” apoptosis comprises cell autodigestion with enzymatic reactions and cell removal by phagocytes without inflammatory response. Caspases, which are cysteine proteases, play a crucial role in regulating apoptosis.[13,18,19] QVD-OPh is an irreversible pancaspase inhibitor whose neuroprotective effects have been demonstrated in experimental ischemia–hypoxia, stroke, and SCI models.[3,20] Q-VD-OPh acts as an inhibitor of caspase9/3, caspase 8/10, and caspase 12, which are major caspase pathways for apoptosis.[21,22] Various experimental studies have investigated the efficacy of caspase inhibitors in neuroprotection after SCI, and positive results have been reported.[15,23–25] Since 1996, preclinical studies have demonstrated that riluzole alone improves SCI outcomes such as reduced tissue cavitation, better preservation of white matter and motor neurons, better mitochondrial function, better somatosensory evoked potentials, and locomotor scores.[26] This study aimed to investigate the efficacy of NMDA receptor antagonists/sodium channel blockers and pancaspases inhibitors alone and in combination for preventing apoptosis that occurs after a primary injury.

MATERIALS AND METHODS In total, 45 healthy male Sprague Dawley rats obtained from the Experimental Research Center of Medical School of Istanbul, Istanbul University were used. The rats weighed 250–300 g and aged 10–12 months. They were housed under diurnal light conditions, i.e., 12 h of darkness and 12 h of Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

light, and they were fed a standard diet during the study. All experimental protocols were approved by the institutional ethical committees and local institutional animal care and use committee of İstanbul University.

Q-VD-OPh was obtained from Calbiochem (Kimeksİstanbul). In brief, 0.4 mg/kg Q-VD-OPH, a solid form of wide-spectrum caspase inhibitors (dissolved in DMSA solution:1 mg Q-VD-OPh/10 ml DMSA) and 5 mg/kg riluzole (Rilutek Sanofi/Avantis), a NMDA antagonist, were intraperitoneally administered to every rat at 1 h after the trauma.[11]

1. Experimental Groups Rats were randomly categorized into the following five groups, with each group comprising nine rats with properties as listed below (Table 1).

Group1: After the trauma following thorocal 7, 8, 9 laminectomy, only SCI was induced and no medication was administered.

Group2: After the trauma following thoracal 7, 8, 9 laminectomy, physiological serum was intraperitoneally administered (0.9% NaCl).

Group 3 (treatment group; Q-VD-O Phgroup): After the trauma following thorocal 7, 8, 9 laminectomy, only QVD-OPh was intraperitoneally administered.

Group 4 (treatment group; riluzole group): After the trauma following thoracal 7, 8, 9 laminectomy, only riluzole was intraperitoneally administered.

Group 5 (treatment group; riluzole–Q-VD-OPh group): After the trauma following thoracal 7, 8, 9 laminectomy, riluzole and Q-VD-OPh were intraperitoneally administered in combination.

Surgical Procedure This study was conducted according to the principles of American National Society for Medical Research of National Academy of Sciences for the access and maintenance of laboratory animals. All the rats were prepared for surgery with Table 1. Description of the experimental groups

Physiological serum (%0.9 NaCl)

Q-VD-OPh

Riluzole

Group 1 Group 2

+

Group 3

+

Group 4

+

Group 5

+

+

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overnight starving. General anesthesia was performed using 60 mg/kg ketamine (Ketalar; Eczacıbaşı/İstanbul, Turkey) and 9 mg/kg xylazine (Rompun-Bayer/İstanbul, Turkey). After general anesthesia, the dorsal part of each rats was shaved, and after local antisepsis, with the reference of the interscapular distance, a midline incision was made. Paravertebral muscles were bluntly dissected. After identification of thoracal laminas 7-8-9, total laminectomies and bilateral facetectomies were performed. (T7-9) Transverse processes were also removed to have a wide opening of the spinal cord, enabling the vertical clipping of the spinal cord. The dura mater was left intact during all these processes. The spinal cord of the rats of each group was compressed for 30 s using a Yaşargil aneurysm clip, and after removing the clip, the layers were closed in a standard manner.

In Group 1 no drug was administered. In the Group 2, physiological serum; in Group 3, 0.4 mg/kg Q-VD-OPh; in Group 4, 5 mg/kg riluzole; in Group 5, 0.4 mg/kg Q-VD-OPh and 5 mg/kg riluzole was intraperitoneally administered immediately after the trauma and the following 5 days. After 5 days, the rats were re-anesthetized by intraperitoneally injecting Ketalar (65 mg/kg). The thorax wall was incised and was cranially lifted and fixed. The diaphragm and pericardium were also incised. After the intracardiac injection of 2-cc KCl solution in the right ventricle, cardiac contractions were monitored.

When the contractions ended, the rats were placed in the prone position, and via the former dorsal incision, spinal cord specimens were harvested from the laminectomy field. The specimens were fixed in 0.1 mol phosphate-buffered (pH7.4) 2.5% glutaraldehyde solution. Paraffin blocks were prepared from the specimens that were fixed 2.5% glutaraldehyde solution.

Histological Analysis Hematoxylin and eosin (H&E) staining and TUNEL staining were performed for histological assessment. Hematoxylin staining is the primary method for revealing necrosis and apoptosis in cells.Terminal deoxynucleotidyl transferase (TdT)-mediated dUTP-biotin nick and labeling (TUNEL) staining is based on the principle of specific binding of TdTto the 3-OH groups of DNA. After exposing the nuclear DNA of the histological sections, TdT is used to add dUTP-biotin to the endings of the DNA fragments.

Xylene was added to the paraffin blocks according to H&E staining. After soaking the samplesin alcohol, they were placed in water and immersed in hematoxylin for 5 min. The samples were washed under running tap water and were allowed to turn purple. After incubation in eosin for 2-3 min, the samples were rinsed again under running tap water, fixated with alcohol, and mounted with xylene-based Canada balsam.

For TUNEL staining, the samples were incubated in an incu454

bator overnight at 56°C. Then, the samples were immersed in xylene for 30 min, in 96% alcohol for 10 min, 80% alcohol for 5 min, 70% alcohol for 5 min, and rinsed with distilled water. The samples were taken in TBS and dried. After 20 min, the samples were washed with TBS. Then, 3% H2O2 with methanol was performed on the samples, and after 5 min, the samples were washed using TBS. The 10X Klenow equilibration buffer, which was diluted 1:10 with distilled water, was performed and incubated for 30 min. After washing, the residue was soaked up using a paper towel, and pre-prepared Klenow labeling reaction mix and Klenow enzyme solution were performed on the samples. The samples were then mounted with paraffin and incubated for 1.5 h at 37°C in the incubator. Next, they were rinsed with TBS, and STOP buffer was performed. At 5 min after washing, the blocking buffer was performed. After 10 min, without being washed up with TBS, diluted 50X conjugate 1:50 blocking buffer was dripped.

After 30 min, samples were washed with TBS, and DAB buffer was performed. After 10 min, samples were washed with distilled water. Methyl green was performed. After 30 s, the color was adjusted using acetone. Then, samples were dried and mounted with xylene.

The specimens were examined using the Olympus BX50 microscope at a magnification of 20×, and 2-3 mm thick sections of specimens were evaluated. For evaluating apoptosis, the percentage of cell numbers were classified as 0–25,[27] 25–50,[28] 50–75,[29] and 75–100.[30]

Clinical Neurological Examination Clinical motor examination was performed on the third and seventh day as previously described by Tarlov.[9] According to this description: Grade 5: Complete recovery.

Grade 4: Ability to walk; but posterior limbs have slight spasticity and lack of coordination.

Grade 3: Ability to get up but not being able to walk.

Grade 2: Minimal voluntary motor function of the posterior limbs but not being able to stand up on the posterior limbs.

Grade 1: No movement.

Evaluation with Inclined Plane Test In 1977, Rivlin et al.[31] described the inclined plane test as an objective testing of motor functions. In this test, after horizontally placing the animal on an inclined plane, the angle between the ground and plane was gradually augmented. The maximum angle at which the rat could stand for 5 s on this plane without being overthrown was noted to be the degree of inclined plane for the animal. This test was repeated on the first, third, and fifth day for all groups.

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Statistical Analysis

(b)

Except for the inclined plane test, all variables were assessed using Kruskal–Wallis and Mann–Whitney two-way comparison. In the two-way comparison, Bonferroni correction (significance level/correction number) was used for the level of significance. ANOVA and Scheffe’s two-way comparison were used for comparing the inclined plane test degrees.

RESULTS Histological Findings Lymphocyte Mann–Whitney test results showed a statistically significant difference in lymphocyte counts of the riluzole alone and riluzole–Q-VD-OPh groups (Groups 4 and 5) compared with those of the other groups. No significant difference was found among the other groups (Groups 1, 2, and 3). Furthermore, no statistically significant difference was observed between Groups 4 and 5.

PNL Mann–Whitney test results showed a statistically significant difference in PNL counts of the riluzole alone and riluzole– Q-VD-OPh groups (Groups 4 and 5) compared with those of the other groups. No significant difference was found among the other groups (Groups 1, 2, and 3).In addition, no statistically significant difference was observed between Groups 4 and 5.

Necrosis Mann–Whitney test results showed a statistically significant difference in necrotic cell counts of the riluzole alone and riluzole–Q-VD-OPh groups (Groups 4 and 5) compared with those of the other groups. No significant difference was found among the other groups (Groups 1, 2, and 3). Moreover, no statistically significant difference was observed between Groups 4 and 5.

Apoptosis Mann–Whitney test results showed a statistically significant

Figure 1. (a) A histopathological specimen prepared using TUNEL staining from the trauma only group showing an increased number of apoptotic cells. (b) A specimen prepared using TUNEL staining from the combination group showing a decrease in apoptotic cells and necrotic cavitation.

difference in apoptotic cell counts of the Q-VD-OPh alone and riluzole–Q-VD-OPh groups (Groups 3 and 5) compared with those of the other groups. No significant difference was found among the other groups (Groups 1, 2, and 4). In addition, no statistically significant difference was observed between Groups 3 and 5 (Fig. 1a, b).

Functional Findings Mann–Whitney U test, a two-way comparison method, results showed a statistically significant difference in better motor functions, assessed by the Tarlov motor grading scale, in Group 3 (Q-VD-OPh group) than inthe trauma only and placebo groups (Groups 1 and 2). Although Group 5 had better results with regard to better motor functions, no statistically significant difference was found between Group 5 and Groups 1, 2, and 4. No statistically significant difference was observed between Groups 3 and 5.

InclinedPlane Test Assessments At the end of the fifth day, a statistically significant difference was observed regarding better inclined plane scores in Groups 3 and 5 compared with those in the other groups. There was no statistically significant difference between Groups 3 and 5, as well as that among Groups 1, 2, and 4 (Table 2).

DISCUSSION In Turkey, the incidence of SCI is 500–600 new cases per year,

Table 2. Significance of the presence of lymphocyte, PNL, necrosis, apoptosis, and Tarlov scale/inclined plane scores for each group

Group 1

Group 2

Group 3

Group 4

Group 5

Lymphocyte

p<0.001

p<0.001

PNL

p<0.001

p<0.001

Necrosis

p<0.001

p<0.001

Apoptosis

p<0.001

Tarlov scale

p<0.001

Inclined plane scores

p<0.001

p<0.001 p<0.001

PNL: Polymorphonuclear leukocyte.

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and the prevalence is 12.7/1000000 per year.[32] SCI is a serious health problemwhich generally occurs in individuals aged 16–30 years and causes loss of income and labor, thereby leading to an increase in treatment and care expenses.[33,34] Although recent literature has basic current guidelines that propose surgery (decompression and stabilization) as a primary intervention for treating SCI, a basic guideline for medically treating SCI is required.[33,34] Nowadays, research is particularly based on the prevention or reduction of secondary damage after SCI.[35,36] The primary problem of secondary damage is necrosis and apoptosis. Excitatory neurotransmitters such as glutamate play an important role in necrosis, and under pathological conditions, they may cause excitotoxicity. Excitotoxicity affects via two different pharmacologic and electrophysiological receptor groups: metabotropic and ionotropic receptors.

[29,37–40] The best known ionotropic receptor is the NMDA receptor.[29,40,41] It has been stated that in cortical cell cultures where oxygen or glucose is absent, neurons primarily die via excitotoxic necrosis, but when this exitotoxicity is blocked by combined NMDA receptor antagonists, these neurons are dead because of apoptosis.[42,43] Apoptosis is an active process that uses cellular protein and energy. It is a programmed cell death in which the autodigestion of cells through enzymatic reactions and macrophage phagocytation occur.[44] Caspase-dependent signaling pathways play a crucial role in inducing apoptosis.

To date, 14 mammalian caspases have been confirmed. There are extrinsic and intrinsic apoptopic pathways in which caspases function. Among the caspases, caspase-8 is primarily activated in the extrinsic pathway, whereascaspase-9 andcaspase-12 are basic mediators in the intrinsic pathway. A pancaspase inhibitor, Q-VD-OPh, prevents apoptosis via the following three basic mechanisms:[21,22,45] 1- By inhibiting the activation of the caspase-9 and caspase-3, which was initiated by cytochrome C secreted from the mitochondria.

2- By inhibiting the activation of caspase-8 and caspase-10, which is activated after binding to the TNF-alpha and Fas/ CD95 death receptors.

riluzole protects motor neurons from the exitotoxic effects of glutamatic acid, which is secreted after cell death owing to anoxia.[11,49] In our study, statistically better resultsfor functional motor findings were obtained in Group 5 (Q-VD-OPh and riluzole) than in the trauma and riluzole only groups. There was no significant difference between Group 3 (Q-VD-OPh group) and 5. Regarding inclined plane test score findings on the third and fifth day, statistically better results were observed Groups 3 and 5 than in Groups 1, 2, and 4. No statistically significant difference was observed among Groups 1, 2, and 4. Furthermore, no statistically significant difference was observed when Groups 3 and 5 were compared. As indicators of secondary damage, histopathological findings such as necrosis, lymphocyte count, and PNL count were investigated.

Regarding necrosis, PNL counts, and lymphocyte counts, statistically better results were observed in Groups 4 (riluzole group) and 5 than in Groups 1, 2, and 3. There was no statistically significant difference between Groups 4 and 5.

Regarding the apoptosis rate, no statistically significant difference was observed between Groups 1, 2, and 4. However, we found statistically better results in Groups 3 and 5than in Groups 1, 2, and 4.

Conclusion We found statistically better results in Group 5 (Q-VD-OPh andriluzole, an NMDA receptor antagonist) with regard to neurological findings, particularly the contribution of Q-VDOPh was significant, although the use of riluzole appeared to be ineffective. We also noted statistically better results in the Q-VD-OPh alone and Q-VD-OPh–riluzole groups than in the other groups with regard to inclined plane score findings.

We conclude that Q-VD-OPh significantly reduced the apoptosis rate but had no effect on PNL and lymphocyte counts, which are indicators of necrosis and inflammation. We also noted that riluzole significantly reduced PNL and lymphocyte counts, whereas it had no apparent effect on the apoptosis rate. Thus, we observed that a combination of Q-VD-OPh, a pancaspase inhibitor, and riluzole, an NMDA receptor antagonist, significantly reduced the apoptosis and necrosis, which are indicators of secondary damage.

Although the role of necrosis is more distinct in SCI, we conclude that therapies against the prevention of apoptosis may lead to better results for these injuries.

3- By inhibiting the activation of caspase-12 that is located on the membrane of the endoplasmic reticulum and is a basic mediator for ER-mediated apoptosis.

Conflict of interest: None declared.

Riluzole, a voltage-dependent sodium channel inhibitor, is also a mediator of the postsynaptic glutamate transfer and has a role in the G protein signaling guanylyl cyclase cascade. Riluzole is still being extensively used to treat ALS patients worldwide.[11,46–48] In vitro studies have shown that

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2. Dumont RJ, Verma S, Okonkwo DO, Hurlbert RJ, Boulos PT, Ellegala DB, et al. Acute spinal cord injury, part II: contemporary pharmacothera-

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24. Akdemir O, Berksoy I, Karaoğlan A, Barut S, Bilguvar K, Cirakoğlu B, et al. Therapeutic efficacy of Ac-DMQD-CHO, a caspase 3 inhibitor, for rat spinal cord injury. J Clin Neurosci 2008;15:672–8.

25. Karaoğlan A, Kaya E, Akdemir O, Sağmanligil A, Bilguvar K, Cirakoğlu B, et al. Neuroprotective effects of Ac.YVAD.cmk on experimental spinal cord injury in rats. Surg Neurol 2008;69:561–7.

26. Tator CH, Hashimoto R, Raich A, Norvell D, Fehlings MG, Harrop JS, et al. Translational potential of preclinical trials of neuroprotection through pharmacotherapy for spinal cord injury. J Neurosurg Spine 2012;17:157–229.

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33. Schwab ME, Bartholdi D. Degeneration and regeneration of axons in the lesioned spinal cord. Physiol Rev 1996;76:319–70.

34. Tator CH. Biology of neurological recovery and functional restoration after spinal cord injury. Neurosurgery 1998;42:696–707.

35. Faden AI. Pharmacotherapy in spinal cord injury: a critical review of recent developments. Clin Neuropharmacol 1987;10:193–204.

36. Janssen L, Hansebout RR. Pathogenesis of spinal cord injury and newer treatments. A review. Spine (Phila Pa 1976) 1989;14:23–32.

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DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Deneysel omurilik yaralanmasında genel kaspaz inhibitörü Q-VD-OPh ve NMDH reseptör antagonisti riluzole’ün izole ve birlikte kullanımı Dr. Halil Can,1 Dr. Aydın Aydoseli,2 Dr. Cengiz Gömleksiz,1 Dr. Burcu Göker,3 Dr. Muhittin Emre Altunrende,4 Dr. Müge Dolgun,2 Dr. Altay Sencer2 Medicine Hospital, Beyin ve Sinir Cerrahisi Kliniği, İstanbul İstanbul Üniversitesi İstanbul Tıp Fakültesi, Beyin ve Sinir Cerrahisi Anabilim Dalı, İstanbul Liv Hospital, Beyin ve Sinir Cerrahisi Kliniği, İstanbul 4 Gaziosmanpaşa Taksim Eğitim ve Araştırma Hastanesi, Beyin ve Sinir Cerrahisi Kliniği, İstanbul 1 2 3

AMAÇ: Travma sonrası omurilik yaralanmalarında “ikincil hasar” olarak tanımlanan süreçte N-metil-D-aspartik asit reseptör antagonisti riluzole ve apoptozisin temel efektörü olan kaspazların genel inhibitörü Q-VD-OPh’nın ayrı ayrı ve birlikte kullanımlarının ikincil hasar gelişimi üzerine olan etkilerinin incelemesi amaçlandı.

GEREÇ VE YÖNTEM: Bu çalışmada Sprague-Dawley türünden sağlıklı 45 adet erkek sıçan kullanıldı. Omurilik travması dorsal 7, 8, 9 laminektomi sonrası klip kompresyon yöntemi kullanılarak gerçekleştirildi. İlaçlar travmadan hemen sonra başlamak üzere beş gün boyunca intraperitoneal olarak uygulandı. Travma sonrası denekler Tarlov skalası ve eğik düzlem testi ile değerlendirildi. Beş gün sonra alınan omurilik örnekler hemotoksilen - eozin ve TUNEL boyama yöntemi kullanılarak histolojik incelemesi yapıldı.

BULGULAR: Histolojik inceleme sonrası enflamatuvar yanıt, nekroz ve apoptoz riluzole ve kombine ilaç kullanılan grupta diğer gruplara göre istatiksel olarak anlamlı iyi sonuçlar elde edildi. Deneklerin klinik motor fonksiyon değerlendirilmesinde Q-VD-OPh kullanılan grupta diğer gruplara göre istatistiksel olarak anlamlı iyi sonuçlar elde edildi.

TARTIŞMA: Q-VD-OPh ve riluzole-Q-VD-OPh kombinasyonun travmada ikincil hasarın sınırlandırılmasında istatistiksel olarak iyi klinik ve histolojik sonuçlar elde edildi. Spinal travma sonrası ikincil hasarın etkisinin ortadan kaldırılması veya sınırlanması için laboratuvar çalışmaları daha kapsamlı yapılmalıdır.

Anahtar sözcükler: Apoptozis; kaspazlar; nekroz; NMDA reseptör antagonisti; omurilik yaralanması; pankaspaz inhibitörü; riluzol; sinir dokusunun korunması; Q-VD-OPh. Ulus Travma Acil Cerrahi Derg 2017;23(6):452–458

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EXPERIMENTAL STUDY

A new perspective on life-saving procedures in a battlefield setting: Emergency cricothyroidotomy, needle thoracostomy, and chest tube thoracostomy with night vision goggles Sedat Bilge, M.D.,1 Attila Aydın, M.D.,1 Meltem Bilge, M.D.,3 Cemile Aydın, M.D.,4 Erdem Çevik, M.D.,2 Mehmet Eryılmaz, M.D.1 1

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

2

Department of Emergency Medicine, Sultan Abdülhamit Training and Research Hospital, İstanbul-Turkey

3

Department of Anesthesiology and Reanimation, Dışkapı Training and Research Hospital, Ankara-Turkey

4

Department of Internal Medicine, Ankara Etimesgut State Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: In the patients with multiple and serious trauma, early applications of life-saving procedures are related to improved survival. We tried to experimentally determine the feasibility of life-saving interventions that are performed with the aid of night vision goggles (NVG) in nighttime combat scenario.

METHODS: Chest tube thoracostomy (CTT), emergency cricothyroidotomy (EC), and needle thoracostomy (NT) interventions were performed by 10 combatant medical staff. The success and duration of interventions were explored in the study. Procedures were performed on the formerly prepared manikins/models in a bright room and in a dark room with the aid of NVG. Operators graded the ease of interventions.

RESULTS: All interventions were found successful. Operators stated that both CTT and EC interventions were more difficult in dark than in daytime (p<0.05). No significant difference was observed in the difficulty in the NT interventions. No significant difference was observed in terms of completion times of interventions between in daytime and in dark scenario.

CONCLUSION: The operators who use NVGs have to be aware of that they can perform their tactic and medical activities without taking off the NVGs and without the requirement of an extra light source.

Keywords: Battlefield; darkness nighttime; emergency cricothyroidotomy; needle thoracostomy; night vision goggles; tube thoracostomy.

INTRODUCTION An accurate and rapid prehospital response to life-threatening injuries is of great importance in both civil and military critical care. The loss of airway is the third leading cause of preventable death on the battlefield,[1,2] and approximately 1% of emergency airway management cases require surgical airway opening.[3] It has been reported that approximately 8%–15% of Address for correspondence: Attila Aydın, M.D. Gülhane Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Ankara, Turkey Tel: +90 312 - 304 20 00 E-mail: drattilaaydin@gmail.com Submitted: 24.02.2016 Accepted: 25.02.2017

Ulus Travma Acil Cerrahi Derg 2017;23(6):459–465 doi: 10.5505/tjtes.2017.71670 Copyright 2017 TJTES

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cases with airway obstruction, which develop due to penetrating maxillofacial or neck trauma, can be prevented by emergency cricothyroidotomy (EC) intervention.[4,5] The success rate of the procedure varies from 62% to 100%, depending on the operator.[6] EC is a life-saving procedure in the battlefield when airway interventions are ineffective or contraindicated.

[7] EC is one of the last available options in difficult airway algorithms, when the state of “can’t intubate, can’t ventilate” exists.[6] The survival rate of patients is low if this procedure is chosen. For patients with multiple and serious trauma, the early application of endotracheal intubation (ETI) and pleural drainage by the field team prior to hospitalization is associated with improved survival. Early responses in cases with tension pneumothorax (TPNX) are known to decrease mortality.[8] When TPNX is determined in the field, needle thoracostomy (NT) has to be performed by a combat medic. According to the Advanced Trauma Life Support and Prehospital Trauma Life Support (PHTLS) guidelines, the first choice of treatment in TPNX is NT, which is applied in the second intercostal 459

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space (ICS) on the midclavicular line.[9,10] This life-saving procedure transforms TPNX to simple pneumothorax prior to the application of chest tube thoracostomy (CTT), which is the definitive method of treatment.[2,11] Although the failure rate is significant, it is extremely important for decreasing intrapleural pressure and gaining time to prepare for CTT. The success rate of procedures decreases on the battlefield due to the limited number of medical personnel, insufficient light, stress, noise, and ongoing hostilities. This situation becomes even more difficult, especially in nighttime conditions, due to light discipline. Due to this limitation, soldiers commonly use night vision goggles (NVG) during military operations conducted at nighttime.[12] Although NVG are widely used, negligible research can be made in the dark with NVG in terms of the evaluation and care of the patients. To be able to effectively determine wound characteristics and perform the necessary interventions at night, vision and light restrictions can be mitigated with the use of tactical NVG. The study by Butler et al.[5] describes a tragic example of the harm and damage that can be caused when an extra light source is used by paramedics/medics in the field of combat in the absence of NVG that we recommend. The method that should be used in a tactical light-restricted environment is still unknown. We considered that the success rate of EC, NT, and CTT management at night with NVG would be the same as that in daylight.

The aim of the present study was to compare EC, NT, and CTT procedures, which would be managed in daylight and in a dark room with the aid of NVG, in terms of their success rates and administration duration. The aim of our study was to experimentally establish the feasibility of these life-saving interventions performed by combatant medical staff in a nighttime combat scenario with the aid of NVG.

MATERIALS AND METHODS Participants and Assessment Tool The GATA Ethics Committee approved the study (04/2015-

(a)

(b)

786). In our study, all interventions were performed by experienced combatant medical staff, including 10 members who had been trained in Battlefield Advanced Trauma Life Support, which is a part of military tactical training. All members had >5 years of experience in tactical emergency medicine and tactical night operations with NVG. The operators were trained for EC, NT, and CTT procedures by specialists in military emergency medicine. This refreshment training (theoretical and practical), including anatomical landmarks and procedural tools, lasted for 60 min for each individual application. EC, NT, and CTT procedures were performed in the daytime by the naked eye in a bright room on previously prepared manikins/models (Fig. 1a-c). The second group of the same procedures was performed in a dark room, entirely insulated from light and with the aid of NVG (Fig. 2a-c). Interventions performed in daylight and in a dark room were randomized using www.randomizer.org, and all operators repeated each intervention twice. The study investigated the success and duration of the interventions. Operators graded the ease of intervention using a visual analog scale (VAS), with scores from 1 to 10: 10 for the most difficult interventions and 1 for the easiest interventions. These parameters were examined by specialists in military emergency medicine who were responsible for the study, and the results were recorded. During the interventions in a dark room, the operators and specialists in emergency medicine used monocular NVG (Aselsan 983A, Turkey-1995) (Fig. 3a).

Phases of Manikins/Models Formation Needle Thoracostomy Manikin: A manikin (Simulaids Inc., Tension Pneumothorax Simulator, Woodstock, New York, USA) was used for this model (Fig. 3b).

Model of Emergency Cricothyroidotomy: The trachea was simulated with the air-draining tube of a mechanical ventilator (2.5-cm diameter). For fixation, the lateral walls of the simulated trachea were restricted with spume. Pieces of

(c)

Figure 1. (a) Cricothyroidotomy intervention in daytime. (b) Needle thoracostomy intervention in daytime. (c) Chest tube thoracostomy intervention in daytime.

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(a)

(b)

(c)

Figure 2. (a) Cricothyroidotomy intervention in nighttime with night vision goggle (NVG). (b) Needle thoracostomy intervention in nighttime with NVG. (c) Chest tube thoracostomy intervention in nighttime with NVG.

spume were placed on the trachea for simulating the thyroid and cricoid cartilage. Silk plaster was placed between these cartilages to form the cricothyroid membrane (CTM).

Chicken meat was used to simulate subdermal tissues (Fig. 3c), and neck-like plastic moulage was used to simulate the skin (Fig. 3d).

Model of Tube Thoracostomy: The internal surface of a sheep thorax was covered with greased cooking paper to simulate the parietal pleura. For simulating the dermal and subdermal tissues, chicken meat and skin was used to cover the external surface of the sheep thorax (Fig. 3e).

cm of transverse incisions of the skin and subdermal tissue performed on the ICS; a “pop” sound must be heard to ensure that the parietal pleura in penetrated. In the fourth step, the site of the Heimlich valve to the chest tubing is clamped; the part that would be advanced to the thorax is placed in the pleural space with the aid of a curved Kelly clamp and from the area on which the blunt dissection is performed.

(a)

(b)

(c)

(d)

(e)

(f)

Procedure Steps and Criteria for Procedural Success Needle Thoracostomy: The first step is the determination by palpation of the second ICS by the operator. In the second step, a 16-G needle is placed on the second ICS midclavicular line by advancing it from the upper margin of the lower rib so that the sound of air is heard.

Emergency Cricothyroidotomy: The first step is the determination of the space to reach the CTM by the operator by palpating the thyroid and cricoid cartilage. In the second step, the CTM is palpated with one hand, whereas the other hand is fixing the trachea. In the third step, a vertical skin incision is made, down to the CTM using a #10 scalpel, and the CTM is reached by making a blunt dissection. In the fourth step, a horizontal incision is made on the CTM, and the opening is secured with a tracheal hook. The fifth step requires placing a tracheostomy cannula and expanding the cuff with 10 cc of air. In the sixth step, the bag valve mask is tied, and bilateral lung ventilation and inflation are observed.

Tube Thoracostomy: The first step is the determination of the fourth or fifth ICS as the selected localization by the operator by palpating the related area. In the second step, the upper part of the lower rib is marked in the ICS where the intervention will be performed; this is followed by the consecutive local anesthesia procedures of the skin, subdermal tissue, and parietal pleura. In the third step, the simulated parietal pleura is reached by blunt dissection, following 4–5 Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Figure 3. (a) Night Vision Goggle. (b) Model of Needle Thoracostomy. (c) Cricothyroidotomy neck model without plastic moulage. (d) Model of Emergency Cricothyroidotomy (Completed). (e) Model of Tube Thoracostomy (Completed).

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In the fourth step, the distal end of the chest tube is clamped.

The proximal end of the chest tube is held with a curved Kelly clamp that is used to guide the chest tube through the tract.

The chest tube is advanced to the pleural space from the dissection area. In the fifth step, a tube is connected to the Heimlich valve, and the clamp is extracted. In the sixth step, the tube is fixed with a skin suture.

Sample Size We calculated that a minimum of eight patients in each group would be required to detect a 20-s difference between groups, assuming a standard deviation (SD) of 20 s with 80% power at an α level of 0.05.

Statistical Analysis Windows SPSS 22.0 (IBM statistics for Windows version 22, IBM Corporation, Armonk, New York, United States) was used for data analysis. Descriptive data were expressed as the median values and SD (minimum–maximum). The Wilcoxon test was used for comparing the two groups. Comparison of more than two groups was made using the Friedman test.

Dual analyses were performed using the Bonferroni corrected Wilcoxon test when the Friedman test results revealed statistically significant differences. A p value of <0.005 was considered as statistically significant.

RESULTS Abbreviations for applications performed in daytime by the naked eye were expressed as “Day.” Conversely, “NVG” was used for interventions using NVG (such as EC-D, NT-NVG, and CT-D).

Difficulty Degree of Procedures Operators rated the difficulties in CTT-NVG and CTT-Day, and the CTT-Day and CTT-NVG VAS scores were 5.20 and 7.05, respectively; the difference was statistically significant (p<0.007).

EC-NVG and EC-Day difficulty was compared, and EC-Day and EC-NVG VAS scores were 3.50 and 5.50, respectively; the difference was statistically significant (p<0.005). NT-Day and NT- NVG VAS scores were the same, and no significant difference was observed in the difficulty between NT-NVG and NT-Day (p=1.0) (Table 1).

Success Rate All interventions performed with the naked eye in the daytime and by NVG in the dark were found to be successful.

Completion Time of Procedures Completion time of CTT-day was 304.930 s, of CTT-NVG was 307.860 s, of EC-Day was 97.42 s, of EC-NVG was 97.740 s, of NT-Day was 13.346 s, and of NT-NVG was 13.349 s. No significant difference was found between completion time of CTTDay and CTT-NVG, EC-Day and EC-NVG, and NT-Day and NT-NVG (p = 0.799, 0.878, and 0.959, respectively) (Table 2).

DISCUSSION The main finding of this study was that there was no difference in the success rate and completion time of CTT, EC, and NT between the daylight and NVG use in dark. The evaluation and management of the patient is highly dependent on good lighting conditions. Strict blackout discipline is extremely important for all military units, including allies. The type of

Table 1. Difficulty degree of procedures (Visuel Analog Scale Scores)

Visuel Analog Scale Score-Day Mean±SD

Visuel Analog Scale Score-NVG

Min-Max (s)

Mean±SD

Min-Max (s)

p#

Chest tube thoracostomy

5.20±0.5

4.5–6

7.05±1.1

5–8.5

0.007

Emergency cricothyroidotomy

3.50±0.6

2.5–4.5

5.50±1

4–7

0.005

Needle thoracostomy 1.40±0.5 1–2 1.40±0.4 1–2 1.0 Wilcoxon Test. NVG: Night vision goggles; SD: Standard deviation.

#

Table 2. Completion time of procedures

Chest tube thoracostomy

Completion Time - Day

Completion Time - NVG

Mean±SD

Min-Max (s)

Mean±SD

Min-Max (s)

304.930±16.5

291.1–334.9

307.860±26.9

280.9–372.9

p#

0.799

Emergency cricothyroidotomy 97.420±24.8 65.8–141.3 97.740±23.2 68.8–134.5 0.878 Needle thoracostomy

13.346±1.76 10.9–16.1 13.30±1.05 10.9–14.6 0.959

Wilcoxon Test. NVG: Night vision goggles; SD: Standard deviation.

#

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response in a tactical light-restricted environment is still a matter of debate.[13,14] To establish wound characteristics and for the related nighttime interventions, vision restrictions are avoided with the use of NVG.

In the randomized controlled trial study conducted by Brummer et al.,[15] Advanced Life Support techniques (ETI and intravenous line insertion) performed by the emergency medical professional in light and dark environments using NVG were compared with regard to the procedural success and velocity. The authors reported that NVG could be used in dark environment in these procedures, but successful results could be obtained in a longer time period compared with that by the conventional methods. They also reported that operators in the study did not have prior experience of NVG, and this could have contributed to this result. They suggested extensive training and routine practice for shortening the durations of applications. MacIntyre et al.[16] showed the accomplishment of surgical airways in a dark environment with the use of NVG. Gellerfors et al.[12] compared the time for successful ETI in manikins in a prospective, randomized, crossover study, and found the duration of ETI with NVG to be longer when compared with their application in daylight conditions. Schwartz and Charity[17] compared intravenous insertion (IVI) procedures in the dark using NVG or a lowlevel Fingerlite light source. The success rate in the Fingerlite group was determined to be statistically higher. They considered that restricted depth perception, especially in monocular NVG, and refocusing the goggles manually, could contribute to this result. Contrary to these results, the success rates did not differ significantly in our study. We determined that interventions by the operators using NVG, were performed in a short time and with complete success. This result is due to the NVG experience of the operators, extensive training, and their routine practice in these procedures. Moreover, it was shown that depth perception affected the extent of success in the IVI and ETI but did not cause any restriction in the CTT, EC, and NT interventions. In conclusion, we established that interventions with NVG in a dark environment do not show any statistically significant differences, and therefore, experienced personnel can perform these interventions in the field without removing their NVG. The following are the EC techniques used: the standard surgical method, tube-over-needle, wire-guided, and rapid four-step technique. On reviewing these methods in the literature, no consensus was found to exist on the superiority of a device or technique. Surgical cricothyroidotomy may be the preferred procedure for emergent airway management on the battlefield given the unique restrictions and considerations.[1,18,19] The open technique via a vertical, midline incision is recommended.

[6] A vertical, midline incision by a prehospital provider who is not a surgeon is recommended. The advantage of this incision is the better visualization of the anatomical structures, with possible enlarging when needed. In addition, the risk of bleeding is lower.[1] EC model and procedural steps were designed Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

according to the prehospital suggested vertical and midline incision. Rates of complications (bleeding, damage to airway structure, false placement, etc.) related to the procedure are high in the prehospital settings.[6] Exposure, visualization, and direct palpation of the CTM are critical for combat medical personnel. When the CTM is visualized, the risk of subcutaneous and esophageal placements decreases.[20,21] Although EC is a difficult procedure to perform unaided, the technique can be easily learned and recalled by minimally trained health care providers.

[22] The success rate and velocity of application of EC varies, depending on the training models. The EC model designed in this present study was compatible with the theoretical and practical education related to the conventional EC techniques of the operators. Although the operators were experienced in NVG use with tactical aim, EC intervention with NVG was their first experience. Therefore, we think that the VAS scores of the interventions performed by NVG were higher than those of the intervention performed during the daytime.

Insufficient needle length, false catheter placement, catheter kinking, and luminal obstruction by blood clot are considered to be among the causes of unsuccessful NT. Chest wall thickness can affect the chances of successful NT.[23] When second ICS midclavicular line and fourth ICS anterior axillary line were compared in terms of the chest wall thickness, 2ICS was found to be significantly thicker. According to the PHTLS guideline, interventions performed at the fourth/fifth ICS anterior axillary line (lateral approach) can be used alternatively.

[23] Givens et al.[24] have used a 5-cm catheter via the 2ICS, and the success rate was found to be approximately 75%. When interventions were performed via the 2ICS with a catheter of 8 cm in length, interventions were found to be successful in more than 90% of the cases.[25] The Committee of Tactical Combat Casualty Care (TCCC) recommends an 8-cm, 14-G needle for an NT. However, a long needle is also known to increase the risk of complications.[6] Extensive bleeding due to large arterial injuries, cardiac tamponade, and neural injury are among these potential complications.[26] A serious complication (left ventricular damage) may occur, especially in the lateral approach.[27] Butler et al. and Rawlins et al.[28] have reported injuries leading to life-threatening bleeding, following NT procedures performed via the 2ICS. We also used 14-G, 8-cm needles in our study, and participants were trained in interventions via the 2ICS, as recommended by the TCCC. Nevertheless, complications could not be reported as the study was conducted with manikin/models. Possible death is prevented by the first therapeutic approach in the prehospital TPNX. However, decompression by needle may also be inefficient due to causes unrelated to the operator, such as a catheter of insufficient length, catheter kinking, and luminal obstruction by blood clot.

Although the first-line treatment option in prehospital TPNX has been accepted as NT, we suggest that operators will mandatorily apply CTT in the battlefield in the future, in the event of possible failure or irresponsiveness to therapy. Therefore, 463

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we tested the skills of the operators for CTT intervention both in the daytime and at night.

Dominguez et al.[29] have reported the essentials of CTT as the clinical signs of a stable patient and the evaluation of the intrathoracic air and blood by chest X-ray and thorax CT, rather than the prehospital application of NT alone. Considering operation under field conditions, together with the absence of the appropriate visualization methods for a casualty requiring CT and the possible length of time it can take to evacuate the wounded, what should the treatment of choice be next to NT for casualties not responding to NT and showing slowly deteriorating clinical signs? Prehospital chest drainage was demonstrated to improve the survival of severe trauma patients.[8] The authors claimed that simple thoracostomy is safe and effective in prehospital trauma management and that the procedure requires trained and experienced operators.[30] In this case, CTT would be the last choice of treatment. Combat medics generally respond to casualties on the operating field. However, regarding this procedure, combat medics are restricted in terms of their training, skill, and legal authority. When the options are either the possibility of preventing the death of a casualty or restrictive factors in the field resulting in casualties not responding to NT, the loss of the casualty would become a matter of dispute. In a prospective study, Schmidt et al.[31] investigated 624 consecutive patients with chest injuries and reported that prehospital CTT is safe, effective, and associated with low morbidity. We believe that CTT is an effective procedure for the severely injured and that it simplifies treatment in prehospital care while keeping scene times to a minimum. In future cases considered for CTT, with the use of NVG, it would be possible to perform this procedure in the operating field in the dark. In our study, all participant operators successfully completed CTT interventions with NVG. When compared with those conducted in the daytime, the duration of the CTT procedures conducted in nighttime conditions did not show significant difference. This projection provides immense support for future CTT applications in the field. The findings of this study, in terms of VAS scores for CTT and the duration necessary for completion of the procedure, confirmed that CTT can be successfully applied in prehospital systems.

According to the VAS scale results, the CTT-NVG and ECNVG interventions in the CTT and EC procedures were difficult for the operators. This result was considered to be due to the operators’ lack of experience in these procedures using NVG. Because NT intervention is more straightforward and has fewer procedural steps than CTT and EC interventions, no difference was observed between NT-Day and NT-NVG. This result demonstrated that training for the interventions performed using NVG should be regularly repeated. Our study has several important limitations. The first limitation is the use of models instead of real patients in our study. Use of the organs or tissues of dead animals or the combination of organic and plastic materials may be more useful in these 464

interventions instead of using the manikins alone, which are produced from plastic materials. We consider that procedural duration and success might vary in actual conditions due to factors, such as bleeding, foreign bodies, battlefield situations, and noise, which can be evaluated as a second limitation. The study has not been tested in the dark in terms of tactical considerations and security, which is the third limitation. The fourth limitation is the relatively small number of sampling in our study, and to our knowledge, a study with which our results can be compared is not available in the literature.

Conclusion Medical providers must acquire knowledge and experience about the signs, diagnosis, and treatment of TPNX and airway obstruction. They must be able to perform these types of life-saving procedures (EC, NT, and CTT) related to preventable causes of death and undergo frequent training. Training with NVG in a dark room performed on models and manikins may also contribute to the procedural success and duration of these life-saving interventions performed in the daytime and may also help enhance the operators’ skills at night. Operators who use NVG have to be aware that they can perform their tactical and medical activities without taking off their NVG and without the need for extra light sources when they have to perform interventions for EC, NT, and CTT in the dark. In addition, we consider that NVG use in EC, NT, and CTT interventions performed by paramedics/medics who work as members of humanitarian aid institutions and perform first aid in the dark in chaotic or disorganized circumstances can offer safety both for the providers of first aid and the wounded individuals. Future studies could include a larger number of participants and different types of NVG. Conflict of interest: None declared.

REFERENCES 1. Mabry RL, Edens JW, Pearse L, Kelly JF, Harke H. Fatal airway injuries during Operation Enduring Freedom and Operation Iraqi Freedom. Prehosp Emerg Care 2010;14:272–7.

2. Proctor MD, Campbell-Wynn L. Effectiveness, usability, and acceptability of haptic-enabled virtual reality and mannequin modality simulators for surgical cricothyroidotomy. Mil Med 2014;179:260–4.

3. Quick JA, MacIntyre AD, Barnes SL. Emergent surgical airway: comparison of the three-step method and conventional cricothyroidotomy utilizing high-fidelity simulation. J Emerg Med 2014;46:304–7.

4. Kelly JF, Ritenour AE, McLaughlin DF, Bagg KA, Apodaca AN, Mallak CT, et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 versus 2006. J Trauma 2008;64(2 Suppl):S21-6.

5. Butler FK Jr, Holcomb JB, Giebner SD, McSwain NE, Bagian J. Tactical combat casualty care 2007: evolving concepts and battlefield experience.

Mil Med 2007;172:1–19.

6. Mabry R, Frankfurt A, Kharod C, Butler F. Emergency Cricothyroidotomy in Tactical Combat Casualty Care. J Spec Oper Med 2015;15:11–9.

7. Melchiors J, Todsen T, Nilsson P, Wennervaldt K, Charabi B, Bøttger M, et al. Preparing for emergency: a valid, reliable assessment tool for emergency cricothyroidotomy skills. Otolaryngol Head Neck Surg

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8. Schmidt U, Frame SB, Nerlich ML, Rowe DW, Enderson BL, Maull KI, et al. On-scene helicopter transport of patients with multiple injuries-comparison of a German and an American system. J Trauma 1992;33:548-53.

9. Bach PT, Sølling C. Failed needle decompression of bilateral spontaneous tension pneumothorax. Acta Anaesthesiol Scand 2015;59:807–10.

10. Ng C, Tsung JW. Point-of-care ultrasound for assisting in needle aspiration of spontaneous pneumothorax in the pediatric ED: a case series. Am J Emerg Med 2014;32:488.

11. Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube thoracostomy: complications and its management. Pulm Med 2012;256878.

12. Gellerfors M, Svensén C, Linde J, Lossius HM, Gryth D. Endotracheal Intubation With and Without Night Vision Goggles in a Helicopter and Emergency Room Setting: A Manikin Study. Mil Med 2015;180:1006– 10.

13. Bozeman WP, Eastman ER. Tactical EMS: an emerging opportunity in graduate medical education. Prehosp Emerg Care 2002;6:322–4.

14. Rinnert KJ, Hall WL. Tactical emergency medical support. Emerg Med Clin North Am 2002;20:929–52.

15. Brummer S, Dickinson ET, Shofer FS, McCans JP, Mechem CC. Effect of night vision goggles on performance of advanced life support skills by emergency personnel. Mil Med 2006;171:280–2.

16. MacIntyre A, Markarian MK, Carrison D, Coates J, Kuhls D, Fildes JJ. Three-step emergency cricothyroidotomy. Mil Med 2007;172:1228–30.

17. Schwartz RB, Charity BM. Use of night vision goggles and low-level light source in obtaining intravenous access in tactical conditions of darkness.

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18. Sebesta J. Special lessons learned from Iraq. Surg Clin North Am 2006;86:711–26.

19. Adams BD, Cuniowski PA, Muck A, De Lorenzo RA. Registry of emergency airways arriving at combat hospitals. J Trauma 2008;64:1548–54.

20. Yıldız G, Göksu E, Şenfer A, Kaplan A. Comparison of ultrasonography and surface landmarks in detecting the localization for cricothyroidotomy. Am J Emerg Med 2016;34:254–6.

21. Feng Y, Deng H, Liu X, Xu G, Huang Z, Yan B, et al. A new strategy for difficult airway management with visual needle cricothyroidotomy: a manikin study. Am J Emerg Med 2014;32:1391–4.

22. Mabry RL, Nichols MC, Shiner DC, Bolleter S, Frankfurt A. A comparison of two open surgical cricothyroidotomy techniques by military medics using a cadaver model. Ann Emerg Med 2014;63:1–5.

23. Kolinsky DC, Moy HP. Evidence-based EMS: needle decompression.

Recent data may cause us to reconsider our preferred thoracostomy location. EMS World 2015;44:28–30.

24. Givens ML, Ayotte K, Manifold C. Needle thoracostomy: implications of computed tomography chest wall thickness. Acad Emerg Med 2004;11:211–3.

25. Chang SJ, Ross SW, Kiefer DJ, Anderson WE, Rogers AT, Sing RF, et al.

Evaluation of 8.0-cm needle at the fourth anterior axillary line for needle chest decompression of tension pneumothorax. J Trauma Acute Care Surg 2014;76:1029–34.

26. Butler KL, Best IM, Weaver WL, Bumpers HL. Pulmonary artery injury and cardiac tamponade after needle decompression of a suspected tension pneumothorax. J Trauma 2003;54:610–1.

27. Wernick B, Hon HH, Mubang RN, Cipriano A, Hughes R, Rankin DD, et al. Complications of needle thoracostomy: A comprehensive clinical review. Int J Crit Illn Inj Sci 2015;5:160–9.

28. Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003;20:383–4.

29. Dominguez KM, Ekeh AP, Tchorz KM, Woods RJ, Walusimbi MS, Saxe JM, et al. Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax? Am J Surg 2013;205:329–32.

30. Massarutti D, Trillò G, Berlot G, Tomasini A, Bacer B, D’Orlando L, et al. Simple thoracostomy in prehospital trauma management is safe and effective: a 2-year experience by helicopter emergency medical crews. Eur J Emerg Med 2006;13:276–80.

31. Schmidt U, Stalp M, Gerich T, Blauth M, Maull KI, Tscherne H. Chest tube decompression of blunt chest injuries by physicians in the field: effectiveness and complications. J Trauma 1998;44:98–101.

DENEYSEL ÇALIŞMA - ÖZET OLGU SUNUMU

Savaş alanında hayat kurtarıcı prosedürlere yeni bir bakış: Gece görüş gözlükleri ile acil krikotroidotomi, iğne torakostomi ve göğüs tüp torakostomi Dr. Sedat Bilge,1 Dr. Attila Aydın,1 Dr. Meltem Bilge,3 Dr. Cemile Aydın,4 Dr. Erdem Çevik,2 Dr. Mehmet Eryılmaz1 Gülhane Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, Ankara Sultan Abdülhamit Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, İstanbul 3 Dışkapı Eğitim ve Araştırma Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Ankara 4 Ankara Etimesgut Devlet Hastanesi, İç Hastalıkları Kliniği, Ankara 1 2

AMAÇ: Ağır ve çoklu travma hastalarında, hayat kurtarıcı prosedürlerin erken uygulanması artmış sağ kalım ile ilişkilidir. Gece yapılan savaş senaryosunda bu hayat kurtarıcı girişimlerin gece görüş gözlüğü (GGG) yardımıyla uygulanabilirliğini deneysel olarak saptamaya çalıştık.

GEREÇ VE YÖNTEM: Göğüs tüp torakostomi (GTT), acil krikotroidotomi (AK) ve iğne torakostomi (IT) girişimleri 10 adet askeri sağlık personeli tarafından gerçekleştirildi. Çalışmada girişimlerin başarı ve süreleri incelendi. Prosedürler, hazırlanan maket/model üzerinde gündüz aydınlık odada ve GGG yardımı ile karanlık odada yaptırıldı. Operatörler girişimlerin kolaylığını derecelendirdi.

BULGULAR: Tüm girişimler başarılı bulundu. Operatörler, gece yapılan GTT ve AK girişimlerini gündüz saatlerinde yapılan girişimlere göre zor buldu (p<0.05). İğne torakostomi grupları arasında zorluk açısından anlamlı fark yoktu. Girişimlerin tamamlanma süreleri açısından karşılaştırıldığında, gündüz ve gece senaryoları arasında fark yoktu.

TARTIŞMA: Gece görüş gözlüğü kullanan operatörler, taktik ve medikal aktivitelerini yaparken gece görüş gözlüklerini çıkarmalarına ve ekstra ışık kaynağı kullanmalarına gerek olmadığı konusunda uyanık olmalıdırlar.

Anahtar sözcükler: Acil krikotroidotomi; gece görüş gözlükleri; iğne torakostomi; karanlık; savaş alanı; tüp torakostomi.

Ulus Travma Acil Cerrahi Derg 2017;23(6):459–465

doi: 10.5505/tjtes.2017.71670

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ORIGIN A L A R T IC L E

Clinical infection in burn patients and its consequences Cem Emir Güldoğan, M.D.,1 Murat Kendirci, M.D.,2 Deniz Tikici, M.D.,3 Emre Gündoğdu, M.D.,4 Ahmet Çınar Yastı, M.D.2,3 1

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

2

Department of General Surgery, Hitit Univesity Faculty of Medicine, Çorum-Turkey

3

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

4

Department of General Surgery, Bahçeşehir University Faculty of Medicine, Liv Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: Burn injuries facilitate invasive infections and sepsis not only by destroying the continuity of the protective skin barrier but also through systemic effects. The burn wound, blood, and urine samples are frequently cultured to determine the pathogen agent. The aim of this study was to analyze pathogen growth in patients’ cultures confirmed as “infection positive” by the hospital Infection Control Committee and to assess the clinical implications of these growths.

METHODS: Hospitalized patients included in the study were those with a total burned body surface area of >10% and “presence of infection” confirmed by the Infection Control Committee. The patients were evaluated with respect to age, gender, burn etiology, the total body surface area burned (TBSA), the presence of inhalation injury, sepsis, positive cultures, the microorganisms cultured in wound-blood-urine samples, and septic focus.

RESULTS: Of the total 36 (10.3%) “infection-positive” patients, 26 (72.2%) were male; the mean age of patients was 44±21 years.

The mean burned TBSA of the whole group was 45.58%±23.1%. Acinetobacter baumannii was the most isolated organism in the wound cultures. In patients with confirmed infection, there was a correlation between the pathogen isolated in urine cultures and mortality rates (p=0.023). Sepsis was diagnosed in 23 (63.9%) patients, of whom 21 had inhalation injuries. There was a significant correlation between inhalation injury and sepsis (p=0.015), and both the presence of sepsis or inhalation injury increased mortality (p=0.027 and p=0.009, respectively).

CONCLUSION: According to the study data, the TBSA burned demonstrated a greater significance for mortality, although the presence of sepsis and/or urinary tract infection should also be noted as a cause of mortality in burned patients.

Keywords: Acinetobacter baumannii; Candida albicans; infection; sepsis.

INTRODUCTION Burn injuries constitute hard-to-manage trauma both for the patients and physicians due to the development of many complications following the injury, the treatment process, and even after wound healing. One of the major functions of the body skin is to ensure protection against microorganisms in the external environment. When burn injuries occur, this integrity is destroyed, thereby facilitating penetration of microAddress for correspondence: Cem Emir Güldoğan, M.D. Bestekar Sok., No: 8, 06680 Kavaklıdere, Çankaya, Ankara, Turkey Tel: +90 312 - 508 52 44 E-mail: drguldogan@gmail.com Submitted: 25.02.2017 Accepted: 14.03.2017

Ulus Travma Acil Cerrahi Derg 2017;23(6):466–471 doi: 10.5505/tjtes.2017.16064 Copyright 2017 TJTES

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organisms from the injured area and microorganism growth in the necrotic tissues resulting from the burn. Burn injuries have a suppressive effect on the immune system; therefore, there is a tendency for endogenous and exogenous infections to increase in these patients. The incidents caused by the state of infection or the progression of infection in burn patients constitute a serious cause of mortality.[1] The aim of this study was to analyze pathogen growth in patients’ cultures, confirmed as “infection positive” by the hospital Infection Control Committee, to assess the clinical implications of these growths, to reveal the septic focus, and to examine the relationship of these parameters with mortality.

MATERIALS AND METHODS The records of patients hospitalized in the Burn Treatment Center and Burn Intensive Care Unit of our hospital beUlus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Güldoğan et al. Clinical infection in burn patients and its consequences

tween 01/01/2014 and 07/31/2015 were reviewed. The admission criteria of the Turkish Burn Treatment Algorithm were followed in all cases.[2] Of the total patients hospitalized between the aforementioned dates, those with late complications of burn and social indications were excluded from the study. Patients included in the study had moderate and major burns with a total burned body surface area of >10% and “presence of infection” confirmed by the Infection Control Committee. The patients were evaluated with respect to age, gender, burn etiology, the total body surface area burned (TBSA), the presence of inhalation injury, sepsis, positive wound-blood-urine cultures, the microorganisms cultured, septic focus, and the microorganisms cultured in the septic focus.

In our clinic, the wound, catheter, blood, and urine cultures of patients transferred from other units are sampled once they are hospitalized. These samples are routinely cultured once a week from the intensive care unit (ICU) patients. In non-ICU patients, cultures are taken in the case of an emerging imTable 1. Grouping of patients by age and etiology of burns

n

%

15–39

19

52.8

40–59

9

27.8

8

19.4

Age

≥60

paired general condition (such as incongruity, appetite disturbance, decrease in exercise capacity, or behavioral changes) or changes in laboratory values (such as observed in leukopenia, thrombocytopenia, or leukocytosis). Wound swab cultures were taken after wound cleansing during changing of dressings.

The Pearson Chi-square and Student-t tests were used for statistical analysis of the study data. Multivariate analysis was performed using the logistic regression test. A P value of <0.05 was considered statistically significant.

RESULTS The records of 649 in-patients who met the study criteria were retrospectively evaluated. After excluding patients with minor burns, 349 patients with burned TBSA >10% constituted the study group. Of these, 36 (10.3%) patients were confirmed with “infection” by the Infection Control Committee. The incidence of infection on the study date was 11.07%.

There were 26 (72.2%) male and 10 (27.8%) female patients with a mean age of 44±21 years. Patients in the 15–39 years age group comprised 52.8% of the patient group (Table 1). In the evaluation of burn percentages of the patients, the mean burned TBSA of the whole group was 45.58%±23.1% (range, 11%–94%), 18.00%±5.7% (range, 11%–27%) in patients with burned TBSA <30%, and 57.72%±16.2% (range, 30%–94%) in patients with >30% burned TBSA.

Flame burn was found to have the leading etiology (n=26, 72.2%), followed by scalding, electrical burn, and chemical Etiology burn (Table 1).

Total

36 100

Flame

26

72.2

Scalding

5

13.9

Electrical

4

11.1

1

2.8

Chemical

Total

36 100

Acinetobacter baumannii was the most isolated organism in the wound cultures and it was positive in 19 patients, as the single factor of infection in 13 patients (36.1%) and among the multiple factors in six patients. Pseudomonas aeruginosa was isolated in 14 wounds. Of these wounds, it was the single factor in eight patients (22.2%) and among the multiple factors

Table 2. Microorganisms isolated from wound, blood, and urine cultures Wound cultures

n

%

Blood cultures

A. baumannii

13 36.1

A. baumannii

P. aeroginosa

8 22.2

MSSA

MRSA

1 2.8

n

%

2 50

Urine cultures C. albicans

n

%

4 80

1 25 P. mirabilis + A. baumannii 1 20

P. aeroginosa + A. baumannii 1 25

P. aeroginosa + A. baumannii 5 13.9 MRSA+ P. aeroginosa

1 2.8

A. baumannii + E. coli

1 2.8

M. morganii

1 2.8

C. albicans

1 2.8

Total

31 100

4 100

5 100

MRSA: Metisilin resistant Staphylococcus aereus; MSSA: Methisilin sensitive Staphylocaccus aereus.

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Güldoğan et al. Clinical infection in burn patients and its consequences

Table 3. Growth rates in cultures according to %TBSA burned Culture

Total body surface area <%30

Total body surface area >%30

p

n

Blood

+

2

18.2

–

9

81.8

23

92

32 88.9

11

100

25

100

36 100

Total

%

Total

n

%

n %

2

8

4 11.1 0.356

Urine

+

1

9.1

4

16

5 13.9 0.510

–

11

90.9

21

84

31 86.1

Total

12

100

25

100

36

100

Wound

+

9

81.8

22

88

31

86.1

–

2

18.2

3

12

5 13.9

11

100

25

100

36 100

Total

in six patients (Table 2). The most frequently yielded multiple bacteria were the coexistence of P. aeruginosa + A. baumannii (13.9%).

Of the 36 patients with confirmed “infection,” blood cultures were positive for infection in 4 (11.1%). A. baumannii was isolated in 50% of these patients, followed by methicillin-sensitive Staphylococcus aureus (MSSA) and coexistence of P. aeruginosa + A. baumannii (Table 2). In the study group, 5 (14%) patients had positive urine culture. The most frequently isolated microorganism was Candida albicans (80%) (Table 2).

Eleven (30.6%) patients had <30% TBSA burned, whereas 25 (69.4%) had major extensive burn injuries. The comparison of the cultured microorganisms between these groups is summarized in Table 3.

The overall mortality rate in the study group was 30.56% (11/36). There was no mortality in the patients with burned TBSA of <30%, whereas it significantly increased in patients with burned TBSA of >30% (Table 4).

In patients with confirmed infection, there was a statistically significant correlation between the isolation in urine cultures and the mortality rates (p=0.023; Table 5). However, no statistically significant difference was found between the blood and wound-borne infections and mortality.

0.490

Table 4. Mortality rates according to the total body surface area burned Total body surface area

Mortality

p

+ –

<%30

0

11

>%30

11 (44%)

14 (56%)

0.007

Table 5. The relationship between microorganism isolation in cultures, sepsis, and inhalation injury with mortality

Mortality +

Mortality –

p

n % n % Blood + 2 50 2 50 0.356

– 9 28.1 23 71.9

Urine + 4 80 1 20 0.023

– 7 22.6 24 77.4

Wound + 9 29 22 71 0.490

– 2 40 3 60

Sepsis

+

– 1 7.7 12 92.3

10

43.5

13

56.5

0.027

Inhalation + 10 47.6 11 52.4 0.009

– 1 6.7 14 93.3

Sepsis was diagnosed in 23 (63.9%) patients, of whom 21 had inhalation injuries. There was a significant correlation between inhalation injury and sepsis (p=0.015). In patients with inhalation injury, infection progresses to sepsis at a rate as high as 81%.

only one case of mortality who did not have sepsis and that patient was in>30% TBSA burned group.

Of the patients with sepsis, 10 (45.5%) died. The presence of sepsis was determined to significantly increase mortality (p=0.027), and the presence of inhalation injury also significantly increased mortality (p=0.009) (Table 5). There was

The wound itself was the only septic focus in 16 patients. In one patient (4.3%), positive culture was determined in the wound, blood, and urine, and this was a fatal case (Table 6).

The causes of sepsis are shown in Table 12. A. baumannii was

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the only septic organism isolated in nine patients (39.1%), followed by P. aeruginosa (13%) (Table 7).

The organism causing sepsis in cases of isolated focus was determined as A. baumannii as the sole cause of infection in the Table 6. Septic focus Septic focus

n

%

Wound

16 69.6

Blood

1 4.3

Wound-urine

3 13

Wound-blood

1 4.3

Blood-urine

1 4.3

Wound-blood-urine

1 4.3

Table 7. Cause of sepsis Cause of sepsis

n

%

A. baumannii

9 39.1

P. aeroginosa

3 13

MRSA

2 8.7

C. albicans

1 4.3

A. baumannii – P. aeroginosa

4 17.4

A. baumannii – C. albicans

1 4.3

MRSA - P. aeroginosa

1 4.3

P. aeroginonsa – C. albicans

1 4.3

A. baumannii – P. aeroginosa – C. albicans 1

4.3

MRSA: Metisilin resistant Staphylococcus aereus.

wound, blood, and urine in 9 (39.1%) patients. In cases with multiple infectious agents, coexistence of A. baumannii and P. aeruginosa was determined as the cause of sepsis in 4 (17.4%) patients. Wound was the most frequently encountered septic focus. In 16 (69.6%) patients, the focus was limited to the burn wound; and the wound site was determined to contribute to sepsis in a total of 21 (21/23, 91.3%) patients (Table 8).

The Chi-square test was used to determine the significance of the variables of inhalation injury, sepsis, TBSA burned, age, presence of septic focus, and pathogen growth in urine.

These independent variables were subjected to logistic regression analysis to determine the variables to be used in the multivariate analysis, which was used to predict the likely effects of prognostic factors on mortality.

In determining the prognostic factors affecting the dependent variable of “survival” in the logistic regression analysis, the Forward Stepwise Selection technique was used. In the model created with all the independent parameters, TBSA was found to be the parameter with the greatest effect on mortality. Exp (βp) values show the odds ratios. The probabilities would have an adverse effect if the β coefficients obtained are positive. Based on these results, the level of the surface area burned was found to increase mortality 0.766 fold.

DISCUSSION Patients in the 15–39 years age group constituted the vast majority of the study group with “infection” confirmed by the Infection Control Committee. This shows that the time taken for treatment and rehabilitation would cause a serious workforce loss.[3] Those in the 40–59 years age group constituted the second largest group of patients in this study, followed by those aged ≥59 years.

Table 8. The relationship between the culture site and the cause of sepsis Culture site

W

B

B+U

W+U

W+B

All

Total

n n n n n n n %

Cause of sepsis A. baumannii

7 – 1 – 1 – 9 39.1

P. aeroginosa

3 – – – – – 3 13

MRSA

1 1 – – – – 2 8.7

C. albicans

– – – 1 – – 1 4.3

A. baumannii - P. aeroginosa

4 – – – – – 4 17.4

A. baumannii - C. albicans

– – – 1 – – 1 4.3

MRSA - P. aeroginosa

1 – – – – – 1 4.3

P. aeroginosa - C. albicans

– – – 1 – – 1 4.3

A. baumannii - P. aeroginosa - C. albicans – – – – – 1 1 4.3 Total, n (%)

16 (69.6)

1 (4.3)

1 (4.3)

3 (13)

1 (4.3)

1 (4.3)

23

100

W: Wound; B: Blood; B+U: Blood+urine; W+U: Wound+urine, W+B: Wound+blood; MRSA: Metisilin resistant Staphylococcus aereus.

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Güldoğan et al. Clinical infection in burn patients and its consequences

In recent years, there has been a significant increase in the success rates of burn shock and early resuscitation, with better understanding of burn physiology and developments in both medical monitoring and ICU patient management. This has consequently decreased morbidity and mortality rates.

Through the degradation of the integrity of the protective skin barrier due to burn injuries, both endogenous and exogenous access and proliferation of bacteria are facilitated.

Furthermore, the necrotic tissue remnants serve as a proliferative medium for microorganisms. The prolonged hospital stay increases the likelihood of exposure to nosocomial infections, which then complicates the treatment of the patient.[4] Although wound infection rates are reduced with appropriate antibiotic selection and rational drug use, wound infection continues to be a cause of sepsis and mortality in burn patients.[1,5,6] The incidence of infection on the study date was 11.07%. The detected prevalence rates of infected patients (6.9%) appear to be in line with results of similar studies performed both in Europe and Turkey.[7,8] The application of early excision and grafting as burn management practice is known to reduce the mortality rate in burn patients.[9] In our facility, early excision and grafting has become a standard treatment. However, wound infection and sepsis remain a common problem among hospitalized patients. In the current study, the most common wound infection agents were found to be A. baumannii (36.1%), P. aeruginosa (22.2%), and the coexistence of these two (13.9%).

This is similar to data reported by experienced burn centers.

[10] These two microorganisms should certainly be considered prior to empirical treatment.

Approximately 10% of the current study patients diagnosed with infection had positive blood cultures. The organism most commonly isolated in blood cultures was A. baumannii, followed by MSSA and the coexistence of P. aeruginosa + A. baumannii. These microorganisms have come into prominence as a cause of sepsis in many burn units.[11] Antibiotics should not be used for prophylaxis in burn, because it is well known that prophylactic antibiotic usage leads to colonization of resistant strains.[12] In cases where sepsis is strongly suspected, the initial antibiotic regimen to be delivered until the laboratory results are obtained should cover these organisms.

In the current study, positive urine cultures were observed in 14% of the patients and C. albicans was isolated in 80% of the patients. In patients with infection, positive urine cultures significantly increased the mortality rates. Our previous study revealed urinary candidiasis as a more indicative factor for mortality than positive blood culture.[9] Venous blood samples are taken during routine microbiological procedures.

Not sampling arterial blood for culture may result in delay for fungal isolation; during this period until fungal findings are determined in the urine, the critical fungal threshold for patients may be reached. However, further studies are required 470

to confirm this hypothesis and because arterial sampling is an invasive procedure, the clinical consequences should be included in the studies.

Inhalation injury is a well-known cause of mortality in burn victims. The presence of inhalation injury in the current study patients significantly increased the mortality rate. On examination of the relationship between the presence of infection and sepsis in patients with inhalation injury, it was concluded that inhalation injury facilitates progression of the infection to sepsis. In this study, the rate of progress to sepsis was found to be 81% in patients with inhalation injury, thus indicating that presence of inhalation injury in burn patients increases susceptibility to sepsis and this must be taken into consideration in the treatment of burns.

The results of this study showed that development of sepsis is a serious determinant for mortality. Infection with A. baumannii, in particular, was found to be a significant factor in in increasing mortality rate. In burn patients considered to have infection or sepsis, the antibiotics to be selected for the period until the culture results are obtained should also cover these microorganisms.

In this study, higher mortality rates were observed in patients with extensive burn injuries and wound infection. However, despite positive wound cultures, no mortality was observed in the group with burned TBSA <30%. This suggested that in patients with extensive burn injuries, many other factors in addition to wound sepsis could affect mortality. However, as reported previously,[9] an accompanying positive urine culture significantly increases mortality rates. Nonetheless, as a result of the multivariate analysis of patients with “infection” confirmed by the Infection Control Committee, the most prominent factor affecting mortality was determined as the percentage of body surface area burned.

Conclusion The infections and sepsis that develop in burn wounds are still a significant cause of mortality in patients with burn injuries.

Cases with extensive burn injuries are subjected to multi-systemic effects; therefore, mortality can also occur for various reasons other than wound sepsis. The wounds of these patients should be regularly evaluated, cultures should be taken whenever a wound infection is suspected, and antibiograms should be performed. Antibiotherapies administered should be prescribed according to the antibiogram result, although the possible microorganisms should be previously identified, and the antibiotics to be administered until the antibiogram results are obtained should be decided by taking the clinical flora into consideration. With the use of multivariate analysis in the group studied, the results of the current study demonstrated a greater significance of the body surface area burned, and it should be noted that the presence of urinary tract Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

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infection and sepsis can be a cause of mortality in patients with burn injuries.

Conflict of interest: None declared.

REFERENCES 1. Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn wound infections. Clin Microbiol Rev 2006;19:403¬–34.

2. Yastı AÇ, Şenel E, Saydam M, Özok G, Çoruh A, Yorgancı K. Guideline and treatment algorithm for burn injuries. Ulus Travma Acil Cerrahi Derg 2015;21:79–89.

3. Sözen İ, Guldogan CE, Kismet K, Sabuncuoğlu MZ, Yasti AÇ. Outpatient burn management and unnecessary referrals. Ulus Travma Acil Cerrahi Derg 2015;21:27–33.

4. Gomez R, Murray CK, Hospenthal DR, Cancio LC, Renz EM, Holcomb JB, et al. Causes of mortality by autopsy findings of combat casualties and civilian patients admitted to a burn unit. J Am Coll Surg 2009;208:348–54.

5. Mayhall CG. The epidemiology of burn wound infections: then and now.

Clin Infect Dis 2003;37:543–50.

6. Driscoll JA, Brody SL, Kollef MH. The epidemiology, pathogenesis and treatment of Pseudomonas aeruginosa infections. Drugs 2007;67:351– 68.

7. Nicastri E, Petrosillo N, Martini L, Larosa M, Gesu GP, Ippolito G; INFNOS Study Group. Prevalence of nosocomial infections in 15 Italian hospitals: first point prevalance study for the INF-NOS project. Infection 2003;31 Suppl 2:10–5.

8. Klavs I, Bufon Luznik T, Skerl M, Grgic-Vitek M, Lejko Zupanc T, Dolinsek M, et al; Slovenian Hospital-Acquired Infections Survey Group.

Prevalance of and risk factors for hospital-acquired infections in Sloveniaresults of the first national survey, 2001. J Hosp Infect 2003;54:149–57.

9. Senel E, Yasti AC, Reis E, Doganay M, Karacan CD, Kama NA. Effects on mortality of changing trends in the management of burned children in Turkey: eight years’ experience. Burns 2009;35:372–7.

10. Raz-Pasteur A, Fishel R, Hardak E, Mashiach T, Ullmann Y, Egozi D. Do wound cultures give information about the microbiology of blood cultures in severe burn patients? Ann Plast Surg 2016;76:34–9.

11. Glasser JS, Guymon CH, Mende K, Wolf SE, Hospenthal DR, Murray CK. Activity of topical antimicrobial agents against multidrug-resistant bacteria recovered from burn patients. Burns 2010;36:1172–84.

12. Sözen İ, Güldoğan CE, Yastı AÇ. Etiology of childhood burns and parental awareness in Turkey. Ulus Cerrahi Derg 2015;32:168–72.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Yanık hastalarında klinik enfeksiyonlar ve sonuçları Dr. Cem Emir Güldoğan,1 Dr. Murat Kendirci,2 Dr. Deniz Tikici,3 Dr. Emre Gündoğdu,4 Dr. Ahmet Çınar Yastı2,3 Altınbaş Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul Hitit Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Çorum Ankara Numune Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, Ankara 4 Bahçeşehir Üniversitesi Tıp Fakültesi, Liv Hospital, Genel Cerrahi Anabilim Dalı, Ankara 1 2 3

AMAÇ: Yanık yaralanmaları, koruyucu cilt bariyerinin sürekliliğini bozmakla kalmayıp aynı zamanda sistemik etkiler yoluyla invaziv enfeksiyonları ve sepsisi de kolaylaştırır. Yanık sahası, kan ve idrar örnekleri, patojen ajanı belirlemek için sıklıkla kullanılanılır. Bu çalışmanın amacı, hastane Enfeksiyon Kontrol Komitesi tarafından ‘enfeksiyon açısından pozitif ’ olarak onaylanan hastaların kültüründeki üremeleri analiz etmek ve bu üremelerin klinik etkilerini değerlendirmektir.

GEREÇ VE YÖNTEM: Çalışmaya %10’dan fazla yanık yüzey alanı olan ve Enfeksiyon Kontrol Komitesi tarafından “enfeksiyon varlığı” olan yatan hastalar dahil edilidi. Hastalar yaş, cinsiyet, yanık etiyolojisi, toplam yanık vücut alanı (TYVA), inhalasyon hasarı varlığı, sepsis, pozitif kültürler, yarakan-idrar numunelerinden alınan mikroorganizmalar ve septik odak açısından değerlendirildi.

BULGULAR: Toplam 36 (%10.3) “enfeksiyon pozitif ” hastanın 26’sı (%72.2) erkek, yaş ortalaması 44±21 idi. Tüm grupta ortalama TYVA %45.58±23.1 idi. Acinetobacter baumannii, yara kültürlerinde en fazla izole edilen organizma idi. Enfeksiyon varlığı doğrulanan hastalarda, idrar kültürlerinde izolasyon ile mortalite oranları arasında bir korelasyon vardı (p=0.023). Yirmi üçünde (%63.9) sepsis tespit edildi; bunlardan 21’inde inhalasyon yaralanması vardı. İnhalasyon hasarı ile sepsis arasında anlamlı bir ilişki vardı (p=0.015) ve hem sepsis hem de inhalasyon yaralanmasının mortaliteyi artırdığı görüldü (sırasıyla, p=0.027 ve p=0.009).

TARTIŞMA: Çalışmanın verilerine göre, yanıklı hastalarda toplam yanıklı vücut yüzey alanı mortalitede daha büyük öneme sahipken, sepsis ve/veya idrar yolu enfeksiyonu varlığı da mortalite nedeni olarak işaret edilmelidir.

Anahtar sözcükler: Acinetobakter baumannii; Candida albicans; enfeksiyon; sepsis.

Ulus Travma Acil Cerrahi Derg 2017;23(6):466–471

doi: 10.5505/tjtes.2017.16064

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ORIGIN A L A R T IC L E

Correlation between ischemia-modified albumin and Ranson score in acute pancreatitis Cem Emir Güldoğan, M.D.,1 Murat Özgür Kılıç, M.D.,1 İlhan Balamir, M.D.,2 Mesut Tez, M.D.,1 Turan Turhan, M.D.2 1

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

2

Department of Biochemistry, Numune Training and Research Hospital, Ankara-Turkey

ABSTRACT BACKGROUND: Although Ranson score is the most commonly used prognostic model in the severity of acute pancreatitis (AP), ischemia-modified albumin (IMA) has been reported as a novel biomarker of various ischemia-based diseases in recent years. The aim of the present study is to investigate the correlation between Ranson score and IMA in patients with AP. METHODS: Forty-three patients with AP were included in the study. All patients were classified as mild and severe AP. Plasma IMA level was measured after diagnosis and before treatment. The correlation between IMA level and amylase level, Ranson score, and disease severity was evaluated.

RESULTS: Twenty-nine (67.4%) patients were diagnosed as mild AP; the remaining 14 (32.6%) patients had moderately severe or severe form of disease, and were classified as severe AP. There was no significant difference in the IMA levels between the patient groups (p=0.737). No correlation between IMA levels and amylase levels (p=0.470), Ranson score (p=0.664), and disease severity (p=0.741) was found.

CONCLUSION: According to the results from the study, IMA does not seem as a useful marker in earlier prediction of disease severity in AP. Despite important disadvantages, Ranson score still indicates the disease severity more accurately.

Keywords: Acute pancreatitis, ischemia-modified albumin, disease severity.

INTRODUCTION Acute pancreatitis (AP) is among the most common causes of acute abdominal emergencies in the world. Although most of the patients with AP have mild disease, approximately 15%–20% cases develop severe or necrotizing form of AP. It is well known that AP, particularly severe form, is associated with increased morbidity and mortality rates.

Therefore, determining disease severity within the first hours after hospital admission is of great importance for both treatment planning and decreasing the morbidity and mortality.

Address for correspondence: Murat Özgür Kılıç, M.D. Talatpaşa Bulvarı, No: 5, 06510 Altındağ, Ankara, Turkey Tel: +90 312 - 508 40 00 E-mail: murat05ozgur@hotmail.com Submitted: 19.08.2016 Accepted: 09.02.2017

Ulus Travma Acil Cerrahi Derg 2017;23(6):472–476 doi: 10.5505/tjtes.2017.51499 Copyright 2017 TJTES

472

To date, many single-parameter and multi-parameter indicators have been reported to predict AP severity. Among those, Ranson criteria are the most widely used grading model; however, the need of many complex parameters and 48 h after admission to obtain a basic predictive score are its main limitations. In this respect, ischemia-modified albumin (IMA), a well-known biomarker of ischemia-based diseases such as stroke, acute mesenteric ischemia, acute pulmonary embolism, and acute coronary syndrome, may be considered as a novel predictor AP severity.[1–4] Apart from being an ischemic marker, IMA has been also reported to be an indicator of oxidative stress.[5] Although the main pathogenesis of AP is self-digestion of the organ by the abnormal activation of digestive enzymes, it was also shown that free oxygen radicals and cytokines have important roles in pancreatic damage and disease course.[6] In this study, we aimed to determine whether serum IMA can be used as a novel and alternative indicator for predicting AP severity.

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Institutional Ethics Committee of Numune Training and Research Hospital approved this study. Written informed consent was obtained from all patients.

MATERIALS AND METHODS Patients and Study Design Forty-three patients diagnosed with AP between December 2015 and April 2016 were included in this prospective clinical study. Patients with diabetes mellitus, chronic renal/hepatic failure, and cirrhosis as well as those aged <18 years were excluded from the study. The following criteria were used for the diagnosis of AP: acute onset of abdominal pain, typical physical examination findings, at least three-fold increase in plasma amylase level, and sonographic and/or tomographic confirmation of AP. Plasma IMA level was measured after AP diagnosis and before treatment. Albumin cobalt binding calorimetric assay, previously described by Bar-Or et al.,[7] was used for IMA measurements, and the results were provided in absorbance unit (ABSU). A formula (serum albumin concentration of the patient/median serum albumin concentration of the study population) × IMA ABSU value was used to eliminate the effect of albumin on IMA, and hence to obtain the corrected IMA. All patients were classified as mild and severe AP, according to the Atlanta criteria based on the presence of organ failure for >48 h and/or local complications.[8] The criteria of organ failure were as follows: shock (systolic blood pressure <90 mmHg), renal failure (serum creatinine level >2 mg/dL after rehydration or hemodialysis), or pulmonary insufficiency (arterial PO2 <60 mmHg at room air or the need for mechanical ventilation). Ranson score was calculated using data in the first 24 h and after 48 h of admission.

Statistical Analysis Statistical analyses were performed using SPSS 17.0 (SPSS Inc., Chicago, Illinois). Kolmogorov–Smirnov test was used to assess the normality of data distribution. The variables were presented as mean ± standard deviation (SD), median and interquartile range (IQ), or number and percentage unless otherwise specified. Chi-square test or Fisher exact test were used to compare categorical data, and Mann–Whitney U-test was used for the comparison of continuous variables. Correlations of IMA with amylase level, Ranson score, and disease severity were analyzed by Spearman’s correlation coefficient.

A p value of <0.05 was considered statistically significant.

RESULTS A total of 43 patients with biliary AP were included in the study. There were 17 (39.5%) males and 26 (60.5%) females, with a mean age of 63.6 (22–90) years. The median length of hospital stay was 6.1 (3–12) days, and no mortality was observed during this period.

A total of 29 (67.4%) patients were diagnosed as mild AP. The remaining 14 (32.6%) patients had moderately severe or severe form of disease, and were classified as severe AP. The patients who had severe form of AP were older than those with mild AP (p=0.020). Ranson score was also higher in patients with severe AP than in those with mild disease (p=0.011).

The mean IMA level was 0.626+0.11 (0.379–0.947) ABSU.

Table 1. The comparison of clinical characteristics, laboratory findings, and Ranson scores of the two groups Parameters Age (year, mean±SD)

Patients with mild AP (n=29)

Patients with severe AP (n=14)

p

56.13±15.5 (22–88)

79.3±9.2 (57–90)

0.020

Female/Male White blood cell (10000/mm3)

16/13

10/4 0.343

10900 (9050–14500)

11300 (7850–13150)

124 (105–179)

140.5 (118.7–172)

0.795

29 (22–38)

51.5 (41.2–66)

<0.001

0.85 (0.76–0.97)

1.2 (0.8–1.7)

0.007

3.6 (3.4–3.8)

3.2 (3–3.7)

0.031

Aspartate aminotransferase (U/L)

176 (110–299)

181 (55–360)

0.826

Alanine aminotransferase (U/L)

185 (106–324)

159 (54–262)

0.422

Glucose (mg/dL) Blood urea (mg/dL) Serum creatinine (mg/dL) Serum albumin (g/dL)

0.534

Total bilirubin (mg/dL)

1.4 (0.7–3.1)

1.7 (1–5.4)

0.254

Direct bilirubin (mg/dL)

1.2 (0.4–3)

0.8 (0.5–3.6)

0.835

303 (223–445)

301 (225–548)

0.959

1327 (460–2872)

1917 (793–2535)

0.468

1 (1–2)

0.011

Lactate dehydrogenase Amylase (U/L) Ranson score (Interquartile range) Ischemia-modified albumin (Absorbance unit)

0 (0–2) 0.621±0.107

0.639±0.125 0.737

AP: Acute pancreatitis; SD: Standard deviation.

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1.000

39 17

IMA (ABSU)

.800

.600

19 Patients

.400

.200

.000

1

Severity of disease

2

Figure 1. Ischemia-modified albumin (IMA) levels in patients with mild AP (1) and severe AP (2) (0.621+0.107 ABSU vs. 0.639+0.125 ABSU, p=0.737).

There was no significant difference in the IMA levels between the patients with mild AP and patients with severe form of disease (p=0.737). The comparison of clinical characteristics, laboratory findings, and Ranson scores of the patients with mild AP and those with severe AP are presented in Table 1.

The correlation between IMA level and amylase level, Ranson score, and disease severity (according to the Atlanta classification) was statistically evaluated. It was found that there was no correlation between IMA levels and amylase levels in the whole study population (rho=+0.116, p=0.470). IMA was also not found to be correlated with Ranson score (rho=−0.070, p=0.664). Similarly, no correlation was observed between IMA level and the disease severity (rho=0.053, p=0.741) (Fig. 1).

DISCUSSION Despite recent advances in diagnostic algorithms, critical care conditions, and other therapeutic approaches, AP, especially severe form of the disease, is still a dangerous disease with a mortality rate of 10%–20%.[9] Approximately half of the deaths are related to multiple organ failure within the first week of the attack while septic complications are mainly responsible for the delayed mortality. Because of the high morbidity and mortality rates in AP, many scoring systems, laboratory tests, and radiological methods have been recommended to estimate the clinical disease course. Some of those grading systems including Ranson,[10] Bedside Severity Index of AP (BISAP),[11] and Imrie/Glasgow[12] include parameters specific to AP whereas others, such as Acute Physiologic and Chronic Health Evaluation System (APACHE)[13] and the Mortality Probability Models (MPM) II[14] scores, are not specific to AP, and are widely used in all critically ill patients.

Apart from the complicated scoring systems, single biochemical markers such as C-reactive protein, procalcitonin, red cell distribution width, and interleukins have also been reported 474

as promising predictors of AP severity.[15–17] However, none of those provide an accurate prediction of disease severity, and thus are not widely used in routine practice. In this regard, IMA, a well-known marker for various ischemic-based diseases, may be considered as a novel and alternative predictor of disease severity considering that poor antioxidant status has been shown to be associated with progression of complications in AP.[18,19] It is known that various ischemic stressors are released from hypoxic tissues, and modify N-terminal amino acids of circulating albumin to a different subtype called as IMA.[20] This biochemical marker has been shown to play important roles in various hypoxic conditions, especially in ischemic heart disease.[2,4,21] Although the pathogenesis of AP is multifactorial, an increasing number of studies have focused on the relationship between the oxidative stress status and AP.[19,22] Oxidative stress is primarily related to excessive production of reactive oxygen metabolites, which can cause damage in pancreatic cells. Free oxygen radicals are also considered to be involved in pancreatic edema and necrosis processes.[23,24] Free oxygen radicals modify the metal binding terminals of human albumin. Therefore, the production of IMA is directly related to the production of free oxygen radicals.[25] In addition, IMA level raises within a few minutes after tissue injury caused by free oxygen radicals, and returns to normal serum level after 6–12 h.

To date, the diagnostic role of IMA in various acute abdominal emergencies has been studied in a number of clinical studies.[2,26,27] In one of those, serum levels of oxidative stress markers including IMA were found to be higher in patients with acute appendicitis than in healthy individuals. However, the authors found no correlation between the pathological extent of acute appendicitis and oxidative stress markers.

[26] In another study, plasma IMA level was found to be significantly higher in acute mesenteric ischemia in comparison to the nonoccluded group, suggesting that IMA might have a diagnostic value in acute thromboembolic occlusion of mesenteric vessels.[2] In the literature, there are only two studies on the association between IMA and AP.[19,28] One of those was an experimental study conducted in rats, which aimed to determine the potential role of IMA in AP.[28] Plasma IMA level was found to be significantly higher in rats with AP than in healthy rats.

It was also shown that IMA was strongly correlated with serum amylase level, indicating that IMA could be considered as a novel diagnostic marker in AP. Moreover, the authors reported IMA as an additional marker to monitor inflammation during AP. The other study was conducted in patients with mild biliary and/or nonbiliary AP, and aimed to investigate the potential diagnostic role of oxidative status with using various oxidative stress parameters including IMA.[19] The primary outcome of the study was that IMA was significantly elevated in patients with AP in comparison to healthy cases.

The authors also showed a positive correlation between IMA and amylase and lipase levels, similar to the study by TopaloUlus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

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glu et al.[28] All those findings obtained from the two studies indicated the diagnostic IMA level in AP. However, the predictive IMA level was not clearly investigated. It is well known that the estimation of disease severity is important in AP management, considering the risk of dangerous complications. In contrast to those studies, the primary aim of the present study was to investigate the prognostic value of IMA in patients with AP. Therefore, there was no control group consisting of healthy patients. In addition, we found no significant association between IMA levels and amylase levels. With regard to this point, it should be stated here that all patients, except one, had a plasma IMA level >0.400 ABSU, which is generally considered as a reference level for ischemia.[29] In the present study, IMA did not also show a correlation with both Ranson score and the Atlanta classification for predicting disease course. In our opinion, our work is the first report on this topic. It should be also noted that the sample size in both the previous studies was lower than that in our study. Consequently, all the findings obtained from the present study showed that IMA does not have any prognostic and predictive value in AP. This study has some limitations. First, the sample size was small, and the majority of patients had Ranson score <4, making the statistical analysis difficult. Second, the measurement of IMA was not repeated after the treatment because the study mainly focused on the predictive value of IMA. Therefore, the effect of IMA in the clinical progress of patients was not evaluated.

In conclusion, this study is the first report on the prognostic role of IMA in patients with AP. According to the results from the present study, IMA does not seem to be a useful marker in earlier prediction of disease severity in patients with AP. However, the results should be confirmed by larger cohort studies. Despite important disadvantages, Ranson score more accurately indicates disease severity in patients with AP.

Acknowledgments This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing Interests

emia-modified albumin in the diagnosis of acute mesenteric ischemia: a preliminary study. Am J Emerg Med 2008;26:202–5.

3. Kaya Z, Kayrak M, Gul EE, Altunbaş G, Toker A, Kiyici M, et al. The Role of Ischemia Modified Albumin in Acute Pulmonary Embolism.

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5. Duarte MM, Rocha JB, Moresco RN, Duarte T, Da Cruz IB, Loro VL, et al. Association between ischemia-modified albumin, lipids and inflammation biomarkers in patients with hypercholesterolemia. Clin Biochem 2009;42:666–71.

6. Closa D. Free radicals and acute pancreatitis: much ado about … something. Free Radic Res 2013;47:934–40.

7. Bar-Or D, Lau E, Winkler JV. A novel assay for cobalt-albumin binding and its potential as a marker for myocardial ischemia: a preliminary report. J Emerg Med 2000;19:311–5.

8. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102–11.

9. Maheshwari R, Subramanian RM. Severe Acute Pancreatitis and Necrotizing Pancreatitis. Crit Care Clin 2016;32:279–90.

10. Ranson JH. The timing of biliary surgery in AP. Ann Surg 1979;189:654– 63.

11. Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in AP: a large population-based study. Gut 2008;57:1698–703.

12. Leese T, Shaw D. Comparison of three Glasgow multifactor prognostic scoring systems in AP. Br J Surg 1988;75:460–2.

13. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818–29.

14. Lemeshow S, Teres D, Klar J, Avrunin JS, Gehlbach SH, Rapoport J. Mortality Probability Models (MPM II) based on an international cohort of intensive care unit patients. JAMA 1993;270:2478–86.

15. Rau B, Steinbach G, Gansauge F, Mayer JM, Grunert A, Beger HG. The potential role of procalcitonin and interleukin 8 in the prediction of infected necrosis in AP. Gut 1997;41:832–40.

16. Stimac D, Fisic E, Milic S, Bilic-Zulle L, Peric R. Prognostic values of IL-6, IL-8, and IL-10 in AP. J Clin Gastroenterol 2006;40:209–12.

17. Senol K, Saylam B, Kocaay F, Tez M. Red cell distribution width as a predictor of mortality in AP. Am J Emerg Med 2013;31:687–9.

18. Abu-Zidan FM, Bonham MJ, Windsor JA. Severity of acute pancreatitis: a multivariate analysis of oxidative stress markers and modified Glasgow criteria. Br J Surg 2000;87:1019–23.

The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

19. Baser H, Can U, Karasoy D, Ay AS, Baser S, Yerlikaya FH, et al. Evaluation of oxidant/anti-oxidants status in patients with mild acute pancreatitis. Acta Gastroenterol.Belg 2016;79:23–8.

Conflict of interest: None declared.

20. Dekker MS, Mosterd A, van ‘t Hof AW, Hoes AW. Novel biochemical markers in suspected acute coronary syndrome: systematic review and critical appraisal. Heart 2010;96:1001–10.

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24. Inoue S, Kawanishi S. Oxidative DNA damage induced by simultaneous generation of nitric oxide and superoxide. FEBS Lett 1995;371:86–8.

25. Gidenne S, Ceppa F, Fontan E, Perrier F, Burnat P. Analytical performance of the albumin cobalt binding (ACB) test on the Cobas MIRA Plus analyzer. Clin Chem Lab Med 2004;42:455–61.

26. Dumlu EG, Tokaç M, Bozkurt B, Yildirim MB, Ergin M, Yalcin A, et al. Correlation between the serum and tissue levels of oxidative stress markers and the extent of inflammation in acute appendicitis. Clinics

2014;69:677–82.

27. Guven S, Kart C, Guvendag Guven ES, Cetin EC, Menteşe A. Is the measurement of serum ischemia-modified albumin the best test to diagnose ovarian torsion? Gynecol Obstet Invest 2015;79:269–75.

28. Topaloglu N, Kucuk A, Tekin M, Yildirim S, Erbas M, Kiraz HA, et al.

Serum Ischemia-Modified Albumin Levels in Experimental Model of Acute Pancreatitis. J Coll Physicians Surg Pak 2015;25:395–8.

29. Kadıoğlu H, Kaptanoğlu L. İskemik Modifiye Albüminin Acil Cerrahide Kullanımı. J Kartal TR 2012;23:106–9.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut pankreatitte iskemi modifiye albümin ve Ranson skoru arasındaki korelasyon Dr. Cem Emir Güldoğan,1 Dr. Murat Özgür Kılıç,1 Dr. İlhan Balamir,2 Dr. Mesut Tez,1 Dr. Turan Turhan2 1 2

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

AMAÇ: Ranson skoru akut pankreatitin (AP) şiddetinde en yaygın kullanılan prognostik model olmasına karşın, iskemi modifiye albümin (İMA) son yıllarda çeşitli iskemi temelli hastalıklar için yeni bir belirteç olarak bildirilmiştir. Amaç AP hastalarında Ranson skoru ve İMA arasındaki korelasyonu araştırmaktır.

GEREÇ VE YÖNTEM: Kırk üç AP hastası çalışmaya dahil edildi. Tüm hastalar hafif ve şiddetli AP olarak sınıflandırıldı. Plazma İMA seviyesi tanıdan sonra ve tedaviden öncesi ölçüldü. İskemi modifiye albümin düzeyi ile amilaz düzeyi, Ranson skoru ve hastalığın şiddeti arasındaki ilişki değerlendirildi.

BULGULAR: Yirmi dokuz (%67.4) hastaya hafif AP tanısı konarken, 14 (%32.6) hasta orta şiddetli veya şiddetli hastalık formuna sahipti ve şiddetli AP olarak sınıflandırıldı. Hasta grupları arasında İMA düzeylerinde anlamlı bir fark yoktu (p=0.737). İskemi modifiye albümin düzeyleri ile amilaz düzeyleri (p=0.470), Ranson skoru (p=0.664) ve hastalık şiddeti (p=0.741) arasında korelasyon saptanmadı.

TARTIŞMA: Çalışmadan elde edilen sonuçlara göre, İMA AP’de hastalık şiddetinin erken tahmininde yararlı bir belirteç olarak görünmemektedir. Önemli dezavantajlarına rağmen, Ranson skoru hastalığın şiddetini daha doğru göstermektedir.

Anahtar sözcükler: Akut pankreatit; hastalık şiddeti; iskemi modifiye albümin.

Ulus Travma Acil Cerrahi Derg 2017;23(6):472–476

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ORIGIN A L A R T IC L E

Role of inflammatory markers in decreasing negative appendectomy rate: A study based on computed tomography findings Ebru Ozan, M.D.,1 Gökçe Kaan Ataç, M.D.,1 Kaan Alişar, M.D.,1 Aslıhan Alhan, M.D.2 1

Department of Radiology, Ufuk University Faculty of Medicine, Ankara-Turkey

2

Department of Statistics, Ufuk University Faculty of Arts and Sciences, Ankara-Turkey

ABSTRACT BACKGROUND: This study aimed to investigate the role of inflammatory markers in decreasing negative appendectomy rate (NAR) based on their relation with findings of acute appendicitis (AA) on computed tomography (CT).

METHODS: Ninety-two patients who underwent CT examination with suspected AA were included. We investigated the relation between CT findings of AA and laboratory inflammatory markers and also performed receiver operating characteristic (ROC) analysis to calculate cut-off values of inflammatory markers and CT findings of AA. Appendectomy cases were re-evaluated considering cut-off values to make the operation decision and NAR was recalculated. Chi-squared test was used to compare the actual and recalculated NAR. RESULTS: Cut-off values of appendiceal diameter, appendiceal wall thickness, and caecal wall thickness were 7.9, 2, and 2.3 mm, respectively, for the diagnosis of AA. Cut-off values of WBC , NLR, and CRP on ROC analysis were 7.47, 4.06 and 13, respectively, for the diagnosis of AA. When the actual and recalculated NAR (21.9% versus 9.1%) were compared, the difference was found to be almost significant (p=0.058).

CONCLUSION: Inflammatory markers are not sufficiently powerful on their own to accurately diagnose AA. However, particularly in equivocal cases, proposed cut-off values may be helpful for accurate diagnosis and a lower NAR can be achieved.

Keywords: Acute appendicitis; C-reactive protein; computed tomography; negative appendectomy rate; neutrophil to lymphocyte ratio.

INTRODUCTION Acute appendicitis (AA) is the most common acute surgical abdominal emergency; hence, appendectomy is a very common emergency operation performed worldwide.[1] Diagnosis is usually based on the combination of initial clinical and laboratory evaluation with imaging modalities. Clinical symptoms include periumbilical pain migrating to the right lower quadrant, nausea, and vomiting, but unfortunately, a clear clinical picture consistent with AA is found in only 50%–60% Address for correspondence: Ebru Ozan, M.D. Ufuk Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Ankara, Turkey Tel: +90 312 - 204 40 00 E-mail: ebrusanhal@yahoo.com Qucik Response Code

of patients.[2] Negative appendectomy rate (NAR) still remains high; therefore, several appendicitis scores, inflammatory markers, and imaging modalities have been proposed to reduce this rate.[3–5] Computed tomography (CT) has been reported to improve diagnostic accuracy in AA and reduce NAR.[5] On the other hand, recent studies have investigated the diagnostic accuracy of inflammatory markers including mean platelet volume (MPV), red cell distribution width (RDW), and neutrophil to lymphocyte ratio (NLR) in various inflammatory or infectious conditions including AA.[6,7] Therefore, the purpose of our study was to investigate the role of inflammatory markers including white blood cell (WBC) count, C-reactive protein (CRP), MPV, RDW, and NLR, in decreasing NAR based on CT findings of AA.

Ulus Travma Acil Cerrahi Derg 2017;23(6):477–482 doi: 10.5505/tjtes.2017.36605

MATERIALS AND METHODS

Copyright 2017 TJTES

Patients who underwent CT examination for suspected AA between March 2015 and February 2016 were included. A retrospective review of all available medical records includ-

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ing laboratory, surgery, pathology, and discharge summary was performed for each patient. The study protocol was approved by the institutional ethics committee, and written informed consent was waived.

Patients One hundred and five adult patients (aged ≥18 years) who underwent CT examination for suspected AA were initially included. Subsequently, 13 were excluded, of whom seven patients were lost to follow-up, three had unavailable or incomplete medical records, and one and two were diagnosed with pseudomembranous colitis and non-specific colitis, respectively, after initial interpretations. Finally, 92 patients (43 men, 49 women, age range 18–79; mean age 40) were included. Final diagnoses based on pathological results or clinical followup for at least 3 months were used as the reference standard.

Imaging Technique All CT exams were performed on a 16-row multi-detector CT scanner (Lightspeed 16, General Electric, Milwaukee, USA). Abdominal region from the diaphragm to symphysis pubis was scanned after intravenous non-ionic iodinated contrast material injection (ioversol, Optiray 300/100, Mallinckrodt). All patients drank 1.5 L of water mixed with 50 mL of iodinated contrast material (sodium and meglumin diatrizoat, Urografin 50 mL, Schering) 1 h before the exam. Imaging parameters were 5-mm slice thickness, 1.3 pitch, 1 s of tube rotation, 120 kV, and noise index of 16. Each examination was recruited from our Picture Archiving and Communication System (Centricity PACS, GE Healthcare, General Electric, Milwaukee, USA) and was loaded to a workstation with three megapixel monitors (BARCO, Brussels).

Image Analysis All CT scans were retrospectively interpreted, based on the consensus of two national board-certified radiologists with 5 and 15 years of experience in abdominal imaging, respectively. Radiologists knew that the patients all had suspected AA; however, they were blinded to the original CT reports, laboratory and surgical findings, and pathological results. All images were reviewed with the following CT findings assessed: (1) appendiceal diameters; (2) appendiceal wall changes; (3) cecal changes; (4) periappendiceal inflammatory changes; (5) phlegmon or abscess formation; and (6) lymph node en-

largement (Table 1). Appendiceal diameters were measured from the outer wall to the outer wall twice using electronic calipers on magnified images by each observer, and the two measurements were then averaged. Appendiceal wall changes were classified as absent, enhancing thick wall, and defect in enhancing thick wall. Thick appendiceal wall was defined as a wall thickness of ≥2 mm. Cecal changes were classified as absent, thick wall, and thick wall with pericecal fluid. Cecal wall thickening was assessed by comparing to the wall thickness of the ascending colon immediately distal to the cecum, and maximal wall thickness was measured. Periappendiceal inflammatory changes were subjectively classified as absent, mild, and moderate to severe. Phlegmon was defined as diffuse inflammation of the periappendiceal fat with ill-defined fluid collections, whereas discrete collection with definable walls was defined as an abscess. Lymph node enlargement was defined as absent when the short axis of the largest lymph node in pericecal area was <5 mm, as mild when it was 5–10 mm, and as prominent when it was >10 mm. In addition, patients were subjectively classified using four grades from normal (grade 1) to perforated AA (grade 4) based on CT findings (Table 2) (Fig. 1). This grading system was generated by modifying two previously described systems.[8,9]

Laboratory Analysis After completion of the image analysis process, medical records of patients with suspected diagnosis of AA were reviewed and WBC count (103/µL), MPV (fL), RDW (%), NLR, and CRP level (mg/L) obtained on complete blood count (CBC) were noted. CBC was obtained just after the physical examination during initial referral. Laboratory analyses were performed using an Abbott ARCHITECT c8000 Clinical Chemistry Analyzer for all patients. NLR was calculated by dividing the percentage values of neutrophils and lymphocytes.

Statistical Analysis SPSS (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) was used for statistical analysis. Normality of data for continuous variables was analyzed using Shapiro– Wilk’s test. Inter-group differences were analyzed with oneway analysis of variance for normally distributed parameters and with Kruskal–Wallis test for non-normally distributed parameters. Paired comparisons were performed using Tukey’s

Table 1. Computed tomography findings assessed Appendiceal diameter <6 mm

Appendiceal Cecal changes wall changes Absent

Absent

Periappendiceal inflammatory changes

Phlegmon or abscess formation

Lymph node enlargement

Absent

Absent

Absent

6–10 mm

Enhancing thick wall

Thick wall

Mild

Phlegmon

Mild

>10 mm

Defect in enhancing

Thick wall with

Moderate to severe

Abscess

Prominent

thick wall

pericaecal fluid

478

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Table 2. Computed tomography grades for acute appendicitis Grade

Computed tomography definition

Computed tomography findings

1

Normal

Normal appendix

2

Mild apendicitis

Fluid-filled appendix of >6 mm with enhancing thick wall with/without mild

periappendiceal inflammatory changes

3

Appendicitis periappendicitis

Grade 2 definition plus moderate to severe periappendiceal inflammatory changes

4

Perforated appendicitis

Grade 3 definition plus a defect in enhancing thick wall with/without phlegmon or abscess

test for normally distributed parameters and Mannâ&#x20AC;&#x201C;Whitney test with Bonferroni correction for non-normally distributed parameters. A p-value of <0.017 (0.05/3 times multiple comparisons) was considered statistically significant to determine whether CT findings were related to inflammatory markers.

A p-value of <0.008 (0.05/6 times multiple comparisons) was considered statistically significant to determine differences in levels of inflammatory markers between CT grades. Receiver operating characteristic (ROC) analysis was used to determine the cut-off values. Appendectomy cases were re-evaluated considering the cut-off values to make the operation decision and NAR was recalculated. Chi-square test was used to compare the actual and recalculated NAR. The statistical significance level was set at p<0.05.

RESULTS Of the 92 patients included in our study, 64 underwent ap-

(a)

(c)

pendectomy and 50 were pathologically proven to have AA, whereas in 14 patients, the appendix was found to be normal.

In 4 of 50 patients who were pathologically proven to have AA, CT examinations were considered negative for AA. In 28 patients who were not operated, AA was excluded based on negative CT examinations and clinical follow-up. CT had a sensitivity of 92% and a specificity of 95% for the diagnosis of AA. Appendiceal diameter, cecal changes, and periappendiceal inflammatory changes were found to be significantly related to WBC count, NLR, and CRP level (p<0.05). Appendiceal wall change was found to be significantly related to WBC count, MPV, NLR, CRP level, and phlegmon; abscess formation was found to be significantly related to MPV, NLR, and CRP level; and lymph node enlargement was found to be significantly related to NLR and CRP (p<0.05).

The cut-off values of appendiceal diameter, appendiceal wall

(b)

(d)

Figure 1. Examples of CT grades for AA. (a) Grade 1; axial contrast enhanced CT (CECT) image shows a normal appendix. (b) Grade 2; axial CECT image shows an enlarged appendix measuring 11 mm in diameter, with an enhancing thick wall and mild periappendiceal inflammatory changes. (c) Grade 3; axial CECT image shows an enlarged appendix measuring 12 mm in diameter, with an enhancing thick wall and moderate to severe periappendiceal inflammatory changes. (d) Grade 4; axial CECT image shows a perforated appendix with somewhat ill-defined borders and free air locules in the surrounding mesentery.

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Table 3. Cut-off values for CT signs with their respective specificities and corresponding sensitivities CT sign Appendiceal diameter (mm) Appendiceal wall thickness (mm) Caecal wall thickness (mm)

Cut-off value

Sensitivity (%)

Specificity (%)

7.9

92

92

2

82

83

2.3

72

80

Table 4. Cut-off values for inflammatory markers with their respective specificities and

corresponding sensitivities Inflammatory marker

Cut-off value

Sensitivity (%)

Specificity (%)

White blood cell count (103/µL) 7.47 90 35 Neutrophil to lymphocyte ratio C-reactive protein (mg/L)

4.06

68

73

13

66

80

thickness, and cecal wall thickness were 7.9 mm [sensitivity 0.92, specificity 0.92 (95% CI: 0.909–0.994); p=0.0001], 2 mm [sensitivity 0.82, specificity 0.83 (95% CI: 0.824–0.955); p=0.0001], and 2.3 mm [sensitivity 0.72, specificity 0.80 (95% CI: 0.735–0.899); p=0.0001] for the diagnosis of AA (Table 3).

tion decision was accepted to require minimum one of the inflammatory markers and minimum one of the CT signs above the cut-off values. Accordingly, recalculated NAR was found to be 9.1%. When the actual and recalculated NAR (21.9% versus 9.1%) were compared, the difference was found to be almost significant (p=0.058).

Of the 92 patients in our study population, 44, 29, 13, and 6 patients were classified as grade 1, 2, 3, and 4 on the basis of CT findings, respectively. CT grades were found to be significantly related to WBC, NLR, and CRP level (p<0.05).

DISCUSSION

Based on the pathological examination and clinical follow-up, the study population consisted of 50 patients with the final diagnosis of AA, whereas in 42 patients, AA was excluded (14 were proven to have pathologically normal appendix, 28 were clinically excluded). In terms of final diagnosis, patients were grouped as positive and negative for AA. When the relation of inflammatory markers between these groups was analyzed, significant differences were found in WBC, NLR, and CRP level (p<0.05). The cut-off values of WBC, NLR, and CRP on ROC analysis were 7.47 [sensitivity 0.90, specificity 0.35 (95% CI: 0.532–0.737); p=0.0185], 4.06 [sensitivity 0.68, specificity 0.73 (95% CI: 0.586–0.783); p=0.0008], and 13 [sensitivity: 0.66, specificity: 0.80 (95% CI: 0.658–0.842); p=0.0001] for the diagnosis of AA, respectively (Table 4).

Considering the agreement between the surgeon’s decisions and pathological diagnoses, of the 64 patients who underwent appendectomy, 50 were grouped as concordant cases and 14 were grouped as discordant cases (comprising also the negative appendectomy group). These groups were re-evaluated in terms of the operation decision, considering aforementioned cut-off values of inflammatory markers and CT signs (appendiceal diameter, appendiceal wall thickness, and cecal wall thickness). The criterion for the surgeon’s opera480

Despite the frequency of AA and the use of different diagnostic approaches including appendicitis scores, laboratory markers, and imaging modalities, accurate diagnosis remains difficult. High NARs have been reported in our country as well as in some other countries.[3,10,11] Recently, diagnostic values of MPV, RDW, and NLR are increasingly being evaluated in patients with suspected AA, although largely varied results have been reported.[12,13] To our knowledge, there are no published studies that have investigated the role of these inflammatory markers in decreasing NAR based on CT findings of AA. MPV is a marker of platelet activation that has been shown to reflect the inflammatory burden.[14] Several studies have evaluated the diagnostic value of MPV in AA; nevertheless, some of them advocate for an increase, while some others advocate for a decrease, in MPV levels. RDW is a measure of the variability of red blood cell size and has been shown to predict various inflammatory conditions.[15,16] Based on CT findings examined in our study, only appendiceal wall change and phlegmon or abscess formation was found to be significantly related to MPV. No significant difference was found regarding the relation between any of these findings and RDW. As thick wall, enhancing wall, or defect in the wall are components of appendiceal wall change on CT, when wall change is present, this may represent either early or advanced stages of the disease. According to the results of our study, CT findUlus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Ozan et al. Role of inflammatory markers in decreasing negative appendectomy rate

ings of AA seem to represent different stages of inflammation and thus may be related to different inflammatory markers depending on the inflammation stage. Regarding its relationships with CT findings, MPV seems to be related to both early and advanced stages of inflammation. However, further studies should be conducted to evaluate its relationship with CT findings of AA.

when used in combination with the physical examination and imaging modalities, particularly in discordant and equivocal cases.

In our study, we also evaluated the relation between final diagnoses and laboratory markers. No significant differences were found in the means of MPV and RDW levels, which was discordant with some recent studies.[6,7] However, Bozkurt et al.[17] concluded that MPV was not a useful diagnostic marker in AA, in accordance with our study results. NLR was found to be a useful diagnostic parameter for the diagnosis of AA in children,[18] and it was also found to be more valuable than WBC and CRP in terms of diagnostic accuracy.[19] The proposed cut-off values of WBC, NLR, and CRP in the present study were 7.47, 4.06, and 13 for the diagnosis of AA, respectively.

1. Debnath J, Kumar R, Mathur A, Sharma P, Kumar N, Shridhar N, et al.

On the Role of Ultrasonography and CT Scan in the Diagnosis of Acute Appendicitis. Indian J Surg 2015;77:221–6.

One of the most important results of our study was that CT had a significant diagnostic utility with a sensitivity of 92% and specificity of 95%, consistent with prior studies evaluating the performance of CT imaging in AA.[20,21] Our study results revealed a relatively high NAR. At our institution, the primary imaging modality in suspected AA is ultrasound, and CT mainly serves as a problem-solving imaging modality in equivocal cases. As our sample was limited to patients who only underwent CT examination, we believe this rate might not reflect the exact NAR in our institution.

However, high NARs were also reported in previous studies conducted in our country and in others worldwide.[3,10,11] Therefore, to analyze the effect of the proposed cut-off values in the present study, the actual and recalculated NARs were compared and the difference was found to be almost significant. We believe the cut-off values proposed in our study, particularly in equivocal cases, may have a value in the diagnosis of AA and thus may help decrease NAR. Our study has several limitations. First, due to the absence of surgical–pathological proof in patients who were not operated, final diagnoses were based on clinical follow-up. Second, the study had a small sample size limited to one institution of cohort. A relatively small percentage of patients with suspected diagnosis of AA are going to CT in our institution, which may have introduced substantial bias. Third, there may be value in correlating the cut-off values of CT signs and inflammatory markers with common mimics of AA on CT (i.e., Crohn’s Disease and cecal tumors), but due to our exclusion criteria and lack of such cases in our study population, this was not feasible.

In conclusion, proposed cut-off values of WBC, NLR, and CRP level may be helpful to diagnose AA and reduce NAR Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Conflict of interest: None declared.

REFERENCES

2. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000;215:337–48.

3. Kırkıl C, Karabulut K, Aygen E, Ilhan YS, Yur M, Binnetoğlu K, et al. Appendicitis scores may be useful in reducing the costs of treatment for right lower quadrant pain. Ulus Travma Acil Cerrahi Derg 2013;19:13–9.

4. Engin O, Calik B, Yildirim M, Coskun A, Coskun GA. Gynecologic pathologies in our appendectomy series and literature review. J Korean Surg Soc 2011;80:267–71.

5. Raja AS, Wright C, Sodickson AD, Zane RD, Schiff GD, Hanson R, et al. Negative appendectomy rate in the era of CT: an 18-year perspective.

Radiology 2010;256:460–5.

6. Tanrikulu CS, Tanrikulu Y, Sabuncuoglu MZ, Karamercan MA, Akkapulu N, Coskun F. Mean platelet volume and red cell distribution width as a diagnostic marker in acute appendicitis. Iran Red Crescent Med J 2014;16:e10211.

7. Narci H, Turk E, Karagulle E, Togan T, Karabulut K. The role of mean platelet volume in the diagnosis of acute appendicitis: a retrospective case-controlled study. Iran Red Crescent Med J 2013;15:e11934.

8. Kim HC, Yang DM, Lee CM, Jin W, Nam DH, Song JY, et al. Acute appendicitis: relationships between CT-determined severities and serum white blood cell counts and C-reactive protein levels. Br J Radiol 2011;84:1115–20.

9. Miki T, Ogata S, Uto M, Nakazono T, Urata M, Ishibe R, et al. Enhanced multidetector-row computed tomography (MDCT) in the diagnosis of acute appendicitis and its severity. Radiat Med 2005;23:242–55.

10. National Surgical Research Collaborative. Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy. Br J Surg 2013;100:1240–52.

11. Joshi MK, Joshi R, Alam SE, Agarwal S, Kumar S. Negative Appendectomy: an Audit of Resident-Performed Surgery. How Can Its Incidence Be Minimized? Indian J Surg 2015;77:913–7.

12. Narci H, Turk E, Karagulle E, Togan T, Karabulut K. The role of red cell distribution width in the diagnosis of acute appendicitis: a retrospective case-controlled study. World J Emerg Surg 2013;8:46.

13. Albayrak Y, Albayrak A, Albayrak F, Yildirim R, Aylu B, Uyanik A, et al.

Mean platelet volume: a new predictor in confirming acute appendicitis diagnosis. Clin Appl Thromb Hemost 2011;17:362–6.

14. Cicek T, Togan T, Akbaba K, Narci H, Aygun C. The value of serum mean platelet volume in testicular torsion. J Int Med Res 2015;43:452–9.

15. Şenol K, Saylam B, Kocaay F, Tez M. Red cell distribution width as a predictor of mortality in acute pancreatitis. Am J Emerg Med 2013;31:687– 9.

16. Sadaka F, O’Brien J, Prakash S. Red cell distribution width and outcome in patients with septic shock. J Intensive Care Med 2013;28:307–13.

17. Bozkurt S, Köse A, Erdogan S, Bozali GI, Ayrik C, Arpaci RB, et al.

MPV and other inflammatory markers in diagnosing acute appendicitis.

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19. Markar SR, Karthikesalingam A, Falzon A, Kan Y. The diagnostic value of neutrophil: lymphocyte ratio in adults with suspected acute appendicitis. Acta Chir Belg 2010;110:543–7.

20. van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker J, Boermeester MA. Acute appendicitis: meta-analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology 2008;249:97–106.

21. Old JL, Dusing RW, Yap W, Dirks J. Imaging for suspected appendicitis.

Am Fam Physician 2005;71:71–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Enflamatuvar belirteçlerin negatif apendektomi oranını azaltmadaki rolü: Bilgisayarlı tomografi bulgularına dayanan bir çalışma Dr. Ebru Ozan,1 Dr. Gökçe Kaan Ataç,1 Dr. Kaan Alişar,1 Dr. Aslıhan Alhan2 1 2

Ufuk Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Ankara Ufuk Üniversitesi Fen Edebiyat Fakültesi, İstatistik Bölümü, Ankara

AMAÇ: Bu çalışmada enflamatvuar belirteçlerin negatif apendektomi oranını düşürmedeki rolünün, akut apandisitin (AA) bilgisayarlı tomografi (BT) bulgularına dayanarak araştırılması amaçlandı.

GEREÇ VE YÖNTEM: Akut apandisit ön tanısıyla BT incelemesi yapılan 92 hastanın bilgileri geriye dönük olarak tarandı. Enflamatvuar belirteçler ile BT bulguları arasındaki ilişki araştırılarak, ROC analizi ile enflamatvuar belirteçler ve BT bulgularına ait kesim değerleri belirlendi. Apendektomi yapılan olgular, bu kesim değerlerine göre yeniden değerlendirilerek negatif apendektomi oranı yeniden hesaplandı. Gerçek negatif apendektomi oranı ile yeniden hesaplanan negatif apendektomi oranı arasındaki fark ki-kare testi kullanılarak analiz edildi.

BULGULAR: Apendiks çapı, apendiks duvar kalınlığı ve çekum duvar kalınlığı için kesim değerleri sırasıyla, 7.9 mm, 2 mm ve 2.3 mm olarak bulundu.

Beyaz küre sayımı, nötrofil/lenfosit oranı ve C-reaktif protein için kesim değerleri sırasıyla, 7.47, 4.06 ve 13 olarak bulundu. Gerçek negatif apendektomi oranı ile kesim değerlerine göre yeniden hesaplanan negatif apendektomi oranı arasındaki istatistiksel fark neredeyse anlamlı idi (p=0.058).

TARTIŞMA: Enflamatvuar belirteçler AA kesin tanısı için tek başlarına yetersizdir. Ancak, çalışmamızda bulunan kesim değerleri, özellikle arada kalınan olgularda, kesin tanı için faydalı olarak negatif apendektomi oranının düşürülmesine katkı sağlayabilir.

Anahtar sözcükler: Akut apandisit; bilgisayarlı tomografi; C-reaktif protein; negatif apendektomi oranı; nötrofil/lenfosit oranı.

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ORIGIN A L A R T IC L E

Spontaneous rectus sheath hematoma in cardiac in patients: a single-center experience Ebubekir Gündeş, M.D., Durmuş Ali Çetin, M.D., Ulaş Aday, M.D., Hüseyin Çiyiltepe, M.D., Kamuran Cumhur Değer, M.D., Orhan Uzun, M.D., Aziz Serkan Senger, M.D., Erdal Polat, M.D., Mustafa Duman, M.D., Department of Gastroenterological Surgery, Kartal Koşuyolu High Speciality Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: This study presents the relationship between mortality and spontaneous rectus sheath hematoma (RSH) in inpatients receiving anticoagulant and antiaggregant treatment for cardiac pathology at cardiology and cardiovascular surgery clinics.

METHODS: Within the scope of our study, the cases of 27 patients who were diagnosed with spontaneous RSH between January 2010 and December 2015 at Kartal Kosuyolu High Speciality Training and Research Hospital were retrospectively evaluated.

RESULTS: Of the 27 patients, 19 (70.4%) were female and 8 (29.6%) were male. The mean age was 63±12 (32–84) years. All the patients had at least one comorbidity that necessitated follow-up. Fourteen patients received only anticoagulant treatment, 8 received only antiaggregant treatment, and the remaining 5 received both types of treatment. Physical examination of all patients revealed painful palpable masses in the lower quadrants of the abdomen. According to the results of computed tomography (CT) scans, which showed the size and localization of the masses, 7 of the cases were classified as Type I, 6 as Type II, and 14 as Type III. Although 23 of the cases received medical treatment, the remaining 4 patients received surgical treatment. Eight (29.6%) patients suffered mortality.

CONCLUSION: RSH is rare, but its prevalence is increased among patients receiving anticoagulant and antiaggregant treatment for cardiac reasons. The mortality rate markedly increased among patients who contracted RSH during hospitalization for cardiac reasons, had comorbidities, and experienced additional complications due to extended hospitalization.

Keywords: Anticoagulant treatment, antiplatelet treatment; rectus sheath hematoma.

INTRODUCTION Although rectus sheath hematoma (RSH) is a rare condition that has been reported in a limited number of studies, it has well-defined pathogenesis, treatment clinics, and treatment modalities.[1] It is an uncommon cause of acute abdominal pain. Despite the fact that RSH is mostly self-limiting, it may lead to unnecessary surgical procedures or even death if the patient is not diagnosed. RSH very rarely occurs in children and can develop at any age among adults.[1,2] It most frequent-

Address for correspondence: Ebubekir Gündeş, M.D. Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Gastroenteroloji Cerrahisi Kliniği, İstanbul, Turkey Tel: +90 216 - 500 15 00 E-mail: ebubekir82@hotmail.com Submitted: 27.05.2016 Accepted: 06.04.2017

Ulus Travma Acil Cerrahi Derg 2017;23(6):483–488 doi: 10.5505/tjtes.2017.67672 Copyright 2017 TJTES

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ly appears on the right side beneath the umbilicus and is almost always unilateral.[3] Rectus muscular sheath hematoma is 2 to 3 times more prevalent in women than men. Although there are many possible risk factors, it has been reported that an increase in the number of spontaneous RSH cases occurred at the same time as that in anticoagulant treatments. Patients undergoing this type of treatment may suffer from hemodynamic instability because the treatment increases the likelihood of hemorrhage during RSH formation.[4,5] Treatment of RSH is conservative because the illness is mostly self-limiting, but surgical treatment is recommended for complicated and large hematomas, which can cause hemodynamic disorders (such as rupture opening up to the peritoneum and infection).[1,2,5,6] This study describes the relationship between mortality and spontaneous RSH in inpatients receiving anticoagulant and antiaggregant treatment for a cardiac pathology at cardiology and cardiovascular surgery clinics.

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MATERIALS AND METHODS Within the scope of our study, data of 27 patients who were diagnosed with spontaneous RSH between January 2010 and December 2015 at Department of Gastroenterological Surgery, Kartal Kosuyolu High Speciality Education and Training Hospital were retrospectively evaluated after consent was obtained from Dr. Lütfi Kırdar Kartal Training and Research Hospital’s Board of Clinical Research Evaluation (Registration No;89513307/1009/518). The study included inpatients at cardiology and cardiovascular surgery clinics who contracted spontaneous RSH during hospitalization and after evaluation received conservative or surgical treatment.

The patients’ anamnesis, age, sex, comorbidities, and reason for starting antiaggregant and/or anticoagulant treatment were recorded following investigation of the hospital’s archive files and electronic archive system. Patients were classified in line with Berná et al.’s[7] classification for hematomas according to the radiological diagnostic method utilized at the diagnostic stage and the size and localization of the hematoma.

Patients’ international normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (aPTT) and hematocrit (hct), platelet, and leukocyte levels were recorded at the time of diagnosis. The day of hospitalization and decrease in hemoglobin and hct levels at the time of diagnosis were identified. The medical and surgical treatment methods for hematoma following diagnosis, amount of blood and blood product replacement, morbidity and mortality rates of the patients in the early phase of the disease, and duration of hospitalization were also investigated.

Table 1. Clinical and demographic characteristics of the patients Sex (n=27)

Female

Male

Age (years)

19 (70.4%) 8 (29.6%) 63±12 (32–84)

Anticoagulant treatment (n=14; 51.8%)

Oral anticoagulant

10

Low-molecular-weight heparin

4

Antiplatelet treatment (n=8; 29.6%)

Acetylsalicylic acid

Klopidogrel

Acetylsalicylic acid + Klopidogrel

Anticoagulant + antiplatelet treatment

4 2 2 5 (18.5%)

Comorbidities Hypertension

8

Diabetes mellitus

8

Atrial fibrillation

9

Coronary artery disease

7

Chronic obstructive pulmonary disease

4

Chronic renal failure

4

Cerebrovascular disease

3

Other (Cirrhosis, PVT, PE)

3

Indications for anticoagulant and antiplatelet treatments

Atrial fibrillation

8

Valve replacement

5

Statistical Analysis

Coronary artery bypass graft

5

Statistical Package for the Social Sciences (SPSS 21 Inc., Chicago, IL, USA) was used for biostatistical analysis. The collected data were expressed as means (±SD), minimums and maximums, or percentages. The hct levels at hospitalization and at the time of RSH diagnosis were compared using a paired t-test. Spearman test was performed to analyze the mortality correlations. P values of <0.05 were considered to be statistically significant.

Acute myocardial infarction

5

Coronary angiography-stent placement

4

PVT: Portal vein thrombosis, PE: Pulmomary embolism.

Patients

contracted RSH due to cardiac reasons while they were being treated in inpatient clinics. When the patients were evaluated with regards to abdominal injection, it was observed that insulin was not administered, although 8 of the patients were diabetic, and the arm was used as the injection site for patients who had low-molecular-weight heparin.

During the study, 27 patients with spontaneous RSH were treated at our clinic. Of these, 19 (70.4%) were female and 8 (29.6%) were male. The mean age was 63±12 (32–84) years.

All the patients had at least one comorbidity that necessitated follow-up. The clinical and demographic characteristics of the patients are summarized in Table 1.

Of the patients, 14 received only anticoagulant treatment, 8 received only antiaggregant treatment, and the remaining 5 received both types of treatment. Anticoagulant and antiplatelet treatments are the most common indicators of atrial fibrillation (n=8).

RESULTS

At the time of diagnosis, no patient had a history of trauma or abdominal surgery within the previous month or pregnancy or peritoneal dialysis at any point in their lives. All patients 484

Diagnosis Physical examination of all the patients revealed painful palpable masses in the lower quadrants of the abdomen (Fig. Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

soyisim et al. Spontaneous rectus sheath hematoma in cardiac in patients

Table 2. Computed tomography findings of patients

n

%

Mean±SD

Type 1

7

25.9

2

6

22.2

3

14

51.8

Size (mm)

130±68 (40–300)

Localization

16

59.2

Left

Right

8

29.6

Bilateral

3

11.1

SD: Standard deviation.

Figure 1. Ecchymosis in the upper, lower, and pelvic abdominal area.

1). Abdominal ultrasonography (USG) was initially performed for 8 patients, and then all 27 patients underwent abdominal computed tomography (CT). According to the results of the CT scans, which revealed the size and localization of the masses, the majority of cases were classified as Type III (n=14, 51.8%) (Fig. 2a-c). The largest hematomas revealed by the CT scans averaged 130±68 (40–300) mm. The majority of hematomas were located in the right quadrant of the abdomen (n=16, 59.2%). The patients’ radiological results are summarized in Table 2.

There was a significant relationship between hematoma size and tomographic type (p=0.003). Based on the level of significance of the groups, there is no difference between Type 1 and Type 2. However, there was a significant difference between these types and Type 3. There was not a significant relationship between the number of transfusions and type of hematoma (p=0.222).

According to the laboratory values obtained at the time of diagnosis, the INR levels of all patients using warfarin were

(a)

(b)

Table 3. Laboratory values of patients

Mean±SD

International normalized ratio Prothrombin time

2.02±1.5 (1–7) 20.5±10.7 (12.7–61)

Activated partial thromboplastin time

36.1±15.4 (20.7–96.1)

Hematocrit

27.07±4.19 (16.9–36.6)

Hematocrit level at first Platelet count 10 /L

35.48±3.87 (30.1–44.6) 249.1±89.06 (83–459)

9

Leukocyte

10866±4016 (4500–23900)

SD: Standard deviation.

above 2. The hct levels of patients with levels of 35.48±3.87 (30.1–44.6) at the time of hospitalization were 27.07±4.19 (16.9–36.6) on the day of RSH diagnosis, a decrease that was statistically significant (p<0.05). The laboratory results of the patients are summarized in Table 3.

Treatment Only 4 of the patients who were diagnosed with RSH did not have to undergo blood transfusion at follow-ups. Accord-

(c)

Figure 2. (a) Computed tomography scan showing Type I rectus sheath hematoma. (b) Type II hematoma. Computed tomography scan showing hyperdense bilateral hematoma. (c) Computed tomography scan showing Type III hematoma.

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Table 4. Follow-up and treatment

n

%

Mean±SD

Blood transfusion Yes

23

85.1

No

4

14.81

Mean number of transfusion

10±12 (1–45)

Treatment Medical

23

85.1

Surgery

4

14.9

Mortality

8 29.6

Length of stay in hospital

23.2±20.8 (5–92)

The time of diagnosis after hospitalization

13±16 (3–70)

SD: Standard deviation.

ing to the radiology results, all the cases not requiring blood transfusion were classified as Type I. Twenty-three patients enrolled in the study received blood transfusions, which averaged to 10±12 (1–45) units. Moreover, mortality was significantly correlated with the requirement of blood transfusion (p=0.001). Ten of these 23 patients underwent cardiac surgery during their hospitalization.

Of the 27 patients, 23 received medical treatment and the remaining 4 received surgical treatment. For patients who underwent surgery, the need for surgery was identified when the hematoma ruptured into the peritoneum. The mean duration of hospitalization was 23.2±20.8 (5–92) days, and the mean time of RSH diagnosis was 13±16 (3–70) days. Eight (29.6%) patients suffered mortality. Five of these patients underwent cardiac surgery, and the other 3 patients attended follow-ups to check for acute myocardial infarction and atrial fibrillation. Of the 8 patients who suffered mortality, 7 died due to sepsis related to hospital-acquired pneumonia and 1 due to hemorrhagic shock after massive hemorrhage. The patients’ follow-ups and treatments are summarized in Table 4.

DISCUSSION The rectus abdominis muscle, one of the structures that forms the anterior abdominal wall, is located within an aponeurotic sheath alongside the inferior and superior epigastric veins. Rupture of these veins or the rectus abdominis muscle leads to RSH.[8] RSH is a rare but significant disease that can imitate an acute abdomen because of its clinical manifestation. It is often overlooked as a possibility in emergency rooms (ERs), and the causes of acute abdominal pain are investigated more commonly.[9,10] However, RSH should be taken into consideration during the evaluation of acute abdominal pain, particularly for inpatients receiving anticoagulant or antiaggregant treatment for reasons other than those that led them to visit the ER. 486

RSH mostly occurs in people in their 60s and twice as often in female patients because they have less rectus muscle mass.[1,2] In line with the literature, most of the patients in our study were older than 60 years, and 70% were female.

This disease is more frequently seen in older age groups due to their higher use of anticoagulant and antiaggregant drugs.

Moreover, more spontaneous RSH cases have been reported for senior individuals because the elasticity of their epigastric veins decreases with atheromatous mural changes.[11] The probable risk factors for RSH include trauma, rapid and sudden changes in position, anticoagulant treatment, antiaggregant treatment, recent history of surgery, acute asthma and COPD exacerbations and coughing attacks, injections, and pregnancy.[12] Recently, the gradual increase in the use of antiaggregant and anticoagulant treatments, particularly at cardiology and cardiovascular surgery clinics, has led to an increase in the prevalence of RSH.[5] Hematomas related to anticoagulant treatment are generally formed 4–14 days after initiation of treatment.[13,14] All the patients in our study had been hospitalized for cardiac reasons or had been receiving antiaggregant treatment and on average had contracted RSH on the 13th day of hospitalization.

USG, CT, and magnetic resonance imaging techniques are used to diagnose RSH. The sensitivity of USG, which is the easiest and most rapidly available diagnostic tool for initial investigation of patients suspected to have RSH, is between 80% and 90%. The results of USG generally reveal accurate information about the size and localization of the mass.[15,16] It may, however, be difficult to differentiate intra-abdominal lesions from extra-abdominal lesions. In our study, USG was used as the first diagnostic tool for only 8 patients, and CT was used for the final comprehensive diagnosis.

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soyisim et al. Spontaneous rectus sheath hematoma in cardiac in patients

USG results, elimination of other intra-abdominal pathologies, and classification of RSH with sensitivity and authenticity rates of 100%.[6,17] Berná et al.[7] devised a system of classification for RSH that takes CT results into consideration. Final diagnoses of all the patients in our study were obtained using CT. According to the results, 7 of our patients were Type I, 6 were Type II, and 14 were Type III. Four of the patients with Type I RSH followed up without the need for blood transfusion. We believe that the reason why Type III was more common than the other types was related to the higher amount of hemorrhage in patients who had contracted RSH when taking anticoagulant or antiaggregant treatment.

to comorbidities.[22] Eight (29.6%) patients in our study suffered mortality, which was a higher rate than that reported in previous studies.[1,2] We believe that this was due to the high rate of comorbidities and the fact that our patients were diagnosed with RSH while they were undergoing medical and surgical treatment for serious cardiac problems. It was not possible to say that all deaths were related to RSH due to patients’ pre-existing heterogeneous cardiac diseases and interventions. However, as mentioned above, the relationship between the number of blood transfusions and mortality rate in this heterogeneous group suggests that mortality increases in RSH patients who need more blood transfusions.

RSH is mostly self-limiting, and thus, its treatment is conservative. Under such a treatment plan, it is advised that anticoagulant treatment be stopped in cases of anticoagulant-related bleeding, and vitamin K, factor replacement, or fresh-frozen plasma should be utilized when necessary. Application of ice on the hematoma area, non-steroidal antiinflammatory analgesics, and bed rest can also be sufficient.

[12,13,18,19] Surgical treatment, however, is recommended for complicated hematomas (showing rupture into the peritoneum, infection, etc.) and large hematomas causing hemodynamic disorders. Surgeons make an incision in the mass, drain the hematoma, wash it with saline, and if possible, ligate the bleeding vein (but the vein cannot be detected in most cases).

[1,2] Approximately 85% of the patients in our study received conservative treatment. Surgical procedures were performed for 4 patients because their hematomas ruptured into the peritoneum. All the patients in our study had been receiving anticoagulant and/or antiaggregant treatment for major cardiac diseases. Because stopping these treatments was contraindicated for cardiac diseases, they were maintained for patients who had stable hemodynamic follow-up results, laboratory parameters, and hematoma sizes.

Limitations

Interventional radiological techniques can be performed as an alternative to surgery in serious cases of active bleeding.

Using the selective embolization technique to treat bleeding veins is not preferred because it requires significant experience to be performed correctly, it is not always feasible, and the hematoma remains in that area after bleeding is stopped.

[20] Because of the lack of an experienced interventional radiological department at our hospital, embolization could not performed for any patient.

RSH-related mortality is rare.[2] However, the mortality rate increases for patients suffering from hematomas related to anticoagulant treatment.[8] In a clinical study conducted by Dağ et al.,[21] the authors found that 9% of patients with RSH who had been on anticoagulants suffered mortality.There are no studies on the factors affecting mortality in patients in which RSH was directly related to anticoagulant treatment.

It has, however, been established that mortality related to bleeding in the upper gastrointestinal system occurring after anticoagulant treatment was to a large extent related Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Our work has a few important limitations. The first and most important limitation is the retrospective nature of the study.

Second, the study population is heterogeneous because it includes patients with various ailments that require hospitalization, such as atrial fibrillation, heart valve disease, and acute myocardial infarction. Despite these limitations, this study is important because it provides detailed follow-up information about patients who contracted RSH during hospitalization for cardiac reasons.

Conclusion Although RSH is rare, its prevalence increases among patients receiving anticoagulant and antiaggregant treatments for cardiac reasons. The mortality rates of RSH reported in literature are low, but in our study, the mortality rate markedly increased among patients who contracted RSH during hospitalization for cardiac reasons, had comorbidities, and suffered from additional complications due to extended hospitalization. Therefore, RSH is a condition that needs to be considered in differential diagnosis because it may cause serious morbidity and/or mortality in patients receiving anticoagulant and antiaggregant treatment for cardiac diseases who have low hct levels and newly developed abdominal pain.

Conflict of interest: None declared.

REFERENCES 1. Linhares MM, Lopes Filho GJ, Bruna PC, Ricca AB, Sato NY, Sacalabrini M. Spontaneous hematoma of the rectus abdominis sheath: a review of 177 cases with report of 7 personal cases. Int Surg 1999;84:251–7.

2. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore) 2006;85:105–10.

3. Klingler PJ, Wetscher G, Glaser K, Tschmelitsch J, Schmid T, Hinder RA. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc 1999;13:1129–34.

4. Salemis NS, Gourgiotis S, Karalis G. Diagnostic evaluation and management of patients with rectus sheath hematoma. A retrospective study. Int J Surg 2010;8:290–3.

5. Alla VM, Karnam SM, Kaushik M, Porter J. Spontaneous rectus sheath hematoma. West J Emerg Med 2010;11:76–9.

6. Fitzgerald JE, Fitzgerald LA, Anderson FE, Acheson AG. The changing

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7. Berná JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging 1996;21:62–4.

8. Hildreth DH. Anticoagulant therapy and rectus sheath hematoma. Am J Surg 1972;124:80–6.

9. Siu WT, Tang CN, Law BK, Chau CH, Li MK. Spontaneous rectus sheath hematoma. Can J Surg 2003;46:390.

10. Maharaj D, Ramdass M, Teelucksingh S, Perry A, Naraynsingh V. Rectus sheath haematoma: a new set of diagnostic features. Postgrad Med J 2002;78:755–6.

11. Verhagen HJ, Tolenaar PL, Sybrandy R. Haematoma of the rectus abdominis muscle. Eur J Surg 1993;159:335–8.

12. Berná JD, Zuazu I, Madrigal M, García-Medina V, Fernández C, Guirado F. Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging 2000;25:230–4.

13. Bownik H, Afsar-manesh N, Jakoi A. A growing problem: A case of rectus sheath hematoma. Proceedings of UCLA Healthcare 2010;14:1– 4.

14. DeLaurentis DA, Rosemond GP. Hematoma of the rectus abdominis muscle complicated by anticoagulation therapy. Am J Surg 1966;112:859–63.

15. Moreno Gallego A, Aguayo JL, Flores B, Soria T, Hernández Q, Ortiz S,

et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath haematoma. Br J Surg 1997;84:1295–7.

16. Fukuda T, Sakamoto I, Kohzaki S, Uetani M, Mori M, Fujimoto T, et al.

Spontaneous rectus sheath hematomas: clinical and radiological features.

Abdom Imaging 1996;21:58–61.

17. Luhmann A, Williams EV. Rectus sheath hematoma: a series of unfortunate events. World J Surg 2006;30:2050–5.

18. Ozucelik DN, Neslihan Y, Emet M, Coskun S. Spontaneous rectus sheath hematoma presenting with acute abdominal pain: a case series and review of the literature. Ann Saudi Med 2005;25:250–4.

19. Dubinsky IL. Hematoma of the rectus abdominis muscle: case report and review of the literature. J Emerg Med 1997;15:165–7.

20. Magill ST, del Prado G, Chiovaro J. Embolization of hemorrhaging rectus sheath hematoma. J Gen Intern Med 2014;29:408–9.

21. Dağ A, Ozcan T, Türkmenoğlu O, Colak T, Karaca K, Canbaz H, et al.

Spontaneous rectus sheath hematoma in patients on anticoagulation therapy. Ulus Travma Acil Cerrahi Derg 2011;17:210–4.

22. Thomopoulos KC, Mimidis KP, Theocharis GJ, Gatopoulou AG, Kartalis GN, Nikolopoulou VN. Acute upper gastrointestinal bleeding in patients on long-term oral anticoagulation therapy: endoscopic findings, clinical management and outcome. World J Gastroenterol 2005;11:1365–8.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Kardiyak nedenlerle hastanede yatan hastalarda spontan rektus kılıf hematomu: Tek merkez deneyimi Dr. Ebubekir Gündeş, Dr. Durmuş Ali Çetin, Dr. Ulaş Aday, Dr. Hüseyin Çiyiltepe, Dr. Kamuran Cumhur Değer, Dr. Orhan Uzun, Dr. Aziz Serkan Senger, Dr. Erdal Polat, Dr. Mustafa Duman Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Gastroenteroloji Cerrahisi Kliniği, İstanbul

AMAÇ: Bu yazıda kardiyak patoloji nedeniyle kardiyoloji ve kalp damar cerrahisi kliniklerinde antikoagülan ve antiagregan tedavisi altında spontan gelişen rektus kılıf hematomunun mortalite ile ilişkisi sunuldu.

GEREÇ VE YÖNTEM: Ocak 2010 ve Aralık 2015 tarihleri arasında Kartal Koşuyolu Yüksek İhtisas Eğitim ve Araştırma Hastanesi’nde spontan rektus kılıf hematom tanılı 27 hasta geriye dönük olarak değerlendirildi.

BULGULAR: Hastaların 19’u (%70.4) kadın, sekizi (%29.6) erkek olup yaş ortalamaları 63±12 (dağılım, 32- 84) yıldı. Hastaların tamamında en az bir olmak üzere takip gerektiren ek hastalık mevcuttu. Hastaların 14’ü sadece antikoagülan tedavi, sekizi sadece antiagregan tedavi ve geri kalan beş hasta ise hem antikoagülan hem de antiagregan tedavi almaktaydı. Fizik muayenede olguların tümünde karın alt kadranlarında ağrılı palpabl kitle vardı.

Bilgisayarlı tomografideki boyut ve lokalizasyona göre tiplendirildiğinde olguların yedisi Tip 1, altısı Tip 2, 14’ünün ise Tip 3 olduğu saptandı. Olguların 23’üne tıbbi tedavi uygulanırken geriye kalan dört hastayada cerrahi tedavi uygulandı. Sekiz (%29.6) hastada mortalite izlendi.

TARTIŞMA: Sonuç olarak, rektus kılıf hematomu nadir olup kardiyak nedenlerle antikoagülan ve antiagregan alan hastalarda sıklığı artmaktadır.

Kardiyak nedenlerle hastane yatışı esnasında rektus kılıf hematomu gelişen, ek hastalıkları olan ve hastanede kalış süresinin uzaması nedeniyle ek komplikasyonlar gelişen hastalarda mortalite önemli ölçüde artmaktadır.

Anahtar sözcükler: Antiagregan tedavi; antikoagülan tedavi; rektus kılıf hematomu.

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ORIGIN A L A R T IC L E

Computed tomography findings of primary epiploic appendagitis as an easily misdiagnosed entity: Case series and review of literature Rabia Ergelen, M.D.,1 Ruslan Asadov, M.D.,1 Burcu Özdemir, M.D.,1 Derya Tureli, M.D.,1 Baha Tolga Demirbaş, M.D.,2 Davut Tuney, M.D.1 1

Department of Radiology, Marmara University Faculty of Medicine, İstanbul-Turkey

2

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

ABSTRACT BACKGROUND: Primer epiploic appendagitis (PEA) is an uncommon condition.

METHODS: We retrospectively reviewed the clinical records and computed tomography (CT) findings of 45 patients with PEA. RESULTS: On the basis of physical examination and pain localization, presumptive clinical diagnosis was acute appendicitis (n=13), acute cholecystitis (n=2), acute diverticulitis (n=19), renal colic (n=7) and ovarian pathology (n=4).

CONCLUSION: Although it has no characteristic clinical and laboratory features, CT is the best modality for accurate diagnosis of PEA. Keywords: Appendagitis; epiploic; tomography.

INTRODUCTION Epiploic appendages are peritoneal pouches that arise from the serosal surface of the colon, and they are composed of adipose tissue and blood vessels. Primary epiploic appendagitis (PEA) is an inflammatory condition that may arise from torsion, spontaneous venous thrombosis, or inflammation of the epiploic appendage.

The term epiploic appendagitis was introduced in 1956 by Lynn et al.,[1] and the computed tomography (CT) features were initially described in 1986 by Danielson et al.[2] This condition is a self-limiting local inflammation of epiploic appendages and patients can be successfully treated in the outpatient setting. Before the advent of CT, it was often diagnosed Address for correspondence: Rabia Ergelen, M.D. Marmara Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, İstanbul, Turkey Tel: +90 216 - 505 48 29 E-mail: drergelen@yahoo.com Submitted: 21.05.2016 Accepted: 06.04.2017

Ulus Travma Acil Cerrahi Derg 2017;23(6):489–494 doi: 10.5505/tjtes.2017.99894 Copyright 2017 TJTES

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during surgical exploration.[3] With the increasing use of CT in the evaluation of acute abdominal pain, PEA, a relatively uncommon and benign condition, can now be identified by characteristic radiological findings, thus obviating the need for hospitalization, further studies, or surgical exploration. Today, CT is used with increasing frequency for the assessment of acute abdominal pain in adult patients at the emergency department.

The benefit of CT is that it is possible to identify the cause of acute abdominal pain in a short time, which aids in the optimal management of pain because the patients can be referred either for medical treatment or surgery. In addition, CT helps in avoiding unnecessary hospital admission of patients who can be treated successfully as outpatients, and it provides information when to plan image-guided percutaneous treatment.

There are many intraabdominal pathological entities that enable CT-based diagnosis of acute abdominal emergencies as appendicitis, diverticulitis, bowel obstruction, pancreatitis, perforated peptic ulcer, abscess, pyelonephritis, and obstructive urolithiasis. However, rarer causes of acute abdomen, such as PEA, need to be kept in mind for differential diagnosis in case of acute abdominal pain.

This article aims to review our experience in diagnosing and 489

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Table 1. Demographic, clinical and laboratory findings of all patients Patient

Age

Genders

Presenting complaint

Site

Localization

Presumptive diagnosiss

WBC (x109/L)

1

29

Female

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

11.1

2

51

Male

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

10

3

32

Female

Abdominal pain

RLQ

Ascending colon

Acute diverticulitis

12.9

4

70

Female

Abdominal pain

RLQ

Ascending colon

Acute diverticulitis

23.1

5

35

Male

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

11.9

6

45

Male

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

11.8

7

40

Female

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

9.1

8

38

Male

Abdominal pain

RLQ

Ascending colon

Acute diverticulitis

9.8

9

82

Female

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

8.1

10

65

Female

Abdominal pain

LLQ

Descending colon

Acute diverticulitis

8.5

11

30

Male

Abdominal pain

LLQ

Descending colon

Acute diverticulitis

10.4

12

36

Male

Abdominal pain

LLQ

Descending colon

Acute diverticulitis

11.1

13

39

Male

Abdominal pain

LLQ

Descending colon

Acute diverticulitis

9.9

14

55

Female

Abdominal pain

LLQ

Descending colon

Acute diverticulitis

12.9

15

48

Male

Flank pain

LF

Descending colon

Renal colic

9.6

16

29

Male

Flank pain

LF

Descending colon

Renal colic

6.3

17

23

Male

Flank pain

LF

Descending colon

Renal colic

11.5

18

19

Female

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

10.1

19

51

Male

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

4.5

20

34

Female

Abdominal pain

RUQ

Ascending colon

Acute cholecystitis

9.8

21

45

Female

Abdominal pain

LLQ

Sigmoid colon

Acute diverticulitis

6.4

22

64

Female

Abdominal pain

LLQ

Sigmoid colon

Acute diverticulitis

9.6

23

39

Male

Abdominal pain

LLQ

Sigmoid colon

Acute diverticulitis

9.4

24

20

Female

Abdominal pain

LLQ

Descending colon

Ovarian pathology

10.3

25

70

Female

Abdominal pain

LLQ

Descending colon

Acute diverticulitis

6.2

26

35

Male

Abdominal pain

RUQ

Ascending colon

Acute cholecystitis

9.3 8.3

27

26

Male

Flank pain

LF

Sigmoid colon

Renal colic

28

33

Male

Abdominal pain

LLQ

Sigmoid colon

Acute diverticulitis

10

29

28

Male

Abdominal pain

LLQ

Sigmoid colon

Acute diverticulitis

10.1

30

19

Male

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

10.8

31

11

Male

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

10.7

32

31

Male

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

12.8 12.4

33

65

Female

Abdominal pain

LLQ

Descending colon

Acute diverticulitis

34

34

Female

Flank pain

LLQ

Descending colon

Acute diverticulitis

9.5

35

26

Male

Abdominal pain

LLQ

Sigmoid colon

Acute diverticulitis

11.9

36

41

Female

Abdominal pain

LLQ

Descending colon

Ovarian pathology

8.5

37

43

Female

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

14

38

78

Female

Abdominal pain

LUQ

Transverse colon

Acute diverticulitis

21.8

39

21

Male

Abdominal pain

LLQ

Sigmoid colon

Acute diverticulitis

6.5

40

68

Male

Flank pain

RF

Ascending colon

Renal colic

8

41

55

Male

Flank pain

LF

Descending colon

Renal colic

7.5

42

51

Female

Abdominal pain

LLQ

Descending colon

Ovarian pathology

10.6

43

52

Female

Abdominal pain

RLQ

Ascending colon

Acute appendicitis

10.6

44

50

Female

Flank pain

LF

Descending colon

Renal colic

6.7

45

49

Female

Abdominal pain

LLQ

Descending colon

Ovarian pathology

12.8

RLQ: Right lower quadrant; LLQ: Left lower quadrant; RUQ; Right upper quadrant; LUQ; Left upper quadrant; WBC: White blood cell; LF: Left flank; RF: Right flank.

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Ergelen et al. CT findings of primary epiploic appendagitis as an easily misdiagnosed entity

MATERIALS AND METHODS We retrospectively reviewed the clinical records and CT images of 45 patients diagnosed with PEA in Marmara University Hospital during 2014–2016. All patients were admitted to the emergency department of our hospital with suspected acute abdomen. A detailed medical history taking and physical examination were the initial diagnostic steps for these patients. On the basis of the results of this clinical evaluation and laboratory investigations, the clinicians considered imaging examinations to help arrive at a definitive diagnosis.

As an imaging investigation, intravenous contrast-enhanced abdominal CT was performed with triplanar reformatted images (Somatom Definition Flash, 256-slices, Siemens, Erlangen, Germany) for each patient as a part of the evaluation of acute abdomen. CT was performed with 2.5-mm detector collimation and 5-mm slice thickness. Intravenous contrast material was injected at a rate of 3 ml/s, and portal venous phase images were obtained with a 60–70 ml/s delay after the initiation of contrast injection.

Patients diagnosed with PEA on CT were included in this study and CT findings were reviewed by an experienced radiologist (ER) with 10 years of experience. CT images are reviewed according to diagnostic criteria of PEA. The criteria of CT findings specific for PEA are as follows: I. oval shaped, well-defined focus of hypodense fat tissue; II. thickened peritoneal ring (ring sign III. periappendageal fat stranding (inflammatory change); IV. the central dot sign (thrombosed vessel).[4,5] The patients’ medical records were examined with regard to demographics, initial associated symptoms, white blood cell (WBC) count, presumptive diagnosis, and treatment. This study was approved by the ethical committee of our hospital.

tients according to the pain localization is shown in Figure 1.

On physical examination, all patients had diffuse tenderness around the anatomical localization of PEA and six of them had additional rebound tenderness. Three patients (0.06%) presented with fever and 21 (46%) with elevated WBC counts (>10×109/L). None of the patients had constipation or diarrhea.

Characteristic CT findings of criterion I, II, and III were present in all 45 patients (Fig. 2). Twelve patients had the central dot sign indicative of central venous thrombosis (Fig. 3). The lesions were located in the ascending colon in 19 patients (42%), in the descending colon in 17 patients (37%), in the transverse colon in one patient (0.2%), and in the sigmoid colon in eight patients (17%). Presumptive diagnosis of the patients according to the localization of PEA is shown in Figure 4. Lokalization of PEA was mostly on the anterior wall of the colon (41/45), and only four patients had PEA at the lateral the wall of the colon (0.08%).

20 18

OP

16 Patient number

managing PEA case in a large study population in Marmara University Hospital.

14

AD

12 10 8 6

AD

AA

4

RC

2 0

AC RLQ

RUQ

LLQ

AD LUQ

LF

RC RF

Figure 1. Presumptive diagnosis according to the pain localization is shown (AA: Acute appendagitis; AD: Acute diverticulitis; OP: Ovarian pathology; AC: Acute cholecystitis; RC: Renal colic; RLQ: Right lower quadrant; RUQ; Right upper quadrant; LLQ: Left lower quadrant; LUQ; Left upper quadrant; LF: Left flank; RF: Right flank).

RESULTS Demographic, clinical, and laboratory findings of 45 patients are depicted in Table 1. Patients evaluated included 24 males and 21 females, with a mean age of 42.3 years (range 11–88 years) diagnosed with PEA on CT. All patients presented with acute-onset abdominal pain localized as follows: right lower quadrant in 16 patients (35%), right upper quadrant in two patients (0.4%), left lower quadrant in 19 patients (41%), and left upper quadrant in one patient (0.02%). Therefore, presumptive clinical diagnosis after medical history taking and physical examination, on the basis of physical examination findings and pain localization, was acute appendicitis (13 cases), acute cholecystitis (two cases), acute diverticulitis (19 cases), renal colic (seven cases), and ovarian pathology (four cases). presumptive diagnosis of paUlus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Figure 2. Contrast-enhanced axial computed tomography images show well-defined focus of hypodense fat tissue (black arrow), thickened peritoneal ring. and periappendageal fat stranding (white arrow).

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Ergelen et al. CT findings of primary epiploic appendagitis as an easily misdiagnosed entity

Primary epiploic appendagitis is a rare, benign, localized, and sterile inflammation of the appendix epiploica, resulting from torsion or spontaneous venous thrombosis of the draining vein, usually involving the sigmoid colon or cecum.[6,7] These appendages are susceptible to torsion because of their pedunculated shape with excessive mobility and limited blood supply.[8,9] Several studies with limited number of patients were reported in the literature. Chen et al.[10] reported 21 patients and Saad et al.[11] reported 18 patients diagnosed with PEA in their case reports. Thus, our study seems to have one of the largest study population in the literature.

Figure 3. Contrast-enhanced axial computed tomography images show the central dot sign, indicative of central venous thrombus (arrow).

18

Patient number

16

Sigm C

14 12 10 8

Asc C

Desc C

Sigm C

6 4

Trans C

2

Asc C

0

AA

AD

Desc C Asc C AC

Asc C RC

Desc C OP

Figure 4. Presumptive diagnosis of the patients according to the localization of PEA is shown (Asc C: Ascending colon; Sig C: Sigmoid colon; Desc C: Descending colon; Trans C: Transverse colon; AA: Acute appendagitis; AD: Acute diverticulitis; AC: Acute cholecystitis; RC: Renal colic; OP: Ovarian pathology).

The treatment for all patients was conservative based on their CT findings (such as analgesics and antibiotics). No recurrence of symptoms was documented during any of the follow-up visits during their hospital stay, as defined in the medical records.

DISCUSSION Appendices epiploicae are pouches of subserosal fat lining the entire length of the colon attached to the colonic wall by a vascular stalk, and appearing in two parallel rows next to the anterior and posterior tenia coli. The epiploic appendages vary in shape and size but usually measure about 3 cm in length, each. An average person has approximately 50â&#x20AC;&#x201C;100 appendages clustering most prominently in the cecal and sigmoid region. Each epiploic appendage has one or two small supplying arteries from the colonic vasa recta and has a small draining vein with narrow peduncle.

492

Patients with PEA frequently present with sudden onset of abdominal pain over the affected area, more often in left lower quadrant.[4,7,10,12] In our study, pain was localized for 16 patients in the right lower quadrant (35%), for two patients in the right upper quadrant (0.4%), for 19 patients in the left lower quadrant (41%), and for one patient in the left upper quadrant (0.02%); the distribution was similar to that in previous reports. Therefore, the presumptive clinical diagnosis on the basis of pain localization was acute appendicitis in 11 cases (24%), acute cholecystitis in three cases (0.06%), acute diverticulitis in 19 cases (42%), renal colic in eight cases (17%), and ovarian pathology in four cases (0.08%). Some patients even reported flank pain in our study; therefore, presumptive diagnosis was renal colic for each of these patients, as rarely described previously. None of the 45 patients in the study was clinically suspected to have PEA. PEA can occur at any age with a peak incidence in the fourth to fifth decades, and men are slightly more affected than women.[7,13] In the current study the mean age of patients with PEA was 42.3 years, and there was a slight male predominance (24 males vs. 21 females). This is an important point of view in the differential diagnosis of PEA with acute diverticulitis and omental infarction, because they are frequently seen in elderly patients. Our results were consistent with those reported in the literature.[4,14] There are no characteristic diagnostic laboratory findings in PEA. The WBC count is normal or moderately elevated.

[5,7,13,14] In the current study, the WBC count was slightly elevated in only 46% of patients; thus, this is not a reliable finding for the differentiation of acute colonic diverticulitis and PEA as defined in the literature.[14] In the previous reports, a profound abdominal swelling was reported in 10%â&#x20AC;&#x201C;30% patients diagnosed with PEA, and fever and nausea were also common presenting complaints.[5,14,15] In our study, only three patients (0.06%) had fever and none of them had nausea, vomiting, or a palpable mass in contrast to previous studies; thus, PEA should still be kept in mind in the differential diagnosis of acute abdomen in the absence of fever, nausea, and vomiting.[7,14] Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Ergelen et al. CT findings of primary epiploic appendagitis as an easily misdiagnosed entity

The diagnosis of acute epiploic appendagitis primarily relies on cross-sectional CT, although ultrasound (USG) and MRI are occasionally used. PEA has nonspecific USG findings usually indicative of an inflammation particularly around the location of pain.[16] MRI is not used in evaluation of acute abdomen during routine practice. In our hospital, patients presenting with acute abdomen were routinely evaluated with CT; therefore, our diagnosis of PEA were all on CT. Patients did not undergo USG examinations; thus, we have no experience about the USG findings of patients with PEA. Because of the increasing use of CT in acute abdominal pain, radiologists are likely to define PEA.[4,6] Its characteristic findings are; oval shaped, well-defined focus of hypodense fat tissue, thickened peritoneal ring (ring sign), and periappendageal fat stranding (inflammatory change).[4,9] We confirmed all the characteristic findings of PEA;[1–3] in our study patients 11. In addition, central dot sign indicative of central venous thrombus is defined in the literature in changing frequencies[4,6] n current study, 12 of the patients had the central dot sign (26%), which is less frequent than what is reported in the literature.[15,17] Therefore, the central dot sign is useful for diagnosis, but the absence of this sign cannot preclude the diagnosis of PEA. The weak point in this report is lack of pathological confirmation because of the self-limiting disease course and conservative treatment used in PEA. The following are our concluding points. PEA, although not as rare as it was once thought, is an uncommon condition, but it still should be kept in mind in the evaluation of acute abdomen. The awareness of the clinicians and radiologists regarding the diagnosis of PEA will prevent unnecessary hospital admission and operative treatment of patients with acute abdomen.

Although PEA has no characteristic clinical and laboratory features, CT is the best modality for accurate diagnosis.

Funding/Support None.

Conflict of interest: None declared.

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REFERENCES 1. Dockerty MB, Lynn TE, Waugh JM. A clinicopathologic study of the epiploic appendages. Surg Gynecol Obstet 1956;103:423–33.

2. Danielson K, Chernin MM, Amberg JR, Goff S, Durham JR. Epiploic appendicitis: CT characteristics. J Comput Assist Tomogr 1986;10:142–3.

3. Carmichael DH, Organ CH Jr. Epiploic disorders. Conditions of the epiploic appendages. Arch Surg 1985;120:1167–72.

4. Singh AK, Gervais DA, Hahn PF, Sagar P, Mueller PR, Novelline RA. Acute epiploic appendagitis and its mimics. Radiographics 2005;25:1521–34.

5. Legome EL, Belton AL, Murray RE, Rao PM, Novelline RA. Epiploic appendagitis: the emergency department presentation. J Emerg Med 2002;22:9–13.

6. Ng KS, Tan AG, Chen KK, Wong SK, Tan HM. CT features of primary epiploic appendagitis. Eur J Radiol 2006;59:284–8.

7. Son HJ, Lee SJ, Lee JH, Kim JS, Kim YH, Rhee PL, et al. Clinical diagnosis of primary epiploic appendagitis: differentiation from acute diverticulitis. J Clin Gastroenterol 2002;34:435–8.

8. Carmichael DH, Organ CH Jr. Epiploic disorders. Conditions of the epiploic appendages. Arch Surg 1985;120:1167–72.

9. Ross JA. Vascular loops in the appendices epiploicae; their anatomy and surgical significance, with a review of the surgical pathology of appendices epiploicae. Br J Surg 1950;37:464–6.

10. Chen JH, Wu CC, Wu PH. Epiploic appendagitis: an uncommon and easily misdiagnosed disease. J Dig Dis 2011;12:448–52.

11. Saad J, Mustafa HA, Elsani AM, Alharbi F, Alghamdi S. Primary epiploic appendagitis: reconciling CT and clinical challenges. Indian J Gastroenterol 2014;33:420–6.

12. Vázquez GM, Manzotti ME, Alessandrini G, Lemos S, Perret MC, Catalano HN. Primary epiploic appendagitis: clinical features in 73 cases. Medicina (B Aires) 2014;74:448–50.

13. Sand M, Gelos M, Bechara FG, Sand D, Wiese TH, Steinstraesser L, et al. Epiploic appendagitis--clinical characteristics of an uncommon surgical diagnosis. BMC Surg 2007;7:11.

14. Hwang JA, Kim SM, Song HJ, Lee YM, Moon KM, Moon CG, et al.

Differential diagnosis of left-sided abdominal pain: primary epiploic appendagitis vs colonic diverticulitis. World J Gastroenterol 2013;19:6842–8.

15. Rioux M, Langis P. Primary epiploic appendagitis: clinical, US, and CT findings in 14 cases. Radiology 1994;191:523–6.

16. Almeida AT, Melão L, Viamonte B, Cunha R, Pereira JM. Epiploic appendagitis: an entity frequently unknown to clinicians-diagnostic imaging, pitfalls, and look-alikes. AJR Am J Roentgenol 2009;193:1243–51.

17. Rao PM, Novelline RA. Case 6: primary epiploic appendagitis. Radiology 1999;210:145–8.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Kolaylıkla atlanabilen bir antite olan epiploik apandisitin bilgisayarlı tomografi bulguları: Olgu serisi ve literatürün gözden geçirilmesi Dr. Rabia Ergelen,1 Dr. Ruslan Asadov,1 Dr. Burcu Özdemir,1 Dr. Derya Tureli,1 Dr. Baha Tolga Demirbaş,2 Dr. Davut Tuney1 1 2

Marmara Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, İstanbul Marmara Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul

ARKA PLAN: Primer epiploik apandisit (PEA) nadir görülen bir hastalıktır.

GEREÇ VE YÖNTEM: Bu yazıda PEA tanısı alan 45 hastanın klinik verileri ve bilgisayarlı tomografi (BT) bulguları geriye dönük olarak değerlendirildi.

BULGULAR: Fizik muayene bulguları ve ağrının lokalizasyonuna göre hastalar akut apandisit (n=13), akut kolesistit (n=2), akut diverkülit (n=19), renal kolik (n=7) ve over patolojisi (n=4) öntanılarını aldılar. Bu hastalara BT incelemesi sonucunda PEA tanısı konuldu.

TARTIŞMA: Primer epiploik apandisit patogonomik olmayan klinik ve laboratuvar bulgularına sahiptir ve akut karın hastalıklarının değerlendirilmesinde akılda tutulması gereken bir klinik antitedir.

Anahtar sözcükler: Apandisit; epiploik; tomografi.

Ulus Travma Acil Cerrahi Derg 2017;23(6):489–494

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doi: 10.5505/tjtes.2017.99894

Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

ORIGIN A L A R T IC L E

Early laparoscopic cholecystectomy following acute biliary pancreatitis expedites recovery Seracettin Eğin, M.D., Metin Yeşiltaş, M.D., Berk Gökçek, M.D., Hakan Tezer, M.D., Servet Rüştü Karahan, M.D. Department of General Surgery, Okmeydanı Training and Research Hospital, İstanbul-Turkey

ABSTRACT BACKGROUND: In this retrospective study, we aimed to assess the reliability of early cholecystectomy, risk of recurrent biliary pancreatitis, and their effects on hospital length of stay and morbidity by comparing the results of early and late laparoscopic cholecystectomy in patients with acute biliary pancreatitis.

METHODS: A total of 131 patients, who were diagnosed with acute biliary pancreatitis at Okmeydanı Education and Research Hospital in January 2009–December 2012, were included in the study. Demographic specifications of patients, duration of their complaints, biochemistry and hemogram values at first arrival, Ranson criteria, number of attacks, screenings, operation type and period, number of days between the first attack and operation, hospital length of stay, and complications were recorded. Patients who underwent cholecystectomy within the first 2 weeks were considered early (group 1) and those who under the operation after 2 weeks were considered late (group 2).

RESULTS: There were 47 patients in group 1 and 84 patients in group 2. Open surgery was not performed on any patient, and there was no choledoch injury and mortality. The average hospital length of stay was 7.6±3.0 days in group 1 and 10.7±8.3 days in group 2, with a statistically significant difference between the groups (p=0.006). Two or more number of attacks occurred in 15 patients in group 2 (18%), with a statistically significant difference between the groups (p=0.000).

CONCLUSION: Laparoscopic cholecystectomy is safe as it does not increase operation time and morbidity in biliary pancreatitis with a Ranson score of ≤3 or cause difficulty in dissection. Late cholecystectomy causes recurrent attacks and increases the hospital length of stay and treatment costs. Using randomized controlled studies, the effectiveness and reliability of early cholecystectomy in mild and moderate biliary pancreatitis can be verified.

Keywords: Biliary pancreatitis; laparoscopic cholecystectomy; timing of cholecystectomy.

INTRODUCTION Cholecystectomy is recommended following an acute biliary pancreatitis (ABP) episode to prevent the development of biliary-related complications. However, there is an ongoing debate with regards to the optimal timing of intervention.[1] Acute pancreatitis has an annual incidence of 5–80/100.000 with gallstones being the most common etiology.[2,3] GallAddress for correspondence: Seracettin Eğin, M.D. Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Turkey Tel: +90 212 - 314 55 55 E-mail: seracettin_egin@hotmail.com Submitted: 22.06.2016 Accepted: 28.04.2017

Ulus Travma Acil Cerrahi Derg 2017;23(6):495–500 doi: 10.5505/tjtes.2017.50128 Copyright 2017 TJTES

Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

stone pancreatitis is an inflammatory process due to temporary obstruction of both biliary and pancreatic drainage routes, usually self-limiting in nature. Treatment consists of initial supportive care followed by laparoscopic cholecystectomy (LC). In a few ABP patients, severe pancreatitis develops with impending cholangitis, which necessitates endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction.

Biliary pancreatitis accounts for 40% of pancreatitis cases.

Moderate pancreatitis is encountered in 80% of all cases and severe pancreatitis in 20%, which is associated with high morbidity and mortality.[4] There is a general consensus on performing an interval cholecystectomy when the inflammatory process subsides, following an episode of severe pancreatitis.[5] Recent guidelines recommend early cholecystectomy after moderate biliary pancreatitis episodes.[6–8] However, the definition of early cholecystectomy is not universal. Some authors recommend cholecystectomy after im495

Eğin et al. Early laparoscopic cholecystectomy following acute biliary pancreatitis expedites

mediate convalescence from an ABP episode, whereas others recommend that surgery should be postponed for 2–4 weeks.[8–14] The variation between guidelines is due to an absence of randomized controlled trials. The idea behind early cholecystectomy rests on decreasing the risk of developing recurrent biliary-related complications (i.e., acute pancreatitis, acute cholecystitis, symptomatic bile duct stones, biliary colic). As a recurrent biliary pancreatitis episode may be lifethreatening, early cholecystectomy may prove pivotal.[15] In general practice, surgeons postpone surgery until cessation of the inflammatory process, as evidenced by the absence of abdominal pain and normal liver function tests. However, this approach is not evidence-based and may unnecessarily prolong hospital stay.

We hypothesized that early LC would improve outcomes without additional morbidity and compared the outcomes following early (<2 weeks) and delayed (>2 weeks) LC performed after an ABP episode.

MATERIALS AND METHODS Approval was received for this study from the ethics committee of Okmeydanı Education and Research Hospital. Hospital electronic records were retrospectively extracted for patients with ABP who underwent LC between January 2009 and December 2012. Patients who required conventional bile duct exploration during LC were excluded. Severe and necrotizing pancreatitis cases were excluded. ABP was defined as right upper quadrant pain, a three-fold increase in serum amylase level, and the presence of stones in the gallbladder or biliary ducts. The management of each individual patient with regards to early (<2 weeks) or delayed (>2 weeks) LC was at the discretion of the attending surgeon.

The study cohort was divided into early (<2 weeks; group 1) and delayed (>2 weeks; group 2) LC. Univariate analysis was performed comparing demographics (age, sex), clinical characteristics (duration of symptoms, period from onset to

surgery, episode count, Ranson score), surgical procedure [LC, intraoperative cholangiography, laparoscopic bile duct exploration (LBDE), duration of surgery], complications (retained bile duct stone, intra-abdominal bleeding, postoperative pancreatitis, pancreatic pseudocyst, cystic duct stump leakage), and hospital length of stay (HLOS) between the two treatment groups. Primary endpoint consisted of HLOS, and secondary endpoints were recurrent pancreatitis episodes and postoperative complications. C-reactive protein (CRP) level was used to monitor patient progress. When CRP level failed to decrease or when it reached >150 mg/dL, a contrastenhanced abdominal computerized tomography (CT) scan was indicated to assess for necrotizing pancreatitis. ERCP was selectively performed in both pre and postoperative periods.

When acute cholangitis was associated with ABP, ERCP was preoperatively performed. A total bilirubin level of >4 mg/dL at admission was evaluated with ultrasonography (US) and/ or magnetic resonance cholangiopancreatography (MRCP).

When a dilatation of the biliary tree was encountered, preoperative ERCP was performed.

Statistical Analysis Chi-square or Fisher’s exact tests were used to compare categorical variables. Continuous variables were examined for normality of distribution using the Shapiro–Wilk test. Student’s t test was used for the analysis of normally distributed variables, and the non-parametric Mann–Whitney U test was used for the analysis of values with non-normal distribution.

Statistical analyses were performed using IBM SPSS Statistics 22.0. Statistical significance was set at a p-value of <0.05.

RESULTS Age, sex, duration of symptoms, and Ranson score were not different between the two groups. Duration from onset till surgery and the number of episodes were significantly shorter and less, respectively, in group 1 (Table 1).

Operation time and postoperative complication rates were

Table 1. Demographics and clinical characteristics

Age, Mean±SD/Med (Min-Max)

Group 1 (n=47) Early LC 54.3±17 / 56.0 (17-82)

Group 2 (n=84) Late LC

p

51.9±15.4 / 51.5 (23-83)

0.419

Sex, n (%)

Female

37 (79)

61 (73)

Male

10 (21)

23 (27)

0.440

Symptom duration, Mean±SD–Med (Min-Max)

1.5±1.1 / 1 (1–7)

1.5±1.2 / 1 (1–7)

0.878

Duration from onset to surgery, Mean±SD/Med (Min-Max)

5.7±2.8 / 5 (1–14)

82.8±83.0 / 57.5 (14–496)

0.000

Episode count, Mean±SD/Med (Min-Max)

1.0±0.0 / 1 (1-1)

1.3±0.7 / 1 (1–6)

0.001

Ranson score, Mean±SD/Med (Min-Max)

1.9±1.2 / 2 (0–4)

1.8±1.1 / 2 (0–5)

0.505

LC: Laparoscopic cholecystectomy; SD: Standard deviation; Med: Median; Min: Minimum; Max: Maximum.

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Table 2. Surgical procedure, complications, and outcomes

Early LC

Late LC

p

Operation type, n (%)

LC

43 (91)

77 (92)

LC + IOC

0 (0)

2 (2)

LC + LBDE

4 (9)

5 (6)

77.4±34.8 / 70 (30–195)

76.7±33.4 / 72.5 (25–180)

Duration of surgery, Mean±SD min./Med (Min-Max)

0.971

Postoperative complications, n (%)

Absent

46 (98)

79 (94)

Present

1 (2)

5 (6)

Retained bile duct stone

1 (2)

0 (0)

Intra-abdominal bleeding

0 (0)

1 (1)

Postoperative pancreatitis

0 (0)

1 (1)

Pancreatic pseudocyst

0 (0)

1 (1)

Cystic duct stump leak HLOS, Mean±SD days/Med (Min-Max)

0.315

0 (0)

2 (2)

7.6±3.0 / 7.0 (2–17)

10.7±8.3 / 9.0 (2–72)

0.006

15 (18)

0.000

Recurrent pancreatitis episodes, n (%)

0 (0)

LC: Laparoscopic cholecystectomy; IOC: Intraoperative cholangiography; LBDE: Laparoscopic bile duct exploration; HLOS: Hospital length of stay; SD: Standard deviation; Med: Median; Min: Minimum; Max: Maximum.

Table 3. MRCP and ERCP findings

Preoperative MRCP

Early LC

Late LC

Total

11

19

30

Bile duct pathology Absent

10

17

27

Present

1

2

3

Common bile duct stone

1

1

2

Biliary tree dilatation

0

1

1

Preoperative ERCP

6

8

14

Acute cholangitis Absent

6

3

9

Present

0

Stone extracted

0

5 (acute cholangitis)

5

5 5

Postoperative ERCP

1

3

4

LC+LBDE retained stone

1

0

1

Recurrent pancreatitis

0

1

1

Cystic stump leak

0

2 (stent)

2

MRCP: Magnetic resonance cholangiopancreatography; ERCP: Endoscopic retrograde cholangiopancreatography; LC: Laparoscopic cholecystectomy; LBDE: Laparoscopic bile duct exploration.

not different between the groups. HLOS was significantly shorter in group 1. The incidence of recurrent pancreatitis episodes and emergency room (ER) visits were significantly high in group 2. Postoperative complications were not significantly different between the groups (Table 2).

Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

An abdominal CT scan was indicated in 16 patients, none of whom showed signs compatible with necrotizing pancreatitis.

Preoperative ERCP was preoperatively performed in five patients due to associated acute cholangitis, and gallstones were extracted from common bile duct in all cases. US or MRCP findings were suggestive of bile duct stones in six patients in group 1 and in three patients in group 2 (Table 3).

There was no conversion to conventional cholecystectomy, no biliary tree injury, and no mortality. Two common bile duct stones were identified and extracted with ERCP before discharge in one patient from group 1 who underwent LC and LBDE. One patient from group 2 who underwent LC and LBDE required emergency laparotomy on postoperative day 1 due to intraabdominal hemorrhage, and hemostasis was performed on common bile duct arteries at 3 and 9 o’clock positions. One patient in group 2 developed a pancreatic pseudocyst after ABP, which was initially treated with percutaneous cyst drainage and then with LC after 210 days of the ABP episode. One patient in group 2 had a recurrent ABP after 15 days of LC, which was treated with ERCP. Two patients in group 2 developed bile leakage: in one patient, the leakage was identified as originating from a cystic duct stump and treated with a bile duct stent, whereas in the other patient, a diagnostic laparoscopy with biloma drainage was performed followed

by ERCP and bile duct stenting on postoperative day 13.

DISCUSSION LC performed within 2 weeks of ABP onset was shown to 497

Eğin et al. Early laparoscopic cholecystectomy following acute biliary pancreatitis expedites

decrease HLOS compared with LC performed after 2 weeks.

Similar results were reported in a recent systematic review.

[16] Recurrent pancreatitis was observed in 18% of group 2.

In a recent systematic review, the ER readmission rate due to recurrent biliary pancreatitis was reported as 8%. When readmissions due to acute cholecystitis and biliary colic were taken into account, an 18% readmission rate after late cholecystectomy was reported.[16] Readmissions to ER due to acute cholecystitis or biliary colic were out of the scope of the present study and thus were not recorded. The recurrent biliary pancreatitis rate of 18% in the present study may seem relatively high compared with that of previous data. This may partially be explained by fact that Turkish cuisine and eating habit usually contains high levels of saturated fat. Recurrent biliary pancreatitis is encountered in 4%–50% of cases and may become fatal.[15,17,18] According to our study, only one patient in group 2 developed recurrent biliary pancreatitis with impending necrotizing pancreatitis and pseudocyst formation.

There has been a historical dogma among surgeons to believe that edema caused by pancreatitis would pose dissection difficulties and may increase complication and cause conversion to open surgery rates. In contrast, Sinha[19] proposed that dissection difficulties are encountered more in late cholecystectomies than in early cholecystectomies.

The initial assessment of acute pancreatitis should be performed well and with care. Regardless of the patient’s clinical status, cholecystectomy within the initial 48–72 h is not recommended.[20] Fifteen percent of moderate pancreatitis patients will eventually develop severe pancreatitis.[21,22] Cholecystectomy in the presence of severe pancreatitis may predispose the patient to unbalanced risks.[5] In the present study, the patient cohort consisted of mild or moderate pancreatitis cases. Severe and necrotizing pancreatitis cases were excluded.

When postoperative complications were compared between both groups, no significant differences were observed.

Total bilirubin was reported as the best predictor of common bile duct stones in biliary pancreatitis.[23] Within 2 days of the initial hospital admission, a total bilirubin level of >4 mg/dl was shown to be the best positive predictive value; therefore, preoperative ERCP is unnecessary for patients with more less this bilirubin level.[24] These levels were also reported to substantially increase the likelihood of developing acute cholangitis.[25] In the present study, ERCP was selectively performed in both pre and postoperative periods. According to our study, acute cholangitis was associated with ABP in five patients from group 2. Preoperative ERCP was performed, and in all cases, bile stones were extracted from the common bile duct. A total bilirubin level of >4 mg/dL was evaluated with US and/or MRCP. When dilatation of the biliary tree was encountered, preoperative ERCP was performed. Postoperative ERCP was performed in one patient from group 1 and in three patients from group 2 due to postoperative complications (Table 3).

498

The present study is limited mainly by its retrospective nature and small patient population. No prospective randomized study has reported on the timing of cholecystectomy, other than the trial by Aboulian et al.,[25] until the PONCHO trial of the Dutch Pancreatitis Study Group published in 2015.

This trial was terminated after an interim analysis of 25 patients, who showed no differences in secondary endpoints.

The early cholecystectomy group in this study consisted of operation performed within 48 h of admission. The PONCHO trial is designed to answer the question of whether early cholecystectomy leads to a reduction of re-acceptances for biliary events in patients with a first episode of mild biliary pancreatitis.[26] The first 72-h time interval after randomization is selected for the early cholecystectomy group. For the interval LC group, 25–30 days after randomization are chosen. The PONCHO trial is a superior trial, hypothesizing a reduction in readmission for biliary events in patients with a first episode of mild biliary pancreatitis. The primary endpoint was a composite of gallstone-related complications or mortality occurring within 6 months of randomization before or after cholecystectomy.[27] Readmission rate due to gallstone-related complications or mortality in the interval cholecystectomy group was reported as 17%. According to our study, readmission rate due to recurrent pancreatitis episodes in group 2 was 18%. There was no readmission due to gallstone-related events other than recurrent pancreatitis episodes or mortality in our study. The readmission rate in the late cholecystectomy group in our study also has similar results in the PONCHO trial of the Dutch Pancreatitis Study Group. Readmission rate in the same-admission cholecystectomy group of the PONCHO trial was 5%, while it was 0% in our study. The reason for this may be that the number of cases in our group 1 is 47, whereas that in the PONCHO trial was 128. The other reason may be that the surgeons are biased in the selection of patients in our study.

HLOS after randomization did not differ between groups in the PONCHO trial.[27] However, it was significantly longer in group 2 of our study. The reason for this may be that episode count and duration from onset to surgery is significantly higher in this group (Table 1). Long HLOS means increase in treatment costs.

LC is not preferred in elderly patients due to comorbidity at the first admission. However, the best evidence till date has shown stable tendency in favor of laparoscopic procedures in terms of mortality, morbidity, and cardiac and respiratory complications in selected cases.[28] LC is safe in elderly patients, with low morbidity and mortality rates, and perioperative outcomes in elderly patients depend on the severity of gall bladder disease rather than chronologic age.[29] Early LC can be indicated for elderly patients with mild ABP and acceptable morbidity and mortality risks. LC reduces the risk of complications caused by recurrent pancreatitis in elderly patients. Therefore, surgery should be performed at the first admission.[30] Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Eğin et al. Early laparoscopic cholecystectomy following acute biliary pancreatitis expedites

Cholecystectomy should be performed during index admission in patients with mild acute pancreatitis and should be delayed until clinical resolution in patients with severe acute pancreatitis.[31] Currently, clinical decision making relies on the available retrospective data until novel prospective randomized studies become available.

Conclusion The present study demonstrated that in mild or moderate ABP, LC within 2 weeks of admission of the initial episode decreases HLOS and prevents the development of recurrent pancreatitis. Further large-scale prospective randomized trials are required to document the safety and efficacy of this approach.

Informed Consent This was a retrospective clinical trial, and written informed consent was not obtained from patients who participated in this study.

Conflict of interest: None declared.

REFERENCES 1. Yeo CJ, Cameron JL. Acute pancreatitis. Sabiston DC, editor. Textbook of Surgery. 15th ed. W.B. Saunders Company; 1997. p. 1156–65.

2. Lankisch PG, Burchard-Reckert S, Lehnick D. Underestimation of acute pancreatitis: patients with only a small increase in amylase/lipase levels can also have or develop severe acute pancreatitis. Gut 1999;44:542–4.

3. Byrne MF, Mitchell RM, Stiffler H, Jowell PS, Branch MS, Pappas TN, et al. Extensive investigation of patients with mild elevations of serum amylase and/or lipase is ‘low yield’. Can J Gastroenterol 2002;16:849–54.

4. Banks PA, Freeman ML; Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis.

Am J Gastroenterol 2006;101:2379–400.

5. Nealon WH, Bawduniak J, Walser EM. Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections. Ann Surg 2004;239:741–9.

6. Working Party of the British Society of Gastroenterology; Association of Surgeons of Great Britain and Ireland; Pancreatic Society of Great Britain and Ireland; Association of Upper GI Surgeons of Great Britain and Ireland. UK guidelines for the management of acute pancreatitis. Gut 2005;54 Suppl 3:iii1–9.

7. Forsmark CE, Baillie J; AGA Institute Clinical Practice and Economics Committee; AGA Institute Governing Board. AGA Institute technical review on acute pancreatitis. Gastroenterology 2007;132:2022–44.

8. Uhl W, Warshaw A, Imrie C, Bassi C, McKay CJ, Lankisch PG, et al; International Association of Pancreatology. IAP Guidelines for the Surgical Management of Acute Pancreatitis. Pancreatology 2002;2:565–73.

9. Cameron DR, Goodman AJ. Delayed cholecystectomy for gallstone pancreatitis: re-admissions and outcomes. Ann R Coll Surg Engl 2004;86:358–62.

10. Monkhouse SJ, Court EL, Dash I, Coombs NJ. Two-week target for laparoscopic cholecystectomy following gallstone pancreatitis is achievable and cost neutral. Br J Surg 2009;96:751–5.

11. Sargen K, Kingsnorth AN. Management of gallstone pancreatitis: effects

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of deviation from clinical guidelines. JOP 2001;2:317–22.

12. Lankisch PG, Weber-Dany B, Lerch MM. Clinical perspectives in pancreatology: compliance with acute pancreatitis guidelines in Germany.

Pancreatology 2005;5:591–3.

13. Pezzilli R, Uomo G, Gabbrielli A, Zerbi A, Frulloni L, De Rai P, et al; ProInf-AISP Study Group. A prospective multicentre survey on the treatment of acute pancreatitis in Italy. Dig Liver Dis 2007;39:838–46.

14. Nguyen GC, Boudreau H, Jagannath SB. Hospital volume as a predictor for undergoing cholecystectomy after admission for acute biliary pancreatitis. Pancreas 2010;39:e42–7.

15. Hernandez V, Pascual I, Almela P, Añon R, Herreros B, Sanchiz V, et al. Recurrence of acute gallstone pancreatitis and relationship with cholecystectomy or endoscopic sphincterotomy. Am J Gastroenterol.

2004;99:2417–23.

16. van Baal MC, Besselink MG, Bakker OJ, van Santvoort HC, Schaapherder AF, Nieuwenhuijs VB, et al; Dutch Pancreatitis Study Group. Timing of cholecystectomy after mild biliary pancreatitis: a systematic review.

Ann Surg 2012;255:860–6.

17. Ito K, Ito H, Whang EE. Timing of cholecystectomy for biliary pancreatitis: do the data support current guidelines? J Gastrointest Surg 2008;12:2164–70.

18. Lankisch PG, Bruns A, Doobe C, Weber-Dany B, Maisonneuve P, Lowenfels AB. The second attack of acute pancreatitis is not harmless.

Pancreas 2008;36:207–8.

19. Sinha R. Early laparoscopic cholecystectomy in acute biliary pancreatitis: the optimal choice? HPB (Oxford) 2008;10:332–5.

20. Bouwense SA, Bakker OJ, van Santvoort HC, Boerma D, van Ramshorst B, Gooszen HG, et al; Dutch Pancreatitis Study Group. Safety of cholecystectomy in the first 48 hours after admission for gallstone pancreatitis not yet proven. Ann Surg 2011;253:1053–4.

21. Dambrauskas Z, Gulbinas A, Pundzius J, Barauskas G. Value of the different prognostic systems and biological markers for predicting severity and progression of acute pancreatitis. Scand J Gastroenterol 2010;45:959–70.

22. Papachristou GI, Muddana V, Yadav D, O’Connell M, Sanders MK, Slivka A, et al. Comparison of BISAP, Ranson’s, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol 2010;105:435–41.

23. Chang L, Lo SK, Stabile BE, Lewis RJ, de Virgilio C. Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones. Am J Gastroenterol 1998;93:527–31.

24. Chan T, Yaghoubian A, Rosing D, Lee E, Lewis RJ, Stabile BE, et al. Total bilirubin is a useful predictor of persisting common bile duct stone in gallstone pancreatitis. Am Surg 2008;74:977–80.

25. Aboulian A, Chan T, Yaghoubian A, Kaji AH, Putnam B, Neville A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg 2010;251:615–9.

26. Bouwense SA, Besselink MG, van Brunschot S, Bakker OJ, van Santvoort HC, Schepers NJ, et al; Dutch Pancreatitis Study Group. Pancreatitis of biliary origin, optimal timing of cholecystectomy (PONCHO trial): study protocol for a randomized controlled trial. Trials 2012;13:225.

27. da Costa DW, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, van Brunschot S, et al; Dutch Pancreatitis Study Group.

Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet 2015;386:1261–8.

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World J Gastroenterol 2014;20:17626–34.

29. Rao A, Polanco A, Qiu S, Kim J, Chin EH, Divino CM, et al. Safety of outpatient laparoscopic cholecystectomy in the elderly: analysis of 15,248 patients using the NSQIP database. J Am Coll Surg 2013;217:1038–43.

30. İlhan M, Soytaş Y, Gök AFK, Bademler S, Güloğlu R, Ertekin C. Timing of laparoscopic cholecystectomy in elderly patients with mild acute biliary pancreatitis. Turkish Journal of Geriatrics 2016;19:162–8.

31. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline: management of acute pancreatitis. Can J Surg 2016;59:128–40.

ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut biliyer pankreatiti izleyen erken laparoskopik kolesistektomi iyileşme sürecini kısaltır Dr. Seracettin Eğin, Dr. Metin Yeşiltaş, Dr. Berk Gökçek, Dr. Hakan Tezer, Dr. Servet Rüştü Karahan Okmeydanı Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul

AMAÇ: Bu geriye dönük çalışmamızda akut biliyer pankreatitli hastalarda erken ve geç laparoskopik kolesistektomi sonuçlarımızı karşılaştırarak, erken kolesistektominin güvenilirliğini, tekrarlayan biliyer pankreatit riskini, yatış günü ve morbidite üzerindeki etkilerini araştırmayı amaçladık.

GEREÇ VE YÖNTEM: Okmeydanı Eğitim ve Araştırma Hastanesinde Ocak 2009 – Aralık 2012 arasında akut biliyer pankreatitli 131 hasta çalışmaya alındı. Hastaların demografik özellikleri, şikayetlerinin süresi, ilk gelişteki biyokimya ve hemogram değerleri, Ranson skoru, atak sayısı, görüntülemeler, ameliyat türü ve süresi, ilk ataktan ameliyata kadar geçen gün sayısı, yatış günü ve komplikasyonlar kaydedildi. Ameliyatlarını ilk iki haftada olanlar erken (Grup 1), iki haftadan sonrakiler geç (Grup 2) olarak değerlendirildi.

BULGULAR: Grup 1’deki 47, Grup 2’deki 84 hastaya laparoskopik kolesistektomi yapıldı. Hiçbir olguda açık ameliyata geçilmedi, koledok yaralanması olmadı ve mortalite gelişmedi. Yatış günü ortalaması, Grup 1’de 7.6±3.0 gün, Grup 2’de 10.7±8.3 gün idi ve gruplar arasında istatistiksel anlamlı fark bulundu (p=0.006). İki ve üzerinde atak sayısı Grup 2’deki hastaların 15’inde (%18) saptandı ve istatistiksel anlamlı fark bulundu (p=0.000).

TARTIŞMA: Ranson ≤3 biliyer pankreatitlerde erken laparoskopik kolesistektomi, operasyon süresi ve morbiditeyi artırmadığından ve diseksiyon güçlüğü yaratmadığından güvenle uygulanabilir. Geç kolesistektomiler tekrarlayan ataklar, yatış günü ve tedavi maliyetlerinde artışa neden olmaktadır.

Randomize kontrollü çalışmalarla hafif ve orta biliyer pankreatitlerde erken kolesistektominin etkinliği ve güvenilirliği doğrulanmalıdır.

Anahtar sözcükler: Biliyer pankreatit; kolesistektominin zamanlaması; laparoskopik kolesistektomi.

Ulus Travma Acil Cerrahi Derg 2017;23(6):495–500

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doi: 10.5505/tjtes.2017.50128

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ORIGIN A L A RT I C L E

Bridge treatment for early cholecystectomy in geriatric patients with acute cholecystitis: Percutaneous cholecystostomy Sezgin Zeren, M.D.,1 Zülfü Bayhan, M.D.,1 Cengiz Koçak, M.D.,2 Uğur Kesici, M.D.,3 Mehmet Korkmaz, M.D.,4 Mehmet Fatih Ekici, M.D.,1 Mustafa Cem Algın, M.D.,1 Faik Yaylak, M.D.1 1

Department of General Surgery, Dumlupınar University Faculty of Medicine, Kütahya-Turkey

2

Department of Pathology, Dumlupınar University Faculty of Medicine, Kütahya-Turkey

3

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

4

Department of Radiology, Dumlupınar University Faculty of Medicine, Kütahya-Turkey

ABSTRACT BACKGROUND: The main cause of acute cholecystitis (AC) is gallstones, and the incidence of gallstones in elderly patients is high.

METHODS: In this study, we aimed to investigate the efficacy of percutaneous cholecystostomy (PC) before early cholecystectomy in geriatric patients with AC. This retrospective study included 85 patients undergoing laparoscopic or conventional cholecystectomy during early stage of calculous AC. RESULTS: All patients were over 65 years old and were divided into two groups: Group I, PC plus early cholecystectomy and Group II, only cholecystectomy without PC. Data on age, sex, status of PC before surgery, postoperative complications, postoperative mortality, surgical method, and postoperative hospitalization duration were recorded in our study. The average age in the groups I and II was 75.7±7.5 and 73.7±7.2 years, respectively, indicating insignificant difference (p=0.223). Although postoperative complication rate was two fold in the non-PC group, the PC plus cholecystectomy group has a few complications (p=0.032). Postoperative mortality was evidently lower in patients who first underwent PC and followed by cholecystectomy (p=0.017). The average hospitalization duration in groups I and II were 5.6±2.4 days and 11.2±7.7 days, respectively (p<0.001).

CONCLUSION: Urgent laparoscopic cholecystectomy is still the best surgical treatment modality for calculous AC. Further, our study results showed that in geriatric patients, bridge treatment, such as PC, can be useful for reducing postoperative complication rates.

Keywords: Acute cholecystitis; bridge treatment; cholecystectomy; percutaneous cholecystostomy; postoperative complication.

INTRODUCTION Acute cholecystitis (AC) is known to be an inflammatory status of the gall bladder. Etiology of AC is generally associated with gallstones.[1] Calculous AC is one of the most common disorders leading to admission of patients to emergency department in developed countries. In addition, its incidence is Address for correspondence: Uğur Kesici, M.D. Beykent Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul, Turkey Tel: +90 212 - 444 19 97 E-mail: ugurkesici77@mynet.com Submitted: 30.11.2016 Accepted: 07.04.2017

Ulus Travma Acil Cerrahi Derg 2017;23(6):501–506 doi: 10.5505/tjtes.2017.63668 Copyright 2017 TJTES

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increasing in elderly patients.[2] Human life is getting longer day by day. Therefore, treatment of elderly people has become more important. The patients aged over 65 years are considered as geriatric patients. Especially in cases of geriatric patients, the approach to the treatment of AC varies.[3] To date, the gold standard treatment for AC is laparoscopic cholecystectomy. However, emergency cholecystectomy in geriatric patients with multiple comorbidities may result with high morbidity and mortality rates.[4,5] Percutaneous cholecystostomy (PC) treatment modality has been suggested for geriatric and high-risk patients in recent years.[6] PC is performed by an experienced surgeon or an interventional radiologist under local anesthesia in critically ill geriatric patients.[7–9] PC is being preferred as a bridge treatment before cholecystectomy or a definitive non-surgical treatment method for AC in elderly patients.[2,10–12] In the 501

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majority of the studies, PC was performed initially in AC patients to relieve clinical symptoms, sepsis, and inflammation of the gallbladder. However, only few studies reported any clinical benefit of PC.[13,14] Although the timing of cholecystectomy following PC is still controversial for surgeons, general trend is delayed laparoscopic cholecystectomy (LC). Few studies on early LC after PC have been published. In this study, we investigated the efficacy of PC in geriatric patients and also evaluated the results of early cholecystectomy following PC with many parameters.

MATERIALS AND METHODS This retrospective study was performed in the Department of General Surgery of Dumlupinar University Evliyacelebi Training and Research Hospital between March 2011 and January 2016. Written informed consent was obtained from all patients. The patients’ identities and personal information have not been included in this article.

Data of patients aged over 65 years and who underwent surgery for calculous AC were enrolled. The patients aged under 65 years, having acalculous AC, having obstructive common bile duct stones, and who underwent delayed cholecystectomy were excluded from study. Finally, 85 geriatric patients

who had been operated for calculous AC were included, and data on anamnesis, physical examination (Murphy sign positivity), hemogram parameters, biochemical analysis results, C-reactive protein levels, and ultrasonography and computerized tomography scan results were collected. All AC patients were hospitalized. Intravenous antibiotic (cefazolin) and fluid replacement treatments were administered initially. The patients who did not respond to medical treatment in 36 h directly underwent surgery or PC, followed by cholecystectomy. LC or conventional cholecystectomy was performed 12–72 h later following PC. Data on age, sex, status of PC before surgery, postoperative complications (bleeding, incision site infection, biliary injuries, deep venous thrombosis, and pulmonary embolism) postoperative mortality, surgical method (laparoscopic or conventional surgery), postoperative hospitalization duration, and comorbidities were recorded.

Subsequently, the patients were divided into two groups.

The first group (PC performed group) comprised 40 patients who underwent first ultrasound-guided PC, followed by early LC or conventional cholecystectomy. The second group (no PC group) comprised 45 patients who underwent only early LC or conventional cholecystectomy for AC. We compared early cholecystectomy with or without PC in calculous AC

Table 1. Differences in demographic and clinical data between group I and II patients Parameters

Percutaneous cholecystostomy (n=40)

No percutaneous cholecystostomy (n=45)

Age (years)

75.7±7.5

73.7±7.2

Gender (n, %)

Female

18 (45)

20 (44)

Male

22 (55)

25 (56)

Postop complication (n, %)

No

33 (83)

27 (60)

Yes

7 (17)

18 (40)

Postop mortality (n, %)

No

36 (90)

30 (67)

Yes

4 (10)

15 (33)

5.6±2.4

11.2±7.7

Postop duration of hospitalization (days)

Surgery type (n, %)

Laparoscopic cholecystectomy

25 (63)

20 (44)

Conventional cholecystectomy

15 (37)

25 (56)

4 (10)

9 (20)

Convertion to conventional surgery (n, %)

Comorbidities (n, %)

No

9 (23)

11 (24)

Yes

31 (77)

34 (76)

Statistical analysis (p) 0.223 0.960

0.032

0.017

<0.001 0.096

0.041 0.833

Continuous data were presented as mean ± standard deviation (SD). Categorical data were presented as number (n) and percent (%). Differences in continuous variables between the study groups were analyzed using unpaired t-test. Differences in categorical variables between the study groups were analyzed using Fisher’s exact test.

A p value of <0.05 was considered statistically significant.

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Zeren et al. Percutaneous cholecystostomy

patients. PC was performed transhepatically under local anesthesia by an experienced interventional radiologist team.

Surgical methods were chosen by the surgeons. Some LC procedures were converted to conventional cholecystectomy during surgery because of inadequate Callot’s area dissection and bleeding.

Statistical analyses were performed using GraphPad Prism version 6.05 (GraphPad Software, Inc., CA, USA). All data sets were tested for normality using Kolmogorov–Smirnov test. Data were presented as mean±standard deviation. Categorical data were presented as number (n) and percent (%).

Differences between continuous variables in the study groups were analyzed using unpaired t-test. Differences between categorical variables in the study groups were analyzed using Fisher’s exact test. A P value of <0.05 was considered statistically significant.

thrombosis. Only in one patient of group I, deep venous thrombosis was detected postoperatively. In both groups pulmonary embolism were detected. The occurrence of other complications was higher in the group II than in group I. Biliary injury and incision site infection were markedly higher in group II than in group I (Fig. 2). Although postoperative complication rate was two fold in group II, group I showed a few complications (p=0.032). Consistent with there findings, postoperative mortality was evidently lower in patients who first underwent PC, followed by cholecystectomy (p=0.017) (Fig. 2). No statistical difference was observed in terms of comorbidities between the groups. Another important parameter assessed was postoperative hospitalization duration.

The average hospitalization duration in group I and II was 40

RESULTS

30

A total of 85 patients who met the inclusion criteria were enrolled. Patients’ sociodemographic characteristics are illustrated in Table 1 and Figure 1. The average age in the first and second groups was 75.7±7.5 and 73.7±7.2 years, respectively, with no significant differences (p=0.223).

20

Any morbidities and mortalities were seen in PC. Nevertheless, in one patient, the drainage tube got off from skin came off and did not work. Therefore, PC was performed again.

Mortalities occurred due to high-risk status and older age of patients. In the PC plus cholecystectomy group (group I) and the non-PC group (group II), the LC rates were 63% and 44%, respectively. Same surgical methods were performed in both groups. Notably, the conversion rate from laparoscopic to conventional technique was higher in the non-PC group. The rates of conversion to conventional surgery in groups I and II were 10% (four patients) and 20% (nine patients), respectively, with significant difference between the groups (p=0.041).

Postoperative complications were bleeding, biliary injury, incision site infection, pulmonary embolism, and deep venous

7 (17%)

0

PC

No PC p=0.017

36 (90%)

30

15 (33%)

20 4 (10%)

10 0

PC

No PC

Figure 2. Representative column chart of postoperative complications and mortality of patients in the study groups. PC: Percutaneous cholecystostomy.

40

20

25 (56%)

25 (56%)

25 (63%)

22 (55%)

20 (44%)

20 (44%)

18 (45%)

15 (37%) 11 (24%)

10

0

Female Male No comorbidities Comorbidities Laparoscopic cholecystectomy Conventional cholecystectomy

Postop duration of hospitalization (days)

31 (77%)

p<0.001

30

20

10

0 PC

No PC

Figure 1.

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No postop mortality Postop mortality

30 (67%)

40

30

No postop complication Postop complication

27 (60%) 18 (40%)

10

40

p=0.032

33 (83%)

PC

No PC

Figure 3. Representative box and whisker plot of postoperative hospitalization duration of patients in the study groups. PC: Percutaneous cholecystostomy.

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Zeren et al. Percutaneous cholecystostomy

5.6±2.4 and 11.2±7.7 days, respectively, indicating statistically significant difference with p<0.001, as shown in Table 1 and Figure 3.

after evaluating early or late cholecystectomy following PC. However, we compared early cholecystectomy following PC with emergency cholecystectomy in geriatric patients.

DISCUSSION

Li et al.[24] clarified that PC is a viable treatment method with low complication and mortality rates. In addition, in our study, we observed that postoperative complication and mortality rates were lower in patients who underwent PC plus cholecystectomy than in those who underwent cholecystectomy alone.

In early stage of AC, LC or conventional cholecystectomy is the first choice of treatment according to Tokyo guidelines.

[15] Treating geriatric patients who are unfit for emergency surgery is still a dilemma for surgeons. Although several studies on this subject have been published, an exact consensus for treating high-risk geriatric patients has not been reached.

Medical treatment or interventional procedures are favorable in these patients.

PC is an interventional method used in calculous AC commonly as a definitive or bridge treatment modality. It is generally preferred in high-risk and geriatric patients who are unfit for emergency surgery.[7,12,16–19] While in some studies PC procedures were suggested as initial method for AC, only a few studies offer urgent cholecystectomy.[14] In biliary sepsis especially, acute intervention is recommended to remove the focus of infection. Therefore, PC is not inevitable in geriatric and high-risk patients.[20,21] On the other hand, PC is an interventional treatment and is associated with some risks and complications. The rates of complications associated with PC decrease wen Pc is performed by experienced surgeons. However, bleeding, biliary injury, biloma, catheter infection, tube removal from gallbladder, and bowel injury may be observed after PC.[9,16,17] In our study, one patient experienced catheter displacement, and PC was successfully performed again.

In a recent study, Viste et al.[22] declared that patients who underwent PC had a symptomatic relief with a 96% rate and a low complication rate. Consistent with these findings, our results suggested that there was a low complication rate in group of patients who underwent PC. In addition, in clinical practice, we observed that patients were relieved within 24 h after undergoing PC.

A systematic review by Ambe et al.[16] revealed that PC is a safe method in critically ill patients. In the present study, the sample comprised geriatric patients with many concomitant chronic diseases. The comorbidities between groups were similar. Complications were markedly lower in the PC plus cholecystectomy group than in the cholecystectomy alone group.

We did not observe catheter-dependent complications in our patients because we performed early cholecystectomy following PC. In terms of other complications, we found that incision site infection and biliary injury was much more common in the cholecystectomy alone group. We believe that the reason behind this was the selection of geriatric patients with chronic diseases as the sample in the study. In addition to this, the rates of complications including biliary injury increase with emergency LC. Yeo et al.[25] found that in patients with LC following PC, biliary injury rate was lower. In our study, biliary tract injury was two times more common in the non-PC group.

In group II, only one patient had pulmonary embolism and deep venous thrombosis. These results may be due to the concomitant chronic diseases in the geriatric study population.

In clinical practice, the general approach to treat calculous AC in elderly and high-risk patients is PC. Some physicians have suggested PC in place of LC. However, patients who have PC might have recurrent AC attacks in near future as like as in patients who have nonsurgical treatment modalities.

We suggest that PC should be used as a bridge treatment until definitive surgery.[1,13]

Furthermore, the rate of conversion to conventional surgery was investigated in our study. Some patients underwent LC or conventional cholecystectomy as per the surgeon’s preferences. Karakayali et al.[26] stated that the rate of conversion to open procedure is high in patients undergoing emergency cholecystectomy. The rates of conversion to conventional cholecystectomy in both groups in the present study are similar to those reported in literature. In addition, the rate of conversion from LC to conventional cholecystectomy was higher in that non-PC group than in the PC plus cholecystectomy group.

Another controversy associated with AC is the timing of cholecystectomy after PC. Most researchers perform delayed cholecystectomy.[2] In the literature, a few studies that have investigated early cholecystectomy after PC have been published. Akyürek et al.[23] stated that PC following early cholecystectomy is superior to PC following late cholecystectomy

Therefore, the parameters discussed above affected hospitalization duration and cost-effectivity. A study by Chou et al.[10] and Kapan et al.[27] indicated that patients who underwent PC had decreased hospitalization duration. In this study, we also investigated the postoperative hospitalization duration between the groups and found that patients who underwent

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PC plus cholecystectomy had shorter hospitalization duration than those who underwent cholecystectomy alone. This was because of the lower complication rate in patients who underwent PC. To the best of our knowledge, this is the first study that compared emergency cholecystectomy with urgent cholecystectomy following PC in geriatric patients in terms of postoperative complications and hospitalization duration.

Conclusion Calculous AC may result in with serious complications, including sepsis, thus necessitating urgent surgery in geriatric patients. PC should be performed in geriatric patients to reduce postoperative complications, mortality, morbidity, and hospitalization duration. Emergency surgery without PC can lead to high mortality and complication rates.

Conflict of interest: None declared.

REFERENCES 1. Wang CH, Wu CY, Yang JC, Lien WC, Wang HP, Liu KL, et al. LongTerm Outcomes of Patients with Acute Cholecystitis after Successful Percutaneous Cholecystostomy Treatment and the Risk Factors for Recurrence: A Decade Experience at a Single Center. PLoS One 2016;11:e0148017.

2. Mizrahi I, Mazeh H, Yuval JB, Almogy G, Bala M, Simanovski N, et al.

Perioperative outcomes of delayed laparoscopic cholecystectomy for acute calculous cholecystitis with and without percutaneous cholecystostomy.

Surgery 2015;158:728–35.

3. Fuks D, Duhaut P, Mauvais F, Pocard M, Haccart V, Paquet JC, et al. A retrospective comparison of older and younger adults undergoing early laparoscopic cholecystectomy for mild to moderate calculous cholecystitis. J Am Geriatr Soc 2015;63:1010–6.

4. Margiotta SJ Jr, Willis IH, Wallack MK. Cholecystectomy in the elderly.

Am Surg 1988;54:34–9.

5. Pessaux P, Regenet N, Tuech JJ, Rouge C, Bergamaschi R, Arnaud JP. Laparoscopic versus open cholecystectomy: a prospective comparative study in the elderly with acute cholecystitis. Surg Laparosc Endosc Percutan Tech 2001;11:252–5.

6. McGillicuddy EA, Schuster KM, Barre K, Suarez L, Hall MR, Kaml GJ, et al. Non-operative management of acute cholecystitis in the elderly. Br J Surg 2012;99:1254–61.

7. Howard JM, Hanly AM, Keogan M, Ryan M, Reynolds JV. Percutaneous cholecystostomy-a safe option in the management of acute biliary sepsis in the elderly. Int J Surg 2009;7:94–9.

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

9. Silberfein EJ, Zhou W, Kougias P, El Sayed HF, Huynh TT, Albo D, et al. Percutaneous cholecystostomy for acute cholecystitis in high-risk patients: experience of a surgeon-initiated interventional program. Am J Surg 2007;194:672–7.

10. Chou CK, Lee KC, Chan CC, Perng CL, Chen CK, Fang WL, et al. Early Percutaneous Cholecystostomy in Severe Acute Cholecystitis Reduces the Complication Rate and Duration of Hospital Stay. Medicine (Baltimore) 2015;94:e1096.

11. Patel PP, Daly SC, Velasco JM. Training vs practice: A tale of opposition

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in acute cholecystitis. World J Hepatol 2015;7:2470–3.

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

Gastroenterol Res Pract 2016;2016:3672416.

13. Cheng WC, Chiu YC, Chuang CH, Chen CY. Assessing clinical outcomes of patients with acute calculous cholecystitis in addition to the Tokyo grading: a retrospective study. Kaohsiung J Med Sci 2014;30:459– 65.

14. Anderson JE, Inui T, Talamini MA, Chang DC. Cholecystostomy offers no survival benefit in patients with acute acalculous cholecystitis and severe sepsis and shock. J Surg Res 2014;190:517–21.

15. Mayumi T, Takada T, Kawarada Y, Nimura Y, Yoshida M, Sekimoto M, et al. Results of the Tokyo Consensus Meeting Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:114–21.

16. Ambe PC, Kaptanis S, Papadakis M, Weber SA, Zirngibl H. Cholecystectomy vs. percutaneous cholecystostomy for the management of critically ill patients with acute cholecystitis: a protocol for a systematic review. Syst Rev 2015;4:77.

17. Hadas-Halpern I, Patlas M, Knizhnik M, Zaghal I, Fisher D. Percutaneous cholecystostomy in the management of acute cholecystitis. Isr Med Assoc J 2003;5:170–1.

18. Bala M, Mizrahi I, Mazeh H, Yuval J, Eid A, Almogy G. Percutaneous cholecystostomy is safe and effective option for acute calculous cholecystitis in select group of high-risk patients. Eur J Trauma Emerg Surg 2016;42:761–6.

19. Cha BH, Song HH, Kim YN, Jeon WJ, Lee SJ, Kim JD, et al. Percutaneous cholecystostomy is appropriate as definitive treatment for acute cholecystitis in critically ill patients: a single center, cross-sectional study.

Korean J Gastroenterol 2014;63:32–8.

20. Al-Jundi W, Cannon T, Antakia R, Anoop U, Balamurugan R, Everitt N, et al. Percutaneous cholecystostomy as an alternative to cholecystectomy in high risk patients with biliary sepsis: a district general hospital experience. Ann R Coll Surg Engl 2012;94:99–101.

21. Horn T, Christensen SD, Kirkegård J, Larsen LP, Knudsen AR, Mortensen FV. Percutaneous cholecystostomy is an effective treatment option for acute calculous cholecystitis: a 10-year experience. HPB (Oxford) 2015;17:326–31.

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

23. Akyürek N, Salman B, Yüksel O, Tezcaner T, Irkörücü O, Yücel C, et al.

Management of acute calculous cholecystitis in high-risk patients: percutaneous cholecystotomy followed by early laparoscopic cholecystectomy.

Surg Laparosc Endosc Percutan Tech 2005;15:315–20.

24. Li JC, Lee DW, Lai CW, Li AC, Chu DW, Chan AC. Percutaneous cholecystostomy for the treatment of acute cholecystitis in the critically ill and elderly. Hong Kong Med J 2004;10:389–93.

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

26. Karakayali FY, Akdur A, Kirnap M, Harman A, Ekici Y, Moray G. Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis. Hepatobiliary Pancreat Dis Int 2014;13:316–22.

27. Kapan M, Onder A, Tekbas G, Gul M, Aliosmanoglu I, Arikanoglu Z, et al. Percutaneous cholecystostomy in high-risk elderly patients with acute cholecystitis: a lifesaving option. Am J Hosp Palliat Care 2013;30:167– 71.

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ORİJİNAL ÇALIŞMA - ÖZET OLGU SUNUMU

Akut kolesistitli yaşlı hastalarda erken kolesistektomi için köprü tedavisi: Perkütan kolesistostomi Dr. Sezgin Zeren,1 Dr. Zülfü Bayhan,1 Dr. Cengiz Koçak,2 Dr. Uğur Kesici,3 Dr. Mehmet Korkmaz,4 Dr. Mehmet Fatih Ekici,1 Dr. Mustafa Cem Algın,1 Dr. Faik Yaylak1 Dumlupınar Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Kütahya Dumlupınar Üniversitesi Tıp Fakültesi, Patoloji Anabilim Dalı, Kütahya Beykent Üniversitesi Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, İstanbul 4 Dumlupınar Üniversitesi Tıp Fakültesi, Radyoloji Anabilim Dalı, Kütahya 1 2 3

AMAÇ: Akut kolesistitin (AC) başlıca sebebi safra taşlarıdır. Yaşlı hastalarda safra taşı insidansı artmaktadır. Bu çalışmada, akut kolesistitli yaşlı hastalarda erken kolesistektomi öncesi perkütan kolesistostominin (PK) etkinliğinin araştırılması amaçlandı.

GEREÇ VE YÖNTEM: Bu geriye dönük çalışma konvansiyonel veya laparoskopik kolesistektomiye (LC) giden 85 erken evre akut taşlı kolesistitli hasta içermektedir. Tüm hastalar 65 yaş üzerindedir.

BULGULAR: Hastalar iki gruba ayrıldı. Grup I; PK+erken kolesistektomi ve Grup II; yalnızca kolesistektomi. Çalışmamızda yaş, cinsiyet, cerrahi öncesi PK durumu, ameliyat sonrası komplikasyon, ameliyat sonrası mortalite, cerrahi yöntem ve ameliyat sonrası hastanede kalış süresi kaydedildi.

Ortalama yaş 75.7±7.5 ve 73.7±7.2 idi. İki grup arasında anlamlı fark yoktu (p=0.041). Ameliyat sonrası komplikasyon oranı PK uygulanmayan grupta iki kat iken, PK ile kolesistektomi yapılan grupta az komplikasyon mevcuttu (p=0.032). Ameliyat sonrası mortalite bariz şekilde PK sonrası kolesistektomi uygulanan hastalarda düşüktü (p=0.017). Ortalama hastane yatış süresi grup I’de 5.6±2.4 gün ve Grup 2’de 11.2±7.7 gündü (p<0.001).

TARTIŞMA: Akut taşlı kolesistitte acil laparoskopik kolesistektomi hala en iyi cerrahi yöntemdir. Ayrıca çalışmamıza göre, geriatrik hastalarda perkütan kolesistostomi geçiş tedavisi ameliyat sonrası komplikasyon oranlarını azaltmada faydalı olabilir.

Anahtar sözcükler: Akut kolesistit; erken cerrahi; geriatrik; hastanede kalış; kolesistektomi; perkütan kolesistostomi.

Ulus Travma Acil Cerrahi Derg 2017;23(6):501–506 doi: 10.5505/tjtes.2017.63668

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CA S E SERI ES

Management of capitellar fractures with open reduction and internal fixation using Herbert screws Asif Sultan, M.S., Omar Khursheed, M.S., Mohammad Rafiq Bhat, M.S., Hilal Ahmad Kotwal, M.S., Qazi Waris Manzoor, M.S. Department of Orthopedic Surgery, Government Hospital for Bone & Joint Surgery, Barzulla, Srinagar-India

ABSTRACT BACKGROUND: Capitellar fractures are rare elbow injuries and can cause severe limitation of function if not properly managed.

Numerous treatments have evolved, from closed reduction and cast immobilization to open reduction and internal fixation (ORIF), so as to achieve a stable joint that allows early mobilization. We determined the functional outcomes of treating these fractures with ORIF using Herbert screws via an extensile lateral approach.

METHODS: Fifteen patients with capitellar fractures were included in this retrospective study. A well taken lateral radiograph was important and stressed upon in all patients. All fractures were open reduced and internally fixed using Herbert screws via an extensile lateral approach over a period of 5 years. Clinical, radiographic, and Mayo Elbow Performance Index were evaluated at a mean followup of 3.6 years (range, 1.5–6 years).

RESULTS: Nine type I and six type IV capitellar fractures were identified using Bryan and Morrey classification system. The average time to bone union was 12 weeks (range 8–16 weeks) with no case of nonunion. The mean range of flexion was 130° (range 125°–135°). The average extensor lag was 10° (range 0°–30°), with a functional range of motion of elbow achieved in all patients. On the final follow-up, one case of osteoarthritis was seen, but no evidence of avascular necrosis or heterotrophic ossification was seen.

Two patients needed screw removal. The outcome was excellent in 10 patients and good in five patients.

CONCLUSION: Herbert screw fixation provides stable fixation in capitellar fractures and good to excellent outcomes with excellent elbow motion, can be achieved following internal fixation of these complex fractures using the extended lateral exposure.

Keywords: Capitellar fracture; extended lateral exposure; Herbert screw; open reduction and internal fixation.

INTRODUCTION Intraarticular coronal shear fractures of the capitellum are rare injuries and account for approximately 1% of all elbow fractures and 6% of all distal humeral fractures.[1,2] Capitellar fracture was first described by Cooper[3] as an isolated injury in 1841, followed by Hahn[4] in 1853, who also reported an isolated capitellar fracture in a 63-year-old woman who had poor results due to loss of elbow flexion. The classification of capitellar fractures into two types evolved after further Address for correspondence: Asif Sultan, M.D. Government Hospital For Bone & Joint Surgery, Barzulla, 19000 Srinagar, India Tel: 09419072349 E-mail: drasifsultan@yahoo.com Submitted: 21.10.2016 Accepted: 06.04.2017

Ulus Travma Acil Cerrahi Derg 2017;23(6):507–514 doi: 10.5505/tjtes.2017.57142 Copyright 2017 TJTES

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reports of this injury by Kocher[5] in 1896, Steinthal[6] in 1898, and Lorenz[7] in 1905: type I or “Hahn–Steinthal” fracture and type II or “Kocher–Lorenz” fracture. Capitellar injuries are typically due to its axial loading by forces transmitted through the radial head.[8,9] The fracture is caused by a fall onto the outstretched hand with the elbow in extension or in slight flexion. The impact on the hand creates a force that passes through the forearm to the head of the radius, which acts like a piston and shears off the capitellum.[10] Capitellar fractures can be sustained either by a direct injury with the elbow in flexion or indirectly through an extended radius, as in falling on an outstretched hand.[11] Nevertheless, both these mechanisms can produce a coronal shear fracture. Radial head fractures are associated with indirect trauma and are likely to be present in approximately 24% of patients.[11] Presently, the Bryan and Morrey[12] classification for capitellar fractures into three types with McKee et al.[9] adding a fourth type is in common use. In the AO classification system,[13] capitellar fractures would be identified as 13 B3 (distal end of the humerus, partial articular, and frontal), with B3.1 indicat507

Sultan et al. Management of capitellar fractures with open reduction and internal fixation using Herbert screws

ing isolated capitellar fractures; B3.2, trochlear fractures; and B3.3, capitellar and trochlear fractures.

Many treatments and management methods have been advocated and include closed reduction and immobilization,[14] fracture fragment excision,[15] open reduction with or without internal fixation[16–22] using Kirschner wires (K-wires), cannulated screws or Herbert screws,[23–26] and prosthetic replacement.[27] Herbert screw provides some definite advantages over other methods of internal fixation. It achieves better fracture site compression, provides stable fixation without damaging the articular cartilage, allowing early joint motion and less or no need for second stage hardware removal.[23,28] We present a retrospective study of 15 cases of capitellar fractures treated using Herbert screw fixation over a period of 4 years with a mean follow-up of 3.6 years. The purpose of this present study was to perform an objective and subjective evaluation with functional outcome of patients with capitellar fractures that were treated with internal fixation by inserting Herbert screws in an anterior-to-posterior direction after open reduction via an extensile lateral approach.

MATERIALS AND METHODS Fifteen patients with capitellar fractures were treated from January 2010 to December 2014 and were followed up till July 2016. Patients included 11 female and 4 male patients aged 20–48 years (mean, 35 years), with fracture of the dominant right-hand elbow in three and nondominant left-hand elbow in 12 patients. Inclusion criteria were closed fractures in skeletally mature patients and exclusion criteria were joint laxity and prior degenerative or inflammatory arthritis. All fractures were closed and had occurred following a fall onto the flexed elbow in six or with outstretched hand in nine patients. Distal neurovascular examination of the limb was normal. All patients underwent plain radiographs (anteroposterior and lateral), and CT scan with 3D reconstructions was performed only in cases with associated radial head and epi-

(a)

(b)

condyle fractures. Fractures were classified according to the Bryan and Morrey classification and were of type I in nine and type IV in six patients. According to the AO classification, nine were of 13 B3.1 and six of 13 B3.3 type. Two patients had associated radial head fractures and one had lateral epicondyle fracture. All patients were operated within 7 days after injury.

Patients were operated under general or regional anesthesia, with the patient in supine position. A pneumatic tourniquet was used in all cases. Varus and valgus stress tests were performed to rule out any ligamentous instability. Open reduction of fractures was performed via an extensile lateral approach.[9,25,29,30] A skin incision was made laterally at the elbow, centering over the lateral epicondyle and extending proximally 4–6 cm over the distal end of the humerus to approximately 2 cm distal to the radial head. Dissection was performed through the subcutaneous tissue layers, and the lateral column was identified along with the common extensor origin. The forearm is pronated to avoid any iatrogenic injury to the radial nerve, moving it away from the operating area. The common origin of the radial wrist extensors along with the anterior capsule of the elbow joint was sharply elevated as a single full-thickness flap from the lateral supracondylar ridge anterosuperiorly and distally connected to the “Kocher interval” to reach the fracture site, which was cleared of hematoma and soft-tissue debris so as to allow the proper visualization and orientation of the fracture using normal saline irrigation (Fig. 1a).

Due care was taken to preserve the lateral ulnar collateral ligament origin at the lateral epicondyle along with vascular supply to the capitellum. Anatomic reduction was directly visualized as the fractured capitellum was reduced along the proximal metaphyseal margin and trochlea medially . Capitellar fractures were fixed using two headless cannulated Herbert screws, which were inserted over the guidewires in an anterior-to-posterior direction (Fig. 1b). Screws were sunk

(c)

Figure 1. (a) Exposed capitellar fracture lying anterior to the radial head. (b) Headless cannulated Herbert screws being inserted over the guidewires in an anterior-to-posterior direction. (c) Herbert screws are sunk beneath the articular surface.

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Sultan et al. Management of capitellar fractures with open reduction and internal fixation using Herbert screws

Table 1. Demographic data of patients, fracture type, and associated injuries Patient Age Sex Side Dominant(D)/

(years) involved nondominant arm (ND)

Etiology: fall on

Fracture Associated type injury/fracture

1

33

Female

Left

ND

Flexed elbow

2

34

Female

Left

ND

Outstretched hand

I

3

29

Female

Left

ND

Flexed elbow

IV

4

48

Male

Left

ND

Outstretched hand

I

5

32

Female

Left

ND

Outstretched hand

I

6

20

Male

Right

D

Flexed elbow

IV

7

31

Female

Left

ND

Outstretched hand

I

8

39

Female

Left

ND

Outstretched hand

IV

9

45

Male

Left

ND

Flexed elbow

I

10

43

Female

Right

D

Flexed elbow

I

11

38

Male

Right

D

Outstretched hand

I

12

31

Female

Left

ND

Outstretched hand

I

13

38

Female

Left

ND

Flexed elbow

IV

14

36

Female

Left

ND

Outstretched hand

I

15

28

Female

Left

ND

Outstretched hand

IV

into the articular surface to avoid any damage to the radial head or impingement (Fig. 1c). The common wrist extensor origin was repaired back to soft tissues and periosteum over the lateral supracondylar ridge. The wound was closed in two layers. Radial head fractures in two patients were addressed through the same exposure and fixed using headless screws.

The lateral epicondyle fracture in one patient was too small for screw fixation and was fixed using two K-wires, which were removed after 6 weeks.

Compressive sterile dressing was applied, and the arm was placed in a long arm posterior plaster slab and with the elbow kept in flexion of around 90°. The plaster slab was removed after 1 week, and the sutures were removed and active range of motion exercises of the elbow and forearm were started.

Strengthening exercises were delayed till clinical and radiographic evidence of bone union was seen.

All patients were evaluated using the Mayo Elbow Performance Index (MEPI) Score for function, stability, pain, and range of motion (ROM) at the elbow. Radiographs were assessed for the status of bone union, signs of avascular necrosis (AVN), and osteoarthritis. Further assessment was also performed for wound complications, elbow function, and any other complications. The length of follow-up ranged from 1.5 to 6 years (mean of 3.6 years).

RESULTS Demographic data are displayed in Table 1. Nine type I and six type IV fractures were identified in this series. All patients were right-handed. The dominant hand was injured in three Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

IV

Lateral epicondyle Radial head

Radial head

cases only. The mechanism of injury was a low-energy fall in all cases. All fractures were closed. There were no associated neurovascular injuries. There were two ipsilateral radial head fractures and one lateral epicondyle fracture. No other concomitant upper limb musculoskeletal injuries were observed.

Intraoperatively, trochlear involvement was identified in association with all type IV fractures. The lateral collateral ligament was intact in all fractured elbows, except in one where the lateral collateral ligament was found to be avulsed along with an attached lateral epicondyle fracture fragment.

All fractures united well and the mean time to union was 12 weeks, ranging from 8 to 16 weeks (Fig. 2a, b). No patient had any residual elbow instability or weakness. Extensor power and grip strength were similar to that of the other side. Forearm rotations were not restricted in any of our patients including those with radial head fractures. The average range

(a)

(b)

Figure 2. (a) Final lateral and anteroposterior radiograph following fixation of a type IV capitellar fracture shows union without any sign of avascular necrosis or arthritis. (b) Anteroposterior radiograph showing union of the capitellar and radial head fractures.

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Table 2. Data of patients showing functional and clinical outcomes with MEPI score and complications Patient

Follow-up Reoperation Complications (years)

1

MEPI score

Range of motion in elbow in degrees (normal flexion – extension 0°-135°)

Days from injury to surgery

Extension lag in degrees

6

85

15-135

7 15

2 5.6

90

10-135

3 10

3

85

25-135

3

4 4.6

5.4

90

10-135

3 10

5 4.3

100

0-135

3 0

6

75

30-125

7

100

0-135

3 0

8 3.6

85

15-130

3 15

9 3.5

100

0-135

3 0

10 3.2

90

10-130

3 10

11 2.5

85

15-125

3 15

4

Removal of screws

Extension loss of 25°

Removal of screws

Extension loss of 30°.

and K-wires

Arthritis

7 3.8

25

30

12 2.2

100

0-135

3 0

13 2

90

10-130

3 10

14 1.8

100

0-135

3 0

15 1.5

95

10-135

3 10

MEPI: Mayo Elbow Performance Index.

of flexion was 130° (range, 125°–135°). The mean extensor lag was 10° (range, 0°–30°), with the ROM of the elbow remaining functional in all patients (Table 2). One patient had restriction of elbow extension due to the screw being too long and protruding into the olecranon fossa, thus impinging on the olecranon and not allowing full extension of the elbow. The screws in this patient were removed after 4 months of the primary procedure with some gain in extension. The mean extension lag was 17.5°±8.12 in six patients with type IV fracture compared with 5°±5.83 in nine patients with type I fracture (t=3.49, p=0.0040 which is significant).

Post-traumatic arthritis was seen in one elbow; despite radiographic evidence of arthritis, the clinical and functional result was good. At the final follow-up, no evidence of AVN or heterotrophic ossification was seen in radiographs.

All patients returned to their preinjury level of work status.

Outcomes were excellent in 10 patients and good in 5 with a mean score of 91.33±7.4 (range, 75–100) at the latest follow-up as per the MEPI, which takes pain, motion, stability, and function into consideration. Among patients with type I fracture, the mean MEPI score was 95±7.69 compared with 85.83±7.41 among patients with type IV fracture (t=2.29, p=0.0391, which is statistically significant).

DISCUSSION Despite its rarity, the prevalence of capitellar fractures is four times higher in women than in men,[10,31] and it has been sug510

gested that this is due to the greater carrying angle in females along with weaker bones (osteoporosis).[11] These injuries mostly occur in young persons, and the female preponderance seen in the present series coincides well with the reported literature.[31] Patients with capitellar fractures mostly present with painful swelling of the elbow immediately after an injury. These fractures are often missed on the first examination,[28] as these cannot be clearly seen on anteroposterior radiographs because the fracture lines are not well recognizable against the profile of the distal humerus because of the overlap. They are typically picked and best seen on true lateral views (Fig. 3a, b).[28] A high index of suspicion and good lateral view radiograph is thus warranted to avoid missing this injury. Additionally, in type IV injuries on a lateral view radiograph, a pathognomonic “double arc sign” formed by the overlap of subchondral bone of the capitellum and the trochlear ridge is often seen (Fig. 4a, b).[9] CT scan with 3D reconstructions is usually advised to delineate the medial extent, articular impaction with metaphyseal, or condylar comminution of the fracture.[32] CT scans may be used to properly delineate and classify the fracture preoperatively. We did not routinely perform CT scan in our patients, except in cases with associated injuries around the elbow.

The most frequent type of capitellar fracture is type I (Hahn– Steinthal), which accounts for 47% of all fractures, and the Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

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(a)

(b)

Figure 3. (a, b) Anteroposterior and lateral radiographs demonstrating difficulty in identifying capitellar fracture in anteroposterior views, but picked on lateral views.

(a)

(b)

Figure 4. (a, b) Lateral views showing “double arc sign” in type IV capitellar fractures.

majority of them occur due to fall from standing height.[14] In our study, nine patients were categorized into type I. Type II (Kocher–Lorenz) and type III (comminuted) fractures are found in significantly lower numbers. No type II or type III cases were present in this study. Type IV (McKee) accounts for approximately 36% of capitellar fractures in women and 54% in men.[14] In our study of 15 cases, there were six type IV fractures. Capitellar fractures with radial head fracture occurs in 24% of cases.[14] This series had two cases with radial head fractures and one with associated fracture of lateral epicondyle.

Although there are many different treatment modalities described for capitellar fractures, including closed reduction and immobilization,[14] excision of fracture fragments,[15] prosthetic replacement,[27] ORIF is presently considered as the best treatment.[9,26,32] Fixation has been achieved using K-wires, cancellous screws[22,30] inserted from the posterior to anterior direction, and Herbert screws.[23–26] We used Herbert screws in our series, as fixation of the capitellar fracture usUlus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

ing these screws has been found to be better than using Kwires or cancellous lag screws,[33] directed from the anterior to the posterior direction, as this eliminates the need for further soft-tissue dissection from the posterolateral aspect of condyle, besides achieving good fixation. Herbert screws are terminally threaded, providing fracture site compression through their variable thread pitch designs. The head is buried beneath the articular surface so that it does not hinder joint mobility. This also reduces the need of repeat surgery for screw removal.[28] Two screws were always used to ensure a good rotational control.

We used an extensile lateral approach,[9,25,29,30] a common surgical approach in all patients as it provides adequate exposure to address any extension of the trochlea medially, any impaction, and/or comminution present type IV fractures, thus eliminating the need for the second approach. The skin incision is small, not larger than 6–8 cm. Further, neurovascular structures are not at risk, and radial head and lateral epicondylar fractures can be simultaneously addressed.

Complication rates in our series were few and less than that reported in the literature.[9,34] Two of our patients require reoperations for screw removal, with no influence on the final functional result. One screw was limiting extension, as it was protruding into the olecranon fossa, which improved after its removal (Fig. 5). To prevent screw impingement like this, we recommend routine use of fluoroscopy during surgery so that proper position and screw length will be chosen. We had one post-traumatic osteoarthritis, and it has also been documented in other series (Fig. 6a, b).[9,30,32] The fracture had severe medial comminution and impaction along with lateral epicondylar comminuted fracture. Screws in this patient were also removed. Anatomical reduction of the fracture with careful handling of articular cartilage is critical in preventing arthritis.

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Figure 5. Radiograph showing long screw impinging into the olecranon fossa.

(a)

(b)

Figure 6. (a) Postoperative anteroposterior and lateral radiographs of the capitellum with lateral epicondylar fracture following surgery showing fixation with K-wires for epicondyle along with Herbert screws for the capitellum and (b) at 4 years showing arthritic changes.

Limitation of the elbow motion (flexion and extension) and residual pain are the most common complications associated with capitellar fractures, but forearm rotations (pronation and supination) are rarely affected.[24,32] Flexion was not limited much in our series compared with the normal arm (0°–135°), one patient with arthritis has loss of terminal 10° of flexion. Ten of our patients had an extension lag of 10°–25° but two of our patients had more extension loss due to implant impingement and arthritis. Screw removal was performed in both cases with improvement seen in only the impingement case. The extension lag was statistically significant (p=0.0040) between type I and type IV fractures; mean extension lag was 17.5°±8.12 in six patients with type IV fracture compared with 5°±5.83 in nine patients with type I fracture. Thus, reduction in the ROM of the elbow is seen more commonly in type IV injuries.

Articular damage and deformity, intraarticular or extraarticular adhesions, and prolonged immobilization being major 512

factors causing loss of elbow motion.[35] Accurate anatomical reduction of fracture, stable fixation and early mobilization are keys to achieve painless full motion with desired functional results.[32] MEPI according to fracture subgroup is presented in Table 3.

Among patients with type I fractures, eight had excellent and one had good results, and in patients with type IV fracture, two had excellent and four had good results. Although type I fracture has better functional outcome than type IV fracture, Table 3. Mayo elbow performance index (MEPI) according to the fracture subgroup MEPI

Type I

Type IV

Excellent 8

2

Good 1 4

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the difference is not statistically significant (p=0.0889; Fisher’s exact test).

Although the overall incidence of AVN has been reported in the literature to be 0%–30% in capitellar fractures,[9,28,36] none of our cases showed any signs of AVN at the latest follow-up radiographs, even when most of the times, major fracture fragments were devoid of soft-tissue attachments. With the incidence of AVN being very low, it is always advisable to fix a large free capitellar fragment.[35] Heterotopic ossification has not been usually seen with these fractures.[32] In our series, no case of heterotrophic ossification was seen and no prophylaxis to prevent the same was given.

Early surgical management and good rehabilitation may be a preventing factor, as earlier management of these fractures reduces the risk of developing heterotopic ossification.[37] Our case series shows that ORIF for capitellar fractures using Herbert screws inserted from the anterior to the posterior direction through extensile lateral approach is safe and easy, achieving rigid fixation that allows early mobilization with minimal minor complications, thus achieving excellent outcomes with good elbow motion and function.

Conflict of interest: None declared.

REFERENCES 1. Harrington JP,Mckee MD. Coronal Shear fractures of the capitellum and trochlea. Tech Shoulder Elbow Surg 2000;1:240–6.

2. Jupiter JB, Morrey BF. Fractures of the distal humerus in the adult. In: Morrey BF editor. The elbow and its disorders. 2nd ed. WB Saunders, Philadelphia: 1993; p. 328–66.

3. Cooper SAP. Fractures of the external condyle of the humerus. In: Lee, Cooper SAP, editors. A treatise on dislocations and fractures of the joints.

1st ed. London: Joseph Butler; 1841. p. 508.

4. Hahn NF. Fall von einer besonderen Varietät der Frakturen des Ellenbogens. Zeitschrift fur Wundärzte und Geburtshelfer 1853;6:185– 9.

5. Kocher T. Beiträge zur Kenntniss einiger praktisch wichtiger Frakturformen. Basel: Carl Sallmann; 1896:585–91.

6. Steinthal D. Die isolierte Fraktur der Eminentia Capitata im Ellenbogengelenk. Zentralbl Chirurgie 1898;15:1.

7. Lorenz H. Zur Kenntniss der Fractura Capitelulm Humeri (Eminentia Capitata). Deutsche Zeitschr f Chir.1905;78:531–45.

8. Silveri CP, Corso SJ, Roofeh J. Herbert screw fixation of a capitellum fracture. A case report and review. Clin Orthop Relat Res 1994:123–6.

9. McKee MD, Jupiter JB, Bamberger HB. Coronal shear fractures of the distal end of the humerus. J Bone Joint Surg Am 1996;78:49–54.

10. Lansinger O, Måre K. Fracture of the capitulum humeri. Acta Orthop Scand 1981;52:39–44.

11. Watts AC, Morris A, Robinson CM. Fractures of the distal humeral articular surface. J Bone Joint Surg Br 2007;89:510–5.

12. Bryan RS, Morrey BF. Fractures of the distal humerus. In: Morrey BF, editor. The elbow and its disorders. 1st ed. Philadelphia: WB Saunders; 1985. p. 302–39.

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13. Mueller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. New York: Springer; 1990.

14. Ochner RS, Bloom H, Palumbo RC, Coyle MP. Closed reduction of coronal fractures of the capitellum. J Trauma 1996;40:199–203.

15. Fowles JV, Kassab MT. Fracture of the capitulum humeri. Treatment by excision. J Bone Joint Surg Am 1974;56:794–8.

16. Holdsworth BJ, Mossad MM. Fractures of the adult distal humerus. Elbow function after internal fixation. J Bone Joint Surg Br 1990;72:362–5.

17. Jupiter JB, Neff U, Regazzoni P, Allgower M. Unicondylar fractures of the distal humerus: an operative approach. J Orthop Trauma 1988;2:102–9.

18. Liberman N, Katz T, Howard CB, Nyska M. Fixation of capitellar fractures with the Herbert screw. Arch Orthop Trauma Surg 1991;110:155– 7.

19. McKee MD, Jupiter JB. A contemporary approach to the management of complex fractures of the distal humerus and their sequelae. Hand Clin 1994;10:479–94.

20. Mosheiff R, Liebergall M, Elyashuv O, Mattan Y, Segal D. Surgical treatment of fractures of the capitellum in adults: a modified technique. J Orthop Trauma 1991;5:297–300.

21. Poynton AR, Kelly IP, O’Rourke SK. Fractures of the capitellum-a comparison of two fixation methods. Injury 1998;29:341–3.

22. Farooq M, Mir BA, Farooq M. Coronal shear fractures of the capitellum.

Indian Journal of Orthopedics 2004;38:4:259–60.

23. Singh AP, Singh AP, Vaishya R, Jain A, Gulati D. Fractures of capitellum: a review of 14 cases treated by open reduction and internal fixation with Herbert screws. Int Orthop 2010;34:897–901.

24. Mighell MA, Harkins D, Klein D, Schneider S, Frankle M. Technique for internal fixation of capitellum and lateral trochlea fractures. J Orthop Trauma 2006;20:699–704.

25. Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Open reduction and internal fixation of capitellar fractures with headless screws. J Bone Joint Surg Am 2008;90:1321–9.

26. Vaishya R, Vijay V, Jha GK, Agarwal AK. Open reduction and internal fixation of capitellar fracture through anterolateral approach with headless double-threaded compression screws: a series of 16 patients. J Shoulder Elbow Surg 2016;25:1182–8.

27. Jakobsson A. Fracture of the capitellum of the humerus in adults; treatment with intra-articular chrom-cobolt-molybdenum prosthesis. Acta Orthop Scand 1957;26:184–90.

28. Mahirogullari M, Kiral A, Solakoglu C, Pehlivan O, Akmaz I, Rodop O. Treatment of fractures of the humeral capitellum using herbert screws. J Hand Surg Br 2006;31:320–5.

29. Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA . Open reduction and internal fixation of capitellar fractures with headless screws.s urgical technique. J Bone Joint Surg [Am] 2009;91 Suppl 2:38–49.

30. Dubberley JH, Faber KJ, Macdermid JC, Patterson SD, King GJ. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. J Bone Joint Surg Am 2006;88:46–54.

31. Grantham SA, Norris TR, Bush DC. Isolated fracture of the humeral capitellum. Clin Orthop Relat Res 1981:262–9.

32. Ruchelsman DE, Tejwani NC, Kwon YW, Egol KA. Coronal plane partial articular fractures of the distal humerus: current concepts in management. J Am Acad Orthop Surg 2008;16:716–28.

33. Elkowitz SJ, Polatsch DB, Egol KA, Kummer FJ, Koval KJ. Capitellum fractures: a biomechanical evaluation of three fixation methods. J Orthop Trauma 2002;16:503–6.

34. Ring D, Jupiter JB, Gulotta L. Articular fractures of the distal part of the humerus. J Bone Joint Surg Am 2003;85-A:232–8.

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36. Ong KL, Mahadev A. Cannulated cancellous screw fixation for capitellum

fractures in adolescents. J Orthop Surg (Hong Kong) 2011;19:346–9.

37. Ilahi OA, Strausser DW, Gabel GT. Post-traumatic heterotopic ossification about the elbow. Orthopedics 1998;21:265–8.

OLGU SERİSİ - ÖZET OLGU SUNUMU

Açık redüksiyon ve Herbert vidalarıyla internal fiksasyon yöntemiyle kapitellar kırıkların tedavisi Dr. Asif Sultan, Dr. Omar Khursheed, Dr. Mohammad Rafiq Bhat, Dr. Hilal Ahmad Kotwal, Dr. Qazi Waris Manzoor, Kemik ve Eklem Hastalıkları Devlet Hastanesi, Ortopedi ve Travmatoloji Kliniği, Barzulla, Srinagar-Hindistan

AMAÇ: Kapitellar kırıklar seyrek görülen dirsek yaralanmaları olup uygun biçimde tedavi edilmediğinde ağır fonksiyonel kısıtlamaya neden olabilirler.

Erkenden mobilizasyona olanak sağlayan stabil bir eklem durumunu gerçekleştirmek için kapalı redüksiyon ve alçıyla tespitten açık redüksiyon ve internal fiksasyona (ARİF) kadar sayısız tedavi geliştirilmiştir. Geniş bir lateral yaklaşım yoluyla Herbert vidaları ve ARİF yöntemi kullanarak bu kırıkları tedavi etmenin fonksiyonel sonuçlarını belirledik.

GEREÇ VE YÖNTEM: Bu geriye dönük çalışmaya kapitellar kırıkları olan 15 hasta dahil edildi. İyi çekilmiş bir radyografi önemli olduğundan her hastada bu husus vurgulandı. Beş yıllık çalışma dönemi boyunca tüm kırıklar geniş bir lateral ekspozürle açık redüksiyon ve Herbert vidaları kullanılarak internal fiksasyonla tedavi edildi. Ortalama 3.6 yıllık (dağılım, 1.5–6 yıl) takipte klinik, radyografik bulgular ve Mayo Dirsek Performans İndeksine göre değerlendirmeler yapıldı.

BULGULAR: Bryan ve Morrey sınıflandırma sistemi kullanılarak 9, tip I ve 6 tip IV kapitellar kırık tespit edildi. Kemiğin kaynamasına kadar ortalama 12 hafta (dağılım, 8–16 hafta) geçmiş, tüm kırıklar kaynadı. Ortalama fleksiyon genişliği 130° (dağılım, 125°–135°) idi. Hastaların tümünde fonksiyonel hareket aralığı sağlandı; ortalama ekstansör hareket açıklığı 10° (dağılım, 0°-30°) idi. Son takipte bir olguda osteoartrit görüldü, herhangi bir avasküler nekroz veya heterotrofik osifikasyon gözlenmedi. İki hastada vidaların çıkartılması gerekti. On hastada mükemmel ve beş hastada iyi sonuçlar elde edildi.

TARTIŞMA: Herbert vidasıyla fiksasyon kapitellar kırıklarda stabil bir tespit sağladığı gibi genişletilmiş lateral açınımla bu kompleks kırıkların internal fiksasyonu ardından dirsek hareketliliğinde iyi-mükemmel sonuçlar elde edilebilir.

Anahtar sözcükler: Açık redüksiyon ve internal fiksasyon; genişletilmiş lateral açınım; Herbert vidası; kapitellar kırık.

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CA S E R EP O RT

Delayed bipedicled flap: An alternative and new method for reconstruction of distal leg defect after gunshot trauma: A case report and review of the literature Ali Rıza Yıldırım, M.D., Murat İğde, M.D., Mehmet Onur Öztürk, M.D., Hasan Murat Ergani, M.D., Ramazan Erkin Ünlü, M.D. Department of Plastic Surgery, Ankara Numune Training and Research Hospital, Ankara-Turkey

ABSTRACT Shotgun injury is a trauma that leads to soft tissue defects, in which important structures such as the tendon and bone are exposed with fractures in the distal lower extremity. Because this region has insufficient soft tissue support, local flap options are highly limited.

Although the most suitable options are free or perforator flaps for contemporarily reconstructing that region; owing to such highenergy traumas, the available local flaps are becoming more suitable. Besides having various advantages, bipedicled flaps are commonly used for reconstructing small- and medium-sized lower extremity defects. This study aimed to discuss the use of a delayed bipedicled flap, which has not been previously described in the literature.

Keywords: Bipedicled flap; distal leg; gunshot trauma; surgical delay.

INTRODUCTION Closure of complex skin and soft tissue defects in the distal leg, which result from shotgun injuries, is quite difficult for reconstructive surgery. High-energy injuries in that region frequently result in soft tissue defects with significant structures such as tendon and bone and open tibia fractures being exposed. Because open tibia fractures have high malunion and infection incidences, urgent irrigation and debridement of devitalized soft tissues and bone fragments are required.[1,2] The reconstruction of open tibia fracture accompanied by bone and soft tissue defects is difficult because such regions have poor circulation and insufficient local surplus skin,[3] making reconstruction options limited. For the reconstruction of

Address for correspondence: Ali Rıza Yıldırım, M.D. Ankara Numune Eğitim ve Araştırma Hastanesi, Plastik Cerrahi Kliniği, Ankara, Turkey Tel: +90 312 - 508 45 44 E-mail: prsary86@gmail.com Submitted: 10.06.2016 Accepted: 06.05.2017

Ulus Travma Acil Cerrahi Derg 2017;23(6):515–520 doi: 10.5505/tjtes.2017.90016 Copyright 2017 TJTES

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these defects, various local fasciocutaneous muscle flap and free flap options are available. Because of short operation duration, not involving multiple surgical areas, and low cost, local flaps are simple and favorable. In addition, local flaps can be alternatively used in older patients with comorbidities for whom free flaps are not suitable.[4] Among these local flap options, bipedicled flaps provide sufficient tissue for small- and medium-sized defects, have a constant circulation, are easy and rapid to harvest, and have reasonable donor site morbidity.[5] In this study, existing literature was reviewed with regard to the outcomes of patient who underwent reconstruction by delayed bipedicled flap, which has not been previously described in the literature and is designed differently from classic bipedicled flaps, and the use of that flap in distal leg soft tissue defects was discussed.

CASE REPORT A 17-year-old male patient sustained a shotgun injury from an approximate distance of 3 mm, which resulted in an exposed tibia defect that measured 8×4 cm and 3 cm deep on the anterior tibial compartment of right distal third of the leg (Fig. 1a). At another medical center, because of the fracture in the distal third of the tibia and fibula, bone stabilization was performed via external fixator. Because the wound was not clean, 515

Yıldırım et al. Delayed bipedicled flap: an alternative and new method for reconstruction of distal leg defect after gunshot trauma

(a)

(b)

(c)

Figure 1. (a) As a result of the shotgun injury, an exposed tibia defect measuring 8×4 cm dimensions and 3 cm deep on the anterior tibial compartment of the right distal third of the leg. Planning the flap width to be approximately half of the present defect length, with a 3:1 ratio and 12×4 cm dimensions on the transverse axis. (b) Preoperative view of the flap. (c) Illustration of the flap.

the existing defect was treated with debridement and two sessions of vacuum-assisted closure therapy. Furthermore, following wound culture, wide-spectrum antibiotics therapy was initiated. To evaluate potential vascular injuries, angiography was performed, and anterior tibial artery and peroneal artery injuries were detected. Because two major arteries

(a)

(b)

were injured and the injury zone was wide, reconstruction was primarily planned using local flaps instead of free flaps. At the end of a 2-week follow-up period that involved debridement and dressing procedures, wound culture revealed that the wound was clean. Then, reconstruction with two-stagedelayed bipedicled flaps was planned.

(c)

Figure 2. (a-c) First early postoperative view (anterior, lateral, and medial views, respectively).

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(a)

(b)

(c)

(d)

Figure 3. (a) Illustration of the flap. Two weeks after the first operation, rendering the flap single pedicled by cutting from the lateral and inferior sides of the delay procedure applied flap with respect to the remaining defect area and closure of the defect by rotation. In the secondary operation, flap division must be performed with approximately “x” units lateral, if vertical axis of the remaining defect is regarded as “x” units. (b-d) First early second postoperative view (anterior, lateral, and medial views, respectively).

Under general anesthesia, after surgical debridement, the existing external fixator was removed and implanted in the medial side. Then, the width of the flap was planned to be approximately half of the present defect length, with a 3:1 ratio on the transverse axis (Fig. 1b, c). The flap was preferred on the transverse axis instead of the longitudinal axis because of the following two reasons. First, the bipedicled flap planned for the longitudinal axis would be insufficient for the closure of such a wide defect. Second, the flap would not be able to close the dead space because the defect had a deep pouch. Subsequently, the flap was elevated in the subfascial plane and advanced without tension. The donor site and remaining defect were reconstructed using a splitthickness skin graft till the second stage for biologic dressing (Fig. 2a-c). After 2 weeks, the bipedicled flap was transformed to a single pedicle flap by cutting from the lateral side at the length of the remaining defect site and 3×2 cm end part of the flap was disepithelialized for pouch closure

Figure 4. The lateral view of the flap in the first month of the postoperative follow-up. No major problem was encountered, except for the unhealed partial skin graft area.

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and the flap was adapted to the defect by rotation (Fig. 3ad). The donor site was reconstructed using a split-thickness skin graft. In postoperative care, leg elevation and 1-week patient immobilization was provided. On the third day, the tie-over dressing was removed, and no major problem was encountered, except the unhealed partial skin graft area. In the postoperative period, venous congestion/flap necrosis was not observed. Unhealed partial graft zones in the donor site were observed as postoperative minor complications (Fig. 4). Complete recovery was achieved by minor debridement and dressing. The flap was controlled at 1, 3, and 6 months after surgery (Fig. 5a-c).

DISCUSSION Reconstruction of open tibia fracture with exposed bone and tendon accompanied by defects in the distal third of the leg is quite problematic for reconstructive surgery. Because local flap options are limited for the reconstruction of that region, closure of the current defect is a tough procedure.

Shotgun injury is a complex distal leg defect. The management of defects that occur because of such injuries involves a three-step algorithm that comprises urgent care, early damage control, and late reconstruction steps. The first step includes bleeding control, systematic antibiotics therapy, and infection control by serial debridement; in contrast, the last step involves bone fixation and closure of the defect by soft tissues.[6] Moreover, such injuries can be frequently associated with major fractures (48%), impairment of soft tissue integrity (59%), vascular injuries (35%), and nerve damage.[7] 517

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(a)

(b)

(c)

Figure 5. (a-c) The view of the flap in the third month of postoperative follow-up.

Therefore, controlling defects that result from shotgun injuries using preferred antibiotic therapy and serial debridement owing to over contamination and preparing the wound for reconstruction is crucial. Patient should also be simultaneously evaluated in detail for secondary bone, tendon, and nerve injuries to shotgun injuries.

Free flaps have been lately preferred for the closure of the distal third of leg defects with soft tissues.[8] However, free flaps have various difficulties such as major artery sacrification, long operation duration, donor site morbidity, and requirement of microsurgery experience and equipments.[9] Because shotgun injuries are accompanied by significant vessel injuries, the use of free flaps is limited. In our case, because both the anterior tibial artery and posterior tibial (PT) injury was present, free flap reconstruction was not preferred.

Nowadays, reverse flow sural flaps, local fasciocutaneous flaps, perforator flaps, and bipedicled flaps are used for reconstructing that region.[9–13] Reverse flow sural flaps are indicated for reconstructing distal leg, foot ankle, and heel defects. The flap is advantageous because of being one step, being rapidly and easily dissected, short operation duration, and relatively bloodless surgery. Damage of the peroneal artery and perforators is contraindicated under conditions such as venous insufficiency and absence of the saphenous vein.[8] In such cases, owing to peroneal artery injury as a result of shotgun injury, reconstruction with reverse flow sural flaps was not performed.

In the study conducted by Parrett et al.,[14] a classification was developed according to arteries being intact or not for the reconstruction of defects in the pretibial region of the distal leg.

With respect to this classification, for patients with an open 518

PT artery, posterior tibial artery perforator flaps and medial plantar artery flaps are suggested. PT pedicled perforator flap is the most suitable option for anterior (pretibial) or medial distal leg defects. Although flaps are suggested for small- and medium-sized defects, it can feed up to 19×13 cm skin island over single perforator.[15] The PT pedicled perforator flap is advantageous because it does not sacrifice the muscle and major artery, requires microvascular anastomose, provides sufficient soft tissue support, and supports reconstruction with similar tissues.[16] In propeller flaps, because of pedicle bending, torsion partial/ total flap failure or venous problems can be observed.[17] Bekara et al.[18] compared pedicled perforator flaps with free flaps in the reconstruction of the lower extremity and observed similar complications with both flaps. For the reconstruction of dorsal leg defects, the most appropriate flap was suggested to have a low donor site morbidity and for which the surgeon is more experienced.

Although local flaps have a higher complication rate, they are more frequently preferred because they do not require microsurgery and are simpler.[19] Bipedicled flaps provide successful reconstruction by being used in various anatomical regions. Bipedicled flaps were first defined in 1957 by Crawford[20] and named “double-pedicled;” they are presented as an alternative to tube and cross-leg flaps.[21] Because of their various advantages, bipedicled flaps are used in the reconstruction of the lower extremity. Major advantages include the flap being easier compared with microsurgery techniques, having a safe circulation, minimum donor site morbidity, and less postoperative monitorization need.

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using a similar tissue. In a study, for tibia or implant exposed defects, bipedicled fasciocutaneous flaps were very useful as closing with similar tissue in such defects.[22] Makhlouf et al.[5] suggested that during bipedicled flap-raising processes, axial cutaneous perforators were preserved by longitudinal incision. Nevertheless, Hallock[27] and Schwabegger[28] reported that viability was not influenced unless the width: height ratio of bipedicled fasciocutaneous flaps exceed 4:1.[21] In previous studies, bipedicled flaps were useful in lower extremity reconstructions, in limited use and small dimension (<2.5 cm) defects.[25] However, the use of classic bipedicled flaps for the reconstruction of defects having a deep pouch and wide dimension is not appropriate.

In our case because the defect was wide and had a deep pouch, reconstruction with classic bipedicled flaps did not appear to be possible. The closure without tension and closure of dead space were not possible because the defect radius was large and the pouch was deep, respectively. Hence, the flap was designed as a two-stage bipedicled one on the transverse axis, and after the first session, during circulation monitoring, no problem was observed. Then, by employing the surgical delay procedure, reconstruction was completed.

Surgical delay procedure was first used by Gillies[26] in 1920 for tube flaps to increase the living zones of the flap and necrosis of the distal part.[27] The procedure is obtained by partially interrupting the normal blood flow without changing the flap position.[28] A study revealed that the appropriate time required for flap transfer was 2 weeks.[29] In the present case, after a 2-week surgical delay, the flap was rendered single pedicled and adapted to the defected area by rotation.

During postoperative follow-up, no arterial or venous problem was observed.

In conclusion, high-energy injuries in the distal leg, such as shotgun injuries, can result in soft tissue defects accompanied with bone fractures in which major arteries are damaged.

While evaluating the ideal options for the reconstruction of such defects, the accompanying artery, muscle, bone injuries, patient’s performance, comorbidities, and potential wound infection should be considered. Newly introduced delayed bipedicled flaps should be considered as alternative options for the reconstruction of these defects.

Conflict of interest: None declared.

REFERENCES 1. Khatod M, Botte MJ, Hoyt DB, Meyer RS, Smith JM, Akeson WH. Outcomes in open tibia fractures: relationship between delay in treatment and infection. J Trauma 2003;55:949–54.

2. Dickson K, Katzman S, Delgado E, Contreras D. Delayed unions and nonunions of open tibial fractures. Correlation with arteriography results. Clin Orthop Relat Res 1994:189–93.

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3. Salibian AH, Menick FJ. Bipedicle gastrocnemius musculocutaneous flap for defects of the distal one-third of the leg. Plast Reconstr Surg 1982;70:17–23.

4. Parrett BM, Winograd JM, Lin SJ, Borud LJ, Taghinia A, Lee BT. The posterior tibial artery perforator flap: an alternative to free-flap closure in the comorbid patient. J Reconstr Microsurg 2009;25:105–9.

5. Makhlouf MV, Obermeyer Z. Bipedicle flap for wounds following achilles tendon repair. Plast Reconstr Surg 2008;121:235e–6e.

6. Penn-Barwell JG, Brown KV, Fries CA. High velocity gunshot injuries to the extremities: management on and off the battlefield. Curr Rev Musculoskelet Med 2015;8:312–7.

7. Acartürk TO. Reconstruction of lower extremity close-range shotgun injuries with gracilis free flap: a report of two cases. Ulus Travma Acil Cerrahi Derg 2010;16:367–70.

8. Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibiafibula fractures. Plast Reconstr Surg 2006;117:1315–22.

9. Eser C, Kesiktaş E, Gencel E, Aslaner EE, Yavuz M. An alternative method to free flap for distal leg and foot defects due to electrical burn injury: distally based cross-leg sural flap. Ulus Travma Acil Cerrahi Derg 2016;22:46–51.

10. Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural flap.

Plast Reconstr Surg 2002;109:583–91.

11. Raveendran SS, Perera D, Happuharachchi T, Yoganathan V. Superficial sural artery flap-a study in 40 cases. Br J Plast Surg 2004;57:266–9.

12. Kamath BJ, Joshua TV, Pramod S. Perforator based flap coverage from the anterior and lateral compartment of the leg for medium sized traumatic pretibial soft tissue defects-a simple solution for a complex problem. J Plast Reconstr Aesthet Surg 2006;59:515–20.

13. Granzow JW, Li A, Suliman A, Caton A, Goldberg M, Boyd JB. Bipedicled flaps in posttraumatic lower-extremity reconstruction. J Plast Reconstr Aesthet Surg 2013;66:1415–20.

14. Parrett BM, Talbot SG, Pribaz JJ, Lee BT. A review of local and regional flaps for distal leg reconstruction. J Reconstr Microsurg 2009;25:445–55.

15. Koshima I, Ozaki T, Gonda K, Okazaki M, Asato H. Posterior tibial adiposal flap for repair of wide, full-thickness defect of the Achilles tendon. J Reconstr Microsurg 2005;21:551–4.

16. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and applications. Ann Plast Surg 2003;50:90–9.

17. Gir P, Cheng A, Oni G, Mojallal A, Saint-Cyr M. Pedicled-perforator (propeller) flaps in lower extremity defects: a systematic review. J Reconstr Microsurg 2012;28:595–601.

18. Bekara F, Herlin C, Somda S, de Runz A, Grolleau JL, Chaput B. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis. Microsurgery 2016 Mar 28 [Epub ahead of print], doi:10.1002/micr.30047.

19. Quaba O, Quaba A. Pedicled perforator flaps for the lower limb. Semin Plast Surg 2006;20:103–11.

20. Crawford BS. The repair of defects of the lower limb, using a local flap. Br J Plast Surg 1957;10:32–5.

21. Dujon DG, Khan UD, Aslam S. Bipedicle flaps: simple solutions for difficult problems in the extremities. Br J Plast Surg 1997;50:641–5.

22. Darwish AM. Bipedicled flap in reconstruction of exposed tibia. J Plast Reconstr Aesthet Surg 2010;63:160–3.

23. Hallock GG. Bipedicled fasciocutaneous flaps in the lower extremity.

Ann Plast Surg 1992;29:397–401.

24. Schwabegger A, Ninković M, Wechselberger G, Anderl H. The bipedicled flap on the lower leg, a valuable old method? Its indications and limitations in 12 cases. Scand J Plast Reconstr Surg Hand Surg 1996;30:187–93.

25. Oudit D, Tillo O, McCoubrey G, Crawford L, Juma A. A simplified technique of using bipedicled fasciocutaneous flaps in closure of soft tissue defects of the anterior leg in patients with fasciotomy wounds. J Trauma

519

Yıldırım et al. Delayed bipedicled flap: an alternative and new method for reconstruction of distal leg defect after gunshot trauma 2007;63:1185–6.

26. Gillies HD. The tubed pedicle in plastic surgery. NYJ Med 1920;111:1.

27. Ghali S, Butler PE, Tepper OM, Gurtner GC. Vascular delay revisited.

Plast Reconstr Surg 2007;119:1735–44.

28. Grabb WC, Smith JW, Aston SJ, Beasley RW, Thorne C. Grabb and Smith’s plastic surgery. 6th ed. Philadelphia: Lippicott-Raven; 2007.

29. Milton SH. The effects of “delay” on the survival of experimental pedicled skin flaps. Br J Plast Surg 1969;22:244–52.

OLGU SUNUMU - ÖZET

Gecikmeli bipediküllü flep: Ateşli silah yaralanması sonrası bacak distalindeki defektlerin rekonstrüksiyonu için alternatif ve yeni metod: Olgu sunumu ve literatürün taranması Dr. Ali Rıza Yıldırım, Dr. Murat İğde, Dr. Mehmet Onur Öztürk, Dr. Hasan Murat Ergani, Dr. Ramazan Erkin Ünlü Ankara Numune Eğitim ve Araştırma Hastanesi, Plastik Cerrahi Kliniği, Ankara

Ateşli silah yaralanmaları, bacak distal bölgesinde kırık eşlik eden kemik, tendon gibi önemli yapıların ekspoze olduğu yumuşak doku defektlerine yol açan travmalardan biridir. Bu bölgenin yeterli yumuşak doku desteğine sahip olmaması nedeniyle lokal flep seçenekleri oldukça sınırlıdır. Günümüzde bu bölgenin rekonstrüksiyonu için en uygun seçenekler serbest flepler ve perforator flepler olmasına rağmen bu tür yüksek enerjili travmalar nedeniyle mevcut lokal flepler daha uygun hale gelmektedir. Bipediküllü flepler, çok çeşitli avantajları olması sebebiyle küçük ve orta boyutlu alt ekstremite defeklerinin rekonstrüksiyonunda sıkça kullanılmaktadır. Bu çalışmanın amacı, bacak distalindeki geniş yumuşak doku defektlerinin rekonstrüksiyonu için daha önce literatürde tanımlanmayan gecikmeli bipediküllü flebin kullanımı ve hasta sonuçları üzerinden mevcut literatür gözden geçirilerek flebin kullanımı tartışıldı.

Anahtar sözcükler: Ateşli silah yaralanması; bacak distali; bipediküllü flep; cerrahi geciktirme.

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Endoscopic drainage and cystoduodedonstomy in a child with pancreatic pseudocyst Ufuk Ateş, M.D.,1 Gönül Küçük, M.D.,1 Kubilay Çınar, M.D.,2 Berktuğ Bahadır, M.D.,3 Mehmet Bektaş, M.D.,2 Gülnur Göllü, M.D.,1 Meltem Bingöl Koloğlu, M.D.1 1

Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara-Turkey

2

Department of Gastroenterology, Ankara University Faculty of Medicine, Ankara-Turkey

3

Department of Pediatric Surgery, Mersin University Faculty of Medicine, Mersin-Turkey

ABSTRACT An 11-year-old morbidly obese boy was diagnosed with pancreatic pseudocyst. Following fine needle aspiration, the cyst recurred in 1-month follow-up. Therefore, endoscopic drainage and cystoduodenostomy was performed following endosonography. Control ultrasonography (USG) revealed a completely shrunken cyst. During the 3 years of follow-up, the patient was asymptomatic with no evidence of cyst on computerized tomography scans. Endoscopic drainage and cystoduodenostomy is a minimally invasive, effective, and safe approach in the management of pancreatic pseudocysts in children.

Keywords: Children; drainage; endosonography; pancreas.

INTRODUCTION

CASE REPORT

Pancreatic pseudocysts (PP) are rare, but potentially troublesome problem in the pediatric population. They usually result from pancreatic insult with ductal disruption and majorities are secondary to trauma.[1] When attempts at conservative medical management fail, drainage of the pseudocyst is warranted. Surgical drainage procedures have long been the gold standard for treating persistent, symptomatic pseudocysts.[2] Most recently, laparoscopic and endoscopic techniques have been applied to manage this problem. Endoscopic procedures have mostly been utilized in adult population and the pediatric literature on these techniques is limited. In this case report, we aimed to share our experience in endoscopic drainage and cystoduodenostomy in a child with PP.

An 11-year-old boy presented with abdominal pain and vomiting episodes for 2 months. He had a history of injury during a motor vehicle accident 3 months ago. He was treated for humerus fracture and evaluated for abdominal pain. Abdominal ultrasonography done on the first admission was reported to be normal. However, abdominal computerized tomography (CT) scans done on the second admission demonstrated a 7 × 6-cm cyst located in the head of pancreas, causing duodenal compression (Fig. 1a).

Address for correspondence: Gülnur Göllü, M.D. Ankara Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı Dikimevi, 06100 Ankara, Turkey Tel: +90 312 - 595 62 02 E-mail: drggollu@yahoo.com Submitted: 20.10.2015 Accepted: 06.04.2017

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First, ultrasonography-guided percutaneous aspiration of the cyst was performed, which revealed 50 ml of turbid fluid with increased amylase level. The cyst shrank to 2 cm after aspiration, but enlarged to 8 cm in 1 month of follow-up.

Therefore, endoscopic drainage and cystoduodenostomy was planned. Endosonography done before the procedure showed that there was no vascular structure between the cyst wall and duodenum and there was no epithelial lining or muscular structure in the cyst wall (Fig. 1b). Endoscopy was performed with a side-viewing duodenoscope and revealed extrinsic compression of the duodenal bulb (Fig. 2a). A needle-knife papillotome was then used to incise the duodenal and pseudocyst walls using electrocautery. The needle was withdrawn and the catheter advanced into the cyst to serve as a conduit for guidewire placement (Fig. 2b). The guidewire was advanced into the pseudocyst and was seen coiling in the 521

AteĹ&#x; et al. Endoscopic drainage and cystoduodedonstomy in a child with pancreatic pseudocyst

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(b)

Figure 1. Computerized tomography scan showing a pancreatic pseudocyst at the head of pancreas (arrow) (a) and endosonography view showing the pancreatic pseudocyst without an epithelial lining or muscle wall (b).

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large cavity. Cystoduodenostomy opening was easily dilated using an 8â&#x20AC;&#x201C;10-mm diameter pneumatic balloon (Fig. 2c). Two double-pigtail plastic stents were placed across the cystoduodenostomy window to maintain patency and allow complete resolution of the pseudocyst (Fig. 2d). Postoperative course was uneventful. The patient tolerated oral feeding on postoperative first day and was discharged on postoperative second day. The stents were spontaneously evacuated 12 months after the procedure. During the 3 years of follow-up, the patient remained asymptomatic and is currently doing well with no evidence of cyst on CT scans (Fig. 3).

DISCUSSION

Figure 2. Endoscopic view showing extrinsic compression of the duodenal bulb by the cyst (a), needle-knife papillotome incising duodenal and pseudocyst walls (b), balloon dilatation of cystoduodenostomy opening (c), and double-pigtail stent in the cystoduodenostomy (d).

Figure 3. Follow-up: No evidence of cyst on CT scans.

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Pancreatic pseudocyst (PP) is a rare but potentially troublesome problem in the pediatric population. They usually result from pancreatic insult with ductal disruption and majorities are secondary to trauma.[1] When attempts at conservative medical management fail, draining the pseudocyst is warranted. Surgical drainage procedures have long been the gold standard for treating persistent, symptomatic pseudocysts.[2] Most recently, laparoscopic and endoscopic techniques have been applied to manage this problem. Endoscopic procedures have mostly been used in adult population, and the pediatric literature on these techniques is limited. In this case report, we aimed to share our experience in endoscopic drainage and cystoduodenostomy in a child with PP. Pancreatic pseudocyst is a cystic cavity bound to the pancreas without an epithelial lining, which occurs following an injury to the pancreatic parenchyma or pancreatic duct.[1] It is also a well-recognized complication of acute pancreatitis, chronic pancreatitis, and pancreatic trauma.[3] PP is uncommon in children and majority of these are secondary to trauma.[2] The cyst must be drained when it causes complications such as pain, compression, hemorrhage, infection or fails to spontaneously resolve. The management depends on the size, localization, presence, or absence of infection and age of the pseudocyst.[2] Usually, the size is a good predictor of spontaneous resolution: cysts smaller than 4 cm resolve in 90% of Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Ateş et al. Endoscopic drainage and cystoduodedonstomy in a child with pancreatic pseudocyst

cases, whereas cysts larger than 6 cm have only a 20% chance of resolving.[2]

tion, infection, technical failure to drain the cyst, stent occlusion, stent leakage, stent migration, and recurrence of PP.[3]

The management of PP has changed with the times, mainly during the past decade. Surgical drainage has been the traditional approach and gold standard of treatment because of the superior results.[2] The type of surgical procedure, that is, pseudocystogastrostomy or pseudocystojejunostomy, is largely dependent on the site of PP. These procedures can also be laparoscopically performed. With the advent of USG and CT techniques, percutaneous drainage has been proved to be more feasible and attractive in nonoperative management of PP. According to Warner et al.,[4] most childhood pseudocysts are acute and thin-walled and share no connection with underlying pancreatic duct obstruction or associated disease.

As discussed by Warner et al., in the adult literature, external drainage is recommended only for patients with immature friable pseudocysts or infected and ruptured cysts or for patients who are very ill. However, external drainage is one of the treatment of choice for pseudocysts in children. The procedure can be done quickly and effectively, and it does not preclude other surgical procedures if further measures become necessary. In adults, alcoholic pancreatitis is the principal cause of pseudocysts; however, traumas can also a cause in children. External drainage has not resulted in dismal failure rates in the pediatric age group. The reason for this may be that virtually all pseudocysts in children are traumatic.

The underlying pancreatic duct and parenchyma are usually normal.[5] Although there is a high incidence of pancreaticocutaneous fistula formation after external drainage in adults, this risk is lower in children.[4] As discussed by Burnweit et al.,[5] when PP develops and persists in the post-traumatic setting, percutaneous drainage can be tried in nonoperative management of pancreatic pseudocyst in children. However, its higher recurrence rate is a drawback, and the application largely depends on the expertise of the institutions in pediatric population.[6] We also tried percutaneous drainage initially in our case, but there was recurrence; therefore, endoscopic drainage and cystoduodenostomy were performed.

To assess the wall thickness, to identify major vascular structures, and to find the closest access to fluid cavity, endoscopic ultrasound-guided drainage of PP has been utilized in many centers recently.[7–10] Another advantage of endosonography is that it allows differentiating pseudocyst from duplication cyst by showing that there is no epithelial lining or muscular structure in the cyst wall. In our case, endosonography showed no muscle lining in the cyst wall, and there were no gross vascular structures between duodenal wall and PP that could compromise the success of the procedure.

Since 1985, there have been reports of endoscopic drainage of PP by placing stents between pseudocyst and gastrointestinal tract in adults. However, the experience in pediatric population is limited. The available methods of endoscopic drainage are cystoenterostomy or transpapillary drainage.[3] Transpapillary drainage may be specifically needed for cases associated with pancreatic duct anomalies. For a safe and successful endoscopic drainage, a visible bulging of the gastric or duodenal wall at the site of pseudocyst and a cyst wall thickness less than 1cm are warranted.[3,6] The contraindications of endoscopic drainage are hemorrhage, infection, and a distance greater than 1 cm from the gut lumen to the inner cyst wall.

[2] The thickness of the wall is important because endoscopic drainage becomes technically more difficult in cysts with thicker wall and carries an increased risk of complications and failure.[6] Complications include bleeding, intestinal perforaUlus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

It is recommended that all cystenterostomies should be stented to avoid recurrence and spontaneous stent migration can be minimized by using double-pigtail stents, as done in our case.[7] The duration of leaving the stent in situ has not been well-defined yet. Most investigators report leaving the stent in place for 2–4 months or until ultrasonography confirms pseudocyst resolution before endoscopic removal.

In some adult patients, the stent has been left in place for 2 years without complication, and sometimes the stent has spontaneously passed.[6,7] We were planning to remove the stents 12 months after the procedure; however, they were spontaneously evacuated.

Depending on our experience, the endoscopic drainage of PP and cystoduodenostomy is a minimally invasive, effective, and safe approach, and it is applicable to the pediatric population. In experienced hands, it is a simple and minimal invasive alternative to surgery or percutaneous drainage.

Conflict of interest: None declared.

REFERENCES 1. Teh SH, Pham TH, Lee A, Stavlo PL, Hanna AM, Moir C. Pancreatic pseudocyst in children: the impact of management strategies on outcome.

J Pediatr Surg 2006;41:1889–93.

2. Patty I, Kalaoui M, Al-Shamali M, Al-Hassan F, Al-Naqeeb B. Endoscopic drainage for pancreatic pseudocyst in children. J Pediatr Surg 2001;36:503–5.

3. Al-Shanafey S, Shun A, Williams S. Endoscopic drainage of pancreatic pseudocysts in children. J Pediatr Surg 2004;39:1062–5.

4. Warner RL Jr, Othersen HB Jr, Smith CD. Traumatic pancreatitis and pseudocyst in children: current management. J Trauma 1989;29:597– 601.

5. Burnweit C, Wesson D, Stringer D, Filler R. Percutaneous drainage of traumatic pancreatic pseudocysts in children. J Trauma 1990;30:1273–7.

6. Kimble RM, Cohen R, Williams S. Successful endoscopic drainage of a posttraumatic pancreatic pseudocyst in a child. J Pediatr Surg 1999;34:1518–20.

7. Breckon V, Thomson SR, Hadley GP. Internal drainage of pancreatic pseudocysts in children using an endoscopically-placed stent. Pediatr Surg Int 2001;17:621–3.

8. Sadik R, Kalaitzakis E, Thune A, Hansen J, Jönson C. EUS-guided drainage is more successful in pancreatic pseudocysts compared with abscesses. World J Gastroenterol 2011;17:499–505.

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Ateş et al. Endoscopic drainage and cystoduodedonstomy in a child with pancreatic pseudocyst 9. Kalaitzakis E, Panos M, Sadik R, Aabakken L, Koumi A, Meenan J. Clinicians’ attitudes towards endoscopic ultrasound: a survey of four European countries. Scand J Gastroenterol 2009;44:100–7.

10. Seewald S, Ang TL, Teng KC, Soehendra N. EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis. Dig Endosc 2009;21 Suppl 1:S61–5.

OLGU SUNUMU - ÖZET

Pankreatik psödokistli bir çocukta endoskopik drenaj ve kistoduodenostomi Dr. Ufuk Ateş,1 Dr. Gönül Küçük,1 Dr. Kubilay Çınar,2 Dr. Berktuğ Bahadır,3 Dr. Mehmet Bektaş,2 Dr. Gülnur Göllü,1 Dr. Meltem Bingöl Koloğlu1 1 2 3

Ankara Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Ankara Ankara Üniversitesi Tıp Fakültesi, Gastroenteroloji Anabilim Dalı, Ankara Mersin Üniversitesi Tıp Fakültesi, Çocuk Cerrahisi Anabilim Dalı, Mersin

Pankreas psödokisti tanısı alan 11 yaşındaki erkek çocuğun ince iğne aspirasyon biyopsisi sonrasında takipte birinci ayda tekrarladığı izlendi. Endosonografi yardımlı endoskopik drenaj ve üç yıllık takipte herhangi bir problem olmayan hastanın kontrol bilgisayarlı tomografsinde kist izlenmedi. Çocuklarda pankreatik psödokist yönetiminde endoskopik drenaj ve kistoduodenostomi minimal invaziv, güvenli ve etkin bir yöntemdir.

Anahtar sözcükler: Çocuk; drenaj; endosonografi; pankreas.

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Wrapping degloved fingers with a distal-based radial forearm perforator flap: A repair method for multiple digital degloving injury Yusuf Kenan Çoban, M.D., Özcan Öcük, M.D., Kaan Bekircan, M.D. Department of Plastic Reconstructive and Aesthetic Surgery, İnönü University Turgut Özal Medical Center, Malatya-Turkey

ABSTRACT Degloving hand injuries present challenging situations to hand surgeons as they present with difficulties in reconstructive microsurgery, particularly in multiple digital injuries. Time is a limiting factor when multiple degloving finger amputations are present. Thus, we proposed a repair method for multiple degloving finger injuries that involves coverage with a distal-based reverse forearm flap of all injured fingers in a two-stage procedure. Early vigorous physical therapy after pedicle division of the flap at postoperative third week eliminates joint stiffness problems at wrist and metacarpophalangeal joints.

Keywords: Degloved fingers; radial forearm flap; reverse flap.

INTRODUCTION The three types of mechanisms or nature of injury are cleancut, crush-cut, and crush-avulsion. Degloving injury belongs to the last type of mechanism. As surgeons continue to push the borders of microsurgery, novel techniques are prepared to manage the difficulties of degloving avulsed digits. Venous flow-through flaps or transfer of vessels from adjacent fingers are some of the novel techniques for recovering degloved fingers.[1,2] When the possibility of replantation is not feasible, then some sort of flap must be used to cover the defect. The commonly used methods for hand degloving injury defects include the use of abdominal flaps, anterolateral thigh flap, latissimus dorsi flap, medial arm, and cutaneous free flaps.[1–3] Restoration with abdominal flaps has been shown to lead to poor recovery of hand functions in degloving injuries.[4] There is no one ideal operation to achieve all desired outcomes for the degloved hand. Nazerani et al.[5] described a modified Address for correspondence: Yusuf Kenan Çoban, M.D. İnönü Üniversitesi Turgut Özal Tıp Merkezi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Malatya, Turkey Tel: +90 422 - 341 06 60 E-mail: ykenanc@yahoo.com Submitted: 21.10.2016 Accepted: 12.04.2017

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abdominal flap, which was designed in two layers. One layer covers the dorsum and the other is created in the fatty layer with separate compartments for each finger. The volar surface is left to granulate and is then covered by grafts. All these modifications result in a bulky mass on the fingers and hand.

Radial forearm flap has a thin pliable soft tissue structure.

Several reports have established the ability of this flap for reconstruction of ipsilateral hand injuries.[6,7] There are appropriately 10 small perforators arising from the distal radial artery around the radial styloid process on which the flap may be based upon. Here we report a case with multiple digital degloving injuries treated with distal-based reverse radial forearm perforator flap and discuss the functional results.

CASE REPORT A 24-year-old male was wounded due to compression injury in his right hand in a textile factory. His physical examination showed that his third, fourth, and fifth fingers were totally degloved at the metacarpophalangeal joint level (Fig. 1a and b). He was immediately operated under general anesthesia.

Severe multiple avulsion injuries averted the microsurgical replantation of the amputated parts. To cover the three injured fingers, a more proximal 6×13-cm reverse radial forearm flap was outlined. The involved upper limb was prepared in a sterile maneuver, and the arm was draped. Before inflating the tourniquet, the Allen test was performed. The flap was incised down to fascia and subfascially raised. Proximally, muscle belly and distally, tendon with paratenons were left in525

Ă&#x2021;oban et al. Wrapping degloved fingers with a distal-based radial forearm perforator flap

(a)

(b)

(c)

Figure 1. (a) Dorsal view of the degloved fingers. (b) Volar view of the hand. (c) Early view after the flap transfer.

tact in the donor bed. The incision pierced the muscle bellies and reached the space between the flexor carpi radialis and brachioradialis. At this point, perfusion of the flap was observed after releasing tourniquet. No nerve repair was performed. The flap was then transferred and wrapped around the three fingers and donor side was skin grafted (Fig. 1c).

The area between skin-grafted donor site and pivot point was primarily closed in a zig-zag fashion. A below elbow splint was placed for 3 weeks. At the third postoperative week, the flap and donor site uneventfully healed (Fig. 2a and b). Then, the pedicle was ligated and severed at the end of 3rdpostoperative week. During the postoperative period, joint stiffness occurred at the wrist and metacarpophalangeal joints, which was resolved with early physical therapy. Nevertheless, 90% range of motion at the MP joint of the degloved fingers was achieved, and no functional deficits occurred at the wrist joint. At the 3rd postoperative month, fingers in the flap bulk had a good range of motion.

(a)

(b)

Figure 2. Late view showing the hand following the pedicle division (a) volar view (b) dorsal view.

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DISCUSSION Degloving finger injuries are challenging situations for hand surgeons. Controversies exist regarding whether replantation or revision amputation should be performed. Urbaniak et al.[8] calculated that the general practice of replanting complete avulsion injuries results in compromised hand function.

The mean survival rate for complete avulsion finger injuries undergoing replantation was 66%. Reconstruction of vessels with long vein grafts, venous flow-through flaps, or transfer of vessels from adjacent digits are options for repairing finger avulsion injury. Patients treated with microvascular revascularization or replantation were analyzed according to survival rate, total active range of motion (TAM), and two-point static discrimination data as functional outcomes.

Outcomes obtained from studies may aid surgeons in treatment decision making for finger avulsion injuries. The American Society for Surgery of The Hand grading of results of TAM in tendon repair categories has an excellent result of 100% for the corresponding contralateral digits.[9] Implantation into the abdomen of the degloved hand and tubed flaps usually result in an unacceptable outcome.

In multiple digit degloving injuries, there is a challenge for surgeons due to the complexity of replantation process of avulsion type amputations. In single avulsion type amputation, time is not a limiting factor. An experienced microsurgeon may successfully manage and get a desired outcome in a single degloving avulsion amputation. However, in case of presence of multiple digital degloving injuries, a need for different solution option is clearly evident. Therefore, we proposed a new repair procedure that covers multiple digit degloving injuries.

In a fully flexed position of all degloved digits, a reverse radial forearm flap can easily be reach to cover all fingers. The only disadvantage of the process is maintaining the fixed position of the hand for 3 weeks. After dividing the pedicle and achieving wound healing, an early physical therapy can overcome joint stiffness problems of the hand. Noaman was the first to describe a reverse radial forearm flap wrapped around the complex degloved digit.[10] He performed 26 reversed radial Ulus Travma Acil Cerrahi Derg, November 2017, Vol. 23, No. 6

Çoban et al. Wrapping degloved fingers with a distal-based radial forearm perforator flap

pedicle forearm flaps for 21 patients. He used a dorsal subcutaneous tunnel to reach the finger defects, all of which were single degloved fingers. Our technique was similar to his, but we had to cover much bigger defects as three ulnar side digits had degloved. The dimension of our flap was 6×13 cm, and it was difficult to pass such a big flap through the subcutaneous tunnel. Therefore, we chose a two-staged operation. A much longer pedicle of reverse radial forearm flap is needed to reach multiple digital degloved defects, unlike single degloved fingers. In this way, one retains a longitudinal curtain of fascia between the brachioradialis and flexor carpi radialis muscles, connecting the skin to the radial artery.

Conflict of interest: None declared.

REFERENCES 1. Tok O, Tok L, Ozkaya D, Eraslan E, Ornek F, Bardak Y. Epidemiological characteristics and visual outcome after open globe injuries in children. J AAPOS 2011;15:556–61.

2. Ulrich D, Pallua N. Treatment of avulsion injury of three fingers with a compound thoracodorsal artery perforator flap including serratus ante-

rior fascia. Microsurgery 2009;29:556–9.

3. Kim KS, Kim ES, Kim DY, Lee SY, Cho BH. Resurfacing of a totally degloved hand using thin perforator-based cutaneous free flaps. Ann Plast Surg 2003;50:77–81.

4. Ju J, Li J, Hou R. Microsurgery in 46 cases with total hand degloving injury. Asian J Surg 2015;38:205–9.

5. Nazerani S, Motamedi MH, Nazerani T, Bidarmaghz B. Treatment of traumatic degloving injuries of the fingers and hand: introducing the “compartmented abdominal flap”. Tech Hand Up Extrem Surg 2011;15:151–5.

6. Coban YK, Balik O, Boran C. Cutaneous anthrax of the hand and its reconstruction with a reverse-flow radial forearm flap. Ann Plast Surg 2002;49:109–11.

7. Kaufman MR, Jones NF. The reverse radial forearm flap for soft tissue reconstruction of the wrist and hand. Tech Hand Up Extrem Surg 2005;9:47–51.

8. Urbaniak JR, Roth JH, Nunley JA, Goldner RD, Koman LA. The results of replantation after amputation of a single finger. J Bone Joint Surg Am 1985;67:611–9.

9. Kay S, Werntz J, Wolff TW. Ring avulsion injuries: classification and prognosis. J Hand Surg Am 1989;14:204–13.

10. Noaman HH. Salvage of complete degloved digits with reversed vascularized pedicled forearm flap: a new technique. J Hand Surg Am 2012;37:832–6.

OLGU SUNUMU - ÖZET

Çoklu parmak degloving yaralanmasında bir tamir yöntemi: Yaralı parmakların distal bazlı radiyal önkol perforator flebi ile sarılması Dr. Yusuf Kenan Çoban, Dr. Özcan Öcük, Dr. Kaan Bekircan İnönü Üniversitesi Turgut Özal Tıp Merkezi, Plastik Rekonstrüktif ve Estetik Cerrahi Anabilim Dalı, Malatya

Eldiven tarzı avulsiyon yaralanmaları el cerrahları çözülmesi zor problem oluşturur. Çünkü özellikle çoklu parmak yaralanmasında, rekonstrüktif mikrocerrahi, zaman sınırlaması gibi nedenlerle zorluklar taşır. Biz çoklu parmak “degloivng” yaralanması olan olgular için yeni bir metod öneriyoruz.

Bu teknik iki aşamalı olarak distal bazlı radiyal ön kol flebi ile, yaralanmış tüm parmakların sarılması ve üçüncü hafta flep pedikülünün kesilmesini içeriyor. Erken yoğun fizik tedavi ile, el bileği ve parmak eklemlerinde oluşacak sertlikler önlenecektir.

Anahtar sözcükler: Deglove parmaklar; radiyal ön kol flep; ters akımlı flep.

Ulus Travma Acil Cerrahi Derg 2017;23(6):525–527

doi: 10.5505/tjtes.2017.57227

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